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pdfContract No.:
SS00-05-60084
MPR Reference No.: 6209-139
Youth Transition
Demonstration
36-Month YTD
Follow-Up Instrument
January 7, 2009
Karen CyBulski
Kirsten Barrett
Jillian Stein
Submitted to:
Social Security Administration
Office of Program Development and Research
Suite 700, 400 Virginia Avenue, SW
Washington, DC 20024
Telephone: (202) 358-6448
Facsimile: (202) 358-6505
Project Officer:
Joyanne Cobb
Submitted by:
Mathematica Policy Research, Inc.
600 Maryland Ave., SW, Suite 550
Washington, DC 20024-2512
Telephone: (202) 484-9220
Facsimile: (202) 863-1763
Project Director:
Thomas Fraker
Survey Director:
Karen CyBulski
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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CONTENTS
Section
Page
I.
EDUCATION AND TRAINING ............................................................................1
II. EMPLOYMENT ......................................................................................................7
III. SERVICE UTILIZATION.....................................................................................24
IV. SATISFACTION WITH YTD PROGRAM ..........................................................29
V. AWARENESS OF WAIVERS AND INCENTIVES ...........................................31
VI. HEALTH................................................................................................................37
VIII. SELF-DETERMINATION ..................................................................................44
IX. CRIMINAL BEHAVIOR ......................................................................................49
X. LIVING ARRANGEMENT ..................................................................................62
XI. INCOME ................................................................................................................67
XII. FINAL COMMENTS ............................................................................................86
CONTACT MODULE ..................................................................................................88
NOTE: There is no Section VII in this version.
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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SECTION I: EDUCATION AND TRAINING
I.A1
The first questions are about school. (Are you/Is NAME) currently attending or enrolled in school?
(YTD-9 mod
PROBE: Please include regular high school, special high school, adult basic education or GED
courses, vocational or trade school, and college or university courses.
PROBE: (Do you/Does NAME) go to school?
PROBE: At school they teach (you/him/her) how to do things, like how to read, write, or do math.
PROBE: IF NO: When was the last time (you/he/she) went to school?
PROBE IF SUMMER: (Are you/Is NAME) off school for the summer. Will (you/he/she) be going back
to school in the fall?
INTERVIEWER: CODE “YES” IF ON SUMMER BREAK.
YES ............................................................. 1 (GO TO I.B1)
NO ............................................................... 0
DON‘T KNOW ............................................. d
REFUSED ................................................... r
I.A1a
(Are you/Is NAME) currently in a training program or taking classes to help you learn job skills or get a
job?
PROBE: Please include classes to learn English or improve your reading skills.
YES ............................................................. 1 (GO TO I.B1)
NO ............................................................... 0
DON‘T KNOW ............................................. d
REFUSED ................................................... r
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I.A2
ASK IF NEITHER CURRENTLY IN SCHOOL OR TRAINING PROGRAM:
Did (you/NAME) go to school, attend a training program or take any classes within the past year?
That is, at any time since [oneyrago]?
PROBE: IF DON’T KNOW: When was the last time (you/he/she) went to school or training?
YES ............................................................. 1
NO ............................................................... 0
DON‘T KNOW ............................................. d
(GO TO I.D1)
REFUSED ................................................... r
I.B1
Please tell me the name of each training program or school (you/NAME) attended within the past
year? Let‘s begin with the one you attended most recently and work backwards.
IF UNABLE TO STATE NAME OF SCHOOL OR PROGRAM: I need to enter something that will help
us identify the school later. What could I enter that will help identify it? A street name, an address,
even the color of the building would be helpful.
PROBE: Any others?
INTERVIEWER: RECORD NAME OF EACH PLACE
SCHOOL/TRAINING PROGRAM 1 NAME:
SCHOOL/TRAINING PROGRAM 2 NAME:
SCHOOL/TRAINING PROGRAM 3 NAME:
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SCHOOL 1
I.B2 Thinking about (NAME OF
SCHOOL). What type of school/
training program) is (this/that)?
I.B3 When did you start (this/that)
(school/course/training program)?
SCHOOL 2
SCHOOL 3
Regular high school, ................................1
Regular high school, ............................... 1
Regular high school, ................................1
Special high school for persons with
disabilities, ...............................................2
Special high school for persons with
disabilities, ............................................... 2
Special high school for persons with
disabilities, ...............................................2
Post-secondary, vocational, technical
business or trade school,.........................3
Post-secondary, vocational, technical
business or trade school, ........................ 3
Post-secondary, vocational, technical
business or trade school,.........................3
2-year college or community college, ......4
2-year college or community college, ..... 4
2-year college or community college, ......4
4-year college or university, ....................5
4-year college or university, .................... 5
4-year college or university, ....................5
Or something else (SPECIFY) ................6
Or something else (SPECIFY) ................ 6
Or something else (SPECIFY) ................6
SPECIAL EDUCATION NOT
IN A SCHOOL..........................................7
SPECIAL EDUCATION NOT
IN A SCHOOL ......................................... 7
SPECIAL EDUCATION NOT
IN A SCHOOL..........................................7
HOME SCHOOLED.................................8
HOME SCHOOLED ................................ 8
HOME SCHOOLED.................................8
START DATE:
START DATE:
START DATE:
| | | / 20 | | |
MONTH
YEAR
| | | / 20 | | |
MONTH
YEAR
| | | / 20 | | |
MONTH
YEAR
MORE THAN ONE YEAR AGO ......... 999
MORE THAN ONE YEAR AGO ..........999
MORE THAN ONE YEAR AGO ......... 999
I.B4 (Are you/Is NAME) still attending
(NAME OF SCHOOL)?
YES ..........................................................1
YES ......................................................... 1
YES ..........................................................1
NO............................................................0
NO ........................................................... 0
NO............................................................0
I.B5 IF NOT CURRENTLY ATTENDING,
ASK: And when did you stop going
to (this/that) (school/course/training
program)?
END DATE:
END DATE:
END DATE:
I.B6 IF I.B3 OR I.B5 “DON’T KNOW”—
CANNOT ANSWER EXACT
DATES, PROBE FOR TIME
ATTENDED SCHOOL: Within the
past year about how many months
did (you/NAME) go to (NAME OF
SCHOOL)?
|
PROBE: Your best estimate is fine.
I.C1 IF CURRENTLY IN HIGH SCHOOL,
ASK: (Are you/Is NAME) in
(your/his/her) freshman, sophomore,
junior or senior year of school?
I.C1a IF UNGRADED, ASK: When do you
expect to graduate?
PROBE: How many more years
(do you/does NAME) have left in
school?
| | | / 20 | | |
MONTH
YEAR
|
|
|
| MONTHS
| | | / 20 | | |
MONTH
YEAR
|
|
| MONTHS
IF DON’T KNOW: Was it . . .
IF DON’T KNOW: Was it . . .
IF DON’T KNOW: Was it . . .
All year, including the summer, ...............1
All year, including the summer, ............... 1
All year, including the summer, ...............1
All year, except for the summer
(9 months),...............................................2
All year, except for the summer
(9 months), .............................................. 2
All year, except for the summer
(9 months),...............................................2
About half the year (6 months), ...............3
About half the year (6 months), .............. 3
About half the year (6 months), ...............3
Between 3 and 6 months, or ...................4
Between 3 and 6 months, or ................... 4
Between 3 and 6 months, or ...................4
Less than 3 months? ...............................5
Less than 3 months?............................... 5
Less than 3 months? ...............................5
FRESHMAN/9TH GRADE .......................1
FRESHMAN/9TH GRADE ...................... 1
FRESHMAN/9TH GRADE .......................1
SOPHOMORE/10TH GRADE .................2
SOPHOMORE/10TH GRADE................. 2
SOPHOMORE/10TH GRADE .................2
JUNIOR/11TH GRADE............................3
JUNIOR/11TH GRADE ........................... 3
JUNIOR/11TH GRADE............................3
SENIOR/12TH GRADE ...........................4
SENIOR/12TH GRADE........................... 4
SENIOR/12TH GRADE ...........................4
UNGRADED ............................................5
UNGRADED............................................ 5
UNGRADED ............................................5
INTERVIEWER NOTE: If respondent
reports graduate ―this year‖, code year of
the current school year.
20 | | |
INTERVIEWER NOTE: If respondent
reports graduate ―this year‖, code year of
the current school year.
20 | | |
INTERVIEWER NOTE: If respondent
reports graduate ―this year‖, code year of
the current school year.
20 | | |
or
|
I.C2 What type of classes ([are/were] you
taking/[is/was] NAME taking) at
(NAME OF SCHOOL)? (Are/Were)
the classes mostly vocational
courses to train for a job, like
computer or business courses, or
mostly academic courses, like
English or science?
PROBE: (Are you/Is NAME) taking
courses that are preparing
(you/him/her) for a job or for college?
| MONTHS
| | | / 20 | | |
MONTH
YEAR
|
or
| YEARS
|
|
| YEARS
or
|
|
| YEARS
MOSTLY VOCATIONAL..........................1
MOSTLY VOCATIONAL ......................... 1
MOSTLY VOCATIONAL..........................1
MOSTLY ACADEMIC ..............................2
MOSTLY ACADEMIC ............................. 2
MOSTLY ACADEMIC ..............................2
BOTH, MIXED .........................................3
BOTH, MIXED ......................................... 3
BOTH, MIXED .........................................3
NEITHER—CLASSES ARE
FOR PERSONAL INTEREST,
RECREATION .........................................4
NEITHER—CLASSES ARE
FOR PERSONAL INTEREST,
RECREATION......................................... 4
NEITHER—CLASSES ARE
FOR PERSONAL INTEREST,
RECREATION .........................................4
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SCHOOL 1
I.C3 IF NOT IN HIGH SCHOOL, ASK:
Are (you/Is NAME) – (Were you/Was
NAME) going to (NAME OF
SCHOOL) full-time or part-time?
(NLTS –
S5f)
SCHOOL 2
SCHOOL 3
FULL-TIME ..............................................1
FULL-TIME .............................................. 1
FULL-TIME ..............................................1
PART-TIME .............................................2
PART-TIME ............................................. 2
PART-TIME .............................................2
YES ..........................................................1
YES ......................................................... 1
YES ..........................................................1
NO............................................................0
NO ........................................................... 0
NO............................................................0
GRADUATED ..........................................01
GRADUATED.......................................... 01
GRADUATED ..........................................01
FINISHED CLASSES
WANTED TO TAKE .................................02
FINISHED CLASSES
WANTED TO TAKE ................................ 02
FINISHED CLASSES
WANTED TO TAKE.................................02
PROBE: By full-time, we mean
taking a full course load of 12 credits
or more at a time or being in class at
least 12 hours per week.
I.C4 (Are you/Is NAME) – (Were you/Was
NAME) working toward a diploma,
certificate, or license from this
school?
(NLTS –
S3r)
I.C5 IF NO LONGER ATTENDING
(NAME OF SCHOOL), ASK: Why
(NLTS – did (you/he/she) stop going to
SC1)
(NAME OF SCHOOL)?
TRANSPORTATION PROBLEMS ..........03
TRANSPORTATION PROBLEMS .......... 03
TRANSPORTATION PROBLEMS ..........03
PROBE: Why (are you/is NAME) no
longer taking classes at (NAME OF
SCHOOL)?
DIDN’T GET SERVICES NEEDED .........04
DIDN’T GET SERVICES NEEDED ........ 04
DIDN’T GET SERVICES NEEDED .........04
TOO EXPENSIVE/
COULDN’T AFFORD IT ..........................05
TOO EXPENSIVE/
COULDN’T AFFORD IT .......................... 05
TOO EXPENSIVE/
COULDN’T AFFORD IT ..........................05
PROBE: Did (you/NAME) graduate
or complete (your/his/her) classes, or
did (you/he/she) leave for some other
reason? What was the reason?
DIDN’T HAVE TIME; SCHEDULE
CONFLICT; CONFLICTS WITH
OTHER DEMANDS .................................06
DIDN’T HAVE TIME; SCHEDULE
CONFLICT; CONFLICTS WITH
OTHER DEMANDS................................. 06
DIDN’T HAVE TIME; SCHEDULE
CONFLICT; CONFLICTS WITH
OTHER DEMANDS .................................06
POOR GRADES/NOT DOING
WELL IN SCHOOL ..................................07
POOR GRADES/NOT DOING
WELL IN SCHOOL.................................. 07
POOR GRADES/NOT DOING
WELL IN SCHOOL ..................................07
DIDN’T LIKE SCHOOL ............................08
DIDN’T LIKE SCHOOL ........................... 08
DIDN’T LIKE SCHOOL ............................08
WANTED/NEEDED TO FIND A JOB ......09
WANTED/NEEDED TO FIND A JOB ..... 09
WANTED/NEEDED TO FIND A JOB ......09
OFFERED A JOB/CHOSE TO WORK ....10
OFFERED A JOB/CHOSE TO WORK ... 10
OFFERED A JOB/CHOSE TO WORK ....10
WANTED TO ENTER MILITARY ............11
WANTED TO ENTER MILITARY ........... 11
WANTED TO ENTER MILITARY ............11
DIDN’T GET IN TO THE PROGRAM
SM WANTED ...........................................12
DIDN’T GET IN TO THE PROGRAM
SM WANTED .......................................... 12
DIDN’T GET IN TO THE PROGRAM
SM WANTED ...........................................12
ILLNESS/DISABILITY;
TOO SICK TO GO ...................................13
ILLNESS/DISABILITY;
TOO SICK TO GO .................................. 13
ILLNESS/DISABILITY;
TOO SICK TO GO ...................................13
GOT MARRIED .......................................14
GOT MARRIED ....................................... 14
GOT MARRIED .......................................14
GOT PREGNANT OR HAD
A CHILD...................................................15
GOT PREGNANT OR HAD
A CHILD .................................................. 15
GOT PREGNANT OR HAD
A CHILD...................................................15
MOVED ....................................................16
MOVED ................................................... 16
MOVED ....................................................16
SCHOOL TOO DANGEROUS ................17
SCHOOL TOO DANGEROUS ................ 17
SCHOOL TOO DANGEROUS ................17
WANTED TO TRAVEL ............................18
WANTED TO TRAVEL ........................... 18
WANTED TO TRAVEL ............................18
FRIENDS WEREN’T IN SCHOOL/
FRIENDS WERE DROPPING OUT ........19
FRIENDS WEREN’T IN SCHOOL/
FRIENDS WERE DROPPING OUT ....... 19
FRIENDS WEREN’T IN SCHOOL/
FRIENDS WERE DROPPING OUT ........19
COULDN’T GET ALONG WITH
TEACHERS .............................................20
COULDN’T GET ALONG WITH
TEACHERS............................................. 20
COULDN’T GET ALONG WITH
TEACHERS .............................................20
COULDN’T GET ALONG WITH
OTHER STUDENTS ................................21
COULDN’T GET ALONG WITH
OTHER STUDENTS ............................... 21
COULDN’T GET ALONG WITH
OTHER STUDENTS................................21
COULDN’T GET CHILD CARE ...............22
COULDN’T GET CHILD CARE............... 22
COULDN’T GET CHILD CARE ...............22
PARENTS/FAMILY DID WANT
SM TO GO ...............................................23
PARENTS/FAMILY DID WANT
SM TO GO .............................................. 23
PARENTS/FAMILY DID WANT
SM TO GO ...............................................23
OTHER (SPECIFY) .................................24
OTHER (SPECIFY) ................................. 24
OTHER (SPECIFY) .................................24
PROBE: Any other reason?
LIST NOT READ TO
RESPONDENT.
CHECK ALL THAT APPLY:
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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I.D1
(YTD-14)
DO NOT ASK IF YOUTH IS CURRENTLY IN HIGH SCHOOL:
What is the highest grade or year of school that (you have/NAME has) finished?
8TH GRADE OR LESS ................................ 1
9TH GRADE/FRESHMAN IN HS ................. 2
10TH GRADE/SOPHOMORE IN HS ............ 3
11TH GRADE/JUNIOR IN HS ...................... 4
12TH GRADE/SENIOR IN HS...................... 5
SOME COLLEGE OR
TECHNICAL SCHOOL ................................. 6
COLLEGE OR TECHNICAL SCHOOL ......... 7
UNGRADED SCHOOL................................. 8
HOME SCHOOLED ..................................... 9
OTHER GRADE (SPECIFY) ........................ 10
DON‘T KNOW .............................................. d
REFUSED .................................................... r
PROGRAMMER NOTE: IF YOUTH REPORTED HAVING A HIGH SCHOOL DIPLOMA AT
12M (I.D2=1), SKIP TO I.D3
I.D2
(YTD-15)
ASK IF NOT CURRENTLY IN HIGH SCHOOL:
(Do you/Does NAME) have a high school diploma, a GED, also known as a graduate
equivalency degree, a certificate of completion, or (do you/does [he/she]) have none of
these?
CODE LEFT WITHOUT GRADUATING AS “NONE OF THESE.”
HIGH SCHOOL DIPLOMA ........................... 1
GED ............................................................. 2
CERTIFICATE OF COMPLETION ............... 3
NONE OF THESE ........................................ 4
DON‘T KNOW .............................................. d
REFUSED .................................................... r
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I.D3
ASK IF HIGHEST GRADE WAS COLLEGE OR TECHNICAL
(Do you/Does NAME) have a college degree or a technical certificate?
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
(GO TO SECTION II)
REFUSED .................................................... r
I.D4
ASK IF HAS A COLLEGE DEGREE OR TECHNICAL CERTIFICATE:
What college degrees or technical certificates do (you have/[he/she] has)?
READ IF NECESSARY. CODE ALL THAT APPLY
MASTERS OR HIGHER............................... 1
BACHELORS ............................................... 2
ASSOCIATES .............................................. 3
TECHNICAL CERTIFICATE (SPECIFY
AS MANY AS SAMPLE MEMBER HAS
EARNED) ..................................................... 4
DON‘T KNOW .............................................. d
REFUSED .................................................... r
I.D4_specify. How many technical certificates have you earned?
|
|
| CERTIFICATES
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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SECTION II: EMPLOYMENT
In this section, I will ask questions about jobs that (you/NAME) have had within the past
year. This includes any job or jobs you may currently have as well as jobs that ended
after (MONTH AND YEAR ONE YEAR AGO).
II.A1
(Have you/Has [he/she]) worked at a job or a business at any time within the past
year? Please include all jobs since (MONTH AND YEAR ONE YEAR AGO), even if
(you/NAME) only worked for a short time.
PROBE: Please include jobs that (you/Name) currently (have/has) as well as jobs that
ended within the past year. Also, please include jobs at which (you/Name) (are/is) or
(were/was) self-employed.
PROBES: A job is work either paid or unpaid other than work around the house.
A job could be a school sponsored job or a work study job.
Jobs include internships, apprenticeships and volunteer work even if
(you/NAME) didn‘t get paid.
A job could be working for a business or organization or work that
(you/he/she) do on (your/his/her) own such as babysitting or dog walking,
that (you get/NAME gets) paid to do.
Do not include chores that (you do/NAME does) around the house, even if
(you are/NAME is) paid to do them.
YES.............................................................. 1
NO ............................................................... 0 (GO TO II.F4)
DON‘T KNOW .............................................. d
REFUSED .................................................... r
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II.A1_num. How many jobs (have you /has NAME) had within the past year?
Please include jobs that (you/Name) currently (have/has) as well as jobs that ended
within the past year. Also, please include jobs at which (you/Name) (are/is) or
(were/was) self-employed or only worked at for a short period of time
PROBES: A job is work either paid or unpaid other than work around the house.
