Hello, my name is [ ]. May I please speak with _____?
[IF NECESSARY: [INSERT RESPONDENT FIRST & LAST NAME] has agreed to help with a study about employment programs at [NAME OF ORGANIZATION.]
IF RESPONDENT COMES TO THE PHONE: Hello, my name is [ ]. I’m calling from Abt Associates concerning a study about employment programs at [NAME OF ORGANIZATION] you joined about 15 months ago?
IF PHONE OR IN-PERSON: Thank you for taking the time to talk with me today. I work for Abt Associates, or Abt, which is an independent research company. Abt is helping the Administration for Children and Families in the U.S. Department of Health and Human Services and the Social Security Administration with its evaluation of the Building Evidence on Employment Strategies - or BEES study.
Today, we are contacting you for a survey. You agreed to be in a study about a program offered at [NAME OF ORGANIZATION] called [BEES program]. In this study, we are interested in learning about programs and services that help individuals receiving treatment or recovery services.
This survey will take about 30 minutes. We will be asking you questions about your use of different services that could help you find a job, education and training programs, and substance use treatment. When we are done, you will be sent a $35 gift card, as a thank you.
You agreed to be part of the study around [RAMY] when you signed a consent form to let researchers collect information from you. We need to talk with people who got into the program and those who did not. Your participation in this study will help policymakers and program staff better understand how to help people get better jobs, earn more, and improve general well-being.
[SKIP TO SCREENER/VERFICIATION]
WEB Introduction
Today, we are contacting you for a survey that is part of the Building Evidence on Employment Strategies - or BEES study. You agreed to be in a study about a program offered at [NAME OF ORGANIZATION] called [BEES program] around [RAMY]
.
We are interested in learning about programs and services that help individuals receiving treatment or recovery services. We need to talk with people who got into the program and those who did not. Your participation in this study will help policymakers and program staff better understand how to help people get better jobs, earn more, and improve general well-being.
This survey will take about 30 minutes. We will be asking you questions about your use of different services that could help you find a job, education and training programs, and substance use treatment. When we are done, you will be sent a $35 gift card, as a thank you.
Thank you in advance for taking the time to complete this survey. Abt Associates, (an independent research company), is helping the Administration for Children and Families in the U.S. Department of Health and Human Services and the Social Security Administration (SSA).
Screener/Verification:
CATI: Before we begin, I’d like to confirm that I am speaking with the correct person.
WEB: We need to first confirm that you are the correct person for this survey.
In order to do so, could you please provide your date of birth? ___________ (MM/DD/YYYY)
PROGRAMMER: VALIDATE AGAINST DOB FROM SAMPLE. IF DOB CONFIRMED, SET DOBCONF = 1 AND SKIP TO INFORMED CONSENT, ELSE SET DOBCONF=2.
IF NOSSN4=0 AND DOBCONF=2, SKIP TO FAIL_SCREENER. IF NOSSN4=1 AND DOBCONF=2, CONTINUE TO Q2
Again, to confirm that you are the correct person, could you please provide the last 4 digits of your Social Security number?
PROGRAMMER: VALIDATE LAST 4 SSN FROM SAMPLE. IF SSN4 CONFIRMED, SET SSNCONF = 1 AND SKIP TO INFORMED CONSENT, ELSE SET SSNCONF = 2.
FAIL_SCREENER:
IF DOBCONF=2 AND (NOSSN4=1 AND SSNCONF=2) READ CLOSING BASED ON MODE:
(IF Q1 does not match sample and Q2 does not match sample, read:
CATI DISCONTINUED TEXT Thank you for taking the time to answer these questions. The information you provided does not match our records. I will need to check with my supervisor to determine how to resolve this issue. If we are able to do so, I will give you a call back. Have a nice a day – and thank you.
WEB DISCONTINUED TEXT: Thank you for taking the time to answer these questions. The information you provided does not match our records. We will investigate further to determine how to resolve this issue. If we are able to do so, we will contact you again. Have a nice a day – and thank you.
INFORMED CONSENT
Thank you for confirming this information.
Next, we would like to start with a few assurances:
All of your responses will be kept private.
Your name will not appear in any written reports.
Your responses to these questions are voluntary.
You may choose not to answer any question or to stop the survey.
Your responses will in no way affect your participation in any programs or your receipt of any public benefits or services.
Furthermore, the information you provide will only be used for research about the different employment services related to this study. By participating, you will help the government learn if and how programs like [BEES program] at [ORGANIZATION NAME] make a difference in people’s lives and how to improve them.
According to the Paperwork Reduction Act (PRA), 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: 2/28/2026.
WEB ONLY: Do we have your consent to continue?
1 YES [SKIP TO SECTION A]
2 NO [SKIP TO TERMINATION SCRIPT]
CATI ONLY: And finally, this interview will be recorded for quality control purposes. Do I have your consent to continue?
1 YES [SKIP TO SECTION A]
2 NO
CATI ONLY: May I ask if you are declining to consent to the interview because you are concerned about the possibility of being recorded?
1 DON’T WANT TO BE RECORDED [CONTINUE TO RECORDING ISSUE]
2 DON’T WANT TO DO INTERVIEW [SKIP TO TERMINATION SCRIPT]
CATI ONLY RECORDING ISSUE: I understand. I can turn the recorder off and we can continue with the interview. Would that be OK?
1 Yes [DISABLE RECORDER & CONTINUTE TO SECTION A]
2 No [SKIP TO TERMINATION SCRIPT]
TERMINATION SCRIPT
Thank you for your time. We are sorry that you are not able to participate in our study. If you change your mind, please call 888-474-6121 or email us at beesresearch@abtassoc.com.
SECTION A: HOUSING
A_INTRO:
To start things off, we would like to ask a few questions about you and where you are currently living and where you have lived since [RAMY] – that is the time you agreed to be a part of this study.
A1.
Which of the following best describes your current housing arrangement? Do you:
1 own your own home or apartment,
2 rent your home or apartment,
3 live in transitional housing or sober housing
live in a group home
live with friends or relatives and pay rent to them
live with friends or relatives and not pay rent to them,
7 homeless, living on the street or in your car,
8 live in emergency or temporary housing, that is in a shelter or are
homeless, or
9 have some other housing arrangement? (Please specify: ________________)
97 DON’T KNOW
98 REFUSED
A2.
When did you start living here?
Please just give us your best estimate. This helps us understand your housing situation. Please remember all information you provide is private and will not be shared.
_________________________________________________________ (MM/YYYY)
[RANGE MM=1-12, YYYY:2019- PRESENT YEAR]
97/9997 DON’T KNOW
98/9998 REFUSED
A3.
[IF A1=2, ASK, ELSE SKIP TO A6]
How would you describe where you live? Would you say it is:
Public housing—that is, housing owned by a federal, state or local government agency, such as [state specific program]
Private housing for which part of your rent bill is paid by the government, such as Section 8 or vouchers,
Or private housing paid for by you with no help from the government, that is the entire rent bill is paid without any help from the government to pay the rent.
7 DON’T KNOW
8 REFUSED
A4
[ASK IF A1=2, ELSE SKIP TO A5])
Do you live in a building where you had to apply based on your income?
1 YES
2 NO
7 DON’T KNOW
8 REFUSED
A5.
Do you ever fear for your, or your family’s, safety while staying here?
1 YES
2 NO
7 DON’T KNOW
8 REFUSED
A6.
Since [RAMY], how many times have you moved or changed where you were living?
If you are not certain, your best estimate is fine. This helps us understand your housing situation. Please remember all information you provide is private and will not be shared.
__________NUMBER OF TIMES MOVED [ RANGE 0-18]
95 More than 18 times
97 DON’T KNOW
98 REFUSED
[IF A6=0 SKIP TO SECTION B_INTRO]
A7.
Thinking about all of the places you have lived since [RAMY] ….
Did you ever live in transitional housing? This is also known as recovery or sober housing.
1 YES
2 NO
7 DON’T KNOW
8 REFUSED
A8
Since [RAMY] was there ever a time that you were homeless and living on the street or in your car?
1 YES
2 NO
7 DON’T KNOW
8 REFUSED
A9.
Since [RAMY], was there ever a time where you spent more than one night in emergency or temporary housing, that is a shelter or were homeless?
1 YES
2 NO
7 DON’T KNOW
8 REFUSED
A10.
Since [RAMY], was there ever a time where you had to live for more than one night with friends, relatives, or acquaintances without paying rent because you had no other place to stay?
1 YES
2 NO
7 DON’T KNOW
8 REFUSED
SECTION B: SERVICE RECEIPT AND PARTICIPATION
B_INTRO
Throughout this survey we are going to ask you to think about things that have happened in your life since [RAMY] – this is the date you applied to the [BEES PROGRAM] at [NAME OF ORGANIZATION]. We are interested in what’s happened in the lives of the people who applied – even if you did not participate or were not accepted into [BEES PROGRAM].
B1
First, we would like to learn about all of the assistance you may have received since [RAMY] from any organizations or programs in your community to help you find or keep a job, or to help you deal with problems that interfered in your ability to work. Please do not include help you may have received from family or friends.
