XX-XXXX Baseline Information Form-Head of Household

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: _______________________________________________________________ _________ Street Address B. Apt. # _________________________ _______ ___ ___ ___ ___ ___ 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 First Name: ______________________________ B. Middle Initial: _____ Last Name: _______________________________ H15. Relationship to you: _____________________________ H16. Street Address __________________________________________________________ _________ A. Street Address B. Apt. # _____________________________ _______ ___ ___ ___ ___ ___ C. City D. State E. Zip code H17. Phone Home phone: ( ___ ___ ___) ___ ___ ___- ___ ___ ___ ___ Cell phone: ( ___ ___ ___) ___ ___ ___- ___ ___ ___ ___ H18. Email address: _______________________________________
Contact 2: H19. NAME First Name: ______________________________ B. Middle Initial: _____ Last Name: _______________________________ H20. Relationship to you: _____________________________ H21. Street Address __________________________________________________________ _________ A. Street Address B. Apt. # _____________________________ _______ ___ ___ ___ ___ ___ C. City D. State E. Zip code H22. Phone Home phone: ( ___ ___ ___) ___ ___ ___- ___ ___ ___ ___ 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