Follow-Up Survey for Successful Applicants

APPENDIX C

FOLLOW-UP SURVEY

THIS PAGE IS INTENTIONALLY BLANK

O MB No.: xxxx-xxxx

Expiration Date: xx/xx/20xx

SELF-EMPLOYMENT TRAINING (SET) DEMONSTRATION

Follow-Up Survey

The SET Demonstration is being carried out under the legal authority of PL 105-220 (subtitle D [sections 171 and 172]). Completing this form, which seeks to help the U.S. Department of Labor understand the effects of SET services on customers’ employment-related outcomes, is voluntary. The public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate to the Office of Policy Development and Research, U.S. Department of Labor, Room N5641, 200 Constitution Avenue, NW, Washington, DC, 20210.

Mathematica Policy Research is conducting a survey for the U.S. Department of Labor of people who applied to the Self-Employment Training (SET) Demonstration Program. This survey asks about your experiences with self-employment, self-employment services, wage and salary employment, and overall well-being since applying to that program. Most of the questions we ask refer to a specific date. This is the date you applied to the SET Program.

Your opinions and experiences are extremely important, even if you never participated or are no longer participating in the program. The information you and others provide will be used to improve services for people interested in self-employment. Under the public burden statement required by the Paperwork Reduction Act of 1995, our OMB control number for this information collection is _______  and permission to collect this data expires on ________.  Responding to this questionnaire is completely voluntary.  The survey will take about 60 minutes for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. We will send you a check for $25 once you complete the survey. Please allow about three weeks for the check to arrive.

Your responses are private and will not be shared with the U.S. Department of Labor, staff at the SET project, or any other agency except as required by law.  

You may have received a letter recently which explained the study to you.

You may remember that you applied to the SET program about 18 months ago.

Please note: When asked to enter a dollar amount, please round to the nearest dollar.

For example, for $279.82, enter $280. For $4,725.44, enter $4,725.

To start the survey, we would like to ask you some questions about your main work-related activities currently. Please note that, for this survey, self-employment can include business ventures that represent your main work activity or that you are pursuing on the side or in addition to wage or salary employment. You should consider yourself self-employed even if you did not make any money from the business venture. Also, please count any business ventures in which you were not the sole owner, that is, you were a co-owner.

A1. Are you currently self-employed in your own business, professional practice, or farm?

1 □ Yes

0 □ No

A2. Are you currently working for someone else in a job where you are paid a salary or hourly wage? Please include jobs in which you worked at a private for-profit company, a nonprofit organization, a government agency, or a family business that you did not own.

1 □ Yes

0 □ No

INTERVIEWER: IF A1=1 and A2=1, GO TO A3. IF A1=0 AND A2=0, GO TO A4. OTHERWISE GO TO SECTION B.

A3. Since you are currently both self-employed and working for someone else, which do you consider to be your primary work activity?

MARK ONE ONLY

1

ALL RESPONSES GO TO SECTION B

□ Self-employment

2 □ Working for someone else

3 □ Both are equal

A4. Given that you are not currently self-employed or working for someone else, which of the following best describes your work-related activities over the past month? Were you…

MARK ONE ONLY

1 □ Retired,

2 □ Unable to work because of a disability,

3 □ In school or a training program,

4 □ Unemployed on temporary layoff,

5 □ Unemployed and looking for work,

6 □ Unemployed and not looking for work,

7 □ Caring for a family member, or

8 □ Doing something else? (Specify)

Next, we would like to ask you some questions about any self-employment assistance services or programs that you may have participated in over the past 18 months to help you decide whether self-employment was right for you and establish, or grow a business. These services or programs could include:

One-on-One Meetings with Self-Employment Advisor

B1. Since [RANDOM ASSIGNMENT DATE], have you worked with a self-employment advisor or counselor who met with you one-on-one to regularly track your self-employment needs and progress, and help link you to services or resources to start or expand your own business?

1 □ Yes

0 □ No GO TO B2

B1a. How many meetings with this self-employment advisor or counselor did you participate in since [RANDOM ASSIGNMENT DATE]?

| | | | number of meetings

B1b. On average, how long did each of these meetings with last?

| | | hours | | | minutes

B1c. What organization(s) provided you with this self-employment advisor or counselor?

LIST ALL THAT APPLY

1

2

3

4

5

B1d. Thinking about all the meetings with this self-employment advisor or counselor in which you participated since [RANDOM ASSIGNMENT DATE], about how much did you pay out-of-pocket for these services in total?

Please round to the nearest dollar.

$ | | , | | | | amount

B1e. Overall, how satisfied were you with the services that you received from this self-employment advisor(s) or counselor(s)?

