Professional Documents
Culture Documents
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Milwaukee Young Parenthood Study
Participant Assessment Tools
PRIVACY
We want you to know that:
1. Your answers to these questions will help us learn what people your age know, think, and do.
2. You may skip any questions you do not wish to answer. But we hope that you will answer as
many questions as you can.
3. Your answers will be combined with those of other teens. We will keep your answers private.
PLEASE DO NOT WRITE YOUR NAME ANYWHERE ON THIS SURVEY!
General Instructions
• Read all the answers before marking your choice. If none of the printed answer exactly applies
to you, black out the box beside the answer that best fits.
• Use a pencil to complete this survey
• Completely black out in the box beside your answer choice.
• If you make an error, erase it cleanly and them mark the box beside your correct answer choice.
• Do not make any stray marks
• PLEASE READ EACH QUESTION CAREFULLY.
Follow the directions for responding to each kind of question. These are:
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Milwaukee Young Parenthood Study
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Milwaukee Young Parenthood Study
Participant Assessment Tools
It is better for a person to get married than to go through life being single.
MARK ONE
□ 1 Strongly Agree
□ 2 Agree
□ 3 Neither Agree or Disagree
□ 4 Disagree
□ 5 Strongly Disagree
□ 97 Don’t Know
5. How much do you stay away from people who might get you into trouble?
MARK ONE
□ 1 Almost Never
□ 2 Some of the time
□ 3 Usually
□ 4 Almost Always
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Milwaukee Young Parenthood Study
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Please mark how much the following statements sound like you.
6. I think I should work to get something, if I really want it.
MARK ONE
□ 1 Not at all like me
□ 2 A little like me
□ 3 Mostly like me
□ 4 Very much like me
□ 97 Don’t Know
7. I make decisions to help me reach my goals.
MARK ONE
□ 1 Not at all like me
□ 2 A little like me
□ 3 Mostly like me
□ 4 Very much like me
□ 97 Don’t Know
8. Some young women feel they are not ready to be a parent. For these women, I think adoption is
a good choice.
MARK ONE
□ 1 Not at all like me
□ 2 A little like me
□ 3 Mostly like me
□ 4 Very much like me
□ 97 Don’t Know
The next question is about your mother or father. Or a person like a mother or father to you.
9. How often do you talk to your mother or father about your problems?
MARK ONE
□ 1 Almost never
□ 2 Some of the time
□ 3 Usually
□ 4 Almost Always
□ 96 There is no person who is like a mother or father to me
ABOUT YOUR HEALTH
This next question is about your health.
10. These are some ways people try to avoid sexually transmitted diseases. What way(s) did you try
this month?
MARK ONE OR MORE
□ 1 No method used this month
□ 2 Abstinence (did not have sex this month)
□ 3 Condom
□ 4 Female condom, vaginal pouch
□ 5 Other Method (Describe_______________)
11. How many weeks or months pregnant are you
______1 Weeks or _________2 Months
12. Including this pregnancy, how many times have you been pregnant in your life?
MARK ONE
□ 1 Once
□ 2 Twice
□ 3 Three times
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Milwaukee Young Parenthood Study
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□ 3 10th grade
□ 4 11th grade
□ 5 12th grade
□ 6 Some college
□ 7 College degree or more
□ 97 Don’t know
27. Have you ever been in a job training program?
□ 1 Yes
□ 0 No (SKIP TO #29)
28. Did you ever complete a job training program?
MARK ONE
□ 1 Yes
□ 2 No and not in a job training program
□ 3 No and now in a job training
29. How many hours do you work per week?
WRITE 00 IF YOU DO NOT WORK
______________ Hours per week
30. Do you receive money or aid from any of the following sources?
MARK ALL THAT APPLY
□ a. Medicaid
□ b. Food stamps
□ c. WIC (Women, Infants, and Children) Program
□ d. TANF (Temporary Aid to Needy Families)
□ e. Social Security
□ f. Unemployment or Workers’ Compensation
□ g. Other public aid
□ h. Child support
□ i. My job
□ j. Husband or partner
□ k. Parent(s)
□ l. Other (Describe___________________)
31. What is your main source of financial support?
MARK ONE
□ 1 My job
□ 2 Husband or partner
□ 3 Parents
□ 4 Public aid
□ 5 Other relatives
□ 6 Other (Describe______________________)
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Milwaukee Young Parenthood Study
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Adolescent Family Life Care Programs Core Follow-Up Questionnaire (Time 2-Time 4)
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Milwaukee Young Parenthood Study
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Milwaukee Young Parenthood Study
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1. How important is it to you to graduate high school? Or to graduate vocational or trade school?
Mark ONE
□ 1 Not important at all
□ 2 Somewhat important
□ 3 Very important
□ 4 Extremely important
□ 96 Already graduated
Answer the next question using a scale from 1 to 5. 1 is “not at all” and 5 is “a lot.”
2. How much do you want to get more education or training? This could be college, vocational or
technical school, or a nursing certification.
Mark ONE
□ 1 Not at all
□ 2
□ 3
□ 4
□ 5 A lot
□ 97 Don’t Know
3. How important is it for you to get training to get the kind of job you want?
Mark ONE
□ 1 Not Important
□ 2
□ 3
□ 4
□ 5 Very Important
□ 97 Don’t Know
4. Please mark how much you agree or disagree with this statement:
It is better for a person to get married than to go through life being single.
Mark ONE
□ 1 Strongly Agree
□ 2 Agree
□ 3 Neither Agree or Disagree
□ 4 Disagree
□ 5 Strongly Disagree
□ 97 Don’t Know
5. How much do you stay away from people who might get you into trouble?
Mark ONE
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Milwaukee Young Parenthood Study
Participant Assessment Tools
□ 1 Almost Never
□ 2 Some of the time
□ 3 Usually
□ 4 Almost Always
Please mark how much the following statements sound like you.
8. Some young women feel they are not ready to be a parent. For these women, I think adoption is
a good choice.
Mark ONE
□ 1 Not at all like me
□ 2 A little like me
□ 3 Mostly like me
□ 4 Very much like me
□ 97 Don’t Know
The next question is about your mother or father or a person like a mother or father to you.
9. How often do you talk to your mother or father about your problems?
Mark ONE
□ 1 Almost never
□ 2 Some of the time
□ 3 Usually
□ 4 Almost Always
□ 96 There is no person who is like a mother or father to me
These next questions are about the child you were pregnant with on_________________.
MM/DD/YY
10. Did this pregnancy end in live birth?
□ 1Yes
□ 0No (IF YOUR ANSWER IS “NO,” SKIP TO #30 ON PAGE 4.)
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Milwaukee Young Parenthood Study
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11. When was this child born? ___ ___ / ___ ___
MONTH / YEAR
12. An early birth is one that occurs at 36 weeks or earlier in pregnancy. As far as you know, did you
have an early birth?
Mark ONE
□ 1 Yes
□ 2 No
□ 97 Don’t Know
13. How much did this child weigh at birth?
Mark ONE
□ 1 5 ½ pounds or more
□ 2 Less than 5 ½ pounds
□ 97Don’t know
15. How old was this child when you completely stopped breastfeeding him or her?
Mark ONE
□ 1 I am still breastfeeding
□ 2 Less than 1 month old
□ 3 1 month old to 2 months old
□ 4 3 months old or more
□ 1 Yes
□ 0 No IF YOU ANSWERED “NO,” SKIP TO #30 ON PAGE 4.
17. This next question is about after the birth of this child. About how many times has this child had
a regular check up or “well-baby” visit? This is a visit to the doctor or nurse when your child is
not sick, but to get checked out or to get shots. Would you say . . .
Mark ONE
□ 1 Never (SKIP TO #19 ON PAGE 3)
□ 2 1–3 times
□ 3 4 or more times
□ 97 Don’t know
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Milwaukee Young Parenthood Study
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Yes No Don’t
MARK ON ANSWER FOR EACH Know
a. Diptheria, Tetanus, Pertussis (DTaP)
b. Inactivated Poliovirus (IPV)
c. Haemophilus influenzae type b (Hib)
d. Hepatitis B (HepB)
e. Pneumococcal (PCV)
f. Rotavirus (Rota)
IF YOUR CHILD DOES NOT LIVE WITH YOU, PLEASE SKIP TO #26 ON PAGE 4.
23. This next question is about the past four weeks. Has this child received any regular child care?
This could be a day care, nursery school, play group, babysitter, after school care, relatives, or
some other child care plan. (Regular” means at least once a week for a month or more.)
