DCS 4: SAQ Program Participant Pre-Test
Fatherhood and Marriage Local Evaluation and Cross-Site Data Collection
Instrument DCS-4RF_1_Pre-Test For Community Fathers
DCS 4: SAQ Program Participant Pre-Test
OMB: 0970-0460
OMB
Control
No.: xxxx-xxxx
Expiration Date: xx/xx/xxxx
Respondent
ID #: _____________________ Date:
_______________________________
RESPONSIBLE
FATHERHOOD PROGRAM
For Community-Based Fathers |
|
PRIVACY Thank you for your help with this important study. This survey includes questions about your parenting, relationships, economic stability, wellbeing, and program experiences. Your name will not be on the survey and your responses will remain private to the extent permitted by law. We want you to know that: 1. Your participation in this survey is voluntary. 2. We hope that you will answer all the questions, but you may skip any questions you do not wish to answer. 3. The answers you give will be kept private to the extent permitted by law. |
|
THE PAPERWORK REDUCTION ACT OF 1995 Public reporting burden for this collection of information is estimated to average 25 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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. The information requested in this survey will be used to document how programs receiving HMRF grant funding operate and describe participant outcomes. The data gathered will allow ACF to better monitor grantee progress and performance. In accordance with the requirements of the Privacy Act of 1974, as amended (5 U.S.C. 552a), ACF/OPRE established system of records titled: 09-80-0361 OPRE Research and Evaluation Project Records, HHS/ACF/OPRE. A Federal Register Notice (80 FR 17893) announced the system. |
We
would like get a sense of who you are as a parent. We realize that
children are different and may require different parenting.
Questions in this section are about your child—or if you have more than one, your two youngest children—under the age of 21.
A1a. Do you have any children who are under 21 years old? Please only include your biological or legally adopted children.
MARK one only
1
Yes, I have one child who is younger than age 21
2
Yes, I have more than one child who is younger than age 21 go
to A1d
3 No, I have no children
4 No, all my children are 21 years or older
A1b. What is your child’s first name or initials?
[child1]
A1c. How old is your child? [child 1]
_____________
years GO
TO A1f
A1d. What is your youngest child’s first name or initials? [child 1]
A1e. How old is your youngest child? [child 1]
_____________ years
A1f. Does [CHILD1] live with you all or most of the time?
1 Yes, he or she lives with me all or most of the time go to A3
0 No, he or she does not live with me all or most of the time
A2a. When was the last time you saw [CHILD1]?
MARK one only
1 In the past week
2 In the past month
3 In the past six months
4 In the past year
5 1-2 years ago
6 More than 2 years ago
7 Never
A2b. In the past month, how often did you see [CHILD1]?
1
Every day or almost every day
2 One to three times a week
3 One to three times in the past month
4
I did not see this child in the past month GO
TO A2d
A2c. In the past month when you saw [CHILD1], how many hours per day did you usually spend with [CHILD1]?
| | | hours
A2d. In the past month, how often have you reached out to [CHILD1] even if [CHILD1] did not respond? This includes calling on the phone; sending email, letters, or cards; texting; or using Facebook or FaceTime.
MARK one only
1 Every day or almost every day
2 One to three times a week
3 One to three times in the past month
4 Never in the past month
A2e. In the past month, did you buy things for [CHILD1] that he or she needed like diapers, clothes, school supplies, medicine, or other things he or she needed?
1 Yes
0 No
A2f. Do you have an agreement with the mother of [CHILD1] about spending time with [CHILD1]?
1 Yes, we have a legal document
2 Yes, we have a written agreement that is not court-ordered
3 Yes, we have a verbal understanding
4
No, we have no parenting
agreement go
to A6
A2g. How often does [CHILD1]’s mother follow the agreement?
MARK one only
1 Always
2 Often
3 Sometimes
4 Never
A2h. How often do you follow the agreement?
