Attachment 14 - Baseline Survey and Consent Form for Program Participants_clean

OMB Control Number:1290-0NEW

OMB Expiration Date:

Attachment 14

BASELINE AND CONSENT FORM FOR PROGRAM PARTICIPANTS

informed consent form

[PROGRAM NAME]¹

Apprenticeship Building America Pre-Apprenticeship Impact Study

[PROGRAM NAME] IS PART OF A NATIONAL STUDY

[PROGRAM NAME] is participating in the Apprenticeship Building America Pre-apprenticeship Impact Study, a national study sponsored by the U.S. Department of Labor. The study will learn how pre-apprenticeship programs can help improve the skills and employment outcomes of American workers. The U.S. Department of Labor has asked researchers from the Urban Institute and its partners, Mathematica and Social Policy Research Associate, to assist with the study. We invite you to be a part of the study.

THE STUDY INCLUDES TWO GROUPS

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

WHICH GROUP WILL I BE IN?

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 [PROGRAM NAME services] is not influenced by what you say to us or your answers to the questions you will be asked when you apply. We will let you know which group you are assigned to at the end of the application process.

WHAT HAPPENS IF I AM NOT SELECTED TO RECEIVE [PROGRAM NAME] SERVICES?

If you are not randomly selected to participate in [PROGRAM NAME], you are still eligible to receive a list of other services in the community. You will be still be in the study.

WHAT INFORMATION WILL BE COLLECTED ABOUT ME?

The researchers will contact you over the next couple of years to collect some important information. In about [FILL] months, the researchers will contact you by email so that you can complete a follow-up survey online, which should take about [FILL]. This survey will include topics such as the education and training services you received from [PROGRAM NAME] or other providers in the community, your employment experience, and your earnings. If you are in the program, you may also be asked to participate in other study activities, such as a brief in-person interview.

If you agree to be part of the study, it means you are giving permission for [PROGRAM NAME] to share information with the researchers about the services you receive from the program including information on credits and degrees you have obtained. 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 unemployment insurance. The researchers may request this information for 2 years before and up to 15 years after you enroll in the study.

WILL MY PRIVACY BE PROTECTED?

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] 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.

WHAT ARE THE BENEFITS AND RISKS OF PARTICIPATING IN THE STUDY?

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.

WILL I RECEIVE TOKENS OF APPRECIATION FOR MY PARTICIPATION?

You will not receive a token of appreciation today, but you will receive a token of appreciation for completing the follow-up survey [FILL TIME] from now. The researchers will send you an invitation once we are ready to start the follow-up survey.

IS MY PARTICIPATION VOLUNTARY?

We hope you will want to be in the study but your participation is strictly voluntary. 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 participate in [PROGRAM NAME] if you do not participate in the study. Either way, it will not affect your access to 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 participates in [PROGRAM NAME], you will no longer be able to 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 the study’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 the study team toll-free at 1-8XX-XXX-XXXX.

WHO CAN ANSWER MY QUESTIONS ABOUT THIS RESEARCH?

If you have questions, concerns, or complaints, or think this research has hurt you or made you sick, talk to the research team at the phone number(s) listed above on the first page.

This research is being overseen by an Independent Review Board (“IRB”). An IRB is a group of people who perform independent review of research studies. You may talk to them at [FILL CONTACT INFO] if:

• You have questions, concerns, or complaints that are not being answered by the research team.

• You are not getting answers from the research team.

• You cannot reach the research team.

• You want to talk to someone else about the research.

• You have questions about your rights as a research subject.

SUBJECT’S STATEMENT OF CONSENT

I consent to take part in this research study. This study and the information in this consent form have been explained to me. I have read this consent form or it has been read to me. I have had an opportunity to ask questions and they have been answered to my satisfaction. I have been told that I have not given up any legal rights.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is voluntary. 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, Office of the Chief Information Officer, Attention: Departmental Clearance Officer, 200 Constitution Avenue, N.W., Room N-1301, Washington, DC 20210 or email DOL_PRA_PUBLIC@dol.gov and reference the OMB Control Number 1290-0NEW . Note: Please do not return the completed form to this address.

