Tracking Survey

ID NUMBER LABEL

OMB# 0970-0388

Expires: 10/1/2015

Early Head Start Follow-up Study

2013 Tracking Survey

• Thank you for taking the time to update your contact information for the Early Head Start Follow-up Study.

• Please remember that all the information you provide will be shared ONLY with researchers working on the Early Head Start Follow-up Study and kept private to the extent permitted by law.

• If you are contacted in the future for the study, you can decide at that time whether or not to take part.

• When you are finished completing this form, please use the postage paid return envelope provided to mail it to us.

• When we receive your completed survey, we will send you a check for $10 as a thank you.

• If you have any questions, please call us on the study toll-free number at:

(888) 800-3748.

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This collection of information is voluntary and will be used to maintain up-to-date contact information on the participants of the Early Head Start Research and Evaluation Project. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB number for this information collection is 0970-0388 (Exp. 10/1/15). Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Amy Madigan; ACF / OPRE, 370 L’Enfant Promenade SW, 7th floor West, Washington, DC 20447; Attn: OMB-PRA (0970-0388).

hank you!

1. Please take a look at the names printed on the letter that came with this form. Is your name correct?

 Yes

 No  What is your correct name?

First

Middle

Last

2. Is the child’s name correct?

 Yes

 No  What is the child’s correct name?

First

Middle

Last

3. Are you still this child’s primary caregiver?

 Yes  PLEASE CONTINUE TO THE NEXT QUESTION (#4)

 No  PLEASE SKIP TO SECTION 2 (PAGE 5)

4. What is your current home address?

Street		Apt. Number
City	State	Zip Code

5. Do you receive mail at this address?

 Yes

 No  Where do you receive mail?

Street		Apt. Number
City	State	Zip Code

6. What is the best phone number to use to reach you?

( _______ ) ________ --- ______________

 Cell  Home  Work  Other: _____________

7. What other phone numbers can we use to reach you?

( _______ ) ________ --- ______________	 Cell  Home  Work  Other: _____________
( _______ ) ________ --- ______________	 Cell  Home  Work  Other: _____________
( _______ ) ________ --- ______________	 Cell  Home  Work  Other: _____________

8. What is your email address?  Mark this box if you do not have email.

_____________________________ @ _________________________

9. If you work outside the home, where do you work?

 Mark this box if you do not work outside the home.

Company Name
Street
City	State	Zip Code
Phone Number ( __________ ) ___________ --- __________________ Extension: ___________

10. Do you have any plans to move in the next year?

 Yes

 No  PLEASE SKIP TO QUESTION #11

10a. If you expect to move, when do you expect to move?

^{Approximate Date of Move (Month and Year)}

10b. If you expect to move, where do you expect to move?

City

State

Country

11. In case we are unable to reach you in the future, please give us the names and contact information of three close relatives or friends who are likely to know how to contact you. We will only contact these people if we are unable to contact you directly.

1^st Contact:

First Name		Middle Initial	Last Name
Gender  Male  Female	Preferred Language  English  Spanish  Other: _____________	Relationship to You  Your parent  Your sister/brother  A friend  A former spouse  A current spouse  Someone else: _________________
Street Address					Apt. Number
City				State	Zip Code
Best Phone Number				 Cell  Home  Work  Other: ___________
( __________ ) ___________ --- ___________________
Alternate Phone Number				 Cell  Home  Work  Other: ___________
( __________ ) ___________ --- ___________________
Email _____________________________ @ _________________________

2^nd Contact:

First Name		Middle Initial	Last Name
Gender  Male  Female	Preferred Language  English  Spanish  Other: _____________	Relationship to You  Your parent  Your sister/brother  A friend  A former spouse  A current spouse  Someone else: _________________
Street Address					Apt. Number
City				State	Zip Code
Best Phone Number				 Cell  Home  Work  Other: ___________
( __________ ) ___________ --- ___________________
Alternate Phone Number				 Cell  Home  Work  Other: ___________
( __________ ) ___________ --- ___________________
Email _____________________________ @ _________________________

3^rd Contact:

First Name		Middle Initial	Last Name
Gender  Male  Female	Preferred Language  English  Spanish  Other: _____________	Relationship to You  Your parent  Your sister/brother  A friend  A former spouse  A current spouse  Someone else: _________________
Street Address					Apt. Number
City				State	Zip Code
Best Phone Number				 Cell  Home  Work  Other: ___________
( __________ ) ___________ --- ___________________
Alternate Phone Number				 Cell  Home  Work  Other: ___________
( __________ ) ___________ --- ___________________
Email _____________________________ @ _________________________

After your child turns 18, we would like to follow up with him or her directly. If your child is contacted in the future for the study, they can decide at that time whether or not to take part.

