Form 0990-0290 Follow-up survey

Adolescent Family Life Care Program Core Evaluation

0990-0290Appendix B_Draft Care Follow up_OMB_09-02-08_sbj_MK

Follow-up survey (at birth)

OMB: 0990-0290

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ADOLESCENT FAMILY

LIFE CARE PROGRAMS



DRAFT CORE FOLLOW-UP QUESTIONNAIRE































PRIVACY


We want you to know that:


1. Your answers to these questions will help us learn what people your age know, think, and do.


2. You may skip any questions you do not wish to answer. But we hope that you will answer as many questions as you can.


3. Your answers will be combined with those of other teens. We will keep your answers private.



PLEASE DO NOT WRITE YOUR NAME ANYWHERE ON THIS SURVEY!




According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0290. The time required to complete this information collection is estimated to average 27 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:



U.S. Department of Health & Human Services; OS/OIRM/PRA;

200 Independence Ave., S.W., Suite 531-H; Washington D.C. 20201

Attention: PRA Reports Clearance Officer










To be completed by project staff:



  1. Client ID:








  1. Site Number:









M

M

D

D

Y

Y



  1. Today’s Date:








  1. Site Name: ___________________________



Write the site name on page 3 for item #24, response options 9, 10, and 11.


M

M

D

D

Y

Y



M

M

D

D

Y

Y

  1. Baseline Survey Date








6. Most Recent Survey Date (Baseline or Follow Up)









If this respondent completed a baseline survey for pregnant teens:

  • Write the baseline survey date on page 2 above item #10.

  • Cross out the line that states “These next questions refer to the child born MONTH/YEAR” that appears before item 14.

  • Write the baseline survey date on page 5, item #33

  • Cross out item #34 on page 5.

If this respondent completed a parenting baseline survey:

  • Copy the date that the respondent’s child was born from survey item #14 on the parenting baseline survey to the space above item #14 on this follow-up survey on page 2.

  • Cross out the line that says, “These next questions are about the child you were pregnant with on MM/DD/YY.”

  • Cross out items #10 through #13.

  • Write the baseline survey date on page 5, item #34

  • Cross out item #33 on page 5.



For all surveys:

  • Write the date of this respondent’s most recently completed survey (either baseline or follow up) on page 5 for item #36.





After the survey has been completed and turned in, please complete page 8. You will need to make a copy of the immunization records provided by the adolescent. Do not complete this section in front of the adolescent.

GENERAL INSTRUCTIONS



  1. Read all the answers before marking your choice. If none of the printed answers exactly applies to you, black out the circle beside the answer that best fits.

  2. Use a pencil to complete the survey.

  3. Completely black out the circle beside your answer choice.

INCORRECT CORRECT

  1. If you make a mistake, erase it cleanly and then mark the circle beside your correct answer choice.

  2. Do not make any stray marks.

  3. PLEASE READ EACH QUESTION CAREFULLY.

Follow the directions for responding to each kind of question. These are:

    1. Mark ONE

What is the color of your eyes?

Mark ONE

1 Brown

2 Blue

3 Green

4 Another color

If the color of your eyes is green, you would mark the third circle as shown.



    1. Mark ONE

What is the color of your hair?

Mark ONE

1 Brown

2 Black

3 Blonde

4 Red

5 Some other color (Describe)     Purple    

If your hair is purple, you would mark “Some other color.” Then you would write “purple” in the blank.



GENERAL INSTRUCTIONS (continued)

    1. BLANK BOX

If a question has only a blank box, write your answer in the space provided.

What is the name of the school you are currently attending?

Springfield Middle School



    1. Mark ALL THAT APPLY

Do you plan to do any of the following next week?

Mark one or more

1 Rent a video

2 Go to a baseball game

3 Study at a friend’s house

If you plan to rent a video and go to a baseball game, you mark both.



