Household Roster And Baseline Information Form

OMB No. 2528-0337

Exp. 06/30/2025

PHA Household ID:________

INSTRUMENT 1: HOUSEHOLD ROSTER AND BASELINE INFORMATION FORM

Evaluation of the Community Choice Demonstration

[FOR REVIEWERS

Enrollment is a five-step process. This document includes two of the components: the Household Roster (step 1 below) and Baseline Information Form (step 3 below):

1. Household Roster [Administered by PHA staff; either in-person or remotely (videoconference or phone) and entered into the Enrollment Tool]

2. Informed Consent [Administered by PHA staff; either in-person or remotely (videoconference or phone) and entered into the Enrollment Tool]

   1. Head of Household Consent

   2. Consent for Child Data Collection (signed by Head of Household)

   3. Other Adult consent if other adults are present. If not, Other Adult consent will be obtained after enrollment.

3. Baseline Information Form (BIF) [Administered by PHA staff; either in-person or remotely and entered into the Enrollment Tool]

4. Baseline Survey [Self-administered by Head of Household; either in-person on provided tablet or remotely on own device]

5. Random Assignment, and communication of assignment status [Performed by PHA staff]

The Household Roster and Baseline Information Form are administered by PHA staff as online forms to the heads of all households enrolling in the Demonstration. A small amount of information (the Household Roster) is collected from the head of household prior to the head of household providing consent to participate, and more information (the Baseline Information Form) is collected from the head of household after they provide consent.]

Introduction

The information I am going to ask you about will only be used for the Community Choice Demonstration.

This research is conducted under the authority of the Secretary of the U.S. Department of Housing and Urban Development to undertake programs of research, studies, testing, and demonstration related to the mission and programs of HUD (12 USC 1701z-1 et seq.).

The information you provide may be used to help HUD improve the voucher program. I am going to record your name, date of birth, and Social Security number to confirm that you have not already enrolled in the Community Choice Demonstration. You will be asked some questions about your contact information and the members of your household. Your responses will not affect your current or future receipt of housing assistance or other benefits. The collection of this information has been approved by the Office of Management and Budget under OMB No. 2528-0337, which expires on 06/30/2025. Please remember that your participation is voluntary and you can choose not to answer any question. We appreciate your input.

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to evaluate the US Department of Housing and Urban Development’s Community Choice Demonstration. Public reporting burden for this collection of information is estimated to average 45 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 #: 2528-0337, Exp: 06/30/2025. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Anna P. Guido at [email protected] or 202-402-5535.

[Uppercase letter (“A”, “B”,…) denotes a separate survey item.]HOUSEHOLD ROSTER – BEFORE CONSENT FOR THE STUDY

1. For PHA staff [not asked to the head of household]: PHA Name:

________________

[This element will be pre-filled by the Enrollment MIS, and the PHA user will not be able to edit it.]

2. For PHA staff [not asked to the head of household]: Is the family an existing voucher family or a new admissions voucher family?

1. Existing voucher family

2. New admissions voucher family

3. For PHA staff: Head of household information [If possible, please copy and paste from your records. If not possible, ask for information (except Household ID number) from head of household.]:

1. First Name, Middle Name, Last Name, Suffix

2. Date of Birth (MM/DD/YYYY)

3. Social Security Number

4. [If no SSN] Alien Registration Number

5. [PHA] Household ID Number

Please collect the following information from the head of household before you begin the consent process with the head of household. If desired, PHA staff can use PHA records to fill in the number of children and adults, names, and ages before the enrollment meeting begins, then confirm this information during the enrollment meeting.

Your household includes everyone who lives with you.

4. How many children aged 17 or younger are in your household? [New question]

____________

5. [Loop over # of children provided in Q‎4] For Child #, please tell me their first and last name, and age in years.

1. First name

2. Last name

3. Age in years

4. Are you the parent or guardian of this child? [CMTO]

1. Yes [SKIP TO NEXT CHILD. If this is the LAST CHILD, skip to question 6.]

2. No

1. Does the parent or guardian of this child live in the household with you? [NEW]

1. Yes

2. No [SKIP TO NEXT CHILD. If this is the LAST CHILD, skip to question 6.]

6. What is the name of the parent or guardian? [NEW]

First name

Last name

7. How is this child related to the parent or guardian? [NEW]

1. Birth child

2. Adopted child

3. Grandchild

4. Foster child

5. Birth child of Spouse/Partner

6. Other _____________

7. Prefer not to answer

6. How many people aged 18 and over are there in your household other than yourself? [New question]

____________

7. [Loop over # of adults provided in Q‎6] For Adult # other than yourself, please tell me their first name, last name and age in years.

