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pdfATTACHMENT I
YOUTH SURVEY INSTRUMENT
OMB ControlOMB
#: CONTROL
0960-0799
# XXXX
OMB
EXPIRATION
DATE:
XX/XX/XXXX
Expiration Date: xx/xx/xxxx
PROMISE 18-Month Follow-Up Surveys:
Youth Questionnaire
Draft 3: December 15, 2014
Administrative Notes:
•
The surveys will be administered beginning 19 months after random assignment anniversary date (to
allow for a full 18 months of exposure to services). This instrument is designed in an intervieweradministered format. The parent and youth modules are each designed to take approximately 25
minutes to complete.
•
Consent for participation in both interviews (parent, youth, 18-month and 5-year) was collected from
parent during enrollment in PROMISE. All youth provided assent at the time of enrollment.
•
The target respondent for the parent survey is the parent or guardian who completed the consent
form at the time of enrollment. However, if this parent is not willing or able to take part in the
interview, the youth’s other parent or guardian who resides in the same household as youth could
complete the interview.
•
Parent modules will be completed first, followed by the youth modules. Youth may complete the youth
modules him or herself, or with support from a parent / guardian or other trusted adult. If a youth is
not able to complete his / her interview – these modules may be completed by a proxy. If a proxy
interview is conducted, no items that are subjective in nature will be included in the interview.
•
Interviews will be conducted in English or Spanish. Formatting is used to guide interviewing staff on
question administration. Text shown in ALL CAPS is not read aloud. Text in underline format is
emphasized.
•
Programming logic will be used to route respondents to the next applicable item or section based on
responses provided. The target universe for each item (based on skip logic or other criteria, such as
age), is shown in the bar located above the item number.
•
Logic for which set of respondents complete specific sections are shown in the section outline as well
as in the programming specifications at the start of each section.
•
o
For cases where the youth lives apart from a parent or guardian (such as in a group home or
institutional setting), we will interview the parent or guardian who is most knowledgeable
about the youth’s education and services received.
o
Youth identified as living in their own household, apart from parents or guardians, will
respond to a subset of the parent modules during the youth interview. In these cases, the
parent module will be completed by the parent who provided consent at enrollment.
If a youth is found to be deceased, the case will be coded as ineligible and no further contact will be
attempted.
PROMISE:
18-MONTH
YOUTH
QUESTIONNAIRE
YOUTH MODULES
VII.
Youth: Introduction
VIII.
Youth Education
IX.
Youth Employment, Credentials & Work-Based
Experiences
X.
Youth Service Receipt in Past 18 months
XI.
Youth’s Self-Determination and Expectations for the
Future
XII.
Youth’s Health and Well-Being
XIII.
Youth Demographics and Contact Information
2|Page
Asked of
Self-Reporting Youth
Asked of
Youth’s Proxy
Respondent
x
x
x
x
x
x
x
x
x
x
x
x
x
YOUTH INTRODUCTION
VII.
Youth: Introduction
Asked of
Self-Reporting Youth
Asked of Youth’s
Proxy Respondent
x
x
SECTION VII. PART A. YOUTH INTRODUCTION
ALL
[INTERVIEWER’S FULL NAME], [YOUTH] [NAME OF PARENT SURVEY RESPONDENT (I.Q1 OR I.Q2
RESPONSE POPULATED]
VII.A1.
HI! My name is [INTERVIEWER’S FULL NAME]. I’m calling from Mathematica Policy Research on
behalf of the Social Security Administration as part of an important national study. May I please
speak to [YOUTH]?
IF NEEDED: We have completed an interview with [NAME OF PARENT SURVEY RESPONDENT
(I.Q1 OR I.Q2 RESPONSE POPULATED], and we are calling to begin [YOUTH]’s interview now.
INTERVIEWER: IF SPEAKING TO PROXY (FROM PARENT / GUARDIAN INTERVIEW), SELECT “3”
BELOW.
CODE ONE ONLY
SPEAKING TO YOUTH ........................................................................................ 1
CONTINUE
YOUTH COMES TO THE PHONE ....................................................................... 2
CONTINUE
SPEAKING TO YOUTH’S PROXY ....................................................................... 3
CONTINUE
WHAT IS CALL ABOUT ....................................................................................... 4
CONTINUE
YOUTH BUSY, UNAVAILABLE, NOT HOME ..................................................... 5
BARRIER
YOUTH MOVED/LIVES ELSEWHERE ............................................................... 6
BARRIER
YOUTH SPEAKS SPANISH [SPANISH-SPEAKING INTERVIEWER] ................ 7
CONTINUE
YOUTH DOES NOT SPEAK ENGLISH OR SPANISH ........................................ 8
BARRIER
YOUTH HAS HEALTH PROBLEM ....................................................................... 9
BARRIER
YOUTH IN INSTITUTION ..................................................................................... 10
UNAVAILABLE
YOUTH DECEASED ............................................................................................ 11
INELIGIBLE
WRONG NUMBER ............................................................................................... 12
BARRIER
HUNG UP DURING INTRODUCTION ................................................................. 13
BARRIER
3|Page
YOUTH INTRODUCTION
VII.A1=1-4 OR 7
[YOU / YOUTH] [PROMISE PROGRAM NAME] [FILL $30 IF DATE OF INTERVIEW IS > 10 DAYS FROM
SAMPLE RELEASE DATE, FILL $40 IF DATE OF INTERVIEW IS < 10 DAYS FROM RELEASE DATE].
VII.A2.
About a year and a half ago, [you / YOUTH] enrolled in a research study through [PROMISE
PROGRAM NAME]. [You may remember completing / YOUTH completed] a form where [you /
YOUTH] agreed to take part in two interviews. This is the first one. The next one will be about
three years from now.
This interview takes about 25 minutes to complete. There are questions about [your / YOUTH’S]
education, experiences with jobs, services [you / YOUTH] may have received, [your / YOUTH’S]
hopes for the future, and some general information about [your / YOUTH’S] day-to-day life.
You will get a [$30 / $40] gift card for completing it.
IF NEEDED:
•
•
•
•
•
The questions have been worded so you can answer for yourself. If you wish, you can ask
someone to stay nearby in case you need help.
All of your answers will be held in strict confidence.
Nothing you say will affect [your / YOUTH’s] SSI benefits now or in the future.
Most questions are worded so young people can answer for themselves.
We can start now and take a break if you need one.
YES - CONTINUE INTERVIEW WITH YOUTH ................................................... 1
YES - CONTINUE INTERVIEW WITH YOUTH’S PROXY................................... 2
NOT A GOOD TIME ............................................................................................. 3
BARRIER
REFUSED ............................................................................................................. 4
BARRIER
4|Page
YOUTH INTRODUCTION
VII.A2. = 1 OR 2
VII.A2_1.
Before we begin, I want to confirm that you read in the letter that we sent you. In it there
was information about how SSA can use and share the information you provide. I can read
it to you now if you didn’t read it in the letter.
Section 1110 of the Social Security Act, as amended, authorizes us to request this
information. We will use this information to evaluate the impact of services provided to
you (the minor participant or household member) during your participation in the
Promoting Readiness of Minors in SSI (PROMISE) project. Providing us this information is
voluntary. Failing to provide us with all or part of the information will not affect the SSI
benefits that you, your child, or other household members receive now or in the future.
We may use the information for the administration of our programs, including sharing
information:
1.
To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and the Department of Veterans Affairs);
and,
2.
To facilitate audit, investigative, or statistical research activities necessary to
assure the integrity and improvement of our programs (e.g., to the Bureau of Census and
to private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice entitled, Supplemental Security
Income Studies, Surveys, Records and Extracts (Statistics), 60-0203. Additional
information about this and other system of records notices and our programs are available
from our Internet website at www.socialsecurity.gov or at your local Social Security office.
Do I have your permission to begin?
CODE ONE ONLY
YES – BEGIN INTERVIEW WITH YOUTH .......................................................... .1
YES – BEGIN INTERVIEW WITH YOUTH’S PROXY………………………………2
NOT A GOOD TIME ............................................................................................. 3
SET CALLBACK
REFUSED ............................................................................................................. r
STATUS AS REFUSAL
VII.A2_1 = 1 OR 2
[YOUTH], [HIS/HER]
VII.A3.
Are there any kinds of supports or assistive technologies you’d like to use to complete this
interview? (NLTS2012, I14 modified)
INTERVIEWER: IF SPEAKING TO PROXY, SELECT “1” BELOW.
CODE ALL THAT APPLY
NO SUPPORT NEEDED-PROCEED ................................................................... 0
PARENT REQUESTED PROXY INTERVIEW FOR YOUTH .............................. 1
PARENT WILL ASSIST WITH STUDENT INTERVIEW ...................................... 2
VOICE AMPLIFICATION ...................................................................................... 3
VIDEO RELAY ...................................................................................................... 4
5|Page
YOUTH INTRODUCTION
OTHER TECHNOLOGY ....................................................................................... 99
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... D
REFUSED ............................................................................................................. R
IF OTHER SPECIFY (99): What other type of assistive technology should we use?
YOUTH INTERVIEW BY PROXY (VII.A2_1 =2 OR VII.A3=1)
[YOUTH]
VII.A4.
Thanks for agreeing to complete the survey on [YOUTH]’s behalf. Would you please tell me
your first and last name?
IF NEEDED: This information tells us who answered the questions and will be used to send you
the $30 payment after completing the interview.
___________________________________________________ (STRING 30)
FIRST NAME
___________________________________________________ (STRING 30)
MIDDLE INITIAL/NAME
___________________________________________________ (STRING 60)
LAST NAME
DON’T KNOW ....................................................................................................... d
TERMINATE
REFUSED ............................................................................................................. r
TERMINATE
6|Page
YOUTH INTRODUCTION
VII.A4= NAME POPULATED
[YOUTH]
VII.A5. How are you related to [YOUTH]? (NLTS2012, J1d)
INTERVIEWER:
WHAT IS THE RELATIONSHIP OF THE PROXY TO THE YOUTH?
CODE ONE ONLY
PARENT ............................................................................................................... 1
SIBLING ................................................................................................................ 2
OTHER FAMILY MEMBER .................................................................................. 3
SOMEONE FROM [YOUTH]’S SCHOOL ............................................................ 4
SOMEONE FROM AN AGENCY/ SERVICE PROVIDER.................................... 5
OTHER (SPECIFY) .............................................................................................. 99
___________________________________________________ (STRING 100)
DON’T KNOW ....................................................................................................... d
TERMINATE
REFUSED ............................................................................................................. r
TERMINATE
IF OTHER SPECIFY (99): Relationship to youth:
ALL YOUTH AND PROXIES: VII.A2_1 = 1 OR 2
[your / YOUTH] [YOUTH FIRST AND LAST NAME]
VII.A6.
May I double check the spelling of [your / YOUTH’s] name? I have [YOUTH FIRST AND LAST
NAME], is that correct?
IF SELF REPORT AND IF NEEDED: This information tells us who answered the questions today.
It will also be used to send you the $30 after completing the interview.
INTERVIEWER: CORRECT, AS NEEDED:
___________________________________________________ (STRING 30)
[FIRST NAME]
___________________________________________________ (STRING 30)
[MIDDLE INITIAL / NAME]
___________________________________________________ (STRING 60)
[LAST NAME]
CORRECT AS SHOWN - CONTINUE ................................................................. 1
CORRECTIONS MADE, CONTINUE ................................................................... 2
REFUSED ............................................................................................................. r
PROGRAMMER: IF UPDATE MADE AND VII.A2=1 (YOUTH RESPONDING ON HIS / HER OWN), USE
UPDATED FIRST NAME FOR SUBSEQUENT FILLS ON “YOUTH” (FOR YOUTH’S NAME).
7|Page
YOUTH EDUCATION
VIII.
Asked of
Self-Reporting Youth
Asked of
Youth’s Proxy Respondent
x
x
Youth Education
SECTION VIII. PART A. YOUTH’S EDUCATIONAL STATUS AND CREDENTIALS
ALL: VII.A2_ 1=1 OR 2
[ARE YOU/IS YOUTH, [DO YOU/ DOES YOUTH], [YOU/(HIM/HER)], [YOU/(HE/SHE)]
VIII.A1. The first question is about school.
[ARE YOU/IS YOUTH] currently attending or enrolled in school? Please include middle or high
school, adult basic education or GED courses, vocational or trade school. (YTD-12 I.A1)
PROBE:
(DO YOU/DOES YOUTH) go to school?
PROBE IF SUMMER:
INTERVIEWER:
(ARE YOU/IS YOUTH) off school for the summer? Will [YOU/ (HE/SHE)] be
going back to school in the fall?
CODE “YES” IF ON SUMMER BREAK.
