Instrument 6: Staff survey (Teacher survey and Home Visitor survey)

OMB No.: 0970-0354

Expiration Date: xx/xx/20xx

Staff Survey – Home Visitor

Draft for OMB

July 2019

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. 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 and expiration date for this collection are OMB #: 0970-0354, Exp: XX/XX/XXXX.

INTRODUCTION

Thank you for taking the time to let us speak with you today. This survey is part of the Baby FACES study. We obtained permission from the director of your program to talk with you about your experiences in Early Head Start. We appreciate your time and effort in completing this survey.

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. Your participation in the study is voluntary. Please be assured that all information you provide will be kept private to the extent permitted by law. The questions I will be asking today have been approved by the Federal Office of Management and Budget, also known as OMB. We are only allowed to ask you these questions and you can only answer them if there is a valid OMB control number. For the questions asked as part of today’s discussion, the OMB control number is 0970-0354 and it expires on XX/XX/20XX.

The survey will take about 30 minutes to complete.

SECTION B. STAFF DEVELOPMENT AND SUPERVISION

The first questions are about the supervision, coaching, and training provided by your program. First, I’d like to ask you a few questions about your supervisor.

Source: Adapted from Baby FACES 2009

B1. Does your supervisor use an individual career or professional development plan to provide you with professional development and training?

YES 1

NO 0

DON’T HAVE A PROFESSIONAL DEVELOPMENT PLAN 2

DON’T KNOW/REFUSED d

Source: Adapted from Baby FACES 2009

B3. Do you have one-on-one supervision meetings, group supervision meetings, or both?

ONE-ON-ONE SUPERVISION 1

GROUP SUPERVISION 2 GO TO B5

BOTH 3

NONE 0 GO TO B6

DON’T KNOW/REFUSED d GO TO B6

IF ONE-ON-ONE SUPERVISION OR BOTH (B3=1 OR B3=3), ASK:

Source: Adapted from Baby FACES 2018

B4. How many times a year do you typically have one-on-one supervision meetings?

| | | | TIMES PER YEAR

DON’T KNOW/REFUSED d

IF GROUP SUPERVISION OR BOTH (B3=2 OR B3=3), ASK:

Source: Adapted from Baby FACES 2018

B5. How many times a year do you typically have group supervision meetings?

| | | | TIMES PER YEAR

DON’T KNOW/REFUSED d

IF any SUPERVISION OR BOTH (B3=1,2 OR B3=3), ASK:

Source: New Item

B5c. Does your supervisor conduct formal performance reviews with you?

YES 1

NO 0

IF B5c=1, ASK:

Source: New Item

B5d. How many times a year does your supervisor conduct a formal performance review with you?

| | | | TIMES PER YEAR

DON’T KNOW/REFUSED d

Source: Adapted from Baby FACES 2018

B6. These next questions are about coaching. Some people may think of this as mentoring. A coach is a person, usually someone other than your supervisor, who has expertise in specific areas and provides ongoing professional development, performance feedback, and works with staff to improve practice.

Please tell me which of the following statements is the most applicable to you.

I have a coach who is different from my supervisor 1

My coach is also my supervisor 2 GO TO B9.1

I don’t have a coach 0 GO TO B9.1

DON’T KNOW/REFUSED d GO TO B9.1

IF RESPONDENT HAS COACH (B6=1), ASK:

Source: Adapted from Baby FACES 2018

B6a. Is your coach a person whose sole job is coaching (that is, not consultants or staff whose primary role is as a home visitor, manager, or director)?

YES 1

NO 0

DON’T KNOW/REFUSED d

IF RESPONDENT HAS COACH (B6=1), ASK:

Source: Adapted from Baby FACES 2018

B7. How many times a year do you typically meet with your coach?

| | | | TIMES PER YEAR

DON’T KNOW/REFUSED d

ASK BASED ON RESPONSES TO B6 (IF NO COACH, IF COACH AND SUPERVISOR ARE SAME, OR DON’T KNOW/REFUSED)

Source: Adapted from Baby FACES 2018

B9.1 Supervisors have different approaches or ways of supporting home visitors in improving their practice. Please tell me whether your supervisor uses each of the following methods when working with you.

