Instrument 5: Parent Child Report

OMB No.: 0970–0354

Expiration Date: X/XX/20XX

Instrument: PCR [version] [Eng/Sp]

AFFIX LABEL HERE

PCR [version] [Eng/Sp]

Parent Child Report

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

• Version 1: Newborn to 7 months

• Version 2: 8 months to 16 months

• Version 3: 17 months to 30 months

• Version 4: 31 months to 37 months

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

Draft for OMB (Redacted)

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB number for this information collection is 0970–0354 and the expiration date is X/XX/XXXX.

ABOUT THIS SURVEY

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

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

1 □ 2 □ 3 □

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

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

• If you have any questions, please contact the Baby FACES team at Mathematica Policy Research at 1-833-763-2178.

INTERNAL NOTE: IN VERSION OF INSTRUMENT FOR STUDY FAMILIES, KEEP BELOW BOX ON SAME PAGE AS ‘ABOUT THIS SURVEY’ BOX ABOVE.

ABOUT YOU AND YOUR CHILD

Source: Baby FACES 2018

R1. What is your relationship to the Baby FACES child?

1 □ Mother / Female Guardian

2 □ Father / Male Guardian

3 □ Grandmother

4 □ Grandfather

5 □ Other Relative

6 □ Other Non-Relative

Source: Baby FACES 2018

R2. What is this child’s date of birth?

| | | / | | | / | | | | |

month day year

Source: BITSEA, A1-A2 (PROPRIETARY)

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

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

section a: social skills

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

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

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

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

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

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

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

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

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

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

section b: vocabulary checklist

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

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

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

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

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

Source: MacArthur-Bates Communicative Development Inventories.

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

Included in versions: 2 [8-16 mos]

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

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

Source: MacArthur-Bates Communicative Development Inventories.

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

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

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

Source: MacArthur-Bates Communicative Development Inventories.

Source: Items C6-C7 adapted from Baby FACES 2009 Parent Interview

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

section c: child well-being

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

C6. Does your child have an Individualized Family Service Plan (IFSP)? This is a written treatment plan that describes your child’s current levels of functioning, specific needs, and what early intervention services he/she will receive.

0 □ No GO TO C7

1 □ Yes

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

0 □ No

1 □ Yes

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

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

Source: Parenting Stress Index, 4th Edition Short Form, D1 & D2a-D2c (PROPRIETARY)

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

section d: raising a child

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

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

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

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

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

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

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

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

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

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

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

DO NOT INCLUDE ITEMS g AND o IN VERSIONS 1 [NEWBORN TO 7 MOS] AND 2 [8-16 MOS]

section e: relationships and feelings

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

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

©1992 Pianta, University of Virginia.

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

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

(Items in E3 asked of pregnant respondents in parent survey)

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

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

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

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

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

Source: Healthy Families Parenting Inventory (Social Support subscale)

Source: CESD-R. Permissions: Items in this section are from Eaton WW, Muntaner C, Smith C, Tien A, Ybarra M. Center for Epidemiologic Studies Depression Scale: Review and revision (CESD and CESD-R). In: Maruish ME, ed. The Use of Psychological Testing for Treatment Planning and Outcomes Assessment. 3rd ed. Mahwah, NJ: Lawrence Erlbaum; 2004:363-377

I8. Below is a list of ways you may have felt or behaved. Please mark how often you have felt this way in the past week or so.

	MARK ONE PER ROW
	LESS THAN 1 DAY	1‑2 DAYS in past week	3‑4 DAYS in past week	5‑7 DAYS in past week	nearly every day for 2 weeks
a. My appetite was poor	0 □	1 □	2 □	3 □	4 □
b. I could not shake off the blues	0 □	1 □	2 □	3 □	4 □
c. I had trouble keeping my mind on what I was doing	0 □	1 □	2 □	3 □	4 □
d. I felt depressed	0 □	1 □	2 □	3 □	4 □
e. My sleep was restless	0 □	1 □	2 □	3 □	4 □
f. I felt sad	0 □	1 □	2 □	3 □	4 □
g. I could not get going	0 □	1 □	2 □	3 □	4 □
h. Nothing made me happy	0 □	1 □	2 □	3 □	4 □
i. I felt like a bad person	0 □	1 □	2 □	3 □	4 □
j. I lost interest in my usual activities	0 □	1 □	2 □	3 □	4 □
k. I slept much more than usual	0 □	1 □	2 □	3 □	4 □
l. I felt like I was moving too slowly	0 □	1 □	2 □	3 □	4 □
m. I felt fidgety	0 □	1 □	2 □	3 □	4 □
n. I wished I were dead	0 □	1 □	2 □	3 □	4 □
o. I wanted to hurt myself	0 □	1 □	2 □	3 □	4 □
p. I was tired all the time	0 □	1 □	2 □	3 □	4 □
q. I did not like myself	0 □	1 □	2 □	3 □	4 □
r. I lost a lot of weight without trying to	0 □	1 □	2 □	3 □	4 □
s. I had a lot of trouble getting to sleep	0 □	1 □	2 □	3 □	4 □
t. I could not focus on important things	0 □	1 □	2 □	3 □	4 □

