OMB Approval Number: 0970-0151
Esp 06/2000 |
RESPONDENT ID ___ ___
___ ___ ___ |
BATCH # 8-10/
CARD# 11-12/01 |
Head
Start Family and Child Experiences Survey
Fall '97 Parent Interview |
INTERVIEWER:
|
RECORD CHILD'S
NAME BELOW. REMOVE SHEET AND DESTROY AFTER VERIFYING CHILD'S NAME.
|
CHILD'S NAME _____________________________ |
Head
Start Family and Child Experiences Survey
Fall '97 Parent Interview
Cover Sheet |
Respondent ID number: ___
___ -___ - ___ - ___ ___ ___ |
|
Head Start Center: _______________________________ |
|
City and State: _______________________________ |
|
Field Interviewer ID number:
___ ___ ___ |
|
Date of Interview: |
__ __/ __ __/ __ __ |
|
month day year |
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|
Time of interview start: |
__ __ : __ __ |
|
hour minute |
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Time of interview end: |
__ __ : __ __ |
|
hour minute |
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Interview location: |
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Head Start center |
01 |
CHILD's home |
02 |
Other (Please specify) |
03 |
|
|
Will the interview be completed
in whole or in part with an interpreter? |
|
|
|
If so, what language will
be used? _______________________________ |
IF YES: Have
Interpreter sign confidentiality form before interview |
Thank you for agreeing to talk with me.
The purpose of this study is to learn more about families in the Head
Start Program as well as learn more about the Head Start Program your
child attends. We want to learn how Head Start provides different
kinds of services to children and families. I want to talk with you
(again) so we can understand about Head Start from a parent's point
of view. Information from this study will be used to help Head Start
better serve children and their families.
I will ask you questions and write down your answers. You may stop
me at any time, and you may go back to earlier questions to change
your answers. No one from the Head Start Program will see or hear
your answers. Your participation is completely voluntary. If you
choose not to complete this interview, it will not affect you or
your child’s participation in Head Start programs. The things
you tell me are very important, so please be as accurate as possible.
Occasionally, I may have to ask a question that does not apply to
you. If that happens, just tell me and I will move on to the next
question. Our interview should take approximately one hour. Do you
have any questions?
Before we begin, let me read the following to you: |
|
Notice:
According to the Paperwork Reduction Act of 1995, no persons
are required to respond to a collection of information unless
it displays a valid OMB Control Number. The valid OMB Control
Number for this information collection is 0970-0151 (expires
06/2000). The time required to complete this information collection
is estimated to average 1 hour per response, including time
to review instructions, search existing data resources, gather
the data needed, and complete and review the information collection.
|
|
|
At the end of the interview, I will give
you some addresses as well as some phone numbers in case you would
like more information about the study or this interview. Do you have
any questions? |
INTERVIEWER: |
USE CHILD’S
NAME WHENEVER “CHILD” (ALL CAPITAL LETTERS) APPEARS
IN A QUESTION.
PROBE AND ENTER 99 FOR “DON’T KNOW” RESPONSES.
DO NOT READ “DON’T KNOW” RESPONSE CATEGORIES.
|
First, I need to ask about your relationship
with CHILD. |
1. |
Is CHILD the correct name of your child? |
INTERVIEWER:
|
After verifying
name of child, remove cover sheet and destroy. DO NOT WRITE
NAME OF CHILD ON QUESTIONNAIRE. |
|
2. |
We want to interview the person most responsible for
CHILD’s care. Are you that person? |
|
|
3. |
Who is most responsible for CHILD’s care? |
|
Name: _______________________________ |
Address: _______________________________ |
Phone: _______________________________ |
|
|
|
4. |
What is your relationship to CHILD? |
|
DO
NOT READ LIST. CIRCLE ONE RESPONSE. |
|
|
Mother |
01 |
SKIP TO A1 |
Father |
02 |
SKIP TO A1 |
Stepmother |
03 |
SKIP TO A1 |
Stepfather |
04 |
SKIP TO A1 |
Grandmother |
05 |
|
Grandfather |
06 |
|
Great Grandmother |
07 |
|
Great Grandfather |
08 |
|
Sister/stepsister |
09 |
|
Brother/stepbrother |
10 |
|
Other Relative or In-law (Female) |
11 |
|
Other Relative or In-law (Male) |
12 |
|
Foster Parent (Female) |
13 |
|
Foster Parent (Male) |
14 |
|
Other Non-relative (Female) |
15 |
|
Other Non-relative (Male) |
16 |
|
Parent's Partner (Female) |
17 |
|
Parent's Partner (Male) |
18 |
|
Don't Know/ Didn't Respond |
99 |
|
|
5. |
Are you CHILD’s legal guardian? |
|
|
A. ABOUT YOUR CHILD
AND FAMILY |
|
A1. |
Is CHILD a boy or a girl? |
|
|
|
A2. |
What is CHILD’S birth date?
|
__ __/ __ __/ __ __ |
month day year |
|
A3. |
When did CHILD begin Head Start? |
|
A4. |
How did you and CHILD find out about this
Head Start program? |
|
DO
NOT READ LIST. CIRCLE ALL THAT APPLY. |
|
|
Family/friend |
01 |
Referral from another agency |
02 |
Word of mouth |
03 |
Head Start came to visit at our home |
04 |
Previous children in Head Start |
05 |
Flyer/mailing |
06 |
Other (Please specify) __________ |
07 |
|
A5. |
How does CHILD usually get to the Head
Start Program to attend classes or group activities? |
|
DO
NOT READ LIST. CIRCLE ALL THAT APPLY. |
|
|
Head Start school bus |
|
01 |
Personal transportation (including car or car
pool) |
|
02 |
Public transportation (bus/subway) |
|
03 |
Walks |
|
04 |
Other (Please specify) ____________________ |
|
05 |
Don't Know (Give prompt) |
|
99 |
|
A6. |
How long does it take for CHILD to travel
from home to the Center? __ __ minutes |
A7. |
How many days per week does CHILD attend
Head Start class? __ __ days/week |
A8. |
How many hours per day does CHILD spend
in Head Start class? __ __ hours/day |
A9. |
Did CHILD attend any center-based child
care or child development programs before (he/she) entered Head Start? |
|
|
A10. |
How old was CHILD when (he/she) first started
such a program? __ __ months |
A11. |
How old was CHILD when (he/she) stopped
attending that program? __ __ months |
|
|
A12. |
Including any other children (or grandchildren)
who may have been in Head Start, how long have you been involved with
Head Start as a (parent/grandparent/primary caregiver)? |
|
(Suggested Probe): Is this your first child
in Head Start? __ __ years OR __ __ months |
A13. |
Were you ever enrolled in Head Start as
a child? |
|
No |
01 |
Yes |
02 |
Don't Know |
99 |
|
B. ACTIVITIES WITH
YOUR CHILD
Now I have some questions about you and CHILD at home. |
|
B1. |
How many times have you or someone in your
family read to CHILD in the past week? Would you say... |
|
READ
LIST. CIRCLE ONE RESPONSE. |
|
|
Not at all |
01 |
SKIP TO B2 |
Once or twice |
02 |
|
Three or more times |
03 |
|
Every day |
04 |
|
|
|
B1a. |
Who read to CHILD in the past week? |
|
|
DO
NOT READ LIST. CIRCLE ALL THAT APPLY. |
|
|
|
Mother/Mother-figure |
01 |
Father/Father-figure |
02 |
Other household member |
03 |
Non-household member |
04 |
|
B2. |
For about how long does CHILD enjoy
being read to at a sitting? PROBE: About how many
minutes? |
|
CODE
000 IF CHILD DOESN'T LIKE TO BE READ TO AT ALL. |
|
|
__ __ __ minutes |
B3. |
In the past week, have you or someone in
your family done the following things with CHILD?
(READ LIST BELOW) |
B4. |
IF YES: How many times
have you done this in the past week? Would you say one or two times,
or three or more? |
B5. |
AFTER COMPLETING ALL OF B3 AND
B4(a-k), ASK THE FOLLOWING FOR EACH ACTIVITY CODED “YES”
IN B3: Who (Read Item)? |
|
B3.
In the past week, have you or someone in your family... |
B4. |
B5. |
How
many times? |
Who
(READ ITEM)?
