Supplemental Baseline Questions (grantees)

Instrument 1: Supplemental Baseline Questions

This attachment presents the Supplemental Baseline Questions in the order in which they will appear in the PRS. The supplemental questions will add no more than 15 minutes to existing data collection at program enrollment.

[OMB # and expiration date]

HPOG-Impact Supplemental Baseline Questions

Education

1. Has the participant ever attended any of the following education and training programs?

1. Adult basic education

₁Yes

₂No

₃Not reported

2. English as second language

₁Yes

₂No

₃Not reported

3. Vocational, technical or trade school (other than college)

₁Yes

₂No

₃Not reported

4. Classes in how to succeed in school (for example, college success course)

₁Yes

₂No

₃Not reported

5. Classes in how to succeed at work (for example, work habits, communication)

₁Yes

₂No

₃Not reported

Expectations, self-perceptions and motivations

What is the highest level of education that the participant eventually expects to complete? (Choose one category.) 1 No additional school 2 GED or equivalent 3 Regular high school diploma 4 Alternative non-academic credential, including industry-recognized credential, certification of completing vocational training, etc. 5 Associate’s degree (for example, AA, AS) 6 Bachelor’s degree (for example, BA, BS) 7 Graduate (Master’s, Doctoral, or other advanced professional) degree 8Not reported

Thinking about the near future, does the participant expect to be going to school full-time or part-time if he/she is selected to participate in HPOG? 1Full-time 2Part-time 3Not reported

Does the participant expect to be working for pay in the next few months? 1 Yes  2 No 3Not reported If yes, how many hours does the participant expect to be working in a typical week? ___ Hours/week

If the participant is not selected to participate in HPOG this year, what are his/her plans for education and work? Does he/she plan to: Enroll in another vocational training program? 1Yes 2No 3Not reported Enroll in a basic education and training program, such as GED prep, basic English or math, etc.? 1Yes 2No 3Not Applicable (already attained GED or high school diploma) 4Not reported Complete a regular high school diploma? 1Yes 2No 3Not Applicable (already attained GED or high school diploma) 4Not reported Enroll in four-year or community college? 1Yes 2No 3Not Applicable (currently enrolled) 3Not reported Seek employment? 1Yes  2No 3Not Applicable (currently employed) 4Not reported If yes, does the participant plan to seek employment in the healthcare field? 1Yes 2No 3Not reported

When it comes to careers, some people are more certain than others that they know where they are headed and how to get there. Please ask the participant how strongly he/she agrees/disagrees that the following statements reflect his/her career situation: (Strongly disagrees, Disagrees, Agrees, Strongly agrees)

How much does the participant agree that he/she knows…:

Strongly Disagrees

Disagrees

Agrees

Strongly Agrees

…how to make a plan that will help achieve his/her goals for the next 5 years?

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…the occupation he/she wants to enter?

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…the type of organization he/she wants to work for?

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In the past 12 months, please note how often each of the following situations interfered with the participant’s school, work, job search, or family responsibilities: (Never, Almost never, Sometimes, Fairly often, Very often)

How often has the participant had problems or difficulties with:

Never

Almost Never

Sometimes

Fairly Often

Very Often

Child care arrangements?

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Transportation?

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An illness or health condition?

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Alcohol or drug use?

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Please ask the participant how strongly he/she agrees/disagrees with the following statements about his/her work preferences: (Strongly agrees, Agrees, Disagrees, Strongly disagrees)

How much does the participant agree that he/she:

Strongly Agrees

Agrees

Disagrees

Strongly Disagrees

…will take any job even if the pay is low?

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…only wants the kind of job that is related to his/her training?

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Please ask the participant how much a job must pay per hour for it to make sense for him/her to take it. $____.__/Hour Do not know

In general, some people have an easier or harder time with problems or difficulties. Please ask the participant how he/she would respond to the following statements: (Not at all true, Somewhat true, Mostly true, Entirely true)

How true are the following statements?:

Not at all True

Somewhat True

Mostly True

Entirely True

I can always manage to solve difficult problems if I try hard enough.

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If someone opposes me, I can find the means and ways to get what I want.

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It is easy for me to stick to my aims and accomplish my goals.

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I am confident that I could deal efficiently with unexpected events.

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Thanks to my resourcefulness, I know how to handle unforeseen situations.

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I can solve most problems if I invest the necessary effort.

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I can remain calm when facing difficulties because I can rely on my coping abilities.

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When I am confronted with a problem, I can usually find several solutions.

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If I am in trouble, I can usually think of a solution.

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I can usually handle whatever comes my way.

