TIES Baseline Survey

Instrument 1: TIES Father Baseline Survey

PRIVACY STATEMENT: This survey is covered by the Privacy Act. This means that your participation is voluntary, so you can skip any or all the questions in this survey. If you decide to skip any or all the questions, you may lose the chance to receive innovative services that may help you achieve your goals in your work and family life. The purpose of this survey is to find out which parts of fatherhood programs are the most effective at improving the lives of participating fathers and their children and co-parents. The information you provide may be shared with state and federal agencies and researchers involved in similar work. The legal authority for this project is [insert funding stream for the project]. If you would like more information about this project, please see Systems of Records Notice (SORN) 09-80-0361, OPRE Research and Evaluation Project Records.

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to gather preliminary information about the fatherhood field and explore with fatherhood programs the research questions that are of interest and the design options that are feasible. Public reporting burden for this collection of information is estimated to average 22 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. The answers you give will be kept private. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is XXXX-XXXX and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact Dina Israel; Dina.Israel@mdrc.org, and Michelle Manno; Michelle.Manno@mdrc.org ; Attn: OMB-PRA (XXXX-XXXX).

Section A: Background and Family Information

The first set of questions is about your children and family. These questions will give us more information about your children’s ages and your relationships with them.

A1. How many children do you have between 0 and 4 years of age?

[INSERT NUMBER; MAXIMUM IS 15]

A2. How many children do you have between 5 and 9 years of age?

[INSERT NUMBER; MAXIMUM IS 15]

A3. How many children do you have between 10 and 17 years of age?

[INSERT NUMBER; MAXIMUM IS 15]

A4. How many children do you have aged 18 years or older?

[INSERT NUMBER; MAXIMUM IS 15]

[CREATE VARIABLE THAT ADDS UP RESPONSES FOR A1 – A3 CALLED #MINORKIDS. CREATE VARIABLE THAT ADDS UP RESPONSES FOR A1 – A4 CALLED #KIDS.]

A5. How many of your kids have you seen in person, spoken to on the phone or on FaceTime, or texted with in the last 30 days (including messaging on WhatsApp)?

[INSERT NUMBER; MAXIMUM IS NUMBER OF KIDS REPORTED ABOVE]

A6. How many of your kids live with you all or part of the time?

[INSERT NUMBER; MAXIMUM IS NUMBER OF KIDS REPORTED ABOVE]

[IF #KIDS > 1, THEN GO TO A7. ELSE SKIP TO A9.]

A7. Do all of your children have the same mother?

• ₁ Yes [SKIP TO A9]

• ₂ No

• ₈₈ Don’t Know [SKIP TO A9]

• ₉₉ Decline to Answer [SKIP TO A9]

A8. How many different mothers do these children have?

[INSERT NUMBER; RANGE 1 TO #KIDS]

• ₈₈ Don’t Know

• ₉₉ Decline to Answer

[IF #MINORKIDS = 0, THEN SKIP TO SECTION C]

[IF #MINORKIDS => 1, THEN SKIP TO A9]

A9. [IF ONLY 1 CHILD] What is the first name of your child? You can also share a nickname if you’d prefer.

[INSERT NAME OF CHILD] [SKIP TO SECTION B]

IF “Don’t Know” or “Decline to Answer”: use skip logic for “your child” during section B.

IF FATHER PROVIDES NAME, FILL IN NAME OF CHILD FOR SECTION B.

[IF MORE THAN 1 CHILD] What is the first name of your youngest child? You can also share a nickname if you’d prefer.

[INSERT NAME OF YOUNGEST CHILD]

• ₈₈ Don’t Know

• ₉₉ Decline to Answer

IF “Don’t Know” or “Decline to Answer”: use skip logic for “your child” during section B.

IF FATHER PROVIDES NAME, FILL IN NAME OF CHILD FOR SECTION B.

Section B: Father Involvement & Quality of Relationship with Child

The next set of questions is about your relationship with your child -- [INSERT NAME].

