HPOG-Impact 15-month Participant Follow-Up survey

Health Profession Opportunity Grants (HPOG) program

HPOG Appendix I HPOG-Impact 15-Month Partic Follow-Up Survey and HPOG-NIE Treatment revised 7 26 13

HPOG-Impact 15-month Participant Follow-Up survey

OMB: 0970-0394

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Supporting Statement for OMB Clearance Request


Appendix I: HPOG-Impact and HPOG-NIE 15-month Participant Follow-Up Survey


National Implementation Evaluation of the Health Profession Opportunity Grants (HPOG) to Serve TANF Recipients and Other Low-Income Individuals and HPOG Impact Study


0970-0394





April 24, 2013

Revised July 25, 2013



Submitted by:

Office of Planning,
Research & Evaluation

Administration for Children & Families

U.S. Department of Health
and Human Services




Federal Project Officers:

Molly Irwin and Mary Mueggenborg

Appendix I: HPOG-Impact and HPOG-NIE 15-month Participant Follow-Up Survey





Introduction

Hello, my name is [ ]. May I please speak with _____?

Thank you for taking the time to talk with me today. This interview will take about 40 minutes to complete, and when we are done, we will send you a $30 check, in appreciation for your time. I work for a company called Abt SRBI. Abt SRBI is an independent research company and we are helping the Administration for Children and Families (ACF) in the U.S. Department of Health and Human Services (HHS) with its evaluation of the Health Profession Opportunity Grants (HPOG) program. You agreed to be part of the study around [RAD] (when you signed a consent form to let researchers collect information from you).

We need to talk with people who got into the program and those who did not. Your participation in this study will help policymakers and program operators better understand how to help people attain educational credentials and find and keep jobs in the healthcare field. This interview will include questions on your education activities, your use of services, and your overall well-being.

Before we begin the survey, I would like to assure you that all of your responses on this survey will be kept private; your name will not appear in any written reports we produce. Your responses to these questions are completely voluntary. That means you may choose not to answer any question, or you may stop the interview if you wish, but we hope you don’t. Your responses to these questions will in no way affect your participation in any programs or your receipt of any kinds of public benefits or services. The information you provide will be kept private and only used for this study.

According to the Paperwork Reduction Act (PRA), an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is 0970-0394 and it expires xx/xx/xxxx. If you have comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, please send them to [Contact Name]; [Contact Address]; Attn: OMB-PRA (0970-0397).Do you have any questions before we begin?

Let’s begin now.

Screener/Verification:

First I just need to verify that I am speaking with the correct person.

  1. What is your date of birth? ___________ (MM/DD/YYYY)

  2. What are the last 4 digits of your Social Security Number? __ __ __ __

School or Training Experiences



My first set of questions is about any school or training experiences you have had since [RAD]. To help you remember this date, our records show that it was about then that you applied for the [HPOG] program [AT (NAME OF HOST INSITUTION, IF DIFFERENT FROM PROGRAM NAME)].



  1. Since [RAD], have you taken any classes or been in an instructional program of any kind anywhere, even for a short time? This may have included classes on basic skills, ESL, college courses, occupational training, or other skills such as how to succeed in school or career readiness. These classes may have been offered by a community organization, college, high school, employer, or somewhere else.

  • Yes (ASK Q1a below)

  • No (GO TO Q24 p.10)

  • REFUSED (GO TO Q24 p.10)

  • DON’T KNOW (GO TO Q24 p.10)

  1. IF YES: Are you currently enrolled in any classes, or enrolled but between terms, at some place that is providing education or training?

  • Yes

  • No

  • Don’t know

  • Refused


  1. At what type of place(s) have you taken these classes? Choose all that apply.

  • Adult education /adult high school/community school/night school

  • Community based/nonprofit organization

  • Private school/company that provides training

  • Community or technical college (2 year college)

  • 4 year college/university

  • State unemployment/employment office

  • One-stop career center

  • Your place of employment

  • Someplace else, specify:____

  • REFUSED

  • DON’T KNOW



  1. I’m going to mention some different types of classes. For each one, please tell me if it is a type that you are taking or have taken since [RAD]. I’m interested in any classes you have taken, even if you only went for a short time.


Yes

No

Don’t know

Refused

  1. Classes to learn English as a Second Language? Do not count regular college classes or occupational training. I will ask you about these classes separately.

  1. Classes to improve your basic reading, writing, or math skills or prepare for a high school equivalency or college placement test? Again, do not count any classes providing regular college credit or occupational training.

  1. Classes providing regular college credit?

  1. Classes providing occupational training, but not for college credit?

  1. Classes in other skills, such as how to succeed at school, work, or other areas of life? Please include any such classes, whether for college credit or not.



IF ANSWERED “YES” TO Q3a (classes to learn English as a second language), CONTINUE.

IF DID NOT ANSWER “YES” TO Q3a, GO TO INSTRUCTION BELOW Q5 THIS PAGE.

I have a few questions about the English as a Second Language, or ESL classes you have taken.

  1. Regardless of whether you finished them, how many ESL classes have you taken since [RAD]?

__ __ __ number of ESL classes

  • REFUSED

  • DON’T KNOW



  1. How many ESL classes have you completed since [RAD]?

__ __ __ number of basic skills classes

  • REFUSED

  • DON’T KNOW

IF ANSWERED “YES” TO Q3b (classes to improve basic skills), CONTINUE.

IF DID NOT ANSWER “YES” TO Q3b, GO TO INSTRUCTION BELOW Q7 NEXT PAGE.

Now I have some questions about the basic skills classes you have taken.

  1. Regardless of whether you completed them, how many basic skills classes have you taken since [RAD]?

__ __ __ number of basic skills classes

  • REFUSED

  • DON’T KNOW

  1. How many basic skills classes have you completed since [RAD]?

__ __ __ number of basic skills classes

  • REFUSED

  • DON’T KNOW



IF ANSWERED “YES” TO Q3e (other skills classes), CONTINUE.

IF DID NOT ANSWER “YES” TO Q3e, GO TO INSTRUCTION BELOW Q13 p. 6.



Now I’d like to ask about the classes you have taken in other skills, such as how to succeed at school, work, or other areas of life. I’m interested in any classes you have taken of this type, whether or not they were for college credit.

