PHE QED Baseline Information Form_June2022_clean (1)

^{Pathway Home Evaluation}
Quasi-experimental design (QED) Baseline Information Form of Study Participants

June 2022

The OMB control number for this collection is 1290-xxxx and expires on [month/day/year]. 

According to the Paperwork Reduction Act of 1995, no person is required to respond to a collection of information unless such collection displays a valid OMB control number. Collection of this information is authorized by Section 169 of the Workforce Innovation and Opportunity Act (WIOA). The obligation to respond to this collection is voluntary. We estimate it takes about 15 minutes to complete this collection of information, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing the collection of information.  Please send comments regarding the burden estimate or any other aspect of this collection of information to the U.S. Department of Labor, Chief Evaluation Office, 200 Constitution Ave NW, Washington, DC 20210, or email [email protected] and reference OMB control number 1290-xxxx.

This page has been left blank for double-sided copying.

Today’s Date: | | |/| | |/| | | | |

Month Day Year

B. EDUCATION AND EMPLOYMENT HISTORY

OMB No.: XXXX-XXXX

Baseline Information Form

Expiration Date: XX/XX/XXXX

A. PARTICIPANT INFORMATION

□ Check if currently incarcerated

A1. What is your full name?

________________________________________________ First Name Middle Name/Initial Last Name

A2. What is your social security number? This is just for research purposes and will be kept strictly private.

| | | |-| | |-| | | | |

A3. What is your date of birth?

| | | / | | | / | | | | |

month day year

A4. What is your state or county prison ID? If you have multiple, please provide the most recently issued ID.

| | | | | |-| | | | □ N/A or don’t know

□ State prison ID □ County prison ID

A4. What county do you expect to return to when you are released?

The following questions will be used to help the study team understand the education and employment of program applicants prior to incarceration. They will not be used for program admission.

B1. Just before being incarcerated, were you enrolled in any type of school?

1 □ Yes – Full time

2 □ Yes – Part time

0 □ No

B2. What is the highest level of education you have completed, including any education received while incarcerated?

SELECT one only

1 □ Some high school

2 □ High school diploma

3 □ GED/HiSET/TASC

4 □ Certificate of Completion

5 □ Some college

6 □ Associate’s degree or vocational degree

7 □ Bachelor’s degree

8 □ Master’s degree or higher

9 □ None of these

B3. Do you have any specialized education or work credentials or certificates? Do not include a high school diploma, GED, or college degree.

1 □ Yes (name of credential/certificate)

0 □ No

B4. Have you ever had a paying job lasting 3 months or longer?

1 □ Yes

0 □ No SKIP TO C1

B5. How many months or years of work experience do you have? Do not include work experience while incarcerated. You should include time when you were self-employed.

| | | years and | | | months

B6. Prior to your (most recent) incarceration, were you working?

IF NO: Were you looking for work?

1 □ Yes, regular work

2 □ Yes, occasional or temporary work

(SKIP TO SECTION C)

3 □ No, but looking for work

4 □ No, and not looking for work

B6a. The next questions are about the job you had just before your (most recent) incarceration. Please think about the job you had just before your current incarceration, even if it wasn’t your best job.

How many hours per week were you working at the job you had just before your current incarceration?

(If you had more than one job, please answer about the job where you worked the most hours.)

SELECT one only

1 □ Working 30 hours per week or more

2 □ Working 1 to 29 hours per week

B6b. Still thinking about the job you had just before this (most recent) incarceration, how much money did you make, on average, at this job?

$

1 □ Hourly 2 □ Weekly 3 □ Bi-weekly 4 □ Monthly

B6c. What kind of company was it (where you worked just before incarceration)? What does the company make, sell, or do?

B6d. What was your job title (at the job you had just before incarceration)?

C. EXPERIENCE WITH CRIMINAL JUSTICE SYSTEM

C. EXPERIENCE WITH CRIMINAL JUSTICE SYSTEM

The next questions are about your experience with the criminal justice system. Your answers will only be used for evaluating the program and will not be used for anything other than research purposes. To help the study team understand if and how the program’s services are helping individuals, they need to understand what life was like for people before their current incarceration.

