8 & 9 - Baseline surveys
Building Bridges and Bonds (B3)
9 - Baseline Survey for Sites Testing Employment Intervention
8 & 9 - Baseline surveys
OMB: 0970-0485
9 - Baseline Survey for Sites Testing Employment 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
SITE
Program Sites:
21. Fortune Society - NYC
22. Kanawha Institute for Social Research (KISRA) – Dunbar, WV
23. Ohio Department of Job and Family Services – Passages, Inc. – Cleveland, OH
Site Program Names (Inserts for A1):
21. Parenting, Healthy relationship or Employment services received at Fortune Society
22. West Virginia ReForm Initiative
23. Jobs for Dads
Building Bridges and Bonds
Enrollment Survey
OMB Control No.: xxxx-xxxx
Expiration Date: xx/xx/201x
[BEGIN SURVEY USING AUDIO AND TEXT DISPLAY]
INTRO1:
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
INTRO2:
Thank you for your help with this important study. The survey asks questions about your employment, financial well-being, parenting and co-parenting relationships, involvement with the criminal justice system, and child support. It also asks your thoughts and opinions about how to handle various situations. 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?
[NAME]
1 Yes
2 No [SKIP TO FAIL_SCREENER]
S2.
Is this your date of birth?
[DOB]
1 Yes [SKIP TO CONTINUE]
2 No
FAIL_SCREENER
IF S1=2 OR S2=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 [SITE PROGRAM NAME], 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
4 Help relating well to other people
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 A6]
7 Don’t Know [SKIP TO A6]
8 Decline to Answer [SKIP TO A6]
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 service 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. How interested are you in participating in services related to parenting your child or children in the next 12 months?
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: Employment
B1. Do you currently have a job? This includes permanent full-time or part-time jobs, or temporary, transitional or seasonal jobs.
1 Yes [SKIP TO B3]
2 No
7 Don’t Know
8 Decline to Answer
B2. Just to be sure, have you done any work in the past 2 weeks for pay? This could be any work that was paid for in cash, or work done in exchange for meals, clothing, a place to live, or something else. It could be on-the-books or off-the-books work, self-employment, temporary work, work as a day laborer, or working side jobs.
1 Yes
2 No [SKIP TO B20]
7 Don’t Know [SKIP TO B20]
8 Decline to Answer [SKIP TO B20]
B3. How many jobs do you currently have? This includes permanent full-time or part-time jobs, temporary, transitional, or seasonal jobs, any other work that was paid for in cash, or work done in exchange for meals, clothing, a place to live, or something else.
_________________
NUMBER OF JOBS (RANGE: 1- 10)
97 Don’t Know
98 Decline to Answer
B4. IF NUMBER OF JOBS IN B3 = 1, SKIP TO B7
Thinking of all your current jobs, how many hours did you usually work per week in the last month? Please consider all hours, including any extra hours, overtime, work you did at home, and so forth.
__________________________
NUMBER OF HOURS (RANGE: 1 to 80)
97 Don’t Know
98 Decline to Answer
B5.How much did you earn from all of these jobs in the last week? Please include regular pay, tips, commissions, and overtime pay.
$ ___ ___ , ___ ___ ___ . ___ ___
AMOUNT (RANGE: .01-to 99,999.94) [SKIP TO B6]
99999.96 Work done in exchange for meals, clothing, a place to live, or something else
[SKIP TO B7]
99999.97 Don’t Know
99999.98 Decline to Answer
B5a. In the last week, did you earn ...
1 $1 to $99
2 $100 to $249
3 $250 to $499
4 $500 to $749
5 $750 to $999
6 $1,000 or more
7 Don’t Know [SKIP TO B7]
8 Decline to Answer [SKIP TO B7]
B6. Was that…
1 before taxes, or
2 after taxes
7 Don’t Know
8 Decline to Answer
B7. IF B3 >1 OR B3 = DON’T KNOW, DECLINE TO ANSWER, READ/DISPLAY VERSION 1. ELSE READ/DISPLAY VERSION 2.
VERSION 1: Now please think about the job where you worked the most hours in the past 2 weeks. What is the name of this employer? We will not contact your employer.
VERSION 2: What is your employer’s name? We will not contact your employer.
_______________________
NAME OF EMPLOYER
96 Self Employed
97 Don’t Know
98 Decline to Answer
B8. IF B3 = DON’T KNOW, DECLINE TO ANSWER, READ/DISPLAY VERSION 1. ELSE READ/DISPLAY VERSION 2.
VERSION 1: I’d like to ask you some questions about the job that you worked at for the most hours in the last two weeks. When did this job start? Please provide the month and year for when the job started.
VERSION 2: I’d like to ask you some questions about that job. When did this job start? Please provide the month and year for when the job started.
IF RESPONDENT ENTERS A MONTH AND YEAR, SKIP TO B9.
IF RESPONDENT DOES NOT ENTER A MONTH BUT DOES ENTER A YEAR, GO TO B8a.
IF RESPONDENT ENTERS A MONTH BUT NO YEAR, SKIP TO B9.
