Learner Consent and Baseline Intake Form

APPENDIX C. LEARNER CONSENT AND BASELINE INTAKE FORM

This page has been left blank for double-sided copying.

OMB Number:

Expiration Date:

Connecting Adults to Success: Evaluation of Career Navigator Training (CATS Study)

Learner Consent and Baseline Intake Forms

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is [xxxx-xxxx]. The time required to complete this information collection is estimated to average 10 minutes, including the time to review and complete the consent and baseline intake survey. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC 20202. If you have comments or concerns regarding the content or the status of your individual submission of this form, write directly to: U.S. Department of Education, Institute of Education Sciences, 550 12th Street, SW, Washington, DC 20202.

A. CONSENT – LEARNER SURVEY

ALL

[ADULT EDUCATION PROVIDER SITE]

A1. [ADULT EDUCATION PROVIDER SITE] and its career navigators are taking part in a national study that the U.S. Department of Education is sponsoring. This study will help the agency learn more about the effects of providing training for career navigators who work with adult learners. Mathematica is leading this study and partnering with Manhattan Strategy Group and Social Policy Research. Please read the information below and confirm whether you are willing to participate in the study.

Navigators are people who provide services to help students transition to jobs, college, and other training. Other names for career navigators are college navigators, coaches, transition coordinators, counselors, or case managers. The study will compare two groups of career navigators. One group will receive training as part of the study now. The other group will receive the training two years from now. The study team will randomly choose the group of navigators that receives the training now using a process like a coin flip. All career navigators at [ADULT EDUCATION PROVIDER SITE] are in the same group. You will not know whether they have received the training.

By giving permission to be in the study, you agree to the following:

• You will take a short survey. The survey asks about your current employment, your use of career navigation services, and your career plans and goals for the future. This survey will take about 10 minutes to complete.

• [ADULT EDUCATION PROVIDER SITE] may share information with the study team about you and the services you receive from the program.

• The study team will share some information that identifies you (your name, date of birth, social security number) with federal, state, and testing agencies to get data about your employment, earnings, and education for the length of the study. This information could include:

  • Information about your job(s) from the National Directory of New Hires

  • Information about your education from the National Student Clearinghouse (NSC), Federal Student Aid Database (FSA), and high school equivalency test providers (e.g., GED TASC and HiSET)

Here are some other things to know about the study:

• The study will use your data for research purposes only.

• The study team will give the Department of Education a data file that includes your personally identifiable information. The agency or other researchers might use this file to collect longer-term information on employment, earnings and education for learners who are part of this study.

• Study reports will summarize all learners’ findings and will not identify you. None of the reports prepared for this study will include information that identifies you.

• Taking the survey is completely voluntary. You can skip any question that you don’t want to answer. If you are unsure of how to answer a question, please give the best answer you can, rather than leaving it blank. The study will use your responses for research purposes only.

• Participating in the study has no known risks. There are also no direct benefits. However, your participation will help us learn about how career navigators help adult learners succeed in achieving their education and employment goals.

• The researchers conducting this study follow the confidentiality and data protection requirements of the U.S. Department of Education’s IES (The Education Sciences Reform Act of 2002, Title I, Part E, Section 183).

Please indicate below whether you agree to be in the study. If you have any questions about the study, please contact Mathematica’s survey director, Lisbeth Goble, at XXX-XXX-XXXX or email her at XXX@mathematica-mpr.com.

 I understand the study description and I agree to participate in the study 1

Electronic Signature

• I do not agree to participate in the study 2

B. INTRODUCTORY QUESTIONS – LEARNER SURVEY

PROGRAMMER NOTE: SURVEY IS ONLY FOR LEARNERS WHO CONSENT INTO STUDY (A1 = 1)

ALL

B1. Thank you for agreeing to participate in the study, Connecting Adults to Success: Evaluation of Career Navigator Training. The first set of questions will collect some personal information about you.

 CONTINUE 1

IF NAME POPULATED IN ADVANCE from DATA IN rapter system

[FIRST AND LAST NAME]

B2. Our records indicate that your name is [FIRST AND LAST NAME]. Is that correct?

Please note that your name will be kept in confidence and will not be linked to answers in any reports we create.

