NEW - Instrument #20: HM Follow-up survey - Study Participants

OMB No.: 0970-0403

Expiration Date: xx/xx/20xx

PACT

Healthy Marriage

Follow-up Survey

October 14, 2013

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0970-0403. The time required to complete this information collection is estimated to average 45 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

CONTENTS

Section Page

i. introduction ii

A. CONTACT INFORMATION 1 1

B. family structure 2

C. PARENTING 8

D. relationSHIP quality 11

E. ECONOMIC STABILITY 19

F. MENTAL HEALTH 24

G. Service receipt 25

H. CONTACT INFORMATION 2 29

all

i1. May I please speak with [SAMPLE MEMBER]? My name is [NAME] and I’m calling from Mathematica Policy Research, a research company in Princeton, New Jersey.

SAMPLE MEMBER AVAILABLE 1 GO TO i3

SAMPLE MEMBER COMES TO PHONE 2 GO TO i3

SAMPLE MEMBER NOT AVAILABLE 3 GO TO i2

SAMPLE MEMBER DECEASED 0 GO TO END2

i1=2

i2. When would be a good time to reach [SAMPLE MEMBER]?

INSTRUCTION: RECORD DATE AND TIME FOR CALL BACK.

INSTRUCTION: MAKE AN APPOINTMENT USING THE PARALLEL BLOCK.

INSTRUCTION: USE THE ‘APPOINTMENT’ TAB OR PRESS <CTRL-S> TO INVOKE THE APPOINTMENT MAKING DIALOG.

(STRING 20)

i1=1

Fill [PACT PARTNER] from [BASELINE A9 or A9a]

i3. (Hello, my name is [NAME] and I’m calling from Mathematica Policy Research, a research company in Princeton, New Jersey.) I’m calling you about the PACT study you joined when you applied to the [GRANTEE PROGRAM] about a year ago with [PACT PARTNER]. You may have received a letter recently to let you know that we would be calling you for a follow-up interview for our study. I’d like to interview you today.

The interview will take about 45 minutes and you will receive $25 for completing the interview. Your participation in the survey is voluntary. You do not have to answer any questions that make you uncomfortable.

To help us protect your privacy, we have obtained a Certificate of Confidentiality from the National Institutes of Health. With this Certificate, the researchers cannot be forced to disclose information that may identify you, even by a court subpoena, in any federal, state, local, civil, criminal, legislative, administrative, or other proceedings. The researchers will use the Certificate to resist any demands for information that would identify you, with one exception. The Certificate of Confidentiality does not prevent the researchers from disclosing information that would identify you as a participant in the research project if you tell the interviewers anything that suggests you are very likely to harm yourself, that you are planning to hurt another person or child, or that someone is likely to harm you.

You should understand that a Certificate of Confidentiality does not prevent you, or a member of your family, from voluntarily releasing information about yourself or your involvement in this research.

You may or may not benefit from participating in this study.

Because we want to get your opinion, it is important that you answer the questions without help from anyone else. Of course, you can share what you said with others after we have completed the interview.

This interview may be recorded so my supervisor can monitor the interview and make sure that the questions are asked correctly. These recordings will be destroyed when the study is completed.

Is now a good time to start?

YES 1 GO TO i5

NO 0

i3=0

i4. When would be a good time to do the interview?

INSTRUCTION: RECORD DATE AND TIME FOR CALL BACK.

INSTRUCTION: MAKE AN APPOINTMENT USING THE PARALLEL BLOCK.

INSTRUCTION: USE THE ‘APPOINTMENT’ TAB OR PRESS <CTRL-S> TO INVOKE THE APPOINTMENT MAKING DIALOG.

(STRING 20)

i3=1

i5. I just need to verify that I am speaking with the correct person. What is your date of birth?

| | | / | | | / | | | | |

MONTH DAY YEAR

(1-12) (1-31) (1900-1996)

PROGRAMMER NOTE: IF AT LEAST 2 DATA ELEMENTS MATCH GO TO A1a

DON’T KNOW d GO TO i6

REFUSED r GO TO i6

BIRTHDAY INCORRECT= LESS THAN 2 DATA ELEMENTS MATCH MM/DD/YYYY GO TO i6

PROGRAMMER: NOTE AT LEAST TWO PIECES OF BIRTHDAY INFORMATION MUST MATCH FOR VERIFICATION (FOR EXAMPLE, MONTH AND YEAR)

i5=BIRTHDATE INCORRECT, d OR r

i6. And what are the last 4-digits of your Social Security Number?

| | | | | LAST FOUR IF MATCH GO TO A1a

(NUMBER RANGE)

DON’T KNOW d GO TO i7

REFUSED r GO TO i7

SSN INCORRECT FF GO TO i7

i6= d, r or FF

i7. I’m sorry. I need to check my records before I can interview you. Is this the best time to reach you in the future?

YES 1

NO, CALL BACK INFO 0

(STRING 20)

INSTRUCTION: RECORD DATE AND TIME FOR CALL BACK.

i7=answer

i8. Thank you for taking time to speak with me. Goodbye.

Great. Thank you for taking the time to talk with me today. Before we get started I would like to make sure we have your name recorded correctly.

ALL

A1a. Can you verify your first name?

P

BSF 36 Month Follow-up

ROBE: Can you spell that for me please?

(STRING 20)

FIRST NAME

ALL

A

BSF 36 Month Follow-up

1b. And your middle name please?

PROBE: Can you spell that for me please?

(STRING 20)

MIDDLE NAME

ALL

A

BSF 36 Month Follow-up

1c. And your last name please?

PROBE: Can you spell that for me please?

(STRING 20)

LAST NAME

ALL

Fill [RESP FIRST name] from a1a.

A2. Are you usually called [RESP FIRST NAME] or do you go by another name?

I

BSF 15 Month Follow-up

NSTRUCTION: IF SAME JUST HIT ENTER.

PROBE: Can you spell that for me please?

(STRING 20)

FIRST NAME

The next questions are about you and [PACT PARTNER].

ALL

B

BSF 15 month follow-up

1. Are you and [PACT PARTNER]…

married, 1 GO TO B5

divorced, 2

separated, or 3

have you never been married to each other? 4

MARRIAGE ANNULLED 5

WIDOWED/PARTNER DIED 6 GO TO B7

DON’T KNOW d

REFUSED r

SOFT CHECK: IF BASELINE C1=1, 2 OR 3 AND FOLLOW UP B1=4 ASK: You previously told us you were [FILL marital status from baseline] and now you are reporting you have never been married. Are you and [PACT PARTNER], married, divorced, separated or have you never been married to each other?

