DCS-1: Applicant Characteristics - Program Staff

O MB Control No.:xxxx-xxxx

Expiration Date: xx/xx/xxxx

Respondent ID #: _____________________

Date: _______________________________

HEALTHY MARRIAGE/

RESPONSIBLE FATHERHOOD PROGRAM

APPLICANT CHARACTERISTICS

PRIVACY

Thank you for your help with this important study. This survey asks questions about your demographic characteristics, financial well-being, health, and what brought you to the program. Your name will not be on the survey and your answers will be private to the extent permitted by law. We want you to know that:

1. Your participation in this survey is voluntary.

2. We hope that you will answer all the questions, but you may skip any questions you do not wish to answer.

3. The answers you give will be kept private to the extent permitted by law.

THE PAPERWORK REDUCTION ACT OF 1995

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 information requested in this survey will be used to document how programs receiving HMRF grant funding operate and describe participant outcomes. The data gathered will allow ACF to better monitor grantee progress and performance. In accordance with the requirements of the Privacy Act of 1974, as amended (5 U.S.C. 552a), ACF/OPRE established system of records titled: 09-80-0361 OPRE Research and Evaluation Project Records, HHS/ACF/OPRE. A Federal Register Notice (80 FR 17893) announced the system.

A1. Are you male or female?

¹  Male

²  Female

A2. What is your current age?

MARK one only

¹  Under 18 years old

²  18 – 20 years

³  21 – 24 years

⁴  25 – 34 years

⁵  35 – 44 years

⁶  45 – 54 years

⁷  55 – 64 years

⁸  65 years or older

A3. Which of the following best describes 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

⁶  Other (Please specify): _____________________________________________________

A4. What is your ethnicity?

¹  Hispanic or Latino

⁰  Not Hispanic or Latino GO TO A6a

A5a. Where were you born?

MARK one only

¹  In the United States

²  Outside the United States. In what country were you born? __________________________

A5b. Where was your mother born?

MARK one only

¹  In the United States

²  Outside the United States. In what country was your mother born? ____________________

A5c. Where was your father born?

MARK one only

¹  In the United States

²  Outside the United States. In what country was your father born? _____________________

A6a. Which language is spoken in your home most of the time?

¹  English GO TO B1

²  Spanish

³  Other. Please specify _______________________

A6b. How well do you speak English?

MARK one only

¹  Very well

²  Well

³  Not well

⁴  Not at all

B1. In the past month, have you or anyone in your household received the following types of assistance?

	MARK ONE BOX IN EACH ROW
	yes	no
a. Temporary Assistance for Needy Families (TANF)	1 	0 
b. Supplemental Security Income (SSI)	1 	0 
c. Social Security Disability Insurance (SSDI)	1 	0 
d. Supplemental Nutrition Assistance Program (SNAP) / Food stamps	1 	0 
e. Women, Infants, and Children (WIC)	1 	0 
f. Unemployment insurance	1 	0 
g. Housing choice voucher (sometimes called Section 8)	1 	0 
h. Cash assistance	1 	0 
i. Child support	1 	0 
j. Other (Please specify)	1 	0 

B2. What is your current living situation?

MARK one only

¹  Own home

²  Rent

³  Live rent-free (a relative or someone else rents/owns the home)

⁴  Live in shelter, halfway house, or treatment center

⁵  Live on streets, car, abandoned building, or other place not meant for sleeping

⁶  Other (Please specify): _____________________________________________________

B3. Are you currently in school or college?

¹  Yes

⁰  No GO TO B5

B4. What is your current grade?

MARK one only

¹  Less than 9th grade

²  9th grade

³  10th grade

⁴  11th grade

⁵  12th grade

⁶  College

B5. What is the highest degree, diploma, or certification you have earned?

MARK one only

¹  No degree or diploma earned

²  High school General Education Development or GED

³  High school diploma

⁴  Vocational/technical certification

⁵  Some college but no degree completion

⁶  Associate’s degree

⁷  Bachelor’s degree

⁸  Master’s degree/Advanced degree

B6a. What is your current employment status?

mark all that apply

¹  Full-time employment (usually work 35 or more hours a week)

²  Part-time employment (usually work 1 – 34 hours a week)

³  Employed, but number of hours changes from week to week

⁴  Temporary, occasional, or seasonal employment, or odd jobs for pay

⁵  Not currently employed

B6b. Are you…

	MARK ONE BOX IN EACH ROW
	yes	no
a. Actively looking for work?	1 	0 
b. Retired?	1 	0 
c. Disabled?	1 	0 
d. In school or college full or part time?	1 	0 

[IF B6a = 1, 2, 3, OR 4]

B7. In the past 30 days, how much money did you make?