IF RESPONDENT DOES NOT ENTER A MONTH OR A YEAR, DISPLAY “DON’T KNOW” AND “DECLINE TO ANSWER” OPTIONS.
________________________ MM (RANGE: 1-12)
________________________ YYYY (RANGE: 1950-current year)
97/9997 Don’t Know
98/9998 Decline to Answer
B8a. Did you start this job in winter, spring, summer or fall of [INSERT YEAR FROM B8] {that year}?
13 Winter
14 Spring
15 Summer
16 Fall
97 Don’t Know
98 Decline to Answer
B9. Which of the following best describes this work? Is it…
1 a permanent job [SKIP TO B9b]
2 a temporary, transitional, or seasonal job that is not permanent [SKIP TO B9b]
3 a series of day labor or odd jobs (work where you have to find new jobs on a regular basis in order to get paid), or [SKIP TO B9b]
4 something else
7 Don’t Know [SKIP TO B9b]
8 Decline to Answer [SKIP TO B9b]
B9a. Please describe what type of work this is in your own words.
_______________
TYPE OF JOB
7 Don’t Know
8 Decline to Answer
B9b. SKIP IF B7 = 96.
Are you self-employed or do you own your own business?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
B10. Are taxes deducted from your pay for this job?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
B11. Is this job…
1 full-time work (which means 35 hours or more per week)
2 part time work (which means less than 35 hours per week)
3 work where the hours vary substantially from week to week
7 Don’t Know
8 Decline to Answer
B12. In the last month, how many hours did you usually work per week at this job? Please consider all hours, including any extra hours, overtime, work you did at home, and so forth. Please do not include weeks in which you missed work because of illness or vacation. If you have worked for less than one month, please think of the hours in the weeks you have worked so far.
__________________________
NUMBER OF HOURS (RANGE: 1 to 80)
97 Don’t Know
98 Decline to Answer
B13. How are you paid for this work? Is it…
1 by check or direct deposit [SKIP TO B14]
2 in cash [SKIP TO B14]
3 done in exchange for meals, or clothing, or a place to live, or [SKIP TO B14]
4 in some other way
7 Don’t Know [SKIP TO B14]
8 Decline to Answer [SKIP TO B14]
B13a. Please describe how you are paid for this work.
_______________
HOW PAID FOR WORK7 Don’t Know
8 Decline to Answer
B14. Which of the following best describes your employer? Your employer is the company, program or individual who hired you to do this work and who pays you for this work. Please mark all that apply. Is your employer…
1 a staffing or temp agency [SKIP TO B15]
2 an employment or fatherhood program [SKIP TO B15]
3 the company or individual the work is being done for [SKIP TO B15]
4 someone else
7 Don’t Know [SKIP TO B15]
8 Decline to Answer [SKIP TO B15]
B14a. Please describe the type of employer you have in your own words.
_______________
DESCRIPTION OF EMPLOYER
7 Don’t Know
8 Decline to Answer
B15. How did you get this job? Did you…
1 apply for a job at a company or program that you work for, [SKIP TO B16]
2 apply for work at a staffing or temp agency, [SKIP TO B16]
3 show up to a location where people come to look for workers that can help with a particular job, or [SKIP TO B16]
4 do something else?
7 Don’t Know [SKIP TO B16]
8 Decline to Answer [SKIP TO B16]
B15a. Please describe how you got this job in your own words.
_______________
HOW YOU GOT JOB7 Don’t Know
8 Decline to Answer
B16. SKIP TO B18 IF B13 = 3 OR 4.
How much did you earn from this job in the last week? Please include regular pay, tips, commissions, and overtime pay.
$ ___ ___ , ___ ___ ___ . ___ ___
AMOUNT (RANGE: .01-to 99,999.94) [SKIP TO B17]
99999.97 Don’t Know
99999.98 Decline to Answer
B16a. In the last week, did you earn ...
1 $1 to $99
2 $100 to $249
3 $250 to $499
4 $500 to $749
5 $750 to $999
6 $1,000 or more
7 Don’t Know [SKIP TO B18]
8 Decline to Answer [SKIP TO B18]
B17. Was that …
1 before taxes, or
2 after taxes
7 Don’t Know
8 Decline to Answer
B18.Some employers offer health insurance for their employees, but sometimes workers don’t participate or receive health coverage due to cost or other reasons. For this job, would you say:
1 no health insurance is available
2 health insurance is available, but you don’t participate, or
3 you are covered by health insurance made available by your employer
7 Don’t Know
8 Decline to Answer
B19.Which of the following other benefits are available to you on your job?
B19a. Does your job offer sick days with full pay?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
B19b. Does your job offer paid vacation?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
B19c. Does your job offer paid holidays?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
B19d. Does your job offer dental benefits, including any offered at a cost to you?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
B19e. Does your job offer a retirement or 401K plan?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
B19f. Does your job offer tuition reimbursement?
1 Yes [SKIP TO B35]
2 No [SKIP TO B35]
7 Don’t Know [SKIP TO B35]
8 Decline to Answer [SKIP TO B35]
B20. Have you ever had a job or done any work for pay?
