Document
Baseline information form for participants (Attachment D)
ICR 202012-0970-018 · OMB 0970-0537 · Object 107449901.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Baseline information form for participants (Attachment D) |
| Author | Patrick Cremin |
| Last Modified By | Writer |
| File Modified | 2020-12-18 |
| File Created | 2026-10-12 |
| Conversion State | complete |
Extracted Text
Client Information
Confirm housing authority
1 Chicago Housing Authority
2 Housing Authority of Cook County
Is there at least one child aged 17 or under in the household?
1 Yes 2 No
Did the family recently move into an opportunity neighborhood?
1 Yes, in the past 6 months
2 Yes, in the past 7-12 months
3 No (family is not eligible for study)
Head of Household First Name: Last Name:
Date of birth:
SSN:
Household ID or Entity ID:
Voucher issuance date:
Voucher expiration date:
Voucher Number:
How well does the tenant speak English? (Choose only one)
1¦ Very well 2¦ Well 3¦ Not very well 4¦ Not at all 9¦ Decline to answer
F.11. Child’s name
1
2
3
4
First: __________________________
Last: __________________________
9 Decline to answer
First: __________________________
Last: __________________________
9 Decline to answer
First: __________________________
Last: __________________________
9 Decline to answer
First: __________________________
Last: __________________________
9 Decline to answer
F.12. Are you the parent/guardian of this child?
1 Yes 2 No [SKIP to next child]
9 Decline to answer
1 Yes 2 No [SKIP to next child]
9 Decline to answer
1 Yes 2 No [SKIP to next child]
9 Decline to answer
1 Yes 2 No [SKIP to next child]
9 Decline to answer
F.13. What is the child’s age?
Age: __________________________
9 Decline to answer
Age: __________________________
9 Decline to answer
Age: __________________________
9 Decline to answer
Age: __________________________
9 Decline to answer
F.14. What grade is he/she in?
1 Not in school [SKIP to F16]
2 Early Head Start
3 Pre-school
4 Pre-K 5 Kindergarten
6 1st Grade 7 2nd Grade
8 3rd Grade 9 4th Grade
10 5th Grade 11 6th Grade
12 7th Grade 13 8th Grade
14 9th Grade 15 10th Grade
16 11th Grade 17 12th Grade
18 Post-secondary school 19 Other (Specify): ______________
99 Decline to answer
Not in school [SKIP to F16]
2 Early Head Start
3 Pre-school
4 Pre-K 5 Kindergarten
6 1st Grade 7 2nd Grade
8 3rd Grade 9 4th Grade
10 5th Grade 11 6th Grade
12 7th Grade 13 8th Grade
14 9th Grade 15 10th Grade
16 11th Grade 17 12th Grade
18 Post-secondary school 19 Other (Specify): ______________
99 Decline to answer
Not in school [SKIP to F16]
2 Early Head Start
3 Pre-school
4 Pre-K 5 Kindergarten
6 1st Grade 7 2nd Grade
8 3rd Grade 9 4th Grade
10 5th Grade 11 6th Grade
12 7th Grade 13 8th Grade
14 9th Grade 15 10th Grade
16 11th Grade 17 12th Grade
18 Post-secondary school 19 Other (Specify): ______________
99 Decline to answer
Not in school [SKIP to F16]
2 Early Head Start
3 Pre-school
4 Pre-K 5 Kindergarten
6 1st Grade 7 2nd Grade
8 3rd Grade 9 4th Grade
10 5th Grade 11 6th Grade
12 7th Grade 13 8th Grade
14 9th Grade 15 10th Grade
16 11th Grade 17 12th Grade
18 Post-secondary school 19 Other (Specify): ______________
99 Decline to answer
F.15. What is the name of the school the child currently attends?
Name of school:
_________________________
9 Decline to answer
Name of school:
_________________________
9 Decline to answer
Name of school:
_________________________
9 Decline to answer
Name of school:
_________________________
9 Decline to answer
F.16. Has a doctor or other health professional EVER told you that [CHILD] had asthma?
1 Yes 2 No 3 Don’t know
9 Decline to answer
Yes 2 No 3 Don’t know
9 Decline to answer
Yes 2 No 3 Don’t know
9 Decline to answer
Yes 2 No 3 Don’t know
9 Decline to answer
F.17. How many attacks of wheezing has [CHILD] had in the last 12 months?
Number of attacks: _____________
9 Decline to answer
Number of attacks: _____________
9 Decline to answer
Number of attacks: _____________
9 Decline to answer
Number of attacks: _____________
9 Decline to answer
YOUR CONTACT INFORMATION
Current address:
City:
State:
Zip Code:
Home phone #: ( )
Cell #: ( )
Work #: ( )
Is this address the best one to mail something to you? 1 Yes 2 No
Alternative address:
City:
State:
ZIP Code:
Email address:
Which is the primary social network you use? 1 Facebook 2 Twitter 3 Instagram 4 Other (specify): _______________
9 Decline to answer _______________
What name do you use in that social network?
Can we contact you by text message? 1 Yes 2 No 9 Decline to answer
What is your preferred mode of contact? (Check all that apply) A Phone B Text C Email
D 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 complete all three boxes if possible.
1. Name:
How is this person related to you? 1 Spouse/Partner 2 Parent 3 Sister/Brother 4 Adult child 5 Friend 6 Other
Current address:
City:
State:
ZIP Code:
Home phone #: ( )
Cell #: ( )
Work #: ( )
Email address:
2. Name:
How is this person related to you? 1 Spouse/Partner 2 Parent 3 Sister/Brother 4 Adult child 5 Friend 6 Other
Current address:
City:
State:
ZIP Code:
Home phone #: ( )
Cell #: ( )
Work #: ( )
Email address:
3. Name:
How is this person related to you? 1 Spouse/Partner 2 Parent 3 Sister/Brother 4 Adult child 5 Friend 6 Other
Current address:
City:
State:
ZIP Code:
Home phone #: ( )
Cell #: ( )
Work #: ( )
Email address:
The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to understand programs that aim to improve employment outcomes for low-income adults. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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. The OMB number and expiration date for this collection are OMB #: XXXX-XXXX, Exp: XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Dan Bloom (MDRC); 200 Vesey Street, 23rd Floor, New York, NY 10281-2103.