#1 - BIF - Baseline and modification

IDENTIFYING INFORMATION

1. WHAT IS YOUR NAME?

___________________________ FIRST

______ M.I.

_____________________________________________ LAST

2. WHAT IS YOUR DATE OF BIRTH?

___ ___ / ___ ___ / ___ ___ ___ ___ (MONTH) (DAY) (YEAR)

3. WHAT IS YOUR SOCIAL SECURITY NUMBER?

___ ___ ___ - ___ ___ - ___ ___ ___ ___

4. WHAT IS YOUR ADDRESS?

_____________________________________________ STREET ADDRESS

__________________ APT #

__________________________________ CITY

________ STATE

__________________ ZIP

5a. WHAT IS YOUR PRIMARY PHONE NUMBER? (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

5b. WHAT IS YOUR SECONDARY PHONE NUMBER? (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

1□ HOME

2□ CELL

3□ WORK

1□ HOME

2□ CELL

3□ WORK

6. WHAT IS YOUR E-MAIL ADDRESS?

__________________________________@______________________

BACKGROUND AND FAMILY CHARACTERISTICS

7. WHAT IS YOUR SEX?

1□ MALE 2□ FEMALE

8. WHAT IS YOUR MARITAL STATUS?

1□ NOW MARRIED 2□ WIDOWED 3□ DIVORCED 4□ SEPARATED 5□ NEVER MARRIED

9. ARE YOU OF HISPANIC, LATINO, OR SPANISH ORIGIN?

1□ NO, NOT OF HISPANIC, LATINO, OR SPANISH ORIGIN 2□ YES, MEXICAN, MEXICAN AM., CHICANO 3□ YES, PUERTO RICAN 4□ YES, CUBAN 5□ YES, ANOTHER HISPANIC, LATINO, OR SPANISH ORIGIN

10. WHAT IS YOUR RACE? (MARK ONE OR MORE)

1□ WHITE 2□ BLACK, AFRICAN AM., OR NEGRO 3□ AMERICAN INDIAN OR ALASKA NATIVE 4□ NATIVE HAWAIIAN OR PACIFIC ISLANDER 5□ ASIAN

BACKGROUND AND FAMILY CHARACTERISTICS
11. WERE YOU BORN IN ONE OF THE 50 U.S. STATES, WASHINGTON D.C., OR PUERTO RICO? 1□ YES 2□ NO  IN WHAT YEAR DID YOU COME TO LIVE IN THE UNITED STATES, WASHINGTON D.C., OR PUERTO RICO? ___ ___ ___ ___
12a. DO YOU SPEAK A LANGUAGE OTHER THAN ENGLISH AT HOME? 1□ YES 2□ NO (PLEASE SKIP TO 13)
IF YES, HOW WELL DO YOU:
12b. SPEAK ENGLISH? 1□ VERY WELL 2□ WELL 3□ NOT WELL 4□ NOT AT ALL	12c. READ ENGLISH? 1□ VERY WELL 2□ WELL 3□ NOT WELL 4□ NOT AT ALL
13. WHICH OF THE FOLLOWING LIVE IN YOUR HOUSEHOLD AT LEAST HALF THE TIME? (MARK ONE OR MORE): 01□ YOUR SPOUSE 02□ YOUR UNMARRIED PARTNER 03□ YOUR BIOLOGICAL OR ADOPTED CHILDREN 04□ OTHER CHILDREN UNDER AGE 18 05□ YOUR MOTHER OR FATHER 06□ YOUR OTHER RELATIVES 07□ YOUR SPOUSE’S MOTHER OR FATHER 08□ YOUR SPOUSE’S OTHER RELATIVES 09□ FRIENDS 10□ OTHERS 11□ NO ONE ELSE
14. HOW MANY ADULTS AGE 18 OR OLDER, INCLUDING YOURSELF, LIVE WITH YOU AT LEAST HALF THE TIME? ____ ADULTS
15a. HOW MANY CHILDREN UNDER AGE 18 LIVE WITH YOU AT LEAST HALF THE TIME? (INCLUDE BIOLOGICAL, ADOPTED, FOSTER, STEP, AND ANY OTHER CHILDREN): _­­­___ CHILDREN (IF ZERO, PLEASE SKIP TO 17 ON PAGE 4)
15b. FOR HOW MANY OF THESE CHILDREN ARE YOU OR YOUR SPOUSE THE LEGAL GUARDIAN? ____ CHILDREN (IF ZERO, PLEASE SKIP TO 17 ON PAGE 4)

