(17) Head Start parent survey for plus study (AI/AN FACES)

DRAFT

OMB #: 0970-0151

Expiration Date: X/XX/2018

American Indian and Alaska Native Head Start Family and Child Experiences Survey

Head Start AI/AN Fall 2015 Parent Survey

Paperwork Reduction Act Statement: The referenced collection of information is voluntary. 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 valid OMB control number for this information collection is 0970-0151 which expires XX/XX/2018. The time required to complete this collection of information is estimated to average 30 minutes, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the collection of information. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Mathematica Policy Research, 1100 1st Street, NE, 12th Floor, Washington, DC 20002, Attention: Jerry West.

SCREENER

ALL

SC1. The person most responsible for [CHILD]’s care should complete this survey. Are you that person?

 Yes 1 GO TO SC1a

 No 0 GO TO GetNameIntro

NO RESPONSE M GO TO GetNameIntro

sc1 = 1

SC1a. Do you live in the same household as [CHILD]?

 Yes 1 GO TO SKIP BOX SC0d

 No 0 GO TO GetNameIntro

NO RESPONSE M GO TO GetNameIntro

SC1, SC1a = 0 OR M

GetNameIntro. [Among the people that live with [CHILD], please/Please] enter the name, address, and phone number of the person most responsible for [CHILD]’s care.

First Name:

Middle Initial:

Last Name:

Street Address 1:

Street Address 2:

City:

State:

Zip:

(___) ___-____

TELEPHONE

NO RESPONSE M GO TO END

PROGRAMMER NOTE

IF SC1=0, M OR SC1a = 0, M TERMINATE SURVEY AFTER GETNAMEINTRO.

SKIP BOX SC0d

IF CHILD IS HEAD START (BASED ON PRELOAD), GO TO SC2b_2. ELSE, GO TO SC2c_2.

CHILD IS HEAD START (BASED ON PRELOAD)

SC2b_2. According to our records [CHILD] is still attending Head Start. Is that correct?

 Yes 1 GO TO INT2

 No 0

NO RESPONSE M

SMS DESIGNATION FOR CHILD = UNKNOWN OR SC2b_2 = 0 OR M

SC2c_2. What grade or year of school is [CHILD] attending? (Click here for definitions of response options.)

 Head Start 1 GO TO INT2

 Kindergarten 2 END

 Transitional Kindergarten (Before Kindergarten) 3 END

 Pre-first Grade (After Kindergarten) 4 END

 First Grade 5 END

 Un-graded or Home Schooled 6 SC2C_2new

 Special Education 7 END

 Nursery/Preschool/Prekindergarten 8 END

 Something else (SPECIFY) 99

Specify

 Not enrolled in school 11 END

NO RESPONSE M END

PROGRAMMER: CREATE A HELP SCREEN (TO POP UP IN A SEPARATE WINDOW) WITH THE FOLLOWING DEFINITIONS:

Nursery/preschool/pre-kindergarten: Programs that offer classes prior to kindergarten, primarily serving 3 and 4 year-old children. These may be offered by public and private organizations.

Transitional (or readiness) kindergarten: Extra year of school for kindergarten-age eligible children who are judged not ready for kindergarten.

Kindergarten: Traditional year of school primarily for 5-year-olds prior to first grade.

Pre-first (transitional first) grade (after k): Extra year of school for children who have attended kindergarten but have been judged not ready for first grade.

Un-graded: A classroom containing kindergarten-aged students (possibly in combination with other ages), not formally identified as a "kindergarten" class.

SC2c_2 = 99

SC2c_2Specify. Please enter the grade your child is in.

GRADE

(RANGE NUMBER RANGE)

NO RESPONSE M

SC2C_2=6

SC2C_2new. What grade would [CHILD] be in if [he/she/he or she] were attending a school with regular grades?

 Head Start 1 GO TO INT2

 Kindergarten 2 SC2c_2Exit

 Transitional Kindergarten (Before Kindergarten) 3 SC2c_2Exit

 Pre-first Grade (After Kindergarten) 4 SC2c_2Exit

 First Grade 5 SC2c_2Exit

 Special Education 7 SC2c_2Exit

 Nursery/Preschool/Prekindergarten 8 SC2c_2Exit

NO RESPONSE M END

(SC2c_2 = 2-9 OR M) OR (SC2c_2new = 2-9 or m)

SC2c_2Exit : Right now we are only looking at children attending Head Start. We do not have any more questions for you now, but thank you for your time.

sc2b_2=1 or sc2c_2=1 or sc2c_2new=1

INT2. Thank you for filling out this survey. [As you may remember, the/The] purpose of this study is to learn more about families in the Head Start Program. [(IF SPRING 2016 AND NO PREVIOUS INTERVIEW) When we spoke to parents from [CHILD]’s Head Start program last fall we were unable to interview you.]

We also want to learn more about the program [CHILD] attends. This will help us understand Head Start from a parent’s point of view, including some information about your child’s home environment. Information from this study will be used to help Head Start better serve all children and their families.

Your answers to the survey questions are private to the extent permitted by law. Neither your name nor [CHILD]’s name will be attached to any of the information you give us. All of the study results will be reported for groups of parents; no results will be analyzed or reported for individuals. If you are uncomfortable answering any questions, you may skip them and move on to the next question.

Your participation is completely voluntary. If you choose not to fill out this survey, it will not affect you or your child’s participation in the Head Start Program or any of the services that you or your child receives. Your answers are very important, so please be as accurate as possible. Occasionally, you may be asked a question that does not apply to you or that you may not want to answer. If that happens, you can move on to the next question.

ALL

MODE-1. After completing this online survey you will receive a gift card to thank you for your help. This survey will take about 30 minutes.

ALL

SC3_intro. We would like to make sure we have your name recorded correctly.

BOX SC3a

IF PRELOADED NAME NE EMPTY, GO TO SC3. PRELOAD RESPONDENT FIRST NAME, MIDDLE NAME/INITIAL, LAST NAME FROM DATABASE.

ELSE, IF PRELOADED NAME = EMPTY, GO TO SC3a.

PRELOADED NAME NE EMPTY

SC3. Is the correct spelling of your name below?

[DISPLAY PRELOADED FIRST NAME, MIDDLE NAME/INITIAL, LAST NAME]

 Yes, my name is spelled correctly 1 GO TO SC7

 This is my name, but it is misspelled 2

 No, this is not my name 3

NO RESPONSE M

SC3 = 2, 3, M OR PRELOADED NAME = EMPTY

SC3a. Please enter the correct spelling of your name.

First Name:

Middle Initial:

Last Name:

NO RESPONSE M

SC3 = 3, M

SC3b. What is your telephone number?

PROGRAMMER: INSERT PHONE MASK

(___) ___-____

 Do not have a telephone number 1

NO RESPONSE M

SC3 = 3, M

SC3c. What is your email address?

 Do not have email 0

NO RESPONSE M

ALL

SC7. What is your birth date?

(FIELD DESCRIPTION)

MM/DD/YYYY

(RANGE DATE RANGE)

NO RESPONSE M

ALL

SC8. Now, we would like to make sure we have the correct spelling of your child’s name. Is the information below correct?

First Name: [FILL]

Middle Name/Initial: [FILL]

Last Name: [FILL]

 Yes 1 GO TO SC9

 No 0

NO RESPONSE M

sc8 = 2

SC8a. What is the correct spelling of your child’s name? Please enter it below.

First Name:

Middle Initial:

Last Name:

NO RESPONSE M

ALL

SC9. What is your relationship to [CHILD]? (Click here for definitions of response options.)

 Biological mother 11

 Biological father 12

 Adoptive mother 13

 Adoptive father 14

 Stepmother 15

 Stepfather 16

 Grandmother 17

 Grandfather 18

 Great grandmother 19

 Great grandfather 20

 Sister/stepsister 21

 Brother/stepbrother 22

 Other relative or in-law (female) 23

 Other relative or in-law (male) 24

 Foster parent (female) 25

 Foster parent (male) 26

 Other non-relative (female) 27

 Other non-relative (male) 28

 Parent’s partner (female) 29

 Parent’s partner (male) 30

NO RESPONSE M

PROGRAMMER: MAKE TEXT AVAILABLE ON HELP SCREEN THAT OPENS IN SEPARATE WINDOW:

Biological Mother: Child's female biological parent. This may be the birth mother, but could also apply to a mother who used a surrogate mother to have her biological child.

Biological Father: Child's male biological parent. This could also apply to a father who used a surrogate mother to have his biological child.

Adoptive Mother: The female who has taken the child into her own family by legal process to raise as her own child.

Adoptive Father: The male who has taken the child into his own family by legal process to raise as his own child.