A job could be a school sponsored job or a work study job.
Jobs include internships, apprenticeships and volunteer work even if
(you/NAME) didn‘t get paid.
A job could be working for a business or organization or work that
(you/he/she) do on (your/his/her) own such as babysitting or dog walking,
that (you get/NAME gets) paid to do.
Do not include chores that (you do/NAME does) around the house, even if
(you are/NAME is) paid to do them.
|
|
| JOBS
DON‘T KNOW .............................................. d
REFUSED .................................................... r
IF II.A1=1 and II.A1_num=DK or R, TREAT AS 1 JOB. IF II.A1=D or R and II.A1_num=D or
R, skip to II.F4.
(II.A2 thru II.E2 ASKED FOR EACH JOB AT II.A1 – NOTE IN REFERENCE TO THIS
FOLLOWING II.E2)
II. A2 ONE JOB: What is the name of the place where [you work or worked at/NAME works or
worked at]?
IF II.A1_num>1 FIRST JOB: Now, I would like to get more information about each job [you
have/NAME has] has since [RA date]. I'd like to start with the [your/his/her] most recent job and
work backwards. What is the name of the place [you/NAME] currently work at or worked at
most recently? Please include jobs at which [you are /he is / she is] self-employed.
IF II.A1_num>1 2nd, 3rd, 4th,...x JOBs: Now, I would like to get more information about each of
the other jobs [you have/NAME has] had since [RA date]. What is the name of the second
place [you have/he has/she has] worked at since [RA Date]? Please include jobs at which [you
are /NAME is] self-employed.
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JOB 1
CURRENT/MAIN JOB/OR MOST RECENT JOB
II.A2 What is the name of the place where
(you/he/she) (work/worked)?
PROBE: Please include jobs at which (you
are/NAME is) self-employed.
II.B1
(Do you/Does NAME) currently work at (NAME
OF PLACE)?
JOB 2
NEXT MOST RECENT JOB
NAME OR PLACE:__________________________
NAME OR PLACE:__________________________
_________________________________________
_________________________________________
OR
OR
SELF-EMPLOYED ........................... 99
SELF-EMPLOYED .......................... 99
YES .................................................................................. 1
YES ...................................................................................1
NO .................................................................................... 0
NO.....................................................................................0
IF SELF-EMPLOYED: (Do you/Does NAME)
still currently do this job? (GO TO II.B3)
II.B2 What does (NAME OR PLACE) make or do?
PROBE: What kind of place is (NAME OR
PLACE)?
II.B3 What (do/did) (you/he/she) do at (NAME OR
PLACE)?
PROBE: What (are/were) (your/his/her)
responsibilities?
PROBE: What kinds of things (have you/ has
[he/she]) done there?
PROBE: Tell me what (you/he/she) (do/did)
when (you/he/she) (get/got) to work? After that?
Then what?
IF SELF-EMPLOYED, ASK: What (do/did)
(you/he/she) do?
__________________________________________
__________________________________________
__________________________________________
__________________________________________
RECORD VERBATIM AND CODE:
RECORD VERBATIM AND CODE:
_______________________________________________
_______________________________________________
ASSEMBLY WORK (SORTING STUFFING) .................. 1
ASSEMBLY WORK (SORTING STUFFING) ...................1
ANIMAL CARE (DOG WALKING,
VETERINARY HELPER) ................................................. 2
ANIMAL CARE (DOG WALKING,
VETERINARY HELPER) ..................................................2
CAMP COUNSELOR ....................................................... 3
CAMP COUNSELOR .......................................................3
CASHIER—GROCERY STORE,
FAST FOOD PLACE, ETC. ............................................. 4
CASHIER—GROCERY STORE,
FAST FOOD PLACE, ETC. ..............................................4
CHILD CARE—BABYSITTING/MOTHERS HELPER ..... 5
CHILD CARE—BABYSITTING/MOTHERS HELPER .....5
CLEANING—JANITOR/MAID ......................................... 6
CLEANING—JANITOR/MAID ..........................................6
CLERICAL—FILING, RECEPTIONIST,
SECRETARY, TYPING.................................................... 7
CLERICAL—FILING, RECEPTIONIST,
SECRETARY, TYPING ....................................................7
COMPUTER WORK—DATA ENTRY/PROGRAMMING/
WEB PAGE DEVELOPMENT ........................................8
COMPUTER WORK—DATA ENTRY/PROGRAMMING/
WEB PAGE DEVELOPMENT ........................................ 8
DELIVERY—OF FOOD OR NEWSPAPERS
OR PRESCRIPTIONS ..................................................... 9
DELIVERY—OF FOOD OR NEWSPAPERS
OR PRESCRIPTIONS ......................................................9
FARM WORK ................................................................... 10
FOOD SERVICE—BUS BOY, WAITER, COOK ............. 11
FARM WORK ...................................................................10
FOOD SERVICE—BUS BOY, WAITER, COOK..............11
GARDENING AND GROUNDS MAINTENANCE............ 12
GARDENING AND GROUNDS MAINTENANCE ............12
GAS STATION ATTENDANT .......................................... 13
GAS STATION ATTENDANT...........................................13
HEALTH CARE AIDE—PERSONAL CARE
ATTENDANT, NURSES AIDE ......................................... 14
HEALTH CARE AIDE—PERSONAL CARE
ATTENDANT, NURSES AIDE .........................................14
MECHANIC (AUTO REPAIR) .......................................... 15
MECHANIC (AUTO REPAIR) ..........................................15
RETAIL SALES ................................................................ 16
RETAIL SALES ................................................................16
SKILLED LABOR APPRENTICE—PLUMBER,
CARPENTER, ELECTRICIAN ......................................... 17
SKILLED LABOR APPRENTICE—PLUMBER,
CARPENTER, ELECTRICIAN .........................................17
SPORTS RELATED—UMPIRE, CADDY,
REFEREE, COACH, LIFEGUARD .................................. 18
SPORTS RELATED—UMPIRE, CADDY,
REFEREE, COACH, LIFEGUARD ...................................18
STOCK CLERK—GROCERY STORE
OR DRUG STORE........................................................... 19
STOCK CLERK—GROCERY STORE
OR DRUG STORE ...........................................................19
USHER—MOVIE THEATER ........................................... 20
USHER—MOVIE THEATER ............................................20
OTHER (SPECIFY).......................................................... 21
OTHER (SPECIFY) ..........................................................21
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
Prepared by Mathematica Policy Research, Inc.
10
(REV—1/7/09)
JOB 3
NEXT MOST RECENT JOB
JOB 4
NEXT MOST RECENT JOB
JOB 5
NEXT MOST RECENT JOB
NAME OR PLACE:__________________________
NAME OR PLACE:__________________________
NAME OR PLACE:__________________________
_________________________________________
_________________________________________
_________________________________________
OR
OR
OR
SELF-EMPLOYED .......................... 99
SELF-EMPLOYED ........................... 99
SELF-EMPLOYED .......................... 99
YES .................................................................................. 1
YES .................................................................................. 1
YES .................................................................................. 1
NO.................................................................................... 0
NO .................................................................................... 0
NO.................................................................................... 0
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
RECORD VERBATIM AND CODE:
RECORD VERBATIM AND CODE:
RECORD VERBATIM AND CODE:
_______________________________________________
_______________________________________________
_______________________________________________
ASSEMBLY WORK (SORTING STUFFING) .................. 1
ASSEMBLY WORK (SORTING STUFFING) .................. 1
ASSEMBLY WORK (SORTING STUFFING) .................. 1
ANIMAL CARE (DOG WALKING,
VETERINARY HELPER) ................................................. 2
ANIMAL CARE (DOG WALKING,
VETERINARY HELPER) ................................................. 2
ANIMAL CARE (DOG WALKING,
VETERINARY HELPER) ................................................. 2
CAMP COUNSELOR ...................................................... 3
CAMP COUNSELOR ....................................................... 3
CAMP COUNSELOR ...................................................... 3
CASHIER—GROCERY STORE,
FAST FOOD PLACE, ETC. ............................................. 4
CASHIER—GROCERY STORE,
FAST FOOD PLACE, ETC. ............................................. 4
CASHIER—GROCERY STORE,
FAST FOOD PLACE, ETC. ............................................. 4
CHILD CARE—BABYSITTING/MOTHERS HELPER .... 5
CHILD CARE—BABYSITTING/MOTHERS HELPER ..... 5
CHILD CARE—BABYSITTING/MOTHERS HELPER .... 5
CLEANING—JANITOR/MAID ......................................... 6
CLEANING—JANITOR/MAID.......................................... 6
CLEANING—JANITOR/MAID ......................................... 6
CLERICAL—FILING, RECEPTIONIST,
SECRETARY, TYPING ................................................... 7
CLERICAL—FILING, RECEPTIONIST,
SECRETARY, TYPING.................................................... 7
CLERICAL—FILING, RECEPTIONIST,
SECRETARY, TYPING ................................................... 7
COMPUTER WORK—DATA ENTRY/PROGRAMMING/
WEB PAGE DEVELOPMENT ........................................ 8
COMPUTER WORK—DATA ENTRY/PROGRAMMING/
WEB PAGE DEVELOPMENT.........................................8
COMPUTER WORK—DATA ENTRY/PROGRAMMING/
WEB PAGE DEVELOPMENT ........................................ 8
DELIVERY—OF FOOD OR NEWSPAPERS
OR PRESCRIPTIONS ..................................................... 9
DELIVERY—OF FOOD OR NEWSPAPERS
OR PRESCRIPTIONS ..................................................... 9
DELIVERY—OF FOOD OR NEWSPAPERS
OR PRESCRIPTIONS ..................................................... 9
FARM WORK .................................................................. 10
FOOD SERVICE—BUS BOY, WAITER, COOK ............. 11
FARM WORK ................................................................... 10
FOOD SERVICE—BUS BOY, WAITER, COOK ............. 11
FARM WORK .................................................................. 10
FOOD SERVICE—BUS BOY, WAITER, COOK ............. 11
GARDENING AND GROUNDS MAINTENANCE ........... 12
GARDENING AND GROUNDS MAINTENANCE............ 12
GARDENING AND GROUNDS MAINTENANCE ........... 12
GAS STATION ATTENDANT .......................................... 13
GAS STATION ATTENDANT .......................................... 13
GAS STATION ATTENDANT.......................................... 13
HEALTH CARE AIDE—PERSONAL CARE
ATTENDANT, NURSES AIDE ........................................ 14
HEALTH CARE AIDE—PERSONAL CARE
ATTENDANT, NURSES AIDE ......................................... 14
HEALTH CARE AIDE—PERSONAL CARE
ATTENDANT, NURSES AIDE ........................................ 14
MECHANIC (AUTO REPAIR) ......................................... 15
MECHANIC (AUTO REPAIR) .......................................... 15
MECHANIC (AUTO REPAIR) ......................................... 15
RETAIL SALES................................................................ 16
RETAIL SALES ................................................................ 16
RETAIL SALES................................................................ 16
SKILLED LABOR APPRENTICE—PLUMBER,
CARPENTER, ELECTRICIAN ........................................ 17
SKILLED LABOR APPRENTICE—PLUMBER,
CARPENTER, ELECTRICIAN ......................................... 17
SKILLED LABOR APPRENTICE—PLUMBER,
CARPENTER, ELECTRICIAN ........................................ 17
SPORTS RELATED—UMPIRE, CADDY,
REFEREE, COACH, LIFEGUARD .................................. 18
SPORTS RELATED—UMPIRE, CADDY,
REFEREE, COACH, LIFEGUARD .................................. 18
SPORTS RELATED—UMPIRE, CADDY,
REFEREE, COACH, LIFEGUARD .................................. 18
STOCK CLERK—GROCERY STORE
OR DRUG STORE .......................................................... 19
STOCK CLERK—GROCERY STORE
OR DRUG STORE ........................................................... 19
STOCK CLERK—GROCERY STORE
OR DRUG STORE .......................................................... 19
USHER—MOVIE THEATER ........................................... 20
USHER—MOVIE THEATER ........................................... 20
USHER—MOVIE THEATER ........................................... 20
OTHER (SPECIFY) ......................................................... 21
OTHER (SPECIFY) .......................................................... 21
OTHER (SPECIFY) ......................................................... 21
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
Prepared by Mathematica Policy Research, Inc.
11
(REV—1/7/09)
JOB 1
CURRENT/MAIN JOB/OR MOST RECENT JOB
II.B4
When did (you/he/she) start
working at (NAME OR PLACE)?
IF SELF-EMPLOYED, SAY:
When did (you/he/she) start
working as a (JOB FROM II.B3)?
II.B5
START DATE:
| | | / 20 | | |
MONTH
YEAR
JOB 2
NEXT MOST RECENT JOB
START DATE:
| | | / 20 | | |
MONTH
YEAR
MORE THAN ONE YEAR AGO ............................... 9999
MORE THAN ONE YEAR AGO ............................... 9999
IF CURRENT JOB ASK: How did
(you/he/she) find this job?
NEWSPAPER AD ...................................................................1
NEWSPAPER AD .................................................................. 1
INTERNET ..............................................................................2
INTERNET ............................................................................. 2
PROBES: How did (you/he/she)
hear about this job?
EMPLOYMENT AGENCY (PRIVATE) ...................................3
EMPLOYMENT AGENCY (PRIVATE) .................................. 3
JOB PLACEMENT OFFICE AT SCHOOL .............................4
JOB PLACEMENT OFFICE AT SCHOOL............................. 4
FRIENDS OR RELATIVES .....................................................5
FRIENDS OR RELATIVES .................................................... 5
DIRECT APPLICATION TO EMPLOYER ..............................6
DIRECT APPLICATION TO EMPLOYER ............................. 6
VOC REHAB OR OTHER SERVICE AGENCY .....................7
VOC REHAB OR OTHER SERVICE AGENCY .................... 7
ONE STOP OR WORKFORCE DEVELOPMENT
CENTER (UNEMPLOYMENT OFFICE).................................8
ONE STOP OR WORKFORCE DEVELOPMENT
CENTER (UNEMPLOYMENT OFFICE) ................................ 8
THE YTD PROGRAM [FILL LOCAL NAMES) .......................9
THE YTD PROGRAM [FILL LOCAL NAMES) ...................... 9
OTHER (SPECIFY).................................................................10
OTHER (SPECIFY) ................................................................ 10
II.B6 How many hours per week (do/did
you) (does/did [he/she]) usually
work at this job?
USE THE FOLLOWING PROBES
TO CALCULATE HOURS
WORKED:
|
|
|
|
|
|
HOURS PER WEEK USUALLY WORKED
HOURS PER WEEK USUALLY WORKED
OR
OR
IF CANNOT ANSWER EXACT HOURS, PROBE FOR
RANGE: (Do you/Does NAME) think (you/he/she) work . . .
IF CANNOT ANSWER EXACT HOURS, PROBE FOR
RANGE: (Do you/Does NAME) think (you/he/she)
work . . .
Which days do (you/he/she) work?
What time do (you/he/she) start
work?
What time do (you/he/she) finish
work?
(Do you/Does NAME) take a break
for lunch?
Less than 10 hours per week?......................................... 1
II.C1 Next, I’d like to ask you some
questions about how ((you are) /
(he/she is) /(you were) / (he/she
was)] paid at (NAME or PLACE] ).
Hour, day, week, month, year .......................................... 1
Hour, day, week, month, year ......................................... 1
Things............................................................................... 2
Things .............................................................................. 2
Some other way (SPECIFY) ............................................ 3
Some other way (SPECIFY)............................................ 3
Unpaid .............................................................................. 4
Unpaid.............................................................................. 4
(Do you/Did you/Does NAME/Did
NAME) get paid by the hour or by
how many things (you/he/she)
(make/do/sell/makes/does/sells)?
10-20 hours per week? .................................................... 2
Less than 10 hours per week? ........................................ 1
21-30 hours per week? .................................................... 3
10-20 hours per week? .................................................... 2
Or more than 30 hours per week? ................................... 4
21-30 hours per week? .................................................... 3
Or more than 30 hours per week?................................... 4
PROBES: Are you paid a certain
amount per day, per week, per
month, or per year?
Do you get a salary?
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
Prepared by Mathematica Policy Research, Inc.
12
(REV—1/7/09)
JOB 3
NEXT MOST RECENT JOB
START DATE:
| | | / 20 | | |
MONTH
YEAR
JOB 4
NEXT MOST RECENT JOB
START DATE:
| | | / 20 | | |
MONTH
YEAR
JOB 5
NEXT MOST RECENT JOB
START DATE:
| | | / 20 | | |
MONTH
YEAR
MORE THAN ONE YEAR AGO ............................... 9999
MORE THAN ONE YEAR AGO ............................... 9999
MORE THAN ONE YEAR AGO
.................................................................................. 999
9
NEWSPAPER AD .................................................................. 1
NEWSPAPER AD................................................................... 1
NEWSPAPER AD .................................................................. 1
INTERNET.............................................................................. 2
INTERNET .............................................................................. 2
INTERNET.............................................................................. 2
EMPLOYMENT AGENCY (PRIVATE) ................................... 3
EMPLOYMENT AGENCY (PRIVATE) ................................... 3
EMPLOYMENT AGENCY (PRIVATE) ................................... 3
JOB PLACEMENT OFFICE AT SCHOOL ............................. 4
JOB PLACEMENT OFFICE AT SCHOOL ............................. 4
JOB PLACEMENT OFFICE AT SCHOOL ............................. 4
FRIENDS OR RELATIVES .................................................... 5
FRIENDS OR RELATIVES .................................................... 5
FRIENDS OR RELATIVES .................................................... 5
DIRECT APPLICATION TO EMPLOYER.............................. 6
DIRECT APPLICATION TO EMPLOYER .............................. 6
DIRECT APPLICATION TO EMPLOYER.............................. 6
VOC REHAB OR OTHER SERVICE AGENCY .................... 7
VOC REHAB OR OTHER SERVICE AGENCY..................... 7
VOC REHAB OR OTHER SERVICE AGENCY .................... 7
ONE STOP OR WORKFORCE DEVELOPMENT
CENTER (UNEMPLOYMENT OFFICE) ................................ 8
ONE STOP OR WORKFORCE DEVELOPMENT
CENTER (UNEMPLOYMENT OFFICE) ................................ 8
ONE STOP OR WORKFORCE DEVELOPMENT
CENTER (UNEMPLOYMENT OFFICE) ................................ 8
THE YTD PROGRAM [FILL LOCAL NAMES) ....................... 9
THE YTD PROGRAM [FILL LOCAL NAMES) ....................... 9
THE YTD PROGRAM [FILL LOCAL NAMES) ....................... 9
OTHER (SPECIFY) ................................................................ 10
OTHER (SPECIFY) ................................................................ 10
OTHER (SPECIFY) ................................................................ 10
|
|
|
|
|
|
|
|
|
HOURS PER WEEK USUALLY WORKED
HOURS PER WEEK USUALLY WORKED
HOURS PER WEEK USUALLY WORKED
OR
OR
OR
IF CANNOT ANSWER EXACT HOURS, PROBE FOR
RANGE: (Do you/Does NAME) think (you/he/she) work . . .
IF CANNOT ANSWER EXACT HOURS, PROBE FOR
RANGE: (Do you/Does NAME) think (you/he/she)
work . . .
IF CANNOT ANSWER EXACT HOURS, PROBE FOR
RANGE: (Do you/Does NAME) think (you/he/she)
work . . .
