Baseline survey for adults

INSTRUMENT 10

adult baseline survey

This page intentionally left blank for double sided copying

STREAMS

Adult Baseline Survey

February 2016

CONTENTS

Section Page

i. INTRODUCTION 5

A. DEMOGRAPHICS 12

B. RELATIONSHIP ATTITUDES AND SKILLS 18

C. CURRENT RELATIONSHIPS 21

D. CHILDREN 28

E. EMPLOYMENT AND FINANCES 34

F. WELL BEING 40

G. ABOUT THE PROGRAM 44

H. contact information 46

PROGRAMMER:

PRELOAD STAFF NAMES AND program NAMES.

ALL

INTRO1. Hello, could you please tell me the name of the program you are calling from?

TBD 1

TBD 2

TBD 3

TBD 4

ALL

INTRO2. Can you please tell me your name?

CONTINUE 1

NAME NOT IN LIST 99

IF OTHER SPECIFY (99): INTERVIEWER: ENTER STAFF MEMBER’S NAME (STRING 50)

soft check: if intro2=99: INTERVIEWER: stop! a supervisor must approve this staff person’s name before you can proceed.

supervisor: enter password to unlock interview.

ALL

INTRO3. Thank you for that information. Can you please hand the phone to the client?

CONTINUE 1

INTRO1=01

i1. Hello, my name is [INTERVIEWER NAME], and I work for Mathematica Policy Research. I understand that you are interested in [PROGRAM NAME] and the STREAMS study. Is that correct?

YES 1 GO TO i2

NO 0 GO TO i1a

i1=0

i1a. Please tell me why you are not interested in participating.

(STRING 250)

i1=0

i1b. Your participation is important because it will help us learn about services for couples like you in the future. All information we collect will be kept strictly private, and if you are eligible for the study, you will receive $10 for completing the survey today. Will you reconsider and agree to participate in the STREAMS study?

YES, I WILL PARTICIPATE 1 GO TO i2

NO, I WILL NOT PARTICIPATE 0 GO TO i6c

i1 = 1

i2. Thanks for taking the time to talk to me today. Please stop me at any time if you have a question.

[PROGRAM NAME] is part of the STREAMS study, a national study being conducted by the U.S. Department of Health and Human Services. The study is being done to learn more about which services help people improve their relationships, as well as improve their economic stability. The Department of Health and Human Services asked researchers from an organization called Mathematica to assist with the study. We invite you to be a part of the study.

The study is being done to learn how well programs like [PROGRAM NAME] work. This program aims to help people improve their relationships (and get and keep good jobs). The study will determine whether the program achieves those aims, and will help us learn whether there are ways these kinds of programs can be improved.

The [PROGRAM NAME] program is for (couples/parents). If you participate in the program you (and your partner) can attend a series of group workshops where you can learn how to communicate better and improve your relationship skills. (You can also get help with employment problems you might be facing.)

If you want to be in the program, you (and your partner) have to agree to be a part of the STREAMS study. If you (and your partner) decide that you do not want to be a part of the study, you will not be able to participate in the [PROGRAM NAME] program. You will be given information about other services that you can receive in the community. You will be free to participate in any of these other services provided by other organizations to get help with your relationship or employment issues.

If you decide to be in the [PROGRAM NAME] program and the study and you are eligible for the study, I will ask you to complete a short survey on the telephone with me today. This will take about 30 minutes. You will receive $10 once you complete the survey in appreciation of your time.

Do you have any questions about what I’ve said so far?

YES 1

NO 0 GO TO i3

i2=1

i2a. What is your question?

(STRING 250)

INTERVIEWER: PRESS Alt-F1 TO ACCESS FAQ

ALL

i3. In about 12 months, the researchers will contact you again by phone and ask you about topics such as your relationships, your employment, and services you receive. The decision to participate in the survey is voluntary and will have no effect on your participation in the program. We will provide more information about this survey later, and you can decide in 12 months whether to participate.

You may also be asked to participate in focus groups. We will provide more information about these activities later, and your participation is voluntary.

If you agree to be part of the study, it means you are giving permission for the [PROGRAM NAME] program to share information with the researchers about the services you receive from the program. The research team may also contact federal and state agencies for information about your employment and earnings. We will ask you for your social security number.  We want to assure you that it will be kept private and will only be used for research purposes. It may be used in requests to federal and state agencies for more information about your employment and earnings and may be used to locate you more easily for the interview in a year’s time. 

Do you have any questions at this time?

YES 1

NO 0 GO TO i4

i3=1

i3a. What is your question?

(STRING 250)

INTERVIEWER: PRESS Alt-F1 TO ACCESS FAQ

ALL

i4. This study will look at two groups: those who receive the [PROGRAM NAME]’s program services, and those who receive referrals to other existing services in the community. The study will compare outcomes for the two groups. A computer will randomly select which group you will be in. One of the groups will receive [PROGRAM NAME] program services at no cost to them. The other group will be able to receive referrals to other organizations for services, but not the [PROGRAM NAME] program services.

The computer works like a flip of a coin; assignment to a group is completely random. This procedure makes sure that assignments to the groups are fair. Everyone who agrees to join the study has the same chance of being placed into either group. The chance of being able to receive services is not influenced by what you say to program staff or your answers to the questions on the telephone. A staff member from [PROGRAM NAME] will let you know which group you are assigned to after you (and your partner) complete today’s interview.

If you are not randomly assigned to participate in [PROGRAM NAME], you will be provided with information about other services available to you in the community, and you will be able to talk to a staff person about those other services.

Do you have any questions now?

YES 1

NO 0 GO TO i5

i4=1

i4a. What is your question?

(STRING 250)

INTERVIEWER: PRESS Alt-F1 TO ACCESS FAQ

ALL

i5. At any time, after you have been randomly assigned, you can call Mathematica’s help line to say that you no longer want the program to share information about you with the Mathematica researchers, and that will have no effect on the services available to you.

Everything you tell the researchers will be used for research purposes only, unless we are required by law to release it for some other purpose. The Department of Health and Human Services may allow other researchers to use the information that you provide, and researchers may use your name and contact information to get in touch with you in the future for research purposes. Nobody will ever publish your name in connection with the information you provide.  Instead, information about you will be combined with information about other people in the study, so researchers can describe the overall program effects and participants’ experiences.

Your participation in the study could help in providing services in the future to other people like you.

You may feel uncomfortable answering some questions in the interview. You can refuse to answer those questions if you wish, and it will not change your participation in the program. Although researchers will take many steps to protect all study information, there is a small risk that non-researchers could see it, including information about your employment and earnings. In addition, representatives from the Department of Health and Human Services and the New England Institutional Review Board (IRB) may inspect and have access to confidential information as they ensure your rights as a study participant are protected.

Do you have any questions now?

YES 1

NO 0 GO TO i5b

i5=01

i5a. What is your question?

(STRING 250)

INTERVIEWER: PRESS Alt-F1 TO ACCESS FAQ

ALL

i5b. To help us protect your privacy, we have obtained a Certificate of Confidentiality from the National Institutes of Health. With this Certificate, the researchers cannot be forced to disclose information that may identify you, even by a court subpoena, in any federal, state, local, civil, criminal, legislative, administrative, or other proceedings. The researchers will use the Certificate to resist any demands for information that would identify you, with one exception. The Certificate of Confidentiality does not prevent the researchers from disclosing information that would identify you as a participant in the research project if you tell me anything that suggests you are very likely to harm yourself, that you are planning to hurt another person or child, or that someone is likely to harm you.

You should understand that a Certificate of Confidentiality does not prevent you, or a member of your family, from voluntarily releasing information about you or your involvement in this research. If an insurer, employer or other person obtains your written consent to receive research information, then the researchers may not use the Certificate to withhold that information.

Do you have any questions now?

YES 1

NO 0 GO TO i5d

i5b=01

i5c. What is your question?

(STRING 250)

INTERVIEWER: PRESS Alt-F1 TO ACCESS FAQ

i1=01

15d. We hope you will want to be in the study but your participation is strictly voluntary. However, if you do not want to be in the study, you cannot be entered into the computer system to see if you can receive services from [PROGRAM NAME]. If you agree to be in the study and later decide you do not want to answer some or all study questions or have information from the program shared with researchers, you may decline at any time. By agreeing now to be in the study, even if later you tell us you want to withdraw from the study, you are authorizing researchers to use information that was collected about you before you withdrew.