Step Mother: The female other than the child's mother who is married to the child's father.

Step Father: The male other than the child's father who is married to the child's mother.

Foster Parent (Female): The female with whom the child is placed temporarily, usually through a social service agency and/or a court.

Foster Parent (Male): The male with whom the child is placed temporarily, usually through a social service agency and/or a court.

Parent’s Partner (Female): The female who has a "partner-like" relationship with one of the child's parents or guardians. "Living as married" is another way of describing the relationship.

Parent’s Partner (Male): The male who has a "partner-like" relationship with one of the child's parents or guardians. "Living as married" is another way of describing the relationship.

SC9 = 23, 24, 27, OR 28

SC9_1. How are you related to [CHILD]?

(CLICK HERE FOR DEFINITIONS OF RESPONSE OPTIONS.)

Select one only

 Girlfriend or female partner of [CHILD]’s parent/guardian 1

 Boyfriend or male partner of [CHILD]’s parent/guardian 2

 Female guardian 3

 Male guardian 4

 Daughter/Son of [CHILD]'s parent’s partner 5

 Other relative of [CHILD]'s parent’s partner 6

NO RESPONSE M

PROGRAMMER: HELP SCREEN SHOULD OPEN IN A SECOND WINDOW.

Girlfriend or Female Partner of CHILD's Parent/Guardian: The female who has a "partner-like" relationship with one of the child's parents or guardians. "Living as married" is another way of describing the relationship.

Boyfriend or Male Partner of CHILD's Parent/Guardian: The male who has a "partner-like" relationship with one of the child's parents or guardians. "Living as married" is another way of describing the relationship.

Female Guardian: The female legally placed in charge of the affairs of the child.

Male Guardian: The male legally placed in charge of the affairs of the child.

Daughter/son of CHILD's Parent's Partner: The child of the person who has a "partner-like" relationship with one of the child's parents or guardians.

Other Relative of CHILD's Parent's Partner: Some other relative of the person who has a "partner-like" relationship with one of the child's parents or guardians.

Other Non-relative: If one of the codes for non-relative above does not better describe the relationship of the person to the child, and there is no family relationship through blood, marriage, adoption, or partnership (i.e., living together as married), use this code.

SC9 = 12, 14-30, M

SC9a. What is the first name of [CHILD]’s biological mother?

FIRST NAME

(STRING (NUM))

NO RESPONSE M

SC9 = 11, 13, 15-30, M

SC9b. What is the first name of [CHILD]’s biological father?

FIRST NAME

(STRING (NUM))

NO RESPONSE M

SC9 = 17-30, M

SC10. Are you [CHILD]’s legal guardian?

 Yes 1 GO TO VERSION BOX A

 No 0

NO RESPONSE M

SC10 = 0 or m

SC11. Please enter the name, address, and phone number of [CHILD]’s legal guardian.

First Name:

Middle Initial:

Last Name:

Street Address 1:

Street Address 2:

City:

State:

Zip:

(___) ___-____

TELEPHONE

NO RESPONSE M

A. ABOUT YOUR CHILD

IF GENDER = MISSING

A1. Is [CHILD] a boy or a girl?

 Girl 1

 Boy 2

NO RESPONSE M

IF BIRTHDAY = MISSING

A2. What is [CHILD]’s birth date?

BIRTH DATE

MM/DD/YYYY

NO RESPONSE M

ALL

A3. Is [CHILD] of Spanish, Hispanic, or Latino origin?

 Yes 1

 No 0

NO RESPONSE M

ALL

A5. What is [CHILD]’s race? You may enter more than one if you like.

Select all that apply

 White 11 GO TO A6

 Black or African American 12 GO TO A6

 American Indian or Alaska Native 13

 Asian 27 GO TO A6

 Native Hawaiian, or other Pacific Islander 26 GO TO A6

 Another race (SPECIFY) 25 GO TO A6

Specify

NO RESPONSE M

IF a5=13

A5a. Is [CHILD] currently enrolled in an American Indian or Alaska Native tribe?

Select one only

 Yes, enrolled 2

 No, but have applied and awaiting approval 1

 No, not enrolled 0

NO RESPONSE M

ALL

A6. Please enter the country [CHILD] was born in.

Select one only

 USA 059

 Canada 301

 Mexico 303

 Another country (SPECIFY) 600

Specify

NO RESPONSE M

ALL

A8. Did [CHILD] participate in Early Head Start?

Early Head Start is a program designed to provide services to enhance development of children from birth to three years of age.

 Yes 1

 No 0

NO RESPONSE M

B. ABOUT HOUSEHOLD

ALL

NOTE: BE SURE THAT THE RESPONDENT IS INCLUDED IN THE LIST OF HOUSEHOLD MEMBERS.

NOTE: CONFIRM LIST OF HOUSEHOLD MEMBERS AND THEIR RELATIONSHIPS TO [CHILD] WITH RESPONDENT.

NOTE: IF ANY CHANGE IS NEEDED TO THE HOUSEHOLD MEMBERS OR THEIR RELATIONSHIPS TO [CHILD], PRESS 0 TO ENTER THE HH ROSTER.

NOTE: CORRECT RELATIONSHIP CODES OR ADD OR DELETE HH MEMBERS ON THE NEXT SCREENS.

B3. Please list the first names of all the other people who normally live in your household. Please do not include anyone staying there temporarily who usually lives somewhere else.

B3.

FIRST NAME

a.

b.

c.

d.

e.

f.

g.

h.

i.

j.

k.

ALL

B4. Please list the ages and relationships to [CHILD] of all the other people who normally live in your household. Please do not include anyone staying there temporarily who usually lives somewhere else.

If a child is less than one year old, please enter “0” for the age.

AGE

NO RESPONSE M

PROGRAMMER BOX B4a

IF B4 = CHILD, FILL CHILD’S NAME FROM SC8 (PRELOADED), CALCULATE AND FILL AGE FROM A2 IF FIRST TIME CHILD IS RECORDED IN HH GRID OR SHOW (PRELOADED)

IF B4 = RESPONDENT, CALCULATE AND FILL AGE FROM SC7 IF FIRST TIME RESPONDENT IS RECORDED IN HH GRID OR SHOW (PRELOADED) IF RESPONDENT ALREADY IN GRID, FILL RELATIONSHIP FROM SC9

See BOX

b4 GT or = 18

B5. What is [NAME]’s relationship to [CHILD]? (Click here for definitions of response options.)

Select one only

 Biological or adoptive mother 1

 Biological or adoptive father 2

 Stepmother 3

 Stepfather 4

 Grandmother 5

 Grandfather 6

 Great grandmother 7

 Great grandfather 8

 Sister/stepsister 9

 Brother/stepbrother 10

 Other relative or in‑law (female) 11

 Other relative or in‑law (male) 12

 Foster parent (female) 13

 Foster parent (male) 14

 Other non-relative (female) 15

 Other non-relative (male) 16

 Parent’s partner (female) 17

 Parent’s partner (male) 18

NO RESPONSE M

PROGRAMMER: MAKE TEXT AVAILABLE ON HELP SCREEN THAT OPENS IN SEPARATE WINDOW:

Biological Mother: Child's female biological parent. This may be the birth mother, but could also apply to a mother who used a surrogate mother to have her biological child.

Biological Father: Child's male biological parent. This could also apply to a father who used a surrogate mother to have his biological child.

Adoptive Mother: The female who has taken the child into her own family by legal process to raise as her own child.

Adoptive Father: The male who has taken the child into his own family by legal process to raise as his own child.

Step Mother: The female other than the child's mother who is married to the child's father.

Step Father: The male other than the child's father who is married to the child's mother.

Foster Parent (Female): The female with whom the child is placed temporarily, usually through a social service agency and/or a court.

Foster Parent (Male): The male with whom the child is placed temporarily, usually through a social service agency and/or a court.

Parent’s Partner (Female): The female who has a "partner-like" relationship with one of the child's parents or guardians. "Living as married" is another way of describing the relationship.

Parent’s Partner (Male): The male who has a "partner-like" relationship with one of the child's parents or guardians. "Living as married" is another way of describing the relationship.

B5 = 1

B5a1. [Are you/Is [NAME]] [CHILD]’s ...

(Click here for definitions of biological or birth mother and adoptive mother.)

PROGRAMMER: HELP SCREEN SHOULD POP UP IN A SEPARATE WINDOW.

Biological or Birth Mother: Child's female biological parent. This may be the birth mother, but could also apply to a mother who used a surrogate mother to have her biological child.

Adoptive Mother: The female who has taken the child into her own family by legal process to raise as her own child.

