Individual/Households Respondents

Evaluation of Supplemental Nutrition Assistance Program (SNAP) Employment and Training Pilots.

C.1_Registration Document_English

Individual/Households Respondents

OMB: 0584-0604

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ATTACHMENT C.1

registration document

english




OMB Control No.: 0584-0604

Expiration Date: 00/00/20xx

SNAP E&T Pilots

Registration Document



Public Burden Statement

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 valid OMB control number for this information collection is 0584-0604. The time required to complete this information collection is estimated to average 12 minutes including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate to Food and Nutrition Service, U.S. Department of Agriculture, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302.


Contact Info:

1. Participant Name:

First Name: Shape2

Middle Initial: Shape3

Last Name: Shape4

2a. In the past 3 years, have you gone by any other names?

Yes 1

No 0 GO TO Q3

2b. Please provide any other names you have been using to identify yourself over the past 3 years (including Maiden name):

First Name1: Shape5

Last Name1: Shape6



First Name2: Shape7

Last Name2: Shape8



3. What is your current address?

Street Address 1: Shape9

Street Address 2: Shape10

City: Shape11

State: Shape12

Zip: Shape13


No fixed address/No mailing address


4. What is your date of birth?

Shape14

MONTH DAY YEAR

5. Social Security Number:

Shape15

6. Gender:

Male 1

Female 2

Other (Specify) 3

___________________________________________

7. Landline Phone Number:

Shape16


None



7a. Under whose name is that phone listed?

My own name 1

Someone else’s name (SPECIFY) 2

First Name: Shape17

Last Name: Shape18

8. Cell Phone Number:

Shape19



None – GO TO Q9

8a. Do we have your permission to text you to notify you about future surveys for this pilot?

Yes 1

No 0

9. Email Address:

Shape20

None


DEMOGRAPHIC and well-being information:

10. Are you...

Hispanic or Latino, 1

Not Hispanic or Latino 0


11. Please choose one or more races that you consider yourself to be.

Select all that apply

American Indian or Alaska Native 1

Asian 2

Black or African American 3

Native Hawaiian or Pacific Islander, or 4

White 5

12. What is your primary spoken language?

Select one only

English 1 GO TO Q13

Spanish 2

Shape21

Other (SPECIFY) 3




12a. How well would you say you speak English? Would you say…

Very well 1

Well 2

Not well, or 3

Not at all 4

13. Are you currently…

Select one only

Married 1

Living with someone as married, 2

Separated, 3

Divorced, 4

Widowed, or 5

Never married? 6


14. What is the highest grade or degree you have completed?

Select one only:

Less than 8th grade 1

8th to 12th Grade, no diploma 2

General Equivalency Diploma (GED) 3

High School Diploma 4

Adult Basic Education (ABE) certificate 5

Some college but no degree 6

Vocational/Technical degree or certificate 7

Business degree/certificate 8

Associates degree (AA) 9

Bachelor’s degree or equivalent (BA/BS) 10

Master’s degree (MA/MS) or higher (MD, Ph.D) 11

Other (SPECIFY) 12

Shape22


14a. In general would you say your health is excellent, very good, good, fair or poor?

Excellent 1

Very good 2

Good 3

Fair 4

Poor 5



household composition:

15. Including yourself, how many people live with you? (Please include babies, small children, people who are not related to you, and people who are temporarily away.)

Shape23 (NUMBER OF PEOPLE LIVING WITH YOU, INCLUDING YOU)

16. Do all the people who live with you share the food that is bought for the household?

Yes 1 GO TO 18

No 0

17. Including yourself, how many people in your household share the food that is bought for the household?

Shape24 (NUMBER OF PEOPLE IN HOUSEHOLD THAT SHARE FOOD WITH YOU, INCLUDING YOU)

18. And (of those), how many people are children age 18 or younger?

Shape25 (NUMBER OF CHILDREN AGE 18 OR YOUNGER)


employment history:

19. Have you ever worked for pay? Please include self-employment.

Yes 1

No 0 GO TO 25a


20. Are you currently self-employed or working at a job for pay?

Yes 1 GO TO 22

No 0

21. In what month and year did your last job end?

Shape26

MONTH YEAR

The next questions are about your current or most recent job. (If you currently have more than one job or had more than one job recently, give answers about your job with the most hours.)

22. What is the name of the company at which you currently or most recently worked?

Shape27

Self-employed 1


22a. What (is/was) your job title?

Shape28

23. What are (or were) your main duties at this company? Please be specific.

Shape29

24. IF CURRENTLY WORKING, OR DATE LAST JOB ENDED IS LESS THAN 5 YEARS: How many hours per week do (or did) you usually work at your main job?

