A.2.2.d Survey

Appendix A A.2.2.d–8

Source: Visits: 12 month Mode: Self-administered (Mail-in) Estimated Time:		BAR CODE LABEL OR SUBJECT ID HERE |___|___|___|___|___|___|___|___|

12 Month Father Questionnaire

Instructions

1	This booklet contains questions about how you feel, your baby’s behavior and how you and your partner divide the duties of raising your baby.
2	Use a No. 2 pencil, or a blue or black ink pen only. Do not use a felt-tipped pen or a red ink pen.
3	Make solid marks that fill the oval completely. Do not use a or an to record an answer.
4	If you need to change an answer, be sure to erase or mark out the unwanted marks completely.
5	Mark only one response for each question, unless otherwise directed.

These first questions are about different things you may do as a parent.

1. Please indicate how often do you feel the following ways or do the following things.

How often do you feel the following ways or do the following things:	All of the Time	Some of the Time	Rarely	Never
a. Talk a lot about your child to friends and family?	O	O	O	O
b. Carry pictures of your child with you wherever you go?	O	O	O	O
c. Find yourself thinking about your child?	O	O	O	O
d. Think holding and cuddling your child is fun?	O	O	O	O
e. Think it’s more fun to get your child something new than to get yourself something new?	O	O	O	O

2. How strongly do you agree or disagree with the following statement:

Babies have to learn they can’t be picked up every time they cry.

O Strongly agree

O Agree

O Neither agree nor disagree

O Disagree

O Strongly disagree

3. Do you read or look at books with your child?

O Yes

O No  Go to Question 5

4. How often do you read or look at books with your child?

O Every day

O 5–6 days a week

O 2–4 days a week

O Once a week or less

5. When you are reading to or looking at books with your child, do you try to teach your child:

O No, he/she is too young

O No, I don’t have time

O Yes, occasionally

O Yes, often

6. Does your child watch TV and/or DVDs?

O Yes

O No  Go to Question 10

7. How often does your child watch TV and/or DVDs?

O Every day

O 5–6 days a week

O 2–4 days a week

O Once a week or less

8. How often does your child watch TV and/or DVDs:	Never	Occasionally	Almost Every Day	All the time
a. For entertainment?	O	O	O	O
b. For education?	O	O	O	O
c. To relax or calm them?	O	O	O	O
d. To keep them occupied while you get other things done?	O	O	O	O

9. When you are watching TV or DVDs with your child, do you try to teach your child:

O No, he/she is too young

O No, I don’t have time

O Yes, occasionally

O Yes, often

10. How often do you play with toys with your baby?

O Every day

O 5–6 days a week

O 2–4 days a week

O Once a week or less

11. How often do you go for walks with your baby?

O Every day

O 5–6 days a week

O 2–4 days a week

O Once a week or less

The next set of questions asks about how you think most young children act, how they grow, and how to care for them. Please answer each of the following questions based on young children, in general, not about your child and how he or she acts. Think about what you know about young children you have had contact with or anything you have read.

12. For each of the following statements, indicate whether, for most children, you agree or disagree with the statements, or are not sure.

	Agree	Disagree	Not Sure
a. All infants need the same amount of sleep.	O	O	O
b. A young brother or sister may start wetting the bed or thumb-sucking when a new baby arrives in the family.	O	O	O
c. A child thinks he or she is speaking correctly even when he or she says words and sentences in unusual or different ways, like “I goed to town” or “What the dollie have.”	O	O	O
d. Children learn all of their language by copying what they have heard adults say.	O	O	O

13. The next statements are about the age at which young children can first do something. If you think the age is about right, record you agree. If you don’t agree, indicate whether you think a child is younger or older when they can first do these things. If you aren’t sure, then indicate that you are not sure.

	Agree	Disagree: Older	Disagree: Younger	Not Sure
A 1-year old knows right from wrong.	O	O	O	O
A baby will begin to respond to her name at 10 months.	O	O	O	O
Most infants are ready to be toilet trained by 1 year of age.	O	O	O	O
A baby of 12 months can remember toys he has watched being hidden.	O	O	O	O
One-year-olds often cooperate and share when they play together.	O	O	O	O
A baby is about 7 months old before she can reach for and grab things.	O	O	O	O
A baby usually says his first real word by 6 months of age.	O	O	O	O

14. The next set of items is about your relationship with your spouse or partner.

Please indicate the extent to which you agree or disagree with each statement.

	Strongly Disagree	Somewhat Disagree	Neutral	Somewhat Agree	Strongly Agree
a. My spouse/partner listens to me when I need someone to talk to.	O	O	O	O	O
b. I can state my feelings without him getting defensive.	O	O	O	O	O
c. I often feel distant from my spouse/partner.	O	O	O	O	O
d. My spouse/partner can really understand my hurts and joys.	O	O	O	O	O
e. I feel neglected at times by my spouse/partner.	O	O	O	O	O
f. I sometimes feel lonely when we’re together.	O	O	O	O	O

15. Now I am going to ask you about work clothing. Some people work at jobs where their skin, clothes, or shoes get dirty or stained. Think about everyone in your household. Does anyone ever routinely come home with dirty or stained skin, work clothes, or shoes? By “dirty” or “stained” we mean their skin or clothes have dust, grease, or other visible chemical spots on them.

O Yes

O No  Go to Page 8

16. Who is it that comes home with dirty or stained skin, work clothes, or shoes? Is it:

O You

O Others in the home

O Both you and others in the home

The following question is about those who come home with dirty or stained clothing.

17. How often do you or anyone in your household:

	Every Day	5–6 Times a Week	3–4 Times a Week	1–2 Times a Week	Never
a. Come home from work with dirty hands or skin?	O	O	O	O	O
b. Wear dirty work shoes inside your home?	O	O	O	O	O
c. Wear dirty work clothes inside your home?	O	O	O	O	O

18. How often do you or anyone in your household wash work clothes at home?

O Every day

O 5–6 times a week

O 3–4 times a week

O 1–2 times a week  Go to Page 8

O Never  Go to Page 8

19. Are your work clothes washed separately from other clothes?

O Yes

O No

20. What types of materials have you or anyone in your household brought home on work clothes or shoes?

O Dirt

O Wood dust

O Grease

O Pesticides

O Metal dust

O Coal or mining dust

O Animal hair

O Fibers (such as asbestos or fiberglass)

O Other __________________

Specify

The next questions are about your child’s exposure to environmental tobacco smoke.

21. Do you currently smoke cigarettes or use any other tobacco products? O Yes O No 22. Including yourself, how many smokers live in your home now? ___________ NUMBER OF SMOKERS 23. Do you or does anyone smoke inside the house? O Yes O No

24. Which of the following statements describes the rules about smoking inside your home now? O No one is allowed to smoke anywhere inside my home, O Smoking is allowed in some rooms at some times, or O Smoking is permitted anywhere inside by home. 25. On average, about how many hours per day do people smoke in the same room as your baby, or near enough that he/she can smell the smoke? Please consider all the places your baby is during the day, including at home, at daycare, or some other place. If he/she is not exposed to smoke, enter “0”. ___________ NUMBER OF HOURS

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