10-20 hours per week? .................................................... 2
Less than 10 hours per week?......................................... 1
Less than 10 hours per week? ......................................... 1
21-30 hours per week? .................................................... 3
10-20 hours per week? .................................................... 2
10-20 hours per week? .................................................... 2
Or more than 30 hours per week?................................... 4
21-30 hours per week? .................................................... 3
21-30 hours per week? .................................................... 3
Or more than 30 hours per week? ................................... 4
Or more than 30 hours per week? ................................... 4
Hour ................................................................................. 1
Hour.................................................................................. 1
Hour.................................................................................. 1
Things .............................................................................. 2
Things............................................................................... 2
Things............................................................................... 2
Some other way (SPECIFY) ............................................ 3
Some other way (SPECIFY) ............................................ 3
Some other way (SPECIFY) ............................................ 3
Unpaid.............................................................................. 4
Unpaid .............................................................................. 4
Unpaid .............................................................................. 4
Less than 10 hours per week? ........................................ 1
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
Prepared by Mathematica Policy Research, Inc.
13
(REV—1/7/09)
JOB 1
CURRENT/MAIN JOB/OR MOST RECENT JOB
II.C2 About how much (are you/is NAME) paid
on this job?
PROBES: How much (do
you/does[he/she]) get paid for each thing
(you/he/she)
(make/do/sell/makes/does/sells)?
$|
|
|
|.|
|
| per hour/thing
|
|
| things/hour
$|
|
|
|.|
|
|
|
|
|.|
|
| per hour/thing
|
|
| things/hour
or
| per day .....................................1
$|
|
|
|.|
|
| per day .....................................1
per week...................................2
per week ..................................2
every other week......................3
every other week .....................3
twice a month ...........................4
twice a month ...........................4
once a month ...........................5
once a month ...........................5
OTHER (SPECIFY)..................6
OTHER (SPECIFY) .................6
Net pay .............................................................................1
Net pay .............................................................................1
Before taxes......................................................................2
Before taxes .....................................................................2
Is that the amount of pay (you
bring/[he/she] brings) home or is that the
amount of (your/his/her) pay before
taxes are taken out?
II.C3 (Does/Did) this job offer. . .
II.C4 Sometimes people need changes made
at their job to help them with their work
or to help them try new things. These
could be changes to their workspace,
work schedule, tasks or responsibilities.
$|
or
How many things (do you/does [he/she])
(make/do/sell) in an (hour/day/week)?
PROGRAMMER: SKIP NET
PAY/BEFORE TAXES IF PAID HOURLY
OR BY THE THING
|
JOB 2
NEXT MOST RECENT JOB
YES
NO
YES
NO
Health insurance?.......................................... 1
0
Health insurance? ......................................... 1
0
Paid vacation or sick leave? .......................... 1
0
Paid vacation or sick leave? .......................... 1
0
Any kind of pension or retirement plan?........ 1
0
Any kind of pension or retirement plan? ....... 1
0
YES ...................................................................................1
YES...................................................................................1
NO.....................................................................................0
NO ....................................................................................0
II.C5 Did (JOB FROM E4) make these
changes for (you/him/her)?
YES ...................................................................................1
YES...................................................................................1
NO.....................................................................................0
NO ....................................................................................0
II.C6 What change did they make?
WHEELCHAIR ACCESSIBILITY.....................................1
CUSTOM DESIGNED WORKSPACE ............................2
COMPUTER-RELATED ASSISTIVE
TECHNOLOGY DEVICE .................................................3
COMMUNICATION-RELATED ASSISTIVE
TECHNOLOGY DEVICE .................................................4
CHANGE IN WORK SCHEDULE....................................5
CHANGE IN JOB TASKS/RESPONSIBILITIES .............6
OTHER (SPECIFY) .........................................................7
WHEELCHAIR ACCESSIBILITY ....................................1
CUSTOM DESIGNED WORKSPACE ............................2
COMPUTER-RELATED ASSISTIVE
TECHNOLOGY DEVICE .................................................3
COMMUNICATION-RELATED ASSISTIVE
TECHNOLOGY DEVICE .................................................4
CHANGE IN WORK SCHEDULE ...................................5
CHANGE IN JOB TASKS/RESPONSIBILITIES .............6
OTHER (SPECIFY) .........................................................7
.........................................................................................
.........................................................................................
Since (you/NAME) started
(your/his/her) job, (have you/has
he/she) needed any sort of changes
made at [JOB FROM E4] because of
(your/his/her) disability or health
problem?
PROBE: Did they make any other
changes?
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
Prepared by Mathematica Policy Research, Inc.
14
(REV—1/7/09)
JOB 3
NEXT MOST RECENT JOB
$|
|
|
|
|.|
|
| per hour/thing
|
|
| things/hour
JOB 4
NEXT MOST RECENT JOB
$|
|
|.|
|
|
|
or
$|
|
|
|.|
|
|
|
JOB 5
NEXT MOST RECENT JOB
per hour/thing
$|
| things/hour
|
|
|
or
| per day..................................... 1
$|
|
|
|.|
|
|.|
|
| per hour/thing
|
|
| things/hour
or
| per day..................................... 1
$|
|
|
|.|
|
| per day..................................... 1
per week .................................. 2
per week .................................. 2
per week .................................. 2
every other week ..................... 3
every other week ..................... 3
every other week ..................... 3
twice a month .......................... 4
twice a month .......................... 4
twice a month .......................... 4
once a month ........................... 5
once a month ........................... 5
once a month........................... 5
OTHER (SPECIFY) ................. 6
OTHER (SPECIFY) ................. 6
OTHER (SPECIFY) ................. 6
Net pay ............................................................................. 1
Net pay ............................................................................. 1
Net pay ............................................................................. 1
Before taxes ..................................................................... 2
Before taxes ..................................................................... 2
Before taxes ..................................................................... 2
YES
NO
YES
NO
YES
NO
Health insurance? .......................................... 1
0
Health insurance? .......................................... 1
0
Health insurance? .......................................... 1
0
Paid vacation or sick leave? .......................... 1
0
Paid vacation or sick leave? .......................... 1
0
Paid vacation or sick leave? .......................... 1
0
Any kind of pension or retirement plan? ........ 1
0
Any kind of pension or retirement plan? ........ 1
0
Any kind of pension or retirement plan? ........ 1
0
YES .................................................................................. 1
YES .................................................................................. 1
YES .................................................................................. 1
NO .................................................................................... 0
NO .................................................................................... 0
NO .................................................................................... 0
YES .................................................................................. 1
YES .................................................................................. 1
YES .................................................................................. 1
NO .................................................................................... 0
NO .................................................................................... 0
NO .................................................................................... 0
WHEELCHAIR ACCESSIBILITY .................................... 1
CUSTOM DESIGNED WORKSPACE ............................ 2
COMPUTER-RELATED ASSISTIVE
TECHNOLOGY DEVICE ................................................ 3
COMMUNICATION-RELATED ASSISTIVE
TECHNOLOGY DEVICE ................................................ 4
CHANGE IN WORK SCHEDULE ................................... 5
CHANGE IN JOB TASKS/RESPONSIBILITIES ............. 6
OTHER (SPECIFY) ......................................................... 7
WHEELCHAIR ACCESSIBILITY .................................... 1
CUSTOM DESIGNED WORKSPACE ............................ 2
COMPUTER-RELATED ASSISTIVE
TECHNOLOGY DEVICE ................................................ 3
COMMUNICATION-RELATED ASSISTIVE
TECHNOLOGY DEVICE ................................................ 4
CHANGE IN WORK SCHEDULE ................................... 5
CHANGE IN JOB TASKS/RESPONSIBILITIES ............. 6
OTHER (SPECIFY) ......................................................... 7
WHEELCHAIR ACCESSIBILITY .................................... 1
CUSTOM DESIGNED WORKSPACE ............................ 2
COMPUTER-RELATED ASSISTIVE
TECHNOLOGY DEVICE ................................................ 3
COMMUNICATION-RELATED ASSISTIVE
TECHNOLOGY DEVICE ................................................ 4
CHANGE IN WORK SCHEDULE ................................... 5
CHANGE IN JOB TASKS/RESPONSIBILITIES............. 6
OTHER (SPECIFY)......................................................... 7
.........................................................................................
.........................................................................................
........................................................................................
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
Prepared by Mathematica Policy Research, Inc.
15
(REV—1/7/09)
JOB 1
CURRENT/MAIN JOB/OR MOST RECENT JOB
II.D1 At (your/his/her) job, do most of the
other workers have disabilities?
JOB 2
NEXT MOST RECENT JOB
YES .................................................................................. 1
YES...................................................................................1
NO .................................................................................... 0
NO ....................................................................................0
II.D2 Is (NAME OR PLACE) part of any
school sponsored work activities like a
work-study job, an internship, or part
of a school-based business?
YES .................................................................................. 1
YES...................................................................................1
NO .................................................................................... 0
NO ....................................................................................0
II.D4 When did (you/he/she) stop working
at . . .
END DATE:
END DATE:
Probe: In which month did
(you/he/she) (start/stop)?
Probe: What was the weather like?
Probe: Was it around a holiday or
(your/his/her) birthday?
Probe: Was it during the school year
or during the summer?
Probe: (Is/Was) this a summer job?
Interview note: If respondent report
still working at this job, reset II.B1 to
1.
II.E1
IF NOT CURRENT JOB, ASK: Why
did (you/he/she) leave this job?
PROBE: Why (are you/is NAME) no
longer working (NAME OR PLACE)?
PROBE FOR MAIN REASON.
| | | / 20 | | |
MONTH
YEAR
| | | / 20 | | |
MONTH
YEAR
STILL WORKING ..................................................... 9999
STILL WORKING ..................................................... 9999
IF CANNOT ANSWER EXACT DATES, PROBE FOR
TIME WORKED AT THIS JOB: How long (have
[you/he/she] worked/did [you/he/she] work) at
(NAME OR PLACE)?
PROBE: Your best estimate is fine.
IF CANNOT ANSWER EXACT DATES, PROBE FOR
TIME WORKED AT THIS JOB: How long (have
[you/he/she] worked/did [you/he/she] work) at
(NAME OR PLACE)?
PROBE: Your best estimate is fine.
|
|
| MONTHS ......................................................... 1
|
|
| MONTHS .........................................................1
|
|
| WEEKS .......................................................... 2
|
|
| WEEKS...........................................................2
OR
OR
IF CANNOT ANSWER TIME WORKED, PROBE FOR
RANGE: (Do you/Does NAME) think (you/he/she) worked
at (NAME OR PLACE) . . .
IF CANNOT ANSWER TIME WORKED, PROBE FOR
RANGE: (Do you/Does NAME) think (you/he/she) worked
at (NAME OR PLACE) . . .
Three months of less?...................................................... 1
Three months of less? ......................................................1
4-6 months? ..................................................................... 2
4-6 months?......................................................................2
Or more than 6 months? .................................................. 3
Or more than 6 months? ..................................................3
Job was too hard ........................................................... 1
Job was too easy .......................................................... 2
Found a better job ......................................................... 3
Temporary job ended .................................................... 4
Went back to school ...................................................... 5
Job did not pay enough................................................. 6
Does not need the money ............................................. 7
Did not like boss ............................................................ 8
Did not like coworkers ................................................... 9
Transportation problems ............................................... 10
I moved to far ................................................................ 11
Job moved too far ......................................................... 12
Fired/performance problems ......................................... 13
Health reasons .............................................................. 14
Employer wouldn’t provide accommodations
needed to succeed at job .............................................. 15
Had a baby .................................................................... 16
Family obligations ......................................................... 17
Did not want to loose disability or other benefits .......... 18
Parents do not want youth to work ............................... 19
Youth does not want to work......................................... 20
Job was too hard ........................................................... 1
Job was too easy ........................................................... 2
Found a better job ......................................................... 3
Temporary job ended .................................................... 4
Went back to school ...................................................... 5
Job did not pay enough ................................................. 6
Does not need the money ............................................. 7
Did not like boss ............................................................ 8
Did not like coworkers ................................................... 9
Transportation problems ............................................... 10
I moved to far................................................................. 11
Job moved too far .......................................................... 12
Fired/performance problems ......................................... 13
Health reasons .............................................................. 14
Employer wouldn’t provide accommodations
needed to succeed at job .............................................. 15
Had a baby .................................................................... 16
Family obligations .......................................................... 17
Did not want to loose disability or other benefits .......... 18
Parents do not want youth to work ................................ 19
Youth does not want to work ......................................... 20
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
Prepared by Mathematica Policy Research, Inc.
16
(REV—1/7/09)
JOB 3
NEXT MOST RECENT JOB
JOB 4
NEXT MOST RECENT JOB
JOB 5
NEXT MOST RECENT JOB
YES .................................................................................. 1
YES .................................................................................... 1
YES ...................................................................................1
NO.................................................................................... 0
NO...................................................................................... 0
NO.....................................................................................0
YES .................................................................................. 1
YES .................................................................................... 1
YES ...................................................................................1
NO.................................................................................... 0
NO...................................................................................... 0
NO.....................................................................................0
END DATE:
END DATE:
END DATE:
| | | / 20 | | |
MONTH
YEAR
| | | / 20 | | |
MONTH
YEAR
| | | / 20 | | |
MONTH
YEAR
STILL WORKING...................................................... 9999
STILL WORKING ..................................................... 9999
STILL WORKING ..................................................... 9999
IF CANNOT ANSWER EXACT DATES, PROBE FOR TIME
WORKED AT THIS JOB: How long (have [you/he/she]
worked/did [you/he/she] work) at (NAME OR PLACE)?
PROBE: Your best estimate is fine.
IF CANNOT ANSWER EXACT DATES, PROBE FOR TIME
WORKED AT THIS JOB: How long (have [you/he/she]
worked/did [you/he/she] work) at (NAME OR PLACE)?
PROBE: Your best estimate is fine.
IF CANNOT ANSWER EXACT DATES, PROBE FOR TIME
WORKED AT THIS JOB: How long (have [you/he/she]
worked/did [you/he/she] work) at (NAME OR PLACE)?
PROBE: Your best estimate is fine.
|
|
| MONTHS ........................................................ 1
|
|
| MONTHS .........................................................1
|
|
| MONTHS .........................................................1
|
|
| WEEKS .......................................................... 2
|
|
| WEEKS ...........................................................2
|
|
| WEEKS ...........................................................2
OR
OR
OR
IF CANNOT ANSWER TIME WORKED, PROBE FOR
RANGE: (Do you/Does NAME) think (you/he/she) worked at
(NAME OR PLACE) . . .
IF CANNOT ANSWER TIME WORKED, PROBE FOR
RANGE: (Do you/Does NAME) think (you/he/she) worked at
(NAME OR PLACE) . . .
IF CANNOT ANSWER TIME WORKED, PROBE FOR
RANGE: (Do you/Does NAME) think (you/he/she) worked at
(NAME OR PLACE) . . .
Three months of less? ..................................................... 1
Three months of less? ......................................................1
Three months of less? ......................................................1
4-6 months? ..................................................................... 2
4-6 months? ......................................................................2
4-6 months? ......................................................................2
Or more than 6 months?.................................................. 3
Or more than 6 months? ..................................................3
Or more than 6 months? ..................................................3
Job was too hard ...........................................................1
Job was too easy ...........................................................2
Found a better job .........................................................3
Temporary job ended ....................................................4
Went back to school ......................................................5
Job did not pay enough .................................................6
Does not need the money .............................................7
Did not like boss ............................................................8
Did not like coworkers ...................................................9
Transportation problems................................................10
I moved to far .................................................................11
Job moved too far ..........................................................12
Fired/performance problems .........................................13
Health reasons...............................................................14
Employer wouldn’t provide accommodations
needed to succeed at job ..............................................15
Had a baby ....................................................................16
Family obligations ..........................................................17
Did not want to loose disability or other benefits...........18
Parents do not want youth to work ................................19
Youth does not want to work .........................................20
Job was too hard ............................................................... 1
Job was too easy ............................................................... 2
Found a better job ............................................................. 3
Temporary job ended ........................................................ 4
Went back to school .......................................................... 5
Job did not pay enough ..................................................... 6
Does not need the money ................................................. 7
Did not like boss ................................................................ 8
Did not like coworkers ....................................................... 9
Transportation problems ................................................... 10
I moved to far..................................................................... 11
Job moved too far .............................................................. 12
Fired/performance problems ............................................. 13
Health reasons .................................................................. 14
Employer wouldn’t provide accommodations
needed to succeed at job .................................................. 15
Had a baby ........................................................................ 16
Family obligations .............................................................. 17
Did not want to loose disability or other benefits............... 18
Parents do not want youth to work .................................... 19
Youth does not want to work ............................................. 20
Job was too hard ...........................................................1
Job was too easy ...........................................................2
Found a better job .........................................................3
Temporary job ended ....................................................4
Went back to school ......................................................5
Job did not pay enough .................................................6
Does not need the money .............................................7
Did not like boss ............................................................8
Did not like coworkers ...................................................9
Transportation problems ...............................................10
I moved to far .................................................................11
Job moved too far ..........................................................12
Fired/performance problems .........................................13
Health reasons ..............................................................14
Employer wouldn’t provide accommodations
needed to succeed at job ..............................................15
Had a baby ....................................................................16
Family obligations ..........................................................17
Did not want to loose disability or other benefits...........18
Parents do not want youth to work ................................19
Youth does not want to work .........................................20
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
Prepared by Mathematica Policy Research, Inc.
17
(REV—1/7/09)
JOB 1
CURRENT/MAIN JOB/OR MOST RECENT JOB
II.E2
II.E3
II.E4
II.E5
JOB 2
NEXT MOST RECENT JOB
Overall, how happy
([are/were] you/[is/was] NAME) with
(your/his/her) job at (JOB FROM E4)?
Would (you/he/she) say . . .
very happy,.................................................................. 1
very happy, ................................................................. 1
a little happy, or........................................................... 2
a little happy, or .......................................................... 2
not happy? .................................................................. 3
not happy? .................................................................. 3
IF CURRENT JOB, ASK: Does
(your/his/her) job make good use of your
skills and abilities?
YES ............................................................................. 1
IF CURRENT JOB, ASK: (Do you/Does
NAME) think (your/his/her) job is very
interesting, somewhat interesting, or
boring?
IF CURRENT JOB, ASK: If (you/NAME)
had the chance would you get a different
job?
II.F1.
NO ............................................................................... 0
VERY INTERESTING, ................................................ 1
SOMEWHAT INTERESTING ..................................... 2
BORING, ..................................................................... 3
YES ............................................................................. 1
NO ............................................................................... 0
CONTINUE WITH OTHER JOB(S) OR
COMPLETE JOB GRID.
CONTINUE WITH OTHER JOB(S) OR
COMPLETE JOB GRID.
NEXT JOB........................................ 1 GO TO JOB 2
NEXT JOB ....................................... 1 GO TO JOB 3
NO MORE JOBS.............................. 0 GO TO II.F2
NO MORE JOBS ............................. 0 GO TO II.F2
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
Prepared by Mathematica Policy Research, Inc.
18
(REV—1/7/09)
JOB 3
NEXT MOST RECENT JOB
JOB 4
NEXT MOST RECENT JOB
JOB 5
NEXT MOST RECENT JOB
very happy, .................................................................. 1
very happy, ................................................................. 1
very happy,.................................................................. 1
a little happy, or ........................................................... 2
a little happy, or .......................................................... 2
a little happy, or ........................................................... 2
not happy? .................................................................. 3
not happy? .................................................................. 3
not happy? .................................................................. 3
CONTINUE WITH OTHER JOB(S) OR
COMPLETE JOB GRID.
