OMB No.: 0970–0354
Expiration Date: 10/31/2021
Instrument: PCR [version] [Eng/Sp]
AFFIX LABEL HERE
PCR [version] [Eng/Sp]
This
crosswalk version of the questionnaire includes items to be asked of
parents of children ages newborn to 36 months, flagged as
appropriate for the relevant age forms:
Version
1: Newborn to 7 months
Version
2: 8 months to 16 months
Version
3: 17 months to 30 months
Version
4: 31 months to 37 months
Pregnant
women will not be asked to complete the Parent Child Report.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB number for this information collection is 0970–0354 and the expiration date is 10/31/2021.
ABOUT THIS SURVEY |
1 □ 2 □ 3 □
|
INTERNAL NOTE: IN VERSION OF INSTRUMENT FOR STUDY FAMILIES, KEEP BELOW BOX ON SAME PAGE AS ‘ABOUT THIS SURVEY’ BOX ABOVE.
ABOUT YOU AND YOUR CHILD |
Source: Baby FACES 2018
R1. What is your relationship to the Baby FACES child?
1 □ Mother / Female Guardian
2 □ Father / Male Guardian
3 □ Grandmother
4 □ Grandfather
5 □ Other Relative
6 □ Other Non-Relative
Source: Baby FACES 2018
R2. What is this child’s date of birth?
| | | / | | | / | | | | |
month day year
Source:
BITSEA, A1-A2 (PROPRIETARY)
Included
in versions: 2 [8-16 mos], 3 [17-30 mos], and 4 [31-37 mos]
Same
items for all age versions (appropriate for 12-36 months only)
section
a: social skills
A1. The first set of questions contains statements about 1- to 3-year-old children. Many statements describe normal feelings and behaviors, but some describe things that can be problems. Some may seem too young or too old for your child. Please do your best to answer every question.
Items
A1a to A1hh are protected under copyright and have been redacted
from this instrument.
Source:
Briggs-Gowan, M.J., and A.S. Carter. The Brief Infant–Toddler
Social and Emotional Assessment (BITSEA). San Antonio, TX: Harcourt
Assessment, 2006.
A2. The following questions are about feelings and behaviors that can be problems for young children. Some of the questions may be a bit hard to understand, especially if you have not seen them in a child. Please do your best to answer them anyway.
Items
A2a to A2h are protected under copyright and have been redacted from
this instrument.
Source:
Briggs-Gowan, M.J., and A.S. Carter. The Brief Infant–Toddler
Social and Emotional Assessment (BITSEA). San Antonio, TX: Harcourt
Assessment, 2006.
Source: MacArthur-Bates Communicative Development Inventories, Infant and Toddler Short Forms and CDI-III (PROPRIETARY)
Included in versions: 2 [8-16 mos], 3 [17-30 mos], and 4 [31-37 mos]; Different item sets for age versions
section b: vocabulary checklist
PARENTS WILL BE ASKED TO COMPLETE THE CDI WORD LIST IN EITHER ENGLISH OR SPANISH (BASED ON PRIMARY HOME LANGUAGE) USING THE RELEVANT AGE FORM: LEVEL I (8-18 MONTHS); LEVEL II (16-30 MONTHS); OR LEVEL III (30-37 MONTHS). THESE AGE-BASED VOCABULARY LISTS INCLUDE APPROXIMATELY 100 WORDS EACH AND ARE APPENDED AT THE END OF THIS DOCUMENT. |
B1. Below is a list of typical words in young children’s vocabularies. We are interested specifically in the words your child understands or says in English.
For words your child does not yet understand, mark the first column (does not understand). For words your child understands but does not yet say on his/her own, mark the second column (understands). For words your child understands and also says on his/her own, mark the third column (understands and says). If your child uses a different pronunciation of a word or another word with the same meaning (for example, “raffe” for “giraffe” or “nana” for “grandma”) mark the word anyway. For each item, please mark only one response.
Remember, this is a “catalogue” of words that are used by many different children. Don’t worry if your child knows only a few right now.
These
items are protected under copyright and have been redacted from this
instrument.
Source:
MacArthur-Bates Communicative Development Inventories.
Source:
MacArthur-Bates Communicative Development Inventories, Infant Long
Form, First Communicative Gestures (12 items) (PROPRIETARY)
Included
in versions: 2 [8-16 mos]
B2.1. When infants are first learning to communicate, they often use gestures to make their wishes known. For each item below, mark the response that describes your child’s actions right now.
Items
B2.1a to B2.1l are protected under copyright and have been redacted
from this instrument.
Source:
MacArthur-Bates Communicative Development Inventories.
