Young Adult Baseline Survey
Evaluation of the Transition Living Program
C. TLP_YouthBaselineSurvey_forNSchange_withBCF_CLEAN_20180502
Young Adult Baseline Survey
OMB: 0970-0383
TLP Outcomes Study Young Adult Baseline Survey
TLP OUTCOMES STUDY
YOUNG ADULT BASELINE SURVEY
TLP Outcomes Study Young Adult Baseline Survey
Programming Notes
Display “back” “next” “or" buttons and on each screen.
Display a reminder not to use the forward and back buttons in the internet browser but to use the survey forward and back buttons.
Display a progress bar on each screen.
Time out after 7 minutes of inactivity. Display a one-minute timeout warning enabling user to extent time out period another 7 minutes.
Unless otherwise specified (by “select all that apply”), only one answer is permitted per item.
Participants may skip any item.
For select questions, if a response/answer is not provided, after respondent clicks “continue,” the following pop-up warning should appear confirming that they want to skip. It should read: “We didn’t get an answer to one or more of the last questions. Please provide your best answer(s), even if you're not completely sure. If you prefer to skip this question(s), you can click "Next".”
Special codes:
Code a legitimate (planned) skip as -101
Code unplanned skips as -9999
Code “don’t know” as -98
Code refusals (i.e., “rather not say”) as -99
Code not applicable (i.e., “does not apply to me”) as -100
Item-specific programming notes appear in Blue Font throughout the survey.
Notations regarding the construct being measured and/or its source are shown in Red Font. These must NOT be displayed on the programmed survey.
Yellow Highlighting indicates information that is pending and will be updated.
Section headings (in black font) may be displayed if desired.
Welcome
WELCOME TO THE TLP OUTCOMES STUDY SURVEY!
You are part of an important study called the TLP Outcomes Study.
What’s the study about?
The study is learning about how communities can help young adults like you develop the skills they need to build strong futures. Participation in this study is voluntary.
What will happen?
When you joined the study, you were asked to take part in three surveys over 12 months. This is the first one. You will get a $30 electronic gift card to Amazon.com for your time completing it.
The questions in this survey take about 37 minutes to answer. You will be asked about the places you’ve stayed, your experiences, thoughts and feelings. You may skip questions or stop answering questions at any time.
What happens to my answers?
Only the study team and authorized study team members can see your answers. Your answers will be combined and reported with the answers of all the other people in the study.
Who should I contact if I have any questions about the study?
If you have any questions about the study, you can email or call the people who are doing the study at [email protected] or (855) 579-6654. This is a free call.
Continue
OMB Control No: 0970-0383
Expiration Date: XX/XX/XXXX
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)
Public reporting burden of this collection of information is estimated to average 0.62 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to [Contact Name]; [Contact Address]; Attn: OMB-PRA (xxxx-xxxx).
Gift Card Information
First, we want to make sure we know where to send your electronic gift card after you complete this survey.
Gift1. After you finish and submit your survey, we will email or text you an electronic gift card to Amazon.com. How would you like us to send you the gift card?
(Select only one answer)
Email it to me [ ] 01
Text it to my cell phone [ ] 02
I do not have an email address or cell phone you can send it to [ ] 00
[If Gift1 = 0, ask Gift3.]
[If Gift1 = 1 or 2, ask Gift2]
[If Gift1 skipped, ask Gift2c]
[If Gift1=1 and no email in contact form, ask to Gift 2c_alt]
[If Gift1=2 and no cell in contact form, ask to Gift 2c_alt]
Gift2. Please confirm where to send your electronic gift card
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Yes (01) |
No (00) |
[if Gift1 = 1 present:
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[if Gift1 = 2 present:
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[If Gift2a=1, skip to Section A, If Gift2b = 1, ask Gift 2d]
[If Gift2a or Gift2b = 0, ask Gift2c]
Gift2c. Please tell us how to send you your electronic gift card:
(Select only one answer)
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Enter the [email address/ cell phone number] we should use here: |
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Email it to me at: |
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Text it to my cell phone: |
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02 |
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I do not have an email address or cell phone you can send it to |
03 |
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[If Gift2c = 3, Go to Gift3]
[If no response is selected = “Please select Email it to me at, Text it to my cell phone, or I do not have an email address or cell phone you can send it to.” IF STILL NOT ANSWERED: Go to Gift3]
[If Gift2c = 1 and email is left blank = “Please enter your email.” IF STILL NOT ANSWERED: Go to Gift3]
[If Gift2c = 2 and cell phone number is left blank = “Please enter your 10 digit cell phone number.” IF STILL NOT ANSWERED: Go to Gift3]
[If email entered is not standard email format = “The email address is not valid. Please enter a valid
email address.” IF STILL NOT CORRECTED: Go to Gift3]
[If not all ten digits or if letters are entered for the cell phone number = “Phone Number must be 10 digits (numbers only). The first three are the Area Code. Please re-enter the 10 digit cell phone number.” IF STILL NOT CORRECTED: Go to Gift3]
Gift2c_alt. Please provide your [if Gift1=1 email address/ Gift1=2 cell phone], so we can send you your electronic gift card:
(Select only one answer)
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Enter the [email address/ cell phone number] we should use here: |
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Email it to me at: |
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01 |
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Text it to my cell phone: |
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02 |
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I do not have an email address or cell phone you can send it to |
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03 |
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[If Gift2c_alt= 3, Go to Gift3]
[If no response is selected = “Please select Email it to me at, Text it to my cell phone, or I do not have an email address or cell phone you can send it to.” IF STILL NOT ANSWERED: Go to Gift3]
[If Gift2c_alt = 1 and email is left blank = “Please enter your email.” IF STILL NOT ANSWERED: Go to Gift3]
[If Gift2c_alt = 2 and cell phone number is left blank = “Please enter your 10 digit cell phone number.” IF STILL NOT ANSWERED: Go to Gift3]
[If email entered is not standard email format = “The email address is not valid. Please enter a valid
email address.” IF STILL NOT CORRECTED: Go to Gift3]
[If not all ten digits or if letters are entered for the cell phone number = Phone Number must be 10 digits (numbers only). The first three are the Area Code. Please re-enter the 10 digit cell phone number. IF STILL NOT CORRECTED: Go to Gift3]
[If Gift1, Gift2c or Gift2c_alt = 2 (text), ask Gift 2d]
Gift2d. In order to text you your gift card codes, we need to know which company provides your cell phone service (Please select one):
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AT&T |
[Insert provider logo] |
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Boost Mobile |
[Insert provider logo] |
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Cricket |
[Insert provider logo] |
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Sprint |
[Insert provider logo] |
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T-Mobile |
[Insert provider logo] |
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US Cellular |
[Insert provider logo] |
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Verizon |
[Insert provider logo] |
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Virgin Mobile |
[Insert provider logo] |
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Company Not Listed |
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I Don’t Know |
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[If Gift2d = “AT&T” “Boost Mobile” “Cricket” “Sprint” “T-Mobile” “US Cellular” “Verizon” or “Virgin Mobile” go to Section A]
If Gift2d = “company not listed” or “don’t know” show the following prompt and redirect the participant to provide an email or mailing address. “We can only send a text message to the companies that are listed on screen. If the company that provides your cell phone service is not listed or you do not know the name of your cell provider, we will not be able to text your gift card information to you.” Go to Gift2e]
Gift2e. Please tell us how to send you your electronic gift card:
(Select only one answer)
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Enter the [email address/mailing address] we should use here: |
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Email it to me at: |
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Mail it to me: |
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I do not have an email address or mailing address you can send it to |
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[If Gift2e = 2, Go to Gift 3]
[If Gift2e = 3, Go to Gift4]
[If no response is selected = “Please select Email it to me at, Mail it to me or I do not have an email address or mailing address you can send it to.” IF STILL NOT ANSWERED: Go to Gift4]
[If Gift2e = 1 and email is left blank = “Please enter your email.” IF STILL NOT ANSWERED: Go to Gift4]
[If email entered is not standard email format = “The email address is not valid. Please enter a valid
email address.” IF STILL NOT CORRECTED: Go to Gift3]
Gift3. Earlier you told us that you do not have an email address or a cell phone where we can text your electronic gift card. We can mail it to you instead.