MARK ONE ONLY

1 □ Very satisfied

2 □ Somewhat satisfied

3 □ Neither satisfied nor dissatisfied

4 □ Somewhat dissatisfied

5 □ Very dissatisfied

CLASSES, WORKSHOPS, OR SEMINARS

B2. Since [Random Assignment Date], have you participated in any in-person classes, workshops, or seminars on topics related to starting, operating, or growing a business? Please do not include online courses here.

1 □ Yes

0 □ No GO TO B3

B2a. About how many in-person classes, workshops, or seminars have you participated since [RANDOM ASSIGNMENT DATE]?

| | | | number of sessions

B2b. On average, about how long did each of these in-person classes, workshops, or seminars last?

| | | hours | | | minutes

B2c. Thinking about all the in-person classes, workshops, or seminars on topics related to operating a business in which you have participated since [RANDOM ASSIGNMENT DATE], about how much did you pay out-of-pocket for all of these classes, workshops, or seminars?

Please round to the nearest dollar.

$ | | , | | | | amount

B3. Since [RANDOM ASSIGNMENT DATE], have you accessed any online courses on topics related to starting, operating, or growing a business? Please do not include in-person classes here.

1 □ Yes

0 □ No GO TO B4

B3a. About how many online courses on topics related to operating a business have you accessed since [RANDOM ASSIGNMENT DATE]?

| | | | number of online courses

B3b. On average, about how much time did you spend taking each of these online courses? For example if for one course you completed 4 one hour sessions, enter 4 hours.

| | | hours | | | minutes

B3c. Thinking about all of the online courses on topics related to operating a business that you have accessed since [RANDOM ASSIGNMENT DATE], about how much did you pay out-of-pocket for these courses?

Please round to the nearest dollar.

$ | | , | | | | amount

INDIVIDUALIZED BUSINESS DEVELOPMENT SUPPORT

In this section we would like to ask you about individualized business development support you received that focused on specific issues, for example developing your business and marketing strategies, managing your finances, applying for loans or grants, hiring employees, or using information technology.

Please do not include any time spent in periodic meetings with a self-employment advisor(s) or counselor(s) who met with you regularly to track your self-employment needs and progress, and/or helped link you to specific services or resources for your business.

B4. Since [RANDOM ASSIGNMENT DATE], have you received any individualized business development support on specific issues that you were encountering in starting or expanding your own business(es)?

1 □ Yes

0 □ No GO TO B5

B4a. How many of these sessions did you participate in since [RANDOM ASSIGNMENT DATE]?

| | | | number of sessions

B4b. On average, how long did each session last?

| | | hours | | | minutes

B4c. Thinking about all of the business development support sessions that you have participated in since [RANDOM ASSIGNMENT DATE], about how much did you pay out-of-pocket for all of these services?

Please round to the nearest dollar.

$ | | , | | | | amount

PEER ADVICE/NETWORKING GROUPS FOR ENTREPRENEURS

Next, we will ask you about groups in which you may have participated to share ideas, strategies, or information with other individuals who are self-employed or trying to start a business.

B5. Since [RANDOM ASSIGNMENT DATE], have you participated in any in-person peer advice or networking group meetings for self-employed persons or persons interested in becoming self-employed? Please do not include online groups here.

1 □ Yes

0 □ No GO TO B6

B5a. How many in-person peer group meetings have you attended since [RANDOM ASSIGNMENT DATE]?

| | | | number of sessions

B5b. On average, how long did each of these in-person peer group meetings last?

| | | hours | | | minutes

B5c. Thinking about all of the in-person peer group meetings that you have attended since [RANDOM ASSIGNMENT DATE], about how much did you pay out-of-pocket for these services?

Please round to the nearest dollar.

$ | | , | | | | amount

B6. Since [RANDOM ASSIGNMENT DATE], have you participated in any online peer discussion groups or forums for people who are currently self-employed or are interested in becoming self employed?

1 □ Yes

0 □ No GO TO B7

B6a. Which of the following best describes your participation level in those online peer discussion groups or forums?

MARK ONE ONLY

1 □ Daily

2 □ A few times a week

3 □ A few times a month

4 □ Every couple of months

5 □ Rarely

MENTORING

Next, we would like to ask you about experiences you may have had with an experienced business owner who mentored you as you were developing your business idea, or starting and growing your business.

Don’t include anyone we have already talked about.

B7. Since [RANDOM ASSIGNMENT DATE], have you worked with one or more experienced business owner(s) who acted as your personal mentor(s)?

1 □ Yes

0 □ No GO TO B8

B7a. About how many meetings have you had with all personal mentor(s) since [RANDOM ASSIGNMENT DATE]?

| | | | number of meetings

B7b. Typically, how long did each of these meetings last?

| | | hours | | | minutes

B7c. Thinking about all of the mentoring meetings since [RANDOM ASSIGNMENT DATE], about how much did you pay out-of-pocket for these services?

Please round to the nearest dollar.

