Parent Interview

Spring 2007

Child ID number:
Birth date:

Third Grade Follow-Up

Parent Interview
Cohort B

Date:_______________________		Interview complete: 
Interviewer: ________________________________		Interview for second child in household: 
		ID OF FIRST CHILD IN HOUSEHOLD

Westat

START TIME:___________AM/PM

SC. ELIGIBILITY

WILL THE INTERVIEW BE COMPLETED USING AN INTERPRETER?

YES 1

NO 2 (GO TO

INTRODUCTION BEFORE SC1)

NAME OF INTERPRETER: __________________________________________

WHAT LANGUAGE WILL BE USED? ___________________________________

CONFIRM INTERPRETER HAS SIGNED CONFIDENTIALITY FORM THEN CONTINUE.

Hello, my name is _____________________and I work for Westat, a national research organization that is conducting an exciting study called Building Futures: Head Start Impact Study – Third Grade Follow-up. This study is looking at how children learn and grow as they continue in school. You may remember us from a similar interview we conducted before.

SC1. We would like to interview the person most responsible for [CHILD]’s care. Are you that person?

yes 1 (GO TO SC4)

no 2

SC2. Who is most responsible for [CHILD]’s care?

Name:

Address:

City State Zip

Telephone:

SC3. Is that person available to talk with me now?

yes 1 (RESTART

INTERVIEW)

no 2 (RESCHEDULE
INTERVIEW WITH SC2 PERSON)

SC4. What is your birth date?

|___|___| |___|___| |___|___|

MONTH DAY YEAR

SC5. Please confirm how you are related to [CHILD]. Are you (his/her)...

Birth Mother 01 (GO TO SC8) Adoptive Mother 03 (GO TO SC8) Stepmother. 05 Grandmother. 07 Great Grandmother 09 Sister/stepsister 11 Other Relative or In-law (Female) 13 Foster Parent (Female) 15 Other Non-relative (Female) 17 Parent’s Partner (Female) 19

Birth Father. 02 (GO TO SC8) Adoptive Father. 04 (GO TO SC8) Stepfather 06 Grandfather 08 Great Grandfather 10 Brother/stepbrother 12 Other Relative or In-law (Male) 14 Foster Parent (Male). 16 Other Non-relative (Male) 18 Parent’s Partner (Male) 20

SC6. Are you [CHILD]’s legal guardian?

yes 1 (GO TO SC8)

no 2

SC7. Is now a convenient time to conduct the interview with you?

yes 1 (GO TO INTRODUCTION)

no 2

IF THIS IS NOT A CONVENIENT TIME, RESCHEDULE THE INTERVIEW WITH THIS RESPONDENT.

INTRODUCTION

During the interview, I will ask you questions and put your answers in the computer. You may stop me at any time, and you may go back to earlier questions to change your answers. There are no right or wrong answers to these questions. Only the researchers will see or hear your answers. All of the study results will be reported for groups of parents; no results will be reported for individuals. Your participation is completely voluntary. If you choose not to complete this interview, it will not affect you or your child’s participation in any services or programs. The things you tell me are very important, so please be as accurate as possible. Occasionally, I may have to ask a question that does not apply to you or your family. If that happens, just tell me and I will move to the next question. You may recognize some questions from past interviews, but it is important to ask them again. The interview should take approximately 1 hour. After the interview, you will receive $30.00. It is just one of the ways that we say thank you for your time. As part of this study, we will also do the child assessment with [CHILD] and ask [CHILD]’s teacher some questions.

Before we begin, let me read the following which is required by the Federal government:

NOTICE: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB Control Number. The valid OMB Control Number for this information collection is . The time required to complete this information collection is estimated to average 1 hour per response, including time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

Do you have any questions before we begin?

A. SCHOOL EXPERIENCE

Now I’d like to talk to you about [CHILD]’s school experiences.

A1. What is [CHILD]'s current grade in school? Is s/he in... (CIRCLE ONLY ONE)

First grade 01

Second grade 02

Third grade 03

Fourth grade 04

Attending school, ungraded 05

Other (SPECIFY)_______________________ 06

CHART A2.– CURRENT SCHOOL EXPERIENCE

a1. Which of the following best describes the school setting that [CHILD] is in? Public school 01 Catholic school 02 Private school, other religious affiliation 03 Private school, not religiously affiliated 04 Home school 05 Other (SPECIFY) 06 ________________________________		a2. What is the name, address, and telephone number of this school? ______________________________ School Name ______________________________ Address ______________________________ City State (_____)______________________ Telephone	a3. What is the name of [CHILD]’s teacher there? _________________________ For coders only: Teacher=1	a4. What month and year did [CHILD] begin going to [GRADE IN A1] at this school? |__|__| |__|__| Month Year
a5. Altogether, how many hours per week does [CHILD] typically attend this school? |__|__| Total # of hours per week

A3. Is this [CHILD]’s first year in (INSERT GRADE)?

YES 1

NO 2

A4. Has your child had a different teacher this year or the same teacher he/she had last year?

Different teacher 1

Same teacher 2

A5. Has your child received any special instruction or tutoring in school this year?

YES 1

NO 2

A6. Approximately how many days has [CHILD] been absent from class since the beginning of the school year, that is, since last September?

|_____|_____| DAYS ABSENT

IF A6=0, SKIP TO A8.

A7. What is the most frequent reason for [CHILD]’s missing days? (CIRCLE ONE)

ILLNESS OF CHILD 01

ILLNESS OF FAMILY MEMBER 02

CONFLICT WITH PARENT’S WORK OR SCHOOL SCHEDULE 03

LACK OF TRANSPORTATION 04

BAD WEATHER 05

CHILD DID NOT WANT TO GO 06

PARENT DECISION NOT TO SEND CHILD OR TO SEND

CHILD ELSEWHERE 07

OTHER (SPECIFY ___________________________________) 08

A8. Since the beginning of this school year, has [CHILD] been in the same school?

YES 1 (GO TO B1)

NO 2

DON’T KNOW 8 (GO TO B1)

A9. How many different schools has [CHILD] attended?

|_____|_____| NUMBER OF SCHOOLS

B. School communication and involvement

B1. For each statement that I read you, please tell me how well [CHILD]’s school has been doing the following things during the school year:

[IF NECESSARY, READ AFTER EACH STATEMENT: Would you say [CHILD]’s school does this very well, just OK, or doesn’t do it at all? (USE RESPONSE CARD)(CIRCLE ONE RESPONSE FOR EACH ITEM)]

	Does it very well	Just OK	Does not do it at all	Don’t know
a. Lets you know (between report cards) how [CHILD] is doing in school	1	2	3	8
b. Helps you understand what children at [CHILD]’s age are like	1	2	3	8
c. Makes you aware of chances to volunteer at the school	1	2	3	8
d. Provides workshops, materials, or advice about how to help [CHILD] learn at home	1	2	3	8
e. Provides information on community services to help [CHILD] or your family	1	2	3	8
f. Understands the needs of families who don’t speak English	1	2	3	8

B2. In general how often and in what way do you usually have contact with [CHILD]’s teacher about his/her daily activities or behavior? (USE RESPONSE CARD)(CIRCLE ONE RESPONSE FOR EACH ITEM)

	Daily	Weekly	Monthly	Less than Monthly	Never
a. Talk to the teacher in person	1	2	3	4	5
b. Teacher calls you	1	2	3	4	5
c. Receive written notes from teacher	1	2	3	4	5
d. Schedule meetings or conferences with teacher	1	2	3	4	5
e. Teacher conducts home visits	1	2	3	4	5
f. Teacher sends home examples of [CHILD]’s work	1	2	3	4	5

B3. When [CHILD]'s teacher sends home notes or newsletters, are these in a language that you speak?

