Family Baseline Survey

OMB Control No: _____

Expiration date: ______

Length of time for instrument: 1.00 hour

ATTACHMENT 6: MIHOPE FAMILY BASELINE SURVEY

5/29/2012

ALL

CALL-IN

SC1 Hello, and thanks for calling. My name is [FULL NAME] and I work at Mathematica Policy Research in Princeton, New Jersey.

[PARENT] 1 SC2

HUNG UP 8 TERMINATE

REFUSED r RANDOM

ASSIGNMENT

SC1=1

Fill CHILD from PRELOAD

SC2 As the MIHOPE study representative has already mentioned, the purpose of the study is to learn more about families who enroll in home visiting programs and how those programs provide different kinds of services to children and families.

I will ask you some questions and type in your answers. This interview should take about an hour to complete. There are no right or wrong answers to these questions. The things you tell me are very important, so please be as accurate as possible.

You may stop me at any time, and you may ask me to go back to earlier questions to change your answers. If I ask you something that you are uncomfortable answering, just tell me and I will move on to the next question.

Everything we talk about today is completely confidential. No one from the home visiting program will see or hear your answers. All of the study results will be reported for groups of parents; no results will be analyzed or reported for individuals.

Your participation is completely voluntary. If you choose not to complete this interview, it will not affect you or your child’s participation in home visiting services. When we finish, the MIHOPE study representative will give you gift for your child and Mathematica will send you a $25 gift card to thank you for your help.

If you have any questions at any time during the interview, please feel free to ask them. Do you have any questions before we begin?

YES 1 FAQ

NO 0

DON’T KNOW d

REFUSED r

ALL

SC3 First, I’d like to confirm your name.

INTERVIEWER: SPELL NAME FOR RESPONDENT.

PROGRAMMER: ALLOW RESPONDENT INFO TO BE ENTERED/REVISED IN INFO SCREEN

(STRING 15)

FIRST NAME

(STRING 15)

MIDDLE INITIAL/NAME

(STRING 30)

LAST NAME

DON’T KNOW d

REFUSED r

ALL

SC4 Do you go by any other name?

YES 1

NO 0 SC7

DON’T KNOW d SC6

REFUSED r SC6

SC4=1

SC5 What is that name? ENTER NAME

(STRING 99)

DON’T KNOW d

REFUSED r

PROGRAMMER: GO TO INFO SCREEN AND LOAD UNDER “OTHER NAME”

ALL

Fill PARENT’S DOB from PRELOAD

SC6 Now I’d like to confirm your date of birth. What is your birth date?

PROGRAMMER: ALLOW BIRTH DATE INFO TO BE ENTERED/REVISED IN INFO SCREEN

| | | / | | | / | | | | | (1963 – 1998)

Month Day Year

DON’T KNOW d SC8

REFUSED r SC8

SC7=d,r

SC7 How old are you?

| | | YEARS (15 – 50)

DON’T KNOW d

REFUSED r

NON-PREGNANT MOMS

Fill CHILD from PRELOAD

SC8 Now, I would like to make sure we have [CHILD]’s name recorded correctly.

PROGRAMMER: DISPLAY CHILD’S NAME

INTERVIEWER: READ NAME TO RESPONDENT AND VERIFY SPELLING

NAME CORRECT 1

NAME INCORRECT 2

DON’T KNOW d

REFUSED r

INTERVIEWER: IF RESPONDENT GIVES DIFFERENT NAME, MAKE SURE YOU ARE TALKING ABOUT THE RIGHT CHILD AND CORRECT FIRST NAME.

IF THE NAME IS CORRECT, PRESS ENTER.

SC8=2

SC9 May I have the correct spelling of [CHILD]’s name?

(STRING 15)

FIRST NAME

(STRING 15)

MIDDLE INITIAL/NAME

(STRING 30)

LAST NAME

DON’T KNOW d

REFUSED r

NON-PREGNANT MOMS

Fill CHILD from PRELOAD

SC10 Is [CHILD] a boy or a girl?

INTERVIEWER: CONFIRM IF ALREADY KNOWN

BOY 1

GIRL 2

DON’T KNOW d

REFUSED r

NON-PREGNANT MOMS

SC11 What is [CHILD]’s birth date?

| | | / | | | / | | | | | (2011 – 2013)

Month Day Year

DON’T KNOW d

REFUSED r

PREGNANT MOMS

SC12 What is your due date?

| | | / | | | / | | | | | (2011 – 2014)

Month Day Year

DON’T KNOW d

REFUSED r

Section A. Perinatal and Child Health

all

A1 How many weeks or months pregnant were you when you had your first visit for prenatal care? Do not count a visit that was only for a pregnancy test or only for WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children).

| | | NUMBER OF WEEKS

(1-42)

| | | NUMBER OF MONTHS

(1-9)

DIDN’T RECEIVE ANY PRENATAL CARE 88

IF GIVES TRIMESTER RESPONSE:

1ST TRIMESTER, WEEKS UNSPECIFIED 55

2ND TRIMESTER, WEEKS UNSPECIFIED 66

3RD TRIMESTER, WEEKS UNSPECIFIED 77

DON’T KNOW d

REFUSED r

A1=88 OR A TRIMESTER RESPONSE OF 66 OR 77

if a1=88 display “at all” if a1=66 or 77, display “earlier”

A2 What kept you from getting prenatal care (at all/earlier)?

NOTHING, I GOT IT AS SOON AS I WANTED/DIDN’T WANT/NEED IT.…0

I COULDN’T GET AN APPOINTMENT WHEN I WANTED ONE 1

I DIDN’T HAVE ENOUGH MONEY OR INSURANCE TO PAY FOR MY VISITS 2

I HAD NO TRANSPORTATION TO GET TO THE CLINIC OR DOCTOR’S OFFICE 3

THE DOCTOR OR MY HEALTH PLAN WOULD NOT START CARE AS EARLY AS I WANTED 4

I HAD TOO MANY OTHER THINGS GOING ON 5

I COULDN’T TAKE TIME OFF FROM WORK OR SCHOOL 6

I DIDN’T HAVE MY MEDICAID (OR STATE MEDICAID NAME) CARD 7

I HAD NO ONE TO TAKE CARE OF MY CHILDREN .8

I DIDN’T KNOW THAT I WAS PREGNANT 9

I DIDN’T WANT PRENATAL CARE, OR 10

SOME OTHER REASON? (SPECIFY) 99

(STRING (NUM))

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): What other reason?

NON-PREGNANT MOMS

Fill CHILD, CHILD’S GENDER from PRELOAD

A3 How much did [CHILD] weigh when [he/she] was born?

| | | POUNDS (1 – 14) | | | OUNCES (0 – 28) A5

DON’T KNOW d A4

REFUSED r A5

A3=d,r

Fill CHILD from PRELOAD

A4 Was [CHILD]’s birth weight…

Normal (5 1/2 lbs. [2.5 kilograms] or more), 1

Low (between 3 1/2 [1.5 kilograms] and 5 1/2 lbs. [2.5 kilograms]), or 2

Very low (under 3 1/2 lbs. [1.5 kilograms])? 3

DON’T KNOW d

REFUSED

NON-PREGNANT MOMS

A5 Was [CHILD] born earlier than the due date?

