Instrument 5: Baseline survey - HM Study Participants

O MB No.: 0970-0403

Expiration Date: xx/xx/xxxx

PACT

Healthy Marriage

Baseline Survey CATI

June 13, 2013

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 0970-0403. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

CONTENTS

Section Page

i. introduction ii

A. CONTACT INFORMATION 1 1

B. DEMOGRAPHIC AND SOCIOECONOMIC CHARACTERISTICS 6

c. RELATIONSHIP STATUS 9

d. PARENTING 17

e. relationSHIP quality 22

F. ECONOMIC STABILITY 27

G. BACKGROUND AND WELL BEING 33

H. MOTIVATION TO PARTICIPATE IN PROGRAM 36

I. CONTACT INFORMATION 2 38

INTERVIEWER SELECT STAFF NAME AND PROGRAM NAME FROM DROP DOWN MENU.

PROGRAMMER:

PRELOAD STAFF NAMES AND program NAMES.

ALL

INTRO1 . INTERVIEWER: WAS THIS CALL RECEIVED ON THE INTERVIEWER LINE OR THE SUPERVISOR LINE?

NOTE: YOU SHOULD NOT SELECT SUPERVISOR LINE UNLESS YOU WERE GIVEN PERMISSION TO DO SO BY YOUR SUPERVISOR.

1-888-xxx-xxxx (INTERVIEWER LINE) 1

1-xxx-xxx-xxxx (SUPERVISOR LINE) 0

ALL

INTRO1A. Hello, could you please tell me the name of the program you are calling from?

EL PASO CENTER FOR CHILDREN 1

JEWISH FAMILY AND CHILDREN’S SERVICE (JFCS) 2

UNIVERSITY BEHAVIORAL ASSOCIATES (UBA) 3

ALL

INTRO2. Can you please tell me your name?

PROGRAMMER: PROVIDE DROP-DOWN LIST OF STAFF NAMES

CONTINUE 1

NAME NOT IN LIST 99

IF OTHER SPECIFY (99): INTERVIEWER: ENTER STAFF MEMBER’S NAME (STRING 50)

soft check: if intro2=99: INTERVIEWER: BEFORE RECORDING A NEW NAME, PLEASE DOUBLE-CHECK THAT YOU CODED THE PROGRAM NAME CORRECTLY.

intro1=0

INTRO2a. Why is the client required to attend the program?

COURT ORDER 1

WILDCARD (SPECIFY) 99

(STRING 50)

IF OTHER SPECIFY (99): INTERVIEWER: ENTER OTHER REASON (STRING 50)

ALL

INTRO3. Thank you for that information. Can you please hand the phone to the client?

CONTINUE 1

PROGRAMMER: IF INTRO1=0, GO TO 7, ELSE GO TO 1.

intro1=1

i1. Hello, my name is [INTERVIEWER NAME], and I work for Mathematica Policy Research. I understand that you are interested in [PROGRAM NAME] and the Parents and Children Together study. Is that correct?

YES 1 GO TO i2

NO 0 GO TO i1a

i1=00

i1a. Please tell me why you are not interested in participating.

(STRING 250)

i1=00

i1b. Your participation is important because it will help us learn about services for couples like you in the future. All information we collect will be kept strictly private, and if you are eligible for the study, you will receive $10 for completing the survey today. Will you reconsider and agree to participate in the PACT study?

YES, I WILL PARTICIPATE 1 GO TO i2

NO, I WILL NOT PARTICIPATE 0 GO TO i6b

i1=1 or i1b=1

i2. Great. Thanks for taking the time to talk to me today. I would like to tell you a little bit more about the study, which is called PACT for short. Please stop me at any time if you have a question.

The [PROGRAM NAME] is part of the Parents and Children Together (PACT) study, a national study being conducted by the U.S. Department of Health and Human Services. The study is being done to learn more about which services help couples build a better relationship and be better parents as well as improve their economic stability. The Department of Health and Human Services asked researchers from an organization called Mathematica to assist with the study. We invite you to be a part of the study.

The study is being done to learn how well programs like [PROGRAM NAME] work. This program aims to help couples build better relationships, have healthy interactions with their children, and get and keep good jobs. The study will determine whether the program achieves those aims, and will help us learn whether there are ways these kinds of programs can be improved.

The [PROGRAM NAME] program is for couples. If you want to be in the program, you and your partner have to agree to be a part of the PACT study. If you and your partner decide that you do not want to be a part of the study, you will not be able to participate in the [PROGRAM NAME] program. You will be given information about other services that you can receive in the community.

If you decide to be in the [PROGRAM NAME] program and the study and you are eligible for the study, I will ask you to complete a short survey on the telephone with me today. I will ask you questions about yourself, your partner and your child or children. This will take about 30 minutes. You will receive $10 once you complete the survey in appreciation of your time.

Do you have any questions about what I’ve said so far?

YES 1

NO 0 GO TO i3

i2=1

i2a. What is your question?

(STRING 250)

INTERVIEWER: PRESS Alt-F1 TO ACCESS FAQ

ALL

i3. In about 12 months, the researchers will contact you again by phone and ask you about topics such as your relationships with your partner, your interactions with your child or children, your relationship with other family members, your employment, and services you receive.

At that time, you may also be asked to participate in focus groups, in-person interviews, and to complete check lists about interactions with your child. Researchers may also ask if it’s alright to interview your child. We will provide more information about these activities later, and your participation is voluntary.

The decision to participate in the survey in 12 months, the interviews, and the check lists are voluntary and will have no effect on your participation in the program. We will provide more information about these activities later, and you can decide in 12 months whether to participate in the survey, interviews, and check lists.

If you agree to be part of the study, it means you are giving permission for the [PROGRAM NAME] program to share information with the researchers about the services you receive from the program. We will ask you for your social security number.  We want to assure you that it will be kept private and will only be used for research purposes. It may be used in requests to federal and state agencies for more information about your employment and earnings and child support agreements and may be used to locate you more easily for the interview in a year’s time.  

Do you have any questions at this time?

YES 1

NO 0 GO TO i4

i3=1

i3a. What is your question?

(STRING 250)

INTERVIEWER: PRESS Alt-F1 TO ACCESS FAQ

ALL

i4. This study will look at two groups of couples: those who receive the [PROGRAM NAME]’s program services, and those who receive referrals to other existing services in the community. The study will compare outcomes for the two groups. A computer will randomly select which group you will be in. One of the groups will receive [PROGRAM NAME] program services at no cost to them. The other group will be able to receive referrals to other organizations for services, but not the [PROGRAM NAME] program services.

The computer works like a flip of a coin; assignment to a group is completely random. This procedure makes sure that assignments to the groups are fair. Everyone who agrees to join the study has the same chance of being placed into either group. The chance of being able to receive services is not influenced by what you say to program staff or your answers to the questions on the telephone. A staff member from [PROGRAM NAME] will let you know which group you are assigned to after you and your partner complete today’s interview.

If you are not randomly assigned to participate in [PROGRAM NAME] program, you will be provided with information about other services available to you in the community, and you will be able to talk to a staff person about those other services.

Do you have any questions now?

YES 1

NO 0 GO TO i5

i4=1

i4a. What is your question?

(STRING 250)

INTERVIEWER: PRESS Alt-F1 TO ACCESS FAQ

ALL

i5. At any time, after you have been randomly assigned, you can call Mathematica’s help line to say that you no longer want the program to share information about you with the Mathematica researchers, and that will have no effect on the services available to you.

Everything you tell the researchers will be used for research purposes only, unless we are required by law to release it for some other purpose. The Department of Health and Human Services may allow other researchers to use the information that you provide, and researchers may use your name and contact information to get in touch with you in the future for research purposes. Nobody will ever publish your name in connection with the information you provide.  Instead, information about you will be combined with information about other people in the study, so researchers can describe the overall program effects and participants’ experiences.

Your participation in the study could help in providing services in the future to other couples like you.

You may feel uncomfortable answering some questions in interviews. You can refuse to answer those questions if you wish, and it will not change your participation in the program. Although researchers will take many steps to protect all study information, there is a small risk that non-researchers could see it, including information about your employment and earnings, child support agreements and involvement with the criminal justice system. In addition, representatives from the Department of Health and Human Services and the New England Institutional Review Board (IRB) may inspect and have access to confidential information as they ensure your rights as a study participant are protected.

Do you have any questions now?

YES 1

NO 0 GO TO i5b

i5=01

i5a. What is your question?

(STRING 250)

INTERVIEWER: PRESS Alt-F1 TO ACCESS FAQ

ALL

i5b. To help us protect your privacy, we have obtained a Certificate of Confidentiality from the National Institutes of Health. With this Certificate, the researchers cannot be forced to disclose information that may identify you, even by a court subpoena, in any federal, state, local, civil, criminal, legislative, administrative, or other proceedings. The researchers will use the Certificate to resist any demands for information that would identify you, with one exception. The Certificate of Confidentiality does not prevent the researchers from disclosing information that would identify you as a participant in the research project if you tell me anything that suggests you are very likely to harm yourself, that you are planning to hurt another person or child, or that someone is likely to harm you.

You should understand that a Certificate of Confidentiality does not prevent you, or a member of your family, from voluntarily releasing information about yourself or your involvement in this research. If an insurer, employer or other person obtains your written consent to receive research information, then the researchers may not use the Certificate to withhold that information.

Do you have any questions now?

YES 1

NO 0 GO TO i5d

i5b=01

i5c. What is your question?

(STRING 250)

INTERVIEWER: PRESS Alt-F1 TO ACCESS FAQ

i1=01

i5d. We hope you will want to be in the study but your participation is strictly voluntary. However, if you do not want to be in the study, you cannot be entered into the computer system to see if you can receive services from [PROGRAM NAME]. If you agree to be in the study and later decide you do not want to answer some or all study questions or have information from the program shared with researchers, you may decline at any time. By agreeing now to be in the study, even if later you tell us you want to withdraw from the study, you are authorizing researchers to use information that was collected about you before you withdrew.