$ | | , | | | | amount

OTHER SELF-EMPLOYMENT SERVICES RECEIVED

B8. Since [RANDOM ASSIGNMENT DATE], have you received any other types of self-employment services that we haven’t already talked about?

1 □ Yes

0 □ No GO TO BOX B9

B8a. What were these services?

NO SELF-EMPLOYMENT SERVICES

BOX B9

IF ANY B1 – B8 = 1, GO TO B10. ELSE, CONTINUE.

B9. Why didn’t you participate in any self-employment services or programs since [RANDOM ASSIGNMENT DATE]?

MARK ALL THAT APPLY

1 □ Didn’t think services would be helpful

2 □ Services located too far away

3 □ Times inconvenient

4 □ Didn’t want to wait for classes to begin

5 □ Decided to postpone self-employment

6 □ Decided not to pursue self-employment at all

7 □ Too busy

8 □ Services too expensive

9 □ Child care problems

10 □ Transportation problems

11 □ Other (Specify)

BOX B10

IF ANY B1 – B8 = 1, GO TO B10. ELSE, GO TO B13.

TOPICS ADDRESSED BY SELF-EMPLOYMENT SERVICES

Below is a list of topics commonly addressed by the self-employment services we just discussed, including mentors. Please indicate whether any of the services that you received since [RANDOM ASSIGNMENT DATE] addressed each of the following topics. For each topic, please indicate if the services received were helpful in addressing the topic.

INTERVIEWER: IF ANY B10a - p = 1, ASK B11 IMMEDIATELY FOLLOWING.

B10. Did any of the self-employment assistance services that you received cover…

	MARK ONE RESPONSE PER ROW
	YES	NO
a. Deciding whether or not to pursue self-employment?	1 □	0 □
b. Refining your business idea(s)?	1 □	0 □
c. Developing your business marketing strategy?	1 □	0 □
d. Promoting your business using social media?	1 □	0 □
e. Understanding the laws and regulations that apply to your business?	1 □	0 □
f. Registering your business?	1 □	0 □
g. Improving your credit?	1 □	0 □
h. Bookkeeping?	1 □	0 □
i. Preparing your business taxes?	1 □	0 □
j. Hiring and managing employees?	1 □	0 □
k. Managing relations with clients?	1 □	0 □
l. Using computers or other technology?	1 □	0 □
m. Obtaining financing for your business?	1 □	0 □
n. Working with business partners?	1 □	0 □
o. Working with investors?	1 □	0 □
p. Anything else? (Specify).	1 □	0 □

B11. Since [RANDOM ASSIGNMENT DATE] What organization(s) provided you with the most services?

LIST UP TO THREE

1

2

3

B11a. Thinking about all of the self-employment services that you have received, how would you rate your overall satisfaction with the services that you received?

MARK ONE ONLY

1 □ Extremely satisfied

2 □ Somewhat satisfied

3 □ Neither satisfied nor dissatisfied

4 □ Somewhat dissatisfied

5 □ Extremely dissatisfied

B12. Are there any services that you did not have access to, did not receive, or did not receive enough of that could have helped you in starting or growing your own business?

1 □ Yes

0 □ No GO TO B13

B12a. What additional services would have been helpful to you?

SELF-EMPLOYMENT MILESTONES

B13. Have you started or updated a business plan since [RANDOM ASSIGNMENT DATE]?

1 □ Yes

0 □ No

B13a. Since [RANDOM ASSIGNMENT DATE], did you complete a business plan or finish revisions on a plan that you already had at [RANDOM ASSIGNMENT DATE]?

1 □ Yes

0 □ No GO TO B15

B14. Since [RANDOM ASSIGNMENT DATE], did you receive any help writing or updating a business plan? Please include any help received from an advisor or counselor, a mentor, or someone in a networking group or workshop (even if you did not complete the business plan).

1 □ Yes

0 □ No

MARKETING PLAN

B15. Since [RANDOM ASSIGNMENT DATE], did you develop or update a marketing plan?

1 □ Yes

0 □ No GO TO B17

B16. Since [RANDOM ASSIGNMENT DATE], did you receive any help writing or updating your marketing plan? Please include any help received from an advisor or counselor, a mentor, or someone in a networking group or workshop even if you did not complete the marketing plan.

1 □ Yes

0 □ No

SOURCES OF BUSINESS CAPITAL

B17. Since [RANDOM ASSIGNMENT Date], have you received any help identifying sources of loans?

1 □ Yes

0 □ No

B18. Since [RANDOM ASSIGNMENT DATE], have you applied for a loan from a bank or financial institution?

1 □ Yes

0 □ No GO TO B20

B19. Since [RANDOM ASSIGNMENT Date], have you received any help with completing loan applications?

1 □ Yes

0 □ No

B20. Did you actually borrow money from any source for your business since [RANDOM ASSIGNMENT DATE]?

1 □ Yes

0 □ No GO TO B21

B20a. From what source(s) have you borrowed money for the business?

