Baseline Parent Survey

[Survey programming instructions will be inserted here and throughout the survey. In addition, notes to the interviewer will be inserted here and appear throughout the survey. Information for programming or the interviewer are in blue italics. Section sub-headers that indicate specific scales (e.g., “Current Housing Situation” or “Depressive Symptoms”) will not be read or displayed on the survey visible to parents/caregivers.]

Welcome

Thank you for being part of the Parents Empowering Parents study. As I mentioned before, you will be asked to do a survey twice as part of the study—once now and again in about 15 months. You will get a $40 Visa gift card for completing this survey.

For the survey, I will ask you some questions. Some of the questions are personal or ask about things that may be difficult to talk about. The survey will ask about things like sense of hope, strengths and needs, stress, substance use and recovery, housing and household situations, financial situations, personal characteristics, and experiences with child welfare, domestic violence, discrimination, and mental health. You will have the option to answer some questions on your own, if you would like.

Your participation is completely voluntary. That means you may choose not to answer any question, or you may stop the survey if you wish. You can skip any question or take a break whenever you like. This should take about 45 minutes.

I want you to know that we keep what you say private. The only exception is if we learn that you or someone else is in danger, we will try to make sure you or that person get help and are safe. If this needed to happen, it would follow a safety reporting process, flagging immediate concerns about safety to the study director, and, if needed, to the appropriate agency. When the researchers write about the survey or study, your name will not be attached to your answers and will be combined with the answers of the 2,000 other parents being interviewed. Child welfare will not see your answers and nothing you say in the survey will affect your case or any of the services you get. Survey data that does not identify you in any way will be stored in a restricted access data archive for use by other verified researchers at the completion of the study.

After you finish the survey, I’ll check the computer for your randomly selected study group. The selection happens in a different system and your interview answers will not influence your study group.

According to the Paperwork Reduction Act (PRA), 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 #: 0970-0616, Exp: 09/30/2026.

This project is subject to the Privacy Act. Your participation is voluntary. Your data will be used solely for statistical research and evaluation. Your data may be shared with researchers involved in similar work and with federal agencies that may have additional data that can inform this study. No identifying information will be available to future researchers, but the information collected in this study may be used for future research studies. The legal authority for this project is 42 U.S.C. § 1310a and Public Law 115-271. For System of Records Notice (SORN) information, please see the SORN number 09-80-0361, “OPRE Research and Evaluation Project Records.”

What questions can I answer for you? If you are ready, we can begin the survey.

Verification

Before we begin, I want to make sure I have the correct record pulled up..

A1. What is your legal name?

First: _______________

Middle: _______________

Last: _______________

Interviewer: Does legal name match records?

1 Yes – ASK A2

2 No [SKIP TO TERMINATION SCRIPT]

A2. What is your date of birth?

__/__/____

MM/DD/YYYY

Interviewer: Does date of birth match records?

1 Yes - CONTINUE

2 No [SKIP TO TERMINATION SCRIPT]

TERMINATION SCRIPT

Thank you for taking the time to answer these questions. The information you provided does not match the record I have pulled up. Please allow me a moment to investigate further to determine how to resolve this issue.

INTERVIEWER: POSTPONE SURVEY AND GO BACK TO RESD TO CONFIRM YOU ARE ACCESSING THE CORRECT PARTICIPANT LINK. IF SO AND THE WRONG RECORD IS STILL BEING PULLED UP, LET THE PARTICIPANT KNOW YOU WILL NEED TO SPEAK WITH YOUR SUPERVISOR AND WILL NEED TO RESCHEDULE THE APPOINTMENT. [EXIT SURVEY]

Thank you very much. I also want to acknowledge that some of the topics we discuss today may be difficult. I’d like to suggest that you think of at least one person who you can go to for support or to debrief after this [INTERVIEWER PAUSES]. Let’s begin the survey.

HOUSING/HOUSEHOLD COMPOSITION

[Section preamble:] People live in many kinds of housing. Sometimes for a short time (temporary) and sometimes for longer. We want to start the survey by asking a few questions about where you live now, where you’ve stayed in the past year, and who lives with you.

Current housing situation

HOUS-1. Which of the following best describes your current living situation? By “current living situation” we mean where you slept the majority of nights in the past week. [Interviewer: READ ALL CATEGORIES]

**[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will only be able to select one option.]**	1= Yes
House or apartment you own or rent. This does not include your parent’s home or apartment
A friend, relative, or partner’s house or apartment and you are paying part or all of the rent. By partner, we mean a boyfriend, girlfriend, fiancé, or significant other.
A friend, relative, or partner’s house or apartment but you are not paying rent.
Permanent housing program, transitional housing program, sober housing program, or some other housing assistance program
Emergency shelter or domestic violence shelter
Hotel or motel
Car or another vehicle, abandoned building, or anywhere outside
Somewhere else (Please specify: _____________________)
98 = Don’t Know
[Display only for interviewer, not to be read aloud] 99 = Prefer not to answer [refused]

Housing stability - housing mobility

HOUS-2. Now I’d like to ask you to think about the past year, that is since [DISPLAY MONTH, YEAR for ONE YEAR PRIOR TO INTERVIEW]. Think about all the different places you have lived or stayed during the past year. How many different places have you lived or stayed? Please include the place where you currently live or stay.

# of places: _________ [1-49]

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

INTERVIEWER NOTE: IF RESPONDENT ANSWERED ‘CAR’ TO PREVIOUS QUESTION, CONSIDER THIS ONE PLACE WHEN COUNTING NUMBER OF PLACES.

INTERVIEWER NOTE: IF ASKED BY RESPONDENT:  THIS SHOULD INCLUDE ALL PLACES THE RESPONDENT HAS LIVED, INCLUDING HOMELESS SHELTERS. IF RESPONDENT CYCLED BACK AND FORTH BETWEEN TWO PLACES, COUNT EACH ONLY ONCE.

Housing stability – eviction

HOUS-3. During the past year have you been evicted or forced to move when you didn’t want to? Answer yes if you are in the middle of an eviction.

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will only be able to select one option.]

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Household composition

HOUS-4. How many adults, aged 18 and older, currently live with you?

Include everyone aged 18 and older who usually stays with you at least two nights a week, even if they are away from home right now. Do not include yourself.

# adults _________ [0-20]

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

HOUS_5. How many children, under the age of 18, do you have? Please include your biological, adoptive, foster or stepchildren.

# children _________ [0-20]

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

ASK IF HOUS-5 = 1-20

HOUS-5a. How many children, under the age of 18, currently live with you? Please include your biological, adoptive, foster, step, or other children that spend at least two nights a week with you.

