Family follow-up survey
Mother and Infant Home Visiting Program Evaluation (MIHOPE)
MIHOPE 2_family follow up survey for OMB revised_April 2015_clean
Family follow-up survey
OMB: 0970-0402
OMB
No.: 0970-0402
Expiration
Date: 6/30/2016
ATTACHMENT 1: FAMILY FOLLOW-UP SURVEY
MIHOPE
15-Month Follow-Up Survey
March 25, 2015
SC. SCREENER |
PROGRAMMER BOX IF RESPONDENT WAS PREGNANT AT THE TIME OF BASELINE SURVEY, SET SC0=1; IF RESPONDENT WAS NOT PREGNANT AT THE TIME OF BASELINE SURVEY, SET SC0=2. |
CALL-IN |
FILL RESPONDENT PHONE NUMBER AND EXTENSION FROM PRELOAD |
MakeDialPhone.
phone number details:
phone number= [phone number]
extension= [extension]
auto dial 1 CallDialer
manual dial 2 DialResult
quick exit 3 Finished
respondent calling in 4 Hello1
field interviewer calling in 5 Hello1
Makedialphone=1 |
CallDialer.
INTERVIEWER: please click on the button in the field with three dots to make the call.
CALL OUT |
DialResult.
INTERVIEWER: code result of dialing
someone answers 1 Hello
no answer 2 LeaveCase
busy 3 LeaveCase
answering machine 4 Verified
answering service 5 AnsService
PRIVACY MANAGER 6 Finished
PHONE/LINE PROBLEMS 7 PhoneProb
CHANGED TO NEW NUMBER 8 PhoneNumber
dialresult=4 |
NAME FROM PRELOAD |
Verified.
INTERVIEWER: DID RECORDING VERIFY [name] at this number?
Yes 1 Finished
No 0 Finished
dialresult=5 |
AnsService.
INTERVIEWER: IS THIS THE ANSWERING SERVICE FOR [NAME]?
YES, [NAME]’S ANSWERING SERVICE 1 Finished
NO, DEFINITELY NOT [NAME]’S ANSWERING SERVICE 2 Finished
DON’T KNOW, WOULDN’T SAY, NO NAME WAS GIVEN 3 AnsOther
ansservice=3 |
AnsOther.
INTERVIEWER: please enter what was said
(STRING 100) Finished
AnsOther
dialresult=7 |
PhoneProb.
INTERVIEWER: code phone problem
not in service; disconnected; not working 1 Finished
temporarily not in service 2 Finished
circuit problems; circuits overloaded 3 Finished
fast busy; fast ring; no ring 4 Finished
computer/fax line 5 Finished
PAGER 6 Finished
CELL PHONE 7 Finished
OTHER PHONE DEVICE……………………………………………………… 8 Finished
dialresult=1 |
Hello. Hello, my name is [INTERVIEWER NAME]. I am calling on behalf of Mathematica Policy Research in Princeton, New Jersey. May I please speak to [NAME]?
speaking to [name] 1 SampMemb
[name] comes to the phone 2 SampMemb
person asks what call is about 3 WhatAbout
[name] CAN BE REACHED AT ANOTHER NUMBER 4 PhoneNumber
[NAME] doesn’t live here/MOVED 5 NewCont
[NAME] has a health problem/ deceased 6 RespGone
[NAME] is in an institution/jail 7 Go to institution
[NAME] NOT AVAILABLE FOR NON-TEMPORARY REASON 8 RespGone
not available, need to call back 9 CallBack
never heard of [name]/wrong number 10 PhoneCheck
hung up during introduction 11 STATUS 640, Exit
Makedialphone=4,5 |
Hello1. Hello, my name is [INTERVIEWER NAME] from Mathematica Policy Research. May I ask your name?
speaking to [name] 1 SC2
[name] called to make appointment 2 MAKE APPOINTMENT
[name] called to refuse 3 CODE REFUSAL BY R
someone else called to refuse 4 CODE REFUSAL BY OTHER
someone else called to say [name] deceased 5 RESPGONE
someone else called to say child deceased 6 Sorry
HELLO=3 |
WhatAbout. I’m calling to conduct a follow-up interview for the MIHOPE study. May I speak with her? IF RE-ENTRY: I’m calling to finish the interview we are conducting with [NAME] for the MIHOPE study. May I speak with her?
[NAME] COMES TO THE PHONE 1 SampMemb
SUPERVISOR REVIEW Finished
[name] CAN BE REACHED AT ANOTHER NUMBER 3 PhoneNumber
[NAME] doesn’t live here/MOVED 4 NewCont
[NAME] has a health problem/ deceased 5 RespGone
[NAME] NOT AVAILABLE FOR NON-TEMPORARY REASON 6 RespGone
[NAME] is in an institution/jail 7 Go to institution
not available, need to call back 8 CallBack
never heard of [name]/wrong number 9 PhoneCheck
hung up during introduction 10 STATUS 640, Exit
hello = 7 or whatabout=7 |
Institution. INTERVIEWER: ENTER TYPE OF INSTITUTION.
HOSPITAL 1 HomeSoon
NURSING HOME 2 RespGone
ASSISTED LIVING FACILITY 3 RespGone
GROUP HOME 4 RespGone
JAIL OR PRISON 5 RespGone,
(hello = 7 or whatabout=7) and (institution = 1) |
|
HomeSoon. Do you expect [NAME] to come home from the hospital within two to four weeks?
YES ARRANGE CALLBACK 1 Go to Callback
NO 2 Go to RespGone
UNABLE TO RESPOND OVER THE TELEPHONE 3 Go to RespGone
WHATABOUT=1 OR HELLO=1,2 AND RE-ENTRY |
IF HELLO = 1, OMIT FIRST SENTENCE. IF RE-ENTRY, OMIT THE SECOND, THIRD AND FOURTH SENTENCES. FILL MONTH and YEAR OF PREVIOUS INTERVIEW |
SampMemb. Hello, my name is [INTERVIEWER NAME], and I’m calling from Mathematica Policy Research in Princeton, New Jersey. I’m calling about the MIHOPE study. You joined MIHOPE and completed a telephone interview back in [MONTH YEAR[. You should have received a letter from us recently reminding you about this interview. I’m calling to conduct the follow up interview for MIHOPE. May we begin now?
[IF RE-ENTRY: I’m calling to finish the interview we are conducting for the MIHOPE study. Is now a good time to finish it?
YES, CONTINUE INTERVIEW 1 SC2
NO, NOT A GOOD TIME……………………………….. 2 CallBack
DID NOT RECEIVE OR DOES NOT RECALL THE LETTER 3 Go to NoLetter
WANTS MORE INFORMATION 4 Go to MoreInfo
HUNG UP DURING INTRODUCTION 5 Status 640, Exit
SUPERVISOR REVIEW 6 Status 380, Exit
REFUSED r Status 200, Exit
sampmemB=3 |
The letter explained the purpose of the MIHOPE study and reminded you of your participation in the study and of this follow up component of the study. |
NoLetter. The letter explained [MORE INFO] Can we begin now?
BEGIN INTERVIEW 1 SC2
WANTS ANOTHER LETTER 2 Go to ReadLetter
WANTS MORE INFORMATION 3 Go to MoreInfo
NOT A GOOD TIME 4 Go to Callback
HUNG UP DURING INTRODUCTION 5 Status 640, Exit
REFUSED r Status 200, Exit
sampmemb = 4 or noletter = 3 |
The letter explained the purpose of the MIHOPE study and reminded you of your participation in the study and of this follow up component of the study. |
MoreInfo. [MORE INFO] Shall we begin?
BEGIN INTERVIEW 1 SC2
WANTS ANOTHER LETTER 2 Go to ReadLetter
NOT A GOOD TIME 3 Go to Callback
HUNG UP DURING INTRODUCTION 4 Status 640, Exit
REFUSED r Status 200, Exit
noletter = 2 or moreinfo = 2 |
ReadLetter. May I read the letter to you and then we can begin?
YES, READ THE LETTER FROM HARD COPY 1 SC2
NO, WANTS ANOTHER LETTER FIRST 2 Go to SendLetter
HUNG UP DURING INTRODUCTION 3 Status 640, Exit
REFUSED r Status 200, Exit
ReadLetter = 2 |
SendLetter. Okay, I'll mail another letter and will call back in a few days
STREET STRING (25)
CITY STRING (25)
STATE STRING (25)
| | | | | | - | | | | |
ZIP CODE Status 831, Go toThanks
00501-99950 0001-9999
DON’T KNOW……………………………………………..d Status 831, Go toThanks
REFUSED……………………………………………..r Status 200, Exit
Hello=5 |
and [CHILD] IF SC0 = 2; ELSE NO ADDITIONAL FILL FILL MONTH and YEAR OF PREVIOUS INTERVIEW |
NEWCONT. I’m calling to conduct a follow-up interview for the MIHOPE study that [NAME] is participating in. [NAME] joined MIHOPE back in [MONTH YEAR] and agreed to be contacted again to participate in a follow up interview about herself [and [CHILD]]. May I have [NAME]’s address and phone number so I can contact her?
YES, new or updatedinformation given 1 UPDATE INFO SCREEN;
SEND TO LOCATING
No, won’t give info 2 THANKS; SEND TO LOCATING
WANTS TO GIVE HER INFO AND HAVE HER CALL US 3 THANKS; GIVE TOLL FREE#
DON’t know d THANKS; SEND TO LOCATING
REFUSED r THANKS; SEND TO LOCATING
Hello=6 or HELLO=7 OR hello1=5 |
IF HELLO=6 OR HELLO1=5, DISPLAY FIRST TWO SENTENCES IF HELLO1=5, OMIT THIRD SENTENCE IF SC0=1 DISPLAY “her 15-month old child”; IF SC0=2 DISPLAY [CHILD] |
RespGone. IF Hello = 6 or Hello1=5, FIRST SAY: I’m very sorry for your loss. Please accept my condolences. PAUSE.
I’m calling to conduct a follow-up interview for the MIHOPE study that [NAME] joined and was participating in with [her child [CHILD]/her 15-month old child]. May I please speak to the person who is caring for the child, such as a parent or guardian?
UPDATE INFO SCREEN WITH NAME AND SET NEW RESPONDENT =1
YES, new or updatedinformation given 1 UPDATE INFO SCREEN;
SEND TO LOCATING
No, won’t give info 2 THANKS; SEND TO LOCATING
WANTS TO GIVE HER INFO AND HAVE HER CALL US 3 THANKS; GIVE TOLL FREE#
DON’t know d THANKS; SEND TO LOCATING
REFUSED r THANKS; SEND TO LOCATING
rESPgONE=ans OR SC14=1 |
DISPLAY NAME FROM RESPGONE SCREEN |
NEWRESP. Is [NAME] available to speak right now?
YES, person comes to phone / speaking to person 1 SC2
NO 0 CALLBACK
DOESN’T LIVE HERE 2 NEWNUMB
CHILD IS DECEASED 3 SORRY
DON’t know d THANKS; SEND TO LOCATING
REFUSED r THANKS; SEND TO LOCATING
NEWRESP=2 |
NEWNUMB. May I please have the number where I can reach [NAME]?
YES 1 UPDATE INFO SCREEN; NEWADD
DON’t know d NEWADD
REFUSED r NEWADD
newnumb=1, d,r |
NEWADD. May I please have the address or city where I can reach [NAME]?
YES 1 UPDATE INFO SCREEN;
SEND TO LOCATING
DON’t know d THANKS; SEND TO LOCATING
REFUSED r THANKS; SEND TO LOCATING
HELLO1=6 or NEWRESP=3 |
SORRY. I’m very sorry for your loss. Please accept my condolences. PAUSE. You will no longer be contacted for the MIHOPE study. Good-bye.
END CALL. STATUS AS FOCAL CHILD DECEASED.
HELLO=8 or WHATABOUT=2 OR SAMPMEMB=2 OR NEWRESP=0 |
CallBack. When would be a good time to call back?
INTERVIEWER: make appointment ON CONTACT SHEET
Hello=9 |
Fill PHONE NUMBER from preload |
PhoneCheck. I’m sorry, I must have misdialed. I thought I dialed [PHONE NUMBER]. Is that the number I’ve reached?
YES, right number, no such person 1 WRONGNUMBER
NO, wrong connection/misdial 2 THANKS
supervisor review required 3 THANKS, SUP REVIEW
refused to confirm number 4 THANKS, SET CALLBACK
PHONECHECK=1 AND RE-ENTRY |
FILL MONTH and YEAR OF PREVIOUS INTERVIEW |
WrongNumber. I’m [INTERVIEWER NAME] from Mathematica Policy Research in Princeton, New Jersey. We spoke to someone there back in [MONTH YEAR] and according to the information I have, we were supposed to call back to interview [NAME]. There must have been some mistake.
Thanks you for your help.
END CALL. INTERVIEWER: SEND CASE TO LOCATING
HELLO=4 |
PhoneNumber. Please give me the telephone number, area code first.
| | | | - | | | | - | | | | | HaveExten
refused to GIVE number r THANKS, SEND TO LOCATING
PHONEnumber=ANS |
HaveExten. Is there an extension number?
programmer: display phone number
YES 1 EXTENSION
NO 0 THANKS, SEND TO LOCATING
HAVEEXTEN=1 |
Extension. What is the extension number?
programmer: display phone number
| | | | | extension………………………………………..THANKS, SEND TO LOCATING
(0-9999)
HELLO=4 |
PhoneType. Is this a home phone, business phone or a cell phone?
home phone 1
office phone 2
home and office phone 3
cell phone 4
pager 5
COMPUTER/FAX LINE 6
OTHER 7
ALL |
FILL CONTACT INFORMATION FROM PREVIOUS ITEMS |
Confirm.
programmer: fill contact information from previous items
interviewer: confirm the info above with respondent, then press enter.
