Parent Survey

RESPONDENT ID# _______________ Project LAUNCH Parent Survey

Ages: 4 weeks to 18 months

Project LAUNCH Parent Survey: 4 weeks to 18 months

INFORMED CONSENT FORM FOR RESEARCH PARTICIPATION
PROJECT LAUNCH PARENT SURVEY*

We are conducting a study to learn about the social and emotional development of children from birth to eight years of age who live in your community. This study is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), an agency within the U.S. Department of Health and Human Services (HHS). Our research asks parents about following topics: children’s health; children’s social and emotional health; parent-child relationships; parent well-being; home environments; and parental social support.

If you choose to participate, you will be asked to fill out a survey about one of your children, who is between the ages of 0-8 years old. It will take about 30 minutes to complete. We plan to conduct this survey annually for two years and hope you will participate in the survey each year.

There are no risks in participating in this research beyond those experienced in everyday life. However, some of the questions are personal and may make you uncomfortable. Your participation in this study is voluntary. You can stop at any time, and you do not have to answer any questions you do not want to answer. Refusal to take part in or withdrawing from this study will not involve any penalty or loss of benefits you would receive otherwise.

Your responses will be kept private to the extent permitted by law. All findings will be reported in aggregate. If there are any publications or presentations resulting from this research, no personally-identifiable information will be shared because your name will not be linked to your answers. If you choose to withdraw from the study, we will maintain and analyze the data collected up to the time of withdrawal. However, if you request that we destroy all of your data and exclude your responses from the study results, we will honor your request.

Please contact Shannon TenBroeck, a member of the evaluation team at NORC, at (415) 315-2006 with questions, complaints, or concerns about this research. If you have any questions about your rights as a research participant, please contact the NORC Institutional Review Board (IRB) Manager by toll-free phone number at (866) 309-0542.

You must be 18 years of age or older to take part in this research study. If you agree to take part in this research study, please sign your name and indicate the date below. You will be given a copy of this consent form for your records.

_____________________________________________ _____________________

Participant Signature Date

Contacting you about future research:

This study will collect data from the same group of participants once per year for a total of two years. As such, we plan to keep your contact information on file for two years and contact you about participating in future parts of this study.

If you are interested in participating in future parts of this study and agree to your contact information being held in a secure location, please initial below.

_______________

Participant Initials

* The informed consent will be incorporated into the web survey. In lieu of a signature, respondents will be asked to click an “I consent” button in the survey.

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. OMB number: 0970-0373; Expiration date: XX/XX/XXXX

Project LAUNCH Parent Survey, 4 weeks-18 months

Child Demographics

1. Child’s name: ______________________________

2. Date of Birth (mm/dd/yyyy): __ __/ __ __/ __ __ __ __

3. What is [CHILD NAME]’s sex?

• Male

  

• Female

Other – Please specify child’s sex: _____________________

4. Is your [CHILD NAME] of Hispanic, Latino/a, or Spanish origin?

• No, not of Hispanic, Latino/a, or Spanish origin

  

• Yes – Mexican, Mexican American, Chicano/a

  

• Yes – Puerto Rican

  

• Yes – Cuban

  

• Yes – Another Hispanic, Latino/a, or Spanish origin – please specify: ____________________

5. What is [CHILD NAME]’s race? (One or more categories may be selected)

• White

  

• Black or African American

  

• American Indian or Alaska Native

  

• Asian Indian

  

• Chinese

  

• Filipino

  

• Japanese

  

• Korean

  

• Vietnamese

  

• Other Asian – please specify: ___________________

  

• Native Hawaiian

  

• Guamanian or Chamorro

  

• Samoan

  

• Other Pacific Islander – please specify: ____________________

  

• Another race – please specify child’s race: ______________________

6. What language does [CHILD NAME] speak at home?

English

• Spanish

  

• [list other majority languages in study population]

  

• Other ______________

7. How many individuals are in your household? (please provide the numbers below)

1. Adults ____

2. Children ages 0-5 ____

3. Children ages 6-12 ____

4. Children ages 13-17 ____

8. What is the birth order of [CHILD NAME]?

   1. First born (eldest child)

   2. Second born

   3. Third born

   4. Fourth born

   5. Fifth born

   6. Other, please specify: ___________

9. Is [CHILD NAME] covered by any form of health insurance or health plan?

Note: :  A health plan would include any private insurance plan through your employer or a plan that you purchased yourself, as well as a government program like Medicare or Medicaid.