YES, BORN EARLIER THAN DUE DATE 1

NO, BORN ON TIME OR AFTER DUE DATE 2 A7

DON’T KNOW d

REFUSED r

A5=1

Fill CHILD from PRELOAD

A6 How many weeks before the due date was [CHILD] born?

PROBE: Your best estimate is fine.

INTERVIEWER: IF LESS THAN A WEEK, CODE 1.

| | | WEEK(S) ALLOW DECIMAL

(1 - 20)

DON’T KNOW d

REFUSED r

NON-PREGNANT MOMS

Fill CHILD’S GENDER, CHILD’S name from PRELOAD

A7 After [CHILD] was born, how long did [he/she] stay in the hospital?

LESS THAN 24 HOURS (LESS THAN 1 DAY), 1

24 TO 48 HOURS (1 TO 2 DAYS), 2

3 TO 5 DAYS, 3

6 TO 14 DAYS, 4

MORE THAN 14 DAYS, 5

BABY NOT BORN IN HOSPITAL 6

BABY IS STILL IN THE HOSPITAL 7

DON’T KNOW d

REFUSED r

A7 LT 6

Fill CHILD’S GENDER, NAME from preload

A8 Were any of these days in the Neonatal Intensive Care Unit (NICU), or were they all in the regular nursery?

PROBE: NICU-also known as a newborn intensive care unit, intensive care nursery (ICN), or special care baby unit (SCBU)—is an intensive care unit specializing in the care of ill or premature newborn infants

all in nicu 1

SOME IN NICU……………………………………………………………………2

ALL IN REGULAR NURSERY 3

DON’T KNOW d

REFUSED r

A8=1 OR 2

Fill CHILD from preload

A

8a. How long did [CHILD] stay in the neonatal intensive care unit (NICU) after birth?

| | | | | days [SKIP]

(NUMBER RANGE)

DON’T KNOW d [SKIP]

REFUSED r [SKIP]

NON-PREGNANT MOMS

Fill CHILD from preload

A9 Is there a place you usually take [CHILD] for well child care, such as shots (vaccinations) and routine exams?

YES 1

NO 0

DON’T KNOW d

REFUSED r

NON-PREGNANT MOMS

Fill CHILD from preload

A10 Do you exclusively breastfeed, breast and bottle feed formula, or bottle feed formula only?

YES 1 A11

NO 0 A13

DON’T KNOW d A13

REFUSED r A13

A10=1

A11 How long do you intend to exclusively breastfeed?

Probe: IF RESPONDENT SAYS “AS LONG AS I’M ABLE TO:” How long are you hoping that will be?

| | | WEEKS (1-26 WEEKS)

| | | MONTHS (1-6 MONTHS)

| | | YEARS (1 – 6 YEARS)

DON’T KNOW d

REFUSED r

Fill CHILD from preload

A12 For how many weeks or months did [you/{CHILD/TWIN}’s mother] breastfeed/ have [you/{CHILD/TWIN}’s mother] been breastfeeding [CHILD]?

| | | WEEKS (1-26 WEEKS)

| | | MONTHS (1-7 MONTHS)

DON’T KNOW d

REFUSED r

A10=0,d,r

Fill CHILD from preload

A13 How old was [CHILD/TWIN] in months when you began feeding (him/her) formula or cow’s milk?

| | | MONTHS (1-7 MONTHS)

DON’T KNOW d

REFUSED r

Fill CHILD from preload

A14 Has [CHILD/TWIN] begun eating solid foods?

YES 1 A15

NO 0

DON’T KNOW d

REFUSED r

A10=1

Fill CHILD from preload

A15 How old was [CHILD/TWIN] in months when solid food was first introduced? Solid foods include cereal and baby food in jars, but not finger foods.

| | | MONTHS (1-7 MONTHS)

DON’T KNOW d

REFUSED r

non-pregnant moms

Fill CHILD, CHILD’S GENDER from preload

A16 Emotionality Subtest of the EASI-II (5 items)

ALL

B1 The next questions are about your health (IF PREGNANT, “before your current pregnancy”). In general, would you say your health is…

Excellent, 1

Very good, 2

Good, 3

Fair, or 4

Poor? 5

DON’T KNOW d

REFUSED r

ALL

B2 How tall are you without shoes?

| | | FEET (3 – 6)

| | | INCHES (0 – 11) ALLOW DECIMAL

| | | METERS

| | | CENTIMETERS

DON’T KNOW d

REFUSED r

ALL

IF PREGNANT, FILL THIS TIME, IF NOT PREGNANT FILL CHILD’S NAME

B3 Just before you got pregnant (IF PREGNANT, FILL “this time” IF NOT PREGNANT FILL “with [CHILD]”), how much did you weigh? Your best estimate is fine.

| | | | POUNDS (085 – 500)

| | | | KILOS

DON’T KNOW d

REFUSED r

all

IF PREGNANT, FILL THIS TIME, IF NOT PREGNANT FILL CHILD’S NAME

B4 Before you got pregnant (IF PREGNANT, “this time” IF NOT PREGNANT, “with [CHILD]”), were you ever told by a doctor, nurse, or other health care worker that you had Type 1 or Type 2 diabetes? This is not the same as gestational diabetes or diabetes that starts during pregnancy.

YES 1

NO 0

DON’T KNOW d

REFUSED r

all

if pregnant, display “this pregnancy” if not pregnant, display “your pregnancy with [child]” fill child from preload or sc10

B5 During (this pregnancy/your pregnancy with [CHILD]), were you told by a doctor, nurse, or other health care worker that you had gestational diabetes (diabetes that started during this pregnancy)?

haven’t been tested yet

YES 1

NO 0

DON’T KNOW d

REFUSED r

all

B6 During (this/your pregnancy with [CHILD]) did you have high blood pressure, hypertension (including pregnancy-induced hypertension [PIH]), preeclampsia, or toxemia?

YES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

B7 The following questions are about activities you might do during a typical day. Does your health now limit you in these activities?

[READ STATEMENT]. Are you limited a lot, limited a little, or not limited at all?

	Yes, limited a lot	limited a little		No, not limited at all		DON’T KNOW		REFUSED
a. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf?	1		2		3		d		r
b. Climbing several flights of stairs?	1		2		3		d		r

ALL

B8 Is there a place you go for general health care, if you are sick or need advice about your health - that is, any care except prenatal care or family planning?

YES 1

NO 0

DON’T KNOW d

REFUSED r

b8=1

INSERT FILL CONDITION OR DELETE ROW

B

8a. What kind of place do you go?

Clinic 1

Health Center 2

Hospital 3

Doctor’s office 4

Some other place 99

(STRING 99)

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): What kind of place do you go to for general health care?

ALL

B9. Is there a place you go, or have gone, for family planning or birth control?

YES 1

NO 0

DON’T KNOW d

REFUSED r

b9=1

INSERT FILL CONDITION OR DELETE ROW

B

9a. What kind of place do you go/ did you go?

The same place I receive general health care 1

Clinic 2

Health Center 3

Hospital 4

Doctor’s office 5

Some other place 99

(STRING 99)

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): What kind of place do you go to?

