Form 1 Young Adult Baseline Survey
Evaluation of the Transition Living Program
Attachment_A_Young Adult Baseline Survey 2015
Young Adult Baseline Survey
OMB: 0970-0383
TLP Young Adult Baseline Survey
TLP YOUNG ADULT BASELINE SURVEY
STARS [insert logo]
Young Adult Baseline Survey
Programming Notes
Display “back” “next” “or " buttons and on each screen.
Display a reminder not to use the forward and back buttons in the internet browser but to use the survey forward and back buttons.
Display a progress bar on each screen.
Time out after 7 minutes of inactivity. Display a one- minute timeout warning enabling user to extent time out period another 7 minutes.
Unless otherwise specified (by “select all that apply”), only one answer is permitted per item.
Participants may skip any item.
For each question, if a response/answer is not provided, after respondent clicks “continue,” the following pop-up warning should appear confirming that they want to skip. It should read: “Oops - we didn’t get an answer to one or more of the last questions. Are you sure you want to move forward?” and provide two options: “Yes - next question” and “No - go back to last question.”
Code a legitimate (planned) skip as -101
Item-specific programming notes appear in Blue Font throughout the survey.
Notations regarding the construct being measured and/or its source are shown in Red Font. These must NOT be displayed on the programmed survey.
Section headings (in black font) may be displayed if desired.
Welcome
WELCOME TO THE STARS SURVEY!
[insert study logo]
You are part of an important study called STARS (Successful Transitions to Adulthood Research Study).
What’s the study about?
The study is learning about how communities can help young adults like you develop the skills they need to build strong futures,
What will happen?
When you joined STARS, you were asked to take part in several surveys over 12 months. This is the first one. You will get a [$xx] electronic gift card to Amazon.com for completing it.
The questions in this survey take about 30 minutes to answer. You will be asked about the places you’ve stayed, your experiences, thoughts and feelings. You may skip questions or stop answering questions at any time.
What happens to my answers?
Only the research team will be able to see your answers. Your name will not be attached to your answers. Your answers will be combined and reported with the answers of over 1,200 other young adults.
Who should I contact if I have any questions about the study?
If you have any questions about STARS, you can call the people who are doing the study at (XXX) XXX-XXXX. This is a free call.
Continue
The Paperwork Reduction Act Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is xxxx-xxxx, and it expires xx/xx/xxxx. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to [Contact Name]; [Contact Address]; Attn: OMB-PRA (xxxx-xxxx).
Gift Card Information
First, we want to make sure we know where to send your electronic gift card after you complete this survey.
Gift1. After you finish and submit your survey, we will email or text you an electronic gift card to Amazon.com. How would you like us to send you the gift card?
(Select only one answer)
Email it to me [ ] 01
Text it to my cell phone [ ] 02
I do not have an email address or cell phone you can send it to [ ] 00
[If Gift1 = 0, ask Gift3.]
[If Gift1 = 1 or 2, ask Gift2]
Gift2. Please confirm where to send your electronic gift card
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Yes (01) |
No (00) |
[if Gift1 = 1 present:
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[if Gift1 = 2 present:
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[If Gift2a or Gift2b = 0, ask Gift2c, else skip to Section A]
Gift2c. If not, please tell us how to send you your electronic gift card:
(Select only one answer)
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Enter the [email address/ cell phone number] we should use here: |
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Email it to me at: |
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Text it to my cell phone: |
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Gift3. Earlier you told us that you do not have an email address or a cell phone where we can text your electronic gift card. We can mail it to you instead.
Gift3a. Is the address below where we should send it?
[Insert contact info from sample file. If no address info in sample file, skip to Gift3b]
Street Address
City ____________________ State ________ Zip Code
Yes [ ] 01
No [ ] 00
[If Gift3a =0, allow R to correct contact info Change Information : Continue
Gift3b. Please tell us where to mail your electronic gift card:
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Street Address |
_______________________________ |
City |
_______________________________ |
State |
_______________________________ |
Zip Code |
_______________________________ |
[Ensure that address is complete and in valid format]
NOTE: This is to be presented in the study web portal as part of the staff-administered enrollment process….the information should be captured separate from and prior to the baseline survey
NOTES TO PROGRAMMERS:
Item-specific programming notes appear in ALL CAPS BLUE FONT throughout the survey. General programming notes: Participants should be allowed to skip any item they choose. However, we need to have an email or cell phone for follow up survey invitations. |
Your Contact Information
Thank you for being part of our study! In order to contact you about surveys and send you reminders about the study, we need your contact information. We will only use this information for the study and we will NOT discuss or share any of your information with anyone outside of the study team. |
CI_1. What is your full legal name?
(a) First: [ALPHA ONLY]
(b) Middle: [ALPHA ONLY]
(c) Last: [ALPHA ONLY]
[USE FIRST AND LAST NAMES FOR DUPLICATE CHECKING]
CI_2. What is your birthdate?
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Month
Day
Year
[USE FOR DUPLICATE CHECKING]
CI_3. Where were you born?
-
City
State
Country
[USE FOR DUPLICATE CHECKING]
CI_4. What is your….?
