BUILD Healthy Marriage Adult Program Entrance Survey

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Healthy Marriage Adult Program
	Entrance 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. DEMOGRAPHIC CHARACTERISTICS 
[ASK ALL]
A1. 	What is your sex? If you prefer not to answer, skip to question A2.
  1		Female
  2		Male
[ASK ALL]
A2. 	What is your current age? 
	|     |     |  YEARS OLD
[HARD CHECK: IF A2 < 18 OR A2 > 99 = Program participants must be 18 to 99 years old.
IF A2 = NON-NUMERIC = Please enter your current age in years.]
[SOFT CHECK: IF A2 = NO RESPONSE = This question is very important. Please enter your age.]
[ASK ALL]
A3a. 	What is your ethnicity?
 mark ONE ONLY
  1		Hispanic or Latino
  2		Not Hispanic or Latino
[ASK ALL]
A3b.	What is your race?
Mark all that apply
  1	□	American Indian or Alaska Native
  2	□	Asian
  3	□	Black or African American
  4	□	Native Hawaiian or other Pacific Islander
  5	□	White
  6	□	Other (specify) __________________
[ASK IF A2 < 21 OR NO RESPONSE]
[SKIP IF A2 >= 21]
A4.  	Which of the following describes your experience with foster care? 
MARK ONE ONLY
  1		I have never been in foster care
  2		I left foster care over 6 months ago
  3		I recently (in the past 6 months) left foster care
  4		I am currently in foster care
  5		Not sure


[ASK ALL]
A5. 	Have you ever served on active duty in the U.S. Armed Forces, Reserves, or National Guard?
  1		Yes
  0		No


B. PARENTING AND CO-PARENTING
[ASK ALL]
B1.  	How many children do you have who are newborn up to 24 years old? Do not include current pregnancies. 
	|     |     |  CHILDREN UP to 24 YEARS OLD
[SOFT CHECK: IF B1 = NO RESPONSE = This question is very important. Please provide an answer.]
[HARD CHECK: IF B1 < 0 = Number of children must be 0 or greater.
IF B1 = NON-NUMERIC = Please enter count of children as a number.]
[IF B1 = 0 OR NO RESPONSE, GO TO C1]
[ASK IF B1 > 0]
[SKIP IF B1 = 0 OR NO RESPONSE]
B2. 	How many live with you all or most of the time? 
	|     |     |  CHILDREN up to 24 years old
[HARD CHECK: IF B2 < 0 = Number of children must be 0 or greater.
IF B2 = NON-NUMERIC = Please enter count of children as a number.
IF B2 > B1 = Number of children must be [B1] or fewer.]
The next questions are about your youngest child. We only ask about your youngest child to reduce the number of questions on the survey. 
[ASK IF B1 > 0]
[SKIP IF B1 = 0 OR NO RESPONSE]
B3. 	What is your youngest child’s first name or initials?
	
[SOFT CHECK: IF B3 = NO RESPONSE = This question is very important. Please provide a response.]
[ASK IF B1> 0]
[SKIP IF B1 = 0 OR NO RESPONSE]
B4. 	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 B4 > 11 MONTHS = Please enter age in years for children over 11 months old.
HARD CHECK IF B4 > 24 YEARS = Your child’s age should be less than 25 years old.
HARD CHECK IF B4 = 0 OR NON-NUMERIC = Please enter the age of your child in months or years.
HARD CHECK IF B4 > 0 AND MONTHS / YEARS DROP-DOWN = NO RESPONSE = Please select months or years.]
[SOFT CHECK IF B4 = NO RESPONSE = Please enter the age of your child in months or years.]
[ASK IF B1 > 0]
[SKIP IF B1 = 0 OR NO RESPONSE]
B5. 	Does [YOUNGEST] live with you all or most of the time?
  1		Yes, he or she lives with me all or most of the time 	GO TO B7
  0		No, he or she does not live with me all or most of the time
[IF B5 = NO RESPONSE, GO TO B11]

[ASK IF B5 = 0]
[SKIP IF B5 = 1 OR NO RESPONSE] 
B6. 	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
[ASK IF B5 = 1 OR B6 = 1]
[SKIP IF (B5 = 0 OR NO RESPONSE) AND (B6 = 2, 3, 4, OR NO RESPONSE)]
B7. 	Please tell us how often you’ve felt or acted this way in the past month with [YOUNGEST].

