Baseline information form for participants (Attachment D)

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YOUR CONTACT INFORMATION
Name: 
Date of birth:
SSN: 
Current address:
City:
State:
ZIP Code:
Home phone #:   (         )
Cell #:  (         )
Work #:  (         )
Is this address the best one to mail something to you?  1  Yes      2 No 
Alternative address:
City:
State:
ZIP Code:
Email address: 
Which is the primary social network you use?  1  Facebook    2  Twitter    3  Instagram   4  Other (specify): _______________
                                                                                                                                                   9  Decline to answer _______________
What name do you use in that social network? 
Can we contact you by text message?    1  Yes           2   No                                              9  Decline to answer
What is your preferred mode of contact?  (Check all that apply)  A   Phone    B  Text    C  Email   
                                                                                                      D   Other (specify): ____________________________




CONTACT INFORMATION: RELATIVES AND FRIENDS
INSTRUCTIONS: In the space below, please provide contact information for three close relatives or friends who are likely to know how to reach you over the next year. We will only contact these people if we are unable to contact you directly. Please complete all three boxes if possible. 

1. Name: 
How is this person related to you?   1 Spouse/Partner      2 Parent     3 Sister/Brother     4 Friend     5 Other 
Current address:
City:
State:
ZIP Code:
Home phone #:   (         )
Cell #:   (         )
Work #:   (         )
Email address:

2. Name: 
How is this person related to you?   1 Spouse/Partner      2 Parent     3 Sister/Brother     4 Friend     5 Other
Current address:
City:
State:
ZIP Code:
Home phone #:   (         )
Cell #:   (         )
Work #:   (         )
Email address:

3. Name: 
How is this person related to you?   1 Spouse/Partner      2 Parent     3 Sister/Brother     4 Friend     5 Other
Current address:
City:
State:
ZIP Code:
Home phone #:   (         )
Cell #:   (         )
Work #:   (         )
Email address:





The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to understand programs that aim to improve employment outcomes for low-income adults. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB number and expiration date for this collection are OMB #: 0970-0537, Exp: 11/30/2022. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Megan Millenky (MDRC); 200 Vesey Street, 23rd Floor, New York, NY 10281-2103.