YES ....................................................................................................................... 1
GO TO VIII.A2
NO ........................................................................................................................ 0
DON’T KNOW ....................................................................................................... d
GO TO VIII.A4
REFUSED ............................................................................................................. r
GO TO VIII.A4
VIII.A1=0
[HAVE YOU/ HAS YOUTH], [RA DATE], [YOU/(HE/SHE)]
VIII.A1a. [Have you / Has YOUTH] gone to school at any time since [RA DATE]?
PROBE:
IF DON’T KNOW: When was the last time [YOU / (HE/SHE)] went to school?
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
GO TO VIII.A4
DON’T KNOW ....................................................................................................... d
GO TO VIII.A4
REFUSED ............................................................................................................. r
GO TO VIII.A4
8|Page
YOUTH EDUCATION
VIII.A1=1 OR VIII.A1a=1
[IS/WAS]
VIII.A2. What type of school [is/was] this? (YTD-12 I.B2, modified response)
CODE ONE ONLY
MIDDLE OR HIGH SCHOOL (INCLUDING MAGNET AND CHARTER SCHOOLS)
MIDDLE OR HIGH SCHOOL THAT SERVES ONLY STUDENTS WITH
DISABILITIES ....................................................................................................... 2
HOME SCHOOL (BY PROFESSIONAL OR PARENT) ....................................... 3
POSTSECONDARY: COLLEGE OR UNIVERSITY ............................................. 4
ANOTHER TYPE OF SCHOOL (SPECIFY) ........................................................ 99
___________________________________________________ (STRING 50)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): Specify type of school:
9|Page
1
YOUTH EDUCATION
NOT CURRENTLY ATTENDING SCHOOL, BUT ATTENDED SINCE RA DATE (VIII.A1a=1)
[YOU/HE/SHE], [ARE YOU/ IS YOUTH], [YOU/YOUTH], [YOUR/(HIS/HER)]
VIII.A3 Why did (YOU/YOUTH) stop going to school? (YTD-12 I.C5)
PROBE:
Why [ARE YOU/IS YOUTH] no longer taking classes at school?
PROBE:
Did [YOU/ YOUTH] graduate or complete [YOUR/ (HIS/HER)] classes, or did [YOU/
(HE/SHE)] leave for some other reason? What was the reason?
CODE ALL THAT APPLY
GRADUATED ....................................................................................................... 01
FINISHED CLASSES WANTED TO TAKE .......................................................... 02
TRANSPORTATION PROBLEMS ....................................................................... 03
DIDN’T GET SERVICES NEEDED ...................................................................... 04
TOO EXPENSIVE/ COULDN’T AFFORD IT ........................................................ 05
DIDN’T HAVE TIME; SCHEDULE CONFLICT; CONFLICTS WITH OTHER
DEMANDS ............................................................................................................ 06
POOR GRADES/NOT DOING WELL IN SCHOOL.............................................. 07
DIDN’T LIKE SCHOOL ......................................................................................... 08
WANTED/NEEDED TO FIND A JOB ................................................................... 09
OFFERED A JOB/CHOSE TO WORK ................................................................. 10
WANTED TO ENTER MILITARY ......................................................................... 11
DIDN’T GET IN TO THE PROGRAM SM WANTED ............................................ 12
ILLNESS/DISABILITY; TOO SICK TO GO .......................................................... 13
GOT MARRIED .................................................................................................... 14
GOT PREGNANT OR HAD A CHILD................................................................... 15
MOVED ................................................................................................................. 16
SCHOOL TOO DANGEROUS ............................................................................. 17
WANTED TO TRAVEL ......................................................................................... 18
FRIENDS WEREN’T IN SCHOOL/FRIENDS WERE DROPPING OUT .............. 19
COULDN’T GET ALONG WITH TEACHERS ...................................................... 20
COULDN’T GET ALONG WITH OTHER STUDENTS ......................................... 21
COULDN’T GET CHILD CARE ............................................................................ 22
PARENTS/FAMILY DID WANT SM TO GO ......................................................... 23
INELIGIBLE DUE TO AGE ................................................................................... 24
CLASSES ENDED/PROGRAM ENDED .............................................................. 25
EXPELLED ........................................................................................................... 26
GENERAL DISCIPLINARY PROBLEMS ............................................................. 27
CHANGED SCHOOL/PROGRAM ........................................................................ 28
GOT ARRESTED ................................................................................................. 29
OTHER (SPECIFY) .............................................................................................. 99
___________________________________________________ (STRING (NUM))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What other reason?
10 | P a g e
YOUTH EDUCATION
EVER ENROLLED IN SCHOOL SINCE RA: VIII.A1=1 OR VIII.A1a=1
[YOU/ [YOUTH]] [RA DATE]
VIII.A4. Since [RA DATE], did [YOU/ YOUTH] get promoted or move on to a higher grade in school? (NEW)
YES ....................................................................................................................... 1
NO ........................................................................................................................
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
EVER ENROLLED IN SCHOOL SINCE RA: VIII.A1=1 OR VIII.A1a=1
[RA DATE] [YOU/ [YOUTH]
VIII.A5. Since [RA DATE], did [YOU/YOUTH] repeat any grade? (NEW)
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
EVER ENROLLED IN SCHOOL SINCE RA: VIII.A1=1 OR VIII.A1a=1
[YOU/ [YOUTH], [RA DATE]
VIII.A6. Since [RA DATE], did [you /YOUTH] repeat any classes that [you / YOUTH] had failed? (NEW)
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
GO TO VIII.A7
DON’T KNOW ....................................................................................................... d
GO TO VIII.A7
REFUSED ............................................................................................................. r
GO TO VIII.A7
VIII.A6=1
[YOU/ [YOUTH]], [RA DATE]
VIII.A6a. Since [RA DATE], how many classes did [YOU/YOUTH] have to repeat because [you / YOUTH]
received a failing grade? (NEW)
|
|
|
| CLASSES
(01-100)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
11 | P a g e
YOUTH EDUCATION
EVER ENROLLED IN SCHOOL SINCE RA: VIII.A1=1 OR VIII.A1a=1
[RA DATE] [Have you / Has YOUTH]
VIII.A7. Since [RA DATE] [have you /has YOUTH] been suspended or expelled from school? (NEW)
INTERVIEWER: IF INTERVIEW IS BEING CONDUCTED IN SUMMER, ASK YOUTH / PROXY TO
REFER TO THE MOST RECENT ACADEMIC YEAR.
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
VIII.D8A: EVER ENROLLED IN SCHOOL SINCE RA: VIII.A1=1 OR VIII.A1a=1
VIII.D8B: ALL ROWS WHERE VIII.D8A=1
[DO YOU/DOES YOUTH], [DO YOU/ DOES (HE/SHE)]
VIII.D8A.
[DO YOU/ DOES YOUTH] have a … (YTD-12 I.D2)
VIII.D8B.
FOR EACH ROW, IF D8A=1, ASK: DID [YOU/ YOUTH] earn this after [RA DATE]? (NEW)
IF VIII.D8A=1, ASK D8B.
VIII.D8A.
(CODE ONE PER ROW)
YES
NO
REF
DK
YES
NO
REF
DK
a. High school diploma?
1
0
R
D
1
0
R
D
b. Certificate of completion?
1
0
R
D
1
0
R
D
c. GED (also known as a general
equivalency degree or general
education degree)?
1
0
R
D
1
0
R
D
12 | P a g e
YOUTH EDUCATION
ALL: VII.A2_1 =1 OR 2
[YOU HAVE/ YOUTH HAS]
VIII.A9. What is the highest grade or year of school that [YOU HAVE/YOUTH HAS] finished? (YTD-12 I.D1)
CODE ONE ONLY
5TH GRADE OR LESS ........................................................................................ 1
6TH GRADE ......................................................................................................... 2
7TH GRADE ......................................................................................................... 3
8TH GRADE ......................................................................................................... 4
9TH GRADE/FRESHMAN IN HS ......................................................................... 5
10TH GRADE/SOPHOMORE IN HS.................................................................... 6
11TH GRADE/JUNIOR IN HS .............................................................................. 7
12TH GRADE/SENIOR IN HS.............................................................................. 8
SOME COLLEGE OR TECHNICAL SCHOOL ..................................................... 9
COMPLETED 2-YEAR COLLEGE/TECHNICAL SCHOOL ................................. 10
COMPLETED 4-YEAR COLLEGE/TECHNICAL SCHOOL ................................. 11
UNGRADED SCHOOL/PROGRAM ..................................................................... 12
HOME SCHOOLED .............................................................................................. 13
OTHER (SPECIFY) .............................................................................................. 99
___________________________________________________ (STRING 50)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): Other grade or year of school
13 | P a g e
YOUTH EDUCATION
SECTION VIII. PART B.YOUTH’S EDUCATIONAL ACCOMMODATIONS
VIII.B1A-E: ALL YOUTH AND PROXIES (VII.A2_1 =1 OR 2)
VIII.B2A-D: ALL ROWS WHERE VIII.B1=0
[YOU HAVE/ [YOUTH] HAS], [RA DATE], [HAVE YOU/ HAS [YOUTH]], [YOU/HE/SHE], [YOU/YOUTH],
[YOU/HIM/HER], [YOU/HIS/HER]
VIII.B1. Next, I am going to read a list of services, accommodations or help that some people get at
school. Please tell me whether or not (YOU HAVE/ YOUTH HAS) received any of these since [RA
DATE]. (YTD-12 I.E1)
VIII.B2. IF VIII.B1=0, THEN ASK: Did (you/YOUTH) need...
If VIII.B1=0, ASK:
VIII.B1 (Code one per row)
VIII.B2 (Code one per row)
YES
NO
DK
REF
YES
NO
DK
REF
a. Any accommodations in how [you/
(he/she)] take tests, like more time to
take tests, or a different setting to take
tests?
1
0
d
r
1
0
d
r
b. Any accommodations in how
[you/(he/she) handle class
assignments, like having more time to
finish assignments or getting different
assignments?
1
0
d
r
1
0
d
r
Any person assigned to help
[you/YOUTH], like a tutor, an
interpreter, or someone who takes
notes for [you/ (him/her)] in class?
This can also include an aide or staff
person who comes to class with [you /
YOUTH] to help provide any other
support needed in the classroom.
1
0
d
r
1
0
d
r
d. Any adaptations to [your/ (his/her)]
classrooms, like a special desk for
[you/ (him/her)] or different equipment
because of a disability?
1
0
d
r
1
0
d
r
e. Any other accommodations at school
during the last year?
1
0
d
R
c.
(SPECIFY)____ (STRING 100)
IF OTHER SPECIFY: Other accommodations at school during the last year:
14 | P a g e
YOUTH EDUCATION
ALL: VII.A2_1 =1 OR 2
[YOU/ YOUTH]
VIII.B2e.
Were there any other accommodations [you/YOUTH] needed that [you/ (he/she)] did not
receive?
CODE ALL THAT APPLY
YES (SPECIFY) .................................................................................................... 99
___________________________________________________ (STRING 200)
NO ........................................................................................................................ 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What type of accommodation(s) were needed but not received?
SECTION VIII. PART C.YOUTH’S TRAINING
ALL: VII.A2_1 =1 OR 2
[YOU/ YOUTH], [RA DATE], [YOU/HE/SHE]
VIII.C1. Since [RA DATE] did (you/YOUTH) attend a training program or take any classes outside of school
to help you learn job skills or get a job?
PROBE:
IF DON’T KNOW: When was the last time (you/he/she) went to training outside of the
school?
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
GO TO IX.INTRO
DON’T KNOW ....................................................................................................... d
GO TO IX.INTRO
REFUSED ............................................................................................................. r
GO TO IX.INTRO
VIII.C1=1
[ARE YOU/ IS YOUTH] [YOU / YOUTH]
VIII.C2. [ARE YOU/IS YOUTH] currently in a training program or taking classes outside of school to help
[you/ YOUTH] learn job skills or get a job? (YTD-12 I.A1a)
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
GO TO VIII.C4
DON’T KNOW ....................................................................................................... d
GO TO VIII.C4
REFUSED ............................................................................................................. r
GO TO VIII.C4
15 | P a g e
YOUTH EDUCATION
UNDERTOOK TRAINING SINCE RA DATE: VIII.C1=1 OR VIII.C2=1
VIII.C3. What type of training (is/was) this? (Modified YTD-12 I.B2)
CODE ALL THAT APPLY
VOCATIONAL, TECHNICAL, BUSINESS, OR TRADE SCHOOL ....................... 1
LIFE SKILLS TRAINING ....................................................................................... 2
JOB SKILLS TRAINING ....................................................................................... 3
LEADERSHIP SKILLS / SELF-DETERMINATION SKILLS TRAINING ............... 4
OTHER (SPECIFY) .............................................................................................. 99
___________________________________________________ (STRING 150)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What type of training (is/was) this?
