Track Changes of 10 - 6 Month Follow-up Survey for Sites testing Parenting Intervention

OMB Control No.: 0970-0485

Expiration Date: 9/30/2019

Expiration Date: 9/30/2019

10 - 6 month Follow-up Survey for Sites Testing Parenting Intervention

Building Bridges and Bonds

6-Month Follow-up Survey

OMB Control No.: xxxx-xxxx0970-0485

Expiration Date: xx/xx/201x9/30/2019

Table of Contents

Introduction………………………………………………………………………………………………………………………………4

Module A: Service Receipt and Participation……………………………………………………………………………..8

Module B: Household and family structure…………………….………………………………………………………..16

Module C: Father/Child Contact……………………………………………………………………………..……………….20

Module D: Father Engagement and Child Temperament .………………………………………………………..25

Module E: Discipline and Parenting Skills………………………………………………………………………………..29

Module F: Father/Child Relationship Quality ………………………………………………………………………….31

Module G: Parenting Efficacy……………………………………………..……………………………………………………33

Module H: Father Commitment to Child………………………………………………………………………………….34

Module I: Co-Parenting Relationship Quality…………………..………………………………………………………36

Module J: Child Support……………………………………………………………………………..……………………………39

Module K: Employment ……………………………………………………………………………..…………………………..42

Module L: Cognitive and Behavioral………………………………………………………………………………………..51

Module M: Respondent Contact Information………………………………………………………………………….54

CAPI PROGRAM ONLY:

[INTERVIEWER: DO NOT READ]

P1: HOW IS THE SURVEY BEING ADMINISTERED:

1. BY PHONE [SKIP TO INTRO]

2. IN-PERSON – NON-INCARCERATED [SKIP TO INTRO]

3. IN-PERSON – INCARCERATED

P2: IF INCARCERATED, HOW WAS THE DATA COLLECTED:

1. CELLPHONE CALL TO PHONE CENTER

2. CAPI SURVEY CONDUCTED ON LAPTOP

3. PAPER SURVEY

Hello. My name is _____________. I am here/calling from Abt SRBI on behalf of the Building Bridges and Bonds study or B3. Could I please speak with __________________?

INTERVIEWER: IF NECESSARY, READ: “(RESPONDENT) has agreed to help with a study on fatherhood programs in (CATI: INSERT SITE LOCATION).

INTERVIEWER: IF FIRST PERSON WAS NOT REPONDENTRESPONDENT AND NOW TALKING TO RESPONDENT, READ: “Hello. My name is _____________. I am here/calling from Abt SRBI. I’m contacting/calling you about the Building Bridges and Bonds or B3 study you joined about 6-9 months ago.”

Thank you for taking the time to speak with me today.

I am conducting interviews with people who agreed to be in a study about a program called [INTERVENTION NAME]Just Beginning offered at [SITE PROGRAM NAME]. The study is called Building Bridges and Bonds or B3 for short. It is funded by the U.S. Department of Health and Human Services and my company, Abt SRBI, is conducting this survey. You may have received a letter recently about the B3 study.

You entered the study in [RA Month, RA Year].  Your participation in this study will help policy-makers better understand how to help people deal with parenting and find and keep jobs. This interview will include questions about your parenting and co-parenting relationships, child support, employment, and financial well-being.

This interview should only take about 40 minutes.  [IF P1=3: SKIP THIS SENTENCE] [FOR CAPI VERSION: I] We will mail or e-mail [IF P1=2; give] you a $35 gift card [IF P1=2; money order] as a “thank you” for completing the interview.

Before we begin, I’d like to confirm that I am speaking with the correct person.

S1.

In order to do so, could you please give me your date of birth?

___________________ MONTH RANGE 1-12

___________________ DAY RANGE 1-31

___________________ YEAR RANGE 1930-2005

PROGRAMMER: VALIDATE AGAINST DOB FROM SAMPLE. IF DOB CONFIRMED, SET DOBCONF = 1 AND SKIP TO INFORMED CONSENT, ELSE SET DOBCONF=2.

S2.

Again, to confirm that I am speaking with the correct person, could you please give me the last four digits of your social security number?

____________________________

PROGRAMMER: VALIDATE LAST 4 SSN FROM SAMPLE. IF SSN4 CONFIRMED, SET SSNCONF = 1 AND SKIP TO INFORMED CONSENT, ELSE SET SSNCONF = 2.

FAIL_SCREENER

IF DOBCONF=2 and SSNCONF =2, SAY:

Thank you for taking the time to answer these questions. The information you provided does not match our records. I will need to check with my supervisor to determine how to resolve this issue. If we are able to do so, I will give you a call back.”

INFORMED CONSENT

Thank you for confirming this information with me.

Before we begin the survey, I would like to assure you that all of your responses on this survey will be kept private to the extent permitted by the law; the research staff has been trained in protecting private information and your name will not appear in any written reports we produce. All of the study results will be reported for groups of individuals; no results will be analyzed or reported for individuals.

Your responses to these questions are also completely voluntary. That means you may choose not to answer any question, or you may stop the interview if you wish, but we hope you don’t. Your responses to these questions will in no way affect your participation in the [PROGRAM NAME] program or affect your receipt of any kinds of public benefits or services.

According to the Paperwork Reduction Act, public reporting burden for this collection of information is estimated to average 40 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. Aan 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 control number for this collection is xxxx-xxxx0970-0485 and it expires xx/xx/xxxx9/30/2019. Please sSend comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Erika Lundquist; 16 E 34^th St, MDRC, 19^th Floor, New York, NY 10016; (212) 340-8605; Attn: OMB-PRA (XXXX-XXXX0970-0485).

[FOR CAPI: ELIMINATE THE FOLLOWING SENTENCE ABOUT MONITORING] And finally, this interview might be monitored or recorded for quality control purposes. Do I have your consent to continue?

1 YES (GO TO PRIVACY1)

2 NO [READ TERMINATION SCRIPT]

May I ask if you are declining to consent because you are concerned about the possibility of being recorded, or is it because you do not want to participate in the interview?

1 Don’t want to be recorded [CONTINUE TO RECORDING ISSUE]

2 Don’t want to do the interview [SKIP TO TERMINATION SCRIPT]

RECORDING ISSUE: I understand your concern. I can turn the recorder off and we can continue with the interview. Would that be satisfactory?

1 Yes [DISABLE RECORDER & CONTINUTE TO PRIVACY 1]

2 No [SKIP TO TERMINATION SCRIPT]

PRIVACY1

IF P1=3, SKIP TO PRIVACY3; ELSE:

[IF INTERVIEW IS WITH INCARCERATED RESPONDENT SKIP TO PRIVACY 3]

[IF INTERVIEW OVER THE PHONE]:

Thank you. Before we start with the main survey, I want to ask an additional question to ensure we properly keep you responseresponses private.

Are you currently living in a work release center or half-way house?

1 YES – IN A WORK RELEASE CENTER OR HALFWAY HOUSE

2 NO [SKIP TO PRIVACY3]

7 DK [SKIP TO PRIVACY3]

8 REF [SKIP TO PRIVACY3]

[IF INTERVIEW IN PERSON AND RESPONDENT NOT INCARCERATED]:

INTERVIEWER: ARE YOU CURRENTLY SPEAKING TO RESPONDENT ON SITE IN A WORK RELEASE CENTER OR HALFWAY HOUSE?

1 YES – IN A WORK RELEASE CENTER OR HALFWAY HOUSE

2 NO [SKIP TO PRIVACY3]

7 DK [SKIP TO PRIVACY3]

8 REF [SKIP TO PRIVACY3]

PRIVACY2

We want to make sure that you are in a place where you can answer questions without concerns of risk and that no one with authority over you is influencing your decision to participate in this survey. We also want to make sure that your conversation is not being monitored by anybody with authority over you. If at any point you feel uncomfortable telling me information, just let me know and we will stop the interview.

INTERVIEWER: IF RESPONDENT IS HESITANT ABOUT PROCEEDING, TRY TO UNDERSTAND AND ADDRESS HIS/HER CONCERN.

STOP INTERVIEW AND SCHEDULE CALLBACK IF APPROPRIATE.

REMEMBER TO LEAVE HELPFUL NOTES FOR NEXT INTERVIEWER.

1 CONTINUE

2 STOP INTERVIEW [ASSIGN DISPOSTION TO RECONTACT]

PRIVACY3

Okay then.

[IF RESPONDENT IS INCARCERATED THEN ADD:]

[If P1 = 3/In-Person Incarcerated Interview then add:] Before we begin, some of the questions in this survey may not be applicable given your current living situation. Please do your best to answer the questions.

[FOR ALL RESPONDENTS]: Let’s begin the survey.

1 [SKIP TO SECTION A]

TERMINATION SCRIPT

Thank you for taking the time to speak with me today. I’m sorry that you aren’t able to participate in our study. If you change your mind and decide you would like to participate, please call XXX-XXX-XXXX.

Module A: Service Receipt and Participation

Aside from any services your received at [B3 program] or [name of its formal partners], weWe would like to learn about other services you received in your community. Please do not include services from [B3 program] or [name of its formal partners]other service providers in your responses.

A1. Excluding help from [B3 program] or [name of its formal partners], sinceSince [RA month, RA year] didhave you receivereceived help from any program to develop or improve your parenting skills?

1 YES

2 NO [SKIP TO A2]

7 DON’T KNOW [SKIP TO A2]

8 REFUSED [SKIP TO A2]

A1a. Can you name the service providers that helped you?

________________

VERBATIM

97 DON’T KNOW

98 REFUSED

A1a. Was the help you received to develop or improve your parenting skills delivered most oftenMOST OFTEN in a workshop/group setting or one-on-one with a case manager or other staff?

1 Workshop/group setting

2 One-on-one with case manager or other staff

7 DON’T KNOW

8 REFUSED

A1b. How many times did you receive help to develop or improve your parenting skills since [RA month, RA year]?

How many weeks did you participate in these parenting services since [RA month, RA year]?

IF NEEDED: This help could be from workshops or one-on-one conversations with program staff.

______________________

Number of weeks

97 DON’T KNOW

98 REFUSED

A1c. ]During those weeks, how many hours a week did you usually spend receiving these parenting services?

INTERVIEWER IF NECESSARY: your best estimates are fine.

INTERVIEWER: ROUND UP IF NEEDED.

____________

Numer of hours/week (Range: 1-99)

997 DON’T NOW

998 REFUSED

A1d. Did you complete this program?

              1 YES

              2 NO

              7 DON’T KNOW

A2. andHow often did your child or children participate in programsthese parenting services with you?

1 Always or services together that were supposed to help you improve your father/child relationship?almost always

1 YES

2 NO [SKIP TO A3]Often

3 Sometimes

4 Rarely

5 Never

7 DON’T KNOW [SKIP TO A3]

8 REFUSED [SKIP TO A3]

A2a. Can you name the providers that offered these services?