Do you have any questions now?

YES 1

NO 0 GO TO i6

i5d=1

i5e. What is your question?

(STRING 250)

INTERVIEWER: PRESS Alt-F1 TO ACCESS FAQ

ALL

i6. Do you agree to be in the PACT study?

YES 1 GO TO A1

NO 0

i1=0 OR if i6=0

i6a. Please tell me why you are not interested in participating in the PACT study.

(STRING 250)

i1=0 OR if i6=0

i6b. Your participation is important because it will help us learn about services for couples like you in the future. All information we collect will be kept strictly private, and you will receive a $10 gift card once you complete the survey today. Will you reconsider and agree to participate in the PACT study?

YES, I WILL PARTICIPATE 1 GO TO i2

NO, I WILL NOT PARTICIPATE 0

i1b = 0

i6c. If you do not want to be part of the study, you will not be able to participate in [PROGRAM NAME] and you will be given information about other services that you can receive in the community. Will you reconsider and agree to participate in the PACT study?

YES, I WILL PARTICIPATE 1 GO TO i2

NO, I WILL NOT PARTICIPATE 0

i6c = 0

i6d. Thank you very much for your time. Can you please hand the phone back to the staff person at [PROGRAM NAME]?

INTERVIEWER: INFORM PROGRAM STAFF THAT RESPONDENT WILL NOT BE PART OF THE PACT STUDY AND WILL NOT BE IN THE PROGRAM BUT WILL RECEIVE INFORMATION ABOUT OTHER SERVICES IN THE COMMUNITY.

INTRO1=0

i7. Hello, my name is [INTERVIEWER NAME], and I work for Mathematica Policy Research. Thanks for taking the time to talk to me today. I would like to tell you a little bit more about the [PROGRAM NAME] program.

The [PROGRAM NAME] program is participating in a study being conducted by the U.S. Department of Health and Human Services, and Mathematica is assisting with the study. The study is called Parents and Children Together, or PACT, for short. Because you are required to receive services from [PROGRAM NAME], we are not asking you to participate in the PACT study. However, [PROGRAM NAME] will need to record some information about you in the PACT database in order to track your participation in their program. Everything you tell the researchers will be used for research purposes only, unless we are required by law to release it for some other purpose.

Do you have any questions?

YES 1

NO 0 GO TO i7b

i7=01

i7a. What is your question?

(STRING 250)

INTERVIEWER: PRESS Alt-F1 TO ACCESS FAQ

i7=00

i7b. Do you agree to allow [PROGRAM NAME] to record your information in the PACT database?

YES 1 GO TO A1

NO 0

i7b=00

FILL STAFF MEMBER NAME FROM INTRO2 ANSWER

i7c. Thank you very much for your time. Can you please hand the phone back to [STAFF MEMBER NAME]?

INTERVIEWER: INFORM PROGRAM STAFF THAT RESPONDENT DID NOT AGREE TO HAVE THEIR INFORMATION RECORDED IN THE PACT DATABASE. DO NOT GIVE RESPONDENT A GIFT CARD.

Thank you. I would like to start by asking you some questions about yourself.

ALL

A1. What is your full name? Please spell that for me.

INTERVIEWER: CONFIRM LAST NAME GIVEN IS THEIR FULL LEGAL NAME (i.e. ARE THERE TWO LAST NAMES OR HYPHENATED LAST NAME).

(STRING 50)

FIRST NAME

(STRING 50)

MIDDLE INITIAL/NAME

(STRING 50)

LAST NAME

ALL

FILL FULL NAME FROM A1

A1a. I want to make sure that we call you by the correct name. Do you go by another name besides [FULL NAME]?

YES 1

NO 0 GO TO A2

A1a=01

A1b. Please spell that name for me.

(STRING 50)

NAME

ALL

A2. What is your date of birth?

| | | / | | | / | | | | |

(01-12) (01-31) (1900-2013)

MONTH DAY YEAR

SOFT CHECK: IF OUT OF RANGE < 18 YEARS OLD; I recorded (fill A2 ANSWER). Is that correct? PROGRAMMER: IF R CONFIRMS THEY ARE <18 YEARS OLD, GO TO END2.

all

A3. What is your Social Security Number?

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

(000-999) (00-99) (0000-9999)

DON’T KNOW d

REFUSED r

all

A3a. INTERVIEWER INSTRUCTION:

RWTW

ASK OR VERIFY: Are you male or female?

MALE 1

FEMALE 2

all

A4. What is your address?

PROBE: Is there an apartment number?

STREET 1

STREET 2

APT. #

CITY

STATE

ZIP

all

A5. What is your home telephone number?

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

NO LANDLINE AT HOME, ONLY CELL PHONE 0

DON’T KNOW d

REFUSED r

all

A6. Do you have a cell phone?

YES 1

NO 0 GO TO A9

DON’T KNOW d GO TO A9

REFUSED r GO TO A9

a6=1

A6a. What is your cell phone number?

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

DON’T KNOW d

REFUSED r

SKIP IF INTRO1=0

A

Youthbuild

7. I am going to ask you about the kind of cell phone service plan you have with your cell phone provider.

	YES	NO	DK	REF
a. Do you have a contract?	1	0	d	r
b. Do you have a ‘pay as you go’ plan?	1	0	d	r
c. Do you have unlimited calling?	1	0	d	r
d. Do you have unlimited texting?	1	0	d	r
e. OTHER (SPECIFY)	1	0	d	r
(100)

IF OTHER SPECIFY (99): specify other type of plan

SKIP IF INTRO1=0 A7d=0

A8. Is it okay for us to text you at this number?

YES 1

NO 0

D

PACT developed

ON’T KNOW d

REFUSED r

ALL

A9. What is the full name of the person that will participate in [PROGRAM NAME] with you? Please spell that name for me.

INTERVIEWER: CONFIRM LAST NAME GIVEN IS THE FULL LEGAL NAME (i.e. ARE THERE TWO LAST NAMES OR HYPHENATED LAST NAME).

(STRING 50)

FIRST NAME

(STRING 50)

MIDDLE INITIAL/NAME

(STRING 50)

LAST NAME

all

A

RWTW

9a. Is [PARTNER/SPOUSE NAME] male or female?

MALE 1

FEMALE 2

HARD CHECK: IF [A3a=1 AND A9a=1] OR [A3a=2 AND A9a=2] GO TO END3

ALL

INSERT first NAME FROM A9 as [PARTNER/SPOUSE NAME]

A10. I want to make sure that we use (his/her) correct name. Does [PARTNER/SPOUSE NAME] go by another name?

YES 1

NO 0 GO TO A11

DON’T KNOW d GO TO A11

REFUSED r GO TO A11

PROGRAMMER: IF INTRO1=0 AND A10=0, DK, OR R, GO TO END4

A10=1

A10a. Please spell that name for me.

(STRING 50)

NAME

DON’T KNOW d

REFUSED r

PROGRAMMER: IF INTRO1=0 AND A10a= NAME GIVEN, DK or R, GO TO END4

ALL

A11. Do you have a biological or adopted child that lives with you?

YES 1 GO TO B1

NO 0

DON’T KNOW d

REFUSED r

A11=0, DK, R

IF A9a=1 FILL “HIM” IF A9a=2 FILL “HER”

FILL [PARTNER/SPOUSE NAME] FROM A9 OR A10a

A11a. Does [PARTNER/SPOUSE NAME] have a biological or adopted child that lives with (him/her)?

YES 1 GO TO B1

NO 0

DON’T KNOW d

REFUSED r

A11=0, DK, R AND A11a=0, DK, R

FILL [PARTNER/SPOUSE NAME] FROM A9 OR A10a

A11b. Are you and [PARTNER/SPOUSE NAME] expecting a child together?

YES 1 GO TO B1

NO 0 GO TO B1

DON’T KNOW d GO TO B1

REFUSED r GO TO B1

Next, I would like to ask you some questions about your background.

All

B1. Are you Hispanic, Latino, or of Spanish origin?

OMB

INSTRUCTION: IF RESPONDENT ONLY SAYS “YES”, PROBE: Are you Mexican, Mexican American, Chicano, Puerto Rican, Cuban, or of other Hispanic, Latino or Spanish origin?

NO, NOT OF HISPANIC, LATINO OR SPANISH ORIGIN 0

YES, MEXICAN, MEXICAN AMERICAN, CHICANO 1

YES, PUERTO RICAN 2

YES, CUBAN 3

YES, ANOTHER HISPANIC, LATINO OR SPANISH ORIGIN 4

DON’T KNOW d

REFUSED r

All

B

OMB

2. What is your race?

AMERICAN INDIAN OR ALASKA NATIVE 1

ASIAN 2

BLACK OR AFRICAN AMERICAN 3

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER 4

WHITE 5

OTHER (SPECIFY) 99

(STRING 50)

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): SPECIFY OTHER RACE

All

B3. What country were you born in?

U

BSF

NITED STATES 1 GO TO B5

PUERTO RICO 2

CANADA 3

MEXICO 4

CUBA 5

DOMINICAN REPUBLIC 6

EL SALVADOR 7

HAITI 8

JAMAICA 9

GUATEMALA 10

NICARAGUA 11

OTHER COUNTRY (SPECIFY) 99

(STRING 50)

DON’T KNOW d GO TO B5

REFUSED r GO TO B5

IF OTHER SPECIFY (99): SPECIFY OTHER COUNTRY

b3 ne 1, d or r

B4. When did you first come to live in the United States?

I

BSF

NSTRUCTION: FIRST CODE IF ANSWER IS ‘SPECIFIC YEAR’ OR ‘NUMBER OF YEARS AGO’. YOU WILL BE ABLE TO ENTER SPECIFIC YEAR OR NUMBER OF YEARS ON THE NEXT SCREEN.

