Supporting Healthy Marriage (SHM) Project - 12 month follow up data collection. Instrument #1: Survey

SUPPORTING HEALTHY MARRIAGE PROJECT

12-MONTH FOLLOW-UP SURVEY INSTRUMENT

Table of Contents

1. Introduction…………………………………………………………………2

2. Household Structure………………………………………………………..4

3. Ideals, Expectations, and Standards about Marital Relationships……...6

4. Marital Status and Stability……………………………………………….10

5. Marital Relationship Outcomes…………………………………………...15

6. Participation in Services…………………………………………………...21

7. Co-Parenting………………………………………………………………..27

8. Non-Resident Measures…………………………………………………….34

9. Child Outcomes……………………………………………………………..35

10. Parental Well-being…………………………………………………………37

11. Economic Security and Material Hardship………………………………..39

12. Social Support………………………………………………………………..43

13. Locating and Demographic Information….………………………………..44

INTRODUCTION

SOURCE FOR INTRODUCTION: BSF

May I please speak with [SAMPLE MEMBER]? My name is [NAME] and I’m calling from [Research company], a research company in [Location of research company].

SAMPLE MEMBER AVAILABLE	1
SAMPLE MEMBER NOT AVAILABLE	2

If not available:

What do you think would be the best time to reach [SAMPLE MEMBER]?/When would be a good time to do the interview?)

INSTRUCTION: RECORD DATE AND TIME FOR CALL BACK.

CALL BACK INFORMATION

Hello, my name is [NAME] and I’m calling from [Interviewer’s Company], a research company in [City where company is located]. I’m calling you about the Supporting Healthy Marriage study you joined about a year ago. You may have already received a letter letting you know that we would be calling. Did you receive that letter?

• Yes

• No

• DK

• Ref

When you joined the study, you and [SPOUSE] were each asked to complete a short questionnaire and we told you that we would be contacting each of you again to learn how you are doing.

The interview will take about 50 minutes and you will receive a gift card $30 for completing it. Everything that you tell me is confidential. Your spouse will also receive a $30 gift card for completing the interview as well.

Is now a good time to start? Are you free for the next 50 minutes to answer these questions?

OK TO CONTINUE	1
NOT A GOOD TIME	2

(When would be a good time to reach [SAMPLE MEMBER]?/When would be a good time to do the interview?)

INSTRUCTION: RECORD DATE AND TIME FOR CALL BACK

CALL BACK INFORMATION

I just need to verify that I am speaking with the correct person. What is your date of birth?

Respondent’s Birthday	MM/DD/YYYY
DK	d
Ref	r

If DOB is incorrect:

I’m sorry. I need to check my records before I can interview you. Is this the best time to reach you in the future?

INSTRUCTION: RECORD DATE AND TIME FOR CALL BACK

Yes
No, Call Back Info

If DOB is correct:

Are the last 4 digits of your Social Security Number? ___ ___ ___ ___

[INTERVIEWER – ENTER SSN EVEN IF IT MATCHES THE SAMPLE INFO]

COMPARE RESPONSE GIVEN TO LAST FOUR DIGITS OF SSN ON SAMPLE FILE. IF THE 4 DIGITS GIVEN AGREE WITH THE NUMBER ON THE FILE, SKIP TO NAME ITEM BELOW. IF THEY DO NOT AGREE, DISCONTINUE THE INTERVIEW. IF SSN IS MISSING IN THE SAMPLE AND THERE IS A MISMATCH IN DOB, SKIP TO DISCONTINUED TEXT.

IF INTERVIEW DISCONTINUED: I’m sorry. I was unable to pull up the correct questionnaire. I will need to check with my supervisor to look into the problem. I will re-contact you when the problem is resolved. Thank you for your time.

I would also like to make sure we have your name recorded correctly.

Can you confirm that your name is:

Enter name [First, Middle, Last]

Yes (Skip next)

No

If No, What is your name? [First, Middle, Last]

Enter name [First, Middle, Last]

Are you usually called [Respondent’s First Name] or do you go by another name?

INSTRUCTION: IF SAME, CONTINUE

INSTRUCTION: IF DIFFERENT NAME, CHANGE TO USUAL NAME WHICH WILL BE USED TO FILL IN THE REMAINDER OF SURVEY

PROBE: Can you spell that for me please?

Alternative Name of Respondent

Our records indicate that you were married when you first entered the study. Before we get started, I would like to make sure that I have the correct name of your spouse at that time.

Enter name [First, Middle, Last]

Yes (Skip next)

No

If No, What is his/her name? [First, Middle, Last]

Enter name [First, Middle, Last]

Is he/she usually called [Respondent’s First Name] or does h/she go by another name?

INSTRUCTION: IF SAME, CONTINUE

INSTRUCTION: IF DIFFERENT NAME, CHANGE TO USUAL NAME WHICH WILL BE USED AS FILL IN THE REMAINDER OF SURVEY

PROBE: Can you spell that for me please?

Alternative Name of Spouse/Former spouse

Great! Let’s get started with some questions I have for you about your family.

SECTION A: HOUSEHOLD STRUCTURE

A. Last year you gave us some information about all the children living in your household. I’m going to ask you some questions about those children to make sure the information we have is correct. (HTE KS/MO 15-month follow up)

INTERVIEWER: LOOP THROUGH AND ASK Q. 1 through Q. 2 FOR ALL CHILDREN LISTED AT BASELINE. IF MORE THAN ONE CHILD, START WITH THE OLDEST AND WORK DOWN TO THE YOUNGEST.

	Yes	No	DK	Ref
1. Is [CHILD] still living with you at least half the time?	SKIP TO Q. 2	ASK Q. 1a			HTE KS/MO 15-month
1a. And who does [CHILD] usually live with? INTERVIEWER: DO NOT READ CHOICES, HAVE RESPONDENT ANSWER AND CODE FOR RESPONSE Biological father Biological mother Maternal grandparent(s) Paternal grandparent(s) Other relative(s) Friend Foster care Adoptive parent Other…Specify DK Ref					Fragile Families 1-year mother follow-up
2. Just to check, is his/her birthday [BIRTHDATE LISTED AT BASELINE]?		Can you please tell me his/her correct birthday? ENTER DATE.			Fragile Families

3. Are there any other children under the age of 18, including biological, adoptive, foster, step, or other children or relatives currently living in your home at least half the time who I did not mention? [HTE KS/MO 15-month follow-up]

• Yes [COMPLETE QUESTION 3 GRID BELOW]

• No [SKIP TO Q. 4]

• DK

• Ref

Key:

1=Biological/adoptive child

2=Step-child

3=Foster child

4=Other relative under 18

5=Other dependent child

6=Unspecified or don’t know

7=Refused

3a. What is the child’s first name?	3b.What is child’s last name?	3c.What is child’s date of birth?	3d. Is the child a…?	3e. How is the child related to you?	3f. How is the child related to your spouse?
A: Name: R efused	Name:	MM/DD/YY	Male Female Ref	1 2 3 4 5 6 7	1 2 3 4 5 6 7
B: Name: Refused	Name:	MM/DD/YY	Male Female Ref	1 2 3 4 5 6 7	1 2 3 4 5 6 7
C: Name: Refused	Name:	MM/DD/YY	Male Female Ref	1 2 3 4 5 6 7	1 2 3 4 5 6 7

4. How many adults 18 years or older live in your home at least half the time? (SHM Baseline)

WAIT FOR ANSWER. And that includes you, correct?

• ENTER NUMBER OF ADULTS

• DK

• Ref

5. Can you tell me the names of each of the adults, their ages, and their relationship to you? (New)

	NAME	AGE	RELATIONSHIP TO RESPONDENT
5a
5b
5c

SECTION B: IDEALS, EXPECTATIONS, AND STANDARDS ABOUT MARITAL RELATIONSHIPS

Views of Marriage

Now, I want to ask you a few questions about marriage in general. These questions ARE NOT intended to be about your marriage in particular, but about your views of marriage in general.

1. Please indicate whether you strongly agree, agree, disagree, or strongly disagree with each of the following statements. First…. [READ STATEMENT]. Do you…

	Strongly Agree	Agree	Disagree	Strongly Disagree	DK	Ref	Source
It is much better for everyone if the man earns the money and the woman takes care of the house and family.	1	2	3	4			Fragile Families
If a husband and wife both work full-time, they should share household chores equally.	1	2	3	4			SHM Baseline, NSFH
Mothers are more important than fathers in raising children.	1	2	3	4			New
The important decisions should be made by husbands	1	2	3	4			Fragile Families
Wives should feel as free as their husbands to say what they think and feel in a marriage.	1	2	3	4			New
Marriage is a lifelong relationship and should not be ended except in extreme circumstances.	1	2	3	4			New (Cognitive tested)

2. In your opinion, should divorce in this country be easier or more difficult to obtain that it is now? (GSS; Martin and Parashar, 2003)

• Easier

• More difficult

• Same [VOLUNTEERED]

• DK

• Ref

3. Here are some statements that describe beliefs and opinions some people have about marriage and what it takes to get along in a marriage. For each statement, please indicate whether you strongly agree, agree, disagree, or strongly disagree with the statement. First…. [READ STATEMENT]. Do you…

	Strongly Agree	Agree	Disagree	Strongly Disagree	DK	Ref	Source
Once a couple starts to have marriage problems, it usually is not possible to fix them.	1	2	3	4			NSFH
Couples should not have to work on their relationships in order to have a happy marriage.	1	2	3	4			NSFG, Modified
Married persons should be willing to give up things that are important to them for the sake of their marriage.	1	2	3	4			New
Most people can learn to communicate better with their spouse.	1	2	3	4			New
Most [husbands/ wives ASK ONLY OF OPPOSITE GENDER] cannot be trusted to be sexually faithful.	1	2	3	4			Fragile Families, revised
In a happy marriage, husbands and wives should know what each other is thinking without having to talk about it.	1	2	3	4			New
When one spouse says something mean or hurtful, it is OK for the other spouse to say something mean or hurtful back.	1	2	3	4			New
When husbands and wives have very different views about important things in the family, it is best not to talk about those things.	1	2	3	4			New
It is sometimes OK for couples to get a little rough physically, like pushing or hitting.	1	2	3	4			New