Did you receive help with … |
|
a. preparing a resume, filling out job applications, or preparing for job interviews? |
1 YES 2 NO 7 DON’T KNOW 8 REFUSED |
b. …getting referrals to jobs or looking for jobs, including subsidized jobs, or deciding what kinds of jobs to look for? |
1 YES 2 NO 7 DON’T KNOW 8 REFUSED |
c …planning your future career or educational goals, including a work or job assessment? |
1 YES 2 NO 7 DON’T KNOW 8 REFUSED |
d. …paying for transportation for a job or paying for work tools or uniforms? This may include money for gas, car repairs, bus passes, a loan of a vehicle, and the like. |
1 YES 2 NO 7 DON’T KNOW |
e. … supports, accommodations, or coaching while working, provided by someone other than your employer? |
1 YES 2 NO 7 DON’T KNOW 8 REFUSED |
f. … On-the-Job Training (OJT) as part of a program that reimbursed your employer for some of your wages during a training period? |
1 YES 2 NO 7 DON’T KNOW 8 REFUSED |
g. … how to act when you are at work? This includes issues like being on time, managing your tasks, relating to your supervisor, and handling conflicts. |
1 YES 2 NO 7 DON’T KNOW 8 REFUSED |
h. …learning how to answer employers’ questions about your past work experience, education, criminal history, etc.? |
1 YES 2 NO 7 DON’T KNOW 8 REFUSED |
i. … understanding how work earnings or wage increases could affect eligibility for public benefits, such as SSI, SSDI, TANF, Food Stamps, or Medicaid? |
1 YES 2 NO 7 DON’T KNOW 8 REFUSED |
j. …some other employment service? |
1 YES (Please specify: _______) 2 NO 7 DON’T KNOW 8 REFUSED
|
[IF B1a1- B1 ALL EQ 2,7 OR 8 SKIP TO B6)]
B2
Are you currently receiving any of these services related to finding or keeping a job?
1 YES
2 NO
7 DON’T KNOW
8 REFUSED
B3
[IF NUMBER OF 1/YES RESPONSES IN B1a -B1j SUMS TO 1, SHOW] How much time since [RAMY] did you spend participating in this service related to finding or keeping a job? Please give your answer in either days, weeks, or months.
[IF NUMBER OF 1/YES RESPONSES IN B1a-B1j SUMS TO MORE THAN 1, SHOW] How much time since [RAMY] did you spend participating in these services related to finding or keeping a job? Please give your answer in either days, weeks, or months.
____________________
AMOUNT OF TIME [RANGE: 1-300]
996 MORE THAN 18 MONTHS
997 DON’T KNOW
998 REFUSED
B3a
[IF NEEDED, CONFIRM UNIT OF TIME] Was that in days, weeks or months?
1 Days
2 Weeks
3 Months
7 DON’T KNOW
8 REFUSED
B4
Where did you receive this help related to finding or keeping a job since [RAMY]? Was it at…
[INTERVIEWER: READ LIST, SELECT ALL THAT APPLY]
[NOTE: RESPONSE OPTIONS MAY BE CUSTOMIZED BY SITES]
FOR FRANKLIN-STARK- kept for reference
1 [BEES PROGRAM],
2 the Department of Job & Family Services, or the welfare office,
3 OhioMeansJobs [local WIOA/OneStop]
4 An unemployment office,
5 the Bureau of Vocational Rehabilitation or vocational rehabilitation agency,
6 the Food Assistance Program or SNAP,
7 An organization that addresses mental health or substance use, such as a clubhouse or community mental health center,
8 A community-based organization that provides employment services or other social services, or
96 from some other place? (Please specify:________________________)
97 DON’T KNOW – [UNIQUE RESPONSE – SKIP TO B6]
98 REFUSED – [UNIQUE RESPONSE – SKIP TO B6]
FOR 12&12
1 [BEES PROGRAM] at [ORGANIZATION NAME],
2 Oklahoma Human Services, or the welfare office,
3 Oklahoma Works or Tulsa American Jobs Center (AJC) , that is the local WIOA/One Stop]
4 An unemployment office,
5 Oklahoma Department of Rehabilitation Services or vocational rehabilitation agency,
6 Food Stamps or SNAP,
7 An organization that addresses mental health or substance use, such as a clubhouse or community mental health center,
8 A community-based organization that provides employment services or other social services, such as Family & Children’s Services or
96 from some other place? (Please specify:________________________)
97 DON’T KNOW – [UNIQUE RESPONSE – SKIP TO B6)]
98 REFUSED – [UNIQUE RESPONSE – SKIP TO B6]
FOR ZEPF
1 [BEES PROGRAM] at [ORGANIZATION NAME],
2 the Department of Job & Family Services, or the welfare office,
3 OhioMeansJobs, that is the local WIOA/OneStop
4 An unemployment office,
5 Opportunities with Ohioans with Disabilities (or OOD), or vocational rehabilitation agency,
6 the Food Assistance Program or SNAP,
7 An organization that addresses mental health or substance use, such as a clubhouse or community mental health center,
8 A community-based organization that provides employment services or other social services, or
96 from some other place? (Please specify:________________________)
97 DON’T KNOW – [UNIQUE RESPONSE – SKIP TO B6]
98 REFUSED – [UNIQUE RESPONSE – SKIP TO B6]
[IF NUMBER RESPONSES IN B4 SUMS 1, SKIP TO, B6)]
B5.
[IF NUMBER RESPONSES IN B4 SUMS TO MORE THAN 1, SHOW] Where did you receive most of these services? Was it at…
[RECALL & DISPLAY ANY RESPONSES FROM JBHLPPLCE, DO NOT RECALL 97 OR 98 - SELECT ONE.]
FOR FRANKLIN-STARK
1 [BEES PROGRAM],
2 the Department of Job and Family Services, or the welfare office,
3 OhioMeansJobs
4 An unemployment office,
5 the Bureau of Vocational Rehabilitation or vocational rehabilitation agency,
6 the Food Assistance Program or SNAP,
7 An organization that addresses mental health or substance use, such as a clubhouse or community mental health center,
8 A community-based organization that provides employment services or other social services, or
96 [RECALL B4=96 TEXT]
97 DON’T KNOW
98 REFUSED
FOR 12&12
1 [BEES PROGRAM] at [ORGANIZATION NAME],
2 Oklahoma Human Services, or the welfare office,
3 Oklahoma Works or Tulsa AJC, the local WIOA/OneStop
4 An unemployment office,
5 Oklahoma Department of Rehabilitation Services or vocational rehabilitation agency,
6 Food Stamps or SNAP,
7 An organization that addresses mental health or substance use, such as a clubhouse or community mental health center,
8 A community-based organization that provides employment services or other social services, such as Family & Children’s Services or96 [RECALL B4=96 TEXT]
97 DON’T KNOW
98 REFUSED
FOR ZEPF
1 [BEES PROGRAM] at [ORGANIZATION NAME],
2 the Department of Job & Family Services, or the welfare office,
3 OhioMeansJobs, the local WIOA/OneStop
4 An unemployment office,
5 Opportunities with Ohioans with Disabilities (or OOD), or vocational rehabilitation agency,
6 the Food Assistance Program or SNAP,
7 An organization that addresses mental health or substance use, such as a clubhouse or community mental health center,
8 A community-based organization that provides employment services or other social services, or
96 [RECALL B4=96 TEXT]
97 DON’T KNOW
98 REFUSED
B6
Have you participated in any kind of education or training classes since [RAMY]? For example,
GED preparation, classes at a training center or community college, or somewhere else?
When answering, please only include classes you have attended at least once. and i any classes that you started before [RAMY] that continued after [RAMY.]
1 YES
2 NO [SKIP TO CRTLICRVD (A10)]
7 DON’T KNOW [SKIP TO CRTLICRVD (A10)]
8 REFUSED [SKIP TO CRTLICRVD (A10)]
B6a EDTRAIN00 (A9).
Have you enrolled in any of the following types of education or training classes since [RAMY]?
B6b. Vocational or technical training? For example training for careers in areas like auto repair, commercial driving, HVAC technician, medical coding and billing, etc.
|
1 YES 2 NO 7 DON’T KNOW 8 REFUSED |
B6c English as a Second Language, ESL classes? |
1. YES 2. NO 7 DON’T KNOW 8 REFUSED |
B6d. Adult Basic Education or GED courses? (INTERVIEWER: IF R SAYS “I am taking ABE”, MARK AS YES) |
1 YES 2 NO 7 DON’T KNOW 8 REFUSED |
B6e. Associate degree program? |
1 YES (SKIP TO B7) 2 NO 7 DON’T KNOW 8 REFUSED |
B6f Bachelors degree program? |
1 YES (SKIP TO B7)) 2 NO 7 DON’T KNOW 8 REFUSED |
B6g Graduate school |
1 YES 2 NO 7 DON’T KNOW 8 REFUSED |
B6h Some other type of education or training? |
1 YES (Please specify: _______) 2 NO 7 DON’T KNOW 8 REFUSED
|
[IF ALL B6a-B6h ARE 2,7, AND/OR 8 SKIP TO B14]
[IF B6a=1 ASK B7a ELSE SKIP B8a]
B7a What was the name of the program or school that offered the vocational or training classes? If you attended more than one program or school, please list them all.
Please list each program separately:
B7a1 ________________________________________________________________
B7a2 ______________________________________________________________
B7a3 ________________________________________________________________
B7a4 ________________________________________________________________
B7a5 ________________________________________________________________
7 DON’T KNOW [UNIQUE RESPONSE]
8 REFUSED [UNIQUE RESPONSE]
B7b
When did you start these vocational and training classes? That is when was your first class?
Your best guess is fine.
________________________________________________________________________
MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = YYYY - CURRENT YEAR, 9997, 9998)
97/9997 DON’T KNOW
98/9998 REFUSED
B7c
In total, for about how long did you attend these vocational and training classes?
__________________AMOUNT OF TIME [RANGE:1-300]
995 Still attending [SKIP TO B8a]
996 More than 18 months [SKIP TO B8a]
997 DON’T KNOW [SKIP TO B8a]
998 DECLINE TO ANSWER
B7c
[IF NEEDED, CONFIRM UNIT OF TIME} Was that in….
1 Days
2 Weeks
3 Or months
7 DON’T KNOW
8 DECLINE TO ANSWER
[IF B6b=1 ASK B8a ELSE SKIP TO B9a]
B8a
What was the name of the program or school that offered the English as a Second Language, or ESL classes?
Please specify: _______________
7 DON’T KNOW
8 REFUSED
B8b
When did you start these ESL classes? That is, when was your first class? Your best guess is fine.
________________________________________________________________________
MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = YYYY - CURRENT YEAR, 9997, 9998)
97/9997 DON’T KNOW
98/9998 REFUSED
B8c
In total, for about how long did you attend these ESL classes?
