Baseline Information Form

OMB Number 1290-XXX

Exp. Date XX/XX/2020

SSN: ___ ___ ___ - ___ ___ - ___ ___ ___ ___

TECHHIRE BASELINE INFORMATION FORM

1. Today’s Date:

____/_____/____

(mm/dd/yyyy)

2. Program Location:

₁ TechHire site #1 (City, State)

₂ TechHire site #2 (City, State)

₃ TechHire site #3 (City, State)

₄ TechHire site #4 (City, State)

₅ SWFI site #1 (City, State)

₆ SWFI site #2 (City, State)

3. RA Results:

Research Group Status:

₁ Program Group

₂ Control Group

ELIGIBILITY SCREENING QUESTIONS

1. First Name:_____________________________________ Middle Initial: _____ Last Name:_________________________________________

2. Date of Birth:

____/____/____

(mm/dd/yyyy)

3. Social Security Number: _______ -______-_________

4. Did the customer provide evidence that they are authorized to work in the U.S.? ₁ Yes ₂ No

Assessment Scores (e.g. TABE, WorkKeys, etc.)

Assessment Score 1: _____

Assessment Score 2: _____

INFORMED CONSENT

5. Did the customer sign the Informed Consent/Agreement to Participate form? ₁ Yes ₂ No

BASELINE INFORMATION FORM QUESTIONS

Demographic information

6. Gender: ₁ Female ₂ Male ₃ Other (specify) __________ ₄ No answer

7. Are you a citizen of the United States?

₁Yes, born in the United States, Puerto Rico, Guam, the U.S. Virgin Islands or Northern Marianas, or born abroad of American parent(s)

₂Yes, a U.S. citizen by naturalization

₃No, not a citizen of the United States (e.g., U.S. permanent resident, U.S. non-citizen national, or alien registered to work in the U.S.)

₄No answer

8. Race/ethnicity:

a. Do you consider yourself to be Hispanic or Latino? ₁ Yes ₂ No ₃ No answer

b. Please choose one or more races that you consider yourself to be [SELECT ALL THAT APPLY]:

_b1 American Indian or Alaska Native

_b2 Asian

_b3 Black or African American

_b4 Native Hawaiian or Pacific Islander

_b5 White

9. Primary language:

   1. What is your primary spoken language?

₁ English [GO TO ITEM #10]

₂ Spanish

₃ Other (specify) _________

₄ No Answer

2. How well would you say you speak English? Would you say…

₁ Very well

₂ Well

₃ Not well

₄ Not at all

Household composition information

Marital Status: 1 Single, never married 5 Divorced 2 Married and living with spouse 6 Widowed [GO TO ITEM #12] 3 Married but living apart from spouse 7 No answer [GO TO ITEM #12] 4 Legally separated

Are you currently living with a partner (boyfriend/ girlfriend)? 1 Yes 2 No 3 No Answer

12. Including yourself, how many people are living in your home?

__________

13. Thinking of all of the income received by you and any live-in spouse or partner in [PRIOR MONTH], what was your total monthly income?

$_______________

[NOTE: Please include income you and your live-in spouse/partner received from all sources, before taxes, including earnings from a job, cash benefits received from government programs such as SSI or SSDI, and any retirement, pension, investing, or savings income that you receive regular payments from

14. How much of this income in [prior month] was your own income?

$_______________

[NOTE: Please include income you received from all sources, before taxes, including earnings from a job, cash benefits received from government programs such as SSI or SSDI, and any retirement, pension, investing, or savings income that you receive regular payments from.]

Are you pregnant, or a parent or legal guardian for any children under age 19? 1 Yes, I am pregnant and/or have children in the following age ranges 1a Pregnant 1b 0 to 11 months 1c 1 to 5 years and 11 months 1d 6 to 12 years and 11 months 1e 13 to 17 years and 11 months 1f 18 to 18 years and 11 months 2 No [GO TO ITEM #18] 3 No answer [GO TO ITEM #18]

[SKIP IF ANSWERED NO, or NO ANSWER TO ITEM #15] Do any of these children live with you at least half of the time? 1 Yes, children in the following age ranges live with me 1a 0 to 11 months 1b 1 to 5 years and 11 months 1c 6 to 12 years and 11 months 1d 13 to 17 years and 11 months 1e 18 to 18 years and 11 months 2 No [GO TO ITEM #18] 3 No answer [GO TO ITEM #18]

[SKIP IF ANSWERED NO, or NO ANSWER TO ITEM #16] How many children under age 19 –for whom you are a parent or legal guardian—live with you at least half of the time? ____ [GO TO ITEM 17b] How many of these children are under age 13? ____[GO TO ITEM 17c] How many of these children are under age 18? ____

