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pdfATTACHMENT O.1
12-MONTH FOLLOW-UP SURVEY
ENGLISH VERSION
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ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
OMB Control No.: 0584-xxxx
Expiration Date: 00/00/20xx
SNAP E&T Pilots
12-MONTH
FOLLOW-UP SURVEY
ENGLISH
August 7, 2015
Public Burden Statement
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0584-xxxx. The time required to complete this information collection is estimated to average 32 minutes
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Send comments regarding this burden estimate to Food and Nutrition
Service, U.S. Department of Agriculture, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302.
Prepared by Mathematica Policy Research, Inc.
O.1.3
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
S. INTRODUCTION AND SCREENING
S1.
My name is [fill INTERVIEWER NAME] from Mathematica Policy Research. I’m following
up on a letter sent to you from the U.S. Department of Agriculture, Food and Nutrition
Service. About a year ago in [fill RA MONTH/YEAR], while enrolling in [STATE SNAP
NAME], you agreed to be part of a study about employment and training programs.
This study will help programs better meet the needs of people who are looking for jobs.
Your participation is completely voluntary. You may skip any questions that you don’t
want to answer. We’ll mail you a $30 gift card when you complete the survey. This won’t
affect any benefits you may be receiving in any way.
For quality assurance purposes, this call may be monitored or recorded.
Let’s begin now.
CODE ONE ONLY
S1a.
BEGIN INTERVIEW .............................................................................................. 1
GO TO S2
NOT A GOOD TIME, SCHEDULE CALLBACK .................................................... 2
Callback
HUNG UP DURING INTRODUCTION.................................................................. 3
Status 640
DOESN’T REMEMBER STUDY ........................................................................... 4
GO TO S1a
SUPERVISOR REVIEW ....................................................................................... 5
Status 380
REFUSED ............................................................................................................. r
Status 200
[IF S1=4] In [fill RA MONTH/YEAR], while enrolling in SNAP employment and training
services you filled out paperwork including a Consent Form to participate in some
surveys. This survey asks questions about your work history, skills and training needs,
and challenges you faced in getting the training you wanted to get and keep a job in your
area. The questions may jog your memory so how about we get started?
CODE ONE ONLY
S2.
YES, BEGIN INTERVIEW ..................................................................................... 1
GO TO S2
NO, SUPERVISOR REVIEW ................................................................................ 2
Status 380
NOT A GOOD TIME, SCHEDULE CALLBACK .................................................... 3
Callback
REFUSED ............................................................................................................. r
Status 200
BLAISE SCREEN: SHOW DOB FROM SAMPLE.
To get started I need to verify that I am speaking with the correct person. Could you please
tell me your date of birth?
PROBE IF RESPONDENT RESISTS:
please tell me the month and day?
I have your year of birth as [fill YEAR], would you
IF NECESSARY: READ DOB ALOUD AND CONFIRM.
RECORD:
| | |/| | |/|
MONTH DAY
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| |
YEAR
|
IF MATCHES SAMPLE INFO Start Survey (A1), IF DOES NOT
MATCH SAMPLE INFO, ASK S3
REFUSED ............................................................................................................. r
Prepared by Mathematica Policy Research, Inc.
O.1.1
GO TO S3
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
BLAISE SCREEN: SHOW LAST 4-DIGITS OF SS# FROM SAMPLE.
S3.
Again, for verification purposes, could you please tell me the last four digits of your social
security number?
IF NECESSARY: Please remember that all of your responses on this survey will be kept
private and will not affect any benefits you receive now or in the future.
IF NECESSARY: READ LAST 4-DIGITS ALOUD AND CONFIRM.
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| LAST FOUR SSN DIGITS IF MATCHES SAMPLE INFO - START SURVEY
(A1), IF DOES NOT MATCH
SAMPLE INFO, GO TO S4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
S4.
I am sorry. Before I continue with the interview I will need to check with my supervisor.
Thank you for your time.
Prepared by Mathematica Policy Research, Inc.
O.1.2
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
A. Household Characteristics
The first few questions are about you and the people you live with.
A1.
Including yourself, how many people live with you? Please include babies, small children,
people who are not related to you, and people who are temporarily away.
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| PEOPLE IN HOUSEHOLD
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
A2.
IF A1>1: Do all the people who live with you share the food that is bought for the
household?
YES ....................................................................................................................... 1
GO TO A4
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
A3.
IF A1>1: Including yourself, how many people in your household share the food that is
bought for the household?
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| PEOPLE WITH SHARED FOOD
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
A4.
IF A1>1 AND A3>1: How many of those (N) people are children age 18 or younger?
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| PEOPLE UNDER 18
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
Prepared by Mathematica Policy Research, Inc.
O.1.3
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
B. Employment
Now I’d like to ask you about any jobs you may currently have, and jobs you may have had since
[fill RA MONTH/YEAR].
B1.
Are you currently working at a job for pay, or self-employed?
YES ....................................................................................................................... 1
GO TO B3
NO ......................................................................................................................... 0
B2.
DON’T KNOW ....................................................................................................... d
GO TO B20
REFUSED ............................................................................................................. r
GO TO B20
IF NO: What is the main reason you are not currently working?
IF R MENTIONS HOW LAST JOB ENDED (I.E. FIRED, LAID OFF) PROBE: What is the main
reason you have not been able to get a new job?
CODE ONE ONLY
COULD NOT FIND WORK OR LACK OF JOBS AVAILABLE IN THE AREA...... 1
LACK NECESSARY SCHOOLING, TRAINING, SKILLS OR EXPERIENCE ...... 2
COULD NOT GET ALONG WITH SUPERVISOR OR CO-WORKERS ............... 3
PHYSICAL OR MENTAL HEALTH PROBLEMS .................................................. 4
ALCOHOL OR SUBSTANCE ABUSE .................................................................. 5
FAMILY RESPONSIBILITIES; CARING FOR CHILDREN, SPOUSE, OR
PARENTS; PREGNANCY .................................................................................... 6
ATTENDING SCHOOL ......................................................................................... 7
TRANSPORTATION ISSUES OR PROBLEMS (NO CAR OR NO PUBLIC
TRANSPORTATION AVAILABLE, TRANSPORTATION COSTS TOO
MUCH) .................................................................................................................. 8
LANGUAGE BARRIER/LIMITED ENGLISH PROFICIENCY ............................... 9
CHOSE NOT TO WORK....................................................................................... 10
SOME OTHER REASON (SPECIFY) ................................................................... 99
___________________________________________________________
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
B3.
Including any current job(s), how many different places have you worked for pay on a
regular basis since [FILL RA MO/YR]? Please exclude odd jobs, side jobs, and under-thetable jobs.
CODE ONE ONLY
NONE .................................................................................................................... 0
GO TO C1
1 ............................................................................................................................ 1
2 ............................................................................................................................ 2
3 ............................................................................................................................ 3
4 ............................................................................................................................ 4
5 ............................................................................................................................ 5
6 OR MORE .......................................................................................................... 6
DON’T KNOW ....................................................................................................... d
GO TO C1
REFUSED ............................................................................................................. r
GO TO C1
Prepared by Mathematica Policy Research, Inc.
O.1.4
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
JOB 1
B4.
Please tell me
the name of the
companies,
organizations, or
people you've
worked for. Start
with your
[current/most
recent] job or
jobs, [then the
most recent jobs
that you had.]
JOB 2
JOB 3
JOB 4
COMPANY NAME (SPECIFY) .......1
COMPANY NAME (SPECIFY) .......1
COMPANY NAME (SPECIFY) ...... 1
__________________________
__________________________
__________________________
SELF-EMPLOYED ..........................2
SELF-EMPLOYED ..........................2
DON’T KNOW .................................d
JOB 5
COMPANY NAME (SPECIFY) ...... 1
COMPANY NAME (SPECIFY) ...... 1
___________________________
___________________________
SELF-EMPLOYED ......................... 2
SELF-EMPLOYED ......................... 2
SELF-EMPLOYED ......................... 2
DON’T KNOW .................................d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
REFUSED .......................................r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
YES .................................................1
YES .................................................1
YES .................................................1
YES .................................................1
YES .................................................1
NO ...................................................0
NO ...................................................0
NO ...................................................0
NO ...................................................0
NO ...................................................0
DON’T KNOW .................................d
DON’T KNOW .................................d
DON’T KNOW .................................d
DON’T KNOW .................................d
DON’T KNOW .................................d
REFUSED .......................................r
REFUSED .......................................r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
B4b. IF NO: In what
state [is/was] this
job?
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B5.
PROBE: And
what job did you
have before
that?
B4a. IF B4 NE 2:
[Is/Was] the job
at [FILL
COMPANY
NAME in [FILL
STATE]?
IF B4=2: [Is/Was
this job in [FILL
STATE]?
B6.
When did you
start working for
[yourself/FILL
COMPANY
NAME]?
IF NO LONGER
WORKING THERE
(IF B1=NO): When
did that job end?
|
| STATE
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| STATE
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| STATE
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| STATE
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| STATE
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
REFUSED .......................................r
REFUSED .......................................r
REFUSED .......................................r
REFUSED .......................................r
REFUSED .......................................r
| | |/| | |
MONTH YEAR
| | |/| | |
MONTH YEAR
| | |/| | |
MONTH YEAR
| | |/| | |
MONTH YEAR
| | |/| | |
MONTH YEAR
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DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
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|/|
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|/|
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MONTH YEAR
MONTH YEAR
MONTH YEAR
MONTH YEAR
MONTH YEAR
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
Prepared by Mathematica Policy Research, Inc.