INTERVIEWER: RECORD RESPONSE GIVEN.

B1 NE 1 AND B1 NE 6

B

BSF 15 month follow-up

2. Which of the following statements best describes your current relationship with [PACT PARTNER]?

We are romantically involved on a steady basis. 1 GO TO B3

We are involved in an on-again and off-again relationship. 2 GO TO B3

We are not in a romantic relationship. 3 GO TO B2a

DON’T KNOW d GO TO B3

REFUSED r GO TO B3

b2=3

if B1=2 or 3 Fill “marriage”

B

BSF 15 month follow-up

2a. When did your [romantic relationship/marriage] with [PACT PARTNER] end?

| | | / | | | | | DATE RELATIONSHIP ENDED GO TO B2b

(01-12) (2012-2100)

MONTH YEAR

DON’T KNOW d GO TO B2b

REFUSED r GO TO B2b

B2=3

B2b. I am going to read you a list of reasons that people give for why their relationships ended. For each reason, tell me if this is why your relationship with [PACT PARTNER] ended.

Was it because…[STATEMENT a-j]

BSF 15-month follow-up	CODE ONE PER ROW
	YES	NO	DK	REF
a. the two of you were not communicating well or were arguing too much?	1	0	d	r
b. you lacked support from family members?	1	0	d	r
c. you and [PACT PARTNER] were living too far apart?	1	0	d	r
d. one of you cheated or was unfaithful?	1	0	d	r
e. one of you could not keep a job or contribute enough financially to the family?	1	0	d	r
f. you or [PACT PARTNER] was abusive or violent?	1	0	d	r
g. one of you used drugs or alcohol?	1	0	d	r
h. one of you went to jail or prison?	1	0	d	r
i. one of you was not a good parent or role model?	1	0	d	r
j. were there any other reasons why your romantic relationship ended? IF YES. what were those other reasons? (SPECIFY)	1	0	d	r

B2=3

B2c. Do you think it is a good thing for you that you and [PACT PARTNER] broke up?

Y

PACT Developed

ES 1 GO TO B5

NO 0 GO TO B5

DON’T KNOW d GO TO B5

REFUSED r GO TO B5

B1 = 2,4,5, d OR r and B2= 1 or 2

B3. Are you and [PACT PARTNER] engaged to be married?

Y

BSF 15 month follow-up

ES 1 GO TO B4

NO 0

DON’T KNOW d

REFUSED r

B3=0 or d or r

if b3=0 FILL “Although you are not engaged”

B

Adapted from Scott Stanley

3a. [Although you are not engaged], have you and [PACT PARTNER] made a specific plan together to get married?

YES 1 GO TO B4

NO 0 GO TO B5

DON’T KNOW d GO TO B5

REFUSED r GO TO B5

b3=1 or b3a=1

B

BSF 15 month follow-up

4. When are you planning to get married?

INTERVIEWER INSTRUCTION: RECORD ONLY MONTH AND YEAR. IF NO MONTH GIVEN, MARK AS MISSING.

PROGRAMMER NOTE: ALLOW REFUSAL IN MM/YYYY

| | | / | | | | | DATE PLANNING TO MARRY

(01-12) (2012-2100)

MONTH YEAR

INTERVIEWER INSTRUCTION: IF NO DATE IS GIVEN, DO NOT PROBE

NO DATE HAS BEEN SET 13

DON’T KNOW d

REFUSED r

b1 NE 6

B

BSF 15 month follow-up

5. Do you currently live with [PACT PARTNER] in the same household …

all of the time, 1 GO TO B7

most of the time, 2

some of the time, or 3

none of the time? 4

DON’T KNOW d

REFUSED r

B1 NE 6 AND b5 NE 1

B

BSF 15 month follow-up

6. How often do you and [PACT PARTNER] see or talk to each other? Is it…

every day or almost every day, 1

a few times a week, 2

a few times a month, 3

about once a month, 4

only a few times in the past year, or 5

hardly ever or never? 6

DON’T KNOW d

REFUSED r

PROGRAMMER NOTE:
IF BASELINE A11b or C14=1 (EXPECTING A BABY) GO TO B7. IF BASELINE A11b or C14 NE 1 (NOT EXPECTING A BABY) GO TO C1.

BASELINE A11b=1 OR C14=1 (EXPECTING A BABY)

FILL “had” IF FEMALE; “fathered” IF MALE

B

BSF 36 month follow- up

7. Our records indicate that about a year ago you told us that you and [PACT PARTNER] were expecting a baby.

Did you have that baby?

INTERVIEWER INSTRUCTION: IF RESPONDENT REPORTS MULTIPLE BIRTHS, ENTER “YES.” AND ENTER THE NUMBER OF BABIES AT B7a.

INTERVIEWER INSTRUCTION: IF RESPONDENT REPORTS DATE OF BIRTH, ANSWER “YES” AND ENTER DATE OF BIRTH AT B7b.

IF RESPONDENT ANSWERS NO WITHOUT EXPLANATION, PROBE: I’m sorry…what happened?

IF B7=4 OR B7=6 SAY: I’m very sorry to hear that. Our condolences for your loss.

YES 1 GO TO B7a

YES, BUT BABY DIED 2 GO TO C1

NO 3 GO TO C1

NO, MISCARRIAGE 4 GO TO C1

NO, ABORTION 5 GO TO C1

NO, BABY DIED 6 GO TO C1

NO, DENY PREGNANCY 7 GO TO C1

DON’T KNOW d GO TO C1

REFUSED r GO TO C1

B7=1

B

BSF 15 month follow-up

7a. ENTER WITHOUT ASKING IF KNOWN: OTHERWISE PROBE: How many babies did you have?

INTERVIEWER INSTRUCTION: ENTER THE NUMBER OF BABIES BORN

IF B7a=0 SAY: I’m very sorry to hear that. Our condolences for your loss.

| | | NUMBER OF BABIES BORN GO TO B7b

(1-99)

BABY DIED 0 GO TO C1

B7a ≥1

B7a =1 fill “was the baby”

B 7a ≥ 2 OR MORE fill “were these babies”

B

BSF 15 month follow-up

7b. What date [was the baby/were these babies] born?