MARK ONLY ONE PER ROW

Never
Hardly ever
Sometimes
Often
a.	I am happy being with [YOUNGEST]	
1  
2  
3  
4  
b.	[YOUNGEST] and I are very close to each other	
1  
2  
3  
4  
c.	I try to comfort [YOUNGEST] when he/she is upset	
1  
2  
3  
4  
d.	I spend time with [YOUNGEST] doing what he/she likes to do.	
1  
2  
3  
4  
[ASK IF (B5 = 1 OR B6 = 1) AND B4 > 12 YEARS] 
B8.	Below are some questions about the different types of things you do with your child. Please share how often you have engaged in the following activities during the last month (30 days). 

MARK ONLY ONE PER ROW

Never
1 to 2 days per month
3 to 4 days per month
2 or 3 days per week
Every day or almost every day
a.   How often have you attended religious services with [YOUNGEST]? 	
1  
2  
3  
4  
5  
b. How often have you done other religious activities with [YOUNGEST], such as praying together or reading religious stories?
1  
2  
3  
4  
5  


[ASK IF B5 = 1 OR B6 = 1]
[SKIP IF (B5 = 0 OR NO RESPONSE) AND (B6 = 2, 3, 4, OR NO RESPONSE)]
B9. 	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 B5 = 1 OR B6 = 1]
[SKIP IF (B5 = 0 OR NO RESPONSE) AND (B6 = 2, 3, 4, OR NO RESPONSE)]
B10.	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 (B1 > 0 AND (B5 = 1 OR NO RESPONSE)) OR (B5 = 0 AND (B6 = 1, 2, 3, OR NO RESPONSE))]
[SKIP IF (B1 = 0 OR NO RESPONSE) OR B6 = 4]
B11. 	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

C. ECONOMIC WELL BEING
[ASK ALL]
C1.  	In the past month, have you or anyone in your household received the following types of assistance?

MARK ONE RESPONSE PER ROW

YES
NO
a.	Temporary Assistance for Needy Families (TANF)	
1  
0  
b.	Supplemental Security Income (SSI)	
1  
0  
c.	Social Security Disability Insurance (SSDI)	
1  
0  
d.	Supplemental Nutrition Assistance Program (SNAP)/Food stamps	
1  
0  
e.	Women, Infants, and Children (WIC)	
1  
0  
f.	Unemployment insurance	
1  
0  
g.	Housing choice voucher (sometimes called Section 8)	
1  
0  
h.	Cash assistance	
1  
0  
i.	Child support	
1  
0  
[ASK ALL]
C2.  	What is your current living situation? 
MARK ONE ONLY
  1		Own your home or have a mortgage
  2		Rent or pay some amount toward rent
  3		Live rent free with a friend or relative
  4		Couch surf or move from home to home
  5		Live in a shelter, halfway house, or treatment center
  6		Live on the streets, in a car, abandoned building, or another place not meant for sleeping
  7		In prison, jail, or detention center
  8		Other
[ASK ALL]
C3.  	Are you currently in school, working toward your high school GED, or in college or other post-high school education? 
  1		Yes
  0		No	GO TO C5
[SOFT CHECK: IF C3 = NO RESPONSE = This question is very important. Please select an answer.]
[IF C3 = NO RESPONSE, ASK C4]

[ASK IF C3 = 1 OR NO RESPONSE]
[SKIP IF C3 = 0]  
C4. 	What is your current grade? 
MARK ONE ONLY
  1		Less than 9th grade
  2		9th grade
  3		10th grade
  4		11th grade
  5		12th grade
  6		Working toward a high school GED
  7		College
  8		Vocational/technical training or other post-high school education
[SOFT CHECK: IF C4 = NO RESPONSE = This question is very important. Please select an answer.]
[IF C4 = NO RESPONSE, ASK C5]
[ASK IF C3 = 0 OR {(C3 = 1 OR NO RESPONSE) AND (C4 = 6, 7, 8, OR NO RESPONSE)}]
[SKIP IF C4 = 1, 2, 3, 4, OR 5] 
C5.	What is the highest degree, diploma, or certification you have earned? 
MARK ONE ONLY
  1		No degree or diploma earned
  2		High school GED
  3		High school diploma
  4		Vocational/technical certification
  5		Some college, but no degree
  6		Associate’s degree
  7		Bachelor’s degree, Master’s degree or other advanced degree

[ASK ALL]
C6.	What is your current employment status? 