__________________________

VERBATIM

97 DON’T KNOW

98 REFUSED

A2b. How many times did you participate in these services with your child or children since [RA month, RA year]?

___________________________

VERBATIM

97 DON’T KNOW

98 REFUSED

A2c. Was this program or service most often done in a workshop/group setting or one-on-one with a case manager or other staff?

1 Workshop/ Group setting

2 One-on-one with a case manager

7 DON’T KNOW

8 REFUSED

A2d. Did you complete this program?

              1 YES

              2 NO

              7 DON’T KNOW

8 REFUSED

A3. Excluding any help from [B3 program] or [name of its formal partners], Ssince [RA month, RA year] did you receive assistance from any program to help you to improve your communication and relationship with a spouse, co-parent, or romantic partner? your child or children’s other parent or legal guardian? These are sometimes called “healthy relationship” services.

1 YES

2 NO [SKIP TO A4]

7 DON’T KNOW [SKIP TO A4]

8 REFUSED [SKIP TO A4]

A3a. Can you name the service providers that helped you?

______________________

VERBATIM

97 DON’T KNOW

98 REFUSED

A3a. Were the healthy relationship services How many times didWas the assistance you receive helpreceived to improve your communication and relationhip with your child or children’s other parent or legal guardian since [RA month, RA year]?MOST OFTEN delivered in a workshop/group setting or one-on-one with a case manager or other staff?

________________________

VERBATIM

97 DON’T KNOW

98 REFUSED

A3c. Was the assistance you received to help you improve your communication and relationship with your child or children’s other parent or legal guardian most often in a workshop/group setting or one-on-one with a case manager or other staff?

1 Workshop/group setting

2 One-on-one with case manager or other staff

7 DON’T KNOW

8 REFUSED

Did you complete this program?

              1 YES

              2 NO

              7 DON’T KNOW

8 REFUSED

A3b. How many weeks did you receive help to improve your communication and relationhip with your childExcluding help from [B3 program] or [name of its formal partners],children’s other parent or legal guardian participate in healthy relationship services since [RA month, RA year]?

IF NEEDED: This help could be from workshops or one-on-one conversations with program staff.

________________________

Number of weeks

97 DON’T KNOW

98 REFUSED

A3c. During those weeks, how many hours a week did you usually spend receiving these services?

INTERVIEWER IF NECESSARY: your best estimates are fine.

INTERVIEWER: ROUND UP IF NEEDED.

____________

Numer of hours/week (Range: 1-99)

997 DON’T NOW

998 REFUSED

A3d. How often did your spouse, co-parent, or romantic partner participate in these healthy relationship services with you?

1 always or almost always

2 often

3 sometimes

4 rarely

5 never

8 DON’T KNOW

9 REFUSED

A4. Since [RA month, RA year], did you receive help to find or keep a job from a case manager, counselor, or help you deal with problems that interfered withanother service provider in your ability to workcommunity?

PROBESIF NEEDED: this could include help preparing a resume, filling out a job application, preparing for a job interview, deciding what jobs to look for, looking for jobs, help with transportation, or help obtaining work clothes or supplies.

1 YES

2 NO [SKIP TO A5]

7 DON’T KNOW [SKIP TO A5]

8 REFUSED [SKIP TO A5]

A4a. Can you name the service providers that helped you?

__________________________

VERBATIM

97 DON’T KNOW

98 REFUSED

A4a. How many times did you receive help to get or keep a job since [RA month, RA year]? Was the help you received to find or keep a job MOST OFTEN delivered in a workshop/group setting or one-on-one with a case manager or other staff?

___________________________

VERBATIM

97 DON’T KNOW

98 REFUSED

1 Workshop/ group setting

2 One-on-one with a case manager or other staff

7 DON’T KNOW

8 REFUSED

A4b. DidHow many weeks did you receive complete this program? help to get or keep a job since [RA month, RA year]?

              1 YES

              2 NO

              7 DON’T KNOW

8 REFUSED

IF NEEDED: This help could be from workshops or one-on-one conversations with program staff.

___________________________

Number of weeks

97 DON’T KNOW

98 REFUSED

A4c. How During those weeks, how many timeshours a week did you receive substance abuseusually spend receiving these services since [RA month, RA year]??

____________________________

VERBATIM

97NTERVIEWER IF NECESSARY: your best estimates are fine.

INTERVIEWER: ROUND UP IF NEEDED.

____________

Numer of hours/week (Range: 1-99)

997 DON’T KNOW

98998 REFUSED

PROBES can be used if needed: this could include, detoxification, outpatient substance abuse treatment, medicinal treatment such as methadone, residential treatment, or self-help groups such as Alcoholics Anonymous or Narcotics Anonymous.

1 YES

2 NO [SKIP TO A6]

7 DON’T KNOW [SKIP TO A6]

8 REFUSED

A5a. Can you name the providers that helped you?

_________________________________

VERBATIM

97 DON’T KNOW

98 REFUSED

A5c. Was the substance abuse service most often delivered in a workshop/group setting or one-on-one with a case manager or other staff member?

1 Workshop/group setting

2 One-on-one with case manager or other staff member

7 DON’T KNOW

8 REFUSED

A5d. Did you complete this program?

              1 YES

              2 NO

              7 DON’T KNOW

8 REFUSED

A6. Excluding help from [B3 program] or [name of its formal partners], since [RA month, RA year] did you participate in any program to learn how patterns of thinking can affect your behavior or the choices you make?

PROBES can be used if needed: Sometimes this is called cognitive-behavioral services.

1 YES

2 NO [SKIP TO A7]

7 DON’T KNOW [SKIP TO A7]

8 REFUSED [SKIP TO A7]

A6a. Can you tell me the name of this service? Was it…

1 Thinking for a Change

2 Reasoning and Rehabilitation

3 Moral Reconation Therapy

4 Aggression Replacement Training

5 Interpersonal Problem Solving

6 Cognitive Interventions Program

7. Courage to Change

8 Other (SPECIFY_________________)

97 DON’T KNOW

98 REFUSED

A6b. Did you participate in this service while in jail or prison?

1 YES

2 NO

3 I have never been to jail or prison

7 DON’T KNOW

8 REFUSED

A6c. How many times did you receive this service since [RA month, RA year]?

____________________________

VERBATIM

97 DON’T KNOW

98 REFUSED

A6d. Was this service most often delivered in a workshop/group setting or one-on-one with a case manager or other staff member?

1 Workshop/group setting

2 One-on-one with case manager or other staff member

A6e. Did you complete this program?

              1 YES

              2 NO

              7 DON’T KNOW

8 REFUSED

Now, I want to ask you about your overall experiences with the [B3 organization].

A5. Are you still receiving support from [B3 organization]?

1 YES [SKIP TO A5b]

2 NO

3 I NEVER RECEIVED SUPPORT FROM [B3 ORGANIZATION] [SKIP TO B1]

7 DON’T KNOW

8 REFUSED

8 REFUSED

A5a. What was the main reason you stopped going to [B3 organization]? Was it that,

1 The program was I finished the program or service

2 I got what I needed before the program was finished

3 I did not like the program or service

4 I did not learn anything new

5 I had other commitments

6 Transportation or coordination issues

7 GotI got a job, or

8 Other Some other reason (SPECIFY_______________)

97 DON’T KNOW

98 REFUSED

97 DON’T KNOW

98 REFUSED

A5b. How often are you still in touch with staff at [B3 organization]?

1 Every day or almost every day

2 3 or 4 times per week

32 1 or 2 times per week

43 2 or 3 times in the past month

54 Once in the past month

65 Less than once a month, or

76 Not at all

97 DON’T KNOW

98 REFUSED

A5c. How often are you in touch with other fathers from [B3 organization]?

1 Every day or almost every day

2 3 or 4 times per week

32 1 or 2 times per week

34 2 or 3 times in the past month

54 Once in the past month

65 Less than once a month, or

76 Not at all

97 DON’T KNOW

98 REFUSED

These next questions are about your overall experiences with the [B3 organization]

A6. Thinking back on all the support and services you have received from [B3 organization], how helpful washave the programservices been to you on a scale from 1 – 105 where 1 is not very helpful and 105 is very helpful?

1 2 3 4 5 6 7 8 9 10

Not very helpful Very helpful

97 DON’T KNOW

98 REFUSED

A6a. Think back to all the times that the [B3 staff] contacted you – either by phone, email, text, or another way – how satisfied are you with the amount of contact from staff? Answer using a scale from 1 to 105, where 1 is you heard from them too much, 3 is you heard from them the right amount, and 5 is you did not hear from them enough and 10 is you heard from them too much.

1 2 3 4 5 6 7 8 9 10

Did not hear from them enough

2

3 heard from them the right amount

4

5 Heard from them too much

7 DON’T KNOW

8 REFUSED

97 DON’T KNOW

98 REFUSED

A6b. How would you rate the instructors and staff at [B3 organization] at understanding who you are and where you are coming from?

1 Excellent

2 Very good

3 Good

4 Fair

5 Poor

7 DON’T KNOW

8 REFUSED

IF RANDOM ASSIGNMENT = PROGRAM GROUP THEN GO TO A9A; IF RANDOM ASSIGNMENT = CONTROL GROUP THEN GO TO B1A.

A7. While you were involved in the [Just Beginning] programNowadays, how often diddo you use the skills were you learning between the program sessions?you learned from [B3 organization]?

1 Every day or almost every day

2 At least once a week

3 At least once a month

4 Less than once a month, or

7 DON’T KNOW

8 REFUSED

A9b. Nowadays, how often do you use the skills or strategies you learned in the [Just Beginning] program sessions?

1 Every day

2 Once a week

3 Once a month

4 Less than once a month

5 NEVERnever

7 DON’T KNOW

8 REFUSED

Module B: Household and family structure

The next questions ask about your biological and adoptedhow many children you told us about a few months agohave in different age groupsabout your children and relationships.

[BASELINE SURVEY RESPONSES TO B1A, B1B, B1C, B1D, AND B1E WILL BE FILLED IN WHERE IT SAYS #KIDS0T2, #KIDS3T4, #KIDS5T9, #KIDS10T17, #KIDS18PLUS]

B1a.1. [IF #KIDS0T2 >[DISPLAY DROP DOWN MENU WITH OPTIONS 0 THEN ASK B1A1.THROUGH 10 FOR QUESTIONS

B1. How many children do you have?

________

Number of children

97 Don’t Know

98 Decline to Answer

[CREATE VARIABLE FROM B1 RESPONSE CALLED #KIDS. IF B1 IS 97, 98 OR MISSING, #KIDS=97. IF #KIDS0T2 = 0KIDS IS = 1, THEN SKIP TO B4.]