1 Yes
2 No [SKIP TO B37]
7 Don’t Know [SKIP TO B37]
8 Decline to Answer [SKIP TO B37]
B21. I’d like to ask you some questions about the job that ended most recently. When did this job end?
IF RESPONDENT ENTERS A MONTH AND YEAR, SKIP TO B22.
IF RESPONDENT DOES NOT ENTER A MONTH BUT DOES ENTER A YEAR, GO TO B21a.
IF RESPONDENT ENTERS A MONTH BUT NO YEAR, SKIP TO B22.
IF RESPONDENT DOES NOT ENTER A MONTH OR A YEAR, DISPLAY “DON’T KNOW” AND “DECLINE TO ANSWER” OPTIONS.
_________________ MM (RANGE: 1-12)
_________________ YYYY (RANGE: 1950-current year)
97/9997 Don’t Know
98/9998 Decline to Answer
B21a. Did this job end in winter, spring, summer or fall of [INSERT YEAR FROM B21]/{that year}?
13 Winter
14 Spring
15 Summer
16 Fall
97 Don’t Know
98 Decline to Answer
B22. When did this job start? Please provide the month and year for when the job started.
IF RESPONDENT ENTERS A MONTH AND YEAR, SKIP TO B23.
IF RESPONDENT DOES NOT ENTER A MONTH BUT DOES ENTER A YEAR, GO TO B22a.
IF RESPONDENT ENTERS A MONTH BUT NO YEAR, SKIP TO B23.
IF RESPONDENT DOES NOT ENTER A MONTH OR A YEAR, DISPLAY “DON’T KNOW” AND “DECLINE TO ANSWER” OPTIONS.
___________________________ MM (RANGE: 1-12)
___________________________ YYYY (RANGE: 1950-current year)
97/9997 Don’t Know
98/9998 Decline to Answer
B22a. Did you start this job in winter, spring, summer or fall of [INSERT YEAR FROM B22]/{that year}?
13 Winter
14 Spring
15 Summer
16 Fall
97 Don’t Know
98 Decline to Answer
B23. What was the name of your employer? We will not contact your employer.
_____________________________
NAME OF EMPLOYER
96 Self Employed
97 Don’t Know
98 Decline to Answer
B24. Which of the following best describes this work? Was it…
1 a permanent job [SKIP TO B24b]
2 a temporary, transitional, or seasonal job that was not permanent [SKIP TO B24b]
3 a series of day labor or odd jobs (work where you had to find new jobs on a regular basis in order to get paid), or [SKIP TO B24b]
4 something else
7 Don’t Know [SKIP TO B24b]
8 Decline to Answer [SKIP TO B24b]
B24a. Please describe what type of work this was in your own words.
_______________
TYPE OF JOB
7 Don’t Know
8 Decline to Answer
B24b. SKIP IF B23 = 96.
Were you self-employed or did you own your own business?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
B25. Were taxes deducted from your pay for this job?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
B26. Was this job…
1 full-time work (which means 35 hours or more per week)
2 part time work (which means less than 35 hours per week)
3 work where the hours varied substantially from week to week
7 Don’t Know
8 Decline to Answer
B27. In the last month you worked at this job, how many hours per week did you usually work at this job? Please consider all hours, including any extra hours, overtime, work you did at home, and so forth. Please do not include weeks in which you missed work because of illness or vacation. If you worked at this job for less than a month, please think of the hours per week when you were there.
__________________________
NUMBER OF HOURS (RANGE: 1 to 80)
97 Don’t Know
98 Decline to Answer
B28. How were you paid for this work? Was it…
1 by check or direct deposit [SKIP TO B29]
2 in cash [SKIP TO B29]
3 done in exchange for meals, or clothing, or a place to live, or [SKIP TO B29]
4 in some other way
7 Don’t Know [SKIP TO B29]
8 Decline to Answer [SKIP TO B29]
B28a. Please describe how you were paid for this work.
_______________
HOW PAID FOR WORK7 Don’t Know
8 Decline to Answer
B29. Which of the following best describes your employer? Your employer is the company, program or individual who hired you to do this work and who paid you for this work. Please mark all that apply. Was your employer…
1 a staffing or temp agency [SKIP TO B30]
2 an employment or fatherhood program [SKIP TO B30]
3 the company or individual the work was being done for [SKIP TO B30]
4 someone else
7 Don’t Know [SKIP TO B30]
8 Decline to Answer [SKIP TO B30]
B29a. Please describe the type of employer you had in your own words.
_______________
DESCRIPTION OF EMPLOYER
7 Don’t Know
8 Decline to Answer
B30. How did you get this job? Did you…
1 apply for a job at a company or program that you work for, [SKIP TO B31]
2 apply for work at a staffing or temp agency, [SKIP TO B31]
3 show up to a location where people come to look for workers that can help with a particular job, or [SKIP TO B31]
4 do something else?
7 Don’t Know [SKIP TO B31]
8 Decline to Answer [SKIP TO B31]
B30a. Please describe how you got this job in your own words.
_______________
HOW YOU GOT JOB
7 Don’t Know
8 Decline to Answer
B31. SKIP TO B33 IF B28 = 3 OR 4.
