K_12- to 18-Month Follow-Up Participant Survey_Phase 2_CLEAN

OPRE Evaluation - Building Evidence on Employment Strategies for Low-Income Families (BEES) [Impact, implementation, and descriptive studies]

K_12- to 18-Month Follow-Up Participant Survey_Phase 2_CLEAN

OMB: 0970-0537

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0970-0537 can be found here:

2024-05-01 - No material or nonsubstantive change to a currently approved collection
2023-12-13 - No material or nonsubstantive change to a currently approved collection

Document [docx]

Download: docx | pdf

A Shape2 ttachment K – 12-18 Month Follow-Up Participant Survey

^Introduction

Hello, my name is [ ]. May I please speak with _____?

IF RESPONDENT COMES TO THE PHONE: I’m calling on behalf of [BEES program].

IF PHONE OR IN-PERSON: I work for Abt Associates, or Abt, which is an independent research company. Abt is helping the Administration for Children and Families (ACF) in the U.S. Department of Health and Human Services (HHS) with its evaluation of the Building Evidence on Employment Strategies (BEES) study. We are conducting a survey with you because you agreed to be in a study about a program offered at [NAME OF ORGANIZATION] called [BEES program]. Thank you for taking the time to talk with me today.

This survey will include questions on your employment and education activities, your use of services, and your overall well-being. This survey will take about 30 minutes to complete. When we are done, we will send you a link to access a $25 gift card, as a thank you. You agreed to be part of the study around [RAD] when you signed a consent form to let researchers collect information from you. We need to talk with people who got into the program and those who did not. Your participation in this study will help policymakers and program staff better understand how to help people get better jobs, earn more, and improve general well-being.

Before we begin the survey, I would like to assure you that all of your responses during this survey will be kept private; your name will not appear in any written reports we produce. Your responses to these questions are completely voluntary. That means you may choose not to answer any question, or you may stop the survey if you wish, but we hope you don’t. Your responses to these questions will in no way affect your participation in any programs or your receipt of any kinds of public benefits or services. The information you provide will be kept private and only used for studies about the different types of employment services that are the focus of this study. By participating in this study, you will help the government learn if and how programs like [BEES program] make a difference in people’s lives and how to improve programs in the future.

According to the Paperwork Reduction Act (PRA), this collection of information is voluntary and will be used to understand programs that aim to improve employment outcomes for low-income adults Public reporting burden for this collection of information is estimated to average 30 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 number and expiration date for this collection are OMB #: XXXX-XXXX, Exp: XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Dan Bloom (MDRC); 200 Vesey Street, 23^rd Floor, New York, NY 10281-2103.

Do you have any questions before we begin?

Let’s begin now.

Screener/Verification:

First I just need to verify that I am speaking with the correct person.

Read the following text and ask Q1 of everyone.

What is your date of birth? ___________ (MM/DD/YYYY)

Ask Q2 only if the DOB in Q1 does not match what is in our records.

What are the last 4 digits of your Social Security number?

DISCONTINUED TEXT: I’m sorry. I was unable to pull up the correct questionnaire. I will need to check with my supervisor to look into the problem. I will re-contact you when the problem is resolved. Thank you for your time.

SECTION A: SERVICE RECEIPT AND PARTICIPATION

a0.

Since [RAMY], have you received [non-employment services relevant to BEES program]

INTERVIEWER, IF NECESSARY, SAY: That is the date you applied to get into the [BEES program]. Please tell me about both help/services you have received from [BEES program], and help/services you have received from other programs or organizations.

1 YES

2 NO

7 DK

8 REF

A1.

I would like you to tell me about assistance you may have received since random assignment (month, year) [RAMY] from organizations and programs in your community to help you find or keep a job, or to help you deal with problems that interfered in your ability to work.

INTERVIEWER, IF NECESSARY, SAY: That is the date you applied to get into the [BEES program]. Please tell me about both help you have received from [BEES program], and help you have received from other programs or organizations.

Did you receive help with …
Did you receive help with …
a. …preparing a resume or filling out job applications?	1 YES 2 NO 7 DK 8 REF
b. …preparing for job interviews?	1 YES 2 NO 7 DK 8 REF
c. …looking for jobs, including subsidized jobs, or deciding what kinds of jobs to look for?	1 YES 2 NO 7 DK 8 REF
d. ...getting referrals to available jobs or setting up interviews for specific job openings?	1 YES 2 NO 7 DK 8 REF
e. …planning your future career or educational goals, including a work or job assessment?	1 YES 2 NO 7 DK 8 REF
f. …paying for transportation for a job or paying for work tools or uniforms?	1 YES 2 NO 7 DK 8 REF
g. …training to learn a new job or skill?	1 YES 2 NO 7 DK 8 REF
h. …education to learn a new job or skill?	1 YES 2 NO 7 DK 8 REF
i. … supports, accommodations, or coaching while working, provided by someone other than your employer?	1 YES 2 NO 7 DK 8 REF
j. … On-the-Job Training (OJT ) as part of a program that reimbursed your employer for some of your wages during a training period?	1 YES 2 NO 7 DK 8 REF
k. … how to act when you are at work? This includes issues like being on time, managing your tasks, relating to your supervisor, and handling conflicts.	1 YES 2 NO 7 DK 8 REF
l. …some other employment service?	1 YES (SPECIFY: _______) 2 NO 7 DK 8 REF

A2.

Are you currently receiving any of these services related to finding or keeping a job?

1 YES

2 NO

7 DK

8 REF

A3.

You indicated that you received help related to finding or keeping a job since [RAMY].

IF NUMBER OF 1/YES RESPONSES IN A1 SUMS TO 1, SHOW: Where did you receive this help most often? Was it…

IF NUMBER OF 1/YES RESPONSES IN A1 SUMS TO MORE THAN 1, SHOW: Where did you receive most of these services? Was it…

INTERVIEWER: READ LIST, SELECT ONE.