Do you have any questions now?

YES 1

NO 0 GO TO i6

i5d=1

i5e. What is your question?

(STRING 250)

INTERVIEWER: PRESS Alt-F1 TO ACCESS FAQ

ALL

i6. Do you agree to be in the STREAMS study?

YES 1 GO TO A1

NO 0

if i6=0

i6a. Please tell me why you are not interested in participating in the STREAMS study.

(STRING 250)

i6=0

i6b. Your participation is important because it will help us learn about services for couples like you in the future. All information we collect will be kept strictly private, and you will receive $10 once you complete the survey today. Will you reconsider and agree to participate in the STREAMS study?

YES, I WILL PARTICIPATE 1 GO TO A1

NO, I WILL NOT PARTICIPATE 0

i1b = 0 OR i1b = 0

i6c. If you do not want to be part of the study, you will not be able to participate in [PROGRAM NAME] and you will be given information about other services that you can receive in the community. Will you reconsider and agree to participate in the STREAMS study?

YES, I WILL PARTICIPATE 1 GO TO

PROGRAMMER BOX i1

NO, I WILL NOT PARTICIPATE 0 GO TO i6d

programmer BOX i1:

IF i6c = 1 AND i1b = 0, go to i2

IF i6c = 1 AND i1b NE 0, go to A1

i6c = 0

i6d. Thank you very much for your time. Can you please hand the phone back to the staff person at [PROGRAM NAME]?

INTERVIEWER: INFORM PROGRAM STAFF THAT RESPONDENT WILL NOT BE PART OF THE STREAMS STUDY AND WILL NOT BE IN THE PROGRAM BUT WILL RECEIVE INFORMATION ABOUT OTHER SERVICES IN THE COMMUNITY.

ALL

ACS

A1. What is your full name? Please spell that for me.

INTERVIEWER: CONFIRM LAST NAME GIVEN IS THEIR FULL LEGAL NAME (i.e. ARE THERE TWO LAST NAMES OR HYPHENATED LAST NAME).

(STRING 50)

FIRST NAME

(STRING 50)

MIDDLE INITIAL/NAME

(STRING 50)

LAST NAME

SOFT CHECK: CONFIRM SPELLING OF NAME WITH RESPONDENT: [FILL NAME GIVEN].

IF NECESSARY, GO BACK TO A1 TO CORRECT SPELLING.

ALL

FILL FULL NAME FROM A1

A1a. I want to make sure that we call you by the correct name. Do you go by another name besides [FIRST NAME]?

YES 1

NO 0 GO TO A2

All

A1b. Please spell that name for me.

(STRING 50)

NAME

All

ACS

A1c. INTERVIEWER: CODE IF KNOWN, OTHERWISE ASK: Are you male or female?

MALE 1

FEMALE 2

All

ACS

A2. What is your date of birth?

| | | / | | | / | | | | |

(01-12) (01-31) (1900-2013)

MONTH DAY YEAR

SOFT CHECK: IF OUT OF RANGE < 18 YEARS OLD; I recorded (fill A2 ANSWER). Is that correct? PROGRAMMER: IF R CONFIRMS THEY ARE <18 YEARS OLD, GO TO END2.

All

ACS, mod for STREAMS

A3. Are you Hispanic, Latino, or of Spanish origin?

YES 1

NO, NOT OF HISPANIC, LATINO OR SPANISH ORIGIN 0

DON’T KNOW d

REFUSED r

All

ACS, mod for STREAMS

A4. What is your race?

AMERICAN INDIAN OR ALASKA NATIVE 1

ASIAN 2

BLACK OR AFRICAN AMERICAN 3

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER 4

WHITE 5

OTHER (SPECIFY) 99

(STRING 50)

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): SPECIFY OTHER RACE

all

PREP

A5. Do you consider yourself to be …

straight 1

gay 2

lesbian 3

bisexual 4

or are you not sure? 5

DON’T KNOW d

REFUSED r

all

ACS

A6. What country were you born in?

UNITED STATES 1

PUERTO RICO 2

MEXICO 3

DOMINICAN REPUBLIC 4

CUBA 5

EL SALVADOR 6

GUATEMALA 7

THE PHILLIPINES 8

CHINA 9

INDIA 10

SOUTH KOREA 11

HAITI 12

OTHER COUNTRY (SPECIFY) 99

(STRING 50)

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): SPECIFY OTHER COUNTRY

A3 NE 0, D, OR R

ACS

A7. What country was your mother born in?

UNITED STATES 1

PUERTO RICO 2

MEXICO 3

DOMINICAN REPUBLIC 4

CUBA 5

EL SALVADOR 6

GUATEMALA 7

OTHER COUNTRY (SPECIFY) 99

(STRING 50)

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): SPECIFY OTHER COUNTRY

A3 NE 0, D, OR R

ACS

A8. What country was your father born in?

UNITED STATES 1

PUERTO RICO 2

MEXICO 3

DOMINICAN REPUBLIC 4

CUBA 5

EL SALVADOR 6

GUATEMALA 7

OTHER COUNTRY (SPECIFY) 99

(STRING 50)

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): SPECIFY OTHER COUNTRY

All

ACS

A9. What language is spoken in your home most of the time?

ENGLISH 1

SPANISH 2

OTHER LANGUAGE (SPECIFY) 99

(STRING 50)

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): SPECIFY OTHER LANGUAGE

A9 NE 1

ACS

A10. How well would you say you speak English? Would you say…

Very well, 1

Well, 2

Not well, or 3

Not at all? 4

DON’T KNOW d

REFUSED r

All

ACS

A11. Are you currently enrolled in school or college?

INTERVIEWER: IF YES, PROBE FOR HIGH SCHOOL OR COLLEGE. FOR GED PROGRAMS, CODE 3.

YES, HIGH SCHOOL 1

YES, COLLEGE 2 GO TO A12

YES, OTHER TYPE OF SCHOOL 3 GO TO A12

NO, NOT IN SCHOOL 4 GO TO A12

DON’T KNOW d GO TO A12

REFUSED r GO TO A12

a11=1

ACS

A12. What is your current grade?

LESS THAN 9TH GRADE 1

9TH GRADE 2

10TH GRADE 3

11TH GRADE 4

12TH GRADE 5

DON’T KNOW d

REFUSED r

GO TO B1

a11 ne 1

ACS

A13. What is the highest level of education you have completed?

INTERVIEWER: IF RESPONDENT SAYS “HIGH SCHOOL,” PROBE: Did you receive a diploma or GED?

INTERVIEWER: IF RESPONDENT SAYS “COLLEGE,” PROBE: Did you receive an associates or a bachelor’s degree?

DID NOT COMPLETE HIGH SCHOOL OR GED 1

HIGH SCHOOL: DIPLOMA 2

HIGH SCHOOL: GENERAL EDUCATION DEVELOPMENT OR GED 3

SOME COLLEGE 4

2-YEAR OR 3-YEAR COLLEGE DEGREE (ASSOCIATE’S DEGREE) 5

VOCATIONAL/TECHNICAL SCHOOL DIPLOMA/CERTIFICATION 6

4-YEAR COLLEGE DEGREE (BACHELOR’S DEGREE) 7

GRADUATE OR PROFESSIONAL DEGREE (e.g., MA, MBA, Ph.D., JD, MD) 8

DON’T KNOW d

REFUSED r

ALL

Foshee et al 1992

Foshee et al 1992

Foshee et al 1992

Foshee et al 1992

Foshee et al 1992

Stanley and Rhoades

Stanley and Rhoades

Stanley and Rhoades

Stanley and Rhoades

Stanley and Rhoades

Child Trends 3M Project mod for STREAMS

PREP

PREP

B1. Next I’m going to read you some statements about relationships. For each, tell me whether you strongly agree, agree, disagree, or strongly disagree. [FILL A-H]. Do you strongly agree, agree, disagree, or strongly disagree?

