Parent Child Report

OMB No.: 0970–0354

AFFIX LABEL HERE

Expiration Date: xx/xx/xxxx

Parent Child Report

This cross-walk version of the questionnaire includes items to be asked of parents of children ages newborn to 36 months, flagged as appropriate for the relevant age forms:

• Version 1: Newborn to 7 month

• Version 2: 8 months to 16 months

• Version 3: 17 months to 30 months

• Version 4: 31 months to 37 months

Pregnant women will not be asked to complete the Parent Child Report.

Draft for OMB (Redacted)

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 0970–0354 and the expiration date is XX/XX/XXXX.

ABOUT THIS SURVEY

• The questions in this survey are about you and your child, your child’s health, and your family routines. This collection of information will be used to describe the characteristics of children and families served by Early Head Start, and the characteristics and features of programs and staff that serve them.

• The survey will take about 15 minutes to complete. The questions in this survey can be answered by marking an “X” in the box. For a few questions, you will be asked to write in a brief response.

1 □ 2 □ 3 □

• If you are unsure how to answer a question, please give the best answer you can rather than leaving it blank.

• Your participation in the study is voluntary. All information you provide will be kept private to the extent permitted by law. Your name and your child’s name will not be attached to any information you give us. Your answers will not affect you or your child’s participation in any Early Head Start program.

• If you have any questions, please contact the Baby FACES team at Mathematica Policy Research at [insert toll-free number].

ABOUT YOU AND YOUR CHILD
R1. What is your relationship to the Baby FACES child? 1 □ Mother / Female Guardian 2 □ Father / Male Guardian 3 □ Grandmother 4 □ Grandfather 5 □ Other Relative 6 □ Other Non-Relative	R2. What is this child’s date of birth? | | | / | | | / | | | | | month day year R3 only for version of instrument for parents of children 8-16 months old. Parents of children 8 to 11 months will be routed out of the BITSEA (Section A). R3. Is this child 12 months of age or older? 0 □ No GO TO B1 (PAGE XX) 1 □ Yes

Source: BITSEA, A1-A2 (PROPRIETARY)

Included in versions: 2 [8-16 mos], 3 [17-30 mos], and 4 [31-37 mos]

Same items for all age versions (appropriate for 12-36 months only)

A1. The first set of questions contains statements about 1- to 3-year-old children. Many statements describe normal feelings and behaviors, but some describe things that can be problems. Some may seem too young or too old for your child. Please do your best to answer every question.

For each statement, please mark the answer that best describes your child in the past month.

Items A1a to A1hh are protected under copyright and have been redacted from this instrument.

Source: Briggs-Gowan, M.J., and A.S. Carter. The Brief Infant–Toddler Social and Emotional Assessment (BITSEA). San Antonio, TX: Harcourt Assessment, 2006.

A2. The following questions are about feelings and behaviors that can be problems for young children. Some of the questions may be a bit hard to understand, especially if you have not seen them in a child. Please do your best to answer them anyway.

For each statement, please mark the answer that best describes your child in the past month.

Items A2a to A2h are protected under copyright and have been redacted from this instrument.

Source: Briggs-Gowan, M.J., and A.S. Carter. The Brief Infant–Toddler Social and Emotional Assessment (BITSEA). San Antonio, TX: Harcourt Assessment, 2006.

Source: MacArthur-Bates Communicative Development Inventories, Infant and Toddler Short Forms and CDI-III (PROPRIETARY)

Included in versions: 2 [8-16 mos], 3 [17-30 mos], and 4 [31-37 mos]; Different item sets for age versions

PARENTS WILL BE ASKED TO COMPLETE THE CDI WORD LIST IN EITHER ENGLISH OR SPANISH (BASED ON PRIMARY HOME LANGUAGE) USING THE RELEVANT AGE FORM: LEVEL I (8-18 MONTHS); LEVEL II (16-30 MONTHS); OR LEVEL III (30-37 MONTHS). THESE AGE-BASED LISTS INCLUDE APPROXIMATELY 100 WORDS EACH.

