#1 - Bif

Innovative Strategies for Self Sufficiency (ISIS) Baseline

BIF 11-1-11_clean

#1 - BIF

OMB: 0970-0397

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IDENTIFYING INFORMATION


1. WHAT IS YOUR NAME?



___________________________

FIRST


______

M.I.


_____________________________________________

LAST


2. WHAT IS YOUR DATE OF BIRTH?



___ ___ / ___ ___ / ___ ___ ___ ___

(MONTH) (DAY) (YEAR)


3. WHAT IS YOUR SOCIAL SECURITY NUMBER?



___ ___ ___ - ___ ___ - ___ ___ ___ ___


4. WHAT IS YOUR ADDRESS?



_____________________________________________

STREET ADDRESS


__________________

APT #




__________________________________

CITY


________

STATE


__________________

ZIP


5a. WHAT IS YOUR PRIMARY PHONE NUMBER?


(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___


5b. WHAT IS YOUR SECONDARY PHONE NUMBER?


(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

1 HOME

2 CELL

3 WORK

1 HOME

2 CELL

3 WORK


6. WHAT IS YOUR E-MAIL ADDRESS?


__________________________________@______________________


BACKGROUND AND FAMILY CHARACTERISTICS

7. WHAT IS YOUR SEX?


1 MALE

2 FEMALE

8. WHAT IS YOUR MARITAL STATUS?

1 NOW MARRIED

2 WIDOWED

3 DIVORCED

4 SEPARATED

5 NEVER MARRIED

9. ARE YOU OF HISPANIC, LATINO, OR SPANISH ORIGIN?

1 NO, NOT OF HISPANIC, LATINO, OR SPANISH ORIGIN

2 YES, MEXICAN, MEXICAN AM., CHICANO

3 YES, PUERTO RICAN

4 YES, CUBAN

5 YES, ANOTHER HISPANIC, LATINO, OR SPANISH ORIGIN

10. WHAT IS YOUR RACE? (MARK ONE OR MORE)

1 WHITE

2 BLACK, AFRICAN AM., OR NEGRO

3 AMERICAN INDIAN OR ALASKA NATIVE

4 NATIVE HAWAIIAN OR PACIFIC ISLANDER

5 ASIAN


BACKGROUND AND FAMILY CHARACTERISTICS

11. WERE YOU BORN IN ONE OF THE 50 U.S. STATES, WASHINGTON D.C., OR PUERTO RICO?

1 YES

2NO IN WHAT YEAR DID YOU COME TO LIVE IN THE UNITED STATES, WASHINGTON D.C., OR PUERTO RICO? ___ ___ ___ ___

12a. DO YOU SPEAK A LANGUAGE OTHER THAN ENGLISH AT HOME?

1YES

2NO (PLEASE SKIP TO 13)

IF YES, HOW WELL DO YOU:

12b. SPEAK ENGLISH?

1VERY WELL

2WELL

3NOT WELL

4NOT AT ALL

12c. READ ENGLISH?

1VERY WELL

2WELL

3NOT WELL

4NOT AT ALL

13. WHICH OF THE FOLLOWING LIVE IN YOUR HOUSEHOLD AT LEAST HALF THE TIME? (MARK ONE OR MORE):

01YOUR SPOUSE

02YOUR UNMARRIED PARTNER

03YOUR BIOLOGICAL OR ADOPTED CHILDREN

04OTHER CHILDREN UNDER AGE 18

05YOUR MOTHER OR FATHER

06YOUR OTHER RELATIVES

07YOUR SPOUSE’S MOTHER OR FATHER

08YOUR SPOUSE’S OTHER RELATIVES

09FRIENDS

10OTHERS

11NO ONE ELSE

14. HOW MANY ADULTS AGE 18 OR OLDER, INCLUDING YOURSELF, LIVE WITH YOU AT LEAST HALF THE TIME? ____ ADULTS

15a. HOW MANY CHILDREN UNDER AGE 18 LIVE WITH YOU AT LEAST HALF THE TIME? (INCLUDE BIOLOGICAL, ADOPTED, FOSTER, STEP, AND ANY OTHER CHILDREN):


_­­­___ CHILDREN (IF ZERO, PLEASE SKIP TO 17 ON PAGE 4)

15b. FOR HOW MANY OF THESE CHILDREN ARE YOU OR YOUR SPOUSE THE LEGAL GUARDIAN?