Shape30 (HOURS PER WEEK) - GO TO Q25

Varies/Don’t know 1


24a. How many hours did you work during the last week you worked?


Shape31 (HOURS DURING LAST WEEK WORKED)


Don’t know 1

24b. IF 24a=DK: Would you say you worked….

Less than 20 hours per week, 1

Between 20 and 29 hours per week, 2

Between 30 and 39 hours per week, 3

Between 40 and 49 hours per week, or 4

50 or more hours per week? 5



25. IF CURRENTLY WORKING, OR DATE LAST JOB ENDED IS LESS THAN 5 YEARS: What was your current or most recent rate of pay, before taxes and deductions at your main job? IF RATE OF PAY VARIES, PROBE FOR AVERAGE RATE OF PAY

Shape32 PER

Select one only

Hour 1

Week 2

Every 2 weeks 3

Twice per month 4

Once per month 5

Year 6

Other (SPECIFY) 7

Shape33


25a. What is the main reason you (have never worked/are not currently working)?

Select only one.

Could not find work or lack of jobs available in the area 1

Lack necessary schooling, training, skills or experience 2

Could not get along with supervisor or co-workers 3

Physical or mental health problems 4

Alcohol or substance abuse 5

Family responsibilities; caring for children, spouse, or parents 6

Attending school 7

Transportation issues or problems (no car or no public transportation available, transportation costs too much) 8

Chose not to work 9

Felony record 10

Other (SPECIFY) 11

Shape34


other program receipt:

26. Do you, or anyone in your household, currently receive assistance from any of the following programs?

Select all that apply

SNAP (Food Stamps) [also known as STATE SNAP NAME] 1

TANF (Temporary Assistance to Needy Families) [also known as STATE TANF NAME] 2

Medicaid [also known as STATE MEDICAID NAME] 3

General Assistance 4

Unemployment Compensation 5

SSI or SSDI (Supplemental Security Income/Social Security Disability Insurance) 6

Section 8 or Public Housing Assistance 7

WIC (Women, Infants, and Children food program) 8

Other (SPECIFY) 9

Shape35


None 0 GO TO 28


Shape36

IF SNAP NOT SELECTED,

GO TO Q28




27. IF CURRENTLY RECEIVING SNAP: Before you began receiving SNAP benefits this most recent time, had you ever participated in SNAP before?


Yes 1

No 0


other contacts:

28. Please provide the name, address, email address, and phone number(s) of two close relatives or friends who do not live with you but who are likely to know how to contact you in the next year. We will only contact these people if we cannot reach you directly.

PERSON 1:

Name:

First Name: Shape37

Middle Initial: Shape38

Last Name: Shape39

Address:

Street Address 1: Shape40

Street Address 2: Shape41

City: Shape42

State: Shape43

Zip: Shape44

Phone number:

Shape45


(LANDLINE)

Shape46

(CELL)

Email address:

Shape47

What is this person’s relationship to you?

Parent 1

Grandparent 2

Child 3

Brother/Sister 4

Friend/Neighbor 5

Employer 6

Shape48

Other (SPECIFY) 7




PERSON 2:

Name:

First Name: Shape49

Middle Initial: Shape50

Last Name: Shape51

Address:

Street Address 1: Shape52

Street Address 2: Shape53

City: Shape54

State: Shape55

Zip: Shape56

Shape57 Phone number:

(LANDLINE)

Shape58

(CELL)

Email address:

Shape59

What is this person’s relationship to you?

Parent 1

Grandparent 2

Brother/Sister 3

Friend/Neighbor 4

Employer 5

Shape60

Other (SPECIFY) 6




FOR COUNSELOR USE ONLY:


Likely to be assigned to following track:


   Track A   (FILL SITE-SPECIFIC INFO)

                n/a—Very likely – Somewhat Likely – Somewhat Unlikely – Very Unlikely


   Track B    (FILL SITE-SPECIFIC INFO)

                 n/a—Very likely – Somewhat Likely – Somewhat Unlikely – Very Unlikely


    Track C    (FILL SITE-SPECIFIC INFO)

                n/a—Very likely – Somewhat Likely – Somewhat Unlikely – Very Unlikely


    Track D   (FILL SITE-SPECIFIC INFO)

                n/a—Very likely – Somewhat Likely – Somewhat Unlikely – Very Unlikely


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleSNAP ET Baseline Info Form
SubjectWeb - client-friendly
AuthorMATHEMATICA
File Modified0000-00-00
File Created2021-01-15

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