36-Month Follow-up Survey (Previously approved; no content changes)
Pathways for Advancing Careers and Education (PACE) – Third Follow-up Data Collection
PACE Followup OMB Appendix M Previously Approved 36 Month Followup Survey
36-Month Follow-up Survey (Previously approved; no content changes)
OMB: 0970-0397
Supporting Statement for OMB Clearance Request
Appendix M: 36-Month Follow-up Survey
Pathways for Advancing Careers and Education (PACE) – Follow-up Data Collection
OMB No. 0970-0397
March 2017
Submitted by:
Office of Planning,
Research
and Evaluation
Administration for
Children
and Families
U.S. Department of Health and Human Services
PACE 36-Month Followup Survey
Introduction
Hello, my name is [ ]. May I please speak with _____?
Thank you for taking the time to talk with me today. I work for Abt SRBI. Abt SRBI is an independent research company and we are helping the Administration for Children and Families (ACF) in the U.S. Department of Health and Human Services (HHS) with its study called Pathways for Advancing Careers and Education or PACE for short. (When you entered the study it was called Innovative Strategies for Increasing Self-Sufficiency.) We are conducting interviews with people who agreed to be in a study about a program offered at [Name of organization] called [program name].
We are getting ready to contact all of the people who joined the study so we can do a follow-up survey with them. This interview will include questions on your employment and education activities, your use of services, and your overall well-being. Once we complete the survey, we would like to ask you some questions about the interview experience. This entire process will take about 60 minutes..
When we are done, we will send you a $40 check, as a token of appreciation for your time. You agreed to be part of the study around [RAD] (when you signed a consent form to let researchers collect information from you). [INTERVIEWERIF RESPONDENT COMPLETETED 15 MONTH SURVEY READ AS NECESSARY: This is a follow-up to the interview you participated in MONTH/YEAR OF LAST INTERVIEW.]
We need to talk with people who got into the program and those who did not. Your participation in this study will help policymakers and program operators better understand how to help people attain educational credentials and find and keep jobs. Before we begin the survey, I would like to assure you that all of your responses on this survey will be kept private; your name will not appear in any written reports we produce. Your responses to these questions are completely voluntary. That means you may choose not to answer any question, or you may stop the interview if you wish, but we hope you don’t. Your responses to these questions will in no way affect your participation in any programs or your receipt of any kinds of public benefits or services. The information you provide will be kept private and only used for this study. By participating in this study, you will help the government learn if and how programs like [LOCAL PROGRAM NAME] make a difference in people’s lives and how to improve programs in the future.
According to the Paperwork Reduction Act (PRA), 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 0970-0397 and it expires xx/xx/xxxx. If you have comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, please send them to [Contact Name]; [Contact Address]; Attn: OMB-PRA (xxxxxxx).Do you have any questions before we begin?
Let’s begin now.
Screener/Verification:
First I just need to verify that I am speaking with the correct person.
What is your date of birth? ___________ (MM/DD/YYYY)
INTERVIEWER: ENTER DATE USING FORMAT BELOW. ENTER DOB EVEN IF IT MATCHES THE SAMPLE INFO. CATI NOTE: DISPLAY DOB
Respondent’s Birthday: ________ / ________ / ____________
MM DD YYYY
REFUSED -1
DON’T KNOW -2
CATI/CAPI: IF DOB AGREES WITH THE BIRTH DATE ON THE FILE, SKIP TO B1. ELSE, CONTINUE.
What are the last 4 digits of your Social Security Number?
RECORD LAST 4 DIGITS: ___ ___ ___ ___
REFUSED q -1
DON’T KNOW q -2
CATI/CAPI NOTE: DISPLAY LAST 4 DIGITS SSN
INTERVIEWER – ENTER LAST 4 DIGITS OF SSN EVEN IF IT MATCHES THE SAMPLE INFO
CATI/CAPI: IF THE 4 DIGITS GIVEN BY RESPONDENT AGREE WITH THE NUMBER ON THE FILE, SKIP TO B1.
IF SSN IS MISSING IN THE SAMPLE OR IS A MISMATCH WITH WHAT IS ENTERED AND THERE IS A MISMATCH IN DOB, DISPLAY DISCONTINUED TEXT.
CATI: IF INTERVIEW DISCONTINUED: I’m sorry. I was unable to pull up the correct questionnaire. I will need to check with my supervisor to look into the problem. I will re-contact you when the problem is resolved. Thank you for your time.
B. Employment and training history
I’d first like to get a general idea of some of the things you may have done since [MONTH AND YEAR OF RAD]. At that time you applied to be part of a program offered at [NAME OF ORGANIZATION] called [PROGRAM NAME]. I’m interested in whether you were employed, taking part in a training program, or involved in other activities during this time. In answering the questions, please include any full or part-time jobs or classes which have lasted at least one month.
Let’s begin with what you were doing in [MONTH AND YEAR OF RAD], when you applied to be part of [PROGRAM NAME] at [NAME OF ORGANIZATION].
In [MONTH AND YEAR OF RAD], were you working at a job for pay, or going to school, both working for pay and going to school, or neither working nor going to school?
WORKING AT A JOB FOR PAY
GOING TO SCHOOL
BOTH WORKING AT A JOB FOR PAY AND GOING TO SCHOOL
NEITHER WORKING AT A JOB FOR PAY OR GOING TO SCHOOL
IF B1 = JOB ONLY OR BOTH JOB AND SCHOOL: Okay, we are going to start with some questions about your job at that time. If you had more than one job, please talk about your main job. GO TO SECTION F, JOB SPELL.1
IF B1 = SCHOOL ONLY: Alright, let’s first talk about the classes you were taking in [MONTH AND YEAR of RAD]. GO TO SECTION C, SCHOOL SPELL
IF B1 = NEITHER JOB NOR SCHOOL, CONTINUE.
What were you doing at that time, were you…(Choose all that apply)
Enrolled in classes and waiting for classes to start or in between terms
Waiting for a job that you were offered to start
Looking for a job
Caring for your children or other family members
Dealing with health issues such as illness, injury, or pregnancy
Other
Don’t know
Refused
Since [MONTH AND YEAR OF RAD], have you taken any classes, worked at a job for pay, or both taken classes and worked for pay?
WORKED AT A JOB FOR PAY [GO TO SECTION F, JOB SPELL]
TAKEN CLASSES [GO TO SECTION C, SCHOOL SPELL]
BOTH WORKED FOR PAY AND TAKEN CLASSES
NO, R NEITHER WORKED FOR PAY NOR TOOK CLASSES [GO TO B9]
REFUSED [GO TO QUESTION I4 IN SECTION I]
DON’T KNOW [GO TO QUESTION I4 IN SECTION I,]
Which did you do first?
Started a job for pay [GO TO SECTION F, JOB SPELL#1]
Went to school or started classes [GO TO SECTION C, SCHOOL SPELL]
Don’t know
Refused
CATI/CAPI IF NO REMAINING FULLY EMBEDDED SPELLS AND NO PERIODS OF NO ACTIVITY, GO TO SECTION I, EDUCATION AND CAREER GOALS.
IF ANY FULLY EMBEDDED SCHOOL SPELLS WERE DISCOVERED, RECOVER INFORMATION FOR OLDEST SUCH SPELL: I would like now to return to the time between [SPELL START DATE] and [SPELL END DATE] when you were attending [SCHOOL NAME] while working at [EMPLOYER NAME]. GO TO SCHOOL SPELL.
IF MULTIPLE FULLY EMBEDDED SCHOOL SPELLS WERE DISCOVERED, REPEAT B5 FOR EACH.
IF ANY FULLY EMBEDDED WORK SPELLS WERE DISCOVERED DURING SCHOOL SPELLS, RECOVER INFORMATION FOR OLDEST SUCH SPELL: I would like now to return to the time between [SPELL START DATE] and [SPELL END DATE] when you were working at [EMPLOYER NAME] while going to school at [SCHOOL NAME]. GO TO JOB SPELL.
IF MULTIPLE FULLY EMBEDDED WORK WHILE AT SCHOOL SPELLS WERE DISCOVERED, REPEAT B6 FOR EACH.
IF ANY FULLY EMBEDDED WORK SPELLS WERE DISCOVERED DURING OTHER WORK SPELLS, RECOVER INFORMATION FOR OLDEST SUCH SPELL: I would like now to return to the time between [SPELL START DATE] and [SPELL END DATE] when you were working at [EMPLOYER NAME] while also working at [EMPLOYER NAME]. GO TO JOB SPELL.
IF MULTIPLE FULLY EMBEDDED WORK WITHIN WORK SPELLS WERE DISCOVERED, REPEAT B7 FOR EACH.
CATI/CAPI: REVIEW START AND END DATES OF EACH SPELL. IF ANY SPELL HAS A PERIOD OF MISSING ACTIVITY.. IF NO MISSING PERIODS OF FOUR MONTHS OR LONGER, GO TO QUESTION I4 IN SECTION I, EDUCATION AND CAREER GOALS
We are almost done talking about your employment and training history. Before we go on to other topics, according to my notes between [GAP START DATE] and [GAP END DATE], you were neither working nor going to school. Is that correct?
INTERVIEWER: IF NO, PROBE TO DETERMINE IF R WAS WORKING OR WAS IN SCHOOL.
YES
NO, R WAS WORKING [GO TO SECTION F, JOB SPELL]
NO, R HAD SCHOOL SPELL [GO TO SECTION C, SCHOOL SPELL]
NO, R WAS WORKING AND HAD A SCHOOL SPELL [GO TO SECTION F, JOB SPELL]
What was the main reason you did not have a job during that time?
DID NOT WANT TO WORK
COULD NOT FIND A JOB
UNABLE TO WORK BECAUSE OF INJURY, ILLNESS, OR DISABILITY
OTHER, SPECIFY: ____________________________
DON’T KNOW
REFUSED
What was the main reason you could not go to school during that time?
