24-month interview
Version 1 (06-24-11)
I. Tracking InformatioN
First, I just want to confirm your full name andyour child’s full name.
1. Confirmation of Names
Name of Primary Respondent ______
Name of Target Child ______
Target Child Date of Birth ______(DD/MM/YYYY)
2. What is your relationship to (CHILD NAME)?
1 = BIOLOGICAL PARENT
2 = ADOPTIVE PARENT
3 = FOSTER PARENT
4 = MARRIED STEP-PARENT
5 = UNMARRIED PARTNER OF PARENT
6 = GRANPARENT
7 = AUNT/UNCLE
8 = OTHER (SPECIFY) ______
2. Are you still living at (INSERT ADDRESS INFORMATION)?
0 = No
1 = Yes (SKIP TO QUESTION 3)
2a. Please tell me your current address.
3. Is this phone number, the one I am using right now, the best number to reach you, or is there another number that is better?
We’d really like to continue to follow (CHILDNAME) in our study. When we last met, you provided us with contact information for three individuals who did not live with you, but would know how to reach you if you were to move. I would like to quickly review this information with you to make sure everything is up-to-date.
[Repeat questions 4a and 4b for each individual listed on Appointment Sheet]
4a.Is this person still a good person for us to contact if we lost touch with you?
0 = No [Cross name off of Appointment Sheet]
1 = Yes(GO TO QUESTIONS 4b & 4c)
4b. Let me confirm the phone numbers. I have (INSERT NUMBER) as (INSERT NAME)’s (home, cell, work) phone.
[Repeat as necessary to confirm all phones, and record numbers on the Appointment Sheet as needed.]
4c. Let me confirm the address. I have (INSERT ADDRESS) as (NAME)’s address.
[Repeat as necessary to confirm all addresses on the Appointment Sheet as needed.]
4d. Is there anyone else who is not on this list who would be a good contact for us—a friend, neighbor, family member, or co-worker who would probably always know how to find you or your family?
0 =No
1 = Yes [Record name, address, and phone number(s) on Appointment Sheet]
5. Do you have any plans to move in the next 6-8 months?
0 = No (SKIP TO QUESTION 6)
1 = Yes
88 = Don’t Know (SKIP TO QUESTION 6)
5a.Do you know the contact information for the place where you plan to move?
(get address and phone numbers for new location)
6. Some families in our project have told us that they use email. Do you use email regularly?
0 =No [SKIP TO NEXT SECTION]
1 = Yes
7. If you do use email do you mind giving me your email address as an alternate means of getting in touch with you?
Email Address: ______
ASK ONLY IF RESPONDENT IS A NEW PRIMARY CAREGIVER FOR THE CHILD
Now we would like to ask you a few questions about your relationship with (TARGET CHILD).
8. How long have you been the primary caregiver for (TC NAME)? ______(Months)
9. Do you have legal custody of (TC NAME)?
0 = No
1 = Yes
99 = Refused
10. What was the primary reason why you became the primary caregiver for (TC NAME)?
DEMOGRAPHICS
Updates and Household Demographics
Thank you for all that information about how to contact you. This will be helpful when we try and contact you in the future. Now, we would like to ask you several questions about how you and your baby are doing, and who currently lives in your home. We’ve asked some of these questions before but we want to be able to know about changes in your and (CHILD NAME)’s lives.
1. First of all, in general, how has (CHILDNAME) been doing? Probes:
*What new things has (he/she) been doing?
*Are you pleased about (CHILDNAME)’s progress, or do you have any concerns?
*Have you had any major life changes since the last time we spoke with you?
2. Are you currently in a relationship with someone?
0 = No (Skip to QUESTION 5)
1 = Yes
3. What is your marital status?
1 = Single, never married
2 = Living with partner
3 = Married
4 = Separated
5 = Widowed
6 = Divorced
4. How long have you been in this relationship?
Years _____
Months _____
5. Are you living with or married to your baby’s father?
0 = No
1 = Yes, living with father (Skip to QUESTION 8)
2 = Yes, married to father (Skip to QUESTION 8)
6. Does your baby ever see his/her biological father?
0 = No
1 = Yes
7. (ONLY ASK IF UNCLEAR) Is the child’s father deceased?
