YCC Parent Baseline Information Form (individuals)

OMB No.: xxxx-xxxx

Expiration Date: xx/xx/xxxx

Youth CareerConnect

Parent Background Information Form (BIF)

A1. What is your relationship to the student applying for the program?

MARK ONE ONLY

1 □ Biological or adoptive mother

2 □ Biological or adoptive father

3 □ Stepmother or female partner of the student’s parent or guardian

4 □ Stepfather or male partner of the student’s parent or guardian

5 □ Foster mother

6 □ Foster father

7 □ Grandmother/Grandfather

8 □ Other (specify)

A2. How many people currently live in the same household with the student applying for the program? Please INCLUDE yourself, but DO NOT include the student applying to the program.

	Number of People
a. Children, age 17 or younger	| | |
b. Adults, age 18 and older	| | |

A3. What is the MAIN language spoken in the student’s home?

MARK ONE ONLY

1 □ English

2 □ Spanish

3 □ Another language (specify)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is xxxx-xxxx. The time required to complete this collection of information is estimated to average 19 minutes, including the time to review instructions, search existing data resources, gather the data needed and complete and review the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to NAME at xxx-xxx-xxxx or NAME@___.gov and reference the OMB Control Number xxxx-xxxx.

A 4. Please check each of the following sources of income that anyone in your household received in the past month.

MARK ALL THAT APPLY

1 □ Wages and salary

2 □ Food Stamps or SNAP benefits

3 □ Medicaid

4 □ Social Security or pension benefits

5 □ SSI, SSDI, or other disability benefits

6 □ Welfare benefits or General Assistance

7 □ Unemployment benefits

8 □ Other (specify)

9 □ None of the above

A5. What is the most recent period you worked for pay?

MARK ONE ONLY

1 □ Last week

2 □ Last month

3 □ Last 6 months

4 □ More than 6 months ago

5 □ I have never worked for pay GO TO A7

A6. How many hours per week, including regular overtime hours, do you/did you usually work at all paid jobs? Your best estimate is fine.

| | | hours per week

A7. Do you hold a vocational certificate?

A vocational certificate is a certificate from a college or trade school for completion of a program providing job-focused training for specific careers such as physician’s assistants, paralegals, pharmacy technicians, automotive mechanics, and information systems programmers.

MARK ONE ONLY

1 □ Yes

0 □ No

d □ I don’t know

A8. In the table below, please use the first column to indicate your highest level of education, and the second column to indicate the highest education of any adult currently living in your household , including yourself.

MARK ONE RESPONSE IN EACH COLUMN

	Your highest level of education	Highest level of education in household
a. Did not finish high school	1 □	1 □
b. Graduated from high school or received a general education development (GED) certificate	2 □	2 □
c. Graduated from a 2-year school (such as a vocational or technical school, junior college, or a community college)	3 □	3 □
d. Graduated from a 4-year college	4 □	4 □
e. Completed a masters, Ph.D. or other advanced degree (such as an MD for doctors or LLD for lawyers)	5 □	5 □
f. I don’t know		d □

B1. Which of the following describes the student?

MARK ONE ONLY

1 □ Hispanic or Latino

2 □ Not Hispanic or Latino

B2. Which of the following describes the student?

MARK ALL THAT APPLY

1 □ White

2 □ Black or African American

3 □ Asian

4 □ Native Hawaiian or Other Pacific Islander

5 □ American Indian or Alaskan Native

6 □ Some other race (specify)

B3. In the 2015–2016 school year, was the student approved to receive free or reduced-price school lunches?

MARK ONE ONLY

1 □ Yes

0 □ No

d □ I don’t know

B4. How many times has the student changed schools since the beginning of 1st grade?

Do not count changes that occurred because the student changed grade level (for example, was promoted from an elementary to a middle school) or because the school district reconfigured schools (for example, merged the school the student was in).

MARK ONE ONLY

0 □ Zero

1 □ Once

2 □ Twice

3 □ Three or more times

B5. As things stand now, do you think the student will receive a vocational certificate?