[IF MORE THAN ONE CHILD]. We know that you have more than one child. But to keep the length of the survey manageable you only need to think about [INSERT NAME] when you answer the next set of questions.

B1. What is [NAME OF CHILD]’s gender? Please select all that apply.

• ₁ Male

• ₂ Female

• ₃ Genderqueer (transgender, non-binary, gender fluid, genderless, genderfree, gender nonconforming)

• ₄ An identity not listed here (please specify, B1a)

• ₈₈ Don’t know

• ₉₉ Decline to answer

B1a. Please specify the gender identity of [NAME OF CHILD]:

[INSERT NAME OF YOUNGEST CHILD]

B2. Is [NAME OF CHILD] younger than 2 years old?

• ₁ Yes

• ₂ No

• ₈₈ Don’t Know

• ₉₉ Decline to Answer

B2a. How old is [NAME OF CHILD]?

[If B2a = 1 Yes INSERT NUMBER; RANGE 0 TO 24 months;

If B2a = 2 No INSERT NUMBER; RANGE 0 TO 24 years;

If B2a = 88/99 INSERT NUMBER; RANGE 0 TO 24 years;]

• ₈₈ Don’t Know

• ₉₉ Decline to Answer

B2b. What is [NAME OF CHILD]’s birth date?

[MONTH DROPDOWN]

• Don’t Know

• Decline to Answer

[DAY DROPDOWN]

• Don’t Know

• Decline to Answer

[YEAR DROPDOWN] [RANGE IS 1998 – 2024]

• ₈₈ Don’t Know

• ₉₉ Decline to Answer

B3. Do you live with [NAME OF CHILD]’s mother?

• ₁ Yes

• ₂ No

• ₈₈ Don’t know

• ₉₉ Decline to answer

B4. Does [NAME OF CHILD] live with you all or most of the time?

• ₁ Yes

• ₂ No

• ₈₈ Don’t Know

• ₉₉ Decline to answer

B5. What is the first name of [NAME OF CHILD]’s mother? You can share a nickname if you’d prefer.

[INSERT NAME OF YOUNGEST CHILD’S MOTHER]

• ₈₈ Don’t Know

• ₉₉ Decline to answer

[IF B4 = 1, SKIP TO B9]

B6. Who does [NAME OF CHILD] usually live with most of the time? Select all the adults in this list who would apply.

• ₁ Biological mother

• ₂ Grandparent(s)

• ₃ Other relative(s)

• ₄ Friend

• ₅ Foster care

• ₆ Adoptive parent

• ₇ Other

• ₈₈ Don’t Know

• ₉₉ Decline to Answer

B7. Do you have shared custody of [NAME OF CHILD]?

• ₁ Yes

• ₂ No

• ₈₈ Don't know

• ₉₉ Decline to Answer

B8. In the past 30 days, how many times did [NAME OF CHILD] spend the night with you?

• ₁ Every day or almost every day

• ₂ 3 or 4 times per week

• ₃ 1 or 2 times per week

• ₄ 2 or 3 times in the past month

• ₅ Once in the past month

• ₆ Not at all

• ₈₈ Don’t know

• ₉₉ Decline to answer

B9. In general, how satisfied are you with the amount of time you spend with [NAME OF CHILD]?

• ₁ Very satisfied

• ₂ Somewhat satisfied

• ₃ Not satisfied

• ₈₈ Don’t Know

• ₉₉ Decline to Answer

B10. How close do you feel to [NAME OF CHILD]?

• ₁ Very close

• ₂ Close

• ₃ Somewhat close

• ₄ Not very close

• ₈₈ Don’t know

• ₉₉ Decline to answer

B11. How much do you agree with the following statement. I wish I had a better relationship with [NAME OF CHILD].