4. People expect different things in a good marriage. I’m going to read a list of some of the things people expect in marriage, and I’d like to know how important you feel each one should be. For each one, please tell me if you think it should be very important, somewhat important, somewhat unimportant, or very unimportant thing to expect in a good marriage. (New)

	Very Important	Somewhat Important	Not Very Important	DK	Ref
First, financial security… Do you think it is very important, somewhat important, somewhat unimportant, or very unimportant for people to expect this in a good marriage?	1	2	3
Next, love and affection	1	2	3
Sharing household chores	1	2	3
Personal growth	1	2	3
A respected place in the community	1	2	3
A good sex life	1	2	3
Common interests and activities	1	2	3
Common beliefs	1	2	3
Companionship	1	2	3

5. Which of these items do you think is the most important thing to expect from a good marriage? _____

SECTION C: MARITAL STATUS AND STABILITY

The next questions are about you and [SPOUSE]. (BSF)

1. Are you and [SPOUSE] currently…

Married?	1	Skip to Q.2
Divorced?	2	Skip to Q.3
Separated?	3	Skip to Q.3
DK
Ref

Or did you and [SPOUSE]

Have your marriage annulled?	4	Skip to Q.3
DK Ref

Or are you widowed?

	5	“I am so sorry to hear about your loss. WAIT FOR RESPONSE. Do you think that it would be OK for me to ask you a few questions about your children? WAIT FOR RESPONSE, IF RESPONDENT ANSWERS “NO,” SAY: “Would another time be better?” SKIP TO SECTION G
DK	D
Ref	R

O THER, specify

2. Are you currently living with [SPOUSE/FORMER SPOUSE]? [Only select one option.] (New)

All of the time	1		Option 1 in Q.5
Most of the time	2		Option 1 in Q. 5
Some of the time	3		Option 1 in Q. 5
None of the time	4		Option 2 in Q. 5
DK	D
Ref	R

3. How often do you and [SPOUSE/FORMER SPOUSE] see each other? Is it…(adapted BSF)

More than once a day	1
Every day or almost every day	2
A few times a week	3
A few times a month	4
About once a month	5
Only a few times in the past year	6
Hardly ever or never	7	DO NOT ASK QUESTIONS IN SECTION D
DK	d
REF	r

4. How often do you and [SPOUSE/FORMER SPOUSE] talk to each other? Is it… (adapted BSF)

More than once a day	1
Every day or almost every day	2
A few times a week	3
A few times a month	4
About once a month	5
Only a few times in the past year	6
Hardly ever or never	7	DO NOT ASK QUESTIONS IN SECTION D
DK	d
REF	r

5. OPTION 1: How many times have you and [SPOUSE] lived apart for one or more nights since [RAD]?

OPTION 2: Including this current time of living apart, how many times have you and [SPOUSE/FORMER SPOUSE] lived apart since [RAD]?

• [IF ANSWER IS “0,” SKIP TO Q.8]

• DK

• Ref

6. OPTION 1: Thinking about all of the times that you and [SPOUSE/FORMER SPOUSE] have lived apart since [RAD], what is the total amount of time that you and [SPOUSE/FORMER SPOUSE] have lived apart for?

OPTION 2: Thinking about all of the times that you and [SPOUSE/FORMER SPOUSE] lived apart since [RAD], including this most time apart, what is the total amount of time that you and [SPOUSE] have lived apart for?

PROBE: If you don’t know the exact amount of time, you can just give me an estimate in months of how long you think you were living apart.

Days and Months

[If less than 1 month, enter number of days, and enter 0 for months. If more than 1 month, enter number of months rounded to the nearest month.]

• DK

• Ref

7. OPTION 1: For the most recent spell that you and [SPOUSE] lived apart from one another, can you me what the main reason was for your separation? (BSF)

OPTION 2: Can you tell me what the main reason is that you and [SPOUSE/FORMER SPOUSE] do not currently live together? (BSF)

[INTERVIEWER: DO NOT READ CHOICES, CODE FOR THE RESPONSE THE RESPONDENT GIVES, UNLESS RESPONDENT CANNOT COME UP WITH A REASON.]

PROMPT, IF NECESSARY: Was/Is it because…

		If YES, Was it you, [SPOUSE], or both of you?
a. You and/or [SPOUSE/FORMER SPOUSE] were/are in the military?	Yes No DK Ref	You [SPOUSE/FORMER SPOUSE] Both DK Ref
b. You or [SPOUSE/FORMER SPOUSE] work far away from home?	Yes No DK Ref	You [SPOUSE/FORMER SPOUSE] Both DK Ref
c. The two of you were not communicating well or were arguing too much?	Yes No DK Ref	You [SPOUSE/FORMER SPOUSE] Both DK Ref
d. Of lack of support from family members?	Yes No DK Ref	You [SPOUSE/FORMER SPOUSE] Both DK Ref
e. You or [SPOUSE/FORMER SPOUSE] were/was visiting or living with relatives?	Yes No DK Ref	You [SPOUSE/FORMER SPOUSE] Both DK Ref
f. You or [SPOUSE/FORMER SPOUSE] cheated or were unfaithful?	Yes No DK Ref	You [SPOUSE/FORMER SPOUSE] Both DK Ref
g. You or [SPOUSE/FORMER SPOUSE] went to jail or prison?	Yes No DK Ref	You [SPOUSE/FORMER SPOUSE] Both DK Ref
h. You or [SPOUSE/FORMER SPOUSE] were/was abusive or violent?	Yes No DK Ref	You [SPOUSE/FORMER SPOUSE] Both DK Ref
i. You or [SPOUSE/FORMER SPOUSE] used drugs or alcohol?	Yes No DK Ref	You [SPOUSE/FORMER SPOUSE] Both DK Ref
j. You or [SPOUSE/FORMER SPOUSE] could not keep a job or contribute enough financially to the family?	Yes No DK Ref	You [SPOUSE/FORMER SPOUSE] Both DK Ref
k. You or [SPOUSE] were/was not a good parent or role model?	Yes No DK Ref	You [SPOUSE/FORMER SPOUSE] Both DK Ref
l. Other reasons why you and [SPOUSE] live(d) apart?	SPECIFY:	You [SPOUSE/FORMER SPOUSE] Both DK Ref

8. Had you ever been married prior to this marriage? (SHM Baseline)

• Yes

• No (GO TO 9)

• DK

• REF

8a. How many times were you married prior to (RA Date)? (New)

• 0

• 1

• 2

• 3

• 4 or more

• DK

• Ref

9. [If currently divorced, separated, or marriage annulled OR currently married and living together “none of the time,”]

Are you currently involved in a romantic relationship with [someone other than [SPOUSE/FORMER SPOUSE]/with someone else]? (BSF)

[If married and living together at least “some of the time,” skip to SECTION D]

• Yes

• No (Skip to SECTION D)

• DK

• Ref

9a.Do you currently live with him/her in the same household…(BSF)

All of the time,	1
Most of the time,	2
Some of the time,	3
None of the time, or	4
DK	D
Ref	R

9b. Are you currently married to him/her? (BSF)

• Yes

• No

• DK

• Ref

SECTION D: MARITAL RELATIONSHIP OUTCOMES

1. The next questions are about your relationship with [SPOUSE/FORMER SPOUSE]. Please tell me if you strongly agree, agree, disagree, or strongly disagree with the following statements. [IF RESPONDENT ANSWERED “HARDLY EVER OR NEVER” TO Q. C3. AND/OR Q. C4, SKIP TO SECTION E. OTHERWISE, FOLLOW INSTRUCTIONS IN INDIVIDUAL CELLS, I.E. WHICH QUESTIONS TO OMIT FOR SEPARATED/DIVORCED RESPONDENTS.]

		Strongly Agree	Agree	Disagree	Strongly Disagree	Source
a	[SPOUSE/FORMER SPOUSE] understands that there are times when I do not feel like talking, and times when I do.	1	2	3	4	Unknown-co
b	If I was unhappy, I would stay married to [SPOUSE] because my family expects it.**	1	2	3	4	Cognitive testing
c	I trust [SPOUSE] completely.**	1	2	3	4	SHM Baseline
d	[SPOUSE] knows and understands me.**	1	2	3	4	BSF
e	[SPOUSE] makes sacrifices for the good of our marriage.**	1	2	3	4	Cognitive testing
f	If I was unhappy, I would stay married to [SPOUSE] because of our children.**	1	2	3	4	New
g	I am comfortable expressing how I feel about sex with [SPOUSE]. **	1	2	3	4	ENRICH
h	I can count on [SPOUSE] to be there for me.**	1	2	3	4	SHM Baseline
i	It is hard for me to talk with [SPOUSE/FORMER SPOUSE] about the important things in our lives.	1	2	3	4	SHM Baseline
j	[SPOUSE/FORMER SPOUSE] respects me.	1	2	3	4	BSF
k	I believe this relationship can be strong even through hard times.**	1	2	3	4	SHM Baseline
l	I view our marriage as lifelong.**	1	2	3	4	SHM Baseline
m	I feel appreciated by [SPOUSE/FORMER SPOUSE].	1	2	3	4	BSF
n	If I was unhappy, I would stay married to [SPOUSE] because of religious reasons.**	1	2	3	4	New
o	[SPOUSE] expresses love and affection towards me. **	1	2	3	4	SHM Baseline

** Not administered to separated couples.

2. Please indicate whether each of the following happens all of the time, most of the time, some of the time, or none of the time.

