Baseline Informati Baseline Information Form

U.S. Department of Labor
Job Training Evaluation

Baseline Information Form

Dear Participant:

This form requests information about your household. Your answers to these questions will not affect your chances of getting into this employment training program. The information will be used for research purposes only and will be kept confidential to the extent allowed by law.

Thank you very much for helping us with this important study.

MARKING DIRECTIONS

 Use a blue or black ink pen or dark pencil.

 Do not use felt tip markers or gel pens.

 Put an “X” in the box that best describes your answer.

Correct:  □ □ □

 To change an answer, mark the new one and circle it.

Correct:  □  □

 Please PRINT where applicable. Enter only one letter or number per box: | J | O | B | S |

Public Burden Statement, OMB #1205-0507, expires 06/30/2019.

Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. Respondent's obligation to reply is required to obtain benefits under P.L 111-5.  Public reporting burden for this collection of information is estimated to average 13 minutes per response, including the time for reading instructions, and completing and reviewing the requested information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Division of Adult Services, Room S-4209, Washington, D.C. 20210 (Paperwork Reduction Project Control No. 1205-0481NOA).

C ONTACT INFORMATION

1. Please print your name:

FIRST NAME

MIDDLE NAME

LAST NAME

2. Your street address:

STREET (1)

STREET (2) APT.

CITY STATE ZIP

3. Your telephone numbers:

Cell/Mobile: (| | | |)-| | | |-| | | | |

Home: (| | | |)-| | | |-| | | | |

Work: (| | | |)-| | | |-| | | | |

4. Your email addresses:

Home:

Work:

Other:

5. Your Social Security Number:

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

6. What is your date of birth?

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

MONTH DAY YEAR

EDUCATION

7A. What is the highest degree or level of school you have completed?

MARK ONLY ONE

1  No formal education

2  12th grade or less, no diploma

3  High school graduate

4  GED

5  Technical, trade or vocational degree

6  Some college credit, but no degree

7  Associate’s degree

8  Bachelor’s degree

9  Master’s degree or higher

7B. What is the highest degree or level of school you expect to complete?

MARK ONLY ONE

1  No formal education

2  12th grade or less, no diploma

3  High school graduate

4  GED

5  Technical, trade or vocational degree

6  Some college credit, but no degree

7  Associate’s degree

8  Bachelor’s degree

9  Master’s degree or higher

8. Are you currently enrolled in school or in another training program? (Do not include this training program to which you are applying.)

MARK ALL THAT APPLY

1  Currently enrolled in high school or GED program

2  Currently enrolled in vocational, technical, or trade school

3  Currently enrolled in 2 or 4 year college

4  Currently enrolled in another job training program

0  Not currently enrolled in school or any other training program

9 . Have you ever attended any of the following education and training programs either in the U.S. or elsewhere?

MARK ALL THAT APPLY

1  Adult basic education (these programs usually teach reading and math)

2  English as a Second Language (ESL)

3  Job training at a vocational, technical or trade school

4  College courses that did not lead to the degrees you already listed in Question 7A and 7B

5  Other (PLEASE SPECIFY BELOW)

6  None

BACKGROUND

10. Are you male or female?

1 □ Male

2 □ Female

11. What is your current marital status?

MARK ONLY ONE

1  Married

2  Living with a partner

3  Widowed

4  Divorced/Separated

5  Never Married

12. Are you of Spanish, Hispanic, or Latino origin?

1  Yes

2  No

13. Do you consider yourself to be . . .

MARK ONE OR MORE

1  American Indian or Alaskan Native

2  Asian

3  Black or African-American

4  Native Hawaiian or other Pacific Islander

5  White

6  Other (PLEASE SPECIFY BELOW)

14. Do you speak a language other than English at home?

1  Yes

2  No

15. Do you . . .

MARK ONLY ONE

1  Own the place where you live

2  Rent your own place or contribute to rent at a friend or family’s place

3  Live rent free

16. How many of your children (18 years or younger) currently live in your household?

0  No children living in household  GO TO Q17

| | | CHILDREN



16a. What is the age (in years) of the youngest child currently living in your household?

| | | AGE OF YOUNGEST CHILD

(ENTER “0” IF CHILD IS UNDER 1 YEAR OLD)

17. Not including yourself, how many employed adults (18 years or older) currently live in your household?

0  No other employed adults living in household

| | | EMPLOYED ADULTS, NOT INCLUDING SELF

18. What is your U.S. citizenship status?

MARK ONLY ONE

1  U.S. Citizen

2  Legal Resident

19. Have you ever been convicted of a felony?

1  Yes

2  No

20. Do you have a health problem or disability that prevents you from working or limits the kind or amount of work you can do?

