Client Biweekly Updates Form

Appendix C:
[EOC Site Name] Client Baseline Information Form

For EOC Staff to Complete: Name of EOC staff member assigned to EOC client (who the text messages will be coming from): __________________________________________________

Client Background Information

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

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

Contact Information

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

4. Is this cell phone number temporary or permanent?

   • Temporary

   • Permanent

Information Required to Inform the Customization of the Intervention

5. 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: (MM-DD-YYYY)

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

  • Please specify college(s)/program(s) of interest: __________________

  • Intended enrollment date: (MM-DD-YYYY)

• I have already applied to college(s)/program(s) where I would like to enroll, but I have not yet been accepted.

  • Please specify college(s)/program(s): __________________________

  • Intended enrollment date: (MM-DD-YYYY)

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

  • Please specify college/program: ______________________________

  • Intended enrollment date: (MM-DD-YYYY)

6. FAFSA filing status (please check one):

• I have not begun the FAFSA filing process

• I have begun the FAFSA filing process, but have not yet completed it

• 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

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

   • Yes, their ages are: _____________________

   • No

8. Do you plan to work and attend school at the same time?

   • Yes

   • No

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 information collection is XXXX-XXXX. The time required to complete this information collection is estimated to take an average of 5 minutes, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collected. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Ave., SW, Washington, DC 20210-4537 or email [email protected] and reference the OMB Control Number XXXX-XXXX.

                                                                                                    OMB NO.:

                                                                                                    EXPIRATION DATE:

Notice of Confidentiality

Information collected for this study comes under the confidentiality and data protection requirements of the Institute of Education Sciences (The Education Sciences Reform Act of 2002, Title I, Part E, Section 183). Responses to this data collection will be used only for statistical purposes. The reports prepared for the study will summarize findings across the sample and will not associate responses with a specific Education Opportunity Center (EOC) grantee or individual. We will not provide information that identifies you or your EOC to anyone outside the study team, except as required by law.