Attachment_H_Instrument_4RF_4_CommunityMothers_ExitSurvey_clean

OMB No.: 0970-0566

Expiration Date: 04/30/2024

Community-Based Fathers Program
Exit Survey
(Version for Mothers)

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. 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

GO TO A1b

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.

[ASK IF CHILDREN = I HAVE ONE CHILD; I HAVE MORE THAN ONE CHILD]

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

GO TO A1e

1  Yes, this is my biological child

2  Yes, this is my legally adopted child

0  No GO TO A1d

[SOFT CHECK: IF A1c = NO RESPONSE; This question is very important. Please select an answer.]

[ASK IF BIOLOGICAL OR LEGALLY ADOPTED CHILD = NO OR IF A1c = NO RESPONSE]

A1d. What is your relationship to [CHILD1]?

SELECT ONE ONLY

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

2  Foster mother

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.

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 A3

0  No, he or she does not live with me all or most of the time GO TO A1g

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

IF A1f = NO RESPONSE, GO TO A1g

A1g. When is the last time you saw [CHILD1]?

select ONE ONLY

GO TO A2a

1  In the past week

2  In the past month

3  In the past 6 months

4  In the past year

GO TO A2c

5  1 to 2 years ago

6  More than 2 years ago

7  Never

SOFT CHECK: IF A1g = NO RESPONSE; This question is very important. Please select an answer.

IF A1g = NO RESPONSE, GO TO A2c

A2a. In the past month, how often did you see [CHILD1]?

SELECT ONE ONLY

1  Every day or almost every day

GO TO A2b

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 GO TO A2c

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

IF A2a = NO RESPONSE, GO TO A2c

A2b. In the past month when you saw [CHILD1], how many hours per day did you usually spend with [CHILD1]? Do not include hours the child is sleeping.

| | | hours per day

[HARD CHECK: IF A2b > 24; Time must be less than or equal to 24 hours.

HARD CHECK: IF A2b = non-numeric OR A2b < 0; Please enter a number. Time must be less than or equal to 24 hours.]

A2c. In the past month, how often have you reached out to [CHILD1] even if [CHILD1] 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

A2d. Do you have an agreement with the father of [CHILD1] about spending time with [CHILD1]?

SELECT ONE ONLY

1  Yes, we have a legal document

GO TO A2e

2  Yes, we have a written agreement that is not court-ordered

3  Yes, we have a verbal understanding

GO TO A3

4  No, we have no parenting agreement

[SOFT CHECK: IF A2e = NO RESPONSE; This question is very important. Please select an answer.]

[IF A2d = NO RESPONSE, THEN A3]

A2e. How often does [CHILD1]’s father follow the agreement?

SELECT ONE ONLY

1  Always

2  Often

3  Sometimes

4  Never

A2f. How often do you follow the agreement?

SELECT ONE ONLY

1  Always

2  Often

3  Sometimes

4  Never

[ASK IF LIVES WITH CHILD1 or SAW CHILD1 = IN PAST WEEK OR PAST MONTH]

A3. 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 LIVES WITH CHILD1 or SAW CHILD1 = IN PAST WEEK OR PAST MONTH]

A4. 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 or her?	1 	0 
	c. ... talk to [CHILD1] about what he or she did wrong?	1 	0 

[ASK IF LIVES WITH CHILD1 or SAW CHILD1 = IN PAST WEEK OR PAST MONTH and CHILD1 AGE > 12 YEARS]

A5a. Below are some questions about the different types of things you do with your child. Please share how often you have engaged in the following activities during the last month (30 days).

