Attachment_H_Instrument_4HM_3_Youth_EntranceSurvey_clean

OMB No.: 0970-0566

Expiration Date: 4/30/2024

Healthy Marriage Youth 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 [Current Point of Contact Name] at nform2helpdesk@mathematica-mpr.com.

A. ATTITUDES ABOUT MARRIAGE AND RELATIONSHIPS

[ASK ALL]

First, we would like to hear about your attitudes about marriage.

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

	SELECT ONE RESPONSE PER ROW
	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE
a. There is only one true love out there who is right for me to marry	1 	2 	3 	4 
b. In the end, feelings of love should be enough to sustain a happy marriage	1 	2 	3 	4 
c. Living together before marriage will improve a couple’s chances of remaining happily married	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 better for children if their parents are married	1 	2 	3 	4 
i. Living together is just the same as being married	1 	2 	3 	4 

[ASK ALL]

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

	SELECT ONE RESPONSE PER ROW
	ALMOST NO CHANCE	SOME CHANCE BUT PROBABLY NOT	A 50-50 CHANCE	A GOOD CHANCE	ALMOST CERTAIN
a. You will have a healthy marriage with 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 	6 

[ASK ALL]

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

	SELECT ONE RESPONSE PER 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 
h. Do not fear each other?	1 	2 	3 	4 

[ASK ALL]

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

	SELECT ONE RESPONSE PER 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 

[ASK ALL]

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

	SELECT ONE RESPONSE PER 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 

B. ATTITUDES ABOUT SEX

[ASK ALL]

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

	SELECT ONE RESPONSE PER 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 upset if I got someone pregnant at this age. / FEMALE: I would be upset 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 

[ASK ALL]

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

	SELECT ONE RESPONSE PER 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 comfortable saying “no” even if my friends are having sex.	1 	2 	3 	4 

C. RELATIONSHIP SKILLS

[ASK ALL]

C1. Do you have a boyfriend/girlfriend?

1  Yes GO TO C2

0  No GO TO C1a

SOFT CHECK: IF C1 = NO RESPONSE; This question is very important. Please select an answer.

IF C1 = NO RESPONSE, GO TO D1

[ASK IF BOYFRIEND/GIRLFRIEND = NO]

C1a. How much do you agree or disagree with the following statements?

	SELECT ONE RESPONSE PER ROW
	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE
a. I believe I will be able to effectively deal with conflicts that arise in my relationship.	1 	2 	3 	4 
b. I feel good about my ability to make a romantic relationship last.	1 	2 	3 	4 
c. I am very confident when I think of having a stable, long-term relationship.	1 	2 	3 	4 
d. I have the skills needed for a lasting, stable romantic relationship.	1 	2 	3 	4 
e. I am able to recognize the warning signs of a bad relationship.	1 	2 	3 	4 
f. I know what to do when I recognize the warning signs of a bad relationship.	1 	2 	3 	4 

[ASK IF BOYFRIEND/GIRLFRIEND = NO]

C1b. How good or bad are you at each of the following?

	SELECT ONE RESPONSE PER ROW
	I AM EXTREMELY GOOD AT THIS	I AM GOOD AT THIS	I AM BAD AT THIS	I AM EXTREMELY BAD AT THIS
a. Admitting that you might be wrong during a disagreement	1 	2 	3 	4 
b. Avoiding saying things that could turn a disagreement into a big 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 

[ASK IF BOYFRIEND/GIRLFRIEND = YES]

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

	SELECT ONE RESPONSE PER 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 

[ASK IF BOYFRIEND/GIRLFRIEND = YES]

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

	SELECT ONE RESPONSE PER 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 

[ASK IF BOYFRIEND/GIRLFRIEND = YES]

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

	SELECT ONE RESPONSE PER 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 

D: CONTACT WITH CHILDREN

[D1: ASK ALL]

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 END SURVEY

2  I have one or more children, but they do not live with me answer d2-d5 then end survey

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

SOFT CHECK: IF D1 = NO RESPONSE; This question is very important. Please select an answer.

IF D1 = NO RESPONSE, END SURVEY

D2. How old is your youngest child?

| | | 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 D2 > 19; Your child’s age should be less than 20 years.

HARD CHECK: IF D2 = non-numeric OR D2 < 0; Please enter a number. Your child’s age should be less than 20 years.

HARD CHECK IF D2 = 0; Please enter the age of your child in months or years.

SOFT CHECK IF D2= NO RESPONSE: Please enter the age of your child in months or years.

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

SELECT ONE ONLY

GO TO D4a

1  In the past week

2  In the past month

3  In the past 6 months

GO TO D5

4  In the past year

5  1 – 2 years ago

6  More than 2 years ago

7  Never

SOFT CHECK: IF D3 = NO RESPONSE; This question is very important. Please select an answer.

IF D3 = NO RESPONSE; GO TO D4a

[Ask if D3=1 or 2]

D4a. In the past month, how often did you see or visit your youngest child?

SELECT ONE ONLY

1  Every day or almost every day

GO TO D4b

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

SOFT CHECK: IF D4a = NO RESPONSE; This question is very important. Please select an answer.

IF D4a = NO RESPONSE; GO TO D4b

[Ask if D4a=1, 2, 3]

D4b. In the past month when you saw your youngest child, how many hours per day did you usually spend with that child? Do not include hours the child is sleeping.

| | | hours

HARD CHECK: IF D4b > 24; Time must be less than or equal to 24 hours.

HARD CHECK: IF D4b = non-numeric OR D4b < 0; Please enter a number. Time must be less than or equal to 24 hours.

SOFT CHECK IF D4b= NO RESPONSE: Please enter the number of hours per day you usually spend with that child.

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 in the past month

4  Never in the past month

E: PARENTING AND CO-PARENTING

[SECTION E: ASK IF D1 = 3]

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

E1. How old is your youngest child?

| | | 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 E1 > 19; Your child’s age should be less than 20 years.

HARD CHECK: IF E1 = non-numeric OR E1 < 0; Please enter a number. Your child’s age should be less than 20 years.

HARD CHECK IF E1 = 0; Please enter the age of your child in months or years.

SOFT CHECK IF E1= NO RESPONSE: Please enter the age of your child in months or years.

E2. Thinking about your youngest child, how often does each of the following happen in your family?

	SELECT ONE RESPONSE PER 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 what he/she likes to do	1 	2 	3 	4 

E3. Over the past month, did you…

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

E4. 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

E5. How much do you agree or disagree with the following statement?

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

SELECT ONE ONLY

1  Strongly agree

2  Agree

3  Disagree

4  Strongly disagree

E6. Would you be able to count on the child’s other parent to take care of your child or children in an emergency?

SELECT ONE ONLY

1  Yes

0  No

d  Don’t know

Thank you for completing this survey!