□ 1 Yes
□ 2 No (SKIP TO #26)
24. Which of these has been your main child care provider in the past four weeks?
Mark ONE
□ 1 Child’s father/stepfather
□ 2 My brother/sister aged 13 years or older
□ 3 My brother/sister younger than 13 years old
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Milwaukee Young Parenthood Study
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□ 4 Child’s grandparent
□ 5 Other relative
□ 6 Non-relative or babysitter
□ 7 Nursery/preschool
□ 8 Family day care
□ 9________________________________________________________________
□ 10 Day care center referred by ________________________________________
□ 11 Other day care center not referred by ________________________________
□ 12 Other (Describe__________________________________________________)
□ 13 Child has not received regular child care in the past four weeks
26. Which of these statements best describes your relationship with your child’s father?
Mark ONE
□ 1 We do not talk to each other
□ 2 We hardly ever see or talk to each other
□ 3 We are just friends
□ 4 We are involved in an on-again, off-again relationship
□ 5 We are romantically involved on a steady basis but are not married
□ 6 We are married (SKIP TO #31)
□ 7 Don’t know
IF YOU ARE MARRIED TO THE FATHER OF YOUR CHILD, SKIP TO #31.
27. Do you and your child’s father have a legal agreement for child support, alimony, custody,
visitation, or where the child will live?
□ 1 Yes
□ 2 No
28. Does your child’s father give you money or buy clothes for your child? Or pay for doctor visits or
provide other kinds of support?
□ 1 Yes
□ 2 No
29. Does your child’s father help you in other ways, such as watching the child or helping with
chores?
□ 1 Yes
□ 2 No
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Milwaukee Young Parenthood Study
Participant Assessment Tools
32. These are some ways people try to avoid sexually transmitted diseases. What way(s) did you try
this month?
Mark ALL THAT APPLY
□ a. No method used this month
□ b. Abstinence (did not have sex this month)
□ c. Condom
□ d. Female condom, vaginal pouch
□ e. Other (Describe_______________)
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Milwaukee Young Parenthood Study
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ABOUT YOU
These questions ask about you.
37. What is your current school status?
Mark ONE
□ 1 In school or GED program
□ 2 Graduated from high school or completed GED (SKIP TO #39)
□ 3 Dropped out of school
□ 4 Other (Describe______________)
38. IF YOU HAVE NOT FINISHED YOUR HIGH SCHOOL OR COMPLETED YOUR GED:
Do you want to have another baby before you finish high school?
□ 1 Yes
□ 0 No
□ 97 Don’t know
39. What is the highest grade you have completed?
Mark ONE
□ 1 8th grade or below
□ 2 9th grade
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Milwaukee Young Parenthood Study
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th
□ 3 10 grade
th
□ 4 11 grade
th
□ 5 12 grade
□ 6 Some college
□ 7 College degree or more
□ 97 Don’t know
43. Do you receive money or aid from any of the following sources?
Mark ALL THAT APPLY
□ a. Medicaid
□ b. Food stamps
□ c. WIC (Women, Infants, and Children) Program
□ d. TANF (Temporary Aid to Needy Families)
□ e. Social Security
□ f. Unemployment or Workers’ Compensation
□ g. Other public aid
□ h. Child support
□ i. My job
□ j. Husband or partner
□ k. Parent(s)
□ l. Other (Describe___________________)
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Milwaukee Young Parenthood Study
Participant Assessment Tools
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Milwaukee Young Parenthood Study
Participant Assessment Tools
15. Imagine that this later pictures how American society is set up.
• At the top of the ladder are the people who are the best off—they have the most money,
the highest amount of school, and the jobs that bring the most respect.
• At the bottom are people who are the worst off—they have the least money, little or no
education, no jobs or jobs that no one wants.
Now think about your family. Please tell us where you think your family would be on this
ladder. Fill in the circle that best represents where your family would be on this ladder.
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Milwaukee Young Parenthood Study
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16. Now assume that the ladder is a way of picturing your school
• At the top of the ladder are the people in your school with the most respect, the highest
grades, and the highest standing.
• At the bottom of the ladder are the people who no one respects, no one wants to hang
around with and have the worst grades.
Where would you place yourself on this ladder? Fill in the circle that best represents where you
would be on this ladder.
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Milwaukee Young Parenthood Study
Participant Assessment Tools
Instructions: The questions in this scale ask you about your feelings and thoughts during the last month.
In each case, please indicate with a check how often you felt or thought a certain way.
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Milwaukee Young Parenthood Study
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Directions: Please read each of the following questions and respond by selecting how much you agree or
disagree with each statement.
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Milwaukee Young Parenthood Study
Participant Assessment Tools
For the next statement, choose your response form the choices “1” to “5” below.
22. I feel that I am:
1. a very good parent,
2. a better than average parent,
3. an average parent,
4. a person who has some trouble being a parent.
5. not very good at being a parent.
For the next statement, choose your responses from the choices “1” to “5” below
32. I have found that getting my child to do something
or stop doing something is: .................................................................................. 1 2 3 4 5
1. much harder than I expected,
2. somewhat harder than I expected,
3. about as hard as I expected,
4. somewhat easier than I expected,
5. much easier than I expected,
33. Think carefully and count the number of things which yourchild does that bothers you. For example:
dawdles, refuses to listen, overactive, cries, interrupts, fights, whines, etc.
Please fill in the number which includes the number of things you counted.
1. 1-3
2. 4-5
3. 6-7
4. 8-9
5. 10+
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Milwaukee Young Parenthood Study
Participant Assessment Tools
Introduction: ‘‘In the following questions, we are interested in the way other people have treated you
or your beliefs about how other people have treated you. Can you tell me if any of the following has
ever happened to you:’’
1) At any time in your life, have you ever been unfairly fired? 1 2
2) For unfair reasons, have you ever not been hired for a job? 1 2
3) Have you ever been unfairly stopped, searched, questioned, physically threatened or 1 2
abused by the police?
4) Have you ever been unfairly discouraged by a teacher or advisor from continuing your 1 2
education?
5) Have you ever moved into a neighborhood where neighbors made life difficult for you 1 2
or your family?
For each situation to which the participant replied ‘‘yes,’’ the follow-up question was:
What do you think was the main reason for this experience?
• Your ancestry or national origins
• Your gender
• Your race
• Your age
• Your religion
• Your height or weight
• Your shade of skin color
• Your sexual orientation
• Your education or income level
• A physical disability
• Other
In your day-to-day life, how often have any of the following things happened to you?
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Milwaukee Young Parenthood Study
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Respondents who indicated any of these events occurred at least once were then asked one question,
covering all the situations:
What do you think was the main reason for this/these experience(s)?
• Your ancestry or national origins
• Your gender
• Your race
• Your age
• Your religion
• Your height or weight
• Your shade of skin color
• Your sexual orientation
• Your education or income level
• A physical disability
• Other
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Milwaukee Young Parenthood Study
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Cannot Moderately
do at certain Certain
all can do can do
0 1 2 3 4 5 6 7 8 9 10
For each of the following items, write a number from 0 - 10, using the scale above.
When things aren't going well for you, how confident are you that you can:
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against him.
He said things to my friends about me to turn them against 1 2 3 4
me.
21 I ridiculed or made fun of him in front of others. 1 2 3 4
He ridiculed or made fun of me in front of others. 1 2 3 4
22 I told him how upset I was. 1 2 3 4
He told me how upset he was. 1 2 3 4
23. I kept track of who he was with and where he was 1 2 3 4
He kept track of who I was with and where I was. 1 2 3 4
24. I blamed him for the problem. 1 2 3 4
He blamed me for the problem. 1 2 3 4
25. I kicked, hit or punched him. 1 2 3 4
He kicked, hit or punched me. 1 2 3 4
26. I left the room to cool down. 1 2 3 4
He left the room to cool down. 1 2 3 4
27. I gave in, just to avoid conflict 1 2 3 4
He gave in, just to avoid conflict 1 2 3 4
28.I accused him of flirting with another girl. 1 2 3 4
He accused me of flirting with another guy. 1 2 3 4
29. I deliberately tried to frighten him. 1 2 3 4
He deliberately tried to frighten me. 1 2 3 4
30. I slapped him or pulled his hair. 1 2 3 4
He slapped me or pulled my hair. 1 2 3 4
31. I threatened to hurt him 1 2 3 4
He threatened to hurt me. 1 2 3 4
32. I threatened to end the relationship. 1 2 3 4
He threatened to end the relationship. 1 2 3 4
33. I threatened to hit him or throw something at him. 1 2 3 4
He threatened to hit me or throw something at me. 1 2 3 4
34. I pushed, shoved, or shook him. 1 2 3 4
He pushed, shoved, or shook me. 1 2 3 4
35. I spread rumors about him. 1 2 3 4
He spread rumors about me. 1 2 3 4
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Milwaukee Young Parenthood Study
Participant Assessment Tools
Directions: You are now going to be asked a series of questions about your relationships with various
people in your life. In response to each question, please check one of the following boxes:
not at all
a little
some
a lot
1) To what extent could you turn to the following people for advice about problems?
Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
2) How often do you need to work hard to avoid conflict with the following people?
Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
3) To what extent could you turn to the following people for help with a problem?
Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
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Milwaukee Young Parenthood Study
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Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
5) To what extent can you count on the following people to give you honest feedback, even if you
might not want to hear it?
Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
6) How much do the following people make you feel guilty?
Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
7) How much do you have to "give in" in your relationship with the following people?
Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
8) To what extent can you count on the following people to help you if a family member very close to
you died?
Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
9) How much do the following people want you to change?
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Milwaukee Young Parenthood Study
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Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
10) How much more do you give than you get from your relationship with the following people?
Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
11) How positive a role do the following people play in your life?
Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
12) How significant is your relationship with the following people in your life?
Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
13) How close will your relationship be with the following people in 10 years?
Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
14) How much would you miss the following people if the two of you could not see or talk with each
other for a month?
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Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
15) How critical of you are the following people?
Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
16) If you wanted to go out and do something this evening, how confident are you that the following
people would be willing to do something with you?
Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
17) How responsible do you feel for the following people’s well-being?
Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
18) How much do you depend on the following people?
Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
19) To what extent can you count on following people to listen to you when you are very angry at
someone else?
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Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
20) How much would you like the following people to change?
Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
21) How angry do the following people make you feel?
Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
22) How much do you argue with the following people?
Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
23) To what extent can you really count on the following people to distract you from your worries
when you feel under stress?
Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
24) How often do the following people make you feel angry?
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Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
25) How often do the following people try to control or influence your life?
Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
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Fragile Families and Child Well-Being Study (Survey of New Parents) Mother’s One Year
Follow-Up Survey, Public Version
Now I would like to ask you some questions about things (YOUR PARTNER) does with (CHILD).
For each activity, please tell me how many days a week he/she does this in a typical week.
How many days does he/she usually (READ ITEM)?
Record Never as 0.
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Now I would like to ask you some questions about things YOU do with (CHILD).
For each activity, please tell me how many days a week you do this in a typical week.
How many days do you usually (READ ITEM)?
Record Never as 0.
Fragile Families Caregiving Activities Additional Questions (Time 3 and Time 4 only)
C4. Sometimes children behave well and sometimes they don’t. In the past month, has (PARTNER)
spanked (CHILD) because he/she was misbehaving or acting up?
1) Everyday or nearly everyday 2) A few times a week 3) A few times this past month
4) Only once or twice
C5. In the past month, how often has (PARTNER) spent one or more hours a day with (CHILD)?
1) Everyday or nearly everyday 2) A few times a week 3) A few times this past month
4) Only once or twice 5) Not at all
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C5A. How often do you think (PARTNER) should spend one or more hours a day with (CHILD)?
1) Everyday or nearly everyday 2) A few times a week 3) A few times this past month
4) Only once or twice 5) Not at all
Do you think he spends too much time, not enough time, or just about the right amount of time with
(CHILD)?
C5B. Have you ever asked (PARTNER) to spend more time with (CHILD)?
1) Yes 2) No
The following questions are about how parents work together in raising a child. Please tell me how often
the following statements are true for you and (PARTNER)?
(READ ITEM). Would you say it’s always true, sometimes true or rarely true?
1) Yes 2) No
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very frequently
frequently
occasionally
very rarely
never
QUES2 When I am caring for the baby I get feelings that the child is
deliberately being difficult or trying to upset me:
very frequently
frequently
occasionally
very rarely
never
QUES3 Over the last two weeks I would describe my feelings for the baby as:
dislike
slight affection
moderate affection
intense affection
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almost always
usually
sometimes
rarely
almost never
QUES5 Regarding my overall level of interaction with the baby I believe I am:
very frequently
frequently
occasionally
almost never
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QUES7 When I am with the baby and other people are present I feel proud of
the baby:
very frequently
frequently
occasionally
almost never
QUES8 I try to involve myself as much as possible in child care and looking
after the baby:
this is true
this is untrue
QUES9 I find myself talking to people (other than my partner) about the baby:
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very frequently
frequently
occasionally
not at all
QUES14 When I have been away from the baby for a while and I am about to be
with him/her again, I usually feel:
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QUES15 Over the past three months I have found myself just sitting looking at
the sleeping baby for periods of five minutes or more:
very frequently
frequently
a few times
not at all
QUES16 I now think of the baby as:
QUES17 Regarding the things that we have had to give up because of the baby:
QUES18 Over the past three months, I have felt that I do not have enough time
for myself or to pursue my own interests:
very frequently
occasionally
not at all
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I am very impatient
I am a bit impatient
I am moderately patient
I am extremely patient
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INSTRUCTIONS: The following questionnaire includes a series of statements which may be applied to
yourself. Read each of the statements and determine if you AGREE or DISAGREE with the statement-
check the best response. Be honest when giving your answers. Remember to read each statement: it is
important not to skip statements.
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Part A
In the past 12 months, did you:
1. Drink any alcohol (more than a few sips)?
□ Yes
□ No
2. Smoke any marijuana or hashish?
□ Yes
□ No
3. Use anything else to get high? “anything else” includes illegal drugs, over the counter and
prescription drugs, and things that you sniff or “huff”
□ Yes
□ No
Part B
1. Have you ever ridden in a car driven by someone (including yourself) who was “high” or had
been using alcohol or drugs?
□ Yes
□ No
2. Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?
□ Yes
□ No
3. Do you ever use alcohol or drugs while you are by yourself, alone?
□ Yes
□ No
4. Do you ever forget things you did while using alcohol or drugs?
□ Yes
□ No
5. Do your family or friends ever tell you that you should cut down on your drinking or drug use?
□ Yes
□ No
6. Have you gotten into trouble while you were using alcohol or drugs?
□ Yes
□ No
PARTNER
Please answer all questions about your partner honestly; your answers will be kept confidential.
Part A
In the past 12 months, did your partner:
4. Drink any alcohol (more than a few sips)?
□ Yes
□ No
5. Smoke any marijuana or hashish?
□ Yes
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□ No
6. Use anything else to get high? “anything else” includes illegal drugs, over the counter and
prescription drugs, and things that you sniff or “huff”
□ Yes
□ No
Part B
7. Has your partner ever ridden in a car driven by someone (including yourself) who was “high” or
had been using alcohol or drugs?
□ Yes
□ No
8. Does your partner ever use alcohol or drugs to relax, feel better about his/herself, or fit in?
□ Yes
□ No
9. Does your partner ever use alcohol or drugs while he/she is by his/herself, along?
□ Yes
□ No
10. Does your partner ever forget things he/she did while using alcohol or drugs?
□ Yes
□ No
11. Does your partner’s family or friends ever tell him/her that he/she should cut down on his/her
drinking or drug use?
□ Yes
□ No
12. Has your partner gotten into trouble while he/she was using alcohol or drugs?
□ Yes
□ No
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1. Is there anything that happened to you that was really bad or something else you saw that was
really scary?
□ Yes
□ No
How often have you experienced each of the following in the last two months?
