MDHHS-5416-DADS.pdf
PDF 2 MB Posted
- Attached to
- MDHHS 5416 DADS
- Solicitation number
- RFQ 171 260000000427 1
- Issued by
- Michigan
About this file
This document is a survey instrument developed by the Michigan Department of Health and Human Services (MDHHS) for the Michigan Father and Infant Project (PRAMS), designed to collect data from fathers about their health, experiences, and support systems related to pregnancy and infant care. The survey is comprehensive and covers multiple domains including paternal health status, mental health, substance use, healthcare access, preparation for fatherhood, baby care involvement, breastfeeding support, safe sleep practices, childcare considerations, experiences with discrimination, socioeconomic conditions, and work leave policies. The survey is formatted for self-administration with checkbox response options and includes questions spanning the 12 months before pregnancy through the current period following birth. Respondents can complete the survey in writing or by phone at the toll-free number 844-997-7267, with all information maintained as confidential.
The survey collects demographic information including household income ranges, race and ethnicity, parental contribution to infant basic needs, and household composition. Special attention is given to social determinants of health such as housing stability, food security, transportation access, and utility stability. The instrument also captures adverse childhood experiences and current life stressors to assess contextual factors affecting paternal wellbeing. No pricing, contract term, or procurement details are specified in this survey document; it functions as a data collection tool for the PRAMS program to understand the health and social needs of fathers in Michigan and inform policy and program development related to paternal and infant health outcomes.
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Other files
| File | Type | Posted |
|---|---|---|
| State of Michigan Print Mail Management Terms Conditions (1).docx | DOCX document | |
| Standard Contract Terms - Short Form.pdf | ||
| MDHHS-5416-DADS English Rev. 3-26 BID REQUEST 8-26.docx | DOCX document |
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YOUR INFORMATION IS CONFIDENTIAL
If you want to know more about the Michigan Father and Infant Project, or want to do the survey over the phone call toll free: 844-997-7267 or email: PRAMSMI@Michigan.gov www.Michigan.gov/PRAMS
Complete and return for a
Father Infant
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December
January February March April May June
July August September October November
December
January February March April May June
July August September October November
July August September October November December
June
January February March April May https://www.vertex42.com/calendars/3-year-calendar.html 3-Year Calendar Template © 2014 Vertex42.com. Free to Print.
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Please check the box next to your answer or follow the directions included with the question.
You may be asked to skip some questions that do not apply to you.
YOUR HEALTH
The first questions are about your recent health.
1. What is your date of birth?
Month Day Year
2. How tall are you without shoes?
centimetersOR
Write ONE answer inchesfeet &
3. How much do you weigh?
pounds OR kilos
Write ONE answer
| � Excellent |
| � Very good |
| � Good |
| � Fair |
| � Poor |
4. Would you say that in general that your health is: Check ONE answer
| � 0-3 hours |
| � 4-6 hours |
| � 7-8 hours |
| � 9 hours or more |
5. In the last week, how much time, on average, did you spend sleeping each night?
Check ONE answer
6. Thinking about your mental health, how many days during the past 30 days was your mental health not good (this might include stress, depression, and problems with emotions)?
Number of days (0-30)
| No | Yes | |
| a. | Had serious difficulty hearing, or are |
you deaf?
b. Have serious difficulty seeing, even when wearing glasses, or are you blind?...
c. Had serious difficulty walking or climbing stairs?
d. Had serious difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition?
e. Had difficulty with dressing or bathing yourself?
f. Had difficulty doing errands alone such as visiting a doctor’s office or shopping because of a physical, mental, or emotional condition?
7. Have you ever...?
For each one, check No or Yes.
