Survey of caregivers - MIHOPE-K

Mother and Infant Home Visiting Program Evaluation (MIHOPE): Kindergarten Follow-Up (MIHOPE-K)

Instrument 1_MIHOPE-K_Survey of caregivers

Survey of caregivers - MIHOPE-K

OMB: 0970-0402

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0970-0402 can be found here:

2023-07-18 - Revision of a currently approved collection

Document [docx]

Download: docx | pdf

MIHOPE-K Structured Interview with Caregivers

July2019

Mother and Infant Home Visiting Program Evaluation

MIHOPE-K

Structured Interview with Caregivers

September 2021

Note: As indicated in Supporting Statement A, the structured interview has over one hour’s worth of questions, but we plan to use a technique called “planned missingness” to ensure that each respondent receives only 59 minutes of interview items. In other words, groups of respondents will be assigned to answer only a portion of the items in this draft so that an individual’s total response time is 59 minutes or less.

This collection of information is voluntary and will be used to learn how home visiting programs benefit families. 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 0970-0402 and the expiration date is 11/30/2021.

SC. INTRO/SCREENER

Call Attempt:

FieldInfo. Hello, my name is [INTERVIEWER NAME]. May I have your name?

[IF NO ONE ANSWERS AND DIRECTED TO VOICEMAIL/ANSWERING DEVICE]

MessageScript. Hello. My name is [INTERVIEWER NAME] calling from Mathematica Policy Research. I am trying to reach [FULLNAME] to complete an interview for MIHOPE. [CURRENT RESPONDENT FIRST] will receive a $25 gift card for completing the interview. Please call us as soon as possible to complete the interview. The toll-free number is 1-800-273-6813. Again, the number to call us back is 1-800-273-6813. Thank you.

[IF SOMEONE ANSWERS]

Source: MIHOPE2

Item title: Hello

SC1. Hello, my name is [NAME]. I am calling on behalf of Mathematica Policy Research in Princeton, New Jersey. May I please speak to [NAME]?

INTERVIEWER: IF ASKS WHAT ABOUT, SAY: [I’m calling to complete a follow-up interview for the MIHOPE home visiting study. May I speak with her?/ IF RE-ENTRY: I’m calling to finish the interview we are conducting with [FIRSTNAME] for the MIHOPE study. May I speak with her?]

speaking to [name] 1 mostres

[name] comes to the phone 2 mostres

need to callback (no appt) 3 finish

Need to callback (set appt) 4 sC1e

[NAME] HAS MOVED/HAS new number 5 SC1c

[NAME] has a health problem 6 SC1d

[NAME] is in an institution/JAIL 7 SC1b

[nAME] DOESN’T SPEAK ENGLISH 8 lang

never heard of [name]/wrong number 9 FINISH

hung up during introduction (HUDI) 10

[NAME] IS DECEASED 11 sc14A_3

CHILD IS DECEASED 12 sorry

[NAME] IS UNAVAILABLE DURING FIELD PERIOD (OTHER rEASON) 13 calllater

Respondent Call-In:

CallIn. Hello, my name is [INTERVIEWER NAME]. May I ask your name?

SPEAKING TO [FIRSTNAME] 1

[FIRSTNAME] CALLED TO MAKE APPOINTMENT 2 SC1e

[FIRSTNAME] CALLED TO REFUSE 3

SOMEONE ELSE CALLED TO REFUSE 4

SOMEONE ELSE CALLED TO SAY [FIRSTNAME] DECEASED 5 SC14a_3

[FIRSTNAME] HAS A HEALTH PROBLEM 6 SC1d

[FIRSTNAME] IS IN AN INSTITUTION (HOSPITAL, GROUP HOME, JAIL) 7 SC1b

[FIRSTNAME] HAS MOVED/HAS NEW NUMBER 8 SC1c

[FIRSTNAME] DOES NOT SPEAK ENGLISH 9 LANG

CHILD IS DECEASED 10 SORRY

[FIRSTNAME] IS UNAVAILABLE DURING FIELD PERIOD (OTHER REASON) 11 CALLLATER

CallInBestNum. In case we get disconnected, is the phone number you are calling from the best one to use to call you back?

YES 1

NO 0

DON’T KNOW d

REFUSED r

CallInNewNum. IF CALLINBESTNUM = 1
Please tell me the number you are calling from, area code first.

IF CALLINBESTNUM = 0
Please give me the best telephone number to use, area code first.

| | | | - | | | | - | | | | |

(0-999) (0-999) (0-9999)

Is there an extension number?

| | | | | | |

(0-999999)

DON’T KNOW d

REFUSED r

CallInNewNumTZ. What time zone is that in?

If NEEDED: What time is it there?

Eastern Time (US & Canada) [(FILL CURRENT TIME)] 62

Indiana (East) [(FILL CURRENT TIME)] 63

Central Time (US & Canada) [(FILL CURRENT TIME)] 65

ARIZONA [(FILL CURRENT TIME)] 68

MOUNTAIN TIME (US & CANADA) [(FILL CURRENT TIME)] 70

PACIFIC TIME (US & CANADA) [(FILL CURRENT TIME)] 71

ALASKA [(FILL CURRENT TIME)] 72

HAWAII [(FILL CURRENT TIME)] 73

BAJA CALIFORNIA [(FILL CURRENT TIME)] 93

Lang. Please allow me a moment to locate a [LANG] speaking interviewer.

[IF NEW RESPONDENT, GO TO NEWRESP INSTEAD]

MostRes. I’m calling about the MIHOPE study. You should have received a letter [and an email] from us recently informing you that we would be reaching out to talk to you again. The purpose of the MIHOPE study is to learn how home visiting can make a difference for children and families. We would like to check in with you to hear how your child is doing as [he/she/he or she] grows up.

[We last spoke to you when [CHILD] was about [15 months old / 2½ years old / 3½ years old], and now we’re following up again.]

ONLY COMPLETED BASELINE SURVEY (INTERVIEWHISTORY = 1 OR 2)

You may remember joining the MIHOPE study about home visiting in [FILL WITH MONTH YEAR OF BASELINE SURVEY COMPLETION]. We haven’t been able to get in touch with you since then, but would still like to speak with you in this next phase of the study.

ALL
For this interview, I need to speak to [[CHILD]/the child who was due to be born on [DUE DATE]]’s birth mother, if she lives in the same household as the child. Are you [[CHILD]/the child who was due to be born on [DUE DATE]]’s birth mother?

Yes, RESPONDENT IS MOTHER 1 SC14a_2

NO, RESPONDENT IS NOT MOTHER 2 MOMLIVEWITH

NO, MOTHER DECEASED 3 MOSTRES2

MomLiveWith. Does [[CHILD]/the child who was due to be born on [DUE DATE]]’s birth mother live in the same household as the child?

CODE ONE ONLY

YES 1 SC14a_3

NO 2 MOSTRES2

NO, MOTHER DECEASED 3 MOSTRES2

MostRes2. [I am very sorry to hear that. Please accept my condolences. PAUSE]

To confirm, are you still the person who is most responsible for [CHILD]’s care?

YES 1 SC14a_2

NO 0 SC14a_3

[IF NEW RESPONDENT]

NewResp. I’m calling about the MIHOPE study [[NAME]/[BIRTHMOTHER FULL NAME]] joined [in [FILL MONTH AND YEAR OF BASELINE INTERVIEW when she was pregnant/and was participating in with [CHILD]/her child]. The purpose of the MIHOPE study is to learn how home visiting can make a difference for children and families. I was told that you are the person who is [caring for her child who was due to be born on [FILL DUE DATE]/most responsible for [CHILD]’s care.] Is that correct?

YES 1 SC14a_2

NO 0 SC14a_3

DON’T KNOW d SC14a_3

REFUSED r

[IF [NAME] IN HOSPITAL, ELSE GO TO SC14a_3]

Source: MIHOPE2

Item title: HomeSoon

SC1b. Do you expect [NAME] to come home from the hospital within the next four weeks?

YES 1 SC1e

NO 2 SC14a_3

UNABLE TO RESPOND OVER THE TELEPHONE 3 SC1e

DON’T KNOW D SC1e

REFUSED R SC1e

Source: MIHOPE2

Item title: KnowWhere

SC1c. I’m calling to conduct a follow-up interview for a study that [NAME] is participating in. [NAME] joined the study in [MONTH YEAR] and agreed to be contacted again to participate in a follow up interview. May I have [NAME]’s address, email address, and phone number so I can contact him or her?

YES, NEW OR UPDATED INFORMATION GIVEN 1 SC1c_1

NO, WON’T GIVE INFO 2 FINISH

WANTS TO GIVE HER INFO AND HAVE HER CALL US 3 GIVENUM

DON’T KNOW D FINISH

REFUSED R FINISH

GiveNum. [NAME] can reach us at 1-800-273-6813 to complete the study.

Source: MIHOPE2

Item title: KnowWhere_phone

SC1c_1. Please give me the telephone number, area code first.

|___|___|___| - |___|___|___| - |___|___|___|___|

(0-999) (0-999) (0-9999)

REFUSED TO GIVE NUMBER 0 SC1C_4

SC1c_2b. Is there an extension number?

|___|___|___|___| EXTENSION

(0-9999)

DON’T KNOW D SC1c_4

REFUSED R SC1c_4

KnowWherePhoneTZ. What time zone is that in?

If NEEDED: What time is it there?

Eastern Time (US & Canada) [(FILL CURRENT TIME)] 62

Indiana (East) [(FILL CURRENT TIME)] 63

Central Time (US & Canada) [(FILL CURRENT TIME)] 65

ARIZONA [(FILL CURRENT TIME)] 68

MOUNTAIN TIME (US & CANADA) [(FILL CURRENT TIME)] 70

PACIFIC TIME (US & CANADA) [(FILL CURRENT TIME)] 71

ALASKA [(FILL CURRENT TIME)] 72

HAWAII [(FILL CURRENT TIME)] 73

BAJA CALIFORNIA [(FILL CURRENT TIME)] 93

Source: New item

Item title: KnowWhere_email

SC1c_4. Please give me [NAME’S] email address.

_______________________________________@_________________

REFUSED TO GIVE EMAIL 0 SC1c_5

Source: New item

Item title: KnowWhere_email

SC1c_5. Please tell me the best address for [NAME].

What is the first line of the address?

_______________________________________________ (STRING 60)

STREET 1

Is there an apartment or unit number for this address?

_______________________________________________ (STRING 60)

STREET 2

Town or city?

_______________________________________________ (STRING 25)

CITY

State?

_______________________________________________ (STRING 2)

STATE

And what is the zip code?

|___|___|___|___|___| - |___|___|___|___| ZIP CODE

00501-99950 0001-9999

REFUSED TO GIVE ADDRESS 0 FINISH

GO TO FINISH

SC1d. [IF [NAME] HAS COGNITIVE/INTELLECTUAL IMPARIMENT, OTHER IMPAIRMENT, OR IS DECEASED, GO TO SC14a_3]

[IF [NAME] HAS SENSORY IMPAIRMENT OR VOCAL/SPEECH IMPAIRMENT]

AmpRelay. I can increase the volume of my voice or [FIRSTNAME]'s voice, or we could use a relay service. Would either of these enable [him / her / him or her] to complete the interview?

