Form Baseline Survey Baseline Survey Baseline Survey

OMB # XXXX-XXXX

Exp. XX/XXXX

BASELINE SURVEY

This survey explores your experiences prior to entering the Transitional Living Program (TLP). The survey asks questions about your housing situation, general attitudes and beliefs, health issues, and activities. The survey should last approximately 30 minutes and is completely voluntary. You can choose not to answer any question.

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)

Public reporting burden for this collection of information is estimated to average .5 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

The information provide in the survey will remain strictly confidential and will have no effect on your participation in the Transitional Living Program or any other assistance you may be receiving.

B1. When is your birthday?

Month		Day		Year

Questions about your housing and experience in and goals for participating in this Transitional Living Program…

B2. Excluding your current stay in this TLP, have you been in any other TLP before?

Yes [ ] 01

No  GO TO QUESTION B3. [ ] 02

B2a. If yes, how many times have you enrolled in any TLP, including your stay in this TLP? ________

B2b. If yes, think about your last TLP you this one, why did you leave? (Check all that apply.)

I successfully completed the program [ ] 01

Program rules were too strict for me to live by [ ] 02

I couldn't make the contribution I was required to make to rent [ ] 03

I didn’t like/get along with the other youth in the TLP [ ] 04

I didn't like/get along with staff at the TLP [ ] 05

It was not possible for me to meet the education/employment requirements of the TLP [ ] 06

I found a better housing option elsewhere [ ] 07

I needed a break/time-out from the program [ ] 08

I was asked to leave/kicked out of the TLP [ ] 09

Other (Please specify) [ ] 94

B2c. If yes, why did you return to another TLP? (Check all that apply.)

I needed housing [ ] 01

I am now able to meet program participation requirements, because I completed a
drug/alcohol treatment program [ ] 02

I completed time in a jail/corrections facility [ ] 03

I now feel okay about program rules, which I thought were too strict before [ ] 04

I now understand and agree with the TLP program goals in a way
that I did not when I first enrolled in the TLP [ ] 05

Other (Please specify) [ ] 94

B3. Excluding the current episode of homelessness that made you eligible for the TLP, have you been homeless before? For example, have there been periods of time in your life when you slept outside or in places that are not meant for sleeping (such as a bus terminal or abandoned building), slept in an emergency shelter for homeless people, or had to stay with friends or other people because you had no other place to stay?

No, this is my first time being homeless [ ] 01

Yes, I have been homeless before coming to this TLP [ ] 02

B3a. If yes, how many times in your life have you been homeless?

None [ ] 01

Once [ ] 02

Two times [ ] 03

Three times [ ] 04

Four or more times [ ] 05

B3b. If yes, how many nights have you been homeless in total (over the course of your life)?

About 1-3 nights [ ] 01

About a week (7 nights) [ ] 02

More than a week, but less than a month [ ] 03

About a month [ ] 04

Two to six months [ ] 05

More than six months, but less than a year [ ] 06

A year or more [ ] 07

B4. What kind of living situation were you in prior to entering this TLP? (Check all that apply.)

I was living independently—that is, living alone paying for my own private room, apartment or housing, and not living with family [ ] 01

I was living in a private room, apartment or house, with a roommate/roommates, and

paying for my share of the rent [ ] 02

I was living with friend(s) without a written agreement (like a signed lease) and not paying

rent or not paying rent regularly [ ] 03

I was living with my parents or other family members [ ] 04

I was living in a foster home with my foster family [ ] 05

I was living in another type of foster care placement besides a family home, such as a

group home ..........................................................................................................................[ ] 16

I was living in a shelter [ ] 07

I was living in a transitional living program different from this one [ ] 08

I was living in a formal, supervised or partially supervised non-foster care group home

or halfway house [ ] 09

I was living on the streets or in other places that are not meant for sleeping—such as an abandoned building, bus terminal, or car [ ] 10

I was living in an educational institute (residential college, etc.)...........................................[ ] 11

I was living in a correctional facility/jail or detention center [ ] 12

I was living in a residential treatment facility as part of a substance abuse recovery plan ..[ ] 13