BACKGROUND AND FAMILY CHARACTERISTICS

16. DO YOU HAVE ANY CHILDREN UNDER AGE 18 WHO DO NOT LIVE WITH YOU AT LEAST HALF THE TIME?

₁□ NO

₂□ YES  HOW MANY CHILDREN? ____

EDUCATIONAL BACKGROUND

17. WHAT IS THE HIGHEST DEGREE OR LEVEL OF SCHOOL YOU HAVE COMPLETED? (MARK ONE):

₁□ GRADE 1 THROUGH 11  PLEASE WRITE THE HIGHEST GRADE YOU COMPLETED 1-11 HERE: ___ ___

₂□ 12^th GRADE – NO DIPLOMA

₃□ GED OR ALTERNATIVE CREDENTIAL

₄□ REGULAR HIGH SCHOOL DIPLOMA

₅□ SOME COLLEGE CREDIT, BUT LESS THAN 1 YEAR OF COLLEGE CREDIT

₆□ 1 OR MORE YEARS OF COLLEGE CREDIT, BUT NO DEGREE

₇□ ASSOCIATE’S DEGREE (FOR EXAMPLE, AA, AS)

₈□ BACHELOR’S DEGREE OR HIGHER (FOR EXAMPLE BA, BS)

18. HAVE YOU RECEIVED A POST-SECONDARY VOCATIONAL OR TECHNICAL CERTIFICATE OR DIPLOMA?

₁□ YES

₂□ NO

19. HAVE YOU EVER ATTENDED ANY OF THE FOLLOWING EDUCATION AND TRAINING PROGRAMS? (MARK ONE OR MORE):

₁□ ADULT BASIC EDUCATION

₂□ ENGLISH AS SECOND LANGUAGE

₃□ VOCATIONAL, TECHNICAL OR TRADE SCHOOL (OTHER THAN COLLEGE)

₄□ CLASSES IN HOW TO SUCCEED IN SCHOOL (FOR EXAMPLE, COLLEGE SUCCESS COURSE)

₅□ CLASSES IN HOW TO SUCCEED AT WORK (FOR EXAMPLE, WORK HABITS, COMMUNICATION)

₆□ NONE OF THE ABOVE

20. WHAT IS THE HIGHEST LEVEL OF EDUCATION THAT YOU EVENTUALLY EXPECT TO COMPLETE? (MARK ONE)

₁□ NO ADDITIONAL SCHOOL

₂□ GED OR ALTERNATIVE CREDENTIAL

₃□ REGULAR HIGH SCHOOL DIPLOMA

₄□ ASSOCIATE’S DEGREE (FOR EXAMPLE, AA, AS)

₅□ BACHELOR’S DEGREE (FOR EXAMPLE BA, BS)