YES – INCREASE VOLUME ON PHONE 1 SC1d_1

YES – USE RELAY SERVICE 2 RELAYPHONE

NO 3 FINISH

DON’T KNOW d SC1e

RelayPhone. May I have the telephone number of the relay service we should use to reach [FIRSTNAME]?

| | | | - | | | | - | | | | |

(0-999) (0-999) (0-9999)

DON’T KNOW d SC1e

RespAvail. Is [FIRSTNAME] available now?

YES 1

NO – NEEDS CALL BACK 0 SC1e

DON’T KNOW d SC1e

[IF [NAME] HAS SHORT TERM HEALTH PROBLEM OR PHYSICAL IMPAIRMENT]

CallLater. Will [FIRSTNAME] be able to talk on the telephone if I call back in the next four weeks?

YES/MAYBE - CALLBACK 1 SC1e

NO 0 SC14a_3

DON’T KNOW d SC1e

Source: MIHOPE2

Item title: NewContact

SC1d_1. Is [NAME] available now?

YES 1 SC2

NO – NEEDS CALL BACK 0 SC1e

DON’T KNOW D

REFUSED R

GO TO FINISH

Source: MIHOPE2

Item title: SetAppt

SC1e. When would be a good time to call back?

|___|___|:|___|___| AM/PM

HOUR MINUTES

|___|___| / |___|___| / |___|___|___|___|

MONTH DAY YEAR

(1-12) (1-31) (RANGE)

ConfPhoneExit. Please confirm the phone number we have on file.

The phone number we have is:

PHONE:

Is that correct?

YEs, Correct 1

NO, edit PHONE 2 NEWPHONE

NO, NEW PHONE 3 NEWPHONE

CALL ENDED BEFORE ASKING 4

REFUSED r

NewPhone. Starting with the area code, please give me the best telephone number to use to call you back.

| | | | - | | | | - | | | | |

(0-999) (0-999) (0-9999)

Is there an extension number?

| | | | | | |

(0-999999)

DON’T KNOW d

REFUSED r

NewPhoneTZExit. What time zone is that in?

If NEEDED: What time is it there?

Eastern Time (US & Canada) [(FILL CURRENT TIME)] 62

Indiana (East) [(FILL CURRENT TIME)] 63

Central Time (US & Canada) [(FILL CURRENT TIME)] 65

ARIZONA [(FILL CURRENT TIME)] 68

MOUNTAIN TIME (US & CANADA) [(FILL CURRENT TIME)] 70

PACIFIC TIME (US & CANADA) [(FILL CURRENT TIME)] 71

ALASKA [(FILL CURRENT TIME)] 72

HAWAII [(FILL CURRENT TIME)] 73

BAJA CALIFORNIA [(FILL CURRENT TIME)] 93

GO TO FINISH

Source: MIHOPE2

Item title: NoLetter

SC1g_1. The letter [and email] explained the purpose of the MIHOPE study and that we would be calling to conduct a follow-up interview.

Can we begin now?

YES, BEGIN INTERVIEW 1 SC2

WANTS ANOTHER LETTER 2 SC1g_2

NOT A GOOD TIME 4 SC1E

Source: MIHOPE2

Item title: ReadLetter

SC1g_2. May I tell you a little more about the study?

YES, READ STUDY DESCRIPTION 1 SC2

NO, WANTS ANOTHER LETTER FIRST 2 SC1g_3

Source: Adapted from MIHOPE2

Item title: SendEmail

SC1g_3. If you provide me with your email address, I can email you the letter right now and will call back in a couple of days. What is the best email address for you?

Okay, I'll email [her/you] the letter. I would like to confirm that we have your correct email address.

INTERVIEWER: READ ADDRESS, MAKE ANY CORRECTIONS

____________________________________@____________________

WANTS THE LETTER TO BE MAILED 1 SC1g_4

DON’T KNOW D

REFUSED R

Source: MIHOPE2

Item title: SendLetter

SC1g_4. Okay, I’ll mail another letter and will call back in a few days. I would like to confirm that we have your correct address.

The address we have is:

INTERVIEWER: READ ADDRESS, MAKE ANY CORRECTIONS

Is that correct?

[IF INCORRECT] Please tell me the best address to send the letter.

What is the first line of the address?

_______________________________________________ (STRING 60)

STREET 1

Is there an apartment or unit number for this address?

_______________________________________________ (STRING 60)

STREET 2

Town or city?

_______________________________________________ (STRING 25)

CITY

State?

_______________________________________________ (STRING 2)

STATE

And what is the zip code?

|___|___|___|___|___| - |___|___|___|___| ZIP CODE

00501-99950 0001-9999

DON’T KNOW D

REFUSED R

GO TO FINISH

Source: Adapted from MIHOPE2

Title: SampMemb

SC2. [Hello, my name is [INTERVIEWER]. I am calling from Mathematica Policy Research in Princeton, New Jersey.]

[IF INTERVIEW ALREADY STARTED] [I’m calling to finish the interview we are conducting for the MIHOPE study. As a reminder, we’d like to learn about how [CHILD] is doing and to ask you some questions about your family. When we finish, we will sendyou a $25 gift card to thank you for your help. These questions take about 1 hour, but may take less time today since we already began the interview.]

[IF NEW RESPONDENT AND 15-MONTH, 2.5 AND 3.5 Y/O CHECK-IN INTERVIEWS NOT COMPLETED AND RESPONDENT PREGNANT AT BASELINE: [[NAME] was pregnant when we interviewed her and she agreed to speak to us again. We were unable to reach her at that time, but we’d like to follow up now.

In this interview, we’d like to learn about how [[CHILD]/(your/her) child] is doing and to ask you some questions about your family. These questions take about 1 hour. We will ask about your health, your child’s health, what you do as a parent, your child’s development, and your family’s economic situation. We will also ask you questions on more sensitive topics including substance use, prison time, intimate partner violence, and child maltreatment. When we finish, we will sendyou a $25 gift card to thank you for your help. There are no right or wrong answers to these questions. You may stop me at any time, and you may ask me to go back to earlier questions to change your answers. If I ask you something that you are uncomfortable answering, just tell me and I will move on to the next question.

Your participation is completely voluntary. Everything we talk about today is private unless there is concern that you or someone else may be harmed. For example, we would tell someone if we learn about evidence of child abuse or neglect, and they may report this to Child Protective Services. All of the study results will be reported for groups of parents; no results will be analyzed or reported for individuals.

IF STUDY STATE = WA

A nonprofit organization called MDRC is running this study, and Dr. Charles Michalopoulos is the Principal Investigator. You may call the Washington State Institutional Review Board if you have questions about your rights or concerns/complaints about the research. The WSIRB oversees this study to make sure that the rights of people who take part are protected. You can call at 1-800-583-8488. You don't have to give your name if you call.

We truly appreciate your help and your continued participation in this important study.

Also, you should know that this interview has been approved by the federal Office of Management and Budget or OMB. We're not allowed to ask you these questions and you don't have to answer them unless there is a valid OMB control number. For this interview, the OMB control number is 0970-0402 and it expires on November 30, 2021.

If you have any questions at any time during the interview, please feel free to ask them. Do you have questions before we begin?

PROCEED WITH INTERVIEW 1 SC3

DID NOT RECEIVE OR DOES NOT RECALL LETTER 2 SC1g

NOT A GOOD TIME/CALLBACK 0 SC1e

HUNG UP DURING INTRODUCTION 3 FINISH

Source: MIHOPE2

Item title: Consent

SC3. Do you consent to participate in this interview for the MIHOPE study?

YES 1

NO 0 FINISH

DON’T KNOW D FINISH

SOFT CHECK: You said that you do not consent to participate in this MIHOPE interview. Is that correct?

SC3a. Are you in a place where you can safely talk on the phone and answer my questions?

YES, BEGIN INTERVIEW 1

NOT A GOOD TIME 2 SC1e

DON’T KNOW d SC1e

REFUSED r SC1e

ConfirmRec. This call will be monitored or recorded for quality assurance purposes.

IF NEW RESPONDENT OR FIRST INTERVIEW SINCE BASELINE, CONTINUE;

ELSE GO TO CI4_a

Source: MIHOPE2

Item title: Name

SC4. First, I’d like to confirm the spelling of your name. Would you please spell your first and last name for me?

NAME IS CORRECT 1

NAME IS INCORRECT 2

REFUSED R

[IF SC4=2]

Source: MIHOPE2

SC4_open. Would you please spell your first and last name for me?

________________________________________________________ (STRING (15))

FIRST NAME

________________________________________________________ (STRING (15))

MIDDLE INITIAL/NAME

________________________________________________________ (STRING (30))

LAST NAME

Source: MIHOPE2

Item title: DOB

SC6. What is your birth date?

|___|___| / |___|___| / |___|___|___|___|

MONTH DAY YEAR

(1-12) (1-31) (RANGE)

DON’T KNOW D

REFUSED R

[IF SC6 = DK, R]

Source: MIHOPE2

Item title: Age

SC5. How old are you?

|___|___|___| YEARS

0-100

REFUSED R

[IF WE ALREADY HAVE ADDRESS]

CI4_a. Please confirm your address.

The address we have is:

[ADDRESS]

Is that correct?

YES 1 MailTo

NO 0 CI4

REFUSED R MailTo

Source: Adapted from MIHOPE2

CI4. Please give me your address.

What is the first line of the address?

_______________________________________________ (STRING 60)

STREET 1

Is there an apartment or unit number for this address?

_______________________________________________ (STRING 60)

STREET 2

Town or city?

_______________________________________________ (STRING 20)

CITY

State?

_______________________________________________ (STRING 2)

STATE

And what is the zip code?

|___|___|___|___|___| - |___|___|___|___| ZIP CODE

00501-99950 0001-9999

REFUSED R

IF FIRST INTERVIEW SINCE BASELINE AND WAS NOT PREGNANT AT BASELINE, CONTINUE; ELSE, IF FIRST INTERVIEW SINCE BASELINE AND WAS PREGNANT AT BASELINE, GO TO SC8; ELSE, GO TO SC7a

Source: MIHOPE2

Item title: CorrectName

SC7. Now, we would like to make sure we have [CHILD]’s name recorded correctly. Would you please spell [CHILD]’s name for me?

NAME IS CORRECT 1

NAME IS INCORRECT 2

CHILD IS DECEASED 3 SORRY

DON’T KNOW D

REFUSED R

IF SC7=2

SC7_open. Would you please spell [CHILD]’s name for me?

________________________________________________________ (STRING (15))

FIRST NAME

________________________________________________________ (STRING (15))

MIDDLE INITIAL/NAME

________________________________________________________ (STRING (30))

LAST NAME

SC7a. [Just to confirm, what sex was [CHILD] assigned at birth, on their original birth certificate?]

BOY 1

GIRL 2

DON’T KNOW D

REFUSED R

SC7b. [What is the gender identity of [CHILD]?]

BOY 1

GIRL 2

TRANSGENDER BOY 3

TRANSGENDER GIRL 4

GENDERQUEER (NON-BINARY, GENDERLESS, GENDER NONCONFORMING) 5

AN IDENTITY NOT LISTED HERE 6

DON’T KNOW D

REFUSED R

SC7c. [What pronouns does [CHILD] use?]

SHE/HER 1

HE/HIM 2

THEM/THEM 3

[XE/XEM 4

ZE/ZIR 5

SIE/HIR 6

ZE/ZIM 7

PRONOUNS NOT LISTED HERE] 8

DON’T KNOW D

REFUSED R

[IF FIRST INTERVIEW SINCE BASELINE AND WAS PREGNANT AT BASELINE, ELSE GO TO S1X]

Source: MIHOPE2

Item title: Pregnancy

SC8. When [you/[NAME]] joined MIHOPE, [you were/she was] pregnant and [your/her] baby was due on [DUE DATE]. Did [you/[NAME]] have a single or multiple birth?