1 [BEES program],

2 [Local name] or WELFARE OFFICE,

3 [Local name for WORKFORCE CENTER, WIA PROGRAM, CAREER CENTER, OR ONE-STOP],

4 AN UNEMPLOYMENT OFFICE,

5 Department of Rehabilitation or vocational rehabilitation agency

6 [LOCAL FOOD STAMP PROGRAM] OR SNAP OFFICE,

7 An organization that addresses mental health or substance use (such as a clubhouse or community mental health center), or

8 A community-based organization that provides employment services or other social services, or

9 SOME OTHER SOURCE? (SPECIFY________________________)

97 DON’T KNOW

98 REFUSED

A4.

How much time since [RAMY] did you spend participating in these services related to finding or keeping a job? Please give your answer in either days, weeks, or months.

01 RESPONSE PROVIDED IN DAYS: SPECIFY: ____________ (RANGE 1-90)

02 RESPONSE PROVIDED IN WEEKS: SPECIFY: ____________ (RANGE 1-52)

03 RESPONSE PROVIDED IN MONTHS SPECIFY: ____________ (RANGE 1-25)

97 DK

98 REF

A5.

In the month after you applied to [BEES program], that is, [RESTORE RAMY + 1 MONTH], how much time did you spend, receiving these services related to finding or keeping a job? Please consider services from any source. Please give your answer in either days or weeks.

01 RESPONSE PROVIDED IN DAYS: SPECIFY: ____________ (RANGE 1-31)

02 RESPONSE PROVIDED IN WEEKS: SPECIFY: ____________ (RANGE 1-4)

96 NONE IN THAT MONTH

97 DK

98 REF

A6.

Thinking of the people you have worked with at agencies or organizations since [RAMY], is there a person to whom you can turn for advice or support when you have problems or things that worry you?

1 YES

2 NO [SKIP TO A9]

7 DON’T KNOW [SKIP TO A9]

8 REFUSED [SKIP TO A9]

A7.

At which organization or program did this person work? Was it…

1 [Local name for workforce center, WIA program, career center, or one-stop]

2 Family Resource Centers, [state specific program], or Welfare to Work,

3 Department of Rehabilitation or vocational rehabilitation agency,

4 An organization that addresses mental health or substance use (such as a clubhouse, or community mental health center)

5 A community-based organization that provides social services, or

6 Some other place? (Specify________)

97 DK

98 REF

A8.

Are you still in touch with this person?

1 YES

2 NO

97 DON’T KNOW

98 REFUSED

A9.

Have you enrolled in any of the following types of education or vocational training classes since [RAMY]?

	1. YES	2. NO	7. DK	8. REF
1.) Vocational training program?
2.) Technical or trade school? [insert relevant examples of local programs]
3.) ESL classes (English as Second Language)?
3.) Adult basic education or GED courses?
4.) 2-year or community college?
5.) 4-year college or university?
6.) Graduate school?
7.) Somewhere else? (SPECIFY:________)

A.9a. (IF YES TO ANY A9)

Were any of these education or vocational training classes taken online?

1 YES
2 NO

97 DON’T KNOW

98 REFUSED

FOR EACH “YES” TO A9_1 TO A9_7, ASK A9.B TO A9E:

A.9B_1 to 6 (Only for A9 1 to 6)

What was the name of the program or school that offered the [A9 response] classes?

Specify: _______________

97 Don’t know

98 Refused

A.9C_1 to 7

Are you currently enrolled in these [A9 response] classes?

1 YES
2 NO

97 DON’T KNOW

98 REFUSED

PROGRAMMING NOTE: IF A.9C_X=1 (currently enrolled in classes) THEN DO NOT ASK A9D BUT CODE AS 77/7777 AND CONTINUE ON TO A9.E ELSE, ASK A9E.

A.9D_1 to 7

When did you stop taking these [A9 response] classes?

Probe: Could you give me your best estimate? This helps us understand how long you were taking classes. Please remember all information you provide is private and will not be shared.

______________________________________________________________________

MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = YYYY-CURRENT YEAR, 9997, 9998)

77/7777 STILL TAKING CLASSES

97/9997 DON’T KNOW

98/9998 REFUSED

A.9E_1 to 7

When did your classes at [A9.B response] start?

________________________________________________________________________

MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = YYYY - CURRENT YEAR, 9997, 9998)

97/9997 DON’T KNOW

98/9998 REFUSED

A10.

Now I’d like to ask you about professional certifications and licensures that you’ve obtained. Since [RAMY], have you earned or received a professional certification or state or industry license?

INTERVIEWER, IF NECESSARY: A professional certification or license shows you are qualified to perform a specific job and includes things like Licensed Realtor, Certified Medical Assistant, Certified Construction Manager, a Project Management Profession or PMP certification, or an IT certification.

1 YES

2 NO [SKIP TO A12]

97 DON’T KNOW [SKIP TO A12]

98 REFUSED [SKIP TO A12]

A11.

What type of license or certification is it?

INTERVIEWER PROBE: What type of trade or work does it qualify you to do?

_____________________________________________________________________

VERBATIM

97 DON’T KNOW

98 REFUSED

A12.

Since [RAMY], have you received help for problems related to substance use?

1 YES

2 NO [GO TO A19]

7 DON’T KNOW [GO TO A19]

8 REFUSED [GO TO A19]

A13.

What type of treatment did you receive for problems related to substance use? Was it …

1 hospital inpatient,

2 inpatient in a residential drug treatment program,

3 intensive outpatient,

4 outpatient.

5 or some other type? (Specify_______)

97 DK

98 REF

A14. When did you start receiving this help?

______________________________________________________

MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = YYYY - CURRENT YEAR, 9997, 9998)

97/9997 DON’T KNOW

98/9998 REFUSED

A15.

Are you still receiving this help?

1 YES (SKIP TO A17)
2 NO

97 DON’T KNOW

98 REFUSED

A16.

When was the last time you received this help?

______________________________________________________

MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = YYYY - CURRENT YEAR, 9997, 9998)

97/9997 DON’T KNOW

98/9998 REFUSED

A17.

During the time in which you were receiving help for problems related to substance use, how often did you receive help? Was it…

Four or more times a week
Two or three times a week,
Once a week,
2-3 times a month,
Once a month, or
Less than once a month?

A18.

Have you been taking any of the following while in the care of a medical professional during the past [30 days]?

1 methadone,

2 buprenorphine (including Subutex ®, Suboxone ®)

3 naltrexone (including Vivitrol ®)

97 DK

98 REF

A19.