__________________AMOUNT OF TIME [RANGE:1-300]
995 Still attending [SKIP TO B9a]
996 More than 18 months [SKIP TO B9a]
997 DON’T KNOW [SKIP TO EB9a]
998 DECLINE TO ANSWER [SKIP TO B9a]
B8d
[IF NEEDED, CONFIRM UNIT OF TIME] Was that in….
1 Days
2 Weeks
3 Or months
7 DON’T KNOW
8 DECLINE TO ANSWER
[IF B6c=1 ASK B9a ELSE SKIP TO B10a]
B9a
What was the name of the program or school that offered the Adult Basic Education or GED classes?
Please specify: _______________
7 DON’T KNOW
8 REFUSED
B9b
When did you start these Adult Basic Education or GED classes? That is, when was your first class? Your best guess is fine.
________________________________________________________________________
MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = YYYY - CURRENT YEAR, 9997, 9998)
97/9997 DON’T KNOW
98/9998 REFUSED
B9c
In total, for about how long did you attend these Adult Basic Education or GED classes?
__________________AMOUNT OF TIME [RANGE:1-300]
995 Still attending [SKIP TO B10a]
996 More than 18 months [SKIP TO B10a]
997 DON’T KNOW [SKIP TO B10a]
998 DECLINE TO ANSWER [SKIP TO B10a]
B9d
[IF NEEDED, CONFIRM UNIT OF TIME] Was that in….
1 Days
2 Weeks
3 Or months
7 DON’T KNOW
8 DECLINE TO ANSWER
[IFB6d=1 B10a ELSE SKIP TO B11a
B10a
What was the name of the program or school that offered the Associate degree program?
Please specify: _______________
7 DON’T KNOW
8 REFUSED
B10b
When did you start these Associate degree classes? That is, when did you take your first class? Your best guess is fine.
________________________________________________________________________
MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = YYYY - CURRENT YEAR, 9997, 9998)
97/9997 DON’T KNOW
98/9998 REFUSED
B10c
In total, for about how long did you attend these Associate degree classes?
__________________AMOUNT OF TIME [RANGE:1-300]
995 Still attending [SKIP TO B11a]
996 More than 18 months [SKIP TO B11a]
997 DON’T KNOW [SKIP TO B11a]
998 DECLINE TO ANSWER [SKIP TO B11a]
B10d
[IF NEEDED, CONFIRM UNIT OF TIME] Was that in….
1 Days
2 Weeks
3 Or months
7 DON’T KNOW
8 DECLINE TO ANSWER
[IF B6e =1 ASK B11a ELSE SKIP TO B12a]
B11a
What was the name of the program or school that offered the Bachelor’s degree program?
Please specify: _______________
7 DON’T KNOW
8 REFUSED
B11b
When did you start these Bachelor’s degree classes? That is, when did you take your first class? Your best guess is fine.
________________________________________________________________________
MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = YYYY - CURRENT YEAR, 9997, 9998)
97/9997 DON’T KNOW
98/9998 REFUSED
B11c
In total, for about how long did you attend these Bachelor’s degree classes?
__________________AMOUNT OF TIME [RANGE:1-300]
995 Still attending [SKIP TO B12a]
996 More than 18 months [SKIP TO B12a]
997 DON’T KNOW [SKIP TO B12a]]
998 DECLINE TO ANSWER [SKIP TO B12a]
B11d
[IF NEEDED, CONFIRM UNIT OF TIME] Was that in….
1 Days
2 Weeks
3 Or months
7 DON’T KNOW
8 DECLINE TO ANSWER
[B6f=1 ASK B12a ELSE SKIP TO B13a]
B12a
What was the name of the program or school that offered the Graduate school classes?
Please specify: _______________
7 DON’T KNOW
8 REFUSED
B12b
When did you start these Graduate school classes? That is, when did you take your first class? Your best guess is fine.
________________________________________________________________________
MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = YYYY - CURRENT YEAR, 9997, 9998)
97/9997 DON’T KNOW
98/9998 REFUSED
B12c
In total, for about how long did you attend these Graduate degree classes?
__________________AMOUNT OF TIME [RANGE:1-300]
995 Still attending [SKIP TO B13a]
996 More than 18 months [SKIP TO B13a]
997 DON’T KNOW [SKIP TO B13a]
998 DECLINE TO ANSWER [SKIP TO B13a]
B12d
[IF NEEDED, CONFIRM UNIT OF TIME] Was that in….
1 Days
2 Weeks
3 Or months
7 DON’T KNOW
8 DECLINE TO ANSWER
[IF B6g=1 ASK B13a ELSE SKIP TO B14]
B13a
When did you start [RECALL B6g =1 SPECIFY TEXT, IF BLANK SHOW “this other education or training program you mentioned”]classes? That is, when did you take your first class? Your best guess is fine.
________________________________________________________________________
MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = YYYY - CURRENT YEAR, 9997, 9998)
97/9997 DON’T KNOW
98/9998 REFUSED
B13b
In total, for about how long did you attend these classes?
__________________AMOUNT OF TIME [RANGE:1-300]
995 Still attending [SKIP TO B14]
996 More than 18 months [SKIP TO B14]]
997 DON’T KNOW [SKIP TO B14]
998 DECLINE TO ANSWER [SKIP TO B14]]
B13c2
[IF NEEDED, CONFIRM UNIT OF TIME] Was that in….
1 Days
2 Weeks
3 Or months
7 DON’T KNOW
8 DECLINE TO ANSWER
[IF ALL B6a-g) ARE 2,7, AND/OR 8 SKIP TO B16]
B14
Since [RAMY], have you earned or received any technical, vocational, or professional certifications or licenses, perhaps from a community college, or training program?
For our purposes:
A technical/ vocational certification or license may show that you are qualified to perform specific jobs like auto repair, commercial driving, HVAC technician, or medical coding and billing, for example.
A professional certification or license shows you are qualified to perform specific jobs like, Certified Medical Assistant, Certified Construction Manager, or an IT certification.
1 YES
2 NO [SKIP TO B16]
7 DON’T KNOW [SKIP TO B16]
8 REFUSED [SKIP TO B16]]
B15
What type of licenses or certifications did you receive? What type of trade or work do they quality you to do?
Please list each license or certificate separately:
B15a ________________________________________________________________
B15b ________________________________________________________________
B15c ________________________________________________________________
B15d ________________________________________________________________
B15e ________________________________________________________________
B15f ________________________________________________________________
97 DON’T KNOW [UNIQUE RESPONSE]
98 REFUSED [UNIQUE RESPONSE]
B16
The next few questions ask about your experiences with receiving help for problems related to substance use from any type of program or organization. As a reminder, none of your responses from this survey will be shared with program staff or government agencies.
Since [RAMY], have you received help for problems related to alcohol or other substance use?
1 YES
2 NO [SKIP TO SECTION C]
7 DON’T KNOW [SKIP TO SECTION C]
8 REFUSED [SKIP TO SECTION C]
B16
What type of services did you receive for problems related to alcohol or other substance use? Did you receive …
Please select all that apply.
1 Emergency room services, including detox
2 Hospital inpatient services, including detox
3 Specialized residential program services(e.g. rehab)
4 Outpatient treatment services
5 Community based program (e.g. 12-step type, AA, etc)
6 or some other type? (Please specify:_______)
7 DON’T KNOW [UNIQUE RESPONSE –SKIP TO SECTION C]
8 REFUSED [UNIQUE RESPONSE - SKIP TO SECTION C]
[IF B16=1 ASK B17a, ELSE SKIP B18a]
B17a
When did you start receiving in an emergency room?
______________________________________________________
MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = YYYY - CURRENT YEAR, 9997, 9998)
97/9997 DON’T KNOW
98/9998 REFUSED
B17b
Since [RAMY], in total, for about how long do you think you received this sort of help?
__________________AMOUNT OF TIME [RANGE:1-300]
996 More than 18 months
997 DON’T KNOW
998 DECLINE TO ANSWER
B17c
[IF NEEDED, CONFIRM UNIT OF TIME] Was that in….
1 Days
2 Weeks
3 Or months
7 DON’T KNOW
8 DECLINE TO ANSWER
[B16=2
ASK, ELSE SKIP TO B18a]
B17a
When did you start receiving help as a hospital inpatient?
______________________________________________________
MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = YYYY - CURRENT YEAR, 9997, 9998)
97/9997 DON’T KNOW
98/9998 REFUSED
B17b
Since [RAMY], in total, for about how long do you think you received this sort of help?
__________________AMOUNT OF TIME [RANGE:1-300]
996 More than 18 months
997 DON’T KNOW
998 DECLINE TO ANSWER
B17c
[IF NEEDED, CONFIRM UNIT OF TIME] Was that in….
1 Days
2 Weeks
3 Or months
7 DON’T KNOW
8 DECLINE
TO ANSWER
[B16=3 ASK, ELSE SKIP B19a]
B18a
When did you start receiving help in the specialized residential program?
______________________________________________________
MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = YYYY - CURRENT YEAR, 9997, 9998)
97/9997 DON’T KNOW
98/9998 REFUSED
B18b
Since [RAMY], in total, for about how long do you think you received this sort of help?
__________________AMOUNT OF TIME [RANGE:1-300]
996 More than 18 months
997 DON’T KNOW
998 DECLINE TO ANSWER
B18c
[IF NEEDED, CONFIRM UNIT OF TIME] Was that in….
1 Days
2 Weeks
3 Or months
7 DON’T KNOW
8 DECLINE TO ANSWER
[B16=4 ASK, ELSE SKIP TO B20a]
B19a
When did you start receiving help with outpatient services?
______________________________________________________
MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = YYYY - CURRENT YEAR, 9997, 9998)
97/9997 DON’T KNOW
98/9998 REFUSED
B19b
Since [RAMY], in total, for about how long do you think you received this sort of help?
__________________AMOUNT OF TIME [RANGE:1-300]
996 More than 18 months
997 DON’T KNOW
998 DECLINE TO ANSWER
B19c
[IF NEEDED, CONFIRM UNIT OF TIME] Was that in….
