Baseline Information Form

Appendix C.1. Baseline Information Form

U.S. Department of Labor
TAACCCT Round 4 Evaluation

Baseline Information Form

«Site_Name_1»

«ID»

Dear Participant:

This form requests information about your household. Your answers to these questions will not affect your chances of getting into this employment training program. The information will be used for research purposes only and will be kept confidential to the extent allowed by law.

Thank you very much for helping us with this important study.

MARKING DIRECTIONS

 Use a blue or black ink pen or dark pencil.

 Do not use felt tip markers or gel pens.

 Put an “X” in the box that best describes your answer.

Correct:  □ □ □

 To change an answer, mark the new one and circle it.

Correct:  □  □

 Please PRINT where applicable. Enter only one letter or number per box: | J | O | B | S |

Public Burden Statement, OMB #XXX, expires 00/00/0000.

Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. Respondent's obligation to reply is required to obtain benefits under P.L 111-5.  Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reading instructions, and completing and reviewing the requested information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Division of Adult Services, Room S-4209, Washington, D.C. 20210 (Paperwork Reduction Project Control No. 1205-0481NOA).

CONTACT INFORMATION

1. Please print your name:

FIRST NAME

MIDDLE NAME

LAST NAME

2. Your street address:

STREET (1)

STREET (2) APT.

CITY STATE ZIP

3. Your telephone numbers:

Cell/Mobile: (| | | |)-| | | |-| | | | |

Home: (| | | |)-| | | |-| | | | |

Work: (| | | |)-| | | |-| | | | |

4. Your email addresses:

Home:

Work:

Other:

5. Your Social Security Number:

| | | | - | | | - | | | | |

BACKGROUND

6. Are you male or female?

1 □ Male

2 □ Female

7. What is your date of birth?

| | | / | | | / | | | | |

MONTH DAY YEAR

8. What is your current marital status?

MARK ONLY ONE

1  Married

2  Living with a partner

3  Widowed

4  Divorced/Separated

5  Never Married

9. Are you of Spanish, Hispanic, or Latino origin?

1  Yes

2  No

10. Do you consider yourself to be . . .

MARK ONE OR MORE

1  American Indian or Alaskan Native

2  Asian

3  Black or African-American

4  Native Hawaiian or other Pacific Islander

5  White

11. Do you speak a language other than English at home?

1  Yes

2  No

12. Do you . . .

MARK ONLY ONE

1  Own the place where you live

2  Rent your own place or contribute to rent at a friend or family’s place

3  Live rent free

13. How many of your children (18 years or younger) currently live in your household?

0  No children living in household  GO TO Q14

| | | CHILDREN



13a. What is the age (in years) of the youngest child currently living in your household?

| | | AGE OF YOUNGEST CHILD

(ENTER “0” IF CHILD IS UNDER 1 YEAR OLD)

14. Not including yourself, how many adults (18 years or older) currently live in your household?

0  No other adults living in household

| | | ADULTS, NOT INCLUDING SELF



14a. Of the adults living with you, how many are employed?

| | | EMPLOYED ADULTS, NOT INCLUDING SELF

15. What is your U.S. citizenship status?

MARK ONLY ONE

1  U.S. Citizen

2  Legal Resident

16. Have you ever been convicted of a felony?

1  Yes

2  No

EDUCATION

17. What is the highest degree or level of school you have completed?

MARK ONLY ONE

1  No formal education

2  12th grade or less, no diploma

3  High school graduate

4  GED

5  Technical, trade or vocational degree

6  Some college credit, but no degree

7  Associate’s degree

8  Bachelor’s degree

9  Master’s degree or higher

18. What is the highest degree or level of school you expect to complete?

MARK ONLY ONE

1  No formal education

2  12th grade or less, no diploma

3  High school graduate

4  GED

5  Technical, trade or vocational degree

6  Some college credit, but no degree

7  Associate’s degree

8  Bachelor’s degree

9  Master’s degree or higher

19. Are you currently enrolled in school or in a job training program? (Do not include the program to which you are applying.)