Since [RAMY], have you received help for problems related to your emotions, nerves, anger management or mental health? This would include help dealing with depression, anxiety, or other conditions from a mental health center, a therapist, a psychologist or psychiatrist, social worker, counselor, doctor, or other provider.

1 YES

2 NO [GO TO SECTION B]

97 DON’T KNOW [GO TO SECTION B]

98 REFUSED [GO TO SECTION B]

A20.

Where did you receive help with problems related to your emotions, nerves, anger management or mental health? Was it at…

1 A private therapist’s or psychiatrist’s office,

2 [local program name(s)] or other community mental health center

3 [local hospital name(s)] or other hospital

4 [local treatment facilities] or other in-patient treatment facility

5 A vocational rehabilitation agency,

6 [local organization name(s)] or other community-based organization

7 or some other place? (Specify_______)

97 DK

98 REF

A21. When did you start receiving this help?

______________________________________________________

MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = YYYY - CURRENT YEAR, 9997, 9998)

97/9997 DON’T KNOW

98/9998 REFUSED

A22.

Are you still receiving this help?

1 YES (SKIP TO A24)
2 NO

97 DON’T KNOW

98 REFUSED

A23.

When was the last time you received this help?

______________________________________________________

MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = YYYY - CURRENT YEAR, 9997, 9998)

97/9997 DON’T KNOW

98/9998 REFUSED

A24.

During the time in which you were receiving this help, how often did you receive help? Was it…

Four or more times a week
Two or three times a week,
Once a week,
2-3 times a month,
Once a month, or
Less than once a month?

SECTION B: PROGRAM SATISFACTION

PROGRAM GROUP ONLY

Now, I’m going to ask you some questions about your experiences with [BEES program].

b1.

Since [RAMY], have you received any services from [BEES program] or participated in any [BEES program] activities?

1 YES

2 NO [SKIP TO B3]

7 DON’T KNOW

8 REFUSED

b2.

Which of the following best describes your current situation with [BEES program]?

[Response options may be customized by site]

1 Currently working with an [employment specialist], but haven’t found a job yet, [GO TO SECTION C]

2 Found a job and currently working with an [employment specialist], [SKIP TO B5]

3 Started the program but stopped before you found a job, [SKIP TO B4]

4 Started the program and stopped after you found a job, [SKIP TO B4] or

5 Never worked with [BEES program] staff on employment-related activities? [SKIP TO B3]

7 DON’T KNOW

8 REFUSED

b3.

What was the primary reason you did not participate in [BEES program]?

[Response options may be customized by site]

1 You didn’t have transportation/had issues with transportation

2 You were incarcerated

3 You didn’t have the time

4 You got a job

5 You moved

6 You were expecting a child

7 You had child care problems

8 You had health problems or an injury

9 A family member became ill

10 You had pressure from your family

11 You did not like the program

12 You did not like or get along with the program staff

13 You no longer wanted to find employment

14 Some other reason (SPECIFY:________)

97 DK

98 REF

[ALL B3 RESPONSES GO TO SECTION C]

b4.

What was the primary reason you stopped going to [BEES program]?

[Response options may be customized by site]

1 You didn’t have transportation/had issues with transportation

2 You were incarcerated

3 You didn’t have the time

4 You got a job

5 You moved

6 You were expecting a child

7 You had child care problems

8 You had health problems or an injury

9 A family member became ill

10 You had pressure from your family

11 You did not like the program

12 You did not like or get along with the program staff

13 You no longer wanted to find employment

14 Some other reason (SPECIFY:________)

97 DK

98 REF

[ALL B4 RESPONSES GO TO NEXT SECTION]

b5.

Did [BEES program] staff help you find a job?

1 YES

2 NO

7 DK

8 REF

b6.

How satisfied were you with the job you found? Were you…

1 Very satisfied,

2 Somewhat satisfied,

3 Not very satisfied, or

4 Not at all satisfied?

7 DK

8 REF

B7.

Thinking of your whole experience with [program name], how satisfied are you with the service you’ve received from [program name] and its partners?

Very satisfied.
Somewhat Satisfied.
Not very satisfied, or.
Not at all satisfied?

[Child Support Specific Questions: B8 through B10 will only be used with relevant programs]

B8.

Thinking about the last conversation you had with your child support caseworker, please state whether you strongly agree, agree, disagree or strongly disagree/don’t’ know with the following statements.

Your caseworker was polite and friendly
Your caseworker treated you with courtesy and respect.
Your caseworker was impartial and nonjudgemental.
Your caseworker understood the details of your case.
Your caseworker kept you informed of what was happening on your case.

B9.

One of the most important parts of this study is learning about how this program can help noncustodial parents and their relationship with their children. In order to do that, we need to ask a few questions about each of your children

How many children do you have?

1
2
3
4
5
6 or more

B10.

In general, would you say your relationship with your children is excellent, very good, good, fair, or poor?

Excellent
Very good
Good
Fair
Poor
DK
No answer

SECTION C: EMPLOYMENT

Now, I’m going to ask you some questions about any jobs you may have had since [RAMY], which is when you applied to [BEES program].

[Note: The below grid provides an overview of employment questions. It is a summary of the information covered in this section for reference and is not read to respondents.]

Type of Job	Information collected about this job (highlighted are asked of all job ‘types’)
Current job (if the participant has multiple current jobs, we ask about the one where the person works the most hours)	Employer name
	Start date of job
	Type of company/organization (self, temp, gov't, private, etc.)
	Type of employment (permanent, seasonal, etc.)
	Type of shift
	Hours worked per week
	Wage before taxes
	Health insurance and other benefits for this job
	Received a promotion at this job/likelihood of future promotion
	Agency/program that helped get participant the job (if any)
	Most important resource used to find job
Other current jobs (up to 3)	Employer name
	Start date of job
	Hours worked per week
	Wage before taxes
	Most important resource used to find job
Other (not current) jobs since random assignment (up to 7)	Employer name
	End date of job
	Start date of job
	Hour worked per week
	Wage before taxes
	Reasons stopped working at job

C1.

Are you currently working for pay? This includes any work where you get paid including self-employment, temporary work, work as a day laborer, work “off the books,” and paid work at an employment program.