How much did you earn from this job in the last week you worked at this job? Please include regular pay, tips, commissions, and overtime pay.
$ ___ ___ , ___ ___ ___ . ___ ___
AMOUNT (RANGE: .01-to 99,999.94) [SKIP TO B32]
99999.97 Don’t Know
99999.98 Decline to Answer
B31a. In the last week you worked there, did you earn ...
1 $1 to $99
2 $100 to $249
3 $250 to $499
4 $500 to $749
5 $750 to $999
6 $1,000 or more
7 Don’t Know [SKIP TO B33]
8 Decline to Answer [SKIP TO B33]
B32. Was that …
1 before taxes, or
2 after taxes?
7 Don’t Know
8 Decline to Answer
B33.Some employers offer health insurance for their employees, but sometimes workers don’t participate or receive health coverage due to cost or other reasons. For this job, would you say:
1 no health insurance was available
2 health insurance was available, but you didn’t participate, or
3 you were covered by health insurance made available by your employer
7 Don’t Know
8 Decline to Answer
B34.Which of the following other benefits were available to you on your job?
B34a. Did your job offer sick days with full pay?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
B34b. Did your job offer paid vacation?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
B34c. Did your job offer paid holidays?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
B34d. Did your job offer dental benefits, including any offered at a cost to you?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
B34e. Did your job offer a retirement or 401K plan?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
B34f. Did your job offer tuition reimbursement?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
B35. In total, how much did you work in the last three years?
1 did not work
2 less than 6 months
3 7-12 months
4 13-24 months
5 more than 24 months
7 Don’t Know
8 Decline to Answer
B36. Have you ever worked for the same employer for 6 or more months?
1 Yes
2 No [SKIP TO B37]
7 Don’t Know [SKIP TO B37]
8 Decline to Answer [SKIP TO B37]
B36a. Were you working at this job within the last year?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
B37. Are you currently looking for a job?
1 Yes
2 No [SKIP TO B39]
7 Don’t Know [SKIP TO B39]
8 Decline to Answer [SKIP TO B39]
B38. How long have you been looking for a job? Would you say:
1 Less than a week [SKIP TO C1]
2 More than a week, but less than a month; [SKIP TO C1]
3 Between a month and six months [SKIP TO C1]
4 Longer than six months [SKIP TO C1]
7 Don’t Know [SKIP TO C1]
8 Decline to Answer [SKIP TO C1]
B39. Why aren’t you looking for a job? Please mark all that apply.
1 You own a business [SKIP TO C1]
2 You already have a job [SKIP TO C1]
3 You’re on vacation [SKIP TO C1]
4 Due to illness [SKIP TO C1]
5 Due to a temporary layoff [SKIP TO C1]
6 You’re in school or a training program [SKIP TO C1]
7 You’re disabled [SKIP TO C1]
8 You don’t want to or need to work [SKIP TO C1]
9 You believe no work is available [SKIP TO C1]
10 You have transportation problems [SKIP TO C1]
11 You have legal issues [SKIP TO C1]
12 It doesn’t pay to work [SKIP TO C1]
13 You just found a job [SKIP TO C1]
14 Some other reason
97 Don’t Know [SKIP TO C1]
98 Decline to Answer [SKIP TO C1]
B39a. Please describe the reason you are not looking for a job.
_______________
WHY NOT LOOKING FOR JOB
7 Don’t Know
8 Decline to Answer
Module C: Criminal justice
The next few questions ask about your involvement with the criminal justice system.
C1. Have you ever been convicted of a crime? Please consider both juvenile and adult convictions.
1 Yes
2 No [SKIP TO C4]
7 Don’t Know
8 Decline to Answer
C2. Have you ever been convicted of a felony?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
C3. Have you ever been incarcerated in state or federal prison?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
C4. Have you ever been incarcerated in a local or county jail?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
C5.
IF C3 = 1 or C4 = 1:
When were you last released from prison or
jail?
IF RESPONDENT ENTERS A MONTH AND YEAR, SKIP TO C6.
IF RESPONDENT DOES NOT ENTER A MONTH BUT DOES ENTER A YEAR, GO TO C5a.
IF RESPONDENT ENTERS A MONTH BUT NO YEAR, SKIP TO C6.
IF RESPONDENT DOES NOT ENTER A MONTH OR A YEAR, DISPLAY “DON’T KNOW” AND “DECLINE TO ANSWER” OPTIONS.
__________________ MM (RANGE: 1-12)
__________________ YYYY (RANGE: 1950-current year)
97/9997 Don’t Know
98/9998 Decline to Answer
[CREATE VARIABLE THAT CALCULATES DAYS SINCE RELEASE CALLED #DAYS_SINCE_RELEASE. ASSUME THE RELEASE WAS ON THE LAST DAY OF THE MONTH. IF 97/9997 OR 98/9998 SELECTED, #DAYS_SINCE_RELEASE SHOULD BE BLANK (MISSING). IF NO YEAR GIVEN, ASSUME THE MOST RECENT OCCURANCE OF THE GIVEN MONTH.]