		All of the time	Most of the time	Some of the time	None of the time	Source
a	[SPOUSE/FORMER SPOUSE] listens to me when I need someone to talk to.	1	2	3	4	SHM Baseline
b	[SPOUSE/FORMER SPOUSE] and I talk about things that happened during our day.	1	2	3	4	BSF Modified
c	[SPOUSE/FORMER SPOUSE] and my arguments get very heated.	1	2	3	4	Cognitive testing
d	After an argument, [SPOUSE/FORMER SPOUSE] and I stay mad at one another.	1	2	3	4	Cognitive testing
e	[SPOUSE] and I have similar views about what is important in life.**	1	2	3	4	SHM Baseline
f	I do things to show [SPOUSE] I value him/her.**	1	2	3	4	Cognitive testing
g	We enjoy doing even ordinary, day-to-day things together.**	1	2	3	4	Cognitive testing

** Not administered to separated couples.

In the last month…..

		Daily	2-3 times per week	About once a week	1-3 times a month	Never	DK	Ref
h	How often did you and [SPOUSE] spend time together as a couple, just the two of you?**	1	2	3	4	5			Cognitive testing
i	How often did you and [SPOUSE/FORMER SPOUSE] spend time together with your children.	1	2	3	4	5			Cognitive testing

	Would you say…
3. When you have a serious disagreement with [SPOUSE/FORMER SPOUSE], how often did you:	Never	Hardly ever	Sometimes	Often	Source
Just keep your thoughts to yourself?	1	2	3	4	EHS/NSFH/ ECLS-B
Discuss your disagreements respectfully?	1	2	3	4	EHS/NSFH/ ECLS-B
Argue in front of the children?	1	2	3	4	EHS/NSFH/ ECLS-B
Work on it together to find a resolution?	1	2	3	4	CCQ

4.	Never	Hardly ever	Sometimes	Often	Source
In the last three months, how often did you and [SPOUSE/FORMER SPOUSE] have a serious disagreement? Was it never, hardly ever, sometimes, or often?	1	2	3	4	Modified from SHM Baseline

5. Please indicate whether each of the following happens never, hardly ever, sometimes, or often in your relationship.

	Never	Hardly ever	Sometimes	Often	Source
a. Small issues suddenly become big arguments.	1	2	3	4	BSF
b. [SPOUSE/FORMER SPOUSE] and I are good at working out our differences.	1	2	3	4	BSF
c. When we argue, past hurts get brought up again.	1	2	3	4	Cognitive testing
d. [SPOUSE/FORMER SPOUSE] is rude and mean to me when we disagree.	1	2	3	4	Cognitive testing

6. The following questions are about how you and [SPOUSE/FORMER SPOUSE] feel about your children. When thinking of these questions please include your biological, adoptive, and stepchildren. Please tell me if you strongly agree, agree, disagree, or strongly disagree with the following statements.

		Strongly Agree	Agree	Disagree	Strongly Disagree	Source
a	[SPOUSE/FORMER SPOUSE] is willing to make sacrifices to help take care of our kids.	1	2	3	4	Cognitive testing
b	[SPOUSE/FORMER SPOUSE] takes his/her responsibilities for our children seriously.	1	2	3	4	BSF
c	I could/can raise our kids just as well without [SPOUSE/FORMER SPOUSE].	1	2	3	4	Cognitive testing

[SKIP TO QUESTION 16A IF COUPLE IS SEPARATED]

7. These questions are about extended family, such as grandparents, parents, sisters and brothers, aunts and uncles, and so on. Please tell me if you strongly agree, agree, disagree, or strongly disagree.

		Strongly agree	Agree	Disagree	Strongly disagree
a	I can count on [SPOUSE] to help with whatever problems my extended family faces.	1	2	3	4	Cognitive testing
b	[SPOUSE] respects and values my extended family.	1	2	3	4	Cognitive testing

8. Sometimes couples are not always faithful to each other. In the last three months, has [SPOUSE] cheated on you with someone else? Is that…[BSF]

INSTRUCTION: IF RESPONDENT ANSWERS ‘DK’ DO NOT PROBE.

Definitely yes,	1
Probably yes,	2
Probably no, or	3
Definitely no?	4
DK	d
REF	r

9. In the last three months, have you cheated on [SPOUSE] with someone else?

YES	1
NO	0
DK	d
REF	r

No matter how well people get along, there are times when they disagree, get annoyed with the other person, want different things from each other, or just have spats or fights because they are in a bad mood, are tired, or for some other reason. People also have many different ways of trying to settle their differences. (Modified from BSF)

In the last three months, how many times has [SPOUSE] …
		TIMES
6.	thrown something at you?	0	1	2	3-5	6+
7.	pushed, shoved, hit, slapped, or grabbed you?	0	1	2	3-5	6+
8.	used a knife, gun, or weapon on you?	0	1	2	3-5	6+
9.	choked, slammed, kicked, burned, or beat you?	0	1	2	3-5	6+
10	used threats or force (like hitting, holding down, or using a weapon) to make you have sex?	0	1	2	3-5	6+

10. Here is a list of things that might happen when you have disagreements.

11.	In the last three months how often…	Never	Hardly Ever	Sometimes	Often
a	Have you felt afraid that [SPOUSE] would hurt you? Was it never, hardly ever, sometime, or often?	1	2	3	4
b	Have your arguments gotten physical?	1	2	3	4
c	Has [SPOUSE] accused you of having an affair?	1	2	3	4
d	Tried to keep you from seeing or talking with your friends or family?	1	2	3	4
e	Kept money from you, made you ask for money, or taken your money?	1	2	3	4
f	Yelled or screamed at you?	1	2	3	4
g	Made you feel stupid?	1	2	3	4
h	Blamed you for his/her problems?	1	2	3	4
i	Threatened to hurt you or the children?	1	2	3	4

12. In the last three months, have you thought about getting help for your marriage? (New)

• Yes

• No

• DK

• Ref

13. In the last three months, have you ever thought your marriage was in trouble? (SAQ)

• Yes

• No [GO TO SECTION D]

• DK

• Ref

14. In the last three months, have you spoken to anyone about the possibility that you and [SPOUSE] might separate or get a divorce? (Child Trends)

• Yes

• No

• DK

• Ref

15. All things considered, on a scale from 1 to 7, where 1 is “completely unhappy,” 4 is neither happy nor unhappy (neutral), and 7 is “completely happy”, how happy are you with your marriage to [SPOUSE]? (SAQ)

1	2	3	4	5	6	7	DK	Ref
						

16. And, how often are you satisfied with: [INTERVIEWER: ASK ALL QUESTIONS TO INTACT COUPLES, BUT ONLY A, B, AND E TO SEPARATED COUPLES.]

	All the time	Most of the time	Some of the time	None of the time
The way [SPOUSE/FORMER SPOUSE] and you communicate?	1	2	3	4
The way you and [SPOUSE/FORMER SPOUSE] handle your problems and disagreements?	1	2	3	4
The amount of time you spend together as a couple?**	1	2	3	4
The emotional side of your relationship?**	1	2	3	4
The responsibility [SPOUSE/FORMER SPOUSE] takes for raising your children?	1	2	3	4
Your sex life?**	1	2	3	4
How you divide household chores?**	1	2	3	4
The way you handle your money and debt?**	1	2	3	4

**Not administered to separated couples.

SECTION E: PARTICIPATION IN SERVICES

1. Marriage Education Services

We are interested in the types of services you may have received since [RAD] to help you work on your marriage or relationship with your spouse.

1 Since [RAD:] ________] have you been enrolled in any program(s) where you received services or counseling to help you work on your marriage or your relationship by yourself or with your spouse? (CSS)

• YES

• NO (SKIP TO Q. 2)

• DK

• REF

1a. Since [RAD:] ________] have you received marriage education, marriage counseling or mentoring services by yourself or with your spouse? (CSS)

• By his or herself

• With spouse

• DK

• Ref

1b.Were these meetings typically group sessions with other couples or with only you and your spouse? (BSF, CSS)

• Group

• Couple [Skip to Q. 6]

• DK

• Ref

1c. About how many classes, workshops, or group sessions did you attend since [RA DATE]? (BSF, CSS)

• 1 (Ask 1d.) PROBE: Did your spouse attend with you?

  • Yes

  • No

  • DK

  • Ref

• 2 (Ask 1d, 1e, 1f)

• 3 (Ask 1d, 1e, 1f)

• 4 OR MORE (Ask 1d, 1e, 1f)

• DK

• Ref

1d. About how many hours did the class, workshop or group session last?

(BSF)

• R ECORD RESPONSE

• DK

• Ref

1e. How often did [SPOUSE/FORMER SPOUSE] attend the class, workshop or group session with you? (BSF)

• All of the time

• Most of the time

• Some of the time

• A few times

• None of the time

• DK

• REF

1f. Where did you receive these services? Name program(s): (CSS)

• Enter program(s):

• DK

• Ref

2. About how many of the services that you were assigned to did you actually attend? Was it … (CSS)

• None of them

• Some of them

• Most of them (skip to Q. 4)

• All of them (skip to Q. 4)

3. What are the reasons that you didn’t attend?

• RECORD ANSWER

• DK

• Ref

PROBE: Of the following, was it because … (CSS)

		Check all that apply
a	Of the health of your spouse, child, or yourself?	
b	You had trouble finding child care?	
c	You had trouble finding transportation?	
d	Of a family issue?	
e	Of a problem with your housing?	
f	Of a conflict with your job?	
g	Of a conflict with your school or training program?	
h	Of religious observance?	
i	You didn’t want to participate?	
j	You did not find the program to be helpful?	
k	A feeling that the group meetings weren’t helpful?	
l	A feeling that attendance at group meeting was causing more conflict with [SPOUSE/FORMER SPOUSE]?	
m	DK
n	Ref
o	Other, specify

2. Perception of Program

[INTERVIEWER: THESE QUESTIONS SHOULD ONLY BE ASKED TO RESPONDENTS WHO ANSWERED “GROUP” TO 1A]

4. Do you ever socialize with, see, or talk on the phone with other people from marriage education classes, workshops, or group sessions outside of the program? (CSS)

• YES (Ask 4a)

• NO (Skip to Q 5.)

