Download:
pdf |
pdfOMB No.: 0970–0354
Expiration Date: 10/31/2021
Instrument: PCR [version] [Eng/Sp]
AFFIX LABEL HERE
PCR [version] [Eng/Sp]
Parent Child Report
Draft for OMB (Redacted)
This crosswalk version of the questionnaire includes items to be asked of parents of children ages newborn
to 36 months, flagged as appropriate for the relevant age forms:
• Version 1: Newborn to 7 months
• Version 2: 8 months to 16 months
• Version 3: 17 months to 30 months
• Version 4: 31 months to 37 months
Pregnant women will not be asked to complete the Parent Child Report.
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 OMB number for this information collection is 0970–0354 and the expiration date is 10/31/2021.
ABOUT THIS SURVEY
• The questions in this survey are about you and your child, your child’s health, and your family
routines. This collection of information will be used to describe the characteristics of children and
families served by Early Head Start, and the characteristics and features of programs and staff that
serve them.
• The survey will take about 15 minutes to complete. The questions in this survey can be answered
by marking an “X” in the box. For a few questions, you will be asked to write in a brief response.
1□
2□
3□
• If you are unsure how to answer a question, please give the best answer you can rather than leaving
it blank.
• Your participation in the study is voluntary. All information you provide will be kept private to the
extent permitted by law. Your name and your child’s name will not be attached to any information
you give us. Your answers will not affect you or your child’s participation in any Early Head Start
program.
• If you have any questions, please contact the Baby FACES team at Mathematica Policy Research
at 1-833-763-2178.
Prepared by Mathematica Policy Research
2
OMB (Redacted)
INTERNAL NOTE: IN VERSION OF INSTRUMENT FOR STUDY FAMILIES, KEEP BELOW BOX ON SAME PAGE AS
‘ABOUT THIS SURVEY’ BOX ABOVE.
ABOUT YOU AND YOUR CHILD
Source: Baby FACES 2018
R1. What is your relationship to the Baby FACES child?
1
2
3
4
5
6
□ Mother / Female Guardian
□ Father / Male Guardian
□ Grandmother
□ Grandfather
□ Other Relative
□ Other Non-Relative
Source: Baby FACES 2018
R2. What is this child’s date of birth?
|
|
MONTH
|/|
|
DAY
|/|
|
|
|
|
YEAR
Prepared by Mathematica Policy Research
3
OMB (Redacted)
Source: BITSEA, A1-A2 (PROPRIETARY)
Included in versions: 2 [8-16 mos], 3 [17-30 mos], and 4 [31-37 mos]
Same items for all age versions (appropriate for 12-36 months only)
SECTION A: SOCIAL SKILLS
A1.
The first set of questions contains statements about 1- to 3-year-old children. Many statements describe
normal feelings and behaviors, but some describe things that can be problems. Some may seem too young
or too old for your child. Please do your best to answer every question.
For each statement, please mark the answer that best describes your child in the past month.
Items A1a to A1hh are protected under copyright and have been redacted from this instrument.
Source: Briggs-Gowan, M.J., and A.S. Carter. The Brief Infant–Toddler Social and Emotional Assessment (BITSEA).
San Antonio, TX: Harcourt Assessment, 2006.
Prepared by Mathematica Policy Research
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OMB (Redacted)
A2.
The following questions are about feelings and behaviors that can be problems for young children. Some
of the questions may be a bit hard to understand, especially if you have not seen them in a child. Please do
your best to answer them anyway.
For each statement, please mark the answer that best describes your child in the past month.
Items A2a to A2h are protected under copyright and have been redacted from this instrument.
Source: Briggs-Gowan, M.J., and A.S. Carter. The Brief Infant–Toddler Social and Emotional Assessment (BITSEA).
San Antonio, TX: Harcourt Assessment, 2006.