C1. How many times have you been arrested, including arrests for technical violations of parole or probation?

1 □ Once

2 □ Two to five times

3 □ Six to ten times

4 □ Eleven to nineteen times

5 □ Twenty or more times

C1a. How old were you the first time that you were arrested? If you are not sure, use your best guess.

| | | AGE AT FIRST ARREST

C2. Approximately how many of these arrests resulted in at least one conviction?

| | | NUMBER OF ARRESTS RESULTING IN CONVICTON

IF 0 SKIP TO C5a

C3. Have you ever been convicted of a felony?

1 □ Yes

0 □ No

C4. Have you ever been convicted of any of the following:

1. Theft, burglary, robbery, or larceny 1 □ Yes 0 □ No

2. Assault, battery, or other violent offenses 1 □ Yes 0 □ No

3. Drug or alcohol offenses (such as 1 □ Yes 0 □ No

DUI/DWI, possession, distribution)

4. Disorderly conduct, loitering, 1 □ Yes 0 □ No

disturbing the peace

5. Financial crimes such as fraud, 1 □ Yes 0 □ No

embezzlement, or forgery

6. Something else:________________ 1 □ Yes 0 □ No

C5a. Not including your current period of incarceration, how many times have you been incarcerated in a juvenile or adult correctional facility?

0 □ Never IF 0 SKIP TO C6

1 □ Once

2 □ Two times

3 □ Three to five times

4 □ Six to nine times

5 □ Ten or more times

C5b. IF C5a>0: For how long had you been out before you started your current incarceration period?

C6. What was the start date of your (current/most recent) period of incarceration?

| | | / | | | / | | | | |

month day year

C7. What is the reason for your current incarceration?

Was it a….

(If more than one reason, please select the most serious offense.)

SELECT one only

1 □ Felony

2 □ Misdemeanor

3 □ Violation of probation or parole

C8. What charge is your current incarceration most closely tied to? If your current incarceration is for a technical violation of parole or probation, please select the charge most closely tied to your parole or probation.

select One only

1 □ Theft, burglary, robbery, or larceny

2 □ Assault, battery, or other violent offense

3 □ Drug or alcohol offense (such as DUI/DWI, possession, distribution)

4 □ Disorderly conduct, loitering, disturbing the peace

5 □ Financial crime such as fraud, embezzlement, or forgery

6 □ Something else?__________________________

C9. What is the maximum length of your current sentence?

SELECT one only

0 □ N/A – awaiting sentence

1 □ Less than 90 days

2 □ At least 90 days, but less than 6 months

3 □ 6 months to less than 12 months

4 □ Between 1 and 2 years

5 □ Between 3 and 5 years

6 □ More than 5 years

C10. What is your best guess on the date that you will be released?

| | | / | | | | |

month year

N □ N/A, on work release

C11. Not including your current period of incarceration, what is the total time you have spent incarcerated over your lifetime?

1 □ This is my first incarceration

2 □ Less than 6 months

3 □ 6 months to less than 12 months

4 □ Between 1 and 2 years

5 □ Between 3 and 5 years

6 □ More than 5 years

D. PROGRAM PARTICIPATION

D1. Are you required to participate in [PROGRAM NAME]?

1 □ Yes

0 □ No

D2. What services are you hoping to get from the program?

Mark All That Apply

1 □ Employment services (job search assistance, job readiness training, and job placement)

2 □ Case management (a dedicated individual to assist with planning and access to services)

3 □ Supportive services (e.g., housing assistance or mental health services)

4 □ Training for a specific job

(specify job):_____________________________

5 □ Anything else?

(specify):_____________________________

E. PARTICIPANT DEMOGRAPHICS

The next questions will help the study team understand program participants. They will only be used for statistical purposes.

E1. What is your gender?

mark all that apply

1 □ Female

2 □ Male

3 □ Transgender female

4 □ Transgender male

5 □ Gender variant/non-binary

6 □ Other gender identity (specify):

r □ Prefer not to answer

E2. Are you Hispanic or Latino?