ATTENDED TRAINING / CLASSES OUTSIDE OF SCHOOL SINCE RA (VIII.C1 = 1 OR VIII.C2 = 1)
[RA DATE], [YOU/ YOUTH]
VIII.C4. Since [RA DATE], did [you/ YOUTH] receive a training diploma, certificate, or license? (NEW)
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
16 | P a g e
YOUTH EMPLOYMENT, CREDENTIALS, AND WORK-BASED EXPERIENCES
IX.
Youth Employment, Credentials & Work-Based
Experiences
Asked of
Self-Reporting Youth
Asked of
Youth’s Proxy Respondent
x
x
SECTION IX. PART A. YOUTH EMPLOYMENT
ALL YOUTH AND PROXIES (VII.A2_1 =1 OR 2)
[YOU/YOUTH], [RA DATE], [MONTH AND YEAR OF RA] [you are / YOUTH is]
IX.Intro.
Next I’ll ask questions about jobs that [YOU/YOUTH] have had since [RA DATE]. This includes
any job or jobs [YOU/YOUTH] may have now, as well as jobs that ended after [MONTH AND
YEAR OF RA].
When we talk about employment, please include paid or unpaid jobs, but not chores around
the house – even if [you are / YOUTH is] paid to do them.
CONTINUE ...........................................................................................................
1
ALL YOUTH AND PROXIES (VII.A2_1 =1 OR 2)
[HAVE YOU/HAS YOUTH], [RA DATE], [YOU/YOUTH], [YOU (ARE OR WERE) / YOUTH (IS OR WAS)], [YOU
ARE/ YOUTH IS], [YOU / YOUTH] [YOUR/(HIS/HER)], [YOU/(HE/SHE)], [YOU GET/YOUTH GETS]
IX.A1. (HAVE YOU/HAS YOUTH) worked at a job or a business at any time since [RA DATE]? Please
include all jobs since [RA DATE], even if [you/YOUTH] only worked for a short time. Please
include jobs at which [YOU (ARE OR WERE) / YOUTH (IS OR WAS)] self-employed.
IF NEEDED:
Do not include chores around the house, even if (YOU ARE/YOUTH IS) paid to do
them.
IF NEEDED:
A job is work, either paid or unpaid, other than chores around the house. A job
could be a school-sponsored job or a work study job. Jobs include internships,
apprenticeships and volunteer work even if (YOU/YOUTH) didn’t get paid. A job
could be working for a business or organization or work that [YOU/ (HE/SHE)] do
on [YOUR/ (HIS/HER)] own such as babysitting or dog walking, that (YOU
GET/YOUTH GETS) paid to do.
IF NEEDED:
Self-employed means that you work for yourself or own your own business.
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
GO TO IX.A21
DON’T KNOW ....................................................................................................... d
GO TO IX.A21
REFUSED ............................................................................................................. r
GO TO IX.A21
SOFT CHECK: IX.A1=0: May I confirm I have correctly recorded that (you have / YOUTH has) not
done any work since [RA DATE], paid or unpaid, even volunteer or community service work?
17 | P a g e
YOUTH EMPLOYMENT, CREDENTIALS, AND WORK-BASED EXPERIENCES
IX.A1=1
[WERE YOU/ WAS YOUTH], [YOU/(HE/SHE)]
IX.A2. [WERE YOU/ WAS YOUTH] paid or did [YOU/ (HE/SHE)] receive income through self-employment
in any of these jobs? (NEW)
PROBE:
Self-employed means that you work for yourself/ or own your own business.
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IX.A1=1
[HAVE YOU/HAS YOUTH], [CALCULATE AND FILL MONTH AND YEAR ONE YEAR PRIOR]. [RA DATE], [YOU
DO/ YOUTH DOES], [YOU ARE/YOUTH IS] [MONTH AND YEAR ONE YEAR AGO], [YOUR/(HIS/HER)], [YOU
GET/YOUTH GETS]
IX.A3. Now let’s talk about jobs you have had within the past 12 months – that is since [CALCULATE
AND FILL MONTH AND YEAR ONE YEAR PRIOR]. This includes any job or jobs you may currently
have as well as jobs that have ended in the past year.
[HAVE YOU/HAS YOUTH] worked at a job or a business at any time in the past year?
IF NEEDED:
Please include all jobs since [RA DATE], even if [you/YOUTH] only worked for a
short time. Include paid or unpaid jobs, but not chores around the house, even if
[you are / YOUTH is] paid to do them.
IF NEEDED:
A job could be a school-sponsored job or a work study job. Jobs include
internships, apprenticeships and volunteer work even if (YOU/YOUTH) didn’t get
paid. A job could be working for a business or organization or work (you do /
YOUTH does) on [(your / (his/her)] own, such as babysitting or dog walking, that
(YOU GET/ YOUTH GETS) paid to do.
IF NEEDED:
Self-employed means that you work for yourself/ or own your own business.
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
GO TO IX.A21
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK, IF IX.A3=0: May I confirm I have recorded this correctly, that (you have / YOUTH
has) done no work in the past year, paid or unpaid, even volunteer or community service work?
18 | P a g e
YOUTH EMPLOYMENT, CREDENTIALS, AND WORK-BASED EXPERIENCES
IX.A3=1
[HAVE YOU/ HAS YOUTH], (YOU/ YOUTH), (HAVE/HAS), [YOU (ARE / WERE)/ YOUTH (IS / WAS)] , [MONTH
AND YEAR ONE YEAR AGO]
IX.A4. How many jobs [have you /has YOUTH] had within the past year?
Please include jobs that [YOU/YOUTH] currently [HAVE/HAS] as well as jobs that ended within the
past year. Please include jobs at which [YOU (ARE / WERE)/ YOUTH (IS / WAS)] self-employed. Do
not include chores around the house, even if (YOU ARE/YOUTH IS) paid to do them.
INTERVIEWER: JOBS SUCH AS YARD WORK OR BABYSITTING COUNT AS ONE ‘JOB’ EACH (SELF
EMPLOYED AS A . . . ). PROBE TO CONFIRM THESE ARE NOT COUNTED IN TERMS OF THE
NUMBER OF TIMES SUCH A JOB WAS PERFORMED IN THE PAST YEAR.
| | | JOBS
(01-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: May I confirm I have recorded that (You have/ YOUTH has) had [FILL IX.A3a] jobs in the past
year?
PROGRAMMER SKIP BOX 9
IF WORKED IN PAST YEAR (IXA3=1) and NUMBER OF JOBS (IX.A4) = DK or
R, TREAT AS 1 JOB.
IF WORKED IN PAST YEAR IXA3 = D or R and NUMBER OF JOBS IX.A4= D
or R, GO TO IX.A22.
(IX.A5 thru IX.A19 ASKED FOR EACH JOB AT IX.A4 – UP TO 10 JOBS.
19 | P a g e
YOUTH EMPLOYMENT, CREDENTIALS, AND WORK-BASED EXPERIENCES
YOUTH HAS OR HAD >1 JOB: IX.A3a>1
[YOU HAVE/ YOUTH HAS], [YOUR/HIS/HER], [YOU/YOUTH], [YOU ARE/HE IS/ SHE IS] [MONTH AND YEAR
ONE YEAR AGO]
IX.A5. IF IX.A3a = 1, (ONE JOB), FILL: Now, I would like to get more information about this job. What is
the name of the place [YOU/YOUTH] currently work at or worked at most recently?
IF IX.A3a > 1, FIRST JOB, FILL: Now, I would like to get more information about each job [YOU
HAVE/YOUTH HAS] had in the past year. I'd like to start with the [YOUR/ (HIS/HER)] most recent
job and work backwards. What is the name of the place [YOU/YOUTH] currently work at or worked
at most recently? Please include jobs at which [YOU ARE/ (HE IS/SHE IS)] self-employed.]
IF IX.A3 > 1, AND LOOPING TO NEXT JOB FILL: Now, I’d like to get more information about each
of the other jobs [you have/YOUTH has] had in the past year. What is the name of the next place
[you have/he has/she has] worked at since [MONTH AND YEAR ONE YEAR AGO]?
PROBE:
Please include jobs at which [you were/YOUTH was] self-employed.
NAME OF PLACE WORKED (1-10)
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
________________Name of place worked – 1
(STRING 150)
________________Name of place worked – 2
(STRING 150)
________________Name of place worked – 3
(STRING 150)
________________Name of place worked – 4
(STRING 150)
________________Name of place worked – 5
(STRING 150)
________________Name of place worked – 6
(STRING 150)
________________Name of place worked – 7
(STRING 150)
________________Name of place worked – 8
(STRING 150)
________________Name of place worked – 9
(STRING 150)
________________Name of place worked – 10
(STRING 150)
Self
employed
DK
REF
99
d
r
99
d
r
99
d
r
99
d
r
99
d
r
99
d
r
99
d
r
99
d
r
99
d
r
99
d
r
PROGRAMMER: USE “NAME OF PLACE” PROVIDED IN IX.A5a-j, AS FILL, WHERE APPLICABLE, FOR
ITEMS IX.A6-IX.A18.
20 | P a g e
YOUTH EMPLOYMENT, CREDENTIALS, AND WORK-BASED EXPERIENCES
JOB 1
CURRENT OR MOST RECENT JOB
JOB(S) 2-10
NEXT MOST RECENT JOB(S)
IX.A3a=01-99
IX.A6. (Do you/Does YOUTH) currently
work at (NAME OF PLACE)?
YES ............................................................... 1
YES ............................................................... 1
NO ................................................................. 0
NO ................................................................. 0
RECORD VERBATIM AND CODE:
________________________________________
RECORD VERBATIM AND CODE:
_______________________________________
ASSEMBLY WORK (SORTING STUFFING) .............1
ANIMAL CARE (DOG WALKING,
VETERINARY HELPER) ............................................2
CAMP COUNSELOR ..................................................3
CASHIER—GROCERY STORE,
FAST FOOD PLACE, ETC. ........................................4
CHILD CARE—BABYSITTING/MOTHERS
HELPER ......................................................................5
CLEANING—JANITOR/MAID ....................................6
CLERICAL—FILING, RECEPTIONIST,
DATA ENTRY .............................................................7
COMPUTER WORK—DATA ENTRY/
PROGRAMMING/
WEB PAGE DEVELOPMENT .................................. 8
DELIVERY—OF FOOD OR NEWSPAPERS
OR PRESCRIPTIONS ................................................9
FARM WORK..............................................................10
FOOD SERVICE—BUS BOY, WAITER, COOK ........11
GARDENING AND GROUNDS MAINTENANCE ......12
GAS STATION ATTENDANT .....................................13
HEALTH CARE AIDE—PERSONAL CARE
ATTENDANT, NURSES AIDE ....................................14
MECHANIC (AUTO REPAIR) .....................................15
RETAIL SALES ...........................................................16
SKILLED LABOR APPRENTICE—PLUMBER,
CARPENTER, ELECTRICIAN ....................................17
SPORTS RELATED—UMPIRE, CADDY,
REFEREE, COACH, LIFEGUARD .............................18
STOCK CLERK—GROCERY STORE
OR DRUG STORE .....................................................19
USHER—MOVIE THEATER ......................................20
OTHER (SPECIFY) ....................................................21
ASSEMBLY WORK (SORTING STUFFING) ............. 1
ANIMAL CARE (DOG WALKING,
VETERINARY HELPER) ............................................ 2
CAMP COUNSELOR ................................................. 3
CASHIER—GROCERY STORE,
FAST FOOD PLACE, ETC. ........................................ 4
CHILD CARE—BABYSITTING/MOTHERS
HELPER ..................................................................... 5
CLEANING—JANITOR/MAID .................................... 6
CLERICAL—FILING, RECEPTIONIST,
DATA ENTRY ............................................................. 7
COMPUTER WORK—DATA ENTRY/
PROGRAMMING/
WEB PAGE DEVELOPMENT ...................................8
DELIVERY—OF FOOD OR NEWSPAPERS
OR PRESCRIPTIONS ................................................ 9
FARM WORK ............................................................. 10
FOOD SERVICE—BUS BOY, WAITER, COOK........ 11
GARDENING AND GROUNDS MAINTENANCE ...... 12
GAS STATION ATTENDANT..................................... 13
HEALTH CARE AIDE—PERSONAL CARE
ATTENDANT, NURSES AIDE ................................... 14
MECHANIC (AUTO REPAIR) .................................... 15
RETAIL SALES .......................................................... 16
SKILLED LABOR APPRENTICE—PLUMBER,
CARPENTER, ELECTRICIAN ................................... 17
SPORTS RELATED—UMPIRE, CADDY,
REFEREE, COACH, LIFEGUARD ............................. 18
STOCK CLERK—GROCERY STORE
OR DRUG STORE ..................................................... 19
USHER—MOVIE THEATER ...................................... 20
OTHER (SPECIFY) .................................................... 21
START DATE: | | | / 20 | | |
MONTH
YEAR
START DATE: | | | / 20 | | |
MONTH
YEAR
MORE THAN ONE YEAR AGO ............... 9999
MORE THAN ONE YEAR AGO ............... 9999
IF SELF-EMPLOYED: (Do you/Does
YOUTH) still currently do this job?
