NHES Screeners and Questionnaires

2012 National Household Education Survey (NHES 2012) Full Scale Data Collection

Appendix B NHES 2012 Questionnaires

NHES Screeners and Questionnaires

OMB: 1850-0768

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1850-0768 can be found here:

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Appendix B.

NHES: 2012 Questionnaires

Screener Questionnaires
1. Without name*^,^
2. With name*^,^
Topical Questionnaires
1. Early Childhood Program Participation*^,^
2. Early Childhood Program Participation – short form for 4^th mailing
3. Parent and Family Involvement in Education – Enrolled Students*^,^
4. Parent and Family Involvement in Education – Homeschooled Students*^,^
5. Parent and Family Involvement in Education – Enrolled Short Form for 4^th mailing

* A Spanish version will be created after OMB approval.

^ The Census version will be created after OMB approval and will differ only in cover design from the questionnaires shown in this appendix.

Screener Questionnaire Without Name

Commonly Asked Questions

Q: How did you get my address?

A: Your address was randomly selected from among all of the home addresses in the nation. It was selected using scientific sampling methods to represent other households in the U.S.

Q: Why don’t you ask more questions about education in this questionnaire?

A: The purpose of this questionnaire is to find out if anyone in your household is eligible for the next stage of the survey. If so, we will send a second questionnaire that will ask about educational experiences of a member of your household.

Q: If there are no children or anyone currently in school in my household, should I respond?

A: Yes, you should respond to this survey. Once you return the questionnaire, the study will be able to see if anyone in your household is eligible for the next and final survey. If no one is eligible, you will not receive another survey.

Q: Why should I take part in this study? Do I have to do this?

A: This survey is the only way that the Department of Education can learn about children’s care, early learning activities, and schooling from your perspective. You represent thousands of other households like yours, and you cannot be replaced. Your answers and opinions are very important to the success of this study. You may choose not to answer any or all questions in this survey. In order for the survey to be representative it is important that you complete and return this questionnaire. Those who do not return the survey will not be represented in key statistics used by policymakers and researchers.

Q: How will the information I provide be used? Will my privacy be protected?

A: Your responses will be combined with those of others to produce statistical summaries and reports. Your individual data will not be reported. Your answers may be used only for statistical purposes and may not be disclosed, or used, in identifiable form for any other purpose except as required by law (Section 9573, 20 US Code).

Q: How much time will it take?

A: On average, it should take 3 minutes for you to respond, including the time for reviewing instructions and completing and reviewing the collection of information.

Q: Who is sponsoring the study? Is this study conducted by the Federal Government?

A: The National Center for Education Statistics, within the Department of Education, is authorized to conduct this study (Section 9543, 20 US Code). This study has been approved by the Office of Management and Budget, the office that reviews all federally sponsored surveys. The approval number assigned to this study is XXXX-XXXX. You may send any comments about this survey, including its length, to the Federal Government. Write to: Andrew Zukerberg, National Center for Education Statistics, U.S. Department of Education, 1990 K Street NW, Room 9036, Washington, DC 20006-5650. You may send e-mail to XXX. If you have any questions about the study, contact XXX toll-free at 1-xxx-xxx-xxxx.

OMB No. XXXX-XXXX: Approval Expires XX/XX/XXXX

National Household Education Survey

The National Center for Education Statistics is authorized to conduct this survey under Section 9543, 20 US Code. Your participation is voluntary. Your answers may be used only for statistical purposes and may not be disclosed, or used, in identifiable form for any other purpose except as required by law (Section 9573, 20 US Code). The information you provide will be combined with information from other participants to produce statistical summaries and reports.

Start Here	► Start with the youngest youth or child who is age 20 or younger.	Youth / Child 1 ▼	Youth / Child 2 ▼	Youth / Child 3 ▼	Youth / Child 4 ▼	Youth / Child 5 ▼
The Department of Education is studying households with youth or children age 20 or younger. Each household is different, and we need your response so we can send you a survey that is right for your household. ► Return this form even if there are no youth or children in this household after marking the correct box in item 1. ► This survey should be filled out by an adult household member living at this address. ► Please use a blue or black pen if available. 1. Are there any youth or children age 20 or younger living in this household? Do not include those living in college housing. Y es N o GO TO box A at the bottom. 2. How many youth or children age 20 or younger live in this household? \|__\|__\| number age 20 or younger ► Continue answering questions 3 through 6 for each youth or child living in this household.		Youth / Child 1 ▼	Youth / Child 2 ▼	Youth / Child 3 ▼	Youth / Child 4 ▼	Youth / Child 5 ▼
	3. How old is this child in years?	Mark for babies less than 1 year old \|__\|__\| age in years	Mark for babies less than 1 year old \|__\|__\| age in years	Mark for babies less than 1 year old \|__\|__\| age in years	Mark for babies less than 1 year old \|__\|__\| age in years	Mark for babies less than 1 year old \|__\|__\| age in years
	4. What is this child’s sex?	Male Female	Male Female	Male Female	Male Female	Male Female
	5. Is this child currently in Mark [X] ONE only.	Public or private school, or preschool, Homeschool instead of school for some or all classes, or Not in school? G O TO youth/child 2.	Public or private school, or preschool, Homeschool instead of school for some or all classes, or Not in school? G O TO youth/child 3.	Public or private school, or preschool, Homeschool instead of school for some or all classes, or Not in school? G O TO youth/child 4.	Public or private school, or preschool, Homeschool instead of school for some or all classes, or Not in school? G O TO youth/child 5.	Public or private school, or preschool, Homeschool instead of school for some or all classes, or Not in school? R eturn survey.
	6. What is this child’s current grade or equivalent?	Preschool Kindergarten write \|__\|__\| grade 1 through 12 College or vocational school None of these	Preschool Kindergarten write \|__\|__\| grade 1 through 12 College or vocational school None of these	Preschool Kindergarten write \|__\|__\| grade 1 through 12 College or vocational school None of these	Preschool Kindergarten write \|__\|__\| grade 1 through 12 College or vocational school None of these	Preschool Kindergarten write \|__\|__\| grade 1 through 12 College or vocational school None of these
	► Please verify you have listed the 5 youngest youth or children living in this household in columns 1 through 5 above.

A If you marked in question 1 that no one in your household is age 20 or younger, please stop here and return this survey to us in the enclosed envelope. It is important that we receive a response from every household selected for this study. Thank you for your time.			► Thank you. Please return this form in the postage-paid envelope provided or mail it to: National Household Education Survey Toll-free number for questions: 1-XXX-XXX-XXXX

Screener Questionnaire With Name

Commonly Asked Questions

Q: How did you get my address?

A: Your address was randomly selected from among all of the home addresses in the nation. It was selected using scientific sampling methods to represent other households in the U.S.

Q: Why don’t you ask more questions about education in this questionnaire?

Q: If there are no children or anyone currently in school in my household, should I respond?

Q: Why should I take part in this study? Do I have to do this?

Q: How will the information I provide be used? Will my privacy be protected?

Q: How much time will it take?

A: On average, it should take 3 minutes for you to respond, including the time for reviewing instructions and completing and reviewing the collection of information.

Q: Who is sponsoring the study? Is this study conducted by the Federal Government?

OMB No. XXXX-XXXX: Approval Expires XX/XX/XXXX

National Household Education Survey

Start Here Shape10

► Start with the youngest youth or child who is age 20 or younger.

Youth / Child 1

▼

Youth / Child 2

▼

Youth / Child 3

▼

Youth / Child 4

▼

Youth / Child 5

▼

The Department of Education is studying households with youth or children age 20 or younger. Each household is different, and we need your response so we can send you a survey that is right for your household.

► Return this form even if there are no youth or children in this household after marking the correct box in item 1.

► This survey should be filled out by an adult household member living at this address.

► Please use a blue or black pen if available.

1. Are there any youth or children age 20 or younger living in this household?

Do not include those living in college housing.

Y es
N o GO TO box A at the bottom.

2. How many youth or children age 20 or younger live in this household?

|__|__| number age 20 or younger

► Continue answering questions 3 through 7 for each youth or child living in this household.

3. What is his or her first name, initials, or nickname?

First names will be used only to ask you questions about the education of a specific child.

First name/initials/nickname

4. How old is this child in years?

Mark for babies less than 1 year old

|__|__| age in years

Mark for babies less than 1 year old

|__|__| age in years

Mark for babies less than 1 year old

|__|__| age in years

Mark for babies less than 1 year old

|__|__| age in years

Mark for babies less than 1 year old

|__|__| age in years

5. What is this child’s sex?

Male
Female

Male
Female

Male
Female

Male
Female

Male
Female

6. Is this child currently in

Mark [X] ONE only.

Public or private school, or preschool,
Homeschool instead of school for some or all classes, or
Not in school?

G O TO youth/child 2.

Public or private school, or preschool,
Homeschool instead of school for some or all classes, or
Not in school?

G O TO youth/child 3.

Public or private school, or preschool,
Homeschool instead of school for some or all classes, or
Not in school?

G O TO youth/child 4.

Public or private school, or preschool,
Homeschool instead of school for some or all classes, or
Not in school?

G O TO youth/child 5.

Public or private school, or preschool,
Homeschool instead of school for some or all classes, or
Not in school?

R eturn survey.

7. What is this child’s current grade or equivalent?

Preschool
Kindergarten

write

|__|__| grade 1 through 12

College or vocational school

None of these

Preschool
Kindergarten

write

|__|__| grade 1 through 12

College or vocational school
None of these

Preschool
Kindergarten

write

|__|__| grade 1 through 12

College or vocational school
None of these

Preschool
Kindergarten

write

|__|__| grade 1 through 12

College or vocational school
None of these

Preschool
Kindergarten

write

|__|__| grade 1 through 12

College or vocational school
None of these

► Please verify you have listed the 5 youngest youth or children living in this household in columns 1 through 5 above.

A If you marked in question 1 that no one in your household is age 20 or younger, please stop here and return this survey to us in the enclosed envelope. It is important that we receive a response from every household selected for this study. Thank you for your time.

► Thank you. Please return this form in the postage-paid envelope provided or mail it to:

National Household Education Survey

Toll-free number for questions: 1-XXX-XXX-XXXX

ECPP Questionnaire

The National Household Education Survey

Our Children’s Future: A Survey of Young Children’s Care and Education

Thank you for helping us with this survey. Based on the information we received from your household in your last survey, we’re asking you to complete this final step.

U.S. Department of Education

National Center for Education Statistics

ponsored by

Instructions

In response to the survey you answered earlier, we recorded that the child/youth listed below has not yet started kindergarten. If this child is attending public or private school or is homeschooled for kindergarten through 12^th grade or equivalent, please call us at the toll-free number below so we can be sure you received the correct survey.

These questions should be filled in by a parent or guardian who knows about:

Please answer all the survey questions thinking about this child or youth.

To answer a question, simply mark  the box that best represents your answer.

Please use a black or blue pen, if available, to complete this survey.

If this questionnaire has been sent to the wrong household or the child/youth listed above does not live here, please call to let us know.

Our toll-free number is 1-888-880-3033.

We are authorized to collect this information by Section 9543, 20 U.S. Code. You do not have to provide

the information requested. However, the information you provide will help the Department of Education’s ongoing efforts to learn more about the educational experiences of children and families. There are no

penalties should you choose not to participate in this study. Your answers may be used only for statistical

purposes and may not be disclosed, or used, in identifiable form for any other purpose except as required

by law (Section 9573, 20 U.S. Code). Your responses will be combined with those from other participants

to produce summary statistics and reports.

This survey is estimated to take an average of 20 minutes, including time for reviewing instructions and

completing and reviewing the collection of information. An agency may not conduct or sponsor, and a

person is not required to respond to, a collection of information unless it displays a currently valid OMB

control number. Send comments regarding this burden estimate or any other aspect of this collection of

information, including suggestions for reducing this burden, to: Andrew Zukerberg, National Center for

Education Statistics, U.S. Department of Education, 1990 K Street NW, Room 9036, Washington, DC

20006-5650. Do not return the completed form to this address.

1 . Childhood Care and Programs

► Thank you for your help with the previous survey your household completed.

► Answer all the survey questions thinking about the child listed below:

► Care Your Child Receives from Relatives

These questions ask about different types of child care this child may now receive on a regular basis from someone other than his/her parents or guardians.

1. Is this child now receiving care from a relative other than a parent or guardian on a regular basis, for example, from grandparents, brothers or sisters, or any other relatives?

N
GO TO question 17
o
Y es

2. Are any of these care arrangements regularly scheduled at least once a week?

N
GO TO question 17
o
Y es

3. These next questions are about the care that this child receives from the relative who provides the most care. How is that relative related to this child?

M ark ONE only.

Grandmother/Grandfather
Aunt /Uncle
Brother /Sister
Another relative

4 . How old is the relative who provides the most care to this child?

Shape26

age

5. Is this care provided in your home or another home?

Own home
Other home
Both

6. How many days each week does this child receive care from this relative?

| Shape27 __| days each week

7. How many hours each week does this child receive care from this relative?

| Shape28 __|__| hours each week

8. How old was this child in years and months when this particular regular care arrangement with this relative began?

| Shape30 Shape29 __ years months

9. What language does this relative speak most when caring for this child?

English
Spanish
A language other than English or Spanish
English and Spanish equally
English and another language equally

1 0. Will this relative care for this child when the child is…

▼

Yes

▼

Sick but does not have a fever?

Shape32

Sick and has a fever?

Shape33

11. Is there any charge or fee for the care this child receives from this relative, paid either by you or some other person or agency?

N
GO TO question 15
o
Y es

12. Do any of the following people, programs, or organizations help pay for this relative to care for this child?

M ark ONE box for each item below.

		No ▼	Yes ▼
a.	A relative of this child outside your household who provides money specifically for that care, not including general child support
b.	Temporary Assistance for Needy Families, or TANF
c.	Another social service, welfare, or child care agency
d.	An employer, not including a tax-free spending account for child care
e.	Someone else

1 3. How much does your household pay for this relative to care for this child, not counting any money that may be received from others to help pay for care?