1 Days
2 Weeks
3 Or months
7 DON’T KNOW
8 DECLINE TO ANSWER
B19d
During the time in which you were receiving help for problems related to alcohol or other substance use, how often did you receive these outpatient services? Was it…
Four or more times a week,
Two or three times a week,
Once a week,
2-3 times a month
Once a month, or
Less than once a month
DON’T KNOW
REFUSED
[IF B16=5 ASK, ELSE SKIP TO B21a]
B20a
When did you start receiving community-based services, such as a 12-step program, AA, or something similar?
______________________________________________________
MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = YYYY - CURRENT YEAR, 9997, 9998)
97/9997 DON’T KNOW
98/9998 REFUSED
B20b
Since [RAMY], in total, for about how long do you think you received this sort of help?
__________________AMOUNT OF TIME [RANGE:1-300]
996 More than 18 months
997 DON’T KNOW
998 DECLINE TO ANSWER
B20c
[IF NEEDED, CONFIRM UNIT OF TIME] Was that in….
1 Days
2 Weeks
3 Or months
7 DON’T KNOW
8 DECLINE TO ANSWER
B20d
During the time in which you were receiving help for problems related to alcohol or other substance use, how often did you receive these outpatient services? Was it…
Four or more times a week,
Two or three times a week,
Once a week,
2-3 times a month
Once a month, or
Less than once a month
DON’T KNOW
REFUSED
[IF B16=6 “ OTHER” ASK, ELSE SKIP TO B22]
B21a
When did you start receiving [RECALL B16=6 SPECIFY OR Display “this other type of help related to alcohol or other substance use”]?
______________________________________________________
MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = YYYY - CURRENT YEAR, 9997, 9998)
97/9997 DON’T KNOW
98/9998 REFUSED
B21b
Since [RAMY], in total, for about how long do you think you received this sort of help?
__________________AMOUNT OF TIME [RANGE:1-300]
996 More than 18 months
997 DON’T KNOW
998 DECLINE TO ANSWER
B21c
[IF NEEDED, CONFIRM UNIT OF TIME] Was that in….
1 Days
2 Weeks
3 Or months
7 DON’T KNOW
8 DECLINE TO ANSWER
B21d
During the time in which you were receiving help for problems related to substance use, how often did you receive this help? Was it…
Four or more times a week,
Two or three times a week,
Once a week,
2-3 times a month
Once a month, or
Less than once a month
DON’T KNOW
REFUSED
B22
Since [RAMY], have you ever participated in an opioid treatment program (OPT) or a Medication Assisted Treatment Program (MAT) that perhaps included dosing with medications such as methadone, buprenorphine, naltrexone, Antabuse, etc.?
1 YES
2 NO [SKIP TO SECTION C]
7 DON”T KNOW [SKIP TO SECTION C]
8 REFUSED [SKIP TO SECTION C]
B22a
Since [RAMY], in total, for about how long do you think you received this sort of help?
__________________AMOUNT OF TIME [RANGE:1-300]
996 More than 18 months
997 DON’T KNOW
998 DECLINE TO ANSWER
B22b
[IF NEEDED, CONFIRM UNIT OF TIME] Was that in….
1 Days
2 Weeks
3 Or months
7 DON’T KNOW
8 DECLINE TO ANSWER
B22c
During the time in which you were receiving help for problems related to substance use, how often did you receive this help? Was it…
Four or more times a week,
Two or three times a week,
Once a week,
2-3 times a month
Once a month, or
Less than once a month
DON’T KNOW
REFUSED
B23
Have you been taking any of the following while in the care of a medical professional during the past 30 days as part of a treatment program for alcohol or substance use issues?
Please select all that apply.
1 methadone,
2 buprenorphine (including Subutex ®, ®)
3 naltrexone (including Vivitrol ®)
4 antabuse
6 Or something else? (Please specify:__________)
5 Or none of these
7 DON’T KNOW
8 REFUSED
SECTION C: PROGRAM SATISFACTION
[PROGRAM GROUP ONLY – ALL ELSE SKIP TO SECTION D – EMPLOYMENT]
C_INTRO
The next set of questions are about your experiences with services that are offered as part of [BEES PROGRAM] at [ORGANIZATION NAME] . [IF B4=1 DISPLAY “While you may have shared some of your experiences already, we have just a few more program specific questions to ask.”]
Just as a reminder - [BEES PROGRAM] is a program with [NAME OF ORGANIZATION] that you agreed to participate in as part of a research study.
C1
Are you currently working for pay? This includes any work where you get paid including self-employment, temporary work, work as a day laborer, work “off the books,” and paid work at an employment program.
1 YES
2 NO
7 DON’T KNOW
8 REFUSED
C2
Are you currently, receiving any employment services from [BEES PROGRAM ] or participating in any [BEES PROGRAM] activities to help you find, get, or keep a job?
1 YES [SKIP TO CHECKPOINT1]
2 NO
7 DON’T KNOW
8 REFUSED
C3.
Since [RAMY], have you received any services from [BEES PROGRAM ] or participated in any [BEES PROGRAM] activities to help you find, get, or keep a job?
1 YES
2 NO
7 DON’T KNOW
8 REFUSED
[CHECKPOINT1
NO JOB, CURR WORK WITH BEES : C1=2,7,8 AND C2=1 SKIP TO C8]
NO JOB NO CURR BEES, YES PAST BEES: C1=2,7,8 AND C2=2,7,8 AND C3=1 SKIP TO C6
NO JOB, NO CURR BEES, NO PAST BEES: C1=2,7,8 AND C2=2,7,8 AND C3=2,7,8 SKIP TO C4
CURR WORK, NO CURR BEES, NO PAST BEES: C1=1 AND C2=2,7,8 AND C3=2,7,8 SKIP TO C4
CURR WORK, CURR WORK WITH BEES: C1=1, C2=1 SKIP TO C8)
CURR WORK, NOT CURR BEES, PAST BEES YES: C1=1, C2=2,7,8, C3=1 SKIP C6]
C4
What was the reason, or reasons, you did not participate in [BEES PROGRAM] employment services? Was it because…
[NOTE: RESPONSE OPTIONS MAY BE CUSTOMIZED BY SITES]]
Please select all that apply.
1 you got a job
2 you moved away
you had transportation issues
you had childcare problems
you or a family member had health problems
you were focusing on recovery
you did not have the time
you did not like the program or get along with the staff
you were worried you might lose your benefits if you got a job
you no longer wanted a job, or
there was some other reason (Please specify:________)
97 DON’T KNOW [UNIQUE RESPONSE – SKIP TO SECTION D]
98 REFUSED [UNIQUE RESPONSE – SKIP TO SECTION D]
[IF C4 ONLY 1 RESPONSE IS SELECTED SKIP TO SECTION D OR IF C4 EQUAL TO 97 OR 98, SKIP TO SECTION D]
C5
Of the reasons you mentioned, which would you say is the primary reason you did not participate in [BEES PROGRAM ] employment services? Was it because
[RECALL AND DISPLAY ONLY RESPONSES SELECTED IN C4 – SELECT 1]
1 you got a job
2 you moved away
3 you had transportation issues
4 you had childcare problems
5 you or a family member had health problems
6 you were focusing on recovery
7 you did not have the time
8 you did not like the program or get along with the staff
9 you were worried you might lose your benefits if you got a job
10 you no longer wanted a job, or
11 [RECALL C4=9 TEXT]
97 DON’T KNOW
98 REFUSED
[ALL C5 RESPONSES SKIP TO SECTON D]
C6
What was the reason, or reasons, you stopped going to [BEES PROGAM] for employment services? Was it because…
[NOTE: RESPONSE OPTIONS MAY BE CUSTOMIZED BY SITES]
Please select all that apply.
1 you got a job
2 you moved away
3 you had of transportation issues
4 you had childcare problems
5 you or a family member had health problems
6 you were focusing on recovery
7 you did not have the time
8 you did not like the program or get along with the staff
9 you were worried you might lose your benefits if you got a job
10 you no longer wanted a job, or
11 there was some other reason (Please specify:________)
97 DON’T KNOW [UNIQUE RESPONSE – SKIP TO C9]
98 REFUSED [UNIQUE RESPONSE – SKIP TO C9]
[IF C6 =1, AND ONLY 1, SKIP TO C8
IF C6 ONLY 1 RESPONSE EQUAL TO (2,3,5,6,7,8,9, 10,11,12,13,OR 14 IS SELECTED SKIP TO C9]
C7
What was the primary reason you stopped going to [BEES PROGAM] for employment services? Was it because…
[NOTE: RESPONSE OPTIONS MAY BE CUSTOMIZED BY SITES]
[RECALL RESPONSES FROM C6 – SELECT 1]
1 you got a job
2 you moved away
3 you had transportation issues
4 you had childcare problems
5 you or a family member had health problems
6 you were focusing on recovery
7 you did not have the time
8 you did not like the program or get along with the staff
9 you were worried you might lose your benefits if you got a job
10 you no longer wanted a job, or
11[ [RECALL C6=11TEXT]
97 DON’T KNOW
98 REFUSED
[IF C7=1, ASK C8 ELSE SKIP TO C9]
C8
Did the [BEES PROGRAM] staff at [NAME OF ORGANIZATION] help you find a job?
1 YES
2 NO
7 DON’T KNOW
8 REFUSED
C9
Thinking of your whole experience with [BEES PROGRAM], how satisfied are you with the employment services you’ve received? Are you…
Very satisfied.
Somewhat Satisfied.
Not very satisfied, or.
Not at all satisfied?
7 DON’T KNOW
8 REFUSED
SECTION D: EMPLOYMENT
D_INTRO
[ASKED OF TO ALL RESPONDENTS]
[IF RESEACR GROUP=PROGRAM & C1=1 DISPLAY “ Earlier you mentioned that you were currently working, now we would like to learn a bit more about that job and any other jobs you may have had since [RAMY], which is when you applied to [BEES PROGRAM] at [ORGANIZATION NAME].