₆□ GRADUATE (MASTER’S, DOCTORAL, OR OTHER ADVANCED PROFESSIONAL) DEGREE

EDUCATIONAL BACKGROUND
21. WHAT IS THE HIGHEST LEVEL OF SCHOOL COMPLETED BY YOUR:
a. MOTHER (OR GUARDIAN #1)? 1□ NOT A HIGH SCHOOL GRADUATE 2□ GED OR ALTERNATIVE CREDENTIAL 3□ REGULAR HIGH SCHOOL DIPLOMA 4□ SOME COLLEGE CREDIT, BUT NO DEGREE 5□ ASSOCIATE’S DEGREE (FOR EXAMPLE, AA, AS) 6□ BACHELOR’S DEGREE OR HIGHER (FOR EXAMPLE BA, BS) 7□ DON’T KNOW	b. FATHER (OR GUARDIAN #2)? 1□ NOT A HIGH SCHOOL GRADUATE 2□ GED OR ALTERNATIVE CREDENTIAL 3□ REGULAR HIGH SCHOOL DIPLOMA 4□ SOME COLLEGE CREDIT, BUT NO DEGREE 5□ ASSOCIATE’S DEGREE (FOR EXAMPLE, AA, AS) 6□ BACHELOR’S DEGREE OR HIGHER (FOR EXAMPLE BA, BS) 7□ DON’T KNOW
EDUCATIONAL BACKGROUND
22. DO YOU HAVE ANY BROTHERS OR SISTERS WHO HAVE ATTENDED COLLEGE? 1□ YES 2□ NO 3□ DO NOT HAVE ANY BROTHERS OR SISTERS
23. WHAT GRADES DID YOU USUALLY GET IN HIGH SCHOOL? (MARK ONE):
1□ DID NOT ATTEND HIGH SCHOOL IN THE U.S. 2□ MOSTLY A’s 3□ MOSTLY B’s		4□ MOSTLY C’s 5□ MOSTLY D’s 6□ MOSTLY F’s
EMPLOYMENT AND INCOME
24. ARE YOU CURRENTLY WORKING AT A JOB FOR PAY? (MARK ONE)
1□ YES HOW MANY HOURS PER WEEK ON AVERAGE ARE YOU CURRENTLY WORKING? (INCLUDE ALL JOBS)		___ ___ HOURS/WEEK
2□ NO, BUT I WORKED BEFORE  WHEN DID YOU LAST WORK?		___ ___ / ___ ___ ___ ___ (MONTH) (YEAR)
3□ NO, I NEVER WORKED (PLEASE SKIP TO 27)
25. IF YOU ANSWERED “YES” OR “NO, BUT I WORKED BEFORE” TO Q25: ABOUT HOW MUCH DO/DID YOU TYPICALLY EARN PER HOUR BEFORE TAXES IN YOUR CURRENT OR MOST RECENT JOB? (ANSWER FOR YOUR MAIN JOB IF MORE THAN ONE) $ ___ ___ . ___ ___ PER HOUR IN CURRENT/MOST RECENT JOB IF YOU DO NOT KNOW THE HOURLY RATE, PLEASE GIVE EARNINGS IN ONE OF THE CATEGORIES BELOW: $ ___ ___ ___ ___ PER DAY $ ___ ___ ___ ___ PER WEEK $ ___ ___ ___ ___ EVERY 2 WEEKS $ ___ ___ ___ ___ TWICE A MONTH $ ___ ___ ___ ___ EVERY MONTH $ ___ ___ ___ ___ OTHER (SPECIFY TIME PERIOD: ____________________________________)