SINGLE 1 SC10

MULTIPLE 2 SC9

HAD A MISCARRIAGE OR STILLBIRTH 0 SORRY

CHILD IS DECEASED 3 SORRY

Source: MIHOPE2

Item title: NumberBabies

SC9. How many babies did [you/[NAME]] give birth to?

0: MISCARRIAGE, STILLBIRTH, OR DECEASED 0 SORRY

1 1

2 2

3 3

4 4

IF SC8=2, ASK SC10-SC12 FOR AS MANY TIMES AS NUMBER OF CHILDREN MENTIONED IN SC9

Source: MIHOPE2

Item title: OtherName

SC10. [IF SC10 OF PRIOR LOOP = 3 (DECEASED)] I am very sorry. Please accept my condolences.

Could you please spell [your/[NAME]’s] [(first/second/third/fourth)] child’s name for me?

________________________________________________________ (STRING (15))

FIRST NAME

________________________________________________________ (STRING (15))

MIDDLE INITIAL/NAME

________________________________________________________ (STRING (30))

LAST NAME

CHILD IS DECEASED 3

DON’T KNOW D

REFUSED R

Source: MIHOPE2

Item title: BoyGirl

SC13. [What sex was [CHILD] assigned at birth, on their original birth certificate?]

BOY 1

GIRL 2

CHILD IS DECEASED 3 SORRY

DON’T KNOW D

REFUSED R

SC13b. [What is the gender identity of [CHILD]?]

BOY 1

GIRL 2

TRANSGENDER BOY 3

TRANSGENDER GIRL 4

GENDERQUEER (NON-BINARY, GENDERLESS, GENDER NONCONFORMING) 5

AN IDENTITY NOT LISTED HERE 6

DON’T KNOW D

REFUSED R

SC13c. [What pronouns does [CHILD] use?]

SHE/HER 1

HE/HIM 2

THEM/THEM 3

[XE/XEM 4

ZE/ZIR 5

SIE/HIR 6

ZE/ZIM 7

PRONOUNS NOT LISTED HERE] 8

DON’T KNOW D

REFUSED R

Source: MIHOPE2

Item title: DOB

SC13a. What is [CHILD]’s birth date?

|___|___| / |___|___| / |___|___|___|___|

MONTH DAY YEAR

(1-12) (1-31) (RANGE)

DOB CORRECT 1

DOB INCORRECT 2

DON’T KNOW D

REFUSED R

Source: MIHOPE2

Item title: FocalChildIntro

SC14. [CHILD] has been randomly selected to be the focal child for this interview. The questions we ask in this interview will be about [CHILD].

CONTINUE 1

CHILD IS DECEASED 2 SORRY

Source: Adapted from FACES 2009 Kindergarten Teacher Survey

S1x. What grade or year of school [is [CHILD] enrolled in/will [CHILD] be enrolled in this upcoming year]?

CHILD NOT ENROLLED IN SCHOOL/FORMAL CARE SETTING 0 GO TO A_END

PRESCHOOL 1 GO TO A_END

PREKINDERGARTEN 2 GO TO A_END

HEAD START 3 GO TO A_END

TRANSITIONAL KINDERGARTEN (BEFORE K) 4 GO TO A_END

KINDERGARTEN 5

FIRST GRADE 6

SECOND GRADE 7 GO TO A_END

OTHER (SPECIFY) 99

____________________________________________________________

[IF S1x = 1 TO 4 OR 7]

A_END. Since your child is not in kindergarten or first grade, we would just like to confirm your current contact information. GO TO SECTION J (BUT DO NOT MAKE AN APPOINTMENT).

Source: MIHOPE2

Item title: LivingWChild

SC14a_2. Are you currently living with [[CHILD]/the child who was due to be born on [DUE DATE]]?

YES 1 SC2

NO 0 SC14a_3

CHILD IS DECEASED 2

SC14a_3. [IF [NAME] DECEASED] I’m very sorry for your loss. Please accept my condolences.

I’m calling to conduct a follow-up interview for the MIHOPE study that [NAME] joined [in [FILL MONTH AND YEAR OF BASELINE INTERVIEW] when she was pregnant/and was participating in with [CHILD]]. May I please speak with the person who is caring for [her child who was due to be born on [FILL DUE DATE]/[CHILD], such as a parent or guardian]?

IF SC14_2=0 OR (((NEWRESP=0 OR D) OR MOSTRES2=0) AND MOTHER COMPLETED SURVEY AFTER BASELINE OR WAS NOT PREGNANT AT BASELINE)

Who is the person living with [CHILD] who is most responsible for [CHILD’s] care?

IF MOMLIVEWITH = 1

Can I please speak with [[CHILD]/the child who was due to be born on [DUE DATE]]’s mother?

SPEAKING TO RIGHT PERSON, CONTINUE 1 SC14a_3a

SPEAKING TO RIGHT PERSON, BUT IT IS NOT A GOOD TIME 2 SC14a_3a

SOMEONE ELSE – COMES TO PHONE 3 SC14a_3a

SOMEONE ELSE – BUT NOT CURRENTLY AVAILABLE 4 SC14a_3a

SOMEONE ELSE – BUT LIVES ELSEWHERE 5 SC14a_3a

NO PARENT/GUARDIAN AVAILABLE 6

SOMEONE ELSE – REFUSE TO PROVIDE INFO 7

DON’T KNOW D ADDSKIP

SC14a_3a. Please give me the correct spelling of [your/his or her] full name.

First name?

____________________________________________________ (STRING (20))

FIRST NAME

Middle initial

____________________________________________________ (STRING (15))

MIDDLE INITIAL/NAME

Last name?

____________________________________________________ (STRING (30))

LAST NAME

DON’T KNOW D THANKS

REFUSED R THANKS

[IF SC14a_3=1 OR 3, GO TO SC2, IF SC14a_3=2, GO TO SC1e]

[IF SC14a_3=4]

SC14a_3a1. Is the telephone number I reached you on the best number to use to call [PROXY FIRST NAME]?

YES 1 SC14a_3c

NO 0 SC14a_3b

DON’T KNOW D SC14a_3c

REFUSED R SC14a_3c

[IF SC14a_3=5 OR SC14a_3b=0]

SC14a_3b. Please give me [PROXY FIRST NAME]’s telephone number, area code first?

|___|___|___| - |___|___|___| - |___|___|___|___|

(0-999) (0-999) (0-9999)

Is there an extension number?

| | | | | | |

(0-999999)

DON’T KNOW D

REFUSED R

SC14a_3b1. What time zone is that in?

If NEEDED: What time is it there?

Eastern Time (US & Canada) [(FILL CURRENT TIME)] 62

Indiana (East) [(FILL CURRENT TIME)] 63

Central Time (US & Canada) [(FILL CURRENT TIME)] 65

ARIZONA [(FILL CURRENT TIME)] 68

MOUNTAIN TIME (US & CANADA) [(FILL CURRENT TIME)] 70

PACIFIC TIME (US & CANADA) [(FILL CURRENT TIME)] 71

ALASKA [(FILL CURRENT TIME)] 72

HAWAII [(FILL CURRENT TIME)] 73

BAJA CALIFORNIA [(FILL CURRENT TIME)] 93

SC14a_3c. Please tell me the best address for [FIRST NAME]?

What is the first line of the address?

_______________________________________________ (STRING 60)

STREET 1

Is there an apartment or unit number for this address?

_______________________________________________ (STRING 60)

STREET 2

Town or city?

_______________________________________________ (STRING 20)

CITY

State?

_______________________________________________ (STRING 2)

STATE

And what is the zip code?

|___|___|___|___|___| - |___|___|___|___| ZIP CODE

00501-99950 0001-9999

DON’T KNOW D

REFUSED R

SC14a_3d. Please give me [NAME]’s email address.

__________________________________________@______________

DON’T KNOW D

REFUSED R

[ALL]

Source: MIHOPE2

Item title: Relationship

SC15. [Just to confirm, what/What] is your relationship to [CHILD]?

BIOLOGICAL MOTHER 11

BIOLOGICAL FATHER 12

BIOLOGICAL PARENT 35

ADOPTIVE MOTHER 13

ADOPTIVE FATHER 14

ADOPTIVE PARENT 36

STEPMOTHER 15

STEPFATHER 16

STEPPARENT 37

COUSIN (FEMALE) 17

COUSIN (MALE) 18

[COUSIN (NON-BINARY)] 38

AUNT 19

UNCLE 20

GRANDMOTHER 21

GRANDFATHER 22

GRANDPARENT 39

GREAT GRANDMOTHER 23

GREAT GRANDFATHER 24

GREAT GRANDPARENT 40

SISTER/STEPSISTER 25

BROTHER/STEPBROTHER 26

SIBLING/STEPSIBLING 41

OTHER RELATIVE OR IN-LAW (FEMALE) 27

OTHER RELATIVE OR IN-LAW (MALE) 28

[OTHER RELATIVE OR IN-LAW (NON-BINARY) 42

FOSTER PARENT (FEMALE) 29

FOSTER PARENT (MALE) 30

[FOSTER PARENT (NON-BINARY)] 43

OTHER NON-RELATIVE (FEMALE) 31

OTHER NON-RELATIVE (MALE) 32

[OTHER NON-RELATIVE (NON-BINARY)] 44

PARENT’S PARTNER (FEMALE) 33

PARENT’S PARTNER (MALE) 34

PARENT’S PARTNER (NON-BINARY) 45

DON’T KNOW D

REFUSED R

IF SITE = UNIVERSITY OF NEVADA RENO AND SC15 NE 25

SC15_ScrOut. We are currently only interviewing [CHILD]’s biological mother. Because of that, we do not have any more questions for you today.

INSTRUCTION: SELECT “1” TO CONTINUE.

CONTINUE 1 FINISH

[IF NEW RESPONDENT OR FIRST INTERVIEW SINCE BASELINE]

Source: MIHOPE2

Item title: TimeWChild

SC16. For how many months have you lived with [CHILD]?

|___|___|___|

SINCE CHILD WAS BORN 98

DON’T KNOW D

REFUSED R

HARD CHECK: IF RESPONSE IS GT AGE OF CHILD: I recorded that you have lived with [CHILD] for [FILL RESPONSE AT SC16] months but [CHILD] is only [FILL AGE OF CHILD] months old. Is that correct?

[IF RESPONDENT IS NOT BIO MOM]

Source: MIHOPE2

Item title: NotMom

SC17. Why is [CHILD]’s biological mother not living with (him/her)?

MOTHER LEFT/MOVED AWAY 11

MOTHER DECEASED 12

MOTHER INCARCERATED 13

MOTHER IN HOSPITAL 14

MOTHER IN OTHER INSTITUTION 15

MOTHER HAS DRUG/ALCOHOL ISSUES 16

MOTHER HAS MENTAL HEALTH ISSUES 17

MOTHER IS AT SCHOOL 18

MOTHER IN THE ARMED FORCES 19

POLICE OR COURT ORDER 20

CHILD PROTECTIVE SERVICES ORDER 21

DOMESTIC VIOLENCE SITUATION 22

CHILD ABUSE SITUATION 23

OTHER (SPECIFY) 24

______________________________________________(STRING (NUM))

DON’T KNOW D

REFUSED R

SORRY. IF SINGLE BIRTH AND CHILD DECEASED OR MULTIPLE BIRTH AND ALL CHILDREN DECEASED, THEN SAY I’m very sorry to hear that. Please accept my condolences. PAUSE. You will no longer be contacted for the MIHOPE study. Thank you for participating. Good-bye.