	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE
a. A good couple relationship is based on mutual respect.	1	2	3	4
b. In a good couple relationship, you don’t always get your own way.	1	2	3	4
c. Relationships go better if partners make decisions together.	1	2	3	4
d. People are more likely to succeed in their relationships if they take things slowly.	1	2	3	4
e. It is important to know a person well before having sex with them.	1	2	3	4
f. Having a casual sexual relationship with someone is no big deal.	1	2	3	4
g. If you are really in love, you can stop working on your relationship.	1	2	3	4
h. Ending a bad romantic relationship is a good thing.	1	2	3	4
i. There are times when hitting or pushing between people who are in a couple is okay.	1	2	3	4
j. Violence between partners can improve a couple’s relationship.	1	2	3	4
k. Some couples need to use violence to solve their problems.	1	2	3	4
l. Sometimes violence is the only way to express your feelings.	1	2	3	4
m. Violence in a couple’s relationship is a personal matter and people should not interfere.	1	2	3	4

ALL

B2. Next I’m going to read you some statements about how you think about romantic relationships. For each statement, tell me whether you strongly agree, agree, disagree, or strongly disagree. [FILL A-D]. Do you strongly agree, agree, disagree, or strongly disagree?

Venum and Fincham, 2011

Venum and Fincham, 2011

Venum and Fincham, 2011

Venum and Fincham, 2011

Baylor evaluation of ARYA

Child Trends 3M Project

	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE
a. I believe I will be able to effectively deal with conflicts that arise in my relationships.	1	2	3	4
b. I feel good about my ability to make a romantic relationship last.	1	2	3	4
c. I can recognize the signs of a violent or unhealthy relationship.	1	2	3	4
d. I am very confident when I think of having a stable, long term relationship.	1	2	3	4
e. I have the skills needed for a lasting stable romantic relationship.	1	2	3	4
f. I have the skills to leave a violent or unhealthy relationship.	1	2	3	4

ALL

PPS

B3. Do you strongly agree, agree, disagree, or strongly disagree with the following statements. [FILL a-b] Do you strongly agree, agree, disagree, or strongly disagree.

	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE
a. Living together is just the same as being married.	1	2	3	4
b. It is better for children if their parents are married.	1	2	3	4

ALL

Buhrmester et al. 1988

Buhrmester et al. 1988

Buhrmester et al. 1988

Buhrmester et al. 1988

Buhrmester et al. 1988

B4. The following questions are about how you might deal with different situations. For each situation, tell me whether you are extremely good at this, good at this, okay at this, or bad at this. [FILL A-E]. Would you say you are extremely good at this, good at this, okay at this, or bad at this?

	EXTREMELY GOOD	GOOD	OKAY	BAD
a. Admitting that you might be wrong during an argument.	1	2	3	4
b. Avoiding saying things that could turn a disagreement into a fight.	1	2	3	4
c. Accepting another person’s point of view even if you don’t agree with it.	1	2	3	4
d. Listening to another person’s opinion during a disagreement.	1	2	3	4
e. Working through problems without arguing.	1	2	3	4

ALL

STREAMS

C1. Next, we’re going to ask you some questions about your relationships. In the past year, how many romantic partners have you been involved with?

PROBE: Your best guess is fine.

| | | NUMBER OF PARTNERS

(0-99)

DON’T KNOW d

REFUSED r

C1 NE 0, D, or r

FILL number of relationships from c1

IF C1=1, FILL “RELATIONSHIP”, ELSE FILL “RELATIONSHIPS”

SHM

C2. Thinking about the [FILL FROM C1] romantic relationship[s] you have had in the past year, have any of your partners …

	YES	NO	DK	R
a. tried to keep you from seeing or talking with your friends?	1	0	d	r
b. made you feel stupid?	1	0	d	r
c. kept money from you or taken your money without asking?	1	0	d	r
d. made you feel afraid that they might hurt you?	1	0	d	r
e. pushed, hit, slapped, or kicked you?	1	0	d	r

All

ACS

C3. Now I’d like to ask about your current relationships. What is your current marital status? Are you …

engaged, 1

married, 2

divorced, 3

separated, or 4

have you never been married? 5

WIDOWED 6

DON’T KNOW d

REFUSED r

C3=1

PACT

C3a. When are you planning to get married?

INTERVIEWER INSTRUCTION: RECORD ONLY MONTH AND YEAR.

PROGRAMMER NOTE: ALLOW REFUSAL IN MM/YYYY

| | | / | | | | | DATE PLANNING TO MARRY

(01-12) (2016-2025)

MONTH YEAR

INTERVIEWER INSTRUCTION: IF NO DATE IS GIVEN, DO NOT PROBE

NO DATE HAS BEEN SET 13

DON’T KNOW d

REFUSED r

C3 ne 1 or 2

C4. Which of the following best describes your relationship status?

ACS

I am romantically involved with someone on a steady basis, 1

I am involved in an on-again and off-again relationship, or 2

I am not in a relationship? 3 GO TO C12

DON’T KNOW d GO TO C12

REFUSED r GO TO C12

IN A RELATIONSHIP: (C3 = 1 OR 2) OR (C4 = 1 OR 2)

IF C3=2 FILL “SPOUSE” ELSE FILL “PARTNER”

PACT

PACT

C5. I would like to ask you a few questions about your [spouse/partner]. What is your [spouse/partner]’s first name?

IF NEEDED: I just need this information to refer to (him/her) for these next questions. I will not share this information with anyone. If you prefer, you can just give me (his/her) initials.

(STRING 50)

NAME

(C3 = 1 OR 2) OR (C4 = 1 OR 2)

fill [partner name] from c5

PACT

C5a. Is [PARTNER NAME] a man or a woman?

MAN 1

WOMAN 2

DON’T KNOW d

REFUSED r

(C3 = 1 OR 2) OR (C4 = 1 OR 2)

C6. How much of the time do you live with [PARTNER NAME]? Would you say…

ACS

All of the time, 1

Most of the time, 2

Some of the time, or 3

None of the time? 4

DON’T KNOW d

REFUSED r

(C3 = 1 OR 2) OR (C4 = 1 OR 2)

BSF

C7. Now I would like to ask about how you feel about your relationship with [PARTNER NAME]. On a scale from 0 to 10, where 0 is not at all happy and 10 is completely happy, taking all things together, how happy would you say your relationship with [PARTNER NAME] is?

You can choose any number from 0 to 10.

| | | HAPPINESS

(0-10)

DON’T KNOW d

REFUSED r

(C3 = 1 OR 2) OR (C4 = 1 OR 2)

For C8i IF C3=2 fill “MARRIAGE” ELSE FILL “RELATIONSHIP”

I’m going to ask you some questions about [PARTNER NAME].

C8. Tell me whether you strongly agree, agree, disagree, or strongly disagree with the following statements.

PACT HM Baseline

PACT HM Baseline

PACT HM Baseline

PPS

PPS

PPS

PPS

PPS

PPS

[STATEMENT a-h] Do you strongly agree, agree, disagree, or strongly disagree?

	CODE ONE PER ROW
	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE	DK	REF
a. [PARTNER NAME] is honest and truthful with me.	1	2	3	4	d	r
b. I can trust [PARTNER NAME] completely.	1	2	3	4	d	r
c. [PARTNER NAME] can be counted on to help me.	1	2	3	4	d	r
d. [PARTNER NAME] knows and understands me.	1	2	3	4	d	r
e. [PARTNER NAME] listens to me when I need someone to talk to.	1	2	3	4	d	r
f. [PARTNER NAME] respects me.	1	2	3	4	d	r
g. [PARTNER NAME] shows love and affection.	1	2	3	4	d	r
h. I feel appreciated by [PARTNER NAME].	1	2	3	4	d	r
i. I view our [marriage/relationship] as lifelong.	1	2	3	4	d	r

(C3 = 1 OR 2) OR (C4 = 1 OR 2)

IF C5a=1, FILL “HE”; IF C5a=2, FILL “SHE”

BSF

PACT HM Baseline

PPS

PACT HM Baseline

PPS

PACT HM Baseline

PPS

PPS

PPS

PPS

PPS

PPS

PPS

PPS

PPS

PPS

C9. Now I am going to read you some statements about things you and [PARTNER NAME] may experience when you are together. Tell me if this never happens, hardly ever happens, sometimes happens, or often happens. [STATEMENT A-O]…Does this happen never, hardly ever, sometimes, or often?