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| No | Yes | |
| a. | Type 1 or Type 2 diabetes............................... | |
| b. | High blood pressure or hypertension........ | |
| c. | High cholesterol or triglycerides ................. | |
| d. | Chronic obstructive pulmonary disease |
(COPD)
| e. | Heart disease....................................................... |
| f. | Depression........................................................... |
| g. | Anxiety.................................................................. |
| h. | Asthma.................................................................. |
8. Do your currently have any of the following health conditions? For each one, check No if you do not have the condition and Yes if you do.
| � No |
| � Yes |
9. During the last 12 months, did you have a family doctor or primary care physician?
| No | Yes | |
| a. | Regular checkup with a family doctor....... | |
| b. | Visit for an injury or illness............................. | |
| c. | Visit for a chronic condition........................... | |
| d. | Visit to urgent care............................................ | |
| e. | Visit to the emergency room........................ | |
| f. | Visit for family planning or birth control. | |
| g. | Visit for depression or anxiety...................... | |
| h. | Visit to have my teeth cleaned..................... | |
| i. | Other...................................................................... |
Please tell us:
10. In the last 12 months, did you have any of the following healthcare visits? For each one, check No or Yes.
If you did not have any healthcare visits in the last 12 months, go to Page 3, Question 14.
No Yes Talk to me about...
| a. | My weight............................................................. |
| b. | Regularly checking my blood pressure..... |
| c. | Watching my cholesterol or |
triglycerides
| d. | My desire to have or not have children..... |
| e. | Birth control methods..................................... |
| f. | Sexually transmitted infections such as |
chlamydia, gonorrhea, syphilis, or HIV
g. Doing monthly self-exams or screening for testicular cancer
| h. | Getting up to date on my vaccines ............ |
| i. | Other...................................................................... |
Please tell us:
11. During any of your healthcare visits in the last 12 months, did a healthcare provider talk to you about any of the following things? For each one, check No or Yes.
No Yes Ask me...
a. If I smoked cigarettes or used e-cigarettes (“vapes”) or other smokeless tobacco
| b. | If I was drinking alcohol ................................. |
| c. | If I was using marijuana .................................. |
| d. | If I was using illegal drugs.............................. |
| e. | If someone was hurting me emotionally |
or physically
| f. | If I felt depressed or anxious ........................ |
| g. | Other...................................................................... |
Please tell us:
12. During any of your healthcare visits in the last 12 months, did a healthcare provider ask you any of the following things? For each one, check No or Yes.
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| � No |
| � Yes |
| � I don’t remember |
13. In the last 12 months, did a healthcare provider ask you a series of questions, in person or on a form, to know if you were feeling down, depressed, anxious, or irritable?
| � Always |
| � Often |
| � Sometimes |
| � Rarely |
| � Never |
14. Since your new baby was born, how often have you felt down, depressed, or hopeless?
| � Always |
| � Often |
| � Sometimes |
| � Rarely |
| � Never |
15. Since your new baby was born, how often have you had little interest or little pleasure in doing things?
| � Always |
| � Often |
| � Sometimes |
| � Rarely |
| � Never |
16. Since your new baby was born, how often have you felt nervous, anxious, or on edge?
| � Always |
| � Often |
| � Sometimes |
| � Rarely |
| � Never |
17. Since your new baby was born, how often have you not been able to stop or control worrying?
This question is about your health insurance.
� Private health insurance (paid for by me, someone else, or through a job)
| � Medicaid |
| � Healthy Michigan Plan |
| � TRICARE or other military healthcare |
| � Indian Health Service (IHS) or other tribal |
program � Other health insurance Please tell us:
� I don’t have any health insurance now
18. What kind of health insurance do you have now?
Check ALL that apply
The next questions are about cigarettes, e-cigarettes, and other tobacco products.
| � Every day |
| � Some days |
| � I don’t smoke now |
| � I’ve never smoked |
19. How often do you smoke cigarettes?
| � Every day |
| � Some days |
| � I don’t use e-cigarettes or other electronic |
nicotine products now � I’ve never used e-cigarettes or other electronic nicotine products
20. How often do you use e-cigarettes (“vapes”) or other electronic nicotine products?
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The next questions are about drinking alcohol.
