OMB Control Number:
ATTACHMENT A: BASELINE INFORMATION FORM
[Note: PHA staff will administer the BIF. The BIF will not be handed out to participants]
HUD STEPPED AND TIERED RENT DEMONSTRATION INTRODUCTION SCRIPT TO BE USED BY PHA STAFF |
[Note: Program staff will review the Informed Consent Form (ICF) with program participants right before the Baseline Information Form is administered. The script also touches on a few points covered in the ICF].
As mentioned, as part of your enrollment into the Stepped and Tiered Rent Demonstration study, the Study Team would like you to complete a short questionnaire that asks about you and your household. Your responses will help the Study Team understand the families participating in this study. Your responses will not be shared with the [PHA]. After the study is complete or at HUD’s request, the Study Team will transfer your data with your responses to HUD, which will be linked to your other identifiable information. HUD intends to use your information only for research.
The questionnaire should take about 7 minutes. I will read the questions and some possible answer choices, and then I will input your answers into MDRC’s system.
Are you able to take this survey in English or would you prefer to take it in another language?
[If respondent prefers English, continue in English.]
[If respondent requests language assistance, follow the PHA’s language assistance process.]
Completing the questionnaire is voluntary and you may skip any questions you do not wish to answer. None of your responses will affect your eligibility to receive housing assistance, or whether you are assigned to the [Tiered/Stepped] Rent Rules Group or the Standard Rent Rules Group. That assignment will be decided completely at random. You can learn more about how the Study Team will protect your information by reviewing the PRA Burden and Privacy Act Statement on the last page of the Informed Consent Form that we just reviewed.
Do you have any questions or concerns about completing the questionnaire?
[If no questions or concerns with proceeding] Great. Thank you. Let’s get started.
[If not able to or does not want to complete the questionnaire during study enrollment] Would you be willing to complete the questionnaire over the phone at a later time?
[If agreeing to complete the questionnaire over the phone at a later date] Thanks, someone from the Study Team will call you sometime soon.
[If not agreeing to complete the questionnaire over the phone at a later date, proceed to the Contact Information section of questionnaire]. OK, you can choose not to complete the questionnaire, but we do need to record your contact information for the Study Team. [Collect contact information]
HUD STEPPED AND TIERED RENT DEMONSTRATION INTRODUCTION SCRIPT TO BE USED BY SURVEY FIRM INTERVIEWERS |
SEL_LANG. INTERVIEWER: PLEASE SELECT THE LANGUAGE FOR THIS CALL.
ENGLISH
SPANISH
OTHER (SPECIFY)
INT09. INTERVIEWER: HIT "NEXT" TO BEGIN A CATI INTERVIEW
CZ. CATI ATTEMPT (GOTO INT10)
INT10. Is this an incoming or outgoing call?
IC. Incoming (GOTO CI_INTRO)
OK. Outgoing (GOTO INT00)
09. Not dialed-need to exit case (GOTO CNOTES)
CI_INTRO. INTERVIEWER: PLEASE SELECT RESPONSE AND PRESS "NEXT" TO CONTINUE
01. CONTINUE WITH RESPONDENT (GOTO SRCE1_R)
02. CONTINUE WITH ALTERNATE (GOTO SRCE1_A)
SRCE1_R. Are you responding to...
INTERVIEWER: CHECK ALL THAT APPLY
01 A post card?
02 An email?
03 A voicemail message?
05 A request to call us by a friend or family member?
06 Other, specify
07 DON’T KNOW
08 REFUSED
ALL GOTO Q_CONT
SRCE1_A. Are you responding to...
INTERVIEWER: CHECK ALL THAT APPLY
01 A post card?
02 An email?
03 A voicemail message?
05 A request to call us by a friend or family member?
06 Other, specify
07 DON’T KNOW
08 REFUSED
ALL GOTO PRE52
INT00. What is the result of this call?