O.1.5
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
JOB 1
B7.
B9.
IF B1=NO: What
was your main
reason for
leaving [FILL
COMPANY
NAME]?
How many hours
per week,
including
overtime hours,
(do/did) you
usually work at
[FILL COMPANY
NAME]?
CODE ONE ONLY
JOB 2
JOB 3
CODE ONE ONLY
CODE ONE ONLY
JOB 4
CODE ONE ONLY
JOB 5
CODE ONE ONLY
LAYOFF, COMPANY
DOWNSIZED, OR PLANT
CLOSED .........................................1
LAYOFF, COMPANY
DOWNSIZED, OR PLANT
CLOSED .........................................1
LAYOFF, COMPANY
DOWNSIZED, OR PLANT
CLOSED .........................................1
LAYOFF, COMPANY
DOWNSIZED, OR PLANT
CLOSED .........................................1
LAYOFF, COMPANY
DOWNSIZED, OR PLANT
CLOSED .........................................1
FIRED .............................................2
FIRED .............................................2
FIRED .............................................2
FIRED .............................................2
FIRED .............................................2
QUIT ...............................................3
QUIT ...............................................3
QUIT ...............................................3
QUIT ...............................................3
QUIT ...............................................3
BECAME DISABLED......................4
BECAME DISABLED ......................4
BECAME DISABLED......................4
BECAME DISABLED......................4
BECAME DISABLED......................4
MOVED AWAY FROM THAT
AREA ..............................................5
MOVED AWAY FROM THAT
AREA ..............................................5
MOVED AWAY FROM THAT
AREA ..............................................5
MOVED AWAY FROM THAT
AREA ..............................................5
MOVED AWAY FROM THAT
AREA ..............................................5
JOB WAS TEMPORARY AND
ENDED ...........................................6
JOB WAS TEMPORARY AND
ENDED ...........................................6
JOB WAS TEMPORARY AND
ENDED ...........................................6
JOB WAS TEMPORARY AND
ENDED ...........................................6
JOB WAS TEMPORARY AND
ENDED ...........................................6
OTHER (SPECIFY) ........................99
OTHER (SPECIFY) ........................99
OTHER (SPECIFY) ........................99
OTHER (SPECIFY) ........................99
OTHER (SPECIFY) ........................99
__________________________
__________________________
__________________________
__________________________
__________________________
DON’T KNOW.................................d
DON’T KNOW.................................d
DON’T KNOW.................................d
DON’T KNOW.................................d
DON’T KNOW.................................d
REFUSED.......................................r
REFUSED .......................................r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
| | | TOTAL HOURS WORKED IN
A TYPICAL WEEK
| | | TOTAL HOURS WORKED IN
A TYPICAL WEEK
| | | TOTAL HOURS WORKED IN
A TYPICAL WEEK
| | | TOTAL HOURS WORKED IN
A TYPICAL WEEK
| | | TOTAL HOURS WORKED IN
A TYPICAL WEEK
HOURS (VARY/VARIED)
EACH WEEK ................................. n
HOURS (VARY/VARIED)
EACH WEEK ................................. n
HOURS (VARY/VARIED)
EACH WEEK ................................. n
HOURS (VARY/VARIED)
EACH WEEK ................................. n
HOURS (VARY/VARIED)
EACH WEEK ................................. n
DON’T REMEMBER ...................... d
DON’T REMEMBER ...................... d
DON’T REMEMBER ...................... d
DON’T REMEMBER ...................... d
DON’T REMEMBER ...................... d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
B9a. IF B9=n: How
many hours did
you work during
the last week you
worked?
| | | TOTAL HOURS WORKED
DURING LAST WEEK WORKED
| | | TOTAL HOURS WORKED
DURING LAST WEEK WORKED
| | | TOTAL HOURS WORKED
DURING LAST WEEK WORKED
| | | TOTAL HOURS WORKED
DURING LAST WEEK WORKED
| | | TOTAL HOURS WORKED
DURING LAST WEEK WORKED
DON’T REMEMBER ...................... d
DON’T REMEMBER ...................... d
DON’T REMEMBER ...................... d
DON’T REMEMBER ...................... d
DON’T REMEMBER ...................... d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
B10. How many days
per week (do/did)
you usually
work?
| |TOTAL DAYS WORKED IN A
TYPICAL WEEK
| |TOTAL DAYS WORKED IN A
TYPICAL WEEK
| |TOTAL DAYS WORKED IN A
TYPICAL WEEK
| |TOTAL DAYS WORKED IN A
TYPICAL WEEK
| |TOTAL DAYS WORKED IN A
TYPICAL WEEK
DAYS (VARY/VARIED) EACH
WEEK ............................................ n
DAYS (VARY/VARIED) EACH
WEEK ............................................ n
DAYS (VARY/VARIED) EACH
WEEK ............................................ n
DAYS (VARY/VARIED) EACH
WEEK ............................................ n
DAYS (VARY/VARIED) EACH
WEEK ............................................ n
DON’T REMEMBER ...................... d
DON’T REMEMBER ...................... d
DON’T REMEMBER ...................... d
DON’T REMEMBER ...................... d
DON’T REMEMBER ...................... d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
| | TOTAL DAYS WORKED DURING
LAST WEEK WORKED
| | TOTAL DAYS WORKED DURING
LAST WEEK WORKED
| | TOTAL DAYS WORKED DURING
LAST WEEK WORKED
| | TOTAL DAYS WORKED DURING
LAST WEEK WORKED
| | TOTAL DAYS WORKED DURING
LAST WEEK WORKED
B10a. IF B10=n: How
many days did
you work during
the last week you
worked?
DON’T REMEMBER ...................... d
DON’T REMEMBER ...................... d
DON’T REMEMBER ...................... d
DON’T REMEMBER ...................... d
DON’T REMEMBER ...................... d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
Prepared by Mathematica Policy Research, Inc.
O.1.6
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
JOB 1
JOB 2
JOB 3
JOB 4
JOB 5
CODE ONE ONLY
CODE ONE ONLY
CODE ONE ONLY
CODE ONE ONLY
CODE ONE ONLY
As a regular full-time or parttime employee, ............................. 1
As a regular full-time or parttime employee, ............................. 1
As a regular full-time or parttime employee, ............................. 1
As a regular full-time or parttime employee, ............................. 1
As a regular full-time or parttime employee, ............................. 1
For a temporary help agency,
a company that contracts out
you or your services, or as an
on-call employee, ......................... 2
For a temporary help agency,
a company that contracts out
you or your services, or as an
on-call employee, ......................... 2
For a temporary help agency,
a company that contracts out
you or your services, or as an
on-call employee, ......................... 2
For a temporary help agency,
a company that contracts out
you or your services, or as an
on-call employee, ......................... 2
For a temporary help agency,
a company that contracts out
you or your services, or as an
on-call employee, ......................... 2
As an independent
contractor, independent
consultant, free-lance worker,
or self-employed, or..................... 3
As an independent
contractor, independent
consultant, free-lance worker,
or self-employed, or..................... 3
As an independent
contractor, independent
consultant, free-lance worker,
or self-employed, or..................... 3
As an independent
contractor, independent
consultant, free-lance worker,
or self-employed, or..................... 3
As an independent
contractor, independent
consultant, free-lance worker,
or self-employed, or..................... 3
As a day laborer? ......................... 4
As a day laborer? ......................... 4
As a day laborer? ......................... 4
As a day laborer? ......................... 4
As a day laborer? ......................... 4
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
B12. What kind of
company is [FILL
COMPANY
NAME]- what do
they make, do, or
sell?
KIND OF BUSINESS OR
INDUSTRY (SPECIFY) .................. 1
KIND OF BUSINESS OR
INDUSTRY (SPECIFY) .................. 1
KIND OF BUSINESS OR
INDUSTRY (SPECIFY) .................. 1
KIND OF BUSINESS OR
INDUSTRY (SPECIFY) .................. 1
KIND OF BUSINESS OR
INDUSTRY (SPECIFY) .................. 1
__________________________
__________________________
__________________________
___________________________
___________________________
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
B12a. What (is/was)
your job title?
JOB TITLE (SPECIFY) .................. 1
JOB TITLE (SPECIFY) .................. 1
JOB TITLE (SPECIFY) .................. 1
JOB TITLE (SPECIFY) .................. 1
JOB TITLE (SPECIFY) .................. 1
B11. Which of the
following best
describes your
employment at
[FILL COMPANY
NAME]?
(Are/Were) you
working…
B13. What (do/did)
you do there what (is/was)
your job?
__________________________
__________________________
__________________________
___________________________
___________________________
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
JOB DUTIES (SPECIFY) ............... 1
JOB DUTIES (SPECIFY) ............... 1
JOB DUTIES (SPECIFY) ............... 1
JOB DUTIES (SPECIFY) ............... 1
JOB DUTIES (SPECIFY) ............... 1
__________________________
__________________________
__________________________
___________________________
___________________________
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
Prepared by Mathematica Policy Research, Inc.
O.1.7
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
JOB 1
B14. What (is/was)
your
(current/most)
recent rate of pay
before taxes and
deductions at
[FILL COMPANY
NAME]?
