Baseline Information Form

Form Approved

OMB Control No. 1290-XXXX

Expiration Date X/XX/2020

Cascades Job Corps College and Career Academy Research Study

Baseline Information Form

Dear Participant,

Welcome! This form gathers information about you and your family. Your answers to these questions will not affect your chances of getting into the Cascades Job Corps College and Career Academy. The information will be used for research purposes only and will be kept private to the extent allowed by law.

Thank you very much for helping us with this important study.

Notes for OMB Review: Text in italics is instructions for participants. Yellow text boxes indicate sources for questions. Study participants will not see these yellow boxes. They will be visible only to instrument reviewers.

The main item sources are:

• The Baseline Information Form for the National Guard Youth Challenge Job Challenge Evaluation, conducted by Mathematica Policy Research for the Department of Labor (DOL) (OMB No. 1291-0008).

• The Baseline Information Form for the Ready to Work (RTW) Evaluation, conducted by Abt Associates for DOL (OMB No. 1205-0507).

• The Baseline Survey for the National Evaluation of Youth Corps, developed by Abt Associates for CNCS (OMB No. 3045-0119).

• The Baseline Contact Form and Baseline Survey for the Successful Transitions to Adulthood Research Study (STARS), conducted by Abt Associates for the U.S. Department of Health and Human Services (HHS) (OMB No. 0970-0383).

• The Intake Form for the Evaluation and System Design for Career Pathways Programs: 2nd Generation of HPOG (HPOG Next Gen Design), conducted by Abt Associates for HHS (OMB No. 0970-0462).

• The Baseline Data Sheet for the National Impact Study of the National Guard Youth ChalleNGe Programs, conducted by MDRC (1291-0008)).

• New questions are identified as such.

An asterisk (*) denotes the set of questions that we anticipate will be auto-filled into the Participant Data System from data collected in the Job Corps Management Information System (MIS). For that reason, the burden estimate in Statement A assumes that participants will not fill out these 12 questions as part of the Baseline Information Form.

1. Your Contact Information

Source: Unless otherwise noted, all questions in Section A (“Your Contact Information”) come from the National Guard Youth Challenge Job Challenge Baseline Information Form.

Please provide your:

A1. Name:

FIRST NAME

MIDDLE NAME

LAST NAME

A2. Nickname: _______________________________

0  None

A3. Date of birth: | | | / | | | / | | | | |

MONTH DAY YEAR

A4. Social Security Number:

| | | | - | | | - | | | | |

A5. Cell phone number:

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

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

Source for A6: Adapted from the RTW Baseline Information Form.

A6. May we send automated text messages to your cell phone?

The research team will need to contact you in about 18 months to complete another survey. We will stay in touch every few months between now and then to make sure we have your most recent contact information. If you agree to be contacted by text message, please keep in mind that your cell phone carrier may charge you a fee to receive or send text messages. Whether or not you get charged a fee depends on your plan.

1  Yes

0  No

[If A6= ‘Yes’ ask A6a, else go to A7]

Source for A6a: New question.

A6a. Do you have a “smart phone” (a phone with internet and email access)?

1  Yes

0  No

97 I don’t know

A7. What is the email address you use most often? ____________________________

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

Source for A8: Adapted from the RTW Baseline Information Form.

A8. May we contact you through Facebook, Twitter, Instagram, or other social networks?

1  Yes

0  No

[If A8= ‘Yes’ ask A8a, else go to B1]

Source for A8a: Adapted from the National Guard Youth Challenge Job Challenge Baseline Information Form.

A8a. What is your username for each network?

1 Facebook:

Name:

2 Twitter:

Tag:

3 Instagram:

Name:

4 Other (Specify): ____________________

Name:

2. Future Contact

We want to be sure we can reach you when it is time to complete the 18 month follow-up survey, so we will stay in touch every few months between now and then to make sure we have your most recent contact information. In case we have trouble reaching you, we ask you to give us contact information for people who will always know where you are and how to reach you. We will NOT discuss or share any of your personal information or survey answers with anyone you list as a contact. Your personal information and answers are private.

