Baseline Questionnaire for Youth Transition Process Demo

APPENDIX B
BASELINE QUESTIONNAIRE

MPR Reference No.: 6209-133
OMB Control No.: 0960-0687
Expiration Date:
6/30/2007

Youth Transition
Demonstration
Baseline Questionnaire
February 13, 2007

Karen CyBulski
Anne Ciemnecki

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

1

(2/13/07)

YTD BASELINE CONTACT MODULE

IF COLORADO:
FILL SPONSOR WITH “SOCIAL SECURITY ADMINISTRATION”
FILL PROGRAM NAME WITH “COLORADO YOUTH WINS“
IF CUNY:
FILL SPONSOR WITH “SOCIAL SECURITY ADMINISTRATION”
FILL PROGRAM NAME WITH “CUNY YOUTH TRANSITION DEMONSTRATION PROJECT”
IF ERIE:
FILL SPONSOR WITH “SOCIAL SECURITY ADMINISTRATION”
FILL PROGRAM NAME WITH “TRANSITION WORKS”
PROGRAMMER. If site is CUNY go to Hello_PG (always ask for parent at CUNY).
IF AGE < 18 GO TO Hello_PG.
SCRIPTS WHEN YOUTH IS AGE 18 OR OLDER
Hello_SM.
Hello, my name is [INTERVIEWER’S FULL NAME]. I am calling on behalf of
[SPONSOR/PROGRAM NAME]. May I please speak to (NAME) or (NAME’s)
legal guardian?
INTERVIEWER NOTE: IF NOT SPEAKING WITH ADULT, CONFIRM THAT
(HE/SHE) IS SM’s LEGAL GUARDIAN. OTHERWISE
SET CALLBACK IF SM NOT AVAILABLE.
SPEAKING TO SAMPLE MEMBER...............................1
SM COMES TO THE PHONE ........................................2

(LegalGuard1)

SPEAKING TO LEGAL GUARDIAN...............................3
GUARDIAN COMES TO THE PHONE ..........................4

(Consent_1_0)

WHAT IS CALL ABOUT .................................................5 (WhatAbout_SM)
SM/GUARDIAN BUSY, UNAVAILABLE, NOT HOME ..6 (CALL BACK)
SM MOVED/LIVES ELSEWHERE ................................7 (KnowWhere)
SM/GUARDIAN SPEAKS SPANISH
[Spanish-speaking interviewer - interim status 410] .......8
SM DOES NOT SPEAK ENGLISH OR SPANISH .........9
GUARDIAN DOES NOT SPEAK ENGLISH

(Interpret)

OR SPANISH .................................................................10
SM HAS HEALTH PROBLEM ........................................11 (HealthProb)
SM IN INSTITUTION ......................................................12 (Institution)
SM DECEASED .............................................................13 (Deceased)
WRONG NUMBER.........................................................14 (Locating)
HUNG UP DURING INTRODUCTION ...........................15 (HUDI)

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

1

(2/13/07)

WhatAbout_SM.
(NAME) should have received a letter explaining that we would be calling about a
research study that will help people with disabilities become as independent as
they can. May I please speak with (NAME) or (NAME’s) legal guardian?
INTERVIEWER NOTE: IF NOT SPEAKING WITH ADULT, CONFIRM THAT
(HE/SHE) IS SM’s LEGAL GUARDIAN. OTHERWISE
SET CALLBACK IF SM NOT AVAILABLE.
SM COMES TO THE PHONE ........................................1 (LegalGuard1)
GUARDIAN COMES TO THE PHONE ..........................2 (Consent)
SM/GUARDIAN BUSY, UNAVAILABLE, OR
NOT HOME ....................................................................3 (CALL BACK)
SM MOVED/LIVES ELSEWHERE .................................4 (KnowWhere)
SM/GUARDIAN SPEAKS SPANISH
[Spanish-speaking interviewer - interim status 410] .......5
SM DOES NOT SPEAK ENGLISH OR SPANISH .........6
GUARDIAN DOES NOT SPEAK ENGLISH
OR SPANISH .................................................................7

(Interpret)

SM/GUARDIAN PHYSICALLY OR MENTALLY
SM HAS HEALTH PROBLEM ........................................8 (HealthProb)

SCRIPTS WHEN YOUTH IS LESS THAN AGE 18
Hello_PG.

Hello, my name is [INTERVIEWER’S FULL NAME]. I am calling on behalf of
[SPONSOR/PROGRAM NAME]. May I please speak to a parent or guardian of
(NAME)?
SPEAKING TO PARENT................................................1 (Speaking)
PARENT COMES TO THE PHONE...............................2 (SampMemb)
WHAT IS CALL ABOUT .................................................3 (WhatAbout_PG)
PARENT BUSY, UNAVAILABLE, OR NOT....................4 (CALL BACK)
PARENT MOVED/LIVES ELSEWHERE ........................5 (Moved)
PARENT ONLY SPEAKS SPANISH
[Spanish-speaking interviewer - interim status 410] .......6
PARENT DOES NOT SPEAK ENGLISH
OR SPANISH .................................................................7 (Interpret)
YOUTH IS DECEASED..................................................8 (Dead)
NEVER HEAD OF SM....................................................9 (WrongNum)
HUNG UP DURING INTRODUCTION ...........................10 (HUDI)

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

2

(2/13/07)

WhatAbout_PG.
The parents or guardian of (NAME) should have received a letter explaining that
we would be calling about a research study that will help youth become as
independent as they can. Can I please speak with a parent or guardian of
(NAME)?
SPEAKING TO PARENT/COMES TO PHONE..............1 (ComeOn)
PARENT BUSY, UNAVAILABLE, OR NOT HOME........2 (CALL BACK)
PARENT MOVED/LIVES ELSEWHERE ........................3 (Moved)
PARENT ONLY SPEAKS SPANISH
[Spanish-speaking interviewer - interim status 410] .......4
PARENT DOES NOT SPEAK ENGLISH
OR SPANISH .................................................................5 (Interpret)
HUNG UP DURING INTRODUCTION ...........................6 (HUDI)

LegalGuard1. You should have received a letter explaining asking you to be in a research study
that will help young adults with disabilities become as independent as they can.
The study is being sponsored by the Social Security Administration. We are
calling because you receive benefits from Social Security.
Do you have a legal guardian? A legal guardian is someone who has the legal
authority to make decisions on your behalf?
YES ................................................................................1 (LegalGuard2)
NO ..................................................................................0 (SampMemb)

LegalGuard2. Before continuing the interview with you, I need to speak with your legal
guardian. Is your legal guardian available?
GUARDIAN COMES TO THE PHONE ..........................1 (Consent)
GUARDIAN BUSY, UNAVAILABLE, OR NOT HOME ...2 (CALL BACK)

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

3

(2/13/07)

COLORADO TEXT:
IF GUARDIAN COMES TO PHONE: Hello my name is ________. I am calling
on behalf of [PROGRAM NAME].
You or (NAME) should have received a letter asking (NAME) to be in a research
study that will help young adults with disabilities become as independent as they
can. The study is being sponsored by the Social Security Administration. We
are calling because (NAME) receives benefits from Social Security. To be in the
study your or (NAME) will be asked to answer interview questions three times. I
am calling today for the first interview. The interview questions take about 20
minutes to answer and are about (NAME), work and school, and how (he/she)
gets along day-to-day. (His/Her) participation is voluntary and all answers will be
held in strict confidence. If you agree, I will ask you or (NAME) the questions
now and when I am done, send you a form saying (NAME) want to be in the
study. When you complete the form and return it, (NAME) will get a $10.00 gift
card. In addition, (he/she) will get a $10.00 gift card after every research
interview for the study.
The letter also explained that half of the young adults who participate in the
research study will be offered extra services from Colorado Youth WINS. These
services will help (NAME) get services, understand (his/her) benefits, explore
career choices, and get a job. In addition to the extra services, (NAME) will also
get to use special rules that will protect the benefits (he/she) gets from Social
Security while (he/she) is in the study. Because Colorado Youth WINS does not
have space for everyone who might want to participate, we will randomly select
who gets to participate and who does not. Randomly selecting is like a lottery or
tossing a coin. It is a fair way to decide who gets services and who does not.
Most questions are worded so that young people with disabilities can answer for
themselves. There are a few questions for parents/guardians that I would like to
ask you first. Then I would like to continue with (NAME). It would be helpful for
you to stay nearby in case (NAME) needs help.
When we are done with the interview, I will mail you a form to sign saying that
(NAME) agrees to be a part of the study. We will review that form when we
complete the interview, or we can do it first if you prefer.
Do I have your permission to begin the interview?
YES, CONTINUE............................................................1 (GO TO Q.PAR1)
NOT A GOOD TIME ......................................................2 (CALL BACK)
REFUSED .....................................................................3 (REFUSAL)

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

5

(2/13/07)

Consent.

SCRIPT FOR LEGAL GUARDIAN AGE 18 OR OLDER.
PROGRAMMER: WE WILL HAVE TEXT FOR EACH SITE. THIS IS THE
GENERIC TEXT.
IF GUARDIAN COMES TO PHONE: Hello my name is ________. I am calling
on behalf of [PROGRAM NAME].
You or (NAME) should have received a letter asking (NAME) to be in a research
study that will help young adults with disabilities become as independent as they
can. The study is being sponsored by the Social Security Administration. We
are calling because (NAME) receives Social Security benefits. All you [or NAME]
needs to do to be in the study is be interviewed three times. I am calling today
for the first interview. The interview questions take about 15 minutes to answer
and are about (NAME), work and school, and how (he/she) gets along day-today. (His/Her) participation is voluntary and all answers will be held in strict
confidence. If you agree, I will ask you or (NAME) the questions now and when I
am done, send you a form saying (NAME) want to be in the study. When you
complete the form and return it, (NAME) will get $10.00. In addition, (he/she) will
get $10.00 after every research interview for the study.
The letter also explained that half of the young adults who participate in the
research study will be offered extra services from [PROGRAM NAME AND
DESCRIPTION]. These services will help (NAME) train for or find a job or get
ready for adulthood. In addition to the extra services, (NAME) will also get to use
special rules that will protect (his/her) Social Security benefits while (he/she) is in
the study. Because [PROGRAM NAME] does not have space for everyone who
might want to participate, we will randomly select who gets to participate and who
does not. Randomly selecting is like a lottery or tossing a coin. It is a fair way to
decide who gets services and who does not.
Most questions are worded so that young people with disabilities can answer for
themselves. There are a few questions for parents/guardians that I would like to
ask you first. Then I would like to continue with (NAME). It would be helpful for
you to stay nearby in case (NAME) needs help.
Do I have your permission to begin?
YES, CONTINUE............................................................1 (GO TO Q.PAR1)
NOT A GOOD TIME .......................................................2 (CALL BACK)
REFUSED ......................................................................3 (REFUSAL)

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

4

(2/13/07)

ERIE TEXT

SCRIPT FOR LEGAL GUARDIAN AGE 18 OR OLDER.
IF GUARDIAN COMES TO PHONE: Hello my name is ________. I am calling
on behalf of [PROGRAM NAME].
You or (NAME) should have received a letter asking (NAME) to be in a research
study that will help young adults with disabilities become as independent as they
can. The study is being sponsored by the Social Security Administration. We
are calling because (NAME) receives Social Security benefits. All you [or NAME]
needs to do to be in the study is be interviewed three times. I am calling today
for the first interview. The interview questions take about 15 minutes to answer
and are about (NAME), work and school, and how (he/she) gets along day-today. (His/Her) participation is voluntary and all answers will be held in strict
confidence. If you agree, I will ask you or (NAME) the questions now and when I
am done, send you a form saying (NAME) want to be in the study. When you
complete the form and return it, (NAME) will get a $10.00 Target gift card. In
addition, (he/she) will get a $10.00 gift card after every research interview for the
study.
The letter also explained that half of the young adults who participate in the
research study will be offered extra services from Transition WORKS. These
services will help (NAME) develop goals and work on plans to meet those goals.
Possible goals can include career exploration, education, and social
opportunities. Transition WORKS will help (NAME) find and keep a job that
matches (his/her) interests, abilities and goals. In addition to the extra services,
(NAME) will also get to use special rules that will protect (his/her) Social Security
benefits while (he/she) is in the study. Transition WORKS will work with you to
better understand (NAME’s) SSA benefits. Because [PROGRAM NAME] does
not have space for everyone who might want to participate, we will randomly
select who gets to participate and who does not. Randomly selecting is like a
lottery or tossing a coin. It is a fair way to decide who gets services and who
does not.
Most questions are worded so that young people with disabilities can answer for
themselves. There are a few questions for parents/guardians that I would like to
ask you first. Then I would like to continue with (NAME). It would be helpful for
you to stay nearby in case (NAME) needs help.
Do I have your permission to begin?
YES, CONTINUE............................................................1 (GO TO Q.PAR1)
NOT A GOOD TIME ......................................................2 (CALL BACK)
REFUSED .....................................................................3 (REFUSAL)

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

6

(2/13/07)