$|
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JOB 2
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JOB 3
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JOB 4
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JOB 5
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DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
PROBE: If your pay
(varies/varied),
please provide an
average amount.
CODE ONE ONLY
B14a. ACCEPT MOST
CONVENIENT PAY PER HOUR .................................... 1
PERIOD.
PER WEEK .................................... 2
PROBE: I am not
ONCE EVERY TWO WEEKS ........ 3
asking how often
TWICE A MONTH .......................... 4
you get paid, but
PER YEAR ..................................... 5
how much you
make, for
DAY/DAILY .................................... 6
example, an hour,
PER MONTH.................................. 7
per week, per
PER EVENT/ACTIVITY/ UNIT/
year.
JOB/ COURSE/ ASSIGNMENT..... 8
CODE ONE ONLY
PER HOUR .................................... 1
CODE ONE ONLY
PER HOUR .................................... 1
PER WEEK .................................... 2
PER WEEK .................................... 2
ONCE EVERY TWO WEEKS ........ 3
ONCE EVERY TWO WEEKS ........ 3
TWICE A MONTH .......................... 4
TWICE A MONTH .......................... 4
PER YEAR ..................................... 5
PER YEAR ..................................... 5
DAY/DAILY .................................... 6
DAY/DAILY .................................... 6
PER MONTH.................................. 7
PER MONTH.................................. 7
PER EVENT/ACTIVITY/ UNIT/
JOB/ COURSE/ ASSIGNMENT ..... 8
PER EVENT/ACTIVITY/ UNIT/
JOB/ COURSE/ ASSIGNMENT..... 8
PER MINUTE ................................. 9
PER MINUTE ................................. 9
PER MILE ...................................... 10
PER MILE ...................................... 10
PER MILE ...................................... 10
OTHER (SPECIFY)........................ 99
OTHER (SPECIFY)........................ 99
PER MINUTE ................................. 9
OTHER (SPECIFY)........................ 99
__________________________
__________________________
__________________________
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
Prepared by Mathematica Policy Research, Inc.
O.1.8
CODE ONE ONLY
PER HOUR .................................... 1
CODE ONE ONLY
PER HOUR .................................... 1
PER WEEK .................................... 2
PER WEEK .................................... 2
ONCE EVERY TWO WEEKS ........ 3
ONCE EVERY TWO WEEKS ........ 3
TWICE A MONTH .......................... 4
TWICE A MONTH .......................... 4
PER YEAR ..................................... 5
PER YEAR ..................................... 5
DAY/DAILY .................................... 6
DAY/DAILY .................................... 6
PER MONTH.................................. 7
PER MONTH.................................. 7
PER EVENT/ACTIVITY/ UNIT/
JOB/ COURSE/ ASSIGNMENT..... 8
PER EVENT/ACTIVITY/ UNIT/
JOB/ COURSE/ ASSIGNMENT..... 8
PER MINUTE ................................. 9
PER MINUTE ................................. 9
PER MILE ...................................... 10
PER MILE ...................................... 10
OTHER (SPECIFY)........................ 99
___________________________
DON’T KNOW ................................ d
REFUSED
r
OTHER (SPECIFY)........................ 99
___________________________
DON’T KNOW ................................ d
REFUSED ...................................... r
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
B15. Which of the
following
benefits
(are/were)
available to you
on your job, even
if you (are/were)
not receiving
them….
CATI PROGRAM: IS
THERE ANOTHER
JOB TO ASK ABOUT?
JOB 1
JOB 2
JOB 3
JOB 4
JOB 5
CODE ALL THAT APPLY
CODE ALL THAT APPLY
CODE ALL THAT APPLY
CODE ALL THAT APPLY
CODE ALL THAT APPLY
Health insurance or
membership in an HMO or
PPO plan? ..................................... 1
Health insurance or
membership in an HMO or
PPO plan? ..................................... 1
Health insurance or
membership in an HMO or
PPO plan? ..................................... 1
Health insurance or
membership in an HMO or
PPO plan? ..................................... 1
Health insurance or
membership in an HMO or
PPO plan? ..................................... 1
Dental insurance? ........................ 2
Dental insurance? ........................ 2
Dental insurance? ........................ 2
Dental insurance? ........................ 2
Dental insurance? ........................ 2
Paid vacation? .............................. 3
Paid vacation? .............................. 3
Paid vacation?.............................. 3
Paid vacation?.............................. 3
Paid vacation?.............................. 3
Paid holidays? .............................. 4
Paid holidays? .............................. 4
Paid holidays?.............................. 4
Paid holidays?.............................. 4
Paid holidays?.............................. 4
Paid sick leave? ........................... 5
Paid sick leave? ........................... 5
Paid sick leave? ........................... 5
Paid sick leave? ........................... 5
Paid sick leave? ........................... 5
Retirement, 401(k), or
pension benefits? ........................ 6
Retirement, 401(k), or
pension benefits? ........................ 6
Retirement, 401(k), or
pension benefits? ........................ 6
Retirement, 401(k), or
pension benefits? ........................ 6
Retirement, 401(k), or
pension benefits? ........................ 6
Tuition assistance or
reimbursement? ........................... 7
Tuition assistance or
reimbursement? ........................... 7
Tuition assistance or
reimbursement? ........................... 7
Tuition assistance or
reimbursement? ........................... 7
Tuition assistance or
reimbursement? ........................... 7
NONE ............................................. 8
NONE ............................................. 8
NONE ............................................. 8
NONE ............................................. 8
NONE ............................................. 8
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
YES...GO TO NEXT JOB – B4a
YES...GO TO NEXT JOB – B4a
YES...GO TO NEXT JOB – B4a
YES...GO TO NEXT JOB – B4a
GO TO C1
NO………...GO TO C1
NO………...GO TO C1
NO………...GO TO C1
NO………...GO TO C1
Prepared by Mathematica Policy Research, Inc.
O.1.9
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
C. Participation in E&T Programs and Services
Now we are going to ask you about employment training, job search, and other services you may
have received.
C1.
First, we are interested in learning about any career counseling or one-on-one assistance
you may have received from an employment professional at any location to help you find a
job. Since [FILL RA MONTH/YEAR], have you had any contact, in-person or by phone, with
an employment professional or case manager from an employment, welfare or other
agency or organization?
PROBE: “Employment professional” is a general name and may include counselors or
case managers.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
GO TO C4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
C2.
GO TO C4
Since [FILL RA MONTH/YEAR], about how many times did you meet with an employment
professional or case manager in person or by phone?
|
|
| NUMBER OF TIMES MET W/ EMPLOYMENT PROF/CASE MANAGER
GO TO C3
DON’T KNOW ........................................................................................................ d
REFUSED .............................................................................................................. r
C2a.
GO TO C4
Would you say . . .
None, .................................................................................................................... 0
1, ........................................................................................................................... 1
2 or 3, .................................................................................................................... 2
4 or 5, or ............................................................................................................... 4
More than 5 meetings in person or by phone? ................................................ 6
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
C3.
Were these meetings mostly in person or mostly by phone?
MOSTLY IN PERSON ............................................................................................ 0
MOSTLY BY PHONE ............................................................................................. 1
EQUALLY IN PERSON AND BY PHONE ............................................................. 2
DON’T KNOW ........................................................................................................ d
REFUSED .............................................................................................................. r
C4.
Since [FILL RA MONTH/YEAR], did you complete any career assessment tests to find out
what type of job you would be best suited for?
Prepared by Mathematica Policy Research, Inc.
O.1.10
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
NO C5-C8 THIS VERSION.
C9.
Since [FILL RA MONTH/YEAR], have you participated in job search training or assistance
activities to help with things such as resume writing, interviewing, and networking?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
Now I’m going to ask you about education or training programs you may have participated in,
including any training programs that helped you learn job skills or prepare for an occupation,
general educational programs, such as adult basic education or GED courses, ESL classes, college,
or other types of school, and any paid or unpaid internships and apprenticeships.
C10.
Since [fill RA MO/YR], did you participate in any education or training programs?
PROBE:
Include classes you may have attended to learn English (ESL classes) or
improve your reading skills.
PROBE:
Include training provided by an employer, for self-employment, or on-the-job
training (OJT).
YES .................................................................................................................................1
C11.
NO ...................................................................................................................................0
GO TO C12
DON’T KNOW .................................................................................................................d
GO TO C27a
REFUSED .......................................................................................................................r
GO TO C27a
How many different education and training programs have you participated in since [fill
RA MO/YR]?
|
|
| NUMBER OF PROGRAMS - GO TO C13
DON’T KNOW .................................................................................................................d
GO TO C27a
REFUSED .......................................................................................................................r
GO TO C27a
Prepared by Mathematica Policy Research, Inc.
O.1.11
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
C12.
Why have you not participated in any education or training programs since [fil RA M/YR]?
