Background Information Form (Previously titled Young Adult Baseline Survey)

OMB Control No: 0970-0383

Expiration Date: 09/30/2021

Young Adult Background Information Form

Welcome! This form gathers some basic information about you.

Thank you very much for helping us with this important study.

1. What is your birthdate?

Month		Day		Year

2. What is your Social Security Number (SSN)?

SSN

3. Would you describe your gender as male, female, or something else?

(Select only one answer.)

Male [ ]

Female [ ]

Transgender Male to Female [ ]

Transgender Female to Male [ ]

Something else [ ]

Don’t know [ ]

Rather not say [ ]

4. What is your race?

(Select all that apply.)

White [ ]

Black, or African American [ ]

American Indian or Alaska Native [ ]

Native Hawaiian or Other Pacific Islander [ ]

Asian [ ]

Other (Please specify) [ ]

5. Are you of Hispanic, Latino, or Spanish Origin?

(Select only one answer.)

No, not of Hispanic, Latino, or Spanish origin [ ]

Yes, Puerto Rican [ ]

Yes, Cuban [ ]

Yes, another Hispanic, Latino, or Spanish origin [ ]

This question asks about whether you or your family had ever received government benefits before you enrolled in the TLP/MGH program. The information you provide will be used for research purposes only and will be kept private to the extent allowed by law.

6. At the time you enrolled in the TLP or MGH, had you or your family ever received welfare or cash assistance (also known as Temporary Assistance for Needy Families or TANF)?

(Select only one answer.)

Yes, I (or my family) received TANF dollars [ ]

No, I (or my family) have never received TANF dollars [ ]

Don’t know [ ]

Rather not say [ ]

The novel Coronavirus/COVID-19 is a global pandemic. The United States declared a state of emergency in March 2020. This affected people in lots of different ways. We are interested in how the pandemic may have affected you

7. How did COVID-19 impact your housing?

(Select all that apply.)

I lost my housing because of COVID-19 [ ]

I entered TLP because of COVID-19 [ ]

I stayed longer in TLP because of COVID-19 [ ]

I left TLP early because of COVID-19 [ ]

I moved back in with family because of COVID-19 [ ]

COVID-19 did not impact on housing [ ]

Other (Please specify:______________) [ ]

8. How did COVID-19 impact your education?

(Select all that apply.)

I started a new school, college, or education program because of COVID-19 [ ]

I was planning to enroll in a school, college, or education program but did not because of COVID-19 [ ]

My school, college, or education program closed because of COVID-19 [ ]

I did not complete one or more courses I was taking because of COVID-19 [ ]

My schoolwork or courses moved online because of COVID-19 and I was unable to attend them [ ]

I dropped out of my school, college, or education program because of COVID-19 [ ]

My schoolwork or courses moved online because of COVID-19 and I continued to attend them [ ]

COVID-19 did not impact my education [ ]

Other (Please specify:_________________) [ ]

9. How did COVID-19 impact your employment?

(Select all that apply.)

I lost or left a job because of COVID-19 [ ]

I took time off of work due to concerns about my health related to COVID-19 [ ]

I started a new job or changed jobs because of COVID-19 [ ]

The number of hours I normally worked increased because of COVID-19 [ ]

The number of hours I normally worked decreased because of COVID-19 [ ]

COVID-19 did not impact on employment [ ]

Other (Please specify:_______________) [ ]

10. After you finish and submit this form, we will email or text you an electronic gift card to Amazon.com. How would you like us to send you the gift card?

If you select to receive your gift card by text message, please keep in mind that your cell phone carrier may charge you a fee to receive or send text messages. Whether or not you get charged a fee depends on your plan.

(Select only one answer)

		Enter the email address or cell phone number we should use here:
	Email it to me at:	___________________________
	Text it to my cell phone:	___________________________
	Mail it to me care of the TLP or MGH

[Programming Note: If no response is provided to Question 7, display the following prompt: “Because you did not provide an email address, a cell phone number to send a text, or select to receive your gift card in the mail, we cannot send you an electronic gift card. If you would like to receive a gift card, please select one of these options before you click “Submit.” If you have any questions, please email [email protected] or call (855) 579-6654. This is a free call.”]

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)

Public reporting burden of the described voluntary collection of information is estimated to average 0.25 hours per youth response . 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 Alisa Santucci, Abt Associates, 6130 Executive Blvd, Rockville, MD 20852; Attn: OMB-PRA 0970-0383.

TLP YOS: Young Adult Background Information Form Page 1