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Self-Administered Survey
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Self-Administered Survey |
| Subject | survey questionnaire |
| Keywords | survey |
| Author | Mathematica |
| Last Modified By | Writer |
| File Modified | 2026-04-29 |
| File Created | 2026-08-22 |
| Conversion State | complete |
Extracted Text
Healthy Marriage Youth Program Exit Survey Thank you for participating in this program. Throughout the program we will ask you to provide information so that we can better support you, and to help monitor the program’s performance. We hope you will answer all the questions asked by program staff or in surveys, but you may skip any questions you do not want to answer. Your answers will be kept private as required by law. PRINCIPAL PURPOSE: The information you provide will be used primarily to (a) provide you with services, (b) monitor and help improve the performance of Healthy Marriage and Responsible Fatherhood (HMRF) programs, and (c) help understand HMRF services and participants across programs. ROUTINE USES: Your information will be kept private and cannot be used against you in any law enforcement action. Your information may be combined with information from other individuals but you will not be personally identifiable. However, there may be circumstances where disclosure of your personal information may be requested; in these cases, processes are in place to further protect your information for such requests. These requests may include: (a) by a congressional office if you ask that office to help obtain a copy of your records; (b) to coordinate and respond to a data security breach; (c) for research or evaluation purposes; (d) for administrative or legal actions; or (e) by contractors supporting the purpose and uses described here, but only on a must know basis in order to perform their duties. Please see the sources below for more information about these routine uses. DISCLOSURE: This request is voluntary. The relevant SORN is 09-80-0361, OPRE Research and Evaluation Project Records. AUTHORITY: 42 U.S.C. 613 - Research, evaluations, and national studies; 42 U.S.C. 628b - National random sample study of child welfare; 42 U.S.C. 1310 - Cooperative research or demonstration projects; 42 U.S.C. 9836 - Designation of Head Start agencies; 42 U.S.C. Subchapter II-B - Child Care and Development Block Grant; and Pub L. No. 110-161, Division G, Title II, Payments to States for the Child Care and Development Block Grant (121 STAT. 2179). a. BACKGROUND AND ATTITUDES ABOUT MARRIAGE AND RELATIONSHIPS [ASK ALL] A1. How much do you agree or disagree with this statement? I view marriage as lifelong. MARK ONE ONLY 1 Strongly agree 2 Agree 3 Disagree 4 Strongly disagree [ASK ALL] A2. When you think of your future, what do you think are the chances that… MARK ONLY ONE PER ROW Almost no chance Some chance but probably not A 50-50 chance A good chance Almost certain a. You will have a healthy marriage with one person for life? 1 2 3 4 5 b. You will live with a boyfriend/ girlfriend without being married? 1 2 3 4 5 c. You will have a child without being married? 1 2 3 4 5 [ASK ALL] A3. In the past month, about how often have you attended religious services? MARK ONE ONLY 1 I did not attend religious services in the past month 2 1 to 3 times in the past month 3 1 to 3 times a week 4 Every day or almost every day B. RELATIONSHIP SKILLS [ASK ALL] B1. How much do you agree or disagree with the following statements? MARK ONLY ONE PER ROW Strongly agree Agree Disagree Strongly disagree a. I believe I will be able to effectively deal with conflicts that arise in my relationship. 1 2 3 4 b. I feel good about my ability to make a romantic relationship last. 1 2 3 4 c. I am very confident when I think of having a healthy relationship. 1 2 3 4 d. I have the skills needed for a healthy romantic relationship. 1 2 3 4 e. I am able to recognize the warning signs of a bad relationship. 1 2 3 4 f. I know what to do when I recognize the warning signs of a bad relationship. 