I was living in a mental health hospital or psychiatric residential treatment facility......................[ ] 14

I was living with a non-foster care unrelated adult but not in a “host home” or not in a residential setting where an adult is responsible to be present at all hours and provide supervision ...[ ] 15

I was living in a non-foster care “host home” where an adult is responsible to be present at all hours and provide supervision ......... ...................................................................................[ ] 16

In a military setting (base, camp, deployment or combat zone) [ ] 17

In another living situation (Please specify)............................................................................[ ] 94

B5. What was your reason for leaving the living situation you selected in B4? (Check all that apply.)

I was evicted or kicked out for not keeping up with my rent/mortgage [ ] 01

I was evicted or kicked out for some other reason [ ] 02

I completed my sentence in a corrections facility/jail or detention center [ ] 03

I left because my living situation was unsafe [ ] 04

I left because of problems getting along/conflict [ ] 05

I became too old to remain in my living situation [ ] 06

Other (Please specify) [ ] 94

B6. In the past 30 days, have you received any of the following services?

	In the past 30 days, have you received any of the following services?
	Yes	No	Don’t Know
Counseling/therapy/support groups (not family)
Counseling/therapy/support groups with family members
Peer-to-peer counseling
Physical/mental heath care
Educational services/tutoring/GED prep.
Vocational training
Life-skills training/Learning to live independently
Counseling/education on safe sex/prevention/abstinence
Financial planning/money management assistance
Employment service/career planning/job-coaching
Substance abuse treatment
Parenting education/child care/pregnancy supports
Legal services
Family reunification supports/assistance
Mentoring
Organized recreational activities such as an after school or community athletic or arts program
Transitional, exit care, or aftercare planning
Voluntary participation in organized activities intended to help others or the community
Other services (Please specify)

B7. How important are each of the following goals for participating in the TLP?

	This goal for my participation in the TLP is…
	1.	2.	3.	4	5
	Not at all important to me	A little important to me	Somewhat important for me	Very important for me.	Does not apply to me
Obtaining a high school diploma, getting a GED, or getting other additional formal education or training
Getting and keeping a job
Learning to deal better with people, to avoid getting into fights, and/or to manage my temper
Getting away from peers/friends who are involved in harmful or destructive behaviors
Getting stable housing
Accessing other public services/supports
Overcoming drug/alcohol dependency
Developing a connection with positive role models
Having a safe place to have my baby
Developing skills to live on my own and make positive decisions
Other goals (Please specify)

Questions about your attitudes and beliefs and about people in your life…

B8. Rate each of the following as true for you.

	1. Not at all true	2. Not very true	3. Sort of true	4. Very true
I can always manage to solve difficult problems if I try hard enough
If someone opposes me, I can find ways to get what I want
It is easy for me to stick to a plan and accomplish my goals
I know how to handle unexpected situations well
I can solve most problems if I invest the necessary effort
I can remain calm when facing difficulties because I can rely on my coping abilities
When I am confronted with a problem, I can usually find a solution and sometimes more than one solution
If I am in trouble, I can usually think of something to do
No matter what comes my way, I am usually able to handle it

B9. Rate each of the following as true for you.

	1. Not at all true	2. Not very true	3. Sort of true	4. Very true
I often think I am a failure (a “loser”)
I often feel ashamed of myself
I wish I had more to be proud of
I am happy with myself as a person
I am the kind of person I want to be
I like being just the way I am
I am as good a person as I want to be

B10. In your life, are there adults inside and/or outside the TLP who...

	Inside the TLP		Outside of the TLP
	Yes	No	Yes	No
…pay attention to what’s going on in your life?
…say something nice to you if you do something good?
…you can talk to about personal problems?
…you can go to if you are really upset about something?
…care about what happens to you?
…you can talk to about your goals and help you reach them?

B11. What is your current marital status? (Check one response.)

Married [ ] 01

Not Married [ ] 02

B12. How many children do you have (even if they don’t live with you)? ________

B12a. If you have children, how many of them currently live with you? ________

B13. Are you currently pregnant or expecting to become a father in the next 9 months?