Mailing address
(a) Street Number: [ALPHA NUMERIC]
(b) Street Name: [ALPHA ONLY]
(c) Apartment/Unit Number: [ALPHA NUMERIC]
(d) City: [ALPHA ONLY]
(e) State: [PROVIDE DROP-DOWN MENU]
(f) Zip Code: [NUMERIC ONLY]
[IF PROVIDED, ENSURE MAILING ADDRESS IS COMPLETE]
(g) Cell Phone Number: -- [NUMERIC ONLY]
(h) Other Phone Number: -- [NUMERIC ONLY]
(i) Email Address: [ALPHA NUMERIC + .COM, .NET, .EDU, ETC]
[IF CI_1G (CELL) IS PROVIDED ASK CI_5, ELSE GO TO CI_6]
CI_5a. Is it OK for the STARS research team to text your cell phone about the study?
(Please keep in mind that your cell phone carrier may charge a fee to receive or send text messages, depending on your plan.)
Yes 01
No 00
CI_5b. Is it OK for the STARS research team to leave a message on your cell phone about the study?
Yes 01
No 00
[IF CI_1H (OTHER PHONE) IS PROVIDED ASK CI_6, ELSE GO TO CI_7]
CI_6. Is it OK for the STARS research team to leave a message on your other phone about the study?
Yes 01
No 00
[IF CI_1I (EMAIL) IS PROVIDED ASK CI_7, ELSE GO TO CI_8]
CI_7. Is it OK for the STARS research team to email you about the study?
Yes 01
No 00
[IF CI_4A-F (MAILING ADDRESS) IS PROVIDED ASK CI_8, ELSE GO TO CI_9]
CI_8. Is it OK for the STARS research team to contact you at your mailing address about the study?
Yes 01
No 00
Alternate Contact Information
You are important to the study! We want to be sure we can reach you about future surveys. In case we have trouble reaching you, we ask you to give us contact information for two 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 confidential. |
CI_9. Could you provide the name and contact information for a trusted friend, family member, or other person? Someone who will always know where you are and how to reach you in the future in case we have difficulty.
(a) First Name: [ALPHA ONLY]
(b) Last Name: [ALPHA ONLY]
(c) Relationship to you: [ALPHA NUMERIC]
(d) Phone Number: -- [NUMERIC ONLY]
(e) Email Address: [ALPHA NUMERIC + .COM, .NET, .EDU, ETC]
Mailing Address:
(f) Street Number: [ALPHA NUMERIC]
(g) Street Name: [ALPHA ONLY]
(h) Apartment/Unit Number: [ALPHA NUMERIC]
(i) City: [ALPHA ONLY]
(j) State: [PROVIDE DROP-DOWN MENU]
(k) Zip Code: [NUMERIC ONLY]
(l) Contact notes: [OPEN TEXT FIELD TO INSERT OTHER RELEVANT INFO]
CI_10. Could you provide the name and contact information for another trusted friend, family member, or other person? Someone who will always know where you are and how to reach you in the future in case we have difficulty.
(a) First Name: [ALPHA ONLY]
(b) Last Name: [ALPHA ONLY]
(c) Relationship to you: [ALPHA NUMERIC]
(d) Phone Number: -- [NUMERIC ONLY]
(e) Email Address: [ALPHA NUMERIC + .COM, .NET, .EDU, ETC]
Mailing Address:
(f) Street Number: [ALPHA NUMERIC]
(g) Street Name: [ALPHA ONLY]
(h) Apartment/Unit Number: [ALPHA NUMERIC]
(i) City: [ALPHA ONLY]
(j) State: [PROVIDE DROP-DOWN MENU]
(k) Zip Code: [NUMERIC ONLY]
(l) Contact notes: [OPEN TEXT FIELD TO INSERT OTHER RELEVANT INFO]
Social Media
STARS may soon be on Twitter, Facebook, or another form of social media. We are interested in what social media you use and if it would be OK for us to contact you there in the future . |
CI_11.What forms of social media do you use? (Select all that apply.)
Do you use…? |
Yes (01) |
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[IF CI_11 ITEM = 01, ASK CORRESPONDING CI_12 ITEM]
CI_12. Would it be OK for the STARS research team to….?
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Yes (01) |
No (00) |
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[IF CI_12 ITEM = 01, ASK CORRESPONDING CI_13 ITEM]
CI_13. What is…?
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____________________________________ |
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____________________________________ |
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____________________________________ |
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____________________________________ |
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____________________________________ |
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____________________________________ |
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____________________________________ |
Thank you for providing your contact information! We are glad you are part of our study. [IF 6-MO/9-MO TRACKING SURVEY ADD: We will be in touch soon for future surveys.] |
Section A: Housing Experiences
We want to start by asking about the places you’ve stayed and your experiences with homelessness By homeless we mean that you had a period of time in your life when you:
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History of Homelessness
A1. Over your entire life, including right now, about how many times have you been homeless?
1 time [ ] 01
2 times [ ] 02
3 times [ ] 03
4 or more times [ ] 04
A2. Over your entire life, including right now, about how many nights in total have you been homeless?
About 1 to 3 nights [ ] 01
More than 3 nights but less than 1 week [ ] 02
About 1 week (7 nights) [ ] 03
More than a week, but less than a month [ ] 04
About 1 month [ ] 05
More than 1 month but less than 6 months [ ] 06
About 6 months [ ] 07
More than 6 months, but less than 1 year [ ] 08
1 year or more [ ] 09
Section B: Where You Stay
Housing History Series
The next questions ask about the places you have stayed in the past 12 months, since [current date minus 12 months]. This includes times when you were in a shelter or residential program for homeless people or homeless in an unsheltered location (for example outside, on the street, in a car, bus terminal or abandoned building).
For each place that you have stayed, we will ask you about when you started and stopped staying there and what kind of a place it was.
We will ask you to think backwards in time – from last night until [current date minus 12 months].
B1a. Where did you stay last night? If the place has a name please tell us the name.