FINISH. Thank you very much for your time.

A. CHILD DEVELOPMENT AND SCHOOL PERFORMANCE

The next questions are about the child care arrangements you used for [CHILD] the year just before (he/she) entered kindergarten – that is, from fall [PREKYR] to spring [PREKYR].

Source: Adapted from Excel study

CD1. Thinking about the year before [CHILD] started kindergarten [FILL PREKYR], besides the time when child care centers/schools first closed due to the COVID-19 pandemic, where did [he/she] spend [his/her] time during daytime hours?

PROBE: Anything else?

PROBE: IF RESPONDENT SAYS PRESCHOOL OR PRE-K, ASK Was this in a public school, a Head Start program, or another type of preschool?

PROBE: IF RESPONDENT SAYS DAYSCARE, ASK: Was the daycare at a center or in someone’s home?

Head Start program 1

Preschool/Pre-K in a public school 2

An early education center, Montessori school, or nursery school other than Head Start 3

Daycare in a center or child care center 9

Preschool/Pre-K in a private setting 10

An in-home child care program/daycare or family child care program 4

Care by a parent 5

Care by a member of your family or household 6

Transitional kindergarten (before kindergarten) 7

Other, specify: _______________________ 8

DON’T KNOW D

REFUSED R

[IF MORE THAN ONE NUMERICAL RESPONSE OPTION SELECTED IN CD1]

Source: Adapted from Excel study

CD1a. In which of these settings would you say [CHILD] spent the most time during daytime hours?

PROBE: On a usual day, not thinking of the time when child care centers/schools first closed due to the COVID-19 pandemic in spring 2020.

PROBE: IF RESPONDENT SAYS CHILD SPENT SAME AMOUNT OF TIME IN SETTINGS, SAY: In which of these settings was [CHILD] most recently [not thinking of the time when child care centers/schools first closed due to the COVID-19 pandemic in spring 2020]?

Head Start program 1

Preschool/Pre-K in a public school 2

An early education center, Montessori school, or nursery school other than Head Start 3

An in-home child care program/daycare or family child care program 4

Daycare in a center or child care center 9

Preschool/Pre-K in a private setting 10

Care by a parent 5

Care by a member of your family or household 6

Transitional kindergarten (before kindergarten) 7

[FILL ‘OTHER’ RESPONSE FROM CD1] 8

DON’T KNOW D

REFUSED R

[IF ONLY ONE RESPONSE OPTION CHOSEN IN CD1 AND CD1=1,2,3,4,7, 9, 10 OR MORE THAN ONE RESPONSE OPTION CHOSEN IN CD1 AND CD1a=1,2,3,4,7, 9, OR 10]

Source: Adapted from MIHOPE Check-in

CD1a_1. Can you please tell me the name of this center or program?

____________________________________________________

DON’T KNOW D

REFUSED R

[IF ONLY ONE RESPONSE OPTION CHOSEN IN CD1 AND CD1=1,2,3,4, 7, 9, 10 OR MORE THAN ONE RESPONSE OPTION CHOSEN IN CD1 AND CD1a=1,2,3,4,7,9, OR 10]

Source: Adapted from Excel study

CD1b. On average, how many days per week did [he/she] go to [NAME OF CHILDCARE PROGRAM FROM CD1A_1]?

PROBE: In the year just before [CHILD] entered kindergarten [FILL PREKYR], not thinking of the time when child care centers/schools first closed due to the COVID-19 pandemic in spring 2020.

|___|___|___| DAYS

(1-7)

DON’T KNOW D

REFUSED R

[IF ONLY ONE RESPONSE OPTION CHOSEN IN CD1 AND CD1=1,2,3,4,7, 9, 10 OR MORE THAN ONE RESPONSE OPTION CHOSEN IN CD1 AND CD1a=1,2,3,4,7, 9, OR 10]

Source: New item

CD1c. Was [CHILD] in…

a part-day, morning only program, 1

a part-day, afternoon only program, or 2

a full-day program? 3

DON’T KNOW D

REFUSED R

[IF ONLY ONE RESPONSE OPTION CHOSEN IN CD1 AND CD1=6 TO 8 OR MORE THAN ONE RESPONSE OPTION CHOSEN IN CD1 AND CD1a=6 TO 8]

Adapted from Excel study/MIHOPE Check-in

CD1d. On average, how many hours per week was your child in this childcare arrangement?

PROBE: In the year just before [CHILD] entered kindergarten [not thinking of the time when child care centers/schools first closed due to the COVID-19 pandemic in spring 2020].

|___|___|___| HOURS

(1-168)

DON’T KNOW D

REFUSED R

SOFT CHECK: I entered that [CHILD] was in this childcare arrangement for [FILL CD1D] hours per week. Is this correct?

[IF S1X = 6 (in first grade)]

Next, we’d like to talk about [CHILD]’s school experiences last year, that is from approximately August or September 2020 through June 2021.

CD10. Did [CHILD] attend kindergarten last year, [either in-person or remotely]?

YES 1

NO 0

DON’T KNOW D

REFUSED R

[IF S1X = 6 (in first grade) and CD10 = YES]

CD11. Now, thinking about [CHILD]'s kindergarten experiences last year, from August or September 2020 through June 2021, how would you describe the type(s) of class setup that [CHILD] spent [his/her/their] time in during the 2020 – 2021 school year? Would you say that [CHILD] attended only in-person, only remotely, or some sort of hybrid setup of classes. You can choose more than one.

PROBE: By in-person instruction, I mean at school 5 days a week. By hybrid instruction, I mean some time receiving instruction in-person and some time receiving instruction remotely/virtually.

MARK ALL THAT APPLY

Only in-person, five days per week 1

Only remote or virtual class 2

Hybrid: A mix of in-person and remote or virtual 3

DON’T KNOW D

REFUSED R

[IF S1X = 6 (in first grade) and CD10 = YES]

CD12. Thinking again about [CHILD]’s kindergarten experiences last year, from August or September 2020 through June 2021, how would you describe the type of class setup that [CHILD] spent most of [her/his/their] time in during the 2020-2021 school year? Would you say...

CODE ONE ONLY

Only in-person, five days per week 1

Only remote or virtual class 2

Hybrid: A mix of in-person and remote or virtual 3

DON’T KNOW D

REFUSED R

[IF S1X = 6 (in first grade) and CD10 = YES AND CD12 = 1]

CD13a. During the 2020 – 2021 school year, approximately how many total months did [CHILD] spend receiving in-person instruction, five days per week?

|___|___|___|MONTHS

DON’T KNOW D

REFUSED R

CD13b. On a typical day of in-person instruction, how many hours did [CHILD] spend at school?

|___|___|___| HOURS

DON’T KNOW D

REFUSED R

[IF S1X = 6 (in first grade) and CD10 = YES and CD12 = 2]

CD14a. During the 2020 – 2021 school year, approximately how many total months did [CHILD] spend receiving only remote/virtual instruction?

|___|___|___|MONTHS

DON’T KNOW D

REFUSED R

CD14b. During a typical week of remote/virtual instruction, how many days a week did [CHILD] receive instruction?

|___|___|___| DAYS

DON’T KNOW D

REFUSED R

CD14c. On a typical day of remote/virtual instruction, how many hours did [CHILD] attend a live virtual class together with the teacher (either with the whole class or a smaller group)?

|___|___|___|HOURS

DON’T KNOW D

REFUSED R

[IF S1X = 6 (in first grade) and CD10 = YES and CD12 = 3]

CD15a. During the 2020 – 2021 school year, approximately how many total months did [CHILD] spend receiving hybrid instruction?

|___|___|___|MONTHS

DON’T KNOW D

REFUSED R

CD15b. During a typical week of hybrid instruction, how many days per week did [CHILD] receive in-person instruction?

|___|___|___| DAYS

DON’T KNOW D

REFUSED R

CD15b.1. On a typical day of in-person instruction, how many hours did [CHILD] spend at school?

|___|___|___|HOURS

DON’T KNOW D

REFUSED R

CD15c. During a typical week of hybrid instruction, how many days per week did [CHILD] receive remote/virtual instruction?

|___|___|___| DAYS

DON’T KNOW D

REFUSED R

CD15c.1. On a typical day of remote/virtual instruction, how many hours did [CHILD] attend a live virtual class together with the teacher (either with the whole class or a smaller group)?

|___|___|___|HOURS

DON’T KNOW D

REFUSED R

[IF S1x = 6 (in first grade) and CD10 = YES AND IF CD13a OR CD14a OR CD15a < [X MONTHS]

CD16. Thinking again about [CHILD]’s kindergarten experiences from August or September 2020 through June 2021, how would you describe the type of class setup that [CHILD] spent the second most amount of [her/his/their] time in?

CODE ONE ONLY (ONLY DISPLAY RESPONSE OPTIONS SELECTED IN CD11 AND EXCLUDE RESPONSE SELECTED IN CD12)

Only in-person, five days per week 1

Only remote or virtual class 2

Hybrid: A mix of in-person and remote or virtual 3

DON’T KNOW D

REFUSED R

[IF CD16 = 1, DISPLAY CD13; IF CD16 = 2, DISPLAY CD14; IF CD16 = 3, DISPLAY CD15]

[IF CD11 = 2 AND CD11 != 1 AND CD11 !=3]

CD17. Was your child offered the option to attend school in-person (5 days a week) or in a hybrid mode (a mix of in-person and remote/virtual instruction) during the 2020 – 2021 school year?

YES 1

NO 0

DON’T KNOW D

REFUSED R

[IF S1X = 5, FILL kindergarten; IF S1X = 6, FILL first grade]

Next, we will talk about [CHILD]’s [kindergarten / first grade] experiences.

CD18. [How would you describe the type of class setup that [CHILD] currently experiences? Would you say that [CHILD] attends school only in-person, only remotely, or some sort of hybrid setup of classes?]

CODE ONE ONLY

Only in-person, five days per week 1

Only remote or virtual class 2

Hybrid: A mix of in-person and remote or virtual 3

DON’T KNOW D

REFUSED R

[IF CD18 = 1]

CD19a. [During the current school year, approximately how many total months did [CHILD] spend receiving in-person instruction, five days per week?

|___|___|___|MONTHS

DON’T KNOW D

REFUSED R

CD19b. [On a typical day of in-person instruction, how many hours did [CHILD] spend at school?]

|___|___|___| HOURS

DON’T KNOW D

REFUSED R

[IF CD18 = 2]

CD20a. [During the current school year, approximately how many total months did [CHILD] spend receiving only remote/virtual instruction?

|___|___|___|MONTHS

DON’T KNOW D

REFUSED R

CD20b. [During a typical week of remote/virtual instruction, how many days a week did [CHILD] receive instruction?]

|___|___|___| DAYS

DON’T KNOW D

REFUSED R

CD20c. [On a typical day of remote/virtual instruction, how many hours did [CHILD] attend a live virtual class together with the teacher (either with the whole class or a smaller group)?]

|___|___|___|HOURS

DON’T KNOW D

REFUSED R

CD20d. [Was your child offered the option to attend school in-person (5 days a week) or in a hybrid mode (a mix of in-person and remote/virtual instruction) during the current school year?]

