|
Date: ____________________ |
Interviewer: ___________________________________ |
|
Complete |
|
Hello, may I speak with [SPRING ’98
RESPONDENT]? |
S1. |
SPRING ’98 RESPONDENT IS: |
|
THERE AND AVAILABLE |
1 |
(GO TO MAIN INTRODUCTION) |
NOT CURRENTLY AVAILABLE |
2 |
|
NO LONGER THERE |
3 |
(GO TO S3) |
|
S2. |
When would be the best time for me
to call back to reach (him/her)?
BEST DAY:_______________________ TIME:______________________
|
|
|
THANK RESPONDENT
AND END CONVERSATION. RECORD CALLBACK INFORMATION ON CALL
RECORD. |
|
|
S3. |
I am trying to reach the person most
responsible for [CHILD]. Would that (still) be [SPRING ’98 RESPONDENT]?
YES .........................................................
1
NO............................................................
2 (GO TO S5)
|
S4. |
Could you please tell me how I can reach
(him/her)? |
|
STREET: ____________________________________________________________
CITY: _____________________________________ STATE: ________ ZIP:_______
TELEPHONE: ________________________________________________________ |
|
|
THANK RESPONDENT
AND END CONVERSATION. USE INFORMATION OBTAINED ABOVE TO
CONTACT SPRING ’98 RESPONDENT. |
|
|
S5. |
Who is most responsible for [CHILD]’s
care? |
|
NAME: ____________________________________________________________
ADDRESS: ________________________________________________________
CITY: ___________________________________ STATE: ________ ZIP:_______
TELEPHONE: ______________________________________________________ |
S6. |
What is (your/his/her)
relationship to [CHILD]? (DO NOT READ LIST. CIRCLE ONE RESPONSE.)
|
|
MOTHER (BIRTH/ADOPTIVE) |
01 |
FATHER (BIRTH/ADOPTIVE) |
02 |
STEPMOTHER |
03 |
STEPFATHER |
04 |
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 |
|
S7. |
Since last spring, how many months (have/has
(you/he/she) been the person most responsible for [CHILD]’s
care? |
|
|
|
|
NUMBER OF MONTHS: __________ |
S8. |
MOST RESPONSIBLE PERSON IS: |
|
PERSON YOU ARE CURRENTLY SPEAKING WITH |
1 |
(GO TO MAIN INTRODUCTION) |
SOMEONE ELSE |
2 |
(THANK R AND END CONVERSATION.
USE INFORMATION FROM S5 TO
CONTACT MOST RESPONSIBLE PERSON) |
|
|
MAIN INTRODUCTION |
|
(Hello), my name is __________
and I am (calling) from Westat. We are part of the research
team that is conducting a study of the Head Start Program. (You
may remember that) someone from the research team talked to
(you/SPRING ’98 RESPONDENT) last Spring, while your child,
[CHILD’S NAME], was attending Head Start. As
part of this same study, the Family and Child Experiences
Survey, we would like to again interview you, administer a
child assessment to [CHILD] and ask [CHILD]’s current
teacher some questions. The study will help us learn more
about what happens to children and families who participate
in Head Start and what happens when the children enter kindergarten.
We want to get your point of view on how [CHILD] is doing
in kindergarten and what is now happening in your family.
This information will be used to help Head Start better serve
children and families. To thank you and [CHILD] for your participation,
you will receive $15.00 and [CHILD] will receive a small gift.
|
|
S9. |
We would like to ask you a few
questions now, (similar to the interview you did in person last spring).
It should take about 30 minutes. |
|
IF THIS
IS NOT A GOOD TIME TO COMPLETE THE INTERVIEW, RECORD APPOINTMENT
TIME BELOW AND ON THE CALL RECORD. THEN COMPLETE THE CONSENT/TEACHER
PERMISSION FORM. |
|
|
APPOINTMENT INFORMATION:
BEST DAY:_______________________ BEST TIME:
_______________________ |
|
First, I want you to know that your participation
is completely voluntary and your responses will be kept completely
confidential. |
S10. |
Did (CHILD) keep going to Head Start until
the end of the program year, or did (he/she) stop going before the
program ended? |
|
Kept going to end of program year |
1 (SKIP TO SECTION A.) |
Stopped going before end of program year |
2 |
Other(especifique) |
3 |
|
S11. |
When did (CHILD) stop
going to Head Start? |
|
_______ |
/ |
____ |
/ |
_______ |
MONTH |
|
DAY |
|
YEAR |
|
S12. |
Why did (CHILD) stop going to Head Start?
What was the most important reason?
(CIRCLE ONLY ONE) |
|
ILLNESS (CHILD) |
01 |
ILLNESS (FAMILY MEMBER) |
02 |
CONFLICT WITH PARENT’S WORK
OR SCHOOL SCHEDULE |
03 |
LACK OF TRANSPORTATION |
04 |
BAD WEATHER |
05 |
CHILD DID NOT WANT TO GO |
06 |
PARENT DECISION NOT TO SEND CHILD OR TO SEND
CHILD ELSEWHERE |
07 |
NEEDED FULL DAY CHILD CARE |
08 |
OTHER (PLEASE SPECIFY): __________________________________ |
09 |
|
S13. |
After he/she stopped going to Head Start
and before he/she started kindergarten (or first grade), did you enroll
(CHILD) in another preschool or child development program? |
|
|
|
IF MORE THAN ONE PROGRAM,
ASK ABOUT PRIMARY PROGRAM. |
|
S14. |
What kind of program was that? Was it. |
|
A public school prekindergarten, |
1 |
A private school prekindergarten or nursery school,
|
2 |
A child care center or child development program,
|
3 |
Another Head Start program, or |
4 |
Somewhere else? (Specify): _________________________ |
5 |
|
S15. |
For how many days a
week did (CHILD) go to that program |
|
DAYS A WEEK________
|
S16. |
How many hours a week
was (CHILD) at that program?
HOURS A WEEK________
|
S17. |
As far as helping (CHILD) learn and get
ready for school, do you think that program was . |
|
Not as good as Head
Start, |
1 |
Just as good as Head Start, or |
2 |
Better than Head Start? |
3 |
|
S18. |
After he/she stopped going to Head Start
and before (he/she) started Kindergarten (or first grade) did (CHILD)
receive child care on a regular basis from someone other than a parent?
(That is, child care other than in the preschool program you just
told me about. Don’t count occasional use of babysitters.) |
|
YES |
1 |
|
NO |
2 |
(SKIP TO SECTION A.) |
|
S19. |
Where was that care provided? (IF MORE
THAN ONE CHILD CARE ARRANGEMENT, ASK ABOUT PRIMARY ARRANGEMENT. 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 or neighborhood’s home |
04 |
Family day care home |
05 |
Child care center |
06 |
Otro (especifique) |
07 |
|
S20. |
Was that person or place licensed, certified,
or regulated? |
|
|
S21. |
For how many days a week was (CHILD)
cared for (by that person/in that place)?