A drink can be 1 glass of wine, can or bottle of beer or hard seltzer, shot of liquor, or mixed drink.
| � 15 or more drinks a week |
| � 7 to 14 drinks a week |
| � 1 to 6 drinks a week |
| � Less than one drink a week |
| � I don’t drink |
21. How many alcoholic drinks do you have in an average week?
| � 5 or more days |
| � 2 to 4 days |
| � 1 day |
| � No days |
22. During the past month how many days did you have 5 or more alcoholic drinks in a 2-hour time span?
| No | Yes | |
| a. | During the 12 months before my infant’s |
mother got pregnant
| b. | During my infant’s mother’s pregnancy... |
| c. | Since my new baby was born....................... |
23. During any of the following time periods, did you drink alcohol?
For each time period, check No if you did not drink then or Yes if you did.
| No | Yes | |
| a. | During the 12 months before my infant’s |
mother got pregnant
| b. | During my infant’s mother’s pregnancy... |
| c. | Since my new baby was born....................... |
24. During any of the following time periods, did you use marijuana or hash in any form?
For each time period, check No if you did not use then or Yes if you did.
Go to Question 23
| No | Yes | |
| a. | During the 12 months before my infant’s |
mother got pregnant
| b. | During my infant’s mother’s pregnancy... |
| c. | Since my new baby was born....................... |
The next questions are about the time around when your infant’s mother got pregnant with your new baby.
| � I wanted her to be pregnant later |
| � I wanted her to be pregnant sooner |
| � I wanted her to be pregnant then |
| � I didn’t want her to be pregnant then or at any |
time in the future � I wasn’t sure what I wanted
26. Thinking back to just before your infant’s mother got pregnant, how did you feel about her becoming pregnant?
Check ONE answer
| � No |
| � Yes |
27. When your infant’s mother got pregnant with your new baby, were you and your infant’s mother trying to get pregnant?
Go to Page 5, Question 29
Go to Page 5, Question 28
25. During any of the following time periods, did you take or use prescription pain relievers such as hydrocondone (Vicodin), oxycodone (Percocet) or codeine? For each time period, check No if you did not take or use then or Yes if you did.
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| � No |
| � Yes |
| � I don’t know |
28. When your infant’s mother got pregnant, were either of you doing anything to keep from getting pregnant? This can include having a vasectomy, having tubes tied, using birth control pills, condoms, natural family planning, or other methods.
Go to Question 30
� I wanted her to get pregnant or didn’t mind if she did
� I thought she couldn’t get pregnant at that time
� I had side effects from the birth control method I was using
� I had problems getting birth control when I needed it
� I thought I was sterile (could not get anyone pregnant at all)
| � I didn’t want to use anything |
| � My infant’s mother didn’t want me to use |
anything
| � I forgot to use a birth control method | |
| � We are same sex partners/spouses | |
| � Other | Please tell us: |
29. What were your or your infant’s mother’s reasons for not doing anything to keep from getting pregnant?
Check ALL that apply
If you were not doing anything to keep from getting pregnant, go to Question 31.
| � Condoms |
| � Vasectomy (male sterilization) |
| � Withdrawal (pulling out) |
| � Natural family planning or fertility awareness |
methods (such as rhythm or calendar method or fertility apps)
| � I was not using birth control | |
| � My infant’s mother was using birth control | |
| � None | |
| � I don’t know | |
| � Other | Please tell us: |
30. What kind of birth control were you using when your infant’s mother got pregnant?
Check ALL that apply
� A pregnancy, childbirth, or parenting class provided by a hospital or other organization
| � Prenatal care visits |
| � 20-week ultrasound for my new baby |
| � Labor or delivery of my new baby |
| � Postpartum visits for my infant’s mother |
| � A visit with my baby’s doctor or pediatrician |
| � A visit to the emergency room or urgent care |
for my infant’s mother � A visit to the emergency room or urgent care for my new baby � Other Please tell us:
31. Since your infant’s mother became pregnant until now, did you attend any of the following kinds of pregnancy related classes, healthcare visits, or hospital visits?
Check ALL that apply
Go to Question 31
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PREPARING FOR BABY
The next questions are about information fathers may be interested in around the time a new baby is born.
| � Family |
| � Friends |
| � Websites about fatherhood (such as |
fatherhood.gov) � Social media (such as Facebook, X/Twitter, Instagram, or Reddit) � Peer parenting groups (virtual or in-person groups specifically for fathers or parenting) � My health care provider(s) (such as a primary care doctor, nurse, counselor, or therapist) � My baby’s health care provider(s) (such as a pediatrician) � Birth preparation groups (such as hospital based birthing or parenting classes, Lamaze classes)
| � I google or look things up on the internet |
| � Other people or groups Please tell us: |
� I do not have people or groups I go to for fatherhood/parenthood resources
32. Which of the following people or places do you normally go to for information specific to fatherhood or parenthood?
Check ALL that apply
a. What to expect during pregnancy and delivery
No Yes Wanted information Received information
b. What to expect in the month after delivery with my baby at home No Yes Wanted information Received information
33. When you were preparing to be a new father or when you became a new father, what information about pregnancy did you want, and did you receive the information you wanted? For each one, check No or Yes for Wanted Information and Received Information.