ALL |
|
IF RESPONDENT=NAME, DISPLAY “you” ; IF NEW RESPONDENT=1, DISPLAY [NAME]. IF child’s name is known, fill [CHILD] else if respondent =name fill “your child” or if new respondent fill “her child” |
|
FILL MONTH and YEAR OF PREVIOUS INTERVIEW |
|
SC2. We previously interviewed [you/NAME] for the MIHOPE study in (MONTH) of (YEAR). The purpose of the study is to learn about families who enroll in home visiting programs and how these programs provide different kinds of services to children and families.
NEW RESPONDENT=1 AND SC0=1
[NAME] was pregnant when we interviewed her and she agreed to speak to us again when her child was about 15 months old.
NEW RESPONDENT=1 AND SC0=2
[NAME] agreed to speak to us again when [CHILD] was about 15 months old.
ALL
We’d like to speak with you to learn about [CHILD]’s/ (your/her) child’s development and to ask you some questions about your family. I will 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. When we finish, we will send you a $25 gift card to thank you for your help.
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.
Your participation is completely voluntary. Everything we talk about today is completely private. All of the study results will be reported for groups of parents; no results will be analyzed or reported for individuals.
Also, you should know that this interview has been approved by the federal Office of Management and Budget or OMB. We're not allowed to ask you these questions and you don't have to answer them unless there is a valid OMB control number. For this interview, the OMB control number is 0970-0402 and it expires 06/30/2016.
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 REFER TO FAQ
NO 0
DON’T KNOW d
REFUSED r
RESPONDENT IS NOT LIVING WITH CHILD 2 SC14B
NEW RESPONDENT=1 |
SC2A. Do you consent to participate in this interview for the MIHOPE study?
YES 1 SC3
DON’t know d THANKS; SET CALLBACK
REFUSED r FINISHED
ALL |
SC3. First, I’d like to confirm the spelling of your name. Would you please spell your name for me?
display name as interviewer note
INTERVIEWER: CONFIRM SPELLING OF NAME.
PROGRAMMER: ALLOW RESPONDENT INFO TO BE ENTERED/REVISED IN INFO SCREEN. FIRST, HAVE INTERVIEWER INDICATE WHETHER THE NAME IS SPELLED CORRECTLY, THEN IF INCORRECT, ALLOW NAME TO BE REVISED,
(STRING (15))
FIRST NAME
(STRING (15))
MIDDLE INITIAL/NAME
(STRING (30))
LAST NAME
DON’T KNOW d
REFUSED r
NEW RESPONDENT=1 |
SC4DOB. What is your birth date?
| | | / | | | / | | | | |
MONTH DAY YEAR
DON’T KNOW d
REFUSED r
SOFT CHECK (IF SC4 = IF DOB IS EQUAL TO OR GREATER THAN 50 YEARS OLD): INTERVIEWER: I ENTERED YOUR DATE OF BIRTH AS [FILL DOB]. IS THIS CORRECT? |
PROGRAMMER BOX IF NEW RESPONDENT =1 AND DATE OF BIRTH IS < 18 YEARS, TERMINATE INTERVIEW AND SEND CASE TO SUPERVISOR REVIEW to be statused as ineligible for follow up.
|
NEW RESPONDENT = 0 |
Fill DOB from PRELOAD |
SC5DOB. What is your birth date?
PROGRAMMER: DISPLAY DOB AS INTERVIEWER NOTE
PROGRAMMER: ALLOW BIRTH DATE INFO TO BE ENTERED/REVISED IN INFO SCREEN
INTERVIEWER: COMPARE RESPONSE WITH BIRTH DATE DISPLAYED
| | | / | | | / | | | | |
MONTH DAY YEAR
DOB CORRECT 1
DOB INCORRECT 2
DON’T KNOW d
REFUSED r
SOFT CHECK (IF SC5DOB = IF DOB IS EQUAL TO OR GREATER THAN 50 YEARS OLD): INTERVIEWER: I ENTERED YOUR DATE OF BIRTH AS [FILL DOB]. IS THIS CORRECT? |
SC4DOB=d,r OR SC5DOB=d, r |
SC6. How old are you?
| | | YEARS
DON’T KNOW d
REFUSED r
SOFT CHECK (IF SC6 = IF AGE IS EQUAL TO OR GREATER THAN 50 YEARS OLD): INTERVIEWER: I entered your age AS [FILL age]. IS THIS CORRECT? |
PROGRAMMER BOX IF NEW RESPONDENT = 1 AND IS < 18 YEARS, TERMINATE INTERVIEW AND SEND CASE TO SUPERVISOR REVIEW to be statused as ineligible for follow up. IF baseline respondent, then no range check necessary; continue interview. |
SC0=2 (NOT PREGNANT AT BASELINE) |
Fill CHILD from PRELOAD |
SC7. Now, I would like to make sure we have [CHILD]’s name recorded correctly.
PROGRAMMER: DISPLAY CHILD’S NAME as interviewer note
INTERVIEWER: VERIFY SPELLING
NAME CORRECT 1 SC13
NAME INCORRECT 2 CORRECT NAME
child deceased 3 Sorry2
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 RESPONDENT DOES NOT KNOW [CHILD] GO TO SUPERVISOR REVIEW.
IF THE NAME IS CORRECT, PRESS ENTER.
SC0 = 1 (PREGNANT AT BASELINE) |
IF RESPONDENT=NAME, DISPLAY “you” and fill due date ; IF NEW RESPONDENT=1, DISPLAY [NAME] |
SC8. When [you/[NAME]] joined MIHOPE, [you were/she was] pregnant and your baby was due on [DUE DATE]. Did [you/[NAME]] have a single or multiple birth?
SINGLE 1 SC11
MULTIPLE 2
HAD A MISCARRIAGE OR STILLBIRTH 77 Sorry2
child deceased 3 Sorry2
DON’T KNOW d STATUS AS 380, EXIT
REFUSED r STATUS AS 380, EXIT
sc8=2 |
IF RESPONDENT=NAME, DISPLAY “you” ; IF NEW RESPONDENT=1, DISPLAY [NAME] |
SC9. How many babies did [you/[NAME]] give birth to?
1 1
2 2
3 3
4 4child deceased 5 Sorry2
PROGRAMMER BOX SC10-SC12 IF SC8=2, ASK SC10-SC12 FOR AS MANY TIMES AS NUMBER OF CHILDREN MENTIONED IN SC9 |
SC0=1 |
IF RESPONDENT=NAME, DISPLAY “your” ; IF NEW RESPONDENT=1, DISPLAY [NAME] |
fill “first, second, third, or fourth child” depending on number of babies reported at SC9 |
SC10. Could you please spell [your/[NAME]’s] [(first/second/third/fourth)] child’s name for me?
(STRING (15))
FIRST NAME
(STRING (15))
MIDDLE INITIAL/NAME
(STRING (30))
LAST NAME
DON’T KNOW d
REFUSED r
INTERVIEWER: IF SINGLE BIRTH AND CHILD IS DECEASED, ENTER DECEASED IN sc13 CONTINUE TO SORRY2.
ALL |
IF SC0=1,Fill CHILD FROM SC10. IF SC0=2, FILL CHILD FROM PRELOAD |
SC13. Is [CHILD] a boy or a girl?
INTERVIEWER: CONFIRM IF ALREADY KNOWN
BOY 1
GIRL 2
child deceased 3 Sorry2/SC10
DON’T KNOW d
REFUSED r
PROGRAMMER: IF SINGLE BIRTH AND CHILD DECEASED GO TO SORRY2. IF MULTIPLE BIRTH AND CHILD DECEASED GO TO SC10 FOR NEXT CHILD.
ALL |
IF SC0=1,Fill CHILD FROM SC10. IF SC0=2, FILL CHILD FROM PRELOAD |
SC13a. What is [CHILD]’s birth date?
DISPLAY CHILD’S DOB AS INTERVIEWER NOTE
| | | / | | | / | | | | |
PROGRAMMER: ALLOW BIRTH DATE INFO TO BE ENTERED/REVISED IN INFO SCREEN
sc0=2 AND datE OF BIRTH CORRECT 1
sc0=2 AND DATE OF BIRTH INCORRECT 2 DOB SCREEN
sc0=1 3 DOB SCREEN
child deceased 0 Sorry2/SC10
DON’T KNOW d STATUS AS 200; EXIT
REFUSED r STATUS AS 200; EXIT
PROGRAMMER: IF SINGLE BIRTH AND CHILD DECEASED GO TO SORRY2. IF MULTIPLE BIRTH AND CHILD DECEASED GO TO SC10 FOR NEXT CHILD.
IF SC0=2 (i.e. Respondent was NOT pregnant at baseline) and child’s entered date of birth and name does not match prefilled info (OBTAINED at baseline), END CALL AND SEND TO SUPERVISOR REVIEW. |
sc8=2 |
IF SC0=1,Fill CHILD FROM SC10. IF SC0=2, FILL CHILD FROM PRELOAD |
SC14. [CHILD] has been randomly selected to be the focal child for this interview. The questions we ask in this interview will be about [CHILD].
IF RESPONDENT SAYS CHILD DECEASED, THEN DON’T ASK SC14A; CODE CHILD DECEASED IN SC14A
ALL |
IF SC0=1,Fill CHILD FROM SC10. IF SC0=2, FILL CHILD FROM PRELOAD |
SC14a. Are you currently living with [CHILD]?
YES 1
NO 0
child deceased 2 Sorry2
IF RESPONDENT SAYS CHILD DECEASED, SAY “I’m very sorry for your loss. Please accept my condolences. [CHILD] will be the focal child for this interview. The questions we ask in this interview will be about [CHILD].
PROGRAMMER SELECT ONE OF THE SURVIVING CHILDREN AS THE FOCAL CHILD.
SC14a=0 |
IF SC0=1,Fill CHILD FROM SC10. IF SC0=2, FILL CHILD FROM PRELOAD |
SC14b. Who is the person most responsible for [CHILD]’s care?
Gave name 1 RECORD NAME AND GO BACK TO NEWRESP
PERSON ON THE PHONE 2
Hung up 3 TERMINATE, REFUSAL
DOESN’T KNOW NAME OF CAREGIVER BECAUSE CHILD IN FOSTER CARE 4 TERMINATE, LOCATING
Child deceased 5 SORRY2
DON’T KNOW d SUP REVIEW; TERMINATE,
REFUSED r TERMINATE; REFUSAL
HARD CHECK: IF respondent says they are responsible for the child’s care even if they are not living with child., say “I recorded that you are not living with [CHILD] but that you are the person most responsible for [CHILD]’s care. Can you provide the name of the person who is living with [CHILD] and is most responsible for [his/her] care?” |
NEW RESPONDENT =1 |
Fill CHILD FROM SC10 |
SC15. What is your relationship to [CHILD]?
RELATIONSHIP CODES:
BIOLOGICAL FATHER 12
ADOPTIVE MOTHER 13
ADOPTIVE FATHER 14
STEPMOTHER 15
STEPFATHER 16
COUSIN (FEMALE) 17
COUSIN (MALE) 18
AUNT 19
UNCLE 20
GRANDMOTHER. 21
GRANDFATHER 22
GREAT GRANDMOTHER 23
GREAT GRANDFATHER 24
SISTER/STEPSISTER 25
BROTHER/STEPBROTHER 26
OTHER RELATIVE OR IN-LAW (FEMALE) 27
OTHER RELATIVE OR IN-LAW (MALE) 28
FOSTER PARENT (FEMALE) 29
FOSTER PARENT (MALE). 30
OTHER NON-RELATIVE (FEMALE) 31
OTHER NON-RELATIVE (MALE) 32
PARENT’S PARTNER (FEMALE) 33
PARENT’S PARTNER (MALE) 34
child deceased 35 Sorry2
SORRY2. I’m very sorry for your loss. Please accept my condolences. PAUSE. You will no longer be contacted for the MIHOPE study. Good-bye.
END CALL. STATUS AS FOCAL CHILD DECEASED.
SC14a=1 |
Fill CHILD FROM SC10 |
SC16. For how many months have you lived with [CHILD]?
INTERVIEWER: IF RESPONDENT SAYS ALL OF THE TIME, ENTER CHILD’S AGE IN MONTHS.
| | | months
(1-26)
LESS THAN ONE MONTH 0
DON’T KNOW d
REFUSED r
HARD CHECK: IF RESPONSE IS GT AGE OF CHILD; I recorded that you have lived with [CHILD] for [FILL RESPONSE AT SC16] but [CHILD] is only [FILL AGE OF CHILD] old. Is that correct? |
NEW RESPONDENT=1. SKIP IF HELLO = 6 (MOTHER DECEASED) |
Fill CHILD FROM SC10 |
SC17. Why is [CHILD]’s mother not living with (him/her)?
CODE ALL THAT APPLY
MOTHER LEFT/MOVED AWAY 1
MOTHER DECEASED 2
MOTHER INCARCERATED 3
MOTHER IN HOSPITAL 4
MOTHER IN OTHER INSTITUTION 5
MOTHER HAS DRUG/ALCOHOL ISSUES 6
MOTHER.HAS MENTAL HEALTH ISSUES 7
MOTHER.IS AT SCHOOL 8
MOTHER IN THE ARMED FORCES 9
POLICE OR COURT ORDER 10
CHILD PROTECTIVE SERVICES ORDER 11
DOMESTIC VIOLENCE SITUATION 12
CHILD ABUSE SITUATION 13
OTHER (SPECIFY) _______________________________(STRING 200) 99
INTERVIEWER: ENTER 1 TO CONTINUE
CH. CHILD HEALTH AND DEVELOPMENT
all |
CHIntro. The first questions are about [CHILD]’s health.
