Baseline Survey

OMB No.: 1820-xxxx

Expiration Date: xx/xx/20xx

RSA-DIF Baseline Survey

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1820-xxxx. Public reporting burden for this collection of information is estimated to average 0.16 hour per response, including time for reviewing instructions, and completing and reviewing the collection of information. The obligation to respond to this collection is voluntary. If you have any comments concerning the accuracy of the time estimate, suggestions for improving this individual collection, or if you have comments or concerns regarding the status of your individual form, application, or survey, please contact Diandrea Bailey, Office of Special Education and Rehabilitative Services, Rehabilitation Services Administration, 400 Maryland Avenue Washington, DC 20202 directly.

10/3/2024

I. CONSENT

ALL

OVER18. First, are you 18 years of age or older?

MARK ONLY ONE

m Yes 1

m No, I am under 18 years of age 2

All

FILL: if OVER18 = 1 “By checking this box, you agree that you have read and understood the information above and that you agree to take part in this study”.

IF OVER18 = 2, “By checking this box, you agree that you have read and understood the information above and that you agree to take part in this study on behalf of your child”

I1. I understand that:

1. U.S. Department of Education’s Rehabilitation Services Administration is funding projects in 14 states.

2. The goal of these projects is to increase employment for people with disabilities.

3. If you choose to, you will be a part of a research study about [vocational rehabilitation agency name]’s project. If you choose not to be in the study, you can still receive services from the agency.

4. Mathematica and their partners M. Davis and Company are conducting this research study.

5. There will be no cost to you to be in the study.

6. You will be asked questions in a survey at two times. The first time will be now as you enroll in the project. The second time will be in the fall of 2026.You may also be asked to participate in an interview sometime in the next few years.

7. [If the participant is completing the consent] I give permission for my parent, caregiver or guardian to talk about my experience in the SWTCIE project, in a short interview or focus group. 

8. I do not have to take part if I do not want to. I do not need to answer any questions if I do not want to. I can choose to no longer be in this study at any time.

The personally identifiable information (PII) requested on this form is collected as authorized by Consolidated Appropriations Act, 2022, P.L. 117-103 Rehabilitation Services, March 15, 2022. The researchers conducting this study follow the confidentiality and data protection requirements, as required by law. Your responses will be kept private and used only for research purposes. Your responses will be combined with the responses of other respondents and no individual names will be reported. While there are no direct benefits to participants and participation is voluntary, your participation will help us learn how states can help increase employment for people with disabilities. While your information will not be disclosed outside of the Department, there may be circumstances where information may be shared with a third party, such as a Freedom of Information Act request, court orders or subpoena, or if a breach or security incident would occur affecting the system, etc.

If you have any questions, please contact Mathematica staff at [email protected]. If you have any questions or concerns about your rights as a study participant, please contact the Health Media Labs Institutional Review Board at (202) 753-5040.

I2. By checking this box, you agree that you have read and understood the information above and that you [agree to take part in this study/agree to take part in this study on behalf of your child].

m YES 1 GO TO A1

m NO 0 GO TO

CONSENT_END

IF i2=0

CONSENT_END. Thank you for your time.

A. INTRODUCTION

i2=1

A1. This survey is for people using services from vocational rehabilitation agencies. In [STATE] that agency is known as [STATE VR NAME].

Who is completing this survey?

MARK ONE ONLY

m I am a parent or guardian completing on behalf of my child 2 GO TO A3

m I am completing it myself or with help 1

m Someone else is completing the survey 3 GO TO A3

If A1=1

A2. Please record your name below.

(STRING 30)

[FIRST NAME]

(STRING 30)

[MIDDLE INITIAL]

(STRING 30)

[LAST NAME]

if a1 = 2 or 3

A3. Please record the name of the person you are completing the survey for below.

(STRING 30)

[PARTICIPANT FIRST NAME]

(STRING 30)

[PARTICIPANT MIDDLE INITIAL]

(STRING 30)

[PARTICIPANT LAST NAME]

B. EMPLOYMENT

The first questions are about [your/NAME’s] current work-related activities.

