Baseline Informati XX-XXXX

OMB Control Number: 2528-0296

Expiring: XX-XX-XXXX

HUD FAMILY SELF-SUFFICIENCY EVALUATION

ADULT FORM

FOR INTERVIEWER: Please complete an Adult Form for the head of household only after completing the Household Form with the head of household.

Household and Person Identifiers

A1. HA Entity ID/ Household Identification Number [Length will vary by HA]

___ ___ ___ ___ ___ ___ ___ ___ ___

A2. HA Member Number: ___ ___ [Head of Household should be “01”]

A3. Name

1. First Name: ______________________________

2. Middle Name: ____________________________

3. Last Name: _______________________________

A4. Social Security Number:

___ ___ ___ - ___ ___ - ___ ___ ___ ___

A5. Date of Birth:

_____ /___ ___ /___ ___ ___ ___

MM DD YYYY

A6. What is your relationship to the Section 8 head of household?

• ₁ I am the head of household

• ₂ I am the head of household’s spouse/legal domestic partner

• ₃ I am the head of household’s child

• ₄ I am the head of household’s parent

• ₅ I am an extended relative of the head of household

• ₆ I am not related to the head of household

A7. Informed Consent Form signed?

• ₁ Yes

• ₂ No

Baseline Information Form Questions

A8. Gender:

• ₁ Male

• ₂ Female

• ₃ No Answer

A9. What is your marital status?

• ₁ Married, living with spouse

• ₂ Living with a partner

• ₃ Single

• ₄ Separated

• ₅ Divorced

• ₆ Widow/Widower

• ₇ No Answer

A10. Do you consider yourself to be Spanish, Hispanic, or Latino?

• ₁ Yes

• ₂ No

• ₃No answer

A11. Do you consider yourself to be:

Check all that apply:

• _A White

• _B Black or African American

• _C American Indian or Alaska Native

• _D Asian

• _E Hawaiian Native/other Pacific Islander

• _F Decline to Answer

A12. What is your citizenship status?

• ₁ I am a U.S. citizen by birth [Go to A14]

• ₂ I am a U.S. citizen by naturalization [Go to A13]

• ₃ I am a legal permanent resident [Go to A13]

• ₄ I have refugee or asylee status [Go to A13]

• ₅ No answer [Go to A14]

A13. How long have you lived in the U.S.?

• ₁ Less than 5 years

• ₂ 5 to 9.99 years

• ₃ 10 to 19.99 years

• ₄ 20 years or longer

• ₅ No Answer

Educational Attainment

A14. What is the highest level of education that you have completed?

• ₁ Grade 9 or less

• ₂ Grade 10 or grade 11

• ₃ Attended grade 12 but did not receive high school diploma or GED certificate

• ₄GED certificate

• ₅High school diploma

• ₆Some college

• ₇Associate’s or two-year degree

• ₈Four-year college degree or higher

• ₉No Answer

A15. Are you currently taking college courses for credit?

• ₁ Yes

• ₂ No

• ₃ No Answer

A16. Do you have any type of trade license or training certificate? For example: A Commercial Driver’s License (CDL), Certified Nursing Assistant (CNA), or some other kind of certificate?

• ₁ Yes

• ₂ No

• ₃ No Answer

A17. Are you currently taking any training courses or education classes to improve your skills, help you do a job, or find employment? Please include things like computer training, basic skills and any courses or classes to help you with a specific job?

• ₁ Yes

• ₂ No

• ₃ No Answer

Employment Status

A18. Are you currently working for pay or self- employed?

• ₁ Yes [Go to A19]

• ₂ No [Go to A23]

• ₃ No Answer [Go to A23]

A19. Which situation best describes your current employment?

• ₁ I work for pay at a regular job

• ₂ I am self-employed

• ₃ I work at a temporary or seasonal job

• ₄ No Answer

A20. How many jobs do you currently have?

• ₁ 1

• ₂ 2

• ₃ 3

• ₄ 4 or more

• ₅ No Answer

A21. Counting all of your current jobs or businesses, how many hours do you typically work per week?

_______ Hours

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

A.

• ₁ 1-20 hours

• ₂ 21-34 hours

• ₃ 35-48 hours

• ₄ 49 or more hours

• ₅ No Answer

A22. Counting all of your current jobs or businesses, how much do you earn before taxes?

A. Pay:	B. Per:
$ _________. ______	1Hour
A.1 No Answer	2 Day	______ A.Number of days per week of work
	3Week 4Every two weeks 5Twice per month 6Month 7Year 8 Other A.________________________ Specify 9 No Answer

A23. In the past 12 months, about how many months have you worked for pay or earned money from self-employment? Count any month in which you worked at least one day part-time or full-time.

• ₅₅ Did not work at any time

• ₁ 1 Month

• ₂ 2 Months

• ₃ 3 Months

• ₄ 4 Months

• ₅ 5 Months

• ₆ 6 Months

• ₇ 7 Months

• ₈ 8 Months

• ₉ 9 Months

• ₁₀ 10 Months

• ₁₁ 11 Months

• ₁₂ 12 Months

• ₁₃ No Answer

A24. Could you use public transportation (such as a bus, train, subway, or light-rail) to get to work, if necessary?

