Baseline data collection – staff

Attachment B

Baseline data collection

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Evaluation of Employment Coaching for TANF and Related Populations

Baseline Data Collection

June 7, 2017

PUBLIC VERSION

D3a and b: Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc. (PAR), 16204 North Florida Avenue, Lutz, Florida 33549, from the Behavior Rating Inventory of Executive Function Adult Version by Robert M. Roth, PhD, Peter K. Isquith, PhD and Gerard A. Gioia, PhD, Copyright 1996, 1998, 2001, 2003, 2004, 2005 by PAR. Further reproduction is prohibited without permission from PAR.

For Review Only, Do NOT Copy

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

CONTENTS

Section Page

i. INTRODUCTION 1

A. CONTACT INFORMATION 1 3

B. DEMOGRAPHIC AND SOCIOECONOMIC CHARACTERISTICS 6

C. EMPLOYMENT STATUS AND BARRIERS 9

D. GOAL SETTING, GOAL PURSUIT, AND SELF-REGULATION SKILLS 14

E. CONTACT INFORMATION 2 18

i. INTRODUCTION

ALL

[PROGRAM NAME] is participating in the Evaluation of Employment Coaching for TANF and Related Populations, a national study being conducted by the U.S. Department of Health and Human Services. The study is being done to learn more about whether providing people with a coach to assist them with setting and meeting goals helps them get and keep a job. The study will also help us learn whether there are ways to make the [coaching/program] work better. The U.S. Department of Health and Human Services has asked researchers from Mathematica Policy Research and its partner, Abt Associates, to assist with the study. We invite you to be a part of the study.

All study participants will be in one of two groups: (1) those who are offered [coaching/PROGRAM NAME’s services], and (2) those who are not but are still eligible to receive [regular case management/referrals to other services in the community]. The study will compare outcomes for people in each group.

A computer will randomly select which group you will be in. The computer works like a flip of a coin—assignment to a group is random. This procedure makes sure that assignments to the groups are fair. Everyone who agrees to participate in the study has the same chance of being placed into either group. The chance of being able to receive [coaching/PROGRAM NAMEservices] is not influenced by what you say to us or your answers to the questions you will be asked when you apply. [I/NAME OF STAFF MEMBER] will let you know which group you are assigned to at the end of the application process.

If you are not randomly selected to [receive coaching/participate in PROGRAM NAME], you are still eligible to [receive regular case management services/a list of other services in the community].

If you decide to be in the study, I will ask you to answer some questions today. I will ask you questions about yourself, your family, your employment history, and your receipt of public assistance. These questions will take about 20 minutes to answer.

In about [NUMBER] months and again in [NUMBER] months, the researchers will send you an invitation with a user ID and password so that you can complete a follow-up survey online, which should take about one hour. If the researchers don’t hear from you, then they will contact you by phone or in person. You will be asked about topics such as the services you received from [PROGRAM NAME] or other providers in the community, your employment, and your earnings. If you are in the program, you may also be asked to participate in other study activities, such as a two-hour in-person interview and video recording of one or more of your coaching sessions to be reviewed by members of the research team.

If you agree to be part of the study, it means you are giving permission for our program to share information with the researchers about the services you receive from the program. The researchers may use information you provide to consult directories of contact information to help them contact you about completing the follow-up surveys and verify your identity. The researchers may also contact federal and state agencies for information about your employment and earnings and your receipt of benefits from such programs as Temporary Assistance for Needy Families (TANF) and unemployment insurance. The researchers may request this information for two years before and up to 10 years after you enroll in the study.

Everything you tell the researchers will be used for research purposes only, unless the researchers are required by law to release it for some other purpose. All data will be kept securely and the researchers will not share your individual data with [PROGRAM NAME], the TANF agency, or federal officials. Nobody will ever publish your name in connection with the information you provide. Instead, information about you will be combined with information about other people in the study, so researchers can describe the overall program effects and participants’ experiences.

To help us protect your privacy, the researchers have obtained a Certificate of Confidentiality from the National Institutes of Health. With this Certificate, the researchers cannot be forced to disclose information that may identify you, even by a court subpoena, in any federal, state, or local civil, criminal, administrative, legislative, or other proceedings. The researchers will use the Certificate to resist any demands for information that would identify you, with one exception. The Certificate of Confidentiality does not prevent the researchers from disclosing information that would identify you as a participant in the research project if you tell the interviewers anything that suggests you are very likely to harm yourself, that you are planning to hurt another person or child, or that someone is likely to harm you.

You should understand that a Certificate of Confidentiality does not prevent you or a member of your family from voluntarily releasing information about yourself or your involvement in this research. If an insurer, employer, or other person obtains your written consent to receive research information, then the researchers may not use the Certificate to withhold that information.

You may or may not benefit personally from participating in this study, but your participation in the study could help in improving services offered in the future to other people like you.

There are very minimal risks associated with participating in the study. You may feel uncomfortable answering some questions, but you can always refuse to answer those questions if you wish, and it will not change your participation in the program or the study. Although researchers will take many steps to protect all study information, there is a small risk that non-researchers could see it, including information about your employment and earnings and TANF benefits. In addition, representatives from the U.S. Department of Health and Human Services and New England Institutional Review Board may inspect and have access to confidential information as they ensure your rights as a study participant are protected.

You will not receive a token of appreciation today, but you will receive a token of appreciation for completing the follow-up surveys. The researchers will send you an invitation once we are ready to start a follow-up survey. The invitation will contain all the information you need to participate. For each of the two follow-up surveys you will receive a $35 gift card as a token of appreciation if you complete the survey within four weeks of receiving the invitation. If you complete the survey later than four weeks after receiving the invitation, you will receive a $25 gift card as a token of appreciation for completing the survey.

We hope you will want to be in the study but your participation is strictly voluntary. If you participate in the study, the researchers will ask you to participate in surveys, will collect some data on you from [PROGRAM NAME] and federal and state agencies, and may ask you to participate in other data collection activities. However, you will never be required to answer questions in the survey, participate in an interview, or be videotaped. If you decide now that you do not want to participate in the study, the researchers will not collect any information about you. However, you cannot [receive coaching/participate in PROGRAM NAME] if you do not participate in the study. Either way, it will not affect your access to TANF or other public benefits.

If you agree to be in the study now, you can withdraw from the study later. However, if you withdraw from the study and were assigned to the group that [receives coaching services/participates in PROGRAM NAME], you will no longer be able to [receive coaching/participate in PROGRAM NAME]. By agreeing now to be in the study, even if later you tell us you want to withdraw from the study, you are authorizing researchers to use information that was collected about you before you withdrew. To withdraw from the study, you must call Mathematica’s help line and provide a written letter or email confirming that you no longer want to be in the study.

If you have any questions you can call Mathematica toll-free at 1-8XX-XXX-XXXX.

i1. Do you agree to participate in the Evaluation of Employment Coaching for TANF and Related Populations?

 YES 1

 NO 0 END

INTERVIEWER: IF RESPONDENT REFUSES TO BE IN THE STUDY THEN DO NOT PROCEED WITH THE INTERVIEW.

Thank you for agreeing to participate in the study. [I/We] would like to start by asking you some questions about yourself.

ALL

A1. What is your full name? Please spell that for me.

INSTRUCTION: CONFIRM LAST NAME GIVEN IS THEIR FULL LEGAL NAME (i.e., ARE THERE TWO LAST NAMES OR HYPHENATED LAST NAME).

PACT

INSTRUCTION: PLEASE ASK FOR MIDDLE NAME OF CLIENT

FIRST NAME

(STRING 50)

MIDDLE NAME

(STRING 20)

LAST NAME

(STRING 50)

ALL

A1a. I want to make sure that we call you by the correct name. Do you go by another name?

PACT

 YES 1

 NO 0 A2

 DON’T KNOW d A2

 REFUSED r A2

A1A=01

A1b. Please spell that name for me.

PACT

NAME

(STRING 50)

 DON’T KNOW d

 REFUSED r

ALL

A2. What is your date of birth?

