Participant Baseline Information Form

Appendix D

Baseline Information Form

Appendix D

Baseline Information Form

Updated 10.3.12

STED Baseline Information Form

STED

Demographic Information

Social Security Number*				used for matching to other data sources
Social Security Number: As noted on the Informed Consent Form, your social security number will be used to collect information from state and federal agencies about your employment, earnings, TANF and other public assistance. Provision of the social security number is required for participation in the STED project. Without it, researchers will be unable to access critical information about how STED programs benefit participants.
Date of Birth				mm/dd/yyyy
U.S. Citizen	Yes	No		 Decline to answer
Authorized To Work	Yes	No		 Decline to answer
Gender	Male	Female		 Decline to answer

Ethnicity Hispanic, Latino/a, or Spanish origin

 No, not of Hispanic, Latino/a, or Spanish origin

 Yes, Mexican American, Chicano/a

 Yes, Puerto Rican

 Yes, Cuban

 Yes, Another Hispanic

 Decline to answer

Race

(Allow multiple responses)

 White

 Black of African American

 American Indian or Alaska Native

 Hawaiian Native

 Filipino

 Samoan

 Guamanian or Chamorro

 Other Pacific Islander

 Asian Indian

 Chinese

 Korean

 Vietnamese

 Japanese

 Other Asian

 Other, specify_________

 Decline to answer

Primary Language

• English

• Spanish

• Other

Limited English Proficient

 Yes

 No

 Decline to answer

Marital Status

 Never Married

 Currently Married

 Separated

 Divorced

 Widowed

 Decline to answer

Participant Lives With

 Alone

 Wife/Husband

 Girlfriend/Boyfriend

 Parent/Stepparent

 Friend(s)

 Grandparent

 Own Child(ren)

 Other Child(ren)

 Sister/Brother

 Other Relative

 Other Non-Relative

 Decline to answer

Housing Status at Enrollment

 Own apartment, room, or house

 Rent apartment, room, or house

 Halfway house/ transitional house

 Residential treatment

 Homeless

 Staying at someone's apartment, room, or house (Stable)

 Staying at someone's apartment, room, or house (Unstable)

 Decline to answer

Highest Grade Completed

 0 - No school grades completed

 1 - First grade completed

 2 – Second grade completed

 3 – Third grade completed

 4 – Fourth grade completed

 5 – Fifth grade completed

 6 – Sixth grade completed

 7 - Seventh grade completed

 8 – Eight grade completed

 9 – Ninth grade completed

 10 – Tenth grade completed

 11 – Eleventh grade completed

12 – Twelfth grade completed

 13 – 1 school year completed in college or full-time technical school

 14 – 2 school years completed in college or full-time technical school

 15 – 3 school years completed in college or full-time technical school

 16 – Education beyond the Bachelor’s degree

 Decline to answer

Highest Degree Attained

 Attained High School Diploma

 Attainted GED or Equivalent

 Attained Certificate of Attendance/Completion

 Associate Degree

 Bachelor’s degree or equivalent

 Masters, Professional or Doctoral degree

 Decline to answer

Individual With Disability

 Yes

 No

 Decline to answer

Based on self report, at point of random assignment

Cares for/lives with someone with a disability

 Yes

 No

 Decline to answer

Based on self report, at point of random assignment

Ever convicted of a crime

 Yes

 No

 Decline to answer

Ever Incarcerated for a Federal or State Offense

 Yes

 No

 Decline to answer

Number of Minor Children (Please provide age of each child reported)

 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

Age of

Child # 1 ________

Child # 2 ________

Child # 3 ________

Child # 4 ________

Child # 5 ________

Age of

Child # 6 ________

Child # 7 ________

Child # 8 ________

Child # 9 ________

Child # 10 ________

 Decline to answer

Number of Minor Children Living With Participant

 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 Decline to answer

[If custodial parent] child support received:

 Yes

No

 Decline to answer

Child support order in force:

 Yes

No

 Decline to answer

Individual Monthly Income at Enrollment

None

 $1 - $500

 $501 - $1,000

 $1,001 - $2,500

 $2,501 - $5,000

 More than $5,000

 Decline to answer

Medical Benefits

 Medicaid

 Medicare

 Private health insurance from work or family member

 Other

 None

 Decline to answer

Mental Health Treatment

 Yes

 No

 Decline to answer

Ever received as of point of random assignment

Substance Abuse Treatment

 Yes

 No

 Decline to answer

Ever received as of point of random assignment

Employment History

Currently Employed		 Yes		 No	 Decline to answer
If no, have you ever been employed?		 Yes		 No	 Decline to answer
If not currently employed and have never been employed, go to next section (TANF Recipient Information)
Start Date of Most Recent Job			 Decline to answer		mm/dd/yyyy
Ending Date of Most Recent Job			 Decline to answer		mm/dd/yyyy
Job Title	Building and Grounds Cleaning and Maintenance Occupations Community and Social Services Occupations Construction and Extraction Occupations	Food Preparation and Serving Related Occupations Healthcare Support Occupations Installation, Maintenance, and Repair Occupations			Office and Administrative Support Occupations Personal Care and Service Occupations Production Occupations Protective Service Occupations Sales and Related Occupations Transportation and Material Moving Occupations
	Other, Specify:_________________________				 Decline to answer
Hourly Wage		$			 Decline to answer
Have you ever worked for the same employer for 6 months or more?		Yes		No	 Decline to answer
In total, how much did you work during the last three years?		 Less Than 6 Months  7 – 12 Months  13 – 24 Months			 More Than 24 Months  Did Not Work  Decline to answer

TANF Recipient Information

Starting date of current receipt period

 Decline to answer

mm/dd/yyyy

Public Assistance at Enrollment

 Social Security Insurance (SSI) or Social Security Disability (SSD)

 Temporary Assistance for Needy Families (TANF)

 Welfare for single adults or general assistance (GA)

 Unemployment insurance

 Food stamps/SNAP

 Division of AIDS Services Income Support (DAS)

 Other government sources

 No Benefits

 Decline to answer

Ever received cash assistance prior to current receipt

 Yes

No

 Decline to answer

Type of cash assistance previously received:

 TANF/AFDC	 General Assistance  SSI/SSDI/Disability
 Other	 Decline to answer

Lifetime TANF/AFDC received

Months

 Decline to answer

D-1