1 - Screening questions for parenting intervention (Applicant)

                                                                                                                                                          OMB #: XXXX-XXXX

                                                                                                                                             EXPIRATION: XX/XX/201X

1 - Screening Questions for Parenting Intervention

step-by-step guidance for Just Beginning eligibility process

Read to applicant: This short survey asks a few questions about your children to determine whether you are eligible for Just Beginning services. Answering these questions is voluntary. We hope you will answer the questions to determine if you are eligible for the available program services. The survey is estimated to take about 5 minutes to complete. Your name will not be included in any written reports and your answers will be kept private to the extent permitted by law.

1. Screen for Eligibility

Ask Q1: Do you have any biological or adopted children who are at least 2 months old and younger than 3 years old?

1. Yes

2. No [FATHER IS INELIGIBLE]

Note to facilitator: “Adopted” is intended to include children with whom father has a permanent legal tie. So, adopted would mean that the father is not the biological father, but he has gone through the legal process of legally adopting the child.

Ask Q2: How many biological or adopted children do you have who are at least 2 months old and younger than 3 years old?

1. One child

2. Two or more children [SKIP TO Q4]

Ask Q3: Have you seen this child in person in the past 30 days?

1. Yes

2. No [FATHER IS INELIGIBLE]

Ask Q3a: Was this required to be a supervised visit?

1. Yes [FATHER IS INELIGIBLE. PLEASE RECORD THIS IN NFORM AS INELIGIBLE FOR ANOTHER REASON (SUPERVISED VISITS)]

2. No

Ask Q3b. What is the name of your child who is at least 2 months old and younger than 3 years old?

_______________________________

[FILL IN FIRST NAME OF FOCAL CHILD] [GO TO Q5]

Ask Q4: Have you seen any of your children who are at least 2 months old and younger than 3 years old in person in the past 30 days?

1. Yes

2. No [FATHER IS INELIGIBLE]

Ask Q4a: How many of these children have you seen in person in the past 30 days?

1. One child

2. Two or more children [SKIP TO Q4a2]

Ask Q4a1: Was this required to be a supervised visit?

1. Yes [FATHER IS INELIGIBLE. PLEASE RECORD THIS IN NFORM AS INELIGIBLE FOR ANOTHER REASON (SUPERVISED VISITS)]

2. No [SKIP to Q5]

Ask Q4a2: How many of these were supervised visits and how many were not?

1. All visits were supervised [FATHER IS INELIGIBLE. PLEASE RECORD THIS IN NFORM AS INELIGIBLE FOR ANOTHER REASON (SUPERVISED VISITS)]

2. Visits were unsupervised with only one child [THIS CHILD SHOULD BE FOCAL CHILD]

3. Visits were unsupervised with two or more children [SEE NOTES BELOW TO HELP PICK THE FOCAL CHILD]

Note to facilitator: If father says he sees two or more children in the age range the same amount, then staff will say: “We usually recommend that fathers participate in this program with the child they see the most often or, if you have more than one child you see a lot, then the child that is the youngest. Is there any reason why you think it would be better to participate with a child under 3 years of age who is not your youngest child?” If yes, then discuss. If no, then ask: What is the name of your youngest child?

[If the father has twins/triplets in the age range, then the staff person will ask the names of the twins/triplets and select the first in alphabetical order to be the focal child. He can still bring both/all babies to the sessions.]

_______________________________

[FILL IN FIRST NAME OF FOCAL CHILD] [GO TO Q5]

Note to facilitator: Q5 through Q13 will fill in the name of focal child supplied above in place of references to “[name of child]”

Ask Q5: How old is [NAME OF CHILD]?

______ Years and ______ Months of age

Ask Q6: Is [NAME OF CHILD] a boy or a girl?

1. Boy

2. Girl

Ask Q7: Does [NAME OF CHILD] live with you all or most of the time?

1. Yes [SKIP TO Q9]

2. No

Ask Q8: Who does [NAME OF CHILD] usually live with?

1. Biological mother [GO TO Q10]

2. Grandparent(s) [GO TO Q11]

3. Other relative(s) [GO TO Q11]

4. Friend [GO TO Q11]

5. Foster care [GO TO Q11]

6. Adoptive parent [GO TO Q11]

7. Other [GO TO Q11]

Ask Q9. Do you and [NAME OF CHILD]’s mother live together?

1. Yes

2. No

Ask Q10. What is the name of [NAME OF CHILD]’s mother?

__________________________________ _________________________________

FIRST NAME OF FOCAL CHILD’S MOTHER LAST NAME OF FOCAL CHILD’S MOTHER [GO TO Q12]

Ask Q11. What is the name of the person [NAME OF CHILD] usually lives with?

__________________________________ _________________________________

FIRST NAME OF FOCAL CHILD’S GUARDIAN LAST NAME OF FOCAL CHILD’S GUARDIAN

Ask Q12. Are you or your family involved in the child welfare system?

1. Yes [using guidelines in the next section, staff member discusses with father to determine eligibility]

2. No

Note to facilitator: Child welfare is referred to as ACS in New York City, DHS in Philadelphia, and DCFS in Los Angeles.

Ask Q13. Is there any legal restriction on your being with [NAME OF CHILD], such as a restraining order?

1. Yes [using guidelines in the next section, staff member discusses with father to determine eligibility]

2. No

Note to facilitator: A “legal restriction” refers to anything related to intimate partner violence or child welfare.

2. Note Eligiblity Decision

S1. If Q12=Yes or Q13=Yes: [Review specific circumstances to determine eligibility. Contact your supervisor if you’re unsure of how to proceed.]

S2. Is the staff currently aware of any other circumstances indicating that this father cannot participate in Just Beginning with his child (such as untreated serious mental illness)?

1 Yes [FATHER IS INELIGIBLE]

2 No

S3. Please mark whether the father is eligible or ineligible for Just Beginning services:

□ Eligible

□ Ineligible

THE PAPERWORK REDUCTION ACT OF 1995

This collection of information is voluntary and will be used to learn about the effects of parenting and employment services for fathers. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB number for this information collection is 0970-XXXX and the expiration date is XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Erika Lundquist; 16 E 34^th St, MDRC, 19^th Floor, New York, NY 10016; (212) 340-8605; Attn: OMB-PRA (0907-XXXX).

THE PAPERWORK REDUCTION ACT OF 1995

This collection of information is voluntary and will be used to learn about the effects of parenting and employment services for fathers. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB number for this information collection is 0970-0XXX and the expiration date is XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Erika Lundquist; 16 E 34^th St, MDRC, 19^th Floor, New York, NY 10016; (212) 340-8605; Attn: OMB-PRA (XXXX-XXXX).