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a. Advice on parenting a newborn No Yes Wanted information Received information
b. Information on my baby’s growth and learning No Yes Wanted information Received information
c. Advice on co-parenting with my infant’s mother No Yes Wanted information Received information
d. The importance of placing my baby to sleep on their back No Yes Wanted information Received information
e. How to create a safe sleeping space for my baby No Yes Wanted information Received information
f. How to support my infant’s mother’s breastfeeding No Yes Wanted information Received information
g. How to properly install and use an infant car seat No Yes Wanted information Received information
34. When you were preparing to be a new father or when you became a new father, what information about caring for your baby did you want, and did you receive the information you wanted? For each one, check No or Yes for Wanted Information and Received Information.
a. Applying for or understanding time off from work (Family Medical Leave/FMLA) No Yes Wanted information Received information
b. Finding or understanding health insurance related to having a baby No Yes Wanted information Received information
c. Finding financial assistance, support, or resources No Yes Wanted information Received information
d. Finding legal assistance for or understanding child support or custody, or parenting time (PT) orders No Yes Wanted information Received information
35. When you were preparing to be a new father or when you became a new father, what information about financial or legal concerns did you want, and did you receive the information you wanted? For each one, check No or Yes for Wanted Information and Received Information.
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YOUR AND YOUR BABY’S RELATIONSHIP
The next questions are about your new baby’s living situation.
| � No |
| � Yes |
36. Do you live with your new infant’s mother now?
Number of children
� None- my new baby is my only child
37. Not including your new baby, how many children do you have?
Go to Question 39
| � All of my children live with me |
| � Some, but not all of my other children live |
with me � None of my other children live with me
38. How many of your other children live with you?
| � No |
| � Yes |
39. Is your baby alive now?
We are very sorry for your loss.
Go to Page 11, Question 60
| � No |
| � Yes, part of the time |
| � Yes, all of the time |
| � My baby is still in the hospital |
40. Does your new baby live with you now?
Check ONE answer
Go to Page 9, Question 42
| No | Yes | |
| a. | There was a change in the relationship |
status with my infant’s mother
b. My infant’s mother and I were never living together
c. There are personal issues with my infant’s mother or thier family (non-legal issues) .
| d. | I have issues with my housing...................... |
| e. | There is a custody order in place................. |
| f. | My baby needs additional medical care . |
| g. | My infant’s mother and I are apart due |
to work, school, extended travel, or deployment
h. I was in jail or prison
i. Other
Please tell us:
41. What are the reasons your new baby does not live with you all of the time? For each item, check No or Yes.
Check ONE answer
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| � Very satisfied |
| � Somewhat satisfied |
| � Neutral |
| � Somewhat dissatisfied |
| � Very dissatisfied |
42. In the past month, how satisfied or dissatisfied are you with how often you see or spend time with your new baby?
| � Not at all |
| � Less than once a week |
| � About once a week |
| � Several times a week |
| � Every day or almost every day |
43. In the past month, how often do you see or spend time with your new baby?
| � Strongly agree |
| � Somewhat agree |
| � Somewhat disagree |
| � Strongly disagree |
| � I don’t know |
44. Being a parent is harder than I thought it would be. Do you...
| � Strongly agree |
| � Somewhat agree |
| � Somewhat disagree |
| � Strongly disagree |
| � I don’t know |
45. I honestly believe I have all the skills necessary to be a good father to my child. Do you...
| � Strongly agree |
| � Somewhat agree |
| � Somewhat disagree |
| � Strongly disagree |
| � I don’t know |
46. Being a new father is stressful for me. Do you...
If you baby is not living with you now, go to Page 11, Question 60.
