Baseline information form for participants (Attachment D)

Attachment D – Baseline Information Form for Participants

First and Last Name ______________________ OMB Control No: ____-____

BEES ID Number ______________________ (Office Use Only) Expiration Date: __/__/____

YOUR CONTACT INFORMATION
Name:
Date of birth:		SSN:
Current address:
City:	State:		ZIP Code:
Home phone #: ( )	Cell #: ( )		Work #: ( )
Email address:
Which is the primary social network you use?  Facebook  Twitter  Personal blog  Other __________________
What name do you use in that social network?
Can we contact you by text message?  Yes  No
What is your preferred mode of contact?  Phone  Text  Email  Other __________________
CONTACT INFORMATION: RELATIVES AND FRIENDS INSTRUCTIONS: In the space below, please provide contact information for three close relatives or friends who are likely to know how to reach you over the next year. We will only contact these people if we are unable to contact you directly. Please complete all three boxes if possible.
1. Name:
How is this person related to you?  Spouse/Partner  Parent  Sister/Brother  Friend  Other _______________
Current address:
City:	State:		ZIP Code:
Home phone #: ( )	Cell #: ( )		Work #: ( )
Email address:
2. Name:
How is this person related to you?  Spouse/Partner  Parent  Sister/Brother  Friend  Other _______________
Current address:
City:	State:		ZIP Code:
Home phone #: ( )	Cell #: ( )		Work #: ( )
Email address:
3. Name:
How is this person related to you?  Spouse/Partner  Parent  Sister/Brother  Friend  Other _______________
Current address:
City:	State:		ZIP Code:
Home phone #: ( )	Cell #: ( )		Work #: ( )
Email address:

A. Demographic Information
A.1 Sex		 Male  Female
A.2 What is your ethnicity? (Select one or more)		 Hispanic or Latino  Not Hispanic or Latino
A.3 What is your race? (Select one or more)		 American Indian or Alaska Native  Asian  Black or African American  Native Hawaiian or Other Pacific Islander  White
A.4 Primary language spoken at home		 English  Spanish  Other _______________
A.5 How well do you speak English?		 Very well  Well  Not very well  Not at all
B. Education
B.1 What is the highest degree or year of school that you have attained?		 Less than a high school diploma  Some college  High school diploma or equivalent  Bachelor’s degree or higher
C. Employment History
C.1 Are you currently working for pay?		 Yes  No
C.2 Are you working 35 or more hours per week?		 Yes  No
C.3 How many jobs did you work last week?		_______________
C.4 In total, how many months did you work for pay during the past year (including your current job)?		 Did not work  4-6 months  10 or more months  Less than 4 months  7-9 months
C.5 Are you currently looking for work?		 Yes  No
D. Household Information
D.1 Number of people in your household (including yourself):		Number of people Children under age 18: _______________ Adults age 18 or older: _______________		Do you have a spouse or partner who lives in your household?  Yes  No
D.2 Which of the following best describes your current housing arrangement during the past month?		 Own your own home or apartment  Rent your home or apartment  Live in emergency or temporary housing, that is in a shelter or were homeless  Live in transitional housing or sober housing  Live in a group home  Live with friends or relatives and pay rent to them  Live with friends or relatives and not pay rent to them  Have some other housing arrangement? _____________________
E. Justice Involvement
E.1 Have you been arrested in the past 12 months?  Yes  No	E.2 Have you ever been convicted of a crime?  Yes  No		E.3 Are you currently on parole or probation?  Yes  No			E.4 Have you ever been incarcerated?  Yes  No