Write ‘0’ if your household does not pay this relative for care.

Shape44 Shape45 Shape46 Shape47 $ .00

Is that amount per…

Hour
Day
Week
Month
Year
Every 2 weeks
O ther Specify:

14. How many children from your household is this amount for, including this child?

This child only
2 children
3 children
4 children
5 or more children

15. Does this child have any other care arrangements with a relative on a regular basis?

N
GO TO question 17
o
Y es

16. How many total hours each week does this child spend in those other care arrangements with relatives?

| Shape52 __|_ hours each week

► Shape53 Care Your Child Receives from Non-relatives

The next questions ask about any care this child receives from someone not related to him/her, either in your home or someone else’s home. This includes home child care providers or neighbors, but not day care centers or preschools.

17. Is this child now receiving care in your home or another home on a regular basis from someone who is not related to him/her?

N
GO TO question 35
o
Y es

18. Are any of these care arrangements regularly scheduled at least once a week?

N
GO TO question 35
o
Y es

19. These next questions are about the care that this child receives from someone who is not related to him/her who provides the most care.

Is this care provided in your own home or in another home?

Own home
Other home
Both

20. Does this person who cares for this child live in your household?

21. How many days each week does this child receive care from this person?

Shape58 days each week

Shape59

22. How many hours each week does this child receive care from this person?

Shape60 hours each week

23. How old was this child in years and months when this particular regular care arrangement with this person began?

Shape62 Shape61 years months

24. Was this care provider someone you already knew?

25. Is this child’s care provider age 18 or older?

26. What language does this care provider speak most when caring for this child?

English
Spanish
A language other than English or Spanish
English and Spanish equally
English and another language equally

27. Will this care provider care for this child when this child is…

▼

Yes

▼

Sick but does not have a fever?

Shape63

Sick and has a fever?

Shape64

2 8. Would you recommend this care provider to another parent?

29. Is there any charge or fee for the care this child receives from this care provider, paid either by you or some other person or agency?

N
GO TO question 33
o
Y es

30. Do any of the following people, programs, or organizations help pay for this person to care for this child?

M ark ONE box for each item below.

		No ▼	Yes ▼
a.	A relative of this child outside your household who provides money specifically for that care, not including general child support
b.	Temporary Assistance for Needy Families, or TANF
c.	Another social service, welfare, or child care agency
d.	An employer, not including a tax-free spending account for child care
e.	Someone else

Shape74

31. How much does your household pay for this person to care for this child, not counting any money that may be received from others to help pay for care?

Write ‘0’ if your household does not pay this non-relative for care.

$ Shape78 Shape76 Shape75 Shape77 .00

Is that amount per…

Hour
Day
Week
Month
Year
Every 2 weeks
O ther Specify:

32. How many children from your household is this amount for, including this child?

This child only
2 children
3 children
4 children
5 or more children

33. Does this child have any other home-based care arrangements on a regular basis with someone who is not a relative? Do not include arrangements at day care centers or preschools.

N
GO TO question 35
o
Y es

34. How many total hours each week does this child spend in those other care arrangements with non-relatives?

Shape83 hours each week

► Shape84 Day Care Centers and Preschool Programs Your Child Attends

The next questions ask about any day care centers and early childhood programs that this child attends. This does not include care provided in a private home.

35. Is this child now attending a day care center, preschool, or prekindergarten not in a private home?

N
GO TO question 54
o
Y es

36. Does this child go to a day care center, preschool, or prekindergarten, at least once each week?

N
GO TO question 54
o
Y es

37. The next questions ask about the program where this child spends the most time.

Is this child’s current program a day care program, a preschool program, or a prekindergarten program?

Day care
Preschool
Prekindergarten

38. Is this program a Head Start or Early Head Start program?

Head Start and Early Head Start are federally sponsored preschool programs primarily for children from low-income families.

No
Yes
Don’t know

3 9. Where is this program located?

M ark ONE only.

In a church, synagogue, or other place of worship
In a public elementary or secondary school
In a private elementary or secondary school
At a college or university
At a community center
At a public library
In its own building, office space, or storefront
Some other place

S Shape98 Shape91 Shape92 Shape93 Shape94 Shape95 Shape96 Shape97 pecify:

40. Is this program run by a church, synagogue, or other religious group?

41. Is this program located at your workplace or this child’s other parent’s workplace?

42. How many days each week does this child go to this program?

Shape99 days each week

43. How many hours each week does this child go to this program?

Shape100 hours each week

44. How old was this child in years and months when he/she started going to this particular program?

Shape101 Shape102 years months

45. What language does this child’s main care provider or teacher at this program speak most when caring for this child?

E nglish
Spanish
A language other than English or Spanish
English and Spanish equally
English and another language equally

46. Would you recommend this program to another parent?

47. Does this program provide any of the following services to this child or your family?

M ark ONE box for each item below.

		No ▼	Yes ▼
a.	Hearing, speech, or vision testing
b.	Physical examinations
c.	Dental examinations
d.	Formal testing for developmental or learning problems
e.	Sick child care when this child is sick but does not have a fever
f.	Sick child care when this child is sick and has a fever

48. Is there any charge or fee for this program, paid either by you or some other person or agency?

N
GO TO question 52
o
Yes

4 9. Do any of the following people, programs, or organizations help pay for this child to go to this program?

M ark ONE box for each item below.

		No ▼	Yes ▼
a.	A relative of this child outside your household who provides money specifically for that care, not including general child support
b.	Temporary Assistance for Needy Families, or TANF
c.	Another social service, welfare, or child care agency
d.	An employer, not including a tax-free spending account for child care
e.	Someone else

50. How much does your household pay for this child to go to this program, not counting any money that you may receive from others to help pay for care?

Write ‘0’ if your household does not pay for this program.

$ Shape122 Shape121 Shape119 Shape120 .00

Is that amount per…

Hour
Day
Week
Month
Year
Every 2 weeks
O ther Specify:

51. How many children from your household is this amount for, including this child?

T his child only
2 children
3 children
4 children
5 or more children

52. Does this child have any other care arrangements at a day care center or preschool on a regular basis?

N
GO TO question 54
o
Y es

53. How many total hours each week does this child spend at those day care centers or preschools?

Shape128 hours each week

► Continue with section 2.

2 . Finding and Choosing Care for Your Child

54. Has this child ever attended a Head Start or Early Head Start program?

Head Start and Early Head Start are federally sponsored preschool programs primarily for children from low-income families.

No
Yes
Don’t know

55. What is the main reason your household wanted a care program for this child in the past year?

M ark ONE box.

To provide care when a parent was at work or school
To prepare child for school
To provide cultural or language learning
To make time for running errands or relaxing
Some other reason
Did not have care in the past year

5 6. Do you feel there are good choices for child care or early childhood programs where you live?

No
Yes
Don’t know

57. How much difficulty did you have finding the type of child care or early childhood program you wanted for this child?

H
GO TO question 59
ave not tried

to find care

Did not find the child care program you wanted
A lot of difficulty
Some difficulty
A little difficulty
No difficulty

58. How important was each of these reasons when you chose the child care arrangement or program where this child spends the most time?

a. The location of the arrangement?

Not at all important
A little important
Somewhat important
Very important

b. The cost of the arrangement?

Not at all important
A little important
Somewhat important
Very important

c. The reliability of the arrangement?

N ot at all important
A little important
Somewhat important
Very important

d. The learning activities at the arrangement?

Not at all important
A little important
Somewhat important
Very important

e. The child spending time with other kids his/her age?

Not at all important
A little important
Somewhat important
Very important

f. The times during the day that this caregiver is able to provide care?

Not at all important
A little important
Somewhat important
Very important

g. The number of other children in the child’s care group?

Not at all important
A little important
Somewhat important
Very important

► Continue with section 3, question 59 on the next page.

3. Family Activities

The next questions ask about this child’s activities with family members in the past week

or month.

59. About how many books does this child have of his/her own, including those shared with brothers or sisters?

Shape136 Shape135 Shape134 number of books

60. How many times have you or someone in your family read to this child in the past week?

N
GO TO question 62
ot at all
times

61. About how many minutes on each of those times did you or someone in your family read to this child?

Shape139 minutes

62. In the past week, how many times has anyone in your family done the following things with this child?

a. Told this child a story? (Do not include reading to this child.)

Not at all
1 or 2 times
3 or more times

b. Taught this child letters, words, or numbers?

Not at all
1 or 2 times
3 or more times

Shape141 Shape140

c. Sang songs with this child?

Not at all
1 or 2 times
3 or more times

d. Worked on arts and crafts with this child?

Not at all
1 or 2 times
3 or more times

63. In the past month, have you or someone in your family visited a library with this child?

64. In the past month, have you or someone in your family visited a bookstore with this child?

65. In the past week, how many days has your family eaten the evening meal together?

Write ‘0’ if none.

days

► Continue with section 4 on the next page.

Shape143

4. Things Your Child May be Learning

These next questions ask about things that different children do at different ages. These things may or may not be true for this child.

66. Is this child under 2 years old or is he/she 2 years old or older?

U
GO TO question 74
nder 2 years
2 years or older

67. Can this child identify the colors red, yellow, blue, and green by name?

No
Yes, some of them
Yes, all of them

68. Can this child recognize the letters of the alphabet?

No
Yes, some of them
Yes, most of them
Yes, all of them

69. How high can this child count?

This child cannot count
Up to 5
Up to 10
Up to 20
Up to 50
Up to 100 or more

70. Can this child write his/her first name, even if some of the letters are backwards?

Shape146

71. Does this child ever read or pretend to read storybooks on his/her own?

N
GO TO question 74
o
Y es

72. Does this child actually read the words written in the book, or does he/she look at the book and pretend to read?

P retends to read
A
GO TO question 74
ctually reads the written

words

Does both

73. When this child pretends to read a book, does it sound like a connected story, or does he/she tell what is in each picture without much connection between them?

Sounds like connected story
Tells what’s in each picture
Does both
Does neither

► Continue with section 5, question 74 on the next page.

5 . This Child’s Health

74. In general, how would you describe this child’s health?

Excellent
Very good
Good
Fair
Poor

75. Has a health, education, or early intervention professional told you that this child has any of the following conditions?

M ark ONE box for each item below.

		No ▼	Yes ▼
a.	A specific learning disability
b.	An intellectual disability (mental retardation)
c.	A speech or language impairment
d.	A serious emotional disturbance
e.	Deafness or another hearing impairment
f.	Blindness or another visual impairment not corrected with glasses
g.	An orthopedic impairment
h.	Autism
i.	Pervasive Developmental Disorder (PDD)
j.	Attention Deficit Disorder, ADD or ADHD
k.	A developmental delay
l.	Traumatic brain injury
m.	Another health impairment lasting 6 months or more

Shape168

76. (If child is under 3 years old) Has a health, education, or early intervention professional told you this child is “at-risk” for a substantial developmental delay?

No
Yes
Child is age 3 or older

77. Did you mark yes to any condition in question 75 or question 76?

N
GO TO question 85
o
Y es

78. Is this child receiving services for his/her condition?

N
GO TO question 83
o
Y es

79. Are these services provided by any of the following sources?

M ark ONE box for each item below.

		No ▼	Yes ▼
a.	Your local school district
b.	A state or local health or social service agency
c.	A doctor, clinic, or other health care provider

8 0. Are any of these services provided through an Individualized Family Service Plan (IFSP) or an Individualized Educational Program (IEP)?

N
GO TO question 83
o
Y es

81. Did any adult in your household work with the service provider or school to develop or change this child’s IFSP or IEP?

82. Since September, how satisfied or dissatisfied have you been with the following aspects of this child’s IFSP or IEP?

a. The service provider’s or school’s communication with your family?

Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Does not apply

b. The child’s special needs teacher or therapist?

Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Does not apply

c. The service provider’s or school’s ability to accommodate the child’s special needs?

Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Does not apply

d. The service provider’s or school’s commitment to help your child learn?

Very satisfied
S omewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Does not apply

83 Is this child currently enrolled in any special education classes or services?

84. Does this child’s condition interfere with his/her ability to do any of the following things?

M ark ONE box for each item below.

Child no longer has condition

		No ▼	Yes ▼
a.	Learn................................... ….
b.	Participate in play with other children.....................................
c.	Go on outings...........................
d.	Make friends.............................

► Continue with section 6, question 85 on the next page.

6 . Child’s Background

85. In what month and year was this child born?

Shape190 Shape191 Shape192 Shape193

month year

86. Where was this child born?

O ne of the 50 United States or the District of Columbia

Shape195

GO TO question 88

One of the U.S. territories

(Puerto Rico, Guam, American Samoa, U.S. Virgin Islands, or Mariana Islands)

Another country

87. How old was this child when he/she first moved to the 50 United States or the District of Columbia?

Shape196

age

88. Is this child of Spanish, Hispanic, or Latino origin?

89. What is this child’s race? You may mark one or more races.

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White

{89B. What is this child’s sex? [variable print – no sex on screener]

Male
F emale}

90. Since September, has this child usually lived at this address or another address (for example, because of a joint custody arrangement)?

Do not include vacation properties.

Child usually lived at this address
Child usually lived at another address

91. What language does this child speak most at home?

Shape198 Mark ONE only.

C
GO TO Section 7
hild has not

started to speak

English
Spanish
A language other than English or Spanish
English and Spanish equally
English and another language equally

92 Is this child currently enrolled in English as a second language, bilingual education, or an English immersion program?

► Continue with section 7 on the next page.

. Child’s Family

PARENT 1 LIVING IN HOUSEHOLD

Answer questions 93 to 109 about yourself if you are the child’s parent or guardian.

If you are not the child’s parent or guardian, answer questions 93 to 109 about one of this child’s parents or guardians living in the household.

93. Is this parent or guardian the child’s…

Biological parent
Adoptive parent
Stepparent
Foster parent
Grandparent
Other guardian

94. Is this person male or female?

Male
Female

95. What is the current marital or partner status of this parent or guardian?

M ark ONE only.