	YES	NO	don’t know/ refused
a. Discuss what they observe during home visits?	1	0	d
b. Provide written feedback on what they observe during home visits?	1	0	d
c. Have you watch a video tape of yourself conducting a home visit?	1	0	d
d. Have you observe another home visitor (live or video)?	1	0	d
e. Model good home visiting practices?	1	0	d
f. Suggest trainings for you to attend or certifications for you to obtain?	1	0	d
g. Provide trainings to you?	1	0	d
h. Review child assessment data with you?	1	0	d
i. Provide materials or resources to you?	1	0	d
j. Help you set goals or make plans to improve your practice?	1	0	d
k. Make themselves available or check in with you?	1	0	d
l. Assist you with specific needs or challenges?	1	0	d
m. Help you think about your own practice and problem-solve to address challenges?	1	0	d

ASK BASED ON RESPONSES TO B6 (IF THEY HAVE A COACH WHO IS DIFFERENT FROM THEIR SUPERVISOR)

Source: Adapted from Baby FACES 2018

B9.2 Coaches and supervisors have different approaches or ways of supporting home visitors in improving their practice. For each method used, please tell me who uses the approach: your coach, your supervisor, both, or neither. Does your coach or supervisor…

PROBE: THE FIRST TIME RESPONDENT SAYS NO, PLEASE CONFIRM THAT NEITHER COACH NOR SUPERVISOR DO THIS.

	CODE ONE PER ROW
	coach	supervisor	both		neither		don’t know/ refused
a. Discuss what they observe during home visits?	1	2	3		0		d
b. Provide written feedback on what they observe during home visits?	1	2	3		0		d
c. Have you watch a video tape of yourself conducting a home visit?	1	2	3		0		d
d. Have you observe another home visitor (live or video)?	1	2	3		0		d
e. Model good home visiting practices?	1	2	3		0		d
f. Suggest trainings for you to attend or certifications for you to obtain?	1	2	3		0		d
g. Provide trainings to you?	1	2	3		0		d
h. Review child assessment data with you?	1	2	3		0		d
i. Provide materials or resources to you?	1	2	3		0		d
j. Help you set goals or make plans to improve your practice?	1	2	3		0		d
k. Make themselves available or check in with you?	1	2	3		0		d
l. Assist you with specific needs or challenges?	1	2	3		0		d
m. Help you reflect on your own practice and problem-solve to address challenges?	1	2	3		0		d

INSTRUCT RESPONDENT TO CONSULT SHOW CARD (purple)

Source: Adapted from Baby FACES 2018

B13. Next, I’d like to ask you about trainings that you may have received from this program since September.

This can include one-on-one training, training received through workshops, or training you may have completed online. This can also include on-site or off-site training. For each topic, please tell me whether or not you received the training since September. Then, please indicate the usefulness of the training received. Since September, did you receive training aimed at…

					CODE ONE PER ROW
		A Since September, did you receive training aimed at…			B [Ask only if A= YES] How useful was this training? Was it…
		YES		NO	very useful	somewhat useful	not too useful	not at all useful
b. Supporting positive parent-child relationships?		1		0	4	3	2	1
c. Supporting positive home visitor-family interactions?		1		0	4	3	2	1
e. Engaging parents and families in program activities and in children’s learning?		1		0	4	3	2	1
l. General communication skills and strategies (for example, showing empathy, interest, and responsiveness)?		1		0	4	3	2	1
f. Supporting children who are dual language learners and their families?		1		0	4	3	2	1
m. Culturally responsive strategies and working with diverse families?		1		0	4	3	2	1
h. Understanding the ways in which parents learn (for example, learning through hands-on experiences and feedback)?		1		0	4	3	2	1
q. Helping parents use available materials and resources to support children’s learning and development?		1		0	4	3	2	1

Turning next to curricula and assessments...

Source: Adapted from Baby FACES 2009

B15. Do you use any specific curriculum for your home visiting services?

YES, SPECIFIC CURRICULUM 1

YES, COMBINATION 2

NO 0 GO TO B18a

DON’T KNOW/REFUSED d GO TO B18a

INTERVIEWER: INSTRUCT RESPONDENT TO CONSULT SHOW CARD (white)

IF HOME VISITOR USES SPECIFIC CURRICULUM OR A COMBINATION OF CURRICULA (B15=1 OR 2), HAND SHOW CARD AND ASK:

Source: Adapted from Baby FACES 2018

B16. What curricula or curriculum do you use in your home visiting services? Please just tell me the name or names. CODE ALL THAT APPLY IN COLUMN A