CARING FOR BABY
| O | S | N N/A | |
| a. | Get up with my baby when |
he/she wakes up during the night
b. Soothe my baby when he/she is upset
| c. | Take my baby to the doctor......... |
| d. | Stay home to care for my baby |
when he/she is ill
e. Take my baby to or from the sitter or day care center
47. When the following things happen or need to be done, how often are you the one who does them? Do you often, sometimes, or never do them? For each one, check O for often, S for sometimes, or N for never. If the task does not apply or has not happened yet, check N/A.
| � Never |
| � Once or twice |
| � A few times a month |
| � A few times a week |
| � Every day or almost every day |
48. In the past month, how often have you looked after your new baby while your infant’s mother did other things?
� No, someone else is my baby’s primary caregiver
| � No, I share equal responsibility with others |
| � Yes |
49. Are you your new baby’s primary caregiver?
A primary caregiver is the main person responsible for your baby’s day-to-day physical care.
Check ONE answer
Check ONE answer
Check ONE answer
Check ONE answer
Go to Page 10, Question 50
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The next questions are about breastfeeding.
| � I wanted her to breastfeed |
| � I did not want her to breastfeed |
| � I had no opinion about whether she would |
breastfeed
50. When your new baby was born, what did you think about your infant’s mother breastfeeding your baby?
| � My baby was not breastfed |
| � My baby was breastfed for less than 1 week |
| � My baby was breastfed for: |
� My baby is still being breastfed or fed pumped milk
51. How many weeks or months was your new baby breastfed or fed pumped milk?
week(s) OR month(s)
Check ONE answer
The next questions are about how your baby sleeps.
| � No |
| � Yes |
52. In the past 2 weeks, have you placed your new baby to sleep at night or during naps?
Go to Page 11, Question 56
| No | Yes | |
| a. | On their side........................................................ | |
| b. | On their back....................................................... | |
| c. | On their stomach............................................... |
53. In the past 2 weeks, how did you place your new baby to sleep at night and during naps?
For each one, check No or Yes.
| No | Yes | |
| a. | In a crib, portable crib, or bassinet.............. | |
| b. | On a twin or larger mattress or bed............ | |
| c. | On a couch, sofa, or armchair........................ | |
| d. | In an infant car seat........................................... | |
| e. | In a swing, rocker, or other inclined |
sleeper
| f. | In an in-bed sleeper.......................................... |
| g. | In a baby board or cradleboard................... |
| h. | Other...................................................................... |
Please tell us:
54. In the past 2 weeks, where have you placed your new baby to sleep at night or during naps? For each one, check No or Yes.
| No | Yes | |
| a. | In a sleeping sack or wearable blanket...... | |
| b. | In a swaddled blanket...................................... | |
| c. | Comforters, quilts, blankets, or non-fitted |
sheets
d. Soft toys, cushions, or pillows, including nursing pillows
| e. | Crib bumper pads (mesh or non-mesh).... |
| f. | Other...................................................................... |
Please tell us:
55. In the past 2 weeks, has your new baby been placed to sleep with the following?
For each one, check No or Yes.
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The next questions are about childcare for your new baby.
| � No |
| � Yes |
| � I don’t know |
56. Do you feel there are good choices for child care or early childhood programs where you live?
| � No |
| � Yes |
57. Have you ever searched for child care or an early childhood program for your new baby?
Go to Question 60
| � No difficulty |
| � A little difficulty |
| � Some difficulty |
| � A lot of difficulty |
| � I did not find the the type of childcare I wanted |
58. How much difficulty did you have finding the type of child care or early childhood program you wanted for your new baby?
Go to Question 60
No Yes
| a. | The cost was too high...................................... |
| b. | The location was not convenient................ |
| c. | The quality was lower than I expected..... |
| d. | There were no open spots for infants |
or I was put on a waitlist
e. I needed child care or a program for infants with special needs
f. Other difficulty
Please tell us:
59. What were the reasons you had difficulty finding child care or early childhood programs for your new baby? For each one check No or Yes.
