Download:
pdf |
pdfATTACHMENT H
PARENT SURVEY INSTRUMENT
OMB ControlOMB
#: CONTROL
0960-0799
# XXXX
OMB
EXPIRATION
DATE:
XX/XX/XXXX
Expiration Date: xx/xx/xxxx
PROMISE 18-Month Follow-Up Surveys:
Parent / Guardian Questionnaire
Draft 3: December 15, 2014
Administrative Notes:
•
The surveys will be administered beginning 19 months after random assignment anniversary date (to
allow for a full 18 months of exposure to services). This instrument is designed in an intervieweradministered format. The parent and youth modules are each designed to take approximately 35
minutes to complete.
•
Consent for participation in both interviews (parent, youth, 18-month and 5-year) was collected from
parent during enrollment in PROMISE. All youth provided assent at the time of enrollment.
•
The target respondent for the parent survey is the parent or guardian who completed the consent
form at the time of enrollment. However, if this parent is not willing or able to take part in the
interview, the youth’s other parent or guardian who resides in the same household as youth could
complete the interview.
•
Parent modules will be completed first, followed by the youth modules. Youth may complete the youth
modules him or herself, or with support from a parent / guardian or other trusted adult. If a youth is
not able to complete his / her interview – these modules may be completed by a proxy. If a proxy
interview is conducted, no items that are subjective in nature will be included in the interview.
•
Interviews will be conducted in English or Spanish.
•
Formatting is used to guide interviewing staff on question administration. Text shown in ALL CAPS is
not read aloud. Text in underline format is emphasized.
•
Programming logic will be used to route respondents to the next applicable item or section based on
responses provided. The target universe for each item (based on skip logic or other criteria, such as
age), is shown in the bar located above the item number.
•
Logic for which set of respondents complete specific sections are shown in the section outline as well
as in the programming specifications at the start of each section.
•
o
For cases where the youth lives apart from a parent or guardian (such as in a group home or
institutional setting), we will interview the parent or guardian who is most knowledgeable
about the youth’s education and services received.
o
Youth identified as living in their own household, apart from parents or guardians, will
respond to a subset of the parent modules during the youth interview. In these cases, the
parent module will be completed by the parent who provided consent at enrollment.
If a youth is found to be deceased, the case will be coded as ineligible and no further contact will be
attempted.
PROMISE: 18-MONTH PARENT GUARDIAN QUESTIONNAIRE
Overview of the 18-Month Instruments
PARENT / GUARDIAN MODULES
Asked of …
Parent or Guardian
of Participating
Youth
(where youth
resides with a
parent / guardian)
Consenting
Parent of
Independent
Youth
Independent
Youth
X
I.
Introduction
X
X
II.
Parent: Service Receipt in Past 18 months
X
X
III.
Parent Employment Experience and
Credentials
X
X
IV.
Parent: Individual and Family Well-Being
X
V.
Parent’s Expectations for Youth
X
X
VI.
Parent Demographics & Contact Information
X
X
X
Variables from sample file used to populate logic within the instrument include:
Fill variable in questionnaire specifications
PROGRAM NAME
STATE PROGRAM LOCATED IN
PROMISE SERVICES (TREATMENT) OR USUAL SERVICES GROUP
ASSIGNMENT
FIRST AND LAST NAME OF CONSENTING PARENT / GUARDIAN
RA DATE
RA MONTH
RA YEAR
FIRST / LAST NAME OF YOUTH
CONSENTING PARENT MAILING ADDRESS
CONSENTING PARENT PHONE
YOUTH MAILING ADDRESS
YOUTH PHONE
2|Page
Sample file variable name
TEXT FILLS FOR SPECIFIC SITES AND STATES
Program
State
AR
CA
MD
NY
WI
ASPIRE
Health Insurance Marketplace
Name
Federal Marketplace
Covered California
(http://www.coveredca.com/)
Maryland Health Connection
(http://www.marylandhealthcon
nection.gov/)
NY State of Health
(https://nystateofhealth.ny.gov/)
Federal Marketplace
State-Specific Name
for Medicaid
Arkansas Medicaid
Medi-Cal
State-Specific Name for
TANF
TANF
CalWORKs
Medicaid or
HealthChoice
Temporary Cash Assistance
(TCA)
Partnership for Long
Term Care or Medicaid
Medicaid HMO Program
Family Assistance (FA)
AZ: Federal Marketplace
CO: Connect for Health
Colorado
http://connectforhealthco.com/
MT=federal marketplace,
ND=federal marketplace,
SD=federal marketplace,
Utah=federal marketplace
(individual) and Avenue H
http://www.avenueh.com/
AZ: AHCCCS
(pronounced ‘access’)
CO: Medical Assistance
Program (CO) /
Medicaid
MT: Passport to Health /
Medicaid or Passport
ND: Medicaid (ND)
SD: Medicaid (SD)
UT: Medicaid (UT)
Arizona: Cash Assistance
(CA)
Colorado: Colorado Works
Montana: TANF
North Dakota: TANF
South Dakota: TANF
Utah: TANF
TANF
Name for Case Manager
Connector
Career Service Coordinator
(CSC)
Case manager and Family
Employment Specialist
Research Demonstration Site
(RDS) case manager
Division of Vocational
Rehabilitation (DVR)
counselor
Case Manager
I. PARENT: INTRODUCTION
Asked of …
Section I. Introduction
Parent or
Guardian of
Participating
Youth
Consenting Parent
of Independent
Youth
Independent
Youth
x
x
x
ALL
[INTERVIEWER’S FULL NAME], [PROMISE PROGRAM], [NAME OF CONSENTING PARENT] [YOUTH]
I. Hello.
Hi! My name is [INTERVIEWER’S FULL NAME]. I’m calling from Mathematica Policy Research
on behalf of the Social Security Administration, as part of an important national study. May I
please speak to [NAME OF CONSENTING PARENT]?
IF UNAVAILABLE, ASK FOR ANOTHER PARENT OR GUARDIAN.
INTERVIEWER: IF YOUTH ANSWERS, BRIEFLY EXPLAIN WE NEED TO BEGIN WITH THE PARENT
QUESTIONS FIRST AND THEN WOULD THEN LIKE TO SPEAK WITH HIM / HER AFTERWARDS.
CODE ONE ONLY
SPEAKING TO [CONSENTING PARENT] .......................................................... 1
CONTINUE
SPEAKING TO OTHER PARENT / GUARDIAN .................................................. 2
CONTINUE
WHAT IS CALL ABOUT ....................................................................................... 3
CONTINUE
PARENT / GUARDIAN BUSY, UNAVAILABLE ................................................... 4
NOT AVAILABLE
PARENT / GUARDIAN MOVED / LIVES ELSEWHERE ...................................... 5
NOT AVAILABLE
PARENT / GUARDIAN ONLY SPEAKS SPANISH [GET SPANISH-SPEAKING
INTERVIEWER] .................................................................................................... 6
CONTINUE OR SET CB
PARENT / GUARDIAN DOES NOT SPEAK ENGLISH OR SPANISH ................ 7
BARRIER
PARENT / GUARDIAN HAS HEALTH PROBLEM ............................................... 8
BARRIER
PARENT / GUARDIAN IN AN INSTITUTION....................................................... 9
BARRIER
YOUTH IS DECEASED ........................................................................................ 10
INELIGIBLE
PARENT / GUARDIAN IS DECEASED ................................................................ 11
BARRIER
NEVER HEAD OF PARENT / GUARDIAN .......................................................... 12
BARRIER
WRONG NUMBER ............................................................................................... 13
BARRIER
HUNG UP DURING INTRODUCTION ................................................................. 14
BARRIER
4|Page
I. PARENT: INTRODUCTION
I.HELLO = 1, 2, OR 3
[YOUTH]
I. ELIG. I’m calling to complete an interview with [YOUTH]’ parent or legal guardian, as well as an interview
with [YOUTH]. To confirm I am speaking with someone who can complete this interview, can you
please tell me how you are related to [YOUTH]?
CODE ONE ONLY
MOTHER (BIOLOGICAL OR ADOPTED) ............................................................ 1
GO TO I.ELIG_2
FATHER (BIOLOGICAL OR ADOPTED) ............................................................. 2
GO TO I.ELIG_2
LEGAL GUARDIAN .............................................................................................. 3
GO TO I.ELIG_2
STEP MOTHER .................................................................................................... 4
GO TO I.ELIG_2
STEP FATHER ..................................................................................................... 5
GO TO I.ELIG_2
LEGAL GUARDIAN .............................................................................................. 6
GO TO I.ELIG_2
FOSTER PARENT: FOSTER MOTHER .............................................................. 7
GO TO I.ELIG_2
FOSTER PARENT: FOSTER FATHER ............................................................... 8
GO TO I.ELIG_2
OTHER FAMILY MEMBER (PROXY FOR PARENT OR GUARDIAN) ............... 9
GO TO I.ELIG_2
SOMEONE FROM [YOUTH]’S SCHOOL, GROUP HOME, OR OTHER
INSTITUTION ....................................................................................................... 10
SOMEONE FROM AN AGENCY/ SERVICE PROVIDER.................................... 11
OTHER (SPECIFY) .............................................................................................. 99
___________________________________________________ (STRING 150)
DON’T KNOW ....................................................................................................... d
TERMINATE
REFUSED ............................................................................................................. r
TERMINATE
IF OTHER SPECIFY (99): Other relationship is:
I.ELIG = 10, 11, 99
[CONSENTING PARENT] [YOUTH]
I.ELIG_1.
Thanks for this information. We’d like to ask the remaining questions with [CONSENTING
PARENT], and then we’ll reach out to [YOUTH] for (his / her) interview.
CODE ONE ONLY
[CONSENTING PARENT NAME] COMES TO PHONE ...................................... 1
CONTINUE
CONSENTING PARENT NOT AVAILABLE ......................................................... 2
SET CALLBACK
CONSENTING PARENT WILL NOT PARTICIPATE ........................................... 3
BARRIER – REFUSAL
5|Page
I. PARENT: INTRODUCTION
I.ELIG = 1-9 OR I.ELIG_1=1
[CONSENTING PARENT NAME] [YOUTH] [him/her]
I.ELIG_2.
May I confirm that you are the person who is most knowledgeable about the day-to-day
activities of [YOUTH], and that you are the legal guardian of [YOUTH] and can answer
questions about [him/her]? This includes knowledge of services or supports that he / she may
have received.
CODE ONE ONLY
YES – CONFIRMED AS KNOWLEDGEABLE AND LEGAL GUARDIAN............ 1
CONTINUE
NO – NOT THE MOST KNOWLEDGEABLE ADULT .......................................... 2
SET CALLBACK
NO – NOT THE LEGAL GUARDIAN…………………………………………………3
SUPERVISOR REVIEW
WILL NOT PARTICIPATE .................................................................................... 3
BARRIER – REFUSAL
I.ELIG_2=1
[you / CONSENTING PARENT NAME] [PROMISE PROGRAM NAME] [you may remember completing] [FILL$30
IF DATE OF INTERVIEW IS > 10 DAYS FROM LAUNCH / FILL $40 IF DATE OF INTERVIEW IS < 10 DAYS
FROM LAUNCH].
I.Consent.
IF SPEAKING TO CONSENTING PARENT: About a year and a half ago, [you /
CONSENTING PARENT NAME] enrolled in a program called [PROMISE PROGRAM NAME].
In that application, [you may remember completing] a consent form which explained that
the study included two interviews. This is the first interview.
The questions will cover topics such as: your health and wellbeing, services received over
the last year or so, and your educational and employment experiences. This interview
takes about 35 minutes to complete.
You will receive [$30 / $40] for completing the interview.
I’d like to begin with some questions for you and then talk to (YOUTH). Do I have your
permission to begin?
IF NEEDED: All your answers will be held in strict confidence. Nothing you say will affect
your child’s SSI benefits now or in the future. We can start now and take a break whenever
you need one.
IF SPEAKING TO NON-CONSENTING PARENT: We are conducting a health study for SSA.
This study includes two interviews, and this is the first one. The questions will cover
topics such as: health and wellbeing, services received over the last year or so, and
educational and employment experiences. This interview takes about 35 minutes to
complete.
You will receive [$30 / $40] for completing the interview.
I’d like to begin with some questions for you and then talk to (YOUTH).
IF NEEDED: All your answers will be held in strict confidence. Nothing you say will affect
your child’s SSI benefits now or in the future. We can start now and take a break whenever
you need one.
CODE ONE ONLY
YES ....................................................................................................................... 1
6|Page
I. PARENT: INTRODUCTION
NOT A GOOD TIME ............................................................................................. 2
SET CALLBACK
REFUSED ............................................................................................................. r
STATUS AS REFUSAL
I.CONSENT = 1
I. Consent_2. Before we begin, I want to confirm that you read in the letter that we sent you. In it there
was information about how SSA can use and share the information you provide. I can read
it to you now if you didn’t read it in the letter.
Section 1110 of the Social Security Act, as amended, authorizes us to request this
information. We will use this information to evaluate the impact of services provided to
you (the minor participant or household member) during your participation in the
Promoting Readiness of Minors in SSI (PROMISE) project. Providing us this information is
voluntary. Failing to provide us with all or part of the information will not affect the SSI
benefits that you, your child, or other household members receive now or in the future.
We may use the information for the administration of our programs, including sharing
information:
1.
To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and the Department of Veterans Affairs);
and,
2.
To facilitate audit, investigative, or statistical research activities necessary to
assure the integrity and improvement of our programs (e.g., to the Bureau of Census and
to private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice entitled, Supplemental Security
Income Studies, Surveys, Records and Extracts (Statistics), 60-0203. Additional
information about this and other system of records notices and our programs are available
from our Internet website at www.socialsecurity.gov or at your local Social Security office.
Do I have your permission to begin?
CODE ONE ONLY
YES ....................................................................................................................... 1
NOT A GOOD TIME ............................................................................................. 2
SET CALLBACK
REFUSED ............................................................................................................. r
STATUS AS REFUSAL
7|Page
I. PARENT: INTRODUCTION
I.CONSENT_2 = 1
[YOUTH] [NAME OF CONSENTING PARENT]
I.R TYPE.
To help us know which questions to ask first, we need to know where [YOUTH] lives or
stays most of the time.
Does [YOUTH] live with you, with another parent or legal guardian, or somewhere else?
INTERVIEWER: IF YOUTH NO LONGER LIVES WITH PARENT OR GUARDIAN: CODE “4”
BELOW. THIS DRIVES IMPORTANT SKIP LOGIC.
CODE ONE ONLY
YOUTH LIVES WITH ME / [NAME OF CONSENTING PARENT] ....................... 1
YOUTH LIVES WITH OTHER PARENT OR GUARDIAN .................................... 2
OTHER SETTING (NOT WITH PARENT OR GUARDIAN), E.G. GROUP
HOME, INSTITUTION, OR BOARDING SCHOOL .............................................. 3
YOUTH NO LONGER LIVES WITH PARENT/ GUARDIAN (INDEPENDENT) ... 4
SOFT CHECK: IF I.RTYPE_4=1: May I confirm I have recorded correctly that [YOUTH] no longer lives with
any parent, a foster parent, or any legal guardian?