0 = Never 3 = Often
1. Headaches 0 1 2 3
2. Insomnia (trouble getting to sleep) 0 1 2 3
3. Weight loss (without dieting) 0 1 2 3
4. Stomach problems 0 1 2 3
5. Sexual problems 0 1 2 3
6. Feeling isolated from others 0 1 2 3
7. "Flashbacks" (sudden, vivid, distracting memories) 0 1 2 3
8. Restless sleep 0 1 2 3
9. Low sex drive 0 1 2 3
10. Anxiety attacks 0 1 2 3
11. Sexual over activity 0 1 2 3
12. Loneliness 0 1 2 3
13. Nightmares 0 1 2 3
14. "Spacing out" (going away in your mind) 0 1 2 3
15. Sadness 0 1 2 3
16. Dizziness 0 1 2 3
17. Not feeling satisfied with your sex life 0 1 2 3
18. Trouble controlling your temper 0 1 2 3
19. Waking up early in the morning and can't get back to sleep 0 1 2 3
20. Uncontrollable crying 0 1 2 3
21. Fear of men 0 1 2 3
22. Not feeling rested in the morning 0 1 2 3
23. Having sex that you didn't enjoy 0 1 2 3
24. Trouble getting along with others 0 1 2 3
25. Memory problems 0 1 2 3
26. Desire to physically hurt yourself 0 1 2 3
27. Fear of women 0 1 2 3
28. Waking up in the middle of the night 0 1 2 3
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In this country, people come from different cultures and have different words to describe different
customs of cultures of ethnic groups. Some examples of ethnic names are Mexican-Americans,
Hispanics, Black, Asian-Americans, American Indians, Anglo-Americans, and Whites.
Belonging to one or more ethnic groups, and the feelings associated with these groups, can have an
influence on various areas of our lives. The following questions will help us understand what your
attitudes and thoughts are in reference to your ethnic group.
In terms of ethnic groups, I consider myself:_________________
Disagree Slightly
Disagree Slightly Neutral Agree Agree
1. I have dedicated time to find out more about my
1 2 3 4 5
ethnic group, such as history, tradition and customs.
2. I am active in organizations or social groups
where the majority of its members are of my own 1 2 3 4 5
ethnic group.
3. I have a clear idea about what my ethnic group is
1 2 3 4 5
and what it means to me/
4. I have thought a lot about how my ethnic group
1 2 3 4 5
influences my life.
5. I am happy being a part of my ethnic group. 1 2 3 4 5
6. I feel I identify with the ethnic group I belong to. 1 2 3 4 5
7. I clearly understand what belonging to my ethnic
1 2 3 4 5
group means.
8. To learn more about my ethnic roots, I have
1 2 3 4 5
talked to others about my ethnic group.
9. I am proud of my ethnic group. 1 2 3 4 5
10. I participate in cultural activities from my own
ethnic group, for example, special foods, music and 1 2 3 4 5
customs.
11. I feel great affection toward my ethnic group. 1 2 3 4 5
12. I feel comfortable with my cultural heritage and
1 2 3 4 5
ethnic group.
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Directions: For each of the following items, think about whether or not each situation has happened in
the past six months or not
Yes No
Did you go without food because you didn’t have the money to pay for it? 1 2
Was your telephone, electricity, or gas turned off? 1 2
Did you miss an appointment to have or change your plans because you had no 1 2
transportation to get there?
Did you have legal problems? 1 2
Did you drop out of school? 1 2
Did you get expelled from school? 1 2
Did a family member die? 1 2
Did a friend die? 1 2
Did you see violence? 1 2
Was anyone else in your household a victim of a crime? 1 2
Were you a victim of crime? 1 2
Did you(r partner) have a miscarriage? 1 2
Did you become ill? 1 2
Did another family member become ill? 1 2
Did you lose your housing? 1 2
Did you have trouble with your teacher(s)? 1 2
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Consumer Assessment of Healthcare Providers and Systems (Time 3 and Time 4 Only)
Please answer the questions for the child listed on the envelope. Please do not answer for any other
children.
1. Our records show that your child got care from the doctor named below in the last 12 months.
Is that right?
1
Yes If Yes, Go to Question 2
2
No If No, Go to Question 26
The questions in this survey booklet will refer to the doctor named in Question 1 as “this doctor.”
Please think of that doctor as you answer the survey.
2. Is this the doctor you usually see if your child needs a check-up or gets sick or hurt?
1
Yes
2
No
4. In the last 12 months, how many times did your child visit this doctor for care?
1
None If None, Go to
Question 26
2
1 time
3
2
4
3
5
4
6
5 to 9
7
10 or more times
5. In the last 12 months, did you phone this doctor’s office to get an appointment for your child for
an illness, injury or condition that needed care right away?
1
Yes
2
No If No, Go to Question 7 on Next Page
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6. In the last 12 months, when you phoned this doctor’s office to get an appointment for care your
child needed right away, how often did you get an appointment as soon as you thought your
child needed?
1
Never
2
Almost Never
3
Sometimes
4
Usually
5
Almost Always
6
Always
7. In the last 12 months, did you make any appointments for a check-up or routine care for your
child with this doctor?
1
Yes
2
No If No, Go to Question 9
8. In the last 12 months, when you made an appointment for a check-up or routine care for your
child with this doctor, how often did you get an appointment as soon as you thought your child
needed?
1
Never
2
Almost Never
3
Sometimes
4
Usually
5
Almost Always
6
Always
9. In the last 12 months, did you phone this doctor’s office with a medical question about your
child during regular office hours?
1
Yes
2
No If No, Go to Question 11
10. In the last 12 months, when you phoned this doctor’s office during regular office hours, how
often did you get an answer to your medical question that same day?
1
Never
2
Almost Never
3
Sometimes
4
Usually
5
Almost Always
6
Always
11. In the last 12 months, did you phone this doctor’s office with a medical question about your
child after regular office hours?
1
Yes
2
No If No, Go to Question 13 on Next Page
12. In the last 12 months, when you phoned this doctor’s office after regular office hours, how often
did you get an answer to your medical question as soon as you needed?
1
Never
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2
Almost Never
3
Sometimes
4
Usually
5
Almost Always
6
Always
13. Wait time includes time spent in the waiting room and exam room. In the last 12 months, how
often did your child see this doctor within 15 minutes of his or her appointment time?
1
Never
2
Almost Never
3
Sometimes
4
Usually
5
Almost Always
6
Always
14. In the last 12 months, how often did this doctor explain things about your child’s health in a way
that was easy to understand?
1
Never
2
Almost Never
3
Sometimes
4
Usually
5
Almost Always
6
Always
15. In the last 12 months, how often did this doctor listen carefully to you?
1
Never
2
Almost Never
3
Sometimes
4
Usually
5
Almost Always
6
Always
16. In the last 12 months, did you talk with this doctor about any problems or concerns you had
about your child’s health?
1
Yes
2
No If No, Go to Question 18
17. In the last 12 months, how often did this doctor give you easy to understand instructions about
taking care of these health problems or concerns?
1
Never
2
Almost Never
3
Sometimes
4
Usually
5
Almost Always
6
Always
18. In the last 12 months, how often did this doctor seem to know the important information about
your child’s medical history?
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1
Never
2
Almost Never
3
Sometimes
4
Usually
5
Almost Always
6
Always
19. In the last 12 months, how often did this doctor show respect for what you had to say?
1
Never
2
Almost Never
3
Sometimes
4
Usually
5
Almost Always
6
Always
20. In the last 12 months, how often did this doctor spend enough time with your child?
1
Never
2
Almost Never
3
Sometimes
4
Usually
5
Almost Always
6
Always
21. In the last 12 months, did this doctor order a blood test, x-ray or other test for your child?
1
Yes
2
No If No, Go to Question 23
22. In the last 12 months, when this doctor ordered a blood test, x-ray or other test for your child,
how often did someone from this doctor’s office follow up to give you those results?
1
Never
2
Almost Never
3
Sometimes
4
Usually
5
Almost Always
6
Always
23. Using any number from 0 to 10, where 0 is the worst doctor possible and 10 is the best doctor
possible, what number would you use to rate this doctor?
0
0 Worst doctor possible
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10 Best doctor possible
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24. In the last 12 months, how often were clerks and receptionists at this doctor’s office as helpful as
you thought they should be?
1
Never
2
Almost Never
3
Sometimes
4
Usually
5
Almost Always
6
Always
25. In the last 12 months, how often did clerks and receptionists at this doctor’s office treat you with
courtesy and respect?
1
Never
2
Almost Never
3
Sometimes
4
Usually
5
Almost Always
6
Always
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Brief Infant-Toddler Social and Emotional Assessment (Time 3 and Time 4 Only)
*Note: The BITSEA has been ordered and will be submitted when it arrives. However, the ITSEA (longer
version from which the items are taken is included as a separate attachment)
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DIRECTIONS: On the following pages are sentences that describe some of the different ways a person
might think or feel about the Young Parenthood Program staff member providing these parenting
support sessions. As you read through the sentences mentally insert the name of Young Parenthood
Program staff member in place of ____________ in the text.
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
If the statement describes the way you always feel (or think) circle the number 7; if it never applies to
you circle the number 1. Use the numbers in between to describe the variations between these
extremes.
