Instrument 1_SYSIL Youth Survey_extension_CLEAN

Instrument 1

SYSIL Youth Survey (Baseline and Follow-Ups 1-3)

Revised December 2021

This page has been left blank for double-sided copying.

OMB No.: xxxx-xxxx

Expiration Date: xx/xx/20xx

S
upporting Youth to be Successful in Life Survey (SYSIL) Youth Survey

March 2021

PRIVACY

Thank you for your help with this important study. The information you provide will be used to help us understand what challenges youth in foster care face and will help shape programs and improve services provided to youth like you.

We want you to know that:

1. The survey is estimated to take 25 minutes to complete.

2. Your name will not be on the survey. The answers you give will never be identified as yours. Your responses will be combined with those of other people your age.

3. Please answer all questions as well as you can. We hope that you will answer all the questions, but you may skip any questions you do not wish to answer.

4. Your answers and everything you say will be kept private to the extent permitted by law.

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13): Public reporting burden for this collection of information is estimated to average 0.5 hours 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 for this information collection is 0970-0XXX and the expiration date is XX/XX/20XX. If you have any comments on this collection of information, including estimated time to complete, please contact Dr. M.C. Bradley at Mathematica at 855-888-2092 or by email at: SYSIL@mathematica-mpr.com.

A. BACKGROUND

These first questions ask for some general background information.

A1. What is your date of birth? If you do not know your full date of birth, please enter whatever information you do know.

| | | / | | | / | | | | |

month day year

d  Don’t know/Not sure

A2. What is your ethnicity?

MARK ONE ONLY

1  Hispanic or Latino

2  Not Hispanic or Latino

d  Don’t know

98  Choose not to answer

A3. What is your race?

MARK 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

d  Don’t know

98  Choose not to answer

A4. What sex was recorded on your original birth certificate?

MARK ONE ONLY

1  Male

2  Female

d  Don’t know

98  Choose not to answer

A5. How do you describe yourself?

MARK ONE ONLY

1  Male

2  Female

3  Transgender male

4  Transgender female

5  Other (for example, non-binary, genderqueer, gender fluid, or intersex)

d  Don’t know/Not sure

98  Choose not to answer

A6. Which of the following best represents how you think of yourself?

MARK ONE ONLY

1  Straight, that is, not lesbian or gay

2  Lesbian

3  Gay

4  Bisexual

5  I think of myself some other way (Please specify): ____________________________________________________

6  Don’t know

7  Choose not to answer

B. EDUCATION AND EMPLOYMENT

The following questions ask about your education and employment experience.

B1. We would like to understand your current status with education or training. This question applies to school, college, a GED course, trade school, vocational training, or any other type of formal education or training course that involves a diploma, degree, credential, or certificate at the end.

Which of the following best describes your education status right now?

MARK ONE ONLY

1  NOT currently enrolled in any school or educational course  GO TO B4

2  Currently enrolled, but NOT attending regularly (when school or the course is in session)

3  Currently enrolled and attending regularly (when school or the course is in session)

98  Choose not to answer

B2. What grade or level of school are you currently enrolled in?

MARK ONE ONLY

1  6th grade

2  7th grade

3  8th grade

4  9th grade

5  10th grade

6  11th grade

7  12th grade

8  GED course

9  Vocational training classes or trade school

10  College

GO TO B4

11  My school does not have grade levels

12  Other (specify)

13  Don’t know

98  Choose not to answer

B3. About how often were you usually absent from school during the past 3 months, including excused and unexcused absences?

MARK ONE ONLY

1  Did not miss school

2  Less than 1 day per month

3  About 1 day per month

4  About 1 day every 2 weeks

5  About 1 day a week

6  2 days per week

7  3 or more days per week

B4. What is the highest degree, certification, or grade level you have completed? If you are currently enrolled, please select the previous grade or highest degree received.

MARK ONE ONLY

1  Under 8th grade

2  8th grade

3  9th grade

4  10th grade

5  11th grade

6  High school diploma/GED

7  Some vocational training or trade school, no credential or certificate

8  Vocational training or trade school, received credential or certificate

9  Certificate program

10  Some college credit, but less than 1 year of college credit

11  1 or more years of college credit, but no degree

12  Associate’s degree (a 2 year degree from a community college; e.g., A.A.)

13  Bachelor’s degree (a 4 year degree from a college or university; e.g., B.A. or B.S.)

14  Higher degree (graduate degree; Masters or Doctorate)

15  None of the above

98  Choose not to answer

B5. Do you have a plan to get further education or training? Please think about any education courses, trade school, or vocational training.

1  Yes

0  No  GO TO B8

[IF AGE IS > OR = 16]

[Ask a IF B4_6 ne 1; ask b if B4_8 ne 1; ask c if B4_8 ne 1; ask d if B4_12 ne 1; ask e if B4_13 ne1; ask f if B4_14 ne 1]

B6. How likely do you think it is that you will do the following before you turn 25?

	NOT AT ALL LIKELY	SOMEWHAT LIKELY	VERY LIKELY	NOT SURE	CHOOSE NOT TO ANSWER
a. Obtain a GED or high school diploma	1 	2 	3 	9 	98 
b. Obtain a vocational certificate (document showing you have been trained for a particular trade/job)	1 	2 	3 	9 	98 
c. Obtain a vocational license (State or Local Government recognizes you as a qualified professional in a trade/business)	1 	2 	3 	9 	98 
d. Obtain an Associate’s degree	1 	2 	3 	9 	98 
e. Obtain a Bachelor’s degree	1 	2 	3 	9 	98 
f. Obtain a graduate degree	1 	2 	3 	9 	98 

[IF AGE IS > OR = 16]

B7. Please indicate how much each statement is like you?