OK. Someone is anwering your call (GOTO INTRO_RESP)
10. Answering Machine - Respondent Script (GOTO INT01)
AB. Answering Machine - Alternate contact Script (GOTO INT51)
50. No answer (GOTO CNOTES)
48. Regular Busy (GOTO CNOTES)
49. Fast Busy (GOTO CNOTES)
55. Number disconnected, no longer in service (GOTO CNOTES)
53. Fax / data line (GOTO CNOTES)
54. Number temporarily disconnected (GOTO CNOTES)
56. Unable to connect to number at this time (GOTO CNOTES)
52. Call blocking (GOTO CNOTES)
01. Additional outcome codes (GOTO UE1)
INT01. This message is for <FNAME> <NAME>. My name is INTERVIEWER NAME. I am calling from Decision Information Resources on behalf of the U.S. Department of Housing and Urban Development and [PHA_NAME]. You have the opportunity to participate in a paid survey of rental assistance recepients and public housing residents. Please call our survey line at XXX-XXX-XXXX. When you call, please reference Case Number <CASEID>. Thank you.
11. Answering Machine - Respondent Name (first/last/full) (GOTO CNOTES)
17. Answering Machine - No Message Left (GOTO CNOTES)
14. Answering Machine – Other (GOTO CNOTES)
OK. Someone answers (GOTO INTRO_RESP)
INT51. Hello, I am calling from Decision Information Resources on behalf of the U.S. Department of Housing and Urban Development and [PHA_NAME]. We are trying to reach <FNAME> <NAME> to do a paid survey over the phone or online. They listed you as someone who would know how to reach them in the event that they moved. If you know how to reach <FNAME> <NAME>, please give us a call at XXX-XXX-XXXX.
If you don't know <FNAME> <NAME>, please call the same number, XXX-XXX-XXXX, so we can remove you from our list. Please refer to Case Number so we can quickly find the record in our computer when you call. Thank you.
AD. Answering Machine - Alternate Contact name (GOTO CNOTES)
AC. Answering Machine - Respondent Name (first/last/full) (GOTO CNOTES)
AA. Answering Machine - No Message Left (GOTO CNOTES)
AF. Answering Machine – Other (GOTO CNOTES)
OK. Someone answers (GOTO PRE52)
INTRO_RESP. Hello, my name is INTERVIEWER NAME and I am calling from Decision Information Resources on behalf of the U.S. Department of Housing and Urban Development and [PHA_NAME]. May I speak with <FNAME> <NAME>?
01 RESPONDENT ON THE PHONE - CONTINUE (GOTO Q_CONT)
02 RESPONDENT IS COMING TO THE PHONE (GOTO Q_CONT)
03 RESPONDENT NOT AVAILABLE (GOTO NOTAVAIL1)
04 REFUSED (GOTO INT03)
05 WRONG NUMBER FOR R (GOTO CNOTES)
07 ALTERNATE CONTACT ON THE LINE (GOTO PRE52)
08 RESPONDENT BREAKOFF - HANG-UP/DISCONNECT (GOTO CNOTES)
09 WRONG NUMBER – UNABLE TO VERIFY (GOTO CNOTES)
PRE52. Hello, my name is INTERVIEWER NAME. I am calling from Decision Information Resources on behalf of the U.S. Department of Housing and Urban Development and [PHA_NAME]. I am trying to reach <FNAME> <NAME> to do a telephone interview with them. They gave us your name and number as someone who would know how to reach them. Do you know how I can reach them?
1 YES, R IS AVAILABLE NOW (GOTO ALT_SCREEN1)
2 YES, R USES THIS NUMBER BUT NOT AVAILABLE AT THE MOMENT – SET CALLBACK AT THIS NUMBER FOR R (GOTO INT20)
3 YES, A NEW NUMBER IS AVAILABLE FOR R (GOTO NEWPHONE)
4 NO, BUT SOMETIMES HEARS FROM R (GOTO ALT_SCREEN2)
5 NO, DOES NOT KNOW HOW TO REACH R (GOTO INT54)
6 WRONG NUMBER – DOES NOT KNOW R (GOTO CNOTES)
7 SET CALLBACK AT THIS NUMBER FOR ALT (GOTO INT21)
8 ALT REFUSED PARTICIPATION (GOTO CNOTES)
9 ALT BREAKOFF - HANG-UP/DISCONNECT (GOTO CNOTES)
11 WRONG NUMBER – UNABLE TO VERIFY (GOTO CNOTES)
INT20. Thanks, what is the best time to call back to get in touch with <FNAME> <NAME>?
