Parents Baseline Questionnaire

A

Program ID#__________ Classroom ID#__________ Child ID#___________

Do not write in box. For study use only.

ccording to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is xxxx-xxxx. The time required to complete this information collection is estimated to average 20 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 any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Rafael Valdivieso, U.S. Department of Education, 555 New Jersey Avenue, NW, Room 506E, Washington, D.C. 20208.

Responses to this data collection will be used only for statistical purposes. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific program or individual. We will not provide information that identifies you or your program to anyone outside the study team, except as required by law.

Your cooperation in completing this survey is needed to make the results of this study comprehensive, reliable, and timely.

2. PARENT/Guardian BASELINE QUESTIONNAIRE

DATE: Month__ __ Day__ __ Year __ __ __ __

Information about your child:

1. Child’s Name: First _______________________ Last ____________________________

2. Child’s sex:  Male

 Female

3. Child’s Date of Birth: MONTH__ __

DAY__ __

YEAR __ __ __ __

4. Is child of Hispanic or Latino origin?

• Yes

• No

5. Please select one or more of the following categories to best describe your child’s race.

• American Indian or Alaska Native

• Black or African American

• Asian

• Native Hawaiian or other Pacific Islander

• White

6. When did the child begin attending this child care program? Month __ __ Year __ __ __ __

7. In a typical week, how many hours does the child attend this program? ___________ hours

8. To the best of your knowledge right now, how likely is it that the child will continue to attend this child care program for at least the next 9 months? Mark one response.

 Definitely or almost definitely

 Likely

 Unlikely

Information about you and the child’s family/household:

9. Your name__________________________________________

10. What is your relationship to the child? Are you the child’s . . . Mark one response.

• Biological mother

• Biological father

• Step-mother

• Step-father

• Adoptive mother

• Adoptive father

• Foster mother

• Foster father

• Grandmother

• Grandfather

• Aunt

• Uncle

• Cousin

• Sibling (Brother/Sister)

• Other Relative

Specify______________________

• Other Non-relative

Specify______________________

11. Your contact information:

Home phone: _ _ _- _ _ _- _ _ _ _

Work phone: _ _ _- _ _ _- _ _ _ _ ext. ________

Mobile phone: _ _ _- _ _ _- _ _ _ _

Address: ______________________________________________

City: ___________________________

State: _______

Zip: _____________

E-mail address: _________________________________

12. Relative or friend who can be contacted if we cannot reach you:

Name_____________________________________

Relationship to child____________________________

Home phone: _ _ _- _ _ _- _ _ _ _

Mobile phone: _ _ _- _ _ _- _ _ _ _

E-mail address: _________________________________

NOTE: For the following questions we are interested in learning more about people who live with the child in the same household. Please consider this when answering the remaining questions.

13. The child lives with the . . . Mark one response.

 Mother only (e.g., biological, step, adoptive, or foster)

 Father only (e.g., biological, step, adoptive, or foster)

 Mother and father

 Neither parent, child lives with a single guardian (e.g., Aunt, Grandmother)

Specify guardian’s relationship to child__________________

• Neither parent, child lives with a guardian and guardian’s spouse/partner or two guardians (e.g., Grandmother and Grandfather)

Specify both guardians’ relationship to child ______________

__________________________________________________

 Other

Specify ___________________

14. How many siblings (brothers/sisters) live with the child in the same household? ________

Enter 0 (zero) above if the child does not have siblings or does not live in the same household with his/her siblings and skip to question 16.

15. Child’s siblings

	(If different from child listed at the top of this form)	Date of Birth			Does sibling also attend this child care program?
First Name	Last Name	Month	Day	Year	Yes	No
1.
2.
3.
4.
5.
6.
7.
8.

16. What is your age? ______years

17. Are you employed and/or in school? Mark one response.

 Employed

• In school

• Both employed and in school

• Neither

18. If you are employed, how many hours do you work in a typical week?

___________ Hours per week

 Not Applicable (not employed)

19. If you are in school, how many hours do you attend classes in a typical week?

___________ Hours per week

 Not Applicable (not in school)

20. What is your highest level of education? Mark one response.

• Less than high school diploma/ no GED

• A high school diploma or GED

• Some college, but no degree

• An associate’s of arts (A.A.) degree

• A bachelor’s degree (B.A. or B.S.)

• Graduate or professional school but no degree

• Master’s degree (M.A. or M.S. etc)

• Doctorate degree (PhD or EDD)

• Professional degree after bachelor’s degree (MD, DDS, JD, etc.)

21. What is the language most often spoken in the child’s home? Mark one response.

• English

• Spanish

• Other

• Specify

NOTE: The following questions are about the child’s other parent/guardian in the household. If the child lives with you and there is no other parent/guardian in the household, skip to the end of the questionnaire.

22. What is the child’s other parent/guardian’s age? ________years

23. Is the child’s other parent/guardian employed and/or in school? Mark one response.

 Employed

• In school

• Both employed and in school

• Neither

24. If the child’s other parent/guardian is employed, how many hours does he/she work in a typical week?

___________ Hours per week

 Not Applicable (not employed)

25. If the child’s other parent/guardian is in school, how many hours does he/she attend classes in a typical week?

___________ Hours per week

 Not Applicable (not in school)

26. What is the child’s other parent/guardian’s highest level of education? Mark one response.

• Less than high school diploma/ no GED

• A high school diploma or GED

• Some college, but no degree

• An associate’s of arts (A.A.) degree

• A bachelor’s degree (B.A. or B.S.)

• Graduate or professional school but no degree

• Master’s degree (M.A. or M.S. etc)

• Doctorate degree (PhD or EDD)

• Professional degree after bachelor’s degree (MD, DDS, JD, etc.)

Thank you for taking the time to complete this questionnaire.

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