Parent Follow-up Questionnaire

Program ID#__________ Classroom ID#__________ Child ID#___________

Do not write in box. For study use only.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number.  The valid OMB control number for this information collection is xxxx-xxxx.  The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:  U.S. Department of Education, Washington, D.C. 20202-465.  If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Rafael Valdivieso, U.S. Department of Education, 555 New Jersey Avenue, NW, Room 506E, Washington, D.C. 20208.

Responses to this data collection will be used only for statistical purposes. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific program or individual. We will not provide information that identifies you or your program to anyone outside the study team, except as required by law.

Your cooperation in completing this survey is needed to make the results of this study comprehensive, reliable, and timely.

PARENT/Guardian FoLLOW-UP QUESTIONNAIRE

DATE: Month__ __ Day__ __ Year __ __ __ __

Information about your child:

1. Child’s Name: First _______________________ Last ____________________________

2. Does this child still attend the child care program he/she was attending about a year ago when we first contacted you about this study?

• Yes →Go to question 3

• No →Go to question 5

3. What is the name of that child care program or child care provider? ____________________

4. Currently, in a typical week, how many hours does this child attend this child care program?_____hours

5. How many different regular child care arrangements do you currently have for this child? Please include all child care arrangements you have for this child on a regular basis from someone other than his/her parents. This includes regular care and early childhood programs but not occasional babysitting.

• One

• Two

• Three

• Four or more

• None, child does not currently attend child care →Go to question 9

For the next few questions please tell us about the child care program this child attends most often.

6. In a typical week, how many hours does the child attend this program? _____ hours

7. How many days each week does the child attend this program? ______ days

8. What type of child care program is this?

• Child care provided in a private home

• A child care center (e.g., a preschool, day care center, nursery school etc.)

• Other (please specify) ________________________

Information about you and the child’s family/household:

9. Your name__________________________________________

10. What is your relationship to the child? Are you the child’s . . . Mark one response.

• Biological mother

• Biological father

• Step-mother

• Step-father

• Adoptive mother

• Adoptive father

• Foster mother

• Foster father

• Grandmother

• Grandfather

• Aunt

• Uncle

• Cousin

• Sibling (Brother/Sister)

• Other Relative

Specify______________________

• Other Non-relative

Specify______________________

11. Your contact information:

Home phone: _ _ _- _ _ _- _ _ _ _

Work phone: _ _ _- _ _ _- _ _ _ _ ext. ________

Mobile phone: _ _ _- _ _ _- _ _ _ _

Address: ______________________________________________

City: ___________________________

State: _______

Zip: _____________

E-mail address: _________________________________

12. Relative or friend who can be contacted if we cannot reach you:

Name_____________________________________

Relationship to child____________________________

Home phone: _ _ _- _ _ _- _ _ _ _

Mobile phone: _ _ _- _ _ _- _ _ _ _

E-mail address: _________________________________

NOTE: For the following questions we are interested in learning more about people who live with the child in the same household. Please consider this when answering the remaining questions.

13. The child lives with the . . . Mark one response.

 Mother only (e.g., biological, step, adoptive, or foster)

 Father only (e.g., biological, step, adoptive, or foster)

 Mother and father

 Neither parent, child lives with a single guardian (e.g., Aunt, Grandmother)

Specify guardian’s relationship to child__________________

• Neither parent, child lives with a guardian and guardian’s spouse/partner or two guardians (e.g., Grandmother and Grandfather)

Specify both guardians’ relationship to child ______________

__________________________________________________

 Other

Specify ___________________

14. How many siblings (brothers/sisters) live with the child in the same household? ________

Enter 0 (zero) above if the child does not have siblings or does not live in the same household with his/her siblings and skip to question 16.

15. Child’s siblings

	(If different from child listed at the top of this form)	Date of Birth
First Name	Last Name	Month	Day	Year
1.
2.
3.
4.
5.
6.
7.
8.

16. What is your age? ______years

17. Are you employed and/or in school? Mark one response.

 Employed

• In school

• Both employed and in school

• Neither

18. If you are employed, how many hours do you work in a typical week?

___________ Hours per week

 Not Applicable (not employed)

19. If you are in school, how many hours do you attend classes in a typical week?

___________ Hours per week

 Not Applicable (not in school)

20. What is your highest level of education? Mark one response.

• Less than high school diploma/ no GED

• A high school diploma or GED

• Some college, but no degree

• An associate’s of arts (A.A.) degree

• A bachelor’s degree (B.A. or B.S.)

• Graduate or professional school but no degree

• Master’s degree (M.A. or M.S. etc)

• Doctorate degree (PhD or EDD)

• Professional degree after bachelor’s degree (MD, DDS, JD, etc.)