	SELECT ONE RESPONSE PER ROW
	NEVER	1 TO 2 DAYS PER MONTH	3 OR 4 DAYS PER MONTH	2 OR 3 DAYS PER WEEK	EVERY DAY OR ALMOST EVERY DAY
a. How often have you watched TV with [CHILD1]?	1 	2 	3 	4 	5 
b. How often have you gone for a walk with [CHILD1]?	1 	2 	3 	4 	5 
c. How often have you had a meal with [CHILD1]?	1 	2 	3 	4 	5 
d. How often have you gone with [CHILD1] to a park?	1 	2 	3 	4 	5 
e. How often have you played or assisted [CHILD1] with sports?	1 	2 	3 	4 	5 
f. How often have you watched over or cared for [CHILD1] when other adults were not around?	1 	2 	3 	4 	5 
g. How often have you played board games or chess with [CHILD1]?	1 	2 	3 	4 	5 
h. How often have you hugged [CHILD1]?	1 	2 	3 	4 	5 
i. How often have you encouraged [CHILD1]?	1 	2 	3 	4 	5 
j. How often have you told [CHILD1] you loved him or her?	1 	2 	3 	4 	5 
k. How often have you taught [CHILD1] to make good choices?	1 	2 	3 	4 	5 

[ASK IF LIVES WITH CHILD1 or SAW CHILD1 = IN PAST WEEK OR PAST MONTH AND CHILD1 AGE > 6 YEARS AND <=12 YEARS]

A5b. Below are some questions about the different types of things you do with your child. Please share how often you have engaged in the following activities during the last month (30 days).

	SELECT ONE RESPONSE PER ROW
	NEVER	1 TO 2 DAYS PER MONTH	3 OR 4 DAYS PER MONTH	2 OR 3 DAYS PER WEEK	EVERY DAY OR ALMOST EVERY DAY
a. How often have you played toys with [CHILD1]?	1 	2 	3 	4 	5 
b. How often have you had meals with [CHILD1]?	1 	2 	3 	4 	5 
c. How often have you hugged [CHILD1]?	1 	2 	3 	4 	5 
d. How often have you watched over or cared for [CHILD1] when other adults were not around?	1 	2 	3 	4 	5 
e. How often have you read with [CHILD1]?	1 	2 	3 	4 	5 
f. How often have you taught [CHILD1] to take turns or to wait for rewards?	1 	2 	3 	4 	5 
g. How often have you encouraged [CHILD1]?	1 	2 	3 	4 	5 
h. How often have you told [CHILD1] you loved him or her?	1 	2 	3 	4 	5 
i. How often have you talked with [CHILD1]?	1 	2 	3 	4 	5 

[ASK IF LIVES WITH CHILD1 or SAW CHILD1 = IN PAST WEEK OR PAST MONTH AND CHILD1 AGE > 1 YEAR AND <= 6 YEARS]

A5c. Below are some questions about the different types of things you do with your child. Please share how often you have engaged in the following activities during the last month (30 days).

	SELECT ONE RESPONSE PER ROW
	NEVER	1 TO 2 DAYS PER MONTH	3 OR 4 DAYS PER MONTH	2 OR 3 DAYS PER WEEK	EVERY DAY OR ALMOST EVERY DAY
a. How often have you played toys with [CHILD1]?	1 	2 	3 	4 	5 
b. How often have you had meals with [CHILD1]?	1 	2 	3 	4 	5 
c. How often have you hugged [CHILD1]?	1 	2 	3 	4 	5 
d. How often have you watched over or cared for [CHILD1] when other adults were not around?	1 	2 	3 	4 	5 
e. How often have you played rough-and-tumble or roughhoused with [CHILD1]?	1 	2 	3 	4 	5 
f. How often have you read with [CHILD1]?	1 	2 	3 	4 	5 
g. How often have you taught [CHILD1] to take turns or to wait for rewards?	1 	2 	3 	4 	5 
h. How often have you encouraged [CHILD1]?	1 	2 	3 	4 	5 
i. How often have you told [CHILD1] you loved him or her?	1 	2 	3 	4 	5 
j. How often have you talked with [CHILD1]?	1 	2 	3 	4 	5 

[ASK IF LIVES WITH CHILD1 or SAW CHILD1 = IN PAST WEEK OR PAST MONTH AND CHILD1 AGE <= 1 YEAR]

A5d. Below are some questions about the different types of things you do with your child. Please share how often you have engaged in the following activities during the last month (30 days).

