Supporting Healthy Marriage (SHM) Project: Control Services Survey
Supporting Healthy Marriage (SHM) Project: Control Services Survey
SHM Control Services OMB Instrument
Supporting Healthy Marriage (SHM) Project: Control Services Survey
OMB: 0970-0330
Contract No.: 223-03-0034
Contract Amount: $74,938,364
SUPPORTING STATEMENT
FOR OMB CLEARANCE: INSTRUMENT
DHHS/ACF
SUPPORTING HEALTHY MARRIAGE (SHM)
PROJECT EVALUATION
LOW-INCOME MARRIED COUPLES DATA COLLECTION ACTIVITIES –
CONTROL SERVICES SURVEY
August 22, 2007
Prepared for: |
Prepared by: |
|
|
Department of Health and Human Services Administration for Children and Families |
MDRC |
370 L’Enfant Promenade, SW |
16 East 34th Street, 19th Floor |
Washington, DC 20447 |
New York, NY 10016 |
Phone: 202-401-5372 |
Phone: 212-340-8678 |
|
|
Project Officer: |
Principal Investigator: |
Mark Fucello |
Virginia Knox |
Attachment A: Control Services Survey Instrument
INTERVIEWER: PLEASE FILL IN THE FOLLOWING INFORMATION THAT WILL BE NEEDED FOR TEXTFILLS AND SKIP PATTERNS DURING THE INTERVIEW.
RAD:
GROUP: PROGRAM
CONTROL
RESPONDENT NAME:
CONSENT:
Hello this is ________________. I’m calling from Abt Associates on behalf of the Supporting Healthy Marriage project. May I please speak to (RESPONDENT NAME)?
We are conducting a study to learn more about the kinds of services that people have received to help them work on their marriages. We want to find out what kinds of services are available in your community and whether people take advantage of them. The purpose of my call is to test a survey we would like to use in this study.
This interview should only take about five to ten minutes of your time. Participation is completely voluntary. Your name will not be connected with any information you give me. What you say will not affect your ability to receive services now or in the future. You may refuse to answer any question. In appreciation for helping us, we will send you a gift of $10 for completing the interview. If you are ready, we can begin.
1. Since [RAD: ________] have you received any services or counseling to help you work on your marriage or your relationship with your spouse? This could include services or counseling you received by yourself or with your spouse. Some people call these services marriage education, marriage therapy, or mentoring. How about those?
1 YES
2 NO (SKIP TO Q.21)
8 DON’T KNOW (SKIP TO Q.21)
7 REFUSED (SKIP TO Q.21)
2. Were any of these services to help you work on your marriage or your relationship with your spouse provided in classes, workshops or groups?
1 YES
2 NO (SKIP TO Q.13A)
8 DON’T KNOW (SKIP TO Q.13A)
7 REFUSED (SKIP TO Q.13A)
3A. What was the name of the class, workshop or group?
8 DON’T KNOW
7 REFUSED
4A. What organization or program provided this class, workshop or group?
PROBE: Where was this class, workshop or group held?
8 DON’T KNOW
7 REFUSED
5A. Where did you hear about this class, workshop, or group?
[INTERVIEWER: DO NOT READ LIST]
1 [SHM PROGRAM]
2 OTHER (PLEASE SPECIFY): ________________________________________
8 DON’T KNOW
7 REFUSED
6A. Were you supposed to attend this class, workshop or group with your spouse?
1 YES
2 NO
8 DON’T KNOW
7 REFUSED
7A. How many times did you attend these classes or workshops since [RAD: ________]? Was it…
1 Once
2 Two to five times
3 Six to 10 times
4 11 to 20 times
5 More than 20 times
8 DON’T KNOW
7 REFUSED
8A. About how long did you spend at each session?
NUMBER OF HOURS: ___________
8 DON’T KNOW
7 REFUSED
9A. How often did you attend these classes, workshops or groups with your spouse? Was it…
1 Always
2 Sometimes
3 Seldom
4 Never
8 DON’T KNOW
7 REFUSED
10A. Did you attend any other classes, workshops, or groups to help you work on your marriage?
1 YES
2 NO (SKIP TO BOX A)
8 DON’T KNOW (SKIP TO BOX A)
7 REFUSED (SKIP TO BOX A)
3B. What was the name of the class, workshop or group?