IF B7b=0 SAY: I’m very sorry to hear that. Our condolences for your loss.

| | | / | | | / | | | | | CHILD DATE OF BIRTH

(01-12) (01-31) (2013-2015)

MONTH DAY YEAR

BABY DIED 0 GO TO C1

B7a =1

B7a ≥ 2 OR MORE: SAY “Thinking of the baby born first on that date…”

INTERVIEWER: CODE SEX. IF NECESSARY ASK:

B7c. Is this baby a boy or a girl?

B

BSF 15 month follow-up

OY 1

GIRL 2

DON’T KNOW d GO TO C1

REFUSED r GO TO C1

B7c = 1 or 2

FILL “him” IF B7c=1, “her” IF B7c=2

B

BSF 15 month follow-up

7d. So I can refer to [him/her] later in the survey; what do you usually call [him/her]?

(STRING 20)

FIRST NAME

INSTRUCTION; IF RESPONDENT DOES NOT GIVE FIRST NAME PROBE FOR A NAME OR INITIALS

DON’T KNOW d GO TO C1

REFUSED r GO TO C1

ALL

C

PAM

1. Now, I would like to talk about you and [PACT PARTNER] as parents.

The following statements are about [PACT PARTNER]’s and your involvement in the care of your children.

For each statement, please answer if overall you strongly agree, agree, disagree, or strongly disagree. In your answers, you should include children you have in common, as well as other children you live with.

[STATEMENT a-j] Overall, do you strongly agree, agree, disagree, or strongly disagree with this statement?

	CODE ONE PER ROW
	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE	DK	REF
a. I believe [PACT PARTNER] is a good parent.	1	2	3	4	d	r
b. [PACT PARTNER] and I communicate well about our children.	1	2	3	4	d	r
c. I feel good about [PACT PARTNER]’s judgment about what is right for our children.	1	2	3	4	d	r
d. [PACT PARTNER] makes my job of being a parent easier.	1	2	3	4	d	r
e. [PACT PARTNER] and I are a good team.	1	2	3	4	d	r
f. [PACT PARTNER] knows how to handle children well.	1	2	3	4	d	r
g. When there is a problem with our children, we work out a good solution together.	1	2	3	4	d	r
h. [PACT PARTNER] is willing to make personal sacrifices to help take care of our children.	1	2	3	4	d	r
i. Talking to [PACT PARTNER] about our children is something I look forward to.	1	2	3	4	d	r
j. [PACT PARTNER] pays a great deal of attention to our children.	1	2	3	4	d	r

ALL

If # of children at Baseline ≥ 2 (more than one potential focal child): [“The computer has selected one of your children for me to ask additional questions about.”]

Now, I would like to ask you some questions about the time you spend with [FOCAL CHILD].

All

C2. Does [FOCAL CHILD] live with you all of the time, most of the time, some of the time, or none of the time?

PACT Developed

all of the time, 1

most of the time, 2

some of the time, or 3

none of the time? 4

DON’T KNOW d

REFUSED r

All

C2a. Does [FOCAL CHILD] live with [PACT PARTNER] all of the time, most of the time, some of the time, or none of the time?

PACT Developed

all of the time, 1

most of the time, 2

some of the time, or 3

none of the time? 4

DON’T KNOW d

REFUSED r

IF FOCAL CHILD IS 0-5 ASK C3a, C3b, C3c

IF FOCAL CHILD IS 6-15 ASK C3d-C3i

IF FOCAL CHILD IS 16-21 ASK C3d, C3e, C3f, C3h, C3i

FOR C3b IF BASELINE D4=1 FILL “HIM”, IF BASELINE D4=2 FILL “HER”

FOR C3e IF BASELINE D4=1 FILL “HIS”, IF BASELINE D4=2 FILL “HER”

FOR C3g, h, and i IF BASELINE D4=1 FILL “HE”, IF BASELINE D4=2 FILL “SHE”

C3. How often in the past month have you…[STATEMENT A-I]. Would you say never, once in a while, somewhat often, or very often.

	CODE ONE PER ROW
	NEVER	ONCE IN A WHILE	SOMEWHAT OFTEN	VERY OFTEN	DK	REF
a SHM . read books or told stories to [FOCAL CHILD]?	0	1	2	3	d	r
b SHM . fed [FOCAL CHILD] or given [him/her] something to eat?	0	1	2	3	d	r
c SHM . played with [FOCAL CHILD] inside or outdoors?	0	1	2	3	d	r
d EHS modified . had a meal with [FOCAL CHILD]?	0	1	2	3	d	r
e SHM . talked with [FOCAL CHILD] about [his/her] friends?	0	1	2	3	d	r
f SHM Adapted . spent time with [FOCAL CHILD doing things [he/she] likes to do?	0	1	2	3	d	r
g Panel Study of Income Dynamics . worked on homework together?	0	1	2	3	d	r
h. talked with [FOCAL CHILD] about things [he/she] is especially interested in?	0	1	2	3	d	r
i SHM . took [FOCAL CHILD] places [he/she] needed to go?	0	1	2	3	d	r

IF FOCAL CHILD IS 0-6 ASK C4c AND C4d

IF FOCAL CHILD IS 6-21 ASK C4a, b, c, and d

FOR C4a IF BASELINE D4=1 FILL “HIS”, IF BASELINE D4=2 FILL “HER”

FOR C3c and C3d IF BASELINE D4=1 FILL “HE”, IF BASELINE D4=2 FILL “SHE”

C4. How often do you [STATEMENT a-d]? Would you say never, once in a while, somewhat often, or very often.

	CODE ONE PER ROW
	NEVER	ONCE IN A WHILE	SOMEWHAT OFTEN	VERY OFTEN	DK	REF
a Modified from PPQ . encourage [FOCAL CHILD] to talk about [his/her] feelings?	0	1	2	3	d	r
b PACT developed . talk to [FOCAL CHILD] about how things are going at school or work?	0	1	2	3	d	r
c Modified from PPQ . praise [FOCAL CHILD] when [he/she] behaves well or meets a goal?	0	1	2	3	d	r
d SHM . show patience with [FOCAL CHILD] when [he/she] is upset?	0	1	2	3	d	r

IF FOCAL CHILD IS 0-2 GO TO D1

IF FOCAL CHILD IS 3-15 ASK C5a-f

IF FOCAL CHILD IS 16-21 ASK C5a, d, and e

FOR C5c BASELINE D4=1 FILL “HE”, IF BASELINE D4=2 FILL “SHE”

C5. Thinking about the times when [FOCAL CHILD] has done something wrong, how often do you…[STATEMENT A-F]? Would you say never, once in a while, somewhat often, or very often.

