Head Start Family Voices Pilot Study

ATTACHMENT A5

PARENT QUESTIONNAIRE

OMB No: Expiration Date:

Head Start Family Voices Pilot Study

Parent Questionnaire

Spring 2013

MPRID:	| | | | | | |
Interviewer ID:	| | | | | |
Date Completed:	| | | / | | | / | 2 | 0 | 1 | 3 | Month Day Year

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is xxxx-xxxx. The time required to complete this collection of information is estimated to average 15 minutes, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the collection of information. This information collection is voluntary. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Mathematica Policy Research, 1100 1st Street, NE, 12th Floor, Washington, DC 20002, Attention: Nikki Aikens.

ABOUT THIS SURVEY

• This questionnaire is an important part of a larger study Mathematica Policy Research is conducting for the Administration for Children and Families, U.S. Department of Health and Human Services. The overall purpose of the Head Start Family Voices Pilot Study is to better understand the experiences and engagement of families participating in Head Start and Early Head Start. Participation in this project is voluntary.

• Most of the questions can be answered by placing an “X” or a “” in the box. For a few questions, you will be asked to provide a brief response.

 or 

| 0 | 2 | YEARS

• If you are unsure how to answer a question, please give the best answer you can.

• The information you provide will be used for research purposes only and will remain private to the extent allowed by law. No one from your child’s program will see your individual responses, and your name will not be attached to any information you give us.

• Your responses will not affect you or your child’s participation in Early Head Start or Head Start, or influence the services you and your child may be receiving.

A1. Are you currently receiving home visits from Early Head Start because you are pregnant?

1 □ Yes, I am pregnant and a home visitor from the program has visited me in my home

0 □ No, I am pregnant but am not receiving home visits

-4 □ I AM NOT PREGNANT

A2. Do you have any children who currently attend Early Head Start?

1 □ Yes

0 □ No

A3. How many of your children currently attend Early Head Start?

| | | CHILD(REN)

A3a. Please tell us the ages of each child who is currently enrolled in Early Head Start. Please provide age in years. If the child is less than 1 year old, please indicate as “00.”

Child #1: | | | YEARS Child #2: | | | YEARS Child #3: | | | YEARS

A3b. Which of the following describes the kind of care you or your child(ren) receive from your Early Head Start program? If you have more than one child enrolled in Early Head Start and they receive different service options, you may indicate ‘yes’ for more than one option.

	MARK ALL THAT APPLY
	YES	NO
a. Services are provided at a child care center and staff may have visited your child in your home a few times per year	1 □	0 □
b. A home visitor, home educator, or home-based teacher from the program visits your child in your home on a regular basis and the program may have also organized group socializations at a child care center	1 □	0 □
c. Your child receives both center-based and home-based services, such as going to a center several days per week and getting home visits at least monthly	1 □	0 □

A4. Do you have any children who currently attend Head Start?

1 □ Yes

0 □ No

A5. How many of your children currently attend Head Start?

| | | CHILD(REN)

A5a. Please tell us the ages of each child who is currently enrolled in Head Start. Please provide age in years.

Child #1: | | | YEARS Child #2: | | | YEARS Child #3: | | | YEARS

A5b. Which of the following describes the kind of care you or your child(ren) receive from your Head Start program? If you have more than one child enrolled in Head Start and they receive different service options, you may indicate ‘yes’ for more than one option.

	MARK ALL THAT APPLY
	YES	NO
a. Services are provided at a child care center and staff may have visited your child in your home a few times per year	1 □	0 □
b. A home visitor , home educator, or home-based teacher from the program visits your child in your home on a regular basis and the program may have also organized group socializations at a child care center	1 □	0 □
c. Your child receives both center-based and home-based services, such as going to a center several days per week and getting home visits at least monthly	1 □	0 □

A6. Before this program year, did you or any of your child(ren) attend any Early Head Start or Head Start program?

1 □ Yes

0 □ No

A7. Are you…

1 □ Male?

2 □ Female?

A8. Please describe your relationship to the (child/children) enrolled in Early Head Start or Head Start. If you have more than one child enrolled in Early Head Start or Head Start and your relationship to each child is different, provide only one relationship for each child.

1 □ Biological parent

2 □ Adoptive parent

3 □ Stepparent

4 □ Guardian or foster parent

5 □ Grandparent

6 □ Sibling or stepsibling

7 □ Other relative (Specify): ________________________________

8 □ Other non-relative (Specify): _____________________________

9 □ I am currently pregnant with/expecting my first child

A9. In what year were you born?

| 1 | 9 || | | YEAR OF YOUR BIRTH

A9a. How old were you when you gave birth to or adopted your first child?

| | | YEARS

1 □ I am currently pregnant with/expecting my first child

A10. Are you of Spanish, Latino, or Hispanic origin?