INTERVIEWER: enter 1 to continue
all |
CH1. Overall, would you say [CHILD]'s health is…
Excellent, 1
Very good, 2
Good, 3
Fair, or 4
Poor? 5
DON’T KNOW d
REFUSED r
pregnant at baseline |
Fill CHILD’S GENDER, CHILD’S name from PRELOAD |
CH2. 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
15 TO 30 DAYS, 5
MORE THAN ONE MONTH, 6
BABY NOT BORN IN HOSPITAL 7
BABY IS STILL IN THE HOSPITAL 8
DON’T KNOW d
REFUSED r
all. if CH2 = 7, ask ch3 as “Did [child] spend any days in the Neonatal Intensive Care Unit (NICU) after birth? |
CH3. 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
YES, ALL IN NICU 1
YES, SOME IN NICU 2
NO, ALL IN REGULAR NURSERY 3
DON’T KNOW d
REFUSED r
CH3=1 OR 2 |
CH4. How long did [CHILD] stay in the neonatal intensive care unit (NICU) after birth?
| | | days
(1-AGE OF CHILD IN DAYS)
DON’T KNOW d
REFUSED r
HARD CHECK: IF GT CH3; I recorded that [CHILD] was in the hospital for [CH2] days but was in the NICU for [CH4] days. Is that correct? |
all |
CH5. Was [CHILD] seen by a doctor, nurse, or other health care worker for a one week check-up after (he/she) was born?
YES 1
NO 0
DON’T KNOW d
REFUSED r
all |
CH6. Was [CHILD] seen by a doctor, nurse, or other health care worker for (his/her) 12-month well-child check-up?
YES 1
NO 0
DON’T KNOW d
REFUSED r
all |
CH7. Was [CHILD] seen by a doctor, nurse, or other health care worker for (his/her) 15-month well-child check-up?
YES 1
CHILD HASN’T BEEN FOR CHECK-UP YET, BUT CHECK –UP IS SCHEDULED 2
NO 0
DON’T KNOW d
REFUSED r
all |
CH8. Has [CHILD] gone as many times as you wanted for a well-baby checkup?
YES 1
NO 0
DON’T KNOW d
REFUSED r
all |
CH9. Do you think [CHILD] is missing any of the immunizations or shots for children (his/her) age?
YES 1
NO 0
DON’T KNOW d
REFUSED r
all |
CH10. 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
all |
CH11. Is there a place [CHILD] usually goes when (he/she) is sick or you need advice about (his/her) health?
YES 1
NO 0
DON’T KNOW d
REFUSED r
ch11 ne 0 |
CH12. Is it a doctor’s office, emergency room, hospital outpatient department or clinic?
Doctor’s office 1
hospital emergency room 2
hospital outpatient department 3
clinic or health center 4
OTHER (SPECIFY) 99
(STRING 200)
DON’T KNOW d
REFUSED r
IF OTHER SPECIFY (99): What kind of place is it? |
all |
CH13. A personal doctor or nurse is a health professional who knows [CHILD] well and is familiar with [his/her] health history. This can be a general doctor, a pediatrician, a specialist doctor, a nurse practitioner, or a physician's assistant. Do you have one or more persons you think of as [CHILD]'s personal doctor or nurse?
YES, ONE PERSON 1
YES, MORE THAN ONE PERSON 2
NO 0
DON’T KNOW D
REFUSED r
all |
CH14. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and others who specialize in one area of health care. During the past 12 months, did [CHILD] see a specialist?
YES 1
NO 0
DON’T KNOW d
REFUSED r
ch14 ne1 |
CH15. During the past 12 months, did you or a doctor think that [CHILD] needed to see a specialist?
YES 1
NO 0
DON’T KNOW d
REFUSED r
ch14=1 or ch15= 1 |
CH16. During the past 12 months, how much of a problem, if any, was it to get the care from the specialists that [CHILD] needed? Would you say it was…
A big problem, 1
A small problem, or 2
Not a problem? 3
DON’T KNOW d
REFUSED r
all |
CH17. Has a doctor, nurse, or other medical professional told you that [CHILD] has developmental delays?
YES 1
NO 0
DON’T KNOW d
REFUSED r
all |
CH18. Does [CHILD] have any chronic condition for which (he/she) is seen regularly by a doctor?
YES 1
NO 0
DON’T KNOW d
REFUSED r
ch18=1 |
CH19. What is the problem or condition?
ASTHMA 1
DIABETES 2
CONGENITAL HEART PROBLEMS 3
EPILEPSY 4
CEREBRAL PALSY 5
SPINA BIFIDA 6
SICKLE CELL ANEMIA 7
CYSTIC FIBROSIS 8
CANCER 9
AIDS 10
OTHER (SPECIFY) ___________________(STRING 200) 99
DON’T KNOW d
REFUSED r
ALL |
CH20. Does anyone help you arrange or coordinate [CHILD]’s care among the different doctors or services that (he/she) uses?
PROBE: By “arrange or coordinate,” I mean: Is there anyone who helps you make sure that [CHILD] gets all the health care and services (he/she) needs, that health care providers share information, and that these services fit together and are paid for in a way that works for you?
YES 1
NO 0
DON’T KNOW d
REFUSED r
ALL |
CH21. During the past 12 months, have you felt that you could have used extra help arranging or coordinating [CHILD]’s care among the different health care providers or services?
YES 1
NO 0
DON’T KNOW d
REFUSED r
ALL |
CH22. During the past 12 months, how often did you get as much help as you wanted with arranging or coordinating [CHILD]’s care? Would you say…
Never, 1
Sometimes, or 2
Usually? 3
DON’T KNOW d
REFUSED r
ALL |
CH23. Has [CHILD] made any emergency room visits since (he/she) was born?
YES 1
NO 0
DON’T KNOW d
REFUSED r
all |
CH24. Not including when [CHILD] was born, how many different times has (he/she) stayed in a hospital for at least one night?
| | | times
(0-50)
DON’T KNOW d
REFUSED r
SOFT CHECK: IF CONDITION (e.g. GT 20); Soft check statement/question. I recorded that [CHILD] stayed in a hospital [CH24] times for at least one night. Is that correct? |
CH24 gte 1 |
CH25. Not including when [CHILD] was born, altogether, how many nights did [CHILD] stay in a hospital?
| | nights
(0-50)
DON’T KNOW d
REFUSED r
HARD CHECK: IF CH25 IS LESS THAN CH24;. I recorded that [CHILD] spent [CH25] nights in the hospital since (he/she) was born but has stayed in the hospital [CH24] times for at least one night. Is that correct? |
CH24 GTE 1 |
If CH24=1, ‘Was this hospitalization’ ; if CH24 GT 1, ‘Were any of these hospitalizations’ |
CH26. (Was this hospitalization/ Were any of these hospitalizations) because of an accident or injury? For example, burns, falls, poisoning or choking?
YES 1
NO 0
DON’T KNOW d
REFUSED r
CH24 GT 1 AND ch26=1 |
NUMBER FROM CH24 |
CH27. How many of the [CH24] hospitalizations were because of an accident or injury?
| | | HOSPITALIZATIONS
(0-50)
DON’T KNOW d
REFUSED r
SOFT CHECK: IF NUMBER IS GT 20; Soft check statement/question. I recorded that [CH27] of the hospitalizations were because of an accident or injury. Is that correct? |
all |
CH28. Sometimes people have difficulties in getting medical care when they need it. In the past 12 months, have you delayed or gone without health care for [CHILD]?
YES 1
NO 0
DON’T KNOW d
REFUSED r
all |
CH29. During the past 12 months, was there any time when [CHILD] needed prescription medications?
YES 1
NO 0
DON’T KNOW d
REFUSED r
CH29=1 |
CH30. Did [CHILD] receive all prescription medications (he/she) needed?
YES 1
NO 0
DON’T KNOW d
REFUSED r
all |
CH31. The next questions are about [CHILD]’s dental health. Do you clean [CHILD]'s teeth or gums every day, either by wiping with a clean, damp cloth or with a small, soft toothbrush?
YES 1
NO 0
DON’T KNOW d
REFUSED r
all |
CH32. During the past 12 months, did [CHILD] see a dentist for any kind of dental care, including check-ups, dental cleanings, x-rays, or filling cavities? Include visits to dental hygienists and all types of dental specialists.
YES 1
NO 0
DON’T KNOW d
REFUSED r
ch32=1 |
CH33. During the past 12 months, how many times did [CHILD] see a dentist for preventive dental care, such as check-ups and dental cleanings?
| | | times
(1-20)
DON’T KNOW d
REFUSED r
SOFT CHECK: IF NUMBER IS GT 20. I recorded that [CHILD] saw a dentist [CH33] times during the past 12 months. Is that correct? |
all PROGRAMMER: ALLOW DECIMAL RESPONSE |
CH34. How old was [CHILD] in months when (he/she) started to…
PROGRAMMER: RANGE IS 0-26 MONTHS
interviewer: CODE ZERO IF RESPONDENT REPORTS CHILD HAS NOT ACHIEVED MILESTONE YET
|
MONTHS
|
a. Sit alone, steady, without support? |
| | |. | | | |
b. Crawl on hands and knees? |
| | | | | | |
c. Pull (him/her)self to a standing position? |
| | |. | | | |
d. First walk while holding on to something, such as furniture? |
| | |.| | | |
e. First walk without holding onto anything? |
| | |.| | | |
HARD CHECK: IF NUMBER IS GT CURRENT AGE OF CHILD. I recorded that [CHILD] started to [FILL STEM] at [CH34] months of age, but [CHILD] is currently [CURRENT AGE IN MONTHS] months old. Is that correct? |
all |
CH35. Where does [CHILD] sleep?
PROBE: IF RESPONDENT SAYS “IN A CRIB,” ASK, “Is the crib in an adult’s room, in a room with a sibling, or in a separate room by (him/her)self?”
INFANT CRIB IN A SEPARATE ROOM 1
INFANT CRIB IN ADULT’S ROOM 2
IN ADULT’S BED 3
INFANT CRIB IN A ROOM WITH SIBLING 4
OTHER (SPECIFY) 99
(STRING 100)
DON’T KNOW d
REFUSED r
IF OTHER SPECIFY (99): Where does [CHILD] sleep? |
all |
CH36. In what position does [CHILD] sleep most of the time? Is it…
On (his/her) belly, 1
On (his/her side), or 2
On (his/her) back? 3
DON’T KNOW d
REFUSED r
ALL PROGRAMMER; ALLOW DECIMAL RESPONSE |
CH37. How much time does [CHILD] spend in sleep during the night, that is, between 7 in the evening and 7 in the morning?
INTERVIEWER CODE WHOLE NUMBER OR FRACTION. CODE 1/2 HOUR AS 0.5, 1/4 OF AN HOUR AS 0.25 AND 3/4 OF AN HOUR AS 0.75.
| | | HOURS (0-12), | | | (1-99)
DON’T KNOW d
REFUSED r
ALL PROGRAMMER: ALLOW DECIMAL RESPONSE |
CH38. How much time does [CHILD] spend in sleep during the day, that is, between 7 in the morning and 7 in the evening?
INTERVIEWER CODE WHOLE NUMBER OR FRACTION.
CODE 1/2 HOUR AS 0.5, 1/4 OF AN HOUR AS 0.3 AND 3/4 OF AN HOUR AS 0.7.
| | HOURS (0-12) . | | (1-9)
DON’T KNOW d
REFUSED r
all |
CH39. How many times on average does [CHILD] wake at night?
| | times
(0-30)
DON’T KNOW d
REFUSED r
SOFT CHECK: IF CONDITION (e.g. GT 20); Soft check statement/question. I recorded that [CHILD] wakes up [CH39] times during the night. Is that correct? |
ch39 gt 0 programmer: allow decimal response |
CH40. How much time does [CHILD] spend in wakefulness during the night between the hours of 10 pm and 6 am?
INTERVIEWER CODE WHOLE NUMBER OR FRACTION. CODE 1/2 HOUR AS 0.5, 1/4 OF AN HOUR AS 0.25 AND 3/4 OF AN HOUR AS 0.75.
| | | HOURS (0-12) . | | | (1-99)
DON’T KNOW d
REFUSED r
all programmer; allow decimal response |
CH41. How long does it take to put [CHILD] to sleep in the evening?
INTERVIEWER CODE WHOLE NUMBER OR FRACTION. CODE 1/2 HOUR AS 0.5, 1/4 OF AN HOUR AS 0.25 AND 3/4 OF AN HOUR AS 0.75.
| | | HOURS (0-12) . | | | (1-99)
DON’T KNOW d
REFUSED r
all |
CH42. How does [CHILD] usually fall asleep? Is it while…
Feeding, 1
Being rocked, 2
Being held, 3
In bed alone, or 4
In bed near an adult? 5
OTHER (SPECIFY) 99
(STRING 100)
DON’T KNOW d
REFUSED r
IF OTHER SPECIFY (99): Insert Other specify statement/question. How does child usually fall asleep? |
all [PROGRAM AS A TIME SCREEN] |
CH43a. At what time does your baby usually fall asleep for the night?
ENTER TIME AS HOURS AND MINUTES
| | | HOUR (1-12):| | | MINUTE (0-60)
DON’T KNOW d
REFUSED r
CH43a ne d,r |
CH43b. ENTER AM OR PM
AM 1
PM 2
DON’T KNOW d
REFUSED r
SOFT CHECK: IF CONDITION (e.g. 1:00AM – 5:00AM); Soft check statement/question. I recorded that [CHILD] usually falls asleep at [CH43]. Is that correct? |
all |
CH44. Do you consider [CHILD]'s sleeping to be problematic? Would you say it is…
A very serious problem, 1
A small problem, or 2
Not a problem at all? 3
DON’T KNOW d
REFUSED r
all |
CH45. Next, I’m going to read you a series of topics. For each, please tell me whether a doctor, nurse, health care worker, home visitor or other professional has discussed these topics with you. Please count only discussions, not reading materials or videos.
|
YES |
NO |
a. How you and your family can be exposed to lead in your environment? |
1 |
0 |
b. What steps you can take to prevent you and your family from being exposed to lead? |
1 |
0 |
c. How eating fish containing high levels of mercury could affect your baby? |
1 |
0 |
all |
CH46. Has a doctor, nurse, health care worker, home visitor or other professional told you about what can happen if a baby is shaken?
