Pathway
Home Evaluation
Quasi-experimental
design (QED) Baseline Information Form of Study Participants
November 2022
The
OMB control number for this collection is 1290-0039 and expires on
8/31/2025.
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 1290-0039.
This page has been left blank for double-sided copying.
Today’s Date: | | |/| | |/| | | | |
|
B. EDUCATION AND EMPLOYMENT HISTORY
OMB No: 1290-0039
Expiration Date: 8/31/2025
□ Check if currently incarcerated
Baseline
Information Form
ELIGIBILITY
AND ENROLLMENT INFORMATION
FACILITY NAME:
________________________________________________
CASEWORKER NAME (or name of individual enrolling
participant):
_________________________________________________
Consent. CONFIRM PARTICIPANT SIGNED CONSENT FORM
1 □ Yes, signed
2
□
No STOP. HAVE PARTICIPANT SIGN CONSENT
FORM BEFORE PROCEEDING
PartType. IS THE STUDY PARTICIPANT BEING ENROLLED INTO PATHWAY HOME OR THE COMPARISON GROUP?
1
□ Program
Group GO TO RelDate
0 □
Comparison
Group
DQCond. WHY IS THIS INDIVIDUAL NOT ELIGIBLE FOR THE
PATHWAY HOME PROGRAM?
1 □ Participant is being released to a county
not served by program
2 □ Participant is not expected to be released
between 20 and 180 days from now
3
□
Not
sentenced yet GO TO RelCounty
RelDate. WHAT IS THE EXPECTED RELEASE DATE FOR THIS
STUDY PARTICIPANT? THIS SHOULD BE THE SAME
DATE YOU USED TO DETERMINE WHETHER
THE PERSON WAS ELIGIBLE FOR THE PATHWAY
HOME GRANT PROGRAM.
| | | / | | | / | | | | |
month day year
RelCounty. WHAT COUNTY IS THE STUDY PARTICIPANT BEING
RELEASED INTO?
A. PARTICIPANT INFORMATION
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
A5. What county do you expect to return to when you are released?
B.
EDUCATION AND EMPLOYMENT HISTORY
The following questions will be used to help the study team understand the education and employment of study participants prior to incarceration.
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
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
n
□
No
work experience/Have never worked
SKIP
TO C1
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
3 □ No, but looking for work
4 □ No, and not looking for work
B6a. The next questions are about the last job you had before your current/most recent incarceration.
How many hours per week were you working at the last job you had just before your current/most recent incarceration?
(If you were working two jobs at the same time, 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 last job you had before your (current/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 before incarceration)? What does the company make, sell, or do?
B6d. What was your job title (at the last job you had 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 the study and will not be used for anything other than research purposes. To help the study team understand if and how services are helping individuals, they need to understand what life was like for people before their (current/most recent) incarceration.
C1. How old were you the first time that you were arrested? If you are not sure, use your best guess.
| | | AGE AT FIRST ARREST
C1a. 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
C2. Approximately how many times have you been convicted?
| | | NUMBER OF CONVICTONS IF 0 SKIP TO C5a
C3. Have you ever been convicted of a felony?
1 □ Yes
0 □ No
C4. [If cohort NE 2] Have you ever been convicted of any of the following:
Theft, burglary, robbery, or larceny 1 □ Yes 0 □ No
Assault, battery, or other violent offenses 1 □ Yes 0 □ No
Drug or alcohol offenses (such as 1 □ Yes 0 □ No
DUI/DWI, possession, distribution)
Disorderly conduct, loitering, 1 □ Yes 0 □ No
disturbing the peace
Financial crimes such as fraud, 1 □ Yes 0 □ No
embezzlement, or forgery
Something else:________________ 1 □ Yes 0 □ No
C5a. Not including your (current/most recent) period of incarceration, how many times have you been incarcerated in an adult correctional facility?
0 □ Never
1 □ Once
2 □ Two times
3 □ Three to five times
4 □ Six to nine times
5 □ Ten or more times
C5b. IF Cohort NE 2 and 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 was the reason for your (current/most recent) 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/most recent) 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/was) the maximum length of your (current/most recent) 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
[Skip C10 and C11 if cohort = 2]
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
5 □ More than 5 years
D. REENTRY SERVICES
The next question asks about what services you would be interested in receiving.
[Skip D1 if cohort = 2]
D1. Are you required to participate in [PROGRAM NAME]?
1 □ Yes
D2. Which of the following services would you be interested in receiving if they were available to you?
SELECT 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 study participants. They will only be used for statistical purposes.
E1. What is your gender?
Select 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?
select 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?
select one only
1 □ English
2 □ Spanish
3 □ Other (specify)
E5. How would you best describe your marital status?
select 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 your (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.
[Skip F1a and F1b if cohort = 2]
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 [most recent] 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
F2b. How would you best describe your [living situation/ 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 your address/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
H4. Thank you for enrolling in the study.
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?
select 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.
The
study team 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!
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Reentry Employment Opportunities OMB Statements |
Subject | OMB |
Author | MATHEMATICA |
File Modified | 0000-00-00 |
File Created | 2023-08-01 |