This questionnaire is CONFIDENTIAL; neither your therapist nor the agency will see your answers.
Work fast, your first impressions are the ones we would like to see.
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Role (circle): MOB FOB ID: _____ Session: ____ Date: _________
1. _______________ and I agree about the things I will need to do in this parenting support program.
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
2. What I am doing in this parenting support program gives me new ways of looking at parenthood.
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
4. _______________ does not understand what I am trying to accomplish in this parenting support program.
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
6. _______________ and I are working towards mutually agreed upon goals.
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
8. We agree on what is important for me to work on regarding developing better co-parenting skills.
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
9. _______________ and I trust one another.
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
10. _______________ and I have different ideas on what my co-parenting issues are.
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
11. We have established a good understanding of the kind of changes that would be good for me.
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
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DIRECTIONS: On the following pages there are sentences that describe some of the different ways a
therapist might think or feel about his/her client(s). As you read the sentences mentally insert the name
of the couple you are working with in the place of ____________ in the text. Try to think about your
client as “a couple” rather than “two individuals.”
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
If the statement describes the way you always feel (or think) circle the number 7; if it never applies to
you circle the number 1.
Use the numbers in between to describe the variations between these extremes.
This questionnaire is CONFIDENTIAL; neither the couple nor the agency will see your answers.
Work fast, your first impressions are the ones we would like to see.
© A. O. Horvath, 1981, 1984, 1991; based on revision by Tracey & Kokotowitc 1989.
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Role (circle): MOB FOB ID: _____ Session: ____ Date: _________
1. _______________ and I agree about the steps to be taken to improve their co-parenting skills.
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
2. My client and I both feel confident about the usefulness of our current activity in these co-parenting
support sessions.
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
4. I have doubts about what we are trying to accomplish in these co-parenting support sessions.
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
8 We agree on what co-parenting skills are important for _______________ to work on.
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
10. _______________ and I have different ideas on what their co-parenting issue are.
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
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11. We have established a good understanding between us of the kind of changes that would be good for
_______________.
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
12. _______________ believes the way we are working to improve their co-parenting skills is correct.
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
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Maternal Information
4. Did mother get WIC food for herself during this pregnancy? __ Yes __ No
Hypertension
__ Prepregnancy (Chronic)
__ Gestational (PIH, preeclampsia)
__ Eclampsia
9. Infections present and/or treated during this pregnancy (Check all that apply)
__ Gonorrhea
__ Syphillis
__Chlamydia
__ Hepatitis B
__ Hepatitis C
__ None of the above
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__ Cervical cerclage
__ Tocolysis
Newborn Information
14. Date of Birth (MM/DD/YYYY): ____________
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21. If not single birth, born first, second, third, etc. (specify):___________________________
24. Is infant living at time of report? __ Yes __ No __ Infant transferred, status unknown
Paternal Information
26. Is father’s name listed on the birth certificate? ____ Yes _____ No
Demographic Data
27. Is mother married? ___ Yes ___ No
If no, has paternity acknowledgement been signed in the hospital? __ Yes __ No
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Education/Hispanic origin/race for mother & father: I am assuming you have this information elsewhere
& do not need it on this form
*these measures are taken directly from the NCHS’ 2003 (most recent) birth certificate:
http://www.cdc.gov/nchs/data/dvs/birth11-03final-acc.pdf
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The goals of the first interview are as follows. We are using a semi-structured interview format for the following
reasons:
Following the interview outline : Throughout the interview, you should closely follow the questions as outlined
below. However, you can deviate from the presented order if an issue comes up earlier in your conversation.
If you need to ask questions that have already been explicitly answered, acknowledge the repetitiveness, but
still ask. For example, if the adolescent spontaneously tell you that they never used birth control, when you get
to that part of the interview, you can say something like this: “You already sort of answered this question, but
let me go ahead and ask it again to see if you have anything to add.” Often this leads to a little more detail and
sometimes a completely different answer.
If the adolescent is all over the place, you may want to provide more structure. For example, you may want to
say "I'm going to ask you about ----- in a few minutes, but for the time being let's finish talking about -----.
Probing : It's important to probe some answers. For example, if the adolescent's response to a basic question
such as "could you describe your relationship with -----." is "I don't know", find some way of helping him/her to
be more definitive.
It is often useful to ask for specific examples, which might help to clarify a somewhat vague response.
When probing, it is very important that you don't make suggestions about what the adolescent might mean -
probes should be open ended - don't put your words into the adolescents mouth. Ask questions like "what was
that like for you?" "please tell me more about that" "what do you mean?".
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I will be asking you a number of questions during the next hour or so. These questions cover many topics
surrounding becoming a parent and your family but will start with some basic background questions. I will be
recording this interview. This recording will only be used for the purposes of this study. If you do not
understand any of the questions I ask, please let me know and I try to rephrase or explain them.
In this interview, we will be talking about a co-parent. What I mean when I say co-parent is (partner name).
We don’t want to make assumptions about your involvement or relationship with (partner name) other than
that you will both be parents to this child.
How did you meet? Tell me the whole story of how your relationship got to where it is now.
Please think of three words that will help me get an idea of what your relationship is like?
Now I am going to go back and ask you to explain why you chose those three words. One way to do this is for
you to give me an example of how your relationship is __________.
What are your feelings about (partner)? (or How do you feel about him or her?) (Probe for more than one
feeling)
How has your relationship changed since you found out she is pregnant (or that you are pregnant)?
Now I am going ask you to describe (partner’s) personality. Think of three words that describe (partner).
I am going to go back and ask you to explain why you chose those three words. One way to do this is for you to
give me an example of how he or she is __________.
Are there things about your partner that you wish you could change? (probe for examples)
Now please give me three words that (partner) would use to describe you.
Again, please give me an example for each word or explain why he or she might use that word to describe you.
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Please describe a time or a situation when you felt really close to (partner)?
In what ways do you think your relationship with ______ will change over the next year?
What kinds of things do you disagree about? Can you give me an example of a recent disagreement or
argument?
How do you usually work things out when you have disagreements like this?
Are there any other issues you think that the two of you need to resolve?
What is the most serious fight or argument you have had with _____? What happened?
Have you ever gotten into a physical fight with _____? What happened? (who hit who? Was there injury?) How
did that get resolved?
(If yes) How did you and ---- make that decision?
What was your response to finding out that you are going to have a baby?
Thinking ahead about 6 months, what do you think it will be like for the two of you to have a baby to take care
of together?
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What is (was) your father like? Please give me three words that describe him (and examples for each word).
Please describe a time or a situation when you felt really close to your father?
What is your mother like? Please give me three words that describe her (and examples for each word).
Please describe a time or a situation when you felt really close to your mother?
Does she know you are pregnant or expecting
If yes,
How has your relationship changed since she found out you are pregnant (or got ____ pregnant?)
Parent's Relationship
How would you describe your parent’s relationship? (ask for three words)
In what ways do you want your relationship with ---- to be different from your parents’ relationship? (ask for
examples)
In what ways do you want your relationship to be similar to your parents relationship (ask for details).
Who is going to take care of the baby (non-financial care and support)?
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What do you think life would be like if you were no longer involved with her?
Have either of you been with other partners since you started going out?
Services.
Are you receiving any help from a case manager, such as a social worker or nurse.
I want to talk a little bit about being successful. Tell me about someone who you know who you think is
successful. What about their situation makes them successful in your mind?
So now we have a sense of a successful person you know, but let's talk more generally, maybe about other ways
of being successful or other kinds of success. How would you describe success for a (Black/Latino) who is 25
years old?
And now for whites….Does "success" mean something different for young people who are white?
Have you ever felt that being (Black/Latino) makes it difficult to reach your goals or be successful?
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[If yes] Can you tell me about a specific time when you thought being Black/Latino got in the way of your
success?
Have you ever felt that young white people are able to reach their goals more easily? If yes…tell me about that.
Can you tell me about a moment in your life when you thought about this issue…the difference between
opportunities for whites and Blacks/Latinos?
Ending:
I've asked you a lot of questions about a lot of things, can you think of anything that I haven't asked you about
that you see as being important to understanding you?
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Milwaukee Young Parenthood Study
Participant Assessment Tools
INTRODUCTION: Today we’re going to be talking about how things have been going since the last
interview, which was when you were pregnant. We’ll begin by asking questions about your child and
your relationship with your child’s mother/father
In this interview, we will be talking about a co-parent. What I mean when I say co-parent is (partner
name). We don’t want to make assumptions about your involvement or relationship with (partner
name) other than that you will both be parents to (baby’s name).