• Yes, my name is correct as shown 1

• No, I need to make updates to my name 2

B2 = 2 OR NAME NOT POPULATED IN ADVANCE from DATA In rapter system

B3. Please record your name below.

Your name will be kept in confidence and will not be linked to answers in any reports we create.

(STRING 30)

[FIRST NAME]

(STRING 1)

[MIDDLE INITIAL]

(STRING 30)

[LAST NAME]

ALL

B4. Is there an alternate name that you go by? This could be a name that you publicly use on other forms.

For example, if your first name is Robert but everyone refers to you as Bob or Rob.

 No 1

 Yes 2

Specify (STRING 100)

all

*This item will only be asked if the data provided cannot be obtained from adult education provider records.

B5*. Please enter your date of birth.

This helps confirm who completed the survey. Your date of birth will be kept in confidence and will not be linked to your answers in any reports.

programmer:

MONTH DAY YEAR

(1-12) (1-31) (1950-2003)

all

B6. Please enter your Social Security Number (SSN).

This will help the research team collect administrative data on your employment, earnings, and educational attainment. Your SSN will be kept in confidence and will not be linked to your answers in any reports.

programmer: COLLECT EACH PIECE OF SSN WITH SEPARATE FIELDS

 I don’t know my Social Security Number 1

 I do not have a Social Security Number 2

ALL

*This item will only be asked if the data provided cannot be obtained from adult education provider records.

B7*. Are you of Hispanic or Latino origin?

 Yes 1

 No 2

 I don’t know d

 I do not wish to answer r

ALL

*This item will only be asked if the data provided cannot be obtained from adult education provider records.

B8*. What is your race?

Select all that apply

 American Indian or Alaska Native 1

 Asian 2

 Black or African American 3

 Native Hawaiian or other Pacific Islander 4

 White 5

 I don’t know d

 I do not wish to answer r

ALL

B9. What is your gender? (HRC)

Select all that apply

 Male 1

 Female 2

 Non-binary/third gender 3

 I use another term 4

 I do not wish to answer r

ALL

B9a. Do you identify as transgender? (HRC)

 Yes 1

 No 2

 I do not wish to answer r

ALL

B10. Do you speak a language other than English at home? (American Community Survey, Q14a)

 Yes 1

 No 2

B10 = 1

B10a. What is this language? (American Community Survey, Q14b)

Specify (STRING 100)

B10 = 1

B10b. How well do you speak English? (American Community Survey, Q14c)

 Very well 1

 Well 2

 Not well 3

 Not at all 4

ALL

B11. What is your current marital status—are you now married, separated, divorced, widowed, or have you never been married? (NextGen, B6)

 Married 1

 Separated 2

 Divorced 3

 Widowed 4

 Never married 5

ALL

B12. Including you, how many people live in your household in total? (Modified, PROMISE 60-Month Y2_A_Q6, YTD36M-X.C2)

people in household

(1-25)

 I don’t know d

 I do not wish to answer r

ALL

B13. How many children under the age of 18 are in your household? (NextGen, B7a)

number of children under age 18

(1-15)

 There are no children under the age of 18 in my household 1

IF B13 ENTRY IS 1 OR MORE

B14. How many of these are your biological children? (Modified, PROMISE 60-Month Y2_D_A3)

NUMBER OF BIOLOGICAL CHILDREN

(0-15)

 I don’t know d

ALL

B15. In general, would you say that your health is . . . (P60M Y2_D_B1, P18M XII.A1, YTD36M VI.B1/SF1)

• Excellent 1

 Very good 2

 Good 3

 Fair 4

 Poor 5

ALL

*This item will only be asked if the data provided cannot be obtained from adult education provider records.

B16*. What is the highest degree or level of school that you have completed? (NTEWS Survey)

 Elementary, middle, or high school, but no high school diploma or alternative high school credential (for example, GED) 1

 High school diploma 2

 Alternative high school credential (for example, GED) 3

 Some college credit, no degree 4

 Vocational certificate or diploma (for example, cosmetology, automotive repair) 5

Specify (STRING 150)

 Associate’s degree (for example, AA, AS) 6

 Bachelor’s degree (for example, BA, BS) 7

 Master’s degree (for example, MA, MS) or higher (for example, MD, PhD) 8

C. PLANS AND SELF-REPORTED LIKELIHOOD OF USING CAREER NAVIGATION SERVICES – LEARNER SURVEY

ALL

C1. The next set of questions will ask about your career and education plans and goals.