MARK ALL THAT APPLY

1 □ Personal or family home equity loan

2 □ Personal or business credit card(s)

3 □ Business loan from a government agency

4 □ Business loan from a bank or financial institution

5 □ Loan from family or friend(s)

B21. Since [RANDOM ASSIGNMENT DATE], have you received any help identifying grants or other non-loan sources of business capital?

1 □ Yes

0 □ No

B21a. Since [RANDOM ASSIGNMENT DATE], have you received any help applying for grants?

1 □ Yes

0 □ No

B22. Since [RANDOM ASSIGNMENT DATE], have you applied for a grant or other non-loan source of business capital?

1 □ Yes

0 □ No GO TO C1

B23. Did you receive one or more grants or other non-loan sources of business capital since [RANDOM ASSIGNMENT DATE]?

MARK ONE ONLY

1 □ Received one or more grants

2 □ Received other type(s) of non-loan business capital

3 □ Received both grants and other non-loan help

0 □ Didn’t receive either type of help

The next questions are about the businesses you have undertaken or been pursuing since [RANDOM ASSIGNMENT DATE].

Remember, self-employment can include business ventures that represent your main work activity or that you are pursuing on the side or in addition to wage or salary employment. You should consider yourself self-employed even if you did not make any or much money from the business venture.

INTERVIEWER: GO TO C2 IF A1=1. ELSE, ASK C1.

C1. At any time since [RANDOM ASSIGNMENT DATE] have you owned your own business or been self-employed in your own business, professional practice, or farm?

1 □ Yes

0 □ No

INTERVIEWER: GO TO BOX C27 if C1=00 AND A1=00

C2. How many distinct businesses have you undertaken since [RANDOM ASSIGNMENT DATE]? Please include any businesses that you have co-owned.

| | | | number of ventures

C3. Over the last 12 months, how much were your net earnings from self-employment after business expenses, but before taxes and deductions were taken out? (If you lost money, please report loss as negative earnings.)

$ | | | | , | | | | total amount

Now, we would like to ask you some detailed questions about your most recent or current business or self-employment venture. If you currently have or most recently had more than one business, please answer these questions referring to the business that you considered to be your main business or self-employment venture since [RANDOM ASSIGNMENT DATE].

C4. What is the name of your current or most recent business or self-employment venture?

Specify

C4a. What is the zip code where this business is or was located?

| | | | | | zip code

C5. What kind of business is this? What did you make, sell, or do?

Specify

C6. When did you establish or start operating this business or self-employment venture? Your best estimate is fine.

| | | / | | | | |

month year

C7. Is this business or self-employment venture. . .

	MARK ONE RESPONSE PER ROW
	YES	NO
a. registered with your state?	1 □	0 □
b. registered with your county?	1 □	0 □
c. registered with your city or town?	1 □	0 □
d. incorporated? Please include C-Corps, S. Corps, and LLCs.	1 □	0 □

C8. Since you started this business, have you . . .

	MARK ONE RESPONSE PER ROW
	YES	NO
a. used a financial planning program or software?	1 □	0 □
b. created a website or social networking site, such as Facebook, for the business?	1 □	0 □
c. gotten a checking account for the business?	1 □	0 □
d. obtained an employer identification number (EIN) or other tax identification number for the business?	1 □	0 □

C9. Since [RANDOM ASSIGNMENT DATE], how many hours did you usually work in an average day at this business? Please include any time that you spent working from home, whether or not you compensated yourself for this time.

| | | average number of hours per day

C9a. And how many days did you usually work in an average week at this business?

| | | average number of days per week

C10. Since [RANDOM ASSIGNMENT DATE], how many weeks did you work? Please include any time that you spent working from home, whether or not you compensated yourself for this time.

| | | number of weeks

C11. Since [RANDOM ASSIGNMENT DATE], have any family members, people living in your household, or friends worked in this business without being paid?

1 □ Yes

0 □ No GO TO C12

C11a. How many people?

| | | number of people

C12. On average since [RANDOM ASSIGNMENT DATE], how much were the monthly receipts or sales for this business? Your best estimate is fine.

$ | | | | , | | | | total amount

C13. On average since [RANDOM ASSIGNMENT DATE], how much did you typically pay yourself in salary and wage payments from this business?

$ | | | | , | | | | total amount IF “0”, go to C14

C13a. Was that per week, per month, per year or something else?

MARK ONE ONLY

1 □ Per hour

2 □ Per day

3 □ Per week

4 □ Every two weeks

5 □ Twice a month

6 □ Monthly

7 □ Per year

8 □ Other(Specify)

C14. In total, since [RANDOM ASSIGNMENT DATE], how much did you pay yourself in bonuses or profit distributions from this business? Please include money that you might have occasionally drawn out of the business for personal use.