DID NOT WANT TO GO TO SCHOOL
COULD NOT GET INTO ANY SCHOOLS I WANTED
COULD NOT AFFORD IT
NOT ENOUGH TIME
UNABLE TO GO TO SCHOOL BECAUSE OF INJURY, ILLNESS, OR DISABILITY
INCARCERATED
PREGNANCY/CHILDBIRTH
FAMILY RESPONSIBILITIES
TRANSPORTATION
INCARCERATED
PREGNANCY/CHILDBIRTH
FAMILY RESPONSIBILITIES
TRANSPORTATION
OTHER, SPECIFY: ____________________________
DON’T KNOW
REFUSED
GO TO QUESTION I4 IN SECTION I, EDUCATION AND CAREER GOALS
C.. School Spell
IF OVERLAPPING/embedded SCHOOL spell: You already mentioned that in [start date] you started taking classes at [SCHOOL NAME], [GO TO C4]. OTHERWISE, CONTINUE.
[IF B1=SCHOOL AT RAD:] What is the name of the place where you were taking classes at in [MONTH AND YEAR OF RAD]?
[IF B3=SCHOOL OR B3=BOTH AND B4=SCHOOL :] What is the name of the place where you were taking classes?
[IF NEW SCHOOL:] What is the name of the next place where you were taking classes?
____________________ (CHECK SPELLING)
About when did you start taking classes at [SCHOOL NAME]? Please give me the month and year you started.
___ ___ / ___ ___ ___ ___
M M / Y Y Y Y
Are you still taking classes at [SCHOOL NAME]? If you are in between terms, please consider that as currently taking these classes.
YES
NO [SKIP TO C6]
REFUSED [SKIP TO C6]
DON’T KNOW [SKIP TO C6]
CATI NOTE: CURRENTLY ENROLLED [C3=YES OR E4C=STILL ATTENDING], USE WORDING1; IF NOT CURRENTLY ENROLLED [C3=NO OR E4C=NOT STILL ATTENDING], USE WORDING2.
While taking classes at [SCHOOL NAME], [have you been/were you] a student mainly full-time, mainly part-time, or an equal mix of full-time and part time?
FULL-TIME
PART-TIME
EQUAL MIX
REFUSED
DON’T KNOW
[Have you earned/did you earn] any regular college credits in these regular college classes at [SCHOOL NAME]?
YES
NO [SKIP TO C6]
REFUSED [SKIP TO C6]
DON’T KNOW [SKIP TO C6]
[IF YES]: How many credits [have you earned/did you earn]? ____________
REFUSED
DON’T KNOW
IF CURRENTLY ENROLLED [C3=YES], SKIP TO C8. IF FOCAL SCHOOL SPELL IS FULLY EMBEDDED SCHOOL SPELL, SKIP TO C7.OTHERWISE, CONTINUE.
About when did you stop taking classes at [SCHOOL NAME]? Please give me the month and year you last attended.
___ ___ / ___ ___ ___ ___
M M / Y Y Y Y
Did you complete your classes at [SCHOOL NAME], or did you stop without completing them?
COMPLETED the program (SKIP TO INSTRUCTIONS ABOVE C8)
STOPPED WITHOUT COMPLETING the program
REFUSED (SKIP TO Q16)
DON’T KNOW (SKIP TO Q16)
[IF STOPPED]: What was the main reason that you stopped taking classes at [SCHOOL NAME]?
POOR GRADES
TOO HARD/WASN’T GETTING IT
CLASSES OR PROGRAM POORLY TAUGHT
STARTED OTHER SCHOOL/TRAINING
NOT ENOUGH MONEY TO CONTINUE
NOT ENOUGH TIME TO CONTINUE
DIDN’T LIKE PROGRAM
LOST MOTIVATION
NOT INTERESTED IN PROGRAM
DIDN’T THINK IT WOULD HELP ME FIND A JOB
ILLNESS
PREGNANCY
CHILD CARE ISSUES
OTHER FAMILY REASONS
TRANSPORTATION/COORDINATION PROBLEMS
FOUND JOB/RE-EMPLOYED
OTHER (SPECIFY)____
REFUSED
DON’T KNOW
IF FOCAL SCHOOL SPELL IS CLASSIFIED AS A FULLY EMBEDDED SPELL, THEN RETURN TO INSTRUCTIONS AFTER B4 IN SECTION B.
While taking classes at [SCHOOL NAME], were there any periods of a month or more when you were not attending classes? Please do not include time when you were on school planned breaks such as spring, summer, or holiday breaks.
YES (GO TO SECTION D, GAP)
NO
REFUSED
DON’T KNOW
While you were taking classes at [SCHOOL NAME], were you also working for pay at a job for at least 4 weeks [IF WORKED DURING SCHOOL GAP [BOTH C8=YES AND D2=YES]: [different from the job you already told me about]?
Yes (GO TO QUESTION E1 IN SECTION E, OVERLAPPING SPELL)
No
Refused
Don’t know
IF THE RESPONDENT IS STILL ATTENDING THE SCHOOL THAT IS THE FOCUS OF THIS SPELL [C3=YES], THEN RETURN TO INSTRUCTIONS AFTER B4 IN SECTION B. OTHERWISE CONTINUE WITH C10.
After you stopped taking classes at [SCHOOL NAME] in [STOP DATE], what did you do next? Did you go to a new school, work at a job for pay or do other activities?
I WENT TO A NEW SCHOOL (REPEAT C1-C10 FOR THE NEXT SCHOOL)
I WORKED AT A JOB FOR PAY (GO TO SECTION F, JOB SPELL)
I DID OTHER ACTIVITIES (GO TO SECTION H, OTHER ACTIVITIES SPELL)
D. Gap
Please tell me a little more about that time you were not taking classes for a month or more while enrolled in [SCHOOL NAME].
When did you stop taking classes?
___ ___ / ___ ___ ___ ___
M M / Y Y Y Y
REFUSED
DON’T KNOW
When did you return to classes at [SCHOOL NAME]?
___ ___ / ___ ___ ___ ___
M M / Y Y Y Y
REFUSED
DON’T KNOW
Did you have a job during that period?
YES
NO [RETURN TO C9 IN SECTION C, SCHOOL SPELL TO COMPELTE QUESTIONS REGARDING FOCAL SCHOOL SPELL]
REFUSED
DON’T KNOW
What was the name of the employer? INTERVIEWER PROBE: Where did you work?
_____________ EMPLOYER NAME [THIS SPELL WILL BE TREATED AS A FULLY EMBEDDED WORK WITHIN SCHOOL SPELL]
IF VOLUNTEERED: Self-employed
Refused
Don’t know
When did you start working for [EMPLOYER]? Please tell me the month and year that you started.
_______ MONTH ________ YEAR
Refused
Don’t know
When did you stop working for [EMPLOYER]? Please give the month and year.
_______ MONTH ________ YEAR
Still employed
Refused
Don’t know
[RETURN TO C9 IN SECTION C, SCHOOL SPELL TO COMPELTE QUESTIONS REGARDING FOCAL SCHOOL SPELL]
E. Overlap Spell
Job during School Spell
I’d like to learn just a little bit about that job before we finish talking about your time at [SCHOOL].
What was the name of your employer? INTERVIEWER PROBE: Where did you work?
_____________ OVERLAPPING EMPLOYER NAME
IF VOLUNTEERED: Self-employed
Refused
Don’t know
When did you start working for [OVERLAPPING EMPLOYER]? Please tell me the month and year that you started.
_______ MONTH ________ YEAR
Refused
Don’t know
When did you stop working for [OVERLAPPING EMPLOYER]? Please give the month and year.
_______ MONTH ________ YEAR
Still employed
Refused
Don’t know
IF JOB END DATE IS BEFORE SCHOOL END DATE AT SCHOOL [E1C=BEFORE C6] = FULLY EMBEDDED SPELL, CONTINUE ELSE
OR STILL EMPLOYED [E1C=STILL EMPLOYED], CONTINUE.
IF JOB END DATE IS AFTER SCHOOL END DATE AT SCHOOL, GO TO SECTION F, JOB SPELL
Was that the only job you had while going to [school] or did you have other jobs while attending there? Please include only other paid jobs where you worked at least 6 hours per week.
I did not have any other jobs for pay [GO TO SECTION F, JOB SPELL QF.14]
I had more jobs for pay
Refused [GO TO SECTION F, JOB SPELL QF.14]
Don’t know [GO TO SECTION F, JOB SPELL QF.14]
What was the name of your other employer? INTERVIEWER PROBE: Where else did you work?
_____________ EMPLOYER3 NAME
IF VOLUNTEERED: Self-employed
Refused
Don’t know
When did you start working for [EMPLOYER3]? Please tell me the month and year that you started.
_______ MONTH ________ YEAR
Refused
Don’t know
When did you stop working for [EMPLOYER3]? Please give the month and year.
_______ MONTH ________ YEAR
Still employed
Refused
Don’t know
IF JOB END DATE IS BEFORE SCHOOL END DATE AT EMPLOYER1, REPEAT E2 AND E3.
IF JOB END DATE IS AFTER SCHOOL END DATE AT SCHOOL1, GO TO SECTION F, JOB SPELL
School During Job Spell
[IF SCHOOL SPELL REPORTED WITHIN WORK SPELL] I’d like to learn just a little bit about the classes you were taking while working for [EMPLOYER1].
What is the name of the place where you were taking classes at that time? (CHECK SPELLING)
____________________ SCHOOL
Refused
Don’t know
About when did you start taking classes at [SCHOOL]? Please give me the month and year you started.
___ ___ / ___ ___ ___ ___
M M / Y Y Y Y
Refused
Don’t know
About when did you stop taking classes at [SCHOOL]? Please give me the month and year you last attended.
___ ___ / ___ ___ ___ ___
M M / Y Y Y Y
Still attending
Refused
Don’t know
IF SCHOOL END DATE IS BEFORE JOB END DATE AT EMPLOYER1, CONTINUE.