MARK ONE RESPONSE PER ROW

YES
NO
a.	Full-time employment (usually work 35 or more hours a week)	
1  
0  
b.	Part-time employment (usually work 1–34 hours a week)	
1  
0  
c.	Employed, but number of hours change from week to week	
1  
0  
d.	Temporary, occasional, or seasonal employment, or odd jobs for pay	
1  
0  
e.	Stay-at-home parent or homemaker	
1  
0  
f.	Not currently employed	
1  
0  
[SOFT CHECK: IF C6a = 1 = DISABLE C6f]
[IF ALL C6a-C6f = NO RESPONSE, ASK C7b]
[ASK IF ANY (C6a, C6b, C6c, OR C6d) = 1]
[SKIP IF ALL (C6a, C6b, C6c, AND C6d) = 0 OR NO RESPONSE]
C7a.  	Are you looking for a different job?
  1		Yes
  0		No
[ASK IF ALL (C6a, C6b, C6c, AND C6d) = 0 OR NO RESPONSE]
[SKIP IF ANY (C6a, C6b, C6c, OR C6d) = 1]
C7b.  	Are you looking for a job?
  1		Yes
  0		No
[ASK ALL]
C8.  	Some people experience challenges that make it hard to find or keep a good job. Do any of the following make it difficult for you to find or keep a job? 
Mark all that apply
  1	□	I have a criminal record
  2	□	I do not have reliable transportation
  3	□	I do not have the right clothes for a job (including uniforms)
  4	□	I do not have good enough child care or family help
  5	□	I do not have the right skills or education for good jobs
  6	□	I have a physical disability or poor health
  7		None of the above
[SOFT CHECK: IF C8 = 7 = DISABLE OTHER OPTIONS]

[ASK ALL]
C9. 	How often do you find it difficult to pay your bills?
MARK ONE ONLY
  1		Never
  2		Once in a while
  3		Somewhat often
  4		Very often
[ASK ALL]
C10. 	How much do you agree or disagree with each of the statements below? 

MARK ONLY ONE PER ROW

Strongly agree
Agree
Disagree
Strongly disagree
a.	I know how to apply for a job	
1  
2  
3  
4  
b.	I feel confident in my ability to search for a job I want	
1  
2  
3  
4  
c.	I feel confident in my interviewing skills	
1  
2  
3  
4  
[ASK IF ANY (C6a, C6b, C6c, OR C6d) = 1]
[SKIP IF ALL (C6a, C6b, C6c, AND C6d) = 0 OR NO RESPONSE]
C11. 	How confident are you in working out differences respectfully with your boss or coworkers?
MARK ONE ONLY
  1		Not at all
  2		Somewhat
  3		Very

D. HEALTHY MARRIAGE/RELATIONSHIPS
[ASK ALL]
D1. 	How much do you agree or disagree with the following statements:

MARK ONLY ONE PER ROW

Strongly agree
Agree
Disagree
Strongly disagree
a.	It is better for children if their parents are married	
1  
2  
3  
4  
b.	Living together is just the same as being married	
1  
2  
3  
4  
[ASK ALL] 
D2. 	What is your current marital status?
MARK ONE ONLY
  1		Married
  2		Engaged
  3		Separated
  4		Divorced
  5		Widowed
  6		Never married
[ASK IF D2 = 3, 4, 5, 6, OR NO RESPONSE]
[SKIP IF D2 = 1 OR 2] 
D3. 	What is your current partner status? 
MARK ONE ONLY
  1		No current partner (unpartnered or single)	GO TO D10
  2		I am romantically involved or in a committed relationship with someone on a steady basis
  3		I am involved in an on-again and off-again relationship
[IF D3 = NO RESPONSE, GO TO D10]
[ASK IF (D2 = 1 OR 2) OR (D3 = 2 OR 3)]
[SKIP IF (D2 = 3, 4, 5, 6, OR NO RESPONSE) AND (D3 = 1 OR NO RESPONSE)]
D4.  	How much of the time do you live with your current spouse or partner? 
MARK ONE ONLY
  1		All of the time
  2		Most of the time
  3		Some of the time
  4		None of the time

[ASK IF (D2 = 1 OR 2) OR (D3 = 2 OR 3)]
[SKIP IF (D2 = 3, 4, 5, 6, OR NO RESPONSE) AND (D3 = 1 OR NO RESPONSE)]
D5. 	This question is about your relationship with your partner/spouse. During the past month, how often did the following happen?