1. First name

2. Last name

3. Age in years

8. What is the primary (or main) language that your family speaks at home? (Programmer: Customize list for each site.) [CMTO-modified]

1. English

2. Spanish

3. Mandarin

4. Cantonese

5. Tagalog

6. Vietnamese

7. Arabic

8. French or French Creole

9. Korean

10. Russian

11. German

12. Other (specify)­­­___________

13. Prefer not to answer

9. Which language would you prefer for the consent form and baseline survey form? [New question]
   (Select only one answer.)

1. English

2. Spanish

3. Other: _________

10. To make sure we can reach you in the future, we would like to confirm contact information for you. What is your cell phone number?

____________

11. If you have an additional phone number, please tell me that number:

1. No additional number

2. Number ___________________

12. May we send text messages to your cell phone? Message and data rates may apply.

1. Yes

2. No

13. May we leave you voice messages?

1. Yes

2. No

14. What is your email address?

_______________

15. May we send you email messages?

1. Yes

2. No

16. What is the best method for the study to contact you: phone, email, or text?

1. Phone or voice message

2. Email

3. Text message

4. No preference

Baseline Information FoRm (BIF)– AFTER CONSENT

[Note to reviewers: Some of the questions include brackets at the end indicating whether the question was adopted or adapted from other prior surveys. These references will not be included in the questions read by PHAs or answered by families.]

Please collect the following information from the head of household after the head of the household has provided consent:

17. For PHA staff: Head of household’s physical address (If existing voucher family, please copy and paste from your records. If not possible, ask for information from head of household):

1. Street Address, Apt. No

2. City

3. State

4. Zip Code

18. Is this address the best address to mail something to you?

1. Yes (Skip to BIF‎20)

2. No

19. If not, what address should we use if we mail something to you?

1. Street Address, Apt. No.

2. City

3. State

4. Zip Code

We would also like to collect contact information for three people who will always know how to reach you but who live at a different address than you. This information will be used by [PHA] and our research partners if we have a hard time reaching you and would be kept strictly confidential.

20. [Other Contact. PHA staff will confirm from options “Supplement to Application for Federally Assisted Housing” if completed or collect below if not completed.] Could you tell us the name of a person who does not live with you but who will always know how to contact you?

1. First Name, Middle Name, Last Name, Suffix

2. Street Address, Apt. No.

3. City

4. State

5. Zip Code

6. Cell Telephone Number

7. Home Telephone Number

8. Relationship (friend, relative, please specify)

9. Email address

21. Could you tell us the name of a second person who does not live with you but who will always know how to contact you?

1. First Name, Middle Name, Last Name, Suffix

2. Street Address, Apt. No.

3. City

4. State

5. Zip Code

6. Cell Telephone Number

7. Home Telephone Number

8. Relationship (friend, relative, please specify)

9. Email address

22. Could you tell us the name of a third person who does not live with you but who will always know how to contact you?

A. First Name, Middle Name, Last Name, Suffix

B. Street Address, Apt. No.

C. City

D. State

E. Zip Code

F. Cell Telephone Number

G. Home Telephone Number

H. Relationship (friend, relative, please specify)

I. Email address

Now I’d like to ask you a few more questions about the people in your household.

23. A. [Loop over adults named in Household Roster Q‎7] How is [Name of Adult #] related to you? [ACS-modified]

1. Spouse/Partner

2. Child of household head

3. Parent of household head

4. Live-in aide

5. Other _______________

We would like to ask [Name of Adult #] if they will agree to be part of this study. We are asking for the contact information of [Name of Adult #] so we can send them a consent form to sign.

‎23. B. What is the cell phone number of [Name of Adult #]?

____________

‎23. C. What is the email address of [Name of Adult #]?

____________

‎23. D. [IF BIF‎23A NOT EQUAL TO Live-in aide] Is [Name of Adult #] currently working for pay? [CMTO-modified]

1. Yes

2. No

3. Prefer not to answer

‎23. E. [IF BIF‎23D = Yes] What zip code or street and city does [Name of Adult #] currently work in, or does he or she work in multiple neighborhoods? [CMTO-modified]

1. ___________ (5 character zip code)

2. [If zip code not known] Street address and city (or street and city): _______________ (255 characters)

3. Neighborhood or town name: __________________

4. Multiple neighborhoods

5. Don’t Know

Now I would like to ask you a few questions about your children, their schools, and their health.

