Tracking Survey
Tracking of Participants in the Early Head Start Research and Evaluation Project
ATTACHMENT C Tracking Survey Telephone Version REV2
Tracking Survey
OMB: 0970-0388
E
OMB#
0970-0388
Expires:
10/1/2015
TRACKING SURVEY 2013
FOR TELEPHONE INTERVIEWER ADMINISTRATION
May I please speak with (PRIMARY CAREGIVER NAME)?
IF NEEDED: This is (INTERVIEWER NAME) calling from RAND about the Early Head Start Study he/she has been participating in.
IF INFORMED THAT PCG MOVED
>rdi2< I’m calling to speak with (CHILD NAME)’s primary caregiver. Does (CHILD NAME) still live there?
YES …1 GO TO >childthere<
NO……0
>rdi2a< Do you have a new number where I can reach (PRIMARY CAREGIVER NAME)?
YES …1 ENTER NEW NUMBER AND CALL
NO …..0 CODE MOVED NO NEW NUMBER
IF INFORMED THAT PCG IS AWAY FOR DURATION OF STUDY (JAIL, OUT OF COUNTRY, ETC.)
>Paway< I’m calling to speak with (CHILD NAME)’s primary caregiver. Does (CHILD NAME) still live there?
YES …1 GO TO >childthere<
NO……0 GO TO >childnotthere<
IF INFORMED THAT PCG IS DECEASED
>Pdead< I’m very sorry. I’m calling to speak with (CHILD NAME)’s primary caregiver. Does (CHILD NAME) still live there?
YES …1 GO TO >childthere<
NO.…..0 GO TO >childnotthere<
>childthere< May I speak to his/her primary caregiver?
YES….1 GO TO >newpcg<
CALLBACK
REFUSED
>childnotthere< Do you have a number where I can reach (CHILD’S NAME)’s new primary caregiver?
YES….1
NO...…0 GO TO >npcg9<
>briefnewpcg<
ENTER NAME AND NUMBER PROVIDED BY INFORMANT
NAME __________
PHONE NUMBER _______________
[PROGRAMMER: CODE CASE 1.21 FINAL BRIEF NEW PCG COMPLETE]
PRIMARY CAREGIVER COMES TO THE PHONE
>intr< Hello, my name is _______. I am calling from RAND about the Early Head Start Follow-up Study that you and (CHILD NAME) participated in in the past. We sent you a letter to let you know we would be calling. Did you get that letter?
YES, RECEIVED LETTER
>intr_let< As we said in the letter, we are calling because the information learned from this study has been so valuable that the government hopes to continue the study with the same children. They hope to learn how taking part in Head Start or other preschool programs affects children’s learning when the children are older. We are contacting you now just to update your contact information in our records, and to ask a few questions about how you and (CHILD NAME) are doing. This will just take a few minutes, and when it is completed we will send you a check for $10 as a thank you.
IF NEEDED: RAND is a non-profit research organization. The U.S. Department of Health and Human Services has asked RAND to contact families who have participated in the Early Head Start Research and Evaluation Project to update their contact information.
IF NEEDED: We are calling you because you and (CHILD NAME) have participated in the Early Head Start Research and Evaluation Project in the past, and we want to be able to reach you again in the future for this important study. This is the study you enrolled in at (SITE NAME) when (CHILD NAME) was a baby.
Do you have a few minutes to do this now?
YES ……………...1
NO, CALLBACK…5
R VOLUNTEERS NO LONGER CHILD’S PCG….7 GO TO >newpcg<
REFUSED………..r
NO, DID NOT RECEIVE LETTER
>intrnolet< The letter was to let you know we would be calling you just to update your contact information in our records, and to ask a few questions about how you and (CHILD NAME) are doing. The information learned from this study has been so valuable that the government hopes to continue the study with the same children. They hope to learn how taking part in Head Start or other preschool programs affects children’s learning when the children are older. This will just take a few minutes, and when it is completed we will send you a check for $10 as a thank you.
