Head Start Family Background Questionnaire

Head Start Family Background Questionnaire

In this questionnaire, we would like to know more about your child who currently attends a Head Start program. In our focus group today, we will be talking about your child’s experiences in this Head Start program. Please answer the following questions with reference to your child who currently attends this Head Start program.

If you have more than one child currently in a Head Start program, please answer questions for your child who is preparing to go to kindergarten next school year.

If you have twins that are both transitioning into kindergarten, consider the overall experience that both children are having in preparation for the kindergarten transition.

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to help better understand how Head Start programs, elementary schools, and community organizations are supporting children and families as they transition into kindergarten. Public reporting burden for this collection of information is estimated to average of 15 minutes, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB number and expiration date for this collection are OMB #: 0970-XXXX, Exp: XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Stacy Ehrlich, [email protected] or 1155 E. 60^th Street, Chicago, IL 60637.

1. Are you the person most responsible for this child’s care?

 No

 Yes

2. If you answered NO to question 1, who is the person most responsible for this child’s care?

______________________________________________________________________________

3. What is your relationship to this child?

 Biological mother

 Biological father

 Adoptive mother

 Adoptive father

 Grandmother

 Grandfather

 Other legal guardian

 Another family member, but not a legal guardian

4. Are you this child’s legal guardian?

 No

 Yes

5. If you answered no to question 4, who is this child’s legal guardian?

______________________________________________________________________________

6. Is this your first child in a Head Start program?

 No

 Yes

7. Is this the first time you and one of your children have experienced transitioning from Head Start into Kindergarten?

 No

 Yes

8. The following situations may require special attention as you and your child are preparing for the transition to kindergarten. Please check off whether any of the follow apply to you, your child, or your family (Please check all that apply):

Family/child speaks a language other than English

Family has specific cultural or religious needs

Child is living with disabilities

Child has special education needs

Child and family have experienced trauma

Child is in foster/kinship care

Family history of housing instability or homelessness

Family history of food insecurity

Other (Please explain): _________________________________________

9. Since your child began going to his/her Head Start program, have you (or other adults in the household):

	Yes	No
Reached out to someone in the elementary school to ask questions?
Been contacted by someone in an elementary school for any reason?
Received any written materials about the kindergarten transition?
Received activities you can do with your child to prepare for the transition?
Received information about the model of instruction offered for kindergarten (in-person, virtual, or hybrid)?
Participated in kindergarten registration (either virtually or in person)?
Participated in a kindergarten screening for your child (either virtually or in person)?
Visited the school or kindergarten classroom your child will be going to next school year (either virtually or in-person)?
Been invited to a kindergarten and/or elementary school event (either virtually or in person)?
Had a transition meeting with your child’s kindergarten teacher or other elementary school staff (either virtually or in person)?

10. During this past program year while your child attended this Head Start program, have you (or other adults in the household):

	Yes	No
Attended a general Head Start program meeting, for example an open house (either virtually or in person)?
Gone to a regularly scheduled parent-teacher conference with your child’s teacher (either virtually or in person)?
Attended a program/center or class event, such a play, because of your child (either virtually or in person)?
Acted as a volunteer at the program/center or served on a committee (either virtually or in person)?
Attended or chaperoned a field trip (either virtually or in person)?

11. Please list how many children you care for within each age range in the table below. Include the child/children you have been thinking about throughout this survey, and any other children you care for.

Age	Number of Other Children
Less than a year old
1-2 years
3-4 years old
5-6 years old
7-8 years old
9-10 years old
10+ years old

12. How long have you lived in your current residence?

 Less than 6 months

 6 to 12 months

 1 to 3 years

 4 to 6 years

 7 years or more

13. What language(s) do you speak with your children at home? Please check all that apply.

 English

 Spanish

 Other (specify): ___________________________________________________

14. What is your race/ethnicity? Please check all that apply. 

 African American/Black

 American Indian/Alaskan Native

 Asian

 Native Hawaiian or Other Pacific Islander

 White

 Other (specify): ____________________________________________________

15. Are you of Hispanic, Latino, or Spanish origin?

 Yes

 No

16. To which gender identity do you most identify?

 Man

 Woman

 Non-binary

17. What is the highest level of education you have completed?

 Less than high school

Some high school

 High School graduate or equivalent (e.g., GED)

 Some college (i.e., courses but no degree)

 Vocational/Technical certificate or diploma

 Associate degree (AA)

 Bachelor’s degree (BA/BS)

 Some graduate work (i.e., courses but no degree)

 Master’s degree (MA)

 Doctoral or Professional degree (e.g., PhD, MD, etc.)

As part of our study, we will be following up with some parents after their child begins kindergarten in the fall. If you participate, you will receive an additional incentive. Would you be willing to be contacted to participate in that interview?

 Yes

Best contact phone number: ______________________

Best contact email: _____________________________

 No

Thank You!

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