# children _________ [0-20]

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

HOUS-5b. How many children that live with you are you responsible for? Include only children under 18 years old.

# children responsible for_________ [0-20]

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Marital and cohabitation status

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will only be able to select one option.]

HOUS-6. What is your current marital status? Are you… [select one]

1 Married

2 Divorced

3 Separated

4 Widowed

5 Never married

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

HOUS-7a. [IF MARRIED HOUS-6 = 1] Does your spouse currently live with you?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

HOUS-7b. [ELSE HOUS-6 = 2,3,4,5,99] Do you have a partner who currently lives with you? By partner, we mean a boyfriend, girlfriend, fiancé, or significant other.

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

CASE ENGAGEMENT

[Section preamble:] The next set of questions are about your experiences and interactions with child welfare/Child Protective Services (CPS). When answering these questions, please think about your current or most recent experience with child welfare/CPS. In these questions, case means your most recent child welfare/CPS case, and caseworker means your child welfare caseworker/social worker. Remember that the information you share will be kept private and your name will never appear in reports.

Please tell me how much you agree or disagree with each of the following. [INSERT ATTRIBUTE]. Would you say you Strongly disagree, Disagree, Neither disagree nor agree, Agree or Strongly agree?

INTERVIEWER: Repeat the scale for the first three attributes and then as needed if the participant seems unsure

[Note: This scale will be programmed and presented in tabular format for survey administration. Each item will appear in a column on the left side of the table and the response options along the top row of the table. PROGRAMMING: Randomize the presentation of these questions.]

Item	1 = Strongly disagree	2 = Disagree	3 = Neither disagree nor agree	4 = Agree	5 = Strongly agree	[Display only for interviewer, not to be read aloud] 98= Don’t Know 99 = Prefer not to answer [refused]
Engagement Subscale
CEE-1. My caseworker and I communicate well with one another.
CEE-2. I feel heard at the meetings about my case. INTERVIEWER NOTE: IF RESPONDENT INDICATES THEY HAVE NOT HAD A MEETING ABOUT THEIR CASE YET, SELECT ‘NOT APPLICABLE’ PROGRAMMING NOTE: ALLOW A ‘NOT APPLICABLE’ RESPONSE FOR CEE_2.
CEE-3. I feel confident advocating for myself and my children.
CEE-4. I feel hopeful about how my case will turn out.
Disaffection Subscale
CED-5. I don’t trust my caseworker.
CED-6. I am frustrated about my case.
CED-7. I feel excluded from deciding what is on my case plan.
CED-8. I am confused about what my caseworker expects from me.
CED-9. I am worried about how things will turn out for my family.
Motivation Subscale
CEM-10. I understand what I need to do to make progress on my case.
CEM-11. I feel like I can do what I need to do to make progress on my case.
CEM-12. I feel like the services I’m offered will help me.
CEM-13. Completing the things on my case plan will help me resolve my case.

ADULT WELL-BEING: MENTAL/EMOTIONAL HEALTH

PROGRAMMING NOTE: IF MODE=1 (IN PERSON), DISPLAY THE FOLLOWING TEXT PRIOR TO INTRO_DEP:

<AWB_MEH> BASE: MODE=IN PERSON

In the next series of questions, you have the option to complete these questions on your own or I can continue to read the questions to you. If you choose to complete the questions on your own, you can read them to yourself or turn on audio and have the questions read to you. Some people may find these questions difficult to talk about, which is why we are giving you this choice.

The questions discuss ways you may have felt recently, support systems you may have used and how your relationship with your [HOUS_5A=1 ‘child’/HOUS_5A NE 1 ‘children’] is typically.

Would you like to complete this section on your own or have me continue reading the questions to you?

1 ☐ ON MY OWN CONTINUE TO SELFAD_MEH, SA_MODE_1=1

2 ☐ INTERVIEWER ADMINISTERED SKIP TO INTRO_DEP, SA_MODE_1=2

IF <SELFAD_MEH> BASE: AWB_MEH=1

SELFAD_MEH. Would you like the questions to be read to you? If so, I can provide you with a headset for privacy.

1 ☐ YES, PROVIDE HEADSET AND PLAY AUDIO

2 ☐ YES, PLAY AUDIO BUT DO NOT PROVIDE HEADSET

3 ☐ NO, DO NOT PLAY AUDIO

INTERVIEWER NOTE: IF THE RESPONDENT WOULD LIKE AUDIO AND THE HEADPHONES PLUG IN THE HEADPHONES, HAND THE TABLET TO THE RESPONDENT AND INSTRUCT THEM TO CLICK NEXT TO COMPLETE THE SERIES OF QUESTIONS.

IF THE RESPONDENT DOES NOT WANT AUDIO OR DOES NOT WANT THE HEADPHONES, CLICK NEXT AND HAND THE TABLET TO THEM.

PROGRAMMER NOTE: CREATE A FLAG TO INDICATE WHICH OPTION THE RESPONDENT HAS CHOSEN, AS FOLLOWS:

AWB_MEH=1 THEN SA_MODE_1=1 (SELF ADMINISTERED)

AWB_MEH=2 THEN SA_MODE_1=2 (INTERVIEWER LED)

PROGRAMMER NOTE: IF SELFAD_MEH=1 OR 2 PLAY THE AUDIO FILES STARTING ON THE INTRO_DEP SCREEN

PROGRAMMING NOTE: WHEN AWB_MEH=1 INSERT A TRANSITION PAGE THAT DISPLAYS:

SELFAD_MEH=1 Please click the NEXT button once you have your headset on to continue the survey. The audio will begin playing each time a new screen appears. You can pause, resume, rewind and control the volume on each screen.

SELFAD_MEH=2 OR 3 Please click next to continue the survey

[Section preamble] Next, we ask about your health, life, and relationships. People have different thoughts, experiences, connections, and approaches to life.

In responding to the questions in this section, please keep 3 points in mind:

1. Please respond truthfully to each statement. There are no right or wrong answers – only your opinions.

2. Some statements may seem like others, but no two statements are exactly the same.

3. You are encouraged to respond to every statement.

Depressive symptoms

We’ll begin with some of the ways you may have felt or behaved. Please select how often you have felt this way during the past week that is since last [CURRENT DAY OF WEEK, E.G. Monday].

[INSERT ATTRIBUTE]. Would you say Rarely or none of the time (less than 1 day, Some or a little of the time (1-2 days), Occasionally or a moderate amount (3-4 days) or Most of the time (5-7 days)?