0 = No
1 = Yes (Skip to NEXT SECTION)
- Who lives with you now?
8a. (Insert CHILD NAME)?
0 = No
1 = Yes
8b. Spouse or Partner?
0 = No
1 = Yes
8c. Other Adults?
0 = No (SKIP TO QUESTION 8F)
1 = Yes
8d. How many other adults live with you? (Specify) ______
8e. Other children (not-including CHILD)?
0 = No (SKIP TO QUESTION 9)
1 = Yes
8g. How many other children live with you? (Specify) ______
9. Have you given birth to or adopted any additional children since we last visited with you when your child was approximately 6-months-old?
0 = No (SKIP TO NEXT SECTION)
1 = Yes
10. How many children have you given birth to or adopted? ______
11. Please tell me the names and birth dates of any children you have given birth to or adopted since we last visited with you:
Child’s First and Last Name: ______Date of Birth: ______
Child’s First and Last Name:______Date of Birth: ______
DEMOGRAPHICS
Employment and Income
Now we would like to ask you some questions about your job situation, financial circumstances, and any school or job training that you may have received since we last visited you in (month of last visit).
1. Are you currently employed?
0 = No (Skip to QUESTION 3)
1 = Yes
2. Counting all of your jobs, how many hours per week do you spend at work? ______
[Skip to Question 5 if PR does not have a spouse / partner living in the home]
3. Is your spouse/partner currently employed?
0 = No (Skip to QUESTION 9)
1 = Yes
4. Counting all jobs, how many hours per week does your spouse/partner spend at work? ______
5. What was the total household income for your family last year, including income from all sources?
(Gross or Pre-Tax Income)
1 = Less than $10,000
2 = $10,000 – $19,999
3 = $20,000 – $29,999
4 = $30,000 – $39,999
5 = $40,000 $ $49,999
6 = $50,000 $ $59,999
7 = $60,000 $ $74,999
8 = $75,000 $ $99,999
9 = $100,000 – $149,999
10 = $150,000+
88 = Don’t Know
99 = Refused
health & development
Maternal & Infant Health
We are interested in knowing about your and (CHILD NAME)’s health care and general health since we last spoke in (insert month of last visit).
1. Do you have a regular doctor or health care provider?
0 = No
1 = Yes
2. What is the name and location of the practice at which you receive your health care?
(Ask for name and location of most recent practice where mother received health care if no regular provider)
3. In general, how do you pay for your health care?
1 = We pay for it ourselves
2 = We have health insurance or are covered by an HMO or preferred provider plan
3 = Medicaid, CHIPS, or other public program
4 = Other (Specify) ______
4. Are you using any form of birth control at this time?
0 = No (ASK QUESTION 4a)
1 = Yes
4a. Are you currently pregnant?
0 = No
1 = Yes
5.In general, how would you rate your overall health?
1 = Poor
2 = Fair
3 = Good
4 = Very Good
5 = Excellent
6. Does (CHILD NAME) have a regular doctor or health care provider?
0 = No (SKIP TO QUESTION 8)
1 = Yes
7. What is the name and location of the practice at which your child receives his/her health care?
(Ask for name and location of most recent practice where child received health care if no regular provider)
8. When was the last time you took (CHILD NAME) to see the doctor for a general examination (also known as a “well child check up”)?
