Form 1 Survey Form

---

Overview

Read this first
1A&B-your program. Submit once.
Section 2 - about each child
Section 3 - responses of child
Data capture for Section 1A & B
Data capture for Sections 2 & 3

---

Sheet 1: Read this first

MENTORING CHILDREN OF PRISONERS PROGRAM (MCP) RELATIONSHIP QUALITY SURVEY		OMB NO.: 0970-0308
		EXPIRATION DATE: 08/31/2009
This series of spreadsheets is for MCP grantees who are administering the Mentoring Children of Prisoners (MCP) Relationship Quality Survey away from access to OLDC, using a laptop or PC, each spreadsheet per child. We recommend you save each spreadsheet for each child when it is completed under the following style: Even when using this spreadsheet method, the survey should be conducted with the child by phone. Do not mail these spreadsheets to FYSB. When you have finished conducting surveys and recording data, to enter data efficiently into OLDC from a series of these surveys, contact tech support at 1-866-577-0771 for assistance.
It is important to remember that this spreadsheet does not include validation tests or other security protections, unlike OLDC, so enter your data carefully. The spreadsheet, except for data entry cells, is "protected" to provide a degree of "insurance." You can edit or change any entries any time before submitting.
Parts A and B should be filled out only one time, to describe your program.
Sections 2 and 3 are for each unique child. You should save these sections for each child separately under a filename that protects the child's identify but which distinquishes both your program and each child surveyed, e.g., BBBSMD - 1, BBBSMD - 2, etc. (A mentor ID can be BBBSMD - 1M.) Saving each interview will also save the Section 1A and B worksheets, but that is not a problem. Be sure the data you enter in 1A and 1B about your program is the same in each copy, or be sure that only the correct version of Section 1 is transmitted to ACF when you are ready. The "Mentor / Child Log Number" that you will create in Section 2, as well as the Mentor and Child ID numbers, also to be created in Section 2, will automatically appear in Section 3.
There are specific instructions for each section under the tabs below.
Basically, you will enter data in cells highlighted in green, like the one at the right. You will not have access to any other part of the spreadsheets, to protect the format. However, you can make changes at any time in a given cell. Be sure to save all changes that you wish to keep. Each data sheet will have a cell or cells in which to record the name of your organization, so we may distinquish your records from others.
How This Report Will Be Used
The information will be used for reporting to the US Congress in the Annual Performance Report in the President’s Budget and to the Office of Management and Budget (OMB) in the Executive Office of the President. It will also be used in research by US DHHS and in responding to questions from other researchers. Providing such information in a survey approved by OMB is a requirement in the terms and conditions of your MCP grant.

---

Sheet 2: 1A&B-your program. Submit once.

MENTORING CHILDREN OF PRISONERS PROGRAM (MCP) RELATIONSHIP QUALITY SURVEY
Section 1 Program Questions
(Fill out Section 1 only once. Sections 2 and 3 are filled out for each child)
The Family and Youth Services Bureau (US DHHS) needs your cooperation in providing the following vital information about your program, the children of prisoners it serves, and the characteristics of their relationships with their mentors.	Enter your answers in the highlighted cells below	(comments can be entered in this column)
1 A. Questions About Your Program
Please be sure you have answered these questions about your organization before you return the results from the interviews with each child.
1. Organizational name of mentoring program:
Street:
City:
State:
Zip:
2. Is your organization partnered with some other national or regional mentoring resource? (YES/NO)		List Partners below.
3. The date when your organization first started a mentoring program: (This may be before you achieved your first mentoring match.) (MM/D/YYYY)
4. The date when your organization first started a mentoring program specifically targeting children of prisoners (MM/DD/YYYY):
5. How does your program monitor existing relationships? (check all that apply)
a. Staff query mentors about meetings with mentees on a regular basis:
b. Mentors report their meetings with mentees to staff in phoned reports:
c. Written reports by mentors are: Monthly:
Bi monthly:
Quarterly
Other schedule (describe):
6. My organization is (check all that apply):
a. Primarily a faith-based organization:
b. A community based organization:
c. Partnering with one faith-based organization:
d. Partnering with more than one organization of the same faith denomination:
e. Partnering with more than one organization of multiple faith denominations:
f. A public (non educational) organization (State or local):
g. An educational institution:
h. An affiliate of Big Brothers Big Sisters
i. My organization utilize the Amachi model
j. Other (describe):
1 B. Longevity of Matched Relationships
These questions focus on a particular point in time (July 1, 2006) and somewhat differ from similar questions in the Quarterly AFC Online Data Collection system (OLDC). These questions refer only to youth in your active caseload who are ages nine or above.
7. How many youth ages nine or above are currently in active matches (same youth and adult) in your caseload as of July 1?
8. How many youth ages nine or above experienced a termination of relationship (regardless of who initiated it or how long it had lasted) in the thirty days prior to July 1?
9. How many cases of youth ages nine or above terminated before the relationship had lasted 3 full months.
10. How many cases involving youth ages nine or above in your current active caseload (as of July 1) have been active (same youth and adult) from nine months through eleven months?
11. How many cases involving youth ages nine or above in your current active caseload (as of July 1) have been active (same youth and adult) for a full twelve months?
12. How many cases involving youth ages nine or above in your current active caseload (as of July 1) have been active (same youth and adult) more than twelve mo
13. How many cases involving youth ages nine or above in your current active caseload (as of July 1) have been active (same youth and adult) more than 18 months?
Comments