CONTINUE WITH OTHER JOB(S) OR
COMPLETE JOB GRID.
CONTINUE WITH OTHER JOB(S) OR
COMPLETE JOB GRID.
NEXT JOB ........................................ 1 GO TO JOB 4
NEXT JOB ....................................... 1 GO TO JOB 5
NEXT JOB ........................................ 1 GO TO JOB 6
NO MORE JOBS.............................. 0 GO TO II.F2
NO MORE JOBS ............................. 0 GO TO II.F2
NO MORE JOBS.............................. 0 GO TO II.F2
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
Prepared by Mathematica Policy Research, Inc.
19
(REV—1/7/09)
II.F2
Thank you for telling me about these jobs, I just want to be sure we haven‘t missed any
job (you/NAME) had in the past year. We just spoke about (your/NAME‘s) job at (LIST
JOBS). Did (you/NAME) have any other jobs during the past year, even ones that
lasted for just a short time?
PROBES: A job is work, either paid or unpaid, other than work around the house.
A job could be a school sponsored job or a work study job.
Jobs include internships, apprenticeships, and volunteer work, even if you
don't get paid.
A job could be working for a business or organization or work that
(you/he/she) do on (your/his/her) own such as babysitting or dog walking.
Do not include chores that (you do/NAME does) around the house, even if
(you are/NAME is) paid to do them.
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
(GO TO II.F4)
REFUSED .................................................... r
II.F2_num. How many other jobs did (you /NAME) have during the past year?
PROBE: Please do no include jobs you already told me about.
PROBE: That is since (month and year 1 year ago).
PROBE: Please include all jobs, even if (you/NAME) only worked for a short period of
time. Please include jobs at which (you/Name) (were/was) self-employed.
|
|
| JOBS
DON‘T KNOW .............................................. d (GO TO II.F4)
REFUSED .................................................... r (GO TO II.F4)
II.F3
Did any of these jobs last more than two weeks?
PROBE: So (you/NAME) had NUMBER job(s) that lasted less than two weeks?
YES.............................................................. 1 (GO BACK TO II.A2)
NO ............................................................... 0
DON‘T KNOW .............................................. d
REFUSED .................................................... r
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
Prepared by Mathematica Policy Research, Inc.
20
(REV—1/7/09)
II.F4
Next I would like you to think about the year before this year, that is from (month and
year 2 years ago) to (month and year 1 year ago). (Other than any jobs you have just
told me about) Did (you/NAME) work at a job or a business at any time in the year
before the past year?
PROBE:
Please include all jobs, even if (you/NAME) only worked for a short period
of time. Please include jobs at which (you/Name) (were/was) selfemployed.
PROBES: A job is work, either paid or unpaid, other than work around the house.
A job could be a school sponsored job or a work study job.
Jobs include internships, apprenticeships, and volunteer work, even if you
don't get paid.
A job could be working for a business or organization or work that
(you/he/she) do on (your/his/her) own such as babysitting or dog walking.
Do not include chores that (you do/NAME does) around the house, even if
(you are/NAME is) paid to do them.
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
(GO TO NOTE BEFORE II.G4)
REFUSED .................................................... r
II.F4_num. How many jobs did (you /NAME) have during the year before the past year?
PROBE: Please do no include jobs you already told me about.
PROBE: That is from (month and year 2 years ago) to (month and year 1 year ago).
PROBE: Was it one job, or more than one job. INTERVIEWER CONTINUE PROBING
TO GET NUMBER OF JOBS.
PROBE: Please include all jobs, even if (you/NAME) only worked for a short period of
time. Please include jobs at which (you/Name) (were/was) self-employed, like baby
sitting or cutting the lawn.
|
|
| JOBS (GO TO NOTE BEFORE II.G4)
DON‘T KNOW .............................................. d
REFUSED .................................................... r
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
Prepared by Mathematica Policy Research, Inc.
21
(REV—1/7/09)
II.F5
Did (you/ NAME) have 2 or 3 jobs, 4 or 5 jobs, or more than 5 jobs?
PROBE: That is from (month and year 2 years ago) to (month and year 1 year ago).
2 OR 3 ......................................................... 1
4 OR 5 ......................................................... 2
MORE THAN 5............................................. 3
DON‘T KNOW .............................................. d
REFUSED .................................................... r
NOTE: THERE IS NO II.G1 TO II.G3 IN THIS VERSION
IF CURRENTLY EMPLOYED GO TO SECTION III.
II.G4
(NBS-B28.)
ASK IF NOT CURRENTLY EMPLOYED:
(Have you/Has [he/she]) been looking for work during the last four weeks?
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
(GO TO II.G6)
REFUSED .................................................... r
II.G5
(NBS - B29.)
ASK IF LOOKING FOR WORK:
Next, I am going to read you a list of things that some people do to look for work.
Please tell me whether or not (you/NAME) did any of these things during the last four
weeks.
To look for work in the last four weeks, did (you/NAME) . . .
YES
NO
a. Contact (your/his/her) state‘s One Stop office, (CO: WIN Center),
Workforce Development office, or unemployment office? ........................
1
0
b. Ask friends or relatives? ..........................................................................
1
0
c. Look through job advertisements in a newspaper or on the internet? ......
1
0
d. Contact the State Vocational Rehabilitation Agency or
(STATE VR NAME)? ...............................................................................
1
0
e. Contact any employers in person, by mail, or by phone? ........................
1
0
Do anything else that I didn‘t mention? (SPECIFY: What was it?) .........
1
0
f.
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
Prepared by Mathematica Policy Research, Inc.
22
(REV—1/7/09)
GO TO SECTION III
II.G6
(NBS-B25.)
ASK IF NOT LOOKING FOR WORK:
I am going to read a list of reasons people do not work. For each, please tell me if it is
a reason why (you are/[he/she] is) not currently working. (Are you/Is NAME) not
working because . . .
READ IF NEEDED: I know (you are/[he/she] is) not able to work, but the study rules
require us to ask all respondents the same questions.
YES
NO
a. A physical or mental condition prevents (you/NAME) from
working?....................................................................................................
1
0
b. (You do/NAME does) not have reliable transportation to and from
work? ........................................................................................................
1
0
c. ASK IF CURRENTLY IN SCHOOL OR TRAINING PROGRAM:
(You are/NAME is) too busy with school to work? .....................................
1
0
d. (You are/NAME is) waiting to complete (your/his/her) education or
a training program? ...................................................................................
1
0
e. Workplaces are not accessible to people with (your/his/her)
disability? ..................................................................................................
1
0
f.
(You/NAME) do not want to lose benefits such as disability or
Medicaid? ..................................................................................................
1
II.G7
(NBS-B26.)
NA
0
Are there any other reasons why (you are/NAME is) not working that I didn‘t mention?
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
(GO TO SECTION III)
REFUSED .................................................... r
II.G8
What are they?
(NBS-B27.)
INTERVIEWER: ENTER VERBATIM RESPONSE.
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
Prepared by Mathematica Policy Research, Inc.
23
(REV—1/7/09)
SECTION III: SERVICE UTILIZATION
III.A1 My next questions are about services or training (you/NAME) might have received in
the past year. Since Since (MONTH AND YEAR 1 YEAR AGO), (have/has) . . .
(NLTS - F8
PROGRAMMER: IF YES ASK III.A2
YES
NO
1
0
1
0
PROBE: Career counseling, is where someone talked with
(you/NAME) about different types of jobs or careers,
and the training and skills they require?
c. (you/NAME) had help in finding or applying for a job, such as how
to find jobs available, fill out an application, write a resume, or go
for an interview? ...............................................................................
1
0
PROBE: A resume is a summary of (your/NAME‘s) job
qualifications.
d. (you/NAME) done any job shadowing? ............................................
1
0
PROBE: Job shadowing is a way for youth to learn about job
opportunities by tagging along with a worker to see what kind of
activities are performed as part of his or her particular job.
e. (you/NAME) had help in getting into a school or training program,
including helping with an application or interview? ...........................
1
0
a. (you/NAME) been taught skills needed for life, like counting
change, telling time or using public transportation? ..........................
b. (you/NAME) had career counseling, like help in learning which jobs
are a good match with (your/NAME‘s) skills and interests? ..............
PROBE: For example, where someone told (you/him/her) about
jobs that are available and how to apply for them? Or if
someone helped you complete an application for
college.
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
Prepared by Mathematica Policy Research, Inc.
24
(REV—1/7/09)
III.A2a IF III.A1a IS YES: In the last three months, how many times did (you/ NAME) get
training in skills needed for life?
PROBE: Like counting change, telling time, or using public transportation.
PROBE: Your best estimate is fine.
PROBE: Did (you/NAME) get this training this month, last month, the month before that.
IF YES: About how often each week during that month did (you/NAME) get this training.
|
|
| TIMES (GO TO III.A1b)
DON‘T KNOW .............................................. d
REFUSED .................................................... r
III.A3a In the past 3 months, would you say that (you/NAME) received this service or training …
More than once a week ................................ 1
About once a week....................................... 2
More than once a month .............................. 3
About once a month, or ................................ 4
Less often than that? .................................... 5
DON‘T KNOW .............................................. d
REFUSED .................................................... r
GO TO III.A1b
III.A2b IF III.A1b IS YES: In the last three months, how many times did (you/ NAME) get career
counseling?
PROBE: Like help in learning which jobs are a good match with (your/NAME‘s) skills
and interests.
PROBE: You best estimate is fine.
PROBE: Did (you/NAME) get this training this month, last month, the month before that.
IF YES: About how often each week during that month did (you/NAME) get this training.
|
|
| TIMES (GO TO III.A1c)
DON‘T KNOW .............................................. d
REFUSED .................................................... r
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
Prepared by Mathematica Policy Research, Inc.
25
(REV—1/7/09)
III.A3b In the past 3 months, would you say that (you/NAME) received this service or training …
More than once a week ................................ 1
About once a week....................................... 2
More than once a month .............................. 3
About once a month, or ................................ 4
Less often than that? .................................... 5
DON‘T KNOW .............................................. d
REFUSED .................................................... r
GO TO III.A1c
ASK III.A1c
III.A2c IF III.A1c IS YES: In the last three months, how many times did (you/ NAME) get help in
applying for a job?
PROBE: Such as how to find jobs available, fill out an application, write a resume, or go
for an interview.
PROBE: You best estimate is fine.
PROBE: Did (you/NAME) get this training this month, last month, the month before that.
IF YES: About how often each week during that month did (you/NAME) get this training.
|
|
| TIMES (GO TO III.A1d)
DON‘T KNOW .............................................. d
REFUSED .................................................... r
III.A3c In the past 3 months, would you say that (you/NAME) received this service or training …
More than once a week ................................ 1
About once a week....................................... 2
More than once a month .............................. 3
About once a month, or ................................ 4
Less often than that? .................................... 5
DON‘T KNOW .............................................. d
REFUSED .................................................... r
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
Prepared by Mathematica Policy Research, Inc.
26
(REV—1/7/09)
GO TO III.A1d
III.A2d IF III.A1d IS YES: In the last three months, how many times did (you/ NAME) do job
shadowing?
PROBE Job shadowing is a way for youth to learn about job opportunities by tagging
along with a worker to see what kind of activities are performed as part of his or her
particular job.
PROBE: You best estimate is fine.
PROBE: Did (you/NAME) get this training this month, last month, the month before that.
IF YES: About how often each week during that month did (you/NAME) get this training.
|
|
| TIMES (GO TO III.A1e)
DON‘T KNOW .............................................. d
REFUSED .................................................... r
III.A3d In the past 3 months, would you say that (you/NAME) received this service or training …
More than once a week ................................ 1
About once a week....................................... 2
More than once a month .............................. 3
About once a month, or ................................ 4
Less often than that? .................................... 5
DON‘T KNOW .............................................. d
REFUSED .................................................... r
GO TO III.A1e
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
Prepared by Mathematica Policy Research, Inc.
27
(REV—1/7/09)
III.A2e IF III.A1e IS YES: In the last three months, how many times did (you/ NAME) get help in
getting into a school or training program?
PROBE: For example, where someone told (you/him/her) about jobs that are available
and how to apply for them? Or if someone helped you complete an application for
college.
PROBE: You best estimate is fine.
PROBE: Did (you/NAME) get this training this month, last month, the month before that.
IF YES: About how often each week during that month did (you/NAME) get this training.
|
|
| TIMES (GO TO SECTION IV)
DON‘T KNOW .............................................. d
REFUSED .................................................... r
III.A3e In the past 3 months, would you say that (you/NAME) received this service or training …
More than once a week ................................ 1
About once a week....................................... 2
More than once a month .............................. 3
About once a month, or ................................ 4
Less often than that? .................................... 5
DON‘T KNOW .............................................. d
REFUSED .................................................... r
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
Prepared by Mathematica Policy Research, Inc.
28
(REV—1/7/09)
SECTION IV: SATISFACTION WITH YTD PROGRAM
THIS SECTION IS ASKED OF YOUTH IN TREATMENT GROUP WHO RECEIVED
YTD SERVICES. TREATMENT YOUTH WITH NO 12-MONTH INTERVIEW BEGIN
SECTION. TREATMENT YOUTH WHO DID NOT REPORT PARTICIPATION IN YTD
AT 12 MONTH SKIP TO SECTION V. CONTROL YOUTH SKIP TO SECTION V.
My next questions are about (your/NAMEs) experiences with (YTD PROGRAM). This is
the program through Social Security that helps young people with disabilities become
more independent. (You were/NAME was) eligible for this program beginning on
(RA DATE).
IV.E1.1 How much has (your/his/her) experience with (YTD PROGRAM) helped (you/him/her)
(OPENING
in the following areas?
DOORS –
S1Q16)
INTERVIEWER: READ STATEMENT. . .
Did (YTD PROGRAM) help (you/NAME) very much, somewhat, a little, or not at all?
IV.E1.2 IF NOT AT ALL, ASK: Did (you/he/she) need this help?
IV.E1.2
IV.E1.1
A
LITTLE
NOT
AT
ALL
Volunteered:
Did not
participate
in YTD
program
a. Getting workrelated
knowledge and
skills? ....................................................
1
2
3
4
5
1
0
b. Working
effectively with
others? ..................................................
1
2
3
4
5
1
0
c. Understanding
yourself? ...............................................
1
2
3
4
5
1
0
d. Developing
clearer career
goals? ...................................................
1
2
3
4
5
1
0
VERY
MUCH
SOME
WHAT
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
Prepared by Mathematica Policy Research, Inc.
29
YES
NO
(REV—1/7/09)
IV.E1.2
IV.E1.1
A
LITTLE
NOT
AT
ALL
Volunteered:
Did not
participate
in YTD
program
3
4
5
1
0
Developing a
sense of
confidence in
what (you
are/[he/she] is)
able to do? ............................................
1
2
3
4
5
1
0
g. Getting a job? ........................................
1
2
3
4
5
1
0
VERY
MUCH
SOME
WHAT
e. Gaining
information
about career
opportunities?........................................
1
2
f.
IV.E4
(NLTS - F9f) (Mod)
YES
NO
How useful has the help or services that (you/NAME) got from (YTD PROGRAM) been
in your life? Would you say . . .
Very useful, .................................................. 1
Somewhat useful,......................................... 2
Not very useful, or ........................................ 3
Not at all useful? .......................................... 4
DON‘T KNOW .............................................. d
REFUSED .................................................... r
IV.F1
Would you recommend (YTD PROGRAM) to a friend or family member?
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
REFUSED .................................................... r
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
Prepared by Mathematica Policy Research, Inc.
30
(REV—1/7/09)
SECTION V: AWARENESS OF WAIVERS AND INCENTIVES
V.A1
(EIDP-mod)
Next, I‘d like to ask you a few questions about your understanding about Social Security
benefits. Please tell me whether you agree or disagree with these statements about
Social Security benefits.
PROBE: If you‘re not sure, please just say so.
a.
b.
V.B1
(NBS –E3)
As soon as people start working they stop
getting their Social Security benefits
As soon as people start working they lose their
medical coverage
AGREE
NOT
SURE
DISAGREE
1
2
3
1
2
3
I‘m going to read a list of incentives and supports that Social Security offers to people
getting disability benefits, to encourage them to work. Please tell me if you have ever
heard of these incentives or supports or used any of them.
Have you ever heard of a Plan for Achieving Self-Support or a PASS Plan? This is a
Social Security incentive that lets (you/beneficiaries) set aside money to be used to help
(you/them) reach a work goal. The money set aside does not affect (your/their) benefits.
PROBE: Have you ever heard of this plan?
PROBE: If you‘re not sure, please just say so.
YES.............................................................. 1
NO/NOT SURE ............................................ 0
(GO TO V.C1)
REFUSED .................................................... r
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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V.B2
ASK IF HEARD OF PASS:
I‘m going to read a list of different work goals. Please tell me if you think a PASS Plan
could be used for each goal.
Could (you/NAME) use a PASS Plan to . . .
YES
1
1
1
1
NO
0
0
0
0
a.
b.
c.
d.
Pay for college?
Start (your/his/her) own business?
Pay a job coach?
Pay for accommodations (you/he/she) need(s)?
V.B3
ASK IF HEARD OF PASS:
(Have you/Has NAME) used a Plan for Achieving Self-Support or a PASS Plan since
(RA/DATE)?
(NBS-E4)
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
REFUSED .................................................... r
V.C1
(NBS-E5)
Mod.
Have you ever heard of the general earned income exclusion? This is an incentive
where Social Security does not count the first $65 of (your/NAME‘s) earnings in a month,
and then only counts a portion of (your/his/her) earnings when determining (your/his/her)
monthly payment.
PROBE:
Have you ever heard of this exclusion?
PROBE:
If you‘re not sure, please just say so.
YES.............................................................. 1
NO/NOT SURE ............................................ 0
(GO TO V.D1)
REFUSED .................................................... r
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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V.C2
ASK IF HEARD OF GENERAL EARNED INCOME EXCLUSION
What portion of (your/NAME) earnings after the first $65 does Social Security count
against (your/his/her) SSI benefit? Does Social Security count one dollar for each dollar
([you/he/she] earn/[he/she] earns), one dollar for each two dollars ([you/he/she]
earn/[he/she] earns), one dollar for each three dollars ([you/he/she] earn/[he/she] earns),
or one dollar for each four dollars ([you/he/she] earn/[he/she] earns)?
PROBE:
Does Social Security count all of (your/his/her) earnings in reducing your
SSI benefit, half of (your/his/her) earnings, one-third of (your/his/her) earnings, or onequarter of (your/his/her) earnings?
1 FOR 1 (ALL) .............................................. 1
1 FOR 2 (HALF) ........................................... 2
1 FOR 3 (ONE-THIRD) ................................ 3
1 FOR 4 (ONE-QUARTER) .......................... 4
DON‘T KNOW .............................................. d
REFUSED .................................................... r
V.C3
ASK IF HEARD OF THE GENERAL EARNED INCOME EXCLUSION:
(Have you/Has NAME) used the general earned income exclusion since (RA DATE)?
(NBS-E6)
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
REFUSED .................................................... r
V.D1
(NBS-E9)
Have you ever heard of Continued Medicaid Eligibility or Medicaid While Working? This
is a Social Security incentive that lets (you/beneficiaries) keep (your/their) LOCAL
MEDICAID NAME insurance after (you/they) go to work, even if (your/their) benefits
have stopped.
