Baseline data collection – staff

OPRE Evaluation: Evaluation of Employment Coaching for TANF and Other Related Populations [Experimental impact study and an Implementation study]

Attachment B Coaching Baseline Questionnaire_PUBLIC_v8_clean

Baseline data collection – staff

OMB: 0970-0506

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Attachment B

Baseline data collection













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OMB No.: XXXX-XXXX

Expiration Date: XX/XX/20XX

Evaluation of Employment Coaching for TANF and Related Populations

Baseline Data Collection

June 7, 2017

PUBLIC VERSION

D3a and b: Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc. (PAR), 16204 North Florida Avenue, Lutz, Florida 33549, from the Behavior Rating Inventory of Executive Function Adult Version by Robert M. Roth, PhD, Peter K. Isquith, PhD and Gerard A. Gioia, PhD, Copyright 1996, 1998, 2001, 2003, 2004, 2005 by PAR. Further reproduction is prohibited without permission from PAR.

For Review Only, Do NOT Copy

According to the Paperwork Reduction Act of 1995, no persons are 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 XXXX-XXXX. The time required to complete this information collection is estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.







CONTENTS

Section Page

i. INTRODUCTION 1

A. CONTACT INFORMATION 1 3

B. DEMOGRAPHIC AND SOCIOECONOMIC CHARACTERISTICS 6

C. EMPLOYMENT STATUS AND BARRIERS 9

D. GOAL SETTING, GOAL PURSUIT, AND SELF-REGULATION SKILLS 14

E. CONTACT INFORMATION 2 18



i. INTRODUCTION

ALL

[PROGRAM NAME] is participating in the Evaluation of Employment Coaching for TANF and Related Populations, a national study being conducted by the U.S. Department of Health and Human Services. The study is being done to learn more about whether providing people with a coach to assist them with setting and meeting goals helps them get and keep a job. The study will also help us learn whether there are ways to make the [coaching/program] work better. The U.S. Department of Health and Human Services has asked researchers from Mathematica Policy Research and its partner, Abt Associates, to assist with the study. We invite you to be a part of the study.

All study participants will be in one of two groups: (1) those who are offered [coaching/PROGRAM NAME’s services], and (2) those who are not but are still eligible to receive [regular case management/referrals to other services in the community]. The study will compare outcomes for people in each group.

A computer will randomly select which group you will be in. The computer works like a flip of a coin—assignment to a group is random. This procedure makes sure that assignments to the groups are fair. Everyone who agrees to participate in the study has the same chance of being placed into either group. The chance of being able to receive [coaching/PROGRAM NAMEservices] is not influenced by what you say to us or your answers to the questions you will be asked when you apply. [I/NAME OF STAFF MEMBER] will let you know which group you are assigned to at the end of the application process.

If you are not randomly selected to [receive coaching/participate in PROGRAM NAME], you are still eligible to [receive regular case management services/a list of other services in the community].

If you decide to be in the study, I will ask you to answer some questions today. I will ask you questions about yourself, your family, your employment history, and your receipt of public assistance. These questions will take about 20 minutes to answer.

In about [NUMBER] months and again in [NUMBER] months, the researchers will send you an invitation with a user ID and password so that you can complete a follow-up survey online, which should take about one hour. If the researchers don’t hear from you, then they will contact you by phone or in person. You will be asked about topics such as the services you received from [PROGRAM NAME] or other providers in the community, your employment, and your earnings. If you are in the program, you may also be asked to participate in other study activities, such as a two-hour in-person interview and video recording of one or more of your coaching sessions to be reviewed by members of the research team.

If you agree to be part of the study, it means you are giving permission for our program to share information with the researchers about the services you receive from the program. The researchers may use information you provide to consult directories of contact information to help them contact you about completing the follow-up surveys and verify your identity. The researchers may also contact federal and state agencies for information about your employment and earnings and your receipt of benefits from such programs as Temporary Assistance for Needy Families (TANF) and unemployment insurance. The researchers may request this information for two years before and up to 10 years after you enroll in the study.

Everything you tell the researchers will be used for research purposes only, unless the researchers are required by law to release it for some other purpose. All data will be kept securely and the researchers will not share your individual data with [PROGRAM NAME], the TANF agency, or federal officials. Nobody will ever publish your name in connection with the information you provide. Instead, information about you will be combined with information about other people in the study, so researchers can describe the overall program effects and participants’ experiences.