____ CHILDREN (IF ZERO, PLEASE SKIP TO 17 ON PAGE 4)


BACKGROUND AND FAMILY CHARACTERISTICS

16. DO YOU HAVE ANY CHILDREN UNDER AGE 18 WHO DO NOT LIVE WITH YOU AT LEAST HALF THE TIME?

1NO

2YES HOW MANY CHILDREN? ____

EDUCATIONAL BACKGROUND

17. WHAT IS THE HIGHEST DEGREE OR LEVEL OF SCHOOL YOU HAVE COMPLETED? (MARK ONE):

1GRADE 1 THROUGH 11 PLEASE WRITE THE HIGHEST GRADE YOU COMPLETED 1-11 HERE: ___ ___

212th GRADE – NO DIPLOMA

3GED OR ALTERNATIVE CREDENTIAL

4REGULAR HIGH SCHOOL DIPLOMA

5SOME COLLEGE CREDIT, BUT LESS THAN 1 YEAR OF COLLEGE CREDIT

61 OR MORE YEARS OF COLLEGE CREDIT, BUT NO DEGREE

7ASSOCIATE’S DEGREE (FOR EXAMPLE, AA, AS)

8BACHELOR’S DEGREE OR HIGHER (FOR EXAMPLE BA, BS)

18. HAVE YOU RECEIVED A POST-SECONDARY VOCATIONAL OR TECHNICAL CERTIFICATE OR DIPLOMA?

1YES

2NO

19. HAVE YOU EVER ATTENDED ANY OF THE FOLLOWING EDUCATION AND TRAINING PROGRAMS? (MARK ONE OR MORE):

1ADULT BASIC EDUCATION

2ENGLISH AS SECOND LANGUAGE

3VOCATIONAL, TECHNICAL OR TRADE SCHOOL (OTHER THAN COLLEGE)

4CLASSES IN HOW TO SUCCEED IN SCHOOL (FOR EXAMPLE, COLLEGE SUCCESS COURSE)

5CLASSES IN HOW TO SUCCEED AT WORK (FOR EXAMPLE, WORK HABITS, COMMUNICATION)

6NONE OF THE ABOVE

20. WHAT IS THE HIGHEST LEVEL OF EDUCATION THAT YOU EVENTUALLY EXPECT TO COMPLETE? (MARK ONE)

1NO ADDITIONAL SCHOOL

2GED OR ALTERNATIVE CREDENTIAL

3REGULAR HIGH SCHOOL DIPLOMA

4ASSOCIATE’S DEGREE (FOR EXAMPLE, AA, AS)

5BACHELOR’S DEGREE (FOR EXAMPLE BA, BS)

6GRADUATE (MASTER’S, DOCTORAL, OR OTHER ADVANCED PROFESSIONAL) DEGREE


EDUCATIONAL BACKGROUND

21. WHAT IS THE HIGHEST LEVEL OF SCHOOL COMPLETED BY YOUR:

a. MOTHER (OR GUARDIAN #1)?

1NOT A HIGH SCHOOL GRADUATE

2GED OR ALTERNATIVE CREDENTIAL

3REGULAR HIGH SCHOOL DIPLOMA

4SOME COLLEGE CREDIT, BUT NO DEGREE

5ASSOCIATE’S DEGREE (FOR EXAMPLE, AA, AS)

6BACHELOR’S DEGREE OR HIGHER (FOR EXAMPLE BA, BS)

7DON’T KNOW

b. FATHER (OR GUARDIAN #2)?

