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pdfAPPENDIX C
12-MONTH FOLLOW-UP QUESTIONNAIRE
MPR Reference No.: 6209
Youth Transition
Demonstration
12-Month YTD Follow-Up
Instrument
February 9, 2007
INTRODUCTION TO STUDY
SampMemb. SCRIPT FOR SAMPLE MEMBER AGE 18 OR OLDER.
Hello, my name is ________________ and I am calling from Mathematica Policy
Research. We recently sent you a letter about a study we are doing for the
Social Security Administration.
You may remember being interviewed by telephone about a year ago. At that
time you answered questions over the phone and we sent you a consent form to
sign and a $10 INCENTIVE. IF TREATMENT, ADD: We also gave you a
chance to be part of the (NAME OF LOCAL YTD PROGRAM). When we spoke
to you a year ago, we explained that the study would have three interviews. This
is the second one. The questions I am calling to ask are about you, your
schooling, jobs, health, and how you are getting along day to day. The interview
takes about 40 minutes to complete by telephone. I will send you a $10
INCENTIVE when we are done. Let’s begin.
IF NEEDED: The questions have been worded so you can answer for yourself.
If you wish, you can ask someone to stay nearby in case you need help.
IF R DOES NOT REMEMBER LETTER, ADD:
- All your answers will be held in strict confidence.
- Nothing you say will affect the SSI benefits you get now or in the future.
- Most questions are worded so that young people with disabilities can answer
for themselves.
- If it would be better, an interviewer can come to your home instead of doing
this by telephone.
- We can start now and take a break if you need one.
YES, CONTINUE............................................................1 (GO TO I.A1)
NOT A GOOD TIME .......................................................2 (CALL BACK)
DID NOT RECEIVE LETTER/DOESN’T RECALL .........3 (NoLetter)
NEED FIELD INTERVIEW .............................................4 (Field Review)
REFUSAL .......................................................................5 (REFUSAL)
YTD-12 Month Follow-Up (lb)-q14.doc
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Parent.
SCRIPT FOR PARENTS OF YOUTH UNDER AGE 18 AND YOUTH AT CUNY.
Hello, my name is ________________ and I am calling from Mathematica Policy
Research. We recently sent you a letter about a study we are doing for the
Social Security Administration.
You may remember being interviewed by telephone about a year ago. At that
time you answered questions about (NAME) over the phone, we sent you a
consent form to sign, and a $10 INCENTIVE. IF TREATMENT, ADD: We also
gave (NAME) a chance to be part of the (NAME OF LOCAL YTD PROGRAM).
When we spoke to you a year ago, we explained that the study would have three
interviews. This is the second one. The questions I am calling to ask are about
(NAME), (his/her) schooling, jobs, health, and how (he/she) is getting along day
to day. The interview takes about 40 minutes to complete by telephone. I will
send (NAME) a $10 INCENTIVE when we are done. Just like we did before,
there are a few questions for parents that I would like to ask you first.
Most questions 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.
Let’s begin.
IF R DOES NOT REMEMBER LETTER, ADD:
- All your answers will be held in strict confidence.
- Nothing you say will affect the SSI benefits you get now or in the future.
- Most questions are worded so that young people with disabilities can answer
for themselves.
- If it would be better, an interviewer can come to your home instead of doing
this by telephone.
- We can start now and take a break if you need one.
YES, CONTINUE............................................................1 (GO TO I.A1)
NOT A GOOD TIME .......................................................2 (CALL BACK)
DID NOT RECEIVE LETTER/DOESN’T RECALL .........3 (NoLetter)
NEED FIELD INTERVIEW .............................................4 (Field Review)
REFUSAL .......................................................................5 (REFUSAL)
YTD-12 Month Follow-Up (lb)-q14.doc
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SECTION I: EDUCATION AND TRAINING
THIS SECTION ASKED OF PARENTS OR INDEPENDENT YOUTH.
Intro.
Many of the questions in this interview ask about what (you have/[NAME] has) been
doing since we last spoke to you around [RA DATE]. What happened around that time
that will help you remember that date?
PROBE: Like a special event or birthday.
RECORD MEMORY AID ___________________________________________.
I.A1
(YTD-9 mod
The first questions are about school. (Are you/Is [NAME]) currently attending or
enrolled in school?
PROBE: Please include regular high school, adult basic education or GED courses,
vocational or trade 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: (Are you/Is [NAME]) off school for the summer. Will
(you/he/she) be going back to school in the fall?
INTERVIEWER: CODE “YES” IF ON SUMMER BREAK.
YES .............................................................. 1 (GO TO I.B1)
NO ................................................................ 0
DON’T KNOW .............................................. d
REFUSED .................................................... r
I.A1a
(Are you/Is [NAME]) currently in a training program or taking classes to help you learn
job skills or get a job?
PROBE: Please include classes to learn English or improve your reading skills.
YES .............................................................. 1 (GO TO I.B1)
NO ................................................................ 0
DON’T KNOW .............................................. d
REFUSED .................................................... r
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I.A2
ASK IF NOT CURRENTLY IN SCHOOL:
Did (you/NAME) go to school, attend a training program or take any classes since
(RA DATE/MEMORY AID)?
PROBE: IF DON’T KNOW: When was the last time (you/he/she) went to school or
training?
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
(GO TO I.D1)
REFUSED .................................................... r
I.B1
Please tell me the name of each program or school (you/NAME) attended or training
course you took since (RA DATE/MEMORY AID)? Let’s begin with the last one and
work backwards.
PROBE: Any others?
INTERVIEWER: RECORD NAME OF EACH PLACE
SCHOOL 1 NAME:
SCHOOL 2 NAME:
SCHOOL 3 NAME:
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SCHOOL 1
I.B2 Thinking about (NAME OF
SCHOOL). What type of school/
training program) is (this/that)?
I.B3 When did you start (this/that)
(school/course/training program)?
SCHOOL 2
SCHOOL 3
Regular high school,................................1
Regular high school, ............................... 1
Regular high school,................................1
Special high school for persons with
disabilities, ...............................................2
Special high school for persons with
disabilities,............................................... 2
Special high school for persons with
disabilities, ...............................................2
Post-secondary, vocational, technical
business or trade school, ........................3
Post-secondary, vocational, technical
business or trade school, ........................ 3
Post-secondary, vocational, technical
business or trade school, ........................3
2-year college or community college,......4
2-year college or community college, ..... 4
2-year college or community college,......4
4-year college or university, ....................5
4-year college or university,.................... 5
4-year college or university, ....................5
Or something else (SPECIFY) ................6
Or something else (SPECIFY)................ 6
Or something else (SPECIFY) ................6
SPECIAL EDUCATION NOT
IN A SCHOOL..........................................7
SPECIAL EDUCATION NOT
IN A SCHOOL ......................................... 7
SPECIAL EDUCATION NOT
IN A SCHOOL..........................................7
HOME SCHOOLED.................................8
HOME SCHOOLED ................................ 8
HOME SCHOOLED.................................8
| | | / 20 | | |
MONTH
YEAR
START DATE:
| | | / 20 | | |
MONTH
YEAR
START DATE:
| | | / 20 | | |
MONTH
YEAR
START DATE:
MORE THAN ONE YEAR AGO ......... 999
MORE THAN ONE YEAR AGO..........999
MORE THAN ONE YEAR AGO ......... 999
I.B3 (Are you/Is [NAME]) still attending
(NAME OF SCHOOL)?
YES..........................................................1
YES ......................................................... 1
YES..........................................................1
NO............................................................0
NO ........................................................... 0
NO............................................................0
I.B5 IF NOT CURRENTLY ATTENDING,
ASK: And when did you stop going
to (this/that) (school/course/training
program)?
END DATE:
I.B6 IF I.B4 OR I.B5 “DON’T KNOW”—
CANNOT ANSWER EXACT
DATES, PROBE FOR TIME
ATTENDED SCHOOL: Since
(RA DATE/MEMORY AID) about
how many of those months did
(you/NAME) go to (NAME OF
SCHOOL)?
PROBE: Your best estimate is fine.
I.C1 IF CURRENTLY IN HIGH SCHOOL,
ASK: (Are you/Is [NAME]) in
(your/his/her) freshman, sophomore,
junior or senior year of school?
| | | / 20 | | |
MONTH
YEAR
|
|
|
|
| MONTHS
| | | / 20 | | |
MONTH
YEAR
END DATE:
|
|
| MONTHS
IF DON’T KNOW: Was it . . .
IF DON’T KNOW: Was it . . .
IF DON’T KNOW: Was it . . .
All year, including the summer, ...............1
All year, including the summer,............... 1
All year, including the summer, ...............1
All year, except for the summer
(9 months),...............................................2
All year, except for the summer
(9 months), .............................................. 2
All year, except for the summer
(9 months),...............................................2
About half the year (6 months), ...............3
About half the year (6 months), .............. 3
About half the year (6 months), ...............3
Between 3 and 6 months, or ...................4
Between 3 and 6 months, or................... 4
Between 3 and 6 months, or ...................4
Less than 3 months? ...............................5
Less than 3 months?............................... 5
Less than 3 months? ...............................5
FRESHMAN/9TH GRADE.......................1
FRESHMAN/9TH GRADE ...................... 1
FRESHMAN/9TH GRADE.......................1
SOPHOMORE/10TH GRADE .................2
SOPHOMORE/10TH GRADE................. 2
SOPHOMORE/10TH GRADE .................2
JUNIOR/11TH GRADE............................3
JUNIOR/11TH GRADE ........................... 3
JUNIOR/11TH GRADE............................3
SENIOR/12TH GRADE ...........................4
SENIOR/12TH GRADE........................... 4
SENIOR/12TH GRADE ...........................4
UNGRADED ............................................5
UNGRADED............................................ 5
UNGRADED ............................................5
I.C1a IF UNGRADED, ASK: When do you
expect to graduate?
PROBE: How many more years
(do you/does [NAME] have left in
school?
| MONTHS
| | | / 20 | | |
MONTH
YEAR
END DATE:
|
20 |
|
or
|
|
|
20 |
|
or
| YEARS
|
|
| YEARS
|
20 |
|
or
|
|
| YEARS
PROBE: How many more years
(do you/does [NAME]) have left in
school?
I.C2 What type of classes ([are/were] you
taking/[is/was] [NAME] taking) at
(NAME OF SCHOOL)? (Are/Were)
the classes mostly vocational
courses to train for a job, like
computer or business courses, or
mostly academic courses, like
English or science?
MOSTLY VOCATIONAL..........................1
MOSTLY VOCATIONAL ......................... 1
MOSTLY VOCATIONAL..........................1
MOSTLY ACADEMIC..............................2
MOSTLY ACADEMIC ............................. 2
MOSTLY ACADEMIC..............................2
BOTH, MIXED .........................................3
BOTH, MIXED......................................... 3
BOTH, MIXED .........................................3
NEITHER—CLASSES ARE
FOR PERSONAL INTEREST,
RECREATION .........................................4
NEITHER—CLASSES ARE
FOR PERSONAL INTEREST,
RECREATION......................................... 4
NEITHER—CLASSES ARE
FOR PERSONAL INTEREST,
RECREATION .........................................4
PROBE: (Are you/Is [NAME]) taking
courses that are preparing
(you/him/her) for a job or for college?
YTD-12 Month Follow-Up (lb)-q14.doc
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SCHOOL 1
I.C3 IF NOT CURRENTLY IN HIGH
SCHOOL, ASK: Are (you/Is
[NAME]) – (Were you/Was [NAME])
going to (NAME OF SCHOOL)
full-time or part-time?
(NLTS –
S5f)
SCHOOL 2
SCHOOL 3
FULL-TIME ..............................................1
FULL-TIME.............................................. 1
FULL-TIME ..............................................1
PART-TIME .............................................2
PART-TIME............................................. 2
PART-TIME .............................................2
PROBE: By full-time, we mean
taking a full course load of 12 credits
or more at a time or being in class at
least 12 hours per week.
I.C4 (Are you/Is [NAME]) – (Were
you/Was [NAME]) working toward a
diploma, certificate, or license from
this school?
YES..........................................................1
YES ......................................................... 1
YES..........................................................1
(NLTS –
S3r)
NO............................................................0
NO ........................................................... 0
NO............................................................0
I.C5 IF NO LONGER ATTENDING
(NAME OF SCHOOL), ASK: Why
(NLTS – did (you/he/she) stop going to
SC1)
(NAME OF SCHOOL)?
GRADUATED ..........................................01
GRADUATED.......................................... 01
GRADUATED ..........................................01
FINISHED CLASSES
WANTED TO TAKE.................................02
FINISHED CLASSES
WANTED TO TAKE ................................ 02
FINISHED CLASSES
WANTED TO TAKE.................................02
TRANSPORTATION PROBLEMS ..........03
TRANSPORTATION PROBLEMS.......... 03
TRANSPORTATION PROBLEMS ..........03
PROBE: Why (are you/is [NAME])
no longer taking classes at (NAME
OF SCHOOL)?
DIDN’T GET SERVICES NEEDED.........04
DIDN’T GET SERVICES NEEDED ........ 04
DIDN’T GET SERVICES NEEDED.........04
TOO EXPENSIVE/
COULDN’T AFFORD IT ..........................05
TOO EXPENSIVE/
COULDN’T AFFORD IT.......................... 05
TOO EXPENSIVE/
COULDN’T AFFORD IT ..........................05
PROBE: Did (you/NAME) graduate
or complete (your/his/her) classes, or
did (you/he/she) leave for some other
reason? What was the reason?
DIDN’T HAVE TIME; SCHEDULE
CONFLICT; CONFLICTS WITH
OTHER DEMANDS .................................06
DIDN’T HAVE TIME; SCHEDULE
CONFLICT; CONFLICTS WITH
OTHER DEMANDS................................. 06
DIDN’T HAVE TIME; SCHEDULE
CONFLICT; CONFLICTS WITH
OTHER DEMANDS .................................06
POOR GRADES/NOT DOING
WELL IN SCHOOL ..................................07
POOR GRADES/NOT DOING
WELL IN SCHOOL.................................. 07
POOR GRADES/NOT DOING
WELL IN SCHOOL ..................................07
DIDN’T LIKE SCHOOL............................08
DIDN’T LIKE SCHOOL ........................... 08
DIDN’T LIKE SCHOOL............................08
WANTED/NEEDED TO FIND A JOB......09
WANTED/NEEDED TO FIND A JOB ..... 09
WANTED/NEEDED TO FIND A JOB......09
OFFERED A JOB/CHOSE TO WORK....10
OFFERED A JOB/CHOSE TO WORK ... 10
OFFERED A JOB/CHOSE TO WORK....10
WANTED TO ENTER MILITARY ............11
WANTED TO ENTER MILITARY ........... 11
WANTED TO ENTER MILITARY ............11
DIDN’T GET IN TO THE PROGRAM
SM WANTED...........................................12
DIDN’T GET IN TO THE PROGRAM
SM WANTED .......................................... 12
DIDN’T GET IN TO THE PROGRAM
SM WANTED...........................................12
ILLNESS/DISABILITY;
TOO SICK TO GO...................................13
ILLNESS/DISABILITY;
TOO SICK TO GO .................................. 13
ILLNESS/DISABILITY;
TOO SICK TO GO...................................13
GOT MARRIED .......................................14
GOT MARRIED....................................... 14
GOT MARRIED .......................................14
GOT PREGNANT OR HAD
A CHILD...................................................15
GOT PREGNANT OR HAD
A CHILD .................................................. 15
GOT PREGNANT OR HAD
A CHILD...................................................15
MOVED....................................................16
MOVED ................................................... 16
MOVED....................................................16
SCHOOL TOO DANGEROUS ................17
SCHOOL TOO DANGEROUS................ 17
SCHOOL TOO DANGEROUS ................17
WANTED TO TRAVEL ............................18
WANTED TO TRAVEL ........................... 18
WANTED TO TRAVEL ............................18
FRIENDS WEREN’T IN SCHOOL/
FRIENDS WERE DROPPING OUT ........19
FRIENDS WEREN’T IN SCHOOL/
FRIENDS WERE DROPPING OUT ....... 19
FRIENDS WEREN’T IN SCHOOL/
FRIENDS WERE DROPPING OUT ........19
COULDN’T GET ALONG WITH
TEACHERS .............................................20
COULDN’T GET ALONG WITH
TEACHERS............................................. 20
COULDN’T GET ALONG WITH
TEACHERS .............................................20
COULDN’T GET ALONG WITH
OTHER STUDENTS................................21
COULDN’T GET ALONG WITH
OTHER STUDENTS ............................... 21
COULDN’T GET ALONG WITH
OTHER STUDENTS................................21
COULDN’T GET CHILD CARE ...............22
COULDN’T GET CHILD CARE............... 22
COULDN’T GET CHILD CARE ...............22
PARENTS/FAMILY DID WANT
SM TO GO...............................................23
PARENTS/FAMILY DID WANT
SM TO GO .............................................. 23
PARENTS/FAMILY DID WANT
SM TO GO...............................................23
OTHER (SPECIFY) .................................24
OTHER (SPECIFY)................................. 24
OTHER (SPECIFY) .................................24
YTD-12 Month Follow-Up (lb)-q14.doc
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I.D1
ASK BOTH IN SCHOOL AND OUT OF SCHOOL YOUTH. DO NOT ASK IF YOUTH IS
CURRENTLY IN HIGH SCHOOL:
What is the highest grade or year of school that (you have/[NAME] has) finished?