  1. Regardless of whether you completed them, how many other skills classes have you taken since [RAD]?

______ number of other skills classes

  • REFUSED

  • DON’T KNOW


  1. Were these other skills classes offered for college credit?

  • YES

  • SOME BUT NOT ALL

  • NO

  • REFUSED

  • DON’T KNOW

  1. In total, for about how many days or weeks have you attended these other skills classes?

__ __ __ number of days

OR

__ __ __ number of weeks

  • REFUSED

  • DON’T KNOW



  1. And for about how many hours have you attended these other skills classes each week?

__ __ __ number of hours

  • REFUSED

  • DON’T KNOW



  1. Are you currently taking any other skills classes right now?

  • YES

  • NO

  • REFUSED

  • DON’T KNOW



  1. How many other skills classes have you completed since [RAD]?

______ number of other skills classes

  • REFUSED

  • DON’T KNOW

  1. I’m going to read a list of subjects that other skills classes sometimes cover. For each one, please tell me whether it received a great deal of attention, some attention, or no attention in any of the other skills classes you have taken since [RAD]:


A great deal of attention

Some attention

No attention

Don’t know

Refused

  1. Career planning

  1. Study skills, such as locating information, taking notes, and preparing for classes and exams

  1. Finding a job or moving to a different job

  1. Critical thinking and problem-solving skills

  1. Finding help with problems at school, work, or home

  1. Finding and applying for financial aid for school

  1. Managing time effectively

  1. Working in groups

  1. Communicating well (for example, good listening and speaking skills)

  1. Managing stress and anger

  1. Staying motivated

  1. Acting professionally (for example, how to dress, show good attendance habits, be respectful)

  1. Managing money and personal finances

  1. Handling parenting and other family responsibilities



IF ANSWERED “YES” TO Q3c (classes providing regular college credit), CONTINUE.

IF DID NOT ANSWER “YES” TO Q3c, GO TO INSTRUCTION BELOW Q19a p.8.









Now I have some questions about classes you have taken for regular college credit.

  1. Regardless of whether you finished them, about how many classes for college credit have you enrolled in since [RAD]?

______ number of classes

  • REFUSED

  • DON’T KNOW



  1. Have you earned any regular college credits so far since [RAD]?

  • YES (CONTINUE)

  • NO (GO TO Q19)

  • REFUSED (GO TO Q19)

  • DON’T KNOW (GO TO Q19)

  1. IF YES: How many credits have you earned?

__ __ __ number of credits

    • Don’t know

    • Refused


  1. About when did you start taking classes for college credit? Please give me the month and year you started.

___ ___ month ___ ___ ___ ___ year

  1. Are you currently taking any classes for college credit? Answer “yes” if you are on a spring, summer, or holiday break.

  • YES (GO TO Q19)

  • NO (ASK Q18a BELOW)

  • REFUSED (GO TO Q19)

  • DON’T KNOW (GO TO Q19)

  1. IF NO: About when did you stop taking college credit classes? Please give me the month and the year you last attended.

___ ___ month ___ ___ ___ ___ year

    • Don’t know

    • Refused


  1. Did you start any classes for college credit that you did not complete?

  • YES (ASK Q19a NEXT PAGE)

  • NO (GO TO INSTRUCTION BELOW Q19a NEXT PAGE)

  • REFUSED (GO TO INSTRUCTION BELOW Q19a NEXT PAGE)

  • DON’T KNOW (GO TO INSTRUCTION BELOW Q19a NEXT PAGE)

  1. IF YES: What was the main reason that you stopped attending these classes?

DO NOT READ LIST, RECORD FULL ANSWER AND THEN BACKFILL ONE RESPONSE AFTER RESPONDENT ANSWERS

  • POOR GRADES

  • TOO HARD/WASN’T GETTING IT

  • CLASSES OR PROGRAM POORLY TAUGHT

  • STARTED OTHER SCHOOL/TRAINING

  • NOT ENOUGH MONEY TO CONTINUE

  • NOT ENOUGH TIME TO CONTINUE

  • DIDN’T LIKE PROGRAM

  • LOST MOTIVATION

  • NOT INTERESTED IN PROGRAM

  • DIDN’T THINK IT WOULD HELP ME FIND A JOB

  • ILLNESS

  • PREGNANCY

  • CHILD CARE ISSUES

  • OTHER FAMILY REASONS

  • TRANSPORTATION/COORDINATION PROBLEMS

  • FOUND JOB/RE-EMPLOYED

  • OTHER (SPECIFY)____

  • REFUSED

  • DON’T KNOW

IF ANSWERED “YES” TO Q3d (classes providing occupational training), CONTINUE.

IF DID NOT ANSWER “YES” TO Q3d, GO TO CREDENTIALS SECTION p. 10.



Now I’d like to ask about the occupational training classes you said you have taken. These were the job training classes you have taken that were not for college credit but covered more than basic English and math skills.

  1. Regardless of whether you finished them, how many occupational training classes have you taken since [RAD]?

__ __ __ number of classes

  • Don’t know

  • Refused


  1. About when did you start taking occupational training classes? Please give me the month and year you started.

___ ___ month ___ ___ ___ ___ year

  • Don’t know

  • Refused


  1. Are you currently receiving this occupational training?

  • YES (GO TO Q23 NEXT PAGE)

  • NO (ASK 22a NEXT PAGE)

  • REFUSED (GO TO Q23 NEXT PAGE)

  • DON’T KNOW (GO TO Q23 NEXT PAGE)

  1. IF NO: About when did you stop taking occupational training classes? Please give me the month and year you last attended.

___ ___ month ___ ___ ___ ___ year

  • Don’t know

  • Refused



  1. Did you start any occupational training that you did not complete?

  • YES (ASK Q23a BELOW)

  • NO (GO TO CREDENTIALS SECTION NEXT PAGE)

  • REFUSED (GO TO CREDENTIALS SECTION NEXT PAGE)

  • DON’T KNOW (GO TO CREDENTIALS SECTION NEXT PAGE)

  1. IF YES: What was the main reason that you stopped attending the training?

DO NOT READ LIST, RECORD FULL ANSWER AND THEN BACKFILL ONE RESPONSE AFTER RESPONDENT ANSWERS

  • POOR GRADES

  • TOO HARD/WASN’T GETTING IT

  • CLASSES OR PROGRAM POORLY TAUGHT

  • STARTED OTHER SCHOOL/TRAINING

  • NOT ENOUGH MONEY TO CONTINUE

  • NOT ENOUGH TIME TO CONTINUE

  • DIDN’T LIKE PROGRAM

  • LOST MOTIVIATION

  • NOT INTERESTED IN PROGRAM

  • DIDN’T THINK IT WOULD HELP ME FIND A JOB

  • ILLNESS

  • PREGNANCY

  • CHILD CARE ISSUES

  • OTHER FAMILY REASONS

  • TRANSPORTATION/COORDINATION PROBLEMS

  • FOUND JOB/RE-EMPLOYED

  • OTHER (Please SPECIFY)____

  • REFUSED

  • DON’T KNOW

Credentials

Now I’m going to ask you questions about your overall training experience since [RAD].

  1. Have you taken classes to prepare for work in a particular occupation?

  • YES (ASK 24a BELOW)

  • NO (GO TO Q25 THIS PAGE)

  • REFUSED (GO TO Q25 THIS PAGE)

  • DON’T KNOW (GO TO Q25 THIS PAGE)

  1. IF YES: Have you taken classes to prepare for work in a particular healthcare occupation?

  • Yes (ASK Q24ai BELOW)

  • No (GO TO Q25 THIS PAGE)

  • Refused (GO TO Q25 THIS PAGE)

  • Don’t know (GO TO Q25 THIS PAGE)

  1. IF YES: I am going to read you a list of types of healthcare occupations. Please tell me which types you have prepared for when taking those classes. Choose all that apply.