ALL

B10 How many more children would you like to have?

| | | NUMBER

(0-12)

DON’T KNOW d

REFUSED r

B10 ne 0,d,r

B11 How old would you like [CHILD] to be when you have your next child?

| | | MONTHS

(9-24)

| | | YEARS

(1-16)

DON’T KNOW d

REFUSED r

ALL

B12. Empathy Subscale of the AAPI-2, 10 items

all

C Intro The next questions are about your background.

INTERVIEWER: enter 1 to continue

ALL

C1 Are you of Hispanic, Latino, or Spanish origin?

INTERVIEWER: IF YES, ASK: What is your origin? CODE ALL RESPONSES.

NO, NOT OF HISPANIC, LATINO/A OR SPANISH ORIGIN 0

YES, MEXICAN, MEXICAN AMERICAN, CHICANO/A 1

YES, PUERTO RICAN 2

YES, CUBAN 3

YES, ANOTHER HISPANIC, LATINO/A OR SPANISH ORIGIN 4

DON’T KNOW d

REFUSED r

ALL

C2 What is your race?

INTERVIEWER: CODE ALL RESPONSES. ASK: Any other?

WHITE 11

BLACK OR AFRICAN AMERICAN 12

AMERICAN INDIAN OR ALASKA NATIVE 13

ASIAN INDIAN 14

CHINESE 15

FILIPINO 16

JAPANESE 17

KOREAN 18

VIETNAMESE 19

OTHER ASIAN 20

NATIVE HAWAIIAN 21

GUAMANIAN OR CHAMORRO 22

SAMOAN 23

OTHER PACIFIC ISLANDER 24

OTHER (SPECIFY) 99

(STRING 20)

DON’T KNOW d

REFUSED r

ALL

C3 Is any language other than English spoken in your home?

YES 1 C4

NO 0 C7

DON’T KNOW d C7

REFUSED r C7

C3=1

C4 What other languages are spoken in your home?

FRENCH 11

SPANISH 12

CAMBODIAN (KHMER) 13

CHINESE 14

HAITIAN CREOLE 15

HMONG 16

JAPANESE 17

KOREAN 18

VIETNAMESE 19

ARABIC 20

OTHER (SPECIFY) 99

(STRING 20)

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): What other language? (STRING 100)

C3=1

Fill LAN from C4

C5 How well do you speak [LAN]? Would you say . . .

Very well, 1

Well, 2

Not very well, or 3

Not at all? 4

DON’T KNOW d

REFUSED r

C3=1

Fill LAN from C4

C6 How well do you speak English? Would you say . . .

Very well, 1

Well, 2

Not very well, or 3

Not at all? 4

DON’T KNOW d

REFUSED r

all

C7 In what country were you born?

USA 059

MEXICO 303

GUATEMALA 313

CUBA 327

DOMINICAN REPUBLIC 329

INDIA 210

CHINA 207

PHILIPPINES 233

JAPAN 215

KOREA 217

VIETNAM 247

GUAM 066

SAMOA 527

OTHER (SPECIFY) 600

(STRING (NUM))

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (600): What other country?

all

C8 What is the highest grade or year of school that you have completed?

PROBE: IF GED: Before you received your GED, what was the highest grade or year of school you completed?

HIGHEST GRADE/YEAR IN SCHOOL SPECIFY GRADE 1

| | | GRADE (1 – 11)

HIGH SCHOOL DIPLOMA 2

ASSOCIATE DEGREE 3

BA/BS DEGREE 4

MA/MASTERS 5

PHD/DOCTORATE 6

SOME COLLEGE BUT NO DEGREE COMPLETION 8

NO REGULAR/FORMAL SCHOOL EDUCATION 0

OTHER (SPECIFY) 99

(STRING (NUM))

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): Please specify your highest level of education completed (string 99)

all

C9 Are you currently taking any education or training classes? This could include high school, ABE, GED or college courses, or any job skills training.

YES 1 C11

NO 0

DON’T KNOW d

REFUSED r

C10=0

child

C10 Do you plan to take any education or training classes before ([CHILD]’s/your unborn child’s) first birthday?

YES 1

NO 0

DON’T KNOW d

REFUSED r

if respondent’s age gte 18

C11 Are you currently serving in the military?

YES 1 C13

NO 0 C14

DON’T KNOW d C14

REFUSED r C14

C12=1

C12 Which of the following best describes your military status?

On active duty (not a member of the National Guard/Reserve), 1

As a member of the National Guard or Reserve in a full-time active duty program (AGR/FTS/AR), or 2

As a traditional National Guard/Reserve member (e.g., drilling unit, IMA, IRR)? 3

DON’T KNOW d

REFUSED r

PROGRAMMER BOX (NUM)

ALL RESPONSES, GO TO D1

D1 Intro I’m now going to ask you some questions about the people who live in your household.

INTERVIEWER: ENTER 1 TO CONTINUE

all

FILL [CHILD] FROM PRELOAD

D1A. Besides you (IF PREGNANT: “and [CHILD]”) does anyone else live in your household?

YES 1 D1B

NO 0 D2

DON’T KNOW d D1B

REFUSED r D1B

PROGRAMMER BEGIN LOOP

start by collecting all persons names first. then ask for dob, GENDER, AND RELATIONSHIP TO [CHILD] FOR EACH MEMBER OF THE HOUSEHOLD.

Starting with the oldest person, please tell me the names of all the other people who normally live here.

INTERVIEWER: IF R IS UNCOMFORTABLE, YOU CAN ASK THEM TO PROVIDE INITIALS ONLY AND NO NAMES. IF R IS UNCOMFORTABLE GIVING DATES OF BIRTH, SHE CAN JUST GIVE YEAR OF BIRTH

PROBE: Who else lives here?

WHAT IS [NAME]’S AGE?

IS [NAME] MALE OR FEMALE?

WHAT IS [NAME]’S RELATIONSHIP TO ([CHILD]/YOUR UNBORN CHILD)?

RELATIONSHIP CODES:

BIOLOGICAL MOTHER 11

BIOLOGICAL FATHER 12

ADOPTIVE MOTHER 13

ADOPTIVE FATHER 14

STEPMOTHER 15

STEPFATHER 16

GRANDMOTHER. 17

GRANDFATHER 18

GREAT GRANDMOTHER 19

GREAT GRANDFATHER 20

SISTER/STEPSISTER 21

BROTHER/STEPBROTHER 22

OTHER RELATIVE OR IN-LAW (FEMALE) 23

OTHER RELATIVE OR IN-LAW (MALE) 24

FOSTER PARENT (FEMALE) 25

FOSTER PARENT (MALE). 26

OTHER NON-RELATIVE (FEMALE) 27

OTHER NON-RELATIVE (MALE) 28

PARENT’S PARTNER (FEMALE) 29

PARENT’S PARTNER (MALE) 30

	Q#	Q#	Q#	Q#
	NAME	(DOB for minors, age for adults)	GENDER	RELATIONSHIP
a.	(STRING 20)	| | |/| | |/| | | | |	| | |	| | |
b.	(STRING 20)	| | |/| | |/| | | | |	| | |	| | |
c.	(STRING 20)	| | |/| | |/| | | | |	| | |	| | |
d.	(STRING 20)	| | |/| | |/| | | | |	| | |	| | |
e.	(STRING 20)	| | |/| | |/| | | | |	| | |	| | |
f.	(STRING 20)	| | |/| | |/| | | | |	| | |	| | |

END LOOP

END LOOP AT LAST HOUSEHOLD MEMBER.

aLL RESPONDENTS GO TO D2

all

D2 How many times have you moved in the past 12 months?

| | | NUMBER (0 – 12)

DON’T KNOW d

REFUSED r

BIO father not living in household or mother not married to BIO father (E2 NE 1)

D3 Do you have a spouse or partner?