23 SPOKE TO R - CALL-BACK (GOTO CNOTES)
20 HARD APPOINTMENT (GOTO CB)
21 SOFT APPOINTMENT (GOTO CB)
INT21. Thanks, what is the best time to call back to get in touch with you?
A1 SPOKE TO R - CALL-BACK (GOTO CNOTES)
A4 HARD APPOINTMENT (GOTO CB)
A5 SOFT APPOINTMENT (GOTO CB)
NEWPHONE. INTERVIEWER: ENTER NEW PHONE NUMBER (FORMAT 9999999999)
TZ_01. What time zone does the owner of this phone live in?
INTERVIEWER: IF PERSON ON THE PHONE DOESN´T KNOW THE TIME ZONE FOR PHONE, ASK IN WHAT STATE DOES THE OWNER OF THIS PHONE LIVE IN? AND SELECT BEST OPTION.
00 Unknown
02 Midway Island, Samoa
03 Hawaii
04 Alaska
05 Pacific Time (PST)
07 Mountain Time (MT)
08 Arizona
12 Central Time (CST)
13 Eastern Time (EST)
19 Atlantic/Puerto Rico
RELATION01.
INTERVIEWER: SELECT THE RELATIONSHIP OF OWNER OF NEW NUMBER
INTERVIEWER: IF YOU ARE SPEAKING WITH THE RESPONDENT, CHOOSE RESPONDENT AND CLICK NEXT.
100 Respondent
101 Mother
102 Father
103 Aunt
104 Uncle
105 Grandmother
106 Grandfather
107 Sister
108 Brother
109 Guardian
110 Cousin
111 Step Mother
112 Step Father
113 Wife
114 Friend
115 Custodian
116 Husband
117 Son
118 Daughter
120 Nephew
121 Neice
122 Child's Mother
123 Other
124 Child's Father
125 Friend
126 Foster Parent
199 Unknown
LANG01.
INTERVIEWER: SELECT LANGUAGE FOR NEW NUMBER
INTERVIEWER: HIT NEXT TO CONTINUE - DO NOT USE ESC/BACK BUTTONS
EN English
ES Spanish
PHTYPE01. Is this a home, work or cell number?
1 Home
2 Work
3 Cell
5 Other
6 Unknown
ADD101.
INTERVIEWER: CLICK “NEXT” TO SKIP THIS QUESTION
SUPERVISORS ENTER INFORMATION IF AVAILABLE
Address Line 1
Address Line 1
Address Line 1
City
State
Zip
NN_CB.
Is there a specific date or time when the new number should be called?
INTERVIEWER INSTRUCTIONS: IF A SPECIFIC TIME/DATE WERE NOT PROVIDED, SELECT "NO"
1 Yes (GOTO CB)
2 No (GOTO CNOTES)
CB. INTERVIEWER: ENTER DATE AND TIME
DISPLAY CALENDAR TO ALLOW INTERVIEWER TO CHOOSE DATE & TIME FOR HARD APPOINTMENT. GO TO CNOTES.
(ALL GOTO CNOTES)
ALT_SCREEN1. Thanks, may I speak with <FNAME> <NAME>?
1. Continue (GOTO INTRO_RESP)
ALT_SCREEN2. May I leave our toll free number with you and you could ask them to call us?
INTERVIEWER: IF YES, SAY: The number is 866-986-1968. Thank you.
1 LEFT MESSAGE WITH ALT (GOTO CNOTES)
2 DID NOT LEAVE MESSAGE WITH ALT (GOTO CNOTES)
Q_CONT. You have the opportunity to participate in a paid survey of rental assistance recepients and public housing residents. The U.S. Department of Housing and Urban Development, or HUD, and [PHA_NAME] wants to learn more about the experience of residents like you. You can learn more about how the Study Team will protect your information by reviewing the Paperwork Reduction Act Burden and Privacy Act Statement on the last page of the Informed Consent Form that you received during your study enrollment meeting. The survey takes most people about 7 minutes to complete, and you will receive a <INCENTIVE> gift card as a thank you for your time. You can skip questions you do not want to answer.
