XX-XXXX Baseline Information Form-Head of Household

Family Self-Sufficiency Program Evaluation

FSS_A_4a_BIF_Household

FSS Evaluation

OMB: 2528-0296

Document [docx]
Download: docx | pdf

OMB Control Number: 2528-0296

Expiring: XX-XX-XXXX


HUD FAMILY SELF-SUFFICIENCY EVALUATION

BASELINE INFORMATION FORM

H. HOUSEHOLD FORM

FOR INTERVIEWER: This form should be completed by the head of the household.

H1. HA Entity ID/ Household Identification Number:


___ ___ ___ ___ ___ ___ ___ ___ ___ [Length will vary by HA]

H2. Head of Household’s Social Security Number:


___ ___ ___ - ___ ___ - ___ ___ ___ ___

H3. Home Address:


_______________________________________________________________ _________

  1. Street Address B. Apt. #


_________________________ _______ ___ ___ ___ ___ ___

  1. City D. State E. Zip code

H4. How long have you received Section 8 rental assistance as head of household?


  • 1 Less than 1 year

  • 2 1-3.99 years

  • 3 4-6.99 years

  • 4 7-9.99 years

  • 5 10 or more years

  • 6 No Answer

H5. How much do you pay in rent and utilities per month? Please include only the amount that you or other household members pay "out-of-pocket" or with your own funds.

[ROUND TO THE NEAREST DOLLAR] $____________


[IF YOU DON’T KNOW THE EXACT AMOUNT, PLEASE CHECK ONE RANGE AMOUNT BELOW]

A.

  • 1$0

  • 2$1 -  $99

  • 3$100 - $199

  • 4$200 - $299

  • 5$300 - $399

  • 6$400 - $499

  • 7$500 - $599

  • 8$600 - $699

  • 9$700 - $799

  • 10$800 - $899

  • 11$900 - $999

  • 12$1,000 or more

  • 13 No Answer

H6. Including yourself, how many adults, aged 18 years old or older, lived in your household at least two nights a week during the past month?

    • 1 1

    • 2 2

    • 3 3

    • 4 4 or more

    • 5 No Answer

H7. How many children, aged less than 18 years old, lived in your household at least two nights a week during the past month?

  • 55 No children [Skip to H9]

  • 1 1

  • 2 2

  • 3 3

  • 4 4

  • 5 5

  • 6 6

  • 7 7

  • 8 8

  • 9 9

  • 10 10 or more

  • 99 No Answer [Skip to B9]

H8. What are the ages of these children?

[Drop-down menu. Open as many fields as indicated by H7:]