 CONTINUE 1

ALL

C2. Why are you pursuing adult education courses at this time?

Select all that apply

 I want to improve my work-related skills related to my current job 1

 I want to improve my language skills related to my current job 2

 I am looking for a promotion or position change at my current job 3

 I want to improve my work-related skills to find a new job 4

 I want to improve my language skills to find a new job 5

 I am hoping to gain work-related skills that will be beneficial in my personal life 6

 I am hoping to gain language skills that will be beneficial in my personal life 7

 Other (Please specify) 8

 I don’t know d

ALL

C3. After completing your adult education courses, how likely are you to do the following…

	Select one per row
	DEFINITELY WILL	PROBABLY WILL	PROBABLY WON’T	DEFINITELY WON’T
a. Enroll in college courses.	1 	2 	3 	4 
b. Enroll in additional job training (for example, going to a program to prepare for a skilled trade such as automotive repair or cosmetology).	1 	2 	3 	4 
c. Look for a new job at your current employer.	1 	2 	3 	4 
d. Look for a new job at a new employer.	1 	2 	3 	4 
e. Look for a new job in a career or occupation you have not previously worked in.	1 	2 	3 	4 
f. Start a new business.	1 	2 	3 	4 
g. Look for contract work (for example, being hired for short-term work to design or develop a website).	1 	2 	3 	4 

ALL

[ADULT EDUCATION PROVIDER SITE]

C4. The next set of questions will ask about your interest in getting services from [ADULT EDUCATION PROVIDER SITE].

 CONTINUE 1

ALL

[ADULT EDUCATION PROVIDER SITE]

C5. Are you interested in getting help from [ADULT EDUCATION PROVIDER SITE] with any of the following?

This help would be provided directly by adult education program staff.

	Yes	No	I’m not sure
a. Enrolling in college	1 🔾	2 🔾	3 🔾
b. Enrolling in job or skills training classes, such as in automotive repair or cosmetology	1 🔾	2 🔾	3 🔾
c. Finding a job	1 🔾	2 🔾	3 🔾
d. Developing job skills	1 🔾	2 🔾	3 🔾
e. Career planning, exploration, and counseling	1 🔾	2 🔾	3 🔾
f. Educational planning	1 🔾	2 🔾	3 🔾
g. Soft skill building, such as goal setting, communication, and problem-solving	1 🔾	2 🔾	3 🔾
h. Other service [SPECIFY]	1 🔾	2 🔾	3 🔾

FILL ROW BELOW IF YES SELECTED IN C5

C6. How important is it for you to get this help?

	Very important	Important	Slightly important	Not at all important
a. Enrolling in college	1 🔾	2 🔾	3 🔾	4 🔾
b. Enrolling in job or skills training classes, such as in automotive repair or cosmetology	1 🔾	2 🔾	3 🔾	4 🔾
c. Finding a job	1 🔾	2 🔾	3 🔾	4 🔾
d. Developing job skills	1 🔾	2 🔾	3 🔾	4 🔾
e. Career planning, exploration, and counseling	1 🔾	2 🔾	3 🔾	4 🔾
f. Educational planning	1 🔾	2 🔾	3 🔾	4 🔾
g. Soft skill building, such as goal setting, communication, and problem-solving	1 🔾	2 🔾	3 🔾	4 🔾
h. Other service [SPECIFY]	1 🔾	2 🔾	3 🔾	4 🔾

FILL ROW BELOW IF YES SELECTED IN C5

C7. How soon do you want to get this help?