DATE OF BIRTH

PACT

MONTH DAY YEAR

(01-12) (01-31) (1918-2001)

SOFT CHECK: IF OUT OF RANGE < 18 YEARS OLD; I recorded (fill A2 ANSWER). Is that correct? PROGRAMMER: IF R CONFIRMS THEY ARE <18 YEARS OLD, GO TO END.

all

A3. What is your Social Security number?

NUMBER

(000-999) (00-99) (0000-9999)

PACT

 DON’T KNOW d

 REFUSED r

all

PACT

A4. What is your home telephone number?

HOME TELEPHONE

(201-989) (200-999) (0000-9999)

 NO LANDLINE 1

 DON’T KNOW d

 REFUSED r

all

A5a. Do you have a cell phone?

 YES 1

PACT

 NO 0 B1

 DON’T KNOW d B1

 REFUSED r B1

a5a=01

PACT

A5b. What is your cell phone number?

CELL PHONE

(201-989) (200-999) (0000-9999)

 DON’T KNOW d

 REFUSED r

A5a=01

YB 30 Mth J3

A6. Is it okay for us to text you at this number? Message and data rates may apply.

 YES 1

 NO 0

 DON’T KNOW d

 REFUSED r

ALL

A7. What is another phone number where you can be reached?

PHONE NUMBER

YB 30 Mth J3

(201-989) (200-999) (0000-9999)

 DON’T KNOW d

 REFUSED r

Staff-administered: Next, I would like to ask you some questions about your background.

Self-administered: The next questions are about your background.

All

OMB

B1. Are you Hispanic, Latino, or of Spanish origin?

 YES 1

 NO, NOT OF HISPANIC, LATINO OR SPANISH ORIGIN 0

 DON’T KNOW d

 REFUSED r

All

OMB

B2. What is your race?

Select all that apply

 AMERICAN INDIAN OR ALASKA NATIVE 1

 ASIAN 2

 BLACK OR AFRICAN AMERICAN 3

 NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER 4

 WHITE 5

 OTHER (SPECIFY) 99

Specify (STRING (NUM))

 DON’T KNOW d

 REFUSED r

IF OTHER SPECIFY (99): SPECIFY OTHER RACE

all

SOGI report modiified

B3. How do you describe yourself?

Select one only

 Male 1

 Female, or 2

 Would you describe yourself in some other way? 3

Specify (STRING (NUM))

 DON’T KNOW d

 REFUSED r

All

B4. What is the highest level of education you have completed?

COBRA tailored for TANF

IF RESPONDENT SAYS “HIGH SCHOOL,” PROBE: Did you receive a diploma or GED?

Select one only

 DID NOT COMPLETE HIGH SCHOOL OR GED 1

 HIGH SCHOOL: DIPLOMA (NOT GENERAL EDUCATION DEVELOPMENT OR GED) 2

 GENERAL EDUCATION DEVELOPMENT OR GED 3

 SOME COLLEGE BUT NO DEGREE 4

 2-YEAR OR 3-YEAR COLLEGE DEGREE (ASSOCIATE’S DEGREE) 5

 4-YEAR COLLEGE DEGREE (BACHELOR’S DEGREE) 6

 GRADUATE OR PROFESSIONAL DEGREE (e.g., MA, MBA, Ph.D., JD, MD) 7

 NEVER ATTENDED SCHOOL 8

 DON’T KNOW d

 REFUSED r

All

CPS

modified

B5. What is your current marital status—are you now married, separated, divorced, widowed, or have you never been married?

Select one only

 MARRIED 1

 SEPARATED 2

 DIVORCED 3

 WIDOWED 4

 NEVER MARRIED 5

 DON’T KNOW d

 REFUSED r

Staff-administered: Now I would like to ask you some questions about the people who live with you.

Self-administered: The next questions are about people who live with you.

All

JSA

B6. How many adults age 18 or older currently live in your household at least half the time? Please include yourself.

ADULTS

(1-99)

INTERVIEWER: IF THE RESPONDENT SAYS “0” THEN REMIND THEM THAT THEY SHOULD INCLUDE THEMSELVES IN THIS TOTAL.

