Attachment A.3 Baseline Survey

YTED Baseline Survey

Privacy Act Statement
Collection and Use of Personal Information

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. The OMB control number for this information collection is XXXX-0XXX, expiring xx-xxx-20xx. We estimate that it will take about xx minutes to read the instructions, gather the facts, and answer the questions. You may send comments about our time estimate above to: Social Security Administration, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

Sections 205 and 1110 of the Social Security Act, as amended, allow the Social Security Administration (SSA) to collect this information, which SSA will use to evaluate the Youth Transition Exploration Demonstration research study. Providing this information is voluntary; not providing all or part of the information will not affect any SSA benefit. As law permits, SSA may use and share the information you submit, including with other Federal agencies, contractors, cooperative agreement awardees, and others, as outlined in the routine uses within System of Records Notices (SORN) 60-0089, 60-0218, and 60-0320 available at www.ssa.gov/privacy.The information you submit may also be used in computer matching programs to establish or verify eligibility for Federal benefit programs and to recoup debts under these programs.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 15 minutes to read the instructions and answer the questions. You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address.

The Youth Transition Exploration (YTE) intervention helps youth with disabilities move successfully into the adult labor force. The YTE Demonstration (YTED) will provide evidence on the impact of the YTE intervention on youth: (1) employment and earnings, (2) Supplemental Security Income (SSI) and Social Security Disbaility Insurance (SSDI) benefit receipt, and (3) satisfaction and well-being.

The Pennsylvania Office of Vocational Rehabilitation; University of Maryland’s Center for Transition and Career Innovation; and Mathematica, a research company, are working together on this project. As part of this study, we will interview youth who wish to enroll in YTE services.

Thank you for agreeing to take part in this survey. Participation is voluntary but very important. The survey takes about 15 minutes to complete. Your responses will be kept private and used only for research purposes. You may skip any question you do not want to answer. Your responses will be combined and reported with other responses in total; no individual names or responses will be reported.

If you have any questions about the survey, please contact Mathematica at 1-8XX-XXX-XXXX (this is a toll-free call).

1. Education

The first questions are about your education.

A1. Are you currently attending or enrolled in school?

Please include middle or high school, adult basic education or GED courses, vocational or trade school, or college.

MARK ONE ONLY

1  Yes

0  No

A2. What type of school are you currently attending?

MARK ONE ONLY

1  Middle school

2  High school

3  Adult basic education or GED program

4  Trade, technical, or vocational school

5  College or graduate school

6  Another type of school (Please specify: ___________________________________________)

A3. What is the highest degree or level of school you have completed?

MARK ONE ONLY

1  Less than high school

2  Some high school, no diploma

3  High school graduate, diploma or the equivalent (for example, GED or certificate of completion)

4  Some college credit, no degree

5  Associate degree (2-year college)

6  Bachelor’s degree (4-year college) or higher

7  Another type of degree or schooling (Please specify: __________________________________)

2. Employment

The next questions are about your employment.

B1. Have you ever worked for pay?

MARK ONE ONLY

1  Yes

0  No SKIP TO QUESTION B7

B2. Are you currently working for pay?

MARK ONE ONLY

1  Yes SKIP TO QUESTION B4

0  No

B3. In what month and year did you last work for pay?

| | | month | | | | | year

B4. About how much [are/were] you paid at this job, before taxes and deductions? Your best estimate is fine.

• If your pay [varies/varied], please provide an average amount.

• If you [are/were] paid per job or for completing a particular task, please tell [us/me] the total amount you usually [make/made] per week or per month while doing this type of work.

• If you worked at more than one job, answer about the job where you worked the most hours.

$ | | | | , | | | | . | | |

MARK ONE ONLY

1  Per hour

2  Per day

3  Per week

4  Once every two weeks

5  Twice a month

6  Per month

7  Per year

8  Other (Please specify: __________________________________________________________)

B5. About how many hours per week, including regular overtime hours [do/did] you usually work on [this/that] job? Your best estimate is fine.

If your hours (vary/varied), please provide an average number.

| | | | hours per week

B6. How satisfied [are/were] you with this job?

MARK ONE ONLY

1  Very satisfied

GO TO SECTION C

2  Somewhat satisfied

3  Somewhat dissatisfied

4  Very dissatisfied

B7. In the past 12 months, have you been looking for work?

MARK ONE ONLY

1  Yes

0  No

3. Health Status and Well-Being

The next questions are about your health.

C1. Have you ever been identified as having any of the following?

