Attachment D-5_BEES_BIF IPS FQHC_Clean

Attachment D-5 – Baseline Information Form for Participants

First and Last Name ______________________ OMB Control No: 0970-0537

BEES ID Number ______________________ (Office Use Only) Expiration Date: 11/30/2022

YOUR CONTACT INFORMATION
Name:
Date of birth:			SSN:
Current address:
City:		State:			ZIP Code:
Home phone #: ( )		Cell #: ( )			Work #: ( )
Is this address the best one to mail something to you? 1 Yes 2 No
Alternative address:
City:	State:			ZIP Code:
Email address:
Which is the primary social network you use? 1 Facebook 2 Twitter 3 Instagram 4 Other (specify): _______________ 9 Decline to answer _______________
What name do you use in that social network?
Can we contact you by text message? 1 Yes 2 No 9 Decline to answer
What is your preferred mode of contact? (Check all that apply) A  Phone B Text C Email D  Other (specify): ____________________________

A. Demographic Information
A.1 Sex		1 Male 2 Female 9 Decline to answer
A.2 What is your ethnicity?		1 Hispanic or Latino 2 Not Hispanic or Latino 9 Decline to answer
A.3 What is your race? (Check all that apply)		A American Indian or Alaska Native B Asian C Black or African American D Native Hawaiian or Other Pacific Islander E White F  Other (specify): _____________ G  Decline to answer
A.4 Primary language spoken at home		1 English 2 Spanish 3 Other (specify): _____________ 9 Decline to answer
A.5 How well do you speak English?		1 Very well 2 Well 3 Not very well 4 Not at all 9 Decline to answer
B. Education
B.1 What is the highest degree or year of school that you have attained?		1 Less than a high school diploma 2 High school diploma or equivalent 3 Some college or technical training 4 Associate’s degree or other two-year degree 5 Bachelor’s degree or higher 9 Decline to answer
C. Employment History
C.1 Are you currently working for pay?		1 Yes 2 No 9 Decline to answer
C.2 Are you working 35 or more hours per week?		1 Yes 2 No 9 Decline to answer
C.3 How many jobs did you work last week?		_______________ 9 Decline to answer
C.4 In total, how many months did you work for pay during the past year (including your current job)?		1Did not work 2 Less than 4 months 3 4-6 months 4 7-9 months 5 10 or more months 9 Decline to answer
C.5 Are you currently looking for work?		1 Yes 2 No 9 Decline to answer
[If applicable to current state of pandemic, ask C6. Otherwise, skip to C7a.]
C.6a Which of the following statements describes your current employment status due to the COVID-19 pandemic?		1 You are working reduced hours due to the pandemic 2 You are not working due to the pandemic 3 Your employment status is not currently affected by the pandemic 9  Decline to answer
(Ask if answered “You are working reduced hours” or “You are not working” to C6a) C.6b Are you [working reduced hours] because [OR: not working]: (Check all that apply)		1 Your employer reduced employees or hours 2 You need to care for your child or someone else 3 You are concerned for your health or the health of others in your household 4 You are sick with COVID-19 or its lingering symptoms 5 None of these apply 9  Decline to answer
(If asked C6b, skip C7a & b) C.7a Which of the following statements describes your employment status at any point in the past year due to the COVID-19 pandemic?		1 You worked reduced hours due to the pandemic 2 You did not work due to the pandemic 3 Your employment status was not affected by the pandemic in the past year 9  Decline to answer
(Ask if answered “You worked reduced hours” or “You did not work” to C7a) C.7b Did you [work reduced hours] because [OR: not work]: (Check all that apply)		1 Your employer reduced employees or hours 2 You needed to care for your child or someone else 3 You were concerned for your health or the health of others in your household 4 You were sick with COVID-19 or its lingering symptoms 5 None of these apply 9  Decline to answer
D. Household Information
D.1 Which of the following best describes your [current housing arrangement during the past month? [OR: housing arrangement prior to entering name of program?]		1 Own your own home or apartment 2 Rent your home or apartment 3 Live in emergency or temporary housing, that is in a shelter or were homeless 4 Live in transitional housing or sober housing 5 Live in a group home 6 Live with friends or relatives and pay rent to them 7 Live with friends or relatives and not pay rent to them 8 Have some other housing arrangement? _____________________ 9 Decline to answer
D.2 Number of people in your household (including yourself):		Number of people Children under age 18: _______________ 9 Decline to answer Adults age 18 or older: _______________ 9 Decline to answer				D.3 Do you have a spouse or partner who lives in your household? 1 Yes 2 No 9 Decline to answer
E. Justice Involvement
E.1 Have you been arrested in the past 12 months? 1 Yes 2 No 9 Decline to answer	E.2 Have you ever been convicted of a crime? 1 Yes 2 No 9 Decline to answer		E.3 Are you currently on parole or probation? 1 Yes 2 No 9 Decline to answer		E.4 Have you ever been incarcerated? 1 Yes 2 No 9 Decline to answer

F. Benefit Receipt
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 because of a disability in the past year as an adult? (Probe: This could have been payments from Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI).)			1 Yes 2 No 3 Don’t know 9 Decline to answer
F.2 Are you currently receiving checks or electronic payments from the Social Security Administration because of a disability?			1 Yes 2 No 3 Don’t know 9 Decline to answer
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?			1 Yes 2 No 3Don’t know 9 Decline to answer
F.4 Are you currently awaiting a decision by the Social Security Administration on a pending disability application?			1 Yes 2 No 3 Don’t know 9 Decline to answer
F.5 During the past year, did you or anyone in your household receive income or assistance from any of the following sources? (Check all that apply)			A Disability benefits from SSA (SSI or SSDI) B TANF or [state specific TANF name] C Unemployment insurance (UI) D Worker’s compensation E Short-term disability F Food stamps/SNAP/[state specific program]				G WIC H HCV/Section 8/public housing I Veterans benefits J Medicaid or CHIP K None of the above L Decline to answer
G. Substance Use
G.1 Are you currently taking opioid medications for pain that have been prescribed by a physician or dentist?										1 Yes 2 No 9 Decline to answer
IF YES, G.1a …what is the name of that medication?										_____________________ 9 Decline to answer
G.1b …how long have you been taking it?										_____________________ 1 Days 2 Weeks 3 Months 4 Years 9 Decline to answer
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.)										1 Yes 2 No 9 Decline to answer
G.3 How many days in the past 30 have you used....? How many years in your life have you regularly used....? [“Decline to answer” options will appear for each question and each substance below.]
		Past 30 days Lifetime (years)							Past 30 days Lifetime (years)
Alcohol – Any use at all		_______ _______				Cocaine			_______ _______
Alcohol – To Intoxication		_______ _______				Methamphetamine			_______ _______
Heroin		_______ _______				Amphetamines (other than methamphetamine)			_______ _______
Fentanyl		_______ _______				Cannabis			_______ _______
Methadone (outside of methadone maintenance treatment)		_______ _______				Hallucinogens			_______ _______
Other opioids/opiates/ painkillers		_______ _______				Inhalants			_______ _______
Barbiturates		_______ _______				More than one substance per day (including alcohol)			_______ _______
Other sedatives, hypnotics, or tranquilizers		_______ _______				Other (specify): _____________			_______ _______
G.6 Which substance is the main problem? _____________________________ 9 Decline to answer
G.7 How long was your last period of voluntary abstinence from this substance?						_______ months 99 Decline to answer
G.8 How many months ago did this abstinence end?						_______ months 99 Decline to answer
G.9 How many times have you:						Had alcohol DT’s ________ 99 Decline to answer Overdosed on drugs ________ 99 Decline to answer
G.10 How many times in your life have you been treated for:						Alcohol abuse ________ 99 Decline to answer Drug abuse ________ 99 Decline to answer
G.11 How many of these were detox only?						Alcohol ________ 99 Decline to answer Drugs ________ 99 Decline to answer
G.12 How much money would you say you spent during the past 30 days on:						Alcohol $________ 99 Decline to answer Drugs $________ 99 Decline to answer
G.13 How many days have you been treated in an outpatient setting for alcohol or drugs in the past 30 days?						______ days 99 Decline to answer
G.14 How many days in the past 30 have you experienced difficulty with alcohol?						______ days 99 Decline to answer
G.15 How many days in the past 30 have you experienced difficulty with drugs?						______ days 99 Decline to answer
G.16 How troubled or bothered have you been in the past 30 days by these alcohol problems?						1 Not at all 2 Slightly 3 Moderately 4 Considerably 5 Extremely 9 Decline to answer
G.17 How troubled or bothered have you been in the past 30 days by these drug problems?						1 Not at all 2 Slightly 3 Moderately 4 Considerably 5 Extremely 9 Decline to answer
G.18 How important to you now is treatment for these alcohol problems?						1 Not at all 2 Slightly 3 Moderately 4 Considerably 5 Extremely 9 Decline to answer
G.19 How important to you now is treatment for these drug problems?						1 Not at all 2 Slightly 3 Moderately 4 Considerably 5 Extremely 9 Decline to answer
G.20 Have you been taking any of the following while in the care of a medical professional during the past 30 days? (Check all that apply)						A methadone B buprenorphine (including Subutex ®, Suboxone ®) C naltrexone (including Vivitrol ®) D None of the above E Decline to answer
G.21 Have you smoked any cigarettes in the past 2 years?						1 Yes 2 No 9 Decline to answer
G.22 How many cigarettes or packs do you currently smoke on an average day (a pack has 20 cigarettes)?						___________ cigarettes / packs (circle one) 99 Decline to answer
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?				1 All the time 2 Most of the time 3 Some of the time 4 A little of the time 5 None of the time 9 Decline to answer
H.1b …you feel hopeless?				1 All the time 2 Most of the time 3 Some of the time 4 A little of the time 5 None of the time 9 Decline to answer