[If Gift2c or Gift2c_alt = 3 or skipped or Gift2e = 2 or skipped or the email or cell entered at Gift2c, Gift2c_alt, Gift2e is not valid, present this text instead: “You did not provide an email address or a cell phone where we can text your electronic gift card. We can mail it to you instead.”]
Gift3a. Is the address below where we should send it?
[Insert contact info provided at CI_4A-F, Agency Portal – Participant Record Creation. If no address provided, Go to Gift3b]
Street Address
City ____________________ State ________ Zip Code
Yes [ ] 01
No [ ] 00
[If Gift3a = 0 or skipped, ask Gift3b]
Gift3b. Please tell us where to mail your electronic gift card:
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Street Address |
_______________________________ |
City |
_______________________________ |
State |
_______________________________ |
Zip Code |
_______________________________ |
[If Gift3b left blank (skipped), Go to Gift4]
[Apt# can be left blank]
[If Street Address is left blank = “Please enter your street address.” IF STILL NOT ANSWERED: Go to Gift4]
[If City is left blank = “Please enter your city.” IF STILL NOT ANSWERED; Go to Gift4]
[If numeric values are entered for the City = “Only letters may be entered for your city. We need a valid address.” IF STILL NOT CORRECTED: Go to Gift4]
[If Zip Code is left blank = “Please enter your zip code.” IF STILL NOT ANSWERED: Go to Gift4]
[If letters are entered in the zip = “Zip code must be 5 digits (numbers only). We need a valid address.” IF STILL NOT CORRECTED: Go to Gift4]
[If no contact information provided for gift card (no email, no cell, no mailing address), present the following statement
Gift4. Because you did not provide an email address, a cell phone number to send a text, or a complete mailing address, we cannot send you an electronic gift card. If you have any questions, please email [email protected] or call (855) 579-6654. This is a free call.
I would like to provide contact information…………………………………………….……………....[ ] 01
I understand I will not receive an electronic gift card ………………………………………..……....[ ] 02
[If Gift4 = 1, Go to Gift1]
[If Gift4 = 2, Go to section A]
Baseline Contact Form
Young Adult Baseline Contact Information Form
NOTE: This Baseline Contact Form is to be presented in the study web portal as part of the staff-administered study enrollment process….the information should be captured separate from and prior to the baseline survey
NOTES TO PROGRAMMERS: Item-specific programming notes appear in ALL CAPS BLUE FONT. General programming notes: Participants should be allowed to skip any item they choose. However, we need to have an email or cell phone for follow up survey invitations. |
Your Contact Information
Thank you for being part of our study! In order to contact you about surveys and send you reminders about the study, we need your contact information. We will only use this information for the study and we will NOT discuss or share any of your information with anyone outside of the study team. |
CI_1. What is your full legal name?
(a) First: [ALPHA ONLY]
(b) Middle: [ALPHA ONLY]
(c) Last: [ALPHA ONLY]
[USE FIRST AND LAST NAMES FOR DUPLICATE CHECKING]
CI_2. What is your birthdate?
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Month
Day
Year
[USE FOR DUPLICATE CHECKING]
CI_3. Where were you born?
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City
State
Country
[USE FOR DUPLICATE CHECKING]
CI_4. What is your….?
Mailing address
(a) Street Number: [ALPHA NUMERIC]
(b) Street Name: [ALPHA ONLY]
(c) Apartment/Unit Number: [ALPHA NUMERIC]
(d) City: [ALPHA ONLY]
(e) State: [PROVIDE DROP-DOWN MENU]
(f) Zip Code: [NUMERIC ONLY]
[IF PROVIDED, ENSURE MAILING ADDRESS IS COMPLETE]
(g) Cell Phone Number: -- [NUMERIC ONLY]
(h) Other Phone Number: -- [NUMERIC ONLY]
(i) Email Address: [ALPHA NUMERIC + @ + .COM, .NET, .EDU, ETC]
[IF CI_4G (CELL) IS PROVIDED ASK CI_5, ELSE GO TO CI_6]
CI_5a. Is it OK for the research team to text your cell phone about the study?
(Please keep in mind that your cell phone carrier may charge a fee to receive or send text messages, depending on your plan.)
Yes 01
No 00
CI_5b. Is it OK for the research team to leave a message on your cell phone about the study?
Yes 01
No 00
[IF CI_4H (OTHER PHONE) IS PROVIDED ASK CI_6, ELSE GO TO CI_7]
CI_6. Is it OK for the research team to leave a message on your other phone about the study?
Yes 01
No 00
[IF CI_4I (EMAIL) IS PROVIDED ASK CI_7, ELSE GO TO CI_8]
CI_7. Is it OK for the research team to email you about the study?
Yes 01
No 00
[IF CI_4A-F (MAILING ADDRESS) IS PROVIDED ASK CI_8, ELSE GO TO CI_9]
CI_8. Is it OK for the research team to contact you at your mailing address about the study?
Yes 01
No 00
Alternate Contact Information
You are important to the study! We want to be sure we can reach you about future surveys. In case we have trouble reaching you, we ask you to give us contact information for two people who will always know where you are and how to reach you. We will NOT discuss or share any of your personal information or survey answers with anyone you list as a contact. Your personal information and answers are confidential. |
CI_9. Could you provide the name and contact information for a trusted friend, family member, or other person? Someone who will always know where you are and how to reach you in the future in case we have difficulty.
(a) First Name: [ALPHA ONLY]
(b) Last Name: [ALPHA ONLY]
(c) Relationship to you: [ALPHA NUMERIC]
(d) Phone Number: -- [NUMERIC ONLY]
(e) Email Address: [ALPHA NUMERIC + @ + .COM, .NET, .EDU, ETC]
Mailing Address:
(f) Street Number: [ALPHA NUMERIC]
(g) Street Name: [ALPHA ONLY]
(h) Apartment/Unit Number: [ALPHA NUMERIC]
(i) City: [ALPHA ONLY]
(j) State: [PROVIDE DROP-DOWN MENU]
(k) Zip Code: [NUMERIC ONLY]
(l) Contact notes: [OPEN TEXT FIELD TO INSERT OTHER RELEVANT INFO]
CI_10. Could you provide the name and contact information for another trusted friend, family member, or other person? Someone who will always know where you are and how to reach you in the future in case we have difficulty.