	SELECT ONE RESPONSE PER ROW
	NO	MOSTLY NO	SOMEWHAT	MOSTLY YES	YES
a. I have talked about my education plans with an adult who cares about me..	0 	1 	2 	3 	4 
b. I know what type (college, trade school) education I need for the work I want to do..	0 	1 	2 	3 	4 
c. I know how to get into the school, training, or job I want after high school.	0 	1 	2 	3 	4 

The following questions are about employment.

B8. Have you ever had a job where you worked for pay?

1  Yes

0  No  GO TO B12

98  Choose not to answer  GO TO B12

IF B8 = 1

B9. How old were you when you first worked for pay? Your best estimate is fine.

| | | Years old

98  Choose not to answer

[IF B8 = 1 AND (B1 = 2 OR 3)]

B10. Do you work for pay during the school year?

1  Yes

0  No

98  Choose not to answer

[IF B8 = 1 AND (B1 = 2 OR 3)]

B11. Do you work for pay over the summer or during school vacations?

1  Yes

0  No

98  Choose not to answer

B12. What is your current employment status?

MARK ONE ONLY

1  Employed full-time (35 hours a week or more either at one job or multiple jobs)

2  Employed part-time (less than 35 hours per week)

3  Not employed, but seeking employment

4  Not employed and not seeking employment

5  Not employed because I have a disability that prevents me from working

6  Other

98  Choose not to answer

We are interested in some basic information about your recent income. Please answer these questions as accurately as you can as of today.

B13. Do you currently receive income from any source? (This does not include any income source that has been terminated.)

MARK ONE ONLY

1  Yes

0  No  GO TO B18

d  Don’t know

98  Choose not to answer  GO TO B18

IF B13 = 1 OR D

B14. Do you currently receive earned income from a job or business you own? (In other words, income from employment, such as wages, salary, or self-employment.)

MARK ONE ONLY

1  Yes

0  No  GO TO B16

d  Don’t know

98  Choose not to answer  GO TO B16

IF B14 = 1 OR D

B15. What is the current amount of money you receive monthly from earned income? (If too difficult to answer, you can give the amount of money received LAST month, as well as you can remember.)

$___________________

B16. Do you currently receive income from any other source? (For example, from public assistance, stipends, disability, panhandling, friends or family, etc.)

MARK ONE ONLY

1  Yes

0  No  GO TO B18

d  Don’t know

98  Choose not to answer  GO TO B18

IF B16 = 1 OR D

B17. What is the current amount of money you receive monthly from other sources? (If too difficult to answer, you can give the amount of money received LAST month, as well as you can remember.)

$___________________

[IF AGE IS > OR = 16]

B18. Have you ever…

	SELECT ONE RESPONSE PER ROW
	YES	NO
a. Developed a resume?	1 	0 
b. Filled out a job application?	1 	0 
c. Prepared for a job interview?	1 	0 
d. Used public transportation to get where you needed to go?	1 	0 

[IF AGE IS > OR = 16]

B19. Are the following statements like me?

	SELECT ONE RESPONSE PER ROW
	NO	MOSTLY NO	SOMEWHAT	MOSTLY YES	YES
a. I know how to develop a resume.	0 	1 	2 	3 	4 
b. I know how to fill out a job application.	0 	1 	2 	3 	4 
c. I know how to prepare for a job interview.	0 	1 	2 	3 	4 
d. I know how to use public transportation to get where I need to go.	0 	1 	2 	3 	4 

C. HOUSING

The following questions ask about housing, including any experience you may have had being homeless.

C1. Have you ever been homeless? This includes couch surfing, doubling up, living in a car, on the street or staying in a homeless shelter, or other place not meant to be a residence because you do not have a regular place to sleep at night.

1  Yes

0  No  GO TO C3

98  Choose not to answer  GO TO C3

If C1= 1

C2. When you have experienced homelessness, was this before you entered foster care, after you entered foster care, or both?

MARK ALL THAT APPLY

1  Only before entering foster care

2  Only after entering foster care

3  Both before and after entering foster care

98  Choose not to answer

ALL

C3. In the last 3 months, how many times have you moved or changed living situations? If you are in foster care, please include any times you chose to leave a placement (went AWOL or ran away), as well as times you moved from one placement to another.

1  None

2  1 time

3  2-4 times

4  5-9 times

5  10 or more times

C4. In which of the following places have you spent at least one night in the last 3 months? Please include only those places where you stayed out of necessity/because you had nowhere else to stay. Do not include places you stayed for fun (for example, to spend the night at a friend’s or boyfriend/girlfriend’s place, or to visit family).

MARK ALL THAT APPLY

1 □ At the house or apartment of a foster parent

2 □ In a house or apartment with my immediate family (parent or guardian) that we rent or own

3 □ At another family member’s house or apartment

4 □ At a group home

5 □ At my own apartment (I pay rent)

6 □ Temporarily staying with friends or couch surfing or doubling up

7 □ At my boyfriend/girlfriend/partner’s home

8 □ At a shelter

9 □ In a transitional housing program

10 □ A treatment facility or center (hospital, detox, etc.)

11 □ Inside a car, abandoned building, etc.

12 □ Outside in the park, on the street, in a tent, etc.

13 □ At a transit station (subway or bus station or the airport)

14 □ A jail, prison, or detention facility

15 □ Hotel/motel

16 □ Other (specify)

98 □ Choose not to answer

ON THE WEB SURVEY, ONLY RESPONSES SELECTED IN C4 WILL SHOW UP IN C5

C5. Now please think about the last month. Over the last month, where did you sleep most nights?

