Attachment F4 – Youth 12 Month Follow-Up Survey
OMB # XXXX-XXXX
Exp. XX/XXXX
TLP YOUTH
TWELVE MONTH FOLLOW-UP SURVEY
F1. Where do you currently live? (Please check the one response that best describes your living situation.)
Living independently—that is, living alone paying for my own private room, apartment or housing, and not living with family [ ] 01
In a private room, apartment or house, with a roommate/roommates, and paying for my
share of the rent [ ] 02
With friend(s) without a written agreement (like a signed lease) and not paying rent or not paying rent regularly [ ] 03
With my parents or other family members [ ] 04
In a foster home with a foster family [ ] 05
In another type of foster care placement besides a family home, such as a group home [ ] 06
In a shelter [ ] 07
In a transitional living program different from this one [ ] 08
In a formal, supervised or partially supervised non-foster care group home or
halfway house [ ] 09
On the streets or in other places that are not meant for sleeping—such as an abandoned building, bus terminal, or car [ ] 10
In an educational institute (residential college, etc.).............................................................[ ] 11
In a correctional facility/jail or detention center [ ] 12
In a residential treatment facility as part of a substance abuse recovery plan..................... [ ] 13
In a mental health hospital or psychiatric residential treatment facility [ ] 14
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
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
Don’t know [ ] XX
F2. Do you expect to remain in this housing situation for the next 6 months?
Yes [ ] 01
No [ ] 02
F3. In the past 12 months, have you been homeless—that is, have you ever: slept outside or in a place that was 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, I have not been homeless over the past 12 months [ ] 01
Yes, I have been homeless over the past 12 months [ ] 02
F3a. If yes, in the past 12 months, about how many nights have you been homeless in total?
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
More than a month [ ] 05
F4. In the past 12 months, what kinds of services have you received (if any) and by whom?
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F4a. Service received? |
F4b. Service provided by… |
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Yes |
No |
Don’t Know |
TLP you exited |
Another program or agency |
Counseling/therapy/support groups (not family) |
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Counseling/therapy/support groups with family members |
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Peer-to-peer counseling |
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Physical/mental healthcare |
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Educational services/tutoring/GED prep. |
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Vocational training |
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Life-skills training/Learning to live independently |
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Counseling/education on safe sex/prevention/abstinence |
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Financial planning/money management assistance |
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Employment service/career planning/job-coaching |
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Substance abuse treatment |
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Parenting education/child care/pregnancy supports |
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Legal services |
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Family reunification supports/assistance |
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Mentoring |
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Organized recreational activities such as an after school or community athletic or arts program |
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Transitional, exit care, or aftercare planning |
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Voluntary participation in organized activities intended to help others or the community |
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Other services (Please specify)
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F5. Rate the following as true for you.
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1.Not at all true |
2.Not very true |
3.Sort of true |
4.Very |
I can always manage to solve difficult problems if I try hard enough |
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If someone opposes me, I can find ways to get what I want |
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It is easy for me to stick to my aims and accomplish my goals |
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I know how to handle unexpected situations well |
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I can solve most problems if I invest the necessary effort |
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I can remain calm when facing difficulties because I can rely on my coping abilities |
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When I am confronted with a problem, I can usually find one and sometimes more than one solution |
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If I am in trouble, I can usually think of something to do |
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No matter what comes my way, I am usually able to handle it |
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F6. Rate each of the following as true for you.
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1.Not at all true |
2.Not very true |
3. Sort of true |
4.Very |
I often think I am a failure (a “loser”) |
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I often feel ashamed of myself |
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I wish I had more to be proud of |
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I am happy with myself as a person |
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I am the kind of person I want to be |
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I like being just the way I am |
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I am as good a person as I want to be |
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F7. In your life, are there adults who...
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Yes |
No |
…pay attention to what’s going on in your life? |
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…say something nice to you if you do something good? |
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…you can talk to about personal problems? |
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…you can talk to about your goals and help you reach them? |
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…you can go to if you are really upset about something? |
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…care about what happens to you? |
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F8. What is your current marital status? (Check one response.)
Married. [ ] 01
Not married [ ] 02
F9. How many children do you have (even if they don’t live with you)? ________
F9a. If you have children, how many of them currently live with you? ________
F10. Are you currently pregnant or expecting to become a father in the next 9 months?
Yes [ ] 01
No [ ] 02
F11. During the last 12 months since you left the 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 during the last 12 months since you left the TLP,
(b) did you receive services/care for health needs you have identified? (Check all that apply.)
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a. Did you have any of the following health needs? |
b. Did you receive services/care for this health need? |
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Yes |
No |
Yes |
No |
I was physically sick |
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I was injured |
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I needed mental health care or counseling |
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I had a chronic (on-going) health problem |
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I needed dental care |
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I needed prescription medicines |
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I used preventive health care/had a regular check-up by a doctor |
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I needed prenatal services or care for my child |
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I had another healthcare need (Please specify)
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F12. During the past 4 weeks, how much of the time…
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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? |
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…have you felt calm and peaceful? |
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…have you felt downhearted and blue? |
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…were you a happy person? |
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…have you felt so down in the dumps that nothing could cheer you up? |
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F13. Do you have health insurance?
