DCS 4: SAQ Program Participant Pre-Test

OMB Control No.: xxxx-xxxx

Expiration Date: xx/xx/xxxx

Respondent ID #: _____________________

Date: _______________________________

RESPONSIBLE FATHERHOOD program PRE-PROGRAM SURVEY For Incarcerated Fathers

PRIVACY Thank you for your help with this important study. This survey includes questions about your parenting, relationships, economic stability, well-being, and program experiences. Your name will not be on the questionnaire 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.

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 A1c

³  No, I have no children

⁴  No, all my children are 21 years or older

A1b. What is your child’s name or initials?

[child1] GO TO A2a

A1c. What is your youngest child’s first name or initials?

[child1]

A1d. How old is [CHILD 1]?

_____________ years

A2a. When is 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]?

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  I did not see this child in the past month

A2c. In the past month, how often did you talk to [CHILD1] on the phone?

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  I did not talk on the phone with this child in the past month

A2d. In the past month, how often have you sent letters to [CHILD1]?

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  I did not send letters to this child in the past month

[If A2a = 3 - 7 and A2c = 4, GO TO B1]

A3. In the past month, how often have you talked with [CHILD1] about things he/she is especially interested in?

MARK one only

¹  Never

²  Hardly ever

³  Sometimes

⁴  Often

[If A2a = 3 – 7, GO TO A5]

A4. 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 he/she is upset	1 	2 	3 	4 

[If A1a = 2, continue to A5a; else, GO TO B1.]

Now think about your next youngest biological or legally adopted child, [CHILD2].

A5a. What is your next youngest child’s first name or initials?

[child2]

A5b. How old is [CHILD 2]?

_____________ years

A6a. When is 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

A6b. In the past month, how often did you see [CHILD2]?

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  I did not see this child in the past month

A6c. In the past month, how often did you talk with [CHILD2] on the phone?

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  I did not talk on the phone with this child in the past month

A6d. In the past month, how often have you sent letters to [CHILD2]?

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  I did not send letters to this child in the past month

[If A6a = 3 - 7 and A6c = 4, GO TO B1]

A6e. In the past month, how often have you talked with [CHILD2] about things he/she is especially interested in?

MARK one only

¹  Never

²  Hardly ever

³  Sometimes

⁴  Often

If A6a = 3 – 7 GO TO B1.

A7. 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 he/she is upset	1 	2 	3 	4 

B1. 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
a. I would like to learn new job skills.	1 	2 	3 	4 
b. I have good job skills.	1 	2 	3 	4 

B2. Do you have a job now?

¹  Yes

⁰  No GO TO B3

B2a. Is it a work release job?

¹  Yes

⁰  No

B2b. When did you start working in this job?

| | | / | | | | | month/year

B3. Have you participated in education or job training programs in the past month?

⁰  No

¹  Yes (please describe):

B4. Below are some general statements about child support. For each statement, please indicate whether you believe it is true or false. If you don’t know, mark “I don’t know” for that statement.

	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 

SKIP IF A1a=3 OR 4

B5. Do you have a legal arrangement or child support order that requires you to provide financial support for any of your children?

MARK one only

¹  Yes

²  No

³  I don’t know

SKIP IF A1a=3 OR 4

B6. Do you know how to request a change in your child support order if your income changes?

MARK one only

¹  Yes

⁰  No

GO TO QUESTION C1 ON NEXT PAGE

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, off-again relationship

C4. When is the last time you saw your current partner/spouse?

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

C5. In the past month, how often have you talked on the phone with your partner/spouse?

MARK one only

¹  Every day or almost every day

²  One to three times a week

³  One to three times a month

⁴  I did not talk to my spouse/partner on the phone in the past month

C6. Please indicate how often the following happened in the past month.

	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 

C7. Please indicate how often the following happened in the past month.

	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 
b. My partner/spouse yelled or screamed at me.	1 	2 	3 	4 

C8. 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

GO TO QUESTION D1 ON NEXT PAGE

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

D4. When did you enter jail/prison for this current detention?

| | | / | | | | | month/year

D5. How long is your current sentence? Enter number of months and years.

| | | months | | | years

D6. Prior to this, have you been in jail or prison before?

¹  Yes

⁰  No END SURVEY

D7. Altogether, how many years have you been in jail or prison over your life?

| | | years

THANK YOU FOR COMPLETING THIS SURVEY!