Appendix F. Instrument 3 First follow-up survey
Appendix F. Instrument 3 First follow-up survey.docx
OPRE Evaluation: Next Generation of Enhanced Employment Strategies Project [Impact, Descriptive, and Cost Studies]
Appendix F. Instrument 3 First follow-up survey
OMB: 0970-0545
Appendix F. Instrument 3 First follow-up survey
Next Generation of Enhanced Employment Strategies Project
First Follow-up Survey
COMPUTER ASSISTED WEB INTERVIEW (CAWI) ALL
COMPUTER ASSISTED TELEPHONE INTERVIEW (CATI) ALL
Intro.* [IF CATI: My name is [fill Interviewer Name] and I’m calling on behalf of the U.S. Department of Health and Human Services.] Recently, you should have received a letter about a survey Mathematica is conducting for the U.S. Department of Health and Human Services. The [NEXTGEN PROGRAM] is participating in the Next Generation of Enhanced Employment Strategies Project and this survey is part of that study. To inform the study, we need to hear about your experiences including your use of employment services, your jobs, your health, and your receipt of benefits. Your participation in this study will help policymakers and program staff better understand how to improve programs like [NEXTGEN PROGRAM]. Mathematica will mail you a $40 gift card when the survey is completed.
You agreed to be part of the study around [RA MONTH/YEAR] when you talked with staff from [NEXTGEN PROGRAM].
All of your responses will be kept private; your name will not appear in any written reports we produce. Your responses to these questions are completely voluntary. That means you may choose not to answer any question, or you may stop the survey at any time.
According to the Paperwork Reduction Act (PRA), this collection of information is voluntary. Public reporting burden for this collection of information is estimated to average 50 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. A government 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.
[IF CATI: Do you have any questions before we begin?]
COMPUTER ASSISTED WEB INTERVIEW (CAWI) ALL
COMPUTER ASSISTED TELEPHONE INTERVIEW (CATI) DO NOT DISPLAY
How to complete the survey
Thank you for taking the time to complete this survey.
There are no right or wrong answers.
To answer a question, click the box that indicates your response or fill in your response.
To continue to the next webpage, press the "Next" button.
To go back to the previous webpage, click the "Back" button. Please note that this command is only available in some sections.
Do not use the navigation arrows in your browser.
If you need to stop before you have finished, you can close the survey and come back to it at any time. The responses you gave before leaving will be securely stored and available when you return to complete the survey.
Select “Next” to begin the survey.
CATI/CAWI: ALL |
CATI: First we are going to ask you some questions to check that we are speaking with the correct person.
CAWI: First we are going to ask you some questions to check that we are surveying the correct person.
IF PROGRAM=[PROGRAM NAME, WHOSE PARTICIPANTS ARE NOT YOUTH] IF CAWI DO NOT SHOW DK OR REF |
Intro2. When you enrolled in the [NEXTGEN PROGRAM] in [RA MONTH/YEAR], what was your marital status?
MARRIED 1
SEPARATED 2
DIVORCED 3
WIDOWED 4
NEVER MARRIED 5
DON’T KNOW d
REFUSED r
CATI/CAWI HARD CHECK: AN ANSWER MUST BE PROVIDED FOR THIS QUESTION, IF ASKED |
PROGRAMMER BOX
IF SSN EXISTS AT BASELINE, GO TO INTRO3. IF SSN DOES NOT EXIST AT BASELINE, GO TO INTRO4. |
CATI/CAWI: ALL with SSN at baseline IF CAWI DO NOT SHOW DK OR REF |
Intro3.* And what are the last 4-digits of your Social Security number?
| | | | | LAST FOUR
(0000-9999)
DON’T KNOW d GO TO INTRO4
REFUSED r GO TO INTRO4
CATI HARD CHECK: AN ANSWER MUST BE PROVIDED FOR THIS QUESTION.
CAWi hard check: an anSwer must be provided to go to the next question. this is to protect your privacy to make sure no one accesses the information provided in the survey. |
PROGRAMMER BOX
IF INTRO2 (MARITAL STATUS) MATCHES RECORDS AND INTRO3 (SSN) MATCHES, GO TO A1. OTHERWISE GO TO INTRO4 |
IF CAWI DO NOT SHOW DK OR REF |
INTRO4.* What is your date of birth?
| | | / | | | / | | | | |
MONTH DAY YEAR
(1-12) (1-31) (MIN-MAX)
DON’T KNOW d
REFUSED r
CATI HARD CHECK: AN ANSWER MUST BE PROVIDED FOR THIS QUESTION.
CAWi hard check: an anSwer must be provided to go to the next question. this is to protect your privacy to make sure no one accesses the information provided in the survey. |
PROGRAMMER BOX
IF PROGRAM=[PROGRAM NAME, WHOSE PARTICIPANTS are not youth]: IF INTRO2 (MARITAL STATUS) MATCHES AND INTRO3 (SSN) DOES NOT MATCH AND INTRO4 (DOB) DOES NOT MATCH THEN GO TO INTRO5. IF INTRO2 (MARITAL STATUS) DOES NOT MATCH AND INTRO3 (SSN) DOES MATCH AND INTRO4 (DOB) DOES NOT MATCH THEN GO TO INTRO5. IF INTRO2 (MARITAL STATUS) DOES NOT MATCH AND INTRO3 (SSN) DOES NOT MATCH AND INTRO4 (DOB) DOES NOT MATCH THEN GO TO INTRO5. IF INTRO2 (MARITAL STATUS) DOES NOT MATCH AND INTRO3 (SSN) DOES NOT MATCH AND INTRO4 (DOB) DOES MATCH THEN GO TO INTRO5.
OTHERWISE GO TO A1.
IF PROGRAM=[PROGRAM NAME, WHOSE PARTICIPANTS ARE YOUTH]: IF INTRO3 (SSN) DOES MATCH AND INTRO4 (DOB) DOES NOT MATCH THEN GO TO INTRO5. IF INTRO3 (SSN) DOES NOT MATCH AND INTRO4 (DOB) DOES MATCH THEN GO TO INTRO5. IF INTRO3 (SSN) DOES NOT MATCH AND INTRO4 (DOB) DOES NOT MATCH THEN GO TO INTRO5.
OTHERWISE GO TO A1. |
INTRO5.*
CATI: Thank you for your response. I need to check our records before continuing the interview. Please hold on a moment while I get my supervisor.
CON’T ………………………………………………………………………………1 GO TO INTRO6
CAWI: Thank you for your time. We need to check our records before continuing the interview. Please contact the Mathematica Survey Operations Center at 1-XXX-XXX-XXXX and ask for a survey representative at Mathematica to complete the survey.
cati ONLY iNTRO5=1 |
INTRO6.*
CATI ONLY: Can you tell me the name of the street that you lived on when you first enrolled in the program on [RA MONTH/YEAR]?
(STRING 20)
INSTRUCTION: Record address given by respondent
DON’T KNOW d GO TO INTRO7
REFUSED r GO TO INTRO7
CATI HARD CHECK: AN ANSWER MUST BE PROVIDED FOR THIS QUESTION. |
PROGRAMMER BOX IF INTRO6 MATCHES PHYSICAL STREET ADDRESS THEN GO TO A1 OTHERWISE, GO TO INTRO7 |
cati ONLY |
INTRO7.*
CATI ONLY: I’m sorry. I need to check my records before I can interview you. Is this the best time to reach you in the future?
YES 1
NO, CALL BACK INFO 0
(STRING 20)
cati ONLY |
INTRO8.*
CATI ONLY: And is [PHONE] the best number to reach you?
YES 1
NO, RECORD NEW PHONE FOR CALL BACK 0
(STRING 20)
INSTRUCTION: RECORD DATE AND TIME FOR CALL BACK.
A. SERVICE RECEIPT
CATI: First, we are going to ask you about services you may have received to help you find or keep a job.
CAWI: The first set of questions are about services you may have received to help you find or keep a job.
CATI/CAWI: ALL IF CAWI DO NOT SHOW DK OR REF |
A1.* CATI: I would like you to tell me about one-on-one help you may have received since [RA MONTH/YEAR] from organizations in your community to help you find or keep a job or to help you deal with problems that made it hard for you to find or keep a job.
CAWI: We would like to ask you about one-on-one help you may have received since [RA MONTH/YEAR] from organizations in your community to help you find or keep a job or to help you deal with problems that made it hard for you to find or keep a job.
PROBE: [RA MONTH/YEAR] is the date you applied to get into the [NEXTGEN PROGRAM].
[IF TREATMENT GROUP] Please include both help you may have received one-on-one from [NEXTGEN PROGRAM] and help you may have received one-on-one from other programs or organizations in the community. We/I will ask you about help received as part of a group later.
[IF CONTROL] Please include help you may have received one-on-one from any programs or organizations in the community. We/I will ask you about help received as part of a group later.
Since [RA MONTH/YEAR], did you receive one-on-one help with…
CODE ONE PER ROW
|
YES |
NO |
DK |
REF |
a. …planning your future career, which could include an assessment of your interests and skills? |
1 |
0 |
d |
r |
b. …preparing a resume or filling out job applications? |
1 |
0 |
d |
r |
c. …preparing for job interviews? |
1 |
0 |
d |
r |
d. …looking for jobs or deciding what kinds of jobs to look for? |
1 |
0 |
d |
r |
e. …getting referrals to available jobs or setting up interviews for specific job openings? |
1 |
0 |
d |
r |
f. …how to act when you are at work? This includes being on time, managing your tasks, getting along with your supervisor, and handling conflicts. |
1 |
0 |
d |
r |
g. …clearing or sealing criminal records or other legal help? |
1 |
0 |
d |
r |
h. … finding or paying for child care or care for other dependents? |
1 |
0 |
d |
r |
i. … finding or paying for transportation? |
1 |
0 |
d |
r |
j. …paying for clothing, tools, or other supplies for work? |
1 |
0 |
d |
r |
k. …understanding how work may affect your eligibility for benefits you need such as Social Security, disability insurance, workers’ compensation, or Medicaid? |
1 |
0 |
d |
r |
l. …any personal assistance services that help you work, for example a job coach, sign language interpreter, a reader or interpreter for the blind, or a personal care attendant? |
1 |
0 |
d |
r |
n. …any other one-on-one employment help? (Please specify: ______________) |
1 |
0 |
d |
r |
CATI/CAWI: ALL IF CAWI DO NOT SHOW DK OR REF |
A2.* CATI: Next, I would like you to tell me about help you may have received as part of a group since [RA MONTH/YEAR] from organizations in your community to help you find or keep a job or to help you deal with problems that made it hard for you to find or keep a job.
CAWI: Next, we would like to ask you about help you may have received as part of a group since [RA MONTH/YEAR] from organizations in your community to help you find or keep a job or to help you deal with problems that made it hard for you to find or keep a job.
PROBE: [RA MONTH/YEAR] is the date you applied for the [NEXTGEN PROGRAM].
[IF TREATMENT GROUP] Please include both help you may have received in a group from [NEXTGEN PROGRAM] and help you may have received in a group from other programs or organizations.
[IF CONTROL] Please include help you may have received in a group from any programs or organizations in the community.