I.RTYPE_4=1 AND I.HELLO=2
[YOUTH]
I.R TYPE2. Thanks for this information. Since [YOUTH] lives in (his / her) own household, apart from any
parent or guardian, we’d like to ask the remaining questions with [CONSENTING PARENT
NAME], and then we will reach out to [YOUTH] for (his / her) portion of the interview.
CODE ALL THAT APPLY
[NAME OF CONSENTING PARENT] COMES TO PHONE ............................... 1
CONTINUE
YOUTH LIVES WITH OTHER PARENT OR GUARDIAN .................................... 2
SET CALLBACK
I.RTYPE_1= 1
[CONSENTING PARENT NAME]
I.Q1.
To begin, may I double check the spelling of your name? I have [CONSENTING PARENT NAME], is
that correct?
IF NEEDED:
This information tells us who answered the questions and will be used to send you
the $30 payment after completing the interview.
INTERVIEWER:
CORRECT OR UPDATE, IF NEEDED
___________________________________________________ (STRING 20)
[FIRST NAME]
___________________________________________________ (STRING 50)
[LAST NAME]
GO TO I.Q3
CORRECT AS SHOWN - CONTINUE ................................................................. 1
GO TO I.Q3
REFUSED ............................................................................................................. r
GO TO I.Q3
8|Page
I. PARENT: INTRODUCTION
I.RTYPE_2=1 OR I.RTYPE_3=1
[CONSENTING PARENT NAME] [YOUTH] [TEXT FILL IF I.ELIG=9]
I.Q2.
I see that [CONSENTING PARENT NAME] gave permission for [YOUTH] to enroll in PROMISE,
however, either of [YOUTH]’s parent(s) or guardian(s) [IF I.ELIG=9, FILL: or someone who can
respond on their behalf] that is knowledgeable about services [YOUTH] receives can answer these
questions.
May I have your first and last name please?
PROBE:
This information tells us who answered the questions and will be used to send you the
$30 payment after completing the interview.
___________________________________________________ (STRING 30)
FIRST NAME
___________________________________________________ (STRING 30)
MIDDLE INITIAL/NAME
___________________________________________________ (STRING 60)
LAST NAME
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
I.CONSENT_2 = 1
I.Q3.
The first few questions ask about your household and living situation. Your answers will help
make the interview go faster because I will know which questions apply to you. Are you…
(NLTS2012, H1)
INTERVIEWER: PROBE, FOR CURRENT MARITAL STATUS. IF DIVORCED, NOW REMARRIED, THE
STATUS WOULD BE “1” (MARRIED).
CODE ONE ONLY
Married ................................................................................................................. 1
In a marriage-like relationship........................................................................... 2
Divorced .............................................................................................................. 3
GO TO I.Q5
Separated ............................................................................................................ 4
GO TO I.Q5
Widowed, or ........................................................................................................ 5
GO TO I.Q5
Single, never married? ...................................................................................... 6
GO TO I.Q5
DON’T KNOW ....................................................................................................... d
GO TO I.Q5
REFUSED ............................................................................................................. r
GO TO I.Q5
SOFT CHECK: IF I.Q3=D or R; This information helps us know which types of questions to ask about your
household. Are there any questions I can answer or any concerns you may have about answering this
question that I could help address?
PROGRAMMER:
9|Page
FOR ALL SUBSEQUENT ITEMS THAT FILL [SPOUSE/PARTNER] FILL SPOUSE IF
I.Q3 = 1, FILL PARTNER IF I.Q3 = 2
I. PARENT: INTRODUCTION
I.Q3= 1 OR 2
[spouse / partner]
I.Q4.
Does your (spouse / partner) lives in the same household with you?
PROBE: Your answer to this question helps me make sure you get asked only the questions that
apply to you.
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
GO TO I.Q5
DON’T KNOW ....................................................................................................... d
GO TO I.Q5
REFUSED ............................................................................................................. r
GO TO I.Q5
I.CONSENT_2 = 1
[YOUTH]
I.Q5.
Some of our questions are only asked of males or females. May I confirm, is [YOUTH] male or
female?
PROBE:
This information also helps us tailor the questions in specific ways – such as using
“he” or “she” to describe [YOUTH], where needed.
MALE .................................................................................................................... 1
FEMALE ............................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
PROGRAMMER: APPLY THIS LOGIC FOR ALL SUBSEQUENT ITEMS REFERENCING THE YOUTH:
IF 1.Q5=1, THEN USE MALE FILLS (HIM, HIS, HE).
IF I.Q5=2, THEN USE FEMALE FILLS (HER, SHE)
IF I.Q5= D OR R, THEN PRESENT BOTH POSSIBLE FILLS (HIM / HER), (HE / SHE), (HIS / HER) AND
INTERVIEWERS WILL APPLY APPROPRIATE TEXT, AS NEEDED.
I.CONSENT_2 = 1
[YOUTH]
I.Q6.
Are there any other youth ages 14-21 living or staying in the same household with [YOUTH]?
PROBE:
Your answer to this question helps me make sure you get asked only the questions
that apply to you.
YES ....................................................................................................................... 1
NO ........................................................................................................................ 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
10 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
Asked of …
II.
Parent: Service Receipt in Past 18 months
SECTION II PART A.
Parent or Guardian
of Participating
Youth
Consenting Parent
of Independent
Youth
X
X
Independent
Youth
SPECIAL EDUCATION SERVICES AND SUPPORTS
I.CONSENT_2 = 1
[YOUTH] [and your (spouse / partner)]
II.A.INTRO.
These next questions are about special education and other education services
that [YOUTH] might have received.
CONTINUE .............................................................................................. 1
I.CONSENT_2 = 1
[RA DATE] [YOUTH]
II.A1.
Since [RA DATE], did [YOUTH] receive special education services or have an IEP
(Individualized Education Program)? (NLTS2012, modified)
IF NEEDED:
“IEP” stands for an Individualized Education Program. An IEP is a written
statement for each student with a disability that sets goals for the student in school, says how
progress will be measured, describes the special education and related services the school will
provide, how much the student will be in the regular class with nondisabled students, and lists
accommodations or modifications needed to measure what the student knows through tests.
IF NEEDED: After a student turns 16, the IEP must also include goals for what the student is
interested in doing after high school and services needed to help the student reach those goals.
This could include goals related to post-secondary education, training, or employment.
YES
............................................................................................... 1
NO
............................................................................................... 0
NOT APPLICABLE / NOT IN HIGH SCHOOL SINCE [RA DATE] ..... 2
DON’T KNOW ..................................................................................... d
REFUSED ........................................................................................... r
11 | P a g e
GO TO II.A4
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
II.A1=1, 0, D OR R
[RA DATE] [RA YEAR] AND [YOUTH]
II.A2.
Since [RA DATE], has [YOUTH] had a Section 504 plan? (NLTS2012, modified)
IF NEEDED: A Section 504 plan, which falls under civil-rights law, removes barriers so
students with disabilities can participate in school as freely as possible.
This may include students who do not need an IEP but may need extra help or
assistance to participate fully in school. Such help may include more time on
tests, or sitting in the front of the classroom. An IEP is more concerned with
providing educational services.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
II.A1=1, 0, D OR R
[RA DATE], [YOUTH], [HE/SHE]
II.A3.
Since [RA DATE], have you or another adult in the household met with teachers to set
goals for what [YOUTH] will do after high school and make a plan for how [HE/SHE] will
achieve them? Sometimes this is called a transition plan or a transition focused IEP.
(NLTS12 2012, modified)
YES ....................................................................................................................... 1
NO ......................................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
I.CONSENT_2 = 1
[RA DATE] [YOUTH]
II.A4.
Since [RA DATE], has [YOUTH] gotten any help with school expenses, obtaining a
computer, getting accommodations at school, or help with any other school-related
supports that we haven’t already talked about? This help could have been provided by the
school or by some other organization.
IF NEEDED: This could include help with school expenses and support for any kid of
school, including high school, post-secondary education, or vocational training.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
12 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
SECTION II PART B.
OTHER YOUTH SERVICES
I.CONSENT_2 = 1
[YOUTH] [RA DATE] [TEXT FILL IF PROMISE SERVICE GROUP] [PROMISE PROGRAM NAME]
II.B.INTRO.
My next questions are about other services or training [YOUTH] might have
received since [RA DATE]. Please only include services or training provided by
someone outside of [YOUTH]’s family.
[IF PROMISE SERVICES GROUP INSERT: I don’t know which services [YOUTH]
received through [PROMISE PROGRAM NAME], so in the next set of questions,
please tell me about those, along with any other services [YOUTH] received].
After these questions about [YOUTH], I will ask some questions about services or
training you may have received since [RA DATE].
CONTINUE ............................................................................
13 | P a g e
1
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
I.CONSENT_2 = 1
[RA DATE], [YOUTH], [HIS / HER], [HIM / HER], [PROMISE SERVICES GROUP FILL BASED ON
SITE], [HE/SHE], [WI STATE-SPECIFIC TEXT FILL]
II.B1.-II.B11.
Since [RA DATE] has [YOUTH] … (Please only include services or training
provided by someone outside of [YOUTH]’s family.)
IF NEEDED: This help could have come from one of the places you’ve already told
me about.
CODE ONE PER ROW
YES
NO
DK
REF
B1. Worked with anyone to determine [his/her] needs and help connect
[him/her] to services and supports related to education, employment,
health, housing or anything else? This person is sometimes called a
case manager [IF PROMISE SERVICES GROUP: or a [SITE NAME - CASE
MGR].
1
2
d
r
B2. Been taught skills needed for life? This includes skills such as telling
time, interacting with people socially, or using public transportation.
1
2
d
r
B3. Had any training to teach [him/her] about being a leader or about how to
speak up for [HIM/HER] self to get the things [HE/SHE] wants or needs?
This is sometimes called self-advocacy or self-determination training.
1
2
d
r
B4. Participated in activities to help [HIM/HER] learn about what jobs match
[HIS/HER] skills and interests?
1
2
d
r
B5. Had help with learning about or getting into a school or training program,
including help with an application, entrance exam, or interview? For
example, where someone told [HIM/HER] about training programs or
schools that are available and how to apply for them? Or if someone
helped [YOUTH] complete an application for college or vocational school.
1
2
d
r
B6. Had any training to help him learn new job skills? Please do not include
any training [YOUTH] had on-the-job directly from [HIS/HER] employer.
1
2
d
r
B7. Had help in finding or applying for a job, such as help finding jobs
available, filling out an application, writing a resume, or going for an
interview?
1
2
d
r
B8. Received any help while working at a job, such as help with job
accommodations, or learning job duties? This could include help from a
job coach. Please don’t include any help given by [YOUTH]’s employer.
1
2
d
r
B9. Received any help with learning about, getting, or using assistive
technology? IF NEEDED: This could include help with special tools or
equipment, software, or devices that help [YOUTH] perform school or
work activities that are difficult to do because of [HIS/HER] disability.
1
2
d
r
B10. Had help in understanding Social Security, SSI, or other program
benefits and rules? This is sometimes called benefits counseling or
benefits planning. IF NEEDED: SSI stands for Supplemental Security
Income.
1
2
d
r
B11. Since [RA DATE], has [YOUTH] had help learning about how to save
and manage money, [IF WI: including help with an Individual
Development Account or IDA]?
1
2
d
r
14 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
I.CONSENT_2 = 1
[RA DATE], [YOUTH] [him / her]
II.B12. Since [RA DATE], has [YOUTH] had any other services to help prepare [him/her] for
working, going to school, or living independently? Please only include services or training
provided by someone outside of [YOUTH]’s family.
IF NEEDED: This help could have come from one of the places you’ve already told me
about.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 2
GO TO Box 1
DON’T KNOW ....................................................................................................... d
GO TO Box 1
REFUSED ............................................................................................................. r
GO TO Box 1
II.B12=1
[YOUTH]
II.B12a. What kind of services did [YOUTH] receive?
___________________________________________________ (STRING 100)
OTHER SERVICES
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
PROGRAMMER SKIP BOX 1
IF NONE OF THE FOLLOWING SERVICES WERE RECEIVED (ALL ITEMS II.B1= 0, II.B4=0,
II.B6=0, II.B7=0, II.B8=0, II.B10=0, AND 11.B11=0) GO TO II.B.13. ELSE GO TO II.B PROVIDERINTRO.
15 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
IF ANY ITEM (II.B1, II.B4, II.B6, II.B7, II.B8, II.B10, OR II.B11=0)
[YOUTH]
II.B. PROVIDER-INTRO.
Thanks for this information. Now I’d like to ask about the places [YOUTH] received the
services you have just told me about.
CONTINUE ........................................................................................................... 1
II.B1=1
[YOUTH] [HIM / HER] [HIS/HER]
II.B1a. Who did [YOUTH] work with to determine (his/her) needs and help connect (him/her) to
services?
IF NEEDED: Who provided those services? Please tell me the name of the agency or
program.
PROBE 1: IF UNABLE TO STATE NAME OF PROVIDER: I need to enter something that
will help us identify the provider later. Do you know his or her first or last
name? Was he/she a doctor, a therapist, a vocational rehabilitation counselor,
or some other type of provider?
PROBE 2: Anyone else?
___________________________________________________ (STRING 100)
PROVIDER NAME -1
___________________________________________________ (STRING 100)
PROVIDER NAME -2
___________________________________________________ (STRING 100)
PROVIDER NAME -3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
16 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
II.B4=1
[YOUTH] [HIS/ HER]
II.B4a. Who did [YOUTH] speak to about [HIS/HER] career plans or go to for help learning about
[HIS/HER] job interests?
IF NEEDED: Who provided those services? Please tell me the name of the agency or
program.
PROBE 1: IF UNABLE TO STATE NAME OF PROVIDER: I need to enter something that
will help us identify the provider later. Do you know his or her first or last
name? Was he/she a doctor, a therapist, a vocational rehabilitation counselor,
or some other type of provider?
PROBE 2: Anyone else?
___________________________________________________ (STRING 100)
PROVIDER NAME -1
___________________________________________________ (STRING 100)
PROVIDER NAME -2
___________________________________________________ (STRING 100)
PROVIDER NAME -3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
II.B6=1
II.B6a. Who provided the job skills training?
IF NEEDED: Who provided those services? Please tell me the name of the agency or
program.
PROBE 1: IF UNABLE TO STATE NAME OF PROVIDER: I need to enter something that
will help us identify the provider later. Do you know his or her first or last
name? Was he/she a doctor, a therapist, a vocational rehabilitation counselor,
or some other type of provider?
PROBE 2: Anyone else?
___________________________________________________ (STRING 100)
PROVIDER NAME -1
___________________________________________________ (STRING 100)
PROVIDER NAME -2
___________________________________________________ (STRING 100)
PROVIDER NAME -3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
17 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
II.B7=1
[YOUTH]
II.B7a. Who helped [YOUTH] in trying to find or apply for a job?
IF NEEDED: Who provided those services? Please tell me the name of the agency or
program.
