Baseline Information Form

APPENDIX B MDRC

FSS EVALUATION

BASELINE INFORMATION FORM

ADD OMB CONTROL NUMBER

Public reporting burden for providing this information is estimated to average 15 minutes per study participant, including the time for reviewing instructions and completing and reviewing the information provided. 

HOUSEHOLD FORM

FOR INTERVIEWER: This form should be completed by the head of the household. Please enter the Household Identification Number provided by the PHA: ___ ___ ___ ___ ___ ___ ___ ___ ___
Home Address: _______________________________________________________________ _________ Street Address Apt. # _________________________ _______ ___ ___ ___ ___ ___ City State Zip code ( ___ ___ ___) ___ ___ ___- ___ ___ ___ ___ Home phone ( ___ ___ ___) ___ ___ ___- ___ ___ ___ ___ Mobile phone
Including yourself, how many adults 18 years old or older lived in your household at least two nights a week during the past month? ________ No Answer
How many children who are under the age of 18 lived in your household at least two nights a week during the past month? Please include biological, adopted, step, and foster children. _______________ Don’t know No Answer	(If answer to question is 1 or more) How many children do you have in each age category? < 1 year: _________ 1 year  to 2 years: _____ 3 years to 5 years: ______ 6 years  to 12 years:_____ 13 years to 17 years:____ Don’t know No Answer
Including your own income, approximately how much was your total household income during the past 12 months before taxes? [Include all forms of income – earnings (including self-employment), child support, and any public cash assistance – that you or other members of your household received.] $0 $1   -   $4,999 $5,000   -   $9,999 $10,000 - $14,999 $15,000 - $19,999 $20,000 - $24,999 $25,000 - $29,999 $30,000 or higher Don’t know No Answer
Do you currently receive Temporary Assistance for Needy Families (TANF) or Safety Net Assistance (SNA) – ADAPT PROGRAM NAME, AS NEEDED)? 1 Yes 2 No Don’t know No Answer	Do you currently receive food stamps? 1 Yes 2 No Don’t know No Answer
How long have you received Section 8 rental assistance? (Choose only one) 1 Less than 1 year 2 1-3.99 years 3 4-6.99 years 4 7-9.99 years 5 10 or more years Don’t know No Answer
How much do you pay in rent and utilities? $____________per month No answer
Since [DATE], was there ever a time when, because of cost, you or your household was not able to: (Choose all that apply) A Pay your rent B Pay your utility bills C Pay your telephone bill D Buy food E Buy prescription drugs Don’t Know No Answer
What is the primary (or main) language your family speaks at home?” (Choose only one) 1 English 2 Spanish 3 French 5 Chinese 6 Russian 4 Other: ___________________ Don’t Know No Answer
Please provide the names and telephone numbers of two family members or friends who will know how to reach you if we have difficulty contacting you.** Contact 1: First Name: ______________________________Middle Initial: _____ Last Name: _______________________________ Relationship to you: _____________________________ __________________________________________________________ _________ Street Address Apt. # _____________________________ _______ ___ ___ ___ ___ ___ City State Zip code Home phone: ( ___ ___ ___) ___ ___ ___- ___ ___ ___ ___ Cell phone: ( ___ ___ ___) ___ ___ ___- ___ ___ ___ ___ Work phone: ( ___ ___ ___) ___ ___ ___- ___ ___ ___ ___ Email: _______________________________________
Contact 2 First Name: ______________________________Middle Initial: _____ Last Name: _______________________________ Relationship to you: _____________________________ __________________________________________________________ _________ Street Address Apt. # _____________________________ _______ ___ ___ ___ ___ ___ City State Zip code Home phone: ( ___ ___ ___) ___ ___ ___- ___ ___ ___ ___ Cell phone: ( ___ ___ ___) ___ ___ ___- ___ ___ ___ ___ Work phone: ( ___ ___ ___) ___ ___ ___- ___ ___ ___ ___ Email: _______________________________________

ADULT FORM

FOR INTERVIEWER:

Each adult enrolling in the program should complete a separate form.

