Forms

APPENDIX B
STUDY BASELINE FORMS:
STUDY REGISTRATION, CONSENT, AND CONTACT INFORMATION FORMS

APPENDIX B.1
STUDY REGISTRATION FORM

FOR COUNSELOR USE ONLY:

Study ID #: |

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OMB Control No.: 1205-0482
Expiration Date: 09/30/2014

STUDY REGISTRATION FORM

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Use black or blue ink to complete this form. Make heavy dark marks that fill the square completely.
Correct Mark

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Incorrect Marks

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X

Please PRINT where applicable. Enter only one number per box. | 1 | 9 |
1.

Today’s Date: |

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Month

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Day

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□ Male
2 □ Female

Year

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Name:
7.
First Name

2a.

MI

Gender:

Last Name

Home Phone Number:

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IF NONE, MARK HERE

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Maiden Name:

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Area Code

Under whose name is that phone listed?
3.

1

Address:

□ My own name

2

□ Someone else’s name (Write in):

_________________
_____________________________

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Street

Apt. #

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First Name

8.
___________________ |
City

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State

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Cell Phone Number:

Date of Birth: |

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Month

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Day

Year

Social Security Number:
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Area Code

9.

Email Address:

10.

Are you of Hispanic, Latino, or Spanish origin?

□ Yes
0 □ No
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FOR COUNSELOR USE ONLY

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IF NONE, MARK HERE

ZIP Code

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4.

Last Name

11.

What is your race?
MARK ONE OR MORE BOXES

□ White
□ Black or African American
3 □ American Indian or Alaska Native
4 □ Asian
5 □ Native Hawaiian or Pacific Islander
1

A. LWIA Name:

2

B. Center Name:
C. WIA Counselor’s Name:
First Name

D. Customer’s Qualification status:

E. Training:

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2□
3□
4□
1

VL
SL
SU
VU

F.

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2□
3□
4□
1

MI

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2□
1

Provider:
C.C./T.C. - 2-yr.
P
U/C - 4-yr.
O (Write in):

Last Name

12.

What is your primary spoken language?
MARK ONE BOX

□ English
□ Spanish
3 □ Other (Write in):
1

D

2

A

13.

What is your marital status right now?
MARK ONE BOX

□ Married
□ Separated
3 □ Divorced
1

4

2

5

□ Widowed
□ Never married
CONTINUE ON BACK ►

2011 WIA Study Registration Form (9-26-11)

14.

15.

or had more than one job recently, give answers about your
job with the most hours.)

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20.

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# OF PEOPLE LIVING WITH YOU,
INCLUDING YOU

Which of the following degrees, diplomas, or
certificates have you received?
MARK ALL THAT APPLY

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2□
3□
4□
5□
6□
7□
8□
9□
10 □
11 □
12 □
13 □
1

16.

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0□

18.

How many hours per week do (or did) you usually
work at your main job?

High School Diploma
Adult Basic Education (ABE) certificate
General Educational Development (GED)
Vocational/Technical degree or certificate

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23.

Associates degree (AA)
Bachelor’s degree or equivalent (BA/BS)

| HOURS PER WEEK

What was your current or most recent rate of pay,
before taxes and deductions at your main job?
$|

Master’s degree or equivalent (MA/MS)

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3□
4□
5□
6□
1
2

24.

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Cents

Hour
Week
Every 2 weeks
Twice per month
Year
Other (Write in): __________________________

Do you or anyone in your household currently
receive assistance from any of the following
programs?

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2□
3□
4□
5□
6□
0□
1

GO TO #24

GO TO #20

25.

In what month and year did your last job end?
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MARK ALL THAT APPLY

No

Month

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MARK ONE BOX

Other (Write in):

Yes

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(if pay varies, enter an average amount)

Other professional degree/certificate

No

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Dollars

Doctor’s degree (MD, Ph.D.)

Are you currently working?

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Business degree/certificate

Yes

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0□
19.

22.

Elementary, Middle, or Junior High diploma

Have you had a job in the past five years?

