Baseline Information Form

APPENDIX B

HUD RENT REFORM DEMONSTRATION

BASELINE INFORMATION FORM

NOTE: This information is provided by the voucher holder / head of household.

Personal Identifiers
1. HA Entity ID/ Household Identification Number: ___ ___ ___ ___ ___ ___ ___ ___ ___ [Length will vary by HA]
2. Head of Household’s Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
3. Name 3.A First Name: ______________________________ 3.B Middle Name: ____________________________ 3.C Last Name: _______________________________
4. Date of Birth: _____ /___ ___ /___ ___ ___ ___ MM DD YYYY
5. What is your marital status? 1 Married, living with spouse 2 Living with a partner 3 Single 4 Separated 5 Divorced 6 Widow/Widower 7 No answer
6. What is your citizenship status? 1 I am a U.S. citizen by birth [Go to 8] 2 I am a U.S. citizen by naturalization [Go to 7] 3 I am a legal permanent resident [Go to 7] 4 I have refugee or asylee status [Go to 7] 5 No answer [Go to 8]
7. How long have you lived in the U.S.? 1 Less than 5 years 2 5 to 9.99 years 3 10 to 19.99 years 4 20 years or longer 5 No answer
8. How long have you received Section 8 rental assistance as a head of household? 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 6 No answer
Primary Language
9. What is the primary (or main) language that your family speaks at home? 1 English 2 Spanish 3 Chinese 4 Other _____________________ 4.A Specify 5 No answer
Household Finances and Material Hardship
10. Do you currently receive SNAP/food stamps? 1 Yes 2 No 3 No answer			11. Do you currently receive TANF or [Insert name of state or local public assistance program]? 1 Yes 2 No 3 No answer
12. 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. 1 $0 2 $1 - $4,999 3 $5,000 - $9,999 4 $10,000 - $14,999 5 $15,000 - $19,999 6 $20,000 - $24,999 7 $25,000 - $29,999 8 $30,000 or higher 9 No answer
13. In general, how do your or your households finances usually work out at the end of the month?  1 There is some money left over, 2 There is just enough to make ends meet, or 3 There is not enough money to make ends meet? 4 No answer
14. In the past 12 months was there ever a time when, because of cost, you or your household were not able to:
14.a. Pay your rent? 1 Yes [Go to 14A1] 2 No [Go to 14B] 3 No answer [Go to 14B]		14.a.1. How often did this happen in the past 12 months? 1 1 Month 2 2 or 3 months 3 4 to 6 months 4 6 or more months 5 No answer
14.b. Pay your utility bills? 1 Yes [Go to 14B1] 2 No [Go to 14C] 3 No answer [Go to 14C]		14.b.1. How often did this happen in the past 12 months? 1 1 Month 2 2 or 3 months 3 4 to 6 months 4 6 or more months 5 No answer
14.c. Pay your telephone bill? 1 Yes [Go to 14C1] 2 No [Go to 14D] 3 No answer [Go to 14D]		14.c.1. How often did this happen in the past 12 months? 1 1 Month 2 2 or 3 months 3 4 to 6 months 4 6 or more months 5 No answer
14.d. Buy food? 1 Yes [Go to 14D1] 2 No [Go to 14E] 3 No answer [Go to 14E]		14.d.1. How often did this happen in the past 12 months? 1 1 Month 2 2 or 3 months 3 4 to 6 months 4 6 or more months 5 No answer
14.e. Buy prescriptions for medicine? 1 Yes [Go to 14E1] 2 No [Go to 14F] 3 No answer [Go to 14F]		14.e.1. How often did this happen in the past 12 months? 1 1 Month 2 2 or 3 months 3 4 to 6 months 4 6 or more months 5 No answer
14.f. See a doctor or get medical assistance? 1 Yes [Go to 14F1] 2 No [Go to 15] 3 No answer [Go to 15]		14.f.1. How often did this happen in the past 12 months? 1 1 Month 2 2 or 3 months 3 4 to 6 months 4 6 or more months 5 No answer
Personal Finances
15. Do you currently have a savings or checking account at a bank or a credit union? 1 Yes 2 No 3 No answer
16. 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. Do not include pension funds or retirement accounts. 1 $0 2 $1- $500 3 $501-$1,000 4 $1,001-$2,000 5 $2,001-$5,000 6 $5,001-$10,000 7 $10,001-$20,000 8 More than $20,000 9 No answer