  • Administrative (such as Medical Records and Health Information Technicians)

  • Technical (such as Medical and Clinical Laboratory Technicians)

  • Direct personal care (such as Home Health Aids or Certified Nursing Assistants)

  • Other, Please specify: _____________________________________________

  • REFUSED

  • DON’T KNOW



  1. In the next set of questions we are interested the highest level of education you have completed as of right now. I will first ask about the highest academic degree and then I will ask about the highest occupational training.

  1. As of right now, what is the highest degree or level of regular academic education that you have completed?

  • Grade 1 through 12 (no high school degree/GED)

  • High school diploma

  • GED or alternative credential

  • Some college credit but less than one year of college credit

  • One or more years of college credit, but no degree

  • Associate’s degree

  • Bachelor’s degree or above

  • REFUSED

  • DON’T KNOW

  1. As of right now, what is the highest level of occupational training that you have completed?

  • No formal training (GO TO INSTRUCTION BELOW Q25bi NEXT PAGE)

  • Some non-degree coursework or training, but no professional, state, or industry certificate, license, or credential (GO TO INSTRUCTION BELOW Q25bi NEXT PAGE)

  • A professional, state, or industry certificate, license, or credential (PROBE: A professional certification or license shows you are qualified to perform a specific job like Licensed Realtor, Certified Medical Assistant, Certified Construction Manager, or an IT certification) (ASK Q25bi BELOW)

  • Refused

  • Don’t know

  1. What type of professional, state, or industry certificate, license, or credential did you receive? (RECORD VERBATIM) ________________________________________________

IF ANSWERED “YES” TO Q1, CONTINUE.

IF DID NOT ANSWER “YES” TO Q1 (no training since RAD), GO TO INSTRUCTION ABOVE Q28 p.16.

Services and Assistance Received

In the next set of questions we are interested in the types of services and assistance you may have received since [RAD].

We will start with financial assistance. We are interested in helping you may have received paying for school-related expenses—such as tuition, books, and lab, certification or exam fees—or living expenses—such as rent, food, child care, and transportation while you studied.

  1. I’m going to read a list of funding sources of that you might have used to pay for these school or living expenses. For each item, please tell me if the funding source helped pay for these expenses since [RAD].


Yes

No

Don’t know

Refused

  1. Your own earnings

  1. Earnings from a spouse or partner

  1. Savings—either your own or a spouse/partner’s savings

  1. Financial help from a parent or other family member

  1. Loans in your name

  1. Loans in your parents’ name

  1. Pell grant or other government grant or scholarship—not counting loans that you have to pay back

  1. Grant or scholarship from any non-government source, such as a community based or nonprofit organization--not counting loans that you do not have to pay back

  1. Financial support from your employer

  1. Funds from a one-stop career center or state unemployment/employment office

  1. Financial support from a school, such as a technical, community, or four-year college

  1. Another funding source (specify: _______________________________)


IF ANSWERED “YES” IN ANY ITEM IN Q26a–l, CONTINUE.


IF DID NOT ANSWER “YES” IN ANY ITEM IN Q26a–l, GO TO Q27 p.15.


For each source you named, I am now going to ask which types of expenses were paid by the source.


  1. IF Q26a “YES”: Did your own earnings help pay for:


Yes

No

Don’t know

Refused

  1. Tuition and/or other school-related expenses?

  1. Living expenses?



  1. IF Q26b “YES”: Did your spouse/partner’s earnings help pay for:


Yes

No

Don’t know

Refused

  1. Tuition and/or other school-related expenses?

  1. Living expenses?



  1. IF Q26c “YES”: Did your own or your spouse/partner’s savings help pay for:


Yes

No

Don’t know

Refused

  1. Tuition and/or other school-related expenses?

  1. Living expenses?



  1. IF Q26d “YES”: Did the financial help from your parent or other family member help pay for:


Yes

No

Don’t know

Refused

  1. Tuition and/or other school-related expenses?

  1. Living expenses?



  1. IF Q26e “YES”: Did the loans in your name help pay for:


Yes

No

Don’t know

Refused

  1. Tuition and/or other school-related expenses?

  1. Living expenses?



  1. IF Q26f “YES”: Did the loans in your parents’ name help pay for:


    Yes

    No

    Don’t know

    Refused

    1. Tuition and/or other school-related expenses?

    1. Living expenses?

  2. IF Q26g “YES”: Did the Pell grant or other government grant or scholarship—not counting loans that you have to pay back help pay for:


Yes

No

Don’t know

Refused

  1. Tuition and/or other school-related expenses?

  1. Living expenses?



  1. IF Q26h “YES”: Did the grant or scholarship from any non-government source help pay for:


Yes

No

Don’t know

Refused

  1. Tuition and/or other school-related expenses?

  1. Living expenses?



  1. IF Q26i “YES”: Did the financial support from your employer help pay for:


Yes

No

Don’t know

Refused

  1. Tuition and/or other school-related expenses?

  1. Living expenses?



  1. IF Q26j “YES”: Did the funds from a one-stop career center or state unemployment/employment office help pay for:


Yes

No

Don’t know

Refused

  1. Tuition and/or other school-related expenses?

  1. Living expenses?



  1. IF Q26k “YES”: Did the financial support from a school help pay for:


Yes

No

Don’t know

Refused

  1. Tuition and/or other school-related expenses?

  1. Living expenses?


  1. IF Q26l “YES”: Did the [OTHER SOURCE SPECIFIED IN Q26l] help pay for:


Yes

No

Don’t know

Refused

  1. Tuition and/or other school-related expenses?

  1. Living expenses?


IF ANSWERED “YES” IN ANY ITEM IN Q26g–l, CONTINUE.


IF DID NOT ANSWER “YES” IN ANY ITEM IN Q26g–l, GO TO Q27 THIS PAGE.


  1. In your opinion, how helpful have HPOG staff been in helping you access these sources of funding that can help pay for school expenses, such as tuition, books, and lab or exam fees? Would you say the HPOG staff have been…

  • Very helpful

  • Somewhat helpful

  • Not at all helpful

  • Don’t know

  • Refused


  1. In your opinion, how helpful have HPOG staff been in helping you access these sources of funding that can help pay for living expenses, such as rent, food, child care, and transportation while you studied? Would you say the HPOG staff have been…

  • Very helpful

  • Somewhat helpful

  • Not at all helpful

  • Don’t know

  • Refused


  1. How difficult would you say it has been to obtain enough financial support for school? Would you say that it has been very difficult, somewhat difficult, or not very difficult to obtain enough financial support for school?

  • VERY DIFFICULT

  • SOMEWHAT DIFFICULT

  • NOT VERY DIFFICULT

  • REFUSED

  • DON’T KNOW

In the next set of questions we are interested in the types of services other than financial assistance that you may have received since [RAD].

  1. I’m going to read a list of types of services and assistance. Please let me know if you have received any of the following since [RAD]. Since [RAD], have you received [SERVICE FROM BELOW] from any source?


