Rent Reporting Baseline Information Form

OMB #: 2528-0345

OMB Expiration Date: 01/31/2027

Rent Reporting Baseline Information Form

BASELINE INFORMATION FORM-SAMPLE INFORMATION

Thank you for your interest in the Rent Reporting Study. The information I am going to ask you about will only be used for the Rent Reporting Study.

First, I am going to record your name, date of birth, and Social Security number to confirm that you have not already enrolled in the Rent Reporting Study. After that we will review a form that describes the Rent Reporting Study and what the study requirements are for those who agree to participate. You should know that your participation in this study is voluntary. If you agree to participate in the study I will ask you to sign the consent form. I will then ask you some additional questions about your financial conditions. Your responses will not affect your current or future receipt of housing assistance or other benefits. Please remember that your participation is voluntary and you can choose not to answer any question. We appreciate your input.

PHA staff will enter the following items into the enrollment record:

1. First Name

2. Middle Name

3. Last Name

4. Suffix

5. Date of Birth (MM/DD/YYYY)

6. Social Security Number

7. [If no SSN] Alien Registration Number

8. [PHA] Household ID Number

9. EMAIL Address*

1. If no email address, check here:

10. How is enrollment being completed?

• ₁ In Person

• ₂ Phone

• ₃ Paper (skip to Statement)

*PHA STAFF WILL PAUSE HERE AND PROCEED TO OBTAIN INFORMED CONSENT, ONCE OBTIAINED CONTINUE WITH BASELINE INFORMATION FORM*

Thank you for agreeing to be part of this important study. Next, we will ask you some questions about your financial conditions, which will provide important context for interpreting the findings from the study. You may reply that you “don’t know” or decline to answer any question.

BASELINE INFORMATION QUESTIONS

Q1: Overall, how satisfied are you with your current personal financial situation? Please use a 10-point scale, where 1 means “Not at All Satisfied” and 10 means “Extremely Satisfied.”

1 Not at all satisfied

2

3

4

5 Neither Satisfied nor Dissatisfied

6

7

8

9

10 Extremely satisfied

98 Don’t know

99 Prefer not to say

Q2: How would you rate your current credit record?

1 Very bad

2 Bad

3 About average

4 Good

5 Very good

98 Don’t know

99 Prefer not to say

Q3: How important is it to you to improve your credit score over the next 12 months?

1 Very Important

2 Somewhat Important

3 Neutral

4 Not very important

5 Not at all important

98 Don’t know

99 Prefer not to say

Q4: What is the most important reason that a higher credit score would help you? (Choose one)

1 I could move to a better place to live

2 I could buy a car

3 I could get a credit card

4 I could start a business

5 I could get a new job

6 Other ________ (open text)

98 Don’t know

99 Prefer not to say

Q5: In a typical month, how difficult is it for you to cover your expenses and pay all your bills?

1 Very difficult

2 Somewhat difficult

3 Not at all difficult

98 Don’t know

99 Prefer not to say

Q6: In the last 12 months, which one of the following best describes your household’s income?

1 Roughly the same amount each month

2 Occasionally varies from month to month

3 Varies quite often from month to month

98 Don’t know

99 Prefer not to say

Q7: How confident are you that you could come up with $400 if an unexpected need arose within the next month?"

1 Not at all confident

2 Not very confident

3 Somewhat confident

4 Very confident

98 Don’t know

99 Prefer not to say

Q8: During the last 3 months, was there a time when you were worried you would not

have enough food to eat because of a lack of money or other resources?

1 Yes

2 No

98 Don’t know

99 Prefer not to say

Q9: Do you have a personal checking or savings account at a bank or credit union?

1 Yes

2 No

98 Don’t know

99 Prefer not to say

Q10: If you were to set a financial goal for yourself today, how confident are you in your ability to achieve it?"

1 Not at all confident

2 Not very confident

3 Somewhat confident

4 Very confident

98 Don’t know

99 Prefer not to say

Q11: HUD may choose to do additional data collection in the future as part of this study. If that were to happen, researchers might ask you to participate in future surveys or interviews. Your participation in any future research activities is voluntary. Either the Evaluator or other HUD-approved researchers could conduct these surveys or interviews in the future. What is the best method to contact you (phone call, text, email)?

