4: Entrance and Exit Surveys - Program staff (entrance and exit on paper)

OMB No.: 0970-0XXX

Expiration Date: xx/xx/xxxx

Reentering Fathers Program
Entrance Survey

This survey asks questions about your parenting, economic stability, relationships/marriage, and personal development. Your name will not be on the survey, and your responses will remain private. 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.

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to support program performance monitoring and program improvement activities for Healthy Marriage and Responsible Fatherhood programs. 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. This is a voluntary collection of information. The answers you give will be kept private. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0XXX and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact Dr. Mathew Stange at nform2.0helpdesk@mathematica-mpr.com.

A. PARENTING AND CO-PARENTING

We would like to get a sense of who you are as a parent. We realize that children are different and may require different parenting.

Questions in this section are about your child—or if you have more than one child, your youngest and oldest children—who is 24 years old or younger.

A1a. Do you have any children who are 24 years old or younger? Please include biological children, adopted children, stepchildren, foster children, and any child or youth up to age 24 whom you are actively raising and who is the child of a partner or relative but who is not your biological or legally adopted child.

SELECT ONE ONLY

1  Yes, I have one child who is 24 years old or younger

2  Yes, I have more than one child who is 24 years old or younger

3  No, I have no children

4  No, all my children are 25 years old or older

[SOFT CHECK: IF A1a = NO RESPONSE; This question is very important. Please select an answer.

IF A1a = NO RESPONSE, GO TO B1]

A1b. What is your youngest child’s first name or initials?

A1c. Is this your biological or legally adopted child?

SELECT ONE ONLY

1  Yes, this is my biological child

2  Yes, this is my legally adopted child

0  No GO TO A1d

A1d. What is your relationship to [CHILD1]?

SELECT ONE ONLY

1  Father figure to spouse's or partner's biological child

2  Foster father

3  Relative

4  Other (specify)

A1e. How old is [CHILD1]?

| | | years old or | | | months

[SHOW OPEN-TEXT FIELD AND DROP-DOWN FOR CLIENT TO SELECT MONTHS OR YEARS]

HARD CHECK IF CHILD AGE > 11 MONTHS; Enter age in years for children over 11 months old.

HARD CHECK IF CHILD AGE > 24; Your child’s age should be less than 25 years old.

HARD CHECK IF CHILD AGE = 0 OR NON-NUMERIC; Please enter the age of your child in months or years.

SOFT CHECK IF CHILD AGE = NO RESPONSE; Please enter the age of your child in months or years.

A2a. When was the last time you saw [CHILD1]?

SELECT ONE ONLY

1  In the past week

2  In the past month

3  In the past 6 months

4  In the past year

5  1 to 2 years ago

6  More than 2 years ago

7  Never

[SOFT CHECK: IF A2a = NO RESPONSE; This question is very important. Please select an answer.]

A2b. In the past month, how often did you see [CHILD1]?

SELECT ONE ONLY

1  Every day or almost every day

2  One to three times a week

3  One to three times in the past month

4  I did not see this child in the past month

A2c. In the past month, how often did you talk to [CHILD1] on the phone?

SELECT ONE ONLY

1  Every day or almost every day

2  One to three times a week

3  One to three times in the past month

4  I did not talk on the phone with this child in the past month

A2d. In the past month, how often have you sent letters to [CHILD1]?

SELECT ONE ONLY

1  Every day or almost every day

2  One to three times a week

3  One to three times in the past month

4  I did not send letters to this child in the past month

A3. In the past month, how often have you talked with [CHILD1] about things he or she is especially interested in?

SELECT ONE ONLY

1  Never

2  Hardly ever

3  Sometimes

4  Often

A4. Please reflect on the degree to which each of the following statements currently applies to your relationship with your child.

	SELECT ONE RESPONSE PER ROW
	ALWAYS	OFTEN	SOMETIMES	RARELY	NEVER
a. How often do you feel disappointed with [CHILD1]?	1 	2 	3 	4 	5 
b. How often do you wish that [CHILD1] was different?	1 	2 	3 	4 	5 
c. How often do you feel proud of [CHILD1]?	1 	2 	3 	4 	5 
d. How often do you feel angry or irritated with [CHILD1]?	1 	2 	3 	4 	5 
e. How often do you accept [CHILD1] the way he or she is?	1 	2 	3 	4 	5 
f. How often do you feel you and your child understand each other?	1 	2 	3 	4 	5 
g. How often do you and your child argue and fight?	1 	2 	3 	4 	5 

[ASK IF CHILDREN = MORE THAN ONE CHILD 24 YEARS OLD OR YOUNGER ELSE GO TO A8]

Now think about your oldest child.

A5a. What is this child’s first name or initials?

A5b. Is this your biological or legally adopted child?

SELECT ONE ONLY

1  Yes, this is my biological child

2  Yes, this is my legally adopted child

0  No GO TO A5c

A5c. What is your relationship to [CHILD2]?