YES 1

NO 2

B4. During this school year, about how many times have you gone to meetings or participated in activities at [CHILD]’s school?

|____|____| NUMBER OF TIMES

B5. This year, have the following reasons made it harder for you to participate in activities at [CHILD]'s school? How about…

	YES	NO
a. Inconvenient meeting times? Has that made it harder for you to participate in activities at [CHILD]'s school?	1	2
b. No child care keeps your family from going to school meetings or events? Has that made it harder for you to participate in activities at [CHILD]'s school?	1	2
c. Family members can't get time off from work? Has that made it harder for you to participate in activities at [CHILD]'s school?	1	2
d. Problems with safety going to the school? Has that made it harder for you to participate in activities at [CHILD]'s school?	1	2
e. Problems with transportation to the school? Has that made it harder for you to participate in activities at [CHILD]'s school?	1	2
f. Problems because you or members of your family speak a language other than English and meetings are conducted only in English? Has that made it harder for you to participate in activities at [CHILD]'s school?	1	2
g. You don't hear about things going on at school that you might want to be involved in? Has that made it harder for you to participate in activities at [CHILD]'s school?	1	2
h. The school does not make your family feel welcome? Has that made it harder for you to participate in activities at [CHILD]'s school?	1	2

B6. How far in school do you expect [CHILD] to go? Would you say you expect [him/her]…

To receive less than a high school

diploma 1

To graduate from high school 2

To attend two or more years of

college 3

To finish a four- or five-year college

degree 4

To earn a master's degree or

equivalent, or 5

To finish a Ph.D., M.D., or other advanced

degree 6

B7. Please indicate how strongly you agree or disagree with the following statements:

	Strongly Disagree	Disagree	Not Sure	Agree	Strongly Agree
a. Your child's school is a good place for your child to be	1	2	3	4	5
b. The staff at your child's school is doing good things for your child	1	2	3	4	5
c. You have confidence in the people at your child's school	1	2	3	4	5
d. Your child's school is doing a good job of preparing children for their futures	1	2	3	4	5
e. Your child's school is safe	1	2	3	4	5
f. Your child's school provides bad influences for (him/her)	1	2	3	4	5
g. Your child's school meets (his/her) academic needs	1	2	3	4	5
h. Your child's school meets (his/her) social and behavior needs	1	2	3	4	5
i. Doing well in school will improve [CHILD]'s chances of having a good life when (he/she) grows up	1	2	3	4	5
j. Getting good grades in school doesn't guarantee that [CHILD] will get a good job when (he/she) grows up	1	2	3	4	5
k. Even if [CHILD] is successful in school, it doesn't mean it will help (him/her) fulfill (his/her) dreams	1	2	3	4	5

B8. As far as you know, is [CHILD] going to be promoted to the next grade this coming fall, or will he/she spend another year in (kindergarten/first grade/second grade/other program)?

YES, WILL BE PROMOTED TO
NEXT GRADE 1

NO, WILL SPEND ANOTHER YEAR IN

SAME GRADE 2

NO, WILL GO INTO A TRANSITIONAL

CLASS 3

C. OTHER CHILD CARE

C1. You just told me about [CHILD]’s schooling. Now I want to ask about other kinds of care you use for [CHILD] between the hours of 8 a.m. and 6 p.m. Monday through Friday. During these hours, does [CHILD] regularly spend time in an extended day, before- or after-school program, or any other child care arrangement, including care by relatives or neighbors?

PROBE: ANYTIME BETWEEN THE HOURS OF 8 A.M. AND 6 P.M. MONDAY THROUGH FRIDAY?

yes 1 (COMPLETE

CHART C-2)

no 2 (PROBE RE: ANY

BEFORE- AND AFTER-SCHOOL CARE OR ANY REGULAR CHILD CARE; IF NONE, GO TO SECTION D)

CHART C2. – ADDITIONAL SETTINGS FOR CHILDREN

a1. Which of the following best describes the additional setting that [CHILD] is in between the hours of 8 AM – 6 PM Monday through Friday? If there is more than one setting, please start with the setting that is used most often. (CIRCLE ONE RESPONSE) A before- or after-school, or extended day program at [CHILD]’s school 1 A before- or after-school program in a place other than [CHILD]’s school. For example: a YMCA, Boys and Girls Club 2 A child care center 3 Someone else’s home 4 Own home 5 Other (SPECIFY) 6 ___________________________________	a2. What month and year did [CHILD] begin going to [NAME OF SETTING]? |__|__| |__|__| Month Year				a3. Altogether, how many hours per week does [CHILD] typically spend in this setting? ________________________ Total # of hours per week
a4. Which of the following factors did you consider in choosing this arrangement? (CHECK YES OR NO FOR EACH ITEM)				a5. Which of these factors was the most important? [ENTER ONE FROM A-H]		a6. Are there any additional settings? YES 1 (GO TO CONTINUED CHART C2 BELOW) NO 2 (GO TO SECTION D)
		YES	NO
a. safety		1	2
b. convenient location		1	2
c. transportation was available		1	2
d. convenient hours		1	2
e. type of program		1	2
f. what [CHILD] would learn and do while there		1	2
g. characteristics of other children in setting		1	2
h. child really wanted to attend		1	2

CHART C2. – ADDITIONAL SETTINGS FOR CHILDREN (CONTINUED)

b1. Which of the following best describes the additional setting that [CHILD] is in between the hours of 8 AM – 6 PM Monday through Friday? If there is more than one setting, please start with the setting that is used most often. (CIRCLE ONE RESPONSE) A before- or after-school, or extended day program at [CHILD]’s school 1 A before- or after-school program in a place other than [CHILD]’s school. For example: a YMCA, Boys and Girls Club 2 A child care center 3 Someone else’s home 4 Own home 5 Other (SPECIFY) 6 ___________________________________	b2. What month and year did [CHILD] begin going to [NAME OF SETTING]? |__|__| |__|__| Month Year				b3. Altogether, how many hours per week does [CHILD] typically spend in this setting? ________________________ Total # of hours per week
b4. Which of the following factors did you consider in choosing this arrangement? (CHECK YES OR NO FOR EACH ITEM)				b5. Which of these factors was the most important? [ENTER ONE FROM A-H]		b6. Are there any additional settings? YES 1 (GO TO CONTINUED CHART C2 BELOW) NO 2 (GO TO SECTION D)
		YES	NO
a. safety		1	2
b. convenient location		1	2
c. transportation was available		1	2
d. convenient hours		1	2
e. type of program		1	2
f. what [CHILD] would learn and do while there		1	2
g. characteristics of other children in setting		1	2
h. child really wanted to attend		1	2