• ₁ Strongly agree

• ₂ Agree

• ₃ Disagree

• ₄ Strongly disagree

• ₈₈ Don’t know

• ₉₉ Decline to answer

Section C: Parenting and Parent-Child Relationship Quality

The next set of questions aims to gather information about parenting. Please answer the questions as best you can. As a reminder, no one will see your answers to these questions and they will not be shared outside the research team. If you do not want to answer a question, you can choose “decline to answer.”

Nurturing Activities

[Source: Parenting Practices Questionnaire, from PACT tech appendix]

C1. Thinking about [NAME OF CHILD], how often do you…

[IF B2 = 0 TO 3, ONLY ANSWER C1a AND C1b. IF B2 = 4 or older, ANSWER ALL FOUR: C1a – C1d]

	Never	Once in a while	Somewhat often	Very often	Don’t know	Decline to answer
C1a. Show patience with [NAME OF CHILD] when they are upset?	☐0	☐1	☐2	☐3	☐88	☐99
C1b. Praise [NAME OF CHILD] for behaving well or meeting a goal?	☐0	☐1	☐2	☐3	☐88	☐99
C1c. Talk to [NAME OF CHILD] about how things are going at childcare, work, or school?	☐0	☐1	☐2	☐3	☐88	☐99
C1d. Encourage [NAME OF CHILD] to talk about their feelings?	☐0	☐1	☐2	☐3	☐88	☐99

Non-Violent and Harsh Discipline

[Source: Parent-Child Conflict Tactics Scale]

C2. This is a list of things that parents sometimes do and that you may have done in the past year. For each one, please indicate whether you have done it once in the past year; twice in the past year; 3 to 5 times, 6 to 10 times, 11 to 20 times, or more than 20 times in the past year. If you have not done it in the past year, but have done it before then, then choose that option.

	Once	Twice	3-5 times	6-10 times	11-20 times	More than 20 times	Not in past year, but before then	None	Don’t know	Decline to answer
C2a. You explained why something was wrong.	☐1	☐2	☐3	☐4	☐5	☐6	☐7	☐0	☐88	☐99
C2b. You put [NAME OF CHILD] in “time out” or sent your child to their room.	☐1	☒2	☐3	☐4	☐5	☐6	☐7	☐0	☐88	☐99
C2c. You gave [NAME OF CHILD] something else to do instead of what they were doing wrong.	☐1	☐2	☐3	☐4	☐5	☐6	☐7	☐0	☐88	☐99
C2d. You took away privileges or grounded [NAME OF CHILD].	☐1	☐2	☐3	☐4	☐5	☐6	☐7	☐0	☐88	☐99
C2e. You shouted, yelled, or screamed at [NAME OF CHILD].	☐1	☐2	☐3	☐4	☐5	☐6	☐7	☐0	☐88	☐99
C2f. You spanked [NAME OF CHILD] with your hand when they did something wrong.	☐1	☐2	☐3	☐4	☐5	☐6	☐7	☐0	☐88	☐99

Parent-Child Relationship Quality

[Pianta, 1992 – Parent-Child Relationship Scale – closeness subscale - from the NICHD SECCYD]

C3. The next set of questions are about your relationship with [NAME OF CHILD]. How much do each of the following statements apply to your relationship with [NAME OF CHILD]?

	Definitely does not apply	Does not really applied	Not sure	Applies somewhat	Definitely applies	Don’t know	Decline to answer
C3a. I share an affectionate, warm relationship with my child.	☐1	☐2	☐3	☐4	☐5	☐88	☐99
C3b. If upset, my child will seek comfort from me.	☐1	☐2	☐3	☐4	☐5	☐88	☐99
C4c. My child values their relationship with me.	☐1	☐2	☐3	☐4	☐5	☐88	☐99
C4d. When I praise my child, they beam with pride.	☐1	☐2	☐3	☐4	☐5	☐88	☐99
C4e. My child spontaneously shares information about themself.	☐1	☐2	☐3	☐4	☐5	☐88	☐99
C4f. My child tries to please me.	☐1	☐2	☐3	☐4	☐5	☐88	☐99
C4g. It is easy to be in tune with what my child is feeling.	☐1	☐2	☐3	☐4	☐5	☐88	☐99
C4h. I’ve noticed my child copying my behavior or way of doing things.	☐1	☐2	☐3	☐4	☐5	☐88	☐99
C4i. My child openly shares their feelings and experiences with me.	☐1	☐2	☐3	☐4	☐5	☐88	☐99
C4j. My interactions with my child make me feel effective and confident as a parent.	☐1	☐2	☐3	☐4	☐5	☐88	☐99