Yes

No

Don’t know

Refused

    1. Academic advising, such as help choosing courses

    1. Financial aid advising, for example, help completing a financial aid application or information on accessing available financial aid

    1. Tutoring in subjects where you needed extra help

    1. Career counseling

    1. Job search or placement assistance

    1. Help arranging for supports to help you manage school or work, for example, child care, transportation, housing, counseling/treatment for personal/family problems – sometimes called “case management”

    1. Assessments or tests to learn about your skills sets, such as WorkKeys, COMPASS, or TABE

    1. Personal counseling

    1. Peer support groups

    1. Emergency assistance, or funds to cover the costs of unexpected personal crisis, such as utility shut off or car repair

    1. Incentives, for example, a gift card for completing a course



IF ANSWERED “YES” IN ANY ITEM FROM Q28a–k, CONTINUE.


IF DID NOT ANSWER “YES” IN ANY ITEM FROM Q28a-k, GO TO INSTRUCTIONS BELOW Q27xii, p. 19.

For each support service you named, I am now going to ask how many times you received the service since [RAD].

  1. IF Q31a YES: About how many times did you receive academic advising?

  • 1-2

  • 3-4

  • 5-6

  • 7-8

  • 9+

  • REFUSED

  • DON’T KNOW

  1. IF Q31b YES: About how many times did you receive financial aid advising?

  • 1-2

  • 3-4

  • 5-6

  • 7-8

  • 9+

  • REFUSED

  • DON’T KNOW

  1. IF Q31c YES: About how many times did you receive tutoring?

  • 1-2

  • 3-4

  • 5-6

  • 7-8

  • 9+

  • REFUSED

  • DON’T KNOW

  1. IF Q31d YES: About how many times did you receive career counseling?

  • 1-2

  • 3-4

  • 5-6

  • 7-8

  • 9+

  • REFUSED

  • DON’T KNOW

  1. IF Q31e YES: About how many times did you receive job search or placement assistance?

  • 1-2

  • 3-4

  • 5-6

  • 7-8

  • 9+

  • REFUSED

  • DON’T KNOW

  1. IF Q31f YES: About how many times did you receive help arranging for supports or case management?

  • 1-2

  • 3-4

  • 5-6

  • 7-8

  • 9+

  • REFUSED

  • DON’T KNOW

  1. IF Q31g YES: About how many times have you taken comprehensive assessments?

  • 1-2

  • 3-4

  • 5-6

  • 7-8

  • 9+

  • REFUSED

  • DON’T KNOW

  1. IF Q31h YES: About how many times did you receive personal counseling?

  • 1-2

  • 3-4

  • 5-6

  • 7-8

  • 9+

  • REFUSED

  • DON’T KNOW

  1. IF Q31i YES: About how many times did you met with peer support groups?

  • 1-2

  • 3-4

  • 5-6

  • 7-8

  • 9+

  • REFUSED

  • DON’T KNOW

  1. IF Q31j YES: About how many times did you receive emergency assistance?

  • 1-2

  • 3-4

  • 5-6

  • 7-8

  • 9+

  • REFUSED

  • DON’T KNOW

  1. IF Q31k YES: About how many times did you receive incentives?

  • 1-2

  • 3-4

  • 5-6

  • 7-8

  • 9+

  • REFUSED

  • DON’T KNOW

  1. In your opinion, how helpful have HPOG staff been in providing or helping you access these support services? Would you say the HPOG staff have helped ….

  • A great deal

  • Some

  • Not at all

  • REFUSED

  • DON’T KNOW

IF DID NOT ANSWER “YES” TO Q1 (no training since RAD), GO TO EDUCATION GOALS SECTION p.21.

IF ANSWERED “YES” TO Q1, CONTINUE.



Now I’m going to ask you questions about your overall training experience since [RAD].

  1. During your overall training experience since [RAD], have you been offered any of the following opportunities for direct experiences with occupations related to your studies or career goals?


Yes

No

Don’t know

Refused

    1. Work study job

    1. Clinical experience or practicum

    1. Arranged visits from or to learn about individual employers

    1. Class taught by instructors from local employer or offered on-site at local employer

    1. An apprenticeship

    1. Other work experience (Please specify: __________)



IF DID NOT ANSWER “YES” IN ANY ITEM FROM Q29a–f, GO TO Q30 NEXT PAGE.


IF ANSWERED “YES” IN ANY ITEM FROM Q29a–f, CONTINUE.



    1. In your opinion, how helpful have HPOG staff been in providing or helping you access these kinds of opportunities for direct experiences with occupations related to your studies or career goals? Would you say the HPOG staff have been …

  • Very helpful

  • Somewhat helpful

  • Not at all helpful

  • Refused

  • Don’t know



  1. Think about all of the classes you have taken and all of the supports you received since [RAD]. In general, how satisfied were you with your overall training experience? Would you say you were …

  • Very satisfied

  • Somewhat satisfied

  • Not satisfied

  • Refused

  • Don’t know



  1. Since [RAD], how much emphasis has there been on being part of a community with other students, instructors, and staff? Would you say a great deal, some, or none?

  • A GREAT DEAL

  • SOME

  • NONE

  • REFUSED

  • DON’T KNOW

Education Goals

Now I’d like to talk to you a bit about your education goals.

IF ANSWERED “NO” TO Q1, (no training since RA) CONTINUE.

IF ANSWERED “YES” TO Q1 (training since RA), GO TO INSTRUCTIONS ABOVE Q33 NEXT PAGE.



  1. Can you tell me the main reason why you have not enrolled in school since [RAD]?

DO NOT READ LIST, RECORD FULL ANSWER AND THEN BACKFILL ONE RESPONSE

    • You don’t feel you need more education right now?

    • You are waiting to apply for a particular program?

    • You aren’t sure what would be the best program for you?

    • You don’t think you have strong enough academic skills/credentials?

    • You don’t have enough time due to work?

    • You don’t have enough time due to family responsibilities?

    • You don’t think you could get enough financial aid to afford to go?

    • You haven’t been able to get into the kind of program you wanted?

    • Some other reason? Please specify: ________________________

    • Refused (GO TO Q34 NEXT PAGE)

    • Don’t know (GO TO Q34 NEXT PAGE)


  1. Are there other important reasons why you have not enrolled in school since [RAD]?

  • Yes (CONTINUE)

  • No (GO TO Q34 NEXT PAGE)

  • Refused (GO TO Q34 NEXT PAGE)

  • Don’t know (GO TO Q34 NEXT PAGE)


  1. What are the other important reasons why you have not enrolled in school since [RAD]?

DO NOT READ LIST, RECORD FULL ANSWER AND THEN BACKFILL ONE RESPONSE


    • You don’t feel you need more education right now

    • You are waiting to apply for a particular program

    • You aren’t sure what would be the best program for you

    • You don’t think you have strong enough academic skills/credentials

    • You don’t have enough time due to work

    • You don’t have enough time due to family responsibilities

    • You don’t think you could get enough financial aid to afford to go

    • You haven’t been able to get into the kind of program you wanted

    • Other (please specify: ____________________ )

    • Refused

    • Don’t know



IF ANSERED “NO” TO Q1a (not currently enrolled), CONTINUE.

