8 & 9 - Baseline surveys
Building Bridges and Bonds (B3)
8 - Baseline Survey for Sites Testing Parenting Intervention
8 & 9 - Baseline surveys
OMB: 0970-0485
8 - Baseline Survey for Sites Testing Parenting Intervention
PROGRAMMING INSTRUCTIONS ANNOTATIONS/NOTES:
A SOLID LINE ACROSS THE PAGE INDICATES A NEW SCREEN WILL BE DISPLAYED ON THE SURVEY SCREEN – OTHERWISE, EACH QUESTION SHOULD BE DISPLAYED ON ITS OWN SCREEN
TEXT INSERTIONS ARE INDICATED BY [ ]
SOURCE OF INSERTIONS WILL BE A WEB SERVICE DESIGNED TO RECEIVE SECURED INFORMATION FROM NFORM UNLESS INDICATED OTHERWISE. FIELDS TO BE SENT TO THE WEB SERVICE INCLUDE:
nFORM ID #
NAME
DATE OF BIRTH
FOCAL CHILD FIRST NAME
FOCAL CHILD AGE IN MONTHS
FIRST NAME OF MOTHER/GUARDIAN OF FOCAL CHILD
SITE
Program Sites (SiteCode):
SITE CODE:
11. Children’s Institute, Inc. - LA
12. People for People, Inc. - Philadelphia
13. Seedco – NYC
Site Program Names (Inserts for A1 based on SiteCode):
SITE CODE:
11. Project Fatherhood
12. Project D.A.D.
13. Strong Fathers, Stronger Families
If the respondent advances by leaving an answer blank, they will be prompted with the following message “We are very interested in hearing about your experiences. As we mentioned at the start, however, you can choose not to answer specific questions.” The same question will again appear, but with the choices “don’t know” and “decline to answer” available.
Building Bridges and Bonds
Enrollment Survey
OMB Control No.: xxxx-xxxx
Expiration Date: xx/xx/201x
[BEGIN SURVEY USING AUDIO AND TEXT DISPLAY]
INTRO1:
Please select the language of this survey/ Seleccione el idioma de esta encuesta:
1 English / Inglés
2 Spanish / Español
INTRO2:
For your convenience, this survey has the ability to present question and answer choices using audio. Please select 1 to continue playing the audio or select 2 to turn the audio off. You will be given another opportunity to change your selection before the main part of the survey begins:
1 Continue with Audio
2 Turn Audio off
INTRO3:
Thank you for your help with this important study. The survey asks questions about your parenting and co-parenting relationships, child support, employment, and financial well-being. Your participation in this survey is voluntary. We hope that you will answer all the questions, but you may skip any questions you do not wish to answer. Your name will not be included in any written reports and your answers will be kept private to the extent permitted by law. This survey will take about 30 minutes to complete.
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 30 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 34th
St, MDRC, 19th
Floor, New York, NY 10016;
(212) 340-8605; Attn: OMB-PRA (XXXX-XXXX).
Before we begin, please verify your identity.
S1.
Is this your name?
[fathername]
1 Yes
2 No [SKIP TO FAIL_SCREENER]
S2.
Is this your date of birth?
[FatherDOB]
1 Yes
2 No [SKIP TO FAIL_SCREENER]
S3.
Is this your child’s name?
[NAME OF CHILD]
1 Yes
2 No [SKIP TO FAIL_SCREENER]
S4.
Is this the name of [NAME OF CHILD]’s/{your child’s} mother or guardian?
[NAME OF MOTHER OR GUARDIAN]
1 Yes [SKIP TO CONTINUE]
2 No [SKIP TO FAIL_SCREENER]
FAIL_SCREENER
IF S1=2 OR S2=2 OR S3=2 OR S4=2, DISPLAY:
Thank you for taking the time to answer these questions. The information you provided does not match our records. Please show this screen to the staff member who was just helping you.
Continue
Thank you for confirming this information.
A few instructions before you begin…
To respond to a question, select the best answer and then hit the "NEXT" button. If you do not want to answer a question, you can hit "NEXT" without selecting an answer and you will be given the option of declining to answer.
If you have questions or need help at any time during the survey, please let the staff member who has been helping you know.
Finally, before we begin the survey, this is your last chance to change whether the audio is used during the survey. Please select whichever option is most comfortable for you. Whatever option you choose determines how the survey will behave from now until the end of the survey.
1 Continue with Audio ON
2 Continue with Audio OFF
Let’s begin the survey.
Module A: Service Receipt and Participation
[DO NOT DISPLAY “DON’T KNOW” AND “DECLINE TO ANSWER” OPTIONS WHEN QUESTION IS INITIALLY PRESENTED. IF THE RESPONDENT SELECTS “NEXT” WITHOUT ANSWERING, DISPLAY THE QUESTION AGAIN WITH “DON’T KNOW” AND “DECLINE TO ANSWER” OPTIONS INCLUDED AND PLAY AUDIO FILE WHICH INCLUDES THESE IN THE ANSWER SET]
A1. In the last 12 months, have you participated in [IF SITE CODE = 11, INSERT “Project Fatherhood”, IF =12, INSERT “Project D.A.D”, IF = 13, INSERT “Strong Fathers, Stronger Families”] or another program that offered services related to employment, parenting, communicating with your child or children’s other parent or legal guardian, or helping you relate well to other people?