Parenting Stress Index Short Form – Adapted from Child First Pandemic Study Follow-up (Whiteside-Mansell et al., 2007)

C5. Having a child can sometimes be stressful. The next set of questions contains statements about how stressful having a child has been for you and the ways in which you have had to adjust your life. Thinking about your relationship with [INSERT CHILD NAME], please mark if you strongly disagree, mildly disagree, mildly agree, or strongly agree with each of the following statements.

	Strongly disagree	Mildly disagree	Mildly agree	Strongly agree	Don’t know	Decline to answer
C5a. You find yourself giving up more of your life to meet your child’s needs than you ever expected.	☐1	☐2	☐3	☐4	☐88	☐99
C5b. You feel trapped by your responsibilities as a parent	☐1	☐2	☐3	☐4	☐88	☐99
C5c. Since having your child, you have been unable to do new and different things	☐1	☐2	☐3	☐4	☐88	☐99
C5d. Since having your child, you feel that you are almost never able to do things that you like to do	☐1	☐2	☐3	☐4	☐88	☐99
C5e. Having your child has caused more problems than you expected in your romantic relationship(s).	☐1	☐2	☐3	☐4	☐88	☐99
C5f. Your child rarely does things for you that make you feel good	☐1	☐2	☐3	☐4	☐88	☐99
C5g. Most times you feel that your child does not like you and does not want to be close to you	☐1	☐2	☐3	☐4	☐88	☐99
C5h. Your child smiles at you much less than you expected	☐1	☐2	☐3	☐4	☐88	☐99
C5i. When you do things for your child, you get the feeling that your efforts are not appreciated very much	☐1	☐2	☐3	☐4	☐88	☐99
C5j. You expected to have closer and warmer feelings for your child than you do and this bothers you	☐1	☐2	☐3	☐4	☐88	☐99
C5k. Sometimes your child does things that bother you just to be mean	☐1	☐2	☐3	☐4	☐88	☐99

Section D: Co-parenting Relationship

The next set of questions is about your relationship with [INSERT CHILD NAME]’s mother – [INSERT MOTHER NAME]. These questions are designed so that anyone should be able to answer them, regardless of their relationship with their co-parent.

D1. About how often do you speak directly with [INSERT MOM NAME] in-person, over the phone, on FaceTime or video call, or through text message?

• ₁ Every day

• ₂ 3 – 4 times per week

• ₃ 1 – 2 times per week

• ₄ Every other week

• ₅ Once a month

• ₆ Less than once a month

• ₈₈ Don’t know

• ₉₉ Decline to answer

Constructive Communication

[Source: SHM 12-month follow-up technical appendix; adapted from Cowan’s scale]

D2. How often do you feel the following way about your relationship with [INSERT MOTHER NAME]?

	Never	Hardly ever	Sometimes	Often	Don’t know	Decline to Answer
D2a. I feel good about working out differences with [INSERT MOTHER NAME].	☐1	☐2	☐3	☐0	☐88	☐99
D2b. Past hurts get brought up when arguing with [INSERT MOTHER NAME].	☐1	☐2	☐3	☐0	☐88	☐99
D2c. I feel respected even when I disagree with [INSERT MOTHER NAME].	☐1	☐2	☐3	☐0	☐88	☐99
D2d. During arguments, I take breaks when needed.	☐1	☐2	☐3	☐0	☐88	☐99
D2e. I discuss disagreements respectfully.	☐1	☐2	☐3	☐0	☐88	☐99
D2f. I work together with [INSERT MOTHER NAME] to find resolution.	☐1	☐2	☐3	☐0	☐88	☐99

Destructive Communication

[Source: SHM 12-month follow-up technical appendix, adapted from Cowans]

D3. How often do you feel the following way about your relationship with [INSERT MOTHER NAME]?