	NEVER	HARDLY EVER	SOMETIMES	OFTEN	DK	R
a. [PARTNER NAME] and I are good at working out our differences.	1	2	3	4	d	r
b. I feel respected even when [PARTNER NAME] and I disagree.	1	2	3	4	d	r
c. [PARTNER NAME] is rude or mean to me when we disagree.	1	2	3	4	d	r
d. When [PARTNER NAME] and I have a serious disagreement, we work on it together to find a solution.	1	2	3	4	d	r
e. When [PARTNER NAME] and I have a serious disagreement, we discuss our disagreements respectfully.	1	2	3	4	d	r
f. [PARTNER NAME] seems to view my words or actions more negatively than I mean them to be.	1	2	3	4	d	r
g. During arguments, [PARTNER NAME] and I are good at taking breaks when we need them.	1	2	3	4	d	r
h. When [PARTNER NAME] and I argue, past hurts get brought up again.	1	2	3	4	d	r
i. [PARTNER NAME] understands that there are times when I do not feel like talking and times when [he/she] does.	1	2	3	4	d	r
j. Our arguments become very heated.	1	2	3	4	d	r
k. [PARTNER NAME] is good at calming me when I get upset.	1	2	3	4	d	r
l. Small issues suddenly become big arguments.	1	2	3	4	d	r
m. We are pretty good listeners, even when we have different positions on things.	1	2	3	4	d	r
n. [PARTNER NAME] or I stay mad at one another after an argument.	1	2	3	4	d	r
o. Even when arguing, we can keep a sense of humor.	1	2	3	4	d	r
p. When we argue, one of us withdraws and refuses to talk about it anymore.	1	2	3	4	d	r

(C3 = 1 OR 2) OR (C4 = 1 OR 2)

PPS

C10. How satisfied are you with the way you and [PARTNER NAME] handle conflict? Would you say…

very satisfied, 1

somewhat satisfied, or 2

not at all satisfied? 3

DON’T KNOW d

REFUSED r

c3=1 or 2

if c3 = 2 FILL “to someone else besides [partner]”

IF C3=1, FILL “please do not count…”

PACT HM Baseline

C11. Have you ever been married ([to someone else] besides [PARTNER])? (Please do not count your current engagement.)

YES 1

NO 0

DON’T KNOW d

REFUSED r

c11=1 or c3=2, 3, 4, or 6

If c3=2 or 4 and IF C11=1, fill: “Including your current marriage,”

PACT HM Baseline

C12. [Including your current marriage,] in total, how many times have you been married?

| | | # OF MARRIAGES

(1-99)

DON’T KNOW d

REFUSED r

(C3 = 1 OR 2) OR (C4 = 1 OR 2)

PACT HM Baseline

C13. Sometimes couples are not always faithful to each other. Has [PARTNER] cheated on you with someone else in the past 12 months? Would you say…

Definitely yes, 1

Probably yes, 2

Probably no, or 3

Definitely no? 4

DON’T KNOW d

REFUSED r

(C3 = 1 OR 2) OR (C4 = 1 OR 2)

PACT HM Baseline

C14. In the past 12 months, have you cheated on [PARTNER] with someone else?

YES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

STREAMS

D1. Now I’d like to ask you some questions about children. How many children do you have?

IF NECESSARY: Please do not include current pregnancies.

| | | NUMBER OF CHILDREN

(1-99)

NONE 0 GO TO D6

DON’T KNOW d GO TO D6

REFUSED r GO TO D6

D1>1

ACS

D2. How many of these children are under 21 years old?

IF NECESSARY: Please do not include current pregnancies.

| | | NUMBER OF CHILDREN

(1-99)

NONE 0 GO TO D6

DON’T KNOW d GO TO D6

REFUSED r GO TO D6

D1=1

ACS

D2a. Is this child under 21 years old?

YES 1

NO 0 GO TO D6

DON’T KNOW d GO TO D6

REFUSED r GO TO D6

D2>0 OR D2A=1

IF D1=1 or D2=1 FILL “IS THIS CHILD”/”CHILD” ELSE FILL “ARE THESE CHILDREN”/”CHILDREN”

ACS

D3. [Is this child/Are these [FILL D2 NUMBER] children all] your legally adopted or biological [child(ren)]?

YES 1 GO TO D5

NO 0

DON’T KNOW d GO TO D5

REFUSED r GO TO D5

D2>1 AND D3=0

D4. How many of these are your biological or legally adopted children?

ACS

| | | NUMBER OF CHILDREN

(1-99)

NONE 0 GO TO D6

DON’T KNOW d GO TO D6

REFUSED r GO TO D6

(D2>1 AND D3=1) OR D4>1

D5. How many of these [FILL D2 OR D4 ANSWER] children live with you all or most of the time?

ACS

| | | NUMBER OF CHILDREN

(0-99)

DON’T KNOW d GO TO D6

REFUSED r GO TO D6

(d2=1 and D3=1) OR D4=1 OR (D2a=1 AND D3=1)

D5a. Does this child live with you all or most of the time?

ACS/PPS

YES 1

NO 0

DON’T KNOW d

REFUSED r

(C3 = 1 OR 2) OR (C4 = 1 OR 2)

D6. Does [PARTNER NAME] have any children with other partners?

STREAMS

YES 1

NO 0 GO TO D8

DON’T KNOW d GO TO D8

REFUSED r GO TO D8

D6=1

IF A1c=1 FILL “FATHER”; IF A1c=2 FILL “MOTHER”

D7. Are you a [mother/father] figure to any of [PARTNER]’s children?

ACS

YES 1

NO 0

DON’T KNOW d

REFUSED r

D3=1 OR D4>0

IF D2A=1 AND (D3=1 OR D4=1), FILL “CHILD”

(IF D2>2 AND D4=2) OR (D2=2 AND D3=1), FILL “CHILDREN”

(IF D2>2 AND D4>2) OR (D2>2 AND D3=1), FILL “TWO YOUNGEST CHILDREN”

IF D3=0, FILL “FOR THESE QUESTIONS…”

PPS

PACT

PPS

BSF

PPS

BSF

PACT

These next questions are about your (children/two youngest children/child). (For these questions, let’s just focus on your biological or legally adopted children.)

	CHILD 1	CHILD 2
D8. [FOR CHILD 1 (IF D2>1 AND (D3=1 OR D4>1)), FILL: Starting with the youngest child, /FOR CHILD 2, FILL: Now thinking of the next youngest child,] please spell this child’s first and last name for me. INSTRUCTION; IF RESPONDENT DOES NOT GIVE FULL NAME PROBE FOR A NAME OR INITIALS	FIRST NAME LAST NAME	FIRST NAME LAST NAME
D3=1 OR D4>0 D9. [CHILD 1 ONLY: I want to make sure that we use [CHILD]’s correct first name.] Do you call [CHILD] by a different name?	YES 1 NO 0 GO TO D10 DON’T KNOW d GO TO D10 REFUSED r GO TO D10	YES 1 NO 0 GO TO D10 DON’T KNOW d GO TO D10 REFUSED r GO TO D10
D9=1 D9a. Please spell that name for me.	NOTE: IF NICKNAME, USE AS FILL FOR [CHILD FIRST NAME] IN REMAINDER OF SURVEY NICKNAME DON’T KNOW d REFUSED r	NOTE: IF NICKNAME, USE AS FILL FOR [CHILD FIRST NAME] IN REMAINDER OF SURVEY NICKNAME DON’T KNOW d REFUSED r
D3=1 OR D4>0 CODE SEX. IF NECESSARY ASK: D10. Is [CHILD] a boy or girl?	BOY 1 GIRL 2 DON’T KNOW d REFUSED r	BOY 1 GIRL 2 DON’T KNOW d REFUSED r
D3=1 OR D4>0 D11. How old is [CHILD FIRST NAME]?	| | | . | | (0-99.9) WEEKS 1 MONTHS 2 YEARS 3 DECEASED 4 GO TO D8, CHILD 2, IF D2>1 AND (D3=1 OR D4>1), ELSE GO TO D22 INTERVIEWER: IF D11=4, THEN SAY: I’m very sorry to hear that. Our condolences for your loss. DON’T KNOW d REFUSED r	| | | . | | (0-99.9) WEEKS 1 MONTHS 2 YEARS 3 DECEASED 4 GO TO D22 INTERVIEWER: IF D11=4, THEN SAY: I’m very sorry to hear that. Our condolences for your loss. DON’T KNOW d REFUSED r
(D3=1 OR D4>0) AND D11 NE 4 D12. Does [CHILD FIRST NAME] live with you...	all of the time, 1 most of the time, 2 some of the time, or 3 none of the time? 4 DON’T KNOW d REFUSED r	all of the time, 1 most of the time, 2 some of the time, or 3 none of the time? 4 DON’T KNOW d REFUSED r
(D3=1 OR D4>0) AND D11 NE 4 D13. In the past month, how often have you spent time with [CHILD FIRST NAME] in person? Would you say, every day or almost every day, a few times a week, a few times a month, once or twice, or never?	EVERY DAY OR ALMOST EVERY DAY 1 A FEW TIMES A WEEK 2 A FEW TIMES A MONTH 3 ONCE OR TWICE 4 NEVER 5 DON’T KNOW d REFUSED r	EVERY DAY OR ALMOST EVERY DAY 1 A FEW TIMES A WEEK 2 A FEW TIMES A MONTH 3 ONCE OR TWICE 4 NEVER 5 DON’T KNOW d REFUSED r