---

Sheet 3: Section 2 - about each child

MENTORING CHILDREN OF PRISONERS PROGRAM (MCP) RELATIONSHIP QUALITY SURVEY		Organizational name of mentoring program:
Section 2 & 3 Child - Mentor Relationships
(Fill out Sections 2 & 3, once for each child.)
2. Questions About This Child
This survey is for children age 9 and above as of July 1, 2006, who have been in a relationship that has lasted nine or more months with the same mentor. An automatically generated code will identify each child in the survey, in such a way as to keep records organized but protect their privacy. Agencies should maintain a secure record of the identifiers in this survey for each child, but only the code will be reported to ACF. Results in reference to specific children should only be shared on a need to know basis strictly according to agency policy, for example, when counseling mentors or compiling evaluation information.
Confidentiality: Sections 2 and 3 are for each unique child. The online system will automatically generate a code for this child and the mentor but not this spreadsheet version. You must create your own log number (see #1 below) and should save these sections for each child separately under a filename that protects the child's identify but which distinquishes both your program and each child surveyed, e.g., BBBSMD - 1, BBBSMD - 2, etc. ACF will not know the identities of the child or mentor. You may provide your own code as long as it protects their identities. It is recommended that you print a copy of this form and the interview and keep it safely in the child’s file for agency use only. You may wish to add the real names of the child and mentor to the paper copy. It is your responsibility to maintain the security of your records.	Enter data in boxes in this column as indicated below (yes/no, dates, numbers, or X to select from an option)
1. Date of the interview: (MM/DD/YYYY)
2. Mentor / Child Log Number (Please create your own unique ID for this match. It will also appear on the interview sheet.):
a. Mentor ID Number (This number will also appear on the interview sheet):
b. Child ID Number (This number will also appear on the interview sheet):
3. How was this interview conducted? (check one):
a. Over the telephone (If at all possible, the interview should be by phone. See instructions at the beginning of Section 3.)
b. In-person, paper-and-pencil or on-line form completed by program staff member
4. Age of child: (6 years, 6 months = 6.5, 10 years, 2 months = 10.17
5a. Race of child (enter X for one or more):
- American Indian or Alaska Native
- Asian
- Black, or African American
- Native Hawaiian or Other Pacific Islander
- White
5b. Ethnicity of Child (enter X for one):
- Not Hispanic or Latino
- Hispanic or Latino
- Not Provided
6. Gender of child (M/F):
7. Age of mentor (age in years is sufficient):
8a. Race of mentor (enter X for one or more):
- American Indian or Alaska Native
- Asian
- Black, or African American
- Native Hawaiian or Other Pacific Islander
- White
8b. Ethnicity of Mentor (enter X for one):
- Not Hispanic or Latino
- Hispanic or Latino
- Not Provided
9. Gender of mentor (M/F):
10. Date this relationship began, when mentor and mentee first met "officially" as a mentoring pair (MM/DD/YYYY):
11. How many times has the child met with the mentor in person over the past thirty days?
sixty days?
ninety days?
12. Name of interviewer:
Position of interviewer:
Phone number of interviewer:

---

Sheet 4: Section 3 - responses of child

MENTORING CHILDREN OF PRISONERS PROGRAM (MCP) RELATIONSHIP QUALITY SURVEY		Organizational name of mentoring program:
3. Questions For This Child		0
You should conduct the interview over the telephone. Only if it is not possible to survey the youth on the telephone, please survey the youth in person. Even if youth are old enough to read the questions, interviewers should read the questions aloud to the youth and interviewers should complete the form. (This ensures that all youth, even those who cannot read, will comprehend the questions and provide reliable data. A Spanish language version is available from tech support at app_support@acf.hhs.gov) Please explain the purpose of the interview to the parent/guardian: to learn how the child feels about their mentoring relationship and study the program's effectiveness so as to improve it in the future. You can share with them the statements that the child will respond to. Inform them that the results will be confidential and not shared with the mentor.	Enter your answers in the highlighted cells below
Please ask each child age 9 and above as of July 1, 2006, (in mentoring relationships that have lasted nine or more months as of that date) the questions in the survey below over the telephone. Earlier tests of this instrument indicate that it works very well (and is simpler to administer) when conducted this way. The mixture of negative and positively-framed questions is known to improve accuracy and is the result of careful testing by the developers in a variety of mentoring programs.
Answers can be entered by staff directly into the OLDC online form or in the boxes at the right. The mentor should not be informed of the child's responses and this assurance should be provided to the parent and the child.
Parental permission was received to interview this child according the agencies policies governing parental notification or permission. If the answer is No and parental permission is not given, after explaining the nature and value of the survey or sharing the questions, then conclude the interview without proceeding further. A response of No will allow the system to save the data entered up to this point.
Yes
No
Case Management : (Case management by the agency and follow-up training for individual mentors to improve relationship quality based on results from these interviews should not single out results in ways that identify individual children or mentors. The agency can ensure mentor/child privacy during mentor training by discussing results in terms of the combined responses of the entire group rather than for individual cases.) Children and parents should be reassured about privacy and that it’s not a test for them or a report card on their mentor.
Parents/guardians should be strongly encouraged to allow their child privacy (since the test results may lose accuracy if the parent is listening in and the child may censor their answers), but ultimately it's their decision. If a parent insists on listening to the interview, please indicate in the following box:
Parent did not listen.
Parent listened.
Tell the child:
For each of the following sentences, decide how true the sentence is for your feelings about your mentor. Then tell me the number that fits best with each statement. If you think the statement is not at all true, say '1' or "not at all true;" if you think it is not very true, say '2' or "not very true;" if the statement is sort of true, say '3' or "sort of true;" or if you think it is very true, say '4' or "very true." Your answers will not be shared with your mentor and will be kept private. This is not a "report card" on your mentor. It will help us make a better program for you.
Mentor / Child Log Number (the ID created in Section 2 will appear here):	0
a. Mentor ID Number (the ID created in Section 2 will appear here):	0
b. Child ID Number (the ID created in Section 2 will appear here):	0
Interviewer: Please enter a code 1, 2, 3 or 4 based on the child's response to each question, according to the following scheme:
1 = Not At All True 2 = Not Very True 3 = Sort of True 4 = Very True
1. My mentor has lots of good ideas about how to solve a problem.
2. My mentor makes fun of me in ways I don't like.
3. My mentor helps me take my mind off things by doing something with me.
4. When I'm with my mentor, I feel ignored.
5. Sometimes my mentor promises we will do something, then we don't do it.
6. My mentor is always interested in what I want to do.
7. I wish my mentor was different.
8. When I'm with my mentor, I feel mad.
9. My mentor and I like to do a lot of the same things.
10. When my mentor gives me advice, it makes me feel kind of stupid.
11. I wish my mentor knew me better.
12. I wish my mentor spent more time with me.
13. When I'm with my mentor, I feel important.
14. I wish my mentor asked me more about what I think.
15. I feel I can't trust my mentor with secrets because my mentor would tell my parent/guardian.
16. When I'm with my mentor, I feel happy.
17. When I'm with my mentor, I feel disappointed.
18. My mentor shows up when he/she is supposed to.
19. When I'm with my mentor, I feel bored.
20. When something is bugging me, my mentor listens while I talk about it.