 DON’T KNOW d

 REFUSED r

All

JSA

B7. How many children under age 18 live with you at least half the time? This includes biological, adopted, foster, step, and any other children.

CHILDREN

(0-99)

 DON’T KNOW d

 REFUSED r

all

The next question is about where you live.

B8. Do you currently own your home or apartment or have a mortgage, rent it, pay some amount toward rent, live rent free with a friend or relative, or do you have some other arrangement?

OWN OR HAVE MORTGAGE 1

RENT 2

PAY SOME OF THE RENT 3

LIVE RENT FREE (SOMEONE ELSE RENTS/OWNS HOUSE OR APARTMENT) 4

LIVE IN SHELTER 5

LIVE ON STREETS 6

LIVE IN ABANDONED BUILDING/CAR 7

OTHER (SPECIFY) 99

(STRING 250)

DON’T KNOW d

REFUSED r

IF OTHER SPECIFY (99): What is the other arrangement?

all

B9. The next questions are about sources of income and other support that you and other members of your household may have received in the past month.

In the past month, have you or anyone in your household received any income from [fill statements a-j]?

	CODE ONE RESPONSE PER ROW
	YES	NO	DK	REF
a. Temporary Assistance for Needy Families, or TANF (this is also known as welfare)	1	0	d	r
b. Supplemental Security Income, or SSI	1	0	d	r
c. Social Security Disability Insurance, or SSDI	1	0	d	r
d. Food stamps or SNAP	1	0	d	r
e. Women, Infants, and Children, or WIC	1	0	d	r
f. Unemployment Insurance	1	0	d	r
g. Housing choice vouchers, Section 8, project-based rental assistance, public housing, housing where an agency helps you pay the rent, or other housing assistance	1	0	d	r

The next questions are about work you have done for pay.

ALL

CSPED

C1. Are you currently working for pay?

Working for pay can include regular paid jobs, odd jobs, temporary jobs, work done in your own business, “under the table” work, or any other types of work you have done for pay.

 YES 1 C4

 NO 0

 DON’T KNOW d

 REFUSED r

C1 NE 1

WFNJ tailored for TANF

C2. In the past 30 days have you worked for pay?

PROBE: Please include any regular paid jobs, odd jobs, temporary jobs, work in your own business, “under the table” work, or any other types of work you have done.

 YES 1 C4

 NO 0

 DON’T KNOW d

 REFUSED r

c2 NE 1

PACT

C3. In what month and year did you last work for pay?

PROBE: Please include any regular paid jobs, odd jobs, temporary jobs, work in your own business, “under the table” work, or any other types of work you have done.

C4

MONTH YEAR

(1-12) (1957-2017)

 NEVER WORKED FOR PAY 0 C5

 DON’T KNOW d C4

 REFUSED r C4

C3 NE 0

IF C1 = 1, fill ”DO” and “varies”; IF C2=1, FILL ”DID”
and “varied”

WIA –tailored for TANF

C4. How much [do/did] you get paid before taxes and deductions, at this job?

PROBE: If your pay [varies/varied], please provide an average amount. If you are paid per job or for completing a particular task, please tell us the total amount you usually made per week or per month while doing this type of work.

IF THE RESPONDENT DOES NOT PROVIDE A PAY PERIOD THEN PROBE: And, is that per hour, per week, per month, once every two weeks, twice a month, per year, day/daily, or something else?

INSTRUCTION: ACCEPT MOST CONVENIENT PAY PERIOD.

INSTRUCTION: IF ANSWER IS GREATER THAN $50 PER HOUR, $2000 PER WEEK, $4000 ONCE EVERY 2 WEEKS, $4000 TWICE A MONTH, $100,000 PER YEAR, $400 DAY/DAILY, OR $8000 MONTH, SAY: “I recorded [c4 and c4 amount answer]. Is that correct?”