MARK ONE ONLY

1  At the house or apartment of a foster parent

2  In a house or apartment with my immediate family (parent or guardian) that we rent or own

3  At another family member’s house or apartment

4  At a group home

5  At my own apartment (I pay rent)

6  Temporarily staying with friends or couch surfing or doubling up

7  At my boyfriend/girlfriend/partner’s home

8  At a shelter

9  In a transitional housing program

10  A treatment facility or center (hospital, detox, etc.)

11  Inside a car, abandoned building, etc.

12  Outside in the park, on the street, in a tent, etc.

13  At a transit station (subway or bus station or the airport)

14  A jail, prison, or detention facility

15  Hotel/motel

16  Other (specify)

98  Choose not to answer

C6. How safe do you feel when you sleep [FILL FROM C5]?

MARK ONE ONLY

1  Very safe

2  Safe

3  Somewhat safe

4  Somewhat unsafe

5  Unsafe

6  Very unsafe

d  Don't know

98  Choose not to answer

C7. Have you ever run away and spent the night away from a foster care placement? A placement could include placement in a home with foster parents or placement in a group home.

1  Yes

0  No

98  Choose not to answer

The next few questions ask about your current or most recent foster care placement.

C10. Are you currently in foster care?

1  Yes  GO TO C19

0  No

d  Don’t know

98  Choose not to answer

IF C10=0

C11. Where are you currently living?

1  With parent(s)

2  With other relatives

3  Your own apartment

4  Hotel or motel

5  Friend’s apartment or home

6  Family member’s apartment/home

7  On the street

8  Residential treatment facility

9  Other (specify)

d  Don’t know

98  Choose not to answer

IF C10=0

C12. About how long have you been living in this place?

| | | Number [1-99]

1  years

2  months

3  weeks

[IF C10 = 0 or d or 98]

C13. Are you currently receiving other services or assistance provided by the [COUNTY NAME] Department of Human Services? That is, do you currently have an open case with the [COUNTY NAME] Department of Human Services or [COUNTY NAME] Child Welfare? You may also think of this as your foster care case.

1  Yes  GO TO C16

0  No

d  Don’t know  GO TO C16

98  Choose not to answer  GO TO C16

[If C13 = 0]

C15. What was the primary reason your [COUNTY NAME] Department of Human Services/Child Welfare case was closed?

MARK ONE ONLY

1  The county closed my case because I aged out of the system

2  I voluntarily closed my case after my 18th birthday

3  I was reunited with my biological parents or other relatives

4  I was adopted

5  My caregiver became my permanent legal guardian

6  I ran away and never returned to foster care

7  I exited to another system (for example, the criminal justice system or juvenile justice system)

8  I was unsuccessfully discharged from foster care

9  Other (specify)

d  Don’t know

98  Choose not to answer

[If C10 = 0]

C16. Which of the following best describes your last foster care placement?

MARK ONE ONLY

1  With my foster parent(s) who are unrelated to me

2  With relatives who are also my foster parents

3  In a group home or residential facility

4  In an independent living apartment

5  Placed somewhere else (specify)

d  Don’t know

98  Choose not to answer

3  2-4 times

4  5-9 times

5  10 or more times

[If C10 = 1]

C19. Which of the following best describes your current foster care placement?

MARK ONE ONLY

1  With my foster parent(s) who are unrelated to me

2  With relatives who are also my foster parents

3  In a group home or residential facility

4  In an independent living apartment

5  Placed somewhere else (specify)

d  Don’t know

98  Choose not to answer

[If C10 = 1]

C22. Now please think about where you currently live. How long have you been living at your CURRENT placement?

MARK ONE ONLY

1  Less than 3 months

2  3 months to 6 months

3  6 months to 1 year

4  1 to 5 years

5  6 to 10 years

6  More than 10 years

98  Choose not to answer

D. RELATIONSHIPS AND COMMUNICATION

The next few questions ask about your relationships and communication with people in your life.

D1. Are there people other than the professionals in your life you could call who would help you out in an emergency?

1  Yes

0  No  GO TO D3

98  Choose not to answer  GO TO D3

[IF D1 = 1]

D2. If yes, how many? Your best estimate is fine.

| | | people

d  Don’t know

D3. Do you have supportive connections with any of the following?

MARK ALL THAT APPLY

1 □ Spiritual or religious community

2 □ Sports teams, academic teams, or other programs like band, choir, theater, etc.

3 □ Clubs or organizations like YMCA, Boy Scouts, Girl Scouts, Boys and Girls Club, etc.

4 □ Mentor from a program (Big Brother/Big Sister, Urban League, Junior Achievement, etc.)

5 □ Friends

6 □ Family

7 □ Chafee worker or case manager

8 □ Other (specify)

D4. For each of the situations below, please indicate whether there are enough people you can count on, too few people, or no one you can count on.

	SELECT ONE RESPONSE PER ROW
	ENOUGH PEOPLE YOU CAN COUNT ON	TOO FEW PEOPLE	NO ONE YOU CAN COUNT ON	DON’T KNOW	CHOOSE NOT TO ANSWER
a. When you need to talk to someone about something personal or private – for instance, if you had something on your mind that was worrying you or making you feel down? Do you have…	1 	2 	3 	d 	98 
b. When you need advice or information – for example, if you didn’t know where to get something or how to do something you needed to do? Do you have…	1 	2 	3 	d 	98 
c. When you need someone to help you out – for instance, run an errand for you, lend you money, food, clothing or drive you somewhere you needed to go? Do you have…	1 	2 	3 	d 	98 

D5. For each of the people listed below, please indicate the strength of your relationship with them right now (very weak, weak, moderate, strong, very strong). In categories where there is more than one person, choose the most meaningful relationship and answer about that person.

You can list up to two additional people in the last two rows. Select the best response for each row.