1 Yes
2 No [SKIP TO A3]
7 Don’t Know [SKIP TO A3]
8 Decline to Answer [SKIP TO A3]
A2. What specific types of support did you receive? [Select all that apply]
1 Support to find or keep a job
2 Help to develop or improve your parenting skills
3 Help to improve your relationship with your child or children’s other parent or guardian
7 Don’t Know
8 Decline to Answer
A3. In the last 12 months, have you participated in any program to learn how patterns of thinking can affect your behavior or the choices you make? Sometimes these services are called cognitive-behavioral services.
1 Yes
2 No [SKIP TO A8]
7 Don’t Know [SKIP TO A8]
8 Decline to Answer [SKIP TO A8]
A4. Can you tell me the name of this program or programs? Mark all that apply. Was it…
1 Thinking for a Change [SKIP TO A5]
2 Reasoning and Rehabilitation [SKIP TO A5]
3 Moral Reconation Therapy [SKIP TO A5]
4 Aggression Replacement Training [SKIP TO A5]
5 Interpersonal Problem Solving [SKIP TO A5]
6 Cognitive Interventions Program [SKIP TO A5]
7 Courage to Change [SKIP TO A5]
8 Something else
97 Don’t Know [SKIP TO A5]
98 Decline to Answer [SKIP TO A5]
A4a. What was the name of the program?
_________________
NAME OF PROGRAM
7 Don’t Know
8 Decline to Answer
A5. About how many cognitive-behavioral sessions did you participate in?
1 1 – 5 sessions
2 6 – 10 sessions
3 11 – 15 sessions
4 16 or more sessions
7 Don’t Know
8 Decline to Answer
A6. Did you complete a cognitive-behavioral program?
1 Yes
2. No
7 Don’t Know
8 Decline to Answer
A7. Did you participate in any of these sessions while you were in jail or prison?
1 Yes
2 No
3 I have never been in jail or prison
7 Don’t Know
8 Decline to Answer
A8. The staff may have discussed with you a workshop where you would spend time with your child and get some advice on parenting. How interested would you be in attending this type of workshop?
1 Very interested
2 Somewhat interested
3 Not very interested
7 Don’t Know
8 Decline to Answer
A9. How interested are you in participating in services related to obtaining or keeping employment in the next 12 months?
1 Very interested
2 Somewhat interested
3 Not very interested
7 Don’t Know
8 Decline to Answer
A10. How interested are you in participating in services related to healthy relationships with a partner or spouse in the next 12 months?
1 Very interested
2 Somewhat interested
3 Not very interested
7 Don’t Know
8 Decline to Answer
Module B: Household and family structure
The next questions ask how many children you have in different age groups. When answering, please include all of your biological and adopted children.
[DISPLAY DROP DOWN MENU WITH OPTIONS 0 THROUGH 10 FOR QUESTIONS B1A, B1B, B1C, B1D, B1E]
B1a. How many children do you have between 0 and 2 years of age?
___________
Number of children
97 Don’t Know
98 Decline to Answer
B1b. How many children do you have that are 3 or 4 years old?
___________
Number of children
97 Don’t Know
98 Decline to Answer
8 Decline to Answer
B1c. How many children do you have between 5 and 9 years old?
___________
Number of children
97 Don’t Know
98 Decline to Answer
8 Decline to Answer
1 8 Decline to Answer
B1d. How many children do you have between 10 and 17 years old?
___________
Number of children
97 Don’t Know
98 Decline to Answer
8 Decline to Answer 7 Don’t Know
8 DeclineB1e. How many children do you have aged 18 years or older?
___________
Number of children
97 Don’t Know
98 Decline to Answer
[CREATE VARIABLE THAT ADDS UP RESPONSES FOR B1A THROUGH B1e CALLED #KIDS. IF B1A, B1B, B1C, B1D, AND B1E ALL ARE 97 OR 98, #KIDS=97. IF #KIDS IS = 1, THEN SKIP TO C1.]
B2. How many of your kids have you seen in person in the last 30 days?
[DISPLAY DROP DOWN MENU WITH OPTIONS 0 TO #KIDS; IF #KIDS=97, DROP DOWN SHOULD DISPLAY 0 TO 20]
97 Don’t Know
98 Decline to Answer
B3. How many of your kids live with you all or part of the time?
[DISPLAY DROP DOWN MENU WITH OPTIONS 0 TO #KIDS; IF #KIDS=97, DROP DOWN SHOULD DISPLAY 0 TO 20]
97 Don’t Know
98 Decline to Answer
B4. Do all of your children have the same mother?
1 Yes [SKIP TO C1]
2 No
7 Don’t Know [SKIP TO C1]
8 Decline to Answer [SKIP TO C1]
B5. How many different mothers do these children have?
____________________
NUMBER OF MOTHERS (RANGE: 1 TO #KIDS; IF #KIDS=97, DROP DOWN SHOULD DISPLAY 0 TO 20]
97 Don’t Know
98 Decline to Answer
Module C: Father/Child Contact
[IN THIS SECTION AND THE REMAINDER OF SURVEY, THE NAME OF THE FOCAL CHILD WILL APPEAR ON THE SCREEN WHERE IT SAYS “[NAME OF CHILD]”, BUT THE PRE-RECORDED VOICE WILL SAY THE TEXT IN THE CURLY BRACKETS.]
This8 Decline to Answer survey will be asking you a number of questions about your relationship with [NAME OF CHILD]/{your child}. [IF AUDIO “ON”, THEN READ: Throughout this series of questions, the pre-taped voice will not be saying the name of your child, but your child’s name will appear on the screen.]
C1. What is [NAME OF CHILD]/{your child}’s birth date?
