Baseline Information Form

Job Search Assistance Strategies (JSA) Evaluation - Contact updates, Interim Surveys and Six-Month Follow-up Survey

JSA OMB Attachment A Baseline Information Form - July 2014 - Revised

Baseline Information Form

OMB: 0970-0440

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Supporting Statement

For the Paperwork Reduction Act of 1995: Approval for the Baseline Data Collection, Implementation Study Site Visits, and Staff Surveys for the Job Search Assistance (JSA) Strategies Evaluation


Attachment A: Baseline Information Form




OMB No. 0970-0440





August 11, 2014



Submitted by:

Office of Planning,
Research & Evaluation

Administration for Children & Families

U.S. Department of Health
and Human Services


Federal Project Officer

Erica Zielewski


U.S. Department of Health and Human Services

Job Search Assistance (JSA) Strategies Evaluation

Baseline Information Form



This form asks questions about your background. The questions cover a range of topics, including your family, your education, and your past employment. Your answers to these questions will not affect your eligibility for services here or elsewhere. The information will be used for research purposes only and will be kept confidential to the extent allowed by law. If you have any questions, please ask the staff person who gave you this form.



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



MARKING DIRECTIONS

Use a blue or black ink pen or dark pencil.

Do not use felt tip markers or gel pens.

Put an “X” in the box that best describes your answer.

Shape1 Correct:

To change an answer, mark the new one and circle it.

Shape3 Shape2 Correct:

Shape4

J

O

B

S

Please PRINT where applicable. Enter only one letter or number per box.








Burden Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this collection is 0970-0440; this number is valid through XX/XX/XXXX. Public reporting burden for this collection of information is estimated to average 12 minutes, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.







PERSONAL CONTACT INFORMATION


1. WHAT IS YOUR NAME?



___________________________

FIRST


______

M.I.


_____________________________________________

LAST


2. WHAT IS YOUR DATE OF BIRTH?



___ ___ / ___ ___ / ___ ___ ___ ___

(MONTH) (DAY) (YEAR)


3. WHAT IS YOUR SOCIAL SECURITY NUMBER?


___ ___ ___ - ___ ___ - ___ ___ ___ ___


4. WHAT IS YOUR ADDRESS?



_____________________________________________

STREET ADDRESS


__________________

APT #




__________________________________

CITY


________

STATE


__________________

ZIP


5a. WHAT IS YOUR PRIMARY PHONE NUMBER?


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


5b. WHAT IS YOUR SECONDARY PHONE NUMBER?


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

HOME

CELL

WORK

HOME

CELL

WORK


6. MAY WE SEND A TEXT MESSAGE TO YOUR CELL PHONE?


YES NO


7. WHAT IS YOUR E-MAIL ADDRESS?


__________________________________@______________________


8. MAY WE CONTACT YOU THROUGH FACEBOOK?


IF YES, HOW IS YOUR NAME LISTED ONFACEBOOK?


YES NO


_________________________________________________________

BACKGROUND AND FAMILY CHARACTERISTICS

9. WHAT IS YOUR SEX?


1 MALE

2 FEMALE

10. WHAT IS YOUR MARITAL STATUS?

1 NOW MARRIED

2 WIDOWED

3 DIVORCED

4 SEPARATED

5 NEVER MARRIED

11. ARE YOU OF HISPANIC, LATINO, OR SPANISH ORIGIN?

1 NO, NOT OF HISPANIC, LATINO, OR SPANISH ORIGIN

2 YES, MEXICAN, MEXICAN AM., CHICANO

3 YES, PUERTO RICAN

4 YES, CUBAN

5 YES, ANOTHER HISPANIC, LATINO, OR SPANISH ORIGIN

BACKGROUND AND FAMILY CHARACTERISTICS

12. WHAT IS YOUR RACE? (MARK ONE OR MORE)

1 WHITE

2 BLACK OR AFRICAN AMERICAN

3 AMERICAN INDIAN OR ALASKA NATIVE

4ASIAN INDIAN

5CHINESE

6FILIPINO

7JAPANESE

8KOREAN

9VIETNAMESE

10OTHER ASIAN

11 NATIVE HAWAIIAN

12 GUAMANIAN OR CHAMORRO

13SAMOAN

14OTHER PACIFIC ISLANDER

13. WHICH OF THE FOLLOWING LIVE IN YOUR HOUSEHOLD AT LEAST HALF THE TIME? (MARK ONE OR MORE):

01YOUR SPOUSE

02YOUR UNMARRIED PARTNER

03YOUR BIOLOGICAL OR ADOPTED CHILDREN

04OTHER CHILDREN UNDER AGE 18

05YOUR MOTHER OR FATHER

06YOUR OTHER RELATIVES

07YOUR SPOUSE’S MOTHER OR FATHER

08YOUR SPOUSE’S OTHER RELATIVES

09FRIENDS

10OTHERS

11NO ONE ELSE

14. HOW MANY ADULTS AGE 18 OR OLDER, INCLUDING YOURSELF, LIVE IN YOUR HOUSEHOLD AT LEAST HALF THE TIME? ____ ADULTS

15. HOW MANY CHILDREN UNDER AGE 18 LIVE WITH YOU AT LEAST HALF THE TIME? (INCLUDE BIOLOGICAL, ADOPTED, FOSTER, STEP, AND ANY OTHER CHILDREN):

_­­­___ CHILDREN

16. WHAT IS THE AGE (IN YEARS) OF THE YOUNGEST CHILD CURRENTLY LIVING IN YOUR HOUSEHOLD (ANSWER ZERO IF THE CHILD HAS NOT REACHED HIS/HER FIRST BIRTHDAY)?