Since [RA MONTH/YEAR] did you receive help as part of a group with…
CODE ONE PER ROW
|
YES |
NO |
DK |
REF |
a. …preparing a resume or filling out job applications? |
1 |
0 |
d |
r |
b. …preparing for job interviews? |
1 |
0 |
d |
r |
c. …looking for jobs or deciding what kinds of jobs to look for? |
1 |
0 |
d |
r |
d …how to act when you are at work? This includes being on time, managing your tasks, getting along with your supervisor, and handling conflicts. |
1 |
0 |
d |
r |
e. …understanding how work may affect your eligibility for benefits you need such as Social Security, disability insurance, workers’ compensation, or Medicaid? |
1 |
0 |
d |
r |
f. … getting support from other job seekers? |
1 |
0 |
d |
r |
g. …any other employment help provided in a group? (Please specify: ______________) |
1 |
0 |
d |
r |
|
|
|
|
|
CATI/CAWI: IF A1 OR A2 HAS AT LEAST ONE YES RESPONSE IF CAWI DO NOT SHOW DK OR REF |
A3. You said that you received help related to finding or keeping a job since [RA MONTH/YEAR]. Did you receive this help at any of the following places?
Select all that apply
[NAME OF LOCAL WELFARE PROGRAM], 1
[NAME OF AMERICAN JOB CENTERS IN STATE] or an unemployment office, 2
Food Stamp Program or SNAP, 3
[NAME OF LOCAL VOCATIONAL REHABILITATION PROGRAM] 4
[NEXTGEN PROGRAM] 5
[NAME OF SITE-SPECIFIC PROVIDER 1] 6
[NAME OF SITE-SPECIFIC PROVIDER 2] 7
[NAME OF SITE-SPECIFIC PROVIDER 3] 8
[NAME OF SITE-SPECIFIC PROVIDER 4] 9
[NAME OF SITE-SPECIFIC PROVIDER 5] 10
Any other place (SPECIFY: __________) 11
DON’T KNOW d
REFUSED r
SKIP BOX ALLOW FOR UP TO 11 PROVIDERS. ASK A4 TO A7B FOR UP TO 11 PROVIDERS, ONE FOR EACH PROVIDER TYPE SELECTED AT A3.
IF A3 = D,R OR SKIPPED GO TO A8 IF A1 AND A2 DO NOT HAVE AT LEAST ONE YES RESPONSE, GO TO A8 |
CATI/CAWI: A3 HAS RESPONSE IF CAWI DO NOT SHOW DK OR REF |
A4. When did you start receiving help from [A3 PROVIDER NAME]?
______ MONTH / ___________ YEAR
DON’T KNOW d
REFUSED r
CATI/CAWI: A3 HAS RESPONSE IF CAWI DO NOT SHOW DK OR REF |
A5. Are you still receiving help from [A3 PROVIDER NAME]?
YES 1 A7
NO 0 A6
DON’T KNOW d A6
REFUSED r A6
CATI/CAWI: A3 HAS RESPONSE AND A5=0, D, R IF CAWI DO NOT SHOW DK OR REF |
A6. When did you stop receiving help from [A3 PROVIDER NAME]?
______ MONTH / ___________ YEAR A7
DON’T KNOW d
REFUSED r
CATI/CAWI: A3 HAS RESPONSE IF CAWI DO NOT SHOW DK OR REF |
A7. Since [RA MONTH/YEAR], when you were receiving help from [A3 PROVIDER NAME], about how often did you go to the program or talk with program staff? Please include time when staff may have met with you at your home or their office or spoken with you on the phone.
PROBE: Your best estimate is fine.
Every day 1
More than once a week 2
Once a week 3
A few times per month 4
About once a month, or 5
Less often than once a month 6
DON’T KNOW d
REFUSED r
CATI/CAWI: A3 HAS RESPONSE IF CAWI DO NOT SHOW DK OR REF |
A7a. On average, how long was each meeting or session with program staff at [A3 PROVIDER NAME]?
______ MINUTES SKIP BOX
Provide a range 1 A7B
DON’T KNOW d A7B
REFUSED r A7B
CATI/CAWI: A7A = 1,D,R IF CAWI DO NOT SHOW DK OR REF |
A7b. On average, would you say each meeting or session with program staff at [A3 PROVIDER NAME] was…
Less than 15 minutes 1
15 to 29 minutes 2
30 to 44 minutes 3
45 to 59 minutes 4
1 to 2 hours 5
More than 2 hours, but less than 4 hours 6
About four hours or half a day, or was it 7
More than four hours per meeting or session? 8
DON’T KNOW d
REFUSED r
SKIP BOX LOOP THROUGH A4 TO A7B FOR EACH PROVIDER AT A3.
ELSE GO TO A8
|
CATI/CAWI: ALL IF CAWI DO NOT SHOW DK OR REF |
The next questions ask you about your participation in education and training programs. First, [we/I] will ask about education programs.
A8.* Since [RA MONTH YEAR], did you participate in any education programs that were not provided by an employer? These include high school, adult basic education or GED courses, English as a Second Language classes, online courses, and college or other types of school. Do not include training programs to develop skills for a particular job or occupation. [We/I] will ask you about those later.
YES 1 A8A
NO 0 A9
DON’T KNOW d A9
REFUSED r A9
CATI/CAWI: A8 = 1 IF CAWI DO NOT SHOW DK OR REF |
A8a. What are the names of the education programs you attended since [RA MONTH YEAR], (starting with the first one you attended)?
_____________________ SPECIFY NAME OF EDUCATION PROGRAM
SKIP BOX ALLOW FOR UP TO 3 EDUCATION PROGRAMS. ASK A8A FOR UP TO 3 PROGRAMS, THEN ASK A8b-A8i FOR EACH PROGRAM. IF MORE THAN 3, ASK ABOUT THE LAST THREE.
|
CATI/CAWI: A8 = 1 IF CAWI DO NOT SHOW DK OR REF |
A8b. When did you start attending [A8A PROGRAM NAME]?
______ MONTH / ___________ YEAR
DON’T KNOW d
REFUSED r
CATI/CAWI: A8 = 1 IF CAWI DO NOT SHOW DK OR REF |
A8c. Are you still participating in [A8A PROGRAM NAME] now?
YES 1 A8E
NO 0 A8D
DON’T KNOW d A8D
REFUSED r A8D
CATI/CAWI: A8C NE 1 IF CAWI DO NOT SHOW DK OR REF |
A8d. And when did you stop attending [A8A PROGRAM NAME]?
______ MONTH / ___________ YEAR
DON’T KNOW d
REFUSED r
CATI/CAWI: A8=1 IF CAWI DO NOT SHOW DK OR REF |
A8e. What kind of education program (are/were) you attending? (Is/Was) it…
Regular high school 1 A8G
GED or General Education Development classes 2 A8F
ESL – English as a Second Language 3 A8F
Adult education classes for which you did not receive credits 4 A8F
A two-year program at a community college 5 A8G
A four-year program at a college or university 6 A8G
A graduate or professional program 7 A8G
Something else (SPECIFY:__________) 8 A8F
DON’T KNOW d A8F
REFUSED r A8F
CATI/CAWI: A8=1 and a8e = (2,3,4,8,d,r) IF CAWI DO NOT SHOW DK OR REF if program = [program name that offers education and training services] display option 11. Otherwise do not display option 11.
|
A8f. At what type of place (do/did) you participate in [A8A PROGRAM NAME]?
REGULAR HIGH SCHOOL 1
COMMUNITY COLLEGE OR 2 YEAR COLLEGE 2
4 YEAR COLLEGE OR UNIVERSITY 3
LOCAL SERVICE PROVIDER OR OTHER NON-PROFIT PRIVATE AGENCY 4
ONLINE 5
VOCATIONAL SCHOOL, TRADE SCHOOL, OR CAREER CENTER 6
ADULT EDUCATION, COMMUNITY SCHOOL, ADULT HIGH SCHOOL, NIGHT SCHOOL 7
[NAME OF AMERICAN JOB CENTERS IN STATE] OR AN UNEMPLOYMENT OFFICE 8
[NAME OF LOCAL VOCATIONAL REHABILITATION PROGRAM] 9
GOVERNMENT AGENCY OR THE MILITARY 10
[NEXTGEN PROGRAM] 11
SOMETHING ELSE (SPECIFY:__________) 12
DON’T KNOW d
REFUSED r
CATI/CAWI: A8=1 and A8C NE 1 IF CAWI DO NOT SHOW DK OR REF |
A8g. Did you complete the program?
YES 1
NO 0
DON’T KNOW d
REFUSED r
CATI/CAWI: A8=1 AND A8C NE 1 AND A8g NE 0 IF CAWI DO NOT SHOW DK OR REF |
A8h. Did you receive a diploma or degree from the program?
YES 1
NO 0
DON’T KNOW d
REFUSED r
CATI/CAWI: A8H=1 IF CAWI DO NOT SHOW DK OR REF |
A8i. What specific diploma or degree did you receive for completing that program?
GED OR GENERAL EDUCATION DEVELOPMENT 1
REGULAR HIGH SCHOOL DIPLOMA (NOT A GED) 2
ASSOCIATE’S DEGREE 3
BACHELOR’S DEGREE 4
GRADUATE DEGREE OR PROFESSIONAL DEGREE 5
OTHER (SPECIFY:__________) 6
DON’T KNOW d
REFUSED r
CATI/CAWI: ALL IF CAWI DO NOT SHOW DK OR REF |
The next questions ask about your participation in training programs. Do not include any programs [we already discussed / you already reported].
A9.* Since [RA MONTH YEAR/FIRST FOLLOW UP MONTH YEAR], did you participate in any training programs to build skills for a particular job or occupation? Do not include training programs provided by any employer. [We/I] will ask you about those later.
YES 1 A9A
NO 0 A10
DON’T KNOW d A10
REFUSED r A10
CATI/CAWI: A9 = 1 IF CAWI DO NOT SHOW DK OR REF |
A9a. What are the names of the training programs you attended since [RA MONTH YEAR], (starting with the first one you attended)?
PROBE: Do not include any programs you already reported.
_____________________ SPECIFY NAME OF TRAINING PROGRAM
SKIP BOX ALLOW FOR UP TO 3 TRAINING PROGRAMS. ASK A9A FOR UP TO 10 PROGRAMS, THEN ASK A9B-A9H FOR EACH PROGRAM. IF MORE THAN 3, ASK ABOUT THE LAST 3 ATTENDED.
|
CATI/CAWI: A9 = 1 IF CAWI DO NOT SHOW DK OR REF |
A9b. When did you start attending [A9A PROGRAM NAME]?
______ MONTH / ___________ YEAR
DON’T KNOW d
REFUSED r
CATI/CAWI: A9 = 1 IF CAWI DO NOT SHOW DK OR REF |
A9c. Are you still participating in [A9A PROGRAM NAME] now?
YES 1 A9E
NO 0 A9D
DON’T KNOW d A9D
REFUSED r A9D
CATI/CAWI: A9C NE 1 IF CAWI DO NOT SHOW DK OR REF |
A9d. And when did you stop attending [A9A PROGRAM NAME]?
______ MONTH / ___________ YEAR
DON’T KNOW d
REFUSED r
CATI/CAWI: A9=1 IF CAWI DO NOT SHOW DK OR REF |
A9e. What kind of job (are/were) you being trained for or what (are/were) you learning to do in that program?
PROBE: For example, some kinds of jobs are a medical coding, accounting, pharmacy tech, truck driving, or web developer.
SPECIFY JOB TRAINING: ____________________________________ 1
DON’T KNOW d
REFUSED r
CATI/CAWI: A9=1 IF CAWI DO NOT SHOW DK OR REF if program = [program name that offers education and training services] display option 10. Otherwise do not display option 10.
|
A9f. At what type of place (do/did) you participate in [A9A PROGRAM NAME]?