STREAMS

STREAMS

STREAMS

STREAMS

PAM

PAM

PPS

PPS

PPS

	CHILD 1	CHILD 2
(D12 NE 4, D, OR R) AND (D13 NE 5, D, OR R) AND (D11 NE 4) D14. Next, I am going to read you some statements. For each statement, tell me how often you have felt or acted this way toward [CHILD] in the past month. [PROGRAMMER: FILL a-d] Would you say this happened never, hardly ever, sometimes, or often? a. I am happy being with [CHILD]. b. [SKIP if child is age <1 year] [CHILD] and I are very close to each other. c. I try to comfort [CHILD] when [he/she] is upset. d. [SKIP if child is age <1 year] I spend time with [CHILD] doing what [he/she] likes to do.	NEVER 0 HARDLY EVER 1 SOMETIMES 2 OFTEN 3 DON’T KNOW d REFUSED r	NEVER 0 HARDLY EVER 1 SOMETIMES 2 OFTEN 3 DON’T KNOW d REFUSED r
(D12 NE 4, D, OR R) AND (D13 NE 5, D, OR R) AND (D11 NE 4) D15. Over the past month, how often did you… [PROGRAMMER: FILL a-c]. Would you say this happened never, 1-3 times a month, 1-3 times a week, or every day or almost every day? a. …yell, shout, or scream at [CHILD] because you were mad at him/her b. [SKIP if child is age <1 year]…talk to [CHILD] about what he/she did wrong? c. …hit, spank, grab, or use physical punishment with [CHILD]?	NEVER 0 1-3 x MONTH 1 1-3 x WEEK 2 EVERY DAY OR ALMOST EVERY DAY 3 DON’T KNOW d REFUSED r	NEVER 0 1-3 x MONTH 1 1-3 x WEEK 2 EVERY DAY OR ALMOST EVERY DAY 3 DON’T KNOW d REFUSED r
IF ((C3=1 OR 2) OR (C4=1 OR 2)) AND D11 NE 4 D16. Is [PARTNER NAME] the (father/mother) of [CHILD FIRST NAME]?	YES 1 GO TO D19 NO 0 GO TO D18 DON’T KNOW d GO TO D22 REFUSED r GO TO D22	YES 1 GO TO D19 NO 0 GO TO D17 DON’T KNOW d GO TO D22 REFUSED r GO TO D22
IF D2>1 AND (D3=1 OR D4>1) AND D11 NE 4 AND D16 = 0 AND D18a = 1 D17. Is [CHILD 1, D18 NAME] the (father/mother) of [CHILD 2 FIRST NAME]?		YES 1 GO TO D22 NO 0 GO TO D18 DON’T KNOW d GO TO D18 REFUSED r GO TO D18
IF (D17 = 0, D OR R) OR (D2>1 AND (D3=1 OR D4>1) AND D11 NE 4 AND D16 = 0 AND (CHILD 1, D18a) = 0) D18. Please tell me [CHILD FIRST NAME]’s (mother/father)’s first name so I can refer to (her/him) in the next questions.	PARENT____________________________ DON’T KNOW d REFUSED r	PARENT__________________________ DON’T KNOW d REFUSED r
D18a. Do you have more than one child with [CHILD 1, PARENT NAME]	YES 1 NO 0 DON’T KNOW d REFUSED r	YES 1 NO 0 DON’T KNOW d REFUSED r
SKIP IF CHILD 2 PARENT IS THE SAME AS CHILD 1 D19. How much do you agree or disagree with the following statements? [PARENT] and I work well together as parents. Would you say you strongly agree, agree, disagree, or strongly disagree?	STRONGLY AGREE 1 AGREE 2 DISAGREE 3 STRONGLY DISAGREE 4 DON’T KNOW d REFUSED r	STRONGLY AGREE 1 AGREE 2 DISAGREE 3 STRONGLY DISAGREE 4 DON’T KNOW d REFUSED r
SKIP IF CHILD 2 PARENT IS THE SAME AS CHILD IF D18a=1 FILL “children”, ELSE, FILL “child” D20. [PARENT] and I communicate well about our (child/children). IF NEEDED: Would you say you strongly agree, agree, disagree, or strongly disagree?	STRONGLY AGREE 1 AGREE 2 DISAGREE 3 STRONGLY DISAGREE 4 DON’T KNOW d REFUSED r	STRONGLY AGREE 1 AGREE 2 DISAGREE 3 STRONGLY DISAGREE 4 DON’T KNOW d REFUSED r
SKIP IF CHILD 2 PARENT IS THE SAME AS CHILD IF D18a=1 FILL “children”, ELSE, FILL “child” D21. When there is a problem with our (child/children), [PARENT] and I work out a good solution together. IF NEEDED: Would you say you strongly agree, agree, disagree, or strongly disagree?	STRONGLY AGREE 1 AGREE 2 DISAGREE 3 STRONGLY DISAGREE 4 DON’T KNOW d REFUSED r	STRONGLY AGREE 1 AGREE 2 DISAGREE 3 STRONGLY DISAGREE 4 DON’T KNOW d REFUSED r

ALL

IF A1c=1 FILL “with anyone”

ACS

D22. Are you expecting a baby (with anyone) now?

YES 1

NO 0 GO TO E1

DON’T KNOW d GO TO E1

REFUSED r GO TO E1

D22=1

HM Baseline PACT developed

D23. When is your baby due?

| | | / | | | / | | | | | DUE DATE

(01-12) (01-31) (2016-2020)

MONTH DAY YEAR

INTERVIEWER INSTRUCTION: ALLOW REFUSAL FOR MM/DD/YYYY

INTERVIEWER INSTRUCTION: IF DAY UNKNOWN RECORD ONLY MONTH AND YEAR.

INTERVIEWER INSTRUCTION: IF EXPECTING BABY WITH MORE THAN ONE PARTNER, ASK FOR SOONEST DUE DATE

DON’T KNOW d

REFUSED r

D22=1 AND [(C3 = 1 OR 2) OR (C4 = 1 OR 2)]

if a1c=1, fill “mother”; if a1c=2, fill “father”

STREAMS

D24. Is [PARTNER NAME] the [mother/father] of this baby?

PARTNER NAME 1

SOMEONE ELSE 2

DON’T KNOW d GO TO D26

REFUSED r GO TO D26

D24=1 OR 2

if d24=0, fill “thIS partner”, else fill partner name

D25. Right before the pregnancy, did you want to have a baby with [PARTNER NAME/this partner]? Would you say…

PACT HM Baseline

definitely yes, 1

probably yes, 2

probably no, or 3

definitely no? 4

DON’T KNOW d

REFUSED r

D22=1

PACT HM Baseline

D26. Would you say this pregnancy came sooner than you wanted, at about the right time, or later than you wanted?

SOONER 1

RIGHT TIME 2

LATER 3

DIDN’T CARE 4

DON’T KNOW d

REFUSED r

all

ACS

E1. The next questions are about sources of income and other support that you and other members of your household may have received in the past month.

In the past month, have you or anyone in your household received any income from [fill statements a-i]?