Is this a good time for you to do the survey?
01 CONTINUE WITH RESPONDENT (GOTO SCRN1)
02 SET CALLBACK WITH RESPONDENT (GOTO INT20)
08 RESPONDENT REFUSED (GOTO INT20)
09 NOT TALKING TO RESPONDENT (GO TO INTRO_RESP)
SCRN1.
Before we begin, I’d
like to confirm that I am speaking with the correct person.
In order to do so, could
you please tell me your date of birth?
DOB: ____ ____ ____ ____
INTERVIEWER: ENTER MONTH AND DAY, E.G. “May 15th, 1974” = 0515
9997 DON’T KNOW (DENY_TX)
9998 REFUSED (DENY_TX)
IF SCRN1= DOB FROM SAMPLE FILE GO TO CONSENT1
IF (SCRN1 ≠ DOB) RMNCONF = 2; GOTO DENY_TX
DENY_TX.
There seems to be a technical
problem with your file. Thank you for your time
and patience.
We will contact you as soon as we resolve this problem. Your
information is important to us and to the success of this study.
Have a nice
day/evening.
INTERVIEWER: PRESS NEXT TO END SURVEY
INT01. This message is for <FNAME> <NAME>. My name is INTERVIEWER NAME. I am calling from Decision Information Resources on behalf of the U.S. Department of Housing and Urban Development and [PHA_NAME]. You have the opportunity to participate in a paid survey of rental assistance recepients and public housing residents. Please call our survey line XXX-XXX-XXXX. When you call, please reference Case Number <CASEID>. Thank you.
11 Answering Machine - Respondent Name (first/last/full) (GOTO CNOTES)
17 Answering Machine - No Message Left (GOTO CNOTES)
14 Answering Machine – Other (GOTO CNOTES)
OK Someone answers (GO TO INTRO_RESP)
INT51. Hello, I am calling from Decision Information Resources on behalf of the U.S. Department of Housing and Urban Development and [PHA_NAME]. We are trying to reach <FNAME> <LNAME> to do a paid survey over the phone or online. They listed you as someone who would know how to reach them in the event that they moved. If you know how to reach <FNAME>, please give us a call at XXX-XXX-XXXX.
If you don't know <FNAME>, please call the same number, XXX-XXX-XXXX, so we can remove you from our list. Please refer to Case Number <CASEID> so we can quickly find the record in our computer when you call. Thank you.
11 Answering Machine - Respondent Name (first/last/full) (GOTO CNOTES)
17 Answering Machine - No Message Left (GOTO CNOTES)
14 Answering Machine – Other (GOTO CNOTES)
OK Someone answers (GO TO INTRO_RESP)
INT54. Is there someone else I could call who might know their address or phone number or who might be able to get a message to them?
57 YES – ADD NEW ALTERNATE CONTACT (GOTO NEWPHONE)
71 WRONG NUMBER FOR R (GOTO CNOTES)
UE1. Who were you speaking with?
Respondent
Alternate contact
Gatekeeper
ALL GO TO UE2.
UE2.
Why did this call end?
Requested a callback (GO TO Cb_checkpoint)
Refused (GO TO UE_REF1)
Hung up or got disconnected (GO TO UE3)
Spanish language interviewer needed [IF UE1=01 DISPLAY “(30)”; ELSE DISPLAY “(AI)”] (GO TO CNOTES AND CODE 30 OR AI BASED ON RESPONSE TO UE1)
Language barrier – language other than English or Spanish needed (31) (GO TO CNOTES and code 31)
RESPONDENT DECEASED (35) (GO TO CNOTES AND CODE 35)
Respondent physically or mentally unable/incompetent (34) (GO TO CNOTES AND CODE 34)
Supervisor Review (07) – Indicate reason in call notes (GO TO CNOTES and code 07)
Callback path:
CB_CHECKPOINT.
IF QUEX_START EQ MISSING AND UE1=1 (R), ASK INT23
IF QUEX_START EQ MISSING AND UE1 NE 1 (NOT THE R), ASK INT24
IF QUEX_START=1, ASK INT22
INT23. WHAT KIND OF CALLBACK DID THE PERSON REQUEST?