MARK ONE OR MORE BOXES

1  Attention Deficit Disorder (ADD or ADHD)

2  Autism spectrum disorders (Autistic Disorder, Asperger’s Syndrome, Rett’s Disorder, Pervasive Developmental Disorder, Pervasive Developmental Disorder Not Otherwise Specified)

3  Emotional or behavioral disorder or serious emotional disturbance

4  Hard of hearing or hearing impairment, even with a hearing aid device

5  Specific learning disability

6  Intellectual or developmental disability

7  Speech impairment/communication impairment

8  Physical or orthopedic impairment

9  Visual impairment, partial sight, or blindness, even with glasses or correction

10  Other (Please specify: __________________________________________________________)

11  Never had a major health condition or disability

C2. In general, how would you rate your health?

MARK ONE ONLY

1  Excellent

2  Very good

3  Good

4  Fair

5  Poor

C3. How much does your health now limit you in moderate activities such as moving a table, pushing a vacuum cleaner, or playing a sport?

MARK ONE ONLY

1  A lot

2  A little

3  Not at all

C4. How much does your health now limit you in climbing several flights of stairs?

MARK ONE ONLY

1  A lot

2  A little

3  Not at all

C5. During the past 4 weeks, how much of the time have you accomplished less than you would have liked to as a result of your physical health?

MARK ONE ONLY

1  All of the time

2  Most of the time

3  Some of the time

4  A little of the time

5  None of the time

C6. During the past 4 weeks, how much of the time were you limited in the kind of work or other regular daily activities you do as a result of your physical health?

MARK ONE ONLY

1  All of the time

2  Most of the time

3  Some of the time

4  A little of the time

5  None of the time

C7. During the past 4 weeks, how much of the time have you accomplished less than you would have liked to as a result of any emotional problems, such as feeling depressed or anxious?

MARK ONE ONLY

1  All of the time

2  Most of the time

3  Some of the time

4  A little of the time

5  None of the time

C8. During the past 4 weeks, how much of the time did you not do work or other activities as carefully as usual as a result of any emotional problems, such as feeling depressed or anxious?

MARK ONE ONLY

1  All of the time

2  Most of the time

3  Some of the time

4  A little of the time

5  None of the time

C9. During the past 4 weeks, how much did pain interfere with your normal work, including both work outside the home and housework?

MARK ONE ONLY

1  All of the time

2  Most of the time

3  Some of the time

4  A little of the time

5  None of the time

C10. These next questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please provide an answer that comes closest to the way you have been feeling.

During the past 4 weeks, how much of the time have you felt calm and peaceful?

MARK ONE ONLY

1  All of the time

2  Most of the time

3  Some of the time

4  A little of the time

5  None of the time

C11. How much of the time during the past 4 weeks did you have a lot of energy?

MARK ONE ONLY

1  All of the time

2  Most of the time

3  Some of the time

4  A little of the time

5  None of the time

C12. How much of the time during the past 4 weeks have you felt downhearted and depressed?

MARK ONE ONLY

1  All of the time

2  Most of the time

3  Some of the time

4  A little of the time

5  None of the time

C13. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?

MARK ONE ONLY

1  All of the time

2  Most of the time

3  Some of the time

4  A little of the time

5  None of the time

C14. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

MARK ONE ONLY

1  Yes

0  No

4. Career and Education Expectations

The next questions are about your career and educational goals.

D1. How far do you think you will get in school?

MARK ONE ONLY

1  Less than high school (will not graduate or get a GED)

2  High school diploma

3  GED

4  Technical or trade school

5  Associate degree (2-year college)

6  Bachelor’s degree (4-year college) or higher

D2. Do your personal goals include getting a job, moving up in a job, or learning a new skill?

MARK ONE ONLY

1  Yes

0  No

D3. Within 10 years, how likely do you think it is that you will be working at a job for pay or profit? By ‘working at a job for pay or profit’ we mean at a job where you get paid money for the work you do.

MARK ONE ONLY

1  Very likely

2  Somewhat likely

3  Not very likely

4  Not at all likely

D4. Within 10 years, how likely do you think it is that you will earn enough to support yourself without financial help from your family?

MARK ONE ONLY

1  Very likely

2  Somewhat likely

3  Not very likely

4  Not at all likely

5. Demographics

The next questions are about you and your background. This information will be used to ensure information is collected accurately from state and federal databases for our research. All of this information will be kept private.

E1. What is your full legal name?

First name

Last name

Preferred first name if different from legal name

E2. What is your date of birth?