12. What is your child’s email address?  Mark this box if they do not have email.

_____________________________ @ _________________________

13. What is your child’s cell phone number?  No Cell Phone

Cell Phone Number

( __________ ) ___________ --- ___________________

14. Please list any other ways to reach your child directly?

________________________________________________________________________________________________________________________________________________________________________________________________________________________

15. Thinking ahead to when your child is 18, where do you think your child will be living?

 With you

 With another family member

 On his/her own or with roommates

 In a college dorm

 In the military

 Somewhere else: _______________________________________________________

Now we’d like to ask you a few questions about how your child is doing.

16. Will (or did) your child graduate high school or get a GED before Fall 2013?

 Yes, Graduated high school

 Yes, GED

 No  PLEASE SKIP TO QUESTION #18

17. If Yes, will (or does) your child go to college?

 Yes

 No

18. What school will your child attend in Fall 2013?

 Mark this box if the child will not be in school.

School Name

City

19. What grade will your child be in Fall 2013? (For college/vocational school grade=13)

^Grade:

20. What do you think are the chances your child will graduate from college?

 No chance

 Some chance

 About 50/50

 Pretty likely

 It will happen

21. What do you think are the chances your child will have a good job by age 30?

 No chance

 Some chance

 About 50/50

 Pretty likely

 It will happen

22. Has your child ever had any contact with the juvenile justice system? This would include:

• being picked up by the police for breaking the law

• being found guilty for a crime or a delinquent offense

• being on probation or court supervision

• being held at juvenile hall or in jail

 Yes

 No

 Don’t Know

23. Overall, would you describe your child’s health as…

 Excellent

 Very good

 Good

 Fair

 Poor?

Now a few questions about you.

24. What is the highest grade or year of school that you have completed?

 Less than high school

 High school or GED

 Vocational school or 2 year Associate’s Degree

 College or graduate school

25. Which of the following best describes your present work or school situation?

 Working full-time (35 hours a week or more)

 Working part-time (less than 35 hours per week)

 Unemployed and looking for work

 Unemployed and not looking for work

 Full-time homemaker

 In school

 Too disabled to work

 Some other situation (specify): ___________________________________________

26. These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.

How much of the time during the past 4 weeks...

1. Have you felt calm and peaceful?

 All of the time

 Most of the time

 A good bit of the time

 Some of the time

 A little of the time

 None of the time

2. Did you have a lot of energy?

 All of the time

 Most of the time

 A good bit of the time

 Some of the time

 A little of the time

 None of the time

3. Have you felt downhearted and blue?

 All of the time

 Most of the time

 A good bit of the time

 Some of the time

 A little of the time

 None of the time

Thank you for the updated information. Please use the postage paid return envelope provided to mail this form to us. When we receive it, we will send you a check for $10. You should receive it in two to three weeks.

Thank you for taking part in the Early Head Start Follow-up Study!

1. Who is this child’s primary caregiver now? (What is his/her name)?

 Mark this box if you do not know.

First

Middle

Last

2. What is this person’s relationship to the child?

^{Relationship to Child}

 Parent  Non-relative foster parent

 Grandparent  Other non-relative

 Other relative  Someone else: ___________________________

3. About when did this person become the child’s primary caregiver?

^{Approximate Date (Month and Year)}

4. What is the best phone number to reach this person?

( ________ ) ________ --- _________________

 Cell  Home  Work  Other: _________

5. Do you have any other phone numbers for this person?

( ________ ) ________ --- _________________	 Cell  Home  Work  Other: _________
( ________ ) ________ --- _________________	 Cell  Home  Work  Other: _________
( ________ ) ________ --- _________________	 Cell  Home  Work  Other: _________

6. What is this person’s email address?  Mark this box if you do not have email.

__________________________ @ _______________________

7. What is the child’s current home address?

Street		Apt. Number
City	State	Zip Code

8. What is the child’s permanent home address?  Same as current home address

Street		Apt. Number
City	State	Zip Code

END OF SURVEY

Thank you very much for your help.

If you are in contact with the child’s new primary caregiver, we’d appreciate it if you could give him/her our toll-free number: 1-888-800-3748 and let them know we are trying to reach them about the study.

Please use the postage paid return envelope provided to mail this form to us. When we receive it, we will send you a check for $10. You should receive it in two to three weeks.

Thank you for taking part in the Early Head Start Follow-up Study!

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