Form BIF Baseline Information Form

Participant ID #: |___|___|___|___|___|___|___|___|

(For Office Use Only)

National Guard Youth ChalleNGe Job ChalleNGe Evaluation

Background Information Form

Today’s Date: |____|____|/|____|____|/|____|____|____|____|

Please print clearly. Use pen only.

1. Your name:

First name Middle initial Last name

2. Your home address:

Address Apt. #

City State Zip code

3. 0 □ None Nickname(s):

4. Social Security number:

|____|____|____|-|____|____|-|____|____|____|____|

5. Date of birth:

|____|____| / |____|____| / |____|____|____|____|

Month Day Year

6. Sex: 1 □ Male 2 □ Female

7. Are you Spanish/Hispanic/Latino?

1 □ Yes 0 □ No

8. What is your race?

CHECK ALL THAT APPLY

1 □ Hawaiian Native or other Pacific Islander

2 □ White

3 □ Black or African American

4 □ Asian

5 □ American Indian or Alaskan

6 □ Other (specify) ______________________________

9. Home Phone Number:

(|____|____|____|)-|____|____|____|-|____|____|____|____|

Area code

10. Primary language currently spoken at home

11. 0 □ CHECK THIS BOX IF YOU DO NOT HAVE A CELL PHONE

Cell phone number:

(|____|____|____|)-|____|____|____|-|____|____|____|____|

Area code

12. 0 □ CHECK THIS BOX IF YOU DO NOT HAVE AN EMAIL ADDRESS

What is the email address you use most often?

__________________________________________________

13. Do you have an account on any of the following?

CHECK ALL THAT APPLY

1 □ Facebook?

Name:

2 □ Instagram?

Name:

3 □ Twitter?

Tag:

14. Do you have any other social networking accounts?

1 □ Yes – URL Address:

0 □ No

15. Do you have a personal blog or website?

1 □ Yes – URL Address:

0 □ No

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

CHECK ALL THAT APPLY

1 □ Regular mail 5 □ Facebook

2 □ Email 6 □ Instagram

3 □ Cell Phone 7 □ Twitter

4 □ Text 8 □ Other

17. In what year did you last attend school?

|____|____|____|____|

18. What is the last grade you completed in school?

CHECK ONE

1 □ 6th or below

2 □ 7th

3 □ 8th

4 □ 9th

5 □ 10th

6 □ 11th

7 □ 12th

19. During the last two years you attended school, did you receive free or reduced-priced lunches?

1 □ Yes 0 □ No

20. Were you ever suspended from school?

1 □ Yes 0 □ No

TURN FORM OVER

21. When you entered Youth ChalleNGe, did you have a high school diploma or GED certificate?

1 □ Yes 0 □ No

22. Have you ever received any special education services?

1 □ Yes 0 □ No

23. Which of the following best describes your housing status prior to entering Youth ChalleNGe?

CHECK ONE

1 □ Living with own family

2 □ Own/rent apartment, room, house

3 □ Permanently living at someone’s apartment, room, house

4 □ Temporarily staying at someone’s apartment, room, house

5 □ Staying with foster guardian/In foster system

6 □ Halfway house/Transitional house

7 □ Residential treatment

8 □ Homeless

24. Were you employed immediately before entering Youth ChalleNGe?

1 □ Yes 0 □ No

25. Have you ever had a paying job lasting 3 months or longer?

1 □ Yes 0 □ No

26. Are you married?

1 □ Yes 0 □ No

27. Do you have any children?

1 □ Yes 0 □ No

28. How would you rate your overall health?

CHECK ONE

1 □ Very good

2 □ Good

3 □ Fair

4 □ Poor

5 □ Very poor

29. In the 6 months before you entered Youth ChalleNGe, did you use marijuana?

1 □ Yes 0 □ No

30. In the 6 months before you entered Youth ChalleNGe, did you use any other type of illegal drug, taken a prescription drug in a way that was not prescribed, or inhaled something to get high?

1 □ Yes 0 □ No

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays an Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is xxxx-xxxx. The time required to complete this collection of information is estimated to average 8 minutes, including the time to review instructions, gather the data needed and complete and review the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Molly Irwin at 202-693-5091 or [email protected] and reference the OMB Control Number xxxx-xxxx.

31. Have you ever been taken into custody or arrested?

1 □ Yes 0 □ No

32. Have you ever been found guilty of a status offense? By “status offense”, we mean conduct that would not be a crime if it was committed by an adult. Typical status offenses include truancy, running away from home, violating curfew, and underage use of alcohol.

1 □ Yes 0 □ No

33. Have you ever been convicted of a crime?

1 □ Yes 0 □ No

34. Have you ever spent time in a juvenile detention facility?

1 □ Yes 0 □ No

35. Have you ever spent time in an adult detention facility?

1 □ Yes 0 □ No

36. When you entered Youth ChalleNGe, were you on probation or parole?

1 □ Yes 0 □ No

37. Parent or legal guardian name:

__ _

First name Middle initial Last name

38. Parent or legal guardian address:

Address Apt. #

City State Zip code

39. Parent or legal guardian home phone number:

(|____|____|____|)-|____|____|____|-|____|____|____|____|

Area code

40. Parent or legal guardian cell phone number:

(|____|____|____|)-|____|____|____|-|____|____|____|____|

Area code

There may be a time when we need to contact you after you leave the Youth ChalleNGe program. In case we are not able to reach you directly, is there someone else that we could call who would know how to get hold of you?

41. Contact’s name:

__ _

First name Middle initial Last name

42. Contact’s cell phone number:

(|____|____|____|)-|____|____|____|-|____|____|____|____|

Area code

THANK YOU FOR YOUR TIME