Redesign of the Head Start Family and Child Experiences Survey (FACES 2012)

ATTACHMENT A.4

FACES Pilot Study SWYC web specs

OMB No: 0970-0355

Expiration Date: 1/31/2015

FACES Pilot Study

SWYC

Last Updated October 24, 2013

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Intro1.

Head Start Family and Child Experiences Survey (FACES)

Pilot Study

Survey of Well-Being of Young Children

Parent Questionnaire

Welcome to the Head Start Family and Child Experiences Survey (FACES) Pilot Study Parent Survey on the web. Please refer to the instructions you received to find your Login ID and Password. To begin the survey, enter your Login ID and Password in the fields below and then click continue. If you do not have your Login ID and Password, please contact First Last at 1-888-xxx-xxxx, or email us at FACES_Pilot@mathematica-mpr.com.

Login ID:

Password:

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 0970-0355. 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: Jerry West.

intro1= continue

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Intro2.

SURVEY INFORMATION

Mathematica Policy Research (Mathematica) is conducting the Head Start Family and Child Experiences Survey (FACES) Pilot Study under contract with the Administration for Children and Families (ACF) of the U.S. Department of Health and Human Services (DHHS).

Please be assured that all information you provide will be kept private. Using the Login Identification Number and Password ensures that the information you provide to the study will be protected and will only be seen by selected members of the study team. The next page provides you with general instructions on how to complete the survey.

Please click on one of the buttons below to begin or exit the survey.

Begin your survey

Exit

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Intro3.

Instructions for completing the questionnaire

Thank you for taking the time to complete this survey.

• There are no right or wrong answers.

• To respond to a question, use your mouse to select your response.

• To continue to the next webpage, click on the “Next” or “Continue” button.

• To go back to the previous webpage, click on the “Back” or “Previous” button. Please note that this command is only available in certain sections.

• If you need to stop before you have finished, the “Suspend” button at the bottom of each page allows you to exit the survey. The responses you give prior to clicking "Suspend" will be securely stored and available when you return to complete the survey.

• For security purposes, you will be timed out if you are idle for longer than 30 minutes. When you decide to continue the survey, you will need to log in again using your login ID and password.

Please click on one of the buttons below to begin or exit the survey.

Begin your survey

Exit

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FILL CENTER, CHILD’S NAME, PARENT’S NAME FROM PRELOAD

SC1. Hello! Welcome to the FACES Pilot Study Parent Survey web site!

Center: [CENTER]

Child: [CHILD]

Parent: [PARENT NAME]

Thank you for agreeing to participate in the FACES Pilot Study. The purpose of the study is to make sure our collection procedures work well with different groups of parents. Your participation in this survey is voluntary, and you may skip any questions. Your responses are private and will not be reported except as aggregate numbers. This web survey asks about your child’s development and your family. Please use your mouse to select the answer that applies or type in your response in the space provided. Completing the survey will take about 10-15 minutes. We will mail you a gift card valued at $15 after you complete the survey.

In a few weeks, we may contact you by telephone to ask a few questions about your experience answering the questions on this survey. After that phone call, we would mail you an additional gift card valued at $20 to thank you for your help.

sc1 = continue

FILL CHILD’S NAME FROM PRELOAD

SC2. First, we’d like to confirm some information. Are you the parent or guardian of [CHILD]?

 Yes 1

 No 0 END

NO RESPONSE M

sc2=1

FILL CHILD’S DOB FROM PRELOAD

SC3. Is this [CHILD]’s date of birth?

PROGRAMMER: DISPLAY CHILD’S DOB

 Yes 1

 No 0 SC4

NO RESPONSE M

sc3=0

SC4. What is [CHILD]’s date of birth?

DATE OF BIRTH

MM/DD/YYYY

(RANGE DATE RANGE)

NO RESPONSE M

SOFT CHECK: IF CONDITION (e.g. YEAR LT 1997); Insert Soft check statement/question

HARD CHECK: IF CONDITION (e.g. GE 2007); Insert Hard check statement/question

SOFT CHECK: IF Q#=NO RESPONSE; Insert Soft check statement/question

HARD CHECK: IF Q#=NO RESPONSE; Insert Hard check statement/question

PROGRAMMER BOX SC4

Calculate child’s age

PROGRAMMER BOX A1

if child’s age GTE 35 months 0 days and LTE 46 months 31 days, administer a1a through a1j

if child’s age GTE 47 months 0 days and lte 58 months 31 days, administer a1e through a1n

if child’s age GTE 59 months 0 days and lte 65 months 31 days, administer a1g through a1p

see box

FILL CHILD’S NAME FROM PRELOAD. IF PRELOAD GENDER= FEMALE, FILL “SHE, HER;” IF PRELOAD GENDER= MALE, FILL “HE, HIM, HIS”

SECTION A: DEVELOPMENTAL MILESTONES

A1. These questions are about your [CHILD]’s development. Please tell us how much your child is doing each of these things. If [CHILD] doesn't do something any more, choose the answer that describes how much (he/she) used to do it. Please be sure to answer ALL the questions.