1 = Within the last month
2 = Within the last 3 months
3 = More than 3 months ago
4 = I don’t remember the last time (target child) had a general examination
5 = I don’t take (target child) to the doctor for general examinations (SKIP TO QUESTION 18)
9. In general, how do you pay for (CHILD NAME)’s health care?
1 = We pay for it ourselves
2 = We have health insurance or are covered by an HMO or preferred provider plan
3 = Medicaid, CHIPS, or other public program
4 = Other (Specify) ______
10. Is (CHILD NAME) up-to-date on his/her immunizations?
0 = No
1 = Yes
11. Does your baby have a medical problem or developmental disability diagnosed by a doctor?
(such as birth defect/handicaps, hepatitis, HIV)
0 = No (SKIP TO QUESTION 12)
1 = Yes
8a. If yes, describe:______
12. In general, how would you rate your child’s overall health?
1 = Poor
2 = Fair
3 = Good
4 = Very Good
5 = Excellent
13. In the past 6 months, has (CHILD NAME) had any accidents or injuries?
0 = No (SKIP TO QUESTION 15)
1 = Yes
88 = Mother Refuses to Answer (SKIP TO QUESTION 15)
13a. (If yes) How many times? ______
14. What was the type of injury / injuries? (select all that apply)?
1 = Fall
2 = Scald / Burn
3 = Cut
4 = Hit by Someone
5 = Hit by Something
6 = Poisoning (Specify ______)
7 = Other (Specify ______)
88 = Mother Refuses to Answer
15. Inthe past 6 months, how many times have you seen your child’s health care provider for illness, injuries, or emergencies? ______
16. In the past 6 months, have you brought your child to the emergency room or department for an illness, injury, or emergency?
0 = No (SKIP TO QUESTION 17)
1 = Yes
88 = Mother Refuses to Answer (SKIP TO QUESTION 17)
16a. (If yes)How many times? ______
17. In the past 6 months, has your child stayed over in the hospital for an illness, injury, or emergency?
0 = No
1 = Yes
88 = Mother Refuses to Answer
18. To the best of your knowledge, has anyone in your family ever been reported to Child Protective Services?
0 = No (SKIP TO NEXT SECTION
1 = Yes
88 = Mother Refuses to Answer (SKIP TO NEXT SECTION)
23a. (If yes) When did that occur?
______
Month Year
family support
ECHO & Family Services
Now we would like to ask about community services and resources you and your family may have used in the past 6 months.
1. How much external support i.e. community services, other people/organizations or churches do you feel you need in the following areas (essentially, anything not provided by biological parents):
None at all / Some support / Medium/Enough support / A lot of support / Prefer not to answerFinancial and Material Needs
Medical Care and Child Development
Parenting and Family Needs
Child Care Needs
2. In the past 6 months, have you received services for:
Organization Name / Did you use this service? / How many times did you use this service? / Are you still using this service? / How much were you helped by this service?Department of Social Services (DSS) outreach worker (such as Erika Ward) / Yes
No
I prefer not to answer / 1 Time
2-5 Times
More than 5
N/A / Yes
No / Not at all
A little
Somewhat
A lot
WIC (Women, Infant, and Children) / Yes
No
I prefer not to answer / 1 Time
2-5 Times
More than 5
N/A / Yes
No / Not at all
A little
Somewhat
A lot
SSI (Social Security Income) / Yes
No
I prefer not to answer / 1 Time
2-5 Times
More than 5
N/A / Yes
No / Not at all
A little
Somewhat
A lot
Medicaid Waiver for Family Planning Services / Yes
No
I prefer not to answer / 1 Time
2-5 Times
More than 5
N/A / Yes
No / Not at all
A little
Somewhat
A lot
Medicaid (FOR YOU, not your child) / Yes
No
I prefer not to answer / 1 Time
2-5 Times
More than 5
N/A / Yes
No / Not at all
A little
Somewhat
A lot