SPECIFY YEAR 1

SPECIFY NUMBER OF YEARS AGO 2

| | | | | YEAR

(1900 - 2013)

OR

| | |.| | NUMBER OF YEARS AGO

(0-99.9)

DON’T KNOW d

REFUSED r

All

B5. What is the highest level of education you have completed?

COBRA tailored for PACT

INTERVIEWER: IF RESPONDENT SAYS “HIGH SCHOOL,” PROBE: Did you receive a diploma or GED?

DID NOT COMPLETE HIGH SCHOOL OR GED 1

HIGH SCHOOL: DIPLOMA 2

HIGH SCHOOL: GENERAL EDUCATION DEVELOPMENT OR GED 3

SOME COLLEGE/SOME POSTSECONDARY VOCATIONAL COURSES 4

2-YEAR OR 3-YEAR COLLEGE DEGREE (ASSOCIATE’S DEGREE) 5

VOCATIONAL SCHOOL DIPLOMA 6

4-YEAR COLLEGE DEGREE (BACHELOR’S DEGREE) 7

SOME GRADUATE WORK/NO GRADUATE DEGREE 8

GRADUATE OR PROFESSIONAL DEGREE (e.g., MA, MBA, Ph.D., JD, MD) 9

NEVER ATTENDED SCHOOL 10 GO TO B6

DON’T KNOW d

REFUSED r

b3 NE 1 AND B5 NE 10

B5a. Did you complete this education in the United States?

Y

PACT developed

ES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

B

BSF

6. What is your primary language?

ENGLISH 1

SPANISH 2

OTHER (SPECIFY) 99

(STRING 50)

DON’T KNOW d

REFUSED r

The next questions are about you and [PARTNER/SPOUSE NAME].

ALL

C

BSF 15 month follow-up

1. Are you and [PARTNER/SPOUSE NAME]…

Married, 1

Divorced, 2

Separated, or 3

Have you never been married to each other? 4 GO TO C5

DON’T KNOW d GO TO C5

REFUSED r GO TO C5

C1 = 1, 2 or 3

C

BSF 15 month follow-up

2. When did you get married to [PARTNER/SPOUSE NAME]?

INTERVIEWER INSTRUCTION: RECORD ONLY MONTH AND YEAR.

PROGRAMMER NOTE: ALLOW REFUSAL IN MM/YYYY

| | | / | | | | | DATE OF MARRIAGE

(01-12) (1900-2014)

MONTH YEAR

DON’T KNOW d GO TO C5

REFUSED r GO TO C5

C1= 3 AND C2 NOT=DK, RF

C

BSF 15 month follow-up

3. And when did you separate from [PARTNER/SPOUSE NAME]?

INTERVIEWER INSTRUCTION: RECORD ONLY MONTH AND YEAR.

PROGRAMMER NOTE: ALLOW REFUSAL IN MM/YYYY GO TO C5

| | | / | | | | | DATE OF SEPARATION

(01-12) (1900-2014)

MONTH YEAR

DON’T KNOW d GO TO C5

REFUSED r GO TO C5

C1=2 AND C2 NOT=DK, RF and c3 NOT= DK, RF

C

BSF 15 month follow-up

4. When did the divorce become final?

INTERVIEWER INSTRUCTION: RECORD ONLY MONTH AND YEAR.

PROGRAMMER NOTE: ALLOW REFUSAL IN MM/YYYY

| | | / | | | | | DATE OF END OF MARRIAGE GO TO C5

(01-12) (1900-2014)

MONTH YEAR

DON’T KNOW d GO TO C5

REFUSED r GO TO C5

C1 ≠ 1

C

BSF 15 month follow-up

5. Which of the following statements best describes your current relationship with [PARTNER/SPOUSE NAME]?

We are romantically involved on a steady basis. 1 GO TO C6

We are involved in an on-again and off-again relationship. 2 GO TO C6

We are not in a romantic relationship. 3 GO TO C10

DON’T KNOW d GO TO C6

REFUSED r GO TO C6

C1 ≠ 1 and c5 ≠ 3

C

BSF baseline

6. How long have you been romantically involved with [PARTNER/SPOUSE NAME]?

INSTRUCTION: FIRST CODE IF ANSWER IS ‘SPECIFY TOTAL NUMBER’ OR ‘SPECIFY DATE’ YOU WILL BE ABLE TO ENTER NUMBER OF UNITS OR SPECIFIC DATE ON THE NEXT SCREEN.

SPECIFY TOTAL NUMBER (UNITS) 1

SPECIFY DATE 2

| | |.| | # OF UNITS

MONTHS 1

YEARS 2

WEEKS (IF LESS THAN ONE WEEK, ENTER 1 WEEK) 3

OR

| | | / | | | | | SPECIFIC DATE

(01-12) (1900-2014)

DON’T KNOW d

REFUSED r

[C1 =4, dk OR r] and [c5= 1 or 2]

C

BSF 15 month follow-up

7. Are you and [PARTNER/SPOUSE NAME] engaged to be married?

YES 1

NO 0 GO TO C10

DON’T KNOW d GO TO C10

REFUSED r GO TO C10

C7=1

C

BSF 15 month follow-up

7a. Have you and [PARTNER/SPOUSE NAME] made a specific plan together to get married?

YES 1

NO 0 GO TO C10

DON’T KNOW d GO TO C10

REFUSED r GO TO C10

C7a = 1

C

BSF 15 month follow-up

8. When are you planning to get married?

INTERVIEWER INSTRUCTION: RECORD ONLY MONTH AND YEAR.

PROGRAMMER NOTE: ALLOW REFUSAL IN MM/YYYY

| | | / | | | | | DATE PLANNING TO MARRY

(01-12) (2012-2100)

MONTH YEAR

INTERVIEWER INSTRUCTION: IF NO DATE IS GIVEN, DO NOT PROBE

NO DATE HAS BEEN SET 13 GO TO C10

DON’T KNOW d GO TO C10

REFUSED r GO TO C10

C1 = 2, 4, dk OR r AND C5 NE 3 AND C7 NE 0, DK OR RF AND C7a NE 0, DK OR RF AND C8 NE 13, DK OR RF

C

BSF 15 month follow-up

9. What do you think the chances are you will marry [PARTNER/SPOUSE NAME] in the future? Would you say . . .

No chance, 0

A little chance, 1

A 50-50 chance, 2

A pretty good chance, or 3

An almost certain chance? 4

DON’T KNOW d

REFUSED r

ALL

C

BSF 15 month follow-up

10. Do you currently live with [PARTNER/SPOUSE NAME] in the same household …

All of the time, 1 GO TO C12

Most of the time, 2

Some of the time, or 3

None of the time? 4

DON’T KNOW d

REFUSED r

if c10 ≠ 1

C

BSF 15 month follow-up

11. How often do you and [PARTNER/SPOUSE NAME] see or talk to each other? Is it…

Every day or almost every day, 1

A few times a week, 2

A few times a month, 3

About once a month, 4

Only a few times in the past year, or 5

Hardly ever or never? 6

DON’T KNOW d

REFUSED r

ALL

if c1 = 1 or 3 fill “to someone else besides [partner/spouse name]”

if c1=2 fill “to someone else”

C

BSF 15 month follow-up

12. Have you ever been married [[to someone else] besides [PARTNER/SPOUSE NAME]]?

YES 1

NO 0 GO TO C14

DON’T KNOW d GO TO C14

REFUSED r GO TO C14

C12 = 1

If c1=1 or 3 and IF C12=1, fill: “Including your current marriage,”

C

BSF 15 month follow-up

13. [Including your current marriage,] in total, how many times have you been married?

| | | # OF MARRIAGES

(1-99)

DON’T KNOW d

REFUSED r

SOFT CHECK: [IF C1=1,2 OR 3 AND C12=1 AND C13 < 2] OR [IF C1=1,2 OR 3 AND C12=0 AND C13 < 1] You mentioned in a previous question that you were married [INTERVIEWER INSTRUCTION: THE NUMBER OF MARRIAGES IN THIS QUESTION SHOULD BE MORE THAN 1], can you confirm how many times you have been married including your current marriage? [INTERVIEWER: IF C13=0 OR 1AFTER SOFT CHECK, PLEASE CHANGE ANSWER IN C1.

A11=1 or a11a=1

Now I have some questions about your children.

C

PACT developed

14. Are you and [PARTNER/SPOUSE NAME] expecting a baby together now?

YES 1

NO 0 GO TO C15

DON’T KNOW d GO TO C15

REFUSED r GO TO C15

A11b=1 OR C14=1

C

PACT developed

14a. When is your baby with [PARTNER/SPOUSE NAME] due?

| | | / | | | / | | | | | DUE DATE

(01-12) (01-31) (2013-2015)

MONTH DAY YEAR

INTERVIEWER INSTRUCTION: ALLOW REFUSAL FOR MM/DD/YYYY

INTERVIEWER INSTRUCTION: IF DAY UNKNOWN RECORD ONLY MONTH AND YEAR.

DON’T KNOW d

REFUSED r

SOFT CHECK: IF DATE GIVEN FOR BABY DUE IS ON OR BEFORE DATE OF INTERVIEW [DATE BABY DUE < DATE OF INTERVIEW] ASK: I want to make sure I have the date the baby is due recorded correctly, you told me the baby is due [Fill date from C14a] is that correct? INTERVIEWER CORRECT DATE GIVEN IF NECESSARY IN C14a.

A11b=1 OR C14=1

C

NSFG

EG-12a

14b. Right before the pregnancy, did you want to have a baby with [PARTNER/SPOUSE NAME]? Would you say…

Definitely yes, 1

Probably yes, 2

Probably no, or 3

Definitely no? 4 GO TO C15

DON’T KNOW d

REFUSED r

[A11b=1 OR C14=1] and c14b=1,2,3 d or r

C

NSFG

EG-17

14c. Would you say this pregnancy came sooner than you wanted, at about the right time, or later than you wanted?

