Examining Equity of the Administration for Children and Families' Healthy Marriage and Responsible Fatherhood (HMRF) Client Surveys

Instrument 2a. HM Youth Demographic Survey: English

OMB No.: 0970-0630

Expiration Date: 03/31/2027

Instrument 2a. Healthy Marriage Youth Participant Demographic Survey

2024

THE PAPERWORK REDUCTION ACT OF 1995

This collection of information is voluntary and will be used to provide the Administration for Children and Families with information to help refine and guide performance measure development in the area of healthy marriage and responsible fatherhood. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB number and expiration date for this collection are OMB #: 0970-0630, Exp: 03/31/2027. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to [insert study point of contact].

YOUTH SURVEY: Thank you for your interest in this research study. We want your feedback on surveys that you have recently taken or will soon take. These surveys are used by the Administration for Children and Families (ACF) and programs to improve healthy marriage and relationship education programs for youth.

This survey will take about 5 minutes and will ask you some questions about yourself. Taking part in this study is completely voluntary, which means you can choose to do this or choose not to and there are no consequences if you choose not to.

You do not have to answer any questions that you are not comfortable with. You can also stop at any time. The information from these questions will help us understand who participated in the study.

Your name and any identifiable information will not be reported on an individual level. Your answers to these questions will not be shared with your parents or guardians, teachers, or anyone outside of our research team.

1. What grade are you in? [If on summer break, which grade did you just finish?]

 5th 1

 6th 2

 7th 3

 8th 4

 9th 5

 10th 6

 11th 7

 12th 8

 Not enrolled in any school/home-schooled

2. How old are you?

3. Which of the following best describes how you currently identify yourself?

SELECT ALL THAT APPLY

□ Female 1

□ Male 2

□ Nonbinary 3

□ I use a different term (please describe) 4

 I prefer not to answer n

4. What is your race and/or ethnicity?

SELECT ALL THAT APPLY AND ENTER ADDITIONAL DETAILS IN THE SPACES BELOW.

1 o American Indian or Alaska Native –

Enter, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

2 o Asian – Provide details below

a o Chinese b o Asian Indian c o Filipino

d o Vietnamese e o Korean f o Japanese

Enter, for example, Pakistani, Hmong, Afghan, etc.

3 o Black or African American – Provide details below

a o African American b o Jamaican c o Haitian

d o Nigerian e o Ethiopian f o Somali

Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc.

4 o Hispanic or Latino – Provide details below

a o Mexican b o Puerto Rican c o Salvadoran

c o Cuban e o Dominican f o Guatemalan

Enter, for example, Colombian, Honduran, Spaniard, etc.

5 o Middle Eastern or North African – Provide details below

a o Lebanese b o Iranian c o Egyptian

d o Syrian e o Iraqi f o Israeli

Enter, for example, Moroccan, Yemeni, Kurdish, etc.

6 o Native Hawaiian or Pacific Islander – Provide details below

a o Native Hawaiian b o Samoan c o Chamorro

d o Tongan e o Fijian f o Marshallese

Enter, for example, Chuukese, Palauan, Tahitian, etc.

7 o White – Provide details below

a o English b o German c o Irish

c o Italian e o Polish f o Scottish

Enter, for example, French, Swedish, Norwegian, etc.

d  Don’t know

r  Refused

END. Thank you.

[Please click the SUBMIT button.]

This page has been left blank for double-sided copying.

OMB No.: 0970-0630

Expiration Date: 03/31/2027

Instrument 2b. Healthy Marriage and Responsible Fatherhood Adult Participant Demographic Survey

2024

THE PAPERWORK REDUCTION ACT OF 1995

This collection of information is voluntary and will be used to provide the Administration for Children and Families with information to help refine and guide performance measure development in the area of healthy marriage and responsible fatherhood. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB number and expiration date for this collection are OMB #: 0970-0630, Exp: 03/31/2027. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to [insert study point of contact].

ADULT SURVEY Thank you for your interest in this research study. We want your feedback on surveys that you have recently taken or will soon take as part of your [Healthy Marriage Relationship Education]/Responsible Fatherhood workshop. These surveys are used by the Administration for Children and Families (ACF) and programs to improve healthy marriage and relationship education and responsible fatherhood programs.

This survey will take about 5 minutes and will ask you some questions about yourself. Participation in the study and the following survey is voluntary and you do not have to answer any question you are not comfortable with. You can also stop at any time. The information from these questions will help us understand who participated in the study.

Your name and any identifiable information will not be reported on an individual level. Your answers to these questions will not be shared with anyone outside of our research team, including your workshop teacher.

All

1. How old are you?

2. Which of the following best describes how you currently identify yourself?

SELECT ALL THAT APPLY

□ Female/Woman 1

□ Male/Man 2

□ Nonbinary 3

□ I use a different term (please describe) 4

 I prefer not to answer n

3. What is your race and/or ethnicity?

Select all that apply and enter additional details in spaces below.

1 o American Indian or Alaska Native –

Enter, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

2 o Asian – Provide details below

a o Chinese b o Asian Indian c o Filipino

d o Vietnamese e o Korean f o Japanese

Enter, for example, Pakistani, Hmong, Afghan, etc.

3 o Black or African American – Provide details below

a o African American b o Jamaican c o Haitian

d o Nigerian e o Ethiopian f o Somali

Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc.

4 o Hispanic or Latino – Provide details below

a o Mexican b o Puerto Rican c o Salvadoran

c o Cuban e o Dominican f o Guatemalan

Enter, for example, Colombian, Honduran, Spaniard, etc.

5 o Middle Eastern or North African – Provide details below

a o Lebanese b o Iranian c o Egyptian

d o Syrian e o Iraqi f o Israeli

Enter, for example, Moroccan, Yemeni, Kurdish, etc.

6 o Native Hawaiian or Pacific Islander – Provide details below

a o Native Hawaiian b o Samoan c o Chamorro

d o Tongan e o Fijian f o Marshallese

Enter, for example, Chuukese, Palauan, Tahitian, etc.

7 o White – Provide details below

a o English b o German c o Irish

c o Italian e o Polish f o Scottish

Enter, for example, French, Swedish, Norwegian, etc.

d  Don’t know

r  Refused

All

4. What is your current marital status?

 Married 1

 Engaged 2

 Separated 3

 Divorced 4

 Widowed 5

 Never married 6

Q4 = 3,4,5,6

5. What is your current relationship status?

 No current partner (unpartnered) 1

 I am romantically involved or in a committed relationship with someone on a steady basis 2

 I am involved in an on-again and off-again relationship 3

Q4 = 1,2 OR Q5 = 2,3

6. How much of the time do you live with your current partner?

 All of the time 1

 Most of the time 2

 Some of the time 3

• None of the time 4

All

7. Do you have any children (include any biological, adopted, or step children)?

 Yes 1

 No 0

Q7 = 1

8. How many children do you have? Include any biological, adopted, or step children.

Q7 = 1

9. [Does your child/Do any of your children] live with you all or most of the time?

 Yes 1

 No 0

END. Thank you.

[Please click SUBMIT to complete this survey.]

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Mathematica
File Modified	0000-00-00
File Created	2025-02-17