	CODE ONE PER ROW
	NEVER	ONCE IN A WHILE	SOMEWHAT OFTEN	VERY OFTEN	DK	REF
a Modified from CTSPC . take away privileges from [FOCAL CHILD]?	0	1	2	3	d	r
b Modified from CTSPC . explain why something was wrong?	0	1	2	3	d	r
c Modified from CTSPC . encourage [FOCAL CHILD] to do something else instead of what [he/ she] was doing wrong?	0	1	2	3	d	r
d Modified from CTSPC . shout, yell, or scream at [FOCAL CHILD]?	0	1	2	3	d	r
e Modified from CTSPC . call [FOCAL CHILD] dumb or lazy or some other name like that?	0	1	2	3	d	r
f Modified from CTSPC . spank [FOCAL CHILD] with your hand?	0	1	2	3	d	r

Now, I would like to ask about your relationship with [PACT PARTNER].

B1 ne 6

D

BSF 15 month follow-up modified for PACT

1. Taking all things together, on a scale from 1 to 10, where 1 is not at all happy and 10 is completely happy, how happy would you say your relationship with [PACT PARTNER] is?

| | |

(1-10)

DON’T KNOW d

REFUSED r

B1=1 OR B2= 1 OR 2

B1 = 1, FILL “marriage”, B2=1 OR 2 FILL “relationship”

D

Adapted from Scott Stanley

1a. On a scale from 1 to 10, where 1 is not at all committed and 10 is completely committed, how committed are you to your [marriage/relationship] with [PACT PARTNER]?

| | |

(1-10)

DON’T KNOW d

REFUSED r

B1=1 OR B2= 1 OR 2

B1 = 1, FILL “marriage”, B2=1 OR 2 FILL “relationship”

D

Adapted from Scott Stanley

1b. On a scale from 1 to 10, where 1 is not at all committed and 10 is completely committed, how committed would you say [PACT PARTNER] is to your [marriage/relationship]?

| | |

(1-10)

DON’T KNOW d

REFUSED r

IF B1=1 OR B2=1 OR 2 (IF MARRIED, ROMANTICALLY INVOLVED, OR IN AN ON-AGAIN, OFF-AGAIN RELATIONSHIP)

D2. Tell me whether you strongly agree, agree, disagree, or strongly disagree with the following statements about your current relationship with [PACT PARTNER].

BSF 15 month follow-up

[STATEMENT a-f] Do you strongly agree, agree, disagree, or strongly disagree?

	CODE ONE PER ROW
	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE	DK	REF
a BSF 15 month follow-up . [PACT PARTNER] shows love and affection.	1	2	3	4	d	r
b BSF 36 month follow-up . [PACT PARTNER] and I often talk about things that happen to each of us during the day.	1	2	3	4	d	r
c BSF 36 month follow-up . [PACT PARTNER] and I enjoy doing even ordinary, day-to-day things together.	1	2	3	4	d	r
d BSF 36 month follow-up . I want my relationship with [PACT PARTNER] to stay strong no matter what rough times we may have.	1	2	3	4	d	r
e BSF 36 month follow-up . [PACT PARTNER] encourages or helps me to do things that are important to me.	1	2	3	4	d	r
f BSF 36 month follow-up . I am satisfied with my sexual relationship with [PACT PARTNER].	1	2	3	4	d	r

B1 NE 6 (PARTNER IS ALIVE) AND B6 NE 6 (HAS SOME CONTACT WITH PARTNER)

D

BSF 15 month follow-up

3. Tell me whether you strongly agree, agree, disagree, or strongly disagree with the following statements about your current relationship with [PACT PARTNER].

[STATEMENT A-G] Do you strongly agree, agree, disagree, or strongly disagree?

	CODE ONE PER ROW
	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE	DK	REF
a BSF 15 month follow-up . [PACT PARTNER] is honest and truthful with me.	1	2	3	4	d	r
b BSF 15 month follow-up . I trust [PACT PARTNER] completely.	1	2	3	4	d	r
c BSF 15 month follow-up . [PACT PARTNER] can be counted on to help me.	1	2	3	4	d	r
d BSF 15 month follow-up . [PACT PARTNER] knows and understands me.	1	2	3	4	d	r
e BSF 15 month follow-up . [PACT PARTNER] listens to me when I need someone to talk to.	1	2	3	4	d	r
f BSF 15 month follow-up . [PACT PARTNER] respects me.	1	2	3	4	d	r
g BSF 15 month follow-up . I feel appreciated by [PACT PARTNER].	1	2	3	4	d	r

b1 ne 6 (partner IS ALIVE) and b6 ne 6 (HAS some contact WITH PARTNER)

D

BSF 15 month
follow-up

4. I am going to read you some statements about things you may experience when you are with [PACT PARTNER]. Please tell me if this happens with you and [PACT PARTNER]. Tell me if this often happens, sometimes happens, almost never happens, or never happens.

[STATEMENT a - f] Does this happen often, sometimes, almost never, or never?

	CODE ONE PER ROW
BSF 15 month follow-up	OFTEN	SOMETIMES	ALMOST NEVER	NEVER	DK	REF
a. We are good at solving our differences.	1	2	3	4	d	r
b SHM . [PACT PARTNER] is rude and mean to me when we disagree.	1	2	3	4	d	r
c BSF 15 month follow-up . [PACT PARTNER] is good at calming me when I get upset.	1	2	3	4	d	r
d BSF 15 month follow-up . Little arguments turn into ugly fights with accusations, criticisms, name calling, or bringing up past hurts.	1	2	3	4	d	r
e BSF 15 month follow-up . We are pretty good listeners, even when we have different positions on things.	1	2	3	4	d	r
f BSF 15 month follow-up . [PACT PARTNER] blames me for things that go wrong.	1	2	3	4	d	r
g BSF 15 month follow-up . Even when arguing we can keep a sense of humor.	1	2	3	4	d	r
h BSF 15 month follow-up . When we argue, I feel personally attacked by [PACT PARTNER].	1	2	3	4	d	r

b1 ne 6 (partner IS ALIVE) and b6 ne 6 (HAS some contact WITH PARTNER)

D4. continued: I am going to read you some statements about things you may experience when you are with [PACT PARTNER]. Please tell me if this happens with you and [PACT PARTNER]. Tell me if this often happens, sometimes happens, almost never happens, or never happens. [STATEMENT i-q] Does this happen often, sometimes, almost never, or never?