IF SCHOOL END DATE IS AFTER JOB END DATE AT EMPLOYER1, GO TO SECTION C, SCHOOL SPELL
Was that the only school you attended while working at [EMPLOYER1] or did you also attend classes at other places while working there?
ONLY SCHOOL ATTENDED WHILE AT [EMPLOYER1] [RETURN TO INSTRUCTIONS AFTER F12 IN SECTION F, JOB SPELL FOR FOCAL JOB]
TOOK CLASSES AT ANOTHER PLACE AS WELL
REFUSED
DON’T KNOW
What is the name of the other place where you were taking classes at that time? (CHECK SPELLING)?
____________________ SCHOOL2
About when did you start taking classes at [SCHOOL2]? Please give me the month and year you started.
___ ___ / ___ ___ ___ ___
M M / Y Y Y Y
Refused
Don’t know
About when did you stop taking classes at [SCHOOL2]? Please give me the month and year you last attended.
___ ___ / ___ ___ ___ ___
M M / Y Y Y Y
Still attending
Refused
Don’t know
IF SCHOOL2 END DATE IS BEFORE JOB END DATE AT EMPLOYER1, REPEAT E5 AND E6.
IF SCHOOL2 END DATE IS AFTER JOB END DATE AT EMPLOYER1, GO TO SECTION C, SCHOOL SPELL
Job Spell During Job Spell
[IF WORK SPELL REPORTED WITHIN WORK SPELL:] I’d like to learn just a little bit about that second job before we finish talking about your time at [EMPLOYER].
What was the name of your other employer? INTERVIEWER PROBE: Where else did you work?
_____________ EMPLOYER2 NAMESelf-employed
Refused
Don’t know
When did you start working for [EMPLOYER2]? Please tell me the month and year that you started.
_______ MONTH ________ YEAR
Refused
Don’t know
What was the name of your other employer? INTERVIEWER PROBE: Where else did you work?
_____________ EMPLOYER3 NAME
Self-employed
Refused
Don’t know
When did you start working for [EMPLOYER3]? Please tell me the month and year that you started.
_______ MONTH ________ YEAR
Refused
Don’t know
When did you stop working for [EMPLOYER3]? Please give the month and year.
_______ MONTH ________ YEAR
Still employed
Refused
Don’t know
IF EMPLOYER3 END DATE IS BEFORE JOB END DATE AT EMPLOYER1, REPEAT E8 AND E9.
IF EMPLOYER3 END DATE IS AFTER JOB END DATE AT EMPLOYER1, GO TO SECTION F, JOB SPELL AND START TO GET ADDITIONAL INFORMATION ON EMPLOYER2
F. JOB SPELL
IF B1=JOB AT RAD OR NEW JOB: GO TO F1
IF B3=JOB or B3=both and b4=job: GO TO F1e
IF OVERLAPPING JOB: You already mentioned that in [start date] you started working for [employer]. GO TO F3
[IF JOB AT RAD:] What was the name of your employer in [MONTH AND YEAR OF RAD]?
[IF NEW JOB:] What was the name of your next employer?
INTERVIEWER PROBE: Where did you work?
_____________ EMPLOYER1 NAME (GO TO F2)
Self-employed
Don’t know(GO TO F2)
Refused(GO TO F2)
When did you start working for yourself? Please tell me the month and year that you started.
_______ MONTH ________ YEAR
Don’t know
Refused
How much did you earn per week working for yourself?
$ ___ ___ ___ ___ PER WEEK
Don’t know
Refused
[IF R DOESN’T KNOW WEEKLY RATE] Can you tell me how much you earned for some other time period besides weekly, such as per hour, per day, every two weeks, or month?
$ ___ ___ ___ ___ PER HOUR
$ ___ ___ ___ ___ PER DAY
$ ___ ___ ___ ___ EVERY 2 WEEKS/TWICE A MONTH
$ ___ ___ ___ ___ EVERY MONTH
$ ___ ___ ___ ___ PER JOB/PER PIECE
$ ___ ___ ___ ___ PER COMMISSION
$ ___ ___ ___ ___ ANNUALLY
Were you self-employed within the healthcare field?
Yes
No
Don’t know
Refused
When did you stop working for yourself? Please tell me the month and year that you stopped.
_______ MONTH ________ YEAR (GO TO F11)
IF VOLUNTEERED: STILL SELF-EMPLOYED (GO TO SECTION G
Don’t know (GO TO F11)
Refused (GO TO F11)
[IF FIRST JOB AFTER RA:] What was the name of your employer?
_____________ EMPLOYER1 NAME (GO TO F2)
Self-employed (GO TO F1A)
Don’t know(GO TO F2)
Refused(GO TO F2)
When did you start working for yourself? Please tell me the month and year that you started. RECORD RESPONSE ON SPELL DROPSHEET
_______ MONTH ________ YEAR
Don’t know
Refused
How much did you earn per week working for yourself?
$ ___ ___ ___ ___ PER WEEK (SKIP TO F1h)
Don’t know
Refused (SKIP TO F1h)
[IF F1g-DON’T KNOW] Can you tell me how much you earned for some other time period besides weekly, such as per hour, per day, every two weeks, or month?
$ ___ ___ ___ ___ PER HOUR
$ ___ ___ ___ ___ PER DAY
$ ___ ___ ___ ___ EVERY 2 WEEKS/TWICE A MONTH
$ ___ ___ ___ ___ EVERY MONTH
$ ___ ___ ___ ___ PER JOB/PER PIECE
$ ___ ___ ___ ___ PER COMMISSION
$ ___ ___ ___ ___ ANNUALLY
Were you self-employed within the healthcare field?
Yes
No
Don’t know
Refused
When did you stop working for yourself? Please tell me the month and year that you stopped. RECORD RESPONSE ON SPELL DROPSHEET
_______ MONTH ________ YEAR (GO TO F13)
IF VOLUNTEERED: Still self-employed (GO TO SECTION G, YELLOW BANNER)
Don’t know (GO TO F13)
Refused (GO TO F13)
When did you start working for [EMPLOYER]? Please tell me the month and year that you started.
_______ MONTH ________ YEAR
Don’t know
Refused
When you started working for [EMPLOYER], about how much did you typically earn per hour before taxes?
$ ___ ___ . ___ ___ PER HOUR
Don’t know
Refused
[IF R DOESN’T KNOW HOURLY RATE] Can you tell me how much you earned for some other time period besides hourly, such as per day, per week, every two weeks, or month?
$ ___ ___ ___ ___ PER DAY
$ ___ ___ ___ ___ PER WEEK
$ ___ ___ ___ ___ EVERY 2 WEEKS/TWICE A MONTH
$ ___ ___ ___ ___ EVERY MONTH
$ ___ ___ ___ ___ PER JOB/PER PIECE
$ ___ ___ ___ ___ PER COMMISSION
$ ___ ___ ___ ___ ANNUALLY
When you started working for [EMPLOYER], about how many hours a week did you work in a typical week?
_____ HOURS PER WEEK
Don’t know
Refused
[SKIP FOR FULLY EMBEDDED WORK SPELLS WITHIN WORK/SCHOOL SPELLS] Are you still working for [EMPLOYER]?
Yes
No [SKIP TO F6]
Don’t know [SKIP TO F6]
Refused [SKIP TO F6]
About how much do you typically earn per hour before taxes in your current job at [EMPLOYER] now?
$ ___ ___ . ___ ___ PER HOUR
Don’t know
Refused
[IF R DOESN’T KNOW HOURLY RATE] Can you tell me how much you earned for some other time period besides hourly, such as per day, per week, every two weeks, or month?
$ ___ ___ ___ ___ PER DAY
$ ___ ___ ___ ___ PER WEEK
$ ___ ___ ___ ___ EVERY 2 WEEKS/TWICE A MONTH
$ ___ ___ ___ ___ EVERY MONTH
$ ___ ___ ___ ___ PER JOB/PER PIECE
$ ___ ___ ___ ___ PER COMMISSION
$ ___ ___ ___ ___ ANNUALLY
How many hours per week on average are you currently working at [EMPLOYER]?
___ ___ hours/week
Refused
Don’t know
GO TO SECTION G, JOB CONDITIONS
[SKIP FOR FULLY EMBEDDED WORK SPELLS WITHIN WORK/SCHOOL SPELLS] Was [EMPLOYER] your last employer? INTERVIEWER PROBE: Is [EMPLOYER] the only employer you have worked for since [MONTH AND YEAR OF RAD]?
Yes (GO TO SECTION G, JOB CONDITIONS)
No
Don’t know
Refused
Towards the end of your job with [EMPLOYER], about how much did you typically earn per hour before taxes?
$ ___ ___ . ___ ___ PER HOUR
Don’t know
Refused
[IF R DOESN’T KNOW HOURLY RATE] Can you tell me how much you earned for some other time period besides hourly, such as per day, per week, every two weeks, or month?
$ ___ ___ ___ ___ PER DAY
$ ___ ___ ___ ___ PER WEEK
$ ___ ___ ___ ___ EVERY 2 WEEKS/TWICE A MONTH
$ ___ ___ ___ ___ EVERY MONTH
$ ___ ___ ___ ___ PER JOB/PER PIECE
$ ___ ___ ___ ___ PER COMMISSION
$ ___ ___ ___ ___ ANNUALLY
Towards the end of your job with [EMPLOYER], about how many hours a week did you work in a typical week?
_____ HOURS PER WEEK
Don’t know
Refused
[SKIP FOR FULLY EMBEDDED WORK SPELLS WITHIN JOB/SCHOOL SPELLS] When did you stop working for [EMPLOYER]? Please give the month and year.
_______ MONTH ________ YEAR
Don’t know
Refused
Why did you stop working for [EMPLOYER]? Did you lose or quit that job, or was it a temporary job that ended?