Birthdate: | | | / | | | / | | | | |

Month Day Year

E3. What is your Social Security number?

| | | | - | | | - | | | | |

E4. What is your gender?

MARK ONE OR MORE BOXES

1  Male

2  Female

3  Transgender

4  Non-binary/Third gender

5  Prefer not to say

6  Prefer to self-describe (Please specify: _____________________________________________)

E5. What is your race and/or ethnicity?

MARK ONE OR MoRE BOXES

1  American Indian or Alaska Native

For example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

2  Asian

For example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.

3  Black or African-American

For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.

4  Hispanic or Latino

For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.

5  Middle Eastern or North African

For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.

6  Native Hawaiian or other Pacific Islander

For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.

7  White

For example, English, German, Irish, Italian, Polish, Scottish, etc.

8  Other (Please specify: ____________________________________________________)

E6. What is your marital status?

MARK ONE ONLY

1  Single/never married

2  Married

3  Separated

4  Divorced

5  Widowed

E7. Which of the following best describes your housing during the past month?

MARK ONE ONLY

1  Own your own home or apartment

2  Rent your home or apartment

3  Homeless or live in emergency or temporary housing, such as a shelter

4  Live in a halfway house, sober house, or other transitional housing

5  Live in a group home

6  Live with friends or relatives and pay rent

7  Live with friends or relatives and do not pay rent

8  Some other arrangement (Please specify: __________________________________)

E8. Which of the following adults (age 18 or older) live in your household?

MARK ONE OR MoRE BOXES

1  Mother

2  Father

3  Siblings

4  Aunt or uncle

5  Spouse

6  Unmarried domestic partner

7  Roommate

8  Other (Please specify: __________________________________)

E9. During the past year, did you or anyone in your household receive income or assistance from any of the following sources?

MARK ONE OR MoRE BOXES

1  Temporary Assistance for Needy Families (TANF)

2  Unemployment Insurance

3  Worker’s Compensation

4  Short-term disability, not including Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI)

5  Food Stamps/Supplemental Nutrition Assistance Program (SNAP)

6  Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

7  Housing Choice Voucher, also known as Section 8 or Public Housing

8  Veterans Benefits

9  Medicaid (or Medical Assistance [MA] or HealthChoices) or Children’s Health Insurance Program (CHIP)

E10. What is the primary language spoken in your home?

MARK ONE ONLY

1  English

2  Spanish

3  Some other language (Please specify: ______________________________________________)

6. Contact Information

To help us get back in touch with you in a year for your second survey, please provide your contact information below. This information will be kept private and will only be used to contact you about this research.

F1. What is your mailing address? We will reach out to you in about a year for your second survey.

Address:

City, State, Zip Code:

F2. What is the best telephone number to reach you?

| | | | - | | | | - | | | | |

Area Code Number

F2a. Is this number a…

1  Cell phone

2  Landline

3  Work/office

F3. What is another telephone number to reach you?

| | | | - | | | | - | | | | |

Area Code Number

F3a. Is this number a…

1  Cell phone

2  Landline

3  Work/office

F4. What is the best time to reach you during the day?

F5. What is the best email address where we may send you study-related information?

To help us get back in touch with you in a year for your second survey, please provide the name, address, and telephone number of three people who will always know how to reach you. This information will be kept private and will only be used if we are unable to reach you.

FIRST PERSON

F6. Please provide the name of someone who will always know how to contact you.

First name

Last name

F7. What is this person’s address?

Address:

City, State, Zip Code:

F8. What is the best telephone number to reach this person?

| | | | - | | | | - | | | | |

Area Code Number

F9. Is this number a…

1  Cell phone

2  Landline

3  Work/office

F10. What is this person’s relationship to you?

SECOND PERSON

F11. Please provide the name of someone else who will always know how to contact you.

First name

Last name

F12. What is this person’s address?

Address:

City, State, Zip Code:

F13. What is the best telephone number to reach this person?

| | | | - | | | | - | | | | |

Area Code Number

F14. Is this number a…

1  Cell phone

2  Landline

3  Work/office

F15. What is this person’s relationship to you?

THIRD PERSON

F16. Please provide the name of someone else who will always know how to contact you.

First name

Last name

F17. What is this person’s address?

Address:

City, State, Zip Code:

F18. What is the best telephone number to reach this person?

| | | | - | | | | - | | | | |

Area Code Number

F19. Is this number a…

1  Cell phone

2  Landline

3  Work/office

F20. What is this person’s relationship to you?

Thank you for taking the time to complete this survey.

DRAFT Mathematica 1 8/22/2024