Education/training history information

18. What is the highest level of education that you have completed? [Please check one]

₁ Less than a High School Diploma or General Educational Development ₅ Some College or Advanced Training Certificate

₂ General Educational Development (GED) ₆ Associate’s Degree

₃ High School Diploma (HSD) ₇ Four-year College Degree or Higher

₄ Certificate of attendance/completion as a result of successfully completing an ₈ No answer

Individualized Education Program (IEP) for students with disabilities

19. Are you currently enrolled in any of the following education or training programs?

a. High School / GED preparation course

₁ Yes ₂ No ₃ No answer

b. College courses toward an Associate’s or Two-Year Degree

₁ Yes ₂ No ₃ No answer

c. College courses toward a Bachelor’s or Four-Year Degree

₁ Yes ₂ No ₃ No answer

d. Vocational Education

₁ Yes [PLEASE SPECIFY]____________________

₂ No

₃ No answer

e. Other (not listed)

₁ Yes [PLEASE SPECIFY]____________________

₂ No

₃ No answer

20. 1. Have you ever participated in training for one of the following industries?

₁ Yes, I participated in training for the following industries [Please check all that apply.]:

_1a Information Technology (IT)

_1b Financial services

_1c Advanced Manufacturing

_1d Health Care

_1e Broadband

_1f Other (please specify)_________

₂ No [GO TO ITEM #21]

₃ No answer [GO TO ITEM #21]

2. [SKIP IF ANSWERED NO or NO ANSWER to 20a] Have you obtained a license or certificate within one of the following industries?

₁ Yes, I obtained a license or certificate within the following industries [Please check all that apply.]:

_1a Information Technology (IT)

_1b Financial services

_1c Advanced Manufacturing

_1d Health Care

_1e Broadband

_1f Other (please specify)_________

₂ No

₃ No answer

Well-being information

21. Are you, or is anyone in your household, currently receiving assistance from any of the following programs? [Select all that apply]

_21a SNAP (Food Stamps) [also known as STATE SNAP NAME]

_21bTANF (Temporary Assistance to Needy Families) [also known as STATE TANF NAME]

_21cMedicaid [also known as STATE MEDICAID NAME]

_21dGeneral Assistance [also known as STATE GENERAL ASSISTANCE NAME]

_21eUnemployment Compensation

_21fSSI or SSDI (Supplemental Security Income/Social Security Disability Insurance)

_21gSection 8 (also known as Housing Choice Vouchers or HCV) or Public Housing Assistance

_21hWIC (Women, Infants, and Children food program)

_21iPublic medical insurance for your children [insert local program names]

_21jOther (SPECIFY)___________

22. WHICH OF THE FOLLOWING BEST DESCRIBES YOUR LIVING SITUATION? DO YOU LIVE IN:

1YOUR OWN PLACE

2YOUR PARENT’S OR RELATIVE’S HOME

3A FRIEND’S HOME

4A SUPERVISED INDEPENDENT LIVING ARRANGEMENT

5A GROUP SHELTER

6HOMELESS/LIVING ON THE STREET

7OTHER

8NO ANSWER

23. Have you ever been arrested?

₁ Yes ₂ No ₃ No answer

Have you ever been convicted of a crime? 1 Yes 2 No 3 No answer

Have you ever been incarcerated? 1 Yes 2 No 3 No answer

26. [SKIP if not parent or legal guardian for any children under 19]

    1. Do you have childcare or after-school supervision arrangements in place for your children?

₁ Yes ₂ No ₃ No answer

2. [SKIP if 26a is NO or NO ANSWER] Do you pay for the full cost of your childcare arrangements?

₁ Yes ₂ No ₃ No answer

3. [SKIP if 26a is NO or NO ANSWER] Please check all that apply:

₁A government agency, your employer, or someone else outside your household (e.g. friends or relatives) pays for part or all of the costs of this child care.

₂The amount I contribute to child care costs depends upon my income

27. Does difficulty finding childcare or after-school supervision for your children limit the type or amount of work that you can do?

₁ Yes                           ₂ No                                   ₃ I do not have children living with me.     ₄No answer        

28. Do you have a physical or mental health condition that limits the kind or amount of work you can do?

₁ Yes ₂ No ₃ No answer

29. Do you have access to a car or public transportation so that you can get to work?

₁ Yes ₂ No ₃ No answer

Employment history information

30. Have you ever been employed? ₁ Yes ₂ No [GO TO ITEM #36]

31. Are you currently employed? ₁ Yes ₂ No [GO TO ITEM #33]

32. How many jobs are you currently working? [SKIP, IF CURRENTLY NOT WORKING]

₁ One ₂ Two ₃ Three ₄ Four or more

33. Please provide the following information on your current or most recent job. If you are currently working at two or more jobs, please provide information about the job for which you work the most hours. [SKIP IF NEVER EMPLOYED]