To help us protect your privacy, the researchers have obtained a Certificate of Confidentiality from the National Institutes of Health. With this Certificate, the researchers cannot be forced to disclose information that may identify you, even by a court subpoena, in any federal, state, or local civil, criminal, administrative, legislative, or other proceedings. The researchers will use the Certificate to resist any demands for information that would identify you, with one exception. The Certificate of Confidentiality does not prevent the researchers from disclosing information that would identify you as a participant in the research project if you tell the interviewers anything that suggests you are very likely to harm yourself, that you are planning to hurt another person or child, or that someone is likely to harm you.

You should understand that a Certificate of Confidentiality does not prevent you or a member of your family from voluntarily releasing information about yourself or your involvement in this research. If an insurer, employer, or other person obtains your written consent to receive research information, then the researchers may not use the Certificate to withhold that information.

You may or may not benefit personally from participating in this study, but your participation in the study could help in improving services offered in the future to other people like you.

There are very minimal risks associated with participating in the study. You may feel uncomfortable answering some questions, but you can always refuse to answer those questions if you wish, and it will not change your participation in the program or the study. Although researchers will take many steps to protect all study information, there is a small risk that non-researchers could see it, including information about your employment and earnings and TANF benefits. In addition, representatives from the U.S. Department of Health and Human Services and New England Institutional Review Board may inspect and have access to confidential information as they ensure your rights as a study participant are protected.

You will not receive a token of appreciation today, but you will receive a token of appreciation for completing the follow-up surveys. The researchers will send you an invitation once we are ready to start a follow-up survey. The invitation will contain all the information you need to participate. For each of the two follow-up surveys you will receive a $35 gift card as a token of appreciation if you complete the survey within four weeks of receiving the invitation. If you complete the survey later than four weeks after receiving the invitation, you will receive a $25 gift card as a token of appreciation for completing the survey.

We hope you will want to be in the study but your participation is strictly voluntary. If you participate in the study, the researchers will ask you to participate in surveys, will collect some data on you from [PROGRAM NAME] and federal and state agencies, and may ask you to participate in other data collection activities. However, you will never be required to answer questions in the survey, participate in an interview, or be videotaped. If you decide now that you do not want to participate in the study, the researchers will not collect any information about you. However, you cannot [receive coaching/participate in PROGRAM NAME] if you do not participate in the study. Either way, it will not affect your access to TANF or other public benefits.

If you agree to be in the study now, you can withdraw from the study later. However, if you withdraw from the study and were assigned to the group that [receives coaching services/participates in PROGRAM NAME], you will no longer be able to [receive coaching/participate in PROGRAM NAME]. By agreeing now to be in the study, even if later you tell us you want to withdraw from the study, you are authorizing researchers to use information that was collected about you before you withdrew. To withdraw from the study, you must call Mathematica’s help line and provide a written letter or email confirming that you no longer want to be in the study.

If you have any questions you can call Mathematica toll-free at 1-8XX-XXX-XXXX.

i1. Do you agree to participate in the Evaluation of Employment Coaching for TANF and Related Populations?

YES 1

NO 0 END

INTERVIEWER: IF RESPONDENT REFUSES TO BE IN THE STUDY THEN DO NOT PROCEED WITH THE INTERVIEW.

Shape5


Thank you for agreeing to participate in the study. [I/We] would like to start by asking you some questions about yourself.

ALL

A1. What is your full name? Please spell that for me.

INSTRUCTION: CONFIRM LAST NAME GIVEN IS THEIR FULL LEGAL NAME (i.e., ARE THERE TWO LAST NAMES OR HYPHENATED LAST NAME).

Shape6

PACT

INSTRUCTION: PLEASE ASK FOR MIDDLE NAME OF CLIENT

Shape7



FIRST NAME

(STRING 50)

Shape8



MIDDLE NAME

(STRING 20)

Shape9



LAST NAME

(STRING 50)


ALL

A1a. I want to make sure that we call you by the correct name. Do you go by another name?

Shape10

PACT

YES 1

NO 0 A2

DON’T KNOW d A2

REFUSED r A2

A1A=01

Shape11

A1b. Please spell that name for me.

