Self-Administered Survey

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Healthy Marriage Youth 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 < 13 OR A2 > 24 = Program participants must be 13 to 24 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 IF A2 >= 17 OR NO RESPONSE]
[SKIP IF A2 < 17]
A5. 	Have you ever served on active duty in the U.S. Armed Forces, Reserves, or National Guard?
  1		Yes
  0		No

B. ECONOMIC WELL-BEING 
[ASK IF A2 >= 18 OR NO RESPONSE]
[SKIP IF A2 < 18]  
B1.  	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]
B2.  	What is your current living situation? 
MARK ONE ONLY
  		Live with parent(s) and do not pay rent  
  		Live with other relatives or friends and do not pay rent
  		Rent or pay some amount toward rent
  		Own your home or have a mortgage
  		Couch surf or move from home to home
  		Live in a shelter, halfway house, or treatment center
  		Live on the streets, in a car, abandoned building, or another place not meant for sleeping
  		In prison, jail, or detention center
  		Other

[ASK ALL]
B3.  	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 B5
[SOFT CHECK: IF B3 = NO RESPONSE = This question is very important. Please select an answer.]
[IF B3 = NO RESPONSE, ASK B4]
[ASK IF B3 = 1 OR NO RESPONSE]
[SKIP IF B3 = 0]  
B4. 	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 B4 = NO RESPONSE = This question is very important. Please select an answer.]
[IF NO RESPONSE, ASK B5]
[ASK IF B3 = 0 OR {(B3 = 1 OR NO RESPONSE) AND (B4 = 6, 7, 8, OR NO RESPONSE)}]
[SKIP IF B4 = 1, 2, 3, 4, OR 5] 
B5.  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 IF B3 = 0 OR {(B3 = 1 OR NO RESPONSE) AND (B4 = 6, 7, 8, OR NO RESPONSE)}]
[SKIP IF B4 = 1, 2, 3, 4, OR 5] 
B6.  	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 B6a = 1 = DISABLE B6f]
[IF ALL B6a-B6f = NO RESPONSE, ASK B7b]
[ASK IF ANY (B6a, B6b, B6c, OR B6d) = 1]
[SKIP IF {ALL (B6a, B6b, B6c, AND B6d) = 0 OR NO RESPONSE} OR (B4 = 1, 2, 3, 4, OR 5)]
B7a.  	Are you looking for a different job?
  1		Yes
  0		No
[ASK IF {ALL (B6a, B6b, B6c, AND B6d) = 0 OR NO RESPONSE}]
[SKIP IF ANY (B6a, B6b, B6c, OR B6d) = 1 OR (B4 = 1, 2, 3, 4, OR 5)] 
B7b.  	Are you looking for a job?
  1		Yes
  0		No
[ASK IF B3 = 0 OR {(B3 = 1 OR NO RESPONSE) AND (B4 = 6, 7, 8, OR NO RESPONSE)}]
[SKIP IF B4 = 1, 2, 3, 4, OR 5] 
B8.  	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 B8 = 7 = DISABLE OTHER OPTIONS]
C. BACKGROUND AND ATTITUDES ABOUT MARRIAGE AND RELATIONSHIPS 
[ASK ALL]
C1.	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]
C2. 	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]
C3.	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

D. RELATIONSHIP SKILLS
[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.	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]
D2. 	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  
[ASK ALL]
D3. 	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  

E. PARENTING AND CO-PARENTING
[ASK ALL]
E1. 	Do you have any children of your own living with you?
MARK ONE ONLY
  1		No, I do not have any children	GO TO F1
  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 E1 = NO RESPONSE = This question is very important. Please select an answer.]
[IF E1 = NO RESPONSE, GO TO F1]
[ASK IF E1 = 2 OR 3]
[SKIP IF E1 = 1 OR NO RESPONSE]
E2.	What is your youngest child’s first name or initials?
_____________________________________________________________________________
[SOFT CHECK: IF E2 = NO RESPONSE = This question is very important. Please provide a response.]
[ASK IF E1 = 2 OR 3]
[SKIP IF E1 = 1 OR NO RESPONSE]
E3. 	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 E3 > 11 MONTHS = Please enter age in years for children over 11 months old.
HARD CHECK IF E3 > 19 YEARS = Your child’s age should be less than 20 years old.
HARD CHECK IF E3 = 0 OR NON-NUMERIC = Please enter the age of your child in months or years.
HARD CHECK IF E3 > 0 AND MONTHS / YEARS DROP-DOWN = NO RESPONSE = Please select months or years.]
[SOFT CHECK IF E3 = NO RESPONSE = Please enter the age of your child in months or years.]
[ASK IF E1 = 2]
[SKIP IF E1 = 1, 3, OR NO RESPONSE] 
E4. 	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 E4 = NO RESPONSE = This question is very important. Please select an answer.]
[IF E4 = NO RESPONSE, GO TO E5]

[ASK IF E4 = 1 OR (E1 = 2 AND E4 = NO RESPONSE)]
E5. 	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 E1 = 3]
[SKIP IF E1 = 1, 2, OR NO RESPONSE]
E6. 	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 E1 = 3]
[SKIP IF E1 = 1, 2, OR NO RESPONSE]
E7.	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 E1 = 3 OR (E1 = 2 AND E4 = 1, 2, 3, OR NO RESPONSE)]
[SKIP IF (E1 = 1 OR NO RESPONSE) OR E4 = 4] 
E8. 	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
F. ABOUT THE PROGRAM
[ASK ALL]
F1.  	How or where did you hear about this program?
[DISPLAY OPTION 1 IF B3 = 1 OR NO RESPONSE]
[HIDE OPTION 1 IF B3 = 0]  
Mark all that apply
  	□	My school offered the program or class
  	□	Newspaper ad, billboard, or a flyer
  	□	Radio ad, TV commercial, or news story
  	□	Internet ad or social media 
  	□	Government agency, such as TANF, WIC, child support, child protective services, child welfare, or parole/probation office
  	□	Community organization, such as a school, hospital, maternity clinic, doctor’s office, place of worship, Head Start, or Healthy Start center
  	□	Program offered in prison or criminal legal facility
  	□	Program staff in the community or at a community event, such as a street fair
  	□	Word of mouth (friends, family, acquaintances)
	□	Other 
[ASK ALL]
F2. 	What is the main reason you chose to enroll in this program? 
[DISPLAY OPTION 1 IF B3 = 1 OR NO RESPONSE]
[HIDE OPTION 1 IF B3 = 0]    
MARK ONE ONLY
  		To meet a school requirement
  		My friends were coming
  		To learn how to improve my personal relationships, such as with my partner or co-parent
  		To learn about being a better parent
  		To find a job or a better job
  		My spouse/partner asked me to come
  		My parole/probation officer told me to enroll in a program like this
  		A court ordered me to enroll in a program like this
  		Other (specify) 	
[SOFT CHECK IF Other (specify) is selected but nothing is specified = This question is very important. Please provide an answer.]
Thank you for completing this survey!