B1. Below is a list of typical words in young children’s vocabularies. We are interested specifically in the words this child understands or says in English.

For words your child does not yet understand, mark the first column (does not understand). For words your child understands but does not yet say, mark the second column (understands). For words your child understands and also says, mark the third column (understands and says). If your child uses a different pronunciation of a word (for example, “raffe” for “giraffe” or “sketti” for “spaghetti”) mark the word anyway. For each item, please mark only one response.

Remember, this is a “catalogue” of words that are used by many different children. Don’t worry if your child knows only a few right now.

These items are protected under copyright and have been redacted from this instrument.

Source: MacArthur-Bates Communicative Development Inventories.

Source: MacArthur-Bates Communicative Development Inventories, Infant Long Form, First Communicative Gestures (12 items) (PROPRIETARY)

Included in versions: 2 [8-16 mos]

B2.1. When infants are first learning to communicate, they often use gestures to make their wishes known. For each item below, mark the response that describes your child’s actions right now.

Items B2.1a to B2.1l are protected under copyright and have been redacted from this instrument.

Source: MacArthur-Bates Communicative Development Inventories.

Source: MacArthur-Bates Communicative Development Inventories, Toddler Short Form and CDI-III, Combining words (PROPRIETARY)

Included in versions: 3 [17-30 mos] and 4 [31-37 mos]

B2.2. This item is protected under copyright and has been redacted from this instrument.

Source: MacArthur-Bates Communicative Development Inventories.

section c: child health

Source: Items C1-C7 adapted from Baby FACES 2009 Parent Interview

Included in versions: 1 [newborn-7 mos], 2 [8-16 mos], 3 [17-30 mos], and 4 [31-37 mos]; items vary slightly by age (see annotations below)

In this section, we would like to learn about your child’s overall health, health care, and general well-being.

C1. Which of the following best describes your child’s overall health?

1 □ Excellent

2 □ Very good

3 □ Good

4 □ Fair

5 □ Poor

C2. Does your child have a regular health care provider? This can include a doctor, nurse, or other health care worker.

0 □ No GO TO C3

1 □ Yes

C2a. Did your Early Head Start program help you find your child’s regular health care provider?

0 □ No

1 □ Yes

C3. How old was your child when they last saw a doctor, nurse, or other health care worker for a well-visit or regular checkup? Please record your child’s age in months at the time of the visit.

IF YOUR CHILD WAS LESS THAN 1 MONTH OLD, WRITE ‘01’ BELOW

|___|___| MONTHS OLD

C4. What is your child’s immunization status?

1 □ has received all required shots for his/her age (completely up-to-date)

2 □ has received most of the required shots

3 □ has received only a few of the required shots

4 □ my child has not received any immunizations

NOT INCLUDED IN VERSION 1 (PARENTS OF CHILDREN NEWBORN TO 7 MONTHS)

C5. Has your child ever seen a dentist?

0 □ No

1 □ Yes

C6. Does [CHILD] have an Individualized Family Service Plan (IFSP)? This is a written plan that describes goals for your child and the services (he/she) should receive.

0 □ No GO TO C7

1 □ Yes

C6a. Was this plan developed with the help of staff at your child’s Early Head Start program?

0 □ No

1 □ Yes

C7. Below is a list of different special needs that children sometimes have. Some of these may not apply to your child, but please do your best to answer every question. For each statement, please mark only one response. Does your child have…

	MARK ONE PER ROW
	Does your child have…
	NO	YES
a. behavioral trouble or difficulty paying attention to learn?.........................	0 	1 
b. difficulty hearing and understanding speech in a normal conversation?	0 	1 
c. difficulty seeing objects in the distance or letters on paper?....................	0 	1 
d. any physical development issues such as problems with the way (he/she) uses (his/her) arms or legs?............................................................	0 	1 
e. a below-normal activity level?........................................................................	0 	1 
f. difficulty with speech or communicating?....................................................	0 	1 
g. trouble sleeping because of a breathing problem or sleep apnea? This does not include temporary snoring due to a cold or congestion……………………………………………………………………………	0 	1 
h. a developmental disability or delay?.............................................................	0 	1 

Source: Parenting Stress Index, 4th Edition Short Form (PROPRIETARY)

Included in versions: 1 [newborn-7 mos], 2 [8-16 mos], 3 [17-30 mos], and 4 [31-37 mos]; same items for all age versions

D1. Having a child can sometimes be stressful. The next set of questions contains statements about how stressful having a child has been for you and the ways in which you have had to adjust your life. For each statement, please mark how much you agree or disagree.