CHART C2. – ADDITIONAL SETTINGS FOR CHILDREN (CONTINUED)

c1. Which of the following best describes the additional setting that [CHILD] is in between the hours of 8 AM – 6 PM Monday through Friday? If there is more than one setting, please start with the setting that is used most often. (CIRCLE ONE RESPONSE) A before- or after-school, or extended day program at [CHILD]’s school 1 A before- or after-school program in a place other than [CHILD]’s school. For example: a YMCA, Boys and Girls Club 2 A child care center 3 Someone else’s home 4 Own home 5 Other (SPECIFY) 6 ___________________________________	c2. What month and year did [CHILD] begin going to [NAME OF SETTING]? |__|__| |__|__| Month Year				c3. Altogether, how many hours per week does [CHILD] typically spend in this setting? ________________________ Total # of hours per week
c4. Which of the following factors did you consider in choosing this arrangement? (CHECK YES OR NO FOR EACH ITEM)				c5. Which of these factors was the most important? [ENTER ONE FROM A-H]		c6. Are there any additional settings? YES 1 (GO TO CONTINUED CHART C2 BELOW) NO 2 (GO TO SECTION D)
		YES	NO
a. safety		1	2
b. convenient location		1	2
c. transportation was available		1	2
d. convenient hours		1	2
e. type of program		1	2
f. what [CHILD] would learn and do while there		1	2
g. characteristics of other children in setting		1	2
h. child really wanted to attend		1	2

D. aCTIVITIES WITH YOUR CHILD

Now I have some questions about things you do with [CHILD] when he/she is at home.

D1. In this section, please tell me whether this happens at your house never or hardly ever, sometimes, or often.

	Never or hardly ever		Sometimes			Often
a. Does your child help plan family activities?	1		2			3
b. Does your child like to get involved in family activities?	1		2			3
c. Does your child go with members of the family to movies, sports events, or other outings?	1		2			3
d. Does your child go with members of the family to Church, Synagogue, or Sunday School? (If not applicable to your family, please circle 1)	1		2			3
e. Do you find time to listen to your child when he or she wants to talk to you?	1		2			3
f. Do you and your child do things together at home?	1		2			3
g. How often do you have a family chat with your child?	1		2			3
h. Does your child help you?	1		2			3
i. Does your child prefer to be with his or her friends rather than with the family?	1		2			3
j. Do you talk with your child about how he or she is doing in school?	1		2			3
	Less than 30 min	30 min to 1 hour		1 to 3 hours	3 to 5 hours		More than 5 hours
k. On the average, how much time each day are you together with your child on weekdays, that is, when you and your child are both awake?	1	2		3	4		5
l. And on weekends?	1	2		3	4		5
m. On weekdays, how much of that time are you doing something together, like making something, playing a game, or going out together?	1	2		3	4		5
n. And on weekends?	1	2		3	4		5
	Not really		Sometimes			Almost always
o. In general, are these activities enjoyable?	1		2			3

D2. In the past week, how often did [CHILD] read to (himself/herself) or to others outside of school? Would you say…

Never? 1

Once or twice a week? 2

Three to six times a week? 3

Every day? 4

D3. In the past month, that is, since [MONTH][DAY], has anyone in your family done the following things with [CHILD]?

	YES	NO
a. Gone to a play, concert, or other live show	1	2
b. Visited an art gallery, museum, or historical site	1	2
c. Visited a zoo, aquarium, or petting farm	1	2
d. Attended an athletic or sporting event in which [CHILD] was not a player?	1	2

D4. Outside of school hours in the past year, has [CHILD] participated in…

	YES	NO
a. Dance lessons?	1	2
b. Organized athletic activities, like basketball, soccer, baseball, or gymnastics?	1	2
c. Organized clubs or recreational programs like scouts?	1	2
d. Music lessons, for example, piano, instrumental music or singing lessons?	1	2
e. Art classes or lessons, for example, painting, drawing, sculpture?	1	2
f. Organized performing arts programs, such as children's choirs, dance programs, or theater performances?	1	2

D5. Now I have some questions about [CHILD]'s homework. How often does [CHILD] do homework either at home or somewhere else outside of school? Would you say…

Never, 1 (GO TO D7)

Less than once a week, 2

1 to 2 times a week, 3

3 to 4 times a week, or 4

5 or more times a week? 5

D6. Approximately how much time is set aside every day for [CHILD] to do homework?

|_____|_____|

MINUTES

D7. How often have you read books, magazines, or the newspaper, during the past week? Was it …. (CIRCLE ONE RESPONSE)

Not at all, 1

Once or twice, 2

Three or more times, or 3

Every day? 4

D8. Which of the following items does your family have in your home?

	YES	NO
a. A daily/weekly newspaper	1	2
b. Magazine	1	2
c. Dictionary or an encyclopedia	1	2

D9. About how many children's books does [CHILD] have in your home now, including library books? Please only include books that are for children.

|_____|_____|

BOOKS

D10. In the past month, that is, since [MONTH][DAY], has anyone in your family visited a library with [CHILD]?

YES 1

NO 2

D11. Does [CHILD] have (his/her) own library card?

YES 1

NO 2

D12. Do you have a computer that [CHILD] uses?

YES 1

NO 2 (GO TO SECTION E)

D13. In an average week, how often does [CHILD] use the computer? Would you say…

Never? 1

Once or twice a week? 2

Three to six times a week? 3

Every day? 4

D14. In an average week, how often does [CHILD] use the computer for educational purposes and homework, such as to improve reading or math skills? Would you say…

Never? 1

Once or twice a week? 2

Three to six times a week? 3

Every day? 4

E. DISABILITIES

Now I have a few questions about [CHILD]’s health and well-being.

E1. Do you have any serious concerns about [CHILD]’s development or behavior?

YES 1

NO 2

E2. Did a doctor or other professional ever tell you that [CHILD] has any special needs or disabilities—for example, physical difficulties, emotional, language, hearing, or learning difficulties, or other special needs?

YES 1

NO 2 (GO TO F4)

IF E1 AND E2 ARE NO, GO TO F1.

E3. How did the doctor or other health or education professional describe [CHILD]’s special needs? Does [CHILD] have…

	YES	NO
a. A specific learning disability	1	2
b. Mental retardation	1	2
c. A speech or language impairment	1	2
d. An emotional/behavioral disorder	1	2
e. Deafness or another hearing impairment	1	2
f. Blindness or another visual impairment	1	2
g. An orthopedic impairment	1	2
h. Asthma
i. Another health impairment lasting six months or more (SPECIFY)____________________________________	1	2
j. Autism	1	2
k. Traumatic brain injury	1	2
l. Non-categorical/Developmental delay?	1	2
m. Any other disability (SPECIFY) _____________________	1	2

E4. How helpful has your child's school been with…(READ EACH ITEM BELOW) Would you say not at all helpful, somewhat helpful, or very helpful?