DO NOT READ CHOICES. CIRCLE ALL THAT APPLY. |
|
No
|
Yes |
1-2 |
3+ |
Mother
/Mother Figure |
Father
/Father Figure |
Other
Household Member |
Non-
Household Member |
- Told (him/her) a story?
|
01 |
02 |
1-2 |
3+ |
01 |
02 |
03 |
04 |
- Taught (him/her) letters, words, or numbers?
|
01 |
02 |
1-2 |
3+ |
01 |
02 |
03 |
04 |
- Taught (him/her)songs or music?
|
01 |
02 |
1-2 |
3+ |
01 |
02 |
03 |
04 |
- Worked on arts and crafts with (him/her)?
|
01 |
02 |
1-2 |
3+ |
01 |
02 |
03 |
04 |
- Played with toys or games indoors?
|
01 |
02 |
1-2 |
3+ |
01 |
02 |
03 |
04 |
- Played a game, sport, or exercised together?
|
01 |
02 |
1-2 |
3+ |
01 |
02 |
03 |
04 |
- Took (him/her) along while doing errands like going to
the post the bank, or the store?
|
01 |
02 |
1-2 |
3+ |
01 |
02 |
03 |
04 |
- Involved (him/her) in household chores like cooking, cleaning,
the table, or caring for pets?
|
01 |
02 |
1-2 |
3+ |
01 |
02 |
03 |
04 |
- Talked about what happened in Head Start?
|
01 |
02 |
1-2 |
3+ |
01 |
02 |
03 |
04 |
- Talked about TV programs or videos?
|
01 |
02 |
1-2 |
3+ |
01 |
02 |
03 |
04 |
- Played counting games like singing songs with numbers
or reading books with numbers?
|
01 |
02 |
1-2 |
3+ |
01 |
02 |
03 |
04 |
|
|
|
B6. |
In the past month, that is since
(MONTH)(DAY), has anyone in your family done the following things
with CHILD? |
B7. |
AFTER COMPLETING ALL OF B6(a-k),
ASK THE FOLLOWING FOR EACH ACTIVITY CODED “YES”:
Who has (READ ITEM) with CHILD? |
|
B6.
In the past month, that is since (MONTH)(DAY), has anyone in
your family done the following things with CHILD? |
B7.
[ASK ONLY AFTER COMPLETING ALL OF B6] |
Who
has (READ ITEM) with CHILD?
[DO NOT READ CHOICES. CIRCLE ALL THAT APPLY. IF NOT MOTHER/
OR FATHER/, CLARIFY IF HOUSEHOLD OR NON-HOUSEHOLD MEMBER.] |
|
No
|
Yes |
Mother
/Mother Figure |
Father
/Father Figure |
Other
Household Member |
Non-
Household Member |
- Visited a library?
|
01 |
02 |
01 |
02 |
03 |
04 |
- Gone to a movie?
|
01 |
02 |
01 |
02 |
03 |
04 |
- Gone to a play, concert, or other live show?
|
01 |
02 |
01 |
02 |
03 |
04 |
- Gone to a mall?
|
01 |
02 |
01 |
02 |
03 |
04 |
- Visited an art gallery, museum, or historical site?
|
01 |
02 |
01 |
02 |
03 |
04 |
- Visited a playground, park, or gone on a picnic?
|
01 |
02 |
01 |
02 |
03 |
04 |
- Visited a zoo or aquarium?
|
01 |
02 |
01 |
02 |
03 |
04 |
- Talked with CHILD about (his/her) family history or ethnic
heritage?
|
01 |
02 |
01 |
02 |
03 |
04 |
- Attended an event sponsored by a community, ethnic, or
religous group.
|
01 |
02 |
01 |
02 |
03 |
04 |
- Attended an athletic or sporting event in which CHILD
was not a player?
|
01 |
02 |
01 |
02 |
03 |
04 |
|
|
|
B8. |
Which of the following do you have in your
home for you or CHILD to look at or read? |
|
|
|
|
NO |
YES |
- Children's books
|
01 |
02 |
- Comic books
|
01 |
02 |
- Magazines for children
|
01 |
02 |
- Magazines for adults like Newsweek or People or Sports
Illustrated
|
01 |
02 |
- Newspapers
|
01 |
02 |
- Catalogs
|
01 |
02 |
- Religious books like a bible or prayer book
|
01 |
02 |
- Dictionaries or encyclopedias
|
01 |
02 |
- Other books like novels or biographies or non-fiction
|
01 |
02 |
|
C. DISABILITIES |
C1. |
Does CHILD have any special needs or disabilities--for
example, physical, emotional, language, hearing, learning difficulty,
or other special needs? |
|
No |
01 |
SKIP TO D1 |
Yes |
02 |
|
Don't Know |
99 |
SKIP TO D1 |
|
C2. |
How would you describe CHILD’S special need or
needs? PROBE: Any others? |
|
DO
NOT READ LIST. CIRCLE ALL THAT APPLY. |
|
|
A specific learning disability |
|
01 |
Mental retardation |
|
02 |
A speech impairment |
|
03 |
A language impairment |
|
04 |
An emotional/behavioral disorder |
|
05 |
Deafness |
|
06 |
Another hearing impairment |
|
07 |
Blindness |
|
08 |
Another visual impairment |
|
09 |
An orthopedic impairment |
|
10 |
Another health impairment lasting six months or more |
|
11 |
Autism |
|
12 |
Traumatic brain injury |
|
13 |
Non-categorical/Developmental delay |
|
14 |
Other (Please specify) |
|
15 |
Don't know |
|
99 |
|
C3. |
(Does/Do) CHILD’s (disability/disabilities) affect
(his/her) ability to learn? |
|
No |
01 |
Yes |
02 |
Don't Know |
99 |
|
C4. |
Did you or another family member participate in developing
an Individualized Education Program or Plan (IEP) for CHILD? |
|
SHOW
PARENT A COPY OF AN IEP USED BY PROGRAM. |
|
|
No |
01 |
|
Yes |
02 |
SKIP TO C6 |
Don't Know |
99 |
SKIP TO D1 |
|
C5. |
Why not? __________________________________________
___________________________________________________
___________________________________________________ SKIP TO D1
(Suggested Probe: Were you given the opportunity to participate?)
|
C6. |
How satisfied are you with the plan? Are you ... |
|
READ
LIST. CIRCLE ONE RESPONSE. |
|
|
Very dissatisfied |
01 |
Somewhat dissatisfied |
02 |
Somewhat satisfied |
03 |
Very satisfied |
04 |
Don't Know |
99 |
|
D. YOUR CHILD'S ACTIVITIES
These next questions are about things that different children do at
different ages. These things may or may not be true for CHILD. |
D1. |
Can CHILD recognize... |
|
READ
LIST. CIRCLE ONE RESPONSE. |
|
|
All of the letters of the alphabet, |
01 |
Most of them, |
02 |
Some of them, or |
03 |
None of them? |
04 |
|
D2. |
How high can CHILD count? Would you say... |
|
READ
LIST. CIRCLE ONE RESPONSE. |
|
|
Not at all |
01 |
Up to five |
02 |
Up to ten |
03 |
Up to twenty |
04 |
Up to fifty, or |
05 |
Up to 100 or more |
06 |
|
D3. |
How many written numbers can CHILD recognize? ____
numbers |
D4. |
If CHILD had a pile of blocks, what is the largest
number (she/he) can tell you (she/he) has? |
|
___ ___ ___ largest number |
D5. |
Can CHILD button (his/her) clothes? |
|
|
D6. |
Does CHILD hold a pencil properly? |
|
|
D7. |
How often does CHILD like to write or pretend to write?