Source:
MacArthur-Bates Communicative Development Inventories, Toddler Short
Form and CDI-Iii, Combining words (PROPRIETARY)
Included
in versions: 3 [17-30 mos] and 4 [31-37 mos]
B2.2. This item is protected under copyright and has been redacted from this instrument.
Source: MacArthur-Bates Communicative Development Inventories.
Source:
Items C6-C7 adapted from Baby FACES 2009 Parent Interview
Included
in versions: 1 [newborn-7 mos], 2 [8-16 mos], 3 [17-30 mos], and 4
[31-37 mos]
section
c: child well-being
In this section, we would like to learn about your child’s general well-being.
C6. Does your child have an Individualized Family Service Plan (IFSP)? This is a written treatment plan that describes your child’s current levels of functioning, specific needs, and what early intervention services he/she will receive.
0 □ No GO TO C7
1 □ Yes
C6a. Was this plan developed with the help of staff at your child’s Early Head Start program?
0 □ No
1 □ Yes
C7. Below is a list of different special needs that children sometimes have. Some of these may not apply to your child, but please do your best to answer every question. For each statement, please mark only one response. Does your child have…
|
MARK ONE PER ROW |
|
|
Does your child have… |
|
|
NO |
YES |
a. behavioral trouble or difficulty paying attention to learn? |
0 |
1 |
b. difficulty hearing and understanding speech in a normal conversation? |
0 |
1 |
c. difficulty seeing objects in the distance or letters on paper? |
0 |
1 |
d. any physical development issues such as problems with the way he/she uses his/her arms or legs? |
0 |
1 |
e. a below-normal activity level? . |
0 |
1 |
f. difficulty with speech or communicating? |
0 |
1 |
g. trouble
sleeping because of a breathing problem or sleep apnea? |
0 |
1 |
h. a developmental disability or delay? |
0 |
1 |
Source: Parenting Stress Index, 4th Edition Short Form, D1 & D2a-D2c (PROPRIETARY)
Included in versions: 1 [newborn-7 mos], 2 [8-16 mos], 3 [17-30 mos], and 4 [31-37 mos]; same items for all age versions
section d: raising a child
D1. Having a child can sometimes be stressful. The next set of questions contains statements about how stressful having a child has been for you and the ways in which you have had to adjust your life. For each statement, please mark how much you agree or disagree.
Items
D1a to D1gg are protected under copyright and have been redacted
from this instrument.
Source:
Parenting Stress Index, 4th Edition Short Form.
D2a. This item is protected under copyright and has been redacted from this instrument.
Source: Parenting Stress Index, 4th Edition Short Form.
D2b. This item is protected under copyright and has been redacted from this instrument.
Source: Parenting Stress Index, 4th Edition Short Form.
D2c. This item is protected under copyright and has been redacted from this instrument.
Source: Parenting Stress Index, 4th Edition Short Form.
Source: Child-Parent Relationship Scale, Short Form (CPRS-SF)
Included in versions: 1 [newborn-7 mos], 2 [8-16 mos], 3 [17-30 mos], and 4 [31-37 mos]
DO NOT INCLUDE ITEMS g AND o IN VERSIONS 1 [NEWBORN TO 7 MOS] AND 2 [8-16 MOS]
section e: relationships and feelings
E1. Please think about the degree to which each of the following statements currently applies to your relationship with your child. For each statement, please mark only one response.
|
MARK ONE PER ROW |
||||
|
How much does this currently apply to your relationship with your child?
|
||||
|
DEFINITELY DOES NOT APPLY
|
NOT REALLY
|
NEUTRAL/ NOT SURE
|
APPLIES SOMEWHAT
|
DEFINITELY APPLIES
|
a. I
share an affectionate, warm relationship with my child |
1 □ |
2 □ |
3 □ |
4 □ |
5 □ |
b. My
child and I always seem to be struggling with each other |
1 □ |
2 □ |
3 □ |
4 □ |
5 □ |
c. If
upset, my child will seek comfort from me |
1 □ |
2 □ |
3 □ |
4 □ |
5 □ |
d. My
child is uncomfortable with physical attention or touch from me
|
1 □ |
2 □ |
3 □ |
4 □ |
5 □ |
e. My
child values his/her relationship with me |
1 □ |
2 □ |
3 □ |
4 □ |
5 □ |
f. When
I praise my child, he/she beams with pride |
1 □ |
2 □ |
3 □ |
4 □ |
5 □ |
g. My
child spontaneously shares information about himself/herself |
1 □ |
2 □ |
3 □ |
4 □ |
5 □ |
h. My
child easily becomes angry at me |
1 □ |
2 □ |
3 □ |
4 □ |
5 □ |
i. It
is
easy to be in tune with what my child is feeling |
1 □ |
2 □ |
3 □ |
4 □ |
5 □ |
j. My
child remains angry or is resistant after being disciplined |
1 □ |
2 □ |
3 □ |
4 □ |
5 □ |
k. Dealing with my child drains my energy |
1 □ |
2 □ |
3 □ |
4 □ |
5 □ |
l. When my child is in a bad mood, I know we’re in for a long and difficult day |
1 □ |
2 □ |
3 □ |
4 □ |
5 □ |
m. My child’s feelings toward me can be unpredictable or can change suddenly |
1 □ |
2 □ |
3 □ |
4 □ |
5 □ |
n. My
child is sneaky or manipulative with me |
1 □ |
2 □ |
3 □ |
4 □ |
5 □ |
o. My
child openly shares his/her feelings and experiences with me |
1 □ |
2 □ |
3 □ |
4 □ |
5 □ |
©1992 Pianta, University of Virginia.