	Not at all helpful	Somewhat helpful	Very helpful
a. Identifying [CHILD'S] special needs or disabilities	1	2	3
b. Suggesting you get a professional opinion	1	2	3
c. Finding resources to meet [CHILD'S] special needs	1	2	3
d. Helping you to provide for [CHILD'S] special needs at home (for example, special diets, recommended therapy)	1	2	3

E5. Does [CHILD] have an Individualized Education Program or Plan (IEP)?

yes 1

no 2

E6. Does [CHILD] currently have any physical or mental conditions that would limit or prevent (his/her) ability to…

	YES	NO
a. do usual childhood activities such as play or participate in games or sports?	1	2
b. attend school regularly?	1	2
c. do regular schoolwork?	1	2

F. YOUR CHILD’S BEHAVIOR

F1. In general, thinking about [CHILD] now or over the past month, tell me how well the following statements describe [CHILD]’s usual behavior. For each one, tell me if it is very true, sometimes true, or not true.

	Very True	Sometimes True	Not True
a. Makes friends easily?	1	2	3
b. Enjoys learning?	1	2	3
c. Has temper tantrums or hot temper?	1	2	3
d. Can’t concentrate or pay attention for long?	1	2	3
e. Is very restless, and fidgets a lot?	1	2	3
f. Likes to try new things?	1	2	3
g. Shows imagination in work and play?	1	2	3
h. Is unhappy, sad, or depressed?	1	2	3
i. Comforts or helps others?	1	2	3
j. Hits and fights with others?	1	2	3
k. Worries about things for a long time?	1	2	3
l. Accepts friends’ ideas in sharing and playing?	1	2	3
m. Doesn’t get along with other kids?	1	2	3
n. Wants to hear that he or she is doing okay?	1	2	3
o. Feels worthless or inferior?	1	2	3
p. Has difficulty making changes from one activity to another?	1	2	3
q. Is nervous, high-strung, or tense?	1	2	3
r. Acts too young for (his/her) age?	1	2	3
s. Is disobedient at home?	1	2	3

G. household rules and parenting practices

Now I’d like to ask you a few questions about how you deal with your child at home.

G0. Here are some statements that parents of young children say about themselves. I’m going to read the statements, and after each one, please tell me if it is exactly like you, very much like you, somewhat like you, not much like you, or not at all like you. (USE RESPONSE CARD)

	Exactly like you	Very much like you	Some-what like you	Not much like you	Not at all like you
a. There are times I just don't have the energy to make my child behave as (he/she) should	1	2	3	4	5
b. My child and I have warm intimate moments together	1	2	3	4	5
c. I teach my child that misbehavior or breaking the rules will always be punished one way or another	1	2	3	4	5
d. I encourage my child to be curious, to explore, and to question things	1	2	3	4	5
e. I do not allow my child to get angry with me	1	2	3	4	5
f. I am easygoing and relaxed with my child	1	2	3	4	5
g. I believe that a child should be seen and not heard	1	2	3	4	5
h. I make sure my child knows that I appreciate what (he/she) tries to accomplish	1	2	3	4	5
i. I have little or no difficulty sticking with my rules for my child even when close relatives (including grandparents) are there	1	2	3	4	5
j. I encourage my child to be independent of me	1	2	3	4	5
k. Once I decide how to deal with a misbehavior of my child, I follow through on it	1	2	3	4	5
l. I believe physical punishment to be the best way of disciplining	1	2	3	4	5
m. I control my child by warning (him/her) about the bad things that can happen to (him/her)	1	2	3	4	5

G1. Please answer yes or no to the following items. In your house, are there rules or routines about…

	YES	NO
a. What TV programs [CHILD] can watch?	1	2
b. How many hours [CHILD] can watch TV?	1	2
c. What kinds of food [CHILD] eats?	1	2
d. What time [CHILD] goes to bed?	1	2
e. What chores [CHILD] does?	1	2

G2. About how many hours does [CHILD] usually watch TV in your home each day?

|____|____| HOURS

G3. Sometimes children mind pretty well and sometimes they don’t. Have you spanked [CHILD] in the past month for not minding?

yes 1

no 2 (GO TO H5)

G4. About how many times in the past week?

|____|____| NUMBER OF TIMES

G5. Now I'm going to read some statements. Please tell me whether you strongly agree, agree, are not sure, disagree, or strongly disagree.

	Strongly agree	Agree	Not sure	Disagree	Strongly disagree
a. I often have the feeling that I cannot handle things very well	1	2	3	4	5
b. I find myself giving up more of my life to meet my children's needs than I ever expected	1	2	3	4	5
c. I feel trapped by my responsibilities as a parent	1	2	3	4	5
d. Since having this child, I have been unable to do new and different things	1	2	3	4	5
e. Since having a child, I feel that I am almost never able to do things that I like to do	1	2	3	4	5
f. I am unhappy with the last purchase of clothing I made for myself	1	2	3	4	5
g. There are quite a few things that bother me about my life	1	2	3	4	5
h. Having a child has caused more problems than I expected in my relationship with my spouse (or male/female friend)	1	2	3	4	5
i. I feel alone and without friends	1	2	3	4	5
j. When I go to a party, I usually expect not to enjoy myself	1	2	3	4	5
k. I am not as interested in people as I used to be	1	2	3	4	5
l. I don't enjoy things as I used to	1	2	3	4	5
m. My child rarely does things for me that make me feel good	1	2	3	4	5
n. Sometimes I feel my child doesn't like me and doesn't want to be close to me	1	2	3	4	5
o. My child smiles at me much less than I expected	1	2	3	4	5
p. When I do things for my child, I get the feeling that my efforts are not appreciated very much	1	2	3	4	5
q. When playing, my child doesn't often giggle or laugh	1	2	3	4	5
r. My child doesn't seem to learn as quickly as most children	1	2	3	4	5
s. My child doesn't seem to smile as much as most children	1	2	3	4	5
t. My child is not able to do as much as I expected	1	2	3	4	5
u. It takes a long time and it is very hard for my child to get used to new things	1	2	3	4	5
v. For the next statement, choose your response from the choices 1 to 5 below: I feel that I am: 1. not very good at being a parent 2. a person who has some trouble being a parent 3. an average parent 4. a better than average parent 5. a very good parent	1	2	3	4	5
w. I expected to have closer and warmer feelings for my child than I do and this bothers me	1	2	3	4	5
x. Sometimes my child does things that bother me just to be mean	1	2	3	4	5

G6. Does your child have a set time to be home on school nights?

No 1 (GO TO G8)

S ometimes 2 (GO TO G7)

Always 3

G7. If sometimes or always, what is the time your child has to be home?

______________ AM

TIME PM

G8. Does your child have a set time to be home on weekend nights during the school year?

N o 1 (GO TO G11)

Sometimes 2 (GO TO G9)

Always 3

G9. What is the time your child has to be home?

______________ AM

TIME PM

G10. If your child did not come home by the set time, would you know?

No 1

Probably 2

Certainly 3

G11. If you (or another adult) are not home when your child leaves the house, does your child leave you a note or call you to let you know where he or she is going?