• DK

• Ref

4a. How often? 

• Once a week

• Once a month

• Once every two months

• Once every six months

• DK

• Ref

4b. Do you socialize as couples or do wives get together and/or husbands get together? [Check all that apply.] (New)

• As a couple

• Wives get together

• Husbands get together

• DK

• Ref

5. Do you feel that your marriage education group should have kept meeting for more weeks, should have met fewer weeks, or met just about the right number of weeks? (New)

		Should have kept meeting for more weeks	Should have met fewer weeks	Met just about the right number of weeks	DK	Ref
a	I feel that the marriage education classes…	1	2	3

5a. In the marriage education classes, would you have liked to…? (New)

		More	Less	Same	DK	Ref
a	Spend more time in group discussions?	1	2	3
b	Spend more time practicing skills with my spouse?	1	2	3
c	Spend more time with the facilitator teaching and explaining new ideas?	1	2	3

5b. How often did the classes focus on topics that were important to you and your spouse? (New)

• All of the time

• Most of the time

• Some of the time

• None of the time

• DK

• Ref

C. Other Marriage Services

6. Since [RAD], other than through workshops, classes and group, did you meet with any kind of social worker, counselor, therapist, or clergy member to work on your relationship? (adapted from BSF)

• YES

• NO (Skip to Q. 7)

• DK

• Ref

6a. Since [RAD], about how many times did you meet with this person/these people? (BSF)

• 1

• 2 [ASK ALWAYS, ETC RESPONSES IN 6C]

• 3 [ASK ALWAYS, ETC RESPONSES IN 6C]

• 4 or more [ASK ALWAYS, ETC RESPONSES IN 6C]

• DK

• Ref

6b. About how long did the sessions with this person last? (BSF)

• Record Response

• DK

• Ref

6c. Did [SPOUSE/FORMER SPOUSE] attend the session with you? (BSF)

• Yes/No [or if more than one session]

  • Always

  • Sometimes

  • Seldom

  • Never

D. Supplemental Services

7. Since [RAD], did you

a	Participate in any classes, groups, or workshops to help you improve your parenting skills? (BSF)	Yes No DK Ref
b	Participate in a job training program? (BSF)	Yes No DK Ref
c	Get services to help you with anger management or domestic violence? (BSF)	Yes No DK Ref
d	Get mental health services, such as counseling, or help with emotional problems? (BSF/ERA)	Yes No DK Ref
e	Get services to help you deal with drug or alcohol abuse? (BSF/ERA)	Yes No DK Ref
f	Get services to help you with domestic violence issues? (BSF)	Yes No DK Ref

8. There are many kinds of programs and organizations that help people find jobs, training, food, housing, childcare, health care, and help with other problems they may have. For each of the following, please tell me whether you have spoken with anyone from an agency, program, or school, or with a social worker, case manager or counselor offering these kinds of help since [RAD]? (ERA)

a	Help finding or paying for child care arrangements?	Yes No DK Ref
b	Help with housing problems?	Yes No DK Ref
c	Help finding or paying for transportation to work or transportation to child care?	Yes No DK Ref
d	Help getting Food Stamps or TANF?	Yes No DK Ref
e	Help getting Medicaid or regular access to medical treatment or regular checkups?	Yes No DK Ref
f	Help handling a financial emergency such as possible eviction, or if your car broke down, etc?	Yes No DK Ref
g	Take any classes to finish high school, get a GED, or finish college? (BSF)	Yes No DK Ref
h	Get vocational training for a specific job, trade, or occupation to enhance your job opportunities? (BSF)	Yes No DK Ref
i	Take any classes to learn English? (BSF)	Yes No DK Ref

SECTION F: CO-PARENTING AND PARENTING

[INTERVIEWER: IF ONE PARENT IS DECEASED, SKIP Q. 5, 6, 7, 8, 9, 10]

[IF RESPONDENT ANSWERED “EVERY DAY OR ALMOST EVERY DAY,” “A FEW TIMES A WEEK,” “A FEW TIMES A MONTH,” “ABOUT ONCE A MONTH,” OR “ONLY A FEW TIMES IN THE PAST YEAR,” TO ITEM C. 3, ASK ALL ITEMS IN SECTION F (UNLESS OTHERWISE NOTED). IF RESPONSDENT ANSWERED “HARDLY OR NEVER,” SKIP Q. 5, 6, 7, 8]

1. Which of the following statements best describes your relationship with [SPOUSE/FORMER SPOUSE] when it comes to parenting? (Survey Team/Fragile Families)

• We get along very well.

• We get along okay.

• We do not get along well at all.

• DK

• Ref

Family Routines

2. In the last week, please tell me the number of days…

		0	1	2	3	4	5	6	7
a	Your family eats dinner together.	□	□	□	□	□	□	□	□
b	And, how many days the evening meal is served at a regular time?	□	□	□	□	□	□	□	□

[ECLS-B 24 month survey]

Family Expressiveness

3. Do you strongly agree, agree, disagree, or strongly disagree with the following statements about your family?

		Strongly agree	Agree	Disagree	Strongly disagree	DK	Ref
a	Family members help and support one another.	1	2	3	4
b	Family members express deep affection and love for one another.	1	2	3	4
c	Family members are encouraged to express their thoughts and feelings.	1	2	3	4
d	Family members fight a lot.	1	2	3	4
e	Family members put one another down, or blame one another for family troubles.	1	2	3	4

[Moos Family Environment Scale/Halberstadt, 1983)]

Aggravation

4. Please tell me if you strongly agree, agree, disagree, or strongly disagree with the following statements.

		Strongly agree	Agree	Disagree	Strongly disagree	DK	Ref
a	Being a parent is harder than I thought it would be.	1	2	3	4
b	I feel trapped by my responsibilities as a parent.	1	2	3	4
c	I find that taking care of my child(ren) is more work than pleasure.	1	2	3	4
d	I am usually too busy to joke and play around with my child(ren).	1	2	3	4
e	Even when I’m in a bad mood, I show my child(ren) a lot of love.	1	2	3	4
f	By the end of a long day, I find it hard to be warm and loving toward my child(ren).	1	2	3	4

[Fragile Families, Mother 36-month follow-up; PSID-CDS II, Primary Caregiver Child Interview]

5. The following questions are about the ways in which parents raise their children. Please tell me how often the following statements are true for you and [SPOUSE/FORMER SPOUSE]:

		All of the time	Most of the time	Some of the time	Never	DK	Ref
a	When [SPOUSE/FORMER SPOUSE] is with the child(ren), he/she acts like the kind of parent you want for your child(ren)… Would you say…	1	2	3	4
b	You can trust [SPOUSE/FORMER SPOUSE] to take good care of the child(ren)…	1	2	3	4
c	[SPOUSE/FORMER SPOUSE] supports you in the way you want to raise the child(ren)…	1	2	3	4

[Cognitive testing]

6. For each of these items, do you strongly agree, agree, disagree, or strongly disagree with the statement?

		Strongly agree	Agree	Disagree	Strongly agree	DK	Ref
a	I believe that [SPOUSE/FORMER SPOUSE] is a good parent.	1	2	3	4
b	When there is a problem with the child(ren), [SPOUSE/FORMER SPOUSE] and I work out a good solution together.	1	2	3	4
c	When I’m having a rough day with the (child)ren, I can turn to [SPOUSE/FORMER SPOUSE] for support and advice.	1	2	3	4
d	When I have to make rules for the child(ren), [SPOUSE/FORMER SPOUSE] backs me up.	1	2	3	4

[Revised from Building Strong Families, First Follow-Up Father Survey]

7. Now I would like to read you a list of issues that parents may have disagreements about. For each one, please tell me how often you and [SPOUSE/FORMER SPOUSE] disagree.

		Never	Hardly Ever	Sometimes	Often	DK	Ref
a	Setting rules and disciplining the child(ren) Would you say…	1	2	3	4
b	The child(ren)’s daily routines and schedules	1	2	3	4
c	Selecting child care or schools	1	2	3	4
d	How money is spent on the child(ren)	1	2	3	4
e	Who does childcare tasks	1	2	3	4
f	Supervision and limit setting	1	2	3	4
g	The activities that the child(ren) participate in	1	2	3	4
h	The amount of time each of you spend with the child(ren)	1	2	3	4

[Revised from ECLS-B, 9 and 24-Month Surveys Non-Resident Father Questionnaires]

8. People handle raising children and running a household differently. Please tell me if YOU or [SPOUSE] is primarily responsible for the following duties, or if you share the responsibility equally.

[INTERVIEWER: ASK THIS ITEM ONLY TO COUPLES WHO ARE INTACT AT FOLLOW-UP]

		My spouse is primarily responsible for	We share this responsibility equally	I am primarily responsible for	DK	Ref
a	Cooking/household chores?	1	2	3
b	Running errands, like picking up items from the store?	1	2	3
c	Caring for children?	1	2	3
d	Handling finances, money, paying bills?	1	2	3
e	Earning family income?	1	2	3

[New]

INTERVIEWER: Now, I’d like to ask you some questions about [FOCAL CHILD]…

[IF NON-RESIDENTIAL PARENT OF FOCAL CHILD, ASK ITEMS 9 AND 10: IF RESIDENT PARENT OR COUPLE IS INTACT, SKIP TO Q. 11]

9. During the past month, how many times have/has [YOU] sent a card, letter, e-mail, text message, or phone call to [FOCAL CHILD]? [NLSY97: round 1 youth]

• Never

• Once or twice

• Three or four times

• More often

• DK

• Ref

9. During the past month, about how often did [YOU] see

[FOCAL CHILD]? [NLSY97: round 1 youth]

• Not at all

• Once or twice

• Three or four times

• More often

• DK

• Ref

[IF PARENT DOES NOT HAVE CONTACT OR SEE FOCAL CHILD, GO TO ITEM 1 IN SECTION G]

IF [FOCAL CHILD] IS 5 YEARS OLD OR YOUNGER AT FOLLOW-UP ASK ITEM 11a – 11F.