Prepared by Mathematica Policy Research
5
OMB (Redacted)
Source: MacArthur-Bates Communicative Development Inventories, Infant and Toddler Short Forms and CDI-III
(PROPRIETARY)
Included in versions: 2 [8-16 mos], 3 [17-30 mos], and 4 [31-37 mos]; Different item sets for age versions
SECTION B: VOCABULARY CHECKLIST
PARENTS WILL BE ASKED TO COMPLETE THE CDI WORD LIST IN EITHER ENGLISH OR SPANISH (BASED ON
PRIMARY HOME LANGUAGE) USING THE RELEVANT AGE FORM: LEVEL I (8-18 MONTHS); LEVEL II (16-30 MONTHS);
OR LEVEL III (30-37 MONTHS). THESE AGE-BASED VOCABULARY LISTS INCLUDE APPROXIMATELY 100 WORDS EACH
AND ARE APPENDED AT THE END OF THIS DOCUMENT.
B1.
Below is a list of typical words in young children’s vocabularies. We are interested specifically in the
words your child understands or says in English.
For words your child does not yet understand, mark the first column (does not understand). For words
your child understands but does not yet say on his/her own, mark the second column (understands). For
words your child understands and also says on his/her own, mark the third column (understands and
says). If your child uses a different pronunciation of a word or another word with the same meaning (for
example, “raffe” for “giraffe” or “nana” for “grandma”) mark the word anyway. For each item, please
mark only one response.
Remember, this is a “catalogue” of words that are used by many different children. Don’t worry if your
child knows only a few right now.
These items are protected under copyright and have been redacted from this instrument.
Source: MacArthur-Bates Communicative Development Inventories.
Prepared by Mathematica Policy Research
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INTERNAL CROSSWALK
Source: MacArthur-Bates Communicative Development Inventories, Infant Long
Form, First Communicative Gestures (12 items) (PROPRIETARY)
Included in versions: 2 [8-16 mos]
B2.1.
When infants are first learning to communicate, they often use gestures to make their wishes known. For
each item below, mark the response that describes your child’s actions right now.
Items B2.1a to B2.1l are protected under copyright and have been redacted from this instrument.
Source: MacArthur-Bates Communicative Development Inventories.
Source: MacArthur-Bates Communicative Development Inventories, Toddler
Short Form and CDI-Iii, Combining words (PROPRIETARY)
Included in versions: 3 [17-30 mos] and 4 [31-37 mos]
B2.2. This item is protected under copyright and has been redacted from this instrument.
Source: MacArthur-Bates Communicative Development Inventories.
Prepared by Mathematica Policy Research
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INTERNAL CROSSWALK
Source: Items C6-C7 adapted from Baby FACES 2009 Parent Interview
Included in versions: 1 [newborn-7 mos], 2 [8-16 mos], 3 [17-30 mos], and 4
[31-37 mos]
SECTION C: CHILD WELL-BEING
In this section, we would like to learn about your child’s general well-being.
C6.
Does your child have an Individualized Family Service Plan (IFSP)? This is a written treatment plan that
describes your child’s current levels of functioning, specific needs, and what early intervention services
he/she will receive.
0
1
□
□
No
GO TO C7
Yes
C6a. Was this plan developed with the help of staff at your child’s Early Head Start program?
0
1
C7.
□
□
No
Yes
Below is a list of different special needs that children sometimes have. Some of these may not apply to
your child, but please do your best to answer every question. For each statement, please mark only one
response. Does your child have…
MARK ONE PER
ROW
Does your child
have…
NO
YES
a. behavioral trouble or difficulty paying attention to learn?...................................
0
1
b. difficulty hearing and understanding speech in a normal conversation?..........
0
1
c.
0
1
d. any physical development issues such as problems with the way he/she uses
his/her arms or legs? ...............................................................................................
0
1
e. a below-normal activity level? ................................................................................. .
0
1
f.
difficulty with speech or communicating?.............................................................
0
1
g. trouble sleeping because of a breathing problem or sleep apnea?
This does not include temporary snoring due to a cold or congestion .......................
0
1
h. a developmental disability or delay? ......................................................................
0
1
difficulty seeing objects in the distance or letters on paper? .............................