Enter the Household Identification Number provided by the PHA:

___ ___ ___ ___ ___ ___

Informed Consent Form signed (check here): 

Social Security Number: ___ ___ ___ - ___ ___ -___ ___ ___ ___

First Name: ______________________________ Middle Initial: _____

Last Name: _______________________________

Date of Birth:

___ /____ ____ / ____ ____ ____ ____

MM DD YYYY

Gender: (Choose only one)

• ₁ Male

• ₂ Female

What is your marital status? (Choose only one)

• ₁ Single

• ₂ Separated

• ₃ Divorced

• ₄ Widow/Widower

• ₅ Married

• ₆ In a Legal Domestic Partnership

• Don’t know

• No Answer

What is your relationship to the Section 8 head of household? (Choose only one)

• ₁ I am the head of household

• ₂ I am their spouse/legal domestic partner

• ₃ I am their child

• ₄ I am their parent

• ₅ I am an extended relative

• ₆ I am not related to the head of household

• Don’t know

• No Answer

Are you Spanish, Hispanic, or Latino?

₁ Yes

₂ No

• Don’t Know

• No Answer

Please choose one or more races that you consider yourself to be:

• White

• Black or African American

• American Indian or Alaska Native

• Asian

• Native Hawaiian or Other Pacific Islander

• Don’t Know

No Answer

What is your citizenship status? (Choose only one)

• ₁ I am a U.S. citizen by birth

• ₂ I am a U.S. citizen by naturalization

• ₃ I am a legal permanent resident

• ₉₉ No answer

If you are not a U.S. citizen by birth, how long have you been in the U.S.? (Choose only one)

__________ year (s)

• Don’t know

• No Answer

Education and Training

What is the highest level of education that you have completed? (Choose only one)

• ₁ Grade 9 or less

• ₂ Grade 10 or Grade 11

• ₃ Attended grade 12 but did not receive High School diploma or GED

• ₄High School Diploma

• ₅GED

• ₆Some College

• ₇Associate’s or two-year degree

• ₈Four-year college degree or higher

• Don’t know

• No Answer

Are you currently taking college courses for credit?

• ₁ Yes

• ₂ No

• Don’t know

• No Answer

Since [Date] have you taken any training courses or education classes to improve your skills, help you do a job or find employment? Please include things like computer training, basic skills and any courses or classes to help you with a specific job or type of work.

• ₁ Yes

• ₂ No

• Don’t know

• No Answer

Do you have any type of trade license or training certificate? For example:, a Commercial Drivers License (CDL), Certified Nursing Assistant (CNA), or some other kind of certificate.

• ₁ Yes

• ₂ No

• Don’t know

• No Answer

Work Status

Are you currently working?

• ₁ Yes

• ₂ No

• Don’t know

• No Answer

How many jobs do you currently have?

• ₁ 1

• ₂ 2

• ₃ 3

• ₄ 4 or more

• Don’t know

• No Answer

Are you self-employed?

• ₁ Yes

• ₂ No

• Don’t know

• No Answer

How many hours do you typically work per week? If you are currently working more than one job, please give the total hours for all jobs combined.

_______ hours

• Don’t know

• No Answer

How much do you earn before taxes? If you are currently working more than one job, please give the total amount for all jobs combined.

$ _________. ______ per	1hour (If working only one job)
	2 day ______ number of days per week
	3week
	4two weeks
	5twice a month
	6month
	7year
	Don’t know No Answer

In the past year, about how many months have you worked? (Count any month in which you worked at least one day part or full time)

__________

• Don’t know

• No Answer

Health and Health Insurance

What kind of health insurance are you currently AND primarily covered by? (Choose only one)

• ₁By public health insurance (ex.: Medicaid, Family Health Plus, etc.¹)

• ₂ By employer-provided health insurance through either my work or my spouse’s work (even if you pay for a part of it)

• ₃Other health insurance

• ₄I am not covered by health insurance

• Don’t know

• No Answer

Do you currently receive SSI or SSDI?  