IF NEEDED: RAND is a non-profit research organization. The U.S. Department of Health and Human Services has asked RAND to contact families who have participated in the Early Head Start Research and Evaluation Project to update their contact information.
IF NEEDED: We are calling you because you and (CHILD NAME) have participated in the Early Head Start Research and Evaluation Project in the past, and we want to be able to reach you again in the future for this important study. This is the study you enrolled in at (SITE NAME) when (CHILD NAME) was a baby.
Do you have a few minutes to do this now?
YES ……………...1
NO, CALLBACK…5
R VOLUNTEERS NO LONGER CHILD’S PCG…7 GO TO >newpcg<
REMAIL LETTER AND SET CALLBACK
REFUSED………..r
>intro1< The contact information that we collect from you will be shared only with researchers working on the Early Head Start Follow-up Study and kept private to the extent permitted by law. Providing updated contact information and answering the questions is completely voluntary. If you are contacted in the future for the study, you can decide at that time whether or not to take part. As I mentioned, once we update your contact information, we will send you a check for $10 as a thank you.
IF NEEDED: GIVE NAMES/NUMBERS OF WHOM TO CONTACT FOR MORE INFORMATION.
>monitor< I need to let you know this call may be monitored by a supervisor for quality control.
BEGIN CONTACT INTERVIEW
>Q1< We have your name as (FILL PRIMARYCAREGIVER NAME). Is this correct?
YES…..1 GO TO >Q2<
NO……0
>Q1a< What is your correct name?
FIRST ________MIDDLE________LAST_________
>Q2< We have your child’s name as (FILL CHILD NAME). Is this correct?
YES….1 GO TO >Q3<
NO……0
>Q2a< What is the child’s correct name?
FIRST ________MIDDLE________LAST_________
>Q3< Are you still (CHILD NAME)’s primary caregiver?
YES…..1
NO…….0 GO TO >newpcg<
[PROGRAMMER: DON’T KNOW AND REFUSED FOLLOW YES PATH]
>Q4< What is your current home address?
STREET __________________________________ APT NUMBER ______
CITY ___________________________STATE ___ ZIP CODE __________
>Q5< Do you receive mail at this address?
YES…1 GO TO >Q6<
NO…..0
>Q5a< Where do you receive mail?
STREET____________________________APT NUMBER ______
CITY ________________________STATE _ ZIP CODE ______
>Q6< What is the best phone number to reach you on?
( _____ ) ______ - ______________ EXT ____
☐ DON’T KNOW OR REFUSED GO TO >Q8<
Is that your cell __, home __, work _, or something else? _SPECIFY___
>Q7< What other phone numbers could we call you on?
>PHONE1@1< ( _____ ) ______ - ______________ EXT ____
☐ NO OTHER PHONE NUMBERS GO TO >Q8<
Is that your cell __, home __, work _, or something else? __SPECIFY___
>PHONE2@2< ( _____ ) ______ - ______________ EXT ____
☐ NO OTHER PHONE NUMBERS GO TO >Q8<
Is that your cell __, home __, work _, or something else? __SPECIFY___
>PHONE3@3< ( _____ ) ______ - ______________ EXT ____
☐ NO OTHER PHONE NUMBERS GO TO >Q8<
Is that your cell __, home __, work _, or something else? __SPECIFY___
>Q8< What is your email address?
____________________________@_________________
☐ DOESN’T HAVE EMAIL, REFUSED OR DON’T KNOW
>Q9< Do you work outside the home?
YES…1
NO…..0 GO TO >Q10<
>Q9a< Where do you work?
COMPANY NAME ___________________________________________
STREET ADDRESS __________________________________________________________
CITY ___________________________STATE _______ ZIP CODE _________
PHONE NUMBER ( _____ ) ______ - __________ EXT __________
☐ REFUSED
>Q10< Do you have any plans to move in the next year?
YES….1
NO…...0 GO TO >Q11<
>Q10a< Approximately what date would you move?