F. Benefit Receipt [Note that an asterisk (*) indicates the questions will only be asked in SSA-FUNDED SITES)
F.1 For this next question, please consider only yourself, not anyone else in your household. Have you received a check or electronic payment from the Social Security Administration in the past year as an adult? * (Probe: This could have been payments from Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI).)			 Yes  No  Don’t know
F.2 Are you currently receiving checks or electronic payments from the Social Security Administration because of a disability?			 Yes  No  Don’t know
F.3 As an adult, in the past five years have you applied to the Social Security Administration to receive checks or electronic payments because of a disability?			 Yes  No  Don’t know
F.4 Are you currently awaiting a decision by the Social Security Administration on a pending disability application?*			 Yes  No  Don’t know
F.5 During the past year, did you or anyone in your household receive income or assistance from any of the following sources?			 Disability benefits from SSA (SSI or SSDI)  TANF or [state specific TANF name]  Unemployment insurance (UI)  Worker’s compensation  Short-term disability				 Food stamps/SNAP/[state specific program]  WIC  HCV/Section 8/public housing  Veterans benefits  Medicaid or CHIP
G. Substance Use [Only to be used with relevant populations except G.2, which will be asked of everyone]
G.1 Are you currently taking opioid medications for pain that have been prescribed by a physician or dentist?										 Yes  No
IF YES, G.1a …what is the name of that medication?										_____________________
G.1b …how long have you been taking it?										_____________________
G.2 Have you ever, even once, used any prescription pain reliever in any way a doctor did not direct you to use it?  (This would include using it without a prescription of your own; or using it in greater amounts, more often, or longer than you were told to take it; or using it in any other way a doctor did not direct you to use it.)										 Yes  No
G.3 How many days in the past 30 have you used....? How many years in your life have you regularly used....?
		Past 30 days Lifetime (years)							Past 30 days Lifetime (years)
Alcohol – Any use at all		_______ _______			Cocaine				_______ _______
Alcohol – To Intoxication		_______ _______			Amphetamines				_______ _______
Heroin		_______ _______			Cannabis				_______ _______
Fentanyl		_______ _______			Hallucinogens				_______ _______
Methadone (outside of methadone maintenance treatment)		_______ _______			Inhalants				_______ _______
Other opioids/opiates/ painkillers		_______ _______			More than one substance per day (including alcohol)				_______ _______
Barbiturates		_______ _______			Other _____________________				_______ _______
Other sedatives, hypnotics, or tranquilizers		_______ _______
G.6 Which substance is the main problem? _____________________________
G.7 How long was your last period of voluntary abstinence from this substance?					_______ months
G.8 How many months ago did this abstinence end?					_______ months
G.9 How many times have you:					Had alcohol DT’s ________ Overdosed on drugs ________
G.10 How many times in your life have you been treated for:					Alcohol abuse ________ Drug abuse ________
G.11 How many of these were detox only?					Alcohol ________ Drugs ________
G.12 How much money would you say you spent during the past 30 days on:					Alcohol $________ Drugs $________
G.13 How many days have you been treated in an outpatient setting for alcohol or drugs in the past 30 days?					______ days
G.14 How many days in the past 30 have you experienced difficulty with alcohol?					______ days
G.15 How many days in the past 30 have you experienced difficulty with drugs?					______ days
G.16 How troubled or bothered have you been in the past 30 days by these alcohol problems?					 Not at all  Slightly  Moderately  Considerably  Extremely
G.17 How troubled or bothered have you been in the past 30 days by these drug problems?					 Not at all  Slightly  Moderately  Considerably  Extremely
G.18 How important to you now is treatment for these alcohol problems?					 Not at all  Slightly  Moderately  Considerably  Extremely
G.19 How important to you now is treatment for these drug problems?					 Not at all  Slightly  Moderately  Considerably  Extremely
G.20 Have you been taking any of the following while in the care of a medical professional during the past 30 days?					 methadone  buprenorphine (including Subutex ®, Suboxone ®)  naltrexone (including Vivitrol ®)
G.21 Have you smoked any cigarettes in the past 2 years?					 Yes  No
G.22 How many cigarettes or packs do you currently smoke on an average day (a pack has 20 cigarettes)?					___________ cigarettes / packs (circle one)
H. Mental Health
H.1 During the last 30 days, about how often did
H.1a …you feel so depressed that nothing could cheer you up?				 All the time  Most of the time  Some of the time  A little of the time  None of the time
H.1b …you feel hopeless?				 All the time  Most of the time  Some of the time  A little of the time  None of the time
H.1c …you feel restless or fidgety?				 All the time  Most of the time  Some of the time  A little of the time  None of the time
H.1d …you feel that everything was an effort?				 All the time  Most of the time  Some of the time  A little of the time  None of the time
H.1e …you feel worthless?				 All the time  Most of the time  Some of the time  A little of the time  None of the time
H.1f …you feel nervous?				 All the time  Most of the time  Some of the time  A little of the time  None of the time
I. Disability Status [Only to be used with relevant populations, except for I.7 which will be asked of everyone]
I.1 Are you deaf or do you have serious difficulty hearing?								 Yes  No
I.2 Are you blind or do you have serious difficulty seeing, even when wearing glasses?								 Yes  No
I.3 Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?								 Yes  No
I.4 Do you have serious difficulty walking or climbing stairs?								 Yes  No
I.5 Do you have difficulty dressing or bathing?								 Yes  No
I.6 Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?								 Yes  No
I.7 Does a physical or mental condition limit the kind or amount of work you can do?								 Yes  No  Don’t know
J. Health [Only to be used with relevant populations, except J.1 which will be asked of everyone]
J.1 In general, would you say your health is:				 Excellent  Very good  Good  Fair  Poor
J.2 The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
J.2a Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf				 Yes, limited a lot  Yes, limited a little  No, not limited at all