(a) First Name: [ALPHA ONLY]
(b) Last Name: [ALPHA ONLY]
(c) Relationship to you: [ALPHA NUMERIC]
(d) Phone Number: -- [NUMERIC ONLY]
(e) Email Address: [ALPHA NUMERIC + @ + .COM, .NET, .EDU, ETC]
Mailing Address:
(f) Street Number: [ALPHA NUMERIC]
(g) Street Name: [ALPHA ONLY]
(h) Apartment/Unit Number: [ALPHA NUMERIC]
(i) City: [ALPHA ONLY]
(j) State: [PROVIDE DROP-DOWN MENU]
(k) Zip Code: [NUMERIC ONLY]
(l) Contact notes: [OPEN TEXT FIELD TO INSERT OTHER RELEVANT INFO]
[At this point the baseline contact form should be finalized and saved as a record. The following ‘thank you’ screen should occur on a new page after the baseline contact information record has been saved.]
Social Media
STARS may soon be on Twitter, Facebook, or another form of social media. We are interested in what social media you use and if it would be OK for us to contact you there in the future . |
CI_11.What forms of social media do you use? (Select all that apply.)
Do you use…? |
Yes (01) |
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[IF CI_11 ITEM = 01, ASK CORRESPONDING CI_12 ITEM]
CI_12. Would it be OK for the STARS research team to….?
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Yes (01) |
No (00) |
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[IF CI_12 ITEM = 01, ASK CORRESPONDING CI_13 ITEM]
CI_13. What is…?
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____________________________________ |
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____________________________________ |
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____________________________________ |
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____________________________________ |
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____________________________________ |
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____________________________________ |
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____________________________________ |
Thank you for providing your contact information! We are glad you are part of our study.
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Section A: Housing Experiences
We want to start by asking about the places you’ve stayed and your experiences with homelessness. By homeless we mean that you had a period of time in your life when you:
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History of Homelessness
A1. Over your entire life, including right now, about how many times have you been homeless?
1 time [ ] 01
2 times [ ] 02
3 times [ ] 03
4 or more times [ ] 04
A2. Over your entire life, including right now, about how many nights in total have you been homeless?
About 1 to 3 nights [ ] 01
More than 3 nights but less than 1 week [ ] 02
About 1 week (7 nights) [ ] 03
More than a week, but less than a month [ ] 04
About 1 month [ ] 05
More than 1 month but less than 6 months [ ] 06
About 6 months [ ] 07
More than 6 months, but less than 1 year [ ] 08
1 year or more [ ] 09
Section B: Where You Stay
Housing History Series
The next questions ask about the places you have stayed in the past 12 months, since [current date minus 12 months]. This includes times when you were in a shelter or residential program for people who are homeless or homeless in an unsheltered location (for example outside, on the street, in a car, bus terminal or abandoned building).
For each place that you have stayed, we will ask you about when you started and stopped staying there and what kind of a place it was.
We will ask you to think backwards in time – from last night until [current date minus 12 months].
B1a. Where did you stay last night? If the place has a name please tell us the name.
________________ [open ended, tag response as: name situation #a, used in later items. If B1a is left blank, pipe in “the place you stayed last night” for B2a through B11a.]
B2a. When did you start staying at [name situation #a]?
Click here to see a calendar of the past few months. Calendar
[Present calendar for reference]
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Month
Day
Year
[Day can be blank]
[If date entered is after today’s date, present this prompt once: “Please review the date you entered.”]
[Items B3a – B4a intentionally removed]
B5a. How would you describe [name situation #a]?
(Select only one answer.)
The [insert TLP name] Transitional Living Program (TLP) [ ] 01
Another Transitional Living Program (TLP) [ ] 02
Another residential program for people who are homeless that provides a long-term
place to stay and services [ ] 03
In a shelter (for example, emergency shelter or basic center program) [ ] 04
In an unsheltered location (for example, staying outside, on the street,
in a car, bus terminal or abandoned building) [ ] 05
Foster home or group home [ ] 06
Room, apartment or house (not as part of a homeless program) [ ] 07
Institution (for example, hospital, mental health facility, drug or alcohol treatment facility,
prison, jail, detention center) [ ] 08
School or college dormitory (or dorm) [ ] 09
Military setting (for example, base camp, deployment, combat zone) [ ] 10
Other (please specify) [ ] 94
[If B5a is skipped, present this prompt once: “We didn’t get an answer for this question. Please provide your best answer, even if you're not completely sure. If you prefer to skip this question, you can click "Next".”]
B6a. When you started staying in [name situation #a], did you think it would be temporary? By temporary, we mean it would only last a short time (for example, couch surfing, crashing, or just passing through).
Yes, I thought it would be temporary [ ] 01
No, I thought I would be there a while [ ] 00
I was not sure [ ] 02
I don’t remember [ ] -98
[If B5a = 7 (room/apt/house), present B7a – B8a, else skip to B9a]
B7a. At [name situation #a], are you staying…
(Select all that apply.)
Alone [ ] 01
With one or more family members [ ] 02
With one or more friends [ ] 03
Other (please specify) [ ] 94
B8a. At [name situation #a], are you paying rent or part of the rent?
(Select only one answer.)
Yes, I always paid (pay) rent [ ] 02
Yes, I sometimes paid (pay) rent [ ] 01
No, I never paid (pay) rent [ ] 00
B9a. Do you feel safe in [name situation #a]?
Yes [ ] 01
No [ ] 00
Don’t know……………………………………………………………………………………… .[ ] -98
[Item B10a intentionally removed]
B11a. Have you stayed anywhere else in the past 12 months, since [current date minus 12 months]?
Yes [ ] 01
No [ ] 00
[If B11a is skipped, present this prompt once: “We didn’t get an answer for this question. Please provide your best answer, even if you're not completely sure. If you prefer to skip this question, you can click "Next".”]
[If B11a = 1, continue to housing history loop. If B11a = 0 or skipped, skip to next section]
Housing History Loop:
Note the questions asked in the loop are (nearly) identical to B1a – B11a
[B1b begins Housing History Loop: First turn through loop is B1b – B11b and occurs if B11a = 1 (stayed somewhere else in past 12 months). The loop is repeated again (B1c-B11c) if B11b = 1 (stayed somewhere else since RA). The loop continues to be repeated until B11# = 0 with a maximum of 3 times through the loop (ending with B11d). Thus, we capture up to 4 living situations in the housing history series.]
B1b. What is the name of the place you stayed just before [name situation #a]? If this is a program, please use its official name.
Remember you can include times when you were in a shelter or residential program for people who are homeless or homeless in an unsheltered location (for example outside, on the street, in a car, bus terminal or abandoned building).
________________ [open ended, tag response as: name situation #b, used in later items. If B1b is left blank, pipe in “the place you stayed just before [name situation #a]” for B2a through B11b.]
B2b. When did you start staying at [name situation #b]?
Click below to see a calendar of the past few months. Calendar
[Present calendar for reference]
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Month
Day
Year
[Day can be blank]
[If date entered is after today’s date or after the date provided at B2a, present this prompt once: “Please review the date you entered.”]
[Item B3b intentionally removed]
B4b. When did you stop staying there? Your best guess is fine.
Click below to see a calendar of the past few months. Calendar
[Present calendar for reference]
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Month
Day
Year
[Day can be blank]
[If date entered is after today’s date or the date provided at B2a or before the date provided at B2b, present this prompt once: “Please review the date you entered.”]