LOST JOB (SKIP TO F11)
QUIT JOB
TEMPORARY JOB ENDED (SKIP TO F11)
DON’T KNOW (SKIP TO F11)
REFUSED (SKIP TO F11)
[IF QUIT:] What was the main reason you quit working for [EMPLOYER]?
GOT A NEW/DIFFERENT JOB
WENT BACK TO SCHOOL
UNABLE TO WORK BECAUSE OF INJURY, ILLNESS, OR DISABILITY
INCARCERATED
PREGNANCY/CHILDBIRTH
FAMILY RESPONSIBILITIES
NOT INTERESTED IN WORKING
DIDN’T LIKE THE TYPE OF WORK I WAS DOING
DIDN’T LIKE OR GET ALONG WITH THE PEOPLE I WORKED WITH
OTHER. (SPECIFY: ________________)
DON’T KNOW
REFUSED
[SKIP FOR FULLY EMBEDDED WORK SPELLS WITHIN JOB/SCHOOL SPELLS] While you were working for [EMPLOYER], were you working at any other jobs for pay for at least 6 hours a week?
Yes (GO TO E7 IN SECTION E, OVERLAP SPELL)
No
Don’t know
Refused
[SKIP FOR FULLY EMBEDDED WORK SPELLS WITHIN JOB/SCHOOL SPELLS] While you were working for [EMPLOYER], were you also going to school or taking classes?
Yes (GO TO E4 IN SECTION E, OVERLAP SPELL)
No
Don’t know
Refused
IF QUESTION F10A = GOT A NEW/DIFFERENT JOB, REPEAT SECTION F, JOB SPELL
IF QUESTION F10A = WENT BACK TO SCHOOL, GO TO SECTION C, SCHOOL SPELL
IF OPEN-ENDED SPELL COVERING THE CURRENT DAY HAS BEEN COMPLETED, RETURN SECTION B, EMPLOYMENT AND TRAINING HISTORY, TO INSTRUCTIONS FOLLOWING QUESTION B4
IF ALL FULLY EMBEDDED WORK SPELLS WITHIN JOB/SCHOOL SPELLS COMPLETED, RETURN TO INSTRUCTIONS BEFORE B8 IN SECTION B, EMPLOYMENT AND TRAINING HISTORY
OTHERWISE, GO TO SECTION H, OTHER SPELL
G. JOB CONDITIONS
CATI NOTE: IF THIS IS ABOUT THE RESPNDENTS’ CURRENT JOB [F5=YES], USE WORDING1; IF THIS IS ABOUT THE RESPONDENTS’ MOST RECENT JOB [F6=YES], USE WORDING2.
This next set of questions is about your [current job/most recent job].
What kind of work do you do in your current job, that is, what is your occupation? If you have more than one job, please answer for your main job.
________________________________________________________________________
Refused
Don’t know
What [are/were] your usual activities or duties at this job? (For example, typing, keeping account books, filing, selling cars, operating printing press, taking blood samples)
________________________________________________________________________
Refused
Don’t know
What [is/was] your job title? ________________________________________________________________________
Refused
Don’t know
IF RESPONDENT NOT ASSOCIATED WITH AN HPOG/ISIS SITE, SKIP TO G5
I am sorry if this is obvious, is this occupation in the field of healthcare?
YES
NO
REFUSED
DON’T KNOW
[Do/Did] you usually work a regular daytime schedule or some other schedule at [EMPLOYER]?
A REGULAR DAYTIME SCHEDULE (ANYTIME BETWEEN 6AM TO 6PM)
SOME OTHER SCHEDULE
REFUSED
DON’T KNOW
Which of the following best describes the hours you usually (work/worked) at [EMPLOYER]?
A regular evening shift (Anytime between 2 pm to Midnight),
A regular night shift (Anytime around 9pm to 8am),
A rotating shift - one that changes periodically from day to evenings or night,
A split shift - one consisting of two distinct periods each day,
An irregular schedule arranged by employer, or
Some other schedule? (SPECIFY)
REFUSED
DON’T KNOW
How much do you agree or disagree with the following statements about your job at [EMPLOYER]:
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Strongly agree |
Somewhat agree |
Somewhat disagree |
Strongly disagree |
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[Are/Were] any of the following benefits available to you at [EMPLOYER]? If you [had] wanted it, [can you receive/could you have received]:
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Yes |
No |
Refused |
Don’t Know |
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For each of the following statements, I want you to tell me how much it [applies/applied] to your job at [EMPLOYER].
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How much do you agree or disagree with the following statement: There [are/were] many opportunities for career advancement for me with my [current/last] employer. Would you say you…
Strongly agree
Agree
Disagree
Strongly disagree
Refused
Don’t know
How closely related [is/was] your job at [EMPLOYER] to the education and training you had when you were last in school or training? Would you say…
Closely related
Somewhat related
Not related
REFUSED
DON’T KNOW
IF RESPONDENT NOT ASSOCIATED WITH AN HPOG/ISIS SITE OR IF RESPONDENT IS ASSOCIATED WITH AN HPOG/ISIS SITE BUT JOB IS NOT IN HEALTHCARE [G4= NO], SKIP TO INTRODUCTION ABOVE G12
How much do you agree or disagree with the following statement: The education or training you had when you were last in school or training prepared you well for work in the healthcare field? Would you say you...
Strongly agree
Agree
Disagree
Strongly disagree
REFUSED
DON’T KNOW
Now we would like to ask you about any formal job training you have received from your [current/last] employer.
Think about the skills that [are/were] needed for doing your job as a(n) [job name]. [Have you participated/Did you participate] in a formal training program offered by your employer or a union that helped you learn or improve the skills needed to do your job?
Yes
No
REFUSED
DON’T KNOW
IF CURRENT JOB, RETURN TO SECTION F, JOB SPELL, AT QUESTION F.13
IF MOST RECENT JOB (CURRENTLY NOT EMPLOYED), RETURN TO SECTION F, JOB SPELL, AT QUESTION F. 11
H. OTHER SPELL
So [your job ended on ****/you left/finished [SCHOOL] on ****] and you did not immediately get a [new] job or switch to a [new] school.
After [your job ended/your left school] what was your main activity at that time were you…?
Enrolled in classes and waiting for classes to start or in between terms
Waiting to start a new job
Looking for a job
Caring for your children or other family members
Dealing with health issues such as illness, injury, or pregnancy
Other
Refused
Don’t know
Did you ever work for pay, take classes, or do both after [DATE LAST JOB OR SCHOOL SPELL ENDED]
YES, WORKED FOR PAY [GO TO SECTION F, JOB SPELL; MODIFY WORDING TO REFLECT DELAY]
YES, WENT TO SCHOOL/TOOK CLASSES [GO TO SECTION C, SCHOOL SPELL; MODIFY WORDING TO REFLECT DELAY]
YES, BOTH
NO [GO TO SECTION I, EDUCATION AND CAREER GOALS]
REFUSED [GO TO SECTION I, EDUCATION AND CAREER GOALS]
DON’T KNOW [GO TO SECTION I, EDUCATION AND CAREER GOALS]
Which did you do first?
WORKED FOR PAY [GO TO SECTION F, JOB SPELL; MODIFY WORDING TO REFLECT DELAY]
WENT TO SCHOOL/TOOK CLASSES [GO TO SECTION C, SCHOOL SPELL; MODIFY WORDING TO REFLECT DELAY]
I. Education And Career Goals
IF NO SCHOOL SPELLSDISCOVERED IN SECTION B, SKIP TO I4. OTHERWISE, CONTINUE.
Now I’m going to ask you questions about your overall training experience since [RA MONTH YEAR].
Since [RA MONTH AND YEAR], have you taken classes to prepare for work in a particular occupation?
YES
NO (SKIP TO I2)
REFUSED (SKIP TO I2)
DON’T KNOW (SKIP TO I2)
What occupation or occupations was/were the classes preparing you for?
________________________________________________________________________
Refused
Don’t know
Did you start any occupational training that you did not complete?
YES
NO
REFUSED
DON’T KNOW
IF RESONDENT NOT ASSOCIATED WITH HPOG/ISIS SITES, SKIP TO I2
Earlier, you reported taking classes to prepare for work in [PREVIOUSLY REPORTED TARGET OCCUPATION(S)]. I am sorry if this obvious, but would you say that [CATI: USE SECOND WORDING IF MORE THAN ONE TARGET OCCUPATION LISTED: this occupation is || overall you are preparing for work] in the field of healthcare?
YES
NO (SKIP TO I2)
REFUSED (SKIP TO I2)
DON’T KNOW (SKIP TO I2)
[IF I1c=YES]: Did you start any healthcare occupational training that you did not complete?
YES
NO
REFUSED
DON’T KNOW
Since [RA MONTH AND YEAR], have you received a diploma/certificate or academic degree for completing any regular college classes?
YES
NO (SKIP TO I3)
REFUSED (SKIP TO I3)
DON’T KNOW (SKIP TO I3)
How many diploma, certificate or academic degrees have you received since [RA MONTHand YEAR]?
#___________________
[IF YES:] What kind of diploma/certificate or degree have you received? MARK ALL THAT APPLY
a diploma/certificate requiring less than a full year’s worth of credit
a diploma/certificate requiring a full year or more’s worth of credit (but less than an Associate’s Degree)
an Associate’s Degree
Bachelor’s degree or higher
Other (specify)
REFUSED
DON’T KNOW
IF MORE THAN ONE DIPLOMA/CERTIFICATE OR DEGREE, REPEAT B-c FOR EACH ONE
IF RESONDENT NOT ASSOCIATED WITH HPOG/ISIS SITES, SKIP TO I2C
Is this [DIPLOMA/CERTIFICATE/DEGREE] related to working in the field of healthcare?
YES
NO
REFUSED
DON’T KNOW
When did you receive the [DIPLOMA/CERTIFICATE/DEGREE]? Please give me the month and year.