Please include tips, bonuses, commissions, and regular overtime pay and count all money you received before taxes and deductions. If you held more than one job, include your total earnings from all of your work during the past 30 days. Do not include the earnings of other people who live with you.

Your best estimate is fine.

MARK ONE ONLY

¹  Less than $500

²  $500 – $1,000

³  $1,001 – $2,000

⁴  $2,001 – $3,000

⁵  $3,001 – $4,000

⁶  $4,001 – $5,000

⁷  More than $5,000

B8. Do you have health insurance (either through your job, your partner’s job, your parents’ job, Medicaid, Medicare, or a health exchange)?

MARK one ONLY

¹  Yes

⁰  No

^d  I don’t know

[IF B6a = 1, 2, 3, OR 4]

B9. Do you have other benefits through your job, such as paid vacation leave, paid sick leave, or life insurance?

MARK one only

¹  Yes

⁰  No

^d  I don’t know

[IF B6a = 1, 2, 3, OR 4]

B10. When did you first start working in the job you have now? If you have more than one job, think about the job for which you worked the most hours during the past 30 days.

| | | / | | | | | month / year

B11. Please list your two most recent employers.

B12. Some people experience challenges that make it hard to find or keep a good job.

How much do the following make it hard for you to find or keep a job?

	MARK ONE BOX IN EACH ROW
	not at all	a little	a lot
a. Do not have reliable transportation	1 	2 	3 
b. Do not have right clothes for a job (including uniforms)	1 	2 	3 
c. Do not have documentation for legal employment (e.g., birth certificate)	1 	2 	3 
d. Do not have good enough childcare or family help	1 	2 	3 
e. Have a criminal record	1 	2 	3 
f. Do not have the right skills or education for good jobs	1 	2 	3 
g. Have substance use or mental health problems	1 	2 	3 

C1. What is your current marital status?

MARK ONE ONLY

¹  Married

²  Engaged

³  Separated

⁴  Divorced

⁵  Widowed

⁶  Never married

C2. What is your current partner status?

MARK ONE ONLY

¹  No current partner (unpartnered) GO TO C4a or C4b

²  I am romantically involved with someone on a steady basis

³  I am involved in an on-again and off-again relationship

C3. How much of the time do you live with your partner?

MARK ONE ONLY

¹  All of the time

²  Most of the time

³  Some of the time

⁴  None of the time

[If A1 = 2]

C4a. Are you currently pregnant?

¹  Yes

⁰  No

[If A1 = 1]

C4b. Are any women currently pregnant with your child?

¹  Yes

⁰  No

C5. How many children do you have who are under 21 years old? Do not include current pregnancies.

______________ number of children

C6. How many of these are your biological or legally adopted children?

______________ number of biological or legally adopted children

C7. How many of your biological or legally adopted children live with you all or most of the time?

______________ number of children that live with you all or most of the time

[ASK IF C1 = 1 or 2 OR C2 = 2 OR 3]

C8. Are you a mother/father figure to any of your partner’s children?

¹  Yes

²  No

³  My partner has no children

[ASK IF A2 = 1 OR 2]

C9. What is your current foster care status?

MARK ONE ONLY

¹  I have never been in foster care

²  I recently (in last the past 6 months) transitioned out of foster care

³  I am preparing to transition out of foster care

⁴  I am currently in foster care, with no current transition plans in place

D1. In general, how would you describe your health?

MARK ONE ONLY

¹  Poor

²  Fair

³  Good

⁴  Very good

⁵  Excellent

E1. How or where did you hear about [PROGRAM]?

MARK ALL THAT APPLY

¹  Word of mouth (friends, family, acquaintances)

²  Newspaper ad, billboards, or a flyer

³  Radio ad or a TV spot

⁴  Internet ad or social media such as Facebook, Twitter

⁵  Government agency, such as the Office of Child Support Enforcement, TANF, WIC, Child Welfare (CPS), parole/probation office, other agency

⁶  Community organization, such as a school, hospital, maternity clinic, doctor’s office, place of worship, Head Start, or Healthy Start center

⁷  Program staff or event

⁸  School staff, such as a teacher or counselor

⁹  Other (Please specify): _____________________________________________________

E2. Why did you choose to enroll in this program?

MARK ONE ONLY

¹  To learn about being a better parent

²  To learn how to improve my personal relationships

³  To find a job or a better job

⁴  My friends were coming

⁵  My spouse/partner asked me to come

⁶  My parole/probation officer told me to enroll in a program like this

⁷  A court ordered me to enroll in a program like this

⁸  Other (Please specify): _____________________________________________________

Thank you for completing this survey!