	Within the next month	Within the next six months	Within the next year	More than one year from now	I don’t know
a. Enrolling in college	1 🔾	2 🔾	3 🔾	4 🔾	d 🔾
b. Enrolling in job or skills training classes, such as in automotive repair or cosmetology	1 🔾	2 🔾	3 🔾	4 🔾	d 🔾
c. Finding a job	1 🔾	2 🔾	3 🔾	4 🔾	d 🔾
d. Developing job skills	1 🔾	2 🔾	3 🔾	4 🔾	d 🔾
e. Career planning, exploration, and counseling	1 🔾	2 🔾	3 🔾	4 🔾	d 🔾
f. Educational planning	1 🔾	2 🔾	3 🔾	4 🔾	d 🔾
g. Soft skill building, such as goal setting, communication, and problem-solving	1 🔾	2 🔾	3 🔾	4 🔾	d 🔾
h. Other service [SPECIFY]	1 🔾	2 🔾	3 🔾	4 🔾	d 🔾

ALL

[ADULT EDUCATION PROVIDER SITE]

C8. Are you interested in getting help from [ADULT EDUCATION PROVIDER SITE] with any of the following?

	Yes	No	I’m not sure
a. Child care	1 🔾	2 🔾	3 🔾
b. Health services	1 🔾	2 🔾	3 🔾
c. Housing search/placement	1 🔾	2 🔾	3 🔾
d. Psychological counseling or other mental health services	1 🔾	2 🔾	3 🔾
e. Transportation	1 🔾	2 🔾	3 🔾
f. Translator services	1 🔾	2 🔾	3 🔾
g. Legal services, such as legal support for child support, tenant eviction, or immigration	1 🔾	2 🔾	3 🔾
h. Help getting public assistance, such as applying for Temporary Assistance for Needy Families (TANF) or the Supplemental Nutrition Assistance Program (SNAP)	1 🔾	2 🔾	3 🔾
i. Disability screening	1 🔾	2 🔾	3 🔾
j. Support groups	1 🔾	2 🔾	3 🔾
k. Mentoring	1 🔾	2 🔾	3 🔾
l. Other service [SPECIFY]	1 🔾	2 🔾	3 🔾
FILL ROW BELOW IF YES SELECTED IN C8

C9. How important is it for you to get this help?

	Very important	Important	Slightly important	Not at all important
a. Child care	1 🔾	2 🔾	3 🔾	4 🔾
b. Health services	1 🔾	2 🔾	3 🔾	4 🔾
c. Housing search/placement	1 🔾	2 🔾	3 🔾	4 🔾
d. Psychological counseling or other mental health services	1 🔾	2 🔾	3 🔾	4 🔾
e. Transportation	1 🔾	2 🔾	3 🔾	4 🔾
f. Translator services	1 🔾	2 🔾	3 🔾	4 🔾
g. Legal services, such as legal support with child support, tenant eviction, or immigration	1 🔾	2 🔾	3 🔾	4 🔾
h. Help getting public assistance such as applying for Temporary Assistance for Needy Families (TANF) or the Supplemental Nutrition Assistance Program (SNAP)	1 🔾	2 🔾	3 🔾	4 🔾
i. Disability screening	1 🔾	2 🔾	3 🔾	4 🔾
j. Support groups	1 🔾	2 🔾	3 🔾	4 🔾
k. Mentoring	1 🔾	2 🔾	3 🔾	4 🔾
l. Other service [SPECIFY]	1 🔾	2 🔾	3 🔾	4 🔾

D. EMPLOYMENT AND BENEFITS – LEARNER SURVEY

ALL

D1. The next set of questions will ask about your employment history.

 CONTINUE 1

all

[CUrrent year]

D2. Have you worked for pay at any time over the past 5 years? That is, from [CURRENT YEAR – 5 YEARS] to [CURRENT YEAR].

Working for pay can include regular paid jobs, odd jobs, temporary jobs, work done in your own business, jobs or tasks you find using a web or mobile app, “under the table” work, “off the books” work, apprenticeships, or any other types of work you have done for pay.

 Yes 1

 No 2

 I don’t know 3

D2 = 1

[CUrrent year]

D3. How many jobs have you had during the past 5 years? As a reminder, these would be jobs from [CURRENT YEAR – 5 YEARS] to [CURRENT YEAR].

(0-100) NUMBER OF JOBS

 I don’t know d

D2 = 1

D4. Are you currently working for pay?