(YTD-14)
8TH GRADE OR LESS ................................ 1
9TH GRADE/FRESHMAN IN HS ................. 2
10TH GRADE/SOPHOMORE IN HS............ 3
11TH GRADE/JUNIOR IN HS ...................... 4
12TH GRADE/SENIOR IN HS...................... 5
SOME COLLEGE OR
TECHNICAL SCHOOL ................................. 6
COLLEGE OR TECHNICAL SCHOOL......... 7
UNGRADED SCHOOL................................. 8
HOME SCHOOLED...................................... 9
OTHER GRADE (SPECIFY) ........................ 10
DON’T KNOW .............................................. d
REFUSED .................................................... r
I.D2
(YTD-15)
ASK IF NOT CURRENTLY IN HIGH SCHOOL:
(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/does [he/she]) have none of
these?
CODE LEFT WITHOUT GRADUATING AS “NONE OF THESE.”
HIGH SCHOOL DIPLOMA ........................... 1
GED.............................................................. 2
CERTIFICATE OF COMPLETION ............... 3
NONE OF THESE ........................................ 4
DON’T KNOW .............................................. d
REFUSED .................................................... r
YTD-12 Month Follow-Up (lb)-q14.doc
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I.D3
ASK IF HIGHEST GRADE WAS COLLEGE OR TECHNICAL SCHOOL:
(Do you/Does [NAME]) have a college degree or a technical certificate?
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
REFUSED .................................................... r
I.D4
ASK IF HAS A COLLEGE DEGREE OR TECHNICAL CERTIFICATE:
What is the highest college degree or technical certificate that (you have/[he/she] has)?
READ IF NECESSARY.
MASTERS OR HIGHER............................... 1
BACHELORS ............................................... 2
ASSOCIATES............................................... 3
TECHNICAL CERTIFICATE (SPECIFY
AS MANY AS SAMPLE MEMBER HAS
EARNED) ..................................................... 4
DON’T KNOW .............................................. d
REFUSED .................................................... r
IF NO SCHOOL IN LAST YEAR, GO TO II.A1
YTD-12 Month Follow-Up (lb)-q14.doc
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I.E1
(NLTS-S3)
I.E1a
ASK OF PARENT AND YOUTH:
Next, I am going to read (you/him/her) a list of services, accommodations or help that
some people get at school. Please tell me whether or not (you have/[he/she] has)
received any of these since (RA DATE/MEMORY AID).
IF NO, ASK: Did (you/NAME) need (this/any other) accommodation.
I.E1
I.E1a
YES
NO
YES
NO
a. (Have you/Has [he/she]) had any accommodations in how
(you/he/she) take tests, like more time to take tests, or a
different setting to take tests? ................................................
1
0
1
0
b. (Have you/Has [he/she]) had any accommodations in how
(you/he/she) handle class assignments, like having more
time to finish assignments or getting different assignments?.
1
0
1
0
c. Has there been any person assigned to help [you/NAME]),
like a tutor, an interpreter, or someone who takes notes for
(you/him/her) in class? ...........................................................
1
0
1
0
d. Have there been any adaptations to (your/his/her)
classrooms, like a special desk for (you/him/her) or different
equipment because of a disability? ........................................
1
0
1
0
e. (Have you/Has [NAME]) received any other
accommodations at school during the
last year (SPECIFY)?.............................................................
1
0
1
0
IF NOT IN HIGH SCHOOL SINCE RA DATE, GO TO II.A1
YTD-12 Month Follow-Up (lb)-q14.doc
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I.F1
ASK BOTH PARENT AND YOUTH:
The next few questions are about special education services (you/NAME) might be
(receiving/have received). Students who have a disability or learning problem
sometimes receive special education services based on an Individual Education
Program, or IEP. The IEP spells out the classroom settings, services, and learning
supports a student should receive to meet his or her special needs. Since (RA
DATE/MEMORY AID), (have you/has [NAME]) received any kind of special education
services?
(Are you/Is [NAME]) now receiving/Have you/Has [NAME] received) any type of special
education since (RA DATE/MEMORY AID)?
PROBE: Do not include gifted or talented programs.
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
(GO TO II.A1)
REFUSED .................................................... r
I.F2
(NLTS - R7a
ASK BOTH PARENT AND YOUTH:
Since (RA DATE/MEMORY AID), did (you/he/she) go to a meeting at school about an
Individualized Education Plan, or IEP, for special education program or services?
PROBE:
An Individual Education Plan is an outline of educational goals for a student
based on test scores and assessments from a child study team. The IEP
contains a statement of goals for the student and a plan of how to achieve
them.
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
REFUSED .................................................... r
YTD-12 Month Follow-Up (lb)-q14.doc
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I.F3
(NLTS)
R7b
ASK BOTH PARENT AND YOUTH:
Did (you/NAME) meet with adults at school to set goals for what (you/he/she) will do
after high school and make a plan for how to achieve them? Sometimes this is called a
transition plan.
YES .............................................................. 1 (GO TO I.F4)
NO ................................................................ 0
DON’T KNOW .............................................. d
REFUSED .................................................... r
IF I.F2 AND I.F3 ARE BOTH NO – YOUTH DID NOT
ATTEND IEP MEETING AND YOUTH DID NOT HAVE A
TRANSITION PLAN – END OF SECTION - GO TO II.A1
I.F4
(NLTS -R7c
ASK BOTH PARENT AND YOUTH:
How much choice did (you/he/she) have about the goals on (your/his/her) (IEP [or]
transition plan)? Did (you/NAME) have almost no choice about the goals, some choice,
or a lot of choice?
ALMOST NO CHOICE ................................. 1
SOME CHOICE ............................................ 2
A LOT OF CHOICE ...................................... 3
DON’T KNOW ABOUT ANY GOALS ........... 4
DON’T KNOW .............................................. d
REFUSED .................................................... r
YTD-12 Month Follow-Up (lb)-q14.doc
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I.F5
ASK BOTH PARENT AND YOUTH:
Thinking about how involved (you were/[NAME] was) in the decisions about
(your/his/her) (IEP [or] transition plan]. Did (you/NAME) want to be more involved, less
involved, or (were you/was [he/she]) involved about the right amount?
MORE INVOLVED........................................ 1
LESS INVOLVED ......................................... 2
RIGHT AMOUNT.......................................... 3
NO OPINION ................................................ 4
DON’T KNOW .............................................. d
REFUSED .................................................... r
I.F6
PARENT ONLY QUESTION:
Do you think (NAME)’s IEP goals (are/were) too challenging for (him/her), not
challenging enough for (him/her) or just right for (him/her)?
TOO CHALLENGING ................................... 1
NOT CHALLENGING ENOUGH .................. 2
JUST RIGHT ................................................ 3
DON’T KNOW .............................................. d
REFUSED .................................................... r
I.F7
IF YOUTH HAD TRANSITION PLAN ASK BOTH PARENT AND YOUTH:
How useful has this planning been in helping (you/NAME) prepare for life after high
school? Would (you/he/she) say it has been very useful, somewhat useful, not very
useful, or not at all useful?
VERY USEFUL............................................. 1
SOMEWHAT USEFUL ................................. 2
NOT VERY USEFUL .................................... 3
NOT AT ALL USEFUL.................................. 4
DON’T KNOW .............................................. d
REFUSED .................................................... r
YTD-12 Month Follow-Up (lb)-q14.doc
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SECTION II: EMPLOYMENT
II.A1
THIS SECTION ASKED OF ALL YOUTH.
My next questions are about jobs. (Have you/Has [he/she]) worked for pay at a job or a
business at any time since (RA DATE/MEMORY AID)?
PROBES: A job is work for pay other than work around the house. Stipends are pay.
A job could be a school sponsored job or a work study job.
A job could be working for a business or organization or work that
(you/he/she) do on (your/his/her) own such as babysitting or dog walking.
YES .............................................................. 1
NO ................................................................ 0 (GO TO II.G1)
II.A2
(Are you/Is [NAME]) currently working at a job or business for pay?
PROBES:
(Do you/Does [NAME]) have a job now?
A job is work for pay other than work around the house. Stipends are pay.
A job could be a school sponsored job or a work study job.
A job could be working for a business or organization or work that
(you/he/she) do on (your/his/her) own such as babysitting or dog walking.
YES .............................................................. 1
NO ................................................................ 0 (GO TO II.A6)
II.A3
(Do you/Does [NAME]) have more than one job now?
YES .............................................................. 1
NO ................................................................ 0 (RECORD AS JOB 1
AND GO TO II.A6)
YTD-12 Month Follow-Up (lb)-q14.doc
Prepared by Mathematica Policy Research, Inc.
13
(REV—2/9/07)
II.A4
IF HAS A CURRENT JOB: How many different jobs (do you/does [he/she]) have now?
|
II.A5
|
| JOBS
DETERMINE MAIN JOB AND RECORD RESPONSES
IN II.B1-II.F1. LIST OTHER CURRENT JOBS IN JOB
TABLE, AFTER II.A6 BELOW.
I would like to talk about (your/his/her) [main] job. [Tell me about the different jobs
(you/he/she) have now and we can decide which is (your/his/her) main job?]
IF MORE THAN ONE CURRENT JOB, THE MAIN JOB IS THE:
•
JOB AT WHICH THE SAMPLE MEMBER WORKS THE MOST HOURS
•
JOB WHICH THE SAMPLE MEMBER HAS HAD THE LONGEST
PROBES: At which job (do you/does [he/she]) work the most hours? Spend the most
time? Which job (have you/has [he/she]) had the longest?
YTD-12 Month Follow-Up (lb)-q14.doc
Prepared by Mathematica Policy Research, Inc.
14
(REV—2/9/07)
PAGE INTENTIONALLY LEFT PAGE
YTD-12 Month Follow-Up (lb)-q14.doc
Prepared by Mathematica Policy Research, Inc.
15
(REV—2/9/07)
II.A6
IF NO CURRENT JOB:
(Have you/Has [NAME]) had (a job/ more than one job) since (RA DATE/MEMORY
AID)?
IF CURRENTLY HAS A JOB:
(Have you/Has [NAME]) worked any place else since (RA DATE/MEMORY AID)?
IF YES, ASK: Where else did (you/he/she) work?
What (was/were) the (name/names) of the other (place/places)
(you/he/she) worked?
What (do you/does [he/she]) call the place where (you/he/she)
(work/worked)?
Who (do/did) (you/he/she) work for?
FOR EACH PLACE, DETERMINE START AND END DATES FOR THE JOB.
When did (you/he/she) start working at (NAME OR PLACE)?
PROBES:
When did (you/he/she) start working as a (JOB)?
When did (you/he/she) stop working at (______)?
How long (have/did) (you/he/she) (worked/work) at (____)?
In which month did (you/he/she) (start/stop)?
What was the weather like?
Was it around a holiday or (your/his/her) birthday?
Was it during the school year or during the summer?
(Is/Was) this a summer job?
PRIORITIZE JOBS AS FOLLOWS:
CURRENT JOB IS NUMBER 1.
IF MORE THAN ONE CURRENT JOB, NUMBER JOBS IN ORDER OF DURATION,
WITH THE LONGEST JOBS HAVING THE LOWEST NUMBERS OR HIGHEST
PRIORITIES.
THEN, NUMBER THE MOST RECENT JOBS NEXT, ACCORDING TO THEIR START
DATES.
IF JOBS HAVE THE SAME START DATE, ASSIGN JOBS OF LONGEST DURATION
THE HIGHEST PRIORITIES WITH THOSE LASTING THE LONGEST HAVING THE
LOWEST NUMBERS.
YTD-12 Month Follow-Up (lb)-q14.doc
Prepared by Mathematica Policy Research, Inc.
16
(REV—2/9/07)
JOB NAME
CURRENT
START DATE
END DATE
NUMBER
1.
YES ............. 01
NO ............... 00
| | |/| | |
MONTH YEAR
| | |/| | |
MONTH YEAR
|
|
|
2.
YES ............. 01
NO ............... 00
| | |/| | |
MONTH YEAR
| | |/| | |
MONTH YEAR
|
|
|
3.
YES ............. 01
NO ............... 00
| | |/| | |
MONTH YEAR
| | |/| | |
MONTH YEAR
|
|
|
4.
YES ............. 01
NO ............... 00
| | |/| | |
MONTH YEAR
| | |/| | |
MONTH YEAR
|
|
|
5.
YES ............. 01
NO ............... 00
| | |/| | |
MONTH YEAR
| | |/| | |
MONTH YEAR
|
|
|
6.
YES ............. 01
NO ............... 00
| | |/| | |
MONTH YEAR
| | |/| | |
MONTH YEAR
|
|
|
7.
YES ............. 01
NO ............... 00
| | |/| | |
MONTH YEAR
| | |/| | |
MONTH YEAR
|
|
|
8.
YES ............. 01
NO ............... 00
| | |/| | |
MONTH YEAR
| | |/| | |
MONTH YEAR
|
|
|
9.
YES ............. 01
NO ............... 00
| | |/| | |
MONTH YEAR
| | |/| | |
MONTH YEAR
|
|
|
10.
YES ............. 01
NO ............... 00
| | |/| | |
MONTH YEAR
| | |/| | |
MONTH YEAR
|
|
|
ASK QUESTIONS II.B1 – 11.F1 ABOUT JOBS 1-5.
YTD-12 Month Follow-Up (lb)-q14.doc
Prepared by Mathematica Policy Research, Inc.
17
(REV—2/9/07)
JOB 1
CURRENT/MAIN JOB/OR MOST RECENT JOB
II.B1 Tell me about (your/NAME’s) job at ____________.
INTERVIEWER: RECORD WHAT YOU ARE TOLD
IN II.B4-B6. THEN ASK II.C1.
What is the name of the place where (you/he/she)
(work/worked)?
JOB 2
NEXT MOST RECENT JOB
NAME OR PLACE:__________________________
NAME OR PLACE:__________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
OR
SELF-EMPLOYED...........................1
OR
GO TO II.B3
SELF-EMPLOYED...........................1
GO TO II.B3
PROBE: What (do you/does [he/she]) call the place
where (you/he/she) (work/worked)?
PROBE: Who (do/did) (you/he/she) work for?
II.B2 What does (NAME OR PLACE) make or do?
PROBE: What kind of place is (NAME OR PLACE)?
II.B3 What (do/did) (you/he/she) do at (NAME OR
PLACE)?
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
RECORD VERBATIM AND CODE:
RECORD VERBATIM AND CODE:
_______________________________________________
_______________________________________________
PROBE: What (are/were) (your/his/her)
responsibilities?
_______________________________________________
_______________________________________________
ASSEMBLY WORK (SORTING STUFFING) .................. 11
ASSEMBLY WORK (SORTING STUFFING) .................. 11
PROBE: What kinds of things (have you/ has
[he/she]) done there?
ANIMAL CARE (DOG WALKING,
VETERINARY HELPER) ................................................. 12
ANIMAL CARE (DOG WALKING,
VETERINARY HELPER) ................................................. 12
PROBE: Tell me what (you/he/she) (do/did) when
(you/he/she) (get/got) to work? After that? Then
what?