[ELSE DISPLAY] Now we would like to learn about any jobs you may have had since [RAMY], which is when you applied to [BEES PROGRAM] at [ORGANIZATION NAME].
[IF RESEACR GROUP=PROGRAM & C1=1 SKIP TO D3]
D1
Have you worked for pay at all since [RAMY]? This would include any work where you get paid such as self-employment, temporary work, work as a day laborer, work “off the books,” and paid work at an employment program.
1 YES [SKIP TO D3]
2 NO
7 DON’T KNOW
8 REFUSED
D2
A
lot of people have irregular, odd, or side jobs, or do extra work to
make ends meet.
Have
you done e
any
work like that which you do for pay since [RAMY]?
1 YES ]
2 NO
7 DON’T KNOW
8 REFUSED
[IF D1=2, 7,8 AND D2=2,7, 8 SKIP TO D35a]
JOB ROSTER [ALLOW UP TO 9]
D3
We would like to start with getting a list of all of the jobs you have had since [RAMY]. We would like to make a list of any current jobs, and work backwards -- meaning what was the job before this one, the job before that, and so forth.
This is simply to help make later questions more clear. We will not contact any employers. If you don’t want to give the employer’s name, just tell us what your job title was or the kind of work you did.
INTERVIEWER: RECORD VERBATIM
PROGRAMMER: ALLOW 9 COMPANY NAMES.
D3a_1 [DISPLAY FIRST TIME THROUGH]
What is the most recent job you have had since [RAMY]? This might be a current job, or what you were doing before now.
D3a_2-9 [DISPLAY]
What is the job you had before this one since [RAMY]?
_________ _________________________________________________________
INTERVIEWERS: FOR EACH JOB, CONFIRM IF SELF-EMPLOYED OR NOT
EMPLOYER _X (1-9)
95 SELF-EMPLOYED FOR THIS JOB
96 [SHOW ONLY D3a_2-9] No other jobs [SKIP TO D3_SUMM]
97 DON’T KNOW
98 REFUSED
[PROGRAMMER IF FIRST JOB & RESPONSE=97.98 SKIP TO D33, IF JOB 2-9, & RESPONSE=97,98 SKIP TO D3_SUM]
D3b_X (1-9) Is this a current job?
1 YES ]
2 NO
7 DON’T KNOW
8 REFUSED
D3c
[ASK IF D3b_9 =1,2,7.8] How many jobs in TOTAL have you had since RAMY?
______________Number of Jobs [RANGE=1-90]
97 DON’T KNOW
98 REFUSED
D3_SUMM
Just to make sure we have this right -:
Your current job/jobs are the following:
PROGRAMMER DISPLAY D3a1-D3a9 where D3b1-D3b9=1 – LIST THE NAMES OF ALL CURRENT JOBS
Other jobs that you have worked at since [RAMY] are the following:
PROGRAMMER DISPLAY D3a1-D3a9 where D3b1-D3b9=2,7,8– LIST THE NAMES OF ALL OTHER JOBSW/NOT CURRENT
[PROGRAMMER IF D3c ANSWERED DISPLAY] And you had [RECALL D3c VALUE] other jobs all since [RAMY].
PROGRAMMER:CAN WE BUILD IN A WAY TO CORRECT FOR CATI & WEB?
CURRENT JOBS (MAIN EMPLOYER, THEN UP TO 2 MORE CURRENT JOBS)
D4.
Considering all of your current jobs – which one would you consider your main employer?
For our purposes, your main employer is the one where you work the most hours, or where you have worked the longest.
This is simply to help make later questions more clear. We will not contact your employer. If you would like, you can tell me your job title instead.
[PROGRAMMER DISPLAY D3a1-D3a_9 FOR CASES WHERE D3b1-D3b9=1
RESPONDENT SELECTS – SET THIS SELECTION AS “MAIN EMP”]
CURRENT JOB & MAIN EMPLOYER SERIES
D5
When did your job with [MAINEMP] start?
________________________________________________________________________
MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = 2015 - CURRENT YEAR, 9997, 9998)
97/9997 DON’T KNOW
98/9998 REFUSED
D6
Including overtime, how many hours per week do you work with [MAINEMP]?
If your schedule is irregular or varies, how many hours did you work in the last week you worked at this job?
___________________
NUMBER OF HOURS [RANGE: 1 to 80]
96 OVER 80 HOURS PER WEEK
97 DON’T KNOW
98 REFUSED
D7
What is your wage at [MAINEMP], before taxes? Please include tips, commissions, and regular overtime pay.
INTERVIEWER: IF JOB IS ON AN IRREGULAR SCHEDULE OR A COMMISSION BASIS, PROBE FOR HOW MUCH R MAKES IN A TYPICAL WEEK.
DISPLAY FOR WEB: If you work an irregular schedule, or for commissions, please try to estimate how much you make in a typical week.
$ ___ ___ , ___ ___ ___ . ___ ___
AMOUNT [RANGE: .01 -to 50,000.00]
99999.96 MORE THAN $50,000
99999.97 DON’T KNOW [SKIP TO INSTRUCTION BEFORE D10]
99999.98 REFUSED [SKIP TO INSTRUCTION BEFORE D10]
D8
Is that:
INTERVIEWER: READ CATEGORIES UNTIL RESPONDENT INDICATES THE CORRECT SELECTION.
1 …per hour?
2 …per week?
3 …per day?
4 …every 2 weeks?
5 …twice monthly?
6 …monthly
7 …annually?
8 …or per task?
9 …Or some other way? (Please specify: ________________)
97 DON’T KNOW
98 REFUSED
D9
Just to confirm, was that ……
1 before taxes, or
2 after taxes?
7 DON’T KNOW
8 REFUSED
D10
What was the most important resource you used to find this job at [MAINEMP]? Was it…
1 a friend, relative, or acquaintance,
2 a job posting or help-wanted ad found in the newspaper, on the computer, or somewhere else,
3 [BEES PROGRAM] at [ORGANIZATION NAME]
4 an employment placement service at school or training provider,
5 an employment program, such as a local WIOA/OneStop or an unemployment office
6 a church or community center
7 an employer that decided to retain you permanently after you were placed there in a temporary, transitional, or subsidized job,
8 or something else? (Please specify: ________________)
97 DON’T KNOW
98 REFUSED
D11
Did staff from any agency or organization help you get this job?
1 YES
2 NO
7 DON’T KNOW
8 REFUSED
D12.
What kind of work do you do for or at [MAINEMP]? For example, are you a teacher, nurse’s aide, plumber, child care provider, cook, builder, etc?
INTERVIEWER: ENTER VERBATIM RESPONSE< PROBE AS NEEDED
WEB INSTRUCTION DISPLAY: Please enter enough information so that we can understand the kind of work you do and what industry or economic sector you work in.
TEXT BOX __________
97 DON’T KNOW
87 REFUSED
D13
Is this job…
1 permanent employment, including part-time work,
2 seasonal work, temporary work through a temp agency, day labor, an odd job,
3 something else? (Please specify:: ________________)
97 DON’T KNOW
98 REFUSED
D14
Which of the following best describes your usual weekly work schedule at your job during the last month. Would you say you worked a…
1 daytime shift,
2 an evening shift,
3 a night shift,
4 a rotating shift, that is one that changes regularly from days to evenings to nights,
5 a split shift, that is one consisting of two distinct periods each day,
6 an irregular schedule, that is one that changes from day to day or week to week, or
7 something else? (Please specify: ________________)
97 DON’T KNOW
98 REFUSED
[IF B3a FOR MAINEMP=95 SKIP TO CUREMPCHK]]
D14
Which of the following benefits are available to you on your job, even if you do not participate or use them?
|
YES |
NO |
DON’T KNOW |
REFUSED |
a.) Health insurance? |
1 |
2 |
7 |
8 |
b.) Sick days with full pay? |
1 |
2 |
7 |
8 |
c.) Paid vacation? |
1 |
2 |
7 |
8 |
d.) Paid holidays? |
1 |
2 |
7 |
8 |
e.) Dental benefits, including any offered at a cost to you? |
1 |
2 |
7 |
8 |
f.) A retirement or 401K plan? |
1 |
2 |
7 |
8 |
g.). Tuition reimbursement? |
1 |
2 |
7 |
8 |
D16
While working for [MAINEMP] since [RAMY] have you received a promotion while working at this job, meaning that you moved to a higher position or job title? That is, have you had any changes to your job responsibilities, with or without, any changes to your wages or salary?
1 YES
2 NO
7 DON’T KNOW
8 REFUSED
D17
Do you think you are likely to move up or be promoted in the future?
1 YES
2 NO
7 DON’T KNOW
8 REFUSED
[CUREMPCHK—IF THERE ARE OTHER CURRENT JOBS FROM D3_SUM, ASK NEXT SERIES FOR UP TO 2 MORE ADDITIONAL JOBS, ELSE SKIP TO D34 – SOURCES FOR ALL OTHER JOBS]
D18
We are interested in knowing a few things about your other current jobs --- not as much as we just asked you about [MAINEMP], just a few to help us understand your current employment situation better.
PROGRAMMER – LOOP THROUGH D18aX-D18f_x FOR UP TO 2 CURRENT JOBS – TAKE FROM OTHER CURRENT JOB LIST D3_SUM “EMPLOYER X” ARE THE NEXT 2 D3a1-9 where D3b1-9=1]
D18a_x(1-2)
[DISPLAY FIRST TIME THROUGH] When did your job with [FILL EMPLOYER X] start?]
[DISPLAY SECOND TIME THROUGH] Now, lets move on to your other current job at [FILL EMPLOYER X]. When did your job with [FILL EMPLOYER X] start?
________________________________________________________________________
MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = 2015 - CURRENT YEAR, 9997, 9998)
97/9997 DON’T KNOW
98/9998 REFUSED
D18a_x (1-2)
Including overtime, how many hours per week do you work with [FILL EMPLOYER X]?