(0-999,999.99) AMOUNT

Select one only

 PER HOUR 1

 PER WEEK 2

 MONTH 3

 ONCE EVERY TWO WEEKS 4

 TWICE A MONTH 5

 PER YEAR 6

 DAY/DAILY 7

 OTHER (SPECIFY) 99

Specify (STRING 100)

 DON’T KNOW d

 REFUSED r

C1=1 OR C2=1

WFNJ tailored for TANF

C5. In the past 30 days, how much money did you make from work? Please include tips, bonuses, commissions, and regular overtime pay and count all money you received before taxes and deductions. If you held more than one job, include your total earnings from all of your work during the past 30 days.

AMOUNT C7

(1-999,999

 DON’T KNOW d C6

 REFUSED r C6

C5=d OR r

WFNJ tailored for TANF

C6. Staff-administered: I just need to know a range. Can you tell me if it was . . .

Self-administered: We just need to know a range. Was it . . .

Select one only

 $0 - $500, 1

 $501 - $1,000, 2

 $1,001 to $2,000, 3

 $2,001 to $3,000, 4

 $3,001 to $4,000, 5

 $4,001 to $5,000, or 6

 More than $5,000? 7

 DON’T KNOW d

 REFUSED r

C1 OR C2=1

IF C1 = 1, fill “do”; IF C2=1, FILL “DID”

PACT tailored for TANF

C7. How many hours (do/did) you usually work per week at your current or most recent job?

Select one only

 1-19 hours, 1

 20-34 hours, 2

 35-44 hours, 3

 45 hours or more 4

 DON’T KNOW d

 REFUSED r

ALL

CSPED tailored for TANF

C8. Staff-administered: Now I am going to read you a list of things that some people find challenging in finding and keeping a good job.

Please tell me if the following has made it not at all hard, a little hard, somewhat hard, very hard, or extremely hard for you to find or keep a good job in the past year.

[FILL a-g]. Would you say that made it not at all hard, a little hard, somewhat hard, very hard, or extremely hard for you to find or keep a good job in the past year?

INSTRUCTION: IF NEEDED READ RESPONSE CATEGORIES FOR B-G

Self-administered: The next set of questions are about things that some people find challenging in finding and keeping a good job.

Would you say that [FILL a-g] made it not at all hard, a little hard, somewhat hard, very hard, or extremely hard for you to find or keep a good job in the past year?

Select one per row

	NOT AT ALL	A LITTLE	SOMEWHAT	VERY	EXTREMELY	DK	REF
a. Not having reliable transportation	0 	1 	2 	3 	4 	d 	r 
b. Not having good enough childcare or family help	0 	1 	2 	3 	4 	d 	r 
c. Not having the right clothes or tools for work	0 	1 	2 	3 	4 	d 	r 
d. Not having the right skills or education	0 	1 	2 	3 	4 	d 	r 
e. Having a criminal record	0 	1 	2 	3 	4 	d 	r 
f. A lack of jobs available in your area	0 	1 	2 	3 	4 	d 	r 
g. Not being able to do certain kinds or amounts of work, training, or school work because of your health	0 	1 	2 	3 	4 	d 	r 

ALL

CSPED

C9. Do you currently have a valid driver’s license? By valid we mean that it not expired, and has not been suspended or taken away.

 YES 1

 NO 0

 DON’T KNOW d

 REFUSED r

ALL

Mathematica developed

C9a. In the past six months, have you ever not been able to apply to a job because you didn’t have a valid driver’s license?

  YES ………………………………………………………………………………………1

 NO 0

 DON’T KNOW d

 REFUSED r

ALL

IF C1 = 1 THEN DO NOT ASK D.

D1. Staff-administered: Now I am going to ask you about employment-related behaviors.

Please tell me if you strongly disagree, disagree, agree, or strongly agree with the following statements.

Self-administered: The next set of questions are about employment-related behaviors.

Please indicate if you strongly disagree, disagree, agree, or strongly agree with the following statements.