• Very Weak: No Contact

• Weak: Infrequent contact; you can’t count on this adult for support.

• Moderate: Some contact with this adult but may not be consistent; you feel a connection but can’t count on this adult all the time.

• Strong: Contact at least once per month; you feel a connection of the heart, mind or spirit with this person; you can usually count on this person.

• Very Strong: Contact at least once per week; you feel a long-term connection of the heart, mind or spirit with this person; you can count on this person to be there for you when needed.

• N/A: Not applicable/does not apply to you because the person is deceased or you have no siblings or relatives.

	SELECT ONE RESPONSE PER ROW
	VERY WEAK	WEAK	MODERATE	STRONG	VERY STRONG	NOT APPLICABLE
a. Birth, adoptive or stepmother	1 	2 	3 	4 	5 	6 
b. Birth, adoptive or stepfather	1 	2 	3 	4 	5 	6 
c. Older brothers or sisters	1 	2 	3 	4 	5 	6 
d. Younger brothers or sisters	1 	2 	3 	4 	5 	6 
e. Other adult relatives such as aunts, uncles, or grandparents	1 	2 	3 	4 	5 	6 
f. Cousins	1 	2 	3 	4 	5 	6 
g. Friends	1 	2 	3 	4 	5 	6 
h. Other caring person (such as a current or former foster parent/guardian, Chafee worker, case manager, social worker, teacher, coworker, friend, coach, mentor, spiritual leader, counselor, therapist, etc.) List this person’s relationship to you:	1 	2 	3 	4 	5 	6 
i. Other caring person (such as a current or former foster parent/guardian, Chafee worker, case manager, social worker, teacher, coworker, friend, coach, mentor, spiritual leader, counselor, therapist, etc.) List this person’s relationship to you:	1 	2 	3 	4 	5 	6 

D6. We are interested in how you feel about the following statements. Read each statement carefully. Using the options provided, indicate how much or how little each statement feels like you.

	SELECT ONE RESPONSE PER ROW
	NOT AT ALL LIKE ME	A LITTLE LIKE ME	SORT OF LIKE ME	A LOT LIKE ME	VERY MUCH LIKE ME
a. There are people in my life who encourage me to do my best.	1 	2 	3 	4 	5 
b. I have someone who I can share my feelings and ideas with.	1 	2 	3 	4 	5 
c. I have someone in my life who I look up to.	1 	2 	3 	4 	5 
d. I have someone in my life who doesn’t judge me.	1 	2 	3 	4 	5 
e. I feel lonely.	1 	2 	3 	4 	5 
f. I have someone I can count on for help when I need it..	1 	2 	3 	4 	5 
g. I have someone who supports me in developing my interests and strengths.	1 	2 	3 	4 	5 
h. I have a friend or family member to spend time with on holidays and special occasions.	1 	2 	3 	4 	5 
i. I know for sure that somebody really cares about me.	1 	2 	3 	4 	5 
j. I have someone in my life who is proud of me.	1 	2 	3 	4 	5 
k. There is an adult family member who is there for me when I need them (for example, my birth or adoptive parent, spouse, adult sibling, extended family member, legal guardian, non-biological chosen family).	1 	2 	3 	4 	5 
l. There is an adult, other than a family member who is there for me when I need them.	1 	2 	3 	4 	5 
m. I have friends who stand by me during hard times.	1 	2 	3 	4 	5 
n. I feel that no one loves me.	1 	2 	3 	4 	5 
o. My spiritual or religious beliefs give me hope when bad things happen.	1 	2 	3 	4 	5 
p. I try to help other people when I can.	1 	2 	3 	4 	5 
q. I do things to make the world a better place like volunteering, recycling, or community service.	1 	2 	3 	4 	5 

D7. Please indicate how much you agree or disagree with the following statements:

	SELECT ONE RESPONSE PER ROW
	STRONGLY DISAGREE	DISAGREE	NEUTRAL	AGREE	STRONGLY AGREE
a. An adult has made a commitment to provide a permanent parent-like relationship to you.	1 	2 	3 	4 	5 
b. While in foster care, you have connected or re-connected with relatives or caring adults who will be lifelong supportive connections	1 	2 	3 	4 	5 
c. You are living with an adult who has or plans to adopt you or become your legal guardian	1 	2 	3 	4 	5 
d. You feel very disconnected from any caring adults	1 	2 	3 	4 	5 

The next few questions ask about your relationships and communication with friends.

D8. Are the following statements like me?

	SELECT ONE RESPONSE PER ROW
	NO	MOSTLY NO	SOMEWHAT	MOSTLY YES	YES
a. My relationships are free from hitting, slapping, shoving, being made fun of, or name calling	0 	1 	2 	3 	4 
b. I can deal with anger without hurting others or damaging things.	0 	1 	2 	3 	4 
c. I think about how my choices impact others.	0 	1 	2 	3 	4 

E. SOCIAL AND EMOTIONAL WELLBEING

The following questions are about your attitudes and feelings.

E1. We are interested in how you feel about the following statements. Read each statement carefully. Using the opinions provided, indicate how much or how little each statement feels like you.

	SELECT ONE RESPONSE PER ROW
	NOT AT ALL LIKE ME	A LITTLE LIKE ME	SORT OF LIKE ME	A LOT LIKE ME	VERY MUCH LIKE ME
a. I learn from my mistakes.	1 	2 	3 	4 	5 
b. I believe I will be okay even when bad things happen.	1 	2 	3 	4 	5 
c. I do a good job of handling problems in my life.	1 	2 	3 	4 	5 
d. I try new things even if they are hard.	1 	2 	3 	4 	5 
e. When I have a problem, I come up with ways to solve it.	1 	2 	3 	4 	5 
f. I give up when things get hard.	1 	2 	3 	4 	5 
g. I deal with my problems in a positive way (like asking for help).	1 	2 	3 	4 	5 
h. I keep trying to solve problems even when things don’t go my way.	1 	2 	3 	4 	5 
i. Failure just makes me try harder.	1 	2 	3 	4 	5 
j. No matter how bad things get, I know the future will be better.	1 	2 	3 	4 	5 

E2. Sometimes problems can get in the way of doing everyday activities. How hard is it for you to do each of the following?