___________________MONTH (Range 1-12)
___________________DAY (Range 1-31)
___________________YEAR (Range 2010-Current Year)
97 Don’t Know
98 Decline to Answer
C2. Do you live with [NAME OF CHILD]’s/{your child’s} mother?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
C3. Does [NAME OF CHILD]/{your child} live with you all or most of the time?
1 Yes [SKIP TO D1]
2 No
7 Don’t Know
8 Decline to Answer
C4. Who does [NAME OF CHILD]/{your child} usually live with?
1 Biological mother
2 Grandparent(s)
3 Other relative(s)
4 Friend
5 Foster care
6 Adoptive parent
7 Don’t Know
8 Decline to Answer
C5. How long does it usually take for you to get from your home to [NAME OF CHILD]/{your child}’s home?
1 Less than 10 minutes
2 10-19 minutes
3 20-39 minutes
4 40 to 59 minutes
5 1 to 2 hours
6 More than 2 hours
7 I have never been to my child’s home
97 Don’t Know
98 Decline to Answer
C6. In the past 30 days, how often did you talk on the phone; send letters, cards or texts; use FaceTime, Facebook, or other social media with [NAME OF CHILD]/{your child}?
1 Every day or almost every day
2 3 or 4 times per week
3 1 or 2 times per week
4 2 or 3 times in the past month
5 Once in the past month
6 Not at all
7 [NAME OF CHILD]/{My child} is too young for this
97 Don’t Know
98 Decline to Answer
C7. When did you last see [NAME OF CHILD]/{your child} in person?
1 Within the last week
2 Between 7 – 14 days ago
3 Between 15 – 29 days ago
4 More than 1 month ago
7 Don’t Know
8 Decline to Answer
C8. In the past 30 days, how often did you see [NAME OF CHILD]/{your child} in person?
1 Every day or almost every day
2 3 or 4 times per week
3 1 or 2 times per week
4 2 or 3 times in the past month
5 Once in the past month
6 Not at all
7 Don’t Know
8 Decline to Answer
C9. In the past 30 days, how often did [NAME OF CHILD]/{your child} spend the night with you?
1 Every day or almost every day
2 3 or 4 times per week
3 1 or 2 times per week
4 2 or 3 times in the past month
5 Once in the past month
6 Not at all
7 Don’t Know
8 Decline to Answer
C10. Has your legal paternity been established? That is, did you sign any document that identifies you as the legal father of [NAME OF CHILD]/{your child} or has the court ruled that you are the father?
1 Yes, legal paternity
2 No
7 Don't know
8 Decline to Answer
C11. Do you have shared custody of [NAME OF CHILD]/{your child}?
1 Yes
2 No
7 Don't know
8 Decline to Answer
C12. Do you have an agreement with the mother or guardian of [NAME OF CHILD]/{your child} about spending time with [NAME OF CHILD]/{your child}?
1 Yes, we have a legal document
2 Yes, we have a written agreement that is not court-ordered
3 Yes, we have a verbal understanding
4 No, we have no parenting agreement
7 Don’t Know
8 Decline to Answer
[IF C5 = 7, THEN SKIP TO C14]
C13. When you spend time with [NAME OF CHILD]/{your child}, how often are you at the home where [NAME OF CHILD]/{your child} usually lives?
1 Always or almost always
2 Often
3 Sometimes
4 Rarely
5 Never
7 Don’t Know
8 Decline to Answer
[IF C2 = YES THEN SKIP TO C15]
C14. If you have a spouse or partner that is not [NAME OF CHILD]/{your child}’s mother, how encouraging or discouraging is your spouse or partner of your involvement with [NAME OF CHILD]/{your child}?
1 Very discouraging
2 Somewhat discouraging
3 Neutral
4 Somewhat encouraging
5 Very encouraging
0 I do not have a spouse or partner
7 Don’t Know
8 Decline to Answer
C15. In general, how satisfied are you with the amount of time you spend with [NAME OF CHILD]/{your child}?
1 Very satisfied
2 Somewhat satisfied
3 Not satisfied
7 Don’t Know
8 Decline to Answer
C16. The next questions list some things that can make it hard for fathers to spend time with their children. Thinking about the past month, please indicate how often you think each of the following statements applied to you.
C16a. In the past month, my work or school schedule made it hard for me to spend time with [NAME OF CHILD]/{my child}.
1 Often
2 Sometimes
3 Never
7 Don’t Know
8 Decline to Answer
C16b. In the past month, car problems or lack of transportation made it hard for me to spend time with [NAME OF CHILD]/{my child} .
1 Often
2 Sometimes
3 Never
7 Don’t Know
8 Decline to Answer
C16c. In the past month, not having a stable place to live made it hard for me to spend time with [NAME OF CHILD]/{my child}.
1 Often
2 Sometimes
3 Never
7 Don’t Know
8 Decline to Answer
[If C2 = YES, THEN SKIP TO C16E]
C16d. In the past month, it was hard to spend time with [NAME OF CHILD]/{my child} because his or her mother’s spouse or boyfriend did not want me around.
1 Often
2 Sometimes
3 Never
9 [NAME OF CHILD]’S/{my child’s} mother does not have a spouse or partner
7 Don’t Know
8 Decline to Answer
C16e.In the past month, a court order or legal restriction made it hard for me to spend time with [NAME OF CHILD]/{my child}.
1 Often
2 Sometimes
3 Never
9 There is no court order or legal restriction that makes it hard for me to spend time with [FOCAL CHILD NAME]/{my child}
7 Don’t Know
8 Decline to Answer
Module D: Father Engagement
The next questions ask about how often you did certain activities with [NAME OF CHILD]/{your child} in the past 30 days. Some of these activities may fit better with a child of his or her age than others. If any of them don’t make sense to you, that’s fine, you can just say that you didn’t do them at all.