Working for pay can include regular paid jobs, odd jobs, temporary jobs, work done in your own business, jobs or tasks you find using a web or mobile app, “under the table” work, “off the books” work, apprenticeships, or any other types of work you have done for pay.

 Yes 1

 No 2

 I don’t know d

D4 = 2

D5. In what month and year did you last work for pay?

MONTH YEAR

(1-12) (1950-Current year)

 I don’t know d

D4 = 1

D6. Do you currently have more than one job?

 Yes 1

 No 2

D2 = 1

IF D6 = 1, FILL [currently WORK], [work]

ELSE, FILL [WORKED]

D7. The next set of questions are about your current or most recent job. If you [currently work/ worked] at more than one job, please answer these questions about the job where you [work/worked] the most hours.

 CONTINUE 1

D2 = 1

IF D4 = 1, FILL [current], [Do], [work], [Are], [own], [working], [am]

ELSE, FILL [Most recent], [did], [were], [owned], [worked], [was]

D8. In your [current/most recent] job, [do/did] you work for an employer or [are/were] you self-employed?

By self-employed we mean you [work/worked] for yourself or [own/owned] your business. If you are [working/worked] for an employer or company, it is not self-employment.

 [Work/worked] for an employer 1

 I [am/was] self-employed 2

 I don’t know d

D2 = 1

IF D4 = 1, FILL [Do], [current]

ELSE, FILL [Did], [most recent]

D9. What [do/did] you do at your [current/most recent] job? Please enter a description of the work that you [do/did] and then select the type of work that best applies to your job. (Modified, PROMISE 60-Month Y2_C_A9, P18M IX.A7/YTD36M-II.B3)

(STRING 150)

 Assembly work (sorting, stuffing) 1

 Animal care (dog walking, grooming, veterinary helper) 2

 Cashier – grocery store, fast food place, retail 3

 Childcare – babysitting, teacher’s aide 4

 Cleaning – janitor/maid 5

 Clerical – filing, receptionist 6

 Computer work – data entry, programming, web page developing 7

 Delivery person – food, newspapers, prescriptions, packages 8

 Farming and/or agriculture 9

 Food service – bus boy, waiter/waitress, host, bartender, cook 10

 Gardening and ground maintenance 11

 Health care aide – personal care attendant, nurse’s aide 12

 Military 13

 Sales – retail 14

 Skilled labor – plumber, carpenter, electrician 15

 Stock clerk – retail (grocery or drug store) 16

 Other, not listed above 17

 I don’t know d

D2 = 1

IF D4 = 1, FILL [do], [current], [varies], [are], [make]

ELSE, FILL [did], [most recent], [varied], [were], [made]

D10. How much [do/did] you get paid before taxes and deductions, at your [current/most recent] job?

If your pay [varies/varied], please provide an average amount. If you [are/were] paid per job or for completing a particular task, please enter the total amount you usually [make/made] per week or per month while doing this type of work. (Modified, PROMISE 60-Month Y2_C_A15, P18M- IX.A7/YTD36M-II.B3)

Please enter the amount first and then select over what time period you are reporting your pay.

(0-999,999.99) AMOUNT

 Per hour 1

 Per week 2

 Every month 3

 Once every two weeks 4

 Twice a month 5

 Once per year 6

 By day/daily 7

 Other way (Specify) 99

Specify (STRING 100)

 I don’t know d

D2 = 1

IF D4 = 1, FILL [do], [does]

ELSE, FILL [did]

D11. How many hours per week, including regular overtime hours, [do/did] you usually work at this job? (PROMISE 60-Month Y2_C_A11, P18M- IX.A10)

If the number of hours you work changes from week to week, please check the button below.

HOURS PER WEEK

 Check here if number of hours changes from week to week 1

 I don’t know d

D11 = 1, D or missing

IF D4 = 1, FILL [work]

ELSE, FILL [worked]

D12. Do you think you usually [work/worked] …(PROMISE 60-Month Y2_C_A12, P18M-X.A10, YTD36M-II.B6)

 Less than 10 hours per week? 0

 10-20 hours per week? 1

 21-30 hours per week? 2

 31-35 hours per week? 3

 More than 35 hours per week? 4

 Or was this a one-day or short-term opportunity? 5

 I don’t know d

D6 = 1

D13. How many total hours per week do you usually work across all of your jobs? (PROMISE 60-Month Y2_C_A11, P18M- IX.A10)

If the number of hours you work across all of your jobs changes from week to week, please check the button below.