________________ [open ended, tag response as: name situation #a, used in later items]
B2a. When did you start staying at [name situation #a]?
Click here to see a calendar of the past few months. Calendar
[Present calendar for reference]
-
Month
Day
Year
[Items B3a – B4a intentionally removed]
B5a. How would you describe [name situation #a]?
(Select only one answer.)
The [insert TLP name] Transitional Living Program (TLP) [ ] 01
Another Transitional Living Program (TLP) [ ] 02
Another residential program for homeless people that provides a long-term
place to stay and services [ ] 03
In a shelter (for example, emergency shelter or basic center program) [ ] 04
In an unsheltered location (for example, staying outside, on the street,
in a car, bus terminal or abandoned building) [ ] 05
Foster home or group home [ ] 06
Room, apartment or house (not as part of a homeless program) [ ] 07
Institution (for example, hospital, mental health facility, drug or alcohol treatment facility,
prison, jail, detention center) [ ] 08
School or college dormitory (or dorm) [ ] 09
Military setting (for example, base camp, deployment, combat zone) [ ] 10
Other (please specify) [ ] 94
B6a. When you started staying in [name situation #a], did you think it would be temporary? By temporary, we mean it would only last a short time (for example, couch surfing, crashing, or just passing through).
Yes, I thought it would be temporary [ ] 01
No, I thought I would be there a while [ ] 00
I was not sure [ ] 02
I don’t remember [ ] -98
[If B5a = 7 (room/apt/house), present B7a – B8a, else skip to B9a]
B7a. At [name situation #a], are you staying…
(Select all that apply.)
Alone [ ] 01
With one or more family members [ ] 02
With one or more friends [ ] 03
Other (please specify) [ ] 94
[Logic check: If B7a = 1 (alone), R cannot also select 2 (friends) or 3 (family)]
B8a. At [name situation #a], are you paying rent or part of the rent?
(Select only one answer.)
Yes, I always paid (pay) rent [ ] 02
Yes, I sometimes paid (pay) rent [ ] 01
No, I never paid (pay) rent [ ] 00
B9a. Do you feel safe in [name situation #a]?
Yes [ ] 01
No [ ] 00
Don’t know……………………………………………………………………………………… .[ ] -98
[Item B10a intentionally removed]
B11a. Have you stayed anywhere else in the past 12 months, since [current date minus 12 months]?
Yes [ ] 01
No [ ] 00
[If B11a = 1, continue to housing history loop. If B11a = 0, skip to next section]
Housing History Loop:
Note the questions asked in the loop are (nearly) identical to B1a – B11a
[B1b begins Housing History Loop: First turn through loop is B1b – B11b and occurs if B11a = 1 (stayed somewhere else in past 12 months). The loop is repeated again (B1c-B11c) if B11b = 1 (stayed somewhere else since RA). The loop continues to be repeated until B11# = 0 with a maximum of 3 times through the loop (ending with A11d). Thus, we capture up to 4 living situations in the housing history series.]
B1b. What is the name of the place you stayed just before [name situation #a]? If this is a program, please use its official name.
Remember you can include times when you were in a shelter or residential program for homeless people or homeless in an unsheltered location (for example outside, on the street, in a car, bus terminal or abandoned building).
________________ [open ended, tag response as: name situation #b, used in later items]
B2b. When did you start staying at [name situation #b]?
Click here to see a calendar. Calendar
[Present calendar for reference]
-
Month
Day
Year
[Item B3b intentionally removed]
B4b. When did you stop staying there? Your best guess is fine.
Click here to see a calendar. Calendar
[Present calendar for reference]
-
Month
Day
Year
B5b. How would you describe [name situation #b]?
(Select only one answer.)
The [insert TLP name] Transitional Living Program (TLP) [ ] 01
Another Transitional Living Program (TLP) [ ] 02
Another residential program for homeless people that provides a long-term
place to stay and services [ ] 03
Homeless in a shelter (for example, emergency shelter or basic center program) [ ] 04
Homeless in an unsheltered location (for example, staying outside, on the street,
in a car, bus terminal or abandoned building) [ ] 05
Foster home or group home [ ] 06
Room, apartment or house (not as part of a homeless program) [ ] 07
Institution (for example, hospital, mental health facility, drug or alcohol treatment facility,
prison, jail, detention center) [ ] 08
School or college dormitory (or dorm) [ ] 09
Military setting (for example, base camp, deployment, combat zone) [ ] 10
Other (please specify) [ ] 94
B6b. When you started staying in [name situation #b], did you think it would be temporary? By temporary, we mean it would only last a short time (for example, couch surfing, crashing, or just passing through).
Yes, I thought it would be temporary [ ] 01
No, I thought I would be there a while [ ] 00
I was not sure [ ] 02
I don’t remember [ ] -98
[If B5b = 7 (room/apt/house), present B7b – B8b, else skip to B9b]
B7b. In [name situation #b], were you staying…
(Select all that apply.)
Alone [ ] 01
With one or more family members [ ] 02
With one or more friends [ ] 03
Other (please specify) [ ] 94
[Logic check: If B7b = 1 (alone), R cannot also select 2 (friends) or 3 (family)]
B8b. In [name situation #b], were you paying rent or part of the rent?
(Select only one answer.)
Yes, I always paid rent [ ] 02
Yes, I sometimes paid rent [ ] 01
No, I never paid rent [ ] 00
B9b. Did you feel safe in [name situation #b]?