YES 1

NO 0

DON’T KNOW d

REFUSED r

d3=1

D3a What is the name of your spouse or partner?

(STRING 20)

FIRST NAME

DON’T KNOW d

REFUSED r

r has spouse/PARTNER

FILL SPOUSE FROM HOUSEHOLD ROSTER, or new item

D4 Is [SPOUSE] currently serving in the military?

YES 1 D5

NO 0

DON’T KNOW d

REFUSED r

d4=1

D5 Which of the following best describes your spouse or partner’s military status?

On active duty (not a member of the National Guard/Reserve), 1

As a member of the National Guard or Reserve in a full-time active duty program (AGR/FTS/AR), or 2

As a traditional National Guard/Reserve member (e.g., drilling unit, IMA, IRR)? 3

DON’T KNOW d

REFUSED r

ALL

D6 Intro The next questions are about ([CHILD]’s/ your unborn child’s) father.

INTERVIEWER: ENTER 1 TO CONTINUE

ENTER 1 TO CONTINUE 1

PARTICIPANTS IN WHICH THE BIOLOGICAL FATHER IS NOT LIVING IN HOUSEHOLD

Fill CHILD from preload

D7 What is the first name of [CHILD]’s biological father?

(STRING 20)

FIRST NAME

DON’T KNOW d

REFUSED r

all

fill CHILD’S BIOLOGICAL FATHER from household roster or E1

D8 Are you and [BIO FATHER] currently . . .

Married, 1

Divorced, 2

Separated, or 3

Have you never been married to each other? 4 D8a

BIO FATHER DECEASED n GO TO E1

DON’T KNOW d

REFUSED r

d8=4

FILL bio father FROM d7

D8a Are you and [BIO FATHER] currently in a romantic relationship?

YES 1

NO 0

DON’T KNOW d

REFUSED r

FOR PARTICIPANTS IN WHICH THE BIOLOGICAL DAD IS NOT LIVING IN HOUSEHOLD

Fill NAME OF CHILD’S BIO FATHER from E1 or household roster

D9 How old is [BIO FATHER]?

PROBE: Your best estimate is fine.

| | | YEARS (15 – 65)

BIO FATHER DECEASED n GO TO E1

DON’T KNOW d

REFUSED r

pregnant moms

Fill NAME OF CHILD’S BIO FATHER from E1 or household roster; IF NOT LIVING WITH BIO FATHER, FILL “did you ever”

D10 Since this pregnancy began, (did you ever live/how many months have you lived) in the same household as [BIO FATHER]?

| | | MONTHS (0 - 9)

THE ENTIRE PREGNANCY

DON’T KNOW d

REFUSED r

non-PREGNANT MOMS WHO LIVE WITH BIO FATHER

Fill NAME OF CHILD’S BIO FATHER from E1 or household roster, Fill CHILD’S DOB from preload

D11 Since [CHILD’S DOB], how many months have you lived in the same household as [BIO FATHER]?

| | | MONTHS (0 – 6)

THE ENTIRE TIME

DON’T KNOW d

REFUSED r

pregnant moms

Fill NAME OF CHILD’S BIO FATHER from E1 or household roster; if pregnant, display “this pregnancy” if not pregnant, display “your pregnancy with [child]” fill child from preload or sc10

D12 During the past (3 months/NUMBER OF MONTHS PREGNANT) of your pregnancy, how often did [BIO FATHER] buy things for your pregnancy or to prepare for the baby, such as formula, diapers, clothes or toys, or give you money to buy things for the baby? Would you say . . .

Every day or almost every day, 1

A few times a week, 2

A few times a month, 3

Less often than a few times a month, or 4

Never? 5

DON’T KNOW d

REFUSED r

pregnant moms

Fill NAME OF CHILD’S BIO FATHER from E1 or household roster; if pregnant, display “this pregnancy” if not pregnant, display “your pregnancy with [child]” fill child from preload or sc10

D13 During the (3 months/NUMBER OF MONTHS PREGNANT)pregnancy, how often did [BIO FATHER] help you in other ways, such as getting ready for the baby, helping around the house or with chores, or providing transportation to prenatal visits or other places you needed to go? Would you say . . .

Every day or almost every day, 1

A few times a week, 2

A few times a month, 3

Less often than a few times a month, or 4

Never? 5

DON’T KNOW d

REFUSED r

non-pregnant moms

Fill CHILD from preload; Fill NAME OF CHILD’S BIO FATHER from E1 or household roster

D14 During the past 3 months, how often did [BIO FATHER] buy things for [CHILD], such as formula, diapers, clothes, or toys, or give you money to buy things for [CHILD]? Would you say . . .

Every day or almost every day, 1

A few times a week, 2

A few times a month, 3

Less often than a few times a month, or 4

Never? 5

DON’T KNOW d

REFUSED r

NON-pregnant moms

Fill CHILD from preload; Fill NAME OF CHILD’S BIO FATHER from E1 or household roster

D15 During the past 3 months, how often did [BIO FATHER] help you in other ways, such as caring for [CHILD], helping around the house or with chores, or providing transportation to places you needed to go? Would you say . . .

Every day or almost every day, 1

A few times a week, 2

A few times a month, 3

Less often than a few times a month, or 4

Never? 5

DON’T KNOW d

REFUSED r

IF R HAS PARTNER/SPOUSE

D16 All things considered, on a scale from 1 to 7, where 1 is “completely unhappy” and 7 is “completely happy,” how happy are you with your spouse or partner?

INTERVIEWER: IF NECESSARY, YOU MAY READ CATEGORIES TO RESPONDENT

Completely unhappy 1

Moderately unhappy 2

Slightly UNhappy 3

Not happy or unhappy 4

Slightly happy 5

Moderately happy or 6

Completely happy 7

DON’T KNOW d

REFUSED r

all

E Intro The next questions are about income and services you or other members or your household may have received.

INTERVIEWER: enter 1 to continue

ENTER 1 TO CONTINUE 1

all

E1 Are you currently working for pay?

YES 1 E4

NO 0 E2

DON’T KNOW d E2

REFUSED r E2

E1 ne1

E2 Are you currently on maternity leave?

YES 1 E3

NO 0 E4

DON’T KNOW d E4

REFUSED r E4

ALL

IF PREGNANT, DISPLAY “YOUR UNBORN CHILD” IF NOT PREGNANT DISPLAY [CHILD]. FILL CHILD’S NAME FROM PRELOAD OF SC10

E3 Do you plan to work for pay before ([CHILD]/ your unborn child) turns one year old?

YES 1

NO 0

DON’T KNOW d

REFUSED r

all

E4 How many months were you employed (did you work for pay) during the past 3 years (including your current job)?