Married
In a registered domestic partnership or civil union
Living with a partner
Separated
Divorced
Widowed
Never married

9 6. What was the first language this parent or guardian learned to speak?

M ark ONE only.

E
GO TO question 98
nglish
Spanish
A language other than English or Spanish
English and Spanish equally
English and another language equally

97. What language does this person speak most at home now?

M ark ONE only.

English
Spanish
A language other than English or Spanish
English and Spanish equally
English and another language equally

98. Where was this parent or guardian born?

O
GO TO question 100
ne of the 50 United States or the District of Columbia

Shape207

One of the U.S. territories

(Puerto Rico, Guam, American Samoa, U.S. Virgin Islands, or Mariana Islands)

Another country

99. How old was this person when he or she first moved to the 50 United States or the District of Columbia?

Shape208

age

100. Is this person of Spanish, Hispanic, or Latino origin?

101. What is this person’s race? You may mark one or more races.

American Indian or Alaska Native
A sian
Black or African American
Native Hawaiian or other Pacific Islander
White

102. What is the highest grade or level of school that this parent or guardian completed?

M ark ONE only.

8^th grade or less
High school, but no diploma
High school diploma or equivalent (GED)
Vocational diploma after high school
Some college, but no degree
Associate’s degree (AA, AS)
Bachelor’s degree (BA, BS)
Some graduate or professional education, but no degree
Master’s degree (MA, MS)
Doctorate degree (PhD, EdD)
Professional degree beyond bachelor’s degree (MD, DDS, JD, LLB)

103. Is he or she currently attending or enrolled in a school, college, university, or adult learning center, or receiving vocational education or job training?

Shape211

104. Which of the following best describes this person’s employment status?

M ark ONE only.

Employed for pay or income
Self-employed
U
GO TO question 106
nemployed or

o Shape213 ut of work

F ull-time student
Stay at home

GO TO question 107

arent

Retired
Disabled or

unable to work

105. (If employed or self-employed) About how many hours per week does he or she usually work for pay or income, counting all jobs?

Shape216

GO TO question 107

hours

106. (If unemployed or out of work) Has this parent or guardian been actively looking for work in the past 4 weeks?

107. In the past 12 months, how many months (if any) has this person worked for pay or income?

Shape217

months

108. How old is this person?

Shape218

age

109. How old was this person when he or she first became a parent to any child?

Shape219

age

Don’t know

Shape220

PARENT 2 LIVING IN HOUSEHOLD

Answer questions 110 to 127 about a second parent or guardian living in the household.

110. Is there a second parent or guardian living in this household?

N
GO TO question 128
o
Y es

111. Is this person the child’s…

Biological parent
Adoptive parent
Stepparent
Foster parent
Grandparent
Other guardian

112. Is this person male or female?

Male
Female

113.What is the current marital or partner status of this parent or guardian?

M ark ONE only.

Married
In a registered domestic partnership or civil union
Living with a partner
Separated
Divorced
Widowed
Never married

1 14. What was the first language this parent or guardian learned to speak?

M ark ONE only.

E
GO TO question 116
nglish
Spanish
A language other than English or Spanish
English and Spanish equally
English and another language equally

115.What language does this person speak most at home now?

M ark ONE only.

English
Spanish
A language other than English or Spanish
English and Spanish equally
English and another language equally

116. Where was this parent or guardian born?

O
GO TO question 118
ne of the 50 United States or the District of Columbia

Shape230

One of the U.S. territories

(Puerto Rico, Guam, American Samoa, U.S. Virgin Islands, or Mariana Islands)

Another country

117. How old was this person when he or she first moved to the 50 United States or the District of Columbia?

Shape231

age

118. Is this person of Spanish, Hispanic, or Latino origin?

1 19. What is this person’s race? You may mark one or more races.

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White

120. What is the highest grade or level of school that this parent or guardian completed?

Mark [X] ONE only.

8^th grade or less
High school, but no diploma
High school diploma or equivalent (GED)
Vocational diploma after high school
Some college, but no degree
Associate’s degree (AA, AS)
Bachelor’s degree (BA, BS)
Some graduate or professional education, but no degree
Master’s degree (MA, MS)
Doctorate degree (PhD, EdD)
Professional degree beyond bachelor’s degree (MD, DDS, JD, LLB)

121. Is he or she currently attending or enrolled in a school, college, university, or adult learning center, or receiving vocational education or job training?

1 22. Which of the following best describes this person’s employment status?

M ark ONE only.

Employed for pay or income
Self-employed
U
GO TO question 124
nemployed or

o Shape235 ut of work

F ull-time student
Stay at home

GO TO question 125

arent

Retired
Disabled or

unable to work

123. (If employed or self-employed) About how many hours per week does he or she usually work for pay or income, counting all jobs?

Shape237

GO TO question 125

hours

124. (If unemployed or out of work) Has this parent or guardian been actively looking for work in the past 4 weeks?

125. In the past 12 months, how many months (if any) has this person worked for pay or income?

Shape239

months

126. How old is this person?

Shape240

age

127. How old was this person when he or she first became a parent to any child?

Shape241

age

Don’t know

8. Your Household

128. Including yourself, how many total people live in this household?

Shape242

people

129. Other than the parents or guardians already reported, how many of the following people live in the household with this child?

Example:

Brother(s)

Write ‘0’ if none.

This child’s….	Number
Brother(s)…………...
Sister(s)……………..
Aunt(s)………………
Uncle(s)……………..
Grandmother(s)…….
Grandfather(s)……..
Cousin(s)……………
Parent’s girlfriend/ boyfriend/ partner….
Other relative(s)……
Other non-relative(s)

Shape253 Shape254

130. How are you related to this child?

M ark ONE only.

Mother (birth, adoptive, step, or foster)
Father (birth, adoptive, step, or foster)
Aunt
Uncle
Grandmother
Grandfather
Parent’s girlfriend/ boyfriend/ partner
O ther relationship – Specify:

Shape257

131. Which language(s) are spoken at home by the adults in this household?

M ark all that apply.

English
Spanish or Spanish Creole
French (including Patois, Creole, Cajun)
Chinese
O ther languages – Specify:

Shape260

► Continue with question 132 on the next page.

1 32. In the past 12 months, did your family ever receive benefits from any of the following programs?

M ark ONE box for each item below. Shape264

		No ▼	Yes ▼
a.	Temporary Assistance for Needy Families, or TANF
b.	Your state welfare or family assistance program
c.	Women, Infants, and Children, or WIC
d.	Food Stamps
e.	Medicaid
f.	Child Health Insurance Program (CHIP)
g.	Section 8 housing assistance

133. Which category best fits the total income of all persons in your household over the past 12 months?

Include your own income.

Include money from jobs or other earnings, pensions, interest, rent, Social Security payments, and so on.

$0 to $10,000
$10,001 to $20,000
$20,001 to $30,000
$30,001 to $40,000
$40,001 to $50,000
$50,001 to $60,000
$60,001 to $75,000
$75,001 to $100,000
$100,001 to $150,000
$150,001 or more

Shape272

134. How many years have you lived at this address?

Write ‘0’ if less than 1 year.

Shape273 years at this address

135. Is this house…

Shape274 Mark ONE only.

Owned or being bought by someone in this household,
Rented by someone in this household, or
Occupied by some other arrangement?

136. Other than this address, does anyone in this household currently receive mail at another address including P.O. Boxes?

137. Do you have access to the internet at this address?

138. Is there at least one telephone inside this home that is currently working and not a cell phone?

139. Do you have a working cell phone?

Thank you.

Please return this questionnaire in the postage-paid envelope provided. If you have lost the envelope, mail the completed questionnaire to:

National Household Education Survey

[RETURN ADDRESS HERE]

Commonly Asked Questions

Q: How did you get my address?

A: Your address was randomly selected from among all of the home addresses in the nation. It was selected using scientific sampling methods to represent other households in the United States.

Q: How did you get my child’s name and age?

A: When you returned the initial National Household Education Survey to us, we randomly chose one child to ask additional questions about. We are interested in understanding your child’s experiences with care and early education.

Q: Why should I take part in this study? Do I have to do this?

A: You represent thousands of other households like yours, and you cannot be replaced. Your answers and opinions are very important to the success of this study. You may choose not to answer any or all questions in this survey. In order for the survey to be representative, it is important that you complete and return this questionnaire. Those who do not return the survey will not be represented in key statistics used by policymakers and researchers.

Q: How will the information I provide be used? Will my privacy be protected?

Q: I have more than one child in my household. Will I receive additional surveys for the other children in my household?

A: No, each household will receive a survey for only one child, even if there are multiple children living in the household. In households with multiple children, one child was randomly selected to be included in the study.

Q: How will my response help the Department of Education?

A: The Department of Education wants to understand the care and early education of children. This survey is the only way that the Department of Education can learn about the types of care and early learning activities children receive. Your responses will be combined with those from other households to inform educators, policymakers, schools, and universities about changes in the condition of education in the United States. Reports from past surveys can be found at www.nces.ed.gov/nhes.

Q: Who is sponsoring the study? Is this study conducted by the Federal Government?

A: The National Center for Education Statistics, within the Department of Education, is authorized to conduct this study (Section 9543, 20 U.S. Code). This study has been approved by the Office of Management and Budget, the office that reviews all federally sponsored surveys. The approval number assigned to this study is XXXX-XXXX. You may send any comments about this survey, including its length, to the Federal Government. Write to: Andrew Zukerberg, National Center for Education Statistics, U.S. Department of Education, 1990 K Street NW, Room 9036, Washington, DC 20006-5650. You may send e-mail to XXX. If you have any questions about the study, contact XXX toll-free at 1-xxx-xxx-xxxx.

ECPP Short form for 4th Mailing

The National Household Education Survey

Our Children’s Future: A Survey of Young Children’s Care and Education

Thank you for helping us with this survey. Based on the information we received from your household in your last survey, we’re asking you to complete this final step.

U.S. Department of Education

National Center for Education Statistics

ponsored by

Instructions

In response to the survey you answered earlier, we recorded that the child/youth listed below has not yet started kindergarten. If this child is attending public or private school or is homeschooled for kindergarten through 12^th grade or equivalent, please call us at the toll-free number below so we can be sure you received the correct survey.

These questions should be filled in by a parent or guardian who knows about:

Please answer all the survey questions thinking about this child or youth.

To answer a question, simply mark  the box that best represents your answer.

Please use a black or blue pen, if available, to complete this survey.

If this questionnaire has been sent to the wrong household or the child/youth listed above does not live here, please call to let us know.

Our toll-free number is 1-888-880-3033.

We are authorized to collect this information by Section 9543, 20 U.S. Code. You do not have to provide

penalties should you choose not to participate in this study. Your answers may be used only for statistical

purposes and may not be disclosed, or used, in identifiable form for any other purpose except as required

by law (Section 9573, 20 U.S. Code). Your responses will be combined with those from other participants

to produce summary statistics and reports.

This survey is estimated to take an average of 10 minutes, including time for reviewing instructions and

completing and reviewing the collection of information. An agency may not conduct or sponsor, and a

person is not required to respond to, a collection of information unless it displays a currently valid OMB

control number. Send comments regarding this burden estimate or any other aspect of this collection of

information, including suggestions for reducing this burden, to: Andrew Zukerberg, National Center for

Education Statistics, U.S. Department of Education, 1990 K Street NW, Room 9036, Washington, DC

20006-5650. Do not return the completed form to this address.

1 . Childhood Care and Programs

► Thank you for your help with the previous survey your household completed.

► Answer all the survey questions thinking about the child listed below:

This page asks about different types of child care this child may now receive on a regular basis.

Relative care is care a child receives from someone other than his/her parents or guardians.
Non-relative care is care the child receives from someone not related to him/her, either in your home or someone else’s home. This includes home child care providers or neighbors, but not day care centers or preschools.
Day care center, preschool, or prekindergarten care refers to care centers and early childhood programs that this child attends. This does not include care provided in a private home.

1. Is this child now receiving care from a relative other than a parent or guardian on a regular basis, for example, from grandparents, brothers or sisters, or any other relatives?

2. (If child cared for by relative) Are any of these care arrangements regularly scheduled at least once a week?

No
Yes
Not applicable

1 7. Is this child now receiving care in your home or another home on a regular basis from someone who is not related to him/her?

18. (If child cared for by non-relative) Are any of these care arrangements regularly scheduled at least once a week?

No
Yes
Not applicable

35. Is this child now attending a day care center, preschool, or prekindergarten not in a private home?

N
GO TO SECTION X
o
Y es

36. Does this child go to a day care center, preschool, or prekindergarten, at least once each week?

N
GO TO SECTION X
o
Y
GO TO Question 37
es

37. The next questions ask about the program where this child spends the most time.

Is this child’s current program a day care program, a preschool program, or a prekindergarten program?

Day care
Preschool
Prekindergarten

38. Is this program a Head Start or Early Head Start program?

Head Start and Early Head Start are federally sponsored preschool programs primarily for children from low-income families.

No
Yes
Don’t know

3 9. Where is this program located?

M ark ONE only.

In a church, synagogue, or other place of worship
In a public elementary or secondary school
In a private elementary or secondary school
At a college or university
At a community center
At a public library
In its own building, office space, or storefront
Some other place

S Shape291 Shape284 Shape285 Shape286 Shape287 Shape288 Shape289 Shape290 pecify:

40. Is this program run by a church, synagogue, or other religious group?

41. Is this program located at your workplace or this child’s other parent’s workplace?

42. How many days each week does this child go to this program?

Shape292 days each week

43. How many hours each week does this child go to this program?

Shape293 hours each week

44. How old was this child in years and months when he/she started going to this particular program?

Shape294 Shape295 years months

45. What language does this child’s main care provider or teacher at this program speak most when caring for this child?

E nglish
Spanish
A language other than English or Spanish
English and Spanish equally
English and another language equally

47. Does this program provide any of the following services to this child or your family?

M ark ONE box for each item below.