A vocational certificate is a certificate from a college or trade school for completion of a program providing job-focused training for specific careers such as physician’s assistants, paralegals, pharmacy technicians, automotive mechanics, and information systems programmers

MARK ONE ONLY

1 □ Yes

0 □ No

d □ I don’t know

B6. As things stand now, how far do you think the student will get in school?

MARK ONE ONLY

1 □ Less than high school degree (will not graduate or get GED)

2 □ High school diploma or GED

3 □ Technical or trade school

4 □ 2-year college graduate

5 □ 4-year college graduate

6 □ Masters, Ph.D. or other advanced degree (such as an MD for doctors or LLD for lawyers)

B7. During the 2015–2016 school year, how often have you or another adult outside of school discussed education after high school with your student?

MARK ONE ONLY

0 □ Never

1 □ About once or twice during the school year

2 □ More than twice during the school year

d □ I don’t know

B8. Were you involved in making the decision to apply to [FILL PROGRAM NAME]?

MARK ONE ONLY

1 □ Yes

GO TO SECTION C

0 □ No

d □ I don’t know

B9. People apply to or enroll in a program for many different reasons. Some of these reasons are listed below. How important were each of these reasons in the decision to apply to [FILL PROGRAM NAME]?

	MARK ONE PER ROW
	Not important	Important	Very important
a. The program will help the student to go to college	1 □	2 □	3 □
b. The program will help the student to get his or her life on track	1 □	2 □	3 □
c. The program will help the student to get a job	1 □	2 □	3 □
d. The program will help the student to get more training	1 □	2 □	3 □
e. The student’s friends are joining the program	1 □	2 □	3 □
f. It is the best program in school	1 □	2 □	3 □
g. It is the only program available	1 □	2 □	3 □
h. Other (specify)	1 □	2 □	3 □

A very important part of this study will be a follow-up survey with the student in three years. These last questions ask for information to help us reach you in case we cannot reach the student directly for the next survey.

C1. What is your name?

Please note, this information will not be shared or published in any reports. We ask for this information only if we have trouble getting in touch with the student directly.

First Name:

Last Name:

C2. Please provide your current address.

Address

Apartment Number

City, State, Zip Code

C3. Please provide your phone number(s).

Home: | | | | - | | | | - | | | | |

Area Code Number

Cell: | | | | - | | | | - | | | | |

Area Code Number

Work: | | | | - | | | | - | | | | |

Area Code Number

C4. Does your cell phone plan include unlimited texting?

1 □ Yes

0 □ No

C5. May we send you text messages? Message and data rates may apply.

1 □ Yes

0 □ No

C6a. What is the email address you use most often?

C6b. If you have another email address, what is it?

C7. Do you have an account with any of the following?

MARK ALL THAT APPLY

1 □ Facebook?

Name:

2 □ Twitter?

Tag:

0 □ None

C8. How would you prefer to be contacted in the future?

MARK ALL THAT APPLY

1 □ Regular mail

2 □ Email

3 □ Call home phone

4 □ Call cell phone

5 □ Text message

6 □ Facebook

7 □ Twitter

8 □ Other

C9. Please provide contact information for two friends or relatives, such as the student’s grandparents, who are likely to know how to reach you or the student approximately three years from now. We will contact these people only if we have trouble contacting you or the student directly and we will not share any of your information with them.

First relative or friend:

First Name

Last Name

Relationship to You

Contact information for first relative or friend:

Address

Apartment Number

City, State, Zip Code

Email Address

Home: | | | | - | | | | - | | | | |

Area Code Number

Cell: | | | | - | | | | - | | | | |

Area Code Number

Work: | | | | - | | | | - | | | | |

Area Code Number

Second relative or friend:

First Name

Last Name

Relationship to You

Contact information for second relative or friend:

Address

Apartment Number

City, State, Zip Code

Email Address

Home: | | | | - | | | | - | | | | |

Area Code Number

Cell: | | | | - | | | | - | | | | |

Area Code Number

Work: | | | | - | | | | - | | | | |

Area Code Number

Thank you for taking the time to complete this survey.

Prepared by Mathematica Policy Research 13