D1. In the past 30 days, how often did you sing songs with [NAME OF CHILD]/{your child}?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don't Know
8 Decline to Answer
D2. In the past 30 days, how often did you dance with [NAME OF CHILD]/{your child}?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don’tDon't Know
8 Decline to Answer
D3. In the past 30 days, how often did you READ stories to [NAME OF CHILD]/{your child}?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don’t Know
8 Decline to Answer
D4. In the past 30 days, how often did you TELL stories to [NAME OF CHILD]/{your child}?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don’t Know
8 Decline to Answer
D5. In the past 30 days, how often did you talk to [NAME OF CHILD]/{your child} about the things that they looked at, grabbed, or pointed to.
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don’t Know
8 Decline to Answer
D6. In the past 30 days, how often did you hug or show physical affection to [NAME OF CHILD]/{your child}?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don’t Know
8 Decline to Answer
D7. In the past 30 days, how often did you praise [NAME OF CHILD]/{your child}?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don't Know
8 Decline to Answer
D8. In the past 30 days, how often did you soothe [NAME OF CHILD]/{your child} if he or she was crying?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don't Know
8 Decline to Answer
D9. In the past 30 days, how often did you tell [NAME OF CHILD]/{your child} you loved him or her?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don’t Know
8 Decline to Answer
D10. In the past 30 days, how often did you try to get [NAME OF CHILD]/{your child} to smile or laugh?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don't Know
8 Decline to Answer
D11. In the past 30 days, how often did you take [NAME OF CHILD]/{your child} for a ride on your shoulders or back?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don't Know
8 Decline to Answer
D12. In the past 30 days, how often did you carry [NAME OF CHILD]/{your child} in your arms or hold him or her in your lap?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don’t Know
8 Decline to Answer
D13. In the past 30 days, how often did you and [NAME OF CHILD]/{your child} play together with toys?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don’t Know
8 Decline to Answer
D14. In the past 30 days, how often did you take [NAME OF CHILD]/{your child} with you to visit relatives?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don’t Know
8 Decline to Answer
D15. In the past 30 days, how often did you take [NAME OF CHILD]/{your child} shopping with you?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don't Know
8 Decline to Answer
D16. In the past 30 days, how often did you go to a restaurant or out to eat with [NAME OF CHILD]/{your child}?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don't Know
8 Decline to Answer
D17. In the past 30 days, how often did you take [NAME OF CHILD]/{your child} to play with other children?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don't Know
8 Decline to Answer
D18. In the past 30 days, how often did you put [NAME OF CHILD]/{your child} to bed?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don't Know
8 Decline to Answer
D19. In the past 30 days, how often did you give [NAME OF CHILD]/{your child} a bath?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don't Know
8 Decline to Answer
D20. In the past 30 days, how often did you roll a ball, toss a ball, or play games with a ball with [NAME OF CHILD]/{your child}?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don’t Know
8 Decline to Answer
D21. In the past 30 days, how often did you go for a walk with [NAME OF CHILD]/{your child}?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don't Know
8 Decline to Answer
D22. In the past 30 days, how often did you bounce [NAME OF CHILD]/{your child} up and down on your knee?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don't Know
8 Decline to Answer
D23. In the past 30 days, how often did you stay home to care for [NAME OF CHILD]/{your child} when he or she was sick?
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 My child has not been sick in the past month
97 Don't Know
98 Decline to Answer
D24. In the past 30 days, how often did you help get [NAME OF CHILD]/{your child} dressed?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don't Know
8 Decline to Answer
D25. In the past 30 days, how often did you change [NAME OF CHILD]/{your child}’s} diaper, or help him or her use the toilet?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don't Know
8 Decline to Answer
D26. In the past 30 days, how often did you prepare meals or bottles for [NAME OF CHILD]/{your child}?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don’t Know
8 Decline to Answer
D27. In the past 30 days, how often did you assist [NAME OF CHILD]/{your child} with eating or give [NAME OF CHILD]/{your child} a bottle?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don’t Know
8 Decline to Answer
D28. In the past 30 days, how often did you get up with [NAME OF CHILD]/{your child} when he or she woke up during the night?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don't Know
8 Decline to Answer
D29. In the past 30 days, how often did you play outside in the yard, a park, or a playground with [NAME OF CHILD]/{your child}?
1 More than once a day
2 About once a day
3 A few times a week
4 A few times a month
5 Rarely
6 Not at all in the past month
7 Don’t Know
8 Decline to Answer
D30. Do you agree or disagree with this statement: There is not much point talking to [NAME OF CHILD]/{my child}, because he or she is too young to understand me.
1 Strongly Agree
2 Agree
3 Disagree
4 Strongly Disagree
7 Don’t Know
8 Decline to Answer
to Answer
Module E: Discipline
E1. Sometimes children behave pretty well and sometimes they don't. In the past month, have you spanked [NAME OF CHILD]/{your child} because he or she was misbehaving or acting up?
1 Yes
2 No [SKIP TO F1]
7 Don’t Know [SKIP TO F1]
8 Decline to Answer [SKIP TO F1]
E1a. Did you do this:
1 Every day or nearly every day
2 A few times a week
3 A few times this past month
4 Once or twice in the past month
7 Don’t Know
8 Decline to Answer
Module F: Father/Child Relationship Quality
In this next section, you will be asked some more questions about your current relationship with [NAME OF CHILD]/{your child}.