COMMUNITY COLLEGE OR 2 YEAR COLLEGE 1
4 YEAR COLLEGE OR UNIVERSITY 2
LOCAL SERVICE PROVIDER OR OTHER NON-PROFIT PRIVATE AGENCY 3
ONLINE 4
VOCATIONAL SCHOOL, TRADE SCHOOL, OR CAREER CENTER 5
ADULT EDUCATION, COMMUNITY SCHOOL, ADULT HIGH SCHOOL, NIGHT SCHOOL 6
[NAME OF AMERICAN JOB CENTERS IN STATE] OR AN UNEMPLOYMENT OFFICE 7
[NAME OF LOCAL VOCATIONAL REHABILITATION PROGRAM] 8
GOVERNMENT AGENCY/MILITARY 9
[NEXTGEN PROGRAM] 10
SOMETHING ELSE (SPECIFY: ________) 11
DON’T KNOW d
REFUSED r
CATI/CAWI: A9=1 AND A9C NE 1 IF CAWI DO NOT SHOW DK OR REF |
A9g. Did you complete the program?
YES 1
NO 0
DON’T KNOW d
REFUSED r
CATI/CAWI: A9=1 AND A9C NE 1 AND A9G NE 0 IF CAWI DO NOT SHOW DK OR REF |
A9h. Did you get a professional certificate or state or industry license?
PROBE: A professional certificate or license shows you are qualified to perform a specific job and includes things like Certified Medical Assistant, Certified Construction Manager, a Project Management Professional certification, or an IT certification.
YES 1
NO 0
DON’T KNOW d
REFUSED r
CATI/CAWI: ALL IF CAWI DO NOT SHOW DK OR REF |
The next questions ask you about your participation in training programs provided at or by any of your employers since [RA MONTH YEAR]. Do not include any programs [we already discussed / you have already reported].
A10.* Since [RA MONTH YEAR], did you participate in any paid or unpaid training programs to develop skills for a particular job or occupation provided at or by any of your employers? Include classroom or on-line training, on-the-job training, internships or externships, work experience, and apprenticeships.
YES 1 A10A
NO 0 A11
DON’T KNOW d A11
REFUSED r A11
CATI/CAWI: A10 = 1 IF CAWI DO NOT SHOW DK OR REF |
A10a. What type(s) of employer training program(s) did you participate in since [RA MONTH YEAR], (starting with the first one you attended)? We are looking for the name or type of training program, not the name of the employer.
PROBE: Do not include any programs you already reported.
_____________________ SPECIFY NAME OR TYPE OF TRAINING PROGRAM
SKIP BOX ALLOW FOR UP TO 3 WORK-BASED TRAINING PROGRAMS. ASK A10A FOR UP TO 10 PROGRAMS, THEN ASK A10B-A10I FOR EACH PROGRAM. IF MORE THAN THREE, ASK ABOUT THE LAST THREE. |
CATI/CAWI: A10 = 1 IF CAWI DO NOT SHOW DK OR REF |
A10b. When did you start attending the [A10A PROGRAM NAME] employer training program?
______ MONTH / ___________ YEAR
DON’T KNOW d
REFUSED r
CATI/CAWI: A10 = 1 IF CAWI DO NOT SHOW DK OR REF |
A10c. Are you still participating in the [A10A PROGRAM NAME] employer training program now?
YES 1 A10E
NO 0 A10D
DON’T KNOW d A10D
REFUSED r A10D
CATI/CAWI: A10C NE 1 IF CAWI DO NOT SHOW DK OR REF |
A10d. And when did you stop attending the [A10A PROGRAM NAME] employer training program?
______ MONTH / ___________ YEAR
DON’T KNOW d
REFUSED r
CATI/CAWI: A10=1 IF CAWI DO NOT SHOW DK OR REF |
A10e. What kind of job or tasks (are/were) you being trained for or what (are/were) you learning to do in that program?
PROBE: For example, some kinds of jobs or tasks are medical coding, accounting, pharmacy tech, truck driving, web developer, project management, welding, customer relations.
SPECIFY JOB TRAINING: ____________________________________ 1
DON’T KNOW d
REFUSED r
CATI/CAWI: A10=1 IF CAWI DO NOT SHOW DK OR REF |
A10f. (Do/did) you participate in the [A10A PROGRAM NAME] employer training program in a classroom, online, on-the-job or in some other way?
Select all that apply
CLASSROOM 1
ONLINE 2
ON-THE-JOB 3
SOME OTHER WAY (SPECIFY:__________) 4
DON’T KNOW d
REFUSED r
CATI/CAWI: A10=1 AND A10C NE 1 IF CAWI DO NOT SHOW DK OR REF |
A10g. Did you complete the program?
YES 1
NO 0
DON’T KNOW d
REFUSED r
CATI/CAWI: A10=1 AND A10C nE 1 AND A10G NE 0 IF CAWI DO NOT SHOW DK OR REF |
A10h. Did you get a professional certificate or state or industry license?
PROBE: A professional certificate or license shows you are qualified to perform a specific job and includes things like Certified Medical Assistant, Certified Construction Manager, a Project Management Professional certification, or an IT certification.
YES 1
NO 0
DON’T KNOW d
REFUSED r
CATI/CAWI: ALL IF CAWI DO NOT SHOW DK OR REF |
A11.* Since [RA MONTH YEAR], have you participated in any of the following work-based opportunities?
-
CODE ONE RESPONSE PER ROW
YES
NO
DK
REF
a. Informational interviews or job site tours
PROBE: An informational interview is when a person talks with an employer about their career, an industry, or the workplace but is not being interviewed for a job.
1
0
d
r
b. Job shadowing
PROBE: Job shadowing is when a person observes or “shadows” someone doing a job of interest to them.
1
0
d
r
c. Community service or volunteering
1
0
d
r
CATI/CAWI: ALL IF CAWI DO NOT SHOW DK OR REF |
The next questions are about services you may have received related to your health and well-being.
A12.* Since [RA MONTH YEAR], have you received help for problems related to emotions, nerves, anger management or mental health? This would include help dealing with depression, anxiety, or other conditions from a mental health center, a therapist, a psychologist or psychiatrist, social worker, counselor, doctor, or other provider.
YES 1 A12A
NO 0 A13
DON’T KNOW d A13
REFUSED r A13
CATI/CAWI: A12=1 IF CAWI DO NOT SHOW DK OR REF IF PROGRAM = [PROGRAM NAME THAT OFFERS MENTAL HEALTH SERVICES] DISPLAY OPTION 5. OTHERWISE DO NOT DISPLAY OPTION 5. |
A12a. Where did you receive help with problems related to emotions, nerves, anger management or mental health? Was it…
SELECT ALL THAT APPLY
A mental health agency 1
A clinic or doctor’s office 2
A hospital, or 3
Some other type of place (please specify) 4
[NEXTGEN PROGRAM] 5
DON’T KNOW d
REFUSED r
CATI/CAWI: ALL IF CAWI DO NOT SHOW DK OR REF |
A13.* Since [RA MONTH YEAR], have you received help for problems related to drug or alcohol use?
YES 1 A13A
NO 0 B1
DON’T KNOW d B1
REFUSED r B1
CATI/CAWI: A13=1 IF CAWI DO NOT SHOW DK OR REF IF PROGRAM = [PROGRAM NAME THAT OFFERS SUBSTANCE OR ALCOHOL USE SERVICES] DISPLAY OPTION 6. OTHERWISE DO NOT DISPLAY OPTION 6. |
A13a. At what type of place did you receive help for problems related to drug or alcohol use? Was it…
SELECT ALL THAT APPLY
A hospital or clinic with overnight stays, 1
A hospital or clinic without overnight stays, 2
A residential substance treatment program with overnight stays, 3
A non-residential substance treatment program without overnight stays, 4
A support group, such as Alcoholics Anonymous or Narcotics Anonymous 5
[NEXTGEN PROGRAM] facilities, or 6
Some other type place SPECIFY (__________) 7
DON’T KNOW d
B. EMPLOYMENT AND EARNINGS
CATI/CAWI: ALL IF CAWI DO NOT SHOW DK OR REF |
CATI: Now I would like to ask some questions about work.
CAWI: The next questions are about work.
B1.* Are you currently working for pay?
Working for pay can include regular paid jobs, odd jobs, temporary jobs, work done in your own business, jobs or tasks you find using a web or mobile app, “under the table” work, “off the books” work, paid work experience, apprenticeships, or any other types of work you have done for pay.
YES 1 B3
NO 0 B2
DON’T KNOW d B2
REFUSED r B2
CATI/CAWI: B1 NE= 1 IF CAWI DO NOT SHOW DK OR REF |
B2. Have you worked for pay at any time since [RA MONTH YEAR]?
YES 1 B4A
NO 0 B11
DON’T KNOW d B11
REFUSED r B11
PROGRAMMER: SET LIMIT OF 10 (CURRENT OR FORMER, TOTAL) JOBS
|
JOB 1 |
JOB 2 |
|
B1 =1 IF CAWI DO NOT SHOW DK OR REF CATI FILL “FIRST I AM GOING TO ASK ABOUT YOUR CURRENT JOB OR JOBS” FOR JOB 1 ONLY. CAWI FILL “THE NEXT QUESTIONS ARE ABOUT YOUR CURRENT JOB OR JOBS.” FOR JOB 1 ONLY. B3. CATI: [First I am going to ask about your current job or jobs.] Please tell me who you work for. CAWI: [The next questions are about your current job or jobs.] Please tell us who you work for. CATI/CAWI: This could include the names of regular paid jobs, odd jobs, temporary jobs, work done in your own business, jobs or tasks you find using a web or mobile app, “under the table” work, “off the books” work, paid work experiences, apprenticeships, or any other types of work you have done for pay. If you currently work at more than one job, please start with the job where you usually work the most hours. |
JOB NAME (SPECIFY) 1 (STRING 50) SELF EMPLOYED 2 DON’T KNOW d REFUSED r PROGRAMMER: IF B3 = d, r, make [JOB NAME] be “Job 1” for Job 1, “Job 2” for Job 2, etc. INTERVIEWER: IF B3=d, r, THEN SAY: That’s okay, we’ll just refer to this job as “Job 1” in the next few questions. |
JOB NAME (SPECIFY) 1 (STRING 50) SELF EMPLOYED 2 DON’T KNOW d REFUSED r
|
|
CATI/CAWI B1=1 (CURRENTLY EMPLOYED) IF CAWI DO NOT SHOW DK OR REF B4. Including all types of jobs, do you currently have any other paid jobs? Working for pay can include regular paid jobs, odd jobs, temporary jobs, work done in your own business, “under the table” work, “off the books” work, paid work experiences, apprenticeships, or any other types of work you have done for pay. |
YES 1 GO TO B3, JOB 2 NO 0 GO TO B4b DON’T KNOW d GO TO B4b REFUSED r GO TO B4b
IFB1=1 LOOP B4 JOBS UNTIL B4=(0,d, r). WHEN B4= 0,d,or r GO TO B4b JOB 1. |
YES 1 GO TO B3, JOB 3 NO 0 GO TO B4b DON’T KNOW d GO TO B4b REFUSED r GO TO B4b
IFB1=1 LOOP B4 JOBS UNTIL B4=(0,d, r). WHEN B4= 0,d,or r GO TO B4b JOB 1. |
|
B2=1 (NOT CURRENTLY EMPLOYED) IF CAWI DO NOT SHOW DK OR REF B4a. CATI: Since [RA MONTH YEAR], please tell me who you worked for. CAWI: Since [RA MONTH YEAR], please indicate who you worked for. CATI/CAWI: This could include the names of regular paid jobs, odd jobs, temporary jobs, work done in your own business, jobs or tasks you found using a web or mobile app, “under the table” work, “off the books” work, paid work experiences, apprenticeships, or any other types of work you have done for pay. If you had more than one job, please start with the job where you worked the most hours. |
JOB NAME (SPECIFY) 1 (STRING 50) SELF EMPLOYED 2 DON’T KNOW d REFUSED r |
JOB NAME (SPECIFY) 1 (STRING 50) SELF EMPLOYED 2 DON’T KNOW d REFUSED r |
|
If TOLD INTERVIEWER THAT NO MORE CURRENT JOBS or NOT CURRENTLY EMPLOYED BUT EMPLOYED SINCE RA MONTH YEAR
IF CAWI DO NOT SHOW DK OR REF
B4b. CATI: Have you had any other paid jobs since [RA MONTH YEAR] that you haven’t told me about? CAWI: Have you had any other paid jobs since [RA MONTH YEAR]?