Almost Never 1

Sometimes 2

Almost Always 3

G12. Do you know who your child's companions are when he or she is not at home?

Almost Never 1

Sometimes 2

Almost Always 3

G13. When you are not at home, does your child know how to get in touch with you?

Almost Never 1

Sometimes 2

Almost Always 3

G14. Is it important to you to know what your child is doing when he or she is not at home?

No, not important 1

Yes, somewhat important 2

Yes, very important. 3

G15. Sometimes children spend time caring for themselves, either at home or somewhere else, without an adult or older child responsible for them. Does [CHILD] spend time caring for (himself/herself) on a regular basis before or after school?

yes 1 (GO TO G16)

no 2 (GO TO H1)

G16. How many hours per week does [CHILD] take of (himself/herself)?

|____|____| HOURS

H. YOU AND YOUR FAMILY

RESPONDENT IS: (CIRCLE ONE)
[CHILD]’s BIRTH/ADOPTIVE MOTHER	1 (ASK QUESTIONS ABOUT RESPONDENT, GO TO H7.)
not [CHILD]’s BIRTH/ADOPTIVE MOTHER	2 (ASK QUESTIONS ABOUT BIRTH MOTHER, GO TO H1.)

Now I’m going to ask you some questions about (you/[CHILD]’s mother).

H1. Is [child]’s mother in this household?

MOTHER IN HOUSEHOLD 1 (GO TO H7)

MOTHER NOT IN HOUSEHOLD 2

MOTHER DECEASED 3 (GO TO BOX BEFORE H14)

H2. Does [child]’s mother live in the same city or county as [child]?

YES 1

NO 2

H3. In the past month, on about how many days has [CHILD] seen (his/her) mother?

|__|__|__| DAYS

H4. How long has it been since [CHILD] last had contact with (his/her) mother?

NEVER HAD CONTACT 000

DON’T KNOW 998

OR

a. NUMBER:		b. UNIT:
		DAYS 1
|__|__|__|		WEEKS 2
		MONTHS 3
		YEARS 4

H5. Since September, has your family received any child support payments for [child] from (his/her) mother?

YES 1

NO 2

H6. Since September, has your family received any other financial support for [CHILD] from (his/her) mother?

YES 1

NO 2

H7. What was the first language (you/she) learned to speak?

ENGLISH 1

SPANISH 2

ENGLISH AND SPANISH EQUALLY 3

ENGLISH AND ANOTHER
LANGUAGE EQUALLY 4

ANOTHER LANGUAGE 5

(SPECIFY) ____________________

H8. What is (your/her) current marital status?

MARRIED 1

SEPARATED 2

DIVORCED 3

WIDOWED 4

NEVER MARRIED 5

H9. Since the beginning of this school year, have/has (you/[CHILD]’S mother)...

	YES	NO	DON’T KNOW
a. Attended a general school meeting, for example, an open house, a back-to-school night or a meeting of a parent-teacher organization?	1	2	8
b. Gone to a regularly-scheduled parent-teacher conference with [CHILD]’s teacher?	1	2	8
c. Attended a school or class event, such as a play or sports event for [CHILD]?	1	2	8
d. Acted as a volunteer at the school or served on a committee?	1	2	8

IF CHILD’S MOTHER IS NOT IN
HOUSEHOLD (H1=2),

CHECK THIS BOX .… AND

GO TO BOX BEFORE H14.

H10. Since September, (have you/has she) attended or enrolled in any courses from a school, college or university?

YES 1

NO 2

H11. What is the highest grade or year of school that (you/she) completed? (Circle one response) (PROBE: IF COMPLETED 12TH GRADE, Did you earn a diploma?)

UP TO 8TH GRADE 01

9TH TO 11TH GRADE 02

12TH GRADE BUT NO DIPLOMA 03

HIGH SCHOOL DIPLOMA 04

GED 05

VOC/TECH PROGRAM AFTER HIGH SCHOOL BUT NO

VOC/TECH DIPLOMA 06

VOC/TECH DIPLOMA AFTER HIGH SCHOOL 07

SOME COLLEGE BUT NO DEGREE 08

ASSOCIATE’S DEGREE 09

BACHELOR’S DEGREE 10

GRADUATE OR PROFESSIONAL SCHOOL BUT NO DEGREE 11

MASTER’S DEGREE (MA, MS) 12

DOCTORATE DEGREE (PhD, EdD) 13

PROFESSIONAL DEGREE AFTER BACHELOR’S DEGREE

(MEDICINE/MD; DENTISTRY/DDS; LAW/JD/LLB; ETC.) 14

H12. (Are you/Is she) currently working full-time, working part-time, looking for work, in school, in a training program, keeping house, or doing something else? (circle ONLY one)

WORKING FULL-TIME (35 HOURS OR MORE PER WEEK) 01 WORKING PART-TIME 02 LOOKING FOR WORK 03 LAID OFF FROM WORK 04 IN SCHOOL/TRAINING 05 IN JAIL/PRISON 06 IN MILITARY 07 KEEPING HOUSE 08 SOMETHING ELSE (SPECIFY) _______________________ 09

GO TO BOX BEFORE H14

H13. (Are you/Is she) still working for the same employer for whom (you were/she was) working 12 months ago?

YES 1

NO 2

RESPONDENT IS: (CIRCLE ONE)
[CHILD]’s BIRTH/ADOPTIVE FATHER	1 (ASK QUESTIONS ABOUT RESPONDENT, GO TO H20.)
not [CHILD]’s BIRTH/ADOPTIVE FATHER……………………………………….	2 (ASK QUESTIONS ABOUT BIRTH FATHER, GO TO H14.)

H14. Is [child]’s father in this household?

FATHER IN HOUSEHOLD 1 (GO TO H20)

FATHER NOT IN HOUSEHOLD 2

FATHER DECEASED 3 (GO TO BOX
BEFORE H27)

H15. Does [CHILD]’s father live in the same city or county as [CHILD]?

YES 1

NO 2

H16. In the past month, on about how many days has [child] seen (his/her) father?

|__|__|__| DAYS

H17. How long has it been since [CHILD] last had contact with (his/her) father?

[CHILD] NEVER HAD CONTACT 000

DON’T KNOW 998

OR

a. NUMBER:		b. UNIT:
		DAYS 1
|__|__|__|		WEEKS 2
		MONTHS 3
		YEARS 4

H18. Since September, has your family received any child support payments for [child] from (his/her) father?

YES 1

NO 2

H19. Since September, has your family received any other financial support for [CHILD] from (his/her) father?

YES 1

NO 2

H20. What was the first language you/he learned to speak?

ENGLISH 1

SPANISH 2

ENGLISH AND SPANISH EQUALLY 3

ENGLISH AND ANOTHER
LANGUAGE EQUALLY 4

ANOTHER LANGUAGE 5

(SPECIFY) ____________________

H21. What is (your/his) current marital status?