___ ___ / ___ ___ ___ ___
M M / Y Y Y Y
REFUSED
DON’T KNOW
Since [RA MONTH AND YEAR], have you received any diplomas or certificates for completing any vocational training?
YES
NO (SKIP TO I3d)
REFUSED (SKIP TO I3d)
DON’T KNOW (SKIP TO I3d)
i, How many diploma/certificate or academic degrees have you received for vocational training since [RA MONTHand YEAR]?
#___________________
IF MORE THAN ONE DIPLOMA OR CERTIFICATE, REPEAT a-c FOR EACH ONE
What is the name of the diploma or certificate you received?
________________________________________________________________________
Refused
Don’t know
IF RESONDENT NOT ASSOCIATED WITH HPOG/ISIS SITES, SKIP TO I3C
Is this diploma or certificate related to working in the field of healthcare?
YES
NO
REFUSED
DON’T KNOW
When did you receive the [DIPLOMA/CERTIFICATE]? Please give me the month and year.
___ ___ / ___ ___ ___ ___
M M / Y Y Y Y
REFUSED
DON’T KNOW
Since [RA MONTH AND YEAR], have you received a professional, state, or industry certification, license, or credential? PROBE: A professional certification or license shows you are qualified to perform a specific job like Licensed Realtor, Certified Medical Assistant, Certified Construction Manager, or an IT certification.
YES
NO (SKIP TO I4)
REFUSED (SKIP TO I4)
DON’T KNOW (SKIP TO I4)
IF MORE THAN ONE CERTIFICATION, LISCENSE, OR CREDENTIAL, REPEAT e-h FOR EACH ONE
What is the name of the professional, state, or industry certification, license, or credential you received?
________________________________________________________________________
Refused
Don’t know
Is this certification, license, or credential related to working in the field of healthcare?
YES
NO
REFUSED
DON’T KNOW
When did you receive the [CERTIFICATION/LISCENSE/CREDENTIAL]? Please give me the month and year.
___ ___ / ___ ___ ___ ___
M M / Y Y Y Y
REFUSED
DON’T KNOW
What entity issued the [CERTIFICATION/LISCENSE/CREDENTIAL]?
YES
NO
REFUSED
DON’T KNOW
In the next set of questions we are interested the highest level of education you eventually expect to complete. I will first ask about the highest academic degree and then I will ask about the highest level of occupational training.
What is the highest level of regular academic education that you eventually expect to complete?
Grades 1-12 (no high school degree/GED)
High school diploma
GED or alternative credential
Some college credit but less than one year of college credit
One or more years of college credit, but no degree
Associate’s degree (SKIP TO I5)
Bachelor’s degree (SKIP TO I5)
Graduate degree (SKIP TO I5)
REFUSED
DON’T KNOW
IF I4a=ASSOCIATE’S, BACHELOR’S OR GRADUATE DEGREE, SKIP TO I5
Do you expect to receive: [MARK ALL THAT APPLY]
A vocational certificate or diploma issued by a technical college or institute?
A professional, state, or industry certification, license, or credential. PROBE: A professional certification or license shows you are qualified to perform a specific job like Licensed Realtor, Certified Medical Assistant, Certified Construction Manager, or an IT certification.
REFUSED
DON’T KNOW
How much do you agree or disagree with the following statement: I am making progress towards my long-range educational goals? Would you say you…
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
REFUSED
DON’T KNOW
I am going to read you two statements. Please tell me whether you would you say you strongly agree, somewhat agree, somewhat disagree, or strongly disagree with the following statements:
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Strongly agree |
Somewhat agree |
Somewhat disagree |
Strongly disagree |
Refused |
Don’t know |
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J. Services And Assistance
IF RESPONDENT IS NOT ASSOCIATED WITH VIDA, SAN DIEGO, OR INSTITUTO, SKIP TO SECTION K.
In some cities and communities, there are community organizations that help students get into college and then offer further supports while they are in college such as scholarships and group discussions of the challenges that students face in college. I am going to name services that such organizations sometimes provide. These same services can also be provided by colleges. We are only interested in services you received from a community organization, please do not include services provided by a college.. For each service, please tell me if have you received any assistance from such organizations since [RAD]:
Please include any services or assistance you received from [PROGRAM NAME] in your response.
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Yes |
No |
Refused |
Don’t Know |
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K. 21st Century Skills
The next set of questions cover a wide range of beliefs and attitudes about yourself and life in general.
I’m going to read some statements about how people approach various tasks in life. For each, please tell me if you strongly agree, somewhat agree, somewhat disagree, or strongly disagree that the statement applies to you. Be honest—there are no right or wrong answers!
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
REF
DK
a.
New ideas and projects sometimes distract me from previous ones.
b.
Setbacks don’t discourage me.
c.
I have been obsessed with a certain idea or project for a short time but later lost interest.
d.
I am a hard worker.
e.
I often set a goal but later choose to pursue a different one.
f.
I often have difficulty maintaining my focus on projects that take more than a few months to complete.
g.
I finish whatever I begin.
h.
I am diligent.
[INTRODUCE K2:] The following contains a series of statements you might use to describe your behavior, opinions, interests, and feelings. Some are quite general while others ask about your feelings at work or school. If you are not currently working or going to school, please think about how you would respond if you were.
After I read each statement please decide how it describes you using the following scale: Strongly disagree, moderately disagree, slightly disagree, slightly agree, moderately agree, strongly agree. Please don’t spend too much time deciding on any one answer. Although some items are similar, answer each without considering your other answers.
Reviewer Note: scales below from copyrighted ACT Inc. instruments, only allowed to show illustrative items.
Academic self-confidence scale (12 items) measures a student’s commitment to staying in school and getting a credential. Illustrative items:
I am a fast learner
I am less talented than other students (reverse-coded)
Now I’m going to read a series of statements about your feelings about different aspects of life. For each one, please tell me whether you strongly agree, somewhat agree, somewhat disagree, or strongly disagree with that statement:
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Strongly agree |
Somewhat agree |
Somewhat disagree |
Strongly disagree |
REF |
DK |
a. |
I am confident I get the success I deserve in life. |
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b. |
Sometimes I feel depressed. |
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c. |
When I try, I generally succeed. |
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d. |
Sometimes when I fail I feel worthless. |
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e. |
I complete tasks successfully. |
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f. |
Sometimes, I do not feel in control of my work. |
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g. |
Overall, I am satisfied with myself. |
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h. |
I am filled with doubts about my competence. |
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i. |
I determine what will happen in my life. |
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j. |
I do not feel in control of my success in my career. |
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k. |
I am capable of coping with most of my problems. |
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l. |
There are times when things look pretty bleak and hopeless to me. |
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Now I’d like to talk to you a bit about your education and career goals.
Say you needed advice or help in taking a next step on a career pathway of interest to you. Please tell me if there is anyone you’d be comfortable turning to:
YES
NO
REF
DK
a.
Who has a college degree?
b.
Who is currently going to college?
c.
Who works at a local college, either as a teacher or staff member providing help to applicants or students?
d.
Who works for a local community organization helping people find education and training, work, and related supports?
e.
Who works in an occupation of interest to you?
f.
Who has a management job in a work setting matching to your career interests?
The following statements are about help from other people. Please indicate whether you strongly agree, somewhat agree, somewhat disagree, or strongly disagree with each item.
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
REF
DK
a.
There are people I can depend on to help me if I really need it.
b.
I feel that I do not have close personal relationships with other people.
c.
There is no one I can turn to for guidance in times of stress.
d.
There are people who enjoy the same social activities that I do.
e.
I do not think other people respect my skills and abilities.
f.
If something went wrong, no one would come to my assistance.
g.
I have close relationships that provide me with a sense of emotional security and well-being.
h.
I have relationships where my competence and skills are recognized.
i.
There is no one who shares my interests and concerns.
j.
There is a trustworthy person I could turn to for advice if I were having problems.
When it comes to careers, some people are more certain than others that they know where they are headed and how to get there. Please indicate for each item whether you strongly agree, somewhat agree, somewhat disagree, or strongly disagree that it reflects your career situation:
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
REF
DK
a.
I’m not sure how to accurately assess my abilities and challenges.
b.
I know how to make a plan that will help me achieve my goals for the next 5 years.
c.
I know how to get help from staff and teachers with any issues that might arise when I am at school.
d.
I’m not sure what type of job is best for me.
e.
I know the type of employer I want to work for.
f.
I know the occupation I want to be in.
g.
I’m not sure what kind of education and training program is best for me.
In the past 12 months, please note how often each of the following situations interfered with your school, work, job search, or family responsibilities: very often, fairly often, sometimes, almost never, or never.
Very often
Fairly often
Sometimes
Almost never
Never
REF
DK
a.
Child care arrangements?
b.
Transportation?
c.
Alcohol or drug use?
d.
An illness or health condition?
e.
Another situation?
In the past month, how often have you felt: very often, fairly often, sometimes, almost never, or never.
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Very often |
Fairly often |
Sometimes |
Almost never |
Never |
REF |
DK |
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a. |
That you were unable to control the important things in life? |
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b. |
Confident about your ability to handle your personal problems? |
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c. |
That things were going your way? |
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d. |
That difficulties were piling up so high that you could not overcome them? |
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With regard to the English language, how well do you:
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Very Well |
Well |
Not Well |
Not At All |
REF |
DK |
a. |
Understand it when it is spoken to you? |
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b. |
Speak it? |
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c. |
Read it? |
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d. |
Write it? |
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L. HOUSEHOLD COMPOSITION
Now I’d like to talk to you about your family and current household.
Besides you, who among the following live in your household at least half the time?