YES 1

NO 0

DON’T KNOW D

REFUSED R

[IF CD18 = 3]

CD21a. [During the current school year, approximately how many total months did [CHILD] spend receiving hybrid instruction?

|___|___|___|MONTHS

DON’T KNOW D

REFUSED R

CD21b. [During a typical week of hybrid instruction, how many days per week did [CHILD] receive in-person instruction?]

|___|___|___| DAYS

DON’T KNOW D

REFUSED R

CD21b.1. [On a typical day of in-person instruction, how many hours did [CHILD] spend at school?]

|___|___|___|HOURS

DON’T KNOW D

REFUSED R

CD21c. [During a typical week of hybrid instruction, how many days per week did [CHILD] receive remote/virtual instruction?]

|___|___|___| DAYS

DON’T KNOW D

REFUSED R

CD21c.1. [On a typical day of remote/virtual instruction, how many hours did [CHILD] attend a live virtual class together with the teacher (either with the whole class or a smaller group)?

|___|___|___|HOURS

DON’T KNOW D

REFUSED R

Source: Social Skills Improvement System (SSIS); PROPRIETARY

(Subscales: Engagement and self-control)

CD7.

Source: Social Skills Improvement System (SSIS); PROPRIETARY

(Subscales: internalizing, externalizing, and hyperactivity/inattention)

CD8.

Source: New item

CD9. (Before starting kindergarten did/Has) [CHILD] ever receive(d) early intervention services?

PROBE: Early intervention is a system of services that helps young children with delays or disabilities learn the skills that develop during the first three years of life. Some examples include support to help a child learn how to crawl, walk, or talk.

YES 1

NO 0

DON’T KNOW D

REFUSED R

[IF EVER RECEIVED EARLY INTERVENTION]

Source: New item

CD9a. For what reason(s)?

CODE ALL THAT APPLY

VISION IMPAIRMENT/BLINDNESS 1

HEARING IMPAIRMENT/HARD OF HEARING/DEAFNESS 2

MOTOR IMPAIRMENT 3

SPEECH IMPAIRMENT/DIFFICULTY COMMUNICATING 4

INTELLECTUAL DISABILITY/DEVELOPMENTAL DELAY 5

AUTISM SPECTRUM DISORDER (ASD) OR PERVASIVE DEVELOPMENTAL DISORDER (PDD) 6

BEHAVIOR PROBLEMS/HYPERACTIVITY/ATTENTION DEFICIT (ADD OR ADHD) 7

OPPOSITIONAL DEFIANT DISORDER 8

OTHER (SPECIFY) 99

________________________________________________________________

DON’T KNOW D

REFUSED R

B. SOCIAL SUPPORT AND RELATIONSHIPS

The next questions are about you and your relationships with others.

R1. Do you currently have a spouse, partner, or significant other?

YES 1

NO 0

DON’T KNOW D

REFUSED R

Source: Adapted from the Supporting Healthy Marriage Survey

R2. How would you describe your current relationship status? Are you…

Single, 1 GO TO R3

Casually dating, 2 GO TO R3

Romantically involved, 3 GO TO R3

In a committed relationship, 4 GO TO R3

Engaged, or 5 GO TO R3

Married? 6 GO TO R3a

DON’T KNOW D

REFUSED R

Source: Adapted from the Supporting Healthy Marriage Survey

R3. And what is your marital status? Are you…

Never married 1

Separated, but still legally married 2

Had marriage annulled 3

Divorced 4

Widowed 5

DON’T KNOW D

REFUSED R

[IF MARRIED, SEPARATED BUT STILL LEGALLY MARRIED, ENGAGED, IN A COMMITTED RELATIONSHIP, OR ROMANTICALLY INVOLVED or R1=1]

Source: New item

R3a. What is the first name of your spouse, partner, or significant other?

PROBE: I am only asking for this information so that I can refer to this person by name when asking you some of the next questions.

_____________________________________________________________________________

DON’T KNOW D

REFUSED R

[IF MARRIED, SEPARATED BUT STILL LEGALLY MARRIED, ENGAGED, IN A COMMITTED RELATIONSHIP, OR ROMANTICALLY INVOLVED or R1=1]

Source: Adapted from MIHOPE

R3b. What is [[SPOUSE/PARTNER FIRST NAME]/your spouse or partner]’s relationship to [CHILD]?

BIOLOGICAL MOTHER 11

BIOLOGICAL FATHER 12

BIOLOGICAL PARENT 39

ADOPTIVE MOTHER 13

ADOPTIVE FATHER 14

ADOPTIVE PARENT 40

STEPMOTHER 15

STEPFATHER 16

STEPPARENT 41

PARENT’S GIRLFRIEND 17

PARENT’S BOYFRIEND 18

PARENT’S SPOUSE/PARTNER 19

GRANDMOTHER 21

GRANDFATHER 22

GRANDPARENT 42

GREAT GRANDMOTHER 23

GREAT GRANDFATHER 24

GREAT GRANDPARENT 43

COUSIN 29

AUNT 31

UNCLE 32

OTHER RELATIVE OR IN-LAW 33

FOSTER PARENT 35

OTHER NON-RELATIVE 37

DON’T KNOW D

REFUSED R

[IF MARRIED, SEPARATED BUT STILL LEGALLY MARRIED, ENGAGED, IN A COMMITTED RELATIONSHIP, OR ROMANTICALLY INVOLVED or R1=1]

Source: Adapted from Baby FACES 2018

R3c. Does [[SPOUSE/PARTNER]/your spouse or partner] live with you?

YES 1

NO 0

DON’T KNOW D

REFUSED R

[IF NOT IN RELATIONSHIP WITH BIOLOGICAL FATHER (R3b NE 12) OR NOT IN RELATIONSHIP]

Source: Adapted from MIHOPE

R4b. What is the first name of [CHILD]’s biological father?

PROBE: I am only asking for this information so that I can refer to this person by name when asking you some of the next questions.

________________________________________________________________

DON’T KNOW D

REFUSED R

Source: Maternal Social Support Index

R5a. [Just to confirm, how / How] often does [CHILD] see [you/[BIO DAD]/[his/her] biological father] [including video calls or phone calls]? Would you say…

Every day or almost every day 1

Once or twice a week 2

Once or twice a month 3

Less than once a month 4

A few times a year, or 5

Never? 6

DECEASED 7

DON’T KNOW D

REFUSED R

Source: Maternal Social Support Index

R5b. IF R5a=7: I’m very sorry for your loss. Please accept my condolences.

Is there anyone [else] who you consider to be a father-figure for [CHILD] now?

YES 1

NO 0

DON’T KNOW D

REFUSED R

[IF CHILD HAS FATHER FIGURE (R5b=YES)]

Source: Maternal Social Support Index

R5c. How often does [CHILD] see him [including video calls or phone calls]?

Every day or almost every day, 1

Once or twice a week, 2

Once or twice a month, 3

Less than once a month 4

A few times a year, or 5

Never? 6

DON’T KNOW D

REFUSED R

Source: Adapted from Fragile Families and Child Well-Being Study

https://fragilefamilies.princeton.edu/sites/fragilefamilies/files/ff_mom_q5.pdf

R6. Since [CHILD] was born, how many times have you and [CHILD] been separated for two weeks or more?

INTERVIEWER: ONLY INCLUDE INSTANCES OF SEPARATIONS THAT ARE AT LEAST 14 CONSECUTIVE DAYS.

|___|___| TIMES

NEVER 0

DON’T KNOW D

REFUSED R

[IF R6 = GE 1]

Source: Adapted from Fragile Families and Child Well-Being Study

R6a. Thinking about [this/these] separation[s], why were you and [CHILD] separated?

PROBE: Any other reasons?

CODE ALL THAT APPLY

CHILD ILLNESS 1

RESPONDENT ILLNESS 2

RESPONDENT HAD DRUG/ALCOHOL ISSUES 3

CHILD PROTECTIVE SERVICES ORDER 4

RESPONDENT IN JAIL/PRISON 5

RESPONDENT ON VACATION 6

CHILD VISITED [FATHER/MOTHER] 7

CHILD VISITED RELATIVES 8

POLICE OR COURT ORDER 9

DOMESTIC VIOLENCE SITUATION 10

CHILD ABUSE SITUATION 11

RESPONDENT LEFT/MOVED AWAY 12

RESPONDENT’S WORK SCHEDULE 13

RESPONDENT IN THE ARMED SERVICES 14

MARITAL PROBLEMS (E.G. DIVORCE) 15

Other (SPECIFY) 16

______________________________________________________

DON’T KNOW D

REFUSED R

[IF R6a = 5]

Source: STED ETJD 30 month survey

R6b. What was the total amount of time that you spent in jail or prison since [CHILD] was born?

IF ASKED: Don’t include time spent in halfway houses or work release centers.

IF NEEDED: Is that days, weeks, months, or years?

|___|___|___|

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

DON’T KNOW D

REFUSED R

C. INTIMATE PARTNER VIOLENCE

[ALL WITH CURRENT PARTNER SHOULD BE ASKED PV2/PV1, REGARDLESS OF COHABITATION STATUS (R1=1, R2 = MARRIED, ENGAGED, IN A COMMITTED RELATIONSHIP, OR ROMANTICALLY INVOLVED OR R3 = SEPARATED BUT LEGALLY MARRIED)]

Source: Women’s Experience with Battering Scale (WEB); PROPRIETARY

PV1.

Source: Conflict Tactics Scale (CTS2) PROPRIETARY

(Subscales: Physical assault: perpetration and victimization)

PV2.

Source: Family Environment Scale; PROPRIETARY

PV3.

D. PARENTING

The next questions are about activities you and other family members may do with [CHILD], including some of the routines in your household.

Source: Early Childhood Longitudinal Study – Kindergarten 2010 cohort (ECLS-K)

https://nces.ed.gov/ecls/pdf/kindergarten2011/Fall_K_Parent_Interview.pdf

P1. In a typical week, how often do you or any other family members read books to [CHILD]? Would you say…

PROBE: Include only times family members have read books to the child. Do not include times when the child reads or looks at books by him or herself.

Not at all, 1

Once or twice a week, 2

3-6 times a week, or 3

Every day? 4

DON’T KNOW D

REFUSED R

Source: Adapted from Early Childhood Longitudinal Study – Kindergarten 2010 cohort (ECLS-K)

https://nces.ed.gov/ecls/pdf/kindergarten2011/Fall_K_Parent_Interview.pdf

P2. Generally, for about how many minutes is [CHILD] read to at each of these times?

PROBE: Please include reading in any language. If the child is read to multiple times per day, consider the total number of minutes each day that the child is read to.

|___|___|___| MINUTES

DON’T KNOW D

REFUSED R

Source: Early Childhood Longitudinal Study – Kindergarten 2010 cohort (ECLS-K)

https://nces.ed.gov/ecls/pdf/kindergarten2011/Fall_K_Parent_Interview.pdf

P3. About how many children’s books are in your home now, including library books? Please only include books that are for children. Books shared by siblings may be included. Your best estimate is fine.