	SELECT ONE RESPONSE PER ROW
	VERY DIFFICULT	SOMEWHAT DIFFICULT	NOT TOO DIFFICULT	NOT DIFFICULT AT ALL
a. Get along with adults outside the family (teachers, principals).	1 	2 	3 	4 
b. Control your emotions and stay out of trouble.	1 	2 	3 	4 
c. Express your feelings.	1 	2 	3 	4 

E3. Are the following statements like me?

	SELECT ONE RESPONSE PER ROW
	NO	MOSTLY NO	SOMEWHAT	MOSTLY YES	YES
a. I can take criticism and direction at school or work without losing my temper.	0 	1 	2 	3 	4 
b. I know how to act in social or professional situations.	0 	1 	2 	3 	4 

The next questions are about how you have been feeling in the past 30 days.

E4. During the past 30 days, about how often did you feel…

		SELECT ONE RESPONSE PER ROW
	NONE OF THE TIME	A LITTLE OF THE TIME	SOME OF THE TIME	A LOT OF THE TIME	MOST OF THE TIME	ALL OF THE TIME	DON’T KNOW	CHOOSE NOT TO ANSWER
a. nervous?	1 	2 	3 	4 	5 	6 	d 	98 
b. hopeless?	1 	2 	3 	4 	5 	6 	d 	98 
c. restless or fidgety?	1 	2 	3 	4 	5 	6 	d 	98 
d. so depressed that nothing could cheer you up?	1 	2 	3 	4 	5 	6 	d 	98 
e. that everything was an effort?	1 	2 	3 	4 	5 	6 	d 	98 
f. worthless?	1 	2 	3 	4 	5 	6 	d 	98 

E5. Please read each statement carefully. For each statement please mark whether, during the past month, you felt this way never, once or twice, about once a week, 2 or 3 times a week, almost every day, or every day. Give the best answer you can for each.

During the past month, how often did you feel….

	SELECT ONE RESPONSE PER ROW
	NEVER	ONCE OR TWICE	ABOUT ONCE A WEEK	2 OR 3 TIMES A WEEK	ALMOST EVERY DAY	EVERY DAY
a. Happy	1 	2 	3 	4 	5 	6 
b. Interested in life	1 	2 	3 	4 	5 	6 
c. Satisfied with life	1 	2 	3 	4 	5 	6 
d. That you had something important to contribute to society.	1 	2 	3 	4 	5 	6 
e. That you belonged to a community (like a social group, your school, or your neighborhood)	1 	2 	3 	4 	5 	6 
f. That our society is becoming a better place for people like you	1 	2 	3 	4 	5 	6 
g. That people are basically good	1 	2 	3 	4 	5 	6 
h. That the way our society works makes sense to you	1 	2 	3 	4 	5 	6 
i. That you liked most parts of your personality	1 	2 	3 	4 	5 	6 
j. Good at managing responsibilities of your daily life	1 	2 	3 	4 	5 	6 
k. That you had warm and trusting relationships with others	1 	2 	3 	4 	5 	6 
l. That you had experiences that challenged you to grow and become a better person	1 	2 	3 	4 	5 	6 
m. Confident to think or express your own ideas and opinions	1 	2 	3 	4 	5 	6 
n. That your life has a sense of direction or meaning to it.	1 	2 	3 	4 	5 	6 

E6. Now please think about your relationships with friends, family, and boyfriends or girlfriends. Not including horseplay or joking around, how many times in the past 3 months did……

	SELECT ONE RESPONSE PER ROW
	NEVER	ONCE OR TWICE	SOMETIMES	MANY TIMES	DON’T KNOW	CHOOSE NOT TO ANSWER
a. someone threaten to hurt you, and you thought you might really get hurt	1 	2 	3 	4 	d 	98 
b. someone push, grab, shake, or choke you	1 	2 	3 	4 	d 	98 
c. someone hit you	1 	2 	3 	4 	d 	98 
d. someone beat you up	1 	2 	3 	4 	d 	98 
e. someone steal or destroy your property	1 	2 	3 	4 	d 	98 
f. someone scare you without laying a hand on you	1 	2 	3 	4 	d 	98 

The next few questions ask about alcohol and drug use and other behaviors. All responses will remain private (your responses will not be shared with your case manager or the child welfare agency, etc.).

E7. During the past 30 days, on how many days did you drink alcohol?

1  0 days  GO TO E9

2  1 or 2 days

3  3 to 5 days

4  6 to 9 days

5  10 to 19 days

6  20 to 29 days

7  All 30 days

d  Don’t know

98  Choose not to answer

E8. In the past 30 days, has your use of alcohol caused social problems or caused you to give up, reduce, or have problems at important activities? This could include things like getting into fights, getting into trouble with others, or having problems at work, school, home, or social events.

1  Yes

0  No

d  Don’t know

98  Choose not to answer

E9. During the past 30 days, on how many days did you use marijuana?

1  0 days  GO TO E11

2  1 or 2 days

3  3 to 5 days

4  6 to 9 days

5  10 to 19 days

6  20 to 29 days

7  All 30 days

d  Don’t know

98  Choose not to answer

E10. In the past 30 days, has your use of marijuana caused social problems, or cause you to give up, reduce, or have problems at important activities? This could include things like getting into fights, getting into trouble with others, or having problems at work, school, home, or social events?