Your spouse
Yes (SKIP TO L1C)
No
Refused
Don’t know
: Your unmarried partner
Yes
No
Refused
Don’t know
Your [IF L1A=YES: or your spouse’s/IF L1B=YES: or your partner’s] biological, adopted, or step children aged 17 or younger
Yes
No
Refused
Don’t know
Your [IF L1A=YES: or your spouse’s/IF L1B=YES: or your partner’s] other relatives aged 17 or younger such as younger siblings, nephews and nieces
Yes
No
Refused
Don’t know
Your [IF L1A=YES: or your spouse’s/IF L1B=YES: or your partner’s] mother or father
Yes
No
Refused
Don’t know
Your [IF L1A=YES: or your spouse’s/IF L1B=YES: or your partner’s] adult children or other relatives aged 18 or older
Yes
No
Refused
Don’t know
Anyone else aged 17 or younger such as children of friends or housemates
Yes
No
Refused
Don’t know
Anyone else aged 18 or older such as friends or housemates
Yes
No
Refused
Don’t know
ASK L2 ONLY IF L1C OR L1D OR L1G =YES; ELSE SKIP TO NOTE BEFORE L4.
How many persons aged 17 or younger live with you at least half the time? Include biological, adopted, foster, step, and any other children, as well as younger siblings.
___ ___ number of persons aged 17 or younger
Refused
Don’t know
For how many of these children are you [IF L1A=YES: or your spouse/IF L1B=YES: or your partner] the legal guardian?
___ ___ number of children
Refused
Don’t know
IF GENDER= MALE AND (L1A AND L1B=NO) SKIP TO SECTION M
[IF GENDER= FEMALE: Are you/[IF L1A=YES: Is your spouse/IF L1B=YES: Is your partner] currently pregnant?
YES
NO
REFUSED
DON’T KNOW
[IF RESPONDENT IS FEMALE: Have you/IF L1A=YES: Has your spouse/IF L1B=YES: Has your partner] had a baby since [MONTH AND YEAR OF RAD]?
YES
NO
REFUSED
DON’T KNOW
M. Income and MATERIAL WELL-BEING
Now, I am going to ask you some questions about your personal and household income in [PRIOR MONTH]. Again, I want to assure you that none of your answers will be discussed with anyone. [IF RESPENDENT HAS OTHER HOUSEHOLD MEMBERS [L1A-H = YES]:] I will ask you first about your personal income then I will ask about the income of other members of your household.
Did you personally have income or benefits from any of the following sources in [PRIOR MONTH]?
-
Yes
No
Don’t know
Refused
Temporary Assistance for Needy Families (TANF)
Supplemental Nutrition Assistance Program (SNAP) / Food Stamps
Women, Infants and Children Program (WIC)
Unemployment Insurance (UI) or Worker’s Compensation
Medicaid
Subsidized Child Care
Section 8 / Public Housing
Low Income Home Energy Assistance Program (LIHEAP)
Free or reduced lunch program
Child Support (official or unofficial)
Family and friends (who did not live with you at least half of the time last month)
Other source of income. Please specify.
Thinking of all of the income you received last month, what was your total personal income in [PRIOR MONTH]? Please include your job earnings, benefits, and any other types of income except for tax refunds in your answer. (If needed: Please do not include any refunds of federal, state, or local income taxes you paid in past years.)
$ ____________________ (GO TO INSTRUCTIONS BELOW M2A)
Refused
Don’t know
Would you say your total personal income in [PRIOR MONTH] was…
None ($0)
$500 or less
$501-$1000
$1001-$1500
$1501-$2000
$2001-$2500
$2501 or more
Refused
Don’t know
IF RESPENDENT HAS NO OTHER HOUSEHOLD MEMBERS [L1A-H = NO], SKIP TO M5.
IF RESPENDENT HAS OTHER HOUSEHOLD MEMBERS [L1A-H = YES], CONTINUE.
.
Now, let’s go through the same list of income sources for other household members who lived with you at least half the time last month. In [PRIOR MONTH] did anyone else in your household have income or benefits from any of the following sources?
-
YES
NO
Don’t know
Refused
Temporary Assistance for Needy Families (TANF)
Supplemental Nutrition Assistance Program (SNAP) / Food Stamps
Women, Infants and Children Program (WIC)
Unemployment Insurance (UI) or Worker’s Compensation
Medicaid
Subsidized Child Care
Section 8 / Public Housing
Low Income Home Energy Assistance Program (LIHEAP)
Free or reduced lunch program
Child Support (official or unofficial)
Family and friends (who did not live with you at least half of the time last month)
Other source of income. Please specify.
Thinking of all of the income received by you and the people in your household last month, what was your total income for everyone living together in your household in [PRIOR MONTH]?
Please consider anyone who lived in your household for at least half of [PRIOR MONTH] when you answer this question. (If necessary: Please do not include any refunds of federal, state or local income taxes paid in past years.)
$ ____________________ (SKIP TO M5)
Refused
Don’t know
Which of the following categories best describes your total household income? Please consider income received by anyone who lived in your household for at least half of [PRIOR MONTH] when you answer this question. Would you say your total household income in [PRIOR MONTH] was…
None ($0)
$1 to $500
$501-$1000
$1001-$1500
$1501-$2000
$2001-$2500
$2501 or more
Don’t know
Refused
Did you or will you claim the Earned Income Tax Credit for [PRIOR YEAR]?
YES
NO
REFUSED
DON’T KNOW
IF NO SCHOOL SPELLS DISCOVERED IN SECTION B, SKIP TO M8. OTHERWISE, CONTINUE.
The next few questions are about loans and other debt you may have.
About how much have you personally borrowed overall to go to school since [MONTH AND YEAR OF RAD]?
$___________________________ [SKIP TO M7]
REFUSED [SKIP TO M7]
DON’T KNOW
Would you say that the total amount of money you had to borrow was under $1000, between $1000 and $4999, between $5000 and $9999, or $10000 or more?
UNDER $1,000
$1,000 AND $4,999
$5,000 AND $9,999
$10,0000 OR MORE
REFUSED
DON’T KNOW
About how much have your parents borrowed overall to support you going to school since [MONTH AND YEAR OF RAD]?
$___________________________ [SKIP TO M8]
REFUSED [SKIP TO M8]
DON’T KNOW
Would you say that the total amount of money your parents borrowed was under $1000, between $1000 and $4999, between $5000 and $9999, or $10000 or more?
UNDER $1,000
$1,000 AND $4,999
$5,000 AND $9,999
$10,0000 OR MORE
REFUSED
DON’T KNOW
Now I’d like to ask some questions about your expenses.
Earlier, you reported that you have currently borrowed approximately [$ VALUE EDUCATIONAL DEBT] to pay for school. Now we want to ask about other debt. We are not interested in mortgage debt or car loan debt, but we are interested in the total amount you owe for other reasons, including debts incurred by your spouse if you are married. Please include outstanding balances on all other loans, credit cards and medical bills. Please also include any overdue child support payments. We don’t need an exact amount. Which of the following categories best describes the amount you [IF L1A=YES: and your spouse/IF L1B=YES: and your partner] currently owe IN TOTAL for things other than school, cars, and home?
Would you say your total other debt was…
$0
$1-$2,500
$2,501-$5,000
$5,001-$7,500
$7,501-$10,000
$10,001-$25,000
$25,001-$50,000
Over $50,000
Was there any time in the past 12 months when:
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YES |
NO |
REFUSED |
DON’T KNOW |
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Getting enough food can be a problem for some people. Which of these statements best describes the food eaten in your household in the past 6 months? Would you say there is . . .
Enough of the kinds of food you want
Enough but not always the kinds of food you want
Sometimes not enough to eat
Often not enough to eat
REFUSED
DON’T KNOW
Think again over the past 12 months. Generally, at the end of the month do you end up with: more than enough money left over, some money left over, just enough to make ends meet, or not enough to make ends meet?
ENOUGH MONEY LEFT
SOME MONEY LEFT
JUST ENOUGH MONEY LEFT
NOT ENOUGH MONEY LEFT
REFUSED
DON’T KNOW
IF CURRENTLY EMPLOYED [F5=YES OR E7C=STILL EMPLOYED]=] AND JOB PROVIDES HEALTH INSURANCE [I7A=YES], SKIP TO INTRODUCTION FOLLOWING M12. OTHERWISE, CONTINUE.
Do you have health insurance through some non-job related source such as Medicaid?
YES
NO
REFUSED
DON’T KNOW
Now I’d like to start by asking you some questions about your current housing situation.
Thinking about the place where you are currently living, do you:
Rent your home or apartment
Own your own home
Live with family or friends and pay part of the rent or mortgage
Live with family or friends and do not pay rent
Live in a group shelter or
Live in some other housing arrangement
REFUSED
DON’T KNOW
Which of the following statements best describes how satisfied you are with your neighborhood? Would you say you are...
Very satisfied
Somewhat satisfied
In the middle
Somewhat dissatisfied
Very dissatisfied
REFUSED
DON’T KNOW
IF RESPONDENT SAMPLE FILE INCLUDES A FOCAL CHILD, CONTINUE.
IF RESPONDENT SAMPLE FILE DOES NOT INCLUDE A FOCAL CHILD, GO TO SECTION R, CONTACT INFORMATION.
.
START TIME: ____:_____AM/PM
N. CHILD INTRODUCTION/SCREENER
In the next set of questions, we are interested in collecting more information on your family, particularly your children. Although we are interested in all of the children that you [IF L1a/L1b=YES: your spouse/partner] are the legal guardian for, the study can only collect data on one. . We
the children that you [IF L1a/L1b=YES: your spouse/partner] are the legal guardian for, the study can only collect data on one.
CATI/CAPI:
IF CHILD NAME AND DOB ARE IN SAMPLE FILE: We would like to ask about [CHILD NAME], who was born on [CHILD DOB].
IF CHILD NAME IS MISSING: We would like to ask about your child who was born on [CHILD DOB]. What is that child’s name___________________________.
IF CHILD DOB IS MISSING: We would like to ask about [CHILD NAME], could you please tell me when [CHILD NAME] was born? ______/______/_______.
