Form VIB Household Rost VIB Household Rost VIB Household Roster

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Individual ID: |

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Administration Date: |

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Month
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Child’s Date of Birth: |

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Time-Point:

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Baseline

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Program Exit

Form Name: Household Roster

RPG CROSS-SITE EVALUATION
Household Roster

Individual ID: |

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A.
NOTE TO ADMINISTRATOR: BEFORE PROCEEDING, PLEASE ASK RESPONDENT THE FOLLOWING QUESTION:
Has the child participating in the study lived with you for the past 30 days or longer?
1
0

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Yes

(Please go to item #1 and complete all questions)

No

(Skip this questionnaire and instruct respondent go to the next form)

I’d like to start by asking you a few questions about yourself and then get some information about the household
where [FOCAL CHILD] lives.
A1.

First, what is your first name?

A2.

And what is your last name?

A3.

What is your date of birth?

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MONTH
DAY

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YEAR

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Individual ID: |

A4.

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Are you biologically related to [FOCAL CHILD]?
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d
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A4.1

Yes
No
Don’t know
Refused
IF YES, SAY: How are you related to [FOCAL CHILD]?
INTERVIEWER:

ALLOW RESPONDENT TO ANSWER WITHOUT PROMPT AND MARK THE
APPROPRIATE CATEGORY LISTED BELOW.

INTERVIEWER:

IF RESPONDENT HESITATES, READ THEM THE LIST OF RELATIONSHIPS.

INTERVIEWER:

IF RESPONDENT IDENTIFIES THEMSELVES AS SOMEONE NOT LISTED,
PLEASE RECORD IN THE “SPECIFY OTHER” FIELD. IF THEY SAY THEY ARE
BIOLOGICALLY RELATED (E.G. AUNT) BUT ALSO HAVE ADOPTED THE
CHILD (E.G. ADOPTIVE PARENT), THEN RECORD THIS IN THE “SPECIFY
OTHER” FIELD.

MARK ONE ONLY
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A4.2

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□
□
□
□
□
□
□

Parent
Sibling
Grandparent
Aunt/Uncle
Cousin
Other (Specify)
Don’t know
Refused

IF NO, SAY: What is your relationship to [FOCAL CHILD]?
INTERVIEWER:

ALLOW RESPONDENT TO ANSWER WITHOUT PROMPT AND MARK THE
APPROPRIATE CATEGORY LISTED BELOW.

INTERVIEWER:

IF RESPONDENT HESITATES, READ THEM THE LIST OF RELATIONSHIPS.

MARK ONE ONLY
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□
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Step-parent
Partner of parent (e.g., girlfriend, boyfriend, etc.)
Step brother/sister
Aunt/Uncle
Foster parent
Adoptive parent
Other (Specify)
Don’t know
Refused

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Individual ID: |

A5.

Are you Hispanic or Latino?
1
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d
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A6.

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□
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Yes
No
Don’t know
Refused

What is your race?
MARK ALL THAT APPLY
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American Indian/Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Another race (Specify)
Don’t know
Refused

INTERVIEWER: CODE WITHOUT ASKING RESPONDENT.
IS RESPONDENT MALE OR FEMALE?
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Male
Female
Don’t know

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Individual ID: |

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B.

B1.

What are the first names of all of the people who lived in the household with [FOCAL CHILD] at any time
within the past 30 days (even if they are not there now)?
INTERVIEWER:

RECORD EACH PERSON’S NAME IN THE FIRST COLUMN OF THE ROSTER
(SEE THE TABLE ON PAGE 5).
IF THE RESPONDENT IS HESITANT PROMPT: I don’t need their full names, initials
are fine. I just need a way to refer to them.

B2.

Is [NAME] male or female?
INTERVIEWER:

B3.

RECORD GENDER IN THE SECOND COLUMN OF THE ROSTER.

What is [NAME]’s age?
INTERVIEWER:

RECORD EACH PERSON’S AGE IN THE THIRD COLUMN OF THE ROSTER.
FOR CHILDREN YOUNGER THAN 12 MONTHS, ROUND UP TO 1 YEAR OLD.
FOR CHILDREN 12 MONTHS OR OLDER, ROUND TO THE NEAREST YEAR.
EXAMPLE: 18 MONTHS=2 YEARS.
CODE EXACT AGE IN YEARS IF GIVEN. IF DON’T KNOW/REFUSED, SAY: I just need
an estimate.

B4.

Is [NAME] biologically related to [FOCAL CHILD]?
INTERVIEWER:
B4.1

RECORD WHETHER RELATED IN THE FOURTH COLUMN OF THE ROSTER.

IF YES, SAY: How is [NAME] related to [FOCAL CHILD]?

INTERVIEWER:

RECORD EACH PERSON’S RELATIONSHIP TO THE FOCAL CHILD.
ALLOW RESPONDENT TO ANSWER WITHOUT PROMPT AND ENTER THE
APPROPRIATE CATEGORY LISTED BELOW INTO THE ROSTER.
IF RESPONDENT HESITATES, READ THEM THE LIST OF RELATIONSHIPS.

B4.2

IF NO, SAY: What is [NAME]’s relationship to [FOCAL CHILD]?

INTERVIEWER:

ALLOW RESPONDENT TO ANSWER WITHOUT PROMPT AND ENTER THE
APPROPRIATE CATEGORY LISTED BELOW INTO THE ROSTER.
IF RESPONDENT HESITATES, READ THEM THE LIST OF RELATIONSHIPS.

B5.

Is [NAME] currently living in the household or does not currently live in the household but did [NAME]
live there in the past 30 days?
INTERVIEWER:

RECORD EACH PERSON’S RESIDENT STATUS IN THE FIFTH COLUMN OF THE
ROSTER.

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Individual ID: |

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SELECT ONE RESPONSE PER ROW
B3. AGE
B1. NAME
a. NAME 1 .................

EXACT

B2. GENDER
1
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□ Male
□ Female
□ Don’t know
□ Refused

RANGE
1

10 year old

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b. NAME 2 .................

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2
d
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□ Male
□ Female
□ Don’t know
□ Refused

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6

1
2
d
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□ Male
□ Female
□ Don’t know
□ Refused

□ 11 to 18
□ 19 to 30
□ 31 to 50
□ 51 to 65
□ Older than 65?
□ Newborn to
10 year old

4

c. NAME 3 ..............

□ Newborn to

1

□ 11 to 18
□ 19 to 30
□ 31 to 50
□ 51 to 65
□ Older than 65?
□ Newborn to
10 year old

2

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□ 11 to 18
□ 19 to 30
□ 31 to 50
□ 51 to 65
□ Older than 65?

RELATIONSHIP

B4. BIOLOGICALLY
RELATED?
1
2

□ Biologically related
□ Not biologically
related

d
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□ Don’t know
□ Refused

B4.1 RELATED
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2
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□ Parent
□ Sibling (Brother/Sister)
□ Grandparent
□ Aunt/Uncle
□ Cousin
□ Other (Specify)

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d

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2

□ Biologically related
□ Not biologically
related

d
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□ Don’t know
□ Refused

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2
3
4
5
6

□ Parent
□ Sibling (Brother/Sister)
□ Grandparent
□ Aunt/Uncle
□ Cousin
□ Other (Specify)

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d

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2

□ Biologically related
□ Not biologically
related

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□ Don’t know
□ Refused

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2
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5
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□ Parent
□ Sibling (Brother/Sister)
□ Grandparent
□ Aunt/Uncle
□ Cousin
□ Other (Specify)

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B5. CURRENTLY LIVING
IN HOUSEHOLD?

B4.2 NOT RELATED

□ Step-parent
□ Partner of parent
□ Step-brother/sister
□ Aunt/Uncle
□ Foster Parent
□ Adoptive Parent
□ Other unrelated child
□ Other (Specify)
□ Don’t know
□ Refused
□ Step-parent
□ Partner of parent
□ Step-brother/sister
□ Aunt/Uncle
□ Foster Parent
□ Adoptive Parent
□ Other unrelated child
□ Other (Specify)
□ Don’t know
□ Refused
□ Step-parent
□ Partner of parent
□ Step-brother/sister
□ Aunt/Uncle
□ Foster Parent
□ Adoptive Parent
□ Other unrelated child
□ Other (Specify)
□ Don’t know
□ Refused

1

□ Currently lives in
household

2

□ Does not currently live
in household but lived
there in past 30 days

d
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1

□ Don’t know
□ Refused

□ Currently lives in
household

2

□ Does not currently live
in household but lived
there in past 30 days

d
r

1

□ Don’t know
□ Refused

□ Currently lives in
household

2

□ Does not currently live
in household but lived
there in past 30 days

d
r

□ Don’t know
□ Refused

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Individual ID: |

d. NAME 4 ..............

1
2
d
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□ Male
□ Female
□ Don’t know
□ Refused

1

10 year old

2

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4
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6

e. NAME 5 ..............