21. What is the language most often spoken in the child’s home? Mark one response.

• English

• Spanish

• Other

Specify______________

NOTE: The following questions are about the child’s other parent/guardian in the household. If the child lives with you and there is no other parent/guardian in the household, skip to the end of the questionnaire.

22. What is the child’s other parent/guardian’s age? ________years

23. Is the child’s other parent/guardian employed and/or in school? Mark one response.

 Employed

• In school

• Both employed and in school

• Neither

24. If the child’s other parent/guardian is employed, how many hours does he/she work in a typical week?

___________ Hours per week

 Not Applicable (not employed)

25. If the child’s other parent/guardian is in school, how many hours does he/she attend classes in a typical week?

___________ Hours per week

 Not Applicable (not in school)

26. What is the child’s other parent/guardian’s highest level of education? Mark one response.

• Less than high school diploma/ no GED

• A high school diploma or GED

• Some college, but no degree

• An associate’s of arts (A.A.) degree

• A bachelor’s degree (B.A. or B.S.)

• Graduate or professional school but no degree

• Master’s degree (M.A. or M.S. etc)

• Doctorate degree (PhD or EDD)

• Professional degree after bachelor’s degree (MD, DDS, JD, etc.)

27. Different children have different personalities and different qualities. Please read the statements below and circle a number to show how often your child acts this way.

MOST ALL

OF THE OF THE

NEVER RARELY SOMETIMES TIME TIME

My child...

1. Is cheerful, happy. 1 2 3 4 5

2. Waits his or her turn during activities. 1 2 3 4 5

3. Is warm, loving. 1 2 3 4 5

4. Fights with others. 1 2 3 4 5

5. Is curious and exploring, likes new experiences. 1 2 3 4 5

6. Thinks before he or she acts, is not impulsive. 1 2 3 4 5

7. Talks back to adults when corrected. 1 2 3 4 5

8. Gets along well with other kids. 1 2 3 4 5

9. Usually does what I tell (him/her) to do. 1 2 3 4 5

10. Can get over being upset quickly. 1 2 3 4 5

11. Threatens or bullies others. 1 2 3 4 5

12. Is admired and well liked by other kids. 1 2 3 4 5

13. Argues with others. 1 2 3 4 5

14. Does things for (him/her)self, is self-reliant. 1 2 3 4 5

15. Shows concern for other people's feelings. 1 2 3 4 5

16. Can easily find something to do on (his/her) own. 1 2 3 4 5

17. Shows pride when (he/she) does something well or learns something new. 1 2 3 4 5

18. Has low self-esteem. 1 2 3 4 5

19. Is easily calmed when (he/she) gets angry. 1 2 3 4 5

20. Is able to concentrate or focus on an activity. 1 2 3 4 5

MOST ALL

OF THE OF THE

NEVER RARELY SOMETIMES TIME TIME

21. Appears lonely. 1 2 3 4 5

22. Is helpful and cooperative. 1 2 3 4 5

23. Has temper tantrums. 1 2 3 4 5

24. Is considerate and thoughtful of other kids. 1 2 3 4 5

25. Tends to give, lend, and share. 1 2 3 4 5

26. Is easily embarrassed. 1 2 3 4 5

27. Is obedient, follows rules. 1 2 3 4 5

28. Is calm, easy-going. 1 2 3 4 5

29. Shows anxiety about being with a group of kids. 1 2 3 4 5

30. Sticks with an activity until it is finished. 1 2 3 4 5

31. Gets angry easily. 1 2 3 4 5

32. Is eager to please. 1 2 3 4 5

33. Is patient when (he/she) wants something. 1 2 3 4 5

34. Sticks up for (him/her) self, is self-assertive. 1 2 3 4 5

35. Acts sad or depressed. 1 2 3 4 5

36. Is independent, does things (him/her)self. 1 2 3 4 5

If your child is 16 months or younger please complete the checklist in question 28.

If your child is older than 17 months or older please skip the checklist in question 28 and complete the checklist in question 29.

28. If your child is 16 months or younger complete the following:

29. If your child is 17 months or older please complete the following:

30. In a typical week, how often do you or any other family member do the following things with your child? Would you say not at all, once or twice, 3 to 6 times, or everyday? Please read the statements below and circle a number to show how often you or any other family member does the following things with your child.

	Not at all	Once or twice	3 to 6 times	Everyday
a. Read books to your child?	1	2	3	4
b. Tell stories to your child?	1	2	3	4
c. Sing songs with your child?	1	2	3	4
d. Take your child along while doing errands like going to the post office, the bank, or the store?	1	2	3	4

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