PROBE 1: IF UNABLE TO STATE NAME OF PROVIDER: I need to enter something that
will help us identify the provider later. Do you know his or her first or last
name? Was he/she a doctor, a therapist, a vocational rehabilitation counselor,
or some other type of provider?
PROBE 2: Anyone else?
___________________________________________________ (STRING 100)
PROVIDER NAME -1
___________________________________________________ (STRING 100)
PROVIDER NAME -2
___________________________________________________ (STRING 100)
PROVIDER NAME -3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
II.B8=1
[YOUTH], [HE/SHE]
II.B8a. Who helped [YOUTH] while [HE/SHE] was working at job?
IF NEEDED: Who provided those services? Please tell me the name of the agency or
program.
PROBE 1: IF UNABLE TO STATE NAME OF PROVIDER: I need to enter something that will
help us identify the provider later. Do you know his or her first or last name?
Was he/she a doctor, a therapist, a vocational rehabilitation counselor, or some
other type of provider?
PROBE 2: Anyone else?
___________________________________________________ (STRING 100)
PROVIDER NAME -1
___________________________________________________ (STRING 100)
PROVIDER NAME -2
___________________________________________________ (STRING 100)
PROVIDER NAME -3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
18 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
II.B10=1
[YOUTH]
II.B10a. Who helped [YOUTH] to understand Social Security, SSI, or other benefits?
IF NEEDED: Who provided those services? Please tell me the name of the agency or
program.
PROBE 1: IF UNABLE TO STATE NAME OF PROVIDER: I need to enter something that will
help us identify the provider later. Do you know his or her first or last name?
Was he/she a doctor, a therapist, a vocational rehabilitation counselor, or some
other type of provider?
PROBE 2: Anyone else?
___________________________________________________ (STRING 100)
PROVIDER NAME -1
___________________________________________________ (STRING 100)
PROVIDER NAME -2
___________________________________________________ (STRING 100)
PROVIDER NAME -3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
II.B11=1
[YOUTH]
II.B11a. Who helped [YOUTH] learn about saving and managing money?
IF NEEDED: Who provided those services? Please tell me the name of the agency or
program.
PROBE 1: IF UNABLE TO STATE NAME OF PROVIDER: I need to enter something that will
help us identify the provider later. Do you know his or her first or last name?
Was he/she a doctor, a therapist, a vocational rehabilitation counselor, or some
other type of provider?
PROBE 2: Anyone else?
___________________________________________________ (STRING 100)
PROVIDER NAME -1
___________________________________________________ (STRING 100)
PROVIDER NAME -2
___________________________________________________ (STRING 100)
PROVIDER NAME -3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
19 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
I.CONSENT_2 = 1
[RA DATE], [YOUTH], (him / her), [HE/SHE]
II.B13. Since [RA DATE], has [YOUTH] needed any help or services to help (him / her) preparing
for school or work that [he / she] did not receive?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 2
GO TO BOX 2
DON’T KNOW ....................................................................................................... d
GO TO BOX 2
REFUSED ............................................................................................................. r
GO TO BOX 2
20 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
II.B13=1
[YOUTH] [HE/SHE]
II.B13a.
What help or services did [YOUTH] need that [HE/SHE] did not get?
PROBE: Anything else?
CODE ALL THAT APPLY
DISCOVERING JOB INTERESTS/SKILLS (INCLUDES ASSESSMENTS) ........ 1
INDEPENDENT LIVING SKILLS TRAINING ........................................................ 2
CAREER COUNSELING ...................................................................................... 3
LEARNING HOW TO LOOK FOR A JOB ............................................................. 4
JOB SHADOWING................................................................................................ 5
APPRENTICESHIP/INTERNSHIP ........................................................................ 6
HELP FINDING A JOB.......................................................................................... 7
SUPPORT ON THE JOB (JOB COACHING) ....................................................... 8
HELP GETTING INTO SCHOOL/TRAINING........................................................ 9
UNDERSTANDING SSA/OTHER BENEFITS ...................................................... 10
COMPUTER LITERACY CLASSES ..................................................................... 11
PROBLEM SOLVING............................................................................................ 12
SOCIAL SKILLS TRAINING ................................................................................. 13
FINANCIAL LITERACY/MONEY MANAGEMENT TRAINING ............................. 14
SELF ADVOCACY/DETERMINATION TRAINING ............................................... 15
REFERRAL TO ANOTHER AGENCY .................................................................. 16
TRANSPORTATION SERVICES .......................................................................... 17
HEALTH-RELATED SERVICES ........................................................................... 18
CASE MANAGEMENT.......................................................................................... 19
ACCOMMODATIONS ........................................................................................... 20
OTHER (SPECIFY) ............................................................................................... 99
___________________________________________________ (STRING 50)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): Other service, not listed above:
PROGRAMMER SKIP BOX 2
IF NONE OF THE FOLLOWING SERVICES WERE RECEIVED [B1=0, II.B4=0, II.B6=0,
II.B7=0, II.B8=0, II.B10=0, II.B11=0], SKIP TO II.D. INTRO. ELSE GO TO II.B14.
21 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
IF ANY OF THE FOLLOWING SERVICES WERE RECEIVED [II.B1=1, II.B4=1, II.B6=1, II.B7=1,
II.B8A=1, II.B10A=1, OR II.B11A=1] AND PROVIDER WAS SPECIFIED IN ANY OF THE FOLLOWING
[B1a, B4a, B6a, B7a, B8a, B10a, OR B11a]
II.B14. PROGRAMMER: LIST PROVIDERS POPULATED AS APPLICABLE FROM RESPONSES TO:
II.B1a, II.B4a, II.B6a, II.B7a, II.B8a, II.B10a, and II.B11a.
INTERVIEWER: DOES ANY PROVIDER APPEAR ON THE LIST BELOW MORE THAN ONCE?
IF A PROVIDER APPEARS MORE THAN ONCE, DELETE ONE FROM THE LIST. DO NOT
MARK BOTH PROVIDERS FOR DELETION. ONCE THE LIST IS REVIEWED, SELECT EITHER
“NO OTHER DUPLICATES / DONE” OR “NO DUPLICATES SHOWN ABOVE.”
CODE ALL THAT APPLY
RESPONSE(S) FROM II.B1a_1 (case management) ....................................................... 1
RESPONSE(S) FROM II.B1a_2 (case management) ....................................................... 2
RESPONSE(S) FROM II.B1a_3 (case management) ....................................................... 3
RESPONSE(S) FROM II.B4a_1 (career planning and job interests) ................................. 4
RESPONSE(S) FROM II.B4a_2 (career planning and job interests) ................................. 5
RESPONSE(S) FROM II.B4a_3 (career planning and job interests) ................................. 6
RESPONSE(S) FROM II.B6a_1 (job skills training)........................................................... 7
RESPONSE(S) FROM II.B6a_2 (job skills training)........................................................... 8
RESPONSE(S) FROM II.B6a_3 (job skills training)........................................................... 9
RESPONSE(S) FROM II.B7a_1 (help finding or applying to jobs)..................................... 10
RESPONSE(S) FROM II.B7a_2 (help finding or applying to jobs)..................................... 11
RESPONSE(S) FROM II.B7a_3 (help finding or applying to jobs)..................................... 12
RESPONSE(S) FROM II.B8a_1 (help while working at a job) ........................................... 13
RESPONSE(S) FROM II.B8a_2 (help while working at a job) ........................................... 14
RESPONSE(S) FROM II.B8a_3 (help while working at a job) ........................................... 15
RESPONSE(S) FROM II.B10a_1 (understanding SSI and other benefits) ........................ 16
RESPONSE(S) FROM II.B10a_2 (understanding SSI and other benefits) ........................ 17
RESPONSE(S) FROM II.B10a_3 (understanding SSI and other benefits) ........................ 18
RESPONSE(S) FROM II.B11a_1 (skills for saving and managing money) ....................... 19
RESPONSE(S) FROM II.B11a_2 (skills for saving and managing money) ....................... 20
RESPONSE(S) FROM II.B11a_3 (skills for saving and managing money) ....................... 21
NO OTHER DUPLICATES / DONE ................................................................................... 22
NO DUPLICATES SHOWN ABOVE .................................................................................. 00
PROGRAMMER:
RESPONSE(S) TO II.B14 DETERMINE THE NUMBER OF LOOPS THROUGH THE
NEXT SECTION, IN ITEMS II.C1-II.C6. IF NOT PROVIDERS WERE IDENTIFIED IN
II.B14. SKIP TO II.D INTRO.
22 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
SECTION II PART C. INTENSITY OF SERVICE RECEIPT
IF ANY OF THESE SERVICES RECEIVED [B1=0, II.B4=0, II.B6=0, II.B7=0, II.B8=O, II.B10=0, II.B11=0]
AND NAME OF PROVIDER(S) POPULATED IN [II.B1a, II.B4a, II.B6a, II.B7a, II.B8a, B10a, II.B11a].
[YOUTH] [PROVIDER NAME]
II.C1.
IF >1 PROVIDER, FILL: Now, I have some questions about these providers. Let’s start with
services [YOUTH] received from [PROVIDER NAME].
IF ONLY 1 PROVIDER OR SUBSEQUENT PROVIDERS WHEN >1 PROVIDER, FILL: Next, I
have some questions about services [YOUTH] received from [PROVIDER NAME].
CONTINUE ........................................................................................................... 1
IF ANY OF THESE SERVICES RECEIVED [B1=0, II.B4=0, II.B6=0, II.B7=0, II.B8=O, II.B10=0, II.B11=0]
AND NAME OF PROVIDER(S) POPULATED IN [II.B1a, II.B4a, II.B6a, II.B7a, II.B8a, B10a, II.B11a].
[YOUTH] [PROVIDER], [PROVIDER NAME], [STATE-SPECIFIC NAMES IF APPLICABLE], [PROMISE
SERVICES GROUP MEMBER, DISPLAY: PROMISE/ASPIRE PROGRAM]
II.C2.
Thinking about the place [YOUTH] went to get services from [PROVIDER], what type of
place is this?
PROBE:
Where did [YOUTH] go to get services from [PROVIDER NAME]?
CODE ONE ONLY
VOCATIONAL REHABILITATION AGENCY/VR .................................................. 1
OTHER AGENCY SERVING PERSONS WITH DISABILITIES ........................... 2
AMERICAN JOB CENTER/WORK FORCE DEVELOPMENT CENTER
[STATE-SPECIFIC NAMES IF APPLICABLE]...................................................... 3
HIGH SCHOOL OR OTHER SECONDARY SCHOOL ......................................... 4
POST-SECONDARY SCHOOL (COLLEGE, VOCATIONAL SCHOOL,
UNIVERSITY) ....................................................................................................... 5
(IF PROMISE SERVICES, DISPLAY: PROMISE/ASPIRE PROGRAM) .............. 6
Other Specify Response option ............................................................................ 99
___________________________________________________ (STRING 200)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What type of place is this?
23 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
IF ANY OF THESE SERVICES RECEIVED [B1=0, II.B4=0, II.B6=0, II.B7=0, II.B8=0, II.B10=0, II.B11=0]
AND NAME OF PROVIDER(S) POPULATED IN [II.B1a, II.B4a, II.B6a, II.B7a, II.B8a, B10a, II.B11a].
[YOUTH], [PROVIDER]
II.C2a. When did [YOUTH] start going to [PROVIDER]?
PROBE:
In what month and year?
PROGRAMMER:
|
COLLECT DATE WITH SEPARATE FIELDS
| |/| | | | |
MONTH YEAR
(0-12)
(1997-2019)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF ANY OF THESE SERVICES RECEIVED [B1=0, II.B4=0, II.B6=0, II.B7=0, II.B8=O, II.B10=0, II.B11=0]
AND NAME OF PROVIDER(S) POPULATED IN [II.B1a, II.B4a, II.B6a, II.B7a, II.B8a, B10a, II.B11a].
[YOUTH], [PROVIDER]
II.C2b. Is [YOUTH] still going to [PROVIDER]?
YES………………………………………………………………………………… ....... 1
GO TO II.C4
NO ......................................................................................................................... 2
DON’T KNOW ....................................................................................................... d
GO TO II.C3
REFUSED ............................................................................................................. r
GO TO II.C3
II.C2b=0
[YOUTH], [PROVIDER], [RA DATE]
II.C2c. When did [YOUTH] stop going to [PROVIDER] or when did these services end?
PROBE:
In what month and year?
PROGRAMMER:
|
COLLECT DATE WITH SEPARATE FIELDS
| |/| | | | |
MONTH
YEAR
(0-12)
(1997-2019)
GO TO II.C4
DON’T KNOW ....................................................................................................... d
GO TO II.C3
REFUSED ............................................................................................................. r
GO TO II.C3
SOFT CHECK: IF MM/ YYYY is before [RA DATE]; I recorded that [YOUTH] stopped receiving
services prior to [RA date]. Is this correct? IF YES, GO TO BOX 3.
24 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
START DATE UNKNOWN (II.C2a = d, r)
[RA DATE] [YOUTH] [PROVIDER]
II.C3.
Since [RA DATE] for how many months did [YOUTH] go to [PROVIDER]?
PROBE:
Your best guess is fine.
INTERVIEWER:
IF LESS THAN ONE MONTH, ENTER 0
| | | MONTHS
(0-18)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF ANY OF THESE SERVICES RECEIVED [B1=0, II.B4=0, II.B6=0, II.B7=0, II.B8=O, II.B10=0, II.B11=0]
AND NAME OF PROVIDER(S) POPULATED IN [II.B1a, II.B4a, II.B6a, II.B7a, II.B8a, B10a, II.B11a]. AND
EITHER STILL RECEIVING (II.C2b=1) OR END DATE IN II.C2c IS AFTER [RA DATE].
[YOUTH], [PROVIDER], [HE/SHE]
II.C4.
Since [RA DATE], when [YOUTH] saw [PROVIDER], about how often did [he/she] go?
Your best estimate is fine.
CODE ONE ONLY
Every day ............................................................................................................. 1
More than once a week ....................................................................................... 2
Weekly .................................................................................................................. 3
More than once a month..................................................................................... 4
About once a month, or ...................................................................................... 5
Less often than once a month ........................................................................... 6
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
25 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
IF ANY OF THESE SERVICES RECEIVED [B1=0, II.B4=0, II.B6=0, II.B7=0, II.B8=O, II.B10=0, II.B11=0]
AND NAME OF PROVIDER(S) POPULATED IN [II.B1a, II.B4a, II.B6a, II.B7a, II.B8a, B10a, II.B11a]. AND
EITHER STILL RECEIVING (II.C2b=1) OR END DATE IN II.C2c IS AFTER [RA DATE].
II.C5.
On average, how long was each meeting or session? On average, was it...
CODE ONE ONLY
Less than an hour, .............................................................................................. 1
About one hour ................................................................................................... 2
About 2 hours, ..................................................................................................... 3
About 3 hours ...................................................................................................... 4
About 4 hours or half a day, or was it, .............................................................. 5
More than 4 hours per meeting? ....................................................................... 6
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF ANY OF THESE SERVICES RECEIVED [B1=0, II.B4=0, II.B6=0, II.B7=0, II.B8=O, II.B10=0, II.B11=0]
AND NAME OF PROVIDER(S) POPULATED IN [II.B1a, II.B4a, II.B6a, II.B7a, II.B8a, B10a, II.B11a]. AND
EITHER STILL RECEIVING (II.C2b=1) OR END DATE IN II.C2c IS AFTER [RA DATE].