	CODE ONE RESPONSE PER ROW
	YES	NO	DK	REF
a. Temporary Assistance for Needy Families, or TANF	1	0	d	r
b. Supplemental Security Income, or SSI	1	0	d	r
c. Social Security Disability Insurance, or SSDI	1	0	d	r
d. food stamps or SNAP	1	0	d	r
e. Women, Infants, and Children, or WIC	1	0	d	r
f. Unemployment Insurance	1	0	d	r
g. housing choice vouchers, sometimes called Section 8	1	0	d	r
h. child support	1	0	d	r
i. any other cash assistance [SPECIFY]	1	0	d	r

all

ACS

E2. Do you currently own your home, rent it, pay some amount toward rent, live rent free with a friend or relative, or do you have some other arrangement?

OWN OR HAVE MORTGAGE 1

RENT 2

PAY SOME OF THE RENT 3

LIVE RENT FREE (SOMEONE ELSE RENTS/OWNS HOUSE) 4

LIVE IN SHELTER 5

LIVE ON STREETS 6

LIVE IN ABANDONED BUILDING/CAR 7

OTHER (SPECIFY) 99

(STRING 250)

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): What is the other arrangement?

The next questions are about work you have done for pay.

all

ACS

E3. Work can be any regular paid jobs, odd jobs, temporary jobs, work done in your own business, “under the table” work, “informal” work, or any other types of work you have done for pay. Thinking of all of these types of work, in the past 30 days, have you worked for pay?

YES 1 GO TO E5

NO 0 GO TO E4

DON’T KNOW d GO TO E4

REFUSED r GO TO E4

E3=0, D, OR R

E4. In what month and year did you last work for pay?

WFNJ mod for PACT

PROBE: Please include any regular paid jobs, odd jobs, temporary jobs, work in your own business, “under the table” work, “informal” work, or any other types of work you have done.

|___|___| / |___|___|___|___|

MONTH YEAR

DON’T KNOW d

REFUSED r

E3=1

E5. Is this work seasonal or temporary?

ACS

PROBE: Is this a job that you knew from the beginning would only last a few weeks or months?

YES 1

NO 0

DON’T KNOW d

REFUSED r

E3=1

ACS

E6. How many hours do you usually work in a week? Your best estimate is fine.

| | | HOURS PER WEEK

(1-98.9)

99 OR MORE HOURS PER WEEK 99

VARIES v

DON’T KNOW d

REFUSED r

E3=1

ACS

E7. Including tips, bonuses, commissions, regular pay, and overtime pay from all of the jobs you worked in the past 30 days, how much money did you make before taxes and other deductions? Do not include the earnings of other people who live with you.

PROBE: Your best estimate is fine.

$ | | | , | | | | AMOUNT

DON’T KNOW d

REFUSED r

IF E7=D or R

E7a. Can you tell me if it was . . .

WFNJ

Less than $500, 1

$500 – $1,000, 2

$1,001 – $2,000, 3

$2,001 – $3,000, 4

$3,001 – $4,000, 5

$4,001 – $5,000, or 6

More than $5,000? 7

DON’T KNOW d

REFUSED r

ALL

IF (C3 = 1 OR 2), FILL “your partner’s job”

E8. Do you have health insurance?

ACS

READ IF NECESSARY: This could be either through your job, [your partner’s job], your parents’ job, Medicaid, Medicare, or insurance you purchased on your own or through a health exchange?

YES 1 GO TO E8a

NO 0 GO TO E8b

DON’T KNOW d GO TO E8b

REFUSED r GO TO E8b

E8=1

ACS

E8a. Do you get health insurance through your job?

YES 1 GO TO E9

NO 0 GO TO E8b

DON’T KNOW d GO TO E8b

REFUSED r GO TO E8b

IF (E8=0, D OR R) OR (E8a=0, D OR R)

ACS

E8b. Does your employer offer health insurance?

YES 1

NO 0

DON’T KNOW d

REFUSED r

E3=1 OR E8a=1

ACS

E9. Do you have other benefits through your job, such as paid vacation, paid sick leave, or life insurance?

YES 1

NO 0

DON’T KNOW d

REFUSED r

E3=1

ACS

E10. When did you first start working in the job you have now? If you have more than one job, think about the job for which you worked the most hours during the past 30 days.

| | | / | | | | |

MONTH YEAR

DON’T KNOW d

REFUSED r

ALL

E11. Please tell me the names of your two most recent employers.

ACS

(STRING 250)

(STRING 250)

DON’T KNOW d

REFUSED r

ALL

E12. Please tell me if any of the following apply to you. Are you… [FILL A-C]

ACS

	CODE ONE RESPONSE PER ROW
	YES	NO	DK	REF
a. actively looking for work?	1	0	d	r
b. retired?	1	0	d	r
c. disabled?	1	0	d	r

ALL.

FILL “BETTER” IF E3=1

PPS

E13. Please tell me how much you agree or disagree with the following statement: I would like to get a [better] job. Would you say you strongly agree, agree, disagree, or strongly disagree?

Strongly agree 1

Agree 2

Disagree 3

Strongly disagree 4

DON’T KNOW d

REFUSED r

ALL

ACS

E14. Now I am going to read you a list of things that can make it hard to find or keep a good job.

Please tell me if the following has made it not at all hard, a little hard, or very hard for you to find or keep a good job in the past year. [FILL a-g]. Would you say that made it not at all hard, a little hard, or very hard for you to find or keep a good job in the past year?

	CODE ONE RESPONSE PER ROW
	NOT AT ALL	A LITTLE	A LOT	DK	REF
a. Not having reliable transportation	1	2	3	d	r
b. Not having the right clothes for work	1	2	3	d	r
c. Not having the required documentation for employment, such as a birth certificate	1	2	3	d	r
d. Not having good enough childcare or family help	1	2	3	d	r
e. Having a criminal record	1	2	3	d	r
f. Not having the right skills or education	1	2	3	d	r
g. Having substance use or mental health problems	1	2	3	d	r

These next questions are about how you are doing.

ALL

F1. In general, how would you describe your health? Would you say it is…

ACS

excellent, 1

very good, 2

good, 3

fair, or 4

poor? 5

DON’T KNOW d

REFUSED r

all

F2. Over the last two weeks, how often have you been bothered by any of the following problems?

PHQ-8

PROGRAMMER: FILL a-h

Would you say that the problem happened not at all, several days, more than half the days, or nearly every day in the last two weeks?

	CODE ONE RESPONSE PER ROW
	NOT AT ALL	SEVERAL DAYS	MORE THAN HALF THE DAYS	NEARLY EVERY DAY	DK	REF
a. Little interest or pleasure in doing things.	0	1	2	3	d	r
b. Feeling down, depressed, or hopeless.	0	1	2	3	d	r
c. Trouble falling or staying asleep, or sleeping too much.	0	1	2	3	d	r
d. Feeling tired or having little energy.	0	1	2	3	d	r
e. Poor appetite or overeating.	0	1	2	3	d	r
f. Feeling bad about yourself—or that you are a failure or have let yourself or your family down.	0	1	2	3	d	r
g. Trouble concentrating on things, such as reading the newspaper or watching television.	0	1	2	3	d	r
h. Moving or speaking so slowly that other people could have noticed? Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual.	0	1	2	3	d	r

Now I would like to ask you a few questions about your experience with the criminal justice system.

ALL

BSF

F3. Have you ever been convicted of a crime?

YES 1

NO 0 GO TO F6

DON’T KNOW d GO TO F6

REFUSED r GO TO F6

F3=1

CSPED

F4. Please think of the longest time that you were in an adult correctional institution like a county, state or federal jail or prison. During that time period, how long were you in an adult correctional institution?

INTERVIEWER: IF LESS THAN 1 WEEK, ENTER 1 WEEK.

INTERVIEWER: FIRST ENTER IF RESPONSE IS WEEKS, MONTHS AND/OR YEARS. YOU WILL ENTER THE NUMBER OF YEARS AND/OR MONTH ON NEXT TWO SCREENS.

| | |

CODE ONLY ONE

WEEKS 1

MONTHS 2

YEARS 3

NEVER INCARCERATED 0

DON’T KNOW d

REFUSED r

F3=1

BSF

F5. Are you currently on parole or probation?