PROBE: For example, if you have two children and they share 20 books, include all 20. Do not include books that belong to adults.

|___|___|___|___| BOOKS

DON’T KNOW D

REFUSED R

Source: Early Childhood Longitudinal Study – Kindergarten 2010 cohort (ECLS-K)

https://nces.ed.gov/ecls/pdf/kindergarten2011/Fall_K_Parent_Interview.pdf

P4. Now, please think about the past week. How often did [CHILD] look at picture books outside of school? Would you say…

Never, 1

Once or twice, 2

3 to 6 times, or 3

Every day? 4

DON’T KNOW D

REFUSED R

Source: Early Childhood Longitudinal Study – Kindergarten 2010 cohort (ECLS-K)

https://nces.ed.gov/ecls/pdf/kindergarten2011/Fall_K_Parent_Interview.pdf

P5. In the past week, how often did [CHILD] read to or pretend to read to [himself/herself/themselves] or to others outside of school? Would you say…

Never, 1

Once or twice, 2

3 to 6 times, or 3

Every day? 4

DON’T KNOW D

REFUSED R

Source: Early Childhood Longitudinal Study – Kindergarten 1998 and 2010 cohorts (ECLS-K)

https://nces.ed.gov/ecls/pdf/kindergarten/fallparent.pdf

P6. Now I’d like to ask you about different activities you or any other family members do with [CHILD] in a typical week.

How often do you or any other family members [READ ITEM]: Would you say not at all, once or twice a week, 3 to 6 times a week, or every day?

			CODE ONE PER ROW
	NOT AT ALL	ONCE OR TWICE		3 TO 6 TIMES	EVERY DAY	DON’T KNOW	REFUSED
a. Tell stories to [CHILD]?	1	2		3	4	D	R
b. Sing songs with [CHILD]?	1	2		3	4	D	R
c. Help [CHILD] do arts and crafts?	1	2		3	4	D	R
d. Involve [CHILD] in household chores, like cooking, cleaning, setting the table, or caring for pets?	1	2		3	4	D	R
e. Play games or do puzzles with [CHILD]?	1	2		3	4	D	R
f. Talk about nature or do science projects with [CHILD]?	1	2		3	4	D	R
g. Build something or play with construction toys with [CHILD]?	1	2		3	4	D	R
h. Play a sport or exercise together?	1	2		3	4	D	R
i. Do writing activities with [CHILD]?	1	2		3	4	D	R
j. Do math activities with [CHILD] such as learning numbers, adding, subtracting, or measuring?	1	2		3	4	D	R

Source: Confusion, Hubbub, and Order Scale (CHAOS), shortened version

http://www.performwell.org/index.php?option=com_mtree&task=att_download&link_id=483&cf_id=24

P9. The next set of questions contains statements about your home environment. For each statement I read, please tell me if it is definitely untrue, somewhat untrue, neither true nor untrue, somewhat true, or definitely true. Let’s begin.

[READ ITEM]: Would you say this is definitely untrue, somewhat untrue, neither true nor untrue, somewhat true, or definitely true.


	DEFINITELY UNTRUE	SOMEWHAT TRUE	NEITHER TRUE NOR UNTRUE	SOMEWHAT TRUE	DEFINITELY TRUE	DON’T KNOW	REFUSED
a. We are usually able to stay on top of things PROBE: By “stay on top of things,” I mean that you are usually able to get things done that you need to do.	1	2	3	4	5	D	R
b. It’s a real zoo in our home PROBE: By “zoo,” I mean a place that is noisy or chaotic.	1	2	3	4	5	D	R
c. You can’t hear yourself think in our home PROBE: As in, it’s so noisy and chaotic in your home that it’s hard to focus on what you are thinking about.	1	2	3	4	5	D	R
d. The atmosphere in our home is calm	1	2	3	4	5	D	R
e. The children have a regular bedtime routine	1	2	3	4	5	D	R
f. There is usually a television turned on somewhere in our home	1	2	3	4	5	D	R

Source: Healthy Families Parenting Inventory (HFPI; mobilizing resources); PROPRIETARY

P10.

E. FAMILY ECONOMIC SELF-SUFFICIENCY

Source: MIHOPE2; Baby FACES 2018

SS1. In this next section, we’d like to learn a bit more about your education, your families’ economic situation, and any income supports you may have received.

What is the highest grade or year of school that you have completed?

HIGHEST GRADE/YEAR IN SCHOOL SPECIFY GRADE 1 SS2

|___|___| (GRADE 1-11)

12^TH GRADE, BUT NOT DIPLOMA 2 SS2

HIGH SCHOOL DIPLOMA/EQUIVALENT 3 SS1a

SOME VOCATIONAL/TECHNICAL SCHOOL BUT NO DIPLOMA 4 SS1a

VOCATIONAL/TECHNICAL SCHOOL DIPLOMA 5 SS1a

SOME COLLEGE BUT NO DEGREE COMPLETION 6 SS1a

ASSOCIATE DEGREE 7 SS2

BACHELOR’S DEGREE 8 SS2

GRADUATE OR PROFESSIONAL SCHOOL BUT NO DEGREE 9 SS2

MASTER’S DEGREE (M.A., M.S.) 10 SS2

DOCTORATE DEGREE (PH.D., ED.D.) 11 SS2

PROFESSIONAL DEGREE AFTER BACHELOR’S DEGREE (MEDICINE/MD; DENTISTRY/DDS; LAW/JD/LLB; ETC.) 12 SS2

NO REGULAR/FORMAL SCHOOL EDUCATION 0 SS2

OTHER (SPECIFY) 99

______________________________________________(STRING (NUM))

DON’T KNOW D

REFUSED R

[IF SS1 = 3, 4, 5, 6]

Source: MIHOPE2; Baby FACES 2018

SS1a. Which do you have, a high school diploma or a GED?

High school diploma 1

GED 2

DON’T KNOW D

REFUSED R

Source: MIHOPE2 (public assistance)

SS2. In the past month, have you received income or other assistance from:


	YES	NO	DON’T KNOW	REFUSED
a. Cash welfare which is also known as TANF, or [Local name of TANF]	1	0	D	R
b. Food stamp or Supplemental Nutrition Assistance Program (also known as SNAP)	1	0	D	R
c. Disability insurance such as Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI)	1	0	D	R
d. WIC, that is Special Supplemental Nutrition Program for Women, Infants, and Children	1	0	D	R

Source: New item

SS2f. We just asked about benefits you're receiving, but now we'd like to ask about [CHILD]. Is [CHILD] receiving Supplemental Security Insurance (SSI)?

YES 1

NO 0

DON’T KNOW D

REFUSED R

Source: New item

SS2f_1. [If yes] Is [CHILD] receiving SSI because of [his/her/[CHILD]’s] own disability?

YES 1

NO 0

DON’T KNOW D

REFUSED R

Source: Baby FACES 2018 (job characteristics)

SS3. Are you currently working at a job for pay, including self-employment?

YES 1

NO 0

RETIRED 2

DISABLED/UNABLE TO WORK 3

MATERNITY LEAVE 4

DON’T KNOW D

REFUSED R

Source: Adapted from Baby FACES 2018

SS4. In [MOST RECENT CALENDAR YEAR], what was the total combined income of all members of your household? Please include money from jobs, welfare, social security payments, and any other money income received by you or any other household member in [MOST RECENT CALENDAR YEAR].

PROBE: Your best estimate is fine.

$ |___|___|___|,|___|___|___| PER YEAR

DON’T KNOW D SS4a

REFUSED R

[IF SS4=D]

Source: Baby FACES 2018

SS4a_1. I just need a range. Was it…

$25,000 or less, or 1 GO TO SS4a_2

$More than $25,000? 2 GO TO SS4a_3

DON’T KNOW D

REFUSED R

[IF SS4a_1=1]

Source: Baby FACES 2018

SS4a_2. Was it…

$5,000 or less, 1

$5,001 to $10,000 2

$10,001 to $15,000 3

$15,001 to $20,000, or 4

$20,001 to $25,000 5

DON’T KNOW D

REFUSED R

[IF SS4a_1=2]

Source: Baby FACES 2018

SS4a_3. Was it…

$25,001 to $30,000, 6

$30,001 to $35,000, 7

$35,001 to $40,000, 8

$40,001 to $50,000 9

$50,001 to $75,000, or 10

More than $75,000? 11

DON’T KNOW D

REFUSED R

Source: Current Housing Arrangment and Assistance with Houisng items from STED 12 month and SIF Work Advance 24 month surveys

SS5. Which of the following best describes your current housing arrangement? Do you…

Own your own home or apartment, 1

Rent your home or apartment, 2

Live with family or friends without paying rent or paying reduced rent, or 3

Live in emergency or temporary housing (such as a shelter)? 4

OTHER (Please specify) 99

____________________________________________________________

DON’T KNOW D

REFUSED R

Source: Youth Villages Transitional Living 12-month survey

SS6. How many times have you moved from one address to another during the past 12 months?

|___|___| TIMES

(0-15)

DON’T KNOW D

REFUSED R

Source: USDA U.S. Household Food Security Survey Module—Short Form (food sufficiency)

SS7. I am going to read you several statements that people have made about their food situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for your household in the past 12 months, that is since (DISPLAY CURRENT MONTH AND LAST YEAR).

Within the past 12 months the food that (I/we) bought just didn’t last and we didn’t have money to get more. Was this …

Often true 1

Sometimes true, or 2

Never true? 3

DON’T KNOW D

REFUSED R

Source: USDA U.S. Household Food Security Survey Module—Short Form (food sufficiency)

SS8. (I/We) couldn’t afford to eat balanced meals. Was this…

Often true 1

Sometimes true, or 2

Never true? 3

DON’T KNOW D

REFUSED R

Source: USDA U.S. Household Food Security Survey Module—Short Form (food sufficiency)

SS9. In the past 12 months, that is, since (DISPLAY CURRENT MONTH AND LAST YEAR), did (you/you or other adults in your household) ever cut the size of your meals or skip meals because there wasn’t enough money for food?

YES 1 SS9a

NO 0 SS10

DON’T KNOW D

REFUSED R

[IF SS9=YES]

Source: USDA U.S. Household Food Security Survey Module—Short Form (food sufficiency)

SS9a. How often did this happen? Would you say…

Almost every month, 1

Some months but not every month, or 2

In only 1 or 2 months? 3

DON’T KNOW D

REFUSED R

Source: USDA U.S. Household Food Security Survey Module—Short Form (food sufficiency)

SS10. In the past 12 months, did you ever eat less than you felt you should because there wasn’t enough money for food?

YES 1

NO 0

DON’T KNOW D

REFUSED R

Source: USDA U.S. Household Food Security Survey Module—Short Form (food sufficiency)

SS11. In the past 12 months, were you ever hungry but didn’t eat because there wasn’t enough money for food?

YES 1

NO 0

DON’T KNOW D

REFUSED R

Source: Poverty Tracker (material hardship)

http://povertytracker.robinhood.org/download/RobinHood_PovertyTracker_Spring14.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5027138/

SS12. Now, I am going to ask you questions about hardships you may have faced. In the past 12 months…

Did you not pay the full amount of rent or mortgage because there wasn’t enough money?

YES 1

NO 0

DON’T KNOW D

REFUSED R

Source: Poverty Tracker (material hardship)

SS13. Did you move in with other people, even for a little while, because of financial problems?

PROBE: In the past 12 months.

YES 1

NO 0

DON’T KNOW D

REFUSED R

Source: Poverty Tracker (material hardship)

SS14. Did you not pay the full amount of your phone, gas, oil, or electricity bill because there wasn’t enough money?

PROBE: In the past 12 months.

