Baseline Information Form

Supporting Statement

For the Paperwork Reduction Act of 1995: Approval for the Baseline Data Collection, Implementation Study Site Visits, and Staff Surveys for the Job Search Assistance (JSA) Strategies Evaluation

Attachment A: Baseline Information Form

OMB No. 0970-0440

August 11, 2014

Submitted by:

Office of Planning,
Research & Evaluation

Administration for Children & Families

U.S. Department of Health
and Human Services

Federal Project Officer

Erica Zielewski

U.S. Department of Health and Human Services

Job Search Assistance (JSA) Strategies Evaluation

Baseline Information Form

This form asks questions about your background. The questions cover a range of topics, including your family, your education, and your past employment. Your answers to these questions will not affect your eligibility for services here or elsewhere. The information will be used for research purposes only and will be kept confidential to the extent allowed by law. If you have any questions, please ask the staff person who gave you this form.

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

MARKING DIRECTIONS

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

 Do not use felt tip markers or gel pens.

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

Correct:  □ □ □

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

Correct:  □  □

J

O

B

S

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

Burden Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this collection is 0970-0440; this number is valid through XX/XX/XXXX. Public reporting burden for this collection of information is estimated to average 12 minutes, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

PERSONAL CONTACT INFORMATION

1. WHAT IS YOUR NAME?

___________________________ FIRST

______ M.I.

_____________________________________________ LAST

2. WHAT IS YOUR DATE OF BIRTH?

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

3. WHAT IS YOUR SOCIAL SECURITY NUMBER?

___ ___ ___ - ___ ___ - ___ ___ ___ ___

4. WHAT IS YOUR ADDRESS?

_____________________________________________ STREET ADDRESS

__________________ APT #

__________________________________ CITY

________ STATE

__________________ ZIP

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

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

□ HOME

□ CELL

□ WORK

□ HOME

□ CELL

□ WORK

6. MAY WE SEND A TEXT MESSAGE TO YOUR CELL PHONE?

□ YES □ NO

7. WHAT IS YOUR E-MAIL ADDRESS?

__________________________________@______________________

8. MAY WE CONTACT YOU THROUGH FACEBOOK? IF YES, HOW IS YOUR NAME LISTED ONFACEBOOK?

□ YES □ NO _________________________________________________________

BACKGROUND AND FAMILY CHARACTERISTICS

9. WHAT IS YOUR SEX?

1□ MALE 2□ FEMALE

10. WHAT IS YOUR MARITAL STATUS?

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

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

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

BACKGROUND AND FAMILY CHARACTERISTICS

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

1□ WHITE 2□ BLACK OR AFRICAN AMERICAN 3□ AMERICAN INDIAN OR ALASKA NATIVE 4□ ASIAN INDIAN 5□ CHINESE 6□ FILIPINO 7□ JAPANESE 8□ KOREAN 9□ VIETNAMESE 10□ OTHER ASIAN 11□ NATIVE HAWAIIAN 12□ GUAMANIAN OR CHAMORRO 13□ SAMOAN 14□ OTHER PACIFIC ISLANDER

13. WHICH OF THE FOLLOWING LIVE IN YOUR HOUSEHOLD AT LEAST HALF THE TIME? (MARK ONE OR MORE): 01□ YOUR SPOUSE 02□ YOUR UNMARRIED PARTNER 03□ YOUR BIOLOGICAL OR ADOPTED CHILDREN 04□ OTHER CHILDREN UNDER AGE 18 05□ YOUR MOTHER OR FATHER 06□ YOUR OTHER RELATIVES 07□ YOUR SPOUSE’S MOTHER OR FATHER 08□ YOUR SPOUSE’S OTHER RELATIVES 09□ FRIENDS 10□ OTHERS 11□ NO ONE ELSE 14. HOW MANY ADULTS AGE 18 OR OLDER, INCLUDING YOURSELF, LIVE IN YOUR HOUSEHOLD AT LEAST HALF THE TIME? ____ ADULTS 15. HOW MANY CHILDREN UNDER AGE 18 LIVE WITH YOU AT LEAST HALF THE TIME? (INCLUDE BIOLOGICAL, ADOPTED, FOSTER, STEP, AND ANY OTHER CHILDREN): _­­­___ CHILDREN 16. WHAT IS THE AGE (IN YEARS) OF THE YOUNGEST CHILD CURRENTLY LIVING IN YOUR HOUSEHOLD (ANSWER ZERO IF THE CHILD HAS NOT REACHED HIS/HER FIRST BIRTHDAY)? 0______ AGE OF YOUNGEST CHILD

EDUCATIONAL BACKGROUND

17. WHAT IS THE HIGHEST DEGREE OR LEVEL OF SCHOOL YOU HAVE COMPLETED? (MARK ONE): 1□ GRADE 1 THROUGH 11  PLEASE WRITE THE HIGHEST GRADE YOU COMPLETED 1-11 HERE: ______ 2□ 12th GRADE – NO DIPLOMA 3□ GED OR ALTERNATIVE CREDENTIAL 4□ REGULAR HIGH SCHOOL DIPLOMA 5□ SOME COLLEGE CREDIT, BUT LESS THAN 1 YEAR OF COLLEGE CREDIT 6□ 1 OR MORE YEARS OF COLLEGE CREDIT, BUT NO DEGREE 7□ ASSOCIATE’S DEGREE (FOR EXAMPLE: AA, AS) 8□ BACHELOR’S DEGREE OR HIGHER (FOR EXAMPLE: BA BS)