CODE ALL THAT APPLY
NOTHING OFFERED/DID NOT KNOW OF ANY ...........................................................1
LOCATION NOT ON PUBLIC TRANSPORTATION ROUTES ......................................2
INCONVENIENT OR UNSAFE LOCATION ...................................................................3
TRANSPORTATION ISSUES OR PROBLEMS (NO CAR OR PUBLIC
TRANSPORTATION, TRANSPORTATION COSTS TOO MUCH) ...............................4
COST OF PROGRAM TOO HIGH ..................................................................................5
TOO EXPENSIVE TO GET THERE ...............................................................................6
NEED TO CARE FOR CHILD OR OTHERS; PREGNANCY .........................................7
PROGRAM AT A BAD TIME ..........................................................................................8
DIDN’T SOUND USEFUL ...............................................................................................9
THEIR PROGRAM WASN’T ABOUT SOMETHING I WANTED TO LEARN .................10
WAS IN A PROGRAM BEFORE AND DIDN’T LIKE IT ..................................................11
LIMITED ENGLISH PROFICIENCY/NOT OFFERED IN MY LANGUAGE ....................12
OTHER (SPECIFY) .........................................................................................................99
_____________________________________________________________
DON’T KNOW .................................................................................................................d
REFUSED .......................................................................................................................r
GO TO C27a
Prepared by Mathematica Policy Research, Inc.
O.1.12
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
PROGRAM 1
PROGRAM 2
PROGRAM 3
PROGRAM 4
PROGRAM 5
C13. What (is/are)
the name(s) of
the program(s)
you attended
since [fill RA]?
___________________________
PROGRAM NAME
___________________________
PROGRAM NAME
___________________________
PROGRAM NAME
___________________________
PROGRAM NAME
___________________________
PROGRAM NAME
DON’T KNOW................................. d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW .................................d
DON’T KNOW ................................. d
REFUSED....................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED .......................................r
C14. When did you
start attending
[PROGRAM]?
| | |/| | | |
MONTH YEAR
(1-12) (2014-2016)
| | |/| | | |
MONTH YEAR
(1-12) (2014-2016)
| | |/| | | |
MONTH YEAR
(1-12) (2014-2016)
| | |/| | | |
MONTH YEAR
(1-12) (2014-2016)
| | |/| | | |
MONTH YEAR
(1-12) (2014-2016)
C15. Are you still in
that program?
|
C17. How many
hours per week
(did/do) you
attend that
program?
|
|
|
DON’T KNOW................................. d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW .................................d
REFUSED....................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED .......................................r
YES .......................... 1
C17
YES ...........................1
C17
YES ........................... 1
C17
YES ........................... 1
C17
YES........................... 1
C17
GO TO
NO ............................ 0
C16. When did you
stop attending?
|
GO TO
NO .............................0
GO TO
NO ............................. 0
GO TO
NO............................. 0
GO TO
NO ............................ 0
DON’T KNOW .......... d
C17
GO TO
DON’T KNOW ...........d
C17
GO TO
DON’T KNOW ........... d
C17
GO TO
DON’T KNOW........... d
C17
GO TO
DON’T KNOW .......... d
C17
GO TO
REFUSED ................ r
C17
GO TO
REFUSED ................ r
C17
GO TO
REFUSED .................r
C17
GO TO
REFUSED................. r
C17
GO TO
REFUSED ................ r
C17
GO TO
| | |/| | | |
MONTH YEAR
(1-12) (2014-2016)
|
| | |/| | | |
MONTH YEAR
(1-12) (2014-2016)
|
| | |/| | | |
MONTH YEAR
(1-12) (2014-2016)
|
| | |/| | | |
MONTH YEAR
(1-12) (2014-2016)
|
| | |/| | | |
MONTH YEAR
(1-12) (2014-2016)
|
DON’T KNOW................................. d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW .................................d
REFUSED....................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED .......................................r
|
|
|
|
|
|
| HOURS PER WEEK
|
| HOURS PER WEEK
|
| HOURS PER WEEK
|
| HOURS PER WEEK
|
| HOURS PER WEEK
DON’T REMEMBER....................... d
DON’T REMEMBER ...................... d
DON’T REMEMBER ...................... d
DON’T REMEMBER ...................... d
DON’T REMEMBER.......................d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED .......................................r
Prepared by Mathematica Policy Research, Inc.
O.1.13
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
PROGRAM 1
C18. (Is/Was) this
program meant
to help you
learn job skills
or prepare for
an occupation,
or to provide
general
education?
CODE ONE ONLY
PROGRAM 2
PROGRAM 3
CODE ONE ONLY
CODE ONE ONLY
PROGRAM 4
CODE ONE ONLY
PROGRAM 5
CODE ONE ONLY
JOB SKILLS OR PREPARE FOR
AN OCCUPATION ......................... 1
JOB SKILLS OR PREPARE FOR
AN OCCUPATION ......................... 1
JOB SKILLS OR PREPARE FOR
AN OCCUPATION ......................... 1
JOB SKILLS OR PREPARE FOR
AN OCCUPATION......................... 1
JOB SKILLS OR PREPARE FOR
AN OCCUPATION .........................1
GENERAL EDUCATION ................ 2
GENERAL EDUCATION................ 2
GENERAL EDUCATION ............... 2
GENERAL EDUCATION ............... 2
GENERAL EDUCATION ................2
ENGLISH AS A SECOND
LANGUAGE ................................... 3
ENGLISH AS A SECOND
LANGUAGE ................................... 3
ENGLISH AS A SECOND
LANGUAGE ................................... 3
ENGLISH AS A SECOND
LANGUAGE ................................... 3
ENGLISH AS A SECOND
LANGUAGE....................................3
INTERNSHIP/APPRENTICESHIP . 4
INTERNSHIP/APPRENTICESHIP . 4
INTERNSHIP/APPRENTICESHIP 4
INTERNSHIP/APPRENTICESHIP 4
INTERNSHIP/APPRENTICESHIP .4
ADULT BASIC ED/GED ................. 5
PROBE: General
education
programs include DON’T REMEMBER....................... d
adult basic
REFUSED ...................................... r
education or
GED courses,
college, and
other types of
school.
ADULT BASIC ED/GED ................. 5
ADULT BASIC ED/GED ................ 5
ADULT BASIC ED/GED ................ 5
ADULT BASIC ED/GED .................5
DON’T REMEMBER ...................... d
DON’T REMEMBER ...................... d
DON’T REMEMBER ...................... d
DON’T REMEMBER.......................d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED...................................... r
REFUSED ......................................r
YES ................................................ 1
YES ................................................ 1
YES ................................................ 1
YES ................................................ 1
YES.................................................1
NO .................................................. 0
NO .................................................. 0
NO .................................................. 0
NO.................................................. 0
NO ..................................................0
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW................................ d
DON’T KNOW ................................d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED...................................... r
REFUSED ......................................r
C19. IF C18=1 OR 4:
(Is/Was) this
program
considered to
be “on-the-job”
training?
PROBE: On-the-job
training, also
called “OJT,”
involves getting
on-the-jobexperience from
a particular
employer.
Prepared by Mathematica Policy Research, Inc.
O.1.14
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
PROGRAM 1
C20. IF C18=2: What
kind of general
education
(are/were) you
attending?
C21. What kind of
job (are/were)
you being
trained for or
what (are/were)
you learning to
do in that
program?
CODE ONE ONLY
PROGRAM 2
PROGRAM 3
CODE ONE ONLY
CODE ONE ONLY
PROGRAM 4
CODE ONE ONLY
PROGRAM 5
CODE ONE ONLY
Regular high school, .................... 1
Regular high school, ................... 1
Regular high school, ................... 1
Regular high school, ................... 1
Regular high school, ....................1
GED classes,................................. 2
GED classes, ................................ 2
GED classes, ................................ 2
GED classes, ................................ 2
GED classes, .................................2
Non-credit adult education,......... 3
Non-credit adult education, ........ 3
Non-credit adult education, ........ 3
Non-credit adult education, ........ 3
Non-credit adult education,.........3
A certification or licensing
program, ........................................ 4
A certification or licensing
program, ........................................ 4
A certification or licensing
program, ....................................... 4
A certification or licensing
program, ....................................... 4
A certification or licensing
program, ........................................4
A two-year program at a
community college, ...................... 5
A two-year program at a
community college,...................... 5
A two-year program at a
community college, ..................... 5
A two-year program at a
community college, ..................... 5
A two-year program at a
community college, ......................5
A four or five-year program at a
college or university, ................... 6
A four or five-year program at a
college or university, ................... 6
A four or five-year program at a
college or university, ................... 6
A four or five-year program at a
college or university,................... 6
A four or five-year program at a
college or university, ...................6
A graduate or professional
program, or ................................... 7
A graduate or professional
program, or ................................... 7
A graduate or professional
program, or ................................... 7
A graduate or professional
program, or................................... 7
A graduate or professional
program, or ...................................7
Something else? (SPECIFY).... 99
Something else? (SPECIFY) ... 99
Something else? (SPECIFY) ... 99
Something else? (SPECIFY) ....99
Something else? (SPECIFY).... 99
___________________________
___________________________
___________________________
___________________________
___________________________
ESL-English as a second
language ......................................... 8
ESL-English as a second
language......................................... 8
ESL-English as a second
language ........................................ 8
ESL-English as a second
language ........................................ 8
ESL-English as a second
language .........................................8
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW................................ d
DON’T KNOW ................................d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED...................................... r
REFUSED ......................................r
___________________________
TYPE OF TRAINING/LEARNING
___________________________
TYPE OF TRAINING/LEARNING
___________________________
TYPE OF TRAINING/LEARNING
___________________________
TYPE OF TRAINING/LEARNING
___________________________
TYPE OF TRAINING/LEARNING
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW................................ d
DON’T KNOW ................................d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED...................................... r
REFUSED ......................................r
Prepared by Mathematica Policy Research, Inc.