    1. Start Date: _______(mm)/________(yyyy)

    2. End Date: _______(mm)/________(yyyy) [SKIP IF CURRENTLY WORKING]

    3. Number of hours per week (including overtime): _________[GO TO ITEM #33D]

[IF DON’T KNOW EXACT HOURS PLEASE CHECK ONE RANGE OF HOURS BELOW]

₁ 1-20 hours per week ₃ 35-48 hours per week

₂ 21-34 hours per week ₄ 49+ hours per week

₅ No answer

4. How much do (or did) you earn before taxes? [INCLUDE DECIMAL VALUES]

	1 hour
	2 day ______ Number of days per week
$ _____. __ per	3 week
	4 every two weeks
	5 twice a month
	6 month
	7 year

34. [SKIP IF CUSTOMER IS CURRENTLY NOT WORKING OR WORKS ONLY ONE JOB.]

    1. Including all jobs, how many hours per week do you work? ___________

[IF DON’T KNOW EXACT HOURS PLEASE CHECK ONE RANGE OF HOUR BELOW]

₁ 1-20 hours per week

₂ 21-34 hours per week

₃ 35-48 hours per week

₄ 49+ hours per week

₅ No answer

35. Are you currently or were you over the past 2 years employed within any of the following industries? [SKIP IF ANSWERED NO TO ITEM #30 or #33B IS MORE THAN 2 YEARS AGO]

₁ Yes, I am/was employed within the following industries[ Please check all that apply]:

_1a Information Technology (IT)

_1b Financial services

_1c Advanced Manufacturing

_1d Health Care

_1e Broadband

_1f Other (please specify)______

₂ No

₃ No answer

1. Are you covered by any health insurance plan?

₁ Yes

₂ No

₃ No answer

2. What type of health insurance plan are you covered by? [SKIP IF ANSWERED NO or NO ANSWER to ITEM #36A]

₁ Employer-provided

₂ Publicly funded health insurance for yourself?

(insert program names)

₃ Other [PLEASE SPECIFY] __________________ ₄ No answer

PARTICIPANT AND ADDITIONAL PERSON CONTACT INFORMATION

Thank you very much for your time today. To help us be able to get back in touch with you in the future, we would like to collect your contact information (name, mailing address, telephone number, and email address), as well as contact information for three people who will always know how to reach you but are at a different address than you. This information will be kept strictly confidential and will only be used if we are unable to contact you.

PARTICIPANT CONTACT INFORMATION
First Name		Middle Name	Last Name				Suffix
Street address
Apt. No.	City				State	Zip Code
Is this address the best address to mail something to you? Yes No
If not, what address should we use if we mail something to you?
Street address
Apt. No.	City				State	Zip Code
What is your home phone number? ( ) –				What is your work phone number? ( ) –
What is your cell phone number? ( ) –				May we send text messages to your cell phone? Yes No
Do you have an email address? Yes No If Yes, what is it?
Do you have a Facebook account? Yes No If Yes, what name do you use on your Facebook profile (for example, do you use a nickname or shortened first name)?
May we contact you at your Facebook account in the future? Yes No

CONTACT # 1: Could you tell us the name of a primary person who does not live with you and will always know how to contact you?
First Name		Middle Name			Last Name			Suffix
Street address
Apt. No.	City					State	Zip Code
Home Tel. No. ( ) –			Relationship (friend, relative, please specify)
Cell Tel. No. ( ) –				Work Tel. No. ( ) –
Does he/she have an email address? Yes No If Yes, what is it?

CONTACT # 2: Could you tell us the name of a second person who does not live with you and will always know how to contact you?
First Name		Middle Name		Last Name				Suffix
Street address
Apt. No.	City					State	Zip Code
Home Tel. No. ( ) –			Relationship (friend, relative, please specify)
Cell Tel. No. ( ) –					Work Tel. No. ( ) –
Does he/she have an email address? Yes No If Yes, what is it?

CONTACT # 3: Could you tell us the name of a third person who does not live with you and will always know how to contact you?
First Name		Middle Name		Last Name				Suffix
Street address
Apt. No.	City					State	Zip Code
Home Tel. No. ( ) –			Relationship (friend, relative, please specify)
Cell Tel. No. ( ) –					Work Tel. No. ( ) –
Does he/she have an email address? Yes No If Yes, what is it?

Public reporting burden for this collection of information is estimated to average 30 minutes per respondent. Send comments concerning this burden estimate or any other aspect of this collection of information to the U.S. Department of Labor, Chief Evaluation Office, Room 2218, Constitution Ave., Washington, DC 20210. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The OMB control number for this information collection is 1290-XXXX