YES 1
NO 0
DON’T KNOW d
REFUSED r
all |
CH47. When [CHILD] rides in a car, truck, or van, how often does (he/she) ride in a car seat? Would you say…
Always, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
DON’T KNOW d
REFUSED r
all Brief Infant Toddler Social and Emotional Assessment (BITSEA), 42 items DISPLAY PROBE ON SCREEN WHEN THE RESPONSE CATEGORIES ARE NOT PART OF THE QUESTION STEM |
CH48.
P. PARENTING
bio mom |
P1. Did you ever breastfeed or pump breast milk to feed [CHILD] after delivery?
YES 1
NO 0
DON’T KNOW d
REFUSED r
P1=1 |
P2. Are you currently breastfeeding or feeding pumped milk to [CHILD]?
YES 1
NO 0
DON’T KNOW d
REFUSED r
P2=0 |
P3. How many weeks or months did you breastfeed or pump milk to feed [CHILD]? You may respond in weeks or months.
TO ENTER WEEKS CODE 1, TO ENTER MONTHS CODE 2
INTERVIEWER: ROUND DOWN TO THE NEAREST WHOLE NUMBER IF A FRACTION IS PROVIDED. IF A RANGE IS PROVIDED, RECORD THE LOWER NUMBER
| | | WEEKS (1-52)
| | | MONTHS (1-26)
BABY WAS LESS THAN ONE WEEK 0
DON’T KNOW d
REFUSED r
HARD CHECK: IF P3 GT AGE OF CHILD: I recorded that you breastfed or pumped milk to feed [CHILD] for [P3] months), but [CHILD] is currently [AGE OF CHILD] months old. Is that correct? |
ALL |
P4. How old was [CHILD] when he/she began drinking formula on a regular basis? You may respond in weeks or months.
TO ENTER WEEKS CODE 1, TO ENTER MONTHS CODE 2
interviewer: round down to the nearest whole number if a fraction is provided. if a range is provided, record the lower number.
| | | WEEKS (1-52)
| | | MONTHS (1-26)
BABY WAS LESS THAN ONE WEEK 0
BABY NEVER DRANK FORMULA ON A REGULAR BASIS 99
DON’T KNOW d
REFUSED r
HARD CHECK: IF P4 GT AGE OF CHILD: I recorded that [CHILD] began drinking formula at [P4] months), but [CHILD] is currently [AGE OF CHILD] months old. Is that correct? |
ALL |
P5. How old was [CHILD] the first time (he/she) drank anything other than breast milk or formula? You may respond in weeks or months.
INTERVIEWER NOTE: WATER SHOULD BE COUNTED AS “ANYTHING OTHER THAN BREAST MILK OR FORMULA.”
TO ENTER WEEKS CODE 1, TO ENTER MONTHS CODE 2
interviewer: round down to the nearest whole number if a fraction is provided. if a range is provided, record the lower number.
| | | WEEKS (1-52)
| | | MONTHS (1-26)
BABY WAS LESS THAN ONE WEEK OLD 0
BABY DRINKS ONLY BREASTMILK OR FORMULA 99
DON’T KNOW d
REFUSED r
HARD CHECK: IF P5 GT AGE OF CHILD:. I recorded that [CHILD] began drinking anything other than formula or breastmilk at [P5] months), but [CHILD] is currently [AGE OF CHILD] months old. Is that correct? |
all |
P6. How old was [CHILD] the first time (he/she) ate food (such as baby cereal, baby food or any other food)? You may respond in weeks or months.
interviewer: round down to the nearest whole number if a fraction is provided. if a range is provided, record the lower number.
TO ENTER WEEKS CODE 1, TO ENTER MONTHS CODE 2
| | | WEEKS (1-52)
| | | MONTHS (1-26)
BABY WAS LESS THAN ONE WEEK OLD 0
BABY ONLY DRINKS BREASTMILK OR FORMULA 99
DON’T KNOW d
REFUSED r
HARD CHECK: IF P6 GT AGE OF CHILD. : I recorded that [CHILD] first began eating food at [P6] months), but [CHILD] is currently [AGE OF CHILD] months old. Is that correct? |
ALL |
P7. In the past 7 days, how often did [CHILD] drink 100% pure fruit juice such as orange, mango, apple, grape and pineapple juices? Do not include fruit flavored drinks with added sugar.
FOUR OR MORE TIMES A DAY 1
TWO OR THREE TIMES A DAY 2
ONCE A DAY 3
ALMOST EVERY DAY 4
1 TO 3 TIMES DURING THE PAST 7 DAYS 5
MY CHILD DOES NOT DRINK JUICE 6
DON’T KNOW d
REFUSED r
ALL |
P8. During the past 7 days, how many times did [CHILD] drink fruit drinks that are not 100% fruit (for example, Kool Aid, Sunny Delight, Hi-C, Fruitopia, or Fruitworks), sports drinks (for example, Gatorade), or soda pop (for example, Coke, Pepsi or Mountain Dew)?
FOUR OR MORE TIMES A DAY 1
TWO OR THREE TIMES A DAY 2
ONCE A DAY 3
ALMOST EVERY DAY 4
1 TO 3 TIMES DURING THE PAST 7 DAYS 5
HE/SHE DID NOT DRINK THESE BEVERAGES 5
DON’T KNOW d
REFUSED r
ALL |
P9. During the past 7 days, how many times did [CHILD] eat a meal or snack from a fast food restaurant with no wait service such as McDonald's, Pizza Hut, Burger King, Kentucky Fried Chicken, Taco Bell, Wendy's and so on? Consider eating in, carry out, and delivery of meals to your residence.
Four or more times a day, 1
Two or three times a day, 2
Once a day, 3
Almost every day, or 4
1 to 3 times during the past 7 days 5
HE/SHE DID NOT EAT FAST FOOD 5
DON’T KNOW d
REFUSED r
ALL |
P10. During the past 7 days, how many times did [CHILD] eat candy (including Fruit Roll-Ups and similar items), ice cream, cookies, cakes, brownies, or other sweets?
FOUR OR MORE TIMES A DAY 1
TWO OR THREE TIMES A DAY 2
ONCE A DAY 3
ALMOST EVERY DAY 4
1 TO 3 TIMES DURING THE PAST 7 DAYS 5
HE/SHE DID NOT EAT SWEETS 5
DON’T KNOW d
REFUSED r
ALL |
P11. During the past 7 day, how many times did [CHILD] eat potato chips, corn chips such as Fritos or Doritos, Cheetos, pretzels, popcorn, crackers or other salty snack foods?
FOUR OR MORE TIMES A DAY 1
TWO OR THREE TIMES A DAY 2
ONCE A DAY 3
ALMOST EVERY DAY 4
1 TO 3 TIMES DURING THE PAST 7 DAYS 5
HE/SHE DID NOT EAT SALTY SNACK FOODS 5
DON’T KNOW d
REFUSED r
ALL |
Parent Stress Index- Short Form (PSI-SF), 11 items DISPLAY PROBE ON SCREEN WHEN RESPONSE CATEGORIES ARE NOT PART OF THE QUESTION STEM. |
P12.
ALL |
Conflict Tactics Scale- Parent Child Version (CTS-PC), 13 items. We have obtained developers’ permission to revise the response categories as follows: Once in the past year, Twice in the past year, 3 to 5 times in the past year, 6 or more times in the past year, or has this never happened in the past year? DISPLAY FIRST TWO SENTENCES ON EVERY SCREEN (BUT BOLD ON FIRST SCREEN ONLY) DISPLAY PROBE ON SCREEN WHERE RESPONSE CATEGORIES ARE NOT PART OF THE QUESTION STEM |
P13.
PH. PARENT HEALTH AND WELL-BEING
ALL |
PH1. The next questions are about your health. 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 ALLOW DECIMAL FOR INCHES |
PH2. How tall are you without shoes?
PROBE: You may answer in feet and inches or meters and centimeters.
INTERVIEWER: TO CODE IN FEET AND INCHES, ENTER 1.
TO CODE IN METERS AND CENTIMETERS, ENTER 2.
| | FEET (3 – 6)
| | | INCHES (0 – 11) ALLOW DECIMAL
| | | METERS (0-2)
| | | CENTIMETERS (0-211)
DON’T KNOW d
REFUSED r
ALL |
PH3. How much do you weigh without shoes? Your best estimate is fine.
PROBE: You may answer in pounds or kilos.
INTERVIEWER: TO CODE IN POUNDS, ENTER 1. TO CODE IN KILOS, ENTER 2.
| | | | POUNDS (085 – 500)
| | | | KILOS (038 – 227)
DON’T KNOW d
REFUSED r
ALL |
PH4. The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? [READ ACTIVITY] Are you limited a lot, or limited a little?
|
|
||
|
Yes, limited a lot |
Yes, limited a little |
No, not limited at all |
a. Moderate activities, such as moving a table, pushing a vacuum cleaner, or working in the garden? |
1 |
2 |
3 |
b. Climbing several flights of stairs? |
1 |
2 |
3 |
ALL |
PH5. During the past 4 weeks, how much of the time has your physical or emotional health interfered with your social activities (like visiting friends, relatives, etc.)?
All of the time 1
Most of the time 2
A little of the time 3
None of the time 4
Never 5
DON’T KNOW d
REFUSED r
ALL |
insert conditional fill only if r is female |
PH6. 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
PH6=1 |
PH7. What kind of place do you go/ did you go?
clinic 1
health center 2
doctor’s office 3
hospital emergency room 4
hospital outpatient department 5
planned parenthood 6
OTHER (SPECIFY) 99
(STRING 100)
DON’T KNOW d
REFUSED r
IF OTHER SPECIFY (99): What kind of place do you go to? |
ALL |
PH8. During the past 12 months, have you had an episode of asthma or an asthma attack?
YES 1
NO 0
DON’T KNOW d
REFUSED r
ALL |
PH9. During the past 12 months, did you get a flu shot or the nasal flu vaccine, called Flumist?
PROBE: “A flu shot is usually given in the Fall and protects against influenza for the flu season.”
YES 1
NO 2
DON’T KNOW d
REFUSED r
ALL |
PH10. During the past 12 months, have you been vaccinated with Tdap (Pertussis or Whooping cough vaccine)?
YES 1
NO 0
DON’T KNOW d
REFUSED r
ALL |
PH11. Since [CHILD] was born, have you had any medical problem that caused you to go to the hospital and stay overnight?
YES 1
NO 0
DON’T KNOW d
REFUSED r
All |
PH12. Sometimes people have difficulties in getting medical care when they need it. During the past 12 months, was there any time when you needed medical care or surgery, but did not get it?
YES 1
NO 0
DON’T KNOW d
REFUSED r
All |
PH13. In the past 12 months, was there any time when you needed prescription medicines but could not get them?
YES 1
NO 0
DON’T KNOW d
REFUSED r
ALL |
IF R is bio mom, Fill “SINCE BIRTH OF [CHILD], Otherwise fill “In the past 15 months |
PH14. [Since [CHILD] was born/In the past 15 months], is there a place you go to, or have gone to, for family planning or birth control?
YES 1
NO 0
DON’T KNOW d
REFUSED r
PH14=1 |
PH15. What kind of place do you or did you go to?
clinic 1
health center 2
doctor’s office 3
hospital emergency room 4
hospital outpatient department 5
planned parenthood 6
OTHER (SPECIFY) 99
(STRING 100)
DON’T KNOW d
REFUSED r
IF OTHER SPECIFY (99): What kind of place do you go to? |
female respondents UNDER AGE 50 |
if r is bio mom, fill “since birth of [child]”. otherwise fill “in the past 15 months” |
PH16. Since birth of [CHILD]/In the past 15 months, have you used any form of birth control?
INTERVIEWER: READ THE FOLLOWING PROBE BEFORE CODING RESPONSE IF RESPONDENT SAYS NO OR DON’T KNOW.
PROBE: By birth control, I mean methods such as the following: Withdrawal/pulling out, Natural family planning/safe period/calendar/rhythm, Jelly/cream alone, Foam, Suppository/insert, Contraceptive Sponge, Condom/rubber, IUD, coil, loop, Diaphragm, Pill, Depo-Provera shots, Norplant, Abstinence, Operation/Female sterilization/tubes tied, Operation/Male sterilization/vasectomy.
YES 1
NO 0
DON’T KNOW d
REFUSED r
PH16=1 |
if r is bio mom, fill “since birth of [child]”. otherwise fill “in the past 15 months”
|
PH17. Since birth of [CHILD]/In the past 15 months, which methods of birth control have you used?
PROGRAMMER: IF PH16=0,D,R, THEN DISPLAY
PROBE: By birth control, I mean methods such as the following: Withdrawal/pulling out, Natural family planning/ safe period/calendar/rhythm, Jelly/cream alone, Foam, Suppository/insert, Contraceptive Sponge, Condom/rubber, IUD, coil, loop, Diaphragm, Pill, Depo-Provera shots, Norplant, Abstinence, Operation/Female sterilization/tubes tied, Operation/Male sterilization/vasectomy.
PROBE: Any others?
WITHDRAWAL/PULLING OUT 1
NATURAL FAMILY PLANNING/ SAFE PERIOD/CALENDAR/RHYTHM 2
CONDOM/RUBBER 3
IUD (INCLUDING MIRENA/PARAGUARD) 4
CONTRACEPTIVE SPONGE/DIAPHRAGM/CERVICAL CAP 5
PILL 6
INJECTION ONCE EVERY 3 MONTHS (DEPO PROVERA SHOTS) 7
CONTRACEPTIVE IMPLANT (IMPLANON) 8
CONTRACEPTIVE PATCH (ORTHOEVRA) 9
ABSTINENCE 10
OPERATION/FEMALE STERILIZATION/TUBES TIED 11
OPERATION/MALE STERILIZATION/VASECTOMY 12
EMERGENCY CONTRACEPTION (THE “MORNING AFTER” PILL) 13
OTHER (SPECIFY) 99
(STRING 100)
DON’T KNOW d
REFUSED r
IF OTHER SPECIFY (99): What form of birth control have you used? |
female respondents UNDER AGE 50 |
PH18. Are you currently pregnant?
