#2 - Saq

SAQv2

Self-Administered Questionnaire

«Site_Name»

«ID»

The purpose of this form is to learn about some of the personal qualities and supports that can affect people’s experiences at school and work. It should take you about 30 minutes to complete. At the beginning of each section is a short set of instructions. Please read these instructions carefully. Some of the questions ask you about your emotions or problems you may be having. These questions may make you feel uncomfortable. This information is very important to the study, but you can refuse to answer any question. Program staff will not see your answers. Your answers will not affect your program eligibility. When you are finished, please seal this form in the envelope. ONLY seal the BLUE form in the envelope, and take the sealed envelope to the staff person.

RESOURCES

This first section asks you a series of questions about challenges you have faced or may face in the future. Please mark the box next to the best answer for each question. If there is an arrow next to your answer, read the follow up question and answer it.

1. Thinking about the near future, do you expect to be going to school part-time or full-time if you are selected for this program?

₁□ Part-time

₂□ Full-time

2. Do you expect to be working for pay in the next few months?

₁□ No

₂□ Yes  2a. How many hours do you expect to be working in a typical week?

___ Hours/week

3. How difficult do you expect it will be to find enough time to do well in school?

₁□ Not difficult at all

₂□ Somewhat difficult

₃□ Very difficult

4. While you are in school, do you expect to need financial assistance to help with:

4a. Tuition and fees?

₁□ No

₂□ Yes

4b. Living expenses?

₁□ No

₂□ Yes

5. How difficult do you expect it will be to obtain enough financial support for school?

₁□ Not difficult at all

₂□ Somewhat difficult

₃□ Very difficult

6. Do you have a computer at home?

₁□ No

₂□ Yes  6a. Does this computer have a working Internet connection?

₁□ No

₂□ Yes

7. Do you own a car?

₁□ No

₂□ Yes

8. In the past 12 months has there been a time when you could not pay the full amount of the rent or mortgage that you were supposed to pay?

₁□ No

₂□ Yes

9. Think again over the past 12 months. Generally, at the end of each month do you end up with:

₁□ More than enough money left over

₂□ Some money left over

₃□ Just enough to make ends meet

₄□ Not enough to make ends meet

10. Have you ever been arrested?

₁□ No

₂□ Yes  10a. Have you ever been convicted of a crime?

₁□ No (Skip to Q11)

₂□ Yes

10b. Have you ever been convicted of a felony?

₁□ No

₂□ Yes

PERSONAL QUALITIES AND SKILLS

The following contains a series of statements you might use to describe your behavior, opinions, interests, and feelings when you are taking classes. If you are not currently enrolled in classes, think about how you would respond if you were taking classes.

Read each statement and decide how it describes you by filling in the appropriate response using the following scale: strongly disagree, moderately disagree, slightly disagree, slightly agree, moderately agree, or strongly agree.

Read each statement carefully, but don’t spend too much time deciding on any one answer. Although some items are similar, answer each without considering your other answers.

NOTE: This section of the Personal Information Form includes items from ACT Inc.’s copyrighted Student Readiness Inventory, a standardized and widely-used assessment instrument.
Scale (# items)	Measure
a. Discipline (10)	Amount of effort devoted to school/work and the degree to which person sees him/herself as hardworking and conscientious. Illustrative items: Once I start a task, I see it through to the end. I consistently do my schoolwork/work well.
b. Training commitment (10)	A student’s commitment to staying in school and getting a credential. Illustrative items: Education will help me achieve my goals. I would rather be somewhere else than in school. (reverse-scored)
d. Self-confidence (12)	The belief in one’s ability to perform well in school. Illustrative items: I am a fast learner. I am less talented than other students. (reverse-scored)
e. Steadiness (12)	The tendency to maintain composure and rationality in stressful situations. Illustrative items: I get easily irritated. (reverse-scored) I stay calm in difficult situations.

SOCIAL SUPPORT

The following statements are about help from other people. Please indicate whether you strongly disagree, disagree, agree, or strongly agree with each item.