O.1.15
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
PROGRAM 1
C22. At what type of
place (do/did)
you go to
participate in
that program?
INTERVIEWER: READ
CHOICES IF
NECESSARY
CODE ONE ONLY
PROGRAM 2
PROGRAM 3
CODE ONE ONLY
CODE ONE ONLY
PROGRAM 4
CODE ONE ONLY
PROGRAM 5
CODE ONE ONLY
COMMUNITY COLLEGE/2 YEAR
COLLEGE................................... 1
COMMUNITY COLLEGE/2 YEAR
COLLEGE .................................. 1
COMMUNITY COLLEGE/2 YEAR
COLLEGE .................................. 1
COMMUNITY COLLEGE/2 YEAR
COLLEGE ...................................1
COMMUNITY COLLEGE/2 YEAR
COLLEGE................................... 1
4 YEAR COLLEGE OR
UNIVERSITY .............................. 2
4 YEAR COLLEGE OR
UNIVERSITY.............................. 2
4 YEAR COLLEGE OR
UNIVERSITY ............................. 2
4 YEAR COLLEGE OR
UNIVERSITY ..............................2
4 YEAR COLLEGE OR
UNIVERSITY .............................. 2
PRIVATE PROVIDER OF
TRAINING (SPECIFY) ............... 3
PRIVATE PROVIDER OF
TRAINING (SPECIFY) ............... 3
PRIVATE PROVIDER OF
TRAINING (SPECIFY) ............... 3
PRIVATE PROVIDER OF
TRAINING (SPECIFY)................3
PRIVATE PROVIDER OF
TRAINING (SPECIFY) ............... 3
___________________________
___________________________
___________________________
___________________________
___________________________
COMMUNITY BASED
ORGANIZATION OR OTHER
NON-PROFIT PRIVATE
AGENCY .................................... 4
COMMUNITY BASED
ORGANIZATION OR OTHER
NON-PROFIT PRIVATE
AGENCY .................................... 4
COMMUNITY BASED
ORGANIZATION OR OTHER
NON-PROFIT PRIVATE
AGENCY .................................... 4
COMMUNITY BASED
ORGANIZATION OR OTHER
NON-PROFIT PRIVATE
AGENCY.....................................4
COMMUNITY BASED
ORGANIZATION OR OTHER
NON-PROFIT PRIVATE
AGENCY .................................... 4
ONLINE ...................................... 5
ONLINE ...................................... 5
ONLINE...................................... 5
ONLINE ......................................5
ONLINE ...................................... 5
VOCATIONAL OR TECHNICAL
INSTITUTE/TRAINING
CENTER ..................................... 6
VOCATIONAL OR TECHNICAL
INSTITUTE/TRAINING
CENTER..................................... 6
VOCATIONAL OR TECHNICAL
INSTITUTE/TRAINING
CENTER .................................... 6
VOCATIONAL OR TECHNICAL
INSTITUTE/TRAINING
CENTER .....................................6
VOCATIONAL OR TECHNICAL
INSTITUTE/TRAINING
CENTER ..................................... 6
ADULT ED/COMMUNITY
SCHOOL/ ADULT HS/NIGHT
SCHOOL .................................... 7
ADULT ED/COMMUNITY
SCHOOL/ ADULT HS/NIGHT
SCHOOL .................................... 7
ADULT ED/COMMUNITY
SCHOOL/ ADULT HS/NIGHT
SCHOOL .................................... 7
ADULT ED/COMMUNITY
SCHOOL/ ADULT HS/NIGHT
SCHOOL.....................................7
ADULT ED/COMMUNITY
SCHOOL/ ADULT HS/NIGHT
SCHOOL .................................... 7
EMPLOYER ............................... 8
EMPLOYER ............................... 8
EMPLOYER ............................... 8
EMPLOYER ................................8
EMPLOYER................................ 8
GOVERNMENT
AGENCY/MILITARY................... 9
GOVERNMENT
AGENCY/MILITARY .................. 9
GOVERNMENT
AGENCY/MILITARY .................. 9
GOVERNMENT
AGENCY/MILITARY ...................9
GOVERNMENT
AGENCY/MILITARY................... 9
CAREER CENTER/JOB
CENTER ..................................... 10
CAREER CENTER/JOB
CENTER..................................... 10
CAREER CENTER/JOB
CENTER .................................... 10
CAREER CENTER/JOB
CENTER .....................................10
CAREER CENTER/JOB
CENTER ..................................... 10
STATE UNEMPLOYMENT OR
EMPLOYMENT OFFICE ............ 11
STATE UNEMPLOYMENT OR
EMPLOYMENT OFFICE............ 11
STATE UNEMPLOYMENT OR
EMPLOYMENT OFFICE ........... 11
STATE UNEMPLOYMENT OR
EMPLOYMENT OFFICE ............11
STATE UNEMPLOYMENT OR
EMPLOYMENT OFFICE ............ 11
SENIOR CENTER ...................... 12
SENIOR CENTER...................... 12
SENIOR CENTER ..................... 12
SENIOR CENTER ......................12
SENIOR CENTER ...................... 12
HOTEL OR CONFERENCE
CENTER ..................................... 13
HOTEL OR CONFERENCE
CENTER..................................... 13
HOTEL OR CONFERENCE
CENTER .................................... 13
HOTEL OR CONFERENCE
CENTER .....................................13
HOTEL OR CONFERENCE
CENTER ..................................... 13
HOSPITAL OR MEDICAL
INSTITUTE ................................. 14
HOSPITAL OR MEDICAL
INSTITUTE ................................. 14
HOSPITAL OR MEDICAL
INSTITUTE ................................ 14
HOSPITAL OR MEDICAL
INSTITUTE .................................14
HOSPITAL OR MEDICAL
INSTITUTE ................................. 14
SOME PLACE ELSE
(SPECIFY).................................. 99
SOME PLACE ELSE
(SPECIFY).................................. 99
SOME PLACE ELSE
(SPECIFY) ................................. 99
SOME PLACE ELSE
(SPECIFY) ..................................99
SOME PLACE ELSE
(SPECIFY) .................................. 99
___________________________
___________________________
___________________________
___________________________
___________________________
DON’T KNOW ............................ d
DON’T KNOW ............................ d
DON’T KNOW ............................ d
DON’T KNOW.............................d
DON’T KNOW ............................ d
REFUSED .................................. r
REFUSED .................................. r
REFUSED .................................. r
REFUSED...................................r
REFUSED .................................. r
Prepared by Mathematica Policy Research, Inc.
O.1.16
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
PROGRAM 1
C23. How much of
your own
money did you
or your family
pay for the
program?
$|
|
|,|
|
|
|
PROGRAM COST OUT OF POCKET
PROGRAM 2
$|
|
|,|
|
|
|
PROGRAM COST OUT OF POCKET
PROGRAM 3
$|
|
|,|
|
|
|
PROGRAM COST OUT OF POCKET
PROGRAM 4
$|
|
|,|
|
|
|
PROGRAM COST OUT OF POCKET
PROGRAM 5
$|
|
|,|
|
|
|
PROGRAM COST OUT OF POCKET
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW................................ d
DON’T KNOW ................................d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED...................................... r
REFUSED ......................................r
C23a. IF C23>0.
(Does/Did) this
cover the total
cost of the
program?
YES ................................................ 1
YES ................................................ 1
YES ................................................ 1
YES ................................................ 1
YES.................................................1
NO .................................................. 0
NO .................................................. 0
NO .................................................. 0
NO.................................................. 0
NO ..................................................0
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW................................ d
DON’T KNOW ................................d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED...................................... r
REFUSED ......................................r
C23b. IF NO: Who
(else)
(pays/paid) for
this program?
This may
include an
organization or
grant.
CAREER CENTER OR JOB
CENTER ..................................... 1
CAREER CENTER OR JOB
CENTER..................................... 1
CAREER CENTER OR JOB
CENTER .................................... 1
CAREER CENTER OR JOB
CENTER .....................................1
CAREER CENTER OR JOB
CENTER ..................................... 1
STATE UNEMPLOYMENT/
EMPLOYMENT OFFICE ............ 2
STATE UNEMPLOYMENT/
EMPLOYMENT OFFICE............ 2
STATE UNEMPLOYMENT/
EMPLOYMENT OFFICE ........... 2
STATE UNEMPLOYMENT/
EMPLOYMENT OFFICE ............2
STATE UNEMPLOYMENT/
EMPLOYMENT OFFICE ............ 2
TRADE ADJUSTMENT
ASSISTANCE (TAA OR TRA) ... 3
TRADE ADJUSTMENT
ASSISTANCE (TAA OR TRA) ... 3
TRADE ADJUSTMENT
ASSISTANCE (TAA OR TRA) ... 3
TRADE ADJUSTMENT
ASSISTANCE (TAA OR TRA)....3
TRADE ADJUSTMENT
ASSISTANCE (TAA OR TRA) ... 3
VETERANS AFFAIRS (VA) ....... 4
VETERANS AFFAIRS (VA) ....... 4
VETERANS AFFAIRS (VA) ....... 4
VETERANS AFFAIRS (VA) ........4
VETERANS AFFAIRS (VA)........ 4
PELL GRANT ............................. 5
PELL GRANT ............................. 5
PELL GRANT............................. 5
PELL GRANT .............................5
PELL GRANT ............................. 5
OTHER GOVERNMENT AGENCY
OR ASSISTANCE ...................... 6
OTHER GOVERNMENT AGENCY
OR ASSISTANCE ...................... 6
OTHER GOVERNMENT AGENCY
OR ASSISTANCE ...................... 6
OTHER GOVERNMENT AGENCY
OR ASSISTANCE.......................6
OTHER GOVERNMENT AGENCY
OR ASSISTANCE ...................... 6
OTHER GRANT OR
SCHOLARSHIP FUND .............. 7
OTHER GRANT OR
SCHOLARSHIP FUND .............. 7
OTHER GRANT OR
SCHOLARSHIP FUND .............. 7
OTHER GRANT OR
SCHOLARSHIP FUND ...............7
OTHER GRANT OR
SCHOLARSHIP FUND............... 7
OTHER (SPECIFY) .................... 99
OTHER (SPECIFY) .................... 99
OTHER (SPECIFY) ................... 99
OTHER (SPECIFY) ....................99
OTHER (SPECIFY) .................... 99
___________________________
___________________________
___________________________
___________________________
___________________________
DON’T KNOW ............................ d
DON’T KNOW ............................ d
DON’T KNOW ............................ d
DON’T KNOW.............................d
DON’T KNOW ............................ d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED...................................... r
REFUSED ......................................r
YES ................................................ 1
YES ................................................ 1
YES ................................................ 1
YES ................................................ 1
YES.................................................1
NO .................................................. 0
NO .................................................. 0
NO .................................................. 0
NO.................................................. 0
NO ..................................................0
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW................................ d
DON’T KNOW ................................d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED...................................... r
REFUSED ......................................r
PROBE: Any other
person or
organization?