1
2
d
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□ Male
□ Female
□ Don’t know
□ Refused

1

2

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3

5
6

1
2
d
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□ Male
□ Female
□ Don’t know
□ Refused

□ 11 to 18
□ 19 to 30
□ 31 to 50
□ 51 to 65
□ Older than 65?
□ Newborn to
10 year old

4

f. NAME 6 ..............

□ Newborn to

1

□ 11 to 18
□ 19 to 30
□ 31 to 50
□ 51 to 65
□ Older than 65?
□ Newborn to
10 year old

2

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3
4
5
6

□ 11 to 18
□ 19 to 30
□ 31 to 50
□ 51 to 65
□ Older than 65?

1
2

□ Biologically related
□ Not biologically
related

d
r

□ Don’t know
□ Refused

1
2
3
4
5
6

□ Parent
□ Sibling (Brother/Sister)
□ Grandparent
□ Aunt/Uncle
□ Cousin
□ Other (Specify)

7
8
9
10
11
12
13
14

d

1
2

□ Biologically related
□ Not biologically
related

d
r

□ Don’t know
□ Refused

1
2
3
4
5
6

□ Parent
□ Sibling (Brother/Sister)
□ Grandparent
□ Aunt/Uncle
□ Cousin
□ Other (Specify)

r
7
8
9
10
11
12
13
14

d

1
2

□ Biologically related
□ Not biologically
related

d
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□ Don’t know
□ Refused

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2
3
4
5
6

□ Parent
□ Sibling (Brother/Sister)
□ Grandparent
□ Aunt/Uncle
□ Cousin
□ Other (Specify)

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□ Step-parent
□ Partner of parent
□ Step-brother/sister
□ Aunt/Uncle
□ Foster Parent
□ Adoptive Parent
□ Other unrelated child
□ Other (Specify)
□ Don’t know
□ Refused
□ Step-parent
□ Partner of parent
□ Step-brother/sister
□ Aunt/Uncle
□ Foster Parent
□ Adoptive Parent
□ Other unrelated child
□ Other (Specify)
□ Don’t know
□ Refused
□ Step-parent
□ Partner of parent
□ Step-brother/sister
□ Aunt/Uncle
□ Foster Parent
□ Adoptive Parent
□ Other unrelated child
□ Other (Specify)
□ Don’t know
□ Refused

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□ Currently lives in
household

2

□ Does not currently live
in household but lived
there in past 30 days

d
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1

□ Don’t know
□ Refused

□ Currently lives in
household

2

□ Does not currently live
in household but lived
there in past 30 days

d
r

1

□ Don’t know
□ Refused

□ Currently lives in
household

2

□ Does not currently live
in household but lived
there in past 30 days

d
r

□ Don’t know
□ Refused

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Individual ID: |

g. NAME 7 ..............

1
2
d
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□ Male
□ Female
□ Don’t know
□ Refused

1

10 year old

2

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h. NAME 8 ..............

1
2
d
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□ Male
□ Female
□ Don’t know
□ Refused

□ Newborn to

1

□ 11 to 18
□ 19 to 30
□ 31 to 50
□ 51 to 65
□ Older than 65?
□ Newborn to
10 year old

2

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3
4
5
6

□ 11 to 18
□ 19 to 30
□ 31 to 50
□ 51 to 65
□ Older than 65?

1
2

□ Biologically related
□ Not biologically
related

d
r

□ Don’t know
□ Refused

1
2
3
4
5
6

□ Parent
□ Sibling (Brother/Sister)
□ Grandparent
□ Aunt/Uncle
□ Cousin
□ Other (Specify)

7
8
9
10
11
12
13
14

d

1
2

□ Biologically related
□ Not biologically
related

d
r

□ Don’t know
□ Refused

1
2
3
4
5
6

□ Parent
□ Sibling (Brother/Sister)
□ Grandparent
□ Aunt/Uncle
□ Cousin
□ Other (Specify)

r
7
8
9
10
11
12
13
14

d
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i.

NAME 9 ..............

1
2
d
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□ Male
□ Female
□ Don’t know
□ Refused

1

□ Newborn to
10 year old

2

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3
4
5
6

□ 11 to 18
□ 19 to 30
□ 31 to 50
□ 51 to 65
□ Older than 65?