C5a. Were you released in winter, spring, summer or fall of [INSERT YEAR FROM C5]/{that year}?
13 Winter
14 Spring
15 Summer
16 Fall
97 Don’t Know
98 Decline to Answer
[CALCULATE DAYS SINCE RELEASE CALLED #DAYS_SINCE_RELEASE. USE THE LAST DAY OF THE FOLLOWING MONTHS FOR CALCULATION: WINTER=JANUARY (01), SPRING=APRIL (04), SUMMER=JULY (07) AND FALL=OCTOBER (10). IF 97 OR 98 SELECTED, #DAYS_SINCE_RELEASE SHOULD BE BLANK (MISSING).]
C6. IF C3 = 1 AND C4 = 1:
Was your most recent release from prison or from a local or county jail?
1 Prison
2 Local or county jail
7 Don’t Know
8 Decline to Answer
C7. IF C3 = 1 or C4 = 1, ELSE SKIP TO C8:
What is the total amount of time that you have spent in jail or prison? Don’t include time spent in halfway houses or work release centers. Is it…
1 Less than 1 month
2 1-11 months
3 1-3 years
4 4-9 years
5 10 or more years
7 Don’t Know
8 Decline to Answer
C8. IF C1 = 1:
Are you currently on community supervision, such as parole or probation?
1 Yes
2 No [SKIP TO C10]
7 Don’t Know [SKIP TO C10]
8 Decline to Answer [SKIP TO C10]
C9. IF C8 = 1:
Is it…
1 Parole [SKIP TO C10]
2 Probation [SKIP TO C10]
3 Some other type of community supervision
7 Don’t Know [SKIP TO C10]
8 Decline to Answer [SKIP TO C10]
C9a. Please describe what type of community supervision you are currently on.
_______________
TYPE OF SUPERVISION
7 Don’t Know
8 Decline to Answer
C10. IF C1 = 1:
How old were you the first time you were convicted of a crime? Please consider both juvenile and adult convictions.
__________________________
AGE OF FIRST CONVICTION (RANGE: 1 – 95)
97 Don’t Know
98 Decline to Answer
Module D: Income and Well-being
[IF #DAYS_SINCE_RELEASE < 90 AND NOT MISSING, SKIP TO MODULE E.]
Now I would like to ask you some questions about your income and challenges people sometimes face. When considering your income, please think about income from work, unemployment insurance, disability insurance, public assistance, or any other source of income you have.
D1. 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
D2. In the last 3 months, for about how many months did you have no income?
1 Zero months
2 One or two months
3 Three months
7 Don’t Know
8 Decline to Answer
D3. In the last 3 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 E1]
2 One or two months
3 Three months
7 Don’t Know
8 Decline to Answer
D4. What was the main reason why you ran out of money? Please select one answer.
1 You were unemployed [SKIP TO E1]
2 You couldn’t get enough hours of work from your employer [SKIP TO E1]
3 You had a reduction or termination of benefits (like Unemployment Insurance or disability)
[SKIP TO E1]
4 You had a large bill or other expense to pay [SKIP TO E1]
5 You helped a family member or friend [SKIP TO E1]
6 Some other reason
7 Don’t Know [SKIP TO E1]
8 Decline to Answer [SKIP TO E1]
D4a. Please describe the reason you ran out of money in your own words.
_______________
WHY RAN OUT OF MONEY
7 Don’t Know
8 Decline to Answer
Module E: Cognitive and Behavioral
Below are a number of statements that describe traits and tendancies that people have. For each statement, please indicate how how often the statement applies to you. Some of these questions are tricky to answer; please just do your best.
E1. I finish what I set out to do by the end of the day.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E2. I am good at guessing how long it takes to do something.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E3. I am on time for appointments and activities.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E4. I have a clear plan in mind for what I need to do each day.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E5. I focus on the most important things when I have a lot to do.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E6. I break big tasks down into smaller tasks and set deadlines to get everything done.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E7. I listen before I draw conclusions.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E8. I think before I speak.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E9. I get all the facts before I take action.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E10. I do what I am supposed to do, even if I get frustrated.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E11. I keep my cool, even if my feelings are hurt.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E12. Even in frustrating or annoying situations, I can control my temper.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E13. I can review a past situation to see how I could improve in the future.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E14. I know when I am doing a good job.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E15. I easily recognize when a job is a good match for my skills.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E16. I stay focused on what I am doing.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E17. I keep working until the job is done.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E18. If I am interrupted, I find it easy to get back on track and complete what I started.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E19. I am driven to meet my goals.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E20. I give up short-term pleasures to work on long-term goals.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E21. I set goals and I perform to my best ability.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E22. I have a good memory for facts, dates and details.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E23. I am very good at remembering the things I am supposed to do.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E24. I set reminders to get things done.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
The next couple of questions are about substance use.
E25. 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 Never
2 Rarely
3 Sometimes
4 Often
7 Don’t Know
8 Decline to Answer
E26. In the last month, how often did you have problems getting along with family or friends because of your alcohol or drug use?