IF MORE THAN ONE MENTIONED, ASK: Which of these that you mentioned do you consider the main curriculum? CODE ONE ONLY IN COLUMN B

	CODE ALL THAT APPLY	CODE ONE ONLY
	A. CURRICULA USED	B. MAIN CURRICULUM
a. AGENCY-CREATED CURRICULUM	1	1
c. BABY TALK	33	33
d. BEAUTIFUL BEGINNINGS	3	3
e. CONSCIOUS DISCIPLINE (BABY DOLL CIRCLE TIME)	30	30
f. CREATIVE CURRICULUM LEARNING GAMES/TEACHING STRATEGIES	4	4
h. GROWING GREAT KIDS	9	9
i. HAWAII EARLY LEARNING PROFILE (HELP)	10	10
k. LEARNING ACTIVITIES FOR INFANTS (Magda Gerber, RIE)	14	14
l. ONES AND TWOS (Parenting: The First Three Years curriculum)	15	15
m. PARENTS AS TEACHERS (PAT)	16	16
n. PARTNERS FOR A HEALTHY BABY	21	21
o. PARTNERS IN PARENTING EDUCATION (PIPE)	23	23
s. OTHER (SPECIFY)	28	28
t.		NO MAIN CURRICULUM
u.	DON’T KNOW/REFUSED	DON’T KNOW/REFUSED

IF HOME VISITOR USES SPECIFIC CURRICULUM OR A COMBINATION OF CURRICULA (B15=1 OR 2), ASK

Source: Adapted from FACES 2014 teacher survey

B16a. In the past year, have you or anyone else used a tool or checklist to assess how you use the curriculum? Which of the following best describes how you have used the tool or checklist? Using a tool or checklist to assess how you use the curriculum is sometimes called fidelity of implementation.

I completed a tool or checklist about how I use the curriculum 1

Someone else completed a tool or checklist about how I use the curriculum 2

Neither me nor anyone else used a tool or checklist to assess how I use the curriculum 3

DON’T KNOW/REFUSED d

IF HOME VISITOR USES SPECIFIC CURRICULUM OR A COMBINATION OF CURRICULA (B15=1 OR 2), ASK

Source: FACES 2014 teacher survey

B16b. Which types of support have you received to help you use the main curriculum? Have you received…

	CODE ONE per row
	YES	NO	DON’T KNOW/ REFUSED
a. Help understanding the curriculum?	1	0	d
b. Opportunities to observe someone implementing the curriculum?	1	0	d
c. Refresher training on the curriculum?	1	0	d
d. Help implementing the curriculum?	1	0	d
e. Help planning curriculum-based activities?	1	0	d
f. Help individualizing or tailoring the curriculum for families?	1	0	d
h. Help identifying and/or receiving additional resources to expand the scope of the curriculum and activities?	1	0	d
i. Help implementing the curriculum for children with special needs?	1	0	d
j. Feedback on implementing the curriculum?	1	0	d
k. Feedback about the results of a checklist about how you use the curriculum?	1	0	d

IF HOME VISITOR USES SPECIFIC CURRICULUM OR A COMBINATION OF CURRICULA (B15=1 OR 2), ASK

Source: New Item

B17a. Do you individualize the main curriculum for families that you work with?

YES 1

NO 0

DON’T KNOW/REFUSED d

ASK IF B17A=1

Source: New Item

B17b. What are the tools or resources that you use to individualize the main curriculum for families that you work with?

	CODE ONE PER ROW
	YES	NO	DON’T KNOW/ REFUSED
a. Child assessment data	1	0	d
b. Data related to family needs	1	0	d
c. Classroom observation data	1	0	d
d. Parent input	1	0	d
e. Curriculum developer’s guidance on individualizing the curriculum	1	0	d

Source: New Item

B18a. How do you involve parents when planning home visits? Do you…

	CODE ONE PER ROW
	YES	NO	DON’T KNOW/ REFUSED
a. Review what happened during the last visit?	1	0	d
b. Ask for parental input during the home visit?	1	0	d
c. Discuss what topics and activities they would like to cover in the next visit?	1	0	d
d. Discuss what parents will work on prior to the next visit?	1	0	d
e. Leave a copy of the home visit plan with parents?	1	0	d

Source: Adapted from Baby FACES 2009 Program Director Survey

B19. Since September, have you used any assessments to gather information on children’s development or progress?