Prepared by Mathematica Policy Research
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INTERNAL CROSSWALK
Source: Parenting Stress Index, 4th Edition Short Form, D1 & D2a-D2c (PROPRIETARY)
Included in versions: 1 [newborn-7 mos], 2 [8-16 mos], 3 [17-30 mos], and 4 [31-37 mos]; same items for all age versions
SECTION D: RAISING A CHILD
D1.
Having a child can sometimes be stressful. The next set of questions contains statements about how
stressful having a child has been for you and the ways in which you have had to adjust your life. For each
statement, please mark how much you agree or disagree.
Items D1a to D1gg are protected under copyright and have been redacted from this instrument.
Source: Parenting Stress Index, 4th Edition Short Form.
D2a. This item is protected under copyright and has been redacted from this instrument.
Source: Parenting Stress Index, 4th Edition Short Form.
D2b. This item is protected under copyright and has been redacted from this instrument.
Source: Parenting Stress Index, 4th Edition Short Form.
D2c. This item is protected under copyright and has been redacted from this instrument.
Source: Parenting Stress Index, 4th Edition Short Form.
Prepared by Mathematica Policy Research
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INTERNAL CROSSWALK
Source: Child-Parent Relationship Scale, Short Form (CPRS-SF)
Included in versions: 1 [newborn-7 mos], 2 [8-16 mos], 3 [17-30 mos], and 4 [31-37 mos]
DO NOT INCLUDE ITEMS g AND o IN VERSIONS 1 [NEWBORN TO 7 MOS] AND 2 [8-16 MOS]
SECTION E: RELATIONSHIPS AND FEELINGS
E1.
Please think about the degree to which each of the following statements currently applies to your
relationship with your child. For each statement, please mark only one response.
MARK ONE PER ROW
How much does this currently apply to your relationship with your child?
DEFINITELY
DOES NOT
APPLY
a.
b.
c.
d.
e.
f.
g.
h.
i.
NOT REALLY
NEUTRAL/
NOT SURE
APPLIES
SOMEWHAT
DEFINITELY
APPLIES
I share an affectionate, warm relationship with
my child
.......................................................................
1
□
2
□
3
□
4
□
5
□
My child and I always seem to be struggling
with each other
.......................................................................
1
□
2
□
3
□
4
□
5
□
If upset, my child will seek comfort from me
.......................................................................
1
□
2
□
3
□
4
□
5
□
My child is uncomfortable with physical
attention or touch from me
.......................................................................
1
□
2
□
3
□
4
□
5
□
My child values his/her relationship with me
.......................................................................
1
□
2
□
3
□
4
□
5
□
When I praise my child, he/she beams with
pride
.......................................................................
1
□
2
□
3
□
4
□
5
□
My child spontaneously shares information
about himself/herself
.......................................................................
1
□
2
□
3
□
4
□
5
□
My child easily becomes angry at me
.......................................................................
1
□
2
□
3
□
4
□
5
□
It is easy to be in tune with what my child is
feeling
.......................................................................
1
□
2
□
3
□
4
□
5
□
Prepared by Mathematica Policy Research
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OMB (Redacted)
MARK ONE PER ROW
How much does this currently apply to your relationship with your child?
DEFINITELY
DOES NOT
APPLY
j.
NOT REALLY
NEUTRAL/
NOT SURE
APPLIES
SOMEWHAT
DEFINITELY
APPLIES
My child remains angry or is resistant after
being disciplined
.......................................................................
1
□
2
□
3
□
4
□
5
□
k.
Dealing with my child drains my energy ...
1
□
2
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3
□
4
□
5
□
l.
When my child is in a bad mood, I know we’re in
for a long and difficult day ..........................
1
□
2
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3
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4
□
5
□
1
□
2
□
3
□
4
□
5
□
My child is sneaky or manipulative with me
.......................................................................
1
□
2
□
3
□
4
□
5
□
My child openly shares his/her feelings and
experiences with me
.......................................................................
1
□
2
□
3
□
4
□
5
□
m. My child’s feelings toward me can be
unpredictable or can change suddenly......
n.
o.
©1992 Pianta, University of Virginia.