F1. Do you feel that your relationship with [NAME OF CHILD]{your child} is…
1 Very good
2 Somewhat good
3 Not too good
7 Don’t Know
8 Decline to Answer
F2. How often do you feel disappointed with [NAME OF CHILD]{your child}?
1 Always or almost always
2 Often
3 Sometimes
4 Rarely
5 Never
7 Don’t Know
8 Decline to Answer
F3. How often do you feel proud of [NAME OF CHILD]{your child}?
1 Always or almost always
2 Often
3 Sometimes
4 Rarely
5 Never
7 Don’t Know
8 Decline to Answer
F4. How often do you feel angry or irritated with [NAME OF CHILD]{your child}?
1 Always or almost always
2 Often
3 Sometimes
4 Rarely
5 Never
7 Don’t Know
8 Decline to Answer
The next statements ask you your feelings about being a parent to [NAME OF CHILD]{your child}. Your first reaction should be your answer. For each statement, please indicate how much you agree or disagree with the statement.
F5. My child rarely does things for me that make me feel good
1 Strongly Agree
2 Agree
3 Not Sure
4 Disagree
5 Strongly Disagree
7 Don’t Know
8 Decline to Answer
F6. Most times I feel that my child does not like me and does not want to be close to me
1 Strongly Agree
2 Agree
3 Not sure
4 Disagree
5 Strongly Disagree
7 Don’t Know
8 Decline to Answer
F7. My child smiles at me much less than I expected
1 Strongly Agree
2 Agree
3 Not Sure
4 Disagree
5 Strongly Disagree
7 Don’t Know
8 Decline to Answer
F8. When I do things for my child I get the feeling that my efforts are not appreciated very much
1 Strongly Agree
2 Agree
3 Not sure
4 Disagree
5 Strongly Disagree
7 Don’t Know
8 Decline to Answer
F9. When playing, my child doesn't often giggle or laugh
1 Strongly Agree
2 Agree
3 Not sure
4 Disagree
5 Strongly Disagree
7 Don’t Know
8 Decline to Answer
F10. My child doesn't seem to learn as quickly as most children
1 Strongly Agree
2 Agree
3 Not sure
4 Disagree
5 Strongly Disagree
7 Don’t Know
8 Decline to Answer
F11. My child doesn't seem to smile as much as most children
1 Strongly Agree
2 Agree
3 Not sure
4 Disagree
5 Strongly Disagree
7 Don’t Know
8 Decline to Answer
F12. My child is not able to do as much as I expected
1 Strongly Agree
2 Agree
3 Not sure
4 Disagree
5 Strongly Disagree
7 Don’t Know
8 Decline to Answer
F13 It takes a long time and it is very hard for my child to get used to new things
1 Strongly Agree
2 Agree
3 Not sure
4 Disagree
5 Strongly Disagree
7 Don’t Know
8 Decline to Answer
F14. I expected to have closer and warmer feelings for my child than I do and this bothers me
1 Strongly Agree
2 Agree
3 Not sure
4 Disagree
5 Strongly Disagree
7 Don’t Know
8 Decline to Answer
F18F15. Sometimes my child does things that bother me just to be mean
1 Strongly Agree
2 Agree
3 Not sure
4 Disagree
5 Strongly Disagree
7 Don’t Know
8 Decline to Answer
Module G: Parenting Efficacy
The following statements are about how you think about yourself as a father. Please think about [NAME OF CHILD]/{your child} when answering these questions and indicate how often each statement applies to you.
G1. I am good at helping [NAME OF CHILD]/{my child} when he or she is upset or distressed.
1 Always or almost always
2 Often
3 Sometimes
4 Rarely
5 Never
7 Don’t Know
8 Decline to Answer
G2. I am good at getting [NAME OF CHILD]/{my child} to have fun with me.
1 Always or almost always
2 Often
3 Sometimes
4 Rarely
5 Never
7 Don’t Know
8 Decline to Answer
G3. I am good at providing for [NAME OF CHILD]/{my child}'s financial needs.
1 Always or almost always
2 Often
3 Sometimes
4 Rarely
5 Never
7 Don’t Know
8 Decline to Answer
G4. I am good at providing diapers, milk, or other needed items for [NAME OF CHILD]/{my child}.
1 Always or almost always
2 Often
3 Sometimes
4 Rarely
5 Never
7 Don’t Know
8 Decline to Answer
G5. I am good at getting [NAME OF CHILD]/{my child} to understand what I want him or her to do.
1 Always or almost always
2 Often
3 Sometimes
4 Rarely
5 Never
7 Don’t Know
8 Decline to Answer
G6. I am good at understanding what [NAME OF CHILD]/{my child} wants or needs.
1 Always or almost always
2 Often
3 Sometimes
4 Rarely
5 Never
7 Don’t Know
8 Decline to Answer
G7. I feel that I am:
1 not very good at being a parent
2 a person who has some trouble being a parent
3 an average parent
4 a better than average parent
5 a very good parent
7 Don’t Know
8 Decline to Answer
G8. How much influence do you have in making major decisions for [NAME OF CHILD]/{your child} about things like when he or she goes to the doctor, what religion he or she practices, or who will take care of him or her? Do you have…
1 No influence
2 Some influence
3 A great deal of influence
7 Don’t Know
8 Decline to Answer
Module H: Father Commitment to Child
Please answer each of the upcoming questions by indicating how strongly you agree or disagree with the idea expressed.