DAYS A WEEK________
|
S22. |
For how many hours a week was (CHILD)
cared for (by that person/in that place)?
HOURS A WEEK________
|
A. DEMOGRAPHIC
CHARACTERISTICS |
A1. |
Now, I'd like to confirm [CHILD]'s age.
We have (his/her) birthday listed as [BIRTHDATE]? Is that correct? |
|
|
A2. |
What is [CHILD]’s correct birthdate? |
|
______ |
/ |
_____ |
/ |
______ |
MONTH |
|
DAY |
|
YEAR |
|
A3. |
Now, about your language background. What
was the first language you learned to speak? |
|
ENGLISH |
01 |
(GO
TO B1) |
SPANISH |
02 |
|
ENGLISH AND SPANISH EQUALLY |
03 |
|
ENGLISH AND ANOTHER LANGUAGE EQUALLY |
04 |
|
ANOTHER LANGUAGE |
05 |
|
(SPECIFY) _____________________________________
|
|
|
|
A4. |
What language do you speak most at home
now? |
|
ENGLISH |
01 |
SPANISH |
02 |
ENGLISH AND SPANISH EQUALLY |
03 |
ENGLISH AND ANOTHER LANGUAGE EQUALLY |
04 |
ANOTHER LANGUAGE |
05 |
(SPECIFY) _____________________________________
|
|
|
|
IF S6 WAS ASKED, COPY
RESPONSE TO S6 TO A5 AND GO TO B1. |
|
A5. |
I just want to confirm your relationship
to [CHILD]. Are you (his/her). |
|
MOTHER (BIRTH/ADOPTIVE) |
01 |
FATHER (BIRTH/ADOPTIVE) |
02 |
STEPMOTHER |
03 |
STEPFATHER |
04 |
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 |
|
|
B. CURRENT
SCHOOL STATUS |
B1. |
Now I'd like to talk with you about [CHILD]'s
school experiences. Is [CHILD] attending (or enrolled in) school? |
|
|
B2. |
What grade or year is [CHILD] attending? |
|
HEAD START |
01 |
(GO
TO Q1 ON PAGE 38) |
NURSERY/PRESCHOOL/PREKINDERGARTEN |
02 |
(GO
TO B9) |
TRANSITIONAL KINDERGARTEN (BEFORE K) |
03 |
(GO
TO B3) |
KINDERGARTEN |
04 |
(GO
TO B3) |
PREFIRST GRADE (AFTER K) |
05 |
(GO
TO B3) |
FIRST GRADE |
06 |
(GO
TO B4) |
SECOND GRADE |
07 |
(GO
TO B4) |
UNGRADED |
08 |
(GO
TO B8) |
|
B3. |
Does [CHILD] go to a full-day or part-day
(kindergarten/prefirst grade)? |
|
|
B4. |
How many hours each
day does (he/she) spend in (kindergarten/prefirst grade/first grade/second
grade)? NUMBER OF HOURS PER DAY:
__________ |
B5. |
How many days each week
does (he/she) spend in (kindergarten/prefirst grade/first grade/second
grade)? NUMBER OF DAYS PER WEEK:
__________ |
B6. |
Approximately how many
days has [CHILD] been absent from class since the beginning of the
school year that is, since last September? NUMBER
OF DAYS ABSENT: __________ |
|
IF NUMBER OF DAYS ABSENT IS GREATER THAN 5 CHECK
THIS BOX… |
|
THEN ASK B7. OTHERWISE, GO TO C1. |
|
B7. |
What is the most frequent reason for [CHILD]'s
missing class? |
|
ILLNESS OF CHILD |
01 |
ILLNESS OF FAMILY MEMBER |
02 |
CONFLICT WITH PARENT’S WORK OR SCHOOL SCHEDULE
|
03 |
LACK OF TRANSPORTATION |
04 |
BAD WEATHER |
05 |
CHILD DID NOT WANT TO GO |
06 |
PARENT DECISION NOT TO SEND CHILD OR TO SEND
CHILD ELSEWHERE |
07 |
OTHER (PLEASE SPECIFY) ____________________________ |
08 |
|
|
|
B8. |
What grade would [CHILD] be in if (he/she)
were attending [school/a school with regular grades]? |
|
NURSERY/PRESCHOOL/PREKINDERGARTEN/HEAD
START |
01 |
|
TRANSITIONAL KINDERGARTEN (BEFORE K) |
02 |
(GO TO C1) |
KINDERGARTEN |
03 |
(GO TO C1) |
PREFIRST GRADE (AFTER K) |
04 |
(GO TO C1) |
FIRST GRADE |
05 |
(GO TO C1) |
SECOND GRADE |
06 |
(GO TO C1) |
UNGRADED, NO EQUIVALENT |
07 |
|
|
B9. |
Do you expect [CHILD] to be enrolled in
kindergarten next year or the year after that? |
|
NEXT YEAR |
1 |
YEAR AFTER THAT |
2 |
NEITHER, DON'T EXPECT CHILD TO ATTEND KINDERGARTEN |
3 |
DON'T KNOW |
8 |
|
|
SKIP TO SECTION G, PAGE
14 |
|
|
C. SCHOOL CHARACTERISTICS |
Now let's talk about the school [CHILD]
goes to (now). |
C1. |
Does [CHILD] go to a public or private
school? |
|
PUBLIC |
1 |
(GO TO C4) |
PRIVATE |
2 |
|
|
C2. |
Is the school church-related or not church-related? |
|
CHURCH-RELATED |
1 |
|
NOT CHURCH-RELATED |
2 |
(GO TO C4) |
|
C3. |
Is it a Catholic school? |
|
|
C4. |
Approximately how many students are in
[CHILD]'s class? |
|
|
|
|
NUMBER OF STUDENTS IN CLASS: ______________ |
C5. |
How many teachers are in [CHILD]'s class? |
|
|
|
|
NUMBER OF TEACHERS IN CLASS: ___________ |
C6. |
Since the beginning of this school year,
has [CHILD] been in the same school? |
|
|
|
D. SCHOOL PRACTICES |
D1. |
For each statement that I read you,
please tell me how well [CHILD]'s school has been doing the following
things (during this school year):
[IF NECESSARY, READ AFTER STATEMENTS FOLLOWING THE
FIRST STATEMENT.]: Would you say [CHILD]'s school does this very
well, just O.K., or doesn't do it at all. |
|
|
Does
it very well |
Just
O.K. |
Dos
not do it at all |
Don't
know |
- Lets you know (between report cards) how
[CHILD] is doing in school.
