Peel
Off Child
Name Label
Updater
Name: ___________________________ Updater
Code: ____________________________ (Check
one) Telephone: _____ In Person: _____ Date:
______/______/______
Month
Day Year Start
Time: _______AM PM End Time: ______AM PM
Site
Coordinator Name: _____________________ Caregiver
Language: _______________________ Child
ID
Number:
__________________________
Good [morning, afternoon or evening]. Is this (NAME OF RESPONDENT)? (IF NO, ASK FOR RESPONDENT; IF NOT AVAILABLE, ASK WHEN TO CALL BACK TO TALK WITH HIM/HER.) My name is ______________________, and I’m calling you as a former participant in the Head Start Impact Study and follow-ups. Data collection for the earlier studies has ended; however, in anticipation of a future follow-up, the U.S. Department of Health and Human Services has decided to keep in touch with the children and families beyond 8th grade through the high school years. We are contacting participating study families to maintain up-to-date information. We’d like to ask you a few, brief questions, much like the ones we asked last spring. The interview should take about 15 minutes to complete. We have a few questions about your child’s school and some questions to help make it possible to contact you if we need to in the future.
We would like to thank you for completing this brief phone interview by sending you a check in the amount of 20 dollars. We would like to remind you that all information collected is confidential and will be kept private except as required by law. Your participation is voluntary. You may quit the interview at any time. Your participation will not result in the loss of any current benefits you may have. We truly appreciate your help and your continued support of this important study. May we begin now? (IF AGREES, CONTINUE WITH THE INTERVIEW. IF NO, ASK: When would you like to schedule a date and time to complete this short interview?)
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 0970-0229 (expires________). The time required to complete this information collection is estimated to average 15 – 20 minutes per response, including time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. |
A. CONTACT INFORMATION UPDATE
A-1. Have you moved since May 1, 2011?
YES 1
NO 2
A-2. What is your current street address and telephone number? Also, please tell me whether this is the correct spelling of your name.
(INTERVIEWER SPELL NAME AS LISTED ON CHILD PROFILE, VERIFY WITH RESPONDENT, AND RECORD BELOW WITH PHYSICAL STREET ADDRESS AND TELEPHONE NUMBERS.)
Name: _______________________________________________________
First Name Last Name
Address: _______________________________________________________
Street Apartment
_______________________________________________________
_______________________________________________________
City State Zip
Home Telephone: (__________) - ___________-____________________
(Area Code)
Cell Phone: (__________) - ___________-____________________
(Area Code)
Pager (__________) - ___________-____________________
(Area Code)
Alternate Phone (__________) - ___________-____________________
(Area Code)
A-3. Is this the name and address for us to use when we send you a letter in the mail?
YES 1 (GO TO A-5)
NO 2
A-4. What is the name and address where we should send you a letter in the mail?
Name: _______________________________________________________
First Name Last Name
Address: _______________________________________________________
Street/P.O. Box Apartment
_______________________________________________________
_______________________________________________________
City State Zip
A-5. Should we mail your 20 dollar check to you at (this address/one of these addresses)?
YES, PHYSICAL ADDRESS 1 (GO TO A-7)
YES, LETTER MAILING ADDRESS 2 (GO TO A-7)
NO, ANOTHER NAME AND/OR ADDRESS 3
(NOTE: IF RESPONDENT STATES THAT HE/SHE CANNOT CASH A CHECK, SAY THAT WE WILL SEND A MONEY ORDER AND CHECK BOX BELOW.)
SEND MONEY ORDER
A-6. What is the name and address where we should mail the check?
Name: _______________________________________________________
First Name Last Name
Address: _______________________________________________________
Street/ P.O. Box Apartment
_______________________________________________________
_______________________________________________________
City State Zip
A-7. Are you currently employed?
YES 1
NO 2 (GO TO A-9)
A-8. What is the name, address and telephone number of the place where you work?
Name: _______________________________________________________
Address: _______________________________________________________
Street
_______________________________________________________
_______________________________________________________
City State Zip
Telephone Number (__________) - ___________-____________________
(Area Code)
Alternate Phone: (__________) - ___________-____________________
(Area Code)
A-9. Are you planning to move between now and March 2013?
YES 1
NO 2 (GO TO A-12a)
A-10. Do you know what your new address will be or the general area where you are planning to move?
YES 1
NO 2 (GO TO A-12a)
A-11. What is the area where you are planning to move and, if you know, what will be your new address and telephone number?
(RECORD AS MUCH INFORMATION AS THE RESPONDENT KNOWS.)
Address: _______________________________________________________
Street Apartment
_______________________________________________________
_______________________________________________________
City State Zip
Telephone: (__________) - ___________-____________________
(Area Code)
Just in case we have trouble reaching you in the future, would you please tell me the names, addresses, and telephone numbers of three people who will know how to contact you?