SOONER 1

RIGHT TIME 2

LATER 3

DIDN’T CARE 4

DON’T KNOW d

REFUSED r

all

C

Modified from BSF baseline

15. How many biological children do you have with [PARTNER/SPOUSE NAME]? Please don’t include any children that have not yet been born or children that you or [PARTNER/SPOUSE NAME] had with other partners.

| | | CHILDREN

(0-99)

DON’T KNOW d

REFUSED r

all

IF A3a = 1 FILL “women”, IF A3a = 2, FILL “men”

C

BSF baseline

16. How many biological children do you have with other (men/women) besides [PARTNER/SPOUSE NAME]? Please include all of your children with other (men/women), even if they are not currently living with you. Please do not include children who have not been born yet.

| | | # OF CHILDREN WITH OTHER PARTNER(S)

(0-99)

DON’T KNOW d

REFUSED r

all

IF A3a = 1 FILL “Men”, IF A3a = 2, FILL ”WOMEN”

if a3a = 1, Fill ”Her, if a3a = 2, fill ”HIS

C

BSF baseline modified

17. How many biological children does [PARTNER/SPOUSE NAME] have with other (men/women)? Please include all of (his/her) children with other partners, even if they are not currently living with you. Please do not include children who have not been born yet.

| | | # OF CHILDREN WITH OTHER PARTNER(S)

(0-99)

DON’T KNOW d

REFUSED r

ALL

C

BSF baseline modified

18. Do you or [PARTNER/SPOUSE NAME] have any adopted children?

YES 1

NO 0 GO TO C19

DON’T KNOW d GO TO C19

REFUSED r GO TO C19

C18 = 1

C18a. How many adopted children do you or [PARTNER/SPOUSE NAME] have?

P

BSF baseline modified

ROBE: Please do not include any children you previously told us about.

| | | # OF CHILDREN

(0-99)

DON’T KNOW d

REFUSED r

SOFT CHECK: IF C18a=0 AND C18=1 ASK RESPONDENT: How many adopted children do you or [PARTNER/SPOUSE NAME] have? IF ANSWER REMAINS 0, RECODE C18.

PROGRAMMER INSTRUCTION:

IF C15+C16+C17+C18a=0 GO TO E1

IF C15 + C16 + C17 +C18a ≥ 1 GO TO C19

IF c18=0 FILL NUMBER IF [c15 + c16 + c17 ≥ 1]

IF c18=1 fill number if [C15 + C16 + C17+ c18a ≥ 1]

IF c15 + c16+ C17+ C18a=0 GO TO E1

C19. How many of these [FILL NUMBER] children that you or [PARTNER/SPOUSE NAME] have, live with you?

IF C15+C16 +C17 + C18a=1 ASK Does this child that your or [PARTNER/SPOUSE NAME] have, live with you?”

| | | # OF CHILDREN WHO LIVE WITH RESPONDENT

(0-99)

DON’T KNOW d

REFUSED r

PROGRAMMER INSTRUCTION:

IF C19=0 GO TO D11, ELSE GO TO D1

programmer:

We will roster for up to 10 children.

THIS INCLUDES ALL children OF respondent including biological, adopted and step children living in the respondents’ household

Now, we want to talk about the children in your home. In this section, we want to focus on your or [PARTNER/SPOUSE NAME’s] biological children or adopted children who live with you all or most of the time. Please do not include any current pregnancies.

	CHILD 1	CHILD 2	CHILD 3
T BSF OTAL CHILDREN IN C19> 0 D1. [FOR CHILD 1 (IF C19 > 1), FILL: Starting with the youngest child in your home FOR CHILD 2-10 FILL: Now thinking of the next youngest child in your home,] please spell this child’s first and last name for me. INSTRUCTION; IF RESPONDENT DOES NOT GIVE FULL NAME PROBE FOR A NAME OR INITIALS	FIRST NAME LAST NAME DECEASED 1 GO TO D10 INTERVIEWER: IF D1 =1, THEN SAY: I’m very sorry to hear that. Our condolences for your loss.	FIRST NAME LAST NAME DECEASED 1 GO TO D10 INTERVIEWER: IF D1 =1, THEN SAY: I’m very sorry to hear that. Our condolences for your loss.	FIRST NAME LAST NAME DECEASED 1 GO TO D10 INTERVIEWER: IF D1 =1, THEN SAY: I’m very sorry to hear that. Our condolences for your loss.
D BSF 1 NOT= Deceased D2. [CHILD 1 FILL: I want to make sure that we use [CHILD FIRST NAME]’s correct first name.] Do you call [CHILD FIRST NAME] by a different name?	YES 1 NO 0 GO TO D4 DECEASED 2 GO TO D10 INTERVIEWER: IF D2 =2, THEN SAY: I’m very sorry to hear that. Our condolences for your loss DON’T KNOW d GO TO D4 REFUSED r GO TO D4	YES 1 NO 0 GO TO D4 DECEASED 2 GO TO D10 INTERVIEWER: IF D2 =2, THEN SAY: I’m very sorry to hear that. Our condolences for your loss DON’T KNOW d GO TO D4 REFUSED r GO TO D4	YES 1 NO 0 GO TO D4 DECEASED 2 GO TO D10 INTERVIEWER: IF D2 =2, THEN SAY: I’m very sorry to hear that. Our condolences for your loss DON’T KNOW d GO TO D4 REFUSED r GO TO D4
D BSF 2=1 D3. Please spell that name for me.	NOTE: IF NICKNAME, USE AS FILL FOR [CHILD FIRST NAME] IN REMAINDER OF SURVEY NICKNAME DECEASED 1 GO TO D10 INTERVIEWER: IF D3 =1, THEN SAY: I’m very sorry to hear that. Our condolences for your loss.	NOTE: IF NICKNAME, USE AS FILL FOR [CHILD FIRST NAME] IN REMAINDER OF SURVEY NICKNAME DECEASED 1 GO TO D10 INTERVIEWER: IF D3 =1, THEN SAY: I’m very sorry to hear that. Our condolences for your loss.	NOTE: IF NICKNAME, USE AS FILL FOR [CHILD FIRST NAME] IN REMAINDER OF SURVEY NICKNAME DECEASED 1 GO TO D10 INTERVIEWER: IF D3 =1, THEN SAY: I’m very sorry to hear that. Our condolences for your loss.
D1 NOT=1, D2 NOT=2 AND D3 NOT=1FILL [CHILD FIRST NAME] FROM D1 OR D3 CODE SEX. IF NECESSARY ASK: D4. Is [CHILD FIRST NAME] a boy or girl?	BOY 1 GIRL 2 DON’T KNOW d REFUSED r DECEASED 3 GO TO D10 INTERVIEWER: IF D4 =3, THEN SAY: I’m very sorry to hear that. Our condolences for your loss.	BOY 1 GIRL 2 DON’T KNOW d REFUSED r DECEASED 3 GO TO D10 INTERVIEWER: IF D4 =3, THEN SAY: I’m very sorry to hear that. Our condolences for your loss.	BOY 1 GIRL 2 DON’T KNOW d REFUSED r DECEASED 3 GO TO D10 INTERVIEWER: IF D4 =3, THEN SAY: I’m very sorry to hear that. Our condolences for your loss.
D1 NOT=1, D2 NOT=2, D3 NOT=1 AND D4 NOT-3 D5. What is [CHILD FIRST NAME]’s date of birth?	PROGRAMMER NOTE: ALLOW REFUSAL IN MM/DD/YYYY | | | / | | | / | | | | | (0-12) (01-31) (1900-2014) MONTH DAY YEAR DECEASED 1 GO TO D10 INTERVIEWER: IF D5 =1, THEN SAY: I’m very sorry to hear that. Our condolences for your loss. DON’T KNOW d REFUSED r	PROGRAMMER NOTE: ALLOW REFUSAL IN MM/DD/YYYY | | | / | | | / | | | | | (0-12) (01-31) (1900-2014) MONTH DAY YEAR DECEASED 1 GO TO D10 INTERVIEWER: IF D5 =1, THEN SAY: I’m very sorry to hear that. Our condolences for your loss. DON’T KNOW d REFUSED r	PROGRAMMER NOTE: ALLOW REFUSAL IN MM/DD/YYYY | | | / | | | / | | | | | (0-12) (01-31) (1900-2014) MONTH DAY YEAR DECEASED 1 GO TO D10 INTERVIEWER: IF D5 =1, THEN SAY: I’m very sorry to hear that. Our condolences for your loss. DON’T KNOW d REFUSED r
D PACT developed 5 =D OR R D6. How old is [CHILD FIRST NAME]? Is that weeks, months or years?	| | | (0-99) WEEKS 1 MONTHS 2 YEARS 3 DECEASED 4 GO TO D10 INTERVIEWER: IF D6=4, THEN SAY: I’m very sorry to hear that. Our condolences for your loss. DON’T KNOW d REFUSED r	| | | (0-99) WEEKS 1 MONTHS 2 YEARS 3 DECEASED 4 GO TO D10 INTERVIEWER: IF D6=4, THEN SAY: I’m very sorry to hear that. Our condolences for your loss. DON’T KNOW d REFUSED r	| | | (0-99) WEEKS 1 MONTHS 2 YEARS 3 DECEASED 4 GO TO D10 INTERVIEWER: IF D6=4, THEN SAY: I’m very sorry to hear that. Our condolences for your loss. DON’T KNOW d REFUSED r
A IF D7, CHILD 1 = 1 OR 2 THEN GO TO D8, OR IF D7, CHILD 1 = 3 OR 4, GO TO D10. IF D7, CHILD 2 = 1 OR 2 THEN GO TO D8, OR IF D7, CHILD 2 = 3 OR 4, GO TO D10. IF D7, CHILD 3 = 1 OR 2 THEN GO TO D8, OR IF D7, CHILD 3 = 3 OR 4, GO TO D10. FFCWS tailored for PACT LL IF RESPONDENT SAYS CHILD DOES NOT LIVE IN HOUSEHOLD, CODE AS 4. D7. Does [CHILD FIRST NAME] live with you . . .	All of the time, 1 Most of the time, or 2 Some of the time? 3 NONE OF THE TIME 4 DON’T KNOW d REFUSED r	All of the time, 1 Most of the time, or 2 Some of the time? 3 NONE OF THE TIME 4 DON’T KNOW d REFUSED r	All of the time, 1 Most of the time, or 2 Some of the time? 3 NONE OF THE TIME 4 DON’T KNOW d REFUSED r