|
1 |
2 |
3 |
8 |
- Helps you understand what children at [CHILD]'s
age are like
|
1 |
2 |
3 |
8 |
- Makes you aware of chances to volunteer
at the school
|
1 |
2 |
3 |
8 |
- Provides workshops, materials, or advice
about how to help [CHILD] learn at home
|
1 |
2 |
3 |
8 |
- Provides information on community services
to help [CHILD] or your family
|
1 |
2 |
3 |
8 |
IF LANGUAGE MOST
SPOKEN AT HOME (A4) IS NOT ENGLISH ASK: |
1 |
2 |
3 |
8 |
- Understands the needs of families who don't
speak English
|
1 |
2 |
3 |
8 |
|
|
E. FAMILY/SCHOOL
INVOLVEMENT AND SCHOOL PRACTICES |
Now I'd like to ask you about your involvement
with [CHILD]'s current school. |
E1. |
Since the beginning of this school year,
have you … |
|
|
YES |
NO |
- Attended a general school meeting, for
example, an open house, a back-to-school night or a meeting
of a parent-teacher organization?
|
1 |
2 |
- Gone to a regularly-scheduled parent-teacher
conference with [CHILD]'s teacher?
|
1 |
2 |
- Attended a school or class event, such
as a play, (or) sports event because of [CHILD]?
|
1 |
2 |
- Acted as a volunteer at the school or served
on a committee?
|
1 |
2 |
|
E2. |
During this school year, about how
many times have you gone to meetings or participated in activities
at [CHILD]'s school? NUMBER OF TIMES:
__________ |
|
F. TEACHER FEEDBACK
ON CHILD’S SCHOOL PERFORMANCE AND BEHAVIOR |
Here are some things teachers tell parents
about how their children are doing in school. For each one, please
tell me if a teacher said something like this about [CHILD], or wrote
it in a note or on a report card during this school year, even if
you didn’t agree. |
F1. |
Since the beginning of this school year,
has a teacher said or written that [CHILD]. |
|
|
|
YES |
NO |
a. |
has been doing really well in school? |
1 |
2 |
b. |
has not been learning up to (his/her) capabilities? |
1 |
2 |
c. |
doesn't concentrate, doesn't pay attention for
long? |
1 |
2 |
d. |
has been having trouble taking turns, sharing
or cooperating with other children? |
1 |
2 |
e. |
has often seemed sad or unhappy in class? |
1 |
2 |
f. |
has been very restless, fidgets
all the time, or doesn’t sit still? |
1 |
2 |
g. |
has been having trouble taking turns, sharing
or cooperating with other children? |
1 |
2 |
h. |
gets along with other children
or works well in a group? |
1 |
2 |
i. |
is very enthusiastic and interested
in a lot of different things? |
1 |
2 |
j. |
lacks confidence in learning new things or taking
part in new activities? |
1 |
2 |
k. |
It’s hard to understand what [CHILD] is
saying? |
1 |
2 |
l. |
is often sleepy or tired in class? |
1 |
2 |
m. |
likes to speak out in class and express (his/her)
ideas? |
1 |
2 |
n. |
is often bored in class? |
1 |
2 |
|
F2. |
As far as you know, is [CHILD] going to
be promoted to (first grade/second grade) this coming fall, or will
he/she spend another year in (kindergarten/first grade)? |
|
YES, WILL BE PROMOTED TO (FIRST/SECOND) GRADE |
1 |
NO, WILL SPEND ANOTHER YEAR IN KINDERGARTEN/
FIRST GRADE |
2 |
NO, WILL GO INTO A TRANSITIONAL CLASS
(PREFIRST GRADE) |
3 |
|
F3. |
Now that [CHILD] has been in (kindergarten/first
grade) for most of a school year, how satisfied are you with what
Head Start did to help [CHILD] and your family be prepared for school?
Are you. |
|
Very dissatisfied, |
1 |
Somewhat dissatisfied, |
2 |
Somewhat satisfied, |
3 |
or Very satisfied? |
4 |
|
|
G. YOUR CHILD’S
ABILITIES |
These next questions are about things that
different children do at different ages. These things may or may not
be true for [CHILD]. |
G1. |
Can [CHILD] identify the colors red, yellow,
blue, and green by name? Would you say... |
|
All of them |
1 |
Some of them, or |
2 |
None of them? |
3 |
|
G2. |
Can (he/she) recognize... |
|
All of the letters of the alphabet |
1 |
Most of them |
2 |
Some of them, or |
3 |
None of them? |
4 |
|
G3. |
How high can [CHILD] count? Would you say... |
|
Not at all or |
1 |
Up to five |
2 |
Up to ten |
3 |
Up to twenty |
4 |
Up to fifty, |
5 |
Up to 100 or more? |
6 |
|
G4. |
Does [CHILD]…. |
|
|
|
YES |
NO |
a. |
mostly write and draw rather than scribble? |
1 |
2 |
b. |
write (his/her) first name, even if some of the
letters are backwards? |
1 |
2 |
c. |
trip, stumble, or fall easily? |
1 |
2 |
d. |
stutter or stammer? |
1 |
2 |
e. |
When [CHILD] speaks, is (he/she) understandable
to a stranger? |
1 |
2 |
|
G5. |
Is [CHILD] able to read story books on
(his/her) own now? |
|
|
G6. |
Does [CHILD] actually read the words written
in the book, or does (he/she) look at the book and pretend to read? |
|
READS THE WRITTEN WORDS |
1 |
|
PRETENDS TO READ |
2 |
(GO TO G9) |
DOES BOTH |
3 |
|
|
G7. |
How old was [CHILD] in years and
months when (he/she) began reading simple, whole sentences?