Item:	Strongly disagree	Disagree	Agree	Strongly agree
There are people I can depend on to help me if I really need it.	1□	2□	3□	4□
I feel that I do not have close personal relationships with other people.	1□	2□	3□	4□
There is no one I can turn to for guidance in times of stress.	1□	2□	3□	4□
There are people who enjoy the same social activities that I do.	1□	2□	3□	4□
I do not think other people respect my skills and abilities.	1□	2□	3□	4□
If something went wrong, no one would come to my assistance.	1□	2□	3□	4□
I have close relationships that provide me with a sense of emotional security and well-being.	1□	2□	3□	4□
I have relationships where my competence and skills are recognized.	1□	2□	3□	4□
There is no one who shares my interests and concerns.	1□	2□	3□	4□
There is a trustworthy person I could turn to for advice if I were having problems.	1□	2□	3□	4□

CAREER ORIENTATION AND KNOWLEDGE

When it comes to careers, some people are more certain than others that they know where they are headed and how to get there. Please indicate for each item whether you strongly disagree, disagree, agree, or strongly agree that it reflects your career situation.

How much do you agree that:	Strongly disagree	Disagree	Agree	Strongly agree
You know how to accurately assess your abilities and challenges?	1□	2□	3□	4□
You know how to make a plan that will help achieve your goals for the next 5 years?	1□	2□	3□	4□
You know how to get help from staff and teachers with any issues that might arise at school?	1□	2□	3□	4□
You know the type of job that is best for you?	1□	2□	3□	4□
You know the type of organization you want to work for?	1□	2□	3□	4□
You know the occupation you want to enter?	1□	2□	3□	4□
You know the kind of education and training program that is best for you?	1□	2□	3□	4□

PERSONAL AND FAMILY CHALLENGES

The following sets of questions ask you about challenges you have faced. Each set will ask you to answer for a different period of time. The time period will be in bold. Please be sure to answer only for the period of time for that set of questions.

The questions below ask you about your feelings and thoughts during the last month. The best approach is to answer each question fairly quickly, giving a reasonable estimate without trying to count up the exact number of times.

In the past month, how often have you felt:	Never	Almost never	Sometimes	Fairly often	Very often
That you were unable to control the important things in your life?	1□	2□	3□	4□	5□
Confident about your ability to handle your personal problems?	1□	2□	3□	4□	5□
That things were going your way?	1□	2□	3□	4□	5□
That difficulties were piling up so high that you could not overcome them?	1□	2□	3□	4□	5□

In the past 12 months, please note how often each of the following situations interfered with your school, work, job search, or family responsibilities.

How often have you had problems or difficulties with:	Never	Almost never	Sometimes	Fairly often	Very often
Child care arrangements?	1□	2□	3□	4□	5□
Transportation?	1□	2□	3□	4□	5□
Alcohol or drug use?	1□	2□	3□	4□	5□
An illness or health condition?	1□	2□	3□	4□	5□
Arguments with a family member?	1□	2□	3□	4□	5□
Physical threats/violence from a family member?	1□	2□	3□	4□	5□

PERSONAL AND FAMILY CHALLENGES

Below is a list of the ways you might have felt or behaved in the last week. For each, please indicate how often you felt this way during the past week.

In the last week:	Rarely (less than 1 day)	Some of the time (1-2 days)	Occasionally (3-4 days)	Most of the time (5-7 days)
I was bothered by things that usually don’t bother me.	1□	2□	3□	4□
I felt that I could not shake off the blues even with help from my family or friends.	1□	2□	3□	4□
I had trouble keeping my mind on what I was doing.	1□	2□	3□	4□
I felt depressed.	1□	2□	3□	4□
I felt that everything I did was an effort.	1□	2□	3□	4□
My sleep was restless.	1□	2□	3□	4□
I was happy.	1□	2□	3□	4□
I enjoyed life.	1□	2□	3□	4□
I felt sad.	1□	2□	3□	4□

Thank you for taking the time to complete these surveys! Please seal this form and only this form in the envelope. Then, locate the staff person and bring him/her your forms.