$ | | | | , | | | | total amount

C15. On average, since [RANDOM ASSIGNMENT DATE], how much were your other monthly expenses for this business? Please do not include any payments to yourself, but include any payments to family members. Your best estimate is fine.

$ | | | | , | | | | monthly expenses

C16. What [is/was] the total number of employees that [currently/most recently] work[ed] in this business? Please do not include yourself but include any other paid employees (including family members and business partners).

| | | number of paid employees other than self

0 □ None GO TO C17

C16a. What is the current or most recent monthly payroll for this business?

Please do not include yourself but include any other paid employees (including family members).

| | | monthly payroll

C17. [Is/Was] this business structured as a sole proprietorship?

1 □ Yes GO TO C19

0 □ No

C18. What percent of this business [do/did] you own?

| | | | %

C19. When you first set up your business, did you purchase it from someone else?

1 □ Yes

0 □ No GO TO C22

C20. When did you purchase your business?

| | | / | | | | |

month year

C21. How much did you pay for it?

$ | | | | , | | | | amount

C22. Since [RANDOM ASSIGNMENT DATE], how much of your own money have you invested in this business? Please do not include any money borrowed or received from others such as angel investors, venture capitalists, relatives, or friends or any money you paid for classes or other self-employment training. Your best estimate is fine.

$ | | | | , | | | | amount

0 □ Did not invest any of my own money

C23. Since [RANDOM ASSIGNMENT DATE], how much money have you borrowed for this business? Please only include any money received that needs to be repaid.

$ | | | | , | | | | amount

0 □ Did not borrow any money GO TO C24

C23b. What was the interest rate for the [loan/largest loan] that you obtained for this business since [RANDOM ASSIGNMENT DATE]? If you obtained multiple loans, please answer for the largest loan obtained since [RANDOM ASSIGNMENT DATE].

| | | annual percentage rate

C23c. What was the term or repayment period for [this loan/the largest loan that you obtained] for this business since [RANDOM ASSIGNMENT DATE]?

| | | length

1 □ Weeks

2 □ Months

3 □ Years

4 □ Open

C24. Since [RANDOM ASSIGNMENT DATE], how much money have you received as grants for this business?

$ | | | | , | | | | amount

0 □ Did not receive any grants GO TO C25

C24a. What [is/was/were] the source[s] of these grants?

Specify

C25. Apart from any of your own money, money you borrowed, or grants you received since [RANDOM ASSIGNMENT DATE], did you use any other sources of capital to start or grow this business? You should include funds from investments by venture capitalists or other investors and gifts from family members or friends that do not need to be repaid.

1 □ Yes

0 □ No GO TO C26

C25a. Altogether, how much did you receive from these other sources since [RANDOM ASSIGNMENT DATE]?

$ | | | | , | | | | amount

C25b. What were these other sources of capital?

MARK ALL THAT APPLY

1 □ Gifts or investments from family members

2 □ Gifts or investments from friends

3 □ Funds from venture capitalists or investors

4 □ Other (Specify)

C26. Are you operating this business or self-employment venture currently?

1 □ Yes GO TO C28

0 □ No

C26a. When did you stop operating this business or self-employment venture? Your best estimate is fine.

| | | / | | | | |

month year

C26b. Why did you stop operating this business?

MARK ALL THAT APPLY

1 □ Sold the business

2 □ Business did not provide enough income

3 □ Got hired somewhere else

4 □ Hours too long

5 □ Income too uncertain

6 □ Illness or disability

7 □ Couldn’t obtain financing

8 □ Other (Specify)

C26c. What did you do when you stopped operating this business?

MARK ALL THAT APPLY

1 □ Took a job working for someone else

2 □ Started another business

3 □ Looked for work

4 □ Participated in education or training program

5 □ Took care of child, family member, or sick relative

6 □ Retired

7 □ Was sick

8 □ Other (Specify)

BOX C27.

ASK C27 ONLY IF A1 = 0 AND C1 = 0. ELSE GO TO C28.

C27. At any time since [RANDOM ASSIGNMENT DATE] have you tried to be self-employed or start your own business?

1 □ Yes

0 □ No GO TO D1

C28. What would you say have been the most difficult challenges that you faced in trying to be self-employed or start your own business?

MARK ALL THAT APPLY

1 □ Lack of knowledge about operating or growing the type of business chosen

2 □ Difficulties accessing credit or loans to start or operate the business

3 □ Lack of personal funds, grants, and/or investments to use for business start-up capital

4 □ Insufficient sales, revenues, or cash flow

5 □ Difficulties becoming known or finding customers/clients

6 □ High taxes, insurance fees, or licensing costs

7 □ Competition from similar businesses

8 □ Uncertainty about future prospects or changing economy

9 □ Problems with suppliers or getting source materials for your product/service

10 □ Difficulties finding or hiring qualified staff

11 □ Excessive regulations, paperwork, or documentation requirements

12 □ Amount of time/work involved

13 □ Unexpected personal or family barriers

14 □ Other (Specify)

The next questions are about all wage or salary jobs where you were working for someone else that you have held since [RANDOM ASSIGNMENT DATE].

