Participant Follow up Survey

OMB No.: 1820-xxxx

Expiration Date: xx/xx/20xx

RSA-DIF Follow-up 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

1. CONSENT

ALL

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. [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. 

7. 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.

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.

m Yes 1 GO TO A1

m No 2 GO TO CONSENT END

IF CONSENT = 2

CONSENT END. Thank you for your time.

INTRODUCTION

I1=1

FILL: NAME from pre-load

fill: [state] and [state vr name] from pre-load

You may have received a letter recently to let you know that we would be contacting [NAME] for a survey for the Subminimum Wage to Competitive Integrated Employment (SWTCIE) projects’ national evaluation.

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

ALL

A1. Who is completing this survey?

Mark only one

m I am a parent or guardian completing on behalf of my child 2 GO TO A2c

m I am completing it myself or with help 1 GO TO A2

m Someone else is completing the survey 3 GO TO A2b

F A1

FILL: First Name, MIDDLE NAME and LAST NAME from pre-load

A2. Is this the correct spelling of your name?

[FILL FIRST NAME] [FILL MIDDLE NAME] [FILL LAST NAME]

m Yes 1 GO TO CONSENT

m No, my name is misspelled or has changed 0 GO TO A2a

m No, this is not my name 3 GO TO A2b

HARD CHECK: IF I1 = NO RESPONSE; Please provide an answer to this question and continue.

A2=0

a2a. Please correct the spelling of your name below.

First name

(STRING 20)

Middle name

(STRING 20)

Last name

(STRING 20)

IF A1=3 OR A1=2 OR A2=3

FILL: participant First Name, MIDDLE initial and lAST NAME from pre-load

A2b. Are you completing the survey on behalf of [FILL PARTICIPANT FIRST NAME] [FILL PARTICIPANT MIDDLE NAME] [FILL PARTICIPANT LAST NAME]?

m Yes 1 GO TO A2c

m No 2 GO TO A2d

HARD CHECK: IF I1 = NO RESPONSE; Please provide an answer to this question and continue.

A1 =1 or A2b=1

A2c. Please tell us your name below.

First name

(STRING 20)

Middle name

(STRING 20)

Last name

(STRING 20)

HARD CHECK: IF I1 = NO RESPONSE; Please provide an answer to this question and continue.

A2b=2

A2d. Thank you for your time. We need to check our records before continuing the interview. Please contact us at [toll free number] and ask for [TBD name], to complete the survey.

B. EDUCATIONAL EXPERIENCE

All

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

The next questions are about your school experience.

B1. Are [you/[NAME]] currently attending or enrolled in school?

Please include middle or high school, adult basic education or GED courses, and vocational or trade school?

m YES 1

m NO 2 GO TO B3

NO RESPONSE M

if B1=1

B2. What type of school is this?

Mark only one

m A general high school for students with or without disabilities 1

m A special high school for students with disabilities 2

m A vocational or other post-secondary program 3

m A college 4

m Other (Specify) 5

NO RESPONSE M

ALL

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

B3. 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) 6

NO RESPONSE M

C. EMPLOYMENT

ALL

FILL: if a = 1 “YOU”/“DO YOU”; IF A21= 2,3, “NAME’S”/“Does [NAME]”

The next questions are about [your/NAME’s] current job experience.

C1. [Do you/does [NAME]] currently have a paid job?

m Yes 1

m No 2 GO TO C9

NO RESPONSE M GO TO C9

C1 = 1

FILL: if a = 1 “Do you”/”YOU”; IF A21= 2,3, “Does [NAME]”/”THEY”

C2. 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 [RANGE CHECK: 1-15]

m DON’T KNOW d

NO RESPONSE M

C1 = 1

FILL: if a1 = 1 “Do you/YOU/WORK”; IF A1 = 2,3, “Does [NAME]/[NAME]’S/WORKS”

If C2=1 fill “this job”; if C2>1 fill “their jobs”

C3. How many hours per week [do you/does [NAME]] usually work at this job?