    1. QUESTION WITH A SKIP

  1. Do you ever eat chocolate?

Mark ONE

1 Yes

0 No (SKIP TO #3)

  1. Do you always brush your teeth after you eat chocolate?

Mark ONE

1 Yes

0 No

  1. Did you do any of the following last week?

Mark ALL THAT APPLY

1 Saw a play

2 Went to a movie

3 Attended a sporting event







If you answered “Yes” to Question 1, you go to Question 2. After you answer Question 2, you go to Question 3.


If you answered “No” to Question 1, you skip Question 2. Then you go to Question 3.



ABOUT THE FUTURE

Think about the future and answer these questions:

1. How important is it to you to graduate high school? Or to graduate vocational or trade school?

Mark ONE

1Not important at all

2Somewhat important

3Very important

4 Extremely important

96 Already graduated

Answer the next question using a scale from 1 to 5. 1 is “not at all,” and 5 is “a lot.”

2. How much do you want to get more education or training? This could be college, vocational or technical school, or a nursing certification.

Mark ONE

Not
at all




A lot

Don’t know

1

2

3

4

5

97
3. How important is it for you to get training to get the kind of job you want?

Mark ONE

Not
important




Very important

Don’t know

1

2

3

4

5

97



WHAT YOU THINK

4. Please mark how much you agree or disagree with this statement:

It is better for a person to get married than to go through life being single.

Mark ONE

1Strongly agree

2Agree

3Neither agree nor disagree

4Disagree

5Strongly disagree

97Don’t know

5. How much do you stay away from people who might get you into trouble?

Mark ONE

1Almost never

2Some of the time

3Usually

4Almost always

Please mark how much the following statements sound like you.

6. I think I should work to get something, if I really want it.

Mark ONE

1 Not at all like me

2 A little like me

3 Mostly like me

4 Very much like me

97 Don’t know

7. I make decisions to help me reach my goals.

Mark ONE

1 Not at all like me

2 A little like me

3 Mostly like me

4 Very much like me

97 Don’t know

8. Some young women feel they are not ready to be a parent. For these women, I think adoption is a good choice.

Mark ONE

1Not at all like me

2A little like me

3Mostly like me

4Very much like me

97Don’t know

The next question is about your mother or father. Or a person like a mother or father to you.

9. How often do you talk to your mother or father about your problems?

Mark ONE

1 Almost never

2 Some of the time

3 Usually

4 Almost always

96 There is no person who is like a mother or

father to me



ABOUT YOUR CHILD

These next questions are about the child you were pregnant with on _______________.

MM/DD/YY

1 0. Did this pregnancy end in a live birth?

1 Yes

0 No ( IF YOUR ANSWER IS
“NO,” SKIP TO #30
ON PAGE 4.)



11. When was this child born? ___ ___ / ___ ___

MONTH / YEAR

12. An early birth is one that occurs at 36 weeks or earlier in pregnancy. As far as you know, did you have an early birth?

Mark ONE

1 Yes

0 No

97 Don’t know

13. How much did this child weigh at birth?

Mark ONE

1 5½ pounds or more

2Less than 5½ pounds

97 Don’t know

These next questions refer to the child born
_____________
MONTH / YEAR

14. Did you breastfeed this child at all?

1 Yes

0 No (SKIP TO #16)



15. How old was this child when you completely stopped breastfeeding him or her?

Mark ONE

1 I am still breastfeeding

2 Less than 1 month old

3 1 month old to 2 months old

4 3 months old or more

16. Is this child alive now?

1

IF YOUR ANSWER IS “NO,” SKIP TO #30 ON PAGE 4.

Yes

0 No

17. This next question is about after the birth of this child. About how many times has this child had a regular check up or “well-baby” visit? This is a visit to a doctor or nurse when your child is not sick, but to get checked out or to get shots. Would you say . . .