Shape12

PACT

NAME

(STRING 50)

DON’T KNOW d

REFUSED r


ALL

Shape13

A2. What is your date of birth?

DATE OF BIRTH

Shape14

PACT

MONTH DAY YEAR

(01-12) (01-31) (1918-2001)


SOFT CHECK: IF OUT OF RANGE < 18 YEARS OLD; I recorded (fill A2 ANSWER). Is that correct? PROGRAMMER: IF R CONFIRMS THEY ARE <18 YEARS OLD, GO TO END.


all

Shape15

A3. What is your Social Security number?

NUMBER

(000-999) (00-99) (0000-9999)

Shape16

PACT

DON’T KNOW d

REFUSED r


all

Shape18

Shape17

PACT

A4. What is your home telephone number?

HOME TELEPHONE

(201-989) (200-999) (0000-9999)

NO LANDLINE 1

DON’T KNOW d

REFUSED r

all

A5a. Do you have a cell phone?

YES 1

Shape19

PACT

NO 0 B1

DON’T KNOW d B1

REFUSED r B1


a5a=01

Shape21

Shape20

PACT

A5b. What is your cell phone number?

CELL PHONE

(201-989) (200-999) (0000-9999)

DON’T KNOW d

REFUSED r

A5a=01

Shape22

YB 30 Mth J3

A6. Is it okay for us to text you at this number? Message and data rates may apply.

YES 1

NO 0

DON’T KNOW d

REFUSED r

ALL

Shape23

A7. What is another phone number where you can be reached?

PHONE NUMBER

Shape24

YB 30 Mth J3

(201-989) (200-999) (0000-9999)

DON’T KNOW d

REFUSED r


Shape25

Staff-administered: Next, I would like to ask you some questions about your background.

Self-administered: The next questions are about your background.

All

Shape26

OMB

B1. Are you Hispanic, Latino, or of Spanish origin?

YES 1

NO, NOT OF HISPANIC, LATINO OR SPANISH ORIGIN 0

DON’T KNOW d

REFUSED r

All

Shape27

OMB

B2. What is your race?

Select all that apply

AMERICAN INDIAN OR ALASKA NATIVE 1

ASIAN 2

BLACK OR AFRICAN AMERICAN 3

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER 4

WHITE 5

OTHER (SPECIFY) 99

Shape28

Specify (STRING (NUM))

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): SPECIFY OTHER RACE



all

Shape29

SOGI report modiified

B3. How do you describe yourself?

Select one only

Male 1

Female, or 2

Would you describe yourself in some other way? 3

Shape30

Specify (STRING (NUM))

DON’T KNOW d

REFUSED r



All

B4. What is the highest level of education you have completed?

Shape31

COBRA tailored for TANF

IF RESPONDENT SAYS “HIGH SCHOOL,” PROBE: Did you receive a diploma or GED?

Select one only

DID NOT COMPLETE HIGH SCHOOL OR GED 1

HIGH SCHOOL: DIPLOMA (NOT GENERAL EDUCATION DEVELOPMENT OR GED) 2

GENERAL EDUCATION DEVELOPMENT OR GED 3

SOME COLLEGE BUT NO DEGREE 4

2-YEAR OR 3-YEAR COLLEGE DEGREE (ASSOCIATE’S DEGREE) 5

4-YEAR COLLEGE DEGREE (BACHELOR’S DEGREE) 6

GRADUATE OR PROFESSIONAL DEGREE (e.g., MA, MBA, Ph.D., JD, MD) 7

NEVER ATTENDED SCHOOL 8

DON’T KNOW d

REFUSED r

All

Shape32

CPS

modified

B5. What is your current marital status—are you now married, separated, divorced, widowed, or have you never been married?

Select one only

MARRIED 1

SEPARATED 2

DIVORCED 3

WIDOWED 4

NEVER MARRIED 5

DON’T KNOW d

REFUSED r


Staff-administered: Now I would like to ask you some questions about the people who live with you.

Self-administered: The next questions are about people who live with you.

All

Shape34 Shape33

JSA

B6. How many adults age 18 or older currently live in your household at least half the time? Please include yourself.

