Form ETA-9167 and ETA-9 ETA-9167 and ETA-9 Evaluation of Grants Serving Youth Offenders (Background

Evaluation of the Young Offenders Grants

OMB SUPPORTING STATEMENT APPENDICES

APPENDIX A

consent to participate form

A

The OMB Control Number for this information collection is XXXXX and the expiration date is XX/XX/XXXX.

Public reporting burden for this collection of information is estimated to average 13 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to: XX.

GREEMENT TO PARTICIPATE IN THE EVALUATION OF GRANTS

Serving Youth Offenders

You are invited to be part of the Evaluation of Grants Serving Youth Offenders. This form explains what it means to be in the study. To join the study, sign your name at the end of the form. If you are younger than 18 years old, your parent or guardian will also need to sign the form.

What is the Evaluation of Grants Serving Youth Offenders?

It is a study to learn whether the programs for youth offenders improve youth educational and employment opportunities and reduce reentry into the criminal justice system. The study is run by two organizations: Mathematica Policy Research (Mathematica) and Social Policy Research Associates. The U.S. Department of Labor is sponsoring the study.

Who can be in the study?

Every volunteer who is eligible and appropriate for the [FILL PROGRAM NAME] program can be in the study.

What does it mean to be in the study?

Because there are not enough funds to help everyone eligible to participate, and because the research team plans to study ways in which youth offender programs help improve youth educational and employment opportunities and services, a process called “random assignment” will be used. Random assignment is like a lottery. It has nothing to do with your age, race, gender or other personal traits. If you do not get an invite, you will not be able to enroll in the program for 30 months. However, you will continue to be part of the study, and you will receive a list of other service providers in the community.

What information will the research team collect?

The study team will collect information on you for up to ten years.

• Background information. Some information will come from your program application.

• Interviews. Some information will come from you. The study team may interview you up to three times. You will receive a payment for each interview you do. You do not have to do the interview or answer any questions that make you uncomfortable.

• Program and government records. Other information will come from records about you. These records may include information from the program records. They may also include information at state and federal agencies about your employment and earnings and information from the criminal justice system. In addition, the study team may collect information about your education from the National Student Clearinghouse.

How will the study use your information?

The study team will use your information for research purposes only. The team will follow strict rules to protect your privacy. Your information will be kept private to the extent permitted by law. Your name will never be used in any report written for the project. To help protect your privacy, the study has a Confidentiality Certificate from the U.S. government. It says we do not have to identify you, even under a court order or subpoena. Please keep in mind: This certificate does not mean the government approves or disapproves of the study. Also, the study team will have to report your information if you tell us that you or someone else is in danger. The government may see your information if it audits us, but it, too, will protect your privacy.

What are the benefits and risks of participating in the study?

You will help youth offender programs learn how to provide better services for young people like you. The risks are small. Even if you are not selected for the [FILL PROGRAM NAME] program, you will still be part of the study and will have access to other services in your community. The study team will follow strict rules to keep your data private.

Do I have to be in the study?

No. The decision to be in the study is your choice. However, only people who are in the study will have a chance to be in the [FILL PROGRAM NAME] program. You may drop out of the study at any time by contacting Mathematica (see below). If you drop out, the study team may use the information collected while you were in the study.

Statement

• I have read this form and understand the information presented.

• I agree to be in the Evaluation of Grants Serving Youth Offenders.

• I know the decision to be in the study is my choice.

• I know that I will have a chance to be in the [FILL PROGRAM NAME] program. If I am not selected, I will not be able to be in the program for 30 months.

• I understand I can drop out of the study at any time.

• I know that the study team will follow strict rules to protect my privacy. My name will never appear in any public document.

• I understand that the study team will get information about me. The information will come from myself and program records.

• I understand that my education records are protected under a federal law called the Family Educational Rights and Privacy Act (FERPA). I further understand that I may waive that protection and give the study team access to my records. I agree to waive my rights under FERPA; the study team can get education records about me.

• I understand that I will be contacted to take part in a follow-up survey. I know I do not have to answer any questions that make me uncomfortable.

___________________________________________

Applicant Date of Birth (e.g. 01/01/1995)

_____________________________________

Name of Applicant (Please Print)

______________________________________

Signature of Applicant

_______________________

Date

Name of Parent/Guardian if Under 18 (Please Print)

______________________________________

Signature of Parent/Guardian

_______________________

Date

Questions about the Evaluation of Grants Serving Youth Offenders? Please contact [insert email address] or call [insert phone number].

APPENDIX B

intake form

P

The OMB Control Number for this information collection is XXXXX and the expiration date is XX/XX/XXXX.

Public reporting burden for this collection of information is estimated to average 13 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to: XX.

articipant ID #: |___|___|___|___|___|___|___|___|

(For Office Use Only)

Evaluation of Grants Serving Youth Offenders

Background Information Form

Today’s Date: |__|__|/|__|__|/|__|__|__|__|

Please Print Clearly. Use pen only.