YES 1
NO 0
DON’T KNOW d
REFUSED r
PH18=1 |
PH19. 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).
PROBE: You may answer in weeks, months, or trimesters.
INTERVIEWER: TO CODE IN WEEKS, ENTER 1. TO CODE IN MONTHS, ENTER 2. TO CODE IN TRIMESTERS, ENTER 3.
| | | WEEKS (0 – 42)
| | | MONTHS (0 – 9)
IF GIVES TRIMESTER RESPONSE:
1ST TRIMESTER, WEEKS UNSPECIFIED...................................................... 55
2ND TRIMESTER, WEEKS UNSPECIFIED...................................................... 66
3RD TRIMESTER, WEEKS UNSPECIFIED...................................................... 77
TOO EARLY IN PREGNANCY; R HAS NOT YET HAD FIRST
APPOINTMENT………………………………………………………………….44
DID NOT RECEIVE PRENATAL CARE 88
DON’T KNOW d
REFUSED r
r is bio mom |
PH20. Since [CHILD] was born, have you given birth to another baby?
YES 1
NO 0
DON’T KNOW d
REFUSED r
r is bio mom and ph18 NE 1 or PH20 NE 1 |
PH21. How old would you like [CHILD] to be when you have your next child?
| | |AGE IN YEARS
(1 - 25)
DOES NOT WANT MORE CHILDREN……………………………………….88
DON’T KNOW d
REFUSED r
HI. HEALTH INSURANCE
all |
FILL STATE HEALTH INSURANCE PROGRAM and state specific medicaid name |
HI1. The next questions are about health insurance, including health insurance obtained through employment or purchased directly as well as government programs like [NAME OF STATE HEALTH INSURANCE PROGRAM], Medicare and Medicaid that provide medical care or help pay medical bills.
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/NAME OF STATE SPECIFIC MEDICAID NAME 4
SCHIP (CHIP/CHILDREN’S HEALTH INSURANCE PROGRAM) 5
MILITARY HEALTH CARE (TRICARE/VA/CHAMP-VA) 6
INDIAN HEALTH SERVICE 7
NAME OF STATE-SPONSORED HEALTH PLAN 8
SINGLE SERVICE PLAN (E.G., DENTAL, VISION, PRESCRIPTIONS) 9
NO COVERAGE OF ANY TYPE 0
OTHER (SPECIFY) 99
(STRING 100)
DON’T KNOW d
REFUSED r
IF OTHER SPECIFY (99): What kind of health insurance coverage do you have? |
hi1 = 4 OR 5 |
HI2. What is your [Medicaid/CHIP] ID number? I can wait while you go and get your Medicaid ID card to read me the number. IF [CHILD] HAS A MEDICAID/chip ID, YOU MAY BRING [HIS/HER] CARD AS WELL AS I WILL NEED THIS INFORMATION IN A LATER QUESTION.
interviewer: allow the respondent to retrieve medicaid id card if necessary
PROBE: Like all other information we are collecting, this will be kept private. We are requesting your Medicaid number so that we can obtain your health care records as part of the study.
| | | | | | | | | | | | | | | | | | | | MEDICAID/CHIP ID NUMBER
I HAVE NOT RECEIVED MY MEDICAID/CHIP ID NUMBER YET 0
DON’T KNOW d
REFUSED r
all |
HI3. During the past year, have you ever received help in applying for health insurance for yourself?
YES 1
NO 0
DON’T KNOW d
REFUSED r
hi3=0,d,r |
HI4. 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
if only one item is selected in HI1 and HI1 ne 0, d, r |
fill child from preload |
HI5. Is [CHILD] covered by your health insurance plan?
YES 1
NO 0
DON’T KNOW d
REFUSED r
if more than one item selected in HI1 and HI5 = 0, D,R |
FILL STATE HEALTH INSURANCE PROGRAM and state specific medicaid name |
HI6. What kind of health insurance or health care coverage does [CHILD] have? Include health plans that pay for only one type of service such as accidents or dental care. Exclude private plans that only provide extra cash while hospitalized. If [CHILD] has more than one kind of health insurance, tell me about all the plans that [CHILD] has.
PROBE: Medicaid refers to a medical assistance program that provides health care coverage to low-income and disabled persons.
PRIVATE HEALTH INSURANCE 1
MEDICARE 2
MEDIGAP 3
NAME OF STATE SPECIFIC MEDICAID PROGRAM 4
SCHIP (CHIP/CHILDREN’S HEALTH INSURANCE PROGRAM) 5
MILITARY HEALTH CARE (TRICARE/VA/CHAMP-VA) 6
INDIAN HEALTH SERVICE 7
NAME OF STATE-SPONSORED HEALTH PLAN 8
SINGLE SERVICE PLAN (E.G., DENTAL, VISION, PRESCRIPTIONS) 9
NO COVERAGE OF ANY TYPE 0
OTHER (SPECIFY) 99
(STRING (NUM))
DON’T KNOW d
REFUSED r
IF OTHER SPECIFY (99): What kind of health insurance does [CHILD] have? |
HI1=4 OR 5 or HI6 = 4 or 5 |
HI7. What is [CHILD]’s Medicaid or CHIP ID number? (I can wait while you go and get (CHILD)’s Medicaid ID card to read me the number.)
interviewer: allow the respondent to retrieve medicaid/CHIP id card if necessary
PROBE: Like all other information we are collecting, this will be kept private. We are requesting [CHILD]’s Medicaid/CHIP number so that we can obtain (his/her) health care records as part of the study.
| | | | | | | | | | | | | | | | | | | | | MEDICAID/CHIP ID NUMBER
CHILD HAS NOT RECEIVED MEDICAID/CHIP ID NUMBER YET 0
DON’T KNOW d
REFUSED r
all |
HI8. Have you ever received help in applying for health insurance for [CHILD]?
YES 1
NO 0
DON’T KNOW d
REFUSED r
HI8=0, D OR R |
HI9. Have you ever wanted or needed help in applying for health insurance for [CHILD]?
YES 1
NO 0
DON’T KNOW d
REFUSED r
HH. ABOUT THE HOUSEHOLD
all |
HH1. The next questions are about your household and who lives with you and [CHILD].
INTERVIEWER: enter 1 to continue
NEW RESPONDENT = 1 |
HH2. Is any language other than English spoken in your home?
YES 1
NO 0
DON’T KNOW d
REFUSED r
HH2=1 |
HH3. 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) |
respondent reported more than one language in HH3 |
HH4. Which of these languages is spoken most often in your home?
PROGRAMMER: DISPLAY ONLY LANGUAGES PROVIDED IN HH3
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
HH2=1 |
Fill LAN from HH4 |
HH5. 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
HH2=1 |
HH6. 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
NEW RESPONDENT = 1 |
HH7. 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 20)
DON’T KNOW d
REFUSED r
IF OTHER SPECIFY (600): In what country were you born? |
NEW RESPONDENT = 1 |
HH8. Are you of Hispanic, Latino, or Spanish origin?
INTERVIEWER: IF YES, ASK: What is your 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
NEW RESPONDENT = 1 |
HH9. What is your race? You may name one or more.
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 |
HH10. Is [CHILD] of Hispanic, Latino, or Spanish origin?
INTERVIEWER: IF YES, ASK: What is [CHILD]’s 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 |
HH11. What is [CHILD]’s race? You may name one or more.
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 |
HH12. Besides you and [CHILD] does anyone else live in your household?
YES 1
NO 0
LIVES IN A SHELTER OR GROUP HOME 2
DON’T KNOW d
REFUSED r
hh12=2 |
HH13. Do any members of your family live with you in the shelter or group home?
YES 1
NO 0
DON’T KNOW d
REFUSED r
hh12 = 1 or hh13 = 1 PLEASE FOLLOW MIHOPE BASELINE LOGIC 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. display the respondent’s name in row 1 of the roster and display child in row 2. MAX NUMBER OF PEOPLE IN HOUSEHOLD =18. dob ranges: month= 1-12; day= 1-31 year= 1900-Current YEAR at dob, display interviewer note: ENTER A DK TO GET TO YEAR OF BIRTH QUESTION
|
HH14. Starting with the oldest person, please tell me the first and last names of all the other (IF HH13=1, “members of your family who live with you in the shelter or group home” ELSE “people who normally live here”).
INTERVIEWER: IF R IS UNCOMFORTABLE, YOU CAN ASK THEM TO PROVIDE FIRST NAMES ONLY. INITIALS ONLY ARE ALSO OKAY. IF R IS UNCOMFORTABLE GIVING DATES OF BIRTH, HE/SHE CAN JUST GIVE YEAR OF BIRTH OR AGE (IN YEARS)
PROBE: Who else lives here?
WHAT IS [NAME]’S DATE OF BIRTH? |
IS [NAME] MALE OR FEMALE? |
WHAT IS [NAME]’S RELATIONSHIP TO [CHILD]? PROBE; IF RESPONDENT SAYS “MOTHER”, PROBE: Is that biological mother, adoptive mother or step mother? PROBE: IF RESPONDENT SAYS “FATHER”, PROBE: Is that the biological father, adoptive father or step father? RELATIONSHIP CODES: BIOLOGICAL FATHER 12 ADOPTIVE MOTHER 13 ADOPTIVE FATHER 14 STEPMOTHER 15 STEPFATHER 16 PARENT’S GIRLFRIEND 17 PARENT’S BOYFRIEND 18 PARENT’S SPOUSE/PARTNER (FEMALE) 19 PARENT’S SPOUSE/PARTNER (MALE) 20 GRANDMOTHER. 21 GRANDFATHER 22 GREAT GRANDMOTHER 23 GREAT GRANDFATHER 24 SISTER/STEPSISTER 25 BROTHER/STEPBROTHER 26 FOSTER SISTER 27 FOSTER BROTHER 28 COUSIN (FEMALE) 29 COUSIN (MALE) 30 AUNT 31 UNCLE 32 OTHER RELATIVE OR IN-LAW (FEMALE) 33 OTHER RELATIVE OR IN-LAW (MALE) 34 FOSTER PARENT (FEMALE) 35 FOSTER PARENT (MALE). 36 OTHER NON-RELATIVE (FEMALE) 37 OTHER NON-RELATIVE (MALE) 38
|
|
Q# |
Q# |
Q# |
Q# |
|
FIRST AND LAST NAME |
(DOB) |
GENDER |
RELATIONSHIP |
a. |
(STRING (40)) |
| | |/| | |/| | | | | |
| | | |
| | | |
b. |
(STRING (40)) |
| | |/| | |/| | | | | |
| | | |
| | | |
c. |
(STRING (40)) |
| | |/| | |/| | | | | |
| | | |
| | | |
d. |
(STRING (40)) |
| | |/| | |/| | | | | |
| | | |
| | | |
e. |
(STRING (40)) |
| | |/| | |/| | | | | |
| | | |
| | | |
f. |
(STRING (40)) |
| | |/| | |/| | | | | |
| | | |
| | | |
END LOOP END LOOP AT LAST HOUSEHOLD MEMBER.
|
ALL |
HH15. Do you currently have a spouse or partner?
YES 1
NO 0
DON’T KNOW d
REFUSED r
HH15=1 |
HH16. Does he or she live in this household?
YES 1
NO 0
DON’T KNOW d
REFUSED r
HH15=1 |
HH17. What is your spouse or partner’s first name?
________________________________ (STRING 20)
DON’T KNOW d
REFUSED r
HH15 = 1 |
HH18. What is [SPOUSE FIRST NAME]’s relationship to [CHILD]?
RELATIONSHIP CODES:
BIOLOGICAL FATHER 12
ADOPTIVE MOTHER 13
ADOPTIVE FATHER 14
STEPMOTHER 15
STEPFATHER 16
PARENT’S GIRLFRIEND 17
PARENT’S BOYFRIEND 18
PARENT’S SPOUSE/PARTNER (FEMALE) 19
PARENT’S SPOUSE/PARTNER (MALE) 20
GRANDMOTHER. 21
GRANDFATHER 22
GREAT GRANDMOTHER 23
GREAT GRANDFATHER 24
SISTER/STEPSISTER 25
BROTHER/STEPBROTHER 26
FOSTER SISTER 27
FOSTER BROTHER 28
COUSIN (FEMALE) 29
COUSIN (MALE) 30
AUNT 31
UNCLE 32
OTHER RELATIVE OR IN-LAW (FEMALE) 33
HH15=0 |
HH19. Did you have a spouse or partner at any time during the past year?
YES 1
NO 0
DON’T KNOW d
REFUSED r
HH15 = 0 and HH19=1 |
HH20. What was your spouse or partner’s first name?
Probe: Please tell us the name of your most recent spouse or partner.
________________________________ (STRING 15)
DON’T KNOW d
REFUSED r
NAME PROVIDED IN HH20 |
fill spouse or partner’s first name from hh20 |
HH21. What is [SPOUSE/PARTNER FIRST NAME]’s relationship to [CHILD]?
RELATIONSHIP CODES:
BIOLOGICAL FATHER 12
ADOPTIVE MOTHER 13
ADOPTIVE FATHER 14
STEPMOTHER 15
STEPFATHER 16
PARENT’S GIRLFRIEND 17
PARENT’S BOYFRIEND 18
PARENT’S SPOUSE/PARTNER (FEMALE) 19
PARENT’S SPOUSE/PARTNER (MALE) 20
GRANDMOTHER. 21
GRANDFATHER 22
GREAT GRANDMOTHER 23
GREAT GRANDFATHER 24
SISTER/STEPSISTER 25
BROTHER/STEPBROTHER 26
FOSTER SISTER 27
FOSTER BROTHER 28
COUSIN (FEMALE) 29
COUSIN (MALE) 30
AUNT 31
UNCLE 32
OTHER RELATIVE OR IN-LAW (FEMALE) 33
ALL |
IF BIO DAD IS THE RESPONDENT, FILL “you”. IF RESPONDENT IS ANYONE OTHER THAN BIO DAD, FILL NAME OF CHILD’S BIO DAD FROM PRELOAD OR HOUSEHOLD ROSTER IF AVAILABLE, OTHERWISE FILL “[CHILD]’S biological father.” |
HH22. Since [CHILD] was born, how many months has [CHILD] lived in the same household as you/ [BIO DAD]?
| | | (0-26)
DON’T KNOW d
REFUSED r
HARD CHECK: IF HH22 GT AGE OF CHILD;. I recorded that [CHILD] has lived in the same household as (you/[BIO DAD] for [HH22] months, but [CHILD] is currently [AGE OF CHILD] months old. Is that correct?