Please start off by telling me about your child’s birth. How did that go? Please tell me the whole story.
Were there any complications for the baby? Complications can include things like the cord being
wrapped around (baby’s name) neck, he/she was not breathing or an emergency C section.
Where there any medical complications for you (if interviewing mother) …the mother (if interviewing
father)?
I’d like to get a sense of your (baby’s name) personality… so, could you get us started by choosing 3
words (adjectives) that describe your him/her? (Pause while they list adjectives).
Now, let’s go over each word. Please give an example of something that made you say….. ________?
(Ask for a specific example for each adjective).
Now I would like you to choose 3 words that describe the relationship with your baby. (Pause while they
list words - Probe). I am not asking about you or your baby, but the relationship between you and
(baby’s name)…does that make sense?
Let’s go back over each word. Why did you say….. ________?
(Can you give me an example or something that will help me understand why you said XXX?).
Now I want to ask you about being a parent. Please choose 3 words that describe you as a parent? Let’s
go back over each word. What is it about being a parent that made you say….. ________? (Probe for a
specific events or example for each adjective).
Tell me about a time when – as a parent - you felt really angry or upset. (Probe, if necessary: Can you tell
me a little bit more about the situation?)
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Tell me about a time when - as a parent - you felt happy or joyful. (Probe, if necessary: Can you tell me a
little bit more about the situation?)
How have you changed since the last time you were interviewed?
Are there things about yourself that you wish you could change?
Now I am going ask you to describe (partner’s name) as a parent. Think of three words that describe
him/her. Please explain why you chose those three words.
Has he/she (the father/mother) changed since the last time you were interviewed?
Are there things about (partner’s name) that you wish you could change? (probe for examples)
Please tell me three words that will help me get an idea of what your relationship with XXX is like now?
Now I am going to go back and ask you to explain why you chose those three words.
Please describe how you and your partner work well together to take care of your baby?
Please tell me about a time when you and --- (name) were really “clicking” or felt close as co-parents.
What are some ways that you and (partner’s name) could do a better job of taking care of your baby
together?
Now please give me three words that (partner) would use to describe you. Again, please give me an
example for each word or explain why he or she might use that word to describe you.
What kinds of things do you and your baby’s other parent fight or disagree about?
How do you usually work things out when you have disagreements?
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Milwaukee Young Parenthood Study
Participant Assessment Tools
What other things do you think the two of you need to work out?
What has been the most serious fight you've had with ________ since (baby’s name) was born? What
happened?
Have you gotten into a physical fight with ______ since the last time you were interviewed? What
happened?
What could you do to make your co-parenting relationship with your partner better?
Couples go through lots of changes, we’re interested in what kind of relationship you are in now with
each other.What is your current relationship with (partner’s name)? Are you romantically involved, on
again off again, broken up, or don’t know (or other descriptor provided)?
Thinking about the future….what do you think your co-parenting relationship is going to be like in five
years?
Other services
Are you receiving any help from a case manager, such as a social worker or nurse.
Ending:
I have asked you a lot of questions. Is there anything I have not asked about, but should have in order to
understand you, particularly your experience as a parent?
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Milwaukee Young Parenthood Study
Participant Assessment Tools
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Milwaukee Young Parenthood Study
Participant Assessment Tools
INTRODUCTION: Today we’re going to be talking about how things have been going since the last
interview, which was when your child was around 6 months old.
In this interview, we will be talking about a co-parent. What I mean when I say co-parent is (partner
name). We don’t want to make assumptions about your involvement or relationship with (partner
name) other than that you will both be parents to (baby’s name).
Think back about six months ago and what your life was like six months ago. Now please tell me how
your life changed since the last time you were interviewed?
I’d like to get a sense of your baby’s personality… so, could you get us started by choosing 3 words
(adjectives) that describe your baby? (Pause while they list adjectives).
Now, let’s go over each word. Please give an example of something that made you say….. ________?
(Ask for a specific example for each adjective).
Now I would like you to choose 3 words that describe the relationship with your baby. (Pause while they
list words - Probe). I am not asking about you or your baby, but the relationship between you and your
baby…does that make sense?
Let’s go back over each word. Why did you say….. ________?
(Can you give me an example or something that will help me understand why you said XXX?).
Now I want to ask you about being a parent. Please choose 3 words that describe you as a parent? Let’s
go back over each word. What is it about being a parent that made you say….. ________? (Probe for a
specific events or example for each adjective).
Tell me about a time when, as a parent, you felt really angry or upset. (Probe, if necessary: Can you tell
me a little bit more about the situation?)
Tell me about a time when, as a parent, you felt happy or joyful. (Probe, if necessary: Can you tell me a
little bit more about the situation?)
How have you changed since the last time you were interviewed?
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Milwaukee Young Parenthood Study
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Are there things about yourself that you wish you could change?
Now I am going ask you to describe your partner as a parent. Think of three words that describe
him/her. Please explain why you chose those three words.
Has he/she (the father/mother) changed since the last time you were interviewed?
Are there things about your partner that you wish you could change? (probe for examples)
Please tell me three words that will help me get an idea of what your relationship with XXX is like now?
Now I am going to go back and ask you to explain why you chose those three words.
Please describe how you and your partner work well together to take care of your baby?
Please tell me about a time when you and --- (name) were really “clicking” or felt close as co-parents.
What are some ways that you and your partner could do a better job of taking care of your baby
together?
Now please give me three words that (partner) would use to describe you. Again, please give me an
example for each word or explain why he or she might use that word to describe you.
What kinds of things do you and your child’s other parent fight or disagree about?
How do you usually work things out when you have disagreements?
What other things do you think the two of you need to work out?
What has been the most serious fight you've had with ________ since your child was born? What
happened?
Have you gotten into a physical fight with _________ since the last time you were interviewed? How did
that happen?
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Milwaukee Young Parenthood Study
Participant Assessment Tools
What could you do to make your co-parenting relationship with your partner better?
Thinking about the future….what do you think your co-parenting relationship is going to be like in five
years?
6. Have either of you been with other people (sexually) since you were last interviewed? How has
that affected your relationship?
Other services
Are you receiving any help from a case manager, such as a social worker or nurse.
Ending:
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Milwaukee Young Parenthood Study
Participant Assessment Tools
I have asked you a lot of questions. Is there anything I have not asked about, but should have in order to
understand you, particularly your experience as a parent?
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Milwaukee Young Parenthood Study
Participant Assessment Tools
INTRODUCTION: Today we’re going to be talking about how things have been going since the last
interview, which was when your child was around 12 months old.
In this interview, we will be talking about a co-parent. What I mean when I say co-parent is (partner
name). We don’t want to make assumptions about your involvement or relationship with (partner
name) other than that you will both be parents to (child’s name).
Think back about 1 year ago and what your life was like 1 year ago. Now please tell me how your life
changed since the last time you were interviewed?
I’d like to get a sense of your child’s personality… so, could you get us started by choosing 3 words
(adjectives) that describe your baby? (Pause while they list adjectives).
Now, let’s go over each word. Please give an example of something that made you say….. ________?
(Ask for a specific example for each adjective).
Now I would like you to choose 3 words that describe the relationship with (child’s name). (Pause while
they list words - Probe). I am not asking about you or your child, but the relationship between you and
(child’s name)…does that make sense?
Let’s go back over each word. Why did you say….. ________?
(Can you give me an example or something that will help me understand why you said XXX?).
Describe a time in the last week when you and your child really “clicked”. Tell me more about that?
How did you feel? How do you think your child felt?
(Probe if necessary)
Describe a time in the last week when you and your child really weren’t “clicking”. Tell me more about
that time? How did you feel? How do you think your child felt? (Probe if necessary)
How do you think your relationship with your child is affecting his/her development or personality?
Thinking back to when you were a child, and your relationship with your parents, how does that
influence how you feel about being a parent now?
What things do you want to do the same and what things do you what to do differently as your mother
(in respect to the parenting she provided)?
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Milwaukee Young Parenthood Study
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I’d like you to think of a time you and your child weren’t together and it was a bit stressful for either you
or your child. Can you describe it to me?
Has there been anything that has been a setback for (child’s name), like something that was really hard
for him or her to deal with?
Your child is a toddler and you’ve got some experience as a parent now. If you could do it all over again,
what would you change?
What kind of relationship do you think you will have with (child’s name) when he or she is your age?