MARK ALL THAT APPLY

1  Currently enrolled in high school or a GED program

2  Currently enrolled in a vocational, technical, or trade school

3  Currently enrolled in a 2 or 4 year college

4  Currently enrolled in a job training program

0  Not currently enrolled in school or a job training program

20. Have you ever attended any of the following education and training programs either in the U.S. or elsewhere?

MARK ALL THAT APPLY

1  Adult basic education (these programs usually teach reading and math)

2  English as a Second Language (ESL)

3  A job training program at a vocational, technical or trade school

4  College courses that did not lead to the degrees you already listed in Question 17

5  Other (PLEASE SPECIFY BELOW)

6  None

21. If you are selected for this program, do you expect to be going to school part-time or full-time?

1  Part-time

2  Full-time

PUBLIC ASSISTANCE

22. Does your household receive Section 8 or Public Housing Assistance?

1  Yes

2  No

23. Are you currently receiving TANF (Temporary Assistance for Needy Families)?

1  Yes

2  No

24. Are you currently receiving SNAP (Supplemental Nutrition Assistance Program)? (It used to be called the Food Stamps Program.)

1  Yes

2  No

25. Are you currently receiving unemployment insurance?

1  Yes 2     No _ GO TO QUESTION 26



25a. What is your weekly unemployment insurance benefit? $ | | , | | | |

WORK HISTORY AND EDUCATION/TRAINING PLANS

26. What is your current employment status?

MARK ONE EMPLOYMENT STATUS BOX AND THEN FOLLOW THE ARROWS

I am currently working at one or more jobs or businesses	I am not currently working, but I have worked at one or more jobs or businesses during the last 12 months	It has been longer than 12 months since I last worked at a job or business	I have never been employed
1  	2  	3  	4 
26a. How long have you worked at this job? | | | YEARS | | | MONTHS (if work multiple jobs, record time for your main job)  26b. How many hours do you usually work per week at your main job? | | | HOURS PER WEEK  26c. How many hours per week do you work in total, at all of your jobs? | | | HOURS PER WEEK  26d. How much do you earn per hour at your main job, before taxes and other deductions? $ | | | |.| | | PER HOUR	26e. During how many months out of the last 12 have you worked at a job or business? | | | MONTHS  26f. When you were working, how much did you earn per hour at your main job?  $ | | | |.| | | PER HOUR  26g. What was the main reason for leaving your last job? MARK ONLY ONE 1  Laid off 2  Business closed 3  Temporary/ seasonal work ended 4  Fired/discharged 5  Quit due to pregnancy or childcare 6  Quit due to family reasons 7  Quit due to own health problem 8  Quit to attend school or training program 9  Other (PLEASE SPECIFY BELOW) _______________________________	26h. What was the main reason for leaving your last job? MARK ONLY ONE 1  Laid off 2  Business closed 3  Temporary/ seasonal work ended 4  Fired/discharged 5  Quit due to pregnancy or childcare 6  Quit due to family reasons 7  Quit due to own health problem 8  Quit to attend school or training program 9  Other (PLEASE SPECIFY BELOW) _______________________
GO TO QUESTION 27	GO TO QUESTION 27	GO TO QUESTION 28	GO TO QUESTION 29

27. Please enter your total wages, salary, commissions, bonuses, or tips for all jobs over the last 12 months, before deductions for taxes, bonds, dues, or other items.

$| | | | | |

28. Which of the following industries best matches the business of your current/last employer? MARK ONLY ONE

1  Agriculture, Forestry, Fishing and Hunting

2  Mining, Quarrying, and Oil and Gas Extraction

3  Utilities

4  Construction

5  Manufacturing

6  Wholesale Trade

7  Retail Trade

8  Transportation and Warehousing

9  Information (newspaper, periodical, book, and directory publishers; software publishers; motion picture, video, and sound recording industries; broadcasting; telecommunications, etc.)

10  Finance and Insurance

11  Real Estate and Rental and Leasing

12  Professional, Scientific, and Technical Services (accounting services, research and development services, advertising, marketing, legal services, engineering services, interior design, etc.)

