Participant Baseline Information Form

Subsidized and Transitional Employment Demonstration (STED) and Enhanced Transitional Jobs Demonstration (ETJD)

Appendix_D_STED BIF OMB 10-3-12

Participant Baseline Information Form

OMB: 0970-0413

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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











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