|
YES 1 GO TO B4a, JOB 2 NO 0 GO TO B5 DON’T KNOW d GO TO B5 REFUSED r GO TO B5 IF B4b=1 LOOP B4a AND B4b UNTIL B4b=0,d, or r. WHEN B4b=0, d, or r GO TO B5.
|
YES 1 GO TO B4a, JOB 3 NO 0 GO TO B5 DON’T KNOW d GO TO B5 REFUSED r GO TO B5 IF B4b=1 LOOP B4a AND B4b UNTIL B4b=0,d, or r. WHEN B4b=0, d, or r GO TO B5.
|
|
CATI/CAWI B1=1 OR B2=1 IF CAWI DO NOT SHOW DK OR REF
IF B3 or B4a = 2, FILL “YOURSELF;” ELSE FILL “[JOB NAME 1]” B5. When did you start working for [[JOB NAME 1]/yourself]? INTERVIEWER: RECORD MONTH AND YEAR. NOTE: ALLOW SKIP ON MONTH. |
| | | / | | | | | MONTH YEAR (1-12) (1970-current year) DON’T KNOW d REFUSED r |
| | | / | | | | | MONTH YEAR (1-12) (1970-current year) DON’T KNOW d REFUSED r |
|
CATI/CAWI B1=1 OR B2=1 IF CAWI DO NOT SHOW DK OR REF
If B3 = 2 or B4a = 2 FILL “YOURSELF,” ELSE FILL JOB NAME
B6. Are you still working for [JOB NAME/yourself]? |
YES 1 GO TO B7 NO 0 GO TO B6a DON’T KNOW d REFUSED r |
YES 1 GO TO B7 NO 0 GO TO B6a DON’T KNOW d REFUSED r |
|
CATI/CAWI B6 =0 IF CAWI DO NOT SHOW DK OR REF B6a. When did you stop working at this job? INTERVIEWER: RECORD MONTH AND YEAR. |
| | | / | | | | | MONTH YEAR (1-12) (1970-current year) STILL AT JOB 98 DON’T KNOW d REFUSED r |
| | | / | | | | | MONTH YEAR (1-12) (19703-current year) STILL AT JOB 98 DON’T KNOW d REFUSED r |
|
CATI/CAWI B1=1 OR B2=1 IF CAWI DO NOT SHOW DK OR REF
IF B6=1 FILL “DO,” ELSE FILL “DID” B7. How many hours [do/did] you usually work in a week at this job? Your best estimate is fine. |
| | | HOURS PER WEEK (0-98) 99 OR MORE HOURS PER WEEK 99 DON’T KNOW d REFUSED r
|
| | | HOURS PER WEEK (0-98) 99 OR MORE HOURS PER WEEK 99 DON’T KNOW d REFUSED r
|
|
CATI/CAWI B1=1 OR B2=1 IF CAWI DO NOT SHOW DK OR REF
If B3 = 2 or B4a = 2 FILL “being self-employed” ELSE FILL “your job at [job name]”
FILL ”DO” IF B6=1, ELSE FILL ”DID” FILL “VARIES” / “ARE” / “MAKE” IF B6=1. ELSE FILL “VARIED” / “WERE” / “MADE”
B8. Now thinking about [being self-employed/your job at [JOB NAME]], how much [do/did] you get paid before taxes and deductions, at this job? Please include tips, commissions, and regular overtime.
CATI: PROBE: If your pay [varies/varied], please provide an average amount. If you [are/were] paid per job or for completing a particular task, please tell us the total amount you usually [make/made] while doing this type of work.
CAWI: SOFTCHECK: If your pay [varies/varied], please provide an average amount. If you [are/were] paid per job or for completing a particular task, please tell us the total amount you usually [make/made] 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? ACCEPT MOST CONVENIENT PAY PERIOD. SOFT CHECK: 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 [B8 and B8 amount answer]. Is that correct?” |
$ | | | |,| | | |.| | | AVERAGE (0-999,999.99) AMOUNT PER HOUR 1 PER DAY 2 PER WEEK 3 PER MONTH 4 ONCE EVERY TWO WEEKS 5 TWICE A MONTH 6 PER YEAR 7 OTHER (SPECIFY) 99 (STRING (100)) DON’T KNOW d REFUSED r
|
$ | | | |,| | | |.| | | AVERAGE (0-999,999.99) AMOUNT PER HOUR 1 PER DAY 2 PER WEEK 3 PER MONTH 4 ONCE EVERY TWO WEEKS 5 TWICE A MONTH 6 PER YEAR 7 OTHER (SPECIFY) 99 (STRING (100)) DON’T KNOW d REFUSED r
|
|
CATI/CAWI IF CAWI DO NOT SHOW DK OR REF
FILL WAGE AND HOUR/UNIT FROM B8. IF B8 = 99, D, R, or M, FILL “YOUR CURRENT WAGE” B9. Did you always earn [[B8 WAGE] per [HOUR/UNIT FROM B8]/your current wage] at this job?
|
YES 1 NO 0 DON’T KNOW d REFUSED r
|
YES 1 NO 0 DON’T KNOW d REFUSED r |
|
CATI/CAWI If B9= no IF CAWI DO NOT SHOW DK OR REF FILL “VARIES” IF B6=1. ELSE FILL “VARIED”.
B10. How much were you paid when you started working at this job before taxes and deductions? If your pay [varies/varied], please provide an average amount. ACCEPT MOST CONVENIENT PAY PERIOD. SOFT CHECK: 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 [B10 and B10 amount answer]. Is that correct?” |
$ | | | |,| | | |.| | | AVERAGE (0-999,999.99) AMOUNT PER HOUR 1 PER DAY 2 PER WEEK 3 PER MONTH 4 ONCE EVERY TWO WEEKS 5 TWICE A MONTH 6 PER YEAR 7 OTHER (SPECIFY) 99 (STRING (100)) DON’T KNOW d REFUSED r |
$ | | | |,| | | |.| | | AVERAGE (0-999,999.99) AMOUNT PER HOUR 1 PER DAY 2 PER WEEK 3 PER MONTH 4 ONCE EVERY TWO WEEKS 5 TWICE A MONTH 6 PER YEAR 7 OTHER (SPECIFY) 99 (STRING (100)) DON’T KNOW d REFUSED r |
|
CATI/CAWI: all IF CAWI DO NOT SHOW DK OR REF |
B11.* Since [RA MONTH YEAR], was there anything else you did for pay, such as odd jobs, temporary jobs, work done in your own business, jobs or tasks you found using a web or mobile app, “under the table” work, “off the books” work, paid work experience, apprenticeships, or any other type of work, that we haven’t already talked about?
YES 1 B12
NO 0 B13
DON’T KNOW d B13
REFUSED r B13
CATI/CAWI: B11=1 IF CAWI DO NOT SHOW DK OR REF |
B12. CATI: What is your best guess of how much money you received from these activities in a typical month since [RA MONTH YEAR]? Please do not include money you made from jobs we talked about earlier. We just need your best guess for how much money you’ve received from these activities.
CAWI: What is your best guess of how much money you received from these activities in a typical month since [RA MONTH YEAR]? Please do not include money you made from jobs you reported earlier. Just make your best guess for how much money you’ve received from these activities.
$| | | , | | | |
(0-99,999)
DON’T KNOW d
REFUSED r
CATI/CAWI IF CAWI DO NOT SHOW DK OR REF
ask b13 only if # of current jobs >1 OR there are no current jobs but multiple prior jobs. else skip to b13a
(B1=1 AND (number of Current (b6=1) jobs > 1) OR (B2=1 AND (number of nonCurrent (b6=0/d/r) jobs > 1) AND number of Current (b6=1) jobs = 0
DISPLAY [JOBNAME/SELF-EMPLOYED] FROM B3 IF (B1=1 AND (number of Current (b6=1) jobs > 1) DISPLAY [JOBNAME/SELF-EMPLOYED] FROM B4A IF (B2=1 AND (number of nonCurrent (b6=0/d/r) jobs > 1) AND number of Current (b6=1) jobs = 0
|
B13. For the next questions, please think about the job at which you [currently / most recently] work[ed] the most hours. What is the name of that job? Is it…
[B3JOBNAME1/B3SELF-EMPLOYED1] / [B4AJOBNAME1/B4ASELF-EMPLOYED1] 1
[B3JOBNAME2/B3SELF-EMPLOYED2] / [B4AJOBNAME1/B4ASELF-EMPLOYED2] 2
[B3JOBNAME3/B3SELF-EMPLOYED3] / [B4AJOBNAME1/B4ASELF-EMPLOYED3] 3
[B3JOBNAME4/B3SELF-EMPLOYED4] / [B4AJOBNAME4/B4ASELF-EMPLOYED4] 4
[B3JOBNAME5/B3SELF-EMPLOYED5] / [B4AJOBNAME5/B4ASELF-EMPLOYED5] 5
DON’T KNOW d
REFUSED r
PROGRAMMER BOX to set [jobname]
IF B13 1 TO 5 SET [JOBNAME]=B13JOBNAME.
IF (B13=D or R) AND (number of Current (b6=1) jobs > 1) SET [JOBNAME]= “CURRENT main” IF (B13=D or R) AND (B2=1) AND (number of nonCurrent (b6=0/d/r) jobs > 1) AND number of Current (b6=1) jobs = 0 SET [JOBNAME]=“MOST RECENT main”
IF B13 = LOGICAL SKIP AND NUMBER OF CURRENT JOBS (B6) = 1, SET [JOBNAME] = “Current”
if b13 = logical skip and (number of nonCurrent (b6=0/d/r) jobs > 1) AND number of Current (b6=1) jobs = 0, SET [JOBNAME] = “most recent”
|
PROGRAMMER BOX to set SELFEMPLOYEDFLAG
IF B13 = 1 TO 5 AND B13 PREFILL FOR selected B13 = SELF-EMPLOYED, SET SELFEMPLOYEDFLAG=1
IF B13 = LOGICAL SKIP AND NUMBER OF CURRENT JOBS (B6) = 1 AND b3=2 (SELF-EMPLOYED), SET SELFEMPLOYEDFLAG=1
IF B13 = LOGICAL SKIP AND (number of nonCurrent (b6=0/d/r) jobs > 1) AND number of Current (b6=1) jobs = 0 AND b4a=2 (SELF-EMPLOYED), SET SELFEMPLOYEDFLAG=1
oTHERWISE SET SELFEMPLOYEDFLAG=0
|
CATI/CAWI: B1=1 OR B2=1 if no jobs reported skip to b23
IF CAWI DO NOT SHOW DK OR REF |
B13a. For the next questions, please think about your [JOBNAME] job.
