YCC Student Baseline Information Form (Staff)

OMB No.: xxxx-xxxx

Expiration Date: xx/xx/xxxx

Youth CareerConnect

Student Background Information Form (BIF)

These first questions ask about your school and your schoolwork.

A1. What is the name and location of the school you attend (or last attended) in Fall 2015?

School Name: ____________________

City: ________________ State: ______

A2. In general, how much do you like the school you attend (or last attended) in Fall 2015?

MARK ONE ONLY

1 □ I like it a lot

2 □ I like it

3 □ It’s okay

4 □ I don’t like it at all

A3. How important are good grades to you?

MARK ONE ONLY

1 □ Very important

2 □ Important

3 □ Somewhat important

4 □ Not important at all

A4. In a typical week when school is in session, about how much time do you spend on homework?

Description	Hours
a. Time spent on homework during school hours, such as during study hall	| | |
b. Time spent on homework before or after school hours on weekdays	| | |
c. Time spent on homework during the weekend	| | |

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is xxxx-xxxx. The time required to complete this collection of information is estimated to average 21 minutes, including the time to review instructions, search existing data resources, gather the data needed and complete and review the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to NAME at xxx-xxx-xxxx or NAME@___.gov and reference the OMB Control Number xxxx-xxxx.

A5. How many times did the following things happen during the past 3 months in which you were in school?

	MARK ONE PER ROW
	NEVER	1–2 TIMES	3–4 TIMES	5 OR MORE TIMES
a. I was late for school	1 □	2 □	3 □	4 □
b. I cut or skipped classes	1 □	2 □	3 □	4 □
c. I had an unexcused absence from school	1 □	2 □	3 □	4 □
d. I got in trouble for not following school rules	1 □	2 □	3 □	4 □
e. I was suspended or put on probation	1 □	2 □	3 □	4 □

A6. We’d like to learn more about you. Please respond to the following 8 items. Be honest – there are no right or wrong answers.

	MARK ONE PER ROW
	VERY MUCH LIKE ME	MOSTLY LIKE ME	SOMEWHAT LIKE ME	NOT MUCH LIKE ME	NOT LIKE ME AT ALL
a. New ideas and projects sometimes distract me from previous ones.	1 □	2 □	3 □	4 □	5 □
b. Delays and obstacles don’t discourage me. I bounce back from disappointments faster than most people.	1 □	2 □	3 □	4 □	5 □
c. I have been obsessed with a certain idea or project for a short time but later lost interest.	1 □	2 □	3 □	4 □	5 □
d. I am a hard worker.	1 □	2 □	3 □	4 □	5 □
e. I often set a goal but later choose to follow a different one.	1 □	2 □	3 □	4 □	5 □
f. I have difficulty keeping my focus on projects that take more than a few months to complete.	1 □	2 □	3 □	4 □	5 □
g. I finish whatever I begin.	1 □	2 □	3 □	4 □	5 □
h. I am diligent.	1 □	2 □	3 □	4 □	5 □

The next two questions ask about your education plans for the future.

B1. Do you think you will receive a vocational certificate?

A vocational certificate is a certificate from a college or trade school for completion of a program providing job-focused training for specific careers such as physician’s assistants, paralegals, pharmacy technicians, automotive mechanics, and information systems programmers.

MARK ONE ONLY

1 □ Yes

0 □ No

d □ I don’t know

B2. As things stand now, how far do you think you will get in school?

MARK ONE ONLY

1 □ Less than high school degree (will not graduate or get a general education development (GED) certificate)

2 □ High school diploma or GED

3 □ Technical or trade school

4 □ 2-year college graduate

5 □ 4-year college graduate

6 □ Masters, Ph.D. or other advanced degree (such as an MD for doctors or LLD for lawyers)

d □ I don’t know

The next questions are about activities you participate in.

C1. Did you participate in the following school-sponsored activities in the past twelve months? How many of each type of activity did you participate in?

	PARTICIPATED	NUMBER OF SUCH ACTIVITIES
a. Sports	1 □ Yes 0 □ No	| | |
b. Band, orchestra, chorus, choir, school play, or musical	1 □ Yes 0 □ No	| | |
c. Student government	1 □ Yes 0 □ No	| | |
d. National Junior Honor Society (NJHS) or other academic honor society	1 □ Yes 0 □ No	| | |
e. Clubs such as service clubs, academic clubs, hobby clubs, school yearbook, newspaper, or literary magazine	1 □ Yes 0 □ No	| | |
f. Vocational education club or vocational student organization (for example, DECA, VICA, FFA, FHA)	1 □ Yes 0 □ No	| | |
g. Something else (specify)	1 □ Yes 0 □ No	| | |
h. Did not participate in any school-sponsored activities	0 □

C2. Have you done any of the following?