MARK ONLY ONE

1 □ Yes

0 □ No

A11. What is your racial background?

MARK ALL THAT APPLY

1 □ White

2 □ Black/African American

3 □ Asian

4 □ Native Hawaiian or other Pacific Islander

5 □ American Indian/Alaska Native

6 □ Other (Specify)

A12. What is the highest grade or year of school that you have completed? If you are still in school, please tell us about the last year of schooling you completed.

MARK ONLY ONE

1 □ Eighth grade or less

2 □ Some high school, but no diploma

3 □ High school diploma or GED certificate

4 □ Some technical/vocational school, but no diploma

5 □ Technical/vocational diploma

6 □ Some college courses, but no degree

7 □ Associate’s degree (two-year college)

8 □ Bachelor’s degree (four-year college)

9 □ Graduate or professional degree

A13. Are you currently…

MARK ONLY ONE

1 □ employed for wages, including self-employment,

2 □ out of work but looking for employment, or

3 □ out of work but not looking for employment

(for example, you are retired or disabled/unable to work)

A13a. About how many hours per week do you work?

MARK ONLY ONE

1 □ 5 or less

2 □ 6-20

3 □ 21-40

4 □ 41 or more

A14. Are you currently…

MARK ONLY ONE

1 □ married or living with a partner,

2 □ divorced,

3 □ separated,

4 □ single, or

5 □ widowed?

A15. The next questions are about how you have felt about yourself and your life in the past week. There are no right or wrong answers.

For each question, please indicate how often you have felt or behaved this way during the past week. Did you feel this way rarely or never, some or a little, occasionally or a moderate amount of time, or most or all of the time?

	MARK ONE PER ROW
	RARELY OR NEVER	SOME OR A LITTLE	OCCASIONALLY OR MODERATELY	MOST OR ALL OF THE TIME
a. Bothered by things that usually don’t bother you	1 □	2 □	3 □	4 □
b. You did not feel like eating, your appetite was poor	1 □	2 □	3 □	4 □
c. You could not shake off the blues, even with help from your family and friends	1 □	2 □	3 □	4 □
d. You had trouble keeping your mind on what you were doing	1 □	2 □	3 □	4 □
e. Depressed	1 □	2 □	3 □	4 □
f. That everything you did was an effort	1 □	2 □	3 □	4 □
g. Fearful	1 □	2 □	3 □	4 □
h. Your sleep was restless	1 □	2 □	3 □	4 □
i. You talked less than usual	1 □	2 □	3 □	4 □
j. Lonely	1 □	2 □	3 □	4 □
k. Sad	1 □	2 □	3 □	4 □
l. You could not get “going”	1 □	2 □	3 □	4 □

B1. Do you speak any language other than English?

MARK ONLY ONE

1 □ Yes

0 □ No

B1a. What other languages do you speak?

MARK ALL THAT APPLY

1 □ Spanish

2 □ Chinese (Cantonese, Mandarin)

3 □ Vietnamese

4 □ a Filipino language

5 □ Japanese

6 □ Korean

7 □ American sign language

8 □ Other (Specify): _____________________________________

B2. Which of the following categories best describes your annual household income? Please include the total combined income of all members of your household from all sources before taxes and other deductions.

MARK ONLY ONE

1 □ Less than $10,000

2 □ $10,000 to less than $15,000

3 □ $15,000 to less than $20,000

4 □ $20,000 to less than $25,000

5 □ $25,000 to less than $35,000

6 □ $35,000 to less than $50,000

7 □ $50,000 to less than $75,000

8 □ $75,000 to less than $100,000

9 □ $100,000 or more

B3. Do you now live in…

MARK ONLY ONE

1 □ a house, apartment, or trailer with your family only,

2 □ a house, apartment, or trailer you share with one or more families,

3 □ transitional housing (apartment) or a homeless shelter, or

4 □ somewhere else?

(Specify): ________________________________

B4. How many times have you moved in the last 12 months?

| | | NUMBER

Thank you very much for your help! If you have any questions about this questionnaire or the Head Start Family Voices Pilot Study, please contact Felicia Hurwitz at Mathematica Policy Research at 609-945-3379.

Please return this questionnaire to the Mathematica staff who conducted your interview, or mail it in the provided envelope to:

Mathematica Policy Research

Attn: Felicia Hurwitz – Project 40150

P.O. Box 2393

Princeton, NJ 08543-2393