		No ▼	Yes ▼
a.	Hearing, speech, or vision testing
b.	Physical examinations
c.	Dental examinations
d.	Formal testing for developmental or learning problems
e.	Sick child care when this child is sick but does not have a fever
f.	Sick child care when this child is sick and has a fever

48. Is there any charge or fee for this program, paid either by you or some other person or agency?

N
GO TO question 52
o
Y es

49. Do any of the following people, programs, or organizations help pay for this child to go to this program?

M ark ONE box for each item below.

		No ▼	Yes ▼
a.	A relative of this child outside your household who provides money specifically for that care, not including general child support
b.	Temporary Assistance for Needy Families, or TANF
c.	Another social service, welfare, or child care agency
d.	An employer, not including a tax-free spending account for child care
e.	Someone else

50. How much does your household pay for this child to go to this program, not counting any money that you may receive from others to help pay for care?

Write ‘0’ if your household does not pay for this program or care provider.

$ Shape315 Shape314 Shape312 Shape313 .00

Is that amount per…

Hour
Day
Week
Month
Year
Every 2 weeks
O ther Specify:

51. How many children from your household is this amount for, including this child?

T his child only
2 children
3 children
4 children
5 or more children

Shape319

3. Family Activities

The next questions ask about this child’s activities with family members in the past week

or month.

59. About how many books does this child have of his/her own, including those shared with brothers or sisters?

Shape322 Shape321 Shape320 number of books

60. How many times have you or someone in your family read to this child in the past week?

N
GO TO question 62
ot at all
times

61. About how many minutes on each of those times did you or someone in your family read to this child?

Shape325 minutes

62. In the past week, how many times has anyone in your family done the following things with this child?

a. Told this child a story? (Do not include reading to this child.)

Not at all
1 or 2 times
3 or more times

b. Taught this child letters, words, or numbers?

Not at all
1 or 2 times
3 or more times

c. Sang songs with this child?

N ot at all
1 or 2 times
3 or more times

d. Worked on arts and crafts with this child?

Not at all
1 or 2 times
3 or more times

63. In the past month, have you or someone in your family visited a library with this child?

64. In the past month, have you or someone in your family visited a bookstore with this child?

65. In the past week, how many days has your family eaten the evening meal together?

Write ‘0’ if none.

days

4 . Things Your Child May be Learning

These next questions ask about things that different children do at different ages. These things may or may not be true for this child.

66. Is this child under 2 years old or is he/she 2 years old or older?

U
GO TO question 74
nder 2 years
2 years or older

67. Can this child identify the colors red, yellow, blue, and green by name?

No
Yes, some of them
Yes, all of them

68. Can this child recognize the letters of the alphabet?

No
Yes, some of them
Yes, most of them
Yes, all of them

69. How high can this child count?

This child cannot count
Up to 5
Up to 10
Up to 20
Up to 50
Up to 100 or more

70. Can this child write his/her first name, even if some of the letters are backwards?

71. Does this child ever read or pretend to read storybooks on his/her own?

N
GO TO question 74
o
Y es

72. Does this child actually read the words written in the book, or does he/she look at the book and pretend to read?

P retends to read
A
GO TO question 74
ctually reads the written

words

Does both

73. When this child pretends to read a book, does it sound like a connected story, or does he/she tell what is in each picture without much connection between them?

Sounds like connected story
Tells what’s in each picture
Does both
Does neither

Shape337

5. This Child’s Health

74. In general, how would you describe this child’s health?

Excellent
Very good
Good
Fair
Poor

75. Has a health, education, or early intervention professional told you that this child has any of the following conditions?

M ark ONE box for each item below.

		No ▼	Yes ▼
a.	A specific learning disability
b.	An intellectual disability (mental retardation)
c.	A speech or language impairment
d.	A serious emotional disturbance
e.	Deafness or another hearing impairment
f.	Blindness or another visual impairment not corrected with glasses
g.	An orthopedic impairment
h.	Autism
i.	Pervasive Developmental Disorder (PDD)
j.	Attention Deficit Disorder, ADD or ADHD
k.	A developmental delay
l.	Traumatic brain injury
m.	Another health impairment lasting 6 months or more

76. (If child is under 3 years old) Has a health, education, or early intervention professional told you this child is “at-risk” for a substantial developmental delay?

N o
Yes
Child is age 3 or older

6 . Child’s Background

85. In what month and year was this child born?

Shape355 Shape356 Shape357 Shape358

month year

86. Where was this child born?

O ne of the 50 United States or the District of Columbia

Shape360

GO TO question 88

One of the U.S. territories

(Puerto Rico, Guam, American Samoa, U.S. Virgin Islands, or Mariana Islands)

Another country

87. How old was this child when he/she first moved to the 50 United States or the District of Columbia?

Shape361

age

88. Is this child of Spanish, Hispanic, or Latino origin?

89. What is this child’s race? You may mark one or more races.

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White

90.Since September, has this child usually lived at this address or another address (for example, because of a joint custody arrangement)?

o not include vacation properties.

Child usually lived at this address
Child usually lived at another address

91. What language does this child speak most at home?

Shape362 Mark ONE only.

C
GO TO Section 7
hild has not

started to speak

English
Spanish
A language other than English or Spanish
English and Spanish equally
English and another language equally

92 Is this child currently enrolled in English as a second language, bilingual education, or an English immersion program?

7. Child’s Family

PARENT 1 LIVING IN HOUSEHOLD

Answer questions 93 to 109 about yourself if you are the child’s parent or guardian.

If you are not the child’s parent or guardian, answer questions 93 to 109 about one of this child’s parents or guardians living in the household.

93. Is this parent or guardian the child’s…

Biological parent
Adoptive parent
Stepparent
Foster parent
Grandparent
Other guardian

94. Is this person male or female?

Male
Female

95. What is the current marital or partner status of this parent or guardian?

M ark ONE only.

Married
In a registered domestic partnership or civil union
Living with a partner
Separated
Divorced
Widowed
Never married

Shape365

97. What language does this person speak most at home now?

M ark ONE only.

English
Spanish
A language other than English or Spanish
English and Spanish equally
English and another language equally

100. Is this person of Spanish, Hispanic, or Latino origin?

101. What is this person’s race? You may mark one or more races.

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White

102. What is the highest grade or level of school that this parent or guardian completed?

M ark ONE only.

8^th grade or less
High school, but no diploma
High school diploma or equivalent (GED)
Vocational diploma after high school
Some college, but no degree
Associate’s degree (AA, AS)
Bachelor’s degree (BA, BS)
S ome graduate or professional education, but no degree
Master’s degree (MA, MS)
Doctorate degree (PhD, EdD)
Professional degree beyond bachelor’s degree (MD, DDS, JD, LLB)

104.Which of the following best describes this person’s employment status?

M ark ONE only.

Employed for pay or income
Self-employed
Unemployed or

out of work

Full-time student
Stay at home

parent

Retired
Disabled or

unable to work

110. Is there a second parent or guardian living in this household?

8. Your Household

128. Including yourself, how many total people live in this household?

Shape371

people

129. Other than the parents or guardians already reported, how many of the following people live in the household with this child?

Example:

Brother(s)

Write ‘0’ if none.

This child’s….	Number
Brother(s)…………...
Sister(s)……………..
Aunt(s)………………
Uncle(s)……………..
Grandmother(s)…….
Grandfather(s)……..
Cousin(s)……………
Parent’s girlfriend/ boyfriend/ partner….
Other relative(s)……
Other non-relative(s)

1 30. How are you related to this child?

M ark ONE only.

Mother (birth, adoptive, step, or foster)
Father (birth, adoptive, step, or foster)
Aunt
Uncle
Grandmother
Grandfather
Parent’s girlfriend/ boyfriend/ partner
O ther relationship – Specify:

Shape385

131. Which language(s) are spoken at home by the adults in this household?

M ark all that apply.

English
Spanish or Spanish Creole
French (including Patois, Creole, Cajun)
Chinese
O ther languages – Specify:

Shape388

132. In the past 12 months, did your family ever receive benefits from any of the following programs?

M ark ONE box for each item below. Shape392

		No ▼	Yes ▼
a.	Temporary Assistance for Needy Families, or TANF
b.	Your state welfare or family assistance program
c.	Women, Infants, and Children, or WIC
d.	Food Stamps
e.	Medicaid
f.	Child Health Insurance Program (CHIP)
g.	Section 8 housing assistance

133. Which category best fits the total income of all persons in your household over the past 12 months?

Include your own income.

Include money from jobs or other earnings, pensions, interest, rent, Social Security payments, and so on.

$0 to $10,000
$10,001 to $20,000
$20,001 to $30,000
$30,001 to $40,000
$40,001 to $50,000
$50,001 to $60,000
$60,001 to $75,000
$75,001 to $100,000
$100,001 to $150,000
$150,001 or more

134. How many years have you lived at this address?

W rite ‘0’ if less than 1 year.

years at this address

Shape401

135. Is this house…

Shape402 Mark ONE only.

Owned or being bought by someone in this household,
Rented by someone in this household, or
Occupied by some other arrangement?

136. Other than this address, does anyone in this household currently receive mail at another address including P.O. Boxes?

137. Do you have access to the internet at this address?

138. Is there at least one telephone inside this home that is currently working and not a cell phone?

139. Do you have a working cell phone?

Shape403

Thank you.

Please return this questionnaire in the postage-paid envelope provided. If you have lost the envelope, mail the completed questionnaire to:

National Household Education Survey

[RETURN ADDRESS HERE]

Commonly Asked Questions

Q: How did you get my address?

A: Your address was randomly selected from among all of the home addresses in the nation. It was selected using scientific sampling methods to represent other households in the United States.

Q: How did you get my child’s name and age?

Q: Why should I take part in this study? Do I have to do this?

Q: How will the information I provide be used? Will my privacy be protected?

Q: I have more than one child in my household. Will I receive additional surveys for the other children in my household?

Q: How will my response help the Department of Education?

Q: Who is sponsoring the study? Is this study conducted by the Federal Government?

PFI Enrolled Questionnaire

OMB No. XXXX-XXXX Approval Expires XX/XX/XXXX

The National Household Education Survey

A Survey about Students’ and Families’ Experience with Their Schools

Thank you for helping us with this survey. Based on the information we received from your household in your last survey, we’re asking you to complete this final step.

U.S. Department of Education

National Center for Education Statistics

ponsored by

Instructions

In response to the survey you answered earlier, we recorded that the child/youth listed below attends school. If this child is homeschooled instead of attending public or private school, or if this child has not yet started kindergarten, please call us at the toll-free number below so we can be sure you received the correct survey.

These questions should be filled in by a parent or guardian who knows about:

Please answer all the survey questions thinking about this child or youth.

To answer a question, simply mark  the box that best represents your answer.

Please use a black or blue pen, if available, to complete this survey.

If this questionnaire has been sent to the wrong household or the child/youth listed above does not live here, please call to let us know.

Our toll-free number is 1-888-880-3033.

We are authorized to collect this information by Section 9543, 20 U.S. Code. You do not have to provide the information requested. However, the information you provide will help the Department of Education’s ongoing efforts to learn more about the educational experiences of children and families. There are no penalties should you choose not to participate in this study. Your answers may be used only for statistical purposes and may not be disclosed, or used, in identifiable form for any other purpose except as required by law (Section 9573, 20 U.S. Code). Your responses will be combined with those from other participants to produce summary statistics and reports.

This survey is estimated to take an average of 20 minutes, including time for reviewing instructions, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Andrew Zukerberg, National Center for Education Statistics, U.S. Department of Education, 1990 K Street NW, Room 9036, Washington, DC 20006-5650. Do not return the completed form to this address.

1 . Child’s Schooling

► Thank you for your help with the previous survey your household completed.

► Answer all the survey questions thinking about the child listed below:

1. This child’s grade is shown above. Please confirm this child’s grade by marking the grade or year of school this child is attending.

Alt. What is this child’s current grade or year of school? [variable print-no screener grade]

If this child is not assigned a specific grade, mark or write the grade he/she would be in at a school with regular grades.

Child has not yet started kindergarten

Shape405

Please STOP now and call 1-XXX-XXX-XXXX so we can verify that you received the correct survey.

Full-day kindergarten
Partial-day kindergarten

Shape406

grade (1 through 12)

2. Is this child being schooled at home instead of at school for some classes or subjects?

3. What type of school does this child attend?

P rivate, Catholic
P
GO TO question 6 66
rivate, religious

but not Catholic

Private, not religious
P ublic school

4. Is it his/her regularly assigned school?

5. Is this school a charter school?

6 . Did you move to your current neighborhood so that this child could attend his/her current school?

7. Does your public school district let you choose which public school you want this child to attend?

This may include applying to a magnet program in a public school, transferring to another public school within the district, or transferring to a public school outside of the district.

No
Yes
Don’t know

8. Did you consider other schools for this child?

N
GO TO question 11
o
Y es

9. In deciding between schools, did you seek information on the performance of the schools you were considering, like test scores, dropout rates, and so on?

10. Is the school this child attends your first choice, that is, the school you wanted most for him/her to attend?

11. Since the beginning of this school year, has this child been in the same school?

12. In which month did this child start at his/her current school?

Shape412 month (1 through 12)

1 3. How much do you agree or disagree with the following statement:

“This child enjoys school.”

Strongly agree
Agree
Disagree
Strongly disagree

14. Please tell us about this child’s grades during this school year. Overall, across all subjects, what grades does this child get?

Mostly A’s
Mostly B’s
Mostly C’s
Mostly D’s and lower
This child’s school does not give these grades

15. Is he/she currently enrolled in advanced placement classes?

No
Yes
Does not apply

16. Since the beginning of this school year, how many times have any of this child’s teachers or school staff contacted your household about…

Write ‘0’ if none.