B2. A few months ago,How many of your kids have you told usseen in person in the last 30 days?

______________

Number of children

97 Don’t Know

98 Decline to Answer

B3. How many of your kids live with you all or part of the time?

______________

Number of children

97 Don’t Know

98 Decline to Answer

B4. Do all of your children) between 0 and have the same mother?

1 Yes [SKIP TO B6]

2 years old. (Does this child/Do any of No

7 Don’t Know [SKIP TO B6]

8 Decline to Answer [SKIP TO B6]

B5. How many different mothers do these children) live with you at least half of the time have?

1 YES [SKIP TO B1b1]

2 NO

7 DON’T KNOW

8 REFUSED

B1a.2. Did you see (this child/any of these children) in the past 30 days?

1 YES

2 NO

7 DON’T KNOW

8 REFUSED

B1b.1. [IF #KIDS3T4 > 0 THEN ASK B1B1. IF #KIDS3T4 = 0 THEN SKIP TO B1C1]

A few months ago, you told us you had [#KIDS3T4] (child/children) between 3 and 4 years old. (Does this child/Do any of these children) live with you at least half of the time?

1 YES [SKIP TO B1c1]

2 NO

7 DON’T KNOW

8 REFUSED

B1b.2 Did you see (this child/any of these children) in the past 30 days?

1 YES

2 NO

7 DON’T KNOW

8 REFUSED

B1c.1. [IF #KIDS5T9 > 0 THEN ASK B1C1. IF #KIDS5T9 = 0 THEN SKIP TO B1D1]

A few months ago, you told us you had [#KIDS5T9] (child/children) between 5 and 9 years old. (Does this child/Do any of these children) live with you at least half of the time?

1 YES [SKIP TO B1d1]

2 NO

7 DON’T KNOW

8 REFUSED

B1c.2. Did you see (this child/any of these children) in the past 30 days?

1 YES

2 NO

7 DON’T KNOW

8 REFUSED

B1d.1. [IF #KIDS10T17 > 0 THEN ASK B1D1. IF #KIDS10T17 = 0 THEN SKIP TO B1E1]

A few months ago, you told us you had [#KIDS10T17] (child/children) between 10 and 17 years old. (Does this child/Do any of these children) live with you at least half of the time?

1 YES [SKIP TO B1e1]

2 NO

7 DON’T KNOW

8 REFUSED

B1d.2. Did you see (this child/any of these children) in the past 30 days?

1 YES

2 NO

7 DON’T KNOW

8 REFUSED

B1e.1 [IF #KIDS18PLUS > 0 THEN ASK B1E1. IF #KIDS18PLUS = 0 THEN SKIP TO B2]

A few months ago, you told us you had [#KIDS18PLUS] (child/children) 18 years of age or older. (Does this child/Do any of these children) live with you at least half of the time?

1 YES [SKIP TO B2]

2 NO

7 DON’T KNOW

8 REFUSED

B1e.2 Did you see (this child/any of these children) in the past 30 days?

1 YES

2 NO

7 DON’T KNOW

8 REFUSED

B2Please choose an answer from the numbers listed in the box below when you click on the down arrow.

____________________

NUMBER OF MOTHERS (RANGE: 1 TO #KIDS; IF #KIDS=97, DROP DOWN SHOULD DISPLAY 0 TO 20]

97 Don’t Know

98 Decline to Answer

B6. What is your current marital status?

1 Married living together [SKIP TO B5B8]

2 Separated

3 Never married

4 Divorced, or

5 Widowed

7 DON’T KNOW

8 REFUSED

B4. What is your current partnerrelationship status?

1 No I don’t have a current partner [SKIP TO B6]

2 DatingI’m currently dating

3 InI’m in a committed relationship but not

4 I’m engaged or married

4 Engaged to be married

5 I’m married

7 DON’T KNOW

8 REFUSED

7 DON’T KNOW

8 REFUSED

B5. Do you live with your spouse or partner…?

1 All of the time

2 Most of the time

3 Some of the time, or

4 None of the time

7 DON’T KNOW

8 REFUSED

A few months ago, you indicated that you had a child [AGE] years old named [FOCALCHILDNAME]. We would like to ask you some questions about your relationship with [FOCALCHILDNAME].

[IF CHILD IS DECEASED, INTERVIEWER SAYS: “I am so sorry for your loss.” THEN IF #KIDS>1, SKIP TO J1; OR IF #KIDS = 1, SKIP TO K1]

B9. Does your spouse or partner have any children that are not your biological children?

1 YES

2 NO [SKIP TO C1B11]

7 DON’T KNOW [SKIP TO C1B11]

8 REFUSED [SKIP TO C1B11]

B6B10. Are you a father figure to any of your spouse or partner’s children?

1 YES

2 NO

7 DON’T KNOW

8 REFUSED

B6. Which of the following best describes your relationship to [FOCALCHILDNAME]?

1 Biological father
2 Adoptive father
3 Step father
4 Foster parent
5 Father figure

6 Other (specify)

7 DON’T KNOW

8 REFUSED

B7. Were you present at the time of [FOCALCHILDNAME]’s birth?

1 YES

2 NO

7 DON’T KNOW

8 REFUSED

B8. Have you been part of [FOCALCHILDNAME]’s life continuously since (his/her) birth?

1 YES [SKIP TO C1]

2 NO

7 DON’T KNOW

8 REFUSED

B9. [SKIP IF BABY WAS 6 MONTHS OR YOUNGER AT BASELINE BECAUSE CAN DEFAULT TO LESS THAN 1 YEAR.] How long have you been a part of [FOCALCHILDNAME]'s life?

1 For less than 1 year
2 For 1-2 years
3 For more than 2 years

Module C: Father/Child Contact

A few months ago, you indicated that you had a child [AGE] years old named [FOCALCHILDNAME]. We would like to ask you some questions about your relationship with [FOCALCHILDNAME].

[IF CHILD IS DECEASED, INTERVIEWER SAYS: “I am so sorry for your loss.” THEN IF #KIDS>1, SKIP TO J1; OR IF #KIDS = 1, SKIP TO K1]

C1. Does [NAME OF CHILD] Do you live with you all or most of the time? [FOCALCHILDNAME]’s mother?

1 YES

2 NO

7 DON’T KNOW

8 REFUSED

C2. Does [FOCALCHILDNAME] live with you all or most of the time?

1 YES [SKIP TO D1]

2 NO

7 DON’T KNOW

8 REFUSED

C3. Who does [FOCALCHILDNAME] usually live with?

1 BiologicalTheir biological mother

2 GrandparentTheir grandparent(s)

3 OtherWith other relative(s)

4 FriendWith a friend

5 FosterIn foster care

6 AdoptiveWith an adoptive parent

7. Other (specify_________)

977 DON’T KNOW

98 REFUSED

C4. How long many minutes does it usually take for you to get from your home to [FOCALCHILDNAME]’s home?

_________________

Number of minutes

1 Less than 10 minutes

2 10-19 minutes

3 20-39 minutes

4 40 -59 minutes

5 1 to 2 hours

6 More than 2 hours, or

7966 I have never been to my child’s home

977 DON’T KNOW

8988 REFUSED

C5. In the past 30 days, how often did you talk on the phone; send letters, cards or texts, use FaceTime, Facebook, or other social media with [FOCALCHILDNAME]?

1 Every day or almost every day

2 3 or 4 times per week

3 1 or 2 times per week

4 2 or 3 times in the past month

5 Once in the past month, or

6 Not at all

7 DON’T KNOW

8 REFUSED

NAME OF9 MY CHILD IS TOO YOUNG FOR THIS

C6. When did you last see [FOCALCHILDNAME] in person?

1 Within the last week

2 Between 7 – 14 days ago

3 Between 15 – 29 days ago

4 1 – 2 months ago [SKIP TO C9]

5 3 – 6 months ago, or [SKIP TO C9]

6 More than 6 months ago [SKIP TO C9]

7 DON’T KNOW

8 REFUSED

C7. In the past 30 days, how often did you see [FOCALCHILDNAME] in person?

1 Every day or almost every day

2 3 or 4 times per week

3 1 or 2 times per week

4 2 or 3 times in the past month

5 Once in the past month, or

6 Not at all

7 DON’T KNOW

8 REFUSED

C8. In the past 30 days, how often many times did [FOCALCHILDNAME] spend the night with you?

_________________

Number of times [RANGE 0-30]

1 Every day or almost every day

2 3 or 4 times per week

3 1 or 2 times per week

4 2 or 3 times in the past month

5 Once in the past month, or

6 Not at all

97 DON’T KNOW

98 REFUSED

C9. Has your legal paternity been established? That is, did you sign any document that identifies you as the legal father of [FOCALCHILDNAME] or has the court ruled that you are the father?

1 Yes, legal paternity

1 YES, LEGAL PATERNITY

2 NO

7 DON’T KNOW

8 REFUSED

C9C10. Do you have shared custody of [FOCALCHILDNAME]?

1 YES

2 NO

7 DON’T KNOW

8 REFUSED

C9aC11. Do you have an agreement with the mother or guardian of [FOCALCHILDNAME] about spending time with [FOCALCHILDNAME]?

1 Yes, we have a legal document

2 Yes, we have a written agreement that is not court-ordered

3 Yes, we have a verbal understanding, or

4 No, we have no parenting agreement

7 DON’T KNOW

8 REFUSED

C10[IF C4 = 7 THEN SKIP TO C13]

C9. When you spend time with [FOCALCHILDNAME], how often are you at the home where [FOCALCHILDNAME] usually lives?

1 Always or almost always

2 Often

3 Sometimes

4 Rarely, or

5 Never

97 DON’T KNOW

98 REFUSED

C11[IF C1 = 1 THEN SKIP TO C14]. IF B4=1 (DON’T HAVE A CURRENT PARTNER), THEN SKIP TO C14.

C10. If you have a new spouse or partner that is not [FOCALCHILDNAME]’s mother, how encouraging or discouraging is your spouse or partner of your involvement with [FOCALCHILDNAME]?

1 Very discouraging

2 Somewhat discouraging

3 Neutral

4 Somewhat encouraging, or

5 Very encouraging, or

0 I DO NOT HAVE A NEW SPOUSE OR PARTNER do not have a new spouse or partner

7 DON’T KNOW

8 REFUSED

C11. In general, how satisfied are you with the amount of time you spend with [FOCALCHILDNAME]?

1 Very satisfied

2 Somewhat satisfied, or

3 Not satisfied

7 DON’T KNOW

8 REFUSED

Now we are going to list some things that can make it hard for fathers to spend time with their children. Thinking about the past month, please let me know how often you think each of the following statements applied to you.

