Participant Baseline Survey and Consent Form

Appendix A.

Participant Baseline Survey and Consent Form (English)

OMB Control Number:

Expiration Date:

Strengthening Community Colleges Training Grants Program Round 4 (SCC4) Evaluation

Participant Consent and Baseline Intake Forms

Public reporting for this survey is estimated to average 0.25 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintain the data needed, and completing and submitting the survey. This collection of information is voluntary. You are not required to respond to this collection of information unless it displays a valid OMB control number. Please send comments regarding the burden estimate or any other aspect of this collection of information to the U.S. Department of Labor, Office of the Chief Information Officer, Attention: Departmental Clearance Officer, 200 Constitution Avenue, N.W., Room N-1301, Washington, DC 20210 or email DOL_PRA_PUBLIC@dol.gov and reference OMB Control Number [1290-0xxx]. Please do not send your completed survey to this address.

I. CONSENT

ALL

[SCC4 COMMUNITY COLLEGE]

I1. [SCC4 COMMUNITY COLLEGE] IS PART OF A NATIONAL STUDY 

[SCC4 COMMUNITY COLLEGE] is taking part in a national study sponsored by the U.S. Department of Labor, called the Strengthening Community Colleges Training Grants Program Evaluation. This study will help the agency learn more about how providing intensive supports as part of career pathways programs affect student employment, earnings, and education outcomes. An organization called Mathematica will lead this study. They will partner with the Community College Research Center and Social Policy Research Associates. Please read the information below and confirm whether you are willing to participate in the study.

If you consent to participate in the study, you will be assigned to one of two groups. The first group can get the normal supports offered by [SCC4 COMMUNITY COLLEGE]. The second group can get the normal supports plus student success coaching and enhanced supports. The study will compare outcomes for people in the two groups). All participants who participate in the study will be able to receive services at [SCC4 COMMUNITY COLLEGE]. As part of the study, you will also be asked to participate in the data collection activities described below.

Which group will I be in?

A computer will decide the group you will be in. The computer works like a lottery or flip of a coin—assignment to a group is random. This process makes sure that assignments to the groups are fair. Everyone who agrees to participate in the study has the same chance of being in either group. What you say to us or your answers to the application questions will not change your chance of receiving student success coaching and enhanced supports through [SCC4 COMMUNITY COLLEGE]. You will learn your group assignment at the end of the application process.

What happens if I am not selected to receive the student success coaching and enhanced supports?

If you are not assigned to get student success coaching and enhanced supports, you will still receive normal services available to students at [SCC4 COMMUNITY COLLEGE]. You will still be in the study.

What happens if I do not wish to participate today?

If you do not wish to participate in the study today, you may still participate in your program at [SCC4 COMMUNITY COLLEGE]. You will still receive normal services available to students at [SCC4 COMMUNITY COLLEGE], but will not receive student success coaching and enhanced supports. You will not be in the study.

What information about me will the study collect?

If you agree to be in the study, we will collect some information about you.

1. Before you are assigned to a group, you will complete a short form with some questions about you. It should take about 15 minutes to complete the form.

2. [SCC4 COMMUNITY COLLEGE] will share information with us about the services you receive.

3. The researchers will gather information about your employment and earnings from a federal agency using your name and Social Security number.

4. The researchers will ask you to complete a survey in fall 2027. It should take about 15 minutes. This survey will cover education and training services you received from [SCC4COMMUNITY COLLEGE], or other community groups. It will also ask about your employment experience and your earnings. Responding to this survey is voluntary. [SCC4 COMMUNITY COLLEGE] staff will not know if you responded, and it will not affect your services. You will receive a $30 gift card if you choose to respond.

5. If you are assigned to the group that can get student success coaching and enhanced supports, we may ask you to do an in-person interview. The interview will ask about your experiences with your program and employment. It will take about 45 minutes. You will receive a $45 gift card after completing this interview. You do not have to participate in the interview.

Will the study protect my privacy?

The researchers conducting this study follow the confidentiality and data protection requirements, as required by law. Your responses will be kept private and used only for research purposes. We will store all data securely and the researchers will not share your data with [SCC4 COMMUNITY COLLEGE]. Nobody will ever publish your name in connection with the information you provide. Instead, the study will combine information about you with information about other people in the study. While your information will not be disclosed outside of the Department, there may be circumstances where information may be shared with a third party, such as a Freedom of Information Act request, court orders or subpoena, or if a breach or security incident affects the data management system.

If you agree to be in the study, we will use your name and Social Security number to match your program and survey data with data that federal agencies have on your earnings, employment, and apprenticeship participation. Researchers will make every effort to keep your data secure according to a Data Security Plan. Health Media Labs, our institutional review board, will review and approve that plan. The review board is a group of people who independently review research studies to protect study participants.

What are the benefits and risks of participating in the study?