INTERVIEWER NOTE: THIS IS ALSO KNOWN AS SECTION 1619(b).
YES.............................................................. 1
NO/NOT SURE ............................................ 0
(GO TO V.E1)
REFUSED .................................................... r
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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V.D2
(NBS-E10)
ASK IF HEARD OF CONTINUED MEDICAID ELIGIBILITY:
(Have you/Has NAME) used the Continued Medicaid Eligibility or Medicaid While
Working since (RA DATE)?
INTERVIEWER NOTE: THIS IS ALSO KNOWN AS SECTION 1619(b).
YES.............................................................. 1
NO ............................................................... 0
REFUSED .................................................... r
V.E1
(NBS-E12)
Have you ever heard of the student earned-income exclusion? This is a Social Security
incentive where if (you are/[he/she] is) in school, up to (AMOUNT PER MONTH: $1,640
for 2009) of earnings per month are not counted when Social Security figures (your/the)
benefit.
YES.............................................................. 1
NO/NOT SURE ............................................ 0
(GO TO V.F1)
REFUSED .................................................... r
V.E2
ASK IF HEARD OF SEIE:
(Have you/Has NAME) used the student earned-income exclusion since (RA DATE)?
(NBS-E13)
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
REFUSED .................................................... r
V.F1
(NBS-E12)
ASK IF LESS THAN AGE 18 AT RANDOM ASSIGNMENT:
Have you ever heard of the Continuing Disability Review or Age 18 Medical
Redetermination? This is when Social Security determines whether or not an SSI
recipient is eligible to receive SSI benefits as an adult.
YES.............................................................. 1
NO/NOT SURE ............................................ 0
(GO TO V.G1)
REFUSED .................................................... r
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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V.F2
ASK IF AGE LESS THAN 18 AT RANDOM ASSIGNMENT, HEARD OF CDR AND IS
A TREATMENT CASE:
If (you/NAME) are found no longer eligible for benefits, will (you/NAME) continue
receiving benefits from Social Security for as long as (you continue/ he/she continues) to
participate in (YTD PROGRAM NAME)?
YES.............................................................. 1
NO/NOT SURE ............................................ 0
REFUSED .................................................... r
V.G1 Have you ever heard of an Individual Development Account or an IDA? An IDA is a
special bank account that helps (you/NAME) save for (your/his/her) education, the
purchase of a first home, or to start a business.
PROBE:
Have you ever heard of this special bank account?
PROBE:
If you‘re not sure, please just say so.
YES.............................................................. 1
NO/NOT SURE ............................................ 0
(GO TO V.H1)
REFUSED .................................................... r
ASK IF HEARD OF IDA:
V.G2 (Have you/Has NAME) used an IDA since (RA DATE)?
PROBE:
An individual development account.
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
REFUSED .................................................... r
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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V.H1 If you wanted information about how working would affect (your/NAME) Social Security
benefits where would you get that information?
CODE ALL THAT APPLY
BENEFITS PLANNER/BPAO/WIPA ............. 1
INTERNET ................................................... 2
FRIENDS/FAMILY ....................................... 3
ONE STOP CENTER/WORKFORCE
DEVELOPMENT CENTER/
[IF COLORADO: WIN CENTERS] ................ 4
SOCIAL SECURITY OFFICE ....................... 5
SOCIAL SECURITY WEBSITE .................... 6
VOCATIONAL REHABILITATION
AGENCY ...................................................... 7
YTD PROGRAM .......................................... 8
OTHER (SPECIFY) ...................................... 9
.....................................................................
DON‘T KNOW .............................................. d
REFUSED .................................................... r
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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(REV—1/7/09)
SECTION VI: HEALTH
THIS SECTION ASKED OF ALL YOUTH.
Now I will ask you some questions about (your/NAME‘s) health and daily activities.
VI.A1
(NLTS-Q5)
Some people have a disability or special need that makes it hard for them to do some
things. (Do you/Does NAME) consider (yourself/himself/herself) to have any kind of
disability?
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
(GO TO VI.B1)
REFUSED .................................................... r
VI.A2
Can (you/NAME) describe (your/his/her) disability to others?
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
REFUSED .................................................... r
VI.B1
In general, would (you/he/she) say that (your/NAME‘s) health is. . .
(YTD-30)
(SF-1)
Excellent, ..................................................... 1
Very good,.................................................... 2
Good, ........................................................... 3
Fair, or ......................................................... 4
Poor? ........................................................... 5
DON‘T KNOW .............................................. d
REFUSED .................................................... r
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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VI.B1a Compared to one year ago, how would (you/NAME) rate (your/his/her) health in general
now? Is it . . .
(NBS-I9)
(SF-36)
Much better now,.......................................... 1
Somewhat better now,.................................. 2
About the same, ........................................... 3
Somewhat worse now, or ............................. 4
Much worse now? ........................................ 5
DON‘T KNOW .............................................. d
REFUSED .................................................... r
The next two question are about activities (you/NAME) might do during a typical day.
VI.B2
(SF-12)
During a typical day, does (your/NAME‘s) health now limit (you/him/her) in doing
moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or
playing golf?
PROBE, IF YES: Does (your/NAME‘s) health limit you a little or a lot?
Yes, limited a lot .......................................... 1
Yes, limited a little ........................................ 2
No, not limited at all ...................................... 3
VI.B3
(SF-12)
During a typical day, does (your/NAME‘s) health now limit (you/him/her) in climbing
several flights of stairs?
PROBE, IF YES: Does (your/NAME‘s) health limit you a little or a lot?
PROBE, IF RESPONDENT REPORTS THAT THEY DON‘T PERFORM STAIRCLIMBING ASK: Could you climb several flights of stairs if you needed to?
Yes, limited a lot .......................................... 1
Yes, limited a little ........................................ 2
No, not limited at all ...................................... 3
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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The next two questions ask about (your/NAME‘s) physical health and (your/his/her) daily
activities.
VI.B4 During the past 4 weeks, how much of the time have (you/NAME) accomplished less
than (you/he/she) would have liked to as a result of (your/his/her) physical health?
(SF-12)
Would you say . . .
All, ................................................................ 1
Most, ............................................................ 2
Some, .......................................................... 3
A little, or ...................................................... 4
None of the time? ......................................... 5
VI.B5 During the past 4 weeks, how much of the time (were you/was NAME) limited in the kind
of work or other regular daily activities (you do/[he/she] does) as a result of (your/his/her)
(SF-12)
physical health? Would you say . . .
All, ................................................................ 1
Most, ............................................................ 2
Some, .......................................................... 3
A little, or ...................................................... 4
None of the time? ......................................... 5
Now I will ask about any emotional problems and (your/NAME‘s) daily activities.
VI.B6 During the past 4 weeks, how much of the time (have you/has NAME) accomplished
less than (you/he/she) would have liked to as a result of any emotional problems, such
(SF-12)
as feeling depressed or anxious? Would you say . . .
All, ................................................................ 1
Most, ............................................................ 2
Some, .......................................................... 3
A little, or ...................................................... 4
None of the time? ......................................... 5
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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VI.B7 During the past 4 weeks, how much of the time did (you/he/she) not do work or other
activities as carefully as usual as a result of any emotional problems, such as feeling
(SF-12)
depressed or anxious? Would you say . . .
All, ................................................................ 1
Most, ............................................................ 2
Some, .......................................................... 3
A little, or ...................................................... 4
None of the time? ......................................... 5
VI.B8 During the past 4 weeks, how much did pain interfere with (your/NAME‘s) normal work,
including both work outside the home, housework, or school work? Did it interfere . . .
(SF-12)
Not at all, ...................................................... 1
A little bit, ..................................................... 2
Moderately, .................................................. 3
Quite a bit, or ............................................... 4
Extremely? ................................................... 5
These next questions are about how (you feel/NAME feels) and how things have been with
(you/him/her) during the past 4 weeks. For each question, please give me the one answer that
comes closest to the way (you have/NAME has) been feeling.
VI.B9 During the past 4 weeks, how much of the time (have you/has NAME) felt calm and
peaceful? Would you say . . .
(SF-12)
All, ................................................................ 1
Most, ............................................................ 2
Some, .......................................................... 3
A little, or ...................................................... 4
None of the time? ......................................... 5
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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VI.B10 During the past 4 weeks, how much of the time did (you/NAME) have a lot of energy?
Would you say . . .
(SF-12)
All, ................................................................ 1
Most, ............................................................ 2
Some, .......................................................... 3
A little, or ...................................................... 4
None of the time? ......................................... 5
VI.B11 During the past 4 weeks, how much of the time have (you/NAME) felt downhearted and
depressed? Would you say . . .
(SF-12)
All, ................................................................ 1
Most, ............................................................ 2
Some, .......................................................... 3
A little, or ...................................................... 4
None of the time? ......................................... 5
VI.B12 During the past 4 weeks, how much of the time has (your/NAME‘s) physical health or
emotional problems interfered with your social activities, like visiting with friends or
(SF-12)
relatives? Would you say . . .
All, ................................................................ 1
Most, ............................................................ 2
Some, .......................................................... 3
A little, or ...................................................... 4
None of the time? ......................................... 5
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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VI.C1
(YTD-38)
For the next set of activities, please tell me how often (you do/NAME does) the activity
by (yourself/himself/herself).
The first (next) activity is ACTIVITY. (Do you/Does NAME) do it by
(yourself/himself/herself) most of the time, some of the time, or none of the time.
IF NONE OF THE TIME: Could (you/NAME) ACTIVITY by yourself it if (you/he/she)
had the chance to or needed to?
IF NONE, ASK: Could
(you/he/she) (ACTIVITY)
if (you/he/she) had the
chance to or needed to?
MOST
SOME
NONE
YES
NO
a. Deciding how to spend (your/his/her)
money ...................................................
1
2
3
1
0
b. Picking clothes to wear ..........................
1
2
3
1
0
c. Making snacks or sandwiches ...............
1
2
3
1
0
d. Riding public transportation alone .........
1
2
3
1
0
e. Deciding how to spend (your/his/her)
free time ................................................
1
2
3
1
0
f.
Taking medication .................................
1
2
3
1
0
g. Making doctor‘s appointments ...............
1
2
3
1
0
VI.C2
(Have you/Has NAME) been in a drug or alcohol treatment program since (RA DATE)?
Please include both residential and outpatient programs.
PROBE: Was this in the past three years?
JC-H27
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. D
(GO TO SECTION VIII)
REFUSED .................................................... R
VI.C3
JC-h28
How many drug or alcohol treatment programs did you attend since (RA DATE)?
|___|___| PROGRAMS
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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ASK VI.D1 TO VI.D3 FOR EACH PROGRAM
VI.D1
JC-h29
When did (you/NAME) begin attending (that/the) ([next] most recent) drug or alcohol
treatment program?
|___|___| MONTH
20|___|___| YEAR
VI.D2
JC-h30
How long (were you/was NAME) in that drug or alcohol treatment program?
INTERVIEWER: IF STILL ATTENDING, CIRCLE CODE 99.
|___|___| UNITS
DAYS ........................................................... 1
WEEKS ........................................................ 2
MONTHS ..................................................... 3
YEARS ......................................................... 4
STILL ATTENDING ...................................... 99
VI.D3
Where (do/did) (you/NAME) receive that drug or alcohol treatment? Was it in
JC-h31
PROBE: By a long-term residential program we mean one that was longer than three
months.
a hospital,..................................................... 1
a free-standing detoxification center, ............ 2
a short-term residential program, ................. 3
a long-term residential program, ................... 4
a methadone program, ................................. 5
an out-patient drug-free program, or............ 6
did you receive drug or alcohol treatment
in another setting? (SPECIFY) .................... 7
_
NOTE: THERE IS NO SECTION VII IN THIS VERSION
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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SECTION VIII: SELF-DETERMINATION
IF PROXY GO TO VIII.B1
DO NOT ASK PROXY:
VIII.A1 Next I‘m going to read a list of statements. For each one please tell me how much you
(YITS -I1)
agree or disagree with the statement. There are no right or wrong answers.
INTERVIEWER: READ STATEMENT.
Do you agree or disagree? Do you (dis)agree a lot or a little?
AGREE A
LOT
AGREE A
LITTLE
DISAGREE A
LITTLE
DISAGREE
A LOT
a. You have little control over the things
that happen to you .............................
1
2
3
4
b. There is really no way you can solve
some of the problems you have ........
1
2
3
4
There is little you can do to change
many of the important things in your
life.. ....................................................
1
2
3
4
d. You often feel helpless in dealing
with the problems of life .....................
1
2
3
4
e. Sometimes you feel like you are
being pushed around in life.. .............
1
2
3
4
What happens to you in the future
mostly depends on you ......................
1
2
3
4
g. You can do just about anything you
really set your mind to... ....................
1
2
3
4
h. You tell other people how you feel
when they upset you or hurt your
feelings ..............................................
1
2
3
4
You know how to get the information
you need ............................................
1
2
3
4
You have a good sense of the path
you want to take in life and the steps
to get there.........................................
1
2
3
4
k. Your personal goals include working
or continuing to work in a paid job ...........
1
2
3
4
Your job opportunities will be limited
by discrimination, because of your
gender, race or disability ...................
1
2
3
4
m. You know of paying jobs that you
would like to try. .................................
1
2
3
4
n. You often reach the personal goals
that you have set for yourself. ...........
1
2
3
4
c.
f.
i.
j.
l.
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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AGREE A
LOT
AGREE A
LITTLE
DISAGREE A
LITTLE
DISAGREE
A LOT
o. You know of the supports that you
need to be successful in a job or
school ................................................
1
2
3
4
p. You tell other people what you would
like to do now and in the future..........
1
2
3
4
q. You know of the special laws that
protect people with disabilities ...........
1
2
3
4
VIII.A2. The next list of statements are about activities that people sometimes take part in. For
(ARC Selfeach, I‘d like you to tell me how often you do the activity when you have the chance to
Determination)
it. Please tell me if you do you not do it, do it sometimes, do it most of the time, or do it
every time you have the chance. There are not right or wrong answers.
DO
DO NOT
SOMETIMES
EVEN IF I
WHEN I
HAVE THE HAVE THE
CHANCE
CHANCE
DO MOST
OF THE
TIME I
HAVE THE
CHANCE
DO EVERY
TIME I
HAVE THE
CHANCE
a. You keep your own personal items
together ..............................................
1
2
3
4
b. You keep good personal care and
grooming ............................................
1
2
3
4
1
2
3
4
d. You keep appointments and
meetings.
1
2
3
4
e. You plan weekend activities that you
like to do ............................................
1
2
3
4
You are involved in activities outside
the home ............................................
1
2
3
4
g. You volunteer for things that you are
interested in .......................................
1
2
3
4
h. You go to restaurants that you like ....
1
2
3
4
You choose gifts to give to family and
friends ................................................
1
2
3
4
You choose how to spend your
personal money .................................
1
2
3
4
c.
f.
i.
j.
You make friends with other people
your age .............................................
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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VIII.A3 Next, I am going to read you two statements. Then, I want you to tell me the one that
best describes you. Choose only one answer for each question. There are no right or
(NLTS-2)
wrong answers. Let‘s start.
VIII.A3a READ IF NECESSARY: Which of the following statements best describes you?
You tell others when you have a new or different
opinion, or ................................................... 1
You usually agree with other‘s opinions
and/or ideas ................................................. 2
DON‘T KNOW .............................................. d
REFUSED .................................................... r
VIII.A3b READ IF NECESSARY: Which of the following statements best describes you?
You can make your own decisions, or ......... 1
Other people make decisions for you ........... 2
DON‘T KNOW .............................................. d
REFUSED .................................................... r
VIII.A3c READ IF NECESSARY: Which of the following statements best describes you?
You can get what you want by working hard,
or ................................................................ 1
You need good luck to get what you want .... 2
DON‘T KNOW .............................................. d
REFUSED .................................................... r
VIII.A3d READ IF NECESSARY: Which of the following statements best describes you?
You keep trying even after you get something
wrong, or ..................................................... 1
It is no use to keep trying because it will not
work ............................................................. 2
DON‘T KNOW .............................................. d
REFUSED .................................................... r
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VIII.A3e READ IF NECESSARY: Which of the following statements best describes you?
You usually make good choices, or ............. 1
You usually do not make good choices ........ 2
DON‘T KNOW .............................................. d
REFUSED .................................................... r
VIII.A3f READ IF NECESSARY: Which of the following statements best describes you?
You will be able to make choices that are
important to you, or ..................................... 1
Your choices will not be honored.................. 2
DON‘T KNOW .............................................. d
REFUSED .................................................... r
DO NOT ASK IF DISABILITY IS BLINDNESS
VIII.B1 (Do you/Does NAME) have a driver‘s license or learners permit?
(NLTS-P15)
YES.............................................................. 1 (GO TO VIII.B3)
NO ............................................................... 0
DON‘T KNOW .............................................. d
REFUSED .................................................... r
ASK IF NO DRIVER’S LICENSE OR LEARNERS PERMIT:
VIII.B2 How likely (do you/does [he/she]) think it is that (you/he/she) will get a driver‘s license?
(NLTS-V11)
(Do you/Does NAME) think (you/he/she) . . .
Definitely will, ............................................... 1
Probably will, ................................................ 2
Probably won‘t, or ........................................ 3
Definitely won‘t? ........................................... 4
DON‘T KNOW .............................................. d
REFUSED .................................................... r
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VIII.B3 (Do You/Does NAME) get any bills in (your/his/her) own name that (you are/[he/she] is)
responsible for paying?
PROBE: Such as a bill for a cell phone, electricity, internet access, credit card, rent, or
a magazine subscription.
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
REFUSED .................................................... r
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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SECTION IX: CRIMINAL BEHAVIOR
IX.A1 Now I‘m going to ask you about things some young people do. All of your answers will
be private; nothing you say will be told to anyone else.
First, think about (your/NAME‘s) friends. How often (do you/does [he/she]) and
(your/his/her) friends get together to have fun or hang out? Would you say . . .
Never, .......................................................... 1
Hardly ever, .................................................. 2
Sometimes, or .............................................. 3
Often? .......................................................... 4
DOES NOT HAVE FRIENDS ....................... 5
DON‘T KNOW .............................................. d
REFUSED .................................................... r
IX.B1
JC-J20
Young people sometime get in trouble with the law. These next questions are about
experiences (you/NAME) may have had with the police or courts.
(Have you/Has NAME) ever been arrested or charged with a delinquency or criminal
complaint?
PROBE: Please include probation or parole violations.
PROBE: Do not include minor motor vehicle violations.
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
(GO TO SECTION X)
REFUSED .................................................... r
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IX.B2
JC-J20
IF YES: (Have you/Has NAME) been arrested or charged with a delinquency or
criminal complaint, since (RA DATE)?
PROBE: Did this happen within the past three years?
PROBE: Please include probation or parole violations.
PROBE: Do not include minor motor vehicle violations.
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
(GO TO IX.I1)
REFUSED .................................................... r
IX.B3 How many times (have you /has NAME) been arrested or charged with a delinquency or
criminal complaint since (RA DATE)?
JC-J21
INTERVIEWER: PROBE TO GET NUMBER OF ARRESTS
|
IX.C1
JC-J22
(MOD)
|
| ARRESTS
When were (you/NAME) (most recently/next most recently) arrested or charged with a
delinquency or criminal complaint?
|___|___| MONTH
20|___|___| YEAR
IX.C2
What were all of the charges brought against (you/NAME) by the police on (ARREST
DATE)?