		Often	Sometimes	Never	DOES NOT APPLY	DON’T KNOW	REFUSED
C13a	Living too far away makes it hard for me to spend time with [NAME OF CHILD]	1	2	3		7	8
C12a	MyIn the past month, my work or school schedule makesmade it hard for me to spend time with [FOCALCHILDNAME]	1	2	3	9	7	8
C12b	CarIn the past month, car problems or lack of transportation makemade it hard for me to spend time with [FOCALCHILDNAME]	1	2	3	9	7	8
C12c	Being homeless, or living inIn the past month, not having a car or shelter makesstable place to live made it hard for me to spend time with [FOCALCHILDNAME]	1	2	3	9	7	8
C13e	My house or apartment is not safe or not comfortable for [NAME OF CHILD]	1	2	3		7	8
C13f	My neighborhood is not safe for [NAME OF CHILD]	1	2	3		7	8
C13g	[IF C11=0 SKIP TO C13h] My new partner makes it difficult for me to see [NAME OF CHILD]	1	2	3		7	8
C13h	[NAME OF CHILD]’s mother or guardian makes it difficult for me to see him or her.	1	2	3		7	8
C12d	[NAME OF CHILD]'sIF C2=1 THEN SKIP TO C16eMODULE E] In the past month, it was hard to spend time with [FOCALCHILDNAME] because (his/her) mother‘s spouse or guardian has a new partner who doesdid not want me around.	1	2	3	9	7	8
C12e	AIn the past month, a court order or legal restriction makesmade it hard for me to spend time with [FOCALCHILDNAME]	1	2	3	9	7	8

Module D: Father Engagement

[IF (C6 = 4, 5, 6, 7, or 8) THEN INTERVIEWER WILL ASK: “Just to confirm, have you seen [FOCALCHILDNAME] in person in the last 30 days?” IF FATHER ANSWERS “NO” THEN SKIP TO D30 ]

The next questions ask about how often you did certain activities with [FOCALCHILDNAME] in the past 30 days. SomeIf some of these activities may fit better with a child of their age than others. If any of them don’t make sense because [FOCALCHILDNAME] is too young or old for them, it's okay to you, that’s fine, you can just say that you don’tdidn't do them at all.

In the past 30 days, how often did you (READ ITEM)? Was it every day or almost everymore than once a day, about once a day, 3 or 4a few times pera week, 1 or 2a few times per week, 2 or 3 times in the pasta month, once in the past monthrarely, or not at all.?

		Every day or almost everyMore than once a day	3-4 times per weekAbout once a day	1-2A few times pera week	2-3A few times in the pasta month	Once in the past monthRarely	Not at all in the past month	DON’T KNOW	REFUSED
D1.	Sing songs with [FOCALCHILDNAME]?	1	2	3	4	5	6	7	8
D2.	Dance with [FOCALCHILDNAME]?	1	2	3	4	5	6	7	8
D3.	Read stories to [FOCALCHILDNAME]?	1	2	3	4	5	6	7	8
D4.	Tell stories to [FOCALCHILDNAME]?	1	2	3	4	5	6	7	8
D5.	Talk to [FOCALCHILDNAME] about the things that (he/she) looked at, grabbed, or pointed to?	1	2	3	4	5	6	7	8
D6.	Hug or show physical affection to [FOCALCHILDNAME]?	1	2	3	4	5	6	7	8
D7.	Praise [NAME OF CHILDFOCALCHILDNAME]?	1	2	3	4	5	6	7	8

			More than once a day		About once a day		A few times a week		A few times a month		Rarely		Not at all in the past month		DON’T KNOW			REFUSED
D8.		Soothe [NAME OF CHILDFOCALCHILDNAME] if they (he/she) were was crying?		1		2		3		4		5		6		7	8
D9.		TakeTell [FOCALCHILDNAME] you to visit relatives?loved them(him/her)?		1		2		3		4		5		6		7	8
D10.		Try to get [FOCALCHILDNAME] to smile or laugh?		1		2		3		4		5		6		7	8
D11.		Take [FOCALCHILDNAME] for a ride on your shoulders or back?		1		2		3		4		5		6		7	8
D12.		Carry [FOCALCHILDNAME] in your arms or hold (him/her) in your lap?		1		2		3		4		5		6		7	8
D13.		Take [NAME OF CHILD] shopping with you?In the past 30 days, how often did you and [FOCALCHILDNAME] play together with toys?		1		2		3		4		5		6		7	8
D14.		In the past 30 days, how often did you take [FOCALCHILDNAME] with you to visit relatives?				2		3		4		5		6		7	8

			More than once a day		About once a day		A few times a week		A few times a month		Rarely		Not at all in the past month		DON’T KNOW			REFUSED
D8D14.		Take [NAME OF CHILDIn the past 30 days, how often did you take [FOCALCHILDNAME] with you to a religious service or religious eventvisit relatives?		1		2		3		4		5		6		7	8
				Every day or almost everyMore than once a day		3-4 times per weekAbout once a day		1-2A few times pera week		2-3A few times in the pasta month		Once in the past monthRarely		Not at all in the past month		DON’T KNOW	REFUSED
D15.		Take [NAME OF CHILD]FOCALCHILDNAME] shopping with you to an activity at a community center or "Y"??		1		2		3		4		5		6		7	8
D16.		Go to a restaurant or out to eat with [NAME OF CHILDFOCALCHILDNAME]?		1		2		3		4		5		6		7	8
D17.		GoTake [FOCALCHILDNAME] to a public place like a zoo or museumplay with [NAME OF CHILD]?other children?		1		2		3		4		5		6		7	8
D18.		Try to tease [NAME OF CHILD] to get (him/her) to laugh?Put [FOCALCHILDNAME] to bed?		1		2		3		4		5		6		7	8
D19.		Take [NAME OF CHILD] for a ride on your shoulders or back?Give [FOCALCHILDNAME] a bath?		1		2		3		4		5		6		7	8
D14.		Turn [NAME OF CHILD] upside down or toss (her/him) up in the air?		1		2		3		4		5		6		7	8
D20.		Play together with [NAME OF CHILD] with toys for building things, like blocks, Lincoln Logs, or Legos?Roll a ball, toss a ball, or play games with a ball with [FOCALCHILDNAME]		1		2		3		4		5		6		7	8
D21.		Visit friendsGo for a walk with [NAME OF CHILDFOCALCHILDNAME]?		1		2		3		4		5		6		7	8
D22.		Bounce [FOCALCHILDNAME] up and down on your knee?		1		2		3		4		5		6		7	8
D23.		Stay home to care for [FOCALCHILDNAME] when (he/she) was sick?		1		2		3		4		5		6		7	8

		Every day or almost everyMore than once a day	3-4 times per weekAbout once a day	1-2A few times pera week	2-3A few times in the pasta month	Once in the past monthRarely	Not at all in the past month	DON’T KNOW	REFUSED
D17.	Take [NAME OF CHILD] to play with other children?	1	2	3	4	5	6	7	8
D18.	Put [NAME OF CHILD] to bed?	1	2	3	4	5	6	7	8
D19.	Give [NAME OF CHILD] a bath?	1	2	3	4	5	6	7	8
D20.	Roll a ball, toss a ball, or play games with a ball with [NAME OF CHILD]	1	2	3	4	5	6	7	8
D21.	Go for a walk with [NAME OF CHILD]?	1	2	3	4	5	6	7	8
D22.	Bounce [NAME OF CHILD] on your knee?	1	2	3	4	5	6	7	8
D23.	Stay home to care for [NAME OF CHILD] when (he/she) was ill?	1	2	3	4	5	6	7	8
		More than once a day	About once a day	A few times a week	A few times a month	Rarely	Not at all in the past month	DON’T KNOW	REFUSED
D24.	Help get [FOCALCHILDNAME] dressed?	1	2	3	4	5	6	7	8
D25.	Change [FOCALCHILDNAME]’s diaper, or help (him/her) use the toilet?	1	2	3	4	5	6	7	8
D26.	Prepare meals or bottles for [FOCALCHILDNAME]?	1	2	3	4	5	6	7	8
D27.	Assist [FOCALCHILDNAME] with eating or give (him/her) a bottle?	1	2	3	4	5	6	7	8
D28.	Get up with [FOCALCHILDNAME] when (he/she) woke up during the night?	1	2	3	4	5	6	7	8
D29.	Play outside in the yard, a park, or a playground with [FOCALCHILDNAME]?	1	2	3	4	5	6	7	8

		Every day or almost every day	3-4 times per week	1-2 times per week	2-3 times in the past month	Once in the past month	Not at all	DON’T KNOW	REFUSED
D28.	Get up with [NAME OF CHILD] when (he/she) woke up during the night?	1	2	3	4	5	6	7	8

I have a couple more questions about when you and [NAME OF CHILD] spend time together. Please indicate how much

D30. Do you agree or disagree with the next two statementsthis statement: There is not much point talking to [FOCALCHILDNAME], because he/she is too young to understand me.

D29. I am comfortable letting [NAME OF CHILD] set the pace when we are together.

1 Strongly Agree

2 Agree

3 Disagree

4 Strongly Disagree

977 DON’T KNOW

988 REFUSED

As the parent, it is my job to choose the games or activities [NAME OF CHILD] and I do together.

1 Strongly Agree

2 Agree

3 Disagree

4 Strongly Disagree

97 DON’T KNOW

98 REFUSED

Module E: Discipline and Parenting Skills

[IF C6 = 5 or 6 THEN INTERVIEWER WILL ASK: “Just to confirm, have you seen [FOCALCHILDNAME] in person in the last 3 months?” IF FATHER ANSWERS “NO” THEN SKIP TO F1]

Children often do things that are wrong, disobey, or make their parents angry. In the past 3 months, we would like to know what you have done when [FOCALCHILDNAME] did something wrong or made you upset or angry. If any of these things don’t make sense for a child of your age, that’s fine, you can just say you “never” do them.

(First), in the past 3 months, how many times did you (READ ITEM)? Was it once in the past 3 months, twice, 3-5 times, 6-10 times, 11-20 times, moreMore than 2010 times, or this never happened in the past 3 months?

		Once	Twice	3-5 Times	6-10 Times	11-20 TimesMore than 10 times	never More than 20 times	DON’T KNOWnever	REFUSEDDON’T KNOW	REFUSEDN/A CHILD TOO YOUNG
E1.	Explain to [FOCALCHILDNAME] why something (he/she) did was wrong.	1	2	3	4	5	60	07	78	89
E2.	Put [FOCALCHILDNAME] in "time out" or send [FOCALCHILDNAME] to (his/her) room.	1	2	3	4	5	60	07	78	89
E3.	Give (him/her) something else to do instead of what (he/she) was doing.	1	2	3	4	5	60	07	78	89
E4.	Shout, yell, or scream at [FOCALCHILDNAME].	1	2	3	4	5	60	07	78	89

E6.