Yes [ ] 01
No [ ] 00
Don’t know……………………………………………………………………………………… .[ ] -98
[Item B10b intentionally removed]
B11b. So far, you have told us about [insert name(s) of previously identified situation(s), name situation #a, name situation #b, etc.].
Have you stayed anywhere else since [current date minus 12 months]?
Yes [ ] 01
No [ ] 00
[End of Loop. If B11b = 1, loop back and begin with B1c. If B11b = 0, exit loop and continue to next question. Looping continues until B11#=0 with a maximum of 3 times through the loop, ending with B11d. (Thus, we capture up to 4 living situations in the housing history series.) After 3 times through the loop, if B11d = 1 then, present B12 - B13.]
[If B11d = 1 then present B12, Else if B11d=0 skip to next section]
B12. How many other places have you stayed from [insert RA date] to today?
________________ # places
B13. What types of places were they?
(Select all that apply)
[Randomly order/rotate all options presented for B13]
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Yes (01) |
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Section C: TLP and Service Experiences
Prior TLP Experience
The next few questions are about your experiences with Transitional Living Programs like the [insert TLP name] program that you are currently applying to. We will use the abbreviation TLP throughout this survey to refer to the Transitional Living Program. A TLP is a residential program for homeless people that provides a long-term place to stay and services.
[If B5(a, b, c, or d.) = 1, auto fill C1 as 1 and skip to C2]
C1. Have you ever stayed in the [insert TLP name] Transitional Living Program (TLP) before now?
Yes [ ] 01
No [ ] 00
Don’t Know [ ] -98
[If B5(a, b, c, d) = 2 “Other Transitional Living Program” auto fill C2 as 1 and skip to C3]
C2. Have you ever stayed in a Transitional Living Program (TLP) other than [insert TLP name]?
Yes [ ] 01
No [ ] 00
Don’t Know [ ] -98
[If B5(a, b, c, d) = in {1, 2, 3 (ever in this/other TLP or TLP-like program)} auto fill C3 as 1 and skip to C4;
Else if {C1=1 or C2=1 (ever in this/other TLP)} then go to C4;
Else continue to C3]
C3. Have you ever stayed in a residential program for homeless people that provides long-term services and a place to stay?
Yes [ ] 01
No [ ] 00
Don’t Know [ ] -98
The next few questions are about programs and services you may have participated in.
Recent Service Receipt
[Item C4 intentionally removed]
C5. In the past 30 days, since [insert current date minus 30 days] have you received any of the following services?
(Select all that apply)
[Items have been partitioned into four groupings. Present the main question stem before each grouping. Randomly order/rotate the items within each grouping.]
[C5 Grouping #1.]
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Yes (01) |
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[C5 Grouping #2.]
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Yes (01) |
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[C5 Grouping #3.]
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Yes (01) |
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[C5 Grouping #4.]
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Yes (01) |
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[Items C6-C7 intentionally removed]
C8. People have different goals. On a scale of 1 to 3, where 1 = Not At All Important to Me and 3 = Very Important to Me, how important are each of the following goals for you?
[Randomly order/rotate the items]
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Not at all important to me 1 |
Somewhat important to me 2 |
Very important to me 3 |
Does not apply to me (-99) |
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Section D: Your Feelings and Health
The next few questions are about your feelings.
[Item D1 intentionally removed]
Depressive Symptoms
D2. Below is a list of the ways you might have felt or behaved. How often you have felt this way during the past week?
During the past week… |
Hardly ever or never (00) |
Some of the time (01) |
Much or most of the time (02) |
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Traumatic Stress
D3. The next questions are about problems and complaints that people sometimes have in response to stressful life experiences. Please indicate how much you have been bothered by each problem in the past month. For these questions, the response options are: “not at all”, “a little bit”, “moderately”, “quite a bit”, or “extremely”.
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Not at all 1 |
A little bit 2 |
Moderately 3 |
Quite a bit 4 |
Extremely 5 |
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Supportive Relationships with Adults
D4. Currently, in your life, are there responsible adults or mentors who…
(Select yes or no for each).
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Yes (01) |
No (00) |
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Section E: Education and Training
The next questions are about your education and training experiences.
Educational Progress
E1. What is the highest level of education you have completed? (By completed we mean the grade or level you have actually finished, not the grade or level you are currently in. If you are in high school, and it is summer, what grade did you complete this spring?)
(Select one response.)
6th grade or less [ ] 01
7th grade [ ] 02
8th grade [ ] 03
9th grade [ ] 04
10th grade [ ] 05
11th grade [ ] 06
GED or high school equivalency [ ] 07
High school diploma (12th grade) [ ] 08
Some vocational or trade school after graduating high school or getting your GED [ ] 09
Earned a credential from a vocational or trade school after graduating high school
or getting your GED [ ] 10
Associate's degree (community or two-year college) [ ] 11
Some college [ ] 12
Four-year college degree or higher [ ] 13
E2. Have you ever repeated a grade or been held back?
Yes [ ] 01
No [ ] 00
E3. Have you ever been suspended from school?
Yes [ ] 01
No [ ] 00
E4. Have you ever been expelled from school?
Yes [ ] 01
No [ ] 00
E5. Have you ever dropped out of school?