Source:
Healthy Families Parenting Inventory (Parent/Child Interaction and
Social Support subscales), E2-E3 (PROPRIETARY)
Included
in versions: 1 [newborn-7 mos], 2 [8-16 mos], 3 [17-30 mos], and 4
[31-37 mos]; same
items for all age versions
(Items
in E3 asked of pregnant respondents in parent survey)
E2. Below is a list of statements that describes how some parents may behave or feel about their child. For each statement, please mark the answer that best fits for you.
Items E2a to E2j are protected under copyright and have been redacted from this instrument. Source: Healthy Families Parenting Inventory (Parent/Child Interaction subscale) |
E3. The below statements also describe how some parents may behave or feel. For each statement, please mark the answer that best fits for you.
Items E3a to E3e are protected under copyright and have been redacted from this instrument. Source: Healthy Families Parenting Inventory (Social Support subscale) |
Source:
CESD-R. Permissions:
Items in this section are from Eaton WW, Muntaner C, Smith C, Tien
A, Ybarra M. Center for Epidemiologic Studies Depression Scale:
Review and revision (CESD and CESD-R). In: Maruish ME, ed. The Use
of Psychological Testing for Treatment Planning and Outcomes
Assessment. 3rd ed. Mahwah, NJ: Lawrence Erlbaum; 2004:363-377
I8. Below is a list of ways you may have felt or behaved. Please mark how often you have felt this way in the past week or so.
|
MARK ONE PER ROW |
|||||
|
LESS THAN 1 DAY |
1‑2 DAYS in past week |
3‑4 DAYS in past week |
5‑7 DAYS in past week |
nearly every day for 2 weeks |
|
a. My appetite was poor
|
0 □ |
1 □ |
2 □ |
3 □ |
4 □ |
|
b. I could not shake off the blues
|
0 □ |
1 □ |
2 □ |
3 □ |
4 □ |
|
c. I had trouble keeping my mind on what I was doing
|
0 □ |
1 □ |
2 □ |
3 □ |
4 □ |
|
d. I felt depressed
|
0 □ |
1 □ |
2 □ |
3 □ |
4 □ |
|
e. My sleep was restless
|
0 □ |
1 □ |
2 □ |
3 □ |
4 □ |
|
f. I felt sad
|
0 □ |
1 □ |
2 □ |
3 □ |
4 □ |
|
g. I could not get going
|
0 □ |
1 □ |
2 □ |
3 □ |
4 □ |
|
h. Nothing made me happy
|
0 □ |
1 □ |
2 □ |
3 □ |
4 □ |
|
i. I felt like a bad person
|
0 □ |
1 □ |
2 □ |
3 □ |
4 □ |
|
j. I lost interest in my usual activities
|
0 □ |
1 □ |
2 □ |
3 □ |
4 □ |
|
k. I slept much more than usual
|
0 □ |
1 □ |
2 □ |
3 □ |
4 □ |
|
l. I felt like I was moving too slowly
|
0 □ |
1 □ |
2 □ |
3 □ |
4 □ |
|
m. I felt fidgety
|
0 □ |
1 □ |
2 □ |
3 □ |
4 □ |
|
n. I wished I were dead
|
0 □ |
1 □ |
2 □ |
3 □ |
4 □ |
|
o. I wanted to hurt myself
|
0 □ |
1 □ |
2 □ |
3 □ |
4 □ |
|
p. I was tired all the time
|
0 □ |
1 □ |
2 □ |
3 □ |
4 □ |
|
q. I did not like myself
|
0 □ |
1 □ |
2 □ |
3 □ |
4 □ |
|
r. I lost a lot of weight without trying to
|
0 □ |
1 □ |
2 □ |
3 □ |
4 □ |
|
s. I had a lot of trouble getting to sleep
|
0 □ |
1 □ |
2 □ |
3 □ |
4 □ |
|
t. I could not focus on important things
|
0 □ |
1 □ |
2 □ |
3 □ |
4 □ |
|
The National Suicide Prevention Lifeline is available 24/7 for free and confidential support for people in distress or for crisis resources for you or your loved ones. Call 1-800-273-8255 or vist the website at suicidepreventionlifeline.org.
