DCS 4: SAQ Program Participant Pre-Test

OMB Control No.: 0970-0460

Expiration Date: 07/31/2018

Respondent ID #: _____________________

Date: _______________________________

healthy marriage program PRE-PROGRAM SURVEY For Adult-Focused Programs

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 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.

Some of the questions on this survey ask you to enter dates or times.  If you type an answer that is out of range for dates or times, like typing 13 instead of 1 through 12 to identify a month, a message will appear asking you to correct your entry.  If you get one of these messages and need help, please contact the program staff member who set up the survey.

[A1a: ASK ALL]

We would like to 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 child, 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 children or children you have legally adopted.

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

GO TO B1

³  No, I have no children

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

SOFT CHECK: IF A1a = NO RESPONSE; This question is very important. Please select an answer.

IF A1a = NO RESPONSE, GO TO B1

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

[child1] GO TO A1d

SOFT CHECK: IF A1b = NO RESPONSE; This question is very important. Please select an answer.

IF A1b = NO RESPONSE, GO TO A1d

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

[child1]

A1d. How old is [YOURCHILD1]?

_____________ years

SOFT CHECK: IF A1d > 20; Your child’s age should be less than 21 years.

HARD CHECK: IF A1d = non-numeric OR A1d < 0; Please enter a number. Your child’s age should be less than 21 years.

A1e. Does [YOURCHILD1] live with you all or most of the time?

¹  Yes, he or she lives with me all or most of the time

²  No, he or she does not live with me all or most of the time

SOFT CHECK: IF A1e = NO RESPONSE; This question is very important. Please select an answer.

IF A1e = NO RESPONSE AND A1a=2, GO TO A4; ELSE GO TO B1

A2. Please answer questions in A2 for [YOURCHILD1] only.

A2a. Please tell us how often you’ve felt or acted this way in the past month with [YOURCHILD1].

	MARK ONE BOX IN EACH ROW
	NEVER	HARDLY EVER	SOMETIMES	OFTEN
a. I am happy being with [MYCHILD1]	1 	2 	3 	4 
b. [MYCHILD1] and I are very close to each other	1 	2 	3 	4 
c. I try to comfort [MYCHILD1] when he/she is upset	1 	2 	3 	4 
d. I spend time with [MYCHILD1] doing what he/she likes to do	1 	2 	3 	4 

A2b. 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 [YOURCHILD1]?	1 	2 	3 	4 
b. ... yell, shout, or scream at [YOURCHILD1] because you were mad at him/her?	1 	2 	3 	4 
c. ...talk to [YOURCHILD1] about what he/she did wrong?	1 	2 	3 	4 

A3. How much do you agree or disagree with the following statement?

[MYCHILD1]’s other parent and I work well together as parents.

MARK one only

¹  Strongly agree

²  Agree

³  Disagree

⁴  Strongly disagree

[IF A1a = 2, CONTINUE TO A4; ELSE, GO TO A7]

A4. Now think about your next youngest biological or legally adopted child.

A4a. What is your next youngest child’s first name or initials?

[CHILD2]

A4b. How old is [YOURCHILD2]?

_____________ years

SOFT CHECK: IF A4b > 20; Your child’s age should be less than 21 years.

HARD CHECK: IF A4b = non-numeric OR A4b < 0; Please enter a number. Your child’s age should be less than 21 years.

A4c. Does [YOURCHILD2] 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 A5a

²  No, he or she does not live with me all or most of the time IF A1e = 1, GO TO A7; ELSE go to B1

SOFT CHECK: IF A4c = NO RESPONSE; This question is very important. Please select an answer.

IF A4c = NO RESPONSE AND A1E = 1, GO TO A7, ELSE if A4c = NO RESPONSE and A1E != 1, THEN GO TO B1

Please answer questions in A5 for [YOURCHILD2] only.

A5a. Please tell us how often each of the following happens in your family.