ADULTS

(1-99)

INTERVIEWER: IF THE RESPONDENT SAYS “0” THEN REMIND THEM THAT THEY SHOULD INCLUDE THEMSELVES IN THIS TOTAL.

DON’T KNOW d

REFUSED r

All

Shape35 Shape36

JSA

B7. How many children under age 18 live with you at least half the time? This includes biological, adopted, foster, step, and any other children.

CHILDREN

(0-99)

DON’T KNOW d

REFUSED r





all

The next question is about where you live.

B8. Do you currently own your home or apartment or have a mortgage, rent it, pay some amount toward rent, live rent free with a friend or relative, or do you have some other arrangement?

OWN OR HAVE MORTGAGE 1

RENT 2

PAY SOME OF THE RENT 3

LIVE RENT FREE (SOMEONE ELSE RENTS/OWNS HOUSE OR APARTMENT) 4

LIVE IN SHELTER 5

LIVE ON STREETS 6

LIVE IN ABANDONED BUILDING/CAR 7

OTHER (SPECIFY) 99

(STRING 250)

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): What is the other arrangement?



all

B9. The next questions are about sources of income and other support that you and other members of your household may have received in the past month.

In the past month, have you or anyone in your household received any income from [fill statements a-j]?


CODE ONE RESPONSE PER ROW


YES

NO

DK

REF

a. Temporary Assistance for Needy Families, or TANF (this is also known as welfare)

1

0

d

r

b. Supplemental Security Income, or SSI

1

0

d

r

c. Social Security Disability Insurance, or SSDI

1

0

d

r

d. Food stamps or SNAP

1

0

d

r

e. Women, Infants, and Children, or WIC

1

0

d

r

f. Unemployment Insurance

1

0

d

r

g. Housing choice vouchers, Section 8, project-based rental assistance, public housing, housing where an agency helps you pay the rent, or other housing assistance

1

0

d

r


Shape38

The next questions are about work you have done for pay.

ALL

Shape39

CSPED

C1. Are you currently working for pay?

Working for pay can include regular paid jobs, odd jobs, temporary jobs, work done in your own business, “under the table” work, or any other types of work you have done for pay.

YES 1 C4

NO 0

DON’T KNOW d

REFUSED r


C1 NE 1

Shape40

WFNJ tailored for TANF

C2. In the past 30 days have you worked for pay?

PROBE: Please include any regular paid jobs, odd jobs, temporary jobs, work in your own business, “under the table” work, or any other types of work you have done.

YES 1 C4

NO 0

DON’T KNOW d

REFUSED r


c2 NE 1

Shape41

PACT

C3. In what month and year did you last work for pay?



Shape42

PROBE: Please include any regular paid jobs, odd jobs, temporary jobs, work in your own business, “under the table” work, or any other types of work you have done.

C4

MONTH YEAR

(1-12) (1957-2017)

NEVER WORKED FOR PAY 0 C5

DON’T KNOW d C4

REFUSED r C4


C3 NE 0

IF C1 = 1, fill ”DO” and “varies”; IF C2=1, FILL ”DID”
and “varied”



Shape43

WIA –tailored for TANF

C4. How much [do/did] you get paid before taxes and deductions, at this job?

PROBE: If your pay [varies/varied], please provide an average amount. If you are paid per job or for completing a particular task, please tell us the total amount you usually made per week or per month while doing this type of work.

IF THE RESPONDENT DOES NOT PROVIDE A PAY PERIOD THEN PROBE: And, is that per hour, per week, per month, once every two weeks, twice a month, per year, day/daily, or something else?



INSTRUCTION: ACCEPT MOST CONVENIENT PAY PERIOD.

Shape44

INSTRUCTION: IF ANSWER IS GREATER THAN $50 PER HOUR, $2000 PER WEEK, $4000 ONCE EVERY 2 WEEKS, $4000 TWICE A MONTH, $100,000 PER YEAR, $400 DAY/DAILY, OR $8000 MONTH, SAY: “I recorded [c4 and c4 amount answer]. Is that correct?”

