Permanency Innovations Initiative - AZ, CAPP, IL

Pre-testing of Evaluation Surveys

C1-7, 9 DCFS Instruments

Permanency Innovations Initiative - AZ, CAPP, IL

OMB: 0970-0355

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0970-0355 can be found here:

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C1. DCFS Biological Parent Study Contact Form

OMB NO: 0970-0355
EXPIRATION DATE: 01/31/2015

C1. DCFS Biological Parent Study Contact Form

Complete this form when a parent who is the focus of reunification services consents to the release of their contact information.

Evaluation ID

Youth Name

Did the parent agree to release his/her contact information?		Yes	No
Parent Contact Information
Parent Name			Relationship to the child if not biological parent
Is the parent more comfortable reading in Spanish?
Yes	No

Phone:	Alternate Phone:

Address:
Apt/Room/Bldg:
City:	State:	Zip Code:


Alternate Address:
Apt/Room/Bldg:
City:	State:	Zip Code:

FOR OFFICE USE
Staff person who completed this document:
Date document completed:	/ /

Burden Statement: This collection of information is voluntary and will be used to evaluate the Permanency Innovations Initiative. Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Reports Clearance Officer (Attn: OMB/PRA 0970-0355), Office of Planning, Research and Evaluation, Administration for Children and Families, Department of Health and Human Services, 370 L’Enfant Promenade S.W., Washington DC 20447.

C2. Biological Parent FAQ Letter and Consent Script

OMB NO: 0970-0355
EXPIRATION DATE: 01/31/2015

C2. Biological Parent FAQ Letter and Consent Script

FAQ Letter

This document will be on Illinois Department of Children and Family Services Letterhead

Dear Parent,

Westat invites you to take part in a study with the Illinois Department of Children and Family Services (DCFS). Westat, a company hired by the U.S. Department of Health and Human Services is leading the study. Please read the following information carefully. Your choice to take part in the study or not will not affect your case or the services that you and your family get.

Westat will also ask your child, [insert child’s name], to take part in the study.

Why is Westat doing this study?

The study will assist us in learning whether the services you and your child receive help children leave foster care sooner. We want your help in finding out if these services work.

Why are you asking me to take part in this study?

DCFS assigned your family (using a random process like a coin flip) to get one of two types of services that are meant to help you. With either service, a caseworker will continue to meet with you and your child, make home visits, refer you and your child to needed services, and check on how you and your child are doing. However, you and your child may also receive additional services depending on your DCFS assignment. These extra services will focus on helping you to understand your child’s emotions and behaviors, improve the way you respond to your child’s emotions and behaviors, and learn ways to lower your stress. You will be told if you are chosen to receive these extra services.

While you are getting these services, Westat wants to study whether the services you receive help families.

What am I being asked to do now?

At this time, we are asking you to agree to let DCFS share your contact information with Westat. If you do not want your contact information shared with Westat, please call the number below to let DCFS know. If you do not call the number below by (date TBD), DCFS will share your contact information with Westat and a researcher will call you to tell you more about the study.

Do I have to take part in this study?

No. After the researcher tells you more about the study, you can decide if you want to take part in the study. Even if you agree to be in the study, you can stop being in the study at any time. Taking part in the study or not will not affect the services that you and your child receives.

What will I be asked to do if I agree to take part in the study?

In order to study the services you and your child receive, we are asking you to take part in two phone interviews: at the start of services and 6 months later. During the interviews, you will answer questions about your thoughts and feelings in response to stress and the way in which you respond to others, and about the supports you have in your life.

The phone interviews will happen at a time that is best for you. Each interview will take no more than 20 minutes.

Do I get anything for being interviewed?

Yes. You will receive a $15 gift card for taking part in each phone interview. The gift card will be sent to you by postage mail after the interview.

Are there any risks to taking part in the study?

We do not think there are any risks to you from participating in this study other than normal discomfort from talking about sensitive topics. If any of the questions make you feel upset or sad, you can talk with your caseworker. You can also skip questions that you do not want to answer or end the interview at any time. The researcher also has a list of local mental health agencies that he or she can provide you.

Will what I share during the interviews be kept private?

We will keep your information private to the extent permitted by law. We will not include information that identifies you or your family in any reports; information will only be reported for the entire group of families studied. The information you provide will not be shared with your caseworker. However, it may be shared with a therapist that serves you and/or your child to help with service planning. We will use your information for research only.

To help us keep your information private, we received a Certificate of Confidentiality from the U.S. Department of Health and Human Services. With this Certificate, no one can force us to share information that may identify you, even in any court or legal proceeding or under a court order or subpoena. But, we will in all cases take necessary action, including reporting to authorities, to prevent harm to yourself or others. This includes reporting suspected child abuse or neglect.

What if I do not want DCFS to share my contact information with Westat?

If you do not want DCFS to share your contact information with Westat, please call [insert DCFS contact name] at [insert DCFS contact number] by (DATE TBD).

What if I have questions about the study?

If you have any questions about the study, please call Raquel Ellis 1-800-WESTAT1 (937-8281), x5173, or raquelellis@westat.com. If you have any questions about your rights as a person taking part in the study, please contact the Westat Institutional Review Board (IRB) Administrator at 1-800-WESTAT1 (937-8281), x8828.

Consent Information Script

Hello, my name is ______. I work with Westat. May I speak with [insert parent name]? [Allow time for person on phone to reply that they are the parent or to go get the parent.] I am calling to follow up on a letter that the Illinois Department of Children and Family Services (DCFS) sent you about a study you can take part in. Do you have a few minutes for me to tell you more about the study?

If no, ask: When can I call you back to talk to you about the study? [Schedule date/time to call respondent back to discuss the study.]

If not interested in participating, say: Okay, that is no problem at all. Thank you for your time.

If yes, say: Okay, before I go on, I need to let you know that I am going to record this phone call so I can record if you want to take part or not.

[Interviewer, start recorder and proceed with reading the script below.]

Introduction and PURPOSE OF STUDY

The U. S. Department of Health and Human Services has hired Westat, a research company, to study the services Illinois Department of Children and Family Services (DCFS) provides to families. The study will assist us in learning whether the services you and your child receive help children leave foster care sooner. We want your help in finding out if these services work.