Yes

5. No

   

6. Unsure

10. If yes, which of the following is [CHILD NAME]’s main source of health insurance?

A plan purchased through your employer

A plan purchased through your spouse's employer

7. A plan you purchased yourself directly from an insurance company

   

8. A plan you purchased yourself through a state or federal marketplace (e.g., [INSERT state-specific marketplace name] or healthcare.gov)

   

9. Medicaid/[INSERT state-specific Medicaid name]

   

10. Some other source. Please specify: _____________________________

11. What is the highest level of education you completed?

11. Less than high school

    

12. High school or high school equivalent (GED)

    

13. Some college

    

14. 2-year college degree (e.g., Associate’s degree)

    

15. 4-year college degree or higher (e.g., Bachelor’s degree, Master’s degree, PhD)
    
    
    

12. Do you have a job either full or part time?

Yes, full time

Yes, part time

16. No

    

17. Retired

    

18. Disabled

    

19. Unable to work
    
    
    

13. What is the total annual income of your household?

20. Less than $10,000

    

21. $10,000 – less than $25,000

    

22. $25,000 – less than $50,000

    

23. $50,000 or more

Child Health Status

	Yes	No
Does [CHILD NAME] currently need or use medicine prescribed by a doctor, other than vitamins?	⃝	⃝
Does [CHILD NAME] need or use more medical care, mental health or educational services than is usual for most children of the same age?	⃝	⃝
Is [CHILD NAME] limited or prevented in any way in [CHILD NAME]’s ability to do the things most children of the same age can do?	⃝	⃝
Does [CHILD NAME] need or get special therapy, such as physical, occupational, or speech therapy?	⃝	⃝
Does [CHILD NAME] have any kind of emotional, developmental, or behavioral problem for which [CHILD NAME] needs treatment or counseling?	⃝	⃝

For each condition, please tell me if a doctor or other health care provider ever told you that [CHILD NAME] had the condition, even if [CHILD NAME] does not have the condition now.	Yes	No
Has a doctor or health professional ever told you that [CHILD NAME] has any of the following conditions?
Attention Deficit Disorder or Attention Deficit Hyperactive Disorder	⃝	⃝
Depression	⃝	⃝
Anxiety Problems	⃝	⃝
Behavior or conduct problems	⃝	⃝
Autism, Asperger’s Disorder, pervasive development disorder, or other autism spectrum disorder	⃝	⃝
Intellectual disability or mental retardation	⃝	⃝

Child Physical Health

Preventive care/Screening

	# of Times
During the past 12 months/since [CHILD NAME]’s birth, how many times did [CHILD NAME] see a doctor, nurse, or other health care provider for preventive medical care such as a physical exam or well-child checkup?
	Yes	No
During the past 12 months/since [CHILD NAME]’s birth, did [CHILD NAME] see a dentist for any kind of dental care, including check-ups, dental cleanings, x-rays, or filling cavities?	⃝	⃝
Has [CHILD NAME] ever had his/her vision tested with pictures, shapes, or letters?	⃝	⃝
Sometimes a child’s doctor or other health care providers will ask a parent to fill out a questionnaire at home or during their child’s visit. During the past 12 months, did a doctor or other health care provider have you fill out a questionnaire about specific concerns or observations you may have about [CHILD NAME]’s development, communication, or social behaviors? (If No, skip to question 24)	⃝	⃝
a. Did this questionnaire ask you about your concerns or observations about how [CHILD NAME] talks or makes speech sounds?	⃝	⃝
b. Did this questionnaire ask you about your concerns or observations about how [CHILD NAME] interacts with you and others?	⃝	⃝
c. Did this questionnaire ask you about your concerns or observations about words and phrases [CHILD NAME] uses and understands?	⃝	⃝
d. Did this questionnaire ask you about your concerns or observations about how [CHILD NAME] behaves and gets along with you and others?	⃝	⃝

Service receipt

	Yes	No
During the past 12 months, was there any time when [CHILD NAME] needed health care but it was delayed or not received?	⃝	⃝
(If No, skip to question 25) If Yes, was it…
Medical Care?	⃝	⃝
Dental Care?	⃝	⃝
Vision Care?	⃝	⃝
Mental health services?	⃝	⃝
Something else?	⃝	⃝
During the past 12 months, did [CHILD NAME] see a specialist other than a mental health professional?	⃝	⃝