H8_1 Child # 1

  • 55 Less than 1 year old

  • 1 1 year old

  • 2 2 years old

  • 3 3 years old

  • 4 4 years old

  • 5 5 years old

  • 6 6 years old

  • 7 7 years old

  • 8 8 years old

  • 9 9 years old

  • 10 10 years old

  • 11 11 years old

  • 12 12 years old

  • 13 13 years old

  • 14 14 years old

  • 15 15 years old

  • 16 16 years old

  • 17 17 years old

  • 99 No Answer


H8_2 Child # 2

  • 55 Less than 1 year old

  • 1 1 year old

  • 2 2 years old

  • 3 3 years old

  • 4 4 years old

  • 5 5 years old

  • 6 6 years old

  • 7 7 years old

  • 8 8 years old

  • 9 9 years old

  • 10 10 years old

  • 11 11 years old

  • 12 12 years old

  • 13 13 years old

  • 14 14 years old

  • 15 15 years old

  • 16 16 years old

  • 17 17 years old

  • 99 No Answer


H8_3 Child # 3

  • 55 Less than 1 year old

  • 1 1 year old

  • 2 2 years old

  • 3 3 years old

  • 4 4 years old

  • 5 5 years old

  • 6 6 years old

  • 7 7 years old

  • 8 8 years old

  • 9 9 years old

  • 10 10 years old

  • 11 11 years old

  • 12 12 years old

  • 13 13 years old

  • 14 14 years old

  • 15 15 years old

  • 16 16 years old

  • 17 17 years old

  • 99 No Answer

H8_4 Child # 4

  • 55 Less than 1 year old

  • 1 1 year old

  • 2 2 years old

  • 3 3 years old

  • 4 4 years old

  • 5 5 years old

  • 6 6 years old

  • 7 7 years old

  • 8 8 years old

  • 9 9 years old

  • 10 10 years old

  • 11 11 years old

  • 12 12 years old

  • 13 13 years old

  • 14 14 years old

  • 15 15 years old

  • 16 16 years old

  • 17 17 years old

  • 99 No Answer

H8_5 Child # 5

  • 55 Less than 1 year old

  • 1 1 year old

  • 2 2 years old

  • 3 3 years old

  • 4 4 years old

  • 5 5 years old

  • 6 6 years old

  • 7 7 years old

  • 8 8 years old

  • 9 9 years old

  • 10 10 years old

  • 11 11 years old

  • 12 12 years old

  • 13 13 years old

  • 14 14 years old

  • 15 15 years old

  • 16 16 years old

  • 17 17 years old

  • 99 No Answer


H8_6 Child # 6

  • 55 Less than 1 year old

  • 1 1 year old

  • 2 2 years old

  • 3 3 years old

  • 4 4 years old

  • 5 5 years old

  • 6 6 years old

  • 7 7 years old

  • 8 8 years old

  • 9 9 years old

  • 10 10 years old

  • 11 11 years old

  • 12 12 years old

  • 13 13 years old

  • 14 14 years old

  • 15 15 years old

  • 16 16 years old

  • 17 17 years old

  • 99 No Answer

H8_7 Child # 7

  • 55 Less than 1 year old

  • 1 1 year old

  • 2 2 years old

  • 3 3 years old

  • 4 4 years old

  • 5 5 years old

  • 6 6 years old

  • 7 7 years old

  • 8 8 years old

  • 9 9 years old

  • 10 10 years old

  • 11 11 years old

  • 12 12 years old

  • 13 13 years old

  • 14 14 years old

  • 15 15 years old

  • 16 16 years old

  • 17 17 years old

  • 99 No Answer


H8_8 Child # 8

  • 55 Less than 1 year old

  • 1 1 year old

  • 2 2 years old

  • 3 3 years old

  • 4 4 years old

  • 5 5 years old

  • 6 6 years old

  • 7 7 years old

  • 8 8 years old

  • 9 9 years old

  • 10 10 years old

  • 11 11 years old

  • 12 12 years old

  • 13 13 years old

  • 14 14 years old

  • 15 15 years old

  • 16 16 years old

  • 17 17 years old

  • 99 No Answer


H8_9 Child # 9

  • 55 Less than 1 year old

  • 1 1 year old

  • 2 2 years old

  • 3 3 years old

  • 4 4 years old

  • 5 5 years old

  • 6 6 years old

  • 7 7 years old

  • 8 8 years old

  • 9 9 years old

  • 10 10 years old

  • 11 11 years old

  • 12 12 years old

  • 13 13 years old

  • 14 14 years old

  • 15 15 years old

  • 16 16 years old

  • 17 17 years old

  • 99 No Answer

H8_10 Child # 10

  • 55 Less than 1 year old

  • 1 1 year old

  • 2 2 years old

  • 3 3 years old

  • 4 4 years old

  • 5 5 years old

  • 6 6 years old

  • 7 7 years old

  • 8 8 years old

  • 9 9 years old

  • 10 10 years old

  • 11 11 years old

  • 12 12 years old

  • 13 13 years old

  • 14 14 years old

  • 15 15 years old

  • 16 16 years old

  • 17 17 years old

  • 99 No Answer





Household Finances and Material Hardship

H9. Do you currently receive SNAP/food stamps?

  • 1 Yes

  • 2 No

  • 3 No Answer

H10. Do you currently receive TANF or [state or local public assistance program]?

  • 1 Yes

  • 2 No

  • 3 No Answer

H11. Including your own income, approximately how much was your total household income during the past 12 months before taxes?

[Include all forms of income – earnings (including self-employment), child support, and any public cash assistance – that you or other members of your household received.]

  • 1$0

  • 2$1   -   $4,999

  • 3$5,000   -   $9,999

  • 4$10,000 - $14,999

  • 5$15,000 - $19,999

  • 6$20,000 - $24,999

  • 7$25,000 - $29,999

  • 8$30,000 or higher

  • 9No Answer

H12. In the past 12 months was there ever a time when, because of cost, you or your household was not able to: (Choose all that apply)


A Pay your rent

B Pay your utility bills

C Pay your telephone bill

D Buy food

E Buy prescription drugs

F None of the above

  • G Decline to answer


Primary Language

H13.What is the primary (or main) language that your family speaks at home?

  • 1 English

  • 2 Spanish

  • 3 French

  • 5 Chinese

  • 6 Russian

  • 7Arabic

  • 8 Farsi

  • 9 Armenian

  • 10Vietnamese

  • 11 Other A._____________________

  • 12No Answer Specify


Additional Contact Information [To Be Answered by Head of Household]

Please provide the names and telephone numbers of two family members or friends who will know how to reach you if we have difficulty contacting you.

Contact 1:


H14. NAME


  1. First Name: ______________________________ B. Middle Initial: _____



  1. Last Name: _______________________________



H15. Relationship to you: _____________________________


H16. Street Address


__________________________________________________________ _________

A. Street Address B. Apt. #


_____________________________ _______ ___ ___ ___ ___ ___

C. City D. State E. Zip code


H17. Phone


  1. Home phone: ( ___ ___ ___) ___ ___ ___- ___ ___ ___ ___



  1. Cell phone: ( ___ ___ ___) ___ ___ ___- ___ ___ ___ ___



H18. Email address: _______________________________________









Contact 2:


H19. NAME


  1. First Name: ______________________________ B. Middle Initial: _____



  1. Last Name: _______________________________



H20. Relationship to you: _____________________________



H21. Street Address


__________________________________________________________ _________

A. Street Address B. Apt. #



_____________________________ _______ ___ ___ ___ ___ ___

C. City D. State E. Zip code


H22. Phone


  1. Home phone: ( ___ ___ ___) ___ ___ ___- ___ ___ ___ ___


  1. Cell phone: ( ___ ___ ___) ___ ___ ___- ___ ___ ___ ___



H23. Email address: _______________________________________






FOR INTERVIEWER: PROCEED WITH COMPLETING THE ADULT FORM FOR THIS HOUSEHOLD.



2

OMB Control Number: 2528-0296

Updated: 10/2/2013

HUD FSS Study - SITE

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleFSS_A_4a_BIF_Household
File Modified0000-00-00
File Created2021-01-23

© 2024 OMB.report | Privacy Policy