	SELECT ONE RESPONSE PER ROW
	NEVER	1 TO 2 DAYS PER MONTH	3 OR 4 DAYS PER MONTH	2 OR 3 DAYS PER WEEK	EVERY DAY OR ALMOST EVERY DAY
a. How often have you fed or given a bottle to [CHILD1]?	1 	2 	3 	4 	5 
b. How often have you praised [CHILD1]?	1 	2 	3 	4 	5 
c. How often have you watched over or cared for [CHILD1] when his or her father was not around?	1 	2 	3 	4 	5 
d. How often have you put [CHILD1] to sleep?	1 	2 	3 	4 	5 
e. How often have you played toys with [CHILD1]?	1 	2 	3 	4 	5 
f. How often have you talked to [CHILD1]?	1 	2 	3 	4 	5 
g. How often have you hugged [CHILD1]?	1 	2 	3 	4 	5 
h. How often have you told [CHILD1] you loved him or her?	1 	2 	3 	4 	5 
i. How often have you sung to [CHILD1]?	1 	2 	3 	4 	5 
j. How often have you read to [CHILD1]?	1 	2 	3 	4 	5 
k. How often have you told stories to [CHILD1]?	1 	2 	3 	4 	5 

[ASK IF CHILDREN = I HAVE MORE THAN ONE CHILD]

Now think about your oldest child.

A6a. What is this child’s first name or initials?

[ASK IF CHILDREN = I HAVE MORE THAN ONE CHILD]

A6b. Is this your biological or legally adopted child?

SELECT ONE ONLY

GO TO A6d

1  Yes, this is my biological child

2  Yes, this is my legally adopted child

0  No

[IF A6b = NO RESPONSE, THEN A6c]

[ASK IF CHILDREN = I HAVE MORE THAN ONE CHILD AND BIOLOGICAL OR LEGALLY ADOPTED CHILD = NO]

A6c. What is your relationship to [CHILD2]?

SELECT ONE ONLY

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

2  Foster mother

3  Relative

4  Other (specify)

[ASK IF CHILDREN = I HAVE MORE THAN ONE CHILD]

A6d. How old is [CHILD2]?

| | | 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.

A7. 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 A9

0  No, he or she does not live with me all or most of the time GO TO A8a

SOFT CHECK: IF A8 = NO RESPONSE; This question is very important. Please select an answer.

IF A8 = NO RESPONSE, GO TO A9a

A8a. When is the last time you saw [CHILD2]?

SELECT ONE ONLY

GO TO A8b

1  In the past week

2  In the past month

3  In the past 6 months

4  In the past year

GO TO A8d

5  1 or 2 years ago

6  More than 2 years ago

7  Never

SOFT CHECK: IF A8a = NO RESPONSE; This question is very important. Please select an answer.

IF A8a = NO RESPONSE, GO TO A8d

A8b. In the past month, how often did you see [CHILD2]?

SELECT ONE ONLY

1  Every day or almost every day

GO TO A8c

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 GO TO A8d

SOFT CHECK: IF A8b = NO RESPONSE; This question is very important. Please select an answer.

[IF A8b = NO RESPONSE, THEN A8d]

A8c. In the past month when you saw [CHILD2], how many hours per day did you usually spend with [CHILD2]? Do not include hours the child is sleeping.

| | | hours per day

[HARD CHECK: IF A8c > 24; Time must be less than or equal to 24 hours.

HARD CHECK: IF A8c = non-numeric OR A8c < 0; Please enter a number. Time must be less than or equal to 24 hours.]

A8d. In the past month, how often have you reached out to [CHILD2] even if [CHILD2] 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

A8e. Do you have an agreement with the father of [CHILD2] about spending time with [CHILD2]?