Number

a.	Behavior problems this child is having in school
b.	Problems this child is having with school work
c.	Very good behavior
d.	Very good school work

Shape418

17. Since the beginning of this school year, how many days has this child been absent from school?

days

18. Since starting kindergarten, has this child repeated any grades?

N
GO TO question 20
o
Y es

19. What grade or grades did he/she repeat?

Shape422 Mark all that apply.

Elementary through Middle school

Kindergarten
First grade
Second grade
Third grade
Fourth grade
Fifth grade
Sixth grade
Seventh grade
Eighth grade

High school

Ninth grade - freshman
Tenth grade - sophomore
Eleventh grade - junior
Twelfth grade - senior

20. Has this child ever had the following experiences?

ark ONE box for each item below.

		No ▼	Yes ▼
a.	An out-of-school suspension
b.	An in-school suspension not counting detentions
c.	Been expelled from school

21. How far do you expect this child to go in his/her education?

Shape430 Mark ONE only.

Complete less than a high school diploma
Graduate from high school
Attend a vocational or technical school after high school
Attend two or more years of college
Earn a bachelor’s degree
Earn a graduate degree or professional degree beyond a bachelor's

22. How would you describe his/her work at school?

Shape431 Mark ONE only.

Excellent
Above average
Average
Below average
Failing

Shape432

23. Some students take school-related courses over the internet. Is this child receiving any instruction this way?

N
GO TO question 26
o
Y es

24. Is that instruction provided by any of the following places?

M ark all that apply.

Your local public school
A charter school
Another public school
A private school
A college, community college, or university
S omeplace else—Specify:

25. Is there a charge or fee for that instruction?

► Continue with section 2, question 26.

2. Families & School

26. Since the beginning of this school year, has any adult in this child’s household done any of the following things at this child’s school?

Mark [X] ONE box for each item below.

		No ▼	Yes ▼
a.	Attended a school or class event, such as a play, dance, sports event, or science fair…	□	□
b.	Served as a volunteer in this child’s classroom or elsewhere in the school………	□	□
c.	Attended a general school meeting, for example, an open house, or a back-to-school night.	□	□
d.	Attended a meeting of the parent-teacher organization or association.	□	□
e.	Gone to a regularly scheduled parent-teacher conference with this child’s teacher.	□	□
f.	Participated in fundraising for the school.	□	□
g.	Served on a school committee…………………….	□	□
h.	Met with a guidance counselor in person.	□	□

27. During this school year, how many times has any adult in the household gone to meetings or participated in activities at this child’s school?

Shape438 number of times

Shape439

28. During this school year, has your family received any of the following:

a. Notes or emails specifically about this child from his/her teachers or school administrators?

b. Newsletters, memos, emails, or notices addressed to all parents?

c. Phone calls specifically about this child from his/her teachers or school administrators?

29. How well has this child’s school been doing the following things during this school year?

a. Letting you know how this child is doing in school between report cards.

Very well
Just okay
Not very well
Does not do it at all

b. Providing information about how to help this child with homework.

Very well
Just okay
Not very well
Does not do it at all

c. Providing information about why this child is placed in particular groups or classes.

V ery well
Just okay
Not very well
Does not do it at all

d. Providing information on your expected role at this child’s school.

Very well
Just okay
Not very well
Does not do it at all

e. Providing information on how to help this child plan for college or vocational school.

Very well
Just okay
Not very well
Does not do it at all
Does not apply

3 0. How satisfied or dissatisfied are you with each of the following:

a. The school this child attends this year?

Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied

b. The teachers this child has this year?

Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied

c. The academic standards of the school?

Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied

d. The order and discipline at the school?

Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied

e. The way that school staff interacts with parents?

Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied

Shape442

3. Homework

31. How often does this child do homework at home, at an after-school program, or somewhere else outside of school?

Less than once a week
1 to 2 days a week
3 to 4 days a week
5 or more days a week
N
GO TO section 4
ever
Child does not

have homework

32. In an average week, how many hours does this child spend on homework outside of school?

Shape444 number of hours per week

33. How do you feel about the amount of homework this child is assigned?

The amount is about right
It’s too much
It’s too little

34. How does this child feel about the amount of homework he or she is assigned?

The amount is about right
It’s too much
It’s too little

35. Is there a place in your home that is set aside for this child to do homework?

No
Yes
Child does not do homework at home

3 6. How often does any adult in your household check to see that this child’s homework is done?

Never
Rarely
Sometimes
Always

37. During this school year, about how many days in an average week does anyone in your household help this child with his/her homework?

Less than once a week
1 to 2 days a week
3 to 4 days a week
5 or more days a week
Never

► Continue with section 4, question 38.

4. Family Activities

Shape446

38. In the past week, has anyone in your family done the following things with this child?

M ark ONE box for each item below.

		No ▼	Yes ▼
a.	Told him/her a story (Do not include reading to this child.)
b.	Done activities like arts and crafts, coloring, painting, pasting, or using clay
c.	Played board games or did puzzles with him/her
d.	Worked on a project like building, making, or fixing something……..
e.	Played sports, active games, or exercised together
f.	Discussed with him/her how to manage time
g.	Talked with him/her about the family’s history or ethnic heritage

39. In the past week, how many days has your family eaten the evening meal together?

Write ‘0’ if none.

days

4 0. In the past month, has anyone in your family done the following things with this child?

Shape457 Mark ONE box for each item below.

		No ▼	Yes ▼
a.	Visited a library
b.	Visited a bookstore
c.	Gone to a play, concert, or other live show
d.	Visited an art gallery, museum, or historical site
e.	Visited a zoo or aquarium
f.	Attended an event sponsored by a community, religious, or ethnic group
g.	Attended an athletic or sporting event outside of school in which this child was not a player

► Continue with section 5, question 41 on the next page.

5. Child’s Health

Shape465

41. In general, how would you describe this child’s health?

Excellent
Very good
Good
Fair
Poor

42. Has a health or education professional told you that this child has any of the following conditions?

Mark ONE box for each item below. Shape467 Shape466

		No ▼	Yes ▼
a.	A specific learning disability
b.	An intellectual disability (mental retardation)
c.	A speech or language impairment
d.	A serious emotional disturbance
e.	Deafness or another hearing impairment
f.	Blindness or another visual impairment not corrected with glasses
g.	An orthopedic impairment
h.	Autism
i.	Pervasive Developmental Disorder (PDD)………………….
j.	Attention Deficit Disorder, ADD or ADHD
k.	A developmental delay
l	Traumatic brain injury………….
m.	Another health impairment lasting 6 months or more ….

4 3. Did you mark yes to any condition in question 40?

N
GO TO question 51
o
Y es

44. Is this child receiving services for his/her condition?

N
GO TO question 49
o
Y es

45. Are these services provided by any of the following sources?

M ark ONE box for each item below.

		No ▼	Yes ▼
a.	Your local school district
b.	A state or local health or social service agency
c.	A doctor, clinic, or other health care provider

46. Are any of these services provided through an Individualized Education Program (IEP)?

N
GO TO question 49
o
Y es

47. Did any adult in your household work with the service provider or school to develop or change this child’s IEP?

48. During this school year, how satisfied or dissatisfied have you been with the following aspects of this child’s IEP?

a . The service provider’s or school’s communication with your family?

Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Does not apply

b. The child’s special needs teacher or therapist?

Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Does not apply

c. The service provider’s or school’s ability to accommodate the child’s special needs?

Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Does not apply

d. The service provider’s or school’s commitment to help your child learn?

Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Does not apply

4 9. Is this child currently enrolled in any special education classes or services?

50. Does this child’s condition interfere with his/her ability to do any of the following things?

M ark ONE box for each item below.

Child no longer has condition

		No ▼	Yes ▼
a.	Learn................................... ….
b.	Participate in sports, clubs, or other organized activities.........
c.	Attend school on a regular basis........................................
d.	Make friends............................

► Continue with section 6, question 51 on the next page.

6. Child’s Background

51. In what month and year was this child born?

Shape502 Shape503 Shape504 /

month year

52. Where was this child born?

O
GO TO question 54
ne of the 50 United States or the District of Columbia

Shape506

One of the U.S. territories

(Puerto Rico, Guam, American Samoa, U.S. Virgin Islands, or Mariana Islands)

Another country

53. How old was this child when he/she first moved to the 50 United States or the District of Columbia?

Shape507

age

54. Is this child of Spanish, Hispanic, or Latino origin?

55. What is this child’s race? You may mark one or more races.

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White

{55B.What is this child’s sex? [variable print – no sex on screener]

Male
Female}

5 6. For this school year, does this child usually live at this address or another address (for example, because of a joint custody arrangement)?

Do not include vacation properties.

Child usually lives at this address
Child usually lives at another address

57. What language does this child speak most at home?

Shape509 Mark ONE only.

C
GO TO Section 7
hild is not able to speak
English
Spanish
A language other than English or Spanish
English and Spanish equally
English and another language equally

58. Is this child currently enrolled in English as a second language, bilingual education, or an English immersion program?

► Continue with section 7, on the next page.

7. Child’s Family

PARENT 1 LIVING IN HOUSEHOLD Answer questions 59 to 78 about yourself if you are the child’s parent or guardian.

If you are not the child’s parent or guardian, answer questions 59 to 78 about one of this child’s parents or guardians living in the household.

59. Is this parent or guardian the child’s…

Biological parent
Adoptive parent
Stepparent
Foster parent
Grandparent
Other guardian

60. Is this person male or female?

Male
Female

61. What is the current marital or partner status of this parent or guardian?

M ark ONE only.

Married
In a registered domestic partnership or civil union
Living with a partner
Separated
Divorced
Widowed
Never married

2. What was the first language this parent or guardian learned to speak?

M ark ONE only.

E
GO TO question 67
nglish
Spanish
A language other than English or Spanish
English and Spanish equally
English and another language equally

63. What language does this person speak most at home now?

M ark ONE only.

E
GO TO question 67
nglish
Spanish
A language other than English or Spanish
English and Spanish equally
English and another language equally

64. How difficult is it for this person to participate in activities at this child's school because he/she speaks a language other than English?

Very difficult
Somewhat difficult
Not at all difficult

65. Does the school have interpreters who speak this person’s native language for meetings or parent-teacher conferences?

66. Does the school have written materials, such as newsletters or school notices, that are translated into this person’s native language?

67. Where was this parent or guardian born?

O
GO TO question 69
ne of the 50 United States or the District of Columbia

Shape520

One of the U.S. territories

(Puerto Rico, Guam, American Samoa, U.S. Virgin Islands, or Mariana Islands)

Another country

68. How old was this person when he or she first moved to the 50 United States or the District of Columbia?

Shape521

age

69. Is this person of Spanish, Hispanic, or Latino origin?

70. What is this person’s race? You may mark one or more races.

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White

7 1. What is the highest grade or level of school

that this parent or guardian completed?

M ark ONE only.

8^th grade or less
High school, but no diploma
High school diploma or equivalent (GED)
Vocational diploma after high school
Some college, but no degree
Associate’s degree (AA, AS)
Bachelor’s degree (BA, BS)
Some graduate or professional education, but no degree
Master’s degree (MA, MS)
Doctorate degree (PhD, EdD)
Professional degree beyond bachelor’s degree (MD, DDS, JD, LLB)

72. Is he or she currently attending or enrolled in a school, college, university, or adult learning center, or receiving vocational education or job training?

73. Which of the following best describes this person’s employment status?

M ark ONE only.

Employed for pay or income
Self-employed
U
GO TO question 75
nemployed or

o Shape525 ut of work

F ull-time student
Stay at home

GO TO question 76

arent

Retired
Disabled or

unable to work

7 4. (If employed or self-employed) About how many hours per week does he or she usually work for pay or income, counting all jobs?

Shape529

GO TO question 76

hours

75. (If unemployed or out of work) Has this parent or guardian been actively looking for work in the past 4 weeks?

76. In the past 12 months, how many months (if any) has this person worked for pay or income?

Shape530

months

77. How old is this person?

Shape531

age

78. How old was this person when he or she first became a parent to any child?

Shape532

age

Don’t know

P ARENT 2 LIVING IN HOUSEHOLD Answer questions 79 to 99 about a second parent or guardian living in the household.

79. Is there a second parent or guardian living in this household?

N
GO TO question 100
o
Y es

80. Is this person the child’s…

Biological parent
Adoptive parent
Stepparent
Foster parent
Grandparent
Other guardian

81. Is this person male or female?

Male
Female

82. What is the current marital or partner status of this parent or guardian?

M ark ONE only.

Married
In a registered domestic partnership or civil union
Living with a partner
Separated
Divorced
Widowed
Never married

8 3. What was the first language this parent or guardian learned to speak?

M ark ONE only.

E
GO TO question 88
nglish
Spanish
A language other than English or Spanish
English and Spanish equally
English and another language equally

84. What language does this person speak most at home now?

M ark ONE only.

E
GO TO question 88
nglish
Spanish
A language other than English or Spanish
English and Spanish equally
English and another language equally

85. How difficult is it for this person to participate in activities at this child's school because he/she speaks a language other than English?

Very difficult
Somewhat difficult
Not at all difficult

86. Does the school have interpreters who speak this person’s native language for meetings or parent-teacher conferences?

87. Does the school have written materials, such as newsletters or school notices, that are translated into this person’s native language?

Shape543

88. Where was this parent or guardian born?

O
GO TO question 90
ne of the 50 United States or the District of Columbia

Shape545

One of the U.S. territories

(Puerto Rico, Guam, American Samoa, U.S. Virgin Islands, or Mariana Islands)

Another country

89. How old was this person when he or she first moved to the 50 United States or the District of Columbia?

Shape546

age

90. Is this person of Spanish, Hispanic, or Latino origin?

91. What is this person’s race? You may mark one or more races.

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White

► Continue with question 92 on the next page.

9 2. What is the highest grade or level of school that this parent or guardian completed?

Mark [X] ONE only.

8^th grade or less
High school, but no diploma
High school diploma or equivalent (GED)
Vocational diploma after high school
Some college, but no degree
Associate’s degree (AA, AS)
Bachelor’s degree (BA, BS)
Some graduate or professional education, but no degree
Master’s degree (MA, MS)
Doctorate degree (PhD, EdD)
Professional degree beyond bachelor’s degree (MD, DDS, JD, LLB)

93. Is he or she currently attending or enrolled in a school, college, university, or adult learning center, or receiving vocational education or job training?