Now I want to ask you about being a parent. Please choose 3 words that describe you as a parent? Let’s
go back over each word. What is it about being a parent that made you say….. ________? (Probe for a
specific events or example for each adjective).
Tell me about a time when, as a parent, you felt really angry or upset. (Probe, if necessary: Can you tell
me a little bit more about the situation?)
How did this (event) affect your child? (or how do you think your child felt when this happened?)
How do you know when (child’s name) is upset? What does he/she do?
Does your child ever feel hurt or unhappy because of something you did? Please tell me about that?
How did you respond to that?
About you:
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Milwaukee Young Parenthood Study
Participant Assessment Tools
How have you changed since the last time you were interviewed?
Are there things about yourself that you wish you could change?
Now I am going ask you to describe (partner’s name) as a parent. Think of three words that describe
him/her. Please explain why you chose those three words.
Has he/she (the father/mother) changed since the last time you were interviewed?
Are there things about (partner’s name) that you wish you could change? (probe for examples)
Please tell me three words that will help me get an idea of what your relationship with XXX is like now?
Now I am going to go back and ask you to explain why you chose those three words.
Please describe how you and (partner’s name) work well together to take care of your child?
Please tell me about a time when you and --- (name) were really “clicking” or felt close as co-parents.
What are some ways that you and (partner’s name) could do a better job of taking care of your baby
together?
Now please give me three words that (partner) would use to describe you. Again, please give me an
example for each word or explain why he or she might use that word to describe you.
What kinds of things do you and your child’s other parent fight or disagree about?
How do you usually work things out when you have disagreements?
What other things do you think the two of you need to work out?
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Milwaukee Young Parenthood Study
Participant Assessment Tools
What has been the most serious fight you've had with ________ since your child was born? What
happened?
Have you gotten into a physical fight with _________ ? How did that happen?
What could you do to make your co-parenting relationship with your partner better?
Thinking about the future….what do you think your co-parenting relationship is going to be like in five
years?
Other services
Are you receiving any help from a case manager, such as a social worker or nurse.
I want to talk a little bit about being successful. Tell me about someone who you know who you think is
successful. What about their situation makes them successful in your mind?
So now we have a sense of a successful person you know, but let's talk more generally, maybe about
other ways of being successful or other kinds of success. How would you describe success for a
(Black/Latino) who is 25 years old?
And now for whites….Does "success" mean something different for young people who are white?
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Milwaukee Young Parenthood Study
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Have you ever felt that being (Black/Latino) makes it difficult to reach your goals or be successful?
[If yes] Can you tell me about a specific time when you thought being Black/Latino got in the way of your
success?
Have you ever felt that young white people are able to reach their goals more easily? If yes…tell me
about that.
Can you tell me about a moment in your life when you thought about this issue…the difference between
opportunities for whites and Blacks/Latinos?
Ending:
I have asked you a lot of questions. Is there anything I have not asked about, but should have in order to
understand you, particularly your experience as a parent?
90
# Parent triorm
- g TI S E A
(hild's
name D a t eb
o if r t h - l-l- Ageinmonths
-
mm 00 yy
Parent/Guardian
name D:tp romnlptpd I I S e xI B o y n G i r l
mm 00 yy
W a s y o u r c h i l d b o r n p r e m a t u r e l y ? I Yl feysensN, w o h a t w a s t h e e x p e c t e d d a t e o f b i r t /h ?
*/ * *
d i t ho t h eyr o u n cg h i l d r e(nn o ti n c l u d i nbgr o t h e a
I na t y p i c awl e e kh, o wm u c ht i m ed o e ys o u cr h i l ds p e n w r sn ds i s t e r s )- ? h o u r ps e rw e e k
D oy o uu s ea n yt y p eo f c h i l d c afroery o u cr h i l d ?n Y e sf l N o l f y e sh, o wm a n yh o u r ds oy o uu s ec h i l d c airnea t y p i c awl e e k ?- hours
D i dy o u cr h i l dh a v e
a n yp r o b l e ma st b i r t h ?n Y e sI N o l f y e sp, l e a seex p l a i n
This section contains statements about 12- to 36-month-old children. Many statements describe normal feelings
and behaviors, but some statements describe feelings and behaviors that may be a problem. Please do your best to
answer every statement.
Not SomewhatVery
true/ true/ true/
P i e a sr ier c l teh eC N E t e s c r i by ec su cr h i l r lb?e, h a v iionrt h eL A SM
r e s p 0 ntshea ib € sC I 0 l il H rarely sometimesoften
1. lsbothered
byloudnoises
orbright
lights. 0 1 2
2. Takes
a while
tofeelcomfortable (10minutes
innewplaces orm0re). 0 1 2
hurtsooftenthatyoucan't
3. Gets takey0ureyes
offhimorher. 0 1 2
4. Acts
aggressive
whenfrustrated. 0 1 2
5. lsquiet
0rless
active
innewsituations. 0 1 2
6. Gets whenleftwithanelvbabysitter.
upset (N:Never
used
babysitter/ 0 1 2
7. Responds
thefirsttimehisorhername
iscalled. 0 1 2
pleasure
8. 5hows when (forexample,
heorshesucceeds claps
forself). 0 l 2
9. Puts afterplaying.
toysaway 0 1 2
10.Seems
nervous,
tense,
orfearful. 0 1 2
11.lsrestless
andcan't
sitstill. 0 1 2
12.Gets rerywound playing.
uporsillywhen 0 r 2
,l3.
Actsbossy. 0 1 2
.l4.
lsconstantly
moving. 0 l 2
15.Dislikes
some
foods
because
ofhowtheyfeel. 0 1 2
16.Follows
rules. 0 1 2
17.lsbothered
bycertain (smells).
odors 0 ' l 2
18.Wakes
upatnight
andneeds
help
tofallasleep
again. 0 1 2
19.Getsupset leftwithafamiliar
when babysitter (N.Have
orrelative. notused
asitter
0rrelative
intheastmonth) 0 1 2
downwhenyousay"Shh."
20. Quiets 0 1 2
\ , . , . .i , , , i . I , . . . ; ,
rsBN 0l,5qEa7r3-7
1 2 3 4 5 6 7 8 9 1 0 1 1 2 A BC D E ililillt
"1,*?j:,, S e t t i o nA r a n t i n u e d Not Somewhat Very
{!?'i.i.;
tl-:'ic-, true/ true/ true/
.l#45; i r l s 3 ii1l il1 l rr h eC l l ii q - { l ) 0 ri i! i\ai ri r e s i c i e l r - r i b pr: h" ;tul C* b' te h a v iio* ri h t i A 5 i i \ ' 4 0 N i H rarelv sometimes
often
orhasa tantrum
21.Cries untilheorsheisexhausted. 0 1 2
22. Refuses
toeatfoods
thatrequire
chewing. 0 ' l 2
t0getattenti0n
23. Misbehaves fromadults. 0 1 2
todoasyouask.
24.Tries 0 1 2
25. Plays f0r5 minutes
withtoys orlonger. 0 1 2
people
26. Hugs 0rpat.
witha squeeze (N:Physically
unable) 0 1 2 N
27.Has
started (like
heorshehadoutgrown
something
d0ing usea pacifier). 0 1 2
28. lsafraid
ofcertain
animals.
Whatanimal(s)? 0 1 2
2 9 . l sa f r a i d
o fc e r t a itnh i n g s . W ht a
h ti n g ( s ) ?
n i t ho t h epre o p l e .
3 1 .H a n g0 sny 0 u0 rw a n t s0b ei ny o ulra pw h e w 0 1 2
ITSEA
P a r e nFt o r n r
SectionA cantinued liot SomewhatVery
true/ true/ true/
P l e a scei r c lteh e0 N Er e s p 0 nlshea tb e sdt e s c r i byeosu cr h i l d
s b e h a v iionrt h eL A SM
T0NiH rarely sometimesoften
52. Does
notreact
when
hurt.
53. lseasily
startled.
54. lsaffectionate
withloved
ones.
55. lswell-behaved.
you(orother
56. Prefers parent)
overother
adults.
57.Laughs
easily
ora lot.
58. lsstubborn.
59.Won'ttouch
some
objects
because
ofhowtheyfeel.
60. lshard
tosoothe
whenupset.
61.Runs inpublic
away places.
62. Sleeps
through
thenight.
63. 0ftengets
veryupset.
64. Gags
orchokes
onfood.
65. Wants
todothings
forself.
66. Points
toaskfor
something.