IX.A3a=01-99
IX.A7. What (do/did) (you/he/she) do at
(NAME OR PLACE)?
PROBE: What (are/were) [your/
(his/her)] responsibilities?
PROBE: What kinds of things [have
you/ has (he/she)] done there?
PROBE: Tell me what [(you/
(he/she)] (do/did) when [you/ (he/she)]
(get/got) to work? After that? Then
what?
IF SELF-EMPLOYED, ASK: What
(do/did) [you/ (he/she)] do?
IX.A3a=01-99
IX.A8. When did [you/ (he/she)] start
working at (NAME OR PLACE)?
IF SELF-EMPLOYED, SAY: When
did [you/ (he/she)] start working as a
(JOB FROM B3)?
INTERVIEWER: IF JOB BEGAN > 1 YR
AGO AND R CANNOT RECALL
START DATE, SELECT “MORE
THAN ONE YR AGO”
21 | P a g e
YOUTH EMPLOYMENT, CREDENTIALS, AND WORK-BASED EXPERIENCES
JOB 1
CURRENT OR MOST RECENT JOB
JOB(S) 2-10
NEXT MOST RECENT JOB(S)
IF CURRENT JOB: IX.A6=1
IX.A9.
How did [you/ (he/she)] find this
job?
PROBES: How did [you/ (he/she)]
hear about this job?
NEWSPAPER AD .............................................. 1
INTERNET ......................................................... 2
EMPLOYMENT AGENCY (PRIVATE) ................ 3
SPECIAL EDUCATOR, VOCATIONAL
EDUCATOR, COUNSELOR, OR OTHER
SCHOOL STAFF................................................ 4
FRIENDS OR RELATIVES ................................. 5
DIRECT APPLICATION TO EMPLOYER ........... 6
VOC REHAB OR OTHER SERVICE AGENCY... 7
AMERICAN JOB CENTERS (UNEMPLOYMENT
OFFICE, FORMERLY KNOWN AS ONE
STOPS OR WORKFORCE DEVELOPMENT
CENTERS) ........................................................ 8
[PROMISE PROGRAM] ..................................... 9
OTHER (SPECIFY) ............................................ 10
NEWSPAPER AD .............................................. 1
INTERNET ......................................................... 2
EMPLOYMENT AGENCY (PRIVATE) ................ 3
SPECIAL EDUCATOR, VOCATIONAL
EDUCATOR, COUNSELOR, OR OTHER
SCHOOL STAFF................................................ 4
FRIENDS OR RELATIVES ................................. 5
DIRECT APPLICATION TO EMPLOYER ........... 6
VOC REHAB OR OTHER SERVICE AGENCY ... 7
AMERICAN JOB CENTERS (UNEMPLOYMENT
OFFICE, FORMERLY KNOWN AS ONE
STOPS OR WORKFORCE DEVELOPMENT
CENTERS)......................................................... 8
[PROMISE PROGRAM] ..................................... 9
OTHER (SPECIFY) ............................................ 10
| | |
HOURS PER WEEK USUALLY WORKED
| | |
HOURS PER WEEK USUALLY WORKED
OR
OR
IX.A3a=01-99
IX.A10.
How many hours per week [(do
or did you) / (does or did
YOUTH)] usually work at this
job?
USE THE FOLLOWING PROBES TO
CALCULATE HOURS WORKED:
Which days do [you/ (he/she)] work?
What time do [you/ (he/she)] start
work?
What time do [you/ (he/she)] finish
work?
[Do you/Does YOUTH] take a break
for lunch?
IF CANNOT ANSWER EXACT HOURS, PROBE
FOR RANGE: (Do you/Does YOUTH) think
(you/he/she) work . . .
IF CANNOT ANSWER EXACT HOURS, PROBE
FOR RANGE: (Do you/Does YOUTH) think
(you/he/she) work . . .
Less than 10 hours per week? ....................... 1
10-20 hours per week? .................................. 2
21-30 hours per week? .................................. 3
Or more than 30 hours per week? .................. 4
Less than 10 hours per week? ....................... 1
10-20 hours per week? .................................. 2
21-30 hours per week? .................................. 3
Or more than 30 hours per week? .................. 4
Hour, day, week, month, year ........ 1
Things ............................................ 2
Some other way (SPECIFY)........... 99
Hour, day, week, month, year ........ 1
Things............................................ 2
Some other way (SPECIFY) .......... 99
Unpaid ........................................... 4 GO TO IX.A13
Unpaid ........................................... 4 GO TO IX.A13
IX.A3a=01-99
IXA11.
Next, I’d like to ask you some
questions about how [(you
are) / (he/she is)] / [(you were) /
(he/she was)] paid at (NAME or
PLACE).
[(Do or Did you/Does or did YOUTH)]
get paid by the hour or by how many
things (you/he/she)
(make/do/sell/makes/does/sells)?
PROBES: Are you paid a certain
amount per day, per week, per month,
or per year?
Do you get a salary?
22 | P a g e
YOUTH EMPLOYMENT, CREDENTIALS, AND WORK-BASED EXPERIENCES
JOB 1
CURRENT OR MOST RECENT JOB
JOB(S) 2-10
NEXT MOST RECENT JOB(S)
IF PAID JOB: (IX.A11=1, 2, OR 99)
IX.A12.
About how much (are you/is
YOUTH) paid on this job?
PROBES: How much [do you/does
(he/she)] get paid for each thing [you/
(he/she)]
(make/do/sell/makes/does/sells)?
How many things (do you/does
[he/she]) (make/do/sell) in an
(hour/day/week)?
Is that the amount of pay (you bring/
[he/she] brings) home or is that the
amount of [your/ (his/her)] pay before
taxes are taken out?
PROGRAMMER: SKIP NET
PAY/BEFORE TAXES IF PAID
HOURLY OR BY THE THING
$|
|
|
|
|.|
|
| per hour/thing
|
|
| things/hour
$|
|
|
|
or
$|
|
|
|.|
|
|.|
|
| per hour/thing
|
|
| things/hour
or
| per day....................... 1
per week ........................ 2
every other week ........... 3
twice a month ................ 4
once a month ................. 5
OTHER (SPECIFY) ....... 6
$|
|
|
|.|
|
| per day....................... 1
per week ........................ 2
every other week ........... 3
twice a month ................ 4
once a month ................. 5
OTHER (SPECIFY) ....... 6
Before taxes (Gross pay) ............................... 1
After taxes (Net pay) ...................................... 2
Before taxes (Gross pay) ............................... 1
After taxes (Net pay) ...................................... 2
YES
Health insurance? ..................................... 1
Paid vacation or sick leave? ..................... 1
Any kind of pension or retirement plan? ... 1
YES
Health insurance?...................................... 1
Paid vacation or sick leave? ...................... 1
Any kind of pension or retirement plan? ... 1
IF PAID JOB: (IX.A11=1,2, OR 99)
IX.A13.
(Does/Did) this job offer. . .
PROBE: It does not matter if you use this
benefit / take the benefit or not. Our
focus in this question is simply on
whether or not it is offered to you.
NO
0
0
0
NO
0
0
0
IX.A3a=01-99
IX.A14.
At this job, do most of the
other workers have
disabilities?
YES ............................................................... 1
YES ............................................................... 1
NO ................................................................. 0
NO ................................................................. 0
YES ............................................................... 1
YES ............................................................... 1
NO ................................................................. 0
NO ................................................................. 0
IX.A3a=01-99
IX.A15
(Is/was) this job at (NAME OR
PLACE) part of any school
sponsored work activities like
a work-study job, an
internship, or part of a schoolbased business?
23 | P a g e
YOUTH EMPLOYMENT, CREDENTIALS, AND WORK-BASED EXPERIENCES
JOB 1
CURRENT OR MOST RECENT JOB
JOB(S) 2-10
NEXT MOST RECENT JOB(S)
NOT CURRENT JOB (IX.A6=0)
IX.A16.
When did (you/he/she) stop
working at . . .
Probe: In which month did
(you/he/she) stop?
Probe: What was the weather like?
Probe: Was it around a holiday or
[your/ (his/her)] birthday?
Probe: Was it during the school year
or during the summer?
Probe: (Is/Was) this a summer job?
INTERVIEW: IF RESPONDENT
REPORTS STILL WORKING AT
THIS JOB, CHANGE RESPONSE
TO IX.A6 TO 1.
STILL WORKING ..................................... 9999
STILL WORKING..................................... 9999
END DATE:
END DATE:
| | | / 20 | | |
MONTH
YEAR
IF CANNOT PROVIDE EXACT DATE, PROBE FOR
TIME WORKED AT THIS JOB: How long did
[you/he/she] work) at (NAME OR PLACE)?
PROBE: Your best estimate is fine.
|
|
| MONTHS....................................... 1
|
|
| WEEKS ........................................ 2
| | | / 20 | | |
MONTH
YEAR
IF CANNOT ANSWER EXACT DATES, PROBE
FOR TIME WORKED AT THIS JOB: How long
(have [you/he/she] worked/did [you/he/she] work) at
(NAME OR PLACE)?
PROBE: Your best estimate is fine.
|
|
| MONTHS....................................... 1
|
|
| WEEKS ........................................ 2
OR
OR
IF CANNOT ANSWER TIME WORKED, PROBE
FOR RANGE: (Do you/Does NAME) think
(you/he/she) worked at (NAME OR PLACE) . . .
Three months of less? ................................... 1
4-6 months?................................................... 2
Or more than 6 months? ................................ 3
IF CANNOT ANSWER TIME WORKED, PROBE
FOR RANGE: (Do you/Does NAME) think
(you/he/she) worked at (NAME OR PLACE) . . .
Three months of less? ................................... 1
4-6 months?................................................... 2
Or more than 6 months? ................................ 3
NOT CURRENT JOB (IX.A6=0)
IX.A17 Why did (you/he/she) leave this
job?
PROBE: Why (are you/is NAME) no
longer working (NAME OR PLACE)?
PROBE FOR MAIN REASON.
CODE ONE REASON ONLY.
IF RESPONSE IS “DOES NOT WANT TO
WORK,” PROBE FOR THE REASON
WHY.
CODE ONE ONLY
Job was too hard...................................................... 1
Job was too easy ..................................................... 2
Found a better job .................................................... 3
Temporary job ended............................................... 4
Went back to school ................................................ 5
Job did not pay enough ........................................... 6
Does not need the money........................................ 7
Did not like boss....................................................... 8
Did not like coworkers .............................................. 9
Transportation problems .......................................... 10
I moved to far ........................................................... 11
Job moved too far .................................................... 12
Fired/performance problems ................................... 13
Health reasons ......................................................... 14
Employer wouldn’t provide accommodations
needed to succeed at job......................................... 15
Had a baby ............................................................... 16
Family obligations .................................................... 17
Did not want to lose disability or other benefits ....... 18
Parents do not want youth to work .......................... 19
End of job training program ..................................... 21
Other (specify) ......................................................... 22
CODE ONE ONLY
Job was too hard ..................................................... 1
Job was too easy ..................................................... 2
Found a better job ................................................... 3
Temporary job ended .............................................. 4
Went back to school ................................................ 5
Job did not pay enough ........................................... 6
Does not need the money ....................................... 7
Did not like boss ...................................................... 8
Did not like coworkers ............................................. 9
Transportation problems ......................................... 10
I moved to far........................................................... 11
Job moved too far .................................................... 12
Fired/performance problems ................................... 13
Health reasons ........................................................ 14
Employer wouldn’t provide accommodations
needed to succeed at job ........................................ 15
Had a baby .............................................................. 16
Family obligations .................................................... 17
Did not want to lose disability or other benefits....... 18
Parents do not want youth to work .......................... 19
End of job training program ..................................... 21
Other (specify) ......................................................... 22
Liked it very much, ..................................... 1
Somewhat liked it, or.................................. 2
Did not like it? ............................................ 3
Liked it very much ...................................... 1
Somewhat liked it, or.................................. 2
Did not like it? ............................................ 3
IX.A3a=01-99
IX.A18
Overall, how much did [you /
(he/she)] like this job at (NAME
OF PLACE)? Would
(you/he/she) say that [you /
(he/she)] . . .
CONTINUE WITH OTHER JOB(S) OR
COMPLETE JOB GRID.
IF NO MORE JOBS GO TO IX.A19, ELSE GO TO
JOB 2
24 | P a g e
CONTINUE WITH OTHER JOB(S) OR
COMPLETE JOB GRID.
IF NO MORE JOBS GO TO IX.A19, ELSE GO TO
NEXT JOB IN SEQUENCE (3, 4, 5, …)
YOUTH EMPLOYMENT, CREDENTIALS, AND WORK-BASED EXPERIENCES
IX.A3a>0
[YOU/YOUTH], [YOUR/YOUTH], [YOU DO/YOUTH DOES], [YOU ARE/YOUTH IS] [YOUR / (HIS/ HER)]
IX.A19. Thank you for telling me about these jobs, I just want to be sure we haven’t missed any job
(you/YOUTH) had in the past year. We just spoke about (your/YOUTH’S) job at:
[FILL JOB(s) FROM A4 AND JOB(S) FROM A5a-j.]