SampMemb. SCRIPT FOR SM IF AGE 18 OR OLDER.
PROGRAMMER: WE WILL HAVE TEXT FOR EACH SITE. THIS IS THE
GENERIC TEXT.
IF SM COMES TO PHONE: Hello my name is ________. I am calling on behalf
of [PROGRAM NAME].
You should have received a letter explaining asking you to be in a research study
that will help young adults with disabilities become as independent as they can.
The study is being sponsored by the Social Security Administration. We are
calling because you receive Social Security benefits.
All you need to do to be in the study is be interviewed three times. I am calling
today for the first interview. The interview questions take about 15 minutes to
answer and are about your work and school, and how you get along day-to-day.
Your participation is voluntary and all answers will be held in strict confidence. If
you agree, I will ask you the questions now and when I am done, send you a
form saying you want to be in the study. When you complete the form and return
it, you will get $10.00. In addition, you will get $10.00 after every research
interview for the study.
The letter also explained that half of the young adults who participate in the
research study will be offered extra services from [PROGRAM NAME AND
DESCRIPTION]. These services will help you train for or find a job or get ready
for adulthood. In addition to the extra services, you will also get to use special
rules that will protect your Social Security benefits while you are in the study.
Because [PROGRAM NAME] does not have space for everyone who might want
to participate, we will randomly select who gets to participate and who does not.
Randomly selecting is like a lottery or tossing a coin. It is a fair way to decide
who gets services and who does not.
The questions have been worded so you can answer for themselves. If you
wish, you can ask [LEGAL GUARDIAN’S NAME] to stay nearby in case you need
help.
May we begin the interview now?
YES, CONTINUE............................................................1 (GO TO Q.1)
NOT A GOOD TIME .......................................................2 (CALL BACK)
DID NOT RECEIVE LETTER/DOESN’T RECALL .........3 (NoLetter)
REFUSAL .......................................................................4 (REFUSAL)

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

7

(2/13/07)

COLORADO TEXT:
IF SM COMES TO PHONE: Hello my name is ________. I am calling on behalf
of [PROGRAM NAME].
You should have received a letter asking you to be in a research study that will
help young adults with disabilities become as independent as they can. The
study is being sponsored by the Social Security Administration. We are calling
because you receive benefits from Social Security. To be in the study your or
you will be asked to answer interview questions three times. I am calling today
for the first interview. The interview questions take about 20 minutes to answer
and are about you, work and school, and how you get along day-to-day. Your
participation is voluntary and all answers will be held in strict confidence. If you
agree, I will ask you or you the questions now and when I am done, send you a
form saying you want to be in the study. When you complete the form and return
it, you will get a $10.00 gift card. In addition, you will get a $10.00 gift card after
every research interview for the study.
The letter also explained that half of the young adults who participate in the
research study will be offered extra services from Colorado Youth WINS. These
services will help you get services, understand your benefits, explore career
choices, and get a job. In addition to the extra services, you will also get to use
special rules that will protect the benefits you get from Social Security while you
are in the study. Because Colorado Youth WINS does not have space for
everyone who might want to participate, we will randomly select who gets to
participate and who does not. Randomly selecting is like a lottery or tossing a
coin. It is a fair way to decide who gets services and who does not.
When we are done with the interview, I will mail you a form to sign saying that
you agree to be a part of the study. We will review that form when we complete
the interview, or we can do it first if you prefer.
Do I have your permission to begin the interview?
YES, CONTINUE............................................................1 (GO TO Q.1)
NOT A GOOD TIME .......................................................2 (CALL BACK)
DID NOT RECEIVE LETTER/DOESN’T RECALL .........3 (NoLetter)
REFUSAL .......................................................................4 (REFUSAL)

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

8

(2/13/07)

ERIE TEXT:

SCRIPT FOR SM IF AGE 18 OR OLDER.
IF SM COMES TO PHONE: Hello my name is ________. I am calling on behalf
of [PROGRAM NAME].
You should have received a letter explaining asking you to be in a research study
that will help young adults with disabilities become as independent as they can.
The study is being sponsored by the Social Security Administration. We are
calling because you receive Social Security benefits.
All you need to do to be in the study is be interviewed three times. I am calling
today for the first interview. The interview questions take about 15 minutes to
answer and are about your work and school, and how you get along day-to-day.
Your participation is voluntary and all answers will be held in strict confidence. If
you agree, I will ask you the questions now and when I am done, send you a
form saying you want to be in the study. When you complete the form and return
it, you will get a $10.00 Target gift card. In addition, you will get a $10.00 gift
card after every research interview for the study.
The letter also explained that half of the young adults who participate in the
research study will be offered extra services from Transition WORKS. These
services will help you develop goals and work on plans to meet those goals.
Possible goals can include career exploration, education, and social
opportunities. Transition WORKS will help you find and keep a job that matches
your interests, abilities and goals. In addition to the extra services, you will also
get to use special rules that will protect your Social Security benefits while you
are in the study. Transition WORKS will work with you to better understand your
SSA benefits. Because Transition WORKS does not have space for everyone
who might want to participate, we will randomly select who gets to participate and
who does not. Randomly selecting is like a lottery or tossing a coin. It is a fair
way to decide who gets services and who does not.
The questions have been worded so you can answer for themselves. If you
wish, you can ask [LEGAL GUARDIAN’S NAME] to stay nearby in case you need
help.
May we begin the interview now?
YES, CONTINUE............................................................1 (GO TO Q.1)
NOT A GOOD TIME .......................................................2 (CALL BACK)
DID NOT RECEIVE LETTER/DOESN’T RECALL .........3 (NoLetter)
REFUSAL .......................................................................4 (REFUSAL)

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

9

(2/13/07)

SCRIPT FOR PARENTS OF YOUTH UNDER AGE 18. THIS IS THE GENERIC TEXT.
IF SM COMES TO PHONE: Hello my name is ________. I am calling on behalf
of [PROGRAM NAME].
You should have received a letter asking (NAME) to be in a research study that
will help young adults with disabilities become as independent as they can. The
study is being sponsored by the Social Security Administration. We are calling
because (NAME) receives Social Security benefits. All you [or NAME] needs to
do to be in the study is be interviewed three times. I am calling today for the first
interview. The interview questions take about 15 minutes to answer and are
about (NAME), work and school, and how (he/she) gets along day-to-day.
(His/Her) participation is voluntary and all answers will be held in strict
confidence. If you agree, I will ask you or (NAME) the questions now and when I
am done, send you a form saying (NAME) want to be in the study. When you
complete the form and return it, (NAME) will get $10.00. In addition, (he/she) will
get $10.00 after every research interview for the study.
The letter also explained that half of the young adults who participate in the
research study will be offered extra services from [PROGRAM NAME AND
DESCRIPTION]. These services will help (NAME) train for or find a job or get
ready for adulthood. In addition to the extra services, (NAME) will also get to use
special rules that will protect (his/her) Social Security benefits while (he/she) is in
the study. Because [PROGRAM NAME] does not have space for everyone who
might want to participate, we will randomly select who gets to participate and who
does not. Randomly selecting is like a lottery or tossing a coin. It is a fair way to
decide who gets services and who does not.
Most questions have been worded so that young people with disabilities can
answer for themselves. There are a few questions for parents that I would like to
ask you first. Then I would like to continue with (NAME). It would be helpful for
you to stay nearby in case (NAME) needs help.
Do I have your permission to begin?
YES, CONTINUE............................................................1 (GO TO Q.PAR1)
NOT A GOOD TIME .......................................................2 (CALL BACK)
DID NOT RECEIVE LETTER/DOESN’T RECALL .........3 (NoLetter)
REFUSAL .......................................................................4 (REFUSAL)

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

10

(2/13/07)

SCRIPT FOR PARENTS OF YOUTH AT CUNY.
IF SM COMES TO PHONE: Hello my name is ________. I am calling on behalf
of [PROGRAM NAME].
You should have received a letter asking (NAME) to be in a research study that
will help young people with disabilities become more independent. The study is
being sponsored by the Social Security Administration. We are calling because
(NAME) receives Social Security benefits. All (NAME) needs to do to be in the
study is be interviewed three times. I am calling today for the first interview. The
interview questions take about 15 minutes to answer and are about (NAME),
work and school, and how (he/she) gets along day-to-day. (His/Her) participation
is voluntary and all answers will be held in strict confidence. If you agree, I will
ask you and (NAME) the questions now and when I am done, send you a form
for you and (NAME) to sign saying you want to be in the study. When you
complete the form and return it, (NAME) will get a $10.00 Metro Card. In
addition, (he/she) will get a $10.00 Metro Card after every research interview for
the study.
The letter also explained that half of the young adults who participate will be part
of a research study called the Youth Transition Demonstration Project. This is a
special program at CUNY colleges in the Bronx. The program meets on
Saturdays on either the Hostos Community College or Lehman College campus.
It includes recreation classes, workshops, job planning, and opportunities for paid
summer work. Parents also attend workshops on Saturdays. These workshops
help parents understand benefits from Social Security and the transition to adult
life.
(NAME) will also get to use special rules that will protect (his/her) Social Security
benefits while (he/she) is in the study. Because the Youth Transition
Demonstration program does not have space for everyone who might want to
participate, we will randomly select who gets to participate and who does not.
Randomly selecting is like a lottery or tossing a coin. It is a fair way to decide
who gets services and who does not. If (NAME) is selected for the program
(he/she) and a parent or guardian will be expected to attend the program on
Saturdays.
Most questions have been worded so that young people with disabilities can
answer for themselves. There are a few questions for parents that I would like to
ask you first. Then I would like to continue with (NAME). It would be helpful for
you to stay nearby in case (NAME) needs help.
Do I have your permission to begin?
YES, CONTINUE............................................................1 (GO TO Q.PAR1)
NOT A GOOD TIME .......................................................2 (CALL BACK)
DID NOT RECEIVE LETTER/DOESN’T RECALL .........3 (NoLetter)
REFUSAL .......................................................................4 (REFUSAL)

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

11

(2/13/07)

SCRIPT FOR PARENTS OF YOUTH UNDER AGE 18. THIS IS THE COLORADO TEXT.
IF SM COMES TO PHONE: Hello my name is ________. I am calling on behalf
of [PROGRAM NAME].
You should have received a letter asking you to be in a research study that will
help young adults with disabilities become as independent as they can. The
study is being sponsored by the Social Security Administration. We are calling
because you receive benefits from Social Security. To be in the study your or
you will be asked to answer interview questions three times. I am calling today
for the first interview. The interview questions take about 20 minutes to answer
and are about you, work and school, and how you get along day-to-day. Your
participation is voluntary and all answers will be held in strict confidence. If you
agree, I will ask you or you the questions now and when I am done, send you a
form saying you want to be in the study. When you complete the form and return
it, you will get a $10.00 gift card. In addition, you will get a $10.00 gift card after
every research interview for the study.
The letter also explained that half of the young adults who participate in the
research study will be offered extra services from Colorado Youth WINS. These
services will help you get services, understand your benefits, explore career
choices, and get a job. In addition to the extra services, you will also get to use
special rules that will protect the benefits you get from Social Security while you
are in the study. Because Colorado Youth WINS does not have space for
everyone who might want to participate, we will randomly select who gets to
participate and who does not. Randomly selecting is like a lottery or tossing a
coin. It is a fair way to decide who gets services and who does not.
When we are done with the interview, I will mail you a form to sign saying that
you agree to be a part of the study. We will review that form when we complete
the interview, or we can do it first if you prefer.
Do I have your permission to begin the interview?
YES, CONTINUE............................................................1 (GO TO Q.PAR1)
NOT A GOOD TIME .......................................................2 (CALL BACK)
DID NOT RECEIVE LETTER/DOESN’T RECALL .........3 (NoLetter)
REFUSAL .......................................................................4 (REFUSAL)

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

12

(2/13/07)

SCRIPT FOR PARENTS OF YOUTH UNDER AGE 18. THIS IS THE ERIE TEXT.
IF SM COMES TO PHONE: Hello my name is ________. I am calling on behalf
of [PROGRAM NAME].
You should have received a letter asking you to be in a research study that will
help young adults with disabilities become as independent as they can. The
study is being sponsored by the Social Security Administration. We are calling
because you receive benefits from Social Security. To be in the study your or
you will be asked to answer interview questions three times. I am calling today
for the first interview. The interview questions take about 20 minutes to answer
and are about you, work and school, and how you get along day-to-day. Your
participation is voluntary and all answers will be held in strict confidence. If you
agree, I will ask you or you the questions now and when I am done, send you a
form saying you want to be in the study. When you complete the form and return
it, you will get a $10.00 gift card. In addition, you will get a $10.00 gift card after
every research interview for the study.
The letter also explained that half of the young adults who participate in the
research study will be offered extra services from Transition WORKS. These
services will help (NAME) develop goals and work on plans to meet those goals.
Possible goals can include career exploration, education, and social
opportunities. Transition WORKS will help (NAME) find and keep a job that
matches (his/her) interests, abilities and goals. In addition to the extra services,
(NAME) will also get to use special rules that will protect (his/her) Social Security
benefits while (he/she) is in the study. Transition WORKS will work with you to
better understand (NAME’s) SSA benefits. Because Transition WORKS does
not have space for everyone who might want to participate, we will randomly
select who gets to participate and who does not. Randomly selecting is like a
lottery or tossing a coin. It is a fair way to decide who gets services and who
does not.
When we are done with the interview, I will mail you a form to sign saying that
you agree to be a part of the study. We will review that form when we complete
the interview, or we can do it first if you prefer.
Do I have your permission to begin the interview?
YES, CONTINUE............................................................1 (GO TO Q.PAR1)
NOT A GOOD TIME .......................................................2 (CALL BACK)
DID NOT RECEIVE LETTER/DOESN’T RECALL .........3 (NoLetter)
REFUSAL .......................................................................4 (REFUSAL)

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

13

(2/13/07)

NoLetter.