	Never	Hardly never	Sometimes	Often	Don’t know	Decline to Answer
D3a. Small issues suddenly become big arguments	☐1	☐2	☐3	☐0	☐88	☐99
D3b. [INSERT MOTHER NAME] is rude and mean when I disagree	☐1	☐2	☐3	☐0	☐88	☐99
D3c. [INSERT MOTHER NAME] seems to view my words or actions more negatively than I meant them to be	☐1	☐2	☐3	☐0	☐88	☐99
D3d. [INSERT MOTHER NAME] and I stay mad at each other after an argument	☐1	☐2	☐3	☐0	☐88	☐99
D3e. Arguments between [INSERT MOTHER NAME] and I become very heated	☐1	☐2	☐3	☐0	☐88	☐99
D3f. [INSERT MOTHER NAME] yells or screams during arguments	☐1	☐2	☐3	☐0	☐88	☐99
D3g. [INSERT MOTHER NAME] blames me for their problems during arguments	☐1	☐2	☐3	☐0	☐88	☐99
D3h. When [INSERT MOTHER NAME] and I fight, things get physical [FROM PACT]	☐1	☐2	☐3	☐0	☐88	☐99

Satisfaction with Co-parenting Relationship

[Source: SHM 12-month follow-up technical appendix; adapted from Cowans]

D4. How much do you agree with the following statements about your relationship with [INSERT MOTHER NAME]?

	Strongly disagree	Disagree	Agree	Strongly agree	Don’t know	Decline to Answer
D4a. [INSERT MOTHER NAME] and I get along when it comes to parenting.	☐1	☐2	☐3	☐4	☐88	☐99
D4b. I am happy with the relationship I have with [INSERT MOTHER NAME].	☐1	☐2	☐3	☐4	☐88	☐99
D4c. I wish I had a better relationship with [INSERT MOTHER NAME].	☐1	☐2	☐3	☐4	☐88	☐99

Section E: Child Support

The next set of questions aims to gather information about any child support that fathers might pay. The questions you receive will vary depending on whether you pay child support or live with your child all the time.

[Source: Adapted from B3 baseline]

E1. Do you have a legal arrangement or child support order that requires you to provide financial support for any children you have with [INSERT MOTHER NAME]?

• ₁ Yes

• ₂ No [SKIP TO E3]

• ₈₈ Don't know

• ₉₉ Decline to Answer

E2. [IF E1 = YES, Don’t know, or Decline to answer] In the past month, how much did you pay for that legal order or arrangement you have with [INSERT MOTHER NAME]? Please do not include any money you have paid directly to [INSERT MOTHER NAME].

[INSERT NUMBER; MAXIMUM IS 10,000]

• ₈₈ Don’t Know

• ₉₉ Decline to Answer

E3. In the past month, have you given financial support to [INSERT MOTHER NAME] directly, instead of or in addition to any formal child support you may have paid?

• ₁ Yes

• ₂ No [SKIP TO E5]

• ₈₈ Don't know

• ₉₉ Decline to Answer

E4. [IF E3 = 1, don’t know, or decline to answer] How much money did you give directly to [INSERT MOTHER NAME] in the past month? Please do not include money you already reported on that you paid as part of a formal child support order.

[INSERT NUMBER; MAXIMUM IS 10,000]

• ₈₈ Don’t Know

• ₉₉ Decline to Answer

E5. In the past month, did you buy things for [INSERT CHILD NAME] like clothes, diapers, school supplies, medicine, or other things they needed? Please only include money you spent directly on your child, not money you gave to [INSERT MOTHER NAME].