1 Never
2 Rarely
3 Sometimes
4 Often
7 Don’t Know
8 Decline to Answer
There are many things that can cause stress in your life such as loss of a job, problems at work, problems with the law, conflicts with your child or co-parent, conflicts with your landlord or people you live with, or something else. The next set of questions ask what you've been doing to cope with a problem you have faced recently. Please think about a recent stressful situation you experienced and tell us how much you did each of these things.
E27. Did you think about a plan for what you could do to change the situation?
1 I didn’t do this at all
2 I did this a little bit
3 I did this a lot
7 Don’t Know
8 Decline to Answer
E28. Did you get help or advice from other people about what to do?
1 I didn’t do this at all
2 I did this a little bit
3 I did this a lot
7 Don’t Know
8 Decline to Answer
E29. Did you try to see the situation in a different way, to make it seem more positive?
1 I didn’t do this at all
2 I did this a little bit
3 I did this a lot
7 Don’t Know
8 Decline to Answer
E30. Did you think about a strategy or steps to take about the situation?
1 I didn’t do this at all
2 I did this a little bit
3 I did this a lot
7 Don’t Know
8 Decline to Answer
E31. Did you get comfort and understanding from someone about the situation?
1 I didn’t do this at all
2 I did this a little bit
3 I did this a lot
7 Don’t Know
8 Decline to Answer
E32. Did you blame others for what happened?
1 I didn’t do this at all
2 I did this a little bit
3 I did this a lot
7 Don’t Know
8 Decline to Answer
E33. Did you take action to make the situation better?
1 I didn’t do this at all
2 I did this a little bit
3 I did this a lot
7 Don’t Know
8 Decline to Answer
E34. Overall, how well did you maintain self-control in this situation, on a scale from 1 to 5 with 1 being not at all well and 5 being very well:
1 2 3 4 5
Not at all well Very Well
7 Don’t Know
8 Decline to Answer
E35. What type of stressful situation were you thinking about in your responses to the previous questions?
1 Problems at work/with supervisor [SKIP TO E36]
2 Problems with the law [SKIP TO E36]
3 Conflicts with co-parent [SKIP TO E36]
4 Conflicts/issues with child [SKIP TO E36]
5 Conflicts with landlord or people you live with [SKIP TO E36]
6 Something else
7 Don’t Know [SKIP TO E36]
8 Decline to Answer [SKIP TO E36]
E35a. Please describe what type of stressful situation you were thinking about.
_______________
TYPE OF SITUATION
7 Don’t Know
8 Decline to Answer
E36. In the past month, how often did you experience situations or conflicts with others that caused you stress such as problems at work, problems with the law, conflicts with a co-parent or child, conflicts with your landlord or people you live with, or anything else that caused you stress?
1 Never
2 Rarely
3 Sometimes
4 Often
7 Don’t Know
8 Decline to Answer
The next set of statements describe different ways people act and think. For each statement, try to think about how often the statement is true for you.
E37. I consider how my actions will affect others.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E38. I plan ahead.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E39. I think about what may happen as a result of my actions.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E40. It is hard for me to make decisions.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E41. I think of several different ways to solve a problem.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E42. I analyze problems by looking at all the choices.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E43. I make decisions without thinking about consequences.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E44. I make good decisions.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E45. I think about what causes my current problems.
1 Rarely
2 Sometimes
3 Often
7 Don’t Know
8 Decline to Answer
E46. How would you rate the amount of control you have over your work or your ability to find work 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
E47. 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
Module F: 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.
F1. Are you required by a court or state agency to pay child support for any children?
1 Yes
2 No [SKIP TO F10]
7 Don’t Know [SKIP TO F10]
8 Decline to Answer [SKIP TO F10]
F2. 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 = 1-20)
97 Don’t Know
98 Decline to Answer
F3. What is the amount of your regularly scheduled required payment through the child support system?
$ ___ , ___ ___ ___ . ___ ___
AMOUNT OWED (RANGE: 1 to 9,999.95)
9999.97 Don’t Know [SKIP TO F5]
9999.98 Decline to Answer [SKIP TO F5]
F4. Is that…
1 per week [SKIP TO F5]
2 every other week [SKIP TO F5]
3 per month, or [SKIP TO F5]
4 some other time period
7 Don’t Know [SKIP TO F5]
8 Decline to Answer [SKIP TO F5]
F4a. Please describe what the time period is for the amount you mentioned.
_______________
7 Don’t Know
8 Decline to Answer
F5. Last month, did you pay the full amount of the payment ordered by the court or state agency?
1 Yes [SKIP TO F7]
2 No
7 Don’t Know
8 Decline to Answer
F6. 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
F7. 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
F8. In the past 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
F9. 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
F10. Do you have any children, of any age, who don’t live with you all of the time?
1 Yes
2 No [SKIP TO G1]
7 Don’t Know [SKIP TO G1]
8 Decline to Answer [SKIP TO G1]
F11. 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 F14]
7 Don’t Know [SKIP TO F14]
8 Decline to Answer [SKIP TO F14]
F12. 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
F13. How many children did this cover?