[If #KIDS = 1 OR (#KIDS=97 AND (B2=1, 97 OR 98) AND (B3=1, 97 OR 98)) THEN ASK H1A; ELSE IF #KIDS > 1 OR (#KIDS=97 AND ((B2>1 AND B2<> 97 OR 98) OR (B3>1 AND B3<> 97 OR 98))) THEN ASK H1B]
H1a. My relationship with [NAME OF CHILD]/{my child} is more important than anything else in my life.
1 Strongly Agree
2 Agree
3 Disagree
4 Strongly Disagree
7 Don’t Know
8 Decline to Answer
H1b. My relationships with my children are more important to me than anything else in my life.
1 Strongly Agree
2 Agree
3 Disagree
4 Strongly Disagree
7 Don’t Know
8 Decline to Answer
H2. Being a father is a big part of who I am.
1 Strongly Agree
2 Agree
3 Disagree
4 Strongly Disagree
7 Don’t Know
8 Decline to Answer
H3. I will always want to be meaningfully involved in [NAME OF CHILD]/{my child}’s life.
1 Strongly Agree
2 Agree
3 Disagree
4 Strongly Disagree
7 Don’t Know
8 Decline to Answer
H4. Sometimes other interests and responsibilities of mine have to come before my relationship with [NAME OF CHILD]/{my child}.
1 Strongly Agree
2 Agree
3 Disagree
4 Strongly Disagree
7 Don’t Know
8 Decline to Answer
H5. I can see myself losing interest in [NAME OF CHILD]/{my child} a few years from now.
1 Strongly Agree
2 Agree
3 Disagree
4 Strongly Disagree
7 Don’t Know
8 Decline to Answer
H6. Not being a part of [NAME OF CHILD]/{my child}’s life would be one of the worst things that could happen to me.
1 Strongly Agree
2 Agree
3 Disagree
4 Strongly Disagree
7 Don’t Know
8 Decline to Answer
H7. Sometimes things come up that get in the way of plans to spend time with children. How often do you have to cancel plans with [NAME OF CHILD]/{your child}?
1 Often
2 Sometimes
3 Rarely
4 Never
7 Don’t Know
8 Decline to Answer
H8. If you were not able to see [NAME OF CHILD]/{your child} in the next month, how much would you miss them?
1 A great deal
2 Somewhat
3 A little bit
4 Not at all
7 Don’t Know
8 Decline to Answer
H9. How much influence do you think you have on [NAME OF CHILD]/{your child}’s life right now?
1 A great deal
2 Some
3 A little
4 None
7 Don’t Know
8 Decline to Answer
H10. How much influence do you think you will have on [NAME OF CHILD]/{your child}’s life over the long-term?
1 A great deal
2 Some
3 A little
4 None
7 Don’t Know
8 Decline to Answer
Module I: Co-Parenting Relationship Quality
[IN THIS SECTION, THE NAME OF THE MOTHER/GUARDIAN WILL APPEAR ON THE SCREEN, BUT THE PRE-RECORDED VOICE WILL SAY THE TEXT IN THE CURLY BRACKETS {}.]
The next questions are about your relationship with [NAME OF MOTHER/GUARDIAN]/{your child’s mother or guardian}. [IF AUDIO “ON”, THEN READ: In these questions, this person’s name will appear on the screen and the audio recording will refer to this person as “your child’s mother or guardian”.]
Please think about [NAME OF MOTHER/GUARDIAN]/{your child’s mother or guardian} when answering these questions and let us know if you strongly agree, agree, disagree, or strongly disagree with each of the following statements.
I1. [NAME OF MOTHER/GUARDIAN]/{My child’s mother or guardian} tells me I am doing a good job or otherwise lets me know I am being a good father.
1 Strongly Agree
2 Agree
3 Disagree
4 Strongly Disagree
7 Don’t Know
8 Decline to Answer
I2. [NAME OF MOTHER/GUARDIAN]/{My child’s mother or guardian} makes negative comments, jokes, or sarcastic comments about the way I am as a parent.
1 Strongly Agree
2 Agree
3 Disagree
4 Strongly Disagree
7 Don’t Know
8 Decline to Answer
I3. [NAME OF MOTHER/GUARDIAN]/{My child’s mother or guardian} contradicts the decisions I make about [NAME OF CHILD]/{my child}.
1 Strongly Agree
2 Agree
3 Disagree
4 Strongly Disagree
7 Don’t Know
8 Decline to Answer
I4. [NAME OF MOTHER/GUARDIAN]/{My child’s mother or guardian} turns to other people to parent [NAME OF CHILD]/{my child} even though I am an engaged father.
1 Strongly Agree
2 Agree
3 Disagree
4 Strongly Disagree
7 Don’t Know
8 Decline to Answer
I5. [NAME OF MOTHER/GUARDIAN]/{My child’s mother or guardian} undermines me as a father.
1 Strongly Agree
2 Agree
3 Disagree
4 Strongly Disagree
7 Don’t Know
8 Decline to Answer
I6. [NAME OF MOTHER/GUARDIAN]/{My child’s mother or guardian} makes it hard for me to spend time with [NAME OF CHILD]/{my child}.
1 Strongly Agree
2 Agree
3 Disagree
4 Strongly Disagree
7 Don’t Know
8 Decline to Answer
I7. [NAME OF MOTHER/GUARDIAN]/{My child’s mother or guardian} makes it hard for me to talk with [NAME OF CHILD]/{my child}.
1 Strongly Agree
2 Agree
3 Disagree
4 Strongly Disagree
7 Don’t Know
8 Decline to Answer
I8. [NAME OF MOTHER/GUARDIAN]/{My child’s mother or guardian} and I have conflicts about scheduling time or activities with [NAME OF CHILD]/{my child}.