1 YES [SKIP TO C2]

2 NO

7 DON’T KNOW

8 REFUSED

C1a.

A lot of people have irregular, odd, or side jobs, or do extra work to make ends meet. Do you currently have any work like that?

1 YES

2 NO

7 DON’T KNOW

8 REFUSED

____________________________________________________________________________________

C2 . (c2_1 – C2_20)

These next questions are about any full-time or part-time regular jobs, self-employment, paid work at an employment program, odd jobs such as occasional babysitting, hairdressing, painting or repair work, temporary jobs or any other jobs at which you worked since [RAMY]. Let’s make a list.

PROGRAMMER NOTE: IF C1=1 OR C1A= 1, USE “CURRENT”, ELSE USE “MOST RECENT”: Starting with your (current/most recent) employer, please tell me the names of all companies you’ve worked for and any self-employment you’ve had since [RAMY]. RECORD ALL FIRMS/JOBS MENTIONED.

IF NECESSARY: This is simply to help make later questions more clear. We will not contact your employer. If you would like, you can tell me your job title instead.

PROBE FOR JOBS 2-20: What other companies have you worked for or what self-employment have you had since [RAMY]?

INTERVIEWER: RECORD VERBATIM

PROGRAMMER: ALLOW UP TO 20 COMPANY NAMES.

PROGRAMMER: IF C1=1 OR C1A=1, DO NOT ACCEPT 0 (NO EMPLOYMENT SINCE RAMY).

__________________________________________________________________

EMPLOYER (1-20)

0 NO EMPLOYMENT SINCE [RAMY] [SKIP TO C19]

96 NO OTHER JOB [only shown for jobs 2-20]

97 DON’T KNOW

98 REFUSED

PROGRAMMING NOTE: IF C2_1 = 97 OR 98 GO TO C20. IF ANY SUBSEQUENT JOBS (C2_2 – C2_20 = 97 OR 98) GO TO TOTJOBCONFIRM.

AFTER EACH EMPLOYER NAME IS GIVEN, ASK C2_CURR:

C2_CURR. (C2_CURR_1 THROUGH C2_CURR_20)

Is this a current job?

1 YES

2 NO

7 DK

8 REF

PROGRAMMER: IF C2_CURR=1 THEN C1A=1

C2_TOTJOB

So, it sounds like you had [FILL TOTAL NUMBER OF JOBS INCLUDING SELF-EMPLOYMENT FROM RECONCILIATION TABLE] during the period from [RAMY] to now. Does this sound correct?

1 YES, CONTINUE GO TO C3

2 NO, RETURN TO C2 AND TRY AGAIN

7 DON’T KNOW, CONTINUE GO TO C3

8 REFUSED, CONTINUE GO TO C3

PROGRAMMING NOTE: IF C2_CURR=1 (JOB GIVEN IN C2 IS CURRENT) THEN DO NOT ASK C3 BUT CODE C3 AS 77/7777 AND CONTINUE ON TO C4. ELSE, ASK C3.

C3. (C3_1-20)

When did your job at [FILL EMPLOYER 1] end?

Probe: Could you give me your best estimate? This helps us understand how long you were working. Please remember all information you provide is private and will not be shared.

______________________________________________________________________

MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = 2016-CURRENT YEAR, 9997, 9998)

77/7777 STILL WORKING

97/9997 DON’T KNOW

98/9998 REFUSED

C4. (C4_1-20)

When did your job with [FILL EMPLOYER 1] start?

________________________________________________________________________

MM (RANGE = 1-12, 97, 98) /YYYY (RANGE = 2015 - CURRENT YEAR, 9997, 9998)

97/9997 DON’T KNOW

98/9998 REFUSED

C5. (C5_1-20)

PROGRAMMING NOTE: IF C3=77/7777 STILL WORKING USE “DO” AND EXCLUDE “WHEN YOU LEFT” TEXT, OTHERWISE USE “DID” AND INCLUDE “WHEN YOU LEFT” TEXT.

Including overtime, how many hours per week (do/did) you work with [FILL EMPLOYER 1] (when you left)?

INTERVIEWER: IF SCHEDULE IS IRREGULAR OR VARIES: How many hours did you work in the last week you worked at this job?

___________________

NUMBER OF HOURS (RANGE: 1 to 80)

96 OVER 80 HOURS PER WEEK

97 DON’T KNOW

98 REFUSED

C6A. (C6a_1-20)

What (is/was) your wage at [FILL EMPLOYER 1] (just before you left), before taxes? Please include tips, commissions, and regular overtime pay.

INTERVIEWER: IF JOB IS ON AN IRREGULAR SCHEDULE OR A COMMISSION BASIS, PROBE FOR HOW MUCH R MAKES IN A TYPICAL WEEK.

$ ___ ___ , ___ ___ ___ . ___ ___

AMOUNT (RANGE: .01 -to 50,000.00)

99999.96 MORE THAN $50,000

99999.97 DON’T KNOW [SKIP TO INSTRUCTION BEFORE C8]

99999.98 REFUSED [SKIP TO INSTRUCTION BEFORE C8]

C6B. (C6b_1-20)

Was that:

INTERVIEWER: READ CATEGORIES UNTIL RESPONENT INDICATES THE CORRECT SELECTION.

1 …per hour?

2 …per week?

3 …per day?

4 …every 2 weeks?

5 …twice monthly?

6 …monthly

7 …annually?

8 …or per task?

9 OTHER (SPECIFY: ________________)

97 DON’T KNOW

98 REFUSED

C7. (C7_1-20)

Is that …

1 before taxes, or

2 after taxes?

7 DON’T KNOW

8 REFUSED

C8. (C8_1-20)

What was the most important resource you used to find this job at [FILL EMPLOYER 1]? Was it…

1 a friend, relative, or acquaintance,

2 a job posting or help-wanted ad found in the newspaper, on the computer, or somewhere else,

3 an employment placement service at school or training provider,

4 a church or community center,

5 an employer that decided to retain you permanently after you were placed there in a temporary, transitional, or subsidized job,

6 an employment program ,

7 or something else? (SPECIFY: ________________)

97 DON’T KNOW

98 REFUSED

C9. (C9_1-20)

Why did you stop working at [FILL EMPLOYER 1]? [ALLOW ONLY ONE RESPONSE]

INTERVIEWER, IF MORE THAN ONE RESPONSE GIVEN, SAY: Which of your answers was the primary reason you stopped working at this job?