SPOKE TO R – CALL BACK (GO TO CNOTES)
HARD APPOINTMENT (GO TO CB)
SOFT APPOINTMENT (GO TO CB)]
INT22. WHAT KIND OF CALLBACK DID THE PERSON REQUEST?
HARD APPOINTMENT – PARTIAL
SOFT APPOINTMENT – PARTIAL
INT24. WHAT KIND OF CALLBACK DID THE PERSON REQUEST?
A1. SPOKE TO ALT – CALL BACK (GO TO CNOTES)
A2. SPOKE TO GATEKEEPER – CALL BACK (GO TO CB)
A4. HARD APPOINTMENT (GO TO CB)
A5. SOFT APPOINTMENT (GO TO CB)
CB.
01. ______________ENTER A DATE AND TIME
DISPLAY CALENDAR TO ALLOW INTERVIEWER TO CHOOSE DATE & TIME FOR HARD APPOINTMENT. GO TO CNOTES.
UE3. Did the person say anything before breaking off, or did it appear that the person hung-up or got disconnected?
YES, THE PERSON SAID SOMETHING BEFORE BREAKING OFF (GO TO REFUSAL PATH à UE_REF1)
NO, THE PERSON DID NOT SAY ANYTHING (CALL ENDED DUE TO A HANG-UP OR DISCONNECT) (GO TO CNOTES AND CODE 63 OR AY BASED ON RESPONSE TO UE1)
Refusal path:
UE_REF1. Did the person provide a reason for refusal?
YES, THE PERSON PROVIDED A REASON FOR REFUSING
NO, THE PERSON DID NOT PROVIDE A REASON FOR REFUSING (GO TO REF_CHECKPOINT)
UE_REF2. What was the reason for refusal? CHOOSE ALL THAT APPLY
PROGRAMMER: USE CHECK BOXES. IF 10 IS CHECKED, ALL OTHER OPTIONS SHOULD BE INACTIVE.
NOT INTERESTED
TOO BUSY / DON’T HAVE TIME TO PARTICIPATE IN SURVEYS
CONFIDENTIALITY
LEGITIMACY
PERSON DOES NOT DO SURVEYS OVER THE PHONE
NEGATIVE OPINIONS ABOUT JOB CORPS OR THE GOVERNMENT
INCENTIVE AMOUNT TOO LOW / NOT ENOUGH MONEY
QUESTIONS ARE TOO PERSONAL
OTHER REASON PROVIDED
NO REASON PROVIDED
REF_CHECKPOINT.
IF WE ARE TALKING TO A RESPONDENT (UE1=1 OR QUEX_START NE MISSING), ASK INT46; ELSE ASK INT45.
INT46. Was this a soft or hard refusal?
INTERVIEWER: A HARD REFUSAL CAN INCLUDE THE FOLLOWING:
HOSTILE OR VIOLENT TONE
PROFANITY DIRECTED AT THE INTERVIEWER OR SURVEY
THREATENING LEGAL ACTION
SOFT REFUSAL
HARD REFUSAL
GO TO UE_REF4
INT45. Was this a soft or hard refusal?
INTERVIEWER: A HARD REFUSAL CAN INCLUDE THE FOLLOWING:
HOSTILE OR VIOLENT TONE
PROFANITY DIRECTED AT THE INTERVIEWER OR SURVEY
THREATENING LEGAL ACTION
AW. SOFT REFUSAL
AX. HARD REFUSAL
UE_REF4. Did the person specifically request to be taken off of the list?
YES (NEW TMOL CODE FOR R (DR) OR ALT (DA) BASED ON UE1 RESPONSE; RESPONDENT TMOL DEACTIVATES THE ENTIRE CASE; ALTERNATE TMOL WILL CYCLE, BUT ALT NUMBER CAN NEVER BE CALLED AGAIN)
NO (CASE WILL BE CODED AS A HARD OR SOFT REFUSAL DEPENDING ON SELECTION AT INT45 OR INT46)
PROGRAMMER NOTE: IF CASE IS BOTH A TMOL AND A REFUSAL (HARD OR SOFT), THE TMOL WILL BE THE FINAL DISPOSITION.