D1. At any time since [RANDOM ASSIGNMENT DATE] have you had a job in which you worked for someone else and got paid a wage or salary? Please include odd jobs and off-the-books employment.

1 □ Yes

0 □ No

INTERVIEWER INSTRUCTION: GO TO E1 if D1=00 AND A2=00.

D2. Over the last 12 months, how much did you earn in wages, salary, commissions, bonuses, or tips from all jobs in which you worked for someone else? Please give amount before taxes and deductions were taken out.

$ | | | | , | | | | amount

D3. Currently, how many different (full- and part-time) wage or salary jobs do you have where you work for someone else?

| | | total jobs

0 □ None

Now, we would like to ask you some detailed questions about your current or most recent job working for someone else since [RANDOM ASSIGNMENT DATE] from which you received a wage or salary income. If you currently have or most recently had more than one job, please think about the job for which you had the most income since [RANDOM ASSIGNMENT DATE]. Do not include odd jobs or off-the-books employment here.

D4. What is the name of the employer for your [current/most recent] wage and salary job?

EMPLOYER NAME

D5. When did you start working for (EMPLOYER)? Your best estimate is fine.

| | | / | | | | |

month year

D6. What kind of company [is/was] [EMPLOYER]? What [do/did] they make, sell, or do? Please be specific.

TYPE OF PRODUCT OR SERVICE

D7. What [do/did] you do there? What [is/was] your job title?

Specify

D8. Which of the following best describes your employment status at [EMPLOYER]?
Are or were you . . .

MARK ONE ONLY

1 □ an employee, working for pay at a private company

2 □ an employee, working for pay at a nonprofit organization

3 □ a local, state, or federal government employee

4 □ working in a family business that you did not own, or

5 □ on active military duty?

6 □ Other (Specify)

D9. Since [RANDOM ASSIGNMENT DATE], how long did you work at a salary or hourly-wage job for someone else?

1  All 12 months GO TO D10

| | | WEEKS

D10. Since [RANDOM ASSIGNMENT DATE], how many hours did you usually work in an average week at [EMPLOYER]?

Your best estimate is fine.

| | | hours per week

D11. What [is/was] your [current/most recent] rate of pay before taxes and other deductions? Please include any tips, bonuses, or commissions.

$ | | | | , | | | | amount

MARK ONE ONLY

1 □ Per day

2 □ Per week

3 □ Once every two weeks

4 □ Twice a month

5 □ Per month

6 □ Per year

D12. When did you stop working for [EMPLOYER]?

| | | / | | | | |

month year

0 □ Still at job GO TO E1

D13. Why did you stop working at [EMPLOYER]?

MARK ONE ONLY

1 □ Quit

2 □ Retired

3 □ Laid off

4 □ Fired

5 □ Work, period or temporary job ended

6 □ Other (Specify)

D14. When that job ended, what did you do?

MARK ONE ONLY

1 □ Started a business

2 □ Worked on starting my own business

3 □ Took another job

4 □ Looked for work

5 □ Participated in education or training program

6 □ Took care of child, family member or sick relative

7 □ Retired

8 □ Was sick

9 □ Other (Specify)

PROGRAMMER: ASK E1 AND E2 ONLY IF (A1=1 OR A2=1 OR C26=1 OR D12=0). ELSE, GO TO E3.

E1. Overall, how satisfied are you with your current employment situation?

MARK ONE ONLY

1 □ Extremely satisfied

2 □ Somewhat satisfied

3 □ Neither satisfied nor dissatisfied

4 □ Somewhat dissatisfied

5 □ Extremely dissatisfied

AVAILABILITY OF FRINGE BENEFITS

E2. Currently, do you qualify for any of the following benefits from either a wage or salary job or through your own business?

	MARK ONE RESPONSE PER ROW
	YES	NO
a. Paid sick leave?	1 □	0 □
b. Paid vacation?	1 □	0 □
c. Paid holidays?	1 □	0 □
d. Access to health insurance, for example an HMO or PPO plan?	1 □	0 □
e. Access to dental insurance?	1 □	0 □
f. Retirement or pension benefits, a 401K plan?	1 □	0 □
g. Life insurance?	1 □	0 □
h. Disability insurance?	1 □	0 □
i. Profit-sharing, or stock options?	1 □	0 □
j. Any other benefits? (Specify)	1 □	0 □

HEALTH INSURANCE

E3. Currently, are you covered by health insurance? Please include health insurance coverage from any source, including your own self-employment venture or small business, a job in which you work for another employer, the job of a family member, or a public insurance program.

1 □ Yes

0 □ No GO TO E4

E3a. What is the primary source of that insurance?

