Student Assent and Baseline Forms

For study staff use only
Student ID:

Contact Information

1. Please print your name, address, home telephone number, and e-mail address.

Name:
	Last name First name MI
Address (include number, street, apartment number, P. O. box, etc.)
	City State Zip Code
Telephone:	( ________ ) _________ - ___________	 I do not have a telephone
E-mail address:	_________________________________	 I do not have an e-mail address

2. Please provide the name of one parent or guardian with whom you live most of the time.

Name:
	Last name First name MI

3. What is your parent or guardian’s work phone number?

Work telephone:

( _______ ) ________ - __________ ext. ______

 Does not have a work telephone

4. Is your parent or guardian’s address and telephone number the same as yours?

Check one response:

• No

• Yes  Skip to Question 6

5. Please fill in your parent or guardian’s address and telephone number in the space below. If you don't know the complete address, fill in as much as you know.

Address (include number, street, apartment number, P. O. box, etc.
	City State Zip Code
Home telephone:	( ________ ) _________ - ___________	 She does not have a telephone

Please provide the names and contact information of TWO people close to you.

6. Please write in the name and telephone number of a relative or close friend who does not live with you and who will always know how to contact you.

Name:
	Last name First name MI
Telephone:	( ________ ) _________ - ___________

7. What is this person's relationship to you?

Check one response:

• A parent

• A grandparent

• An aunt or uncle

• A brother or sister

• A friend

• Other

8. Please write in the name and telephone number of another relative or close friend who does not live with you and who will always know how to contact you.

Name:
	Last name First name MI
Telephone:	( ________ ) _________ - ___________

9. What is this person's relationship to you?

Check one response:

• A parent

• A grandparent

• An aunt or uncle

• A brother or sister

• A friend

• Other

Background Information

10. What is your sex?

• Male

• Female

11. Are you Hispanic or Latino/Latina?

• Yes

• No

12. Please select one or more of the following choices to best describe your race.

Please select one or more:

• White

• Black/African American

• Asian

• Native Hawaiian or Other Pacific Islander

• American Indian or Alaska Native

13. Is English your native language (the first language you learned to speak when you were a child)?

• Yes

• No

14. When were you born?

__________ / __________ / __________

Month Day Year

15. What is the grade level and school you are attending this year (2006-2007)? What is the grade level and school you will be attending next year (2007-2008)?

	2006-2007 School Year	2007-2008 School Year
Grade level	7th 8th 9th 10th	8th 9th 10th 11th
School	(Name of School) Same school as last year	(Name of School) Same school as last year

Family Background

16. Do you have brothers and sisters? Include stepbrothers or stepsisters who live or have lived in your home.

• Yes

• No  Skip to Question 18

17. How many brothers and sisters do you have, how old are they, and are they in college?

	Brothers	Sisters
How many siblings do you have?	_________ Brothers	___________ Sisters
Are any older than 17 years old?	Yes No	Yes No
Are any of your siblings participating now in Upward Bound	Yes No	Yes No
Are any of your siblings in college?	Yes No	Yes No

18. How far in school did your parents go? Indicate your mother's (or female guardian’s) and father's (or male guardian’s) highest level of education.

Mother’s (or female guardian’s) highest level (Mark one response)	Father’s (or male guardian’s) highest level (Mark one response)
Did not finish high school	Did not finish high school
Graduated from high school or equivalent (GED)	Graduated from high school or equivalent (GED)
Graduated from high school and attended a two-year school (such as a vocational or technical school, a junior college, or a community college), but did not complete a degree	Graduated from high school and attended a two-year school (such as a vocational or technical school, a junior college, or a community college), but did not complete a degree
Graduated from a two-year school (such as a vocational or technical school, junior college, or a community college)	Graduated from a two-year school (such as a vocational or technical school, junior college, or a community college)
Graduated from high school and went to college, but did not complete a four-year degree	Graduated from high school and went to college, but did not complete a four-year degree
Graduated from college	Graduated from college
Completed a Master’s degree or equivalent	Completed a Master’s degree or equivalent
Completed a Ph.D., M.D., or other advanced professional degree	Completed a Ph.D., M.D., or other advanced professional degree
Don’t know	Don’t know
Does not apply	Does not apply

