DCS 4: SAQ Pre-Test and Post-Test - Program Staff Entry

OMB Control No.: xxxx-xxxx

Expiration Date: xx/xx/xxxx

Respondent ID #: _________________

Date: ___________________________

healthy marriage program POST-PROGRAM SURVEY For Youth-Focused Programs

PRIVACY Thank you for your help with this important study. This survey includes questions about your attitudes about marriage and relationships, your relationship experiences, parenting, and program experiences. Your name will not be on the questionnaire and your responses will remain private to the extent permitted by law. We want you to know that: 1. Your participation in this survey is voluntary. 2. We hope that you will answer all the questions, but you may skip any questions you do not wish to answer. 3. The answers you give will be kept private to the extent permitted by law.

THE PAPERWORK REDUCTION ACT OF 1995

Public reporting burden for this collection of information is estimated to average 25 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The information requested in this survey will be used to document how programs receiving HMRF grant funding operate and describe participant outcomes. The data gathered will allow ACF to better monitor grantee progress and performance. In accordance with the requirements of the Privacy Act of 1974, as amended (5 U.S.C. 552a), ACF/OPRE established system of records titled: 09-80-0361 OPRE Research and Evaluation Project Records, HHS/ACF/OPRE. A Federal Register Notice (80 FR 17893) announced the system.

A1. How much do you agree or disagree with the following statements about marriage?

	MARK ONE BOX IN EACH ROW
	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE
a. Marriages are happy or unhappy and there is not much you can do to change it.	1 	2 	3 	4 
b. If you are happily married, you don’t need to work on your relationship.	1 	2 	3 	4 
c. Marriage should be lifelong.	1 	2 	3 	4 
d. It is okay to live with a boyfriend/girlfriend without being married.	1 	2 	3 	4 
e. It is okay to live with a boyfriend/girlfriend without a plan to be married.	1 	2 	3 	4 
f. It is okay to have kids without being married.	1 	2 	3 	4 
g. It is okay to have kids without a plan to be married.	1 	2 	3 	4 
h. It is hard on kids to be raised by a single parent.	1 	2 	3 	4 

A2. When you think of your future, what do you think are the chances that…

	MARK ONE BOX IN EACH ROW
	ALMOST NO CHANCE	SOME CHANCE (BUT PROBABLY NOT)	A 50-50 CHANCE	A GOOD CHANCE	ALMOST CERTAIN
a. You will be married to one person for life?	1 	2 	3 	4 	5 
b. You will live with a boyfriend/girlfriend without being married?	1 	2 	3 	4 	5 
c. You will have a child without being married	1 	2 	3 	4 	5 

A3. In a healthy relationship, how important is it that couples…

	MARK ONE BOX IN EACH ROW
	NOT AT ALL IMPORTANT	A LITTLE IMPORTANT	PRETTY IMPORTANT	VERY IMPORTANT
a. Do not cheat on each other?	1 	2 	3 	4 
b. Do not call each other names?	1 	2 	3 	4 
c. Do not threaten each other?	1 	2 	3 	4 
d. Do not push, shove, hit, slap, or grab each other?	1 	2 	3 	4 
e. Do not argue?	1 	2 	3 	4 
f. Encourage each other when life is hard?	1 	2 	3 	4 
g. Enjoy spending time together?	1 	2 	3 	4 

A4. How much do you agree or disagree with the following statements about relationships?

	MARK ONE BOX IN EACH ROW
	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE
a. In a healthy relationship it is essential for couples to talk about things that are important to them.	1 	2 	3 	4 
b. Even in a good relationship, couples will occasionally have trouble talking about their feelings.	1 	2 	3 	4 
c. A relationship is stronger if a couple doesn’t talk about their problems.	1 	2 	3 	4 

A5. How much do you agree or disagree with the following statements about relationships?

	MARK ONE BOX IN EACH ROW
	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE
a. A person who makes their partner angry on purpose deserves to be hit.	1 	2 	3 	4 
b. Sometimes physical violence, such as hitting or pushing, is the only way to express your feelings.	1 	2 	3 	4 
c. Violence between dating partners is a personal matter and people should not interfere.	1 	2 	3 	4 
d. It’s okay to stay in a relationship even if you’re afraid of your boyfriend/girlfriend.	1 	2 	3 	4 

A6. Since completing the PROGRAM, have you…

	MARK ONE BOX IN EACH ROW
	YES	NO
a. Ended a relationship that was emotionally unhealthy or abusive?	1 	0 
b. Ended a relationship that was just not working for you?	1 	0 
c. Ended a relationship that was physically unhealthy or abusive?	1 	0 

B1. How much do you agree or disagree with the following statements about sex?

	MARK ONE BOX IN EACH ROW
	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE
a. A person should only have sex with someone they love.	1 	2 	3 	4 
b. A person should only have sex if they are married or made a lifelong commitment.	1 	2 	3 	4 
c. MALE: I would be devastated if I got someone pregnant at this age. FEMALE: I would be devastated if I got pregnant at this age.	1 	2 	3 	4 
d. I would feel comfortable having sex with someone I was attracted to but didn’t know very well.	1 	2 	3 	4 
e. Two people who are in love do not need to use condoms/birth control.	1 	2 	3 	4 
f. At my age right now, having sexual intercourse would create problems.	1 	2 	3 	4 
g. At my age right now, it is okay to have sexual intercourse if I use protection, like a condom, the pill, etc.	1 	2 	3 	4 

B2. How much do you agree or disagree with the following statements about sex?

	MARK ONE BOX IN EACH ROW
	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE
a. If my boyfriend/girlfriend wanted to have sex, but I didn’t, I would find it pretty hard to say “no”.	1 	2 	3 	4 
b. I feel good enough about myself that I can say “no” even if my friends are having sex.	1 	2 	3 	4 

C1. Do you have a boyfriend/girlfriend?