If your schedule is irregular or varies, how many hours did you work in the last week you worked at this job?
___________________
NUMBER OF HOURS [RANGE: 1 to 80]
96 OVER 80 HOURS PER WEEK
97 DON’T KNOW
98 REFUSED
D18c_x(1-2)
What is your wage at [FILL EMPLOYER_X], before taxes? Please include tips, commissions, and regular overtime pay.
INTERVIEWER: IF JOB IS ON AN IRREGULAR SCHEDULE OR A COMMISSION BASIS, PROBE FOR HOW MUCH R MAKES IN A TYPICAL WEEK.
DISPLAY FOR WEB: If you work an irregular schedule, or for commissions, please try to estimates how much you would make in a typical week.
$ ___ ___ , ___ ___ ___ . ___ ___
AMOUNT [RANGE: .01 -to 50,000.00]
99999.96 MORE THAN $50,000
99999.97 DON’T KNO [SKIP TO D18f_x(1-2)
99999.98 REFUSED [SKIP TO INSTRUCTION D18f_x(1-2)]
D18d_x(1-2)
Is that:
INTERVIEWER: READ CATEGORIES UNTIL RESPONDENT INDICATES THE CORRECT SELECTION.
1 …per hour?
2 …per week?
3 …per day?
4 …every 2 weeks?
5 …twice monthly?
6 …monthly
7 …annually?
8 …or per task?
9 …Or some other way? (Please specify: ________________)
97 DON’T KNOW
98 REFUSED
D18e_x (1-2)
Just to confirm, was that ……
1 before taxes, or
2 after taxes?
7 DON’T KNOW
8 REFUSED
D18f_x(1-2)
What was the most important resource you used to find this job at [FILL EMPLOYER_x]? Was it…
1 a friend, relative, or acquaintance,
2 a job posting or help-wanted ad found in the newspaper, on the computer, or somewhere else,
3 [BEES PROGRAM] at [ORGANIZATION NAME]
4 an employment placement service at school or training provider,
5 an employment program, such as a local WIOA/OneStop or an unemployment office
6 a church or community center
7 an employer that decided to retain you permanently after you were placed there in a temporary, transitional, or subsidized job,
8 or something else? (Please specify: ________________)
97 DON’T KNOW
98 REFUSED
D18g_x(1-2)
Did staff from any agency or organization help you get this job?
1 YES
2 NO
7 DON’T KNOW
8 REFUSED
[PROGRAMMER – LOOP BACK FOR NEXT CURRENT JOB IF MORE THAN 1, ONCE LOOP IS COMPLETED 2x, SKIP TO D34]
PRIOR JOB LOOP
[ASK FOR ONLY 1 JOB GET FROM D3_SUM FOR FIRST D3a1-9 WHERE D3b1-9=2,7,8]
D19
We would like to know a little bit about your most recent job since [RAMY]
When did your job with [FILL EMPLOYER X] start?
________________________________________________________________________
MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = 2015 - CURRENT YEAR, 9997, 9998)
97/9997 DON’T KNOW
98/9998 REFUSED
D20
When did your job at [FILL EMPLOYER X] end?
If you don’t know, please just give us your best estimate? This helps us understand how long you were working. All information you provide is private and will not be shared.
______________________________________________________________________
MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = 2016-CURRENT YEAR, 9997, 9998)
97/9997 DON’T KNOW
98/9998 REFUSED
D21
Including overtime, how many hours per week did you work with [FILL EMPLOYER X] when you left?
If your scheduled varied or was irregular, about how many hours did you work in the last week you worked at this job?
___________________
NUMBER OF HOUR [RANGE: 1 to 80]
96 OVER 80 HOURS PER WEEK
97 DON’T KNOW
98 REFUSED
D22
What was your wage at [FILL EMPLOYER_X] just before you left before taxes? Please include tips, commissions, and regular overtime pay.
INTERVIEWER: IF JOB IS ON AN IRREGULAR SCHEDULE OR A COMMISSION BASIS, PROBE FOR HOW MUCH R MAKES IN A TYPICAL WEEK.
DISPLAY FOR WEB: If you work an irregular schedule, or for commissions, please try to estimates how much you would make in a typical week.
$ ___ ___ , ___ ___ ___ . ___ ___
AMOUNT [RANGE: .01 -to 50,000.00]
99999.96 MORE THAN $50,000
99999.97 DON’T KNOW [SKIP TO INSTRUCTION BEFORE D25]
99999.98 REFUSED [SKIP TO INSTRUCTION BEFORE D25]
D23
Was that:
INTERVIEWER: READ CATEGORIES UNTIL RESPONDENT INDICATES THE CORRECT SELECTION.
1 …per hour?
2 …per week?
3 …per day?
4 …every 2 weeks?
5 …twice monthly?
6 …monthly
7 …annually?
8 …or per task?
9 ….or some other way? (Please specify: ________________)
97 DON’T KNOW
98 REFUSED
D24
Was that …
1 before taxes, or
2 after taxes?
7 DON’T KNOW
8 REFUSED
D25
What was the most important resource you used to find this job at [FILL EMPLOYER_x]? Was it…
1 a friend, relative, or acquaintance,
2 a job posting or help-wanted ad found in the newspaper, on the computer, or somewhere else,
3 [BEES PROGRAM] at [ORGANIZATION NAME]
4 an employment placement service at school or training provider,
5 an employment program, such as a local WIOA/OneStop or an unemployment office
6 a church or community center
7 an employer that decided to retain you permanently after you were placed there in a temporary, transitional, or subsidized job,
8 or something else? (Please specify: ________________)
97 DON’T KNOW
98 REFUSED
D26
Did staff from any agency or organization help you get this job?
1 YES
2 NO
7 DON’T KNOW
8 REFUSED
D27
What was the main reason you stopped working at [FILL EMPLOYER X]? Was it because…
[ALLOW ONLY ONE RESPONSE]
1 you got a new or different job
2 you were laid off
3 you were not interested in working
4 you were unable to work because of injury
5 you were unable to work because of illness
6 you were unable to work because of physical disability
7 you were unable to work because of mental disability
8 you were incarcerated
9 of pregnancy or childbirth
10 of family responsibilities
11 you were going to school
12 you found that the work just did not suit you
13 you relapsed
14 oe some other reason (Please specify: ________________)
97 DON’T KNOW
98 REFUSED
D28
What kind of work do you do for or at [FILL EM)PLOYER X]? For example, are you a teacher, nurse’s aide, plumber child care provider, cook, builde, etc.
INTERVIEWER: ENTER VERBATIM RESPONSE< PROBE AS NEEDED
WEB INSTRUCTION DISPLAY: Please enter enough information so that we can understand the kind of work you do and what industry or economic sector you work in.
TEXT BOX __________
97 DON’T KNOW
87 REFUSED
D29
Was this job…
1 permanent employment, including part-time work,
2 seasonal work, temporary work through a temp agency, day labor, an odd job,
3 something else? (Please specify:: ________________)
97 DON’T KNOW
98 REFUSED
D30
Which of the following best describes your usual weekly work schedule at your job during the last month you were working there. Would you say you worked a…
1 daytime shift,
2 an evening shift,
3 a night shift,
4 a rotating shift, that is one that changes regularly from days to evenings to nights,
5 a split shift, that is one consisting of two distinct periods each day,
6 an irregular schedule, that is one that changes from day to day or week to week, or
7 something else? (Please specify: ________________)
9 DON’T KNOW
98 REFUSED
[IF EMPLOYER X for D3ax=95 SKIP TO D33]
D31
Which of the following benefits were available to you at FILL EMPLOYER X], even if you do not participate or use them with [FILL EMPLOYER X]?
|
YES |
NO |
DON’T KNOW |
REFUSED |
a.) Health insurance? |
1 |
2 |
7 |
8 |
b.) Sick days with full pay? |
1 |
2 |
7 |
8 |
c.) Paid vacation? |
1 |
2 |
7 |
8 |
d.) Paid holidays? |
1 |
2 |
7 |
8 |
e.) Dental benefits, including any offered at a cost to you? |
1 |
2 |
7 |
8 |
f.) A retirement or 401K plan? |
1 |
2 |
7 |
8 |
g.). Tuition reimbursement? |
1 |
2 |
7 |
8 |
D33
Did staff from any agency or organization help you get this job?
1 YES
2 NO
7 DON’T KNOW
8 REFUSED
D34 [ASK OF EVERYONE WITH JOBS IN D3_SUM THAT WE HAVE NOT ASKED ABOUT TO DATE]
Earlier you also mentioned that you worked at the following:
[PROGRAMMER -RECALL JOBS NOT DISCUSSED IN RECENT JOB LOOPS D3_SUM, IF 95 SELECTED, DISPLAY “The job where you were self-employed”:
We are interested in knowing, which, if any of the following resources you used to find any of these jobs?
(Please select all that apply.)
1 a friend, relative, or acquaintance,
2 a job posting or help-wanted ad found in the newspaper, on the computer, or somewhere else,
3 [BEES PROGRAM] at [ORGANIZATION NAME]
4 an employment placement service at school or training provider,
5 an employment program, such as a local WIOA/OneStop or an unemployment office
6 a church or community center
7 an employer that decided to retain you permanently after you were placed there in a temporary, transitional, or subsidized job,
8 or something else? (Please specify: ________________)
97 DON’T KNOW
98 REFUSED
[PROGRAMMER ALL SKIP TO D36]
NO WORK SINCE RAMY
D35
What are some of the reasons why you have not worked at a job since [RAMY]? Would you say it was because…
(Please select all that apply)
1 of an injury
2 of an illness
3 of a physical disability
4 of a mental disability
5 you were incarcerated
6 of a pregnancy or birth of a child
7 of family responsibilities
8 you were going to school
9 you were unable to find work
10 you were not interested in working
11 you relapsed
12 Or some other reason? (Could you please specify: ________________)
97 DON’T KNOW [UNIQUE RESPONSE] [SKIP TO D36]
98 REFUSED [UNIQUE RESPONSE] ] [SKIP TO D36]
[IF D35 ONLY 1 RESPONSE SELECTED AND NOT EQUAL TO 97 OR 98 SKIP TO D36]
D35a
Of the reasons you mentioned, which would you say is the main reason you have not worked at a job since [RAMY]?