______________________
NUMBER OF CHILDREN (RANGE: 1-20)
97 Don’t Know
98 Decline to Answer
F14. During the past month did you buy food for any of your children that do not live with you all of the time?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
F15. During the past month did you purchase clothing or diapers for any of your children that do not live with you all of the time?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
F16. During the past month did you pay for or provide child care or babysitting for any of your children that do not live with you all of the time?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
F17. During the past month did you pay for medicine or health care for any of your children that do not live with you all of the time?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
F18. During the past month did you help with bills or payments for any of your children that do not live with you all of the time?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
F19. During the past month did you buy toys, books, or school supplies for any of your children that do not live with you all of the time?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
F20. During the past month did you pay for or provide help with transportation to daycare, school, appointments, or other activities for any of your children that do not live with you all of the time?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
Module G: Parenting
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 G1A, G1B, G1C, G1D]
G1a.How many children do you have between 0 and 4 years of age?
___________
NUMBER OF CHILDREN
97 Don’t Know
98 Decline to Answer
G1b. How many children do you have between 5 and 9 years of age?
___________
NUMBER OF CHILDREN
97 Don’t Know
98 Decline to Answer
G1c. How many children do you have between 10 and 17 years of age?
___________
NUMBER OF CHILDREN
97 Don’t Know
98 Decline to Answer
G1d. 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 G1A THROUGH G1C CALLED #MINORKIDS. CREATE VARIABLE THAT ADDS UP RESPONSES FOR G1A THROUGH G1D CALLED #KIDS.]
G2. How many of your kids have you seen in person in the last 30 days?
[DISPLAY DROP DOWN MENU WITH OPTIONS 0 TO #KIDS]
G3. 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 > 1, THEN GO TO G4. ELSE SKIP TO G6a.]
G4. Do all of these children have the same mother?
1 Yes [SKIP TO G6a]
2 No
7 Don’t Know [SKIP TO G6a]
8 Decline to Answer [SKIP TO G6a]
G5. How many different mothers do these children have?
____________________
NUMBER OF MOTHERS [RANGE: 1 TO #KIDS]
97 Don’t Know
98 Decline to Answer
[IF #MINORKIDS = 0, THEN SKIP TO END]
[IF #MINORKIDS > 1, THEN SKIP TO G6B]
G6a. What is the name of your child?
_____________________________
NAME OF CHILD [SKIP TO G7]
7 Don’t Know
8 Decline to Answer
G6a1. Please enter the initials of your child. Giving the initials of your child will help the interviewer ask questions about the same child the next time we talk to you.
_____________________________
INITIALS OF CHILD [SKIP TO G7]
7 Don’t Know [SKIP TO G7]
8 Decline to Answer [SKIP TO G7]
G6b. What is the name of your youngest child?
_____________________________
NAME OF YOUNGEST CHILD [SKIP TO G7]
7 Don’t Know
8 Decline to Answer
G6b1. Please enter the initials of your youngest child. Giving the initials of your child will help the interviewer ask questions about the same child the next time we talk to you.
_____________________________
INITIALS OF YOUNGEST CHILD
7 Don’t Know
8 Decline to Answer
[IN THE REMAINDER OF THIS SECTION, THE NAME OF THE YOUNGEST 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. IF THE REPONDENT REFUSED TO GIVE THE NAME OF HIS CHILD ((G6A = 7 OR 8 AND G6A1 = 7 OR 8) OR (G6B = 7 OR 8 AND G6B1 = 7 OR 8) THEN THE TEXT IN THE CURLY BRACKETS SHOULD APPEAR ON THE SCREEN.]
[IF (G6A1 = 7 OR 8) OR (G6B1 = 7 OR 8) AND #KIDS > 1 THEN READ: “The next series of questions are about your relationship with your youngest child. Please think about your youngest child when answering these questions.”
IF (G6A1 = 7 OR 8) OR (G6B1 = 7 OR 8) AND #KIDS = 1 THEN READ: “The next series of questions are about your relationship with your child.
ELSE READ: The next series of questions are about your relationship with [NAME OF CHILD]/{your child that you just named}.]
[IF AUDIO “ON” AND G6b OR G6b1 ARE NOT MISSING, 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 if you provided it.]
G7. Is [NAME OF CHILD]/{your child} male or female?
1 Male
2 Female
7 Don’t Know
8 Decline to Answer
G8. How old is [NAME OF CHILD]/{your child}?
___________________
AGE (RANGE 1-21)
97 Don’t Know
98 Decline to Answer
G8a. What is [NAME OF CHILD]/{your child}’s birth date?
___________________Month (Range 1-12)
___________________Day (Range 1-31)
___________________Year (Range 1995-Current Year)
97 Don’t Know
98 Decline to Answer
G9. Do you live with [NAME OF CHILD]’s/{your child’s} mother?
1 Yes
2 No
7 Don’t Know
8 Decline to Answer
G10. Does [NAME OF CHILD]/{your child} live with you all or most of the time?
1 Yes
2 No [SKIP TO G11]
7 Don’t Know [SKIP TO G11]
8 Decline to Answer [SKIP TO G11]
G10a. What is the name of [NAME OF CHILD]/{your child}’s mother?