IF ANSWERED “YES” TO Q1a (currently enrolled), GO TO Q34 THIS PAGE

  1. IF NOT CURRENTLY ENROLLED: Are you planning to go back to school at some point?

  • YES

  • NO

  • REFUSED

  • DON’T KNOW



  1. In the next set of questions we are interested the highest level of education you eventually expect to complete. I will first ask about the highest academic degree and then I will ask about the highest level of occupational training.



  1. What is the highest level of regular academic education that you eventually expect to complete?

  • Grades 1-12 (no high school degree/GED)

  • High school diploma

  • GED or alternative credential

  • Some college credit but less than one year of college credit

  • One or more years of college credit, but no degree

  • Associate’s degree

  • Bachelor’s degree

  • Graduate degree

  • REFUSED

  • DON’T KNOW



  1. What is the highest level of occupational training that you eventually expect to complete?

  • No formal training

  • Some non-degree coursework or training, but no professional, state, or industry certificate, license, or credential.

  • A professional, state, or industry certificate, license, or credential. PROBE: A professional certification or license shows you are qualified to perform a specific job like Licensed Realtor, Certified Medical Assistant, Certified Construction Manager, or an IT certification.

  • REFUSED

  • DON’T KNOW



  1. How much do you agree or disagree with the following statement: I am making progress towards my long-range educational goals? Would you say you strongly agree, somewhat agree, somewhat disagree, strongly disagree?

  • Strongly agree

  • Somewhat agree

  • Somewhat disagree

  • Strongly disagree

  • REFUSED

  • DON’T KNOW

Healthcare and Employment Experience

This next set of questions, I’d like to ask you about your current employment and healthcare experiences. I’ll start with questions about your current employment.

  1. Are you currently working at a job for pay?

  • YES (ASK CONTINUE)

  • NO (GO TO Q37 p.25)

  • REFUSED (GO TO Q37 p.25)

  • DON’T KNOW (GO TO Q37 p.25)

  1. How many hours per week on average are you currently working? Include all jobs if you have more than one job.

___ ___ ___ number of hours

  • Refused

  • Don’t know


  1. About how much do you typically earn per hour before taxes in your current job? Answer for your main job if more than one.

$___ ___ ___ . ___ ___ per hour (GO TO Q36c THIS PAGE)

  • Refused (CONTINUE)

  • Don’t know (GO TO Q36c THIS PAGE)


  1. [IF R DOESN’T KNOW HOURLY RATE]: Can you tell me how much you earned for some other time period besides hourly, such as per day, per week, every two weeks, or month?

$ ___ ___ ___ . ___ ___ PER DAY

$ ___ ___ ___ . ___ ___ PER WEEK

$ ___ ___ ___ . ___ ___ EVERY 2 WEEKS/TWICE A MONTH

$ ___ ___ ___ . ___ ___ EVERY MONTH

$ ___ ___ ___ . ___ ___ PER JOB/PER PIECE

$ ___ ___ ___. ___ ___ PER COMMISSION

$ ___ ___ ___ . ___ ___ ANNUALLY



  1. Do you work for a healthcare employer?

  • YES (GO TO Q36d NEXT PAGE)

  • NO (ASK Q36di BELOW)

  • REFUSED (ASK Q36di BELOW)

  • DON’T KNOW (ASK Q36di BELOW)

  1. Have you worked for a healthcare employer since [RAD]?

  • Yes

  • No

  • Refused

  • Don’t know


  1. Are you employed in a healthcare job?

  • YES (GO TO Q36dii THIS PAGE)

  • NO (ASK Q36di BELOW)

  • REFUSED (ASK Q36di BELOW)

  • DON’T KNOW (ASK Q36di BELOW)

  1. Have you worked in a healthcare job since [RAD]?

  • Yes (ASK Q36dii BELOW)

  • No (GO TO Q36diii THIS PAGE)

  • Refused (GO TO Q36diii THIS PAGE)

  • Don’t know (GO TO Q36diii THIS PAGE)


  1. I am going to read you a list of types of healthcare occupations. Please tell me which type best describes the healthcare jobs you have had since [RAD]. (Choose all that apply if you have had more than one healthcare job since [RAD].):

  • Administrative (such as Medical Records and Health Information Technicians)

  • Technical (such as Medical and Clinical Laboratory Technicians)

  • Direct personal care (such as Home Health Aids or Certified Nursing Assistants)

  • Other, Please specify

  • REFUSED

  • DON’T KNOW



GO TO Q36e, THIS PAGE



  1. IF DID NOT WORK IN HEALTHCARE SINCE RAD: What kind of work do you do in your current job, that is, what is your occupation? If you have more than one job, please answer for your main job.

__________________________________________________________________

  • Refused

  • Don’t know



  1. What is your current job title? If you have more than one job, please answer for your main job.

________________________________________________________________________

  • Refused

  • Don’t know





  1. At your current job, does your employer offer health insurance, regardless of whether you take it from them?

  • YES (GO TO Q36fi BELOW)

  • NO (GO TO Q36fii THIS PAGE)

  • REFUSED (GO TO Q36fii THIS PAGE)

  • DON’T KNOW (GO TO Q36fii THIS PAGE)

  1. IF YES INSURANCE: Do you receive insurance through your employer?

  • YES (GO TO CAREER GOALS SECTION p.28)

  • NO (GO TO Q36fii BELOW)

  • REFUSED (GO TO Q36fii BELOW)

  • DON’T KNOW (GO TO Q36fii BELOW)



  1. IF NO EMPLOYER INSURANCE: Do you receive insurance from another source?

  • YES (GO TO CAREER GOALS SECTION p.28)

  • NO (GO TO CAREER GOALS SECTION p.28)

  • REFUSED (GO TO CAREER GOALS SECTION p.28)

  • DON’T KNOW (GO TO CAREER GOALS SECTION p.28)



  1. IF 36 “NO” (NOT EMPLOYED): Have you worked at a job for pay since [RAD]?

  • Yes (CONTINUE)

  • No (GO TO CAREER GOALS SECTION p.28)

  • Refused (GO TO CAREER GOALS SECTION p.28)

  • Don’t know (GO TO CAREER GOALS SECTION p.28)



  1. How many hours per week on average were you working at your most recent job? Include all jobs at that time if you had more than one job.

___ ___ ___ number of hours

  • Refused

  • Don’t know



  1. About how much did you typically earn per hour before taxes in your most recent job? If you had more than one job, please answer for your main job.

$___ ______ ___ . ___ ___ per hour (GO TO Q37c NEXT PAGE)

  • Refused (GO TO Q37c NEXT PAGE)

  • Don’t know (ASK Q37bi BELOW)



  1. IF DOESN’T KNOW HOURLY RATE: Can you tell me how much you earned for some other time period besides hourly, such as per day, per week, every two weeks, or month?