PROGRAMMER: WE WILL HAVE TEXT FOR EACH SITE. BELOW IS THE
GENERIC > 18 TEXT.
The letter explained that (your/NAME’s) name was selected from a list of persons
who receive SSI or SSDI benefits. The letter also explained that half of the youth
who participate in the research study will be offered services from [PROGRAM
NAME]. These services will help you train for a job or get ready for adulthood.
The letter also explained that we would be calling to interview you. The
questions should take about 15 minutes to answer. All of your answers will be
held in strict confidence. You can decide not to be in the study, or you can skip
questions, or drop out at any time, without loss of benefits. I can read the letter
to you now and we can begin the interview.
YES, CONTINUE............................................................1 (GO TO Q.1)
NOT A GOOD TIME .......................................................2 (CALL BACK)
WANTS ANOTHER LETTER .........................................3 (SendLetter)
REFUSAL .......................................................................4 (REFUSAL)

GENERIC < 18 TEXT
The letter explained that (NAME’s) name was selected from a list of youth who
receive SSI or SSDI benefits. The letter explained that half of the youth who
participate in the research study will be offered services from [PROGRAM
NAME]. These services will help (NAME) train for a job or get ready for
adulthood.
The letter also explained that we would be calling to interview you. The
questions should take about 15 minutes to answer. All of your answers will be
held in strict confidence. You can decide that (NAME) will not to be in the study,
or you can skip questions, or drop out at any time, without loss of benefits. I can
read the letter to you now and we can begin the interview.
YES, CONTINUE............................................................1 (GO TO PAR1)
NOT A GOOD TIME .......................................................2 (CALL BACK)
WANTS ANOTHER LETTER .........................................3 (SendLetter)
REFUSAL .......................................................................4 (REFUSAL)

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

14

(2/13/07)

CUNY TEXT:
The letter explained that (NAME’s) name was selected from a list of youth who
receive benefits from Social Security. The letter explained that half of the youth
who participate in the research study will be offered services from the Youth
Transition Demonstration. These services will help (NAME) become more
independent.
The letter also explained that we would be calling to interview you. The
questions should take about 20 minutes to answer. All of your answers will be
held in strict confidence. You can decide that (NAME) will not to be in the study,
or you can skip questions, or drop out at any time, without loss of benefits. I can
read the letter to you now and we can begin the interview.
YES, CONTINUE............................................................1 (GO TO PAR1)
NOT A GOOD TIME .......................................................2 (CALL BACK)
WANTS ANOTHER LETTER .........................................3 (SendLetter)
REFUSAL .......................................................................4 (REFUSAL)

SendLetter.

I would be happy to send another letter. Please tell me the address where I
should send the letter.
INTERVIEWER NOTE: ADDRESS ENVELOPE FOR REMAIL.
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:

StartNow.

That letter will be mailed today. Can we begin the interview now?
YES, BEGIN INTERVIEW ..............................................1 (GO TO Q1)
NO (INTERVIEWER SCHEDULE CALLBACK
IN 2 WEEKS) [letter requested - code 831]...................2 (CALL BACK)

HealthProb.

ENTER TYPE OF HEALTH PROBLEM
HEARING PROBLEM.....................................................1
SPEECH PROBLEM ......................................................2

(AmpTTY)

PHYSICAL PROBLEM ...................................................3 (CallLater)
COGNITIVE PROBLEM .................................................4 (NeedProxy)

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

15

(2/13/07)

CallLater.

Will (NAME) be able to talk on the telephone if I call back next week or will
(NAME) need help with the interview?
PROBE: The interview is designed to be answered by young adults with
disabilities.
YES/MAYBE WOULD ABLE TO DO NEXT WEEK........1 (CALL BACK)
NO, WOULD NEED HELP FROM A PROXY.................0 (NeedProxy)

AmpTTY.

I can get on a get a phone that will amplify my voice or (NAME’s), or we could
use a TTY service or instant messenger. Would either of these enable (NAME)
to complete the interview?
INTERVIEWER: IF SITE IS CUNY AND THE YOUTH IS DEAF, PLEASE PUT
THE CASE IN SUPERVISOR REVIEW.
YES - amplifier phone.....................................................1 (AmpPhone)
YES - TTY ......................................................................2 (CallTTY)
YES - instant messenger................................................3 (IMInterview)
NO ..................................................................................4 (NeedProxy)

AmpPhone.

Please hold while I get the amplifier phone.
INTERVIEWER: WHEN HAVE AMPLIFIER PHONE, ASK RESPONDENT TO
CALL SM TO THE PHONE.
SM COMES TO PHONE ................................................1 (SampMemb)
CALLBACK.....................................................................2 (CALLBACK)

CallTTY.

I will call back in a few minutes after I have the help of a TTY operator.
INTERVIEWER: NEED TO ARRANGE NEXT CALL WITH TTY OPERATOR.
ARRANGE CALL WITH TTY OPERATOR.....................1 (SampMemb)
IF UNSUCCESSFUL, SET CALLBACK .........................2 (CALLBACK)

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

16

(2/13/07)

IMInterview.

INTERVIEWER: NEED TO COMPLETE BASELINE USING INSTANT
MESSENGER.
SM COMES TO PHONE, BEGIN WITH IM....................1 (SampMemb)
CALLBACK.....................................................................2 (CALLBACK)

PROGRAMMER: IF SITE IS COLORADO GO TO A11.
SM DOESN’T SPEAK ENGLISH OR SPANISH
[FINAL STATUS INELIGIBLE - PROGRAM
CAN’T SERVE - 461]......................................................1
SM SPEAKS ENGLISH OR SPANISH...........................2

Interpret.

Perhaps there is someone who could interpret the questions on behalf of
(NAME)/(NAME’s) legal guardian. Is there someone there who can translate?
YES, SPEAKING TO INTERPRETER............................1
YES, BUT NOT A GOOD TIME......................................2

(InterpreterName)

NO INTERPRETER AVAILABLE ...................................3 (Lang)

InterpreterName.
IF SPEAKING WITH INTERPRETER: What is your name?
IF NOT SPEAKING WITH INTERPRETER: What is the interpreter’s name?
RECORD FIRST AND LAST NAME
BEGIN BASELINE..........................................................1 (SampMemb)
SCHEDULE CALLBACK [INTERIM STATUS 400] ........2 (CALL BACK)

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

17

(2/13/07)

Lang.

What language does (NAME) speak?
CHINESE (CANTONESE)..............................................1
CHINESE (MANDARIN) .................................................2
CHINESE (NON-SPECIFIED) ........................................3
HMONG..........................................................................4
ITALIAN ..........................................................................5
JAPANESE.....................................................................6
PORTUGUESE ..............................................................7
RUSSIAN........................................................................8
VIETNAMESE ................................................................9
OTHER ASIAN (SPECIFY) ............................................10
OTHER (SPECIFY) ........................................................11

LangCB.

Thank you. We will try to arrange for an interpreter to call (NAME).
SCHEDULE CALLBACK [INTERIM STATUS 400]

Deceased.

I am very sorry to hear that (he/she) passed away.
Thank you. Please accept my condolences. Good-bye.
[END INTERVIEW - FINAL STATUS 440 - DECEASED]

Institution.

ENTER TYPE OF INSTITUTION
HOSPITAL......................................................................1 (HomeSoon)
NURSING HOME ...........................................................2
ASSISTED LIVING FACILITY ........................................3

(Capable)

GROUP HOME...............................................................4
JAIL OR PRISON ...........................................................5 (Release)

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

18

(2/13/07)

HomeSoon.

Do you expect (NAME) to come home from the hospital within a week or two?
YES, APPOINTMENT MADE .........................................1 (CALL BACK)
SM UNABLE TO RESPOND, NEED PROXY ................2 (NeedProxy)

Release.

(NAME) should have received a letter explaining that we would be calling about a
research study that will help young adults become as independent as they can.
The study is being sponsored by the Social Security Administration. When do
you expect (NAME) to get out of jail?
INTERVIEWER: WILL SM BE OUT OF JAIL DURING THE BASELINE DATA
COLLECTION FIELD PERIOD?
IF YES, SCHEDULE CALL BACK FOR ANTICIPATED TIME
OF RELEASE.
IF NO, CODE NOT AVAILABLE DURING FIELD PERIOD.
APPOINTMENT MADE
[incarcerated -interim status 421] ...................................1
NOT AVAILABLE DURING FIELD PERIOD
[FINAL STATUS - 430] ...................................................2

Capable.

(NAME) should have received a letter explaining that we would be calling about a
research study that will help young adults become as independent as they can.
The study is being sponsored by the Social Security Administration. The
questions I will be asking are about (NAME), work and school, and how (he/she)
gets along day-to-day.
If I called (NAME) at the group facility, would (he/she) be able to answer
questions (himself/herself) or would someone need to answer on (his/her)
behalf?
SM COULD RESPOND..................................................1 (Facility)
SM COULD NOT RESPOND, NEED PROXY................2 (NeedPRoxy)

Facility.

I would like to talk to (NAME) over the telephone about this research study.
Where is (NAME) living?
NAME OF PLACE:

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

19

(2/13/07)

FacAddress. What is the address?
ADDRESS OF PLACE:

FacPhone.

What is the phone number?
INTERVIEWER: RECORD PHONE NUMBER ON CONTACT SHEET.
PHONE NUMBER OF PLACE:
INTERVIEWER: RECORD BEST TIME TO REACH SM ON CONTACT SHEET.
CALL SM AT NEW NUMBER.........................................1 (CALL BACK)

NeedProxy.

Perhaps there is someone who could answer the questions on behalf of (NAME).
Is there a (legal guardian family member or friend) who is knowledgeable about
(his/her) school and work experiences and how (he/she) gets along day-to-day?
YES, LEGAL GUARDIAN CAN PROXY.........................1 (ProxyName)
YES, PROXY OTHER THAN LEGAL GUARDIAN.........2 (ProxyName2)
NO PROXY AVAILABLE
[FINAL STATUS - NO PROXY 470] ...............................3

ProxyName.

May I please have (your/his/her) legal guardian’s name?

LEGAL GUARDIAN’S FIRST AND LAST NAME (GO TO ProxyRel)

ProxyName2. Who is the person who is most knowledgeable about (NAME’s) school and work
experiences and how (he/she) gets along day-to-day?
May I please have (your/his/her) name?

PROXY’S FIRST AND LAST NAME

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

20

(2/13/07)

ProxyRel.

How (are you/is proxy) related to (NAME)?
SPOUSE.........................................................................1
PARTNER ......................................................................2
SIBLING .........................................................................3
PARENT .........................................................................4
NIECE/NEPHEW............................................................5
OTHER RELATIVE.........................................................6
FRIEND ..........................................................................7
OTHER (SPECIFY) ........................................................8

Speaking.

INTERVIEWER: ARE YOU SPEAKING TO PROXY? IS PROXY AVAILABLE?
SPEAKING TO PROXY..................................................1 (ProxyStart)
NOT SPEAKING TO PROXY,
PROXY NOT AVAILABLE,
NEED TO GET MORE INFORMATION ........................2 (ProxyThere)

ProxyStart.

I’d like to begin the interview now.
BEGIN BASELINE IN ETO.............................................1 (GO TO Q.1)
SCHEDULE CALLBACK ................................................2 (CALL BACK)

ProxyThere.

Does (NAME OF PROXY) live at this phone number or do I need to call
somewhere else to speak with (him/her)?
PROXY LIVES AT THIS NUMBER SCHEDULE CALLBACK ................................................1 (CALL BACK)
PROXY LIVES ELSEWHERE ........................................2 (ProxyPhone)

ProxyPhone. May I please have (his/her) telephone number?
TELEPHONE NUMBER:

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

21

(2/13/07)

ProxyAddr.

And (his/her) address?
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:

(GO TO Thanks)

KnowWhere. (NAME) should have recently received a letter explaining that we calling about a
research study that will help young adults with disabilities become as
independent as they can. The study is being sponsored by the Social Security
Administration.
Do you know how we can reach (NAME)?
YES ................................................................................1 (NewPhone)
YES, NEED CALLBACK.................................................2 (CALLBACK)
NO [send to searching - interim status 530] ...................3

NewPhone.

Could you please give me the number where I can reach (him/her)?
INTERVIEWER: RECORD PHONE NUMBER AND ADDRESS ON CONTACT
SHEET.
TELEPHONE NUMBER:

New Address. May I please have (her/his) address?
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:

Thanks.

Thank you very much for your time. (exit case)

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

22

(2/13/07)

PARENT MODULE
PAR1.

INTERVIEWER: CODE IF ALREADY KNOWN.
To begin I’d like to ask some questions about you.
How are you related to (NAME)?
BIOLOGICAL/ADOPTIVE MOTHER ..............................1
BIOLOGICAL/ADOPTIVE FATHER ...............................2
FOSTER MOTHER ........................................................3
FOSTER FATHER..........................................................4
STEP MOTHER..............................................................5
STEP FATHER...............................................................6
GRANDMOTHER ...........................................................7
GRANDFATHER ............................................................8
AUNT..............................................................................9
UNCLE ...........................................................................10
OTHER RELATIVE (SPECIFY)......................................11
NONRELATIVE (SPECIFY) ...........................................12

PAR1a. What is your name?
FIRST NAME:
LAST NAME:

PAR2.

Does (NAME) live with you?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

23

(2/13/07)

5P.

What is (your/NAME’s) home address?
INTERVIEWER: IF R REFUSES PROBE FOR ZIP CODE.
PROBE: What street does (he/she) live on? In what town?
ADDRESS:
APARTMENT:
CITY:
|

|

ZIP CODE: |

|

STATE: |

PROGRAMMER:

5aP.

|

|

|

|-|

|

|

|

|

CHECK IF SM HAS AN ELIGIBLE ZIP CODE. IF INELIGIBLE, GO
TO 5aP, ELSE GO TO Q.6P.

I’m sorry (NAME) does not live in an area that is served by the Youth Transition
Demonstration. Thank you for your time.
[final status OUT OF AREA - INELIGIBLE]

6P.

And, what is (your/NAME’s) home telephone number?
(| | | |)-|
AREA CODE

|

|

|-|

|

|

|

|

NO HOME TELEPHONE NUMBER ...............................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

24

(2/13/07)

45P.