1  Yes

2  No

EMPLOYMENT STATUS

21. What is your current employment status?

MARK ONE EMPLOYMENT STATUS BOX AND THEN FOLLOW THE ARROWS

I am currently working at one or more jobs or businesses	I am not currently working, but I have worked at one or more jobs or businesses during the last 12 months	It has been longer than 12 months since I last worked at a job or business
1  	2  	3  
21a. How long have you worked at this job? | | | YEARS | | | MONTHS (if work multiple jobs, record time for your main job)  21b. How many hours do you usually work per week at your main job? | | | HOURS PER WEEK  21c. How hours per week do you work in total, at all of your jobs? | | | HOURS PER WEEK  21d. How much do you earn per hour at your main job, before taxes and other deductions? Please include amount in tips, if applicable. $ | | | |.| | | PER HOUR	21d. During how many months out of the last 12 have you worked at a job or business? | | | MONTHS  21e. When you were working, how much did you earn per hour at your main job?  $ | | | |.| | | PER HOUR  21f. What was the main reason for leaving your last job? MARK ONLY ONE 1  Laid off 2  Business closed 3  Temporary/ seasonal work ended 4  Fired/discharged 5  Quit due to pregnancy or childcare 6  Quit due to family reasons 7  Quit due to own health problem 8  Quit to attend school or training program 9  Never employed 10  Other (PLEASE SPECIFY BELOW) _________________________________	21f. What was the main reason for leaving your last job? MARK ONLY ONE 1  Laid off 2  Business closed 3  Temporary/ seasonal work ended 4  Fired/discharged 5  Quit due to pregnancy or childcare 6  Quit due to family reasons 7  Quit due to own health problem 8  Quit to attend school or training program 9  Never employed 10  Other (PLEASE SPECIFY BELOW) _______________________
GO TO QUESTION 22	GO TO QUESTION 22	GO TO QUESTION 22

OPINIONS ABOUT WORK OPPORTUNITIES

For Questions 22 and 23 please mark how well each statement describes your current situation.

	MARK ONE COLUMN PER ROW
	very much	a little	not at all	not applicable
22. My ability to work is limited because it is not easy to find affordable, quality child care for the hours I need	1 	2 	3 	0 
23. problems with transportation (car, public transit) limit my ability to work	1 	2 	3 

For Questions 24 through 28 please mark how well each statement describes your current situation.

	MARK ONE PER ROW PER COLUMN
	strongly agree	agree	disagree	strongly disagree
24. I will take any job even if the pay is low	1 	2 	3 	4 
25. I want only the kind of job that I trained for	1 	2 	3 	4 
26. I am willing to work part-time if no full-time offer is available	1 	2 	3 	4 
27. I am willing to work unusual or unpredictable schedules	1 	2 	3 	4 

28. Please enter the lowest hourly wage you are willing to accept. $ | | | |.| | | PER HOUR

99  Don’t Know

29. Please enter the number of years (and/or months) of experience you have in the industry for which you are applying for training.

| | | YEARS | | | MONTHS

99  No Experience

30. Please enter your total wages, salary, commissions, bonuses, or tips for all jobs over the last 12 months, before deductions for taxes, bonds, dues, or other items.

$| | | | | |

99  Don’t Know

31. Please enter your households’ total income over the last 12 months including earnings, pensions, public assistance, alimony, child support, Veteran’s payments, etc., before deductions for taxes, bonds, dues, or other items.

$| | | | | | |

99  Don’t Know

32. What is the most important reason you decided to apply to this job training program?

MARK ONLY ONE

1  Find work

2  Career change

3  Career Advancement

4  Educational Advancement

5  Personal Reasons

6  Other (PLEASE SPECIFY BELOW)

P UBLIC ASSISTANCE

33. Does your household receive Section 8 or Public Housing Assistance?

1  Yes

2  No

34. Are you currently receiving TANF (Temporary Assistance for Needy Families)?

1  Yes

2  No

35. Are you currently receiving SNAP (Supplemental Nutrition and Assistance Program)? (It used to be called the Food Stamp Program.)

1  Yes

2  No

36. Are you currently receiving unemployment insurance?

1  Yes 2     No _ GO TO QUESTION 37



36a. What is your weekly unemployment insurance benefit?

$ | | , | | | |

FUTURE CONTACT

37. May we send an automated text message to your cell phone?

1  Yes

2  No

38. May we contact you through Facebook, Twitter, MySpace, or other social network?

1  Yes 2     No _ GO TO QUESTION 39



38a. What is your username and network?

USERNAME 1: ______

NETWORK 1: ______

USERNAME 2: ______

NETWORK 2: ______

39. Please provide contact information of 3 close friends or relatives we can contact in case you move and we cannot easily locate you for the follow-up interview in 18 months. All information will be held confidential to the extent permitted by law and will only be used to locate you if we have trouble contacting you directly. _

39a. Relative or friend #1:

NAME

RELATIONSHIP TO YOU

STREET APT.

CITY STATE ZIP

Cell/Mobile: (| | | |)-| | | |-| | | | |

Home: (| | | |)-| | | |-| | | | |

HOME EMAIL

WORK EMAIL

39b. Relative or friend #2:

NAME

RELATIONSHIP TO YOU

STREET APT.

CITY STATE ZIP

Cell/Mobile: (| | | |)-| | | |-| | | | |

Home: (| | | |)-| | | |-| | | | |

HOME EMAIL

WORK EMAIL

39c. Relative or friend #3

NAME

RELATIONSHIP TO YOU

STREET APT.

CITY STATE ZIP

Cell/Mobile: (| | | |)-| | | |-| | | | |

Home: (| | | |)-| | | |-| | | | |

HOME EMAIL

WORK EMAIL

Thank you for completing this survey!

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