Attachment_H_Instrument_4HM_1_Adult_EntranceSurvey

OMB No.: 0970-0566

Expiration Date: 4/30/2024

Healthy Marriage Adult Program
Entrance Survey

Thank you for participating in this program. Throughout the program we will ask you to provide information so that we can better support you, and to help monitor the program’s performance. We hope you will answer all the questions asked by program staff or in surveys, but you may skip any questions you do not want to answer. Your answers will be kept private as required by law.

PRINCIPAL PURPOSE: The information you provide will be used primarily to (a) provide you with services, (b) monitor and help improve the performance of Healthy Marriage and Responsible Fatherhood (HMRF) programs, and (c) help understand HMRF services and participants across programs.

ROUTINE USES: Your information will be kept private and cannot be used against you in any law enforcement action. Your information may be combined with information from other individuals but you will not be personally identifiable. However, there may be circumstances where disclosure of your personal information may be requested; in these cases, processes are in place to further protect your information for such requests. These requests may include: (a) by a congressional office if you ask that office to help obtain a copy of your records; (b) to coordinate and respond to a data security breach; (c) for research or evaluation purposes; (d) for administrative or legal actions; or (e) by contractors supporting the purpose and uses described here, but only on a must know basis in order to perform their duties. Please see the sources below for more information about these routine uses.

DISCLOSURE: This request is voluntary. The relevant SORN is 09-80-0361, OPRE Research and Evaluation Project Records.

AUTHORITY: 42 U.S.C. 613 - Research, evaluations, and national studies; 42 U.S.C. 628b - National random sample study of child welfare; 42 U.S.C. 1310 - Cooperative research or demonstration projects; 42 U.S.C. 9836 - Designation of Head Start agencies; 42 U.S.C. Subchapter II-B - Child Care and Development Block Grant; and Pub L. No. 110-161, Division G, Title II, Payments to States for the Child Care and Development Block Grant (121 STAT. 2179).

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 0970-0566 and the expiration date is 04/30/2024. If you have any comments on this collection of information, please contact Hannah McInerney at nform2helpdesk@mathematica-mpr.com.

A. PARENTING

[ASK ALL]

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

GO TO B1

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?

[SOFT CHECK: IF A1b = NO RESPONSE; This question is very important. Please select an answer.]

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

[ASK IF BIOLOGICAL OR LEGALLY ADOPTED CHILD = NO OR A1C= NO RESPONSE]

A1d. What is your relationship to [CHILD1]?

SELECT ONE ONLY

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

2  Foster parent

3  Relative

4  Other (specify)

A1e. How old is [CHILD1]?

| | | years old or | | | months old

[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.

A1f. Does [CHILD1] live with you all or most of the time?

SELECT ONE ONLY

1  Yes, he or she lives with me all or most of the time GO TO A2a

0  No, he or she does not live with me all or most of the time IF A1a = 2, GO TO A4A ELSE GO TO A7

[SOFT CHECK: IF A1f = NO RESPONSE; This question is very important. Please select an answer.

IF A1f = NO RESPONSE AND A1a = 2, GO TO A4; ELSE GO TO B1]

A2a. Please tell us how often you’ve felt or acted this way in the past month with [CHILD1].

	SELECT ONE RESPONSE PER ROW
	NEVER	HARDLY EVER	SOMETIMES	OFTEN
a. I am happy being with [CHILD1]	1 	2 	3 	4 
b. [CHILD1] and I are very close to each other	1 	2 	3 	4 
c. I try to comfort [CHILD1] when he/she is upset	1 	2 	3 	4 
d. I spend time with [CHILD1] doing what he/she likes to do	1 	2 	3 	4 

A2b. Over the past month, did you…

	SELECT ONE RESPONSE PER ROW
	YES	NO
a. ...hit, spank, grab, or use physical punishment with [CHILD1]?	1 	0 
b. ...yell, shout, or scream at [CHILD1] because you were mad at him/her?	1 	0 
c. ...talk to [CHILD1] about what he/she did wrong?	1 	0 

A3. How much do you agree or disagree with the following statement?