Items D1a to D1gg are protected under copyright and have been redacted from this instrument.

Source: Parenting Stress Index, 4th Edition Short Form.

D2a. This item is protected under copyright and has been redacted from this instrument.

Source: Parenting Stress Index, 4th Edition Short Form.

D2b. This item is protected under copyright and has been redacted from this instrument.

Source: Parenting Stress Index, 4th Edition Short Form.

D2c. This item is protected under copyright and has been redacted from this instrument.

Source: Parenting Stress Index, 4th Edition Short Form.

Source: Child-Parent Relationship Scale, Short Form (CPRS-SF)

Included in versions: 1 [newborn-7 mos], 2 [8-16 mos], 3 [17-30 mos], and 4 [31-37 mos]

E1. Please think about the degree to which each of the following statements currently applies to your relationship with your child. For each statement, please mark only one response.

	MARK ONE PER ROW
	How much does this currently apply to your relationship with your child?
	DEFINITELY DOES NOT APPLY	NOT REALLY	NEUTRAL/ NOT SURE	APPLIES SOMEWHAT	DEFINITELY APPLIES
a. I share an affectionate, warm relationship with my child	1 □	2 □	3 □	4 □	5 □
b. My child and I always seem to be struggling with each other	1 □	2 □	3 □	4 □	5 □
c. If upset, my child will seek comfort from me	1 □	2 □	3 □	4 □	5 □
d. My child is uncomfortable with physical attention or touch from me	1 □	2 □	3 □	4 □	5 □
e. My child values his/her relationship with me	1 □	2 □	3 □	4 □	5 □
f. When I praise my child, he/she beams with pride	1 □	2 □	3 □	4 □	5 □
g. My child spontaneously shares information about himself/herself	1 □	2 □	3 □	4 □	5 □
h. My child easily becomes angry at me	1 □	2 □	3 □	4 □	5 □
i. It is easy to be in tune with what my child is feeling	1 □	2 □	3 □	4 □	5 □
j. My child remains angry or is resistant after being disciplined	1 □	2 □	3 □	4 □	5 □
k. Dealing with my child drains my energy	1 □	2 □	3 □	4 □	5 □
l. When my child is in a bad mood, I know we’re in for a long and difficult day	1 □	2 □	3 □	4 □	5 □
m. My child’s feelings toward me can be unpredictable or can change suddenly	1 □	2 □	3 □	4 □	5 □
n. My child is sneaky or manipulative with me	1 □	2 □	3 □	4 □	5 □
o. My child openly shares his/her feelings and experiences with me	1 □	2 □	3 □	4 □	5 □

Source: Healthy Families Parenting Inventory (Parent/Child Interaction and Social Support subscales), E2-E3 (PROPRIETARY)

Included in versions: 1 [newborn-7 mos], 2 [8-16 mos], 3 [17-30 mos], and 4 [31-37 mos]; same items for all age versions

E2. Below is a list of statements that describes how some parents may behave or feel about their child. For each statement, please mark the answer that best fits for you.

Items E2a to E2j are protected under copyright and have been redacted from this instrument.

Source: Healthy Families Parenting Inventory (Parent/Child Interaction subscale)

E3. The below statements also describe how some parents may behave or feel. For each statement, please mark the answer that best fits for you.

Items E3a to E3e are protected under copyright and have been redacted from this instrument.

Source: Healthy Families Parenting Inventory (Social Support subscale)

E4. Below, please record the date you completed this form.

DATE COMPLETED: | | | / | | | / | | | | |

month day year

Thank you for your participation in Baby FACES!