Would you say ... |
|
READ
LIST. CIRCLE ONE RESPONSE. |
|
|
Never |
01 |
Has done it once or twice |
02 |
Sometimes |
03 |
Often |
04 |
Don't Know |
99 |
|
D8. |
Does CHILD mostly write and draw rather than scribble? |
|
|
D9. |
Can CHILD write (his/her) first name even if some of
the letters are backward? |
|
No |
01 |
Yes |
02 |
Don't Know |
99 |
|
D10. |
Does CHILD trip, stumble, or fall easily? |
|
|
D11. |
When CHILD speaks, is (he/she) understandable to a
stranger? |
|
|
D12. |
Did CHILD start speaking later than other children
you know? |
|
|
D13. |
Does CHILD stutter or stammer? |
|
|
D14. |
Does CHILD ever look at a book with pictures and pretend
to read? |
|
|
D15. |
When CHILD pretends to read a book, does it sound like
a connected story, or does (he/she) tell what’s in each picture
without much connection between them? |
|
DO
NOT READ LIST. CIRCLE ONE RESPONSE. |
|
|
Sounds like connected story |
01 |
Tells what's in each picture |
02 |
Does both |
03 |
|
D16. |
Does CHILD recognize (his/her) own first name in writing
or in print? |
|
No |
01 |
Yes |
02 |
Don't Know |
99 |
|
D17. |
Can CHILD identify the colors red, yellow, blue, and
green by name? Would you say... |
|
READ
LIST. CIRCLE ONE RESPONSE. |
|
|
All of them, |
01 |
Some of them, or |
02 |
None of them? |
03 |
|
E. YOUR CHILD'S BEHAVIOR |
E1. |
In general, thinking about CHILD now or over the past
month, tell me how well the following statements describe CHILD’S
usual behavior: For each one, tell me if it is very true
or often true, sometimes or somewhat true, or not true. |
|
READ
LIST. CIRCLE ONE RESPONSE FOR EACH. |
|
|
|
Very True or Often
True |
Sometimes or Somewhat
True |
Not/ True |
- Makes friends easily?
|
01 |
02 |
03 |
- Enjoys learning?
|
01 |
02 |
03 |
- Has temper tantrums or hot temper?
|
01 |
02 |
03 |
- Can't concentrate, can't pay attention for long?
|
01 |
02 |
03 |
- Is very restless, and fidgets a lot?
|
01 |
02 |
03 |
- Likes to try new things?
|
01 |
02 |
03 |
- Shows imagination in work and play?
|
01 |
02 |
03 |
- Is unhappy, sad, or depressed?
|
01 |
02 |
03 |
- Comforts or helps others?
|
01 |
02 |
03 |
- Hits and fights with others?
|
01 |
02 |
03 |
- Worries about things for a long time?
|
01 |
02 |
03 |
- Accepts friends' ideas in sharing and playing?
|
01 |
02 |
03 |
- Doesn't get along with other kids?
|
01 |
02 |
03 |
- Wants to hear that he or she is doing okay?
|
01 |
02 |
03 |
- Feels worthless or inferior?
|
01 |
02 |
03 |
- Makes changes from one activity to another with difficulty?
|
01 |
02 |
03 |
- Is nervous, highstrung, or tense?
|
01 |
02 |
03 |
- Acts too young for (his/her) age?
|
01 |
02 |
03 |
- Is disobedient at home?
|
01 |
02 |
03 |
|
F. HOUSEHOLD RULES
Now I'd like to ask you a few questions about rules and setting limits
in the home. |
F1. |
In your house, are there rules or routines about. .
. |
|
READ
LIST. CIRCLE ONE RESPONSE FOR EACH. |
|
|
|
NO |
YES |
NA |
- What TV programs CHILD can watch?
|
01 |
02 |
03 |
- How many hours CHILD can watch TV?
|
01 |
02 |
03 |
- What kinds of food CHILD eats?
|
01 |
02 |
03 |
- What time CHILD goes to bed?
|
01 |
02 |
03 |
- What chores CHILD does?
|
01 |
02 |
03 |
|
F2. |
Sometimes children mind pretty well and sometimes they don’t.
Have you spanked CHILD in the past week for not minding? |
|
|
F3. |
About how many times in the past week? ____ number of
times |
F4. |
Have you used time out or sent CHILD to (his/her) room in the past
week for not minding? |
|
|
F5. |
About how many times in the past week? ____ number of
times |
F6. |
If CHILD has a tantrum in a public place, such as a supermarket,
what do you do? PROBE "NEVER HAPPENS":
If it did happen, what would you
do? PROBE: Anything else? |
|
DO
NOT READ LIST. CIRCLE ALL THAT APPLY. |
|
|
Ignore (Him/her) |
01 |
Pick up child and leave place |
02 |
Leave and expect child to follow |
03 |
Talk to child |
04 |
Threaten to take away treats/privileges |
05 |
Shout at child |
06 |
Spank child |
07 |
Slap or shake (him/her) |
08 |
Threaten "time out" when you get home |
09 |
Threaten another punishment at home |
10 |
Threaten child with response of other household
adult |
11 |
Try to calm child down |
12 |
Give in to child's tantrum |
13 |
Other (Please specify) |
14 |
|
G. YOU AND YOUR FAMILY
Now I’m going to ask you some questions about you and your family.
Remember that all of your responses will remain confidential. |
G1. |
What is your birth date? |
__ __/ __ __/ __ __ |
|
month day year |
|
G2. |
What is your current marital status? |
|
Single, never married |
01 |
Married |
02 |
Separated |
03 |
Divorced |
04 |
Widowed |
05 |
|
G2a. |
How old were you at the birth of your first child? ____
years old |
G3. |
Including yourself, how many adults age 18 and older live
in your household? ___ number of adults |
G4. |
Including CHILD, how many children age 17 and younger live
in your household? ___ number of children |
G5. |
Please tell me the first name of everyone in your household. PROBE:
Is there anyone else in your household? |
|
|
|
|
IF
YOUNGER THAN 25: |
IF
OLDER THAN 15: |
IF
OLDER THAN 15: |
G5.
First Name |
G6.
What is NAME's relationship to CHILD?
(See codes below) |
G7.
How old is NAME? |
G8.
Is or was this person ever enrolled in Head Start or Early Head
Start
01=No
02=Yes
90=NA
99=Don't Know |
G9.
Is NAME employed?
01=No
02=Yes
90=NA
99=Don't Know |
G10.
Does NAME have a high school diploma or GED?