RESPONDENT DIDN’T WORK 0

Less than 6 months 1

7 to 12 MONTHS 2

13 to 24 MONTHS 3

More than 24 months 4

DON’T KNOW d

REFUSED r

E4 GT 1

programmer: we need to revise the year date each calendar year. fill prior month.

E5 Last month, that is (MONTH/YEAR), what were your approximate total annual earnings from your work, including tips and overtime pay? When answering, please include income from all jobs you held last month.

PROBE: Please do not include earnings from anyone else in your household.

INTERVIEWER: ASK THIS QUESTION OPEN-ENDED AND WAIT FOR RESPONSE. USE CATEGORIES BELOW TO PROBE IF RESPONDENT IS UNSURE.

PROBE: Would you say it was . . .[READ CATEGORIES]

Less than $500, 1

$500 to $999, 2

$1,000 to $1,499, 3

$1,500 to $1,999, 4

$2,000 to $2,499, 5

$2,500 to $2,999, 6

$3,000 to $3,499, or 7

$3,500 or over? 8

DON’T KNOW d

REFUSED r

all

Fill Local TANF from preload; Fill SPOUSE/PARTNER from household roster

E6 Please tell me whether you or any other members of your household received income or benefits from the following sources in the past month. This includes anyone who you support and/or supports you and lives in your household. [READ STATEMENT]

PROBE: Did you or any other members of your household receive income from this source in the past month?

	yes	no	don’t know	refused
a. Cash welfare which is also known as TANF, or [Local name of TANF]	1	0	d	r
b. Food stamp or Supplemental Nutrition Assistance Program (SNAP) benefits	1	0	d	r
c. Disability insurance such as Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI)	1	0	d	r
d. Earnings from other household members including [SPOUSE/PARTNER]? Please report any earnings before taxes or other deductions, and include tips, commissions, and overtime pay	1	0	d	r
e. Benefits from WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children)	1	0	D	r

all

E7 During the past year, have you ever received help in applying for public benefits, including TANF, SNAP, or WIC?

YES 1

NO 0

DON’T KNOW d

REFUSED r

E7=0,d,r

E7a During the past year, did you ever want or need help in applying for public benefits, including TANF, SNAP, or WIC?

YES 1

NO 0

DON’T KNOW d

REFUSED r

E7=1

E7b Are you currently receiving help in applying for public benefits, including TANF, SNAP, or WIC?

YES 1

NO 0

DON’T KNOW d

REFUSED r

all

E8 Some earnings and income come from other sources, like unemployment insurance or help from family and friends. Thinking about these other sources of income, what is the total amount of additional income that that you received (in addition to earnings) and the total amount of any income or earnings any other adult members of your household received last month?

PROBE: Your best estimate is fine.

| | | |, | | | | NUMBER

(0-250,000)

DON’T KNOW d

REFUSED r

E8=d,r

E9 Was it . . .

Less than $1,000, 1

$1,000 or more, but less than $2,000, 2

$2,000 or more but less than $3,000, 3

$3,000 or more but less than $4,000, 4

$4,000 or more but less than $5,000, 5

$5,000 or more but less than $7,500, 6

$7,500 or more but less than $10,000, or 7

More than $10,000? 8

DON’T KNOW d

REFUSED r

ALL

E10 Do you currently have any of the following… [READ ITEM].

	yes	no	DON’T KNOW	REFUSED
a. A checking account?	1	0	d	r
(a=NO) A_1 Could you get one if you wanted to?	1	0	d	r
(a=NO) A_2 Does anyone else in your household have one?	1	0	d	r
b. A savings account?	1	0	d	r
(b=NO) B_1 Could you get one if you wanted to?	1	0	d	r
(b=NO) B_2 Does anyone else in your household have one?	1	0	d	r
c. A credit card?	1	0	d	r
(c=NO) C_1 Could you get one if you wanted to?	1	0	d	r
(c=NO) C_2 Does anyone else in your household have one?	1	0	d	r
PROGRAMMER: ASK ONLY IF RESPONDENT IS OLD ENOUGH TO DRIVE IN HER STATE d. A driver’s license?	1	0	d	r
(d=NO) D_1 Could you get one if you wanted to?	1	0	d	r
(d=NO) D_2 Does anyone else in your household have one?	1	0	d	r

all

E11 Please tell me whether the next two statements are often true, sometimes true, or never true for your family within the past 12 months, that is, since (MONTH/YEAR).

Within the past 12 months we worried whether our food would run out before we got money to buy more. Was this . . .

Often true, 1

Sometimes true, or 2

Never true? 3

DON’T KNOW d

REFUSED r

all

E12 Within the past 12 months the food we bought just didn’t last and we didn’t have money to get more. Was this . . .

Often true, 1

Sometimes true, or 2

Never true? 3

DON’T KNOW d

REFUSED r

all

E13 The next questions are about health insurance, Including health insurance obtained through employment or purchased directly as well as government programs like Medicare and Medicaid that provide medical care or help pay medical bills. Are you covered by health insurance or some other kind of health care plan?

YES 1

NO 0

DON’T KNOW d

REFUSED r

all

E14 What kind of health insurance or health care coverage do you have? Include those that pay for only one type of service (nursing home care, accidents, or dental care). Exclude private plans that only provide extra cash while hospitalized. If you have more than one kind of health insurance, tell me about all the plans that you have.

PROBE: IF R GIVES A NAME OF A HEALTH INSURANCE PLAN, LIKE “BLUE CROSS/BLUE SHIELD,” ASK: Is that private insurance paid for by you or an employer, or is it paid for by the state or federal government, like Medicaid or [STATE SPECIFIC MEDICAID NAME]?

IF R TELLS YOU ABOUT CHILD’S INSURANCE, DO NOT RECORD HERE. THAT GETS CODED IN A SUBSEQUENT QUESTION.

PRIVATE HEALTH INSURANCE 1

MEDICARE 2

MEDIGAP 3

MEDICAID 4

SCHIP (CHIP/CHILDREN’S HEALTH INSURANCE PROGRAM) 5

MILITARY HEALTH CARE (TRICARE/VA/CHAMP-VA) 6

INDIAN HEALTH SERVICE 7

STATE-SPONSORED HEALTH PLAN 8

SINGLE SERVICE PLAN (E.G., DENTAL, VISION, PRESCRIPTIONS) 9

NO COVERAGE OF ANY TYPE 10

OTHER (SPECIFY) 99

(STRING (NUM))

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): What other insurance?

all

E15 During the past year, have you ever received help in applying for health insurance for yourself?

YES 1 E15b

NO 0 E15a

DON’T KNOW d E15a

REFUSED r E15a

E15=0,d,r

E15a During the past year, did you ever want or need help in applying for health insurance for yourself?

YES 1

NO 0

DON’T KNOW d

REFUSED r

E15=1

E15b Are you currently receiving help in applying for health insurance for yourself?

YES 1

NO 0

DON’T KNOW d

REFUSED r

non-pregnant moms

Fill child from preload

E16 Does [CHILD] have any kind of health care coverage, including health insurance, prepaid plans such as HMOS, or government plans such as Medicaid?

PROBE: Medicaid refers to a medical assistance program that provides health care coverage to low-income and disabled persons. The Medicaid program is a joint federal-state program that is administered by the states. HMO is Health Maintenance Organization.