MARRIED 1

SEPARATED 2

DIVORCED 3

WIDOWED 4

NEVER MARRIED 5

REFUSED 7

DON’T KNOW 8

H22. Since the beginning of this school year, (have you/has [CHILD]’s father)...

	YES	NO	DON’T KNOW
a. Attended a general school meeting, for example, an open house, a back-to-school night or a meeting of a parent-teacher organization?	1	2	8
b. Gone to a regularly-scheduled parent-teacher conference with [CHILD]’s teacher?	1	2	8
c. Attended a school or class event, such as a play or sports event for [CHILD]?	1	2	8
d. Acted as a volunteer at the school or served on a committee?	1	2	8

IF CHILD’S FATHER IS NOT IN
HOUSEHOLD (H14=2),
CHECK THIS BOX … AND

GO TO BOX BEFORE H27.

H23. Since September, (have you/has he) attended or enrolled in any courses from a school, college or university?

YES 1

NO 2

H24. What is the highest grade or year of school that (you/he) completed? (Circle one response) (PROBE: IF COMPLETED 12TH GRADE, Did you earn a diploma?)

UP TO 8TH GRADE 01

9TH TO 11TH GRADE 02

12TH GRADE BUT NO DIPLOMA 03

HIGH SCHOOL DIPLOMA 04

GED 05

VOC/TECH PROGRAM AFTER HIGH SCHOOL BUT NO

VOC/TECH DIPLOMA 06

VOC/TECH DIPLOMA AFTER HIGH SCHOOL 07

SOME COLLEGE BUT NO DEGREE 08

ASSOCIATE’S DEGREE 09

BACHELOR’S DEGREE 10

GRADUATE OR PROFESSIONAL SCHOOL BUT NO DEGREE 11

MASTER’S DEGREE (MA, MS) 12

DOCTORATE DEGREE (PhD, EdD) 13

PROFESSIONAL DEGREE AFTER BACHELOR’S DEGREE

(MEDICINE/MD; DENTISTRY/DDS; LAW/JD/LLB; ETC.) 14

H25. (Are you/Is he) currently working full-time, working part-time, looking for work, in school, in a training program, keeping house, or doing something else? (circle ONLY ONE)

WORKING FULL-TIME (35 HOURS OR MORE PER WEEK) 01 WORKING PART-TIME 02 LOOKING FOR WORK 03 LAID OFF FROM WORK 04 IN SCHOOL/TRAINING 05 IN JAIL/PRISON 06 IN MILITARY 07 KEEPING HOUSE 08 SOMETHING ELSE (SPECIFY) _______________________ 09

GO TO BOX BEFORE H27

H26. (Are you/Is he) still working for the same employer for whom (you were/he was) working 12 months ago?

YES 1

NO 2

IF RESPONDENT IS CHILD’S BIRTH/ADOPTIVE MOTHER

OR BIRTH/ADOPTIVE FATHER,

OR SAME RESPONDENT AS SPRING (SC1 = YES),
CHECK THIS BOX AND GO TO H33.

OTHERWISE GO TO H27.

Now I’m going to ask some questions about you.

H27. What is your birth date?

_______/______ /19 _____

MONTH DAY YEAR

H28. Are you of Spanish origin, Hispanic, or Latino?

YES 1

NO 2 (GO TO H30)

H29. Which one of these best describes you?

Mexican, Mexican American, Chicano, 1

Puerto Rican, 2

Cuban, or 3

Another Spanish/Hispanic/Latino group 4

H30. What is your race? You may name more than one if you like. (Circle all that APPLY)

a. WHITE 01

b. BLACK, AFRICAN AMERICAN, OR NEGRO 02

c. AMERICAN INDIAN OR ALASKA NATIVE
(SPECIFY) ____________________________________ 03

d. ASIAN INDIAN 04

e. CHINESE 05

f. FILIPINO 06

g. JAPANESE 07

h. KOREAN 08

i. VIETNAMESE 09

j. ASIAN (NOT FURTHER SPECIFIED) 10

k. NATIVE HAWAIIAN 11

l. GUAMANIAN OR CHAMORRO 12

m. SAMOAN 13

n. OTHER PACIFIC ISLANDER (SPECIFY) ____________ 14

15. ANOTHER RACE (SPECIFY) _____________________ 15

H31. What is the highest grade or year of school that you completed? (Circle one RESPONSE) (PROBE: IF COMPLETED 12^TH GRADE, Did you earn a diploma?)

UP TO 8TH GRADE 01

9TH TO 11TH GRADE 02

12TH GRADE BUT NO DIPLOMA 03

HIGH SCHOOL DIPLOMA 04

GED 05

VOC/TECH PROGRAM AFTER HIGH SCHOOL BUT NO

VOC/TECH DIPLOMA 06

VOC/TECH DIPLOMA AFTER HIGH SCHOOL 07

SOME COLLEGE BUT NO DEGREE 08

ASSOCIATE’S DEGREE 09

BACHELOR’S DEGREE 10

GRADUATE OR PROFESSIONAL SCHOOL BUT NO DEGREE 11

MASTER’S DEGREE (MA, MS) 12

DOCTORATE DEGREE (PhD, EdD) 13

PROFESSIONAL DEGREE AFTER BACHELOR’S DEGREE

(MEDICINE/MD; DENTISTRY/DDS; LAW/JD/LLB; ETC.) 14

H32. Since September, have you attended or enrolled in any courses from a school, college or university?

YES 1

NO 2

H33. Please tell me the first name of everyone in your household.

PROBE: Is there anyone else in your household?

H33a. First Name	H33b. How is [NAME] related to [CHILD]? (See codes below)		H33c. How old is [NAME]?
a. [CHILD]
b. RESPONDENT
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
RELATIONSHIP CODES:
01=Birth Mother 02=Birth Father 03=Adoptive Mother 04=Adoptive Father 05=Stepmother 06=Stepfather 07=Grandmother 08=Grandfather 09=Great grandmother 10=Great grandfather 11=Sister/Stepsister		12=Brother/Stepbrother 13=Other relative or in-law (female) 14=Other relative or in-law (male) 15=Foster parent (female) 16=Foster parent (male) 17=Other non-relative (female) 18=Other non-relative (male) 19=Parent’s partner (female) 20=Parent’s partner (male) 97=Refused 98=Don’t know/Didn’t Respond

I. INCOME, HOUSING, and NEIghborhood characteristics

Now I would like to ask you some questions about the sources of income for your household. This information will remain confidential.

I-1. Are you covered by health insurance other than Medicaid through your job or the job of another employed adult?

yes 1

no 2

I-2. Are you covered by Medicaid or under a state health insurance program?

YES 1

NO 2

I-3. Do you have prescription drug coverage?

YES 1

NO 2

I-4. Is [CHILD] covered by health insurance other than Medicaid through your job or the job of another employed adult?

yes 1

no 2

I-5. Is [CHILD] covered by Medicaid or under a state health insurance program?

YES 1

NO 2

I-6. In the past three months, have you had difficulty…

	YES	NO
a. Paying your rent?	1	2
b. Paying your electric and heating bills?	1	2
c. Buying food for your family?	1	2
d. Buying clothes for your child(ren)?	1	2

I-7. Including yourself, how many adults contribute to your household income?

|__|__| ADULTS

I-8. Now, including everyone in your household, what was the total income for your household last month before taxes and other deductions? Your best guess would be fine.

