2019 60-Month Survey - Youth Interview – Self-Administered Questionnaire

APPENDIX D

YOUTH ABBREVIATED QUESTIONNAIRE

OMB # 0960-0799

OMB Expiration Date: [DATE]

SID: [SID]

P.O. Box 2393

Princeton, NJ 08543-2393

Telephone (844)-306-5011

www.mathematica-mpr.com

[YOUTH ADDRESS]

[YOUTH CITY, STATE ZIP]

[DATE (MM/DD/YYYY)]

Dear [YOUTH FITST AND LAST NAME]:

Thank you for enrolling in the [PROMISE PROGRAM NAME/ASPIRE-STATE] study in [FILL MONTH AND YEAR OF RA]. The Social Security Administration (SSA) hired Mathematica Policy Research to evaluate this program. The study will help SSA learn how to better help young adults and their families. When you enrolled, [PROMISE PROGRAM NAME/ASPIRE-STATE] explained that Mathematica would reach out to you about completing two interviews. We now want to complete the final one with you.

Over the past few weeks, we have tried to reach you by phone but have not been able to complete a survey with you.

W e need your help. Would you complete the enclosed survey?

• We hope to receive it by [DATE OF RELEASE + 2.5 WKS].

• You will receive a $30 gift card for completing the survey.

• The postage is prepaid – there is no cost to you for returning it.

Have questions or want to complete by phone?

Please call us! Our toll-free phone number is 844-306-5011. Only you can tell us about your unique experiences. We look forward to hearing from you soon.

S incerely,

Holly H. Matulewicz

Survey Director for the [PROMISE PROGRAM NAME/ASPIRE-STATE] Evaluation

For more information, visit the SSA website at https://www.ssa.gov/disabilityresearch/promise.htm

Para información e instrucciones en español, llame 844-306-5011 por favor.

Privacy Act Statement

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.

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 information collection is 0960-0799. The time required to complete this information collection is estimated to average 20 to 35 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

OMB # 0960-0799

OMB Expiration Date: [DATE]

SID: [SID]

[PROMISE/ASPIRE-STATE]:

5-Year Survey of Youth

This study is sponsored by the Social Security Administration (SSA)

This form is to be completed by:

[YOUTH FIRST AND LAST NAME]

Your input matters!

Please return the completed form in the postage-paid envelope provided.

About this study.

This study is paid for by the Social Security Administration (SSA). SSA hired Mathematica Policy Research to carry it out. There are about 12,000 youth and parents taking part in this study across the country.

About five years ago, you enrolled in a program called [PROMISE PROGRAM NAME/ASPIRE-STATE]. You may remember completing a consent form, which explained that the study includes a survey. The survey questions will cover topics such as education, employment, health, well-being, and expectations for the future. You’ll receive a $30 gift card for completing the survey.

Who should complete the survey?

The survey is meant to be completed by [YOUTH FIRT AND LAST NAME], who enrolled in [PROMISE PROGRAM NAME/ASPIRE-STATE]. You may ask a family member or friend to help you answer the questions.

How do I complete the survey?

Start on the next page with the first question – Q1 – and continue on to each question that follows. After reading a question, choose the answer that best applies to you. Make a mark in the box next to that choice. You can use a pen or pencil.

Prefer to complete the survey by phone?

Call us, toll free, at 844-306-5011.

Is the survey voluntary?

Yes! You can choose not to take part or skip any question you do not want to answer. But we need your help to make the study a success. Your input matters. Only you can tell us about your own experiences.

Where do I mail the survey?

We provided an envelope with the mailing address pre-printed. Just insert the completed survey into the envelope, seal it, and put it in the mail. No postage is needed.

Return it to Mathematica at:

Mathematica Policy Research

Attn: PROMISE/ASPIRE Evaluation (40304.XXX)

P.O. Box 2393

Princeton, NJ 08543-2393

Other questions?

Please call us, toll free, at 844-306-5011.

BEGIN HERE

Q1. Who is completing this form?

□ I am completing it myself or with help

□ An adult is completing it on behalf of [YOUTH]

Q2. How are you related to [YOUTH]?

Q3. What is your name?

first name middle last name

Q4. What month and year were you, (YOUTH FIRST NAME), born?

| | | / | | | | |

MONTH YEAR

Q5. Do you live with [ENROLLING PARENT], with another parent or legal guardian, in a group home or institution, or somewhere else?

□ Live with [ENROLLING PARENT]

□ Live with other parent or guardian

□ Live in a group home, institution, or boarding school

□ Live somewhere else, no longer live with parent/guardian

Q6. Including you, how many people live or stay in your household in total?

| | | people

Q7. Are you currently attending or enrolled in school?

Please include high school, adult basic education or GED courses, vocational or trade school, or college or university courses.

• If you are off school for the summer, will you be going back to school in the fall? If so, select “yes” below.

• If you attend a transition program or take special courses for youth ages 18-22 through the school district, select “yes” below.

□ Yes

□ No

Q8. What is the highest grade or year of school that you have finished?