YES 1

NO 0

DON’T KNOW d

REFUSED r

non-pregnant moms

child’s gender, state medicaid name, state schip name

E17 Is [he/she] insured by Medicaid or the State Children’s Health Insurance Program or S-CHIP? In this state, the program is sometimes called [FILL MEDICAID NAME, S-CHIP NAME].

YES 1

NO 0

DON’T KNOW d

REFUSED r

non-pregnant moms

E18 Have you ever received help in applying for health insurance for [CHILD]?

YES 1 E18b

NO 0 E18a

DON’T KNOW d E18a

REFUSED r E18a

E18=0,d,r

child

E18a Have you ever wanted or needed help in applying for health insurance for [CHILD]?

YES 1

NO 0 E19

DON’T KNOW d E19

REFUSED r E19

E18=1

E18b Are you currently receiving help in applying for health insurance for [CHILD]?

YES 1

NO 0

DON’T KNOW d

REFUSED r

NON-PREGNANT MOMS

child

E19 Since [CHILD] was born, has s/he been in child care or taken care of by anyone other than yourself on a regular basis?

YES 1 E19b

NO 0 E19a

DON’T KNOW d E19a

REFUSED r E19a

E19=0,d,r

E19a Since [CHILD] was born, did you ever want or need child care services for [CHILD]?

YES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

F1 Generalized Anxiety Scale-7 (GAD-7), 7 items

ALL

F2 Center for Epidemiological Studies Depression Scale (CES-D), 10 items

ALL
F 3 Pearlin Mastery Scale, 7 items

ALL

F4 Wechsler Adult Intelligence Scale-R (WAIS-R), select items

ALL

F5 Attachment Style Questionnaire- Short Form (ASQ-SF) 25 items

all

F6 The next questions are about smoking cigarettes during the past 2 years. Have you smoked at least 100 cigarettes in the past 2 years?

YES 1

NO 0

DON’T KNOW d

REFUSED r

F6 = 0, d, r

F7 Have you smoked any cigarettes in the past 2 years?

YES 1 F8

NO 0 F11

DON’T KNOW d F11

REFUSED r F11

F6=1 or F7=1

F8 In the 3 months before you got pregnant, how many cigarettes or packs did you smoke on an average day?

INTERVIEWER: ENTER “0” IF RESPONDENT DID NOT SMOKE.

ENTER “1” IF RESPONDENT SMOKED LESS THAN 1 CIGARETTE A DAY.

PROBE: A pack has 20 cigarettes.

| | | NUMBER (1-60) AND CODE

CIGARETTES 1

PACKS 2

DON’T KNOW d

REFUSED r

F6=1 or F7=1

F9 In the last 3 months of your pregnancy, how many cigarettes or packs did you smoke on an average day?

INTERVIEWER: ENTER “0” IF RESPONDENT DID NOT SMOKE.

ENTER “1” IF RESPONDENT SMOKED LESS THAN 1 CIGARETTE A DAY.

PROBE: A pack has 20 cigarettes

| | | NUMBER (1-60) AND CODE

CIGARETTES 1

PACKS 2

DON’T KNOW d

REFUSED r

F6=1 or F7=1

F10 How many cigarettes or packs do you currently smoke on an average day?

INTERVIEWER: ENTER “0” IF RESPONDENT DID NOT SMOKE.

ENTER “1” IF RESPONDENT SMOKED LESS THAN 1 CIGARETTE A DAY.

PROBE: A pack has 20 cigarettes

| | | NUMBER (1-60) AND CODE

CIGARETTES 1

PACKS 2

DON’T KNOW d

REFUSED r

ALL

F11 Which of the following statements best describes the rules about smoking inside your home now?

No one is allowed to smoke anywhere inside my home, 1

Smoking is allowed in some rooms or at some times, or 2

Smoking is permitted anywhere inside my home? 3

DON’T KNOW d

REFUSED r

ALL

F12 The next questions are about drinking alcoholic beverages. By a “drink” we mean a can or bottle of beer, a wine cooler or glass of wine, a shot of liquor, or a mixed drink.

During the 3 months before you got pregnant, how many alcoholic drinks did you have in an average week?

NOTE: A HELP SCREEN IS AVAILABLE WITH EQUIVALENCES

DIDN’T DRINK THEN 0

LESS THAN 1 DRINK 1

1 TO 3 DRINKS 2

4 TO 6 DRINKS 3

7 TO 13 DRINKS 4

14 TO 19 DRINKS 5

20 OR MORE DRINKS 6

DON’T KNOW d

REFUSED r

all

F13 During the 3 months before you got pregnant, how many times did you drink 4 alcoholic drinks or more in one sitting? Would you say…

PROBE: A sitting is a two hour time span.

6 or more times, 4

4 to 5 times, 3

2 to 3 times, 2

1 time, or 1

Never? 0

DON’T KNOW d

REFUSED r

ALL

IF PREGNANT AND LESS THAN 3 MONTHS PREGNANT (CALCULATE FROM SC12) DISPLAY NUMBER OF MONTHS PREGNANT

F14 In the last 3 (NUMBER OF MONTHS PREGNANT) months of your pregnancy, how many alcoholic drinks did you have in an average week?

NOTE: A HELP SCREEN IS AVAILABLE WITH EQUIVALENCES.

DIDN’T DRINK THEN 0

LESS THAN 1 DRINK 1

1 TO 3 DRINKS 2

4 TO 6 DRINKS 3

7 TO 13 DRINKS 4

14 TO 19 DRINKS 5

20 OR MORE DRINKS 6

DON’T KNOW d

REFUSED r

ALL

IF PREGNANT AND LESS THAN 3 MONTHS PREGNANT (CALCULATE FROM SC12) DISPLAY NUMBER OF MONTHS PREGNANT

F15 In the last 3 (NUMBER OF MONTHS PREGNANT)months of your pregnancy, how many times did you drink 4 alcoholic drinks or more in one sitting? Would you say…

PROBE: A sitting is a two hour time span.

6 or more times, 4

4 to 5 times, 3

2 to 3 times, 2

1 time, or 1

Never? 0

DON’T KNOW d

REFUSED r

ALL

F15a The next questions are about drug use on your own before and during pregnancy. By “on your own” we mean either without a doctor’s prescription, in larger amounts than prescribed, or for a longer period than prescribed. Did you use any of the following drugs on your own in the month before you got pregnant? [READ LIST, CODE ONE FOR EACH]

	YES	NO	DON’T KNOW	REFUSED
a. Prescription drugs?	1	0	d	r
(IF YES) What kinds? ENTER MEDICINE NAMES:
b. Marijuana (pot, bud) or Hashish (Hash)?	1	0	d	r
c. Amphetamines(uppers, ice, speed, crystal meth, crank)?	1	0	d	r
d. Cocaine (rock, coke, crack) or heroin (smack, horse)?	1	0	d	r
e. Tranquilizers (downers, ludes) or hallucinogens (LSD/acid, PCP/angel dust, ecstasy)?	1	0	d	r
f. Sniffing gasoline, glue, hairspray, or other aerosols?	1	0	d	r

F15a_ANY=1

F15b Did you use any of the following drugs on your own while you were pregnant? [READ LIST, CODE ONE FOR EACH]

	YES	NO	DON’T KNOW	REFUSED
a. Prescription drugs?	1	0	d	r
(IF YES) What kinds? ENTER MEDICINE NAMES
b. Marijuana (pot, bud) or Hashish (Hash)?	1	0	d	r
c. Amphetamines(uppers, ice, speed, crystal meth, crank)?	1	0	d	r
d. Cocaine (rock, coke, crack) or heroin (smack, horse)?	1	0	d	r
e. Tranquilizers (downers, ludes) or hallucinogens (LSD/acid, PCP/angel dust, ecstasy)?	1	0	d	r
f. Sniffing gasoline, glue, hairspray, or other aerosols?	1	0	d	r

all

F16 During the past year, have you received help or treatment for alcohol or substance abuse problems?