(0-999,999.99) AMOUNT

Select one only

PER HOUR 1

PER WEEK 2

MONTH 3

ONCE EVERY TWO WEEKS 4

TWICE A MONTH 5

PER YEAR 6

DAY/DAILY 7

OTHER (SPECIFY) 99

Shape45

Specify (STRING 100)

DON’T KNOW d

REFUSED r


C1=1 OR C2=1

Shape47 Shape46

WFNJ tailored for TANF

C5. In the past 30 days, how much money did you make from work? Please include tips, bonuses, commissions, and regular overtime pay and count all money you received before taxes and deductions. If you held more than one job, include your total earnings from all of your work during the past 30 days.

AMOUNT C7

(1-999,999

DON’T KNOW d C6

REFUSED r C6


C5=d OR r

Shape48

WFNJ tailored for TANF

C6. Staff-administered: I just need to know a range. Can you tell me if it was . . .

Self-administered: We just need to know a range. Was it . . .

Select one only

$0 - $500, 1

$501 - $1,000, 2

$1,001 to $2,000, 3

$2,001 to $3,000, 4

$3,001 to $4,000, 5

$4,001 to $5,000, or 6

More than $5,000? 7

DON’T KNOW d

REFUSED r

C1 OR C2=1

IF C1 = 1, fill “do”; IF C2=1, FILL “DID”

Shape49

PACT tailored for TANF

C7. How many hours (do/did) you usually work per week at your current or most recent job?

Select one only

1-19 hours, 1

20-34 hours, 2

35-44 hours, 3

45 hours or more 4

DON’T KNOW d

REFUSED r



ALL

Shape50

CSPED tailored for TANF

C8. Staff-administered: Now I am going to read you a list of things that some people find challenging in finding and keeping a good job.

Please tell me if the following has made it not at all hard, a little hard, somewhat hard, very hard, or extremely hard for you to find or keep a good job in the past year.

[FILL a-g]. Would you say that made it not at all hard, a little hard, somewhat hard, very hard, or extremely hard for you to find or keep a good job in the past year?

INSTRUCTION: IF NEEDED READ RESPONSE CATEGORIES FOR B-G

Self-administered: The next set of questions are about things that some people find challenging in finding and keeping a good job.

Would you say that [FILL a-g] made it not at all hard, a little hard, somewhat hard, very hard, or extremely hard for you to find or keep a good job in the past year?

Select one per row


NOT AT ALL

A LITTLE

SOMEWHAT

VERY

EXTREMELY

DK

REF

a. Not having reliable transportation

0

1

2

3

4

d

r

b. Not having good enough childcare or family help

0

1

2

3

4

d

r

c. Not having the right clothes or tools for work

0

1

2

3

4

d

r

d. Not having the right skills or education

0

1

2

3

4

d

r

e. Having a criminal record

0

1

2

3

4

d

r

f. A lack of jobs available in your area

0

1

2

3

4

d

r

g. Not being able to do certain kinds or amounts of work, training, or school work because of your health

0

1

2

3

4

d

r



ALL

Shape51

CSPED

C9. Do you currently have a valid driver’s license? By valid we mean that it not expired, and has not been suspended or taken away.

YES 1

NO 0

DON’T KNOW d

REFUSED r


ALL

Shape52

Mathematica developed

C9a. In the past six months, have you ever not been able to apply to a job because you didn’t have a valid driver’s license?

YES ………………………………………………………………………………………1

NO 0

DON’T KNOW d

REFUSED r



Shape53


ALL

IF C1 = 1 THEN DO NOT ASK D.

D1. Staff-administered: Now I am going to ask you about employment-related behaviors.

Please tell me if you strongly disagree, disagree, agree, or strongly agree with the following statements.

Self-administered: The next set of questions are about employment-related behaviors.

Please indicate if you strongly disagree, disagree, agree, or strongly agree with the following statements.



Shape54 Shape55 Shape56 Shape57

ADAPTED FROM

GOAL SETTING

ADAPTED FROM

GOAL SETTING

ADAPTED FROM

LASER

ADAPTED FROM

LASER

Select one per row


STRONGLY DISAGREE

DISAGREE

AGREE

STRONGLY AGREE

DK

REF

a. I set long-term employment goals that I hope to achieve within a year, such as finding a job, finding a better job, getting promoted, or enrolling in further education.

1

2

3

4

d

r

b. I set specific short-term goals that will allow me to achieve my long-term employment goals.