	CODE ONE PER ROW
	OFTEN	SOMETIMES	ALMOST NEVER	NEVER	DK	REF
i BSF 15 month follow-up . When we discuss something, [PACT PARTNER] acts as if I am totally wrong.	1	2	3	4	d	r
j BSF 36 month follow-up . During arguments, we are good at taking breaks when we need them.	1	2	3	4	d	r
k BSF 36 month follow-up . When we argue, one of us is going to say something we will regret.	1	2	3	4	d	r
l BSF 36 month follow-up . [PACT PARTNER] seems to view my words or actions more negatively than I mean them to be.	1	2	3	4	d	r
m BSF 36 month follow-up . When we argue, one of us withdraws and refuses to talk about it anymore.	1	2	3	4	d	r
n BSF 15 month follow-up . I feel respected even when we disagree.	1	2	3	4	d	r
o PACT . One or both of us continue to hold grudges even after discussing our disagreements.	1	2	3	4	d	r
I PACT F BASELINE A9A=1 FILL “HE” IF BASELINE A9A=2 FILL “SHE” p. When [PACT PARTNER] raises a problem in our relationship, [he/she] makes me feel like I need to defend myself.	1	2	3	4	d	r
q PACT . [PACT PARTNER] and I compromise during disagreements.	1	2	3	4	d	r

B1=1 OR B2= 1 OR b2=2

B1 = 1, FILL “marriage”, B2=1 OR 2 FILL “relationship”

D

SHM

5. In the last three months, have you ever thought your [marriage/relationship] was in trouble?

YES 1

NO 0

DON’T KNOW d

REFUSED r

SKIP IF B1=6 (PARTNER DIED)

D

BSF 15 month follow-up

6. Sometimes couples are not always faithful to each other. Since [RA DATE] has [PACT PARTNER] cheated on you with someone else? Is that…

IF B2=3 (NOT IN A ROMANTIC RELATIONSHIP): Please think only about the time after [RA DATE] and before your romantic relationship with [PACT PARTNER] ended.

definitely yes, 1

probably yes, 2

probably no, or 3

definitely no? 4

WAS NEVER IN A ROMANTIC RELATIONSHIP 99 GO TO D8

DON’T KNOW d

REFUSED r

SKIP IF B1=6 (PARTNER DIED) OR D6=99

D7. Since [RA DATE], have you cheated on [PACT PARTNER] with someone else?

BSF 15 month follow-up

IF B2=3 (NOT IN A ROMANTIC RELATIONSHIP): Please think only about the time after [RA DATE] and before your romantic relationship with [PACT PARTNER] ended.

YES 1

NO 0

WAS NEVER IN A ROMANTIC RELATIONSHIP 99

DON’T KNOW d

REFUSED r

IF B1 NE 6 (PARTNER IS ALIVE)

D8. Next I’m going to read a list of things that might have happened to you in the past year. Please answer “yes” or “no” to each of the following statements. In the past year, did [PACT PARTNER] [STATEMENT A-M]…

Conflict Tactic Scale	CODE ONE PER ROW
	YES	NO	DK	REF
a. throw something at you that could hurt?	1	0	d	r
b. twist your arm or hair?	1	0	d	r
c. push or shove you?	1	0	d	r
d. grab you?	1	0	d	r
e. slap you?	1	0	d	r
f. use a knife or gun on you?	1	0	d	r
g. punch or hit you with something that could hurt?	1	0	d	r
h. choke you?	1	0	d	r
i. slam you against the wall?	1	0	d	r
j. kick you?	1	0	d	r
k. beat you up?	1	0	d	r
l. burn or scald you on purpose?	1	0	d	r
m. use threats or force to make you have sex or do sexual things you didn’t want to do?	1	0	d	r

IF B1 NE 6 (PARTNER IS ALIVE)

D9. How often in the past year [STATEMENT A-D]…Was it often, sometimes, rarely, or never?

	CODE ONE PER ROW
	OFTEN	SOMETIMES	RARELY	NEVER	DK	REF
a SHM REVISED FOR PACT . has [PACT PARTNER] made you feel stupid?	1	2	3	4	d	r
b SHM REVISED FOR PACT . has [PACT PARTNER] tried to keep you from seeing or talking with your friends or family?	1	2	3	4	d	r
c SHM REVISED FOR PACT . has [PACT PARTNER] kept money from you, made you ask for money, or taken your money without asking?	1	2	3	4	d	r
d SHM REVISED FOR PACT . have you felt afraid that [PACT PARTNER] would hurt you?	1	2	3	4	d	r

IF B1=6 GO TO E1

IF B2=3 (NOT IN A ROMANTIC RELATIONSHIP) SKIP D10a, b, c, and d

D10. The next questions are about changes that may have occurred over the past year. Please tell me if you strongly agree, somewhat agree, somewhat disagree, or strongly disagree with the following statements.

[STATEMENT a-f] Do you strongly agree, somewhat agree, somewhat disagree, or strongly disagree…

PACT Developed	CODE ONE PER ROW
	STRONGLY AGREE	SOMEWHAT AGREE	SOMEWHAT DISAGREE	STRONGLY DISAGREE	DK	REF
a. I feel closer to [PACT PARTNER] than I did a year ago.	1	2	3	4	d	r
b. [PACT PARTNER] and I have less trouble working out disagreements than we did a year ago.	1	2	3	4	d	r
c. I feel more understood by [PACT PARTNER] than I did a year ago.	1	2	3	4	d	r
d. Compared to a year ago, I am more hopeful that my romantic relationship with [PACT PARTNER] will work out.	1	2	3	4	d	r
e. I know more about what it takes to have a good relationship than a year ago.	1	2	3	4	d	r
f. I feel better about my future financial situation than I did a year ago.	1	2	3	4	d	r

Now, I would like to ask some questions about your work.

ALL

E

WIA

1. Do you currently have a paid job?

YES 1 GO TO E2

NO 0 GO TO E1a

DON’T KNOW d GO TO E1a

REFUSED r GO TO E1a

E1a. Have you had any jobs in the past three months?