8 DON’T KNOW
7 REFUSED
4B. What organization or program provided this class, workshop or group?
PROBE: Where was this class, workshop or group held?
8 DON’T KNOW
7 REFUSED
5B. Where did you hear about this class, workshop, or group?
[INTERVIEWER: DO NOT READ LIST]
1 [SHM PROGRAM]
2 OTHER (PLEASE SPECIFY): ________________________________________
8 DON’T KNOW
7 REFUSED
6B. Were you supposed to attend this class, workshop or group with your spouse?
1 YES
2 NO
8 DON’T KNOW
7 REFUSED
7B. How many times did you attend these classes or workshops since [RAD: ________]? Was it…
1 Once
2 Two to five times
3 Six to 10 times
4 11 to 20 times
5 More than 20 times
8 DON’T KNOW
7 REFUSED
8B. About how long did you spend at each session?
NUMBER OF HOURS: ___________
8 DON’T KNOW
7 REFUSED
9B. How often did you attend these classes, workshops or groups with your spouse? Was it…
1 Always
2 Sometimes
3 Seldom
4 Never
8 DON’T KNOW
7 REFUSED
10B. Did you attend any other classes, workshops, or groups to help you work on your marriage?
1 YES
2 NO (SKIP TO BOX A)
8 DON’T KNOW (SKIP TO BOX A)
7 REFUSED (SKIP TO BOX A)
3C. What was the name of the class, workshop or group?
8 DON’T KNOW
7 REFUSED
4C. What organization or program provided this class, workshop or group?
PROBE: Where was this class, workshop or group held?
8 DON’T KNOW
7 REFUSED
5C. Where did you hear about this class, workshop, or group?
[INTERVIEWER: DO NOT READ LIST]
1 [SHM PROGRAM]
2 OTHER (PLEASE SPECIFY): ________________________________________
8 DON’T KNOW
7 REFUSED
6C. Were you supposed to attend this class, workshop or group with your spouse?
1 YES
2 NO
8 DON’T KNOW
7 REFUSED
7C. How many times did you attend these classes or workshops since [RAD: ________]? Was it…
1 Once
2 Two to five times
3 Six to 10 times
4 11 to 20 times
5 More than 20 times
8 DON’T KNOW
7 REFUSED
8C. About how long did you spend at each session?
NUMBER OF HOURS: ___________
8 DON’T KNOW
7 REFUSED
9C. How often did you attend these classes, workshops or groups with your spouse? Was it…
1 Always
2 Sometimes
3 Seldom
4 Never
8 DON’T KNOW
7 REFUSED
10C. Did you attend any other classes, workshops, or groups to help you work on your marriage?
1 YES
2 NO (SKIP TO BOX A)
8 DON’T KNOW (SKIP TO BOX A)
7 REFUSED (SKIP TO BOX A)
3D. What was the name of the class, workshop or group?
8 DON’T KNOW
7 REFUSED
4D. What organization or program provided this class, workshop or group?
PROBE: Where was this class, workshop or group held?
8 DON’T KNOW
7 REFUSED
5D. Where did you hear about this class, workshop, or group?
[INTERVIEWER: DO NOT READ LIST]
1 [SHM PROGRAM]
2 OTHER (PLEASE SPECIFY): ________________________________________
8 DON’T KNOW
7 REFUSED
6D. Were you supposed to attend this class, workshop or group with your spouse?
1 YES
2 NO
8 DON’T KNOW
7 REFUSED
7D. How many times did you attend these classes or workshops since [RAD: ________]? Was it…
1 Once
2 Two to five times
3 Six to 10 times
4 11 to 20 times
5 More than 20 times
8 DON’T KNOW
7 REFUSED
8D. About how long did you spend at each session?
NUMBER OF HOURS: ___________
8 DON’T KNOW
7 REFUSED
9D. How often did you attend these classes, workshops or groups with your spouse? Was it…
1 Always
2 Sometimes
3 Seldom
4 Never
8 DON’T KNOW
7 REFUSED
10E. Did you attend any other classes, workshops, or groups to help you work on your marriage?
1 YES (RECORD ON SEPARATE SHEET OF PAPER)
2 NO
8 DON’T KNOW
7 REFUSED
BOX A
IF RESPONDENT IS IN PROGRAM GROUP, GO TO Q.11.
IF RESPONDENT IS IN CONTROL GROUP, GO TO Q.13A.