Source for B1, B2: Adapted from the RTW Baseline Information Form.

B1. Please provide contact information for your mother or female guardian.

Please answer this question for your female guardian (for example, your grandmother), if your mother was not the main person who you grew up with. If your mother or female guardian is no longer living or not a part of your life, please provide contact information for your father or a male guardian.

NAME

RELATIONSHIP TO YOU

STREET APT.

CITY STATE ZIP

Cell Phone: (| | | |)-| | | |-| | | | |

Home Phone: (| | | |)-| | | |-| | | | |

Email Address:

B2. Please provide contact information for one of your grandmothers, or another older relative that you are especially close to.

Please list a family member that you think is likely to still be alive and at this address in 18 months.

NAME

RELATIONSHIP TO YOU

STREET APT.

CITY STATE ZIP

Cell Phone: (| | | |)-| | | |-| | | | |

Home Phone: (| | | |)-| | | |-| | | | |

Email Address:

Source for B3: Adapted from the STARS Baseline Contact Form.

B3. Please provide the name and contact information for another trusted friend or family member.

Please list someone who will always know where you are and how to reach you in the future.

NAME

RELATIONSHIP TO YOU

STREET APT.

CITY STATE ZIP

Cell/Mobile: (| | | |)-| | | |-| | | | |

Home: (| | | |)-| | | |-| | | | |

Email Address:

3. Background

Source for C1: RTW Baseline Information Form.

C1. Are you male or female?

1  Male

2  Female

Source for C2: Adapted from the RTW Baseline Information Form. Question was modified to make it readable at the 8th grade level.

*C2. Are you Spanish, Hispanic, or Latino?

1  Yes

0  No

Source for C3: National Guard Youth Challenge Job Challenge Baseline Information Form.

*C3. What is your race?

MARK ALL THAT APPLY

1  White

2  Black or African American

3  Asian

4  Hawaiian Native of other Pacific Islander

5  American Indian or Alaskan

Source for C4: National Guard Youth Challenge Job Challenge Baseline Information Form.

*C4. Are you married?

1  Yes

0  No

Source for C5: Adapted from the National Evaluation of Youth Corps Baseline Survey. Question was modified to make them readable at the 8^th grade level.

*C5. How many dependent children do you have?

Enter 0 for no children.

_____________ # of children

Source for C6: STARS Baseline Contact Form.

*C6. Where were you born?

___________________ ________________ ________________

City State Country

Source for C7: Adapted from RTW Baseline Information Form.

C7. Did you speak a language other than English at home when you were growing up?

1  Yes

0  No

Source for C8, C9: Adapted from the National Evaluation of Youth Corps Baseline Survey. Questions were modified to make them readable at the 8^th grade level.

C8. What is the highest level of education your mother/female guardian completed?

MARK ONLY ONE

Please answer this question for your female guardian (for example, your grandmother), if your mother was not the main person who you grew up with.

1  Did not complete high school (no diploma or GED)

2  High school graduate

3  GED

4  Technical/trade school

5  Some college classes, but no degree

6  Associate’s degree (AA)

7  Bachelor’s degree or higher

97  I don’t know

0  No mother/female guardian

C9. What is the highest level of education your father/male guardian completed?

MARK ONLY ONE

1  Did not complete high school (no diploma or GED)

2  High school graduate

3  GED

4  Technical/trade school

5  Some college classes, but no degree

6  Associate’s degree (AA)

7  Bachelor’s degree or higher

97  I don’t know

0  No father/male guardian

Source for C10, C11: Adapted from the STARS Evaluation Baseline Survey. Question was modified to make it readable at the 8^th grade level.

C10. Is your mother (or female guardian) currently working at a job for pay?

This does not include odd jobs, illegal or “off-the-books” work, or work where she does not get paid.

1  Yes

0  No

97  I don’t know

C11. Is your father (or male guardian) currently working at a job for pay?

This does not include odd jobs, illegal or “off-the-books” work, or work where he does not get paid.

