Service Receipt Questionnaire

Service Receipt Questionnaire

Start of Block: Consent

Q10 You are invited to participate in a research project about the Affordable Housing and Supportive Services Demonstration in your community. The Administration for Children and Families (ACF) at the U.S. Department of Health and Human Services is conducting this study to understand how the program is improving services for residents of this community.

This survey should take about 15 minutes to complete. This survey asks questions about the services you have received in the past six months. Because we want to understand how the program is improving services and outcomes for people over time, we may ask you to complete this survey again at 6 months. Your participation is voluntary, and you have the option to not respond to questions that you choose. Your participation or nonparticipation will not affect your services in this community. Your case worker or service coordinator can assist you in responding to the questions.

The research team will keep your information private. The data from the study will not contain information that can be used to identify you, like your name, contact information, or social security number. If your caseworker helps you complete the survey, you should know that they may have a responsibility to report certain information to the relevant authorities, such as suspected child abuse/neglect.

If you have questions about the study, please contact Juliana Melara via email at Juliana.Melara@acf.hhs.gov or (315) 744-2490. By completing this survey, you consent to participate in the research project.

Q8 Consent 

• I have read the above information and agree to participate in this research project. (1)

• I have read the above information and do not agree to participate in the research project. (2)

Skip To: End of Survey If Consent = I have read the above information and <strong>do not agree to participate</strong> in the research project.

Q7 PAPERWORK REDUCTION ACT OF 1995 (Public Law 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, ACF is gathering data on your grant program to understand the design and effectiveness of the program and to inform technical assistance needs. Public reporting burden for this collection of information is estimated to average 15 minutes per respondent. The control number is OMB #0970-0628 and the expiration date is ##/##/####. If you have any comments on this collection of information, please contact juliana.melara@acf.hhs.gov.  

End of Block: Consent

Start of Block: Background 

Background Thank you for agreeing to participate in Affordable Housing and Supportive Services Demonstration. First, please provide some background information.

Q2 What is your AHSSD Study Individual Unique Identifier? (A staff member will provide this number for you)

________________________________________________________________

Q3 What is your AHSSD Study Household Unique Identifier? (A staff member will provide this number for you)

_____________________________________________________

How long have you lived in your current housing?

• Less than a month (1)

• 1 to 3 months (2)

• 4 to 6 months (3)

• 7 to 9 months (4)

• 10 to 12 months (5)

• More than 12 months (6)

• Don't Know (7)

• Prefer not to answer (8)

How many children under the age of 18 live in your household?

________________________________________________________________

End of Block: Background 

Start of Block: Block 3

Please tell us about assistance you have received in the past 6 months. Please include help you have received from your housing community and help you have received from other organizations or programs.

In the past 6 months, have you received help with…

	Yes (1)	No (2)	Don't Know (3)	Prefer not to answer (4)
Planning your future career or educational goals? (1)
Finding a job or a better job? (2)
Learning about parenting or family skills? (3)
Learning about your personal or household finances? (4)
Enrolling your children in afterschool or recreational programs? (5)
Finding or paying for legal support? (6)
Obtaining food or clothing? (7)
Finding or paying for regularly scheduled child care or care for other dependents? (8)
Finding or paying for drop-in childcare or care for other dependents while you attend appointments, go to class, or take care of things? (9)
Finding, using, or paying for transportation? (10)
Finding or paying for housing? (11)
Paying for basic needs like water bills, heating bills, or food? (12)
Obtaining benefits like disability benefits, Temporary Assistance for Needy Families (TANF), Medicaid, and Unemployment Insurance? (13)
Obtaining documents you need, such as a social security card or photo identification? (14)
Training or education to learn a new job or skill? (15)
Getting treatment for problems related to substance use? (16)
Getting help for problems related to your emotions, nerves, anger management, or mental health? (17)
Getting treatment for any physical medical condition at a hospital clinic, or doctor’s office? (18)

End of Block: Block 3

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