[DISPLAY D35 VALUES SELECTED]
1 of an injury
2 of an illness
3 of a physical disability
4 of a mental disability
5 you were incarcerated
6 of a pregnancy or birth of a child
7 of family responsibilities
8 you were going to school
9 you were unable to find work
10 you were not interested in working
11 you relapsed
12 DISPLAY D35=11 TEXT
97 DON’T KNOW
98 REFUSED
D36
Have you done anything to find work during the past four weeks?
1 YES
2 NO
7 DON’T KNOW
8 REFUSED
SECTION E: PHYSICAL AND MENTAL HEALTH
(SF-12v2®)
[ALL RESPONDENTS ASKED SECTION E]
E_INTRO
Now, we would like to ask you some questions about your health.
E1..
In general, would you say your health is:
1 Excellent
2 Very good
3 Good
4 Fair, or
5 Poor?
7 DON’T KNOW
8 REFUSE
E2.
Following questions are about activities you might do in a typical day…
E2a, In a typical day, how much does your health limit your ability to do moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or play golf? Would you say that it…
1 Limits you a lot
2 Limits you a little
3 Does not limit you at all?
7 DON’T KNOW
8 REFUSED
E2b.
In a typical day, how much does your health limit your ability to climb several flights of stairs? Would you say that it …
1 Limits you a lot
2 Limits you a little
3 Does not limit you at all?
7 DON’T KNOW
8 REFUSED
E3
Now we would like you to think about your physical health. During the past 4 weeks, because of your physical health, how often have you accomplished less than you would have liked with your work or other regular daily activities? Would you say…
1 All of the time
2 Most of the time
3 Some of the time
4 A little of the time
5 None of the time
7 DON’T KNOW
8 REFUSED
E4
During the past 4 weeks, because of your physical health, how often were you limited in the kind of work or other activities you could do? Would you say…
1 All of the time
2 Most of the time
3 Some of the time
4 A little of the time
5 None of the time
7 DON’T KNOW
8 REFUSED
E5
Now we would like you think about any emotional problems (such as feeling depressed or anxious) you may have had during the past 4 weeks.
E6
During past 4 weeks, because of any emotional problems, how often have you accomplished less than you would have liked with your work or other regular daily activities? Would you say…
1 All of the time
2 Most of the time
3 Some of the time
4 A little of the time
5 None of the time
7 DON’T KNOW
8 REFUSED
E7
During past 4 weeks, because of any emotional problems, how often did you do work or other activities less carefully? Would you say…
1 All of the time
2 Most of the time
3 Some of the time
4 A little of the time
5 None of the time
7 DON’T KNOW
8 REFUSED
E8
During the past 4 weeks, how much did pain interfere with your normal work, including both work outside the home and housework? Would you say it interfered was…
1 Not at all,
2 A little bit,
3 Moderately,
4 Quite a bit, or
5 Extremely?
7 DON’T KNOW
8 REFUSED
E9
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…
|
All of the time |
Most of the time |
Some of the time |
A little of the time |
None of the time |
DON’T KNOW |
REFUSED |
a. Have you felt calm and peaceful? Would you say… |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
b. Did you have a lot of energy? Would you say… |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
c. Have you felt downhearted and depressed? |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
E10
During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? Would you say it interfered…
1 All of the time,
2 Most of the time,
3 Some of the time,
4 A little of the time, or
5 None of the time?
7 DON’T KNOW
8 REFUSED
SF-12v2® Health Survey © 1994, 2002 Medical Outcomes Trust and QualityMetric Incorporated. All rights reserved.
(Kessler-6 scale)
E11
During the past 4 weeks, about how often did you feel so depressed that nothing could cheer you up? Would you say….
1 All of the time
2 Most of the time
3 Some of the time
4 A little of the time
5 Or none of the time?
7 DON’T KNOW
9 REFUSED
E12
During the past 4 weeks, about how often did you feel hopeless? Would you say….
1 All of the time
2 Most of the time
3 Some of the time
4 A little of the time
5 Or none of the time?
7 DON’T KNOW
9 REFUSED
E13
During the past 4 weeks, about how often did you feel restless or fidgety? Would you say..
1 All of the time
2 Most of the time
3 Some of the time
4 A little of the time
5 Or none of the time?
7 DON’T KNOW
9 REFUSED
E14
During the past 4 weeks, about how often did you feel that everything was an effort? Would you say….
1 All of the time
2 Most of the time
3 Some of the time
4 A little of the time
5 Or none of the time?
7 DON’T KNOW
9 REFUSED
E15
During the past 4 weeks, about how often did you feel worthless? Would you say….
1 All of the time
2 Most of the time
3 Some of the time
4 A little of the time
5 Or none of the time?
7 DON’T KNOW
9 REFUSED
E16
During the past 4 weeks, about how often did you feel nervous? Would you say….
1 All of the time
2 Most of the time
3 Some of the time
4 A little of the time
5 Or none of the time?
7 DON’T KNOW
9 REFUSED
SECTION F: Substance Use (for relevant populations)
The next set of questions concern alcohol and substance use. We are asking everyone these questions. Please remember that your answers are private and will not be shared. Also, if you don’t want to answer a question, just let me know, and we can move on.
F1
Have you ever had treatment for substance or alcohol use disorder?
1 Substance use
2 Alcohol
3 Both
7 DON’T KNOW [SKIP TO SECTION G]
8 REFUSED [SKIP TO SECTION G]
F2
Which of the following categories best describes how you define yourself now with respect to your alcohol and substance use? Would you say that…
1 You currently use alcohol or other substances, and are not in treatment. [SKIP TO F4]
2 You are in treatment for use of alcohol or other substances
3 You are in recovery following treatment
7 DON’T KNOW
8 REFUSED
F3
Have you experienced any relapses since [RAMY]?
1 Yes
2 No
7 DON’T KNOW
8 REFUSED
[IF F1=1 SKIP TO F10]
F4
How many days in the past 30 days have you experienced difficulty with alcohol?
_____________ days [RANGE 1-30]
0 0 days
97 DON’T KNOW
98 REFUSED
F5
How troubled or bothered have you been in the past 30 days by alcohol problems? Would you say….
1 Not at all
2 Slightly
3 Moderately
4 Considerably
5 Extremely
7 DON’T KNOW
8 REFUSED
F6
How important to you now is treatment for alcohol problems? Would you say…
1 Not at all
2 Slightly
3 Moderately
4 Considerably
5 Extremely
7 DON’T KNOW
8 REFUSED
F7
How many days in the past 30 days have you used alcohol – any use at all?
_____________ days [RANGE 1-30]
0 0 days [SKIP TO NOTE BEFORE F10]
97 DON’T KNOW
98 REFUSED
F8
How many days in the past 30 days have you used alcohol to intoxication?
_____________ days [RANGE 0-30]
97 DON’T KNOW
98 REFUSED
F9
And then, how much money would you say you spent during the past 30 days on alcohol? Your best guess is fine.
$________________ [RANGE= $0-5000]
9997 DON’T KNOW
9998 REFUSED
[IF F1=2, SKIP TO SECTION G]
F10
How many days in the past 30 days have you experienced difficulty with other substances (other than alcohol)?
_____________ days [RANGE 0-30]
97 DON’T KNOW
98 REFUSED
F11
How troubled or bothered have you been in the past 30 days by drug problems? Would you say….
1 Not at all
2 Slightly
3 Moderately
4 Considerably
5 Extremely
7 DON’T KNOW
8 REFUSED
F12
How important to you now is treatment for drug problems? Would you say..
1 Not at all
2 Slightly
3 Moderately
4 Considerably
5 Extremely
7 DON’T KNOW
8 REFUSED
F13
In the past 30 days, have you used any drugs (not including alcohol) without permission of a physician or medical professional?
This would include using a drug 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 [SKIP TO SECTION G]
7 DON’T KNOW
8 REFUSED
F14
How many days in the past 30 days have you used the following - except medications used as prescribed by a doctor to you in the amount, frequency, and method that was instructed:
|
Days [RANGE=0-30] |
DON’T KNOW |
REFUSED |
a. Heroin
|
|
97 |
98 |
b. Fentanyl
|
|
97 |
98 |
c. Methadone (outside of methadone maintenance treatment) |
|
97 |
98 |
d. Other opioids/opiates/painkillers (except MAT use as prescribed by a doctor)
|
|
97 |
98 |
e. Barbiturates
|
|
97 |
98 |
f. Other sedatives, hypnotics, or tranquilizers
|
|
97 |
98 |
g. Cocaine
|
|
97 |
98 |
h. Methamphetamines
|
|
97 |
98 |
i. Amphetamines (other than Methamphetamines)
|
|
97 |
98 |
j. Cannabis
|
|
97 |
98 |
k. Hallucinogens
|
|
97 |
98 |
l. Gabapentin |
|
|
|
m. More than 1 substance per day (including alcohol)
|
|
97 |
98 |
F15
How much money would you say you spent during the past 30 days on these drugs? Your best guess is fine.
[RECALL LIST SELECTED F15a-m>0], BUT NOT 97 OR 98]
$________________ [RANGE= $0-15,000]
99997 DON’T KNOW
99998 REFUSED
SECTION G: HOUSEHOLD INFORMATION, INCOME, AND MATERIAL HARDSHIP
G1.
Now, we would like to change topics and ask some questions about you and your family. What is your current marital status? Are you…
1 Married,
2 Divorced,
3 Separated,
4 Widowed,
5 Or never married?
7 DON’T KNOW
8 REFUSED
G2.
[IF G1=1] Does your spouse currently live with you?
[ELSE] Do you have a partner who currently lives with you?
1 YES
2 NO
7 DON’T KNOW
8 REFUSED
G3
Including yourself, how many adults, aged 18 and older, currently live with you?