YES 1 F17

NO 0 F18

DON’T KNOW d F18

REFUSED r F18

F16=1

programmer; for each YES RESPONSE, GO TO NEXT ITEM IN LIST. FOR EACH no response, display question on screen: DID YOU NEED OR WANT The SERVICE DURING THE PAST YEAR?

F17 I’m going to read a list of places where people may go to receive help or treatment for alcohol or substance abuse problems. For each one, please tell me whether you used the service, or if you needed or wanted the service during the past year.

	Yes	No	Wanted Needed	DK	R
a. Doctor or other health care professional	1	0	3	4	5
b. A hospital or other inpatient program	1	0	3	4	5
c. A support group	1	0	3	4	5
d. A priest, minister, or rabbi	1	0	3	4	5
e. A spiritualist or healer	1	0	3	4	5
f. A social worker, counselor, or other mental health professional	1	0	3	4	5

all

F18 During the past year, have you received mental health help or treatment?

YES 1 F19

NO 0 F20

DON’T KNOW d F20

REFUSED r F20

F18=1

programmer; for each YES RESPONSE, GO TO NEXT ITEM IN LIST. FOR EACH no response, display question on screen: DID YOU NEED OR WANT The SERVICE DURING THE PAST YEAR?

F19 I’m going to read a list of places where people may go to receive mental health services. For each one, please tell me whether you used the service, or if you needed or wanted the service during the past year.

	Yes	No	Wanted or Needed		DK	R
a. Doctor or other health care professional	1	0		3	4	5
b. A hospital or other inpatient program	1	0		3	4	5
c. A support group	1	0		3	4	5
d. A priest, minister, or rabbi	1	0		3	4	5
e. A spiritualist or healer	1	0		3	4	5
f. A social worker, counselor, or other mental health professional	1	0		3	4	5

D8=1 OR D8A=1 OR D16=1; IF D8=1 OR D8A=1, FILL NAME OF BIO DAD FROM D7; IF D16=1, FILL NAME OF SPOUSE FROM D17

F20 WEB Short Form, 6 items

D8=1 OR D8A=1 OR D16=1; IF D8=1 OR D8A=1, FILL NAME OF BIO DAD FROM D7; IF D16=1, FILL NAME OF SPOUSE FROM D17

F21 Conflict Tactics Scale (CTS) adapted for SHM Survey, 9 items

all

F22 Have you ever received any services for domestic violence?

YES 1 F22b

NO 0 F22a

DON’T KNOW d F22a

REFUSED r F22a

F22=0,d,r

F22a Did you ever want or need services for domestic violence?

YES 1

NO 0

DON’T KNOW d

REFUSED r

F22=1

F22b Are you currently receiving services for domestic violence?

YES 1

NO 0

DON’T KNOW d

REFUSED r

all

F23 During the past year, have you received counseling for domestic violence or anger management?

YES 1 F23b

NO 0 F23a

DON’T KNOW d F23a

REFUSED r F23a

F23=0,d,r

F23a During the past year, did you ever want or need counseling for domestic violence or anger management?

YES 1

NO 0

DON’T KNOW d

REFUSED r

F23=1

F23b Are you currently receiving counseling for domestic violence or anger management?

YES 1

NO 0

DON’T KNOW d

REFUSED r

all

F24 Have you been arrested within the past year?

YES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

G21a-c Families enroll in home visiting for many different reasons. What are the main reasons you want to enroll in home visiting?

PROBE: Any other reason? PLEASE CODE UP TO 3 REASONS.

CODE THREE REASONS

TO LEARN HOW TO HAVE A HEALTHY PREGNANCY 1

TO LEARN HOW TO HELP MY BABY BE HEALTHY 2

TO LEARN HOW TO HELP MY BABY LEARN AND DEVELOP 3

TO GET HELP COMPLETING MY EDUCATION OR JOB TRAINING 4

TO HAVE SOMEONE TO TALK TO WHEN I HAVE PROBLEMS 5

TO HELP GET SERVICES FOR MENTAL HEALTH, SUBSTANCE USE, OR DOMESTIC VIOLENCE IN MY FAMILY 6

TO GET TRANSPORTATION TO SER VICES MY FAMILY NEEDS .7

TO GET HEALTH INSURANCE FOR MYSELF OR MY BABY 9

TO GET HELP GETTING FINANCIAL ASSISTANCE 10

TO GET HELP GETTING GOOD CHILD CARE AND CHILD EDUCATION SERVICES 11

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): What other reason?

all

G23 How often do you think you will have home visits? Would you say . . .

A few times a week, 1

Once a week, 2

Once every two weeks, 3

Once a month, or 4

Once every few months? 5

DON’T KNOW d

REFUSED r

all

G24 Mothers have different preferences for what they would like to do in home visits. I will read a list of things that might be a part of home visiting. For each one, please tell me whether this is something you would like to do in home visiting.

	YES, Would LIKE to do this in home visiting	NO, Would NOT like to do this in home visiting	NO OPINION Don’t care either way	DON’T KNOW	REFUSED
a. Watch videos or read about being a parent	1	0	2	d	r
b. Have your home visitor give you feedback on how to interact with your baby	1	0	2	d	r
c. Talk with your home visitor about your own childhood	1	0	2	d	r
d. Make and follow plans to solve a parenting problem	1	0	2	d	r
e. Talk with your home visitor about personal feelings	1	0	2	d	r
f. Get reassurance from your home visitor about being a parent	1	0	2	d	r
g. Make and follow plans to continue a. your education	1	0	2	d	r
h. Make and follow plans to get services your family needs	1	0	2	d	r

all

G25 Did anyone encourage you to enroll in the home visiting program? For example, a relative, a friend, a neighbor, a health care provider or a social services provider?

YES 1

NO 0

DON’T KNOW d

REFUSED r

G25=1

G26 Who encouraged you to enroll in the home visiting program? Was it a family member or relative, a friend, or a provider or other type of professional staff?

PROBE: Anyone else?

FAMILY MEMBER/RELATIVE 1

FRIEND 2

PROVIDER/PROFESSIONAL STAFF 3

OTHER (SPECIFY) 99

(STRING (NUM))

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): What other person encouraged you to enroll in the home visiting program? (string 99)

all

G27 Was there anyone who did not want you to enroll in the home visiting program?

YES 1

NO 0

DON’T KNOW d

REFUSED r

G27=1

G28 Who did not want you to enroll in the home visiting program? Was it a family member or relative, a friend, or a provider or other type of professional staff?

PROBE: Anyone else?