[YOUTH], [PROVIDER]
II.C6.
How useful do you think [PROVIDER]’s help or services (have been / were)?
Would you say …
CODE ONE ONLY
Very useful ........................................................................................................... 1
Somewhat useful................................................................................................. 2
Not very useful or................................................................................................ 3
Not at all useful ................................................................................................... 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
PROGRAMMER SKIP BOX3
CATI: LOOP THROUGH ITEMS II.C1 THROUGH BOX 3 FOR EACH DEDUPLICATED PROVIDER IN ITEM II.B14 (RESPONSE OPTIONS 01-21).
ONCE LOOP(S) (UP TO 21) COMPLETED, PROCEED TO II.D.INTRO.
26 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
SECTION II. PART D. PARENT AND FAMILY SERVICES
PROGRAMMER: IN THIS SERIES, POPULATE:
• SPOUSE / PARTNER FILLS AND RESPONSE OPTIONS IF I.Q3=1 (SPOUSE) OR 2 (PARTNER).
• FILLS AND RESPONSE OPTIONS FOR “OTHER YOUTH IN THE HOUSEHOLD AGES 14-21” IF
I.Q6=1.
I.CONSENT_2 = 1
[(and your (spouse/partner)) (, or other youth in the household ages 14-21, besides (YOUTH))] [RA
DATE], [and your (spouse / partner) (or other youth in the household)] [PROMISE SERVICES GROUP
TEXT FILL] [PROMISE PROGRAM NAME]
II.D.Intro.
Now that I’ve asked about [YOUTH], let’s talk about services or training that you
[(and your (spouse/partner)) (, or other youth in the household ages 14-21, besides
(YOUTH))] might have received since [RA DATE].
IF PROMISE SERVICES GROUP: I don’t know which services you [and your
(spouse / partner) (or other youth in the household)] received from [PROMISE
PROGRAM NAME], so in this section, please tell me about [PROMISE PROGRAM
NAME] services received.
CONTINUE ............................................................................
27 | P a g e
1
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
I.CONSENT_2 = 1
[RA DATE], [and (your (spouse/partner)) (, or other youth in the household ages 14-21)] [IF PROMISE
SERVICES GROUP FILL: or a [SITE NAME FOR CASE MANAGER], [either of],
II.D1-II.D8.
Since [RA Date] have you [(and your (spouse/partner)) (, or other youth in the
household ages 14-21)] …
IF NEEDED: This help could have come from one of the places you’ve already told me about.
CODE ONE PER ROW
YES
NO
DK
REF
1
2
d
r
1
2
d
r
D3. Had any training to help [either of] you learn new job skills? Please
do not include any training provided on-the-job by an employer.
1
2
d
r
D4. Had help in finding or applying for a job, such as help finding jobs
available, filling out an application, writing a resume, or going for an
interview?
1
2
d
r
D5. Had help learning about [YOUTH]’s disability and how to get the
services or supports [he/she] needs, or had training on how to
support [YOUTH]’s independence?
1
2
d
r
1
2
d
r
D7. Had help learning about how to save and manage money [IN WI: ,
including help with an Individual Development Account or IDA]?
1
2
d
r
D8. Since [RA date], have you [or your (spouse/partner)] had help
getting to know other parents in the community who have children
with disabilities?
1
2
d
r
D1. Worked with anyone to determine your needs and help get
education, employment, health, housing or other services?
This person is sometimes called a case manager [IF PROMISE
SERVICES GROUP FILL: or a [SITE NAME FOR CASE MANAGER].
D2. Had help with getting into a school or training program, including
help with an application, entrance exam, or interview?
This could include a place where someone told you [or (your
(spouse/partner) (or other youth in the household ages 14-21)] about
training programs or schools that are available and how to apply for
them. Or if someone helped you complete an application for college
or vocational school.
D6. Had help in understanding Social Security, SSI, or other
government program benefits and rules? This is sometimes called
benefits counseling or benefits planning.
IF NEEDED: SSI stands for supplemental Security Income.
28 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
I.CONSENT_2 = 1
[RA DATE], [(,your (spouse/partner) (or other youth in the household ages 14-21)]
II.D9.
Since [RA DATE], have you [(, your (spouse/partner) (or other youth in the household ages
14-21)] had any other services to help you work, go to school, or help your family in other
ways?
Please do not include services you’ve already told me about.
IF NEEDED: These services could have been provided by a person or place you have
already told me about.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 2
GO TO BOX 4
DON’T KNOW ....................................................................................................... d
GO TO BOX 4
REFUSED ............................................................................................................. r
GO TO BOX 4
II.D9=1
[(,your (spouse/partner) (or other youth in the household ages 14-21)]
II.D9a. What kind of other services did you [(, your (spouse/partner) (or other youth in the
household ages 14-21)] receive?
___________________________________________________ (STRING 200)
SERVICES
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
PROGRAMMER SKIP BOX 4
IF NO SERVICES RECEIVED (II.D1-II.D9. ALL = 0), SKIP TO II.D10. ELSE CONTINUE
TO II.D_PRVDR-INTRO.
IF ANY OF THE FOLLOWING SERVICES WERE RECEIVED – WHERE ANY ITEM: II.D1=1, II.D3=1,
II.D4=1, II.D6=1, OR II.D7=1.
[YOUTH]
II.D_PRVDR-INTRO.
Thanks for this information. Now I’d like to ask about the places you [(, your
(spouse/partner) (or other youth in the household ages 14-21)] received the services you
have just told me about.
CONTINUE ........................................................................................................... 1
29 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
II.D1=1
[(,your (spouse/partner)) (, or other youth in the household)]
II.D1a. Who did you [(, your (spouse/partner)) (, or other youth over age 14 in the household)]
work with to determine your needs and get services?
PROBE:
IF UNABLE TO STATE NAME OF PROVIDER: I need to enter something that
will help us identify the provider later. Do you know his or her first or last
name? Was he/she a doctor, a therapist, a vocational rehabilitation counselor,
or some other type of provider?
PROBE: Anyone else?
___________________________________________________ (STRING 100)
SERVICE PROVIDER -1
___________________________________________________ (STRING 100)
SERVICE PROVIDER -2
___________________________________________________ (STRING 100)
SERVICE PROVIDER -3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
II.D3=1
[(,your (spouse/partner) (or other youth in the household ages 14-21)]
II.D3a. Who provided or helped you [(, your (spouse/partner) (or other youth in the household
ages 14-21)] get this training? This includes training to learn new job skills or to get a job.
PROBE 2: IF UNABLE TO STATE NAME OF PROVIDER: I need to enter something that
will help us identify the provider later. Do you know his or her first or last
name? Was he/she a doctor, a therapist, a vocational rehabilitation counselor,
or some other type of provider?
PROBE 3: Anyone else?
___________________________________________________ (STRING 100)
SERVICE PROVIDER -1
___________________________________________________ (STRING 100)
SERVICE PROVIDER -2
___________________________________________________ (STRING 100)
SERVICE PROVIDER -3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
30 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
II.D4=1
[(,your (spouse/partner) (or other youth in the household ages 14-21)]
II.D4a. Who helped you [(, your (spouse/partner) (or other youth in the household ages 14-21)]
find or apply for jobs?
PROBE 1: IF UNABLE TO STATE NAME OF PROVIDER: I need to enter something that
will help us identify the provider later. Do you know his or her first or last
name? Was he/she a doctor, a therapist, a vocational rehabilitation counselor,
or some other type of provider?
PROBE 2: Anyone else?
___________________________________________________ (STRING 100)
SERVICE PROVIDER -1
___________________________________________________ (STRING 100)
SERVICE PROVIDER -2
___________________________________________________ (STRING 100)
SERVICE PROVIDER -3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
II.D6=1
II.D6a. Who provided this help in understanding government program benefits and rules?
PROBE:
IF UNABLE TO STATE NAME OF PROVIDER: I need to enter something that will
help us identify the provider later. Do you know his or her first or last name?
Was he/she a doctor, a therapist, a vocational rehabilitation counselor, or some
other type of provider?
PROBE:
Anyone else?
___________________________________________________ (STRING 100)
SERVICE PROVIDER-1
___________________________________________________ (STRING 100)
SERVICE PROVIDER -2
___________________________________________________ (STRING 100)
SERVICE PROVIDER -3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
31 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
II.D7=1
II.D7a. Who provided the help in learning how to save and manage money?
PROBE:
IF UNABLE TO STATE NAME OF PROVIDER: I need to enter something that
will help us identify the provider later. Do you know his or her first or last
name? Was he/she a doctor, a therapist, a vocational rehabilitation counselor,
or some other type of provider?
PROBE:
Anyone else?
___________________________________________________ (STRING 100)
SERVICE PROVIDER -1
___________________________________________________ (STRING 100)
SERVICE PROVIDER -2
___________________________________________________ (STRING 100)
SERVICE PROVIDER -3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
I.CONSENT_2 = 1
[RA DATE], [(,your (spouse/partner) (or other youth in the household ages 14-21)] [you/(he/she) / the other
youth]
II.D10. Since [RA DATE], have you [(, your (spouse/partner) (or other youth in the household ages
14-21)] needed any (other) help or services preparing for work, school, or help with family
life that [you/ (he/ she) / the other youth] did not receive?
PROBE:
Please do not include services you’ve already told me about.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 2
GO TO BOX 5
DON’T KNOW ....................................................................................................... d
GO TO BOX 5
REFUSED ............................................................................................................. r
GO TO BOX 5
32 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
II.D10=1
[(your spouse/partner) (or other youth in the household)]
II.D10a.
What help or services did you [(your spouse/partner) (or other youth in the
household)] need that you did not get?
CODE ALL THAT APPLY
DISCOVERING JOB INTERESTS/SKILLS .......................................................... 1
CAREER COUNSELING ...................................................................................... 2
LEARNING HOW TO LOOK FOR A JOB ............................................................. 3
JOB SHADOWING................................................................................................ 4
APPRENTICESHIP/INTERNSHIP ........................................................................ 5
HELP FINDING A JOB.......................................................................................... 6
SUPPORT ON THE JOB (JOB COACHING) ....................................................... 7
HELP GETTING INTO SCHOOL/TRAINING........................................................ 8
UNDERSTANDING SSA/OTHER BENEFITS ...................................................... 9
COMPUTER LITERACY CLASSES ..................................................................... 10
PROBLEM SOLVING............................................................................................ 11
FINANCIAL LITERACY/MONEY MGMT TRAINING ............................................ 12
REFERRAL TO ANOTHER AGENCY .................................................................. 13
TRANSPORTATION SERVICES .......................................................................... 14
HEALTH-RELATED SERVICES ........................................................................... 15
CASE MANAGEMENT.......................................................................................... 16
OTHER (SPECIFY) ............................................................................................... 99
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): Any other services?
PROGRAMMER SKIP BOX 5
IF NONE OF THE FOLLOWING SERVICES WERE RECEIVED [II.D1=0,
II.D3=0, II.D4=0, II.D6=0, OR II.D7=0] SKIP TO III.A.INTRO. ELSE
PROCEED TO II.D11.
33 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
IF ANY OF THE FOLLOWING SERVICES WERE RECEIVED FOR PARENT / SPOUSE, OTHER
YOUTH IN HOUSEHOLD AGES 14-21 [ANY ITEM: II.D1=1 , II.D3=1, II.D4=1, II.D6=1, II.D7=1] AND
PROVIDER WAS SPECIFIED IN ANY OF THE FOLLOWING [II.D1a, II.D3a, II.D4a, II.D6a, II.D7a]
[SPOUSE/PARTNER]
II.D11.
INTERVIEWER: DOES ANY PROVIDER APPEAR ON THE LIST BELOW MORE THAN
ONCE?
IF A PROVIDER APPEARS MORE THAN ONCE, DELETE ONE FROM THE LIST. DO NOT
MARK BOTH PROVIDERS FOR DELETION. ONCE THE LIST IS REVIEWED, SELECT EITHER
“NO OTHER DUPLICATES / DONE” OR “NO DUPLICATES SHOWN ABOVE.”
PROGRAMMER: POPULATE APPLICABLE RESPONSE OPTIONS WITH PROVIDERS
SPECIFIED IN II.D1a, D3a, D4a, D6a, or D7a.
CODE ALL THAT APPLY
FILL RESPONSE II.D1a_1 (case management services) .................................... 1
FILL RESPONSE II.D1a_2 (case management services) .................................... 2
FILL RESPONSE II.D1a_3 (case management services) .................................... 3
FILL RESPONSE II.D3a_1 (training on job skills) ................................................ 4
FILL RESPONSE II.D3a_2 (training on job skills) ................................................ 5
FILL RESPONSE II.D3a_3 (training on job skills) ................................................ 6
FILL RESPONSE II.D4a_1 (help finding or applying for jobs) .............................. 7
FILL RESPONSE II.D4a_2 (help finding or applying for jobs) .............................. 8
FILL RESPONSE II.D4a_3 (help finding or applying for jobs) .............................. 9
FILL RESPONSE II.D6a_1 (help in understanding SSI benefits / program
rules) ..................................................................................................................... 10
FILL RESPONSE II.D6a_2 (help in understanding SSI benefits / program
rules) ..................................................................................................................... 11
FILL RESPONSE II.D6a_3 (help in understanding SSI benefits / program
rules) ..................................................................................................................... 12
FILL RESPONSE II.D7a_1 (help in learning how to save / manage money) ....... 13
FILL RESPONSE II.D7a_2 (help in learning how to save / manage money) ....... 14
FILL RESPONSE II.D7a_3 (help in learning how to save / manage money) ....... 15
NO OTHER DUPLICATES / DONE ...................................................................... 16
NO DUPLICATES SHOWN ABOVE ..................................................................... 00
PROGRAMMER: RESPONSE OPTIONS FROM II.D11 DETERMINE THE NUMBER OF LOOPS
THROUGH THE NEXT SECTION (II.E1 THROUGH II.E8). ONE LOOP FOR EACH UNIQUE
PROVIDER.
34 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
SECTION II.E.
INTENSITY OF SERVICE PROVISION FOR PARENT AND OTHER FAMILY
MEMBERS
PROGRAMMER: IN THIS SERIES, POPULATE:
• SPOUSE / PARTNER FILLS AND RESPONSE OPTIONS IF I.Q3=1 (SPOUSE) OR 2 (PARTNER).
• FILLS AND RESPONSE OPTIONS FOR “OTHER YOUTH IN THE HOUSEHOLD” IF I.Q6=6.
IF THE FOLLOWING SERVICES WERE RECEIVED FOR PARENT / SPOUSE, OTHER YOUTH IN
HOUSEHOLD AGES 14-21 (BASED ON DE-DUPLICATED LIST GENERATED IN II.D11)
[PROVIDER NAME], [(or your spouse/partner) (or other youth in the household)] [TEXT FILL LOGIC
BASED ON PROVIDERS >1]
II.E1.