1NOT A HIGH SCHOOL GRADUATE

2GED OR ALTERNATIVE CREDENTIAL

3REGULAR HIGH SCHOOL DIPLOMA

4SOME COLLEGE CREDIT, BUT NO DEGREE

5ASSOCIATE’S DEGREE (FOR EXAMPLE, AA, AS)

6BACHELOR’S DEGREE OR HIGHER (FOR EXAMPLE BA, BS)

7DON’T KNOW

EDUCATIONAL BACKGROUND

22. DO YOU HAVE ANY BROTHERS OR SISTERS WHO HAVE ATTENDED COLLEGE?

1YES

2NO

3DO NOT HAVE ANY BROTHERS OR SISTERS

23. WHAT GRADES DID YOU USUALLY GET IN HIGH SCHOOL? (MARK ONE):

1DID NOT ATTEND HIGH SCHOOL IN THE U.S.

2MOSTLY A’s

3MOSTLY B’s

4MOSTLY C’s

5MOSTLY D’s

6MOSTLY F’s

EMPLOYMENT AND INCOME

24. ARE YOU CURRENTLY WORKING AT A JOB FOR PAY? (MARK ONE)

1YES HOW MANY HOURS PER WEEK ON AVERAGE ARE YOU CURRENTLY WORKING? (INCLUDE ALL JOBS)


___ ___ HOURS/WEEK

2NO, BUT I WORKED BEFORE WHEN DID YOU LAST WORK?


___ ___ / ___ ___ ___ ___

(MONTH) (YEAR)

3NO, I NEVER WORKED (PLEASE SKIP TO 27)

25. IF YOU ANSWERED “YES” OR “NO, BUT I WORKED BEFORE” TO Q25: ABOUT HOW MUCH DO/DID YOU TYPICALLY EARN PER

HOUR BEFORE TAXES IN YOUR CURRENT OR MOST RECENT JOB? (ANSWER FOR YOUR MAIN JOB IF MORE THAN ONE)


$ ___ ___ . ___ ___ PER HOUR IN CURRENT/MOST RECENT JOB




IF YOU DO NOT KNOW THE HOURLY RATE, PLEASE GIVE EARNINGS IN ONE OF THE CATEGORIES BELOW:

$ ___ ___ ___ ___ PER DAY

$ ___ ___ ___ ___ PER WEEK

$ ___ ___ ___ ___ EVERY 2 WEEKS

$ ___ ___ ___ ___ TWICE A MONTH

$ ___ ___ ___ ___ EVERY MONTH

$ ___ ___ ___ ___ OTHER (SPECIFY TIME PERIOD: ____________________________________)


EMPLOYMENT AND INCOME

26. IN THE PAST MONTH, DID YOU OR ANYONE IN YOUR FAMILY (YOUR SPOUSE OR PARTNER AND ANY OTHER RELATIVES WHO LIVE WITH YOU) HAVE INCOME OR BENEFITS FROM ANY OF THE FOLLOWING SOURCES?

A) JOB EARNINGS?

1 YES

2 NO

ABOUT HOW MUCH WAS IT PER MONTH? $ ___________

B) WIC OR FOOD STAMPS (ALSO KNOWN AS SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM--SNAP)?

1 YES

2 NO

ABOUT HOW MUCH WAS IT PER MONTH? $ ___________

C) PUBLIC ASSISTANCE OR WELFARE

(NOT INCLUDING WIC OR FOOD STAMPS)?

1 YES

2 NO

ABOUT HOW MUCH WAS IT PER MONTH? $ ___________

D) FREE OR REDUCED LUNCH PROGRAM?

1 YES

2 NO


E) UNEMPLOYMENT INSURANCE, WORKER’S COMPENSATION, DISABILITY OR SOCIAL SECURITY BENEFITS?

1 YES

2 NO

ABOUT HOW MUCH WAS IT PER MONTH? $ ___________

F) CHILD SUPPORT (OFFICIAL OR UNOFFICIAL)?

1 YES

2 NO

ABOUT HOW MUCH WAS IT PER MONTH? $ ___________

G) FAMILY AND FRIENDS? (OUTSIDE THE HOUSEHOLD)

1 YES

2 NO

ABOUT HOW MUCH WAS IT PER MONTH? $ ___________

H) GRANTS OR LOANS FOR SCHOOL?