ENTER MONTH
ENTER YEAR
>Q10b< Do you know where?
YES…..1
NO…….0 GO TO >Q11<
CITY ________STATE_____COUNTRY____
>Q11< In case we are unable to reach you in the future, please give us the names and contact information of three close relatives or friends who are likely to know how to contact you. We will only contact these people if we are unable to contact you directly.
CONTINUE……….1
REFUSED…………r GO TO >after 18<
>Q11a< What is the first person’s name?
FIRST NAME ____________ MIDDLE INITIAL __ LAST NAME ____________
INTERVIEWER CODE GENDER: MALE ___ FEMALE: ___
(IF NEEDED: Is that a man or a woman?)
Who is this person?
Your Parent ___ Your Sister/Brother __ A Friend ___ A Current Spouse___
A Former Spouse __ or Someone else?______SPECIFY___________
What is his/her address?
STREET____________________________________ APT# ____
CITY _______________________ STATE _____ ZIP CODE_______
What are his/her phone numbers?
( _____ ) ______ - __________
Is that a Cell _ Home _ Work __ or other type of number?__SPECIFY
( _____ ) ______ - __________
Is that a Cell _ Home _ Work __ or other type of number?__ SPECIFY
What is his/her email address?
__________________________________@___________
What language does he/she speak?
ENGLISH_____
SPANISH____
OTHER _____ SPECIFY______
>Q11b< What is the second person’s name?
☐ NO SECOND CONTACT GO TO >after 18<
FIRST NAME ____________ MIDDLE INITIAL __ LAST NAME ____________
INTERVIEWER CODE GENDER: MALE ___ FEMALE: ___
(IF NEEDED: Is that a man or a woman?)
Who is this person?
Your Parent ___ Your Sister/Brother __ A Friend ___ A Current Spouse___
A Former Spouse __ or Someone else?______SPECIFY___________
What is his/her address?
STREET____________________________________ APT# ____
CITY _______________________ STATE _____ ZIP CODE_______
What are his/her phone numbers?
( _____ ) ______ - __________
Is that a Cell _ Home _ Work __ or other type of number?__SPECIFY
( _____ ) ______ - __________
Is that a Cell _ Home _ Work __ or other type of number?__ SPECIFY
What is his/her email address?
__________________________________@___________
What language does he/she speak?
ENGLISH_____
SPANISH____
OTHER _____ SPECIFY______
>Q11c< What is the third person’s name?
☐ NO THIRD CONTACT GO TO >after 18<
FIRST NAME ____________ MIDDLE INITIAL __ LAST NAME ____________
INTERVIEWER CODE GENDER: MALE ___ FEMALE: ___
(IF NEEDED: Is that a man or a woman?)
Who is this person?
Your Parent ___ Your Sister/Brother __ A Friend ___ A Current Spouse___
A Former Spouse __ or Someone else?______SPECIFY___________
What is his/her address?
STREET____________________________________ APT# ____
CITY _______________________ STATE _____ ZIP CODE_______
What are his/her phone numbers?
( _____ ) ______ - __________
Is that a Cell _ Home _ Work __ or other type of number?__SPECIFY
( _____ ) ______ - __________
Is that a Cell _ Home _ Work __ or other type of number?__ SPECIFY
What is his/her email address?
__________________________________@___________
What language does he/she speak?
ENGLISH_____
SPANISH____
OTHER _____ SPECIFY______
>after18< After (CHILD NAME) turns 18, we would like to follow up with (him/ her) directly. If (CHILD NAME) is contacted in the future for the study, (he/she) can decide at that time whether or not to take part.
>Q12< What is (CHILD NAME)’s email address?
____________________________@_________________
☐ DOESN’T HAVE EMAIL, REFUSED OR DON’T KNOW
>Q13< What is (CHILD NAME)’s cell phone number?
( _____ ) ______ - ______________
☐ DOESN’T HAVE A CELL, REFUSED OR DON’T KNOW
>Q14< Are there any other ways to reach (CHILD NAME) directly after (he/she) turns 18?