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11. About how many of the marriage education workshops at [SHM PROGRAM] that you were assigned to did you actually attend? Was it …
1 None of them
2 Some of them
3 Most of them (SKIP TO Q.13A)
4 All of them (SKIP TO Q.13A)
8 DON’T KNOW (SKIP TO Q.13A)
7 REFUSED (SKIP TO Q.13A)
12. What are the reasons that you didn’t attend? Of the following, was it …
1 A problem with your health
2 Trouble finding child care
3 Trouble finding transportation
4 A family issue
5 A problem with your housing
6 A conflict with your job
7 A conflict with your school or training program
8 Religious observance
9 Your spouse didn't want to attend
10 You didn’t like the program or didn’t feel comfortable attending
11 You were having too much trouble with your marriage
98 DON’T KNOW
97 REFUSED
13A. The next question is about services that are provided one-on-one with just you and a counselor, without your spouse. Some people call these kinds of services marital therapy or counseling. Since [RAD: ________], did you receive this type of service to help you work on your marriage or your relationship?
1 YES
2 NO (SKIP TO Q.17A)
8 DON’T KNOW (SKIP TO Q.17A)
7 REFUSED (SKIP TO Q.17A)
14A. What organization or program provided these services?
__________________________________________________
8 DON’T KNOW
7 REFUSED
15A. Where did you hear about these services? [INTERVIEWER: DO NOT OFFER [SHM PROGRAM] OR OTHER AS OPTIONS. ASK THIS AS AN OPEN-ENDED QUESTION AND CHECK OFF WHATEVER THE ANSWER IS.]
1 [SHM PROGRAM]
2 Other: __________________________________________
8 DON’T KNOW
7 REFUSED
16A. About how many times since [RAD: ________] did you receive these one-on-one services to help you work on your marriage or your relationship? Was it …
1 Once
2 Two to five times
3 Six to 10 times
4 11 to 20 times
5 More than 20 times
8 DON’T KNOW
7 REFUSED
13B. What about other services that are provided one-one-one with just you and a counselor, without your spouse? Since [RAD: ________], did you receive any other one-on-one services without your spouse to help you work on your marriage or your relationship?
PROBE: Some people call these kinds of services marital therapy or counseling. Did you receive any services like that without your spouse?
1 YES
2 NO (SKIP TO Q.17A)
8 DON’T KNOW (SKIP TO Q.17A)
7 REFUSED (SKIP TO Q.17A)
14B. What organization or program provided these services?
__________________________________________________
8 DON’T KNOW
7 REFUSED
15B. Where did you hear about these services? [INTERVIEWER: DO NOT OFFER [SHM PROGRAM] OR OTHER AS OPTIONS. ASK THIS AS AN OPEN-ENDED QUESTION AND CHECK OFF WHATEVER THE ANSWER IS.]
1 [SHM PROGRAM]
2 Other: __________________________________________
8 DON’T KNOW
7 REFUSED
16B. About how many times since [RAD: ________] did you receive these one-on-one services to help you work on your marriage or your relationship? Was it …
1 Once
2 Two to five times
3 Six to 10 times
4 11 to 20 times
5 More than 20 times
8 DON’T KNOW
7 REFUSED
13C. What about other services that are provided one-one-one with just you and a counselor, without your spouse? Since [RAD: ________], did you receive any other one-on-one services without your spouse to help you work on your marriage or your relationship?
PROBE: Some people call these kinds of services marital therapy or counseling. Did you receive any services like that without your spouse?
1 YES
2 NO (SKIP TO Q.17A)
8 DON’T KNOW (SKIP TO Q.17A)
7 REFUSED (SKIP TO Q.17A)
14C. What organization or program provided these services?
__________________________________________________
8 DON’T KNOW
7 REFUSED
15C. Where did you hear about these services? [INTERVIEWER: DO NOT OFFER [SHM PROGRAM] OR OTHER AS OPTIONS. ASK THIS AS AN OPEN-ENDED QUESTION AND CHECK OFF WHATEVER THE ANSWER IS.]
