Rent Reporting Baseline Information Form

OMB #: XXXX-XXXX

OMB Expiration Date: MM/DD/YYY

Rent Reporting Baseline Information Form

BASELINE INFORMATION FORM

Thank you for your interest in the Rent Reporting Study. The information I am going to ask you about will only be used for the Rent Reporting Study.

First, I am going to record your name, date of birth, and Social Security number to confirm that you have not already enrolled in the Rent Reporting Study. After that we will review a form that describes the Rent Reporting Study and what the study requirements are for those who agree to participate. You should know that your participation in this study is voluntary. If you agree to participate in the study I will ask you to sign the consent form. I will then ask you some additional questions about your financial conditions. Your responses will not affect your current or future receipt of housing assistance or other benefits. Please remember that your participation is voluntary and you can choose not to answer any question. We appreciate your input.

PHA staff will enter the following items into the enrollment record:

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

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

C. Social Security Number

D. [If no SSN] Alien Registration Number

E. [PHA] Household ID Number

*PHA STAFF WILL PAUSE HERE AND PROCEED TO OBTAIN INFORMED CONSENT, ONCE OBTIAINED CONTINUE WITH BASELINE INFORMATION FORM*

Thank you for agreeing to be part of this important study. Next, we will ask you some questions about your financial conditions, which will provide important context for interpreting the findings from the study. You may reply that you “don’t know” or decline to answer any question.

Q1: Overall, how satisfied are you with your current personal financial situation? Please use a 10-point scale, where 1 means “Not at All Satisfied” and 10 means “Extremely Satisfied.”

1 Not at all satisfied

2

3

4

5

6

7

8

9

10 Extremely satisfied

98 Don’t know

99 Prefer not to say

Q2: How would you rate your current credit record?

1 Very bad

2 Bad

3 About average

4 Good

5 Very good

98 Don’t know

99 Prefer not to say

Q3: How important is it to you to improve your credit score over the next 12 months?

1 Very

2 Somewhat

3 Neutral

4 Not much

5 Not at all

98 Don’t know

99 Prefer not to say

Q4: What is the most important reason that a higher credit score would help you? (Choose one)

1 I could move to a better place to live

2 I could buy a car

3 I could get a credit card

4 I could start a business

5 I could get a new job

6 Other ________ (open text)

98 Don’t know

99 Prefer not to say

Q5: In a typical month, how difficult is it for you to cover your expenses and pay all your bills?

1 Very difficult

2 Somewhat difficult

3 Not at all difficult

98 Don’t know

99 Prefer not to say

Q6: In the last 12 months, which one of the following best describes your household’s income?

1 Roughly the same amount each month

2 Occasionally varies from month to month

3 Varies quite often from month to month

98 Don’t know

99 Prefer not to say

Q7: How confident are you that you could come up with $400 if an unexpected need arose within the next month?"

1 Not at all confident

2 Not very confident

3 Somewhat confident

4 Very confident

98 Don’t know

99 Prefer not to say

Q8: During the last 3 months, was there a time when you were worried you would not

have enough food to eat because of a lack of money or other resources?

1 Yes

2 No

98 Don’t know

99 Prefer not to say

Q9: Do you have a personal checking or savings account at a bank or credit union?

1 Yes

2 No

98 Don’t know

99 Prefer not to say

Q10: If you were to set a financial goal for yourself today, how confident are you in your ability to achieve it?"

1 Not at all confident

2 Not very confident

3 Somewhat confident

4 Very confident

98 Don’t know

99 Prefer not to say

Q11: HUD may choose to do additional data collection in the future as part of this study. If that were to happen, researchers might ask you to participate in future surveys or interviews. Your participation in any future research activities is voluntary. Either the Evaluator or other HUD-approved researchers could conduct these surveys or interviews in the future. What is the best method to contact you (phone call, text, email)?

IF EMAIL: What is your email address? ________________

IF PHONE OR TEXT: What is your phone number? ________________

Thank you for your time today. We appreciate your participation in this important study.

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 Moving to Work Asset Building Cohort’s Rent Reporting Program and Study. 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 #: XXX-XXXX, Exp: XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to XX at XXXX@XXX or call at XXX-XXX-XXXX.

Privacy Act Statement  

Authority: Section 502 of the Housing and Urban Development Act of 1970 (Public Law 91-609) (12 U.S.C. §§ 1701z-1; 1701z-2(d) and (g)).  

Purpose:  This information is being collected to evaluate the Moving to Work asset building programs.

Routine Use:  HUD intends to release this information for research purposes or to respond to breaches.  For further information, please refer to the System of Records Notice.  

Disclosure:  Your participation in this information collection is voluntary and you can choose not to answer any question that is asked. Your responses will not affect your current or future receipt of housing assistance or other benefits.  

SORN ID:  [Include SORN Name and ID here]