___________________________________________________________
___________________________________________________________
☐ NO OTHER WAYS
>Q15< Thinking ahead to when (CHILD NAME) is 18, where do you think (he/she) will be living?
With you
With another family member
On his/her own or with roommates
In a college dorm
In the military
Or somewhere else (SPECIFY) _____________________
Now we’d like to ask a few questions about how (CHILD NAME) is doing.
>Q16< (Will/Did) (CHILD NAME) graduate high school or get a GED before fall 2013?
YES, GRADUATED HIGH SCHOOL
YES, GED
NO PLEASE SKIP TO QUESTION #18
>Q17< (Will/Does) (CHILD NAME) go to college?
YES
NO
>Q18< What school will (CHILD NAME) attend in the fall of 2013?
SCHOOL _________________________CITY _________________
CHILD DOES NOT/WILL NOT ATTEND SCHOOL ->GO TO Q20
DON’T KNOW
REFUSED
>Q19< What grade will (he/she) be in in fall of 2013?
DROP DOWN
LESS THAN 5TH GRADE
CODE ANY ONE GRADE 5 THROUGH 12
MORE THAN 12TH GRADE
NO GRADE ASSIGNED
>Q20< What do you think are the chances (CHILD NAME) will graduate from college?
Would you say…
No chance
Some chance
About 50/50
Pretty likely
It will happen
>Q21< What do you think are the chances (CHILD NAME) will have a good job by age 30? Would you say…
No chance
Some chance
About 50/50
Pretty likely
It will happen
>Q22< Has (CHILD NAME) ever had any contact with the juvenile justice system? This would include: being picked up by the police for breaking the law, being found guilty for a crime or a delinquent offense, being on probation or court supervision, or being held at juvenile hall or in jail
YES
NO
DON’T KNOW
>Q23< Overall, would you describe (CHILD NAME)’s health as…
Excellent
Very good
Good
Fair
Poor
>now< Now I have a few questions about you.
>Q24< What is the highest grade or year of school that you have completed?
Less than high school
High school or GED
Vocational school or 2 year Associate’s Degree
College or graduate school
>Q25< Which of the following best describes your present work or school situation?
Working full-time (35 hours a week or more)
Working part-time (less than 35 hours per week)
Unemployed and looking for work
Unemployed and not looking for work
Full-time homemaker
In school
Too disabled to work
Or some other situation (SPECIFY): ____________________________
>Q26< The following questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.
How much of the time during the past 4 weeks...
>Q26a< Have you felt calm and peaceful? Would you say…
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
>Q26b< How much of the time during the past 4 weeks did you have a lot of energy?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
>Q26c< How much of the time during the past 4 weeks have you felt downhearted and blue?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
>thanks< Thank you for the updated information. To thank you, we will send you a check for $10. You should receive it in two to three weeks.
Thank you for taking part in the Early Head Start Follow-up Study.
NEW PRIMARY CAREGIVER SECTION
>newpcg< INTERVIEWER: WHO ARE YOU SPEAKING WITH?
1 RESPONDENT (ORIGINAL PRIMARY CAREGIVER IN SAMPLE)
2 NEW PRIMARY CAREGIVER
PROGRAMMER CHECK
IF >NEWPCG< = 1 AND Q3=0 GO TO >npcg1<
IF >NEWPCG< = 2 GO TO >intrnolet<]
IF NEW PRIMARY CAREGIVER
>intrnolet< [if >newpcg< = 2)]
Hello, my name is _______. I am calling from RAND about the Early Head Start Follow-up Study that [FILL PCG NAME] and [FILL CHILD NAME] participated in in the past. We sent [FILL PCG NAME] a letter to let her/him know we would be calling just to update her/his contact information in our records, and to ask a few questions to see how (CHILD NAME) is doing. Since you are (CHILD’S NAME)’s primary caregiver now, we’d like to speak to you. The information learned from the study has been so valuable that the government hopes to continue the study with the same children. They hope to learn how taking part in Head Start or other preschool programs affects children’s learning when the children are older. This will just take a few minutes, and when it is completed we will send you a check for $10 as a thank you.
