SIRF_OMB_6_Non-grantee Use of nFORM ACS_clean

Instrument 6 –Non-Grantee Use of nFORM’s Applicant Characteristics Survey

SIRF will implement an intervention in one site that is not a federal Responsible Fatherhood grantee. Therefore, we are requesting burden to cover collection of data on applicant characteristics from fathers enrolled in a non-grantee site. This applicant characteristics survey is part of the full nFORM information collection request package - Healthy Marriage and Responsible Fatherhood Performance Measures and Additional Data Collection (ICR Ref #202102-0970-014).

OMB No.: 0970-0XXX DRAFT

Expiration Date: xx/xx/xxxx

Applicant Characteristics Survey

Healthy Marriage and Responsible Fatherhood Programs

Thank you for completing this survey. This survey asks questions about your demographic characteristics, financial well-being, and what brought you to the program. Your name will not be on the survey, and your responses will remain private. We want you to know that:

1. Your participation in this survey is voluntary.

2. We hope that you will answer all the questions, but you may skip any questions you do not wish to answer.

3. The answers you give will be kept private.

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to support program performance monitoring and program improvement activities for Healthy Marriage and Responsible Fatherhood programs. 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. This is a voluntary collection of information. The answers you give will be kept private. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0XXX and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact Dr. Mathew Stange at [email protected].

A. DEMOGRAPHIC CHARACTERISTICS

[ASK ALL]

A1. How do you describe yourself?

SELECT ONE ONLY

1  Female

2  Male

3  Other (specify) ______________________________________________________________

[SOFT CHECK: IF GENDER = “NO RESPONSE” = This question is very important. Please select an answer.]

[ASK ALL]

A2. What is your current age?

| | | years old

[HARD CHECK: IF AGE <13 = Youth must be 13 to 30 years old;

IF AGE > 70 = Please confirm your age;

IF AGE = NON-NUMERIC = Please enter your current age in years.

[SOFT CHECK: IF AGE = “NO RESPONSE” = This question is very important. Please enter your age.]

[ASK ALL]

A3. What is your ethnicity?

SELECT ONE ONLY

1  Hispanic or Latino

2  Not Hispanic or Latino

[ASK ALL]

A4. What is your race?

Select All that Apply

1 □ American Indian or Alaska Native

2 □ Asian

3 □ Black or African American

4 □ Native Hawaiian or other Pacific Islander

5 □ White

6 □ Other (specify)

[ASK ALL]

A5. Which language or languages are spoken in your home most of the time?

SELECT ONE ONLY

1  English

2  Spanish

3  English and Spanish equally

4  Other (specify)________________________________________________

B. FINANCIAL WELL-BEING

[ASK IF AGE >= 18]

B1. In the past month, have you or anyone in your household received the following types of assistance?

	SELECT ONE RESPONSE PER ROW
	YES	NO
a. Temporary Assistance for Needy Families (TANF)	1 	0 
b. Supplemental Security Income (SSI)	1 	0 
c. Social Security Disability Insurance (SSDI)	1 	0 
d. Supplemental Nutrition Assistance Program (SNAP)/Food stamps	1 	0 
e. Women, Infants, and Children (WIC)	1 	0 
f. Unemployment insurance	1 	0 
g. Housing choice voucher (sometimes called Section 8)	1 	0 
h. Cash assistance	1 	0 
i. Child support	1 	0 

[ASK ALL]

B2a. What is your current living situation?

SELECT ONE ONLY

1  Own home

2  Rent

3  Live at home with parents or relatives (rent-free)

4  Live with friends (rent-free)

5  Live in a shelter, halfway house, or treatment center

6  Live on the streets, in a car, abandoned building, or another place not meant for sleeping

7  Currently incarcerated GO TO B3

8  Other

[ASK ALL]

B2b. Which of the following best describes where you now live?

SELECT ONE ONLY

1  A large city

2  A suburb near a large city

3  A small city or town

4  A rural area

[ASK ALL]

B3. Are you currently in school, working toward your GED, or in college or other post-high school education?

SELECT ONE ONLY

1  Yes

0  No GO TO B5

[SOFT CHECK: IF CURRENTLY IN SCHOOL = “NO RESPONSE” = This question is very important. Please select an answer.]

[ASK IF CURRENT SCHOOL = YES]

B4. What is your current grade?

SELECT ONE ONLY

1  Less than 9th grade

2  9th grade

GO TO C4

3  10th grade

4  11th grade

5  12th grade

6  Working toward a GED

7  College

8  Vocational/technical training or other post-high school education

[SOFT CHECK: IF CURRENT GRADE = “NO RESPONSE” = This question is very important. Please select an answer.]

[SKIP IF CURRENT GRADE = LESS THAN 9TH GRADE, 9TH GRADE, 10TH GRADE, 11TH GRADE, OR 12TH GRADE]

B5. What is the highest degree, diploma, or certification you have earned?