• ₁ Yes

• ₂ No [SKIP TO E7]

• ₈₈ Don't know

• ₉₉ Decline to Answer

E6. [IF E5 = 1 or don’t know or decline to answer] How much money did you spend directly on [NAME OF CHILD] for things they needed?

[INSERT NUMBER; MAXIMUM IS 10,000]

• ₈₈ Don’t Know

• ₉₉ Decline to Answer

E7. Has your legal paternity been established? That is, did you sign any document that identifies you as the legal father of [NAME OF CHILD] or has the court ruled that you are their father? 

 

• ₁ Yes, legal paternity 

• ₂ No  

• ₈₈ Don't know 

• ₉₉ Decline to Answer 

Section F: Father Well-being

The next set of questions is about experiences you may have had with the criminal legal system.

F1. Have you ever been convicted of a crime? Please consider both juvenile and adult convictions.

• ₁ Yes

• ₂ No [Skip to F8]

• ₈₈ Don't know

• ₉₉ Decline to Answer

F2. [If F1 = Yes, Don’t know, decline to answer] Have you ever been convicted of a felony?

• ₁ Yes

• ₂ No [SKIP TO F9]

• ₈₈ Don't know [SKIP TO F9]

• ₉₉ Decline to Answer [SKIP TO F9]

F3. Have you ever been incarcerated?

• ₁ Yes

• ₂ No [SKIP TO F8]

• ₈₈ Don't know [SKIP TO F8]

• ₉₉ Decline to Answer [SKIP TO F8]

F4. How long were you incarcerated? (most recent time)

[INSERT YEARS (Range is 0 - 75]

• ₈₈ Don't know

• ₉₉ Decline to Answer

[INSERT MONTHS (Range is 0 – 12)]

• ₈₈ Don't know

• ₉₉ Decline to Answer

F5. Have you been incarcerated more than once?

• ₁ Yes

• ₂ No [SKIP TO F8]

• ₈₈ Don't know [SKIP TO F8]

• ₉₉ Decline to Answer [SKIP TO F8]

F6. If you have been incarcerated more than once, how many times?

[INSERT NUMBER; MAXUMUM IS 20]

• ₈₈ Don't know

• ₉₉ Decline to Answer

F7. How long in total have you spent incarcerated?

[INSERT YEARS (Range is 0 - 75]

• ₈₈ Don't know

• ₉₉ Decline to Answer

[INSERT MONTHS (Range is 0 – 12)]

• ₈₈ Don't know

• ₉₉ Decline to Answer

F8. Are you currently on community supervision, such as parole or probation?

• ₁ Yes

• ₂ No

• ₈₈ Don't know

• ₉₉ Decline to Answer

Depression

[Source: CES-D]

F9. The next set of questions is about how you have been feeling recently. Please indicate how often you have felt this way in the past week.

	Less than 1 day	1-2 days	3-4 days	5-7 days	Don’t know	Decline to Answer
F9a. I was bothered by things that usually don’t bother me	☐1	☐2	☐3	☐4	☐88	☐99
F9b. I had trouble keeping my mind on what I was doing	☐1	☐2	☐3	☐4	☐88	☐99
F9c. I felt depressed	☐1	☐2	☐3	☐4	☐88	☐99
F9d. I felt that everything I did was an effort	☐1	☐2	☐3	☐4	☐88	☐99
F9e. I felt hopeful about the future	☐1	☐2	☐3	☐4	☐88	☐99
F9f. I felt fearful	☐1	☐2	☐3	☐4	☐88	☐99
F9g. My sleep was restless	☐1	☐2	☐3	☐4	☐88	☐99
F9h. I was happy	☐1	☐2	☐3	☐4	☐88	☐99
F9i. I was lonely	☐1	☐2	☐3	☐4	☐88	☐99
F9j. I could not “get going”	☐1	☐2	☐3	☐4	☐88	☐99

There are just a few more sets of questions. The survey is almost done.