SELECT ONE ONLY

GO TO A8f

1  Yes, we have a legal document

2  Yes, we have a written agreement that is not court-ordered

3  Yes, we have a verbal understanding

4  No, we have no parenting agreement GO TO A9

SOFT CHECK: IF A8f = NO RESPONSE; This question is very important. Please select an answer.

[IF A8e = NO RESPONSE, THEN A9]

A8f. How often does [CHILD2]’s father follow the agreement?

SELECT ONE ONLY

1  Always

2  Often

3  Sometimes

4  Never

A8g. How often do you follow the agreement?

SELECT ONE ONLY

1  Always

2  Often

3  Sometimes

4  Never

[ASK IF CHILDREN = I HAVE MORE THAN ONE CHILD AND IF LIVES WITH CHILD2 or SAW CHILD2 = IN PAST WEEK OR PAST MONTH]

A9. 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 = I HAVE MORE THAN ONE CHILD AND IF LIVES WITH CHILD2 or SAW CHILD2 = IN PAST WEEK OR PAST MONTH]

A10. 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 or she did wrong?	1 	0 

[ASK IF CHILDREN = I HAVE MORE THAN ONE CHILD AND IF LIVES WITH CHILD2 or SAW CHILD2 = IN PAST WEEK OR PAST MONTH AND CHILD2 AGE > 12]

A11a. Below are some questions about the different types of things you do with your child follow. Please share how often have you engaged in the following activities during the last month (30 days).

	SELECT ONE RESPONSE PER ROW
	NEVER	1 TO 2 DAYS PER MONTH	3 OR 4 DAYS PER MONTH	2 OR 3 DAYS PER WEEK	EVERY DAY OR ALMOST EVERY DAY
a. How often have you watched TV with [CHILD2]?	1 	2 	3 	4 	5 
b. How often have you gone for a walk with [CHILD2]?	1 	2 	3 	4 	5 
c. How often have you had a meal with [CHILD2]?	1 	2 	3 	4 	5 
d. How often have you gone with [CHILD2] to a park?	1 	2 	3 	4 	5 
e. How often have you played or assisted [CHILD2] with sports?	1 	2 	3 	4 	5 
f. How often have you watched over or cared for [CHILD2] when other adults were not around?	1 	2 	3 	4 	5 
g. How often have you played board games or chess with [CHILD2]?	1 	2 	3 	4 	5 
h. How often have you hugged [CHILD2]?	1 	2 	3 	4 	5 
i. How often have you encouraged [CHILD2]?	1 	2 	3 	4 	5 
j. How often have you told [CHILD2] you loved him or her?	1 	2 	3 	4 	5 
k. How often have you taught [CHILD2] to make good choices?	1 	2 	3 	4 	5 

[ASK IF LIVES WITH CHILD2 or SAW CHILD2 = IN LAST WEEK OR LAST MONTH AND CHILD2 AGE > 6 YEARS AND <=12 YEARS]

A11b. Below are some questions about the different types of things you do with your child. Please share how often have you engaged in the following activities during the last month (30 days).

	SELECT ONE RESPONSE PER ROW
	NEVER	1 TO 2 DAYS PER MONTH	3 OR 4 DAYS PER MONTH	2 OR 3 DAYS PER WEEK	EVERY DAY OR ALMOST EVERY DAY
a. How often have you played toys with [CHILD2]?	1 	2 	3 	4 	5 
b. How often have you had meals with [CHILD2]?	1 	2 	3 	4 	5 
c. How often have you hugged [CHILD2]?	1 	2 	3 	4 	5 
d. How often have you watched over or cared for [CHILD2] when other adults were not around?	1 	2 	3 	4 	5 
e. How often have you read with [CHILD2]?	1 	2 	3 	4 	5 
f. How often have you taught [CHILD2] to take turns or to wait for rewards?	1 	2 	3 	4 	5 
g. How often have you encouraged [CHILD2]?	1 	2 	3 	4 	5 
h. How often have you told [CHILD2] you loved him or her?	1 	2 	3 	4 	5 
i. How often have you talked with [CHILD2]?	1 	2 	3 	4 	5 