“[CHILD1]’s other parent and I work well together as parents.”

SELECT ONE ONLY

1  Strongly agree

2  Agree

3  Disagree

4  Strongly disagree

[IF A1a = 2, CONTINUE TO A4a; ELSE, GO TO A7]

A4a. Now think about your oldest child. What is this child’s first name or initials?

A4b. 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 A4c

[ASK IF BIOLOGICAL OR LEGALLY ADOPTED CHILD = NO OR A4b= NO RESPONSE]

A4c. What is your relationship to [CHILD2]?

SELECT ONE ONLY

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

2  Foster parent

3  Relative

4  Other (specify)

A4d. How old is [CHILD2]?

| | | years old or | | | months old

[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.

A4e. Does [CHILD2] live with you all or most of the time?

SELECT ONE ONLY

1  Yes, he or she lives with me all or most of the time GO TO A5a

0  No, he or she does not live with me all or most of the time GO TO A7

SOFT CHECK: IF A4e = NO RESPONSE; This question is very important. Please select an answer.

IF A4e = NO RESPONSE AND A1F = 1, GO TO A7, ELSE GO TO B1

A5a. Please tell us how often you’ve felt or acted this way in the past month with [CHILD2].

	SELECT ONE RESPONSE PER ROW
	NEVER	HARDLY EVER	SOMETIMES	OFTEN
a. I am happy being with [CHILD2]	1 	2 	3 	4 
b. [CHILD2] and I are very close to each other	1 	2 	3 	4 
c. I try to comfort [CHILD2] when he/she is upset	1 	2 	3 	4 
d. I spend time with [CHILD2] doing what he/she likes to do	1 	2 	3 	4 

A5b. Over the past month, did you…

	SELECT ONE RESPONSE PER ROW
	YES	NO
a. ...hit, spank, grab, or use physical punishment with [CHILD2]?	1 	0 
b. ...yell, shout, or scream at [CHILD2] because you were mad at him/her?	1 	0 
c. ...talk to [CHILD2] about what he/she did wrong?	1 	0 

A6. How much do you agree or disagree with the following statement?

“[CHILD2]’s other parent and I work well together as parents.”

SELECT ONE ONLY

1  Strongly agree

2  Agree

3  Disagree

4  Strongly disagree

A7. In the past month, how often have you felt overwhelmed by your parenting responsibilities?

SELECT ONE ONLY

1  Never

2  Hardly ever

3  Sometimes

4  Often

B. JOB AND CAREER ADVANCEMENT

[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	NOT APPLICABLE
a. I would like to learn new job skills	1 	2 	3 	4 	na 
b. I know where to find job openings	1 	2 	3 	4 	na 
c. I know how to apply for a job	1 	2 	3 	4 	na 
d. I feel confident in my ability to conduct an effective job search for a job I want	1 	2 	3 	4 	na 
e. I feel confident in my interviewing skills	1 	2 	3 	4 	na 

[ASK ALL]

B2. Do you have an updated resume that you can give to employers?

SELECT ONE ONLY

1  Yes

0  No

[ASK ALL]

B3a. Do you have a checking account?

SELECT ONE ONLY

1  Yes

0  No

[ASK ALL]

B3b. Do you have a savings account?

SELECT ONE ONLY

1  Yes

0  No

[ASK ALL]

B4. How often do you find it difficult to pay your bills?

SELECT ONE ONLY

1  Never

2  Once in a while

3  Somewhat often

4  Very often

C. PERSONAL DEVELOPMENT

[ASK ALL]

C1. 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 

D. HEALTHY MARRIAGE/RELATIONSHIPS

[ASK ALL]

D1. 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]

D2. 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 D2 = NO RESPONSE; This question is very important. Please select an answer.]

[IF D2 = NO RESPONSE, GO TO D3]

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

D3. What is your current partner status?

SELECT ONE ONLY

1  No current partner (unpartnered) END SURVEY

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

[IF D2 = 3, 4, 5, 6 OR NO RESPONSE AND D3 = NO RESPONSE, End Survey.]

