Study of An Information Strategy to Increase Enrollment in Postsecondary Education

Appendix B:
Study Data From the EOC Client Intake Forms

1. Contact Information

1. Cell phone number (XXX-XXX-XXXX)

2. Home phone number (XXX-XXX-XXXX)

3. Home address (street name, city, state, zip)

4. Email address

2. Data Fields Required for Obtaining Federal Student Aid and National Student Clearinghouse Data

5. Client name (first name, last name, middle initial)

6. Social security number (XXX-XX-XXXX¹), if available

7. Date of birth (YYYY-MM-DD)

3. Data Fields Required to Determine Study Eligibility and for Customization of the Intervention

8. Do you have a high school diploma or equivalent? (Please check one)

• Yes

• No

9. College plans and application status (please check one):

• I would like to explore college classes / programs that would be a good fit for me.

  • Intended enrollment date (e.g., Summer 2018, Fall 2018, Spring 2019, Summer 2019, Fall 2019, Spring 2020, Summer 2020, Fall 2020, 2021 or later):____________

• I have already selected a college/program where I would like to enroll and plan to apply, but I have not yet applied or been accepted.

  • Please specify college:_______________________________

  • Intended enrollment date (e.g., Summer 2018, Fall 2018, Spring 2019, Summer 2019, Fall 2019, Spring 2020, Summer 2020, Fall 2020, 2021 or later ):____________

• I have already applied to the college where I would like to enroll, but I have not yet been accepted.

  • Please specify college:_______________________________

  • Intended enrollment date (e.g., Summer 2018, Fall 2018, Spring 2019, Summer 2019, Fall 2019, Spring 2020, Summer 2020, Fall 2020, 2021 or later ):____________

• I have already been accepted to my college of choice and plan to enroll:

  • Please specify college:____________________________________

  • Intended enrollment date (e.g., Summer 2018, Fall 2018, Spring 2019, Summer 2019, Fall 2019, Spring 2020, Summer 2020, Fall 2020, 2021 or later ):____________

10. FAFSA filing status (please check one):

• I have not begun the FAFSA filing process

• I have begun the FAFSA filing process

• I have completed the FAFSA filing process but have not received my Student Aid Report

• I have completed the FAFSA filing process and have received my Student Aid Report

• I don’t know

11. Are there children in your household for whom you are a caretaker (Yes / No)?

    • Yes, their ages are: _____________________

    • No

4. Demographic Data

12. Gender (please check one):

    • Male

    • Female

13. Are you of Hispanic origin? (please check one)

• Yes, I am of Hispanic origin

• No, I am not of Hispanic origin

14. Race (please check all that apply):

• American Indian / Alaska Native

• Asian

• Black / African American

• Native Hawaiian or Other Pacific Islander

• White

15. Mother’s education (please check one):

• Did not complete high school

• Completed high school / earned GED

• Completed some college

• Earned a certificate or associate’s degree

• Earned a bachelor’s degree

• Don’t know

16. Father’s education (please check one):

• Did not complete high school

• Completed high school / earned GED

• Completed some college

• Earned a certificate or associate’s degree

• Earned a bachelor’s degree

• Don’t know

17. Primary language spoken at home: ________________________

18. What is the total number of persons (including you) in your family’s household? ________

19. What was your family's taxable income (not total income) from last calendar year? $_________ (Please estimate to the best of your ability)

- OR –

Check here if not required to file taxes

1 Some EOCs already collect client SSNs. If an EOC interested in participating in the study does not already collect SSNs and is unwilling to amend their intake form to include this, the study team will consider allowing the site to instead collect the last four digits of client SSNs.