MARK ONE ONLY

1 □ Through your self-employment venture

2 □ Through your wage and salary job

3 □ Through spouse or partner’s employment

4 □ Through a trade association

5 □ Through Medicaid, Medicare, or other public health insurance

6 □ Through a private insurer

7 □ Through the VA

8 □ Through some other source (Specify)

E4. Since [RANDOM ASSIGNMENT DATE], for approximately how long were you without health insurance coverage? Your best estimate is fine.

| | | months

UNEMPLOYMENT COMPENSATION

E5a. Altogether, since [RANDOM ASSIGNMENT DATE], for how many weeks or months have you received unemployment benefits?

| | | weeks OR | | | months IF “0”, GO TO E6

E5b. On average, how much Unemployment Compensation did you receive each week?

$ | | | | , | | | | amount

E5c. Are you still collecting unemployment benefits today?

1 □ Yes GO TO E6

0 □ No

E5d. Why did you stop collecting benefits?

MARK ONE ONLY

1 □ Found other employment

2 □ Benefits ran out

3 □ Went on disability

4 □ No longer needed to work

5 □ Other (Specify)

E6. Since [RANDOM ASSIGNMENT DATE], have you received any of the following from a government program or agency?

	MARK ONE RESPONSE PER ROW
	YES	NO
a. Trade Readjustment Allowances (TRA) or Trade Adjustment Assistance (TAA)	1 □	0 □
b. Job placement services or career counseling from a One-Stop Career Center or state labor exchange	1 □	0 □
c. On-the-job training	1 □	0 □
d. Occupational skills training	1 □	0 □
e. Adult basic education	1 □	0 □
f. Child care, transportation, or other supportive services	1 □	0 □
g. Other (Specify)	1 □	0 □

This section asks questions about your household, including who currently lives with you, your marital status, the sources of income for your household, and any economic hardships that you may have experienced over the past 12 months.

F1. Including yourself, how many adults currently live with you in your household? Please include people who are not related to you and people who are temporarily away.

| | | number of people in the household (including yourself)

F2. How many children under 18 years of age live with you in your household over half the time? Please include biological and adopted children, foster, stepchildren, or grandchildren.

| | | NUMBER

F3. What is your marital status right now?

MARK ONE ONLY

1 □ Married or Civil union

2 □ Living together unmarried

3 □ Separated

4 □ Divorced

5 □ Widowed

6 □ Never married

Now think about your household’s total income during the past twelve months. Please count any income from self-employment, regular jobs, odd jobs, under-the-table jobs, and other work activities; income from Social Security, pensions, rent, interest and dividends, unemployment compensation, welfare, food stamps, child support, and income from any other sources for all members of your household.

F4. In the last 12 months, what was your total household income from all sources before taxes and deductions? Please include income from yourself as well as all members of your household.

$ | | | | , | | | | amount

F5. [INTERVIEWER: ASK ONLY IF F1 > 1] Besides yourself, how many adults in your household worked for pay or were self-employed, either part-time or full-time, over the last 12 months?

| | | number

F6. Has anyone in your household received any of the following in the last 12 months? Remember all of your responses will be kept private.

	MARK ONE RESPONSE PER ROW
	YES	NO
a. Food Stamps or SNAP benefits	1 □	0 □
b. Welfare payments or other public assistance payments such as TANF or General Assistance	1 □	0 □
c. SSI (Supplemental Security Income) or SSDI (Social Security Disability Insurance)	1 □	0 □
d. Social Security benefits	1 □	0 □
e. EITC (Earned Income Tax Credit)	1 □	0 □
f. Housing assistance such as Section 8 vouchers	1 □	0 □
g. Other (Specify)	1 □	0 □

CREDIT HISTORY

F7. Since [RANDOM ASSIGNMENT DATE], have you declared bankruptcy for yourself or your small business?

1 □ Yes

0 □ No

F8. Since [RANDOM ASSIGNMENT DATE], on how many different credit payments, for yourself or your small business, have you been 60 or more days delinquent? Please include mortgages, trade credits, and credit from suppliers.

If January and February mortgage payments were both 60 days late, this would count as two different payments.

MARK ONE ONLY

0  None

1  One

2  Two

3  Three or more

F9. Since [RANDOM ASSIGNMENT DATE], have you or your small business (if applicable) been required by a court order or lawsuit to make payments to a creditor?

1 □ Yes

0 □ No

ECONOMIC HARDSHIPS

Next, we would like to ask you questions about challenges that you or members of your household may have experienced since [Random Assignment Date].

F10. Since [RANDOM ASSIGNMENT DATE], have you…

	MARK ONE RESPONSE PER ROW
	YES	NO
a. missed or been late on a mortgage payment or rent payment?	1 □	0 □
b. received a notice that your mortgage was in default?	1 □	0 □
c. had your house foreclosed on or been evicted?	1 □	0 □
d. had your utilities disconnected?	1 □	0 □
e. been charged a late fee on any monthly credit payments?	1 □	0 □
f. relied on financial assistance from family or friends to help pay your regular living expenses?	1 □	0 □

F11. Since [RANDOM ASSIGNMENT DATE], did you or any household member do any of the following for financial reasons?