17. 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? 1 $0 2 $1- $500 3 $501-$1,000 4 $1,001-$2,000 5 $1,001-$5,000 6 $5,001-$10,000 7 $10,001-$20,000 8 More than $20,000 9 No answer
Educational Attainment
18. What is the highest level of education that you have completed? 1 Grade 9 or less 2 Grade 10 or grade 11 3 Attended grade 12 but did not receive high school diploma or GED certificate 4 GED certificate 5 High school diploma 6 Some college 7 Associate’s or two-year degree 8 Four-year college degree or higher 9 No answer
19. Are you currently taking college courses for credit toward an Associate’s degree or Bachelor’s degree? 1 Yes 2 No 3 No answer
20. Do you have any type of trade license or training certificate? For example: A Commercial Driver’s License (CDL), Certified Nursing Assistant (CNA), or some other kind of certificate. 1 Yes 2 No 3 No answer
21. Are you currently taking any training courses or education classes to improve your skills, help you do a job, or find employment? Please include things like computer training and basic skills courses or classes. 1 Yes 2 No 3 No answer
22. Are you currently receiving job search assistance (such as resume help, interview assistance, etc.) from a housing authority, temp agency, or any other program or organization to find a new or additional job? 1 Yes 2 No 3 No answer
Employment Status
23. Are you currently working for pay or self-employed? 1 Yes [Go to 24] 2 No [Go to 28] 3 No answer [Go to 24]
24. Which situation best describes your current employment? 1 I work for pay at a regular job 2 I am self-employed 3 I work at a temporary or seasonal job 4 No answer
25. How many jobs do you currently have? 1 1 2 2 3 3 4 4 or more 5 No answer
26. Counting all of your current jobs or businesses, how many hours do you typically work per week? _______ Hours [If you don’t know the exact number of hours, please check one range amount below] 26.a 1 1-20 hours 2 21-34 hours 3 35-48 hours 4 49 or more hours 5 No answer
27. Counting all of your current jobs or businesses, how much do you earn before taxes?
27.a. Pay: $ _________. ______ 1 No answer	27.b. Per: 1 Hour 2 Day _______ 2.A Number of days per week of work 3 Week 4 Every two weeks 5 Twice per month 6 Month 7 Year 8 Other ________________________ 8.A Specify 9 No answer
28. In the past 12 months, about how many months have you worked for pay or earned money from self-employment? Count any month in which you worked at least one day part-time or full-time. 55 Did not work at any time 1 1 Month 2 2 Months 3 3 Months 4 4 Months 5 5 Months 6 6 Months 7 7 Months 8 8 Months 9 9 Months 10 10 Months 11 11 Months 12 12 Months 13 No answer
29. Could you use public transportation (such as a bus, train, subway, or light-rail) to get to work, if necessary? 1 Yes 2 No 3 No answer
30. 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 3 No answer
Child Care
31. Do you have any children under the age of 13 for whom you are responsible for and who usually live in your household at least two nights a week? 1 Yes [Go to 32] 2 No [Go to 36] 3 No answer [Go to 36]
32. Do you use any of the following program(s) or person/people to take care of your child(ren) while you are at work or attending a class, school, or job training? [Check all that apply] A Relative (grandparent, aunt, uncle, sibling of the child, etc.) B Unrelated adult in your home or another home C Center-based preschool care (child care center, daycare, nursery school, Head Start, preschool, after-school or before-school program) D After-school or before-school program or, when school is out, a summer camp E Other _________________________________________ E.1 Specify F Do not use any [Go to 36] G No answer