The next questions are about where (NAME) lives and who (he/she) lives with.
What type of place does (NAME) live in?
HOUSE...........................................................................1
APARTMENT .................................................................2
TRAILER ........................................................................3
PUBLIC HOUSING.........................................................4
GROUP HOME...............................................................5
NURSING HOME ...........................................................6

(GO TO Q.48P)

ASSISTED LIVING FACILITY ........................................7
OTHER INSTITUTION (SPECIFY).................................8
OTHER RESIDENTIAL (SPECIFY)................................9
DON’T KNOW ................................................................d
REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

25

(2/13/07)

44P.

Who does (NAME) live with?
INTERVIEWER:

BE SURE TO CODE RESPONDENT IF (HE/SHE) LIVES WITH
YOUTH.

PROGRAMMER:

IF CODE EQUALS 21 ONLY ONE RESPONSE CAN BE
ENTERED

PROBE: Does (NAME) live with anyone else?
CODE ALL THAT APPLY
BIOLOGICAL/ADOPTIVE MOTHER ..............................10
STEP/OTHER MOTHER ................................................11
FOSTER MOTHER ........................................................12
GRANDMOTHER ...........................................................13
AUNT..............................................................................14
SISTER...........................................................................15
BIOLOGICAL/ADOPTIVE FATHER ...............................16
STEP/OTHER FATHER .................................................17
FOSTER FATHER..........................................................18
GRANDFATHER ............................................................19
UNCLE ...........................................................................20
BROTHER ......................................................................21
SPOUSE OR PARTNER ................................................22
LEGAL GUARDIAN ........................................................23
SM’S CHILD ...................................................................24
FOSTER SIBLING..........................................................25
COUSIN..........................................................................26
FRIEND ..........................................................................27
ROOMMATE ..................................................................28
SOMEONE ELSE ...........................................................29
SM LIVES ALONE..........................................................30
DON’T KNOW ................................................................d
REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

26

(2/13/07)

44aP.

Of the people that (NAME) lives with, who are the head of the household?
PROGRAMMER:

DISPLAY ONLY ITEMS CODED IN QUESTION 44P THROUGH
CODE 14.

INTERVIEWER:

CODE PARENTS IF ALREADY KNOWN. CODE UP TO TWO
RESPONSES.

BIOLOGICAL/ADOPTIVE MOTHER ..............................1
STEP/OTHER MOTHER ................................................2
FOSTER MOTHER ........................................................3
GRANDMOTHER ...........................................................4
AUNT..............................................................................5
SISTER...........................................................................6
BIOLOGICAL/ADOPTIVE FATHER ...............................7
STEP/OTHER FATHER .................................................8
FOSTER FATHER..........................................................9
GRANDFATHER ............................................................10
UNCLE ...........................................................................11
BROTHER ......................................................................12
SPOUSE OR PARTNER ................................................13
LEGAL GUARDIAN ........................................................14
SM IS HEAD OF HOUSEHOLD .....................................15
DON’T KNOW ................................................................d
REFUSED ......................................................................r

46P.

Including (NAME), how many people live with (him/her)?
|

|

| NUMBER OF PEOPLE

DON’T KNOW ................................................................d
REFUSED ......................................................................r

47P.

Do any of the people who live with (NAME) have a disability?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d

(GO TO Q.48P)

REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

27

(2/13/07)

47aP.

Who has a disability?
CODE ALL THAT APPLY
BIOLOGICAL/ADOPTIVE MOTHER ..............................1
STEP/OTHER MOTHER ................................................2
FOSTER MOTHER ........................................................3
GRANDMOTHER ...........................................................4
AUNT..............................................................................5
SISTER...........................................................................6
BIOLOGICAL/ADOPTIVE FATHER ...............................7
STEP/OTHER FATHER .................................................8
FOSTER FATHER..........................................................9
GRANDFATHER ............................................................10
UNCLE ...........................................................................11
BROTHER ......................................................................12
SPOUSE OR PARTNER ................................................13
LEGAL GUARDIAN ........................................................14
SM’S CHILD ...................................................................15
FOSTER SIBLING..........................................................16
COUSIN..........................................................................17
FRIEND ..........................................................................18
ROOMMATE ..................................................................19
SOMEONE ELSE OVER AGE 18 (SPECIFY) ...............20
DON’T KNOW ................................................................d
REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

28

(2/13/07)

PROGRAMMER:

IF Q.44P EQUALS 1 OR 7 (FATHER OR MOTHER), SET Q.48P
EQUAL TO 0 (NOT IN FOSTER CARE), ASK Q.59P.
IF Q.44P EQUALS 2 OR 9 (FOSTER MOTHER OR FOSTER
FATHER), SET Q.48P EQUAL TO 1 (IN FOSTER CARE), ASK
Q.59P, ELSE ASK Q.48P.

48P.

Is (NAME) living in a foster care arrangement?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

PROGRAMMER:

HOW TO FILL MOTHER AND FATHER FOR QUESTIONS 59P62P.
IF Q.44aP EQUALS 15 ASK Q.31P (SM LIVES ALONE)
IF Q.45P EQUALS 5, 6, 7 or 8,ASK Q.31P (SM LIVES IN
INSTITUTION OR GROUP SETTING)
IF TWO RESPONSES ARE CODED IN Q.44aP, ASK Q.59P AND
Q.61P.
FILL LOWEST CODE IN “MOTHER” AND HIGHEST CODE IN
“FATHER”
IF ONE RESPONSE IS CODED IN Q.44aP AND CODE IS LESS
THAN “7” – THE HEAD OF HOUSEHOLD IS FEMALE -FILL
RESPONSE IN “MOTHER” AND ASK Q.59P
IF ONE RESPONSE IS CODED IN Q.44aP AND CODE IS 7 OR
HIGHER – THE HEAD OF HOUSEHOLD IS MALE OR
UNDETERMINED GENDER - FILL RESPONSE IN “FATHER”
AND ASK Q.61P

59P.

The next questions are about (NAME’s) (MOTHER).
Did (NAME’s) (MOTHER) graduate from high school?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d

(GO TO Q.60P)

REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

29

(2/13/07)

59aP.

Did (NAME’s) (MOTHER) graduate from a 2-year or a 4-year college?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

60P.

Is (NAME’s) (MOTHER) working now at a job for pay?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

60aP.

What does (NAME’s) (MOTHER) do at her job?
SPECIFY:
DON’T KNOW ................................................................d
REFUSED ......................................................................r
PROGRAMMER: IF FATHER IS BLANK, GO TO Q.31P

61P.

Now I’d like to ask about (NAME’s) (FATHER).
Did (NAME’s) (FATHER) graduate from high school?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d

(GO TO Q.62P)

REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

30

(2/13/07)

61aP.

Did (NAME’s) (FATHER) graduate from a 2-year or a 4-year college?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

62P.

Is (NAME’s) (FATHER) working now at a job for pay?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d

(GO TO Q.31P)

REFUSED ......................................................................r

62aP.

What does (NAME’s) (FATHER) do at her job?
SPECIFY:
DON’T KNOW ................................................................d
REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

31

(2/13/07)

31P.

(NAME) is included in this study because (he/she) is receiving SSI benefits. With what
physical, sensory, learning or other disabilities or problems has (NAME) been
diagnosed?
PROBE:

Does (he/she) have any other disabilities or learning problems? (That
could include a speech problem.)

INTERVIEWER: DO NOT READ CATEGORIES.
CODE ALL THAT APPLY
ASTHMA.........................................................................10
ATTENTION DEFICIT DISORDER (ADD) (ADHD)........11
AUTISM ..........................................................................12
BLINDNESS ...................................................................13
CEREBRAL PALSY........................................................14
DEAFNESS ....................................................................15
DEAFNESS AND BLINDNESS ......................................16
DOWN SYNDROME ......................................................17
DYSLEXIA ......................................................................18
EMOTIONAL DISTURBANCE/BEHAVIOR DISORDER
(ED, BD, HAVING EMOTIONAL PROBLEMS, SED) .....19
HARD OF HEARING/HEARING IMPAIRMENT ............20
HEALTH IMPAIRMENT (SPECIFY) ..............................21
LEARNING DISABILITY (LD).........................................22
MENTAL RETARDATION (EMR, TMR, SMR, MR) .......23
PHYSICAL OR ORTHOPEDIC IMPAIRMENT...............24
SPEECH/COMMUNICATION IMPAIRMENT ................25
SPINA BIFIDA ................................................................26
TRAUMATIC BRAIN INJURY (TBI)................................27
VISUAL IMPAIRMENT/PARTIAL SIGHT .......................28
DEVELOPMENTAL DELAY ...........................................29
OTHER (SPECIFY) ........................................................30
DON’T KNOW ................................................................d
REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

32

(2/13/07)

57P.

Is (NAME) now covered by any government-assisted or public health insurance such
as Medicare, Medicaid, (IF COLORADO: or Child Health Plan Plus, IF CUNY: Child
Health Plus, or Family Health Plus).
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

58P.

Is (NAME) now covered by private health insurance from an employer or union, or that
(NAME’s) family buys directly?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

13P.

Next, I would like to ask about special education. Special education is a program
designed to meet the individual needs of persons with special needs. It is paid for by
the public school system and may take place at a school, at home, or at a hospital.
Does (NAME) now receive any special education services or benefits?
PROBE: Do not include gifted or talented programs.
YES ................................................................................1 (GO TO Q.63P)
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

16P.

Did (NAME) ever receive special education services or benefits?
PROBE: Do not include gifted or talented programs.
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

33

(2/13/07)

63P.

Does (NAME) or does anyone in (his/her) household receive assistance from
temporary assistance to needy families, TANF, or [COLORADO: Colorado Works;
CUNY: Family Assistance]?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

63aP.

Does (NAME) or does anyone in (his/her) household receive assistance from food
stamps?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

64P.

Please tell me which group best describes the total income of all persons in (NAME’s)
household last year, including salaries or other earnings, money from public
assistance, retirement, and so on, for all household members, before taxes. Was
(his/her) household income last year . . .
PROBE IF IN FOSTER CARE: Please answer about the foster family (NAME) was
with last year.
Less than $10,000, .........................................................1
$10,000 or more, but less than $25,000,........................2
$25,000 or more, but less than to $50,000,....................3
$50,000 or more, but less than $75,000,........................4
$75,000 or more, but less than $100,000,......................5
Or was it $100,000 or more? ..........................................6
DON’T KNOW ................................................................d
REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

34

(2/13/07)

ASK4CHILD.

The next questions are about (NAME), (his/her) schooling, and work experience.
They have been worded so that young people with disabilities can answer for
themselves. It would be helpful for you to stay nearby in case (NAME) needs
help.
Is it possible for me to talk with (him/her) now?
INTERVIEWER: IF YOUTH NOT HOME, SCHEDULE A CALLBACK.
INTERVIEWER: IF YOUTH IS AT A DIFFERENT NUMBER, RECORD
NUMBER ON CONTACT SHEET. THANK RESPONDENT
AND CALL YOUTH AT NEW NUMBER.
YES, YOUTH COMES TO PHONE ...............................1 (GO TO Q.CHILD)
NO, YOUTH UNABLE TO RESPOND ...........................0
REFUSED TO GIVE CONSENT ....................................2

ASK4CHILD2. Okay. I can ask you these questions. As we go along, if you feel that (NAME)
would be able to answer the questions, you can put (him/her) on the phone.
(GO TO Q.1)

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

35

(2/13/07)

CHILD. SCRIPT FOR YOUTH UNDER AGE 18.
Hello. My name is (INTERVIEWER’S NAME). I am calling about a research study that
will help youth with disabilities become as independent as they can. The study is being
sponsored by the Social Security Administration. Your ([mother/father] has given me
permission to talk to you) and has already answered a few questions about your family.
Now, I would like to tell you about the study and see if you want to be part of it.
All you need to do to be in the study is be interviewed three times. I am calling today
for the first interview. The interview questions take about 15 minutes to answer and
are about your work and school, and how you get along day-to-day. Your participation
is voluntary and all answers will be held in strict confidence. If you agree, I will ask you
the questions now and when I am done, send a form for you and your parents to sign
saying you want to be in the study. When you complete the form and return it, you will
get $10.00. In addition, you will get $10.00 after every research interview for the study.
The letter also explained that half of the young adults who participate in the research
study will be offered extra services from (PROGRAM NAME AND DESCRIPTION).
These services will help you train for or find a job or get ready for adulthood. In
addition to the extra services, you will also get to use special rules that will protect
(his/her) Social Security benefits while (he/she) is in the study. Because (PROGRAM
NAME) does not have space for everyone who might want to participate, we will
randomly select who gets to participate and who does not. Randomly selecting is like
a lottery or tossing a coin. It is a fair way to decide who gets services and who does
not.
Most questions have worded so that young people with disabilities can answer for
themselves. If you want, you can ask your (mother/father) to stay nearby in case you
need help.
Can we begin?
YES, BEGIN INTERVIEW ..............................................1
NOT A GOOD TIME .......................................................2 (CALL BACK)
REFUSED ......................................................................3 (REFUSED)

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

36

(2/13/07)

CUNY TEXT:
Hello. My name is (INTERVIEWER’S NAME). I am calling about a research study that
will help youth with disabilities become as independent as they can. The study is being
sponsored by the Social Security Administration. Your ([mother/father] has given me
permission to talk to you) and has already answered a few questions about your family.
Now, I would like to tell you about the study and see if you want to be part of it.
To be in the study you will be asked to answer interview questions three times. Today
is the first interview. The interview questions take about 20 minutes to answer and are
about you, work and school, and how (he/she) gets along day-to-day. Your
participation is voluntary and all answers will be held in strict confidence. If you agree,
I will ask you the questions now and when I am done, send you a form saying you want
to be in the study. When you complete the form and return it, you will get a $10.00
MetroCard. In addition, you will get a $10.00 MetroCard after every research interview
for the study.
The letter also explained that half of the young adults who participate in the research
study will be offered extra services from the Youth Transition Demonstration Project.
This is a special program at CUNY colleges in the Bronx. The program meets on
Saturdays on either the Hostos Community College or Lehman College campus. It
includes recreation classes, workshops, job planning, and opportunities for paid
summer work. Parents also attend workshops on Saturdays.
In addition to the extra services, you will also get to use special rules that will protect
the benefits you get from Social Security while you are in the study. Because the
Youth Transition Demonstration program does not have space for everyone who might
want to participate, we will randomly select who gets to participate and who does not.
Randomly selecting is like a lottery or tossing a coin. It is a fair way to decide who gets
services and who does not.
When we are done with the interview, I will mail you a form to sign saying that you
agree to be a part of the study.
Most questions have worded so that young people with disabilities can answer for
themselves. If you want, you can ask your (mother/father) to stay nearby in case you
need help.
Can we begin?