Prepared by Mathematica Policy Research
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OMB (Redacted)
Source: Healthy Families Parenting Inventory (Parent/Child Interaction and Social Support subscales), E2-E3 (PROPRIETARY)
Included in versions: 1 [newborn-7 mos], 2 [8-16 mos], 3 [17-30 mos], and 4 [31-37 mos]; same items for all age versions
(Items in E3 asked of pregnant respondents in parent survey)
E2.
Below is a list of statements that describes how some parents may behave or feel about their child. For
each statement, please mark the answer that best fits for you.
Items E2a to E2j are protected under copyright and have been redacted from this instrument.
Source: Healthy Families Parenting Inventory (Parent/Child Interaction subscale)
E3.
The below statements also describe how some parents may behave or feel. For each statement, please
mark the answer that best fits for you.
Items E3a to E3e are protected under copyright and have been redacted from this instrument.
Source: Healthy Families Parenting Inventory (Social Support subscale)
Prepared by Mathematica Policy Research
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OMB (Redacted)
Source: CESD-R. Permissions: Items in this section are from Eaton WW, Muntaner C, Smith C, Tien A, Ybarra M. Center for Epidemiologic
Studies Depression Scale: Review and revision (CESD and CESD-R). In: Maruish ME, ed. The Use of Psychological Testing for Treatment
Planning and Outcomes Assessment. 3rd ed. Mahwah, NJ: Lawrence Erlbaum; 2004:363-377
I8.
Below is a list of ways you may have felt or behaved. Please mark how often you have felt this way in the
past week or so.
MARK ONE PER ROW
LESS
THAN 1
DAY
a.
My appetite was poor
b.
I could not shake off the blues
c.
I had trouble keeping my mind on what I was doing
d.
I felt depressed
e.
My sleep was restless
f.
g.
i.
I felt like a bad person
j.
I lost interest in my usual activities
k.
I slept much more than usual
l.
□
2
□
3
□
4
□
0
□
1
□
2
□
3
□
4
□
0
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1
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2
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3
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4
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0
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1
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2
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3
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4
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0
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1
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2
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3
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4
□
0
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1
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2
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3
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4
□
0
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1
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2
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3
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4
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0
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1
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2
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3
□
4
□
0
□
1
□
2
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3
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4
□
0
□
1
□
2
□
3
□
4
□
0
□
1
□
2
□
3
□
4
□
0
□
1
□
2
□
3
□
4
□
0
□
1
□
2
□
3
□
4
□
0
□
1
□
2
□
3
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4
□
0
□
1
□
2
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3
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4
□
0
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1
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2
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3
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4
□
0
□
1
□
2
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3
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4
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0
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1
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2
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3
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4
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0
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1
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2
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3
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4
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0
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1
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2
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3
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4
□
m. I felt fidgety
I wished I were dead
o.
I wanted to hurt myself
p.
I was tired all the time
q.
I did not like myself
r.
I lost a lot of weight without trying to
s.
I had a lot of trouble getting to sleep
t.
I could not focus on important things
NEARLY
EVERY DAY
FOR 2 WEEKS
1
I felt like I was moving too slowly
n.
5-7 DAYS
IN PAST
WEEK
□
I could not get going
Nothing made me happy
3-4 DAYS
IN PAST
WEEK
0
I felt sad
h.
1-2 DAYS
IN PAST
WEEK
The National Suicide Prevention Lifeline is available 24/7 for free and confidential support for people in distress or for
crisis resources for you or your loved ones. Call 1-800-273-8255 or vist the website at suicidepreventionlifeline.org.
Prepared by Mathematica Policy Research
13
OMB (Redacted)
The next few questions are about tobacco, alcohol, and drug use.
Source: Adapted from Baby FACES 2009
Item title: TobaccoPast30Days
I5.
During the past 30 days, did you or anyone else in your household smoke tobacco, such as cigarettes or
cigars?
0
1
d
□
□
□
No
Yes
Don’t know
Source: Baby FACES 2018
Item title: VapingPast30Days
I5a.
During the past 30 days, have you or anyone else in your household used nicotine “vaping” products, such
as e-cigarettes?
