5 - B3-specific enrollment data (Applicant)

                                                                                                                                                         OMB #: XXXX-XXXX

                                                                                                                                             EXPIRATION: XX/XX/201X

5 - B3-specific enrollment data

[The nFORM MIS is being developed by the Fatherhood and Marriage Local Evaluation and Cross-site (FaMLE Cross-site) Project for federal Responsible Fatherhood Grantees. This MIS has already been approved by the OMB (0970-0460). Staff members at the Grantees will enter information into nFORM about fathers and their program participation. This instrument describes additional information that will be collected in nFORM for sites in the B3 study.]

[The following information will be collected on a new B3-specific enrollment screen for all sample members:]

What type of cell phone does the father use?

[DROP DOWN MENU]

1. A smartphone

2. A cell phone that is not a smartphone

3. He does not have a cell phone

4. I do not know

Does he have an unlimited text messaging plan?

1. Yes

2. No

3. Don’t know

Social Security Number: _______

[The following data elements will not require any modifications to the nFORM MIS. As part of the B3 study, we will be asking staff members to collect contact information for three additional contacts that could help locate the sample member. Assuming that program staff would already collect contact information for one additional contact, these fields are included in this instrument to reflect the burden associated with us asking staff members to collect more information than they might have collected in the absence of the study. The following information will be collected for all sample members at the bottom of the Application Form screen:]

Additional Contact 1

First Name: Middle Initial: Last Name:

Relationship:

Address

Street (Line 1):

Street (Line 2):

City: State: Zip:

Phone # Social Media:

Home: Email:

Cell: Facebook:

Work: Twitter:

Other:

Additional Contact 2

First Name: Middle Initial: Last Name:

Relationship:

Address

Street (Line 1):

Street (Line 2):

City: State: Zip:

Phone # Social Media:

Home: Email:

Cell: Facebook:

Work: Twitter:

Other:

[The following information will be collected on a new B3-specific enrollment screen in nFORM for sample members in sites testing the employment intervention:]

Criminal Justice ID #s

State ID Number:

State Department of Corrections ID Number:

Other Criminal Justice ID:

□ Federal ID

□ State Parole ID

□ Local Probation ID

□ Local Jail ID

□ State Department of Juvenile Justice ID

____________

ID Number

[The following information will be collected in the additional contacts section on the Application Form screen in nFORM for sample members in sites testing the parenting intervention:]

Information about the focal child

Name _______________

Age (in months) _______________

Gender □ Male □ Female

Resident father □ Yes □ No

Information about the Mother/Guardian of focal child

Name _______________

Address

Street (Line 1):

Street (Line 2):

City: State: Zip:

Phone # Social Media:

Home: Email:

Cell: Facebook:

Work: Twitter:

Other:

Staff can contact mother/guardian? □ Yes □ No

Additional Contact 1 for Co-parent

First Name: Middle Initial: Last Name:

Relationship:

Phone #:

Additional Contact 2 for Co-parent

First Name: Middle Initial: Last Name:

Relationship:

Phone #:

[This box will appear on the client profile page in nFORM. The text is slightly modified from the text that was approved as part of the FaMLE Cross-site OMB package (0970-0460). The modifications include adding detail about the additional burden required for the B3 study and adding a sentence at the end to indicate the additional way that the nFORM data will be used for the B3 study.]

THE PAPERWORK REDUCTION ACT OF 1995

Public reporting burden for this collection of information is estimated to average 2 minutes per response for weekly service data entry for the FaMLE Cross-site data collection, 1 minute per response for eligibility data entry for the B3 study, 9 minutes per response for entry of B3 enrollment data, and 1 minute per response for weekly service data entry for the B3 study. These averages include 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 information requested in this template will be used to document how programs receiving HMRF grant funding operate. The data gathered will allow ACF to better monitor grantee progress and performance. The data will also be used to learn about the effects of parenting and employment services for fathers.