Yes [ ] 01
No [ ] 00
Education History Series
[Begin with E6a- then follow skip patterns]
E6. At any time from [current date minus 12 months] to today have you taken…? |
E7. While you were taking… |
E8. Altogether for how many… |
E9. Which months were you enrolled in… |
E6a.Adult Basic Education (ABE) By adult basic education (ABE), we mean classes to improve basic reading and math skills. This is not high school or college classes Yes [Go to E7a] No [Go to E6b] |
E7a. Adult basic education, how many hours per week did you attend during a normal week? ____# hours Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 5 hours per week 6 to 10 hours per week 11 to 15 hours per week 16 to 20 hours per week 21 to 30 hours per week More than 30 hours per week]
[Once response selected present E8a] |
E8a. Months since [current date minus 12 months] have you taken those classes? ____# months Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 1 month 1 or 2 months 3 to 6 months 7 to 12 months
[Once response selected present E9a] |
E9a. adult basic education? (Select all that apply) [current month, year] [current month, year minus 1 month] [current month, year minus 2 months] [current month, year minus 3 months] […Continue subtracting 1 until reach current date minus 12 months …]
[Once response selected present E6b] |
E6b. English as a Second Language (ESL) classes Yes [Go to E7b] No[Go to E6c] |
E7b. ESL classes, how many hours per week did you attend during a normal week? ____# hours Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 5 hours per week 6 to 10 hours per week 11 to 15 hours per week 16 to 20 hours per week 21 to 30 hours per week More than 30 hours per week]
[Once response selected present E8b] |
E8b. Months since [current date minus 12 months] did you take those classes? ____# months Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 1 month 1 or 2 months 3 to 6 months 7 to 12 months
[Once response selected present E9b] |
E9b. ESL classes? (Select all that apply) [current month, year] [current month, year minus 1 month] [current month, year minus 2 months] [current month, year minus 3 months] […Continue subtracting 1 until reach current date minus 12 months …]
[Once response selected present E6c] |
E6c. GED classes By GED classes, we mean classes to prepare for the GED test Yes [Go to E7c] No [Go to E6d] |
E7c. GED classes, how many hours per week did you attend during a normal week? ____# hours Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 5 hours per week 6 to 10 hours per week 11 to 15 hours per week 16 to 20 hours per week 21 to 30 hours per week More than 30 hours per week]
[Once response selected present E8c] |
E8c. Months since [current date minus 12 months] did you take those classes? ____# months Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 1 month 1 or 2 months 3 to 6 months 7 to 12 months
[Once response selected present E9c] |
E9c. GED classes? (Select all that apply) [current month, year] [current month, year minus 1 month] [current month, year minus 2 months] [current month, year minus 3 months] […Continue subtracting 1 until reach current date minus 12 months …]
[Once response selected present E6d] |
E6d. High school or classes toward a regular high school diploma (do not include ABE, GED, or ESL classes) Yes [Go to E7d] No [Go to E6e] |
E7d. High school or classes toward a regular high school diploma, how many hours per week did you attend during a normal week? ____# hours Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 5 hours per week 6 to 10 hours per week 11 to 15 hours per week 16 to 20 hours per week 21 to 30 hours per week More than 30 hours per week]
[Once response selected present E8d] |
E8d. Months since [current date minus 12 months] did you take those classes? ____# months Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 1 month 1 or 2 months 3 to 6 months 7 to 12 months
[Once response selected present E9d] |
E9d. High school or classes toward a regular high school diploma? (Select all that apply) [current month, year] [current month, year minus 1 month] [current month, year minus 2 months] [current month, year minus 3 months] […Continue subtracting 1 until reach current date minus 12 months …]
[Once response selected present E6e] |
E6e. College or classes toward an Associates degree or Bachelors degree at a 2-year or 4-y college (Do not count recreational classes like exercise or hobbies, courses for the GED, or any courses that don’t provide credit toward a degree) Yes [Go to E7e] No [Go to E6f] |
E7e. College or classes toward an Associates degree or Bachelors degree at a 2-year or 4-y college, how many hours per week did you attend during a normal week? ____# hours Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 5 hours per week 6 to 10 hours per week 11 to 15 hours per week 16 to 20 hours per week 21 to 30 hours per week More than 30 hours per week]
[Once response selected present E8c] |
E8e. Months since [current date minus 12 months] did you take those classes? ____# months Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 1 month 1 or 2 months 3 to 6 months 7 to 12 months
[Once response selected present E9c] |
E9e. College or classes toward an Associates degree or Bachelors degree at a 2-year or 4-y college? (Select all that apply) [current month, year] [current month, year minus 1 month] [current month, year minus 2 months] [current month, year minus 3 months] […Continue subtracting 1 until reach current date minus 12 months …]
[Once response selected present E6d] |
E6f. Vocational, career, or technical training at a community or private college By vocational, career, or technical training, we mean training for a specific job, trade, or occupation. This is not training you get in college courses. It is also not on-the-job training or unpaid work experience Yes [Go to E7f] No [Go to next section] |
E7f. Vocational, career, or technical training at a community or private college, how many hours per week did you attend during a normal week? ____# hours Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 5 hours per week 6 to 10 hours per week 11 to 15 hours per week 16 to 20 hours per week 21 to 30 hours per week More than 30 hours per week]
[Once response selected present E8f] |
E8f. Months since [current date minus 12 months] did you take those classes? ____# months Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 1 month 1 or 2 months 3 to 6 months 7 to 12 months
[Once response selected present E9f] |
E9f. . Vocational, career, or technical training at a community or private college? (Select all that apply) [current month, year] [current month, year minus 1 month] [current month, year minus 2 months] [current month, year minus 3 months] […Continue subtracting 1 until reach current date minus 12 months …]
|
Section F: Employment
The next few questions are about your work experiences.
F1. In the time from [current date minus 12 months] to today, have you worked at a job or business for pay?