01=No,
still in school
02=No, not in school
03=Yes, Diploma
04= Yes, GED
90=NA
99=Don't Know |
- (CHILD)
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- (Respondent)
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RELATIONSHIP
CODES: |
|
|
01=Mother
02=Father
03=Stepmother
04=Grandmother
05=Grandmother
06=Grandfather |
07=Great
grandmother
08=Great grandfather
09=Sister/Stepsister
10=Brother/Stepbrother
11=Other relative or in-law (female)
12=Other relative or in-law (male) |
13=Foster
parent (female)
14=Foster parent (male)
15=Other non-relative (female)
16=Other non-relative (male)
17=Parent's partner (male)
18=Parent's partner (female)
99=Don't know/Didn't Respond |
|
INTERVIEWER:
|
IF MOTHER
IS RESPONDENT ...SKIP TO G18
IF MOTHER IS NOT RESPONDENT AND
NOT IN HOUSEHOLD...GO TO G11
IN HOUSEHOLD...SKIP TO G16 |
|
G11. |
Does CHILD’s mother live within an hour’s ride of CHILD? |
|
No |
01 |
|
Yes |
02 |
|
Mother is deceased |
03 |
SKIP TO G18 |
Don't Know |
99 |
|
|
G12. |
Does she contribute to the financial support of the child? |
|
No |
01 |
Yes |
02 |
Don't Know |
99 |
|
G13. |
How often does CHILD see (his/her) mother? Does (he/she) see her
... |
|
READ
LIST. CIRCLE ONE RESPONSE. |
|
|
Rarely or never |
01 |
Several times a year |
02 |
Several times a month |
03 |
Several times a week |
04 |
Every day |
05 |
Don't know |
99 |
|
G14. |
Is there anyone else who is like a mother to CHILD? |
|
|
G15. |
Who is this person? |
|
DO
NOT READ LIST. CIRCLE ONE RESPONSE. |
|
|
The respondent, |
01 |
The respondent's (spouse/partner) who lives in
the household, |
02 |
The respondent's (spouse/partner) who doesn't
live in the household,.. |
03 |
A relative of the child who lives in the household, |
04 |
A relative of the child who doesn't live in the
household |
05 |
A friend of the family who lives in the household,
or |
06 |
A friend of the family who doesn't live in the
household |
07 |
|
|
ENTER
THE PERSON "LETTER" FROM GRID ON PAGE 22 (QUESTION
G5) BELOW. |
|
|
G15a. |
___ person letter from G5 grid page 22 |
G16. |
What is the highest grade or year of regular school that CHILD’s
mother completed? |
|
DO
NOT READ LIST. CIRCLE ONE RESPONSE. |
|
|
No formal schooling |
00 |
Less than 8th grade |
07 |
8th grade |
08 |
9th grade |
09 |
10th grade |
10 |
11th grade |
11 |
12th grade |
12 |
High school diploma |
13 |
GED |
14 |
Some college |
15 |
Associate's degree |
16 |
Bachelor's degree |
17 |
Graduate degree |
18 |
Don't know |
99 |
|
G17. |
Is she currently working, in school, in a training program, or is
she doing something else? |
|
DO
NOT READ LIST. CIRCLE ALL THAT APPLY. |
|
|
Working |
01 |
IF YES: What is her occupation? _______________________________ |
|
Unemployed |
02 |
Looking for Work |
03 |
Laid off |
04 |
In School/training |
05 |
In Jail/prison |
06 |
In Military |
07 |
Something Else (Please specify) |
08 |
Don't Know |
99 |
|
INTERVIEWER:
|
IF FATHER
IS RESPONDENT ...SKIP TO G25
IF FATHER IS NOT RESPONDENT AND
NOT IN HOUSEHOLD...GO TO G18
IN HOUSEHOLD...SKIP TO G23 |
|
G18. |
Does CHILD’s father live within an hour’s ride of CHILD? |
|
No |
01 |
|
Yes |
02 |
|
Father is deceased |
03 |
SKIP TO G25 |
Don't Know |
99 |
|
|
G19. |
Does he contribute to the financial support of the child? |
|
No |
01 |
Yes |
02 |
Don't Know |
99 |
|
G20. |
How often does CHILD see (his/her) father? Does (he/she) see him
... |
|
READ
LIST. CIRCLE ONE RESPONSE. |
|
|
Rarely or never |
01 |
Several times a year |
02 |
Several times a month |
03 |
Several times a week |
04 |
Every day |
05 |
Don't know |
99 |
|
G21. |
Is there anyone else who is like a father to CHILD? |
|
|
G22. |
Who is this person? |
|
DO
NOT READ LIST. CIRCLE ONE RESPONSE. |
|
|
The respondent, |
01 |
The respondent's (spouse/partner) who lives in
the household, |
02 |
The respondent's (spouse/partner) who doesn't
live in the household,.. |
03 |
A relative of the child who lives in the household, |
04 |
A relative of the child who doesn't live in the
household |
05 |
A friend of the family who lives in the household,
or |
06 |
A friend of the family who doesn't live in the
household |
07 |
|
|
ENTER
THE PERSON "LETTER" FROM GRID ON PAGE 22 (QUESTION
G5) BELOW. |
|
|
G22a. |
___ person letter from G5 grid page 22 |
G23. |
What is the highest grade or year of regular school
that CHILD’s father completed? |
|
DO
NOT READ LIST. CIRCLE ONE RESPONSE. |
|
|
No formal schooling |
00 |
Less than 8th grade |
07 |
8th grade |
08 |
9th grade |
09 |
10th grade |
10 |
11th grade |
11 |
12th grade |
12 |
High school diploma |
13 |
GED |
14 |
Some college |
15 |
Associate's degree |
16 |
Bachelor's degree |
17 |
Graduate degree |
18 |
Don't know |
99 |
|
G24. |
Is he currently working, in school, in a training program, or is
he doing something else? |
|
DO
NOT READ LIST. CIRCLE ALL THAT APPLY. |
|
|
Working |
01 |
IF YES: What is his occupation? _______________________________ |
|
Unemployed |
02 |
Looking for Work |
03 |
Laid off |
04 |
In School/training |
05 |
In Jail/prison |
06 |
In Military |
07 |
Something Else (Please specify) |
08 |
Don't Know |
99 |
|
G25. |
Is any language other than English spoken in your home? |
|
|
G26. |
What are those languages? |
|
DO
NOT READ LIST. CIRCLE ALL THAT APPLY. |
|
|
French |
01 |
Spanish |
02 |
Cambodian (Khmer) |
03 |
Chinese |
04 |
Haitian Creole |
05 |
Hmong |
06 |
Japanese |
07 |
Korean |
08 |
Vietnamese |
09 |
Arabic |
10 |
Other (Please specify) ___________________ |
11 |
|
G27. |
Do you or your family need someone from Head Start to speak to you
in (LANGUAGE from G26)? |
|
|
G28. |
Is someone from Head Start available to speak to you or your family
in (LANGUAGE from G26)? |
|
|
G29. |
Does CHILD ever need or want a member of the Head Start teaching
staff to speak in (LANGUAGE from G26)? |
|
|
G30. |
Is there someone in the classroom at Head Start available for CHILD
to speak in (LANGUAGE from G26)? |
|
|
G31. |
What is CHILD's racial or ethinic background? |
|
DO
NOT READ LIST. CIRCLE ONE RESPONSE. IF MULTIRACIAL, CODE UNDER
"OTHER." |
|
|
Asian or Pacific Islander |
01 |
Black (African American; non Hispanic) |
02 |
White (Caucasian; non-Hispanic) |
03 |
Hispanic (Latino) |
04 |
Native American or American Indian or Alaskan
Native |
05 |
Other (Please specify) _______________________ |
06 |
|
G32. |
In what country was CHILD born? |
|
USA |
01 |
SKIP TO G34 |
Other (Please specify country) ___________________ |
02 |
|
|
G33. |
How many years has CHILD lived in the United States? ______ years |
G34. |
In what country were you born? |
|
USA |
01 |
SKIP TO G38 |
Other (Please specify country) ___________________ |
02 |
|
|
G35. |
How many years have you lived in the United States? ______ years |
G36. |
Did you attend school outside the U.S.? |
|
|
G37. |
How many years did you attend school before coming to the U.S.?
______ years |
G38. |
How many grades of school did you complete? |
|
DO
NOT READ LIST. CIRCLE ONE RESPONSE. |
|
|
No formal schooling |
00 |
Less than 8th grade |
07 |
8th grade |
08 |
9th grade |
09 |
10th grade |
10 |
11th grade |
11 |
12th grade |
12 |
|
G39. |
Do you have a high school diploma or GED? |
|
No |
01 |
SKIP TO G42 |
Yes, Diploma |
02 |
|
Yes, GED |
03 |
|
|
G40. |
Have you attended college? |
|
|
G41. |
Have you received any degrees? (IF YES) What is
your highest degree? |
|
DO
NOT READ LIST. CIRCLE ONE RESPONSE. |
|
|
No |
01 |
Yes, Associate's Degree |
02 |
Yes, Bachelor's Degree |
03 |
Yes, Graduate Degree |
04 |
|
G42. |
Did you attend vocational or trade school? |
|
|
G43. |
Have you obtained any job-related certificates or licenses? |
|
DO
NOT READ LIST. CIRCLE ALL THAT APPLY. |
|
|
No |
01 |
Yes, trade license or certificate |
02 |
Yes, CDA. (Child Development Associate) |
03 |
Yes, other (Please specify) _________________ |
04 |
|
G44. |
Are you currently working towards any certificate, diploma, or degree? |
|
|
G45. |
What kind of certificate, diploma, or degree? |
|
DO
NOT READ LIST. CIRCLE ONE RESPONSE. |
|
|
Trade license or certificate |
01 |
GED certificate (or equivalent) |
02 |
High school diploma |
03 |
Associates degree |
04 |
CDA (Child Development Associate) |
05 |
Bachelor's degree |
06 |
Graduate degree |
07 |
Other (Please specify) |
08 |
|
H. EMPLOYMENT AND INCOME
Now, I would like to ask you some questions about the sources of income
for your household. As I said earilier, this information will remain
confidential and will not be reported to any agency or Head Start. |
H1. |
Do you have any earnings from a job or jobs, including
self-employment? |
|
|
H2. |
How many jobs do you have currently? ___ jobs |
INTERVIEWER:
|
IF MORE
THAN 3 JOBS, ASK FOR JOBS WORKED MOST HOURS.