F10. Over the last two weeks, how often have you been bothered by the following problems?

[Source: G7 Anxiety Scale]

	Not at all	Several days	More than half the days	Nearly every day	Don’t know	Decline to Answer
F10a. Feeling nervous, anxious, or on edge.	☐1	☐2	☐3	☐4	☐88	☐99
F10b. Not being able to stop or control worrying.	☐1	☐2	☐3	☐4	☐88	☐99
F10c. Worrying too much about different things.	☒1	☐2	☐3	☐4	☐88	☐99
F10d. Having trouble relaxing.	☐1	☐2	☐3	☐4	☐88	☐99
F10e. Being so restless that it is hard to sit still.	☐1	☐2	☐3	☐4	☐88	☐99
F10f. Becoming easily annoyed or irritable.	☐1	☐2	☐3	☐4	☐88	☐99
F10g. Feeling afraid, as if something awful might happen.	☐1	☐2	☐3	☐4	☐88	☐99

F11. How would you rate your physical health?

• ₁ Excellent

• ₂ Very good

• ₃ Good

• ₄ Fair

• ₅ Poor

• ₈₈ Don’t know

• ₉₉ Decline to answer

Substance use

[Source: adapted from NIH battery]

F12. The next question is about drinking alcoholic beverages. By a “drink” we mean a can or a bottle of beer, a wine cooler or glass of wine, a shot of liquor, or a mixed drink.

During the past 3 months, how many alcoholic drinks did you have in an average week?

• ₀ None

• ₁ Less than 1 drink

• ₂ 1 to 3 drinks

• ₃ 4 to 6 drinks

• ₄ 7 to 13 drinks

• ₅ 14 to 19 drinks

• ₆ 20 or more drinks

• ₈₈ Don’t know

• ₉₉ Decline to answer

F13. The final set of questions is about drug use on your own. By “on your own” we mean either without a doctor’s prescription, in larger amounts than prescribed, or for a longer period than prescribed.

In the past three months, have you used any of the following drugs on your own?

	Yes	No	Don’t know	Decline to Answer
F13a. Prescription pain killers, including opioids?	☐1	☐2	☐88	☐99
F13b. Marijuana (pot, bud) or hashish (hash)?	☐1	☐2	☐88	☐99
F13c. Other drugs (e.g., amphetamines, meth, cocaine, heroin, tranquilizers, downers, PCP, ecstasy, sniffing aerosols or other products, or any others?)	☐1	☐2	☐88	☐99

Self-efficacy

[Source: Pearlin Mastery Scale]

F14. Please read each of the following statements and indicate whether you strongly agree, agree, disagree, or strongly disagree with each one.

	Strongly Disagree	Disagree	Agree	Strongly agree	Don’t know	Decline to Answer
F14a. I have little control over the things that happen to me.	☐1	☐2	☐3	☐4	☐88	☐99
F14b. There is really no way I can solve some of the problems I have.	☐1	☐2	☐3	☐4	☐88	☐99
F14c. There is little I can do to change many of the important things in my life.	☐1	☐2	☐3	☐4	☐88	☐99
F14d. I often feel helpless in dealing with the problems of my life	☐1	☐2	☐3	☐4	☐88	☐99
F14e. Sometimes I feel that I’m being pushed around in life	☐1	☐2	☐3	☐4	☐88	☐99
F14f. What happens to me in the future mostly depends on me	☐1	☐2	☐3	☐4	☐88	☐99
F14g. I can do just about anything I really set my mind to do	☐1	☐2	☐3	☐4	☐88	☐99

Thank you so much for your participation in this survey today! Your answers will be used to improve this survey in the future. If there is anything else you’d like to share with the research team about yourself, your family, your interest in the program, or anything else, please describe it here:

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