General

	# of Days
During the past 12 months, about how many days did [CHILD NAME] miss childcare because of illness or injury?

	Excellent	Very Good	Good	Fair	Poor
In general, how would you describe [CHILD NAME]’s health?	⃝	⃝	⃝	⃝	⃝

Child Social-Emotional Health

During the past 4 weeks, how often did [CHILD NAME] …	Never	Rarely	Occasionally	Frequently	Very Frequently
Try to do new things	⃝	⃝	⃝	⃝	⃝
Imitate actions of others	⃝	⃝	⃝	⃝	⃝
Keep trying when unsuccessful	⃝	⃝	⃝	⃝	⃝
Show interest in what others were doing	⃝	⃝	⃝	⃝	⃝
Notice changes in surroundings	⃝	⃝	⃝	⃝	⃝
Adjust her/his energy level to the type of play	⃝	⃝	⃝	⃝	⃝
Act happy when praised	⃝	⃝	⃝	⃝	⃝
Explore surroundings	⃝	⃝	⃝	⃝	⃝
Express her/his dislikes	⃝	⃝	⃝	⃝	⃝
Reach for a familiar adult	⃝	⃝	⃝	⃝	⃝
Respond to her/his name	⃝	⃝	⃝	⃝	⃝
React to another child's cry	⃝	⃝	⃝	⃝	⃝
Keep trying to obtain a toy	⃝	⃝	⃝	⃝	⃝
Act in a way that makes others smile or show interest	⃝	⃝	⃝	⃝	⃝
Easily go from one activity to another	⃝	⃝	⃝	⃝	⃝
Seek attention when a familiar adult was with another child	⃝	⃝	⃝	⃝	⃝
Enjoy being around other children	⃝	⃝	⃝	⃝	⃝
Look to familiar adult when exploring her/his surroundings	⃝	⃝	⃝	⃝	⃝
During the past 4 weeks, how often did [CHILD NAME] …	Never	Rarely	Occasionally	Frequently	Very Frequently
Show pleasure when interacting with adults	⃝	⃝	⃝	⃝	⃝
Accept comfort from a familiar adult	⃝	⃝	⃝	⃝	⃝
Smile at familiar adults	⃝	⃝	⃝	⃝	⃝
Act happy	⃝	⃝	⃝	⃝	⃝
Respond positively to adult attention	⃝	⃝	⃝	⃝	⃝
Smile back at a familiar adult	⃝	⃝	⃝	⃝	⃝
Calm down with help from a familiar adult	⃝	⃝	⃝	⃝	⃝
Make eye contact with others	⃝	⃝	⃝	⃝	⃝
Act in a good mood	⃝	⃝	⃝	⃝	⃝
Seek comfort from familiar adults	⃝	⃝	⃝	⃝	⃝
Show affection for a familiar adult	⃝	⃝	⃝	⃝	⃝
Enjoy being cuddled	⃝	⃝	⃝	⃝	⃝
Enjoy interacting with others	⃝	⃝	⃝	⃝	⃝
Respond when spoken to	⃝	⃝	⃝	⃝	⃝

Parent-Child Relationship

Indicate how frequently each statement describes your beliefs or experiences

Never

Sometimes

Often

Almost always

When [CHILD NAME] is upset, I can calm him/her.

⃝

⃝

⃝

⃝

I know what [CHILD NAME] is thinking.

⃝

⃝

⃝

⃝

I can sense [CHILD NAME]’s moods.

⃝

⃝

⃝

⃝

I know when [CHILD NAME] will become upset.

⃝

⃝

⃝

⃝

I know when [CHILD NAME] wants to be left alone.

⃝

⃝

⃝

⃝

I enjoy spending time with [CHILD NAME].

⃝

⃝

⃝

⃝

I know what to say to calm down [CHILD NAME].

⃝

⃝

⃝

⃝

I know what [CHILD NAME] is feeling.

⃝

⃝

⃝

⃝

When upset, [CHILD NAME] comes to me for comfort.

⃝

⃝

⃝

⃝

[CHILD NAME] enjoys spending time with me.