13  Management of Companies and Enterprises

14  Administrative and Support and Waste Management and Remediation Services (office administrative services, employment services, janitorial services, landscaping services, etc.)

15  Educational Services

16  Health Care and Social Assistance

17  Arts, Entertainment, and Recreation

18  Accommodation and Food Services

19  Other Services (automotive repair and maintenance, commercial and industrial machinery repair and maintenance, dry cleaning, religious organizations, etc.)

20  Public Administration (police, firefighters, sanitation workers, social workers, etc.)

29. Please enter your total family income over the last 12 months including earnings, pensions, public assistance, alimony, child support, Veteran’s payments, etc., before deductions for taxes, bonds, dues, or other items.

$| | | | | | |

If you do not know the exact amount, please mark the category below that is closest:

1  $0 8  $35,000 - $39,999

2  $1 - $9,999 9  $40,000 - $44,999

3  $10,000 – $14,999 10  $45,000 - $49,999

4  $15,000 - $19,999 11  $50,000 - $59,999

5  $20,000 - $24,999 12  $60,000 - $69,999

6  $25,000 - $29,999 13  $70,000 - $79,999

7  $30,000 - $34,999 14  $80,000 or Over

30. Do you expect to be working for pay in the next few months?

1  No

2  Yes  30a. How many hours a week do you expect to be working?

___________hours/week

31. What is the most important reason you decided to apply to this program? MARK ONLY ONE

1  Find work

2  Career change

3  Career Advancement

4  Educational Advancement

5  Personal Reasons

6  Other (PLEASE SPECIFY BELOW)

________________________________________

32. Please enter the number of years’ (and/or months’) experience you have in the industry for which you are applying for training.

| | | YEARS | | | MONTHS

99  No Experience

33. If selected for this program, how do you plan to cover tuition and fees? MARK ALL THAT APPLY

1  Your own earnings?

2  Earnings from a spouse or partner?

3  Savings—either your own or a spouse/partner’s savings?

4  Financial help from a parent or other family member?

5  Loans in your name?

6  A Pell grant or other federal grant or scholarship—not counting loans you have to pay back?

7  Funding from my local employment center (such as an individual training account or ITA)

8  A grant or scholarship from a non-government source (such as a community based or non-profit organization)—not counting loans that you have to pay back?

9  Financial support from your employer?

10  Another funding source? _______________________ [SPECIFY]

FUTURE CONTACT

34. May we send a text message to your cell phone?

1  Yes

2  No

35. May we contact you through Facebook, Twitter, LinkedIn, or other social network?

1  Yes 2     No _GO TO QUESTION 36



35 a. What is your username and network?

FACEBOOK ACCOUNT: _____________________________

TWITTER HANDLE: ________________________________

LINKED IN USERNAME: _____________________________

OTHER NETWORK:_________________________________

OTHER NETWORK USERNAME: ______________________

36. Please provide contact information of 3 close friends or relatives we can contact in case you move and we cannot easily locate you for the follow-up interview in 12 months. All information will be held confidential to the extent permitted by law and will only be used to locate you if we have trouble contacting you directly.

36a. Relative or friend #1:

NAME

RELATIONSHIP TO YOU

STREET APT.

CITY STATE ZIP

Cell/Mobile: (| | | |)-| | | |-| | | | |

Home: (| | | |)-| | | |-| | | | |

HOME EMAIL

WORK EMAIL

36b. Relative or friend #2:

NAME

RELATIONSHIP TO YOU

STREET APT.

CITY STATE ZIP

Cell/Mobile: (| | | |)-| | | |-| | | | |

Home: (| | | |)-| | | |-| | | | |

HOME EMAIL

WORK EMAIL

36c. Relative or friend #3

NAME

RELATIONSHIP TO YOU

STREET APT.

CITY STATE ZIP

Cell/Mobile: (| | | |)-| | | |-| | | | |

Home: (| | | |)-| | | |-| | | | |

HOME EMAIL

WORK EMAIL

Thank you for completing this survey!