1 Strongly Agree
2 Agree
3 Disagree
4 Strongly Disagree
7 Don’t Know
8 Decline to Answer
I9. [NAME OF MOTHER/GUARDIAN]/{My child’s mother or guardian} and I are a good parenting team.
1 Strongly Agree
2 Agree
3 Disagree
4 Strongly Disagree
7 Don’t Know
8 Decline to Answer
I10.[NAME OF MOTHER/GUARDIAN]/{My child’s mother or guardian} and I argue about who should make decisions about [NAME OF CHILD]/{my child} .
1 Strongly Agree
2 Agree
3 Disagree
4 Strongly Disagree
7 Don’t Know
8 Decline to Answer
I11. [NAME OF MOTHER/GUARDIAN]/{My child’s mother or guardian} and I try to manage the amount of conflict we have about [NAME OF CHILD]/{my child}.
1 Strongly Agree
2 Agree
3 Disagree
4 Strongly Disagree
7 Don’t Know
8 Decline to Answer
I12. [NAME OF MOTHER/GUARDIAN]/{My child’s mother or guardian} and I make threats to each other when we can't get along in our roles as parents.
1 Strongly Agree
2 Agree
3 Disagree
4 Strongly Disagree
7 Don’t Know
8 Decline to Answer
I13. [NAME OF MOTHER/GUARDIAN]/{My child’s mother or guardian} and I are able to resolve conflicts or arguments over [NAME OF CHILD]/{my child}.
1 Strongly Agree
2 Agree
3 Disagree
4 Strongly Disagree
7 Don’t Know
8 Decline to Answer
Module J: Child Support
The next few questions are about support you provide for your children. As a reminder, none of your responses from this survey will be shared with program staff or government agencies.
J1. Are you required by a court or state agency to pay child support for any children?
1 Yes
2 No [SKIP TO J10]
7 Don’t Know [SKIP TO J10]
8 Decline to Answer [SKIP TO J10]
J2. How many children are you required to pay child support for? Include any children for whom you are required to pay arrears or make back payments.
____________________
NUMBER OF CHILDREN (RANGE = DISPLAY DROP DOWN MENU WITH OPTIONS 0 TO #KIDS; IF #KIDS=97, DROP DOWN SHOULD DISPLAY 0 TO 20)
97 Don’t Know
98 Decline to Answer
J3. What is the amount of your regularly scheduled required payment through the child support system?
$ ___ ___ , ___ ___ ___ . ___ ___
AMOUNT PAID (RANGE 1 to 9,999.95)
9999.97 Don’t Know [SKIP TO J5]
9999.98 Decline to Answer [SKIP TO J5]
J4. Is that…
1 per week [SKIP TO J5]
2 every other week [SKIP TO J5]
3 per month, or [SKIP TO J5]
4 some other time period
7 Don’t Know [SKIP TO J5]
8 Decline to Answer [SKIP TO J5]
J4a. Please describe what the time period is for the amount you mentioned.
_______________
VERBATIM
7 Don’t Know
8 Decline to Answer
J5. Last month, did you pay the full amount of the payment ordered by the court or state agency?
1 Yes [SKIP TO J7]
2 No
7 Don’t Know
8 Decline to Answer
J6. How much child support did you actually pay through the child support system last month?
$ ___ ___ , ___ ___ ___ . ___ ___
AMOUNT PAID (RANGE 0 to 9,999.95)
9999.97 Don’t Know
9999.98 Decline to Answer
J7. How much back child support do you owe?
1 None
2 less than $1,000
3 $1,000 to $4,999
4 $5,000 to $9,999
5 $10,000 to $14,999
6 $15,000 or more
7 Don’t Know
8 Decline to Answer
J8. In the last 6 months, has the state decreased the amount of back child support that you owe?
1 Yes
2 No
3 I did not owe any back child support in the past 6 months.
7 Don’t Know
8 Decline to Answer
J9. In the past 6 months, did your regularly scheduled child support payment amount go up, stay the same, or go down?
1 Amount went up
2 Amount stayed the same
3 Amount went down
7 Don't Know
8 Decline to Answer
J10. Do you have any children, of any age, who don’t live with you all of the time?
1 Yes
2 No [SKIP TO J14]
7 Don’t Know [SKIP TO J14]
8 Decline to Answer [SKIP TO J14]
J11. Not counting any child support required by a court, in the past 30 days did you provide cash for any of your children that do not live with you all of the time?
1 Yes
2 No [SKIP TO J14]
7 Don’t Know [SKIP TO J14]
8 Decline to Answer [SKIP TO J14]
J12. Not counting any child support required by a court, in the past 30 days, approximately how much cash did you provide?
$ ___ ___ , ___ ___ ___ . ___ ___
AMOUNT (RANGE: 0 to 9,999.95)
9999.97 Don’t Know
9999.98 Decline to Answer
[IF #KIDS IS = 1, THEN SKIP TO J14.]
J13. How many children did this cover?
______________________
NUMBER OF CHILDREN (RANGE = DISPLAY DROP DOWN MENU WITH OPTIONS 0 TO #KIDS; IF #KIDS=97, DROP DOWN SHOULD DISPLAY 0 TO 20)
97 Don’t Know
98 Decline to Answer
[IF C3 = 1 YES THEN SKIP TO K1] The next set of questions are about [NAME OF CHILD] {audio should read “the same child earlier questions have asked about”}.