Baseline Survey

OMB No.: 1290-0NEW

Expiration Date:

Apprenticeship Building America Pre-Apprenticeship Impact Study

Baseline Information Form

DATE

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is voluntary. 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, Office of the Chief Information Officer, Attention: Departmental Clearance Officer, 200 Constitution Avenue, N.W., Room N-1301, Washington, DC 20210 or email DOL_PRA_PUBLIC@dol.gov and reference the OMB Control Number 1290-XXXX. Note: Please do not return the completed form to this address.

CONTENTS

Section Page

A. BACKGROUND 3

B. DEMOGRAPHIC AND SOCIOECONOMIC CHARACTERISTICS 5

C. EMPLOYMENT STATUS 9

D. CONTACT INFORMATION 13

E. STAFF USE ONLY 20

A. BACKGROUND

Thank you for agreeing to participate in the study. These first questions will help the study team ensure the right person completes your future surveys.

ALL

A1. Please enter your full name below.

PACT / AP

First name

(STRING 20)

Middle name

(STRING 20)

Last name

(STRING 30)

ALL

PACT / AP

A1a. We want to make sure that we refer to your correct name. Do you go by another name?

 Yes 1

 No 0 GO TO A2

NO RESPONSE d GO TO A2

A1A=01

A1b. Please enter that name below.

PACT AP

First name

(STRING 20)

Middle name

(STRING 20)

Last name

(STRING 30)

ALL

PACT/ AP

A2. What is your date of birth?

PROGRAMMER:INSERT DROPDOWNS WITH FOLLOWING RANGES

Month Day Year

(1-12) (1-31) (1918-2001)

HARD CHECK: IF OUT OF RANGE < 17 YEARS OLD; You indicated that you are below 17 years of age. Is this correct?

If this is correct, continue to the next question by clicking the continue button.

If this is not correct, please update your date of birth and click the continue button.

all

A3. What is your Social Security number?

[HOVER LINK: Social Security Numbers can be used to track whether or not study participants are employed and how much they earn. Your Social Security Number will be kept safe and secure and no one outside the study team will have access to it. The standards for protecting data, including Social Security numbers, are very high and the study team has many years of experience keeping data for evaluations like this one safe.]

PACT / AP

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

NO RESPONSE M

ALL

A4. What is the main reason you are seeking to participate in [PROGRAM NAME]? Would you say it is because you…

Select one only

 Want a career change, 1

 Want to gain skills in your current field, or 2

 Is it for some other reason? 3

Specify (STRING (NUM))

NO RESPONSE M

B. DEMOGRAPHIC AND SOCIOECONOMIC CHARACTERISTICS

The next questions are about your background.

All

B1. What is the highest level of education you have completed?

If you completed high school, please specify whether you received a diploma, General Education Development (GED), HiSET, or Test Assessing Secondary Completion (TASC).

LSUI / AP

Select one only

 Did not complete high school or GED 01

 High School: Received Diploma 02

 High School: Received GED, HiSET, or TASC 03

 Some college or postsecondary vocational courses 04

 2-Year or 3-Year College Degree (Associate’s Degree) or Vocational School Diploma 05

 4-Year college degree (Bachelor’s Degree) 06

 Some graduate work/no graduate degree 07

 Graduate or professional degree (MA, MBA, PH.D., JD, MD) 08

 Never attended school 09

NO RESPONSE M

B1=4 or 5 or 9

B2. Do you have a high school diploma, a General Education Development (GED), a HiSET, or a Test Assessing Secondary Completion (TASC)?

New

Select one only

 Yes, I have a High School Diploma 01

 Yes, I have a GED, HiSET, or TSAC 02

 No, I do not have a High School Diploma, GED, HiSET, or TSAC 03

All

TAA- modified / AP

B3. Are you currently participating in any education and training programs and courses? Please include training programs that help you learn job skills or prepare for an occupation including pre-apprenticeship, as well as general education programs, such as regular high school, adult basic education or GED courses, and college.

 Yes 1

 No 0

NO RESPONSE M

ALL

LSUI / AP

B4. Are you a veteran or a transitioning service member of any branch of the United States Armed Forces?

 Yes 01

 No 00

NO RESPONSE M

all

SOGI report modiified

B5. 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

CPS

modified

B6. What is your current marital status?

Select one only

 Married 01

 Separated 02

 Divorced 03

 Widowed 04

 Never married 05

NO RESPONSE M

All

JSA / AP

B7. How many adults age 18 or older currently live in your household at least half the time? Please include yourself.

Please include people who are temporarily away, for example, at school or in the hospital, and people not related to you.

Number of current household members

(1-99)

NO RESPONSE M

IF B7>1

JSA / AP

B8. 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)

NO RESPONSE M

All

OMB

B9. Are you Hispanic, Latino, or of Spanish origin?

 Hispanic, Latino or of Spanish origin 1

 Not Hispanic, Latino or of Spanish origin 2

NO RESPONSE M

All

OMB

B10. 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 99

Specify (STRING (NUM))

NO RESPONSE M

ALL

SNAP E&T

B11. What is your primary spoken language?

Select one only

 English 01

 Spanish 02

 Other (SPECIFY) 99

B11 = 2 or 99

SNAP E&T

B11a. How well would you say you speak English? Would you say…

Select one only

 Very well 01

 Well 02

 Not well, or 03

 Not at all 04

All

WIA

B12. Now, we have a question about your experience with the criminal justice system. Have you ever been arrested?

 Yes 1

 No 0

 DON’T KNOW d

 REFUSED r

B12=1

REO

B13. Have you ever been incarcerated in a juvenile or adult facility, such as a detention center, jail, or prison?

 Yes 1

 No 0

 DON’T KNOW d

 REFUSED r

C. EMPLOYMENT STATUS

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

LSUI /AP

C1. Have you ever worked for pay? Working for pay can include regular paid jobs, odd jobs, temporary jobs, work done in your own business, jobs or tasks you find using a web or mobile app, “under the table” work, “off the books” work, apprenticeships, or any other types of work you have done for pay.

 YES 1 C2

 NO 0 C10

 DON’T KNOW d C2

 REFUSED r C2

ALL

LSUI /AP

C2. Are you currently working at a job for pay? Working for pay can include regular paid jobs, odd jobs, temporary jobs, work done in your own business, jobs or tasks you find using a web or mobile app, “under the table” work, “off the books” work, apprenticeships, or any other types of work you have done for pay.

Select one response

 Yes 01

 No 00

NO RESPONSE M

C1 = 1 OR D OR R and C2=00 or m

C3. On what date did your most recent job end?

Your best estimate is fine.

LSUI-modified for AP

PROGRAMMER: INSERT DROPDOWNS WITH FOLLOWING RANGES

Month Day Year

▼

▼

▼

(1-12) (1-31) (1900-2019)

NO RESPONSE M

PROGRAMMER BOX:

IF MOST RECENT JOB ENDED WITHIN 24 MONTHS or no response, GO TO C4. set c3flag =1.

OTHERWISE, if most recent job ended more than 24 months ago, GO TO C10.

C2 = 1 or c3flag=1

LSUI / AP, modified

C4. [IF C2=1]: For these next questions, if you have had more than one job in the last two years, please consider whatever job you think of as your main job within the last two years. This could be (one of) your current job(s) or any prior job you had within the last two years.

[IF C2=0 OR M]: For these next questions, if you have had more than one job in the last two years, please consider whatever job you think of as your main job within the last two years.

How many hours per week, including regular overtime hours (do/did) you usually work at your main job?

On average. Your best estimate is fine.

Hours per week

 Varies v

NO RESPONSE M

C2 = 1 or c3flag=1

C5. What kind of work (do/did) you do or duties (do/did) you have at your main job?

LSUI

What [is/was] your occupation?

(STRING 250)

NO RESPONSE M

C2 = 1 or c3flag=1

C6. What kind of company (do/did) you work for—what (do/did) they make, sell, or do?

If self-employed, please enter what you make, sell or do.

LSUI

(STRING 250)

NO RESPONSE M

C2 = 1 or c3flag=1

LSUI / AP

C7. What (is/was) your usual pay, including tips, bonuses and commissions at your main job before taxes or other deductions are taken?

Your best estimate is fine.

You may use a decimal point in your response, but please do not include commas, dashes or other punctuation.

Amount Pay Period

▼

($5.00 - $500,000.00)

PROGRAMMER: USE PAY PERIOD OPTIONS BELOW

 Per hour 01

 Per week 02

 Once every two weeks 03

 Twice a month 04

 Per month 05

 Per year 06

 Some other pay period 99

Specify (STRING 250)

NO RESPONSE M

SOFT CHECKS: OUT OF RANGE PER RESPONSE: You indicated [dollar amount] per [range]. Is this correct?

PER HOUR: >$50; PER WEEK: >$2,000; PER YEAR: >$100,000; ONCE EVERY TWO WEEKS: $4,000; TWICE PER MONTH: >$4,000; PER MONTH: >$8,000

HARD CHECK: IF DOLLAR AMOUNT RESPONSE INCLUDES COMMAS, DASHES, OR OTHER PUNCTUATION; Input invalid. Value not in range -99999.99 to 999999.99.

C7=m or C7=m for amount or per

C8. Please try to estimate your annual pay at your main job. Would you say your annual earnings (are/were)…

LSUI / AP

Select one response

 Less than $10,000 per year, 01

 $10,000 or more, but less than $20,000 per year, 02

 $20,000 or more but less than $30,000 per year, 03

 $30,000 or more but less than $40,000 per year, 04

 $40,000 or more but less than $50,000 per year, 05

 $50,000 or more but less than $75,000 per year, 06

 $75,000 or more but less than $100,000 per year, or 07

 More than $100,000 per year? 08

NO RESPONSE M

C2=1

New

C9. Did your current employer refer you to the [PROGRAM NAME] program for training?

 Yes 01

 No 00

NO RESPONSE M

ALL

C10. Do you, or anyone in your household, currently receive assistance from any of the following programs?

Select all that apply

SNAP E&T, modified

 SNAP (Food Stamps) [also known as STATE SNAP NAME] 1

 Cash assistance, such as TANF (Temporary Assistance to Needy Families) [also known as STATE TANF NAME], general assistance, or SSI or SSDI (Supplemental Security Income/Social Security Disability Insurance) 2

 Unemployment Compensation 3

 Other assistance, such as Medicaid [also known as STATE MEDICAID NAME], Section 8 or Public Housing Assistance or WIC (Women, Infants, and Children food program) 4

 None 0

D. CONTACT INFORMATION

These last questions ask for your contact information so the study team can reach out to you in about [FILL SITE-SPECIFIC MONTHS] to see how you are doing.

ALL

YB 30 Mth

D1. What is your address?

Street Address 1

(STRING 200)

Street Address 2 or Apt

(STRING 200)

City

(STRING 200)

State/Territory

Select▼

(INSERT DROPDOWN)

Zip

(STRING 10)

ALL

LSUI

D2. What is your cell phone number?

□ Check here if you don’t have a cell phone

Cell phone number

NO RESPONSE M

D2 NE M

D3. As part of the follow-up for this evaluation, we may reach out to you periodically by text over the next year to see how things are going for you. May we send you text messages at this number [FILL D2 PHONE]? Message and data rates may apply.

YB 30 Mth J3 modified for AP

 Yes 1

 No 0

NO RESPONSE M

ALL

YB 30 Mth

D4. What is another phone number where you can be reached?

□ Check here if you don’t have another phone number

Other phone number

NO RESPONSE M

D4 NE M

YB 30 Mth

D4a. Is this number, [FILL D4_phone], for a cell phone?

 Yes 1

 No 0

NO RESPONSE M

D4a = 1

if D2=m, fill [As part of the follow-up for this evaluation, we may reach out to you periodically via text over the next year to see how things are going for you.]

D4b. [As part of the follow-up for this evaluation, we may reach out to you periodically via text over the next year to see how things are going for you.] May we send you text messages at this number: ([FILL D4_phone])? Message and data rates may apply.

YB 30 Mth

 Yes 1

 No 0

NO RESPONSE M

ALL

D5. What is your email address?

□ Check here if you don’t have an email address

YB 30 Mth

E-Mail

(STRING 50)

NO RESPONSE M

D5 NE M

D6. If you have another email address, what is it?

□ Check here if you don’t have another email address

YB 30 Mth

E-Mail

(STRING 50)

NO RESPONSE M

ALL

D7. Do you have a Facebook account?

 Yes 1

YB 30 Mth

 No 0 GO TO D8

NO RESPONSE M GO TO D8

D7 = 1

D7a. If we have trouble reaching you, we would like to contact you privately using Facebook. What name do you use on Facebook?

YB 30 Mth

(STRING 100)

NO RESPONSE M

ALL

D8. Do you have a LinkedIn account?

 Yes 1

 No 0 GO TO D9

NO RESPONSE M GO TO D9

D8 = 1

D8a. What name do you use on LinkedIn?

(STRING 100)

NO RESPONSE M

ALL

FILL SECOND PARAGRAPH FOR SECOND AND THIRD LOOP

D9. FIRST PERSON:

YB 30

In case the study team has trouble reaching you, they 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 relative or friend. The study team will not contact these people for any other reason.

What is the name of the first person who will know where you are?

SECOND AND THIRD PERSON:

What is the name of another relative or close friend who will know how to contact you 15 months from now?

First name

(STRING 20)

Middle name

(STRING 20)

Last name

(STRING 20)

NO RESPONSE M GO TO END

□ Check here if there is no one [else] will know how to contact you 1 GO TO END

D9 = ANSWERED

D10. What is [FILL NAME]’s relationship to you?

 Spouse/Partner 1

 Mother 2

 Father 3

 Sister/Brother 4

 Grandmother/Grandfather 5

 Son/Daughter 6

 Friend 7

 Other 8

NO RESPONSE M

D9 = ANSWERED

D11. What is [FILL NAME]’s telephone number?

YB 30

NO RESPONSE M

□ Check here if you can’t find the number. 1

D9 = ANSWERED

D12. What is [FILL NAME]’s address?

Please complete as much of the address as you can.

Street Address 1

(STRING 200)

YB 30

Street Address 2

(STRING 200)

City

(STRING 200)

State/Territory

Select▼

(INSERT DROPDOWN)

Zip

(STRING 10)

NO RESPONSE M

PROGRAMMER LOOP BOX D12.1.

RETURN TO D9 AND ASK FOR ANOTHER CONTACT.

END LOOP IF THIS IS THE THIRD LOOP.

END. You’re finished! Thank you for completing the survey!

YB 30

 Click here and press “Next” to submit your survey 1

E. STAFF USE ONLY

Staff: Please answer the following questions based on any information collected on the applicant that you believe is relevant, as well as your own intuition.

ALL

E1. Likely to be enrolled in the following programs:

Pre-apprenticeshippp

   Program A   (FILL SITE-SPECIFIC INFO)

                n/a—Very likely – Somewhat Likely  – Somewhat Unlikely  – Very Unlikely 

   Program B    (FILL SITE-SPECIFIC INFO)

                 n/a—Very likely – Somewhat Likely  – Somewhat Unlikely  – Very Unlikely 

    Program C    (FILL SITE-SPECIFIC INFO)

                n/a—Very likely – Somewhat Likely  – Somewhat Unlikely  – Very Unlikely 

    Program D   (FILL SITE-SPECIFIC INFO)

                n/a—Very likely – Somewhat Likely  – Somewhat Unlikely  – Very Unlikely 

ALL

Coaching

E2. How likely do you think it is that the participant will regularly participate in the required program activities?

 VERY LIKELY 1

 SOMEWHAT LIKELY 2

 SOMEWHAT UNLIKELY 3

 VERY UNLIKELY 4

ALL

Coaching

E3. How likely do you think it is that participant will obtain an industry-recognized credential through this program?

 VERY LIKELY 1

 SOMEWHAT LIKELY 2

 SOMEWHAT UNLIKELY 3

 VERY UNLIKELY

Baseline Data Collection

Question BY Question JUSTIFICATION

This document provides the source and justification for each question on the Baseline Data Collection.