	MARK ONE BOX IN EACH ROW
	NEVER	HARDLY EVER	SOMETIMES	OFTEN
a. I am happy being with [MYCHILD2]	1 	2 	3 	4 
b. [MYCHILD2] and I are very close to each other	1 	2 	3 	4 
c. I try to comfort [MYCHILD2] when he/she is upset	1 	2 	3 	4 
d. I spend time with [MYCHILD2] doing what he/she likes to do	1 	2 	3 	4 

A5b. 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 [YOURCHILD2]?	1 	2 	3 	4 
b. ... yell, shout, or scream at [YOURCHILD2] because you were mad at him/her?	1 	2 	3 	4 
c. ...talk to [YOURCHILD2] about what he/she did wrong?	1 	2 	3 	4 

A6. How much do you agree or disagree with the following statement?

[MYCHILD2]’s other parent and I work well together as parents.

MARK one only

¹  Strongly agree

²  Agree

³  Disagree

⁴  Strongly disagree

A7. 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

GO TO QUESTION B1 ON THE NEXT PAGE

SECTION B: ASK ALL

B1. Currently, do you…

	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

GO TO QUESTION C1 ON THE NEXT PAGE

[C1: ASK ALL]

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: ASK ALL]

C2. Are you currently in a relationship (whether you are married or unmarried)?

¹  Yes

⁰  No go to D1

SOFT CHECK: IF C2 = NO RESPONSE; This question is very important. Please select an answer.

IF C2 = NO RESPONSE, 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. How much of the time do you live with your partner?

MARK ONE ONLY

¹  All of the time

²  Most of the time

³  Some of the time

⁴  None of the time

C5. This question is about your relationship with your partner/spouse. During the past month, how often did the following happen?

	MARK ONE BOX IN EACH ROW
	NEVER	HARDLY EVER	SOMETIMES	OFTEN
a. My partner/spouse and I were good at working out our differences.	1 	2 	3 	4 
b. I felt respected even when my partner/spouse and I disagreed.	1 	2 	3 	4 
c. When my partner/spouse and I had a serious disagreement, we worked on it together to find a resolution.	1 	2 	3 	4 
d. When my partner/spouse and I had a serious disagreement, we discussed our disagreements respectfully.	1 	2 	3 	4 
e. During arguments, my partner/spouse and I were good at taking breaks when we needed them.	1 	2 	3 	4 
f. When my partner/spouse and I argued, past hurts got brought up again.	1 	2 	3 	4 
g. My partner/spouse understands that there are times when I do not feel like talking and times when he/she does.	1 	2 	3 	4 

C6. During the past month, how often has 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 

C7. In the past month, how often has 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 
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

C9. How much do you agree or disagree with the following statements about your partner/spouse?

	MARK ONE BOX IN EACH ROW
	STRONGLY AGREE	AGREE	DISAGREE	STRONGLY DISAGREE
a. I trust my partner/spouse completely.	1 	2 	3 	4 
b. My partner/spouse knows and understands me.	1 	2 	3 	4 
c. I can count on my partner/spouse to be there for me.	1 	2 	3 	4 
d. I feel appreciated by my partner/spouse.	1 	2 	3 	4 
e. My partner/spouse expresses love and affection toward me.	1 	2 	3 	4 

C10. In the past month, how often have you and your partner/spouse done the following things?

	MARK ONE BOX IN EACH ROW
	ALMOST EVERY DAY	ONCE OR TWICE A WEEK	ONCE OR TWICE A MONTH	LESS OFTEN
a. Talk to each other about the day.	1 	2 	3 	4 
b. Laugh together.	1 	2 	3 	4 
c. Participate together in an activity we both enjoy.	1 	2 	3 	4 

C11. How satisfied are you with your current relationship?

MARK one only

¹  Very satisfied

²  Somewhat satisfied

³  Not satisfied

C12. How much do you agree or disagree with this statement? I view our marriage/relationship as lifelong.

MARK one only

¹  Strongly agree

²  Agree

³  Disagree

⁴  Strongly disagree

GO TO QUESTION D1 ON THE NEXT PAGE

SECTION D: ASK ALL

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 

THANK YOU FOR COMPLETING THIS SURVEY!