The National Suicide Prevention Lifeline is available 24/7 for free and confidential support for people in distress or for crisis resources for you or your loved ones. Call 1-800-273-8255 or vist the website at suicidepreventionlifeline.org.

The next few questions are about tobacco, alcohol, and drug use.

Source: Adapted from Baby FACES 2009

Item title: TobaccoPast30Days

I5. During the past 30 days, did you or anyone else in your household smoke tobacco, such as cigarettes or cigars?

0 □ No

1 □ Yes

d □ Don’t know

Source: Baby FACES 2018

Item title: VapingPast30Days

I5a. During the past 30 days, have you or anyone else in your household used nicotine “vaping” products, such as e-cigarettes?

0 □ No

1 □ Yes

d □ Don’t know

Source: Baby FACES 2018

Item title: ProgramCessationHelp

I5b. Did [PROGRAM] Early Head Start offer resources or support to you or anyone else in your household for reducing or quitting the use of tobacco or nicotine “vaping”?

0 □ No

1 □ Yes

d □ Don’t know

Source: Adapted from MIHOPE 2 Parent Survey

I5c. The next questions are about drinking alcoholic beverages. By a “drink” we mean a can or bottle of beer, a wine cooler or glass of wine, a shot of liquor, or a mixed drink.

During the past 30 days, how many alcoholic drinks did you have in an average week?

maRK ONE ONLY

1 □ None

2 □ Less than 1 drink

3 □ 1 to 3 drinks

4 □ 4 to 6 drinks

5 □ 7 to 13 drinks

6 □ 14 to 19 drinks

7 □ 20 or more drinks

d □ Don’t know

Source: Adapted from MIHOPE 2 Parent Survey

I5d. In the last 30 days, how many times did you or anyone in your household drink 4 alcoholic drinks or more in one day? Would you say…

maRK ONE ONLY

1 □ 6 or more times

2 □ 4 to 5 times

3 □ 2 to 3 times

4 □ 1 time

5 □ Never

Source: New item

I5d1. Did Early Head Start offer resources or support to you or anyone else in your household to help reduce or quit drinking alcohol?

0 □ No

1 □ Yes

d □ Don’t know

Source: Adapted from the National Survey for Drug Use and Health

I5E1. In the past 30 days, have you or has anyone in your household used heroin (smack, horse) or a prescription pain reliever (oxy, percs, vikes) in a way that was not director by a doctor? By “not directed by a doctor” we mean used without a prescription; used in greater amounts, more often, or longer than prescribed; or used in any other way not prescribed by a doctor.

0 □ No

1 □ Yes

d □ Don’t know

Source: Adapted from the National Survey for Drug Use and Health

I5f1. In the past 30 days have you or has anyone in your household used marijuana (weed, pot) or hashish (hash)?

0 □ No

1 □ Yes

d □ Don’t know

Source: Adapted from the National Survey for Drug Use and Health

I5f2. What about other types of drugs, such as amphetamines (uppers, ice, speed, crystal meth, crank), cocaine (rock, coke, crack), tranquilizers (downers, ludes) hallucinogens (LSD, acid, PCP, angel dust, ecstasy), or sniffing gasoline, glue, or aerosols? Have you or anyone in your household used any of these in the past 30 days?

0 □ No

1 □ Yes

d □ Don’t know

Source: Adapted from MIHOPE 2 Parent Survey

I5g. Did Early Head Start offer resources or support to you or anyone else in your household to help reduce or quit using drugs?

0 □ No

1 □ Yes

d □ Don’t know

Finally, we have one last question about your household income.

Source: Baby FACES 2009

L4. In the last 12 months, what was the total income of all members of your household from all sources before taxes and other deductions? Please include your own income and the income of everyone living with you. Please include the money from jobs and public assistance programs, as well as any other sources such as rent, interest, and dividends. Your best estimate is fine.

$|___|___|___|,|___|___|___|

Please mark whether that is per week, every two weeks, per month or per year.

MARK ONE ONLY

1 □ Per week

2 □ Every two weeks

3 □ Per month

4 □ Per year

E4. Please record the date you completed this form.

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

month day year

Thank you for your participation in Baby FACES!