YEARS____________ MONTHS___________ (GO TO H1)
|
G8. |
Does (he/she) ever look at a book with
pictures and pretend to read? |
|
|
G9. |
When (he/she) 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? |
|
SOUNDS LIKE CONNECTED STORY |
1 |
TELLS WHAT'S IN EACH PICTURE |
2 |
DOES BOTH |
3 |
|
|
H. YOUR CHILD’S
BEHAVIOR |
H1. |
I am going to read you a list of statements
describing things that children sometimes do. For each statement,
I want you to tell me how often [CHILD] acts in this way. For each
one, would you say never, sometimes, often, or very
often? |
|
(READ ALL ITEMS. CIRCLE ONE RESPONSE
FOR EACH. REPEAT CATEGORIES AS NECESSARY.) |
|
How often does (CHILD)… |
Never |
Sometimes |
Often |
Very Often |
a. |
Easily join others in play? |
1 |
2 |
3 |
4 |
b. |
Respond appropriately to teasing? |
1 |
2 |
3 |
4 |
c. |
Make and keep friends? |
1 |
2 |
3 |
4 |
d. |
Comfort or help others? |
1 |
2 |
3 |
4 |
e. |
Worry about things? |
1 |
2 |
3 |
4 |
f. |
Listen carefully to others? |
1 |
2 |
3 |
4 |
g. |
Act sad? |
1 |
2 |
3 |
4 |
h. |
Control his/her temper? |
1 |
2 |
3 |
4 |
i. |
Cooperate with family members? |
1 |
2 |
3 |
4 |
j. |
Keep working at something until
he/she is finished? |
1 |
2 |
3 |
4 |
k. |
Argue with others? |
1 |
2 |
3 |
4 |
l. |
Fight with others? |
1 |
2 |
3 |
4 |
m. |
Show interest in a variety of
things? |
1 |
2 |
3 |
4 |
n. |
Have a tantrum when he/she does
not get his/her way? |
1 |
2 |
3 |
4 |
o. |
Concentrate on a task and ignore
distractions? |
1 |
2 |
3 |
4 |
p. |
Easily become angry? |
1 |
2 |
3 |
4 |
q. |
Appear to be lonely? |
1 |
2 |
3 |
4 |
r. |
Help with chores? |
1 |
2 |
3 |
4 |
s. |
Have a problem being accepted
and liked by others? |
1 |
2 |
3 |
4 |
t. |
Act impulsively? |
1 |
2 |
3 |
4 |
u. |
Show low self-esteem? |
1 |
2 |
3 |
4 |
How often is [CHILD].. |
|
|
|
|
v. |
Eager to learn new things? |
1 |
2 |
3 |
4 |
w. |
Hyperactive? |
1 |
2 |
3 |
4 |
x. |
Creative in work or play? |
1 |
2 |
3 |
4 |
y. |
Nervous, high-strung, or tense? |
1 |
2 |
3 |
4 |
z. |
Disobedient at home? |
1 |
2 |
3 |
4 |
|
|
I. ACTIVITIES WITH
YOUR CHILD |
Now I have some questions about you and
your child at home. |
I1. |
How many times have you or someone in your
family read to [CHILD] in the past week? Would you say.. |
|
Not at all, |
1 |
Once or twice, |
2 |
3 or more times, |
3 |
or Every day? |
4 |
|
I2. |
In the past week, have you or someone
in your family done the following things with [CHILD]? IF
YES, ASK: How many times have you or someone in your family done
this in the past week? Would you say one or two times, or three
or more times? |
|
|
|
YES |
NO |
|
1-2
TIMES |
3+
TIMES |
a. |
Told (him/her) a
story? |
1 |
2 |
1 |
2 |
b. |
Taught (him/her)
letters, words, or numbers? |
1 |
2 |
1 |
2 |
c. |
Taught (him/her)
songs or music? |
1 |
2 |
1 |
2 |
d. |
Worked in arts and
crafts with (him/her)? |
1 |
2 |
1 |
2 |
e. |
Played a game, sport,
or exercised together? |
1 |
2 |
1 |
2 |
f. |
Took (him/her) along
while doing errands like going to the post office, the bank,
or the store? |
1 |
2 |
1 |
2 |
g. |
Involved (him/her)
in household chores like cooking, cleaning, setting the table,
or caring for pets? |
1 |
2 |
1 |
2 |
|
I3. |
In the past month, have
you or someone in your family done the following things with [CHILD]? |
|
|
|
YES |
NO |
a. |
Visited a library? |
1 |
2 |
b. |
Gone to a movie? |
1 |
2 |
c. |
Gone to a play, concert, or other live show? |
1 |
2 |
d. |
Gone to a mall? |
1 |
2 |
e. |
Visited an art gallery, museum, or historical
site? |
1 |
2 |
f. |
Visited a playground, park, or gone on a picnic? |
1 |
2 |
g. |
Visited a zoo or aquarium? |
1 |
2 |
h. |
Talked with [CHILD] about (his/her) family history
or ethnic heritage? |
1 |
2 |
i. |
Attended an event sponsored by a community, ethnic,
or religious group? |
1 |
2 |
j. |
Attended an athletic or sporting event in which
[CHILD] was not a player? |
1 |
2 |
|
|
J. HOUSEHOLD RULES |
Now I'd like to ask you a few questions
about rules and setting limits at home. |
J1. |
In your house, are there general rules
about. |
|
|
|
YES |
NO |
a. |
What TV programs [CHILD] can watch? |
1 |
2 |
b. |
How many hours [CHILD] can watch TV? |
1 |
2 |
c. |
What kinds of food [CHILD] eats? |
1 |
2 |
d. |
What time [CHILD] goes to bed? |
1 |
2 |
e. |
What chores [CHILD] does? |
1 |
2 |
|
J2. |
About how many hours a day does [CHILD]
watch television? |
|
HOURS A DAY: __________
|
J3. |
Sometimes kids mind pretty well and sometimes
they don't. Have you spanked [CHILD] in the past week for not minding? |
|
|
J4. |
About how many times in the past week? |
|
NUMBER OF TIMES: __________
|
|
K. HEALTH AND DISABILITY |
Now I have a few questions about [CHILD]'s
health. |
K1. |
Does [CHILD] have any special needs or
disabilities - for example, physical, emotional, language, hearing,
learning difficulty, or other special needs? |
|
|
K2. |
How would you describe [CHILD]’s
needs? Does (she/he) have… |
|
|
|
YES |
NO |
DON'T
KNOW |
a. |
A specific learning disability?
|
1 |
2 |
8 |
b. |
Mental retardation? |
1 |
2 |
8 |
c. |
A speech impairment? |
1 |
2 |
8 |
d. |
A serious emotional disturbance? |
1 |
2 |
8 |
e. |
Deafness or another hearing impairment? |
1 |
2 |
8 |
f. |
Blindness or another visual impairment? |
1 |
2 |
8 |
g. |
An orthopedic impairment? |
1 |
2 |
8 |
h. |
Another health impairment lasting 6 months or
more? |
1 |
2 |
8 |
|
|
IF NO TO K2a-h, CHECK THIS
BOX |
|
|
THEN SKIP TO K6 |
|
|
K3. |
(Does/Do) [CHILD]'s (disability/disabilities)
affect (his/her) ability to learn? |
|
|
K4. |
Did you or another family member participate
in developing an Individualized Education Program or Plan (IEP) for
[CHILD]? |
|
|
K5. |
How satisfied are you with the plan? Would
you say you are. |
|
Very dissatisfied, |
1 |
Somewhat dissatisfied, |
2 |
Somewhat satisfied, or |
3 |
Very satisfied? |
4 |
|
K6. |
Overall, would you say [CHILD]'s health
is. |
|
Excellent, |
1 |
Very good, |
2 |
Good, |
3 |
Fair, or |
4 |
Poor? |
5 |
|
K7. |
Does [CHILD] have a regular health care
provider for routine medical care, for example, well-child care and
check-ups? |
|
|
K8. |
About how long has it been since [CHILD]
last saw a medical doctor or other health professional for a checkup
or other routine care? Would you say. |
|
Less than 1 year, |
1 |
1 year, but less than 2 years, |
2 |
or 2 years, or more? |
3 |
|
K9. |
Has [CHILD] ever been to a dentist or dental
hygienist for dental care? |
|
|
K10. |
About how long has it been since [CHILD]
last saw a dentist or dental hygienist for dental care? Would you
say. |
|
Less than 1 year, |
1 |
1 year, but less than 2 years, |
2 |
or 2 years, or more? |
3 |
|
K11. |
Now some questions about your health.