□ 8th grade or less

□ 9th grade or freshman in high school

□ 10th grade or sophomore in high school

□ 11th grade or junior in high school

□ 12th grade or senior in high school

□ Some college or technical school

□ Vocational, technical, or trade school

□ 2-year or community college program

□ 4-year college or university program

□ Master’s, PhD, or other advanced degree program

□ Ungraded school or program

□ Other

Q9. Some young people finish high school with a diploma or a certificate of completion. Others do not finish high school but then go on to complete a GED, also known as a general equivalency degree or general education degree.

Do you have a …

	Yes	No
a. High school diploma or certificate of completion?	□	□
b. GED, also known as a general equivalency degree or general education degree?	□	□

Q10. In the past year, did you receive a training diploma, certificate, or license?

This training program could be for a number of purposes – to explore career interests, to help you find a job, or to build skills needed for living independently.

□ Yes

□ No

Q11. Below is a list of services some people receive to help prepare for the future.

For each, please mark whether you have received the service from someone who is not part of your family.

In the past year, have you received any supports or services in:

	Yes	No
a. Getting and keeping a job?	□	□
b. Continuing your education beyond high school?	□	□
c. Getting accommodations for school, work, or living independently?	□	□

EMPLOYMENT

Q12. Have you worked at a job or a business at any time in the past year?

This includes any job or jobs you currently have and jobs that ended in the past year. Include paid or unpaid jobs but not chores around the house, even if you are paid to do them.

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 you do on your own, such as babysitting or dog walking, that you get paid to do.

□ Yes

□ No GO TO Q22

Q13. How many jobs have you had in the past year?

Please include jobs that you currently have as well as jobs that ended within the past year, even if you only worked for a short time. Please include jobs at which you are self-employed. Do not include chores around the house, even if you are paid to do them.

| | | NUMBER OF JOBS

Q14. Were you paid or did you receive income through self-employment in any of these jobs?

□ Yes – paid

□ No – not paid

Thinking about the job you work at now or worked at most recently ….

Q15. What is the name of the place you work now or worked at most recently?

Q16. When did you start working at that job?

| | | / | | | | |

MONTH YEAR

Q17. How many hours per week do or did you usually work at this job?

| | | Hours per week

□ No usual hours

Q18. At this job, do or did you get paid by the hour or by how many things you made or sold?

□ Paid by the hour, day, week, month, or year

□ Paid by things made or sold

□ Paid some other way

□ Unpaid job

Q19. About how much are or were you paid on this job?

$ | | | | | . | | |

Q19a. How often were you paid on this job?

□ Per hour

□ Per thing made or sold

□ Per day

□ Per week

□ Every other week

□ Twice a month

□ Once a month

□ Other way

Q20. Do you work at this job now?

□ Yes GO TO Q22

□ No

Q21. When did you stop working at this job?

| | | / | | | | |

MONTH YEAR

Q22. Are you covered by any kind of health insurance or some other kind of health care plan?

This includes private insurance, as well as other types of health insurance you may receive or purchase through government programs.

□ Yes

□ No GO TO Q24

Q23. What kind of health insurance or health care plan are you now covered by?

Please mark one answer for each row in the table below.

	Yes	No
a. Private health insurance This includes any health insurance other than Medicaid, Medicare, or TRICARE.	□	□
b. Medicaid Provides health coverage to eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities.	□	□
c. Medicare Federal health insurance program for certain people with disabilities.	□	□
d. Tricare A health insurance program for military service members and their families.	□	□
e. Children’s Health Insurance Program (CHIP) A free or low-cost health insurance for uninsured children under age 19. This program helps reach uninsured children whose families earn too much to qualify for Medicaid but not enough to get private coverage.	□	□
f. Other kind of insurance not listed above	□	□

Q24. How far do you think you will get in school? What is the highest level of schooling you will complete?

□ Less than high school – will not graduate or get a GED

□ High school diploma or certificate of completion

□ GED

□ Vocational, technical, or trade school

□ 2-year or community college

□ 4-year college or university

□ Master’s, PhD, or other advanced degree

Q25. When you are age 25, do you think you will be living…

□ With parent(s) or guardian(s), sibling(s) or other relative(s)

□ On your own or with a spouse or partner

□ In a group home or institution

□ In another living situation

Q26. 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? Do you think you…

□ Definitely will

□ Probably will

□ Probably won’t

□ Definitely won’t

Q27. When you are age 25, how likely do you think it is that you will earn enough to support yourself without financial help from government benefit programs? Do you think you…

□ Definitely will

□ Probably will

□ Probably won’t

□ Definitely won’t

Q28. 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…

□ Definitely will

□ Probably will

□ Probably won’t

□ Definitely won’t

Q29. What is your home address?

This is where we will mail your thank you letter and gift card for completing this survey.

street address

city state zip code

Q30. What is the best telephone number at which to reach you?

| | | | - | | | | - | | | | |

area code phone number

Q31. Thank you for the time you have spent answering these questions. We’ll send you a gift card for completing this survey. Do you prefer a:

□ Visa gift card

□ Target gift card

□ Walmart gift card

Q32. Today’s date is:

| | | / | | | / | | | | |

MONTH DAY YEAR

Thank you for completing the survey! Please return it in the envelope provided.

If you have any questions, please call us at 844-306-5011.

We’ll send you a thank you letter with the $30 gift card in the next 2-4 weeks.