CAMP COUNSELOR....................................................... 13
CAMP COUNSELOR....................................................... 13
CASHIER—GROCERY STORE,
FAST FOOD PLACE, ETC. ............................................. 14
CASHIER—GROCERY STORE,
FAST FOOD PLACE, ETC. ............................................. 14
CHILD CARE—BABYSITTING/MOTHERS HELPER..... 15
CHILD CARE—BABYSITTING/MOTHERS HELPER..... 15
CLEANING—JANITOR/MAID.......................................... 16
CLEANING—JANITOR/MAID ......................................... 16
CLERICAL—FILING, RECEPTIONIST,
SECRETARY, TYPING.................................................... 17
CLERICAL—FILING, RECEPTIONIST,
SECRETARY, TYPING.................................................... 17
COMPUTER WORK—DATA ENTRY/PROGRAMMING/
WEB PAGE DEVELOPMENT........................................ 18
COMPUTER WORK—DATA ENTRY/PROGRAMMING/
WEB PAGE DEVELOPMENT ........................................18
DELIVERY—OF FOOD OR NEWSPAPERS
OR PRESCRIPTIONS ..................................................... 19
DELIVERY—OF FOOD OR NEWSPAPERS
OR PRESCRIPTIONS ..................................................... 19
FARM WORK................................................................... 20
FOOD SERVICE—BUS BOY, WAITER, COOK ............. 21
FARM WORK................................................................... 20
FOOD SERVICE—BUS BOY, WAITER, COOK ............. 21
GARDENING AND GROUNDS MAINTENANCE............ 22
GARDENING AND GROUNDS MAINTENANCE............ 22
GAS STATION ATTENDANT .......................................... 23
GAS STATION ATTENDANT .......................................... 23
HEALTH CARE AIDE—PERSONAL CARE
ATTENDANT, NURSES AIDE......................................... 24
HEALTH CARE AIDE—PERSONAL CARE
ATTENDANT, NURSES AIDE......................................... 24
IF SELF-EMPLOYED, ASK: What (do/did)
(you/he/she) do?
YTD-12 Month Follow-Up (lb)-q14.doc
Prepared by Mathematica Policy Research, Inc.
MECHANIC (AUTO REPAIR).......................................... 25
MECHANIC (AUTO REPAIR).......................................... 25
RETAIL SALES ................................................................ 26
RETAIL SALES................................................................ 26
SKILLED LABOR APPRENTICE—PLUMBER,
CARPENTER, ELECTRICIAN......................................... 27
SKILLED LABOR APPRENTICE—PLUMBER,
CARPENTER, ELECTRICIAN......................................... 27
SPORTS RELATED—UMPIRE, CADDY,
REFEREE, COACH, LIFEGUARD .................................. 28
SPORTS RELATED—UMPIRE, CADDY,
REFEREE, COACH, LIFEGUARD .................................. 28
STOCK CLERK—GROCERY STORE
OR DRUG STORE........................................................... 29
STOCK CLERK—GROCERY STORE
OR DRUG STORE........................................................... 29
USHER—MOVIE THEATER ........................................... 30
USHER—MOVIE THEATER ........................................... 30
OTHER (SPECIFY).......................................................... 31
OTHER (SPECIFY).......................................................... 31
18
(2/9/07)
JOB 3
NEXT MOST RECENT JOB
JOB 4
NEXT MOST RECENT JOB
JOB 5
NEXT MOST RECENT JOB
NAME OR PLACE:__________________________
NAME OR PLACE:__________________________
NAME OR PLACE:__________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
OR
SELF-EMPLOYED...........................1
OR
GO TO II.B3
SELF-EMPLOYED...........................1
OR
GO TO II.B3
SELF-EMPLOYED...........................1
GO TO II.B3
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
RECORD VERBATIM AND CODE:
RECORD VERBATIM AND CODE:
RECORD VERBATIM AND CODE:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
ASSEMBLY WORK (SORTING STUFFING) .................. 11
ASSEMBLY WORK (SORTING STUFFING) .................. 11
ASSEMBLY WORK (SORTING STUFFING) .................. 11
ANIMAL CARE (DOG WALKING,
VETERINARY HELPER) ................................................. 12
ANIMAL CARE (DOG WALKING,
VETERINARY HELPER) ................................................. 12
ANIMAL CARE (DOG WALKING,
VETERINARY HELPER) ................................................. 12
CAMP COUNSELOR....................................................... 13
CAMP COUNSELOR....................................................... 13
CAMP COUNSELOR....................................................... 13
CASHIER—GROCERY STORE,
FAST FOOD PLACE, ETC. ............................................. 14
CASHIER—GROCERY STORE,
FAST FOOD PLACE, ETC. ............................................. 14
CASHIER—GROCERY STORE,
FAST FOOD PLACE, ETC. ............................................. 14
CHILD CARE—BABYSITTING/MOTHERS HELPER..... 15
CHILD CARE—BABYSITTING/MOTHERS HELPER..... 15
CHILD CARE—BABYSITTING/MOTHERS HELPER..... 15
CLEANING—JANITOR/MAID.......................................... 16
CLEANING—JANITOR/MAID.......................................... 16
CLEANING—JANITOR/MAID ......................................... 16
CLERICAL—FILING, RECEPTIONIST,
SECRETARY, TYPING.................................................... 17
CLERICAL—FILING, RECEPTIONIST,
SECRETARY, TYPING.................................................... 17
CLERICAL—FILING, RECEPTIONIST,
SECRETARY, TYPING.................................................... 17
COMPUTER WORK—DATA ENTRY/PROGRAMMING/
WEB PAGE DEVELOPMENT........................................ 18
COMPUTER WORK—DATA ENTRY/PROGRAMMING/
WEB PAGE DEVELOPMENT........................................ 18
COMPUTER WORK—DATA ENTRY/PROGRAMMING/
WEB PAGE DEVELOPMENT ........................................18
DELIVERY—OF FOOD OR NEWSPAPERS
OR PRESCRIPTIONS ..................................................... 19
DELIVERY—OF FOOD OR NEWSPAPERS
OR PRESCRIPTIONS ..................................................... 19
DELIVERY—OF FOOD OR NEWSPAPERS
OR PRESCRIPTIONS ..................................................... 19
FARM WORK................................................................... 20
FOOD SERVICE—BUS BOY, WAITER, COOK ............. 21
FARM WORK................................................................... 20
FOOD SERVICE—BUS BOY, WAITER, COOK ............. 21
FARM WORK................................................................... 20
FOOD SERVICE—BUS BOY, WAITER, COOK ............. 21
GARDENING AND GROUNDS MAINTENANCE............ 22
GARDENING AND GROUNDS MAINTENANCE............ 22
GARDENING AND GROUNDS MAINTENANCE............ 22
GAS STATION ATTENDANT .......................................... 23
GAS STATION ATTENDANT .......................................... 23
GAS STATION ATTENDANT .......................................... 23
HEALTH CARE AIDE—PERSONAL CARE
ATTENDANT, NURSES AIDE......................................... 24
HEALTH CARE AIDE—PERSONAL CARE
ATTENDANT, NURSES AIDE......................................... 24
HEALTH CARE AIDE—PERSONAL CARE
ATTENDANT, NURSES AIDE......................................... 24
MECHANIC (AUTO REPAIR).......................................... 25
MECHANIC (AUTO REPAIR).......................................... 25
MECHANIC (AUTO REPAIR).......................................... 25
RETAIL SALES ................................................................ 26
RETAIL SALES ................................................................ 26
RETAIL SALES................................................................ 26
SKILLED LABOR APPRENTICE—PLUMBER,
CARPENTER, ELECTRICIAN......................................... 27
SKILLED LABOR APPRENTICE—PLUMBER,
CARPENTER, ELECTRICIAN......................................... 27
SKILLED LABOR APPRENTICE—PLUMBER,
CARPENTER, ELECTRICIAN......................................... 27
SPORTS RELATED—UMPIRE, CADDY,
REFEREE, COACH, LIFEGUARD .................................. 28
SPORTS RELATED—UMPIRE, CADDY,
REFEREE, COACH, LIFEGUARD .................................. 28
SPORTS RELATED—UMPIRE, CADDY,
REFEREE, COACH, LIFEGUARD .................................. 28
STOCK CLERK—GROCERY STORE
OR DRUG STORE........................................................... 29
STOCK CLERK—GROCERY STORE
OR DRUG STORE........................................................... 29
STOCK CLERK—GROCERY STORE
OR DRUG STORE........................................................... 29
USHER—MOVIE THEATER ........................................... 30
USHER—MOVIE THEATER ........................................... 30
USHER—MOVIE THEATER ........................................... 30
OTHER (SPECIFY).......................................................... 31
OTHER (SPECIFY).......................................................... 31
OTHER (SPECIFY).......................................................... 31
YTD-12 Month Follow-Up (lb)-q14.doc
Prepared by Mathematica Policy Research, Inc.
19
(2/9/07)
JOB 1
CURRENT/MAIN JOB/OR MOST RECENT JOB
II.B4
When did (you/he/she) start working at (NAME OR
PLACE)?
START DATE:
IF SELF-EMPLOYED, SAY: When did
(you/he/she) start working as a (JOB FROM II.B3)?
MORE THAN ONE YEAR AGO............................... 9999
| | | / 20 | | |
MONTH
YEAR
JOB 2
NEXT MOST RECENT JOB
START DATE:
| | | / 20 | | |
MONTH
YEAR
MORE THAN ONE YEAR AGO............................... 9999
II.B4a When did (you/he/she) stop working at . . .
END DATE:
In which month did (you/he/she) (start/stop)?
What was the weather like?
| | | / 20 | | |
MONTH
YEAR
END DATE:
| | | / 20 | | |
MONTH
YEAR
STILL WORKING ..................................................... 9999
STILL WORKING..................................................... 9999
IF CANNOT ANSWER EXACT DATES, PROBE FOR
TIME WORKED AT THIS JOB: How long (have
[you/he/she] worked/did [you/he/she] work) at
(NAME OR PLACE)?
IF CANNOT ANSWER EXACT DATES, PROBE FOR
TIME WORKED AT THIS JOB: How long (have
[you/he/she] worked/did [you/he/she] work) at
(NAME OR PLACE)?
PROBE: Your best estimate is fine.
PROBE: Your best estimate is fine.
Was it around a holiday or (your/his/her) birthday?
Was it during the school year or during the
summer?
(Is/Was) this a summer job?
|
|
| MONTHS......................................................... 1
|
|
| MONTHS......................................................... 1
|
|
| WEEKS .......................................................... 2
|
|
| WEEKS .......................................................... 2
OR
II.B5
OR
IF CANNOT ANSWER TIME WORKED, PROBE FOR
RANGE: (Do you/Does [NAME]) think (you/he/she)
worked at (NAME OR PLACE) . . .
IF CANNOT ANSWER TIME WORKED, PROBE FOR
RANGE: (Do you/Does [NAME]) think (you/he/she)
worked at (NAME OR PLACE) . . .
Three months of less? ..................................................... 1
Three months of less? ..................................................... 1
4-6 months? ..................................................................... 2
4-6 months? ..................................................................... 2
Or more than 6 months? .................................................. 3
Or more than 6 months? .................................................. 3
ASK FOR CURRENT OR MOST RECENT JOB:
How did (you/he/she) find this job?
NEWSPAPER AD................................................................ 1
PROBES: How did (you/he/she) hear about this
job?
EMPLOYMENT AGENCY (PRIVATE) ................................. 3
INTERNET........................................................................... 2
JOB PLACEMENT OFFICE AT SCHOOL ........................... 4
FRIENDS OR RELATIVES .................................................. 5
DIRECT APPLICATION TO EMPLOYER ............................ 6
VOCREHAB OR OTHER SERVICE AGENCY .................... 7
ONE STOP OR WORKFORCE DEVELOPMENT
CENTER (UNEMPLOYMENT OFFICE)............................... 8
THE YTD PROGRAM [FILL LOCAL NAMES)...................... 9
OTHER (SPECIFY) ............................................................. 10
YTD-12 Month Follow-Up (lb)-q14.doc
Prepared by Mathematica Policy Research, Inc.
20
(2/9/07)
JOB 3
NEXT MOST RECENT JOB
START DATE:
| | | / 20 | | |
MONTH
YEAR
MORE THAN ONE YEAR AGO............................... 9999
END DATE:
| | | / 20 | | |
MONTH
YEAR
JOB 4
NEXT MOST RECENT JOB
START DATE:
| | | / 20 | | |
MONTH
YEAR
MORE THAN ONE YEAR AGO............................... 9999
END DATE:
| | | / 20 | | |
MONTH
YEAR
JOB 5
NEXT MOST RECENT JOB
START DATE:
| | | / 20 | | |
MONTH
YEAR
MORE THAN ONE YEAR AGO............................... 9999
END DATE:
| | | / 20 | | |
MONTH
YEAR
STILL WORKING ..................................................... 9999
STILL WORKING ..................................................... 9999
STILL WORKING..................................................... 9999
IF CANNOT ANSWER EXACT DATES, PROBE FOR
TIME WORKED AT THIS JOB: How long (have
[you/he/she] worked/did [you/he/she] work) at
(NAME OR PLACE)?
IF CANNOT ANSWER EXACT DATES, PROBE FOR
TIME WORKED AT THIS JOB: How long (have
[you/he/she] worked/did [you/he/she] work) at
(NAME OR PLACE)?
IF CANNOT ANSWER EXACT DATES, PROBE FOR
TIME WORKED AT THIS JOB: How long (have
[you/he/she] worked/did [you/he/she] work) at
(NAME OR PLACE)?
PROBE: Your best estimate is fine.
PROBE: Your best estimate is fine.
PROBE: Your best estimate is fine.
|
|
| MONTHS......................................................... 1
|
|
| MONTHS......................................................... 1
|
|
| MONTHS......................................................... 1
|
|
| WEEKS .......................................................... 2
|
|
| WEEKS .......................................................... 2
|
|
| WEEKS .......................................................... 2
OR
OR
OR
IF CANNOT ANSWER TIME WORKED, PROBE FOR
RANGE: (Do you/Does [NAME]) think (you/he/she)
worked at (NAME OR PLACE) . . .
IF CANNOT ANSWER TIME WORKED, PROBE FOR
RANGE: (Do you/Does [NAME]) think (you/he/she)
worked at (NAME OR PLACE) . . .
IF CANNOT ANSWER TIME WORKED, PROBE FOR
RANGE: (Do you/Does [NAME]) think (you/he/she)
worked at (NAME OR PLACE) . . .
Three months of less? ..................................................... 1
Three months of less? ..................................................... 1
Three months of less? ..................................................... 1
4-6 months? ..................................................................... 2
4-6 months? ..................................................................... 2
4-6 months? ..................................................................... 2
Or more than 6 months? .................................................. 3
Or more than 6 months? .................................................. 3
Or more than 6 months? .................................................. 3
YTD-12 Month Follow-Up (lb)-q14.doc
Prepared by Mathematica Policy Research, Inc.
21
(2/9/07)
JOB 1
CURRENT/MAIN JOB/OR MOST RECENT JOB
II.B6 How many hours per week (do/did you) (does/did
[he/she]) usually work at this job?
|
|
|
|
|
HOURS PER WEEK USUALLY WORKED
HOURS PER WEEK USUALLY WORKED
OR
OR
USE THE FOLLOWING PROBES TO CALCULATE
HOURS WORKED:
Which days do (you/he/she) work?
What time do (you/he/she) start work?
What time do (you/he/she) finish work?
(Do you/Does [NAME]) take a break for lunch?
|
JOB 2
NEXT MOST RECENT JOB
IF CANNOT ANSWER EXACT HOURS, PROBE FOR
RANGE: (Do you/Does [NAME]) think (you/he/she)
work . . .
IF CANNOT ANSWER EXACT HOURS, PROBE FOR
RANGE: (Do you/Does [NAME]) think (you/he/she)
work . . .
Less than 10 hours per week?......................................... 1
Less than 10 hours per week?......................................... 1
10-20 hours per week? .................................................... 2
10-20 hours per week? .................................................... 2
21-30 hours per week? .................................................... 3
21-30 hours per week? .................................................... 3
Or more than 30 hours per week? ................................... 4
Or more than 30 hours per week? ................................... 4
II.C1 Next, I’d like to ask you some questions about how
(you are/[he/she] is) paid at (NAME OR PLACE).
Hour.................................................................................. 1
Hour.................................................................................. 1
Things............................................................................... 2
Things............................................................................... 2
(Do you/Does [NAME]) get paid by the hour
or by how many things (you/he/she)
(make/do/sell/makes/does/sells)?
Some other way (SPECIFY) ............................................ 3
Some other way (SPECIFY) ............................................ 3
II.C2 About how much (are you/is [NAME]) paid on this
job?
PROBES: How much (do you/does[he/she]) get
paid for each thing (you/he/she)
(make/do/sell/makes/does/sells)?
How many things (do you/does [he/she])
(make/do/sell) in an (hour/day/week)?
Is that the amount of pay (you bring/[he/she] brings)
home or is that (your/his/her) pay before taxes are
taken out?
|
$|
|.|
|
II.D2 Is (NAME OR PLACE) part of any school
sponsored work activities like a work-study job, an
internship, or part of a school-based business?
YTD-12 Month Follow-Up (lb)-q14.doc
Prepared by Mathematica Policy Research, Inc.
|
$|
or
$|
|
|
|.|
|
|.|
|
| per hour
or
| per week .................................. 1
$|
|
|
|.|
|
| per week .................................. 1
every other week ..................... 2
every other week ..................... 2
twice a month .......................... 3
twice a month .......................... 3
once a month........................... 4
once a month........................... 4
OTHER (SPECIFY) ................. 5
OTHER (SPECIFY) ................. 5
Net pay ............................................................................. 1
Net pay............................................................................. 1
Before taxes ..................................................................... 2
Before taxes ..................................................................... 2
II.C3 (Does/Did) this job offer. . .