• ₁ Yes

• ₂ No

• ₃ No Answer

A25. Do you have or could you borrow a car, van, or truck, or get a ride to get to work, if necessary?

• ₁ Yes

• ₂ No

• ₃ No Answer

Health and Health Insurance

A26. What kind of health insurance are you currently AND primarily covered by?

• ₁By public health insurance (ex.: Medicaid, Medicare, VA, Tri-Care, or a state or local program)

• ₂ By employer-provided health insurance through either my work or my spouse’s work

• ₃Other health insurance

• ₄I am not covered by health insurance

• ₅No Answer

A27. Do you currently receive SSI or SSDI?

• ₁ Yes

• ₂ No

• ₃ No Answer

Personal Finances

A28. Do you currently have a savings or checking account at a bank or a credit union?

• ₁ Yes

• ₂ No

• ₃ No Answer

A29. How much money do you currently have saved? This includes money at home; in a savings, checking, credit union, or money market account; and certificates of deposit. Do not include pension funds or retirement accounts.

• ₁$0

• ₂$1- $500

• ₃$501-$1,000

• ₄$1,001-$3,000

• ₅$3,001-$5,000

• ₆$5,001-$10,000

• ₇$10,001-$20,000

• ₈More than $20,000

• ₉No Answer

A30. When you think about all your loans including, for example, money borrowed from friends or family, car loans, credit card debt, and student loans, what is the total amount you owe?

• ₁$0

• ₂$1- $500

• ₃$501-$1,000

• ₄$1,001-$3,000

• ₅$3,001-$5,000

• ₆$5,001-$10,000

• ₇$10,001-$20,000

• ₈More than $20,000

• ₉No Answer

Barriers to Employment

A31. Do you have a physical health problem that limits the kind or amount of work that you can do?

• ₁ Yes

• ₂ No

• ₃ No Answer

A32. Do you have an emotional or mental health problem that limits the kind or amount of work that you can do?

• ₁ Yes

• ₂ No

• ₃ No Answer

A33. Does difficulty finding adequate childcare or after school supervision limit the kind or amount of work that you can do?

• ₁ Yes

• ₂ No

• ₃ No Answer

A34. Does the need to care for a sick or disabled family member limit the kind or amount of work that you can do?

• ₁ Yes

• ₂ No

• ₃ No Answer

A35. Have you ever been convicted of a felony?

• ₁ Yes

• ₂ No

• ₃ No Answer

A36. In the past 12 months, have you not taken a job or worked more hours because the extra money you would earn might cause you to lose some or all of the benefits you receive, such as Medicaid, food stamps/SNAP, or TANF?

• ₁ Yes

• ₂ No

• ₃ No Answer

A37. In the past 12 months, have you not taken a job or worked more hours because the extra money you would earn might cause you to pay higher rent or lose your Section 8 voucher?

• ₁ Yes

• ₂ No

• ₃ No Answer

Motivations and Program Understanding

A38. Why are you interested in the FSS program? Please read the following list of possible reasons (Check all that apply).

• _A Help finding work

• _B Help finding a better job

• _C Help keeping your job

• _D Help with dealing with personal issues or family issues that make having a job difficult

• _E Help with accessing services to help your family such as daycare

• _F Help building savings

• _G Help managing your money, debt relief or improving your credit score

• _H Help buying a home

• _I Some other reason _{1._________________________________________}

Specify

• _J None of the above

• _K Declined to answer

A39. Before participating in the orientation meeting had you ever heard of the FSS escrow?

(IF EXPLANATION IS REQUESTED: As discussed at the orientation meeting, the FSS escrow account is a long-term savings account that [local PHA name] opens up for you when an increase in your income due to wages causes your rent to go up. You can get the money in your escrow account once you have successfully completed your Contract of Participation.)

• ₁ Yes

• ₂ No

• ₃ No Answer

Adult Contact Information

A40. Phone Numbers

A.Home phone number:

(___ ___ ___) ___ ___ ___- ___ ___ ___ ___

B. Mobile phone number:

(___ ___ ___) ___ ___ ___- ___ ___ ___ ___

C. Work phone number:

(___ ___ ___) ___ ___ ___- ___ ___ ___ ___

A41. Email address:

_________________________________________________

FOR INTERVIEWER:

A42. How well does the customer speak English?

• ₁ Very well

• ₂ Well

• ₃ Not very well

• ₄ Not at all

• ₅No Answer

If another adult member of this household is enrolling in the HUD Family Self-Sufficiency Evaluation at this time, complete an additional Adult Form with the adult.

GROUP: FSS Group

Control Group

(To be completed after following instructions for back-up random assignment. Circle the group that the MDRC Data Clerk tells you the household has been assigned to.)

4

OMB Control Number: 2528-0296

Updated: 10/2/2013

HUD FSS Study - SITE