B5b. How would you describe [name situation #b]?
(Select only one answer.)
The [insert TLP name] Transitional Living Program (TLP) [ ] 01
Another Transitional Living Program (TLP) [ ] 02
Another residential program for people who are homeless that provides a long-term
place to stay and services [ ] 03
Homeless in a shelter (for example, emergency shelter or basic center program) [ ] 04
Homeless in an unsheltered location (for example, staying outside, on the street,
in a car, bus terminal or abandoned building) [ ] 05
Foster home or group home [ ] 06
Room, apartment or house (not as part of a homeless program) [ ] 07
Institution (for example, hospital, mental health facility, drug or alcohol treatment facility,
prison, jail, detention center) [ ] 08
School or college dormitory (or dorm) [ ] 09
Military setting (for example, base camp, deployment, combat zone) [ ] 10
Other (please specify) [ ] 94
[If B5b is skipped, present this prompt once: “We didn’t get an answer for this question. Please provide your best answer, even if you're not completely sure. If you prefer to skip this question, you can click "Next".”]
B6b. When you started staying in [name situation #b], did you think it would be temporary? By temporary, we mean it would only last a short time (for example, couch surfing, crashing, or just passing through).
Yes, I thought it would be temporary [ ] 01
No, I thought I would be there a while [ ] 00
I was not sure [ ] 02
I don’t remember [ ] -98
[If B5b = 7 (room/apt/house), present B7b – B8b, else skip to B9b]
B7b. In [name situation #b], were you staying…
(Select all that apply.)
Alone [ ] 01
With one or more family members [ ] 02
With one or more friends [ ] 03
Other (please specify) [ ] 94
B8b. In [name situation #b], were you paying rent or part of the rent?
(Select only one answer.)
Yes, I always paid rent [ ] 02
Yes, I sometimes paid rent [ ] 01
No, I never paid rent [ ] 00
B9b. Did you feel safe in [name situation #b]?
Yes [ ] 01
No [ ] 00
Don’t know……………………………………………………………………………………… .[ ] -98
[Item B10b intentionally removed]
B11b. So far, you have told us about [insert name(s) of previously identified situation(s): name situation #a, name situation #b, etc.].
Have you stayed anywhere else since [current date minus 12 months]?
Yes [ ] 01
No [ ] 00
[If B11b is skipped, present this prompt once: “We didn’t get an answer for this question. Please provide your best answer, even if you're not completely sure. If you prefer to skip this question, you can click "Next".”]
[End of Loop. If B11b = 1, loop back and begin with B1c. If B11b = 0, exit loop and continue to next question. Looping continues until B11#=0 with a maximum of 3 times through the loop, ending with B11d. (Thus, we capture up to 4 living situations in the housing history series.)
If B1# is left blank, pipe in the place you stayed just before [name situation #-1]” for B2# through B11#.
After 3 times through the loop, if B11d = 1 or skipped then present B12 - B13. Else if B11d=0 skip to next section]
B12. How many other places have you stayed in the past 12 months, since [current date minus 12 months]?
________________ # places [Valid range: 0-100]
[If value entered is out of range, please present the following prompt once, “Please enter a value between 0 -100.’]
[If letters are entered, please present the following prompt, “Please enter numbers only.”]
[If B12 is skipped, present this prompt once: “We didn’t get an answer for this question. Please provide your best answer, even if you're not completely sure. If you prefer to skip this question, you can click "Next".”]
[If B11d = 1 and B12 > 0 then present B13]
B13. What types of places were they?
(Select all that apply)
[Randomly order/rotate all options presented for B13]
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Yes (01) |
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Section C: TLP and Service Experiences
Prior TLP Experience
The next few questions are about your experiences with Transitional Living Programs like the [insert TLP name] program that you are currently applying to. We will use the abbreviation TLP throughout this survey to refer to the Transitional Living Program. A TLP is a residential program for people who are homeless that provides a long-term place to stay and services.
[If C1, C2, or C3 is skipped, present this prompt once: “We didn’t get an answer for this question. Please provide your best answer, even if you're not completely sure. If you prefer to skip this question, you can click "Next".” If still not answered, go to the next question]
[If B5(a, b, c, or d.) = 1, auto fill C1 as 1 and skip to C2]
C1. Have you ever stayed in the [insert TLP name] Transitional Living Program (TLP) before now?
Yes [ ] 01
No [ ] 00
Don’t Know [ ] -98
[If B5(a, b, c, d) = 2 “Other Transitional Living Program” auto fill C2 as 1 and skip to C3]
C2. Have you ever stayed in a Transitional Living Program (TLP) other than [insert TLP name]?
Yes [ ] 01
No [ ] 00
Don’t Know [ ] -98
[If B5(a, b, c, d) = in {1, 2, 3 (ever in this/other TLP or TLP-like program)} auto fill C3 as 1 and skip to C5;
Else if {C1=1 or C2=1 (ever in this/other TLP)} then go to C5;
Else continue to C3]
C3. Have you ever stayed in a residential program for people who are homeless that provides long-term services and a place to stay?
Yes [ ] 01
No [ ] 00
Don’t Know [ ] -98
The next few questions are about programs and services you may have participated in.
Recent Service Receipt
[Item C4 intentionally removed]
C5. In the past 30 days, since [insert current date minus 30 days] have you received any of the following services?
(Select all that apply)
[Items have been partitioned into four groupings. Present the main question stem before each grouping. Randomly order/rotate the items within each grouping.]
[C5 Grouping #1.]
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Yes (01) |
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[C5 Grouping #2.]
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Yes (01) |
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[C5 Grouping #3.]
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Yes (01) |
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[C5 Grouping #4.]
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Yes (01) |
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[Items C6-C7 intentionally removed]
C8. People have different goals. On a scale of 1 to 3, where 1 = Not At All Important to Me and 3 = Very Important to Me, how important are each of the following goals for you?
[Randomly order/rotate the items]
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Not at all important to me 1 |
Somewhat important to me 2 |
Very important to me 3 |
Does not apply to me (-100) |
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Section D: Your Feelings and Health
The next few questions are about your feelings.
[Item D1 intentionally removed]
Depressive Symptoms
D2. Below is a list of the ways you might have felt or behaved. How often you have felt this way during the past week?
During the past week… |
Hardly ever or never (00) |
Some of the time (01) |
Much or most of the time (02) |
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Traumatic Stress
D3. The next questions are about problems and complaints that people sometimes have in response to stressful life experiences. Please indicate how much you have been bothered by each problem in the past month. For these questions, the response options are: “not at all”, “a little bit”, “moderately”, “quite a bit”, or “extremely”.
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Not at all (01) |
A little bit (02) |
Moderately (03) |
Quite a bit (04) |
Extremely (05) |
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Supportive Relationships with Adults
D4. Currently, in your life, are there responsible adults or mentors who…
(Select yes or no for each).
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Yes (01) |
No (00) |
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Section E: Education and Training
The next questions are about your education and training experiences.
Educational Progress
E1. What is the highest level of education you have completed? (By completed we mean the grade or level you have actually finished, not the grade or level you are currently in. If you are in high school, and it is summer, what grade did you complete this spring?)
(Select one response.)
