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Community-Based Fathers Program Survey
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Community-Based Fathers Program Survey |
| Subject | survey questionnaire |
| Keywords | survey |
| Author | Mathematica |
| Last Modified By | Writer |
| File Modified | 2026-05-13 |
| File Created | 2026-08-22 |
| Conversion State | complete |
Extracted Text
Community Fathers 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 age 24? 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 B9
0 No, he or she does not live with me all or most of the time
[ASK IF B1 > 0 AND (B5 = 0 OR NO RESPONSE)]
[SKIP IF (B1 = 0 OR NO RESPONSE) OR B5 = 1]
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
[IF B6 = NO RESPONSE, GO TO B8]
[ASK IF B6 = 1]
[SKIP IF B6 = 2, 3, 4, OR NO RESPONSE]
B7. In the past month, how often did you see [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 B1 > 0 AND {(B5 = 0 OR NO RESPONSE) AND ((B6 = 2, 3, 4, OR NO RESPONSE) OR B7 = 4)}]
[SKIP IF (B1 = 0 OR NO RESPONSE) OR {B1 > 0 AND (B5 = 1 OR (B6 = 1 AND B7 = 1, 2, 3, OR NO RESPONSE))}]
B8. In the past month, how often have you reached out to [YOUNGEST] even if [YOUNGEST] did not respond? This includes calling on the phone; sending emails, letters, or cards; texting; or using social media.
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 Never in the past month
[ASK IF {B5 = 1 OR (B6 = 1 AND (B7 = 1, 2, 3, OR NO RESPONSE))} AND B4 > 12 YEARS]
B9a. 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 watched TV with [YOUNGEST]?
1
2
3
4
5
b. How often have you gone for a walk with [YOUNGEST]
1
2
3
4
5
c. How often have you had meals with [YOUNGEST]?
1
2
3
4
5
d. How often have you gone with [YOUNGEST] to a park?
1
2
3
4
5
e. How often have you played or assisted [YOUNGEST] with sports?
1
2
3
4
5
f. How often have you watched over or cared for [YOUNGEST] when other adults were not around?
1
2
3
4
5
g. How often have you played board games or chess with [YOUNGEST]?
1
2
3
4
5
h. How often have you hugged [YOUNGEST]?
1
2
3
4
5
i. How often have you encouraged [YOUNGEST]?
1
2
3
4
5
j. How often have you told [YOUNGEST] you loved him or her?
1
2
3
4
5
k. How often have you taught [YOUNGEST] to make good choices?
1
2
3
4
5
l. How often have you attended religious services with [YOUNGEST]?
1
2
3
4
5
m. How often have you done other religious activities with [YOUNGEST], such as praying together or reading religious stories?
1
2
2
4
5
[ASK IF {B5 = 1 OR (B6 = 1 AND (B7 = 1, 2, 3, OR NO RESPONSE))} AND B4 > 6 YEARS AND B4 <= 12 YEARS]
B9b. 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 played toys with [YOUNGEST]?
1
2
3
4
5
b. How often have you had meals with [YOUNGEST]?
1
2
3
4
5
c. How often have you hugged [YOUNGEST]?
1
2
3
4
5
d. How often have you watched over or cared for [YOUNGEST] when other adults were not around?
1
2
3
4
5
e. How often have you read with [YOUNGEST]?
1
2
3
4
5
f. How often have you taught [YOUNGEST] to take turns or to wait for rewards?
1
2
3
4
5
g. How often have you encouraged [YOUNGEST]?
1
2
3
4
5
h. How often have you told [YOUNGEST] you loved him or her?
1
2
3
4
5
i. How often have you talked with [YOUNGEST]?
1
2
3
4
5
[ASK IF {B5 = 1 OR (B6 = 1 AND (B7 = 1, 2, 3, OR NO RESPONSE))} AND B4 > 1 YEAR AND B4 <= 6 YEARS]
B9c. 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 played toys with [YOUNGEST]?
1
2
3
4
5
b. How often have you had meals with [YOUNGEST]?
1
2
3
4
5
c. How often have you hugged [YOUNGEST]?
1
2
3
4
5
d. How often have you watched over or cared for [YOUNGEST] when other adults were not around?
1
2
3
4
5
e. How often have you played rough-and-tumble or roughhoused with [YOUNGEST]?
1
2
3
4
5
f. How often have you read with [YOUNGEST]?
1
2
3
4
5
g. How often have you taught [YOUNGEST] to take turns or to wait for rewards?
1
2
3
4
5
h. How often have you encouraged [YOUNGEST]?
1
2
3
4
5
i. How often have you told [YOUNGEST] you loved him or her?
1
2
3
4
5
j. How often have you talked with [YOUNGEST]?
1
2
3
4
5
[ASK IF {B5 = 1 OR (B6 = 1 AND (B7 = 1, 2, 3, OR NO RESPONSE))} AND B4 <= 1 YEAR]
B9d. 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 fed or given a bottle to [YOUNGEST]?