(PROBE: IF RESPONDENT REPORTS $3,000 OR MORE LAST MONTH, THEN VERIFY THAT REPORTED AMOUNT IS ONLY FOR LAST MONTH AND NOT FOR THE ENTIRE YEAR.)

HOUSEHOLD INCOME $ __ , __ __ __ (GO TO I-10)

(AMOUNT LAST MONTH ONLY)

OR

refused 97 (GO TO I-10)

don’t know 98 (GO TO I-9)

I-9. Would you say it was…

Less than $250, 01

Between $251 and $500, 02

Between $501 and $1,000, 03

Between $1,001 and $1,500, 04

Between $1,501 and $2,000, 05

Between $2,001 and $2,500, or 06

Over $2,500? 07

REFUSED 97

DON’T KNOW 98

The next questions are about housing.

I-10. How many times has [CHILD] moved in the last 12 months?

|____| TIMES

I-11. Do you currently own your home or apartment, pay rent, or live in public or subsidized housing?

OWNS OR IS BUYING HOME OR APARTMENT 1

RENTS (WITHOUT PUBLIC ASSISTANCE) 2

PUBLIC OR SUBSIDIZED HOUSING 3

SOME OTHER ARRANGEMENT 4

I-12. For each of the following items, please tell me how often each one happened to you during the past three months. (READ ITEM) Would you say never, once, or more than once?

More than

Never Once once

a. I saw non-violent crimes take place in my neighborhood –

for example, selling drugs or stealing. 1 2 3

b. I heard or saw violent crime take place in my

neighborhood. 1 2 3

c. I know someone who was a victim of a violent crime

in my neighborhood. 1 2 3

d. I was a victim of violent crime in my neighborhood. 1 2 3

e. I was a victim of violent crime in my home. 1 2 3

f. I was a victim of domestic violence. 1 2 3

I-13. In the past year, has [CHILD] ever been a witness to a violent crime?

YES 1

NO 2

I-14. In the past year, has [CHILD] ever been a victim of a violent crime?

YES 1

NO 2

I-15. At school this past school year, how often has [CHILD]...

Never 1-2 times 3+ times

a. been threatened or bullied by other kids. 1 2 3

b. been in a physical fight 1 2 3

c. had something stolen? 1 2 3

J. HEALTH AND SAFETY PRACTICES

J1. Now I’m going to ask you about your family’s health care needs. Overall, would you say [CHILD]’s health is…

Excellent, 1

Very Good,.. 2

Good, 3

Fair, or. 4

Poor? 5

J2. Would you say your health in general is …

Excellent, 1

Very Good,. 2

Good, 3

Fair, or 4

Poor? 5

J3. Does [CHILD] have an illness or condition that requires regular ongoing care?

YES 1

NO. 2

J4. Has [CHILD] had a check-up or wellness visit in the last year?

YES 1

NO. 2

J5. Do you have a place where you usually take [CHILD] for routine medical care such as regular check-ups? Places can include a doctor’s office, a clinic or health center, a hospital emergency room, or a hospital outpatient clinic.

YES 1

NO. 2 (GO TO J7)

J6. Where does [CHILD] go for this care? (CIRCLE ONLY ONE)

A private doctor 01

An outpatient clinic 02

The emergency room at a hospital 03

Someplace else (SPECIFY) ______________ 04

J7. When [CHILD] is ill, where do you usually take (him/her) for health care? (CIRCLE ONE)

Doctor 01

Clinic or health center 02

Hospital emergency room 03

Hospital outpatient clinic 04

J8. In the last month, how many times has [CHILD] seen a doctor or other medical professional, or visited a clinic or emergency room for an injury?

NEVER 0

ONCE 1

TWICE 2

THREE OR MORE 3

DON’T KNOW 4

REFUSED 5

J9. Has [CHILD] been seen by a dentist in the last year?

YES 1 (GO TO J10)

NO 2 (GO TO J11)

J10. Has [CHILD] been seen by a dentist since September?

YES 1

NO 2

J11. At what age did [CHILD] start brushing (his/her) teeth?

|____| AGE

J12. Has a professional screened or tested [CHILD's] hearing or vision since September?

	YES	NO	DON’T KNOW
a. HEARING	1	2	8
b. VISION	1	2	8

J13. Has [CHILD] had a health care need for which you could not get services?

YES 1

NO 2

J14. Do you or anyone else in your household smoke tobacco such as cigarettes or cigars?

YES 1

NO. 2

J15. During the last 30 days, how often, if ever, did you drink alcoholic beverages, including beer, wine or liquor? Would you say…

Less than once a week, 1

1 or 2 days per week, 2

3 or 4 days per week, 3

5 or 6 days per week, 4

Every day, or 5

Never? 6 (GO TO J17)

J16. On the days that you drank alcoholic beverages (including beer, wine, and liquor) in the last 30 days, how many drinks per day did you usually have?

|___|___| DRINKS PER DAY

J17. Is there (anyone/anyone else) in your household that drinks alcohol?

YES 1

NO 2

J18. Is there anyone in your household who uses drugs?

YES 1

NO 2

K. community services

Many types of community services are available for families with young children. Now I'd like to ask about services your family has received.

K1. Since September, have you or anyone in your household received any of the following services?
	YES	NO
a. Income assistance, including welfare, SSI, or unemployment insurance	1	2
b. Food and nutrition assistance, including food stamps or WIC	1	2
c. Help with housing	1	2
d. Help with utilities (water, heat, electric, telephone)	1	2
e. Job training and employment assistance	1	2
f. Alcohol or drug abuse treatment or counseling	1	2
g. Family counseling or mental health services	1	2
h. Help dealing with family violence	1	2
i. Foster care payments	1	2

K2. Did you or anyone in your household need any services that were not received?

YES 1

NO 2 (GO TO SECTION L)

K3. What were these services?

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

L. YOUR FEELINGS

L1. I am going to read a list of ways you may have felt or behaved. Please tell me how often you have felt this way during the past week: rarely or never, some or a little, occasionally or a moderate amount of time, or most or all of the time? (Circle one response for each item) (USE RESPONSE CARD)

	Rarely or Never	Some or a Little	Occa-sionally or Moderate	Most or All
a. Bothered by things that usually don’t bother you	1	2	3	4
b. You did not feel like eating; your appetite was poor	1	2	3	4
c. That you could not shake off the blues, even with help from your family and friends	1	2	3	4
d. You had trouble keeping your mind on what you were doing	1	2	3	4
e. Depressed	1	2	3	4
f. That everything you did was an effort	1	2	3	4
g. Fearful	1	2	3	4
h. Your sleep was restless	1	2	3	4
i. You talked less than usual	1	2	3	4
j. Lonely	1	2	3	4
k. Sad	1	2	3	4
l. You could not get “going”	1	2	3	4

M. GETTING READY FOR NEXT SCHOOL YEAR

M1. Do you expect [CHILD] to be in the same school this coming fall?