II.D1 At (your/his/her) job, do most of the other workers
have disabilities?
| per hour
YES
NO
YES
NO
Health insurance? .......................................... 1
0
Health insurance? .......................................... 1
0
Paid vacation or sick leave? .......................... 1
0
Paid vacation or sick leave? .......................... 1
0
YES .................................................................................. 1
YES .................................................................................. 1
NO .................................................................................... 0
NO .................................................................................... 0
YES .................................................................................. 1
YES .................................................................................. 1
NO .................................................................................... 0
NO .................................................................................... 0
22
(2/9/07)
JOB 3
NEXT MOST RECENT JOB
|
|
JOB 4
NEXT MOST RECENT JOB
|
|
|
JOB 5
NEXT MOST RECENT JOB
|
|
|
|
HOURS PER WEEK USUALLY WORKED
HOURS PER WEEK USUALLY WORKED
HOURS PER WEEK USUALLY WORKED
OR
OR
OR
IF CANNOT ANSWER EXACT HOURS, PROBE FOR
RANGE: (Do you/Does [NAME]) think (you/he/she)
work . . .
IF CANNOT ANSWER EXACT HOURS, PROBE FOR
RANGE: (Do you/Does [NAME]) think (you/he/she)
work . . .
IF CANNOT ANSWER EXACT HOURS, PROBE FOR
RANGE: (Do you/Does [NAME]) think (you/he/she)
work . . .
Less than 10 hours per week?......................................... 1
Less than 10 hours per week?......................................... 1
Less than 10 hours per week?......................................... 1
10-20 hours per week? .................................................... 2
10-20 hours per week? .................................................... 2
10-20 hours per week? .................................................... 2
21-30 hours per week? .................................................... 3
21-30 hours per week? .................................................... 3
21-30 hours per week? .................................................... 3
Or more than 30 hours per week? ................................... 4
Or more than 30 hours per week? ................................... 4
Or more than 30 hours per week? ................................... 4
Hour.................................................................................. 1
Hour.................................................................................. 1
Hour.................................................................................. 1
Things............................................................................... 2
Things............................................................................... 2
Things............................................................................... 2
Some other way (SPECIFY) ............................................ 3
Some other way (SPECIFY) ............................................ 3
Some other way (SPECIFY) ............................................ 3
$|
|
|.|
|
| per hour
|
$|
or
$|
|
|
|.|
|
|.|
|
| per hour
|
$|
or
| per week .................................. 1
$|
|
|
|.|
|
|.|
|
| per hour
or
| per week .................................. 1
$|
|
|
|.|
|
| per week .................................. 1
every other week ..................... 2
every other week ..................... 2
every other week ..................... 2
twice a month .......................... 3
twice a month .......................... 3
twice a month .......................... 3
once a month........................... 4
once a month........................... 4
once a month........................... 4
OTHER (SPECIFY) ................. 5
OTHER (SPECIFY) ................. 5
OTHER (SPECIFY) ................. 5
Net pay ............................................................................. 1
Net pay ............................................................................. 1
Net pay............................................................................. 1
Before taxes ..................................................................... 2
Before taxes ..................................................................... 2
Before taxes ..................................................................... 2
YES
NO
YES
NO
YES
NO
Health insurance? .......................................... 1
0
Health insurance? .......................................... 1
0
Health insurance? .......................................... 1
0
Paid vacation or sick leave? .......................... 1
0
Paid vacation or sick leave? .......................... 1
0
Paid vacation or sick leave? .......................... 1
0
YES .................................................................................. 1
YES .................................................................................. 1
YES .................................................................................. 1
NO .................................................................................... 0
NO .................................................................................... 0
NO .................................................................................... 0
YES .................................................................................. 1
YES .................................................................................. 1
YES .................................................................................. 1
NO .................................................................................... 0
NO .................................................................................... 0
NO .................................................................................... 0
YTD-12 Month Follow-Up (lb)-q14.doc
Prepared by Mathematica Policy Research, Inc.
23
(2/9/07)
JOB 1
CURRENT/MAIN JOB/OR MOST RECENT JOB
II.E1
IF NOT CURRENT JOB, ASK: Why did
(you/he/she) leave this job?
PROBE: Why (are you/is [NAME]) no longer
working (NAME OR PLACE)?
PROBE FOR MAIN REASON.
II.E2
IF CURRENT JOB, ASK: Overall, how happy
(are you/is [NAME]) with (your/his/her) job at (JOB
FROM E4)? Would (you/he/she) say . . .
Job was too hard........................................................... 1
Job was too easy .......................................................... 2
Found a better job ......................................................... 3
Temporary job ended.................................................... 4
Went back to school...................................................... 5
Job did not pay enough................................................. 6
Does not need the money............................................. 7
Did not like boss............................................................ 8
Did not like coworkers................................................... 9
Transportation problems ............................................... 10
I moved to far ................................................................ 11
Job moved too far ......................................................... 12
Fired/performance problems......................................... 13
Health reasons .............................................................. 14
Employer wouldn’t provide accommodations
needed to succeed at job.............................................. 15
Had a baby.................................................................... 16
Family obligations ......................................................... 17
Did not want to loose disability or other benefits .......... 18
Parents do not want youth to work ............................... 19
Youth does not want to work......................................... 20
JOB 2
NEXT MOST RECENT JOB
Job was too hard........................................................... 1
Job was too easy .......................................................... 2
Found a better job......................................................... 3
Temporary job ended.................................................... 4
Went back to school...................................................... 5
Job did not pay enough................................................. 6
Does not need the money............................................. 7
Did not like boss............................................................ 8
Did not like coworkers................................................... 9
Transportation problems ............................................... 10
I moved to far ................................................................ 11
Job moved too far ......................................................... 12
Fired/performance problems......................................... 13
Health reasons .............................................................. 14
Employer wouldn’t provide accommodations
needed to succeed at job.............................................. 15
Had a baby.................................................................... 16
Family obligations ......................................................... 17
Did not want to loose disability or other benefits .......... 18
Parents do not want youth to work ............................... 19
Youth does not want to work ........................................ 20
very happy,.................................................................... 1
a little happy, or............................................................. 2
not happy? .................................................................... 3
II.F1.
YTD-12 Month Follow-Up (lb)-q14.doc
Prepared by Mathematica Policy Research, Inc.
CONTINUE WITH OTHER JOB(S) OR
COMPLETE JOB GRID.
CONTINUE WITH OTHER JOB(S) OR
COMPLETE JOB GRID.
NEXT JOB........................................1
GO TO JOB 2
NEXT JOB........................................1
GO TO JOB 3
NO MORE JOBS..............................0
GO TO II.G1
NO MORE JOBS..............................0
GO TO II.G1
24
(2/9/07)
JOB 3
NEXT MOST RECENT JOB
Job was too hard........................................................... 1
Job was too easy .......................................................... 2
Found a better job ......................................................... 3
Temporary job ended.................................................... 4
Went back to school...................................................... 5
Job did not pay enough................................................. 6
Does not need the money............................................. 7
Did not like boss............................................................ 8
Did not like coworkers................................................... 9
Transportation problems ............................................... 10
I moved to far ................................................................ 11
Job moved too far ......................................................... 12
Fired/performance problems......................................... 13
Health reasons .............................................................. 14
Employer wouldn’t provide accommodations
needed to succeed at job.............................................. 15
Had a baby.................................................................... 16
Family obligations ......................................................... 17
Did not want to loose disability or other benefits .......... 18
Parents do not want youth to work ............................... 19
Youth does not want to work......................................... 20
CONTINUE WITH OTHER JOB(S) OR
COMPLETE JOB GRID.
JOB 4
NEXT MOST RECENT JOB
JOB 5
NEXT MOST RECENT JOB
Job was too hard........................................................... 1
Job was too easy .......................................................... 2
Found a better job ......................................................... 3
Temporary job ended.................................................... 4
Went back to school...................................................... 5
Job did not pay enough................................................. 6
Does not need the money............................................. 7
Did not like boss............................................................ 8
Did not like coworkers................................................... 9
Transportation problems ............................................... 10
I moved to far ................................................................ 11
Job moved too far ......................................................... 12
Fired/performance problems......................................... 13
Health reasons .............................................................. 14
Employer wouldn’t provide accommodations
needed to succeed at job.............................................. 15
Had a baby.................................................................... 16
Family obligations ......................................................... 17
Did not want to loose disability or other benefits .......... 18
Parents do not want youth to work ............................... 19
Youth does not want to work......................................... 20
CONTINUE WITH OTHER JOB(S) OR
COMPLETE JOB GRID.
Job was too hard........................................................... 1
Job was too easy .......................................................... 2
Found a better job......................................................... 3
Temporary job ended.................................................... 4
Went back to school...................................................... 5
Job did not pay enough................................................. 6
Does not need the money............................................. 7
Did not like boss............................................................ 8
Did not like coworkers................................................... 9
Transportation problems ............................................... 10
I moved to far ................................................................ 11
Job moved too far ......................................................... 12
Fired/performance problems......................................... 13
Health reasons .............................................................. 14
Employer wouldn’t provide accommodations
needed to succeed at job.............................................. 15
Had a baby.................................................................... 16
Family obligations ......................................................... 17
Did not want to loose disability or other benefits .......... 18
Parents do not want youth to work ............................... 19
Youth does not want to work ........................................ 20
CONTINUE WITH OTHER JOB(S) OR
COMPLETE JOB GRID.
NEXT JOB........................................1
GO TO JOB 4
NEXT JOB........................................1
GO TO JOB 5
NEXT JOB........................................1
GO TO JOB 6
NO MORE JOBS..............................0
GO TO II.G1
NO MORE JOBS..............................0
GO TO II.G1
NO MORE JOBS..............................0
GO TO II.G1
YTD-12 Month Follow-Up (lb)-q14.doc
Prepared by Mathematica Policy Research, Inc.
25
(2/9/07)
II.G1
(NBS-B25.)
ASK IF NOT CURRENTLY EMPLOYED AND NOT CURRENTLY IN SCHOOL:
I am going to read a list of reasons people do not work. For each, please tell me if it is
a reason why (you are/[he/she] is) not currently working. (Are you/Is [NAME]) not
working because . . .
READ IF NEEDED: I know (you are/[he/she] is) not able to work, but the study rules
require us to ask all beneficiaries the same questions.
YES
NO
a. A physical or mental condition prevents (you/NAME) from working? .........
1
0
b. (You/NAME) do not have reliable transportation to and from work?...........
1
0
c. (You/NAME) cannot find a job (you want/[he/she] wants)?.........................
1
0
d. (You are/[NAME] is) waiting to finish school or a training program?...........
1
0
e. Workplaces are not accessible to people with (your/his/her) disability? .....
1
0
f.
(You/NAME) do not want to lose benefits such as disability or Medicaid? .
1
0
g. (Your/His/Her) previous attempts to work have been discouraging? ..........
1
0
h. Others do not think (you/he/she) can work? ...............................................
1
0
II.G2
ASK IF NOT CURRENTLY EMPLOYED AND NOT CURRENTLY IN SCHOOL:
Are there any other reasons why (you are/[he/she] is) not working that I didn’t mention?
(NBS-B26.)
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
(GO TO II.G4)
REFUSED .................................................... r
II.G3
ASK IF OTHER REASON NOT WORKING:
What are they?
(NBS-B27.)
INTERVIEWER: ENTER VERBATIM RESPONSE.
DON’T KNOW .............................................. d
REFUSED .................................................... r
YTD-12 Month Follow-Up (lb)-q14.doc
Prepared by Mathematica Policy Research, Inc.
26
(2/9/07)
II.G4
(NBS-B28.)
ASK IF NOT CURRENTLY EMPLOYED AND NOT CURRENTLY IN SCHOOL:
(Have you/Has [he/she]) been looking for work during the last four weeks?
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
(GO TO SECTION III.1A)
REFUSED .................................................... r
II.G5
(NBS - B29.)
ASK IF NOT CURRENTLY EMPLOYED AND NOT CURRENTLY IN SCHOOL:
Next, I am going to read (you/NAME) a list of things that some people do to look for
work. Please tell me whether or not (you/he/she) did any of these things during the
last four weeks.
To look for work in the last four weeks, did (you/he/she) . . .
YES
NO
a. Contact (your/his/her) state’s One Stop office, (CO: WIN Center),
Workforce Development office, or unemployment office?........................
1
0
b. Ask friends or relatives?...........................................................................
1
0
c. Look through job advertisements in a newspaper or on the internet? .....
1
0
d. Contact the State Vocational Rehabilitation Agency or
(STATE VR NAME)?................................................................................
1
0
e. Contact any employers in person, by mail, or by phone? ........................
1
0
f.
1
0
Do anything else that I didn’t mention? (SPECIFY: What was it?).........
YTD-12 Month Follow-Up (lb)-q14.doc
Prepared by Mathematica Policy Research, Inc.
27
(2/9/07)
SECTION III: SERVICE UTILIZATION
THIS SECTION ASKED OF PARENTS OR INDEPENDENT YOUTH.
III.A1 My next questions are about services or training (you/NAME) might have received since
(RA DATE/MEMORY AID). (Have/Has) . . .
(NLTS - F8b)(mod)
YES
NO
1
0
1
0
1
0
1
0
PROBE: Career counseling, is where someone talked with
(you/NAME) about different types of jobs or careers,
and the training and skills they require?
e. (you/NAME) had help in finding or applying for a job, such as how
to find jobs available, fill out an application, write a resume, or go
for an interview?................................................................................
1
0
PROBE: A resume is a summary of (your/NAME’s) job
qualifications.
(you/NAME) had help in getting into a school or training program,
including helping with an application or interview? ...........................
1
0
1
0
1
0
1
0
a. (you/NAME) spoken with anyone about (your/his/her) interests and
what (you/he/she) might enjoy doing in the future? ..........................
b. someone spoken with (your/NAME’s) parent or guardian about
(your/NAME’s) life or future plans? ...................................................
c. (you/NAME) been taught skills needed for life, like counting
change, telling time or using public transportation? ..........................
d. (you/NAME) had career counseling, like help in learning which jobs
are a good match with (your/NAME’s) skills and interests? ..............
f.
PROBE: For example, where someone told (you/him/her) about
jobs that are available and how to apply for them? Or if
someone helped you complete an application for
college.
g. (you/NAME) had help with accommodations at school or work? ......
h. (you/NAME) had help in understanding Social Security benefits
and rules? .........................................................................................
i. PLACEHOLDER FOR PROGRAM SPECIFIC SERVICES FOR
NEW SITES.
NEW SITE SPECIFIC PROGRAM SERVICE?.................................
IF III.A1 a-i ALL=NO, GO TO III.G3
YTD-12 Month Follow-Up (lb)-q14.doc
Prepared by Mathematica Policy Research, Inc.
28
(2/9/07)
III.B1
ASK IF YES TO ANY OF THE SERVICES:
You said that (you/NAME) received the following services since (RATE DATE/
MEMORY AID).
LIST SERVICES THAT YOUTH RECEIVED.
FOR EACH SERVICE ASK:
Where did (you/NAME) get (SERVICE)?
PROBE: Who helped (you/NAME) with (SERVICE)?
PROBE: Any place else? Anyone else?
PROVIDER NAME:
III.B2
What type of place is (PROVIDER NAME)?
READ IF NECESSARY.
VOCATIONAL REHABILITATION AGENCY/VR..... 1
OTHER AGENCY SERVING PERSONS
WITH DISABILITIES................................................ 2
ONE-STOP/WORK FORCE DEVELOPMENT
CENTER/[CO: WIN CENTERS) ............................. 3
(YTD PROGRAM) ................................................... 4
OTHER (SPECIFY) ................................................. 5
DON’T KNOW ......................................................... d
REFUSED ............................................................... r
YTD-12 Month Follow-Up (lb)-q14.doc
Prepared by Mathematica Policy Research, Inc.
29
(2/9/07)
ASK FOR EACH SERVICE PROVIDER CODED “YES” IN
III..B1:
III.C1
Did (you/NAME) get any other services from
(PROVIDER)?
PROVIDER 1
PROVIDER 2
NAME ___________________________
NAME ___________________________
YES ....................................... 1
NO ......................................... 0
III.C2
III.D1
ASK IF SM RECEIVED OTHER SERVICES
FROM PROVIDER:
What other services did (you/NAME) get from
(PROVIDER)?
Did (PROVIDER) refer (you/NAME) to or arrange
for (you/NAME) to go to other places or
services?
