Parent Survey Cohort 2 (4-year-olds)

TRACKING AND BRIEF FOLLOW-UP

PARENT SURVEY FOR

HEAD START CARES

TABLE OF CONTENTS

I. Tracking Script ………………………………………………………………………………………………2

Section A – Contact Information Update …………………………………………………………..3

II. Brief Follow-up Script ………………………..……………………………………………………………6

Section B – Child’s School Experiences ..…………………………………………………………6

• Includes items on: school that child currently attends, school progress, teacher/school contact with parent, special education or other services received by child

Section C – Child’s Social and Emotional Skills …………………………………………………9

• Social Skills Rating System (SSRS): Elementary Level, Parent Questionnaire (Gresham & Elliot, 1990)

Section D – Child’s Behavior Problems ……………………………………………………………11

• Behavior Problems Index (BPI) (Zill & Peterson; 1986)

I. Tracking Script

Good [MORNING, AFTERNOON, EVENING]. May I please speak with (RESPONDENT)?

(IF NOT AVAILABLE, ASK WHEN TO CALL BACK )

My name is (CALLER FIRST NAME). I am working with the Head Start CARES project which you became part of when (CHILD) was at (HS CENTER NAME). Perhaps you remember speaking with someone in the past and completing a survey.

You may have recently received a letter from the project telling you that someone would be calling you. It is nice to talk with you again! We are calling families who were in the study and completing a short interview; you will receive $20.

We have some questions about how (CHILD) is doing, your answers will help us to understand the impact of Head Start CARES on children and how it has affected them as they continue in school and life. We also have questions about your address and contact information so that we can contact you in the future. You are very important to the study, we do not want to lose touch with you!

The interview should take about 30 minutes to complete and your participation is completely voluntary. You may, without penalty, skip any questions you do not wish to answer. However, we hope you will try to answer as many as you can.

Please know that the answers to these questions will be kept private to the extent permissible by law and will be used for research purposes only. To make sure we keep your information as private as possible, all electronic data files that we have will be password-protected.

May we begin now? (IF AGREES, CONTINUE WITH THE INTERVIEW. IF NO, ASK: When would you like to schedule a date and time to complete this short interview?)

NOTICE: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB Control Number. The valid OMB Control Number for this information collection is 0970-0364 (expires________). The time required to complete this information collection is estimated to average 30 minutes per response, including time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

A. Contact Information Update

A1. What is your current address?

______________________________________________________________________

Street/P.O. Box Apartment

______________________________________________________________________

______________________________________________________________________

City State Zip

Home telephone: (__ __ __) - __ __ __-__ __ __ __

(Area Code)

Cell phone: (__ __ __) - __ __ __-__ __ __ __ (Area Code)

Respondent’s email: ________________________________________________________

Spouse or Partner’s name: ___________________________________________________

First Name Last Name

Spouse or partner’s cell phone: (__ __ __) - __ __ __-__ __ __ __

(Area Code)

Spouse or partner’s email: _______________________________________________

A2. Is this the name and address for us to use when we send you a letter in the mail?

YES…….1 (GO TO A4) NO…….2

A3. What is the name and address where we should send you a letter in the mail?

Name: _______________________________________________________

First Name Last Name

Address: _______________________________________________________

Street/P.O. Box Apartment

_____________________________________________________________

______________________________________________________________

City State Zip

A4. We have your name spelled as (SPELL NAME:) ____________________________________________.

A4a. Is this correct? YES…….1 NO…….2 (IF NO ASK FOR CORRECT SPELLING:) _________________.

A5. Are you currently employed?

YES…….1 NO…….2 (GO TO A7)

A6. What is the name, address and telephone number of the place where you work?

Name: _______________________________________________________

Address: _______________________________________________________

Street/P.O. Box

_______________________________________________________

City State Zip

Telephone Number (__________) - ___________-____________________

(Area Code)

Alternate Phone: (__________) - ___________-____________________

(Area Code)

A7. Are you planning to move in the next 12 months?