MARK one only
1 Always
2 Often
3 Sometimes
A3. Please tell us how often you’ve felt or acted this way in the past month with [CHILD1].
|
MARK ONE BOX IN EACH ROW |
|||
|
NEVER |
HARDLY EVER |
SOMETIMES |
OFTEN |
a. I am happy being with [CHILD1] |
1 |
2 |
3 |
4 |
b. [CHILD1] and I are very close to each other |
1 |
2 |
3 |
4 |
c. I try to comfort [CHILD1] when s/he is upset |
1 |
2 |
3 |
4 |
d. I spend time with [CHILD1] doing what s/he likes to do |
1 |
2 |
3 |
4 |
A4. Over the past month, how often did you…
|
MARK ONE BOX IN EACH ROW |
|||
|
NEVER |
1 – 3 TIMES A MONTH |
1 – 3 TIMES A WEEK |
EVERY DAY OR ALMOST EVERY DAY |
a. ...hit, spank, grab, or use physical punishment with [CHILD 1]? |
1 |
2 |
3 |
4 |
b. ...yell, shout, or scream at [CHILD 1] because you were mad at him/her? |
1 |
2 |
3 |
4 |
c. ...talk to [CHILD 1] about what he/she did wrong? |
1 |
2 |
3 |
4 |
A5. In the past month, how often have you...
|
MARK ONE BOX IN EACH ROW |
|||
|
NEVER |
1 – 3 TIMES A MONTH |
1 – 3 TIMES A WEEK |
EVERY DAY OR ALMOST EVERY DAY |
a. Had a meal together with [CHILD1]? |
1 |
2 |
3 |
4 |
b. Taken [CHILD1] places he/she needed to go, such as to school or to the doctor? |
1 |
2 |
3 |
4 |
c. Helped [CHILD1] with his/her bedtime routine or homework? |
1 |
2 |
3 |
4 |
d. Talked with [CHILD1] about things he/she is especially interested in? |
1 |
2 |
3 |
4 |
A6. In the past month, how often have you felt overwhelmed by your parenting responsibilities?
MARK one only
1 Never
2 Hardly ever
3 Sometimes
4 Often
[If A1a = 2, continue to A7a; else, GO TO B1.]
Now think about your next youngest biological or legally adopted child, [CHILD2].
A7a. What is your next youngest child’s first name or initials?
[child2]
A7b. How old is your next youngest child?
____________ years
A8. Does [CHILD2] live with you all or most of the time?
1
Yes, he or she lives with me all or most of the time go
to a10
0
No,
he/she does not live with me all or most of the time go
to A9a
A9a. When was the last time you saw [CHILD2]?
MARK one only
1 In the past week
2 In the past month
3 In the past six months
4 In the past year
5 1-2 years ago
6 More than 2 years ago
7 Never
A9b. In the past month, how often did you see [CHILD2]?
1 Every day or almost every day
2 One to three times a week
3 One to three times in the past month
4
I did not see this child in the past month
GO
TO A9d
A9c. In the past month when you saw [CHILD2], how many hours per day did you usually spend with [CHILD2]?
| | | hours
A9d. In the past month, how often have you reached out to [CHILD2] even if [CHILD2] did not respond? This includes calling on the phone; sending email, letters, or cards; texting; or using Facebook or FaceTime.
MARK one only
1 Every day or almost every day
2 One to three times a week
3 One to three times in the past month
4 Never in the past month
A9e. In the past month, did you buy things for [CHILD2] that he or she needed like diapers, clothes, school supplies, medicine, or other things he or she needed?
1 Yes
0 No
A9f. Do you have an agreement with the mother of [CHILD2] about spending time with [CHILD2]?
1
Yes,
we have a legal document
2 Yes, we have a written agreement that is not court-ordered
3 Yes, we have a verbal understanding
4
No,
we have no parenting agreement go
to A13
A9g. How often does [CHILD2]’s mother follow the agreement?
MARK one only
1 Always
2 Often
3 Sometimes
4 Never
A9h. How often do you follow the agreement?