YES ....................................... 1
GO TO III.D1
NO ......................................... 0
CIRCLE ALL
THAT APPLY
CIRCLE ALL
THAT APPLY
DISCUSSING INTERESTS ........................................... 1
DISCUSSING INTERESTS ............................................1
TEST TO FIND OUT INTERESTS ................................ 2
TEST TO FIND OUT INTERESTS .................................2
BASIC SKILLS TRAINING............................................. 3
BASIC SKILLS TRAINING..............................................3
CAREER COUNSELING ............................................... 4
CAREER COUNSELING ................................................4
LEARNING HOW TO LOOK FOR A JOB ..................... 5
LEARNING HOW TO LOOK FOR A JOB ......................5
JOB SHADOWING......................................................... 6
JOB SHADOWING..........................................................6
APPRENTICESHIP/INTERNSHIP................................. 7
APPRENTICESHIP/INTERNSHIP..................................7
HELP FINDING A JOB .................................................. 8
HELP FINDING A JOB ...................................................8
HELP GETTING INTO SCHOOL................................... 9
HELP GETTING INTO SCHOOL....................................9
UNDERSTANDING SSA BENEFITS............................. 10
UNDERSTANDING SSA BENEFITS..............................10
COMPUTER CLASSES................................................. 11
COMPUTER CLASSES..................................................11
PROBLEM SOLVING .................................................... 12
PROBLEM SOLVING .....................................................12
SOCIAL SKILLS TRAINING .......................................... 13
SOCIAL SKILLS TRAINING ...........................................13
REFERRAL TO ANOTHER AGENCY........................... 14
REFERRAL TO ANOTHER AGENCY............................14
TRANSPORTATION SERVICES .................................. 15
TRANSPORTATION SERVICES ...................................15
HEALTH SERVICES...................................................... 16
HEALTH SERVICES.......................................................16
CASE MANAGEMENT .................................................. 17
CASE MANAGEMENT ...................................................17
ACCOMMODATIONS.................................................... 18
ACCOMMODATIONS.....................................................18
OTHER SERVICES (SPECIFY) .................................... 19
OTHER SERVICES (SPECIFY) .....................................19
DON’T KNOW ................................................................ d
DON’T KNOW .................................................................d
YES ................................................................................ 1
YES .................................................................................1
NO .................................................................................. 0
NO ...................................................................................0
PROBE: Such as transportation services or
other agencies that could help (you/NAME).
YTD-12 Month Follow-Up (lb)-q14.doc
Prepared by Mathematica Policy Research, Inc.
GO TO III.D1
30
(2/9/07)
PROVIDER 3
PROVIDER 4
PROVIDER 5
NAME ___________________________
NAME ___________________________
NAME ___________________________
YES ....................................... 1
NO ......................................... 0
YES ....................................... 1
GO TO III.D1
NO ......................................... 0
CIRCLE ALL
THAT APPLY
YES ....................................... 1
GO TO III.D1
NO ......................................... 0
CIRCLE ALL
THAT APPLY
GO TO III.D1
CIRCLE ALL
THAT APPLY
DISCUSSING INTERESTS ........................................... 1
DISCUSSING INTERESTS ........................................... 1
DISCUSSING INTERESTS ........................................... 1
TEST TO FIND OUT INTERESTS ................................ 2
TEST TO FIND OUT INTERESTS ................................ 2
TEST TO FIND OUT INTERESTS ................................ 2
BASIC SKILLS TRAINING............................................. 3
BASIC SKILLS TRAINING............................................. 3
BASIC SKILLS TRAINING............................................. 3
CAREER COUNSELING ............................................... 4
CAREER COUNSELING ............................................... 4
CAREER COUNSELING ............................................... 4
LEARNING HOW TO LOOK FOR A JOB ..................... 5
LEARNING HOW TO LOOK FOR A JOB ..................... 5
LEARNING HOW TO LOOK FOR A JOB ..................... 5
JOB SHADOWING......................................................... 6
JOB SHADOWING......................................................... 6
JOB SHADOWING......................................................... 6
APPRENTICESHIP/INTERNSHIP................................. 7
APPRENTICESHIP/INTERNSHIP................................. 7
APPRENTICESHIP/INTERNSHIP................................. 7
HELP FINDING A JOB .................................................. 8
HELP FINDING A JOB .................................................. 8
HELP FINDING A JOB .................................................. 8
HELP GETTING INTO SCHOOL................................... 9
HELP GETTING INTO SCHOOL................................... 9
HELP GETTING INTO SCHOOL................................... 9
UNDERSTANDING SSA BENEFITS............................. 10
UNDERSTANDING SSA BENEFITS............................. 10
UNDERSTANDING SSA BENEFITS............................. 10
COMPUTER CLASSES................................................. 11
COMPUTER CLASSES................................................. 11
COMPUTER CLASSES................................................. 11
PROBLEM SOLVING .................................................... 12
PROBLEM SOLVING .................................................... 12
PROBLEM SOLVING .................................................... 12
SOCIAL SKILLS TRAINING .......................................... 13
SOCIAL SKILLS TRAINING .......................................... 13
SOCIAL SKILLS TRAINING .......................................... 13
REFERRAL TO ANOTHER AGENCY........................... 14
REFERRAL TO ANOTHER AGENCY........................... 14
REFERRAL TO ANOTHER AGENCY........................... 14
TRANSPORTATION SERVICES .................................. 15
TRANSPORTATION SERVICES .................................. 15
TRANSPORTATION SERVICES .................................. 15
HEALTH SERVICES...................................................... 16
HEALTH SERVICES...................................................... 16
HEALTH SERVICES...................................................... 16
CASE MANAGEMENT .................................................. 17
CASE MANAGEMENT .................................................. 17
CASE MANAGEMENT .................................................. 17
ACCOMMODATIONS.................................................... 18
ACCOMMODATIONS.................................................... 18
ACCOMMODATIONS.................................................... 18
OTHER SERVICES (SPECIFY) .................................... 19
OTHER SERVICES (SPECIFY) .................................... 19
OTHER SERVICES (SPECIFY) .................................... 19
DON’T KNOW ................................................................ d
DON’T KNOW ................................................................ d
DON’T KNOW ................................................................ d
YES ................................................................................ 1
YES ................................................................................ 1
YES ................................................................................ 1
NO .................................................................................. 0
NO .................................................................................. 0
NO .................................................................................. 0
YTD-12 Month Follow-Up (lb)-q14.doc
Prepared by Mathematica Policy Research, Inc.
31
(2/9/07)
PROVIDER 1
III.E1a When did (you/NAME) start going to
(PROVIDER)?
| | | / |
MONTH
|
PROVIDER 2
| |
YEAR
|
| | | / |
MONTH
|
| |
YEAR
|
PROBE: In what month and year?
III.E1b (Are you/Is [NAME]) still going to
(PROVIDER)?
YES .............................. 1
GO TO III.E2
NO ................................ 0
IF III.E1b=NO, ASK:
III.E1c When did (you/NAME) stop going to
(PROVIDER)?
| | | / |
MONTH
|
| |
YEAR
YES...............................1
GO TO III.E2
NO ................................0
|
| | | / |
MONTH
|
| |
YEAR
|
PROBE: In what month and year?
III.E1d Why did (you/NAME) stop attending the
(PROGRAM/SERVICE)?
IF III.E1a or III.E1c NOT ANSWERED
AND III.E1b NE 0, ASK:
III.E1e For how many months of the past year
(have you/has [NAME]) been
seeing/going to (PROVIDER)?
PROBE: Since (RA DATE/MEMORY
AID), for how many months . . .
YTD-12 Month Follow-Up (lb)-q14.doc
Prepared by Mathematica Policy Research, Inc.
THE PROGRAM WAS FINISHED..................1
THE PROGRAM WAS FINISHED ................. 1
DID NOT LIKE THE PROGRAM/SERVICE—
FOUND IT BORING .......................................2
DID NOT LIKE THE PROGRAM/SERVICE—
FOUND IT BORING....................................... 2
DID NOT LEARN ANYTHING NEW...............3
DID NOT LEARN ANYTHING NEW .............. 3
NO TRANSPORTATION ................................4
NO TRANSPORTATION ............................... 4
BAD TIME OF THE DAY- OTHER
OBLIGATIONS ...............................................5
BAD TIME OF THE DAY- OTHER
OBLIGATIONS .............................................. 5
YOUTH BECAME ILL.....................................6
YOUTH BECAME ILL .................................... 6
FAMILY MEMBER BECAME ILL....................7
FAMILY MEMBER BECAME ILL................... 7
GOT A JOB ....................................................8
GOT A JOB.................................................... 8
DID NOT HAVE ANY FRIENDS AT THE
PROGRAM/SERVICE ....................................9
DID NOT HAVE ANY FRIENDS AT THE
PROGRAM/SERVICE ................................... 9
OTHER (SPECIFY) ........................................10
OTHER (SPECIFY) ....................................... 10
|
|
| MONTHS
|
|
| MONTHS
IF DON’T KNOW OR REFUSED: Was it . . .
IF DON’T KNOW OR REFUSED: Was it . . .
Every month or all year long,..........................1
Every month or all year long, ......................... 1
About six months or half of the year, ..............2
About six months or half of the year, ............. 2
For about 3 or 4 months, or ............................3
For about 3 or 4 months, or ........................... 3
Less than that? ...............................................4
Less than that? .............................................. 4
DON’T KNOW ................................................d
DON’T KNOW................................................ d
32
(2/9/07)
PROVIDER 3
| | | / |
MONTH
|
PROVIDER 4
| |
YEAR
YES .............................. 1
|
GO TO III.E2
NO ................................ 0
| | | / |
MONTH
|
| |
YEAR
| | | / |
MONTH
|
PROVIDER 5
| |
YEAR
YES .............................. 1
|
GO TO III.E2
NO ................................ 0
|
| | | / |
MONTH
|
| |
YEAR
| | | / |
MONTH
|
| |
YEAR
YES...............................1
|
GO TO III.E2
NO ................................0
|
| | | / |
MONTH
|
| |
YEAR
|
THE PROGRAM WAS FINISHED .................1
THE PROGRAM WAS FINISHED..................1
THE PROGRAM WAS FINISHED ................. 1
DID NOT LIKE THE PROGRAM/SERVICE—
FOUND IT BORING .......................................2
DID NOT LIKE THE PROGRAM/SERVICE—
FOUND IT BORING .......................................2
DID NOT LIKE THE PROGRAM/SERVICE—
FOUND IT BORING....................................... 2
DID NOT LEARN ANYTHING NEW ..............3
DID NOT LEARN ANYTHING NEW...............3
DID NOT LEARN ANYTHING NEW .............. 3
NO TRANSPORTATION................................4
NO TRANSPORTATION ................................4
NO TRANSPORTATION ............................... 4
BAD TIME OF THE DAY- OTHER
OBLIGATIONS ...............................................5
BAD TIME OF THE DAY- OTHER
OBLIGATIONS ...............................................5
BAD TIME OF THE DAY- OTHER
OBLIGATIONS .............................................. 5
YOUTH BECAME ILL ....................................6
YOUTH BECAME ILL.....................................6
YOUTH BECAME ILL .................................... 6
FAMILY MEMBER BECAME ILL ...................7
FAMILY MEMBER BECAME ILL....................7
FAMILY MEMBER BECAME ILL................... 7
GOT A JOB ....................................................8
GOT A JOB ....................................................8
GOT A JOB.................................................... 8
DID NOT HAVE ANY FRIENDS AT THE
PROGRAM/SERVICE....................................9
DID NOT HAVE ANY FRIENDS AT THE
PROGRAM/SERVICE ....................................9
DID NOT HAVE ANY FRIENDS AT THE
PROGRAM/SERVICE ................................... 9
OTHER (SPECIFY) ........................................10
OTHER (SPECIFY) ........................................10
OTHER (SPECIFY) ....................................... 10
|
|
| MONTHS
|
|
| MONTHS
|
|
| MONTHS
IF DON’T KNOW OR REFUSED: Was it . . .
IF DON’T KNOW OR REFUSED: Was it . . .
IF DON’T KNOW OR REFUSED: Was it . . .
Every month or all year long, .........................1
Every month or all year long,..........................1
Every month or all year long, ......................... 1
About six months or half of the year,..............2
About six months or half of the year, ..............2
About six months or half of the year, ............. 2
For about 3 or 4 months, or............................3
For about 3 or 4 months, or ............................3
For about 3 or 4 months, or ........................... 3
Less than that?...............................................4
Less than that? ...............................................4
Less than that? .............................................. 4
DON’T KNOW ................................................d
DON’T KNOW ................................................d
DON’T KNOW................................................ d
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PROVIDER 1
III.E2
III.E3
PROVIDER 2
During the months when (you/NAME)
(saw/met with) (PROVIDER), about how
often did (you/he/she) go?
Every day........................................................1
Every day ....................................................... 1
More than once a week ..................................2
More than once a week ................................. 2
PROBE: This could include meetings,
classes, or check-in calls.
Weekly............................................................3
Weekly ........................................................... 3
More than once a month.................................4
More than once a month................................ 4
PROBE: (Your/His/Her) best estimate
is fine.
About once a month .......................................5
About once a month....................................... 5
READ IF NECESSARY.
Less often than once a month ........................6
Less often than once a month ....................... 6
On average, how long was each
meeting or session?
|
|
| MINUTES |
|
| HOURS
|
|
| MINUTES |
|
| HOURS
IF DON’T KNOW OR REFUSED:
On average, was it . . .
IF DON’T KNOW OR REFUSED:
On average, was it . . .
Less than an hour,..........................................1
Less than an hour, ......................................... 1
About one hour, ..............................................2
About one hour, ............................................. 2
About 2 hours, ................................................3
About 2 hours, ............................................... 3
About 3 hours, ................................................4
About 3 hours, ............................................... 4
About 4 hours or half a day, or was it, ............5
About 4 hours or half a day, or was it, ........... 5
More than 4 hours per meeting? ....................6
More than 4 hours per meeting?.................... 6
How useful (do you/does [he/she]) think
the help or services that (you/NAME)
got from (PROVIDER) has been?
Very useful,.....................................................1
Very useful, .................................................... 1
Somewhat useful, ...........................................2
Somewhat useful, .......................................... 2
Would you say . . .
Not very useful, or ..........................................3
Not very useful, or.......................................... 3
Not at all useful?.............................................4
Not at all useful? ............................................ 4
DON’T KNOW ................................................d
DON’T KNOW................................................ d
YES ................................................................1
YES................................................................ 1
NO ..................................................................0
NO ................................................................. 0
PROBE: How much time per day?
(NLTS - F9f) (Mod)
III.F1
III.F2
INTERVIEWER: IS THERE ANOTHER
SERVICE PROVIDER?
GO TO III.G1
YTD-12 Month Follow-Up (lb)-q14.doc
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GO TO III.G1
(2/9/07)
PROVIDER 3
PROVIDER 4
PROVIDER 5
Every day .......................................................1
Every day........................................................1
Every day ....................................................... 1
More than once a week..................................2
More than once a week ..................................2
More than once a week ................................. 2
Weekly ...........................................................3
Weekly............................................................3
Weekly ........................................................... 3
More than once a month ................................4
More than once a month.................................4
More than once a month................................ 4
About once a month .......................................5
About once a month .......................................5
About once a month....................................... 5
Less often than once a month........................6
Less often than once a month ........................6
Less often than once a month ....................... 6
|
|
| MINUTES |
|
| HOURS
|
|
| MINUTES |
|
| HOURS
|
|
| MINUTES |
|
| HOURS
IF DON’T KNOW OR REFUSED:
On average, was it . . .
IF DON’T KNOW OR REFUSED:
On average, was it . . .
IF DON’T KNOW OR REFUSED:
On average, was it . . .
Less than an hour, .........................................1
Less than an hour,..........................................1
Less than an hour, ......................................... 1
About one hour,..............................................2
About one hour, ..............................................2
About one hour, ............................................. 2
About 2 hours,................................................3
About 2 hours, ................................................3
About 2 hours, ............................................... 3
About 3 hours,................................................4
About 3 hours, ................................................4
About 3 hours, ............................................... 4
About 4 hours or half a day, or was it,............5
About 4 hours or half a day, or was it, ............5
About 4 hours or half a day, or was it, ........... 5
More than 4 hours per meeting? ....................6
More than 4 hours per meeting? ....................6
More than 4 hours per meeting?.................... 6
Very useful, ....................................................1
Very useful,.....................................................1
Very useful, .................................................... 1
Somewhat useful,...........................................2
Somewhat useful, ...........................................2
Somewhat useful, .......................................... 2
Not very useful, or ..........................................3
Not very useful, or ..........................................3
Not very useful, or.......................................... 3
Not at all useful? ............................................4
Not at all useful?.............................................4
Not at all useful? ............................................ 4
DON’T KNOW ................................................d
DON’T KNOW ................................................d
DON’T KNOW................................................ d
YES ................................................................1
YES ................................................................1
NO ..................................................................0
NO ..................................................................0
GO TO III.G1
YTD-12 Month Follow-Up (lb)-q14.doc
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GO TO III.G1
GO TO III.G1
35
(2/9/07)
III.G1
Since (RATE DATE/MEMORY AID), (have you/has [NAME]) had . . .