ALL |
IF BIO DAD IS THE RESPONDENT, FILL “you”. OTHERWISE IF RESPONDENT IS NOT BIO DAD, FILL NAME OF CHILD’S BIO DAD FROM PRELOAD OR HOUSEHOLD ROSTER IF AVAILABLE, OTHERWISE FILL “[CHILD]’S biological father.” |
HH23. In the past 3 months, how often did (you/[BIO DAD]/ [CHILD]’s biological father) buy things for [CHILD], such as food, diapers, clothes, or toys, or give 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 4
Never 5
DON’T KNOW d
REFUSED r
R is not bio dad |
FILL NAME OF CHILD’S BIO DAD FROM PRELOAD OR HOUSEHOLD ROSTER IF AVAILABLE, OTHERWISE FILL “[CHILD]’s biological father.” |
HH24. During the past 3 months, how often has ([BIO DAD]/[CHILD]’s biological father) helped 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 4
Never 5
DON’T KNOW d
REFUSED r
R is bio DAD |
HH25. During the past 3 months, how often have you cared for [CHILD], helped around the house or with chores, or provided transportation to places that [CHILD] 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 4
Never 5
DON’T KNOW d
REFUSED r
HH22 IS LT AGE OF CHILD IN MONTHS |
FILL “you” IF RESPONDENT IS BIO DAD. OTHERWISE IF RESPONDENT IS NOT BIO DAD, FILL NAME OF CHILD’S BIO DAD FROM PRELOAD OR HOUSEHOLD ROSTER IF AVAILABLE, OTHERWISE FILL “his/her biological father.” |
HH26. In the past 3 months, about how often has [CHILD] seen (you/[BIO DAD]/ (his/her biological father)? 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 4
Never 5
DON’T KNOW d
REFUSED r
FS. FAMILY SELF-SUFFICIENCY
all |
FS1. The next questions are about the education you've received as well as education-related activities. 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)
12TH GRADE WITH DIPLOMA 2
12th GRADE, BUT NO DIPLOMA 88
ASSOCIATE DEGREE 3
BA/BS DEGREE 4
MA/MASTERS 5
PHD/DOCTORATE 6
SOME COLLEGE BUT NO DEGREE COMPLETION 7
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 grade or year of school completed (string 99) |
FS1=0,1, 88, d, r |
FS1a. Do you have a GED?
YES 1
NO 0
DON’T KNOW d
REFUSED r
all |
FS2. Are you currently taking any education or training classes? This could include (IF FS1 LT 12 YEARS): high school, ABE, GED,) ESL or college courses, or any job skills training.
YES 1
NO 0
DON’T KNOW d
REFUSED r
F2=1 |
FS3. What type of degree or certification are you working towards?
HS diploma 1
GED 2
2-year degree 3
4-year degree 4
graduate degree 5
vocational or technical certificate or license (OTHER SPECIFY) 6
OTHER (SPECIFY) 99
(STRING 99)
DON’T KNOW d
REFUSED r
IF VOCATIONAL OR technical CERTIFICATE OR LICENSE(6): What kind of certificate/license are you working towards ?(RECORD ANSWER in other (specify). IF OTHER SPECIFY (99): What other degree or certification are you working towards? |
ALL |
If FS2=1 fill “after you complete your current program.” |
FS4. Do you plan on pursuing additional education in the future [after you complete your current program]?
YES 1
NO 0
DON’T KNOW d
REFUSED r
FS4=1 |
FS5. What type of degree or certificate do you plan to pursue?
HS diploma 1
GED 2
bachelor’s degree 3
associate’s degree 4
graduate degree 5
vocational or technical certificate or license (other specify) 6
OTHER (SPECIFY) 99
(STRING 99)
DON’T KNOW d
REFUSED r
IF VOCATIONAL OR technical CERTIFICATE OR LICENSE(6): What kind of certificate or license do you plan to pursue? IF OTHER SPECIFY (99): What other degree or certificate do you plan to pursue? |
all |
FS6. During the past year, how many months were you employed/working for pay?
| | | months
(0-12)
DON’T KNOW d
REFUSED r
all |
FS7. Are you currently working for pay?
YES 1
NO 0
DON’T KNOW d
REFUSED r
FS7=1 |
FS8. Would you describe your current job as…
Full time (30 or more hours per week), 1
Part-time with hours most weeks, 2
Seasonal work, 3
Temporary work through a temp agency, 4
Day labor, 5
Odd jobs, or 6
Something else? 99
(STRING 99)
DON’T KNOW d
REFUSED r
IF OTHER SPECIFY (99): What type of hours do you work? |
FS7=1 |
| | | hours
(0-80)
DON’T KNOW d
REFUSED r
FS6 NE 0 |
FILL PREVIOUS MONTH AND YEAR OF PREVIOUS MONTH |
FS10. Last month, that is (MONTH/YEAR), what were your approximate total earnings from your work, including tips and overtime pay? When answering, please include income from all jobs you held last month. Please do not include earnings from anyone else in your household.
PROBE: Your best estimate is fine.
| | | | | ($0-9,990)
DON’T KNOW d
REFUSED r
FS10=d,r |
FS11. Were your earnings last month …
Less than $500, 1
$500 to less than $1,000, 2
$1,000 to less than $1,500, 3
$1,500 to less than $2,000, 4
$2,000 to less than $2,500 5
$2,500 to less than $3,000, 6
$3,000 to less than $3,500, or 7
$3,500 or more? 8
WASN’T WORKING LAST MONTH/ZERO 0
DON’T KNOW d
REFUSED r
all |
Fill Local TANF from preload |
FS12. Have you received income or other assistance from any of the following public benefits 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. Benefits from WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children) |
1 |
0 |
d |
r |
if fs12a=1 or fs12b=1 or fs12c=1 or fs12d=1 |
If FS12a=1 fill TANF or local name of TANF. If FS12b=1 fill food stamp or SNAP, If FS12c=1 fill SSI or SSDI, If FS12d=1 fill WIC. |
FS13. How much [FILL BENEFIT FROM FS12] benefits did you receive in the past month?
$ | | | |___| NUMBER
(0-9,990)
DON’T KNOW d
REFUSED r
all |
fill previous month and year of previous month |
FS14. Now please think about all other members of your household, not including yourself. In the past month, that is in [ MONTH YEAR], what was the total income of all other members of your household from all sources, including earnings and public benefits?
PROBE: Your best estimate is fine.
$ | | | | | (0-9,990)
DON’T KNOW d
REFUSED r
FS14=d,r |
FS15. Were the total earnings of your family members last month? Would you say…
Less than $1,000, 1
$1,000 to less than $2,000, 2
$2,000 to less than $3,000, 3
$3,000 to less than $4,000, 4
$4,000 to less than 5,000, or 5
$5,000 or more? 6
NO INCOME FROM OTHER HOUSEHOLD MEMBERS 0
DON’T KNOW d
REFUSED r
all |
Fill Local TANF from preload |
FS16. During the past year, have you ever received help in applying for public benefits, including TANF, such as [Fill local TANF name], SNAP, food stamps or WIC?
YES 1
NO 0
DON’T KNOW d
REFUSED r
fs16=1 |
FS17. Who provided you with help in applying for public benefits? Was it …
A family member or friend, 1
A caseworker, 2
A social worker, 3
A home visitor, or 4
Someone else? OTHER (SPECIFY) 99
(STRING 99)
DON’T KNOW d
REFUSED r
IF OTHER SPECIFY (99): Who provided you with help in applying for public benefits? INTERVIEWER: PROBE FOR TITLE OR TYPE OF PERSON. DO NOT ENTER NAMES. |
FS16=0,d,r |
Fill local tanf from preload |
FS18. During the past year, did you ever want or need help in applying for public benefits, including TANF, such as [Fill local TANF name], SNAP, WIC or food stamps?
YES 1
NO 0
DON’T KNOW d
REFUSED r
all |
fill current month and previous year. if r is only adult in household, fill “i.” Else, FILL “we” USE AGE OF RESPONDENT FROM HH9 TO DETERMINE WHETHER RESPONDENT IS THE ONLY ADULT IN THE HOUSEHOLD. USE AGE 18 OR OLDER TO CLASSIFY SOMEONE AS AN ADULT |
FS19. Now I am going to read you several statements that people have made about their food situation. For these statements please tell me whether the statement was often true, sometimes true, or never true for your household in the last 12 months, that is since (DISPLAY CURRENT MONTH AND LAST YEAR).
Within the past 12 months the food that (I/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 |
if r is only adult in household, fill “i.” Else, “we” |
FS20. (I/We) couldn’t afford to eat balanced meals Was this . . .
Often true, 1
Sometimes true, or 2
Never true? 3
DON’T KNOW d
REFUSED r
all |
fill current month and previous year. if r is only adult in household, fill “you.” Else, “YOU or other adults in your household” |
FS21. In the last 12 months, that is, since (DISPLAY CURRENT MONTH AND LAST YEAR), did (you/ you or other adults in your household) ever cut the size of your meals or skip meals because there wasn't enough money for food?
YES 1
NO 0
DON’T KNOW d
REFUSED r
FS21=1 |
FS22. How often did this happen?
Almost every month, 1
Some months but not every month, or 2
In only 1 or 2 months? 3
DON’T KNOW d
REFUSED r
all |
FS23. In the last 12 months, did you ever eat less than you felt you should because there wasn't enough money for food?
YES 1
NO 0
DON’T KNOW d
REFUSED r
all |
FS24. In the last 12 months, were you ever hungry but didn't eat because there wasn’t enough money for food?
YES 1
NO 0
DON’T KNOW d
REFUSED r
PM: PARENT MENTAL HEALTH AND SUBSTANCE USE
ALL Center for Epidemiologic Studies Depression Scale (CES-D), 10 items DISPLAY FIRST PARAGRAPH ON EACH SCREEN (BUT ONLY BOLD ON FIRST SCREEN) DISPLAY PROBE ON SCREENS THAT DO NOT HAVE RESPONSE CATEGORIES IN QUESTION STEM |
PM1.
ALL Generalized Anxiety Scale (GAD-7), 7 items DISPLAY FIRST PARAGRAPH ON EVERY SCREEN (BUT ONLY BOLD ON THE FIRST SCREEN) DISPLAY PROBE ON SCREENS THAT DO NOT HAVE RESPONSE CATEGORIES IN QUESTION STEM |
PM2.
IF Pm2a - PM2g = 1,2 or 3 or pm2b=1,2 or 3 or Pm2c=1,2 or 3 or Pm2d=1,2 or 3 or Pm2e=1,2 or 3 or Pm2f=1,2 or 3 or Pm2g=1, 2 or 3. |
PM3. How difficult have these feelings made it for you to do your work, take care of things at home, or get along with other people? Would you say…
Not difficult at all, 1
Somewhat difficult, 2
Very difficult, or 3
Extremely difficult 4
DON’T KNOW d
REFUSED r
ALL Pearlin Mastery Scale, 7 items display probe on screens where the response cateories are not part of the question stem |
PM4.
ALL |
PM5. The next questions are about smoking. 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 (0-60) AND CODE
CIGARETTES 1
PACKS 2
DON’T KNOW d
REFUSED r
ALL |
PM6. 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 2
Smoking is permitted anywhere inside my home 3
DON’T KNOW d
REFUSED r
ALL |
PM7. 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 past 3 months, how many alcoholic drinks did you have in an average week?
NOTE: A HELP SCREEN IS AVAILABLE WITH EQUIVALENCES
NONE 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
Pm7 ne 0 |
PM8. In the last three months, 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 |
PM9. The next questions are about drug use on your own. By “on your own” we mean either without a doctor’s prescription, in larger amounts than prescribed, or for a longer period than prescribed. In the past three months, have you used any of the following drugs on your own? [READ LIST, CODE ONE FOR EACH]
|
|
|||
|
YES |
NO |
DON’T KNOW |
REFUSED |
a. Prescription pain killers? |
1 |
0 |
d |
r |
(IF YES) What kinds? ENTER MEDICINE NAMES: ____________________________(STRING 50) |
|
|
|
|
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 |
PM10. Now I’m going to ask about any help you might have received for mental health problems or alcohol or substance abuse problems or both. During the past year, did you receive help or treatment for mental health issues or alcohol or substance abuse?
yes 1
no 0
DON’T KNOW d
REFUSED r
IF pm10=1 and site specific names are provided |
fill local names of serviceS BY SITE ID. ALLOW UP TO FIVE NAMES TO BE DISPLAYED |
PM11. Some places in your area where you might have gotten services for mental health problems or alcohol or substance abuse problems are [NAME1,NAME2 and NAME3]. There are others too, that I might not have named.
During the past year, did you receive help or treatment for mental health problems or alcohol or substance abuse problems or both from…
[READ IF NO SITE SPECIFIC NAMES PROVIDED: During the past year, where did you receive help or treatment for mental health problems or alcohol or substance abuse problems or both? GO TO OPEN ENDED RESPONSE TO ENTER INFO]
|
YES |
NO |
DON’T KNOW |
REFUSED |
a. [NAME1] |
1 |
0 |
d |
r |
b. [NAME2] |
1 |
0 |
d |
r |
c. [NAME3] |
1 |
0 |
d |
r |
d. Any other program? (SPECIFY) ________________________ |
1 |
0 |
d |
r |
(STRING 200)
|
|
|
|
|
PM10=1 |
PM11a.