⃝

⃝

⃝

⃝

I know how [CHILD NAME] will react in most situations.

⃝

⃝

⃝

⃝

I punish [CHILD NAME] when he/she misbehaves.

⃝

⃝

⃝

⃝

It’s my responsibility as a parent to punish all [CHILD NAME]’s misbehavior.

⃝

⃝

⃝

⃝

I insist that [CHILD NAME] follow the rules of the house.

⃝

⃝

⃝

⃝

I punish [CHILD NAME] so he/she learns the proper respect for others.

⃝

⃝

⃝

⃝

It is important for a child to follow family rules.

⃝

⃝

⃝

⃝

Children should do what parents tell them to do.

⃝

⃝

⃝

⃝

[CHILD NAME] and I go on outings together.

⃝

⃝

⃝

⃝

I teach [CHILD NAME] how to play new games.

⃝

⃝

⃝

⃝

[CHILD NAME] and I take walks together.

⃝

⃝

⃝

⃝

Indicate how frequently each statement describes your beliefs or experiences

Never

Sometimes

Often

Almost always

[CHILD NAME] and I play games together.

⃝

⃝

⃝

⃝

[CHILD NAME] and I do things together outdoors.

I am confident in my parenting ability.

⃝

⃝

⃝

⃝

I make good parenting decisions.

⃝

⃝

⃝

⃝

It is easy for me to make decisions about what [CHILD NAME] should do.

⃝

⃝

⃝

⃝

I have the energy that I need to cope with [CHILD NAME].

⃝

⃝

⃝

⃝

I remain calm when dealing with [CHILD NAME]’s behavior

⃝

⃝

⃝

⃝

I am in control of my household.

⃝

⃝

⃝

⃝

[CHILD NAME] is hard for me to handle.

⃝

⃝

⃝

⃝

During the last year, [CHILD NAME] has been difficult to take care of.

⃝

⃝

⃝

⃝

I lose my temper with [CHILD NAME].

⃝

⃝

⃝

⃝

[CHILD NAME] tests my limits.

⃝

⃝

⃝

⃝

I lose my patience with [CHILD NAME].

⃝

⃝

⃝

⃝

I overreact when [CHILD NAME] misbehaves.

⃝

⃝

⃝

⃝

It's hard being a parent.

⃝

⃝

⃝

⃝

I make a lot of mistakes when dealing with [CHILD NAME].

⃝

⃝

⃝

⃝

Parent Well-Being

These questions concern how you have been feeling over the past week. Fill in the bubble next to each question that best represents how you have been.	Rarely or none of the time (less than 1 day)	Some or a little of the time (1‐2 days)	Occasionally or a moderate amount of time (3‐4 days)	All of the time (5‐7 days)
I was bothered by things that usually don't bother me.	⃝	⃝	⃝	⃝
I had trouble keeping my mind on what I was doing	⃝	⃝	⃝	⃝
I felt depressed.	⃝	⃝	⃝	⃝
I felt that everything I did was an effort.	⃝	⃝	⃝	⃝
I felt hopeful about the future.	⃝	⃝	⃝	⃝
I felt fearful.	⃝	⃝	⃝	⃝
My sleep was restless.	⃝	⃝	⃝	⃝
I was happy.	⃝	⃝	⃝	⃝
I felt lonely.	⃝	⃝	⃝	⃝
I could not "get going."	⃝	⃝	⃝	⃝

Home Environment

In a typical week, how often do you or any other family members do the following things with [CHILD NAME]:	Not at all	Once or twice a week	Three to six times a week	Every day	Refused	Don’t know
Read books to [CHILD NAME]?	⃝	⃝	⃝	⃝	⃝	⃝
Tell stories to [CHILD NAME]?	⃝	⃝	⃝	⃝	⃝	⃝
Sing songs with [CHILD NAME]?	⃝	⃝	⃝	⃝	⃝	⃝
Take [CHILD NAME] along while doing errands like going to the post office, the bank, or the store?	⃝	⃝	⃝	⃝	⃝	⃝
Play peek-a-boo?	⃝	⃝	⃝	⃝	⃝	⃝
Do things like tickle [CHILD NAME], blow on [CHILD NAME]’s belly, or move [CHILD NAME]’s arms and legs around in a playful way?	⃝	⃝	⃝	⃝	⃝	⃝
Take [CHILD NAME] outside for a walk or to play in the yard, a park, or a playground?	⃝	⃝	⃝	⃝	⃝	⃝
Take [CHILD NAME] to a public place like a zoo or museum?	⃝	⃝	⃝	⃝	⃝	⃝