[IF C2>1] PROBE IF NEEDED: How many hours per week [do you/does [NAME]] usually work at your main job?

[IF C2>1] PROBE IF NEEDED: [Your/NAME’S] main job is the job where [you/[NAME] [work/works] 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

C1 = 1

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

If C2=1 fill THIS job, if C2>1 fill YOUR MAIN job

C4. How many weeks per year [do you/does [NAME] usually work at [this job/your main job] including paid vacation and holidays?

[IF B2>1] [Your/NAME’s] main job is the job where [you/[NAME] [work/works] 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

C1 = 1

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

C4a. [Is/Are] the [job/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

C1 = 1

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

C5a. [IF C2 >1 “Let’s talk about the job at which [you/NAME] [work/works] the most hours”]. Which of the following describe [YOUR/NAME’s] job?

Mark only one

m I work at a regular job or business for at least minimum wage 1

m I work at a regular job or business for below minimum wage 2

m I working for piece rate wages below minimum wage 3

m Something else (specify) 4

NO RESPONSE M

C1 = 1

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

C5b. [IF C2 >1 “Let’s talk about the kind of job at which [NAME]/you] [work/works] the most hours”]. Which of the following describes [NAME]’s/your] job?

MARK ALL THAT APPLY

o [I/they] work with a paid job coach 1

o [I/they] work with other people with disabilities working as a team to provide services such as janitorial or lawn care in the community 2

o [I/they] work in a group with disabled persons in a regular business 3

o Something else (specify) 4

NO RESPONSE M

C1 = 1

FILL: if a1 = 2 “you/work/do”; IF A2 = 2,3, “name”/’works/does”

iF C2>1 FILL “Thinking about the job [name]/you works/works the most hours at”

C6. IF C2 >1 [“Thinking about the job [[NAME]/you] [works/work] the most hours at,] what [do/does] [YOU/[NAME] do at (your/[NAME]’s) job?

NO RESPONSE M

C1 = 1

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

C7. About how much [are you/is [NAME]] paid for this job, before taxes or deductions are taken out?

(.01-99999.99) 

m Per hour 1

m Per week 2

m Per two weeks 3

m Per month 4

m Per year 5

m DON’T KNOW d

NO RESPONSE M

C1 = 1

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

FILL: IF C2>1 “Main” else “current”

C8. I am going to read to you a list of benefits that some employers offer their employees. Please tell me whether or not [your/[NAME]’s] [main/current] employer offers [you/[NAME] any of these benefits. 

MARK ALL THAT APPLY

• Health insurance 1 

• Dental benefits 2 

• Sick days with pay 3 

• Don’t know d

NO RESPONSE M

ALL

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

C9. [Do/does] [you/[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.

m Yes 1

m No 0

m Don’t know d

NO RESPONSE M

C1 = 1

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

FILL: if C2 = 1 “job” else “jobs”

If C2=1 fill “current job”

if C2>1 fill “main job”

C10. How happy are [you/[NAME]] with [your/[NAME]’s] current job/main job]?

MARK ONE ONLY

m Very happy 1

m Happy 2

m Not happy 3

NO RESPONSE M

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

C11. How happy [are you/is [NAME]] with the kinds of jobs available to [you/[NAME]]?

MARK ONE ONLY

m Very happy 1

m Happy 2

m Not happy 3

NO RESPONSE M

D. SERVICE RECEIPT

ALL

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

FILL [baseline survey date] from sample file

FILL [STATE VR NAME] FROM SAMPLE FILE

The next questions are about any services [you/NAME] received from [STATE VR NAME]

D1. Since [baseline survey date], [have/has] [you/[NAME]] used or participated in any of the following services?