The next few questions are about tobacco, alcohol, and drug use.
Source: Adapted from Baby FACES 2009
Item title: TobaccoPast30Days
I5. During the past 30 days, did you or anyone else in your household smoke tobacco, such as cigarettes or cigars?
0 □ No
1 □ Yes
d □ Don’t know
Source: Baby FACES 2018
Item title: VapingPast30Days
I5a. During the past 30 days, have you or anyone else in your household used nicotine “vaping” products, such as e-cigarettes?
0 □ No
1 □ Yes
d □ Don’t know
Source: Baby FACES 2018
Item title: ProgramCessationHelp
I5b. Did [PROGRAM] Early Head Start offer resources or support to you or anyone else in your household for reducing or quitting the use of tobacco or nicotine “vaping”?
0 □ No
1 □ Yes
d □ Don’t know
Source: Adapted from MIHOPE 2 Parent Survey
I5c. The next questions are about drinking alcoholic beverages. By a “drink” we mean a can or bottle of beer, a wine cooler or glass of wine, a shot of liquor, or a mixed drink.
During the past 30 days, how many alcoholic drinks did you have in an average week?
maRK ONE ONLY
1 □ None
2 □ Less than 1 drink
3 □ 1 to 3 drinks
4 □ 4 to 6 drinks
5 □ 7 to 13 drinks
6 □ 14 to 19 drinks
7 □ 20 or more drinks
d □ Don’t know
Source: Adapted from MIHOPE 2 Parent Survey
I5d. In the last 30 days, how many times did you or anyone in your household drink 4 alcoholic drinks or more in one day? Would you say…
maRK ONE ONLY
1 □ 6 or more times
2 □ 4 to 5 times
3 □ 2 to 3 times
4 □ 1 time
5 □ Never
Source: New item
I5d1. Did Early Head Start offer resources or support to you or anyone else in your household to help reduce or quit drinking alcohol?
0 □ No
1 □ Yes
d □ Don’t know
Source: Adapted from the National Survey for Drug Use and Health
I5E1. In the past 30 days, have you or has anyone in your household used heroin (smack, horse) or a prescription pain reliever (oxy, percs, vikes) in a way that was not director by a doctor? By “not directed by a doctor” we mean used without a prescription; used in greater amounts, more often, or longer than prescribed; or used in any other way not prescribed by a doctor.
0 □ No
1 □ Yes
d □ Don’t know
Source: Adapted from the National Survey for Drug Use and Health
I5f1. In the past 30 days have you or has anyone in your household used marijuana (weed, pot) or hashish (hash)?
0 □ No
1 □ Yes
d □ Don’t know
Source: Adapted from the National Survey for Drug Use and Health
I5f2. What about other types of drugs, such as amphetamines (uppers, ice, speed, crystal meth, crank), cocaine (rock, coke, crack), tranquilizers (downers, ludes) hallucinogens (LSD, acid, PCP, angel dust, ecstasy), or sniffing gasoline, glue, or aerosols? Have you or anyone in your household used any of these in the past 30 days?
0 □ No
1 □ Yes
d □ Don’t know
Source: Adapted from MIHOPE 2 Parent Survey
I5g. Did Early Head Start offer resources or support to you or anyone else in your household to help reduce or quit using drugs?
0 □ No
1 □ Yes
d □ Don’t know
Finally, we have one last question about your household income.
Source: Baby FACES 2009
L4. In the last 12 months, what was the total income of all members of your household from all sources before taxes and other deductions? Please include your own income and the income of everyone living with you. Please include the money from jobs and public assistance programs, as well as any other sources such as rent, interest, and dividends. Your best estimate is fine.
$|___|___|___|,|___|___|___|
Please mark whether that is per week, every two weeks, per month or per year.
MARK ONE ONLY
1 □ Per week
2 □ Every two weeks
3 □ Per month
4 □ Per year
E4. Please record the date you completed this form.
DATE COMPLETED: | | | / | | | / | | | | |
month day year
Thank you for your participation in Baby FACES!
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | BABY FACES SPRING 2017 PARENT CHILD REPORT |
Subject | SAQ |
Author | MATHEMATICA |
File Modified | 0000-00-00 |
File Created | 2022-03-09 |