Form Exit Survey Exit Survey Exit Survey

OMB # XXXX-XXXX

Exp. XX/XXXX

EXIT SURVEY

This survey explores your experiences since 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 any assistance you may be receiving after exiting the TLP.

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

E1. Why did you leave the TLP? (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

E2. Where do you plan to go immediately after leaving the TLP? (Please check one response.)

To a private room, apartment or house, living alone, paying for my own housing and not living with family [ ] 01

To a private room, apartment or house, with a roommate/roommates, and paying for my

share of the rent [ ] 02

To a friend(s)’ home, without a written agreement (like a signed lease) and not paying rent or

not paying rent regularly [ ] 03

To a parent’s or other family member's home [ ] 04

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

To another type of foster placement besides a family home, such as a group home [ ] 06

To a shelter [ ] 07

To a different transitional living program [ ] 08

To a formal, supervised or partially supervised non-foster care group home

or halfway house [ ] 09

To the street or in other places that are not meant for sleeping—such as an abandoned building, bus terminal, or car [ ] 10

To an educational institute (residential college, etc.) [ ] 11

To a correctional institution, jail or detention center [ ] 12

To a residential treatment facility as part of a substance abuse recovery plan....................[ ] 13

To a mental health hospital or psychiatric residential treatment facility [ ] 14

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

To a non-foster care “host home” where an adult is responsible to be present at all hours and

provide supervision [ ] 16

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

To another living situation (Please specify) [ ] 94

Don’t know [ ] XX

E3. During your stay in the TLP, did you participate in, or receive, an assessment of any kind and, if so, how many times?

	E3a. Assessment received?			E3b. Service provided by…
Type of assessment	Yes	No	Don’t Know	Your TLP	Another program or agency
Career ,employment or vocational
Housing needs
Behavioral or psychological
Physical or mental health
Substance abuse
Skills or aptitude (e.g., life skills, educational, etc)
Other services (Please specify)

E4. Knowing what you know now, if you had to decide all over again whether to join the TLP, what would you decide?

Would definitely join [ ] 01

Would likely join [ ] 02

Not sure [ ] 03

Would definitely not join [ ] 04

E5. How prepared do you feel to live when you leave the TLP? Would you say you feel…
(Check one response.)

Very prepared [ ] 01

Somewhat prepared [ ] 02

Not very well prepared [ ] 03

Not at all prepared [ ] 04

Don't know [ ] XX

E6. Did you receive any of the following services at the TLP (or through a referral from the TLP to another agency/provider)? (Check all that apply.) Which of these were the most helpful to you? (Check the three most helpful.)

	Received Service	Service Offered but not Accepted	Three most helpful
Counseling/therapy/support groups (not family)
Counseling/therapy/support groups with family members
Peer-to-peer counseling
Physical/mental healthcare
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 (If yes go to E6a, b,c, d and e.)
Other services (Please specify)

E6a. Did your participation include helping to plan the TLP’s voluntary activities? [ ]01

E6b. During or after these event(s) did the TLP provide opportunities to discuss or think about the meaning or significance of what you did? .............................................................................[ ]01

E6c. Did your volunteer experience with the TLP affect you or your attitude,

Positive effect .......................................................................................................................[ ]01

Negative effect......................................................................................................................[ ]02

There was very little or no effect...........................................................................................[ ]03

E6d. Did it affect your feelings about yourself?

Positive effect....................................................................................................... .................[ ]01

Negative effect ......................................................................................................................[ ]02

There was very little or no effect........................................................................ ..................[ ]03

E6e. Did it affect your feelings about being part of a larger group or community?

Positive effect ........................................................................................................................[ ]01

Negative effect ......................................................................................................................[ ]02

There was very little or no effect............................................................................................[ ]03

E7. Are there supports or services that were not offered that would have better prepared you to achieve your goals?

Yes [ ] 01

No [ ] 02

E7a. If yes to E7, what are those supports or services? (Check all that apply.)

Counseling/therapy/support groups (not family) [ ] 01

Counseling/therapy/support groups with family members [ ] 02

Peer-to-peer counseling [ ] 03

Physical/mental healthcare [ ] 04

Educational services/tutoring/GED prep. [ ] 05

Vocational training [ ] 06

Life-skills training/Learning to live independently [ ] 07

Counseling/education on safe sex/prevention/abstinence [ ] 08

Financial planning/money management assistance [ ] 09

Employment service/career planning/job-coaching [ ] 10

Substance abuse treatment [ ] 11

Parenting education/child care/pregnancy supports ............................................................[ ] 12

Legal services [ ] 13

Family reunification supports/assistance [ ] 14

Mentoring [ ] 15

Organized recreational activities such as an after school or community athletic

or arts program [ ] 16

Transitional, exit care, or aftercare planning [ ] 17

Voluntary participation in organized activities intended to help others or the community [ ] 18

Other services (Please specify)

____________________________________________________ [ ] 94

E8. To what extent did participating in this TLP help you with each of the following?