Did (you/YOUTH) have any other jobs during the past year, even ones that lasted for just a short
time? Do not include chores that (you do/YOUTH does) around the house, even if (you are/YOUTH
is) paid to do them.
PROBE:
A job is work, either paid or unpaid, other than work around the house.
A job could be a school sponsored job or a work study job. Jobs include internships,
apprenticeships, and volunteer work, even if you don't get paid.
A job could be working for a business or organization or work that (you/he/she) do on
[your/ (his/her)] own such as babysitting or dog walking.
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
GO TO IX.A21
DON’T KNOW ....................................................................................................... d
GO TO IX.A21
REFUSED ............................................................................................................. r
GO TO IX.A21
IX.A19=1
[YOU/ YOUTH], [MONTH AND YEAR 1 YEAR AGO], [YOU WERE/ YOUTH WAS]
IX.A20. How many other jobs did [you /YOUTH] have during the past year? Please do not include jobs you
already told me about. Please include all jobs, even if [YOU/YOUTH] only worked for a short
period of time. Please include jobs at which [YOU WERE /YOUTH WAS] self-employed or
volunteered.
PROBE:
That is since [MONTH AND YEAR 1 YEAR AGO]?
| | | JOBS
(01-99)
DON’T KNOW ....................................................................................................... d
GO TO IX.A21
REFUSED ............................................................................................................. r
GO TO IX.A21
SOFT CHECK IF IX.A20>1: May I confirm that you have had [FILL IX.A20] jobs since this time last
year, in addition to the jobs you have already told me about?
25 | P a g e
YOUTH EMPLOYMENT, CREDENTIALS, AND WORK-BASED EXPERIENCES
IX.A20>0
[YOU/YOUTH], [NUMBER]
IX.A20a.
Did any of these jobs last more than two weeks?
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: To confirm, (YOU/YOUTH) had [value from IX.A20] job(s) that lasted less than two weeks?
PROGRAMMER SKIP BOX 8
IF IX.A20>1, GO TO IX.A5 AND ADD ADDITIONAL JOBS, RETURN THROUGH THE LOOP AS
NEEDED FOR EACH NEW JOB IDENTIFIED. ONCE LOOP(S) COMPLETED, GO TO IX. A21.
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
IX.A21. PROGRAMMER: INSERT DATE THIS SECTION IX.A (YOUTH EMPLOYMENT) WAS COMPLETED
HERE OR POPULATE THIS AS A VERIFICATION OF DATE COMPLETED FOR INTERVIEWER TO
INPUT. THEN CONTINUE.
CONTINUE ........................................................................................................... 1
26 | P a g e
YOUTH SERVICE RECEIPT IN PAST 18 MONTHS
X.
Asked of
Self-Reporting Youth
Asked of
Youth’s Proxy
Respondent
x
x
Youth Service Receipt in Past 18 months
SECTION X. PART A. YOUTH SERVICE RECEIPT IN PAST 18 MONTHS
X.A2A: ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
X.A2B: ALL ROWS WHERE X.A2A=1
[RA DATE] [you/ YOUTH]
X.A2A. Since [RA DATE], [have you / has YOUTH] received any of the following services? (NEW)
X.A2B. IF X.A2A=1 IN ANY ROW THEN ASK: How helpful was this service to [you/ YOUTH] in helping
[you/ YOUTH] prepare for school or work, or to help you prepare for living on [your / (his / her)]
own as an adult? (NEW)
IF X.A2A=YES, THEN ASK: X.A2B
X.A2A
(CODE ONE PER ROW)
YES
NO
Not at all
helpful
Somewhat
helpful
Extremely
helpful
a. Help with a disability or health
issue at school?
1
0
1
2
3
b. Help finding a job or learning about
the kinds of jobs [you / YOUTH]
might like?
1
0
1
2
3
c. Help learning to manage money?
1
0
1
2
3
d. Help understanding government
benefits.
1
0
1
2
3
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
[RA DATE] [you / YOUTH]
X.A3.
Since [RA DATE], have [you / YOUTH] needed any help or services preparing for school or work
that [you / YOUTH] did not receive? (YTD 12-mo)
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
GO TO X.A5
DON’T KNOW ....................................................................................................... d
GO TO X.A5
REFUSED ............................................................................................................. r
GO TO X.A5
27 | P a g e
YOUTH SERVICE RECEIPT IN PAST 18 MONTHS
X.A3=1
[you / YOUTH]
X.A4.
What help or services did [you / YOUTH] need that [you / YOUTH] did not get? (YTD 12-mo)
CODE ALL THAT APPLY
DISCOVERING JOB INTERESTS/SKILLS .......................................................... 1
INDEPENDENT LIVING SKILLS TRAINING ....................................................... 2
CAREER COUNSELING ...................................................................................... 3
LEARNING HOW TO LOOK FOR A JOB ............................................................ 4
JOB SHADOWING ............................................................................................... 5
APPRENTICESHIP/INTERNSHIP ....................................................................... 6
HELP FINDING A JOB ......................................................................................... 7
SUPPORT ONCE ON THE JOB (JOB COACHING) ........................................... 7
HELP GETTING INTO SCHOOL/TRAINING ....................................................... 8
UNDERSTANDING SSA/OTHER BENEFITS ...................................................... 9
COMPUTER LITERACY CLASSES ..................................................................... 10
PROBLEM SOLVING ........................................................................................... 11
SOCIAL SKILLS TRAINING ................................................................................. 12
FINANCIAL LITERACY/MONEY MGMT TRAINING............................................ 13
SELF ADVOCACY/DETERMINATION TRAINING .............................................. 14
REFERRAL TO ANOTHER AGENCY.................................................................. 15
TRANSPORTATION SERVICES ......................................................................... 16
HEALTH-RELATED SERVICES .......................................................................... 17
CASE MANAGEMENT ......................................................................................... 18
ACCOMMODATIONS .......................................................................................... 19
OTHER (SPECIFY) .............................................................................................. 99
___________________________________________________ (STRING 150)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What other service did [you / YOUTH] need but not get?
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
X.A5.
PROGRAMMER: INSERT DATE THIS SECTION X.A (YOUTH SERVICES) WAS COMPLETED HERE
OR POPULATE A VERIFICATION OF DATE COMPLETED FOR INTERVIEWER TO INPUT. THEN
CONTINUE.
CONTINUE ........................................................................................................... 1
28 | P a g e
YOUTH’S SELF-DETERMINATION AND EXPECTATIONS FOR THE FUTURE
Asked of
Self-Reporting Youth
XI.
Youth’s Self-Determination and Expectations for the
Future
Asked of
Youth’s Proxy Respondent
x
SECTION XI. PART A. SELF-DETERMINATION: AUTONOMY
THIS SECTION IS ASKED OF YOUTH IS SELF-REPORTING. PROXY RESPONDENTS SKIP TO XII.A.
SELF-REPORTING YOUTH ONLY: VII.A2_1 =1
XI.A1. Now I am going read some statements. For each, please tell me the answer that best tells how you
act in that situation. There are no right or wrong answers.
PROBE:
Tell me the answer that best tells how you act in this situation.
PROBE:
If your disability limits you from actually performing the activity, but you have control
over the activity – such as a personal care attendant, answer as if you performed that
activity.
CODE ONE PER ROW
I do not do
even if I
have the
chance
I do
sometimes
when I
have the
chance
I do most
of the time
I have the
chance
Do every
time I have
the chance
a. “My friends and I choose activities
that we want to do.” The choices
are… (ARC SD. Scale, 14)
1
2
3
b. “I write letters, texts, or talk on the
phone to friends and family.” (ARC
SD. Scale, 15)
1
2
c. “I go to restaurants that I like.”
(ARC SD. Scale, 18)
1
d. “I choose gifts to give to family and
friends.” The choices are…(ARC
SD. Scale, 30)
e. “I go to movies, concerts, and
dances.” The choices are … (ARC
SD. Scale, 19)
f.
“I plan weekend activities that I like
to do.” (ARC SD. Scale, 12)
g. “I decorate my own room.” (ARC
SD. Scale, 31)
29 | P a g e
DK
REF
4
d
r
3
4
d
r
2
3
4
d
r
1
2
3
4
d
r
1
2
3
4
d
r
1
2
3
4
d
r
1
2
3
4
d
r
YOUTH’S SELF-DETERMINATION AND EXPECTATIONS FOR THE FUTURE
SECTION XI. PART B. SELF-DETERMINATION: PSYCHOLOGICAL EMPOWERMENT
SELF-REPORTING YOUTH ONLY: VII.A2_1 =1
XI.B1. Next, I am going to read you two statements. I want you to tell me the one that best describes you.
Choose only one answer. There are no right or wrong answers.
Which of the following statements best describes you? (ARC SD. Scale, 47)
CODE ONE ONLY
Trying hard at school doesn't do me much good, or ..................................... 1
Trying hard at school will help me get a good job .......................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SELF-REPORTING YOUTH ONLY: VII.A2_1 =1
XI.B2. Which of the following statements best describes you? (ARC SD. Scale, 49)
PROBE:
There are no right or wrong answers.
CODE ONE ONLY
It is no use to keep trying because that won't change things, or.................. 1
I keep trying even after I get something wrong ............................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SELF-REPORTING YOUTH ONLY: VII.A2_1 =1
XI.B3. READ IF NECESSARY: Which of the following statements best describes you? (ARC SD. Scale, 51)
PROBE:
There are no right or wrong answers.
CODE ONE ONLY
I don't know how to make friends, or ............................................................... 1
I know how to make friends............................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
30 | P a g e
YOUTH’S SELF-DETERMINATION AND EXPECTATIONS FOR THE FUTURE
SELF-REPORTING YOUTH ONLY: VII.A2_1 =1
XI.B4. READ IF NECESSARY: Which of the following statements best describes you? (ARC SD. Scale, 53)
PROBE:
There are no right or wrong answers.
CODE ONE ONLY
I do not make good choices, or......................................................................... 1
I can make good choices ................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SELF-REPORTING YOUTH ONLY: VII.A2_1 =1
XI.B5. READ IF NECESSARY: Which of the following statements best describes you? (ARC SD. Scale, 57)
PROBE:
There are no right or wrong answers.
CODE ONE ONLY
My choices will not be honored, or................................................................... 1
I will be able to make choices that are important to me ................................. 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SELF-REPORTING YOUTH ONLY: VII.A2_1 =1
XI.B6. READ IF NECESSARY: Which of the following statements best describes you? (ARC SD. Scale, 55)
PROBE:
There are no right or wrong answers.
CODE ONE ONLY
I will have a hard time making new friends, or ................................................ 1
I will be able to make friends in new situations .............................................. 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
31 | P a g e
YOUTH’S SELF-DETERMINATION AND EXPECTATIONS FOR THE FUTURE
SECTION XI. PART C. SELF-DETERMINATION: SELF-REALIZATION
SELF-REPORTING YOUTH ONLY: VII.A2_1 =1
XI.C1. Now I am going to read some statements. Please tell me whether you think each of these
describes how you feel about yourself or not. Choose the answer that best fits you. There are no
right or wrong answers. (ARC SD Scale, items 65, 68, 72, 71, 63, 70, 64)
PROBE:
You agree or you don’t agree?
CODE ONE PER ROW
Agree
Don’t agree
DK
REF
a. I know what I do best.
1
2
d
r
b. I like myself.
1
2
d
r
c. I am confident in my abilities.
1
2
d
r
d. Other people like me.
1
2
d
r
e. It is better to be yourself than to be popular.
1
2
d
r
f.
1
2
d
r
1
2
d
r
I know how to make up for my limitations.
g. I am loved because I give love.
SECTION XI. PART D. YOUTH’S EXPECTATIONS FOR THE FUTURE
SELF-REPORTING YOUTH ONLY: VII.A2_1 =1
XI.D.Intro
My next questions are about what you think will happen in the future.
CONTINUED ........................................................................................................ 1
32 | P a g e
YOUTH’S SELF-DETERMINATION AND EXPECTATIONS FOR THE FUTURE
SELF-REPORTING YOUTH ONLY: VII.A2_1 =1
XI.D1. How far do you think you will you get in school?
PROBE:
What is highest level of schooling you think you will complete?
INTERVIEWER:
CODE A CERTIFICATE OF COMPLETION OR ATTENDANCE AS “2.”
IF RESPONDENT SAYS “COLLEGE” PROBE AS TO WHETHER THAT IS A 2YEAR OF A 4-YEAR COLLEGE.