94. Which of the following best describes this person’s employment status?

M ark ONE only.

Employed for pay or income
Self-employed
U
GO TO question 96
nemployed or

o Shape549 ut of work

F ull-time student
Stay at home

GO TO question 97

arent

Retired
Disabled or

unable to work

9 5. (If employed or self-employed) About how many hours per week does he or she usually work for pay or income, counting all jobs?

Shape552

GO TO question 97

hours

96. (If unemployed or out of work) Has this parent or guardian been actively looking for work in the past 4 weeks?

97. In the past 12 months, how many months (if any) has this person worked for pay or income?

Shape554

months

98. How old is this person?

Shape555

age

99. How old was this person when he or she first became a parent to any child?

Shape556

age

Don’t know

► Continue with section 8, question 100 on the next page.

8. Your Household

100. Including yourself, how many total people live in this household?

p Shape557 eople

101. Other than the parents or guardians already reported, how many of the following people live in the household with this child?

xample: Brother(s)

Write ‘0’ if none.

This child’s….	Number
Brother(s)…………
Sister(s)…………...
Aunt(s)……………..
Uncle(s)…………….
Grandmother(s)……
Grandfather(s)……..
Cousin(s)……………
Parent’s girlfriend/ boyfriend/ partner…
Other relative(s)……
Other non-relative(s)

Shape568 Shape569

102. How are you related to this child?

M ark ONE only.

Mother (birth, adoptive, step, or foster)
Father (birth, adoptive, step, or foster)
Aunt
Uncle
Grandmother
Grandfather
Parent’s girlfriend/ boyfriend/ partner
O ther relationship – Specify:

Shape572

103. Which language(s) are spoken at home by the adults in this household?

M ark all that apply.

English
Spanish or Spanish Creole
French (including Patois, Creole, Cajun)
Chinese
O ther languages – Specify:

Shape575

► Continue with question 104 on the next page.

Shape576

104. In the past 12 months, did your family ever receive benefits from any of the following programs?

M ark ONE box for each item below. Shape579

		No ▼	Yes ▼
a.	Temporary Assistance for Needy Families, or TANF
b.	Your state welfare or family assistance program
c.	Women, Infants, and Children, or WIC
d.	Food Stamps
e.	Medicaid
f.	Child Health Insurance Program (CHIP)
g.	Section 8 housing assistance

105.Which category best fits the total income of all persons in your household over the past 12 months?

Include your own income.

Include money from jobs or other earnings, pensions, interest, rent, Social Security payments, and so on.

$0 to $10,000
$10,001 to $20,000
$20,001 to $30,000
$30,001 to $40,000
$40,001 to $50,000
$50,001 to $60,000
$60,001 to $75,000
$75,001 to $100,000
$100,001 to $150,000
$150,001 or more

Shape587

106. How many years have you lived at this address?

Write ‘0’ if less than 1 year.

y Shape588 ears at this address

107. Is this house…

Shape589 Mark ONE only.

Owned or being bought by someone in this household,
Rented by someone in this household, or
Occupied by some other arrangement?

108. Other than this address, does anyone in this household currently receive mail at another address including P.O. Boxes?

109. Do you have access to the internet at this address?

110. Is there at least one telephone inside this home that is currently working and not a cell phone?

111. Do you have a working cell phone?

► Continue with question 112 on the next page.

1 12. We would like to identify this child’s school so we can include information about the school in our study.

Using the list of schools below, mark Shape591 the box next to the school this child attends. If this child’s school is not in this list, GO TO question 113.

School Name ▼	Address ▼	City ▼
{SCHOOL 1 UP TO ~40 CHARACTERS}	{ADDRESS 1 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 2 UP TO ~40 CHARACTERS}	{ADDRESS 2 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 3 UP TO ~40 CHARACTERS}	{ADDRESS 3 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 4 UP TO ~40 CHARACTERS}	{ADDRESS 4 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 5 UP TO ~40 CHARACTERS}	{ADDRESS 5 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 6 UP TO ~40 CHARACTERS}	{ADDRESS 6 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 7 UP TO ~40 CHARACTERS}	{ADDRESS 7 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 8 UP TO ~40 CHARACTERS}	{ADDRESS 8 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 9 UP TO ~40 CHARACTERS}	{ADDRESS 9 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 10 UP TO ~40 CHARACTERS}	{ADDRESS 10 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 11 UP TO ~40 CHARACTERS}	{ADDRESS 11 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 12 UP TO ~40 CHARACTERS}	{ADDRESS 12 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 13 UP TO ~40 CHARACTERS}	{ADDRESS 13 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 14 UP TO ~40 CHARACTERS}	{ADDRESS 14 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 15 UP TO ~40 CHARACTERS}	{ADDRESS 15 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}

Shape592

If you found and marked this child’s school in the list provided in question 112, then SKIP this question and return your survey in the postage-paid envelope. Otherwise, continue with question 113.

113. To help us identify the school this child attends, write the name and address of this child’s school in the spaces below.

Please use block or capital letters, for example:

a. School name

SCHOOL NAME

b. School street address

NUMBER AND STREET ADDRESS

c. School city

CITY

d. School state

STATE

e. School zip code

ZIP

Thank you.

Please return this questionnaire in the postage-paid envelope provided. If you have lost the envelope, mail the completed questionnaire to:

National Household Education Survey

[RETURN ADDRESS HERE]

Commonly Asked Questions

Q: How did you get my address?

A: Your address was randomly selected from among all of the home addresses in the nation. It was selected using scientific sampling methods to represent other households in the United States.

Q: How did you get my child’s name and grade?

Q: Why should I take part in this study? Do I have to do this?

Q: How will the information I provide be used? Will my privacy be protected?

Q: I have more than one child in my household. Will I receive additional surveys for the other children in my household?

Q: How will my response help the Department of Education?

A: The Department of Education wants to understand the condition of education in the United States. This survey is the only way that the Department of Education can learn about schooling from your perspective. Your responses will be combined with those from other households to inform educators, policymakers, schools, and universities about changes in the condition of education in the United States. Reports from past surveys can be found at www.nces.ed.gov/nhes.

Q: Who is sponsoring the study? Is this study conducted by the Federal Government?

A: The National Center for Education Statistics, within the Department of Education, is authorized to conduct this study (Section 9543, 20 U.S Code). This study has been approved by the Office of Management and Budget, the office that reviews all federally sponsored surveys. The approval number assigned to this study is 1850-0768. You may send any comments about this survey, including its length, to the Federal Government. Write to: Andrew Zukerberg, National Center for Education Statistics, U.S. Department of Education, 1990 K Street NW, Room 9036, Washington, DC 20006-5650. You may send email to XXX. If you have any questions about the study, contact XXX toll-free at 1-xxx-xxx-xxxx.

PFI Homeschool Questionnaire

OMB No. XXXX-XXXX: Approval Expires XX/XX/XXXX

The National Household Education Survey

A Survey About Homeschooling in America

Thank you for helping us with this survey. Based on the information we received from your household in your last survey, we’re asking you to complete this final step.

U.S. Department of Education

National Center for Education Statistics

ponsored by

Instructions

In response to the survey you answered earlier, we recorded that the child/youth listed below is currently homeschooled for at least some classes. If this child attends public or private school instead of homeschooling, or is not homeschooled for kindergarten through 12^th grade or equivalent, please call us at the toll-free number below so we can be sure you received the correct survey.

These questions should be filled in by a parent or guardian who knows about:

Please answer all the survey questions thinking about this child or youth.

To answer a question, simply mark  the box that best represents your answer.

Please use a black or blue pen, if available, to complete this survey.

If this questionnaire has been sent to the wrong household or the child/youth listed above does not live here, please call to let us know.

Our toll-free number is 1-888-880-3033.

1 . Child’s Homeschooling

► Thank you for your help with the previous survey your household completed.

► Answer all the survey questions thinking about the child listed below:

1. Who is the person that mainly provides this child’s home instruction?

Mother
Father
Grandparent
Brother/sister
Another person

Shape594 Who is that?

2. Is any of this child’s home instruction provided by a private tutor or teacher?

3. Is any of this child’s instruction provided by a local homeschooling group or co-op?

4. Does this child attend a public or private school or a college or university for instruction?

N
GO TO question 7
o
Yes

5 . What type of school(s) does this child attend?

M ark all that apply.

Public school (K-12)
Private school (K-12)
College, community college, or university

6. How many hours each week does this child usually go to a school for instruction? Do not include time spent in extracurricular activities.

Shape598

hours

7 . What grade or year would this child be in if he/she was attending school?

Shape600 Mark ONE only.

Kindergarten

Shape601

Grade (1 through 12)

8. These next questions ask you to estimate the amount of time you homeschool this child.

A. How many days each week is this child homeschooled?

Shape602 days each week

B. About how many total hours each week is he/she homeschooled?

Shape603 hours per week

9. Since September, has this child participated in activities with other children who are homeschooled?

10. Which of the following statements best

describes the teaching style used to homeschool this child?

Shape604

Mark ONE only.

We strictly follow a formal curriculum.
We mostly follow a formal curriculum, but also use informal learning (i.e. child-led learning, "teaching moments").
We mostly use informal learning, but sometimes use a formal curriculum.
We always use informal learning, and never follow a formal curriculum.

1 1. Thinking about sources of curriculum or

books you use to homeschool this child, please tell us about all the sources that apply to you.

Since September, have you used materials from...

Shape606 Mark ONE box for each item below.

		No ▼	Yes ▼
a.	A public library?
b.	A homeschooling catalog, publisher, or individual who specializes in homeschooling materials?
c.	Another educational publisher?
d.	A homeschooling organization?
e.	A church, synagogue, or other religious organization?
f.	Your local public school or school district?
g.	A private school?
h.	A bookstore or other store (including online)?
i.	Websites, excluding retailers?
j.	O ther source— Specify:

12. In the past year, have you or another family member taken any courses, either online or in-person, to help you prepare your child’s home instruction?

No
Yes, both online and in-person
Yes, online only
Yes, in-person only

1 3. Some homeschooled children take courses over the internet taught by people outside the household. Is this child receiving any instruction this way?

N
GO TO question 16
o
Yes

14. Is that instruction provided by any of the following places?

M ark all that apply.

Your local public school
A charter school
Another public school
A private school
A college, community college, or university
Offered by my state
S omeplace else—Specify:

15. Is there a charge or fee for that instruction?

1 6. Thinking about typical grade levels, for

which grades was this child schooled at home for at least some classes or subjects?

M ark all that apply.

Include the current year.

Elementary through Middle school

Kindergarten (Including transitional K and Pre-first grade)
First grade
Second grade
Third grade
Fourth grade
Fifth grade
Sixth grade
Seventh grade
Eighth grade

High School

Ninth grade - freshman
Tenth grade - sophomore
Eleventh grade - junior
Twelfth grade - senior

1 7. There are many different reasons that parents choose to homeschool their children. Did your family choose to homeschool this child because:

M ark ONE box for each item below.

		No ▼	Yes ▼
a.	You are concerned about the school environment, such as safety, drugs, or negative peer pressure?
b.	You are dissatisfied with the academic instruction at other schools?
c.	You prefer to teach this child at home so that you can provide religious instruction?
d.	You prefer to teach this child at home so that you can provide moral instruction?
e.	This child has a physical or mental health problem that has lasted six months or more?
f.	This child has a temporary illness that prevents him/her from going to school?
g.	This child has other special needs that you feel the school can’t or won’t meet?
h.	You are interested in a nontraditional approach to children’s education?
i.	You have another reason for homeschooling your child?

S Shape635 pecify:

Shape636

1 8. Of the reasons your family chose to homeschool this child, which one would you say is the most important to you?

Write the letter from question 17 for the most important reason you chose to homeschool your child.

Shape638 letter from question 17

19. How far do you expect this child to go

in his/her education?

Shape639 Mark ONE only.

Complete less than a high school diploma
Graduate from high school
Attend a vocational or technical school after high school
Attend two or more years of college
Earn a bachelor’s degree
Earn a graduate degree or professional degree beyond a bachelor's

Shape640

20. Thinking about all years this child has been homeschooled, which of the following subject areas has this child been taught during his or her home instruction?

M ark all that apply.

Art
Music
Basic algebra (Algebra I)
Advanced algebra (Algebra II)
Geometry
Calculus
Probability
Scientific inquiry or experiments
Earth sciences or geology
Biology
Chemistry or physics
Geography
English or literature
Computer science (e.g., computer programming)
Social science, history, social studies
Foreign language

► Continue with Section 2, question 21 on the next page.

Shape642

2. Family Activities

2 1. In the past week, has anyone in your family done the following things with this child?

M ark ONE box for each item below.

		No ▼	Yes ▼
a.	Told him/her a story (Do not include reading to this child.)
b.	Done activities like arts and crafts, coloring, painting, pasting, or using clay
c.	Played board games or did puzzles with him/her
d.	Worked on a project like building, making, or fixing something……..
e.	Played sports, active games, or exercised together
f.	Discussed with him/her how to manage time
g.	Talked with him/her about the family’s history or ethnic heritage

22. In the past week, how many days has your family eaten the evening meal together?

Write ‘0’ if none.

Shape652 days

2 3. In the past month, has anyone in your

family done the following things with this child?

M ark ONE box for each item below.

		No ▼	Yes ▼
a.	Visited a library
b.	Visited a bookstore
c.	Gone to a play, concert, or other live show
d.	Visited an art gallery, museum, or historical site
e.	Visited a zoo or aquarium
f.	Attended an event sponsored by a community, religious, or ethnic group
g.	Attended an athletic or sporting event outside of school in which this child was not a player

24. Does your family participate in the activities or meetings of a local homeschooling association, co-op, or other local homeschool group?

