AFL Care Programs - Core Baseline Questionnaire for Pregnant Clients
back to Evaluation Instruments main page According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0290. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
U.S. Department of Health & Human Services; OS/OIRM/PRA;
Independence Ave., S.W., Suite 531-H; Washington D.C. 20201;
Attention: PRA Reports Clearance Officer
OMB NO.: 0990-0290 200
EXPIRATION DATE: 09/30/2008
1. Client ID: ____ ____ ____ ____ ____ ____
2. Site Number: ____ ____ ____ ____ ____ ____
3. Entry Date: ____ ____ ____ ____ ____ ____
AFL CARE PROGRAMS CORE BASELINE QUESTIONNAIRE
Demographics
1. Age (in years only): _________
2. How many months until your due date?
Number of Months................................. _________
Less than 1 month................................. 
10
3. What is your marital status?
CHECK ONE RESPONSE
Single, never married............................. 1
Married................................................ 2
Separated or divorced............................ 3
Widowed.............................................. 4
Other................................................... 5
4. What are your current living arrangements?
CHECK YES OR NO FOR EACH
| Yes | No |
|---|
a. . Alone..................................................................... | 1 | 2 |
b. With spouse........................................................... | 1 | 2 |
c. . With own mother (include stepmother)...................... | 1 | 2 |
d. . With own father (include stepfather).......................... | 1 | 2 |
e. . With baby’s father | 1 | 2 |
f. .. With baby’s father’s mother...................................... | 1 | 2 |
g. . With baby’s father’s father ....................................... | 1 | 2 |
h. With partner............................................................ | 1 | 2 |
i. With other relatives.................................................. | 1 | 2 |
j. With friends............................................................ | 1 | 2 |
k. In a group home/institution....................................... | 1 | 2 |
l. In a foster home...................................................... | 1 | 2 |
m. Other..................................................................... | 1 | 2 |
5. Are you Hispanic or Latino?
Yes............................. 1
No............................... 2
6. What is your race?
CHECK ALL THAT APPLY
White................................................... 1
Black................................................... 2
Asian................................................... 3
Native Hawaiian or Other Pacific Islander... 4
American Indian.................................... 5
7. What is your current school status?
CHECK ONE RESPONSE
In school or GED program......................................... 1
Graduated from high school or completed GED........... 2
Dropped out of school............................................... 3
Other....................................................................... 4
8. What is the highest grade you completed:
CHECK ONE RESPONSE
8th grade or below.................................. 1
9th grade............................................... 2
10th grade............................................. 3
11th grade............................................. 4
12th grade............................................. 5
Some college....................................... 6
College degree or more.......................... 7
Don’t know........................................... 97
9. Have you ever been in a job training program?
Yes............................. 1
No............................... 2 
SKIP TO QUESTION 10
9a. Did you ever complete a job training program?
Yes............................. 1
No............................... 2
Currently attending job training program........ 3
10. How many hours do you work per week?
Hours per week (Enter 00 if not employed)________
11. What is your main source of financial support?
CHECK ONE RESPONSE
Own job............................................... 1
Spouse or partner................................. 2
Parents................................................ 3
Public assistance................................. 4
Other relatives...................................... 5
Other................................................... 6
12. Do you receive money or assistance from any of the following sources?
CHECK YES OR NO FOR EACH
| Yes | No |
|---|
a. . Medicaid................................................................ | 1 | 2 |
b. . Food stamps.......................................................... | 1 | 2 |
c. . WIC....................................................................... | 1 | 2 |
d. TANF..................................................................... | 1 | 2 |
e. . Social Security....................................................... | 1 | 2 |
f. .. Unemployment or Workers’ Compensation................ | 1 | 2 |
g. General Assistance or other aid................................ | 1 | 2 |
h. Child support.......................................................... | 1 | 2 |
i. Own job.................................................................. | 1 | 2 |
j. Spouse or partner.................................................... | 1 | 2 |
k. Parent(s)................................................................ | 1 | 2 |
l. Other..................................................................... | 1 | 2 |
About Your Baby’s Father…
These next questions are about the father of the baby you are expecting.
13. Are you married to him?
Yes............................. 1 SKIP TO QUESTION 18
No .............................. 2
14. Do you plan to marry him?
Yes......................................... 1
No .......................................... 2
Don’t know............................... 97
15. Do you and he have a legal agreement regarding child support, alimony, custody, visitation, or where the child lives?
Yes......................................... 1
No .......................................... 2
16. Does he give you money, buy clothes for the baby, pay for doctor visits, or provide other kinds of support?
Yes............................. 1
No .............................. 2
17. Does he do things to help you with your pregnancy, like providing transportation to the pre-natal clinic or helping with the chores?