• Phone

  • What is your phone number? _________________

• Text

  • What is your cell phone number? _________________

• Email

  • What is your email address? __________________

• No preference

What is your email address? ________________

What is your phone number? ________________

Incentive Module

1. Thank you so much for your time. Now I’d like to confirm your contact information so that we can process your $10 gift card as a token of appreciation for your time. This will also help us know where to send your gift card.

PROGRAMMER NOTE: Prepopulate contact information with information previously recorded at the start of enrollment.

A1a. I have your first name as: _______________________________________

A1b. I have your middle name/initial as? ________________________________

A1c. I have your last name as? ___________________________________

A1d. Does your name have a suffix? ______________________________

2. Can you please provide your current address?

A2a. What is the street address or PO Box number? ___________________

A2b. Is there a complex or building name? ___________________

A2c. Is there an apartment number? ___________________

A2d. In what city? ___________________

A4e. In what state? ___________________

A2f. What is the zip code? ___________________

PROGRAMMING NOTE: IF EMAIL WAS COLLECTED AS PART OF Sample Information or Q11, DISPLAY IT HERE FOR CONFIRMATION; OTHERWISE SKIP TO A3a.

BASE: EMAIL ON FILE

A3. I have your email address as: [EMAIL]. Is this correct?

1 THIS IS CORRECT

2 THIS IS NOT CORRECT [GO TO A3a]

3 DOES NOT HAVE ANY WORKING EMAIL ADDRESSES [GO TO A4]

98 Don’t know

99 Prefer not to say

BASE: NO EMAIL ON FILE OR A3=2

A3a. Do you have an email address?

1 Yes

2 No

98 Don’t know

99 Prefer not to say

<A4> BASE: A3A = 1

A4. What email address should we use to send your gift certificate? __________________________

• 99 Prefer not to provide email address

END 1. Thank you so much for your time. The company Virtual Incentives will be sending you an email with instructions on how to collect and redeem your $10 gift certificate. Reward emails come from “reward@virtualrewardcenter.com” and you should receive your email within 14 days.

If they do not provide an email address (A10=99), follow mail incentive path:

We will mail you a gift certificate valued at $10. First I’ll need to confirm I have the right address to send this to you. Is <A2 ADDRESS> correct?

CAPI: IF WE COLLECT UPDATE, THIS NEW ADDRESS SHOULD UPDATE THE SAMPLE

1. YES, CORRECT [SKIP TO END]

2. NO, NOT CORRECT

A5. What address should we use to mail you the gift certificate?

A5a. What is your street address or PO box number?

A5b. Is there a complex or building name?

A5c. Is there an apartment number?

A5d. In what city?

A5e. In what state?

A5f. What is the zip code?

[END_2.] Thank you so much for your time.

Thank you for your time today. We appreciate your participation in this important study. We will process your gift certificate and you should receive it in the mail within 30 days.

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to evaluate the US Department of Housing and Urban Development’s Moving to Work Asset Building Cohort’s Rent Reporting Program and Study. 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 #: 2528-0345, Exp: 01/31/2027. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to XX at XXXX@XXX or call at XXX-XXX-XXXX.

Privacy Act Statement  

Authority: Section 502 of the Housing and Urban Development Act of 1970 (Public Law 91-609) (12 U.S.C. §§ 1701z-1; 1701z-2(d) and (g)).  

Purpose:  This information is being collected to evaluate the Moving to Work asset building programs.

Routine Use:  HUD intends to release this information for research purposes or to respond to breaches.  For further information, please refer to the System of Records Notice.  

Disclosure:  Your participation in this information collection is voluntary and you can choose not to answer any question that is asked. Your responses will not affect your current or future receipt of housing assistance or other benefits.  

SORN ID:  [Include SORN Name and ID here]: Moving to Work Asset Building Cohort Evaluation Data Files, HUD/PDR-11