Which of the following best describes your employment at that job? [Were/Are] you working . . .
CATI: PROBE: A temporary help agency supplies workers to other companies on an as needed basis.
PROBE: Independent contractors, independent consultants, and freelance workers obtain customers on their own to provide a product or service and can have other employees working for them.
PROBE: Day laborers are people who work as needed. For example, day laborers may get work by waiting at a place where employers pick up people to work for a day or by posting paper or electronic job wanted ads and responding on a day-by-day basis.
PROBE: Some workers find short, in-person jobs or tasks through companies that connect them directly with customers using a website or mobile app. These companies also coordinate payment for the service through the app. Other workers select short, paid tasks through companies that maintain online lists of tasks.
CODE ONE ONLY
as a regular full-time or part-time employee, 1
for a temporary help agency, 2
for an occasional job or task service that relies on a website or mobile app that connects you to customers (such as Uber or Lyft) 3
as an independent contractor, independent consultant, or freelance worker, 4
in your own business, 5
as a day laborer, 6
or something else (PLEASE specify)? 99
_________________________________________(STRING (100))
DON’T KNOW d
REFUSED r
CATI/CAWI: B1=1 OR B2=1 IF CAWI DO NOT SHOW DK OR REF |
B13b. (Is/Was) this job a seasonal or temporary job?
PROBE: (Is/Was) this a job that you knew from the beginning would only last a few weeks or months?
YES 1
NO 0
DON’T KNOW d
REFUSED r
CATI/CAWI: B1=1 OR B2=1 IF CAWI DO NOT SHOW DK OR REF |
B14. (Do/did) you usually work a daytime schedule or some other schedule at your [JOBNAME] job?
PROBE: By daytime schedule, (I/we) mean that you work anytime between 6 A.M. and 6 P.M.
A DAYTIME SCHEDULE (ANYTIME BETWEEN 6 A.M. TO 6 P.M.) 1
SOME OTHER SCHEDULE 2
DON’T KNOW d
REFUSED r
CATI/CAWI: B14=2 IF CAWI DO NOT SHOW DK OR REF |
B15. Which of the following best describes the hours you usually work(ed) at your [JOB NAME] job?
CODE ONE ONLY
An evening shift (anytime between 2 P.M. and midnight) 1
A night shift (anytime between 9 P.M. and 8 A.M.) 2
A rotating shift (one that changes periodically from days to evenings or night) 3
A split shift (one consisting of two distinct period each day) 4
An irregular schedule 5
Some other shift (specify) 99
_________________________________________(STRING (100))
DON’T KNOW d
REFUSED r
CATI/CAWI: B1=1 OR B2=1 IF CAWI DO NOT SHOW DK OR REF |
B16. Which of the following benefits [are/were] available to you at your [JOB NAME] job? (READ EACH ITEM) . . .
CODE ALL THAT APPLY
Health insurance or membership in a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) plan? 1
Paid leave for sick days? 2
Paid leave for vacation? 3
Paid leave for holidays? 4
Dental benefits, including any offered at a cost to you? 5
Retirement benefits or a 401k plan? 6
Tuition reimbursement? 7
None of the above 0
DON’T KNOW d
REFUSED r
CATI/CAWI: B1=1 OR B2=1 IF CAWI DO NOT SHOW DK OR REF |
B17.
IF SELFEMPLOYEDFLAG=1: What kind of work did you do – what do you make, do, or sell?
IF SELFEMPLOYEDFLAG=0: What kind of company is your employer for your [JOBNAME] job – what do they make, do, or sell?
PROBE: What kind of business or industry is this?
KIND OF BUSINESS OR INDUSTRY (SPECIFY: _____________________________) 1
DON’T KNOW d
REFUSED r
CATI/CAWI: B1=1 OR B2=1 IF CAWI DO NOT SHOW DK OR REF |
B18. What were/are your main duties at your [JOBNAME] job? Please be specific.
PROBE: What did you do? For example, driving a tractor, selling shoes, stocking inventory.
INSTRUCTIONS TO INTERVIEWERS: TRY TO GET A VERB.
MAIN DUTIES (SPECIFY: _____________________________) 1
DON’T KNOW d
REFUSED r
CATI/CAWI: (B1=1 OR B2=1) and selfemployedflag=0 IF CAWI DO NOT SHOW DK OR REF |
B19. [Have/Had] you been promoted to a higher position with greater responsibility while working at this job?
YES 1
NO 0
DON’T KNOW d
REFUSED r
CATI/CAWI: (B1=1) and selfemployedflag=0 IF CAWI DO NOT SHOW DK OR REF |
B20. How likely do you think it is that you will be promoted at your [JOBNAME] job in the next 12 months?
Very likely 1
Somewhat likely 2
Not very likely 3
Not likely at all 4
DON’T KNOW d
REFUSED r
IF PROGRAM = [PROGRAM NAME THAT SERVES SSA TARGET POPULATION] CATI/CAWI: (B1=1 OR B2=1) AND B13A = (1, 2, 99, D, or R) IF CAWI DO NOT SHOW DK OR REF |
B21. Please tell me whether or not your [JOBNAME] employer has made any of the following changes because of your physical or mental health condition. Has your employer because of your physical or mental health condition…
-
CODE ONE RESPONSE PER ROW
YES
NO
DK
REF
a. provided you with any special equipment or assistive technology (PROBE: For example, special tools or equipment, software, or devices to accommodate your condition in the workplace.)
1
0
d
r
b. made any changes in your work schedule? (PROBE: For example, working fewer hours, changing the time you arrive or leave, or taking more breaks to accommodate your condition in the workplace.)
1
0
d
r
c. made any changes to the tasks you were assigned or how they are performed? (PROBE: For example, a light duty job or less demanding job tasks to accommodate your condition in the workplace.)
1
0
d
r
d. made any changes to the physical work environment to make things easier for you? (PROBE: For example, modifying your work area, allowing tele-work, improving accessibility in the building, or providing assigned parking to accommodate your condition in the workplace.)
1
0
d
r
e. arranged for co-workers or others to assist you? (PROBE: For example, providing a personal care attendant, interpreter, or job coach while at work.)
1
0
d
r
f. made any other changes that I didn’t mention to accommodate your condition in the workplace?
(SPECIFY: _______________________)
1
0
d
r
-
CATI/CAWI: B1=1 OR B2=1
IF CAWI DO NOT SHOW DK OR REF
B22. How satisfied are you with your [JOBNAME] job? Would you say very satisfied, somewhat satisfied, or not satisfied?
VERY SATISFIED 1
SOMEWHAT SATISFIED 2
NOT SATISFIED 3
DON’T KNOW d
REFUSED r
CATI/CAWI: ALL IF CAWI DO NOT SHOW DK OR REF |
B23.* Are you currently looking for a job?
PROBE: Some people look for work even when they have a job.
YES 1
NO 0
DON’T KNOW d
REFUSED r
CATI/CAWI: B1=0,d,r AND B2= 0,D,R IF CAWI DO NOT SHOW DK OR REF |
B23a. How would you describe your current employment status? Are you . . .
CODE ALL THAT APPLY
Temporarily laid off, 1
Retired, 2
In school or training, 3
Unable to work because of caring for another family member, 4
Unable to work because of pregnancy 5
Unable to work due to illness, disability, or ongoing mental health or substance use issues or treatment, 6
Gave up looking for work 7
Incarcerated, or 8
Something else? (SPECIFY) 99
(STRING (NUM))
DON’T KNOW d
REFUSED r
CATI/CAWI: ALL IF CAWI DO NOT SHOW DK OR REF |
B24.* The next questions are about things that some people find challenging when they try to work or pursue education or training. First, does a physical, mental, or emotional condition limit the kind or amount of work you can do?
Select one only
YES 1
NO 0
DON’T KNOW d
REFUSED r
if program = [PROGRAM NAME, WHOSE PARTICIPANTS ARE YOUTH], do not ask B25.L or B25.Q. CATI/CAWI: ALL IF CAWI DO NOT SHOW DK OR REF |
B25.*
Now, please indicate if each of the following has made it not at all hard, slightly hard, moderately hard, or very hard for you to work or pursue education or training in the past three months. CATI: If something I say does not apply to you, you can say “does not apply.”
Would you say that [FILL a-r] made it not at all hard, slightly hard, moderately hard, or very hard for you to work or pursue education or training in the last three months?
Select one per row
|
NOT AT ALL HARD |
SLIGHTLY HARD |
MODERATELY HARD |
VERY HARD |
N/A |
DK |
REF |
a. Not having reliable transportation |
0 |
1 |
2 |
3 |
n |
d |
r |
b. Not having a driver’s license or a valid driver’s license |
0 |
1 |
2 |
3 |
n |
d |
r |
c. Not having stable housing |
0 |
1 |
2 |
3 |
n |
d |
r |
d. A pregnancy or recent childbirth |
0 |
1 |
2 |
3 |
n |
d |
r |
e. Not having good enough care for a child or someone else in your household who needs care |
0 |
1 |
2 |
3 |
n |
d |
r |
f. Not having the right clothes or tools for work |
0 |
1 |
2 |
3 |
n |
d |
r |
g. Not having the right skills or education |
0 |
1 |
2 |
3 |
n |
d |
r |
h. Having difficulty speaking or reading English |
0 |
1 |
2 |
3 |
n |
d |
r |
i. Having difficulty completing job applications on my own |
0 |
1 |
2 |
3 |
n |
d |
r |
j. Having a criminal record |
0 |
1 |
2 |
3 |
n |
d |
r |
k. Having problems with alcohol or drugs |
0 |
1 |
2 |
3 |
n |
d |
r |
l. Having a gap in employment |
0 |
1 |
2 |
3 |
n |
d |
r |
m. Lack of support or resistance from friends or relatives related to finding a job or working |
0 |
1 |
2 |
3 |
n |
d |
r |
n. Experiencing abuse by a spouse or partner |
0 |
1 |
2 |
3 |
n |
d |
r |
o. A learning disability |
0 |
1 |
2 |
3 |
n |
d |
r |
p. Not finding the right kind of disability-related supports or accommodations |
0 |
1 |
2 |
3 |
n |
d |
r |
q. Losing benefits you need such as Social Security, disability insurance, workers’ compensation, or Medicaid if you took a job or worked more hours |
0 |
1 |
2 |
3 |
n |
d |
r |
r. Other problems that made work, school, or training difficult (SPECIFY:________) |
0 |
1 |
2 |
3 |
n |
d |
r |
IF PROGRAM = [PROGRAM NAME focuses on goal setting and attainment] IF currently employed (B1=1) then do not ask b26d. IF CAWI DO NOT SHOW DK OR REF |
B26. The next questions are about employment-related behaviors.
Please indicate if you strongly disagree, disagree, agree, or strongly agree with the following statements.
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 think I should work on finding a job or a better job1.
1
2
3
4
d
r
d. I think there is nothing I can do about being out of work right now2…………………………………….