MARK one only
1 Always
2 Often
3 Sometimes
4 Never
A10. Please tell us how often you’ve felt or acted this way in the past month with [CHILD2].
|
MARK ONE BOX IN EACH ROW |
|||
|
NEVER |
HARDLY EVER |
SOMETIMES |
OFTEN |
a. I am happy being with [CHILD2] |
1 |
2 |
3 |
4 |
b. [CHILD2] and I are very close to each other |
1 |
2 |
3 |
4 |
c. I try to comfort [CHILD2] when s/he is upset |
1 |
2 |
3 |
4 |
d. I spend time with [CHILD2] doing what s/he likes to do |
1 |
2 |
3 |
4 |
A11. Over the past month, how often did you…
|
MARK ONE BOX IN EACH ROW |
|||
|
NEVER |
A FEW TIMES A MONTH |
A FEW TIMES A WEEK |
EVERY DAY OR ALMOST EVERYDAY |
a. …hit, spank, grab, or use physical punishment with [CHILD2]? |
1 |
2 |
3 |
4 |
b. …yell, shout, or scream at [CHILD2] because you are mad at him/her? |
1 |
2 |
3 |
4 |
c. ...talk to [CHILD2] about what he/she did wrong? |
1 |
2 |
3 |
4 |
A12. In the past month, how often have you...
|
MARK ONE BOX IN EACH ROW |
|||
|
NEVER |
1 – 3 TIMES A MONTH |
1 – 3 TIMES A WEEK |
EVERY DAY OR ALMOST EVERY DAY |
a. Had a meal together with [CHILD2]? |
1 |
2 |
3 |
4 |
b. Taken [CHILD2] places he/she needed to go, such as to school or to the doctor? |
1 |
2 |
3 |
4 |
c. Helped [CHILD2] with his/her bedtime routine or homework? |
1 |
2 |
3 |
4 |
d. Talked with [CHILD2] about things he/she is especially interested in? |
1 |
2 |
3 |
4 |
A13. In the past month, how often have you felt overwhelmed by your parenting responsibilities?
MARK one only
1 Never
2 Hardly ever
3 Sometimes
4 Often
|
MARK ONE BOX IN EACH ROW |
|
|
YES |
NO |
a. Have a checking account? |
1 |
0 |
b. Have a savings account? |
1 |
0 |
c. Use a budget to plan your spending? |
1 |
0 |
B2. How often do you find it difficult to pay your bills?
MARK one only
1 Never
2 Once in a while
3 Somewhat often
4 Very often
B3. How much do you agree or disagree with each of the statements below?
|
MARK ONE BOX IN EACH ROW |
||||
|
STRONGLY AGREE |
AGREE |
DISAGREE |
STRONGLY DISAGREE |
NOT APPLICABLE |
a. I would like to learn new job skills |
1 |
2 |
3 |
4 |
|
b. I have good job skills |
1 |
2 |
3 |
4 |
|
c. I know where to find job openings |
1 |
2 |
3 |
4 |
|
d. I know how to apply for a job |
1 |
2 |
3 |
4 |
|
e. I feel confident in my ability to conduct an effective job search for a job I want |
1 |
2 |
3 |
4 |
|
f. I feel confident in my interviewing skills |
1 |
2 |
3 |
4 |
|
g. I would like to get a job |
1 |
2 |
3 |
4 |
na |
h. I would like to get a better job |
1 |
2 |
3 |
4 |
na |
i. I am usually on time for work |
1 |
2 |
3 |
4 |
na |
j. If I’m not going to go to work, I let my supervisor know ahead of time |
1 |
2 |
3 |
4 |
na |
B4. Do you have an updated resume that you can give to employers?
1 Yes
0 No
B5. Below are some general statements about knowledge of child support. For each statement, please indicate whether you believe it is true or false.
Please complete this question even if you do not have a child support order.
|
MARK ONE BOX IN EACH ROW |
||
|
TRUE |
FALSE |
I DON’T KNOW |
a. Fathers can get help with their child support by calling the child support agency |
1 |
2 |
d |
b. A father has the right to ask for a change in the amount of his child support order |
1 |
2 |
d |
c. The law requires a father to pay child support even if the mother of his child has a new partner |
1 |
2 |
d |
d. The law requires a father to pay child support even if the child’s mother prevents him from seeing his child |
1 |
2 |
d |
B6. Do you have a legal arrangement or child support order that requires you to provide financial support for ANY of your children that do not live with you all or most of the time?