Any other services to help prepare (you/[him/her]) for working or going to school?
YES ......................................................................... 1
NO ........................................................................... 0
DON’T KNOW ......................................................... d
REFUSED ............................................................... r
ASK IF RECEIVED OTHER SERVICES:
III.G2 What other services did (you/NAME) get in the last year that helped prepare
(you/him/her) for working or going to school?
COMPUTER CLASSES .......................................... 1
PROBLEM SOLVING .............................................. 2
SOCIAL INTERACTION SKILLS............................. 3
REFERRAL TO ANOTHER AGENCY..................... 4
TRANSPORTATION SERVICES ............................ 5
CASE MANAGEMENT ............................................ 6
OTHER (SPECIFY) ................................................. 7
DON’T KNOW ......................................................... d
REFUSED ............................................................... r
III.G3
IF III.C2=16, SKIP III.G3. ASK ALTERNATE WORDING IN III.G4:
Since (RATE DATE/MEMORY AID), (have you/has [NAME]) received any health or
health-related services from an agency or organization that serves people with
disabilities in (your/his/her) area?
PROBE: Please don’t include any job or education services that we have already
discussed.
PROBE: Such as help with equipment or devices, or paying for health care.
YES ......................................................................... 1
NO ........................................................................... 0
DON’T KNOW ......................................................... d
REFUSED ............................................................... r
YTD-12 Month Follow-Up (lb)-q14.doc
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(2/9/07)
III.G4
ASK IF RECEIVED HEALTH OR OTHER TYPES OF SERVICES:
(You told me [you/NAME] received health services.) What type of health or healthrelated services did (you/he/she) receive?
HEALTH INSURANCE ............................................ 1
OBTAINING ASSISTIVE DEVICES ........................ 2
PAYING FOR ASSISTIVE DEVICES ...................... 3
HEALTH CARE SERVICES .................................... 4
HELP PAYING FOR MEDICATION ........................ 5
CASE MANAGEMENT ............................................ 6
OTHER (SPECIFY) ................................................. 7
DON’T KNOW ......................................................... d
REFUSED ............................................................... r
III.H1
ASK OF EVERYONE:
Since (RA DATE/MEMORY AID), (have you/has [NAME]) needed any (other) help or
services preparing for work or school that (you/he/she) didn’t receive?
YES ......................................................................... 1
NO ........................................................................... 0
DON’T KNOW ......................................................... d
(GO TO IV.A1)
REFUSED ............................................................... r
YTD-12 Month Follow-Up (lb)-q14.doc
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(2/9/07)
III.H2
What help or services did (you/he/she) need that (you/he/she) did not get?
PROGRAMMER: ONLY DISPLAY SERVICES THAT WERE CODED “NO.”
DISCUSSING INTERESTS ..................................... 1
TEST TO FIND OUT INTERESTS .......................... 2
BASIC SKILLS TRAINING ...................................... 3
CAREER COUNSELING......................................... 4
LEARNING HOW TO LOOK FOR A JOB ............... 5
JOB SHADOWING .................................................. 6
APPRENTICESHIP/INTERNSHIP .......................... 7
HELP FINDING A JOB ............................................ 8
HELP GETTING INTO SCHOOL ............................ 9
UNDERSTANDING SSA BENEFITS ...................... 10
COMPUTER CLASSES .......................................... 11
PROBLEM SOLVING .............................................. 12
SOCIAL SKILLS TRAINING .................................... 13
REFERRAL TO ANOTHER AGENCY..................... 14
TRANSPORTATION SERVICES ............................ 15
HEALTH SERVICES ............................................... 16
CASE MANAGEMENT ............................................ 17
ACCOMMODATIONS ............................................. 18
OTHER (SPECIFY) ................................................. 19
DON’T KNOW ......................................................... d
REFUSED ............................................................... r
YTD-12 Month Follow-Up (lb)-q14.doc
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38
(2/9/07)
SECTION IV: SATISFACTION WITH YTD PROGRAM
THIS SECTION IS ASKED OF PARENTS AND YOUTH IN TREATMENT GROUP.
IF YTD PROGRAM WAS REPORTED AS A SERVICE PROVIDER, GO TO IV.E1
PARENT OR INDEPENDENT YOUTH QUESTIONS
My next questions are about (your/his/her) experiences [ADD IF SPEAKING WITH
PARENT: and (NAME)’s experiences] with (YTD PROGRAM). IF YTD PROGRAM
NOT MENTIONED IN SERVICE UTILIZATION, ADD: This is the program through
Social Security that helps young people with disabilities become more independent.
(You were/[NAME] was) eligible for this program beginning on (RA DATE/MEMORY
AID).
IV.A1
ASK IF YTD PROGRAM WAS NOT REPORTED AS A SERVICE PROVIDER:
Since (RA DATE/MEMORY AID), did (you/NAME) receive any services or participate in
any (YTD PROGRAM) activities?
INTERVIEWER: CODE “YES” EVEN IF ONLY ONCE.
YES .............................................................. 1 (GO TO IV.C1)
NO ................................................................ 0
DON’T KNOW .............................................. d
REFUSED .................................................... r
IV.B1
Since (RA DATE/MEMORY AID), did someone from (YTD PROGRAM) speak with
(you/NAME) to try to meet with (you/NAME) about participating in (YTD PROGRAM)?
INTERVIEWER: CODE “YES” EVEN IF ONLY ONCE.
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
(GO TO V.A1)
REFUSED .................................................... r
YTD-12 Month Follow-Up (lb)-q14.doc
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(2/9/07)
IV.B2
Did (you/NAME) speak to or meet with someone from the (YTD PROGRAM)?
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
(GO TO IV.B3)
REFUSED .................................................... r
IV.B2a Why did (you/NAME) not participate in (YTD PROGRAM)?
(SPECIFY).................................................... 1
DON’T KNOW .............................................. d
REFUSED .................................................... r
GO TO V.A1
IV.B3
ASK IF NO CONTACT WITH YTD PROGRAM:
Why didn’t (you/NAME) speak to or meet with someone from (YTD PROGRAM)?
SPECIFY ...................................................... 1
DON’T KNOW .............................................. d
REFUSED .................................................... r
IF NO CONTACT WITH YTD PROGRAM, NO FURTHER
QUESTIONS IN THIS SECTION - GO TO V.A1
IV.C1
ASK IF YTD PROGRAM WAS NOT REPORTED AS A SERVICE PROVIDER:
When did (you/NAME) start going to (YTD PROGRAM)?
PROBE: In what month and year?
| | | / |
MONTH
| | |
YEAR
|
DON’T KNOW .............................................. d
REFUSED .................................................... r
YTD-12 Month Follow-Up (lb)-q14.doc
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(2/9/07)
IV.C2
(Are you/Is [NAME]) still going to (YTD PROGRAM)?
YES .............................................................. 1 (GO TO IV.D1)
NO ................................................................ 0
DON’T KNOW .............................................. d
REFUSED .................................................... r
IV.C3
When did (you/NAME) stop going to (YTD PROGRAM)?
PROBE: In what month and year?
| | | / |
MONTH
| | |
YEAR
|
DON’T KNOW .............................................. d
REFUSED .................................................... r
IV.C4
Why did (you/NAME) stop going to (YTD PROGRAM)?
THE PROGRAM WAS FINISHED................ 1
DID NOT LIKE THE PROGRAM/
SERVICE FOUND IT BORING..................... 2
DID NOT LEARN ANYTHING NEW............. 3
NO TRANSPORTATION .............................. 4
BAD TIME OF THE DAY—OTHER
OBLIGATIONS ............................................. 5
YOUTH BECAME ILL................................... 6
FAMILY MEMBER BECAME ILL.................. 7
GOT A JOB .................................................. 8
DID NOT HAVE ANY FRIENDS AT THE
PROGRAM/SERVICE .................................. 9
OTHER (SPECIFY) ...................................... 10
DON’T KNOW .............................................. d
REFUSED .................................................... r
YTD-12 Month Follow-Up (lb)-q14.doc
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41
(2/9/07)
IV.D1
For how many months of the past year (have you/has [NAME]) met with or gone to
(YTD PROGRAM)?
|
|
| MONTHS
IF DON’T KNOW OR REFUSED: Was it . . .
Every month or all year long,........................ 1
About six months or half of the year, ............ 2
For about 3 or 4 months, or .......................... 3
Less than that? ............................................. 4
DON’T KNOW .............................................. d
REFUSED .................................................... r
IV.D2
ASK IF YTD PROGRAM WAS NOT REPORTED AS A SERVICE PROVIDER:
During the months when (you/NAME) met with or went to (YTD PROGRAM), about how
often did (you/NAME) go?
PROBE: This could include meetings, classes, or check-in calls.
PROBE: (Your/His/Her) best estimate is fine.
READ IF NECESSARY.
Every day,..................................................... 1
More than once a week, ............................... 2
Weekly,......................................................... 3
More than once a month,.............................. 4
About once a month, or ................................ 5
Less than once a month? ............................. 6
DON’T KNOW .............................................. d
REFUSED .................................................... r
YTD-12 Month Follow-Up (lb)-q14.doc
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42
(2/9/07)
IV.D3
ASK IF YTD PROGRAM WAS NOT REPORTED AS A SERVICE PROVIDER:
On average, how long was each meeting or session?
|
|
| MINUTES
|
|
| HOURS
PROBE: How much time per meeting or session?
IF DON’T KNOW OR REFUSED: Was it . . .
Less than an hour,........................................ 1
About one hour, ............................................ 2
About 2 hours, .............................................. 3
About 3 hours, .............................................. 4
About 4 hours or half a day, or was it ........... 5
More than 4 hours per meeting? .................. 6
DON’T KNOW .............................................. d
REFUSED ....................................................
YTD-12 Month Follow-Up (lb)-q14.doc
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43
(2/9/07)
IV.D4
ASK IF YTD PROGRAM WAS NOT REPORTED AS A SERVICE PROVIDER:
What type of training or help did (you/NAME) get from (YTD PROGRAM)?
PROBE: Anything else?
CODE ALL THAT APPLY
DISCUSSING INTERESTS ..................................... 1
TEST TO FIND OUT INTERESTS .......................... 2
BASIC SKILLS TRAINING ...................................... 3
CAREER COUNSELING......................................... 4
LEARNING HOW TO LOOK FOR A JOB ............... 5
JOB SHADOWING .................................................. 6
APPRENTICESHIP/INTERNSHIP .......................... 7
HELP FINDING A JOB ............................................ 8
HELP GETTING INTO SCHOOL ............................ 9
UNDERSTANDING SSA BENEFITS ...................... 10
COMPUTER CLASSES .......................................... 11
PROBLEM SOLVING .............................................. 12
SOCIAL SKILLS TRAINING .................................... 13
REFERRAL TO ANOTHER AGENCY..................... 14
TRANSPORTATION SERVICES ............................ 15
HEALTH SERVICES ............................................... 16
CASE MANAGEMENT ............................................ 17
ACCOMMODATIONS ............................................. 18
OTHER (SPECIFY) ................................................. 19
DON’T KNOW ......................................................... d
REFUSED ............................................................... r
IV.D5
Did (YTD PROGRAM) refer (you/NAME) to or arrange for (you/NAME) to go to other
places or services?
PROBE: Such as transportation services or other agencies that could help (you/NAME).
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
REFUSED .................................................... r
YTD-12 Month Follow-Up (lb)-q14.doc
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(2/9/07)
ASK OF ALL YOUTH YTD PARTICIPANTS:
IV.E1.1 My next questions are about (your/his/her) experience with (YTD PROGRAM).
(OPENING
Since (RA DATE/MEMORY AID) how much has (your/his/her) experience with
DOORS –
S1Q16)
(YTD PROGRAM) helped (you/him/her) in the following areas?
INTERVIEWER: READ STATEMENT. . .
Did (YTD PROGRAM) help (you/NAME) very much, somewhat, a little, or not at all?
IV.E1.2 IF NOT AT ALL, ASK: Did (you/he/she) need this help?
IV.E1.1
IV.E1.2
SOMEWHAT
A
LITTLE
NOT
AT
ALL
YES
NO
1
2
3
4
1
0
b. Working effectively with others?.............
1
2
3
4
1
0
c. Understanding yourself? ........................
1
2
3
4
1
0
d. Developing clearer career goals? ..........
1
2
3
4
1
0
e. Gaining information about career
opportunities?.........................................
1
2
3
4
1
0
1
2
3
4
1
0
VERY
MUCH
a. Getting job or work-related knowledge
and skills? ..............................................
f.
Developing a sense of confidence in
what (you are/[he/she] is) able to do? ....
IV.E2
Overall, how would (you/he/she) rate (your/his/her) experience at (YTD PROGRAM)?
Would (you/he/she) say it was very good, good, fair, or poor?
VERY GOOD................................................ 1
GOOD........................................................... 2
FAIR ............................................................. 3
POOR ........................................................... 4
DON’T KNOW .............................................. d
REFUSED .................................................... r
YTD-12 Month Follow-Up (lb)-q14.doc
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45
(2/9/07)
IV.E3
How would (you/he/she) rate the instructors and staff at understanding who
(you are/[he/she] is), where (you are/[he/she] is) coming from? Would you say they are
very good, good, fair, or poor?
VERY GOOD................................................ 1
GOOD........................................................... 2
FAIR ............................................................. 3
POOR ........................................................... 4
DON’T KNOW .............................................. d
REFUSED .................................................... r
IV.E4
(NLTS - F9f) (Mod)
How useful (do you/does [he/she]) think the help or services that (you/NAME) got from
(YTD PROGRAM) has been? Would you say . . .
Very useful,................................................... 1
Somewhat useful, ......................................... 2
Not very useful, or ........................................ 3
Not at all useful?........................................... 4
DON’T KNOW .............................................. d
REFUSED .................................................... r
YTD-12 Month Follow-Up (lb)-q14.doc
Prepared by Mathematica Policy Research, Inc.
46
(2/9/07)
SECTION V: AWARENESS OF WAIVERS AND INCENTIVES
THIS SECTION ASKED OF PARENTS OR INDEPENDENT YOUTH, SOME QUESTIONS
ALSO ASKED OF YOUTH.
V.A1
(EIDP-mod)
ASK BOTH PARENT AND YOUTH:
Next, I’d like to ask you a few questions about (your/his/her) understanding about Social
Security benefits. Please tell me whether you agree or disagree with these statements
about Social Security benefits.
AGREE
NOT
SURE
DISAGREE
a. As soon as people start working they stop getting
their Social Security benefits...................................
1
2
3
b. As soon as people start working they lose their
medical coverage ....................................................
1
2
3
IF YOUTH IS IN THE AT RISK GROUP, GO TO VI.A1.
V.B1
(NBS –E3)
ASK BOTH PARENT AND YOUTH:
I’m going to read a list of incentives and supports that Social Security offers to people
getting disability benefits, to encourage them to work. Please tell me if you have ever
heard of these incentives or supports or used any of them.
Have you ever heard of a Plan for Achieving Self-Support or a PASS Plan? This is a
Social Security incentive that lets (you/beneficiaries) set aside money to be used to help
(you/them) reach a work goal. The money set aside does not affect (your/their)
benefits.
PROBE: (Have you/Has [NAME]) ever heard of this plan?
PROBE: If you’re not sure, please just say so.
YES .............................................................. 1
NO/NOT SURE............................................. 0
(GO TO V.C1)
REFUSED .................................................... r
YTD-12 Month Follow-Up (lb)-q14.doc
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V.B2
ASK IF HEARD OF PASS:
I’m going to read a list of different work goals. Please tell me if you think a PASS Plan
could be used for each goal.
Could (you/NAME) use a PASS Plan to . . .
YES
NO
a. Pay for college? .............................................................................
1
0
b. Start (your/his/her) own business?.................................................
1
0
c. Pay a job coach?............................................................................
1
0
d. Pay for accommodations (you/he/she) need(s)? ...........................
1
0
V.B3
(NBS-E4)
ASK IF HEARD OF PASS:
(Have you/Has [NAME]) used a Plan for Achieving Self-Support or a PASS Plan since
(RA/DATE/MEMORY AID)?
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
REFUSED .................................................... r
V.C1
(NBS-E5)
Mod.