1 [SHM PROGRAM]
2 Other: __________________________________________
8 DON’T KNOW
7 REFUSED
16C. About how many times since [RAD: ________] did you receive these one-on-one services to help you work on your marriage or your relationship? Was it …
1 Once
2 Two to five times
3 Six to 10 times
4 11 to 20 times
5 More than 20 times
8 DON’T KNOW
7 REFUSED
13D. What about other services that are provided one-one-one with just you and a counselor, without your spouse? Since [RAD: ________], did you receive any other one-on-one services without your spouse to help you work on your marriage or your relationship?
PROBE: Some people call these kinds of services marital therapy or counseling. Did you receive any services like that without your spouse?
1 YES (RECORD ON SEPARATE SHEET OF PAPER)
2 NO
8 DON’T KNOW
7 REFUSED
17A. The next question is about services that are provided one-on-one by a counselor with just you and your spouse. Since [RAD: ________], did you receive this type of service to help you work on your marriage or your relationship?
PROBE: Some people call these kinds of services marital therapy or counseling. Did you receive any services like that with your spouse?
1 YES
2 NO (SKIP TO Q.21)
8 DON’T KNOW (SKIP TO Q.21)
7 REFUSED (SKIP TO Q.21)
18A. What organization or program provided these services?
8 DON’T KNOW
7 REFUSED
19A. Where did you hear about these services?
[INTERVIEWER: DO NOT READ LIST]
1 [SHM PROGRAM]
2 OTHER, PLEASE SPECIFY:_________________________________________
8 DON’T KNOW
7 REFUSED
20A. About how many times since [RAD: ________] did you and your spouse receive these one-on-one services to help you work on your marriage or your relationship? Was it…
1 Once
2 Two to five times
3 Six to 10 times
4 11 to 20 times
5 More than 20 times
8 DON’T KNOW
7 REFUSED
17B. What about other services that are provided one-one-one by a counselor with just you and your spouse? Since [RAD: ________], did you receive any other one-on-one services with your spouse to help you work on your marriage or your relationship?
PROBE: Some people call these kinds of services marital therapy or counseling. Did you receive any services like that with your spouse?
1 YES
2 NO (SKIP TO Q.21)
8 DON’T KNOW (SKIP TO Q.21)
7 REFUSED (SKIP TO Q.21)
18B. What organization or program provided these services?
8 DON’T KNOW
7 REFUSED
19B. Where did you hear about these services?
[INTERVIEWER: DO NOT READ LIST]
1 [SHM PROGRAM]
2 OTHER, PLEASE SPECIFY:_________________________________________
8 DON’T KNOW
7 REFUSED
20B. About how many times since [RAD: ________] did you and your spouse receive these one-on-one services to help you work on your marriage or your relationship? Was it…
1 Once
2 Two to five times
3 Six to 10 times
4 11 to 20 times
5 More than 20 times
8 DON’T KNOW
7 REFUSED
17C. What about other services that are provided one-one-one by a counselor with just you and your spouse? Since [RAD: ________], did you receive any other one-on-one services with your spouse to help you work on your marriage or your relationship?
PROBE: Some people call these kinds of services marital therapy or counseling. Did you receive any services like that with your spouse?
1 YES
2 NO (SKIP TO Q.21)
8 DON’T KNOW (SKIP TO Q.21)
7 REFUSED (SKIP TO Q.21)
18C. What organization or program provided these services?
8 DON’T KNOW
7 REFUSED
19C. Where did you hear about these services?
[INTERVIEWER: DO NOT READ LIST]
1 [SHM PROGRAM]
2 OTHER, PLEASE SPECIFY:_________________________________________
8 DON’T KNOW
7 REFUSED
20C. About how many times since [RAD: ________] did you and your spouse receive these one-on-one services to help you work on your marriage or your relationship? Was it…
1 Once
2 Two to five times
3 Six to 10 times
4 11 to 20 times
5 More than 20 times
8 DON’T KNOW
7 REFUSED
17D. What about other services that are provided one-one-one by a counselor with just you and your spouse? Since [RAD: ________], did you receive any other one-on-one services with your spouse to help you work on your marriage or your relationship?
PROBE: Some people call these kinds of services marital therapy or counseling. Did you receive any services like that with your spouse?