INTERVIEWER: Repeat the scale for the first three attributes and then as needed if the participant seems unsure

Item	1 = Rarely or none of the time, less than 1 day	2 = Some or a little of the time, 1-2 days	3 = Occasionally or a moderate amount of time, 3-4 days	4 = Most of the time, 5-7 days	98 = Don’t Know 99 = Prefer not to answer [refused]
DEP-1. I was bothered by things that usually don’t bother me.
DEP-2. I had trouble keeping my mind on what I was doing.
DEP-3. I felt depressed.
DEP-4. I felt that everything I did was an effort.
DEP-5. I felt hopeful about the future.
DEP-6. I felt fearful.
DEP-7. My sleep was restless.
DEP-8. I was happy.
DEP-9. I felt lonely.
DEP-10. I could not ‘get going.’

Social support (PAPF – Social Connections subscale)

Next, we want to learn more about the people you have in your life. For each statement, tell me the answer that best describes you during the last couple of months, that is since [TWO MONTHS PRIOR TO INTERVIEW DATE].

[INSERT ATTRIBUTE]. Would you say NOT AT ALL LIKE me or what I believe, NOT MUCH LIKE me or what I believe, A LITTLE LIKE me or what I believe, LIKE me or what I believe or VERY MUCH LIKE me or what I believe?

INTERVIEWER: Repeat the scale for the first three attributes and then as needed if the participant seems unsure

Item	1 = NOT AT ALL LIKE me or what I believe	2 = NOT MUCH LIKE me or what I believe	3 = A LITTLE LIKE me or what I believe	4 = LIKE me or what I believe	5 = VERY MUCH LIKE me or what I believe	98= Don’t Know 99 = Prefer not to answer [refused]
SS – 1. I have someone who will help me get through tough times.
SS -2. I have someone who helps me reset when I get upset.
SS – 3. I have someone who can help me reset if I get frustrated with my child(ren).
SS – 4. I have someone who will encourage me when I need it.
SS – 5. I have someone I can ask for help when I need it.
SS – 6. I have someone I trust who will give me feedback on my parenting.
SS – 7. I have someone who helps me feel good about myself.
SS – 8. I am comfortable asking for help from my family or people who are like family to me. [Interviewer: if state they do not have family or people who are like family, code as 1 = not at all like me]
SS – 9. I have someone to talk to about important things.

Parenting stress

For the following items please think about how your relationship with your [IF HOUSE-5 = 1 “child”, IF HOUSE-5 = 2+ OR PREFER NOT TO ANSWER “children”] typically is. [IF SELFAD_MEH=2 DISPLAY: In this section we will use the term children even if you just have one child.] Please tell me how much you agree or disagree with the following items. Remember, there are no right or wrong answers, only your opinions.

[ATTRIBUTE]. Would you say you Strongly disagree, Disagree, Neither disagree nor agree, Agree or Strongly agree?

INTERVIEWER: Repeat the scale for the first three attributes and then as needed if the participant seems unsure

[Note: This scale will be programmed and presented in tabular format for survey administration. Each item will appear in a column on the left side of the table and the response options along the top row of the table.] PROGRAMMER: IF HOUSE-5 = 1 READ IN “child”. IF HOUSE-5 = 2+ OR PREFER NOT TO ANSWER READ IN “children” for items with “child(ren)”,

Item	1 = Strongly Disagree	2 = Disagree	3 = Neither disagree nor agree	4 = Agree	5 = Strongly Agree	98 = Don’t know 99 = Prefer not to answer [Refused]
PS – 1. I am happy in my role as a parent.
PS – 2. There is little or nothing I wouldn’t do for my child(ren) if it was necessary.
PS – 3. Caring for my child(ren) sometimes takes more energy than I have to give.
PS – 4. I sometimes worry whether I am doing enough for my child(ren).
PS – 5. I feel close to my child(ren).
PS – 6. I enjoy spending time with my child(ren).
PS – 7. My child(ren) is an important source of affection for me.
PS – 8. Having child(ren) gives me a more certain and optimistic view of the future.
PS – 9. The major source of stress in my life is my child(ren).
PS – 10. Having child(ren) leaves little time and flexibility in my life.
PS – 11. Having child(ren) has been financially difficult.
PS – 12. It is difficult to balance different responsibilities because of my child(ren).
PS – 13. The behavior of my child(ren) is often embarrassing or stressful to me.
PS – 14. If I had to do it over again, I might decide not to have child(ren).
PS – 15. I feel overwhelmed by the responsibility of being a parent.
PS – 16. Having child(ren) has meant having too few choices and too little control over my life.
PS – 17. I am satisfied as a parent.
PS – 18. I find my child(ren) enjoyable.

PROGRAMMING NOTE: IF SA_MODE_1=1 DISPLAY THE FOLLOWING TEXT AFTER PS_18:

POST_SA_1 “ Thank you for answering these questions, please hand the tablet back to the Interviewer. “

Overall quality of life (QOL) and general health

Next, please rate your feelings based on your life in the last two weeks, that is since [DATE TWO WEEKS PRIOR TO INTERVIEW DATE]. I will read a rating scale for each question and you can let me know the best answer for you.

QoL – 1. How would you rate your quality of life?

1 Very poor

2 Poor

3 Neither poor nor good

4 Good

5 Very good

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

QoL – 2. How satisfied are you with your health?

1 Very dissatisfied

2 Dissatisfied

3 Neither dissatisfied nor satisfied

4 Satisfied

5 Very satisfied

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Resilience

Now I’d to ask you about how you deal with different types of situations. Please tell me how much you agree or disagree with the following.

[INSERT ATTRIBUTE]. Would you say you Strongly disagree, Disagree, Neither disagree nor agree, Agree or Strongly agree?

INTERVIEWER: Repeat the scale for the first three attributes and then as needed if the participant seems unsure.

Item	1 = Strongly Disagree	2 = Disagree	3 = Neither disagree nor agree	4 = Agree	5 = Strongly Agree	98 = Don’t know 99 = Prefer not to answer
RESIL - 1. I tend to bounce back quickly after hard times.
RESIL – 2. I have a hard time making it through stressful events. [reverse coded, strongly disagree = 5]
RESIL – 3. It does not take me long to recover from a stressful event.
RESIL – 4. It is hard for me to snap back when something bad happens. [reverse coded, strongly disagree = 5]
RESIL – 5. I usually come through difficult times with little trouble.
RESIL – 6. I tend to take a long time to get over set-backs in my life. [reverse coded, strongly disagree = 5]

Protective factors-family functioning- concrete support

For each statement, please select the answer that best describes you during the last couple of months that is since [TWO MONTHS PRIOR TO INTERVIEW DATE].