PARENT AND YOUTH:
Have you ever heard of the general earned income exclusion? This is an incentive
where Social Security does not count the first $65 of (your/NAME’s) earnings in a
month, and then only counts a portion of (your/his/her) earnings when determining
(your/his/her) monthly payment.
PROBE: (Have you/Has [NAME]) ever heard of this exclusion?
PROBE: If you’re not sure, please just say so.
YES .............................................................. 1
NO/NOT SURE............................................. 0
(GO TO V.D1)
REFUSED .................................................... r
YTD-12 Month Follow-Up (lb)-q14.doc
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V.C2
ASK IF HEARD OF GENERAL EARNED INCOME EXCLUSION:
What portion of (your/his/her) earnings after the first $65 does Social Security count
against your SSI benefit? Does Social Security count one dollar for each dollar
([you/he/she] earn/[he/she] earns), one dollar for each two dollars ([you/he/she]
earn/[he/she] earns), one dollar for each three dollars ([you/he/she] earn/[he/she]
earns), or one dollar for each four dollars ([you/he/she] earn/[he/she] earns)?
PROBE: Does Social Security count all of (your/his/her) earnings in reducing your SSI
benefit, half of (your/his/her) earnings, one-third of (your/his/her) earnings, or
one-quarter of (your/his/her) earnings?
1 FOR 1 (ALL) .............................................. 1
1 FOR 2 (HALF) ........................................... 2
1 FOR 3 (ONE-THIRD)................................. 3
1 FOR 4 (ONE-QUARTER) .......................... 4
DON’T KNOW .............................................. d
REFUSED .................................................... r
V.C3
(NBS-E6)
ASK IF HEARD OF THE GENERAL EARNED INCOME EXCLUSION:
(Have you/Has [NAME]) used the general earned income exclusion since
(RA DATE/MEMORY AID)?
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
REFUSED .................................................... r
V.D1
(NBS-E9)
ASK BOTH PARENT AND YOUTH:
Have you ever heard of Continued Medicaid Eligibility or Medicaid While Working? This
is a Social Security incentive that lets (you/beneficiaries) keep (your/their) LOCAL
MEDICAID NAME insurance after (you/they) go to work, even if (your/their) benefits
have stopped.
YES .............................................................. 1
NO/NOT SURE............................................. 0
(GO TO V.E1)
REFUSED .................................................... r
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V.D2
(NBS-E10)
ASK IF HEARD OF CONTINUED MEDICAID ELIGIBILITY:
(Have you/Has [NAME]) used the Continued Medicaid Eligibility or Medicaid While
Working since (RA DATE/MEMORY AID)?
YES .............................................................. 1
NO ................................................................ 0
REFUSED .................................................... r
V.E1
(NBS-E12)
ASK BOTH PARENT AND YOUTH:
Have you ever heard of the student earned-income exclusion? This is a Social Security
incentive where if (you are/[he/she] is/a beneficiary is) in school, up to $1,460 of
earnings per month are not counted when Social Security figures (your/the) benefit.
YES .............................................................. 1
NO/NOT SURE............................................. 0
(GO TO V.F1)
REFUSED .................................................... r
V.E2
(NBS-E13)
ASK IF HEARD OF SEIE:
(Have you/Has [NAME]) used the student earned-income exclusion since
(RA DATE/MEMORY AID)?
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
REFUSED .................................................... r
V.F1
(NBS-E12)
ASK IF AGE LESS THAN 18. ASK BOTH PARENT AND YOUTH.
Have you ever heard of the Continuing Disability Review or Age 18 Medical
Redetermination? This is when Social Security determines whether or not an SSI
recipient is eligible to receive SSI benefits as an adult.
YES .............................................................. 1
NO/NOT SURE............................................. 0
(GO TO V.G1)
REFUSED .................................................... r
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V.F2
ASK IF AGE LESS THAN 18, HEARD OF CDR AND TREATMENT CASE:
If (you/NAME) are determined to be ineligible for adult SSI benefits, will participating in
(YTD PROGRAM NAME) allow you to keep (your/his/her) current benefits?
YES .............................................................. 1
NO/NOT SURE............................................. 0
REFUSED .................................................... r
V.G1
ASK BOTH PARENT AND CHILD:
Have you ever heard of an Individual Development Account or an IDA? An IDA is a
special bank account that helps (you/NAME) save for (your/his/her) education, the
purchase of a first home, or to start a business.
YES .............................................................. 1
NO/NOT SURE............................................. 0
(GO TO V.H1)
REFUSED .................................................... r
V.G2
ASK IF HEARD OF IDA:
(Do you/Does [NAME]) have an IDA?
PROBE: An individual development account.
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
REFUSED .................................................... r
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V.H1
If (you/he/she) wanted information about how working would affect (your/his/her) Social
Security benefits where would (you/he/she) get that information?
CODE ALL THAT APPLY
BENEFITS PLANNER/BPAO/WIPA............. 1
INTERNET.................................................... 2
FRIENDS/FAMILY........................................ 3
ONE STOP CENTER/WORKFORCE
DEVELOPMENT CENTER/
[IF COLORADO: WIN CENTERS]................ 4
SOCIAL SECURITY OFFICE ....................... 5
SOCIAL SECURITY WEBSITE .................... 6
VOCATIONAL REHABILITATION
AGENCY ...................................................... 7
YTD PROGRAM........................................... 8
OTHER (SPECIFY) ...................................... 9
DON’T KNOW .............................................. d
REFUSED .................................................... r
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SECTION VI: HEALTH
THIS SECTION ASKED OF ALL YOUTH.
VI.A1
(NLTS-Q5)
Some people have a disability or special need that makes it hard for them to do some
things. (Do you/Does [NAME]) consider (yourself/himself/herself) to have any kind of
disability?
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
REFUSED .................................................... r
VI.A2
Since (RA DATE/MEMORY AID), (have you/has [he/she]) sought treatment for a drug
or alcohol problem?
WFNJ–J17h
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
REFUSED .................................................... r
VI.B1
(YTD-30)
(SF-1)
Now I have some questions about (your/NAME’s) health.
In general, how would (you/he/she) 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
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VI.B1a Compared to (RA DATE/MEMORY AID), how would (you/NAME) rate (your/his/her)
health in general now? Is it . . .
(NBS-I9)
(SF-2)
Much better now, .......................................... 1
Somewhat better now,.................................. 2
About the same, ........................................... 3
Somewhat worse now, or ............................. 4
Much worse now?......................................... 5
DON’T KNOW .............................................. d
REFUSED .................................................... r
The next two question are about activities (you/NAME) might do during a typical day.
VI.B2
During a typical day, does (your/NAME’s) health now limit (you/him/her) in doing
moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or
playing golf?
PROBE, IF YES: Does (your/NAME’s) health limit you a little or a lot?
Yes, limited a lot .......................................... 1
Yes, limited a little......................................... 2
No, not limited at all ...................................... 3
VI.B3
During a typical day, does (your/NAME’s) health now limit (you/him/her) in climbing
several flights of stairs?
PROBE, IF YES: Does (your/NAME’s) health limit you a little or a lot?
Yes, limited a lot .......................................... 1
Yes, limited a little......................................... 2
No, not limited at all ...................................... 3
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The next two questions ask about (your/NAME’s) physical health and (your/his/her) daily
activities.
VI.B4 During the past 4 weeks, how much of the time have (you/NAME) accomplished less
than (you/he/she) would have liked to as a result of (your/his/her) physical health?
Would you say . . .
(SF-12)
All of the time,............................................... 1
Most of the time, ........................................... 2
Some of the time, ......................................... 3
A little of the time, or..................................... 4
None of the time? ......................................... 5
VI.B5 During the past 4 weeks, how much of the time (were you/was [NAME]) limited in the
kind of work or other regular daily activities (you do/[he/she] does) as a result of
(SF-12)
(your/his/her) physical health? Would you say . . .
All of the time,............................................... 1
Most of the time, ........................................... 2
Some of the time, ......................................... 3
A little of the time, or..................................... 4
None of the time? ......................................... 5
Now I will ask about any emotional problems and (your/NAME’s) daily activities.
VI.B6 During the past 4 weeks, how much of the time (have you/has [NAME]) accomplished
less than (you/he/she) would have liked to as a result of any emotional problems, such
(SF-12)
as feeling depressed or anxious? Would you say . . .
All of the time,............................................... 1
Most of the time, ........................................... 2
Some of the time, ......................................... 3
A little of the time, or..................................... 4
None of the time? ......................................... 5
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VI.B7 During the past 4 weeks, how much of the time did (you/he/she) not do work or other
activities as carefully as usual as a result of any emotional problems, such as feeling
(SF-12)
depressed or anxious? Would you say . . .
All of the time,............................................... 1
Most of the time, ........................................... 2
Some of the time, ......................................... 3
A little of the time, or..................................... 4
None of the time? ......................................... 5
VI.B8 During the past 4 weeks, how much did pain interfere with (your/NAME’s) normal work,
including both work outside the home, housework, or school work? Did it interfere . . .
(SF-12)
Not at all, ...................................................... 1
A little bit, ...................................................... 2
Moderately,................................................... 3
Quite a bit, or ................................................ 4
Extremely?.................................................... 5
These next questions are about how (you/NAME) feel and how things have been with
(you/him/her) during the past 4 weeks. For each question, please give me the one answer that
comes closest to the way (you have/[NAME] has) been feeling.
VI.B9 During the past 4 weeks, how much of the time (have you/has [NAME]) felt calm and
peaceful? Would you say . . .
(SF-12)
All of the time,............................................... 1
Most of the time, ........................................... 2
Some of the time, ......................................... 3
A little of the time, or..................................... 4
None of the time? ......................................... 5
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VI.B10 During the past 4 weeks, how much of the time did (you/NAME) have a lot of energy?
Would you say . . .
(SF-12)
All of the time,............................................... 1
Most of the time, ........................................... 2
Some of the time, ......................................... 3
A little of the time, or..................................... 4
None of the time? ......................................... 5
VI.B11 During the past 4 weeks, how much of the time have (you/NAME) felt downhearted and
depressed? Would you say . . .
(SF-12)
All of the time,............................................... 1
Most of the time, ........................................... 2
Some of the time, ......................................... 3
A little of the time, or..................................... 4
None of the time? ......................................... 5
VI.B12 During the past 4 weeks, how much of the time has (your/NAME’s) physical health or
emotional problems interfered with your social activities, like visiting with friends or
(SF-12)
relatives? Would you say . . .
All of the time,............................................... 1
Most of the time, ........................................... 2
Some of the time, ......................................... 3
A little of the time, or..................................... 4
None of the time? ......................................... 5
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VI.C1
(YTD-38)
For the next set of activities, please tell me how often (you do/[NAME] 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/he/she) (ACTIVITY)
if (you/he/she) had the
chance?
MOST
SOME
NONE
YES
NO
a. Deciding how to spend (your/his/her)
money ....................................................
1
2
3
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
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SECTION VII: EXPECTATIONS ABOUT THE FUTURE
THIS SECTION ASKED OF PARENTS AND YOUTH.
VII.A1 The next questions are about (your/his/her) plans and goals for the next 5 years. For
each one please tell me which statement is what (you/he/she) will most likely do in the
next 5 years.
(YTD-27)
First, I’d like you to think about where (you/NAME) will be living. In the next 5 years,
(do you/does [he/she]) plan to be living with (your/his/her) parents or guardians, (do
you/does [he/she]) plan to be living on (your/his/her) own with help from a counselor or
aide, or (do you/does [he/she]) plan to be living on (your/his/her) own without help?
WITH PARENTS OR GUARDIANS.............. 1
ON OWN WITH HELP.................................. 2
ON OWN WITHOUT HELP .......................... 3
DON’T KNOW .............................................. d
REFUSED .................................................... r
DO NOT ASK IF YOUTH HAS A COLLEGE DEGREE:
VII.A2 Next, I’d like you to think about (your/NAME’s) plans for school. In the next 5 years,
(do you/does [he/she]) (ASK IF IN HIGH SCHOOL: plan to graduate from high school),
(YTD-28.)
plan to attend college or a technical school, or (do you/does [he/she]) have no further
plans for school?
INTERVIEWER: CODE HIGHEST LEVEL OF EDUCATIONAL ATTAINMENT
MENTIONED.
GRADUATE FROM HIGH SCHOOL............ 1
ATTEND COLLEGE OR A
TECHNICAL SCHOOL ................................. 2
GRADUATE COLLEGE................................ 3
HAVE NO PLANS FOR SCHOOL................ 4
DON’T KNOW .............................................. d
REFUSED .................................................... r
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DO NOT ASK IF CURRENTLY WORKING FULL-TIME:
VII.A3 Next, I’d like to (you/NAME) to think about (your/his/her) plans for getting a job. (Is
[NAME]/Are you) now or in the next five years, (do you/does [he/she]) plan to work
(YTD-29.)
part-time for pay, (do you/does [he/she]) plan to work full-time for pay, or (do you/does
[he/she]) have no plans for getting a job?
INTERVIEWER: CODE HIGHEST LEVEL OF WORK MENTIONED.
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
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SECTION VIII: SELF-DETERMINATION
THIS SECTION TO BE ASKED OF YOUTH. IF PROXY GO TO VIII.C1
DO NOT ASK PROXY:
VIII.A1 Next I’m going to read a list of statements. For each one please tell me how much you
(YITS -I1)
agree or disagree with the statement. There are no right or wrong answers.
INTERVIEWER: READ STATEMENT.
Do you agree or disagree? Do you (dis)agree a lot or a little?
AGREE A
LOT
AGREE A
LITTLE
DISAGREE A
LITTLE
DISAGREE
A LOT
a. You have little control over the things
that happen to you .............................
1
2
3
4
b. There is really no way you can solve
some of the problems you have ........
1
2
3
4
There is little you can do to change
many of the important things in your
life.. ....................................................
1
2
3
4
d. You often feel helpless in dealing
with the problems of life.....................
1
2
3
4
e. Sometimes you feel like you are
being pushed around in life.. .............
1
2
3
4
What happens to you in the future
mostly depends on you......................
1
2
3
4
g. You can do just about anything you
really set your mind to... ....................
1
2
3
4
h. You tell other people how you feel
when they upset you or hurt your
feelings ..............................................
1
2
3
4
You know how to get the information
you need ............................................
1
2
3
4
You have a good sense of the path
you want to take in life and the steps
to get there.........................................
1
2
3
4
Your personal goals include
someday working and earning
enough to stop receiving Social
Security disability benefits .................
1
2
3
4
(Your/[NAME]’s) job opportunities
will be limited by discrimination,
because of (your/his/her) gender,
race or disability.................................
1
2
3
4
c.
f.
i.
j.
(NBS-B37a)
k.
l.
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DO NOT ASK IF DISABILITY IS BLINDNESS OR QUADRIPLEGIA, OR IF YOUTH IS
YOUNGER THAN AGE FOR LEARNER’S PERMIT (CO: AGE 15 AND 3 MONTHS;
NY: AGE 16). ASK BOTH PARENT AND YOUTH.
VIII.B1 (Do you/Does [NAME]) have a driver’s license or learners permit?
(NLTS-P15)
YES .............................................................. 1 (GO TO IX.A1)
NO ................................................................ 0
DON’T KNOW .............................................. d
REFUSED .................................................... r
ASK BOTH PARENT AND YOUTH.
ASK IF NO DRIVER’S LICENSE OR LEARNERS PERMIT:
VIII.B2 How likely (do you/does [he/she]) think it is that (you/he/she) will get a driver’s license?
(NLTS-V11)
(Do you/Does [NAME]) think (you/he/she) . . .
Definitely will,................................................ 1
Probably will, ................................................ 2
Probably won’t, or......................................... 3
Definitely won’t? ........................................... 4
DON’T KNOW .............................................. d
REFUSED .................................................... r
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SECTION IX: SOCIAL ACTIVITIES AND CRIMINAL BEHAVIOR
THIS SECTION ASKED OF ALL YOUTH.
IX.A1 Now I’m going to ask you about things some young people do. All of (your/his/her)
answers will be private; nothing (you/he/she) say(s) will be told to anyone else.
First, think about (your/NAME’s) friends. How often (do you/does [he/she]) and
(your/his/her) friends get together to have fun or hang out? Would you say . . .
Never, ........................................................... 1
Hardly ever, .................................................. 2
Sometimes, or .............................................. 3
Often?........................................................... 4
DOES NOT HAVE FRIENDS ....................... 5
DON’T KNOW .............................................. d
REFUSED .................................................... r
IX.B1
(Have you/Has [NAME]) ever been arrested or convicted of a crime?
(WFNJ –J17K
(MOD)
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
(GO TO IX.C1)
REFUSED .................................................... r
IX.B2
IF YES: Did this happen since (RA DATE/MEMORY AID)?