_____________________________
NAME OF YOUNGEST CHILD’S MOTHER [SKIP TO G24]
7 Don’t Know
8 Decline to Answer
G10a1. What are the initials of [NAME OF CHILD]/{your child}’s mother?
_____________________________
INITIALS OF YOUNGEST CHILD’S MOTHER [SKIP TO G24]
7 Don’t Know [SKIP TO G24]
8 Decline to Answer [SKIP TO G24]
G11. Who does [NAME OF CHILD]/{your child} usually live with?
1 Biological mother
2 Grandparent(s) [SKIP TO G12b]
3 Other relative(s) [SKIP TO G12b]
4 Friend [SKIP TO G12b]
5 Foster care [SKIP TO G12b]
6 Adoptive parent [SKIP TO G12b]
7 Don’t Know [SKIP TO G12b]
8 Decline to Answer [SKIP TO G12b]
G12a. What is the name of [NAME OF CHILD]/{your child}’s mother?
_____________________________
NAME OF YOUNGEST CHILD’S MOTHER [SKIP TO G13]
7 Don’t Know
8 Decline to Answer
G12a1. What are the initials of [NAME OF CHILD]/{your child}’s mother?
_____________________________
INITIALS OF YOUNGEST CHILD’S MOTHER [SKIP TO G13]
7 Don’t Know [SKIP TO G13]
8 Decline to Answer [SKIP TO G13]
G12b. What is the name of [NAME OF CHILD]/{your child}’s legal guardian?
_____________________________
NAME OF YOUNGEST CHILD’S GUARDIAN [SKIP TO G13]
7 Don’t Know
8 Decline to Answer
G12b1. What are the initials of [NAME OF CHILD]/{your child}’s legal guardian?
_____________________________
INITIALS OF YOUNGEST CHILD’S GUARDIAN
7 Don’t Know
8 Decline to Answer
[IN THE REMAINDER OF THIS SECTION, THE MOTHER OR LEGAL GUARDIAN’S NAME WILL APPEAR ON THE SCREEN, BUT THE PRE-RECORDED VOICE WILL SAY THE TEXT IN THE CURLY BRACKETS {}. IF THE REPONDENT REFUSED TO GIVE THE NAME OF THE MOTHER OR GUARDIAN ((G12a = 97 OR 98) AND (G12a1 = 97 OR 98)) OR ((G12b = 97 OR 98) AND (G12b1 = 97 OR 98)) THEN THE TEXT IN CURLY BRACKETS SHOULD APPEAR ON THE SCREEN .]
G13. How long does it usually take for you to get to 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 40-59 minutes
5 1 to 2 hours
6 More than 2 hours
7 I have never been to my child’s current home
97 Don’t Know
98 Decline to Answer
G14. 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
G15. 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 1 – 2 months ago [SKIP TO G18]
5 3 – 6 months ago [SKIP TO G18]
6 More than 6 months ago [SKIP TO G18]
7 Don’t Know
8 Decline to Answer
G16. 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
G17. In the past 30 days, how many times 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
G18. 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
G19. Do you have shared custody of [NAME OF CHILD]/{your child}?
1 Yes
2 No
7 Don't know
8 Decline to Answer
G19a. 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
G20. IF G13 = 7, SKIP TO G21.
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 G9=YES, THEN SKIP TO G22]
G21. 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
G22. 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
G23. 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.
G23a. 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
G23b. 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
G23c. 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 G9 = YES, THEN SKIP TO G23E]
G23d. In the past month, it was hard to spend time with [NAME OF CHILD]'s/{My child’s} because their mother’s spouse or boyfriend did not want me around.
1 Often
2 Sometimes
3 Never
9 Does not apply
7 Don’t Know
8 Decline to Answer
G23e. 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 Does not apply
7 Don’t Know
8 Decline to Answer
G24. 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
G25. 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
G26. 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
G27. 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
Please answer each of the upcoming questions by indicating how strongly you agree or disagree with the idea expressed.
[If #KIDS = 1 THEN ASK G28a; ELSE IF #KIDS > 1 THEN ASK G28b]
G28a. 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
G28b. 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
G29. 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
G30. 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
G31. 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
G32. 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
G33. 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
G34. 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
G35. 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
G36. How much influence do you think you have on [NAME OF CHILD]/{your child}’s life right now?
1 A great deal
2 Somewhat
3 A little bit
4 Not at all
7 Don’t Know
8 Decline to Answer
G37. 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 Somewhat
3 A little bit
4 Not at all
7 Don’t Know
8 Decline to Answer
Module H: Co-parenting
You have reached the last section of the survey. Thank you for your time and patience. The next set of questions is about your relationship with [NAME OF MOTHER/GUARDIAN] /{your child’s mother or guardian}. [IF AUDIO “ON” AND THERE IS A NON-MISSING VALUE FOR ANY OF THE FOLLOWING: G12a, G12a1, G12b, or G12b1, 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.
H1. [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
H2. [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
H3. [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
H4. [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
H5. [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
H6. [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
H7. [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
H8. [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
H9. [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
H10. [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
H11. [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
H12. [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
H13. [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
END
Exit
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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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