1  Yes

0  No

d  Don’t know

98  Choose not to answer

For the next few questions, please think about your use of drugs not including marijuana (for example, opioids such as fentanyl, heroin, oxycodone (OxyContin®), hydrodone (Vicodin®), codeine, morphine; amphetamines such as ecstasy, Molly, or Adderall; cocaine, etc. Please only include drugs that were not prescribed for you or were used in a way that was not prescribed for you.

E11. During the past 30 days, on how many days did you use other drugs (not including marijuana)?

1  0 days  GO TO E13

2  1 or 2 days

3  3 to 5 days

4  6 to 9 days

5  10 to 19 days

6  20 to 29 days

7  All 30 days

d  Don’t know

98  Choose not to answer

E12. In the past 30 days, has your use of other drugs caused social problems, or cause you to give up, reduce, or have problems at important activities? This could include things like getting into fights, getting into trouble with others, or having problems at work, school, home, or social events?

1  Yes

0  No

d  Don’t know

98  Choose not to answer

E13. Now please think about the past 3 months. During the past 3 months, how many times were you in a physical fight?

1  0 times

2  1 time

3  2 or 3 times

4  4 or 5 times

5  More than 5 times

d  Don’t know

E14. During the past 3 months, have you had sex without a condom or any other form of contraception?

1  Yes

0  No

98  Choose not to answer

F. INVOLVEMENT WITH THE CRIMINAL JUSTICE SYSTEM

The following section includes questions about possible involvement with the criminal justice system. When answering these questions, please think about any experiences you may have had with the juvenile justice system or with the adult criminal justice system.

F1. Have you ever been arrested?

1  Yes

0  No  GO TO SECTION G

98  Choose not to answer  GO TO SECTION G

[If F1 = 1]

F2. Have you been arrested in the past 3 months?

1  Yes

0  No

98  Choose not to answer

[If F1 = 1]

F3. How many times have you been arrested in your lifetime? Your best estimate is fine.

| | | times

d  Don’t know

98  Choose not to answer

[If F1 = 1]

F4. Have you ever been convicted of any of the following crimes? Please include any experiences you may have had with the juvenile justice system or with the adult criminal justice system.

MARK ONE ONLY

1  Misdemeanor

2  Felony

3  Both

4  Never been convicted

98  Choose not to answer

[If F1 = 1]

F5. Have you ever spent at least one night in jail, prison, or a youth correctional facility such as juvenile hall?

1  Yes

0  No

98  Choose not to answer

[If F1 = 1]

F6. Have you been incarcerated in the past 3 months?

1  Yes

0  No

98  Choose not to answer

G. PHYSICAL HEALTH

The following questions ask about your physical health.

G1. Do you currently have a health care provider such as a doctor, nurse, or nurse practitioner, that you see for regular, annual check-ups and when you have other medical issues?

MARK ONE ONLY

1  Yes – I seek medical care outside of urgent care centers or emergency rooms

2  Yes – I seek medical care only at urgent care centers or emergency rooms

0  No

d  Don’t know

G2. When did you last have a physical examination by a doctor, nurse practitioner, physician’s assistant or other health care professional? Your best estimate is fine.

MARK ONE ONLY

1  Never

2  Within the past 3 months

3  Within the past 3-6 months

4  Within the past 6-12 months

5  1-2 years ago

6  More than 2 years ago

d  Don’t know

98  Choose not to answer

G3. When was the last time you were tested for HIV/STDs? Your best estimate is fine.

MARK ONE ONLY

1  Never

2  Within the past 3 months

3  Within the past 3-6 months

4  Within the past 6-12 months

5  1-2 years ago

6  More than 2 years ago

d  Don’t know

98  Choose not to answer

G4. When did you last have a dental examination by a dentist or hygienist? Your best estimate is fine.

MARK ONE ONLY

1  Never

2  Within the past 3 months

3  Within the past 3-6 months

4  Within the past 6-12 months

5  1-2 years ago

6  More than 2 years ago

d  Don’t know

98  Choose not to answer

[ASK G5 THROUGH G8 ONLY AT FOLLOW-UP WITH YOUTH WHO ARE OUT OF CARE]

G5. Do you have health insurance?

MARK ONE ONLY

1  No health insurance  GO TO G8

2  Medicaid/Health First Colorado

3  Health insurance through employer

4  Other health insurance

5  Don’t know  GO TO G8

[If G5 ne to 1 or 5]

G6. Does your health insurance include coverage for mental health services?

1  Yes

0  No

d  Don’t know

[If G5 ne to 1 or 5]

G7. Does your health insurance include coverage for dental services?

1  Yes

0  No

d  Don’t know

G8. Was there a time in the past 3 months when you needed to see a doctor but could not because of cost?

1  Yes

0  No

d  Don’t know

98  Choose not to answer

H. ACCESS TO SERVICES

This section includes questions about accessing various services and supports.

ON THE WEB SURVEY, RESPONDENTS WILL ONLY BE ASKED IF THEY WERE ABLE TO ACCESS SERVICES

OR TREATMENTS (SECOND COLUMN) THEY INDICATED THEY WANTED TO ACCESS IN THE FIRST

COLUMN.

H1. During the past 3 months, did you want to access services or treatment for the following? If yes, were you able to access those services or treatments?