---

Sheet 5: Data capture for Section 1A & B

0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	12/30/1899	12/30/1899	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
1 a. Organizational name of mentoring program:	1 b. Street:	1 c. City:	1 d. State:	1 e. Zip:	2. Is your organization partnered with some other national or regional mentoring resource? (YES/NO)	List Partners									3. The date when your organization first started a mentoring program: (This may be before you achieved your first mentoring match.)	4. The date when your organization first started a mentoring program specifically targeting children of prisoners:	5 a. Staff query mentors about meetings with mentees on a regular basis:	5 b. Mentors report their meetings with mentees to staff in phoned reports:	5 c. Written reports by mentors are: Monthly:	Bi monthly:	Quarterly	Other schedule (describe):	6 a. Primarily a faith-based organization:	6 b. A community based organization:	6 c. Partnering with one faith-based organization:	6 d. Partnering with more than one organization of the same faith denomination:	6 e. Partnering with more than one organization of multiple faith denominations:	6 f. A public (non educational) organization (State or local):	6 g. An educational institution:	6 h. An affiliate of Big Brothers Big Sisters	6 i. My organization utilize the Amachi model	6 j. Other (describe):	7. How many youth ages nine or above are currently in active matches (same youth and adult) in your caseload as of July 1?	8. How many youth ages nine or above experienced a termination of relationship (regardless of who initiated it or how long it had lasted) in the thirty days prior to July 1?	9. How many cases of youth ages nine or above terminated before the relationship had lasted 3 full months.	10. How many cases involving youth ages nine or above in your current active caseload (as of July 1) have been active (same youth and adult) from nine months through eleven months?	11. How many cases involving youth ages nine or above in your current active caseload (as of July 1) have been active (same youth and adult) for a full twelve months?	12. How many cases involving youth ages nine or above in your current active caseload (as of July 1) have been active (same youth and adult) more than twelve mo	13. How many cases involving youth ages nine or above in your current active caseload (as of July 1) have been active (same youth and adult) more than 18 months?	Comments
1 A. Questions About Your Program																	5. How does your program monitor existing relationships? (check all that apply)						6. My organization is (check all that apply):										1 B. Longevity of Matched Relationships

---

Sheet 6: Data capture for Sections 2 & 3

12/30/99	12/30/1899	0	0	0	0	0.00	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	12/30/99	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
0
1. Date of the interview:	2. Mentor / Child Log Number:	a. Mentor ID Number:	b. Child ID Number:	a. Over the telephone (If at all possible, the interview should be by phone. See instructions at the beginning of Section 3.)	b. In-person, paper-and-pencil or on-line form completed by program staff member	4. Age of child:	- American Indian or Alaska Native	- Asian	- Black, or African American	- Native Hawaiian or Other Pacific Islander							- American Indian or Alaska Native	- Asian	- Black, or African American	- Native Hawaiian or Other Pacific Islander	- White	- Not Hispanic or Latino	- Hispanic or Latino	- Not Provided	9. Gender of mentor:	10. Date this relationship began, when mentor and mentee first met "officially" as a mentoring pair:	11. How many times has the child met with the mentor in person over the past thirty days?	sixty days?	ninety days?	12. Name of interviewer:	Position of interviewer:	Phone number of interviewer:	Yes	No	Parent did not listen.	Parent listened.	Mentor / Child Log Number:	a. Mentor ID Number:	b. Child ID Number:	1. My mentor has lots of good ideas about how to solve a problem.	2. My mentor makes fun of me in ways I don't like.	3. My mentor helps me take my mind off things by doing something with me.	4. When I'm with my mentor, I feel ignored.	5. Sometimes my mentor promises we will do something, then we don't do it.	6. My mentor is always interested in what I want to do.	7. I wish my mentor was different.	8. When I'm with my mentor, I feel mad.	9. My mentor and I like to do a lot of the same things.	10. When my mentor gives me advice, it makes me feel kind of stupid.	11. I wish my mentor knew me better.	12. I wish my mentor spent more time with me.	13. When I'm with my mentor, I feel important.	14. I wish my mentor asked me more about what I think.	15. I feel I can't trust my mentor with secrets because my mentor would tell my parent/guardian.	16. When I'm with my mentor, I feel happy.	17. When I'm with my mentor, I feel disappointed.	18. My mentor shows up when he/she is supposed to.	19. When I'm with my mentor, I feel bored.	20. When something is bugging me, my mentor listens while I talk about it.
	2. Questions About This Child			3. How was this interview conducted? (check one):			5a. Race of child (check one or more):					5b. Ethnicity of Child (check one):					8a. Race of mentor (check one or more):					8b. Ethnicity of Mentor (check one):											3. Questions For This Child Permission		Parent listened/did not listen				3. Questions For This Child	1 = Not At All True; 2 = Not Very True; 3 = Sort of True; 4 = Very True