Would you say your health in general is… |
|
Excellent, |
1 |
Very good, |
2 |
Good, |
3 |
Fair, or |
4 |
Poor? |
5 |
|
K12. |
Does any impairment or health problem now
keep you from working at a job or business? |
|
|
K13. |
Are you limited in the kind or amount
of work you can do because of any impairment or health problem? |
|
|
K14. |
Do you have a regular health care provider
for your own routine medical care, for example, checkups? |
|
|
K15. |
Does anyone in your household smoke cigarettes
regularly? |
|
|
|
L. YOU AND YOUR
FAMILY |
Now I'm going to ask you some questions
about you and your family. |
L1. |
What is your current marital status? |
|
Single, never
married |
1 |
Married |
2 |
Separated |
3 |
Divorced |
4 |
Widowed |
5 |
|
L2. |
Including yourself,
how many adults age 18 and older live in your household?
NUMBER OF ADULTS: __________
|
L3. |
Including [CHILD], how
many children age 17 and younger live in your household?
NUMBER OF CHILDREN: __________
|
L4. |
What is the highest grade or year of school
that you have completed? |
|
UP TO 8TH GRADE |
01 |
9TH TO 11TH GRADE |
02 |
12TH GRADE BUT NO DIPLOMA |
03 |
HIGH SCHOOL DIPLOMA/EQUIVALENT |
04 |
VOC/TECH PROGRAM AFTER HIGH SCHOOL BUT NO VOC/TECH
DIPLOMA |
05 |
VOC/TECH DIPLOMA AFTER HIGH SCHOOL |
06 |
SOME COLLEGE BUT NO DEGREE |
07 |
ASSOCIATE'S DEGREE |
08 |
BACHELOR'S DEGREE |
09 |
GRADUATE OR PROFESSIONAL SCHOOL BUT NO DEGREE
|
10 |
MASTER'S DEGREE (MA, MS) |
11 |
DOCTORATE DEGREE (PhD, EDD) |
12 |
PROFESSIONAL DEGREE AFTER BACHELOR'S DEGREE
(MEDICINE/MD; DENTISTRY/DDS; LAW/JD/LLB; ETC.) |
13 |
DON’T KNOW |
98 |
|
L5. |
Are you currently working towards any certificate,
diploma, or degree? |
|
|
L5A. |
What kind of certificate, diploma, or degree? |
|
TRADE LICENSE OR CERTIFICATE |
01 |
GED CERTIFICATE (OR EQUIVALENT) |
02 |
HIGH SCHOOL DIPLOMA |
03 |
ASSOCIATES DEGREE |
04 |
CHILD DEVELOPMENT ASSOCIATE (CDA) |
05 |
BACHELOR'S DEGREE |
06 |
GRADUATE DEGREE |
07 |
OTHER (PLEASE SPECIFY) ___________________________________
|
08 |
|
L6. |
Have you completed a certificate, diploma,
or degree since last spring? |
|
YES |
1 |
|
NO |
2 |
(GO
TO BOX BEFORE L8) |
|
L7. |
What kind of certificate, diploma, or degree?
(CIRCLE ONE RESPONSE.) |
|
TRADE LICENSE OR CERTIFICATE |
01 |
GED CERTIFICATE (OR EQUIVALENT) |
02 |
HIGH SCHOOL DIPLOMA |
03 |
ASSOCIATES DEGREE |
04 |
CHILD DEVELOPMENT ASSOCIATE (CDA) |
05 |
BACHELOR'S DEGREE |
06 |
GRADUATE DEGREE |
07 |
OTHER (PLEASE SPECIFY) ___________________________________
|
08 |
|
|
RESPONDENT IS: |
|
[CHILD]’s MOTHER.......................................
1 (GO TO BOX BEFORE L18)
NOT [CHILD]’s MOTHER ..............................
2 (CONTINUE WITH L8)
|
|
|
L8. |
Is [CHILD]'s mother in this household? |
|
MOTHER IN HOUSEHOLD |
1 |
(GO TO L12) |
MOTHER NOT IN HOUSEHOLD |
2 |
|
MOTHER DECEASED |
3 |
(GO TO L16) |
|
L9. |
Does [CHILD]'s mother live in the same
city or county as [CHILD]? |
|
|
L10. |
In the past year,
on about how many days has [CHILD] seen (his/her) mother?
NUMBER OF DAYS: _________
|
L11. |
How long has it been since [CHILD] last
had contact with (his/her) mother? |
|
[CHILD] NEVER HAD CONTACT |
00 |
(GO TO
L16) |
DON'T KNOW |
98 |
|
|
|
OR |
|
NUMBER: ______________________ |
DAYS |
1 |
|
WEEKS |
2 |
|
MONTHS |
3 |
|
YEARS |
4 |
|
|
IF NO CONTACT IN LAST 12 MONTHS,
CHECK THIS BOX… |
|
THEN SKIP TO L13. |
|
|
L12. |
Since (the beginning of this school year),
has [CHILD]'s mother. |
|
|
|
YES |
NO |
DON'T
KNOW |
a. |
Attended a general school meeting,
for example, an open house, a back-to-school night, or a meeting
of a parent teacher organization? |
1 |
2 |
8 |
b. |
Gone to a regularly scheduled parent-teacher
conference with [CHILD]'s teacher? |
1 |
2 |
8 |
c. |
Attended a school or class event, such as a sports
event because of [CHILD]? |
1 |
2 |
8 |
d. |
Acted as a volunteer at the school or served
on a committee? |
1 |
2 |
8 |
|
L13. |
What is the highest grade or year of school
that [CHILD'S] mother completed? |
|
UP TO 8TH GRADE |
01 |
9TH TO 11TH GRADE |
02 |
12TH GRADE BUT NO DIPLOMA |
03 |
HIGH SCHOOL DIPLOMA/EQUIVALENT |
04 |
VOC/TECH PROGRAM AFTER HIGH SCHOOL BUT NO VOC/TECH
DIPLOMA |
05 |
VOC/TECH DIPLOMA AFTER HIGH SCHOOL |
06 |
SOME COLLEGE BUT NO DEGREE |
07 |
ASSOCIATE'S DEGREE |
08 |
BACHELOR'S DEGREE |
09 |
GRADUATE OR PROFESSIONAL SCHOOL BUT NO DEGREE
|
10 |
MASTER'S DEGREE (MA, MS) |
11 |
DOCTORATE DEGREE (PhD, EDD) |
12 |
PROFESSIONAL DEGREE AFTER BACHELOR'S DEGREE
(MEDICINE/MD; DENTISTRY/DDS; LAW/JD/LLB; ETC.) |
13 |
DON’T KNOW |
98 |
|
L14. |
Is she currently working, in school, in
a training program, or is she doing something else? (CIRCLE ONE
RESPONSE.) |
|
WORKING FULL-TIME (30 HOURS OR MORE
PER WEEK) |
01 |
WORKING PART-TIME |
02 |
LOOKING FOR WORK |
03 |
LAID OFF FROM WORK |
04 |
IN SCHOOL/TRAINING |
05 |
IN JAIL/PRISON |
06 |
IN MILITARY |
07 |
KEEPING HOUSE |
08 |
SOMETHING ELSE
(PLEASE SPECIFY) ___________________________ |
09 |
DON'T KNOW |
98 |
|
|
IF CHILD’S
MOTHER IS IN HOUSEHOLD, CHECK THIS BOX… |
|
THEN SKIP TO BOX L18.