	D1. SELECT ONE RESPONSE PER ROW		D2. IF YES to D1x ask D2 How would [you/NAME] rate the services [you/name] received?
	YES	NO	EXCELLENT	VERY GOOD	GOOD	FAIR	POOR
a. A job skills training program?	1 m	0 m	1 m	2 m	3 m	4 m	5 m
b. On the job training?	1 m	0 m	1 m	2 m	3 m	4 m	5 m
c. Career counseling?	1 m	0 m	1 m	2 m	3 m	4 m	5 m
d. Help filing out an application, writing a resume, or going for an interview?	1 m	0 m	1 m	2 m	3 m	4 m	5 m
e. Courses to prepare for a high school diploma or a high school equivalency (GED or HiSET)	1 m	0 m	1 m	2 m	3 m	4 m	5 m
f. Vocational training program	1 m	0 m	1 m	2 m	3 m	4 m	5 m
g. College level courses	1 m	0 m	1 m	2 m	3 m	4 m	5 m
h. Getting help or advice from a mentor	1 m	0 m	1 m	2 m	3 m	4 m	5 m

ALL

FILL: if a1 = 1 “you”; IF A1 = 2,3, “THEY”

The next questions are about help [you/they] receive from [PROGRAM NAME].

aLL

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

D3. How would you rate the help [you/[NAME]] [get/gets] from [PROGRAM NAME]?

MARK ONE ONLY

m Excellent 1

m Very good 2

m Good 3

m Fair 4

m Poor 5

m Do not know of [PROGAM NAME] 6 GO TO E1

NO RESPONSE M

NOT D3 = 6

FILL: if a1 = 1 “do”/” YOU”; IF A1 = 2,3, “does”/”NAME””

D4. [Do/Does] [you/[NAME]] have a least one person on the [PROGRAM NAME] staff who really cares about [you/them] and to whom [you/they] can go to talk about personal things?

m Yes 1

m No 2

NO RESPONSE M

NOT D3 = 6

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

D5. In general, how easy or difficult was it for [you/NAME] to get the information [you/[NAME]] wanted about services from [PROGRAM NAME]? Was it…

MARK ONE ONLY

m Very easy 1

m Easy 2

m Neither easy nor difficult 3

m Difficult 4

m Very difficult 5

NO RESPONSE M

E. ABOUT YOU

These last questions are about how [you are/[NAME] is] doing.

ALL

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

E1. Which of the following best describes [your/NAME’s] current living arrangement?

Select one only

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 (specify) 7

NO RESPONSE M

E1 = 7

FILL: if a1 = 2 “YOU/your”; IF A2 = 2,3, “name”/’their”

E1a. 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”

E2. Overall, how would [you/NAME] rate [your/[NAME]’s] health during the past 4 weeks?

Select one only

m Excellent 1

m Very good 2

m Good 3

m Fair 4

m Poor 5

NO RESPONSE M

F. BENEFIT RECEIPT

ALL

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

The next questions are about any services you may have received in the last month.

F1a. Last month, did [you/[NAME]] receive any income from Supplemental Security Income or Supplemental Security Disability Income also known as SSI or SSDI?

Select only one

m Yes 1

m No 0

m Don’t know d

NO RESPONSE M

ALL

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

F1b. Last month, did [you/NAME] receive any income from public assistance or welfare payments?

Please include any payments from the Temporary Assistance for Needy Families or TANF.

Select only one

m Yes 1

m No 0

m Don’t know d

NO RESPONSE M

ALL

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

F1c. Last month, did [you/NAME] receive any income from public assistance payments from your state?

Select only one

m Yes 1

m No 0

m Don’t know d

NO RESPONSE M

All

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

F2. Did [you/[NAME]] receive any food stamps last month?

You may know this as Supplemental Nutrition Assistance Program or SNAP benefits.

Please include only food stamps [you/[NAME]] received for [you/[NAME]] and [your/[NAME]’s] family. Do not include food stamps received separately by other members of [your/[NAME]’s] household.

MARK ONE ONLY

m Yes 1

m No 2

NO RESPONSE M

All

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

F3. Did [you/NAME] receive assistance from any other government program last month? For example, housing or energy assistance?

MARK ONE ONLY

m Yes 1

m No 2

NO RESPONSE M

G. SURVEY EXIT

Thank you for your time, please click “submit” to submit your survey responses.

Prepared by Mathematica 15 Date