H.1c …you feel restless or fidgety?				1 All the time 2 Most of the time 3 Some of the time 4 A little of the time 5 None of the time 9 Decline to answer
H.1d …you feel that everything was an effort?				1 All the time 2 Most of the time 3 Some of the time 4 A little of the time 5 None of the time 9 Decline to answer
H.1e …you feel worthless?				1 All the time 2 Most of the time 3 Some of the time 4 A little of the time 5 None of the time 9 Decline to answer
H.1f …you feel nervous?				1 All the time 2 Most of the time 3 Some of the time 4 A little of the time 5 None of the time 9 Decline to answer
I. Disability Status
I.1 Are you deaf or do you have serious difficulty hearing?								1 Yes 2 No 9 Decline to answer
I.2 Are you blind or do you have serious difficulty seeing, even when wearing glasses?								1 Yes 2 No 9 Decline to answer
I.3 Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?								1 Yes 2 No 9 Decline to answer
I.4 Do you have serious difficulty walking or climbing stairs?								1 Yes 2 No 9 Decline to answer
I.5 Do you have difficulty dressing or bathing?								1 Yes 2 No 9 Decline to answer
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?								1 Yes 2 No 9 Decline to answer
I.7 Does a physical, mental, or emotional condition limit the kind or amount of work you can do?								1 Yes 2 No 3 Don’t know 9 Decline to answer
J. Health
J.1 In general, would you say your health is:				1 Excellent 2 Very good 3 Good 4 Fair 5 Poor 9 Decline to answer
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				1 Yes, limited a lot 2 Yes, limited a little 3 No, not limited at all 9 Decline to answer
J.2b Climbing several flights of stairs				1 Yes, limited a lot 2 Yes, limited a little 3 No, not limited at all 9 Decline to answer
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				1 All the time 2 Most of the time 3 Some of the time 4 A little of the time 5 None of the time 9 Decline to answer
J.3b Were limited in the kind of work or other activities				1 All the time 2 Most of the time 3 Some of the time 4 A little of the time 5 None of the time 9 Decline to answer
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				1 All the time 2 Most of the time 3 Some of the time 4 A little of the time 5 None of the time 9 Decline to answer
J.4b Did work or other activities less carefully than usual				1 All the time 2 Most of the time 3 Some of the time 4 A little of the time 5 None of the time 9 Decline to answer
J.5 During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?				1 Not at all 2 Slightly 3 Moderately 4 Considerably 5 Extremely 9 Decline to answer
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?				1 All the time 2 Most of the time 3 Some of the time 4 A little of the time 5 None of the time 9 Decline to answer
J.6b Did you have a lot of energy?				1 All the time 2 Most of the time 3 Some of the time 4 A little of the time 5 None of the time 9 Decline to answer
J.7 Have you felt downhearted and depressed?				1 All the time 2 Most of the time 3 Some of the time 4 A little of the time 5 None of the time 9 Decline to answer
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.)?				1 All the time 2 Most of the time 3 Some of the time 4 A little of the time 5 None of the time 9 Decline to answer
J.9 During the past year, have you received help or treatment for mental health problems?				1 Yes 2 No 9 Decline to answer
K. Housing
K.1 During the past two years, have you ever been evicted or forced by your landlord to move when you didn’t want to?				1 Yes 2 No 3 In the midst of an eviction 4 Don’t know 9 Decline to answer
K.2 In the past 12 months was there ever a time when, because of cost, you or your household was not able to:
K.2a Pay your rent	1 Yes 2 No 9 Decline to answer
	[If Yes] How often did this happen in the past 12 months? 1 1 Month 2 2 or 3 months 3 4 to 6 months 4 7 or more months 9 Decline to answer
K.2b Pay your utility bills	1 Yes 2 No 9 Decline to answer
	[If Yes] How often did this happen in the past 12 months? 1 1 Month 2 2 or 3 months 3 4 to 6 months 4 7 or more months 9 Decline to answer
K.2c Pay for food needed	1 Yes 2 No 9 Decline to answer
	[If Yes] How often did this happen in the past 12 months? 11 1 time 2 2 or 3 times 3 4 to 6 times 4 7 or more times 9 Decline to answer
K.2d Pay for child care	1 Yes 2 No 9 Decline to answer
	[If Yes] How often did this happen in the past 12 months? 1 1 Month 2 2 or 3 months 3 4 to 6 months 4 7 or more months 9 Decline to answer
K.3 In the last 12 months, was there any time when you did not fill a prescription for medicine because of the cost?					1 Yes 2 No 3 Don’t know/Not sure 9 Decline to answer

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? 1 Spouse/Partner 2 Parent 3 Sister/Brother 4 Friend 5 Other
Current address:
City:	State:	ZIP Code:
Home phone #: ( )	Cell #: ( )	Work #: ( )
Email address:
2. Name:
How is this person related to you? 1 Spouse/Partner 2 Parent 3 Sister/Brother 4 Friend 5 Other
Current address:
City:	State:	ZIP Code:
Home phone #: ( )	Cell #: ( )	Work #: ( )
Email address:
3. Name:
How is this person related to you? 1 Spouse/Partner 2 Parent 3 Sister/Brother 4 Friend 5 Other
Current address:
City:	State:	ZIP Code:
Home phone #: ( )	Cell #: ( )	Work #: ( )
Email address:

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 #: 0970-0537, Exp: 11/30/2022. 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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