Participant Interview Information Form

Parent Interview Information Form

OMB Control No: XXXX

Expiration Date: XXXX

Parent Interview Information Form

Site (site visitor pre-populates):

Interview Number (site visitor pre-populates):

INSTRUCTIONS: Please answer each question below. This information will help make sure the research team talks with a variety of people in this program. Please do not include your name.

1. How many children, under the age of 18, do you have? Please include your biological, adoptive, foster, step, or other children that you are responsible for. _____

2. Of those, how many children, under the age of 18, live with you? By living with you, we mean spends at least two nights a week with you. ___

3. During your first 18 years of life, were you ever in foster care?

☐ Yes

☐ No

☐ Don’t know

☐ Prefer not to answer

4. What is your current gender identity? (Select all that apply.)

☐ Woman

☐ Man

☐ Two-Spirit

☐ I use a different term_______

☐ I don’t know

☐ Prefer not to answer

5. What is your age? (Please mark one.)

☐ Less than 25 years

☐ 26-30 years

☐ 31-40 years

☐ 41-50 years

☐ Over 50 years

6. Are you Hispanic or Latino?

☐ Yes, Hispanic or Latino

☐ No, not Hispanic or Latino

7. What is your race? (Please mark all that apply.)

☐ American Indian or Alaska Native

☐ Asian

☐ Black, African American

☐ Native Hawaiian or other Pacific Islander

☐ White

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to understand programs that provide peer mentoring for parents involved in the child welfare system. Public reporting burden for this collection of information is estimated to average 6 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 OMB number and expiration date for this collection are OMB #: XXXX, Exp: XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Kimberly Francis (Abt Associates); kimberly_francis@abtassoc.com