Attachment B.6 Follow Up Survey

Youth Transition Exploration Demonstration (YTED)
12-Month Follow-Up Survey Instrument

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 20 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.

Privacy Act Statement
Collection and Use of Personal Information

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 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 for Federal benefits eligibility and to recoup debts under these programs.

The Youth Transition Exploration (TE) 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 Disability 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.

You joined YTED about one year ago and agreed to take part in this survey. Once you complete the survey, Mathematica will send you a $50 gift card.

Participation in the survey is voluntary but very important. The survey takes about 20 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).

Do you consent to participate in the survey?

MARK ONE ONLY

1  Yes

0  No SURVEY ENDS

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 SKIP TO QUESTION A3

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 worked for pay in the last 12 months?

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. Let’s talk about services or training that you might have received in the past year.

In the past year, have you worked with anyone to determine your needs and help connect you to services and supports related to education, employment, health, housing, or anything else?

This person could be a case manager, employment specialist or a teacher, for example.

MARK ONE ONLY

1  Yes

0  No

D2. In the past year, have you been taught skills needed for life? This includes skills such as telling time, interacting with people socially, or using public transportation.

MARK ONE ONLY

1  Yes

0  No

D3. In the past year, have you had any training to teach you about being a leader or about how to speak up for yourself to get the things you want or need? This is sometimes called self-advocacy or self-determination training.

MARK ONE ONLY

1  Yes

0  No

D4. In the past year, have you participated in activities to help you learn about what jobs match your skills and interests?

MARK ONE ONLY

1  Yes

0  No

D5. In the past year, have you had help with learning about or getting into a school or training program, including help with an application, entrance exam, or interview? For example, this could include a place where someone told you about training programs or schools that are available and how to apply for them, or if someone helped you complete an application for college or vocational school.

MARK ONE ONLY

1  Yes

0  No

D6. In the past year, have you had any training to help you learn new job skills? Please do not include any training you had on the job directly from an employer.

MARK ONE ONLY

1  Yes

0  No

D7. In the past year, have you had help in finding or applying for a job, such as help finding jobs available, filling out an application, writing a resume, or going for an interview?

MARK ONE ONLY

1  Yes

0  No

D8. In the past year, have you received any help while working at a job, such as help with job accommodations or learning job duties? This could include help from a job coach. Please do not include any help given by an employer.

MARK ONE ONLY

1  Yes

0  No

D9. In the past year, have you received any help with learning about, getting, or using assistive technology?

This could include help with special tools or equipment, software, or devices that help you perform school or work activities that are difficult to do [because of your disability].

MARK ONE ONLY

1  Yes

0  No

D10. In the past year, have you had help with transportation to or from any workplace activity?

MARK ONE ONLY

1  Yes

0  No

D11. In the past year, have you had help learning about how to save and manage money?

MARK ONE ONLY

1  Yes

0  No

D12. In the past year have you had any other services to help you work, go to school, or help your family in other ways?

Please do not include services you’ve already told me about.

MARK ONE ONLY

1  Yes

0  No

D12a. What kind of other services did you receive?

D13. In the past year, did you do any of the following activities?

	YES	NO
a. Take tours of workplaces	1 	0 
b. Follow someone around at work to learn what they do (sometimes called a job shadow)	1 	0 
c. Interview someone, by phone or in-person, about their job to learn more	1 	0 
d. Regularly talk one-on-one with someone about jobs	1 	0 
e. Regularly talk as part of a group with someone from outside of school about jobs	1 	0 
f. Have a paid internship or apprenticeship	1 	0 
g. Have an unpaid internship or apprenticeship	1 	0 
h. Work in a school-based job where you made things or provided services for customers or clients (for example, operating a student store or restaurant, designing websites or apps, making videos or building structures)	1 	0 

D14. In the past year, have you needed any [other] help or services preparing for work or school that you did not receive?

MARK ONE ONLY

1  Yes

0  No

D15. In the past year, what help or services did you need that you did not get?

MARK ONE OR MORE BOXES

1  Discovering job interests/skills

2  Career counseling

3  Learning how to look for a job

4  Job shadowing

5  Apprenticeship/internship

6  Help finding a job

7  Support on the job (job coaching)

8  Help getting into school/training

9  Computer literacy classes

10  Problem solving

11  Financial literacy/money management training

12  Referral to another agency (such as the Department of Health or Department of Human Services)

13  Transportation services

14  Health-related services

15  Case management

16  Other (Please specify: _____________________________________________________)

D16. 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

D17. 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

D18. 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

D19. 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

D20. How satisfied are you with the services you received to help you advance in school or prepare for a job after school?

MARK ONE ONLY

1  Very satisfied

2  Somewhat satisfied

3  Somewhat dissatisfied

4  Very dissatisfied

D21. In the past year, how successful do you think you have been in reaching your employment goals?

MARK ONE ONLY

1  Very successful

2  Somewhat successful

3  Not very successful

4  Not at all successful

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. 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 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: _______________________________________)

E3. What is your marital status?

MARK ONE ONLY

1  Single/never married

2  Married

3  Separated

4  Divorced

5  Widowed

E4. 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: __________________________________)

E5. Who do you live with?

MARK ONE OR MoRE BOXES

1  Parent/guardian

2  Step-parent or parent’s spouse/partner

3  Sibling age 18 or over (including step-sibling, half sibling, or foster sibling)

4  Sibling under age 18 (including step-sibling, half sibling, or foster sibling)

5  Spouse/partner

6  Child

7  Grandparent

8  Aunt/uncle

9  Roomate/housemate

10  Other

E6. 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)

E7. What is the primary language spoken in your home?

MARK ONE ONLY

1  English

2  Spanish

3  Some other language (Please specify: ______________________________________________)

Thank you for taking part in this survey!

DRAFT Mathematica 1 2/26/2024