Youth Information Form (YIF)

OMB Control No: 0970-0383

Expiration Date: 09/30/2021

Youth Information Form

Entry Data

For the selected study participant, please enter the following information as recorded at his or her date of entry into the TLP/MGH program:

1. TLP/MGH program entry date:

   Month		Day		Year

2. Did the study participant enter the TLP/MGH from a Basic Center Program (BCP):

(Select only one answer.)

☐ Yes

☐ No

☐ Don’t know

3. Study participant’s highest educational attainment upon entering the TLP/MGH:

(Select only one answer.)

☐ Less than Grade 5

☐ Grades 5-6

☐ Grades 7-8

☐ Grades 9-11

☐ Grade 12/High school diploma

☐ School program does not have grade levels

☐ GED

☐ Vocational certification

☐ Some college

☐ Associate’s degree

☐ Bachelor’s degree

☐ Graduate degree

☐ Don't know

4. Study participant’s educational enrollment status upon entering the TLP/MGH:

(Select only one answer.)

☐ Enrolled in post-secondary program (i.e., vocational certification, 2-year degree, or 4-year degree)

☐ Enrolled in GED or basic education program (not post-secondary)

☐ Enrolled in school (not post-secondary), attending regularly

☐ Enrolled in school (not post-secondary), attending irregularly

☐ Enrolled in school (not post-secondary), suspended

☐ Not currently enrolled, completed educational goal (diploma, GED, certificate, degree)

☐ Not currently enrolled, dropped out of school

☐ Not currently enrolled, expelled

☐ Don't know

5. Was the study participant employed upon entering the TLP/MGH?

(Select only one answer.)

☐ No

☐ Yes, full-time (30+ hours)

☐ Yes, part-time (<30 hours)

☐ Yes, hours not known

☐ Don't know

6. Study participant’s housing status prior to entering the TLP/MGH:

(Select only one answer.)

☐ Emergency shelter, including hotel or motel paid for voucher with emergency shelter, or RHY-funded Host Home shelter

☐ Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station/airport or anywhere outside)

☐ Safe Haven

☐ Foster care home or foster care group home

☐ Hospital or other residential non-psychiatric medical facility

☐ Jail, prison or juvenile detention facility

☐ Psychiatric hospital or other psychiatric facility

☐ Substance abuse treatment facility or detox center

☐ Residential project or halfway house with no homeless criteria

☐ Hotel or motel paid for without emergency shelter voucher

☐ Transitional housing for homeless persons (including homeless youth)

☐ Host home (non-crisis)

☐ Staying or living in a family member's room, apartment, or house

☐ Staying or living in a friend's room, apartment, or house

☐ Rental by client, no ongoing housing subsidy

☐ Rental by client, with RRH or equivalent subsidy

☐ Rental by client, with Housing Choice Voucher (HCV) (tenant or project-based)

☐ Rental by client in a public housing unit

☐ Rental by client, with VASH housing subsidy

☐ Rental by client, with GPD TIP housing subsidy

☐ Rental by client, with other ongoing housing subsidy

☐ Owned by client, no ongoing housing subsidy

☐ Owned by client, with ongoing housing subsidy

☐ Permanent housing (other than RRH) for formerly homeless persons

☐ Long-term care facility or nursing home

☐ Other

☐ Client doesn't know

☐ Client refused

☐ Data not collected

7. Study participant’s Social Security Number:

_ _ _ - _ _ - _ _ _ _

8. Study participant’s date of birth:

Month		Day		Year

Exit Data

For the selected study participant, please enter the following information as recorded at his or her date of exit from the TLP/MGH program. If the participant has not exited the program, by the end of the end of the study period, please indicate that below.

1. Has the participant exited the TLP/MGH program?

(Select only one answer.)

☐ Yes

☐ No

☐ Don't know

If Yes, ask questions 2-5.

If No or Don’t Know, skip to question 6

2. TLP/MGH program exit date:

Month		Day		Year

3. Did the study participant have a safe exit, as determined by the client?

(Select only one answer.)

☐ Yes

☐ No

☐ Don’t know

4. Did the study participant have a safe exit, as determined by the case manager?

(Select only one answer.)

☐ Yes

☐ No

☐ Don’t know

5. Study participant’s exit destination:

(Select only one answer.)

☐ Emergency shelter, including hotel or motel paid for voucher with emergency shelter, or RHY-funded Host Home shelter

☐ Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station/airport or anywhere outside)

☐ Safe Haven

☐ Foster care home or foster care group home

☐ Hospital or other residential non-psychiatric medical facility

☐ Jail, prison or juvenile detention facility

☐ Psychiatric hospital or other psychiatric facility

☐ Substance abuse treatment facility or detox center

☐ Residential project or halfway house with no homeless criteria

☐ Hotel or motel paid for without emergency shelter voucher

☐ Transitional housing for homeless persons (including homeless youth)

☐ Host home (non-crisis)

☐ Staying or living with family, temporary tenure (e.g. room, apartment or house)

☐ Staying or living with friends, temporary tenure (e.g. room, apartment or house)

☐ Staying or living with family, permanent tenure (e.g. room, apartment or house)

☐ Staying or living with friends, permanent tenure (e.g. room, apartment or house)