MARK ONLY ONE PER ROW

Never
Hardly ever
Sometimes
Often
a.	My partner/spouse and I were good at working out our differences	
1  
2  
3  
4  
b.	I felt respected even when my partner/spouse and I disagreed	
1  
2  
3  
4  
c.	When my partner/spouse and I had a serious disagreement, we worked on it together to find a resolution	
1  
2  
3  
4  
d.	When my partner/spouse and I had a serious disagreement, we discussed our disagreements respectfully	
1  
2  
3  
4  
e.	During arguments, my partner/spouse and I were good at taking breaks when we needed them	
1  
2  
3  
4  
[ASK IF (D2 = 1 OR 2) OR (D3 = 2 OR 3)]
[SKIP IF (D2 = 3, 4, 5, 6, OR NO RESPONSE) AND (D3 = 1 OR NO RESPONSE)]
D6. 	During the past month, how often has the following happened?

MARK ONLY ONE PER ROW

Never
Hardly ever
Sometimes
Often
a.	My partner/spouse was rude or mean to me when we disagreed	
1  
2  
3  
4  
b.	My partner/spouse seemed to view my words or actions more negatively than I meant them to be	
1  
2  
3  
4  
c.	Our arguments became very heated	
1  
2  
3  
4  
d.	Small issues suddenly became big arguments	
1  
2  
3  
4  
e.	My partner/spouse or I stayed mad at one another after an argument	
1  
2  
3  
4  

[ASK IF (D2 = 1 OR 2) OR (D3 = 2 OR 3)]
[SKIP IF (D2 = 3, 4, 5, 6, OR NO RESPONSE) AND (D3 = 1 OR NO RESPONSE)]
D7. 	How confident are you in working out differences respectfully with your spouse or partner?
MARK ONE ONLY
  1		Not at all
  2		Somewhat 
  3		Very
[ASK IF (D2 = 1 OR 2) OR (D3 = 2 OR 3)]
[SKIP IF (D2 = 3, 4, 5, 6, OR NO RESPONSE) AND (D3 = 1 OR NO RESPONSE)]
D8. 	How satisfied are you with your current relationship?
MARK ONE ONLY
  1		Very satisfied
  2		Somewhat satisfied
  3		Not at all satisfied
[ASK IF (D2 = 1 OR 2) OR (D3 = 2 OR 3)]
[SKIP IF (D2 = 3, 4, 5, 6, OR NO RESPONSE) AND (D3 = 1 OR NO RESPONSE)]
D9. 	How much do you agree or disagree with this statement? I view our marriage/relationship as lifelong. 
MARK ONE ONLY
  1		Strongly agree
  2		Agree
  3		Disagree
  4		Strongly disagree

[ASK ALL]
D10.	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


E. ABOUT THE PROGRAM
[ASK ALL]
E1.  	How or where did you hear about this program? 
Mark all that apply
  1	□	Newspaper ad, billboard, or a flyer
  2	□	Radio ad, TV commercial, or news story
  3	□	Internet ad or social media 
  4	□	Government agency, such as TANF, WIC, child support, child protective services, child welfare, or parole/probation office
  5	□	Community organization, such as a school, hospital, maternity clinic, doctor’s office, place of worship, Head Start, or Healthy Start center
  6	□	Program offered in prison or criminal legal facility
  7	□	Program staff in the community or at a community event, such as a street fair
  8	□	Word of mouth (friends, family, acquaintances)
  9	□	My school offered the program or class
10	□	Other 
[ASK ALL]
E2. 	What is the main reason you chose to enroll in this program? 
MARK ONE ONLY
  1		To learn about being a better parent
  2		To learn how to improve my personal relationships, such as with my partner or coparent
  3		To find a job or a better job
  4		To meet a school requirement
  5		My friends were coming
  6		My spouse/partner asked me to come
  7		My parole/probation officer told me to enroll in a program like this
  8		A court ordered me to enroll in a program like this
  9		None of the above