REPEAT H3 AND H4 FOR UP TO THREE JOBS MENTIONED. RECORD IN SPACE
BELOW QUESTIONS. |
|
H3. |
What do you do in (this job / the first job / the second job / the
third job)? [Record answer below] |
H4. |
Is this job full-time or 30 or more hours per week; part-time or
less than 30 hours per week; or seasonal or occasional during certain
times of the year? |
|
H3. |
H4. |
JOB DESCRIPTIONS |
JOB STATUS |
|
|
Seasonal |
Full-time |
Part-time |
1. ______________ |
01 |
02 |
03 |
2. ______________ |
01 |
02 |
03 |
3. ______________ |
01 |
02 |
03 |
|
H5. |
In how many of the last twelve months have you worked? ______ months
worked |
H6. |
Are you currently looking for a job? |
|
|
H7. |
Not including yourself, how many other adults contribute to your
household income? ______ adults |
H8. |
Is CHILD covered by health insurance other than Medicaid through
your job(s) or the job of another employed adult? |
|
|
H9. |
Do you or any member of your household receive any of the following
other sources of household income or support? |
|
READ LIST |
NO |
YES |
- Welfare (TANF)
|
01 |
02 |
- Unemployment Insurance
|
01 |
02 |
- Food Stamps
|
01 |
02 |
- WIC--Special Supplemental Food Program for Women, Infants,
and Children
|
01 |
02 |
|
NOTE: If Yes in d.: |
|
|
|
d1. Is CHILD receiving WIC benefits? |
01 |
02 |
- Child support
|
01 |
02 |
- SSI or SSDI
|
01 |
02 |
- Social Security Retirement or Survivor's benefits
|
01 |
02 |
- Loan repayments--for example, from friends, relatives,
and so forth
|
01 |
02 |
- Medicaid or medical assistance
|
01 |
02 |
- Payments for providing foster care
|
01 |
02 |
- Energy assistance
|
01 |
02 |
- Money given to the family
|
01 |
02 |
- Other (Please specify) __________________________________
|
01 |
02 |
|
COMPLETE TABLE (a - l). IF H9a
AND H9c and H9d ARE all NO, THEN SKIP TO H11 |
H10. |
In some states people who receive different types of public assistance
are being required to do certain things such as take courses, get
job training, or find a job. Are you now required to... |
|
|
NO |
YES |
DK |
- Attend job training?
|
01 |
02 |
99 |
- Attend school or a GED class?
|
01 |
02 |
99 |
- Get a job?
|
01 |
02 |
99 |
- Do something else? (Please specify) ______________________________
|
01 |
02 |
99 |
|
H11. |
Thinking about all of the sources of income you just told me about,
what was the total income for your household last month? |
|
PROBE: Your best guess would be fine. |
|
FAMILY |
$|__|, |__|__|__| |
SKIP TO H13 |
Refused |
98 |
SKIP TO H13 |
Don't Know |
99 |
|
|
H12. |
Would you say it was . . . |
|
less than $250 |
01 |
between $250 and $500 |
02 |
between $500 and $1,000 |
03 |
between $1,000 and $1,500 |
04 |
between $1,500 and $2,000 |
05 |
between $2,000 and $2,500, or |
06 |
over $2,500? |
07 |
Refused |
08 |
Don't Know |
99 |
|
Our next questions are about the place where you and
CHILD live. |
H13. |
In what type of housing do you live? Do you live in ... |
|
READ
LIST. CIRCLE ONE RESPONSE. |
|
|
A house, apartment, or trailer on
your own (only your family) |
01 |
SKIP TO H14 |
A house, apartment, or trailer that you share |
02 |
|
Transitional housing |
03 |
SKIP TO H14 |
A homeless shelter |
04 |
SKIP TO H14 |
Or someplace else? (Please specify) _______________________________ |
05 |
SKIP TO H14 |
|
|
H13a. |
How long have you shared housing? ___ months OR ___
years |
|
H13b. |
Why do you share housing? |
|
DO
NOT READ LIST. CIRCLE ONE RESPONSE. |
|
|
|
Can't afford to live alone/low income |
01 |
To help with the bills/expenses |
02 |
Transitional situation (building a house, etc.) |
03 |
Other (please specify) ___________________________ |
04 |
|
H14. |
How many times have you moved in the last 12 months? ______ times
moved |
H15. |
Do you currently live in public or subsidized housing? |
|
|
H16. |
Since CHILD was born, has your family ever been homeless or not
had a regular place to live? |
|
|
H17. |
How many times has this happened? ______ times |
H18. |
Where did you stay? |
|
DO
NOT READ LIST. CIRCLE ALL THAT APPLY. |
|
|
Homeless shelter |
01 |
On the street |
02 |
In a car |
03 |
In a motel |
04 |
Doubling up with others as a last resort |
05 |
Other (Please specify) ____________________ |
06 |
|
H19. |
What was the longest time you were without a place to live? |
|
____ days or
____ weeks or
____ months |
H20. |
Since CHILD began Head Start have you been without a place to live
at any time? |
|
|
H21. |
Did Head Start help you with this housing problem in any way? (IF
YES) How? |
|
DO
NOT READ LIST. CIRCLE ONE RESPONSE. |
|
|
No, Head Start did not help |
01 |
SKIP TO I1 |
Yes, gave info or made a referral (e.g., phone call) |
02 |
|
Yes, gave help to get the service (e.g., filling out forms,
transportation, providing child care) |
03 |
|
Yes, helped in some other way (Please specify) _____________________ |
04 |
|
|
H22. |
How helpful was this assistance? Was it... |
|
READ
LIST. CIRCLE ONE RESPONSE. |
|
|
Not at all helpful, |
01 |
A little helpful, |
02 |
Helpful, or |
03 |
Very Helpful? |
04 |
|
I. COMMUNITY SERVICES
Families with young children sometimes need help of various kinds.
Now I'd like to ask about how Head Start may have helped your family. |
I1. |
Did you or another family member complete a Head Start
Family Needs Assessment in which you were asked about your family's
particular needs, interests, goals, strengths, and so on? |
|
SHOW
PARENT COPY OF A HEAD START FAMILY
NEEDS ASSESSMENT USED BY PROGRAM |
|
|
No |
01 |
Yes |
02 |
Don't know |
99 |
|
I2. |
Now I have some questions about your household’s
experiences with various community agencies. I would like to know
about services your household has needed since CHILD was born. |
|
FOR
EACH ITEM, READ QUESTION ALONG THE TOP. IF (I2) IS YES ASK I3,
IF (I3) IS YES ASK I4. MOVE ON TO NEXT ITEM. |
|
|
|
I2. |
I3. |
I4. |
|
Since
CHILD was born, have you or anyone in your household needed
... |
IF
YES IN I2: Have you received it? |
IF
YES IN I3: Did Head Start help with this in any way? Why 01t?
or How?