|
|
|
L15. |
In the past 12 months,
(have you/has your family) received any child support payments for
[CHILD] from (his/her) mother? |
|
|
L16. |
Is there anyone else who is like a mother
to [CHILD]? |
|
|
L17. |
Who is this person? Is she. |
|
[THE RESPONDENT], |
1 |
Your (spouse/partner) |
2 |
A relative of the child who lives in the household |
3 |
A relative of the child who doesn't live in the
household |
4 |
A friend of the family who lives in the household,
or |
5 |
A friend of the family who doesn't live in the
household |
6 |
|
|
RESPONDENT IS: |
|
[CHILD]’s FATHER.......................................
1 (GO TO M1)
NOT [CHILD]’s FATHER ...............................
2 (CONTINUE WITH L18)
|
|
|
L18. |
Is [CHILD]'s father in this household? |
|
FATHER IN HOUSEHOLD |
1 |
(GO TO L22) |
FATHER NOT IN HOUSEHOLD |
2 |
|
FATHER DECEASED |
3 |
(GO TO L26) |
|
L19. |
Does [CHILD]'s father live in the same
city or county as [CHILD]? |
|
|
L20. |
In the past year,
on about how many days has [CHILD] seen (his/her) father?
NUMBER OF DAYS: _________ |
L21. |
How long has it been since [CHILD] last
had contact with (his/her) father? |
|
[CHILD] NEVER HAD CONTACT |
00 |
(GO TO L23) |
DON'T KNOW |
98 |
|
|
|
NUMBER: _________________ |
DAYS |
1 |
|
WEEKS |
2 |
|
MONTHS |
3 |
|
YEARS |
4 |
|
|
IF NO CONTACT IN LAST 12 MONTHS,
CHECK THIS BOX… |
|
. |
THEN SKIP TO L25. |
|
L22. |
Since (the beginning of this school year),
has [CHILD]'s father. |
|
|
|
YES |
NO |
DON'T
KNOW |
a. |
Attended a general school meeting,
for example, an open house, a back-to-school night, or a meeting
of a parent teacher organization? |
1 |
2 |
8 |
b. |
Gone to a regularly scheduled parent-teacher
conference with [CHILD]'s teacher? |
1 |
2 |
8 |
c. |
Attended a school or class event, such as a play
or sports event because of [CHILD]? |
1 |
2 |
8 |
d. |
Acted as a volunteer at the school or served
on a committee? |
1 |
2 |
8 |
|
L23. |
What is the highest grade or year of school
that [CHILD'S] father completed? |
|
UP TO 8TH GRADE |
01 |
9TH TO 11TH GRADE |
02 |
12TH GRADE BUT NO DIPLOMA |
03 |
HIGH SCHOOL DIPLOMA/EQUIVALENT |
04 |
VOC/TECH PROGRAM AFTER HIGH SCHOOL BUT NO VOC/TECH
DIPLOMA |
05 |
VOC/TECH DIPLOMA AFTER HIGH SCHOOL |
06 |
SOME COLLEGE BUT NO DEGREE |
07 |
ASSOCIATE'S DEGREE |
08 |
BACHELOR'S DEGREE |
09 |
GRADUATE OR PROFESSIONAL SCHOOL BUT NO DEGREE
|
10 |
MASTER'S DEGREE (MA, MS) |
11 |
DOCTORATE DEGREE (PhD, EDD) |
12 |
PROFESSIONAL DEGREE AFTER BACHELOR'S DEGREE
(MEDICINE/MD; DENTISTRY/DDS; LAW/JD/LLB; ETC.) |
13 |
DON’T KNOW |
98 |
|
L24. |
Is he currently working, in school, in
a training program, or is he doing something else? (CIRCLE ONE
RESPONSE.) |
|
WORKING FULL-TIME (30 HOURS OR MORE
PER WEEK) |
01 |
WORKING PART-TIME |
02 |
LOOKING FOR WORK |
03 |
LAID OFF FROM WORK |
04 |
IN SCHOOL/TRAINING |
05 |
IN JAIL/PRISON |
06 |
IN MILITARY |
07 |
KEEPING HOUSE |
08 |
SOMETHING ELSE
(PLEASE SPECIFY) ___________________________ |
09 |
DON'T KNOW |
98 |
|
|
IF CHILD’S
FATHER IS IN HOUSEHOLD, CHECK THIS BOX… |
|
. |
THEN SKIP TO M1. |
|
L25. |
In the past 12 months,
(have you/has your family) received any child support payments for
[CHILD] from (his/her) father? |
|
|
L26. |
Is there anyone else who is like a father
to [CHILD]? |
|
|
L27. |
Who is this person? Is he. |
|
[THE RESPONDENT], |
1 |
Your (spouse/partner) |
2 |
A relative of the child who lives in the household |
3 |
A relative of the child who doesn't live in the
household |
4 |
A friend of the family who lives in the household,
or |
5 |
A friend of the family who doesn't live in the
household |
6 |
|
|
M. PARENT EDUCATION
|
Now I have some questions about you and
your parents. |
M1. |
What grades (do/did) you usually
get in high school? |
|
MOSTLY A'S (NUMERICAL AVERAGE OF 90-100) |
01 |
|
MOSTLY A'S AND B'S (85-89) |
02 |
|
MOSTLY B'S (80-84) |
03 |
|
MOSTLY B'S AND C'S (75-79) |
04 |
|
MOSTLY C'S (70-74) |
05 |
|
MOSTLY C'S AND D'S (65-69) |
06 |
|
MOSTLY D'S AND LOWER (64 AND BELOW) |
07 |
|
NEVER IN HIGH SCHOOL |
08 |
(GO TO M4) |
|
M2. |
(Is/Was) your high school program… |
|
Academic or college preparatory,
or |
1 |
Commercial or business training, or |
2 |
Vocational or technical? |
3 |
|
M3. |
Now I have a list of high school mathematics
and technical courses. As I read each one, please tell me whether
you have taken that course in high school. |
|
|
|
YES |
NO |
a. |
Elementary Algebra or Algebra I?