Westat is asking you to take part in this study because your child, [insert child’s name], has been selected to take part in a study. It is important that you know that you do not have to be in the study. It is up to you. Even if you agree to be in the study, you can stop being in the study at any time. Your choice will not affect the services that you and your child receive.

Procedures

Now, I’d like to explain more about what the study involves. DCFS assigned your family (using a random process like a coin flip) to get one of two types of services that are meant to help you. With either service, a caseworker will continue to meet with you and your child, make home visits, refer you and your child to needed services, and check on how you and your child are doing. However, you and your child may also receive additional services depending on your DCFS assignment. These extra services will focus on helping you to understand your child’s emotions and behaviors, improve the way you respond to your child’s emotions and behaviors, and learn ways to lower your stress. You will be told if you are chosen to receive these additional services.

While you are getting these services, Westat wants to study whether the services you receive help families.

Participating in interviews:

In order to study the services you and your child receive, we need to find out information about you and your child. We are inviting you to take part in two phone interviews: at the start of services and 6 months later. During the interviews, you will answer questions about your thoughts and feelings in response to stress and the way in which you respond to others, and about the supports you have in your life.

The phone interviews will occur at a time that is best for you. You can ask the researcher questions at any time during the interview. You can also skip questions that you do not want to answer. Each interview will take no more than 15 minutes. There are no right and wrong answers.

Studying your interview responses with DCFS client records:

During the study, the researchers will review the information from questions we ask you and will also review information from the records DCFS has. These records have information about your family, services received from DCFS, and your family’s case progress. We are asking if you will agree to let us to study your answers together with the information we get from your family’s DCFS records. We will use this information only for the study.

RISKS

We do not think there is any risk to you from participating in this study other than normal discomfort from talking about sensitive topics. If any of the questions make you feel upset or sad, you can talk with your caseworker. You can also skip questions that you do not want to answer. The researcher also has a list of local mental health agencies that he or she can provide you.

INCENTIVE FOR PARTICIPATING IN THE STUDY

You will receive a $15 gift card for taking part in each phone interview. The gift card will be sent to you by postage mail after the interview.

BENEFITS FOR PARTICIPATING IN THE STUDY

There are no direct benefits to you in taking part in the interviews. But, taking part will help DCFS find better ways to serve children and families.

PARTICIPANT and data Privacy

We will keep your information private to the extent permitted by law. Wewill not include information that identifies you or your family in any reports; information will only be reported for the entire group of families studied. The information you provide will not be shared with your caseworker. However, it may be shared with a therapist that serves you and/or your child to help with service planning. We will use your information for research only.

To help us keep your information private, we received a Certificate of Confidentiality from the U. S. Department of Health and Human Services. With this Certificate, no one can force us to share information that may identify you, even in any court or legal proceeding or under a court order or subpoena. But, we will in all cases take necessary action, including reporting to authorities, to prevent harm to yourself or others. This includes reporting suspected child abuse or neglect.

To make sure that Westat researchers are collecting the data right, another Westat researcher may ask to listen in during your interview. We will ask you ahead of time so you can decide if the other researcher can listen in or not.

Voluntary participation

As mentioned before, you can decide if you want to take part in the study. Even if you agree to be in the study, you can stop being in the study at any time. Your decision about whether or not to take part in the study will not affect the services that you and your child receive.

CONTACTS FOR QUESTIONS ABOUT THE STUDY

If you have any questions about the study, please call Raquel Ellis 1-800-WESTAT1 (937-8281), x5173, or raquelellis@westat.com. If you have any questions about your rights as person taking part in the study, please contact the Westat Institutional Review Board (IRB) Administrator at 1-800-WESTAT1 (937-8281), x8828. This information is in the letter that DCFS sent to you about the study.

Participation decision

Do you have any questions about anything I read to you? Do you understand everything that I have read to you?

Do you agree to take part in the interviews and let Westat use your interview answers in the study?

 No

If no, say: Okay, that is no problem. Thank you for letting me tell you about the study.

 Yes

If yes, say: Please repeat the following statement if you are willing to take part in the study: I, [insert parent’s name], agree to take part in the study interviews.

Then ask: Do you agree to let Westat study your interview answers with the information we get from the DCFS records on your family?

 Yes  No

RESEARCH STAFF USE ONLY:

Child Evaluation ID______________________

____________________________________ _______________________________________

Study representative’s signature Date

C3. DCFS Biological Parent Interview

OMB NO: 0970-0355
EXPIRATION DATE: 01/31/2015

C3. DCFS Biological Parent Interview

Abbreviated Dysregulation Inventory
Instructions:
I am going to read you a series of statements. I would like you to tell me how often they are true of you by circling the number that best describes you. There are no right or wrong answers.

		Never True	Occasionally True	Mostly True	Always True
1.	I have trouble controlling my temper.	0	1	2	3
2.	I have difficulty remaining seated at school or at home during dinner.	0	1	2	3
3.	I develop a plan for all my important goals.	0	1	2	3
4.	I lose sleep because I worry.	0	1	2	3
5.	I get very fidgety after a few minutes if I am supposed to sit still.	0	1	2	3
6.	I put my plans into action.	0	1	2	3
7.	When I am angry I lose control over my actions.	0	1	2	3
8.	I have difficulty keeping attention on tasks.	0	1	2	3
9.	I think about the future consequences of my actions.	0	1	2	3
10.	I get so frustrated that I often feel like a bomb ready to explode.	0	1	2	3
11.	I get into arguments when people disagree with me.	0	1	2	3
12.	Once I have a goal I make a plan to reach it.	0	1	2	3
13.	I fly off the handle for no good reason.	0	1	2	3
14.	Little things or distractions throw me off.	0	1	2	3
15.	As soon as I see things are not working, I do something about it.	0	1	2	3
16.	There are days when I'm "on edge" all the time.	0	1	2	3
17.	I can’t seem to stop moving.	0	1	2	3
18.	I consider what will happen before I make a plan.	0	1	2	3
19.	I easily become emotionally upset when I am tired.	0	1	2	3
20.	Most of the time I don't pay attention to what I am doing.	0	1	2	3
21.	I think about my mistakes to make sure they don't happen again.	0	1	2	3
22.	Often I am afraid I will lose control of my feelings	0	1	2	3
23.	I get bored easily.	0	1	2	3
24.	I spend time thinking about how to reach my goals.	0	1	2	3
25.	I slam doors when I am mad.	0	1	2	3
26.	I am easily distracted.	0	1	2	3
27.	Failure at a task or in school makes me work harder.	0	1	2	3
28.	My mood goes up and down without reason.	0	1	2	3
29.	I spend money without thinking about it first.	0	1	2	3
30.	I stick to a task until it is finished.	0	1	2	3