INTERVIEWER: Repeat the scale for the first three attributes and then as needed if the participant seems unsure

	1 = NOT AT ALL LIKE me or what I believe	2 = NOT MUCH LIKE me or what I believe	3 = A LITTLE LIKE me or what I believe	4 = LIKE me or what I believe	5 = VERY MUCH LIKE me or what I believe	[Display only for interviewer, not to be read aloud] 98 = Don’t Know 99 = Prefer not to answer [Refused]
PF – 1. I don’t give up when I run into problems trying to get the services I need.
PF – 2. I make an effort to learn about the resources in my community that might be helpful for me.
PF – 3. When I cannot get help right away, I don’t give up until I get the help I need.
PF – 4. I know where to go if my child needs help.
PF – 5. I am willing to ask for help from community programs or agencies.
PF – 6. I know where I can get helpful information about parenting and taking care of children.
PF – 7. Asking for help for my child is easy for me to do.
PF – 8. I know where to get help if I have trouble taking care of emergencies.
PF – 9. I try to get help for myself when I need it.

Agency/ goals (“Hope”)

For the following statements, please tell me the response that best describes how you think about yourself right now. Please take a few moments to focus on yourself and what is going on in your life at this moment.

[INSERT ATTRIBUTE]. Would you say Definitely false, Mostly false, Some-what false, Slightly false, Slightly true, Some-what true, Mostly true or Definitely true?

INTERVIEWER: Repeat the scale for the first three attributes and then as needed if the participant seems unsure

	1 = Definitely false	2 = Mostly false	3 = Some-what false	4 = Slightly false	5 = Slightly true	6 = Some-what true	7 = Mostly true	8 = Definitely true	[Display only for interviewer, not to be read aloud] 98 = Don’t Know 99 = Prefer not to answer [Refused]
HOPE -1. If I should find myself in a jam, I could think of many ways to get out of it.
HOPE – 2. At the present time, I am energetically pursuing my goals.
HOPE – 3. There are lots of ways around any problem that I am facing now.
HOPE – 4. Right now, I see myself as being pretty successful.
HOPE – 5. I can think of many ways to reach my current goals.
HOPE – 6. At this time, I am meeting the goals that I have set for myself.

ADULT WELL-BEING: SUBSTANCE USE

PROGRAMMING NOTE: IF MODE=1 (IN PERSON), DISPLAY THE FOLLOWING TEXT PRIOR TO INTRO_SUD:

<AWB_SUD> BASE: MODE=IN PERSON

AWB_SUD In the next series of questions, you have the option to complete these questions on your own or I can continue to read the questions to you. If you choose to complete the questions on your own, you can read them to yourself or turn on audio and have the questions read to you. Some people may find these questions difficult to talk about, which is why we are giving you this choice.

These next questions ask about alcohol and drug use. They are questions about different experiences some people may have if they use drugs or alcohol.

Would you like to complete this section on your own or have me continue reading the questions to you?

1 ☐ ON MY OWN CONTINUE TO SELFAD_SUD, SA_MODE_2=1

2 ☐ INTERVIEWER ADMINISTERED SKIP TO INTRO_SUD, SA_MODE_2=2

<SELFAD_SUD> BASE: AWB_SU=1

SELFAD_SUD Would you like the questions to be read to you? If so, I can provide you with a headset for privacy.

1 ☐ YES, PROVIDE HEADSET AND PLAY AUDIO

2 ☐ YES, PLAY AUDIO BUT DO NOT PROVIDE HEADSET

3 ☐ NO, DO NOT PLAY AUDIO

INTERVIEWER NOTE: IF THE RESPONDENT WOULD LIKE AUDIO AND THE HEADPHONES PLUG IN THE HEADPHONES, HAND THE TABLET TO THE RESPONDENT AND INSTRUCT THEM TO CLICK NEXT TO COMPLETE THE SERIES OF QUESTIONS.

IF THE RESPONDENT DOES NOT WANT AUDIO OR DOES NOT WANT THE HEADPHONES, CLICK NEXT AND HAND THE TABLET TO THEM.

PROGRAMMER NOTE: CREATE A FLAG TO INDICATE WHICH OPTION THE RESPONDENT HAS CHOSEN, AS FOLLOWS:

AWB_SUD=1 THEN SA_MODE_2=1 (SELF ADMINISTERED)

AWB_SUD=2 THEN SA_MODE_2=2 (INTERVIEWER LED)

PROGRAMMER NOTE: IF SELFAD_SUD=1 OR 2 PLAY THE AUDIO FILES STARTING ON INTRO_SUD SCREEN

PROGRAMMING NOTE: WHEN AWB_SUD=1 INSERT A TRANSITION PAGE THAT DISPLAYS:

SELFAD_SUD=1 Please click the next button once you have your headset on to continue the survey.

SELFAD_SUD=2 OR 3 Please click next to continue the survey

INTRO_SUD The next questions ask about alcohol and drugs. These are questions about different experiences some people may have if they use drugs or alcohol. We are asking these questions of everyone in the study. Remember that the information you provide will be kept private and your name will never appear in reports.

SUDAL – 1. Have you ever used alcohol – Any use at all?

1 Yes

2 No [skip SUBSTANCE USE - ALCOHOL Qs]

98 Don’t Know [skip SUBSTANCE USE - ALCOHOL Qs]

99 Prefer not to answer [Refused] [skip SUBSTANCE USE - ALCOHOL Qs]

SUDOTDA-A1. Have you ever used drugs other than those required for medical reasons?

"Drug use" refers to (1) the use of prescribed or over‐the‐counter drugs in excess of the directions, (2) any nonmedical use of drugs, and (3) using drugs commonly referred to as recreational or street drugs.

1 Yes

2 No [skip SUBSTANCE USE - DRUGS Qs]

98 Don’t Know [skip SUBSTANCE USE - DRUGS Qs]

99 Prefer not to answer [Refused] [skip SUBSTANCE USE - DRUGS Qs]

Readiness for recovery “ladder”

The next questions are about substance use and recovery. There are many unique challenges when it comes to substance use, and people take many paths during their recovery journey.

[For in-person or web administration the statements below will be shown alongside an image of a ladder, with the rungs corresponding to a statement].

SUDRR -1-ALC. I would like you to think of a ladder. Each rung of this ladder shows where various people are in thinking about changing their ALCOHOL use. Select the number that best matches where you are now. [Select one.]

1 I do not have a problem with drinking, and I do not intend to change the way I use alcohol.

2 I might have a problem with drinking, but I have no plans to change the way I use alcohol.

3 I am thinking about changing the way I use alcohol, but I have not made any definite plans.

4 I have decided to change the way I use alcohol and am ready to make some plans.

5 I have taken steps to change the way I use alcohol and will never go back to the way I used before.

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

SUDRR-2-DRU. Once again, I would like you to think of a ladder. Each rung of this ladder shows where various people are in thinking about changing their DRUG use. Select the number that best matches where you are now. [Select one.]