By worked at a job or business for pay, we mean working at a job where you get paid money for the work you do or working for someone besides yourself and getting paid for it. It does not include odd jobs, informal work, illegal or “off-the-books” work, or work where you did not get paid.
Yes [ ] 01
No [ ] 00
[If F1=1 (yes) skip to employment history series (F3a), If F1=0 (not employed) ask F2a]
F2a. Which of the following best describes the reason you have not worked in the time from [current date minus 12 months] to today?
(Select one)
I was in school, [ ] 01
I was looking for work but could not find it [ ] 02
I did not want to work [ ] 03
I was not able to work [ ] 04
I was working odd jobs “off-the-books,” illegally,, not for pay, or informally [ ] 05
[If F2a=04 (unable to work), then ask F2b]
F2b. Why were you not able to work?
Physical or other type of disability [ ] 01
Other (Please specify) [ ] 94
[If F1=1 (employed) employment history series, else skip to next section]
Employment History Series
We’d like to learn more about your work or
employment from [current
date minus 12 months] to today. We will ask you to
think backwards in time from now until [current
date minus 12 months]. Sometimes people
have more than one job at a time. If you had more than one job at a
time, please answer the following questions for each job
separately—one at a time.
F3a. Thinking about the time from [current date minus 12 months] to today, what is the name of the place you currently work or most recently worked?
Remember we mean working at a job where you get paid money for the work you do or working for someone besides yourself and getting paid for it. This does not include odd jobs, informal, illegal, or “off-the-books” work, volunteer work, or work where you did not get paid
________________ [open ended, tag response as: employer #a, used in later items]
F4a. What did you do at [insert employer #a]?
________________ [open ended, tag response as: occupation #a]
F5a. When did you start working at [insert employer #a]?
Click here to see a calendar of the past few months. Calendar [Present calendar for reference]
-
Month
Day
Year
F6a. Are you still working at [insert employer #a]?
Yes [ ] 01
No [ ] 00
[If F6a=0, ask F7a, else skip to F8a]
F7a. When did you stop working at [insert employer #a]?
Click here to see a calendar of the past few months. Calendar [Present calendar for reference]
-
Month
Day
Year
F8a. In an average week, how many hours do you or did you usually work at [insert employer #a]?
________________ # hours per week
F9a. Have you worked anywhere else in the time from [insert current date minus 12 months] to today]?
Yes [ ] 01
No [ ] 00
[If F9a=1, continue to employment history loop, else skip to next section]
Employment History Loop:
Note the questions asked in the loop are (nearly) identical to F3a – F9a
[F3b begins Employment History Loop: First turn through loop is F3b – F9b and occurs if F9a = 1 (worked somewhere else since RA). The loop is repeated again (F3c-F9c) if F9b = 1 (worked somewhere else since RA). The loop continues to be repeated until F9# = 0 with a maximum of three times through the loop (ending with F9d). Thus, we capture up to 4 jobs in the employment history series.]
F3b. What is the name of the place you worked just before [insert name of previously identified employer]? You can give it any name that makes sense to you.
Remember we mean working at a job where you get paid money for the work you do or working for someone besides yourself and getting paid for it. This does not include odd jobs, informal, illegal, or “off-the-books” work, volunteer work, or work where you did not get paid
________________ [open ended, tag response as: employer #b, used in later items]
F4b. What did you do at [insert employer #b]?
________________ [open ended, tag response as: occupation #b]
F5b. When did you start working at [insert employer #b]?
Click here to see a calendar of the past few months. Calendar [Present calendar for reference]
-
Month
Day
Year
F6b. Are you still working at [insert employer #a]?
Yes [ ] 01
No [ ] 00
[If F6b=0, ask F7b, else skip to F8b]
F7b. When did you stop working at [insert employer #b]?
Click here to see a calendar of the past few months. Calendar [Present calendar for reference]
-
Month
Day
Year
F8b. In an average week, how many hours did you usually work at [insert employer #b]?
________________ # hours per week
F9b. So far, you have told us about [insert names of all previously identified employers, employer #a, employer #b, etc.].
Have you worked anywhere else in the time from [current date minus 12 months] to today?
Yes [ ] 01
No [ ] 00
[End of Loop. If F9b = 1, loop back and begin with F3c. If F9b = 0, exit loop and continue to next section. Looping continues until F9#=0 with a maximum of three times through the loop (ending with F9d). Thus, we capture up to 4 jobs in the employment history series]
Money Management
F10. At the end of the month do you usually have…
(Select One.)
Some money left over [ ] 03
Just enough money to make ends meet [ ] 02
Not enough money to make ends meet [ ] 01
F11. Do you currently have a savings account?
Yes [ ] 01
No [ ] 00
F12. Do you currently have a checking account?
Yes [ ] 01
No [ ] 00
Section G. Activities
The next questions are about things you do or activities you’ve participated in.
Civic Engagement
G1. In the time from [current date minus 12 months] to today, have you volunteered to help local community organizations or groups?
Yes [ ] 01
No [ ] 00
[If (enrolled in HS or college in past 12 months), ask G2; else skip to G3]
G2. In the time from [current date minus 12 months] to today, have you participated in any organized activities sponsored by your school or college, such as sports teams, band, or clubs?
Yes [ ] 01
No [ ] 00
Not applicable – Not currently in school [ ] -100
G3. In the time from [current date minus 12 months] to today, have you participated in any organized activities or groups that meet on a regular basis [If enrolled in HS or college in past 12 months) insert the following: and are not sponsored by your school or college]? These could be organizations or clubs, such as Boy or Girl Scouts, or community service groups.