⁰  No go to QUESTION D1

¹  Yes

C2. Please indicate how often the following things happen with your boyfriend/girlfriend.

My boyfriend/girlfriend…

	MARK ONE BOX IN EACH ROW
	NONE OF THE TIME	SOME OF THE TIME	HALF OF THE TIME	MOST OF THE TIME	ALL OF THE TIME
a. Makes me feel good about myself	1 	2 	3 	4 	5 
b. Pressures me to do risky things I don’t want to do	1 	2 	3 	4 	5 
c. Wants to control what I do	1 	2 	3 	4 	5 
d. Tries to make me look bad	1 	2 	3 	4 	5 
e. Puts down my physical appearance or how I look	1 	2 	3 	4 	5 
f. Insults or criticizes my ideas	1 	2 	3 	4 	5 
g. Blames me for his/her problems	1 	2 	3 	4 	5 

C3. When you have a serious disagreement with your boyfriend/girlfriend, how often do you…

	MARK ONE BOX IN EACH ROW
	NONE OF THE TIME	SOME OF THE TIME	HALF OF THE TIME	MOST OF THE TIME	ALL OF THE TIME
a. Just keep your thoughts and feelings to yourself?	1 	2 	3 	4 	5 
b. Discuss your disagreements?	1 	2 	3 	4 	5 
c. End up throwing things or hitting something?	1 	2 	3 	4 	5 
d. Keep arguing until you get your way?	1 	2 	3 	4 	5 
e. Yell or shout?	1 	2 	3 	4 	5 
f. Give each other the silent treatment?	1 	2 	3 	4 	5 

C4. How often do the following things happen with your boyfriend/girlfriend?

	MARK ONE BOX IN EACH ROW
	NONE OF THE TIME	SOME OF THE TIME	HALF OF THE TIME	MOST OF THE TIME	ALL OF THE TIME
a. My boyfriend/girlfriend can count on me to be there when he/she needs me	1 	2 	3 	4 	5 
b. My boyfriend/girlfriend and I talk about the things that really matter	1 	2 	3 	4 	5 
c. I am comfortable sharing my thoughts and feelings with my boyfriend/girlfriend	1 	2 	3 	4 	5 

D1. Do you have children of your own living with you in your home?

SELECT ONE ONLY

¹  No, I do not have any children GO TO F1

²  I have one or more children, but they do not live with me. answer d2 - d5 then GO TO F1

³  I live with at least one of my children go to e1

D2. How old is your youngest child?

_____________ years

D3. When is the last time you saw your youngest child?

SELECT ONE ONLY

¹  In the past week

²  In the past month

³  In the past six months

GO TO D5

⁴  In the past year

⁵  1 – 2 years ago

⁶  More than 2 years ago

⁷  Never

D4a. [IFD3= 1 or 2] In the past month, how often did you see or visit your youngest child?

SELECT ONE ONLY

¹  Every day or almost every day

²  One to three times a week

³  One to three times a month

⁴  I did not see or visit this child in the past month go to D5

D4b. In the past month, when you saw [CHILD], how many hours per day did you usually spend with [CHILD]?

| | | hours

D5. In the past month, how often have you reached out to your youngest child even if he or she did not respond?

This includes calling on the phone; sending email, letters, or cards; texting; or using Facebook or FaceTime.

SELECT ONE ONLY

¹  Every day or almost every day

²  One to three times a week

³  One to three times a month

⁴  I did see or visit this child in the past month

Questions in this section are about your YOUNGEST CHILD that lives with you. Please answer these questions about that child.

E1. Thinking about your youngest child, how often does each of the following happen in your family?

	MARK ONE BOX IN EACH ROW
	NEVER	HARDLY EVER	SOMETIMES	OFTEN
a. I am happy being with my child	1 	2 	3 	4 
b. My child and I are very close to each other	1 	2 	3 	4 
c. I try to comfort my child when he/she is upset	1 	2 	3 	4 
d. I spend time with my child doing things what he/she likes to do	1 	2 	3 	4 

E2. Thinking about the times when your youngest child has done something wrong, how often do you…

	MARK ONE BOX IN EACH ROW
	NEVER	A FEW TIMES A MONTH	A FEW TIMES A WEEK	EVERY DAY OR ALMOST EVERYDAY
a. …hit, spank, grab, or use physical punishment with your child?	1 	2 	3 	4 
b. …yell, shout, or scream at your child because you are mad at him/her?	1 	2 	3 	4 
c. ...talk to [CHILD 1] about what he/she did wrong?.............................................................	1 	2 	3 	4 

E3. In the past month, how often have you felt overwhelmed by your parenting responsibilities?

¹  Never

²  Once in a while

³  Somewhat often

⁴  Very often

E4. How much do you agree or disagree with the following statement?

My child’s other parent and I work well together as parents.

¹  Strongly agree

²  Agree

³  Disagree

⁴  Strongly disagree

E5. Would you be able to count on the child’s other parent to take care of your child or children in an emergency?

¹  Yes

⁰  No

^d  I don’t know

F1. How much do you agree or disagree with the following statements about the program?

	MARK ONE BOX IN EACH ROW
	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE
a. Since attending the program, I better understand what makes a relationship healthy.	1 	2 	3 	4 
b. I have learned new skills in this program that I plan to use in my relationships.	1 	2 	3 	4 
c. I am confident in my abilities to use the skills and knowledge presented in this program.	1 	2 	3 	4 

F2. Overall, how much would you say that this class helped you?

MARK ONE ONLY

¹  A lot

²  Some

³  Not at all

F3. Please share any other thoughts about this program.

THANK YOU FOR COMPLETING THIS SURVEY!