$ ___ ___ ______ ___ PER DAY

$ ___ ___ ___ ___ ___ PER WEEK

$ ___ ___ ___ ___ ___ EVERY 2 WEEKS/TWICE A MONTH

$ ___ ___ ______ ___ EVERY MONTH

$ ___ ___ ___ ___ ___ PER JOB/PER PIECE

$ ___ ___ ___ ___ ___ PER COMMISSION

$ ___ ___ ______ ___ ANNUALLY



  1. Have you worked for a healthcare employer since [RAD]?

  • Yes

  • No

  • Refused

  • Don’t know



  1. Have you worked in a healthcare job since [RAD]?

  • Yes (ASK Q37di BELOW)

  • No (GO TO Q37dii THIS PAGE)

  • Don’t know (GO TO Q37dii THIS PAGE)

  • Refused (GO TO Q37dii THIS PAGE)



  1. IF YES: I am going to read you a list of types of healthcare occupations. Please tell me which type best describes the healthcare jobs you have had since [RAD]. Choose all that apply if you have had more than one healthcare job since [RAD].

  • Administrative (such as Medical Records and Health Information Technicians)

  • Technical (such as Medical and Clinical Laboratory Technicians)

  • Direct personal care (such as Home Health Aids or Certified Nursing Assistants)

  • Other (Please specify: ________________________________________)

  • Refused

  • Don’t know



GO TO Q37e, THIS PAGE



  1. IF HAVE NOT WORKED IN HEALTHCARE SINCE RAD: What kind of work did you do in your most recent job, that is, what was your occupation? If you had more than one job, please answer for your main job.

_______________________________________________

  • Refused

  • Don’t know



  1. What was your job title at your most recent job? If you had more than one job, please answer for your main job.

_______________________________________________

  • Refused

  • Don’t know



  1. At your most recent job, did your employer offer health insurance, regardless of whether you took it from them?

  • Yes (GO TO Q37fi NEXT PAGE)

  • No (GO TO Q37fii NEXT PAGE)

  • Refused (GO TO Q37fii NEXT PAGE)

  • Don’t know (GO TO Q37fii NEXT PAGE)



  1. IF YES: Did you receive insurance through your employer?

  • Yes (GO TO CAREER GOALS SECTION NEXT PAGE)

  • No (GO TO Q37gii BELOW)

  • Refused (GO TO Q37gii BELOW)

  • Don’t know (GO TO Q37gii BELOW)



  1. IF NO: Did you receive insurance from another source?

  • Yes

  • No

  • Refused

  • Don’t know

Career Goals

Now I’d like to talk to you a bit about your career goals.



  1. I am going to read you two statements. Please tell me whether you would you say you strongly agree, somewhat agree, somewhat disagree, or strongly disagree with the following statements:


Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

Don’t know

Refused

    1. I am making progress towards my long-range employment goals.

    1. I see myself on a career path.



  1. Do you expect to be working for pay in the next six months?

    • Yes (CONTINUE)

    • No (GO TO Q40 THIS PAGE)

  • REFUSED (GO TO Q40 THIS PAGE)

  • DON’T KNOW (GO TO Q40 THIS PAGE)

  1. How many hours do you expect to be working in a typical week?

__ __ __ number of hours

    • Refused

    • Don’t know



  1. Do you expect to be working in a healthcare job or for a healthcare employer?

    • Yes

    • No

  • REFUSED

  • DON’T KNOW



  1. I am going to read you two statements about your work preferences. Please tell me whether you would say you strongly agree, somewhat agree, somewhat disagree, or strongly disagree with the following statements:

  1. [IF ANSWERED “YES” IN Q36 (currently working): If I was not currently working, I would/[If ANSWERED “NO” IN Q36 (not currently working): I will] take any job even if the pay is low.

  • Strongly agree

  • Somewhat agree

  • Somewhat disagree

  • Strongly disagree

  • Refused

  • Don’t know


  1. [IF ANSWERED “YES” IN Q36 (currently working): If I was not currently working, I would]/[If ANSWERED “NO” IN Q36 (not currently working): I] want only the kind of job that is related to my training/education?

  • Strongly agree

  • Somewhat agree

  • Somewhat disagree

  • Strongly disagree

  • Refused

  • Don’t know



  1. How much must a job pay per hour for it to make sense for you to take it?

$___ ___ ___ . ___ ___ per hour

    • Refused

    • Don’t know



  1. I am going to read you a list of statements. Please tell me how important is each of the following to you in your life (not, somewhat, or very)?


Very important

Somewhat important

Not important

Don’t know

Refused

    1. Being successful in my line of work

    1. Having lots of money

    1. Being able to find steady work

    1. Becoming an expert in my field of work

    1. Getting a good job



Knowledge of Career Opportunities in Healthcare

Now I’d like to get a sense of your understanding of healthcare related career opportunities in your local area.



  1. Would you say you know the kind of careers that are available in healthcare in your local area?

  • Yes (ASK Q43a BELOW)

  • No (GO TO INSTRUCTIONS BELOW Q43a NEXT PAGE)

  • Refused (GO TO INSTRUCTIONS BELOW Q43a NEXT PAGE)

  • Don’t know (GO TO INSTRUCTIONS BELOW Q43a NEXT PAGE)


    1. What type of credential or degree do you need to qualify for a job like the kinds that you just reported to be available in your local area? Choose one.

  • Certificate, license, or credential

  • Associate’s Degree

  • Bachelor’s degree or higher

  • Work experience/on-the-job training

  • Other reason (please specify: ____________________________)

IF ANSWERED “NO” IN Q36 (not currently working), GO TO BARRIERS IN EMPLOYMENT SECTION p.32.


IF ANSWERED “YES” IN Q36 (currently working), CONTINUE.


  1. In your current job, are there promotion opportunities?

    • Yes (ASK Q44a BELOW)

    • No (GO TO BARRIERS IN EMPLOYMENT SECTION p.32)

  • REFUSED (GO TO BARRIERS IN EMPLOYMENT SECTION p.32)

  • DON’T KNOW (GO TO BARRIERS IN EMPLOYMENT SECTION p.32)



    1. IF YES: Would you need additional education or training to be promoted?

    • Yes (ASK Q44ai BELOW)

    • No (GO TO BARRIERS IN EMPLOYMENT SECTION p.32)

  • REFUSED (GO TO BARRIERS IN EMPLOYMENT SECTION p.32)

  • DON’T KNOW (GO TO BARRIERS IN EMPLOYMENT SECTION p.32)



  1. What type of credential or degree do you need to be promoted? Choose one.

  • Certificate, license, or credential

  • Associate’s Degree

  • Bachelor’s degree or higher

  • Work experience/on-the-job training

  • Other reason (specify)

  • Refused (GO TO BARRIERS IN EMPLOYMENT SECTION p.32)

  • Don’t know (GO TO BARRIERS IN EMPLOYMENT SECTION p.32)



  1. About how long would it take you to earn the credential or degree?

  • 0-3 months

  • 4-6 months

  • 6 months to a year

  • More than a year

  • Refused

  • Don’t know



Barriers to Employment

There are many things that could affect a person’s ability to go to school or work, search for jobs, and manage family responsibilities. The next few questions are about these situations



  1. In the past 12 months, how often did each of the following situations interfere with your school, work, job search, or family responsibilities:


Never

Sometimes

Very often

Don’t know

Refused

    1. Child care arrangements?

    1. Transportation?

    1. Alcohol or drug use?

    1. An illness or health condition?

    1. Other, please specify:

_______________________________



  1. How difficult do you think it is to get a job in your chosen field or occupation?

  • Not difficult (GO TO Perceived Self-Efficacy and Motivation SECTION NEXT PAGE)

  • Somewhat difficult (CONTINUE)

  • Very difficult (CONTINUE)

  • Refused (CONTINUE)

  • Don’t know (CONTINUE)



    1. Do you think any of the following situations make it difficult? Choose all that apply.

    • Child care arrangements?