Swear or curse at [NAME OF CHILD]

1

2

3

4

5

6

0

7

8

		Once	Twice	3-5 Times	6-10 Times	11-20 TimesMore than 10 times	More than 20 timesnever	DON’T KNOWnever	DON’T KNOWREFUSED	REFUSEDN/A CHILD TOO YOUNG
E5.	Spank [FOCALCHILDNAME] on the bottom with your bare hand	1	2	3	4	5	0	7	8	9
E6.	Threaten to spank or hit [FOCALCHILDNAME] but did not actually do it	1	2	3	4	5	60	07	78	89
E7.	Slap [FOCALCHILDNAME] on the hand, arm, or leg	1	2	3	4	5	60	07	78	89
E9E8.	Take away privileges from [FOCALCHILDNAME]	1	2	3	4	5	60	07	78	89

E8. In the past 3 months, did you ever hit (him/her) on the bottom with something like a belt, hairbrush, a stick or some other hard object?

1 YES

2 NO

7 DON’T KNOW

8 REFUSED

Module F: Father/Child Relationship Quality

In this next section, I am going to ask some more questions about your current relationship with [FOCALCHILDNAME].

F1. Do you feel that your relationship with [FOCALCHILDNAME] is…

1 Excellent

2 Very good

23 Somewhat good

3 Not too good

974 Fair

5 Poor

7 DON’T KNOW

988 REFUSED

		Always or almost always	Often	Sometimes	Rarely	Never	DON’T KNOW	REFUSED
F2	How often do you feel disappointed with [FOCALCHILDNAME]?	1	2	3	4	5	7	8
F3	How often do you wish that [FOCALCHILDNAME] was different?	1	2	3	4	5	7	8
F4	How often do you feel proud of [FOCALCHILDNAME]?	1	2	3	4	5	7	8
F5	How often do you feel angry or irritated with [FOCALCHILDNAME]?	1	2	3	4	5	7	8
F6	How often do you accept [FOCALCHILDNAME] the way they are(he/she) is?	1	2	3	4	5	7	8
F7	How often does being a father to [FOCALCHILDNAME] bring you joy?	1	2	3	4	5	7	8

The next statements ask you your feelings about being a parent to [FOCALCHILDNAME]. Your first reaction should be your answer. For each statement, please indicate how much you agree or disagree with the statement.

		Strongly agree	Agree	Not Sure	Disagree	Strongly disagree	DON’T KNOW	REFUSED
F8.	[FOCALCHILDNAME] rarely does things for me that make me feel good	1	2	3	4	5	7	8
F9.	Most times I feel that [FOCALCHILDNAME] does not like me and does not want to be close to me	1	2	3	4	5	7	8
F10.	[FOCALCHILDNAME] smiles at me much less than I expected	1	2	3	4	5	7	8
F11.	When I do things for [FOCALCHILDNAME] I get the feeling that my efforts are not appreciated very much	1	2	3	4	5	7	8
F12.	When playing, [FOCALCHILDNAME] doesn't often giggle or laugh	1	2	3	4	5	7	8
F13.	[FOCALCHILDNAME] doesn't seem to learn as quickly as most children	1	2	3	4	5	7	8
F14.	[FOCALCHILDNAME] doesn't seem to smile as much as most children	1	2	3	4	5	7	8
F15.	[FOCALCHILDNAME] is not able to do as much as I expected	1	2	3	4	5	7	8
F16.	It takes a long time and it is very hard for [FOCALCHILDNAME] to get used to new things	1	2	3	4	5	7	8
		Strongly agree	Agree	Not Sure	Disagree	Strongly disagree	DON’T KNOW	REFUSED

		Strongly agree	Agree	Not Sure	Disagree	Strongly disagree	DON’T KNOW	REFUSED
F17.	I expected to have closer and warmer feelings for [FOCALCHILDNAME] than I do and this bothers me	1	2	3	4	5	7	8
F18.	Sometimes [FOCALCHILDNAME] does things that bother me just to be mean	1	2	3	4	5	7	8

Module G: Parenting Efficacy

The following statements are about how you think about yourself as a father. Please think about [FOCALCHILDNAME] when answering these questions and let me know how often each of the following statements applies to you.

		Always or almost always	Often	Sometimes	Rarely	Never	DON’T KNOW	REFUSED
G1	I am good at helping [FOCALCHILDNAME] when he/she is upset or distressed.	1	2	3	4	5	7	8
G2	I am good at knowing what activity [FOCALCHILDNAME] enjoys.	1	2	3	4	5	7	8
G3	I am good at getting [FOCALCHILDNAME] to have fun with me.	1	2	3	4	5	7	8
G4	I am good at providing for [FOCALCHILDNAME]'s financial needs.	1	2	3	4	5	7	8
G5	I am good at providing diapers, milk, or other needed items for [FOCALCHILDNAME]	1	2	3	4	5	7	8
G6	I am good at getting [FOCALCHILDNAME] to understand what I want him/her to do.	1	2	3	4	5	7	8
G7	I am good at following through with my promises to [FOCALCHILDNAME].	1	2	3	4	5	7	8
G8	I am good at understanding what [FOCALCHILDNAME] wants or needs.	1	2	3	4	5	7	8

G9. I feel that I am:

1 not very good at being a parent

2 a person who has some trouble being a parent

3 an average parent

4 a better than average parent

5 a very good parent

7 DON’T KNOW

8 REFUSED

G10. How much influence do you have in making major decisions for [FOCALCHILDNAME] about things like when (he/she) goes to the doctor, what religion (he/she) practices, or who will take care of (him/her)? Do you have…

1 No influence

2 Some influence

3 A great deal of influence

7 DON’T KNOW

8 REFUSED

Module H: Father Commitment to Child

Please answer each of the upcoming questions by indicating how strongly you agree or disagree with the idea expressed.

		Strongly agree	Agree	Disagree	Strongly disagree	DON’T KNOW	REFUSED
H1a.	[If #KIDS = 1 OR 97 THEN ASK H1A; ELSE ASK H1B] My relationship with [FOCALCHILDNAME] is more important than anything else in my life.	1	2	3	4	7	8
H1b.	My relationships with my children are more important to me than anything else in my life.
H2.	Being the a father of [NAME OF CHILD] is a big part of who I am.	1	2	3	4	7	8
H3.	I will always want to be meaningfully involved in [FOCALCHILDNAME'S] life.	1	2	3	4	7	8
H4.	My relationship with [NAME OF CHILD] often must take a back seat toSometimes other interests and responsibilities of mine. have to come before my relationship with [FOCALCHILDNAME].	1	2	3	4	7	8
H5.	I will probably losecan see myself losing interest in [FOCALCHILDNAME] a few years from now.	1	2	3	4	7	8
H6.	Not being a part of my child’s[FOCALCHILDNAME]’s life would be one of the worst things that could happen to me.	1	2	3	4	7	8

H7. Sometimes things come up that get in the way of plans to spend time with children. How often do you have to cancel plans with [FOCALCHILDNAME]?

1 Always or almost always

2 Often

32 Sometimes

43 Rarely

54 Never

7 DON’T KNOW

8 REFUSED

I have a few more questions about your relationship with [NAME OF CHILD].

		A great deal	SomewhatSome	A little bit	Not at allNone	DON’T KNOW	REFUSED
H8.	If you were unablenot able to see [FOCALCHILDNAME] for the next month, how much would you miss (him/her)?	1	2	3	4	7	8
H9.	How much does your behavior affect [NAME OF CHILD]?How much influence do you think you have on [FOCALCHILDNAME]’s life right now?	1	2	3	4	7	8
H10.	How much influence do you think your relationship with [NAME OF CHILD]you will affect them inhave on [FOCALCHILDNAME]’s life over the long-term?	1	2	3	4	7	8

Module I: Co-Parenting Relationship Quality

I1. [IF C1=NoFATHER DOES NOT LIVE WITH FOCAL CHILD (C2=NO, DON’T KNOW, or REFUSED), THEN SKIP TO I2]

Now we are going to ask some questions about your relationship with [FOCALCHILDNAME]’s mother. Can you tell me the name of [FOCALCHILDNAME]’s mother?

_________________________

NAME OF MOTHER/GUARDIAN [SKIP TO I3]

I2. Now we are going to ask some questions about your relationship with [FOCALCHILDNAME]’s mother or legal guardian., or the person who helps take care of your child. Can you tell me the name of [NAME OF CHILDFOCALCHILDNAME]’s mother or the, legal guardian, or the person who usuallyhelps takes care of [NAME OF CHILDFOCALCHILDNAME]? [IF CLARIFICATION IS NEEDED, INTERVIEWER MAY SAY, “By legal guardian I mean the person, aside from you, who is usually responsible for taking care of [FOCALCHILDNAME].”

__________________________

NAME OF MOTHER/GUARDIAN

I2a. What is [NAME OF MOTHER/GUARDIAN]’s relationship to [FOCALCHILDNAME]?

1 mother

2 grandmother

3 grandfather

4 aunt

5 uncle

6 other relative

7 foster parent

8 other (SPECIFY_______________________)

97 DON’T KNOW

98 REFUSED

[THE RESPONSE to I1 OR I2 WILL BE ENTERED INTO THE “[NAME OF MOTHER/GUARDIAN]” FIELD AND FILLED IN WHENEVER THE SURVEY REFERENCES “[NAME OF MOTHER/GUARDIAN]”]

Please think about [NAME OF MOTHER/GUARDIAN] when answering these questions and let us know if you strongly agree, agree, disagree, or strongly disagree with each of the following statements.