1 I do not have a problem with drugs, and I do not intend to change the way I use drugs.

2 I might have a problem with drugs, but I have no plans to change the way I use drugs.

3 I am thinking about changing the way I use drugs, but I have not made any definite plans.

4 I have decided to change the way I use drugs and am ready to make some plans.

5 I have taken steps to change the way I use drugs and will never go back to the way I used before.

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Substance use- type/ frequency [alcohol] [if SUDAL-1 = 1]

Now we have some additional questions about how you use alcohol.

SUDAL – 1.b. How many days in the past 30 days have you used alcohol – Any use at all? Please provide a number between 0 and 30. Your best estimate is fine.

# days ____ [ 0-30]

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[If SUDAL-1b=0] SUDAL – 1.b1. In the past 6 months, that is since [SIX MONTHS PRIOR TO INTERVIEW DATE] have you used alcohol, any use at all?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer

SUDAL – 1.c. How many years in your life have you used alcohol – Any use at all? Please provide a number between 0 and your age. Your best estimate is fine.

# years ____ [0 to AGE]

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

SUDAL – 2. Have you ever used alcohol – To Intoxication? That is, you have consumed enough alcohol that it affected your behavior or ability to think clearly.

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer

[if yes, SUDAL – 2 =1] SUDAL – 2.b. How many days in the past 30 days have you used alcohol – To Intoxication? Please provide a number between 0 and 30. Your best estimate is fine.

# days ____ [number 0-30]

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[if yes, SUDAL-2=1] SUDAL – 2.c. How many years in your life have you regularly used alcohol – To Intoxication? Please provide a number between 0 and your age. Your best estimate is fine.

# years ____ [0 to AGE]

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

SUDALRA – 1. Do you sometimes take a drink in the morning when you first get up?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

SUDALRA – 2. During the past 6 months, has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

SUDALRA – 3. During the past 6 months, have you had a feeling of guilt or remorse after drinking?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

SUDALRA – 4. During the past 6 months, have you failed to do what was normally expected of you because of drinking?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Substance use- other drugs [if SUDOTDA-A1=1]

In the next questions, we will ask you about drug use in the past 12 months, that is since [MONTH, YEAR ONE YEAR PRIOR TO INTERVIEW DATE]. As a reminder, "drug use" refers to (1) the use of prescribed or over‐the‐counter drugs in excess of the directions, (2) any nonmedical use of drugs, and (3) using drugs commonly referred to as recreational or street drugs.

Again, these questions ask about drug use. They do not ask about alcoholic beverages. Please answer No or Yes to every question. If you have difficulty with a statement, then choose the response that is mostly right.

SUDOTDA-1. In the past 12 months, have you used drugs other than those required for medical reasons?

1 Yes

2 No [skip to treatment Qs – SUDOT-1]

98 Don’t Know [skip to treatment Qs – SUDOT-1]

Prefer not to answer [Refused] [skip to treatment Qs – SUDOT-1]

[if yes, SUDOTDA-1=1]

SUDOTDA-2. In the past 12 months, have you used more than one drug at a time?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[if yes, SUDOTDA-1=1]

SUDOTDA – 3. In the past 12 months, have you been able to stop using drugs when you want to?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[if yes, SUDOTDA-1=1]

SUDOTDA– 4. In the past 12 months, have you had “blackouts” or “flashbacks” as a result of drug use?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[if yes, SUDOTDA-1=1]

SUDOTDA – 5. Have you ever in the past 12 months felt bad or guilty about your drug use?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[if yes, SUDOTDA-1=1]

SUDOTDA – 6. Have your friends or relatives ever in the past 12 months complained about your involvement with drugs?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[if yes, SUDOTDA-1=1]

SUDOTDA – 7. Have you ever in the past 12 months not spent time with your family or missed work because of drug use?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused]

[if yes, SUDOTDA-1=1]

SUDOTDA – 8. In the past 12 months, have you engaged in illegal activities in order to obtain drugs?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused]

[if yes, SUDOTDA-1=1]

SUDOTDA – 9. Have you ever in the past 12 months experienced withdrawal symptoms when you stopped taking drugs?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused]

[if yes, SUDOTDA-1=1]

SUDOTDA – 10. In the past 12 months, have you had medical problems as a result of your drug use such as memory loss, hepatitis, convulsions, bleeding, overdose, etc.?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused]

Substance use- type/ frequency [other drugs] [if ever used drugs SUDOTDA-A1=1]

The next questions ask if you have ever used certain substances that were not medically prescribed to you and how often. If you are not sure about the number of days or years, your best guess is fine. Remember, all of your answers will be kept private, and you can choose to skip any question you would like

	SUDOT – 1. Have you ever used…? 1 Yes 2 No 99 Prefer not to answer [Refused]	[if yes to ever used, ask after each substance before asking next substance] SUDOT – 2. How many days in the past 30 days have you used….? # days ____ [0 to 30] 98 Don’t Know 99 Prefer not to answer [Refused]	[if yes to ever used, ask after each substance before asking next substance] SUDOT – 3. How many years in your life have you regularly used....? If you have never regularly used [SUBSTANCE] enter zero. # years ____ [0 to 97] 98 Don’t Know 99 Prefer not to answer [Refused]
Cannabis such as Marijuana, Weed, Pot, Grass or Hash
Cocaine such as coke or crack
Heroin
Fentanyl
Hallucinogens such as LSD, Psilocybin or mushrooms, PCP, Ketamine or Special K, ecstasy or X, MDMA or Molly
Inhalants such as nitrous oxide, glue, gas or paint thinner
Methamphetamines such as crystal meth or ice
Methadone, outside of methadone maintenance treatment
Other opioids/opiates/ painkillers not as prescribed for you by a doctor
Stimulants such as speed, Ritalin, Concerta, Dexedrine, or Adderall
Sedatives, hypnotics, barbiturates (also called ‘downers’ or ‘sleeping pills’) or tranquilizers such as Valium, Serax, Ativan, Xanax, Librium, Rohypnol, GHB or Xylazine (also called ‘tranq’)
More than one substance per day (including alcohol)
Any other substance not already mentioned (specify) _________________

[If answered yes to ever used (SUDOT-1) for more than one above] SUDOT-4. What substance is the main issue? [select one] [display only substances said yes to ever used]