YES 1

NO 0

NOT APPLICABLE- HV ONLY SEES PREGNANT WOMEN n

DON’T KNOW/REFUSED d

INTERVIEWER: INSTRUCT RESPONDENT TO CONSULT SHOW CARD (yellow)

IF CHILD ASSESSMENT TOOLS USED (B19=1), HAND SHOW CARD AND ASK:

Source: Adapted from Baby FACES 2009 Program Director Survey

B21. What child assessments have you used since September this year?

INTERVIEWER PROBE: Any others?

CHILD SCREENERS AND ASSESSMENTS:

	CODE ALL THAT APPLY
SCREENERS	ASSESSMENT USED
a. AGENCY-CREATED SCREENING ASSESSMENT	1
b. AGES AND STAGES QUESTIONNAIRE (ASQ)	2
y. ASQ: SOCIAL-EMOTIONAL	25
aa. BRIEF INFANT TODDLER SOCIAL EMOTIONAL ASSESSMENT (BITSEA)	26
bb. BRIGANCE SCREENER	24
h. DENVER DEVELOPMENTAL SCREENING TEST	8
ASSESSMENTS
cc. BRIGANCE ASSESSMENT	29
f CREATIVE CURRICULUM TOOLS (MAY ALSO BE KNOWN AS TEACHING STRATEGIES GOLD)	6
g. DESIRED RESULTS DEVELOPMENTAL PROFILES-R (DRDP)	7
i. DEVEREUX EARLY CHILDHOOD ASSESSMENT (DECA)	9
j. EARLY LEARNING ACCOMPLISHMENT PROFILE	10
m. HIGH SCOPE CHILD OBSERVATION RECORD (COR)	13
n. INFANT-TODDLER DEVELOPMENTAL ASSESSMENT (IDA)	14
o. INFANT TODDLER SOCIAL EMOTIONAL ASSESSMENT (ITSEA)	15
p. OTHER (SPECIFY)	22

IF CHILD ASSESSMENT TOOLS USED (B19=1), ASK:

Source: Baby FACES 2018

B26. Please tell me whether you feel each of the following are challenges to using child assessment data or data used to understand family needs to plan and provide services for individual families.

[READ ITEM]… Would you say this is a challenge or not a challenge?

	CODE ONE PER ROW
	yes, this is a challenge	no, this is not a challenge	don’t know/refused
a. Not having the technology I need to collect and work with data?	1	2	d
b. Not having enough time to collect the data I need?	1	2	d
c. Not knowing how to accurately collect child assessment data or data to understand family needs?	1	2	d
d. Not knowing how I can use data to individualize or improve the strategies I use with families?	1	2	d
e. Lack of understanding of what the data mean?	1	2	d
f. Not having child assessment tools that are well adapted for home visiting settings?	1	2	d

SECTION C: ORGANIZATIONAL CLIMATE

This next section is about your work environment and the people you work with.

Source: Adapted from TCU- Survey of Organizational Functioning

C1. INTERVIEWER: INSTRUCT RESPONDENT TO CONSULT SHOW CARD (green)

Please tell me the extent to which you disagree or agree with the following statements about your Early Head Start program. For each statement, please tell me whether you strongly disagree, disagree, neither disagree nor agree, agree, or strongly agree.[READ FIRST ITEM] How strongly do you disagree or agree with this statement? What about…[CONTINUE WITH REST OF LIST]?

	CODE ONE PER ROW
	STRONGLY DISAGREE	DISAGREE	NEITHER DISAGREE NOr AGREE	AGREE	STRONGLY AGREE	DON’T KNOW/ REFUSED
a. Staff in this program get along very well.	1	2	3	4	5	d
b. There is too much friction among staff members.	1	2	3	4	5	d
c. The staff in this program always work together as a team.	1	2	3	4	5	d
d. Staff in this program are always quick to help one another when needed.	1	2	3	4	5	d
e. Mutual trust and cooperation among staff in this program are strong.	1	2	3	4	5	d
f. Everybody in this program does their fair share of work.	1	2	3	4	5	d
g. Ideas and suggestions from staff get fair consideration by program management.	1	2	3	4	5	d
h. The formal and informal communication channels in this program work very well.	1	2	3	4	5	d
i. Program staff are always kept well informed.	1	2	3	4	5	d
i. More open discussions about program issues are needed in this program.	1	2	3	4	5	d
k. Staff members always feel free to ask questions and express concerns in this program.	1	2	3	4	5	d
l. You are under too many pressures to do your job effectively.	1	2	3	4	5	d
m. Staff members often show signs of stress and strain.	1	2	3	4	5	d
n. The heavy workload in this program reduces program effectiveness.	1	2	3	4	5	d
o. Staff frustration is common in this program.	1	2	3	4	5	d
p. You are satisfied with your present job.	1	2	3	4	5	d
q. You feel appreciated for the job you do.	1	2	3	4	5	d
r. You like the people you work with.	1	2	3	4	5	d
s. You give high value to the work you do in this program.	1	2	3	4	5	d
t. You are proud to tell others where you work.	1	2	3	4	5	d
u. You would like to find a job somewhere else.	1	2	3	4	5	d