67. Points yousomething
toshow faraway.
68. lsbothered
bybeing (forexample,
inmotion swinging,
spinning,
being
tossed
intheair,orbouncing).
upgrouchy
69.Wakes orina badmood.
70. Has
trouble
falling
asleep
orstaying
asleep.
71. Tries youfeelbetter
tomake wheny0u're
upset.
72. Stays
stillwhile
being
changed,
dressed,
orbathed.
73. Has
trouble
calming
down
when
upset.
74. Demands
a lotofattention.
/5. Sits
for5 minutes youread
while a story.
76. lsworried
orupset
when someone
ishurt.
77.Iriesto"make-up"
aftermisbehaving.
beheldtogotosleep.
78. Must
79.lsimpatient
oreasily
frustrated.
80. lsinterested
inother
babies
andchildren.
81. Likes
figuring
things
out,likestacking
blocks.
82. Can fora longtime(n0tincluding
payattention TV).
83. lsaffectionate
withstrangers.
84. lsaware people's
ofother feelings.
85. When getsverystill,freezes,
upset, ordoesn't
move.
86. Has
trouble
adjusting
t0changes.
Sttl i,ttt ,,1 irtttlitttrLtl oli t/t.\-l h(t,<'..
ITSEA
P a r e nFt o r m 3
SectionA continued ilot SomewhatVery
tlue/ tru€/ true/
P l e a scei r c lteh e0 N Er e s p 0 nl shea tb e sdt e s c r i byeosu cr h i l d b' se h a v iionrt h eL A SM
T0NIH. rarery sometimesoften
ishurt(forexample,
s0me0ne
tohelpwhen
87.Tries gives
atoy). 0 1 2
,)
88. lsshywithnewadults. 0 1 L
heorshewants.
towaitforthings
89. lsable 0 1 2
')
a lot.
90. Cries 0 1
playful
91. lmitates youaskhimorherto.
when
sounds 0 1 2
')
else(forexample,
aresomething
thatobjects
92. Pretends uses asphone).
banana 0 1
rightaway.
newfoods
93.Accepts 0 1 2
orfeeds
95. Hugs orstuffed
dolls animals. 0 1 2
-)
96. lsa perfectionist. 0 1
'I
orwaving
clapping
97.lmitates bye-bye. (N:Physlcally
unable) 0 2
when
98. lsnotafraid be.
should 0 1
orgives
99.Jokes youthings yousmile
tomake orlaugh. 0 1 2
orgrouchy.
100.lsirritable 0 1 2
,l
101.Pays
careful when
attention being
taught new.
something 0 2
102.Looks
unhappy anyreason.
orsadwithout 0 1 2
more
103.Sleeps hisorherage.
children
thanother 0 1 2
'I
toeat.
104.Refuses 0 I
105.lscurious newthings.
about 0 1 2
(nightteftlrs).
toyouforafewminutes
respond
anddoesn't 0 1 )
106.Wakes
upscreaming
1 0 7 l.s w h i n y o r f u s s yhwehoerns hi sen o f t i r e d . 0 1 2
108.Feels self.
badabout 0 1 2
109.lsa good
eater. 0 1 2
110.lsshywithnewchildren. 0 1 1
orruins
Breaks
111.lsdestructive. 0npurp0se.
things 0 1 2
tohave
112.Seems noenergy. 0 1
,l
orpouts.
angry
113.Gets 0 2
'I
ornightmares.
dreams
upfromscary
114.Wakes 0
1 1 5W
. antstosleepinsomeoneelse'sroomorbed. ( N . A l w a y s s h a r e s a r o o m0o r b e d1) 2
i 1 6 .H a s t e m p e r t a n t r u m s . 0 1 2
117.Hits, you(orother
orkicks
bites, parent). 0 1 2
118.lsa picky
eater. 0 1 I
atyoufromacross
back
119.Smiles a r00m. 0 1 2
')
withdrawn.
120.5eems 0 1
sad,
veryunhappy,
121.Seems ordepressed. 0 1 2
,l
when
122.0beys tostopbeing
asked aggressive. 0 I
T S E AP a r e nFt o r m
S e c t i o nA c o n t i n u e d Not SomewhatVery
true/ true/ true/
P l e a sc ei r c iteh e0 N Er e s p 0 nt5hea tb e sdt e s c r r byeosu cr h i l d b' se h a v iionrt h eL A 5 M
T 0NTH. rarely s0metimesoften
123.Refuses food(s)
toeatcertain for2 days
ormore. 0 1 I
124.Purposely tohurtyou(orother
tries parent). 0 1 2
'125.
Gets
upset
when asked
tochangeactivities. 0 1 I
126.Hurts (forexample,
selfonpurpose bangs
head). 0 1 2
t
\ Has your child begun to combine words, such as morejuice? Pleasecheck one box and follow the instructions next
to that box.
In the last month, did your child have any contact (more than 0 hours per week) with other young children
(not includingbrothers and sisters)? Please check one box and folbw the instructions next to that box.
1. Takes
turns playing
when withothers. 0 1 - )
2. Tests
other toseeiftheywillgetangry.
children 0 1 2
3. Asks
forthings
nicely playing
when withchildren. 0 t t
4. Hits,
shoves,
kicks,
orbites (notincluding
children orsister).
brother 0 1 2
5. Has
atleast
onefavorite (achild).
friend 0 1 2
6. Picks
onorbullies
other
children. 0 1 2
7. Plays
wellwithother
children. 0 t l
8. Teases
other
children. 0 1 2
"house"
9. Plays withother
children. 0 1 2
10.Won'tletother play
children withhisorhergroup. 0 1 2
,l1.
Hurts
other 0npurp0se.
children 0 1
I
1
L
T S E AP a r e nF
t orm 5
The questionsin the next sectionask about feelingsand behaviorsthat can be problemsfor young children. Some
of the questionsmay be a bit hard to understandespeciallyif you have not seenthe behaviorin your child. Please
do your best to answerthem anYwaY.
Not SomewhatVety
true/ true/ true/
P l e a :cei r c ltei i e0 l ' i Er e s p 0 r rt shea tb e sdt e s c r i bveosu rc h i l d 'bse h a v i iontt h eL A SM
I 0NTH rarely sometimesoften
unaware
out.lstotally
1. Spaces happening
ofwhat's himorher.
around 0 1 2
(ontact.
physical
2. Avoids 0 1
eyecontact.
notmake 0 1 2
3. Does
1
4 . H a s a b o d y t i c o r t w i t ( h h e o r s h e s e e m s u n a b l e t o c o n t r o l ( f o r e x a m p l e , e y e s , m o u t h , n o s0e , 0 r l e1g s t w i t c h ) .
L
7. Hurts onpurPose.
animals 0 1 2
getting
about
8. lsreryworried dirty. 0 1 L
orneat.
tobeclean
things
9. Needs 0 1
1 0 .P l a y s g a m e s w i t h o t h e r c h i l d r e n i n w h i c h t h e y l o o k a t o r t o u c h e a c h o t h e r ' s p r i v a t e p a r t s0. 1
ownhairout(such
12. Pulls aseyelashes, hair)'
orhead
eyebrows, 0 1 1
L
atyou,putsyourhand
looking
13.Without such
onobjects, aswind-up themwork.
tomake
toys, 0 1
bodY.
14.Worriesaboutown 0 1 L
,l
15.Puts
things order
inaspecial andover.
over 0 2
("p00ps").
movements
withownbowel
16. Plays 0 1
movements
bowel
17.Has (forexample,
heorsheshouldn't
where 0nthefloor). 0 1 2
("pees")
18. Urinates heorsheshouldn't.
where 0 1 2
pretend
outthesame
19.Acts theme giveonexomple
Please
overandover. below. 0 1 2
a particular
20. Repeats over
movement andover(likerocking,
spinning). giveanexomple
Pleose below'
orphrase
action
thesame
21. Repeats overandover. giveonexample
Pleose below.
P/ease
habits.
22. Hasverystrange below.
describe
Pleose
onthingsheorsheshouldn't.
Chews below.
describe
ParentForm
ITSEA
The following questions concern vour general f-eelingsabout your child's behavior.
1 . How worried ilre you about vour child's behavior, emotions, or relationships?
n N o t a t a l lw o r r i e d
n A l i t t l ew o r r i e d
n Worried
n Very worried
n N o t a t a l lw o r r i e d
if A little worried
[] Worried
n Very worried
ITSEA
P a r e nF
t orm