APPENDIX D_Parent or Guardian Questionnaire_redacted
National Study to Inform the 21st Century Community Learning Centers (CCLC) Program
APPENDIX D_Parent or Guardian Questionnaire_redacted
OMB: 1850-0964
Appendix D:
Parent or Guardian Questionnaire
OMB No.: xxxx-xxxx
Expiration Date: xx/xx/xxxx
U.S. DEPARTMENT OF EDUCATION
National Study of Continuous Quality Improvement to Inform the 21st Century Community Learning Centers Program
Parent/Guardian Questionnaire
DRAFT April 2021
This questionnaire is part of the National Study of Continuous Quality Improvement to Inform the 21st Century Community Learning Centers Program, a national evaluation being conducted for the U.S. Department of Education by Mathematica. The questionnaire asks about your child’s behavior as well as their afterschool enrollment history and future plans for enrollment. If you have any questions about the study or your afterschool center’s participation, email us at [STUDY EMAIL]@mathematica-mpr.com.
We would like you to know that:
The survey takes about 10 minutes to complete.
Your answers will be kept private; no information that identifies you, your child, the afterschool center, or your child’s school will be reported. Your responses are protected by the Education Sciences Reform Act of 2002, Title I, Part E, Section 183. We will not provide information that identifies you, your child, the afterschool center, or your child’s school to anyone outside the study team except if required by law. The reports prepared for this study will not provide information about a specific district, school, afterschool center, or person.
This survey is voluntary. That means you can choose whether or not to take it, and you can stop taking the survey at any time. You may skip any questions you do not wish to answer; however, we hope that you answer as many questions as you can. Your answers to questions will not affect your child’s enrollment in the afterschool center now or in the future and will only be shared with the study team (they will not be shared with anyone from the afterschool center).
There is no risk to completing the parent/guardian questionnaire. All members of the study team sign a pledge to keep your information private. All staff with access to study data have received clearance from the U.S. Department of Education and are subject to severe legal punishment if study information is not kept private. Any data that identifies you will be destroyed at the end of the study. If you have any questions about your rights as a research volunteer, contact HML IRB toll free at 1-202-753-5040 and reference IRB number 844MATH21.
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If you would like a copy of this disclosure statement, please contact Kristina Rall at KRall@mathematica-mpr.com or (202) 264-3468.
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A. Your child’s behavior
The following question asks about your child’s behavior.
A1. Thinking about your child’s behavior during the past month, how often did your child…
If you did not see your child in a situation listed below, take your best guess about how your child would behave in that situation.
SSIS Social and Emotional Learning Brief Scales (SSIS SELb; Elliott et al. 2020; 20 items)
This question will have 20 additional items. These items will consist of all 20 items in the SSIS SELb—Parent K-12 assessment. The items will ask parents or guardians to report behaviors of their child that reflect the child’s social and emotional skills. For each item, they will select how often their child displays each behavior (never, seldom, often, or almost always). The SSIS SELb is proprietary.
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NEVER
SELDOM
OFTEN
ALMOST ALWAYS
REDACTED
1
2
3
4
REDACTED
1
2
3
4
REDACTED
1
2
3
4
REDACTED
1
2
3
4
REDACTED
1
2
3
4
Keep working towards an important goal even when there was a problem
1
2
3
4
REDACTED
1
2
3
4
REDACTED
1
2
3
4
REDACTED
1
2
3
4
REDACTED
1
2
3
4
REDACTED
1
2
3
4
Stay focused on the same goal
1
2
3
4
REDACTED
1
2
3
4
REDACTED
1
2
3
4
REDACTED
1
2
3
4
REDACTED
1
2
3
4
REDACTED
1
2
3
4
Stay focused on a project that matters a lot to them even when there were a lot of distractions
1
2
3
4
REDACTED
1
2
3
4
REDACTED
1
2
3
4
REDACTED
1
2
3
4
REDACTED
1
2
3
4
REDACTED
1
2
3
4
Try again when they failed to reach an important goal
1
2
3
4
B. Your child’s enrollment in [NAME OF AFTERSCHOOL CENTER]
The next set of questions asks for information about the length of time your child has previously been enrolled in [NAME OF AFTERSCHOOL CENTER] and future plans for enrollment.