33. Do you pay for any of the following program(s) or person/people to take care of your child(ren) while you are at work or attending a class, school, or job training? [Check all that apply] A Relative (grandparent, aunt, uncle, sibling of the child, etc.) B Unrelated adult in your home or another home C Center-based preschool care (child care center, daycare, nursery school, Head Start, preschool, after-school or before-school program) D After-school or before-school program or, when school is out, a summer camp E Other _________________________________________ E.1 Specify F Do not pay for any [Go to 34] G No answer
34. How much in total do you currently pay per week for all child care arrangements? $_____________($0-$1,000, 1001=More than $1,000) [If you don’t know the exact amount, please check one range amount below] 34.a. 1 $1 - $100 2 $101 - $250 3 $251 - $500 4 $501 - $750 5 $751 - $1000 6 More than $1000 7 No answer
35. Are you currently receiving help paying for child care from [Insert name of state agency] or any other program or agency? 1 Yes 2 No 3 No answer
Employment Access Issues
36. Does difficulty paying for child care or after-school supervision limit the kind or amount of work that you can do? 1 Yes 2 No 3 No answer
37. Do you have a physical health problem that limits the kind or amount of work that you can do? 1 Yes 2 No 3 No answer
38. Do you have an emotional or mental health problem that limits the kind or amount of work that you can do? 1 Yes 2 No 3 No answer
39. 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 3 No answer
40. Have you ever been convicted of a felony? 1 Yes 2 No 3 No answer
Health and Health Insurance
41. What kind of health insurance are you currently AND primarily covered by? 1 By public health insurance (ex.: Medicaid, Medicare, VA, Tri-Care, or a state or local program) 2 By employer-provided health insurance through either my work or my spouse’s work 3 Other private health insurance 4 I am not covered by health insurance 5 No answer
Contact Information
Please provide address and phone numbers for the voucher holder/ head of household.
42. Home Address: _______________________________________________________________ _________ 42.A Street Address 42.B Apt. # _________________________ _______ ___ ___ ___ ___ ___ 42.C City 42.D State 42.E Zip code
43. Phone Numbers 43.A Home phone number: (___ ___ ___) ___ ___ ___- ___ ___ ___ ___ 43.B Mobile phone number: (___ ___ ___) ___ ___ ___- ___ ___ ___ ___ 43.C Work phone number: (___ ___ ___) ___ ___ ___- ___ ___ ___ ___
44. Email address: _________________________________________________
Additional Contact Information
Please provide the names, address, and telephone numbers of two family members or friends who will know how to reach you if we have difficulty contacting you.
CONTACT 1: 45. Name 45.A First Name: ______________________________ 45.B Middle Initial: _____ 45.C Last Name: _______________________________ 46. Relationship to you: _____________________________ 47. Street Address ___________________________________________________ _________ 47.A Street Address 47.B Apt. # _____________________________ _______ ___ ___ ___ ___ ___ 47.C City 47.D State 47.E Zip code 48. Phone 48.A Home phone: ( ___ ___ ___) ___ ___ ___- ___ ___ ___ ___ 48.B Cell phone: ( ___ ___ ___) ___ ___ ___- ___ ___ ___ ___ 49. Email address: _______________________________________
CONTACT 2: 50. Name 50.A First Name: ______________________________ 50.B Middle Initial: _____ 50.C Last Name: _______________________________ 51. Relationship to you: _____________________________ 52. Street Address __________________________________________________ _________ 52.A Street Address 52.B Apt. # _____________________________ _______ ___ ___ ___ ___ ___ 52.C City 52.D State 52.E Zip code 53. Phone 53.A Home phone: ( ___ ___ ___) ___ ___ ___- ___ ___ ___ ___ 53.B Cell phone: ( ___ ___ ___) ___ ___ ___- ___ ___ ___ ___ 54. Email address: _______________________________________

FOR INTERVIEWER:

55. How well does the client speak English?

₁ Very well

₂ Well

₃ Not very well

₄ Not at all

₅ No answer

5

OMB Control Number: ADD WHEN ISSUED

Rent Reform Demonstration- SITE