ALL GO TO CALL NOTES AT THE END OF THE UNIVERSAL EXIT
HUD STEPPED AND TIERED RENT DEMONSTRATION BASELINE INFORMATION FORM |
|
NOTE: This information is provided by the head-of-household.
Personal Identifiers |
1.A First Name: ______________________________ 1.B Middle Name: ____________________________ 1.C Last Name: _______________________________ |
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ [Length will vary by HA] |
___ ___ ___ - ___ ___ - ___ ___ ___ ___ |
___ ___ / ___ ___ / ___ ___ ___ ___ MM DD YYYY |
5. How long have you received Section 8 rental assistance or lived in public housing as a head-of-household? 1m Less than 1 year 2m 1 - 3.99 years 3m 4 - 6.99 years 4m 7 - 9.99 years 5m 10 or more years 6m No answer |
Educational Attainment |
6. What is the highest level of education that you have completed? 1m Grade 8 or less 2m High school (grades 9-12) but did not receive high school diploma or GED certificate 3m GED certificate 4m High school diploma 5m Some college 6m Associate’s or two-year degree 7m Four-year college degree or higher 9m No answer |
Employment Status |
7. Are you currently working for pay or self-employed? 1m Yes [Go to 8] 2m No [Go to 10] 3m No answer [Go to 8] |
8. Which situation best describes your current employment? Check all that apply. 1q I work for pay at a regular job 2q I am self-employed 3q I work at a temporary or seasonal job 4m No answer |
9. Counting all of your current jobs or businesses, how many hours do you typically work per week? If your hours of work vary, please say the average number of hours per week that you worked during the past 4 weeks. Your best guess would be fine. _______ Hours [Note: If the respondent does not know the exact number of hours: enter 99 for Q9 and review the range amounts in Q9a and check one] 9a. 1m 1-20 hours 2m 21-34 hours 3m 35-48 hours 4m 49 or more hours 5m No answer |
10. In the past 12 months, about how many months have you worked for pay or earned money from self-employment? Count any month in which you worked at least one day part-time or full-time. 55m Did not work at any time [Go to 10a] 1 1 Month [Go to 11] 2 2 Months [Go to 11] 3 3 Months [Go to 11] 4 4 Months [Go to 11] 5 5 Months [Go to 11] 6 6 Months [Go to 11] 7 7 Months [Go to 11] 8 8 Months [Go to 11] 9 9 Months [Go to 11] 10 10 Months [Go to 11] 11 11 Months [Go to 11] 12 12 Months [Go to 11] 13m No answer [Go to 10a] |
10a. When was the last time you worked part-time or full-time? 1m 1-2 years ago 2m 3-5 years ago 3m 6-10 years ago 4m More than 10 years ago 5m No answer |
10b. Are you currently looking for work? 1m Yes 2m No 3m No answer |
Employment Access Issues |
11. Would any of the following circumstances make it difficult for you to get a job, work more hours, or get a better job: |
11a. Difficulty paying for or accessing child care or after-school supervision? 1m Yes 2m No 3m No answer |
11b. A physical or mental health issue? 1m Yes 2m No 3m No answer |
11c. The need to care for a sick or disabled family member? 1m Yes 2m No 3m No answer |
11d. Transportation challenges? 1m Yes 2m No 3m No answer |
Household Finances and Material Hardship |
12. Do you currently receive SNAP/food stamps? 1m Yes 2m No 3m No answer |
13. In general, how do you or your household’s finances usually work out at the end of the month? Is there… 1m Some money left over 2m Just enough to make ends meet 3m Not enough money to make ends meet 4m No answer |
14a. In the last 12 months was there ever a time when you or your household did not pay the full amount of your rent on time? 1m Yes 2m No 3m No answer |
14b. In the last 12 months has there been a time when you or your household had service turned off by the gas or electric company, or the oil company would not deliver oil because payments were not made? 1m Yes 2m No 3m No answer |
14c. In the last 12 months, have you or your household had cellular or landline phone service disconnected because payments were not made? 1m Yes 2m No 3m No answer |
14d. In the last 12 months was there ever a time when you or your household were not able to buy food because of cost? 1m Yes 2m No 3m No answer |
Personal Finances |
15. Do you currently have a savings or checking account at a bank or a credit union? 1m Yes 2m No 3m No answer |