ALL

FILL: if a1 = 1 “Do you”; IF A1 = 2,3, “Does [NAME]”

B1. [Do you/does NAME] currently have a paid job?

m Yes 1

m No 0 GO TO B7

NO RESPONSE M GO TO B7

B1 = 1

FILL: if a1 = 1 “Do you”; IF A1 = 2,3, “Does [NAME]”

B2. How many jobs [do you/does NAME] currently have?

Include both part-time and full-time jobs, but only include jobs [you/they] hold for pay.

NUMBER OF JOBS

(STRING 1-15)

m DON’T KNOW d

NO RESPONSE M

B1 = 1

FILL: if a1 = 1 “Do you”; IF A1 = 2,3, “Does [NAME]”

B3. How many hours per week [do you/does NAME] usually work at this job?

[IF B2>1] PROBE IF NEEDED: How many hours per week [do you/does NAME] usually work at your main job?

[IF B2>1] PROBE IF NEEDED: [Your/NAME’S] main job is the job where [you/they] work the most hours.

Include overtime if [you/they] usually work overtime.

Hours per week

[RANGE CHECK: 1-60]

m DON’T KNOW d

NO RESPONSE M

B1 = 1

FILL: if a1 = 1 “you”; IF A1 = 2,3, “[NAME]/they”

If b2=1 fill THIS job, if b2>1 fill MAIN JOB

B4. How many weeks per year [do you/does NAME] usually work at [this job/your main job/their main job] including paid vacation and holidays?

[IF B2>1] [Your/NAME’s] main job is the job where [you/they] work the most hours.

There are 52 weeks in a year.

If [you/they] have worked less than a year, please answer for the number of weeks [you/they] expect to work.

WEEKS PER YEAR

(STRING 1-52)

m DON’T KNOW d

NO RESPONSE M

B4a. [Is the job/Are the jobs] [you/[NAME]] [have/has] year-round or do [you/they] work only part of the year?

m Year round 1

m Part of the year 2

m DON’T KNOW d

NO RESPONSE M

B1 = 1

FILL: if a1 = 1 “Are you”; IF A1 = 2,3, “[ is [NAME]]”

B2=1 Fill “This Job”

B2>1 Fill “your main job”

B5. About how much [are you/is [NAME]] paid for [this job/your/[NAME’S] main job], before taxes or deductions are taken out?

Your best guess is fine.

(.01-99999.99) 

m Per hour 1

m Per week 2

m Per two week 3

m Per month 4

m Per year 5

m DON’T KNOW d

NO RESPONSE M

b1 = 1

FILL: if a1 = 1 “you”/”your”; IF A1 = 2,3, “NAME”/”THEIR”

If B2=1 fill “current job”

if B2>1 fill “main job”

B6. How happy [are/is] [you/NAME] with [your/their] [current job/main job]?

MARK ONE ONLY

m Very happy 1

m Happy 2

m Not happy 3

NO RESPONSE M

ALL

FILL: if a1 = 1 “Do you”; IF A1 = 2,3, “Does [NAME]”

B7. [Do you/does NAME] currently attend a day program or workshop at least once a week?

PROBE: These are also known as activities or services that can help build [your/their] skills, including socialization and daily living skills to foster greater independence.

This may also be known as day habilitation.

MARK ONE ONLY

m Yes 1

m No 0

m Don’t know d

m Choose not to answer r

NO RESPONSE M

ALL

FILL: if a1 = 1 “are you”/”you”; IF A1 = 2,3, “is [NAME]”/”THEM”

B8. How happy [are you/is NAME] with the kinds of jobs available to [you/them]?

MARK ONE ONLY

m Very happy 1

m Happy 2

m Not happy 3

NO RESPONSE M

C. DEMOGRAPHIC INFORMATION

I have a few more questions about [you/NAME].

ALL

FILL: if a1 = 1 “your”; IF A1 = 2,3, “ [NAME]’s”

C1. Which of the following best describes [your/NAME’s] current living arrangement?

