Baseline information form for participants (Attachment D)

Attachment D-4 – Baseline Information Form for Participants

First and Last Name ______________________ OMB Control No: ____-____

BEES ID Number ______________________ (Office Use Only) Expiration Date: __/__/____

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

A. Demographic Information
A.1 Sex	1 Male 2 Female 9 Decline to answer
A.2 What is your ethnicity?	1 Hispanic or Latino 2 Not Hispanic or Latino 9 Decline to answer
A.3 What is your race? (Check all that apply)	A American Indian or Alaska Native B Asian C Black or African American D Native Hawaiian or Other Pacific Islander E White F  Other (specify): _____________ G  Decline to answer
A.4 Primary language spoken at home	1 English 2 Spanish 3 Other (specify): _____________ 9 Decline to answer
B. Education
B.1 What is the highest degree or year of school that you have attained?	1 Less than a high school diploma 2 High school diploma or equivalent 3 Some college or technical training 4 Associate’s degree or other two-year degree 5 Bachelor’s degree or higher 9 Decline to answer
C. Employment History
C.1 Are you currently working for pay?	1 Yes 2 No [SKIP to C3] 9 Decline to answer
C.2 Are you working 35 or more hours per week?	1 Yes 2 No 9 Decline to answer
C.3 In total, how many months did you work for pay during the past year (including your current job)?	1Did not work 2 Less than 4 months 3 4-6 months 4 7-9 months 5 10 or more months 9 Decline to answer
C.4 Does any other adult, aged 18 years old or older, living in your household currently work for pay?	1 Yes 2 No 9 Decline to answer
[If applicable to current state of pandemic, ask C6. Otherwise, skip to C7a.]
C.6a Which of the following statements describes your current employment status due to the COVID-19 pandemic?	1 You are working reduced hours due to the pandemic 2 You are not working due to the pandemic 3 Your employment status is not currently affected by the pandemic 9  Decline to answer
(Ask if answered “You are working reduced hours” or “You are not working” to C6a) C.6b Are you [working reduced hours] because [OR: not working]: (Check all that apply)	1 Your employer reduced employees or hours 2 You need to care for your child or someone else 3 You are concerned for your health or the health of others in your household 4 You are sick with COVID-19 or its lingering symptoms 5 None of these apply 9  Decline to answer
(If asked C6b, skip C7a & b) C.7a Which of the following statements describes your employment status at any point in the past year due to the COVID-19 pandemic?	1 You worked reduced hours due to the pandemic 2 You did not work due to the pandemic 3 Your employment status was not affected by the pandemic in the past year 9  Decline to answer
(Ask if answered “You worked reduced hours” or “You did not work” to C7a) C.7b Did you [work reduced hours] because [OR: not work]: (Check all that apply)	1 Your employer reduced employees or hours 2 You needed to care for your child or someone else 3 You were concerned for your health or the health of others in your household 4 You were sick with COVID-19 or its lingering symptoms 5 None of these apply 9  Decline to answer

D. Benefit Receipt
D.1 Do you or anyone in your household currently receive income or assistance from any of the following sources? (Check all that apply)		A Disability benefits from SSA (SSI or SSDI) B TANF or [state specific TANF name] C Unemployment insurance (UI) D Worker’s compensation E Short-term disability F Food stamps/SNAP/[state specific program]		G WIC H Public housing I Veterans benefits J Medicaid or CHIP K Child Support L None of the above M Other (specify): _____________________ N Decline to answer
E. Health
E.1 In general, would you say your health is:			1 Excellent 2 Very good 3 Good 4 Fair 5 Poor 9 Decline to answer
E.2 Do you have a physical problem that limits the kind or amount of work that you can do?			1 Yes 2 No 3 Don’t know 9 Decline to answer
E.3 Do you have an emotional or mental health problem that limits the kind or amount of work you can do?			1 Yes 2 No 3 Don’t know 9 Decline to answer
E.4 During the last 30 days, about how often did
E.4a …you feel so depressed that nothing could cheer you up?			1 All the time 2 Most of the time 3 Some of the time 4 A little of the time 5 None of the time 9 Decline to answer
E.4b …you feel hopeless?			1 All the time 2 Most of the time 3 Some of the time 4 A little of the time 5 None of the time 9 Decline to answer
E.4c …you feel restless or fidgety?			1 All the time 2 Most of the time 3 Some of the time 4 A little of the time 5 None of the time 9 Decline to answer
E.4d …you feel that everything was an effort?			1 All the time 2 Most of the time 3 Some of the time 4 A little of the time 5 None of the time 9 Decline to answer
E.4e …you feel worthless?			1 All the time 2 Most of the time 3 Some of the time 4 A little of the time 5 None of the time 9 Decline to answer
E.4f …you feel nervous?			1 All the time 2 Most of the time 3 Some of the time 4 A little of the time 5 None of the time 9 Decline to answer
F. Housing and Household Information
F.1 Number of people in your household (including yourself):			Number of people Children under age 18: _______________ 9 Decline to answer Adults age 18 or older: _______________ 9 Decline to answer
F.2 Do you have a spouse or partner who lives in your household?			1 Yes 2 No 9 Decline to answer
F.3 Do you have access to a car that runs?			1 Yes 2 No 9 Decline to answer
F.4 Do you have a valid driver license?			1 Yes 2 No 9 Decline to answer
F.5 Did you receive any help with housing search assistance from any of the following organizations?			1 Housing Choice Partners 2 Public Housing Authority 3 Other (specify):____________________ 9 Decline to answer
F.6 What is the main reason that you recently moved to your current neighborhood?			1 Better schools for my children 2 To be closer to my job 3 To get a different job 4 To be in a safer neighborhood 5 To get a bigger or better home 6 To be near my family, or 7 Other (specify):_______________ 9 Decline to answer
F.7 Which of the following statements best describes how satisfied you are with your current neighborhood?			1 Very satisfied 2 Somewhat satisfied 3 In the middle 4 Somewhat dissatisfied 5 Very dissatisfied 9 Decline to answer
F.8 Which of the following statements best describes how satisfied you are with your current apartment or house?			1 Very satisfied 2 Somewhat satisfied 3 In the middle 4 Somewhat dissatisfied 5 Very dissatisfied 9 Decline to answer
F.9 In the past 12 months was there ever a time when, because of cost, you or your household was not able to:
F.9a Pay your rent	1 Yes 2 No 9 Decline to answer
	[If Yes] How often did this happen in the past 12 months? 1 1 Month 2 2 or 3 months 3 4 to 6 months 4 7 or more months 9 Decline to answer
F.9b Pay your utility bills	1 Yes 2 No 9 Decline to answer
	[If Yes] How often did this happen in the past 12 months? 1 1 Month 2 2 or 3 months 3 4 to 6 months 4 7 or more months 9 Decline to answer
F.9c Pay for food needed	1 Yes 2 No 9 Decline to answer
	[If Yes] How often did this happen in the past 12 months? 11 1 time 2 2 or 3 times 3 4 to 6 times 4 7 or more times 9 Decline to answer
F.9d Pay for child care	1 Yes 2 No 9 Decline to answer
	[If Yes] How often did this happen in the past 12 months? 1 1 Month 2 2 or 3 months 3 4 to 6 months 4 7 or more months 9 Decline to answer
F.9e Pay to fill a prescription for medicine	1 Yes 2 No 9 Decline to answer
F.9f Pay to see a doctor or get medical assistance	1 Yes 2 No 9 Decline to answer

F.10. “Now, I would like to ask you a set of questions for each child that currently lives in your household. Remind me how many children do you have?”
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, 23^rd Floor, New York, NY 10281-2103.

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