NOTE: IF THE RESPONDENT STATES SOMETHING OTHER THAN BIOLOGICAL, BIRTH, OR ADOPTIVE MOTHER GO BACK TO B5 AND UPDATE RELATIONSHIP.

 Biological or birth mother or 1

 Adoptive mother? 2

NO RESPONSE M

B5 = 2

B5a2. [Are you/Is [NAME]] [CHILD]’s ...

(Click here for definitions of biological or birth father and adoptive father.)

PROGRAMMER: HELP SCREEN SHOULD POP UP IN A SEPARATE WINDOW.

Biological or Birth Father: Child's male biological parent. This could also apply to a father who used a surrogate mother to have his biological child.

Adoptive Father: The male who has taken the child into his own family by legal process to raise as his own child.

NOTE: IF THE RESPONDENT STATES SOMETHING OTHER THAN BIOLOGICAL, BIRTH, OR ADOPTIVE FATHER GO BACK TO B5 AND UPDATE RELATIONSHIP

 Biological or birth father or 1

 Adoptive father? 2

NO RESPONSE M

B5 = 15 or 16

B5a3. How is [NAME FROM B3] related to [CHILD]?

(CLICK HERE FOR DEFINITIONS OF RESPONSE OPTIONS.)

PROGRAMMER: HELP SCREEN SHOULD OPEN IN A SECOND WINDOW.

Girlfriend or Female Partner of CHILD's Parent/Guardian: The female who has a "partner-like" relationship with one of the child's parents or guardians. "Living as married" is another way of describing the relationship.

Boyfriend or Male Partner of CHILD's Parent/Guardian: The male who has a "partner-like" relationship with one of the child's parents or guardians. "Living as married" is another way of describing the relationship.

Female Guardian: The female legally placed in charge of the affairs of the child.

Male Guardian: The male legally placed in charge of the affairs of the child.

Daughter/son of CHILD's Parent's Partner: The child of the person who has a "partner-like" relationship with one of the child's parents or guardians.

Other Relative of CHILD's Parent's Partner: Some other relative of the person who has a "partner-like" relationship with one of the child's parents or guardians.

Other Non-relative: If one of the codes for non-relative above does not better describe the relationship of the person to the child, and there is no family relationship through blood, marriage, adoption, or partnership (i.e., living together as married), use this code.

Select one only

 Girlfriend or female partner of [CHILD]’s parent/guardian 1

 Boyfriend or male partner of [CHILD]’s parent/guardian 2

 Female guardian 3

 Male guardian 4

 Daughter/Son of [CHILD]'s parent’s partner 5

 Other relative of [CHILD]'s parent’s partner 6

NO RESPONSE M

PROGRAMMER BOX B8

ONLY ASK RELATIONSHIP (B5) IF B4 IS 18 OR OLDER. DO NOT ASK RESPONDENT TO SPECIFY RELATIONSHIPS FOR CHILDREN UNDER 18

B3. FIRST NAME	B4. AGE	B4b. PARTNER/SPOUSE STATUS	B5. RELATIONSHIP
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.

See BOX

MoreHH. Is there anyone else in your household? Have we missed anyone who usually lives here who is temporarily away from home for work or military duty or living in a dorm at school, or any babies or small children?

 Yes 1 GO TO B3

 No 0

NO RESPONSE M

PROGRAMMER NOTE: IF THE RESPONDENT REPORTS THERE IS SOMEONE ELSE IN THE HOUSEHOLD (MoreHH=YES/1), OPEN ITEM B3 AT THE NEXT AVAILABLE ROW TO RECORD INFORMATION ABOUT HOUSEHOLD MEMBER.

[PROGRAMMER NOTE: NEED TO COMPARE NAMES IN B3a-k TO PRELOADED NAME IF SC3=1, TO NAME REPORTED IN SC3a IF SC3=2, AND IN BOTH CASES TO ANY ALTERNATIVE NAME REPORTED IN SC6. NameCheck SHOULD BE ASKED IF B3a-k IS NOT EQUAL TO ANY OF THESE RESPONSES.]

HOUSEHOLD MEMBERS OTHER THAN RESPONDENT AND FOCAL CHILD ARE LISTED

B4a. Do you have a spouse or partner who lives in this household?

• Yes 1

• No 0

NO RESPONSE M

B4a = 1

B4b. Who in the household is your spouse or partner?

NOTE: ENTER NUMBER NEXT TO NAME OF PERSON WHO IS [RESPONDENT]'S SPOUSE/PARTNER.

NOTE: IF NAME NOT LISTED, BACK UP AND ADD PERSON (IF PART OF HOUSEHOLD).

IF PRE-LOADED RELATIONSHIP TO CHILD IS ONE OF THESE: BIO/ADOPTIVE MOTHER, BIO/ADOPTIVE FATHER, STEP-MOTHER/FATHER OR IF SC9=11, 12, 13, 14, 15, 16 AND B5a-k CONTAINS ANY OTHER HH MEMBER WITH RELATIONSHIP 01, 02, 03, 04 (BIO/ADOPTIVE MOTHER OR FATHER, STEP-MOTHER/FATHER)

B9. Are you and [FATHER/MOTHER/YOUR SIGNIFICANT OTHER NAME]…

Select one only

 married, 1

 in a registered domestic partnership or civil union, 5

 divorced 2

 separated, 3

 not married, or 4

 living with a partner in a committed relationship? 6

NO RESPONSE M

b9 = 2, 3, 4, M

B10. Which of the following statements best describes your current relationship with [(FATHER/MOTHER/YOUR SIGNIFICANT OTHER) NAME]? Would you say…

Select one only

 we are romantically involved on a steady basis, 1

 we are involved in an on-again and off-again relationship, 2

 we are just friends, or 3

 we are not in any kind of relationship? 4

NO RESPONSE M

D. ACTIVITIES WITH YOUR CHILD

ALL

D1. The next questions are about you and [CHILD] at home.

How many times have you or someone in your family read to [CHILD] in the past week?

Note: By family, we mean the people living together in your household.

Would you say…

 not at all, 1

 once or twice, 2

 three or more times, but not every day, or 3

 every day? 4

NO RESPONSE M

ALL

D3. In the past week, have you or someone in your family done the following things with [CHILD]?

The following activities can be done in your native language or in English.

	Select one per row
	Yes	No
a. Told [him/her/him or her] a story?	1 	0 
b. Taught [him/her/him or her] letters, words, or numbers?	1 	0 
c. Taught [him/her/him or her] songs or music, including traditional or ceremonial songs?	1 	0 
d. Worked on arts and crafts (such as painting or jewelry making) with [him/her/him or her]?	1 	0 
e. Played with toys or games indoors?	1 	0 
f. Danced, played a game, sport, or exercised together?	1 	0 
g. Took [him/her/him or her] along while doing errands like going to the post office, store, tribal center or office, doctor, or to check on elderly family members?	1 	0 
h. Involved [him/her/him or her] in household chores like cooking, cleaning or picking up after him/herself, setting the table, caring for animals such as pets or livestock or helping with planting or chopping wood?	1 	0 
i. Talked about what happened in Head Start?	1 	0 
j. Talked about TV programs or videos?	1 	0 
k. Played counting games like singing songs with numbers or reading books with numbers with [him/her/him or her]?	1 	0 
l. Played a board game or a card game with [him/her/him or her]?	1 	0 
m. Played with blocks with [him/her/him or her]?	1 	0 
n. Counted different things with [him/her/him or her], like twigs, stones, grapes, or stars?	1 	0 

D3a = 1 TOLD STORIES IN pAST WEEK

D3a1. How many times have you or someone in your family told stories to [CHILD] in the past week? Would you say…

 once or twice, 2

 three or more times, but not every day, or 3

 every day? 4

NO RESPONSE M

ALL

D5. About how many children’s books does [CHILD] have in your home now, including library books? Please only include books that are for children. (Your best estimate is fine.)

NUMBER

NO RESPONSE M

ALL

D5a. In the past week, has [CHILD] done the following with someone in your community (outside of your family)?

	Select one per row
	Yes	No
a. Listened to Elders tell stories?	1 	0 
b. Participated in traditional ways, including carving, harvesting, collecting, hunting, and fishing?	1 	0 
c. Danced, sang, or drummed at a pow-wow or other community cultural activity?	1 	0 
d. Worked on traditional arts and crafts, such as beading, blanket weaving, or making jewelry, a basket, a painting, or pow-wow regalia?	1 	0 
e. Participated in traditional ceremonies?	1 	0 
f. Played American Indian or Alaska Native games?	1 	0 

ALL

D7. Is any language other than English spoken in your home?

 Yes 1

 No 0 GO TO D10a

NO RESPONSE M GO TO D10a

D7 = 1

D8. What other languages are spoken in your home?

