SPNS COOPERATIVE AGREEMENT EVALUATION

MODULE 36: FAMILY COMPOSITION FORM INSTRUCTIONS

Citation: Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1996). Module 36: Family Composition Form. Available: www.TheMeasurementGroup.com. Culver City, California: The Measurement Group.

Answer questions by either filling in a circle, or writing a number or letter in a square box. If the answer goes in a square box, you must use a CAPITAL LETTER or number that does not touch the side of the box. Print only one letter or number in each box. If the letters or numbers that you print touch the sides of the boxes, or if you do not clearly print the information, the computer will "kick out" the form and we will need to return it to you to be completed correctly. If the question asks the answer to be filled in a circle, make sure that the circle is completely darkened. Only darken one circle for each question unless the instructions specifically tell you to darken as many as apply for that question.

Specific Parts of the Module 36: Family Composition Form

ID Letters/ID Numbers. These boxes are provided for entering the unique identifier your site is using to track client information. The four boxes on the left are to be used for letters, while the ten boxes on the right are reserved for numbers. You may use letters, numbers, or a combination of letters and numbers, for identification purposes. If you use a combination of letters and numbers, however, please use the letters first in your alphanumeric sequence (for example, if your unique identifier is MD-1479, the letters "M" and "D" would be entered in the first two of the four boxes reserved for letters and the numbers "1", "4", "7", and "9" would be entered into the first four of the ten boxes reserved for numbers). If you are unsure about a client’s unique identifier, check with your project director.

Site. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form. Site codes are 3 letters.

Sub-Provider. This field may be used to designate specific sites or providers within your project. If appropriate, enter the code for the service provider agency doing the activity. Provider codes can be up to 3 letters.

Date. Enter the numbers representing today's date (the date of the activity) in these boxes. Enter the month as a number from 01 to 12 for January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the current year (for example, "95" for 1995). Make sure that if a month or day is less than 10, you place a "0" before the number.

Staff Code. Each staff member should be assigned a unique number code (up to 3 digits). Make sure than each new staff member has a unique code. Do not reassign any staff codes that have been previously assigned. Enter the 3-digit code for the person who provided the services. If the staff code is less than 3 digits, place "0"s before the number. For example, 3 is "003."

Client Gender. Darken the circle next to the response that indicates the person's gender.

Note: This module is designed as a structured interview form. For each section, follow the instructions to ask the questions in the order indicated. You may skip over some questions if the respondent answers in certain ways that warrant a skip, as indicated on the form. It is important to ask probing questions if the client appears uncertain or hesitant about a response, as these questions concern private matters that may be difficult to discuss. Probes may lead to a more accurate response than the initial response.

Interviewer Read: "In this interview, I will ask you some questions about you and your family. This interview is anonymous, meaning that your name does not appear anywhere on this form."

Do you have a lover/partner/spouse? (one only)
Darken the circle next to "No" if the person does not have a lover or spouse. Darken the circle next to "Don’t Know" if the person does not know. Darken the circle next to "Refused" if the person refuses to answer. If the person answers "No" or "Don’t Know" or "Refused," skip to question 2. Darken the circle next to "Yes" if the person has a lover, partner or spouse and continue with questions 1a and 1b.

What is her/his HIV status? (one only)
Darken the circle next to "Positive" if his/her HIV status is positive. Darken the circle next to "Negative" if his/her HIV status is negative. Darken the circle next to "Don’t Know" if the person does not know. Darken the circle next to "Refused" if the person refuses to answer.

Do you and he/she live together? (one only)
Darken the circle next to "Yes" if the person does live with the lover or spouse. Darken the circle next to "No" if the person does not live with the lover or spouse. Darken the circle next to "Don’t Know" if the person does not know. Darken the circle next to "Refused" if the person refuses to answer.

Do you have any children? (one only)
Darken the circle next to "Yes" if the person has children. Darken the circle next to "No" if the person does not have children. Darken the circle next to "Don’t Know" if the person does not know. Darken the circle next to "Refused" if the person refuses to answer.

How many children do you have? (one only)
Darken the circle next to the number which indicates how many children the client has.

Do your children live with you? (one only)
Darken the circle next to "Yes" if the person’s children live with him/her. Darken the circle next to "No" if the person’s children do not live with him/her. Darken the circle next to "Don’t Know" if the person does not know. Darken the circle next to "Refused" if the person refuses to answer.

For each of your children, please tell me his or her age and whether he or she is HIV positive, negative, or if his/her HIV status is not known: Space to respond is provided for up to nine children. For each child, darken the appropriate circle to indicate the child’s gender and HIV status. Enter the child’s age in years or months as appropriate. If the age is less than a two-digit number, place a and HIV status. Enter the child’s age in years or months as appropriate. If the age is less than a two-digit number, place a zero to the left of the number. For example, if the child is three years old, you would write in "03" in the boxes located above "years."

Is there anyone else, other than your spouse and children, related to you by birth or marriage living in your household? (one only)
Darken the circle next to "Yes" if the person lives with relations. Darken the circle next to "No" if the person does not live with people related to him/her. Darken the circle next to "Don’t Know" if the person does not know. Darken the circle next to "Refused" if the person refuses to answer.

If yes, how many relations live in your household? (one only)
Darken the circle next to the number which indicates how many relations live in the client’s household.

What is his/her (or their) relationship to you? (all that apply)
Darken the circle (s) next to the appropriate responses. If "Other," specify by writing in the relation in the boxes provided.

Is there anyone, other than your lover/partner, unrelated to you by birth or marriage living in your household? (one only)
Darken the circle next to "Yes" if the person lives with people unrelated by birth or marriage. Darken the circle next to "No" if the person does not live with people unrelated by birth or marriage. Darken the circle next to "Don’t Know" if the person does not know. Darken the circle next to "Refused" if the person refuses to answer.

If yes, how many unrelated persons live in your household? (one only)
Darken the circle next to the number which indicates how many unrelated people live in the client’s household.

What is his/her (or their) relationship to you? (all that apply)
Darken the circle (s) next to the appropriate responses. If "Other," specify by writing in the relationship in the boxes provided.