Involvement/Engagement

9. In the past month, how often did you …

		Daily	Weekly	Less Often	Never	DK	Ref
a	Play inside with toys, such as blocks or legos with [FOCAL CHILD]?	1	2	3	4
b	Take [FOCAL CHILD] for a walk or to play outside?	1	2	3	4
c	Sing songs or nursery rhymes with [FOCAL CHILD]?	1	2	3	4
d	Read books or tell stories to [FOCAL CHILD]?	1	2	3	4
e	Deal with [FOCAL CHILD] when he/she did something wrong?	1	2	3	4
f	Comfort or soothe [FOCAL CHILD] when he/she is crying or upset?	1	2	3	4

[ECLS-B]

IF [FOCAL CHILD] IS 6 - 11 YEARS OLD AT FOLLOW-UP ASK ITEM 12a – 12f.

Involvement/Engagement

9. About how often in the past month have you:

		Daily	Weekly	Less Often	Never	DK	Ref
a	Talked with [FOCAL CHILD] about school, grades, and/or other things that (he/she) does at school? Was it…	1	2	3	4
b	Spent time with [FOCAL CHILD] doing one of (his/her) favorite activities, like shopping, playing a sport, going to a movie, watching TV, or playing videogames?	1	2	3	4
c	Talked with [FOCAL CHILD] about (his/her) relationships with friends?	1	2	3	4
d	Dealt with [FOCAL CHILD] when he/she did something wrong?	1	2	3	4
e	Comforted or sooth [FOCAL CHILD] when he/she was upset?	1	2	3	4
f	Read a book with [FOCAL CHILD] or talk about a book he or she was reading?	1	2	3	4

[PSID-CDS]

IF [FOCAL CHILD] IS 12 - 15 YEARS OLD AND AT FOLLOW-UP ASK ITEM 13a – 13f.

Involvement/Engagement

9. About how often in the past month have you:

		Daily	Weekly	Less Often	Never	DK	Ref
a	Talked with [FOCAL CHILD] about school, grades, and/or other things that (he/she) does at school? Would you say…	1	2	3	4
b	Spent time with [FOCAL CHILD] doing one of (his/her) favorite activities, like shopping, playing a sport, or going to a movie, play, museum, or concert?	1	2	3	4
c	Talked with [FOCAL CHILD] about (his/her) relationships, like (his/her) relationships with friends or someone (he/she) is dating?	1	2	3	4
d	Dealt with [FOCAL CHILD] when he/she did something wrong?	1	2	3	4
e	Talked with [FOCAL CHILD] about a personal problem he/she is having?
f	Talked about a book [FOCAL CHILD] was reading?

[PSID-CDS]

IF [FOCAL CHILD] IS 6 - 15 YEARS OLD AT FOLLOW-UP ASK ITEM 14a – 14e.

Monitoring/Supervision

14. Over the past month, how often did you know…

		Always	Usually	Sometimes	Almost Never	DK	Ref
a	…where (FOCAL CHILD) was before and after school? Would you say…	1	2	3	4
b	…who (FOCAL CHILD) was with before and after school?	1	2	3	4
c	…whether (FOCAL CHILD) came home when he/she was supposed to?	1	2	3	4
d	…whether (FOCAL CHILD) had finished his/her schoolwork?	1	2	3	4
e	…which TV programs (FOCAL CHILD) watched?	1	2	3	4

[MFIP Report]

Warmth and Harsh Discipline

15. [ASK Q. 15 IN REFERENCE TO ALL FOCAL CHILDREN] Over the past month, how many times did you…

		Daily	Weekly	Less Often	Never	DK	Ref
a	…hug, kiss, or show other physical affection to [FOCAL CHILD]? Was it….	1	2	3	4
b	How many times did you praise [FOCAL CHILD]?	1	2	3	4
c	Yell, shout, scream at, or threaten [FOCAL CHILD]?	1	2	3	4
d	Hit, spank, grab or use physical punishment with [FOCAL CHILD]?	1	2	3	4

[MFIP; NEWWS]

SECTION G: NON-RESIDENT INVOLVEMENT

INTERVIEWER: ADMINISTER QUESTIONS 1 and 2 TO CUSTODIAL PARENT IF PARENTS DO NOT LIVE TOGETHER WITH FOCAL CHILD.

1. During the past month, how many times have/has [FORMER SPOUSE] sent a card, letter, e-mail, text message, or phone call to [FOCAL CHILD]? [NLSY97: round 1 youth]

• Never

• Once or twice

• Three or four times

• More often

2. During the past month, about how often did [FORMER SPOUSE] see [FOCAL CHILD]? [NLSY97: round 1 youth]

• Not at all

• Once or twice

• Three or four times

• More often

Child Support Payment (all ages)

[IF RESPONDENT IS A NON-RESIDENT BIOLOGICAL OR ADOPTIVE PARENT, PLEASE ANSWER THE QUESTIONS DIRECTLY. IF THE RESPONDENT IS THE RESIDENT PARENT ANSWER THE QUESTIONS ABOUT THE NON-RESIDENT BIOLOGICAL PARENT’S PRACTICIES]

[IF FORMER SPOUSE IS NOT THE BIOLOGICAL PARENT OF FOCAL CHILD, DO NOT ASK MEASURES ABOUT CHILD SUPPORT.]

3. Since [YOU/FORMER SPOUSE] stopped living with [FOCAL CHILD],

have/has (you/he/she) ever contributed money or child support for [FOCAL CHILD]’s

upbringing? [adapted from NSFG 2002]

□ Yes

□ No (SKIP TO NEXT SECTION)

4. Last month, how much money for child support did you/he/she give? [adapted from NSFG 2002, NCAMOUNT]

_________ Record Response

□ DK

□ Ref

4. Thinking about child support, do you have a legal agreement, an informal agreement, or no agreement at all with [FORMER SPOUSE]? [ECLS-B 9-month interview, BF200; Fragile Families Father 12 month interview, FC19A]

□ Legal

□ Informal

□ No arrangement

4. In the last month, have/has [YOU/FORMER SPOUSE] spent money on [FOCAL CHILD]’s? [Fragile Families 36-month interview A1-A5, C30E1-5]

		Yes	No
A	Clothes?	□	□
B	Medicine/health care?	□	□
C	Schooling/child care?	□	□
D	Food?	□	□

SECTION H: CHILD OUTCOMES

INTERVIEWER: ASK Q. 1A-1L TO BOTH PARENTS OF INTACT AND SEPARATED COUPLES. IF THERE ARE NO CHILDREN IN HOME OLDER THAN 1 YEAR, ASK ONLY Q. 1G AND 1L.

1. I am going to read a list of items that sometimes describe children. For each item, please tell me if this is true for (any of) your child(ren) during the past three months.

INTERVIEWER: IF YES, ASK: WHICH CHILD?

			If yes, which child(ren)?
a	Have any of your child(ren) ever had an accident or injury that required medical attention?	Yes No DK Ref
b	Do any of your child(ren) hit, kick, push, or hurt other children or adults outside the family?	Yes No DK Ref
c	Do any of your child(ren) destroy things that belong to others on purpose?	Yes No DK Ref
d	Have you ever gotten a call or note home because any of your child(ren) had a behavior or discipline problem at daycare/school?	Yes No DK Ref
e	Are any of your child(ren) very timid, afraid of new things or new situations?	Yes No DK Ref
f	Are any of your child(ren) high-strung, tense, and nervous?	Yes No DK Ref
g	Have any of your child(ren) been unhappy, sad, or depressed?	Yes No DK Ref
h	Do any of your child(ren) withdraw and want to be alone a lot?	Yes No DK Ref
i	Do any of your child(ren) smoke, drink, use drugs, or skip school?	Yes No DK Ref
j	Do any of your child(ren) have a lot of difficulty getting along with their siblings?	Yes No DK Ref
k	Do any of your child(ren) have a lot of difficulty getting along with other children?	Yes No DK Ref
l	Do any of your children have sleep problems?	Yes No DK Ref

[ JOBS, ECLS-B, CD080, NCSH, National Survey of Children: Wave 1]

SECTION I: PARENTAL WELL-BEING

Stress:

Now I am going to ask you some questions about situations that may cause stress in your life. (PSS, Cohen & Williamson)

1. In the last month, how often have you….

		Never	Hardly ever	Sometimes	Often	DK	Ref
a	Felt that you were unable to control the important things in your life?	1	2	3	4	d	ref
b	Felt that things were going your way?	1	2	3	4	d	ref
c	Felt confident about your ability to handle your personal problems?	1	2	3	4	d	ref

Financial Strain

2. The next set of items will ask you to think about your feelings toward your and your family’s financial situation. Please tell us how true the following statements are to your life. Respond with not true at all, somewhat true, mostly true, or very true. (Conger et al, 1999).

		Not true at all	Somewhat true	Mostly True	Very true	DK	Ref
a	I worry about paying my monthly bills.	1	2	3	5	d	ref
b	I worry that there won’t be enough money to buy clothing, household items, food, and medical care.	1	2	3	5	d	ref
c	We never seem to have enough money to buy something we’d like to have or go somewhere just for fun.	1	2	3	5	d	ref

Mental Health

3. These next questions are about feelings you may have experienced over the past 30 days. Choose only one option for each statement. During the past 30 days, how often did you feel…(National Health Interview Survey)

		Never	Hardly Ever	Sometimes	Often	DK	Ref
a	…so sad that nothing could cheer you up?	1	2	3	4	d	ref
b	…nervous?	1	2	3	4	d	ref
c	…restless or fidgety?	1	2	3	4	d	ref
d	…hopeless?	1	2	3	4	d	ref
e	…that everything was an effort?	1	2	3	4	d	ref
f	…worthless?	1	2	3	4	d	ref

Physical Health:

4. Would you say that your health in general is…(SAQ)

• Excellent

• Very good

• Good

• Fair

• Poor

• DK

• Ref

Substance Abuse:

5. In the last month, have you had five or more drinks on any one day?

• Yes (Ask a, b, and c)

• No (Skip to Q. 6)

In the past month…(SAQ)

	Yes	No	DK	Ref
Have you felt you should cut down on your drinking?	1	2	d	ref
Have people annoyed you by complaining about your drinking?	1	2	d	ref
Have you ever felt bad or guilty about your drinking?	1	2	d	ref

6. In the last month, have you used drugs other than those prescribed by a doctor or purchased over the counter for illness?