Y

PACT developed

ES 1 GO TO E3b

NO 0 GO TO E10

DON’T KNOW d GO TO E10

REFUSED r GO TO E10

NOTE: SPACE FOR 3RD, 4TH, 5TH & 6TH JOB WILL BE IN CATI PROGRAM.

	JOB 1	JOB 2
E1=1 (CURRENTLY EMPLOYED) E WIA 2. Please tell me who you work for. This could be the name of a company, organization, person, or it could be yourself.	COMPANY NAME (SPECIFY) 99 (STRING 50) SELF-EMPLOYED 2 DON’T KNOW d REFUSED r	COMPANY NAME (SPECIFY) 99 (STRING 50) SELF-EMPLOYED 2 DON’T KNOW d REFUSED r
E1=1 (CURRENTLY EMPLOYED) E WIA 3. Do you have any other jobs now?	YES 1 GO TO E3a, JOB 2 NO 0 GO TO E3c DON’T KNOW d GO TO E3c REFUSED r GO TO E3c	YES 1 GO TO E3a, JOB 3 NO 0 GO TO E3c DON’T KNOW d GO TO E3c REFUSED r GO TO E3c
E IF E3=1 LOOP E3 AND E3a UP TO 6 JOBS UNTIL E3=0, d, or r. WHEN E3=0, d, or r GO TO E3c. 3=1 (CURRENTLY EMPLOYED) E WIA 3a. Please tell me who you work for on that job? INTERVIEWER INSTRUCTION: PROBE FOR A DIFFERENT NAME IF THEY GIVE THE SAME RESPONSE AS E2.		COMPANY NAME (SPECIFY) 1 (STRING 50) SELF-EMPLOYED 2 DON’T KNOW d REFUSED r
IF E1a=1 (NOT CURRENTLY EMPLOYED) E3b. Please tell me who you worked for? INTERVIEWER INSTRUCTION: PROBE FOR A DIFFERENT NAME IF THEY GIVE THE SAME RESPONSE AS E2 and E3a.	COMPANY NAME (SPECIFY) 99 (STRING 50) SELF-EMPLOYED 2 DON’T KNOW d REFUSED r	COMPANY NAME (SPECIFY) 99 (STRING 50) SELF-EMPLOYED 2 DON’T KNOW d REFUSED r
I IF E3c=1 LOOP E3b AND E3b UNTIL E3c=0, d OR r FOR UP TO 6 JOBS. WHEN E3c=0, d, or r GO TO E4, JOB 1. IF E3c=1 LOOP E3b AND E3b UNTIL E3c=0, d OR r FOR UP TO 6 JOBS. WHEN E3c=0, d, or r GO TO E4, JOB 2. F E3=(0, d, or r) (TOLD INTERVIEWER THAT NO MORE CURRENT JOBS) OR E1a=1 (NOT CURRENTLY EMPLOYED BUT EMPLOYED IN PAST 3 MONTHS) E WIA 3c. Have you had any other jobs in the past three months that you haven’t already told me about?	YES 1 GO TO E3b, JOB 2 NO 0 GO TO E4 DON’T KNOW d GO TO E4 REFUSED r GO TO E4	YES 1 GO TO E3b, JOB 3 NO 0 GO TO E4 DON’T KNOW d GO TO E4 REFUSED r GO TO E4
E1=1 or E1a=1 E WIA 4. Now thinking of your job at [JOB NAME 1] When did you start working for [JOB NAME 1]? INTERVIEWER: RECORD MONTH AND YEAR. NOTE: ALLOW SKIP ON MONTH.	| | | / | | | | | MONTH (1-12) YEAR (1990-2014) DON’T KNOW d REFUSED r	| | | / | | | | | MONTH (1-12) YEAR (1990-2014) DON’T KNOW d REFUSED r
E1=1 or E1a=1 E WIA 5. When did that job end? INTERVIEWER: RECORD MONTH AND YEAR.	| | | / | | | | | (1-12) (2013-2014) MONTH YEAR STILL AT JOB 98 DON’T KNOW d REFUSED r	| | | / | | | | | (1-12) (2013-2014) MONTH YEAR STILL AT JOB 98 DON’T KNOW d REFUSED r
E1=1 or E1a=1 FILL “ARE” IF E5=98, ELSE FILL “WERE” E WIA 6. Which of the following best describes your work at [JOB NAME]? (Are/Were) you working . . .	CODE ONE ONLY as a regular full-time or part-time employee, 1 for a temporary help agency, 2 self-employed, 4 as a day laborer, 5 or something else (PLEASE specify)? 99 (STRING 50) DON’T KNOW d REFUSED r	CODE ONE ONLY as a regular full-time or part-time employee, 1 for a temporary help agency, 2 self-employed, 4 as a day laborer, 5 or something else (PLEASE specify)? 99 (STRING 50) DON’T KNOW d REFUSED r