Question #	Question text	Source	Justification
SECTION 0. CONSENT
Consent	I consent to take part in this research study. This study and the information in this consent form have been explained to me. I have read this consent form or it has been read to me. I have had an opportunity to ask questions and they have been answered to my satisfaction. I have been told that I have not given up any legal rights.	Developed by Mathematica	Obtaining consent
SECTION A. BACKGROUND
A1-b	Please enter your full name below and any other names you use.	Parents and Children Together (PACT) Evaluation (OMB No. 0970-0403) America’s Promise (AP) Job-Driven Grant Program Evaluation (OMB No. 1290-0020)	These items will be used to collect contact information necessary to verify the identity of the respondent, to aid in follow-up, and/or to collect administrative data. Date of birth will also be used for defining subgroups, providing control variables for regression models that will increase statistical precision, and to construct weights to adjust for survey nonresponse.
A2	What is your date of birth?
A3	What is your Social Security number?
A4	What is the main reason you are seeking to participate in [PROGRAM NAME]? Would you say it is because you… 1. Want a career change, 2. Want to gain skills in your current field, or 3. Is it for some other reason?	New Developed by Mathematica	This item tracks the reason for participating in apprenticeship programs. We will use it to (1) describe the characteristics of study participants, (2) define subgroups, (3) provide control variables for regression models that will increase statistical precision, and (4) construct weights to adjust for survey nonresponse.
SECTION B. DEMOGRAPHIC AND SOCIOECONOMIC CHARACTERISTICS
B1	What is the highest level of education you have completed? 1. Did not complete high school or GED 2. High School: Received Diploma 3. High School: Received GED, HiSET, or TASC 4. Some college or postsecondary vocational courses 5. 2-Year or 3-Year College Degree (Associate’s Degree) or Vocational School Diploma 6. 4-Year college degree (Bachelor’s Degree) 7. Some graduate work/no graduate degree 8. Graduate or professional degree (MA, MBA, PH.D., JD, MD) 9. Never attended school	Longitudinal Survey of Unemployment Insurance Recipients (LSUI) (OMB No. 1290-0009)	These items measure demographic and socioeconomic characteristics. We will use them to (1) describe the characteristics of study participants and check that random assignment has created treatment and control groups with similar characteristics, (2) define subgroups, (3) provide control variables for regression models that will increase statistical precision, (4) construct weights to adjust for survey nonresponse, and (5) support analysis of the mediating factors driving program impacts. Marital status will enable respondent identity verification in the follow-up survey, along with SSN and DOB. Primary language will aid in follow-up survey administration.
B2	Do you have a high school diploma, a General Education Development (GED), a HiSET, or a Test Assessing Secondary Completion (TASC)?	New Developed by Mathematica
B3	Are you currently participating in any education and training programs and courses?	Trade Adjustment Assistance Evaluation (TAA) (OMB No. 1205-0460)
B4	Are you a veteran or a transitioning service member of any branch of the United States Armed Forces?	LSUI (OMB No. 1290-0009) AP (OMB No. 1290-0020)
B5	How do you describe yourself? 1. Male 2. Female 3. Some other way	Federal Interagency Working Group on Measuring Sexual Orientation and Gender Identity (SOGI) Report
B6	What is your current marital status? 1. Married 2. Separated 3. Divorced 4. Widowed 5. Never married	Adapted from OMB2
B7	How many adults age 18 or older currently live in your household at least half the time?	JSA (OMB No. 0970-0400) AP (OMB No. 1290-0020)
B8	How many children under age 18 live with you at least half the time?	JSA (OMB No. 0970-0400) AP (OMB No. 1290-0020)
B9	Are you Hispanic, Latino, or of Spanish origin?	OMB3
B10	What is your race? Select all that apply. 1. American Indian or Alaska Native 2. Asian 3. Black or African American 4. Native Hawaiian or Other Pacific Islander 5. White	OMB2
B11	What is your primary spoken language? 1. English 2. Spanish 3. Other	Evaluation of SNAP Employment and Training (SNAP E&T) (OMB No. 0584-0604)
B11a	How well would you say you speak English? Would you say… 1. Very well 2. Well 3. Not well 4. Not at all	SNAP E&T (OMB No. 0584-0604)
B12	Have you ever been arrested?	WIA Gold-Standard Evaluation (WIA) (OMB No. 1205-0504)	These items measure baseline barriers to employment. We will use them to (1) describe the characteristics of study participants and check that random assignment has created treatment and control groups with similar characteristics, (2) define subgroups, (3) provide control variables for regression models that will increase statistical precision, and to (4) construct weights to adjust for survey nonresponse.
