Baseline Information Form

Rent Reform Demonstration TO2

HUD Rent Reform Demonstration OMB Submission Appendix B BIF (1.20.15)

Baseline information

OMB: 2528-0306

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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

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