OTHER EXPERIENCES
The next questions are about a variety of topics.
| � Very often |
| � Somewhat often |
| � Not very often |
| � Never |
60. During your life until now, how often have you been discriminated against, prevented from doing something, hassled, or made to feel inferior because of your race, ethnicity, or skin color? Check ONE answer
| No | Yes | |
| a. | Job (hiring, promotion, firing)....................... | |
| b. | Housing (renting, buying, mortgage)........ | |
| c. | Police (stopped, searched, threatened)..... | |
| d. | In the courts........................................................ | |
| e. | At school or my child’s school...................... |
61. Have you ever been treated unfairly due to your race, ethnicity, or skin color in any of the following situations? For each one, check No or Yes.
| No | Yes | |
| a. | My race, ethnicity, or skin color.................... | |
| b. | My type or lack of health insurance............ | |
| c. | My weight............................................................. | |
| d. | My marital status............................................... | |
| e. | Another reason................................................... |
Please tell us:
62. During the last 12 months, did you experience discrimination or were you made to feel inferior while getting any type of health or medical care because of the things listed below? For each one, check No if you did not experience discrimination because of it or Yes if you did.
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| � No |
| � Yes |
63. Have you ever been in jail or prison longer than two days, been on court ordered probation, house arrest, or electronic monitoring, or had court ordered community service?
The time around pregnancy can be difficult.
The next questions are about things that may have happened in the last 12 months.
| No | Yes | |
| a. | I got separated or divorced............................ | |
| b. | I was evicted or forced to move................... | |
| c. | I didn’t have a regular place to sleep.......... | |
| d. | I was homeless or had to sleep outside, |
in a car, or in a shelter
| e. | My spouse, partner, or I lost a job................ |
| f. | My spouse, partner, or I had a cut in |
work hours or pay
g. I had problems paying the rent, mortgage, or other bills
| h. | My spouse or partner went to jail/prison... |
| i. | I went to jail/prison........................................... |
| j. | Someone close to me had a problem |
with drinking or drugs
k. Someone close to me was very sick or died
64. Did any of the following things happen in the last 12 months? For each one, check No or Yes.
a. I worried whether my food would run out before I got money to buy more
Often Sometimes Never
b. The food that I bought just didn’t last, and I didn’t have money to get more
Often Sometimes Never
65. Please tell us how often each of the following happened during the last 12 months.
| No | Yes | |
| a. | I had affordable, reliable transportation... | |
| b. | I had safe housing............................................. | |
| c. | I had consistent and stable housing........... | |
| d. | My house or apartment was too |
crowded
e. I could keep basic utility services on
(heat, water, lights)
f. I had access to a telephone when needed
g. I had other basic needs that were not met Please tell us:
66. During the last 12 months, which of the following statements about basic needs applied to you? For each one, check No or Yes.
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67. Some of these things might happen to people during childhood. Childhood experiences may be important. Please tell us if any of these things happened to you from the time you were born through age 17. For each one, check No or Yes.
| No | Yes | |
| a. | Most of the time I had an adult who |
believed in me and who I could count on to help me
b. A parent or guardian I lived with got divorced or separated
c. We had to move because of problems paying the mortgage or rent
d. Someone in my family or I went hungry because we could not afford enough food
e. A parent or guardian got in trouble with the law or went to jail
f. A parent or guardian I lived with had a serious drinking or drug problem
g. I was in foster care (removed from my home by the court or child welfare agency)
The last questions are about your job and work leave.
| � Employed for wages or self employed | |
| � Out of work for 1 year of more | |
| � Out of work for less than a year | |
| � A stay-at-home parent or caregiver | |
| � A student | |
| � Other | Please tell us: |
68. Are you currently...
Check ONE answer
� I was unemployed or not working at a job for pay
� No, I didn’t take any leave or time off
� Yes, I took leave or time off
69. Did you take leave or time off from work after your new baby was born?
Go to Page 14, Question 75
| � All my leave was paid |
| � All my leave was unpaid |
| � A combination of both |
paid and unpaid leave
70. Was your leave paid, unpaid, or a combination of both?
Check ONE answer
� Paid time off (PTO) such as vacation, personal time, or holiday
| � Paid sick (PSL) or medical leave (PML) | |
| � Paid parental leave | |
| � Other | Please tell us: |
71. What type of paid leave did you take?
Check ALL that apply
Check ONE answer
Go to Page 14, Question 72
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| � No |
| � Yes |
| � My employer is not required to provide FMLA |
| � I don’t know if any of my leave was covered by |
FMLA
72. Was any of your unpaid or paid leave covered or protected by the Family and Medical Leave Act (FMLA)? Private employers with 50 or fewer employees are generally not required to provide
FMLA.