	SELECT ONE RESPONSE PER ROW
	DID YOU WANT TO ACCESS SERVICE OR TREATMENT?		IF YES, WERE YOU ABLE TO ACCESS THE SERVICE OR TREATMENT?
	NO	YES	NO	YES
a. Mental health (therapy, counseling)	1 	0 	1 	0 
b. Substance use or misuse (including drugs and alcohol)	1 	0 	1 	0 
c. Educational/learning disability	1 	0 	1 	0 
d. Developmental disability	1 	0 	1 	0 
e. Physical disability	1 	0 	1 	0 
f. Domestic violence	1 	0 	1 	0 
g. Family Therapy	1 	0 	1 	0 

ON THE WEB SURVEY, RESPONDENTS WILL ONLY BE ASKED IF THEY GOT HELP (SECOND COLUMN) FOR

ITEMS THEY INDICATED THEY WANTED HELP WITH IN THE FIRST COLUMN. ITEMS I THROUGH K WILL BE ASKED ONLY OF YOUTH NO LONGER IN CARE.

H2. During the past 3 months, did you want help with any of the following? If you wanted help, did you get help?

	SELECT ONE RESPONSE PER ROW
	DID YOU WANT HELP?		IF YES, DID YOU GET HELP?
	NO	YES	NO	YES
a. GED Prep	1 	0 	1 	0 
b. ACT or SAT Prep	1 	0 	1 	0 
c. College Applications	1 	0 	1 	0 
d. Planning a career or planning for job training	1 	0 	1 	0 
e. Resume Writing	1 	0 	1 	0 
f. Job interviewing	1 	0 	1 	0 
g. Finding a job	1 	0 	1 	0 
h. Learning how to budget or handle money	1 	0 	1 	0 
i. Assistance with finding an apartment or place to live	1 	0 	1 	0 
j. Help with completing apartment application	1 	0 	1 	0 
k. Help with a down payment or security deposit on an apartment	1 	0 	1 	0 

[ASK ONLY AT FOLLOW-UP OF YOUTH WHO ARE OUT OF CARE]

H3. During the past 3 months have you received…?

	SELECT ONE RESPONSE PER ROW
	YES	NO	DON’T KNOW	CHOOSE NOT TO ANSWER
a. Social Security payments, such as Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), or dependents’ payments?	1 	0 	d 	98 
b. Assistance payments, such as Temporary Assistance to Needy Families or TANF, general assistance, emergency assistance, or other welfare benefits?	1 	0 	d 	98 
c. Unemployment compensation payments?	1 	0 	d 	98 
d. Food stamps, also known as Supplemental Nutrition Assistance Program or SNAP benefits?	1 	0 	d 	98 
e. WIC benefits, also known as the Women, Infants and Children program?	1 	0 	d 	98 
f. Housing assistance from the government, such as living in public housing or receiving housing vouchers?	1 	0 	d 	98 
g. Payments from the [COUNTY] Department of Human Services?	1 	0 	d 	98 
h. Educational benefits for living expenses, tuition, or other education expenses, including the Colorado Education and Training Voucher program?	1 	0 	d 	98 
i. Other benefits or payments? (specify)	1 	0 	d 	98 

[ASK IF AGE > = 17]

H4. Are the following statements like me?

	SELECT ONE RESPONSE PER ROW
	NO	MOSTLY NO	SOMEWHAT	MOSTLY YES	YES
a. I know where to find information about job training.	0 	1 	2 	3 	4 
b. I know how to find financial aid to help pay for my education or training.	0 	1 	2 	3 	4 
c. I know how to get the benefits I am eligible for, such as Social Security, Medicaid, Temporary Assistance for Needy Families (TANF), and Education and Training Vouchers (ETV).	0 	1 	2 	3 	4 

I. PREPARING FOR ADULTHOOD

QUESTIONS IN THIS SECTION WILL ONLY BE ASKED OF YOUTH WHERE AGE IS > OR = 16

The next few questions ask about money management and preparing for the future.

I1. Do you have a checking account?

1  Yes

0  No

I2. Do you have a savings account?

1  Yes

0  No

I3. How much money do you have saved? Your best estimate is fine.

$ | | | , | | | | dollars

d  Don’t know

I4. How many credit cards do you have? Your best estimate is fine.

| | | credit cards

d  Don’t know

[If I4 > 0]

I5. How often do you pay at least the minimum amount due on your credit cards at the end of the month?

MARK ONE ONLY

1  Never

2  Sometimes

3  Most of the time

4  Always

d  Don’t know

The next few questions ask about some challenges you may have experienced during the past 3 months.

[ASK ONLY AT FOLLOW-UP OF YOUTH WHO ARE OUT OF CARE]

I6. Was there ever a time in the past 3 months when…

	SELECT ONE RESPONSE PER ROW
	YES	NO	DON’T KNOW	CHOOSE NOT TO ANSWER
a. You did not buy clothing or shoes that you needed because you did not have enough money?	1 	0 	d 	98 
b. You could not pay your rent or mortgage because you did not have enough money?	1 	0 	d 	98 
c. You were evicted or lost your house because you did not have enough money to pay the rent or mortgage?.	1 	0 	d 	98 
d. You could not pay a utility bill because you did not have enough money? By utility bill, we mean a bill for gas, electricity or telephone service.	1 	0 	d 	98 
e. Your cell phone or telephone service was shut off because you did not have enough money to pay your bill?	1 	0 	d 	98 
f. Your gas or electricity was shut off because you did not have enough money to pay your bill?	1 	0 	d 	98 

[ASK ONLY AT FOLLOW-UP OF YOUTH WHO ARE OUT OF CARE]

I7. Please mark whether you have had any of the following experiences in the past 3 months.

	SELECT ONE RESPONSE PER ROW
	YES	NO	DON’T KNOW	CHOOSE NOT TO ANSWER
a. Did you ever get food or borrow money for food from friends or relatives?	1 	0 	d 	98 
b. Did you ever put off paying a bill so that you would have money to buy food?	1 	0 	d 	98 
c. Did you ever get emergency food from a church, food pantry, or food bank?	1 	0 	d 	98 
d. Did you ever eat any meals at a soup kitchen or community meal program?	1 	0 	d 	98 

I8. Are the following statements like me?