Yes [ ] 01

No [ ] 02

Questions about your health status and healthcare…

B14. During the past 12 months, (a) did you have any of the following health needs? (Count any situation where you thought you should see a doctor, nurse, or other health professional.) And, during the past 12 months, (b) did you receive services/care for health needs you have identified? (Check all that apply.)

	a. Did you have any of the following health needs during the past 12 months?		b. Did you receive services/care for this health need?
	Yes	No	Yes	No
I was physically sick
I was injured
I needed mental health care or counseling
I had a chronic (on-going) health problem (such as asthma or diabetes)
I needed dental care
I needed prescription medicines
I needed regular check-ups with a doctor
I needed prenatal services or care for my child
I had other healthcare need(s) (Please specify)

B15. During the past 4 weeks, how much of the time…

	All of the time	Most of the time	A good bit of the time	Some of the time	A little bit of the time	None of the time
…have you been a very nervous person?
…have you felt calm and peaceful?
…have you felt downhearted and blue?
…were you a happy person?
…have you felt so down in the dumps that nothing could cheer you up?

B16. Do you have health insurance?

Yes, through state or hospital “free care,”such as a free or low cost clinic that doesn’t require insurance [ ] 01

Yes, through a private insurance company [ ] 02

Yes, through my employer [ ] 03

No [ ] 04

Don’t know [ ] 05

Questions about things you do/your activities…

B17. Have you ever voted in a national, state, or local election?

Yes [ ] 01

No [ ] 02

B18. Do you belong to a church, synagogue, temple, mosque, tribal spiritual group, or other religious group?

Yes [ ] 01

No [ ] 02

B19. Do you participate in any school-related extracurricular activities, such as school sports teams, band, or clubs?

Yes [ ] 01

No [ ] 02

Not applicable, because I do not attend school ………………………………………………... [ ] 03

B20. Do you participate in any out-of-school organizations or clubs, such as Boy or Girl Scouts, or community service groups?

Yes [ ] 01

No [ ] 02

B21. Do you volunteer regularly to help local community organizations or groups?

Yes [ ] 01

No [ ] 02

B22. In the last 6 months, have you ever...?

	Yes	No
Skipped a full day of school or work without a real excuse?
Intentionally damaged or destroyed property that did not belong to you?
Stolen something?
Helped in a gambling operation?
Hurt someone badly enough to need medical attention?
Sold illegal drugs?

B23. How many times in the past month did you use any of the following drugs?

	1. I have never used	2. None in the past month	3. Once or twice	4. 3–5 times	5. 6 times or more
Alcohol
Marijuana (pot, weed)
Inhalants (glue, gas, aerosol spray)
Medicine not prescribed for you
Incorrectly using too much or too little of your own prescription medication(s)
Cocaine or crack
Methamphetamines ("speed," "crystal meth")
Heroin
Ecstasy or “club” drugs
Psychedelic drugs like LSD or mescaline
Some other drug (Please write its name) _________________________________

B24. Have you ever had any type of sex with a male or female partner?

Yes [ ] 01

No GO TO QUESTION B25. [ ] 02

B24a. If yes, the very last time you had any type of sex with a male or female partner, was a condom used?

Yes [ ] 01

No [ ] 02

Don't know [ ] 03

B24b. If yes, in the past 12 months, did you receive anything in exchange for having sexual relations, such as money, food, drugs, or shelter?

Yes [ ] 01

No [ ] 02

Don't know [ ] 03

B25. Did any of your caregivers ever sexually molest you, that is, touch you in a sexual way?

Yes [ ] 01

No [ ] 02

B26. Did any of your caregivers ever physically harm you (not including sexual abuse)?

Yes [ ] 01

No [ ] 02

B27. Did any of your caregivers ever emotionally abuse you (but not sexually), such as making serious threats or using words to humiliate you?

Yes [ ] 01

No [ ] 02

B28. Did any of your caregivers ever neglect your basic needs for food or safety?