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Family member income/benefit receipt
In the past month, did anyone in the participant’s family (his/her spouse or partner and any other relatives who live with him/her) have income or benefits from any of the following sources? For each yes, about how much was it per month?
Family had income or benefits from:	Yes	No	How Much
Job earnings			_______
Child support (official or unofficial)			_______
Family and friends (outside the household)			_______
Grants or loans for school			_______
Temporary Assistance for Needy Families (TANF)			_______
General Assistance (GA)			_______
Supplemental Nutrition Assistance Program (SNAP) / Food Stamps			_______
Women, Infants and Children Program (WIC)			_______
Social Security Insurance (SSI)			_______
Social Security Disability Insurance (SSDI)			_______
Unemployment Insurance (UI) or Worker’s Compensation			_______
Refugee Cash Assistance (RCA)			_______
Medicaid			_______
Subsidized Child Care			_______
Section 8 / Public Housing			_______
Low Income Home Energy Assistance Program (LIHEAP)			_______
Free or reduced lunch program			_______

Children
12. Basic information for each child for whom either the participant or his/her spouse/partner is the legal guardian. Include only children under the age of 18 who live with the participant at least half the time. NOTE: We will notify research participants and secure their approval before engaging in any additional data collection on these children; this roster will be used simply to create a sample that we can draw from for future/possible data collection.
	First name of child:	Relationship to participant:	Child birthdate:	Amount of time child lives with participant:	Who else the child lives with:
1	_________________	1Biological child 2Adoptive child 3Stepchild 4Foster child 5 Grandchild/great grandchild 6 Other relative (nephew/niece, cousin) 7 Unrelated dependent	____ / ________ MM / Y Y Y Y	1Full-time (12 months/year) 2> 9 months/year 36-9 months/year 4< 6 months/year		Yes	No
					Biological parent		
					Adoptive parent		
					Step parent		
					Foster parent		
					Parent’s partner (male)		
					Parent’s partner (female)		
					Grandfather/grandmother		
					Great grandfather/great grandmother		
					Other adult relative 18 years or older (aunt/uncle, cousin, niece/nephew)		
					Other adult non-relative 18 years or older (aunt/uncle, cousin, niece/nephew)		
					Sibling/step sibling under 18 years of age		
					Sibling/step sibling 18 years or older		
					Other relative under 18 years of age (aunt/uncle, cousin, niece/nephew)		
					Other non-relative under 18 years of age		
2	_________________	Biological child 2Adoptive child 3Stepchild 4Foster child 5 Grandchild/great grandchild 6 Other relative (nephew/niece, cousin) 7 Unrelated dependent	____ / ________ MM / Y Y Y Y	1Full-time (12 months/year) 2> 9 months/year 36-9 months/year 4< 6 months/year		Yes	No
					Biological parent		
					Adoptive parent		
					Step parent		
					Foster parent		
					Parent’s partner (male)		
					Parent’s partner (female)		
					Grandfather/grandmother		
					Great grandfather/great grandmother		
					Other adult relative 18 years or older (aunt/uncle, cousin, niece/nephew)		
					Other adult non-relative 18 years or older (aunt/uncle, cousin, niece/nephew)		
					Sibling/step sibling under 18 years of age		
					Sibling/step sibling 18 years or older		
					Other relative under 18 years of age (aunt/uncle, cousin, niece/nephew)		
					Other non-relative under 18 years of age		
3	_________________	1Biological child 2Adoptive child 3Stepchild 4Foster child 5 Grandchild/great grandchild 6 Other relative (nephew/niece, cousin) 7 Unrelated dependent	____ / ________ MM / Y Y Y Y	1Full-time (12 months/year) 2> 9 months/year 36-9 months/year 4< 6 months/year		Yes	No
					Biological parent		
					Adoptive parent		
					Step parent		
					Foster parent		
					Parent’s partner (male)		
					Parent’s partner (female)		
					Grandfather/grandmother		
					Great grandfather/great grandmother		
					Other adult relative 18 years or older (aunt/uncle, cousin, niece/nephew)		
					Other adult non-relative 18 years or older (aunt/uncle, cousin, niece/nephew)		
					Sibling/step sibling under 18 years of age		
					Sibling/step sibling 18 years or older		
					Other relative under 18 years of age (aunt/uncle, cousin, niece/nephew)		
					Other non-relative under 18 years of age		
4	_________________	1Biological child 2Adoptive child 3Stepchild 4Foster child 5 Grandchild/great grandchild 6 Other relative (nephew/niece, cousin) 7 Unrelated dependent	____ / ________ MM / Y Y Y Y	1Full-time (12 months/year) 2> 9 months/year 36-9 months/year 4< 6 months/year		Yes	No
					Biological parent		
					Adoptive parent		
					Step parent		
					Foster parent		
					Parent’s partner (male)		
					Parent’s partner (female)		
					Grandfather/grandmother		
					Great grandfather/great grandmother		
					Other adult relative 18 years or older (aunt/uncle, cousin, niece/nephew)		
					Other adult non-relative 18 years or older (aunt/uncle, cousin, niece/nephew)		
					Sibling/step sibling under 18 years of age		
					Sibling/step sibling 18 years or older		
					Other relative under 18 years of age (aunt/uncle, cousin, niece/nephew)		
					Other non-relative under 18 years of age		

Instrument 1: Supplemental Baseline Questions ▌pg. 6