Yes, through a government program such as Medicaid [ ] 01
Yes, through a free or low cost clinic that doesn’t require insurance [ ] 02
Yes, through a private insurance company [ ] 03
Yes, through my employer [ ] 04
No [ ] 05
Don’t know [ ] 06
F14. In the past 6 months have you voted in a national, state or local election?
Yes [ ] 01
No [ ] 02
F15. In the past 6 months, have you joined a church, synagogue, temple, mosque, tribal spiritual group, or other religious group?
Yes [ ] 01
No [ ] 02
F16. In the past 6 months have you participated in any school-related extracurricular activities, such as school sports teams, band, or clubs?
Yes [ ] 01
No [ ] 02
F17. In the past 6 months, have you participated in any out-of-school organizations or clubs, such as Boy or Girl Scouts, or community service groups?
Yes [ ] 01
No [ ] 02
F18. In the past 6 months, have you volunteered regularly to help local community organizations or groups?
Yes [ ] 01
No [ ] 02
F19. Since exiting the TLP, have you ever...?
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Yes |
No |
1. Skipped a full day of school or work without a real excuse? |
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2. Intentionally damaged or destroyed property that did not belong to you? |
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3. Stolen something? |
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4. Helped in a gambling operation? |
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5. Hurt someone badly enough to need medical attention? |
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6. Sold illegal drugs? |
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F20. How many times in the past month did you use any of the following drugs?
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I have never used |
None in the past month |
Once or twice |
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More than 6 times |
Alcohol |
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Marijuana (pot, weed) |
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Inhalants (glue, gas, aerosol spray) |
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Medicine not prescribed for you |
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Incorrectly using too much or too little of your own prescription medication(s) |
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Cocaine or crack |
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Methamphetamines ("speed," "crystal meth") |
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Heroin |
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Ecstasy or “club” drugs |
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Psychedelic drugs like LSD or mescaline |
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Some other drug (Please write its name)
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F21. In the past 6 months, have you had any type of sex with a male or female partner?
Yes [ ] 01
No GO TO QUESTION F14b [ ] 02
F21a. 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
F21b. If yes, in the past 6 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
F22. In the past 6 months, has anyone sexually molested you, that is, touched you in a sexual way?
Yes [ ] 01
No [ ] 02
F23. In the past 6 months, has anyone ever physically harmed you (not including sexual abuse)?
Yes [ ] 01
No [ ] 02
F24. In the past 6 months, has anyone ever emotionally abused you (but not sexually), such as making serious threats or using words to humiliate you?
Yes [ ] 01
No [ ] 02
F25. In the past 6 months, has anyone ever neglected your basic needs for food or safety?
Yes [ ] 01
No [ ] 02
F26. In the past 6 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
F26a. If yes, were you convicted of a criminal offense?
Yes [ ] 01
No [ ] 02
F27. Have you ever spent a night or more in jail, a correctional facility or a juvenile detention center?
Yes [ ] 01
No [ ] 02
F28. 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 29a [ ] 06
F28a. Why are you unable to work?
Physical or other type of disability [ ] 01
Other (please describe)____________________________________________________ [ ] 02
F29. [If answer to F29 is employed full- or part-time or seasonally] Last month, before taxes were taken out, what was your …
29a. What was your hourly pay rate? $_____________
26b. How many hours did you work last month? # hours_______
26c. What was your total monthly income? .........................................................$_____________
F30. 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
F31. Do you currently have a savings account?
Yes [ ] 01
No [ ] 02
F32. 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?
F33. Have you ever served on active duty in the U.S. Military or National Guard?
Yes [ ] 01
No [ ] 02
F34. 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
F35. Are you currently enrolled in school or some other education program (such as vocational training or GED prep)?
Yes [ ] 01
No [ ] 02
F35a. If yes, is this full- or part-time?
Full-time [ ] 01
Part-time [ ] 01
F35b. If yes, what kind of education program is this? (Check one response.)
High school [ ] 01
GED or alternative high-school equivalency program [ ] 01
Vocational school [ ] 01
2-year college [ ] 01
4-year college [ ] 01
Other (Please specify) [ ] 94
F36. Our records show your current contact information is as follows:
Name
Address
City State Zip
Home phone Cell phone
F36a. If that information is not correct, could you please provide the correct information?
Name
Address
City State Zip
Home phone Cell phone
We may want to contact you when you complete the program for a follow-up survey. We are asking you 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.
F37. 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
| File Type | application/msword |
| File Title | BASELINE |
| Author | Falzones |
| Last Modified By | DuntonL |
| File Modified | 2010-04-26 |
| File Created | 2010-04-26 |