1
2
3
4
d
r
C. ECONOMIC INDEPENDENCE AND WELL-BEING
IF PROGRAM=[PROGRAM NAME, WHOSE PARTICIPANTS ARE NOT YOUTH] IF CAWI DO NOT SHOW DK OR REF |
C1. Now (I/we) have some questions about your household. During the past year, did you or anyone in your household receive income or assistance from any of the following sources?
Select all that apply
Disability benefits from the Social Security Administration. These are also called Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) 1
Temporary Assistance for Needy Families (TANF) or
[STATE SPECIFIC TANF NAME] 2
Unemployment Insurance 3
Worker’s Compensation 4
Short-term disability 5
Food Stamps/Supplemental Nutrition Assistance Program (SNAP)/
[STATE-SPECIFIC PROGRAM] 6
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) 7
Housing Choice Voucher, also known as Section 8 or Public Housing 8
Veterans Benefits 9
Medicaid or [STATE SPECIFIC MEDICAID] or Children’s Health Insurance Program (CHIP) 10
NONE OF THE ABOVE 0
DON’T KNOW d
REFUSED r
CATI/CAWI: ALL |
C2.* Now [I/We] have some questions about your current financial situation. [As I read each question, please let me/ please let us] know if you have faced any of the following situations.
In the last six months, has there been a time when…
Select one per row
|
YES |
NO |
N/A |
DK |
REF |
a. …you did not pay the full amount of the rent or mortgage because you could not afford it? |
1 |
0 |
2 |
d |
r |
b. …you were evicted from your home or apartment for not paying the rent or mortgage? |
1 |
0 |
2 |
d |
r |
c. …you filed in court for bankruptcy? |
1 |
0 |
2 |
d |
r |
d. …you did not pay the full amount of the gas, oil, or electricity bills? |
1 |
0 |
2 |
d |
r |
e. …you had service turned off by the gas or electric company, or the oil company would not deliver oil? |
1 |
0 |
2 |
d |
r |
f. …you had cellular or land telephone service turned off because payments were not made? |
1 |
0 |
2 |
d |
r |
g. …you could not fill or had to wait to fill a prescription for medicine when they were needed because you could not afford it? |
1 |
0 |
2 |
d |
r |
h. …you did not pay the full amount of child support payments because you could not afford it? |
1 |
0 |
2 |
d |
r |
i. …you did not pay the full amount of other bills? |
1 |
0 |
2 |
d |
r |
CATI/CAWI: ALL |
C2a.* Getting enough food can be a problem for some people. Which of these statements best describes the food eaten in your household in [PRIOR MONTH]? Would you say there was…
enough of the kinds of food you want, 1
enough, but not always the kinds of food you want, 2
sometimes not enough to eat, or 3
often not enough to eat? 4
DON’T KNOW d
REFUSED r
CATI/CAWI: ALL |
C3.* If you had an emergency, would you be able to count on someone to help you?
Select one only
YES 1
NO 0
DON’T KNOW d
REFUSED r
CATI/CAWI: ALL |
C4.* Is there someone you could turn to if you suddenly needed to borrow $100?
Select one only
YES 1
NO 0
DON’T KNOW d
REFUSED r
Now, [I’d/we’d] like to ask you some questions about your living situation.
IF PROGRAM=[PROGRAM NAME, WHOSE PARTICIPANTS are not youth] IF CAWI DO NOT SHOW DK OR REF |
C5. Which of the following best describes your housing arrangement in [PRIOR MONTH]? Did you…
PROBE: Tell me about the arrangement you spent the most time at in the last month.
own your own home or apartment, 1
rent your home or apartment, 2
homeless or live in emergency or temporary housing, such as a shelter, 3
live in a halfway house, sober house, or other transitional housing, 4
live in a group home 5
live with friends or relatives and pay rent to them 6
live with friends or relatives and not pay rent to them, or 7
some other arrangement? (SPECIFY: __________) 99
DON’T KNOW d
REFUSED r
IF PROGRAM=[PROGRAM NAME, WHOSE PARTICIPANTS are youth] IF CAWI DO NOT SHOW DK OR REF |
C5a. Which of the following best describes your housing arrangement in [PRIOR MONTH]? Did you…
PROBE: Tell me about the arrangement you spent the most time at in the last month.
live with a parent or guardian, 1
rent your home or apartment, 2
homeless or live in emergency or temporary housing, such as a shelter, 3
live in a halfway house, sober house, or other transitional housing, 4
live in a group home 5
live with friends or relatives and pay rent to them 6
live with friends or relatives and not pay rent to them, or 7
some other arrangement? (SPECIFY: __________) 99
DON’T KNOW d
REFUSED r
CATI/CAWI: C5=2 or c5a=2 IF CAWI DO NOT SHOW DK OR REF |
C5b. Do you live in…
public housing – that is, housing owned by a federal, state or local government agency, such as [state specific program], 1
private housing for which part of your rent bill is paid by the government, such as Section 8 or vouchers, or 2
private housing that you pay for without any help from the government 3
DON’T KNOW d
REFUSED r
CATI/CAWI: C5 NE 3 OR C5A NE 3 IF CAWI DO NOT SHOW DK OR REF |
C6. Have you been homeless at any time in the last three months?
PROBE: Include living on the street, in your car, in an abandoned building, in a homeless or domestic violence shelter, or staying at someone else’s home because you have nowhere else to go.
YES 1 C6a
NO 0 C7
DON’T KNOW d C7
REFUSED r C7
CATI/CAWI: C6=1 or c5=3 OR C5A=3 IF CAWI DO NOT SHOW DK OR REF |
C6a. If you add up all the days you have been homeless in the last three months, about how many days have you been homeless? Your best guess is fine.
Number
of days homeless during the last three months
(1-93)
DON’T KNOW d
REFUSED r
CATI: Now, I’d like to ask you some questions about your health.
CAWI: Now, we have some questions about your health. 3
-
CATI/CAWI: ALL
IF CAWI DO NOT SHOW DK OR REF
C7.* In general, would you say your health is:
Excellent, 1
Very good, 2
Good, 3
Fair, or 4
Poor? 5
DON’T KNOW d
REFUSED r
-
CATI/CAWI: ALL
IF CAWI DO NOT SHOW DK OR REF
C8.* The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
CATI: The first question is about…
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf.
CATI: Would you say you are limited a lot, limited a little, or not at all?
YES, LIMITED A LOT 1
YES, LIMITED A LITTLE 2
NO, NOT LIMITED AT ALL 3
DON’T KNOW d
REFUSED r
-
CATI/CAWI: ALL
IF CAWI DO NOT SHOW DK OR REF
C9.* CATI: The second question is about…
Climbing several flights of stairs. Would you say you are limited a lot, limited a little, or not at all?
YES, LIMITED A LOT 1
YES, LIMITED A LITTLE 2
NO, NOT LIMITED AT ALL 3
DON’T KNOW d
REFUSED r
-
CATI/CAWI: ALL
IF CAWI DO NOT SHOW DK OR REF
C10.* During the past 4 weeks how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
CATI: The first statement is that you…
Accomplished less than you would like.
CATI: Would you say that you accomplished less than you would like all of the time, most of the time, some of the time, a little of the time, or none of the time as a result of your physical health?
ALL OF THE TIME 1
MOST OF THE TIME 2
SOME OF THE TIME 3
A LITTLE OF THE TIME 4
NONE OF THE TIME 5
DON’T KNOW d
REFUSED r
-
CATI/CAWI: ALL
IF CAWI DO NOT SHOW DK OR REF
C11.* CATI: The second statement is that you…
Were limited in the kind of work or other activities.
CATI: Would you say that you were limited in the kind of work or other activities all of the time, most of the time, some of the time, a little of the time, or none of the time as a result of your physical health?
ALL OF THE TIME 1
MOST OF THE TIME 2
SOME OF THE TIME 3
A LITTLE OF THE TIME 4
NONE OF THE TIME 5
DON’T KNOW d
REFUSED r
-
CATI/CAWI: ALL
IF CAWI DO NOT SHOW DK OR REF
C12.* During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
CATI: The first item is that you…
Accomplished less than you would like.
CATI: Would you say that you accomplished less than you would like all of the time, most of the time, some of the time, a little of the time, or none of the time as a result of any emotional problems?
ALL OF THE TIME 1
MOST OF THE TIME 2
SOME OF THE TIME 3
A LITTLE OF THE TIME 4
NONE OF THE TIME 5
DON’T KNOW d
REFUSED r
-
CATI/CAWI: ALL
IF CAWI DO NOT SHOW DK OR REF
C13.* CATI: The second item is that you…
Did work or other activities less carefully than usual.
CATI: Would you say that did work or other activities less carefully than usual all of the time, most of the time, some of the time, a little of the time, or none of the time as a result of any emotional problems?
ALL OF THE TIME 1
MOST OF THE TIME 2
SOME OF THE TIME 3
A LITTLE OF THE TIME 4
NONE OF THE TIME 5
DON’T KNOW d
REFUSED r
-
CATI/CAWI: ALL
IF CAWI DO NOT SHOW DK OR REF
C14.* During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? Would you say…
Not at all, 1
A little bit, 2
Moderately, 3
Quite a bit, or 4
Extremely 5
DON’T KNOW d
REFUSED r
-
CATI/CAWI: ALL
IF CAWI DO NOT SHOW DK OR REF
C15.* These next questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks:
Have you felt calm and peaceful?
All of the time, 1
Most of the time, 2
Some of the time, 3
A little of the time, or 4
None of the time 5
DON’T KNOW d
REFUSED r
-
CATI/CAWI: ALL
IF CAWI DO NOT SHOW DK OR REF
C16.* How much of the time during the past 4 weeks did you have a lot of energy?
All of the time, 1
Most of the time, 2
Some of the time, 3
A little of the time, or 4
None of the time 5
DON’T KNOW d
REFUSED r
-
CATI/CAWI: ALL
IF CAWI DO NOT SHOW DK OR REF
C17.* How much of the time during the past 4 weeks have you felt downhearted and depressed?
All of the time, 1
Most of the time, 2
Some of the time, 3
A little of the time, or 4
None of the time 5
DON’T KNOW d
REFUSED r
-
CATI/CAWI: ALL
IF CAWI DO NOT SHOW DK OR REF
C18.* During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? Would you say…
All of the time, 1
Most of the time, 2
Some of the time, 3
A little of the time, or 4
None of the time 5
DON’T KNOW d
REFUSED r
IF PROGRAM = [PROGRAM NAME THAT SERVES THOSE WITH MENTAL HEALTH CONDITIONS] IF CAWI DO NOT SHOW DK OR REF |
CATI: Now I will read you a list of statements about the last 30 days. Please tell me if the following applies to you all of the time, most of the time, some of the time, a little of the time, or none of the time.
C19. During the last 30 days, about how often did you…4
Select one per row
|
ALL THE TIME |
MOST OF THE TIME |
SOME OF THE TIME |
A LITTLE OF THE TIME |
NONE OF THE TIME |
DK |
REF |
a. Feel so depressed that nothing could cheer you up? |
4 |
3 |
2 |
1 |
0 |
d |
r |
b. Feel hopeless? |
4 |
3 |
2 |
1 |
0 |
d |
r |
c. Feel restless or fidgety? |
4 |
3 |
2 |
1 |
0 |
d |
r |
d. Feel that everything was an effort? |
4 |
3 |
2 |
1 |
0 |
d |
r |
e. Feel worthless? |
4 |
3 |
2 |
1 |
0 |
d |
r |
f. Feel nervous? |
4 |
3 |
2 |
1 |
0 |
d |
r |
CATI/CAWI: ALL IF CAWI DO NOT SHOW DK OR REF |
C20.* Taken all together, how would you say things are going these days? Would you say that you are…
Very happy, 1
Pretty happy, or 2
Not too happy? 3
DON’T KNOW d
REFUSED r
CATI: The next questions are about alcohol use. If you do not drink alcohol at all, just say so.