1 GOT A NEW/DIFFERENT JOB

2 LAID OFF

3 NOT INTERESTED IN WORKING

4 UNABLE TO WORK BECAUSE OF INJURY

5 UNABLE TO WORK BECAUSE OF ILLNESS

6 UNABLE TO WORK BECAUSE OF PHYSICAL DISABILITY

7 UNABLE TO WORK BECAUSE OF MENTAL DISABILITY

8 INCARCERATED

9 PREGNANCY/CHILDBIRTH

10 FAMILY RESPONSIBILITIES

11 GOING TO SCHOOL

12 OTHER (SPECIFY: ________________)

97 DON’T KNOW

98 REFUSED

So, it sounds like you have [FILL TOTAL NUMBER OF CURRENT JOBS] current jobs.

For whom do you usually work the most hours?

IF HOURS ARE THE SAME: Who have you worked for the longest?

IF NECESSARY: This is simply to help make later questions more clear. We will not contact your employer.

<1> FILL CURR JOB1

<2> FILL CURR JOB2

<3> FILL CURR JOB3

<4> FILL CURR JOB4

<7> DON’T KNOW, CONTINUE GO USE FIRST JOB LISTED

<8> REFUSED, CONTINUE GO USE FIRST JOB LISTED

C10.

This next set of questions is about your current job at [fill current main employer].

What type of work are you currently doing in this job at [fill current main employer]?

[Response options may be customized by site]

1 General labor or construction,

2 Food service,

3 Administrative,

4 Customer Service,

5 Caregiver,

6 Warehouse,

7 Retail, or

8 Another type of job? (SPECIFY: ___________)

97 DK

98 REF

C11.

What type of company or organization is [fill current main employer]? Is it…

PROBE: Who did the paycheck come from?

1 self-employment,

2 a company, that is a private or not-for-profit employer,

3 a temporary agency,

4 an employment program

5 a transitional job program,

6 a government employer, or

7 something else? (SPECIFY: ________________)

97 DON’T KNOW

98 REFUSED

C12.

Is this job…

1 permanent employment, including part-time work,

2 seasonal work, temporary work through a temp agency, day labor, an odd job, or

3 something else? (SPECIFY: ________________)

97 DON’T KNOW

98 REFUSED

C13.

Which of the following best describes your usual weekly work schedule at your job during the last month? Do/did you work a…

1 daytime shift,

2 an evening shift,

3 a night shift,

4 a rotating shift, that is one that changes regularly from days to evenings to nights,

5 a split shift, that is one consisting of two distinct periods each day,

6 an irregular schedule, that is one that changes from day to day or week to week, or

7 something else? (SPECIFY: ________________)

97 DON’T KNOW

98 REFUSED

C14.

Which of the following benefits are available to you on your job, even if you do not participate or use them?

	YES	NO	DON’T KNOW	REFUSED
a.) Health insurance?	1	2	7	8
b.) Sick days with full pay?	1	2	7	8
c.) Paid vacation?	1	2	7	8
d.) Paid holidays?	1	2	7	8
e.) Dental benefits, including any offered at a cost to you?	1	2	7	8
f.) A retirement or 401K plan?	1	2	7	8
g.). Tuition reimbursement?	1	2	7	8

____________________________________________________________________________________

Shape1 C15.

Since [RAMY] have you received a promotion while working at this job, meaning that you moved to a higher position or job title? This does not include raises or changes in your wage or salary.

1 YES

2 NO

7 DON’T KNOW

8 REFUSED

C16.

Do you think you are likely to move up or be promoted in the future?

1 YES

2 NO

7 DON’T KNOW

8 REFUSED

C17.

Did staff from any agency or organization help you get this job?

1 YES

2 NO [SKIP TO SECTION D]

7 DON’T KNOW [SKIP TO SECTION D ]

8 REFUSED [SKIP TO SECTION D ]

C18 .

What agency or program was it? Was it…

1 [name of BEES program]

2 [local name] or welfare office

3 [local name for workforce center, WIA program, career center, or one-stop]

4 An unemployment office

5 Department of Rehabilitation or vocational rehabilitation agency,

6 An organization that addresses mental health or substance use issues, such as a clubhouse or community mental health center ,

7 A community-based organization that provides that provides employment services or other social services, or

8 Some other program? (Specify________)

97 DK

98 REF

C19 .

What is the main reason you did not work at a job since [RAMY]? [ALLOW ONLY ONE RESPONSE]

Probe: Which of your answers was the primary reason you did not work at a job since [RAMY]?

1 UNABLE TO WORK BECAUSE OF INJURY

2 UNABLE TO WORK BECAUSE OF ILLNESS

3 UNABLE TO WORK BECAUSE OF PHYSICAL DISABILITY

4 UNABLE TO WORK BECAUSE OF MENTAL DISABILITY

5 INCARCERATED

6 PREGNANCY/CHILDBIRTH

7 FAMILY RESPONSIBILITIES

8 GOING TO SCHOOL

9 UNABLE TO FIND WORK

10 NOT INTERESTED IN WORKING

11 OTHER. (SPECIFY: ________________)

97 DON’T KNOW

98 REFUSED

C20.

Have you done anything to find work during the past four weeks?

1 YES

2 NO

7 DON’T KNOW

8 REFUSED

SECTION D: PHYSICAL AND MENTAL HEALTH

(SF-12v2®) Now, I would like to ask you some questions about your health.

D1.

In general, would you say your health is:

1 Excellent

2 Very good

3 Good

4 Fair, or

5 Poor?

7 DK

8 REF

D2.

The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

Yes,

limited

a lot

Yes,

limited

a little

No, not

limited

at all

REF

a. Moderate activities, such as moving a table, pushing
a vacuum cleaner, bowling, or playing golf. Would you say..

b. Climbing several flights of stairs. Would you say…

D3.

During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

All of the time

Most of the time

Some of the time

A little of the time

None of the time

REF

a. Accomplished less than you

would like. Would you say…

b. Were limited in the kind of

work or other activities. Would you say…

D4.