SELECT ONE ONLY

1  No degree or diploma earned

2  High school General Educational Development, or GED

3  High school diploma

4  Vocational/technical certification

5  Some college, but no degree

6  Associate’s degree

7  Bachelor’s degree

8  Master’s degree or advanced degree

[SKIP IF CURRENT GRADE = LESS THAN 9TH GRADE, 9TH GRADE, 10TH GRADE, 11TH GRADE, OR 12TH GRADE]

B6a. What is your current employment status?

SELECT ALL THAT APPLY

1 □ Full-time employment (usually work 35 or more hours a week)

2 □ Part-time employment (usually work 1–34 hours a week)

3 □ Employed, but number of hours change from week to week

4 □ Temporary, occasional, or seasonal employment, or odd jobs for pay

5 □ Stay-at-home parent or homemaker

6  Not currently employed

[SOFT CHECK: IF CURRENT EMPLOYMENT = NOT CURRENTLY EMPLOYED = DISABLE OTHER OPTIONS]

[ASK IF CURRENT EMPLOYMENT = STAY-AT-HOME PARENT OR NOT CURRENTLY EMPLOYED]

B6b. Are you actively looking for work?

SELECT ONE ONLY

1  Yes

0  No

[SKIP IF CURRENT GRADE = LESS THAN 9TH GRADE, 9TH GRADE, 10TH GRADE, 11TH GRADE, OR 12TH GRADE]

B7. In the past 30 days, how much money did you make?

Please include tips, bonuses, commissions, and regular overtime pay, and count all money you received before taxes and deductions and money you earned from informal work or odd jobs. If you held more than one job, include your total earnings from all of your work during the past 30 days. Do not include the earnings of other people who live with you.

Your best estimate is fine.

SELECT ONE ONLY

1  No earnings in the past 30 days

2  $1–$499

3  $500–$1,000

4  $1,001–$2,000

5  $2,001–$3,000

6  $3,001–$4,000

7  $4,001–$5,000

8  More than $5,000

[SKIP IF CURRENT GRADE = LESS THAN 9TH GRADE, 9TH GRADE, 10TH GRADE, 11TH GRADE, OR 12TH GRADE]

B8. Do you have health insurance (either through your job, your partner’s job, your parent’s job, Medicaid, Medicare, or a health exchange)?

SELECT ONE ONLY

1  Yes

0  No

d  I don’t know

[SKIP IF CURRENT GRADE B4 = LESS THAN 9TH GRADE, 9TH GRADE, 10TH GRADE, 11TH GRADE, OR 12TH GRADE, OR IF B6A=5 OR 6 (STAY AT HOME PARENT OR HOMEMAKER, OR NOT CURRENTLY EMPLOYED)]

B9. When did you first start working in the job you have now? If you have more than one job, think about the job you worked at for the most hours during the past 30 days.

| | | / | | | | |

MM YYYY

[HARD CHECK: IF Month > 12 OR Month < 1 = Month must be a number from 1 to 12;

IF Year > Current Year OR Year < 1900 = Year must be the current year or earlier;

HARD CHECK: IF Month= non-numeric; Month must be a number from 1 to 12;

IF Year = non-numeric = Year must be the current year or earlier.]

[SKIP IF CURRENT GRADE = LESS THAN 9TH GRADE, 9TH GRADE, 10TH GRADE, 11TH GRADE, OR 12TH GRADE]

B10. Some people experience challenges that make it hard to find or keep a good job. Do any of the following make it difficult for you to find or keep a job?

SELECT ALL THAT APPLY

1 □ I have a criminal record

2 □ I do not have reliable transportation

3 □ I do not have the right clothes for a job (including uniforms)

4 □ I do not have documentation for legal employment (e.g., birth certificate)

5 □ I do not have good enough child care or family help

6 □ I do not have the right skills or education for good jobs

7 □ I have a physical disability or poor health

8 □ I have substance use or mental health challenges

9  None of the above

[SOFT CHECK: IF JOB CHALLENGES = NONE OF THE ABOVE = DISABLE OTHER OPTIONS]

C. FAMILY STATUS

[SKIP IF CURRENT GRADE = LESS THAN 9TH GRADE, 9TH GRADE, 10TH GRADE, 11TH GRADE, OR 12TH GRADE]

C1a. What is your current marital status?

SELECT ONE ONLY

1  Married

2  Engaged

3  Separated

4  Divorced

5  Widowed

6  Never married/single GO TO C2

[SOFT CHECK: IF MARITAL STATUS = “NO RESPONSE” = This question is very important. Please select an answer.]