    • Transportation?

    • Alcohol or drug use?

    • An illness or health condition?

    • Lack of required education?

    • Lack of experience?

    • Lack of job openings?

    • Other (Please specify)

    • Refused

    • Don’t know




Perceived Self-Efficacy and Motivation

  1. In general, some people have an easier or harder time with these kinds of problems or difficulties. How true do you believe are the following statements: (1 = Not at all true, 2 = Somewhat true, 3 = Mostly true, 4 = Entirely true)


Not at all true

Some­what true

Mostly true

Entirely true

Don’t know

Refused

  1. I can always manage to solve difficult problems if I try hard enough.

  1. It is easy for me to stick to my aims and accomplish my goals.

  1. I am confident that I could deal efficiently with unexpected events.

  1. Thanks to my resourcefulness, I know how to handle unforeseen situations.

  1. I can solve most problems if I invest the necessary effort.

  1. I can remain calm when facing difficulties because I can rely on my coping abilities.

  1. When I am confronted with a problem, I can usually find several solutions.

  1. If I am in trouble, I can usually think of a solution.

  1. I can usually handle whatever comes my way.



Income and Household

Now I’d like to talk to you about your family and current household.


  1. Besides you, who among the following live in your household at least half the time?

    1. Your spouse

  • Yes (GO TO Q48c THIS PAGE)

  • No (ASK Q48b BELOW)

  • Refused (ASK Q48b BELOW)

  • Don’t know (ASK Q48b BELOW)


    1. IF NO SPOUSE: Your unmarried partner

  • Yes

  • No

  • Refused

  • Don’t know


    1. Your [IF Q48b “YES” (UNMARRIED PARTNER): or your partner’s] biological, adopted, or step children aged 17 or younger

  • Yes

  • No

  • Refused

  • Don’t know


    1. Other relatives aged 17 or younger such as younger siblings, nephews and nieces [IF Q48b “YES” (LIVES WITH PARTNER): of yours or your partner’s]

  • Yes

  • No

  • Refused

  • Don’t know


    1. Your mother or father [IF Q48a “YES” (LIVES WITH SPOUSE): or your in-laws)/IF Q48b “YES” (LIVES WITH PARTNER): or your partner’s mother or father]

  • Yes

  • No

  • Refused

  • Don’t know


    1. Your adult children or other relatives aged 18 or older [IF Q48b “YES” (LIVES WITH PARTNER): or those of your partner]

  • Yes

  • No

  • Refused

  • Don’t know


    1. Anyone else aged 17 or younger such as children of friends or housemates

  • Yes

  • No

  • Refused

  • Don’t know


    1. Anyone else aged 18 or older such as friends or housemates

  • Yes

  • No

  • Refused

  • Don’t know


IF ANSWERED “NO” IN Q48c, Q48d, AND Q48g (NO CHILDREN 17 OR YOUNGER), GO TO INSTRUCTIONS BELOW Q50 THIS PAGE.


IF ANSWERED “YES” IN Q48c, Q48d, AND Q48g (CHILDREN 17 OR YOUNGER), CONTINUE.


  1. How many persons aged 17 or younger live with you at least half the time? Include biological, adopted, foster, step, and any other children, as well as younger siblings.

___ ___ number of persons 17 or younger

  • Refused

  • Don’t know


  1. For how many of these children are you or your [IF 48a “YES” MARRIED: spouse/[IF 48b “YES” UNMARRIED PARTNER: partner] the legal guardian?

___ ___ number of children

  • Refused

  • Don’t know


Now, I am going to ask you some questions about your personal and household income in (PRIOR MONTH). I will ask you first about your personal income then I will ask about the income of other members of your household. Again, I want to assure you that none of your answers will be discussed with anyone.


  1. Did you personally have income or benefits from any of the following sources in [PRIOR MONTH]?


Yes

No

Don’t know

Refused

  1. Temporary Assistance for Needy Families (TANF)

  1. Supplemental Nutrition Assistance Program (SNAP) / Food Stamps

  1. Women, Infants and Children Program (WIC)

  1. Unemployment Insurance (UI) or Worker’s Compensation

  1. Medicaid

  1. Subsidized Child Care

  1. Section 8 / Public Housing

  1. Low Income Home Energy Assistance Program (LIHEAP)

  1. Free or reduced lunch program

  1. Job earnings (including tips)

  1. Child Support (official or unofficial)

  1. Family and friends (who did not live with you at least half of the time last month)

  1. Grants or loans for school

  1. Other source of income. Please specify.


  1. IF ANSWERED “YES” IN Q51j: About how much did you receive in job earnings in [PRIOR MONTH]?

$___ ___ ___ ___ . ___ ___


  1. Thinking of all of the income you received last month, what was your total personal income in (PRIOR MONTH)? Please include your job earnings, benefits, and any other types of income except for tax refunds in your answer. [EXPLAIN IF NECESSARY: PLEASE DO NOT INCLUDE ANY REFUNDS OF FEDERAL, STATE OR LOCAL INCOME TAXES PAID IN PAST YEARS].

$ ____________________ (GO TO INSTRUCTIONS BELOW Q53a NEXT PAGE)

  • Refused (CONTINUE)

  • Don’t know (CONTINUE)


  1. Would you say your total personal income in [PRIOR MONTH] was…

  • None ($0)

  • $500 or less

  • $501-$1000

  • $1001-$1500

  • $1501-$2000

  • $2001-$2500

  • $2501 or more

  • Refused

  • Don’t know


IF ANSWERED “NO” TO ALL ITEMS IN Q48a—Q48h (NO OTHER HOUSEHOLD MEMEBRS), GO TO CONTACT INFORMATION SECTION p.38.


IF ANSWERED “YES” TO ANY ITEM IN Q51a—Q51j (OTHER HOUSEHOLDMEMBERS), CONTINUE.


  1. Now, let’s go through the same list of income sources for other household members who lived with you at least half the time last month. In [PRIOR MONTH] did anyone else in your household have income or benefits from any of the following sources?



Yes

No

Don’t know

Refused

  1. Temporary Assistance for Needy Families (TANF)

  1. Supplemental Nutrition Assistance Program (SNAP) / Food Stamps

  1. Women, Infants and Children Program (WIC)

  1. Unemployment Insurance (UI) or Worker’s Compensation

  1. Medicaid

  1. Subsidized Child Care

  1. Section 8 / Public Housing

  1. Low Income Home Energy Assistance Program (LIHEAP)

  1. Free or reduced lunch program

  1. Job earnings (including tips)

  1. Child Support (official or unofficial)

  1. Family and friends (who did not live with you at least half of the time last month)

  1. Grants or loans for school

  1. Other source of income. Please specify.



  1. Thinking of all of the income received by you and the people in your household last month, what was your total income for everyone living together in your household in [PRIOR MONTH]? Please consider anyone who lived in your household for at least half of [PRIOR MONTH] when you answer this question. Please don’t include tax refunds in your answer. [EXPLAIN IF NECESSARY: PLEASE DO NOT INCLUDE ANY REFUNDS OF FEDERAL, STATE OR LOCAL INCOME TAXES PAID IN PAST YEARS].