Include everyone aged 18 and older who usually lives with you, meaning stays with you at least two nights a week, even if they are away from home right now.
_____People, including yourself [RANGE 1-20]
97 DON’T KNOW [SKIP TO G4]
98 REFUSED [SKIP TO G4]
G3a
Does the count of [INSERT G3 VALUE] adults include you?
1 YES
2 NO [RETURN TO G3 AND RE-ASK]
7 DON’T KNOW
8 REFUSED
G4
How many children, under the age of 18, live with you? Please include your biological, adoptive, foster, step, or other children that you are responsible for.
By living with you, we mean spends at least two nights a week with you?
_____ CHILDREN [RANGE 00-20]
97 DON’T KNOW
98 REFUSED
G5
Now we have some questions about your current financial situation. Sometimes due to circumstances beyond your control, it can be difficult to meet all of your financial obligations.
Please consider the following situations, and let us know if you have ever faced any of them.
Since [RAMY], has there been a time when…
|
YES |
NO |
DON’T KNOW |
REF |
a. …you did not pay the full amount of the rent or mortgage because you could not afford it? |
1 |
2 |
7 |
8 |
b. …you were evicted from your home or apartment for not paying the rent or mortgage? |
1 |
2 |
7 |
8 |
c. …you filed in court for bankruptcy? |
1 |
2 |
7 |
8 |
d. …you did not pay the full amount of the gas, oil, or electricity bills? |
1 |
2 |
7 |
8 |
e. …you had service turned off by the gas or electric company, or the oil company would not deliver oil? |
1 |
2 |
7 |
8 |
f. …you had cellular or land telephone service disconnected because payments were not made? |
1 |
2 |
7 |
8 |
g. ...you could not fill or postponed filling a prescription for drugs when they were needed because you could not afford it? |
1 |
2 |
7 |
8 |
h. … you did not pay the full amount of child support payments because you could not afford it? |
1 |
2 |
7 |
8 |
|
1 |
2 |
7 |
8 |
G6
Getting enough food can be a problem for some people. Which of these statements best describes the food eaten in your household in [PRIOR MONTH]?
Would you say there was…
1 enough of the kind of foods you want,
2 enough, but not always the kinds of food you want,
3 sometimes not enough to eat, or
4 often not enough to eat?
7 DON’T KNOW
8 REFUSED
G7
[ASKI IF G3=1] Now, we are going to ask you some questions about the income, that is money and assistance that you may have received since [RAMY]. Again, we want to assure you that none of your answers will be discussed with anyone.
Since [RAMY] did you receive income or assistance from any of the following sources?
[ASK IF G3>1] Now, we are going to ask you some questions about the income, that is money and assistance that came into your household for everyone who lived with you since [RAMY]. Please include all income from all the people who lived together in your household at least two nights a week. Again, I want to assure you that none of your answers will be discussed with anyone.
Since [RAMY], did you or anyone in your household receive income or assistance from any of the following sources?
|
YES |
NO |
DON’T KNOW |
REFUSED |
a. A job? |
1 |
2 |
7 |
8 |
b. Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI)? |
1 |
2 |
7 |
8 |
c. Public assistance or welfare, such as [state specific program] or general relief, not including WIC or food stamps? |
1 |
2 |
7 |
8 |
d. Unemployment Insurance? |
1 |
2 |
7 |
8 |
e. Worker’s compensation? |
1 |
2 |
7 |
8 |
f. Disability? |
1 |
2 |
7 |
8 |
g. Food stamps/SNAP/[state specific program]? |
1 |
2 |
7 |
8 |
h. WIC? |
1
|
2 |
7 |
8 |
i. Energy assistance? |
1
|
2 |
7 |
8 |
j. Housing choice voucher, also known as Section 8, or public housing? |
1 |
2 |
7 |
8 |
k. Veterans benefits |
1 |
2 |
7 |
8 |
l. Other government source? |
1 |
2 |
7 |
8 |
|
|
|
|
|
G8
[ASK IF G3=`1]
For each type of income you said you received, please tell us for how many months you received this income. Again, we want to assure you that none of your answers will be discussed with anyone.
Since [RAMY], for how many months did you receive income or assistance from…
[ASK IF G3>1]
For each type of income you said your household received, please tell us for how many months your household received this income. Again, we want to assure you that none of your answers will be discussed with anyone.
Since [RAMY], for how many months did your household receive income or assistance from…
[RECALL ONLY ITEMS WHERE G7a-1=1]
|
NUMBER OF MONTHS [RANGE: 1-18] |
DON’T KNOW |
REFUSED |
a. ITEM EXCLUDED IN F9 |
|
|
|
b. Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI)? |
___ MONTHS |
97 |
98 |
c. Public assistance or welfare, such as [state specific program] or general relief, not including WIC or food stamps? |
___ MONTHS |
97 |
98 |
d. Unemployment Insurance? |
___ MONTHS |
97 |
98 |
e. Worker’s compensation? |
___ MONTHS |
97 |
98 |
f. Disability? |
__ MONTHS |
97 |
98 |
g. Food stamps/SNAP/[state specific program]? |
___ MONTHS |
97 |
98 |
h. WIC? |
___ MONTHS |
97 |
98 |
i. Energy assistance? |
___ MONTHS |
97 |
98 |
j. Housing choice voucher, also known as Section 8? |
___ MONTHS |
97 |
98 |
k. Veterans benefits |
__ MONTHS |
97 |
98 |
l. Other government source? |
___ MONTHS |
97 |
98 |
G9
What type of health insurance do you currently have?
1 Medicaid, possibly known as [12&12: SoonerCare; no state-specific name for other IPS-SUD and IPS-FQHC states. STATE MEDICAID NAME]
2 Private health insurance, including from the (Affordable Care Act) Exchange or Marketplace
3 Or some other kind? (Please specify: ________)
4 None/uninsured
7 DON’T KNOW
8 REFUSED
H. Contact Information
Respondent Information
Before we complete this portion of the survey, we would also like to make sure we have your contact information recorded correctly. This information will help us to reach you for future surveying efforts, and to ensure that we send your gift card to the correct address. We may also use this information to call you and ask how your survey experience was.
H1. I have your name recorded as [FIRST MI LAST]. Is this still correct or have you changed your name?
YES, STILL CORRECT [SKIP TO H2]
NO, NAME CHANGED
What is your first name now? [IF POSSIBLE, PREFILL FROM FIRST]
What is your middle initial now? [IF POSSIBLE, PREFILL FROM MIDDLE]
What is your last name now? [IF POSSIBLE, PREFILL FROM LAST]
H2.I have your address recorded as [STREET, APT, CITY, STATE, ZIP]. Is this still correct or have you moved?
YES, STILL CORRECT (SKIP TO H3)
NO, MOVED
What is your new street address or PO box number?
Is there a complex
or building name?
Is there an apartment number?
In what city?
In what state?
What is the zip code?
H2a. Would you prefer that the $35 gift card be sent to your current address or is there another address I should send it to?
YES, SEND TO CURRENT ADDRESS [SKIP TO H3] 1
NO, SEND TO DIFFERENT ADDRESS [ASK H2b through H2e] 2
H2b.What is the street address and apartment number you would like use to send the check to?
STREET ADDRESS___________________________________ APT OR UNIT # _______________________________
H2c. In what city?
CITY_____________________________________________________
H2d. In what state?
STATE ___________________________________________________
H2e. What is the zip code?
ZIP_______________________________________________________
H3
have your primary phone number recorded as [xxx-xxx-xxxx]. Is this still correct or do you have a new primary phone number?
1 YES, STILL CORRECT (SKIP TO H4)
2 NO, CHANGED
H3a
What is the new number, starting with the area code?
___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
H3bIs that a home, cell, shelter, work, or other number?
1 Home
2 Cell
3 Shelter
4 Work
5 Other
H4.IF MISSING, SKIP TO H5. IF ≠ MISSING: I have your secondary phone number recorded as [xxx-xxx-xxxx]. Is this still correct or do you have a new secondary phone number?
YES, STILL CORRECT (SKIP TO H5 )
NO, CHANGED
H4aWhat is the new number, starting with the area code?
___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
H3bIs that a home, cell, shelter, work, or other number?
1 Home
2 Cell
3 Shelter
4 Work
5 Other
H5.Do you have another phone number where we can reach you?
YES, ADDITIONAL PHONE NUMBERS AVAILABLE
NO (SKIP TO H6)
What is the new number, starting with the area code?
___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
Is that a home, cell, shelter, work, or other number?
Home
Cell
Shelter
Work
Other
[REPEAT H5 UNTIL ALL PHONE NUMBERS ARE RECORDED]
H6. IF MISSING, SKIP TO H7. IF ≠ MISSING: I have your email address recorded as [abc@abc.abc]. Is this still correct or do you have a new email address?
YES, STILL CORRECT (SKIP TO H7)
NO, CHANGED
NO LONGER HAVE ANY WORKING EMAIL ADDRESSES (SKIP TO INSTRUCTION ABOVE CG)
What is your new email address?
H7. Do you have [IF H6=MISSING: an email address / IF H6≠MISSING: any other email addresses]?
YES, ADDITIONAL EMAIL ADDRESSES ARE AVAILABLE
NO (SKIP TO INSTRUCTIONS ABOVE H8)
What is the additional email address?
[REPEAT H7 UNTIL ALL EMAIL ADDRESSES ARE LISTED]
CATI CLOSING: Thank you very much for participating in this survey. We appreciate the time you have taken to share your experiences with us. You will receive your $35 gift card in the mail in about two to three weeks. Thank you again and have a good day/evening.
WEB INCENTIVE DIRECT FULFILLMENT INSTRUCTIONS AND PROCESS (TO BE INSERTED)
WEB CLOSING: Thank you very much for participating in this survey. We very much appreciate the time you have taken to share your experiences with us. Thank you again and have a good day.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Microsoft Office User |
| File Modified | 0000-00-00 |
| File Created | 2024-07-20 |