B1. During the 2020-2021 school year, how much of the year did your child attend [NAME OF AFTERSCHOOL CENTER] at least once per month either in person or virtually?
MARK ONE ONLY
1 Half of the year or longer
2 Less than half of the year
3 Did
not attend GO TO B3
B2. During the months of the 2020-2021 school year when your child attended [NAME OF AFTERSCHOOL CENTER] either in person or virtually, how often did your child typically attend?
If you aren’t sure, please select the answer that is closest to your best guess.
MARK ONE ONLY
1 Less than 1 day per week
2 1 day per week
3 2 days per week
4 3 days per week
5 4 days per week
6 5 days per week
B3. How likely is it that your child will remain enrolled in [NAME OF AFTERSCHOOL CENTER] at each of the following times?
-
VERY LIKELY
SOMEWHAT LIKELY
NOT AT ALL LIKELY
DON’T KNOW
a. The end of the 2021-2022 school year
1
2
3
d
b. The end of the 2022-2023 school year
1
2
3
d
B4. During the 2021-2022 school year, how many days per week do you expect your child will typically attend [NAME OF AFTERSCHOOL CENTER]?
If you aren’t sure, please select the answer that is closest to your best guess.
MARK ONE ONLY
1 Less than 1 day per week
2 1 day per week
3 2 days per week
4 3 days per week
5 4 days per week
C. Demographics and Contact Information
C1. What is your relationship to your child?
MARK one only
1 Mother
2 Father
3 Stepmother
4 Stepfather
5 Other type of guardian (specify)
C2. Which of the following adults live in the household with your child?
By adult, we mean anyone 18 years old or older.
Please include yourself if you currently live in the same household with your child.
MARK ALL THAT APPLY
1 □ Child’s mother
2 □ Child’s father
3 □ Child’s stepmother
4 □ Child’s stepfather
5 □ Child’s brother (18 years old or older)
6 □ Child’s sister (18 years old or older)
7 □ Child’s aunt
8 □ Child’s uncle
9 □ Child’s grandmother
10 □ Child’s grandfather
11 □ Other (specify)
C3. How many other children under the age of 18 live in the household with your child? Do NOT include the child you are completing this form for.
If no other children under the age of 18 live in the household, please enter “0” and go to C5.
| | | NUMBER
C4. How many children from question C3 also attend [NAME OF AFTERSCHOOL CENTER]?
If no other children from question C3 also attend [NAME OF AFTERSCHOOL CENTER], please enter “0”.
| | | NUMBER
C5. What is the highest degree you have completed?
MARK ONE ONLY
1 High school degree or GED
2 Associate’s degree
3 Bachelor’s degree (B.A., B.S., etc.)
4 Master’s degree (M.A., M.A.T., M.Ed., M.S., etc.)
5 Education specialist or professional diploma (at least one year beyond master’s level)
6 Doctoral degree or equivalent (Ph.D., Ed.D., J.D., M.D.)
7 I do not have a degree
C6. What is your current employment status?
MARK ONE ONLY
1 Employed full-time
2 Employed part-time
3 Not currently employed
4 Retired
C7. Who completed most or all of this questionnaire?
Please note, this information will not be shared or published in any reports. We ask for this information in the event we need to verify any information provided in the survey.
Name:
Email: ______________________________________________________________________________
Phone Number: | | | | - | | | | - | | | | |
Area Code Number
Thank you for taking the time to complete this survey.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Subject | TEMPLATE |
| Author | Mathematica |
| File Modified | 0000-00-00 |
| File Created | 2021-10-09 |
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