24. A. [Loop over children named in Household Roster ‎Q7] How is [Name of Child #] related to you? [ACS-modified; MTO response categories]

1. Birth child

2. Adopted child

3. Grandchild

4. Foster child

5. Birth child of Spouse/Partner

6. Other _____________

7. Prefer not to answer

‎24. B. What grade is [Name of Child #] in? [CMTO]

1. ____ grade

2. Pre-School (a place intended for children between 2 and 4 years of age)

3. Pre-K (a place intended for children between 4 and 5 years of age)

4. Kindergarten

5. Post-secondary school

6. Not in school (Skip to BIF‎24L)

7. Other (specify) ________________

8. Prefer not to answer

‎24. C. [If child’s age is less than 7] What types of childcare do you use for [Name of Child #]? (Check all that apply) [CMTO-modified]

1. I do not use outside childcare

2. Head start daycare center or school kindergarten

3. Babysitter or childcare provider who is a relative

4. Babysitter who is not a relative

5. Private day care from a center

6. Other (specify) ________________________

7. Prefer not to answer

‎24.D. Which school (or Pre-K/Pre-school program) is [Name of Child #] currently attending? [CMTO]

1. Name [Select from pre-populated list if possible]:___________________________________

2. Name (type in if not in list) _____________________

3. Prefer not to answer

‎24. E. How satisfied or dissatisfied are you with the school (or Pre-K/Pre-school program) that [Name of Child #] attends this year? [PFI-NHES-modified]

(1) Very satisfied

(2) Somewhat satisfied

(3) Somewhat dissatisfied

(4) Very dissatisfied

(5) Prefer not to answer

‎24. F. Does [Name of Child #] go to a special class for gifted students or do advanced work in any subjects? [MTO]

1. Yes

2. No

3. Prefer not to answer

‎24. G. Was [Name of Child #] enrolled in special education in the past year or does he or she have an IEP or 504 plan? [CMTO]

1. Yes

2. No

3. Prefer not to answer

‎24. H. During the past two years, has anyone from this [Name of Child #]'s school contacted you to talk about problems he or she was having with schoolwork or behavior? [MTO-modified]

1. Yes

2. No

3. Prefer not to answer

‎24. Ia. Other than typical grade promotion, are you currently considering transferring him or her to a different school (or Pre-K/Pre-school program)? [CMTO]

1. Yes

2. No

3. Not sure

4. Prefer not to answer

24. Ib. [If BIF‎24Ia = yes] What is the reason why you are considering transferring him or her to a different school (or Pre-K/Pre-school program)?

1. _____________

2. Prefer not to answer

‎24. J. Does [Name of Child #] have a disability or chronic physical or mental health condition (such as asthma, diabetes, or ADHD)? [New question]

1. Yes

2. No

3. Prefer not to answer

‎24. K. [If BIF‎24J = yes] What is/are the condition(s)? CHECK ALL THAT APPLY [New question]

1. Asthma

2. Diabetes

3. ADHD

4. Other ____________________________

5. Prefer not to answer

‎24. L. [If BIF‎24K.(3) Asthma is checked] During the past 12 months, has [Name of Child #] visited an emergency room or urgent care center because of his or her asthma? [NHIS]

1. Yes

2. No

3. Prefer not to answer

‎24. M. [If Child # age is 5 years or older] How often does [Name of Child #] seem very anxious, nervous or worried? Would you say… [WG/UNICEF CFM]

1. Daily

2. Weekly

3. Monthly

4. A few times a year

5. Never

6. Prefer not to answer

‎24. N. [If Child # age is 5 years or older] How often does [Name of Child #] seem very sad or depressed? Would you say… [WG/UNICEF CFM]

1. Daily

2. Weekly

3. Monthly

4. A few times a year

5. Never

6. Prefer not to answer

‎24. O. How tall is [Name of Child #] without shoes? [NHIS-modified]

Feet ____________

Inches _____________

Don’t know

Prefer not to answer

‎24. P. How much does [Name of Child #] weigh now? [NHIS-modified]

1. _________pounds

2. Don’t know

3. Prefer not to answer

Sources for Questions (Referenced in Item-by-Item Justification)

Acronym	Full Source Name
ACS	American Community Survey
CMTO	Baseline survey from the Creating Moves To Opportunity Demonstration
CPSFSS	Current Population Survey Food Security Supplement
GSS	General Social Survey
FTHB	Baseline survey from the HUD First-Time Homebuyer Education and Counseling Demonstration
HFSSM:Six-Item	U.S. Household Food Security Survey Module: Six-Item Short Form, Economic Research Service, USDA (September 2012)
HPQ	World Health Organization Health and Work Performance Questionnaire
K6	Kessler-6 items for psychological distress (Kessler et al., 2003)
MTO	Baseline survey from HUD’s Moving to Opportunity for Fair Housing Demonstration
MCSUI	Multi-City Study of Urban Inequality
NHIS	National Health Interview Survey
PFI-NHES	2019 Parent and Family Involvement in Education Survey – National Household Education Surveys Program
Rent Reform (baseline)	Baseline information form from HUD’s Rent Reform Demonstration
WG/UNICEF CFM	Washington Group/UNICEF Child Functioning Module
WTWV	Baseline survey of HUD’s Effects of Housing Vouchers on Welfare Families Evaluation (Mills et al., 2006; also known as the Welfare-to-Work Voucher Evaluation)