PROBE: Do not
include student
loans or
personal bank
loans here
C24. IF C15 NE YES:
Did you
complete the
program?
Prepared by Mathematica Policy Research, Inc.
O.1.17
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
PROGRAM 1
PROGRAM 2
PROGRAM 3
PROGRAM 4
PROGRAM 5
C25. IF NO: What
was the main
reason that you
stopped
attending that
program?
FOUND JOB/REEMPLOYED .... 1
FOUND JOB/REEMPLOYED .... 1
FOUND JOB/REEMPLOYED .... 1
FOUND JOB/REEMPLOYED.....1
FOUND JOB/REEMPLOYED .... 1
COULDN’T AFFORD TO
CONTINUE ................................. 2
COULDN’T AFFORD TO
CONTINUE................................. 2
COULDN’T AFFORD TO
CONTINUE ................................ 2
COULDN’T AFFORD TO
CONTINUE .................................2
COULDN’T AFFORD TO
CONTINUE ................................. 2
PERSONAL PROBLEMS........... 3
PERSONAL PROBLEMS .......... 3
PERSONAL PROBLEMS .......... 3
PERSONAL PROBLEMS ...........3
PERSONAL PROBLEMS ........... 3
NOT INTERESTED/DIDN’T LIKE
PROGRAM ................................. 4
NOT INTERESTED/DIDN’T LIKE
PROGRAM ................................. 4
NOT INTERESTED/DIDN’T LIKE
PROGRAM ................................ 4
NOT INTERESTED/DIDN’T LIKE
PROGRAM .................................4
NOT INTERESTED/DIDN’T LIKE
PROGRAM ................................. 4
INTERVIEWER:
REPEAT
PROGRAM
NAME AS
NEEDED [FILL
PROGRAM
NAME]
DIDN’T THINK IT WOULD HELP
TO FIND A JOB.......................... 5
DIDN’T THINK IT WOULD HELP
TO FIND A JOB ......................... 5
DIDN’T THINK IT WOULD HELP
TO FIND A JOB ......................... 5
DIDN’T THINK IT WOULD HELP
TO FIND A JOB ..........................5
DIDN’T THINK IT WOULD HELP
TO FIND A JOB .......................... 5
STARTED (OTHER)
SCHOOL/TRAINING .................. 6
STARTED (OTHER)
SCHOOL/TRAINING .................. 6
STARTED (OTHER)
SCHOOL/TRAINING ................. 6
STARTED (OTHER)
SCHOOL/TRAINING ..................6
STARTED (OTHER)
SCHOOL/TRAINING .................. 6
DECIDED DIDN’T WANT JOB... 7
DECIDED DIDN’T WANT JOB .. 7
DECIDED DIDN’T WANT JOB .. 7
DECIDED DIDN’T WANT JOB ...7
DECIDED DIDN’T WANT JOB ... 7
ILLNESS/PREGNANCY............. 8
ILLNESS/PREGNANCY ............ 8
ILLNESS/PREGNANCY ............ 8
ILLNESS/PREGNANCY .............8
ILLNESS/PREGNANCY ............. 8
CHILD CARE/FAMILY
TRANSPORTATION/LOGISTICAL
PROBLEMS ............................... 9
CHILD CARE/FAMILY
TRANSPORTATION/LOGISTICAL
PROBLEMS ............................... 9
CHILD CARE/FAMILY
TRANSPORTATION/LOGISTICAL
PROBLEMS ............................... 9
CHILD CARE/FAMILY
TRANSPORTATION/LOGISTICAL
PROBLEMS ................................9
CHILD CARE/FAMILY
TRANSPORTATION/LOGISTICAL
PROBLEMS................................ 9
POOR GRADES......................... 10
POOR GRADES ........................ 10
POOR GRADES ........................ 10
POOR GRADES .........................10
POOR GRADES ......................... 10
COURSES OR PROGRAM
POORLY TAUGHT..................... 11
COURSES OR PROGRAM
POORLY TAUGHT .................... 11
COURSES OR PROGRAM
POORLY TAUGHT .................... 11
COURSES OR PROGRAM
POORLY TAUGHT .....................11
COURSES OR PROGRAM
POORLY TAUGHT..................... 11
OTHER (SPECIFY) .................... 99
OTHER (SPECIFY).................... 99
OTHER (SPECIFY) ................... 99
OTHER (SPECIFY) ....................99
OTHER (SPECIFY) .................... 99
___________________________
___________________________
___________________________
___________________________
___________________________
DON’T KNOW ............................ d
DON’T KNOW ............................ d
DON’T KNOW ............................ d
DON’T KNOW.............................d
DON’T KNOW ............................ d
REFUSED .................................. r
REFUSED .................................. r
REFUSED .................................. r
REFUSED...................................r
REFUSED .................................. r
YES ................................................ 1
YES ................................................ 1
YES ................................................ 1
YES ................................................ 1
YES.................................................1
NO .................................................. 0
NO .................................................. 0
NO .................................................. 0
NO.................................................. 0
NO ..................................................0
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW................................ d
DON’T KNOW ................................d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED...................................... r
REFUSED ......................................r
C26. Did you receive
a diploma/
degree/
certification/
license for
completing that
program?
Prepared by Mathematica Policy Research, Inc.
O.1.18
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
C27. IF C26=1: What
kind of
certificate or
degree/diploma
did you
receive?
CATI PROGRAM: IS
THERE ANOTHER
PROGRAM TO ASK
ABOUT?
PROGRAM 1
PROGRAM 2
PROGRAM 3
PROGRAM 4
PROGRAM 5
PARTICIPATION/ATTENDANCE .. 1
PARTICIPATION/ATTENDANCE .. 1
PARTICIPATION/ATTENDANCE.. 1
PARTICIPATION/ATTENDANCE . 1
PARTICIPATION/ATTENDANCE ..1
GED ................................................ 2
GED................................................ 2
GED ............................................... 2
GED ............................................... 2
GED ................................................2
HIGH SCHOOL DIPLOMA ............. 3
HIGH SCHOOL DIPLOMA............. 3
HIGH SCHOOL DIPLOMA ............ 3
HIGH SCHOOL DIPLOMA ............ 3
HIGH SCHOOL DIPLOMA .............3
ASSOCIATE’S DEGREE ............... 4
ASSOCIATE’S DEGREE ............... 4
ASSOCIATE’S DEGREE ............... 4
ASSOCIATE’S DEGREE............... 4
ASSOCIATE’S DEGREE ...............4
BACHELOR’S DEGREE ................ 5
BACHELOR’S DEGREE ................ 5
BACHELOR’S DEGREE................ 5
BACHELOR’S DEGREE ............... 5
BACHELOR’S DEGREE ................5
ENGLISH PROFICIENCY
CERTIFICATION/ TOEFL .............. 6
ENGLISH PROFICIENCY
CERTIFICATION/ TOEFL .............. 6
ENGLISH PROFICIENCY
CERTIFICATION/ TOEFL.............. 6
ENGLISH PROFICIENCY
CERTIFICATION/ TOEFL ............. 6
ENGLISH PROFICIENCY
CERTIFICATION/ TOEFL ..............6
CERTIFICATE OR LICENSE (E.G. FOOD HANDLER, FORKLIFT
OPERATOR, HAIRDRESSING,
PLUMBING, CDL) .......................... 7
CERTIFICATE OR LICENSE (E.G. FOOD HANDLER, FORKLIFT
OPERATOR, HAIRDRESSING,
PLUMBING, CDL) .......................... 7
CERTIFICATE OR LICENSE (E.G. FOOD HANDLER, FORKLIFT
OPERATOR, HAIRDRESSING,
PLUMBING, CDL) .......................... 7
CERTIFICATE OR LICENSE (E.G. FOOD HANDLER, FORKLIFT
OPERATOR, HAIRDRESSING,
PLUMBING, CDL).......................... 7
CERTIFICATE OR LICENSE (E.G. FOOD HANDLER, FORKLIFT
OPERATOR, HAIRDRESSING,
PLUMBING, CDL) ..........................7
OTHER (SPECIFY) .................... 99
OTHER (SPECIFY) .................... 99
OTHER (SPECIFY) ................... 99
OTHER (SPECIFY) ....................99
OTHER (SPECIFY) .................... 99
___________________________
___________________________
___________________________
___________________________
___________________________
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW ................................ d
DON’T KNOW................................ d
DON’T KNOW ................................d
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED ...................................... r
REFUSED...................................... r
REFUSED ......................................r
YES..........GO TO NEXT
PROGRAM – C14
YES..........GO TO NEXT
PROGRAM – C14
YES..........GO TO NEXT
PROGRAM – C14
YES..........GO TO NEXT
PROGRAM – C14
GO TO C27a
NO………...GO TO C27a
NO………...GO TO C27a
NO………...GO TO C27a
NO………...GO TO C27a
Prepared by Mathematica Policy Research, Inc.