Cannabis such as Marijuana, Weed, Pot, Grass or Hash
Cocaine such as coke or crack
Heroin
Fentanyl
Hallucinogens such as LSD, Psilocybin or mushrooms, PCP, Special K, ecstasy or X, MDMA or Molly
Inhalants such as nitrous oxide, glue, gas or paint thinner
Methamphetamine such as crystal meth or ice
Methadone, outside of methadone maintenance treatment
Other opioids/opiates/painkillers not as prescribed for you by a doctor
Stimulants such as speed, Ritalin, Concerta, Dexedrine, or Adderall
Sedatives, hypnotics, barbiturates (also called ‘downers’ or ‘sleeping pills’), or tranquilizers such as Valium, Serax, Ativan, Xanax, Librium, Rohypnol, GHB, or Xylazine (also called ‘tranq’)
More than one substance per day including alcohol
Other (specify) [display other specify from SUDOT-1]

98 Don’t know

99 Prefer not to answer [Refused]

[If answered yes to ANY ever used (SUDOT-1) above]

SUDOT – 5. How long was your last period of voluntary abstinence from [display substance from SUDOT-4 IF ASKED, ELSE DISPLAY SINGLE SUBSTANCE FROM SUDOT-1], IF SUDOT-4 = 98 OR 99 INSERT “ANY DRUG”]?

______Years (0-60) _______ months (1-12)

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Ask all

SUDOT – 6. Are you currently taking opioid medications for pain such as fentanyl, oxycodone including OxyContin and Percocet, hydrocodone including Vicodin, methadone and buprenorphine that have been prescribed for you by a doctor or dentist?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

PROGRAMMING NOTE: IF SA_MODE_2=1 DISPLAY THE FOLLOWING TEXT AFTER SUDOT_6:

“Thank you for answering these questions. Please hand the tablet back to the Interviewer.”

Ask all

Substance use – treatment engagement

The next questions are about treatment you may or may not have received for substance use. These questions are being asked of everyone, regardless of how you answered previous questions about substance use.

SUDTR – 1. How many times in your life have you been treated for alcohol use? Please include both inpatient and outpatient treatment.

# times ___________ [0-97]

[Interviewer: If respondent says, “I don’t know”, please indicate that an estimate is fine. Please do your best to get an estimated number, if respondent truly doesn’t know can select “don’t know”]

98 Don’t Know

99 Prefer not to answer [Refused]

SUDTR – 2. How many times in your life have you been treated for other substance use? Please include both inpatient and outpatient treatment.

# times ___________ [0-97]

98 Don’t Know

99 Prefer not to answer [Refused]

SUDTR – 3. Which of the following categories best describes how you define yourself now with respect to treatment services for alcohol and/or other substance use? Would you say that… [Select one]

1 You have not had an assessment for treatment and are not currently in treatment.

2 You had an assessment for treatment with recommendations to attend treatment and are not currently in treatment.

3 You currently are in treatment for use of alcohol or other substances.

4 You have completed treatment and are currently in recovery.

98 Don’t Know

99 Prefer not to answer [Refused]

SUDTR – 4. Which of the following professionally assisted formal treatment services have you ever participated in? [Select all that apply]

1 Outpatient addiction treatment

2 Alcohol / drug detoxification services

3 Inpatient or residential treatment for alcohol and/or other substance use

97 None of the above [do not allow other items to be selected]

98 Don’t Know

99 Prefer not to answer [Refused]

SUDTR– 5. Which of the following recovery support services have you ever participated in? [Select all that apply]

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will be able to select multiple options.]

1 Mutual-help support groups such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Women for Sobriety, etc.

2 Sober living environment such as a halfway house, Oxford house, sober house, sober dorm

3 Recovery high schools or college recovery programs or communities [DULUTH COUNTY ONLY: such as Recovery Alliance]

4 Recovery community organization or center (RCO / RCC)

5 Faith-based recovery services such as an addiction recovery support group provided by a church, synagogue, mosque such as ‘Celebrate Recovery’

6 Online recovery communities such as Facebook groups, In The Rooms, etc.

7 Phone applications such as SoberGrid, CHESS, National All Recovery, etc.

8 Peer recovery support (such as one-on-one peer recovery coach/specialist/navigator/mentor)

9 Wellbriety

10 Other (please specify) _____________

97 None of the above

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Now I will ask you if you have been prescribed certain drugs by medical professionals during the past month.

SUDTR– 6. Have you been taking any of the following while in the care of a medical professional during the past 30 days? [Select all that apply.]

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will be able to select multiple options.]

1 Methadone

2 Buprenorphine including Subutex ® and Suboxone ®

3 Naltrexone including Vivitrol ®

4 Antabuse

6 Or something else (Please specify:__________)

97 None of the above

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

ECONOMIC CIRCUMSTANCES

People have different financial situations and circumstances. Some may experience challenges with making ends meet and receiving healthcare and some may not. The next questions ask about your experiences making ends meet and your access to healthcare.

Financial Strain

ECFS – 1. In general, how do your family's finances usually work out at the end of the month? Do you find that you usually end up with…?

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will only be able to select one option.]

Some money left over
Just enough money to make ends meet
Not enough money to make ends meet

98 Don’t know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Material hardship

[Food hardship]

ECMH – 1. In the past 12 months, did you receive free food or meals or vouchers to obtain food? This does not include nutritional cash assistance such as food stamps/SNAP or WIC.

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[Medical hardship]

ECMH – 2 . In the past 12 months, was there anyone in your household who needed to see a doctor or go to the hospital but couldn’t go because of the cost?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[Utility hardship]

ECMH – 3. In the past 12 months, were one or more of your utility services such as electric, water, gas or oil turned off?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

ECMH – 4. In the past 12 months, was service disconnected by the telephone, cell phone, or internet/cable company because payments were not made?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

[Bill-paying hardship]

ECMH – 5. In the past 12 months, did you not pay the full amount of rent or mortgage payments because there was not enough money?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

ECMH – 6. In the past 12 months, did you not pay the full amount of a gas, oil or electricity bill because there was not enough money?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Public Assistance

ECPA – 1. During the past year, did you or anyone in your household receive income or assistance from any of the following sources? [Check all that apply]

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will be able to select more than one option. Checked = 1, Not Checked = 2]

Disability benefits from SSA (SSI or SSDI)
TANF or [state specific TANF name]
Unemployment insurance (UI)
Worker’s compensation
Short-term disability
Food stamps/SNAP/[state specific program]
WIC
HCV/Section 8/public housing
Veterans benefits
Medicaid or CHIP or [state specific name]
None of the above

Don’t Know
Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Health insurance

ECHI – 1. What type of health insurance do you currently have?