Yes [ ] 01
No [ ] 00
Section H: Your Experiences
The next few questions ask things like drug use, sex, and violence. Remember your answers are strictly confidential, and you don't have to answer any question you don't want to.
Exposure to Violence
H1. In the past 12 months, that is since [current date minus 12 months], how often did each of the following things happen?
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Never [0] |
Once [1] |
More than Once [2] |
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Delinquency
H2. In the past 12 months, that is since [current date minus 12 months], how often did you do each of the following things?
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Never [0] |
1 or 2 Times [1] |
3 or 4 Times [2] |
5 or More Times [3] |
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Substance Use
The next two questions are about CIGARETTES and OTHER TOBACCO PRODUCTS.
Think back over the past 30 days and record on how many days, if any, you used cigarettes and/or other tobacco products. |
H3a. During the past 30 days, on how many days did you smoke part or all of a cigarette? (Include menthol and regular cigarettes and loose tobacco rolled into cigarettes)
[Present Options 0-30 days, Don’t know or Can’t say]
-
Days
H3b. During the past 30 days, on how many days did you use other tobacco products? (Include any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe)
[Present Options 0-30 days, Don’t know or Can’t say]
-
Days
The next question is about ALCOHOL. By alcohol, we mean BEER, WINE, WINE COOLERS, MALT BEVERAGES, or HARD LIQUOR.
Different groups of people in the United States may use alcohol for religious reasons. However, this may not be true for your religious, cultural, or ethnic group. For example, some churches serve wine during a church service. If you drink wine at church or for some other religious reason, do not count these times in your answers to the questions below.
Think back over the past 30 days and record on how many days, if any, you consumed alcohol. |
H4a. During the past 30 days, on how many days did you drink one or more drinks of an alcoholic beverage?
[Present Options 0-30 days, Don’t know or Can’t say]
-
Days
The next question is about MARIJUANA or HASHISH. Marijuana is sometimes called weed, blunt, hydro, grass, or pot. Hashish is sometimes called hash or hash oil.
Think back over the past 30 days and record on how many days, if any, you used marijuana or hashish. |
H4b. During the past 30 days, on how many days did you use marijuana or hashish?
[Present Options 0-30 days, Don’t know or Can’t say]
-
Days
The next question is about OTHER ILLEGAL DRUGS, excluding marijuana or hashish, which include substances like inhalants or sniffed substances such as glue, gasoline, paint thinner, cleaning fluid, or shoe polish (used to feel good or to get high), heroin, crack or cocaine, methamphetamine, hallucinogens (drugs that cause people to see or experience things that are not real) such as LSD (sometimes called acid), Ecstasy (MDMA), PCP, peyote (sometimes called angel dust), and prescription drugs used without a doctor’s orders, just to feel good or to get high.
Think back over the past 30 days and report on how many days, if any, you used other illegal drugs. |
H5a. During the past 30 days, on how many days did you use any other illegal drug?
[Present Options 0-30 days, Don’t know or Can’t say]
-
Days
Now we would like to ask about your use of several specific drugs. |
H5b. During the past 30 days, on how many days did you use cocaine or crack?
[Present Options 0-30 days, Don’t know or Can’t say]
-
Days
H5c. During the past 30 days, on how many days did you use methamphetamine? (Also called meth, crystal meth, crank, go, and speed)
[Present Options 0-30 days, Don’t know or Can’t say]
-
Days
H5d. During the past 30 days, on how many days did you inject any drugs? (Count only injections without a doctor’s orders, those you had just to feel good or to get high.)
[Present Options 0-30 days, Don’t know or Can’t say]
-
Days
The next questions are about your sexual behaviors and experiences.
Sexual Risk Behavior
H6. Sexual intercourse is when a male puts his penis into a female’s vagina.
At any time from [current date minus 3 months]. to today, have you had sexual intercourse, even once?
Yes [ ] 01
No [ ] 00
Don't know [ ] -98
H7. At any time from [current date minus 3 months]. to today, have you had sexual intercourse without you or your partner using a condom, even just once?
Yes, I have had sexual intercourse without using a condom [ ] 01
No, I have used a condom each time I had sexual intercourse [ ] 00
Don't know [ ] -98
H8. Anal sex is when a male puts his penis in someone else’s anus, or their butt, or someone lets a male put his penis in their anus or butt.
At any time from [current date minus 3 months] to today, have you had anal sex, even once?
Yes [ ] 01
No [ ] 00
Don't know [ ] -98
H9. In the time from [current date minus 3 months] to today, have you had anal sex without you or your partner using a condom, even just once?
Yes, I have had anal sex without using a condom [ ] 01
No, I have used a condom each time I had anal sex [ ] 00
Don't know [ ] -98
[If H6=1 or H8=1 ask H10a]
H10a. At any time from [current date minus 3 months]. to today, have you received anything in exchange for having sexual relations with another person, such as money, food, drugs, or shelter? By sexual relations we mean sexual intercourse, anal sex, or oral sex.
Yes [ ] 01
No [ ] 00
Don't know [ ] -98
[If H10a=1 ask H10b]
H10b. In the time from [current date minus 3 months] to today, how many times have you received something in exchange for having sexual relations with another person, such as money, food, drugs, or shelter? Your best guess is fine.
______ # times [valid range 1 – 99]
Gender, Gender Identity, Sexual Orientation
H11a. Would you describe your gender as male, female, or something else?
(Select only one answer.)