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
REFUSED .................................................... r
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IX.B3
IF ARRESTED OR CONVICTED OF A CRIME:
For what crime or crimes (were you/was [he/she]) arrested?
SPECIFY CRIME:
DON’T KNOW .............................................. d
REFUSED .................................................... r
IX.B4
(Have you/Has [NAME]) ever been in jail overnight?
(NLTS (mod,
timeframe)
U8b)
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
(GO TO IX.B5)
REFUSED .................................................... r
IX.B4A IF YES: Did this happen since (RA DATE/MEMORY AID)?
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
REFUSED .................................................... r
IX.B5
(Have you/Has [NAME]) ever been on probation or parole?
(NLTS (mod,
timeframe)
U8c)
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
(GO TO IX.B6)
REFUSED .................................................... r
IX.B5A IF YES: (Were you/Was [NAME]) on probation or parole since (RA DATE/MEMORY
AID)?
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
REFUSED .................................................... r
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IX.B6
(NLTS (mod,
timeframe)
U8d)
Since (RA DATE/MEMORY AID), have (you/he/she) been stopped and questioned by
the police (IF YOUTH HAS A DRIVER’S LICENSE OR PERMIT, ADD: except for a
traffic violation)?
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
REFUSED .................................................... r
IX.C1
(Do you/Does [NAME]) belong to a gang?
(NLTS U6
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
REFUSED .................................................... r
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SECTION X: LIVING ARRANGEMENT
THIS SECTION ASKED OF ALL YOUTH.
X.A1
(Are you/Is [NAME]) currently married?
(YTD 52.)
YES .............................................................. 1 (GO TO X.B1)
NO ................................................................ 0
DON’T KNOW .............................................. d
REFUSED .................................................... r
X.A2
IF NOT CURRENTLY MARRIED:
(Are you/Is [NAME]) living with a partner or companion in a spouse-like relationship?
YES .............................................................. 1 (GO TO X.B2)
NO ................................................................ 0
DON’T KNOW .............................................. d
REFUSED .................................................... r
X.B1
PROGRAMMER CODE “0” LIVE WITH OTHER PEOPLE IF LIVES WITH PARTNER:
(Do you/Does [NAME]) live alone or (do you/does [he/she]) live with other people?
(YTD -Q40)
LIVE ALONE................................................. 1 (GO TO X.D1)
LIVE WITH OTHER PEOPLE....................... 0
X.B2
(YTD -Q41)
ASK IF SM LIVES WITH OTHER PEOPLE:
(Do you/Does [NAME]) live in a house or apartment with (your/his/her) family (or foster
family)?
YES .............................................................. 1 (GO TO X.C1)
NO ................................................................ 0
X.B2
(YTD -Q42)
ASK IF SM DOES NOT LIVE IN HOUSE OR APARTMENT:
(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 X.D1)
NO ................................................................ 0
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X.B3
ASK IF SM DOES NOT LIVE IN GROUP HOME OR IF SM DOES NOT LIVE ALONE:
Where (do you/does [NAME]) live?
(YTD Q43)
HOUSE OR APARTMENT
WITH FRIENDS............................................ 1
HOUSE OR APARTMENT WITH
ROOM MATES ............................................. 2
NURSING HOME ......................................... 3
ASSISTED LIVING FACILITY ...................... 4
OTHER INSTITUTIONAL SETTING
(SPECIFY).................................................... 5
OTHER RESIDENTIAL SETTING
(SPECIFY).................................................... 6
DON’T KNOW .............................................. d
REFUSED .................................................... r
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X.C1
ASK IF SM LIVES IN RESIDENTIAL SETTING AND LIVES WITH OTHER PEOPLE:
Who (do you/does [NAME]) live with?
(YTD -Q43)
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
X.C2
Including (yourself/NAME), how many people live with (you/him/her)?
(YTD -Q46)
|
|
| NUMBER OF PEOPLE
DON’T KNOW ................................................................d
REFUSED ......................................................................r
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X.D1
(YTD -Q49)
Next I am going to ask you about all of (your/his/her) biological children, adopted
children, or foster children and any other children for whom (you/he/she) are
responsible who are 18 years old or younger, even if they are not living in (your/his/her)
household right now.
PROGRAMMER: CODE “1” YES IF LIVES WITH OWN CHILD:
(Do you/Does [NAME]) have any children?
YES .............................................................. 1
NO ................................................................ 0
DON’T KNOW .............................................. d
(GO TO XI.A1)
REFUSED .................................................... r
X.D2
(YTD -Q50)
ASK IF SM HAS CHILDREN:
(You mentioned earlier that (you/he/she) live with ([your/his/her] son/daughter).
How many children (do you/does [NAME]) have?
|
X.D3
|
| NUMBER OF CHILDREN
How old (is [your/his/her] child/is [your/his/her] youngest child)?
(YTD -Q51)
INTERVIEWER: IF LESS THAN ONE YEAR, CODE “0.”
|
|
| YEARS
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SECTION XI: INCOME
THIS SECTION ASKED OF PARENTS OR INDEPENDENT YOUTH.
XI.A1
(YTD -57.)
The next questions are about (your/NAME’s) household. You may need someone’s
help to answer these questions.
First, I’d like to about (you/he/she) about health insurance. Health insurance helps pay
for medical expenses, like when (you/he/she) 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
XI.A2
(YTD -58)
(Mod)
(Are you/Is [NAME]) now covered by private health insurance from an employer or
union?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r
XI.A3
(YTD -58)
(Mod)
(Are you/Is [NAME]) now covered by private health insurance that (your/his/her) family
buys directly?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r
IF SM IN GROUP HOME OR FACILITY, SKIP TO XII.A1
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XI.B1 (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;
(YTD 63)
CUNY: Family Assistance)?
YES ................................................................................1
NO ..................................................................................0
DON’T KNOW ................................................................d
REFUSED ......................................................................r
XI.B2
(YTD 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
XI.C1
(YTD 64P)
Please tell me which group best describes the total income of all persons in
(you/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 (you/his/her) household income last year . . .
PROBE IF IN FOSTER CARE: Please answer about the foster family (you
were/[NAME] was) 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
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SECTION XII: FUTURE CONTACT
XII.A1
As part of the research, it is important that we don’t lose touch with (you/NAME). Last
time we spoke with you, you gave us information for the following people. I would like
to confirm their information so we can contact you in two years.
CONFIRM CONTACT INFORMATION FOR PARENTS/GUARDIANS AND OTHER
CONTACTS FROM BASELINE.
XII.B1
Can you please tell me the name of 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:
XII.B2
What is his or her address?
ADDRESS:
APARTMENT:
CITY:
STATE:
ZIP CODE:
XII.B3
What is his or her telephone number?
(| | | |) - |
AREA CODE
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XII.B4
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
XII.C1
INTERVIEWER:
DID SOMEONE HELP YOUTH ANSWER ANY OF THE
QUESTIONS?
YES ................................................................................1
PROXY ANSWERED ALL QUESTIONS........................2
(GO TO XII.D1)
NO ..................................................................................0
XII.C2
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
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XII.D1
Thank you for helping us with this important study. Your answers will help us better
understand how Social Security disability programs affect the lives of people receiving
these benefits.
As a token of our appreciation we will be sending a $10 (GIFT CARD) to you at
(FILL ADDRESS). Is this address correct?
INTERVIEWER:
CONFIRM INFORMATION AND MAKE CORRECTIONS IF
NEEDED.
YES ................................................................................1
NO ..................................................................................0
ADDRESS:
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
XII.D2
We will be calling you again in two years to see how you are doing. Thank you again
for your help.
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CONTACT MODULE
Hello_PG.
SCRIPTS WHEN YOUTH IS LESS THAN AGE 18 OR SITE IS CUNY:
Hello, my name is (INTERVIEWER’S FULL NAME) and I am calling from
Mathematica Policy Research in Princeton, New Jersey. May I please speak
to a parent or guardian of (NAME)?
SPEAKING TO PARENT................................................1 (Parent)
PARENT COMES TO THE PHONE...............................2 (Parent)
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 (Deceased)
NEVER HEAD OF SM....................................................9 (WrongNum)
HUNG UP DURING INTRODUCTION ...........................10 (HUDI)
WhatAbout_PG. Mathematica recently sent the parents or guardian of (NAME) a letter about a
study we are doing for the Social Security Administration. I work for
Mathematica Policy Research, a research company in Princeton, New Jersey.
Can I please speak with a parent or guardian of (NAME)?
SPEAKING TO PARENT/COMES TO PHONE..............1 (Parent)
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)
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Hello_SM.
SCRIPTS WHEN YOUTH IS AGE 18 OR OLDER:
Hello, my name is (INTERVIEWER’S FULL NAME) and I am calling from
Mathematica Policy Research in Princeton, New Jersey. May I please speak
to (NAME)?
SPEAKING TO SAMPLE MEMBER...............................1 (SampMemb)
SM COMES TO THE PHONE ........................................2 (SampMemb)
SPEAKING TO LEGAL GUARDIAN...............................3 (Parent)
GUARDIAN COMES TO THE PHONE ..........................4 (Parent)
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 (Interpret)
GUARDIAN DOES NOT SPEAK ENGLISH
OR SPANISH .................................................................10 (Interpret)
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)
WhatAbout_SM Mathematica recently sent (NAME) a letter about a study we are doing for the
Social Security Administration. I work for Mathematica Policy Research, a
research company in Princeton, New Jersey. Can I please speak with
(NAME)?
SM COMES TO THE PHONE ........................................1 (SampMemb)
GUARDIAN COMES TO THE PHONE ..........................2 (Guardian)
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 (Interpret)
GUARDIAN DOES NOT SPEAK ENGLISH
OR SPANISH .................................................................7 (Interpret)
SM/GUARDIAN PHYSICALLY OR MENTALLY
SM HAS HEALTH PROBLEM ........................................8 (HealthProb)
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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 ________ and I am calling from
Mathematica Policy Research about a study we are doing for the Social Security
Administration.
You may remember being interviewed by telephone about a year ago. At that
time you answered questions over the phone and we sent you a consent form to
sign and a $10 INCENTIVE. IF TREATMENT, ADD: We also gave you a
chance to be part of the (NAME OF LOCAL YTD PROGRAM). When we spoke
to you a year ago, we explained that the study would have three interviews. This
is the second one. The questions I am calling to ask are about you, your
schooling, jobs, health, and how you are getting along day to day. The interview
takes about 40 minutes to complete by telephone. I will send you a $10
INCENTIVE when we are done. Let’s begin.
IF NEEDED: The questions have been worded so you can answer for yourself.
If you wish, you can ask someone to stay nearby in case you need help.
IF NECESSARY, ADD:
- All your answers will be held in strict confidence.
- Nothing you say will affect the SSI benefits you get now or in the future.
- Most questions are worded so that young people with disabilities can answer
for themselves.
- If it would be better, an interviewer can come to your home instead of doing
this by telephone.
- We can start now and take a break if you need one.
YES, CONTINUE............................................................1 (GO TO I.A1)
NOT A GOOD TIME .......................................................2 (CALL BACK)
DID NOT RECEIVE LETTER/DOESN’T RECALL .........3 (NoLetter)
NEED FIELD INTERVIEW .............................................4 (Field Review)
REFUSAL .......................................................................5 (REFUSAL)
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Parent.
SCRIPT FOR PARENTS OF YOUTH UNDER AGE 18. THIS IS THE GENERIC
TEXT.
IF SM COMES TO PHONE: Hello, my name is ________ and I am calling from
Mathematica Policy Research about a study we are doing for the Social Security
Administration.
You may remember being interviewed by telephone about a year ago. At that time
you answered questions about (NAME) over the phone, we sent you a consent form
to sign, and a $10 INCENTIVE. IF TREATMENT, ADD: We also gave (NAME) a
chance to be part of the (NAME OF LOCAL YTD PROGRAM). When we spoke to
you a year ago, we explained that the study would have three interviews. This is the
second one. The questions I am calling to ask are about (NAME), (his/her)
schooling, jobs, health, and how (he/she) getting along day to day. The interview
takes about 40 minutes to complete by telephone. I will send (NAME) a $10
INCENTIVE when we are done. Just like we did before, I would like to begin with
some questions for you and then talk to (NAME).
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.
Let’s begin.
IF NECESSARY, ADD:
- All your answers will be held in strict confidence.
- Nothing you say will affect the SSI benefits you get now or in the future.
- Most questions are worded so that young people with disabilities can answer for
themselves.
- If it would be better, an interviewer can come to your home instead of doing this
by telephone.
- We can start now and take a break if you need one.
YES, CONTINUE............................................................1 (GO TO I.A1)
NOT A GOOD TIME .......................................................2 (CALL BACK)
DID NOT RECEIVE LETTER/DOESN’T RECALL .........3 (NoLetter)
NEED FIELD INTERVIEW .............................................4 (Field Review)
REFUSAL .......................................................................5 (REFUSAL)
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NoLetter.
The letter explained that we would be calling to interview (you/NAME). The
questions should take about 40 minutes to answer. All of your answers will be
held in strict confidence. I can read the letter to you now and we can begin the
interview.
YES, CONTINUE............................................................1 (GO TO I.A1)
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. Let’s begin the interview now.
YES, BEGIN INTERVIEW ..............................................1 (GO TO I.A1)
NO (INTERVIEWER SCHEDULE CALLBACK
IN 2 WEEKS) [letter requested - code 831]....................2 (CALL BACK)
HealthProb. ENTER TYPE OF HEALTH PROBLEM
HEARING PROBLEM.....................................................1 (AmpTTY)
SPEECH PROBLEM ......................................................2 (AmpTTY)
PHYSICAL PROBLEM ...................................................3 (CallLater)
COGNITIVE PROBLEM .................................................4 (NeedProxy)
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)
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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?
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)
IMInterview. INTERVIEWER: NEED TO COMPLETE BASELINE USING INSTANT
MESSENGER.
SM COMES TO PHONE, BEGIN WITH IM ....................1 (SampMemb)
CALLBACK.....................................................................2 (CALLBACK)
Interpret.
Perhaps there is someone who could interpret the questions on behalf of
(NAME/[NAME’s] legal guardian). Is there someone there who can interpret?
YES, SPEAKING TO INTERPRETER............................1 (InterpreterName)
YES, BUT NOT A GOOD TIME......................................2 (InterpreterName)
NO INTERPRETER AVAILABLE ...................................3 (Lang)
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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 (GO TO I.A1)
SCHEDULE CALLBACK [INTERIM STATUS 400] ........2 (CALL BACK)
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]
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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 (Capable)
ASSISTED LIVING FACILITY ........................................3 (Capable)
GROUP HOME...............................................................4 (Capable)
JAIL OR PRISON ...........................................................5 (Release)
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 about a study we are doing for the
Social Security Administration. I work for Mathematica Policy Research, a
research company in Princeton, New Jersey. The questions I will be asking
are about (NAME), work and school, and how (he/she) gets along day-to-day.
When do you expect (NAME) to get out of jail?
SCHEDULE CALL BACK FOR ANTICIPATED TIME OF RELEASE.
APPOINTMENT MADE
[Incarcerated -interim status 421] ...................................1
UNKNOWN/MORE THAN ONE YEAR
[Supervisor Review Needed] ..........................................2
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Capable.
(NAME) should have received a letter about a study we are doing for the Social
Security Administration. I work for Mathematica Policy Research, a research
company in Princeton, New Jersey. 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 RESPOND BY FIELD.................................2 (Field Review)
SM COULD NOT RESPOND, NEED PROXY................3 (NeedProxy)
Facility.
I would like to talk to (NAME) over the telephone about this research study.
Where is (NAME) living?
NAME OF PLACE:
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
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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
ProxyRel.
How (are you/is proxy) related to (NAME)?
SPOUSE.........................................................................1
PARTNER ......................................................................2
SIBLING .........................................................................3
PARENT .........................................................................4
LEGAL GUARDIAN ........................................................5
NIECE/NEPHEW............................................................6
OTHER RELATIVE.........................................................7
FRIEND ..........................................................................8
OTHER (SPECIFY) ........................................................9
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 INTERVIEW .......................................................1 (SampMemb)
SCHEDULE CALLBACK ................................................2 (CALL BACK)
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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:
ProxyAddr.
And (his/her)address?
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
[GO TO Thanks]
KnowWhere. (NAME) should have received a letter about a study we are doing for the Social
Security Administration. I work for Mathematica Policy Research, a research
company in Princeton, New Jersey. The questions I will be asking are about
(NAME), work and school, and how (he/she) gets along day-to-day.
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:
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New Address.
May I please have (his/her) address?
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
Thanks.
Thank you very much for your time.
[exit case]
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| File Type | application/pdf |
| File Title | Microsoft Word - YTD-CP.doc |
| Author | GGustus |
| File Modified | 2007-06-06 |
| File Created | 2007-06-06 |