	JOB 1	JOB 2
E1=1 or E1a=1 FILL “IS” AND “CURRENT” IF E5=98, ELSE FILL “WAS” AND “MOST RECENT” E WIA 7. What (was/is) your (most recent/ current) rate of pay, before taxes and deductions, at that job? PROBE: If your pay (varies/ varied), please provide an average amount. ACCEPT MOST CONVENIENT PAY PERIOD. SOFT CHECK: IF ANSWER IS GREATER THAN $50 PER HOUR, $2000 PER WEEK, $4000 ONCE EVERY 2 WEEKS, $4000 TWICE A MONTH, $100,000 PER YEAR, $400 DAY/DAILY, OR $8000 MONTH, SAY: “I recorded [e7 answer]. is that correct?”	$ | | | |,| | | |.| | | AVERAGE (0-999,999.99) AMOUNT PER HOUR 1 PER WEEK 2 MONTH 3 ONCE EVERY TWO WEEKS 4 TWICE A MONTH 5 PER YEAR 6 DAY/DAILY 7 PER EVENT/ACTIVITY/UNIT/JOB 8 PLUS TIPS/COMMISSION/BONUS 9 OTHER (SPECIFY) 99 (STRING 50) DON’T KNOW d REFUSED r	$ | | | |,| | | |.| | | AVERAGE (0-999,999.99) AMOUNT PER HOUR 1 PER WEEK 2 MONTH 3 ONCE EVERY TWO WEEKS 4 TWICE A MONTH 5 PER YEAR 6 DAY/DAILY 7 PER EVENT/ACTIVITY/UNIT/JOB 8 PLUS TIPS/COMMISSION/BONUS 9 OTHER (SPECIFY) 99 (STRING 50) DON’T KNOW d REFUSED r
E1=1 or E1a=1 IF E5=98, FILL “ARE” ELSE FILL “WERE” E WIA 8. Which of the following benefits (are/were) available to you on your job (READ EACH ITEM) . . . SELECT IF AVAILABLE, BUT NOT USED.	CODE ALL THAT APPLY Health insurance or membership in an HMO or PPO plan? 1 Paid leave for holidays, vacation or illness? 2 DON’T KNOW d REFUSED r	CODE ALL THAT APPLY Health insurance or membership in an HMO or PPO plan? 1 Paid leave for holidays, vacation or illness? 2 DON’T KNOW d REFUSED r
E IF E3=1 OR E3c=1 GO TO E4 [JOB 2-6]. WHEN (E3 NE 1 AND E3c NE 1) OR # OF JOBS COLLECTED =6, GO TO E10. IF E3=1 OR E3c=1 GO TO E4 [JOB 2-6]. WHEN (E3 NE 1 AND E3c NE 1) OR # OF JOBS COLLECTED =6, GO TO E10. 1=1 or E1a=1 If E5=98 FILL “DO”, ELSE FILL “DID” E WIA 9. How many hours (do/did) you usually work in a week on this job? Your best estimate is fine.	| | | HOURS PER WEEK (0-98) 99 OR MORE HOURS PER WEEK 99 DON’T KNOW d REFUSED r	| | | HOURS PER WEEK (0-98) 99 OR MORE HOURS PER WEEK 99 DON’T KNOW d REFUSED r

all

E

PACT developed

10. T

PACT developed

hinking about the past 3 months, was there anything else you did for pay, such as odd jobs, under-the-table jobs, side jobs or informal jobs, that we haven’t already talked about?

YES 1

NO 0 GO TO E12

DON’T KNOW d GO TO E12

REFUSED r GO TO E12

E10=1

E

PACT developed

11. What is your best guess of how much money you made from these activities over the past three months? Please do not include money you made from any jobs we talked about earlier.

PROBE: Your best guess is fine.

$| | | , | | | | IN PAST THREE MONTHS

(0-99,999)

DON’T KNOW d

REFUSED r

e1=0, d, r (not currently employed)

E

PACT developed

12. Some people do not want to get a job because, for example, they are in school or caring for a young child. Would you like to get a job?

YES 1 GO TO E13

NO 0 GO TO E16

DON’T KNOW d GO TO E13

REFUSED r GO TO E13

E1=1

E

PACT developed

12a. How satisfied are you with your current job? Would you say very satisfied, somewhat satisfied, or not satisfied?

VERY SATISFIED 1 GO TO E16

SOMEWHAT SATISFIED 2 GO TO E13

NOT SATISFIED 3 GO TO E13

DON’T KNOW d GO TO E13

REFUSED r GO TO E13

E12=1, d or r OR E12a = 2, 3, d, or r [somewhat satisfied or not satisfied]

if e1=1 fill “better job” if e1=0, d, r fill “Job”

E

PACT developed

13. In the past month have you taken steps to find a [job/better job]?

YES 1 GO TO E15

NO 0

DON’T KNOW d

REFUSED r

E13 ne 1

if e1=1 fill “better job” if e1=0, d, r fill “Job”

E

PACT developed

14. Are you planning to take steps to get a [job/better job] soon?

YES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

E

PACT developed

15. Do you have an updated resume that you can give to employers?

YES 1

NO 0

DON’T KNOW d

REFUSED r

All

E

PACT developed

16. Are you better off financially now than you were a year ago?

YES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

E

PACT developed

17. Do you know how to handle your money and bills better than you did a year ago?

YES 1

NO 0

DON’T KNOW d

REFUSED r

The next questions are about how you are doing.

all

F

PHQ-8

1. Over the last two weeks, how often have you been bothered by any of the following problems?

[STATEMENT a-h] Would you say that the problem happened not at all, on several days, on more than half the days, or on nearly every day in the last two weeks?

	CODE ONE RESPONSE PER ROW
	NOT AT ALL	SEVERAL DAYS	MORE THAN HALF THE DAYS	NEARLY EVERY DAY	DK	REF
a. Little interest or pleasure in doing things.	0	1	2	3	d	r
b. Feeling down, depressed, or hopeless.	0	1	2	3	d	r
c. Trouble falling or staying asleep, or sleeping too much.	0	1	2	3	d	r
d. Feeling tired or having little energy.	0	1	2	3	d	r
e. Poor appetite or overeating.	0	1	2	3	d	r
f. Feeling bad about yourself—or that you are a failure or have let yourself or your family down.	0	1	2	3	d	r
g. Trouble concentrating on things, such as reading the newspaper or watching television.	0	1	2	3	d	r
h. Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual.	0	1	2	3	d	r

Now, I’d like to ask you some questions about services you may have received since [RA MONTH YEAR].

all

G

BSF 15 month follow-up modified for PACT

1. Since [RA MONTH YEAR] did you participate in any group activities to help your relationship? These could have been referred to as classes, workshops, seminars, meetings, or group sessions.

YES 1

NO 0 GO TO G4

DON’T KNOW d GO TO G4

REFUSED r GO TO G4

G1 = 1

G

BSF 15 month follow-up modified for PACT

2. Since [RA MONTH YEAR], about how many hours in total did you attend these group activities?

PROBE: Your best estimate of the number of hours you attended is fine.

| | | NUMBER OF HOURS

(0-99)

DON’T KNOW d

REFUSED r

G2= d or r

G

BSF 15 month follow-up modified for PACT

2a. I just need to know a range. Can you tell me if it was…?

1-5 hours, 1

6-10 hours, 2

11-15 hours, 3

16-20 hours, 4

21-30 hours, or 5

more than 30 hours? 6

DON’T KNOW d

REFUSED r

G1 = 1

G

BSF 15 month follow-up

3. (IF G2=1) Did [PACT PARTNER] attend the group activity with you?

(IF G2 ≥ 2) Did [PACT PARTNER] usually attend the group activity with you?

YES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

G

BSF 15 month follow-up

4. Since [RA MONTH YEAR], did you meet with a social worker, counselor, or clergy member to work on your relationship in sessions that were not part of a workshop, class, or group?