		Strongly Agree	Agree	Disagree	Strongly Disagree	DON’T KNOW	REFUSED
I3.	[NAME OF MOTHER/GUARDIAN] tells me I am doing a good job or otherwise lets me know I am being a good father.	1	2	3	4	7	8
I4.	[NAME OF MOTHER/GUARDIAN] makes negative comments, jokes, or sarcastic comments about the way I am as a parent.	1	2	3	4	7	8
I5.	[NAME OF MOTHER/GUARDIAN] contradicts the decisions I make about [FOCALCHILDNAME].	1	2	3	4	7	8
I6.	[NAME OF MOTHER/GUARDIAN] turns to other people to parent [FOCALCHILDNAME] even though I am an engaged father.	1	2	3	4	7	8
I7.	[NAME OF MOTHER/GUARDIAN] undermines me as a father.	1	2	3	4	7	8
I8.	[NAME OF MOTHER/GUARDIAN] makes it hard for me to spend time with [FOCALCHILDNAME].	1	2	3	4	7	8
I9.	[NAME OF MOTHER/ GUARDIAN] makes it hard for me to talk with [FOCALCHILDNAME].	1	2	3	4	7	8

		Strongly Agree	Agree	Disagree	Strongly Disagree	DON’T KNOW	REFUSED
I10.	[NAME OF MOTHER/GUARDIAN] and I make a good parenting team
I10.	[NAME OF MOTHER/GUARDIAN] and I try to understand where each other are coming from.	1	2	3	4	7	8
		Strongly Agree	Agree	Disagree	Strongly Disagree	DON’T KNOW	REFUSED
I11.	[NAME OF MOTHER/GUARDIAN] and I work together to make joint decisions about [FOCALCHILDNAME]	1	2	3	4	7	8
I12.	[NAME OF MOTHER/GUARDIAN] and I discuss the best way to meet [FOCALCHILDNAME]’S needs.	1	2	3	4	7	8
I13.	[NAME OF MOTHER/GUARDIAN] and I share information about [FOCALCHILDNAME] with each other.	1	2	3	4	7	8
I14.	[NAME OF MOTHER/GUARDIAN] asks about my opinions on issues related to parenting.	1	2	3	4	7	8
I11.	[NAME OF MOTHER/GUARDIAN] and I have conflicts about scheduling. time or activities with [FOCALCHILDNAME].	1	2	3	4	7	8
I12.	[NAME OF MOTHER/GUARDIAN] and I argue about who should make decisions about [FOCALCHILDNAME].	1	2	3	4	7	8
I13.	[NAME OF MOTHER/GUARDIAN] and I try to manage the amount of conflict we have about [FOCALCHILDNAME].	1	2	3	4	7	8

		Strongly Agree	Agree	Disagree	Strongly Disagree	DON’T KNOW	REFUSED
I14.	[NAME OF MOTHER/GUARDIAN] and I make threats to each other when we can't get along in our roles as parents.	1	2	3	4	7	8
I15.	[NAME OF MOTHER/GUARDIAN] and I are able to resolve conflicts or arguments over [FOCALCHILDNAME].	1	2	3	4	7	8

Module J: Child Support

The next few questions are about support you may provide for your children. As a reminder, none of your responses from this survey will be shared with program staff or government agencies.

J1. Are you required by a court or state agency to pay child support for any children?

1 YES

2 NO [SKIP TO J10]

7 DON’T KNOW [SKIP TO J10]

8 REFUSED [SKIP TO J10]

[IF #KIDS IS = 1, THEN SKIP TO J3.]

J2. For howHow many children are you required to pay child support for? Include any children for whichwhom you are required to pay arrears or make back payments.

____________________

NUMBER OF CHILDREN (RANGE = 1-20)

96 MORE THAN 20

97 DON’T KNOW

98 REFUSED

J3. What is the total amount you areof your regularly scheduled required to paypayment through the child support system?

IF NEEDED: This is the total for all of your children.

INTERVIEWER: ROUND TO NEAREST DOLLAR

$_____ , _____ _____ _____

AMOUNT PAID (RANGE 1 to 9995)

9996 $9,996 or more

9997 DON’T KNOW [SKIP TO J5]

9998 REFUSED [SKIP TO J5]

J4. Is that…

1 per week,

2 every other week,

3 per month, or

4 some other time period? (SPECIFY)

7 DON’T KNOW

8 REFUSED

J5. Last month, did you pay the full amount of the payment ordered by the court or state agency?

1 YES [SKIP TO J7]

2 NO

7 DON’T KNOW

8 REFUSED

J6. How much child support did you actually pay through the child support system last month?

$_____ , _____ _____ _____

AMOUNT PAID (RANGE 1 to 9995)

0000 $0 or None

9996 $9,996 or more

9997 DON’T KNOW

9998 REFUSED

J7. How much back child support do you owe?

1 None

2 less than $1,000

3 $1,000 to $4,999

4 $5,000 to $9,999

5 $10,000 to $14,999

6 $15,000 or more

7 DON’T KNOW

8 REFUSED

J8. Since [RA month, RA year], has the state forgiven anydecreased the amount of the back child support debt that you owe?, or did you receive help from a program or agency with decreasing child support payments or debt?

1 YES

2 NO

3 I DID NOT OWE ANY BACK CHILD SUPPORT SINCE [RA MONTH, RA YEAR]

7 DON’T KNOW

8 REFUSED

J9. or did you receive help from a program or agency with decreasing child support payments or debt?Since [RA month, RA year], did your regularly scheduled child support payment amount go up, stay the same, or go down?

1 AMOUNT WENT UP

2 AMOUNT STAYED THE SAME 

3 AMOUNT WENT DOWN

7 DON’T KNOW

8 REFUSED

J10. CATI: IF C2=2 THEN SKIP TO J11

Do you have any children, of any age, who don’t live with you all of the time?

1 YES

2 NO [SKIP TO K1]

7 DON’T KNOW [SKIP TO K1]

8 REFUSED [SKIP TO K1]

J11. Not counting any child support required by a court, in the past 30 days did you provide cash for any of your children that do not live with you all of the time?

1 YES

1 YES

2 NO [SKIP TO J15]

7 DON’T KNOW [SKIP TO J15]

8 REFUSED [SKIP TO J15]

J12. Not counting any child support required by court, in the past 30 days, approximately how much cash did you provide?

INTERVIEWER: ROUND TO NEAREST DOLLAR

$ ____ , ____ ____ ____

AMOUNT (1 to 9995)

0000 $0 or none

9996 $9,996 or more

9997 DON’T KNOW

9998 REFUSED

[IF #KIDS IS = 1, THEN SKIP TO J145.]

J13. How many children did this cover?

______________________

NUMBER OF CHILDREN (RANGE =1-20)

96 More than 20

97 DON’T KNOW

98 REFUSED

J14. Excluding any cash that you have already reported providing. The next set of questions are about [FOCALCHILDNAME]. During the past month did you provide help with any of the following for [FOCALCHILDNAME]?

	YES	NO	DON’T KNOW	REFUSED
a. Buying food	1	2	7	8
b. Purchasing clothing or diapers	1	2	7	8
c. Paying for or providing child care or babysitting	1	2	7	8
d. Paying for medicine or health care	1	2	7	8
e. Helping with bills or payments	1	2	7	8
f. Buying toys, books, or school supplies	1	2	7	8
g. Paying for or providing transportation to daycare, school, appointments, or other activities	1	2	7	8

J15. [IF HAVE MORE THAN #KIDS>1 CHILD]

Now, the next questions are about support you gave to any of your other children who do not live with you. Do not include [FOCALCHILDNAME] when answering this set of questions.

During the past month did you provide help with any of the following for any of your other children that do not live with you?

	YES	NO	DON’T KNOW	REFUSED
a. Buying food	1	2	7	8
b. Purchasing clothing or diapers	1	2	7	8
c. Paying for or providing child care or babysitting	1	2	7	8
d. Paying for medicine or health care	1	2	7	8
e. Helping with bills or payments	1	2	7	8
f. Buying toys, books, or school supplies	1	2	7	8
g. Paying for or providing transportation to daycare, school, appointments, or other activities	1	2	7	8

Module K: Employment

The next questions are about your employment history. Again, I would like to remind you that your answers will remain entirely confidential.

K1. Just to be sure, hSince [RA month, RA year], have you done any work in the past 2 weeks for pay? Please include any part-time, full-time, or temporary jobs, as well as self-employent or your own business. Please do not include any unpaid jobs.

1 YES

2 NO [SKIP TO K2]

7 DON’T KNOW [SKIP TO K2]

8 REFUSED [SKIP TO K2]

K2. It could be on- the- books or off- the- books employmentwork, self-employment, temporary work, work as a day laborer, or working side jobs.A lot of people have irregular, odd, or side jobs, or do extra work to make ends meet. Have you done any work like that for pay since [RA month, RA Year]?

IF NECESSARY: This could be any work that was paid for in cash, or work done in exchange for meals, clothing, a place to live, or something else. It could be on-the-books or off-the-books work, self-employment, temporary work, work as a day laborer, or working side jobs.

1 YES

2 NO [GO TO K6]

3 DON’T KNOW [GO TO K6]

4 REFUSED [GO TO K6]

K3. How many jobs do you currently have? This Since [RA month, RA Year], how many jobs have you had? Self-employment or temporary work in the same field or for the same employer counts as one job.

INTERVIEWER: DAY LABORER WORK COUNTS AS ONE JOB.

_______________________

NUMBER OF JOBS (RANGE: 1- 20)

96 MORE THAN 20

97 DON’T KNOW

98 REFUSED

K4. How much you have worked since [RA month, RA Year]? Please include any work that was paid for in cash, or work done in exchange for meals, or clothing, a place to live, or something else. This could include on the books or off the books employment, self-employment, temporary work, work as a day laborer, or work at irregular, odd, or side jobs. Was it …

1 all the time

2 most of the time

3 half the time

4 some of the time

5 seldom

6 never

7 DON’T KNOW

8 REFUSED

K5. Are you currently working for pay? Do you currently have a job? This includes permanent full-time or part-time jobs, or temporary, transitional or seasonal jobs.

1 YES [SKIP TO K4]

2 NO

7 DON’T KNOW

8 REFUSED

K4. includes permanent full-time or part-time jobs, temporary, transitional, or seasonal jobs, any other work that was paid for in cash, or work done in exchange for meals, clothing, a place to live, or something else.

INTERVIEWER: SELF-EMPLOYMENT OR TEMPORARY OR “TEMP” WORK IN THE SAME FIELD COUNTS AS ONE JOB. DAY LABORER WORK COUNTS AS ONE JOB.

_________________

NUMBER OF JOBS (RANGE: 1- 10)

96 MORE THAN 10

97 DON’T KNOW

98 REFUSED

K5. IF NUMBER OF JOBS IN K4 = 1, GO TO K8

Thinking now about all of theyour current jobs that you’re currently working, in the last month, how many hours per week havedid you usually worked at these jobswork per week in the last month? Please consider all hours, including any extra hours, overtime, work you did at home, and so forth.

__________________________

NUMBER OF HOURS (RANGE: 1 to 80) [SKIP TO K6]

96 OVER 80 HOURS PER WEEK [SKIP TO K6]

97 DON’T KNOW [SKIP TO K6]

98 REFUSED [SKIP TO K6]

99 HOURS ARE IRREGULAR, HOURS VARY WEEK TO WEEK

K5a. INTERVIEWER: IF SCHEDULE IS IRREGULAR OR VARIES: How many hours did you work in the last week you worked at these jobs?

__________________________

__________________________

NUMBER OF HOURS (RANGE: 1 to 80)

96 OVER 80 HOURS PER WEEK

97 DON’T KNOW

98 REFUSED

K6.How much did you earn from these jobs in the last week? Please include regular pay, tips, commissions, regular, and overtime pay.