0
1
d
□
□
□
No
Yes
Don’t know
Source: Baby FACES 2018
Item title: ProgramCessationHelp
I5b. Did [PROGRAM] Early Head Start offer resources or support to you or anyone else in your household for
reducing or quitting the use of tobacco or nicotine “vaping”?
0
1
d
□
□
□
No
Yes
Don’t know
Prepared by Mathematica Policy Research
14
OMB (Redacted)
Source: Adapted from MIHOPE 2 Parent Survey
I5c.
The next questions are about drinking alcoholic beverages. By a “drink” we mean a can or bottle of beer, a
wine cooler or glass of wine, a shot of liquor, or a mixed drink.
During the past 30 days, how many alcoholic drinks did you have in an average week?
MARK ONE ONLY
1
2
3
4
5
6
7
d
□
□
□
□
□
□
□
□
None
Less than 1 drink
1 to 3 drinks
4 to 6 drinks
7 to 13 drinks
14 to 19 drinks
20 or more drinks
Don’t know
Source: Adapted from MIHOPE 2 Parent Survey
I5d. In the last 30 days, how many times did you or anyone in your household drink 4 alcoholic drinks or more
in one day? Would you say…
MARK ONE ONLY
1
2
3
4
5
□
□
□
□
□
6 or more times
4 to 5 times
2 to 3 times
1 time
Never
Source: New item
I5d1. Did Early Head Start offer resources or support to you or anyone else in your household to help reduce or
quit drinking alcohol?
0
1
d
□
□
□
No
Yes
Don’t know
Prepared by Mathematica Policy Research
15
OMB (Redacted)
Source: Adapted from the National Survey for Drug Use and Health
I5E1. In the past 30 days, have you or has anyone in your household used heroin (smack, horse) or a prescription
pain reliever (oxy, percs, vikes) in a way that was not director by a doctor? By “not directed by a doctor” we
mean used without a prescription; used in greater amounts, more often, or longer than prescribed; or used
in any other way not prescribed by a doctor.
0
1
d
□
□
□
No
Yes
Don’t know
Source: Adapted from the National Survey for Drug Use and Health
I5f1. In the past 30 days have you or has anyone in your household used marijuana (weed, pot) or hashish
(hash)?
0
1
d
□
□
□
No
Yes
Don’t know
Source: Adapted from the National Survey for Drug Use and Health
I5f2. What about other types of drugs, such as amphetamines (uppers, ice, speed, crystal meth, crank), cocaine
(rock, coke, crack), tranquilizers (downers, ludes) hallucinogens (LSD, acid, PCP, angel dust, ecstasy), or
sniffing gasoline, glue, or aerosols? Have you or anyone in your household used any of these in the past 30
days?
0
1
d
□
□
□
No
Yes
Don’t know
Source: Adapted from MIHOPE 2 Parent Survey
I5g. Did Early Head Start offer resources or support to you or anyone else in your household to help reduce or
quit using drugs?
0
1
d
□
□
□
No
Yes
Don’t know
Prepared by Mathematica Policy Research
16
OMB (Redacted)
Finally, we have one last question about your household income.
Source: Baby FACES 2009
L4.
In the last 12 months, what was the total income of all members of your household from all sources before
taxes and other deductions? Please include your own income and the income of everyone living with you.
Please include the money from jobs and public assistance programs, as well as any other sources such as
rent, interest, and dividends. Your best estimate is fine.
$|___|___|___|,|___|___|___|
Please mark whether that is per week, every two weeks, per month or per year.
MARK ONE ONLY
1
2
3
4
E4.
□
□
□
□
Per week
Every two weeks
Per month
Per year
Please record the date you completed this form.
DATE COMPLETED: |
|
MONTH
|/|
|
DAY
|/|
|
|
|
|
YEAR
Thank you for your participation in Baby FACES!
Prepared by Mathematica Policy Research
17
OMB (Redacted)
| File Type | application/pdf |
| File Title | BABY FACES SPRING 2017 PARENT CHILD REPORT |
| Subject | SAQ |
| Author | MATHEMATICA |
| File Modified | 2020-02-21 |
| File Created | 2020-02-21 |