#2 - Saq

Supporting Statement for OMB Clearance Request: Self-Administered Questionnaire

Innovative Strategies for Increasing Self-Sufficiency (ISIS)

Contract # HHSP23320072913YC

April 11, 2011

Prepared for

Brendan Kelly

Office of Planning, Research &

Evaluation

Administration for Children & Families

U.S. Department of Health and Human Services

Prepared by

Abt Associates Inc.

ISIS Self-Administered Questionnaire

The purpose of this form is to learn about some of the personal qualities and supports that can affect peoples’ experiences at school and work. To ensure your privacy, researchers will keep your answers confidential and will not identify specific individuals in reports.

RESOURCES

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

[ ] Part-time

[ ] Full-time

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

[ ] YES  2a. IF YES, How many hours do you expect to be working in a typical week?

___ Hours/week

[ ] NO

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

[ ] Not difficult at all

[ ] Somewhat difficult

[ ] Very difficult

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

4a. Tuition and fees? [ ] Yes [ ] No

4b. Living expenses? [ ] Yes [ ] No

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

[ ] Not difficult at all

[ ] Somewhat difficult

[ ] Very difficult

6. Do you have a computer at home?

[ ] YES  6a. IF YES, Does this computer have a working Internet connection?

[ ] YES

[ ] NO

[ ] NO

7. Do you own a car?

[ ] YES

[ ] NO

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

[ ] Yes

[ ] No

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

[ ] More than enough money left over

[ ] Some money left over

[ ] Just enough to make ends meet

[ ] Not enough to make ends meet

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

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

PERSONAL QUALITIES AND SKILLS

11. Next, you will see a series of statements you might use to describe your behavior, opinions, interests, feelings and other characteristics. For each, please decide how it describes you and indicate whether you strongly disagree, moderately disagree, slightly disagree, slightly agree, moderately agree, or strongly agree with that statement.

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

NOTE: This section of the form will include items from ACT Inc.’s copyrighted Student Readiness Inventory and Talent Assessment tools, standardized and widely-used assessment instruments.
Scale (# items)	Measure
a. Discipline (10)	Amount of effort devoted to school/work and the degree to which person sees him/herself as hardworking and conscientious. Illustrative items: Once I start a task, I see it through to the end. I consistently do my schoolwork/work well.
b. Training commitment (10)	A student’s commitment to staying in school and getting a credential. Illustrative items: Education will help me achieve my goals. I would rather be somewhere else than in school. (reverse-scored)
c. Determination/striving (11)	The extent to which one strives to follow through on commitments and obligations. Illustrative items: It is important for me to finish what I start. I bounce back after facing disappointment or failure.
d. Self-confidence (12)	The belief in one’s ability to perform well in school. Illustrative items: I am a fast learner. I am less talented than other students. (reverse-scored)
e. Steadiness (12)	The tendency to maintain composure and rationality in stressful situations. Illustrative items: I get easily irritated. (reverse-scored) I stay calm in difficult situations.
f. Optimism (13)	The tendency to have a positive outlook and confidence in successful outcomes. Illustrative item: I tend to believe things will work out for the best.

CAREER ORIENTATION AND KNOWLEDGE

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

Item	Strongly disagree	Disagree	Agree	Strongly agree
a. You know how to accurately assess your abilities and challenges?
b. You know how to make a plan that will help achieve your goals for the next 5 years?
c. You know how to get help from staff and teachers with any issues that might arise at school?
d. You know the type of job that is best for you?
e. You know the type of organization you want to work for?
f. You know exactly the occupation you want to enter?
g. You know the kind of education and training program that is best for you?

PERSONAL AND FAMILY CHALLENGES

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

In the past month, how often have you felt:	Never	Almost never	Some-times	Fairly often	Very often
a. That you were unable to control the important things in your life?
b. Confident about your ability to handle your personal problems?
c. That things were going your way?
d. That difficulties were piling up so high that you could not overcome them?

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

Problems or difficulties with:	Never	Almost never	Some-times	Fairly often	Very often
a. Child care arrangements
b. Transportation
c. Alcohol or drug use
d. An illness or health condition
e. Arguments with a family member
f. Physical threats/violence from a family member

15. Have you ever been arrested?

[ ] YES  15a. Have you been ever been convicted of a crime?

[ ] YES

[ ] NO

15b. Have you ever been convicted of a felony?

[ ] YES

[ ] NO

[ ] NO

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

In the last week:	Rarely or none of the time (less than 1 day)	Some or a little of the time (1-2 days)	Occasionally or a moderate amount of the time (3-4 days)	Most or all of the time (5-7 days)
a. I was bothered by things that usually don’t bother me.
b. I felt that I could not shake off the blues even with help from my family or friends.
c. I had trouble keeping my mind on what I was doing.
d. I felt depressed.
e. I felt that everything I did was an effort.
f. My sleep was restless.
g. I was happy.
h. I enjoyed life.
i. I felt sad

SITE-SPECIFIC ITEM HERE

Each site will be invited to suggest one item tailored to its specific interests and program features and only that site’s question will appear in the SAQ for that site. Items will be limited to a single question with no more than 10 response categories and likely add no more than 10-20 seconds to completion time.