1 Survey

Appendix A A.2.1.j–7

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

12 Month Mother 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.

1. The first set of items are 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

Q2. Do you work either full-time or part-time for pay?

O Yes

O No  Go to Question 6

Next, think about all the things you do at work and at home.

Q3. The following set of items are things people have said about the difficulties of combining work and family. For each, please indicate to what extent, if at all, are the following items true for you.

	NOT AT ALL TRUE	SOMEWHAT TRUE	FAIRLY TRUE	VERY TRUE
a. My working creates strains for my children.	O	O	O	O
b. Working leaves me with too little time to be the kind of person I want to be.	O	O	O	O
c. Working causes me to miss out on some of the rewarding aspects of being a parent.	O	O	O	O
d. Working leaves me with too little energy to be the kind of parent I want to be.	O	O	O	O
e. Because of the requirements of my job, I have to miss out on home or family activities that I would prefer to participate in.	O	O	O	O
f. Because of the requirements of my job, my family time is less enjoyable and more pressured.	O	O	O	O
g. Thinking about my children interferes with my performance at work.	O	O	O	O
h. Because of my family responsibilities, I have to turn down work activities or opportunities that I would prefer to take on.	O	O	O	O
i. Because of my family responsibilities, the time I spend working is less enjoyable and more pressured.	O	O	O	O
j. When I spend time working, I am bothered by all the things at home that I should be doing.	O	O	O	O
k. During the time set aside for work, I feel resentful because I would really rather be spending time with my family.	O	O	O	O

Q4. In general, how often do you feel pulled apart from having to juggle conflicting obligations?

O Never

O Occasionally

O Often

O Very often

Q5. How often do things add up to being just too much?

O Never

O Occasionally

O Often

O Very often

Q6. The next set of items are things people have said about the benefits of combining work and family. For each, please indicate to what extent, if at all, are the following items true for you.

	NOT AT ALL TRUE	SOMEWHAT TRUE	FAIRLY TRUE	VERY TRUE
a. My working creates strains for my children.	O	O	O	O
b. Working leaves me with too little time to be the kind of person I want to be.	O	O	O	O
c. Working causes me to miss out on some of the rewarding aspects of being a parent.	O	O	O	O
d. Working leaves me with too little energy to be the kind of parent I want to be.	O	O	O	O
e. Because of the requirements of my job, I have to miss out on home or family activities that I would prefer to participate in.	O	O	O	O

Q7. The next series of questions contain statements about children. Many statements describe normal feelings and behaviors, but some describe things that can be problems. Some statements may seem too young or too old for your child. Please indicate the response that best describes your child in the LAST MONTH.

	NOT TRUE/ RARELY	SOMEWHAT TRUE/ SOMETIMES	VERY TRUE/ OFTEN	NO CONTACT WITH OTHER CHILDREN
a. Shows pleasure when he/she succeeds (For example, claps for self)	O	O	O
b. Gets hurt so often that you can’t take your eyes off him/her	O	O	O
c. Seems nervous, tense or fearful	O	O	O
d. Is restless and can’t sit still	O	O	O
e. Follows rules	O	O	O
f. Wakes up at night and needs help to fall asleep again	O	O	O
g. Cries or tantrums until he/she is exhausted	O	O	O
h. Is afraid of certain places, animals or things	O	O	O
i. Has less fun than other children	O	O	O
j. Looks for you (or other parent) when upset	O	O	O
k. Cries or hangs onto you when you try to leave	O	O	O
l. Worries a lot or is very serious	O	O	O
m. Looks right at you when you say his/her name	O	O	O
n. Does not react when hurt	O	O	O
o. Is affectionate with loved ones	O	O	O
p. Won’t touch some objects because of how they feel	O	O	O
q. Has trouble falling asleep or staying asleep	O	O	O
r. Runs away in public places	O	O	O
s. Plays well with other children, not including brother/sister	O	O	O	O
t. Can pay attention for a long time (not including TV)	O	O	O
u. Has trouble adjusting to change	O	O	O
v. Tries to help when someone is hurt. For example, gives a toy	O	O	O
w. Often gets very upset	O	O	O
x. Gags or chokes food	O	O	O

Q7. CONTINUED

	NOT TRUE/ RARELY	SOMEWHAT TRUE/ SOMETIMES	VERY TRUE/ OFTEN	NO CONTACT WITH OTHER CHILDREN
y. Imitates playful sounds when you ask him/her to	O	O	O
z. Refuses to eat	O	O	O
aa. Hits, shoves, kicks or bites children other than brother/sister	O	O	O	O
bb. Is destructive. Breaks or ruins things on purpose.	O	O	O
cc. Points to show you something far away	O	O	O
dd. Hits, bites or kicks you or other parent	O	O	O
ee. Hugs or feeds dolls or stuffed animals	O	O	O
ff. Seems very unhappy, sad, depressed or withdrawn	O	O	O
gg. Purposely tries to hurt you or other parent	O	O	O
hh. When upset, gets very still, freezes or doesn’t move	O	O	O

Q8. The following items are about feelings and behaviors that can be problems for young children. Some of the questions may be a bit hard to understand, especially if you have not seen them in a child. Please do your best to answer them anyway.

	NOT TRUE/ RARELY	SOMEWHAT TRUE/ SOMETIMES	VERY TRUE/ OFTEN
a. Puts things in a special order, over and over	O	O	O
b. Repeats the same action or phrase, over and over	O	O	O
c. Repeats a particular movement, over and over (like rocking, spinning, etc.)	O	O	O
d. “Spaces out.” Is totally unaware of what’s happening around him/her	O	O	O
e. Does not make eye contact	O	O	O
f. Avoids physical contact	O	O	O
g. Eats or drinks things that are not edible, like paper or paint	O	O	O
h. Hurts him/herself on purpose. For example, bangs his or her head.	O	O	O

The following questions ask about your physical safety.

Q9. Since your baby was born, have you been hit slapped, kicked, or otherwise physically hurt by anyone?

O Yes

O No  Go to End of Questionnaire

Q10. Was this by: (You may select more than one answer.)

O Your husband or neighbor

O Your parent

O An other adult family member

O Someone you know, but not a family member

O A stranger

Q11. Within the last year, how often did this happen?

O 1 time

O 2–3 times

O 3 or more times

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