CONTACT INFORMATION

1.

First Name Middle Initial Last Name

2.

Address Apt. #

City State ZIP Code

3. Nickname(s):____________________________ o CheckBox1 None

For the purpose of the study, the research team will need to contact you once or twice a year.

4. What is the best phone number to reach you?

(|__|__|__|)-|__|__|__|-|__|__|__|__|

Area Code

Type: 1 CheckBox1 Home 2 CheckBox1 Cell 3 CheckBox1 Cell - pre-paid 4 CheckBox1 Work

4a. May we send you text messages (standard message and data rates may apply)?

1 CheckBox1 Yes 0 CheckBox1 No

4b. Whose name is that phone listed in?

1 CheckBox1 My own name

2 CheckBox1 Someone else

5. What is the second best phone number to reach you?

(|__|__|__|)-|__|__|__|-|__|__|__|__|

Area Code

Type: 1 CheckBox1 Home 2 CheckBox1 Cell 3 CheckBox1 Cell - pre-paid 4 CheckBox1 Work

5a. May we send you text messages (standard message and data rates may apply)?

1 CheckBox1 Yes 0 CheckBox1 No

5b. Whose name is that phone listed in?

1 CheckBox1 My own name

2 CheckBox1 Someone else

6. What is your primary email address?

7. What is your secondary email address?

8. Do you have a personal blog or website?

1 CheckBox1 Yes – URL Address:

0 CheckBox1 No

9. Select all social networking accounts you are actively using?

CHECK ALL THAT APPLY

1 CheckBox1 Facebook?

Name:

2 CheckBox1 Instagram?

Name:

3 CheckBox1 Twitter?

Tag:

10. Do you have any other social networking accounts?

1 CheckBox1 Yes – URL Address:

0 CheckBox1 No

DEMOGRAPHICS AND BACKGROUND CHARACTERISTICS

11. Social Security Number:

* |___|___|___|-|___|___|-|___|___|___|___|

12. Date of Birth: |___|___| / |___|___| / |___|___|___|___|

Month Day Year

13. Gender: 1 CheckBox1 Male 2 CheckBox1 Female

14. Are you Spanish/Hispanic/Latino?

1 CheckBox1 Yes 0 CheckBox1 No

15. What is your race?

CHECK ALL THAT APPLY

1 CheckBox1 Hawaiian Native or other Pacific Islander

2 CheckBox1 White

3 CheckBox1 Black or African American

4 CheckBox1 Asian

5 CheckBox1 American Indian or Alaskan

6 CheckBox1 Not specified

16. What is your primary language?

1 CheckBox1 English

2 CheckBox1 Spanish

3 CheckBox1 Other Specify:___________________

17. Have you ever been in foster care?

1 CheckBox1 Yes 0 CheckBox1 No

18. Do you have any children?

1 CheckBox1 Yes 0 CheckBox1 No

TURN FORM OVER

19. Are you or anybody in your household receiving welfare, Food Stamps, SNAP, or other forms of cash assistance?

1 CheckBox1 Yes 0 CheckBox1 No

20. Have you ever had a paid job lasting for at least one month?

1 CheckBox1 Yes 0 CheckBox1 No

21. Are you currently employed?

1 CheckBox1 Yes 0 CheckBox1 No

22. Are you currently enrolled in school?

1 CheckBox1 Yes 0 CheckBox1 No

23. What is the last grade you completed in school?

CHECK ONE

1 CheckBox1 6th or below

2 CheckBox1 7th

3 CheckBox1 8th

4 CheckBox1 9th

5 CheckBox1 10th

6 CheckBox1 11th

7 CheckBox1 12th

8 CheckBox1 Some college

24. Have you received a:

1 CheckBox1 High school diploma

2 CheckBox1 GED

3 CheckBox1 Certificate of Completion

4 CheckBox1 No – none of these

25. Which of the following best describes your current housing status?

CHECK ONE

1 CheckBox1 Living with own family

2 CheckBox1 Own/rent apartment, room, house

3 CheckBox1 Permanently living at someone’s apartment, room, house

4 CheckBox1 Temporarily staying at someone’s apartment, room, house

5 CheckBox1 Staying with foster guardian/In foster system

6 CheckBox1 Halfway house/Transitional house

7 CheckBox1 Residential Treatment

8 CheckBox1 Juvenile facility/ Correctional facility

9 CheckBox1 Homeless

26. Have you been diagnosed with a learning disability?

1 CheckBox1 Yes 0 CheckBox1 No

27. Do you have any health problem such as physical or emotional disabilities?

1 CheckBox1 Yes 0 CheckBox1 No

CRIMINAL JUSTICE INVOLVEMENT

28. Who referred you to [insert program name]?

CHECK ONE

1 CheckBox1 Judge

2 CheckBox1 Probation/parole officer

3 CheckBox1 Case manager

4 CheckBox1 School counselor/Truant officer

5 CheckBox1 Family member

6 CheckBox1 Friend

7 CheckBox1 I decided myself

8 CheckBox1 Someone else (specify: ________________________)

29. Were you required to participate in [insert Program Name]?

1 CheckBox1 Yes 0 CheckBox1 No

30. Have you ever been arrested?

1 CheckBox1 Yes 0 CheckBox1 No

31. If yes, how many times have you been arrested?

|___|___|___|

32. Have you ever spent time in a juvenile detention facility?

1 CheckBox1 Yes 0 CheckBox1 No

33. If so, how long was your longest confinement?

|___|___| 1 CheckBox1 Days 2 CheckBox1 Months 3 CheckBox1 Years

34. Are you on probation or parole?

0 CheckBox1 No

1 CheckBox1 Probation

2 CheckBox1 Parole

35. How would you prefer to be contacted in the future?

1 CheckBox1 Regular Mail 5 CheckBox1 Facebook

2 CheckBox1 Email 6 CheckBox1 Twitter

3 CheckBox1 Cell Phone 7 CheckBox1 MySpace

4 CheckBox1 Text 8 CheckBox1 Other

THANK YOU FOR YOUR TIME

FOR COUNSELOR USE ONLY:

A. Counselor’s Name: _______________________________

First Name MI Last Name

B. What are the three primary services you expect this participant to receive?

₁ CheckBox1 Education services

₂ CheckBox1 Vocational services

₃ CheckBox1 Community service placement

₄ CheckBox1 Job search assistance

₅ CheckBox1 Mentoring therapy

CheckBox1 Legal assistance

The OMB Control Number for this information collection is XXXXX and the expiration date is XX/XX/XXXX.

Public reporting burden for this collection of information is estimated to average 13 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to: XX.

I

EVALUATION OF GRANTS SERVING YOUTH OFFENDERS

Contact Information Form

D: | | | | | | | | |

FOR OFFICE USE ONLY

□ No Friends/Relatives

□ Refused

1 . Your Name: first middle initial last

2. Date of Birth: | | |/| | |/| | | | | Month Day Year

3. Today’s Date: | | |/| | |/| | | | | Month Day Year

Social Security Number: |___|___|___|-|___|___|-|___|___|___|___| * Disclosure of SSN is voluntary and not required to participate in this study.

Contact Information - Relatives and Friends

INSTRUCTIONS: In the space below, please provide contact information for three close relatives or friends who are likely to know how to reach you over the next year. We will only contact these people if we are unable to contact you directly. Please complete all three boxes if possible.

1. NAME AND ADDRESS OF RELATIVE OR FRIEND

NAME: Last

First

Middle

ADDRESS: Number and Street

Apt. No.

City

State

ZIP Code

How is this person related to you?

1 □ Mother

2 □ Father

3 □ Sister/Brother

4 □ Friend

5 □ Grandmother/Grandfather

6 □ Other (Specify) ____________________________

TELEPHONE and EMAIL: Home: (________) - ________ - ____________________ Area Code Number

Cell: (________) - ________ - ____________________ Area Code Number

Work: (________) - ________ - __________________________ Area Code Number

Whose name is home phone listed under?

Email Address #1:

Email Address #2:

Which of the following is the primary social network used by this person?

1 □ Facebook 2 □ Twitter

3 □ Personal blog 4 □ Other (Specify)

What name does this person use in that social network?

2. NAME AND ADDRESS OF RELATIVE OR FRIEND

NAME: Last

First

Middle

ADDRESS: Number and Street

Apt. No.

City

State

ZIP Code

How is this person related to you?

1 □ Mother

2 □ Father

3 □ Sister/Brother

4 □ Friend

5 □ Grandmother/Grandfather

6 □ Other (Specify) ____________________________

TELEPHONE and EMAIL: Home: (________) - ________ - ____________________ Area Code Number

Cell: (________) - ________ - ____________________ Area Code Number

Work: (________) - ________ - __________________________ Area Code Number

Whose name is home phone listed under?

Email Address #1:

Email Address #2:

Which of the following is the primary social network used by this person?

1 □ Facebook 2 □ Twitter

3 □ Personal blog 4 □ Other (Specify)

What name does this person use in that social network?

3. NAME AND ADDRESS OF RELATIVE OR FRIEND

NAME: Last

First

Middle

ADDRESS: Number and Street

Apt. No.

City

State

ZIP Code

How is this person related to you?

1 □ Mother

2 □ Father

3 □ Sister/Brother

4 □ Friend

5 □ Grandmother/Grandfather

6 □ Other (Specify) ____________________________

TELEPHONE and EMAIL: Home: (________) - ________ - ____________________ Area Code Number

Cell: (________) - ________ - ____________________ Area Code Number

Work: (________) - ________ - __________________________ Area Code Number

Whose name is home phone listed under?

Email Address #1:

Email Address #2:

Which of the following is the primary social network used by this person?

1 □ Facebook 2 □ Twitter

3 □ Personal blog 4 □ Other (Specify)

What name does this person use in that social network?