1 □ Yes

0 □ No

E3. What is your race?

Mark All That Apply

1 □ American Indian or Alaska Native

2 □ Asian

3 □ Black, African American

4 □ Native Hawaiian or other Pacific Islander

5 □ White

6 □ Other (specify):

E4. What is your primary language?

Mark one only

1 □ English

2 □ Spanish

3 □ Other (specify)

E5. How would you best describe your marital status?

Mark one only

1 □ Single

2 □ In a committed relationship but not married

3 □ Married

4 □ Separated

5 □ Divorced

6 □ Widowed

E6. Do you have any children (include both biological or adopted children)?

1 □ Yes (IF YES: How many?): | | |

0 □ No SKIP TO E9

E7. Prior to this (most recent) incarceration, how many of your children lived with you at least 50% of the time?

| | | NUMBER OF YOUR CHILDREN WHO LIVED WITH YOU

E8. Do you have any legal agreements or child support orders that require you to provide financial support for a child?

1 □ Yes

0 □ No

E9. Do you have a mental or physical disability that limits your ability to work?

1 □ Yes

0 □ No

F. CONTACT INFORMATION

Thanks for all the information you’ve provided so far.

We would like to interview you again [after your release] and we would like to know how to get in touch with you. The next series of questions are just to understand how to best reach you if we have a hard time contacting you for the follow-up survey. Please do your best to answer. We understand that you may not know some of these details yet or they may change, but please give your best guess. And as a reminder, this information will be kept private and never shared with anyone outside the study team. It will only be used to contact you about the follow-up survey.

F1a. What was your living situation just before your incarceration? (IF NECESSARY, READ CATEGORIES)

Mark one only

1 □ Living alone

2 □ Living with a partner

3 □ Living with friends or roommates

4 □ Living with one or both parents

5 □ Living with other family

6 □ Living in a halfway house or shelter

7 □ On the street or in your car

8 □ Other (specify)

F1b. IF F1a NE 6, 7, or 8: Did you own or rent the home you were living in before your incarceration?

1 □ Own 2 □ Paid rent 3 □ Did not own or pay rent

F1c. What was your address before your incarceration?

IF NO ADDRESS BEFORE INCARCERATION: What was the last address you had?

ADDRESS: Number and Street			Apt. No.
City, State	County	ZIP Code

F2a. Do you have a plan for where you will stay when you are released?

1 □ Yes

0 □ No SKIP TO F3

F2b. How would you best describe your planned living situation for when you are released? [IF NECESSARY: Will you be living….]

Mark one only

1 □ Living alone

2 □ Living with a partner

3 □ Living with friends or roommates

4 □ Living with one or both parents

5 □ Living with other family

6 □ Living in a halfway house or shelter

7 □ Transient

8 □ Other (specify)

F2c. What is the address of the place you plan to stay? We understand if you’re not sure; in that case, please give your best guess about the place where you’ll likely stay.

□ SAME AS F1c

ADDRESS: Number and Street				Apt. No.
City, State	ZIP Code	County

F3. What is the best phone number to reach you (after your release)?

| | | |-| | | |-| | | | |

F3a. Is this your personal phone number, or does it belong to a family member or friend?

1 □ Personal phone number

2 □ This number belongs to a family member or friend

3 □ This number belongs to another individual or program

F3b. What is the name of that family member, friend, or other contact?

Name: _________________________________________

Relationship:_____________________________________

F3c. IF F3a=1: Do we have permission to text you at this phone number if we need to reach you?

1 □ Yes 0 □ No n □ N/A – not a cell phone

F4. What is your primary email address?

______________________________________________

F5a. Do you have any social media accounts that may be helpful for contacting you following release?

1 □ Yes – Facebook profile name:_____________________

2 □ Yes – Instagram user name:______________________

3 □ Yes – Other platform: ___________________________

– User name:______________________________

0 □ No SKIP TO NEXT SECTION

F5b. Do you give the study team permission to contact you via social media, such as Facebook and Instagram, if we have trouble reaching you later?