YES…….1 NO…….2 (GO TO A10)

A8. What is your new address? (IF DON’T KNOW GO TO A9)

Address: _______________________________________________________

Street Apartment

_______________________________________________________

_______________________________________________________

City State Zip

Telephone: (__________) - ___________-____________________

(Area Code) (GO TO 10)

A9. What is the area where you are planning to move?

(RECORD AS MUCH INFORMATION AS THE RESPONDENT KNOWS-Street, Neighborhood, City, State, Friend or Relative’s house----get contact information etc.)

A10. We would like to contact you in the future. Please tell me the name, address, email address and phone number of two relatives not living with you and a close friend who would know how to contact you.

Name (First and Last)	Address (Street, Apartment, City, State, Zip)	Telephone (Area Code)-Number	Cell Phone (Area Code)-Number	Email Address	Relationship to You

II. Brief Follow-up Assessment

I am going to ask you some questions about yourself, your child (INSERT CHILD’S NAME) who was enrolled in Head Start previously, and your family. You are allowed to skip any question you do not wish to answer and please remember that your answers to my questions will be kept private.

B. Child’s School Experience

The following questions ask about [CHILD] and his/her current school.

B1. What school is [CHILD] currently attending?

----------------------------------------------------------------------------

B2. What is the address of the school?

----------------------------------------------------------------------------

ZIPCODE |__|__|__|__|__|

B3. What is [CHILD]’s teacher’s name?

----------------------------------------------------------------------------

B4. What grade is [CHILD] currently in?

Preschool ¦₁

Kindergarten ¦₂

Transition grade ¦₃

First grade ¦₄

Second grade ¦₅

Third grade ¦₆

Don’t know ¦₁₆

Refused ¦₁₇

B5. What type of school is [CHILD] currently enrolled in?

Public ¦₁

Private ¦₂

Parochial ¦₃

Don’t know ¦₁₆

Refused ¦₁₇

B6. Does [CHILD] receive special education services?

YES 1

NO 0

DON’T KNOW d

REFUSED r

B7. Does [CHILD] receive ESOL/ELL/ESL services?

(If respondent is unsure, say: ESOL means English for Speakers of Other Languages; ELL means English Language Learners; ESL means English as a Second Language)

YES 1

NO 0

DON’T KNOW d

REFUSED r

B8. During the past 12 months, has the school contacted you or another adult in your household about any problems [CHILD] is having with school, including academic concerns and/or behavior problems?

YES, ONCE 1

YES, MORE THAN ONCE 2

NO 0

DON’T KNOW d

REFUSED r

B9. During the past 12 months, has the school contacted you or another adult in your household about [CHILD] for positive reasons, including academic success and/or improvements in behavior?

YES, ONCE 1

YES, MORE THAN ONCE 2

NO 0

DON’T KNOW d

REFUSED r

B10. During the past 12 months, has [CHILD] received…

	No	Yes	If yes, how many hours per week?
a. Speech or language therapy?	0	1	______ hours
b. Occupational therapy? Occupational therapy helps with the strengthening of fine motor skills including writing, using utensils, cutting, and tying shoe laces.	0	1	______ hours
c. Treatment or counseling from a mental health professional? Mental health professionals include school counselors, psychologists, psychiatrists, psychiatric nurses, and clinical social workers.	0	1	______ hours
d. Physical therapy?	0	1	______ hours
e. Special instruction or tutoring?	0	1	______ hours

B11. Since starting kindergarten, has [CHILD] repeated any grades?

YES 1

NO 0

DON’T KNOW d

REFUSED r

SKIP to B1 IF A11 is NO, DON’T KNOW, or REFUSED

B12. Which grade or grades did [CHILD] repeat? [Mark all that apply.]

Kindergarten ₁

First Grade ₂

Second Grade ₃

Third Grade ₄

Don’t know ₁₆

Refused ₁₇

C. Child’s Social and Emotional Skills [SSRS Measure]

Now I am going to ask you some questions about [CHILD]. The next statements describe the behavior of many children. Tell me how often [CHILD] displays certain social skills.