$ ___ ___ , ___ ___ ___ . ___ ___

AMOUNT (RANGE: .01-to 99,999.94) [SKIP TO K7]

99999.95 MORE THAN $99,999.94

99999.96 WORK DONE IN EXCHANGE FOR MEALS, CLOTHING, A PLACE TO LIVE, OR SOMETHING ELSE [SKIP TO K8]

99999.97 DON’T KNOW

99999.98 REFUSED

K6a. In the last week, did you earn  ...

1    $1 to $99

2    $100 to $249

3    $250 to $499

4    $500 to $749

5    $750 to $999

6    $1,000 or more

7    DON'T KNOW [SKIP TO K8]

8    REFUSED [SKIP TO K8]

K7. Was that…

1 before taxes, or

2 after taxes

7 DON’T KNOW

8 REFUSED

K8. IF K4 >1 OR K4 = DON’T KNOW, REFUSED, READ VERSION 1. ELSE IF K4=1 READ VERSION 2.

VERSION 1: I’d like to ask you some questions about the job you worked at where you work the most hours in the last two weeks. When did this job start?

VERSION 2: I’d like to ask you some questions about your job. When did this job start?

INTERVIEWER PROBE FOR SEASON IF DON’T KNOW MONTH.

_____________________________________________________

MM (RANGE: 1-12) / YYYY (RANGE: 1950-current year)

13 WINTER

14 SPRING

15 SUMMER

16 FALL

01/1950 BEFORE OR ON JANUARY 1950

97/9997 DON’T KNOW

98/9998 REFUSED

K9. Please mark all that apply. Which of the following best describes your usual weekly work schedule at your job during the last month? Did you work…

1 daytime shifts

2 evening shifts (6 P.M. - 11 P.M.)

3 night shifts (11 P.M.-7 A.M.)

4 weekends

5 an irregular schedule, that is one that changed from day to day or week to week

7 DON’T KNOW

8 REFUSED

K10. How far in advance do you usually know what days and hours you will need to work?

1 One week or less

2 Between 1 and 2 weeks

3 Between 2 and 3 weeks

4 Between 3 and 4 weeks

5 4 weeks or more

6 My work schedule doesn’t usually change from week to week

7 DON’T KNOW

8 REFUSED

K11. In the last month, how many hours did you usually work per week have you usually worked at this job? Please consider all hours, including any extra hours, overtime, work you did at home, and so forth. Please do not include weeks in which you missed work because of illness or vacation.

INTERVIEWER: IF R HAS NOT WORKED AT THE JOB FOR A FULL MONTH: If you have worked for less than one month, please think of the hours, overtime, work in the weeks you did at home, and so forth. Please do not include weeks in which you missed work because of illness or vacationhave worked so far.

__________________________

NUMBER OF HOURS (RANGE: 1 to 80) [SKIP TO K10]

96 OVER 80 HOURS PER WEEK [SKIP TO K10]

97 DON’T KNOW [SKIP TO K10]

98 REFUSED [SKIP TO K10]

99 HOURS ARE IRREGULAR, HOURS VARY WEEK TO WEEK

K9a. INTERVIEWER: IF SCHEDULE IS IRREGULAR OR VARIES: How many hours did you work in the last week you worked at these jobs?

__________________________

NUMBER OF HOURS (RANGE: 1 to 80)

96 OVER 80 HOURS PER WEEK

97 DON’T KNOW

K12

98 REFUSED

K10. How much did you earn from this job in the last week? Please include regular pay, tips, commissions, regular, and overtime pay.

$ ___ ___ , ___ ___ ___ . ___ ___

AMOUNT (RANGE: .01-to 99,999.94) [SKIP TO K14K12]

99999.95 MORE THAN $99,999.94

99999.96 WORK DONE IN EXCHANGE FOR MEALS, CLOTHING, A PLACE TO LIVE, OR SOMETHING ELSE [SKIP TO K28K24]

99999.95 MORE THAN $99,999.94

99999.97 DON’T KNOW

99999.98 REFUSED

K13K11. In the last week, did you earn  ...

1    $1 to $99

2    $100 to $249

3    $250 to $499

4    $500 to $749

5    $750 to $999

6    $1,000 or more

97    DON'T KNOW [SKIP TO K28K24]

98    REFUSED [SKIP TO K28K24]

K14K12. Was that…

1 before taxes, or [SKIP TO K28K24]

2 after taxes [SKIP TO K28K24]

7 DON’T KNOW [SKIP TO K28K24]

8 REFUSED [SKIP TO K28K24]

K15. IF K2 AND K3 = NO, DON’T KNOW, OR REFUSED

K13. Did you work at any jobs since [RA month, RA Year]? Again, pleasethis could include any work that was paid for in cash, or work done in exchange for meals, or clothing, a place to live, or something else. ThisIt could include on- the- books or off- the- books employmentwork, self-employment, temporary work, work as a day laborer, or work at irregular, odd, orworking side jobs.

1 YES

2 NO [SKIP TO K28K24]

7 DON’T KNOW [SKIP TO K28K24]

8 REFUSED [SKIP TO K28K24]

K16K14. Since [RA month, RA Year], how many jobs have you had?

INTERVIEWER: SELF-EMPLOYMENT OR TEMPORARY OR “TEMP” WORK IN THE SAME FIELD COUNTS AS ONE JOB. DAY LABORER WORK COUNTS AS ONE JOB.

_______________________

NUMBER OF JOBS (RANGE: 1- 20)

96 MORE THAN 20

97 DON’T KNOW

98 REFUSED

K17K15. Since [RA month, RA Year], what job did you work at for the most weeks? What is that employer’s name?

INTERVIEWER INSTRUCTION:

IF NECESSARY: This is simply to help make later questions more clear. We will not contact your employer. If you would like, you can tell me your job title instead.

_______________________

EMPLOYER’S NAME

96 SELF-EMPLOYED

97 DON’T KNOW

98 REFUSED

K18K16. How long did you work at that job?

____________________________

LENGTH OF TIME AT JOB

97 DON’T KNOW

98 REFUSED

K19K17. Just to confirm, was that…

1 weeks

2 months, or

3 some other time period (SPECIFY_____)

7 DON’T KNOW

8 REFUSED

K20K18. When did this job end?

INTERVIEWER PROBE FOR SEASON IF DON’T KNOW MONTH.

INTERVIEWER INSTRUCTION: IF DATE IS BEFORE [RA MONTH, RA YEAR], ASK HIM IF THERE WAS A JOB HE WORKED AT AFTER THIS JOB. IF SO, GO BACK TO B37 AND ASK ABOUT THIS OTHER JOB.

_________________

MM (RANGE: 1-12)/ YYYY (RANGE: 1950-current year)

13 WINTER

14 SPRING

15 SUMMER

16 FALL

01/1950 BEFORE OR IN JANUARY 1950

97/9997 DON’T KNOW

98/9998 REFUSED

K21K19. When did this job start?

INTERVIEWER PROBE FOR SEASON IF DON’T KNOW MONTH.

_____________________________________________________

MM (RANGE: 1-12)/ YYYY (RANGE: 1950-current year)

13 WINTER

14 SPRING

15 SUMMER

16 FALL

01/1950 BEFORE OR ON JANUARY 1950

97/9997 DON’T KNOW

98/9998 REFUSED

K22. Please mark all that apply. Which of the following best describes your usual weekly work schedule when you left this job? Did you work…

1 daytime shifts

2 evening shifts (6 P.M. - 11 P.M.)

3 night shifts (11 P.M.-7 A.M.)

4 weekends

5 an irregular schedule, that is one that changed from day to day or week to week

7 DON’T KNOW

8 REFUSED

K23. How far in advance did you usually know what days and hours you needed to work?

1 One week or less

2 Between 1 and 2 weeks

3 Between 2 and 3 weeks

4 Between 3 and 4 weeks

5 4 weeks or more

6 My work schedule doesn’t usually change from week to week

7 DON’T KNOW

8 REFUSED

K24K20. In the last month you worked at this job, how many hours per week did you usually work at this job? Please consider all hours, including any extra hours, overtime, work you did at home, and so forth. Please do not include weeks in which you missed work because of illness or vacation.

INTERVIEWER: IF R DID NOT WORK AT THE JOB FOR A FULL MONTH: If you worked at this job for less than a month, please think of the hours per week when you were there.

__________________________

NUMBER OF HOURS (RANGE: 1 to 80) [SKIP TO K21]

96 OVER 80 HOURS PER WEEK [SKIP TO K21]

97 DON’T KNOW [SKIP TO K21]

98 REFUSED [SKIP TO K21]

99 HOURS ARE IRREGULAR, HOURS VARY WEEK TO WEEK

K20a. INTERVIEWER: IF SCHEDULE WASIS IRREGULAR OR VARIEDVARIES: How many hours did you work in the last week you worked at this job?

__________________________

NUMBER OF HOURS (RANGE: 1 to 80)

96 OVER 80 HOURS PER WEEK

97 DON’T KNOW

98 REFUSED

K25K21. How much did you earn from this job in the last week you worked at this job? Please include regular pay, tips, commissions, regular, and overtime pay.

$ ___ ___ , ___ ___ ___ . ___ ___

AMOUNT (RANGE: .01-to 99,999.94) [SKIP TO K27K23]

99999.95 MORE THAN $99,999.94

99999.96 WORK DONE IN EXCHANGE FOR MEALS, CLOTHING, A PLACE TO LIVE, OR SOMETHING ELSE [SKIP TO K28K24]

99999.95 MORE THAN $99,999.94

99999.9 DON’T KNOW

99999.98 REFUSED

K26K22. In the last week you worked there, did you earn ...

1    $1 to $99

2    $100 to $249

3    $250 to $499

4    $500 to $749

5    $750 to $999

6    $1,000 or more

7    DON'T KNOW [SKIP TO K28K24]

8    REFUSED [SKIP TO K28K24]

K27K23. Was that…

1 before taxes, or

2 after taxes

7 DON’T KNOW

8 REFUSED

K28K24. In the last month, how often did you have any problems getting a job, showing up to work, or keeping a job because of your alcohol or drug use?

1 YESOften

2 NOSometimes

3 Rarely

4 Never

7 DON’T KNOW

8 REFUSED

K29K25. In the last month, how often did you have any problems getting along with family or friends because of your alcohol or drug use?

1 YESOften

2 NOSometimes

3 Rarely

4 Never

7 DON’T KNOW

8 REFUSED

Now I am going to ask you a few questions about your income and challenges people sometimes face.

K6. Would you say that your income…

1 stays about the same each month

2 varies a little month by month

3 varies a lot month by month

7 DON’T KNOW

8 REFUSED

K7. In the last 6 months, Since [RA month, RA Year], for about how many months did you have no income?