MARK ONLY ONE

m Live alone 1

m Live with parents or guardians 2

m Live with spouse or partner 3

m Live with other relatives 4

m Live with roommates or unrelated others 5

m Live in a group home with others with disabilities 6

m Other 99

NO RESPONSE M

C1 =99

FILL: if a1 = 1 “YOU”/”your”; IF A1 = 2,3, “name”/’their”

C1a. How would [you/NAME] describe [your/their] current living arrangements?

(STRING 100)

NO RESPONSE M

ALL

FILL: if a1 = 1 “you”/”your”; IF A1 = 2,3, “[NAME]”/”their”

C2. Overall, how would [you/NAME] rate [your/their] health during the past 4 weeks?

MARK ONLY ONE

m Excellent 1

m Very good 2

m Good 3

m Fair 4

m Poor 5

NO RESPONSE M

ALL

FILL: if a1 = 1 “you”; IF A1 = 2,3, “ [NAME]”

C3. What is the highest year or grade [you/NAME] finished in school?

MARK ONLY ONE

m 8th grade or less 1

m Some high school (9th-12th) and no high school diploma 2

m High school diploma, completion certificate, or high school equivalency (GED) 3

m Some college or some of a post-secondary technical or vocational program (did not receive a degree or certificate) 4

m College or post-secondary technical or vocational program (received a degree or certificate) 5

m Other (specify) 99

Specify (STRING (NUM))

NO RESPONSE M

ALL

FILL: if a1 = 1 “are you”; IF A1 = 2,3, “is [NAME]”

C4. [[Are you]/[Is [NAME]] Hispanic or Latino?

MARK ONLY ONE

m Yes, Hispanic or Latino 1

m No, not Hispanic or Latino 2

NO RESPONSE M

ALL

FILL: if a1 = 1 “your”; IF A1 = 2,3, “ [NAME]’s”

C5. What is [your/NAME’s] race?

MARK ALL THAT APPLY

o Alaska Native or American Indian 1

o Asian 2

o Black or African American 3

o Native Hawaiian or Other Pacific Islander 4

o White 5

NO RESPONSE M

D. CONTACT INFORMATION

The last questions are about how to contact [you/NAME] in the future for the follow-up survey. We may also contact [you/NAME] to participate in an interview. Please include contact information for the person who would be best to complete a survey or interview about [your/NAME]’s experiences.

ALL

FILL: if a1 = 1 “your”; IF A1 = 2,3, “ [NAME]’s”

D1. Please provide [your/NAME’s] contact information

First Name: (STRING 50)

Middle Initial:

Last Name: (STRING 50)

Street Address 1: (STRING 50)

Street Address 2: (STRING 10)

City: STRING 50)

State: (STRING 4)

Zip: (STRING 10)

Email address: (STRING 10)

HOME TELEPHONE NUMBER

WORK TELEPHONE NUMBER

CELL NUMBER

if icell number is providedFILL: if a1 = 1 “you”; IF A1 = 2,3, “[name]”

D1a. Would it be ok for us to send [you/“NAME”] a text message when we try to contact [you/“NAME”] for the next survey?

m Yes 1

m No 0

NO RESPONSE M

ALL

FILL: if a1 = 1 “you”; IF A1 = 2,3, “[name]”

D1b. Would it be ok for us to contact [you/[NAME]] about taking part in an interview sometime in the next few years?

This would be in addition to us contacting you about the follow-up survey.

m Yes 1

m No 0

NO RESPONSE M

ALL

FILL: if a1 = 1 “you”; IF A1 = 2,3, “ [NAME]”

D2. Please provide contact information for one other person who will be able to help us get in touch with [you/NAME] in the future.

We will only contact this person if we are not able to reach [you/NAME] to complete a survey. If we contact this person, we will not share any information about [you/NAME] or the study. We will only say we need to locate [you/Name] to complete a survey.

First Name: (STRING 50)

Last Name: (STRING 50)

Street Address 1: (STRING 50)

Street Address 2: (STRING 10)

City: STRING 50)

State: (STRING 4)

Zip: (STRING 10)

Email address: (STRING 10)

HOME TELEPHONE NUMBER

WORK TELEPHONE NUMBER

CELL NUMBER

NO RESPONSE M

Please click “submit” to submit your survey responses.