N
GO TO question 26
o
Yes

25. Since September, how many times has your family gone to meetings or participated in the activities of a local homeschooling association, co-op, or other local homeschool group?

Shape663 number of times

26. Is your family or someone in your household a member of a national homeschooling organization?

Shape664 3. Child’s Health

27. In general, how would you describe this child’s health?

Excellent
Very good
Good
Fair
Poor

28. Has a health or education professional told you that this child has any of the following conditions?

Mark ONE box for each item below. Shape666 Shape665

		No ▼	Yes ▼
a.	A specific learning disability …
b.	An intellectual disability (mental retardation) …
c.	A speech or language impairment …
d.	A serious emotional disturbance …
e.	Deafness or another hearing impairment …
f.	Blindness or another visual impairment not corrected with glasses …
g.	An orthopedic impairment …
h.	Autism …
i.	Pervasive Developmental Disorder (PDD)…………………
j.	Attention Deficit Disorder, ADD or ADHD …
k.	A developmental delay …
l	Traumatic brain injury
m.	Another health impairment lasting 6 months or more ….

2 9. Did you mark yes to any condition in question 28?

N
GO TO question 37
o
Y es

30. Is this child receiving services for his/her condition?

N
GO TO question 35
o
Y es

31. Are these services provided by any of the following sources?

M ark ONE box for each item below.

		No ▼	Yes ▼
a.	Your local school district
b.	A state or local health or social service agency
c.	A doctor, clinic, or other health care provider

32. Are any of these services provided through an Individualized Education Program (IEP)?

N
GO TO question 35
o
Y es

33. Did any adult in your household work with the service provider or school to develop or change this child’s IEP?

34. During this school year, how satisfied or dissatisfied have you been with the following aspects of this child’s IEP?

a . The service provider’s or school’s communication with your family?

Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Does not apply

b. The child’s special needs teacher or therapist?

Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Does not apply

c. The service provider’s or school’s ability to accommodate the child’s special needs?

Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Does not apply

d. The service provider’s or school’s commitment to help your child learn?

Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Does not apply

Shape693

35. Is this child currently enrolled in any special education classes or services?

36. Does this child’s condition interfere with his/her ability to do any of the following things?

M ark ONE box for each item below.

Child no longer has condition

		No ▼	Yes ▼
a.	Learn?................................... ….
b.	Participate in sports, clubs, or other organized activities?.........
c.	Attend school on a regular basis?........................................
d.	Make friends?............................

► Continue with Section 4, question 37 on the next page.

4. Child’s Background

37. In what month and year was this child born?

Shape701 Shape702 Shape703 /

month year

38. Where was this child born?

O
GO TO question 40
ne of the 50 United States or the District of Columbia

Shape705

One of the U.S. territories

(Puerto Rico, Guam, American Samoa, U.S. Virgin Islands, or Mariana Islands)

Another country

39. How old was this child when he/she first moved to the 50 United States or the District of Columbia?

Shape706

age

40. Is this child of Spanish, Hispanic, or Latino origin?

41. What is this child’s race? You may mark one or more races.

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White

{41B.What is this child’s sex? [variable print – no sex on screener]

Male
Female}

4 2. For this school year, does this child usually live at this address or another address (for example, because of a joint custody arrangement)?

Do not include vacation properties.

Child usually lives at this address
Child usually lives at another address

43. What language does this child speak most at home?

Shape708 Mark ONE only.

C hild is not

GO TO SECTION 5

ble to speak

English
Spanish
A language other than English or Spanish
English and Spanish equally
English and another language equally

44. Is this child currently enrolled in English as a second language, bilingual education, or an English immersion program?

► Continue with Section 5, on the next page.

. Child’s Family

PARENT 1 LIVING IN HOUSEHOLD- Answer questions 45 to 61 about yourself if you are the child’s parent or guardian.

If you are not the child’s parent or guardian, answer questions 45 to 61 about one of this child’s parents or guardians living in the household.

45. Is this parent or guardian the child’s…

Biological parent
Adoptive parent
Stepparent
Foster parent
Grandparent
Other guardian

46. Is this person male or female?

Male
Female

47. What is the current marital or partner status of this parent or guardian?

M ark ONE only.

Married
In a registered domestic partnership or civil union
Living with a partner
Separated
Divorced
Widowed
Never married

4 8. What was the first language this parent or guardian learned to speak?

M ark ONE only.

E
GO TO question 50
nglish
Spanish
A language other than English or Spanish
English and Spanish equally
English and another language equally

49. What language does this person speak most at home now?

M ark ONE only.

English
Spanish
A language other than English or Spanish
English and Spanish equally
English and another language equally

50. Where was this parent or guardian born?

O
GO TO question 52
ne of the 50 United States or the District of Columbia

Shape717

One of the U.S. territories

(Puerto Rico, Guam, American Samoa, U.S. Virgin Islands, or Mariana Islands)

Another country

51. How old was this person when he or she first moved to the 50 United States or the District of Columbia?

Shape718

age

52. Is this person of Spanish, Hispanic, or Latino origin?

5 3. What is this person’s race? You may mark one or more races.

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White

54. What is the highest grade or level of school

that this parent or guardian completed?

M ark ONE only.

8^th grade or less
High school, but no diploma
High school diploma or equivalent (GED)
Vocational diploma after high school
Some college, but no degree
Associate’s degree (AA, AS)
Bachelor’s degree (BA, BS)
Some graduate or professional education, but no degree
Master’s degree (MA, MS)
Doctorate degree (PhD, EdD)
Professional degree beyond bachelor’s degree (MD, DDS, JD, LLB)

55. Is he or she currently attending or enrolled in a school, college, university, or adult learning center, or receiving vocational education or job training?

5 6. Which of the following best describes this person’s employment status?

M ark ONE only.

Employed for pay or income
Self-employed
U
GO TO question 58
nemployed or

o Shape723 ut of work

F ull-time student
Stay at home

GO TO question 59

arent

Retired
Disabled or

unable to work

57. (If employed or self-employed) About how many hours per week does he or she usually work for pay or income, counting all jobs?

Shape726

GO TO question 59

hours

58. (If unemployed or out of work) Has this parent or guardian been actively looking for work in the past 4 weeks?

59. In the past 12 months, how many months (if any) has this person worked for pay or income?

Shape727

months

6 0. How old is this person?

Shape729

age

61. How old was this person when he or she first became a parent to any child?

Shape730

age

D on’t know

PARENT 2 LIVING IN HOUSEHOLD Answer questions 62 to 79 about a second parent or guardian living in the household.

62. Is there a second parent or guardian living in this household?

N
GO TO question 80
o
Yes

63. Is this person the child’s…

Biological parent
Adoptive parent
Stepparent
Foster parent
Grandparent
Other guardian

64. Is this person male or female?

Male
Female

65.What is the current marital or partner status of this parent or guardian?

M ark ONE only.

Married
In a registered domestic partnership or civil union
Living with a partner
Separated
Divorced
Widowed
Never married

6 6. What was the first language this parent or guardian learned to speak?

M ark ONE only.

E
GO TO question 68
nglish
Spanish
A language other than English or Spanish
English and Spanish equally
English and another language equally

67.What language does this person speak most at home now?

M ark ONE only.

English
Spanish
A language other than English or Spanish
English and Spanish equally
English and another language equally

68. Where was this parent or guardian born?

O
GO TO question 70
ne of the 50 United States or the District of Columbia

Shape740

One of the U.S. territories

(Puerto Rico, Guam, American Samoa, U.S. Virgin Islands, or Mariana Islands)

Another country

69. How old was this person when he or she first moved to the 50 United States or the District of Columbia?

Shape741

age

7 0. Is this person of Spanish, Hispanic, or Latino origin?

71. What is this person’s race? You may mark one or more races.

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White

72. What is the highest grade or level of school that this parent or guardian completed?

Mark [X] ONE only.

8^th grade or less
High school, but no diploma
High school diploma or equivalent (GED)
Vocational diploma after high school
Some college, but no degree
Associate’s degree (AA, AS)
Bachelor’s degree (BA, BS)
Some graduate or professional education, but no degree
Master’s degree (MA, MS)
Doctorate degree (PhD, EdD)
Professional degree beyond bachelor’s degree (MD, DDS, JD, LLB)

73. Is he or she currently attending or enrolled in a school, college, university, or adult learning center, or receiving vocational education or job training?

N o
Y es

74. Which of the following best describes this person’s employment status?

M ark ONE only.

Employed for pay or income
Self-employed
U
GO TO question 76
nemployed or

o Shape746 ut of work

F ull-time student
Stay at home

GO TO question 77

arent

Retired
Disabled or

unable to work

75. (If employed or self-employed) About how many hours per week does he or she usually work for pay or income, counting all jobs?

Shape748

GO TO question 77

hours

76. (If unemployed or out of work) Has this parent or guardian been actively looking for work in the past 4 weeks?

77. In the past 12 months, how many months (if any) has this person worked for pay or income?

Shape750

months

78. How old is this person?

Shape751

age

79. How old was this person when he or she first became a parent to any child?

Shape752

age

Don’t know

► Continue with Section 6, question 80 on the next page.

6. Your Household

80. Including yourself, how many total people live in this household?

Shape753 people

81. Other than the parents or guardians already reported, how many of the following people live in the household with this child?

Example: Brother(s)

Write ‘0’ if none.

This child’s….	Number
Brother(s)…………...
Sister(s)……………..
Aunt(s)………………
Uncle(s)……………..
Grandmother(s)…….
Grandfather(s)……...
Cousin(s)……………
Parent’s girlfriend/ boyfriend/ partner….
Other relative(s)…...
Other nonrelative(s).

8 2. How are you related to this child?

M ark ONE only.

Mother

(birth, adoptive, step, or foster)

Father

(birth, adoptive, step, or foster)

Aunt
Uncle
Grandmother
Grandfather
Parent’s girlfriend/ boyfriend/ partner
O ther relationship – Specify:

Shape768

83. What language(s) are spoken at home by the adults in this household?

M ark all that apply.

English
Spanish or Spanish Creole
French (including Patois, Creole, Cajun)
Chinese
O ther languages – Specify:

Shape771

► Continue with question 84 on the next page.

84. In the past 12 months, did your family ever receive benefits from any of the following programs?

M ark ONE box for each item below. Shape775

		No ▼	Yes ▼
a.	Temporary Assistance for Needy Families, or TANF
b.	Your state welfare or family assistance program
c.	Women, Infants, and Children, or WIC
d.	Food Stamps
e.	Medicaid
f.	Child Health Insurance Program (CHIP)
g.	Section 8 Housing assistance

85. Which category best fits the total income of all persons in your household over the past 12 months?

Include your own income.

Include money from jobs or other earnings, pensions, interest, rent, Social Security payments, and so on.

$0 to $10,000
$10,001 to $20,000
$20,001 to $30,000
$30,001 to $40,000
$40,001 to $50,000
$50,001 to $60,000
$60,001 to $75,000
$75,001 to $100,000
$100,001 to $150,000
$150,001 or more

8 6. How many years have you lived at this address?

Write ‘0’ if less than 1 year.

Shape784 years at this address

87. Is this house…

Shape785 Mark ONE only.

Owned or being bought by someone in this household,
Rented by someone in this household, or
Occupied by some other arrangement?

88. Other than this address, does anyone in this household currently receive mail at another address including P.O. Boxes?

89. Do you have access to the internet at this address?

90. Is there at least one telephone inside this home that is currently working and not a cell phone?

91. Do you have a working cell phone?

Thank you.

Please return this questionnaire in the postage-paid envelope provided. If you have lost the envelope, mail the completed questionnaire to:

National Household Education Survey

[RETURN ADDRESS HERE]

Commonly Asked Questions

Q: How did you get my address?

A: Your address was randomly selected from among all of the home addresses in the nation. It was selected using scientific sampling methods to represent other households in the United States.

Q: How did you get my child’s name and age?

Q: Why should I take part in this study? Do I have to do this?

Q: How will the information I provide be used? Will my privacy be protected?

Q: I have more than one child in my household. Will I receive additional surveys for the other children in my household?

Q: How will my response help the Department of Education?

A: The Department of Education wants to understand the condition of education in the United States. This survey is the only way that the Department of Education can learn about homeschooling from your perspective. It is the Department of Education’s primary source of information on homeschooling in America. Your responses will be combined with those from other households to inform educators, policymakers, schools and universities about changes in the condition of education in the United States. Reports from past surveys can be found at http://nces.ed.gov/nhes.

Q: Who is sponsoring the study? Is this study conducted by the Federal Government?

A: The National Center for Education Statistics, within the Department of Education, is authorized to conduct this study (Section 9543, 20 U.S. Code). This study has been approved by the Office of Management and Budget, the office that reviews all federally sponsored surveys. The approval number assigned to this study is XXXX-XXXX. You may send any comments about this survey, including its length, to the Federal Government. Write to: Andrew Zukerberg, National Center for Education Statistics, U.S. Department of Education, 1990 K Street NW, Room 9036, Washington, DC 20006-5650. You may send email to XXX. If you have any questions about the study, contact XXX toll-free at 1-xxx-xxx-xxxx.

PFI Enrolled – Short Form

OMB No. XXXX-XXXX Approval Expires XX/XX/XXXX

The National Household Education Survey

A Survey about Students’ and Families’ Experience with Their Schools

Thank you for helping us with this survey. Based on the information we received from your household in your last survey, we’re asking you to complete this final step.

U.S. Department of Education

National Center for Education Statistics

ponsored by

Instructions

In response to the survey you answered earlier, we recorded that the child/youth listed below attends school. If this child is homeschooled instead of attending public or private school, or if this child has not yet started kindergarten, please call us at the toll-free number below so we can be sure you received the correct survey.

These questions should be filled in by a parent or guardian who knows about:

Please answer all the survey questions thinking about this child or youth.

To answer a question, simply mark  the box that best represents your answer.

Please use a black or blue pen, if available, to complete this survey.

If this questionnaire has been sent to the wrong household or the child/youth listed above does not live here, please call to let us know.