	MARK ONE RESPONSE PER ROW
	YES	NO
a. Delay getting preventive medical care such as regular check-ups and dental visits	1 □	0 □
b. Put off getting medical or dental care for an ongoing or chronic condition	1 □	0 □
c. Visit an emergency room instead of going to a doctor’s office	1 □	0 □

Thank you very much for your help. Your answers, together with the answers of other participants, will be used to study self-employment programs. We may need to contact you in the future to clarify some of your responses or to ask if you would be willing to participate in a follow-up to this study.

G1. To help us reach you in the future, we would like some additional information.

First Name:

Middle Initial:

Last Name:

Street Address 1:

Street Address 2:

City, State, Zip Code:

Phone Number: | | | | - | | | | - | | | | |

area code number

G1a. Is this a cell phone?

1 □ Yes

0 □ No GO TO G2

G1b. Does your cell phone plan have unlimited minutes?

1  Yes

0  No

G1c. Does your cell phone plan have unlimited texting?

1  Yes

0  No

G1d. May we send you text messages?

1  Yes

0  No

G2. Is there [a/another] number where you usually can be reached?

1 □ Yes

Phone Number: | | | | - | | | | - | | | | |

area code number

0 □ No GO TO G4

G3. In whose name is that phone listed?

Name:

G3a. And where is that (e.g., neighbor, work)?

Specify:

G3b. Is this a cell phone?

1 □ Yes

0 □ No GO TO G4

G3c. Does your cell phone plan have unlimited minutes?

1  Yes

0  No

G3d. Does your cell phone plan have unlimited texting?

1  Yes

0  No

G3e. May we send you text messages?

1  Yes

0  No

G4. Do you use any video calling services such as Skype, Oovoo, or FaceTime?

1  Yes (Please specify service and username)

0  No

G5. Do you expect to change your name in the next year or so?

1 □ Yes

0 □ No GO TO G6

G5a. What do you expect your name to be?

Name:

G6. Do you expect to move at any time in the next year?

1 □ Yes

0 □ No GO TO G7a

G6a. Approximately when do you think that will be?

Specify:

G6b. Where do you expect to move?

Street Address 1:

Street Address 2:

City, State, Zip Code:

G7a. Do you have an e-mail address?

1 □ Yes

0 □ No GO TO G8

G7b. Please spell your e-mail address.

Email Address: ____________________________________________ @ __________________ . ______

G8. Do you have a Facebook account?

1 □ Yes

0 □ No GO TO G9

G8a. What name do you use on Facebook?

Name:

G9. Do you have a MySpace account?

1 □ Yes

0 □ No GO TO G10

G9a. What name do you use on MySpace?

Name:

G10. Do you have a Twitter account?

1 □ Yes

0 □ No GO TO G11

G10a. What name do you use on Twitter?

Name:

G11. Do you have a social networking account other than Facebook, MySpace, or Twitter?

1 □ Yes

0 □ No GO TO G12

G11a. What social networking provider do you use?

Name:

G11b. What name do you use on the other social networking account?

Name:

CLOSEST FRIEND/RELATIVE INFORMATION

G12. In case we have trouble reaching you, we would like to have the names of three people who do not live with you who would most likely know where you are or who you keep in close contact with. (We will not contact that person for any other reason.)

FIRST CONTACT

First Name:

Middle Initial:

Last Name:

What is (his/her) relationship to you?

Relationship:

Street Address 1:

Street Address 2:

City, State, Zip Code:

Email Address: ____________________________________________ @ __________________ . ______

Phone Number: | | | | - | | | | - | | | | |

area code number

Is this a cell phone number?

1 □ Yes

0 □ No

G13. SECOND CONTACT

First Name:

Middle Initial:

Last Name:

What is (his/her) relationship to you?

Relationship:

Street Address 1:

Street Address 2:

City, State, Zip Code:

Email Address: ____________________________________________ @ __________________ . ______

Phone Number: | | | | - | | | | - | | | | |

area code number

Is this a cell phone number?

1 □ Yes

0 □ No

G14. THIRD CONTACT

First Name:

Middle Initial:

Last Name:

What is (his/her) relationship to you?

Relationship:

Street Address 1:

Street Address 2:

City, State, Zip Code:

Email Address: ____________________________________________ @ __________________ . ______

Phone Number: | | | | - | | | | - | | | | |

area code number

Is this a cell phone number?

1 □ Yes

0 □ No

This completes the survey. Thank you very much for your time and your help. Your answers, together with the answers of other participants, will be used to help improve the types of programs that aim to help people start or grow their own businesses.