INTERVIEWER NOTE: IF MORE THAN ONE ASK: What is the main type of health insurance you use?

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will only be able to select one option.]

Medicaid [specify local names]
Private health insurance, including from the Exchange or Marketplace (Affordable Care Act or Obamacare)
some other kind (Please specify) ___________
None/uninsured

98. Don’t Know

99. Prefer not to answer [Refused] [Display only for interviewer, not to be read aloud]

Usual health care provider

ECHCP – 1. Is there a place you usually go when you are sick and need health care?

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will only be able to select one option.]

Yes
There is no place

98 Don’t know

99 Prefer not to answer [refused]

ECHP – 2. [IF YES]: What kind of place(s)? [select all that apply]

A doctor’s office or health center
Urgent care or clinic in a drug store or grocery store
Hospital emergency room
A VA Medical Center or VA outpatient clinic
Some other place
Does not go to one place most often

98 Don’t know

Prefer not to answer [Refused]

PERSONAL HISTORY/CIRCUMSTANCES

PROGRAMMING NOTE: IF MODE=1 (IN PERSON), DISPLAY THE FOLLOWING TEXT PRIOR TO INTRO_PH:

<PH> BASE: MODE=IN PERSON

PH In the next series of questions, you have the option to complete these questions on your own or I can continue to read the questions to you. If you choose to complete the questions on your own, you can read them to yourself or turn on audio and have the questions read to you. Some people may find these questions difficult to talk about, which is why we are giving you this choice.

These questions ask about difficult experiences you may have had in your life and some people may find them sensitive.

Would you like to complete this section on your own or have me continue reading the questions to you?

1 ☐ ON MY OWN CONTINUE TO SELFAD_PH, SA_MODE_3=1

2 ☐ INTERVIEWER ADMINISTERED SKIP TO INTRO_PH, SA_MODE_3=2

<SELFAD_PH> BASE: PH=1

SELFAD_PH Would you like the questions to be read to you? If so, I can provide you with a headset for privacy.

1 ☐ YES, PROVIDE HEADSET AND PLAY AUDIO

2 ☐ YES, PLAY AUDIO BUT DO NOT PROVIDE HEADSET

3 ☐ NO, DO NOT PLAY AUDIO

INTERVIEWER NOTE: IF THE RESPONDENT WOULD LIKE AUDIO AND THE HEADPHONES PLUG IN THE HEADPHONES, HAND THE TABLET TO THE RESPONDENT AND INSTRUCT THEM TO CLICK NEXT TO COMPLETE THE SERIES OF QUESTIONS.

IF THE RESPONDENT DOES NOT WANT AUDIO OR DOES NOT WANT THE HEADPHONES, CLICK NEXT AND HAND THE TABLET TO THEM.

PROGRAMMER NOTE: CREATE A FLAG TO INDICATE WHICH OPTION THE RESPONDENT HAS CHOSEN, AS FOLLOWS:

PH=1 THEN SA_MODE_3=1 (SELF ADMINISTERED)

PH=2 THEN SA_MODE_3=2 (INTERVIEWER LED)

PROGRAMMER NOTE: IF SELFAD_PH=1 OR 2 PLAY THE AUDIO FILES STARTING ON THE INTRO_PH SCREEN

PROGRAMMING NOTE: WHEN PH=1 INSERT A TRANSITION PAGE THAT DISPLAYS:

SELFAD_PH=1 Please click next once you have your headset on to continue the survey.

SELFAD_PH=2 OR 3 Please click next to continue the survey

INTRO_PH Many people face unique circumstances throughout life. Some may have had personal experiences or circumstances that can be painful. The next set of questions ask about some personal experiences that may be sensitive. Remember that the information you share will be kept private and your name will never appear in reports.

Intimate Partner Violence

PHDV – 1. Within the last year, have you been hit, slapped, kicked or otherwise physically hurt by your partner?

1 Yes

2 No

98 Don’t know

99 Prefer not to answer [Refused]

PHDV-2. Within the last year, have you hit, slapped, kicked or otherwise physically hurt your partner?

1 Yes

2 No

98 Don’t know

99 Prefer not to answer [Refused]

Experience as a child in child welfare system

PHCW - 1. During your first 18 years of life, were you ever in foster care?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused]

Experience as a child with substance use in the home

PHSU- 1. During your first 18 years of life did you live with anyone who was a problem drinker or alcoholic?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused]

PHSU- 2. During your first 18 years of life did you live with anyone who used illegal street drugs or who misused prescription medications?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused]

Justice System Involvement

PHJS-1. During your first 18 years of life was your parent or guardian ever incarcerated?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused]

PHJS-2. There are different ways of being involved in the criminal justice system. Have you ever had any of the following types of justice system involvement as a minor or an adult?

[Note: These response options will be programmed and presented in check box format for survey administration.]

Have you ever been…	1= Yes	2 = No	[Display only for interviewer, not to be read aloud] 99 = Prefer not to answer [refused]
a. Arrested for a crime
b. Charged with a crime
c. Convicted of a crime
d. incarcerated (served time in a jail, prison, or correctional facility)
e. on parole or probation

PROGRAMMING NOTE: IF SA_MODE_3=1 DISPLAY THE FOLLOWING TEXT AFTER PHJS_2E:

“Thank you for answering this set of questions. Please hand the tablet back to the Interviewer. “

Discrimination

[Note: These following questions and their two follow-up questions will be programmed and presented in a matrix for survey administration.]

In the following questions, we are interested in the way other people have treated you. Can you tell me if any of the following has ever happened to you:

PHDS - 1. At any time in your life, have you ever been unfairly fired?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused]

[IF YES, ask the three follow-up questions below, PHDS-FU – 1 through PHDSFU -3, before proceeding]

PHDS - 2. For unfair reasons, have you ever not been hired for a job?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused]

[IF YES, ask the three follow-up questions below, PHDS-FU – 1 through PHDSFU -3, before proceeding]

PHDS - 3. Have you ever been unfairly stopped, searched, questioned, physically threatened or abused by the police?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused]

[IF YES, ask the three follow-up questions below, PHDS-FU – 1 through PHDSFU -3, before proceeding]

PHDS - 4. Have you ever been unfairly discouraged by a teacher or advisor from continuing your education?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused]

[IF YES, ask the three follow-up questions below, PHDS-FU – 1 through PHDSFU -3, before proceeding]

PHDS - 5. Have you ever been unfairly prevented from moving into a neighborhood because the landlord or a realtor refused to sell or rent you a house or apartment?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused]

[IF YES, ask the three follow-up questions below, PHDS-FU – 1 through PHDSFU -3, before proceeding]

PHDS - 6. Do you receive poorer service than other people at restaurants or stores?