IF ONLY 1 PROVIDER OR SUBSEQUENT PROVIDERS WHEN >1 PROVIDER: Now, I have
some questions about the different service providers. Let’s start with services you [(or
your spouse/partner) (or other youth in the household)] received from [PROVIDER NAME]
IF >1 PROVIDER: Now, I have some questions about the different service providers. Let’s
start with services you [(or your spouse/partner) (or other youth in the household)]
received from [PROVIDER NAME].
CONTINUE .........................................................................................
1
IF THE FOLLOWING SERVICES WERE RECEIVED FOR PARENT / SPOUSE, OTHER YOUTH IN
HOUSEHOLD AGES 14-21 (BASED ON DE-DUPLICATED LIST GENERATED IN II.D11)
[PROVIDER], [(or your spouse/partner) (or other youth in the household)] [STATE-SPECIFIC NAMES
FOR JOB CENTER / WORKFORCE DEVELOPMENT CENTERS], [IF TREATMENT, DISPLAY:
PROMISE/ASPIRE PROGRAM]
II.E2.
Thinking about the place you [(or your spouse/partner) (or other youth in the household)]
went to get services from [PROVIDER], what type of place is this?
PROBE:
Where did you [or your spouse/partner] go to get services from [PROVIDER]?
CODE ONE ONLY
VOCATIONAL REHABILITATION AGENCY (VR) ............................................... 1
OTHER AGENCY SERVING PERSONS WITH DISABILITIES ........................... 2
AMERICAN JOB CENTER/WORK FORCE DEVELOPMENT CENTER
[STATE-SPECIFIC NAMES] ................................................................................. 3
(IF PROMISE SERVICES GROUP: [PROMISE PROGRAM NAME] ................... 4
POST-SECONDARY SCHOOL (COLLEGE, VOCATIONAL SCHOOL,
UNIVERSITY) ....................................................................................................... 5
Other ..................................................................................................................... 99
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What type of place is this?
35 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
IF THE FOLLOWING SERVICES WERE RECEIVED FOR PARENT / SPOUSE, OTHER YOUTH IN
HOUSEHOLD AGES 14-21 (BASED ON DE-DUPLICATED LIST GENERATED IN II.D11)
[(or your spouse/partner) (or other youth in the household)] [PROVIDER]
II.E3.
When did you [(or your spouse/partner) (or other youth in the household)] start going to
[PROVIDER]?
PROBE:
In what month and year?
PROGRAMMER:
|
COLLECT DATE WITH SEPARATE FIELDS
| |/| | | |
MONTH
YEAR
(0-12)
(RANGE)
|
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF THE FOLLOWING SERVICES WERE RECEIVED FOR PARENT / SPOUSE, OTHER YOUTH IN
HOUSEHOLD AGES 14-21 (BASED ON DE-DUPLICATED LIST GENERATED IN II.D11)
[(or your spouse/partner) (or other youth in the household)] [PROVIDER]
II.E4.
Are you [(or your spouse/partner) (or other youth in the household)] still going to
[PROVIDER]?
YES ....................................................................................................................... 1
GO TO II.E6
NO ......................................................................................................................... 2
DON’T KNOW ....................................................................................................... d
GO TO II.E6
REFUSED ............................................................................................................. r
GO TO II.E6
II.E4=0
[(or your spouse/partner) (or other youth in the household)] [PROVIDER]
II.E4a. When did you [(or your spouse/partner) (or other youth in the household)] stop going to
[PROVIDER]?
PROBE:
In what month and year?
PROGRAMMER:
|
COLLECT DATE WITH SEPARATE FIELDS
| |/| | | |
MONTH
YEAR
(0-12)
(RANGE)
|
GO TO II.E6
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF II.E4a MM/YYYY before [RA DATE]; I recorded that you [(or your spouse/partner)
(or other youth in the household] stopped receiving services prior to [RA DATE]. Is this correct?
IF YES, GO TO BOX 6.
36 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
II.E4a=d or r
[RA DATE], [SPOUSE/PARTNER], [PROVIDER]
II.E5.
Since [RA DATE] for how many months did you [(or your spouse/partner) (or other youth
in the household)] go to [PROVIDER]? Your best guess is fine.
INTERVIEWER:
IF LESS THAN ONE MONTH, ENTER 0.
| | | MONTHS
(0-18)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF THE FOLLOWING SERVICES WERE RECEIVED FOR PARENT / SPOUSE, OTHER YOUTH IN
HOUSEHOLD AGES 14-21 (BASED ON DE-DUPLICATED LIST GENERATED IN II.D11) AND EITHER
STILL RECEIVING (II.E4=1) OR END DATE AFTER RA DATE [II.E4A]
[(or your spouse/partner) (or other youth in the household)] [PROVIDER]
II.E6.
Since [RA DATE], when you [(or your spouse/partner) (or other youth in the household)]
saw [PROVIDER], about how often did you go? Your best estimate is fine. Was it …
CODE ONE ONLY
Every day ............................................................................................................. 1
More than once a week ....................................................................................... 2
Weekly .................................................................................................................. 3
More than once a month..................................................................................... 4
About once a month, or ...................................................................................... 5
Less often than once a month ........................................................................... 6
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
37 | P a g e
PARENT: SERVICE RECEIPT IN PAST 18 MONTHS
IF THE FOLLOWING SERVICES WERE RECEIVED FOR PARENT / SPOUSE, OTHER YOUTH IN
HOUSEHOLD AGES 14-21 (BASED ON DE-DUPLICATED LIST GENERATED IN II.D11)
II.E7.
On average, how long was each meeting or session? Was it ...
PROBE:
How much time per day?
CODE ONE ONLY
Less than an hour, .............................................................................................. 1
About one hour ................................................................................................... 2
About 2 hours, ..................................................................................................... 3
About 3 hours ...................................................................................................... 4
About 4 hours or half a day, or was it, .............................................................. 5
More than 4 hours per meeting? ....................................................................... 6
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF THE FOLLOWING SERVICES WERE RECEIVED FOR PARENT / SPOUSE, OTHER YOUTH IN
HOUSEHOLD AGES 14-21 (BASED ON DE-DUPLICATED LIST GENERATED IN II.D11)
[PROVIDER] [(or your spouse/partner) (or other youth in the household)]
II.E8.
How useful do you think the help or services that you [(or your spouse/partner) (or other
youth in the household)] got from (PROVIDER) have been? Would you say . . .
CODE ONE ONLY
Very useful, .......................................................................................................... 1
Somewhat useful,................................................................................................ 2
Not very useful, or............................................................................................... 3
Not at all useful? ................................................................................................. 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. R
PROGRAMMER BOX 6
CATI: REPEAT LOOP FOR ITEMS II.E1 TO II.E8 FOR EACH RESPONSE
OPTION SELECTED (01-16) IN ITEM II.D11.
ONCE LOOPS (UP TO 15) ARE COMPLETED, PROCEED TO II.E9.
I.CONSENT_2 = 1
II.E9.
PROGRAMMER: INSERT DATE THIS SECTION (II.E – PARENT / GUARDIAN AND OTHER
FAMILY MEMBERS’ SERVICE RECEIPT) WAS COMPLETED HERE OR POPULATE THIS AS A
VERIFICATION OF DATE COMPLETED FOR INTERVIEWER TO INPUT. THEN CONTINUE.
CONTINUE ............................................................................
38 | P a g e
1
GO TO III.A.INTRO
III. PARENT OR GUARDIAN / SPOUSE EMPLOYMENT EXPERIENCE AND CREDENTIALS
Asked of …
III.
Parent or Guardian
of Participating
Youth
Consenting
Parent of
Independent
Youth
X
X
Parent Employment Experience and Credentials
Independent
Youth
SECTION III. PART A. PARENT/GUARDIAN EMPLOYMENT
PROGRAMMER: IF PARENT/LEGAL GUARDIAN HAS A SPOUSE OR COHABITING PARTNER
WHO LIVES IN THE SAME HOUSEHOLD (I.Q4=1) POPULATE SPOUSE / PARTNER FILLS IN
THIS SECTION.
I.CONSENT_2 = 1
[or your (spouse/ partner)], [RA DATE], [MONTH AND YEAR OF RA], [IF MARRIED / PARTNERSHIP,
FILL: I will ask about your (spouse / partner) next.]
III.A.Intro.
Next, I’lI ask questions about jobs that you [or your (spouse/ partner)] have had
since [RA DATE].
CONTINUE ............................................................................
1
I.CONSENT_2 = 1
[RA DATE], [or your (spouse/ partner)],
III.A1. Have you [or your (spouse/ partner)] worked at a job or a business at any time since [RA
DATE]? Please include all jobs since [RA DATE], even if you only worked for a short time.
Please include jobs that you currently have, as well as jobs that ended within the past year
a half. Also, please include jobs at which you [or your (spouse/ partner)] are or were selfemployed. (YTD-36 II.A1, modified)
INTERVIEWER: IF RESPONDENT IS MARRIED, AND AT LEAST 1 PERSON WORKED,
RECORD “YES” (1) BELOW.
PROBE:
A job could be working for a business or organization or work that you do on
your own. Jobs include internships, apprenticeships and volunteer work even
if you didn’t get paid. A job is work either paid or unpaid other than work
around the house.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 2
GO TO III.A4
DON’T KNOW ....................................................................................................... d
GO TO III.A4
REFUSED ............................................................................................................. r
GO TO III.A4
39 | P a g e
III. PARENT OR GUARDIAN / SPOUSE EMPLOYMENT EXPERIENCE AND CREDENTIALS
III.A1=1
[or your (spouse/ partner)]
III.A2. Were you [or your (spouse/ partner)] paid or self-employed in any of these jobs? By selfemployed, we mean you work for yourself or own your own business. (NEW)
INTERVIEWER: IF RESPONDENT IS MARRIED, AND AT LEAST 1 PERSON WAS PAID OR
WAS SELF EMPLOYED, RECORD “YES” (1) BELOW.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
III.A1=1
[or your (spouse/ partner)]
III.A3. Now, I will ask questions about jobs you [or your (spouse/ partner)] may have had more
recently. Did you [or your (spouse/ partner)] work for pay last month? (NBS, K2A
modified)
CODE ONE ONLY
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
GO TO III.A4
RETIRED .............................................................................................................. 2
GO TO III.A5
UNABLE TO WORK.............................................................................................. 3
GO TO III.A5
DON’T KNOW ....................................................................................................... d
GO TO III.A4
REFUSED ............................................................................................................. r
GO TO III.A4
40 | P a g e
III. PARENT OR GUARDIAN / SPOUSE EMPLOYMENT EXPERIENCE AND CREDENTIALS
RESPONDENT OR SPOUSE WORKED IN LAST MONTH (III.A3=1)
[and / or your (spouse/ partner)] [and / or your (spouse/ partner)]
III.A3a. How much did you [and / or your (spouse/ partner)] earn from all jobs and businesses in
the last month before taxes and deductions? Your best estimate is fine. (NBS K3
modified)
[IF MARRIED / HAS SPOUSE OR PARTNER, FILL: If both of you worked last month, please
combine your earnings with your (spouse / partner’s) earnings for that time period.
INTERVIEWER: IF UNABLE TO PROVIDE EARNINGS BEFORE TAXES, RECORD AFTER
TAX INCOME AND TYPE OF INCOME RECORDED IN THE NEXT ITEM.
$| | | |
(0.01-99999)
|
|
| AMOUNT
MONTHLY INCOME BEFORE TAXES AND DEDUCTIONS (GROSS
INCOME) ............................................................................................................... 1
MONTHLY INCOME AFTER TAXES (NET INCOME) ......................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK IF III.A4 IS >0: May I confirm I have recorded this correctly, that you [and / or your
(spouse/ partner)] earned [FILL VALUE FROM III.A4.] from all jobs and businesses last monthly – and
that amount is [(BEFORE / AFTER)] taxes and other deductions?
RESPONDENT OR SPOUSE WORKED IN LAST MONTH (III.A3=1)
[or your (spouse/ partner)]
III.A3b. Did you [or your (spouse/ partner)] have access to health insurance through your job or
work last month?
You don’t need to have taken the insurance; we just wanted to see if this employer offered
it you as an employment benefit. (NEW)
INTERVIEWER:
IF > 1 EMPLOYER IN THE PAST MONTH, PROBE IF ANY OF THESE
EMPLOYERS OFFERED HEALTH INSURANCE.
IF RESPONDENT HAS A SPOUSE / PARTNER AND RESPONSE TO
THIS ITEM IS YES FOR EITHER ONE, MARK “YES” BELOW.
YES ....................................................................................................................... 1
GO TO III.A5
NO ......................................................................................................................... 2
GO TO III.A5
DON’T KNOW ....................................................................................................... d
GO TO III.A5
REFUSED ............................................................................................................. r
GO TO III.A5
41 | P a g e
III. PARENT OR GUARDIAN / SPOUSE EMPLOYMENT EXPERIENCE AND CREDENTIALS
PARENT / GUARDIAN DID NOT HAVE A JOB LAST MONTH (III.A3=0, D, R)
[or your (spouse/ partner)]
III.A4. Do you [or your (spouse/ partner)] currently want a job, either full or part time? (CPS
Dwant, modified response category)
INTERVIEWER: IF RESPONDENT IS MARRIED, AND EITHER SPOUSE OR PARTNER DID
NOT HAVE A JOB LAST MONTH AND WANTS A JOB, RECORD “YES” (1) BELOW.
YES ....................................................................................................................... 1
MAYBE, IT DEPENDS .......................................................................................... 2
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
I.CONSENT_2 = 1
III.A5. PROGRAMMER: INSERT DATE THIS SECTION (III.A – PARENT / GUARDIAN AND SPOUSE
/ PARTNER EMPLOYMENT) WAS COMPLETED HERE. OR POPULATE THIS AS A
VERIFICATION OF DATE COMPLETED FOR INTERVIEWER TO INPUT. THEN CONTINUE.
CONTINUE .........................................................................................
42 | P a g e
1
GO TO III.B1
III. PARENT OR GUARDIAN / SPOUSE EMPLOYMENT EXPERIENCE AND CREDENTIALS
SECTION III. PART B. PARENT AND SPOUSE PARTNER’S EDUCATIONAL CREDENTIALS
PROGRAMMER: IF PARENT/LEGAL GUARDIAN HAS A SPOUSE OR COHABITING PARTNER
WHO LIVES IN THE SAME HOUSEHOLD (I.Q4=1) POPULATE SPOUSE / PARTNER FILLS IN
THIS SECTION.
I.CONSENT_2 = 1
[and your (spouse/ partner)]
III.B1. What is the highest grade or year of school you [and your (spouse/ partner)] have
finished? (NEW)
INTERVIEWER: READ CATEGORIES IF NECESSARY.
PROGRAMMER: CREATE COLUMN (II.B1B) FOR SPOUSE PARTNER ONLY IF (I.Q4=1).
Select one per column
II.B1A.
II.B1B.