[READ IF ANY RESPONSE TO PM11=1] During the past year where else did you receive help or treatment for mental health problems or alcohol or substance abuse problems?
NO SITE SPECIFIC NAMES PROVIDED IN PRELOAD) OR ALL RESPONSES in PM11= 0,D,R] During the past year, where did you receive help or treatment for mental health problems or alcohol or substance abuse problems or both?
INTERVIEWER: YOU MAY ENTER UP TO FIVE PROGRAMS
|
DON’T KNOW |
REFUSED |
a. [NAME1] a. [OTHER1] (SPECIFY)________________ (STRING 200) |
d |
R |
b. [NAME2] b. [OTHER2] (SPECIFY)________________ (STRING 200) |
d |
R |
c. [NAME3] c. [OTHER3] (SPECIFY)________________ (STRING 200) |
d |
R |
d. [OTHER4] (SPECIFY)________________ (STRING 200) |
d |
R |
e. [OTHER5] (SPECIFY)________________ (STRING 200) |
d |
R |
IF any of Pm11 = 1 or any of pm11A =1 |
PM12. Would you say these services were for mental health, alcohol or substance abuse, or both?
mental health 1
alcohol or substance abuse 2
both, mental health and alcohol and substance use 3
DON’T KNOW d
REFUSED r
PROGRAMMER BOX PM13 and PM14
ASK PM13 and PM14 IN SEQUENCE for each ‘YES’ response in PM10.
PM11a=1 or pm11b=1 or pm11c=1 or pm11d=1 |
fill name of program from pm11 and ask for each “yes” response in pm11 |
PM13. You received help of treatment from [program name from PM11]. Was this …
INTERVIEWER: READ THROUGH LIST. IFTHE RESPONDENT SAYS “YES” TO ONE OF THE SUBITEMS, DO NOT READ THE REST OF THE SUBITEMS.
|
|
|
|
|
|
YES |
NO |
DON’T KNOW |
REFUSED |
a. A hospital empergency room |
1 |
0 |
D |
r |
b. A hospital inpatient program or other inpatient program |
1 |
0 |
d |
r |
c. An outpatient doctor, social worker, counselor or other professional |
1 |
0 |
D |
r |
d. A support group |
1 |
0 |
D |
r |
e. A priest, minister, rabbi, spiritualist or healer |
1 |
0 |
D |
r |
f. Some other type of program? (DO NOT RECORD TYPE) |
1 |
0 |
D |
r |
ASK PM14 for each ‘YES’ response in PM11 and PM11A |
FILL SERVICE FROM pm11 and/or pm11a AND ASK FOR EACH ‘YES’ RESPONSE |
PM14. In the last 12 months, on how many days did you get help from [SERVICE FROM PM11] for mental health issues or alcohol or substance abuse treatment?
PROBE: For example, if you got help from [SERVICE] once a week for 10 weeks, that would be 10 days.
PROBE: IF R SAYS, DON’T KNOW, SAY “Your best estimate is fine.”
1-2 days, 1
3-6 days, 2
7-12 days, 3
13-26 days, 4
26-52 days, or 5
53 days or more? 6
DON’T KNOW d
REFUSED r
pm10 ne 1 |
PM15. During the past year, did you want or need help or treatment for mental health issues or alcohol or substance abuse?
yes, wanted or needed 1
no, did not want or need 2
DON’T KNOW d
REFUSED r
PV. INTIMATE PARTNER VIOLENCE
Women's Experience and Battery Scale (WEB), 6 items respondents who have a spouse or partner (HH15=1) or who had a spouse or partner in the past year, HH19=1 |
IF HH15=1 fill gender of spouse/partner from hh18 ELSE IF HH19=1 FILL GENDER OF PAST SPOUSE OR PARTNER from hh21 if gender is missing and r is female, fill gender=male; if r is male, fill gender=female DISPLAY FIRST SENTENCE On EACH SCREEN (BUT ONLY BOLD ON FIRST SCREEN) DISPLAY PROBE ON SCREENS WHERE THE RESPONSE CATEGORIES ARE NOT PART OF THE QUESTION STEM |
PV1.
Conflict Tactics Scale (CTS) taken from the Supporting Healthy Marriage Survey, 9 items
respondents who have a spouse or partner (HH15=1) or who had a spouse or partner in the past year, HH19=1 |
IF name of spouse or partner is missing, fill “your spouse or partner”.
display following help screen: “Material from the CTS copyright © 2003 by Western Psychological Services. Adapted, translated and reprinted D. Paulsell, Mathematica Policy Research, for specific, limited research use under license of the publisher, WPS, 625 Alaska Avenue, Torrance, California 90503, U.S.A. ([email protected]). No additional reproduction, in whole or in part, by any medium or for any purpose, may be made without the prior, written authorization of WPS. All rights reserved.” |
DISPLAY FIRST SENTENCE in bold on EACH SCREEN DISPLAY PROBE ON SCREENS WHERE THE RESPONSE CATEGORIES ARE NOT PART OF THE QUESTION STEM |
PV2.
C. CRIME
all |
C1. Have you been arrested within the past year?
YES 1
NO 0
DON’T KNOW d
REFUSED r
SS. SOCIAL SERVICES
all |
SS1. The next questions are about various services you and [CHILD] may receive or use.
Is [CHILD] now receiving care in your home or another home on a regular basis, at least once a week, from someone who is not [CHILD]’s parent? This includes other relatives, home child care providers or neighbors, but not day care centers or preschools.
YES 1
NO 0
DON’T KNOW d
REFUSED r
SS1=1 |
SS2. Is this care provided in your own home or in another home?
own home 1
another home 2
both/varies 3
DON’T KNOW d
REFUSED r
SS1=1 |
SS3. How many hours each week does [CHILD] receive care from someone not related to him or her?
PROBE: Your best estimate is fine.
| | hours
(0-99)
DON’T KNOW d
REFUSED r
all |
SS4. Is [CHILD] now attending a day care center or preschool program?
YES 1
NO 0
DON’T KNOW d
REFUSED r
SS4=1 |
SS5. How many hours each week does [CHILD] attend a day care center or preschool program?
PROBE: Your best estimate is fine.
| | | hours
(0-99)
DON’T KNOW d
REFUSED r
all |
SS6. Has [CHILD] ever been found eligible to receive Early Intervention services?
PROBE:
Early Intervention refers to services that are provided to infants and toddlers who have special needs or have or are at risk for developmental delays. Examples of services include speech and language therapy, occupational and physical therapy and counseling and medical services.
YES 1
NO 0
DON’T KNOW d
REFUSED r
SS6=1 |
SS7. In the past year, has [CHILD] used or received Early Intervention services?
YES 1
NO 0
DON’T KNOW d
REFUSED r
SS7=1 |
SS8. On how many days did [CHILD] use or receive Early Intervention services during the past year? Would you say…
PROBE: “For example, if child received services once a week for 10 weeks, that would be 10 days.”
PROBE: IF R SAYS, DON’T KNOW, SAY “Your best estimate is fine.”
1-2 days, 1
3-6 days, 2
7-12 days, 3
13-26 days, 4
26-52 days, or 5
53 days or more? 6
DON’T KNOW d
REFUSED r
SS7 ne 1 |
SS9. In the past year, did you want or need Early Intervention services for [CHILD]?
YES wanted OR NEEDED 1
no Didn’t WANT OR need 0
DON’T KNOW d
REFUSED r
ss7=1 |
SS10. Do [CHILD]’s doctors or other health care providers and early intervention program communicate with one another?
YES 1
NO 0
DON’T KNOW d
REFUSED r
all |
if R is female INCLUDE “OR wOMEN’S”. |
SS11. In the past year, have you or [CHILD] used or received services from a domestic violence (or women’s) shelter?
YES 1
NO 0
DON’T KNOW d
REFUSED r
IF ss11=1 AND SITE SPECIFIC NAMES ARE PROVIDED |
if R is female INCLUDE “OR wOMEN’S”. fill local names of serviceS BY SITE ID. ALLOW FOR UP TO THREE NAMES TO BE displayED. |
SS12. Some places in your area where you might have gotten services from a domestic violence (or women’s) shelter are [NAME1, NAME2 and NAME3]. There are others too that I might not have named.
During the past year, what places have you or [CHILD] received services from…
|
|
|
|
|
|
YES |
NO |
DON’T KNOW |
REFUSED |
a. [NAME1] |
1 |
0 |
d |
r |
b. [NAME2] |
1 |
0 |
d |
r |
c. [NAME3] |
1 |
0 |
d |
r |
d. Any other ? (SPECIFY)________________________ |
1 |
0 |
d |
r |
(STRING 200)
|
|
|
|
|
SS11=1 |
if R is female INCLUDE “OR wOMEN’S”. |
SS12a.
[READ IF ANY RESPONSE TO SS12=1] During the past year where else did you receive services from a domestic violence (or women’s) shelter?
[READ IF SS11 = 1 AND SS12 SKIPPED (NO SITE SPECIFIC NAMES PROVIDED IN PRELOAD) OR ALL RESPONSES in SS12= 0,D,R] During the past year, where did you receive services from a domestic violence (or women’s) shelter?
INTERVIEWER: YOU MAY ENTER UP TO THREE PROGRAMS
|
DON’T KNOW |
REFUSED |
a. [OTHER1] (SPECIFY)________________ (STRING 200) |
d |
R |
b. [OTHER2] (SPECIFY)________________ (STRING 200) |
d |
R |
c. [OTHER3] (SPECIFY)________________ (STRING 200) |
d |
R |
ASK SS13 for each ‘yes’ response in ss12 and ss12a |
if R is female INCLUDE “OR wOMEN’S” fill service from ss12 and/or ss12a and ask for each ‘yes’ response |
SS13. On how many nights did you stay in [name from SS12 or SS12a] during the past year? Would you say…
PROBE: “For example, if you got help from [NAME] once a week for 10 weeks, that would be 10 days.”
PROBE: IF R SAYS, DON’T KNOW, SAY “Your best estimate is fine.”
1-2 days, 1
3-6 days, 2
7-12 days, 3
13-26 days 4
26-52 days, or 5
53 days or more? 6
DON’T KNOW d
REFUSED r
SS11 ne 1 |
if R is female say “oR wOMEN’S” |
SS14. In the past year, did you want or need services from a domestic violence (or women’s) shelter?
yes wanted or needed 1
no didn’t want or need 0
DON’T KNOW d
REFUSED r
all |
SS15. In the past year, have you used or received services for domestic violence counseling or anger management?
YES 1
NO 0
DON’T KNOW d
REFUSED r
ss15=1 and site specific names are provided |
fill local names of serviceS BY SITE ID. ALLOW FOR UP TO THREE NAMES TO BE displayED. |
SS16. Some places in your area where you might have gotten services for domestic violence counseling or anger management are [name1, name2 and name 3]. There are others too that I might not have named. In the past year, have you received services from…
|
|
|
|
|
|
YES |
NO |
DON’T KNOW |
REFUSED |
a. [NAME1] |
1 |
0 |
d |
r |
b. [NAME2] |
1 |
0 |
d |
r |
c. [NAME3] |
1 |
0 |
d |
r |
d. Any other ? (SPECIFY)________________________ |
1 |
0 |
d |
r |
(STRING 200)
|
|
|
|
|
SS15=1 |
SS16a.
[READ IF ANY RESPONSE TO SS16=1] During the past year where else did you receive services for domestic violence counseling or anger management?
[READ IF SS15= 1 AND SS16 SKIPPED (NO SITE SPECIFIC NAMES PROVIDED IN PRELOAD) OR ALL RESPONSES in SS16= 0,D,R] During the past year, where did you receive services for domestic violence counseling or anger management?
INTERVIEWER: YOU MAY ENTER UP TO THREE PROGRAMS
|
DON’T KNOW |
REFUSED |
a. [OTHER1] (SPECIFY)________________ (STRING 200) |
d |
R |
b. [OTHER2] (SPECIFY)________________ (STRING 200) |
d |
R |
c. [OTHER3] (SPECIFY)________________ (STRING 200) |
d |
R |
ASK SS17 for each ‘yes’ response in ss16 and ss16a |
FILL SERVICE FROM ss16 amd/or ss16a AND ASK FOR EACH ‘YES’ RESPONSE |
SS17. On how many days did you use or receive services from [name of program from SS16] during the past year? Would you say…
PROBE: For example, if you got help from a service once a week for 10 weeks, that would be 10 days.
PROBE: IF R SAYS, DON’T KNOW, SAY “Your best estimate is fine.”
1-2 days, 1
3-6 days, 2
7-12 days, 3
13-26 days, 4
26-52 days, or 5
53 days or more? 6
DON’T KNOW d
REFUSED r
SS15 ne 1 |
SS18. In the past year, did you want or need services for domestic violence counseling or anger management?
YES wanted OR NEEDED 1
no Didn’t WANT OR need 0
DON’T KNOW d
REFUSED r
all |
SS19. In the past year, have you or [CHILD] received transportation to needed services?
YES 1
NO 0
DON’T KNOW d
REFUSED r
SS19=1 |
SS20. On how many days did you or [CHILD] receive transportation to needed services during the past year? Would you say…
PROBE: For example, if you got help from a service once a week for 10 weeks, that would be 10 days.
PROBE: IF R SAYS, DON’T KNOW, SAY “Your best estimate is fine.”
1-2 days, 1
3-6 days, 2
7-12 days, 3
13-26 days, 4
26-52 days, or 5
53 days or more? 6
DON’T KNOW d
REFUSED r
SS19 ne 1 |
SS21. In the past year, did you want or need transportation to needed services?
YES, wanted OR NEEDED 1
no Didn’t WANT OR need 0
DON’T KNOW d
REFUSED r
SS19=1 |
SS22. What services did you receive transportation for in the past year?
PROBE: ANY OTHERS?