Yes............................. 1
No .............................. 2
About Your Relationships, Your Goals, and Feelings on Parenting
These next questions are about your relationships with other people, your goals and your feelings about parenting.
18. Looking to the future, do you want to have another baby sometime before finishing high school?
Yes............................. 1
No .............................. 2
Already finished............ 3
Don’t know................... 97
19. Looking to the future, do you want to have another baby sometime before marriage?
Yes............................. 1
No .............................. 2
Already married ........... 3
Don’t know................... 97
FOR EACH OF THE FOLLOWING QUESTIONS CHECK ONLY ONE RESPONSE.
20. How much do you agree with the following statement? It is better for a person to get married than to go through life being single.
Strongly agree......................... 1
Agree .................................... 2
Neither agree nor disagree........ 3
Disagree................................. 4
Strongly disagree.................... 5
Don’t know.............................. 7
21. How often do you talk to your mother or father about your problems? Or how often do you talk to an adult in the household about your problems?
Almost never......................... 1
Some of the time................................ 2
Usually.......................................... 3
Almost always................................. 4
22. How much do you stay away from people who might get you into trouble?
Almost never......................... 1
Some of the time................................. 2
Usually.............................................3
Almost always................................. 4
Please answer the following statements as they apply to you.
23. You think you should work to get something, if you really want it.
Not at all like you.................... 1
A little like you ....................... 2
Mostly like you........................ 3
Very much like you.................. 4
Don't know........................ 97
24. You make decisions to help you achieve your goals.
Not at all like you.................... 1
A little like you ....................... 2
Mostly like you........................ 3
Very much like you.................. 4
Don't know........................ 97
25. I believe that putting a child up for adoption is a good thing for a young woman to do if she feels she is unable to keep and raise the child herself.
Not at all like you....................
1 A little like you ....................... 2
Mostly like you........................ 3
Very much like you.................. 4
Don’t know.............................. 97
About Your Future…
Thinking of the future, please answer the following questions:
26. How important is it to you to graduate high school, vocational or trade school?
Not important at all.................. 1
Somewhat important ............... 2
Very important........................ 3
Extremely important................ 4
Already graduated................... 5
27. On a scale of 1 to 5, where 1 is low and 5 is high, how much do you want to get more education or training such as college, vocational school or a nursing or a teaching certification?
Low | | | | High | Don’t know |
|---|
1 | 2 | 3 | 4 | 5 | 97 |
28. On a scale of 1 to 5, where 1 is low and 5 is high, how important is it for you to get training to get the kind of job you want?
Low | | | | High | Don’t know |
|---|
1 | 2 | 3 | 4 | 5 | 97 |
About Your Health and Healthcare…
These next questions are about your health and healthcare.
29. What is your current form of birth control or protection from sexually transmitted diseases?
CHECK ALL THAT APPLY
No method used..................................................... 1
Abstinence ............................................................ 2 SKIP TO QUESTION 31
Birth control pills ....................................................
3 Condom................................................................. 4
Partner’s vasectomy................................................ 5
Sterilizing operation/tubal ligation ............................ 6
Withdrawal, pulling out............................................ 7
Depo-Provera, injectables ....................................... 8
Norplant................................................................. 9
Rhythm or safe period by calendar............................ 10
Safe period by temperature or cervical mucus test,
natural family planning ...................................... 11
Diaphragm.............................................................. 12
Female condom, vaginal pouch ............................... 13
Foam..................................................................... 14
Jelly or cream......................................................... 15
Cervical cap ........................................................... 16
Suppository............................................................ 17
Today Sponge ....................................................... 18
IUD, coil, loop......................................................... 19
“Morning after” pills or emergency contraception... 20
Other method ........................................................ 21
Respondent sterile.................................................. 22
Respondent’s partner sterile .................................... 23
Lunelle injectable (monthly shot).............................. 24
Contraceptive patch ................................................ 25
30. How would you describe your relationship with your current sexual partner?
Married to him.................................................. 1
Engaged to him ............................................... 2
Living together in a sexual relationship,
but not engaged......................................... 3
Going with him or going steady.......................... 4
Just friends ...................................................... 5
Just met him.................................................... 6
Something else................................................. 7
Don’t know ...................................................... 97
31. In the past 12 months, have you received…
| Yes | No |
|---|
a. a pregnancy test? | 1 | 2 |
b. an abortion? | 1 | 2 |
c. a pap smear? | 1 | 2 |
d. a pelvic exam? | 1 | 2 |
e. prenatal care? | 1 | 2 |
f. post-pregnancy care? | 1 | 2 |
g. counseling for, or been tested or treated for a sexually transmitted disease? | 1 | 2 |
Thank you for participating in this survey!
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