Burden Statement: This collection of information is voluntary and will be used to evaluate the Permanency Innovations Initiative. Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Reports Clearance Officer (Attn: OMB/PRA 0970-0355), Office of Planning, Research and Evaluation, Administration for Children and Families, Department of Health and Human Services, 370 L’Enfant Promenade S.W., Washington DC 20447.

Social Provisions Scale

Instructions

In answering the next set of questions I am going to ask you, I want you to think about your current relationship with friends, family members, coworkers, community members, and so on. Please tell me to what extent you agree that each statement describes your current relationships with other people. Use the following scale to give me your opinion. (Hand a response card.) So, for example, if you feel a statement is very true of your current relationships, you would tell me “strongly agree.” If you feel a statement clearly does not describe your relationships, you would respond “strongly disagree.” Do you have any questions?

Strongly Disagree Disagree Agree Strongly Agree

1 2 3 4

1. There are people I can depend on to help me if I really need it.
2. I feel that I do not have close personal relationships with other people.
3. There is no one I can turn to for guidance in times of stress.
4. There are people who depend on me for help.
5. There are people who enjoy the same social activities I do.
6. Other people do not view me as competent.
7. I feel personally responsible for the well-being of another person.
8. I feel part of a group of people who share my attitudes and beliefs.
9. I do not think other people respect my skills and abilities.
10. If something went wrong, no one would come to my assistance.
11. I have close relationships that provide me with a sense of emotional security and well-being.
12. There is someone I could talk to about important decisions in my life.
13. I have relationships where my competence and skills are recognized.
14. There is no one who shares my interests and concerns.
15. There is no one who really relies on me for their well-being.
16. There is a trustworthy person I could turn to for advice if I were having problems.
17. I feel a strong emotional bond with at least one other person.
18. There is no one I can depend on for aid if I really need it.
19. There is no one I feel comfortable talking about problems with.
20. There are people who admire my talents and abilities.
21. I lack a feeling of intimacy with another person.
22. There is no one who likes to do the things I do.
23. There are people I can count on in an emergency.
24. No one needs me to care for them.

C4. DCFS Foster Parent FAQ Letter and Consent Form

OMB NO: 0970-0355
EXPIRATION DATE: 01/31/2015

C4. DCFS Foster Parent FAQ Letter and Consent Form

FAQ Letter

This document will be on Illinois Department of Children and Family Services Letterhead

Dear Substitute Care Provider,

Westat invites you to take part in a study with the Illinois Department of Children and Family Services (DCFS). Westat, a company hired by the U.S. Department of Health and Human Services, is leading the study. Please read the following information carefully. It is important that you understand the purpose of the study and what it will involve. Your choice to take part in the study or not will not affect your case or the services that you and your family get.

We are inviting you to take part in this study because a child currently in your care, [insert child’s name], has been selected to participate in this study. We will also invite [insert child’s name] to take part in the study. This letter is to give you information about your invitation to participate. You do not have to be in the study. Your choice will not affect the services that you and the child receive.

Why is Westat doing this study?

The study will assist us in learning whether the services you and the child in your care receive help children leave foster care sooner. We want your help in finding out if these services work.

Why do you want me to take part in this study?

DCFS assigned the child in your care and his/her family (using a random process like a coin flip) to get one of two types of services that are meant to help this family and benefit you as well. With either service, a caseworker will continue to meet with you and the child, make home visits, refer you and the child to needed services, and check on how you and the child are doing. However, you may also receive extra services depending on your DCFS assignment. These extra services will focus on improving your understanding of the youth’s emotions and behaviors, improving the way you respond to the youth’s emotions and behaviors, and learn ways to lower your stress. You will be told if you are chosen to receive these extra services.

While you are getting these services, Westat wants to study whether the services you and the child receive help families.

What am I being asked to do now?

Do I have to take part in this study?

No. After the researcher tells you more about the study, you can decide if you want to participate. You can stop being in the study at any time. Taking part in the study or not will not affect the services that you and the child in your care receive.

What will I be asked to do if I take part in the study?

In order to study the services you and the child’s family receive, we need to find out information about you and the child in your care. We are inviting you to participate in two in-person interviews: at the start of services and 6 months later. During the interviews, you will answer questions about the supportive network you have in your life, your parenting practices with the child in your care, and the behaviors of the child in your care.

The interviews will occur at your home at a time that is best for you. For your privacy, you will use a computer to answer the questions. If you need help using the computer or answering the questions, you can ask the researcher questions at any time during the interview. You can also skip questions that you do not want to answer. Each interview will take no more than 40 minutes. There are no right and wrong answers.

Do I get anything for taking part in the study?

Yes. You will get a $20 gift card for taking part in each interview.

Are there any risks or discomforts to taking part in the study?

We do not expect being in the study has any risk. The interview questions do not include sensitive topics. But, if any of the questions make you feel upset or sad, you can talk with the child’s caseworker. You can also skip questions that you do not want to answer. The Westat researcher also has a list of local mental health agencies that he or she can provide you.

Will what I share during the study be kept private?

We will keep your information private to the extent permitted by law. We will not include information that identifies you or your family in any reports; information will only be reported for the entire group of families studied. The information you provide will not be shared with your caseworker. However, it may be shared with a therapist that serves you and/or the child in your care to help with service planning. We will use your information for research only.

What if I do not want DCFS to share my contact information with Westat?

If you do not want DCFS to share your contact information with Westat, please call [insert DCFS contact name] at [insert DCFS contact number] by (DATE TBD).