|
1 |
2 |
b. |
Plane geometry? |
1 |
2 |
c. |
Business Math? |
1 |
2 |
d. |
Computer Science? |
1 |
2 |
e. |
Intermediate Algebra or Algebra II? |
1 |
2 |
f. |
Trigonometry? |
1 |
2 |
g. |
Calculus? |
1 |
2 |
h. |
Physics? |
1 |
2 |
|
M4. |
What is the highest grade or year of school
that your father completed? |
|
UP TO 8TH GRADE |
01 |
9TH TO 11TH GRADE |
02 |
12TH GRADE BUT NO DIPLOMA |
03 |
HIGH SCHOOL DIPLOMA/EQUIVALENT |
04 |
VOC/TECH PROGRAM AFTER HIGH SCHOOL BUT NO VOC/TECH
DIPLOMA |
05 |
VOC/TECH DIPLOMA AFTER HIGH SCHOOL |
06 |
SOME COLLEGE BUT NO DEGREE |
07 |
ASSOCIATE'S DEGREE |
08 |
BACHELOR'S DEGREE |
09 |
GRADUATE OR PROFESSIONAL SCHOOL BUT NO DEGREE
|
10 |
MASTER'S DEGREE (MA, MS) |
11 |
DOCTORATE DEGREE (PhD, EDD) |
12 |
PROFESSIONAL DEGREE AFTER BACHELOR'S DEGREE
(MEDICINE/MD; DENTISTRY/DDS; LAW/JD/LLB; ETC.) |
13 |
DON’T KNOW |
98 |
|
M5. |
What is the highest grade or year of school
that your mother completed? |
|
UP TO 8TH GRADE |
01 |
9TH TO 11TH GRADE |
02 |
12TH GRADE BUT NO DIPLOMA |
03 |
HIGH SCHOOL DIPLOMA/EQUIVALENT |
04 |
VOC/TECH PROGRAM AFTER HIGH SCHOOL BUT NO VOC/TECH
DIPLOMA |
05 |
VOC/TECH DIPLOMA AFTER HIGH SCHOOL |
06 |
SOME COLLEGE BUT NO DEGREE |
07 |
ASSOCIATE'S DEGREE |
08 |
BACHELOR'S DEGREE |
09 |
GRADUATE OR PROFESSIONAL SCHOOL BUT NO DEGREE
|
10 |
MASTER'S DEGREE (MA, MS) |
11 |
DOCTORATE DEGREE (PhD, EDD) |
12 |
PROFESSIONAL DEGREE AFTER BACHELOR'S DEGREE
(MEDICINE/MD; DENTISTRY/DDS; LAW/JD/LLB; ETC.) |
13 |
DON’T KNOW |
98 |
|
M6. |
When you were growing up, did your family
ever receive public assistance? |
|
|
M7. |
What is your religious background? |
|
BAPTIST |
01 |
METHODIST |
02 |
LUTHERAN |
03 |
PRESBYTERIAN |
04 |
EPISCOPAL |
05 |
PENTECOSTAL |
06 |
OTHER PROTESTANT |
07 |
ROMAN CATHOLIC |
08 |
EASTERN ORTHODOX |
09 |
MORMON |
10 |
OTHER CHRISTIAN |
11 |
JEWISH |
12 |
MOSLEM |
13 |
EASTERN RELIGION (BUDDHIST, HINDU, TAO) |
14 |
OTHER RELIGION (SPECIFY) _______________________________
|
15 |
NONE |
16 |
|
M8. |
In the past year, about how often have
you attended religious services? Would you say. |
|
About once a week, |
1 |
2 or 3 times a month, |
2 |
About once a month, |
3 |
Several times during the year, or, |
4 |
Not at all? |
5 |
|
|
N. EMPLOYMENT AND
INCOME |
Now I would like to ask you some questions
about the sources of income for your household. This information will
remain confidential. |
N1. |
Do you have any earnings from a job or
jobs, including self-employment? |
|
|
N2. |
How many jobs do you have currently?
NUMBER OF JOBS: __________
|
N3. |
What
do you do in (this job/ the first job/the second job/the
third job)? |
|
a. |
JOB 1 ________________________
______________________________ |
b. |
JOB 2 ________________________
______________________________ |
c. |
JOB 3 ________________________
______________________________ |
|
N4. Is this job
full-time, 30 or more hours per week; part-time, less
than 30 hours per week; or seasonal or occasional during
certain times of the year? |
|
FULL-TIME |
PART-TIME |
SEASONAL |
1 |
2 |
3 |
1 |
2 |
3 |
1 |
2 |
3 |
|
|
N5. |
In how many of the last six
months have you worked?
MONTHS WORKED:_________
|
N6. |
Are you currently looking for (a/another)
job? |
|
|
N7. |
Not including yourself,
how many other adults contribute to your household income?
NUMBER OF ADULTS:_________
|
N8. |
Does your family have health insurance
other than Medicaid through (your job) or the job of another employed
adult in the household? |
|
|
N9. |
Did you receive any of the following other
sources of household income or support in the past six months? |
|
|
|
YES |
NO |
a. |
Welfare, TANF, or general assistance |
1 |
2 |
b. |
Unemployment insurance |
1 |
2 |
c. |
Food Stamps |
1 |
2 |
d. |
WIC -- Special supplemental food program for
Women, Infants, and Children |
1 |
2 |
e. |
Child support |
1 |
2 |
f. |
SSI or Social Security Retirement, Disability,
or Survivor's benefits |
1 |
2 |
g. |
Payments for providing foster care |
1 |
2 |
|
|
IF N9 a, c, OR
d WERE ANSWERED YES, CHECK THIS BOX…. |
|
. |
THEN ASK N10. OTHERWISE, GO TO N11.
|
|
N10. |
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 or will you soon be required to. |
|
|
|
YES |
NO |
a. |
attend job training? |
1 |
2 |
b. |
attend school or a GED class? |
1 |
2 |
c. |
get a job? |
1 |
2 |
d. |
do something else? (please specify)
____________________ |
1 |
2 |
|
N11. |
Thinking about all of the sources
of income you just told me about, what was the total income for your
household last month before taxes and other deductions? Your best
guess would be fine.
HOUSEHOLD INCOME .......................... $ __
, __ __ __ (GO TO N13)
|
|
OR
|
|
REFUSED |
7 |
(GO TO N13) |
DON'T KNOW |
8 |
(GO TO N12) |
|
N12. |
Would you say it was. |
|
less than $250 |
01 |
between $251 and $500 |
02 |
between $501 and $1,000 |
03 |
between $1,001 and $1,500 |
04 |
between $1,501 and $2,000 |
05 |
between $2,001 and $2,500, or |
06 |
over $2,500 |
07 |
REFUSED |
97 |
DON'T KNOW |
98 |
|
Our next questions are about housing. |
N13. |
Do you now live in . |
|
a house, apartment, or trailer of
your own, |
1 |
a house, apartment, or trailer you share with
another family |
2 |
transitional housing (apartment) or a homeless
shelter, or |
3 |
somewhere else?