JC- J25
(MOD)
PROBE: Why (were you/was NAME) arrested?
Were there any other charges brought against (you/NAME)
Were there any other reasons (you were/NAME was) arrested?
RECORD VERBATIM AND CODE:
_______________________________________________
AGGRAVATED ASSAULT ........................... 1
ARSON ........................................................ 2
BURGLARY ................................................. 3
DISORDERLY CONDUCT ........................... 4
DRUGS - USE OR POSSESSION .............. 5
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DRUGS - SALE OR MANUFACTURE ........ 6
DRUNKENNESS, LIQUOR LAWS, OR
DRIVING WHILE UNDER THE INFLUENCE
(DWI, DUI) ................................................... 7
EMBEZZLEMENT ........................................ 8
FORCIBLE RAPE ........................................ 9
FORGERY OR COUNTERFEITING............. 10
FRAUD ........................................................ 11
GAMBLING .................................................. 12
LARCENY OR THEFT ................................. 13
LOITERING, VAGRANCY, OR CURFEW
VIOLATION .................................................. 14
MOTOR VEHICLE THEFT OR
CARJACKING .............................................. 15
MURDER OR MANSLAUGHTER ................ 16
OFFENSES AGAINST YOUR FAMILY OR
CHILDREN (DOMESTIC VIOLENCE) .......... 17
PAROLE OR PROBATION VIOLATION ...... 18
PROSTITUTION .......................................... 19
ROBBERY ................................................... 20
SEX OFFENSES OTHER THAN RAPE OR
PROSTITUTION .......................................... 21
SHOPLIFTING ............................................. 22
SIMPLE ASSAULT ....................................... 23
STOLEN PROPERTY, EITHER BUYING,
RECEIVING, OR POSSESSING .................. 24
VANDALISM ................................................ 25
EITHER CARRYING OR POSSESSION OF
WEAPONS................................................... 26
OTHER (SPECIFY) ...................................... 27
DON‘T KNOW .............................................. d
REFUSED .................................................... r
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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IX.D1
JC- J26
(MOD)
(Were you/Was NAME) convicted of (that charge/those charges)?
PROBE: (Were you/Was NAME) found guilty?
YES.............................................................. 1 (GO TO IX.E1)
NO ............................................................... 0
DON‘T KNOW .............................................. d
REFUSED .................................................... r
IX.D2
JC- J26
(MOD)
Did (you/NAME) plead guilty to (that charge/those charges)?
YES.............................................................. 1 (GO TO IX.E1)
NO ............................................................... 0
DON‘T KNOW .............................................. d
REFUSED .................................................... r
IX.D3
JC- J26
(MOD)
What happened with (that charge/those charges)?
PROBE: Did (you/ NAME) make a deal or ―cop a plea‖? (Were you/Was NAME)
acquitted? Were the charges dismissed or dropped? Or are the charges still pending?
MADE A DEAL ............................................. 1 (GO TO IX.E1)
ACQUITTED ................................................ 2
DISMISSED OR DROPPED......................... 3
PENDING..................................................... 4
DON‘T KNOW .............................................. d
REFUSED .................................................... r
ASK ABOUT NEXT ARREST. IF NO MORE ARRESTS GO
TO IX.G1
IX.E1
What (were you/was NAME) convicted of or what did (you/NAME) plead guilty to?
JC-J29
PROBE: What crime(s) (were you/was NAME) convicted of?
(Were you/Was NAME) convicted of any other charge?
RECORD VERBATIM AND CODE ALL THAT APPLY:
_______________________________________________
AGGRAVATED ASSAULT ........................... 1
ARSON ........................................................ 2
BURGLARY ................................................. 3
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DISORDERLY CONDUCT ........................... 4
DRUGS - USE OR POSSESSION .............. 5
DRUGS - SALE OR MANUFACTURE ........ 6
DRUNKENNESS, LIQUOR LAWS, OR
DRIVING WHILE UNDER THE INFLUENCE
(DWI, DUI) ................................................... 7
EMBEZZLEMENT ........................................ 8
FORCIBLE RAPE ........................................ 9
FORGERY OR COUNTERFEITING............. 10
FRAUD ........................................................ 11
GAMBLING .................................................. 12
LARCENY OR THEFT ................................. 13
LOITERING, VAGRANCY, OR CURFEW
VIOLATION .................................................. 14
MOTOR VEHICLE THEFT OR
CARJACKING .............................................. 15
MURDER OR MANSLAUGHTER ................ 16
OFFENSES AGAINST YOUR FAMILY OR
CHILDREN (DOMESTIC VIOLENCE) .......... 17
PAROLE OR PROBATION VIOLATION ...... 18
PROSTITUTION .......................................... 19
ROBBERY ................................................... 20
SEX OFFENSES OTHER THAN RAPE OR
PROSTITUTION .......................................... 21
SHOPLIFTING ............................................. 22
SIMPLE ASSAULT ....................................... 23
STOLEN PROPERTY, EITHER BUYING,
RECEIVING, OR POSSESSING .................. 24
VANDALISM ................................................ 25
EITHER CARRYING OR POSSESSION OF
WEAPONS................................................... 26
OTHER (SPECIFY) ...................................... 27
DON‘T KNOW .............................................. d
REFUSED .................................................... r
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IX.E2
JC-J30
Did (you/NAME) serve time in a jail, prison or detention home on that conviction?
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
(GO TO IX.F1)
REFUSED .................................................... r
IX.E3
JC-J31
When did (you/ NAME) start serving time on that conviction?
|___|___| MONTH
|___|___| DAY
20|___|___| YEAR
DON‘T KNOW .............................................. d
REFUSED .................................................... r
IX.E4
(Are you/Is NAME) currently serving time in a jail, prison or detention home?
JC-J32
INTERVIEWER: CODE IF ALREADY KNOWN
YES.............................................................. 1 (GO TO IX.F1)
NO ............................................................... 0
IX.E5
JC-J33
When did (you/ NAME) get out?
|___|___| MONTH
|___|___| DAY
20|___|___| YEAR
DON‘T KNOW .............................................. d
REFUSED .................................................... r
IF SAMPLE MEMBER DOES NOT KNOW OR REFUSES
DATES OF INCARCERATION ASK IX.E6. ELSE ASK IX.F1.
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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IX.E6
JC-J35
How much time did (you/ NAME) serve on that conviction?
INTERVIEWER: PROBE FOR TIME SERVED, NOT LENGTH OF SENTENCE.
|___|___|___| UNITS
DAYS ........................................................... 1
WEEKS ........................................................ 2
MONTHS ..................................................... 3
YEARS ......................................................... 4
DON‘T KNOW .............................................. d
REFUSED .................................................... r
IX.F1
(Were you/Was NAME) put on probation or parole?
JC-J36
PROBATION ................................................ 1
PAROLE ...................................................... 2
BOTH PROBATION AND PAROLE ............. 3
NO PROBATION OR PAROLE .................... 4
DON‘T KNOW .............................................. d
(GO TO BOX
BEFORE IX.G1)
REFUSED .................................................... r
IX.F2
How long (were you/was NAME) put on probation or parole?
|___|___|___| UNITS
DAYS ........................................................... 1
WEEKS ........................................................ 2
MONTHS ..................................................... 3
YEARS ......................................................... 4
DON‘T KNOW .............................................. d
REFUSED .................................................... r
IX.F2
IF YES: (Are you/Is NAME) still on probation or parole for that charge?
JC-J37
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
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REFUSED .................................................... r
ASK ABOUT NEXT ARREST. IF NO MORE ARRESTS
GO TO IX.G1
IX.G1
I just want to make sure we haven‘t missed any arrests or charges since (RA DATE).
Other than the one(s) you‗ve already told me about, (were you/was NAME) arrested or
changed since (RA DATE)?
YES.............................................................. 1
(ADD 1 TO ARRESTS,
GO TO IX.C1)
NO ............................................................... 0
DON‘T KNOW .............................................. d
(GO TO IX.H1)
REFUSED .................................................... r
IX.H1
(Other than the ones you already told me about) Since (RA DATE), (have you/has
NAME) been convicted of, or (have you/has (he/she)) plead guilty to any charge?
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
(GO TO BOX
BEFORE IXI1)
REFUSED .................................................... r
IX.H2
JC-I29
(MO
D)
What [were/are] all the [other] charges (you were/NAME was) [convicted of / or plead
guilty to] since (RA DATE)?
PROBE: Please don‘t count any convictions you already told me about.
PROBE: (Were you convicted of/did you plead guilty to) any other charges?
RECORD VERBATIM AND CODE:
_______________________________________________
AGGRAVATED ASSAULT ........................... 1
ARSON ........................................................ 2
BURGLARY ................................................. 3
DISORDERLY CONDUCT ........................... 4
DRUGS - USE OR POSSESSION .............. 5
DRUGS - SALE OR MANUFACTURE ........ 6
DRUNKENNESS, LIQUOR LAWS, OR
DRIVING WHILE UNDER THE INFLUENCE
(DWI, DUI) ................................................... 7
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EMBEZZLEMENT ........................................ 8
FORCIBLE RAPE ........................................ 9
FORGERY OR COUNTERFEITING............. 10
FRAUD ........................................................ 11
GAMBLING .................................................. 12
LARCENY OR THEFT ................................. 13
LOITERING, VAGRANCY, OR CURFEW
VIOLATION .................................................. 14
MOTOR VEHICLE THEFT OR
CARJACKING .............................................. 15
MURDER OR MANSLAUGHTER ................ 16
OFFENSES AGAINST YOUR FAMILY OR
CHILDREN (DOMESTIC VIOLENCE) .......... 17
PAROLE OR PROBATION VIOLATION ...... 18
PROSTITUTION .......................................... 19
ROBBERY ................................................... 20
SEX OFFENSES OTHER THAN RAPE OR
PROSTITUTION .......................................... 21
SHOPLIFTING ............................................. 22
SIMPLE ASSAULT ....................................... 23
STOLEN PROPERTY, EITHER BUYING,
RECEIVING, OR POSSESSING .................. 24
VANDALISM ................................................ 25
EITHER CARRYING OR POSSESSION OF
WEAPONS................................................... 26
OTHER (SPECIFY) ...................................... 27
DON‘T KNOW .............................................. d
REFUSED .................................................... r
IF JAIL TIME WAS REPORTED SINCE RA GO TO IX.I2a,
ELSE ASK IX.I1.
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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IX.I1
JC-I30
(MOD)
IF NO JAIL TIME SINCE RA DATE
(Have you/Has NAME) ever served time in a jail, prison or detention home?
PROBE: Please only include time served in a jail, prison or detention home if you
were arrested or charged with a crime or delinquency?
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
(GO TO BOX
BEFORE IX.J1)
REFUSED .................................................... r
IX.I2
(Have you/Has NAME) served any time in a jail, prison or detention home since (RA
DATE)?
PROBE: Was this in the past three years?
YES.............................................................. 1 (GO TO IX.I3)
NO ............................................................... 0
DON‘T KNOW .............................................. d
(GO TO BOX
BEFORE IX.K1)
REFUSED .................................................... r
IX.I2a
Next, I would like to ask about time spent in jail, prison or detention home since (RA
DATE)? Other than the time spent in jail that you have already told me about, (have
you, has NAME) served any other time in a jail, prison or detention home since (RA
DATE)?
PROBE: Was this in the past three years?
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
(GO TO BOX
BEFORE IX.K1)
REFUSED .................................................... r
IX.I3
(Other than what you have already told me about,) Since (RA DATE), how many
different times did (you/ NAME) serve time in a jail, prison, or detention home?
PROBE: How many jail terms (have you/has NAME) had since (RA DATE)?
|
|
| NUMBER OF JAIL TERMS
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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IX.I4
(Other than the time you have already told me about,) How much time did (you/
NAME) serve in a jail, prison, or detention home since (RA DATE)?
INTERVIEWER: PROBE FOR TIME SERVED, NOT LENGTH OF SENTENCE. IF
UNSURE, GET BEST ESTIMATE.
|___|___|___| UNITS
DAYS ........................................................... 1
WEEKS ........................................................ 2
MONTHS ..................................................... 3
YEARS ......................................................... 4
DON‘T KNOW .............................................. d
REFUSED .................................................... r
IX.I5
(Are you/Is NAME) currently serving time in a jail, prison or detention home?
JC-J32
INTERVIEWER: CODE IF ALREADY KNOWN
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
REFUSED .................................................... r
IF PROBATION OR PAROLE WAS REPORTED SINCE RA
GO TO IX.J2a, ELSE ASK IX.J1.
IX.J1
(NLTS (mod,
timeframe)
U8c)
IF NO PROBATION OR PAROLE SINCE RA DATE
(Have you/Has NAME) ever been on probation or parole?
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
(GO TO SECTION X)
REFUSED .................................................... r
IX.J2
IF YES: (Were you/Was NAME) on probation or parole since (RA DATE)?
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
(GO TO SECTION X)
REFUSED .................................................... r
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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IX.J2a
Next, I would like to ask about probation or parole. Other than the time spent on
probation or parole that you have already told me about, (have you, has NAME) been
on probation or parole at any other time since (RA DATE)?
PROBE: Was this in the past three years?
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
(GO TO SECTION X)
REFUSED .................................................... r
IX.J3
(Other than the probation or parole time you have already told me about,) Since (RA
DATE), how many different times (have you/has NAME) been on probation or parole?
|
|
| NUMBER OF TIMES ON PROBATION/PAROLE
DON‘T KNOW .............................................. d
REFUSED .................................................... r
IX.I4
(Other than the time you have already told me about,) Since (RA DATE) how long
(were you/ was NAME) put on probation or parole?
|___|___|___| UNITS
DAYS ........................................................... 1
WEEKS ........................................................ 2
MONTHS ..................................................... 3
YEARS ......................................................... 4
DON‘T KNOW .............................................. d
REFUSED .................................................... r
IX.J4
JC-J39
(Are you/Is NAME) currently on parole for any offense?
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
REFUSED .................................................... r
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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IX.J5
JC-J40
(Are you/Is NAME) currently on probation for any offense?
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
REFUSED .................................................... r
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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SECTION X: LIVING ARRANGEMENT
Next, I will ask some questions about (your/ NAME‘s) living arrangement.
X.A1
(YTD 52.)
(Are you/Is NAME) currently married?
YES.............................................................. 1 (GO TO X.A3)
NO ............................................................... 0
DON‘T KNOW .............................................. d
REFUSED .................................................... r
X.A2
IF NOT CURRENTLY MARRIED AND DOES NOT LIVE ALONE:
(Are you/Is NAME) living with a partner or companion in a marriage-like relationship?
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
REFUSED .................................................... r
X.A3
(Do you/Does NAME) live in a house, condo or mobile home that (you/name) or
(your/his/her) family owns?
YES.............................................................. 1 (GO TO X.B1)
NO ............................................................... 0
X.A4
(Do you/Does NAME) live in a house, apartment, condo or mobile home that
(you/name) or (your/his/her) family rents?
YES.............................................................. 1
NO ............................................................... 0 (GO TO X.A6)
X.A5
Some people live in a place that has staff available to help them learn daily activities,
like cleaning the apartment, making nutritious meals, and maintaining a clean and neat
personal appearance. (Do you/Does NAME) live in this type of place?
YES.............................................................. 1 (GO TO X.D1)
NO ............................................................... 0 (GO TO X.B1)
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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X.A6
(Do you/Does NAME) live in a house, apartment, condo or other home for people with
disabilities?
YES.............................................................. 1 (GO TO X.D1)
NO ............................................................... 0
X.A7
(Do you/Does NAME) live in a group home?
PROBE: (Do you/Does NAME) live in home with other people with disabilities and
someone whose job it is to help (you/him/her) or provide supervision?
YES.............................................................. 1 (GO TO X.D1)
NO ............................................................... 0
X.A8
Where (do you/does NAME) live?
JAIL, PRISON, DETENTION CENTER ........ 1(GO TO X.D1)
SHELTER .................................................... 2(GO TO X.D1)
NURSING HOME ......................................... 3 (GO TO X.D1)
ASSISTED LIVING FACILITY ...................... 4 (GO TO X.D1)
OTHER INSTITUTIONAL SETTING
(SPECIFY) ................................................... 5 (GO TO X.D1)
OTHER RESIDENTIAL SETTING
(SPECIFY) ................................................... 6 (GO TO X.B1)
HOMELESS ................................................. 7 (GO TO X.D1)
DON‘T KNOW .............................................. d
REFUSED .................................................... r
X.B1
Other than family members, does someone help (you/NAME) with activities like how to
manage (your/his/her) money, how to do laundry, how to make meals, OR other
activities so that (you/NAME) can live independently.
YES.............................................................. 1
NO ............................................................... 0
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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X.B2
(Do you/Does NAME) live alone or (do you/does [he/she]) live with other people?
(YTD -Q40)
INTERVIEWER: CODE IF ALREADY KNOWN
LIVE ALONE ................................................ 1 (GO TO X.D1)
LIVE WITH OTHER PEOPLE....................... 0
X.C1
ASK IF SM LIVES IN RESIDENTIAL SETTING AND LIVES WITH OTHER PEOPLE:
Who (do you/does NAME) live with?
(YTD -Q43)
PROBE: (Do you/Does NAME) live with anyone else?
CODE ALL THAT APPLY
BIOLOGICAL/ADOPTIVE MOTHER ............ 1
STEP/OTHER MOTHER .............................. 2
FOSTER MOTHER ...................................... 3
GRANDMOTHER......................................... 4
AUNT ........................................................... 5
SISTER ........................................................ 6
BIOLOGICAL/ADOPTIVE FATHER ............. 7
STEP/OTHER FATHER ............................... 8
FOSTER FATHER ....................................... 9
GRANDFATHER .......................................... 10
UNCLE ......................................................... 11
BROTHER ................................................... 12
SPOUSE OR PARTNER .............................. 13
LEGAL GUARDIAN ...................................... 14
SM‘S CHILD ................................................. 15
FOSTER SIBLING ....................................... 16
COUSIN ....................................................... 17
FRIEND ....................................................... 18
ROOMMATE ................................................ 19
SOMEONE ELSE......................................... 20
DON‘T KNOW .............................................. d
REFUSED .................................................... r
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X.C2
Including (yourself/NAME), how many people live with (you/him/her)?
(YTD -Q46)
|
|
| NUMBER OF PEOPLE
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
X.D1
(YTD -Q49)
Next I am going to ask you about all of (your/his/her) biological children, adopted
children, or foster children and any other children for whom (you/he/she) are
responsible, even if they are not living in (your/his/her) household right now.
PROGRAMMER: CODE “1” YES IF LIVES WITH OWN CHILD:
(Do you/Does NAME) have any children for whom (you/he/she) are responsible?
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
(GO TO X.E1)
REFUSED .................................................... r
X.D2
ASK IF SM HAS CHILDREN:
How many children (do you/does NAME) have?
(YTD -Q50)
|
X.D4
|
| NUMBER OF CHILDREN
(Is this child/Are any of these children) (your/NAME‘s) biological child?
YES.............................................................. 1 (GO TO SECTION XI)
NO ............................................................... 0
DON‘T KNOW .............................................. d
REFUSED .................................................... r
ASK FEMALES ONLY
X.E1 (Have you/Has NAME) ever been pregnant?
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
REFUSED .................................................... r
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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ASK MALES ONLY
X.E2 To your knowledge, (have you/has NAME) ever gotten a woman pregnant?
YES.............................................................. 1
NO ............................................................... 0
DON‘T KNOW .............................................. d
REFUSED .................................................... r
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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SECTION XI: INCOME
XI.A1
(YTD -57.)