1 YES (RECORD ON A SEPARATE SHEET OF PAPER)
2 NO
8 DON’T KNOW
7 REFUSED
21. Since [RAD: ________], did you participate in any of these kinds of programs:
1 Parenting programs (Example: Parents As Teachers, Family Expectations)
2 Early Head Start
3 Home visiting programs (Example: Healthy Families, Nurse Family Partnership)
4 None (SKIP TO Q.25)
8 DON’T KNOW (SKIP TO Q.25)
7 REFUSED (SKIP TO Q.25)
INTERVIEWER: QUESTIONS 22 THROUGH 24 SHOULD BE ASKED ABOUT EACH PROGRAM IN WHICH THE RESPONDENT INDICATED HE/SHE PARTICIPATED IN QUESTION 21.
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22A. Was your spouse supposed to attend [PROGRAM IN Q.21: ] with you?
1 YES
2 NO
8 DON’T KNOW
7 REFUSED
23A. How often did you attend [PROGRAM IN Q.21: ] with your spouse? Was it…
1 Always
2 Sometimes
3 Seldom
4 Never
8 DON’T KNOW
7 REFUSED
24A. About how many times did you attend [PROGRAM IN Q.21: ] since [RAD: ________]? Was it …
1 Once
2 Two to five times
3 Six to 10 times
4 11 to 20 times
5 More than 20 times
8 DON’T KNOW
7 REFUSED
22B. Was your spouse supposed to attend [PROGRAM IN Q.21: ] with you?
1 YES
2 NO
8 DON’T KNOW
7 REFUSED
23B. How often did you attend [PROGRAM IN Q.21: ] with your spouse? Was it…
1 Always
2 Sometimes
3 Seldom
4 Never
8 DON’T KNOW
7 REFUSED
24B. About how many times did you attend [PROGRAM IN Q.21: ] since [RAD: ________]? Was it …
1 Once
2 Two to five times
3 Six to 10 times
4 11 to 20 times
5 More than 20 times
8 DON’T KNOW
7 REFUSED
22C. Was your spouse supposed to attend [PROGRAM IN Q.21: ] with you?
1 YES
2 NO
8 DON’T KNOW
7 REFUSED
23C. How often did you attend [PROGRAM IN Q.21: ] with your spouse? Was it…
1 Always
2 Sometimes
3 Seldom
4 Never
8 DON’T KNOW
7 REFUSED
24C. About how many times did you attend [PROGRAM IN Q.21: ] since [RAD: ________]? Was it …
1 Once
2 Two to five times
3 Six to 10 times
4 11 to 20 times
5 More than 20 times
8 DON’T KNOW
7 REFUSED
25. Since [RAD: ________], have you received any other services from [SHM SERVICE PROVIDER]? These services include help getting a job or job training, adult education or GED classes, mental health services, drug or alcohol abuse treatment, help finding or paying for child care, help finding or paying for housing, and help paying for utilities or bills.
1 YES
2 NO (SKIP TO Q.27)
8 DON’T KNOW (SKIP TO Q.27)
7 REFUSED (SKIP TO Q.27)
26. What services did you receive from [SHM SERVICE PROVIDER]?
(INTERVIEWER: CHECK ALL THAT APPLY)
1 HELP GETTING A JOB OR JOB TRAINING
2 ADULT EDUCATION OR GED CLASSES
3 MENTAL HEALTH SERVICES
4 DRUG OR ALCOHOL ABUSE TREATMENT
5 HELP FINDING OR PAYING FOR CHILD CARE
6 HELP FINDING OR PAYING FOR HOUSING
7 HELP PAYING FOR UTILITIES OR BILLS
98 DON’T KNOW
97 REFUSED
27. We would like to update your contact information in our records so that we can contact you for future surveys.
27a. Are you still living at [ADDRESS]?
1 YES (SKIP TO Q.27c)
2 NO
8 DON’T KNOW (SKIP TO Q.27c)
7 REFUSED (SKIP TO Q.27c)
27b. What is your address?
STREET:
CITY, STATE, ZIP:
27c. Is the best phone number to reach you still [PHONE NUMBER]?
1 YES (SKIP TO CLOSING)
2 NO
8 DON’T KNOW (SKIP TO CLOSING)
7 REFUSED (SKIP TO CLOSING)
27d. What is the best phone number to reach you?
PHONE NUMBER:
CLOSING
These are all the questions I have. We will mail your $10 gift in the next week in appreciation for your time. If you have any questions about this study, please call [NAME] at [PHONE NUMBER].
Thank you.
| File Type | application/msword |
| Author | USER |
| Last Modified By | USER |
| File Modified | 2007-08-29 |
| File Created | 2007-08-29 |
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