Male [ ] 00
Female [ ] 01
Transgender Male to Female [ ] 02
Transgender Female to Male [ ] 03
Something else [ ] 04
Don’t know [ ] -98
H11b. Which of the following best represents how you think of yourself?
(Select only one answer.)
Lesbian or gay [ ] 01
Straight, that is, not gay [ ] 02
Bisexual [ ] 03
Something else [ ] 04
I don’t know the answer [ ] -98
[If H11b=04, ask H11c, else skip to H12a]
H11c. What do you mean by something else?
(Select only one answer.)
You are not straight, but identify with another label such as queer, trisexual, omnisexual or
pansexual [ ] 01
You have not figured out or are in the process of figuring out your sexuality [ ] 02
You do not think of yourself as having sexuality [ ] 03
You do not use labels to identify yourself [ ] 04
You mean something else [ ] 05
Don’t know [ ] -98
[Items H12 – H14 intentionally removed]
Abuse and Neglect
The next questions are about situations that may have happened during your life and the ways your caregivers may have mistreated you in the past. By caregivers, we mean the adults who were responsible for taking care of you in the past. Remember, your answers are strictly confidential, and you don't have to answer any question you don't want to.
H15. Did any of your caregivers fail to give you regular meals so that you had to go hungry or ask other people for food?
Yes [ ] 01
No [ ] 02
Don’t Know [ ] -98
Decline to answer [ ] -99
H16. Did any of your caregivers ever throw or push you? For example, push you down a staircase or push you into a wall?
Yes [ ] 01
No [ ] 02
Don’t Know [ ] -98
Decline to answer [ ] -99
H17. Did any of your caregivers ever hit you hard with a fist, or kick you or slap you really hard?
Yes [ ] 01
No [ ] 02
Don’t Know [ ] -98
Decline to answer [ ] -99
H18. Did any of your caregivers ever beat you up such as hitting or kicking you repeatedly?
Yes [ ] 01
No [ ] 02
Don’t Know [ ] -98
Decline to answer [ ] -99
H19. Did you ever have a serious illness or injury or physical disability, but your caregivers ignored it or failed to get you medical care or other treatment for it?
Some examples are an infection that became serious because it was not treated soon enough, an broken bone that did not get fixed, or problems seeing or hearing that were not treated with glasses or hearing aids?
Yes [ ] 01
No [ ] 02
Don’t Know [ ] -98
Decline to answer [ ] -99
H20. Did any of your caregivers ever abandon you?
By “abandon,” we mean leave you, walk out on you, ditch or dump you.
Yes [ ] 01
No [ ] 02
Don’t Know [ ] -98
Decline to answer [ ] -99
H21. Did any of your caregivers ever touch or kiss you against your will?
By “against your will,” we mean when you did not want them to or without your permission.
Yes [ ] 01
No [ ] 02
Don’t Know [ ] -98
Decline to answer [ ] -99
H22. Did any of your caregivers ever have sexual intercourse, oral sex, or anal sex with you against your will?
By “against your will,” we mean when you did not want them to or without your permission
Yes [ ] 01
No [ ] 02
Don’t Know [ ] -98
Decline to answer [ ] -99
Section I: About You
We’re almost done. There are just a few more questions about your background.
I1. Are you of Hispanic, Latino, or Spanish Origin?
(Select only one answer.)
No, not of Hispanic, Latino, or Spanish origin [ ] 01
Yes, Puerto Rican [ ] 01
Yes, Cuban [ ] 02
Yes, another Hispanic, Latino, or Spanish origin [ ] 03
I2. What is your race?
(Select all that apply.)
White [ ] 01
Black, or African American [ ] 02
American Indian or Alaska Native [ ] 03
Native Hawaiian or Other Pacific Islander [ ] 04
Asian [ ] 05
Other (Please specify) [ ] 94
I3a. Were you born in the United States?
Yes [ ] 01
No [ ] 00
[If I3a=0, skip to I4]
I3b. How long have you lived in the United States? _________ # years
I4. What is the language you learned first (that is, what is your native language)?
(Select all that apply.)
English [ ] 01
Spanish [ ] 02
Other (Please specify) [ ] 94
I5a. What is your current marital status?
(Select only one answer.)
Never Married [ ] 01
Married [ ] 02
Separated [ ] 03
Divorced [ ] 04
Widowed [ ] 05
[If I5a=1, ask I5b, else skip to I6a]
I5b. Are you currently staying with a romantic partner (boyfriend or girlfriend), spouse (husband or wife) or someone who is like a spouse to you?
(Select only one answer.)
Yes [ ] 01
No [ ] 00
I6a. Do you have any children (even if they don’t stay with you)?
Yes [ ] 01
No [ ] 00
[If I6a=0, skip to I7]
I6b. How many children do you have (even if they don’t live with you)?
________# children
I7. Are you currently pregnant or expecting to become a father in the next 9 months?
Yes [ ] 01
No [ ] 00
Don’t know……………………………………………………………………………………… .[ ] -98
Closing
Closing1.
Thank you for taking this survey and being part of STARS!
After you submit your survey, we will [insert mode selected: email/text] your electronic gift card to:
[insert gift card contact]
Closing1a. If this information is wrong, click here: CHANGE INFORMATION
Closing 1b. If this information is correct, click here to submit your survey: SUBMIT
(Once you submit your survey, you cannot go back and change your answers.)
Closing1c. You will receive your electronic gift card within [xx] days.
If you have any questions about STARS, you can call the people who are doing the research at (XXX) XXX-XXXX. This is a free call.
Thanks again!
You are a very important part of STARS !
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Jessica Thornton Walker |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |
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