Select all that apply

 [FILL/Your tribal language] 33

 Languages of other tribes 34

 French 11

 Spanish 12

 Another language (specify) 21

Specify

NO RESPONSE M

D7 = 1

D10. What language do you usually speak to [CHILD] at home?

Select one only

 English 25

 Native American or Alaskan language 31

 French 11

 Spanish 12

 Another language (SPECIFY) 21

Specify

NO RESPONSE M

ALL

D10a. Please indicate how often you did each of the things below in the past month.

	SELECT ONE PER ROW
	VERY OFTEN	OFTEN	SOME-TIMES	RARELY	NEVER
a. I spoke our tribal language with my child(ren).	1 	2 	3 	4 	5 
b. I made sure my child(ren) heard our tribal language spoken by others.	1 	2 	3 	4 	5 
c. I encouraged my child(ren) to learn our tribal language (e.g., take classes in school).	1 	2 	3 	4 	5 
d. I used our tribal language in prayers or songs with my child(ren).	1 	2 	3 	4 	5 
e. I used our tribal language in everyday life with my child(ren).	1 	2 	3 	4 	5 
f. I spoke our tribal language with other adults when my child(ren) [was/were] around.	1 	2 	3 	4 	5 

ALL

D10a1. How important is it for you that you child(ren) learns your tribal language?

Select one only

 Very important 1

 Somewhat important 2

 Not at all important 3

NO RESPONSE M

ALL

D10b. What languages are spoken at your child’s Head Start center?

Select all that apply

 English 25

 [FILL/Your tribal language] 33

 Languages of other tribes 34

 French 11

 Spanish 12

 Another language (specify) 21

Specify

NO RESPONSE M

D7 = 1 AND D10 = 11-21, 30, 31, 32, M

D19. How often is there someone in [CHILD]’s Head Start classroom available to talk to [him/her/him or her] in [FILL FROM D8]? Would you say it is…

Select one only

 always, 1

 sometimes, or 2

 never? 3

NO RESPONSE M

H. HOUSEHOLD ROUTINES

ALL

H1. The next questions are about routines in your household.

In a typical week, about how many days does at least some of the family eat the evening meal together?

If it changes each week, please think about a typical week.

NUMBER

NO RESPONSE M

ALL

H8. When is [CHILD]’s regular bedtime?

We are interested in what time [he/she/he or she] usually goes to bed, not what time [he/she/he or she] actually falls asleep.

If your child’s bedtime is after midnight, please enter 11:59PM.

HH:MM  AM  PM

 [CHILD] does not have a usual bedtime 98 GO TO H10

NO RESPONSE M

H8 NE 98

H9. How many times in the last week, Monday through Friday, was [CHILD] put to bed at that time?

NUMBER

NO RESPONSE M

ALL

H10. About what time does [CHILD] usually wake up on a weekday?

We are interested in what time [he/she] wakes up on an average weekday,

HH:MM  AM  PM

 [CHILD] does not wake up at a usual time 98

NO RESPONSE M

ALL

H11. During a typical night, about how many times does [CHILD] wake up and need someone to help [him/her/him or her] settle back to sleep?

NUMBER

NO RESPONSE M

ALL

H11b. About how many nights in the last week (Sunday to Saturday) would you say [CHILD] brushed (his/her/his or her) teeth before bed?

NUMBER

NO RESPONSE M

J. ABOUT CHILD’S MOTHER

ALL

PROGRAMMER VERSION BOX J2

IF BIOLOGICAL OR ADOPTIVE MOTHER IN HOUSEHOLD [B5a-k = 1], AND RESPONDENT IS BIOLOGICAL OR ADOPTIVE MOTHER (SC9 = 11 OR 13), GO TO BOX J9, ELSE GO TO BOX J16a

IF BIOLOGICAL OR ADOPTIVE MOTHER IN HOUSEHOLD [B5a-k = 1], AND RESPONDENT IS NOT BIOLOGICAL OR ADOPTIVE MOTHER (SC9 = 12, 14…30), GO TO J8, ELSE GO TO BOX J16a

IF [CHILD]’s MOTHER NOT IN HOUSEHOLD AND [B5a_k =2_18,M], ASK J1

The next questions are about (you/[CHILD]’s mother).

SEE BOX

B5a – k NE 1

J1. There are many reasons for children not living with their parents. Please select why [CHILD] is not living with [her/his/his or her] mother.

Select all that apply

 [Her/His/His or her] mother is deceased 11

 [Her/His/His or her] mother did not have enough money to raise [her/him/him or her] 12

 [Her/His/His or her] mother got too sick to take care of [her/him/him or her] 13

 [Her/His/His or her] mother had a drinking problem and could not take care of [her/him/him or her] 14

 [Her/His/His or her] mother had a drug problem and could not take care of [her/him/him or her] 15

 [Her/His/His or her] mother is in a residential treatment program for substance abuse and could not bring [her/him/him or her] 24

 [Her/His/His or her] mother had a mental or emotional problem and could not take care of [her/him/him or her]. 16

 [Her/His/His or her] mother was in trouble with the law or had to go to jail 17

 [She/He/He or she] was neglected or abused while living with [her/his/his or her] mother. 18

 Someone at the child welfare office said [she/he/he or she] could not live with (his/her) mother any more. 19

 [Her/His/His or her] family is homeless. 25

 [Her/His/His or her] parents are divorced/separated 22

 Something else (SPECIFY) 21

Specify

NO RESPONSE M

B5a-k = 2-18, M AND J1 = 12-25, M

J7a. Is there anyone else who is like a mother to [CHILD]?

 Yes 1

 No 0 GO TO BOX J3

NO RESPONSE M GO TO BOX J3

B5a-k = 2-18, M AND J1 = 12-25, M

J7a = 1

J7b. Who is this person? Is she . . .

Select one only

 you, 1

 your spouse or partner, 2

 a relative of [CHILD], 3

 a friend of the family, 4

 or someone else (SPECIFY)? 99

Specify (STRING (NUM))

NO RESPONSE M [SKIP]

VERSION BOX J3

IF FIRST INTERVIEW, GO TO J8

IF ANY PREVIOUS INTERVIEW AND J1 ≠ 11, SKIP TO J15,

ELSE GO TO BOX J16a

IF SC9 OR RESPONDENT FLAG =12, 14…30

J8. [We are sorry to learn about [CHILD]’s mother passing.] The next few questions are about [her/[CHILD]’s mother].

What (is/was) her birth date?

MM/DD/YYYY

NO RESPONSE M

ALL

J10. [Are you/Is she/Was she] of Spanish, Hispanic, or Latino origin?

 Yes 1

 No 0 GO TO J12

NO RESPONSE M GO TO J12

ALL

J12. What [is/was] [your/her] race? You may choose more than one if you like.

Select all that apply

 White 11 GO TO J13

 Black or African American 12 GO TO J13

 American Indian or Alaska Native 13

 Asian 27 GO TO J13

 Native Hawaiian, or other Pacific Islander 26 GO TO J13

 Another race (SPECIFY) 25 GO TO J13

Specify

NO RESPONSE M

if j12 = 13

J12a. [Are you currently/Is she currently/Was she] enrolled in an American Indian or Alaska Native tribe?

Select one only

 Yes, enrolled 2

 No, but have applied and awaiting approval 1

 No, not enrolled 0

NO RESPONSE M

ALL

J13. In what country [were you/was she] born?

Select one only

 USA 059

 Canada 301

 Mexico 303

 Another country (SPECIFY) 600

Specify

NO RESPONSE M

PROGRAMMER SKIP BOX j14a

IF SC9 NE 11 (NOT BIOLOGICAL MOTHER) AND SC9 NE 12 (NOT BIOLOGICAL FATHER) AND J1 NE 11 (MOTHER NOT DECEASED), CONTINUE.

OTHERWISE, GO TO J17

SEE BOX

(IF SC9 OR RESPONDENT FLAG = 13-30, M) (R IS NOT BIO PARENT)

J15. The next questions are about [CHILD]’s biological parents...

Are they…

Select one only

 married, 1 GO TO J17

 in a registered domestic partnership or civil union, 5 GO TO J17

 divorced, 2

 separated, 3

 not married, or 4

 living with a partner in a committed relationship? 6

NO RESPONSE M

(J15 = 2, 3, 4, M)

J16. Which of the following statements best describes their current relationship?

Select one only

 They are romantically involved on a steady basis 1

 They are involved in an on-again and off-again relationship 2

 They are just friends, or 3

 They are not in any kind of relationship 4

NO RESPONSE M

B5a-k = 1

J17. During the past week, did [you/[CHILD]’s mother] work at a job for pay or income, including self employment (that is, the past 7 days)?