EMPLOYMENT AND INCOME
26. IN THE PAST MONTH, DID YOU OR ANYONE IN YOUR FAMILY (YOUR SPOUSE OR PARTNER AND ANY OTHER RELATIVES WHO LIVE WITH YOU) HAVE INCOME OR BENEFITS FROM ANY OF THE FOLLOWING SOURCES?
A) JOB EARNINGS?	1□ YES  2□ NO	ABOUT HOW MUCH WAS IT PER MONTH? $ ___________
B) WIC OR FOOD STAMPS (ALSO KNOWN AS SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM--SNAP)?	1□ YES  2□ NO	ABOUT HOW MUCH WAS IT PER MONTH? $ ___________
C) PUBLIC ASSISTANCE OR WELFARE (NOT INCLUDING WIC OR FOOD STAMPS)?	1□ YES  2□ NO	ABOUT HOW MUCH WAS IT PER MONTH? $ ___________
D) FREE OR REDUCED LUNCH PROGRAM?	1□ YES 2□ NO
E) UNEMPLOYMENT INSURANCE, WORKER’S COMPENSATION, DISABILITY OR SOCIAL SECURITY BENEFITS?	1□ YES  2□ NO	ABOUT HOW MUCH WAS IT PER MONTH? $ ___________
F) CHILD SUPPORT (OFFICIAL OR UNOFFICIAL)?	1□ YES  2□ NO	ABOUT HOW MUCH WAS IT PER MONTH? $ ___________
G) FAMILY AND FRIENDS? (OUTSIDE THE HOUSEHOLD)	1□ YES  2□ NO	ABOUT HOW MUCH WAS IT PER MONTH? $ ___________
H) GRANTS OR LOANS FOR SCHOOL?	1□ YES  2□ NO	ABOUT HOW MUCH WAS IT PER MONTH? $ ___________
I) HOUSING CHOICE VOUCHER (KNOWN AS SECTION 8) OR PUBLIC HOUSING?	1□ YES  2□ NO	ABOUT HOW MUCH WAS IT PER MONTH? $ ___________
27. LAST YEAR, WHAT WAS YOUR TOTAL FAMILY INCOME? INCLUDE YOUR OWN EARNINGS AND ANY INCOME FROM YOUR SPOUSE OR PARTNER AND ANY OTHER RELATIVES WHO LIVE WITH YOU: $ _______________________ AMOUNT IF YOU DO NOT KNOW THE EXACT AMOUNT, PLEASE MARK THE CATEGORY BELOW THAT IS CLOSEST:
1□ $0 2□ $1 TO $9,999 3□ $10,000 TO $14,999 4□ $15,000 TO $19,999 5□ $20,000 TO $24,999 6□ $25,000 TO $29,999 7□ $30,000 TO $34,999			08□ $35,000 TO $39,999 09□ $40,000 TO $44,999 10□ $45,000 TO $49,999 11□ $50,000 TO $59,999 12□ $60,000 TO $69,999 13□ $70,000 TO $79,999 14□ $80,000 OR OVER

ALTERNATE CONTACTS Please provide information for three persons not living with you who can help us locate you:
CONTACT #1
WHAT IS HIS/HER NAME?			_____________________________________ FIRST				_____________________________________________ LAST
WHAT IS HIS/HER RELATIONSHIP TO YOU?					_____________________________________________
WHAT IS HIS/HER ADDRESS?					_____________________________________________ STREET ADDRESS					__________________ APT #
					__________________________________ CITY				________ STATE	__________________ ZIP
WHAT IS HIS/HER PRIMARY PHONE NUMBER? (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___					WHAT IS HIS/HER SECONDARY PHONE NUMBER? (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
1□ HOME	2□ CELL	3□ WORK			1□ HOME	2□ CELL		3□ WORK
WHAT IS HIS/HER E-MAIL ADDRESS?					__________________________________@______________________
CONTACT #2
WHAT IS HIS/HER NAME?			_____________________________________ FIRST				_____________________________________________ LAST
WHAT IS HIS/HER RELATIONSHIP TO YOU?					_____________________________________________
WHAT IS HIS/HER ADDRESS?					_____________________________________________ STREET ADDRESS					__________________ APT #
					__________________________________ CITY				________ STATE	__________________ ZIP
WHAT IS HIS/HER PRIMARY PHONE NUMBER? (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___					WHAT IS HIS/HER SECONDARY PHONE NUMBER? (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
1□ HOME	2□ CELL	3□ WORK			1□ HOME	2□ CELL		3□ WORK
WHAT IS HIS/HER E-MAIL ADDRESS?					__________________________________@______________________
CONTACT #3
WHAT IS HIS/HER NAME?			_____________________________________ FIRST				_____________________________________________ LAST
WHAT IS HIS/HER RELATIONSHIP TO YOU?					_____________________________________________
WHAT IS HIS/HER ADDRESS?					_____________________________________________ STREET ADDRESS					__________________ APT #
					__________________________________ CITY				________ STATE	__________________ ZIP
WHAT IS HIS/HER PRIMARY PHONE NUMBER? (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___					WHAT IS HIS/HER SECONDARY PHONE NUMBER? (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
1□ HOME	2□ CELL	3□ WORK			1□ HOME	2□ CELL		3□ WORK
WHAT IS HIS/HER E-MAIL ADDRESS?					__________________________________@______________________

Thank you for completing this form!

Please hand in this form and the signed copy of the white form to the staff person.

Next, please find the blue form in the envelope,

read the instructions on the front cover, and begin to work on it.