These questions will cover topics such as your family activities and your relationship to your child’s school. Everything you tell me is completely private.. This information will be extremely valuable in understanding how programs like [LOCAL PROGRAM NAME] affect your family life.
Over the last 12 months, has {CHILD, born on DOB} lived with you at least half the time?.
Yes
No [GO TO SECTION R, CONTACT INFORMATION]
IF VOLUNTEERED: R DOES NOT HAVE A CHILD MATCHING THAT NAME OR DATE OF BIRTH GO TO SECTION R
Refused [GO TO SECTION R, CONTACT INFORMATION]
Don’t know [GO TO SECTION R, CONTACT INFORMATION]
[IF INTERVIEW TAKES PLACE DURING THE SCHOOL YEAR:] What grade is {CHILD} currently in?
[IF INTERVIEW TAKES PLACE DURING THE SUMMER:] What grade was {CHILD} in the last school year?
Pre-kindergarten (skip to o`1)
Kindergarten (skip to note before o3)
First grade (skip to note before o3)
Second grade (skip to note before o3)
Third grade (skip to note before o3)
Fourth grade (skip to note before o3)
FIFTH GRADE (skip to note before o3)
SIXTH GRADE (skip to note before o3)
SEVENTH GRADE (skip to note before o3)
EIGHTH GRADE (skip to note before o3)
NINTH GRADE (skip to note before o3)
TENTH GRADE (skip to note before o3)
ELEVENTH GRADE (skip to note before o3)
TWELTH GRADE (skip to note before o3)
NOT APPLICABLE, CHILD NOT IN SCHOOL
REFUSED (SKIP TO NOTE BEFORE O3)
DON’T KNOW (skip to note before o3)
[ASK IF N2=CHILD NOT IN SCHOOL:] when was {CHILD} last enrolled in school (month and year)?
_______ ______
Month Year
IF VOLUNTEERED: NEVER ENROLLED (SKIP TO NOTE AFTER N2b)
REFUSED (SKIP TO NOTE AFTER N2b)
DON’T KNOW (SKIP TO NOTE AFTER N2b)
[ASK IF N2a DOES NOT EQUAL ‘NEVER ENROLLED’:] What was the main reason {CHILD} left school at that time?
Expelled/suspended
Poor grades
Got married/pregnant/became a parent
School was dangerous
Didn’t get along with other students
Entered military
Became employed
Financial difficulties—couldn’t afford to go
Child care or other home responsibilities
Drugs or alcohol/other health problem
Refused
Don’t know
if cati/capi: if n2a date is >one year from interview date,, skip to section r, contact information
START TIME: ____:_____AM/PM
O. TIME OUT OF THE HOME/CHILD SUPERVISION
IF CHILD IS IN KINDERGARTEN THROUGH 12TH GRADE, GO TO INTRODUCTION BEFORE O3.
IF CHILD HAS NOT STARTED KINDERGARTEN, CONTINUE.
Preschool-Age Children
First I’d like to ask you some questions about child care arrangements you may have had for {CHILD}. For these questions, please think about a typical week in the last year.
During a typical week, does {CHILD} receive care from someone other than you [IF L1A=YES: or your spouse/IF L1B=YES: or your partner] on a regular basis? This could be from a relative, a babysitter, a child care center, or a preschool.
YES
NO [SKIP TO O7]
REFUSED [SKIP TO O7]
DON'T KNOW [SKIP TO O7]
Who provides this care? [READ LIST AND CHECK ALL THAT APPLY]
Head Start program
Day care center, child care center, nursery school or preschool (NOT public)
A public pre-kindergarten program
Babysitter or nanny (not a relative)
Family daycare (more than one child, not in child’s home)
Sibling
Adult relative in your home or their home
Other, Specify __________
Refused
Don’t know
How many total hours each week does {CHILD} attend these arrangements?
________hours
Refused
Don't know
GO TO QUESTION O7.
Children in Kindergarten through Twelfth Grade
First I’d like to ask you some questions about the people who care for {CHILD}. Different children need different amounts of supervision. For these questions, please think about a typical week in the last year.
Are you or another adult in the family usually present at home before {CHILD} leaves for school?
Yes
No [SKIP TO O4]
Refused [SKIP TO O4]
Don’t know [SKIP TO O4]
If yes, who is usually present?
You
Another adult
Both you and another adult
Refused
Don’t know
Are you or another adult in the family usually present at home after {CHILD} comes home from school?
Yes
No [SKIP TO O5]
Refused [SKIP TO O5]
Don’t know [SKIP TO O5]
If yes, who is usually present?
You
Another adult
Both you and another adult
Refused
Don’t know
Are you or another adult in the family usually present after dinner during the week?
Yes
No [SKIP TO O6]
Refused [SKIP TO O6]
Don’t know [SKIP TO O6]
If yes, who is usually present?
You
Another adult
Both you and another adult
Refused
Don’t know
Are you or another adult in the family usually present with {CHILD} during the weekend?
Yes
No [SKIP TO O7]
Refused [SKIP TO O7]
Don’t know [SKIP TO O7]
If yes, who is usually present?
You
Another adult
Both you and another adult
Refused
Don’t know
All Ages
Next I’d like to ask you some questions about family routines.
In a typical full 7-day week, including the weekend, how many times do you get to eat breakfast with {CHILD}?
____times/week
Refused
Don’t know
In a typical full 7-day week, including the weekend, how many times do you get to eat dinner with {CHILD}?
____times/week
Refused
Don’t know
Who usually puts {CHILD} to bed? [SELECT ALL THAT APPLY]
RESPONDENT
RESPONDENT SPOUSE/PARTNER
OTHER CHILD IN HOUSEHOLD
OTHER RELATIVE
ANOTHER ADULT IN THE HOUSEHOLD
OTHER ADULTS WHO DON’T LIVE IN HOUSEHOLD, (PLEASE SPECIFY:)
NO ONE, CHILD PUTS SELF TO BED
Refused
Don’t know
IF N2=CHILD IN 5TH GRADE OR BELOW, SKIP TO SECTION P.
Children in Sixth through Twelfth Grade
I’m going to read you a list of things a child might do during a typical week. For each of these, tell me how many hours does [CHILD] do each one. If [CHILD] doesn’t do the activity, let me know. Again, please think about a typical week in the last year.
How much time does {CHILD} usually spend during a typical week in each of these activities:
Activity |
# of Hours |
DOES NOT DO THIS ACTIVITY |
Don’t Know |
Refused |
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*IF O8a-g=DOES NOT DO ACTIVITY, CODE 0 HOURS.
What is the main activity that {CHILD} usually does in the hour after dinner during a typical week?
At home doing homework
Is at home listening to music
Is at home watching television, doing computer games
Is at home talking to friends on the phone or computer
Hangs out with friends
Takes care of a sibling at home
Attends an organized sports or other activity
Working in a job
OTHER SPECIFY:__________________________
Refused
Don’t know
P. EDUCATION-RELATED GOALS AND SUPPORT
Next are questions about your hopes and aspirations for {CHILD}.
Knowing {CHILD} as you do, how far do you think [he/she] will actually go in school? Do you think [he/she]
Some high school
Finish high school
Some technical school after high school
Finish technical school after high school
Some college
Finish college
Advanced degree after college (e.g. MA, MD, PhD, Law...)
Refused
Don’t know
How far does {CHILD} say [he/she] would like to go in school?
Some high school
Finish high school
Technical school after high school
Some college
Finish college
Advanced degree after college (e.g. MA, MD, PhD, Law...)
Refused
Don’t know
Now I’d like to talk about {CHILD}’s activities with family members. For these questions, please think about a typical week in the last year.
IF N2=CHILD IN KINDERGARTEN THROUGH TWELFTH GRADE, SKIP TO QUESTION P6.
Preschool-Age Children
In a typical week, how often do you or any other family member read books to or look at picture books with {CHILD}? Would you say …
Not at all
Once or twice a week
Three to six times a week
Every day
Refused
Don’t know
Have you or another family member helped {CHILD} to learn numbers or the alphabet?
Yes
No
Refused
Don’t know
Have you or another family member helped {CHILD} to learn colors or shapes and sizes?
Yes
No
Refused
Don’t know
SKIP TO P9
Children in Kindergarten through Twelfth Grade
In a typical week, how often do you talk to {CHILD} about [his/her] homework assignments or what [he/she] is learning in school?
Never
Once or twice a week
3 – 4 times a week
5 or more times a week
Refused
Don’t know
In a typical week, how often do you or someone in your family help {CHILD} with homework?
Never
Once or twice
3 – 4 times
5 or more times
Refused
Don’t know
In a typical week, how often do you or someone in your family discuss {CHILD}'s report card or grades with [him/her]?
NEVER
RARELY
SOMETIMES
ALWAYS
REFUSED
DON’T KNOW
All Ages
The next few questions are statements parents make about themselves. Please tell me how much you agree or disagree with each of the following statements: disagree very strongly, disagree, disagree just a little, agree just a little, agree, or agree very strongly.
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Disagree very strongly |
Disagree |
Disagree just a little |
Agree just a little |
Agree |
Agree very strongly |
Refused |
DK |
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Q. CHILD OUTCOMES
My last set of questions are about how {CHILD} is doing in school.
IF N2=KINDERGARTEN THROUGH FIFTH GRADE, SKIP TO Q7.
IF N2=SIXTH THROUGH TWELFTH GRADE, SKIP TO Q10.
Preschool-Age Children
How would you rate {CHILD}’s ability to express [him/herself] verbally, compared to other children at the same age?
Far below average
Below average
About average
Above average
Far above average
Refused
Don’t know
How would you rate {CHILD}’s early reading skills, compared to other children at the same age?
Far below average
Below average
About average
Above average
Far above average
Refused
Don’t know
How would you rate {CHILD}’s skills with math or numbers, compared to other children at the same age?