• Yes (Ask d, e, f)

• No (Skip to Q. 7)

In the past month…(SAQ)

	Yes	No	DK	Ref
Have you felt you should cut down on your drug use?	1	2	d	ref
Have people annoyed you by complaining about your drug use?	1	2	d	ref
Have you ever felt bad or guilty about your drug use?	1	2	d	ref

7. In the past year, did [SPOUSE/FORMER SPOUSE] have problems keeping a job or getting along with family and friends because of alcohol or drug abuse? (Survey Team)

• Yes

• No

• DK

• Ref

SECTION J: ECONOMIC SECURITY AND

MATERIAL HARDSHIP

Income

Now, please tell me whether you, your spouse, children, or other family members who live in your household received income from these sources in the past month. This includes anyone who you support and who supports you and lives in your household.

1. Did you, [SPOUSE/CURRENT PARTNER], children, or other family members who live with you receive income from this source in the past month? (BSF)

			(IF YES) How much did you receive [Fill in income source] in the past month?
a	Cash welfare which is also known as TANF, or [Local name of TANF]?	Yes No DK Ref
b	Food stamp benefits?	Yes No DK Ref
c	Disability insurance such as Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI)?	Yes No DK Ref
d	Unemployment Insurance Benefits or UI?	Yes No DK Ref
e	Child support?	Yes No DK Ref
f	Money from friends or relatives outside of the household?	Yes No DK Ref

2. In the past month, did you (or [SPOUSE/FORMER SPOUSE]/Current Partner, children, or other family members]) receive money from any other source, such as rent from boarders, other government benefits, or any other income we have not already talked about? [BSF]

• Yes

• No (Skip to Question 3)

• DK

• Ref

2a. How much money from these other sources did you (or [Father/Mother/Current Partner, children, or other family members]) receive in the past month? [BSF]

• Record Response

• DK

• Ref

Employment

The next questions are about your work. [BSF]

3. Have you worked for pay at any time during the past 12 months? Please include odd jobs and temporary jobs.

• Yes

• No (Skip to Question 10)

• DK

• Ref

4. How many months did you work for pay in the past 12 months?

• RECORD RESPONSE

• DK

• Ref

5. Did you work for pay in the past month?

• YES

• NO (Skip to Question 10)

• DK

• Ref

6. What were your total earnings in the past month before taxes and other deductions? Please include tips, commissions, and overtime pay.

PLEASE ENTER IF RESPONDENT PROVIDED THE AMOUNT…

BEFORE TAXES WITHOUT PROBING

BEFORE TAXES AFTER PROBING

AFTER TAXES

NOT SURE

7. How many hours per week did you typically work last month?

• RECORD RESPONSE (Skip to Question 11)

• DK

• Ref

8. Thinking about the last month that you did work, what were your total earnings during that month before taxes and other deductions? Please include tips, commissions, and overtime pay.

• RECORD RESPONSE

• DK

• Ref

9. Which of the following best describes your usual weekly work schedule(s) at the job(s) that you worked during the last month you worked? Did you work a: [CHECK ALL THAT APPLY. If respondent worked more than one job, interviewer should mark the weekly work schedule for each job worked.]

a	Regular daytime shift	Yes No DK Ref
b	Regular evening shift	Yes No DK Ref
c	Regular night shift	Yes No DK Ref
d	Rotating shift (one that changes regularly from days to evenings to nights)	Yes No DK Ref
e	Split shift (one consisting of two distinct periods each day)	Yes No DK Ref
f	An irregular schedule (one that changes from day to day)	Yes No DK Ref
g	Something else? SPECIFY.	Yes No DK Ref

Difficulty Affording Basic Necessities

10. In the past 6 months, has there been a time when you and your immediate family…[New Hope 24, New Hope 60, MFIP, CT, FTP, IWRE]

a	Were without telephone service for any reason?	Yes No DK Ref
b	Didn’t pay the full amount of the rent or mortgage? BSF	Yes No DK Ref
c	Were evicted from your home or apartment for not paying the rent or mortgage? BSF	Yes No DK Ref
d	Had service turned off by the gas or electric company, or the oil company wouldn’t deliver oil because payments were not made? BSF	Yes No DK Ref
e	Had someone who needed to see a doctor or dentist, or go to the hospital but could not go because there was not enough money?	Yes No DK Ref
e	Had to cut the size of your meals or skip meals because there wasn’t enough money for food? (adapted from USDA)	Yes No DK Ref

Residence

11. Are you living in the same house or apartment as you were in {RA MONTH/YEAR}? [INTERVIEWER: DO NOT ASK THIS QUESTION IF THERE IS A REPORT OF EVICTION IN Q. 10] [New Hope 24]

• YES (Skip to Question 14)

• NO

• DK

• Ref

SSP-36

12. How many times altogether have you moved since {RA MONTH/YEAR}, including your most recent move?

NUMBER OF TIMES | ___|___|

SECTION K: SOCIAL SUPPORT

Instrumental and Emotional Support.

All people sometimes need help from others with different things in their lives.

1. Other than (SPOUSE/FORMER SPOUSE), is there someone you turn to…

a	If you needed $100?	Yes No DK Ref
b	If you wanted to have fun and relax?	Yes No DK Ref
c	If you needed help taking care of your children in the case of an emergency?	Yes No DK Ref
d	If you wanted to talk about things that are very personal or private?	Yes No [SKIP TO Q. 3] DK Ref

[SHM Baseline, BSF, Chapin Hall Community Partnerships for Protecting Children (CPPC)]

Social Networks

2. About how many people do you have in your life that you feel at ease with, can call about private matters, or can call on for help? These people can include clergy, close friends or relatives. Would you say that you have no one, one or two people like this, three to five, six to ten, or more than that?

• No one

• One or two

• Three to five

• Six to ten

• More than that

• DK

• Ref

Social Capital Community Benchmark Survey

3. Some people are members of different organizations like church, job-related, recreation, or fraternal or civic groups. Do you belong to any groups or clubs like these? [Penn State Marital Instability Study]

• Yes

• No

• DK

• Ref

4. Going back to you and [SPOUSE/FORMER SPOUSE’S] relationship, how often do/did you have trouble getting along with [SPOUSE/FORMER SPOUSE]’s family and relatives?

• Often

• Sometimes

• Hardly ever

• Never

• DK

• Ref

Support for Marriage

5. How often do you feel that your family interferes/interfered with your relationship with [SPOUSE/FORMER SPOUSE]?  Would you say: [New]

• Often

• Sometimes

• Hardly ever

• Never

• DK

• Ref

6. How often do you feel that your friends interfere/interfered with your relationship with [SPOUSE/FORMER SPOUSE?  Would you say: [New]

• Often

• Sometimes

• Hardly ever

• Never

• DK

• Ref

SECTION L: LOCATING AND DEMOGRPAHIC INFORMATION

SOURCE FOR LOCATION INFORMATION: BSF

Before we end, I would like to find out a little bit more information about where you’re from.

1. Were you born in the United States?

   • Yes [SKIP TO QUESTION 3]

   • No

   • DK

   • Ref

2. In what country were you born?

• SPECIFY

• DK

• Ref

3. Do you speak a language other than English at home

   • Yes, PROBE: And what language do you speak at home?

   • N o

   • DK

   • Ref

4. Do(es) your child(ren) speak a language other than English at home?

   • Yes

   • No

   • DK

   • Ref

5. (For all participants) How well do you speak English?

   • Very well

   • Well

   • Not well

   • Not at all

   • DK

   • Ref

6. The U.S. is a country made up of many cultures and values that can change when people live in this country. Please tell me if you strongly agree, agree, disagree, or strongly disagree with the following statements:

		Strongly agree	Agree	Disagree	Strongly disagree	DK	Ref
a	I identify with American culture.	1	2	3	4
b	[ASK ONLY IF BORN IN ANOTHER COUNTRY] I identify with the culture of [COUNTRY OF ORIGIN].	1	2	3	4

We are almost done. We will be sending you a check for [$30] within the next two weeks. We need to make sure we have your correct address and some information on other people in case you move.

What is your full address?

PROBE: Can you spell the street name for me please?

PROBE: Is there an apartment number?

PROBE: Besides the P.O. Box, do you have a street address?

ENTER ADDRESS LINE 1

ENTER ADDRESS LINE 2

ENTER NAME OF CITY

ENTER STATE

ENTER ZIP CODE

What is your home phone number?

Home phone number
Does not have a phone
DK
REF

Whose name is that phone number listed in?

ENTER NAME
Listed in Sample member’s name
DK
REF

Is there (a/another) phone number where you can be reached?

Home phone number
No other phone
DK
REF

Whose name is that phone number listed in?

ENTER NAME
Listed in Sample member’s name
DK
REF

What is their relationship to you?

Relationship
DK
REF

Do you (also) have a cell-phone or pager number?

Cell phone/pager number
Does not have phone
DK
REF

As part of the study, we will contact you again in about a year and a half. In case you move, we would like the name, address and telephone number of up to three relatives or close friends who would know where you are. We will only contact them if we have trouble getting in touch with you directly.

PROBE: Your grandmother or your mother or someone else who would always know where you are would be most helpful.

What is the first name of a person who would always know where you are?

PROBE: Can you spell that for me please?