1
2

□ Biologically related
□ Not biologically
related

d
r

□ Don’t know
□ Refused

1
2
3
4
5
6

□ Parent
□ Sibling (Brother/Sister)
□ Grandparent
□ Aunt/Uncle
□ Cousin
□ Other (Specify)

7
8
9
10
11
12
13
14

d
r

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□ Step-parent
□ Partner of parent
□ Step-brother/sister
□ Aunt/Uncle
□ Foster Parent
□ Adoptive Parent
□ Other unrelated child
□ Other (Specify)
□ Don’t know
□ Refused
□ Step-parent
□ Partner of parent
□ Step-brother/sister
□ Aunt/Uncle
□ Foster Parent
□ Adoptive Parent
□ Other unrelated child
□ Other (Specify)

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□ Currently lives in
household

2

□ Does not currently live
in household but lived
there in past 30 days

d
r

1

□ Don’t know
□ Refused

□ Currently lives in
household

2

□ Does not currently live
in household but lived
there in past 30 days

d
r

□ Don’t know
□ Refused

□ Don’t know
□ Refused
□ Step-parent
□ Partner of parent
□ Step-brother/sister
□ Aunt/Uncle
□ Foster Parent
□ Adoptive Parent
□ Other unrelated child
□ Other (Specify)
□ Don’t know
□ Refused

1

□ Currently lives in
household

2

□ Does not currently live
in household but lived
there in past 30 days

d
r

□ Don’t know
□ Refused

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Individual ID: |

j.

NAME 10 ............

1
2
d
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□ Male
□ Female
□ Don’t know
□ Refused

1

10 year old

2

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3
4
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6

k. NAME 11 ............

1
2
d
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□ Male
□ Female
□ Don’t know
□ Refused

1

2

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3

5
6

NAME 12 ............

1
2
d
r

□ Male
□ Female
□ Don’t know
□ Refused

□ 11 to 18
□ 19 to 30
□ 31 to 50
□ 51 to 65
□ Older than 65?
□ Newborn to
10 year old

4

l.

□ Newborn to

1

□ 11 to 18
□ 19 to 30
□ 31 to 50
□ 51 to 65
□ Older than 65?
□ Newborn to
10 year old

2

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3
4
5
6

□ 11 to 18
□ 19 to 30
□ 31 to 50
□ 51 to 65
□ Older than 65?

1
2

□ Biologically related
□ Not biologically
related

d
r

□ Don’t know
□ Refused

1
2
3
4
5
6

□ Parent
□ Sibling (Brother/Sister)
□ Grandparent
□ Aunt/Uncle
□ Cousin
□ Other (Specify)

7
8
9
10
11
12
13
14

d

1
2

□ Biologically related
□ Not biologically
related

d
r

□ Don’t know
□ Refused

1
2
3
4
5
6

□ Parent
□ Sibling (Brother/Sister)
□ Grandparent
□ Aunt/Uncle
□ Cousin
□ Other (Specify)

r
7
8
9
10
11
12
13
14

d

1
2

□ Biologically related
□ Not biologically
related

d
r

□ Don’t know
□ Refused

1
2
3
4
5
6

□ Parent
□ Sibling (Brother/Sister)
□ Grandparent
□ Aunt/Uncle
□ Cousin
□ Other (Specify)

r
7
8
9
10
11
12
13
14

d
r

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□ Step-parent
□ Partner of parent
□ Step-brother/sister
□ Aunt/Uncle
□ Foster Parent
□ Adoptive Parent
□ Other unrelated child
□ Other (Specify)
□ Don’t know
□ Refused
□ Step-parent
□ Partner of parent
□ Step-brother/sister
□ Aunt/Uncle
□ Foster Parent
□ Adoptive Parent
□ Other unrelated child
□ Other (Specify)
□ Don’t know
□ Refused
□ Step-parent
□ Partner of parent
□ Step-brother/sister
□ Aunt/Uncle
□ Foster Parent
□ Adoptive Parent
□ Other unrelated child
□ Other (Specify)
□ Don’t know
□ Refused

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□ Currently lives in
household

2

□ Does not currently live
in household but lived
there in past 30 days

d
r

1

□ Don’t know
□ Refused

□ Currently lives in
household

2

□ Does not currently live
in household but lived
there in past 30 days

d
r

1

□ Don’t know
□ Refused

□ Currently lives in
household

2

□ Does not currently live
in household but lived
there in past 30 days

d
r

□ Don’t know
□ Refused

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Individual ID: |

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INTERVIEWER: WHEN YOU COMPLETE A ROW FOR ONE PERSON, START BACK AT B2 FOR THE NEXT PERSON UNTIL B2-B5 ARE COMPLETED
FOR ALL HOUSEHOLD MEMBERS.

Prepared by Mathematica Policy Research

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