$ __________________ (GO TO CONTACT INFORMATION SECTION NEXT PAGE)

  • Refused (CONTINUE)

  • Don’t know (CONTINUE)


  1. Which of the following categories best describes your total household income? Please consider income received by anyone who lived in your household for at least half of [PRIOR MONTH] when you answer this question. Would you say your total household income in [PRIOR MONTH] was…

  • None ($0)

  • $500 or less

  • $501-$1000

  • $1001-$1500

  • $1501-$2000

  • $2001-$2500

  • $2501 or more

  • Refused

  • Don’t know



Contact Information

Before we complete this portion of the interview, I would also like to make sure I have your contact information recorded correctly.

  1. I have your name recorded as [FIRST MI LAST]. Is this still correct or have you changed your name?

  • YES, STILL CORRECT (GO TO Q56 THIS PAGE)

  • NO, NAME CHANGED


  1. Your first name now?:

  2. Your last name now?:


  1. I have your address recorded as [STREET, APT, CITY, STATE, ZIP]. Is this still correct or have you moved?

  • YES, STILL CORRECT (GO TO Q57 THIS PAGE)

  • NO, MOVED

  • Refused

  • Don’t know

  1. What is your new street address or PO box number?

  2. Is there a complex or building name?

  3. Is there an apartment number?

  4. In what city?

  5. In what state?

  6. What is the zip code?


  1. I have your primary phone number recorded as [xxx-xxx-xxxx]. Is this still correct or do you have a new primary phone number?

  • YES, STILL CORRECT (GO TO Q58 THIS PAGE)

  • NO, NEW NUMBER

  • Refused

  • Don’t know

  1. IF YES: What is the new number, starting with the area code?

  2. IF YES: Is that a home, cell, shelter, work, or other number?

  • Home

  • Cell

  • Shelter

  • Work

  • Other

  1. I have your secondary phone number recorded as [xxx-xxx-xxxx]. Is this still correct or do you have a new secondary number?

  • YES, STILL CORRECT (GO TO Q59 NEXT PAGE)

  • NO, NEW NUMBER

  1. What is the new number, starting with the area code?

  1. Is that a home, cell, shelter, work, or other number?

  • Home

  • Cell

  • Shelter

  • Work

  • Other


  1. Do you have another phone number where we can reach you? This can be your cell phone or work number.

  • YES (CONTINUE)

  • NO (GO TO Q60 THIS PAGE)

  • Refused (GO TO Q60 THIS PAGE)

  • Don’t know (GO TO Q60 THIS PAGE)


  1. What is the number, starting with the area code?

  1. Is that a home, cell, shelter, work, or other number?

  • Home

  • Cell

  • Shelter

  • Work

  • Other

REPEAT Q59 UNTIL ALL PHONE NUMBERS ARE RECORDED


  1. I have your email address recorded as [xxx@xxx.xxx]. Is this still correct or do you have a new email address?

  • YES, CORRECT (GO TO Q61 THIS PAGE)

  • NO, NEW EMAIL

  • Refused

  • Don’t know


  1. What is your new email address?


  1. Do you have any other email addresses?

  • YES

  • NO (GO TO PARAGRAPH ABOVE Q62 THIS PAGE)

  • Refused (GO TO PARAGRAPH ABOVE Q62 THIS PAGE)

  • Don’t know (GO TO PARAGRAPH ABOVE Q62 THIS PAGE)


  1. What is the additional email address?


REPEAT Q61 UNTIL ALL EMAIL ADDRESSES ARE RECORDED

Thank you very much for your time today. To help us be able to get back in touch with you in the future, we would like to review the names, telephone numbers and addresses of the two people you previously mentioned who will always know how to reach you. This information will be kept strictly private and will only be used if we are unable to contact you.


  1. When you applied for [PROGRAM NAME] you said that [CONTACT #1] was a person who would always know where you are and how to reach you. Is [CONTACT#1] still a person who does not live with you and will always know how to contact you?

  • YES (VERIFY CONTACT INFORMATION)

  • NO (ASK Q62a NEXT PAGE)

  • Refused (ASK Q62a NEXT PAGE)

  • Don’t know (ASK Q62a NEXT PAGE)


  1. Could you please tell me the name of a person who does not live with you and will always know how to contact you?

  • YES (ASK Q62ai BELOW)

  • NO (GO TO Q63 THIS PAGE)

  • Refused (GO TO Q63 THIS PAGE)

  • Don’t know (GO TO Q63 THIS PAGE)


IF YES:

  1. What is his/her first name?

  2. What is his/her middle name?

  3. What is his/her last name?

  4. Does his/her name have a suffix?

  5. What is the street address or PO box number?

  6. Is there a complex or building name?

  7. Is there an apartment number?

  8. In what city?

  9. In what state?

  10. What is the zip code?

  11. What is [his/her] home phone number, starting with the area code?

  12. What is [his/her] cell phone number, starting with the area code?

  13. What is [his/her] email address?

  14. What is [his/her] relationship to you?

  • Friend

  • Relative

  • Other (Specify:)

  • Refused

  • Do not know


  1. When you applied for [PROGRAM NAME] you said that [CONTACT #2] was a person who would always know where you are and how to reach you. Is [CONTACT#2] still a person who does not live with you and will always know how to contact you?

  • YES (VERIFY CONTACT INFORMATION)

  • NO (ASK Q63a THIS PAGE)

  • Refused (ASK 63a THIS PAGE)

  • Don’t know (ASK 63a THIS PAGE)


  1. Could you please tell me the name of another person who does not live with you and will always know how to contact you?

  • YES (ASK Q63ai BELOW)

  • NO (GO TO INSTRUCTIONS BELOW Q63xiv NEXT PAGE)

  • Refused (GO TO INSTRUCTIONS BELOW Q63xiv NEXT PAGE)

  • Don’t know (GO TO INSTRUCTIONS BELOW Q63xiv NEXT PAGE)


IF YES:

  1. What is his/her first name?

  2. What is his/her middle name?

  3. What is his/her last name?

  4. Does his/her name have a suffix?

  5. What is the street address or PO box number?

  6. Is there a complex or building name?

  7. Is there an apartment number?

  8. In what city?

  9. In what state?

  10. What is the zip code?

  11. What is [his/her] home phone number, starting with the area code?

  12. What is [his/her] cell phone number, starting with the area code?

  13. What is [his/her] email address?

  14. What is [his/her] relationship to you?

  • Friend

  • Relative

  • Other (Specify:)

  • Refused

  • Do not know


Thank you very much for your time today.



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorJennifer Lewis
File Modified0000-00-00
File Created2021-01-24

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