Select one only

 Yes 1 GO TO J21

 No, [I am/[CHILD]’s mother is] retired 2 GO TO J24

 No, [I am/[CHILD]’s mother is] disabled and unable to work 3 GO TO J24

 No (for reason other than retirement or disability) 0

NO RESPONSE M GO TO J24

B5a-k = 1 AND J17=0

J18. [Were you/Was she] on leave or vacation from a job for the past week (that is, the past 7 days)?

 Yes 1

 No 0

NO RESPONSE M

B5a-k = 1 AND J17=0

J19. [Have you/Has she] actively been looking for work in the past four weeks?

 Yes 1

 No 0

NO RESPONSE M

B5a-k = 1 AND J17=0

J20. Did [you/[CHILD]’s mother] work at a job for pay or income, including self-employment, [in the last 12 months/since [MONTH AND YEAR OF LAST INTERVIEW]]?

 Yes 1

 No 0 GO TO J24

NO RESPONSE M GO TO J24

B5a-k = 1 AND (J17=1 OR J20=1)

J21. About how many total hours per week [do you/did you/does she/did she] usually work for pay or income, counting all jobs? If hours vary, please enter the average hours per week.

(Your best estimate is fine.)

HOURS

NO RESPONSE M

B5a-k = 1

J24. What is the highest grade or year of school that [you/she] completed?

Select one only

 8th grade or lower 1

 9th to 11th grade 2

 12th grade but no diploma 3

 High school diploma or equivalent 4

 Vocational/technical program after high school but no vocational/technical diploma 5

 Vocational/technical diploma after high school 6

 Some college but no degree 7

 Associate’s degree 8

 Bachelor’s degree 9

 Graduate or professional school but no degree 10

 Master’s degree (MA, MS) 11

 Doctorate degree (Ph.D, EdD) 12

 Professional degree after bachelor’s degree (medicine/MD; dentistry/DDS; law/JD/LLB; etc.) 13

NO RESPONSE M

B5a-k = 1

J26. ((Are you/Is she) now attending or enrolled) in any courses, classes, or workshops for work-related reasons or personal interest? Some examples include college or university degree or certificate programs, computer courses, job training courses, basic reading or math classes, family literacy classes or GED preparation classes?

 Yes 1

 No 0

NO RESPONSE M

B5a-k = 1 AND J26 = 1

J27. (Are you/Is she) currently taking courses full-time or part-time?

Select one only

 Full-time 1

 Part-time 2

 Not currently taking 0

NO RESPONSE M

B5a-k = 1 AND J26 = 0, M

J28. (Are you/Is she) currently participating in a job-training or on-the-job-training program?

 Yes 1

 No 0

NO RESPONSE M

J33 BOX

IF CHILD'S BIOLOGICAL MOTHER DOES NOT LIVE IN THE HOUSEHOLD, GO TO J33.

ELSE GO TO SECTION K.

B5a-k NE 1

J33. Now I have some questions about how far away [CHILD]'s mother lives and the amount of contact she has with [him/her].

How many minutes away does [CHILD]'s mother live from [him/her]?

Select one only

 10 minutes or less 1

 11 to 30 minutes 2

 31 to 59 minutes 3

 1 to 2 hours 4

 More than 2 hours 5

NO RESPONSE M

B5a-k NE 1

J35. How long has it been since she last saw [CHILD]?

(FIELD DESCRIPTION)

(RANGE NUMBER RANGE)

NO RESPONSE M

ENTER NUMBER AND UNIT.

IF MOTHER SAW CHILD TODAY, ENTER 1 DAY.

IF MOTHER HAS NEVER SEEN CHILD/CHILDREN, ENTER 0.

J35 BOX

IF LENGTH OF TIME SINCE BIOLOGICAL MOTHER SAW CHILD IS LESS THAN OR EQUAL TO 3 MONTHS, GO TO J36.

ELSE IF LENGTH OF TIME SINCE BIOLOGICAL MOTHER SAW CHILD IS

GREATER THAN 3 MONTHS, GO TO J36 BOX.

ELSE IF J35 = M, GO TO J39.

IF J35 < 3 months

J36. In the last 3 months, that is since [TIME FRAME], on how many days has [CHILD]’s mother seen [him/her]?

Your best guess is fine.

NUMBER OF DAYS

(RANGE NUMBER RANGE)

NO RESPONSE M

J36 BOX

IF LENGTH OF TIME SINCE BIOLOGICAL MOTHER SAW CHILD IS GREATER THAN ONE MONTH, GO TO J37. ELSE, GO TO J39.

IF J36 > 1 MONTH

J37. Why hasn't she seen [CHILD] [more recently]? Is it because...

Select one only

 You do not want her to see [CHILD], 1 GO TO J43

 She does not want to see [CHILD], or 2 GO TO J43

 She has been unable to see [CHILD]? 3

NO RESPONSE M

J37 = 3

J38. Why has she been unable to see [CHILD]? Is it because.…

Select one only

 She lives too far away, 1

 She is sick or disabled, 2

 She is in the military, 3

 She is in jail or prison, or 4

 Some other reason? (SPECIFY) 99

Specify (STRING (NUM))

NO RESPONSE M

IF J35 = M

J39. In the last 3 months, how often have you been in touch with [CHILD]’s mother, either by phone, letter, or other means? Is it…

Select one only

 Every day or almost every day, 1

 Several times a week, 2

 About once a week, 3

 Two or three times a month, 4

 About once a month, or 5

 Less often? 6

NO RESPONSE M

IF B5a-k NE 1

J43. Mothers who do not live with their children sometimes help out with them in other ways. Please tell me whether [CHILD]'s mother has done these things often, sometimes, or never. How often has she done any of the following for [CHILD]?

Select one per row

	OFTEN	SOMETIMES	NEVER
a. Bought clothes, toys, or presents for [CHILD]?	1 	2 	3 
b. Paid for [CHILD]'s medical insurance, doctor bills, or medicines?	1 	2 	3 
c. Helped pay for [CHILD]’s child care expenses?	1 	2 	3 
d. Given you extra money to help out, not including child support?	1 	2 	3 

IF B5a-k NE 1

J44. Thinking about child support, do you have a legal agreement, an informal agreement, or no arrangement at all with [CHILD]'s mother?

Select one only

 Legal 1

 Informal 2

 No arrangement 3

NO RESPONSE M

IF B5a-k NE 1

J45. Do you receive child support from the mother on a regular basis?

 Yes 1

 No 0

NO RESPONSE M

IF B5a-k NE 1

J46. Do you receive financial support from the mother’s family?

 Yes 1

 No 0

NO RESPONSE M

K. ABOUT CHILD’S FATHER

ALL

PROGRAMMER VERSION BOX K1

IF BIOLOGICAL OR ADOPTIVE FATHER IN HOUSEHOLD (B5a-k = 2], AND RESPONDENT IS BIOLOGICAL OR ADOPTIVE FATHER (SC9 = 12 OR 14), GO TO BOX K9, ELSE GO TO BOX K16a

IF BIOLOGICAL OR ADOPTIVE FATHER IN HOUSEHOLD (B5a-k = 2], AND RESPONDENT IS NOT BIOLOGICAL OR ADOPTIVE FATHER (SC9 = 11, 13, 15…30)), GO TO K8, ELSE GO TO BOX K16A

IF [CHILD]’s BIRTH OR ADOPTIVE FATHER NOT IN HOUSEHOLD [B5A-K = 1,3-18,M], ASK K1.

The next questions are about [CHILD]’s father.

SEE BOX

B5a – k = 1, 3 – 18, M

K1. There are many reasons for children not living with their fathers. Please enter why [CHILD] is not living with [her/his/his or her] father.

Select all that apply

 [Her/His/His or her] father is deceased 11

 [Her/His/His or her] father did not have enough money to raise [her/him/him or her] 12

 [Her/His/His or her] father got too sick to take care of [her/him/him or her] 13

 [Her/His/His or her] father had a drinking problem and could not take care of [her/him/him or her] 14

 [Her/His/His or her] father had a drug problem and could not take care of [her/him/him or her] 15

 [Her/His/His or her] father is in a residential treatment program for substance abuse and could not bring [her/him/him or her] 24

 [Her/His/His or her] father had a mental or emotional problem and could not take care of [her/him/him or her] 16

 [Her/His/His or her] father was in trouble with the law or had to go to jail 17

 [He/She/He or she] was neglected or abused while living with [her/his/his or her] father 18

 Someone at the child welfare office said [he/she/he or she] could not live with [his/her/his or her] father any more. 19

 [Her/His/His or her] family is homeless. 25

 [Her/His/His or her] parents are divorced/separated 22

 Father left/did not want child 23

 Something else (specify) 21

Specify

NO RESPONSE M

PROGRAMMER SKIP BOX K2a

ASK K2 THROUGH K7C IF FATHER NOT IN HH, ELSE GO TO VERSION BOX K2

IF ‘NeedFatherDOB’=1, GO TO K8

SEE BOX K2a AND

B5a-k = 1, 3 – 18, M AND K1 = 12-25, M

K7a. Is there anyone else who is like a father to [CHILD]?