FAMILY MEMBER/RELATIVE 1

FRIEND 2

PROVIDER/PROFESSIONAL STAFF 3

OTHER (SPECIFY) 99

(STRING (NUM))

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): What other person did not want you to enroll in the home visiting program? (string 99)

all

H1 We are almost done with the survey. Thank you very much for answering my questions. I just have a few more. First, what is your Social Security Number? This will be kept confidential and only used as a way of identifying you when we need to talk to you again for the next survey.

| | | |-| | |-| | | | | SOCIAL SECURITY NUMBER

DON’T KNOW d

REFUSED r

all

H2a Please tell me the names, addresses and telephone numbers of three people who do not live with you but who will know how to contact you roughly a year from now. This will help us contact you if you move so we can still complete a follow up interview with you.

What is the name of the first person who will know how we can reach you?

interviewer: enter name of person

(STRING 50)

NAME

DON’T KNOW d CONCLUDE

REFUSED r CONCLUDE

H2 ne d,r

H2b How is this person related to you?

BIOLOGICAL MOTHER 11

BIOLOGICAL FATHER 12

ADOPTIVE MOTHER 13

ADOPTIVE FATHER 14

STEPMOTHER 15

STEPFATHER 16

GRANDMOTHER 17

GRANDFATHER 18

GREAT GRANDMOTHER 19

GREAT GRANDFATHER 20

SISTER/STEPSISTER 21

BROTHER/STEPBROTHER 22

OTHER RELATIVE OR IN-LAW (FEMALE) 23

OTHER RELATIVE OR IN-LAW (MALE) 24

FOSTER PARENT (FEMALE) 25

FOSTER PARENT (MALE). 26

OTHER NON-RELATIVE (FEMALE) 27

OTHER NON-RELATIVE (MALE) 28

PARENT’S PARTNER (FEMALE) 29

PARENT’S PARTNER (FEMALE) 30

DON’T KNOW d

REFUSED r

IF OTHER RELATIVE OR IN-LAW (FEMALE) (23): What is her relationship? (string 99)

IF OTHER RELATIVE OR IN-LAW (MALE) (24): What is his relationship? (string 99)

IF OTHER NON-RELATIVE (FEMALE) (27): What is her relationship? (string 99)

IF OTHER NON-RELATIVE (MALE) (28): What is his relationship? (string 99)

H2a NE d,r

H2c What is that person’s telephone number?

INTERVIEWER: WE SHOULD COLLECT TWO NUMBERS PER PERSON, IF POSSIBLE.

| | | | - | | | | - | | | | |

(RANGE) (RANGE) (RANGE)

DON’T KNOW d

REFUSED r

CELL PHONE:

| | | | - | | | | - | | | | |

(RANGE) (RANGE) (RANGE)

DON’T KNOW d

REFUSED r

H2a ne d,r

H2d Please give me their permanent address.

STREET 1

STREET 2

STREET 3

CITY

STATE

ZIP

DON’T KNOW d

REFUSED r

H3a NE d,r

H3a What is the name of a second person?

interviewer: enter name of person

(STRING 50)

NAME

DON’T KNOW d CONCLUDE

REFUSED r CONCLUDE

H3a ne d,r

H3b How is this person related to you?

BIOLOGICAL MOTHER 11

BIOLOGICAL FATHER 12

ADOPTIVE MOTHER 13

ADOPTIVE FATHER 14

STEPMOTHER 15

STEPFATHER 16

GRANDMOTHER 17

GRANDFATHER 18

GREAT GRANDMOTHER 19

GREAT GRANDFATHER 20

SISTER/STEPSISTER 21

BROTHER/STEPBROTHER 22

OTHER RELATIVE OR IN-LAW (FEMALE) 23

OTHER RELATIVE OR IN-LAW (MALE) 24

FOSTER PARENT (FEMALE) 25

FOSTER PARENT (MALE). 26

OTHER NON-RELATIVE (FEMALE) 27

OTHER NON-RELATIVE (MALE) 28

PARENT’S PARTNER (FEMALE) 29

PARENT’S PARTNER (FEMALE) 30

DON’T KNOW d

REFUSED r

IF OTHER RELATIVE OR IN-LAW (FEMALE) (23): What is her relationship? (string 99)

IF OTHER RELATIVE OR IN-LAW (MALE) (24): What is his relationship? (string 99)

IF OTHER NON-RELATIVE (FEMALE) (27): What is her relationship? (string 99)

IF OTHER NON-RELATIVE (MALE) (28): What is his relationship? (string 99)

H3a NE d,r

H3c What is that person’s telephone number?

INTERVIEWER: WE SHOULD COLLECT TWO NUMBERS PER PERSON, IF POSSIBLE.

| | | | - | | | | - | | | | |

(RANGE) (RANGE) (RANGE)

DON’T KNOW d

REFUSED r

CELL PHONE:

| | | | - | | | | - | | | | |

(RANGE) (RANGE) (RANGE)

DON’T KNOW d

REFUSED r

H3a ne d,r

H3d Please give me their permanent address.

STREET 1

STREET 2

STREET 3

CITY

STATE

ZIP

DON’T KNOW d

REFUSED r

H4a NE d,r

H4a What is the name of a third person?

interviewer: enter name of person

(STRING 50)

NAME

DON’T KNOW d CONCLUDE

REFUSED r CONCLUDE

H4a ne d,r

H4b How is this person related to you?

BIOLOGICAL MOTHER 11

BIOLOGICAL FATHER 12

ADOPTIVE MOTHER 13

ADOPTIVE FATHER 14

STEPMOTHER 15

STEPFATHER 16

GRANDMOTHER 17

GRANDFATHER 18

GREAT GRANDMOTHER 19

GREAT GRANDFATHER 20

SISTER/STEPSISTER 21

BROTHER/STEPBROTHER 22

OTHER RELATIVE OR IN-LAW (FEMALE) 23

OTHER RELATIVE OR IN-LAW (MALE) 24

FOSTER PARENT (FEMALE) 25

FOSTER PARENT (MALE). 26

OTHER NON-RELATIVE (FEMALE) 27

OTHER NON-RELATIVE (MALE) 28

PARENT’S PARTNER (FEMALE) 29

PARENT’S PARTNER (FEMALE) 30

DON’T KNOW d

REFUSED r

IF OTHER RELATIVE OR IN-LAW (FEMALE) (23): What is her relationship? (string 99)

IF OTHER RELATIVE OR IN-LAW (MALE) (24): What is his relationship? (string 99)

IF OTHER NON-RELATIVE (FEMALE) (27): What is her relationship? (string 99)

IF OTHER NON-RELATIVE (MALE) (28): What is his relationship? (string 99)

H4a NE d,r

H4c What is that person’s telephone number?

INTERVIEWER: WE SHOULD COLLECT TWO NUMBERS PER PERSON, IF POSSIBLE.

| | | | - | | | | - | | | | |

(RANGE) (RANGE) (RANGE)

DON’T KNOW d

REFUSED r

CELL PHONE:

| | | | - | | | | - | | | | |

(RANGE) (RANGE) (RANGE)

DON’T KNOW d

REFUSED r

H4a ne d,r

H4d Please give me their permanent address.

STREET 1

STREET 2

STREET 3

CITY

STATE

ZIP

DON’T KNOW d

REFUSED r

1