During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?

All of the time

Most of the time

Some of the time

A little of the time

None of the time

REF

a. Accomplished less than you

would like. Would you say…

b. Did work or other activities

less carefully than usual. Would you say…

D5.

During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? Would you say it was…

1 Not at all,

2 A little bit,

3 Moderately,

4 Quite a bit, or

5 Extremely?

7 DK

8 REF

D6.

These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks…

	All of the time	Most of the time	Some of the time	A little of the time	None of the time	DK	REF
a. Have you felt calm and peaceful? Would you say…	1	2	3	4	5	7	8
b. Did you have a lot of energy? Would you say…	1	2	3	4	5	7	8
c. Have you felt downhearted and depressed?	1	2	3	4	5	7	8

D7.

During the past 4 weeks, how much of the time have your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? Would you say it was…

1 All of the time,

2 Most of the time,

3 Some of the time,

4 A little of the time, or

5 None of the time?

7 DK

8 REF

D8. (Kessler-6 scale) During the last 30 days, about how often did

...you feel so depressed that nothing could cheer you up? [response options below]
…you feel hopeless?
…you feel restless or fidgety?
…you feel that everything was an effort?
…you feel worthless?
…you feel nervous?

(response options):

Was it: All of the time, Most of the time, Some of the time, A little of the time, or None of the time?

SECTION E: Substance Use (to be used for relevant populations)

Substance Use
Are you currently taking opioid medications for pain that have been prescribed by a physician or dentist?				 Yes  No
IF YES, …what is the name of that medication?				__________________
…how long have you been taking it?				__________________
Have you ever, even once, used any prescription pain reliever in any way a doctor did not direct you to use it? (This would include using it without a prescription of your own; or using it in greater amounts, more often, or longer than you were told to take it; or using it in any other way a doctor did not direct you to use it.)				 Yes  No

How many days in the past 30 have you used....? How many years in your life have you regularly used....?
	Past 30 days Lifetime (years)		Past 30 days Lifetime (years)
Alcohol – Any use at all	_______ _______	Cocaine	_______ _______
Alcohol – To Intoxication	_______ _______	Amphetamines	_______ _______
Heroin	_______ _______	Cannabis	_______ _______
Fentanyl	_______ _______	Hallucinogens	_______ _______
Methadone (outside of methadone maintenance treatment)	_______ _______	Inhalants	_______ _______
Other opioids/opiates/ painkillers	_______ _______	More than one substance per day (including alcohol)	_______ _______
Barbiturates	_______ _______	Other _____________________	_______ _______
Other sedatives, hypnotics, or tranquilizers	_______ _______
Which substance is the main problem? _____________________________
How long was your last period of voluntary abstinence from this substance?		_______ months
How many months ago did this abstinence end?		_______ months
How many times have you:		Had alcohol DT’s ________ Overdosed on drugs ________
How many times in your life have you been treated for:		Alcohol abuse ________ Drug abuse ________
How many of these were detox only?		Alcohol ________ Drugs ________
How much money would you say you spent during the past 30 days on:		Alcohol $________ Drugs $________
How many days have you been treated in an outpatient setting for alcohol or drugs in the past 30 days?		______ days
How many days in the past 30 have you experienced difficulty with alcohol?		______ days
How many days in the past 30 have you experienced difficulty with drugs?		______ days
How troubled or bothered have you been in the past 30 days by these alcohol problems?		 Not at all  Slightly  Moderately  Considerably  Extremely
How troubled or bothered have you been in the past 30 days by these drug problems?		 Not at all  Slightly  Moderately  Considerably  Extremely
How important to you now is treatment for these alcohol problems?		 Not at all  Slightly  Moderately  Considerably  Extremely
How important to you now is treatment for these drug problems?		 Not at all  Slightly  Moderately  Considerably  Extremely
Have you smoked any cigarettes in the past 2 years?		 Yes  No
How many cigarettes or packs do you currently smoke on an average day (a pack has 20 cigarettes)?		___________ cigarettes / packs (circle one)

SECTION F: HOUSEHOLD INFORMATION, INCOME, AND MATERIAL HARDSHIP

Now, I’d like to ask you some questions about your living arrangements.

Tell me about your housing arrangements over the last [12-18] months, starting with your current housing situation, and going back to when you enrolled in this study in [RAMY].

F1A.1

Which of the following best describes your current housing arrangement? Did you:

1 own your own home or apartment,

2 rent your home or apartment,

3 live in transitional housing or sober housing

4 live in a group home

live with friends or relatives and pay rent to them

6 live with friends or relatives and not pay rent to them,

homeless, living on the street

8 live in emergency or temporary housing, that is in a shelter or were

homeless, or

9 have some other housing arrangement? (SPECIFY: ________________)

97 DON’T KNOW

98 REFUSED

F1B.1 When did you start living here? ____________________________________________________________

Probe: Could you give me your best estimate? This helps us understand how long you have lived/were living there. Please remember all information you provide is private and will not be shared.

F1A.2 - F1A.15 Where did you live before this?

1 own your own home or apartment,

2 rent your home or apartment,

3 live in transitional housing or sober housing

live in a group home
live with friends or relatives and pay rent to them
live with friends or relatives and not pay rent to them,

7 homeless, living on the street

8 live in emergency or temporary housing, that is in a shelter or were

homeless, or

9 have some other housing arrangement? (SPECIFY: ________________)

97 DON’T KNOW

98 REFUSED

F1B.2 – F1B.15 When did you start living there?

____________________________________________________________

FOR EACH HOUSING SITUATION IN F1A.1 – F1A.15, ASK F1C.1 – F1F.15, AS APPLICABLE:

F1C. - F1C.15

[asked if intro question (F1A) response is they rent]

Do/did you live in:

Public housing—that is, housing owned by a federal, state or local government agency, such as [state specific program]
Private housing for which part of your rent bill is paid by the government, such as Section 8 or vouchers,
Do you live in private housing paid for by you with no help from the government (i.e., entire rent bill paid without any help from the government to pay the rent)

7 DON’T KNOW

8 REFUSED

F1D.1 - F1D.15

[asked if intro question response is they rent]

Do/did you live in a building where you had to apply based on your income?