SELECT ONE ONLY

1  Father figure to spouse's or partner's biological child

2  Foster father

3  Relative

4  Other (specify)

A5d. How old is [CHILD2]?

| | | years old or | | | months

[SHOW OPEN TEXT FIELD AND DROPDOWN FOR CLIENT TO SELECT MONTHS OR YEARS]

HARD CHECK IF CHILD AGE > 11 MONTHS; Enter age in years for children over 11 months old.

HARD CHECK IF CHILD AGE > 24; Your child’s age should be less than 25 years old.

HARD CHECK IF CHILD AGE = 0 OR NON-NUMERIC; Please enter the age of your child in months or years.

SOFT CHECK IF CHILD AGE= NO RESPONSE: Please enter the age of your child in months or years.

A6a. When was the last time you saw [CHILD2]?

SELECT ONE ONLY

1  In the past week

2  In the past month

3  In the past 6 months

4  In the past year

5  1 to 2 years ago

6  More than 2 years ago

7  Never

SOFT CHECK: IF A6a = NO RESPONSE; This question is very important. Please select an answer.

A6b. In the past month, how often did you see [CHILD2]?

SELECT ONE ONLY

1  Every day or almost every day

2  One to three times a week

3  One to three times in the past month

4  I did not see this child in the past month

SOFT CHECK: IF A6b = NO RESPONSE; This question is very important. Please select an answer.

A6c. In the past month, how often did you talk with [CHILD2] on the phone?

SELECT ONE ONLY

1  Every day or almost every day

2  One to three times a week

3  One to three times in the past month

4  I did not talk on the phone with this child in the past month

A6d. In the past month, how often have you sent letters to [CHILD2]?

SELECT ONE ONLY

1  Every day or almost every day

2  One to three times a week

3  One to three times in the past month

4  I did not send letters to this child in the past month

A6e. In the past month, how often have you talked with [CHILD2] about things he or she is especially interested in?

SELECT ONE ONLY

1  Never

2  Hardly ever

3  Sometimes

4  Often

A7. Please reflect on the degree to which each of the following statements currently applies to your relationship with your child.

	SELECT ONE RESPONSE PER ROW
	ALWAYS	OFTEN	SOMETIMES	RARELY	NEVER
a. How often do you feel disappointed with [CHILD2]?	1 	2 	3 	4 	5 
b. How often do you wish that [CHILD2] was different?	1 	2 	3 	4 	5 
c. How often do you feel proud of [CHILD2]?	1 	2 	3 	4 	5 
d. How often do you feel angry or irritated with [CHILD2]?	1 	2 	3 	4 	5 
e. How often do you accept [CHILD2] the way he or she is?	1 	2 	3 	4 	5 
f. How often do you feel you and your child understand each other?	1 	2 	3 	4 	5 
g. How often do you and your child argue and fight?	1 	2 	3 	4 	5 

[ASK IF CHILDREN = ONE CHILD OR MORE THAN ONE CHILD AGE 24 OR YOUNGER]

A8. Thinking about [CHILD1], how much do you agree or disagree with each of the statements below?

	SELECT ONE RESPONSE PER ROW
	STRONGLY DISAGREE	DISAGREE	NEUTRAL	AGREE	STRONGLY AGREE
a. The mother of [CHILD1] contradicts the decisions I made about [CHILD1].	1 	2 	3 	4 	5 
b. The mother of [CHILD1] makes negative comments, jokes, or sarcastic comments about the way I parent.	1 	2 	3 	4 	5 
c. The mother of [CHILD1] undermines me as a father.	1 	2 	3 	4 	5 
d. The mother of [CHILD1] and I discuss the best way to meet [CHILD1]’s needs.	1 	2 	3 	4 	5 
e. The mother of [CHILD1] and I share information about [CHILD1] with each other.	1 	2 	3 	4 	5 
f. The mother of [CHILD1] and I make joint decisions about [CHILD1].	1 	2 	3 	4 	5 
g. The mother of [CHILD1] and I try to understand where each other is coming from.	1 	2 	3 	4 	5 
h. The mother of [CHILD1] and I respect each other’s decisions made about [CHILD1].	1 	2 	3 	4 	5 

[ASK IF CHILDREN = MORE THAN ONE CHILD AGE 24 OR YOUNGER]

A9. Thinking about [CHILD2], how much do you agree or disagree with each of the statements below?