� Less than one week
73. Including all paid and unpaid leave, how many weeks or months of leave, in total, did you take or will you take?
weeks OR months
Write ONE answer
No Yes
a. It Improved my relationship with my new infant’s mother
b. It made my relationship with my new infant’s mother worse
| c. | It helped me bond with my new baby...... |
| d. | It helped me return to work refreshed |
and ready to work
e. It made it difficult to pick back up on my work after returning
| f. | It improved my personal physical health. |
| g. | It improved my personal mental health... |
| h. | It improved my lifestyle and health |
behaviors such as getting more sleep or physical activity or eating healthier
i. Taking work leave impacted me in another way Please tell us:
74. How did taking leave from work after your new baby was born impact you? For each one, check No if it was not an impact for you or Yes if it was.
| � Too little time |
| � Just the right amount of time |
| � Too much time |
75. How did you feel about the amount of time you were able to take off after the birth of your new baby? Was it...
No Yes
a. I couldn’t financially afford to take leave
b. I was afraid I’d lose my job if I took leave or stayed on leave longer
c. I had too much work to do to take leave or stay out longer
| d. | My job doesn’t have paid leave ................... |
| e. | I was denied leave............................................. |
| f. | My job doesn’t offer a flexible work |
schedule
g. I hadn’t built up enough leave time to take time off
h. I wanted more work leave but I couldn’t take more time off
i. I wanted to return to work before my leave ended
| j. | I had the right amount of work leave........ |
| k. | It’s not normal in my profession or |
workplace to take leave when you have a new baby
76. Did any of the following things affect your decision about taking leave from work after your new baby was born? For each one, check No or Yes.
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| � $0 to $18,000 |
| � $18,001 to $23,000 |
| � $23,001 to $27,000 |
| � $27,001 to $32,000 |
| � $32,001 to $37,000 |
| � $37,001 to $42,000 |
| � $42,001 to $48,000 |
| � $48,001 to $60,000 |
| � $60,001 to $85,000 |
| � $85,001 or more |
77. During the 12 months before your new baby was born, what was your yearly total household income before taxes? Include your income, your spouse or partner’s income if they lived with you, and any other income you may have received. All information will be kept private and will not affect any services you are getting.
Number of children (under the age of 18)
Number of adults (18 years of age or older)
78. During the 12 months before your new baby was born, how many children and adults, including yourself, depended on this income?
| � Always |
| � Often |
| � Sometimes |
| � Rarely |
| � Never |
79. How often do you contribute things such as money, food, clothing, shelter, or health care to provide for your new baby’s basic needs?
| � No |
| � Yes |
80. Are you Hispanic, Latino/x, or Spanish origin?
| � Black or African American | |
| � White | |
| � American Indian or Alaska Native | |
| � Asian | |
| � Pacific Islander | |
| � Other | Please tell us: |
81. Which one or more of the following would you say is your race?
Check ALL that apply
| � No |
| � Yes |
82. Are you of Middle East or North African (MENA) origin (Arab, Chaldean, Lebanese, Egyptian, etc.)?
83. What is today’s date?
Month Day Year
Go to Page 16.
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We would love to hear more about your story!
Is there anything else you would like to share about your experiences around pregnancy and your new baby or the health and wellbeing of fathers in Michigan?
Thanks for answering our questions!
Your answers will help us work to make fathers and babies healthier.
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The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group on the basis of race, national origin, color, sex, disability, religion, age, height, weight, familial status, partisan considerations, or genetic information.
Sex-based discrimination includes, but is not limited to, discrimination based on sexual orientation, gender identity, gender expression, sex characteristics, and pregnancy.
MDHHS-5416-DADS (3-26)
Received:
Checks:
___/___/___ By:____________
D ○ Yes ○ No
Data Entry: ___/___/___ By:____________
DDE: ___/___/___ By:____________
Verification: ___/___/___ By:____________
For Office Use Only
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File details come from the government source that posted it. Updated .