ADAPTED FROM

GOAL SETTING

ADAPTED FROM

GOAL SETTING

ADAPTED FROM

LASER

ADAPTED FROM

LASER

Select one per row

	STRONGLY DISAGREE	DISAGREE	AGREE	STRONGLY AGREE	DK	REF
a. I set long-term employment goals that I hope to achieve within a year, such as finding a job, finding a better job, getting promoted, or enrolling in further education.	1 	2 	3 	4 	d 	r 
b. I set specific short-term goals that will allow me to achieve my long-term employment goals.	1 	2 	3 	4 	d 	r 
c. I know I need to get a job or a better job and really think I should work on finding one.	1 	2 	3 	4 	d 	r 
d. I guess being out of work is not good, but there is nothing I can do about it right now…………………………………….	1 	2 	3 	4 	d 	r 

D1a, D1b: Noonan, P.M., & Gaumer Erickson, A.S. (2017). The skills that matter: Teaching intrapersonal and interpersonal competencies in any classroom. Thousand Oaks, CA: Corwin.

ALL

Mathematica Developed

D2. In the past 6 months, how often have you been late for a job or a job-related appointment like an interview or meeting with a program worker? Would you say…

Select one only

 Every day or almost every day, 1

 A few times a week, 2

 A few times a month, 3

 About once a month 4

• Only a few times, or 5

 Hardly ever or never? 6

• RESPONDENT DIDN’T HAVE A JOB OR A JOB-RELATED APPOINTMENT 0

• DON’T KNOW d

 REFUSED r

ALL

BRIEF-A

D3.1. Now we are going to discuss behaviors more generally.

During the past month, how often has each of the following behaviors been a problem? Would you say that the following behaviors have been a problem never, sometimes, or often?

**NOTE: The specific wording of items D3.1a-l and D3.2a-h are not shown on this copy of the survey because the items are adapted and reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc., 16204 North Florida Avenue, Lutz, Florida 33549. Further reproduction is prohibited without permission by PAR, Inc.

Select one per row

For Review Only, Do NOT Copy	NEVER	SOMETIMES	OFTEN	DK	REF
a. Item 25 **SEE NOTE ABOVE	0 	1 	2 	d 	r 
b. Item 49	0 	1 	2 	d 	r 
c. Item 52	0 	1 	2 	d 	r 
d. Item 6	0 	1 	2 	d 	r 
e. Item 71	0 	1 	2 	d 	r 
f. Item 75	0 	1 	2 	d 	r 
g. Item 24	0 	1 	2 	d 	r 
h. Item 53	0 	1 	2 	d 	r 
i. Item 9	0 	1 	2 	d 	r 
j. Item 15 -edited	0 	1 	2 	d 	r 
k. Item 63 - edited	0 	1 	2 	d 	r 
l. Item 2	0 	1 	2 	d 	r 

D3.2. During the past month, how often has each of the following behaviors been a problem? Would you say that the following behaviors have been a problem never, sometimes, or often?

	Select one per row
	NEVER	SOMETIMES	OFTEN	DK	REF
a. Item 28	0 	1 	2 	d 	r 
b. Item 69	0 	1 	2 	d 	r 
c. Item 1	0 	1 	2 	d 	r 
d. Item 72	0 	1 	2 	d 	r 
e. Item 23.	0 	1 	2 	d 	r 
f. Item 50	0 	1 	2 	d 	r 
g. Item 64	0 	1 	2 	d 	r 
h. Item 70 -edited	0 	1 	2 	d 	r 

Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc. (PAR), 16204 North Florida Avenue, Lutz, Florida 33549, from the Behavior Rating Inventory of Executive Function Adult Version by Robert M. Roth, PhD, Peter K. Isquith, PhD and Gerard A. Gioia, PhD, Copyright 1996, 1998, 2001, 2003, 2004, 2005 by PAR. Further reproduction is prohibited without permission from PAR. For Review Only, Do NOT Copy

D4. Staff-administered: Next, I’m going to read a list of opinions people have about themselves. After I read each one, I want you to tell me whether you strongly disagree, disagree, agree, or strongly agree.

Self-administered: The next set of items are a list of opinions people have about themselves. Indicate whether you strongly disagree, disagree, agree, or strongly agree with each one.