• ₁ Yes

• ₂ No

• Don’t know

• No Answer

Personal Finances

Do you currently have a savings or checking account at a bank or a credit union?

• YES

• NO

• Don’t know

• No Answer

How much money do you currently have saved? This includes money at home; in a savings, checking, credit union, or money market account; and certificates of deposit. (Choose only one)

• $0

• $1- $500

• $501-$1,000

• $1,001-$3,000

• $3,001-$5,000

• $5,001-$10,000

• $10,001-$20,000

• More than $20,000

• Don’t know

• No Answer

When you think about all your loans including, for example, money borrowed from friends or family, car loans, credit card debt, and student loans, what is the total amount you owe? (Choose only one)

• $0

• $1- $500

• $501-$1,000

• $1,001-$3,000

• $3,001-$5,000

• $5,001-$10,000

• $10,001-$20,000

• More than $20,000

• Don’t know

• No Answer

Additional Barriers to Employment

Do you have a physical health problem that limits the kind or amount of work that you can do? (Choose only one)

• ₁ Yes

• ₂ No

• Don’t know

• No Answer

Do you have an emotional or mental health problem that limits the kind or amount of work that you can do? (Choose only one)

• ₁ Yes

• ₂ No

• Don’t know

• No Answer

Does difficulty finding adequate childcare or after school supervision limit the kind or amount of work that you can do?

• ₁ Yes

• ₂ No

• Don’t know

• No Answer

Does the need to care for a sick or disabled family member limit the kind or amount of work that you can do?

• ₁ Yes

• ₂ No

• Don’t know

• No Answer

Have you ever been convicted of a felony?

• ₁ Yes

• ₂ No

• Don’t know

• No Answer

Can you use public transportation (e.g. bus, train, subway, light-rail) to get to work if necessary?

• ₁ Yes

• ₂ No

• Don’t know

• No Answer

Do you have or could you borrow a car, van or truck, or get a ride to get to work if necessary?

• ₁ Yes

• ₂ No

• Don’t know

• No Answer

Motivations and Program Understanding

Why are you interested in the FSS program? Please read the following list of possible reasons (check all that apply).

Help finding work?

Help finding a better job?

Help keeping your job?

Help with dealing with personal issues or family issues that make having a job difficult?

Help with accessing services to help your family such as daycare

Help building savings?

Help managing your money, debt relief or improving your credit score?

Help buying a home?

Or some other reason?

Other Reason:

₁ Yes ₂ No

₁ Yes ₂ No

₁ Yes ₂ No

₁ Yes ₂ No

₁ Yes ₂ No

₁ Yes ₂ No

₁ Yes ₂ No

₁ Yes ₂ No

₁ Yes ₂ No

₁ Yes ₂ No

₁ Yes ₂ No

________________________

Before participating in the orientation meeting had you ever heard of the FSS escrow?

(IF EXPLANATION IS REQUESTED: As discussed at the orientation meeting, the FSS escrow account is a long-term savings account that [local PHA name] opens up for you when an increase in your income due to wages causes your rent to go up. You can get the money in your escrow account once you have successfully completed your Contract of Participation.)

• ₁ Yes

• ₂ No

• Don’t know

• No Answer

In the past 12 months, have you not taken a job or worked more hours because the extra money you would earn would cause you to:

Lose or reduce other benefits you receive such as

Medicaid, food stamps, or TANF: ₁ Yes ₂ No

Lose your Section 8 voucher: ₁ Yes ₂ No

Adult contact Information

Work phone number:

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

Mobile phone number:

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

Email address:

_________________________________________________

FOR INTERVIEWER: How well does the customer speak English? (Choose only one)

₁ Very well ₂ Well ₃ Not very well ₄ Not at all ₅ No answer

1 The names of the public health insurance programs will vary by site/state.

[Question numbers, response codes, skips patterns, and other instructions will be added to the final instrument]

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