(please specify)
______________________________ |
4 |
|
N14. |
How many times have you moved in
the last six months?
TIMES: ___________
|
N15. |
Do you currently own your own home or apartment,
pay rent, or live in public or subsidized housing? |
|
Owns or is buying home of aparatment |
1 |
Rents (without public assistance) |
2 |
Public or subsidized housing |
3 |
Some other arrangement |
4 |
|
N16. |
Has [CHILD] ever lived apart from [you/(his/her)
mother] for six months or longer, not including vacations or shared
custody arrangements? |
|
|
N17. |
In the last year, has [CHILD] ever been
a witness to a crime or domestic violence? |
|
YES |
1 |
NO |
2 |
REFUSED |
7 |
DON'T KNOW |
8 |
|
N18. |
In the last year, has [CHILD] ever been
the victim of a crime or domestic violence? |
|
YES |
1 |
NO |
2 |
REFUSED |
7 |
DON'T KNOW |
8 |
|
N19. |
Since [CHILD] was born, has anyone in your
household or ([CHILD]'s (biological) (father/mother)) been arrested
or charged with any crime by the police? |
|
YES |
1 |
|
NO |
2 |
(GO TO 01) |
REFUSED |
7 |
(GO TO 01) |
DON'T KNOW |
8 |
(GO TO 01) |
|
N20. |
Did this person spend any time in jail? |
|
YES |
1 |
NO |
2 |
REFUSED |
7 |
DON'T KNOW |
8 |
|
|
O. CHILD CARE |
Now let's talk about any child care arrangements
that you are currently using for [CHILD]. Child care does not include
time in kindergarten class, but may include separate child care arrangements
at school before or after class. |
O1 . |
Is [CHILD] in child care? |
|
|
O2. |
In how many different
child care arrangements does [CHILD] spend time each week?
NUMBER OF ARRANGEMENTS: __________
|
O3. |
Where is the primary care provided? |
|
IN [CHILD]’S HOME WITH SOMEONE
OTHER THAN PARENT |
1 |
RELATIVE’S HOME |
2 |
NONRELATIVE’S HOME |
3 |
AT THE SCHOOL IN A BEFORE- OR AFTER-SCHOOL PROGRAM
(OR WRAP-AROUND CARE) |
4 |
OTHER CHILD CARE CENTER |
5 |
OTHER (PLEASE SPECIFY) __________________________________ |
6 |
|
O4. |
How many hours per week
is this care used?
HOURS PER WEEK: _______
|
O5. |
Who pays for this child care? |
|
|
|
YES |
NO |
a. |
Do you pay for it yourself? |
1 |
2 |
b. |
Does a government agency pay? |
1 |
2 |
c. |
Does an employer pay? |
1 |
2 |
d. |
Do you trade child care with someone else? |
1 |
2 |
e. |
Other (please specify) ________________________________ |
1 |
2 |
|
O6. |
Now I'm going to ask you about [CHILD]'s
experiences in child care. Please let me know which of these answers
best describes [CHILD]'s experience: never, sometimes, often,
or always: |
|
|
|
Never |
Some-
times |
Frequently |
Always |
a. |
[CHILD] feels safe and secure
in care |
1 |
2 |
3 |
4 |
b. |
[CHILD] gets lots of individual attention |
1 |
2 |
3 |
4 |
c. |
[CHILD]’s caregiver is open to new information
and learning |
1 |
2 |
3 |
4 |
|
|
P. YOUR FEELINGS |
P1. |
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. |
|
|
|
Strongly disagree |
Disagree |
Agree |
Strongly agree |
a. |
There is really no way I can solve some of the
problems I have |
1 |
2 |
3 |
4 |
b. |
Sometimes I feel that I’m being pushed
around in life |
1 |
2 |
3 |
4 |
c. |
I have little control over the things that happen
to me |
1 |
2 |
3 |
4 |
d. |
I can do just about anything I really set my
mind to do |
1 |
2 |
3 |
4 |
e. |
I often feel helpless in dealing with the problems
of life |
1 |
2 |
3 |
4 |
f. |
What happens to me in the future depends mostly
on me |
1 |
2 |
3 |
4 |
g. |
There is little I can do to change many of the
important things in my life |
1 |
2 |
3 |
4 |
|
P2. |
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: rarely or never, some
or a little, occasionally or moderately, or most or all of the time.
|
|
|
|
Rarely of never |
Some or a little |
Occasionally
or moderately |
Most or all of the
time |
a. |
Bothered by things that usually
don't bother you |
1 |
2 |
3 |
4 |
b. |
You did not feel like eating; your appetite was
poor |
1 |
2 |
3 |
4 |
c. |
That you could not shake off the blues, even
with help from your family and friends |
1 |
2 |
3 |
4 |
d. |
You had trouble keeping your mind on what you
were doing |
1 |
2 |
3 |
4 |
e. |
Depressed |
1 |
2 |
3 |
4 |
f. |
That everything that you did was an effort |
1 |
2 |
3 |
4 |
g. |
Fearful |
1 |
2 |
3 |
4 |
h. |
Your sleep was restless |
1 |
2 |
3 |
4 |
i. |
You talked less than usual |
1 |
2 |
3 |
4 |
j. |
You felt lonely |
1 |
2 |
3 |
4 |
k. |
You felt sad |
1 |
2 |
3 |
4 |
l. |
You could not get "going" |
1 |
2 |
3 |
4 |
|
|
Those are all the questions that I have
right now. I would like to thank you very much for participating in
this interview. (INTERVIEWER CIRCLE ONE.) |
|
CONSENT/TEACHER INFO ALREADY OBTAINED |
1 |
(GO TO BOX BELOW) |
CONSENT/TEACHER INFO NEEDED |
2 |
(GO TO CONSENT FORM) |
|
|
Please remember that our research team will
be in your area during the weeks of [DATES FROM SCHEDULE].
Someone from that team will contact you to schedule a time
to bring [CHILD] in for an assessment. As I mentioned before,
once the assessment has been completed, you will receive $15
and [CHILD] will receive a toy. |
|
|
COMMENTS:________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
|
|
|
Q. HEAD START TRACKING
INFORMATION
(ONLY IF CHILD IN HEAD START) |
Q1. |
Which Head Start Center
is [CHILD] currently attending? CENTER NAME:
_____________________________________________________
STREET: ____________________________________________________________
CITY: ____________________________ STATE: ____________
ZIP: ___________ |
Q2. |
Is that the same center he/she attended
last year? |
|
YES |
1 |
(GO TO BOX BELOW) |
NO |
2 |
|
|
Q3. |
When did [CHILD] begin attending this center? |
|
________
MONTH |
/________
YEAR |
|
|
We may want to include [CHILD] in the Head Start
part of this study. One of our other team members will be contacting
you with further information. |
|