	1. Not at all	2. A little	3. A medium amount/ moderately	4. A lot	5. Did not participate
Obtaining a high school diploma, getting a GED or getting other 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
Gaining leadership and/or decision-making or life skills
Having a safe place to have my baby
Other goals (Please specify) _______________________________________________

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

E9. 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 my plans 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

E10. 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

E11. In your life, are there adults inside and/or outside the TLP who...

	Within the TLP		Outside 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?

E12. What is your current marital status? (Check one response.)

Married [ ] 01

Not Married [ ] 02

E13. How many children do you have (even if they don’t live with you)? ________

E13a. If you have children, how many of them currently live with you? ________

E14. Are you currently pregnant or expecting to become a father in the next 9 months?

Yes [ ] 01

No [ ] 02

E15. What would you like to be doing two years from now? (Check all that apply.)

Working full-time [ ] 01

Working part-time [ ] 02

Enlisted in military service, National Guard/ Reserves [ ] 03

Participating in national service or volunteer work (for example, Peace Corps,
faith-based volunteer services, etc.) [ ] 04

Caring for my children / parents at home [ ] 05

Attending technical school and/or a community college [ ] 06

Attending school at a four-year college [ ] 07

Other (Please specify) [ ] 94

Questions about your health status and healthcare…

E16. Since entering TLP, (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.) (Check all that apply.) And, since entering TLP, (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?		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 used regular check-ups with a doctor
I needed prenatal services or care for my child
I had other healthcare need(s) (Please specify)

E17. 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?

E18. 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 [ ] XX

Questions about things you do/your activities…

E19. Have you ever voted in a national, state, or local election?

Yes [ ] 01

No [ ] 02

E20. Do you belong to a church, synagogue, temple, mosque, tribal spiritual group, or other religious group?

Yes [ ] 01

No [ ] 02

E21. 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

E22. 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

E23. Do you volunteer regularly to help local community organizations or groups?

Yes [ ] 01

No [ ] 02

E24. Since entering the TLP, have you ever...?

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

E25. How many times in the past month did you use any of the following drugs?

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

E26. Have you ever had any type of sex with a male or female partner?

Yes [ ] 01

No GO TO QUESTION E27. [ ] 02

E26a. 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

E26b. 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 [ ] xx

E27. Did any of your TLP caregivers ever sexually molest you, that is, touch you in a sexual way?

Yes [ ] 01

No [ ] 02

E28. Did any of your TLP caregivers ever physically harm you (not including sexual abuse)?

Yes [ ] 01

No [ ] 02

E29. Did any of your TLP caregivers ever emotionally abuse you (but not sexually), such as making serious threats or using words to humiliate you?

Yes [ ] 01

No [ ] 02

E30. Did any of your TLP caregivers ever neglect your basic needs for food or safety?

Yes [ ] 01

No [ ] 02

E31. Since entering the TLP, 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

E31a. If yes, were you convicted of that criminal offense?

Yes [ ] 01

No [ ] 02

E32. Since entering the TLP, have you spent a night or more in jail, a correctional facility, or juvenile detention?

Yes [ ] 01

No [ ] 02

Questions about your finances, employment and education…

E33. 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 E33a [ ] 06

E33a. If you answered “Not employed, unable to work”, why are you unable to work?

Physical or other type of disability [ ] 01

Other (please describe)____________________________________________________ [ ] 02

E34. [If answer to E33 is employed full- or part-time or seasonally] Last month, before taxes were taken out, what was your …

34a. What was your hourly pay rate? $_____________

34b. How many hours did you work last month? # hours_______

34c. What was your total monthly income? $_____________

E35. 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

E36. Do you currently have a savings account?

Yes [ ] 01

No [ ] 02

E37. 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

___________________________________________________________________________

E38. Have you ever served on active duty in the U.S. Military or National Guard?

Yes [ ] 01

No [ ] 02

E39. 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

E40. Are you currently enrolled in school or some other education program (such as vocational training or GED prep)?

Yes [ ] 01

No [ ] 02

E40a. If yes, is this full- or part-time?

Full-time [ ] 01

Part-time [ ] 02

E40b. 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

E41. Our records show your current contact information is as follows:

[List current contact info from RHYMIS.]

Name

Address

City State Zip

Home phone Cell phone

Email

E41a. 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.

E42. 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

17