EDUCATIONAL BACKGROUND

18. HAVE YOU RECEIVED A POST-SECONDARY VOCATIONAL OR TECHNICAL CERTIFICATE OR DIPLOMA? 1□ YES 2□ NO

19. WHAT GRADES DID YOU USUALLY GET IN HIGH SCHOOL? (MARK ONE):

1□ DID NOT ATTEND HIGH SCHOOL IN THE U.S. 2□ MOSTLY A’s 3□ MOSTLY B’s

4□ MOSTLY C’s 5□ MOSTLY D’s 6□ MOSTLY F’s

EMPLOYMENT AND INCOME

20. ARE YOU CURRENTLY WORKING AT A JOB FOR PAY? (MARK ONE)

1□ YES HOW MANY HOURS PER WEEK ON AVERAGE ARE YOU CURRENTLY WORKING? (INCLUDE ALL JOBS)

___ ___ HOURS/WEEK

2□ NO, BUT I WORKED BEFORE  WHEN DID YOU LAST WORK?

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

3□ NO, I NEVER WORKED

21. IF YOU ANSWERED “YES” OR “NO, BUT I WORKED BEFORE” TO Q22: ABOUT HOW MUCH DO/DID YOU TYPICALLY EARN PER HOUR BEFORE TAXES IN YOUR CURRENT OR MOST RECENT JOB? (ANSWER FOR YOUR MAIN JOB IF MORE THAN ONE) $ ______ . ______ PER HOUR IN CURRENT/MOST RECENT JOB IF YOU DO NOT KNOW THE HOURLY RATE, PLEASE GIVE EARNINGS IN ONE OF THE CATEGORIES BELOW: $ ___ ___ ___ ___ PER DAY $ ___ ___ ___ ___ PER WEEK $ ___ ___ ___ ___ EVERY 2 WEEKS $ ___ ___ ___ ___ TWICE A MONTH $ ___ ___ ___ ___ EVERY MONTH $ ___ ___ ___ ___ OTHER (SPECIFY TIME PERIOD: ____________________________________) 22. EVER WORKED FULL TIME FOR 6 MONTHS OR MORE FOR ONE EMPLOYER? 1□ YES 2□ NO 23. ANY EARNINGS IN THE PAST 12 MONTHS? 1□ YES 2□ NO 24. TOTAL PRIOR TANF RECEIPT (MARK ONE): 1□ NONE 2□ LESS THAN 1 YEAR 3□ 2-5 YEARS 4□ 5-10 YEARS 5□ 10 YEARS OR MORE 25. HOW LONG AGO WAS YOUR PRIOR TANF RECEIPT? 1□ I WAS NOT ON TANF BEFORE 2□ LESS THAN 1 YEAR AGO 3□ 2-5 YEARS AGO 4□ 5-10 YEARS AGO 5□ 10 YEARS OR MORE AGO

ALTERNATE CONTACTS Please provide information for three persons not living with you who can help us locate you:

CONTACT #1

WHAT IS HIS/HER NAME?

_____________________________________ FIRST

_____________________________________________ LAST

WHAT IS HIS/HER RELATIONSHIP TO YOU?

_____________________________________________

WHAT IS HIS/HER ADDRESS?

_____________________________________________ STREET ADDRESS

__________________ APT #

__________________________________ CITY

________ STATE

__________________ ZIP

WHAT IS HIS/HER PRIMARY PHONE NUMBER? (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

WHAT IS HIS/HER SECONDARY PHONE NUMBER? (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

□ HOME

□ CELL

□ WORK

□ HOME

□ CELL

□ WORK

WHAT IS HIS/HER E-MAIL ADDRESS?

__________________________________@______________________

CONTACT #2

WHAT IS HIS/HER NAME?

_____________________________________ FIRST

_____________________________________________ LAST

WHAT IS HIS/HER RELATIONSHIP TO YOU?

_____________________________________________

WHAT IS HIS/HER ADDRESS?

_____________________________________________ STREET ADDRESS

__________________ APT #

__________________________________ CITY

WHAT IS HIS/HER PRIMARY PHONE NUMBER? (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

WHAT IS HIS/HER SECONDARY PHONE NUMBER? (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

□ HOME

□ CELL

□ WORK

□ HOME

□ CELL

□ WORK

WHAT IS HIS/HER E-MAIL ADDRESS?

__________________________________@______________________

CONTACT #3

WHAT IS HIS/HER NAME?

_____________________________________ FIRST

_____________________________________________ LAST

WHAT IS HIS/HER RELATIONSHIP TO YOU?

_____________________________________________

WHAT IS HIS/HER ADDRESS?

_____________________________________________ STREET ADDRESS

__________________ APT #

__________________________________ CITY

WHAT IS HIS/HER PRIMARY PHONE NUMBER? (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

WHAT IS HIS/HER SECONDARY PHONE NUMBER? (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

□ HOME

□ CELL

□ WORK

□ HOME

□ CELL

□ WORK

WHAT IS HIS/HER E-MAIL ADDRESS?

__________________________________@______________________