2021 60-Month Survey - Parent Interview – Self-Administered Questionnaire

APPENDIX C

PARENT 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

[ENROLLING PARENT ADDRESS]

[ENROLLING PARENT CITY, STATE ZIP]

[DATE (MM/DD/YYYY)]

Dear [ENROLLING PARENT FIRST 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] Parent/Guardian

5-Year Survey

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

This form is to be completed by:

[ENROLLING PARENT 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 employment, family well-being, and expectations for [YOUTH]. You’ll receive a $30 gift card for completing the survey.

Who should complete the survey?

The survey is meant to be completed by [ENROLLING PARENT FIRST AND LAST NAME], who enrolled in [PROMISE PROGRAM NAME/ASPIRE-STATE].

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, pick 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. What is your name?

FIRST MIDDLE LAST NAME

Q2. How are you related to [YOUTH]?

□ Mother (biological or adopted)

□ Father (biological or adopted)

□ Stepmother

□ Stepfather

□ Legal guardian–female

□ Legal guardian–male

□ Foster mother

□ Foster father

□ Other family member living in household

□ Non-family member living in household

□ Not related – I am employed by an agency or service provider that works with [YOUTH]

Q3. Are you…

□ Married

□ In a marriage-like relationship

□ Divorced

□ Separated

□ Widowed

□ Single, never married

Q4. Does your spouse/partner live in the same household with you?

□ Yes

□ No

Q5. For verification purposes, what is [YOUTH]’s date of birth?

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

MM DD YYYY

Q6. Does [YOUTH]:

□ Live with you

□ Live with other parent or guardian

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

□ Live on his/her own – apart from parent/ guardian

Q7. Including yourself, how many people live or stay in your household in total?

| | | Number of people in household

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

□ 8th grade or less

□ 9th grade or above, not a high school graduate

□ High school graduate

□ GED

□ Post-high school education, no college degree

□ Vocational technical (voc-tech) degree/certificate

□ 2-year or 3 year college degree/AA degree

□ 4-year college degree/Bachelor’s degree

□ Master’s degree

□ PhD, MD, JD, LLB, or other professional graduate degree

□ Never attended school

□ Other

Q9. Did you work for pay at any time in the past year?

We are interested in both full-time and part-time work for pay or profit.

□ Yes

□ No

□ Retired

Q10. Were your earnings in a typical month last year more or less than $2,500?

Your best estimate is fine.

□ More than $2,500

□ $2,500 or less

If you have a spouse/partner, continue to Q11. If not, go to Q14.

Q11. What is the highest grade or year of school your spouse/partner has finished?

□ 8th grade or less

□ 9th grade or above, not a high school graduate

□ High school graduate

□ GED

□ Post-high school education, no college degree

□ Vocational technical (voc-tech) degree/certificate

□ 2-year or 3 year college degree/AA degree

□ 4-year college degree/Bachelor’s degree

□ Master’s degree

□ PhD, MD, JD, LLB, or other professional graduate degree

□ Never attended school

□ Other

Q12. Did your spouse/partner work for pay at any time in the past year?

We are interested in both full-time and part-time work for pay or profit.

□ Yes

□ No

□ Retired

Q13. Were your spouse/partner’s earnings in a typical month last year more or less than $2,500?

Your best estimate is fine.

□ More than $2,500

□ $2,500 or less

IF NEEDED:

Private health insurance includes any health insurance other than Medicaid, Medicare, or TRICARE.

Medicaid provides health coverage to eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities.

Medicare is the federal health insurance program for certain people with disabilities.

TRICARE is a health insurance program for military service members and their families.

Children’s Health Insurance Program (CHIP) is 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.

Q14. What kind of health insurance or health care plan are you now covered by?

Mark all that apply

□ Private health insurance

□ Medicaid or [STATE MEDICAID NAME]

□ Medicare

□ Tricare

□ Other insurance, not listed above

□ Not covered by any health insurance or health care plan

Q15. What kind of health insurance or health care plan is your spouse/partner now covered by?

Mark all that apply

□ Private health insurance

□ Medicaid or [STATE MEDICAID NAME]

□ Medicare

□ Tricare

□ Other insurance, not listed above

□ Do not have spouse/ partner

□ Not covered by any health insurance or health care plan

Q16. What kind of health insurance or health care plan is [YOUTH] now covered by?

Mark all that apply

□ Private health insurance

□ Medicaid or [STATE MEDICAID NAME]

□ Medicare

□ Tricare

□ Children’s Health Insurance Program (CHIP) or [STATE NAME FOR CHIP]

□ Other insurance not listed above

□ Not covered by any health insurance or health care plan

The next question asks about benefits your household may receive.

This information helps researchers understand how family finances affect students’ ability to go to college or pursue other goals after high school. Your answers will be kept completely private.

Q17. Do you or does anyone in your household receive public assistance from any of the following programs?

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

	Yes	No	Don’t Know
a. Temporary Assistance for Needy Families (TANF) or [STATE NAME FOR TANF] TANF provides families with financial assistance and related support services. These programs may include childcare assistance, job preparation, and work assistance.	□	□	□
b. Supplemental Nutrition Assistance Program (SNAP) or [STATE NAME FOR SNAP] SNAP provides a monthly supplement for purchasing nutritious food. Benefits are provided on an electronic card called an EBT card that is used like an ATM card and accepted at most grocery stores. This program was formerly known as “food stamps.”	□	□	□
c. Housing assistance, such as public housing or Section 8 This is also known as the Housing Choice Voucher Program. Section 8 provides funding to help people pay their rent.	□	□	□
d. Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) SSI and SSDI provides payments to aged, blind, and disabled people (including children).	□	□	□

Q18. How far do you think [YOUTH] will get in school? What is the highest level or year of school you think [YOUTH] will complete? Will he/she:

□ Not complete high school

□ Complete high school with a diploma or a certificate of completion

□ Get a GED

□ Vocational, technical, or trade school

□ 2-year or community college

□ 4-year college or university

□ Master’s, PhD, or other advanced degree

Q19. When [YOUTH] is age 25, do you think he/she will be living…

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

□ On his/her own, with friends, or with a spouse or partner

□ In a group home or institution

□ In another living situation

Q20. When [YOUTH] is age 25, how likely do you think it is that he/she will be working at a paid job?

Do you think he/she…

□ Definitely will

□ Probably will

□ Probably won’t

□ Definitely won’t

Q21. When [YOUTH] is age 25, how likely do you think it is that he/she will earn enough to support himself/herself without financial help from family?

Do you think he/she…

□ Definitely will

□ Probably will

□ Probably won’t

□ Definitely won’t

Q22. When [YOUTH] is age 25, how likely do you think it is that he/she will earn enough to support himself/herself without financial help from government benefit programs?

Do you think he/she…

□ Definitely will

□ Probably will

□ Probably won’t

□ Definitely won’t

The last set of questions will be about how to contact you and [YOUTH].

Q23. What is your mailing address?

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

street address

city state zip code

Q24. What is the best telephone number at which to reach you?

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

area code phone number

Q25. We’d appreciate your help in making sure we have the best way to get in touch with [YOUTH] to complete his/her interview. What is [YOUTH]’s mailing address?

street address

city state zip code

Q26. What is the best telephone number at which to reach [YOUTH]?

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

area code phone number

Q27. 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

Q.28. Today’s date is:

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

MM DD YYYY

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.