INSTRUCTION: HIT DK IF THERE ISN’T A CONTACT

First name of contact
No contact person
DK
REF

And a middle name please?

PROBE: Can you spell that for me please?

MIDDLE NAME OF CONTACT

And a last name please?

PROBE: Can you spell that for me please?

LAST NAME OF CONTACT

What is their relationship to you?

Relationship
DK
REF

Does [he/she] have a nickname?

INSTRUCTION: HIT ENTER IF NO NICKNAME

NICKNAME
No Nickname
DK
REF

What is their full address?

PROBE: Can you spell the street name for me please?

PROBE: Is there an apartment number?

PROBE: Besides the P.O. Box, do they have a street address?

ENTER ADDRESS LINE 1

ENTER ADDRESS LINE 2

ENTER NAME OF CITY

ENTER STATE

ENTER ZIP CODE

What is their home phone number?

Home phone number
Does not have a phone
DK
REF

Whose name is that phone number listed in?

ENTER NAME
Listed in Sample member’s name
DK
REF

Could you tell me the name, address and telephone number of another relative or close friend who will know how to contact you a year and a half from now?

PROBE: Can you spell that for me please?

INSTRUCTION: HIT DK IF THERE ISN’T A CONTACT

First name of contact
No contact person
DK
REF

And a middle name please?

PROBE: Can you spell that for me please?

MIDDLE NAME OF CONTACT

And a last name please?

PROBE: Can you spell that for me please?

LAST NAME OF CONTACT

What is their relationship to you?

Relationship
DK
REF

Does [he/she] have a nickname?

INSTRUCTION: HIT ENTER IF NO NICKNAME

NICKNAME
No Nickname
DK
REF

What is their full address?

PROBE: Can you spell the street name for me please?

PROBE: Is there an apartment number?

PROBE: Besides the P.O. Box, do they have a street address?

ENTER ADDRESS LINE 1

ENTER ADDRESS LINE 2

ENTER NAME OF CITY

ENTER STATE

ENTER ZIP CODE

What is their home phone number?

Home phone number
Does not have a phone
DK
REF

Whose name is that phone number listed under?

ENTER NAME
Listed in Sample member’s name
DK
REF

Could you tell me one more name, address and telephone number of a relative or close friend who will know how to contact you a year and a half from now?

PROBE: Can you spell that for me please?

INSTRUCTION: HIT DK IF THERE ISN’T A CONTACT

First name of contact
No contact person
DK
REF

And a middle name please?

PROBE: Can you spell that for me please?

MIDDLE NAME OF CONTACT

And a last name please?

PROBE: Can you spell that for me please?

LAST NAME OF CONTACT

What is their relationship to you?

Relationship
DK
REF

Does [he/she] have a nickname?

INSTRUCTION: HIT ENTER IF NO NICKNAME

NICKNAME
No Nickname
DK
REF

What is their full address?

PROBE: Can you spell the street name for me please?

PROBE: Is there an apartment number?

PROBE: Besides the P.O. Box, do they have a street address?

ENTER ADDRESS LINE 1

ENTER ADDRESS LINE 2

ENTER NAME OF CITY

ENTER STATE

ENTER ZIP CODE

What is their home phone number?

Home phone number
Does not have a phone
DK
REF

Whose name is that phone number listed in?

ENTER NAME
Listed in Sample member’s name
DK
REF

Thank you very much for your time. Those are all the questions I have right now.

IF COUPLE IS INTACT AND/OR LIVING TOGETHER. Is [SPOUSE] available? I’d like to interview [him/her] too, if [he/she] are around.

If YES: Great, can you put him/her on the phone?

If NO: OK, when would be a good time to reach her/him.

INSTRUCTION: IF [SPOUSE] IS AVAILABLE, ASK TO SPEAK TO HIM/HER. CLOSE THE CURRENT CASE AFTER LEAVING A NOTE ABOUT THIS CASE AND OPEN [SPOUSE’S] CASE.

INSTRUCTION: IF [SPOUSE] ISN’T AVAILABLE, ASK FOR THE BEST TIME TO REACH HIM/HER AND RECORD ON [SPOUSE]’S CONTACT SHEET.

SUPPORTING HEALTHY MARRIAGE PROJECT

Proposed Marital Interaction and Quality Outcome Measures, by Construct

Communication Measures Please tell me if you strongly agree, agree, disagree, or strongly disagree with the following statements about communicating with [SPOUSE/FORMER SPOUSE]: SPOUSE/FORMER SPOUSE] understands that there are times when I do not feel like talking, and times when I do. It is hard for me to talk with [SPOUSE/FORMER SPOUSE] about the important things in our lives. Please indicate whether each of the following happens all of the time, most of the time, some of the time, or none of the time: [SPOUSE/FORMER SPOUSE] listens to me when I need someone to talk to. [SPOUSE/FORMER SPOUSE] and I talk about things that happened during our day.

Sources: SHM Baseline, BSF, FACES II, Cowan & Cowan, and developed by the SHM Team through cognitive testing.

Disagreement and Conflict Resolution Measures . Please indicate whether each of the following happens never, hardly ever, sometimes, or often. In the last three months, how often did you and [SPOUSE/FORMER SPOUSE] have a serious disagreement? In the last three months, when you had a serious disagreement with [SPOUSE/FORMER SPOUSE], how often did you: Just keep your thoughts to yourself? Discuss your disagreements respectfully? Argue in front of the children? Work on it together to find a resolution? Please indicate whether each of the following happens never, hardly ever, sometimes, or often: Small issues suddenly become big arguments. [SPOUSE/FORMER SPOUSE] and I are good at working out our differences. When we argue, past hurts get brought up again. [SPOUSE/FORMER SPOUSE] is rude and mean to me when we disagree. How often does each of the following happen (all of the time, most of the time, some of the time, none of the time)? [SPOUSE/FORMER SPOUSE] and my arguments get very heated. After an argument, [SPOUSE/FORMER SPOUSE] and I stay mad at one another.

Source: SHM Baseline, BSF, EHS, NSFH, ECLS-B, CCQ, GSRH, and developed by the SHM Team through cognitive testing.

Intimacy Measures For each statement please tell me if you strongly agree, agree, disagree, or strongly disagree. [SPOUSE] knows and understands me. [SPOUSE] expresses love and affection towards me. I can count on [SPOUSE] to be there for me. I am comfortable expressing how I feel about sex with [SPOUSE]. I feel appreciated by [SPOUSE]. I trust [SPOUSE] completely. [SPOUSE] respects me. Please tell me whether each of the following is happens all of the time, most of the time, some of the time, or none of the time. [SPOUSE] and I have similar views about what is important in life. I do things to show [SPOUSE] I value him/her.	Source: SHM Baseline, BSF, ENRICH, Walker and Thompson, ISS, and developed by the SHM Team through cognitive testing.
Commitment to Couple Measures Please indicate if you strongly agree, agree, disagree, or strongly disagree with the following statements. [SPOUSE] makes sacrifices for the good of our marriage. I believe this relationship can stay strong even through hard times. I view our marriage as lifelong. Even if I was unhappy, I would stay married to [SPOUSE] because my family expects it. Even if I was unhappy, I would stay married to [SPOUSE] because of religious reasons. Even if I was unhappy, I would stay married to [SPOUSE] because of our children.	Source: SHM Baseline, STMI, RRF, DTS, Commitment Inventory, and developed by the SHM Team through cognitive testing.
Time in Shared Experiences/Interaction Measures Please indicate if you strongly agree, agree, disagree, or strongly disagree with the following statements. [SPOUSE] and I have places to go or things to do that are special for us as a couple We enjoy doing even ordinary, day-to-day things together. Please respond to the following questions with daily, 2-3 times per week, about once a week, 1-3 times a month, or never. In the last month, how often did you and [SPOUSE] spend time together, just the two of you? In the last month, how often did you and [SPOUSE/FORMER SPOUSE] spend time together with your children?	Source: SHM Baseline, BSF, NSFH, and developed by the SHM Team through cognitive testing.
Joint Commitment to Children and Extended Family Measures Do you strongly agree, agree, disagree, or strongly disagree that: [SPOUSE/FORMER SPOUSE] is willing to make sacrifices to help take care of our kids. [SPOUSE/FORMER SPOUSE] takes his/her responsibilities for our children seriously. I could/can raise our kids just as well without [SPOUSE/FORMER SPOUSE]. [SPOUSE/FORMER SPOUSE] supports me in the way I want to raise our child(ren). [Extended Family] Do you strongly agree, agree, disagree, or strongly disagree that: I can count on [SPOUSE] to help with whatever problems my family faces. [SPOUSE] respects and values my family.	Source: BSF and developed by the SHM Team through cognitive testing.
Fidelity Measures Sometimes couples are not always faithful to each other. In the last three months, has [SPOUSE/FORMER SPOUSE] cheated on you with someone else? Would you say definitely yes, probably yes, probably no, or definitely no? In the last three months, have you cheated on [SPOUSE/FORMER SPOUSE] with someone else? Would you say definitely yes, probably yes, probably no, or definitely no?	Source: BSF
Violence Measures In the last three months, how many times has [SPOUSE/FORMER SPOUSE]… Was it 0, 1, 2, 3-5, or 6 or more times? thrown something at you? pushed, shoved, hit, slapped, or grabbed you? used a knife or gun on you? choked, slammed, kicked, burned, or beat you? used force (like hitting, holding down, or using a weapon) to make you have sex? There are five response categories for the above items (0, 1, 2, 3-5, 6+ times). In the last three months, how often have you felt afraid that [SPOUSE] would hurt you? In the last three months, how often has [SPOUSE}: Was it never, hardly ever, sometimes, or often? Accused you of having an affair? Tried to keep you from seeing or talking with your friends or family? Kept money from you, made you ask for money, or taken your money? Yelled or screamed at you? Made you feel stupid on purpose? Blamed you for his/her problems? Threatened to hurt you or the children? In the last three months, how often have your arguments become physical?	Source: SHM Baseline, PMWI
Satisfaction Measures All things considered, on a scale from 1 to 7, where 1 is completely unhappy and 7 is completely happy, how happy are you with your marriage? How often are you satisfied with: Is it all of the time, most of the time, some of the time, or none of the time? The way [SPOUSE/FORMER SPOUSE]] and you communicate. The way you handle you and [SPOUSE/FORMER SPOUSE] handle problems and disagreements. The amount of time you spend together as a couple. The emotional side of your relationship. The responsibility [SPOUSE/FORMER SPOUSE] takes for raising the children. Your sex life. How you divide household chores. The way you handle your money and debt.	Source: SHM Baseline, RELATE, ENRICH, and developed by the SHM Team through cognitive testing.