1 Zero months

2 One or two months

3 Three months or more

7 DON’T KNOW

8 REFUSED

K8. In the last 6 months, Since [RA month, RA Year], about how many months did you run out of money between paychecks, or before the end of the month?

1 Zero months [SKIP TO L1]

2 One or two months

3 Three months or more

7 DON’T KNOW

8 REFUSED

K9. What was the main reason why you ran out of money? Please select one answertell me which of the following best describes the reason.

1 You were unemployed

2 You couldn’t get enough hours of work from your employer

3 AYou had a reduction or termination of benefits (like Unemployment Insurance or disability)

44 You had a large bill or other expense to pay

5 You helped a family member or friend

6 You were incarcerated, or

7 Some other reason (SPECIFY___________)

797 DON’T KNOW

898 REFUSED

Module L: Cognitive and Behavioral

Perceived Stress

Now, I’d like to talk about feelings you may have about how things are going.

In the last month, how often have you…

		Never	Almost Never	Sometimes	Fairly Often	Very Often	DON’T KNOW	REFUSED
L1.	…been upset because of something that happened unexpectedly?	1	2	3	4	5	7	8
L2.	…felt that you were unable to control the important things in your life?	1	2	3	4	5	7	8
L3.	…felt nervous and "stressed"?	1	2	3	4	5	7	8

Never

Almost Never

Sometimes

Fairly Often

Very Often

DON’T KNOW

REFUSED

L4.	…felt confident about your ability to handle your personal problems?	1	2	3	4	5	7	8
L5.	…felt that things were going your way?	1	2	3	4	5	7	8
L6.	…found that you could not cope with all the things that you had to do?	1	2	3	4	5	7	8
L7.	…been able to control irritations in your life?	1	2	3	4	5	7	8
L8.	…felt that you were on top of things?	1	2	3	4	5	7	8
L9.	…been angered because of things that were outside of your control?	1	2	3	4	5	7	8
L10.	…felt difficulties were piling up so high that you could not overcome them?	1	2	3	4	5	7	8

L11. How would you rate the amount of control you have over your work or your ability to find work these days? An answer of 1 means you have no control at all. An answer of 10 means you very much have control. You can choose any number from 1 to 10 to indicate various levels of control you have with your work situation.

1 No control at all

2 Very little control

3 Some control

4 A lot of control

5 Total control

7 DON’T KNOW

8 REFUSED

L12. How would you rate the amount of control you have over your financial situation these days? An answer of 1 means you have no control at all. An answer of 510 means you very much have control. You can choose any number from 1 to 510 to indicate various levels of control you have with your financial situation.

1 No control at all

2 Very little control

3 Some control

4 A lot of control

5 Total control

7 DON’T KNOW

8 REFUSED

Module M: Respondent Contact Information

M1.

At this time we’d like to just confirm some information about you. The information we confirm now will help us be able to get back in touch with you if we need to in the future.  [IF INTERVIEW OVER THE PHONE READ: It will also ensure that your incentive payment is sent to the correct address.]

I have your name listed as [READ AND CONFIRM SPELLING OF [RESPONDENT NAME]. Is that correct?

YES, ALL CORRECT 1

NO, CORRECT FIRST NAME 2

NO, CORRECT MIDDLE NAME 3

NO, CORRECT LAST NAME 4

NO, CORRECT SUFFIX 5

DON’T KNOW 7

REFUSED 8

M2.

Could you please tell me how to spell your name?

M2a.

FIRST: What is your first name?

M2b.

MIDDLE: What is your middle name?

M2c.

LAST: What is your last name?

M2d.

SUFFIX: Is there anything after your last name, like Jr. or Sr.?

M3.

Our records show that your current address is [RESPONDENT ADDRESS]. Is this correct?

YES, ALL OF THAT IS CORRECT 1

NO–UPDATE STREET 2

NO–UPDATE APARTMENT/UNIT 3

NO–UPDATE CITY 4

NO–UPDATE STATE 5

NO–UPDATE ZIP 6

DON’T KNOW 7

REFUSED 8

M3a.

STREET: What is your current street address?

M3b.

APT: What is the apartment number?

M3c.

CITY: In what city do you live?

M3d.

STATE: In what state do you live?

M3e.

ZIP: What is your zip code?

M4. Would you prefer that the $35 gift card be sent to your current address or is there another address I should send it to?

YES, SEND TO CURRENT ADDRESS [SKIP TO M5] 1

NO, SEND TO DIFFERENT ADDRESS [ASK M4a through M4d] 2

M4a. What is the street address and apartment number you would like use to send the check to?

STREET ADDRESS APT OR UNIT #

M4b. In what city?

CITY

M4c. In what state?

STATE

M4d. What is the zip code?

ZIP

[IF INTERVIEW IS IN PERSON SKIP TO M6]

M5.

I called you at [RESPONDENT PHONE NUMBER]. Is this the best number to reach you at?

YES 1 [SKIP TO M7]

NO 2

DON’T KNOW 7 [SKIP TO M7]

REFUSED 8 [SKIP TO M7]

M6.

What is your home phone number, starting with area code?

(____) _____-________

DON’T KNOW 7

REFUSED 8

M7.

Do you have a cell phone number?

YES 1

NO 2 (SKIP TO M8A)

DON’T KNOW 7 (SKIP TO M8A)

REFUSED 8 (SKIP TO M8A)

M7a.

What is your cell phone number, starting with area code?

(____) _____-________

DON’T KNOW 7 (SKIP TO M8A)

REFUSED 8 (SKIP TO M8A)

M7b.

Do we have your permission to contact you on your cell phone via text message?

YES 1

[IF YES, INFORM THE R THAT STANDARD TEXT MESSAGING RATES APPLY AND “WE HOPE THE $35 GIFT CARD WE’RE GIVING YOU WILL HELP PAY BACK ANY COSTS FOR RECEIVING TEXT MESSAGES.”]

NO 2 (SKIP TO M8A)

DON’T KNOW 7 (SKIP TO M8A)

REFUSED 8 (SKIP TO M8A)

M7c.

Do we have your permission to contact you on that number via automated text message?

YES 1

NO 2

DON’T KNOW 7

REFUSED 8

M8A.

Are there any other additional numbers we could use to reach you?

YES 1

NO 2 (SKIP TO M9)

DON’T KNOW 7 (SKIP TO M9)

REFUSED 8 (SKIP TO M9)

M8Aa.

What is that phone number, starting with area code?

(____) _____-________

DON’T KNOW 7

REFUSED 8

M8Ab.

What type of number is that?

Work 1

School 2

Friend 3

Relative 4

Clergy 5

Something else 6

DON’T KNOW 7

REFUSED 8

M8B.

Are there any other additional numbers we could use to reach you?

YES 1

NO 2 (SKIP TO M9)

DON’T KNOW 7 (SKIP TO M9)

REFUSED 8 (SKIP TO M9)

M8Ba.

What is that phone number, starting with area code?

(____) _____-________

DON’T KNOW 7

REFUSED 8

M8Bb.

What type of number is that?

Work 1

School 2

Friend 3

Relative 4

Clergy 5

Something else 6

DON’T KNOW 7

REFUSED 8

M8C.

Are there any other additional numbers we could use to reach you?

YES 1

NO 2 (SKIP TO M9)

DON’T KNOW 7 (SKIP TO M9)

REFUSED 8 (SKIP TO M9)

M8Ca.

What is that phone number, starting with area code?

(____) _____-________

DON’T KNOW 7

REFUSED 8

M8Cb.

What type of number is that?

Work 1

School 2

Friend 3

Relative 4

Clergy 5

Something else 6

DON’T KNOW 7

REFUSED 8

M9.

Do you have an email address?

YES 1

NO 2 (SKIP TO M10)

DON’T KNOW 7 (SKIP TO M10)

REFUSED 8 (SKIP TO M10)

M9a.

What is your email address?

_____________________________@____________ . _________

DON’T KNOW 7

REFUSED 8

M10.

Do you have a Facebook Account?

YES 1

NO 2 (SKIP TO M11)

DON’T KNOW 7 (SKIP TO M11)

REFUSED 8 (SKIP TO M11)

M10A.

May we contact you at your Facebook account in the future?

YES 1

NO 2 (SKIP TO M11)

DON’T KNOW 7 (SKIP TO M11)

REFUSED 8 (SKIP TO M11)

M10B.

What is your Facebook account name?____________________________

M11.

What is the best way for me to reach you in the future? Would you prefer that I call you on the phone, send you a letter in the mail, send you an email, or should I call someone else?

PHONE 1

LETTER 2

EMAIL 3

SOMEONE ELSE 4

FACEBOOK ACCOUNT 5

DON’T KNOW 7

REFUSED 8

[ASK M11A IF M11=1 and M6<>7, 8 and M7a<>2,7,8 and M8Aa_1<>2,7,8]

M11A.

What is the best phone number to call you at? Is it your home phone or your cell phone number, or [IF M8Ab=1,2,3,4,5,6: [INSERT M8Ab RESPONSE] number or [IF M8Bb=1,2,3,4,5,6: [INSERT M8Bb RESPONSE] number or [IF M8Cb=1,2,3,4,5,6 [INSERT M8Cb RESPONSE] number; IF M8Ab=6: LEAVE BLANK]?

HOME PHONE 1

CELL PHONE 2

WORK 3

SCHOOL 4

FRIEND 5

RELATIVE 6

CLERGY 7

SOMETHING ELSE 8

DON’T KNOW 97

REFUSED 98

END

CATI VERSION:

DO NOT READ: FIELD INTERVIEWER PRESENT

1 – YES [SKIP TO ALT ENDING]

2 – NO [CONTINUE]

CAPI VERSION:

IF RESPONDENT IS BEING INTERVIEWED IN PERSON AND HE IS NOT INCARCERATED, (P1=2), SKIP TO CAPI IN-PERSON ENDING

IF RESPONDENT IS BEING INTERVIEWED IN PERSON AND HE IS INCARCERATED, (P1=3), SKIP TO CAPI INCARCERATED ENDING

Exit

Thank you very much for participating in this survey you will receive your $35 gift card in about four to six weeks [CAPI: one to two weeks]. Thank you again and have a good day/evening.

ALT ENDING: 

Thank you very much for participating in this survey.  Please hand the phone back to the interviewer so I can confirm that we have completed the survey.  The interviewer will then be able to give you your $35 gift card.  Thank you and have a good day/evening.

CAPI IN-PERSON ENDING:

Thank you very much for participating in this survey. Here is your $35 gift cardmoney order as a “Thank you” for completing the interview. Have a good day/evening.

CAPI INCARCERATED ENDING:

Thank you very much for participating in this survey. [DESCRIBE THE PROTOCOL FOR HANDLING THE INCENTIVE BASED ON THE AGREED UPON METHOD OF COMPENSATION]

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