B13	Have you ever been incarcerated in a juvenile or adult facility, such as a detention center, jail, or prison?	Reentry Employment Opportunities (REO) (OMB No. 1290-0026)
SECTION C. EMPLOYMENT STATUS
C1	Have you ever worked for pay?	LSUI (OMB No. 1290-0009) AP (OMB No. 1290-0020)	These items measure baseline employment status. We will use them to (1) describe the characteristics of study participants and check that random assignment has created treatment and control groups with similar characteristics, (2) define subgroups, (3) provide control variables for regression models that will increase statistical precision, (4) construct weights to adjust for survey nonresponse, and (5) support analysis of the mediating factors driving program impacts.
C2	Are you currently working for pay?	LSUI (OMB No. 1290-0009) AP (OMB No. 1290-0020)
C3	On what date did your most recent job end?	LSUI (OMB No. 1290-0009) AP (OMB No. 1290-0020)
C4	How many hours per week, including regular overtime hours (do/did) you usually work at your main job?	LSUI (OMB No. 1290-0009) AP (OMB No. 1290-0020)
C5	What kind of work (do/did) you do or duties (do/did) you have at your main job?	LSUI (OMB No. 1290-0009)
C6	What kind of company (do/did) you work for—what (do/did) they make, sell, or do?	LSUI (OMB No. 1290-0009)
C7	What (is/was) your usual pay, including tips, bonuses and commissions at your main job before taxes or other deductions are taken?	LSUI (OMB No. 1290-0009) AP (OMB No. 1290-0020)
C8	Please try to estimate your annual pay at your main job. Would you say your annual earnings (are/were)…	LSUI (OMB No. 1290-0009) AP (OMB No. 1290-0020)
C9	Did your current employer refer you to the [PROGRAM NAME] program for training?	New Developed by Mathematica	This item tracks employer referrals to apprenticeship programs. We will use them to (1) describe the characteristics of study participants and check that random assignment has created treatment and control groups with similar characteristics, (2) define subgroups, (3) provide control variables for regression models that will increase statistical precision, (4) construct weights to adjust for survey nonresponse, and (5) support analysis of the mediating factors driving program impacts.
C10	Do you, or anyone in your household, currently receive assistance from any of the following programs? 1. SNAP (Food Stamps) [also known as STATE SNAP NAME] 2. Cash assistance, such as TANF (Temporary Assistance to Needy Families) [also known as STATE TANF NAME], general assistance, or SSI or SSDI (Supplemental Security Income/Social Security Disability Insurance) 3. Unemployment Compensation 4. Other assistance, such as Medicaid [also known as STATE MEDICAID NAME], Section 8 or Public Housing Assistance or WIC (Women, Infants, and Children food program)	SNAP E&T (OMB No. 0584-0604)	This item measures participation in benefit programs. It will be used to defined (1) define subgroups, (2) provide control variables for regression models that will increase statistical precision, and (3) construct weights to adjust for survey nonresponse.
Section D. CONTACT INFORMATION
D1-D8a	Contact information for the respondent.	LSUI (OMB No. 1290-0009) Impact Evaluation of the YouthBuild Program (YB) (OMB No. 1205-0488)	Contact information for the respondent and for additional contacts who might be able to reach the respondent is necessary to locate the respondent for the first follow-up survey.
D9-D12	Contact information for three contacts who know the respondent.	LSUI (OMB No. 1290-0009) YB (OMB No. 1205-0488)
Section E. STAFF USE ONLY
E1	Likely to be enrolled in the following programs:	SNAP E&T (OMB No. 0584-0604)	These items measure staff predictions about service receipt. These items will be used to (1) define subgroups, (2) construct weights to adjust for survey nonresponse, and (3) support analysis of the mediating factors driving program impacts.
E2	How likely do you think it is that the participant will regularly participate in the required program activities? 1. Very likely 2. Somewhat likely 3. Somewhat unlikely 4. Very unlikely	Evaluation of Employment Coaching for TANF (Coaching) (OMB No. 0970-0506)
E3	How likely do you think it is that participant will obtain an industry-recognized credential through this program? 1. Very likely 2. Somewhat likely 3. Somewhat unlikely 4. Very unlikely	Coaching (OMB No. 0970-0506)

1 All fill-in brackets will be customized for each program

2 http://www.ofm.wa.gov/pop/asr/ofm_standards_race_ethnicity_data.pdf

3 http://www.ofm.wa.gov/pop/asr/ofm_standards_race_ethnicity_data.pdf