Our toll-free number is 1-888-880-3033.

This survey is estimated to take an average of 10 minutes, including time for reviewing instructions, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Andrew Zukerberg, National Center for Education Statistics, U.S. Department of Education, 1990 K Street NW, Room 9036, Washington, DC 20006-5650. Do not return the completed form to this address.

1 . Child’s Schooling

► Thank you for your help with the previous survey your household completed.

► Answer all the survey questions thinking about the child listed below:

3. What type of school does this child attend?

P rivate, Catholic
P
GO TO question 6 66
rivate, religious

but not Catholic

Private, not religious
P ublic school

4. Is it his/her regularly assigned school?

6. Did you move to your current neighborhood so that this child could attend his/her current school?

10. Is the school this child attends your first choice, that is, the school you wanted most for him/her to attend?

1 4. Please tell us about this child’s grades during this school year. Overall, across all subjects, what grades does this child get?

Mostly A’s
Mostly B’s
Mostly C’s
Mostly D’s and lower
This child’s school does not give these grades

16. Since the beginning of this school year, how many times have any of this child’s teachers or school staff contacted your household about…

Write ‘0’ if none.

Number

a.	Behavior problems this child is having in school
b.	Problems this child is having with school work
c.	Very good behavior
d.	Very good school work

21. How far do you expect this child to go in his/her education?

Shape794 Mark ONE only.

Complete less than a high school diploma
Graduate from high school
Attend a vocational or technical school after high school
Attend two or more years of college
Earn a bachelor’s degree
Earn a graduate degree or professional degree beyond a bachelor's

2. Families & School

26. Since the beginning of this school year, has any adult in this child’s household done any of the following things at this child’s school?

Mark [X] ONE box for each item below.

		No ▼	Yes ▼
a.	Attended a school or class event, such as a play, dance, sports event, or science fair…	□	□
b.	Served as a volunteer in this child’s classroom or elsewhere in the school………	□	□
c.	Attended a general school meeting, for example, an open house, or a back-to-school night.	□	□
d.	Attended a meeting of the parent-teacher organization or association.	□	□
e.	Gone to a regularly scheduled parent-teacher conference with this child’s teacher.	□	□
f.	Participated in fundraising for the school.	□	□
g.	Served on a school committee…………………….	□	□
h.	Met with a guidance counselor in person.	□	□

27. During this school year, how many times has any adult in the household gone to meetings or participated in activities at this child’s school?

Shape796 number of times

Shape797

28. During this school year, has your family received any of the following:

a. Notes or emails specifically about this child from his/her teachers or school administrators?

b. Newsletters, memos, emails, or notices addressed to all parents?

c. Phone calls specifically about this child from his/her teachers or school administrators?

29. How well has this child’s school been doing the following things during this school year?

a. Letting you know how this child is doing in school between report cards.

Very well
Just okay
Not very well
Does not do it at all

b. Providing information about how to help this child with homework.

Very well
Just okay
Not very well
Does not do it at all

c. Providing information about why this child is placed in particular groups or classes.

V ery well
Just okay
Not very well
Does not do it at all

d. Providing information on your expected role at this child’s school.

Very well
Just okay
Not very well
Does not do it at all

e. Providing information on how to help this child plan for college or vocational school.

Very well
Just okay
Not very well
Does not do it at all
Does not apply

Shape799

3. Homework

31. How often does this child do homework at home, at an after-school program, or somewhere else outside of school?

Less than once a week
1 to 2 days a week
3 to 4 days a week
5 or more days a week
N
GO TO section 4
ever
Child does not

have homework

36.How often does any adult in your household

check to see that this child’s homework is

done?

Never
Rarely
Sometimes
Always

4. Family Activities

Shape801

40. In the past month, has anyone in your family done the following things with this child?

Shape802 Mark ONE box for each item below.

		No ▼	Yes ▼
a.	Visited a library
b.	Visited a bookstore
c.	Gone to a play, concert, or other live show
d.	Visited an art gallery, museum, or historical site
e.	Visited a zoo or aquarium
f.	Attended an event sponsored by a community, religious, or ethnic group
g.	Attended an athletic or sporting event outside of school in which this child was not a player

► Continue with section 5, question 41 on the next page.

Shape810

5. This Child’s Health

74. In general, how would you describe this child’s health?

Excellent
Very good
Good
Fair
Poor

75. Has a health, education, or early intervention professional told you that this child has any of the following conditions?

M ark ONE box for each item below.

		No ▼	Yes ▼
a.	A specific learning disability
b.	An intellectual disability (mental retardation)
c.	A speech or language impairment
d.	A serious emotional disturbance
e.	Deafness or another hearing impairment
f.	Blindness or another visual impairment not corrected with glasses
g.	An orthopedic impairment
h.	Autism
i.	Pervasive Developmental Disorder (PDD)
j.	Attention Deficit Disorder, ADD or ADHD
k.	A developmental delay
l.	Traumatic brain injury
m.	Another health impairment lasting 6 months or more

76. Did you mark yes to any condition in question 40?

N
GO TO question XX
o
Y es

77. Is this child receiving services for his/her condition?

N
GO TO question xx
o
Y es

78. Are any of these services provided through

an Individualized Educational Program(IEP)?

N
GO TO question xx
o
Y es

6 . Child’s Background

85. In what month and year was this child born?

Shape834 Shape835 Shape836 Shape837

month year

86. Where was this child born?

O ne of the 50 United States or the District of Columbia

Shape839

GO TO question 88

One of the U.S. territories

(Puerto Rico, Guam, American Samoa, U.S. Virgin Islands, or Mariana Islands)

Another country

87. How old was this child when he/she first moved to the 50 United States or the District of Columbia?

Shape840

age

88. Is this child of Spanish, Hispanic, or Latino origin?

89. What is this child’s race? You may mark one or more races.

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White

90.Since September, has this child usually lived at this address or another address (for example, because of a joint custody arrangement)?

o not include vacation properties.

Child usually lived at this address
Child usually lived at another address

91. What language does this child speak most at home?

Shape841 Mark ONE only.

C
GO TO Section 7
hild is not

able to speak

English
Spanish
A language other than English or Spanish
English and Spanish equally
English and another language equally

92 Is this child currently enrolled in English as a second language, bilingual education, or an English immersion program?

7. Child’s Family

PARENT 1 LIVING IN HOUSEHOLD

Answer questions 93 to 109 about yourself if you are the child’s parent or guardian.

If you are not the child’s parent or guardian, answer questions 93 to 109 about one of this child’s parents or guardians living in the household.

93. Is this parent or guardian the child’s…

Biological parent
Adoptive parent
Stepparent
Foster parent
Grandparent
Other guardian

94. Is this person male or female?

Male
Female

95. What is the current marital or partner status of this parent or guardian?

M ark ONE only.

Married
In a registered domestic partnership or civil union
Living with a partner
Separated
Divorced
Widowed
Never married

Shape845 Shape844

97. What language does this person speak most at home now?

M ark ONE only.

English
Spanish
A language other than English or Spanish
English and Spanish equally
English and another language equally

100. Is this person of Spanish, Hispanic, or Latino origin?

101. What is this person’s race? You may mark one or more races.

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White

102. What is the highest grade or level of school that this parent or guardian completed?

M ark ONE only.

8^th grade or less
High school, but no diploma
High school diploma or equivalent (GED)
Vocational diploma after high school
Some college, but no degree
Associate’s degree (AA, AS)
Bachelor’s degree (BA, BS)
Some graduate or professional education, but no degree
Master’s degree (MA, MS)
Doctorate degree (PhD, EdD)
Professional degree beyond bachelor’s degree (MD, DDS, JD, LLB)

104. Which of the following best describes this person’s employment status?

M ark ONE only.

Employed for pay or income
Self-employed
U
GO TO question 106
nemployed or

o Shape849 ut of work

F ull-time student
Stay at home

GO TO question 107

arent

Retired
Disabled or

unable to work

110. Is there a second parent or guardian living in this household?

Shape851

8. Your Household

128. Including yourself, how many total people live in this household?

Shape852

people

129. Other than the parents or guardians already reported, how many of the following people live in the household with this child?

Example:

Brother(s)

Write ‘0’ if none.

This child’s….	Number
Brother(s)…………...
Sister(s)……………..
Aunt(s)………………
Uncle(s)……………..
Grandmother(s)…….
Grandfather(s)……..
Cousin(s)……………
Parent’s girlfriend/ boyfriend/ partner….
Other relative(s)……
Other non-relative(s)

130. How are you related to this child?

M ark ONE only.

Mother (birth, adoptive, step, or foster)
Father (birth, adoptive, step, or foster)
Aunt
Uncle
Grandmother
Grandfather
Parent’s girlfriend/ boyfriend/ partner
O ther relationship – Specify:

Shape866

131. Which language(s) are spoken at home by the adults in this household?

M ark all that apply.

English
Spanish or Spanish Creole
French (including Patois, Creole, Cajun)
Chinese
O ther languages – Specify:

Shape869

132. In the past 12 months, did your family ever receive benefits from any of the following programs?

M ark ONE box for each item below. Shape873

		No ▼	Yes ▼
a.	Temporary Assistance for Needy Families, or TANF
b.	Your state welfare or family assistance program
c.	Women, Infants, and Children, or WIC
d.	Food Stamps
e.	Medicaid
f.	Child Health Insurance Program (CHIP)
g.	Section 8 housing assistance

133. Which category best fits the total income of all persons in your household over the past 12 months?

Include your own income.

Include money from jobs or other earnings, pensions, interest, rent, Social Security payments, and so on.

$0 to $10,000
$10,001 to $20,000
$20,001 to $30,000
$30,001 to $40,000
$40,001 to $50,000
$50,001 to $60,000
$60,001 to $75,000
$75,001 to $100,000
$100,001 to $150,000
$150,001 or more

1 34. How many years have you lived at this address?

Write ‘0’ if less than 1 year.

years at this address

Shape882

135. Is this house…

Shape883 Mark ONE only.

Owned or being bought by someone in this household,
Rented by someone in this household, or
Occupied by some other arrangement?

136. Other than this address, does anyone in this household currently receive mail at another address including P.O. Boxes?

137. Do you have access to the internet at this address?

138. Is there at least one telephone inside this home that is currently working and not a cell phone?

139. Do you have a working cell phone?

►Continue with question 113 on the next page.

1 13. We would like to identify this child’s school so we can include information about the school in our study.

Using the list of schools below mark Shape885 the box next to the school this child attends. If this child’s school is not in this list, GO TO question 114.

School Name ▼	Address ▼	City ▼
{SCHOOL 1 UP TO ~40 CHARACTERS}	{ADDRESS 1 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 2 UP TO ~40 CHARACTERS}	{ADDRESS 2 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 3 UP TO ~40 CHARACTERS}	{ADDRESS 3 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 4 UP TO ~40 CHARACTERS}	{ADDRESS 4 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 5 UP TO ~40 CHARACTERS}	{ADDRESS 5 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 6 UP TO ~40 CHARACTERS}	{ADDRESS 6 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 7 UP TO ~40 CHARACTERS}	{ADDRESS 7 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 8 UP TO ~40 CHARACTERS}	{ADDRESS 8 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 9 UP TO ~40 CHARACTERS}	{ADDRESS 9 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 10 UP TO ~40 CHARACTERS}	{ADDRESS 10 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 11 UP TO ~40 CHARACTERS}	{ADDRESS 11 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 12 UP TO ~40 CHARACTERS}	{ADDRESS 12 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 13 UP TO ~40 CHARACTERS}	{ADDRESS 13 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 14 UP TO ~40 CHARACTERS}	{ADDRESS 14 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}
{SCHOOL 15 UP TO ~40 CHARACTERS}	{ADDRESS 15 UP TO ~30 CHARACTERS}	{CITY UP TO ~15 CH.}

Shape886

If you found and marked this child’s school in the list provided in question 113, then SKIP this question and return your survey in the postage-paid envelope. Otherwise, continue with question 114.

114. To help us identify the school this child attends, write the name and address of this child’s school in the spaces below.

Please use block or capital letters, for example:

a. School name

SCHOOL NAME

b. School street address

NUMBER AND STREET ADDRESS

c. School city

CITY

d. School state

STATE

e. School zip code

ZIP

Thank you.

Please return this questionnaire in the postage-paid envelope provided. If you have lost the envelope, mail the completed questionnaire to:

National Household Education Survey

Westat

1600 Research Blvd. Room RC B16

Rockville, MD 20850-3129

Commonly Asked Questions

Q: How did you get my address?

A: Your address was randomly selected from among all of the home addresses in the nation. It was selected using scientific sampling methods to represent other households in the U.S.

Q: Why should I take part in this study? Do I have to do this?

A: You represent thousands of other households like yours, and you cannot be replaced. Your answers and opinions are very important to the success of this study. You may choose not to answer any or all questions in this survey. In order for the survey to be representative it is important that you complete and return this questionnaire.

Q: How will the information I provide be used?

Q: I have more than one child in my household. Will I receive additional surveys for the other children in my household?

Q: How will my response help the Department of Education?

A: The Department of Education wants to understand the condition of education in the United States. This survey is the only way that the Department of Education can learn about schooling from your perspective. Your responses will be combined with those from other households to inform educators, policy makers, schools and universities about changes in the condition of education in the United States. Reports from past surveys can be found at www.nces.ed.gov/nhes.

Q: Who is sponsoring the study? Is this study conducted by the Federal Government?

A: The National Center for Education Statistics, within the Department of Education, is authorized to conduct this study (Section 9543, 20 U.S Code). Westat has been contracted to conduct this study. This study has been approved by the Office of Management and Budget, the office that reviews all federally sponsored surveys. The approval number assigned to this study is 1850-0768. You may send any comments about this survey, including its length, to the Federal Government. Write to: Andrew Zukerberg, National Center for Education Statistics, U.S. Department of Education, 1990 K Street NW, Room 9036, Washington, DC 20006-5650. You may send e-mail to NHES@xxx.

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