CODE ONE ONLY
Less than high school (will not graduate or get a GED) ................................ 1
High school diploma, ......................................................................................... 2
GED, ..................................................................................................................... 3
Technical or trade school, ................................................................................. 4
2-Year College, .................................................................................................... 5
4-year College, or a ........................................................................................... 6
Master’s, PhD, or other advanced degree? ..................................................... 7
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SELF-REPORTING YOUTH ONLY: VII.A2_1 =1
XI.D2. When you are age 25, do you think you will be living...
CODE ONE ONLY
With parent / guardian(s), ................................................................................. 1
With a sibling or other relative, ......................................................................... 2
On your own or with a spouse or partner, ...................................................... 3
In a group home or institution, or in an ........................................................... 4
Other living situation, ........................................................................................ 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): You will be living …
33 | P a g e
YOUTH’S SELF-DETERMINATION AND EXPECTATIONS FOR THE FUTURE
SELF-REPORTING YOUTH ONLY: VII.A2_1 =1
XI.D3. When you are age 25, how likely do you think it is that you will earn enough to support yourself
without financial help from your family or government benefit programs? Do you think you …
CODE ONE ONLY
Definitely will ....................................................................................................... 1
Probably will........................................................................................................ 2
Probably won’t, or .............................................................................................. 3
Definitely won’t ................................................................................................... 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SELF-REPORTING YOUTH ONLY: VII.A2_1 =1
XI.D4. When you are age 25, how likely do you think it is that you will be working at a paid job? Do you
think you …
CODE ONE ONLY
Definitely will ....................................................................................................... 1
GO TO XII.A1
Probably will........................................................................................................ 2
Probably won’t, or .............................................................................................. 3
Definitely won’t ................................................................................................... 4
DON’T KNOW ....................................................................................................... d
GO TO XII.A1
REFUSED ............................................................................................................. r
GO TO XII.A1
34 | P a g e
YOUTH’S SELF-DETERMINATION AND EXPECTATIONS FOR THE FUTURE
XI.D4 = 2,3, OR 4
FILL TEXT SHOWN BELOW BASED ON RESPONSE TO XI.D4
XI.D5. I am going to read you list of reasons why some people do not work.
[IF XI.D4=2, FILL: For each, please tell me if it is a reason why you are not certain that you will be
working at a paid job when you are age 25.]
[IF XI.D4=3 OR 4, FILL: For each, please tell me if it is a reason why you think you may not be
working at a paid job when you are age 25.] (YTD and NBS, modified)
IF NEEDED: Do you think this is something that may prevent you from working a paid job when
you are 25 years old?
SELECT CODING TYPE
YES
NO
DK
REF
a. Your disability or health will prevent you from working?
1
0
d
r
b. You won’t have reliable transportation to and from work?
1
0
d
r
c. You won’t be able to find a job you want?
1
0
d
r
d. You will still be in school or a training program?
1
0
d
r
e. Workplaces are not accessible to people with your disability?
1
0
d
r
f.
1
0
d
r
g. You just don’t want to work at a job?
1
0
d
r
h. Others do not think you will be able to work?
1
0
d
R
i.
99
0
d
r
You will not want to lose benefits such as disability or Medicaid?
Other reason
_______________ (STRING 100)
IF OTHER SPECIFY (99): What are the other reason(s) why you think you may not be working at a paid job
when you are 25?
35 | P a g e
YOUTH HEALTH AND WELL BEING
XII.
Asked of
Self-Reporting Youth
Asked of
Youth’s Proxy Respondent
x
x
Youth’s Health and Well-Being
SECTION XII. PART A. YOUTH HEALTH
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
(your/ YOUTH’s) [your / (his/ her)]
XII.A1. In general, would [(you/YOUTH] say that [your/ (his / her)] health is . . . (YTD)
CODE ONE ONLY
Excellent, ............................................................................................ 1
Very good, .......................................................................................... 2
Good, ................................................................................................ 3
Fair, or 4 ..............................................................................................
Poor? .................................................................................... 5
DON’T KNOW ......................................................................... d
REFUSED ............................................................................... r
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
[YOU / YOUTH]
XII.A2. My next set of questions will be about health-related choices people make. These questions, like
all the others in this interview, are voluntary. You can decide to answer them or not. During the
past 30 days…
CODE ONE PER ROW
YES
NO
DK
REF
a. Did [you / [YOUTH] use tobacco? IF NEEDED: This many
include smoking cigarettes or using chewing tobacco (as
known as dip, chew, or snuff). (NEW)
1
0
d
r
b. Did [you / [YOUTH] have at least one drink of alcohol? (NLTS2
wave 2)
1
0
d
r
c. Did [you / [YOUTH] use marijuana? (NLTS2 wave 2)
1
0
d
r
1
0
d
r
e. Did [you / [YOUTH] use any kind of illegal drug or pills that
[you / [YOUTH] took without a doctor's prescription? (NLTS2
wave 2, modified)
IF NEEDED: Examples include: any form of cocaine (coke, dust,
snow, blow), LSD, Acid, Ecstasy, Liquid X, Molly, Rohypnol,
Roofies, mushrooms, speed, Methamphetamines (such as Speed,
meth, ice, uppers), or heroin.
36 | P a g e
YOUTH HEALTH AND WELL BEING
SECTION XII. PART B. YOUTH’S ABILITIES AND USE OF SUPPORTS IN DAILY LIFE
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
[YOU DO / YOUTH DOES], [your / (his /her)], [you do / YOUTH does]
XII.INTRO.
Next I’ll ask you about how well [YOU DO/YOUTH DOES] some things in [your / (his /her)]
daily life. If there are things I ask about that [you do / YOUTH does] not do at all, because
of a disability or health condition, please let me know that, as well.
Your answers to these questions help us better understand the experiences of youth who
have enrolled in PROMISE.
CONTINUE ..................................................................
1
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
[YOU DO / YOUTH DOES] [Do you/Does YOUTH]
XII.B1. [Do you/Does YOUTH] experience any difficulty with speaking or communicating with others?
(Pathways Baseline Survey)
YES
................................................................................................ 1
NO
................................................................................................ 0
GO TO XII.B2
DOES NOT DO THIS ACTIVITY AT ALL ............................................ 2
DON’T KNOW ...................................................................................... d
GO TO XII.B2
REFUSED ............................................................................................ r
GO TO XII.B2
XII.B1=1 OR 2
[Do you/Does YOUTH]
XII.B1a. [Do you/Does YOUTH] require special equipment or help from another person to speak or
communicate with others? (Pathways Baseline Survey)
YES
................................................................................................ 1
NO
................................................................................................ 0
DON’T KNOW ...................................................................................... d
REFUSED ............................................................................................ r
37 | P a g e
YOUTH HEALTH AND WELL BEING
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
[Do you/Does YOUTH]
XII.B2. [Do you/Does YOUTH] experience any difficulty with hearing normal conversations? (Pathways
Baseline Survey)
YES
................................................................................................ 1
NO
................................................................................................ 0
GO TO XII.B3
DOES NOT DO THIS ACTIVITY AT ALL ............................................ 2
DON’T KNOW ...................................................................................... d
GO TO XII.B3
REFUSED ............................................................................................ r
GO TO XII.B3
XII.B2=1 OR 2
[Do you/Does the youth]
XII.B2a. [Do you/Does YOUTH] require special equipment or help from another person to hear a normal
conversation? (Pathways Baseline Survey)
YES
................................................................................................ 1
NO
................................................................................................ 0
DON’T KNOW ...................................................................................... d
REFUSED ............................................................................................ r
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
[Do you/Does YOUTH]
XII.B3. [Do you/Does YOUTH] experience any difficulty with seeing, even with the use of prescription
glasses or contact lenses? (Pathways Baseline Survey)
YES
................................................................................................ 1
NO
................................................................................................ 0
GO TO XII.B4
DOES NOT DO THIS ACTIVITY AT ALL ............................................ 2
DON’T KNOW ...................................................................................... d
GO TO XII.B4
REFUSED ............................................................................................ r
GO TO XII.B4
XII.B3=1 OR 2
[Do you/Does YOUTH]
XII.B3a. [Do you/Does YOUTH] require special equipment or help from another person to see, other than
the use of prescription glasses or contact lenses? (Pathways Baseline Survey)
YES
................................................................................................ 1
NO
................................................................................................ 0
DON’T KNOW ...................................................................................... d
REFUSED ............................................................................................ r
38 | P a g e
YOUTH HEALTH AND WELL BEING
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
[Do you/Does YOUTH]
XII.B4. [Do you/Does YOUTH] experience any difficulty with walking, standing, or climbing the stairs?
(Pathways Baseline Survey)
YES
................................................................................................ 1
NO
................................................................................................ 0
GO TO XII.B5
DOES NOT DO THIS ACTIVITY AT ALL ............................................ 2
DON’T KNOW ...................................................................................... d
GO TO XII.B5
REFUSED ............................................................................................ r
GO TO XII.B5
XII.B4=1 OR 2
[Do you/Does YOUTH]
XII.B4a. [Do you/Does YOUTH] require special equipment or help from another person to walk, stand, or
climb the stairs? (Pathways Baseline Survey)
YES
................................................................................................ 1
NO
................................................................................................ 0
DON’T KNOW ...................................................................................... d
REFUSED ............................................................................................ r
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
[Do you/Does YOUTH]
XII.B5. [Do you/Does YOUTH] experience any difficulty with dressing, bathing, or eating? (Pathways
Baseline Survey)
YES
................................................................................................ 1
NO
................................................................................................ 0
GO TO XII.B6
DOES NOT DO THIS ACTIVITY AT ALL ............................................ 2
DON’T KNOW ...................................................................................... d
GO TO XII.B6
REFUSED ............................................................................................ r
GO TO XII.B6
XII.B5=1 OR 2
[Do you/Does YOUTH]
XII.B5a. [Do you/Does YOUTH] require special equipment or help from another person to dress, bathe, or
eat? (Pathways Baseline Survey)
YES
................................................................................................ 1
NO
................................................................................................ 0
DON’T KNOW ...................................................................................... d
REFUSED ............................................................................................ r
39 | P a g e
YOUTH HEALTH AND WELL BEING
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
[Do you/Does YOUTH]
XII.B6. [Do you/Does YOUTH] experience any difficulty with getting around inside the home? (Pathways
Baseline Survey)
YES
................................................................................................ 1
NO
................................................................................................ 0
GO TO XII.B7
DOES NOT DO THIS ACTIVITY AT ALL ............................................ 2
DON’T KNOW ...................................................................................... d
GO TO XII.B7
REFUSED ............................................................................................ r
GO TO XII.B7
XII.B6=1 OR 2
[Do you/Does YOUTH]
XII.B6a. [Do you/Does YOUTH] require special equipment or help from another person to get around
inside the home? (Pathways Baseline Survey)
YES
................................................................................................ 1
NO
................................................................................................ 0
DON’T KNOW ...................................................................................... d
REFUSED ............................................................................................ r
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
[Do you/ Does YOUTH]
XII.B7. [Do you/Does YOUTH] have any difficulty with getting around outside the home, like to school, to
a nearby store or park, or to a neighbor’s house? (Pathways Baseline Survey)
YES
................................................................................................ 1
NO
................................................................................................ 0
GO TO XII.B8
DOES NOT DO THIS ACTIVITY AT ALL ............................................ 2
DON’T KNOW ...................................................................................... d
GO TO XII.B8
REFUSED ............................................................................................ r
GO TO XII.B8
XII.B7=1 OR 2
[Do you/ Does YOUTH]
XII.B7a. [Do you/Does YOUTH] require special equipment or help from another person to get around
outside the home? (Pathways Baseline Survey)
YES
................................................................................................ 1
NO
................................................................................................ 0
DON’T KNOW ...................................................................................... d
REFUSED ............................................................................................ r
40 | P a g e
YOUTH HEALTH AND WELL BEING
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
[Do you/ Does YOUTH]
XII.B8. [Do you/Does YOUTH] experience any difficulty with planning and carrying out activities to
achieve a goal? (Pathways Baseline Survey)
YES
................................................................................................ 1
NO
................................................................................................ 0
GO TO XII.B9
DOES NOT DO THIS ACTIVITY AT ALL ............................................ 2
DON’T KNOW ...................................................................................... d
GO TO XII.B9
REFUSED ............................................................................................ r
GO TO XII.B9
XII.B8=1 OR 2
DO YOU/DOES THE YOUTH
XII.B8a. [Do you/Does YOUTH] require special equipment, assistive technology, or help from another
person to plan and carry out activities to achieve a goal? (Pathways Baseline Survey, modified)
YES
................................................................................................ 1
NO
................................................................................................ 0
DON’T KNOW ...................................................................................... d
REFUSED ............................................................................................ r
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
[DO YOU/ DOES YOUTH]
XII.B9. [Do you/ Does YOUTH] experience any difficulty with learning, remembering, or concentrating?