The next questions are about (your/NAME‘s) health insurance, income and assistance
(you/NAME) may receive. [IF RESPONDENT IS SM ADD]: You may need someone‘s
help to answer these questions.
First, I‘d like to ask about medical expenses and health insurance. Health insurance
helps pay for medical expenses, like when (you/he/she) go to the doctor.
(Are you/Is NAME) now covered by any government-assisted or public health insurance
such as Medicare, Medicaid, (IF COLORADO: or Child Health Plan Plus, IF NY: Child
Health Plus, or Family Health Plus; IF WV: Mountain Health Choices).
YES............................................................................... 1
NO ................................................................................ 0
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
XI.A2
(YTD -58)
(Mod)
(Are you/Is NAME) now covered by private health insurance from an employer or
union?
PROBE [If independent youth]: This includes coverage through your own employer or
union as well as coverage that you may have through your parents' employer or union.
PROBE [If parent]: This includes coverage that you may have for (NAME) through your
own employer or union as well as coverage that (NAME) may have through (his/her
own) employer or union.
YES............................................................................... 1
NO ................................................................................ 0
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
XI.A3
(YTD -58)
(Mod)
(Are you/Is NAME) now covered by private health insurance that (you/NAME) or
(your/his/her) family buys directly?
YES............................................................................... 1
NO ................................................................................ 0
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
APPENDIX B - YTD-36 Month Follow-Up to OMB.doc
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XI.B1
(YTD 63)
Last month, did (you/NAME) receive assistance from temporary assistance for needy
families, TANF, or (COLORADO: Colorado Works; NY: Family Assistance; FLORIDA:
Temporary Cash Assistance; MARYLAND: Temporary Cash Assistance; WEST
VIRGINIA: West Virginia Works])?
YES............................................................................... 1
NO ................................................................................ 0
DON‘T KNOW ............................................................... d
(GO TO X.B1c)
REFUSED ..................................................................... r
XI.B1a. Last month, how much money did (you/NAME) get from TANF?
|__|__|__| DOLLARS (GO TO XI.B2)
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
XI.B1b. Was it …
Less than $100 ............................................................. 1
Between $100 and $199 ............................................... 2
Between $200 and $299 ............................................... 3
Between $300 and $399 ............................................... 4
Between $400 and $499 ............................................... 5
Between $500 and $599 ............................................... 6
Between $600 and $699 ............................................... 7
Or was it more than $700 .............................................. 8
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
IF SM LIVES ALONE, SKIP TO XI.B2
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XI.B1c Last month, did anyone else in (your/NAME‘s) household receive assistance from
temporary assistance for needy families, TANF, or (COLORADO: Colorado Works; NY:
Family Assistance; FLORIDA: Temporary Cash Assistance; MARYLAND: Temporary
(YTD 63)
Cash Assistance; WEST VIRGINIA: West Virginia Works])?
YES............................................................................... 1
NO ................................................................................ 0
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
XI.B2
(YTD 63a)
Last month, did (you/ NAME) receive assistance from food stamps (IF FLORIDA: or
SUNCAP)?
PROBE: This is also known as the supplemental nutrition program or SNAP.
PROBE: Benefits are provided on an electronic card, called an EBT card, that is used
like an ATM card and accepted at most grocery stores.
YES............................................................................... 1
NO ................................................................................ 0
DON‘T KNOW ............................................................... d
(GO TO X.B2c)
REFUSED ..................................................................... r
XI.B2a. Last month, how much money did (you/NAME) get from food stamps?
|__|__|__| DOLLARS (GO TO XI.B3)
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
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XI.B2b. Was it …
Less than $100 ............................................................. 1
Between $100 and $199 ............................................... 2
Between $200 and $299 ............................................... 3
Between $300 and $399 ............................................... 4
Between $400 and $499 ............................................... 5
Between $500 and $599 ............................................... 6
Between $600 and $699 ............................................... 7
Or was it more than $700 .............................................. 8
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
IF SM LIVES ALONE, SKIP TO XI.B3
XI.B2c. Last month, did anyone else in (your/NAME‘s) household receive assistance from food
stamps (IF FLORIDA: or SUNCAP)?
YES............................................................................... 1
NO ................................................................................ 0
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
XI.B3. (Do you/Does NAME) currently receive any governmental housing assistance in paying
rent (such as through public housing or Section 8)?
PROBE: This is also known as the Housing Choice Voucher Program. Section 8
provides funding for rent subsidies for eligible low-income families.
YES............................................................................... 1
NO ................................................................................ 0
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
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XI.C1. Last month, did you (IF MARRIED: or your spouse) receive any income from Social
Security? Please consider both SSI and SSDI payments.
NBS
YES............................................................................... 1
NO ................................................................................ 0
DON‘T KNOW ............................................................... d
(GO TO X.D1)
REFUSED ..................................................................... r
XI.C2
How much income did (you/name) receive last month from Social Security?
|__|,|__|__|__| DOLLARS (GO TO XI.D1)
(1-4000)
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
XI.C2a. Was it less than $500?
YES............................................................................... 1
NO ................................................................................ 0 (GO TO XI.C2c)
DON‘T KNOW ............................................................... d (GO TO XI.D1)
REFUSED ..................................................................... r (GO TO XI.D1)
XI.C2b. Was it . . .
Less than $100 ............................................................. 1
Between $100 and $199 ............................................... 2
Between $200 and $299 ............................................... 3
Between $300 and $399, or .......................................... 4
Was it between $400 and $500 ..................................... 5
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
GO TO XI.D1
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XI.C2c. Was it less than $1,000?
YES............................................................................... 1
NO ................................................................................ 0 (GO TO XI.C2e)
DON‘T KNOW ............................................................... d (GO TO XI.D1)
REFUSED ..................................................................... r (GO TO XI.D1)
XI.C2d. Was it . . .
Between $500 and $599 ............................................... 1
Between $600 and $699 ............................................... 2
Between $700 and $799 ............................................... 3
Between $800 and $899 ............................................... 4
Or was it between $900 and $1,000 .............................. 5
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
GO TO XI.D1
XI.C2e. Was it . . .
Between $1,000 and $1,499 ......................................... 1
Between $1,500 and $1,999 ......................................... 2
Between $2,000 and $2,499 ......................................... 3
Between $2,500 and $2,999 ......................................... 4
Or was it more than $3,000 ........................................... 5
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
IF CURRENLTY EMPLOYED ASK XI.D1, IF NOT
EMPLOYED BUT MARRIED OR LIVING WITH PARTNER
ASK XI.D3, ELSE ASK XI.E1
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IF CURRENTLY EMPLOYED:
XI.D1 Next I‘d like you to think about money earned at jobs. How much money did (you/
NAME) earn last month? Please include (your/NAME‘s) wages, salary, commissions,
bonuses and tips from all jobs you worked last month.
PROBE: How much did (you/he/she) earn last week? (INTERVIEWER MULTIPLY BY
4)
PROBE: How much did (you/he/she) earn last year? (INTERVIEWER DIVIDE BY 12)
|__|,|__|__|__| DOLLARS (GO TO XI.D2)
NO EARNINGS LAST MONTH ..................................... 0 (GO TO XI.D3)
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
XI.D1a. Was (your/his/her) income last month, less than $1,000?
YES............................................................................... 1
NO ................................................................................ 0 (GO TO XI.D1e)
DON‘T KNOW ............................................................... d (GO TO XI.D3)
REFUSED ..................................................................... r (GO TO XI.D3)
XI.D1b. Was it less than $500?
YES............................................................................... 1
NO ................................................................................ 0 (GO TO XI.D1d)
DON‘T KNOW ............................................................... d (GO TO XI.D3)
REFUSED ..................................................................... r (GO TO XI.D3)
XI.D1c. Was it . . .
Less than $100 ............................................................. 1
Between $100 and $199 ............................................... 2
Between $200 and $299 ............................................... 3
Between $300 and $399, or .......................................... 4
Was it between $400 and $500 last month? .................. 5
DON‘T KNOW ............................................................... d (GO TO XI.D3)
REFUSED ..................................................................... r (GO TO XI.D3)
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GO TO XI.D2
XI.D1d. Was it . . .
Between $500 and $599 ............................................... 1
Between $600 and $699 ............................................... 2
Between $700 and $799 ............................................... 3
Between $800 and $899 ............................................... 4
Or was it between $900 and $1,000 last month? ........... 5
DON‘T KNOW ............................................................... d (GO TO XI.D3)
REFUSED ..................................................................... r (GO TO XI.D3)
GO TO XI.D2
XI.D1e. Was it less than $2,000?
YES............................................................................... 1
NO ................................................................................ 0 (GO TO XI.D1g)
DON‘T KNOW ............................................................... d (GO TO XI.D3)
REFUSED ..................................................................... r (GO TO XI.D3)
XI.D1f. Was it . . .
Between $1,000 and $1,199 ......................................... 1
Between $1,200 and $1,399 ......................................... 2
Between $1,400 and $1,599 ......................................... 3
Between $1,600 and $1,799 ......................................... 4
Or was it between $1,800 and $2,000 last month? ........ 5
DON‘T KNOW ............................................................... d (GO TO XI.D3)
REFUSED ..................................................................... r (GO TO XI.D3)
GO TO XI.D2
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XI.D1g. Was it less than $4,000?
YES............................................................................... 1
NO ................................................................................ 0 (GO TO XI.D1i)
DON‘T KNOW ............................................................... d (GO TO XI.D3)
REFUSED ..................................................................... r (GO TO XI.D3)
XI.D1h. Was it . . .
Between $2,000 and $2,499 ......................................... 1
Between $2,500 and $2,999 ......................................... 2
Between $3,000 and $3,499 ......................................... 3
Or was it between $3,500 and $4,000 last month? ........ 4
DON‘T KNOW ............................................................... d (GO TO XI.D3)
REFUSED ..................................................................... r (GO TO XI.D3)
XI.D1i. Was it . . .
Between $4,000 and $4,999 ......................................... 1
Between $5,000 and $5,999 ......................................... 2
Between $6,000 and $6,999 ......................................... 3
Between $7,000 and $7,999 ......................................... 4
Or was it more than $8,000 last month? ........................ 5
DON‘T KNOW ............................................................... d (GO TO XI.D3)
REFUSED ..................................................................... r (GO TO XI.D3)
XI.D2. Was this amount before or after taxes?
BEFORE ....................................................................... 1
AFTER .......................................................................... 2
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
IF MARRIED OR LIVING WITH PARTNER ASK XI.D3,
ELSE ASK XI.E1
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XI.D3. Did you spouse or partner work at a job for pay last month?
YES............................................................................... 1
NO ................................................................................ 0
DON‘T KNOW ............................................................... d
(GO TO X.E1)
REFUSED ..................................................................... r
XI.D4 How much money did (your/NAME‘s) spouse or partner earn last month? Please
include wages, salary, commissions, bonuses and tips from all jobs worked last month.
PROBE: How much did (he/she) earn last week? (INTERVIEWER MULTIPLY BY 4)
PROBE: How much did (he/she) earn last year? (INTERVIEWER DIVIDE BY 12)
|__|,|__|__|__| DOLLARS (GO TO XI.D5)
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
XI.D4a. Was (your/his/her) income last month, less than $1,000?
YES............................................................................... 1
NO ................................................................................ 0 (GO TO XI.D4e)
DON‘T KNOW ............................................................... d (GO TO XI.E1)
REFUSED ..................................................................... r (GO TO XI.E1)
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XI.D4b. Was it less than $500?
YES............................................................................... 1
NO ................................................................................ 0 (GO TO XI.D4d)
DON‘T KNOW ............................................................... d (GO TO XI.E1)
REFUSED ..................................................................... r (GO TO XI.E1)
XI.D4c. Was it . . .
Less than $100 ............................................................. 1
Between $100 and $199 ............................................... 2
Between $200 and $299 ............................................... 3
Between $300 and $399, or .......................................... 4
Was it between $400 and $500 last month? .................. 5
DON‘T KNOW ............................................................... d (GO TO XI.E1)
REFUSED ..................................................................... r (GO TO XI.E1)
GO TO XI.D5
XI.D4d. Was it . . .
Between $500 and $599 ............................................... 1
Between $600 and $699 ............................................... 2
Between $700 and $799 ............................................... 3
Between $800 and $899 ............................................... 4
Or was it between $900 and $1,000 last month? ........... 5
DON‘T KNOW ............................................................... d (GO TO XI.E1)
REFUSED ..................................................................... r (GO TO XI.E1)
GO TO XI.D5
XI.D4e. Was it less than $2,000?
YES............................................................................... 1
NO ................................................................................ 0 (GO TO XI.D4g)
DON‘T KNOW ............................................................... d (GO TO XI.E1)
REFUSED ..................................................................... r (GO TO XI.E1)
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XI.D4f. Was it . . .
Between $1,000 and $1,199 ......................................... 1
Between $1,200 and $1,399 ......................................... 2
Between $1,400 and $1,599 ......................................... 3
Between $1,600 and $1,799 ......................................... 4
Or was it between $1,800 and $2,000 last month? ........ 5
DON‘T KNOW ............................................................... d (GO TO XI.E1)
REFUSED ..................................................................... r (GO TO XI.E1)
GO TO XI.D5
XI.D4g. Was it less than $4,000?
YES............................................................................... 1
NO ................................................................................ 0 (GO TO XI.D4i)
DON‘T KNOW ............................................................... d (GO TO XI.E1)
REFUSED ..................................................................... r (GO TO XI.E1)
XI.D4h. Was it . . .
Between $2,000 and $2,499 ......................................... 1
Between $2,500 and $2,999 ......................................... 2
Between $3,000 and $3,499 ......................................... 3
Or was it between $3,500 and $4,000 last month? ........ 4
DON‘T KNOW ............................................................... d (GO TO XI.E1)
REFUSED ..................................................................... r (GO TO XI.E1)
GO TO XI.D5
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XI.D4i. Was it . . .
Between $4,000 and $4,999 ......................................... 1
Between $5,000 and $5,999 ......................................... 2
Between $6,000 and $6,999 ......................................... 3
Between $7,000 and $7,999 ......................................... 4
Or was it more than $8,000 last month? ........................ 5
DON‘T KNOW ............................................................... d (GO TO XI.E1)
REFUSED ..................................................................... r (GO TO XI.E1)
XI.D5. Was this amount before or after taxes?
BEFORE ....................................................................... 1
AFTER .......................................................................... 2
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
XI.E1 Next I‘d like you to think about money you received from friends or relatives.
Last month, did you receive any money from friends or relatives?
YES............................................................................... 1
NO ................................................................................ 0
DON‘T KNOW ............................................................... d
(GO TO X.F1)
REFUSED ..................................................................... r
XI.E2 How much money did (you/ NAME) receive from friends or relatives last month?
|__|,|__|__|__| DOLLARS (GO TO XI.F1)
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
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XI.E2a. Was it less than $1,000?
YES............................................................................... 1
NO ................................................................................ 0 (GO TO XI.E2e)
DON‘T KNOW ............................................................... d (GO TO XI.F1
REFUSED ..................................................................... r (GO TO XI.F1)
XI.E2b. Was it less than $500?
YES............................................................................... 1
NO ................................................................................ 0 (GO TO XI.E2d)
DON‘T KNOW ............................................................... d (GO TO XI.F1)
REFUSED ..................................................................... r (GO TO XI.F1)
XI.E2c. Was it . . .
Less than $100 ............................................................. 1
Between $100 and $199 ............................................... 2
Between $200 and $299 ............................................... 3
Between $300 and $399, or .......................................... 4
Was it between $400 and $500 last month? .................. 5
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
GO TO XI.F1
XI.E2d. Was it . . .
Between $500 and $599 ............................................... 1
Between $600 and $699 ............................................... 2
Between $700 and $799 ............................................... 3
Between $800 and $899 ............................................... 4
Or was it between $900 and $1,000 last month? ........... 5
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
GO TO XI.F1
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XI.E2e. Was it less than $2,000?
YES............................................................................... 1
NO ................................................................................ 0 (GO TO XI.E2g)
DON‘T KNOW ............................................................... d (GO TO XI.F1)
REFUSED ..................................................................... r (GO TO XI.F1)
XI.E2f. Was it . . .
Between $1,000 and $1,199 ......................................... 1
Between $1,200 and $1,399 ......................................... 2
Between $1,400 and $1,599 ......................................... 3
Between $1,600 and $1,799 ......................................... 4
Or was it between $1,800 and $2,000 last month? ........ 5
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
GO TO XI.F1
XI.E2g. Was it less than $4,000?
YES............................................................................... 1
NO ................................................................................ 0 (GO TO XI.E2i)
DON‘T KNOW ............................................................... d (GO TO XI.F1)
REFUSED ..................................................................... r (GO TO XI.F1)
XI.E2h. Was it . . .
Between $2,000 and $2,499 ......................................... 1
Between $2,500 and $2,999 ......................................... 2
Between $3,000 and $3,499 ......................................... 3
Or was it between $3,500 and $4,000 last month? ........ 4
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
GO TO XI.F1
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XI.E2i. Was it . . .
Between $4,000 and $4,999 ......................................... 1
Between $5,000 and $5,999 ......................................... 2
Between $6,000 and $6,999 ......................................... 3
Between $7,000 and $7,999 ......................................... 4
Or was it more than $8,000 last month? ........................ 5
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
XI.F1 Next I‘d like you to think about money (you/NAME) received from any source we haven‘t
mentioned, such as money from interest, dividends, alimony, child support, or other
public assistance.
Last month, did (you/NAME) receive money from any source we haven‘t discussed?
YES............................................................................... 1
NO ................................................................................ 0
DON‘T KNOW ............................................................... d
(GO TO X.G1)
REFUSED ..................................................................... r
XI.F2 How much money did (you/ NAME) receive from other sources last month?
|__|,|__|__|__| DOLLARS (GO TO XI.G1)
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
XI.F2a. Was it less than $1,000?
YES............................................................................... 1
NO ................................................................................ 0 (GO TO XI.F2c)
DON‘T KNOW ............................................................... d (GO TO XI.G1
REFUSED ..................................................................... r (GO TO XI.G1)
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XI.F2b. Was it less than $500?
YES............................................................................... 1
NO ................................................................................ 0 (GO TO XI.F2d)
DON‘T KNOW ............................................................... d (GO TO XI.G1)
REFUSED ..................................................................... r (GO TO XI.G1)
XI.F2c. Was it . . .
Less than $100 ............................................................. 1
Between $100 and $199 ............................................... 2
Between $200 and $299 ............................................... 3
Between $300 and $399, or .......................................... 4
Was it between $400 and $500 last month? .................. 5
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
GO TO XI.G1
XI.F2d. Was it . . .
Between $500 and $599 ............................................... 1
Between $600 and $699 ............................................... 2
Between $700 and $799 ............................................... 3
Between $800 and $899 ............................................... 4
Or was it between $900 and $1,000 last month? ........... 5
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
GO TO XI.G1
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XI.F2e. Was it less than $2,000?
YES............................................................................... 1
NO ................................................................................ 0 (GO TO XI.F2g)
DON‘T KNOW ............................................................... d (GO TO XI.G1)
REFUSED ..................................................................... r (GO TO XI.G1)
XI.F2f. Was it . . .
Between $1,000 and $1,199 ......................................... 1
Between $1,200 and $1,399 ......................................... 2
Between $1,400 and $1,599 ......................................... 3
Between $1,600 and $1,799 ......................................... 4
Or was it between $1,800 and $2,000 last month? ........ 5
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
GO TO XI.G1
XI.F2g. Was it less than $4,000?