2 NO

7 DON’T KNOW

8 REFUSED

F1E.1. – F1E.15

[asked if intro question response is they rent]

How much do/did you pay in rent per month (out of pocket, not including the portion covered by rental assistance)?

Specify: $__________

97 DON’T KNOW

98 REFUSED

F1F.1 – F1F.15 Did you ever fear for your safety while staying here?

F2.

What is your marital status? Are you…

1 Married,

2 Divorced,

3 Separated,

4 Widowed,

5 Or never married?

7 DK

8 REF

F3.

[IF F2=1] Does your spouse currently live with you?

[ELSE] Do you have a partner who currently lives with you?

1 YES

2 NO

7 DON’T KNOW

8 REFUSED

F4.

Including yourself, how many adults, aged 18 and older, currently live with you? Include everyone aged 18 and older who usually lives there, meaning stays with you at least two nights a week, even if they are away from home right now.

Confirm: Does that count include you?

_____ PEOPLE (RANGE 1-20)

97 DK

98 REF

F5.

How many children, under the age of 18, live with you? Please include your biological, adoptive, foster, step, or other children that you are responsible for.

IF NEEDED: By living with you, we mean spends at least two nights a week with you?

_____ CHILDREN (RANGE 00-20)

97 DK 98 REF

F6.

Now I have some questions about your current financial situation. Sometimes due to circumstances beyond your control, it can be difficult to meet all of your financial obligations. As I read each question, please let me know if you have faced any of the following situations.

Since [RAMY], has there been a time when…

	YES	NO	DON’T KNOW	REF
a. …you did not pay the full amount of the rent or mortgage because you could not afford it?	1	2	7	8
b. …you were evicted from your home or apartment for not paying the rent or mortgage?	1	2	7	8
c. …you filed in court for bankruptcy?	1	2	7	8
d. …you did not pay the full amount of the gas, oil, or electricity bills?	1	2	7	8
e. …you had service turned off by the gas or electric company, or the oil company would not deliver oil?	1	2	7	8
f. …you had cellular or land telephone service disconnected because payments were not made?	1	2	7	8
g. ...you could not fill or postponed filling a prescription for drugs when they were needed because you could not afford it?	1	2	7	8
h. … you did not pay the full amount of child support payments because you could not afford it?	1	2	7	8
...you did not pay the full amount of other bills?	1	2	7	8

F7.

Getting enough food can be a problem for some people. Which of these statements best describes the food eaten in your household in [PRIOR MONTH]? Would you say there was…

1 enough of the kind of foods you want,

2 enough, but not always the kinds of food you want,

3 sometimes not enough to eat, or

4 often not enough to eat?

7 DON’T KNOW

8 REFUSED

F8.

If one adult in household, then ask:

Now, I am going to ask you some questions about the income, that is money and assistance that you may have received since [RAMY]. Again, I want to assure you that none of your answers will be discussed with anyone.

Since [RAMY] did you receive income or assistance from any of the following sources?

NOTE: If multiple people in household, then ask:

Now, I am going to ask you some questions about the income, that is money and assistance that came into your household for everyone who lived with you since [RAMY]. Please include all income from all the people who lived together in your household at least two nights a week. Again, I want to assure you that none of your answers will be discussed with anyone.

Since [RAMY], did you or anyone in your household receive income or assistance from any of the following sources?

	YES	NO	DON’T KNOW	REFUSED
a. A job?	1	2	7	8
b. Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI)?	1	2	7	8
c. Public assistance or welfare, such as [state specific program] or general relief, not including WIC or food stamps?	1	2	7	8
d. Unemployment Insurance?	1	2	7	8
e. Worker’s compensation?	1	2	7	8
f. Disability?	1	2	7	8
g. Food stamps/SNAP/[state specific program]?	1	2	7	8
h. WIC?	1	2	7	8
i. Energy assistance?	1	2	7	8
j. Housing choice voucher, also known as Section 8, or public housing?	1	2	7	8
k. Veterans benefits	1	2	7	8
l. Other government source?	1	2	7	8

F9.

If one adult in household, then ask:

For each type of income you said you received, please tell me for how many months you received this income. Again, I want to assure you that none of your answers will be discussed with anyone.

Since [RAMY], for how many months did you receive income or assistance from…

NOTE: If multiple people in household, then ask:

For each type of income you said your household received, please tell me for how many months your household received this income. Again, I want to assure you that none of your answers will be discussed with anyone.

Since [RAMY], for how many months did your household receive income or assistance from…

	NUMBER OF MONTHS [RANGE: 1-25]	DON’T KNOW	REFUSED
a. ITEM EXCLUDED IN F9
b. Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI)?	___ MONTHS	97	98
c. Public assistance or welfare, such as [state specific program] or general relief, not including WIC or food stamps?	___ MONTHS	97	98
d. Unemployment Insurance?	___ MONTHS	97	98
e. Worker’s compensation?	___ MONTHS	97	98
f. Disability?	__ MONTHS	97	98
g. Food stamps/SNAP/[state specific program]?	___ MONTHS	97	98
h. WIC?	___ MONTHS	97	98
i. Energy assistance?	___ MONTHS	97	98
j. Housing choice voucher, also known as Section 8?	___ MONTHS	97	98
k. Veterans benefits	__ MONTHS	97	98
l. Other government source?	___ MONTHS	97	98

F10.

What type of health insurance do you currently have?

1 Medicaid

2 Private health insurance

3 None/uninsured

7 DON’T KNOW

8 REFUSED

H. Contact Information

Respondent Information

Before we complete this portion of the survey, I would also like to make sure I have your contact information recorded correctly. This information will help us to reach you for future surveying efforts, and to ensure that we send your link to access your gift card to the correct email address. We may also use this information to call you and ask how your survey experience was.

I have your name recorded as [FIRST MI LAST]. Is this still correct or have you changed your name?

YES, STILL CORRECT (SKIP TO H2)
NO, NAME CHANGED

What is your first name now? [IF POSSIBLE, PREFILL FROM FIRST]
What is your middle initial now? [IF POSSIBLE, PREFILL FROM MIDDLE]
What is your last name now? [IF POSSIBLE, PREFILL FROM LAST]

I have your address recorded as [STREET, APT, CITY, STATE, ZIP]. Is this still correct or have you moved?