A-12a. What is the name of the first person?
First Name Last Name
A-12b. How is this person related to [CHILD]? (CIRCLE THE RELATIONSHIP CODE.)
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) |
A-12c.What is his/her home telephone number? (__________) - ___________-_________________
(Area Code)
NO TELEPHONE 1
REFUSED 7
A-12d. What is this person’s address?
Address: _______________________________________________________
Street Apartment
_______________________________________________________
_______________________________________________________
City State Zip
A-12e. Does he/she have a cell phone number?
YES 1
NO 2 (GO TO A12g)
A-12f. What is his/her cell phone number? (__________) - ___________-____________________
(Area Code)
A-12g. Does he/she have a work telephone number?
YES 1
NO 2 (GO TO A-13a)
A-12h. What is his/her work telephone number and the name of the place where he/she works?
Telephone Number (__________) - ___________-____________________
(Area Code)
Name: _______________________________________________________
A-13a. What is the name of the second person?
First Name Last Name
A-13b. How is this person related to [CHILD]? (CIRCLE THE RELATIONSHIP CODE.)
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) |
A-13c. What is his/her home telephone number? (__________) - ___________-________________
(Area Code)
NO TELEPHONE 1
REFUSED 7
A-13d. What is his/her address?
Address: _______________________________________________________
Street Apartment
_______________________________________________________
_______________________________________________________
City State Zip
A-13e. Does he/she have a cell phone number?
YES 1
NO 2 (GO TO A-13g)
A-13f. What is his/her cell phone number? (__________) - ___________-____________________
(Area Code)
A-13g. Does he/she have a work telephone number?
YES 1
NO 2 (GO to A-14a)
A-13h. What is his/her work telephone number and the name of the place where he/she works?
Telephone Number (__________) - ___________-____________________
(Area Code)
Name: _______________________________________________________
A-14a. What is the name of the third person?
First Name Last Name
A-14b. How is this person related to [CHILD]? (CIRCLE THE RELATIONSHIP CODE.)
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) |
A-14c. What is his/her home telephone number? (__________) - ___________-________________
(Area Code)
NO TELEPHONE 1
REFUSED 7
A-14d. What is his/her address?
Address: _______________________________________________________
Street Apartment
_______________________________________________________
_______________________________________________________
City State Zip
A-14e. Does he/she have a cell phone number?
YES 1
NO 2 (GO TO A14g)
A-14f. What is his/her cell phone number? (__________) - ___________-____________________
(Area Code)
A-14g Does he/she have a work telephone number?
YES 1
NO 2 (GO TO B)
A-14h. What is his/her work telephone number and the name of the place where he/she works?
Telephone Number (__________) - ___________-____________________
(Area Code)
Name: _______________________________________________________
B. School Information
Now I have a few questions about where your child is currently in school.
B-1. Is your child currently enrolled in Ninth Grade, Eighth Grade, Seventh Grade, or Sixth Grade?
YES, NINTH GRADE 01
YES, EIGHTH GRADE 02
YES, SEVENTH GRADE 03
YES, SIXTH GRADE 04
NO, UNGRADED 05
Other (Specify) _______________________________ 06
B-2. Which of the following best describes the school setting that [CHILD] is in?
Public School 01
Private School 02
Home School 03
Other (Specify) _______________________________ 04
B-3. What is the name, address, and telephone number of this school?
Name: _______________________________________________________
Address: _______________________________________________________
Street
_______________________________________________________
_______________________________________________________
City State Zip
Telephone: (__________) - ___________-____________________
(Area Code)
C. SCHOOL ENROLLMENT CHANGES
C-1. Between now and March 2013, are you planning to change [CHILD’S] school?
YES 1
IF YES, approximately when? ________________________
Month
NO 2 (GO TO D)
C-2. Do you know the name, address or telephone number of that school or where it will be located?
YES 1
NO 2 (GO TO D)
C-3. What is the area where the school will be located and, if you know it, what is the name, address and telephone number of that school? (RECORD AS MUCH INFORMATION AS THE RESPONDENT KNOWS.)
Name: _______________________________________________________
Address: _______________________________________________________
Street
_______________________________________________________
_______________________________________________________
City State Zip
Telephone: (__________) - ___________-____________________
(Area Code)
END SCRIPT:
That’s all the questions I have. Thank you for your cooperation. You will receive your check for $20 as soon as possible, but it may not be for 6-8 weeks.
(END OF INTERVIEW)
If found, return to:
Westat
1600 Research Boulevard
Room RB 3105 – 8996.01.05
Rockville, MD 20850
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Department of Health and Human Services |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |