Contract No.: 105-95-1936
MPR Reference No.: 8300-220
EARLY HEAD START EVALUATION
PARENT SERVICES
FOLLOW-UP INSTRUMENT
July 26, 2000
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Table of Contents
| Submitted by:
U.S. Department of Health and Human Services
Administration on Children, Youth, and Families
Mary Switzer Building, Room 2411
330 "C" Street, SW
Washington, DC 20201
Project Monitor:
Helen Raikes
|
Submitted by:
Mathematica Policy Research, Inc.
P.O. Box 2393
Princeton, NJ 08543-2393
(609) 799-3535
Project Director:
John M. Love
|
COPYRIGHT INFORMATION FOR MEASURES INCLUDED
IN THIS DOCUMENT
Items C1-C39. FRS. Family Resource Scale. Dunst, Carl J.,
and Hope E. Leet. "Measuring the Adequacy of Resources in Households
with Young Children." Child Care, Health, and Development, vol. 13,
1987, pp.111-125. Available in Dunst, C.J., C.M. Trivette, and A.G. Deal,
editors. Supporting and Strengthening Families. Cambridge, MA: Brookline
Books, 1994. May be reproduced without permission with proper citation
and acknowledgment.
Items L45 a-x. CRS. Client-Relationship Scale. Adapted from
the Nurse-Client Relationship Scale. K. Barnard, University of Washington.
See Barnard, K. “Developing, Implementing and Documenting Interventions
with Parents and Young Children.” Zero to Three Bulletin, vol. 18
(4), 1998, pp. 23-29.
|___|___|
: |___|___|
|
AM…………01 |
| TIME BEGAN |
PM …………02 |
|
|
| |
SECTION A:
FAMILY COMPOSITION |
|
| |
| A1. |
INTERVIEWER: |
IS THE RESPONDENT
THE SAMPLE PERSON FROM THE CONTACT SHEET (NAME ON CONTACT SHEET/NAME
FROM IN7)? |
The first few questions are about you and other family members living
in your household at the present time. |
| |
YES |
1 |
| NO (GO
TO A1F) |
0 |
| |
INTERVIEWER: |
CONFIRM SPELLING OF RESPONDENT’S NAME (NAME ON CONTACT SHEET/NAME
FROM IN7) |
| |
YES, NAME IS SAME AND
SPELLED CORRECTLY |
0 |
| NEED TO CHANGE FIRST NAME |
1 |
| NEED TO CHANGE LAST NAME
|
2 |
| |
| A1F. |
ENTER RESPONDENT’S
CORRECT FIRST NAME. |
| |
| ta1L. |
INTERVIEWER:
DO YOU NEED TO CHANGE LAST NAME? |
| |
YES |
1 |
| NO |
0 |
| |
| A1L. |
RECORD RESPONDENT’S
LAST NAME. |
| |
| Amth. |
INTERVIEWER:
IF NEW RESPONDENT ASK, OTHERWISE GO TO AA3:
When did you begin having responsibility for FOCUS CHILD? |
| |
| |___|___| / |
|___|___| / |
|___|___|___|___| |
| MONTH |
DAY |
YEAR |
|
| SINCE BIRTH |
97 |
| DON’T KNOW |
98 |
| REFUSED |
99 |
| There
is a large table below. Those using a screen reader should follow
the link to the entire table, which includes proper header information.
After returning to this window, follow the anchor to skip the broken
table and go to the next section. |
 |
Table A-1 is broken into
several sections below. To view
the table in its entirety (table will scroll horizontally),
click here
to open a new window. 
|
|
PERSON | 01 | |
PERSON | 02 | |
PERSON
| 03 | |
| AA3. |
IF THE RESPONDENT COMPLETED
THE LAST ROUND OF THE PSI DATA COLLECTION, ASK:
Last time we talked, your family included NUMBER
OF PEOPLE IN FAMILY people, including LIST OF NAMES FROM PREVIOUS
PSI. I would like to verify the information we have about each of
these family members and find out about any family members who have
left and any family members who have joined your household since
LAST INTERVIEW DATE. (If you consider them part of your family)
include (FOCUS CHILD)’s parents who may not live in your household.
IF THE RESPONDENT DID NOT COMPLETE THE LAST
ROUND OF THE PSI DATA COLLECTION, ASK:
The last time this interview was conducted, we recorded
the following people in FOCUS CHILD’s family. (If you consider
them part of your family) include (FOCUS CHILD)’s parents
who may not live in your household.
PROBE: (Is there anyone else in
your family?/Has anyone else joined your family since we last talked?) |
__________
FIRST NAME #01 |
__________
FOCUS CHILD #02 |
__________
FIRST NAME #03 |
| A3. |
Do any of these people no longer
live with you?
IF YES:
Who no longer lives with you? |
INTERVIEWER CODE THE NUMBER
OF THE PERSON TO BE DELETED FROM THE FAMILY. |
INTERVIEWER CODE THE NUMBER
OF THE PERSON TO BE DELETED FROM THE FAMILY. |
INTERVIEWER CODE THE NUMBER
OF THE PERSON TO BE DELETED FROM THE FAMILY. |
| PERSON
| 04 | |
PERSON
| 05 | |
PERSON
| 06 | |
PERSON
| 07 | |
__________
FIRST NAME #03 |
__________
FIRST NAME #03 |
__________
FIRST NAME #03 |
__________
FIRST NAME #03 |
| INTERVIEWER CODE THE NUMBER
OF THE PERSON TO BE DELETED FROM THE FAMILY. |
INTERVIEWER CODE THE NUMBER
OF THE PERSON TO BE DELETED FROM THE FAMILY. |
INTERVIEWER CODE THE NUMBER
OF THE PERSON TO BE DELETED FROM THE FAMILY. |
INTERVIEWER CODE
THE NUMBER OF THE PERSON TO BE DELETED FROM THE FAMILY. |
|
|
PERSON | 01 | |
PERSON | 02 | |
PERSON
| 03 | |
| A5. |
In our last interview, I recorded
that NAME is your RELATIONSHIP FROM PREVIOUS INTERVIEW. Is that
correct?
IF THE RESPONDENT DID NOT COMPLETE THE LAST
ROUND OF THE PSI DATA COLLECTION, ASK:
What is NAME’s relationship to you?
PROBE IF RESPONSE IS CHILD: Is NAME your biological
child, your stepchild, your adopted child, or a custodial child?
INTERVIEWER: FOR COHABITANT’S
CHILD OR ANY OTHER CHILD WHO IS NOT NATURAL, ADOPTED, OR STEP, BUT
FOR WHOM THE SAMPLE MEMBER TAKES RESPONSIBILITY, CODE 03 “OTHER
CUSTODIAL CHILD.” |
| BIOLOGICAL
CHILD |
1 |
| STEPCHILD OR ADOPTED CHILD |
2 |
| OTHER CUSTODIAL
CHILD |
3 |
| GRANDCHILD |
4 |
| PARENT |
5 |
| STEPPARENT |
6 |
| FOSTER PARENT |
7 |
AUNT, UNCLE, GREAT-AUNT,
OR GREAT-UNCLE
|
8 |
GRANDPARENT
OR
GREAT-GRANDPARENT |
9 |
SIBLING (BROTHER
OR SISTER)
|
10 |
| NEPHEW OR
NIECE |
11 |
| COUSIN |
12 |
| HUSBAND OR
WIFE |
13 |
BOYFRIEND OR GIRLFRIEND/
PARTNER |
14 |
FORMER BOYFRIEND
OR FORMER GIRLFRIEND |
15 |
OTHER RELATIVE
OR IN-LAW |
16 |
| NON-RELATIVE |
17 |
| OTHER (SPECIFY) |
0 |
| _______________ |
|
| DON’T KNOW |
98 |
| REFUSED |
99 |
|
| BIOLOGICAL
CHILD |
1 |
| STEPCHILD OR ADOPTED CHILD |
2 |
| OTHER CUSTODIAL
CHILD |
3 |
| GRANDCHILD |
4 |
| PARENT |
5 |
| STEPPARENT |
6 |
| FOSTER PARENT |
7 |
AUNT, UNCLE, GREAT-AUNT,
OR GREAT-UNCLE
|
8 |
GRANDPARENT
OR
GREAT-GRANDPARENT |
9 |
SIBLING (BROTHER
OR SISTER)
|
10 |
| NEPHEW OR
NIECE |
11 |
| COUSIN |
12 |
| HUSBAND OR
WIFE |
13 |
BOYFRIEND OR GIRLFRIEND/
PARTNER |
14 |
FORMER BOYFRIEND
OR FORMER GIRLFRIEND |
15 |
OTHER RELATIVE
OR IN-LAW |
16 |
| NON-RELATIVE |
17 |
| OTHER (SPECIFY) |
0 |
| _______________ |
|
| DON’T KNOW |
98 |
| REFUSED |
99 |
|
| BIOLOGICAL
CHILD |
1 |
| STEPCHILD OR ADOPTED CHILD |
2 |
| OTHER CUSTODIAL
CHILD |
3 |
| GRANDCHILD |
4 |
| PARENT |
5 |
| STEPPARENT |
6 |
| FOSTER PARENT |
7 |
AUNT, UNCLE, GREAT-AUNT,
OR GREAT-UNCLE
|
8 |
GRANDPARENT
OR
GREAT-GRANDPARENT |
9 |
SIBLING (BROTHER
OR SISTER)
|
10 |
| NEPHEW OR
NIECE |
11 |
| COUSIN |
12 |
| HUSBAND OR
WIFE |
13 |
BOYFRIEND OR GIRLFRIEND/
PARTNER |
14 |
FORMER BOYFRIEND
OR FORMER GIRLFRIEND |
15 |
OTHER RELATIVE
OR IN-LAW |
16 |
| NON-RELATIVE |
17 |
| OTHER (SPECIFY) |
0 |
| _______________ |
|
| DON’T KNOW |
98 |
| REFUSED |
99 |
|
|
CONTINUE TO A6 |
CONTINUE TO A6 |
CONTINUE TO A6 |
| PERSON
| 04 | |
PERSON
| 05 | |
PERSON
| 06 | |
PERSON
| 07 | |
| BIOLOGICAL
CHILD |
1 |
| STEPCHILD OR ADOPTED CHILD |
2 |
| OTHER CUSTODIAL
CHILD |
3 |
| GRANDCHILD |
4 |
| PARENT |
5 |
| STEPPARENT |
6 |
| FOSTER PARENT |
7 |
AUNT, UNCLE, GREAT-AUNT,
OR GREAT-UNCLE
|
8 |
GRANDPARENT
OR
GREAT-GRANDPARENT |
9 |
SIBLING (BROTHER
OR SISTER)
|
10 |
| NEPHEW OR
NIECE |
11 |
| COUSIN |
12 |
| HUSBAND OR
WIFE |
13 |
BOYFRIEND OR GIRLFRIEND/
PARTNER |
14 |
FORMER BOYFRIEND
OR FORMER GIRLFRIEND |
15 |
OTHER RELATIVE
OR IN-LAW |
16 |
| NON-RELATIVE |
17 |
| OTHER (SPECIFY) |
0 |
| _______________ |
|
| DON’T KNOW |
98 |
| REFUSED |
99 |
|
| BIOLOGICAL
CHILD |
1 |
| STEPCHILD OR ADOPTED CHILD |
2 |
| OTHER CUSTODIAL
CHILD |
3 |
| GRANDCHILD |
4 |
| PARENT |
5 |
| STEPPARENT |
6 |
| FOSTER PARENT |
7 |
AUNT, UNCLE, GREAT-AUNT,
OR GREAT-UNCLE
|
8 |
GRANDPARENT
OR
GREAT-GRANDPARENT |
9 |
SIBLING (BROTHER
OR SISTER)
|
10 |
| NEPHEW OR
NIECE |
11 |
| COUSIN |
12 |
| HUSBAND OR
WIFE |
13 |
BOYFRIEND OR GIRLFRIEND/
PARTNER |
14 |
FORMER BOYFRIEND
OR FORMER GIRLFRIEND |
15 |
OTHER RELATIVE
OR IN-LAW |
16 |
| NON-RELATIVE |
17 |
| OTHER (SPECIFY) |
0 |
| _______________ |
|
| DON’T KNOW |
98 |
| REFUSED |
99 |
|
| BIOLOGICAL
CHILD |
1 |
| STEPCHILD OR ADOPTED CHILD |
2 |
| OTHER CUSTODIAL
CHILD |
3 |
| GRANDCHILD |
4 |
| PARENT |
5 |
| STEPPARENT |
6 |
| FOSTER PARENT |
7 |
AUNT, UNCLE, GREAT-AUNT,
OR GREAT-UNCLE
|
8 |
GRANDPARENT
OR
GREAT-GRANDPARENT |
9 |
SIBLING (BROTHER
OR SISTER)
|
10 |
| NEPHEW OR
NIECE |
11 |
| COUSIN |
12 |
| HUSBAND OR
WIFE |
13 |
BOYFRIEND OR GIRLFRIEND/
PARTNER |
14 |
FORMER BOYFRIEND
OR FORMER GIRLFRIEND |
15 |
OTHER RELATIVE
OR IN-LAW |
16 |
| NON-RELATIVE |
17 |
| OTHER (SPECIFY) |
0 |
| _______________ |
|
| DON’T KNOW |
98 |
| REFUSED |
99 |
|
| BIOLOGICAL
CHILD |
1 |
| STEPCHILD OR ADOPTED CHILD |
2 |
| OTHER CUSTODIAL
CHILD |
3 |
| GRANDCHILD |
4 |
| PARENT |
5 |
| STEPPARENT |
6 |
| FOSTER PARENT |
7 |
AUNT, UNCLE, GREAT-AUNT,
OR GREAT-UNCLE
|
8 |
GRANDPARENT
OR
GREAT-GRANDPARENT |
9 |
SIBLING (BROTHER
OR SISTER)
|
10 |
| NEPHEW OR
NIECE |
11 |
| COUSIN |
12 |
| HUSBAND OR
WIFE |
13 |
BOYFRIEND OR GIRLFRIEND/
PARTNER |
14 |
FORMER BOYFRIEND
OR FORMER GIRLFRIEND |
15 |
OTHER RELATIVE
OR IN-LAW |
16 |
| NON-RELATIVE |
17 |
| OTHER (SPECIFY) |
0 |
| _______________ |
|
| DON’T KNOW |
98 |
| REFUSED |
99 |
|
| CONTINUE TO A6 |
CONTINUE TO A6 |
CONTINUE TO A6 |
CONTINUE TO A6 |
|
|
PERSON | 01 | |
PERSON | 02 | |
PERSON
| 03 | |
| A6. |
INTERVIEWER: VERIFY OR ASK:
How is NAME related to FOCUS CHILD? |
| BIOLOGICAL
MOTHER |
02 |
| BIOLOGICAL FATHER |
03 |
| STEPPARENT |
06 |
| FOSTER PARENT |
07 |
AUNT, UNCLE,
GREAT-AUNT, OR GREAT-UNCLE
|
08 |
GRANDPARENT OR
GREAT-GRANDPARENT |
09 |
SIBLING (BROTHER
OR SISTER)
|
10 |
| NEPHEW OR NIECE |
11 |
| COUSIN |
12 |
OTHER RELATIVE
OR IN-LAW |
16 |
| NON-RELATIVE |
17 |
OTHER (SPECIFY)
_______________ |
0 |
| DON’T
KNOW |
98 |
| REFUSED |
99 |
|
|
| BIOLOGICAL
MOTHER |
02 |
| BIOLOGICAL FATHER |
03 |
| STEPPARENT |
06 |
| FOSTER PARENT |
07 |
AUNT, UNCLE,
GREAT-AUNT, OR GREAT-UNCLE
|
08 |
GRANDPARENT OR
GREAT-GRANDPARENT |
09 |
SIBLING (BROTHER
OR SISTER)
|
10 |
| NEPHEW OR NIECE |
11 |
| COUSIN |
12 |
OTHER RELATIVE
OR IN-LAW |
16 |
| NON-RELATIVE |
17 |
OTHER (SPECIFY)
_______________ |
0 |
| DON’T
KNOW |
98 |
| REFUSED |
99 |
|
| A7v. |
In our last interview, I recorded that
NAME was born on DATE FROM PREVIOUS INTERVIEW. Is that correct? |
| YES (GO TO
A8) |
1 |
| NO, NOT CORRECT BIRTHDATE |
0 |
| DON’T
KNOW (GO TO A7A) |
8 |
| REFUSED (GO TO A7A) |
9 |
|
| YES (GO TO
A8) |
1 |
| NO, NOT CORRECT BIRTHDATE |
0 |
| DON’T
KNOW (GO TO A7A) |
8 |
| REFUSED (GO TO A7A) |
9 |
|
| YES (GO TO
A8) |
1 |
| NO, NOT CORRECT BIRTHDATE |
0 |
| DON’T
KNOW (GO TO A7A) |
8 |
| REFUSED (GO TO A7A) |
9 |
|
| A7. |
When was NAME born? ZERO
FILL BLANK BOXES. |
| |__|__| /|__|__| /19|__|__| |
| MONTH DAY YEAR |
| ***GO
TO A8*** |
| DON’T
KNOW (GO TO A7A) |
98 |
| REFUSED (GO TO A7A) |
99 |
|
| |__|__| /|__|__| /19|__|__| |
| MONTH DAY YEAR |
| ***GO
TO A8*** |
| DON’T
KNOW (GO TO A7A) |
98 |
| REFUSED (GO TO A7A) |
99 |
|
| |__|__| /|__|__| /19|__|__| |
| MONTH DAY YEAR |
| ***GO
TO A8*** |
| DON’T
KNOW (GO TO A7A) |
98 |
| REFUSED (GO TO A7A) |
99 |
|
| A7A. |
IF RESPONDENT DOES NOT KNOW
OR REFUSES, ASK: Is (he/she) less than 10, between 10 and
17, between 18 and 49, between 50 and 65, or over 65? |
| LESS THAN
10 |
11 |
| 11 TO 17 |
17 |
| 18 TO 49 |
30 |
| 50 TO 65 |
55 |
| OVER 65 |
70 |
|
| LESS THAN
10 |
11 |
| 11 TO 17 |
17 |
| 18 TO 49 |
30 |
| 50 TO 65 |
55 |
| OVER 65 |
70 |
|
| LESS THAN
10 |
11 |
| 11 TO 17 |
17 |
| 18 TO 49 |
30 |
| 50 TO 65 |
55 |
| OVER 65 |
70 |
|
| PERSON
| 04 | |
PERSON
| 05 | |
PERSON
| 06 | |
PERSON
| 07 | |
| BIOLOGICAL
MOTHER |
02 |
| BIOLOGICAL FATHER |
03 |
| STEPPARENT |
06 |
| FOSTER PARENT |
07 |
AUNT, UNCLE,
GREAT-AUNT, OR GREAT-UNCLE
|
08 |
GRANDPARENT OR
GREAT-GRANDPARENT |
09 |
SIBLING (BROTHER
OR SISTER)
|
10 |
| NEPHEW OR NIECE |
11 |
| COUSIN |
12 |
OTHER RELATIVE
OR IN-LAW |
16 |
| NON-RELATIVE |
17 |
OTHER (SPECIFY)
_______________ |
0 |
| DON’T
KNOW |
98 |
| REFUSED |
99 |
|
| BIOLOGICAL
MOTHER |
02 |
| BIOLOGICAL FATHER |
03 |
| STEPPARENT |
06 |
| FOSTER PARENT |
07 |
AUNT, UNCLE,
GREAT-AUNT, OR GREAT-UNCLE
|
08 |
GRANDPARENT OR
GREAT-GRANDPARENT |
09 |
SIBLING (BROTHER
OR SISTER)
|
10 |
| NEPHEW OR NIECE |
11 |
| COUSIN |
12 |
OTHER RELATIVE
OR IN-LAW |
16 |
| NON-RELATIVE |
17 |
OTHER (SPECIFY)
_______________ |
0 |
| DON’T
KNOW |
98 |
| REFUSED |
99 |
|
| BIOLOGICAL
MOTHER |
02 |
| BIOLOGICAL FATHER |
03 |
| STEPPARENT |
06 |
| FOSTER PARENT |
07 |
AUNT, UNCLE,
GREAT-AUNT, OR GREAT-UNCLE
|
08 |
GRANDPARENT OR
GREAT-GRANDPARENT |
09 |
SIBLING (BROTHER
OR SISTER)
|
10 |
| NEPHEW OR NIECE |
11 |
| COUSIN |
12 |
OTHER RELATIVE
OR IN-LAW |
16 |
| NON-RELATIVE |
17 |
OTHER (SPECIFY)
_______________ |
0 |
| DON’T
KNOW |
98 |
| REFUSED |
99 |
|
| BIOLOGICAL
MOTHER |
02 |
| BIOLOGICAL FATHER |
03 |
| STEPPARENT |
06 |
| FOSTER PARENT |
07 |
AUNT, UNCLE,
GREAT-AUNT, OR GREAT-UNCLE
|
08 |
GRANDPARENT OR
GREAT-GRANDPARENT |
09 |
SIBLING (BROTHER
OR SISTER)
|
10 |
| NEPHEW OR NIECE |
11 |
| COUSIN |
12 |
OTHER RELATIVE
OR IN-LAW |
16 |
| NON-RELATIVE |
17 |
OTHER (SPECIFY)
_______________ |
0 |
| DON’T
KNOW |
98 |
| REFUSED |
99 |
|
| YES (GO TO
A8) |
1 |
| NO, NOT CORRECT BIRTHDATE |
0 |
| DON’T
KNOW (GO TO A7A) |
8 |
| REFUSED (GO TO A7A) |
9 |
|
| YES (GO TO
A8) |
1 |
| NO, NOT CORRECT BIRTHDATE |
0 |
| DON’T
KNOW (GO TO A7A) |
8 |
| REFUSED (GO TO A7A) |
9 |
|
| YES (GO TO
A8) |
1 |
| NO, NOT CORRECT BIRTHDATE |
0 |
| DON’T
KNOW (GO TO A7A) |
8 |
| REFUSED (GO TO A7A) |
9 |
|
| YES (GO TO
A8) |
1 |
| NO, NOT CORRECT BIRTHDATE |
0 |
| DON’T
KNOW (GO TO A7A) |
8 |
| REFUSED (GO TO A7A) |
9 |
|
| |__|__| /|__|__| /19|__|__| |
| MONTH DAY YEAR |
| ***GO
TO A8*** |
| DON’T
KNOW (GO TO A7A) |
98 |
| REFUSED (GO TO A7A) |
99 |
|
| |__|__| /|__|__| /19|__|__| |
| MONTH DAY YEAR |
| ***GO
TO A8*** |
| DON’T
KNOW (GO TO A7A) |
98 |
| REFUSED (GO TO A7A) |
99 |
|
| |__|__| /|__|__| /19|__|__| |
| MONTH DAY YEAR |
| ***GO
TO A8*** |
| DON’T
KNOW (GO TO A7A) |
98 |
| REFUSED (GO TO A7A) |
99 |
|
| |__|__| /|__|__| /19|__|__| |
| MONTH DAY YEAR |
| ***GO
TO A8*** |
| DON’T
KNOW (GO TO A7A) |
98 |
| REFUSED (GO TO A7A) |
99 |
|
| LESS THAN
10 |
11 |
| 11 TO 17 |
17 |
| 18 TO 49 |
30 |
| 50 TO 65 |
55 |
| OVER 65 |
70 |
|
| LESS THAN
10 |
11 |
| 11 TO 17 |
17 |
| 18 TO 49 |
30 |
| 50 TO 65 |
55 |
| OVER 65 |
70 |
|
| LESS THAN
10 |
11 |
| 11 TO 17 |
17 |
| 18 TO 49 |
30 |
| 50 TO 65 |
55 |
| OVER 65 |
70 |
|
| LESS THAN
10 |
11 |
| 11 TO 17 |
17 |
| 18 TO 49 |
30 |
| 50 TO 65 |
55 |
| OVER 65 |
70 |
|
 |
|
PERSON | 01 | |
PERSON | 02 | |
PERSON
| 03 | |
| CAPI CHECK: IS NAME
AGE 17 OR YOUNGER BUT NOT CUSTODIAL CHILD OF RESPONDENT (A5 IS NOT
1, 2, OR 3) ? |
|
|
|
| A5b. |
Are you the person who has primary responsibility
for NAME?
PROBE: Are you the person who makes decisions
about the child's care, including (his/her) daily routine, health
care, and child care? |
| YES |
1 |
| NO |
0 |
| DON’T
KNOW |
8 |
| REFUSED |
9 |
|
|
| YES |
1 |
| NO |
0 |
| DON’T
KNOW |
8 |
| REFUSED |
9 |
|
| A8. |
CODE SEX. IF NECESSARY, ASK:
Is NAME male or female? |
| FEMALE |
1 |
| MALE |
0 |
| DON’T
KNOW |
8 |
| REFUSED |
9 |
|
| FEMALE |
1 |
| MALE |
0 |
| DON’T
KNOW |
8 |
| REFUSED |
9 |
|
| FEMALE |
1 |
| MALE |
0 |
| DON’T
KNOW |
8 |
| REFUSED |
9 |
|
| A9. |
Does NAME live with you all the time,
some of the time? |
| ALL THE TIME |
1 |
| SOME OF THE TIME |
2 |
| DON’T
KNOW |
8 |
| REFUSED |
9 |
|
| ALL THE TIME |
1 |
| SOME OF THE TIME |
2 |
| DON’T
KNOW |
8 |
| REFUSED |
9 |
|
| ALL THE TIME |
1 |
| SOME OF THE TIME |
2 |
| DON’T
KNOW |
8 |
| REFUSED |
9 |
|
| A10. |
INTERVIEWER: CHECK A4. IS THERE
ANOTHER PERSON TO ASK ABOUT? |
| YES (GO TO
A5, PERSON 02, PAGE 4) |
1 |
| NO (GO TO A11) |
0 |
|
| YES (GO TO
A5, PERSON 02, PAGE 4) |
1 |
| NO (GO TO A11) |
0 |
|
| YES (GO TO
A5, PERSON 02, PAGE 4) |
1 |
| NO (GO TO A11) |
0 |
|
| PERSON
| 04 | |
PERSON
| 05 | |
PERSON
| 06 | |
PERSON
| 07 | |
|
|
|
|
| YES |
1 |
| NO |
0 |
| DON’T
KNOW |
8 |
| REFUSED |
9 |
|
| YES |
1 |
| NO |
0 |
| DON’T
KNOW |
8 |
| REFUSED |
9 |
|
| YES |
1 |
| NO |
0 |
| DON’T
KNOW |
8 |
| REFUSED |
9 |
|
| YES |
1 |
| NO |
0 |
| DON’T
KNOW |
8 |
| REFUSED |
9 |
|
| FEMALE |
1 |
| MALE |
0 |
| DON’T
KNOW |
8 |
| REFUSED |
9 |
|
| FEMALE |
1 |
| MALE |
0 |
| DON’T
KNOW |
8 |
| REFUSED |
9 |
|
| FEMALE |
1 |
| MALE |
0 |
| DON’T
KNOW |
8 |
| REFUSED |
9 |
|
| FEMALE |
1 |
| MALE |
0 |
| DON’T
KNOW |
8 |
| REFUSED |
9 |
|
| ALL THE TIME |
1 |
| SOME OF THE TIME |
2 |
| DON’T
KNOW |
8 |
| REFUSED |
9 |
|
| ALL THE TIME |
1 |
| SOME OF THE TIME |
2 |
| DON’T
KNOW |
8 |
| REFUSED |
9 |
|
| ALL THE TIME |
1 |
| SOME OF THE TIME |
2 |
| DON’T
KNOW |
8 |
| REFUSED |
9 |
|
| ALL THE TIME |
1 |
| SOME OF THE TIME |
2 |
| DON’T
KNOW |
8 |
| REFUSED |
9 |
|
| YES (GO TO
A5, PERSON 02, PAGE 4) |
1 |
| NO (GO TO A11) |
0 |
|
| YES (GO TO
A5, PERSON 02, PAGE 4) |
1 |
| NO (GO TO A11) |
0 |
|
| YES (GO TO
A5, PERSON 03, PAGE 4) |
1 |
| NO (GO TO A11) |
0 |
|
| YES (GO TO
A5, PERSON 04, PAGE 5) |
1 |
| NO (GO TO A11) |
0 |
|
| A11. |
CAPI CHECK: |
IS THIS THE SAME PRIMARY
CAREGIVER WHO WAS INTERVIEWED LAST TIME AND IS ANY CHILD THAT WAS
IN THE FAMILY AT THE TIME OF THE LAST INTERVIEW NOT LISTED IN A4 AND
A5? |
| |
YES |
1 |
| NO (GO
TO A13) |
0 |
| |
| A12. |
INTERVIEWER:
FOR EACH CHILD NO LONGER IN FAMILY ASK: Last time we spoke
with you, CHILD NAME FROM LAST INTERVIEW was part of your family.
Where is CHILD NAME FROM LAST INTERVIEW now? |
|
Table A12.
| NAME
OF CHILD NO LONGER IN FAMILY |
WHERE CHILD IS NOW |
-----------------------------------
NAME 1 |
| CHILD LIVES WITH RELATIVE |
1 |
CHILD
IS IN FOSTER CARE
|
2 |
| CHILD WAS ADOPTED |
3 |
| CHILD
LIVES WITH FRIENDS |
4 |
| CHILD DIED |
5 |
OTHER
(SPECIFY)
_____________________________ |
0 |
DON’T KNOW
|
8 |
| REFUSED |
9 |
|
|
-----------------------------------
NAME 2 |
| CHILD LIVES WITH RELATIVE |
1 |
CHILD
IS IN FOSTER CARE
|
2 |
| CHILD WAS ADOPTED |
3 |
| CHILD
LIVES WITH FRIENDS |
4 |
| CHILD DIED |
5 |
OTHER
(SPECIFY)
_____________________________ |
0 |
DON’T KNOW
|
8 |
| REFUSED |
9 |
|
|
-----------------------------------
NAME 3 |
| CHILD LIVES WITH RELATIVE |
1 |
CHILD
IS IN FOSTER CARE
|
2 |
| CHILD WAS ADOPTED |
3 |
| CHILD
LIVES WITH FRIENDS |
4 |
| CHILD DIED |
5 |
OTHER
(SPECIFY)
_____________________________ |
0 |
DON’T KNOW
|
8 |
| REFUSED |
9 |
|
|
|
| |
| A13. |
Are there other people living
in your household who are not members of your family? |
| |
YES |
1 |
| NO (GO
TO A15) |
0 |
| DON'T KNOW |
8 |
| REFUSED |
9 |
| |
| A14. |
How many other people currently
live in your household? |
| |
OTHER
HOUSEHOLD MEMBERS |
|___|___| |
| DON'T KNOW |
98 |
| REFUSED |
99 |
| |
A15.
|
Who do you
consider to be the head of your household?
PROBE: By head of household we mean
the person or persons who make the decisions.
ACCEPT RESPONDENT EVEN IF 17 OR YOUNGER. |
| CIRCLE ALL
THAT APPLY |
| PERSON
1 FROM GRID (RESPONDENT) |
1 |
| FOCUS CHILD |
|
| PERSON
3 FROM GRID |
3 |
| PERSON 4 FROM GRID |
4 |
| PERSON
5 FROM GRID |
5 |
| PERSON 6 FROM GRID |
6 |
| PERSON
7 FROM GRID |
7 |
| PERSON 8 FROM GRID |
8 |
| PERSON
9 FROM GRID |
9 |
| PERSON 10 FROM GRID |
10 |
| PERSON 11 FROM GRID |
11 |
| PERSON 12 FROM GRID |
12 |
|
|
| CIRCLE ALL
THAT APPLY |
| PERSON
13 FROM GRID (RESPONDENT) |
13 |
| FOCUS CHILD |
|
| PERSON
14 FROM GRID |
14 |
| PERSON 15 FROM GRID |
15 |
| PERSON
16 FROM GRID |
16 |
| PERSON 17 FROM GRID |
17 |
| PERSON
18 FROM GRID |
18 |
| PERSON 19 FROM GRID |
19 |
| PERSON
20 FROM GRID |
20 |
| OTHER PERSON IN
HOUSEHOLD, NOT IN RESPONDENT’S FAMILY |
0 |
| PERSON 11 FROM GRID |
98 |
| PERSON 12 FROM GRID |
99 |
|
| A16. |
INTERVIEWER:
IF THERE IS NO NEW PRIMARY CAREGIVER, SKIP TO A18.
How do you primarily identify your racial or ethnic
background? |
|
| |
ASIAN
OR PACIFIC ISLANDER |
|
1 |
| BLACK (NOT HISPANIC) |
(GO TO A18) |
2 |
| WHITE
(NOT HISPANIC) |
(GO
TO A18) |
3 |
| AMERICAN INDIAN OR ALASKA
NATIVE |
(GO TO A18) |
4 |
| HISPANIC |
(GO
TO A17B) |
5 |
OTHER (SPECIFY)
_______________ |
(GO TO A18) |
0 |
| DON'T
KNOW |
(GO
TO A18) |
8 |
| REFUSED |
(GO TO A18) |
9 |
| |
| A17A. |
Are you… |
| |
Cambodian
|
1 |
| Chinese |
2 |
| Hmong |
3 |
| Indian |
4 |
| Japanese |
5 |
| Korean |
6 |
| Pacific
Islander |
7 |
Vietnamese,
or
|
8 |
From
another Asian group? (SPECIFY)
_________________ |
0 |
| DON’T
KNOW |
8 |
| REFUSED |
9 |
|
|
| A17B. |
Are you… |
| |
Central
American
|
1 |
| Cuban |
2 |
| Mexican
or Chicano |
3 |
| Puerto Rican |
4 |
| South
American |
5 |
| Dominican
or, |
6 |
From
some other background? (SPECIFY)
_________________ |
0 |
| DON’T
KNOW |
8 |
|
REFUSED |
9 |
| |
A18.
|
Are you currently married,
separated, divorced, widowed, living together unmarried, or have you
never been married? |
| |
MARRIED |
1 |
| SEPARATED |
2 |
| DIVORCED |
3 |
| WIDOWED |
4 |
| LIVING TOGETHER
UNMARRIED |
5 |
NEVER MARRIED, NOT LIVING
TOGETHER UNMARRIED |
0 |
| DON’T
KNOW |
8 |
| REFUSED |
9 |
| |
| A19. |
The next questions are
about your background.
INTERVIEWER: IF
THERE IS NO NEW PRIMARY CAREGIVER, SKIP TO A20.
First, what is your Social Security Number? |
| |___|___|___|
- |___|___| - |___|___|___|___| |
| |
DO NOT HAVE
A SOCIAL SECURITY NUMBER |
7 |
| DON’T KNOW |
8 |
| REFUSED |
9 |
| |
| A20. |
INTERVIEWER: IF THERE
IS NO NEW PRIMARY CAREGIVER, SKIP TO A23. Were
you born in the United States? |
| |
YES |
(GO
TO A23) |
1 |
| NO |
0 |
| DON'T
KNOW |
(GO
TO A23) |
8 |
| REFUSED |
(GO TO A23) |
9 |
| |
| A21. |
In what country were you born?
RECORD VERBATIM. |
| |
COUNTRY: _________________________ |
| DON’T
KNOW |
8 |
| REFUSED |
9 |
| |
| A22. |
How old were you when you
moved to the U.S. for the first time? |
| |
|___|___|
YEARS OLD |
| DON’T
KNOW |
98 |
| REFUSED |
99 |
| |
| A23. |
What is the primary language
you speak at home? |
| |
ENGLISH |
1 |
| SPANISH |
2 |
OTHER (SPECIFY)
______________________ |
0 |
| DON’T KNOW |
8 |
| REFUSED |
9 |
| |
| A24. |
INTERVIEWER: |
CODE WITHOUT ASKING. HOW
WELL DOES THE RESPONDENT SPEAK ENGLISH? |
| |
VERY
WELL |
1 |
| WELL |
2 |
| NOT WELL |
3 |
| NOT AT ALL |
4 |
|