In the table below, mark if you have ever done the activity in the first column. In the second column, mark if you have done the activity in the last month.

	EVER	LAST MONTH
a. Drank alcohol	1 □ Yes 0 □ No	1 □
b. Used or tried marijuana	1 □ Yes 0 □ No	1 □
c. Used or tried another kind of drug	1 □ Yes 0 □ No	1 □

C3. Have you ever been arrested or taken into custody for a crime or illegal offense?

1 □ Yes

0 □ No GO TO D1

C3a. How many times have you been arrested or taken into custody for a crime or illegal offense?

| | | NUMBER OF ARRESTS

The next questions are about your work experience.

D1. Have you ever worked for pay, not counting work around the house?

1 □ Yes, I currently have a job

2 □ Yes, I have worked in the past but am not currently working

When did your last job end?

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

3 □ No I have never had a job GO TO E1, Page 4

D2. Was this work…

1 □ During the summer?

2 □ During the school year?

3 □ Both, during the school year and the summer?

D3. How many hours per week do you currently work at all paid jobs? If you are not currently working, how many hours per week did you work at your most recent job? Your best guess is fine.

| | | hours per week

D4. In a few words, please describe what you do at your current job or what you did at your most recent job, for example, babysitting, mowing lawns, or working in a restaurant?

If you work at more than one job, please tell us about the one in which you work the most hours.

A very important part of this study will be a follow-up survey with you in three years. These last questions ask for information to help us reach you in case we cannot reach you directly for the next survey.

E1. What is your name?

Please note, this information will not be shared or published in any reports.

First name:

Last name:

E2. What is your date of birth?

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

Month Day Year

E3. What is your gender?

1 □ Male

2 □ Female

E4. Do you have any children?

1 □ Yes

0 □ No GO TO E6

E5. Do the children live with you?

1 □ Yes

0 □ No

E6. So we can reach you in the future if needed, please list the address and telephone numbers where you expect you can be reached in the next two years.

Address

Apartment Number

City, State, Zip Code

Home: | | | | - | | | | - | | | | |

Area Code Number

Cell: | | | | - | | | | - | | | | |

Area Code Number

Work: | | | | - | | | | - | | | | |

Area Code Number

Other: | | | | - | | | | - | | | | |

Area Code Number

E7. In whose name is the above home telephone number listed?

First Name:

Last Name:

E8. Does your cell phone plan include unlimited texting?

1 □ Yes

0 □ No

2 □ I do not have a cell phone GO TO E10

E9. May we send you text messages? Message and data rates may apply.

1 □ Yes

0 □ No

E10. What is the email address you use most often?

0 □ I do not have an

email address GO TO E12

E11. If you have another email address, what is it?

E12. Do you have an account with either of the following?

1 □ Facebook?

Name:

2 □ Twitter?

Tag:

0 □ None

E13. Do you have any other social networking accounts?

1 □ Yes (specify site)

0 □ No

E14. Do you have a personal blog or website?

1 □ Yes (specify site)

0 □ No

E15. How would you prefer to be contacted in the future?

MARK ONE ONLY

1 □ Regular mail

2 □ Email

3 □ Call home phone

4 □ Call cell phone

5 □ Text message

6 □ Facebook

7 □ Twitter

8 □ Other (specify)

E16. Please provide contact information for two adults, such as your parents or grandparents, who are likely to know how to reach you over the next three years. If you do not have three adults to list, you can include information for a close friend who would know how to reach you. We will contact these people only if we are unable to contact you directly. Please complete all three contacts if possible.

First relative or friend:

First Name

Last Name

Relationship to You

Contact information for first relative or friend:

Address

Apartment Number

City, State, Zip Code

Email Address

Home: | | | | - | | | | - | | | | |

Area Code Number

Cell: | | | | - | | | | - | | | | |

Area Code Number

Work: | | | | - | | | | - | | | | |

Area Code Number

Second relative or friend:

First Name

Last Name

Relationship to You

Contact information for second relative or friend:

Address

Apartment Number

City, State, Zip Code

Email Address

Home: | | | | - | | | | - | | | | |

Area Code Number

Cell: | | | | - | | | | - | | | | |

Area Code Number

Work: | | | | - | | | | - | | | | |

Area Code Number

Thank you for taking the time to complete this survey.

Prepared by Mathematica Policy Research 2