J14. During the past month did you buy food for [NAME OF CHILD]/{your child}?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
J15. During the past month did you purchase clothing or diapers for [NAME OF CHILD]/{your child}?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
J16. During the past month did you pay for or provide child care or babysitting for [NAME OF CHILD] /{your child}?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
J17. During the past month did you pay for medicine or health care for [NAME OF CHILD]/{your child}?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
J18. During the past month did you help with bills or payments for [NAME OF CHILD]/{your child}?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
J19. During the past month did you buy toys, books, or school supplies for [NAME OF CHILD]/{your child}?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
J20. During the past month did you pay for or provide help with transportation to daycare, school, appointments, or other activities for [NAME OF CHILD]/{your child}?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
Module K: Employment
The next questions are about employment, any experiences you may have had with being incarcerated, and some other challenges you may have faced.
K1. Have you ever worked for the same employer for 6 or more months?
1 Yes
2 No [SKIP TO K2]
7 Don’t Know [SKIP TO K2]
8 Decline to Answer [SKIP TO K2]
K1a. Were you working at this job within the last year?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
K2. In the last month, how often did you have problems getting a job, showing up to work, or keeping a job because of your alcohol or drug use?
1 Often
2 Sometimes
3 Rarely
4 Never
7 Don’t Know
8 Decline to Answer
K3. In the last month, how often did you have problems getting along with family or friends because of your alcohol or drug use?
1 Often
2 Sometimes
3 Rarely
4 Never
7 Don’t Know
8 Decline to Answer
K4. Have you ever been convicted of a crime? Please consider both juvenile and adult convictions.
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
K5. Have you ever been incarcerated in prison or jail?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
K6. Would you say that your income…
1 Stays the same each month
2 Varies a little month by month
3 Varies a lot month by month
7 Don’t Know
8 Decline to Answer
K7. In the last 6 months, for about how many months did you have no income?
1 Zero months
2 One or two months
3 Three months or more
7 Don’t Know
8 Decline to Answer
K8. In the last 6 months, about how many months did you run out of money between paychecks, or before the end of the month?
1 Zero months [SKIP TO L1]
2 One or two months
3 Three months or more
7 Don’t Know
8 Decline to Answer
K9. What was the main reason why you ran out of money? Please select one answer.
1 You were unemployed [SKIP TO L1]
2 You couldn’t get enough hours of work from your employer [SKIP TO L1]
3 You had a reduction or termination of benefits (like Unemployment Insurance or disability) [SKIP TO L1]
4 You had a large bill or other expense to pay [SKIP TO L1]
5 You helped a family member or friend [SKIP TO L1]
6 Some other reason
7 Don’t Know [SKIP TO L1]
8 Decline to Answer [SKIP TO L1]
K9a. Please describe the reason you ran out of money in your own words.
_______________
VERBATIM
7 Don’t Know
8 Decline to Answer
Module L: Cognitive and Behavioral
Below are a number of questions that address how people perceive stress. For each question, please indicate how often you felt that way in the last month.
L1. In the last month, how often have you been upset because of something that happened unexpectedly?
1 Never
2 Almost Never
3 Sometimes
4 Fairly Often
5 Very Often
7 Don’t Know
8 Decline to Answer
L2. In the last month, how often have you felt that you were unable to control the important things in your life?
1 Never
2 Almost Never
3 Sometimes
4 Fairly Often
5 Very Often
7 Don’t Know
8 Decline to Answer
L3. In the last month, how often have you felt nervous and "stressed"?
1 Never
2 Almost Never
3 Sometimes
4 Fairly Often
5 Very Often
7 Don’t Know
8 Decline to Answer
L4. In the last month, how often have you felt confident about your ability to handle your personal problems?
1 Never
2 Almost Never
3 Sometimes
4 Fairly Often
5 Very Often
7 Don’t Know
8 Decline to Answer
L5. In the last month, how often have you felt that things were going your way?
1 Never
2 Almost Never
3 Sometimes
4 Fairly Often
5 Very Often
7 Don’t Know
8 Decline to Answer
L6. In the last month, how often have you found that you could not cope with all the things that you had to do?
1 Never
2 Almost Never
3 Sometimes
4 Fairly Often
5 Very Often
7 Don’t Know
8 Decline to Answer
L7. In the last month, how often have you been able to control irritations in your life?
1 Never
2 Almost Never
3 Sometimes
4 Fairly Often
5 Very Often
7 Don’t Know
8 Decline to Answer
L8. In the last month, how often have you felt that you were on top of things?
1 Never
2 Almost Never
3 Sometimes
4 Fairly Often
5 Very Often
7 Don’t Know
8 Decline to Answer
L9. In the last month, how often have you been angered because of things that were outside of your control?
1 Never
2 Almost Never
3 Sometimes
4 Fairly Often
5 Very Often
7 Don’t Know
8 Decline to Answer
L10. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?
1 Never
2 Almost Never
3 Sometimes
4 Fairly Often
5 Very Often
7 Don’t Know
8 Decline to Answer
L11. How would you rate the amount of control you have over your work or your ability to find work these days?
1
1 No control at all
2 Very little control
3 Some control
4 A lot of control
7 Don’t Know
8 Decline to Answer
L12. How would you rate the amount of control you have over your financial situation these days?
1 No control at all
2 Very little control
3 Some control
4 A lot of control
7 Don’t Know
8 Decline to Answer
END
Exit
Thank you very much for participating in this survey. A staff member will give you your $25 gift card today. Thank you again and have a good day.
Please let the staff know that you are finished with this survey.
POST INTERVIEW
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Emily Brennan |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |
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