Far below average
Below average
About average
Above average
Far above average
Refused
Don’t know
How would you rate {CHILD}’s social skills in the following areas, compared to other children at the same age: far below average, below average, average, above average, or far above average?
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Far below average |
Below average |
Average |
Above average |
Far above average |
Refused |
DK |
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In the past year, how often has another adult (teacher, child care provider, relative) told you that {CHILD} has behavior problems?
3 or more times
1-2 times
Never
Refused
Don’t know
Has {CHILD} been asked to leave any preschool programs?
Yes
No
Refused
Don’t know
SKIP TO SECTION R, CONTACT INFORMATION.
Children in Kindergarten through Fifth Grade
[IF INTERVIEW TAKES PLACE DURING THE SUMMER OR CHILD NOT CURRENTLY ENROLLED IN SCHOOL:] Please think of the how {CHILD} was doing in school last year.
How would you rate {CHILD}’s social skills in the following areas, compared to other children at the same age: far below average, below average, average, above average, or far above average?
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Far below average |
Below average |
Average |
Above average |
Far above average |
Refused |
DK |
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Based on school and teacher reports, how well would you say {CHILD} is doing in reading:
Not well at all
Below average
About average
Well
Very well
Refused
Don’t know
Based on school and teacher reports, how well would you say {CHILD} is doing in math:
Not well at all
Below average
About average
Well
Very well
Refused
Don’t know
Children in Kindergarten through Twelfth Grade
Has {CHILD} repeated any grades in school?
Yes
No
Refused
Don’t know
How many days in the last month was {CHILD} absent from school for any reason? [IF ON SUMMER VACATION OR NOT ENROLLED:] In the last month that {CHILD} was enrolled in school, how many days was {CHILD} absent from school, for any reason?
5 or more days
3 or 4 days
1 or 2 days
0 days
Refused
Don’t know
How many days in the last month was your child late for school? [IF ON SUMMER VACATION OR NOT ENROLLED:] In the last month that {CHILD} was enrolled in school, how many days was {CHILD} late for school?
5 or more days
3 or 4 days
1 or 2 days
0 days
Refused
Don’t know
Since the beginning of this school year, how many times have any of {CHILD}’s teachers or [his/her] school contacted you or any adult in your household about any behavior problems [he/she] is having in school? [IF ON SUMMER VACATION OR NOT ENROLLED:] In the school year {CHILD} was last in school, how many times did any of {CHILD}’s teachers or [his/her] school contacted you or any adult in your household about any behavior problems [he/she] was having in school?
Never
Once or twice
Three or more times
Refused
Don’t know
Since the beginning of this school year, how many times have any of {CHILD}’s teachers or [his/her] school contacted you or any adult in your household about any problems [he/she] is having with school work? [IF ON SUMMER VACATION OR NOT ENROLLED:] In the school year {CHILD} was last in school, how many times did any of {CHILD}’s teachers or [his/her] school contact you or any adult in your household about any behavior problems [he/she] was having with school work?
Never
Once or twice
Three or more times
Refused
Don’t know
In the current school year, has your child been suspended or expelled from school? [IF ON SUMMER VACATION OR NOT ENROLLED:] In the school year {CHILD} was last in school, was your child suspended or expelled from school?
Yes
No
Refused
Don’t know
IF N2=5TH GRADE OR BELOW, SKIP TO SECTION R.
Children in Sixth through Twelfth Grade
Overall, what grades did {CHILD} receive in the last full year of school completed?
Mostly A’s
Mostly A’s and B’s
Mostly B’s
B’s and C’s
Mostly C’s
C’s and D’s
Mostly D’s
Mostly below D
Refused
Don’t know
Not applicable, school does not give out letter grades
[IF DOES NOT HAVE GRADES:] Is {CHILD}…
One of the best students in his/her class
Above the middle in his/her class
In the middle of his/her class
Below the middle of his/her class
Near the bottom of the class
Does not attend school at all.
DON'T KNOW
REFUSED
IF N2= 8TH GRADE OR BELOW, SKIP TO SECTION R,.
Has {CHILD} taken any of the following tests as part of college preparation:
a. Advanced Placement (AP) tests as part of AP course?
Yes
No
Refused
Don’t know
b. PSAT test?
Yes
No
Refused
Don’t know
c. SAT or ACT test?
Yes
No
Refused
Don’t know
R. CONTACT INFORMATION
RESPONDENT INFORMATION
Before we complete this portion of the interview, I would also like to make sure I have your contact information recorded correctly.
I have your name recorded as [FIRST MI LAST]. Is this still correct or have you changed your name?
YES, STILL CORRECT (SKIP TO R3)
NO, NAME CHANGED
What is your first name now?
What is your middle initial now?
What is your last name now?
I have your address recorded as [STREET, APT, CITY, STATE, ZIP]. Is this still correct or have you moved?
YES, STILL CORRECT (SKIP TO R4)
NO, MOVED
What your new street address or PO box number?
Is there a complex or building name?
Is there an apartment number?
In what city?
In what state?
What is the zip code?
I have your primary phone number recorded as [xxx-xxx-xxxx]. Is this still correct or do you have a new primary phone number?
YES, STILL CORRECT (SKIP TO R4)
NO, CHANGED
What is the new number, starting with the area code?
___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
Is that a home, cell, shelter, work, or other number?
Home
Cell
Shelter
Work
Other
c. IF CELL PHONE: Do we have your permission to contact you on that number via text message?
YES,
NO (SKIP TO R4)
Refused
Don’t know
d. Do we have your permission to contact you on that number via automated text message? An automated message is a prewritten message that is sent at a later date. Examples of an automated text message may be one that reminds you to complete a form or call to set up an appointment.
YES,
NO
Refused
Don’t know
I have your secondary phone number recorded as [xxx-xxx-xxxx]. Is this still correct or do you have a new secondary phone number?
YES, STILL CORRECT (SKIP TO R5)
NO, CHANGED
What is the new number, starting with the area code?
___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
Is that a home, cell, shelter, work, or other number?
Home
Cell
Shelter
Work
Other
c. IF CELL PHONE: Do we have your permission to contact you on that number via text message?
YES,
NO (SKIP TO R4)
Refused
Don’t know
d. Do we have your permission to contact you on that number via automated text message? An automated message is a prewritten message that is sent at a later date. Examples of an automated text message may be one that reminds you to complete a form or call to set up an appointment.
YES,
NO
Refused
Don’t know
Do you have another phone number where we can reach you?
YES, ADDITIONAL PHONE NUMBERS AVAILABLE
NO (SKIP TO R6)
What is the new number, starting with the area code?
___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
Is that a home, cell, shelter, work, or other number?
Home
Cell
Shelter
Work
Other
c. IF CELL PHONE: Do we have your permission to contact you on that number via text message?
YES,
NO (SKIP TO R4)
Refused
Don’t know
d. Do we have your permission to contact you on that number via automated text message? An automated message is a prewritten message that is sent at a later date. Examples of an automated text message may be one that reminds you to complete a form or call to set up an appointment.
YES,
NO
Refused
Don’t know
[REPEAT R5 UNTIL ALL PHONE NUMBERS ARE RECORDED]
I have your email address recorded as [[email protected]]. Is this still correct or do you have a new email address?
YES, STILL CORRECT (SKIP TO R7)
NO, CHANGED
What is your new email address?
Do you have any other email addresses?
YES, ADDITIONAL EMAIL ADDRESSES ARE AVAILABLE
NO (SKIP TO INSTRUCTIONS ABOVE R8)
What is additional email address?
[REPEAT R7 UNTIL ALL EMAIL ADDRESSES ARE LISTED]
To help us be able to get back in touch with you in the future, we would like to review the names, telephone numbers and addresses of two people we talked about last time we spoke who will always know how to reach you. This information will be kept strictly private and will only be used if we are unable to contact you.
When we last spoke on [RA MMYYY or Last Intvw MMYYYY] you said that [CONTACT #1] was a person who would always know where you are and how to reach you. Is [CONTACT#1] still a person who does not live with you and will always know how to contact you?
YES (VERIFY CONTACT INFORMATION)
NO
REFUSED
DON’T KNOW
IF NO: Could you please tell me the name of a person who does not live with you and will always know how to contact you?
YES
NO
REFUSED
DON’T KNOW
IF YES:
What is his/her first name?
What is his/her middle name?
What is his/her last name?
Does his/her name have a suffix?
What is the street address or PO box number?
Is there a complex or building name?
Is there an apartment number?
In what city?
In what state?
What is the zip code?
What is [his/her] home phone number, starting with the area code?
___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
What is [his/her] cell phone number, starting with the area code?
___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
What is [his/her] email address?
What is [his/her] relationship to you?
Friend
Relative
Other (Specify:)
REFUSED
DON’T KNOW
When we last spoke on [RA MMYYY or Last Intvw MMYYYY] you said that [CONTACT #2] was a person who would always know where you are and how to reach you. Is [CONTACT#2] still a person who does not live with you and will always know how to contact you?
YES (VERIFY CONTACT INFORMATION)
NO
REFUSED
DON’T KNOW
IF YES, GO TO CLOSING; ELSE:
IF NO: Could you please tell me the name of a second person who does not live with you and will always know how to contact you?
YES
NO
REFUSED
DON’T KNOW
IF YES:
What is his/her first name?
What is his/her middle name?
What is his/her last name?
Does his/her name have a suffix?
What is the street address or PO box number?
Is there a complex or building name?
Is there an apartment number?
In what city?
In what state?
What is the zip code?
What is [his/her] home phone number, starting with the area code?
___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
What is [his/her] cell phone number, starting with the area code?
___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
What is [his/her] email address?
What is [his/her] relationship to you?
Friend
Relative
Other (Specify:)
REFUSED
DON’T KNOW
Thank you very much for your time today.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Abt Single-Sided Body Template |
| Author | Missy Robinson |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |
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