0______ AGE OF YOUNGEST CHILD



EDUCATIONAL BACKGROUND

17. WHAT IS THE HIGHEST DEGREE OR LEVEL OF SCHOOL YOU HAVE COMPLETED? (MARK ONE):

1GRADE 1 THROUGH 11 PLEASE WRITE THE HIGHEST GRADE YOU COMPLETED 1-11 HERE: ______

212th GRADE – NO DIPLOMA

3GED OR ALTERNATIVE CREDENTIAL

4REGULAR HIGH SCHOOL DIPLOMA

5SOME COLLEGE CREDIT, BUT LESS THAN 1 YEAR OF COLLEGE CREDIT

61 OR MORE YEARS OF COLLEGE CREDIT, BUT NO DEGREE

7ASSOCIATE’S DEGREE (FOR EXAMPLE: AA, AS)

8BACHELOR’S DEGREE OR HIGHER (FOR EXAMPLE: BA BS)



EDUCATIONAL BACKGROUND

18. HAVE YOU RECEIVED A POST-SECONDARY VOCATIONAL OR TECHNICAL CERTIFICATE OR DIPLOMA?

1YES

2NO

19. WHAT GRADES DID YOU USUALLY GET IN HIGH SCHOOL? (MARK ONE):

1DID NOT ATTEND HIGH SCHOOL IN THE U.S.

2MOSTLY A’s

3MOSTLY B’s

4MOSTLY C’s

5MOSTLY D’s

6MOSTLY F’s

EMPLOYMENT AND INCOME

20. ARE YOU CURRENTLY WORKING AT A JOB FOR PAY? (MARK ONE)

1YES HOW MANY HOURS PER WEEK ON AVERAGE ARE YOU CURRENTLY WORKING? (INCLUDE ALL JOBS)


___ ___ HOURS/WEEK

2NO, BUT I WORKED BEFORE WHEN DID YOU LAST WORK?


___ ___ / ___ ___ ___ ___

(MONTH) (YEAR)

3NO, I NEVER WORKED

21. IF YOU ANSWERED “YES” OR “NO, BUT I WORKED BEFORE” TO Q22: ABOUT HOW MUCH DO/DID YOU TYPICALLY EARN PER

HOUR BEFORE TAXES IN YOUR CURRENT OR MOST RECENT JOB? (ANSWER FOR YOUR MAIN JOB IF MORE THAN ONE)


$ ______ . ______ PER HOUR IN CURRENT/MOST RECENT JOB


IF YOU DO NOT KNOW THE HOURLY RATE, PLEASE GIVE EARNINGS IN ONE OF THE CATEGORIES BELOW:

$ ___ ___ ___ ___ PER DAY

$ ___ ___ ___ ___ PER WEEK

$ ___ ___ ___ ___ EVERY 2 WEEKS

$ ___ ___ ___ ___ TWICE A MONTH

$ ___ ___ ___ ___ EVERY MONTH

$ ___ ___ ___ ___ OTHER (SPECIFY TIME PERIOD: ____________________________________)

22. EVER WORKED FULL TIME FOR 6 MONTHS OR MORE FOR ONE EMPLOYER?

1YES

2NO

23. ANY EARNINGS IN THE PAST 12 MONTHS?

1YES

2NO

24. TOTAL PRIOR TANF RECEIPT (MARK ONE):

1NONE

2LESS THAN 1 YEAR

32-5 YEARS

45-10 YEARS

510 YEARS OR MORE


25. HOW LONG AGO WAS YOUR PRIOR TANF RECEIPT?

1I WAS NOT ON TANF BEFORE

2LESS THAN 1 YEAR AGO

32-5 YEARS AGO

45-10 YEARS AGO

510 YEARS OR MORE AGO
















ALTERNATE CONTACTS

Please provide information for three persons not living with you who can help us locate you:

CONTACT #1

WHAT IS HIS/HER NAME?

_____________________________________

FIRST

_____________________________________________

LAST

WHAT IS HIS/HER RELATIONSHIP TO YOU?

_____________________________________________

WHAT IS HIS/HER ADDRESS?

_____________________________________________

STREET ADDRESS

__________________

APT #




__________________________________

CITY


________

STATE


__________________

ZIP

WHAT IS HIS/HER PRIMARY PHONE NUMBER?


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

WHAT IS HIS/HER SECONDARY PHONE NUMBER?


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

HOME

CELL

WORK

HOME

CELL

WORK

WHAT IS HIS/HER E-MAIL ADDRESS?

__________________________________@______________________

CONTACT #2

WHAT IS HIS/HER NAME?

_____________________________________

FIRST

_____________________________________________

LAST

WHAT IS HIS/HER RELATIONSHIP TO YOU?

_____________________________________________

WHAT IS HIS/HER ADDRESS?

_____________________________________________

STREET ADDRESS

__________________

APT #




__________________________________

CITY



WHAT IS HIS/HER PRIMARY PHONE NUMBER?


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

WHAT IS HIS/HER SECONDARY PHONE NUMBER?


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

HOME

CELL

WORK

HOME

CELL

WORK

WHAT IS HIS/HER E-MAIL ADDRESS?

__________________________________@______________________

CONTACT #3

WHAT IS HIS/HER NAME?

_____________________________________

FIRST

_____________________________________________

LAST

WHAT IS HIS/HER RELATIONSHIP TO YOU?

_____________________________________________

WHAT IS HIS/HER ADDRESS?

_____________________________________________

STREET ADDRESS

__________________

APT #




__________________________________

CITY



WHAT IS HIS/HER PRIMARY PHONE NUMBER?


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

WHAT IS HIS/HER SECONDARY PHONE NUMBER?


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

HOME

CELL

WORK

HOME

CELL

WORK

WHAT IS HIS/HER E-MAIL ADDRESS?

__________________________________@______________________



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