1

2

3

4

d

r

c. I know I need to get a job or a better job and really think I should work on finding one.

1

2

3

4

d

r

d. I guess being out of work is not good, but there is nothing I can do about it right now…………………………………….

1

2

3

4

d

r


D1a, D1b: Noonan, P.M., & Gaumer Erickson, A.S. (2017). The skills that matter: Teaching intrapersonal and interpersonal competencies in any classroom. Thousand Oaks, CA: Corwin.



ALL

Shape58

Mathematica Developed

D2. In the past 6 months, how often have you been late for a job or a job-related appointment like an interview or meeting with a program worker? Would you say…

Select one only

Every day or almost every day, 1

A few times a week, 2

A few times a month, 3

About once a month 4

  • Only a few times, or 5

Hardly ever or never? 6

  • RESPONDENT DIDN’T HAVE A JOB OR A JOB-RELATED APPOINTMENT 0

  • DON’T KNOW d

REFUSED r


ALL

Shape59

BRIEF-A

D3.1. Now we are going to discuss behaviors more generally.

During the past month, how often has each of the following behaviors been a problem? Would you say that the following behaviors have been a problem never, sometimes, or often?



**NOTE: The specific wording of items D3.1a-l and D3.2a-h are not shown on this copy of the survey because the items are adapted and reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc., 16204 North Florida Avenue, Lutz, Florida 33549. Further reproduction is prohibited without permission by PAR, Inc.



Select one per row

For Review Only, Do NOT Copy

NEVER

SOMETIMES

OFTEN

DK

REF

a. Item 25 **SEE NOTE ABOVE

0

1

2

d

r

b. Item 49

0

1

2

d

r

c. Item 52

0

1

2

d

r

d. Item 6

0

1

2

d

r

e. Item 71

0

1

2

d

r

f. Item 75

0

1

2

d

r

g. Item 24

0

1

2

d

r

h. Item 53

0

1

2

d

r

i. Item 9

0

1

2

d

r

j. Item 15 -edited

0

1

2

d

r

k. Item 63 - edited

0

1

2

d

r

l. Item 2

0

1

2

d

r







D3.2. During the past month, how often has each of the following behaviors been a problem? Would you say that the following behaviors have been a problem never, sometimes, or often?


Select one per row


NEVER

SOMETIMES

OFTEN

DK

REF

a. Item 28

0

1

2

d

r

b. Item 69

0

1

2

d

r

c. Item 1

0

1

2

d

r

d. Item 72

0

1

2

d

r

e. Item 23.

0

1

2

d

r

f. Item 50

0

1

2

d

r

g. Item 64

0

1

2

d

r

h. Item 70 -edited

0

1

2

d

r


Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc. (PAR), 16204 North Florida Avenue, Lutz, Florida 33549, from the Behavior Rating Inventory of Executive Function Adult Version by Robert M. Roth, PhD, Peter K. Isquith, PhD and Gerard A. Gioia, PhD, Copyright 1996, 1998, 2001, 2003, 2004, 2005 by PAR. Further reproduction is prohibited without permission from PAR. For Review Only, Do NOT Copy



D4. Staff-administered: Next, I’m going to read a list of opinions people have about themselves. After I read each one, I want you to tell me whether you strongly disagree, disagree, agree, or strongly agree.

Self-administered: The next set of items are a list of opinions people have about themselves. Indicate whether you strongly disagree, disagree, agree, or strongly agree with each one.

Shape63 Shape62 Shape61

Rosenberg Self Esteem Scale

Rosenberg Self Esteem Scale

Rosenberg Self Esteem Scale

Select one per row


STRONGLY DISAGREE

DISAGREE

AGREE

STRONGLY AGREE

DK

REF

a. I am able to do things as well as most people.

1

2

3

4

d

r

b. I certainly feel useless at times.

1

2

3

4

d

r

c. All in all, I tend to feel that I am a failure.

1

2

3

4

d

r



Shape64


Next, we would like to ask for some contact information.

ALL

Shape65

PACT

E1. What is your address?

PROBE: Where do you receive your mail?

PROBE: Is there an apartment number?