IF NEEDED: RAND is a non-profit research organization. The U.S. Department of Health and Human Services has asked RAND to contact families who have participated in the Early Head Start Research and Evaluation Project to update their contact information.
IF NEEDED: This is the study they enrolled in at (SITE NAME) when (CHILD NAME) was a baby.
IF NEEDED: GIVE NAMES/NUMBERS OF WHO TO CONTACT FOR MORE INFORMATION.
Do you have a few minutes to do this now?
YES ……………...1
NO, CALLBACK…5
REFUSED………..r
>intro1< The contact information that we collect from you will be shared only with researchers working on the Early Head Start Follow-up Study. Providing updated contact information and answering the questions is completely voluntary. If you are contacted in the future for the study, you can decide at that time whether or not to take part. As I mentioned, once we update your contact information, we will send you a check for $10 as a thank you.
>monitor< I need to let you know this call may be monitored by a supervisor for quality control.
>npcg1< Can you tell me who (CHILD NAME)’s primary caregiver is now? (What is his/her/your name)?
FIRST____________MIDDLE______________LAST________________ ___
DON’T KNOW -> GO TO >npcg9<
>npcg2< What is his/her/your relationship to (CHILD NAME)?
PARENT…………………………………1
GRANDPARENT………………………..2
OTHER RELATIVE……………………..3
NON-RELATIVE FOSTER PARENT...4
OTHER NON-RELATIVE………………5
SOMEONE ELSE SPECIFY_______ 6
>npgg3< About when did he/she/you become (CHILD NAME)’s primary caregiver?
(MONTH/YEAR) _____/___________
>npcg4< What is the best phone number to reach (NEW PCG/you) on?
( _____ ) ______ - ______________ EXT_____
DON’T KNOW
REFUSED
Is that his/her cell __, home __, work _, or something else? ________
DON’T KNOW
REFUSED
>npcg5< Do you have any other phone numbers (for NEW PCG)?
☐ CHECK HERE IF NONE
( _____ ) ______ - ______________ EXT______
Is that his/her/your cell __, home __, work _, or something else? __SPECIFY
( _____ ) ______ - ______________ EXT______
Is that his/her/your cell __, home __, work _, or something else? __SPECIFY
( _____ ) ______ - ______________ EXT______
Is that his/her/your cell __, home __, work _, or something else? __SPECIFY
>npcg5a< What is his/her/your email address?
____________________________@_________________
☐ DOESN’T HAVE EMAIL
>npcg6< What is (CHILD NAME)’s current home address?
STREET __________________________________ APT NUMBER ______
CITY ___________________________STATE ___ ZIP CODE __________
>npcg7< What is (CHILD NAME)’s permanent home address?
☐ SAME AS CURRENT ADDRESS
STREET __________________________________ APT NUMBER ______
CITY ___________________________STATE ___ ZIP CODE __________
PROGRAMMER CHECK:
IF >newpcg<=1 GO TO >caddress<
IF >newpcg<=2 GO TO >npcg8<
>npcg8< In case we are unable to reach you in the future, please give us the names and contact information of three close relatives or friends who are likely to know how to contact you. We will only contact these people if we are unable to contact you directly.
CONTINUE……….1
REFUSED…………r GO TO >after18<
>npcg8a< What is the first person’s name?
FIRST NAME ____________ MIDDLE INITIAL __ LAST NAME ____________
INTERVIEWER CODE GENDER: MALE ___ FEMALE: ___
(IF NEEDED: Is that a man or a woman?)
Who is this person?
Your Parent ___ Your Sister/Brother __ A Friend ___ A Current Spouse___
A Former Spouse __ or Someone else?______SPECIFY___________
What is his/her address?
STREET____________________________________ APT# ____
CITY _______________________ STATE _____ ZIP CODE_______
What are his/her phone numbers?