Social Support

Here is a list of some things that other people do for us or give us that may be helpful or supportive. Please read each statement carefully and fill in the bubble in the column that is closest to your situation.	As much as I would like	Almost as much as I would like	Some, but would like more	Less than I would like	Much less than I would like
I have people who care what happens to me.	⃝	⃝	⃝	⃝	⃝
I get love and affection.	⃝	⃝	⃝	⃝	⃝
I get chances to talk to someone about problems at work or with my housework.	⃝	⃝	⃝	⃝	⃝
I get chances to talk to someone I trust about my personal or family problems.	⃝	⃝	⃝	⃝	⃝
I get chances to talk about money matters.	⃝	⃝	⃝	⃝	⃝
I get invitations to go out and do things with other people.	⃝	⃝	⃝	⃝	⃝
I get useful advice about important things in life.	⃝	⃝	⃝	⃝	⃝
I get help when I am sick in bed.	⃝	⃝	⃝	⃝	⃝

Services Received

14. What preschool age group/classroom or elementary school grade is [CHILD NAME] in this year?

1. Preschool classroom: Infant

2. Preschool classroom: Age 1

3. Preschool classroom: Age 2

4. Preschool classroom: Age 3

5. Preschool classroom: Age 4

6. Preschool classroom: Age 5

7. Kindergarten

8. First grade

9. Second grade

10. Third grade

14. What is the name of [CHILD NAME]’s lead or primary teacher this year?

___________________________________________________

14. In the past year have you participated in a program where someone (a nurse, parent educator, home visitor, or someone else) visited your home to offer parental support or child development support?

1. Yes

2. No

If NO, skip to question #128. If YES, answer questions #125-127.

14. Do you remember if the home visitor was from one of these programs? [The list will be tailored to each site]

Note: If you participated in more than one program, please identify the one you participated in most recently.

1. Parents as Teachers

2. Nurse Family Partnership

3. Healthy Families

4. Another program. Please list the name: _____________________

5. Don’t know/Can’t remember

14. Thinking about [THE PROGRAM IDENTIFIED IN #125], how often did the visitor come to your home?

1. More than once per week

2. Once per week

3. Once every two weeks

4. Once per month

5. Only one time ever

6. Other. Please specify:_____________________

7. Don’t know/Can’t remember
   
   
   

14. Thinking about [THE PROGRAM IDENTIFIED IN #125], how long did you participate in the home visiting program?

1. One visit

2. More than one visit, but less than one month

3. 1-2 months

4. 3-4 months

5. 5-6 months

6. 7-8 months

7. 9-10 months

8. 11-12 months

9. More than 12 months

10. Don’t know/Can’t remember

14. In the past year, have you attended any workshops or programs on parenting or child development? (Some examples are Parent Cafes, Triple P, and Nurturing Parenting.) [These will be tailored to each site]

1. Yes

2. No

If NO, skip to question #132. If YES, answer questions #129-131.

14. Was the workshop or program one of the following? [These will be tailored to each site, and will be listed with a brief description]

Note: If you participated in more than one program or workshop, please identify the one you participated in most recently.

• Parent Cafes

• Triple P

• Nurturing Parenting

• Another program or workshop. Please list the name: ____________________

• Don’t know/Can’t remember

14. Thinking about [WORKSHOP OR PROGRAM IDENTIFIED IN #129], how many individual workshop or program sessions did you attend in the past year?

Note: By session, we mean each time it met. For example if a program met three times, on three consecutive Saturdays, and you went to all 3, then you went to 3 sessions.

1. 1 session

2. 2 to 4 sessions

3. 5 to 9 sessions

4. 10 to 14 sessions

5. 15 to 19 sessions

6. 20 or more sessions, please estimate total number: _____________________

7. Don’t know/Can’t remember

14. Thinking about [WORKSHOP OR PROGRAM IDENTIFIED IN #129], how many months in the past year did you attend at least one workshop or program?

Enter number of months: _______

14. In the past year, has [CHILD NAME] been to the pediatrician for health care?

1. Yes

2. No

IF NO, skip to question #134. If YES, answer question #133.

