Baseline Data Collection, Staff

U.S. Department of Labor
Job Training Evaluation

Baseline Information Form

Dear Participant:

This form requests information about your household. Your answers to these questions will not affect your chances of getting into this employment training program. The information will be used for research purposes only and will be kept private to the extent allowed by law.

Thank you very much for helping us with this important study.

MARKING DIRECTIONS

 Use a blue or black ink pen or dark pencil.

 Do not use felt tip markers or gel pens.

 Put an “X” in the box that best describes your answer.

Correct:  □ □ □

 To change an answer, mark the new one and circle it.

Correct:  □  □

J

O

B

S

 Please PRINT where applicable. Enter only one letter or number per box.

Public Burden Statement, OMB 1205-0NEW, expires xx/xxxx.

Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. Respondent's obligation to reply is required to obtain benefits under P.L 111-5.  Public reporting burden for this collection of information is estimated to average 13 minutes per response, including the time for reading instructions, and completing and reviewing the requested information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Division of Adult Services, Room S-4209, Washington, D.C. 20210 (Paperwork Reduction Project Control No. 1205-xxxx).

Mathematica Reference No. 06888

C ONTACT INFORMATION

1. Please print your name:

FIRST NAME

MIDDLE NAME

LAST NAME

2. Your street address:

STREET

STREET APT.

CITY STATE ZIP

3. Your telephone numbers:

Cell/Mobile: (| | | |)-| | | |-| | | | |

Home: (| | | |)-| | | |-| | | | |

Work: (| | | |)-| | | |-| | | | |

4. Your email addresses:

Home:

Work:

5. Your Social Security Number:

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

EDUCATION

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

MARK ONLY ONE

1 □ No formal education

2 □ 12th grade or less, no diploma

3 □ High school graduate

4 □ GED

5 □ Technical, trade or vocational degree

6 □ Some college credit, but no degree

7 □ Associate’s degree

8 □ Bachelor’s degree

9 □ Master’s degree or higher

7. Are you currently enrolled in school or in another training program? (Do not include this training program to which you are applying.)

MARK ALL THAT APPLY

1 □ Currently enrolled in high school or GED program

2 □ Currently enrolled in vocational, technical, or trade school

3 □ Currently enrolled in 2 or 4 year college

4 □ Currently enrolled in another job training program

0 □ Not currently enrolled in school or any other training program

8. Have you ever attended any of the following education and training programs either in the U.S. or elsewhere?

MARK ALL THAT APPLY

1 □ Adult basic education (these programs usually teach reading and math)

2 □ English as a Second Language (ESL)

3 □ Job training at a vocational, technical or trade school

4 □ College courses that did not lead to a degree you already listed in question #6

5 □ Other (PLEASE SPECIFY)

B ACKGROUND

9. Are you male or female?

1 □ Male

2 □ Female

10. What is your date of birth?

| | | / | | | / | | | | |

MONTH DAY YEAR

11. What is your current marital status?

MARK ONLY ONE

1 □ Married

2 □ Widowed

3 □ Divorced/Separated

4 □ Never Married

12. Are you of Spanish, Hispanic, or Latino origin?

1 □ Yes

2 □ No

13. Do you consider yourself to be . . .

MARK ALL THAT APPLY

1 □ American Indian or Alaskan Native

2 □ Asian

3 □ Black or African-American

4 □ Native Hawaiian or other Pacific Islander

5 □ White

14. Do you speak a language other than English at home?

1 □ Yes

2 □ No

15. Do you . . .

MARK ONLY ONE

1 □ Own the place where you live

2 □ Rent your own place or contribute to rent at a friend or family’s place

3 □ Live rent free

16. How many children (18 years or younger) currently live in your household?

0 □ No children living in household GO TO Q17

| | | CHILDREN

16a. What is the age (in years) of the youngest child currently living in your household?

| | | AGE OF YOUNGEST CHILD

17. What is your U.S. citizenship status?

MARK ONLY ONE

1 □ U.S. Citizen

2 □ Legal Resident

18. Have you ever been convicted of a felony?

1 □ Yes

2 □ No

19. Are you deaf or do you have serious difficulty hearing?

1 □ Yes

2 □ No

20. Are you blind or do you have serious difficulty seeing even when wearing glasses?

1 □ Yes

2 □ No

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

1 □ Yes

2 □ No

22. Do you have serious difficulty walking or climbing stairs?

1 □ Yes

2 □ No

23. Do you have difficulty dressing or bathing?

1 □ Yes

2 □ No

24. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?