Yes [ ] 01

No [ ] 02

B29. In the past 12 months, have you ever gone to court for any criminal offense by either a civilian or military court other than minor traffic violations?

Yes [ ] 01

No [ ] 02

B29a. If yes, were you convicted of a criminal offense?

Yes [ ] 01

No [ ] 02

B30. Have you ever spent a night or more in jail, a correctional facility, or a juvenile detention center?

Yes [ ] 01

No [ ] 02

Questions about your finances, employment and education…

B31. Which option best describes your current employment situation? (Check one response.)

Employed full-time [ ] 01

Employed part-time [ ] 02

Employed seasonally/sporadically [ ] 03

Not employed, looking for work [ ] 04

Not employed, in school [ ] 05

Not employed, unable to work PLEASE ANSWER QUESTION B31a. [ ] 06

B31a. If you answered “Not employed, unable to work”, why are you unable to work?

Physical or other type of disability [ ] 01

Other (please describe) _________________________________ [ ] 01

B32. [If answer to B31 is employed full- or part-time or seasonally] Last month, before taxes were taken out …

32a. What was your hourly pay rate? $_____________

32b. How many hours did you work last month? # hours_______

32c. What was your total monthly income? $_____________

B33. At the end of the month do you usually have… (Check one response.)

Some money left over [ ] 01

Just enough to make ends meet [ ] 02

Not enough to make ends meet [ ] 03

B34. Do you currently have a savings account?

Yes [ ] 01

No [ ] 02

B35. What government support services do you currently receive? (Check all that apply.)

Public assistance (TANF, Welfare) [ ] 01

WIC/food stamps [ ] 02

Social security [ ] 03

Unemployment insurance, workers’ compensation, disability insurance [ ] 04

Receive services, but I’m not sure what they are [ ] 05

I don’t receive government support services [ ] 06

Other (Please specify) [ ] 94

B36. Have you ever served on active duty in the U.S. Military or National Guard?

Yes [ ] 01

No [ ] 02

B37. What is the highest level of education you have completed? (Check one response.)

8th grade or less [ ] 01

Some high school, no diploma [ ] 02

High school diploma [ ] 03

High school equivalency, or GED [ ] 04

Vocational or trade school after high school [ ] 05

Some college [ ] 06

Associate's degree (Community or two-year college) [ ] 07

Four-year college degree or higher [ ] 08

B38. Are you currently enrolled in school or some other education program (such as vocational training or GED prep)?

Yes [ ] 01

No [ ] 02

B38a. If yes, is this full- or part-time?

Full-time [ ] 01

Part-time [ ] 02

B38b. If yes, what kind of education program is this? (Check one response.)

High school [ ] 01

GED or alternative high-school equivalency program [ ] 02

Vocational school [ ] 03

2-year college [ ] 04

4-year college [ ] 05

Other (Please specify) [ ] 94

Questions about where you come from…

B39. Were you born in the United States?

Yes [ ] 01

No [ ] 02

B39a. If no, how long have you lived in the United States? _________

B40. What is your native language, that is the language which you learned first?

English [ ] 01

Spanish [ ] 02

Other (Please specify) [ ] 94

B41. Is this contact information for you correct?

Yes [ ] 01

No [ ] 02

[List current contact info from RHYMIS.]

Name

Address

City State Zip

Home phone Cell phone

Email

B41a If that information is not correct, could you please provide the correct information?

Name

Address

City State Zip

Home phone Cell phone

Email

We may want to contact you when you complete the program for a follow-up survey. You may want to provide contact information for parents, guardians, relatives, or other people who know how to get in touch with you in the future. The purpose of collecting this information is to be able to reach you in the future. We will NOT discuss or share any of your personal information with anyone you may have listed as a contact. Your personal information will be strictly confidential.

B42. Could you provide the name and contact information for someone who does not live with you and will always know how to contact you?

Yes [ ] 01

No [ ] 02

Name of additional contact

Additional contact's relationship to you

Email of additional contact

Address of additional contact

Cell phone number of additional contact

Home phone number of additional contact

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