14. What is the name of the pediatrician or medical practice? ________________________

14. In the past year, has [CHILD NAME]’s pediatrician referred [CHILD’S NAME] to see a therapist or counselor?

Note: By therapist or counselor, we mean a professional who is trained to give guidance on personal, social, or emotional issues. A therapist or counselor may be a mental health counselor, social worker, psychologist, or psychiatrist.

1. Yes

2. No

If NO, skip to question #136. If YES, answer question #135.

14. How many times did [CHILD NAME] see the therapist or counselor in the past year based on the pediatrician’s referral?

Note: If [CHILD NAME] was referred to more than one therapist or counselor in the past year, indicate the total number of times [CHILD NAME] visited any counselor as a result of the pediatrician’s referral.

1. 0

2. 1-2

3. 3-5

4. 7-9

5. 10 or more times

6. Don’t know/Can’t remember

14. In the past year, has anyone at [CHILD NAME]’s teacher or school referred [CHILD NAME] to see a therapist or counselor, as defined in question #134?

1. Yes

2. No

Note: By therapist or counselor, we mean a professional who is trained to give guidance on personal, social, or emotional issues. A therapist or counselor may be a mental health counselor, social worker, psychologist, or psychiatrist.

If NO, skip to question #138 (next section). If YES, answer question #137.

14. How many times did [CHILD NAME] see the therapist or counselor in the past year based on teacher/school referral?

Note: If [CHILD NAME] was referred to than more than one therapist or counselor in the past year, indicate the total number of times [CHILD NAME] visited any counselor as a result of the teacher/school referral.

1. 0

2. 1-2

3. 3-5

4. 7-9

5. 10 or more times

6. Don’t know/Can’t remember

Parent’s/Guardian’s Information

We will be conducting this survey with the same parents and guardians two more times—once next year and again the following year. In order to contact you, it is important that we collect some personal information, including your name, address, phone number, and email address.

Your personal information will be used only for the purpose of contacting you about completing future rounds of this survey. Your contact information will be kept strictly private, and it will be stored securely and separately from your survey responses.

14. What is your full name?

________________________________________________________________

FIRST NAME LAST NAME

14. What is your relationship to [SELECTED CHILD]?

1. Mother (including biological, adoptive, or step-mother)

2. Father (including biological, adoptive, or step-father)

3. Legal guardian

4. Grandmother

5. Grandfather

6. Non-relative caregiver

7. Something else (please specify): ________________________

14. What is your primary address?

___________________________________________________

Address Line 1: House # and Street Name

___________________________________________________

Address Line 2: Optional

___________________________________________________

Address Line 3: City, State, and ZIP Code

14. What is your primary telephone number?

( _ _ _ ) _ _ _ - _ _ _ _

14. What type of phone number is it?

1. Cell or mobile

2. Home

3. Office

4. Other (please specify): __________________

14. Do you have a secondary telephone?

1. Yes

2. No

If No, skip to question 146. If Yes, continue to question 144.

14. What is your secondary telephone number?

( _ _ _ ) _ _ _ - _ _ _ _

14. What type of phone is your secondary number?

1. Cell or mobile

2. Home

3. Office

4. Other (please specify): __________________

14. What is your email address? (Please print clearly)

________________________________@_____________________

14. Is there another person who is very knowledgeable about [CHILD NAME]’s education and development, such as another parent or guardian, relative, or caregiver?

1. Yes

2. No

If No, the survey is complete. If Yes, continue to question #148.

14. What is this person’s relationship to [CHILD NAME]?

1. Mother (including a biological, adoptive, or step-mother)

2. Father (including a biological, adoptive, or step-fathers)

3. Legal guardian

4. Grandmother

5. Grandfather

6. Non-relative caregiver

7. Something else (please specify): ________________________

14. What is [CHILD NAME]’s [RELATIONSHIP IDENTIFIED IN #149]’s full name? [Note: We will only contact this person in the event we are unable to reach you in future years of the study.]

______________________________________________________________

First Name Last Name

14. What is [FIRST NAME OF PERSON IDENTIFIED IN #149]’s address?

___________________________________________________

Address Line 1: House # and Street Name

___________________________________________________

Address Line 2: Optional

___________________________________________________

Address Line 3: City, State, and ZIP Code

42