CAWI: The next questions are about your use of alcohol.
CATI/CAWI: ALL IF CAWI DO NOT SHOW DK OR REF |
C21.* How often do you have a drink containing alcohol, such as beer, wine or liquor? Would you say…5
Never, 1 C24
Monthly or less, 2 C22
2 to 4 times a month, 3 C22
2 to 3 times a week, or 4 C22
4 or more times a week 5 C22
DON’T KNOW d C24
REFUSED r C24
CATI/CAWI: c21 = 2, 3, 4, or 5 IF CAWI DO NOT SHOW DK OR REF |
C22. How many drinks containing alcohol do you have on a typical day when you are drinking? Would you say …
PROBE: A standard drink is a 5-ounce glass of wine, a 12-ounce can of beer, or a 1.5-ounce shot.
1 or 2 per day, 1
3 or 4, 2
5 or 6, 3
7 to 9, or 4
10 or more per day 5
DON’T KNOW d
REFUSED r
CATI/CAWI: c21 = 2, 3, 4, or 5 IF CAWI DO NOT SHOW DK OR REF |
C23. How often do you have six or more drinks on one occasion? Would you say…
Never, 1
Less than monthly, 2
Monthly, 3
Weekly, or 4
Daily or almost daily 5
DON’T KNOW d
REFUSED r
CATI: Next, I would like to ask you about your use of drugs, not including alcohol, in the past 6 months. For these questions, using drugs means taking more of a prescription drug than prescribed, taking more of an over-the-counter drug than the directions say, or using any drug for nonmedical reasons. The types of drugs may include cannabis (such as marijuana or hashish), inhalants (such as paint thinner), tranquilizers (such as Valium), barbiturates (such as downers), cocaine (such as crack), stimulants (such as Ritalin or speed), hallucinogens (such as LSD, peyote), or narcotics (such as heroin or pain killers).
Remember, do not include alcohol.
If you have difficulty with a yes or no statement, let me know the response that is mostly right.
CAWI: The following questions ask about your use of drugs (not including alcohol) in the past 6 months.
For these questions, using drugs means (1) taking more of a prescription than prescribed, (2) taking more of an over‐the‐counter drug than the directions say, or (2) using any drug for nonmedical reasons.
The types of drugs may include cannabis (e.g., marijuana, hashish), inhalants (e.g., paint thinner), tranquilizers (e.g., Valium), barbiturates (e.g., downers), cocaine (e.g., crack), stimulants (e.g., Ritalin, speed), hallucinogens (e.g., LSD, peyote), or narcotics (e.g., heroin, pain killers).
Remember, do not include alcohol.
Please answer every question. If you have difficulty with a statement, then choose the response that is mostly right.
CATI/CAWI: ALL IF CAWI DO NOT SHOW DK OR REF |
C24.* In the past 6 months have you used drugs other than those required for medical reasons? 6
YES 1 C25
NO 2 C34
DON’T KNOW d C25
REFUSED r C25
CATI/CAWI: C24=1,D,R IF CAWI DO NOT SHOW DK OR REF |
C25. Do you use more than one drug at a time?
PROBE: Consider your use of drugs, not including alcohol, in the past 6 months.
YES 1
NO 2
DON’T KNOW d
REFUSED r
CATI/CAWI: C24=1,D,R IF CAWI DO NOT SHOW DK OR REF |
C26. Are you always able to stop using drugs when you want to?
PROBE: Consider your use of drugs, not including alcohol, in the past 6 months.
YES 1
NO 2
DON’T KNOW d
REFUSED r
CATI/CAWI: C24=1,D,R IF CAWI DO NOT SHOW DK OR REF |
C27. Have you ever had blackouts or flashbacks as a result of drug use?
PROBE: Consider your use of drugs, not including alcohol, in the past 6 months.
YES 1
NO 2
DON’T KNOW d
REFUSED r
CATI/CAWI: C24=1,D,R IF CAWI DO NOT SHOW DK OR REF |
C28. Do you ever feel bad or guilty about your drug use?
PROBE: Consider your use of drugs, not including alcohol, in the past 6 months.
YES 1
NO 2
DON’T KNOW d
REFUSED r
CATI/CAWI: C24=1,D,R IF CAWI DO NOT SHOW DK OR REF |
C29. Does anyone ever complain about your involvement with drugs?
PROBE: Consider your use of drugs, not including alcohol, in the past 6 months.
YES 1
NO 2
DON’T KNOW d
REFUSED r
CATI/CAWI: C24=1,D,R IF CAWI DO NOT SHOW DK OR REF |
C30. Have you neglected your family because of your drug use?
PROBE: Consider your use of drugs, not including alcohol, in the past 6 months.
YES 1
NO 2
DON’T KNOW d
REFUSED r
CATI/CAWI: C24=1,D,R IF CAWI DO NOT SHOW DK OR REF |
C31. Have you engaged in illegal activities in order to obtain drugs?
PROBE: Consider your use of drugs, not including alcohol, in the past 6 months.
YES 1
NO 2
DON’T KNOW d
REFUSED r
CATI/CAWI: C24=1,D,R IF CAWI DO NOT SHOW DK OR REF |
C32. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
PROBE: Consider your use of drugs, not including alcohol, in the past 6 months.
YES 1
NO 2
DON’T KNOW d
REFUSED r
CATI/CAWI: C24=1,D,R IF CAWI DO NOT SHOW DK OR REF |
C33. Have you had medical problems as a result of your drug use (for example, memory loss, hepatitis, convulsions, or bleeding)?
PROBE: Consider your use of drugs, not including alcohol, in the past 6 months.
YES 1
NO 2
DON’T KNOW d
REFUSED r
CATI/CAWI: ALL IF CAWI DO NOT SHOW DK OR REF |
C34.* The next question asks about using prescription pain relievers in any way a doctor did not direct you to use them.
When you answer this question, please think only about your use of the drug in any way a doctor did not direct you to use it, including:
Using it without a prescription of your own
Using it in greater amounts, more often, or longer than you were told to take it
Using it in any other way a doctor did not direct you to use it
Are you currently taking a prescription painkiller (such as OxyContin, Percocet, or Vicodin) without a prescription or in any way not directed by a doctor?
YES 1
NO 0
DON’T KNOW d
REFUSED r
CATI/CAWI: ALL IF CAWI DO NOT SHOW DK OR REF |
C35.* Now [I/we] have some questions about your experiences with the criminal justice system.
Since [RA MONTH YEAR], have you been arrested?
YES 1 C36
NO 0 C38
DON’T KNOW d C38
REFUSED r C38
IF PROGRAM = [PROGRAM NAME THAT SERVES THOSE WITH current or prior CRIMINAL JUSTICE SYSTEM INVOLVEMENT] CATI/CAWI: C35=1 IF CAWI DO NOT SHOW DK OR REF |
C36. Since [RA MONTH YEAR], how many times have you been arrested?
NUMBER OF ARRESTS
(1-99)
DON’T KNOW d
REFUSED r
IF PROGRAM = [PROGRAM NAME THAT SERVES THOSE WITH current or prior CRIMINAL JUSTICE SYSTEM INVOLVEMENT] CATI/CAWI: C35=1 IF CAWI DO NOT SHOW DK OR REF |
C37. How many of these arrests since [RA MONTH YEAR] resulted in at least one conviction?
NUMBER OF ARRESTS LEADING TO A CONVICTION
(1-99)
DON’T KNOW d
REFUSED r
IF PROGRAM = [PROGRAM NAME THAT SERVES THOSE WITH current or prior CRIMINAL JUSTICE SYSTEM INVOLVEMENT] CATI/CAWI: C35=1,d,r IF CAWI DO NOT SHOW DK OR REF |
C38. Since [RA MONTH YEAR], have you been incarcerated in a juvenile or adult facility, such as a detention center, jail, or prison?
YES 1 C39
NO 0 C40
DON’T KNOW d C40
REFUSED r C40
IF PROGRAM = [PROGRAM NAME THAT SERVES THOSE WITH current or prior CRIMINAL JUSTICE SYSTEM INVOLVEMENT] CATI/CAWI: c38=1 |
C39. What is the total time you have spent in incarceration since [RA MONTH YEAR]? If less than 1 month, please record 1 month.
Your best estimate is fine.
| | | YEARS AND | | | MONTHS
DON’T KNOW d
REFUSED r
IF PROGRAM = [PROGRAM NAME THAT SERVES THOSE WITH current or prior CRIMINAL JUSTICE SYSTEM INVOLVEMENT] CATI/CAWI: c35=1,d,r IF CAWI DO NOT SHOW DK OR REF |
C40. Are you currently on parole or probation?
YES 1
NO 0
DON’T KNOW d
D. PROGRAM SATISFACTION
ALL ITEMS IN THIS SECTION ONLY ASKED ON FIRST FOLLOW-UP
PROGRAM GROUP ONLY
CATI: Now, I’m going to ask you some questions about your experiences with [NEXTGEN PROGRAM].
CAWI: Next are some questions about your experiences with [NEXTGEN PROGRAM].
-
CATI/CAWI: PROGRAM GROUP ONLY
IF CAWI DO NOT SHOW DK OR REF
D1. Since [RA MONTH YEAR], have you received any services from [NEXTGEN PROGRAM] or participated in any [NEXTGEN PROGRAM] activities?
YES 1 D2
NO 2 D5
DON’T KNOW d D5
REFUSED r D5
CATI/CAWI: D1=1 IF CAWI DO NOT SHOW DK OR REF |
D2. How much has your experience with [NEXTGEN PROGRAM] helped you in the following areas?
Would you say [NEXTGEN PROGRAM] helped you very much, somewhat, a little or not at all with…
Select one per row
-
VERY MUCH
SOMEWHAT
A LITTLE
NOT AT ALL
DK
REF
a. …getting work-related skills and knowledge?
1
2
3
4
d
r
b. …working with others?
1
2
3
4
d
r
c. …setting career goals?
1
2
3
4
d
r
d. …getting information about job opportunities?
1
2
3
4
d
r
e. …getting a job?
1
2
3
4
d
r
-
CATI/CAWI: D1=1
IF CAWI DO NOT SHOW DK OR REF
D3. Overall, how would you rate your experience at [NEXTGEN PROGRAM]? Would you say it was very good, good, fair, or poor?
VERY GOOD 1
GOOD 2
FAIR 3
POOR 4
DON’T KNOW d
REFUSED r
-
CATI/CAWI: D1=1
IF CAWI DO NOT SHOW DK OR REF
D4. Are you still receiving any services from [NEXTGEN PROGRAM] or participating in any [NEXTGEN PROGRAM] activities?