16. About how much money do you currently have saved? This includes money at home; in a savings, checking, credit union, or money market account; and certificates of deposit. Do not include pension funds or retirement accounts. Your best guess would be fine. 1m $0 2m $500 or less 3m $501-$1,000 4m $1,001-$3,000 5m More than $3,000 6m No answer |
17. When you think about all your loans including, for example, money borrowed from friends or family, car loans, credit card debt, and student loans, what is the total amount you owe? Your best guess would be fine. 1m $0 2m $1 - $1,999 3m $2,000 - $4,999 4m $5,000 - $9,999 5m $10,000 to $19,999 6m More than $20,000 7m No answer |
Health Insurance |
18. What kind of health insurance are you currently AND primarily covered by? 1m Public health insurance (ex.: Medicaid, state or local program, add other relevant as prompts) 2m Health insurance through either my work, my spouse’s or partner’s work 3m Other private insurance 4m I am not covered by health insurance 5m No answer |
Household Composition |
19. Does your household include? Check all that apply. 1q Spouse or partner 2 Child under age 13 [Go to 20] 3 Child age 13-17 [Go to 20] 4 A child age 18 or over [Go to 20] 5q Other adult 6m None [Go to 23] 7m No answer [Go to 20] |
20. Do you use any of the following programs or people to take care of your child(ren) while you are at work or attending a class, school, or job training? A Yes [Check all that apply] 1 Relative (grandparent, aunt, uncle, sibling of the child, etc.) 2 Unrelated adult in your home or another home 3 Center-based preschool or infant care (child care center, daycare, nursery school, Head Start, preschool, after-school or before-school program for preschool) 4 After-school or before-school program for elementary school 5 Other _________________________________________ 5.A Specify B Do not use any [Go to 23] C No answer [Go to 21] |
21. Do you pay for any of that child care? A Yes [Check all that apply] 1 Relative (grandparent, aunt, uncle, sibling of the child, etc.) 2 Unrelated adult in your home or another home 3 Center-based preschool care (child care center, daycare, nursery school, Head Start, preschool, after-school or before-school program for preschool) 4 After-school or before-school program for elementary school 5 Other _________________________________________ 5.A Specify B Do not pay for any [Go to 23] C No answer [Go to 23] |
22. Are you currently receiving help paying for child care from [Insert name of state agency] or any other program or agency, or do you pay a reduced fee for child care based on your income? 1 Yes 2 No 3 No answer |
Contact Information |
Please provide address and phone numbers for the head-of-household. |
23. Home Address:
_______________________________________________________________ _________ 23.A Street Address 23.B Apt. #
_________________________ _______ ___ ___ ___ ___ ___ 23.C City 23.D State 23.E Zip code |
24. Phone Numbers 24.A Home phone number: (___ ___ ___) ___ ___ ___- ___ ___ ___ ___ 24.B Mobile phone number: (___ ___ ___) ___ ___ ___- ___ ___ ___ ___ 24.C Work phone number: (___ ___ ___) ___ ___ ___- ___ ___ ___ ___ |
25. Do you give the researchers permission to text you at the phone number(s) you have provided? 1m Yes 2m No |
26. Email address: _________________________________________________ |
27. What is your preferred language for receiving communication materials from the study team? 1m English 2m Spanish 3m Other: _____________________ 6.A Specify 5m No answer |
28. What is your preferred method of communication with the study team? 1m Mail 2m Phone call 3m Text 4m Email 5m No answer |
Additional Contact Information |
Please provide the name, telephone numbers, and email address of a family member or friend who will know how to reach you if we have difficulty contacting you. |
CONTACT 1:
29. Name
29.A First Name: ______________________________
29.B Last Name: _______________________________
30. Relationship to you: _____________________________
31. Phone
31.A Home phone: ( ___ ___ ___) ___ ___ ___- ___ ___ ___ ___
31.B Cell phone: ( ___ ___ ___) ___ ___ ___- ___ ___ ___ ___
32. Email address: _______________________________________ |
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 2023-08-26 |