YES 1

NO 0

DON’T KNOW d

REFUSED r

The next questions are about your relationship with your biological parents.

ALL

BSF 15 month follow up

F6. When you were growing up—that is before you turned 18—did you live most of the time with . . .

PROBE: In which of these living situations did you spend most of your time before you turned 18?

both your biological mother and your biological father, 1

your biological mother only, 2 GO TO F8

your biological father only, or 3 GO TO F8

neither of your biological parents? 4 GO TO F8

DON’T KNOW d GO TO F8

REFUSED r GO TO F8

F6=1

BSF 15 month follow up mod for PACT

F7. Did you always live with both of your biological parents until you turned 18?

YES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

BSF 15 month follow up

F8. Were your biological parents ever married to each other?

YES 1

NO 0

DON’T KNOW d

REFUSED r

F7 NE 1 AND if under 21 (calculate from A2)

ACS

F9. Have you ever been in foster care?

CODE ONLY ONE

YES 1

NO 0

DON’T KNOW d

REFUSED r

F9=1

ACS

F10. Are you currently in foster care?

CODE ONLY ONE

YES 1

NO 0

DON’T KNOW d

REFUSED r

F10=0

F11. Did you leave foster care in the past 6 months?

ACS

CODE ONLY ONE

YES 1

NO 0

DON’T KNOW d

REFUSED r

Now, I am going to ask you some questions about your interest in [PROGRAM NAME].

ALL

CSPED

G1. People apply for programs like [FILL PROGRAM NAME] for different reasons. I’m going to read you a list of reasons people sometimes give for applying for [FILL PROGRAM NAME]. Please tell me whether each reason was not at all important, a little important, somewhat important, very important, or extremely important in your decision to apply.

	CODE ONE PER ROW
	NOT AT ALL	A LITTLE	SOMEWHAT	VERY	EXTREMELY	DK	REF
a. To improve your personal relationships.	0	1	2	3	4	d	r
b. To improve your parenting skills.	0	1	2	3	4	d	r
c. To improve your job situation.	0	1	2	3	4	d	r

ALL

G2. How did you hear about [FILL PROGRAM NAME]?

ACS

WORD OF MOUTH (FRIENDS, FAMILY, ACQUAINTANCES) 1

NEWSPAPER AD, BILLBOARDS, OR A FLYER 2

RADIO AD OR A TV SPOT 3

INTERNET AD OR SOCIAL MEDIA SUCH AS FACEBOOK, TWITTER 4

GOVERNMENT AGENCY, SUCH AS THE OFFICE OF CHILD SUPPORT ENFORCEMENT, TANF, WIC, CHILD WELFARE (CPS), PAROLE/PROBATION OFFICE, OTHER AGENCY 5

COMMUNITY ORGANIZATION, SUCH AS A SCHOOL, HOSPITAL, MATERNITY CLINIC, DOCTOR’S OFFICE, PLACE OF WORSHIP, HEAD START, OR HEALTHY START CENTER 6

PROGRAM STAFF OR EVENT 7

SCHOOL STAFF, SUCH AS A TEACHER OR COUNSELOR 8

OTHER (SPECIFY) 99

(STRING 250)

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): How else did you hear about the program?

ALL

G3. Why did you choose to apply to this program?

ACS

TO LEARN ABOUT BEING A BETTER PARENT 1

TO LEARN HOW TO IMPROVE MY PERSONAL RELATIONSHIPS 2

TO FIND A JOB OR A BETTER JOB 3

MY FRIENDS WERE COMING 4

MY SPOUSE/PARTNER ASKED ME TO COME 5

MY PAROLE/PROBATION OFFICER TOLD ME TO ENROLL IN A PROGRAM LIKE THIS 6

A COURT ORDERED ME TO ENROLL IN A PROGRAM LIKE THIS 7

OTHER (SPECIFY) 99

(STRING 250)

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): Why else did you choose to apply to the program?

We are almost finished. I just have a few more questions that will help us contact you in about a year.

ALL

YB 30 Mth J1-mod

H1. What is your street address?

(STRING 200)

Street Address 1

(STRING 200)

Street Address 2 or Apt

(STRING 200)

City

(STRING 200)

State/Territory

(STRING 10)

Zip

DON’T KNOW d

REFUSED r

ALL

YB 30 Mth J1a

H2. Is your mailing address the same as your street address?

YES 1 H4

NO 0

DON’T KNOW d H4

REFUSED r H4

H2 = 0

YB 30 Mth J1b

H3. What is your mailing address?

(STRING 200)

Street /PO BOX Address 1

(STRING 200)

Street/ PO BOX Address 2 or Apt

(STRING 200)

City

(STRING 200)

State/Territory

(STRING 10)

Zip

DON’T KNOW d

REFUSED r

ALL

YB 30 Mth J2

H4. What is your cell phone number?

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

NO CELL PHONE 1 GO TO H6

DON’T KNOW d

REFUSED r

H4 HAS COMPLETE PHONE NUMBER ENTERED

YB 30 Mth J3

H5. May we send you text messages? Message and data rates may apply.

YES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

YB 30 Mth J4

H6. What is your home phone number?

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

NO HOME PHONE 1 GO TO H7

DON’T KNOW d

REFUSED r

H6 HAS COMPLETE PHONE NUMBER ENTERED

YB 30 Mth J4_cell

H7. Is this number, [FILL H6], for a cell phone?

YES 1

NO 0

DON’T KNOW d

REFUSED r

H6 HAS COMPLETE PHONE NUMBER ENTERED

YB 30 Mth J5

H8. Whose name is that number listed under?

(STRING 20)

First name

(STRING 20)

Middle name

(STRING 20)

Last name

DON’T KNOW d

REFUSED r

PROGRAMMER BOX H8a.1

IF H7 = 1, CONTINUE TO H8b;

ELSE, SKIP TO H9.

H7 = 1

YB 30 Mth J5b

H8b. May we send you text messages at this number: ([FILL H6])? Message and data rates may apply.

YES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

YB 30 Mth J6

H9. What is another phone number where you can be reached?

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

NO OTHER NUMBER 1 GO TO H10

DON’T KNOW d

REFUSED r

H9 HAS COMPLETE PHONE NUMBER ENTERED

YB 30 Mth J6_cell

H10. Is this number, [H9], for a cell phone?

YES 1

NO 0

DON’T KNOW d

REFUSED r

H9 HAS COMPLETE PHONE NUMBER ENTERED

YB 30 Mth J7

H11. Whose name is that number listed under?

(STRING 20)

First name

(STRING 20)

Middle name

(STRING 20)

Last name

DON’T KNOW d

REFUSED r

PROGRAMMER BOX H11a.1

IF H10 = 1, CONTINUE TO H11b;

ELSE, SKIP TO H12.

H10 = 1

YB 30 Mth J7b

H11b. May we send you text messages at this number: ([FILL H6_phone])? Message and data rates may apply.

YES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

YB 30 Mth J8a

H12. Are you planning on moving in the next 12 months?

YES 1

NO 0 H13

DON’T KNOW d H13

REFUSED r H13

H12 = 1

YB 30 Mth J8b

H12a. Where will you be moving to?

PROBE: Please provide as much information as you know at this time. Do you know the city and state?

(STRING 200)

Street Address 1

(STRING 200)

Street Address 2 or Apt

(STRING 200)

City

(STRING 200)

State/Territory

(STRING 10)

Zip

DON’T KNOW d

REFUSED r

PROGRAMMER: THIS DOES NOT HAVE TO BE A COMPLETE ADDRESS

all

YB 30 Mth J9

H13. What is the best e-mail address to reach you at?

(STRING 50)

DON’T KNOW d

REFUSED r

PROGRAMMER BOX H13a.1

IF A VALID E-MAIL IS ENTERED (REGARDLESS OF H13a CHECKBOX),

CONTINUE TO H14; ELSE, SKIP TO H15.

H13 IS HAS VALID E-MAIL ENTERED

YB 30 Mth J10

H14. If you have another e-mail address, what is it?

(STRING 50)

DON’T KNOW d

REFUSED r

ALL

Youthbuild

H15. Do you have any of the following social networking accounts?

Do you have a Facebook account?