J.2b Climbing several flights of stairs				 Yes, limited a lot  Yes, limited a little  No, not limited at all
J.3 During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
J.3a Accomplished less than you would like				 All of the time  Most of the time  Some of the time  A little of the time  None of the time
J.3b Were limited in the kind of work or other activities				 All of the time  Most of the time  Some of the time  A little of the time  None of the time
J.4 During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
J.4a Accomplished less than you would like				 All of the time  Most of the time  Some of the time  A little of the time  None of the time
J.4b Did work or other activities less carefully than usual				 All of the time  Most of the time  Some of the time  A little of the time  None of the time
J.5 During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?				 Not at all  A little bit  Moderately  Quite a bit  Extremely
J.6 These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks…
J.6a Have you felt calm and peaceful?				 All of the time  Most of the time  Some of the time  A little of the time  None of the time
J.6b Did you have a lot of energy?				 All of the time  Most of the time  Some of the time  A little of the time  None of the time
J.7 Have you felt downhearted and depressed?				 All of the time  Most of the time  Some of the time  A little of the time  None of the time
J.8 During the past 4 weeks, how much of the time have your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?				 All of the time  Most of the time  Some of the time  A little of the time  None of the time
J.9 During the past year, have you received help or treatment for mental health problems?				 Yes  No
K. Housing and Household Information [Only to be used with relevant populations except for K.2 and K.9, which will be asked of everyone]
K.1 Do you have access to a car that runs?				 Yes  No
K.2 During the past two years, have you ever been evicted or forced by your landlord to move when you didn’t want to?				 Yes  No  In the midst of an eviction  Don’t know
K.3 Which of the following statements best describes how satisfied you are with your current neighborhood?				 Very satisfied  Somewhat satisfied  In the middle  Somewhat dissatisfied  Very dissatisfied
K.4 Which of the following statements best describes how you feel about staying in your current neighborhood if you receive a voucher?				 Very sure I want to stay  Somewhat sure I want to stay  In the middle  Somewhat sure I want to move  Very sure I want to move to a different neighborhood to a different neighborhood
K.5 How would you feel about moving to a neighborhood where almost all of the other residents are of a different race or ethnicity than your own?				 Very good  Good  In the middle  Bad  Very bad
K.6 Would you prefer to continue living in the neighborhood you are currently living in?				 Yes  No
K.7 What is the main reason that you might consider moving to a new neighborhood?				 Better schools for my children  To be near my job  To have better transportation  To get a different job  To be in a safer neighborhood  To get a bigger or better home  To be near my family  I don’t want to move  Other (specify): ________________________________________
K.8 “Now, I would like to ask you a set of questions for each child that currently lives in your household. Remind me how many children do you have? [IF MORE THAN ONE] Which child would you like to begin with?"
K.8a Child’s name				First: __________________________________________ Last: __________________________________________
K.8b What is the child’s age?				Age: __________________________________________
K.8c What grade is he/she in?				 Not in school [SKIP K8e]  Pre-school  Pre-K  Kindergarten  1st Grade  2nd Grade  3rd Grade  4th Grade  5th Grade  6th Grade  7th Grade  8th Grade  9th Grade  10th Grade  11th Grade  12th Grade  Post-secondary school  Other (Specify): ______________
K.8d How satisfied are you with his/her current school? (or Pre-K/Pre-school program?)				 Very satisfied  Somewhat satisfied  In the middle  Somewhat dissatisfied  Very dissatisfied
K.8e. [if child is under age 13] When your child is not in [school/preshool/Pre-K, if applicable] does someone other than yourself care for your child regularly (5 or more hours per week)?				 Yes  No [SKIP to K.9]
K.8f. Who cares for your child regularly (i.e., 5 or more hours per week? Check all that apply.				 Child’s other parent  Other member of household age 18 or over (e.g., a partner or relative)  Other member of household under age 18 (e.g., sibling, cousin)  Relative (not living in the household)  Friend  School (extended day, after care program)  Friend   Neighbor  2nd Grade   4th Grade  5th Grade  6th Grade  7th Grade  8th Grade
				 Neighbor  School program (extended day, after care program)  Child Care center (including Head Start extended day)  Home-based child care (someone who cares for more than 1 child in their home, as their business)  Community organization (such as boys/girls club, YMCA, church program, etc)  Other: ____________
K.8g [for each option in 8f] Do you pay [INSERT K.8f answer] for this care?				 Yes  No
K.9 In the past 12 months was there ever a time when, because of cost, you or your household was not able to:
K.9a Pay your rent	 Yes  No
	[If Yes] How often did this happen in the past 12 months?  1 Month  2 or 3 months  4 to 6 months  6 or more months
K.9b Pay your utility bills	 Yes  No
	[If Yes] How often did this happen in the past 12 months?  1 Month  2 or 3 months  4 to 6 months  6 or more months
K.9c Pay for food needed	 Yes  No
	[If Yes] How often did this happen in the past 12 months?  1-2 times  3 or 4 times  5 or more times
K.9c Pay for child care	 Yes  No
	[If Yes] How often did this happen in the past 12 months?  1 Month  2 or 3 months  4 to 6 months  6 or more months
K.10 In the last 12 months, was there any time when you did not fill a prescription for medicine because of the cost?						 Yes  No  Don’t know/Not sure
K.11a How easy is it to find fresh fruit and vegetables for purchase in your current neighborhood?						 Extremely difficult  Somewhat difficult  Neutral Somewhat Easy  Extremely easy
K.11b Have you purchased fresh fruit or vegetables in the past week for you and/or your household?						 Yes  No

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to understand programs that aim to improve employment outcomes for low-income adults. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB number and expiration date for this collection are OMB #: XXXX-XXXX, Exp: XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Dan Bloom (MDRC); 200 Vesey Street, 23^rd Floor, New York, NY 10281-2103.

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