( _____ ) ______ - __________
Is that a Cell _ Home _ Work __ or other type of number?__SPECIFY
( _____ ) ______ - __________
Is that a Cell _ Home _ Work __ or other type of number?__ SPECIFY
What is his/her email address?
__________________________________@___________
What language does he/she speak?
ENGLISH_____
SPANISH____
OTHER _____ SPECIFY______
>npcg8b< What is the second person’s name?
☐ NO SECOND CONTACT GO TO >after18<
FIRST NAME ____________ MIDDLE INITIAL __ LAST NAME ____________
INTERVIEWER CODE GENDER: MALE ___ FEMALE: ___
(IF NEEDED: Is that a man or a woman?)
Who is this person?
Your Parent ___ Your Sister/Brother __ A Friend ___ A Current Spouse___
A Former Spouse __ or Someone else?______SPECIFY___________
What is his/her address?
STREET____________________________________ APT# ____
CITY _______________________ STATE _____ ZIP CODE_______
What are his/her phone numbers?
( _____ ) ______ - __________
Is that a Cell _ Home _ Work __ or other type of number?__SPECIFY
( _____ ) ______ - __________
Is that a Cell _ Home _ Work __ or other type of number?__ SPECIFY
What is his/her email address?
__________________________________@___________
What language does he/she speak?
ENGLISH_____
SPANISH____
OTHER _____ SPECIFY______
>npcg8c< What is the third person’s name?
☐ NO THIRD CONTACT GO TO >after18<
FIRST NAME ____________ MIDDLE INITIAL __ LAST NAME ____________
INTERVIEWER CODE GENDER: MALE ___ FEMALE: ___
(IF NEEDED: Is that a man or a woman?)
Who is this person?
Your Parent ___ Your Sister/Brother __ A Friend ___ A Current Spouse___
A Former Spouse __ or Someone else?______SPECIFY___________
What is his/her address?
STREET____________________________________ APT# ____
CITY _______________________ STATE _____ ZIP CODE_______
What are his/her phone numbers?
( _____ ) ______ - __________
Is that a Cell _ Home _ Work __ or other type of number?__SPECIFY
( _____ ) ______ - __________
Is that a Cell _ Home _ Work __ or other type of number?__ SPECIFY
What is his/her email address?
__________________________________@___________
What language does he/she speak?
ENGLISH_____
SPANISH____
OTHER _____ SPECIFY______
>after18< After (CHILD NAME) turns 18, we would like to follow up with (him/ her) directly. If (CHILD NAME) is contacted in the future for the study, (he/she) can decide at that time whether or not to take part.
>Q12< What is (CHILD NAME)’s email address?
____________________________@_________________
☐ DOESN’T HAVE EMAIL, REFUSED OR DON’T KNOW
>Q13< What is (CHILD NAME)’s cell phone number?
( _____ ) ______ - ______________
☐ DOESN’T HAVE A CELL, REFUSED OR DON’T KNOW
>Q14< Are there any other ways to reach (CHILD NAME) directly after (he/she) turns 18?
___________________________________________________________
___________________________________________________________
☐ NO OTHER WAYS
>Q15< Thinking ahead to when (CHILD NAME) is 18, where do you think (he/she) will be living?
With you
With another family member
On his/her own or with roommates
In a college dorm
In the military
Or somewhere else (SPECIFY) _____________________
Now we’d like to ask a few questions about how (CHILD NAME) is doing.
>Q16< (Will/Did) (CHILD NAME) graduate high school or get a GED before fall 2013?
YES, GRADUATE HIGH SCHOOL
YES, GED
NO PLEASE SKIP TO QUESTION #18
>Q17< (Will/Did) (CHILD NAME) go to college?
YES
NO
>Q18< What school will (CHILD NAME) attend in the fall of 2013?
SCHOOL _________________________CITY _________________
CHILD DOES NOT/WILL NOT ATTEND SCHOOL ->GO TO Q20
DON’T KNOW
REFUSED
>Q19< What grade will (he/she) be in in the fall of 2013?