PRENATAL CARE 1
DOCTOR’S VISIT FOR CARE OTHER THAN WHEN YOU ARE SICK OR INJURED 2
DENTIST 3
FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 4
SUBSTANCE USE (ALCOHOL AND OTHER DRUGS) TREATMENT 5
MENTAL HEALTH TREATMENT 6
DOMESTIC VIOLENCE SHELTER 7
DOMESTIC VIOLENCE COUNSELING/ANGER MANAGEMENT 8
ADULT EDUCATION SERVICES (INCLUDING GED AND ESL) 9
JOB TRAINING AND EMPLOYMENT 10
PEDIATRIC PRIMARY CARE 11
CHILDCARE 12
EARLY INTERVENTION SERVICES 13
OTHER (SPECIFY) 99
(STRING 200)
DON’T KNOW d
REFUSED r
IF OTHER SPECIFY (99): What other services? |
ALL |
FILL LOCAL NAME OF CHILD PROTECTIVE SERVICES FROM PRELOAD |
SS23. Since [CHILD] was born, has Child Protective Services or [LOCAL NAME OF CHILD PROTECTIVE SERVICES] contacted you about [CHILD]?
YES 1
NO 0
DON’T KNOW d
REFUSED r
all |
SS24. During the past year, have you participated in a home visiting program or parenting program for parents of infants?
yes 1
no 2
DON’T KNOW d
REFUSED r
SS24=1 fill local names of serviceS BY SITE ID. ALLOW FOR UP TO THREE NAMES TO display |
SS25. [READ IF ONE OR MORE SITE SPECIFIC NAMES ARE PROVIDED: Some programs in your area that offer home visiting or parenting services for parents of infant are [NAME1, NAME2 and NAME 3]. There are others too that I might not have named. In the past year, did you participate in….
[READ IF NO SITE SPECIFIC NAMES PROVIDED: During the past year, what home visiting programs or parenting services have you participated in? GO TO OPEN ENDED RESPONSE TO ENTER INFO]
|
|
|
|
|
|
YES |
NO |
DON’T KNOW |
REFUSED |
a. [NAME1] |
1 |
0 |
d |
r |
b. [NAME2] |
1 |
0 |
d |
r |
c. [NAME3] |
1 |
0 |
d |
r |
d. Any other program? (SPECIFY)________________________ |
1 |
0 |
d |
r |
(STRING 200) |
|
|
|
|
SS24=1 |
PM25a.
[READ IF ANY RESPONSE TO PM25=1] During the past year, what other home visiting programs or parenting services have you participated in?
[READ IF SS24 = 1 AND SS25 SKIPPED (NO SITE SPECIFIC NAMES PROVIDED IN PRELOAD) OR ALL RESPONSES in SS25= 0,D,R] During the past year, what home visiting programs or parenting services have you participated in?
INTERVIEWER: YOU MAY ENTER UP TO THREE PROGRAMS
|
DON’T KNOW |
REFUSED |
a. [OTHER1] (SPECIFY)________________ (STRING 200) |
d |
R |
b. [OTHER2] (SPECIFY)________________ (STRING 200) |
d |
R |
c. [OTHER3] (SPECIFY)________________ (STRING 200) |
d |
R |
ask ss26 for each ‘yes’ response in ss25 and ss25a |
fill program name from ss25 and/or ss25a and ask FOR EACH ‘YES’ RESPONSE |
SS26. In the past year, on how many days did you receive home visits from [home visiting program/parenting program from SS25]? Would you say…
PROBE: “For example, if you participated in a program once a week for 10 weeks, that would be 10 days.”
PROBE: IF R SAYS, DON’T KNOW, SAY “Your best estimate is fine.”
1-2 days, 1
3-6 days, 2
7-12 days, 3
13-26 days, 4
26-52 days, or 5
53 days or more? 6
DON’T KNOW d
REFUSED r
SS24=1 |
SS27. Did a home visitor help you receive any of the following services?
|
|
|
|
|
|
Yes |
No |
DK |
R |
a. Prenatal Care |
1 |
0 |
d |
R |
b. Doctor visits for you other than when sick or injured |
1 |
0 |
d |
R |
c. Dentist |
1 |
0 |
d |
R |
d. Family Planning and Reproductive Health Care |
1 |
0 |
d |
R |
e. Substance Use Treatment for Alcohol and other drugs |
1 |
0 |
d |
R |
f. Mental Health Treatment |
1 |
0 |
d |
R |
g. Domestic Violence Shelter |
1 |
0 |
d |
R |
h. Domestic Violence Counseling or Anger Management |
1 |
0 |
d |
R |
i. Adult Education Services including GED and ESL |
1 |
0 |
d |
R |
j. Job Training and Employment |
1 |
0 |
d |
R |
k. Doctor visits for [CHILD] |
1 |
0 |
d |
R |
l. Childcare |
1 |
0 |
d |
R |
m. Public benefits including TANF, SNAP and WIC |
1 |
0 |
d |
R |
NEW RESPONDENTS OR r’s at baseline who did not provide SSN. |
ALLOW ENTRY OF UP TO NINE DIGITS OR JUST THE LAST FOUR |
SS28. We are almost done. Thanks so much for your time and patience. I have a few more questions.
First, what is your Social Security Number? We are collecting this information in order to obtain your health care records for the purposes of the study. Like all information collected, this will be kept private.
INTERVIEWER: ENTER SOCIAL SECURITY NUMBER WITHOUT DASHES
| | | |-| | |-| | | | | SOCIAL SECURITY NUMBER
DOESN’T HAVE A SOCIAL SECURITY NUMBER 98
DON’T KNOW d
REFUSED r
[DISPLAY FOR RESPONDENTS AGE 15 TO 20 YEARS OLD] IF RESPONDENT SAYS SHE DOESN’T KNOW HER SSN: Is anyone with you who might know your number, like your parent or guardian?
IF RESPONDENT IS RELUCTANT TO GIVE NUMBER, SAY: It is very helpful to have this information to obtain your health and birth records for the study. This information will be kept private.
IF RESPONDENT CITES PRIVACY CONCERNS, SAY: I understand your concern. The MIHOPE study team follows strict procedures to protect the information you tell us. This information will be kept private.
INTERVIEWER: DO NOT OFFER THIS OPTION UNTIL YOU HAVE WAITED FOR A RESPONSE AND THE RESPONDENT REMAINS RELUCTANT OR IF THE RESPONDENT SAYS THEY DON’T KNOW OR DOESN’T WANT TO PROVIDE THEIR NUMBER: If you prefer, you can give me the last four digits of your social security number.
ALL |
ALLOW ENTRY OF UP TO NINE DIGITS OR JUST THE LAST FOUR |
SS29. What is [CHILD]’s Social Security Number? We are collecting this information in order to obtain [CHILD]’s health care records for the purposes of the study. Like all information collected for the study, this will be kept private.
INTERVIEWER: ENTER SOCIAL SECURITY NUMBER WITHOUT DASHES
| | | |-| | |-| | | | | SOCIAL SECURITY NUMBER
DON’T KNOW d
REFUSED r
IF RESPONDENT IS RELUCTANT TO GIVE NUMBER SAY: It is very helpful to have this information to be able to obtain your health and birth records for the study. This information will be kept private.
IF RESPONDENT CITES PRIVACY CONCERNS, SAY: I understand your concern. The MIHOPE study team follows strict procedures to protect the information you tell us. This information will be kept private.
INTERVIEWER: DO NOT OFFER THIS OPTION UNTIL YOU HAVE WAITED FOR A RESPONSE AND THE RESPONDENT REMAINS RELUCTANT OR IF THE RESPONDENT SAYS THEY DON’T KNOW OR DOESN’T WANT TO PROVIDE THEIR NUMBER: If you prefer, you can give me the last four digits of your social security number.
all |
if r from baseline, add text in parens and FILL phone FROM PRELOAD |
H1a. I’d like to confirm your contact information (and the contact information you gave us when we last interviewed you.) This will be kept private and only used as a way of contacting you if we have questions or would like to request your participation in another survey. We will be contacting you again when [CHILD] is about 2 and a half years old to compete a brief survey. You can choose whether to participate or not at that time, but we really appreciate your continued participation.
NEW RESP OR BASELINE R WITH NO PHONE NO: What is the best telephone number to reach you at?
R FROM BASELINE: I have your telephone number as [read number]. Is that correct?
| | | | - | | | | - | | | | |
(RANGE) (RANGE) (RANGE)
DON’T KNOW d
REFUSED r
H1a NE D,R |
H1b. Is that a home phone, business phone or cell phone?
home phone 1
office phone 2
home and office phone 3
cell phone 4
DON’T KNOW d
REFUSED r
H1b=1,2 |
H1c. What is an alternate number that we can reach you at if needed?
| | | | - | | | | - | | | | |
NO ALTERNATE TELEPHONE NUMBER 0
DON’T KNOW d
REFUSED r
H1C NE 0, D,R |
H1d. Is that a home phone, business phone or cell phone?
home phone 1
office phone 2
home and office phone 3
cell phone 4
DON’T KNOW d
REFUSED r
ALL |
H1e. NEW R OR BASELINE R WITH NO PRELOAD INFO: What is your e-mail address?
R FROM BASELINE WITH PRELOAD INFO: I have your email address as [READ EMAIL ADDRESS] Is this correct?.
(STRING (50))
E-MAIL ADDRESS
DON’T KNOW d
REFUSED r
H1f. As we mentioned earlier, we will contact you again to complete a brief survey when [CHILD] is about 2 and a half years old. We’d like to contact you in the way that is most convenient for you.
How would you like to be contacted in the future about upcoming surveys? A letter in the mail, an email, a text message, cell phone, home phone, Facebook, or some other way?
CODE ONE ONLY
MAIL 1
EMAIL 2
TEXT MESSAGE 3
CELL PHONE 4
HOME PHONE 5
FACEBOOK 6
Other (specify): 7
DON’T KNOW d
REFUSED r
[IF THEY PREFER TO BE CONTACTED VIA FACEBOOK] What name do you use on Facebook so that we can contact you through your page?
Specify:_________
all new resp: ask for two contacts. r at baseline: prefill with contact info and ask r to confirm info |
H2a. Please tell me the names, addresses, telephone numbers, and e-mail addresses of two people who do not live with you but who will know how to contact you roughly a year from now.
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?
| | | | - | | | | - | | | | |
(RANGE) (RANGE) (RANGE)
DON’T KNOW d
REFUSED r
H2C NE D,R |
H2d. Is that a home phone, business phone or cell phone?
home phone 1
office phone 2
home and office phone 3
cell phone 4
DON’T KNOW d
REFUSED r
H2a ne d, r |
H2e. Please give me their permanent address.
STREET 1
STREET 2
STREET 3
CITY
STATE
ZIP
DON’T KNOW d
REFUSED r
H2a ne d, r |
H2f. Please give me their e-mail address.
(STRING (50))
E-MAIL ADDRESS
INTERVIEWER: CODE E-MAIL ADDRESS TYPE
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 Pmt
REFUSED r Pmt
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?
| | | | - | | | | - | | | | |
(RANGE) (RANGE) (RANGE)
DON’T KNOW d
REFUSED r
H3C NE D,R |
H3d. Is that a home phone, business phone or cell phone?
home phone 1
office phone 2
home and office phone 3
cell phone 4
DON’T KNOW d
REFUSED r
H3a ne d, r |
H3e. 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 |
H3f. Please give me their e-mail address.
(STRING (50))
E-MAIL ADDRESS
INTERVIEWER: CODE E-MAIL ADDRESS TYPE
DON’T KNOW d
REFUSED r
new respondent=1 |
PmtA. Lastly, please provide the address where we should send your thank-you gift card. You will receive it in about 2 weeks.
STREET 1
STREET 2
STREET 3
CITY
STATE
ZIP
DON’T KNOW d
REFUSED r
new respondent=0 |
FILL ADDRESS FROM PRELOAD |
PmtB. Lastly, I would like to confirm the address where we should send your thank-you gift card. You will receive it in about 2 weeks. Is it…
PROGRAMMER: DISPLAY ADDRESS AS INTERVIEWER NOTE. ALLOW ADDRESS INFO TO BE ENTERED/REVISED IN INFO SCREEN
INTERVIEWER: READ ADDRESS TO RESPONDENT
STREET 1
STREET 2
STREET 3
CITY
STATE
ZIP
ADDRESS CORRECT 1
ADDRESS INCORRECT 2
DON’T KNOW d
REFUSED r
ALL |
|
PmtC. Is your mailing address the same as your street address?
YES 1
NO 0
DON’T KNOW d
REFUSED r
pMTC=0 |
|
PmtD. I’d like to confirm your street address.
PROGRAMMER:DISPLAY SECOND ADDRESS AS INTERVIEWER NOTE. ALLOW ADDRESS INFO TO BE ENTERED/REVISED IN INFO SCREEN
INTERVIEWER: EnTER
STREET 1
STREET 2
STREET 3
CITY
STATE
ZIP
DON’T KNOW d
REFUSED r
follow-up visit ne complete |
Appt1. A MIHOPE field interviewer will be calling you soon to schedule a visit to your home to do some activities with you and [CHILD]. She will be calling from a 609 area code, but she lives in your area. You will be paid $20 for completing those activities. We thank you in advance for speaking and meeting with her when she calls.
When would be a good time for a MIHOPE interviewer to meet with you and [CHILD]? By a good time we mean a time when [CHILD] is awake and alert and there are not too many other things going on. Are mornings, afternoons, or evenings generally better?
MORNINGS……………………………………………………1
AFTERNOONS………………………………………………..2
EVENINGS……………………………………………………..3
EITHER………………………………………………………....4
APPT2. Are weekdays or weekends generally better?
WEEKDAYS 1
WEEKENDS 2
EITHER 3
ALL |
This completes the survey! We really appreciate you taking the time to speak with us and share this information. We look forward to speaking with you again when [CHILD] is 2 and a half. Thank you again and have a nice (day/evening). Goodbye.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | MIHOPE 2 FAMILY FOLLOWUP SURVEY CATI PROGAMMER COMPARISON |
| Subject | CATI |
| Author | UNKNOWN |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |
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