YES 1

NO 0

DON’T KNOW D

REFUSED R

Source: Poverty Tracker (material hardship)

SS15. In the past 12 months, was there a time when you or anyone else in your household needed to see a doctor, a dentist, or go to the hospital but couldn’t go because of the cost?

YES 1

NO 0

DON’T KNOW D

REFUSED R

Source: Poverty Tracker (material hardship)

SS16. During the same period, how often did you run out of money between paychecks or before the end of the month? Would you say that happened…

Often, 1

Sometimes, or 2

Never? 3

DON’T KNOW D

REFUSED R

F. MATERNAL HEALTH AND WELL-BEING

Now, we’d like to learn a bit about your overall health and well-being.

MH1x. Have you been pregnant since [CHILD] was born?

YES 1

NO 0 MH3

DON’T KNOW D MH3

REFUSED R MH3

[IF YES]

MH1xa. How many times have you been pregnant since [CHILD] was born?

|___|___|

DON’T KNOW D MH3

REFUSED R MH3

Source: MIHOPE Check-in

MH1. Since [MONTH YEAR OF LAST COMPLETED INTERVIEW], have you given birth to another baby?

PROBE: Not including [CHILD].

YES 1

NO 0

DON’T KNOW D

REFUSED R

Source: MIHOPE Check-in

MH2. How many times have you given birth since [MONTH YEAR OF LAST COMPLETED INTERVIEW]?

PROBE: Not including [CHILD].

| | | TIMES

(1-4)

DON’T KNOW D

REFUSED R

[IF MH2 GE 1]

Source: MIHOPE Check-in

MH2x. People can have single or multiple births. Just to confirm, to how many children have you given birth since [MONTH YEAR OF LAST COMPLETED INTERVIEW]?

PROBE: Not including [CHILD].

| | | CHILD(REN)

(1-8)

DON’T KNOW D

REFUSED R

[IF R HAS HAD SUBSEQUENT BIRTH(S) (MH2 GE 1), ASK FOR EACH]

Source: New item

MH2a. What is the first name of the child you gave birth to since [MONTH YEAR OF LAST COMPLETED INTERVIEW]?

IF MH25 GT 1: Let’s begin with the oldest child first.

PROBE: Not including [CHILD].

CHILD 1: _________________________________________________

CHILD 2: _________________________________________________

CHILD 3: _________________________________________________

CHILD 4: _________________________________________________

DON’T KNOW D

REFUSED R

[IF R HAS HAD SUBSEQUENT BIRTH(S) (MH2 GE 1), ASK FOR EACH]

Source: New item

MH2b. When was [SUBSEQUENT CHILD/that child] born?

CHILD 1: |___|___|/|___|___|/|___|___|___|___|

CHILD 2: |___|___|/|___|___|/|___|___|___|___|

CHILD 3: |___|___|/|___|___|/|___|___|___|___|

CHILD 4: |___|___|/|___|___|/|___|___|___|___|

DON’T KNOW D

REFUSED R

[IF R HAS HAD SUBSEQUENT BIRTH(S) (MH2 GE 1), ASK FOR EACH]

Source: New item

MH2c. How much did [SUBSEQUENT CHILD/that child] weigh when he or she was born?

CHILD 1: | || | Pounds and | || | ounces OR | | | KILOGRAMS

CHILD 2: | || | Pounds and | || | ounces OR | | | KILOGRAMS

CHILD 3: | || | Pounds and | || | ounces OR | | | KILOGRAMS

CHILD 4: | || | Pounds and | || | ounces OR | | | KILOGRAMS

DON’T KNOW D

REFUSED R

[IF R HAS HAD SUBSEQUENT BIRTH(S) (MH2 GE 1), ASK FOR EACH]

Source: New item

MH2d. How many weeks pregnant were you when [SUBSEQUENT CHILD/that child] was born?

| | | WEEKS (Child 1)

| | | WEEKS (Child 2)

| | | WEEKS (Child 3)

| | | WEEKS (Child 4)

DON’T KNOW D

REFUSED R

[IF R HAS HAD SUBSEQUENT BIRTH(S) (MH2 GE 1), ASK FOR EACH]

Source: New item

MH2e. After [SUBSEQUENT CHILD/that child] was born, did he or she spend any time in the Neonatal Intensive Care Unit (NICU)?

YES 1

NO 0

DON’T KNOW D

REFUSED R

IF MH2 IS GT 1, LOOP BACK TO MH2a

Source: Center for Epidemiological Studies Depression Scale (CES-D); PROPRIETARY

MH3.

The next few questions are about drug and alcohol use. As a reminder, all of the information you share with me is private. You do not have to answer any questions that make you feel uncomfortable. Just let me know and I will move on to the next question.

Source: PRAMS, used in MIHOPE2 (substance abuse)

MH4. These questions are about your drug use on your own. By “on your own” we mean either without a doctor’s prescription, in larger amounts than prescribed, or for a longer period than prescribed. In the past three months, have you used any of the following drugs on your own?

CODE ONE PER ROW
	YES	NO	DON’T KNOW	REFUSED
a. Prescription pain killers? (IF YES) What kinds? ENTER PAINKILLER NAMES ______________ (STRING 50)	1	0	D	R
b. Marijuana (pot, bud, weed) or Hashish (Hash)?	1	0	D	R
c. Amphetamines (uppers, ice, speed, crystal meth, crank)?	1	0	D	R
d. Cocaine (rock, coke, crack)?	1	0	D	R
e. Heroin (smack, horse)?	1	0	D	R
f. Tranquilizers (downers, ludes) or hallucinogens (LSD/acid, PCP/angel dust, ecstasy)?	1	0	D	R
g. Sniffing gasoline, glue, hairspray, or other aerosols?	1	0	D	R

Source: MIHOPE 2

MH4x. 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 3 months, how many alcoholic drinks did you have in an average week?

NONE ................................................................................................................................ 0

LESS THAN 1 DRINK ........................................................................................................1

1 TO 3 DRINKS ................................................................................................................ 2

4 TO 7 DRINKS ................................................................................................................ 3

8 TO 13 DRINKS .............................................................................................................. 4

14 TO 19 DRINKS ............................................................................................................ 5

20 OR MORE DRINKS ..................................................................................................... 6

DON’T KNOW D

REFUSED R

[IF NE 0]

MH4ax. In the last three months, how many times did you drink 4 alcoholic drinks or more in one sitting? Would you say…

PROBE: A sitting is a two hour time span.

6 or more times, ............................................................................................................... 4

4 to 5 times, ...................................................................................................................... 3

2 to 3 times, ...................................................................................................................... 2

1 time, or ........................................................................................................................... 1

Never? ............................................................................................................................... 0

DON’T KNOW D

REFUSED R

Source: Perceived Social Support Measure

https://www.ispor.org/awards/16meet/McCarrier-ISPOR-2011-SS-5-Poster.pdf

MH9. How often is each of the following kinds of support available to you if you need it?

[READ ITEM]: Would you say none of the time, a little of the time, some of the time, most of the time, or all of the time?


	NONE OF THE TIME	A LITTLE OF THE TIME	SOME OF THE TIME	MOST OF THE TIME	ALL OF THE TIME	DON’T KNOW	REFUSED
a. Someone to confide in or talk to about your problems	1	2	3	4	5	D	R
b. Someone to get together with for relaxation	1	2	3	4	5	D	R
c. Someone to help you with daily chores if you were sick	1	2	3	4	5	D	R
d. Someone to turn to for suggestions about how to deal with a personal problem	1	2	3	4	5	D	R
e. Someone to love and make you feel wanted	1	2	3	4	5	D	R

Source: Pearlin Mastery Scale PROPRIETARY

MH10.

G. CHILD HEALTH

These next questions are about [CHILD]’s health.

Source: MIHOPE2 (ER visits)

CH1. Has [CHILD] made any emergency room visits in the past 12 months?

YES 1

NO 0

DON’T KNOW D

REFUSED R

[IF ER VISITS IN PAST 12 MOS]

Source: MIHOPE2 (ER visits)

CH1a. How many times has [CHILD] made emergency room visits in the past 12 months?

|___|___| TIMES

(1-50)

DON’T KNOW D

REFUSED R

[IF ER VISITS IN PAST 12 MOS]

Source: MIHOPE2 (ER visits)

CH1b. How many of the [FILL CH1a/these] emergency room visits were because of an accident or injury? For example, burns, falls, poisoning, or choking?

|___|___| VISITS

(0-50)

DON’T KNOW D

REFUSED R

Source: MIHOPE2 (hospital admissions)

CH2. In the past 12 months, how many different times has [CHILD] stayed in a hospital for at least one night?

|___|___| TIMES

(0-50)

DON’T KNOW D

REFUSED R

[IF HOSPITAL OVERNIGHT]

Source: MIHOPE2 (hospital admissions)

CH2a. In the past 12 months, how many nights in total did [CHILD] stay in a hospital?

|___|___| NIGHTS

(1-365)

DON’T KNOW D

REFUSED R

[IF HOSPITAL OVERNIGHT]

Source: MIHOPE2 (hospital admissions)

CH2b. How many of the [FILL CH2] hospitalizations were because of an accident or injury? For example, burns, falls, poisoning, or choking?

|___|___| HOSPITALIZATIONS

(0-50)

DON’T KNOW D

REFUSED R

Source: MIHOPE2 (insurance coverage)

CH3. Does [CHILD] have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as CHIP or Medicaid?

YES 1

NO 0

DON’T KNOW D

REFUSED R

[IF YES]

Source: MIHOPE2 (insurance coverage)

CH3a. What kind of health insurance or health care coverage does [CHILD] have?

PROBE: What’s the name of [CHILD]’s health insurance plan?

SPECIFY

__________________________________________________________________

DON’T KNOW D

REFUSED R

CH3b. Did you sign up for this insurance through an employer, the state or federal government like Medicaid, SCHIP [or [STATE MEDICAID AGENCY]], or through the Affordable Care Act/ACA/Healthcare Marketplace?

If [CHILD] has more than one kind of health insurance, tell me about all the plans that [CHILD] has.

PROBE: IF RESPONDENT SAYS SELF-PAY, ASK: Many people pay for their insurance. I’m interested in how you signed up for this insurance. Was it through your employer, through a program like Medicaid or SCHIP, or through the marketplace?

PROBE: IF RESPONDENT SAYS MEDICARE, ASK: I’m asking only about [CHILD]’s health insurance. To confirm, [CHILD] receives Medicare?

PROBE: IF RESPONDENT SAYS STATE, ASK: Is that Medicaid or SCHIP?

CODE ALL THAT APPLY

HEALTH INSURANCE THROUGH AN EMPLOYER 1

MEDICAID/[FILL IN NAME OF STATE SPECIFIC MEDICAID NAME] 2

SCHIP (CHIP/CHILDREN’S HEALTH INSURANCE PROGRAM) 3

AFFORDABLE CARE ACT/ACA/HEALTHCARE MARKETPLACE 4

MEDICARE 5

SIGNED UP DIRECTLY WITH INSURANCE COMPANY 6

DON’T KNOW D

REFUSED R

H. CHILD MALTREATMENT

The next questions are about what you have done when [CHILD] has made you upset or angry. As a reminder, all of the information you share with me is private. You do not have to answer any questions that make you feel uncomfortable. Just let me know and I will move on to the next question.

Source: Parent Child Conflict Tactics Scale (CTSPC) PROPRIETARY

(Subscales: Abuse: physical and psychological/emotional)

CM1.