What if I have questions?

Consent Form

Introduction and PURPOSE OF STUDY

The U. S. Department of Health and Human Services has hired Westat, a research company, to study the services Illinois Department of Children and Family Services (DCFS) provides to families. The study will assist us in learning whether the services you and the child in your care receive help children leave foster care sooner. We want your help in finding out if these services work.

We are inviting you to take part in this study because a child currently in your care, [insert child’s name], has been selected to take part in a study. You do not have to be in the study. Even if you agree to be in the study, you can stop being in the study at any time. Your choice will not affect the services that you and the child receive.

Procedures

DCFS assigned the child in your care and the child’s family (using a random process like a coin flip) to get one of two types of services that are meant to help this family and benefit you as well. With either service, a caseworker will continue to meet with you and the child, make home visits, refer you and the child to needed services, and check on how you and the child are doing. However, you may also receive extra services depending on your DCFS assignment. These extra services will focus on improving your understanding of the youth’s emotions and behaviors, improving the way you respond to the youth’s emotions and behaviors, and learn ways to lower your stress. You will be told if you are chosen to receive these extra services.

While you are getting these services, Westat wants to study whether the services you receive help families.

Participating in interviews:

In order to study the services you and the child’s family receive, we need to find out information about you and the child in your care. We are asking you to take part in two in-person interviews: at the start of services and 6 months later. During the interviews, you will answer questions about the supports you have in your life, the way you parent the child in your care, and the behaviors of the child in your care.

Studying your interview responses with DCFS client records:

During the study, Westat researchers will review the information from questions we ask you and will also review information from the records DCFS has. These records have information about the child, the child’s family, services received from DCFS, and the family’s case progress. We are asking if you will agree to let us to study your answers together with the information we get from the family’s DCFS records. We will use this information only for the study.

RISKS

We do not think being in the study has any risk. The interview questions do not include sensitive topics. But, if any of the questions make you feel upset or sad, you can talk with the child’s caseworker. You can also skip questions that you do not want to answer. The researcher also has a list of local mental health agencies that he or she can provide you.

INCENTIVE FOR PARTICIPATING IN THE STUDY

You will receive a $20.00 gift card for taking part in each interview.

BENEFITS FOR PARTICIPATING IN THE STUDY

There are no direct benefits to you in taking part in the interviews. But, taking part will help DCFS find better ways to serve children and families.

PARTICIPANT and data Privacy

We will keep your information private to the extent permitted by law. We will not include information that names you or your family in any reports; information will only be reported for the entire group of families studied. The information you provide will not be shared with your caseworker. However, it may be shared with a therapist that serves you and/or the child in your care to help with service planning. We will use your information for research only.

To help us keep your information private, we received a Certificate of Confidentiality from the U. S. Department of Health and Human Services. With this Certificate, no one can force us to share information that may identify you, even in any court or legal proceeding or under a court order or subpoena. But, we will in all cases take necessary action, including reporting to authorities, to prevent harm to yourself or others. This includes reporting suspected child abuse or neglect.

To make sure that the researchers are collecting the data right, another researcher may ask to sit in during your interview. We will ask you ahead of time so you can decide if the other researcher can sit in or not.

Voluntary participation

You can decide if you want to take part in the study. You can stop being in the study at any time. Taking part in the study or not will not affect the services that you and the child in your care receives.

CONTACTS FOR QUESTIONS ABOUT THE STUDY

If you have any questions about the study, please contact:

Raquel Ellis, Westat Study Contact

1-800-WESTAT1 (937-8281), x5173

raquelellis@westat.com

For questions about the your rights as a participant in this study, contact:

The Westat Institutional Review Board (IRB) Administrator, 1-800-WESTAT1 (937-8281), x8828

SIGNATURE

Signing below means that you read or listened to someone read this form to you, that you understand what it says, and you agree to take part in the study. You will receive a copy of this form. If you do not want to take part in the study, please let the researcher know.

_________________________ ____________________________

Participant’s Signature Participant’s Name

Signing below means that you agree to let Westat study your interview answers with the DCFS records for this child’s family.

_________________________ ____________________________

Participant’s Signature Participant’s Name

_________________________

Date

RESEARCH STAFF USE ONLY

Parent declined to participate in data collection.

C5. DCFS Youth FAQ Letter and Assent Form

OMB NO: 0970-0355
EXPIRATION DATE: 01/31/2015

C5. DCFS Youth FAQ Letter and Assent Form

Youth FAQ Letter (ages 11-16)

This document will be on Illinois Department of Children and Family Services Letterhead

Westat, a research company, is inviting you to take part in a research study about services you are getting from the Illinois Department of Children and Family Services (DCFS). You do not have to be in the study. It is up to you. This letter describes some information about the study. A Westat researcher or your caseworker will contact you soon to see if you are interested in meeting with a Westat researcher to learn more about the study.

What is a research study?

A study collects information so people can understand something better.

Why is Westat doing this study?

We want to find out if the services you receive help you and your family. If they do, they may also help other children and families.

What will happen if I am in this study?

If you are okay with taking part in the study, you will meet in a private place with a researcher to answer questions about yourself and your family. The researcher will then come back 6 months later and you will be asked similar questions. The questions will take about 40 minutes to answer. There are no right and wrong answers.

For your privacy, you will use a computer to answer the questions. If you need help using the computer or answering the questions, you can ask the researcher questions at any time during the interview.

What am I being asked to do now?

Nothing. A Westat researcher or your caseworker you or your caregiver soon to schedule a meeting between you and a Westat researcher to help you to learn more about the study.

Do I have to be in the study?

The DCFS guardian has given consent for us to talk to you, but you can choose not to talk to us. Once you meet with the researcher to learn more about the study, you can decide if you want to take part or not. No one will get mad at you if you do not want to be in the study. Your decision will not change the services you currently get.

Do I get anything for being in the study?

Yes. You will get a $20 gift card each time you take part in an interview.

Are there any risks to being in the study?

Talking about family can sometimes make people feel sad. If any of the questions make you feel upset or sad, you can ask to skip those questions. You can also talk with your caseworker if you are still feeling sad or upset after your meeting with the researcher. You can end the meeting with the researcher at any time.