PROGRAMMER: CODE ONE PER ROW

	Select one per row
	Not Yet	Somewhat	Very Much
a. Talks so other people can understand (him/her) most of the time	1 	2 	3 
b. Washes and dries hands without help (even if you turn on the water)	1 	2 	3 
c. Asks questions beginning with “why” or “how” - like “Why no cookie?”	1 	2 	3 
d. Explains the reasons for things—like needing a sweater when it’s cold	1 	2 	3 
e. Compares things - using words like “bigger” or “shorter”	1 	2 	3 
f. Answers questions like “What do you do when you are cold?” or “…when you are sleepy?”	1 	2 	3 
g. Tells you a story from a book or TV	1 	2 	3 
h. Draws simple shapes - like a circle or a square	1 	2 	3 
i. Says words like “feet” for more than one foot and “men” for more than one man	1 	2 	3 
j. Uses words like “yesterday” and “tomorrow” correctly	1 	2 	3 
k. Stays dry all night	1 	2 	3 
l. Follows simple rules when playing a board game or card game	1 	2 	3 
m. Prints (his/her) first name	1 	2 	3 
n. Draws pictures you recognize	1 	2 	3 
o. Stays in the lines when coloring	1 	2 	3 
p. Names the days of the week in the correct order	1 	2 	3 

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FILL CHILD FROM PRELOAD

SECTION B: Preschool Pediatric Symptom Checklist (PPSC)

B1. These questions are about your [CHILD]'s behavior. Think about what you would expect of other children the same age, and tell us how much each statement applies to [CHILD].

Does your child…

PROGRAMMER: CODE ONE PER ROW

	Select one per row
	Not at all	Somewhat	Very Much
a. Seem nervous or afraid?	1 	2 	3 
b. Seem sad or unhappy?	1 	2 	3 
c. Get upset if things are not done in a certain way?	1 	2 	3 
d. Have a hard time with change?	1 	2 	3 
e. Have trouble playing with other children?	1 	2 	3 
f. Break things on purpose?	1 	2 	3 
g. Fight with other children?	1 	2 	3 
h. Have trouble paying attention?	1 	2 	3 
i. Have a hard time calming down?	1 	2 	3 
j. Have trouble staying with one activity?	1 	2 	3 

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FILL CHILD FROM PRELOAD

B2.0. CODE ONE PER ROW

	Select one per row
	Not at all	Somewhat	Very Much
a. Aggressive?	1 	2 	3 
b. Fidgety or unable to sit still?	1 	2 	3 
c. Angry?	1 	2 	3 

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FILL CHILD FROM PRELOAD

B3. These questions are about [CHILD]’s behavior. Think about what you would expect of other children the same age, and tell us how much each statement applies to [CHILD]. Is it hard to…

PROGRAMMER: CODE ONE PER ROW

Select one per row

	Not at all	Somewhat	Very Much
a. Take [CHILD] out in public?	1 	2 	3 
b. Comfort [CHILD]?	1 	2 	3 
c. Know what [CHILD] needs?	1 	2 	3 
d. Keep [CHILD] on a schedule or routine?	1 	2 	3 
e. Get [CHILD] to obey you?	1 	2 	3 

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SECTION C: PARENT’S CONCERNS

C1. These questions are about any concerns you may have about [CHILD].

PROGRAMMER: CODE ONE PER ROW

	Select one per row
	Not at All	Somewhat	Very Much
a. Do you have any concerns about [CHILD]’s learning or development?	1 	2 	3 
b. Do you have any concerns about [CHILD]’s behavior?	1 	2 	3 

INSERT UNIVERSE

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SECTION D: FAMILY QUESTIONS

D1. These questions are about your family.

PROGRAMMER: CODE ONE PER ROW

	Select one per row
	Yes	No
a. Does anyone smoke tobacco at home?	1 	2 
b. In the last year, have you ever drunk alcohol or used drugs more than you meant to?	1 	2 
c. Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?	1 	2 
d. Has a family member’s drinking or drug use ever had a bad effect on your child?	1 	2 
e. In the past month was there any day when you or anyone in your family went hungry because you did not have enough money for food?	1 	2 

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D2. Over the past two weeks, how often have you been bothered by any of the following problems?

PROGRAMMER: CODE ONE PER ROW

	Select one per row
	Not at all	Several days	More than half the days	Nearly every day
a. Having little interest or pleasure in doing things?	1 	2 	3 	4 
b. Feeling down, depressed, or hopeless?	1 	2 	3 	4 

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D3. The next two questions are about your relationship with your spouse or partner. If you do not have a spouse or partner, select “not applicable.”

In general, how would you describe your relationship with your (spouse/partner)?

Select one only

 No tension 1

 Some tension 2

 A lot of tension 3

 Not applicable 4

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D4. Do you and your partner work out arguments with:

Select one only

 No difficulty 1

 Some difficulty 2

 Great difficulty 3

 Not applicable 4

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E1. Please enter the name and address you’d like us to send your $15 gift card to.

First Name

(STRING 20)

Middle Initial

(STRING 1)

Last Name

(STRING 30)

Street Address 1

(STRING 100)

Street Address 2

(STRING 100)

City

(STRING 100)

State

(STRING 2)

Zip

(STRING 5)

SOFT CHECK: IF Q#=NO RESPONSE; Insert Soft check statement/question

HARD CHECK: IF Q#=NO RESPONSE; Insert Hard check statement/question

INSERT UNIVERSE

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E2. As stated earlier, we may want to contact you by telephone in a few weeks to ask some follow-up questions about your experience taking this survey. What is your phone number?

PHONE NUMBER

NO RESPONSE M

SOFT CHECK: IF Q#=NO RESPONSE; Insert Soft check statement/question

HARD CHECK: IF Q#=NO RESPONSE; Insert Hard check statement/question