Each question is answered on a three-point scale: 0 – Never, 1 – Sometimes, 2 – Very Often

[CHILD]…

1. Uses free time at home in an acceptable way.

2. Keeps room clean and neat without being reminded.

3. Speaks in an appropriate tone of voice at home.

4. Joins group activities without being told to.

5. Introduces herself or himself to new people without being told.

6. Responds appropriately when hit or pushed by other children.

7. Asks sales clerks for information or assistance.

8. Attends to speakers at meetings such as in church or youth groups.

9. Politely refuses unreasonable requests from others.

10. Invites others to your home.

11. Congratulates family members on accomplishments.

12. Makes friends easily.

13. Shows interest in a variety of things.

14. Avoids situations that are likely to result in trouble.

15. Puts away toys or other household property.

16. Volunteers to help family members with tasks.

17. Receives criticism well.

18. Answers the phone appropriately.

19. Helps you with household tasks without being asked.

20. Appropriately questions household rules that may be unfair.

21. Attempts household tasks before asking for your help.

22. Controls temper when arguing with other children.

23. Is liked by others.

24. Starts conversations rather than waiting for others to talk first.

25. Ends disagreements with you calmly.

26. Controls temper in conflict situations with you.

27. Gives compliments to friends or other children in the family.

28. Completes household tasks within a reasonable time.

29. Asks permission before using another family member’s property.

30. Is self-confident in social situations such as parties or group outings.

31. Request permission before leaving the house.

32. Responds appropriately to teasing from friends or relatives of his or her own age.

33. Uses time appropriately while waiting for your help with homework or some other

task.

34. Accepts friends’ ideas for playing.

35. Easily changes from one activity to another.

36. Cooperates with family members without being asked to do so.

37. Acknowledges compliments or praise from friends.

38. Reports accidents to appropriate persons.

D. Child’s Behavior Problems [BPI Measure]

Please tell me whether the statement has been OFTEN true, SOMETIMES true, or NOT true of [CHILD] since the beginning of the school year?

[CHILD]…

1. Has sudden changes in mood or feelings.

2. Feels or complains that no one loves_ _.

3. Is rather high strung, tense, or nervous

4. Cheats or tells lies.

5. Is too fearful or anxious.

6. Argues too much.

7. Has difficulty concentrating, cannot pay attention for long.

8. Is easily confused, seems to be in a fog.

9. Bullies, or is cruel or mean to others.

10. Is disobedient at home.

11. Is disobedient at school.

12. Does not seem to feel sorry after _ _ misbehaves.

13. Has trouble getting along with other children.

14. Has trouble getting along with teachers.

15. Is impulsive, or acts without thinking.

16. Feels worthless or inferior.

17. Is not liked by other children.

18. Has a lot of difficulty getting _ _ mind off certain thoughts, has obsessions.

19. Is restless or overly active, cannot sit still.

20. Is stubborn, sullen, or irritable.

21. Has a very strong temper and loses it easily.

22. Is unhappy, sad or depressed.

23. Is withdrawn, does not get involved with others.

24. Breaks things on purpose, deliberately destroys _ _ own or others’ things.

25. Clings to adults.

26. Cries too much.

27. Demands a lot of attention.

28. Is too dependent on others.

29. Feels others are out to get _ _.

.

What is the name and address where we should mail your check?

Name: _______________________________________________________

First Name Last Name

Address: _______________________________________________________

Street/ P.O. Box Apartment

_______________________________________________________

City State Zip

(We can program the survey so that all addresses that were given during the survey are listed here and one can be chosen or if it is a totally new address it can be written in. It is most likely the respondent will give an address for the check that has been previously listed in the survey, a list of addresses to choose from will save time.)

(NOTE: IF RESPONDENT STATES THAT HE/SHE CANNOT CASH A CHECK, SAY THAT WE WILL SEND A MONEY ORDER AND CHECK BOX BELOW.) SEND MONEY ORDER 

*****END CARES TRACKING AND FOLLOW-UP SURVEY*****