[ASK IF LIVES WITH CHILD2 or SAW CHILD2 = IN PAST WEEK OR PAST MONTH AND CHILD2 AGE > 1 YEAR AND <= 6 YEARS]

A11c. Below are some questions about the different types of things you do with your child. Please share how often have you engaged in the following activities during the last month (30 days).

	SELECT ONE RESPONSE PER ROW
	NEVER	1 TO 2 DAYS PER MONTH	3 OR 4 DAYS PER MONTH	2 OR 3 DAYS PER WEEK	EVERY DAY OR ALMOST EVERY DAY
a. How often have you played toys with [CHILD2]?	1 	2 	3 	4 	5 
b. How often have you had meals with [CHILD2]?	1 	2 	3 	4 	5 
c. How often have you hugged [CHILD2]?	1 	2 	3 	4 	5 
d. How often have you watched over or cared for [CHILD2] when other adults were not around?	1 	2 	3 	4 	5 
e. How often have you played rough-and-tumble or roughhoused with [CHILD2]?	1 	2 	3 	4 	5 
f. How often have you read with [CHILD2]?	1 	2 	3 	4 	5 
g. How often have you taught [CHILD2] to take turns or to wait for rewards?	1 	2 	3 	4 	5 
h. How often have you encouraged [CHILD2]?	1 	2 	3 	4 	5 
i. How often have you told [CHILD2] you loved him/her?	1 	2 	3 	4 	5 
j. How often have you talked with [CHILD2]?	1 	2 	3 	4 	5 

[ASK IF LIVES WITH CHILD2 or SAW CHILD2 = IN PAST WEEK OR PAST MONTH AND CHILD2 AGE <= 1 YEAR]

A11d. Below are some questions about the different types of things you do with your child. Please share how often have you engaged in the following activities during the last month (30 days).

	SELECT ONE RESPONSE PER ROW
	NEVER	1 TO 2 DAYS PER MONTH	3 OR 4 DAYS PER MONTH	2 OR 3 DAYS PER WEEK	EVERY DAY OR ALMOST EVERY DAY
a. How often have you fed or given a bottle to [CHILD2]?	1 	2 	3 	4 	5 
b. How often have you praised [CHILD2]?	1 	2 	3 	4 	5 
c. How often have you watched over or cared for [CHILD2] when his or her father was not around?	1 	2 	3 	4 	5 
d. How often have you put [CHILD2] to sleep?	1 	2 	3 	4 	5 
e. How often have you played toys with [CHILD2]?	1 	2 	3 	4 	5 
f. How often have you talked to [CHILD2]?	1 	2 	3 	4 	5 
g. How often have you hugged [CHILD2]?	1 	2 	3 	4 	5 
h. How often have you told [CHILD2] you loved him or her?	1 	2 	3 	4 	5 
i. How often have you sung to [CHILD2]?	1 	2 	3 	4 	5 
j. How often have you read to [CHILD2]?	1 	2 	3 	4 	5 
k. How often have you told stories to [CHILD2]?	1 	2 	3 	4 	5 

[ASK IF CHILDREN = I HAVE MORE THAN ONE CHILD AND IF LIVES WITH CHILD2 or SAW CHILD2 = IN PAST WEEK OR PAST MONTH]