[ASK IF MARITAL STATUS = MARRIED, ENGAGED, SEPARATED, DIVORCED, OR WIDOWED

SKIP IF CURRENT GRADE = LESS THAN 9TH GRADE, 9TH GRADE, 10TH GRADE, 11TH GRADE, OR 12TH GRADE]

C1b. How many times have you been married?

| | time(s)

[SOFT CHECK: IF NUMBER OF MARRIAGES > 4 = “Please confirm the number of times you have been married”;

IF NUMBER OF MARRIAGES = “NO RESPONSE” = This question is very important. Please enter the number of times you have been married.”]

[ASK IF MARITAL STATUS = SEPARATED, DIVORCED, WIDOWED, OR NEVER MARRIED

SKIP IF CURRENT GRADE = LESS THAN 9TH GRADE, 9TH GRADE, 10TH GRADE, 11TH GRADE, OR 12TH GRADE]

C2. What is your current partner status?

SELECT ONE ONLY

1  No current partner (unpartnered or single)

2  I am romantically involved or in a committed relationship with someone on a steady basis

3  I am involved in an on-again and off-again relationship

[SKIP IF CURRENT GRADE = LESS THAN 9TH GRADE, 9TH GRADE, 10TH GRADE, 11TH GRADE, OR 12TH GRADE

SKIP IF CURRENT PARTNER = NO CURRENT PARTNER]

C3. How much of the time do you live with your current partner?

SELECT ONE ONLY

1  All of the time

2  Most of the time

3  Some of the time

4  None of the time

[ASK ALL]

C4. Are you currently pregnant, or is anyone currently pregnant with your child?

SELECT ONE ONLY

1  Yes

0  No

[ASK ALL]

C5a. How many biological children do you have who are age 24 or younger? Do not include current pregnancies.

| | | biological children age 24 or younger

[ASK ALL]

C5b. How many adopted children do you have who are age 24 or younger?

| | | adopted children age 24 or younger

[ASK IF BIOLOGICAL CHILDREN > 0]

C5c. How many of your biological children who are age 24 or younger live with you all or most of the time?

| | | biological children age 24 or younger and living with you

[ASK IF ADOPTED CHILDREN > 0]

C5d. How many of your adopted children who are age 24 or younger live with you all or most of the time?

| | | adopted children age 24 or younger and living with you

[SKIP IF AGE <= 18]

C5e. Not counting your biological or adopted children, how many other children who are age 24 or younger live with you all or most of the time?

| | | other children age 24 or younger and living with you

[ASK ALL]

C5f. Are you actively engaged in raising a child or a youth up to age 24 who is the child of a partner or relative, but is not your biological or legally adopted child?

SELECT ONE ONLY

1  Yes

0  No

[ASK IF AGE < 21]

C6. What is your current foster care status?

SELECT ONE ONLY

1  I have never been in foster care

2  I left foster care over six months ago

3  I recently (in the past six months) left foster care

4  I am currently in foster care

5  Not sure

D. ABOUT THE PROGRAM

[ASK ALL]

D1. How or where did you hear about this program?

[DISPLAY “My school offered the program or class” ONLY IF CURRENT GRADE = LESS THAN 9TH GRADE, 9TH GRADE, 10TH GRADE, 11TH GRADE, OR 12TH GRADE]

SELECT ALL THAT APPLY

1 □ My school offered the program or class

2 □ Newspaper ad, billboards, or a flyer

3 □ Radio ad, TV commercial, or news story

4 □ Internet ad or social media such as Facebook, Twitter

5 □ Government agency, such as the Office of Child Support Enforcement, TANF, WIC, child welfare (CPS), parole/probation office, other agency

6 □ Community organization, such as a school, hospital, maternity clinic, doctor’s office, place of worship, Head Start, or Healthy Start center

7 □ Program offered in prison or criminal justice facility

8 □ Program staff in the community or at a community event, such as a street fair

9 □ Word of mouth (friends, family, acquaintances)

10 □ Other

[ASK ALL]

D2. Why did you choose to enroll in this program?

SELECT ALL THAT APPLY

1 □ To learn about being a better parent

2 □ To learn how to improve my personal relationships , such as with my partner or co-parent

3 □ To find a job or a better job

4 □ To meet a school requirement

5 □ My friends were coming

6 □ My spouse/partner asked me to come

7 □ My parole/probation officer told me to enroll in a program like this

8 □ A court ordered me to enroll in a program like this

9  None of the above

[SOFT CHECK: IF ENROLL = NONE OF THE ABOVE = DISABLE OTHER OPTIONS]

[SKIP IF ENROLL = NONE OF THE ABOVE]

D3. What is the primary reason you chose to enroll in this program?

SELECT ONE ONLY

[LIST FILLS WITH OPTIONS SELECTED IN PREVIOUS QUESTION]

1  To learn about being a better parent

2  To learn how to improve my personal relationships , such as with my partner or co-parent

3  To find a job or a better job

4  To meet a school requirement

5  My friends were coming

6  My spouse/partner asked me to come

7  My parole/probation officer told me to enroll in a program like this

8  A court ordered me to enroll in a program like this

Thank you for completing this survey!