DROP DOWN
LESS THAN 5TH GRADE
CODE ANY ONE GRADE 5 THROUGH 12
MORE THAN 12TH GRADE
NO GRADE ASSIGNED
>Q20< What do you think are the chances (CHILD NAME) will graduate from college? Would you say…
No chance
Some chance
About 50/50
Pretty likely
It will happen
>Q21< What do you think are the chances (CHILD NAME) will have a good job by age 30? Would you say…
No chance
Some chance
About 50/50
Pretty likely
It will happen
>Q22< Has (CHILD NAME) ever had any contact with the juvenile justice system? This would include: being picked up by the police for breaking the law, being found guilty for a crime or a delinquent offense, being on probation or court supervision, or being held at juvenile hall or in jail.
YES
NO
DON’T KNOW
>Q23< Overall, would you describe (CHILD NAME)’s health as…
Excellent
Very good
Good
Fair
Poor
Now I have a few questions about you.
>Q24< What is the highest grade or year of school that you have completed?
Less than high school
High school or GED
Vocational school or 2 year Associate’s Degree
College or graduate school
>Q25< Which of the following best describes your present work or school situation?
Working full-time (35 hours a week or more)
Working part-time (less than 35 hours per week)
Unemployed and looking for work
Unemployed and not looking for work
Full-time homemaker
In school
Too disabled to work
Or some other situation (SPECIFY): ____________________________
>Q26< The following questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.
How much of the time during the past 4 weeks...
>Q26a< Have you felt calm and peaceful? Would you say…
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
>Q26b< How much of the time during the past 4 weeks did you have a lot of energy?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
>Q26c< How much of the time during the past 4 weeks have you felt downhearted and blue?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
GO TO >caddress<
>npcg9< Do you know of anyone who might be able to tell us how to reach (CHILD NAME)’s new primary care giver?
YES
NO -> GO TO >noinfothanks<
REFUSED -> GO TO >noinfothanks<
>Q9a< What is that person’s name?
FIRST NAME ____________ MIDDLE INITIAL __ LAST NAME ____________
What is this person’s relationship to (CHILD NAME)?
SPECIFY _____________________________________________
What are his/her phone numbers?
( _____ ) ______ - __________
Is that a Cell _ Home _ Work __ or other type of number?__SPECIFY
( _____ ) ______ - __________
Is that a Cell _ Home _ Work __ or other type of number?__ SPECIFY
What is his/her address?
STREET____________________________________ APT# ____
CITY _______________________ STATE _____ ZIP CODE_______
GO TO >caddress<
>noinfothanks< Okay, thank you for your time. If you happen to find out who is (CHILD NAME)’s new primary care giver, or the name of someone else who might know, we would really appreciate it if you would call us with that information. Our toll-free number is 1-888-800-3748. We would send you a check for $10 as a thank you.
PROGRAMMER: IF >Paway< CODE PARENT AWAY FOR FIELD PERIOD, NO
NEW PCG
IF >Pdead< CODE PARENT DECEASED, NO NEW PCG
>caddress< Thank you very much for your help. To thank you, we will send you a check for $10. You should receive it in two to three weeks.
ENTER CHECK NAME
ENTER CHECK MAILING ADDRESS
Thank you.
[PROGRAMMER CHECK:
IF >npcg1< AND >npcg4< OR IF >npcg1< AND >npcg6< ARE ANSWERED, CASE IS A FINAL “NEW PCG” COMPLETE.
IF >npcg9< IS ANSWERED, CASE IS A FINAL “POSS NEW PCG INFO” COMPLETE
IF NONE OF THE ABOVE, GO TO NOTE, THEN CODE CASE 9.1 SUPERVISOR REVIEW)
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT |
| Author | Rachel Levitan |
| Last Modified By | DHHS |
| File Modified | 2013-06-04 |
| File Created | 2013-05-31 |
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