6th grade or less [ ] 01
7th grade [ ] 02
8th grade [ ] 03
9th grade [ ] 04
10th grade [ ] 05
11th grade [ ] 06
GED or high school equivalency [ ] 07
High school diploma (12th grade) [ ] 08
Some vocational or trade school after graduating high school or getting your GED [ ] 09
Earned a credential from a vocational or trade school after graduating high school
or getting your GED [ ] 10
Associate's degree (community or two-year college) [ ] 11
Some college [ ] 12
Four-year college degree or higher [ ] 13
E2. Have you ever repeated a grade or been held back?
Yes [ ] 01
No [ ] 00
E3. Have you ever been suspended from school?
Yes [ ] 01
No [ ] 00
E4. Have you ever been expelled from school?
Yes [ ] 01
No [ ] 00
E5. Have you ever dropped out of school?
Yes [ ] 01
No [ ] 00
Education History Series
[Begin with E6a- then follow skip patterns.]
[E7a – E7f, If value entered is out of range, please present the following prompt once, “Please enter a value between 0 to 60.”]
[E8a – E8f, If value entered is out of range, please present the following prompt once, “Please enter a value between 0 to 12.”]
[E7a – E7f and E8a – E8f, If letters are entered, please present the following prompt, “Please enter numbers only.”]
E6. At any time from [current date minus 12 months] to today have you taken…? |
E7. While you were taking… |
E8. Altogether for how many… |
E9. Which months were you enrolled in… |
E6a. Adult Basic Education (ABE) By adult basic education (ABE), we mean classes to improve basic reading and math skills. This is not high school or college classes. Yes [Go to E7a] No [Go to E6b] [If skipped Go to E6b]
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E7a. Adult basic education, how many hours per week did you attend during a normal week? ____# hours [Valid range 0-60] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 5 hours per week 6 to 10 hours per week 11 to 15 hours per week 16 to 20 hours per week 21 to 30 hours per week More than 30 hours per week]
[Once response selected present E8a] |
E8a. Months since [current date minus 12 months] have you taken those classes? ____# months [Valid range 0-12] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 1 month 1 or 2 months 3 to 6 months 7 to 12 months
[Once response selected present E9a] |
E9a. Adult basic education? (Select all that apply) [current month, year] [current month, year minus 1 month] [current month, year minus 2 months] [current month, year minus 3 months] […Continue subtracting 1 until reach current date minus 12 months …]
[Once response selected present E6b] |
E6b. English as a Second Language (ESL) classes Yes [Go to E7b] No[Go to E6c] [If skipped Go to E6c]
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E7b. ESL classes, how many hours per week did you attend during a normal week? ____# hours [Valid range 0-60] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 5 hours per week 6 to 10 hours per week 11 to 15 hours per week 16 to 20 hours per week 21 to 30 hours per week More than 30 hours per week]
[Once response selected present E8b] |
E8b. Months since [current date minus 12 months] did you take those classes? ____# months [Valid range 0-12] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 1 month 1 or 2 months 3 to 6 months 7 to 12 months
[Once response selected present E9b] |
E9b. ESL classes? (Select all that apply) [current month, year] [current month, year minus 1 month] [current month, year minus 2 months] [current month, year minus 3 months] […Continue subtracting 1 until reach current date minus 12 months …]
[Once response selected present E6c] |
E6c. GED classes By GED classes, we mean classes to prepare for the GED test Yes [Go to E7c] No [Go to E6d] [If skipped Go to E6d]
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E7c. GED classes, how many hours per week did you attend during a normal week? ____# hours [Valid range 0-60] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 5 hours per week 6 to 10 hours per week 11 to 15 hours per week 16 to 20 hours per week 21 to 30 hours per week More than 30 hours per week]
[Once response selected present E8c] |
E8c. Months since [current date minus 12 months] did you take those classes? ____# months [Valid range 0-12] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 1 month 1 or 2 months 3 to 6 months 7 to 12 months
[Once response selected present E9c] |
E9c. GED classes? (Select all that apply) [current month, year] [current month, year minus 1 month] [current month, year minus 2 months] [current month, year minus 3 months] […Continue subtracting 1 until reach current date minus 12 months …]
[Once response selected present E6d] |
E6d. High school or classes toward a regular high school diploma (do not include ABE, GED, or ESL classes) Yes [Go to E7d] No [Go to E6e] [If skipped Go to E6e]
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E7d. High school or classes toward a regular high school diploma, how many hours per week did you attend during a normal week? ____# hours [Valid range 0-60] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 5 hours per week 6 to 10 hours per week 11 to 15 hours per week 16 to 20 hours per week 21 to 30 hours per week More than 30 hours per week]
[Once response selected present E8d] |
E8d. Months since [current date minus 12 months] did you take those classes? ____# months [Valid range 0-12] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 1 month 1 or 2 months 3 to 6 months 7 to 12 months
[Once response selected present E9d] |
E9d. High school or classes toward a regular high school diploma? (Select all that apply) [current month, year] [current month, year minus 1 month] [current month, year minus 2 months] [current month, year minus 3 months] […Continue subtracting 1 until reach current date minus 12 months …]
[Once response selected present E6e] |
E6e. College or classes toward an Associate’s degree or Bachelor’s degree at a 2-year or 4-year college (Do not count recreational classes like exercise or hobbies, courses for the GED, or any courses that don’t provide credit toward a degree) Yes [Go to E7e] No [Go to E6f] [If skipped Go to E6f]
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E7e. College or classes toward an Associate’s degree or Bachelor’s degree at a 2-year or 4-year college, how many hours per week did you attend during a normal week? ____# hours [Valid range 0-60] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 5 hours per week 6 to 10 hours per week 11 to 15 hours per week 16 to 20 hours per week 21 to 30 hours per week More than 30 hours per week]
[Once response selected present E8c] |
E8e. Months since [current date minus 12 months] did you take those classes? ____# months [Valid range 0-12] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 1 month 1 or 2 months 3 to 6 months 7 to 12 months
[Once response selected present E9c] |
E9e. College or classes toward an Associate’s degree or Bachelor’s degree at a 2-year or 4-year college? (Select all that apply) [current month, year] [current month, year minus 1 month] [current month, year minus 2 months] [current month, year minus 3 months] […Continue subtracting 1 until reach current date minus 12 months …]
[Once response selected present E6d] |
E6f. Vocational, career, or technical training at a community or private college By vocational, career, or technical training, we mean training for a specific job, trade, or occupation. This is not training you get in college courses. It is also not on-the-job training or unpaid work experience. Yes [Go to E7f] No [Go to next section] [If skipped Go to next section]
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E7f. Vocational, career, or technical training at a community or private college, how many hours per week did you attend during a normal week? ____# hours [Valid range 0-60] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 5 hours per week 6 to 10 hours per week 11 to 15 hours per week 16 to 20 hours per week 21 to 30 hours per week More than 30 hours per week]
[Once response selected present E8f] |
E8f. Months since [current date minus 12 months] did you take those classes? ____# months [Valid range 0-12] Don’t Know
[If “Don’t Know” selected, present: Would you say… Less than 1 month 1 or 2 months 3 to 6 months 7 to 12 months
[Once response selected present E9f] |
E9f. . Vocational, career, or technical training at a community or private college? (Select all that apply) [current month, year] [current month, year minus 1 month] [current month, year minus 2 months] [current month, year minus 3 months] […Continue subtracting 1 until reach current date minus 12 months …]
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Section F: Employment
The next few questions are about your work experiences.