YES 1 E1
NO 2 D5
DON’T KNOW d D5
REFUSED r D5
-
CATI/CAWI: D1=2,d,r Or D4=2,d,r
IF CAWI DO NOT SHOW DK OR REF
if D1=2,d,r display “did not participate”
if D4=2,d,r display “stopped going”
D5. What was the primary reason you (did not participate in / stopped going to) [NEXTGEN PROGRAM]? Was it…
You didn’t have transportation or had issues with transportation 1
You were incarcerated 2
You didn’t have the time 3
You got a job 4
You moved 5
You were expecting a child 6
You had child care problems 7
You had health problems or an injury 8
A family member became ill 9
You had pressure from your family 10
You did not like the program 11
You did not like or get along with the program staff 12
You no longer wanted to find employment 13
You completed the [NEXTGEN PROGRAM] program, or 14
Some other reason? (SPECIFY: __________) 99
DON’T KNOW d
REFUSED r
E. UPDATED CONTACT INFORMATION
CATI/CAWI: ALL |
E1.* Next, we would like to ask for some contact information. Mathematica will contact you in about X [FILL ACCORDING TO THE TIME BETWEEN FIRST AND SECOND FOLLOW-UP SURVEYS] months to see how you are doing and conduct another survey.
What is your address?
PROBE: Where do you receive your mail?
PROBE: Is there an apartment number?
Street Address 1: (STRING (NUM))
Street Address 2: (STRING (NUM))
City: (STRING (NUM))
State: (STRING (NUM))
Zip: (STRING (NUM))
DON’T KNOW d
REFUSED r
CATI/CAWI: ALL |
E2.* What is your email address?
EMAIL ADDRESS
(STRING 50)
DON’T HAVE ONE 0
DON’T KNOW d
REFUSED r
CATI/CAWI: ALL |
E3.* May we contact you through Facebook?
YES 1
NO/DON’T HAVE ACCOUNT 0
DON’T KNOW d
REFUSED r
CATI/CAWI: E3 = 1 |
E3a. What name do you use on Facebook?
USER NAME
(STRING 50)
DON’T KNOW d
REFUSED r
CATI/CAWI: E3 = 1 |
E3b. What is your Facebook url?
USER NAME
(STRING 50)
DON’T KNOW d
REFUSED r
CATI/CAWI: ALL |
E4.* May we contact you through LinkedIn?
YES 1
NO/DON’T HAVE ACCOUNT 0
DON’T KNOW d
REFUSED r
CATI/CAWI: E4 = 1 |
E4a. What name do you use on LinkedIn?
USER NAME
(STRING 50)
DON’T KNOW d
REFUSED r
CATI/CAWI: all |
E5.* What is your home telephone number?
HOME TELEPHONE
(201-989) (200-999) (0000-9999)
NO LANDLINE 1
DON’T KNOW d
REFUSED r
CATI/CAWI: all |
E5a.* Do you have a cell phone?
YES 1
NO 0 E7
DON’T KNOW d E7
REFUSED r E7
CATI/CAWI: E5a=01 |
E5b. What is your cell phone number?
CELL PHONE
(201-989) (200-999) (0000-9999)
DON’T KNOW d
REFUSED r
CATI/CAWI: E5a=01 |
E6. 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
CATI/CAWI: ALL |
E7.* What is another phone number where you can be reached?
PHONE NUMBER
(201-989) (200-999) (0000-9999)
DON’T KNOW d
REFUSED r
CATI/CAWI: ALL |
E8.* As we mentioned, Mathematica will contact you in about X [FILL ACCORDING TO THE TIME BETWEEN FIRST AND SECOND FOLLOW-UP SURVEYS] months to see how you are doing and conduct another survey. In case Mathematica has trouble reaching you, we 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?
FIRST NAME
(STRING 50)
MIDDLE INITIAL
(STRING 1)
LAST NAME
(STRING 50)
DON’T KNOW d END
REFUSED r END
CATI/CAWI: E8 NE D OR R |
E8a. What is (his/her) address?
PROBE: Is there an apartment number?
Street Address 1: (STRING (NUM))
Street Address 2: (STRING (NUM))
City: STRING (NUM))
State: (STRING (NUM))
Zip: (STRING (NUM))
DON’T KNOW d
REFUSED r
CATI/CAWI: E8 NE D OR R |
E8b. What is (his/her) relationship to you?
Select one only
SPOUSE/PARTNER 1
MOTHER 2
FATHER 3
SISTER/BROTHER 4
GRANDMOTHER/GRANDFATHER 5
SON/DAUGHTER 6
FRIEND 7
OTHER (SPECIFY) 99
Specify (STRING 50)
DON’T KNOW d
REFUSED r
IF OTHER SPECIFY (99): ENTER OTHER RELATIONSHIP TYPE |
CATI/CAWI: E8 NE D OR R |
E8c. What is (his/her) home telephone number?
HOME TELEPHONE
(201-989) (200-999) (0000-9999)
NO LANDLINE 1
DON’T KNOW d
REFUSED r
CATI/CAWI: E8 NE D OR R |
E8d. Does (he/she) have a cell phone?
YES 1
NO 0 E8F
DON’T KNOW d E8F
REFUSED r E8F
CATI/CAWI: e8D=1 |
E8e. Can I have that number?
TELEPHONE
(201-989) (200-999) (0000-9999)
DON’T KNOW d
REFUSED r
CATI/CAWI: E8 NE D OR R |
E8f. What is (his/her) work telephone number?
TELEPHONE
(201-989) (200-999) (0000-9999)
NO WORK NUMBER 1
DON’T KNOW d
REFUSED r
CATI/CAWI: E8 NE D OR R |
E8g. What is (his/her) email address?
EMAIL ADDRESS
(STRING 50)
DON’T HAVE ONE 0 E9
DON’T KNOW d E9
REFUSED r E9
CATI/CAWI: E8g NE 0, D, OR R |
E8h. Does (he/she) have another email address?
EMAIL ADDRESS
(STRING 50)
NO 0
DON’T KNOW d
REFUSED r
SECOND CONTACT
CATI/CAWI: E8 NE D OR R |
E9. What is the full name of the second person we should contact?
FIRST NAME
(STRING 50)
MIDDLE INITIAL
(STRING 1)
LAST NAME
(STRING 50)
DON’T KNOW d END
REFUSED r END
CATI/CAWI: E9 NE D OR R |
E9a. What is (his/her) address?
PROBE: Is there an apartment number?
Street Address 1: (STRING (NUM))
Street Address 2: (STRING (NUM))
City: STRING (NUM))
State: (STRING (NUM))
Zip: (STRING (NUM))
DON’T KNOW d
REFUSED r
CATI/CAWI: E9 NE D OR R |
E9b. What is (his/her) relationship to you?
Select one only
SPOUSE/PARTNER 1
MOTHER 2
FATHER 3
SISTER/BROTHER 4
GRANDMOTHER/GRANDFATHER 5
SON/DAUGHTER 6
FRIEND 7
OTHER (SPECIFY) 99
Specify (STRING 50)
DON’T KNOW d
REFUSED r
CATI/CAWI: E9 NE D OR R |
E9c. What is (his/her) home telephone number?
HOME TELEPHONE
(201-989) (200-999) (0000-9999)
NO LANDLINE 1
DON’T KNOW d
REFUSED r
CATI/CAWI: E9 NE D OR R |
E9d. Does (he/she) have a cell phone?
YES 1
NO 0 E9F
DON’T KNOW d E9F
REFUSED r E9F
CATI/CAWI: E9D=1 |
E9e. Can I have that number?
TELEPHONE
(201-989) (200-999) (0000-9999)
DON’T KNOW d
REFUSED r
CATI/CAWI: E9 NE D OR R |
E9f. What is (his/her) work telephone number?
(201-989) (200-999) (0000-9999)
NO WORK NUMBER 1
DON’T KNOW d
REFUSED r
CATI/CAWI: E9 NE D OR R |
E9g. What is (his/her) email address?
EMAIL ADDRESS
(STRING 50)
DON’T HAVE ONE 0 E10
DON’T KNOW d E10
REFUSED r E10
CATI/CAWI: E9G NE D OR R |
E9h. Does (he/she) have another email address?
EMAIL ADDRESS
(STRING 50)
NO 0
DON’T KNOW d
REFUSED r
THIRD CONTACT
CATI/CAWI: E9 NE D OR R |
E10. What is the full name of the third person we should contact?
FIRST NAME
(STRING 50)
MIDDLE INITIAL
(STRING 1)
LAST NAME
(STRING 50)
DON’T KNOW d END
REFUSED r END
CATI/CAWI: E10 NE d OR r |
E10a. What is (his/her) address?
PROBE: Is there an apartment number?
Street Address 1: (STRING (NUM))
Street Address 2: (STRING (NUM))
City: STRING (NUM))
State: (STRING (NUM))
Zip: (STRING (NUM))
DON’T KNOW d
REFUSED r
CATI/CAWI: E10 NE d OR r |
E10b. What is (his/her) relationship to you?
Select one only
SPOUSE/PARTNER 1
MOTHER 2
FATHER 3
SISTER/BROTHER 4
GRANDMOTHER/GRANDFATHER 5
SON/DAUGHTER 6
FRIEND 7
OTHER (SPECIFY) 99
Specify (STRING 50)
DON’T KNOW d
REFUSED r
CATI/CAWI: E10 NE d OR r |
E10c. What is (his/her) home telephone number?
HOME TELEPHONE
(201-989) (200-999) (0000-9999)
NO LANDLINE 1
DON’T KNOW d
REFUSED r
CATI/CAWI: E10 NE d OR r |
E1d. Does (he/she) have a cell phone?
YES 1
NO 0 E10F
DON’T KNOW d E10F
REFUSED r E10F
CATI/CAWI: E10e=1 |
E10e. Can I have that number?
TELEPHONE
(201-989) (200-999) (0000-9999)
DON’T KNOW d
REFUSED r
CATI/CAWI: E10 NE d OR r |
E10f. What is (his/her) work telephone number?
TELEPHONE
(201-989) (200-999) (0000-9999)
NO WORK NUMBER 0
DON’T KNOW d
REFUSED r
CATI/CAWI: E10 NE d OR r |
E10g. What is (his/her) email address?
EMAIL ADDRESS
(STRING 50)
DON’T HAVE ONE 0 END
DON’T KNOW d END
REFUSED r END
CATI/CAWI: E10g NE 0, d, OR r |
E10h. Does (he/she) have another email address?
EMAIL ADDRESS
NO 0
DON’T KNOW d
REFUSED r
CATI/CAWI: ALL |
Completed.* This completes the survey. Thank you for your continued participation in this survey and the Next Generation of Enhanced Employment Strategies Project. We appreciate you taking the time to share this information with us. It is a very important contribution to our study. We will send your $40 gift card in the mail in the next two weeks.
As a reminder, we will contact you again in [TIME UNTIL SECOND FOLLOW-UP] to check in. Thank you again.
1,2 B25a, B25b: Noonan, P.M., & Gaumer Erickson, A.S. (2017). The skills that matter: Teaching intrapersonal and interpersonal competencies in any classroom. Thousand Oaks, CA: Corwin.
3 © 1994, 2002 by QualityMetric Inc. and Medical Outcomes Trust. All Rights Reserved.
4 K-6 Distress Scale: https://www.hcp.med.harvard.edu/ncs/k6_scales.php
6 Skinner HA (1982). The Drug Abuse Screening Test. Addictive Behavior. 7(4):363-371. Note that the follow-up survey asks for a 6 month reference period whereas the baseline asks about a 12 month reference period. This is to avoid overlap in the time period being asked about.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Alicia Harrington |
| File Modified | 0000-00-00 |
| File Created | 2022-05-03 |
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