PARENT /
GUARDIAN
SPOUSE /
PARTNER
TH
GRADE OR LESS
1
1
TH
GRADE OR ABOVE NOT A HIGH SCHOOL GRADUATE
2
2
HIGH GRADUATE
3
3
GED
4
4
POST-HIGH SCHOOL EDUCATION, NO COLLEGE
DEGREE
5
5
VOCATIONAL TECHNICAL (VOC-TECH) DEGREE OR
CERTIFICATE
6
6
2-YEAR OR 3 YEAR COLLEGE DEGREE/AA DEGREE
7
7
4-YEAR COLLEGE DEGREE/ BACHELOR’S DEGREE
8
8
MASTER’S DEGREE
9
9
PHD, MD, JD, LLB OR OTHER PROFESSIONAL
GRADUATE DEGREE
10
10
NEVER ATTENDED SCHOOL
11
11
OTHER – SPECIFY
99
99
8
9
IF OTHER SPECIFY (99): Please specify highest grade or year or school finished (150 CHAR)
43 | P a g e
III. PARENT OR GUARDIAN / SPOUSE EMPLOYMENT EXPERIENCE AND CREDENTIALS
I.CONSENT_2 = 1
[RA DATE] [or your (spouse/ partner)]
III.B2. Since [RA DATE], have you [or your (spouse/ partner)] received any diploma, GED,
certificate, or professional license? (NEW)
INTERVIEWER: MARRIED AND EITHER RESPONDENT OR SPOUSE / PARTNER RECEIVED
ANY OF THESE, SELECT YES BELOW.
CODE ONE ONLY
YES ....................................................................................................................... 1
NO ......................................................................................................................... 2
GO TO III.B3
DON’T KNOW ....................................................................................................... d
GO TO III.B3
REFUSED ............................................................................................................. r
GO TO III.B3
III.CB=1
[RA DATE],
III.B2a. What kind of diploma(s), GED, certificate(s), or professional license(s) did you [or your
(spouse/ partner)] receive since [RA DATE]? (NEW)
INTERVIEWER: IF RESPONDENT HAS SPOUSE / PARTNER – RECORD ALL APPLICABLE
RESPONSES FOR BOTH IN THE CATEGORIES BELOW.
CODE ALL THAT APPLY
GED....................................................................................................................... 1
DIPLOMA FROM VOCATIONAL, TECHNICAL BUSINESS OR TRADE
SCHOOL ............................................................................................................... 2
DIPLOMA FROM 2-YEAR OR 3-YEAR COLLEGE / COMMUNITY
COLLEGE ............................................................................................................. 3
DIPLOMA FROM A 4-YEAR COLLEGE ............................................................... 4
CERTIFICATE FROM A JOB SKILLS TRAINING PROGRAM ............................ 5
OTHER - SPECIFY ............................................................................................... 99
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What did you [or your (spouse/ partner)] receive since [RA DATE]?
44 | P a g e
III. PARENT OR GUARDIAN / SPOUSE EMPLOYMENT EXPERIENCE AND CREDENTIALS
I.CONSENT_2 = 1
(RA DATE) [or your (spouse/ partner)]
III.B3. Have you [or your (spouse/ partner)] gone to school at any time since (RA DATE)? Please
include adult basic education or GED courses, vocational or trade school, college and
university. (NEW)
INTERVIEWER: IF EITHER RESPONDENT OR SPOUSE / PARTNER WENT TO SCHOOL
SINCE [RATE DATE], SELECT YES BELOW.
IF SUMMER:
Are you off school for the summer. Will you [or your (spouse/ partner)] be
going back to school in the fall?
INTERVIEWER:
CODE “YES” IF ON SUMMER BREAK.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 2
GO TO III.B4
DON’T KNOW ....................................................................................................... d
GO TO III.B4
REFUSED ............................................................................................................. r
GO TO III.B4
III.B3=1
[RA DATE] [or your (spouse/ partner)]
III.B3a. Are you [or your (spouse/ partner)] currently attending or enrolled in school? Please
include adult basic education or GED courses, vocational or trade school, college and
university. (NEW)
INTERVIEWER: IF EITHER RESPONDENT OR SPOUSE / PARTNER IS CURRENTLY
ATTENDING OR ENROLLED IN SCHOOL, SELECT YES BELOW.
PROBE:
Do you [or your (spouse/ partner)] go to school now?
IF DON’T KNOW: When was the last time you [or your (spouse/ partner)] went to school?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
45 | P a g e
III. PARENT OR GUARDIAN / SPOUSE EMPLOYMENT EXPERIENCE AND CREDENTIALS
I.CONSENT_2 = 1
[RA DATE], [or your (spouse/ partner)]
III.B4. Since [RA DATE], have you [or your (spouse/ partner)] attended a training program or
taken any classes to improve job skills? Please include classes to learn English or
improve reading skills. (NEW)
INTERVIEWER: IF RESPONSE IS “YES” FOR EITHER RESPONDENT OR SPOUSE /
PARTNER, SELECT YES BELOW.
IF DON’T KNOW: When was the last time [you/ (he/she)] went to training?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 2
GO TO III.B5
DON’T KNOW ....................................................................................................... d
GO TO III.B5
REFUSED ............................................................................................................. r
GO TO III.B5
III.B4=1
[or your (spouse/ partner)]
III.B4a. Are you [or your (spouse/ partner)] currently in a training program or taking classes to
improve job skills? Please include classes to learn English or improve reading skills.
(NEW)
INTERVIEWER: IF RESPONSE IS “YES” FOR EITHER RESPONDENT
OR SPOUSE / PARTNER, SELECT YES BELOW.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
46 | P a g e
III. PARENT OR GUARDIAN / SPOUSE EMPLOYMENT EXPERIENCE AND CREDENTIALS
CURRENTLY OR EVER IN SCHOOL, CLASSES, OR TRAINING PROGRAM (III.B3=1 OR III.B4=1)
[RA DATE] [IS THIS / WAS IT] [PROMISE PROGRAM NAME] [or your (spouse/ partner)]
III.B5. Thinking about the school, training program or classes that you [or your (spouse/ partner)]
are currently attending or you have attended since [RA DATE], what type of school,
training program (is this / was it)? (NEW)
INTERVIEWER: MARRIED AND RESPONSE IS DIFFERENT FOR EACH, PLEASE SELECT
ALL PROGRAMS THAT APPLY (FOR BOTH).
PROGRAMMER: ONLY POPULATE RESPONSE 5 (PROMISE PROGRAM NAME). IF
PROMISE SERVICES GROUP.
CODE ALL THAT APPLY
VOCATIONAL, TECHNICAL BUSINESS OR TRADE SCHOOL ......................... 1
2-YEAR OR 3-YEAR COLLEGE / COMMUNITY COLLEGE ............................... 2
4-YEAR COLLEGE ............................................................................................... 3
JOB SKILLS TRAINING ........................................................................................ 4
[PROMISE PROGRAM NAME] ............................................................................ 5
OTHER .................................................................................................................. 99
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What kind of school or training program was it?
47 | P a g e
PARENT: INDIVIDUAL AND FAMILY WELL-BEING
Asked of …
Parent or Guardian
of Participating
Youth
IV.
Parent: Individual and Family Well-Being
Consenting Parent
of Independent
Youth
Independent
Youth
X
X
SECTION IV. PART A. HOUSEHOLD HEALTH AND CURRENT HEALTH INSURANCE COVERAGE
I.CONSENT_2 = 1
IV.A.Intro.
The next questions are about health insurance, including health insurance
obtained through employment or purchased directly, as well as government
programs like Medicaid and Medicare.
CONTINUE ............................................................................
1
I.CONSENT_2 = 1
[, your (spouse / partner),] [YOUTH] [(you) / your (spouse / partner) / (youth)] [is / are]
IV.A1. Are you [, your (spouse / partner),] or [YOUTH] covered by any kind of health insurance or
some other kind of health care plan? (Source: NHIS, modified)
IF NEEDED: Who is covered?
PROGRAMMER: POPULATE RESPONSE OPTION FOR SPOUSE / PARTNER ONLY IF I.Q3=1 OR 2.
CODE ONE PER ROW
YES
NO
DK
REF
a. PARENT / GUARDIAN IS COVERED
1
2
d
r
b. SPOUSE / PARTNER IS COVERED
1
2
d
r
c.
1
2
d
r
YOUTH IS COVERED
SOFT CHECK: IF ANY HOUSEHOLD MEMBER SHOWS AS NOT COVERED (IV.A1a, A1b, or A1c = 0)
May I confirm that I have recorded your answer correctly – that is that [(you / your (spouse/
partner) / (youth)] [is / are] not covered by any kind of health insurance of any kind at this time.
This includes private insurance, as well as other types of health insurance you may receive or
have purchased through government programs?
48 | P a g e
PARENT: INDIVIDUAL AND FAMILY WELL-BEING
I.CONSENT_2 = 1
IV.A2. Are there any other members of this household who are not covered by any kind of health
insurance? This includes any kind of private insurance, as well as coverage people may
get through the government. (NEW)
CODE ONE ONLY
YES
.................................................................................... 1
NO
.................................................................................... 2
GO TO IV.A3
NO OTHER MEMBERS IN OUR HOUSEHOLD ...................... 3
GO TO IV.A3
DON’T KNOW ......................................................................... d
GO TO IV.A3
REFUSED ............................................................................... r
GO TO IV.A3
IV.A2=1
[VALUE FROM A2a_specify] [YOUTH] [or your spouse / partner)]
IV.A2a. How many other household members are not covered by any kind of health insurance?
| | | NUMBER OF OTHER HOUSEHOLD MEMBERS NOT COVERED
(1-99)
DON’T KNOW ......................................................................... d
SKIP TO IV.A3
REFUSED ............................................................................... r
SKIP TO IV.A3
SOFT CHECK: IF A2a>1; May I confirm I have correctly recorded that [VALUE FROM A2a_specify]
members of your household are not covered by any kind of health insurance – and that number
does not include you, or [YOUTH] [,or your spouse / partner)]?
49 | P a g e
PARENT: INDIVIDUAL AND FAMILY WELL-BEING
IV.A2a>0
(IF IVA2a=1 fill “is” and if >1, fill are), [YOUTH]
IV.A2b. How (is / are) these household members related to [YOUTH]?
CODE ALL THAT APPLY
SISTER ................................................................................................................. 1
BROTHER ............................................................................................................. 2
MOTHER ............................................................................................................... 3
FATHER ................................................................................................................ 4
AUNT..................................................................................................................... 5
UNCLE .................................................................................................................. 6
COUSIN ................................................................................................................ 7
FRIEND ................................................................................................................. 8
OTHER RELATIVE ............................................................................................... 9
OTHER – NO RELATIVE ...................................................................................... 10
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
50 | P a g e
PARENT: INDIVIDUAL AND FAMILY WELL-BEING
ANY (RESPONDENT, SPOUSE, YOUTH) WITH HEALTH INSURANCE COVERAGE (IV.A1A=1 OR
IV.A1B=1 OR IV.A1C=1)
[, your (spouse / partner)] [YOUTH] [STATE MEDICAID NAME]
IV.A3-IV.A6.
Are you [, your (spouse / partner),] or (YOUTH) now covered by any of the follow
types of health insurance?
INTERVIEWER:
CODE ALL THAT APPLY FOR EACH ROW. IF NO ONE HAS A
PARTICULAR TYPE OF COVERAGE, SELECT “NONE OF THESE” FOR
THAT ROW.
IF NEEDED: WHO IS COVERED?
PROGRAMMER: POPULATE COLUMN ONLY IF RESPONSE TO IV.A1A=1 OR IV.A1B=1 OR
IV.A1C=1.
CODE ALL THAT APPLY FOR EACH ROW
SELF
(PARENT /
GUARDIAN)
YOUTH
SPOUSE /
PARTNER
IV.A3. Private health insurance? This includes any
health insurance other than [STATE MEDICAID
NAME] or Medicare. (Source: NHIS, modified)
1
2
3
4
IV.A4. Are you [, your (spouse / partner),] or
[YOUTH] covered by Medicaid, or [STATE
MEDICAID PROGRAM NAME]? (Source: NHIS,
modified)
1
2
3
4
IV.A5. Are you [, is your (spouse / partner),] or is
(YOUTH] covered by Medicare? (NHIS, modified)
1
2
3
4
IV.A6. Are you [, is your (spouse / partner),] or is
(YOUTH] covered by any other kind of health
insurance I have not already asked about?
1
2
3
4
NONE OF
THESE
YOUTH IDENTIFIED AS NOT HAVING MEDICAID: (IV.A4_2=0)
[YOUTH], [FILL STATE-SPECIFIC NAME]
IV.A7. Is [YOUTH] covered by the Children’s Health Insurance Program, also called S-CHIP or
[FILL STATE-SPECIFIC NAME]?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
51 | P a g e
PARENT: INDIVIDUAL AND FAMILY WELL-BEING
SOFT CHECK-1: (IF RESPONDENT IS REPORTED TO HAVE INSURANCE (IV.A1a=1), BUT NO TYPE
OF INSURANCE IS REPORTED (IV.A3_1=0, IV.A4_1=0, IV.A5_1=0, IV.A6_1=0): May I confirm I have
correctly you have health insurance coverage?
If no, (not covered), return to IV.A1a to correct the response, as needed. If yes (covered), return to
IV.A2-IV.A5 to update type of coverage.
SOFT CHECK-2: (IF YOUTH IS REPORTED TO HAVE INSURANCE (IV.A1b=1), BUT NO TYPE OF
INSURANCE IS REPORTED (IV.A3_2=0, IV.A4_2=0, IV.A5_2=0, IV.A6_2=0, OR IV.A7=0): May I
confirm I have correctly [YOUTH] has health insurance coverage?
If no, (not covered) return to IV.A1b to correct the response, as needed. If yes (covered), return to
IV.A3-IV.A6 to update type of coverage.
SOFT CHECK-3: (IF SPOUSE / PARTNER) IS REPORTED TO HAVE INSURANCE (IV.A1c=1), BUT NO
TYPE OF INSURANCE IS REPORTED (IV.A3_3=0, IV.A4_2=0, IV.A5_3=0, OR IV.A6_3=0): May I
confirm I have correctly your (SPOUSE / PARTNER) has health insurance coverage?
If no, (not covered) return to IV.A1c to correct the response, as needed. If yes (covered), return to
IV.A2- IV.A6 to update type of coverage.
52 | P a g e
PARENT: INDIVIDUAL AND FAMILY WELL-BEING
COVERED BY PRIVATE HEALTH INSURANCE (IV.A2_1=1, IV.A2_2=1, OR IV.A2_3=1)
[, your (spouse / partner),] [YOUTH] [, or your (spouse / partner)’s,]
IV.A8.
Is that private insurance through an employer, a union, a family member, or do you
purchase it on your own? (Source: NHIS, modified)
INTERVIEWER: IF COVERED BY MORE THAN ONE PRIVATE INSURANCE COVERAGE, ASK
ABOUT THE PRIMARY OR MAIN COVERAGE.
PROGRAMMER: POPULATE APPLICABLE ROWS WHERE IV.A2_1=1, IV.A2_2=1, OR IV.A2_3=1.