1 YES

2 NO

ABOUT HOW MUCH WAS IT PER MONTH? $ ___________

I) HOUSING CHOICE VOUCHER (KNOWN AS SECTION 8) OR PUBLIC HOUSING?

1 YES

2 NO

ABOUT HOW MUCH WAS IT PER MONTH? $ ___________

27. LAST YEAR, WHAT WAS YOUR TOTAL FAMILY INCOME? INCLUDE YOUR OWN EARNINGS AND ANY INCOME FROM YOUR SPOUSE OR PARTNER AND ANY OTHER RELATIVES WHO LIVE WITH YOU:


$ _______________________ AMOUNT




IF YOU DO NOT KNOW THE EXACT AMOUNT, PLEASE MARK THE CATEGORY BELOW THAT IS CLOSEST:

1 $0

2$1 TO $9,999

3$10,000 TO $14,999

4$15,000 TO $19,999

5$20,000 TO $24,999

6$25,000 TO $29,999

7$30,000 TO $34,999

08 $35,000 TO $39,999

09$40,000 TO $44,999

10$45,000 TO $49,999

11$50,000 TO $59,999

12$60,000 TO $69,999

13$70,000 TO $79,999

14$80,000 OR OVER


ALTERNATE CONTACTS

Please provide information for three persons not living with you who can help us locate you:

CONTACT #1

WHAT IS HIS/HER NAME?

_____________________________________

FIRST

_____________________________________________

LAST

WHAT IS HIS/HER RELATIONSHIP TO YOU?

_____________________________________________

WHAT IS HIS/HER ADDRESS?

_____________________________________________

STREET ADDRESS

__________________

APT #




__________________________________

CITY


________

STATE


__________________

ZIP


WHAT IS HIS/HER PRIMARY PHONE NUMBER?


(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___


WHAT IS HIS/HER SECONDARY PHONE NUMBER?


(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

1 HOME

2 CELL

3 WORK

1 HOME

2 CELL

3 WORK

WHAT IS HIS/HER E-MAIL ADDRESS?

__________________________________@______________________

CONTACT #2

WHAT IS HIS/HER NAME?

_____________________________________

FIRST

_____________________________________________

LAST

WHAT IS HIS/HER RELATIONSHIP TO YOU?

_____________________________________________

WHAT IS HIS/HER ADDRESS?

_____________________________________________

STREET ADDRESS

__________________

APT #




__________________________________

CITY


________

STATE


__________________

ZIP


WHAT IS HIS/HER PRIMARY PHONE NUMBER?


(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___


WHAT IS HIS/HER SECONDARY PHONE NUMBER?


(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

1 HOME

2 CELL

3 WORK

1 HOME

2 CELL

3 WORK

WHAT IS HIS/HER E-MAIL ADDRESS?

__________________________________@______________________

CONTACT #3

WHAT IS HIS/HER NAME?

_____________________________________

FIRST

_____________________________________________

LAST

WHAT IS HIS/HER RELATIONSHIP TO YOU?

_____________________________________________

WHAT IS HIS/HER ADDRESS?

_____________________________________________

STREET ADDRESS

__________________

APT #




__________________________________

CITY


________

STATE


__________________

ZIP


WHAT IS HIS/HER PRIMARY PHONE NUMBER?


(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___


WHAT IS HIS/HER SECONDARY PHONE NUMBER?


(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

1 HOME

2 CELL

3 WORK

1 HOME

2 CELL

3 WORK

WHAT IS HIS/HER E-MAIL ADDRESS?

__________________________________@______________________





Thank you for completing this form!


Please hand in this form and the signed copy of the white form to the staff person.


Next, please find the blue form in the envelope,

read the instructions on the front cover, and begin to work on it.
















File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleBasic Information Form
SubjectUnique ID
AuthorThe following form asks you a series of questions about your bac
File Modified0000-00-00
File Created2021-02-01

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