Shape66

Street Address 1: (STRING (NUM))

Shape67

Street Address 2: (STRING (NUM))

Shape68

City: (STRING (NUM))

Shape69

State: (STRING (NUM))

Shape70

Zip: (STRING (NUM))

DON’T KNOW d

REFUSED r

ALL

E2. What is your email address?

Shape72 Shape71

PACT



EMAIL ADDRESS

(STRING 50)

DON’T HAVE ONE 0

DON’T KNOW d

REFUSED r



ALL

Shape73

PACT tailored for TANF

E3a. Mathematica would like to contact you in about 6 to 12 months to see how you are doing. In case Mathematica has trouble reaching you, Mathematica would like to have the names of three people who would most likely know where you are or who you keep in close contact with, such as a grandmother or grandfather, other relative, or friend. Mathematica will not contact these people for any other reason.

What is the full name of the first person we should contact?

Shape74



FIRST NAME

(STRING 50)

Shape75



MIDDLE INITIAL

(STRING 1)

Shape76



LAST NAME

(STRING 50)

DON’T KNOW d END

REFUSED r END

E3a NE D OR R

E3b. What is (his/her) address?

PROBE: Is there an apartment number?

Shape78 Shape77

PACT

Street Address 1: (STRING (NUM))

Shape79

Street Address 2: (STRING (NUM))

Shape80

City: (STRING (NUM))

Shape81

State: (STRING (NUM))

Shape82

Zip: (STRING (NUM))

DON’T KNOW d

REFUSED r


E3a NE D OR R

E3c. What is (his/her) relationship to you?

Select one only

Shape83

PACT

SPOUSE/PARTNER 1

MOTHER 2

FATHER 3

SISTER/BROTHER 4

GRANDMOTHER/GRANDFATHER 5

SON/DAUGHTER 6

FRIEND 7

OTHER (SPECIFY) 99

Shape84

Specify (STRING 50)

DON’T KNOW d

REFUSED r


IF OTHER SPECIFY (99): ENTER OTHER RELATIONSHIP TYPE



E3a NE D OR R

Shape85

E3d. What is (his/her) home telephone number?

HOME TELEPHONE

(201-989) (200-999) (0000-9999)

Shape86

PACT

NO LANDLINE 1

DON’T KNOW d

REFUSED r

E3a NE D OR R

E3e. Does (he/she) have a cell phone?

Shape87

PACT

YES 1

NO 0 E3g

DON’T KNOW d E3g

REFUSED r E3g


E3e=1

Shape88

E3f. Can I have that number?

TELEPHONE

(201-989) (200-999) (0000-9999)

Shape89

PACT

DON’T KNOW d

REFUSED r

E3a NE D OR R

Shape90

E3g. What is (his/her) work telephone number?

TELEPHONE

(201-989) (200-999) (0000-9999)

Shape91

PACT

NO WORK NUMBER 1

DON’T KNOW d

REFUSED r

E3a NE D OR R

E3h. What is (his/her) email address?

Shape92


EMAIL ADDRESS

(STRING 50)

Shape93

PACT

DON’T HAVE ONE 0 E3a

DON’T KNOW d E3a

REFUSED r E3a

E3h NE 0, D, OR R

E3i. Does (he/she) have another email address?

Shape94


EMAIL ADDRESS

(STRING 50)

Shape95

PACT

NO 0

DON’T KNOW d

REFUSED r


SECOND CONTACT

E3a NE D OR R

E4a. What is the full name of the second person we should contact?

Shape96


FIRST NAME

(STRING 50)

Shape97



MIDDLE INITIAL

(STRING 1)

Shape98



LAST NAME

(STRING 50)

Shape99

PACT

DON’T KNOW d END

REFUSED r END

E4a NE D OR R

E4b. What is (his/her) address?

PROBE: Is there an apartment number?

Shape101 Shape100

PACT

Street Address 1: (STRING (NUM))

Shape102

Street Address 2: (STRING (NUM))

Shape103

City: (STRING (NUM))

Shape104

State: (STRING (NUM))

Shape105

Zip: (STRING (NUM))

DON’T KNOW d

REFUSED r



E4a NE D OR R

E4c. What is (his/her) relationship to you?