YES, STILL CORRECT (SKIP TO H3)
NO, MOVED

What is your new street address or PO box number?
Is there a complex or building name?
Is there an apartment number?
In what city?
In what state?
What is the zip code?

I have your primary phone number recorded as [xxx-xxx-xxxx]. Is this still correct or do you have a new primary phone number?

YES, STILL CORRECT (SKIP TO H4)
NO, CHANGED

What is the new number, starting with the area code?

___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___

Is that a home, cell, shelter, work, or other number?

Home
Cell
Shelter
Work
Other

IF MISSING, SKIP TO H5. IF ≠ MISSING: I have your secondary phone number recorded as [xxx-xxx-xxxx]. Is this still correct or do you have a new secondary phone number?

YES, STILL CORRECT (SKIP TO H5)
NO, CHANGED

What is the new number, starting with the area code?

___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___

Is that a home, cell, shelter, work, or other number?

Home
Cell
Shelter
Work
Other

Do you have another phone number where we can reach you?

YES, ADDITIONAL PHONE NUMBERS AVAILABLE
NO (SKIP TO H6)

What is the new number, starting with the area code?

___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___

Is that a home, cell, shelter, work, or other number?

Home
Cell
Shelter
Work
Other

[REPEAT H5 UNTIL ALL PHONE NUMBERS ARE RECORDED]

IF MISSING, SKIP TO H7. IF ≠ MISSING: I have your email address recorded as [abc@abc.abc]. Is this still correct or do you have a new email address?

YES, STILL CORRECT (SKIP TO H7)
NO, CHANGED
NO LONGER HAVE ANY WORKING EMAIL ADDRESSES (SKIP TO INSTRUCTION ABOVE I8)

What is your new email address?

Do you have [IF H6=MISSING: an email address / IF H6≠MISSING: any other email addresses]?

YES, ADDITIONAL EMAIL ADDRESSES ARE AVAILABLE
NO (SKIP TO INSTRUCTIONS ABOVE H8)

What is the additional email address?

[REPEAT H7 UNTIL ALL EMAIL ADDRESSES ARE LISTED]

To help us be able to get back in touch with you in the future, we would like to review the names, telephone numbers and addresses of three people we talked about last time we spoke who will always know how to reach you. This information will be kept strictly private and will only be used if we are unable to contact you.

When we last spoke in [MONTH AND YEAR OF RAD] you said that [CONTACT #1] was a person who would always know where you are and how to reach you. Is [CONTACT#1] still a person who does not live with you and will always know how to contact you?

YES (VERIFY CONTACT #1 INFORMATION THEN GO TO H9)
NO

REFUSED
DON’T KNOW

IF NO: Could you please tell me the name of a person who does not live with you and will always know how to contact you?

REFUSED
DON’T KNOW

IF YES:

	CONFIRM INFO BELOW	Check if correct	ENTER/CHANGE INFO
first name	[DISPLAY FIRST NAME]	□
middle name	[DISPLAY MIDDLE NAME]	□
Last name	[DISPLAY LAST NAME]	□
Suffix	[DISPLAY SUFFIX]	□
Street Address/PO Box	[DISPLAY STREET ADDRESS]	□
Complex or Building Name	[DISPLAY COMPLEX NAME]	□
Apartment Number	[DISPLAY APT NUMBER]	□
City	[DISPLAY CITY]	□
State	[DISPLAY STATE]	□
Zip	[DISPLAY ZIP]	□
Home Phone	[DISPLAY HOME PHONE]	□
Cell Phone	[DISPLAY CELL PHONE]	□
Email (enter NA if no working email address)	[DISPLAY EMAIL]	□
Relationship	[DISPLAY RELATIONSHIP]	□	1. Friend 2. Relative 3. Other Specify 7. REFUSED 8. DON’T KNOW

When we last spoke in [MONTH AND YEAR OF RAD] you said that [CONTACT #2] was a person who would always know where you are and how to reach you. Is [CONTACT#2] still a person who does not live with you and will always know how to contact you?

YES (VERIFY CONTACT #2 INFORMATION)
NO

REFUSED
DON’T KNOW

IF YES, GO TO I11; ELSE:

IF NO: Could you please tell me the name of a second person who does not live with you and will always know how to contact you?

REFUSED
DON’T KNOW

IF YES:

What is his/her first name?
What is his/her middle name?
What is his/her last name?
Does his/her name have a suffix?
What is the street address or PO box number?
Is there a complex or building name?
Is there an apartment number?
In what city?
In what state?
What is the zip code?
What is [his/her] home phone number, starting with the area code?

___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___

What is [his/her] cell phone number, starting with the area code?

___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___

What is [his/her] email address?
What is [his/her] relationship to you?

Friend
Relative
Other (Specify:)

REFUSED
DON’T KNOW

When we last spoke in [MONTH AND YEAR OF RAD] you said that [CONTACT #3] was a person who would always know where you are and how to reach you. Is [CONTACT#3] still a person who does not live with you and will always know how to contact you?

YES (VERIFY CONTACT #3 INFORMATION)
NO

REFUSED
DON’T KNOW

IF YES, GO TO CLOSING; ELSE:

IF NO: Could you please tell me the name of a second person who does not live with you and will always know how to contact you?

REFUSED
DON’T KNOW

IF YES:

What is his/her first name?
What is his/her middle name?
What is his/her last name?
Does his/her name have a suffix?
What is the street address or PO Box number?
Is there a complex or building name?
Is there an apartment number?
In what city?
In what state?
What is the zip code?
What is [his/her] home phone number, starting with the area code?

___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___

What is [his/her] cell phone number, starting with the area code?

___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___

What is [his/her] email address?
What is [his/her] relationship to you?

Friend
Relative
Other (Specify:)

REFUSED
DON’T KNOW

Thank you very much for your time today.

We want to make sure we know where to send your gift card. How would you like us to send your gift card?

Email: Please provide your email.
Text it to your cell phone: Please provide your cell phone number.
Mail it to you: Please provide your address we can mail it to.

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Patrick Cremin
File Modified	0000-00-00
File Created	2023-09-03