	CHILD 1	CHILD 2	CHILD 3
D RWTW tailored for PACT 7, CHILD 1-10 = 1 OR 2 ASK D8, OTHERWISE GO TO D10. D8. What is [CHILD FIRST NAME]’s relationship to you? if respondent says sTEPCHILD CODE AS 3 Interviewer Instruction: if respondent says son/daughter probe for response categories	BIOLOGICAL CHILD 1 ADOPTED CHILD 2 PARTNER’S CHILD 3 NOT RELATED 4 OTHER (SPECIFY) 99 (STRING 50) DON’T KNOW d REFUSED r	BIOLOGICAL CHILD 1 ADOPTED CHILD 2 PARTNER’S CHILD 3 NOT RELATED 4 OTHER (SPECIFY) 99 (STRING 50) DON’T KNOW d REFUSED r		BIOLOGICAL CHILD 1 ADOPTED CHILD 2 PARTNER’S CHILD 3 NOT RELATED 4 OTHER (SPECIFY) 99 (STRING 50) DON’T KNOW d REFUSED r
D7, CHILD 1-10 = 1 OR 2 ASK D9, D9. What is [CHILD FIRST NAME’s] relationship to [PARTNER/SPOUSE NAME]? if respondent says sTEPCHILD CODE AS 3 Interviewer Instruction: if respondent says son/daughter probe for response categories	BIOLOGICAL CHILD 1 ADOPTED CHILD 2 PARTNER’S CHILD 3 NOT RELATED 4 OTHER (SPECIFY) 99 (STRING 50) DON’T KNOW d REFUSED r	BIOLOGICAL CHILD 1 ADOPTED CHILD 2 PARTNER’S CHILD 3 NOT RELATED 4 OTHER (SPECIFY) 99 (STRING 50) DON’T KNOW d REFUSED r		BIOLOGICAL CHILD 1 ADOPTED CHILD 2 PARTNER’S CHILD 3 NOT RELATED 4 OTHER (SPECIFY) 99 (STRING 50) DON’T KNOW d REFUSED r
A PACT developed IF C19=1 AND D10, CHILD 1=0 GO TO D11 IF C19 ≥2 AND D10, CHILD 1=1 GO TO D1, CHILD 2 IF C19 >1 AND D10, CHILD 1=0, d OR r SOFT CHECK: YOU TOLD US YOU HAD [FILL NUMBER FROM C19] CHILDREN LIVING WITH YOU. IS THAT CORRECT? IF D1, CHILD 1=1 AND D10, CHILD 1=0 GO TO E1 IF C19=2 AND D10, CHILD 1=0 GO TO D11 IF C19 ≥3 AND D10, CHILD 1=1 GO TO D1, CHILD 3 IF C19 >1 AND D10, CHILD 2=0, d OR r SOFT CHECK: YOU TOLD US YOU HAD [FILL NUMBER FROM C19] CHILDREN LIVING WITH YOU. IS THAT CORRECT? IF [D1, CHILD1=1 AND D1, CHILD 2=1] AND [D10, CHILD 1=0 AND D10, CHILD 2=0] GO TO E1 IF C19=3 AND D10, CHILD 1=0 GO TO D11 IF C19≥4 AND D10, CHILD 1=1 GO TO D1, CHILD 4 IF C19 >1 AND D10, CHILD 3=0, d OR r SOFT CHECK: YOU TOLD US YOU HAD [FILL NUMBER FROM C19] CHILDREN LIVING WITH YOU. IS THAT CORRECT? IF [D1, CHILD 1=1,D1, CHILD 2=1 AND D1, CHILD 3=1] AND [D10, CHILD 1=0, D10, CHILD 2=0 AND D10, CHILD 3=0 GO TO E1 LL D10. Do any other biological or adopted children of you or [PARTNER/SPOUSE NAME] live in your home?	YES 1 NO 0 DON’T KNOW d REFUSED r	YES 1 NO 0 DON’T KNOW d REFUSED r		YES 1 NO 0 DON’T KNOW d REFUSED r

FILL CHILD IF C15+C16+C17+C18A=1

FILL CHILDREN IF C15+C16+C17+C18A > 1

D

PAM

11. Now, I would like to talk about you and [PARTNER/SPOUSE NAME] as parents.

PROGRAMMER INSTRUCTION: FILL IF [C15=1 AND C16+C17 ≥1] [This includes children you have in common, as wel as children you or [PARTNER/SPOUSE NAME] have with other partners.]

PROGRAMMER INSTRUCTION: FILL IF [C15=0 AND C16+C17 ≥1] [This includes children you or [PARTNER/SPOUSE NAME] have with other partners.]

For each statement, please answer if you strongly agree, agree, are not sure, disagree, or strongly disagree.

[STATEMENT a to e] Do you strongly agree, agree, are not sure, disagree, or strongly disagree with this statement?

INTERVIEWER: Respondent can refer to Card #1 (blue card) for the answer choices.

	CODE ONE PER ROW
		STRONGLY AGREE	AGREE	NOT SURE	DISAGREE	STRONGLY DISAGREE	DK	REF
a. I feel good about [PARTNER/SPOUSE NAME]’s judgment about what is right for our [child/children].		1	2	3	4	5	d	r
b. [PARTNER/SPOUSE NAME] and I are a good team.		1	2	3	4	5	d	r
c. When there is a problem with [our child/one of our children], [PARTNER/SPOUSE NAME] and I work out a good solution together.		1	2	3	4	5	d	r
d BSF . [PARTNER/SPOUSE NAME] makes my job of being a parent easier.		1	2	3	4	5	d	r
e. [PARTNER/SPOUSE NAME] pays a great deal of attention to our [child/children].		1	2	3	4	5	d	r

ALL

D12. Next, I would like to have your thoughts on a few statements about families. Tell me if you strongly agree, agree, disagree, or strongly disagree with the following statements . . .

INTERVIEWER: Respondent can refer to Card #2 (yellow card) for the answer choices.

BSF 15 month follow-up	CODE ONE PER ROW
	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE	DK	REF
a. Single parents can bring up children just as well as couples can.	1	2	3	4	d	r
b FF . When there are children in the family, parents should stay together even if they don’t get along.	1	2	3	4	d	r
c FF . It is better for a couple to be married than to just live together.	1	2	3	4	d	r
d SHM . Mothers are more important than fathers in raising children.	1	2	3	4	d	r
e. It is better for children if their parents are married.	1	2	3	4	d	r
f FF MOD FOR PACT . A father should provide financial support to his child, even if the mother is living with another man.	1	2	3	4	d	r

ALL

E

BSF 15 month follow-up modified for PACT

1. Now I would like to ask about how you feel in the relationship with [PARTNER/SPOUSE NAME]. On a scale from 0 to 10, where 0 is not at all happy and 10 is completely happy, taking all things together, how happy are you with [PARTNER/SPOUSE NAME]?

You can choose any number from 0 to 10.

| | | DESCRIPTION

(0-10)

DON’T KNOW d

REFUSED r

ALL

IF C1 = 1, FILL “MARRIAGE”, IF C1 NE1 = FILL “RELATIONSHIP”

E

Adapted from Scott Stanley

1a. On a scale from 0 to 10, where 0 is not at all committed and 10 is completely committed, how committed are you to your (marriage/relationship) with [PARTNER/SPOUSE NAME]?

| | | DESCRIPTION

(0-10)

DON’T KNOW d

REFUSED r

ALL

IF C1 = 1, FILL “MARRIAGE”, IF C1 NE1 = FILL “RELATIONSHIP”

E

Adapted from Scott Stanley

1b. On a scale from 0 to 10, where 0 is not at all committed and 10 is completely committed, how committed would you say [PARTNER/SPOUSE NAME] is to your (relationship/marriage)?

| | | DESCRIPTION

(0-10)

DON’T KNOW d

REFUSED r

sKIP IF C5=3

IF C1 = 1, FILL “MARRIAGE”, IF C1 NE1 = FILL “RELATIONSHIP”

E

SHM

2. In the last three months, have you ever thought your (marriage/relationship) was in trouble?

YES 1

NO 0

NOT IN A RELATIONSHIP 99

DON’T KNOW d

REFUSED r

ALL

I’m going to ask you some questions about [PARTNER/SPOUSE NAME].

E3. Tell me whether you strongly agree, agree, disagree, or strongly disagree with the following statements.

[STATEMENT a-h] Do you strongly agree, agree, disagree, or strongly disagree?

INTERVIEWER: Respondent can refer to Card #2 (yellow card) for the answer choices.

BSF 15 month follow-up

	CODE ONE PER ROW
	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE	DK	REF
a. [PARTNER/SPOUSE NAME] is honest and truthful with me.	1	2	3	4	d	r
b. I can trust [PARTNER/SPOUSE NAME] completely.	1	2	3	4	d	r
c. [PARTNER/SPOUSE NAME] can be counted on to help me.	1	2	3	4	d	r
d. [PARTNER/SPOUSE NAME] knows and understands me.	1	2	3	4	d	r
e. [PARTNER/SPOUSE NAME] listens to me when I need someone to talk to.	1	2	3	4	d	r
f. [PARTNER/SPOUSE NAME] respects me.	1	2	3	4	d	r
SKIP IF C5=3 g. [PARTNER/SPOUSE NAME] shows love and affection.	1	2	3	4	d	r
h. I feel appreciated by [PARTNER/SPOUSE NAME].	1	2	3	4	d	r

ALL

E

BSF 15 month
follow-up

4. Now, I am going to read you some statements about things you and [PARTNER/SPOUSE NAME] may experience when you are together. Tell me if this often happens, sometimes happens, hardly ever happens, or never happens.