 Yes 1

 No 0

NO RESPONSE M

SEE BOX K2a AND

B5a-k = 1, 3 – 18, M AND K1 = 12-25, M AND K7a=1

K7b. Who is this person? Is he…

Select one only

 [IF SC9 = 12, 14, 16, 18, 20, 22, 24, 26, 28, 30 (R IS MALE)] you, 1

 your spouse or partner, 2

 a relative of [CHILD], 3

 a friend of the family, 4

 or someone else (SPECIFY)? 99

Specify:

NO RESPONSE M

SC9 OR RESPONDENT FLAG = 11, 13, 15-30, M

K8. [We are sorry to learn about [CHILD]’s father passing. The next few questions are about him/The next questions are about [CHILD]’s father].

What [is/ was] his birth date?

MM/DD/YYYY

NO RESPONSE M

PROGRAMMER SKIP BOX K9

IF THE RESPONDENT [CHILD]’s BIOLOGICAL OR ADOPTIVE FATHER [SC9 = 12,14], FILL “you”.

IF SOMEONE ELSE [SC9 = 11, 13, 15-30, M], FILL “[CHILD]’s FATHER”.

ALL

K10. [Are you/Is he/Was he] of Spanish, Hispanic, or Latino origin?

 Yes 1

 No 0 GO TO K12

NO RESPONSE M GO TO K12

ALL

K12. What [is/was] [your/his] race? You may choose more than one if you like.

Select all that apply

 White 11 GO TO K13

 Black or African American 12 GO TO K13

 American Indian or Alaska Native 13

 Asian 27 GO TO K13

 Native Hawaiian, or other Pacific Islander 26 GO TO K13

 Another race (specify) 25 GO TO K13

Specify

NO RESPONSE M

K12 = 13

K12b. [Are you currently/Is he currently/Was he] enrolled in an American Indian or Alaska Native tribe?

Select one only

 Yes, enrolled 2

 No, but have applied and awaiting approval 1

 No, not enrolled 0

NO RESPONSE M

ALL

K13. In what country [were you/was he] born?

Select one only

 USA 059 GO TO BOX K13a

 Canada 301

 Mexico 303

 Another country (SPECIFY) 600

Specify

NO RESPONSE M

PROGRAMMER SKIP BOX K13a

IF RESPONDENT IS BIRTH OR ADOPTIVE FATHER [SC9 = 12, 14], CONTINUE.

IF NOT BIRTH FATHER AND BIRTH FATHER IS ALIVE, [SC9 = 11, 13, 15 - 30, M AND K1 = 12-25, M] CONTINUE.

IF SOMEONE ELSE AND BIRTH FATHER IS DECEASED, [K1 = 11], GO TO SECTION L.

K1 = 12-25, M AND K13 = 066-600, M

K14. How many years [have you/has he] lived in the United States? (Your best estimate is fine.)

YEARS

NO RESPONSE M

PROGRAMMER SKIP BOX =k16a

IF FATHER IS NOT LIVING IN HOUSEHOLD [B5a-k =1, 3-18, M], GO TO VERSION BOX K33.

SEE BOX

B5a-k=2

K17. During the past week, did [you/[CHILD]’s father] work at a job for pay or income, including self employment (that is, the past 7 days)?

Select one only

 Yes 1 GO TO K21

 No, [I am/[CHILD]’s father is] retired 2 GO TO K24

 No, [I am/[CHILD]’s father is] disabled and unable to work 3 GO TO K24

 No (for reason other than retirement or disability) 0

NO RESPONSE M GO TO K24

B5a-k = 2 AND K17=0

K18. [Were you/Was he] on leave or vacation from a job for the past week (that is, the past 7 days)?

 Yes 1

 No 0

NO RESPONSE M

B5a-k = 2 AND K17=0

K19. [Have you/Has he] actively been looking for work in the past four weeks?

 Yes 1

 No 0

NO RESPONSE M

B5a-k = 2 AND K17=0

K20. Did [you/[CHILD]’s father] work at a job for pay or income, including self-employment, [in the last 12 months/since [MONTH AND YEAR OF LAST INTERVIEW]]?

 Yes 1

 No 0 GO TO VERSION BOX K3

NO RESPONSE M GO TO VERSION BOX K3

B5a-k = 2 AND (K17=1 OR K20=1)

K21. About how many total hours per week [do you/did you/does he/did he] usually work for pay or income, counting all jobs? If hours vary, please enter the average hours per week. (Your best estimate is fine.)

HOURS

NO RESPONSE M

B5a-k = 2

K24. What is the highest grade or year of school that [you/he] completed?

Select one only

 8th grade or lower 1

 9th to 11th grade 2

 12th grade but no diploma 3

 High school diploma/equivalent 4

 Vocational/technical program after high school but no vocational/technical diploma 5

 Vocational/technical diploma after high school 6

 Some college but no degree 7

 Associate’s degree 8

 Bachelor’s degree 9

 Graduate or professional school but no degree 10

 Master’s degree (MA, MS) 11

 Doctorate degree (Ph.D, EdD) 12

 Professional degree after bachelor’s degree (medicine/MD; dentistry/DDS; law/JD/LLB; etc.) 13

NO RESPONSE M

B5a-k = 2

K26. ((Are you/Is he) now attending or enrolled) in any courses, classes, or workshops for work-related reasons or personal interest? Some examples include college or university degree or certificate programs, computer courses, job training courses, basic reading or math classes, family literacy classes or GED preparation classes?

 Yes 1

 No 0

NO RESPONSE M

B5a-k = 2 AND K26 = 1

K27. (Are you/Is he) currently taking courses full-time or part-time?

Select one only

 Full-time 1

 Part-time 2

 Not currently taking 0

NO RESPONSE M

B5a-k = 2 AND K26 = 0, M

K28. (Are you/Is he) currently participating in a job-training or on-the-job-training program?

 Yes 1

 No 0

NO RESPONSE M

K33 BOX

IF CHILD'S BIOLOGICAL FATHER DOES NOT LIVE IN THE HOUSEHOLD, GO TO K33.

ELSE GO TO SECTION L.

B5a-k NE 2

K33. Now I have some questions about how far away [CHILD]'s father lives and the amount of contact he has with [him/her].

How many minutes away does [CHILD]'s father live from [him/her]?

Select one only

 10 minutes or less 1

 11 to 30 minutes 2

 31 to 59 minutes 3

 1 to 2 hours 4

 More than 2 hours 5

NO RESPONSE M

B5a-k NE 2

K35. How long has it been since he last saw [CHILD]?

(FIELD DESCRIPTION)

(RANGE NUMBER RANGE)

NO RESPONSE M

ENTER NUMBER AND UNIT.

IF FATHER SAW CHILD TODAY, ENTER 1 DAY.

IF FATHER HAS NEVER SEEN CHILD/CHILDREN, ENTER 0.

K35 BOX

IF LENGTH OF TIME SINCE BIOLOGICAL FATHER SAW CHILD IS LESS THAN OR EQUAL TO 3 MONTHS, GO TO K36.

ELSE IF LENGTH OF TIME SINCE BIOLOGICAL FATHER SAW CHILD IS

GREATER THAN 3 MONTHS, GO TO K36 BOX.

ELSE IF K35 = M, GO TO K39.

IF K35 < 3 months

K36. In the last 3 months, that is since [TIME FRAME], on how many days has [CHILD]’s father seen [him/her]?

Your best guess is fine.

NUMBER OF DAYS

(RANGE NUMBER RANGE)

NO RESPONSE M

K36 BOX

IF LENGTH OF TIME SINCE BIOLOGICAL FATHER SAW CHILD IS GREATER THAN ONE MONTH, GO TO K37.

ELSE, GO TO K39.

IF K36 > 1 MONTH

K37. Why hasn't he seen [CHILD] [more recently]? Is it because...