1  Yes

0  No

97  I don’t know

Source for C12, C13: Adapted from the RTW Baseline Information Form.

C12. Are you (or your family if you live with them) currently receiving food stamps (also called Supplemental Nutrition and Assistance Program, or SNAP)?

1  Yes

0  No

97  I don’t know

C13. Have you or your family ever received welfare or cash assistance (also called Temporary Assistance for Needy Families, or TANF)?

1  Yes

0  No

97  I don’t know

Source for C14, C15: Adapted from the National Guard Youth Challenge Job Challenge Baseline Information Form.

C14. Have you ever been arrested?

1  Yes

0  No

*C15. Have you ever been convicted of a crime?

1  Yes

0  No

Source for C16: Adapted from the National Guard Youth Challenge Job Challenge Baseline Information Form. Question was modified to make it readable at the 8^th grade level.

C16. Which of the following best describes where you lived just before you applied to Job Corps?

MARK ONLY ONE

1  Living with your family (for example, a parent or grandparent)

2  Own/rent apartment, room, house

3  Permanently living at someone’s apartment, room, or house

4  Temporarily staying at someone’s apartment, room, or house

5  Staying with foster guardian/in foster system

6  In a halfway house/transitional house

7  In a residential treatment center

8  Homeless

9  Living in a college dormitory/on-campus housing

10  Living in military housing/barracks

4. Employment and Education

Source for D1: Adapted from the National Evaluation of Youth Corps Baseline Survey. Question was modified to make it readable at the 8^th grade level.

D1. How have you been spending most of your time in the last 12 months?

MARK ALL THAT APPLY

1  Working full-time (35 or more hours per week)

2  Working part-time (less than 35 hours per week)

3  Going to high school

4  Going to technical/trade school

5  Working on a GED/Alternative school

6  Going to college

7  Looking for a job

8  Taking care of my children / parent / siblings at home

9  Serving in the military / reserves

99  Other (Specify:)________________________________

Source for D2: Adapted from RTW Baseline Information Form.

*D2. Are you currently employed?

1  Yes

0  No

Source for D3: Adapted from the National Evaluation of Youth Corps Baseline Survey. Question was modified to make it readable at the 8^th grade level.

*D3. Have you ever been employed full-time (where you worked 35+ hours per week)?

1  Yes

0  No

Source for D4: Adapted from RTW Baseline Information Form.

*D4. How much do you earn per hour at your current or most recent job?

Enter 0 if you have never worked for pay.

________ dollars per hour

Source for D5: Adapted from the National Impact Study of the National Guard Youth ChalleNGe Programs Baseline Data Sheet.

*D5. Do you have a high school diploma, a GED, or a high school equivalent?

1  Yes

0  No

Source for D6: Adapted from National Guard Youth Challenge Job Challenge Baseline Information Form.

*D6. What is the last grade you completed in school?

MARK ONLY ONE

1  6^th or below

2  7^th

3  8^th

4  9^th

5  10^th

6  11^th

7  12^th

8  Some college or vocational school, no degree

9  Vocational degree or higher

Source for D7: New Question.

*D7. How many months have you been out of school?

Enter 0 if you are currently enrolled in school.

________ # of Months

Source for D8: Adapted from the National Guard Youth Challenge Job Challenge Baseline Information Form.

D8. Have you ever had an Individualized Education Program (IEP) or a “504 plan”?

1  Yes

0  No

Source for D9: National Guard Youth Challenge Job Challenge Baseline Information Form.

D9. Were you ever suspended from school?

1  Yes

0  No

Source for D10: STARS Evaluation Baseline Survey.

D10. Have you ever repeated a grade or been held back?

1  Yes

0  No

5. Your Views and Goals

Source for E1: Adapted from the Baseline Data Sheet for the National Impact Study of the National Guard Youth Challenge Programs.

E1. Who suggested Job Corps to you?