01=01, we were already receiving
02=01, Head Start did 01t help
03=No, we didn’t need their help
04=Yes, referred to service 05=Yes, provided service directly
|
|
No |
Yes |
No |
Yes |
|
|
INCOME
ASSISTANCE |
|
- Income assistance--like welfare, SSI, unemployment insurance
|
01 |
02 |
01 |
02 |
|
- Food and nutrition assistance-- like food Stamps or WIC
|
01 |
02 |
01 |
02 |
|
- Help with housing
|
01 |
02 |
01 |
02 |
|
- Help with utilities (running water, hot water, heat, telephone
service)
|
01 |
02 |
01 |
02 |
|
|
EMPLOYMENT
ASSISTANCE |
|
- Job training and employment assistance
|
01 |
02 |
01 |
02 |
|
- Education assistance -- for example, GED, college, learning
to read, English as a second language
|
01 |
02 |
01 |
02 |
|
- Help getting transportation to a job or training
|
01 |
02 |
01 |
02 |
|
- Child care for CHILD before or after the Head Start day
|
01 |
02 |
01 |
02 |
|
- Child care for other children in the household
|
01 |
02 |
01 |
02 |
|
|
HEALTHCARE |
|
- MEDICAID/local name for MEDICAID
|
01 |
02 |
01 |
02 |
|
- Medical or dental care for CHILD
|
01 |
02 |
01 |
02 |
|
- Medical or dental care for adults
|
01 |
02 |
01 |
02 |
|
- Alcohol or drug abuse treatment or counseling
|
01 |
02 |
01 |
02 |
|
- Mental health services
|
01 |
02 |
01 |
02 |
|
|
SOCIAL
SERVICES |
|
- Legal aid
|
01 |
02 |
01 |
02 |
|
- Help dealing with family violence
|
01 |
02 |
01 |
02 |
|
- Help in solving other family problems
|
01 |
02 |
01 |
02 |
|
|
J. CHILD CARE
Now I'd like to ask you some questions about any child care arrangements,
other than Head Start, that you may have used for CHILD. |
J1. |
Let’s think about the years before CHILD was
enrolled in Head Start. During that time, was (he/she) cared for on
a regular basis (10 hrs/wk or more) by someone other than yourself? |
|
|
J2. |
How old in months was CHILD when (he/she) first started
in a child care arrangement for 10 or more hours per week? |
|
______ months old |
J3. |
Thinking about all of the child care arrangements that
CHILD was in before enrollment in Head Start, (a) where and by whom
was that care provided? (b) Which arrangement did you use most frequently? |
|
|
CIRCLE ALL THAT APPLY
(a) |
CIRCLE THE ONE USED MOST
(b) |
At CHILD's home by a
relative |
01 |
01 |
At CHILD's home by a
non-relative |
02 |
02 |
In a relative's home |
03 |
03 |
In a friend's or neighbor's
home |
04 |
04 |
Family day care home |
05 |
05 |
Other child care center/child
development program |
06 |
06 |
At Head Start (not including
time in class) |
07 |
07 |
Other (Please specify)
____________________________ |
08 |
08 |
|
J4. |
Before enrolling in Head Start, in how many different
arrangements did CHILD spend 10 or more hours per week? |
|
______ arrangements |
Now let’s talk about
any child care arrangements that you use for CHILD right now.
Child care does not include time in Head Start class, but may include
separate child care at the Head Start center before or after class.
This does not include babysitting used for social activities such
as going out in the evening. |
J5. |
Is CHILD in child care before or after Head Start? |
|
|
J6. |
In how many different child care arrangements does
CHILD spend time each week? ______ arrangements |
J7. |
Where is that care provided? |
|
IF
MORE THAN ONE CHILD CARE ARRANGEMENT, ASK ABOUT PRIMARY ARRANGEMENT.
DO NOT READ LIST. CIRCLE ONE RESPONSE. |
|
|
At CHILD's home by a relative |
01 |
At CHILD's home by a non-relative |
02 |
In a relative's home |
03 |
In a friend's or neighbor's home |
04 |
Family day care home |
05 |
Other child care center/child development program |
06 |
At Head Start (not including time in class) |
07 |
Other (Please specify) ______________________________ |
08 |
|
J8. |
Is that person or place licensed, certified, or regulated? |
|
No |
01 |
Yes |
02 |
Don't know |
99 |
|
J9. |
How many hours a week is this care used? ______ hours
per week |
J10. |
Who pays for this child care? |
|
DO
NOT READ LIST. CIRCLE ALL THAT APPLY. |
|
|
|
NO |
YES |
- Do you pay for it yourself?
|
01 |
02 |
- Does a government agency pay?
|
01 |
02 |
- Does an employer pay?
|
01 |
02 |
- Does someone else pay?
|
01 |
02 |
- Do you trade child care with someone else?
|
01 |
02 |
- Is it free or no charge? (PROBE for other categories)
|
01 |
02 |
- Other (Please specify) _____________________
|
01 |
02 |
|
J11. |
Now I’m going to ask you about CHILD’S
experience in this care. Please let me know which answer best describes
CHILD’s experience. |
|
READ
LIST. CIRCLE ONE RESPONSE FOR EACH. |
|
|
|
Never |
Sometimes |
Often |
Always |
Don't Know |
- CHILD feels safe and secure in care.
|
01 |
02 |
03 |
04 |
99 |
- CHILD gets lots of individual attention.
|
01 |
02 |
03 |
04 |
99 |
- CHILD'S caregiver is open to new information and learning.
|
01 |
02 |
03 |
04 |
99 |
|
K. FAMILY HEALTHCARE |
K1. |
Now I'm going to ask you about your family's health
care needs. Overall, would you say CHILD'S health is:... |
|
READ
LIST. CIRCLE ONE RESPONSE. |
|
|
Excellent, |
01 |
Very Good, |
02 |
Good, |
03 |
Fair, or |
04 |
Poor? |
05 |
|
K2. |
Does CHILD have an illness or condition that requires
regular, ongoing care? |
|
|
K3. |
How much did CHILD weigh when (he/she) was born? ______
Pounds ______ Ounces |
|
|
K4. |
Does CHILD have a regular health care provider for
routine medical care, for example, well-child care and checkups? |
|
|
K5. |
Where does CHILD usually go for routine medical care?
Does (he/she) go to a ... |
|
READ
LIST. CIRCLE ONE RESPONSE. |
|
|
Doctor's office or private clinic (including
HMO) |
01 |
Hospital outpatient clinic |
02 |
Hospital emergency room |
03 |
Public health department |
04 |
Community health center |
05 |
Migrant clinic |
06 |
Indian Health Service |
07 |
Or some place else (Please specify) ________________________ |
08 |
|
K6. |
Has Head Start helped you find a regular health care
provider for CHILD? IF YES: How? |
|
DO
NOT READ LIST. CIRCLE ONE RESPONSE. |
|
|
Had a health care provider prior to enrollment |
01 |
Head Start has not helped but I wish it would |
02 |
Found a health care provider on my own |
03 |
Provided information, including brochures, meetings,
or conversations |
04 |
Made referrals, for example, phone calls |
05 |
Provided health care directly |
06 |
Helped in some other way (Please specify) ___________________ |
07 |
|
K7. |
Where does CHILD usually go for medical care when (he/she)
is sick or injured? Does (he/she) go to a ... |
|
Doctor's office or private clinic (including
HMO) |
01 |
Hospital outpatient clinic |
02 |
Hospital emergency room |
03 |
Public health department |
04 |
Community health center |
05 |
Migrant clinic |
06 |
Indian Health Service |
07 |
Or some place else (Please specify) ________________________ |
08 |
|
K8. |
Where does CHILD go for dental care? Does (he/she)
go to a ... |
|
Private dentist's office |
01 |
Hospital dental clinic |
02 |
Public health department dental clinic |
03 |
Community health center dental clinic |
04 |
Migrant dental clinic |
05 |
Indian Health Service dental clinic |
06 |
Some place else (Please specify) ________________________ |
07 |
Or CHILD hasn't been to the dentist yet |
08 |
|
K9. |
Would you say your health in general is excellent,
very good, good, fair, or poor? |
|
|
|
Excellent, |
01 |
Very Good, |
02 |
Good, |
03 |
Fair, or |
04 |
Poor? |
05 |
|
K10. |
Does any impairment or health problem now keep you
from working at a job or business? |
|
|
K11. |
Are you limited in the kind or amount of work you can
do because of any impairment or health problem? |
|
|
K12. |
Does anyone in your household, other than CHILD, have
an illness or condition that requires regular, ongoing care? |
|
|
K13. |
Do you have a regular health care provider for your
own routine medical care, for example, checkups? |
|
|
K14. |
Where do you usually go for routine medical care? Do
you go to a ... |
|
READ
LIST. CIRCLE ONE RESPONSE. |
|
|
Doctor's office or private clinic (including
HMO) |
01 |
Hospital outpatient clinic |
02 |
Hospital emergency room |
03 |
Public health department |
04 |
Community health center |
05 |
Migrant clinic |
06 |
Indian Health Service |
07 |
Or some place else (Please specify) ________________________ |
08 |
|
K15. |
Has Head Start helped you find a regular health care
provider for yourself? IF YES: How? |
|
DO
NOT READ LIST. CIRCLE ONE RESPONSE. |
|
|
Had a health care provider prior to enrollment |
01 |
Head Start has not helped but I wish it would |
02 |
Found a health care provider on my own |
03 |
Provided information, including brochures, meetings,
or conversations |
04 |
Made referrals, for example, phone calls |
05 |
Provided health care directly |
06 |
Helped in some other way (Please specify) ___________________ |
07 |
|
K16. |
Does anyone in your household smoke cigarettes regularly? |
|
|
K17. |
Does anyone in your household have
a drinking problem? |
|
|
K18. |
Does anyone in your household have
a drug problem? |
|
|
L. HOME SAFETY |
L1. |
Please tell me if you follow certain safety practices.