Rosenberg Self Esteem Scale

Rosenberg Self Esteem Scale

Rosenberg Self Esteem Scale

Select one per row

	STRONGLY DISAGREE	DISAGREE	AGREE	STRONGLY AGREE	DK	REF
a. I am able to do things as well as most people.	1 	2 	3 	4 	d 	r 
b. I certainly feel useless at times.	1 	2 	3 	4 	d 	r 
c. All in all, I tend to feel that I am a failure.	1 	2 	3	4 	d 	r 

Next, we would like to ask for some contact information.

ALL

PACT

E1. What is your address?

PROBE: Where do you receive your mail?

PROBE: Is there an apartment number?

Street Address 1: (STRING (NUM))

Street Address 2: (STRING (NUM))

City: (STRING (NUM))

State: (STRING (NUM))

Zip: (STRING (NUM))

 DON’T KNOW d

 REFUSED r

ALL

E2. What is your email address?

PACT

EMAIL ADDRESS

(STRING 50)

 DON’T HAVE ONE 0

 DON’T KNOW d

 REFUSED r

ALL

PACT tailored for TANF

E3a. Mathematica would like to contact you in about 6 to 12 months to see how you are doing. In case Mathematica has trouble reaching you, Mathematica would like to have the names of three people who would most likely know where you are or who you keep in close contact with, such as a grandmother or grandfather, other relative, or friend. Mathematica will not contact these people for any other reason.

What is the full name of the first person we should contact?

FIRST NAME

(STRING 50)

MIDDLE INITIAL

(STRING 1)

LAST NAME

(STRING 50)

 DON’T KNOW d END

 REFUSED r END

E3a NE D OR R

E3b. What is (his/her) address?

PROBE: Is there an apartment number?

PACT

Street Address 1: (STRING (NUM))

Street Address 2: (STRING (NUM))

City: (STRING (NUM))

State: (STRING (NUM))

Zip: (STRING (NUM))

 DON’T KNOW d

 REFUSED r

E3a NE D OR R

E3c. What is (his/her) relationship to you?

Select one only

PACT

 SPOUSE/PARTNER 1

 MOTHER 2

 FATHER 3

 SISTER/BROTHER 4

 GRANDMOTHER/GRANDFATHER 5

 SON/DAUGHTER 6

 FRIEND 7

 OTHER (SPECIFY) 99

Specify (STRING 50)

 DON’T KNOW d

 REFUSED r

IF OTHER SPECIFY (99): ENTER OTHER RELATIONSHIP TYPE

E3a NE D OR R

E3d. What is (his/her) home telephone number?

HOME TELEPHONE

(201-989) (200-999) (0000-9999)

PACT

 NO LANDLINE 1

 DON’T KNOW d

 REFUSED r

E3a NE D OR R

E3e. Does (he/she) have a cell phone?

PACT

 YES 1

 NO 0 E3g

 DON’T KNOW d E3g

 REFUSED r E3g

E3e=1

E3f. Can I have that number?

TELEPHONE

(201-989) (200-999) (0000-9999)

PACT

 DON’T KNOW d

 REFUSED r

E3a NE D OR R

E3g. What is (his/her) work telephone number?

TELEPHONE

(201-989) (200-999) (0000-9999)

PACT

 NO WORK NUMBER 1

 DON’T KNOW d

 REFUSED r

E3a NE D OR R

E3h. What is (his/her) email address?

EMAIL ADDRESS

(STRING 50)

PACT

 DON’T HAVE ONE 0 E3a

 DON’T KNOW d E3a

 REFUSED r E3a

E3h NE 0, D, OR R

E3i. Does (he/she) have another email address?

EMAIL ADDRESS

(STRING 50)

PACT

 NO 0

 DON’T KNOW d

 REFUSED r

SECOND CONTACT

E3a NE D OR R

E4a. What is the full name of the second person we should contact?

FIRST NAME

(STRING 50)

MIDDLE INITIAL

(STRING 1)

LAST NAME

(STRING 50)

PACT

 DON’T KNOW d END

 REFUSED r END

E4a NE D OR R

E4b. What is (his/her) address?

PROBE: Is there an apartment number?

PACT

Street Address 1: (STRING (NUM))

Street Address 2: (STRING (NUM))

City: (STRING (NUM))

State: (STRING (NUM))

Zip: (STRING (NUM))

 DON’T KNOW d

 REFUSED r

E4a NE D OR R

E4c. What is (his/her) relationship to you?