F1. In the time from [current date minus 12 months] to today, have you worked at a job or business for pay?
By worked at a job or business for pay, we mean working at a job where you get paid money for the work you do or working for someone besides yourself and getting paid for it. It does not include odd jobs, informal work, illegal or “off-the-books” work, or work where you did not get paid.
Yes [ ] 01
No [ ] 00
[If F1=1 (yes) or skipped, skip to employment history series (F3a), If F1=0 (not employed) ask F2a]
F2a. Which of the following best describes the reason you have not worked in the time from [current date minus 12 months] to today?
(Select one)
I was in school [ ] 01
I was looking for work but could not find it [ ] 02
I did not want to work [ ] 03
I was not able to work [ ] 04
I was working odd jobs “off-the-books,” illegally, not for pay, or informally [ ] 05
[If F2a=04 (unable to work), then ask F2b]
F2b. Why were you not able to work?
Physical or other type of disability [ ] 01
Other (Please specify) [ ] 94
[If F1=1 (employed) or skipped ask employment history series, else skip to next section]
Employment History Series
We’d like to learn more about your work or
employment from [current
date minus 12 months] to today. We will ask you to
think backwards in time from now until [current
date minus 12 months]. Sometimes people
have more than one job at a time. If you had more than one job at a
time, please answer the following questions for each job
separately—one at a time.
F3a. Thinking about the time from [current date minus 12 months] to today, what is the name of the place you currently work or most recently worked?
Remember we mean working at a job where you get paid money for the work you do or working for someone besides yourself and getting paid for it. This does not include odd jobs, informal, illegal, or “off-the-books” work, volunteer work, or work where you did not get paid
________________ [open ended, tag response as: employer #a, used in later items. If F3a is left blank, pipe in “your first employer” for F4a through F8a.]
F4a. What did you do at [insert employer #a]?
________________ [open ended, tag response as: occupation #a. ]
F5a. When did you start working at [insert employer #a]?
Click here to see a calendar of the past few months. Calendar [Present calendar for reference]
-
Month
Day
Year
[Day can be blank]
[If date entered is after today’s date, present this prompt once: “Please review the date you entered.”]
F6a. Are you still working at [insert employer #a]?
Yes [ ] 01
No [ ] 00
[If F6a=0, ask F7a, else skip to F8a]
F7a. When did you stop working at [insert employer #a]?
Click here to see a calendar of the past few months. Calendar [Present calendar for reference]
-
Month
Day
Year
[Day can be blank]
[If date entered is after today’s date or before the date entered at F5a, present this prompt once: “Please review the date you entered.”]
F8a. In an average week, how many hours do you or did you usually work at [insert employer #a]?
________________ # hours per week [Valid range: 0-168]
[If value entered is out of range, please present the following prompt once, “Please enter a value between 0 -168.”]
[If letters are entered, please present the following prompt, “Please enter numbers only.”]
F9a. Have you worked anywhere else in the time from [insert current date minus 12 months] to today?
Yes [ ] 01
No [ ] 00
[If F9a=1, continue to employment history loop, F9a=2 or skipped, skip to next section
Employment History Loop:
Note the questions asked in the loop are (nearly) identical to F3a – F9a
[F3b begins Employment History Loop: First turn through loop is F3b – F9b and occurs if F9a = 1 (worked somewhere else since RA). The loop is repeated again (F3c-F9c) if F9b = 1 (worked somewhere else since RA). The loop continues to be repeated until F9# = 0 with a maximum of three times through the loop (ending with F9d). Thus, we capture up to 4 jobs in the employment history series.]
F3b. What is the name of the place you worked just before [insert name of previously identified employer]? You can give it any name that makes sense to you.
Remember we mean working at a job where you get paid money for the work you do or working for someone besides yourself and getting paid for it. This does not include odd jobs, informal, illegal, or “off-the-books” work, volunteer work, or work where you did not get paid
________________ [open ended, tag response as: employer #b, used in later items. If F3b is left blank, pipe in “your second employer” for F4b through F8b.]
F4b. What did you do at [insert employer #b]?
________________ [open ended, tag response as: occupation #b]
F5b. When did you start working at [insert employer #b]?
Click here to see a calendar of the past few months. Calendar [Present calendar for reference]
-
Month
Day
Year
[Day can be blank]
[If date entered is after today’s date or the date entered at F5a, present this prompt once: “Please review the date you entered.”]
F6b. Are you still working at [insert employer #b]?
Yes [ ] 01
No [ ] 00
[If F6b=0, ask F7b, F6b=1 or skipped, skip to F8b]
F7b. When did you stop working at [insert employer #b]?
Click here to see a calendar of the past few months. Calendar [Present calendar for reference]
-
Month
Day
Year
[Day can be blank]
[If date entered is after today’s date or before the date entered at F5b, present this prompt once: “Please review the date you entered.”]
F8b. In an average week, how many hours did you usually work at [insert employer #b]?
________________ # hours per week [Valid range: 0 - 168]
[If value entered is out of range, please present the following prompt once, “Please enter a value between 0 -168.”]
[If letters are entered, please present the following prompt, “Please enter numbers only.”]
F9b. So far, you have told us about [insert names of all previously identified employers: employer #a, employer #b, etc.].
Have you worked anywhere else in the time from [current date minus 12 months] to today?
Yes [ ] 01
No [ ] 00
[If F9b=1, continue to employment history loop, F9b=0 or skipped, skip to next section]
[End of Loop. If F9b = 1, loop back and begin with F3c. If F9b = 0 or skipped, exit loop and continue to next section. Looping continues until F9#=0 with a maximum of three times through the loop (ending with F9d). Thus, we capture up to 4 jobs in the employment history series. If F3# is left blank, pipe in “your [third, fourth…] employer” for F4# through F8#.]
Money Management
F10. At the end of the month do you usually have…
(Select One.)
Some money left over [ ] 03
Just enough money to make ends meet [ ] 02
Not enough money to make ends meet [ ] 01
F11. Do you currently have a savings account?
Yes [ ] 01
No [ ] 00
F12. Do you currently have a checking account?
Yes [ ] 01
No [ ] 00
Section G. Activities
The next questions are about things you do or activities you’ve participated in.
Civic Engagement
G1. In the time from [current date minus 12 months] to today, have you volunteered to help local community organizations or groups?
Yes [ ] 01
No [ ] 00
[If E6d, E6e, and/or E6f = Yes (i.e., enrolled in HS or college in past 12 months), ask G2; else skip to G3]
G2. In the time from [current date minus 12 months] to today, have you participated in any organized activities sponsored by your school or college, such as sports teams, band, or clubs?
Yes [ ] 01
No [ ] 00
Does not apply to me – Not currently in school [ ] -100
G3. In the time from [current date minus 12 months] to today, have you participated in any organized activities or groups that meet on a regular basis [If enrolled in HS or college in past 12 months) insert the following: and are not sponsored by your school or college]? These could be organizations or clubs, such as Boy or Girl Scouts, or community service groups.
Yes [ ] 01
No [ ] 00
Section H: Your Experiences
The next few questions ask things like drug use, sex, and violence. Remember your answers are confidential, and you don't have to answer any question you don't want to.