Marital Stability Measures Please respond with yes or no. In the last three months, have you thought about getting help for your marriage? In the last three months, have you ever thought your marriage was in trouble? In the last three months, have you spoken to anyone about the possibility that you and your spouse might separate or get a divorce?

SUPPORTING HEALTHY MARRIAGE PROJECT

LETTER FOR TRACKING SURVEY SAMPLE

SIX MONTHS AFTER RANDOM ASSIGNMENT

<<DATE>>

«RESPONDENT FIRST NAME» «RESPONDENT LAST NAME»

«ADDR1»

«CITY1», «STATE1» «zip10»

«phone10»

Dear «RESPFN»:

About six months ago you completed an interview when you first applied to participate in the <PROGRAM NAME> in <CITY>. This interview was part of a larger research study that you volunteered to participate in. Thank you for participating in that effort.

We are now planning the next stages of this study. During the next several months we would like to interview you again to see how your life has changed since you were first interviewed at the program.

To help us locate you for the next interview we have enclosed a form that we would like you to complete. Please check your address and telephone number on the following page. If your address and telephone number is different from the information listed, please make the appropriate corrections. If you have a second telephone number where we can reach you, please provide that information in the space provided.

Also, please provide us with the names, addresses, and telephone numbers of two people outside your household who usually know where to reach you. We would call these friends or relatives only if we cannot locate you at your address.

After you complete the following page, please return it to us in the enclosed postage-paid envelope. Or, if you prefer, you may call Abt Associates toll-free at 1-XXX-XXX-XXXX and give your updated information to an interviewer over the phone. Our phone center hours are (Eastern Time):

Monday through Friday: 10:00 AM to 9:00 PM

Saturday: 11:00 AM to 9:00 PM

Sunday: 2:00 PM to 9:00 PM

If you hear a recorded message, please leave your name, telephone number, along with your address update and the best time to call you. One of our interviewers will call you back very soon. A $2 bill has been included to thank you for your time and effort. Thank you in advance for your cooperation.

Sincerely yours,

Brenda Rodriguez

Senior Survey Director

Page 2

AFTER YOU COMPLETE THIS FORM, PLEASE RETURN IT TO US IN THE ENCLOSED POSTAGE-PAID ENVELOPE.

(PLEASE PRINT)

 Is this the correct spelling of your name?

«fst_name» «mid_name» «lst_name»

G Yes

G No  The correct spelling is:

first name m.i. last name

 Is this your correct address?

«address», «city», «state» «zip»

G Yes

G No  My correct address is:

street apt. no city state zip

 Is this your correct phone number? «phoneclean»

G Yes

G No  My correct phone number is:

area code telephone number

Please list the name, address, and relationship to you of two people who will always know where to reach you.

(PLEASE PRINT)

 Name :

 Relation to you :

 Address :

City :

State : __________________________ ZIP Code : ________________

 Phone # : (_____)________ - __________

 Name :

 Relation to you :

 Address :

City :

State : __________________________ ZIP Code : ________________

 Phone # : (_____)________ - __________

SUPPORTING HEALTHY MARRIAGE PROJECT

LETTER SENT TO INTRODUCE 12-MONTH DATA COLLECTION EFFORT

<<DATE>>

«RESPONDENT FIRST NAME» «RESPONDENT LAST NAME»

«ADDR1»

«CITY1», «STATE1» «zip10»

«phone10»

Dear «RESPFN»:

In the <RADATE YEAR>, you had an interview with <PROGRAM NAME> in (CITY) as part of the Supporting Healthy Marriage project. At that time, you completed a questionnaire as part of a study about your household composition and your relationship with <R’s PARTNER AT BASELINE>. Thank you for participating in that effort.

We want to interview you again to see how your life has changed since first meeting with the program. In the coming months, a professional interviewer will be in contact with you by phone or in person to set an appointment to conduct the interview.

All of the information you provide is strictly confidential. Your answers will be combined with other people’s and will be reported together as a group. No individual responses will be identified. Your participation in this study will not affect any benefits you might receive now or in the future.

The interview will take about 50 minutes and we will give you $30 in appreciation for your time. Some participants will be invited to take part in an in-home family interaction session. Upon completion of the in-home visit they will receive an additional $25.

Listed at the top of this letter are the address and phone number we have for you in our records. If there is a better phone number or address where you can be reached, or if you have questions, please call our toll free number: 1-XXX-XXX-XXXX.

Thank you in advance for your cooperation.

Sincerely yours,

Brenda Rodriguez

Senior Survey Director

SUPPORTING HEALTHY MARRIAGE PROJECT

OMB Control Number: 0970-0299

Expiration Date: 5/31/2009

Research ID: ________________

Agreement to take part in the Supporting Healthy Marriage Study

You are invited to take part in an important project called Supporting Healthy Marriage. This project will study programs to help couples learn how to get along with each other. The programs will also help couples be better parents. They will also help couples get services to improve their employment or health. A research company called MDRC is doing the study. The federal government is paying for the study.

This study is testing ways to help married couples get along.

This study will offer a new program [Local Program] to married couples. [Local program] will not have room for all couples who want to take part. Some couples will get to be part of [Local Program] but some couples will not. We will pick the couples who will get to be part of the [Local program] randomly, like flipping a coin. If we do not pick you, you can still get other services on your own.

If you agree to be in the study, researchers will collect information about you and your children.

The information you share with the study team is important. It could help make these services available to other couples like you. At the start of the study, you and your spouse will be asked to answer some questions in private. These questions will ask you how well you get along with your spouse, how happy or sad you are, and what makes you upset.

If you agree to be in the study, you and your spouse will be interviewed one or more times over the next seven years by a survey company called Abt Associates. Abt Associates is part of the research team for this study. You will be asked about your marriage, how well you are getting along with your spouse, your experiences with [Local program], and your children. You might also be asked to let us do some activities with your children. You do not have to answer any question that you don’t want to answer. You will get [gift amount] for each interview.

If you agree to be in the study, [Local Program] program will share information with the research team about the services you get over the next five years as well. We might also collect data from [State] about things like your wages and benefits. We might also collect data from [State] about services your children get, and your children’s school test scores.

Taking part in the study is your choice. You may stop being in the study at any time. If you stop being in the study, we will use any information that we have collected before then.

Your Answers Will Be Kept Private

Only the study staff will be able to see information you give them. Your name will never appear in any public document. All the study staff is trained to protect privacy. Information gathered from [State] about you or your children will be marked with a code number, not names. We also have a Confidentiality Certificate (CC) from the US government that adds special protection for the research information about you. It says we do not have to identify you, even under a court order or subpoena. Still, if keeping your answers private would put you, someone else or your child in serious danger, then we will have to tell government agencies to protect you or the other person. And, the government may see your information if it audits us.

Consent to Take Part in the Supporting Healthy Marriage Study

I understand that:

• [Local Program] will not have room for all couples. A random selection process will decide if I can get [Local Program] services.

• If I cannot get [Local Program] services, I will still be part of the study. I can still get other program services in our community.

• I will be contacted by the study team later for an interview. Some of the questions will be about personal things and my feelings. I can refuse to answer any question.

• The study team might use my name or Social Security number to collect data from government agencies.

• All information will be kept confidential, except as required by law or if I request otherwise in writing. However, if a person on the study team or in the program feels that keeping information confidential would result in danger to me or another person, they will have to tell appropriate agencies to protect me or the other person.

I agree to:

• Allow a random selection process to decide if I can get [Local Program] services.

• Answer some questions now and give the study team information about how to reach me for an interview later.

• Let the study team collect information on [Local Program] services that I receive.

• Let state and local agencies give information about me to the study team.

• Let the study team collect information about my children from me and from sources like state and local agencies.

• Allow schools to release my children’s test scores.

I can call [NAME OF PERSON] toll-free at [TELEPHONE NUMBER] at MDRC to ask any questions I may have or to ask about not being part of the study anymore.

Participant

_____________________________

Name of Participant (Printed)

_____________________________ ____________________

Signature of Participant Date

_____________________________

Name of Person Administering this Form (Printed)

_____________________________ ____________________

Signature of Person Administering this Form Date

Consent for children under age 18 who live with you at least half the time

_____________________________

A. Study Participant’s Child’s Name (Printed)

___________________________________ ________________________

Signature of Child’s Legal Parent or Guardian Date

_____________________________

B. Study Participant’s Child’s Name (Printed)

___________________________________ ________________________

Signature of Child’s Legal Parent or Guardian Date

_____________________________

C. Study Participant’s Child’s Name (Printed)

___________________________________ ________________________

Signature of Child’s Legal Parent or Guardian Date

_____________________________

D. Study Participant’s Child’s Name (Printed)

___________________________________ ________________________

Signature of Child’s Legal Parent or Guardian Date

_____________________________

E. Study Participant’s Child’s Name (Printed)

___________________________________ ________________________

Signature of Child’s Legal Parent or Guardian Date

_____________________________

F. Study Participant’s Child’s Name (Printed)

___________________________________ ________________________

Signature of Child’s Legal Parent or Guardian Date

_____________________________

G. Study Participant’s Child’s Name (Printed)

___________________________________ ________________________

Signature of Child’s Legal Parent or Guardian Date

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