1 2 3 4 [ASK ALL] B2. How confident are you in your ability to do each of the following? MARK ONLY ONE PER ROW Not at all Somewhat Very a. Admit that you might be wrong during a disagreement 1 2 3 b. Avoid saying things that could turn a disagreement into a big fight 1 2 3 c. Accept another person’s point of view even if you don’t agree with it 1 2 3 d. Listen to another person’s opinion during a disagreement 1 2 3 e. Work through problems without arguing 1 2 3 C. PARENTING AND CO-PARENTING [ASK ALL] C1. Do you have any children of your own living with you? MARK ONE ONLY 1 No, I do not have any children GO TO D1 2 I have one or more children, who do not live with me 3 I live with at least one of my children [SOFT CHECK: IF C1 = NO RESPONSE = This question is very important. Please select an answer.] [IF C1 = NO RESPONSE, GO TO D1] [ASK IF C1 = 2 OR 3] [SKIP IF C1 = 1 OR NO RESPONSE] C2. What is your youngest child’s first name or initials? _____________________________________________________________________________ [SOFT CHECK: IF C2 = NO RESPONSE = This question is very important. Please provide a response.] [ASK IF C1 = 2 OR 3] [SKIP IF C1 = 1 OR NO RESPONSE] C3. How old is [YOUNGEST]? | | | YEARS OLD or | | | months old [SHOW OPEN-TEXT FIELD AND DROP-DOWN FOR CLIENT TO SELECT MONTHS OR YEARS] [HARD CHECK IF C3 > 11 MONTHS = Please enter age in years for children over 11 months old. HARD CHECK IF C3 > 19 YEARS = Your child’s age should be less than 20 years old. HARD CHECK IF C3 = 0 OR NON-NUMERIC = Please enter the age of your child in months or years. HARD CHECK IF C3 > 0 AND MONTHS / YEARS DROP-DOWN = NO RESPONSE = Please select months or years.] [SOFT CHECK IF C3 = NO RESPONSE = Please enter the age of your child in months or years.] [ASK IF C1 = 2] [SKIP IF C1 = 1, 3, OR NO RESPONSE] C4. When is the last time you saw [YOUNGEST]? MARK ONE ONLY 1 In the past month 2 In the past year 3 More than a year ago 4 Never [SOFT CHECK: IF C4 = NO RESPONSE = This question is very important. Please select an answer.] [IF C4 = NO RESPONSE, GO TO C5] [ASK IF C4 = 1 OR (C1 = 2 AND C4 = NO RESPONSE)] C5. In the past month, how often did you see or visit [YOUNGEST]? MARK ONE ONLY 1 Every day or almost every day 2 One to three times a week 3 One to three times in the past month 4 I did not see this child in the past month [ASK IF C1 = 3] [SKIP IF C1 = 1, 2, OR NO RESPONSE] C6. In the past month, how often have you felt overwhelmed by your parenting responsibilities? MARK ONE ONLY 1 Never 2 Hardly ever 3 Sometimes 4 Often 5 Always [ASK IF C1 = 3] [SKIP IF C1 = 1, 2, OR NO RESPONSE] C7. How much do you agree or disagree with the following statement? “I am confident in my parenting skills.” MARK ONE ONLY 1 Strongly agree 2 Agree 3 Disagree 4 Strongly disagree [ASK IF C1 = 3 OR (C1 = 2 AND C4 = 1, 2, 3, OR NO RESPONSE)] [SKIP IF (C1 = 1 OR NO RESPONSE) OR C4 = 4] C8. How much do you agree or disagree with the following statement? “[YOUNGEST]’s other parent and I work well together as parents.” MARK ONE ONLY 1 Strongly agree 2 Agree 3 Disagree 4 Strongly disagree D. PROGRAM PERCEPTIONS For the next set of questions, we would like you to think about communication skills. Examples of communication skills include paying attention, taking turns speaking, and describing problems using “I” statements (like “I feel…”) instead of “you” statements (like “you are…”). [ASK ALL] D1. During the program, how often did you learn about communication skills? MARK ONE ONLY 1 Never 2 Sometimes 3 Often [ASK IF D1 = 2, 3, OR NO RESPONSE] [SKIP IF D1 = 1] D2. How often have you used communication skills from the program with: MARK ONLY ONE PER ROW Never Sometimes Often Not applicable a. Your parents or guardians? 1 2 3 4 b. Your partner? 1 2 3 4 We’d like you to think back to before you started the program to answer the next questions. [ASK ALL] D3. Before the program, how confident were you in working out differences respectfully with: MARK ONLY ONE PER ROW Not at all Somewhat Very a. Your parents or guardians? 1 2 3 b. Your friends? 1 2 3 c. Your teachers or other school staff? 1 2 3 And now thinking about today: [ASK ALL] D4. How confident are you in working out differences respectfully with: MARK ONLY ONE PER ROW Not at all Somewhat Very a. Your parents or guardians? 1 2 3 b. Your friends? 1 2 3 c. Your teachers or other school staff? 1 2 3 [ASK ALL] D5. How much has your communication with your parents or guardians changed since you started the program? MARK ONE ONLY 1 Gotten worse 2 Stayed about the same 3 Gotten better [ASK ALL] D6. How much do you agree or disagree with the following statement about the program? Since attending the program, I better understand what makes a relationship healthy. MARK ONE ONLY 1 Strongly agree 2 Agree 3 Disagree 4 Strongly disagree [ASK ALL] D7. On a scale from 1 to 5, overall, how helpful was the program to you? Not at all Extremely helpful 1 2 3 4 5 Thank you for completing this survey!