Will what I share during the study be kept private?

We will keep what you tell us private to the extent permitted by law. We will combine what you tell us with what other kids tell us when we write reports about the study. No names will be in these reports.

To help protect your privacy, the government has provided the research team a Certificate of Confidentiality. With this Certificate, we do not have to tell people that you took part in the study or share with others any of the information that you tell us. However, if you tell us that someone has hurt you or that you want to hurt yourself or someone else, we have to tell the authorities. We may also need to share some of your answers with your therapist so that he or she can better serve you.

To make sure the researchers are following rules when asking you questions, someone may ask to sit in on your interview. If someone wants to sit in, the researcher will let you know and ask you to agree first.

What if I have questions?

Youth Assent (ages 11-16)

Westat, a research company, is inviting you to take part in a research study about services you are getting from the Illinois Department of Children and Family Services (DCFS). You do not have to be in the study. It is up to you. A researcher will review this form with you before you decide whether to take part or not.

What is a research study?

A study collects information so people can understand something better.

Why is Westat doing this study?

We want to find out if the services you receive help you and your family. If they do, they may also help other children and families.

What will happen if I am in this study?

Do I get anything for being in the study?

Yes. You will get a $20 gift card each time you take part in an interview.

There are no direct benefits to you in taking part in the interviews. But, taking part will help DCFS come up with better ways to serve children and families.

Are there any risks to being in the study?

Will what I share during the study be kept private?

Do I have to be in the study?

The DCFS guardian has given consent for us to talk to you, but you can choose not to talk to us. No one will get mad at you if you do not want to be in the study. Your decision will not change the services you currently get.

What if I have questions?

If you have questions right now, please talk to the person who reviews this form with you. You can also call the people below.

If you have any questions about the study, please contact:

Raquel Ellis, Westat Study Contact

1-800-WESTAT1 (937-8281), x5173

raquelellis@westat.com

For questions about the your rights as a participant in this study, contact:

The Westat Institutional Review Board (IRB) Administrator, 1-800-WESTAT1 (937-8281), x8828

Signature

Signing this form means that you read or listened to someone read this form to you, you understand what it says, and you agree to take part in the study. You will receive a copy of this form. If you do not want to take part in the study, please let the researcher know.

___________________________________

Child’s Signature

_____________________________________

Print Name

_________________________________________

Child’s Signature

_____________________________________

Print Name

___________________________________

Date

FOR RESEARCH STAFF USE ONLY
Youth declined to participate in data collection.

C6. DCFS Youth and Foster Parent Study Contact Form

OMB NO: 0970-0355
EXPIRATION DATE: 01/31/2015

C6. DCFS Youth and Foster Parent Study Contact Form

Complete this form for each youth enrolled in the study after the foster parent declines or agrees to the release of their contact information.

YOUTH INFORMATION

Youth Name

Evaluation ID

Is the youth more comfortable reading in Spanish?
Yes	No

Foster Parent Contact Information

Did the foster parent agree to the release his/her contact information?

No (skip to caseworker section)

Is this a new foster home within the last month?

Name

Phone:	Alternate Phone:

Address:
Apt/Room/Bldg:
City:	State:	Zip Code:

Caseworker Contact information

Name

Phone:

Alternate Phone:

Work Address:

Room/Bldg:

City:

State:

Zip Code:

FOR OFFICE USE
Staff person who completed this document:
Date document completed:	/ /

C7. DCFS Foster Parent Interview

OMB NO: 0970-0355
EXPIRATION DATE: 01/31/2015

C7. DCFS Foster Parent Interview

Abbreviated Dysregulation Inventory-Parent Version
Instructions:
I am going to read you a series of statements. I would like you to tell me how often they are true of the child in your care by circling the number that best describes you. There are no right or wrong answers.

		Never True	Occasionally True	Mostly True	Always True
1.	The child has trouble controlling his/her temper.	0	1	2	3
2.	The child has difficulty remaining seated at school or at home during dinner.	0	1	2	3
3.	The child develops a plan for all his/her important goals.	0	1	2	3
4.	The child loses sleep because he/she worries.	0	1	2	3
5.	The child gets very fidgety after a few minutes if he/she is supposed to sit still.	0	1	2	3
6.	The child put his or her plans into action.	0	1	2	3
7.	When the child is am angry he/she loses control over his/her actions.	0	1	2	3
8.	The child has difficulty keeping attention on tasks.	0	1	2	3
9.	The child thinks about the future consequences of his/her actions.	0	1	2	3
10.	The child gets so frustrated that he/she often feels like a bomb ready to explode.	0	1	2	3
11.	The child gets into arguments when people disagree with him/her.	0	1	2	3
12.	Once the child has a goal he/she makes a plan to reach it.	0	1	2	3
13.	The child flies off the handle for no good reason.	0	1	2	3
14.	Little things or distractions throw the child off.	0	1	2	3
15.	As soon as the child see things are not working, he/she does something about it.	0	1	2	3
16.	There are days when the child is "on edge" all the time.	0	1	2	3
17.	The child can’t seem to stop moving.	0	1	2	3
18.	The child considers what will happen before he/she makes a plan.	0	1	2	3
19.	The child easily becomes emotionally upset when he/she is tired.	0	1	2	3
20.	Most of the time the child doesn’t pay attention to what he/she is doing.	0	1	2	3
21.	The child thinks about his/her mistakes to make sure they don't happen again.	0	1	2	3
22.	Often the child is afraid he/she will lose control of his/he feelings	0	1	2	3
23.	The child gets bored easily.	0	1	2	3
24.	The child spends time thinking about how to reach his/her goals.	0	1	2	3
25.	The child slams doors when he/she is mad.	0	1	2	3
26.	The child is easily distracted.	0	1	2	3
27.	Failure at a task or in school makes the child work harder.	0	1	2	3
28.	The child’s mood goes up and down without reason.	0	1	2	3
29.	The child spends money without thinking about it first.	0	1	2	3
30.	The child sticks to a task until it is finished.	0	1	2	3

Burden Statement: This collection of information is voluntary and will be used to evaluate the Permanency Innovations Initiative. Public reporting burden of this collection of information is estimated to average 40 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Reports Clearance Officer (Attn: OMB/PRA 0970-0355), Office of Planning, Research and Evaluation, Administration for Children and Families, Department of Health and Human Services, 370 L’Enfant Promenade S.W., Washington DC 20447.