1  I decided myself

2  A relative

3  A school counselor or truant officer

4  A judge/someone from the justice system

99  Someone else (specify): ______________________

Source for E2: Adapted from the National Evaluation of Youth Corps Baseline Survey.

E2. What are the two most important reasons you decided to apply to Job Corps?

MARK ONLY TWO

1  I want to get my GED/ high school diploma

2  I want to join the military

3  I want to go to college/get more training

4  I want to get my life on track

5  I want to get a job

99  Other (specify): ______________________

Source for E3: Adapted from RTW Baseline Information Form. Question modified to make it readable at the 8^th grade level.

E3. What is the highest level of school you expect to complete at some point in your life?

MARK ONLY ONE

If you are not sure, please pick your best guess.

1  I do not plan to complete high school (no diploma or GED)

2  High school graduate

3  GED

4  Technical/trade school

5  Some college classes, but no degree

6  Associate’s degree (AA)

7  Bachelor’s degree or higher

97  I don’t know

Source for E4: New question.

E4. How much are you interested in a career in…

	Not at all (1)	Somewhat (2)	Extremely (3)
Advanced Machining
Automotive and Machine Repair
Construction
Finance and Business Services
Healthcare
Hospitality
Information Technology (IT) Services
Renewable Resources and Energy
Retail Sales and Services
Security Services
Transportation

Source for E5: Self-efficacy scale adapted from the Intake Form for the Evaluation and System Design for Career Pathways Programs: 2nd Generation of HPOG (HPOG Next Gen Design). Question modified to make it readable at the 8^th grade level.

E5. In general, some people have an easier or harder time with problems or difficulties. How true do you think are the following statements?

	Not at all true (1)	Somewhat true (2)	Mostly true (3)	Entirely true (4)
I can always manage to solve difficult problems if I try hard enough.
It is easy for me to stick to my aims and accomplish my goals.
I am confident that I can deal well with unexpected events.
Thanks to my wits, I know how to handle unexpected situations.
I can solve most problems if I invest the necessary effort.
I can remain calm when facing problems because I can rely on my ability to cope.
When I am faced with a problem, I can usually find several solutions.
If I am in trouble, I can usually think of a solution.
I can usually handle whatever comes my way.

Source for E6: Future orientation scale adapted from the Baseline Data Sheet for the National Impact Study of the National Guard Youth Challenge Programs.

E6. To what extent do you agree or disagree with each of these statements?

	Strongly Disagree (1)	Disagree (2)	Mostly Disagree (3)	Mostly Agree (4)	Agree (5)	Strongly Agree (6)
My goals in life are becoming clearer.
I have a pretty good sense of the path I want to take in life and the steps to take to get there.
I have a clear sense of my beliefs and values.
I can envision the kind of person I’d like to become.
I feel my life is filled with meaning, a sense of purpose.

Source for E7: Reaction to challenge scale taken from: Connell, James, Jean Baldwin Grossman and Nancy Resch, The Urban Corps Assessment Package (URCAP) Manual,  Philadelphia PA:  Public/Private Ventures Technical Report September 1995. Eric no. ED391868.

E7. When something bad happens to me in the real world (like having problems in class or at work)…

	Not at all true (1)	Not very true (2)	Sort of true (3)	Very true (4)
I tell myself I’ll do better next time.
I try to figure out what I did wrong so that it won’t happen again.
I try to see what I did wrong.
I try to make sure I do it right next time.
It probably was someone else’s fault.
I get angry at the teacher or boss.
The teacher or boss probably did not explain it well enough.
I say it wasn’t important.
I ignore it.
I tell myself it didn’t matter.

Source for E8: National Guard Youth Challenge Job Challenge Baseline Information Form.

E8. How would you rate your overall health?

MARK ONLY ONE

1  Very good

2  Good

3  Fair

4  Poor

5  Very poor

Abt Associates IRB Approval No. XXXX

Public Burden Statement. Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number.  Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reading instructions, and completing and reviewing the requested information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the [Contact Name; Contact Address] (Paperwork Reduction Project Control No. 1290-xxxx).

Abt Associates  ▌pg. 24