Medicaid or Health Choice (FOR YOUR CHILD) / Yes
No
I prefer not to answer / 1 Time
2-5 Times
More than 5
N/A / Yes
No / Not at all
A little
Somewhat
A lot
Job Seeking Assistance / Yes
No
I prefer not to answer / 1 Time
2-5 Times
More than 5
N/A / Yes
No / Not at all
A little
Somewhat
A lot
Transportation Assistance / Yes
No
I prefer not to answer / 1 Time
2-5 Times
More than 5
N/A / Yes
No / Not at all
A little
Somewhat
A lot
Shelter / Housing Assistance / Yes
No
I prefer not to answer / 1 Time
2-5 Times
More than 5
N/A / Yes
No / Not at all
A little
Somewhat
A lot
Food Assistance / Yes
No
I prefer not to answer / 1 Time
2-5 Times
More than 5
N/A / Yes
No / Not at all
A little
Somewhat
A lot
Clothing Assistance / Yes
No
I prefer not to answer / 1 Time
2-5 Times
More than 5
N/A / Yes
No / Not at all
A little
Somewhat
A lot
Durham Economic Resource Center (DERC) / Yes
No
I prefer not to answer / 1 Time
2-5 Times
More than 5
N/A / Yes
No / Not at all
A little
Somewhat
A lot
Family Planning / Yes
No
I prefer not to answer / 1 Time
2-5 Times
More than 5
N/A / Yes
No / Not at all
A little
Somewhat
A lot
Child Service Coordination (CSC) / Care Coordination for Children (CC4C) / Yes
No
I prefer not to answer / 1 Time
2-5 Times
More than 5
N/A / Yes
No / Not at all
A little
Somewhat
A lot
Mental Health Counseling / Yes
No
I prefer not to answer / 1 Time
2-5 Times
More than 5
N/A / Yes
No / Not at all
A little
Somewhat
A lot
Substance Use Services / Yes
No
I prefer not to answer / 1 Time
2-5 Times
More than 5
N/A / Yes
No / Not at all
A little
Somewhat
A lot
Couples Counseling or Domestic Violence Help / Yes
No
I prefer not to answer / 1 Time
2-5 Times
More than 5
N/A / Yes
No / Not at all
A little
Somewhat
A lot
Child Care Services Association (CCSA) / Yes
No
I prefer not to answer / 1 Time
2-5 Times
More than 5
N/A / Yes
No / Not at all
A little
Somewhat
A lot
Durham’s Alliance for Child Care Access (DACCA) / Yes
No
I prefer not to answer / 1 Time
2-5 Times
More than 5
N/A / Yes
No / Not at all
A little
Somewhat
A lot
Children’s Developmental Service Association (CDSA) for infant assessment / Yes
No
I prefer not to answer / 1 Time
2-5 Times
More than 5
N/A / Yes
No / Not at all
A little
Somewhat
A lot
Other / Yes
No
I prefer not to answer / 1 Time
2-5 Times
More than 5
N/A / Yes
No / Not at all
A little
Somewhat
A lot
Family support
Child Care Services
Now we would like to ask you some questions about child care services your child may receive.
1. Does anyone other than you take regular care of your infant?
0 = No (ASK 1a, THEN SKIP TO QUESTION 2)
1 = Yes
1a. Did you have difficulty trying to access/use center-based childcare services?
0 = No
1 = Yes
1b. If yes, who? (check all that apply):
1 = Spouse/partner
2 = Other family member
3 = Volunteer other person (neighbor, friend)
4 = Paid other individual
5 = Group home
6 = Licensed child care center (ASK QUESTION 1c)
1c. Child care centers are rated by a 5-point “star” system. What level is the child care setting where you take your children (if known)?
1 = 1 star
2 = 2 star
3 = 3 star
4 = 4 star
5 = 5 star
88 = Don’t Know
- If you had an emergency and needed someone to take care of your infant for an overnight or a full day, do you have someone who could help out?
0 = No
1 = Yes
- Do you have someone who helps you with babysitting so that you can get time for yourself?
0 = No
1 = Yes
4. How many hours per week doessomeone outside of your home care for your child? ______
Maternal self-efficacy
Parenting Sense of Competence
The following questions describe some ways parents of young children may feel at times. For each question, please tell me the response that best reflects your opinion.