Do you... |
|
|
No |
Yes |
NA |
Don't know |
- Always use a safety seat or seat belt for CHILD when in
the car
|
01 |
02 |
03 |
99 |
- Keep medicines in childproof bottles and out of children's
reach
|
01 |
02 |
03 |
99 |
- Have at least one operating smoke detector in your home
with a working battery
|
01 |
02 |
03 |
99 |
- Keep cleaning materials out of reach of children and/or
in locked cabinets
|
01 |
02 |
03 |
99 |
- Have a first-aid kit at home
|
01 |
02 |
03 |
99 |
- Keep the poison control center number and other emergency
numbers by the telephone
|
01 |
02 |
03 |
99 |
- Always supervise CHILD when crossing the street or riding
tricycles/bicycles near traffic
|
01 |
02 |
03 |
99 |
- Always keep matches and cigarette lighters out of CHILD's
reach
|
01 |
02 |
03 |
99 |
- Always supervise CHILD when (he/she) is in the bathtub
|
01 |
02 |
03 |
99 |
|
M. HOME AND NEIGHBORHOOD CHARACTERISTICS
The next questions are about situations that can be difficult for
families. I'm going to ask about things that may have happened to
you or others in your household over the past year. Please remember,
all of your answers are held in the strictest confidence. We will
not tell anyone what you say, including Head Start. |
M1. |
For each of the following items, please tell me how
often each one happened to you during the past year. |
|
READ
LIST. CIRCLE ONE RESPONSE FOR EACH. |
|
|
|
Never |
Once |
More than once |
Refused |
- I saw non-violent crimes take place in my neighborhood
-- for example, selling drugs or stealing.
|
01 |
02 |
03 |
98 |
- I heard or saw violent crime take place in my neighborhood.
|
01 |
02 |
03 |
98 |
- I know someone who was a victim of a violent crime in
my neighborhood.
|
01 |
02 |
03 |
98 |
- I was a victim of violent crime in my neighborhood.
|
01 |
02 |
03 |
98 |
- I was a victim of violent crime in my home.
|
01 |
02 |
03 |
98 |
|
M2. |
Has CHILD ever been a witness to a violent
crime or domestic violence? |
|
No |
01 |
Yes |
02 |
Refused |
98 |
Don't know |
99 |
|
M3. |
Has CHILD ever been the victim of a violent
crime or domestic violence? |
|
No |
01 |
Yes |
02 |
Refused |
98 |
Don't know |
99 |
|
M4. |
Since CHILD was born, have you, another household member,
(or a non-household biological parent) been arrested or charged with
any crime by the police? |
|
No |
01 |
SKIP TO M5 |
Yes |
02 |
|
Refused |
98 |
SKIP TO M5 |
|
|
M4a. |
Who was arrested or charged? _______________________________________________ |
|
|
|
|
M4b. |
Did (he/she/they) spend anytime in jail? |
|
|
|
M5. |
Has CHILD ever lived apart from you (or
mother) not including vacations or shared custody arrangements? |
|
M5a. |
For how long? _______________________________________________ |
|
|
|
|
M5b. |
With whom? _______________________________________________ |
|
|
|
N. YOUR FEELINGS |
N1. |
I'm going to read a list of feelings or attitudes people
have about themselves. After I read each one please tell me if you
strongly disagree, disagree, agree, or strongly agree that you feel
this way. |
|
READ
LIST. CIRCLE ONE RESPONSE FOR EACH. |
|
|
|
Strongly Disagree |
Disagree |
Agree |
Strongly Agree |
- There is really no way I can solve some of the problems
I have.
|
01 |
02 |
03 |
04 |
- Sometimes I feel that I'm being pushed around in life.
|
01 |
02 |
03 |
04 |
- I have little control over the things that happen to me.
|
01 |
02 |
03 |
04 |
- I can do just about anything I really set my mind to do.
|
01 |
02 |
03 |
04 |
- I often feel helpless in dealing with the problems of
life.
|
01 |
02 |
03 |
04 |
- What happens to me in the future depends mostly on me.
|
01 |
02 |
03 |
04 |
- There is little I can do to change many of the important
things in my life.
|
01 |
02 |
03 |
04 |
|
I am going to read a list
of ways you may have felt or behaved. Please tell me how often
you have felt this way during the past week. |
N2. |
How often during the past week have you felt (INTERVIEWER:
READ STATEMENT)--would you say: rarely or never, some or
a little of the time, occasionally or a moderate amount of time, or
most or all of the time? |
|
READ
LIST. CIRCLE ONE RESPONSE FOR EACH. |
|
|
|
Rarely or Never (Less than 1 Day) |
Some or a Little (1-2 Days) |
Occasionally or Moderate (3-4 Days) |
Most or All (5-7 Days) |
- Bothered by things that usually don't bother you
|
01 |
02 |
03 |
04 |
- You did not feel like eating; your appetite was poor
|
01 |
02 |
03 |
04 |
- That you could not shake off the blues, even with help
from your family and friends
|
01 |
02 |
03 |
04 |
- You had trouble keeping your mind on what you were doing
|
01 |
02 |
03 |
04 |
- Depressed
|
01 |
02 |
03 |
04 |
- That everything you did was an effort
|
01 |
02 |
03 |
04 |
- Fearful
|
01 |
02 |
03 |
04 |
- Your sleep was restless
|
01 |
02 |
03 |
04 |
- You talked less than usual
|
01 |
02 |
03 |
04 |
- Lonely
|
01 |
02 |
03 |
04 |
- Sad
|
01 |
02 |
03 |
04 |
- You could not get "going"
|
01 |
02 |
03 |
04 |
|
Many people and groups can
be helpful to members of a family raising a young child. We want to
know how helpful different people and groups are to your family. |
N3. |
Please tell me how helpful each of the following have
been to you in terms of raising CHILD over the past 3 to 6 months.