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

37

(2/13/07)

COLORADO TEXT:
Hello. My name is (INTERVIEWER’S NAME). I am calling about a research study that
will help youth with disabilities become as independent as they can. The study is being
sponsored by the Social Security Administration. Your ([mother/father] has given me
permission to talk to you) and has already answered a few questions about your family.
Now, I would like to tell you about the study and see if you want to be part of it.
To be in the study you will be asked to answer interview questions three times. Today
is the first interview. The interview questions take about 20 minutes to answer and are
about you, work and school, and how (he/she) gets along day-to-day. Your
participation is voluntary and all answers will be held in strict confidence. If you agree,
I will ask you the questions now and when I am done, send you a form saying you want
to be in the study. When you complete the form and return it, you will get a $10.00 gift
card. In addition, you will get a $10.00 gift card after every research interview for the
study.
The letter also explained that half of the young adults who participate in the research
study will be offered extra services from Colorado Youth WINS. These services will
help you get services, understand your benefits, explore career choices, and get a job.
In addition to the extra services, you will also get to use special rules that will protect
the benefits you get from Social Security while you are in the study. Because Colorado
Youth WINS does not have space for everyone who might want to participate, we will
randomly select who gets to participate and who does not. Randomly selecting is like
a lottery or tossing a coin. It is a fair way to decide who gets services and who does
not.
When we are done with the interview, I will mail you a form to sign saying that (NAME)
agrees to be a part of the study. We will review that form when we complete the
interview, or we can do it first if you prefer.
Most questions have worded so that young people with disabilities can answer for
themselves. If you want, you can ask your (mother/father) to stay nearby in case you
need help.
Can we begin?

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

38

(2/13/07)

ERIE TEXT:
Hello. My name is (INTERVIEWER’S NAME). I am calling about a research study that
will help youth with disabilities become as independent as they can. The study is being
sponsored by the Social Security Administration. Your ([mother/father] has given me
permission to talk to you) and has already answered a few questions about your family.
Now, I would like to tell you about the study and see if you want to be part of it.
To be in the study you will be asked to answer interview questions three times. Today is
the first interview. The interview questions take about 20 minutes to answer and are
about you, work and school, and how (he/she) gets along day-to-day. Your participation
is voluntary and all answers will be held in strict confidence. If you agree, I will ask you
the questions now and when I am done, send you a form saying you want to be in the
study. When you complete the form and return it, you will get a $10.00 Target gift card.
In addition, you will get a $10.00 gift card after every research interview for the study.
The letter also explained that half of the young adults who participate in the research
study will be offered extra services from Transition WORKS. These services will help
you develop goals and work on plans to meet those goals. Possible goals can include
career exploration, education, and social opportunities. Transition WORKS will help you
find and keep a job that matches (his/her) interests, abilities and goals. In addition to the
extra services, you will also get to use special rules that will protect your Social Security
benefits while you are in the study. Transition WORKS will work with you to better
understand your SSA benefits. Because Transition WORKS does not have space for
everyone who might want to participate, we will randomly select who gets to participate
and who does not. Randomly selecting is like a lottery or tossing a coin. It is a fair way
to decide who gets services and who does not.
When we are done with the interview, I will mail you a form to sign saying that (NAME)
agrees to be a part of the study. We will review that form when we complete the
interview, or we can do it first if you prefer.
Most questions have worded so that young people with disabilities can answer for
themselves. If you want, you can ask your (mother/father) to stay nearby in case you
need help.
Can we begin?

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

39

(2/13/07)

PROGRAMMER: IF NAME IS ON THE DATA FILE, FILL Q.1 WITH NAME AND GO TO
Q.2.
1.

IF RESPONDENT IS THE YOUTH: To begin, I’d like to start with some easy questions.
They will be about you. The first question is . . .
IF RESPONDENT IS PROXY: (To begin/Next) I’d like to ask you some questions about
(NAME).
What is (your/NAME’s) full name?
FIRST NAME:
MIDDLE NAME:
LAST NAME:

PROGRAMMER: PUT INTRODUCTIONS ON SCREEN IF Q.1 WAS SKIPPED.
2.

IF RESPONDENT IS THE YOUTH: To begin, I’d like to start with some easy questions.
They will be about you. The first question is . . .
(Are you/Is [NAME]) a girl or a boy?
IF RESPONDENT IS PROXY: (To begin/Next) I’d like to ask you some questions about
(NAME).
INTERVIEWER: CODE IF ALREADY KNOWN.
Is (NAME) male or female?
GIRL/FEMALE................................................................1
BOY/MALE .....................................................................2

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

40

(2/13/07)

3.

How old (are you/is [NAME])?
|

|

| YEARS OLD

PROGRAMMER: RANGE IS 14 TO 26.
PROGRAMMER: IF AGE EQUALS 26, THEN GO TO Q5a.
PROGRAMMER: PLEASE ADD A CONSISTENCY CHECK ON AGE AND DATE OF
BIRTH.
PROGRAMMER: IF DATE OF BIRTH IS ON THE DATA FILE AND AGE AGREES
WITH THE AGE CALCULATED FROM DATE OF BIRTH, FILL Q.4
WITH DATE OF BIRTH AND GO TO Q.5.
PROGRAMMER: IF AGE DISAGREES WITH THE AGE CALCULATED FROM DATE
OF BIRTH, THEN ASK Q.4.

4.

What is (your/NAME’s) birthday?
PROBE: When were you born?
| | |/| | |/|
MONTH DAY

|

| |
YEAR

|

PROGRAMMER: IF Q.5P WAS ANSWERED, GO TO Q.7.

5.

What is (your/NAME’s) address?
PROBE: Where street do you live on? In what town?
INTERVIEWER: IF R REFUSES, PROBE FOR ZIP CODE.
ADDRESS:
APARTMENT:
CITY:
STATE: |

|

|

ZIP CODE: |

|

|

|

|

|-|

|

|

|

|

PROGRAMMER: CHECK IF SM HAS AN ELIGIBLE ZIP CODE. IF INELIGIBLE, GO
TO Q.5a, OTHERWISE GO TO Q.6.

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

41

(2/13/07)

5a.

IF NOT IN ZIP CODE: I’m sorry (you do/[NAME] does) not live in an area that is served
by the Youth Transition Demonstration. Thank you for your time.
IF AGE 26: I’m sorry the Youth Transition Demonstration can only serve young adults
up to age 25. Thank you for your time.
[final status - INELIGIBLE]

6.

What is (your/NAME’s) home telephone number?
(| | | |)-|
AREA CODE

|

|

|-|

|

|

|

|

NO HOME TELEPHONE NUMBER ...............................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

7.

What is (your/NAME’s) cell phone number?
(| | | |)-|
AREA CODE

|

|

|-|

|

|

|

|

NO CELL PHONE NUMBER .........................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

8.

What is (your/NAME’s) email address?
_____________________@_____________________
NO EMAIL ADDRESS ....................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

42

(2/13/07)

9.

These next questions are about school.
(Are you/Is [NAME]) attending or enrolled in school?
PROBE: (Do you/Does [NAME]) go to school?
PROBE: At school they teach (you/him/her) how to do things, like how to read, write, or
do math.
PROBE, IF NO: When was the last time (you/he/she) went to school?
PROBE IF SUMMER: Will (you/he/she) be going back to school in the fall?
YES ................................................................................1
NO ..................................................................................0 (GO TO Q.14)
DON’T KNOW ................................................................d
REFUSED ......................................................................r

10.

What is the name of (your/NAME’s) school?
PROBE: Where (do you/does [NAME]) go to school?
PROGRAMMER: FILL LIST OF SCHOOLS BY COUNTY HAVE AN OTHER SPECIFY
OPTION.
DON’T KNOW ................................................................d
REFUSED ......................................................................r

11.

What type of school (are you/is [NAME]) attending? Is it a . . .
Regular high school,.......................................................1
Special high school for persons with disabilities,............2
Post-secondary, vocational, technical, business
or trade school,...............................................................3
2-year college or community college, .............................4

(GO TO Q.15)

4-year college or university,............................................5
Or something else? (SPECIFY).....................................6 (GO TO Q.12)
SPECIAL EDUCATION NOT IN A SCHOOL .................7 (GO TO Q.17)
HOME SCHOOLED........................................................8
DON’T KNOW ................................................................d

(GO TO Q.12)

REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

43

(2/13/07)

12.

What grade in high school (are you/is [NAME]) attending?
PROBE IF SUMMER: What is the last grade (you/NAME) completed in school?
9TH GRADE/FRESHMAN IN HIGH SCHOOL ...............1
10TH GRADE/SOPHOMORE IN HIGH SCHOOL .........2
11TH GRADE/JUNIOR IN HIGH SCHOOL....................3
12TH GRADE/SENIOR IN HIGH SCHOOL ...................4
UNGRADED SCHOOL...................................................5
HOME SCHOOLED........................................................8
OTHER GRADE (SPECIFY) ..........................................9
DON’T KNOW ................................................................d
REFUSED ......................................................................r
PROGRAMMER: IF PARENT MODULE WAS ANSWERED, GO TO Q.17.

13.

This next question is about special education. Special education is a program designed
to meet the individual needs of persons with special needs. It is paid for by the public
school system and may take place at a school, at home, or at a hospital.
(Are you/Is [NAME]) now receiving any type of special education services or benefits?
PROBE: Do not include gifted or talented programs.
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r
(GO TO Q.17)

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

44

(2/13/07)

14.

What was the highest grade or year of school that (you/NAME) finished?
8TH GRADE OR LESS ..................................................1
9TH GRADE/FRESHMAN IN HIGH SCHOOL ...............2
10TH GRADE/SOPHOMORE IN HIGH SCHOOL .........3
11TH GRADE/JUNIOR IN HIGH SCHOOL....................4
12TH GRADE/SENIOR IN HIGH SCHOOL ...................5
COLLEGE OR TECHNICAL SCHOOL...........................6
UNGRADED SCHOOL...................................................7
HOME SCHOOLED........................................................8
OTHER GRADE (SPECIFY) ..........................................9
DON’T KNOW ................................................................d
REFUSED ......................................................................r

15.

(Do you/Does [NAME]) have a high school diploma, a GED, also known as a graduate
equivalency degree, a certificate of completion, or do you have none of these?
HIGH SCHOOL DIPLOMA .............................................1
GED................................................................................2
CERTIFICATE OF COMPLETION .................................3
NONE OF THESE ..........................................................4
DON’T KNOW ................................................................d
REFUSED ......................................................................r
PROGRAMMER: IF PARENT MODULE WAS ANSWERED, ASK Q.17.

16.

This next question is about special education. Special education is a program designed
to meet the individual needs of persons with special needs. It is paid for by the public
school system and may take place at a school, at home, or at a hospital.
Did (you/NAME) ever receive any type of special education services or benefits?
PROBE: Do not include gifted or talented programs.
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

45

(2/13/07)

17.

The next questions are about job training and work experiences (you have/[NAME] has)
had during the last year, that is since last (MONTH ONE YEAR AGO).
In the last year, did (you/NAME) receive any training in job skills, vocational education,
career counseling, or help in finding a job?
PROBE: (You/NAME) may have received these services through an internship, an
apprenticeship, a vocational rehabilitation program, a workforce development
center or one-stop career center.
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

19.

Next, please think about work (you have/[he/she] has) done for pay outside the home.
Don’t include chores that (you get/[NAME] gets) paid to do at home.
(Have you/Has [NAME]) ever worked for pay? This could include being a babysitter or
working for a neighbor.
YES ................................................................................1 (GO TO Q.20)
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

18.

In the last year, (have you/has [NAME]) done any volunteer work or community service
activities?
PROBE: You don’t get paid for volunteer work.
PROBE: Please include community service that is part of a school class or other group
activity.
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r
(GO TO Q.23)

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

46

(2/13/07)

20.

(Have you/Has [NAME]) worked for pay in the last year or so?
PROBE: When was the last time (you/he/she) worked for pay?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d

(GO TO Q.23)

REFUSED ......................................................................r

21.

[Have you/Has NAME] worked for pay in the last month or so?
PROBE: When was the last time (you/he/she) worked for pay?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

47

(2/13/07)

22.