A12. 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

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

A13. 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 father of [CHILD1] contradicts the decisions I made about [CHILD1].	1 	2 	3 	4 	5 
b. The father of [CHILD1] makes negative comments, jokes, or sarcastic comments about the way I parent.	1 	2 	3 	4 	5 
c. The father of [CHILD1] undermines me as a mother.	1 	2 	3 	4 	5 
d. The father of [CHILD1] and I discuss the best way to meet [CHILD1]’s needs.	1 	2 	3 	4 	5 
e. The father of [CHILD1] and I share information about [CHILD1] with each other.	1 	2 	3 	4 	5 
f. The father of [CHILD1] and I make joint decisions about [CHILD1].	1 	2 	3 	4 	5 
g. The father of [CHILD1] and I try to understand where each other is coming from.	1 	2 	3 	4 	5 
h. The father of [CHILD1] and I respect each other’s decisions made about [CHILD1].	1 	2 	3 	4 	5 
i. The father of [CHILD1] makes it hard for me to spend time with [CHILD1].	1 	2 	3 	4 	5 
j. The father of [CHILD1] makes it hard for me to talk with [CHILD1].	1 	2 	3 	4 	5 
k. The father of [CHILD1] tells [CHILD1] what he or she is allowed and not allowed to say to me.	1 	2 	3 	4 	5 

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

A14. 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 father of [CHILD2] contradicts the decisions I made about [CHILD2].	1 	2 	3 	4 	5 
b. The father of [CHILD2] makes negative comments, jokes, or sarcastic comments about the way I parent.	1 	2 	3 	4 	5 
c. The father of [CHILD2] undermines me as a mother.	1 	2 	3 	4 	5 
d. The father of [CHILD2] and I discuss the best way to meet [CHILD2]’s needs.	1 	2 	3 	4 	5 
e. The father of [CHILD2] and I share information about [CHILD2] with each other.	1 	2 	3 	4 	5 
f. The father of [CHILD2] and I make joint decisions about [CHILD2].	1 	2 	3 	4 	5 
g. The father of [CHILD2] and I try to understand where each other is coming from.	1 	2 	3 	4 	5 
h. The father of [CHILD2] and I respect each other’s decisions made about [CHILD2].	1 	2 	3 	4 	5 
i. The father of [CHILD2] makes it hard for me to spend time with [CHILD2].	1 	2 	3 	4 	5 
j. The father of [CHILD2] makes it hard for me to talk with [CHILD2].	1 	2 	3 	4 	5 
k. The father of [CHILD2] tells [CHILD2] what he or she is allowed and not allowed to say to me.	1 	2 	3 	4 	5 

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

A15. Do [CHILD1] and [CHILD2] have the same father?

SELECT ONE ONLY

1  Yes, they have the same father

0  No, they have different fathers

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	NOT APPLICABLE
a. I would like to learn new job skills	1 	2 	3 	4 	5 
b. I know where to find job openings	1 	2 	3 	4 	5 
c. I know how to apply for a job	1 	2 	3 	4 	5 
d. I feel confident in my ability to conduct an effective job search for a job I want	1 	2 	3 	4 	5 
e. I feel confident in my interviewing skills	1 	2 	3 	4 	5 

[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

[ASK ALL]

B5. What is your current employment status?

SELECT ALL THAT APPLY

1 □ Full-time employment (usually work 35 or more hours a week)

2 □ Part-time employment (usually work 1–34 hours a week)

3 □ Employed, but number of hours change from week to week

4 □ Temporary, occasional, or seasonal employment, or odd jobs for pay

5 □ Stay-at-home parent or homemaker

6  Not currently employed

[SOFT CHECK: IF CURRENT EMPLOYMENT = NOT CURRENTLY EMPLOYED, DISABLE OTHER OPTIONS]

[ASK IF CURRENT EMPLOYMENT = STAY-AT-HOME PARENT OR NOT CURRENTLY EMPLOYED]

B5a. Are you actively looking for work?

SELECT ONE ONLY

1  Yes

0  No

[ASK ALL]

B6. Are you currently in school, working toward your GED, or in college or other post-high school education?

SELECT ONE ONLY

1  Yes

0  No

[ASK ALL]

B7. In the past 30 days, how much money did you make?

