Baseline Information Form

^{Attachment D: Baseline Information Form (BIF)}
Reentry Employment Opportunities (REO) Evaluation

June 2019

This page has been left blank for double-sided copying.

Baseline Information Form

OMB No.: xxxx-xxxx

Expiration Date: xx/xx/xxxx

A. CONTACT INFORMATION

B. EDUCATION AND EMPLOYMENT HISTORY

Today’s Date: | | |/| | |/| | | | |

Month Day Year

ID: | | | | | | | | | □ Check if currently incarcerated

A1. ________________________________________________

First Name Middle Name Last Name

A2. ________________________________________________

Address Apt. #

________________________________________________

City State ZIP

A3. Nickname(s):____________________________ □ None

A4. Social security number: | | | |-| | |-| | | | |

A5. Please enter your date of birth:

| | | / | | | / | | | | |

month day year

A6. For the purpose of the study, the research team will need to contact you up to a few times a year. Please tell us the best number to reach you and any other number where you might be reached? Please also let us know whose name each phone number is listed under and whether or not we can send you text messages at that number (standard message and data rates may apply).

Phone number:	Phone type:	May we text you?
(| | | |) | | | |-| | | | | Listed to: ______________________	□ Home □ Cell □ Work □ Other	□ Yes □ No
(| | | |) | | | |-| | | | | Listed to: ______________________	□ Home □ Cell □ Work □ Other	□ Yes □ No

A7. What is your primary email address?

A8. Do you have a Facebook account?

1 □ Yes – User name:

0 □ No

B1. Are you currently enrolled in school?

1 □ Yes – Full time 2 □ Yes – Part time 0 □ No

B2. What is the highest level of education you have completed, including any education received while incarcerated?

Mark one only

1 □ Some high school

2 □ High school diploma

3 □ GED/HiSET/TASC

4 □ Certificate of Completion

5 □ Some college

6 □ Associate’s degree or vocational degree

7 □ Bachelor’s degree

8 □ Master’s degree or higher

9 □ None of these

B3. Do you have any specialized education or work credentials or certificates? Do not include a high school diploma, GED, or college degree.

1 □ Yes (name of credential/ certificate)

0 □ No

B4. Have you ever had a paying job lasting 3 months or longer?

1 □ Yes 0 □ No

B5. How many months or years of work experience do you have? Do not include work experience while incarcerated. Please include work experience before and after incarceration. Please include time when you were self-employed.

| | | years OR | | | months

B6. Are you currently working?

1 □ Yes

((SKIP TO SECTION C)

2 □ No, but looking for work

3 □ No, and not looking for work

B6a. What best describes your work status?

Mark one only

1 □ Working 30 hours per week or more

2 □ Working 1 to 29 hours per week

B6b. What does the company you work for make sell or do?

B6c. What is your job title?

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays an Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is xxxx-xxxx. The time required to complete this collection of information is estimated to average 10 minutes, including the time to review instructions, search existing data resources, gather the data needed and complete and review the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to NAME at xxx-xxx-xxxx or NAME@___.gov and reference the OMB Control Number xxxx-xxxx.

C. EXPERIENCE WITH CRIMINAL JUSTICE SYSTEM

These questions are about your experience with the criminal justice system. Your answers will be used for research purposes only.

C1. How did you hear about the [insert Program Name]?

MARK ONE ONLY

1 □ Judge

2 □ Probation/parole/corrections officer

3 □ Case manager

4 □ School counselor/Truant officer

5 □ Family member

6 □ Friend

7 □ Someone else (specify):

C2. Were you required to participate in [insert Program Name]?

1 □ Yes 0 □ No

C3. How many times have you been arrested?

| | | NUMBER OF ARRESTS

C4. How many of these arrests resulted in at least one conviction?

| | | NUMBER OF CONVICTIONS IF 0 SKIP TO C7

C5. Have you ever been convicted of a felony?

1 □ Yes 0 □ No

C6. Have you ever been convicted of any of the following?

Mark All That Apply

1 □ Theft, burglary, robbery, or larceny

2 □ Assault, battery, or other violent offense

3 □ Drug or alcohol offense (DUI/DWI, possession, distribution)

4 □ Disorderly conduct, loitering, disturbing the peace

5 □ Other (specify):

__________________________________

C7. Are you currently on probation or parole?

1 □ Yes – Probation

2 □ Yes – Parole

0 □ No

C8. Have you ever spent time in a…

Mark All That Apply

1 □ Group home or reform school

2 □ Juvenile detention center, jail, prison, or other juvenile facility

3 □ Adult prison, jail, or other adult correctional facility

4 □ No, never spent time in a correctional

facility (SKIP TO SECTION D)

C8a. How many times have you been incarcerated in a juvenile or adult correctional facility?

| | | NUMBER OF INCARCERATIONS

C8b. What was the reason for your most recent incarceration?