PROGRAMMER: IF SM HAS NOT WORKED IN THE LAST MONTH (Q.21 = 0), ASK:
What did (you/NAME) do at (your/his/her) last job?
PROGRAMMER: IF SM HAS WORKED IN THE LAST MONTH (Q.21 = 1), ASK:
What (do you/does [NAME]) do at (your/his/her) job?
ASSEMBLY WORK, SORTING, STUFFING..................1
ANIMAL CARE – E.G., DOG WALKING,
VETERINARY HELPER .................................................2
CAMP COUNSELOR .....................................................3
CASHIER........................................................................4
CHILD CARE, INCLUDING BABYSITTING ...................5
CLEANING – E.G., JANITOR, MAID..............................6
CLERICAL – E.G., FILING, RECEPTIONIST,
SECRETARY, TYPIST ...................................................7
COMPUTER SUPPORT – E.G., DATA ENTRY,
PROGRAMMING, WEB PAGE DEVELOPMENT ..........8
DELIVERY – E.G., FOOD, NEWSPAPERS...................9
FARM LABORER – ANIMALS AND FIELDS .................10
FINANCIAL SERVICES-BANK TELLER ........................11
FOOD SERVICE – BUSBOY, WAITER, COOK.............12
GARDENING AND GROUNDS MAINTENANCE –
LAWN MOWING, GROUNDSKEEPING ........................13
GAS STATION ATTENDANT.........................................14
HEALTH CARE – PERSONAL CARE ATTENDANT,
NURSE’S AIDE ..............................................................15
MARKETING ADVERTISING.........................................16
MECHANIC (AUTO REPAIR).........................................17
RETAIL SALES ..............................................................18
SKILLED LABOR APPRENTICE – PLUMBER,
CARPENTER, ELECTRICIAN........................................19
SORTING, STUFFING ...................................................20
SPORTS RELATED – CADDY, UMPIRE,
REFEREE, COACH, LIFEGUARD,
TEACHING A SPORT ....................................................21
STOCK CLERKS – GROCERY, DRUG STORE............22
USHER – MOVIE THEATER..........................................23
OTHER (SPECIFY) ........................................................24
DON’T KNOW ................................................................d
REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

48

(2/13/07)

23.

The next questions are about computers.
(Do you/Does [NAME]) use a computer or the internet?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d

(GO TO Q.27)

REFUSED ......................................................................r

24.

On average, how often (do you/does [NAME]) use a computer or the internet? Would
you say that (you/NAME) use a computer or the internet almost every day, at least once
a week, at least once a month, or less often than that?
PROBE:

When was the last time (you/NAME) used a computer. And when was the
time before that?
ONCE A DAY .................................................................1
AT LEAST ONCE A WEEK ............................................2
AT LEAST ONCE A MONTH..........................................3
LESS THAN ONCE A MONTH.......................................4
DON’T KNOW ................................................................d
REFUSED ......................................................................r

THERE ARE NO QUESTIONS 25 OR 26 IN THIS VERSION

PROGRAMMER: IF RESPONDENT IS NOT YOUTH, GO TO Q.30.
QUESTIONS 27-29a ARE ASKED DIRECTLY OF THE YOUTH.

27.

The next questions are about your plans and goals for the next 5 years. For each one
please tell me which statement is what you will most likely do in the next 5 years.
First, I’d like you to think about where you will be living. In the next 5 years, do you plan
to be living with your parents or guardians, do you plan to be living on your own with help
from a counselor or aide, or do you plan to be living on your own without help?
WITH PARENTS OR GUARDIANS................................1
ON OWN WITH HELP....................................................2
ON OWN WITHOUT HELP ............................................3
DON’T KNOW ................................................................d
REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

49

(2/13/07)

28.

Next, I’d like you to think about your plans for school. In the next 5 years, do you plan to
graduate from high school, do plan to attend college or a technical school, or do you
have no plans for school.
GRADUATE FROM HIGH SCHOOL..............................1
ATTEND COLLEGE OR A TECHNICAL SCHOOL ........2
HAVE NO PLANS FOR SCHOOL..................................3
DON’T KNOW ................................................................d
REFUSED ......................................................................r

29.

Next, I’d like to you to think about your plans for getting a job. In the next five years, do
you plan to work part-time for pay, do you plan to work full-time for pay, or do you have
no plans for getting a job?
WORK FULL-TIME FOR PAY ........................................1
WORK PART-TIME FOR PAY .......................................2
NOT PLANS FOR GETTING A JOB ..............................3
DON’T KNOW ................................................................d
REFUSED ......................................................................r

30.

Now, I would like to ask you about (your/NAME’s) health.
In general, would you say that (your/NAME’s) health is . . .
Excellent, ........................................................................1
Very good, ......................................................................2
Good,..............................................................................3
Fair, or ............................................................................4
Poor? ..............................................................................5
DON’T KNOW ................................................................d
REFUSED ......................................................................r
PROGRAMMER: IF PARENT MODULE WAS ANSWERED, ASK Q.32.

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

50

(2/13/07)

31.

You are included in this study because you are receiving SSI benefits. With what
physical, sensory, learning or other disabilities or problems (have you/has [NAME]) been
diagnosed?
PROBE:

(Do you/Does [NAME]) have any other disabilities or learning problems?
(That could include a speech problem.)

PROBE:

Why (do you/does [NAME]) get SSI? Why (do you/does [NAME]) go to a
special school?

INTERVIEWER: DO NOT READ CATEGORIES.
CODE ALL THAT APPLY
ASTHMA.........................................................................1
ATTENTION DEFICIT DISORDER (ADD) (ADHD)........2
AUTISM ..........................................................................3
BLINDNESS ...................................................................4
CEREBRAL PALSY........................................................5
DEAFNESS ....................................................................6
DEAFNESS AND BLINDNESS ......................................7
DOWN SYNDROME ......................................................8
DYSLEXIA ......................................................................9
EMOTIONAL DISTURBANCE/BEHAVIOR DISORDER
(ED, BD, HAVING EMOTIONAL PROBLEMS, SED) .....10
HARD OF HEARING/HEARING IMPAIRMENT .............11
HEALTH IMPAIRMENT (SPECIFY) ...............................12
LEARNING DISABILITY (LD).........................................13
MENTAL RETARDATION (EMR, TMR, SMR, MR) .......14
PHYSICAL OR ORTHOPEDIC IMPAIRMENT...............15
SPEECH /COMMUNICATION IMPAIRMENT ................16
SPINA BIFIDA ................................................................17
TRAUMATIC BRAIN INJURY (TBI)................................18
VISUAL IMPAIRMENT/PARTIAL SIGHT .......................19
DEVELOPMENTAL DELAY ...........................................20
OTHER (SPECIFY) ........................................................21
DON’T KNOW ................................................................d
REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

51

(2/13/07)

32.

(Do you/Does [NAME]) use a wheelchair, scooter, walker, crutches or cane to move
around?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

34.

Some people use things to help them read, hear or speak, such as large print or Braille,
a screen reader, hearing aid, American sign language or ASL, TTY or TTD, or speech
recognition software.
(Do you/Does [NAME]) use anything like this?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d

(GO TO Q.36)

REFUSED ......................................................................r

35.

What (do you/does [NAME]) use?
LARGE PRINT OR BRAILLE .........................................1
SCREEN READER.........................................................2
ADAPTED COMPUTER KEYBOARD ............................3
HEARING AID OR HEARING DEVICE ..........................4
AMERICAN SIGN LANGUAGE (ASL)............................5
TTD/TTY.........................................................................6
SPEECH RECOGNITION SOFTWARE .........................7
OTHER (SPECIFY) ........................................................8
DON’T KNOW ................................................................d
REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

52

(2/13/07)

36.

(Do you/Does [NAME]) need the help of other persons with personal care needs such as
eating, bathing, dressing, or getting around inside the home?
YES ................................................................................1
NO ..................................................................................0
(GO TO Q.38)

DON’T KNOW ................................................................d
REFUSED ......................................................................r

37.

(Do you/Does [NAME]) need the help or supervision of other persons with . . .
YES

NO

a. Bathing or showering? ........................................................................

1

0

b. Dressing? ............................................................................................

1

0

c. Eating? ................................................................................................

1

0

d. Getting in or out of bed or chairs?.......................................................

1

0

e. Walking? .............................................................................................

1

0

f.

Getting outside? ..................................................................................

1

0

g. Using the toilet, including getting to the toilet?....................................

1

0

h. Getting around inside the home? ........................................................

1

0

33.

A personal care attendant is someone people hire to help them in daily tasks such as
bathing, dressing, and eating that they cannot do because of a disability or health
condition.
(Do you/Does [NAME]) receive any services from a personal care attendant, other than
a family member or friend?
PROBE:

This does not include personal care assistance that (you receive/[NAME]
receives) from staff at school as a part of the cost of attending that school.
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

53

(2/13/07)

38.

For the next set of activities, please tell me how often (you/NAME) (do/does) the activity
by (yourself/himself/herself).
The first (next) activity is (ACTIVITY). (Do you/Does [NAME]) do it by
(yourself/himself/herself) most of the time, some of the time, or none of the time.
IF NONE OF THE TIME: Could (you/NAME) ACTIVITY by yourself it if (you/he/she) had
the chance?
IF NONE, ASK:
Could you
ACTIVITY if you
had the chance?
MOST

SOME

NONE

YES

a. Deciding how to spend
(your/his/her) money .........................

NO

1

0

b. Picking clothes to wear .....................

1

2

3

1

0

c. Making snacks or sandwiches ..........

1

2

3

1

0

d. Riding public transportation alone.....

1

2

3

1

0

e. Deciding how to spend
(your/his/her) free time ......................

1

2

3

1

0

PROGRAMMER: IF PARENT MODULE WAS ANSWERED, ASK Q.49.
40.

The next questions are about where you live and who you live with.
(Do you/Does [NAME]) live alone or do you live with other people?
LIVE ALONE...................................................................1 (GO TO Q.49)
LIVE WITH OTHER PEOPLE.........................................0

41.

(Do you/Does [NAME]) live in a house or apartment with (your/his/her) family (or foster
family)?
YES ................................................................................1
NO ..................................................................................0

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

54

(2/13/07)

42.

(Do you/Does [NAME]) live in a group home or other residential family with other people
with disabilities and someone whose job it is to help (you/him/her)?
YES ................................................................................1 (GO TO Q.48)
NO ..................................................................................0

43.

Where (do you/does [NAME]) live?
HOUSE OR APARTMENT WITH FRIENDS ..................1
HOUSE OR APARTMENT WITH ROOM MATES .........2
NURSING HOME ...........................................................3
ASSISTED LIVING FACILITY ........................................4

(GO TO Q.48)

OTHER INSTITUTIONAL SETTING (SPECIFY)............5
OTHER RESIDENTIAL SETTING (SPECIFY) ...............6
DON’T KNOW ................................................................d
REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

55

(2/13/07)

44.

Who (do you/does [NAME]) live with?
PROBE: (Do you/Does [NAME]) live with anyone else?
CODE ALL THAT APPLY
BIOLOGICAL/ADOPTIVE MOTHER ..............................10
STEP/OTHER MOTHER ................................................11
FOSTER MOTHER ........................................................12
GRANDMOTHER ...........................................................13
AUNT..............................................................................14
SISTER...........................................................................15
BIOLOGICAL/ADOPTIVE FATHER ...............................16
STEP/OTHER FATHER .................................................17
FOSTER FATHER..........................................................18
GRANDFATHER ............................................................19
UNCLE ...........................................................................20
BROTHER ......................................................................21
SPOUSE OR PARTNER ................................................22
LEGAL GUARDIAN ........................................................23
SM’S CHILD ...................................................................24
FOSTER SIBLING..........................................................25
COUSIN..........................................................................26
FRIEND ..........................................................................27
ROOMMATE ..................................................................28
SOMEONE ELSE ...........................................................29
DON’T KNOW ................................................................d
REFUSED ......................................................................r

THERE IS NO QUESTION 45 IN THIS VERSION

46.

Including (yourself/NAME), how many people live with (you/him/her)?
|

|

| NUMBER OF PEOPLE

DON’T KNOW ................................................................d
REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

56

(2/13/07)

47.

Do any of the people who live with (you/him/her) have a disability?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d

(GO TO Q.48)

REFUSED ......................................................................r

47a.

Who has a disability?
CODE ALL THAT APPLY
BIOLOGICAL/ADOPTIVE MOTHER ..............................1
STEP/OTHER MOTHER ................................................2
FOSTER MOTHER ........................................................3
GRANDMOTHER ...........................................................4
AUNT..............................................................................5
SISTER...........................................................................6
BIOLOGICAL/ADOPTIVE FATHER ...............................7
STEP/OTHER FATHER .................................................8
FOSTER FATHER..........................................................9
GRANDFATHER ............................................................10
UNCLE ...........................................................................11
BROTHER ......................................................................12
SPOUSE OR PARTNER ................................................13
LEGAL GUARDIAN ........................................................14
SM’S CHILD ...................................................................15
FOSTER SIBLING..........................................................16
COUSIN..........................................................................17
FRIEND ..........................................................................18
ROOMMATE ..................................................................19
SOMEONE ELSE (SPECIFY) ........................................20

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

57

(2/13/07)

PROGRAMMER: IF PARENT MODULE WAS ANSWERED, ASK Q.49.
PROGRAMMER: IF Q.44 EQUALS 1 OR 7 (FATHER OR MOTHER), SET Q.48
EQUAL TO 0 (NOT IN FOSTER CARE), ASK Q.49.
IF Q.44 EQUALS 3 OR 9 (FOSTER MOTHER OR FOSTER
FATHER), SET Q.48 EQUAL TO 1 (IN FOSTER CARE), ASK Q.49,
ELSE ASK Q.48.
48.

(Are you/Is [NAME]) in foster care?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

PROGRAMMER: IF Q.44 or Q.44P EQUALS 24 (CHILD), SET Q.49 EQUAL TO (YES
– YOUTH HAS CHILDREN), ASK Q.50.
49.

