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EARLY HEAD START EVALUATION
PARENT SERVICES FOLLOW-UP SCREENER

 

OMB #: 0970-0143 (6-MONTH FOLLOW-UP)

EXPIRES: 10/31/99 (6-MONTH FOLLOW-UP)

  
CASE ID: ______________________________

INTERVIEWER: _________________________

CAPI ID: _______________________________

SCREENER
IN1. Hello, I’m (NAME) and I’m (calling) from (LOCAL RESEARCH INSTITUTION). May I please speak with SAMPLE MEMBER/NAME ON CONTACT SHEET?
      SAMPLE MEMBER AVAILABLE 1  
      SAMPLE MEMBER NOT AVAILABLE 0 arrow GO TO IN4 (PAGE S-4)
IN2.

Recently we sent you a letter about the study (LOCAL RESEARCH INSTITUTION) is doing with the U.S. Department of Health and Human Services to learn more about the needs and experiences of (parents/guardians) of young children. When you applied to Early Head Start, you were told that you would be called about this study a few times over the next few years and you agreed to help us. ([TIME] ago you were interviewed about FOCUS CHILD, you were videotaped doing some activities together, and (he/she) was asked to do some tasks.)

6 MONTH INTERVIEW: This part of the study focuses on some of the services you use and assistance you need and the kinds of things that affect the ability of parents of young children to get jobs, attend school, and care for their children.

12, 15, 24, 36 MONTH INTERVIEW ONLY: You may remember we talked to you about six months ago about some of the services you use and assistance you need and the kinds of things that affect the ability of parents of young children to get jobs, attend school, and care for their children. We would like to talk to you again about the services you have used since we last talked to you.

Your participation is voluntary (CONTROL GROUP ONLY: and will not affect any benefits or services you or your child(ren) may receive now or in the future). The survey will take about 45 minutes to complete and we will give you (LOCAL RESPONDENT PAYMENT) for completing the interview.
IN3. INTERVIEWER: WAS RESPONDENT PREGNANT DURING LAST CONTACT (RANDOMIZATION)?
      YES 1 arrow GO TO A
      NO 0 arrow GO TO IN4 (PAGE S-4)
  A. INTERVIEWER: IS THERE A FOCUS CHILD NAME ON YOUR CONTACT SHEET?
      YES 1 arrow GO TO IN4 (PAGE S-4)
      NO 0 arrow READ B
  B.

When you applied to Early Head Start, you were pregnant. I would like to ask you some questions about your pregnancy.

When was your baby born?
     
|___|___| / |___|___| / 19 |___|___|
MONTH DAY YEAR
   
      BABY NOT BORN 0 arrow GO TO D
  C. Is your baby living with you?
      YES 1 arrow GO TO H (PAGE S-3)
      NO 0  
  D. INTERVIEWER: CODE IF KNOWN, OTHERWISE READ: Why is that?
      STILL PREGNANT 0 arrow GO TO IN4 (PAGE S-4)
      DECEASED 1 arrow READ E AND F (PAGE S-3)
      MISCARRIAGE 2
3		 READ G (PAGE S-3)
      ABORTED
      GAVE UP FOR ADOPTION 4 arrow GO TO ENDING 3
(PAGE S-14)
      IN FOSTER CARE 5
6
7		 READ H (PAGE S-3)
      LIVING WITH OTHER CAREGIVER
      OTHER (SPECIFY)
      ___________________________________________  
  E. I am very sorry to hear that. Please tell me when your child died.
     
|___|___| / |___|___| / 19 |___|___|
MONTH DAY YEAR
   
      DON'T KNOW 8  
      REFUSED 9  
  F. What was the cause of your child’s death?
     

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

    
      DON'T KNOW 8  
      REFUSED 9  
GO TO ENDING 3 (PAGE S-14)
  G. I’m very sorry to hear that. Please tell me the date of your (abortion/miscarriage)?
     
|___|___| / |___|___| / 19 |___|___|
MONTH DAY YEAR
   
      DON'T KNOW 8  
      REFUSED 9  
GO TO ENDING 3 (PAGE S-14)
  H. What is your baby’s name?

PROBE: You can give me a nickname for the baby.
    ___________________________________________________________________    
  I. ASK IF NECESSARY: Is (BABY) a boy or girl?
      MALE 1  
      FEMALE 2  
  J. What is (BABY)’s social security number?
     
|___|___|___| - |___|___| - |___|___|___|
   
      DOESN’T HAVE SOCIAL SECURITY NUMBER 7  
      DON'T KNOW 8  
      REFUSED 9  
   
IN4. INTERVIEWER, CODE IF KNOWN, OTHERWISE, READ: Does SAMPLE MEMBER/NAME ON CONTACT SHEET live here?
      YES 1  
      NO 0  
      DON'T KNOW 8  
           
  A. INTERVIEWER, CODE IF KNOWN, OTHERWISE, READ: Does FOCUS CHILD still live with (you/SAMPLE MEMBER/NAME ON CONTACT SHEET)?
      YES 1  
      NO 0  
      DON'T KNOW 8  
           
  B. INTERVIEWER, CODE WITHOUT ASKING:
           
      BOTH SAMPLE MEMBER AND FOCUS CHILD LIVING THERE 1 arrow GO TO C (PAGE S-5)
      SAMPLE MEMBER NOT LIVING THERE, CHILD IS 2 arrow READ IN5 (PAGE S-6)
      SAMPLE MEMBER IS LIVING THERE, CHILD IS NOT 3 arrow READ IN6 (PAGE S-6)
      CHILD IN FOSTER CARE 4 arrow GO TO IN10 (PAGE S-8)
      CHILD GIVEN UP FOR ADOPTION 5 arrow GO TO ENDING 3 (PAGE S-14)
      NEITHER SAMPLE MEMBER NOR CHILD LIVES THERE 6 arrow GO TO IN17 (PAGE S-12)
      CHILD DECEASED 7 arrow READ E AND F (PAGE S-5)
      DON’T KNOW IF SAMPLE MEMBER OR FOCUS CHILD LIVES THERE 8 arrow ASK TO SPEAK TOSOMEONE ELSE AND GO BACK TO IN4
           
  C. INTERVIEWER: CODE WITHOUT ASKING, OR ASK: Is now a good time to talk to SAMPLE MEMBER?
      YES 1 arrow GO TO IN5 (PAGE S-6)
      NO 0  
           
  D. When would be a good time to (call back/return) to talk with SAMPLE MEMBER/NAME ON CONTACT SHEET?

PROBE: We are conducting a survey of (parents/guardians) of young children.
    INTERVIEWER: RECORD DATE AND TIME FOR CALL BACK/RETURN VISIT ON CONTACT SHEET.
    Thank you for your time. I will (call back/return) when SAMPLE MEMBER/NAME ON CONTACT SHEET is available.
           
EXIT SCREENER
           
    READ IF CHILD IS DECEASED:
  E. I am very sorry to hear that. Please tell me the date of FOCUS CHILD’s death?
     
|___|___| / |___|___| / 19 |___|___|
MONTH DAY YEAR
   
      DON'T KNOW 8  
      REFUSED 9  
           
  F. What was the cause of FOCUS CHILD's death?
     

_________________________________________________________________

_________________________________________________________________

    
      DON'T KNOW 8  
      REFUSED 9  
           
GO TO ENDING 3 (PAGE S-14)
           
  INTERVIEWER: CODE IF KNOWN, IF RESPONDENT IS STILL PREGNANT, CODE “YES”.
   
IN5.

Are you the person who lives with FOCUS CHILD and has primary responsibility for (her/his) care; (are you/who is) the person who makes decisions about FOCUS CHILD’s care, including (her/his) daily routine, health care, and child care?

PROBE: Who is the person who has primary responsibility for caring for FOCUS
CHILD?
      YES 1 arrow GO TO IN16 (PAGE S-11)
      NO 0  
           
IN6.

Who currently has primary responsibility for caring for FOCUS CHILD?

PROBE: This would be the person who makes decisions about FOCUS CHILD’s care, including (his/her) daily routine, health care, and child care.

CAREGIVER’S FULL NAME:_____________________________________________
      CHILD GIVEN UP FOR ADOPTION 7 arrow GO TO ENDING 3 (PAGE S-14)
      DON’T KNOW 8 arrow GO TO IN17 (PAGE S-12)
           
IN7. What is CAREGIVER’s address?
      STREET:_________________________________    
      APT. NUMBER:___________________________    
      CITY:____________________________________    
      STATE:_____________ ZIP CODE: ___________    
      DON'T KNOW 8  
      REFUSED 9  
           
IN8. What is CAREGIVER’s telephone number?
      TELEPHONE NUMBER: (_______) - __________ - ____________    
      NO TELEPHONE 7  
      DON'T KNOW 8  
      REFUSED 9  
           
IN9. What is CAREGIVER’s relationship to FOCUS CHILD?
      PARENT 1 GO TO IN14 (PAGE S-9)
      GRANDPARENT 2
      AUNT OR UNCLE 3
      COUSIN 4
      BROTHER OR SISTER 5
      OTHER RELATIVE (SPECIFY) 6
      _________________________________________  
           
      FOSTER PARENT 7 arrow GO TO IN10 (PAGE S-8)
      ADOPTIVE PARENT 8 arrow GO TO ENDING 3 (PAGE S-14)
      OTHER NONRELATIVE 98 arrow GO TO IN14 (PAGE S-9)
      CHILD DECEASED 99 arrow READ A AND B (PAGE S-8)
           
  A. I am very sorry to hear that. Please tell me the date of FOCUS CHILD’s death?
     
|___|___| / |___|___| / 19 |___|___|
MONTH DAY YEAR
   
      DON'T KNOW 8  
      REFUSED 9  
           
  B. What was the cause of FOCUS CHILD's death?
     

_________________________________________________________________

_________________________________________________________________

    
      DON'T KNOW 8  
      REFUSED 9  
           
GO TO ENDING 3 (PAGE S-14)
           
IN10. What is the name of the agency that placed FOCUS CHILD with his/her foster parents?

INTERVIEWER: BE SURE TO GET THE COMPLETE NAME. IF THE PERSON GIVES YOU AN ACRONYM (SUCH AS DYFS FOR DIVISION OF YOUTH AND FAMILY SERVICES), OBTAIN . THE ENTIRE NAME.

NAME OF AGENCY:__________________________________________________
           
      DON'T KNOW 8  
      REFUSED 9  
           
IN11. What is the name of the FOCUS CHILD’s case worker?

FULL NAME OF CASE WORKER:__________________________________________________
           
      DON'T KNOW 8  
      REFUSED 9  
           
IN12. Do you have a telephone number where I can reach CASE WORKER?
      TELEPHONE NUMBER: (_______) - __________ - ____________    
      DON'T KNOW 8  
      REFUSED 9  
           
IN13. Do you have the address for NAME OF AGENCY?
      STREET:_________________________________    
      SUITE/ROOM NUMBER:____________________    
      CITY:____________________________________    
      STATE:_____________ ZIP CODE: ___________    
      DON'T KNOW 8  
      REFUSED 9  
           
IN14. When did (you/SAMPLE MEMBER) stop having responsibility for FOCUS CHILD?
     
|___|___| / |___|___| / 19 |___|___|
MONTH DAY YEAR
   
      DON'T KNOW 8  
      REFUSED 9  
           
IN15. Why did (you/SAMPLE MEMBER) give up primary responsibility for FOCUS CHILD? RECORD VERBATIM THEN CIRCLE ALL THAT APPLY.
 

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________
           
     
CIRCLE ALL THAT APPLY
      PARENT’S HEALTH 1  
      DRUG USE 2  
      ALCOHOL USE 3  
      COULDN’T AFFORD CHILD 4  
      STATE MANDATED 5  
      DIDN’T WANT TO RAISE CHILD 6  
           
  A. INTERVIEWER: NEW CAREGIVER IS . . .
     
AGENCY arrow GO TO ENDING 1 (PAGE S-14)
     
KNOWN INDIVIDUAL - YOU ARE TALKING TO arrow GO TO IN16 B (PAGE S-11)
     
KNOWN INDIVIDUAL - YOU NEED TO CONTACT arrow GO TO ENDING 1 (PAGE S-14)
           
IN16. IS CAREGIVER THE PERSON ON THE CONTACT SHEET?
     
YES arrow READ IN16A
   
     
NO arrow READ IN16B
   
           
IN16A.

READ IF SAMPLE MEMBER DID NOT HAVE BABY: Even though you did not have your baby, we would like to interview you.

READ TO EVERYONE: (Before we begin/Now), I would like to explain more about this part of the study. The interview is about you and your family. I will ask you about the goals and resources your family has and the services you may have received to help you meet those goals. The interview will take about 45 minutes and we will pay you (LOCAL RESPONDENT PAYMENT) for completing it.
           
GO TO CAPI
           
IN16B.

INTERVIEWER: IF CAREGIVER IS NOT THE PERSON ON CONTACT SHEET, READ: Recently we sent SAMPLE MEMBER/NAME ON CONTACT SHEET a letter about a study LOCAL RESEARCH INSTITUTION is doing with the U.S. Department of Health and Human Services. The purpose of the study is to learn more about the needs and experiences of (parents/guardians) of young children. When SAMPLE MEMBER/NAME ON CONTACT SHEET applied to Early Head Start (she/he) agreed to help us with this study. Since you are the person responsible for FOCUS CHILD, we would like to talk to you about the study.

IF ON TELEPHONE:
We need to have you sign a form consenting to be part of the study. To do this, I need to visit you in person to discuss the study and then interview you. When would be a good time for me to come?

INTERVIEWER: RECORD DATE AND TIME ON CONTACT SHEET.
           