	SELECT ONE RESPONSE PER ROW
	STRONGLY DISAGREE	DISAGREE	NEUTRAL	AGREE	STRONGLY AGREE
a. The mother of [CHILD2] contradicts the decisions I made about [CHILD2].	1 	2 	3 	4 	5 
b. The mother of [CHILD2] makes negative comments, jokes, or sarcastic comments about the way I parent.	1 	2 	3 	4 	5 
c. The mother of [CHILD2] undermines me as a father.	1 	2 	3 	4 	5 
d. The mother of [CHILD2] and I discuss the best way to meet [CHILD2]’s needs.	1 	2 	3 	4 	5 
e. The mother of [CHILD2] and I share information about [CHILD2] with each other.	1 	2 	3 	4 	5 
f. The mother of [CHILD2] and I make joint decisions about [CHILD2].	1 	2 	3 	4 	5 
g. The mother of [CHILD2] and I try to understand where each other is coming from.	1 	2 	3 	4 	5 
h. The mother of [CHILD2] and I respect each other’s decisions made about [CHILD2].	1 	2 	3 	4 	5 

[ASK IF CHILDREN = MORE THAN ONE CHILD AGE 24 or younger]

A10. Do [CHILD1] and [CHILD2] have the same mother?

SELECT ONE ONLY

1  Yes, they have the same mother

0  No, they have different mothers

B. ECONOMIC STABILITY

[ASK ALL]

B1. How much do you agree or disagree with each of the statements below?

	SELECT ONE RESPONSE PER ROW
	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE
a. I would like to learn new job skills.	1 	2 	3 	4 
b. I have good job skills.	1 	2 	3 	4 

[ASK ALL]

B2a. Do you have a job now?

select ONE ONLY

1  Yes GO TO B2b

0  No GO TO B3

[ASK IF HAVE JOB = YES]

B2b. Is it a work release job?

select ONE ONLY

1  Yes

0  No

[ASK IF HAVE JOB = YES]

B2c. 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.

| | | / | | | | |

MM YYYY

[HARD CHECK: IF Month > 12 OR Month < 1; Month must be a number from 1 to 12.

IF Year > Current Year OR Year < 1900; Year must be the current year or earlier.

HARD CHECK: IF Month = non-numeric; Month must be a number from 1 to 12.

IF Year = non-numeric; Year must be the current year or earlier.]

[ASK ALL]

B3. Have you participated in education or job training programs in the past month?

select ONE ONLY

1  Yes

0  No

[ASK IF CHILDREN = ONE CHILD AGE 24 OR YOUNGER OR MORE THAN ONE CHILD AGE 24 OR YOUNGER]

B4. Do you have a legal arrangement or child support order that requires you to provide financial support for any of your children?

select ONE ONLY

1  Yes

0  No

d  I don’t know

[ASK ALL]

B5. Is there someone you could turn to, such as a friend or family member, if you suddenly needed to borrow money?

select ONE ONLY

1  Yes

0  No

d  I don’t know

C. RELATIONSHIPS/MARRIAGE

[ASK ALL]

C1. How much do you agree or disagree with the following statements?

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

[ASK ALL]

C2. What is your current marital status?

SELECT ONE ONLY

1  Married

2  Engaged

3  Separated

4  Divorced

5  Widowed

6  Never married

[SOFT CHECK IF C2 = NO RESPONSE; This question is very important. Please select an answer.]

[ASK IF MARITAL STATUS = SEPARATED, DIVORCED, WIDOWED, NEVER MARRIED, OR NO RESPONSE]

C3. What is your current partner status?

SELECT ONE ONLY

1  No current partner (unpartnered) GO TO D1

2  I am romantically involved or in a committed relationship with someone on a steady basis

3  I am involved in an on-again and off-again relationship

C4. When was the last time you saw your current partner/spouse?

SELECT ONE ONLY

1  In the past week

2  In the past month

3  In the past 6 months

4  In the past year

5  1 to 2 years ago

6  More than 2 years ago

7  Never

C5. In the past month, how often have you talked on the phone with your partner/spouse?

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 talk to my spouse/partner on the phone in the past month

D. PERSONAL DEVELOPMENT

[ASK ALL]

D1. This question is about feelings you may have experienced recently. During the past 30 days, how often have you felt …

	SELECT ONE RESPONSE PER ROW
	NONE OF THE TIME	A LITTLE OF THE TIME	SOME OF THE TIME	MOST OF THE TIME	ALL OF THE TIME
a. Nervous?	1 	2 	3 	4 	5 
b. Hopeless?	1 	2 	3 	4 	5 
c. Restless or fidgety?	1 	2 	3 	4 	5 
d. So depressed that nothing could cheer you up?	1 	2 	3 	4 	5 
e. That everything was an effort?	1 	2 	3 	4 	5 
f. Worthless?	1 	2 	3 	4 	5 

[ASK ALL]

D2. How much do you agree or disagree with the following statements?

	SELECT ONE RESPONSE PER ROW
	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE
a. I have little control over the things that happen to me.	1 	2 	3 	4 
b. I have hope when I think about my future.	1 	2 	3 	4 
c. I wouldn’t know where to go for help if I had money troubles.	1 	2 	3 	4 
d. I have others who will listen when I need to talk about my problems or when I am lonely.	1 	2 	3 	4 
e. I have people I can count on if I am feeling down.	1 	2 	3 	4 
f. If there is a crisis, I have others I can talk to.	1 	2 	3 	4 

Thank you for completing this survey!