1 □ Yes

2 □ No

EMPLOYMENT

25. What is your current employment status?

MARK ONE EMPLOYMENT STATUS BOX AND THEN FOLLOW THE ARROWS

I am currently working at one or more jobs or businesses	I am not currently working, but I have worked at one or more jobs or businesses during the last 12 months	It has been longer than 12 months since I last worked at a job or business
1 □	2 □	3 □
25a. How long have you worked at this job? | | | YEARS | | | MONTHS (if work multiple jobs, record time for the job you’ve held the longest)	25d. During how many months out of the last 12 have you worked at a job or business? | | | MONTHS	GO TO Q26
25b. How many hours do you usually work per week at your main job? | | | HOURS PER WEEK
25c. How much do you earn per hour at your main job, before taxes and other deductions? $ | | | |.| | | PER HOUR	25e. When you were working, how much did you earn per hour at your main job? $ | | | |.| | | PER HOUR
GO TO Q26	GO TO Q26

OPINIONS ABOUT WORK OPPORTUNITIES

For items 26 - 29 please mark how well each statement describes your current situation.

	MARK ONE PER ROW PER COLUMN
	very much	a little	not at all	No children in household
26. Finding quality child care that I can afford limits my ability to work	1 □	2 □	3 □	0 □
27. problems with transportation (car, public transit) limit my ability to work	1 □	2 □	3 □
	strongly agree	agree	disagree	strongly disagree
28. I will take any job even if the pay is low	1 □	2 □	3 □	4 □
29. I only want the kind of job that I trained for	1 □	2 □	3 □	4 □

30. How much must a job pay per hour for it to make sense for you to take it? $ | | | |.| | | PER HOUR

(Please enter the lowest hourly amount you are willing to accept) 99 □ Don’t Know

P UBLIC ASSISTANCE

31. Does your household receive Section 8 or Public Housing Assistance?

1 □ Yes

2 □ No

32. Are you currently receiving TANF (Temporary Assistance for Needy Families)?

1 □ Yes

2 □ No

33. Are you currently receiving SNAP (Supplemental Nutrition and Assistance Program)? (It used to be called the Food Stamp Program.)

1 □ Yes

2 □ No

34. Are you currently receiving unemployment insurance?

1 □ Yes 2 □ No GO TO Q35

34a. What is your weekly unemployment insurance benefit?

$ | | , | | | |

FUTURE CONTACT

35. May we send a text message to your cell phone?

1 □ Yes

2 □ No

36. May we contact you through Facebook?

1 □ Yes 2 □ No GO TO Q37

36a. What is your Facebook username?

37. Please provide contact information of 3 close friends or relatives we can contact in case you move and we cannot easily locate you for the follow-up interview in 18 months. All information will be held in strictest privacy and will only be used to locate you if we have trouble contacting you directly.

37a. Relative or friend #1:

NAME

RELATIONSHIP TO YOU

STREET APT.

CITY STATE ZIP

Cell/Mobile: (| | | |)-| | | |-| | | | |

Home: (| | | |)-| | | |-| | | | |

HOME EMAIL

WORK EMAIL

37b. Relative or friend #2:

NAME

RELATIONSHIP TO YOU

STREET APT.

CITY STATE ZIP

Cell/Mobile: (| | | |)-| | | |-| | | | |

Home: (| | | |)-| | | |-| | | | |

HOME EMAIL

WORK EMAIL

37c. Relative or friend #3

NAME

RELATIONSHIP TO YOU

STREET APT.

CITY STATE ZIP

Cell/Mobile: (| | | |)-| | | |-| | | | |

Home: (| | | |)-| | | |-| | | | |

HOME EMAIL

WORK EMAIL

Thank you for completing this survey!

DRAFT 7/15/11