How helpful have (INSERT PERSON/GROUP) been? (HAVE/HAS)
(PERSON) been not at all helpful, sometimes helpful, generally helpful,
very helpful, or extremely helpful? |
|
READ
LIST. CIRCLE ONE RESPONSE FOR EACH. |
|
|
How helpful (have/has)
been? |
Not Very
Helpful |
Somewhat
Helpful |
Very Helpful |
Not Applicable or Don't Know |
a. |
CHILD's (father/mother/parents) |
01 |
02 |
03 |
99 |
b. |
Grandparents or other relatives |
01 |
02 |
03 |
99 |
c. |
Your friends |
01 |
02 |
03 |
99 |
d. |
Co-workers |
01 |
02 |
03 |
99 |
e. |
Professional helpgivers like
counselors or social workers |
01 |
02 |
03 |
99 |
f. |
Head Start staff |
01 |
02 |
03 |
99 |
g. |
Other child care providers |
01 |
02 |
03 |
99 |
h. |
Religious or social group
member |
01 |
02 |
03 |
99 |
i. |
Anyone else (Please specify) |
01 |
02 |
03 |
99 |
|
N4. |
What are the major ways you feel Head Start could help
CHILD this year? PROBE: Anything else? |
INTERVIEWER:
|
RECORD
ANSWERS BELOW. CODE RESPONSES ON PAGE 59 AT END OF INTERVIEW. |
|
|
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________ |
N5. |
What are the major ways you think Head Start could
help your family this year? PROBE: Anything else? |
INTERVIEWER:
|
RECORD
ANSWERS BELOW. CODE RESPONSES ON PAGE 59 AT END OF INTERVIEW. |
|
|
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________ |
INTERVIEWER:
|
CODE
VERBATIM RESPONSES FROM N4 AND N5 IN GRID BELOW AFTER COMPLETING
INTERVIEW. |
|
|
N4 |
N5 |
|
N4 |
N5 |
Child Benefits |
10 |
10 |
Adult Education |
60 |
60 |
Academic readiness |
11 |
11 |
Preparing for GED |
61 |
61 |
Social interactions with children |
12 |
12 |
GED |
62 |
62 |
Social interactions with adults |
13 |
13 |
Vocational/technical training |
63 |
63 |
Help with speech/language |
14 |
14 |
Adult education class |
64 |
64 |
Child health/nutrition/immunizations |
15 |
15 |
English literacy skills |
65 |
65 |
Child dental services |
16 |
16 |
Finance/budgeting |
66 |
66 |
Mental health counseling |
17 |
17 |
Child Development Associate (CDA) |
67 |
67 |
Help for special needs |
18 |
18 |
Received college degree |
68 |
68 |
Safe haven from home/neighborhood |
19 |
19 |
|
|
|
Family Health
Care |
20 |
20 |
Parenting Benefits |
70 |
70 |
Health education (nutrition/fitness) |
21 |
21 |
Communication skills |
71 |
71 |
Medical services |
22 |
22 |
Discipline |
72 |
72 |
Dental services |
23 |
23 |
Nutrition |
73 |
73 |
Mental Health counseling |
24 |
24 |
Reading/education |
74 |
74 |
|
|
|
Understanding child growth and
development |
75 |
75 |
Child Skills |
25 |
25 |
Food/Clothing |
76 |
76 |
Independence |
26 |
26 |
Holiday gifts/toys/books |
77 |
77 |
Manners |
27 |
27 |
|
|
|
Good habits (pick up toys, set
table) |
28 |
28 |
|
|
|
Referrals and/or
information |
30 |
30 |
Parent Social
Benefits |
80 |
80 |
Social services |
31 |
31 |
Make new friends |
81 |
81 |
Legal aid |
32 |
32 |
Increase self-confidence |
82 |
82 |
Public assistance |
33 |
33 |
Social support/emotional support |
83 |
83 |
Medicaid, etc |
34 |
34 |
Family contentment |
84 |
84 |
Employment |
40 |
40 |
Volunteer Opportunities |
90 |
90 |
Job skills |
41 |
41 |
Housing |
91 |
91 |
Job searching skills |
42 |
42 |
Transportation |
92 |
92 |
Job interviewing skills. |
43 |
43 |
Head
Start can not help |
93 |
93 |
Opportunity to work |
44 |
44 |
|
|
|
Child Care |
50 |
50 |
Other |
98 |
98 |
Before Head Start |
51 |
51 |
________________________________ |
|
|
After Head Start |
52 |
52 |
________________________________ |
|
|
For Other Children |
53 |
53 |
Don't Know |
99 |
99 |
|
N6. |
If you could change anything about Head
Start that you think would help it better serve children and families,
what would it be? |
|
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________ SKIP
TO Section P |
O. CONFIDENCE RATINGS |
|
|
COMPLETE
AFTER INTERVIEW IS CONCLUDED |
|
|
O1. |
Interview Completion Code: |
|
Respondent terminated interview prematurely |
01 |
Respondent refused interview |
02 |
Respondent unable to respond (Please specify)
___________________________________ |
03 |
Interview completed ... |
|
|
O2. |
Please rate the following qualities of the respondent,
the interviewing situation, and the data The Respondent (was/had): |
|
a. |
Able to understand questions easily |
7 |
6 |
5 |
4 |
3 |
2 |
1 |
|
Hardly able to understand |
b. |
Truthful |
7 |
6 |
5 |
4 |
3 |
2 |
1 |
|
Untruthful |
c. |
Accurate |
7 |
6 |
5 |
4 |
3 |
2 |
1 |
|
Inaccurate |
d. |
Interested in the interview |
7 |
6 |
5 |
4 |
3 |
2 |
1 |
|
Not interested in the interview |
e. |
Cooperative |
7 |
6 |
5 |
4 |
3 |
2 |
1 |
|
Uncooperative |
f. |
No English language problem |
7 |
6 |
5 |
4 |
3 |
2 |
1 |
|
Spoke English with great difficulty |
g. |
Interviewed without interruption |
7 |
6 |
5 |
4 |
3 |
2 |
1 |
|
Interrupted often |
h. |
Your opinion about the overall quality
of the data: |
|
High |
7 |
6 |
5 |
4 |
3 |
2 |
1 |
|
Low |
|
|
DON'T
FORGET TO CODE N4 AND N5 ON PAGE 59. |
|
P. TRACKING INFORMATION |
Thank you for spending this time with me.
I would also like to thank you for participating in this interview
and will give you money in just a few minutes. As we explained to
you before, we plan to interview you again in the spring and we need
to know how to get in touch with you. |
P1. |
What is your telephone number? (area
code) __ __ __ - __ __ __ - __ __ __ __ SKIP TO P3A |
|
No telephone |
01 |
Refused |
98 |
|
P2. |
Can you give me a number where you can be reached? (area
code) __ __ __ - __ __ __ - __ __ __ __ |
|
No telephone |
01 |
SKIP TO P3A |
Refused |
98 |
SKIP TO P3A |
|
P3. |
Whose telephone is that? |
|
Name __________________________________________ |
Refused |
98 |
|
|
|
P3a. |
Do you have another phone number like a beeper number
or cell phone number? |
|
|
No beeper or cell phone number |
01 |
|
|
Beeper |
__ __ __ - __ __ __ - __ __ __ __
|
Cell Phone |
__ __ __ - __ __ __ - __ __ __ __
|
|
P4. |
Please give me your permanent address ... |
|
Address |
_________________________________________________________ |
|
Street |
Apt. |
|
_________________________________________________________ |
|
Town/City |
State |
Zip Code |
|
P5. |
Where are you employed? __________________________________________________ |
|
Not employed |
01 |
SKIP TO P7a |
|
P6. |
What is your work telephone phone number? (area
code) __ __ __ - __ __ __ - __ __ __ __ |
Would you please tell me the
names, addresses and telephone numbers of three people who will know
how to contact you a year from now? |
P7a |
Contact 1 name: __________________________________________________ |
P7b. |
Relationship to respondent: ____ Relative (specify)
_______________ ____ Nonrelative |
P7c. |
Address |
_________________________________________________________ |
|
Street |
Apt. |
|
_________________________________________________________ |
|
Town/City |
State |
Zip Code |
|
P8a |
Contact 2 name: __________________________________________________ |
P8b. |
Relationship to respondent: ____ Relative (specify)
_______________ ____ Nonrelative |
P8c. |
Address |
_________________________________________________________ |
|
Street |
Apt. |
|
_________________________________________________________ |
|
Town/City |
State |
Zip Code |
|
P9a |
Contact 3 name: __________________________________________________ |
P9b. |
Relationship to respondent: ____ Relative (specify)
_______________ ____ Nonrelative |
P9c. |
Address |
_________________________________________________________ |
|
Street |
Apt. |
|
_________________________________________________________ |
|
Town/City |
State |
Zip Code |
|
GET SIGNATURE BELOW.
REMOVE SECTION P FROM QUESTIONNAIRE. TEAR OFF LAST PAGE WITH
NAMES AND GIVE TO RESPONDENT.. |
|
I give permission to the contacts
named above to release my current address and phone number to a representative
of the Head Start FACES study. |
_____________________________ |
______________________________ |
_____________ |
Respondent's Signature |
Print Name |
Date |
|
Head
Start Family and Child Experiences Survey |
Thank you very much for your
cooperation. If you have any questions about the study or the inteview,
you may call the following numbers: |
Louisa Tarullo, Ed.D.
Adminstration on Children, Youth and Families
(202) 205-9632 |
David Connell, Ph.D.
Abt Associates, Inc.
(617) 349-2804 |
Nicholas Zill, Ph.D.
Westat, Inc.
(301) 294-4448 |
You may send your comments
regarding the interview burden or any other aspect of this collection
of information, including suggestions for reducing this burden, to: |
Reports Clearance Officer
Adminstration for Children and Families
U.S. Department of Health and Human Services
370 L`Enfant Promenade, S.W.
Washington, D.C. 20447 |
Office of Management and Budget
Paperwork Reduction Project
OMB Control No. 0970-0151 Exp. 06/2000
Washington, D.C. 20503 |
|