HOURS PER WEEK

 Check here if number of hours changes from week to week 1

 I don’t know d

D13 = 1, D or missing

D14. Across all of your jobs, do you think you usually work …(PROMISE 60-Month Y2_C_A12, P18M-X.A10, YTD36M-II.B6)

 Less than 10 hours per week? 0

 10-20 hours per week? 1

 21-30 hours per week? 2

 31-35 hours per week? 3

 More than 35 hours per week? 4

 I don’t know d

ALL

D15. The next set of questions ask about benefits your household may receive.

 CONTINUE 1

ALL

D16. Do you or does anyone in your household receive assistance from any of the following sources? (Modified, PROMISE 60-Month Y2_D_D1, Y2_D_D2, Y2_D_D3, Y2_D_D4, Y2_D_D5)

	YES	NO	I DON’T KNOW	I DO NOT WISH TO ANSWER
a. Temporary Assistance for Needy Families (TANF) TANF provides families with financial assistance and related support services. These programs may include childcare assistance, job preparation, and work assistance.	1 	0 	d 	r 
b. Supplemental Nutrition Assistance Program (SNAP) SNAP provides a monthly supplement for purchasing nutritious food. Benefits are provided on an electronic card, called an EBT card that is used like an ATM card and accepted at most grocery stores. This program was formerly known as “food stamps.”	1 	0 	d 	r 
c. Government housing assistance in paying rent, such as through public housing or Section 8 This is also known as the Housing Choice Voucher Program. Section 8 provides funding to help people pay their rent.	1 	0 	d 	r 
d. Income from Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) because of a disability SSI and SSDI provides payments to aged, blind, and disabled persons (including children).	1 	0 	d 	r 

ALL

D17. That is the end of the questions that you need to complete. Thank you for the time you have spent answering them!

If you completed the survey in person using a staff person’s computer or tablet, please return it to them so that they can complete their section of the survey.

 END LEARNER SURVEY 1

E. PREDICTIONS OF LEARNERS’ SERVICES AND PROGRAM PERSISTENCE, – STAFF SURVEY

ALL

[LEARNER NAME]

E1. The next few questions ask your opinion about how likely [LEARNER NAME] is to use career navigator services based on your interactions to date and your overall experience conducting intake with adult learners. These services could include career exploration and planning assistance, connecting learners to postsecondary institutions and workforce training organizations, identifying and removing barriers to progressing on a career path, assistance accessing financial supports for education, and support developing study and work skills. Career navigators may also be referred to as college navigators, coaches, transition coordinators, counselors.

 CONTINUE 1

ALL

[LEARNER NAME]

E2. How likely is [LEARNER NAME] to use career navigation services?

 Definitely will 1

 Probably will 2

 Probably won’t 3

 Definitely won’t 4

E2 = 1 OR 2

[LEARNER NAME]

E3. How often do you think a career navigator will need to work with [LEARNER NAME]?

 More often than once a month 1

 About once every month 2

 About once every three months 3

 About once every six months 4

 Less than once every six months 5

ALL

[LEARNER NAME]

E4. To what extent could [LEARNER NAME] benefit from ongoing support with career planning?

 A great extent 1

 Somewhat 2

 Very little 3

 Not at all 4

ALL

[LEARNER NAME]

E5. To what extent could [LEARNER NAME] benefit from ongoing support with planning for further education?

 A great extent 1

 Somewhat 2

 Very little 3

 Not at all 4

ALL

[LEARNER NAME]

E6. How likely is [LEARNER NAME] to enroll in another adult education course after the current term?

 Very likely 1

 Likely 2

 Not likely 3

 Very unlikely 4

all

E7. Based on your interactions to date with [LEARNER NAME], is there any additional information that might be useful to understand why [LEARNER NAME] may or may not use career navigator services?

(STRING 500)

 I don’t have any additional information to add 1

ALL

E8. That is the end of the questions that you need to complete. Thank you for the time you have spent answering them!

 END STAFF SURVEY 1