(Please select only the most serious one.)

Mark one only

1 □ Felony

2 □ Misdemeanor

3 □ Violation of probation or parole

4 □ Held while awaiting charges or sentence

C8c. Where were you last incarcerated? (include current incarceration if applicable)

Name of facility:

C9. What is the total time you have spent in incarceration over your lifetime?

(If less than 1 month, please record 1 month.)

| | | years and | | | months

C10. When were you most recently released from an incarceration facility, such as a jail or prison?

| | | / | | | / | | | | |

month day year

0 □ Have not been released yet

D. PARTICIPANT’S DEMOGRAPHICS

D1. What is your gender?

Mark one only

1 □ Female

2 □ Male

3 □ Other

D2. Are you Hispanic or Latino?

1 □ Yes 0 □ No

D3. What is your race?

Mark All That Apply

1 □ American Indian or Alaska Native

2 □ Asian

3 □ Black, African American

4 □ Native Hawaiian or other Pacific Islander

5 □ White

6 □ Other (specify)

D4. What is your primary language?

Mark one only

1 □ English

2 □ Spanish

3 □ Other (specify)

D5. How would you best describe your marital status?

Mark one only

1 □ Single

2 □ In a committed relationship but not married

3 □ Married

4 □ Separated

5 □ Divorced

6 □ Widowed

D6. Do you have children?

1 □ Yes (please specify how many): | | |

0 □ No SKIP TO D9

D7. How many of your children live with you at least 50% of the time?

| | | NUMBER OF CHILDREN WHO LIVE WITH YOU

D8. Do you have any legal agreements or child support orders that require you to provide financial support for a child?

1 □ Yes 0 □ No

D9. Do you have a mental or physical disability that limits your ability to work?

1 □ Yes 0 □ No

D10. How would you best describe your current living situation?

(If incarcerated, describe your living situation before being incarcerated)

Mark one only

1 □ Own my home

2 □ Renting home or apartment

3 □ Living with both parents

4 □ Living with mother only

5 □ Living with father only

6 □ Living with one or more grandparents

7 □ Living with one or more friends (without paying rent)

8 □ Living in a halfway house or shelter

9 □ On the street or in my car

10 □ Other (specify)

Contact Information - Relatives and Friends

INSTRUCTIONS: In the space below, please provide contact information for three close relatives or friends who are likely to know how to reach you over the next year. We will only contact these people if we are unable to contact you directly. Please consider telling us about your grandmother or grandfather, brother or sister, and/or your best friend. Some contact information is better than no contact information! Please provide as many contacts as possible, even if you do not know all of the information.

1. NAME AND ADDRESS OF RELATIVE OR FRIEND

NAME: First

Middle

Last

ADDRESS: Number and Street

Apt. No.

City

State

ZIP Code

How is this person related to you?

1 □ Mother

2 □ Father

3 □ Sister/ brother

4 □ Friend

5 □ Grandmother/ Grandfather

6 □ Other _______________

TELEPHONE and EMAIL: Phone 1: (________) - ________ - _______ Area Code Number

Phone 2: (________) - ________ - __________ Area Code Number

Email Address: _____________________________

Does this person have a Facebook account? 1 Yes – User name: __________________________________________

0  No

2. NAME AND ADDRESS OF RELATIVE OR FRIEND

NAME: First

Middle

Last

ADDRESS: Number and Street

Apt. No.

City

State

ZIP Code

How is this person related to you?

1 □ Mother

2 □ Father

3 □ Sister/ brother

4 □ Friend

5 □ Grandmother/ Grandfather

6 □ Other _______________

TELEPHONE and EMAIL: Phone 1: (________) - ________ - _______ Area Code Number

Phone 2: (________) - ________ - __________ Area Code Number

Email Address: _____________________________

Does this person have a Facebook account? 1 Yes – User name: __________________________________________

0  No

3. NAME AND ADDRESS OF RELATIVE OR FRIEND

NAME: First

Middle

Last

ADDRESS: Number and Street

Apt. No.

City

State

ZIP Code

How is this person related to you?

1 □ Mother

2 □ Father

3 □ Sister/ brother

4 □ Friend

5 □ Grandmother/ Grandfather

6 □ Other _______________

TELEPHONE and EMAIL: Phone 1: (________) - ________ - _______ Area Code Number

Phone 2: (________) - ________ - __________ Area Code Number

Email Address: _____________________________

Does this person have a Facebook account? 1 Yes – User name: __________________________________________

0  No

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays an Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is xxxx-xxxx. The time required to complete this collection of information is estimated to average 10 minutes, including the time to review instructions, search existing data resources, gather the data needed and complete and review the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to NAME at xxx-xxx-xxxx or NAME@___.gov and reference the OMB Control Number xxxx-xxxx.