Please include tips, bonuses, commissions, and regular overtime pay, and count all money you received before taxes and deductions and money you earned from informal work or odd jobs. If you held more than one job, include your total earnings from all of your work during the past 30 days. Do not include the earnings of other people who live with you.

Your best estimate is fine.

SELECT ONE ONLY

1  No earnings in the past 30 days

2  $1–$499

3  $500–$1,000

4  $1,001–$2,000

5  $2,001–$3,000

6  $3,001–$4,000

7  $4,001–$5,000

8  More than $5,000

[SKIP IF CURRENT EMPLOYMENT = STAY-AT-HOME PARENT OR NOT CURRENTLY EMPLOYED]

B8. 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]

B9. Some people experience challenges that make it hard to find or keep a good job. Do any of the following make it difficult for you to find or keep a job?

SELECT ALL THAT APPLY

1 □ I have a criminal record

2 □ I do not have reliable transportation

3 □ I do not have the right clothes for a job (including uniforms)

4 □ I do not have documentation for legal employment (such as a birth certificate)

5 □ I do not have good enough child care or family help

6 □ I do not have the right skills or education for good jobs

7 □ I have a physical disability or poor health

8 □ I have substance use or mental health challenges

9  None of the above

[SOFT CHECK: IF JOB CHALLENGES = NONE OF THE ABOVE = DISABLE OTHER OPTIONS]

[ASK IF CHILD1 LIVES WITH = ‘No, he or she does not live with me all or most of the time’ OR IF CHILD2 LIVES WITH = ‘No, he or she does not live with me all or most of the time’]

B10. Do you have a legal arrangement or child support order that requires you to provide financial support for ANY of your children that do not live with you all or most of the time?

SELECT ONE ONLY

1  Yes

0  No

d  I don’t know

[ASK ALL]

B11. 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

GO TO C4

1  Married

2  Engaged

3  Separated

4  Divorced

GO TO C3

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

GO TO C4

C

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

[SOFT CHECK IF C3 = NO RESPONSE; This question is very important. Please select an answer.]

IF C3 = NO RESPONSE, GO TO D1.

C4. 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

C5. How satisfied are you with your current relationship?

SELECT ONE ONLY

1  Very satisfied

2  Somewhat satisfied

3  Not satisfied

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 

E. PROGRAM PERCEPTION

[ASK ALL]

E1. Since you began attending the program, have you obtained any of the following?

SELECT all that apply

1 □ High school diploma or GED

2 □ Vocational or technical certification

3 □ Other (specify)

na  None of the above

[SOFT CHECK IF E1 = 4, THEN DISABLE OTHER OPTIONS]

[ASK ALL]

E2. On a scale from 1 to 5, overall, how helpful was the program to you?

SELECT ONE ONLY

1  1—not at all

2  2

3  3

4  4

5  5—extremely helpful

[SKIP IF CHILDREN = NO CHILDREN OR ALL CHILDREN AGE 25 OR OLDER]

E3. On a scale from 1 to 5, overall, how helpful was the program for your parenting?

SELECT ONE ONLY

1  1—not at all

2  2

3  3

4  4

5  5—extremely helpful

na  Not addressed by this program

[SKIP IF CHILDREN = NO CHILDREN OR ALL CHILDREN AGE 25 OR OLDER]

E4. On a scale from 1 to 5, overall, how helpful was the program for helping you work together as parents with the father or fathers of your child/children?

SELECT ONE ONLY

1  1—not at all

2  2

3  3

4  4

5  5—extremely helpful

na  Not addressed by this program

0  None of the fathers of my children are involved with my children

[ASK ALL]

E5. On a scale from 1 to 5, overall, how helpful was the program for your financial well-being?

SELECT ONE ONLY

1  1—not at all

2  2

3  3

4  4

5  5—extremely helpful

na  Not addressed by this program

Thank you for completing this survey!