1

Self-employed

What are (or were) your main duties at this
company? PLEASE BE SPECIFIC

No

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0□

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21.

Yes

1

What is the name of your current or former
employer?

1

None

Do you have any health problems—mental,
physical, or emotional—or substance abuse
problems that limit the kind or amount of work
or training that you can do?
1

17.

ANSWER QUESTIONS 20-23 ABOUT YOUR CURRENT OR
MOST RECENT JOB. (If you currently have more than one job

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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Year

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GO TO #20

TANF (Cash assistance)
SSI or SSDI
General Assistance
SNAP (Food Stamps)
Unemployment Compensation
Other (Write in):
IF NONE, MARK HERE

In the past, have you ever used services at this
Center or one similar to it?
1□
Yes
0□
No

Thank you for completing this form. Please return it to
your WIA counselor.

Public Burden Statement
Completing this document, which seeks to help the U.S. Department of Labor understand the effects of WIA-funded services on customers’ employment-related outcomes, is voluntary. The public reporting burden for this collection of information is estimated to average 5 minutes
per response, 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 the Office of Policy Development
and Research, U.S. Department of Labor, Room N5641, 200 Constitution Avenue, NW, Washington, DC 20210.

APPENDIX B.2
CONSENT FORM

OMB Control No.: 1205-0482
Expiration Date: 09/30/2014
FOR COUNSELOR USE ONLY:

Study ID #: |

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CONSENT TO PARTICIPATE
The U.S. Department of Labor is sponsoring a study of some of its employment and training programs that serve adults
and dislocated workers, to learn how well these programs are working and how they can be improved. The national study,
called the Workforce Investment Act (WIA) Adult and Dislocated Worker Programs Gold Standard Evaluation, is being
conducted by a team of researchers at Mathematica Policy Research, Social Policy Research Associates, and MDRC.
By signing this consent form, you are agreeing to take part in this very important study. As a participant in this study, the
following will happen:
•

A computer will assign you to one of three groups. Your placement in one of these groups is like a lottery—it will be
decided completely by chance and will not be affected by any of your characteristics. The group you are assigned to
will affect the services you can access for 15 months. The three groups are:

3. 1. Full-WIA Group: If you are assigned to this group, you will have access to all of the WIA services normally
available to you. This may include access to WIA training funds to help pay for training at a state-approved provider, if
Center staff determine it is available and appropriate for you. Most people will be assigned to this group.
4. 2. Core-and-Intensive Group: If you are assigned to this group, you will have access to all of the WIA services, if
available and appropriate, except WIA-funded training.
5. 3. Core Group: If you are assigned to this group, you will have access to core services. Core services include
services in the resource room such as job listings and access to the Internet. You will not have access to WIA services
that require substantial staff time or to WIA-funded training.
•

The decision to participate in the study is up to you. If you decide not to participate, you will only have access to core
services. You may terminate your participation in the study at any time by writing to the WIA Evaluation, Mathematica
Policy Research, P.O. Box 2393, Princeton, New Jersey 08543-2393 or to Eileen Pederson, WIA Evaluation,
U.S. Department of Labor, ETA, 200 Constitution Ave., NW, Room N-5641, Washington, DC 20210. Any information
we collect about you prior to your termination request will be used for research purposes.

•

You may be contacted by an interviewer from Mathematica to complete two interviews by telephone over the next few
years. These interviews are voluntary, but they are very important to the success of the study. You will receive a
payment for each interview you complete.

•

Government agencies such as the Social Security Administration, Unemployment Insurance agencies, Employment
Service, and agencies that administer the Temporary Assistance for Needy Families (TANF), Supplemental Nutrition
Assistance Program (SNAP), and WIA programs may share information with the research team about your earnings
and government services and benefits you receive for up to 10 years.

•

All information that is collected about you through interviews or agency records will be used for research purposes
only. The information will be kept confidential in accordance with the Privacy Act of 1974 (5 USC 522a), Systems of
Record Notices DOL/ETA-15, unless the law requires otherwise, or you request release of your information in writing.
Your name will never be used in any reports and no information will be reported in any way that can identify you.