(Do you/Does [NAME]) have any children?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d

(GO TO Q.52)

REFUSED ......................................................................r

50.

(You mentioned earlier that you live with your son/daughter).
How many children [do you/does NAME] have?
|

51.

|

| NUMBER OF PEOPLE

How old is (your/NAME’s) (youngest) child?
INTERVIEWER: IF LESS THAN ONE YEAR, CODE 0.
|

|

| YEARS

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

58

(2/13/07)

52.

(Are you/Is [NAME]) currently married?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

53.

(Do you/Does [NAME]) consider yourself to be of Hispanic or Latino origin, such as
Mexican, Puerto Rican, Cuban, or other Spanish background?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

54.

I’m going to read a list of race categories, please choose one or more races that best
describes (your/NAME’s) race? (Are you/Is [NAME]) . . .
INTERVIEWER: IF RESPONDENT SAYS MIXED RACE OR BI- OR MULTIRACIAL,
ASK WHICH RACES THE YOUTH REPRESENTS AND CODE
EACH.
PROBE: (Are you/Is [NAME]) white Hispanic or black Hispanic?
CODE ALL THAT APPLY
American Indian or Alaska Native ..................................1
Asian...............................................................................2
Black or African American ..............................................3
Native Hawaiian or Other Pacific Islander ......................4
White ..............................................................................5
OTHER (SPECIFY) ........................................................6
DON’T KNOW ................................................................d
REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

59

(2/13/07)

55.

What language (do you/does [NAME]) usually speak at home?
ENGLISH........................................................................1
SPANISH........................................................................2
OTHER LANGUAGE (SPECIFY) ...................................3
DON’T KNOW ................................................................d
REFUSED ......................................................................r

PROGRAMMER: IF PARENT MODULE WAS ANSWERED, ASK Q.65.
57.

The next questions are about (your/NAME’s) parents and (your/his/her) household. You
may need someone’s help to answer these questions.
First, I’d like to about you about health insurance. Health insurance helps pay for
medical expenses, like when you go to the doctor.
(Are you/Is [NAME]) now covered by any government-assisted or public health
insurance such as Medicare, Medicaid, (IF COLORADO: or Child Health Plan Plus, IF
CUNY: Child Health Plus, or Family Health Plus).
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

58.

(Are you/Is [NAME]) now covered by private health insurance from an employer or
union, or that (your/his/her) family buys directly?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

60

(2/13/07)

PROGRAMMER: IF YOUTH LIVES IN AN INSTITUTIONAL SETTING, ASK Q.65.
(Q.42 EQUALS 1 OR Q.43 EQUALS 3, 4 OR 5)
PROGRAMMER: IF YOUTH LIVES ALONE, ASK Q.65 (Q.40 EQUALS 1).
PROGRAMMER: HOW TO FILL MOTHER AND FATHER FOR QUESTIONS 59-62
FIRST TEST:

IF Q.44 EQUALS 1 (MOTHER) - FILL CODE IN ‘MOTHER’
IF Q.44 EQUALS 2 (STEP/OTHER MOTHER) AND MOTHER IS BLANK –
FILL CODE IN ‘MOTHER’ ELSE FILL CODE IN FATHER
IF Q.44 EQUALS 7 (FATHER) - FILL CODE IN ‘FATHER’
IF Q.44 EQUALS 8 (STE/OTHER FATHER) AND FATHER IS BLANK –
FILL CODE IN ‘FATHER’ ELSE FILL CODE IN MOTHER
IF MOTHER NOT BLANK, ASK Q.59
IF FATHER NOT BLANK, ASK Q.61, ELSE GO TO SECOND TEST

SECOND TEST:

IF Q.44 EQUALS 3 (FOSTER MOTHER) - FILL CODE IN ‘MOTHER’
IF Q.44 EQUALS 9 (FOSTER FATHER) - FILL CODE IN ‘FATHER’
IF MOTHER NOT BLANK, ASK Q.59
IF FATHER NOT BLANK, ASK Q.61, ELSE GO TO THIRD TEST

THIRD TEST:

IF Q.44 EQUALS 4 (GRANDMOTHER) - FILL CODE IN ‘MOTHER’
IF Q.44 EQUALS 10 (GRANDFATHER) - FILL CODE IN ‘FATHER’
IF MOTHER NOT BLANK, ASK Q.59
IF FATHER NOT BLANK, ASK Q.61, ELSE GO TO FOURTH TEST

FOURTH TEST:

IF Q.44 EQUALS 5 (AUNT) - FILL CODE IN ‘MOTHER’
IF Q.44 EQUALS 11 (UNCLE) - FILL CODE IN ‘FATHER’
IF MOTHER NOT BLANK, ASK Q.59
IF FATHER NOT BLANK ASK Q.61, ELSE GO TO FIFTH TEST

FIFTH TEST:

IF Q.44 EQUALS 14 (LEGAL GUARDIAN) - FILL CODE IN ‘MOTHER’
IF MOTHER NOT BLANK, ASK Q.59, ELSE GO TO SIXTH TEST

SIXTH TEST:

IF Q.44 EQUALS 15 (SPOUSE OR PARTNER) - FILL CODE IN ‘MOTHER’
IF MOTHER NOT BLANK, ASK Q.59, ELSE GO TO Q.63

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

61

(2/13/07)

59.

The next questions are about (your/NAME’s) (MOTHER).
Did (your/NAME’s) (MOTHER) graduate from high school?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d

(GO TO Q.60)

REFUSED ......................................................................r

PROGRAMMER: IF RESPONDENT IS YOUTH, GO TO Q.60
59a.

Did (NAME’s) (MOTHER) graduate from a 2-year or a 4-year college?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

60.

Is (your/NAME’s) (MOTHER) working now at a job for pay?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d

(GO TO Q.61)

REFUSED ......................................................................r

60a.

What does (NAME’s) (MOTHER) do at her job?
SPECIFY:
DON’T KNOW ................................................................d
REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

62

(2/13/07)

PROGRAMMER: IF FATHER IS BLANK, GO TO Q.63
61.

Now I’d like to ask about (NAME’s) (FATHER).
Did (your/NAME’s) (FATHER) graduate from high school?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d

(GO TO Q.62)

REFUSED ......................................................................r

PROGRAMMER: IF RESPONDENT IS YOUTH, GO TO Q.62
61a.

Did (your/NAME’s) (FATHER) graduate from a 2-year or a 4-year college?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

62.

Is (your/NAME’s) (FATHER) working now at a job for pay?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d

(GO TO Q.63)

REFUSED ......................................................................r

62a.

What does (NAME’s) (FATHER) do at her job?
SPECIFY:
DON’T KNOW ................................................................D
REFUSED ......................................................................R

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

63

(2/13/07)

63.

(Do you/Does [NAME]) or does anyone in (your/his/her) household receive assistance
from temporary assistance to needy families, TANF, or [COLORADO: Colorado Works;
CUNY: Family Assistance]?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

63a.

(Do you/Does [NAME]) or does anyone in (your/his/her) household receive assistance
from food stamps?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r

64.

Please tell me which group best describes the total income of all persons in
(your/NAME’s) household last year, including salaries or other earnings, money from
public assistance, retirement, and so on, for all household members, before taxes. Was
(your/his/her) household income last year . . .
PROBE IF IN FOSTER CARE: Please answer about the foster family (NAME) was with
last year.
Less than $10,000, .........................................................1
$10,000 or more, but less than $25,000,........................2
$25,000 or more, but less than to $50,000,....................3
$50,000 or more, but less than $75,000,........................4
$75,000 or more, but less than $100,000,......................5
Or was it $100,000 or more? ..........................................6
DON’T KNOW ................................................................d
REFUSED ......................................................................r

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

64

(2/13/07)

65.

You may need someone’s help to answer these questions.
As part of the research study it is important that we don’t lose touch with (you/NAME).
(Your/His/Her) (parents/foster parents/legal guardians) are people who can help us
contact (you/NAME) in the future.
INTERVIEWER: PLEASE CODE WHO WE NEED CONTACT INFORMATION FOR,
IF UNCERTAIN ASK RESPONDENT.
ONLY MOTHER .............................................................1
ONLY FATHER ..............................................................2 (GO TO Q.69)
MOTHER AND FATHER ................................................3
FOSTER PARENT .........................................................4 (GO TO Q.76)
LEGAL GUARDIAN ........................................................5 (GO TO Q.73)

66.

What is (your/his/her) mother’s name?
FIRST NAME:
LAST NAME:

PROGRAMMER: IF Q.44 EQUALS 1 (LIVES WITH MOTHER), FILL INFORMATION
FROM Q.5P OR Q.5 IN Q.67 AND ASK Q.68.
67.

What is her address?
ADDRESS
APARTMENT:
CITY:
STATE:
ZIP CODE:

68.

What is her telephone number?
(| | | |)-|
AREA CODE

|

|

|-|

|

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

|

|

|

65

(2/13/07)

PROGRAMMER: IF Q.65 EQUALS 3 (BOTH MOTHER AND FATHER), GO TO Q.69,
ELSE GO TO Q.79.
69.

What is (your/his/her) father’s name?
FIRST NAME:
LAST NAME:

PROGRAMMER: IF Q.44 EQUALS 1 AND 7 (LIVES WITH MOTHER AND FATHER),
ASK Q.79. IF Q.65 EQUALS 2 (ONLY FATHER), ASK Q.71.
70.

(Do your/Does [NAME’s]) mother and father live together?
YES ................................................................................1 (GO TO Q.79)
NO ..................................................................................0

PROGRAMMER: IF Q.44 or Q.44P EQUALS 2 (LIVES WITH FATHER), FILL
INFORMATION FROM Q.5P OR Q.5 IN Q.71 AND ASK Q.72.

71.

What is (your/his/her) father’s address?
ADDRESS
APARTMENT:
CITY:
STATE:
ZIP CODE:

72.

What is (your/his/her) father’s telephone number?
(| | | |)-|
AREA CODE

|

|

|-|

|

|

|

|

(GO TO Q.79)

73.

What is (your/his/her) legal guardian’s name?
FIRST NAME:
LAST NAME:

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

66

(2/13/07)

74.

What is (your/his/her) legal guardian’s address?
ADDRESS
APARTMENT:
CITY:
STATE:
ZIP CODE:

75.

What is (your/his/her) legal guardian’s telephone number?
(| | | |)-|
AREA CODE

|

|

|-|

|

|

|

|

(GO TO Q.79)

PROGRAMMER: IF Q.44P OR Q.44 EQUALS 3 (FOSTER MOTHER) ASK Q.76,
ELSE ASK Q.77.
76.

What is (your/NAME’s) foster mother’s name?
FOSTER MOTHER
FIRST NAME:
FOSTER MOTHER
LAST NAME:

PROGRAMMER: IF Q.44P OR Q.44 EQUALS 9 (FOSTER FATHER), ASK Q.77,
ELSE ASK Q.78.
77.

What is (your/NAME’s) foster father’s name?
FOSTER FATHER
FIRST NAME:
FOSTER FATHER
LAST NAME:

78.

What is (their/his/her) telephone number?
(| | | |)-|
AREA CODE

|

|

|-|

|

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

|

|

|

67

(2/13/07)

79.

Can you please tell me the name of a friend or relative who does not live with
(you/NAME) and would know how to reach (you/him/her) if (you move/[NAME] moves) or
(change your/changes [his/her]) telephone number?
What is his or her name?
FIRST NAME:
LAST NAME:

80.

What is his or her address?
ADDRESS
APARTMENT:
CITY:
STATE:
ZIP CODE:

81.

What is his or her telephone number?
(| | | |)-|
AREA CODE

82.

|

|

|-|

|

|

|

|

How is this person related to (you/NAME)?
SISTER...........................................................................1
BROTHER ......................................................................2
GRAND MOTHER ..........................................................3
GRANDFATHER ............................................................4
AUNT..............................................................................5
UNCLE ...........................................................................6
COUSIN..........................................................................7
FRIEND ..........................................................................8
OTHER RELATIVE.........................................................9

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

68

(2/13/07)

83.

Can you please tell me the name of a another friend or relative who does not live with
(you/NAME) and would know how to reach (you/him/her) if (you move/[NAME] moves) or
(change your/changes [his/her]) telephone number?
What is his or her name?
FIRST NAME:
LAST NAME:

84.

What is his or her address?
ADDRESS
APARTMENT:
CITY:
STATE:
ZIP CODE:

85.

What is his or her telephone number?
(| | | |)-|
AREA CODE

86.

|

|

|-|

|

|

|

|

How is this person related to (you/NAME)?
SISTER...........................................................................1
BROTHER ......................................................................2
GRAND MOTHER ..........................................................3
GRANDFATHER ............................................................4
AUNT..............................................................................5
UNCLE ...........................................................................6
COUSIN..........................................................................7
FRIEND ..........................................................................8
OTHER RELATIVE.........................................................9

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

69

(2/13/07)

87.

INTERVIEWER: DID SOMEONE HELP YOUTH ANSWER ANY OF THE
QUESTIONS?
YES ................................................................................1
PROXY ANSWERED ALL QUESTIONS........................2

(GO TO Q.D1)

NO ..................................................................................0

88.

HOW DID THAT PERSON HELP YOUTH?
CODE ALL THAT APPLY
TRANSLATED INTO ANOTHER LANGUAGE...............1
USED ASL......................................................................2
PROVIDED ANSWERS TO A FEW QUESTIONS ........3
PROVIDED ANSWERS TO MANY QUESTIONS ..........4
OTHER (SPECIFY) ........................................................5

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

70

(2/13/07)

SCRIPTS FOR WRITTEN CONSENT
D1.