[STATEMENT a - n] Does this happen often, sometimes, hardly ever, or never?

INTERVIEWER: Respondent can refer to Card #3 (green card) for the answer choices.

	CODE ONE PER ROW
BSF 15 month follow-up	OFTEN	SOMETIMES	HARDLY EVER	NEVER	DK	REF
a. We are good at solving our differences.	1	2	3	4	d	r
b SHM . [PARTNER/SPOUSE NAME] is rude and mean to me when we disagree.	1	2	3	4	d	r
c. [PARTNER/SPOUSE NAME] is good at calming me when I get upset.	1	2	3	4	d	r
d. Little arguments turn into ugly fights with accusations, criticisms, name calling or bringing up past hurts.	1	2	3	4	d	r
e. We are pretty good listeners, even when we have different positions on things.	1	2	3	4	d	r
f. [PARTNER/SPOUSE NAME] blames me for things that go wrong.	1	2	3	4	d	r
g. Even when arguing we can keep a sense of humor.	1	2	3	4	d	r
h. When we argue, I feel personally attacked by [PARTNER/SPOUSE NAME].	1	2	3	4	d	r
i BSF . When we discuss something, [PARTNER/SPOUSE NAME] acts as if I am totally wrong.	1	2	3	4	d	r
j. I feel respected even when we disagree.	1	2	3	4	d	r

ALL

E5. In the last three months how often [STATEMENT A-D]…Was it often, sometimes, hardly ever, or never?

INTERVIEWER: Respondent can refer to Card #3 (green card) for the answer choices.

	CODE ONE PER ROW
	OFTEN	SOMETIMES	HARDLY EVER	NEVER	DK	REF
a SHM REVISED FOR PACT . Has [PARTNER/SPOUSE NAME] made you feel stupid?	1	2	3	4	d	r
b SHM REVISED FOR PACT . Has [PARTNER/SPOUSE NAME] tried to keep you from seeing or talking with your friends or family?	1	2	3	4	d	r
c SHM REVISED FOR PACT . Has [PARTNER/SPOUSE NAME] kept money from you, made you ask for money, or taken your money without asking?	1	2	3	4	d	r
d SHM REVISED FOR PACT . Have you felt afraid that [PARTNER/SPOUSE NAME] would hurt you?	1	2	3	4	d	r

ALL

E

SHM modified for PACT

6. In the past year, how many times has [PARTNER/SPOUSE NAME] pushed, shoved, hit, slapped or grabbed you?

Would you say…

Never, 0

Once, 1

Twice, 2

Three to five times, 3

More than five times? 4

DON’T KNOW d

REFUSED r

ALL

E

BSF 15 month follow-up

7. Sometimes couples are not always faithful to each other. Has [PARTNER/SPOUSE NAME] cheated on you with someone else in the past 12 months? Would you say…

BSF 36 month follow-up tailored for PACT

IF NOT IN A ROMANTIC RELATIONSHIP (C5=3): Sometimes couples are not always faithful to each other. Has [PARTNER/SPOUSE NAME] ever cheated on you with someone else? Would you say…

Definitely yes, 1

Probably yes, 2

Probably no, or 3

Definitely no? 4

WAS NEVER IN A ROMANTIC RELATIONSHIP 99

DON’T KNOW d

REFUSED r

ALL

E

BSF 15 month follow-up

8. In the past 12 months, have you cheated on [PARTNER/SPOUSE NAME] with someone else?

BSF 36 month follow-up tailored for PACT

IF NOT IN A ROMANTIC RELATIONSHIP (C5=3): Have you ever cheated on [PARTNER/SPOUSE NAME] with someone else?

YES 1

NO 0

WAS NEVER IN A ROMANTIC RELATIONSHIP 99

DON’T KNOW d

REFUSED r

The next questions are about work you have done for pay.

ALL

F

WFNJ tailored for PACT

1. In the past 30 days, have you worked for pay? Please include any regular paid jobs, odd jobs, temporary jobs, work in your own business, “under the table” work, “informal” work, or any other types of work you have done.

YES 1 GO TO F3

NO 0

DON’T KNOW d

REFUSED r

F1 NE 1

F

WFNJ tailored for PACT

2. In what month and year did you last work for pay? Please include any regular paid jobs, odd jobs, temporary jobs, work in your own business, “under the table” work, “informal” work, or any other types of work you have done.

| | | | | | | | GO TO F6

MONTH YEAR

(1-12) (1900-2014)

NEVER WORKED FOR PAY 0 GO TO F6

DON’T KNOW d GO TO F6

REFUSED r GO TO F6

F1=1

F

WFNJ tailored for PACT

3. In the past 30 days, how much money did you make? Please include tips, bonuses, commissions, and regular overtime pay, and count all money you received before taxes and deductions. If you held more than one job, include your total earnings from all of your work during the 30 days.

$ | | | | , | | | | AMOUNT GO TO F6

(0-999,999)

DON’T KNOW d

REFUSED r

SOFT CHECK: IF ANSWER = 0; INTERVIEWER: CONFIRM ANSWER WITH RESPONDENT. IF THEY DID RECEIVE PAY, PLEASE CHANGE THE ANSWER IN F3.

SOFT CHECK: IF ANSWER = IS $5,000 OR ABOVE; INTERVIEWER: CONFIRM ANSWER WITH RESPONDENT THIS IS THE AMOUNT THEY MADE IN THE PAST 30 DAYS. IF NOT, PLEASE CHANGE THE ANSWER IN F3.

F3 = D OR R

F4. I just need to know a range. Can you tell me if it was . . .

INTERVIEWER INSTRUCTION: YOU CAN STOP READING WHEN RESPONDENT PROVIDES RANGE.

BSF 15 month follow up

Less than $500, 1 GO TO F6

Between $500 and $750, 2 GO TO F6

Between $750 and $1,000, 3 GO TO F6

Between $1,000 and $1,250, 4 GO TO F6

Between $1,250 and $,1500, 5 GO TO F6

Between $1,500 and $1,750, 6 GO TO F6

Between $1,750 and $2,000, 7 GO TO F6

Between $2,000 and $2,500, 8 GO TO F6

Between $2,500 and $,3000, 9 GO TO F6

Between $3,000 and $3,500, 10 GO TO F6

Between $3,500 and $4,000, 11 GO TO F6

Between $4,000 and $4,500, 12 GO TO F6

Between $4,500 and $5,000, 13 GO TO F6

Between $5,000 and $5,500, 14 GO TO F6

Between $5,500 and $6,000 or 15 GO TO F6

$6,000 or more? 16 GO TO F6

DON’T KNOW d

REFUSED r

F4=D OR R

F

WFNJ

4a. How many weeks this past month did you work?

INTERVIEWER INSTRUCTION: IF LESS THAN 1 WEEK, CODE AS 1.

| | WEEKS

(1-4)

DON’T KNOW d GO TO F6

REFUSED r GO TO F6

F4a = ANSWER

F

RWTW tailored for PACT

4b. How many hours do you usually work in a week? Your best estimate is fine.

| | | HOURS PER WEEK

(1-98.9)

99 OR MORE HOURS PER WEEK 99

DON’T KNOW d GO TO F6

REFUSED r GO TO F6

F4b =ANSWER

F

RWTW tailored for PACT

4c. What is your current hourly rate of pay, before taxes and deductions?

$ | | | | . | | | PER HOUR

(1-999.99)

DON’T KNOW d GO TO F6

REFUSED r GO TO F6

AMOUNT = 4a ANSWER X 4b ANSWER X 4c ANSWER

F

RWTW

4d. Based on what you’ve told me, last month you made about [AMOUNT]. Is that correct?

YES 1

NO 0 GO TO F4a

DON’T KNOW d GO TO F4a

REFUSED r GO TO F4a

SOFT CHECK: IF F4d=0, d or r Say: Ok, let’s go over this again…

INTERVIEWER: GO TO F4a

PROGRAMMER:

if F4D= NO, DON’T know OR REFUSED TWICE, GO TO F5.

If answer at f4d

F

RWTW tailored for PACT

5. In addition to your pay, do you get tips, bonuses, or commissions?

YES 1

NO 0 GO TO F6

DON’T KNOW d GO TO F6

REFUSED r GO TO F6

F5=1

F

RWTW tailored for PACT

5a. In the past 30 days, how much did you receive in tips, bonuses, or commissions?

$ | | | | , | | | | AMOUNT Go to F6

(0-999,999)

DON’T KNOW d

REFUSED r

SOFT CHECK: IF ANSWER = 0; INTERVIEWER: CONFIRM ANSWER WITH RESPONDENT. IF THEY DID NOT RECEIVE TIPS, BONUSES, OR COMMISSIONS, GO BACK TO F5 AND CHANGE TO NO.

F5a = d or r

F5b. I just need to know a range. Can you tell me if it was . . .

INTERVIEWER INSTRUCTION: YOU CAN STOP READING WHEN RESPONDENT PROVIDES RANGE.

BSF 15 month follow up

Less than $500, 1

Between $500 and $750, 2

Between $750 and $1,000, 3

Between $1,000 and $1,250, 4

Between $1,250 and $1,500, 5

Between $1,500 and $1,750, 6

Between $1,750 and $2,000, 7

Between $2,000 and $2,500, 8

Between $2,500 and $3,000, 9

Between $3,000 and $3,500, 10

Between $3,500 and $4,000, 11

Between $4,000 and $4,500, 12

Between $4,500 and $5,000, 13

Between $5,000 and $5,500, or 14

Between $5,500 and $6,000? 15

$6,000 or more? 16

DON’T KNOW d

REFUSED r

all

F

WFNJ

6. The next questions are about where you live.

Do you currently own your home, rent it, pay some amount toward rent, live rent free with a friend or relative, or do you have some other arrangement?