EXIT SCREENER
           
  IF IN PERSON:
Before we begin, I would like to read this form with you. It describes the study and why it is important for you to participate. REVIEW CONSENT FORM WITH PERSON AND HAVE (HIM/HER) SIGN IT.
           
GO TO CAPI
           
IN17. Do you know anyone who would know where to find SAMPLE MEMBER and/or FOCUS CHILD or someone who knows where to find them? SAMPLE MEMBER agreed to be part of a research study and it is important for us to talk to (him/her) or the person who has FOCUS CHILD.
           
     
CIRCLE ALL THAT APPLY
      YES, SAMPLE MEMBER 1 arrow GO TO IN18
      YES, FOCUS CHILD 2 arrow GO TO IN19 (PAGE S-13)
      NO 0 arrow READ IN16B
           
IF PERSON KNOWS HOW TO FIND SAMPLE MEMBER:
           
IN18. Do you have an address where I can contact SAMPLE MEMBER or someone who would know where (he/she) is?
      YES 1 arrow RECORD BELOW IN A
      NO 0 arrow READ B
           
  A. INTERVIEWER:RECORD COMPLETE ADDRESS; INCLUDE APARTMENT NUMBER; RECORD STREET ADDRESS IN ADDITION TO MAILING ADDRESS IF DIFFERENT. IF PERSON WHO KNOWS SAMPLE MEMBER, BE SURE TO RECORD FULL NAME.
     
MAILING ADDRESS   STREET ADDRESS
NAME: __________________________________________________________________________
_____________________________________   _____________________________________
_____________________________________   _____________________________________
_____________________________________   _____________________________________
_____________________________________   _____________________________________
           
  B. Do you have a telephone number where I can reach SAMPLE MEMBER or someone who knows where (he/she) is?
      YES 1 arrow RECORD BELOW
      NO 0 arrow GO TO IN19 (PAGE S-13)
           
  C. INTERVIEWER:RECORD ANY POSSIBLE TELEPHONE NUMBERS WHERE SAMPLE MEMBER CAN BE LOCATED. RECORD AREA CODE.
   

(_______) - __________ - ____________

(_______) - __________ - ____________

(_______) - __________ - ____________
           
IF PERSON KNOWS HOW TO FIND FOCUS CHILD:
           
IN19. Do you have the address where I can find FOCUS CHILD or someone who knows where (he/she) is?
      YES 1 arrow RECORD BELOW IN A
      NO 0 arrow READ B
  A. INTERVIEWER:RECORD COMPLETE ADDRESS; INCLUDE APARTMENT NUMBER; RECORD STREET ADDRESS IN ADDITION TO MAILING ADDRESS IF DIFFERENT. IF PERSON WHO KNOWS FOCUS CHILD, BE SURE TO RECORD FULL NAME.
     
MAILING ADDRESS   STREET ADDRESS
NAME: __________________________________________________________________________
_____________________________________   _____________________________________
_____________________________________   _____________________________________
_____________________________________   _____________________________________
_____________________________________   _____________________________________
           
  B. Do you have a telephone number where I can reach FOCUS CHILD or someone who knows where (he/she) is?
      YES 1 arrow RECORD BELOW IN C
      NO 0 arrow GO TO ENDING 2 (PAGE S-14)
           
  C. INTERVIEWER:RECORD ANY POSSIBLE TELEPHONE NUMBERS WHERE FOCUS CHILD CAN BE REACHED. RECORD AREA CODE.
   

(_______) - __________ - ____________

(_______) - __________ - ____________

(_______) - __________ - ____________
GO TO ENDING 2
           
ENDING 1
    Thank you very much for your time. For this study, we can only interview SAMPLE MEMBER or the person responsible for FOCUS CHILD.
   

EXIT SCREENER AND CONTACTPERSONS LISTED ON THE “PEOPLE WHO CAN HELP FIND ME” FORM.

           
ENDING 2
 

Thank you very much for your time. If you should hear from SAMPLE MEMBER or the person responsible for FOCUS CHILD, please ask (him/her) to contact (SITE COORDINATOR) at (LOCAL RESEARCH INSTITUTION) at (TELEPHONE NUMBER) and say that (he/she) is calling about the Parent Services Interview.

INTERVIEWER: IF NECESSARY, LEAVE WRITTEN INFORMATION ON
“SORRY I MISSED YOU” NOTE PAD PROVIDED.
   

EXIT SCREENER AND CONTACT PEOPLE LISTED IN IN18 AND IN19 AND PERSONS LISTED ON THE “PEOPLE WHO CAN HELP FIND ME” FORM.
           
ENDING 3
  I’m sorry. Because (you do not have your baby/your baby died), the questions in the survey will not apply to you. Thank you very much for your time.
EXIT SCREENER


 

 

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