1 □ Yes

0 □ No

G. Contact Information – Other Connections
We would like to ask you for the name, address, and telephone number of 3 close relatives, friends, or other connections (parole officer, case worker, or social worker is ok) we can contact in case you move and we cannot easily locate you for your next interview. All information collected will be kept private, and we will only contact these people if we are unable to reach you directly after multiple attempts. Please consider telling us about your grandparents, siblings, friends, or staff at service locations that you expect to interact with following release. Some contact information is better than no contact information! Please provide as many contacts as possible, even if you do not know all of the information.
1. What is the name and address of the first relative, friend, or other connection?
NAME: First			Middle			Last
ADDRESS: Number and Street									Apt. No.
City				State			ZIP Code
How is this person related to you?	1 □ Mother 2 □ Father 3 □ Sibling 4 □ Spouse 5 □ Friend 6 □ Grandparent 7 □ Case manager 8 □ Probation/Parole Officer 9 □ Other_________________________________________
What name does this person know you as? In other words, how should we ask for you if we need to contact them? _________________________________________________________________________
TELEPHONE and EMAIL: Phone 1: (________) - ________ - _______ Area Code Number 1 Home 2 Cell 3 Work		Phone 2: (________) - ________ -__________ Area Code Number 1 Home 2 Cell 3 Work			Email Address: _____________________________
Does this person have a Facebook account? 1 Yes – User name: __________________________________________								0  No
2. What is the name and address of the second relative, friend, or other connection?
NAME: First			Middle			Last
ADDRESS: Number and Street									Apt. No.
City				State			ZIP Code
How is this person related to you? 1 □ Mother 2 □ Father 3 □ Sibling 4 □ Spouse 5 □ Friend 6 □ Grandparent 7 □ Case manager 8 □ Probation/Parole Officer 9 □ Other_________________________________________
What name does this person know you as? In other words, how should we ask for you if we need to contact them? _________________________________________________________________________
TELEPHONE and EMAIL: Phone 1: (________) - ________ - _______ Area Code Number 1 Home 2 Cell 3 Work		Phone 2: (________) - ________ -__________ Area Code Number 1 Home 2 Cell 3 Work			Email Address: _____________________________
Does this person have a Facebook account? 1 Yes – User name: __________________________________________								0  No
3. What is the name and address of the third relative, friend, or other connection?
NAME: First			Middle			Last
ADDRESS: Number and Street									Apt. No.
City				State			ZIP Code
How is this person related to you?	1 □ Mother 2 □ Father 3 □ Sibling 4 □ Spouse 5 □ Friend 6 □ Grandparent 7 □ Case manager 8 □ Probation/Parole Officer 9 □ Other_________________________________________
What name does this person know you as? In other words, how should we ask for you if we need to contact them? _________________________________________________________________________
TELEPHONE and EMAIL: Phone 1: (________) - ________ - _______ Area Code Number 1 Home 2 Cell 3 Work		Phone 2: (________) - ________ -__________ Area Code Number 1 Home 2 Cell 3 Work			Email Address: _____________________________
Does this person have a Facebook account? 1 Yes – User name: __________________________________________								0  No

H4. Thank you for enrolling in the study. You will be notified soon whether you were randomly assigned to receive [PROGRAM NAME] services or not.

H5. As mentioned in the consent form, you will receive $15 as a ‘thank you’ for providing us with this information. How would you like the $15 provided to you?

Mark one only

1 □ IF CARD2COMMISSARY=1: Deposited into my commissary account

2 □ IF CARD2FACILITY=1: Sent to the facility in the form of a gift card to be put in my file and provided to me at the time of my release

3 □ IF CARD2COMMUNITY=1: (Or) sent to a family member or friend in the form of a gift card

N □ I do not have anyone the card can be sent to. We will hold the $15 gift card for you until you are released. Just give the study team a call at

[PHONE NUMBER] after you’re released and have an address where it can be mailed to.

H5a. What is the name of the person to whom you want us to send the $15 gift card?

Name:

H5b. What is their address?

ADDRESS: Number and Street			Apt. No.
State	ZIP Code

Thank you again for enrolling in the study!