Head Start Family Voices Pilot Study

ATTACHMENT A1b

PROGRAM RECRUITMENT SCREENER

OMB No: Expiration Date:

Head Start Family Voices Pilot Study

Program Recruitment Screener

Spring 2013

Program ID: | | | | | | |
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 10 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.

I NT1. ARE RESPONDENTS BEING RECRUITED FROM EARLY HEAD START OR HEAD START?

1 □ EARLY HEAD START

2 □ HEAD START

A1. How many pregnant women are currently enrolled in your Early Head Start program?

| | | | NUMBER OF PREGNANT WOMEN

0 □ None

A2. As of January 1, 2013, what is the actual enrollment of children, not including pregnant women, in your Early Head Start program?

PROBE: All we need is an approximation. Your best estimate is fine.

| | | | | NUMBER OF ENROLLED CHILDREN

A3. We would like to understand the way your Early Head Start program plans services to best meet the needs of enrolled families. What proportion of families in your Early Head Start program is currently served through each the following program options?

	PERCENTAGE OF FAMILIES
a. Home-based services, in which Early Head Start services are provided primarily in the child’s home	| | | | PERCENT
b. Center-based services, in which services are provided primarily at a child care center	| | | | PERCENT
c. Some other program option Specify: ________________________________________	| | | | PERCENT

INTERVIEWER CHECK: CONFIRM PERCENTAGES PROVIDED SUM TO 100. IF NOT, ASK FOR CLARIFICATION FROM RESPONDENT.

| | | | PERCENT

A4a. How many family services staff does your Early Head Start program employ?

PROBE: Family services staff may include family service workers, family services managers, family services coordinators, and family services assistants. Please include staff that work part-time as well as full-time.

| | | NUMBER OF FAMILY SERVICES STAFF

A4b. How many home visitors does your Early Head Start program employ?

PROBE: Home visitors, also referred to as home educators or home-based teachers, are staff whose primary function is to make regular home visits to families and children. Please include staff that work part-time as well as full-time.

| | | NUMBER OF HOME VISITORS

A5. In addition to providing Early Head Start services to families, does your program also provide Head Start services?

1 □ Yes

0 □ No

A6. As of January 1, 2013, what is the actual enrollment of children in your Head Start program?

PROBE: All we need is an approximation. Your best estimate is fine.

| | | | | NUMBER OF ENROLLED CHILDREN

A7. We would like to understand the way your Head Start program plans services to best meet the needs of enrolled families. What proportion of families in your Head Start program is currently served through each the following program options?

	PERCENTAGE OF FAMILIES
a. Home-based services, in which Head Start services are provided primarily in the child’s home	| | | | PERCENT
b. Center-based services, in which services are provided primarily at a child care center	| | | | PERCENT
c. Some other program option Specify: ________________________________________	| | | | PERCENT

INTERVIEWER CHECK: CONFIRM PERCENTAGES PROVIDED SUM TO 100. IF NOT, ASK FOR CLARIFICATION FROM RESPONDENT.

| | | | PERCENT

A8a. How many family services staff does your Head Start program employ?

PROBE: Family services staff may include family service workers, family services managers, family services coordinators, and family services assistants. Please include staff that work part-time as well as full-time.

| | | NUMBER OF FAMILY SERVICES STAFF

A8b. How many home visitors does your Head Start program employ?

PROBE: Home visitors, also referred to as home educators or home-based teachers, are staff whose primary function is to make regular home visits to families and children. Please include staff that work part-time as well as full-time.

| | | NUMBER OF HOME VISITORS

A9. In addition to providing Head Start services to families, does your program also provide Early Head Start services?

1 □ Yes

0 □ No

B 1. Programs face many challenges in serving high need or high risk families. We would like to know more about the needs of the enrolled families you serve and how many of them have high needs or are at high risk. Rather than collecting specific information to provide exact figures, please provide your best estimate of the percentage of families who fit each of the following categories. IF RESPONDENT IS HAVING DIFFICULTY RESPONDING, OFFER TO FAX THIS PAGE AND CALL BACK TO COLLECT THEIR RESPONSES.

IF INT1 = 1, FILL WITH EARLY HEAD START; IF INT1 = 2, FILL WITH HEAD START

Thinking about the [Early Head Start/Head Start] families served by your program, what percentage are…	PERCENTAGE OF FAMILIES
a. Teen mothers (under age 20)	0 □ none 1 □ ≤10 percent 2 □ 11 to 25 percent 3 □ 26 to 50 percent 4 □ 51 to 75 percent 5 □ 76 percent or more
b. Single-parent families (primary caregiver of the child is not married to or living with a partner)	0 □ none 1 □ ≤10 percent 2 □ 11 to 25 percent 3 □ 26 to 50 percent 4 □ 51 to 75 percent 5 □ 76 percent or more
c. Families in which the primary caregiver is not employed or in school	0 □ none 1 □ ≤10 percent 2 □ 11 to 25 percent 3 □ 26 to 50 percent 4 □ 51 to 75 percent 5 □ 76 percent or more
d. Families who reside with one or more families, live in transitional housing or a homeless shelter	0 □ none 1 □ ≤10 percent 2 □ 11 to 25 percent 3 □ 26 to 50 percent 4 □ 51 to 75 percent 5 □ 76 percent or more
e. Families with mental health problems	0 □ none 1 □ ≤10 percent 2 □ 11 to 25 percent 3 □ 26 to 50 percent 4 □ 51 to 75 percent 5 □ 76 percent or more
f. Considering each of these five areas, what percentage of families enrolled in your [Early Head Start/Head Start] program have more than three of these characteristics? PROBE: Characteristics include teen mother, single-parent family, unemployed or not in school, transitional housing/homelessness, and mental health problems.	0 □ none 1 □ ≤10 percent 2 □ 11 to 25 percent 3 □ 26 to 50 percent 4 □ 51 to 75 percent 5 □ 76 percent or more

B2. Thinking about the families enrolled in your program, what percentage of families speak…

	PERCENTAGE OF FAMILIES
a. English?	| | | | PERCENT
b. Spanish?	| | | | PERCENT
c. Other language(s)? Please tell me which languages these families speak Specify Lang 1: ________________________________ Specify Lang 2: ________________________________ Specify Lang 3: ________________________________	| | | | PERCENT

INTERVIEWER CHECK: CONFIRM PERCENTAGES PROVIDED SUM TO 100. IF NOT, ASK FOR CLARIFICATION FROM RESPONDENT.

| | | | PERCENT

I have just a few more questions.

C1. What are your program’s hours and days of operation?

| | | : | | | to | | | : | | |

am/pm am/pm

1 □ Monday 2 □ Tuesday 3 □ Wednesday 4 □ Thursday 5 □ Friday

C2. On-Site Coordinator Contact Information

To make it easier for you to coordinate with us, we recommend you designate a point person from your program. If you would like, this person can be you. If your program agrees to take part in the study, the on-site coordinator will help us identify staff and parents from your program who might be interested in participating, and schedule the dates and times when the interviews will take place.

ask only if applicable: Who would you like this person to be?

if other staff identified as on-site coordinator, ask respondent to provide you with his/her contact information below.

if respondent is on-site coordinator, confirm their contact information below.

____________________________________

program name

_____________________________________ _____________________________________

name of on-site coordinator position/title of on-site coordinator

_____________________________________

email address of on-site coordinator

_____________________________________

street address

_____________________________________ ____________ ______________

city state zip code

| | | | - | | | | - | | | | |

phone number