19. How far in school do you think your mother (or female guardian) and father (or male guardian) want you to go?

Your mother (or female guardian) (Mark one response)	Your father (or male guardian) (Mark one response)
Less than high school graduation	Less than high school graduation
High school graduation or GED only	High school graduation or GED only
Attend or complete a 2-year school course in a community or vocational school	Attend or complete a 2-year school course in a community or vocational school
Attend college, but not complete a 4-year degree	Attend college, but not complete a 4-year degree
Graduate from college	Graduate from college
Obtain a Master's degree or equivalent	Obtain a Master's degree or equivalent
Obtain a Ph.D., M.D., or other advanced degree	Obtain a Ph.D., M.D., or other advanced degree
Don't know	Don't know
Does not apply	Does not apply

20. How often do your parents or guardians do the following?

Please mark one response for each line.

	Never	Rarely	Sometimes	Often
Check on whether you have done your homework				
Help you with your homework				
Give you privileges as a reward for good grades				
Limit privileges because of poor grades				
Require you to do work or chores				
Limit the amount of time watching TV/playing video games				
Limit the amount of time going out with friends on school nights				

21. During the most recent semester or term of the school year, how often have you discussed the following with either or both of your parents or guardians?

Please mark one response for each line.

	Never	Sometimes	Often
Selecting courses or programs at school			
School activities or events of particular interest to you			
Things you've studied in class			
Your grades			
Transferring to another school			
Plans and preparation for ACT or SAT tests			
Going to college			
Community, national and world events			
Things that are troubling you			

22. Does your family have the following in your home?

Please mark one response for each line.

	Have	Does not have
A daily newspaper		
Regularly received magazine		
A computer		
Access to the Internet		
DVD player		
Electric dishwasher		
Clothes dryer		
More than 50 books		
A room of your own		
A fax machine		

School Experiences

23. At any time during middle school, junior high school, or high school, have you participated in any programs that help students prepare for college?

• Yes

• No  Skip to Question 25

23. If you participated in any programs that help prepare students for college, what are the names of the programs?

Program Name	Time in Program		Still Participating?
(Name of Program)	Under 1 month 1-3 months	Over 3 months	Yes No
(Name of Program)	Under 1 month 1-3 months	Over 3 months	Yes No
(Name of Program)	Under 1 month 1-3 months	Over 3 months	Yes No
(Name of Program)	Under 1 month 1-3 months	Over 3 months	Yes No

24. How did you hear about the Upward Bound program?

Please select one or more:

• From a guidance counselor at school?

• From one of your teachers?

• From your school principal or vice-principal?

• From a parent or relative?

• From your friends?

• By attending a school assembly or presentation on Upward Bound?

• Some other way? (Please write in:)

Future Plans

25. How important is each of the following to you in your life?

Please mark one response for each line.

	Not important	Somewhat important	Very important
Being successful in my line of work			
Finding the right person to marry and having a happy family life			
Having lots of money			
Having strong friendships			
Being able to find steady work			
Helping other people in my community			
Being able to give my children better opportunities than I’ve had			
Living close to parents and relatives			
Getting away from this area of the country			
Working to correct social and economic inequalities			
Having children			
Having leisure time to enjoy my own interests			
Becoming an expert in my field of work			
Getting a good education			

27. As things stand now, how far in school do you think you will get?

Mark one response:

• Less than high school graduation

• High school graduation or GED only

• Attend or complete a 2-year school course in a community or vocational school

• Attend college, but not complete a 4-year degree

• Graduate from college

• Obtain a Master's degree or equivalent

• Obtain a Ph.D., M.D., or other advanced degree

• Don’t know

26. Do you plan to continue your education after high school?

• Yes  Answer question 28a

• No, I don’t plan to continue my education after high school

• I don’t know if I will continue my education after high school

28a. Which of the following do you plan to attend?

Mark one response:

• Four-year college or university

• Two-year community college

• Vocational, technical or trade school

Thank you for completing this survey.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number The valid OMB control number for this information collection is 1850-0822; it expires MM/DD/YYYY. The time required to complete this information collection is estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

Upward Bound Baseline Information Form 1