Source: Adapted from Organizational Climate Description for Elementary Schools (OCDQ-RE)

C2. INTERVIEWER: INSTRUCT RESPONDENT TO CONSULT SHOW CARD (pink)

Next, I would like to ask your opinion about your program director and how often he or she interacts with you and other home visitors at this program. Please tell me how often the following occurs in your program. For each statement, please tell me whether this occurs rarely, sometimes, often, or very frequently. [READ FIRST ITEM]. How frequently does this occur? What about…[CONTINUE WITH THE REST OF THE LIST]?

	CODE ONE PER ROW
	RARELY	SOMETIMES	OFTEN	VERY FREQUENTLY	DON’T KNOW/ REFUSED
a. The program director goes out of his/her way to help home visitors.	1	2	3	4	d
b. The program director uses constructive criticism.	1	2	3	4	d
c. The program director explains his/her reasons for criticism to home visitors.	1	2	3	4	d
d. The program director listens to and accepts home visitors’ suggestions.	1	2	3	4	d
e. The program director looks out for the personal welfare of home visitors.	1	2	3	4	d
f. The program director treats home visitors as equals.	1	2	3	4	d
g. The program director compliments home visitors.	1	2	3	4	d
h. The program director is easy to understand.	1	2	3	4	d
i. The program director goes out of his/her way to show appreciation to home visitors.	1	2	3	4	d

Source: Baby FACES 2018

C3. Thinking about your safety when going into the homes of your clients, how often do you feel unsafe when conducting home visits? Would you say…

All or almost all of the time, 1

Most of the time, 2

Some of the time, 3

Hardly ever, or 4

Never? 5

DON’T KNOW/REFUSED d

SECTION D: LANGUAGE

Next, we are going to talk about the languages you speak.

Source: Baby FACES 2018

D1. What is your primary language? This is the language that you feel most comfortable communicating in.

ENGLISH 1

SPANISH 2

OTHER (SPECIFY) 3

____________________________________________________________

DON’T KNOW/REFUSED d

Source: Adapted from Baby FACES 2009

D2. Do you speak any language other than [PRIMARY LANGUAGE FROM D1]?

YES 1

NO 0 GO TO E1

DON’T KNOW/REFUSED d GO TO E1

D2=1

Source: Adapted from Baby FACES 2009

D3. What languages?

PROBE: Any other languages?

WRITE IN LANGUAGES OTHER THAN ENGLISH OR SPANISH. THEN CODE EACH LANGUAGE USED IN D2.

SPANISH 1

ENGLISH 2

OTHER (SPECIFY) 3

____________________________________________________________

OTHER (SPECIFY) 4

____________________________________________________________

SECTION F. DEMOGRAPHICS

These last questions are about your background.

Source: OMB Guidance

F1. Are you of Hispanic, Latino/a, or Spanish origin? You may choose one or more.

IF THEY SAY ‘YES’ WITHOUT ELABORATING, ASK: Are you… READ ALL YES CHOICES BELOW (THEY MAY SAY MORE THAN ONE)

NO, NOT OF HISPANIC, LATINA/O OR SPANISH ORIGIN 1

(YES) Mexican, Mexican American, Chicano/a 2

(YES), Puerto Rican 3

(YES), Cuban 4

(YES), Another Hispanic, Latino/a, or Spanish origin 5

DON’T KNOW/REFUSED d

Source: OMB Guidance

F2. What is your race? You may choose one or more. Is it…

White 1

Black or African American 2

American Indian or Alaska Native 3

Asian 4

Native Hawaiian or Other Pacific Islander 5

DON’T KNOW/REFUSED d

Source: Adapted from Baby FACES 2009

F3. What is the highest level of school you have completed?