☐ Rental by client, no ongoing housing subsidy

☐ Rental by client, with RRH or equivalent subsidy

☐ Rental by client, with Housing Choice Voucher (HCV) (tenant or project-based)

☐ Rental by client in a public housing unit

☐ Rental by client, with VASH housing subsidy

☐ Rental by client, with GPD TIP housing subsidy

☐ Rental by client, with other ongoing housing subsidy

☐ Owned by client, no ongoing housing subsidy

☐ Owned by client, with ongoing housing subsidy

☐ Permanent housing (other than RRH) for formerly homeless persons

☐ Long-term care facility or nursing home

☐ Deceased

☐ Other

☐ No exit interview completed

☐ Client doesn't know

☐ Client refused

☐ Data not collected

6. Study participant’s highest educational attainment upon exiting the TLP/MGH, or at the end of the study’s data collection period:

(Select only one answer.)

☐ Less than Grade 5

☐ Grades 5-6

☐ Grades 7-8

☐ Grades 9-11

☐ Grade 12/High school diploma

☐ School program does not have grade levels

☐ GED

☐ Vocational certification

☐ Some college

☐ Associate’s degree

☐ Bachelor’s degree

☐ Graduate degree

☐ Don't know

7. Study participant’s educational enrollment status upon exiting the TLP/MGH, or at the end of the study’s data collection period:

(Select only one answer.)

☐ Enrolled in post-secondary program (i.e., vocational certification, 2-year degree, or 4-year degree)

☐ Enrolled in GED or basic education program (not post-secondary)

☐ Enrolled in school (not post-secondary), attending regularly

☐ Enrolled in school (not post-secondary), attending irregularly

☐ Enrolled in school (not post-secondary), suspended

☐ Not currently enrolled, completed educational goal (diploma, GED, certificate, degree)

☐ Not currently enrolled, dropped out of school

☐ Not currently enrolled, expelled

☐ Don't know

8. Was the study participant employed upon exiting the TLP/MGH, or at the end of the study’s data collection period:

(Select only one answer.)

☐ No

☐ Yes, full-time (30+ hours)

☐ Yes, part-time (<30 hours)

☐ Yes, hours not known

☐ Don't know

9. Was [Name] served by your TLP/MGH during the COVID-19 pandemic (which officially began in March 2020 when the U.S. declared a state of emergency)?

(Select only one answer.)

[ ] Yes

[ ] No

[ ] Don’t know

If yes, go to question 10.

10. When working with [Name] on their ISP, did you need to adjust expectations for any of the following goal areas because of COVID-19?

(Select all that apply.)

[ ] Education

[ ] Employment

[ ] Housing

[ ] Exit Planning

[ ] No modifications were made to these goal areas

If education, employment, housing, or exit planning is selected, go to question 11.

11. How did you modify or adjust expectations for the following elements of [Name]’s individualized service plan (ISP) because of COVID-19?

(Select one response per category.)

	Goal was emphasized	Goal was de-emphasized	No change to emphasis
Education	[ ]	[ ]	[ ]
Employment	[ ]	[ ]	[ ]
Housing	[ ]	[ ]	[ ]
Exit Planning	[ ]	[ ]	[ ]

Aftercare Data

For the selected study participant, please enter the following information as recorded for each successful aftercare contact:

1. Date of aftercare contact:

   Month		Day		Year

2. Study participant’s current housing status:

(Select only one answer.)

☐ Emergency shelter, including hotel or motel paid for voucher with emergency shelter, or RHY-funded Host Home shelter

☐ Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station/airport or anywhere outside)

☐ Safe Haven

☐ Foster care home or foster care group home

☐ Hospital or other residential non-psychiatric medical facility

☐ Jail, prison or juvenile detention facility

☐ Psychiatric hospital or other psychiatric facility

☐ Substance abuse treatment facility or detox center

☐ Residential project or halfway house with no homeless criteria

☐ Hotel or motel paid for without emergency shelter voucher

☐ Transitional housing for homeless persons (including homeless youth)

☐ Host home (non-crisis)

☐ Staying or living in a family member's room, apartment, or house

☐ Staying or living in a friend's room, apartment, or house

☐ Rental by client, no ongoing housing subsidy

☐ Rental by client, with RRH or equivalent subsidy

☐ Rental by client, with Housing Choice Voucher (HCV) (tenant or project-based)

☐ Rental by client in a public housing unit

☐ Rental by client, with VASH housing subsidy

☐ Rental by client, with GPD TIP housing subsidy

☐ Rental by client, with other ongoing housing subsidy

☐ Owned by client, no ongoing housing subsidy

☐ Owned by client, with ongoing housing subsidy

☐ Permanent housing (other than RRH) for formerly homeless persons

☐ Long-term care facility or nursing home

☐ Deceased

☐ Other

☐ Worker unable to confirm

☐ Client doesn't know

☐ Client refused

☐ Data not collected

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)

Public reporting burden of the described voluntary collection of information is estimated to average 0.33 hours per staff response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing 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.

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Alisa Santucci, Abt Associates, 6130 Executive Blvd, Rockville, MD 20852; Attn: OMB-PRA 0970-0383.

TLP YOS: Young Adult Background Information Form Page 1