Appendix Y - Participant baseline information form (Paycheck Plus)

Appendix Y

Paycheck Plus Baseline Information Form

The Paperwork Reduction Act Burden Statement: This collection of information is voluntary and will be used for the Paycheck Plus Study. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is 0970-0413 and it expires 9/30/2017.

The purpose of this form is to collect some background information about you to help with the Paycheck Plus study. All information you provide will be kept confidential.

1. Name: _______________________________________________________________________________ First MI Last									2a. Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
3. Date of Birth: ___ ___ / ___ ___ /___ ___ MM DD YY		4. Gender: (Choose only one) 1. Male 2. Female 3. Other 9. Decline to answer					5. What is your Ethnicity? (Mark one or more) 1. Hispanic or Latino 2. Not Hispanic or Latino 9. Decline to answer
6. What is your race? (mark one or more) 1. American Indian or Alaska Native 2. Asian 3. Black or African American			4. Native Hawaiian or Other Pacific Islander 5. White 9. Decline to answer
7. What is your marital status? (Choose ONLY ONE) Single Single, but living with boyfriend or girlfriend Separated Divorced Widow/Widower Married Legal Domestic Partners					8. Have you ever worked for pay or profit? 1. Yes 2. No (Skip to Question 13.) 9. Decline to answer
9. Are you currently working for pay or profit? 1. Yes 2. No 9. Decline to answer					10. Are you self-employed, that is, do you operate your own business? 1. Yes (Skip to Question 11.) 2. No 9. Decline to answer					11. When did you last work? ___ ___ / ___ ___ ___ ___ MM / YYYY 9999. Decline to answer
12. About how many hours per week do you usually work? (Round to the nearest whole number.) _______ hours 9. Decline to answer				13. If you are currently working, how much do you earn before taxes? If you are currently working more than one job, do not provide an hourly wage.
				$_______._______ per		1. Hour (If only working one job) 2. Day _____ number of days per week 3. Week 4. Two weeks 5. Twice a month 6. Month 7. Year 9. Decline to answer
14. If you are not currently working, have you looked for work in the past 4 weeks? 1. Yes 2. No 9. Decline to answer	15. How much would your pay before taxes have to be for you to consider taking a job that was offered to you (choose only one)?
	$______________ per					1. Hour 2. Week 3. Month 9999. Decline to answer
16. How many children do you have that are under age 19? _______ 99. Decline to answer	17. Do any of these children under age 19 live with you? 1. Yes 2. No 9. Decline to answer							18. Do you have a formal child support order for any of your children? 1. Yes 2. No 9. Decline to answer

19. What is the highest level of school you have completed or the highest degree you have received? 1. 8th grade or lower 2. 9th grade 3. 10th grade 4. 11th grade 5. 12th grade, no degree 6. GED 7. High school diploma 8. Some college, but no degree 9. Technical/AA/2-year college 10. 4-year college 11. Master’s 12. Professional 13. Ph.D. 99. Decline to answer			20. Have you ever been convicted of a felony? 1. Yes 2. No (Skip to Question 21.) 9. Decline to answer (Skip to Question 21.)
			21. Date of most recent felony conviction: ___ ___ / ___ ___ ___ ___ MM / YYYY 9999. Decline to answer
			22. Have you ever been incarcerated? 1. Yes 2. No (Skip to Question 25.) 9. Decline to answer (Skip to Question 25.)
23. Where were you incarcerated? 1. Jail 2. Prison (Skip to Question 24.) 3. Both 9. Decline to answer	24. Date of most recent release from jail: ___ ___ / ___ ___ ___ ___ MM / YYYY 9999. Decline to answer			25. Date of most recent release from prison: ___ ___ / ___ ___ ___ ___ MM / YYYY 9999. Decline to answer
26. Do you have a physical problem that limits the kind or amount of work that you can do? 1. Yes 2. No 9. Decline to answer		27. Do have an emotional or mental health problem that limits the kind or amount of work that you can do? 1. Yes 2. No 9. Decline to answer
28. In general, how would you rate your overall health now? Is it: 1. Excellent 2. Very good 3. Good 4. Fair 5. Poor 9. Decline to answer		29. Taken all together, how would you say things are these days-would you say that you are… 1. Very happy 2. Pretty happy 3. Not too happy 9. Decline to answer
30. Did you or someone else file a tax return for you this year (for tax year 2012)? 1. Yes 2. No (Skip to Question 31.) 9. Decline to answer		31. When you filed your 2012 federal tax return, did you use a free tax preparer or paid tax preparer to prepare your taxes? 1. Free preparer 2. Paid preparer 3. Prepared own taxes 4. Other 9. Decline to answer
32. Workers earning below a certain amount can sometimes get benefits from the government in a tax refund or added to their paycheck. The program is called the Earned Income Tax Credit (EITC). Have you heard of this program? 1. Yes 2. No (Skip to end.) 9. Decline to answer					33. Have you ever received the EITC? 1. Yes 2. No 9. Decline to answer