	SELECT ONE RESPONSE PER ROW
	NO	MOSTLY NO	SOMEWHAT	MOSTLY YES	YES
a. I plan for the expenses that I must pay each month.	0 	1 	2 	3 	4 
b. I can figure out the costs to move to a new place, such as deposits, rents, utilities, and furniture.	0 	1 	2 	3 	4 
c. I use online banking to keep track of my money.	0 	1 	2 	3 	4 
d. I understand the advantages and disadvantages of making purchases with my credit card.	0 	1 	2 	3 	4 
e. I know the advantages and disadvantages of using a check cashing or payday loan store.	0 	1 	2 	3 	4 

I9. How ready do you feel for the following?

	SELECT ONE RESPONSE PER ROW
	NOT AT ALL PREPARED	SOMEWHAT PREPARED	VERY PREPARED	DON”T KNOW	CHOOSE NOT TO ANSWER
a. Living on your own?	1 	2 	3 	d 	98 
b. Getting a job?	1 	2 	3 	d 	98 
c. Managing your money?	1 	2 	3 	d 	98 
d. Finding housing?	1 	2 	3 	d 	98 
e. Arranging for health care?	1 	2 	3 	d 	98 
f. Completing your education?	1 	2 	3 	d 	98 
g. Planning for your future?	1 	2 	3 	d 	98 
h. Handling an emergency if it comes up?	1 	2 	3 	d 	98 

I10. Are the following statements like me?

	SELECT ONE RESPONSE PER ROW
	NO	MOSTLY NO	SOMEWHAT	MOSTLY YES	YES
b. I know what can happen if I break my lease	0 	1 	2 	3 	4 
c. I know how to fill out an apartment rental application	0 	1 	2 	3 	4 
d. I know how to find safe and affordable housing	0 	1 	2 	3 	4 
e. I know how to file my taxes	0 	1 	2 	3 	4 
f. I know how to read and interpret my credit report	0 	1 	2 	3 	4 

I11. Do you own a working car?

1  Yes  GO TO I13

0  No

[IF I11 = 0]

I12. Do you have consistent and reliable access to a working car?

1  Yes

0  No

[ASK ONLY IF OUT OF CARE]

I13. Do you have a plan for where to stay in an emergency?

1  Yes

0  No

d  Don’t know

I14. Which of the following documents do you currently have?

MARK ALL THAT APPLY

1 □ Social security card

2 □ State Driver’s License

3 □ State ID other than Driver’s License

4 □ Birth Certificate

5 □ Green Card

6 □ High School Transcript

7 □ Professional Resume

8 □ Credit Report

9  None of the Above

J. PARENTING

This section asks about any children you may have and their childcare.

J1. How many children do you have, including those not living with you? If you do not have any children, please enter “0”.

| | | children

d  Don’t know

98  Choose not to answer  GO TO SECTION K

[If J1 >0]

J2. Where do your children live?

MARK ALL THAT APPLY

1  With me

2  With the other parent

3  With a relative

4  In a foster home (not with me)

5  With adoptive family

6  Other (specify)

d  Don’t know

98  Choose not to answer

[If J1 >0]

J3. Have any of your children ever lived in foster care?

1  Yes

0  No

d  Don’t know

98  Choose not to answer

[If J2 = 1]

J4. Do you currently have childcare? This would include relatives who take care of your child, as well as paid childcare.

1  Yes

0  No

98  Choose not to answer

[If J2 = 1]

J5. Does your child/do your children have a health care provider, such as a doctor, nurse, or nurse practitioner, that he/she/they see for regular, annual check-ups and when they have other medical issues?

MARK ONE ONLY

1  Yes – my child(ren) has/have a health care provider outside of urgent care centers or emergency rooms

2  Yes – my child(ren) has/have a health care provider only at urgent care centers or emergency rooms

0  No

98  Choose not to answer

K. EMPOWERMENT

K1. The next questions ask how you feel about your life today and how you make decisions about the services and supports you may receive now or in the future. For each statement, please indicate how often you feel this way:

	SELECT ONE RESPONSE PER ROW
	ALWAYS OR ALMOST ALWAYS	MOSTLY	RARELY	SOMETIMES	NEVER OR ALMOST NEVER
a. I focus on the good things in life, not just the problems.	1 	2 	3 	4 	5 
b. I make changes in my life so I can live successfully with my emotional or mental health challenges.	1 	2 	3 	4 	5 
c. I worry that difficulties related to my mental health or emotions will keep me from having a good life.	1 	2 	3 	4 	5 
d. I know how to take care of my mental or emotional health.	1 	2 	3 	4 	5 
e. I feel my life is under control.	1 	2 	3 	4 	5 
f. When a service or support is not working for me, I take steps to get it changed.	1 	2 	3 	4 	5 
g. I tell service providers what I think about services I get from them.	1 	2 	3 	4 	5 
h. I believe that services and supports can help me reach my goals.	1 	2 	3 	4 	5 
i. I am overwhelmed when I have to make a decision about my services or supports.	1 	2 	3 	4 	5 
j. My opinion is just as important as my service providers’ opinion about in deciding about what services and supports and I need.	1 	2 	3 	4 	5 
k. I know the steps to take when I think I am receiving poor services or supports.	1 	2 	3 	4 	5 
l. I understand how my services and supports are supposed to help me.	1 	2 	3 	4 	5 
m. I work with providers to adjust my services or supports so they fit my needs.	1 	2 	3 	4 	5 

Thank you for completing the survey!

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