YES 1

NO 0 GO TO H16

DON’T KNOW d GO TO H16

REFUSED r GO TO H16

H15=1

H15a. What name do you use on Facebook?

PACT

(STRING 50)

DON’T KNOW d

REFUSED r

ALL

H16. Do you have a Instagram account?

PACT

YES 1

NO 0 GO TO H17

DON’T KNOW d GO TO H17

REFUSED r GO TO H17

H16=1

H16a. What name do you use on Instagram?

PACT

(STRING 50)

DON’T KNOW d

REFUSED r

ALL

PACT

H17. We would like to contact you in about a year to see how you are doing. In case we have trouble reaching you, we would like to have the names of three people who would most likely know where you are or who you keep in close contact with, such as a grandmother or grandfather, other relative, or friend. We will not contact these people for any other reason.

What is the full name of the first person we should contact?

(STRING 50)

FIRST NAME

(STRING 50)

MIDDLE INITIAL/NAME

(STRING 50)

LAST NAME

DON’T KNOW d GO TO END1

REFUSED r GO TO END1

H17 NE d OR r

H18. What is (his/her) address?

PACT

PROBE: Is there an apartment number?

(STRING 200)

Street Address 1

(STRING 200)

Street Address 2 or Apt

(STRING 200)

City

(STRING 200)

State/Territory

(STRING 10)

Zip

DON’T KNOW d

REFUSED r

H17 NE d OR r

H19. What is (his/her) relationship to you?

PACT

SPOUSE/PARTNER 1

MOTHER 2

FATHER 3

SISTER/BROTHER 4

GRANDMOTHER/GRANDFATHER 5

FRIEND 6

OTHER (SPECIFY) 99

(STRING 50)

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): ENTER OTHER RELATIONSHIP TYPE

H17 NE d OR r

PACT

H20. What is (his/her) home telephone number?

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

NO LANDLINE 0

DON’T KNOW d

REFUSED r

H17 NE d OR r

H21. Does (he/she) have a cell phone?

PACT

YES 1

NO 0 GO TO H22

DON’T KNOW d GO TO H22

REFUSED r GO TO H22

H21=1

H21a. Can I have that number?

PACT

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

DON’T KNOW d

REFUSED r

H17 NE d OR r

H22. What is (his/her) work telephone number?

PACT

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

NO WORK NUMBER 0

DON’T KNOW d

REFUSED r

H17 NE d OR r

H23. What is (his/her) email address?

PACT

INTERVIEWER: ENTER E-MAIL ON NEXT SCREEN

(STRING 50)

EMAIL ADDRESS

DOESN’T HAVE ONE 0 GO TO H25

DON’T KNOW d GO TO H25

REFUSED r GO TO H25

H17 NE 0, d, OR r

H24. Does (he/she) have another email address?

PACT

INTERVIEWER: ENTER E-MAIL ON NEXT SCREEN

(STRING 50)

EMAIL ADDRESS

DON’T KNOW d

REFUSED r

SECOND CONTACT

ALL

H25. What is the full name of the second person we should contact?

PACT

(STRING 50)

FIRST NAME

(STRING 50)

MIDDLE INITIAL/NAME

(STRING 50)

LAST NAME

DON’T KNOW d GO TO END1

REFUSED r GO TO END1

H25 NE d OR r

H26. What is (his/her) address?

PACT

PROBE: Is there an apartment number?

STREET 1

STREET 2

APT. #

CITY

STATE

ZIP

DON’T KNOW d

REFUSED r

H25 NE d OR r

H27. What is (his/her) relationship to you?

PACT

SPOUSE/PARTNER 1

MOTHER 2

FATHER 3

SISTER/BROTHER 4

GRANDMOTHER/GRANDFATHER 5

FRIEND 6

OTHER (SPECIFY) 99

(STRING 50)

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): ENTER OTHER RELATIONSHIP TYPE

H25 NE d OR r

H28. What is (his/her) home telephone number?

PACT

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

NO LANDLINE 0

DON’T KNOW d

REFUSED r

H25 NE d OR r

H29. Does (he/she) have a cell phone?

PACT

YES 1

NO 0 GO TO H30

DON’T KNOW d GO TO H30

REFUSED r GO TO H30

H29=1

H29a. Can I have that number?

PACT

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

DON’T KNOW d

REFUSED r

H25 NE d OR r

H30. What is (his/her) work telephone number?

PACT

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

NO WORK NUMBER 0

DON’T KNOW d

REFUSED r

H25 NE d OR r

H31. What is (his/her) email address?

PACT

(STRING 50)

EMAIL ADDRESS

DOESN’T HAVE ONE 0 GO TO H33

DON’T KNOW d GO TO H33

REFUSED r GO TO H33

H NE 0, d, or R

H32. Does (he/she) have another email address?

PACT

(STRING 50)

EMAIL ADDRESS

DON’T KNOW d

REFUSED r

THIRD CONTACT

(H17 NE d OR r) AND (H25 NE d OR r)

H33. What is the full name of the third person we should contact?

PACT

(STRING 50)

FIRST NAME

(STRING 50)

MIDDLE INITIAL/NAME

(STRING 50)

LAST NAME

DON’T KNOW d GO TO END1

REFUSED r GO TO END1

H33 NE d OR r

H34. What is (his/her) address?

PACT

PROBE: Is there an apartment number?

STREET 1

STREET 2

APT. #

CITY

STATE

ZIP

DON’T KNOW d

REFUSED r

H33 NE d OR r

H35. What is (his/her) relationship to you?

PACT

SPOUSE/PARTNER 1

MOTHER 2

FATHER 3

SISTER/BROTHER 4

GRANDMOTHER/GRANDFATHER 5

FRIEND 6

OTHER (SPECIFY) 99

(STRING 50)

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): ENTER OTHER RELATIONSHIP TYPE

H33 NE d OR r

H36. What is (his/her) home telephone number?

PACT

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

NO LANDLINE 0

DON’T KNOW d

REFUSED r

H33 NE d OR r

H37. Does (he/she) have a cell phone?

PACT

YES 1

NO 0 GO TO H38

DON’T KNOW d GO TO H38

REFUSED r GO TO H38

H24=1

H37a. Can I have that number?

PACT

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

DON’T KNOW d

REFUSED r

H33 NE d OR r

H38. What is (his/her) work telephone number?

PACT

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

NO WORK NUMBER 0

DON’T KNOW d

REFUSED r

H33 NE d OR r

H39. What is (his/her) email address?

PACT

INTERVIEWER: ENTER E-MAIL ON NEXT SCREEN

(STRING 50)

EMAIL ADDRESS

DOESN’T HAVE ONE 0 GO TO END1

DON’T KNOW d GO TO END1

REFUSED r GO TO END1

H26 NE 0, d, OR r

H40. Does (he/she) have another email address?

PACT

INTERVIEWER: ENTER E-MAIL ON NEXT SCREEN

(STRING 50)

EMAIL ADDRESS

DON’T KNOW d

REFUSED r

END OF CALL

END1. Those are all of the questions I have. You will receive $10 as a token of our appreciation. We will be in touch with you again in about a year to see how you are doing. As I mentioned earlier, a computer will randomly assign you to one of two study groups. Now I need to speak with the staff person at [PROGRAM NAME], so please do not hang up. Please hand the phone back to the staff person, and he or she will let you know which group you have been assigned to. Thank you.

INTERVIEWER: INFORM PROGRAM STAFF THAT RESPONDENT HAS COMPLETED THE INTERVIEW AND HE OR SHE CAN CONTINUE WITH RANDOM ASSIGNMENT. PROVIDE PROGRAM STAFF WITH MPRID.

Respondent under 18

END2. Those are all of the questions I have. Now I need to speak with the staff person at [PROGRAM NAME], so please do not hang up. Can you please hand the phone back to the staff person? Thank you.

INTERVIEWER: INFORM PROGRAM STAFF THAT RESPONDENT HAS COMPLETED THE INTERVIEW AND HE OR SHE CAN ENTER THEIR INFORMATION INTO NFORM. PROVIDE PROGRAM STAFF WITH MPRID. DO NOT GIVE RESPONDENT A GIFT CARD.

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File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	STREAMS CATI
Subject	CATI
Author	MATHEMATICA STAFF
File Modified	0000-00-00
File Created	2021-01-20