(Pathways Baseline Survey)
YES
................................................................................................ 1
NO
................................................................................................ 0
GO TO XII.C.INTRO
DOES NOT DO THIS ACTIVITY AT ALL ............................................ 2
DON’T KNOW ...................................................................................... d
GO TO XII.C.INTRO
REFUSED ............................................................................................ r
GO TO XII.C.INTRO
XIII.B9=1 OR 2
[DO YOU/ DOES YOUTH]
XII.B9a. [Do you/Does YOUTH] require special equipment, assistive technology, or help from another
person to learn, remember, or concentrate? (NEW)
YES
................................................................................................ 1
NO
................................................................................................ 0
DON’T KNOW ...................................................................................... d
REFUSED ............................................................................................ r
41 | P a g e
YOUTH HEALTH AND WELL BEING
SECTION XII.C.
YOUTH’S HEALTH INSURANCE COVERAGE
PROGRAMMER: SECTION C IS ASKED ONLY OF INDEPENDENT YOUTH (I.TYPE_3=1 OR I.TYPE_4=1). ALL
OTHER YOUTH AND PROXIES SKIP TO XIII.A1.
ALL INDEPENDENT YOUTH AND THEIR PROXIES: (VII.A2_1 =1 OR 2) AND [I.TYPE_3=1 OR I.TYPE_4=1
XII.C.Intro.
The next questions are about health insurance, including health insurance obtained
through employment or purchased directly, as well as government programs like Medicaid
and Medicare.
CONTINUE .............................................................................
1
ALL INDEPENDENT YOUTH AND THEIR PROXIES: (VII.A2_1 =1 OR 2) AND [I.TYPE_3=1 OR I.TYPE_4=1
[ARE YOU / IS YOUTH]
XII.C1. [Are you / Is YOUTH] covered by any kind of health insurance or some other kind of health care
plan? (NHIS, modified)
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
GO TO XII.D.INTRO
DON’T KNOW ....................................................................................................... d
GO TO XII.D.INTRO
REFUSED ............................................................................................................. r
GO TO XII.D.INTRO
SOFT CHECK: IF XII.C1=0: May I confirm that I have recorded your answer correctly – that is that [you are
/ YOUTH is] not covered by any kind of health insurance of any kind at this time. This includes private
insurance, as well as any insurance you may get through government programs.
XII.C1=1
[Are you / Is YOUTH], [Are you / Is YOUTH], [or {state Medicaid program name}],
XII.C2-C6.
[Are you / Is YOUTH]…
CODE ONE PER ROW
YES
NO
REF
DK
XII.C2. Now covered by private health insurance? (NHIS, modified)
1
0
R
D
XII.C3. Covered by Medicaid [or {state Medicaid program name}]?
(Source: NHIS, modified)
1
0
R
D
XII.C4. IF YOUTH AGE IS > 18: Covered by Medicare? (NHIS, modified)
1
0
R
D
XII.C5. IF MEDICAID COVERAGE NOT IDENTIFIED (XII.C3=2, d, r):
Covered by the Children’s Health Insurance Program, also called
S-CHIP?
1
0
R
D
XII.C6. Covered by any other kind of health insurance I have not already
asked about?
1
0
R
D
SOFT CHECK: (IF REPORTED TO HAVE INSURANCE (XII.C1=1), BUT NO INSURANCE IS REPORTED
(XII.C2-XII.C6 ALL=0): May I confirm I have correctly you have health insurance coverage? If no, (not
covered), return to XII.C1 to correct the response, as needed. If yes (covered), return to XII.C2-C6 to
record the type of coverage.
42 | P a g e
YOUTH HEALTH AND WELL BEING
XII.C2=1
[you purchase / YOUTH purchases] [your / (his / her)]
XII.C2a.
Is that private insurance through an employer, a union, a family member, or that [you
purchase / YOUTH purchases] on [your / (his / her)] own? (NHIS, modified)
INTERVIEWER:
IF COVERED BY MORE THAN ONE PRIVATE INSURANCE, ASK FOR SOURCE
OF PRIMARY OR MAIN PRIVATE INSURANCE COVERAGE.
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
GO TO XII.D-INTRO
DON’T KNOW ....................................................................................................... d
GO TO XII.D-INTRO
REFUSED ............................................................................................................. r
GO TO XII.D-INTRO
PURCHASED ON OWN: XII.C2a=1
[state marketplace name, or]
XII.C2b.
Was the private insurance purchased through the Affordable Care Act or a health insurance
exchange, sometimes called [state marketplace name, or], Healthcare.gov, or ObamaCare?
(NHIS, modified)
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
GO TO XII.D-INTRO
DON’T KNOW ....................................................................................................... d
GO TO XII.D-INTRO
REFUSED ............................................................................................................. r
GO TO XII.D-INTRO
PURCHASED THROUGH THE AFFORDABLE CARE ACT: XII.C2b=1
[Do you / Does YOUTH]
XII.C2c.
[Do you / Does YOUTH] receive a tax credit to help pay for private insurance premiums?
(Source: NHIS, modified)
YES ....................................................................................................................... 1
NO ........................................................................................................................ 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
43 | P a g e
YOUTH HEALTH AND WELL BEING
SECTION XII.D. HOUSEHOLD BENEFITS AND INCOME
PROGRAMMER:
MODULE IS ASKED OF INDEPENDENT YOUTH (I.RTYPE_3=1 OR I.RTYPE_4=1)
ONLY. ALL OTHER YOUTH AND YOUTH PROXIES SKIP TO XIII.A1.
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2) AND (I.TYPE_3=1 OR I.TYPE_4=1)
XII.D.Intro.
These questions will ask about benefits your household may receive, as well as your
household income.
CONTINUE ..................................................................
1
ALL INDEPENDENT YOUTH AND PROXIES: (VII.A2_1 =1 OR 2) AND (I.TYPE_3=1 OR I.TYPE_4=1)
[Do you / Does YOUTH], [your / YOUTH’s] [FILL STATE-SPECIFIC NAME FOR TANF]
XII.D1. [Do you / Does YOUTH] or does anyone in [your / YOUTH’s] household receive …
CODE ONE PER ROW
YES
NO
DK
REF
a. Assistance from temporary assistance to needy families or [FILL
STATE-SPECIFIC NAME FOR TANF]?
1
0
d
r
b. Assistance from food stamps, or SNAP (the Supplemental Nutrition
Assistance Program).
1
0
d
r
c. Any government housing assistance in paying rent, such as through
public housing or Section 8?
1
0
d
r
d. Receive any income from SSI or SSDI because of a disability?
1
0
d
r
e. Receive retirement income from social security?
1
0
d
r
f. Receive social security survivor’s benefits?
1
0
d
r
1
0
d
r
g.
Receive any other government benefits that we have not yet
accounted for in this list?
XII.D1F=1
[do you receive/ does YOUTH receive]
XII.D2. What other government benefits [do you / does YOUTH] receive?
___________________________________________________ (STRING 100)
BENEFITS
DON’T KNOW ......................................................................... d
REFUSED ............................................................................................................. r
44 | P a g e
YOUTH HEALTH AND WELL BEING
ALL INDEPENDENT YOUTH AND PROXIES: (VII.A2_1 =1 OR 2) AND (I.TYPE_3=1 OR I.TYPE_4=1)
[YOUR / YOUTH’s] [CALCULATE AND FILL PRIOR CALENDAR YEAR]
XII.D3. Please tell me which group best describes the total income of all persons in your household last
year, including salaries or other earnings, money from public assistance, retirement, and so on,
for all household members, before taxes.
Was [your / YOUTH’s] household income last year, that is, in [PRIOR CALENDAR YEAR]. . .
CODE ONE ONLY
LESS THAN $10,000, ........................................................................................... 1
$10,000 OR MORE, BUT LESS THAN $20,000, ................................................. 2
$20,000 OR MORE, BUT LESS THAN TO $30,000, ........................................... 3
$30,000 OR MORE, BUT LESS THAN TO $40,000, ........................................... 4
$40,000 OR MORE, BUT LESS THAN TO $50,000 ............................................ 5
$50,000 OR MORE, BUT LESS THAN $75,000, ................................................. 5
$75,000 OR MORE .............................................................................................. 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
45 | P a g e
YOUTH DEMOGRAPHICS AND CONTACT INFORMATION
XIII.
Asked of
Self-Reporting Youth
Asked of
Youth’s Proxy Respondent
x
x
Youth Demographics and Contact Information
SECTION XIII. PART A. YOUTH’S DEMOGRAPHICS
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
[DO YOU/ DOES YOUTH] [yourself / (himself /herself)]
XIII.A1. [DO YOU/DOES YOUTH] consider [yourself / (himself /herself)] to be of Hispanic or Latino
origin, such as Mexican, Puerto Rican, Cuban, or other Spanish background? (YTD
Baseline, 53)
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
[YOUR/youth’s], [ARE YOU/ IS [YOUTH]]
XIII.A2. I’m going to read a list of race categories, please choose one or more races that best
describes (YOUR/YOUTH’S) race? [ARE YOU/IS YOUTH] . . . (YTD Baseline 54)
INTERVIEWER:
IF RESPONDENT SAYS MIXED RACE OR BI- OR MULTIRACIAL, ASK
WHICH RACES THE YOUTH REPRESENTS AND CODE EACH.
CODE ALL THAT APPLY
American Indian or Alaska Native ..................................................................... 1
Asian..................................................................................................................... 2
Black or African American ................................................................................. 3
Native Hawaiian or Other Pacific Islander ........................................................ 4
White..................................................................................................................... 5
Other race ............................................................................................................ 99
___________________________________________________ (STRING 200)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What is (your race/ YOUTH’s race)
46 | P a g e
YOUTH DEMOGRAPHICS AND CONTACT INFORMATION
SECTION XIII. PART B. YOUTH’S CONTACT INFORMATION
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
[you/ YOUTH], [your / YOUTH’S]
XIII.B.Intro.
The next questions will be about how to contact [you/ YOUTH]. It is important that
we do not lose touch with [you / YOUTH], so I will ask for [your / YOUTH’s] contact
information, such as your address and telephone number, as well as others who
may be able to help us reach [you / YOUTH] in the future.
CONTINUE ........................................................................................................... 0
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
[YOUR/YOUTH’S] [YOUTH RESIDENTIAL ADDRESS FROM SAMPLE FILE]
XIII.B1.
What is your home address? This is where we will mail your thank you letter and
payment for this interview. Is it [YOUTH RESIDENTIAL ADDRESS FROM SAMPLE FILE]?
(YTD Baseline, 5 modified)
PROBE:
Where street do you live on? In what town? If you don’t know the full address,
that’s OK, just share as much as you can remember.
INTERVIEWER:
IF REFUSES, PROBE FOR ZIP CODE.
INTERVIEWER:
IF THIS INTERVIEW WAS COMPLETED BY PROXY, RECORD PROXY’S
ADDRESS BELOW.
SAME ADDRESS AS SHOWN ABOVE ............................................................... 1
DIFFERENT ADDRESS – UPDATE BELOW ....................................................... 99
___________________________________________________
STREET 1
___________________________________________________
STREET 2
___________________________________________________
CITY
___________________________________________________
STATE
___________________________________________________
ZIP
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
47 | P a g e
YOUTH DEMOGRAPHICS AND CONTACT INFORMATION
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
[YOUR/[YOUTH]’S]
XIII.B2. What is the best telephone number to reach [you / YOUTH] at? Is it [YOUTH PHONE FROM
SAMPLE FILE] or another number?
SAME PHONE NUMBER AS SHOWN ABOVE ................................................... …1
DIFFERENT PHONE NUMBER – UPDATE BELOW ........................................... 99
|
|
|
|-| |
(0-999 )
|
|-| |
(0-999)
|
| |
(0-9999)
NO PHONE NUMBER .......................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
XIII.B2>1
[YOUR/[YOUTH]’S]
XIII.B3. Is that a landline or a cell phone?
LAND LINE ............................................................................................................ 1
CELL PHONE ....................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
XIII.B3 =2
[YOUR/YOUTH’S]
XIII.B3a.
Would it be ok for us to send a text message when we try to contact [you/ YOUTH] for
the next survey? Please note that standard text message rates will apply. (NLTS2012,
J11b)
YES ....................................................................................................................... 1
NO, DOES NOT USE TEXT MESSAGING .......................................................... 2
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
48 | P a g e
YOUTH DEMOGRAPHICS AND CONTACT INFORMATION
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
[YOUR/ YOUTH’S] [you check / YOUTH checks]
XIII.B4. What is [your/YOUTH’S] email address? (YTD Baseline, 8)
___________________________________________________ (STRING 100)
Email address
NO EMAIL ADDRESS........................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
IF OTHER SPECIFY (99): What is the email [you check / YOUTH checks] most often?