Social Provisions Scale

Instructions

In answering the next set of questions I am going to ask you, I want you to think about your current relationship with friends, family members, coworkers, community members, and so on. Please tell me to what extent you agree that each statement describes your current relationships with other people. Use the following scale to give me your opinion. (Hand a response card.) So, for example, if you feel a statement is very true of your current relationships, you would tell me “strongly agree”. If you feel a statement clearly does not describe your relationships, you would respond “strongly disagree”. Do you have any questions?

Strongly Disagree Disagree Agree Strongly Agree

1 2 3 4

1. There are people I can depend on to help me if I really need it.
2. I feel that I do not have close personal relationships with other people.
3. There is no one I can turn to for guidance in times of stress.
4. There are people who depend on me for help.
5. There are people who enjoy the same social activities I do.
6. Other people do not view me as competent.
7. I feel personally responsible for the well-being of another person.
8. I feel part of a group of people who share my attitudes and beliefs.
9. I do not think other people respect my skills and abilities.
10. If something went wrong, no one would come to my assistance.
11. I have close relationships that provide me with a sense of emotional security and well-being.
12. There is someone I could talk to about important decisions in my life.
13. I have relationships where my competence and skills are recognized.
14. There is no one who shares my interests and concerns.
15. There is no one who really relies on me for their well-being.
16. There is a trustworthy person I could turn to for advice if I were having problems.
17. I feel a strong emotional bond with at least one other person.
18. There is no one I can depend on for aid if I really need it.
19. There is no one I feel comfortable talking about problems with.
20. There are people who admire my talents and abilities.
21. I lack a feeling of intimacy with another person.
22. There is no one who likes to do the things I do.
23. There are people I can count on in an emergency.
24. No one needs me to care for them.

Parenting Practices Chicago Survey - Parent Version

The following questions have to do with the kinds of things that you and (adolescent’s name) may have talked about, or have done together in the past 2 months. Please choose the response that best represents your answer.

1. When was the last time that you discussed with ______________his/her plans for the coming day?

_Don't_know
More than 1 month ago
Within the last month
Within the last week
Yesterday/Today

2. In the past 2 months, about how often have you discussed with his/her plans for the coming day?

_{Don't know}
_{Less than once a month}
_{At least once a month}
_{At least once a week}
_{Almost every day}

3. When was the last time you talked with about what he/she actually done during the day?

_{Don't know}
_{More than 1 month ago}
_{Within the last month}
_{Within the last week}
_{5= Yesterday/Today}

4. In the past 2 months, about how often have you talked with about what he/she had actually done during the day?

_{Don't know}
_{More than 1 month ago}
_{Within the last month}
_{Within the last week}
_{Yesterday/Today}

5. Does ________have a set time to be home on school nights?

_{No set time}
_{Sometimes set time}
_{Always set time}

6. Does ________have a set time to be home on weekend nights?

_{No set time}
_{Sometimes set time}
_{Always set time}

7. Does _________help with family fun activities?

_{Hardly ever}
_Sometimes
_Often

8. Does__________ like to get involved in such family activities?

_{Hardly ever}
_Sometimes
_Often

9. How often do you have time to listen to when he/she wants to talk to you?

_{Hardly ever}
_Sometimes
_Often

10. Do you and do things together at home?

_{Hardly ever}
_Sometimes
_Often

11. Does _____________go with members of the family to movies, sports events, or other outings?

_{Hardly ever}
_Sometimes
_Often

12. How often do you have a friendly talk with ?

_{Hardly ever}
_Sometimes
_Often

13. Does help you with chores, errands and/or other work?

_{Hardly ever}
_Sometimes
_Often

14. Do you talk with about how he/she is doing in school?

_{Hardly ever}
_Sometimes
_Often

15. On average, how much time are you together with the child on weekdays, that is, when you and your child are both awake?

_{Less than 30 minutes/day}
_{30 minutes to 1 hour}
_{More than 1 hour, less than 3}
_{3 to 6 hours}
_{More than 6 hours}

16. On average, how much time are you together with the child on weekends?

_{Less than 30 minutes/day}
_{30 minutes to 1 hour}
_{More than 1 hour, less than 3}
_{3 to 6 hours}
_{More than 6 hours}

17. On weekdays, how much of that time are you doing something together, like making something, playing a game, talking, or going out together but not just watching TV?

_{Less than 30 minutes/day}
_{30 minutes to 1 hour}
_{More than 1 hour, less than 3}
_{3 to 6 hours}
_{More than 6 hours}

18. On weekends, how much of that time are you doing something together, like making something, playing a game, talking, or going out together but not just watching TV?

_{Less than 30 minutes/day}
_{30 minutes to 1 hour}
_{More than 1 hour, less than 3}
_{3 to 6 hours}
_{More than 6 hours}

19. If __________did not come home by the time that was set, would you know?

_{No or very unlikely}
_Probably
_Certainly

20. When _______is out, do you know what time he/she will be home?

_{No or very unlikely}
_Probably
_Certainly

21. Is it important to you to know what is doing when he/she is outside of the home?

_{No, not important}
_{Yes, somewhat important}
_{Yes, very important}

The following questions ask about where ___________is when he/she is not in school.

22. Where does ______________usually go after school?

_{Don't know}
_{Somewhere else, unsupervised}
_{Home, unsupervised}
_{Somewhere else, supervised}
_{Home, supervised}

23. Where is he/she usually on weekends?

_{Don't know}
_{Somewhere else, unsupervised}
_{Home, unsupervised}
_{Somewhere else, supervised}
_{Home, supervised}

24. If you or another adult are not at home, does _______________leave you a note or call you to let you know where he/she is going?