Select one only

Shape106

PACT

SPOUSE/PARTNER 1

MOTHER 2

FATHER 3

SISTER/BROTHER 4

GRANDMOTHER/GRANDFATHER 5

  • SON/DAUGHTER 6

FRIEND 7

OTHER (SPECIFY) 99

Shape107

Specify (STRING 50)

DON’T KNOW d

REFUSED r


E4a NE D OR R

Shape108

E4d. What is (his/her) home telephone number?

HOME TELEPHONE

(201-989) (200-999) (0000-9999)

NO LANDLINE 1

Shape109

PACT

DON’T KNOW d

REFUSED r



E4a NE D OR R

E4e. Does (he/she) have a cell phone?

YES 1

Shape110

PACT

NO 0 E4g

DON’T KNOW d E4g

REFUSED r E4g


E4e=1

Shape111

E4f. Can I have that number?

TELEPHONE

(201-989) (200-999) (0000-9999)

Shape112

PACT

DON’T KNOW d

REFUSED r

E4a NE D OR R

Shape113

E4g. What is (his/her) work telephone number?


(201-989) (200-999) (0000-9999)

NO WORK NUMBER 1

Shape114

PACT

DON’T KNOW d

REFUSED r

E4a NE D OR R

E4h. What is (his/her) email address?

Shape115


EMAIL ADDRESS

(STRING 50)

DON’T HAVE ONE 0 E4a

Shape116

PACT

DON’T KNOW d E4a

REFUSED r E4a

E4h NE D OR R

E4i. Does (he/she) have another email address?

Shape117


EMAIL ADDRESS

(STRING 50)

NO 0

Shape118

PACT

DON’T KNOW d

REFUSED r


THIRD CONTACT

E4a NE D OR R

E5a. What is the full name of the third person we should contact?

Shape119


FIRST NAME

(STRING 50)

Shape120



MIDDLE INITIAL

(STRING 1)

Shape121



LAST NAME

(STRING 50)

Shape122

PACT

DON’T KNOW d END

REFUSED r END

E5a NE d OR r

E5b. What is (his/her) address?

PROBE: Is there an apartment number?

Shape123

Street Address 1: (STRING (NUM))

Shape124

Street Address 2: (STRING (NUM))

Shape125

City: (STRING (NUM))

Shape126

State: (STRING (NUM))

Shape127

Zip: (STRING (NUM))

Shape128

PACT

DON’T KNOW d

REFUSED r


E5a NE d OR r

E5c. What is (his/her) relationship to you?

Select one only

Shape129

PACT

SPOUSE/PARTNER 1

MOTHER 2

FATHER 3

SISTER/BROTHER 4

GRANDMOTHER/GRANDFATHER 5

  • SON/DAUGHTER 6

FRIEND 7

OTHER (SPECIFY) 99

Shape130

Specify (STRING 50)

DON’T KNOW d

REFUSED r



E5a NE d OR r

Shape131

E5d. What is (his/her) home telephone number?

HOME TELEPHONE

(201-989) (200-999) (0000-9999)

Shape132

PACT

NO LANDLINE 1

DON’T KNOW d

REFUSED r

E5a NE d OR r

E5e. Does (he/she) have a cell phone?

YES 1

Shape133

PACT

NO 0 E5g

DON’T KNOW d E5g

REFUSED r E5g

E5e=1

Shape134

E5f. Can I have that number?

TELEPHONE

Shape135

PACT

(201-989) (200-999) (0000-9999)

DON’T KNOW d

REFUSED r

E5a NE d OR r

Shape136

E5g. What is (his/her) work telephone number?

TELEPHONE

(201-989) (200-999) (0000-9999)

Shape137

PACT

NO WORK NUMBER 0

DON’T KNOW d

REFUSED r


E5a NE d OR r

E5h. What is (his/her) email address?

Shape138


EMAIL ADDRESS

(STRING 50)

Shape139

PACT

DON’T HAVE ONE 0 END

DON’T KNOW d END

REFUSED r END

E5h NE 0, d, OR r

E5i. Does (he/she) have another email address?

Shape140


EMAIL ADDRESS

Shape141

PACT

NO 0

DON’T KNOW d

REFUSED r

END. Those are all of the questions I have. Thank you for your time.

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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleTANF EMPLOYMENT COACHING
SubjectOMB ATTACHMENT
AuthorMATHEMATICA
File Modified0000-00-00
File Created2021-01-14

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