YES 1

NO 0 GO TO G8

DON’T KNOW d GO TO G8

REFUSED r GO TO G8

IF G4 = 1

G

BSF 15 month follow-up

5. Since [RA MONTH YEAR], about how many times did you meet with a social worker, counselor or clergy member to work on your relationship?

| | | NUMBER OF SESSIONS

(0-99)

PROBE: Your best estimate of the number of sessions you attended is fine.

DON’T KNOW d

REFUSED r

IF G4 = 1

IF G5=1 FILL “the”, if G5 ≥ 2 FILL “each”

G

BSF 15 month follow-up

6. About how long did [the/each] meeting last?

| | | HOURS

(0-99)

DON’T KNOW d

REFUSED r

G6= d or r

G

BSF 15 month follow-up modified for PACT

6a. I just need to know a range. Can you tell me if it was…?

1-5 hours, 1

6-10 hours, 2

11-15 hours, 3

16-20 hours, 4

21-30 hours, or 5

more than 30 hours? 6

DON’T KNOW d

REFUSED r

if G4=1

G7. (IF G5=1) Did [PACT PARTNER] attend the meeting with you?

BSF 15 month follow-up

(IF G5 ≥ 2) Did [PACT PARTNER] usually attend the meetings with you?

YES 1

NO 0

DON’T KNOW d

REFUSED r

all

G

BSF 15 month follow-up

8. Since [RA MONTH YEAR], have you…[STATEMENT A-G]

(If G8a (a, d) = 1) How many hours in total did the class last? PROBE: YOUR BEST ESTIMATE IS FINE.

	G8 (a-g)				IF G8a = 1 or G8d =1
	CODE ONE PER ROW				CODE ONE PER ROW
	YES	NO	DK	REF	NUMBER OF HOURS
a BSF 15 month follow-up . participated in any classes to help you improve your parenting skills? Include any workshops or groups you attended on parenting.	1	0	d	r	| | |
b BSF 15 month modified follow-up . participated in a training program for a specific job, trade, or occupation?	1	0	d	r
c BSF 15 month modified follow-up . received names of employers who were interviewing from any organizations, or did any organizations set up interviews with employers for you?	1	0	d	r
d BSF 15 month modified follow-up . participated in any classes that helped you get a job in other ways? For example, they may have helped you create a resume practice interviewing, or talk to you about how to look for a job..	1	0	d	r	| | |
e BSF 15 month follow-up . taken any classes to help you with reading, writing, math skills, learning English, a program to get a GED, or a college degree?	1	0	d	r
f BSF 15 month follow-up . received services to help you with anger management?	1	0	d	r
g BSF 15 month follow-up . received services to help you deal with a mental health, alcohol or substance use problem?	1	0	d	r

PROGRAM GROUP ONLY

G

PACT developed

9. Overall, on a scale from 1 to 10 where 1 is not satisfied and 10 is very satisfied, how satisfied were you with [NAME OF HM PROGRAM]?

| | |

(0-10)

NEVER ATTENDED THE PROGRAM 99 GO TO G11

PROGRAM GROUP ONLY AND G9 NE 99

G10. I’m going to ask you some questions about how much [NAME OF HM PROGRAM] helped you. Tell me if the program services helped you, a lot, some or not at all? [STATEMENT A-C]…would you say a lot, some or not at all?

	CODE ONE RESPONSE PER ROW
	A LOT	SOME	NOT AT ALL	DK	REF
a PACT developed . How much, if at all, did [NAME OF HM PROGRAM] help prepare you for a job or help you get a job?	1	2	3	d	r
b PACT developed . How much, if at all, did [NAME OF HM PROGRAM] help you be a better parent for your children?	1	2	3	d	r
c PACT developed . How much, if at all, did [NAME OF HM PROGRAM] help you with your relationship with [PACT PARTNER]?	1	2	3	d	r

PROGRAM GROUP RESPONDENTS ONLY

G11. How likely are you to recommend [NAME OF HM PROGRAM] to others? Would you say…

PACT developed

a lot, 1

some, or 2

not at all? 3

DON’T KNOW d

REFUSED r

We are almost finished. I just have a few more questions. These will help us contact you if we need to reach you in the future. We will only use this information, including your social networking accounts, if we cannot reach you with the other information you provided us.

all

H1. What is your current address?

PROBE: Is there an apartment number?

STREET 1

STREET 2

APT. #

CITY

STATE

ZIP

all

H2. What is your current home telephone number?

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

NO LANDLINE AT HOME 0

DON’T KNOW d

REFUSED r

all

H3. Do you have a cell phone?

YES 1

NO 0 GO TO H7

DON’T KNOW d GO TO H7

REFUSED r GO TO H7

h3=1

H4. What is your cell phone number?

| | | | - | | | | -| | | | | TELEPHONE

(201-989) (200-999) (0000-9999)

DON’T KNOW d

REFUSED r

h3=1

H

Youthbuild

5. I am going to ask you about the kind of cell phone service plan you have with your cell phone provider.

	YES	NO	DK	REF
a. Do you have a contract?	1	0	d	r
b. Do you have a ‘pay as you go’ plan?	1	0	d	r
c. Do you have unlimited calling?	1	0	d	r
d. Do you have unlimited texting?	1	0	d	r
e. OTHER (SPECIFY)	1	0	d	r
(STRING 100)

IF OTHER SPECIFY (99): specify other type of plan

H5d=1

H6. Is it okay for us to text you at this number?

Y

PACT developed

ES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

H7. What is your email address?

INTERVIEWER: ENTER E-MAIL ON NEXT SCREEN

(STRING 50)

DON’T HAVE ONE 0

DON’T KNOW d

REFUSED r

ALL

H

Youthbuild

8. Do you have a Facebook account?

YES 1

NO 0 GO TO END

DON’T KNOW d GO TO END

REFUSED r GO TO END

H8=1

H8a. What name do you use on Facebook?

(STRING 50)

DON’T KNOW d

REFUSED r

END OF CALL

END1. Those are all of the questions I have. You will receive $25 as a token of our appreciation. Thank you for participating in the PACT study.

END2. I am sorry to hear that, our condolences for your loss. Thank you for your time.

INTERVIEWER: BRING THIS CASE TO LOCATING FOR CONFIRMATION OF DEATH.