_{Almost never}
_Sometimes
_{Almost always}

25. Do you know who _________________'s companions or friends he/she is with when he/she is not at home?

_{Almost never}
_Sometimes
_{Almost always}

26. When you are not at home, does _______know how to get in touch with you?

_{Almost never}
_Sometimes
_{Almost always}

27. When you and _________________are both at home, do you know what he/she is doing?

_{Almost never}
_Sometimes
_{Almost always}

In the past 2 months, when ______________did something that you liked or approved of, how often did you…

28. give him/her a wink or a smile?

_{Almost never}
_Sometimes
_{Almost always}

29. say something nice about it; give him/her praise or give approval?

_{Almost never}
_Sometimes
_{Almost always}

30. give him/her a hug, pat on the back, or a kiss for it?

_{Almost never}
_Sometimes
_{Almost always}

31. give him/her some reward for it, like a present, extra money, or something special to eat?

_{Almost never}
_Sometimes
_{Almost always}

32. give him/her a special privilege such as staying up late, or doing some special activity?

_{Almost never}
_Sometimes
_{Almost always}

33. do something special together, such as going to the movies, to a game, playing a game, or going somewhere?

_{Almost never}
_Sometimes
_{Almost always}

34. Is the discipline you use effective for your son/daughter? Does it work?

_{Not really}
_{Half of the time}
_Usually

35. If your son/daughter is punished, does the punishment work?

_{Not really}
_{Half of the time}
_Usually

36. If you punish___________ does his/her behavior get worse?

_{Almost never}
_Sometimes
_{Almost always}

37. Do you hesitate to enforce the rules with _____________because you fear he/she might then harm someone in your household?

_{Almost never}
_Sometimes
_{Almost always}

38. Do you feel that you must be careful not to upset ?

_{Almost never}
_Sometimes
_{Almost always}

39. Do you feel that other family members must be careful not to upset _____________?

_{Almost never}
_Sometimes
_{Almost always}

40. Do you feel that it is more trouble than it is worth to ask___________ to help you?

_{Almost never}
_Sometimes
_{Almost always}

41. Do you think that ________ will take it out on other children if you try to make him/her obey you?

_{Almost never}
_Sometimes
_{Almost always}

42. When you are by yourself, do you have much difficulty controlling ________________?

_{Almost never}
_Sometimes
_{Almost always}

43. When other adults are present, do you have much difficulty controlling _________________?

_{Almost never}
_Sometimes
_{Almost always}

44. Do you leave ____________alone because of his/her moodiness?

_{Almost never}
_Sometimes
_{Almost always}

45. Do you think that ______will try to get back at you if you try to make him/her obey you?

_{Almost never}
_Sometimes
_{Almost always}

C9. DCFS Youth Interview

OMB NO: 0970-0355
EXPIRATION DATE: 01/31/2015

C9. DCFS Youth Interview

Abbreviated Dysregulation Inventory
Instructions:
I am going to read you a series of statements. I would like you to tell me how often they are true of you by circling the number that best describes you. There are no right or wrong answers.

		Never True	Occasionally True	Mostly True	Always True
1.	I have trouble controlling my temper.	0	1	2	3
2.	I have difficulty remaining seated at school or at home during dinner.	0	1	2	3
3.	I develop a plan for all my important goals.	0	1	2	3
4.	I lose sleep because I worry.	0	1	2	3
5.	I get very fidgety after a few minutes if I am supposed to sit still.	0	1	2	3
6.	I put my plans into action.	0	1	2	3
7.	When I am angry I lose control over my actions.	0	1	2	3
8.	I have difficulty keeping attention on tasks.	0	1	2	3
9.	I think about the future consequences of my actions.	0	1	2	3
10.	I get so frustrated that I often feel like a bomb ready to explode.	0	1	2	3
11.	I get into arguments when people disagree with me.	0	1	2	3
12.	Once I have a goal I make a plan to reach it.	0	1	2	3
13.	I fly off the handle for no good reason.	0	1	2	3
14.	Little things or distractions throw me off.	0	1	2	3
15.	As soon as I see things are not working, I do something about it.	0	1	2	3
16.	There are days when I'm "on edge" all the time.	0	1	2	3
17.	I can’t seem to stop moving.	0	1	2	3
18.	I consider what will happen before I make a plan.	0	1	2	3
19.	I easily become emotionally upset when I am tired.	0	1	2	3
20.	Most of the time I don't pay attention to what I am doing.	0	1	2	3
21.	I think about my mistakes to make sure they don't happen again.	0	1	2	3
22.	Often I am afraid I will lose control of my feelings	0	1	2	3
23.	I get bored easily.	0	1	2	3
24.	I spend time thinking about how to reach my goals.	0	1	2	3
25.	I slam doors when I am mad.	0	1	2	3
26.	I am easily distracted.	0	1	2	3
27.	Failure at a task or in school makes me work harder.	0	1	2	3
28.	My mood goes up and down without reason.	0	1	2	3
29.	I spend money without thinking about it first.	0	1	2	3
30.	I stick to a task until it is finished.	0	1	2	3

Burden Statement: This collection of information is voluntary and will be used to evaluate the Permanency Innovations Initiative. Public reporting burden of this collection of information is estimated to average 40 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Reports Clearance Officer (Attn: OMB/PRA 0970-0355), Office of Planning, Research and Evaluation, Administration for Children and Families, Department of Health and Human Services, 370 L’Enfant Promenade S.W., Washington DC 20447.

Youth Social Support Instrument

This set of questions is about the support you receive from family members, friends, and people in your community. Please choose the response that best represents your answer to the question.

1. Is there an adult (or adults) you can turn to for help if you have a serious problem?

__ NO (0) (Skip to 3)

__ YES (1)

2a. Could you go to a parent or someone who is like a parent, with a serious problem?

__ NO (0)

__ YES (1)

2b. Could you go to another relative (not a parent), with a serious problem?

__ NO (0)

__ YES (1)

2c. Could you go to another adult (not a relative), with a serious problem?

__ NO (0)

__ YES (1)

2d. Could you go to a friend or relative about your age with a serious problem?

__ NO (0)

__ YES (1)

3. In the 6 months, has there been an adult, OUTSIDE OF YOUR FAMILY, who

has encouraged you and believed in you?