If you are still in school or no longer in school, please tell us about the last year of schooling you finished.

LESS THAN A HIGH SCHOOL DIPLOMA 1 GO TO F4

HIGH SCHOOL DIPLOMA OR EQUIVALENT 2 GO TO F4

SOME VOCATIONAL/TECHNICAL SCHOOL, BUT NO DIPLOMA 3 GO TO F4

VOCATIONAL/TECHNICAL DIPLOMA 4 GO TO F4

SOME COLLEGE COURSES, BUT NO DEGREE 5 GO TO F4

ASSOCIATE’S DEGREE 6 GO TO F4A

BACHELOR’S DEGREE 7 GO TO F4A

GRADUATE OR PROFESSIONAL SCHOOL, BUT NO DEGREE 8 GO TO F4A

MASTER’S DEGREE (M.A., M.S.) 9 GO TO F4A

DOCTORATE DEGREE (PH.D., ED.D.) 10 GO TO F4A

PROFESSIONAL DEGREE AFTER BACHELOR’S DEGREE (MEDICINE/MD; DENTISTRY/DDS; LAW/JD/LLB; ETC.) 11 GO TO F4A

DON’T KNOW/REFUSED d

ASK FOR RESPONDENTS WHO REPORTED HAVING LESS THAN AN ASSOCIATE’S DEGREE IN F3

Source: Adapted from Baby FACES 2009

F4. Do you have either of the following credentials or certificates?

	code one per row
	YES, I HAVE IT	NO, i don’t have it	DON’T KNOW/ REFUSED
a. An Infant/Toddler Child Development Associate (CDA) credential	1	0	d
h. Some other kind of CDA credential or state awarded certificate/license	1	0	d

ASK FOR RESPONDENTS WHO REPORTED HAVING LESS THAN AN ASSOCIATE’S DEGREE IN F3

Source: Adapted from Baby FACES 2018

F4.1. Are you currently working toward an associate’s or a bachelor’s degree?

YES 1

NO 0

DON’T KNOW/REFUSED d

ASK FOR RESPONDENTS WHO REPORTED HAVING AN ASSOCIATE’S DEGREE OR HIGHER IN F3

Source: Adapted from Baby FACES 2018

F4.2. Is your degree in Early Childhood Education or a related field?

YES 1

NO 0

DON’T KNOW/REFUSED d

ASK FOR RESPONDENTS WHO REPORTED HAVING AN ASSOCIATE’S DEGREE OR HIGHER IN F3

Source: Adapted from Baby FACES 2018

F4a. Did your degree or graduate work include the study of or a focus on prenatal or infant/toddler development?

YES 1

NO 0

DON’T KNOW/REFUSED d

Source: Adapted from Baby FACES 2018

F5. How many years have you worked as a home visitor serving families with infants and toddlers?

IF LESS THAN ONE YEAR, write 0. ROUND TO WHOLE NUMBERS

| | | NUMBER OF YEARS

DON’T KNOW/REFUSED d

Source: Adapted from Baby FACES 2009

F6. In total, how many years have you been working in Early Head Start?

IF LESS THAN ONE YEAR, WRITE 0. ROUND TO WHOLE NUMBERS

| | | NUMBER OF YEARS

DON’T KNOW/REFUSED d

Source: Adapted from Baby FACES 2018 Center Director survey

F6b. How many years have you been working with this program?

IF LESS THAN ONE YEAR, write 0. ROUND TO WHOLE NUMBERS

| | | NUMBER OF YEARS

DON’T KNOW/REFUSED d

Source: Adapted from Baby FACES 2009

F7. Are you male or female?

MALE 1

FEMALE 2

OTHER 3

DON’T KNOW/REFUSED d

SECTION E: HEALTH

We are almost done. Now I am going to hand you a page of questions for you to complete on your own. Once you have completed it, please place the survey in this envelope and seal it before returning it to me. Please be assured that your responses to these questions will be kept private.

HAND RESPONDENT PAGE OF QUESTIONS AND ENVELOPE.

Thank you very much for your participation and cooperation in this important study.

INTERVIEWER, PLEASE INDICATE TODAY’S DATE:

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

month day year

Source: The Center for Epidemiologic Studies Depression Scale Revised (CESD-R)

E1. For each statement below, please indicate how often you have felt this way in the past week or so by circling your response. Please CODE only one response for each statement.

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

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