OWN OR HAVE MORTGAGE 1

RENT 2

PAY SOME OF THE RENT 3

LIVE RENT FREE (SOMEONE ELSE RENTS/OWNS HOUSE) 4

LIVE IN SHELTER 5

LIVE ON STREETS 6

LIVE IN ABANDONED BUILDING/CAR 7

OTHER (SPECIFY) 99

(STRING 250)

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): What is the other arrangement?

all

F

BSF 15 month follow-up

7. Now, I have some questions about difficulties you may have experienced in the past 12 months. Please tell me if there has been a time during the past 12 months when . . .

	CODE ONE PER ROW
	YES	NO	DK	REF
a. You could not pay the full amount of the rent or mortgage that you were supposed to pay?	1	2	d	r
b. You had service turned off by the water, gas or electric company, or the oil company would not deliver oil because you could not afford to pay the bill?	1	2	d	r
c. You were evicted from your home or apartment because you could not pay the rent or mortgage?	1	2	d	r
d Gallup . You did not have enough money to buy food that you or your family needed?	1	2	d	r

all

Texas SITE fill [Texas works] for [local name of tanf]

NY and FL SITES NO FILL [local name of tanf]

F8. Now, I’m going to ask you about some benefits you or members of your household may have received.

In the past 30 days, please tell me whether you, [PARTNER/SPOUSE NAME], or the children who live with you received cash welfare which is also known as TANF, [or [LOCAL NAME OF TANF]]?

P

BSF 15 month follow-up

ROBE: Did you, [PARTNER/SPOUSE NAME], or the children who live with you receive income from this source in past 30 days?

YES 1

NO 0

DON’T KNOW d

REFUSED r

all

F9. In the 30 days, please tell me whether you, [PARTNER/SPOUSE NAME], or the children who live with you received food stamps, also known as Supplemental Nutrition Assistance Program, or SNAP benefits.

P

BSF 15 month follow-up

ROBE: Did you, [PARTNER/SPOUSE NAME], or the children who live with you receive income from this source in 30 days?

YES 1

NO 0

DON’T KNOW d

REFUSED r

The next questions are about your relationship with your biological parents.

ALL

G1. When you were growing up—that is before you turned 18—did you live most of the time with . . .

BSF 15 month follow up

PROBE: In which of these living situations did you spend most of your time before you turned 18?

Both your biological mother and your biological father, 1

Your biological mother only, 2 GO TO G3

Your biological father only, or 3 GO TO G3

Neither of your biological parents? 4 GO TO G3

DON’T KNOW d GO TO G3

REFUSED r GO TO G3

g1=1

G

BSF 15 month follow up modified for PACT

2. Did you always live with both of your biological parents until you turned 18?

YES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

G3. Were your biological parents ever married to each other?

Y

BSF 15 month follow up

ES 1

NO 0

DON’T KNOW d

REFUSED r

The next question is about how you are doing.

all

G4. Over the last two weeks, how often have you been bothered by any of the following problems?

PHQ-8

PROGRAMMER: FILL a-h

Would you say that the problem happened not at all, several days, more than half the days, or nearly every day in the last two weeks?

INTERVIEWER: Respondent can refer to Card #4 (pink card) for the answer choices.

	CODE ONE RESPONSE PER ROW
	NOT AT ALL	SEVERAL DAYS	MORE THAN HALF THE DAYS	NEARLY EVERY DAY	DK	REF
a. Little interest or pleasure in doing things.	0	1	2	3	d	r
b. Feeling down, depressed, or hopeless.	0	1	2	3	d	r
c. Trouble falling or staying asleep, or sleeping too much.	0	1	2	3	d	r
d. Feeling tired or having little energy.	0	1	2	3	d	r
e. Poor appetite or overeating.	0	1	2	3	d	r
f. Feeling bad about yourself—or that you are a failure or have let yourself or your family down.	0	1	2	3	d	r
g. Trouble concentrating on things, such as reading the newspaper or watching television.	0	1	2	3	d	r
h. Moving or speaking so slowly that other people could have noticed? Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual.	0	1	2	3	d	r

I would like to ask you a few questions about your experience with the criminal justice system.

all

G

BSF

5. Have you ever been arrested?

YES 1

NO 0 GO TO G9

DON’T KNOW d GO TO G9

REFUSED r GO TO G9

G5 = 1

G

SVORI

6. How many times in your life have you been arrested?

INTERVIEWER: CODE 0 IF NEVER ARRESTED

| | | TIMES

(1-200)

NEVER ARRESTED 0 GO TO G9

DON’T KNOW d GO TO G9

REFUSED r GO TO G9

g6 GE 1

G

PACT DEVELOPED

7. Have you ever been convicted of a crime?

YES 1

NO 0 GO TO G9

DON’T KNOW d GO TO G9

REFUSED r GO TO G9

G7 = 1

G8. Are you currently on parole or probation?

Y

SVORI

ES 1

NO 0

DON’T KNOW d

REFUSED r

Now, I would like to ask you a few questions about [PARTNER/SPOUSE NAME’S] experience with the criminal justice system.

all

G

BSF

9. Has [PARTNER/SPOUSE NAME] ever been convicted of a crime?

YES 1

NO 0 GO TO H1

DON’T KNOW d GO TO H1

REFUSED r GO TO H1

G9=1

FILL “he” IF A3a=2, FILL “she” IF A3a=1

G

SVORI

10. Is [he/she] currently on parole or probation?

YES 1

NO 0

DON’T KNOW d

REFUSED r

Now, I’d like to ask you some questions about your interest in [PROGRAM NAME].

ALL

C15 + C16 + C17 + c18a = 1 say “CHILD”,

C15 + C16 + C17 + c18a > 1, say “children”.

H1. People apply to relationship programs for different reasons. I’m going to read you three reasons why people might apply to these programs. Please tell me which of these reasons was most important to you when you decided to apply to [PROGRAM NAME].

PROGRAMMER: FILL a-c

Which of these reasons was most important to you when you decided to apply to [PROGRAM NAME]?

CODE ANSWER AS ‘1’ (MOST IMPORTANT)

PACT developed	CODE ONE ONLY
	NUMBER	DK	REF
a. Improving your relationship with your [child/children].	| | (1)	d	r
b. Improving your job situation.	| | (1)	d	r
c. Improving your relationship with [PARTNER/SPOUSE NAME].	| | (1)	d	r

ALL

C15 + C16 + C17 + c18a = 1 say “CHILD”,

C15 + C16 + C17 + c18a > 1, say “children”.

H1a. Now, of the two remaining reasons, [PROGRAMMER: FILL REMAINING CHOICES] which of these two was most important to you in your decision to apply to the program?

CODE ANSWER AS ‘2’ (2ND MOST IMPORTANT)

INTERVIEWER: CODE REMAINING OPTION AS ‘3’.

PACT developed	CODE ONE PER ROW
	NUMBER	DK	REF
a. Improving your relationship with your [child/children].	| | (2-3)	d	r
b. Improving your job situation.	| | (2-3)	d	r
c. Improving your relationship with [PARTNER/SPOUSE NAME].	| | (2-3)	d	r

all

H

PACT developed

2. On a scale from 0 to 10, where 0 is not important and 10 is very important, how important is it for you to make time to participate in [PROGRAM NAME]? You can pick any number from 0 to 10.

| | | DESCRIPTION

(0-10)

DON’T KNOW d

REFUSED r

all

H

PACT developed

3. On a scale from 0 to 10, where 0 is not important and 10 is very important, how important do you think it is for [PARTNER/SPOUSE NAME] to make time to participate in [PROGRAM NAME]? You can pick any number from 0 to 10.

| | | DESCRIPTION

(0-10)

DON’T KNOW d

REFUSED r

We are almost finished. I just have a few more questions that will help us contact you in about a year. We will only use this information, including your social networking accounts, if we cannot reach you with the information you provided us.

ALL

I1. What is your email address?

(STRING 50)

DON’T HAVE ONE 0

DON’T KNOW d

REFUSED r

ALL

I

Youthbuild

2. Do you have any of the following social networking accounts?

Do you have a Facebook account?

YES 1

NO 0 GO TO I3

DON’T KNOW d GO TO I3

REFUSED r GO TO I3

i2=1

I2a. What name do you use on Facebook?

(STRING 50)

DON’T KNOW d

REFUSED r

ALL

I3. Do you have a MySpace account?

YES 1

NO 0 GO TO I4

DON’T KNOW d GO TO I4

REFUSED r GO TO I4

I3=1

I3a. What name do you use on MySpace?

(STRING 50)

DON’T KNOW d

REFUSED r

ALL

I4. Do you have a Twitter account?

YES 1

NO 0 GO TO I5

DON’T KNOW d GO TO I5

REFUSED r GO TO I5

i4=1

I4a. What name do you use on Twitter?

(STRING 50)

DON’T KNOW d

REFUSED r

ALL

I5. Do you have a social networking account other than Facebook, MySpace, or Twitter?

YES 1

NO 0 GO TO I6a

DON’T KNOW d GO TO I6a

REFUSED r GO TO I6a

i5=1

I5a. What social networking provider do you use?

(STRING 50)

DON’T KNOW d

REFUSED r

ALL

I6a.

We are almost finished. I just have a few more questions that will help us contact you in about a year. We will only use this information, including your social networking accounts, if we cannot reach you with the information you provided us.

What is the full name of the first person we should contact?

(STRING 50)

FIRST NAME

(STRING 50)

MIDDLE INITIAL/NAME

(STRING 50)

LAST NAME

DON’T KNOW d GO TO END1

REFUSED r GO TO END1

I6A NE D OR R

I6b. What is his/her address?

PROBE: Is there an apartment number?

STREET 1

STREET 2

APT. #

CITY

STATE

ZIP

DON’T KNOW d

REFUSED r

I6a NE D OR R

I6c. What is his/her relationship to you?

MOTHER 1

FATHER 2

SISTER/BROTHER 3

GRANDMOTHER/GRANDFATHER 4

FRIEND 5

OTHER (SPECIFY) 99

(STRING 50)

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): ENTER OTHER RELATIONSHIP TYPE

I6a NE D OR R

I6d. What is [his/her] home telephone number?