Select one only

 You do not want him to see [CHILD, 1 GO TO K43

 He does not want to see [CHILD], or 2 GO TO K43

 He has been unable to see [CHILD]? 3

NO RESPONSE M

K37 = 3

K38. Why has he been unable to see [CHILD]? Is it because.…

Select one only

 He lives too far away, 1

 He is sick or disabled, 2

 He is in the military, 3

 He is in jail or prison, or 4

 Some other reason? (SPECIFY) 99

Specify (STRING (NUM))

NO RESPONSE M

IF K35 = M

K39. In the last 3 months, how often have you been in touch with [CHILD]’s father, either by phone, letter, or other means? Is it…

Select one only

 Every day or almost every day, 1

 Several times a week, 2

 About once a week, 3

 Two or three times a month, 4

 About once a month, or 5

 Less often? 6

NO RESPONSE M

B5a-k NE 2

K43. Fathers who do not live with their children sometimes help out with them in other ways. Please tell me whether [CHILD]'s father has done these things often, sometimes, or never. How often has he done any of the following for [CHILD]?

Select one per row

	OFTEN	SOMETIMES	NEVER
a. Bought clothes, toys, or presents for [CHILD]?	1 	2 	3 
b. Paid for [CHILD]'s medical insurance, doctor bills, or medicines?	1 	2 	3 
c. Helped pay for [CHILD]’s child care expenses?	1 	2 	3 
d. Given you extra money to help out, not including child support?	1 	2 	3 

B5a-k NE 2

K44. Thinking about child support, do you have a legal agreement, an informal agreement, or no arrangement at all with [CHILD]'s father?

Select one only

 Legal 1

 Informal 2

 No arrangement 3

NO RESPONSE M

B5a-k NE 2

K45. Do you receive child support from the father on a regular basis?

 Yes 1

 No 0

NO RESPONSE M

B5a-k NE 2

K46. Do you receive financial support from the father’s family?

 Yes 1

 No 0

NO RESPONSE M

L. ABOUT RESPONDENT

PROGRAMMER VERSION BOX L

IF RESPONDENT IS [CHILD]’S BIOLOGICAL OR ADOPTIVE MOTHER OR FATHER [SC9 = 11-14], GO TO SECTION M.

IF RESPONDENT IS NOT BIOLOGICAL OR ADOPTIVE MOTHER OR FATHER [SC9=15-30, M] CONTINUE, ELSE GO TO L17.

ALL

L10. Are you of Spanish, Hispanic, or Latino origin?

 Yes 1

 No 0 GO TO L12

NO RESPONSE M GO TO L12

ALL

L12. What is your race? You may choose more than one if you like.

Select all that apply

 White 11 GO TO L17

 Black or African American 12 GO TO L17

 American Indian or Alaska Native 13

 Asian 26 GO TO L17

 Native Hawaiian, or other Pacific Islander 26 GO TO L17

 Another race (specify) 25 GO TO L17

Specify

NO RESPONSE M

if l12 = 13

L12b. Are you currently enrolled in an American Indian or Alaska Native tribe?

 Yes 1

 No 0

NO RESPONSE M

SC9 = 15-30, M

L17. During the past week, did you work at a job for pay or income, including self-employment (that is, the past 7 days)?

Select one only

 Yes 1 GO TO L21

 No, I am retired 2 GO TO L24

 No, I am disabled and unable to work 3 GO TO L24

 No (for reason other than retirement or disability) 0NO RESPONSE M GO TO L24

L17 = 0

L18. Were you on leave or vacation from a job for the past week?

 Yes 1

 No 0

NO RESPONSE M

L17 = 0

L19. Have you actively been looking for work in the past four weeks?

 Yes 1

 No 0

NO RESPONSE M

L17 = 0

L20. Did you work at a job for pay or income, including self employment, [in the last 12 months/since [MONTH AND YEAR OF LAST INTERVIEW]]?

 Yes 1

 No 0 GO TO L24

NO RESPONSE M GO TO L24

L17 = 1 OR L20 = 1

L21. About how many total hours per week [do you/did you] usually work for pay or income, counting all jobs? If hours vary, please enter the average hours per week. (Your best estimate is fine.)

HOURS

NO RESPONSE M

SC9 = 15-30, M

L24. What is the highest grade or year of school that you completed?

Select one only

 8th grade or lower 1

 9th to 11th grade 2

 12th grade but no diploma 3

 High school diploma/equivalent 4

 Vocational/technical program after high school but no vocational/technical diploma 5

 Vocational/technical diploma after high school 6

 Some college but no degree 7

 Associate’s degree 8

 Bachelor’s degree 9

 Graduate or professional school but no degree 10

 Master’s degree (MA, MS) 11

 Doctorate degree (Ph.D, EdD) 12

 Professional degree after bachelor’s degree (medicine/MD; dentistry/DDS; law/JD/LLB; etc.) 13

NO RESPONSE M

IF SC9 OR RESPONDENT FLAG = 13-30, M

L26. ((Are you now attending or enrolled) in any courses, classes, or workshops for work-related reasons or personal interest? Some examples include college or university degree or certificate programs, computer courses, job training courses, basic reading or math classes, family literacy classes or GED preparation classes?

 Yes 1

 No 0 GO TO L28

NO RESPONSE M GO TO L28

L26 = 1

L27. Are you currently taking courses full-time or part-time?

Select one only

 Full-time 1

 Part-time 2

 Not currently taking 3

NO RESPONSE M

SC9 = 13-30, M

L28. Are you currently participating in a job-training or on-the-job-training program?

 Yes 1

 No 0

NO RESPONSE M

M. INCOME AND HOUSING

ALL

M1. In the past six months, did you or anyone in your household receive any income or support from the following sources...

Select one per row

	Yes	No
a. [FILL WITH STATE WELFARE NAME] or welfare?	1 	0 
b. Unemployment insurance?	1 	0 
c. Food Stamps or SNAP benefits?	1 	0 
d. WIC - Special Supplemental Food Program for Women, Infants, and Children?	1 	0 
e. Child support?	1 	0 
f. SSI or Social Security Retirement, Disability, or Survivor’s benefits?	1 	0 
g. Payments for providing foster care, guardianship subsidies, or adoption assistance?	1 	0 
h. Energy assistance?	1 	0 

ALL

M3_amt. In the last 12 months, what was the total income of all members of your household from all sources before taxes and other deductions? Please include your own income and the income of everyone living with you. Please include money from jobs and public assistance programs, as well as any other sources, such as rental income, interest, dividends, and tribal subsidies or per capita distributions.

$X,XXX

NO RESPONSE M GO TO M4

M3 NE M

M3_per. Is that income per hour, per day, per week, every two weeks, for a month, or for a year?

Select one only

 Per hour 1 GO TO M9

 Per day 2 GO TO M9

 Per week 3 GO TO M9

 Every two weeks 4 GO TO M9

 Month 5 GO TO M9

 Year 6 GO TO M9

 Other (specify) 7 GO TO M9

Specify

NO RESPONSE M

M3_amt= M

M4. Was it…

 $25,000 or less, or 1

 more than $25,000? 2 GO TO M6

NO RESPONSE M GO TO M9

M4=1

M5. Was it…

Select one only

 $5,000 or less, 1 GO TO M9

 $5,001 to $10,000, 2 GO TO M9

 $10,001 to $15,000, 3 GO TO M9

 $15,001 to $20,000, or 4 GO TO M9

 $20,001 to $25,000? 5 GO TO M9

NO RESPONSE M

M4=2

M6. Was it…

Select one only

 $25,001 to $30,000, 6 GO TO M9

 $30,001 to $35,000, 7 GO TO M9

 $35,001 to $40,000, 8 GO TO M9

 $40,001 to $50,000, 9 GO TO M9

 $50,001 to $75,000, or 10 GO TO M9

 more than $75,000? 11 GO TO M9

NO RESPONSE M

ALL

M9. Do you currently own your home or apartment, pay rent, or live in public or subsidized housing?

Select one only

 Own or buying home or apartment 1

 Rent (without public assistance) 2

 Public or subsidized housing 3

 Live with someone else (whether you pay rent or not) 5

 Some other arrangement (SPECIFY) 99

Specify (STRING (NUM))

NO RESPONSE M

ALL

M9a. How often are these statements true about your housing?

Our housing is…

	SELECT ONE PER ROW
	NEVER TRUE	SOMETIMES TRUE	OFTEN TRUE	ALWAYS TRUE
a. Just the right size	1 	2 	3 	4 
b. Crowded	1 	2 	3 	4 
c. Needs major repairs	1 	2 	3 	4 
d. Old and aged	1 	2 	3 	4 
e. Kept in good condition	1 	2 	3 	4 

ALL

M9b. Does your home have adequate…

	SELECT ONE PER ROW
	YES	NO	DOES NOT APPLY – I DON’T HAVE THIS
a. Plumbing?	1 	0 	99 
b. Heating?	1 	0 	99 
c. Insulation?	1 	0 	99 
d. Water?	1 	0 	99 

ALL

M10. People do different things when they are running out of money for food to make their food or food money go further. For each statement below, tell me if it was often true, sometimes true, or never true for [you/your household]. In the last 12 months…

	SELECT ONE PER ROW
	OFTEN TRUE	SOMETIMES TRUE	NEVER TRUE
a. The food that [I/we] bought just didn’t last, and [I/we] didn’t have money to get more	1 	2 	3 
b. [I/We] couldn’t afford to eat balanced meals	1 	2 	3 

ALL

M11. In the last 12 months, did [you/you or other adults in your household] ever cut the size of your meals or skip meals because there wasn’t enough money for food?