MARK ONE

1 Never (SKIP TO #19 ON PAGE 3)

2 1-3 times

3 4 or more times

97 Don’t know

18. When was this child’s last “well baby” visit?

Mark THE MOST RECENT

1 Within the past 3 months

2 Within the past 6 months

3 Within the past 12 months

4 More than a year ago

97 Don’t know





19. Does this child live with you?

Mark ONE

2

(SKIP TO #21)

Yes

1 Sometimes

0 No

20. Where does this child live now?

Mark ONE

1 With the child’s father

2 With other relatives

3 With adoptive family

4 Other (Describe______________________)

97 Don’t know



2 1. Is this child 3 months old or older?

1 Yes

0 No (SKIP TO # 23)

MARK ONE ANSWER FOR EACH

Yes

No

Don’t Know

a.

Diptheria, Tetanus, Pertussis (DTaP)

1

0

97

b.

Inactivated Poliovirus (IPV)

1

0

97

c.

Haemophilus influenzae type b (Hib)

1

0

97

d.

Hepatitis B (HepB)

1

0

97

e.

Pneumococcal (PCV)

1

0

97

f.

Rotavirus (Rota)

1

0

97
22. Has this child had any of the following vaccinations/shots?



IF YOUR CHILD DOES NOT LIVE WITH YOU, PLEASE SKIP TO #26 ON PAGE 4.















2 3. This next question is about the past four weeks. Has this child received any regular child care? This could be a day care, nursery school, play group, babysitter, after school care, relative, or some other child care plan. (“Regular” means at least once a week for a month or more.)

1 Yes

0 No (SKIP TO #26)

24. Which of these has been your main child care provider in the past four weeks?

Mark ONE

1 Child’s father/stepfather

2 My brother/sister aged 13 years or older

3 My brother/sister younger than 13 years old

4 Child’s grandparent

5 Other relative

6 Non-relative or babysitter

7 Nursery/preschool

8 Family day care

9 _______________________________________

10 Day care center referred by ________________

__________________________________________

11 Day care center not referred by_____________

__________________________________________

12 Other (Describe _________________________)

13 Child has not received regular child care in past four weeks

2 5. How many hours a week is this child in child care? This includes all the different plans that you use.

Hours

97MARK HERE IF YOU DON’T KNOW

26. Which of these statements best describes your relationship with your child’s father?

Mark ONE

1We do not see or talk to each other

2We hardly ever see or talk to each other

3We are just friends

4 We are involved in an on-again, off-again relationship

5We are romantically involved on a steady basis but are not married

6We are married (SKIP TO # 31)

7Don’t know

IF YOU ARE MARRIED TO THE FATHER OF YOUR CHILD, SKIP TO #31.

27. Do you and your child’s father have a legal agreement for child support, alimony, custody, visitation, or where the child will live?

1Yes

0 No

28. Does your child’s father give you money or buy clothes for the child? Or pay for doctor visits or provide other kinds of support?

1 Yes

0 No

29. Does your child’s father help you in other ways, such as watching the child or helping with chores?

1Yes

0No

30. What is your marital status?

Mark ONE

1Single, never married (including living with someone or engaged)

2Married

3Separated or divorced

4Widowed

5Other (Describe ______________________)

31. Who do you live with now?

Mark ALL THAT APPLY

  1. I live alone

  1. With husband

  1. With my mother (include stepmother)

  1. With my father (include stepfather)

  1. With this child’s father

  1. With this child’s father’s mother

  1. With this child’s father’s father

  1. With partner

  1. With other relatives

  1. With friends

  1. In a group home/institution

  1. In a foster home

  1. Other (Describe ___________________)



ABOUT YOUR HEALTH

These next questions are about your health and healthcare.

32. These are some ways people try to avoid sexually transmitted diseases. What way(s) did you try this month?

Mark ALL THAT APPLY

a. No method used this month

b. Abstinence (did not have sex this month)

c. Condom

d. Female condom, vaginal pouch

e. Other (Describe ___________________)




33. Our records show that you were pregnant on

______________.

MM/DD/YY

Have you been pregnant since that pregnancy ended?