YES............................................................................... 1
NO ................................................................................ 0 (GO TO XI.F2i)
DON‘T KNOW ............................................................... d (GO TO XI.G1)
REFUSED ..................................................................... r (GO TO XI.G1)
XI.F2h. Was it . . .
Between $2,000 and $2,499 ......................................... 1
Between $2,500 and $2,999 ......................................... 2
Between $3,000 and $3,499 ......................................... 3
Or was it between $3,500 and $4,000 last month? ........ 4
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
GO TO XI.G1
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XI.F2i. Was it . . .
Between $4,000 and $4,999 ......................................... 1
Between $5,000 and $5,999 ......................................... 2
Between $6,000 and $6,999 ......................................... 3
Between $7,000 and $7,999 ......................................... 4
Or was it more than $8,000 last month? ........................ 5
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
XI.G1 You just told me that you received money from (LIST SOURCES) last month, which of
these is (your/NAME‘s) most important source of income?
PROGRAMMER: ONLY SHOW REPORTED SOURCES OF INCOME
TANF ............................................................................ 1
FOOD STAMPS ............................................................ 2
SSI/SSDI ....................................................................... 3
SM‘S JOB ..................................................................... 4
SPOUSE OR PARTNER‘S JOB .................................... 5
FRIENDS AND RELATIVES ......................................... 6
OTHER INCOME .......................................................... 7
DON‘T KNOW ............................................................... d
REFUSED ..................................................................... r
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SECTION XII: FINAL COMMENTS
XII.C1
INTERVIEWER:
DID SOMEONE HELP YOUTH ANSWER ANY OF THE
QUESTIONS?
YES, GOT SOME HELP ON SOME QUESTIONS ........ 1
YES, PROXY ANSWERED ALL QUESTIONS .............. 2
(GO TO XII.D1)
NO ................................................................................ 0
XII.C2
HOW DID THAT PERSON HELP YOUTH?
CODE ALL THAT APPLY
TRANSLATED INTO ANOTHER LANGUAGE ............ 1
USED ASL .................................................................... 2
PROVIDED ANSWERS TO A FEW QUESTIONS ......... 3
PROVIDED ANSWERS TO MANY QUESTIONS.......... 4
EXPLAINED A FEW QUESTIONS ................................ 5
EXPLAINED MANY QUESTIONS ................................. 6
OTHER (SPECIFY) ....................................................... 7
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(All)
XII.D1
Because people like you are such a valued part of what we do, I‘d like you to think
about the survey you just participated in. On a scale from 1 to 10 where one means 'it
was not a good use of time' and ten means, ―it was a good use of time‖, which number
between 1 and 10 best describes how you feel about your experience today?
|___|___|
(01-10)
XII.D2
Thank you for helping us with this important study. Your answers will help us better
understand how Social Security disability programs affect the lives of people receiving
these benefits.
As a token of our appreciation we will be sending a $10 (GIFT CARD) to you at
(FILL ADDRESS). Is this address correct?
INTERVIEWER:
CONFIRM INFORMATION AND MAKE CORRECTIONS IF
NEEDED.
YES............................................................................... 1
NO ................................................................................ 0
ADDRESS:
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
XII.D3
Thank you again for your help.
XII.D4
Are there any final comments you would like to make regarding your participation in
this research?
RECORD VERBATIM:___________________________________________________
_____________________________________________________________________
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CONTACT MODULE
Hello_SM.
Hello, my name is (INTERVIEWER‘S FULL NAME) and I am calling from
Mathematica Policy Research in Princeton, New Jersey. May I please speak
to (NAME)?
SPEAKING TO SAMPLE MEMBER .............................. 1 (SampMemb)
SM COMES TO THE PHONE ....................................... 2 (SampMemb)
SPEAKING TO LEGAL GUARDIAN .............................. 3 (Parent)
GUARDIAN COMES TO THE PHONE .......................... 4 (Parent)
WHAT IS CALL ABOUT ................................................ 5 (WhatAbout_SM)
SM/GUARDIAN BUSY, UNAVAILABLE, NOT HOME ... 6 (CALL BACK)
SM MOVED/LIVES ELSEWHERE ................................ 7 (KnowWhere)
SM/GUARDIAN SPEAKS SPANISH
[Spanish-speaking interviewer - interim status 410]....... 8
SM DOES NOT SPEAK ENGLISH OR SPANISH ......... 9 (Interpret)
GUARDIAN DOES NOT SPEAK ENGLISH
OR SPANISH ................................................................ 10 (Interpret)
SM HAS HEALTH PROBLEM ....................................... 11 (HealthProb)
SM IN INSTITUTION ..................................................... 12 (Institution)
SM DECEASED ............................................................ 13 (Deceased)
WRONG NUMBER ....................................................... 14 (Locating)
HUNG UP DURING INTRODUCTION .......................... 15 (HUDI)
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WhatAbout_SM Mathematica recently sent (NAME) a letter about a study we are doing for the
Social Security Administration. I work for Mathematica Policy Research, a
research company in Princeton, New Jersey. Can I please speak with
(NAME)?
SM COMES TO THE PHONE ....................................... 1 (SampMemb)
GUARDIAN COMES TO THE PHONE .......................... 2 (Guardian)
SM/GUARDIAN BUSY, UNAVAILABLE,
OR NOT HOME ............................................................ 3 (CALL BACK)
SM MOVED/LIVES ELSEWHERE ................................ 4 (KnowWhere)
SM/GUARDIAN SPEAKS SPANISH
[Spanish-speaking interviewer - interim status 410]....... 5
SM DOES NOT SPEAK ENGLISH OR SPANISH ......... 6 (Interpret)
GUARDIAN DOES NOT SPEAK ENGLISH
OR SPANISH ................................................................ 7 (Interpret)
SM/GUARDIAN PHYSICALLY OR MENTALLY
SM HAS HEALTH PROBLEM ....................................... 8 (HealthProb)
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Guardian. SCRIPT FOR GUARDIANS OF YOUTH.
IF GUARDIAN COMES TO PHONE: Hello, my name is ________ and I am calling
from Mathematica Policy Research about a study we are doing for the Social
Security Administration.
You may remember being interviewed by telephone about two years ago. At that
time you answered questions about (NAME) over the phone. About three years ago
we also spoke to you on the phone and sent you a consent form to sign, and a $10
INCENTIVE. IF TREATMENT, ADD: We also gave (NAME) a chance to be part of
the (NAME OF LOCAL YTD PROGRAM). When we spoke to you, we explained
that the study would have three interviews. This is the third and final one. The
questions I am calling to ask are about (NAME), (his/her) schooling, jobs, health,
and how (he/she) getting along day to day. The interview takes about 40 minutes to
complete by telephone. I will send (NAME) a $10 INCENTIVE when we are done.
Unlike the prior interviews when we first started the interview with you and then
spoke with (NAME). I would like to complete today‘s interview with (NAME). It
would be helpful for you to stay nearby in case (NAME) needs help.
Can I please speak with (NAME).
IF NECESSARY, ADD:
- All answers will be held in strict confidence.
- Most questions are worded so that young people with disabilities can answer for
themselves.
- If it would be better, an interviewer can come to your home instead of doing this
by telephone.
YES, CONTINUE .......................................................... 1 (SAMPMEMB)
NOT A GOOD TIME ...................................................... 2 (CALL BACK)
DID NOT RECEIVE LETTER/DOESN‘T RECALL ......... 3 (NoLetter)
NEED FIELD INTERVIEW ............................................ 4 (Field Review)
REFUSAL ..................................................................... 5 (REFUSAL)
SM UNABLE TO COMPLETE INTERVIEW .................. 6 (HEALTHPROB)
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SampMemb.
IF SM COMES TO PHONE: Hello, my name is ________ and I am calling from
Mathematica Policy Research about a study we are doing for the Social Security
Administration.
You may remember being interviewed by telephone about two years ago. At
that time you answered questions over the phone. About three years ago you
also answered questions over the phone and we sent you a consent form to sign
and a $10 INCENTIVE. IF TREATMENT, ADD: We also gave you a chance to
be part of the (NAME OF LOCAL YTD PROGRAM). When we spoke to you, we
explained that the study would have three interviews. This is the third and final
one. The questions I am calling to ask are about you, your schooling, jobs,
health, and how you are getting along day to day. The interview takes about 40
minutes to complete by telephone. I will send you a $10 INCENTIVE when we
are done. Let‘s begin.
IF NEEDED: The questions have been worded so you can answer for yourself.
If you wish, you can ask someone to stay nearby in case you need help.
IF NECESSARY, ADD:
- All your answers will be held in strict confidence.
- Nothing you say will affect the SSI benefits you get now or in the future.
- Most questions are worded so that young people with disabilities can answer
for themselves.
- If it would be better, an interviewer can come to your home instead of doing
this by telephone.
- We can start now and take a break if you need one.
YES, CONTINUE .......................................................... 1 (GO TO I.A1)
NOT A GOOD TIME ...................................................... 2 (CALL BACK)
DID NOT RECEIVE LETTER/DOESN‘T RECALL ......... 3 (NoLetter)
NEED FIELD INTERVIEW ............................................ 4 (Field Review)
REFUSAL ..................................................................... 5 (REFUSAL)
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NoLetter.
The letter explained that we would be calling to interview (you/NAME). The
questions should take about 40 minutes to answer. All of your answers will be
held in strict confidence. I can read the letter to you now and we can begin the
interview.
YES, CONTINUE .......................................................... 1 (GO TO I.A1)
NOT A GOOD TIME ...................................................... 2 (CALL BACK)
WANTS ANOTHER LETTER ........................................ 3 (SendLetter)
REFUSAL ..................................................................... 4 (REFUSAL)
SendLetter. I would be happy to send another letter. Please tell me the address where I
should send the letter.
INTERVIEWER NOTE: ADDRESS ENVELOPE FOR REMAIL.
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
StartNow.
That letter will be mailed today. Let‘s begin the interview now.
YES, BEGIN INTERVIEW ............................................. 1 (GO TO I.A1)
NO (INTERVIEWER SCHEDULE CALLBACK
IN 2 WEEKS) [letter requested - code 831] ................... 2 (CALL BACK)
HealthProb. ENTER TYPE OF HEALTH PROBLEM
HEARING PROBLEM ................................................... 1 (AmpTTY)
SPEECH PROBLEM ..................................................... 2 (AmpTTY)
PHYSICAL PROBLEM .................................................. 3 (CallLater)
COGNITIVE PROBLEM ................................................ 4 (NeedProxy)
CallLater.
Will (NAME) be able to talk on the telephone if I call back next week or will
(NAME) need help with the interview?
PROBE: The interview is designed to be answered by young adults with
disabilities.
YES/MAYBE WOULD ABLE TO DO NEXT WEEK ....... 1 (CALL BACK)
NO, WOULD NEED HELP FROM A PROXY ................ 0 (NeedProxy)
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AmpTTY.
I can get on a get a phone that will amplify my voice or (NAME)‘s, or we could use
a TTY service or instant messenger. Would either of these enable (NAME) to
complete the interview?
YES - amplifier phone ................................................... 1 (AmpPhone)
YES - TTY ..................................................................... 2 (CallTTY)
YES - instant messenger............................................... 3 (IMInterview)
NO ................................................................................ 4 (NeedProxy)
AmpPhone. Please hold while I get the amplifier phone.
INTERVIEWER: WHEN HAVE AMPLIFIER PHONE, ASK RESPONDENT TO
CALL SM TO THE PHONE.
SM COMES TO PHONE ............................................... 1 (SampMemb)
CALLBACK ................................................................... 2 (CALLBACK)
CallTTY.
I will call back in a few minutes after I have the help of a TTY operator.
INTERVIEWER: NEED TO ARRANGE NEXT CALL WITH TTY OPERATOR.
ARRANGE CALL WITH TTY OPERATOR .................... 1 (SampMemb)
IF UNSUCCESSFUL, SET CALLBACK ........................ 2 (CALLBACK)
IMInterview. INTERVIEWER: NEED TO COMPLETE BASELINE USING INSTANT
MESSENGER.
SM COMES TO PHONE, BEGIN WITH IM ................... 1 (SampMemb)
CALLBACK ................................................................... 2 (CALLBACK)
Interpret.
Perhaps there is someone who could interpret the questions on behalf of
(NAME/[NAME‘s] legal guardian). Is there someone there who can interpret?
YES, SPEAKING TO INTERPRETER ........................... 1 (InterpreterName)
YES, BUT NOT A GOOD TIME ..................................... 2 (InterpreterName)
NO INTERPRETER AVAILABLE .................................. 3 (Lang)
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InterpreterName.
IF SPEAKING WITH INTERPRETER: What is your name?
IF NOT SPEAKING WITH INTERPRETER: What is the interpreter‘s name?
RECORD FIRST AND LAST NAME
BEGIN BASELINE ........................................................ 1 (GO TO I.A1)
SCHEDULE CALLBACK [INTERIM STATUS 400] ........ 2 (CALL BACK)
Lang.
What language does (NAME) speak?
CHINESE (CANTONESE) ............................................. 1
CHINESE (MANDARIN) ................................................ 2
CHINESE (NON-SPECIFIED) ....................................... 3
HMONG ........................................................................ 4
ITALIAN ........................................................................ 5
JAPANESE ................................................................... 6
PORTUGUESE ............................................................. 7
RUSSIAN ...................................................................... 8
VIETNAMESE ............................................................... 9
OTHER ASIAN (SPECIFY) ........................................... 10
OTHER (SPECIFY) ....................................................... 11
LangCB.
Thank you. We will try to arrange for an interpreter to call (NAME).
SCHEDULE CALLBACK [INTERIM STATUS 400]
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Deceased.
I am very sorry to hear that (he/she) passed away.
Thank you. Please accept my condolences. Good-bye.
[END INTERVIEW - FINAL STATUS 440 - DECEASED]
Institution.
ENTER TYPE OF INSTITUTION:
HOSPITAL .................................................................... 1 (HomeSoon)
NURSING HOME .......................................................... 2 (Capable)
ASSISTED LIVING FACILITY ....................................... 3 (Capable)
GROUP HOME ............................................................. 4 (Capable)
JAIL OR PRISON .......................................................... 5 (Release)
HomeSoon.
Do you expect (NAME) to come home from the hospital within a week or two?
YES, APPOINTMENT MADE ........................................ 1 (CALL BACK)
SM UNABLE TO RESPOND, NEED PROXY ................ 2 (NeedProxy)
Release.
(NAME) should have received a letter about a study we are doing for the
Social Security Administration. I work for Mathematica Policy Research, a
research company in Princeton, New Jersey. The questions I will be asking
are about (NAME), work and school, and how (he/she) gets along day-to-day.
When do you expect (NAME) to get out of jail?
SCHEDULE CALL BACK FOR ANTICIPATED TIME OF RELEASE.
APPOINTMENT MADE
[Incarcerated -interim status 421] .................................. 1
UNKNOWN/MORE THAN ONE YEAR
[Supervisor Review Needed] ......................................... 2
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Capable.
(NAME) should have received a letter about a study we are doing for the Social
Security Administration. I work for Mathematica Policy Research, a research
company in Princeton, New Jersey. The questions I will be asking are about
(NAME), work and school, and how he/she gets along day-to-day.
If I called (NAME) at the group facility, would (he/she) be able to answer
questions (himself/herself) or would someone need to answer on (his/her)
behalf?
SM COULD RESPOND................................................. 1 (Facility)
SM COULD RESPOND BY FIELD ................................ 2 (Field Review)
SM COULD NOT RESPOND, NEED PROXY ............... 3 (NeedProxy)
Facility.
I would like to talk to (NAME) over the telephone about this research study.
Where is (NAME) living?
NAME OF PLACE:
FacAddress. What is the address?
ADDRESS OF PLACE:
FacPhone.
What is the phone number?
INTERVIEWER: RECORD PHONE NUMBER ON CONTACT SHEET.
PHONE NUMBER OF PLACE:
INTERVIEWER: RECORD BEST TIME TO REACH SM ON CONTACT
SHEET.
CALL SM AT NEW NUMBER........................................ 1 (CALL BACK)
NeedProxy.
Perhaps there is someone who could answer the questions on behalf of (NAME).
Is there a legal guardian, family member, or friend who is knowledgeable about
(his/her) school and work experiences and how (he/she) gets along day-to-day?
YES, LEGAL GUARDIAN CAN PROXY ........................ 1 (ProxyName)
YES, PROXY OTHER THAN LEGAL GUARDIAN ........ 2 (ProxyName2)
NO PROXY AVAILABLE
[FINAL STATUS - NO PROXY 470] .............................. 3
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ProxyName.
May I please have (your/his/her) legal guardian‘s name?
LEGAL GUARDIAN‘S FIRST AND LAST NAME
[GO TO ProxyRel]
ProxyName2. Who is the person who is most knowledgeable about (NAME)‘s school and work
experiences and how (he/she) gets along day-to-day?
May I please have (your/his/her) name?
PROXY‘S FIRST AND LAST NAME
ProxyRel.
How (are you/is proxy) related to (NAME)?
SPOUSE ....................................................................... 1
PARTNER ..................................................................... 2
SIBLING ........................................................................ 3
PARENT ....................................................................... 4
LEGAL GUARDIAN ....................................................... 5
NIECE/NEPHEW .......................................................... 6
OTHER RELATIVE ....................................................... 7
FRIEND ........................................................................ 8
OTHER (SPECIFY) ....................................................... 9
Speaking.
INTERVIEWER: ARE YOU SPEAKING TO PROXY? IS PROXY AVAILABLE?
SPEAKING TO PROXY ................................................ 1 (ProxyStart)
NOT SPEAKING TO PROXY, PROXY
NOT AVAILABLE, NEED TO GET
MORE INFORMATION ................................................. 2 (ProxyThere)
ProxyStart.
I‘d like to begin the interview now.
BEGIN INTERVIEW ...................................................... 1 (SampMemb)
SCHEDULE CALLBACK ............................................... 2 (CALL BACK)
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ProxyThere.
Does (NAME OF PROXY) live at this phone number or do I need to call
somewhere else to speak with (him/her)?
PROXY LIVES AT THIS NUMBER SCHEDULE CALLBACK ............................................... 1 (CALL BACK)
PROXY LIVES ELSEWHERE ....................................... 2 (ProxyPhone)
ProxyPhone. May I please have (his/her)telephone number?
TELEPHONE NUMBER:
ProxyAddr.
And (his/her)address?
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
[GO TO Thanks]
KnowWhere. (NAME) should have received a letter about a study we are doing for the Social
Security Administration. I work for Mathematica Policy Research, a research
company in Princeton, New Jersey.
Do you know how we can reach (NAME)?
YES............................................................................... 1 (NewPhone)
YES, NEED CALLBACK ............................................... 2 (CALLBACK)
NO [send to searching - interim status 530]................... 3
NewPhone.
Could you please give me the number where I can reach (him/her)?
INTERVIEWER: RECORD PHONE NUMBER AND ADDRESS ON CONTACT
SHEET.
TELEPHONE NUMBER:
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New Address.
May I please have (his/her) address?
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
Thanks.
Thank you very much for your time.
[exit case]
Thanks.
Thank you very much for your time.
[exit case]
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| File Type | application/pdf |
| File Title | MEMORANDUM |
| Author | Linda Mendenko |
| File Modified | 2009-01-08 |
| File Created | 2009-01-07 |