D4. How much of the time do you live with your current partner?

SELECT ONE ONLY

1  All of the time

2  Most of the time

3  Some of the time

4  None of the time

D5. This question is about your relationship with your partner/spouse. During the past month, how often did the following happen?

	SELECT ONE RESPONSE PER ROW
	NEVER	HARDLY EVER	SOMETIMES	OFTEN
a. My partner/spouse and I were good at working out our differences.	1 	2 	3 	4 
b. I felt respected even when my partner/spouse and I disagree	1 	2 	3 	4 
c. When my partner/spouse and I had a serious disagreement, we worked on it together to find a resolution.	1 	2 	3 	4 
d. When my partner/spouse and I had a serious disagreement, we discussed our disagreements respectfully.	1 	2 	3 	4 
e. During arguments, my partner/spouse and I were good at taking breaks when we needed them.	1 	2 	3 	4 
f. When my partner/spouse and I argued, past hurts got brought up again.	1 	2 	3 	4 
g. My partner/spouse understands that there are times when I do not feel like talking and times when he/she does.	1 	2 	3 	4 

D6. During the past month, how often has the following happened?

	SELECT ONE RESPONSE PER ROW
	NEVER	HARDLY EVER	SOMETIMES	OFTEN
a. My partner/spouse was rude or mean to me when we disagree	1 	2 	3 	4 
b. My partner/spouse seemed to view my words or actions more negatively than I meant them to be	1 	2 	3 	4 
c. Our arguments became very heated.	1 	2 	3 	4 
d. Small issues suddenly became big arguments.	1 	2 	3 	4 
e. My partner/spouse or I stayed mad at one another after an argument.	1 	2 	3 	4 

D7. In the past month, how often has the following happened?

	SELECT ONE RESPONSE PER ROW
	NEVER	HARDLY EVER	SOMETIMES	OFTEN
a. My partner/spouse blamed me for his/her problems.	1 	2 	3 	4 
b. My partner/spouse yelled or screamed at me.	1 	2 	3 	4 

D8. In the past month, how often has the following happened?

	SELECT ONE RESPONSE PER ROW
	NEVER	HARDLY EVER	SOMETIMES	OFTEN
a. I blamed my spouse/partner for my problems.	1 	2 	3 	4 
b. I yelled or screamed at my spouse/partner.	1 	2 	3 	4 

D9. How satisfied are you with the way you and your partner/spouse handle conflict?

SELECT ONE ONLY

1  Very satisfied

2  Somewhat satisfied

3  Not at all satisfied

D10. How much do you agree or disagree with the following statements about your partner/spouse?

	SELECT ONE RESPONSE PER ROW
	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE	NOT APPLICABLE
a. I trust my partner/spouse completely.	1 	2 	3 	4 	na 
b. My partner/spouse knows and understands me	1 	2 	3 	4 	na 
c. I can count on my partner/spouse to be there for me	1 	2 	3 	4 	na 
d. I feel appreciated by my partner/spouse	1 	2 	3 	4 	na 
e. My partner/spouse expresses love and affection toward me	1 	2 	3 	4 	na 

D11. In the past month, how often have you and your partner/spouse done the following things?

	SELECT ONE RESPONSE PER ROW
	ALMOST EVERY DAY	ONCE OR TWICE A WEEK	ONCE OR TWICE A MONTH	LESS OFTEN
a. Talk to each other about the day.	1 	2 	3 	4 
b. Laugh together.	1 	2 	3 	4 
c. Participate together in an activity we both enjoy.	1 	2 	3 	4 

D12. How satisfied are you with your current relationship?

SELECT ONE ONLY

1  Very satisfied

2  Somewhat satisfied

3  Not at all satisfied

D13. How much do you agree or disagree with this statement? I view our marriage/relationship as lifelong.

SELECT ONE ONLY

1  Strongly agree

2  Agree

3  Disagree

4  Strongly disagree

Thank you for completing this survey!