Exposure to Violence
H1. In the past 12 months, that is since [current date minus 12 months], how often did each of the following things happen?
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Never [00] |
Once [01] |
More than Once [02] |
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Delinquency
H2. In the past 12 months, that is since [current date minus 12 months], how often did you do each of the following things?
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Never [00] |
1 or 2 Times [01] |
3 or 4 Times [02] |
5 or More Times [03] |
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Substance Use
The next two questions are about CIGARETTES and OTHER TOBACCO PRODUCTS.
Think back over the past 30 days and record on how many days, if any, you used cigarettes and/or other tobacco products. |
[For this section, if a value entered is out of range, please present the following prompt once, “Please enter a value between 0 – 30.”]
[If letters are entered, please present the following prompt, “Please enter numbers only.”]
H3a. During the past 30 days, on how many days did you smoke part or all of a cigarette? (Include menthol and regular cigarettes and loose tobacco rolled into cigarettes)
[Present Options 0-30 days, Don’t know or Rather not say]
-
Days
H3b. During the past 30 days, on how many days did you use other tobacco products? (Include any tobacco product other than cigarettes such as snuff, chewing tobacco, and smoking tobacco from a pipe)
[Present Options 0-30 days, Don’t know or Rather not say]
-
Days
The next question is about ALCOHOL. By alcohol, we mean BEER, WINE, WINE COOLERS, MALT BEVERAGES, or HARD LIQUOR.
Different groups of people in the United States may use alcohol for religious reasons. However, this may not be true for your religious, cultural, or ethnic group. For example, some churches serve wine during a church service. If you drink wine at church or for some other religious reason, do not count these times in your answers to the questions below.
Think back over the past 30 days and record on how many days, if any, you consumed alcohol. |
H4a. During the past 30 days, on how many days did you drink one or more drinks of an alcoholic beverage?
[Present Options 0-30 days, Don’t know or Rather not say]
-
Days
The next question is about MARIJUANA or HASHISH. Marijuana is sometimes called weed, blunt, hydro, grass, or pot. Hashish is sometimes called hash or hash oil.
Think back over the past 30 days and record on how many days, if any, you used marijuana or hashish. |
H4b. During the past 30 days, on how many days did you use marijuana or hashish?
[Present Options 0-30 days, Don’t know or Rather not say]
-
Days
The next question is about OTHER ILLEGAL DRUGS, excluding marijuana or hashish, which include substances like inhalants or sniffed substances such as glue, gasoline, paint thinner, cleaning fluid, or shoe polish (used to feel good or to get high), heroin, crack or cocaine, methamphetamine, hallucinogens (drugs that cause people to see or experience things that are not real) such as LSD (sometimes called acid), Ecstasy (MDMA), PCP, peyote (sometimes called angel dust), and prescription drugs used without a doctor’s orders, just to feel good or to get high.
Think back over the past 30 days and report on how many days, if any, you used other illegal drugs. |
H5a. During the past 30 days, on how many days did you use any other illegal drug?
[Present Options 0-30 days, Don’t know or Rather not say]
-
Days
Now we would like to ask about your use of several specific drugs. |
H5b. During the past 30 days, on how many days did you use cocaine or crack?
[Present Options 0-30 days, Don’t know or Rather not say]
-
Days
H5c. During the past 30 days, on how many days did you use methamphetamine? (Also called meth, crystal meth, crank, go, and speed)
[Present Options 0-30 days, Don’t know or Rather not say]
-
Days
H5d. During the past 30 days, on how many days did you inject any drugs? (Count only injections without a doctor’s orders, those you had just to feel good or to get high.)
[Present Options 0-30 days, Don’t know or Rather not say]
-
Days
The next questions are about your sexual behaviors and experiences.
Sexual Risk Behavior
H6. Sexual intercourse is when a male puts his penis into a female’s vagina.
At any time from [current date minus 3 months] to today, have you had sexual intercourse, even once?
Yes [ ] 01
No [ ] 00
Don't know [ ] -98
Rather not say [ ] -99
[If H6=1 ask H7, else skip to H8]
H7. At any time from [current date minus 3 months] to today, have you had sexual intercourse without you or your partner using a condom, even just once?
Yes, I have had sexual intercourse without using a condom [ ] 01
No, I have used a condom each time I had sexual intercourse [ ] 00
Don't know [ ] -98
Rather not say [ ] -99
H8. Anal sex is when a male puts his penis in someone else’s anus, or their butt, or someone lets a male put his penis in their anus or butt.
At any time from [current date minus 3 months] to today, have you had anal sex, even once?
Yes [ ] 01
No [ ] 00
Don't know [ ] -98
Rather not say [ ] -99
[If H8=1,ask H9, else skip to skip to H10a]
H9. In the time from [current date minus 3 months] to today, have you had anal sex without you or your partner using a condom, even just once?
Yes, I have had anal sex without using a condom [ ] 01
No, I have used a condom each time I had anal sex [ ] 00
Don't know [ ] -98
Rather not say [ ] -99
[If H6=1 or H8=1 ask H10a, if H6 or H8 skipped ask H10a; else skip to H11a]
H10a. At any time from [current date minus 3 months] to today, have you received anything in exchange for having sexual relations with another person, such as money, food, drugs, or shelter? By sexual relations we mean sexual intercourse, anal sex, or oral sex.
Yes [ ] 01
No [ ] 00
Don't know [ ] -98
Rather not say [ ] -99
[If H10a=1 ask H10b, if H10a skipped ask H11a]
H10b. In the time from [current date minus 3 months] to today, how many times have you received something in exchange for having sexual relations with another person, such as money, food, drugs, or shelter? Your best guess is fine.
______ # times [valid range 1 – 99]
[If letters are entered, please present the following prompt, “Please enter numbers only.”]
Gender, Gender Identity, Sexual Orientation
H11a. Would you describe your gender as male, female, or something else?
(Select only one answer.)
Male [ ] 00
Female [ ] 01
Transgender Male to Female [ ] 02
Transgender Female to Male [ ] 03
Something else [ ] 04
Don’t know [ ] -98
Rather not say [ ] -99
H11b. Which of the following best represents how you think of yourself?
(Select only one answer.)
Lesbian or gay [ ] 01
Straight, that is, not gay [ ] 02
Bisexual [ ] 03
Something else [ ] 04
Don’t know [ ] -98
Rather not say [ ] -99
[If H11b=04, ask H11c, else skip to H15]
H11c. What do you mean by something else?
(Select only one answer.)
You are not straight, but identify with another label such as queer, trisexual, omnisexual or
pansexual [ ] 01
You have not figured out or are in the process of figuring out your sexuality [ ] 02
You do not think of yourself as having sexuality [ ] 03
You do not use labels to identify yourself [ ] 04
You mean something else [ ] 05
Don’t know [ ] -98
Rather not say [ ] -99
[Items H12 – H14 intentionally removed]
Abuse and Neglect
The next questions are about situations that may have happened during your life and the ways your caregivers may have mistreated you in the past. By caregivers, we mean the adults who were responsible for taking care of you in the past. Remember, your answers are confidential, and you don't have to answer any question you don't want to.
H15. Did any of your caregivers fail to give you regular meals so that you had to go hungry or ask other people for food?
Yes [ ] 01
No [ ] 00
Don’t Know [ ] -98
Rather not say [ ] -99
H16. Did any of your caregivers ever throw or push you? For example, push you down a staircase or push you into a wall?