I. Adverse Childhood Experiences (ACE)

Now, I am going to ask you some questions about events that happened during your childhood. This information will allow us to better understand problems that may occur early in life, and may help others in the future. These can be sensitive topics and some people may feel uncomfortable with these questions. As a reminder, you can ask me to skip any question you do not want to answer. All questions refer to the time period before you were 18 years of age. Now, looking back before you were 18 years of age…

Source: Child Trends ACE Module

(https://www.childtrends.org/wp-content/uploads/2014/07/Brief-adverse-childhood-experiences_FINAL.pdf)

ACE1. Did you live with a parent or guardian who got divorced or separated?

YES 1

NO 2

DON’T KNOW D

REFUSED R

Source: Child Trends ACE Module

ACE2. Did you live with a parent or guardian who died?

YES 1

NO 2

DON’T KNOW D

REFUSED R

Source: Child Trends ACE Module

ACE3. Before the age of 18, did you live with a parent or guardian who served time in jail or prison?

YES 1

NO 2

DON’T KNOW D

REFUSED R

Source: Child Trends ACE Module

ACE4. Did you live with anyone who was mentally ill or suicidal, or severely depressed for more than a couple of weeks?

YES 1

NO 2

DON’T KNOW D

REFUSED R

Source: Child Trends ACE Module

ACE5. Did you live with anyone who had a problem with alcohol or drugs?

YES 1

NO 0

DON’T KNOW D

REFUSED R

Source: Child Trends ACE Module

ACE6. Before the age of 18, did you witness a parent, guardian, or other adult in the household behaving violently toward another? For example, slapping, hitting, kicking, punching, or beating each other up.

YES 1

NO 0

DON’T KNOW D

REFUSED R

Source: Child Trends ACE Module

ACE7. Were you ever the victim of violence or witnessed any violence in your neighborhood?

YES 1

NO 0

DON’T KNOW D

REFUSED R

Source: Child Trends ACE Module

ACE8. Before age 18, how often did your family find it hard to cover the costs of food and housing?

Never, 1

Not often, 2

Somwhat often, or 3

Very often? 4

DON’T KNOW D

REFUSED R

J. Confirming Contact Information

We are almost done! We’d like to confirm [your contact information/the contact information you gave us when we last interviewed you.]

This will be kept private and will only be used as a way of contacting you for future interviews. Your continued participation is very important to the MIHOPE study. Your opinions and experiences are important and you cannot be replaced.

[IF WE ALREADY HAVE PHONE NUMBER]

CI1_a. We have your telephone number as:

[NUMBER]

Is this still the best telephone number to use to reach [you]?

YES 1 CI2

NO 0 CI1

REFUSED R CI2

Source: Adapted from MIHOPE2

Item title: Phone

CI1. Please give me your telephone number, area code first.

|___|___|___| - |___|___|___| - |___|___|___|___|

(0-999) (0-999) (0-9999)

Is there an extension number?

| | | | | | |

(0-999999)

DON’T KNOW D

REFUSED R

NewPhoneTZ. What time zone is that in?

If NEEDED: What time is it there?

Eastern Time (US & Canada) [(FILL CURRENT TIME)] 62

Indiana (East) [(FILL CURRENT TIME)] 63

Central Time (US & Canada) [(FILL CURRENT TIME)] 65

ARIZONA [(FILL CURRENT TIME)] 68

MOUNTAIN TIME (US & CANADA) [(FILL CURRENT TIME)] 70

PACIFIC TIME (US & CANADA) [(FILL CURRENT TIME)] 71

ALASKA [(FILL CURRENT TIME)] 72

HAWAII [(FILL CURRENT TIME)] 73

BAJA CALIFORNIA [(FILL CURRENT TIME)] 93

Source: Adapted from MIHOPE2

Item title: Phone

CI2. Do you have another phone number that you can provide?

YES 1 CI2a

NO 0 CI3_a

Source: Adapted from MIHOPE2

Item title: Phone

CI2a. Please give the telephone number, area code first.

|___|___|___| - |___|___|___| - |___|___|___|___|

(0-999) (0-999) (0-9999)

Is there an extension number?

| | | | | | |

(0-999999)

DON’T KNOW D

REFUSED R

ExtraPhnTZ. What time zone is that in?

If NEEDED: What time is it there?

Eastern Time (US & Canada) [(FILL CURRENT TIME)] 62

Indiana (East) [(FILL CURRENT TIME)] 63

Central Time (US & Canada) [(FILL CURRENT TIME)] 65

ARIZONA [(FILL CURRENT TIME)] 68

MOUNTAIN TIME (US & CANADA) [(FILL CURRENT TIME)] 70

PACIFIC TIME (US & CANADA) [(FILL CURRENT TIME)] 71

ALASKA [(FILL CURRENT TIME)] 72

HAWAII [(FILL CURRENT TIME)] 73

BAJA CALIFORNIA [(FILL CURRENT TIME)] 93

[IF WE ALREADY HAVE EMAIL ADDRESS]

CI3_a. Please confirm your email address. The address we have is:

[EMAIL ADDRESS]

Is this email address correct?

YES 1 CI3

NO 0 MailTo

REFUSED R CI3

Source: Adapted from MIHOPE2

Item title: Email

CI3. Please provide me your email address.

____________________________________________________________ (STRING 50)

DON’T KNOW D

REFUSED R

MailTo. Would you like us to send the payment to you or someone else?

SEND TO ME 1

SOMEONE ELSE 2

REFUSED / DO NOT WANT PAYMENT r

Source: Adapted from MIHOPE2

Item title: AddressGiftCard

CI5a. I would like to [confirm/get] the name and address where we should send the payment.

What is the first name?

(STRING 20)

FIRST NAME

Middle initial

(STRING 1)

MIDDLE INITIAL

Last name?

(STRING 30)

LAST NAME

What is the first line of the payment address?

_______________________________________________ (STRING 60)

STREET 1

Is there an apartment or unit number for this address?

_______________________________________________ (STRING 60)

STREET 2

Town or city?

_______________________________________________ (STRING 20)

CITY

State?

_______________________________________________ (STRING 2)

STATE

And what is the zip code?

|___|___|___|___|___| - |___|___|___|___| ZIP CODE

00501-99950 0001-9999

DON’T KNOW D

REFUSED R

Source: MIHOPE2

Item title: Move

CI7. In case you move, we would like to have the name, address, phone number, and email address of [NUMBALTCONTACTS] [person/people] who [do/does] not live with you who will know how to reach you.

We would only contact [this person/them] if we have trouble getting in touch with you directly.

This information will also be kept private.

FIRST PERSON:

What is the name of the first person who will know how to reach you?

ADDITIONAL CONTACTS:

What is the name of another relative or close friend who will know how to contact you in the future?

____________________________________________________ (STRING (20))

FIRST NAME

____________________________________________________ (STRING (30))

LAST NAME

DON’T KNOW D CI9

REFUSED R CI9

Source: MIHOPE2

Item title: Relationship

CI7_1. And what is [CONTACT FIRST NAME]’s relation to you?

____________________________________________________ (STRING (50))

DON’T KNOW D

REFUSED R

Source: MIHOPE2

Item title:Telephone1

CI7_2. Please give me [CONTACT FIRST NAME]’s telephone number, area code first.

|___|___|___| - |___|___|___| - |___|___|___|___|

(0-999) (0-999) (0-9999)

Is there an extension number?

| | | | | | |

(0-999999)

DON’T KNOW D

REFUSED R

Source: MIHOPE2

Item title: Address1

CI7_4. Please tell me [CONTACT FIRST NAME]’s address.

What is the first line of the address?

_______________________________________________ (STRING 60)

STREET 1

Is there an apartment or unit number for this address?

_______________________________________________ (STRING 60)

STREET 2

Town or city?

_______________________________________________ (STRING 20)

CITY

State?

_______________________________________________ (STRING 2)

STATE

And what is the zip code?

|___|___|___|___|___| - |___|___|___|___| ZIP CODE

00501-99950 0001-9999

DON’T KNOW D

REFUSED R

Source: Adapted from MIHOPE2

Item title: email1

CI7_5. What is [CONTACT FIRST NAME]’s email address?

_______________________________________________@________________

DON’T KNOW D

REFUSED R

[IF MISSING, INCOMPLETE OR NEW RESPONDENT]

Source: Adapted from MIHOPE2

Item title: SSN

CI9a. What is your Social Security Number? We are collecting this information in order to obtain your administrative records, such as health care records, for the purposes of the study. We might also use it to try to locate you in the future. Like all information collected for the study, this will be kept private.

|___|___|___| - |___|___| - |___|___|___|___|

(000-999) (00-99) (0000-9999)

DON’T KNOW D

REFUSED R

[If CI10=0 or child SSN is missing or incomplete]

Source: Adapted from MIHOPE2

Item title: SSN

CI10a. What is [CHILD]’s Social Security Number? We are collecting this information in order to obtain [CHILD]’s administrative records, such as health care records, for the purposes of the study. Like all information collected for the study, this will be kept private.

|___|___|___| - |___|___| - |___|___|___|___|

(000-999) (00-99) (0000-9999)

DON’T KNOW D

REFUSED R

Source: MIHOPE2

Item title: InterviewerCall

Appt1. IF IHAMODECHOICE = INHOME: We’re almost done! We really appreciate all the information you have provided so far. Now’s let’s talk about the home visit part of this phase of MIHOPE. A MIHOPE staff member will be calling you soon to schedule a [visit to your home/virtual visit] to do some fun activities with you and [CHILD]. These activities include math, language, and memory games. We described these activities in the letter that [NAME, MIHOPE study survey director] recently sent to you. The MIHOPE staff member will be calling from a 609 [or display] area code, but she lives in your area. You will be paid $50 for completing those activities. We thank you in advance for speaking and meeting with our interviewer.

IF IHAMODECHOICE = VIRTUAL: [We’re almost done! We really appreciate all the information you have provided so far. Now let’s talk about the home visit part of this phase of MIHOPE. At the end of this call a MIHOPE staff member will schedule a virtual visit to do some fun activities with you and [CHILD]. These activities include math, language, and memory games. We described these activities in the letter that[NAME], the MIHOPE study survey director, recently sent to you. The virtual visit will take [about 2 hours] and a local staff member will drop off everything you will need. This includes a laptop computer and wireless internet. They will wear a mask and follow social distancing guidelines. Everything we drop off will be sanitized before we give it to you. You will be paid $50 for completing those activities. We thank you in advance for speaking with our interviewer.]

THANKS1: Before we conclude the interview, do you have any feedback about the MIHOPE interview that we can share with researchers?

THANKS2: This completes the interview! Thank you for your continued participation in MIHOPE.

[IF S1X NE 1-4 AND IF IHAMODECHOICE = INHOME]: A MIHOPE staff member will be in touch with you soon before your in-home appointment. We really appreciate you taking the time to share this information with us. We will send your $25 gift card in the next two weeks. Thank you again. Goodbye.

[IF IHAMODECHOICE = VIRTUAL]: We really appreciate you taking the time to share this information with us. We will send your $25 gift card in the next two weeks. We would like to transfer you briefly to our virtual visit scheduler to identify an appointment time. Please hold briefly while I transfer you.

S1X = 1 – 4
As a reminder, we may contact you again to participate in study activities when your child is older.. Thank you again. Goodbye.

IF SC15_ScrOut = 1

Thank you very much for your time.

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Raquel af Ursin
File Modified	0000-00-00
File Created	2021-12-01