YES 1 (GO TO SECTION N)

NO 2 (GO TO M2)

M2. What is the name of the school [CHILD] will attend next year?

________________________________

SCHOOL NAME

M3. Where is the school located?

STREET (IF KNOWN)

CITY

N. TRACKING INFORMATION

Thank you for spending this time with me. I would also like to thank you for participating in this interview and will give you your gift in just a few minutes. We may need to contact you in the future, so we need to know how to get in touch with you.

N1. What is your telephone number? ___ ___ ___ -- ___ ___ ___ -- ___ ___ ___ ___

(area code)

Whose name is that number listed under?

Name: ___________________________________________________ (GO TO N4)

NO TELEPHONE 1 (GO TO N2)

REFUSED 7 (GO TO N2)

N2. Can you give me a number where you can be reached?

___ ___ ___ -- ___ ___ ___ -- ___ ___ ___ ___ (GO TO N3)

(area code)

NO TELEPHONE 1 (GO TO N4)

REFUSED 7 (GO TO N4)

N3. Whose telephone is that?

Name: ___________________________________________________

REFUSED 7

N4. Do you have another phone number like a beeper number or cell phone number?

No beeper or cell phone number . 1

Beeper ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___

Cell phone ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___

N5. Please give me your permanent address.

Address:

Street Apt.

Town/City State Zip Code

N6. Where are you employed?

NOT EMPLOYED 1 (GO TO N8a)

N7. What is your work telephone phone number? (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

area code

Would you please tell me the names, addresses, telephone numbers, and work information of three people who will know how to contact you a year from now?

N8a. What is the name of the first person?

N8b. How is this person related to [CHILD]? RELATIVE (SPECIFY) 1

NONRELATIVE 2

N8c. What is their telephone number? ___ ___ ___ -- ___ ___ ___ -- ___ ___ ___ ___

(area code)

NO TELEPHONE 1 (GO TO N8e)

REFUSED 7 (GO TO N8e)

N8d. Whose name is that number listed under?

REFUSED 7

N8e. Do they have another phone number, like a beeper number or a cell phone number?

No beeper or cell phone number . 1

Beeper ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___

Cell phone ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___

N8f. What is their address?

Address:

Street Apt.

Town/City State Zip Code

N8g. Where are they employed?

NOT EMPLOYED 1 (GO TO N9a)

N8h. What is their work telephone number? ___ ___ ___ -- ___ ___ ___ -- ___ ___ ___ ___

(area code)

N9a. What is the name of the second person?

N9b. How is this person related to [CHILD]? RELATIVE (SPECIFY) 1

NONRELATIVE 2

N9c. What is their telephone number? ___ ___ ___ -- ___ ___ ___ -- ___ ___ ___ ___

(area code)

NO TELEPHONE 1 (GO TO N9e)

REFUSED 7 (GO TO N9e)

N9d. Whose name is that number listed under?

REFUSED 7

N9e. Do they have another phone number, like a beeper number or a cell phone number?

No beeper or cell phone number . 1

Beeper ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___

Cell phone ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___

N9f. What is their address?

Address:

Street Apt.

Town/City State Zip Code

N9g. Where are they employed?

NOT EMPLOYED 1 (GO TO N10a)

N9h. What is their work telephone number? ___ ___ ___ -- ___ ___ ___ -- ___ ___ ___ ___

(area code)

N10a. What is the name of the third person?

N10b. How is this person related to [CHILD]? RELATIVE (SPECIFY) 1

NONRELATIVE 2

N10c. What is their telephone number? ___ ___ ___ -- ___ ___ ___ -- ___ ___ ___ ___

(area code)

NO TELEPHONE 1 (GO TO N10e)

REFUSED 7 (GO TO N10e)

N10d. Whose name is that number listed under?

REFUSED 7

N10e. Do they have another phone number, like a beeper number or a cell phone number?

No beeper or cell phone number . 1

Beeper ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___

Cell phone ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___

N10f. What is their address?

Address:

Street Apt.

Town/City State Zip Code

N10g. Where are they employed?

NOT EMPLOYED 1 (GO TO GET

SIGNATURE

BELOW)

N10h. What is their work telephone number? ___ ___ ___ -- ___ ___ ___ -- ___ ___ ___ ___

(area code)

I give permission to the contacts named above to release my current address and phone number to a representative of the Building Futures: Head Start Impact Study, Spring 2007.

________________________________________

Respondent’s signature

End Time: _________ AM/PM

O. Second child eligibility

FOR INTERVIEWER USE ONLY:

O1. Is there a second study child in the household?

YES 1

NO 2 (END INTERVIEW)

O2. What is the name of the second child?_______________________________

NAME

O3. How is [SECOND CHILD] related to [FIRST CHILD]?

Twin brother or sister 1

Other multiple birth relationship 2

Half brother or sister 3 (GO TO O5)

Step brother or sister 4 (GO TO O5)

Adoptive or foster brother or sister 5 (GO TO O5)

No family relationship, just live together 6 (GO TO BOX O6a)

Brother or sister 7 (GO TO O5)

O4. Are [SECOND CHILD] and [FIRST CHILD] identical or fraternal twins?

I dentical 1 (GO TO BOX O6a)

Fraternal 2

O5. Do [SECOND CHILD] and [FIRST CHILD] have the same birth mother?

YES 1

NO 2

O6. Do [SECOND CHILD] and [FIRST CHILD] have the same birth father?

YES 1

NO 2

BOX O6a.

GO TO OTHER CHILD’S BOOKLET, MARK COVER AS SECOND CHILD.

IF RESPONDENT IS SECOND CHILD’S PRIMARY CAREGIVER, ASK ONLY BOLDED QUESTIONS.

OTHERWISE ASK ENTIRE QUESTIONNAIRE.

COMPLETE AFTER INTERVIEW IS CONCLUDED.

P. CONFIDENCE RATINGS

P1. Interview Completion Code:

Respondent terminated interview prematurely 1

Respondent refused interview .. 2

Respondent unable to respond (SPECIFY). 3

Interview completed 4

P2. Please rate the following qualities of the respondent, the interviewing situation, and the quality of the data. The Respondent (was/had):

a. Able to understand questions easily	7	6	5	4	3	2	1	Hardly able to understand
b. Truthful	7	6	5	4	3	2	1	Untruthful
c. Accurate	7	6	5	4	3	2	1	Inaccurate
d. Interested in the interview	7	6	5	4	3	2	1	Not interested in the interview
e. Cooperative	7	6	5	4	3	2	1	Uncooperative
f. No English language problem	7	6	5	4	3	2	1	Spoke English with great difficulty
g. Interviewed without interruptions	7	6	5	4	3	2	1	Interrupted often
h. Your opinion about the overall quality of the data:
High	7	6	5	4	3	2	1	Low

If found, return to:

Westat

1650 Research Boulevard

Room RB3111 – 7433.07.12

Rockville, MD 20850

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Building Futures: Head Start Impact Study - Spring 2007 – PARENT INTERVIEW - COHORT B

DRAFT