Yes [ ] 01
No [ ] 00
Don’t Know [ ] -98
Rather not say [ ] -99
H17. Did any of your caregivers ever hit you hard with a fist, or kick you or slap you really hard?
Yes [ ] 01
No [ ] 00
Don’t Know [ ] -98
Rather not say [ ] -99
H18. Did any of your caregivers ever beat you up such as hitting or kicking you repeatedly?
Yes [ ] 01
No [ ] 00
Don’t Know [ ] -98
Rather not say [ ] -99
H19. Did you ever have a serious illness or injury or physical disability, but your caregivers ignored it or failed to get you medical care or other treatment for it?
Some examples are an infection that became serious because it was not treated soon enough, a broken bone that did not get fixed, or problems seeing or hearing that were not treated with glasses or hearing aids.
Yes [ ] 01
No [ ] 00
Don’t Know [ ] -98
Rather not say [ ] -99
H20. Did any of your caregivers ever abandon you?
By “abandon,” we mean leave you, walk out on you, ditch or dump you.
Yes [ ] 01
No [ ] 00
Don’t Know [ ] -98
Rather not say [ ] -99
H21. Did any of your caregivers ever touch or kiss you against your will?
By “against your will,” we mean when you did not want them to or without your permission.
Yes [ ] 01
No [ ] 00
Don’t Know [ ] -98
Rather not say [ ] -99
H22. Did any of your caregivers ever have sexual intercourse, oral sex, or anal sex with you against your will?
By “against your will,” we mean when you did not want them to or without your permission
Yes [ ] 01
No [ ] 00
Don’t Know [ ] -98
Rather not say [ ] -99
Section I: About You
We’re almost done. There are just a few more questions about your background.
I1. Are you of Hispanic, Latino, or Spanish Origin?
(Select only one answer.)
No, not of Hispanic, Latino, or Spanish origin [ ] 00
Yes, Puerto Rican [ ] 01
Yes, Cuban [ ] 02
Yes, another Hispanic, Latino, or Spanish origin [ ] 03
I2. What is your race?
(Select all that apply.)
White [ ] 01
Black, or African American [ ] 02
American Indian or Alaska Native [ ] 03
Native Hawaiian or Other Pacific Islander [ ] 04
Asian [ ] 05
Other (Please specify) [ ] 94
[If ‘Other’ is selected and no value is entered, display “Please specify for ''Other.””]
I3a. Were you born in the United States?
Yes [ ] 01
No [ ] 00
[If I3a=0, skip to I4]
I3b. How long have you lived in the United States? _________ # years
I4. What is the language you learned first (that is, what is your native language)?
(Select all that apply.)
English [ ] 01
Spanish [ ] 02
Other (Please specify) [ ] 94
I5a. What is your current marital status?
(Select only one answer.)
Never Married [ ] 01
Married [ ] 02
Separated [ ] 03
Divorced [ ] 04
Widowed [ ] 05
I5b. Are you currently staying with a romantic partner (boyfriend or girlfriend), spouse (husband or wife) or someone who is like a spouse to you?
(Select only one answer.)
Yes [ ] 01
No [ ] 00
I6a. Do you have any children (even if they don’t stay with you)?
Yes [ ] 01
No [ ] 00
[If I6a=0, skip to I7]
I6b. How many children do you have (even if they don’t live with you)?
________# children [Valid range 0-10]
[If value entered is out of range, please present the following prompt once, “Please enter a value between 0 – 10.”]
[If letters are entered, please present the following prompt, “Please enter numbers only.”]
I7. Are you currently pregnant or expecting to become a father in the next 9 months?
Yes [ ] 01
No [ ] 00
Don’t know……………………………………………………………………………………… .[ ] -98
Closing
[If contact information was provided present Closing1, if not present Closing2b]
Closing1.
Thank you for taking this survey and being part of the study!
After you submit your survey, we will [insert mode selected: email/text] your electronic gift card to:
[insert gift card contact]
Closing 1a. If this information is correct, click here to submit your survey: SUBMIT [Go to Closing2]
(Once you submit your survey, you cannot go back and change your answers.)
Closing1. If this information is wrong, click here: CHANGE INFORMATION [Go to Closing1b]
Closing1b. Please tell us how to send you your electronic gift card:
(Select only one answer)
|
|
Enter the [email address/cell phone number/mailing address] we should use here: |
|
||||||||||||
|
Email it to me at: |
|
01 |
||||||||||||
|
Text it to my cell phone: |
|
02 |
||||||||||||
|
Mail it to me: |
|
03 |
||||||||||||
|
I do not have an email address, cell phone or mailing address you can send it to (Without an email address, cell phone number or mailing address we cannot send you an electronic gift card.) |
|
04 |
||||||||||||
[If Closing1b = 4, Go to Closing2b]
[If no response is selected = “Please select Email it to me at, Text it to my cell phone, Mail it to me or I do not have an email address, cell phone or mailing address you can send it to.” IF STILL NOT ANSWERED: Go to Closing2b]
[If Closing1b = 1 and email is left blank = “Please enter your email.” IF STILL NOT ANSWERED: Go to Closing2b]
[If Closing1b = 2 and cell phone number is left blank = “Please enter your 10 digit cell phone number.” IF STILL NOT ANSWERED: Go to Closing2b]
[If email entered is not standard email format = “The email address is not valid. Please enter a valid
email address.” IF STILL NOT CORRECTED: Go to Closing2b]
[If not all ten digits or letters are entered for the cell phone number = “Phone Number must be 10 digits (numbers only). The first three are the Area Code. Please re-enter the 10 digit cell phone number.” IF STILL NOT CORRECTED: Go to Closing2b]
[Apt# can be left blank]
[If Street Address is left blank = “Please enter your street address.” IF STILL NOT ANSWERED: Go to Closing2b]
[If City is left blank = “Please enter your city.” IF STILL NOT ANSWERED: Go to Closing2b]
[If numeric values are entered for the City = “Only letters may be entered for your city. We need a valid address.” IF STILL NOT CORRECTED: Go to Closing2b]
[If Zip Code is left blank = “Please enter your zip code.” IF STILL NOT ANSWERED: Go to Closing2b]
[If letters are entered in the zip = “Zip code must be 5 digits (numbers only). We need a valid address.” IF STILL NOT CORRECTED: Go to Closing2b]
Closing2.
If email selected present, “You will receive your electronic gift card within 24 hours. Please check your Inbox and Spam/Junk folder for the email.”
If text selected present, “You will receive your electronic gift card within 1 business day.”
If mail selected, present, “You will receive your electronic gift card within 10 days.”
If you have any questions about the study, you can email or call the people who are doing the research at [email protected] or (855) 579-6654. This is a free call.
Thanks again!
You are a very important part of the study!
[Go Back] [Submit]
Closing2b.
Thank you for taking this survey and being part of the study!
Because you did not provide an email address, a cell phone number to send a text or a complete mailing address we cannot send you an electronic gift card. If you have any questions, please email [email protected] or call (855) 579-6654. This is a free call.
If this information is wrong, click here: [CHANGE INFORMATION]
[If respondent selects [CHANGE INFORMATION] go to Closing 1b]
[Go Back] [Submit]
▌pg.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Jessica Thornton Walker |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |
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