INTERVIEWER: IS THE BASELINE COMPLETE?
YES, NEED TO SEND CONSENT PACKAGE ..............1 (GO TO Q.D4)
NO, SM IS INELIGIBLE..................................................2 (GO TO Q.D3)
NO, CALLBACK NEEDED ............................................3 (GO TO Q.D2)
NO, REFUSED TO CONTINUE
[NEW FINAL STATUS – SCREENER COMPLETE,
BASELINE REFUSAL] ...................................................4

D2.

INTERVIEWER: SCHEDULE A CALLBACK AND RECORD ON CONTACT SHEET.
[NEW INTERIM STATUS NEEDED – SCREENER
COMPLETE, BASELINE PARTIAL]

D3.

Thank you for helping with this study. Unfortunately (you do/[NAME] does) not meet
some of the eligibility requirements. Thank you for you helping with this important study.
[FINAL STATUS INELIGIBLE - DOESN’T MEET
SURVEY CRITERIA - 460]

D4.

Thank you for completing the interview. To continue to be in the research study, we will
(need you/or your parent or guardian) to sign a consent form. This is like a permission
slip.

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

71

(2/13/07)

D4a.

PROGRAMMER: WE WILL HAVE SPECIFIC TEXT FOR EACH SITE. THIS IS THE
GENERIC VERSION.
By signing the form, you are saying that you understand the study and want to continue
to be part of it. Let me review the important points about the study one more time before
I send the form:
If you agree to be in the study, four things will happen:
1.

The researchers at Mathematica will give (you/NAME) a chance to get services
support from (PROGRAM NAME). These services may help you train for or find a
job or get ready for adulthood. In addition to the extra services, (you/SM’s
[NAME]) will also get to use special rules that will protect (you/his/her) Social
Security benefits while (you are/[he/she] is) in the study. Because (PROGRAM
NAME) does not have space for everyone who might want to participate, we will
randomly select who gets to participate and who does not. Randomly selecting is
like a lottery or tossing a coin. It is a fair way to decide who gets services and who
does not.

2.

Mathematica will ask (you/NAME) to answer questions two more times—one year
from now, and three years from now. You can answer those questions by
telephone or in-person. Even if (you agree/[NAME] agrees) to be in the study
today, (you/NAME) do not have to answer questions in the future.

3.

Mathematica will send (you/NAME) a $10.00 gift card to say “thank you” for
answering questions. This money will not affect (your/his/her) Social Security
benefit.

4.

The researchers will look at records from Social Security or other agencies such as
__________________________________________________________________
____________________________________________. They may look at records
until (DATE).

I will be sending out a package of information within the next day or two that provides
more information about the research study.
The package will also contain forms that (your/[NAME’s] parent or legal guardian) and
(you/NAME) must sign and return to us.
The form will give more information about the research study. There will be a place for
you to mark whether (you/SM’s [NAME] want(s)) to participate or not. Please mark one
of these boxes, sign the form, and return it to us in the envelope that will be included in
the package.
Once we receive the form, we will send you a $10 gift card as a token of our
appreciation. You do not have to participate in the research study to receive the gift
card. If you do not return the form, (you/SM’s [NAME]) will not have a chance to be
selected for participation in (PROGRAM NAME) and you will not receive the gift card.
If you have any questions, you can call us toll-free at 800 298-3383.

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

72

(2/13/07)

COLORADO SCRIPT:
Thank you for completing the interview. To continue to be in the research study, we will
need you/or your parent or guardian to sign a consent form. This is like a permission
slip. By signing the form, you are saying that you understand the study and want to
continue to be part of it. Let me review the important points about the study one more
time before I send the form. If you agree to be in the study, four things will happen:
1.

The researchers at MPR will give (you/NAME) a chance to get support from
Colorado Youth WINS. The support will be from a team of three people who will
help (you/NAME) get services, understand (your/his/her) benefits, explore career
choices, and get ready to get a job. If (you are/[NAME] is) selected, (you/he/she)
will also be able to use special rules that are just for youth in the study. These
special rules will protect the benefits (you get/[NAME] gets) from Social Security.
MPR will select youth at random to see who gets the extra support. Selecting at
random is like a lottery or tossing a coin. It is a fair way to make sure that everyone
who wants to get the extra support has a fair chance of getting it.

2.

Mathematica will ask (you/NAME) to answer questions two more times—one year
from now, and three years from now. You can answer those questions by
telephone or in-person. Even if (you agree/[NAME] agrees) to be in the study
today, (you/NAME) do not have to answer questions in the future.

3.

Mathematica will send (you/NAME) a $10.00 gift card to say “thank you” for
answering questions. This money will not affect the benefits (you get/[NAME] gets)
from Social Security.

4.

The researchers will look at records from Social Security or other agencies such as
the Division of Vocational Rehabilitation (DVR), Unemployment Insurance Wage
Records, Colorado Temporary Assistance to Needy Families (TANF), Colorado
Food Stamps, Colorado Workforce Database (Job Link), Local Community Center
Board (CCB), or Colorado Department of Environment and Health. They may look
at records until DATE.

I will be sending out a package of information within the next day or two that provides
more information about the research study. The package will also contain forms that
(your/[NAME’s] parent or legal guardian) and (you/NAME) must sign and return to us.
The form will give more information about the research study. There will be a place for
you to mark whether (you want/[NAME] wants) to participate or not. Please mark one of
these boxes, sign the form, and return it to us in the envelope that will be included in the
package.
Once we receive the form, we will send you a $10 gift card as a token of our
appreciation. You do not have to participate in the research study to receive the gift
card. If you do not return the form (you/NAME) will not have a chance to be selected for
participation in Colorado Youth WINS and you will not receive the gift card.
If I have any questions about this study, you can call Karen CyBulski at MPR. Her
number is 609-936-2797 or 800-951-7357.
Thank you again for participating in the study

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

73

(2/13/07)

CUNY SCRIPT:
Thank you for completing the interview. To continue to be in the research study, we will
need (you/NAME) and (your/his/her) parent or guardian to sign a consent form. This is
like a permission slip. By signing the form, you are saying that you understand the study
and want to continue to be part of it. Let me review the important points about the study
one more time before I send the form. If you agree to be in the study, five things will
happen:
1.

The researchers at MPR will give (you/NAME) a chance to get support from
CUNY’s Youth Transition Demonstration Project. This 20-month program includes:
!
!
!
!
!

Saturday activities at one of the CUNY colleges in the Bronx, including
recreation classes and job classes for (you/NAME), and information and support
classes for (your/his/her) parents.
Person-Centered Planning Meetings for (you/NAME) and (your/his/her) family.
Benefits Counseling for (you/NAME) and (your/his/her) parents.
Summer and After School Job opportunities.
Referrals to other programs and agencies that may help (you/NAME).

In addition to the extra services, (you/NAME) will also get to use special rules that will
protect (you/his/her) Social Security benefits while (you are/[he/she] is) in the study.
Because [program name] does not have space for everyone who might want to
participate, we will randomly select who gets to participate and who does not. Randomly
selecting is like a lottery or tossing a coin. It is a fair way to decide who gets services
and who does not.
2.

Mathematica will ask (you/NAME) to answer questions two more times—one year
from now, and three years from now. You can answer those questions by
telephone or in-person. Even if (you agree/[NAME] agrees) to be in the study
today, (you/NAME) do not have to answer questions in the future.

3.

Mathematica will send (you/NAME) a $10.00 MetroCard card to say “thank you” for
answering questions. This money will not affect the benefits (you get/[NAME] gets)
from Social Security.

4.

If I am selected to participate in CUNY’s Youth Transition Demonstration Project,
from time to time staff will ask me or my parents questions about my experience or
observe me or my parents to evaluate the program.

5.

The researchers will look at records they get from Social Security and other places
such as my school, Unemployment Insurance, Food Stamps, and TANF. They
may look at records through 2010.

I will be sending out a package of information within the next day or two that provides
more information about the research study. The package will also contain forms that
(your/[NAME’s] parent or legal guardian) and (you/NAME) must sign and return to us.

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

74

(2/13/07)

The form will give more information about the research study. There will be a place for
you to mark whether (you want/[NAME] wants) to participate or not. Please mark one of
these boxes, sign the form, and return it to us in the envelope that will be included in the
package.
Once we receive the form, we will send you a $10 MetroCard card as a token of our
appreciation. You do not have to participate in the research study to receive the gift
card. If you do not return the form (you/NAME) will not have a chance to be selected for
participation in CUNY’s Youth Transition Demonstration Project and you will not receive
the gift card.
If I have any questions about this study, you can call Karen CyBulski at MPR. Her
number is 609-936-2797 or 800-951-7357.
Thank you again for participating in the study

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

75

(2/13/07)

ERIE SCRIPT:
Thank you for completing the interview. To continue to be in the research study, we will
need you/or your parent or guardian to sign a consent form. This is like a permission
slip. By signing the form, you are saying that you understand the study and want to
continue to be part of it. Let me review the important points about the study one more
time before I send the form. If you agree to be in the study, four things will happen:
1.

The researchers at MPR will offer (you/NAME) extra services from Transition
WORKS. These services will help (you/NAME) develop goals and work on plans to
meet those goals. You will also work with Neighborhood Legal Services and
Parent Network Center to better understand (your/NAME’s) benefits from Social
Security. MPR will select youth at random to see who gets the extra support.
Selecting at random is like a lottery or tossing a coin. It is a fair way to make sure
that everyone who wants to get the extra support has a fair chance of getting it.

2.

Mathematica will ask (you/NAME) to answer questions two more times—one year
from now, and three years from now. You can answer those questions by
telephone or in-person. Even if (you agree/[NAME] agrees) to be in the study
today, (you/NAME) do not have to answer questions in the future.

3.

Mathematica will send (you/NAME) a $10.00 Target gift card to say “thank you” for
answering questions. This money will not affect the benefits (you get/[NAME] gets]
from Social Security.

4.

The researchers will look at records from Social Security or other agencies such as
the Erie 1 Board of Cooperative Education Services(BOCES). They may look at
records until (DATE).

I will be sending out a package of information within the next day or two that provides
more information about the research study. The package will also contain forms that
(your/[NAME’s] parent or legal guardian) and (you/NAME) must sign and return to us.
The form will give more information about the research study. There will be a place for
you to mark whether (you want/[NAME] wants) to participate or not. Please mark one of
these boxes, sign the form, and return it to us in the envelope that will be included in the
package.
Once we receive the form, we will send you a $10 Target gift card as a token of our
appreciation. You do not have to participate in the research study to receive the gift
card. If you do not return the form (you/NAME) will not have a chance to be selected for
participation in Transition WORKS and you will not receive the gift card.
If I have any questions about this study, you can call Karen CyBulski at MPR. Her
number is 609-936-2797 or 800-951-7357.
Thank you again for participating in the study

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

76

(2/13/07)

D5.

Lastly, I would like to confirm the address to send the packet:
PROGRAMMER: USE ADDRESS FROM Q.5 (Q.5P).
INTERVIEWER: CONFIRM INFORMATION AND MAKE CORRECTIONS IF NEEDED.
NAME:
STREET ADDRESS
CITY:
STATE:
ZIP CODE:

D6.

INTERVIEWER: SHOULD THE CONSENT FORM BE SENT IN ENGLISH OR
SPANISH?
ENGLISH........................................................................1
SPANISH........................................................................2

D7.

Thank you again for participating in the study.
[interim status - baseline complete, send consent]

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

77

(2/13/07)

SCRIPTS FOR FOLLOWING UP ON WRITTEN CONSENT
F1.

Hello, my name is (INTERVIEWER’S NAME). May I please speak to (PERSON WHO
COMPLETED BASELINE)?
YES, PERSON COMES TO PHONE .............................1 (GO TO Q.F2)
YES, BUT NEED TO CALL BACK .................................2 (CALL BACK)
REFUSED ......................................................................r (REFUSAL)

F2.

I am calling on behalf of the Social Security Administration about a research study that
will help youth with disabilities become as independent as they can. You recently
completed an interview and we sent you a packet of information about the study. The
packet also contained a form for you to sign agreeing to participate in the study. We
have not received this form back yet and I was calling to see if you have mailed it back
or if you need us to send you another form.
SENT FORM TO MPR ...................................................1 (GO TO Q.F3)
SEND NEW PACKET.....................................................2 (GO TO Q.F5)
REFUSED TO PROVIDE WRITTEN CONSENT
[NEED NEW FINAL STATUS CODE – REFUSED
WRITTEN CONSENT]....................................................3

F3.

INTERVIEWER: DETERMINE HOW LONG AGO CONSENT WAS RETURNED. IF
MORE THAN TWO WEEKS AGO RESEND A CONSENT PACKAGE.
LESS THAN TWO WEEK AGO .....................................1 (GO TO Q.F7)
MORE THAN TWO WEEKS AGO..................................2 (GO TO Q.F4)

F4.

I am sorry, but we have not received your form and in order for you to participate in the
research study, we must have a signed form. I will send you another form, please sign it
and return it to us.

F5.

I want to confirm that I have the correct address. The packet was sent to:
INTERVIEWER: CONFIRM INFORMATION AND MAKE CORRECTIONS IF NEEDED.
NAME:
STREET ADDRESS
CITY:
STATE:
ZIP CODE:

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

78

(2/13/07)

F6.

Thank you very much for your time. I will be sending out the packet today.
PROGRAMMER: A NEW CONSENT PACKAGE TO BE MAILED FROM SMS.
[interim status - remail consent package]

F7.

Thank you for returning the form to us. As you know we must have a signed form before
you can participate in the research study.
[interim status - consent not received]

P:\YTD-(DC).(gg)\OMB (A. Ciemnecki 2-07)\Appendices\AppB-YTD Baseline-2-13-07 (lb)1.doc

Prepared by Mathematica Policy Research, Inc.

79

(2/13/07)