MARK one only
1
Yes
2 No
3 I don’t know
B7. Do you know how to request a change in your child support order if your income changes?
MARK one only
1 Yes
0 No
d I don’t know
C1. How much do you agree or disagree with the following statements?
|
MARK ONE BOX IN EACH ROW |
|||
|
STRONGLY AGREE |
AGREE |
DISAGREE |
STRONGLY DISAGREE |
a. It is better for children if their parents are married |
1 |
2 |
3 |
4 |
b. Living together is just the same as being married |
1 |
2 |
3 |
4 |
C2. Are you currently in a relationship (whether you are married or not married)?
1
Yes
0
No go
to D1
C3. Which of the following statements best describes your relationship with your current partner?
MARK one only
1 We are married
2 We are romantically involved on a steady basis
3 We are involved in an on-again and off-again relationship
C4. In the past month, how often have the following happened?
|
MARK ONE BOX IN EACH ROW |
|||
|
NEVER |
HARDLY EVER |
SOMETIMES |
OFTEN |
a. My partner/spouse was rude or mean to me when we disagreed. |
1 |
2 |
3 |
4 |
b. My partner/spouse seemed to view my words or actions more negatively than I meant them to be. |
1 |
2 |
3 |
4 |
c. Our arguments became very heated. |
1 |
2 |
3 |
4 |
d. Small issues suddenly became big arguments. |
1 |
2 |
3 |
4 |
e. My partner/spouse or I stayed mad at one another after an argument. |
1 |
2 |
3 |
4 |
C5. In the past month, how often have the following happened?
|
MARK ONE BOX IN EACH ROW |
|||
|
NEVER |
HARDLY EVER |
SOMETIMES |
OFTEN |
a. My partner/spouse blamed me for his/her problems. |
1 |
2 |
3 |
4 |
d. My partner/spouse yelled or screamed at me. |
1 |
2 |
3 |
4 |
C6. How satisfied are you with the way you and your partner/spouse handle conflict?
MARK one only
1 Very satisfied
2 Somewhat satisfied
3 Not at all satisfied
D1. This question is about feelings you may have experienced recently. During the PAST 30 DAYS, how often have you felt…
|
MARK ONE BOX IN EACH ROW |
||||
|
NONE OF THE TIME |
A LITTLE OF THE TIME |
SOME OF THE TIME |
MOST OF THE TIME |
ALL OF THE TIME |
a. Nervous? |
1 |
2 |
3 |
4 |
5 |
b. Hopeless? |
1 |
2 |
3 |
4 |
5 |
c. Restless or fidgety? |
1 |
2 |
3 |
4 |
5 |
d. So depressed that nothing could cheer you up? |
1 |
2 |
3 |
4 |
5 |
e. That everything was an effort? |
1 |
2 |
3 |
4 |
5 |
f. Worthless? |
1 |
2 |
3 |
4 |
5 |
D2. How much do you agree or disagree with the following statements?
|
MARK ONE BOX IN EACH ROW |
|||
|
STRONGLY AGREE |
AGREE |
DISAGREE |
STRONGLY DISAGREE |
a. I have little control over the things that happen to me. |
1 |
2 |
3 |
4 |
b. I have hope when I think about my future. |
1 |
2 |
3 |
4 |
c. I wouldn’t know where to go for help if I had money troubles. |
1 |
2 |
3 |
4 |
d. I have others who will listen when I need to talk about my problems.. |
1 |
2 |
3 |
4 |
e. When I am lonely, there are several people I can talk to. |
1 |
2 |
3 |
4 |
f. I have people I can count on if I am feeling down. |
1 |
2 |
3 |
4 |
g. If there is a crisis, I have others I can talk to. |
1 |
2 |
3 |
4 |
D3. Is there someone you could you turn to, such as a friend or family member, if you suddenly needed to borrow money?
MARK one only
1 Yes
0 No
d I don’t know
THANK YOU FOR COMPLETING THIS SURVEY!
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Responsible Fatherhood Program: Pre-Program Survey |
| Subject | Non-standard SAQ |
| Author | MATHEMATICA |
| File Modified | 0000-00-00 |
| File Created | 2021-01-25 |
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