1
2
3
4
5
b. How often have you praised [YOUNGEST]?
1
2
3
4
5
c. How often have you watched over or cared for [YOUNGEST] when other adults were not around?
1
2
3
4
5
d. How often have you put [YOUNGEST] to sleep?
1
2
3
4
5
e. How often have you played toys with [YOUNGEST]?
1
2
3
4
5
f. How often have you talked with [YOUNGEST]?
1
2
3
4
5
g. How often have you hugged [YOUNGEST]?
1
2
3
4
5
h. How often have you told [YOUNGEST] you loved him or her?
1
2
3
4
5
i. How often have you sung to [YOUNGEST]?
1
2
3
4
5
j. How often have you read with [YOUNGEST]?
1
2
3
4
5
k. How often have you told stories to [YOUNGEST]?
1
2
3
4
5
[ASK IF B1 > 0]
[SKIP IF B1 = 0 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]
[SKIP IF B1 = 0 OR NO RESPONSE]
B11. 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
Now we would like to ask some questions about the other parent or coparent of your youngest child.
[ASK IF B1 > 0]
[SKIP IF (B1 = 0 OR NO RESPONSE)]
B12. Have you seen or talked to the other parent or coparent of [YOUNGEST] in the past month?
1 Yes
0 No
[ASK IF B12 = 1]
[SKIP IF B12 = 0 OR NO RESPONSE]
B13. Thinking about [YOUNGEST], how much do you agree or disagree with each of the statements below?
MARK ONLY ONE PER ROW
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
a. The other parent or coparent of [YOUNGEST] contradicts the decisions I made about [YOUNGEST].
1
2
3
4
5
b. The other parent or coparent of [YOUNGEST] makes negative comments, jokes, or sarcastic comments about the way I parent.
1
2
3
4
5
c. The other parent or coparent of [YOUNGEST] undermines me as a parent.
1
2
3
4
5
d. The other parent or coparent and I discuss the best way to meet [YOUNGEST]’s needs.
1
2
3
4
5
e. The other parent or coparent of [YOUNGEST] and I share information about [YOUNGEST] with each other.
1
2
3
4
5
f. The other parent or coparent of [YOUNGEST] and I make joint decisions about [YOUNGEST].
1
2
3
4
5
g. The other parent or coparent of [YOUNGEST] and I try to understand where each other is coming from.
1
2
3
4
5
h. The other parent or coparent of [YOUNGEST] and I respect each other’s decisions made about [YOUNGEST].
1
2
3
4
5
i. The other parent or coparent of [YOUNGEST] makes it hard for me to spend time with [YOUNGEST].
1
2
3
4
5
j. The other parent or coparent of [YOUNGEST] makes it hard for me to talk with [YOUNGEST].
1
2
3
4
5
k. The other parent or coparent of [YOUNGEST] tells [YOUNGEST] what he or she is allowed and not allowed to say to me.
1
2
3
4
5
C. ECONOMIC STABILITY
[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 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]
C10. 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
[ASK ALL]
C11. 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 IF B1 > 0 AND (B1 > B2 OR B2 = NO RESPONSE)]
[SKIP IF (B1 = 0 OR NO RESPONSE) OR B1 = B2]
C12. Do you have a legal arrangement or child support order that requires you to provide financial support for ANY of your children who do not live with you all or most of the time?
1 Yes
0 No
2 I don’t know
D. MARRIAGE/RELATIONSHIPS
[ASK ALL]
D1. What is your current marital status?
MARK ONE ONLY
1 Married
2 Engaged
3 Separated
4 Divorced
5 Widowed
6 Never married
[ASK IF D1 = 3, 4, 5, 6, OR NO RESPONSE]
[SKIP IF D1 = 1 OR 2]
D2. What is your current partner status?
MARK ONE ONLY
1 No current partner (unpartnered or single) GO TO D6
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 D2 = NO RESPONSE, GO TO D6]
[ASK IF (D1 = 1 OR 2) OR (D2 = 2 OR 3)]
[SKIP IF (D1 = 3, 4, 5, 6, OR NO RESPONSE) AND (D2 = 1 OR NO RESPONSE)]
D3. 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 (D1 = 1 OR 2) OR (D2 = 2 OR 3)]
[SKIP IF (D1 = 3, 4, 5, 6, OR NO RESPONSE) AND (D2 = 1 OR NO RESPONSE)]
D4. How satisfied are you with your current relationship?
MARK ONE ONLY
1 Very satisfied
2 Satisfied
3 Not satisfied
[ASK IF (D1 = 1 OR 2) OR (D2 = 2 OR 3)]
[SKIP IF (D1 = 3, 4, 5, 6, OR NO RESPONSE) AND (D2 = 1 OR NO RESPONSE)]
D5. 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 ALL]
D6. 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
Thank you for completing this survey!