 Yes 1

 No 0 GO TO M13

NO RESPONSE M GO TO M13

M11=1

M12. How often did this happen? Would you say…

Select one only

 almost every month, 1

 some months, but not every month, or 2

 in only 1 or 2 months? 3

NO RESPONSE M

ALL

M13. In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money to buy food?

 Yes 1

 No 0

NO RESPONSE M

ALL

M14. In the last 12 months, were you ever hungry but didn’t eat because you couldn’t afford enough food?

 Yes 1

 No 0

NO RESPONSE M

ALL

M15. Please think about how you feel about your family's economic situation. For each statement, indicate how much you agree or disagree.

	SELECT ONE PER ROW
	STRONGLY AGREE	AGREE	NEUTRAL	DISAGREE	STRONGLY DISAGREE
a. My family has enough money to afford the kind of home we need.	1 	2 	3 	4 	5 
b. We have enough money to afford the kind of clothing we need.	1 	2 	3 	4 	5 
c. We have enough money to afford the kind of food we need.	1 	2 	3 	4 	5 
d. We have enough money to afford the kind of medical care we need.	1 	2 	3 	4 	5 
c. We have enough money to afford the kind of car/transportation we need.	1 	2 	3 	4 	5 

ALL

M16. Think back over the past year. How much difficulty did you have with paying your bills each month? Would you say you had. . .

Select one only

 a great deal of difficulty, 1

 quite a bit of difficulty, 2

 some difficulty, 3

 a little difficulty or, 4

 no difficulty at all? 5

NO RESPONSE M

ALL

M17. Think again over the past 12 months. Generally, at the end of each month do you end up with...

Select one only

 not enough to make ends meet, 1

 almost enough to make ends meet, 2

 just enough to make ends meet, 3

 some money left over, or 4

 more than enough money left over? 5

NO RESPONSE M

P. CHILD HEALTH

ALL

P1. The next questions are about [CHILD]’s health and health related issues.

Overall, would you say [CHILD]’s health is…

Select one only

 excellent, 1

 very good, 2

 good,. 3

 fair, or 4

 poor? 5

NO RESPONSE M

ALL

P4a. Where does [CHILD] usually go if [she/he/he or she] is sick or you have concerns about [his/her/his or her] health?

Select one only

 A private doctor, private clinic, or HMO 1

 An outpatient clinic run by a hospital 2

 The emergency room at a hospital 3

 Public health department or community health center 4

 A migrant health clinic 5

 The Indian Health Service/Tribal Health Clinic or Hospital 6

 Someplace else (Specify) 99

NO RESPONSE M

ALL

P5. Where does [CHILD] go for routine medical care, like well-child care or regular check-ups?

Select one only

 Doesn’t get preventive care/There is no regular place 0 GO TO P5a

 A private doctor, private clinic, or HMO 1

 An outpatient clinic run by a hospital 2

 The emergency room at a hospital 3

 Public health department or community health center 4

 A migrant health clinic 5

 The Indian Health Service/Tribal Health Clinic or Hospital 6

 Someplace else (specify) 7

Specify

NO RESPONSE M GO TO P5a

P5 = 1-7

P5a1. Is that the same place [CHILD] usually goes when [he/she/he or she] is sick or you have concerns about [his/her] health?

 Yes 1

 No 0

NO RESPONSE M

P5=0 OR M

P5a. Does [CHILD] have a regular health care provider?

 Yes 1

 No 0

NO RESPONSE M

ALL

P7. When was the last time [CHILD] saw a doctor for a regular checkup? Was it . . .

Select one only

 6 months ago or less, 1

 more than 6 months ago, but not more than 1 year ago, 2

 more than 1 year ago, but not more than 2 years ago, 3

 more than 2 years ago, or 4

 never? 5

NO RESPONSE M

P7 = 3, 4, 5

P7_1. What were the reasons that [CHILD] has not seen the doctor for a regular checkup recently?

Select all that apply.

 Could not afford the cost 1

 Did not want to spend the money 2

 Insurance did not cover 3

 Doctor’s office is too far away 4

 Doctor’s office is not open at convenient times 5

 Another doctor recommended not doing it 6

 Afraid of or do not like doctors 7

 Unable to take time off from work 8

 Too busy 9

 I did not think anything serious was wrong 10

 Other reason (specify) 11

Specify

NO RESPONSE M

ALL

P8. When was the last time [CHILD] saw a dentist for a regular checkup? Was it . . .

Select one only

 6 months ago or less, 1

 more than 6 months ago, but not more than 1 year ago, 2

 more than 1 year ago, but not more than 2 years ago, 3

 more than 2 years ago, or 4

 never? 5

NO RESPONSE M

P8 = 2, 3, 4, 5

P8_1. What were the reasons that [CHILD] has not seen the dentist recently?

Select all that apply.

 Could not afford the cost 1

 Did not want to spend the money 2

 Insurance did not cover 3

 Dental office is too far away 4

 Dental office is not open at convenient times 5

 Another dentist recommended not doing it 6

 Afraid of or do not like dentists 7

 Unable to take time off from work 8

 Too busy 9

 I did not think anything serious was wrong 10

 Other reason (specify) 11

Specify

NO RESPONSE M

ALL

P8a. Is there a particular dentist or dental clinic that you take [CHILD] for dental care or advice?

 Yes 1

 No 0

NO RESPONSE M

U. YOUR FEELINGS

ALL

U1. The next questions are about how you have felt about yourself and your life in the past week. There are no right or wrong answers.

Please select if you felt this way rarely or never, some or a little, occasionally or a moderate amount of time, or most or all of the time in the past week?

(Click here for a definition of “shake off the blues.”)

HELP SCREEN:

Not being able to “shake off the blues” refers to feeling sad, unhappy, miserable, or down in the dumps for short periods.

Select one per row

	Rarely or never	Some or a little	Occasionally or moderately	Most or all
a. Bothered by things that usually don’t bother you	1 	2 	3 	4 
b. You did not feel like eating, your appetite was poor	1 	2 	3 	4 
c. You could not shake off the blues, even with help from your family and friends	1 	2 	3 	4 
d. You had trouble keeping your mind on what you were doing	1 	2 	3 	4 
e. Depressed	1 	2 	3 	4 
f. That everything you did was an effort	1 	2 	3 	4 
g. Fearful	1 	2 	3 	4 
h. Your sleep was restless	1 	2 	3 	4 
i. You talked less than usual	1 	2 	3 	4 
j. Lonely	1 	2 	3 	4 
k. Sad	1 	2 	3 	4 
l. You could not get “going”	1 	2 	3 	4 

X. TRACKING INFORMATION

ALL

X1. [Thank you for your help. The next questions will be about how to contact you in case we have any questions.]

[Thank you for your time. We will send you your thank-you gift card within the next 2 weeks. [We plan to interview you again in the spring and we need to know how to get in touch with you.]]

The next questions will be about how to contact you or people who will know how to find you.

First, what is your telephone number?

(___) ___-____

 Do not have a telephone number 1 GO TO X2

NO RESPONSE M GO TO X2

NUMBER PROVIDED AT X1

X1a. Whose name is that number listed under?

First Name: GO TO X3a

Middle Initial:

Last Name:

X1 = M

X2. Is there a number where you can be reached?

(___) ___-____

NO RESPONSE M GO TO X4

NUMBER PROVIDED AT X2

X3. Whose telephone is that?

First Name: GO TO X3a

Middle Initial:

Last Name:

NO RESPONSE M GO TO X4

X3 NE M AND X2 NE M

X3a. Do you have another phone number like a cell phone number?

(___) ___-____

CELL PHONE

(___) ___-____

OTHER

 No cell phone or other phone number 1

NO RESPONSE M

ALL

X4. Please enter your full name and permanent address.

First Name:

Middle Initial:

Last Name:

Street Address 1:

Street Address 2:

City:

State:

Zip:

NO RESPONSE M

END. This completes the interview. Thank you for your participation in FACES.

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	AIAN FACES FALL 2015 WORKING PARENT SURVEY
Subject	WEB
Author	MATHEMATICA STAFF
File Modified	0000-00-00
File Created	2021-01-23