CODE ONE PER ROW
THROUGH
EMPLOYER
THROUGH
UNION
THROUGH
FAMILY
MEMBER
PURCHASED
ON OWN
DK
REF
a. PARENT / GUARDIAN
1
2
3
4
d
r
b. YOUTH
1
2
3
4
d
r
c.
1
2
3
4
d
r
SPOUSE / PARTNER
IF INSURANCE PURCHASED ON OWN (IV.A8a_4=1, IV.A8b_4=1, OR IV.A8c_4=1)
[STATE MARKETPLACE NAME]
IV.A9. For each person covered by private insurance, purchased on his / her own, please tell me
whether the private insurance was purchased through the Affordable Care Act or a health
insurance exchange, sometimes called [state marketplace name or] Healthcare.gov, or
ObamaCare? (Source: NHIS, modified)
PROGRAMMER: POPULATE APPLICABLE ROWS WHERE: IV.A8a_4=1, IV.A8b_4=1, OR IV.A8c_4=1.
CODE ALL THAT APPLY
PARENT/ GUARDIAN........................................................................................... 1
YOUTH .................................................................................................................. 2
SPOUSE/ PARTNER ............................................................................................ 3
NONE PURCHASED THROUGH THE AFFORDABLE CARE ACT .................... 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
53 | P a g e
PARENT: INDIVIDUAL AND FAMILY WELL-BEING
IF PURCHASED THROUGH THE AFFORDABLE CARE ACT: (IV.A9_1=1, IV.A9_2=1, OR IV.A9_3=1)
[, does your (spouse / partner),] [YOUTH]
IV.A10. Do you [, does your (spouse / partner),] or [YOUTH] receive a tax credit to help pay for the
private insurance premium? (Source: NHIS, modified)
PROGRAMMER: POPULATE RESPONSE OPTIONS FOR ALL THOSE IDENTIFIED AS
PURCHASING INSURANCE THROUGH THE AFFORDABLE CARE ACT IN IV.A8.
CODE ALL THAT APPLY
PARENT/ GUARDIAN RECEIVES TAX CREDIT ................................................. 1
[YOUTH] RECEIVES TAX CREDIT ...................................................................... 2
(SPOUSE/ PARTNER) RECEIVES TAX CREDIT ................................................ 3
NO ONE RECEIVES TAX CREDIT ...................................................................... 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SECTION IV. PART B. HOUSEHOLD BENEFITS AND INCOME
I.CONSENT_2 = 1
[CALCULATE PRIOR CALENDAR YEAR FROM CURRENT CAL YEAR]
IV.B1. These questions will ask about benefits your household may receive, as well as your
household income. Do you or does anyone in your household receive …
CODE ONE PER ROW
YES
NO
DK
REF
a. Assistance from temporary assistance to needy families or [FILL
STATE-SPECIFIC NAME FOR TANF]?
1
2
r
d
b. Assistance from food stamps, or SNAP (the Supplemental Nutrition
Assistance Program)?
1
2
r
d
c. Any government housing assistance in paying rent, such as through
public housing or Section 8?
1
2
r
d
d. Does anyone in your household besides [YOUTH] receive any income
from SSI or SSDI because of a disability?
1
2
r
d
e.
Does anyone in your household receive retirement income from social
security?
1
2
r
d
f.
Does anyone in your household receive social security survivor’s
benefits?
1
2
r
d
g. Do you or does anyone in your household receive any other benefits
that we have not already accounted for in this list?
1
2
r
d
54 | P a g e
PARENT: INDIVIDUAL AND FAMILY WELL-BEING
IV.B1_g=1
IV.B1f. What other benefit(s) do you, or does anyone else in this household, receive?
___________________________________________________ (STRING 300)
BENEFITS(S)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
I.CONSENT_2 = 1
[FILL PRIOR CALENDAR YEAR]
IV.B2. Please tell me which group best describes the total income of all persons in your
household last year, including salaries or other earnings, money from public assistance,
child support, or retirement, and so on, for all household members, before taxes.
Was your household income last year, that is, in [FILL PRIOR CALENDAR YEAR]. . .
CODE ONE ONLY
LESS THAN $10,000, ........................................................................................... 1
$10,000 OR MORE, BUT LESS THAN $20,000, ................................................. 2
$20,000 OR MORE, BUT LESS THAN TO $30,000, ........................................... 3
$30,000 OR MORE, BUT LESS THAN TO $40,000, ........................................... 4
$40,000 OR MORE, BUT LESS THAN TO $50,000 ............................................ 5
$50,000 OR MORE, BUT LESS THAN $75,000, ................................................. 5
$75,000 OR MORE ............................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
55 | P a g e
PARENT EXPECTATIONS FOR YOUTH
Asked of …
V.
Parent or Guardian
of Participating
Youth
Consenting Parent
of Independent
Youth
X
X
Parent’s Expectations for Youth
Independent Youth
SECTION V. PART A. PARENT EXPECTATIONS FOR YOUTH
I.CONSENT_2 = 1
[YOUTH] [HIS / HER]
V.A.Intro.
These questions will ask about expectations you have for [YOUTH] and (his / her)
future.
CONTINUE ............................................................................
1
I.CONSENT_2 = 1
[HIS/HER], [youth] [HE/SHE]
V.A1.
When the following chores need doing, about how often, on [HIS/HER] own, is [YOUTH]
expected to …(NLTS2)
CODE ONE PER ROW
Never
Sometimes
Usually
Always
a. Fix [HIS/HER] own breakfast or lunch?
1
2
3
4
b. Do [HIS/HER] own laundry?
1
2
3
4
c. Straighten up [HIS/HER] own room or living
area?
1
2
3
4
d. Buy a few things at the store [HE/SHE] needs?
1
2
3
4
I.CONSENT_2 = 1
[HIS/HER], [youth] [HE/SHE]
V.A2.
When the following chores need doing, about how often, on [HIS/HER] own, does [YOUTH]
… (NLTS2)
CODE ONE PER ROW
Never
Sometimes
Usually
Always
a. Fix [HIS/HER] own breakfast or lunch?
1
2
3
4
b. Do [HIS/HER] own laundry?
1
2
3
4
c. Straighten up [HIS/HER] own room or living
area?
1
2
3
4
d. Buy a few things at the store [HE/SHE] needs?
1
2
3
4
56 | P a g e
PARENT EXPECTATIONS FOR YOUTH
I.CONSENT_2 = 1
[YOUTH], [HE/SHE], [HIS/HER]
V.A3.
After [YOUTH] is finished with all of [his/her] schooling, how important to you is it that
[HE/SHE]….
Would you say very important, somewhat important, not very important, or not at all
important? (Erik Carter survey)
IF NEEDED: By “finished with (his / her) schooling, we are talking about the time when
[YOUTH] will have completed all of (his / her education), not completed school for the day.
CODE ONE PER ROW
VERY
IMPORTANT
SOMEWHAT
IMPORTANT
NOT VERY
IMPORTANT
NOT AT ALL
IMPORTANT
DK
REF
a. Work at a paid job?
1
2
3
4
d
r
b. Live somewhere away from
home?
1
2
3
4
d
r
c. Is able to support [HIM/HER] self
without help from family or
government benefit programs?
1
2
3
4
d
r
I.CONSENT_2 = 1
[YOUTH]
V.A4.
How far do you think [YOUTH] will get in school? Will (he / she): (NLTS2012, modified)
PROBE:
What is highest level of schooling you think [YOUTH] will complete?
CODE ONE ONLY
Not complete high school, ................................................................................. 1
GO TO V.A5
Complete high school with a diploma or a certificate of completion, ........... 2
Get a GED, or ...................................................................................................... 3
Continue beyond high school (vocational training, 2-year or
community college, 4 year college, graduate degree)? .................................. 4
GO TO V.A5
DON’T KNOW ....................................................................................................... d
GO TO V.A5
REFUSED ............................................................................................................. r
GO TO V.A5
57 | P a g e
PARENT EXPECTATIONS FOR YOUTH
I.CONSENT_2 = 1
[YOUTH], [HE/SHE]
V.A5.
When [YOUTH] is age 25, do you think [HE/SHE] will be living ... (NLTS2012, modified)
PROBE: IF RESPONDS “LIVES WITH FRIENDS” CODE AS 3.
CODE ONE ONLY
With parents or guardians.................................................................................. 1
With a sibling or other relative, ......................................................................... 2
On (his/her) own or with a spouse or partner, ................................................. 3
In a group home or institution, or in an ........................................................... 4
Other living situation? ........................................................................................ 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): At Age 25. [YOUTH] will be living …
I.CONSENT_2 = 1
[YOUTH], [HE/SHE]
V.A6.
When [YOUTH] is age 25, how likely do you think it is that [he/she] will be working at a
paid job? Do you think [he/ she]… (NLTS2012)
SELECT CODING TYPE
Definitely will, ...................................................................................................... 1
Probably will, ....................................................................................................... 2
Probably won’t, or ............................................................................................... 3
Definitely won’t? ................................................................................................. 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
58 | P a g e
PARENT EXPECTATIONS FOR YOUTH
I.CONSENT_2 = 1
[YOUTH], [HE/SHE], [HIM/HER]
V.A7.
When [YOUTH] is age 25, how likely do you think it is that [HE/SHE] will earn enough to
support [HIM/HER] self without financial help from family or government benefit
programs? Do you think [HE/SHE] … (NLTS2012, modified)
CODE ONE ONLY
Definitely will ....................................................................................................... 1
Probably will ........................................................................................................ 2
Probably won’t, or ............................................................................................... 3
Definitely won’t.................................................................................................... 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
59 | P a g e
PARENT EXPECTATIONS FOR YOUTH
Asked of …
VI.
Parent Demographics & Contact
Information
Parent or Guardian of
Participating Youth
Consenting Parent of
Independent Youth
X
X
Independent
Youth
SECTION VI PART A. PARENT / GUARDIAN DEMOGRAPHIC INFORMATION.
I.CONSENT_2 = 1
VI.A.Intro.
The next set of questions help us understand the experiences of different groups
of people who take part in the survey.
CONTINUE .........................................................................................
1
I.CONSENT_2 = 1
VI.A1. Do you consider yourself to be of Hispanic or Latino origin, such as Mexican, Puerto
Rican, Cuban, or other Spanish background? (YTD Baseline, 53)
YES ....................................................................................................................... 1
NO ......................................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SPOUSE OR PARTNER LIVES WITH RESPONDENT: (I.Q4=1)
[SPOUSE / PARTNER]
VI.A1a. Is your [spouse / partner] of Hispanic or Latino origin, such as Mexican, Puerto Rican,
Cuban, or other Spanish background? (YTD Baseline, 53)
YES ....................................................................................................................... 1
NO ......................................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
60 | P a g e
PARENT EXPECTATIONS FOR YOUTH
I.CONSENT_2 = 1
VI.A2. I’m going to read a list of race categories, please choose one or more races that best
describes your race? Are you . . . (YTD Baseline 54)
PROBE:
Are you white Hispanic or black Hispanic?
CODE ALL THAT APPLY
American Indian or Alaska Native ..................................................................... 1
Asian..................................................................................................................... 2
Black or African American ................................................................................. 3
Native Hawaiian or Other Pacific Islander ........................................................ 4
White..................................................................................................................... 5
Other race ............................................................................................................ 99
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): Please specify race(s) …
SPOUSE OR PARTNER LIVES WITH RESPONDENT: (I.Q4=1)
[SPOUSE / PARTNER]
VI.A3. I’m going to read a list of race categories, please choose one or more races that best
describes your [SPOUSE / PARTNER]’s race? Is your [SPOUSE / PARTNER] . . . (YTD
Baseline 54)
PROBE:
Are you white Hispanic or black Hispanic?
CODE ALL THAT APPLY
American Indian or Alaska Native ..................................................................... 1
Asian..................................................................................................................... 2
Black or African American ................................................................................. 3
Native Hawaiian or Other Pacific Islander ........................................................ 4
White..................................................................................................................... 5
Other race ............................................................................................................ 99
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): Please specify race(s) …
61 | P a g e
PARENT EXPECTATIONS FOR YOUTH
I.CONSENT_2 = 1
IF I.Q3=1 OR 2 THEN FILL [or does your (spouse / partner)]
VI.A4. Do you [or does your (spouse / partner)] have a health problem or a disability which
prevents work or which limits the kind or amount of work you can do?
INTERVIEWER: IF RESPONSE IS YES FOR EITHER RESPONDENT OR SPOUSE /
PARTNER (IF APPLICABLE), RECORD YES BELOW.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SECTION VI PART B. PARENT / GUARDIAN CONTACT INFORMATION
I. CONSENT_2 = 1
VI.B.Intro.
The last set of questions will help us reach you when we complete the next survey
about three years from now.
CONTINUE ............................................................................
1
I.CONSENT_2 = 1
[FILL HOME ADDRESS FROM CONSENTING PARENT]
VI.B1. What is your mailing address? (NLTS2012, A9a)
CONSENTING PARENT’S HOME ADDRESS PROVIDED FROM ENROLLMENT WAS:
[FILL HOME ADDRESS FROM CONSENTING PARENT]
INTERVIEWER: DO NOT PROVIDE ADDRESS FOR CONFIRMATION IF SPEAKING TO NONCONSENTING PARENT
PROBE:
PROBE FOR AND RECORD BOTH P.O. BOX AND STREET ADDRESS
PROBE:
Where do you stay most often?
CONFIRMED ABOVE ADDRESS AS CORRECT ................................................ 1
ADDRESS ABOVE NOT CORRECT – UPDATE AS FOLLOWS: ...................... 99
___________________________________________________
ADDRESS 1
___________________________________________________
ADDRESS 2
___________________________________________________
CITY
___________________________________________________
STATE/ TERRITORY
___________________________________________________
ZIP
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
62 | P a g e
PARENT EXPECTATIONS FOR YOUTH
I.CONSENT_2 = 1
VI.B2. What is the best telephone number at which to reach you: (NTLS2012, A10)
|
| |
(0-999)
|-| | |
(0-999)
|-| | |
(0-9999)
|
|
DOES NOT HAVE A TELEPHONE NUMBER ..................................................... 1
GO TO VI.B5
DON’T KNOW ....................................................................................................... d
GO TO VI.B5
REFUSED ............................................................................................................. r
GO TO V1.B5
VI.B2>1
VI.B2a. Is that a landline or cell phone? (NLTS2012, A10a)
CODE ONE ONLY
LANDLINE ............................................................................................................. 1
CELL PHONE ....................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
VI.B2>1
[FILL PHONE PROVIDED]
VI.B3. Is there another telephone number where we can reach you, besides [FILL PHONE
PROVIDED in VI.B2]? (NLTS2012, I1)
YES ....................................................................................................................... 1
NO ......................................................................................................................... 2
GO TO VI.B4
DON’T KNOW ....................................................................................................... d
GO TO VI.B4
REFUSED ............................................................................................................. r
GO TO VI.B4
VI.B3=1
VI.B3a. What is that number? (NLTS2012, I1a)
|
| |
(0-999)
|-| | |
(0-999)
|-| | |
(0-9999)
|
|
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
63 | P a g e
PARENT EXPECTATIONS FOR YOUTH
VI.B3A>1
VI.B3b. Is that a landline or cell phone? (NLTS2012, I1b)
CODE ONE ONLY
LANDLINE ............................................................................................................. 1
CELL PHONE ....................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ANY CELL (V1.B2A=2 OR VIB3B=2)
VI.B4. When we contact you for the next survey, may we send you a text message on your cell
phone? Please note that standard text message rates will apply. (NLTS2012, A10b REV)
YES ....................................................................................................................... 1
NO ......................................................................................................................... 2
PHONE DOES NOT USE TEXT MESSAGE ........................................................ 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
I.CONSENT_2 = 1
VI.B5. Do you have an e-mail address where we may send you study-related information?