I have read this consent form (or it has been read to me). I understand the information provided in these
materials and voluntarily agree to participate. If I have questions I can call the study toll-free number at
1-800-925-0356.
__________________________________________

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CUSTOMER’S NAME (Printed)

SOCIAL SECURITY NUMBER—LAST 4 DIGITS ONLY

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__________________________________________
CUSTOMER’S SIGNATURE

DATE

Public Burden Statement
Completing this document, which seeks to help the U.S. Department of Labor understand the effects of WIA-funded services on customers’ employment-related outcomes, is
voluntary. The public reporting burden for this collection of information is estimated to average 4 minutes per response, 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 the Office of Policy Development and Research, U.S. Department of Labor, Room N5641, 200 Constitution Avenue, NW, Washington, DC 20210.

WIA Consent Form (9-26-11)

APPENDIX B.3
CONTACT INFORMATION FORM

CONTACT INFORMATION FORM

OMB Control No.: 1205-0482
Expiration Date: 09/30/2014

FOR COUNSELOR USE ONLY:

STUDY ID #: |

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Please print clearly. Use blue or black ink only.

APPLICANT INFORMATION
1.

Name:

2.

Social Security Number—Last 4 Digits only:
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First Name

Middle Initial

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Last Name

CONTACT INFORMATION - RELATIVES AND FRIENDS
INSTRUCTIONS: In the space below, please provide the name, address, email address, and phone number(s) of three close
relatives or friends who do not live with you but who are likely to know how to contact you in the next year. We will only contact
these people if we cannot reach you directly. Please complete all three sections.
3.

NAME AND ADDRESS OF A CLOSE FRIEND OR RELATIVE WHO DOES NOT LIVE WITH YOU

First Name

Middle Initial

Last Name

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Street Address

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Apt. No.

TELEPHONE AND EMAIL:
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City

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State

RELATIONSHIP TO APPLICANT:

□ Parent
□ Grandparent
3 □ Brother/Sister

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Area Code

Cell

MARK ONE BELOW

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Work

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Number

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Area Code

□ Friend/Neighbor
□ Employer
6 □ Other ____________________________

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Home

Zip Code

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Number

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Area Code

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Number

Email Address
NAME AND ADDRESS OF A CLOSE FRIEND OR RELATIVE WHO DOES NOT LIVE WITH YOU

4.

First Name

Middle Initial

Last Name

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Street Address

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Apt. No.

TELEPHONE AND EMAIL:
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City

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State

RELATIONSHIP TO APPLICANT:

□ Parent
□ Grandparent
3 □ Brother/Sister

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2

5

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Area Code

Cell

MARK ONE BELOW

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Work

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Number

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Area Code

□ Friend/Neighbor
□ Employer
6 □ Other ____________________________

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Home

Zip Code

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Number

|) |

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Area Code

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Number

Email Address
NAME AND ADDRESS OF A CLOSE FRIEND OR RELATIVE WHO DOES NOT LIVE WITH YOU

5.

First Name

Middle Initial

Last Name

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Street Address

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Apt. No.

TELEPHONE AND EMAIL:
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City

RELATIONSHIP TO APPLICANT:

□ Parent
□ Grandparent
3 □ Brother/Sister

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State

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4

2

5

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Area Code

Cell

MARK ONE BELOW

□ Friend/Neighbor
□ Employer
6 □ Other ____________________________

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Home

Zip Code

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Area Code

Work

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Area Code

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Number

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Number

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Number

Email Address

Public Burden Statement
Completing this document, which seeks to help the U.S. Department of Labor understand the effects of WIA-funded services on customers’ employment-related outcomes, is voluntary. The public reporting
burden for this collection of information is estimated to average 4 minutes per response, 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 the Office of Policy Development and Research, U.S. Department of Labor,
Room N5641, 200 Constitution Avenue, NW, Washington, DC 20210.

WIA Contact Information Form (9-26-11)