O.1.19
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
C27a. What is the highest grade or degree you have completed?
CODE ONE ONLY
LESS THAN 8TH GRADE...............................................................................................1
8TH TO 12TH GRADE, NO DIPLOMA ...........................................................................2
HIGH SCHOOL DIPLOMA OR GED ..............................................................................3
ADULT BASIC EDUCATION (ABE) CERTIFICATE .......................................................4
SOME COLLEGE BUT NO DEGREE .............................................................................4
VOCATIONAL/TECHNICAL DEGREE OR CERTIFICATE ............................................5
BUSINESS DEGREE OR CERTIFICATE.......................................................................4
ASSOCIATE DEGREE (AA) ...........................................................................................6
BACHELORS DEGREE (BA/BS) ....................................................................................7
MASTERS DEGREE (MA/MS) OR HIGHER (MD, Ph.D) ...............................................8
OTHER (SPECIFY) .........................................................................................................99
________________________________________________________________
DON’T KNOW .................................................................................................................d
REFUSED .......................................................................................................................r
C28.
The next questions are about support services you may have received from an agency or
organization to support you in your job search or training. Please indicate whether you
receive or have received the following support services since [FILL RA MONTH/YEAR].
Since [FILL RA MONTH/YEAR], have you received…
CODE ONE PER ROW
YES
NO
DON’T KNOW
REFUSED
a.
Childcare assistance including vouchers or
funds ...........................................................
1
0
d
r
b.
Transportation assistance (such as gas
cards or bus passes) ..................................
1
0
d
r
c.
Housing assistance ....................................
1
0
d
r
d.
Mental health or substance abuse
counseling ..................................................
1
0
d
r
e.
Clothes, uniforms, tools or other supplies
and equipment ............................................
1
0
d
r
f.
Something else that I haven’t mentioned?
(SPECIFY) ..................................................
1
0
d
r
_____________________________
Prepared by Mathematica Policy Research, Inc.
O.1.20
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
D. Public Assistance
The next questions are about different types of assistance you may be receiving or have received
since (FILL RA MONTH/YEAR). Please remember that all of your responses on this survey will be
kept private and will not affect any benefits you receive now or in the future.
D1.
Since [FILL RA MONTH/YEAR], did you receive any of the following types of assistance…
CODE ONE PER ROW
YES
NO
DON’T KNOW
REFUSED
a. SNAP or Food Stamp benefits also
known as [STATE SNAP NAME]? ......
1
0
d
r
b. TANF or Temporary Assistance to
Needy Families (also known as
[STATE WELFARE NAME])? ..............
1
0
d
r
Other welfare such as General
Assistance? .........................................
1
0
d
r
d. Unemployment Insurance or
Unemployment Benefits? ....................
1
0
d
r
e. SSI or Supplemental Security Income
from the federal, state, or local
government?........................................
1
0
d
r
Section 8 or Public Housing
Assistance? .........................................
1
0
d
r
g. Medicaid also known as [MEDICAID
STATE NAME]?...................................
1
0
d
r
c.
f.
h.
WIC, the Women, Infants, and
Children food program? ......................
1
0
d
r
i.
Any other assistance? (SPECIFY) ......
1
0
d
r
_____________________________
D2a.
IF D1a=YES: For approximately how many months since [FILL RA MONTH/YEAR] did you
receive SNAP or Food Stamp benefits also known as [STATE SNAP NAME]?
|
|
| NUMBER OF MONTHS
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
D2b.
And approximately how much SNAP or Food Stamp benefits did you receive each month?
PROBE: Your best estimate is fine.
IF MONTHLY AMOUNT VARIED, PROBE: How much was the most recent amount?
$|
|
|
| AMOUNT OF SNAP BENEFITS
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
Prepared by Mathematica Policy Research, Inc.
O.1.21
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
D3a.
IF D1b=YES: For approximately how many months since [FILL RA MONTH/YEAR], did you
receive TANF or Temporary Assistance to Needy Families (also known as [STATE
WELFARE NAME])?
|
|
| NUMBER OF MONTHS
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
D3b.
And approximately how much TANF or Temporary Assistance to Needy Families did you
receive each month?
$|
|
|
| AMOUNT OF TANF BENEFITS
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
D4a.
IF D1c=YES: For approximately how many months since [FILL RA MONTH/YEAR], did you
receive other welfare such as General Assistance?
|
|
| NUMBER OF MONTHS
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
D4b.
And approximately how much other welfare such as General Assistance did you receive
each month?
$|
|
|
| AMOUNT OF OTHER WELFARE/GA
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
D5a.
IF D1d=YES: For approximately how many months since [FILL RA MONTH/YEAR], did you
receive Unemployment Insurance?
|
|
| NUMBER OF MONTHS
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
D5b.
And approximately, how much did you receive in Unemployment Insurance each month?
$|
|
|
| AMOUNT OF UNEMPLOYMENT INSURANCE
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
Prepared by Mathematica Policy Research, Inc.
O.1.22
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
D6a.
IF D1e=YES: For approximately how many months since [FILL RA MONTH/YEAR], did you
receive SSI or Supplemental Security Income from the federal, state, or local government?
|
|
| NUMBER OF MONTHS
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
D6b.
And approximately how much did you receive in SSI or Supplemental Security Income
from the federal, state, or local government each month?
$|
|
|
| AMOUNT OF SSI
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
D7.
Did you claim the Earned Income Tax Credit for your earnings last year in [FILL PREVIOUS
YEAR]?
PROBE: The federal government has a special rule that allows working people who make
less than about $49,000 a year to take advantage of something called the Earned Income
Tax Credit, or EITC. They can claim the Earned Income Tax Credit by filling out a special
form called Schedule EIC when they fill out their income taxes, or they can fill out a special
form with their employer.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
GO TO E1
DON’T KNOW ....................................................................................................... d
GO TO E1
REFUSED ............................................................................................................. r
GO TO E1
Prepared by Mathematica Policy Research, Inc.
O.1.23
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
E. Food Security
Now, I’m going to read you several statements that people have made about their food situation.
For these statements, please tell me whether the statement was often true, sometimes true, or
never true for (you/your household) in the last 30 days.
E1.
The first statement is, “(I/We) worried whether (my/our) food would run out before (I/we)
got money to buy more.” Was that often true, sometimes true, or never true for (you/your
household) in the last 30 days?
CODE ONE ONLY
OFTEN TRUE ....................................................................................................... 1
SOMETIMES TRUE .............................................................................................. 2
NEVER TRUE ....................................................................................................... 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
E2.
“The food that (I/we) bought just didn’t last, and (I/we) didn’t have money to get more.”
Was that often, sometimes, or never true for (you/your household) in the last 30 days?
CODE ONE ONLY
OFTEN TRUE ....................................................................................................... 1
SOMETIMES TRUE .............................................................................................. 2
NEVER TRUE ....................................................................................................... 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
E3.
“(I/We) couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for
(you/your household) in the last 30 days?
CODE ONE ONLY
OFTEN TRUE ....................................................................................................... 1
SOMETIMES TRUE .............................................................................................. 2
NEVER TRUE ....................................................................................................... 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF AFFIRMATIVE RESPONSE (i.e., OFTEN TRUE OR SOMETIMES TRUE) TO ONE OR
MORE OF QUESTIONS E1-E3, THEN CONTINUE, ELSE SKIP TO F1.
E4.
In the last 30 days, did (you/you or other adults in your household) ever cut the size of
your meals or skip meals because there wasn’t enough money for food?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
GO TO E5
DON’T KNOW ....................................................................................................... d
GO TO E5
REFUSED ............................................................................................................. r
GO TO E5
Prepared by Mathematica Policy Research, Inc.
O.1.24
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
E4a.
How many days did this happen in the last 30 days?
| | | NUMBER OF DAYS
(1 – 30)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
E5.
In the last 30 days, did (you/you or other adults in your household) ever eat less than you
felt you should because there wasn’t enough money for food?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
E6.
In the last 30 days, were you ever hungry but didn’t eat because there wasn’t enough
money for food?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
E7.
In the last 30 days, did you lose weight because there wasn’t enough money for food?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
E8.
In the last 30 days, did (you/you or other adults in your household) ever not eat for a whole
day because there wasn’t enough money for food?
YES ....................................................................................................................... 1
E8a.