1 Yes

2 No

98 Don’t Know

99 Prefer not to answer [Refused]

[IF YES, ask the three follow-up questions below, PHDS-FU – 1 through PHDSFU -3, before proceeding]

PHDS-FU-1. What do you think was the main reason for this experience? [Select one]

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will only be able to select one option.]

1 Your ancestry or National Origins

2 Your gender

3 Your race

4 Some other aspect of your physical appearance

5 Your sexual orientation

6 Your education

7 Your income level

8 Your mental health

9 Your justice system record

97 Other (please specify)_________

98 Don’t Know

99 Prefer not to answer [Refused]

PHDS-FU-2. When was the last time this happened? [Select one]

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will only be able to select one option.]

1 Past week

2 Past month

3 Past year

4 More than a year ago

98 Don’t Know

99 Prefer not to answer [Refused]

PHDS-FU-3. How many times has this happened in your lifetime?

# ____ [1-89]

97 Too many times to count [presented as check box]

98 Don’t Know

99 Prefer not to answer [Refused]

DEMOGRAPHIC & BACKGROUND INFORMATION

Before we finish the survey, we’d like to ask you about how you identify yourself, your household composition, and your education. We all have many identities that we walk through the world with that impact how we experience systems, institutions and life. We would like for you to share some information with us on a few of these.

Race and ethnicity

BKRE – 1. Are you Hispanic or Latino?

1 Yes, Hispanic or Latino

2 No, not Hispanic or Latino

99 Prefer not to answer [Refused]

BKRE -2. What is your race? Select all that apply.

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will be able to select many options.]

1 American Indian or Alaska Native

2 Asian

3 Black or African American

4 Native Hawaiian or Other Pacific Islander

5 White

99 Prefer not to answer [Refused]

Place of birth and language

BKL – 1. Do you speak a language other than English at home?

1 Yes

2 No

99 Prefer not to answer [Refused]

BKL – 2. Where were you born: [select one]

1 Inside the United States

2 Outside the United States (including US territories)

99 Prefer not to answer [Refused]

BKL – 3. [If born outside the US, BKL-2 = 2] When did you come to live in the United States?

Year: _________ YEAR OF BIRTH-CURRENT YEAR

9999 Prefer not to answer [Refused]

Sex and gender

BKSG - 1. What sex were you assigned at birth, on your original birth certificate? [select one]

1 Male

2 Female

99 Prefer not to answer [Refused]

BKSG – 2. What is your current gender? [Select all that apply]

1 Man

2 Woman

3 Two-Spirit [if respondent is American Indian or Alaska Native]

4 I use a different term _______

98 I don’t know

99 Prefer not to answer

BKSG – 3. Which of the following best represents how you think of yourself? [Select all that apply]

1 Straight, that is, not gay or lesbian

2 Gay or lesbian

3 Bisexual

4 Two-Spirit [if respondent is American Indian or Alaska Native]

5 I use a different term _________

98 I don’t know

99 Prefer not to answer

Education level

BKED - B.1 What is the highest degree or year of school that you have attained? [select one]

[Note: These response options will be programmed and presented in check box format for survey administration. The respondent will only be able to select one option.]

1 Less than a high school diploma

2 High school diploma or equivalent

3 Some college or technical training

4 Associate degree or other two-year degree

5 Bachelor degree or higher

99 Prefer not to answer [Refused]

Employment status

BKEM - C.1 Are you currently working for pay?

1 Yes

2 No

99 Prefer not to answer [Refused]

[If Yes to C.1] BKEM - C.2 Are you working 35 or more hours per week?

1 Yes

2 No

99 Prefer not to answer [Refused]

[If Yes to C.1] BKEM - C.3 How many jobs did you work last week?

# ________

99 Prefer not to answer [Refused]

BKEM - C.4 In total, how many months did you work for pay during the past year (including your current job)?

#___________ 0-12

99 Prefer not to answer [Refused]

BKEM - C.5 Are you currently looking for work?

1 Yes

2 No

99 Prefer not to answer [Refused]

CONTACT INFORMATION & IDENTIFIERS

Lastly, we’d like for you to share with us some contact information so that we know how to reach you for future surveys, and so we know where to send your gift card as a thank you for your participation in today’s survey/interview.

Main phone number [cell] ___________ [required]

Permission to text Y/N

Home phone number ___________

Work phone number ___________

*Email address ____________ [required]

*Address [required]

Street		Apartment #
City	State	Zip Code

Alternative address (e.g., PO Box, or for sending gift card)

Street		Apartment #
City	State	Zip Code

Preferred contact method

Phone
Email
Text
Mail

We would also like for you to share the last four digits of your social security number. This will be used to confirm your identity for the follow-up survey and to match your information in administrative records.

Last 4 digits of SSN: ______________

If no SSN, other government identifier:

Decline to share

Finally, we’d like for you to share up to three contacts who will know how to get in touch with you in case we can’t reach you. We would call these friends or relatives only if we cannot reach you. We would tell them that we are a researcher at Abt Associates, that you provided them as someone who would know how to get in touch with them and ask them if they have any updated contact information. We would not share that you are participating in the study, any details about the services you are receiving, or anything else about you.

Friend or family contact #1

Name

Relationship

Cell phone number

Home phone number

Work phone number

Email address

Mailing address

Friend or family contact #2

Name

Relationship

Cell phone number

Home phone number

Work phone number

Email address

Mailing address

Friend or family contact #3

Name

Relationship

Cell phone number

Home phone number

Work phone number

Email address

Mailing address

Close/Thank you

[The survey will close with a thank you to the participant that includes reminders about the gift card and the next time point we will reach out.]

Thank you for taking the time to complete the survey today. We value your time and your answers.

As I mentioned at the beginning of our chat, some of the topics we discussed today may have been difficult to talk about. If so, please reach out to a person who you trust so you can talk through anything that came up for you during our discussion today. I also have a list of resources that I can send you. Would you like me to share that with you now or would you like me to email that list to you?

[IN PERSON] Here is your $40 gift card for completing the survey and participating in the interview.

1 HAND RESPONDENT RESOURCE LIST

2 EMAIL RESPONDENT RESOURCE LIST

3 REFUSED RESOURCE LIST

[IF OVER THE PHONE] We will be sending the $40 gift card to the address you just provided. If for some reason you do not receive it within the next two weeks, please let me know, and I will look into it.

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Liz Yadav
File Modified	0000-00-00
File Created	2024-07-26

Baseline Parent Survey

Replication of Recovery and Reunification Interventions for Families-Impact Study (R3-Impact)

Instr.1_R3_Baseline_Survey_clean