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Offender Family Questionnaire

Offender Family Services of the Division of Adult Correction, Office of Citizen Services, would appreciate you taking a few minutes to complete the attached questionnaire. The purpose of this questionnaire is to gather information about what services and support systems are needed most for the offenders’ family and children. Offender Family Services recognize that when a loved one is in prison it can be a very difficult time for the family and children.

Please do not write any names on the questionnaire. All information is confidential and will be used only to identify the support and services needed for the offender’s families and their children. Your input is very important so that we will be able to better assist you during this difficult time. Your time and cooperation is very much appreciated.

1. What is your relationship with the individual you have contact with in prison? Specify

2. How often do you visit?

3. How many hours do you have to travel to visit?

4. Do you provide your own transportation to visit? Yes No
If not, how are you able to visit your relative?

5. Do you or other family members maintain contact with your loved one by telephone? Yes No   How many times a month?
By letter? Yes No   How many times a month?

6. Does your loved one in prison have any children? Yes No
(If no, skip to question #10)
How many boys? What are their ages?
How many girls? What are their ages?

7. Does the child/children live with you? Yes No
    a. If not, do you help in any way with the child/children?
    Yes No  If yes, how do you help?
    b. If the child/children do not live with you, what is the relationship of the person/persons they do live with?

8. Is the child/children able to visit their father or mother in prison? Yes No
    a.  If yes, how may times a month?
    b.  Who brings the child/children to visit? (relationship only)
    c.  Does the child/children write to their mother or father? Yes No
    d.  Does the child/children talk with their mother or father by telephone? Yes No  If yes, how often?

9. How is the child/children dealing with their mother/father being in prison and have you seen any changes in their behavior?

10. Do you receive or are you involved with any of the following? (Check all that apply)

Medicaid Medical assistance
SSI (Disability) Work First Program
Medicare Transportation assistance
Food Stamps WIC (Women, infant & child nutrition program)
Assistance with housing Employment services/Employment Security Commission
Support from church Individual/family counseling/mental health services
Child Support Other (specify)

If your loved one in prison has a child/children, does the child/children receive or involved with any of the following? (Check all that apply)

Head Start Boys & Girls Club
Foster care Summer programs
Smart Start School activities
Drug Treatment Church
Subsidized day care Church youth groups
Medicaid Boy Scouts/Girl Scouts
School lunch program Tutoring
Big Brother/Big Sister Counseling/mental health services
After-School Programs Youth Employment services
Vocational (job skills training) services Other-specify:

11.Would you be interested in a family support group in or near you community ? Yes No    If yes, please describe your ideas about a family support group and indicate the county in which you reside.

12. What has been the most difficult thing for you with your loved one in prison?

*Please make any additional comments or suggestions you may have:

If you have specific questions and/or concerns relating to your loved one that you would like to discuss, send an email to the Prisons Family Services Administrator at wmn01@doc.nc.gov.

**THANKS FOR COMPLETING THIS QUESTIONNAIRE!!**