Baseline Information Form

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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.  

A. Your Contact Information 

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.


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] 

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.



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] 

A8a. 	What is your username for each network? 
	1  Facebook:
			Name:	
	2  Twitter:
			Tag: 			
	3  Instagram:
			Name:	
	4  Other (Specify): ____________________
			Name:	
B. 	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.


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:		



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:		
C. Background 

C1.		Are you male or female?
	1		Male
	2		Female

*C2.	Are you Spanish, Hispanic, or Latino?
	1		Yes
	0		No

*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


*C4.	Are you married? 
	1		Yes
	0		No

*C5.	How many dependent children do you have? 
	Enter 0 for no children. 

	_____________ # of children 


*C6. 	Where were you born?
	___________________  ________________  ________________
	               City 			    State			Country 


C7.		Did you speak a language other than English at home when you were growing up?
	1		Yes
	0		No

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

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


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


C14. 	Have you ever been arrested? 
	1		Yes
	0		No



*C15. 	Have you ever been convicted of a crime? 
	1		Yes
	0		No


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
D. Employment and Education 


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:)________________________________


*D2. 	Are you currently employed? 
	1		Yes
	0		No


*D3. 	Have you ever been employed full-time (where you worked 35+ hours per week)? 
 	1		Yes
	0		No


*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 



*D5. 	Do you have a high school diploma, a GED, or a high school equivalent? 
	1		Yes
	0		No


*D6. 	What is the last grade you completed in school? 
	MARK ONLY ONE
	1		6th or below
	2		7th 
	3		8th 
	4		9th 
	5		10th 
	6		11th 
	7		12th 
8		Some college or vocational school, no degree
	9		Vocational degree or higher 
  
 
*D7. 	How many months have you been out of school? 
	Enter 0 if you are currently enrolled in school. 

	________ # of Months 


D8. 	Have you ever had an Individualized Education Program (IEP) or a “504 plan”? 
	1		Yes
	0		No



D9. 		Were you ever suspended from school?
	1		Yes
	0		No


D10. 	Have you ever repeated a grade or been held back? 
	1		Yes
	0		No
E. Your Views and Goals


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): ______________________


		
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): ______________________



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


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


Not at all
(1)
Somewhat
(2)
Extremely
(3)
    a. Advanced Machining



    b. Automotive and Machine Repair



    c. Construction



    d. Finance and Business Services



    e. Healthcare



    f. Hospitality



    g. Information Technology (IT) Services



    h. Renewable Resources and Energy



    i. Retail Sales and Services



    j. Security Services



    k. Transportation





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)
    a. I can always manage to solve difficult problems if I try hard enough.




    b. It is easy for me to stick to my aims and accomplish my goals.




    c. I am confident that I can deal well with unexpected events.




    d. Thanks to my wits, I know how to handle unexpected situations.




    e. I can solve most problems if I invest the necessary effort.




    f. I can remain calm when facing problems because I can rely on my ability to cope.




    g. When I am faced with a problem, I can usually find several solutions.




    h. If I am in trouble, I can usually think of a solution.




    i. I can usually handle whatever comes my way.






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)
    a. My goals in life are becoming clearer.






    b. I have a pretty good sense of the path I want to take in life and the steps to take to get there.






    c. I have a clear sense of my beliefs and values.






    d. I can envision the kind of person I’d like to become.






    e. I feel my life is filled with meaning, a sense of purpose.










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)
    a. I tell myself I’ll do better next time.




    b. I try to figure out what I did wrong so that it won’t happen again.




    c. I try to see what I did wrong.




    d. I try to make sure I do it right next time.




    e. It probably was someone else’s fault.




    f. I get angry at the teacher or boss.




    g. The teacher or boss probably did not explain it well enough.




    h. I say it wasn’t important.




    i. I ignore it.




    j. I tell myself it didn’t matter.






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).