Select one only

PACT

 SPOUSE/PARTNER 1

 MOTHER 2

 FATHER 3

 SISTER/BROTHER 4

 GRANDMOTHER/GRANDFATHER 5

• SON/DAUGHTER 6

 FRIEND 7

 OTHER (SPECIFY) 99

Specify (STRING 50)

 DON’T KNOW d

 REFUSED r

E4a NE D OR R

E4d. What is (his/her) home telephone number?

HOME TELEPHONE

(201-989) (200-999) (0000-9999)

 NO LANDLINE 1

PACT

 DON’T KNOW d

 REFUSED r

E4a NE D OR R

E4e. Does (he/she) have a cell phone?

 YES 1

PACT

 NO 0 E4g

 DON’T KNOW d E4g

 REFUSED r E4g

E4e=1

E4f. Can I have that number?

TELEPHONE

(201-989) (200-999) (0000-9999)

PACT

 DON’T KNOW d

 REFUSED r

E4a NE D OR R

E4g. What is (his/her) work telephone number?

(201-989) (200-999) (0000-9999)

 NO WORK NUMBER 1

PACT

 DON’T KNOW d

 REFUSED r

E4a NE D OR R

E4h. What is (his/her) email address?

EMAIL ADDRESS

(STRING 50)

 DON’T HAVE ONE 0 E4a

PACT

 DON’T KNOW d E4a

 REFUSED r E4a

E4h NE D OR R

E4i. Does (he/she) have another email address?

EMAIL ADDRESS

(STRING 50)

 NO 0

PACT

 DON’T KNOW d

 REFUSED r

THIRD CONTACT

E4a NE D OR R

E5a. What is the full name of the third person we should contact?

FIRST NAME

(STRING 50)

MIDDLE INITIAL

(STRING 1)

LAST NAME

(STRING 50)

PACT

 DON’T KNOW d END

 REFUSED r END

E5a NE d OR r

E5b. What is (his/her) address?

PROBE: Is there an apartment number?

Street Address 1: (STRING (NUM))

Street Address 2: (STRING (NUM))

City: (STRING (NUM))

State: (STRING (NUM))

Zip: (STRING (NUM))

PACT

 DON’T KNOW d

 REFUSED r

E5a NE d OR r

E5c. What is (his/her) relationship to you?

Select one only

PACT

 SPOUSE/PARTNER 1

 MOTHER 2

 FATHER 3

 SISTER/BROTHER 4

 GRANDMOTHER/GRANDFATHER 5

• SON/DAUGHTER 6

 FRIEND 7

 OTHER (SPECIFY) 99

Specify (STRING 50)

 DON’T KNOW d

 REFUSED r

E5a NE d OR r

E5d. What is (his/her) home telephone number?

HOME TELEPHONE

(201-989) (200-999) (0000-9999)

PACT

 NO LANDLINE 1

 DON’T KNOW d

 REFUSED r

E5a NE d OR r

E5e. Does (he/she) have a cell phone?

 YES 1

PACT

 NO 0 E5g

 DON’T KNOW d E5g

 REFUSED r E5g

E5e=1

E5f. Can I have that number?

TELEPHONE

PACT

(201-989) (200-999) (0000-9999)

 DON’T KNOW d

 REFUSED r

E5a NE d OR r

E5g. What is (his/her) work telephone number?

TELEPHONE

(201-989) (200-999) (0000-9999)

PACT

 NO WORK NUMBER 0

 DON’T KNOW d

 REFUSED r

E5a NE d OR r

E5h. What is (his/her) email address?

EMAIL ADDRESS

(STRING 50)

PACT

 DON’T HAVE ONE 0 END

 DON’T KNOW d END

 REFUSED r END

E5h NE 0, d, OR r

E5i. Does (he/she) have another email address?

EMAIL ADDRESS

PACT

 NO 0

 DON’T KNOW d

 REFUSED r

END. Those are all of the questions I have. Thank you for your time.

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