This may include an email to verify your contact information, an invitation to complete the
survey, or a reminder about the survey.
CODE ONE ONLY
YES (SPECIFY EMAIL) ........................................................................................ 1
___________________________________________________ (STRING 50)
NO
................................................................................................................. 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What is the email you check most often?
64 | P a g e
PARENT EXPECTATIONS FOR YOUTH
SECTION VI PART C. CONTACT INFORMATION FOR SPOUSE OR PARTNER
RESPONDENT MARRIED OR IN MARRIED-LIKE RELATIONSHIP (1.Q3=1 OR 2)
[SPOUSE / PARTNER]
VI.C1. In case we have trouble reaching you for the next survey, it’d be helpful to be able to reach
out to your [spouse / partner]. May I have your [spouse / partner]’s first and last name?
___________________________________________________ (STRING 20)
FIRST NAME
___________________________________________________ (STRING 30)
LAST NAME
DON’T KNOW ....................................................................................................... d
GO TO VI.D1
REFUSED ............................................................................................................. r
GO TO VI.D1
65 | P a g e
PARENT EXPECTATIONS FOR YOUTH
SPOUSE / PARTNER DOES NOT LIVE IN SAME HOUSEHOLD AS RESPONDENT (1.Q4=0, D OR R)
AND VI.C1 = POPULATED
[SPOUSE / PARTNER NAME IN VI.C1]
VI.C2. What’s [SPOUSE / PARTNER NAME]’s mailing address? (NLTS2012, A9a)
PROBE:
PROBE FOR AND RECORD BOTH P.O. BOX AND STREET ADDRESS
PROBE:
Where does [SPOUSE / PARTNER NAME] stay most often?
SAME AS MINE .................................................................................................... 1
DIFFERENT (SPECIFY) ....................................................................................... 99
___________________________________________________
ADDRESS 1
___________________________________________________
ADDRESS 2
___________________________________________________
CITY
___________________________________________________
STATE/ TERRITORY
___________________________________________________
ZIP
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
VI.C1=POPULATED
[NAME IN VI.C1] [FILL VI.B2]
VI.C3. What’s the best telephone number at which to reach [NAME IN VI.C1]? (NTLS2012, A10)
SAME AS MINE [FILL VI.B2] ................................................................................ 1
DIFFERENT (SPECIFY) ....................................................................................... 99
|
| |
(0-999)
|-| | |
(0-999)
|-| | |
(0-9999)
|
|
DOES NOT HAVE A TELEPHONE NUMBER ..................................................... 0
GO TO VI.C6
DON’T KNOW ....................................................................................................... d
GO TO VI.C6
REFUSED ............................................................................................................. r
GO TO V1.C6
66 | P a g e
PARENT EXPECTATIONS FOR YOUTH
VI.C3>1
VI.C3a. Is that a landline or cell phone? (NLTS2012, A10a)
CODE ONE ONLY
LANDLINE ............................................................................................................. 1
CELL PHONE ....................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
VI.C3>1
[FILL PHONE PROVIDED IN VI.B2], [NAME IN VI.C1]
VI.C4. Is there another telephone number where we can reach [NAME IN VI.C1], besides [PHONE
IN VI.C3]? (NLTS2012, I1)
YES ....................................................................................................................... 1
NO ......................................................................................................................... 2
GO TO VI.C5
DON’T KNOW ....................................................................................................... d
GO TO VI.C5
REFUSED ............................................................................................................. r
GO TO VI.C5
VI.C3=1
VI.C4a. What is that number? (NLTS2012, I1a)
|
| |
(0-999)
|-| | |
(0-999)
|-| | |
(0-9999)
|
|
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
VI.C4A>1
VI.C4b. Is that a landline or cell phone? (NLTS2012, I1b)
CODE ONE ONLY
LANDLINE ............................................................................................................. 1
CELL PHONE ....................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
67 | P a g e
PARENT EXPECTATIONS FOR YOUTH
VI.C1=POPULATED
[NAME IN VI.C1]
VI.C6. Does [NAME IN VI.C1] have an e-mail address where we may send study-related
information?
CODE ONE ONLY
YES (SPECIFY EMAIL) ...................................................................... 1
___________________________________________________ (STRING 50)
NO
............................................................................................... 2
DON’T KNOW ..................................................................................... d
REFUSED ........................................................................................... r
IF OTHER SPECIFY (99): What is the email [NAME IN VI.C1] check most often?
68 | P a g e
PARENT EXPECTATIONS FOR YOUTH
SECTION VI PART D. CONTACT INFORMATION FOR YOUTH
YOUTH DOES NOT LIVE WITH PARENT RESPONDENT (I.RTYPE = 2, 3, OR 4)
[YOUTH] [PARENT MAILING ADDRESS FROM VI.B1]
VI.D1. Thanks so much for the information you’ve provided. We’d appreciate your help in making
sure we have the best way to get in touch with [YOUTH], to complete [his / her] interview.
What is [YOUTH]’s mailing address? Is it the same as yours or does (he/she) have a
different address? (NLTS2012, A9a modified)
PARENT / GUARDIAN ADDRESS: [FILL PARENT MAILING ADDRESS FROM VI.B1]
PROBE:
PROBE FOR AND RECORD BOTH P.O. BOX AND STREET ADDRESS
PROBE:
Where does [SPOUSE / PARTNER NAME] stay most often?
SAME AS MINE .................................................................................................... 1
DIFFERENT (SPECIFY) ....................................................................................... 99
___________________________________________________
ADDRESS 1
___________________________________________________
ADDRESS 2
___________________________________________________
CITY
___________________________________________________
STATE/ TERRITORY
___________________________________________________
ZIP
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
I.CONSENT_2 = 1
[YOUTH], [FILL PARENT PRIMARY PHONE FROM VI.B2]
VI.D2. What’s the best telephone number at which to reach [YOUTH]? (NTLS2012, A10)
PARENT / GUARDIAN’S PHONE: [FILL PARENT PRIMARY PHONE FROM VI.B2]
SAME AS MINE .................................................................................................... 0
DIFFERENT (SPECIFY) ....................................................................................... 99
|
| |
(0-999)
|-| | |
(0-999)
|-| | |
(0-9999)
|
|
DOES NOT HAVE A TELEPHONE NUMBER ..................................................... 1
GO TO VI.D5
DON’T KNOW ....................................................................................................... d
GO TO VI.D5
REFUSED ............................................................................................................. r
GO TO V1.D5
69 | P a g e
PARENT EXPECTATIONS FOR YOUTH
VI.D2>1
VI.D2a. Is that a landline or cell phone? (NLTS2012, A10a)
CODE ONE ONLY
LANDLINE ............................................................................................................. 1
CELL PHONE ....................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
VI.D2>1
[YOUTH] [FILL PHONE PROVIDED IN VI.D2]
VI.D3. Is there another telephone number where we can reach [YOUTH], besides [PHONE IN
VI.D2]? (NLTS2012, I1)
YES ....................................................................................................................... 1
NO ......................................................................................................................... 2
GO TO VI.D4
DON’T KNOW ....................................................................................................... d
GO TO VI.D4
REFUSED ............................................................................................................. r
GO TO VI.D4
VI.D3=1
VI.D3a. What’s that number? (NLTS2012, I1a)
|
| |
(0-999)
|-| | |
(0-999)
|-| | |
(0-9999)
|
|
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
VI.D3A>1
VI.D3b. Is that a landline or cell phone? (NLTS2012, I1b)
CODE ONE ONLY
LANDLINE ............................................................................................................. 1
CELL PHONE ....................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
70 | P a g e
PARENT EXPECTATIONS FOR YOUTH
I.CONSENT_2 = 1
[YOUTH]
VI.D4. Does [YOUTH] have an e-mail address where we may send study-related information?
CODE ONE ONLY
YES (SPECIFY EMAIL) ........................................................................................ 1
___________________________________________________ (STRING 50)
NO ......................................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What’s the email [YOUTH] check most often?
71 | P a g e
PARENT EXPECTATIONS FOR YOUTH
SECTION VI PART E. PARENT / GUARDIAN – ADDITIONAL CONTACT 1
I.CONSENT_2 = 1
VI.E1. To help us reach you for the next survey, it can be helpful to have contact information for
someone who does not live with you, but that we could contact should we have trouble
reaching you.
Can you please tell me the name of a friend or relative who would know how to reach you
if you move or change your telephone number?
What is his or her name? (YTD Baseline, 79)
___________________________________________________ (STRING 20)
FIRST NAME
___________________________________________________ (STRING 30)
LAST NAME
DON’T KNOW ....................................................................................................... d
GO TO BOX 7
REFUSED ............................................................................................................. r
GO TO BOX 7
VI.E1= POPULATED
[FIRST NAME CONTACT 1]
VI.E2. How is [FIRST NAME CONTACT 1] related to you? (YTD Baseline, 82)
CODE ONE ONLY
SISTER ................................................................................................................. 1
BROTHER ............................................................................................................. 2
MOTHER ............................................................................................................... 3
FATHER ................................................................................................................ 4
AUNT..................................................................................................................... 5
UNCLE .................................................................................................................. 6
COUSIN ................................................................................................................ 7
FRIEND ................................................................................................................. 8
OTHER RELATIVE ............................................................................................... 9
CASE MANAGER / SOCIAL WORKER................................................................ 10
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
72 | P a g e
PARENT EXPECTATIONS FOR YOUTH
VI.E1= POPULATED
[FIRST NAME CONTACT 1]
VI.E3. What is the name of the city and state where [FIRST NAME CONTACT 1]’s lives or stays?
(YTD Baseline, 80 modified)
PROBE: If you don’t know the full address, that’s OK. Please share as much as you can
remember.
___________________________________________________
CITY
___________________________________________________
STATE
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
VI.E1= POPULATED
[FIRST NAME CONTACT 1]
VI.E4.What’s the best telephone number to reach [FIRST NAME CONTACT 1] at? (YTD Baseline, 81
rev)
|
| |
(0-999)
|-| | |
(0-999)
|-| | |
(0-9999)
|
|
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
73 | P a g e
PARENT EXPECTATIONS FOR YOUTH
SECTION VI PART F. PARENT / GUARDIAN - ADDITIONAL CONTACT 2
PROGRAMMER SKIP BOX 7
IF CONTACT PROVIDED IN VI.E1 (POPULATED), CONTINUE TO VI.F1, ELSE GO TO
VI.G1.
CONTACT 1 PROVIDED (VI.E1 NAME POPULATED)
[FIRST NAME CONTACT 1]
VI.F1. Thank you for that information about [FIRST NAME CONTACT 1]. Can you please tell me
the name of another friend or relative who does not live with you and would know how to
reach you if you move or change your telephone number? (YTD Baseline, 83)
What is his or her name?
___________________________________________________ (STRING 20)
FIRST NAME
___________________________________________________ (STRING 10)
MIDDLE INITIAL/NAME
___________________________________________________ (STRING 30)
LAST NAME
DON’T KNOW ....................................................................................................... d
GO TO VI.G1
REFUSED ............................................................................................................. r
GO TO VI.G1
VI.F1=POPULATED
[FIRST NAME CONTACT 2]
VI.F2. How is [FIRST NAME CONTACT 2] related to you? (YTD Baseline, 86)
CODE ONE ONLY
SISTER ................................................................................................................. 1
BROTHER ............................................................................................................. 2
MOTHER ............................................................................................................... 3
FATHER ................................................................................................................ 4
AUNT..................................................................................................................... 5
UNCLE .................................................................................................................. 6
COUSIN ................................................................................................................ 7
FRIEND ................................................................................................................. 8
OTHER RELATIVE ............................................................................................... 9
CASE MANAGER / SOCIAL WORKER................................................................ 10
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
74 | P a g e
PARENT EXPECTATIONS FOR YOUTH
VI.F1=POPULATED
[FIRST NAME CONTACT 2]
VI.F3. What is the name of the city and state where [FIRST NAME CONTACT 2]’s lives or stays?
(YTD Baseline, 84 modified)
PROBE: If you don’t know the full address, that’s OK. Please share as much as you can
remember.
___________________________________________________
CITY
___________________________________________________
STATE
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
VI.F1=POPULATED
[FIRST NAME CONTACT 2]
VI.F4. What is [FIRST NAME CONTACT 2]’s telephone number? (YTD Baseline, 85)
|
| |
(0-999)
|-| | |
(0-999)
|-| | |
(0-9999)
|
|
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
75 | P a g e
PARENT EXPECTATIONS FOR YOUTH
SECTION VI PART G. TRANSITION TO YOUTH INTERVIEW
I.CONSENT_2 = 1
[YOUTH], [HIS/HER]
VI.G1. Before we speak with [YOUTH] for [HIS/HER] interview, what assistive technologies or
supports, if any, should we have available? (NLTS2012, I14)
IF PARENT REQUESTS PROXY INTERVIEW FOR YOUTH: May I confirm that [YOUTH]
would not be able to answer any of the questions on (his / her) own, or with support from
you or another trusted adult?
CODE ALL THAT APPLY
NONE: NO ASSISTIVE TECHNOLOGY .............................................................. 0
PARENT REQUESTS PROXY INTERVIEW FOR YOUTH.................................. 1
PARENT WILL ASSIST WITH STUDENT INTERVIEW ....................................... 2
VIDEO RELAY ...................................................................................................... 3
VOICE AMPLIFICATION ...................................................................................... 4
OTHER TECHNOLOGY ....................................................................................... 99
___________________________________________________ (STRING 50)
DON’T KNOW ....................................................................................................... D
REFUSED ............................................................................................................. R
IF OTHER SPECIFY (99): Other technology needed:
I.CONSENT_2 = 1
ADJUST FILLS FOR YOUTH INTERVIEW BY PROXY (VI.G1_1=1)
[YOU / YOUTH], [YOU ABOUT YOUTH/ YOUTH], [YOU / (HE / SHE)], [continue with the next interview /
speak]
VI.G2. We’ve reached the end of your portion of the survey. Now we need to complete the next
set of questions with [YOU ABOUT YOUTH / YOUTH].
Would [you / (he/she)] be available to [continue with the next interview / speak] now?
YES – ABLE TO BEGIN YOUTH INTERVIEW NOW ........................................... 1
GO TO PARENT CLOSE-1
NO – NOT ABLE TO BEGIN YOUTH INTERVIEW NOW .................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
76 | P a g e
GO TO PARENT CLOSE-1
| File Type | application/pdf |
| Author | Forest Crigler |
| File Modified | 2015-04-30 |
| File Created | 2015-04-30 |