__ NO (0) (Skip to 4)

__ YES (1)

3a. Would you say this has made a difference in your life?

__ NO (0)

__ YES (1)

In the past 6 months, has there been an adult WITHIN YOUR FAMILY, who has

encouraged you and believed in you?

__NO (Skip to 5)

__YES

4a. Would you say this has made a difference in your life?

__NO

__YES

Think about the adult in your life, other than a parent or guardian, who you have felt closest to or who has helped you the most.

Who is this adult?

1 - Your grandfather

2 - Your grandmother

3 - Another relative

4 - A teacher, coach, or other adult at school

5 - Another adult

6 - There is no one like this (skip to next form)

How old were you when {HE/ SHE} first became important in your life?

0 –1 year old 10 - 10 years
2 years 11 - 11 years
3 years 12 - 12 years
4 years 13 - 13 years
5 years 14 - 14 years
6 years 15 - 15 years
7 years 16 - 16 years
8 years 17 - 17 years
9 years 18 - 18 or more years

7. Is this person still living?

0 - No

1 - Yes

9 - I don’t know

If answer is 0 or 9, skip to 11

If answer is 1, skip question 11

8. Is {HE/ SHE} still important to you?

0 - No

1 - Yes

How often do you see {HIM/ HER}?

1 - Less than once a year

2 - About once a year to every few months

3 - About once a month to once a week

4 - Two to five times a week

5 - Almost every day

How often do you communicate with {HIM/ HER} in other ways, like

talking on the phone, sending emails, or writing letters?

1 - Less than once a year

2 - About once a year to every few months

3 - About once a month to once a week

4 - Two to five times a week

5 - Almost every day

11. How old were you the last time you had contact with {HIM/ HER}?

1 - 0 – 1 year old 10 - 10 years

2 - 2 years 11 - 11 years

3 - 3 years 12 - 12 years

4 - 4 years 13 - 13 years

5 - 5 years 14 - 14 years

6 - 6 years 15 - 15 years

7 - 7 years 16 - 16 years

8 - 8 years 17 - 17 years

9 - 9 years 18 - 18 or more years

How much did {HE/ SHE} do the following:

12a. Showed that s/he cared about you and was there to listen when you needed

to talk to someone?

1 - A lot

2 - Some

3 - A Little

4 - Not at all

12b. Taught you things, showed you how to do things, or helped you with

something you were working on?

1 - A lot

2 - Some

3 - A Little

4 - Not at all

How much did {HE/ SHE} do the following:

12c. Spent time with you talking or doing things, or going places with you for

fun?

1 - A lot

2 - Some

3 - A Little

4 - Not at all

12d. Helped you solve problems, or helped you find a way to do something you

wanted to do?

1 - A lot

2 - Some

3 - A Little

4 - Not at all

12e. Helped get you things you needed, took you places you needed to go, or gave

you money?

1 - A lot

2 - Some

3 - A Little

4 - Not at all

How close do/did you feel to {HIM/ HER}?

1 - Extremely close

2 - Quite close

3 - Somewhat close

4 - Not very close

Trauma Symptom Checklist for Children (TSCC) – Alternative Version

Approval is underway to use this instrument. It is designed to assess distress and related symptoms after an acute or chronic trauma including Anxiety, Depression, Anger, Posttraumatic Stress, and Dissociation.

Parent Contact with Youth Instrument¹

The next group of questions is about contact with the parent(s) that your caseworker is working to bring you back together with.

1) First, did you visit with your mother in the past month, or since [insert date from 1 month ago]?

_____ YES

_____ NO

1a) IF YES: How many visits did you have with your mother in the past month?

_________ VISITS

2) Did you have other contact with her in the past month, like phone calls, letters, emails, texting, or contact on Facebook?

_____ YES

_____ NO

2a) IF YES: In the past month, how often did you have …

Phone calls with your mother?

_____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

Letters sent to your mother?

_____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

Letters received from your mother?

_____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

Email exchanges with your mother?

_____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

Text exchanges with your mother?

_____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

Facebook contacts with your mother?

_____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

3) How satisfied are you with this level of visits and contact? Would you say it is…

_____ Not enough contact,

_____ Just the right amount contact, or

_____ Too much contact?

4) Did you visit with your father in the past month?

_____ YES

_____ NO

4a) IF YES: How many visits did you have with him in the past month?

_______ VISITS

5) Did you have other contact with him in the past month, like phone calls, letters, emails, texting, or contact on Facebook?

_____ YES

_____ NO

IF YES: In the past month, how often did you have …

Phone calls with your father?

_____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

Letters sent to your father?

_____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

Letters received from your father?

_____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

Email exchanges with your father?

_____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

Text exchanges with your father?

_____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

Facebook contacts with your father?

_____None

_____Less than once a month

_____Once or twice a month

_____About once a week

_____Several times a week

_____1 to 5 times every day

_____5-10 times every day

______10 or more times every day

6) How satisfied are you with this level of visits and contact? Would you say it is…

_____ Not enough contact,

_____ Just the right amount contact, or

_____ Too much contact?

Emotional Permanency Questions²

The next set of questions are about how supported you feel by people in your life. Choose a response that best describes how much you agree or disagree with each statement.

1) I have people who expect me to always spend holidays like Christmas and Thanksgiving with them.
____ Strongly Agree
____ Somewhat Agree
____ Somewhat Disagree
____ Strongly Disagree

2) At important events like graduations, I am not sure if there will be people there to celebrate with me.
____ Strongly Agree
____ Somewhat Agree
____ Somewhat Disagree
____ Strongly Disagree

3) I know someone I could always go to if I needed a place to sleep, even if it was in the middle of the night.
____ Strongly Agree
____ Somewhat Agree
____ Somewhat Disagree
____ Strongly Disagree

4) I have adults in my life who I can call at any time if I needed something.

____ Strongly Agree

____ Somewhat Agree

____ Somewhat Disagree

____ Strongly Disagree

1 The questions are from the current Illinois Adult Connections Study.

2 Questions 1-3 are from the current Illinois Adult Connections Study and question 4 is a modified question from the Supportive Connections Inventory being used in the Arizona PII evaluation.

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Molly Buck
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File Created	2021-01-27