1 Yes

0 No


34. Have you been pregnant since _____________?

MM/DD/YY

1 Yes

0 No



35. These are some ways people try to avoid pregnancy. What way(s) did you try this month?

Mark ALL THAT APPLY

a. DOES NOT APPLY- I am pregnant now

b. No method used this month

c. Abstinence (did not have sex this month)

d. Birth control pills

e. Condom

f. Withdrawal, pulling out

g. Depo-Provera, injectables (the shot)

h. Natural family planning (rhythm or safe period by calendar, temperature or cervical mucus test)

i. Diaphragm

j. Female condom, vaginal pouch

k. Foam

l. Jelly or cream

m. Cervical cap

n. Suppository

o. Sponge

p. IUD

q. “Morning after” pills or emergency contraception

r. Contraceptive patch

s. NuvaRing (vaginal ring)

t. Implanon

u. Other method (Describe ______________)

36. Since _________________, have you received . . .

MM/DD/YY

Mark ALL THAT APPLY

a. a pregnancy test?

b. an abortion?

c. prenatal care?

d. post pregnancy care?







ABOUT YOU

These questions ask about you.

37. What is your current school status?

Mark ONE

1 In school or GED program

2 Graduated from high school or completed GED (SKIP TO #39)

3 Dropped out of school

4 Other (Describe ____________________)

38. IF YOU HAVE NOT FINISHED HIGH SCHOOL OR COMPLETED YOUR GED:

Do you want to have another baby before you finish high school?

1Yes

0No

97 Don’t know

39. What is the highest grade you have completed?

Mark ONE

18th grade or below

29th grade

310th grade

411th grade

512th grade

6Some college

7College degree or more

97Don’t know

40. Have you ever been in a job training program?

1 Yes

0No (SKIP TO #42)

41. Did you ever complete a job training program?

Mark ONE

1Yes

2No and not now in a job training program

3No and now in a job training program



42. How many hours do you work per week?

W RITE 00 IF YOU DO NOT WORK

Hours per week

43. Do you receive money or aid from any of the following sources?

Mark ALL THAT APPLY

a. Medicaid

b. Food stamps

c. WIC (Women, Infants, and Children) Program

d. TANF (Temporary Aid to Needy Families)

e. Social Security

f. Unemployment or Workers’ Compensation

g. Other public aid

h. Child support

i. My job

j. Husband or partner

k. Parent(s)

l. Other (Describe_____________________)

44. What is your main source of financial support?

Mark ONE

1My job

2Husband or partner

3Parents

4Public aid

5Other relatives

6Other (Describe _______________________)









That's all!

Thank you so very much for your time.



TO BE COMPLETED BY SURVEY ADMINISTRATION STAFF





After the survey has been completed and turned in, please complete this page. You will need to make a copy of the immunization records provided by the adolescent. Do not complete this section in front of the adolescent.







  1. C hild’s birth date (can be copied from item #11):

___ ___ / ___ ___

MONTH / YEAR

  1. Do you have access to this child’s immunization record?

1 Yes

2 No (SKIP TO PAGE 9)





  1. Using the child’s immunization records, mark whether or not the child has received at least one dose of each of the immunizations listed below.

Mark one for each

Yes

No

Unknown/not mentioned

a.

Diptheria, Tetanus, Pertussis (DTaP)

1

0

97

b.

Inactivated Poliovirus (IPV)

1

0

97

c.

Haemophilus influenzae type b (Hib)

1

0

97

d.

Hepatitis B (HepB)

1

0

97

e.

Pneumococcal (PCV)

1

0

97

f.

Rotavirus (Rota)

1

0

97














SURVEY ADMINISTRATOR:

YOU HAVE COMPLETED THIS RECORD ABSTRACTION.

THANK YOU FOR YOUR TIME!





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