SECTION XIII. PART C. MOTHER’S CONTACT INFORMATION
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2) WHERE MOTHER (BIOLOGICAL, ADOPTED, OR
STEP) DID NOT COMPLETE THE PARENT / GUARDIAN INTERVIEW (I.ELIG=2, 3, 5, 6, 7, 8, OR 9]
[YOUR/YOUTH’S]
XIII.C1. What is [YOUR/YOUTH’S] mother’s name? (YTD Baseline, 66)
___________________________________________________ (STRING 30)
FIRST NAME
___________________________________________________ (STRING 30)
MIDDLE INITIAL/NAME
___________________________________________________ (STRING 60)
LAST NAME
DOES NOT HAVE A MOTHER ........................................................................... 1
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
49 | P a g e
GO TO XIII.D1
GO TO XIII.D1
GO TO XIII.D1
YOUTH DEMOGRAPHICS AND CONTACT INFORMATION
XIII.C1=POPULATED NAME
[ADDRESS FROM YOUTH MAILING ADDRESS IN SAMPLE FILE]
XIII.C2. What is her address? Is it [FILL YOUTH MAILING ADDRESS FROM SAMPLE FILE] or
someplace else? (YTD Baseline, 67 modified)
PROBE: Where does she live or stay?
PROBE: If you don’t know the full address, that’s OK, just share as much as you can
remember.
SAME ADDRESS AS YOUTH (SHOWN ABOVE) ............................................... 1
DIFFERENT ADDRESS: UPDATE BELOW: ........................................................ 99
___________________________________________________
STREET 1
___________________________________________________
STREET 2
___________________________________________________
CITY
___________________________________________________
STATE
___________________________________________________
ZIP
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
XIII.C1=POPULATED NAME
[PHONE FROM VI.B2]
XIII.C3. What is the best telephone number to reach her at? Is it [PHONE FROM VI.B2] or another
number? (YTD Baseline, 68 revised)
SAME PHONE NUMBER AS PARENT SURVEY RESPONDENT (SHOWN
ABOVE) ................................................................................................................. …1
DIFFERENT PHONE NUMBER – UPDATE BELOW ........................................... 99
|
|
|
(0-999 )
|-|
|
|
(0-999)
|-|
|
|
|
|
(0-9999)
DOES NOT HAVE A TELEPHONE ...................................................................... 0
GO TO XIII.C4
DON’T KNOW ....................................................................................................... d
GO TO XIII.C4
REFUSED ............................................................................................................. r
GO TO XIII.C4
50 | P a g e
YOUTH DEMOGRAPHICS AND CONTACT INFORMATION
XIII.C3=>1
XIII.C3a. Is that number a land line or cell phone? (NLTS2012, I1b)
CODE ONE ONLY
LANDLINE ............................................................................................................. 1
CELL PHONE ....................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
XIII.C1=POPULATED NAME
[MOTHER FIRST NAME] [you /YOUTH]
XIII.C4. Does [MOTHER FIRST NAME] have an email address we can use in case we need help
contacting [you / YOUTH] for the next part of the study? (NTLS2012, R8)
CODE ONE ONLY
YES (SPECIFY EMAIL) ........................................................... 99
___________________________________________________ (STRING 150)
NO
.................................................................................... 0
DON’T KNOW ......................................................................... d
REFUSED ............................................................................... r
IF OTHER SPECIFY (99): What is the email she checks most often?
51 | P a g e
YOUTH DEMOGRAPHICS AND CONTACT INFORMATION
SECTION XIII. PART D. YOUTH’S FATHER’S CONTACT INFORMATION
ALL YOUTH AND PROXIES: (VII.A2_1 =1 OR 2) WHERE FATHER (BIOLOGICAL, ADOPTED, OR
STEP) DID NOT COMPLETE THE PARENT / GUARDIAN INTERVIEW (I.ELIG=1, 3, 4, 6, 7, 8, OR 9]
[YOUR/ YOUTH’s]
XIII.D1. What is [YOUR/ YOUTH’s] father’s name? (YTD Baseline, 69)
___________________________________________________ (STRING 30)
FIRST NAME
___________________________________________________ (STRING 30)
MIDDLE INITIAL/NAME
___________________________________________________ (STRING 60)
LAST NAME
DOES NOT HAVE A FATHER ............................................................................. 0
GO TO XIII.E1
DON’T KNOW ....................................................................................................... d
GO TO XIII.E1
REFUSED ............................................................................................................. r
GO TO XIII.E1
XIII.D1=POPULATED NAME
[YOUR/YOUTH’s], [MOTHER’S ADDRESS (XIII.C2= POPULATED)]
XIII.D2a.
What is [YOUR/ YOUTH’s] father’s address? Is it [PROGRAMMER IF MOTHER’S
ADDRESS (XIII.C2= POPULATED), FILL HERE] or someplace else? (YTD Baseline, 71
modified)
PROBE: Where does he live or stay? Where does he get mail delivered? If you don’t
know the full address, that’s OK, just share as much as you can remember.
SAME ADDRESS AS MOTHER (SHOWN ABOVE) ............................................ 1
DIFFERENT ADDRESS: UPDATE BELOW: ........................................................ 99
___________________________________________________
STREET 1
___________________________________________________
STREET 2
___________________________________________________
CITY
___________________________________________________
STATE
___________________________________________________
ZIP
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
52 | P a g e
YOUTH DEMOGRAPHICS AND CONTACT INFORMATION
XIII.D1=POPULATED NAME
[YOUR/YOUTH’s]
XIII.D3. What’s the best telephone number to reach [YOUR/ YOUTH’s] father at? (YTD Baseline, 72)
PROGRAMMER: FILL PHONE FROM [VI.B2]
SAME PHONE NUMBER AS PARENT SURVEY RESPONDENT (SHOWN
ABOVE) ................................................................................................................. …1
DIFFERENT PHONE NUMBER – UPDATE BELOW ........................................... 99
|
| |
(0-999)
|-|
| |
(0-999)
|-|
| | |
(0-9999)
|
DOES NOT HAVE A TELEPHONE ...................................................................... 0
GO TO XIII.D4
DON’T KNOW ....................................................................................................... d
GO TO XIII.D4
REFUSED ............................................................................................................. r
GO TO XIII.D4
XIII.D3=>1
XIII.D3a. Is that number a land line or cell phone? (NLTS2012, I1b)
CODE ONE ONLY
LANDLINE ............................................................................................................. 1
CELL PHONE ....................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
XIII.D3=POPULATED NAME
[FATHER FIRST NAME]
XIII.D4. Does [FATHER FIRST NAME] have an email address we can use in case we need help
contacting you for the next part of the study? (NTLS2012, R8)
CODE ONE ONLY
YES (SPECIFY EMAIL) ........................................................... 99
___________________________________________________ (STRING 100)
NO
.................................................................................... 0
DON’T KNOW ......................................................................... d
REFUSED ............................................................................... r
IF OTHER SPECIFY (99): What’s the email he checks most often?
53 | P a g e
YOUTH DEMOGRAPHICS AND CONTACT INFORMATION
SECTION XIII. PART E. YOUTH’S ADDITIONAL CONTACT 1
THIS SECTION IS ASKED OF ALL YOUTH AND PROXIES.
YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
[YOU/YOUTH], [YOU/(HIM/HER)], [YOU MOVE/YOUTH MOVES]
XIII.E1. Can you please tell me the name of a friend or relative who does not live with [you/YOUTH]
and would know how to reach [YOU/ (HIM/HER)] if [YOU MOVE /YOUTH MOVES] or get a
new telephone numbers? (YTD Baseline, 79)
What is his or her name?
___________________________________________________ (STRING 30)
FIRST NAME
___________________________________________________ (STRING 30)
MIDDLE INITIAL/NAME
___________________________________________________ (STRING 60)
LAST NAME
DON’T KNOW ....................................................................................................... d
GO TO CLOSING-1
REFUSED ............................................................................................................. r
GO TO CLOSING-1
XIII.E1= NAME POPULATED
[YOU/NAME]
XIII.E2. How is this person related to [you/ YOUTH]? (YTD Baseline, 82)
CODE ONE ONLY
SISTER ................................................................................................................. 1
BROTHER ............................................................................................................. 2
GRANDMOTHER .................................................................................................. 3
GRANDFATHER ................................................................................................... 4
AUNT..................................................................................................................... 5
UNCLE .................................................................................................................. 6
COUSIN ................................................................................................................ 7
FRIEND ................................................................................................................. 8
OTHER RELATIVE ............................................................................................... 9
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
54 | P a g e
YOUTH DEMOGRAPHICS AND CONTACT INFORMATION
XIII.E1. NAME POPULATED
XIII.E3. What is the city and state in which [NAME FROM XII.E1] lives or stays? (YTD Baseline, 80
modified)
PROBE:
If you don’t know both, that’s OK, just share as much as you can remember.
___________________________________________________
CITY
___________________________________________________
STATE
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
XIII.E1=NAME POPULATED
CONTACT 1
XIII.E4. What’s the best telephone number to reach [CONTACT 1] at? (YTD Baseline, 81)
|
| |
(0-999)
|-| | |
(0-999)
|-| | |
(0-9999)
|
|
DOES NOT HAVE A TELEPHONE ...................................................................... 1
GO TO XIII.F1
DON’T KNOW ....................................................................................................... d
GO TO XIII.F1
REFUSED ............................................................................................................. r
GO TO XIII.F1
SECTION XIII. PART F. YOUTH’S ADDITIONAL CONTACT 2
THIS SECTION IS ASKED OF ALL YOUTH AND PROXIES WHO HAVE PROVIDED AN ADDITIONAL
CONTACT (1). IF NONE WAS PROVIDED, GO TO CLOSING-1.
YOUTH AND PROXIES: (VII.A2_1 =1 OR 2) AND XIII.E1=POPULATED WITH A NAME.
[YOU/YOUTH], [YOU/(HIM/HER)], [YOU MOVE/YOUTH MOVES]
XIII.F1. Can you tell me the name of another friend or relative [YOU/YOUTH] – who may or may not
live with [you / YOUTH] and would know how to reach [YOU/ (HIM/HER)] if [YOU
MOVE/YOUTH MOVES] or change telephone numbers? What is his or her name? (YTD
Baseline, 79)
___________________________________________________ (STRING 30)
FIRST NAME
___________________________________________________ (STRING 30)
MIDDLE INITIAL/NAME
___________________________________________________ (STRING 60)
LAST NAME
DON’T KNOW ....................................................................................................... d
GO TO CLOSING-1
REFUSED ............................................................................................................. r
GO TO CLOSING-1
55 | P a g e
YOUTH DEMOGRAPHICS AND CONTACT INFORMATION
XIII.F1=NAME POPULATED
[you /YOUTH]
XIII.F2. How is this person related to [you/ YOUTH]? (YTD Baseline, 82)
CODE ONE ONLY
SISTER ................................................................................................................. 1
BROTHER ............................................................................................................. 2
GRANDMOTHER .................................................................................................. 3
GRANDFATHER ................................................................................................... 4
AUNT..................................................................................................................... 5
UNCLE .................................................................................................................. 6
COUSIN ................................................................................................................ 7
FRIEND ................................................................................................................. 8
OTHER RELATIVE ............................................................................................... 9
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
XIII.F1=NAME POPULATED
[CONTACT 2 NAME]
XIII.F3. What is the city and state where [NAME FROM XII.G1] lives or stays? (YTD Baseline, 80
modified)
___________________________________________________
CITY
___________________________________________________
STATE
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
XIII.F1=NAME POPULATED
[CONTACT 2 NAME]
XIII.F4. What is the best phone number to reach [CONTACT 2 NAME] at? (YTD Baseline, 81
modified)
|
| |
(0-999)
|-| | |
(0-999)
|-| | |
(0-9999)
|
|
DOES NOT HAVE A PHONE ............................................................................... 0
GO TO CLOSING-1
DON’T KNOW ....................................................................................................... d
GO TO CLOSING-1
REFUSED ............................................................................................................. r
GO TO CLOSING-1
56 | P a g e
YOUTH DEMOGRAPHICS AND CONTACT INFORMATION
YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
[YOU / YOUTH] [CALCULATE DATE OF INTERVIEW FROM SAMPLE LAUNCH DATE. IF > 10 DAYS,
FILL $30, IF < 10 DAYS, FILL $40].
CLOSING-1.
Thank you the time you have spent answering these questions. As we talked about
earlier, we will send you a gift card for completing this interview. We have two
choices – do you prefer a card to Target or Walmart? [You / YOUTH] should receive
your thank you letter which has the [CALCULATE AND FILL: $30 / $40] gift card in
the next 4-6 weeks.
TARGET CARD .................................................................................................... 1
WALMART CARD ................................................................................................. 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
YOUTH AND PROXIES: (VII.A2_1 =1 OR 2)
CLOSING-2.
That completes the interview. Thank you and have a wonderful day!
TERMINATE ......................................................................................................... 1
57 | P a g e
| File Type | application/pdf |
| Author | Forest Crigler |
| File Modified | 2015-04-30 |
| File Created | 2015-04-30 |