StronglyDisagree / Disagree / Mildly
Disagree / Mildly
Agree / Agree / Strongly
Agree
1. / The problems of taking care of a child are easy to solve once you know how your actions affect your child, an understanding I have acquired. / 1 / 2 / 3 / 4 / 5 / 6
2. / Even though being a parent could be rewarding, I am frustrated with my child at this age. / 1 / 2 / 3 / 4 / 5 / 6
3. / My mother and father were more prepared to be a good parent than I am. / 1 / 2 / 3 / 4 / 5 / 6
4. / I would make a fine model for a new parent to follow in order to learn what she or he would need to know in order to be a good parent. / 1 / 2 / 3 / 4 / 5 / 6
5. / Being a parent is manageable, and any problems are easily solved. / 1 / 2 / 3 / 4 / 5 / 6
6. / I meet my own personal expectations for expertise in caring for my child. / 1 / 2 / 3 / 4 / 5 / 6
7. / My talents and interest are in other areas, not in being a parent. / 1 / 2 / 3 / 4 / 5 / 6
8. / If being a parent were only more interesting, I would be motivated to do a better job as a parent. / 1 / 2 / 3 / 4 / 5 / 6
9. / I honestly believe I have all the skills necessary to be a good parent to my child. / 1 / 2 / 3 / 4 / 5 / 6
10. / Being a parent makes me tense and anxious. / 1 / 2 / 3 / 4 / 5 / 6
relationship functioning
Maternal Parenting Behaviors
Next, I would like you to go through this list of ways in which parents might act with their children and indicate how often in the past month you have acted this way with your child. I would like you to tell me whether each thing has happened: never in the past month, once in the past month, twice, 3-5 times, 6-10 times, 11-20 times.
Item # / In the past month, how many times have you… / Never / 1 to 2 times / 3 to 5 times / 6 to 10 times / 11 to 20 times / More than 20 times1 / Read books with [CHILD] / 0 / 1 / 2 / 3 / 4 / 5
2 / Shouted, yelled or screamed at [CHILD] / 0 / 1 / 2 / 3 / 4 / 5
3 / Did things just for fun with [CHILD] (played games like peek-a-boo, went to a fun place like a playground) / 0 / 1 / 2 / 3 / 4 / 5
4 / Did not watch child as carefully as I thought I should, or had to leave [CHILD] home alone / 0 / 1 / 2 / 3 / 4 / 5
5 / Was not able to get [CHILD] the food he/she needed / 0 / 1 / 2 / 3 / 4 / 5
6 / Threatened to spank or hit [CHILD] / 0 / 1 / 2 / 3 / 4 / 5
7 / Comforted [CHILD] when she or he was upset / 0 / 1 / 2 / 3 / 4 / 5
8 / Pushed, grabbed, or shoved [CHILD] / 0 / 1 / 2 / 3 / 4 / 5
9 / Helped [CHILD] when he/she was upset / 0 / 1 / 2 / 3 / 4 / 5
10 / Was unable to take [CHILD] to a doctor when one was needed / 0 / 1 / 2 / 3 / 4 / 5
11 / Hugged or cuddled with [CHILD] / 0 / 1 / 2 / 3 / 4 / 5
12 / Spanked or slapped [CHILD] / 0 / 1 / 2 / 3 / 4 / 5
13 / Praised [CHILD] / 0 / 1 / 2 / 3 / 4 / 5
14 / Told [CHILD] you loved him or her / 0 / 1 / 2 / 3 / 4 / 5
15 / Made [CHILD] stay in one place or put him/her alone in a room (like a time out) / 0 / 1 / 2 / 3 / 4 / 5
16 / Explained why something he/she did was wrong / 0 / 1 / 2 / 3 / 4 / 5
relationship functioning
Father Involvement
INTERVIEWER:
COMPLETE ONLY IF MOTHER IS CURRENTLY IN A RELATIONSHIP; ASK ABOUT CURRENT PARTNER
1. Is this the same individual mother completed the questionnaire for at infant age 6-months?
- No (COMPLETE NON-RESIDENT FATHER QUESTIONNAIRE IN NEXT SECTION)
- Yes (DO NOT COMPLETE NON-RESIDENT FATHER QUESTIONNAIRE IN NEXT SECTION)
Quality of Relationship
Now I would like to ask you some questions about things (FATHER’s NAME) does with (CHILD NAME). For each activity, please tell me how often he typically does this. How frequently does (FATHER’s NAME) usually…?