NO ......................................................................................................................... 0
GO TO F1
DON’T KNOW ....................................................................................................... d
GO TO F1
REFUSED ............................................................................................................. r
GO TO F1
In the last 30 days, how many days did this happen?
| | | NUMBER OF DAYS
(1 – 30)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
Prepared by Mathematica Policy Research, Inc.
O.1.25
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
F. Health and Well-Being
My next questions are about your health and well-being.
F1.
In general would you say your health is excellent, very good, good, fair or poor?
CODE ONE ONLY
EXCELLENT ......................................................................................................... 1
VERY GOOD ........................................................................................................ 2
GOOD ................................................................................................................... 3
FAIR ...................................................................................................................... 4
POOR .................................................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
F2.
Now I am going to ask you some questions about feelings you may have experienced over
the last 2 weeks.
Over the last 2 weeks, how often have you been bothered by any of the following
problems. . .(FILL ITEM)
Would you say - not at all, several days, more than half the days, or nearly every day?
CODE ONE PER ROW
NOT AT ALL
SEVERAL
DAYS
MORE THAN
HALF THE
DAYS
NEARLY
EVERY DAY
DON’T
KNOW
REF
a. Little interest or pleasure in doing things ......................
0
1
2
3
d
r
b. Feeling down, depressed, or hopeless .........................
0
1
2
3
d
r
c. Trouble falling or staying asleep, or sleeping too
much .........................................................................
d. Feeling tired or having little energy ..............................
0
1
2
3
d
r
0
1
2
3
d
r
e. Poor appetite or overeating ..........................................
0
1
2
3
d
r
f. Feeling bad about yourself, or that you are a failure or
have let yourself or your family down. ..........................
0
1
2
3
d
r
e. Trouble concentrating on things, such as reading the
newspaper or watching television ................................
0
1
2
3
d
r
f. Moving or speaking so slowly that other people could
have noticed. Or the opposite-being so fidgety or
restless than you have been moving around a lot
more than usual ...........................................................
0
1
2
3
d
r
Prepared by Mathematica Policy Research, Inc.
O.1.26
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
F2a.
IF ANY F2 RESPONSE IS EQUAL TO 1, 2 OR 3: How difficult have these problems made it
for you to do your work, take care of things at home, or get along with other people?
Would you say…
Not difficult at all, ................................................................................................ 1
Somewhat difficult, ............................................................................................. 2
Very difficult, or ................................................................................................... 3
Extremely difficult? ............................................................................................. 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
F3.
Please indicate the extent to which you agree with this statement …
“I have high self-esteem.”
Would you say that is very untrue of you, somewhat untrue of you, neither true nor untrue
of you, somewhat true of you, or very true of you?
VERY UNTRUE OF YOU...................................................................................... 1
SOMEWHAT UNTRUE OF YOU .......................................................................... 2
NEITHER TRUE NOR UNTRUE OF YOU............................................................ 3
SOMEWHAT TRUE OF YOU ............................................................................... 4
VERY TRUE OF YOU ........................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
F4.
The following statements describe the way some people may feel about themselves.
Please tell me if you strongly disagree, somewhat disagree, somewhat agree, or strongly
agree with each of the following statements…
CODE ONE PER ROW
STRONGLY SOMEWHAT SOMEWHAT
DISAGREE DISAGREE
AGREE
STRONGLY
AGREE
DON’T
KNOW
REF
a. I can do just about anything I really set my mind to ......
1
2
3
4
d
r
b. When I really want to do something, I usually find a
way to succeed at it......................................................
1
2
3
4
d
r
c. Whether or not I am able to get what I want is in my
own hands ....................................................................
1
2
3
4
d
r
d. What happens to me in the future mostly depends on
me ................................................................................
1
2
3
4
d
r
e. I can do the things that I want to do ..............................
1
2
3
4
d
r
Prepared by Mathematica Policy Research, Inc.
O.1.27
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
G. Housing Status and Stability
G1.
Now I’d like to talk about your living arrangements. Where are you living right now?
PROBE: What kind of place do you live in?
PROBE: IF R STAYS IN MORE THAN ONE PLACE: Where do you stay most often?
CODE ONE ONLY
HOUSE, TOWNHOUSE, CONDO ........................................................................ 1
MOBILE HOME/TRAILER..................................................................................... 2
APARTMENT ........................................................................................................ 3
ROOM ................................................................................................................... 4
GROUP QUARTERS (DORMITORY, GROUP HOME, SHELTER,
HOSPITAL, RESIDENTIAL FACILITY, TRANSITIONAL HOUSING,
HALFWAY HOUSE, ETC.).................................................................................... 5
G3.
HOMELESS (NO REGULAR PLACE TO STAY) ................................................. 6
GO TO G4
INCARCERATED .................................................................................................. 7
GO TO H1
OTHER (SPECIFY) ............................................................................................... 8
GO TO G5
DON’T KNOW ....................................................................................................... d
GO TO G5
REFUSED ............................................................................................................. r
GO TO G5
(Thinking of the place you live right now, how/How) long have you lived there? Would you
say…
CODE ONE ONLY
G4.
Less than one year, or ........................................................................................ 1
GO TO G5
One year or longer? ............................................................................................ 2
GO TO G5
DON’T KNOW ....................................................................................................... d
GO TO G5
REFUSED ............................................................................................................. r
GO TO G5
How long have you been without a regular place to stay? Would you say…
CODE ONE ONLY
G5.
Less than one year, or ........................................................................................ 1
GO TO H1
One year or longer? ............................................................................................ 2
GO TO H1
DON’T KNOW ....................................................................................................... d
GO TO H1
REFUSED ............................................................................................................. r
GO TO H1
What is the zip code of where you currently live?
|
|
|
|
|
| ZIP CODE
DON’T KNOW .................................................................................................................d
REFUSED .......................................................................................................................r
Prepared by Mathematica Policy Research, Inc.
O.1.28
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
H. Respondent Follow-Up and Contact Information
H1.
We are almost done. Please provide an address where we can send your $30 gift card.
COLLECT/CONFIRM CURRENT CONTACT INFO FOR RESPONDENT
FIRST NAME
MIDDLE INITIAL/NAME
LAST NAME
ADDRESS 1
ADDRESS 2
CITY
STATE/TERRITORY
| | | | | |-| | |
ZIP CODE (+ 4 IF NEEDED)
H2.
|
|
Thank you for participating in the survey. We would like to interview you again in about 24
months and I would like to know how to get in touch with you. There will be a gift card for
completing that survey as well. Please provide your (home/cell/email).
| | | |-| | | |-|
(200-999)
(100-999)
| | | |-| | | |-|
(200-999)
(100-999)
| | | |-| | | |-|
(200-999)
(100-999)
| | | | PHONE NUMBER - HOME
(0000-9999)
| | | | PHONE NUMBER – CELLULAR
(0000-9999)
| | | | PHONE NUMBER - OTHER
(0000-9999)
EMAIL
DON’T KNOW .......................................................................................... d
REFUSED ................................................................................................ r
Prepared by Mathematica Policy Research, Inc.
O.1.29
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
H3.
I would like to ask you for the name, address, and telephone number of 2 close relatives or
friends we can contact in case you move and we cannot easily locate you for your next
interview. All information collected will be kept private, and will only be used if we cannot
contact you.
CONTACT 1:
FIRST NAME
MIDDLE INITIAL/NAME
LAST NAME
RELATIONSHIP TO RESPONDENT
ADDRESS 1
ADDRESS 2
CITY
STATE/TERRITORY
| | | | | |-| | |
ZIP CODE (+ 4 IF NEEDED)
|
|
| | | |-| | | |-|
(200-999)
(100-999)
| | | | PHONE NUMBER - HOME
(0000-9999)
| | | |-| | | |-|
(200-999)
(100-999)
| | | | PHONE NUMBER – CELLULAR
(0000-9999)
| | | |-| | | |-|
(200-999)
(100-999)
| | | | PHONE NUMBER - OTHER
(0000-9999)
EMAIL
DON’T KNOW .......................................................................................... d
REFUSED ................................................................................................ r
Prepared by Mathematica Policy Research, Inc.
O.1.30
GO TO END
ATTACHMENT O.1: 12 MONTH FOLLOW-UP SURVEY (ENGLISH)
CONTACT 2:
FIRST NAME
MIDDLE INITIAL/NAME
LAST NAME
RELATIONSHIP TO RESPONDENT
ADDRESS 1
ADDRESS 2
CITY
STATE/TERRITORY
| | | | | |-| | |
ZIP CODE (+ 4 IF NEEDED)
|
|
| | | |-| | | |-|
(200-999)
(100-999)
| | | | PHONE NUMBER - HOME
(0000-9999)
| | | |-| | | |-|
(200-999)
(100-999)
| | | | PHONE NUMBER – CELLULAR
(0000-9999)
| | | |-| | | |-|
(200-999)
(100-999)
| | | | PHONE NUMBER - OTHER
(0000-9999)
EMAIL
DON’T KNOW .......................................................................................... d
REFUSED ................................................................................................ r
END.
Thank you for your cooperation. This completes the survey! You should receive your gift
card in about 4 weeks. Thank you again.
Prepared by Mathematica Policy Research, Inc.
O.1.31
| File Type | application/pdf |
| Author | Mathematica Staff |
| File Modified | 2015-10-14 |
| File Created | 2015-10-14 |