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

NO LANDLINE, ONLY CELL PHONE 0

DON’T KNOW d

REFUSED r

I6a NE D OR R

I6e. Does [he/she] have a cell phone?

YES 1

NO 0 GO TO I6g

DON’T KNOW d GO TO I6g

REFUSED r GO TO I6g

I6e=1

I6f. Can I have that number?

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

DON’T KNOW d

REFUSED r

I6a NE D OR R

I6g. What is [his/her] work telephone number?

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

NO WORK NUMBER 0

DON’T KNOW d

REFUSED r

I6a NE D OR R

I6h. What is [his/her] email address?

(STRING 50)

EMAIL ADDRESS

DOESN’T HAVE ONE 0 GO TO I6j

DON’T KNOW d GO TO I6j

REFUSED r GO TO I6j

I6h NE 0, D, OR R

I6i. Does [he/she] have another email address?

(STRING 50)

EMAIL ADDRESS

DON’T KNOW d

REFUSED r

I6a NE D OR R

I6j. Which of the following is the primary social network used by this person?

Facebook, 1

Twitter, 2

MySpace, 3

a personal blog, or 4

some other social network (SPECIFY) 99

(STRING 50)

NONE 0 GO TO I7a

DON’T KNOW d GO TO I7a

REFUSED r GO TO I7a

IF OTHER SPECIFY (99): What other social network do they use?

I6j = 1, 2, 3, 4, or 99

IF I6j=4, FILL “WEB ADDRESS” AND “FOR THAT PERSONAL BLOG” ELSE FILL “NAME” AND “iN THAT SOCIAL NETWORK”

I6k. What (name/web address) does this person use (in that social network/for that personal blog)?

(STRING 50)

NAME

DON’T KNOW d

REFUSED r

SECOND CONTACT

I6A NE D OR R

I7a. What is the full name of the second person we should contact?

(STRING 50)

FIRST NAME

(STRING 50)

MIDDLE INITIAL/NAME

(STRING 50)

LAST NAME

DON’T KNOW d GO TO END1

REFUSED r GO TO END1

I7a NE D OR R

I7b. What is [his/her] address? PROBE: Is there an apartment number?

STREET 1

STREET 2

APT. #

CITY

STATE

ZIP

DON’T KNOW d

REFUSED r

I7a NE D OR R

I7c. What is [his/her] relationship to you?

MOTHER 1

FATHER 2

SISTER/BROTHER 3

GRANDMOTHER/GRANDFATHER 4

FRIEND 5

OTHER (SPECIFY) 99

(STRING 50)

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): ENTER OTHER RELATIONSHIP TYPE

I7a NE D OR R

I7d. What is [his/her] home telephone number?

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

NO LANDLINE, ONLY CELL PHONE 0

DON’T KNOW d

REFUSED r

I7a NE D OR R

I7e. Does [he/she] have a cell phone?

YES 1

NO 0 GO TO I7g

DON’T KNOW d GO TO I7g

REFUSED r GO TO I7g

I7e=1

I7f. Can I have that number?

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

DON’T KNOW d

REFUSED r

I7a NE D OR R

I7g. What is [his/her] work telephone number?

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

NO WORK NUMBER 0

DON’T KNOW d

REFUSED r

I7a NE D OR R

I7h. What is [his/her] email address?

(STRING 50)

EMAIL ADDRESS

DOESN’T HAVE ONE 0 GO TO I7j

DON’T KNOW d GO TO I7j

REFUSED r GO TO I7j

I7h NE 0, d, or r

I7i. Does [he/she] have another email address?

(STRING 50)

EMAIL ADDRESS

DON’T KNOW d

REFUSED r

I7a NE D OR R

I7j. Which of the following is the primary social network used by this person?

Facebook, 1

Twitter, 2

MySpace, 3

a personal blog, or 4

other some other social network? (SPECIFY) 99

(STRING 50)

NONE 0 GO TO I8a

DON’T KNOW d GO TO I8a

REFUSED r GO TO I8a

IF OTHER SPECIFY (99): What other social network do they use?

I7j=1, 2, 3, 4 or 99

IF I7j=4, FILL “WEB ADDRESS” AND “FOR THAT PERSONAL BLOG” ELSE FILL “NAME” AND “iN THAT SOCIAL NETWORK”

I7k. What (name/web address) does this person use (in that social network/for that personal blog)?

(STRING 50)

NAME

DON’T KNOW d

REFUSED r

THIRD CONTACT

I7a NE D OR R

I8a. What is the full name of the third person we should contact?

(STRING 50)

FIRST NAME

(STRING 50)

MIDDLE INITIAL/NAME

(STRING 50)

LAST NAME

DON’T KNOW d GO TO END1

REFUSED r GO TO END1

I8a NE D OR R

I8b. What is [his/her] address?

STREET 1

STREET 2

APT. #

CITY

STATE

ZIP

DON’T KNOW d

REFUSED r

I8a NE D OR R

I8c. What is [his/her] relationship to you?

MOTHER 1

FATHER 2

SISTER/BROTHER 3

GRANDMOTHER/GRANDFATHER 4

FRIEND 5

OTHER (SPECIFY) 99

OTHER (SPECIFY) 99

(STRING 50)

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): ENTER OTHER RELATIONSHIP TYPE

I8a NE D OR R

I8d. What is [his/her] home telephone number?

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

NO LANDLINE, ONLY CELL PHONE 0

DON’T KNOW d

REFUSED r

I8a NE D OR R

I8e. Does [he/she] have a cell phone?

YES 1

NO 0 GO TO I8g

DON’T KNOW d GO TO I8g

REFUSED r GO TO I8g

I8e=1

I8f. Can I have that number?

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

DON’T KNOW d

REFUSED r

I8a NE D OR R

I8g. What is [his/her] work telephone number?

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

NO WORK NUMBER 0

DON’T KNOW d

REFUSED r

I8a NE D OR R

I8h. What is [his/her] email address?

(STRING 50)

EMAIL ADDRESS

DOESN’T HAVE ONE 0 GO TO I8j

DON’T KNOW d GO TO I8j

REFUSED r GO TO I8j

I8h NE 0, d, OR R

I8i. Does [he/she] have another email address?

(STRING 50)

EMAIL ADDRESS

DON’T KNOW d

REFUSED r

I8a NE D OR R

I8j. Which of the following is the primary social network used by this person?

Facebook, 1

Twitter, 2

MySpace, 3

a personal blog, or 4

Some other social network? (SPECIFY) 99

(STRING 50)

NONE 0 GO TO END1

DON’T KNOW d GO TO END1

REFUSED r GO TO END1

IF OTHER SPECIFY (99): What other social network do they use?

I8j=1, 2, 3, 4, or 99

IF I8j=4, FILL “WEB ADDRESS” AND “FOR THAT PERSONAL BLOG” ELSE FILL “NAME” AND “iN THAT SOCIAL NETWORK”

I8k. What (name/web address) does this person use (in that social network/for that personal blog)?

(STRING 50)

NAME

DON’T KNOW d

REFUSED r

END OF CALL

ALL

END1. Those are all of the questions I have. You will receive a $10 gift card as a token of our appreciation. We will be in touch with you again in about a year to see how you are doing. As I mentioned earlier, a computer will randomly assign you and [PARTNER/SPOUSE NAME] to one of two study groups once [he/she] completes the interview. Now I need to speak with the staff person at [PROGRAM NAME], so please do not hang up. Please hand the phone back to the staff person. Thank you.

INTERVIEWER: INFORM PROGRAM STAFF THAT RESPONDENT HAS COMPLETED THE INTERVIEW.

A2 < 18 YEARS OLD AND INTRO1=1

END2. Thank you very much for your time. Those are all of the questions I have. Now I need to speak with the staff person at [PROGRAM NAME], so please do not hang up. Can you please hand the phone back to the staff person?

INTERVIEWER: INFORM PROGRAM STAFF THAT RESPONDENT IS NOT ELIGIBLE TO PARTICIPATE IN THE PACT STUDY BECAUSE THE RESPONDENT IS UNDER 18 YEARS OF AGE. IF PARTNER HAS NOT YET COMPLETED BASELINE, INFORM PROGRAM STAFF TO TELL PARTNER NOT TO CALL IN TO COMPLETE. PROVIDE PROGRAM STAFF WITH MPRID. DO NOT GIVE RESPONDENT A GIFT CARD.

[A3a=1 and a9a=1] or [a3a=2 and a9a=2]

END3. Thank you very much for your time. Those are all of the questions I have. Now I need to speak with the staff person at [PROGRAM NAME], so please do not hang up. Can you please hand the phone back to the staff person?

INTERVIEWER: INFORM PROGRAM STAFF THAT RESPONDENT AND THEIR PARTNER ARE NOT ELIGIBLE TO PARTICIPATE IN THE PACT STUDY. RESPONDENT AND THEIR PARTNER ARE ELIGIBLE TO RECEIVE PROGRAM SERVICES FROM THE SITE. IF PARTNER HAS NOT YET COMPLETED BASELINE, INFORM PROGRAM STAFF TO TELL PARTNER NOT TO CALL IN TO COMPLETE. PROVIDE PROGRAM STAFF WITH MPRID. DO NOT GIVE RESPONDENT A GIFT CARD.

(INTRO1=0 AND A10=0, dk or r) OR (INTRO1=0 AND A10a=Dk or R)

END4. Those are all of the questions I have. Now I need to speak with the staff person at [PROGRAM NAME], so please do not hang up. Can you please hand the phone back to the staff person? Thank you.

INTERVIEWER: INFORM PROGRAM STAFF THAT RESPONDENT HAS COMPLETED THE INTERVIEW AND HE OR SHE CAN ENTER THEIR INFORMATION INTO PACTIS. PROVIDE PROGRAM STAFF WITH MPRID. DO NOT GIVE RESPONDENT A GIFT CARD.