You may or may not benefit from participating in this study, but by taking part in it you could help improve services offered in the future to other people like you.

There is a small risk that others could see your data. This is known as a data breach. These data include your name, Social Security number, employment status, or earnings. If this happens, we will alert you and the federal government and take steps to fix the breach.

You might feel uncomfortable answering some questions. You can always skip those questions if you want. Skipping questions will not change your participation in your program or the study.

Will I receive anything for my participation?

You will receive a $10 gift card today. You can also receive a gift card for responding to text message updates and completing the follow-up survey in fall 2027.

Can I change my mind later?

If you agree to be in the study now, you can withdraw from it later. But if you withdraw from the study and the random process assigns you to the group offered student success coaching and enhanced supports, you will no longer get those services. You may still participate in your program at [SCC4 COMMUNITY COLLEGE] if you withdraw. By agreeing now to be in the study, even if you later tell us you want to withdraw, you authorize the researchers to use the information collected about you before you withdrew. To withdraw from the study, you must call the study’s help line (1-877-XXXX) and provide a written letter or email confirming that you no longer want to be in the study.

If you have any questions, you can email the study team at sccnationaleval@mathematica-mpr.com or call at 1-877-XXX-XXXX.

Who can answer my questions about this research?

If you have questions, concerns, or complaints, or think this research has hurt you, email the research team at sccnationaleval@mathematica-mpr.com. You can also email the project director, Jeanne Bellotti, at jbellotti@mathematica-mpr.com.

If you have questions about your rights as a study participant, you can contact Health Media Labs, the study’s institutional review board at (202) 246-8504.

Subject’s statement of consent

I consent to take part in this research study. The study team has explained the information in this consent form to me. I have read this consent form, or someone has read it to me. I have had a chance to ask questions and they have been answered to my satisfaction. I have been told that I have not given up any legal rights.

m Click here if you have read and understand the above statements and agree to participate in the study 1 A1

m Click here if you do not agree to participate in the study 2 Exit Survey

A. INTRODUCTORY QUESTIONS

PROGRAMMER NOTE: SURVEY IS ONLY FOR PARTICIPANTS WHO CONSENT INTO STUDY (B1 = 1)

ALL

A1. Thank you for agreeing to participate in the study, Strengthening Community Colleges Training Grants Program Evaluation. The first set of questions will collect some personal information about you.

All

A2*. 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]

HARD CHECK: IF FIRST NAME OR LAST NAME = NO RESPONSE; Please provide your full name so we can contact you about additional surveys and study activities and verify your information during the follow-up survey. Thank you.

all

A3. 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) (1950-2007)

HARD CHECK: IF MONTH, DAY, OR YEAR = NO RESPONSE; Please provide your date of birth. This information will be used to verify your identity when we contact you about your follow-up survey. Thank you.

all

A4. Please enter your [SCC4 COMMUNITY COLLEGE] Student ID number.

This helps confirm who completed the survey.

STUDENT ID

(STRING 15)

all

PreFILL WITH PROGRAMS from [scc4 community college]

A5. Which of the following programs are you enrolling in a [SCC4 COMMUNITY COLLEGE].

• [FILL PROGRAM 1] 1

m [FILL PROGRAM 2] 2

m [FILL PROGRAM …] x

m [FILL PROGRAM n] n

m Something else [SPECIFY] r

(STRING 100)

all

[CUrrent year]

A6. Do you plan to enroll in courses full-time or part-time?

m Full-time 1

m Part-time 2

m I don’t know d

all

A7. Please fill in your e-mail address below.

We will use this email to reach you for future study communication, including receiving your $10 electronic gift card for completing this survey.

E MAIL ADDRESS (STRING 75)

NO RESPONSE M

SOFT CHECK: IF EMAIL = NO RESPONSE; Please provide your email address so we can contact you about additional surveys and study activities. Thank you.

ALL

A8*. What is your race and/or ethnicity?

Select all that apply

o American Indian or Alaska Native 1

o Asian 2

o Black or African American 3

o Hispanic or Latino 4

o Middle Eastern or North African 5

o Native Hawaiian or other Pacific Islander 6

o White 7

m I do not wish to answer r

ALL

A9. Are you:

• Male 1

m Female 2

m I do not wish to answer r

ALL

A10. Do you speak a language other than English at home? (American Community Survey, Q14a)

m Yes 1

m No 0

A7 = 1

A10a. What is this language? (American Community Survey, Q14b)

m Spanish 1

m Other language (SPECIFY) 2

(STRING 100)

ALL

A11. What is your current marital status—are you now married, separated, divorced, widowed, or have you never been married? (NextGen, B6)

m Married 1

m Separated 2

m Divorced 3

m Widowed 4

m Never married 5

ALL

A12. How many children under the age of 18 currently live in your household?

Include both biological, foster, adopted, and other children for whom you are responsible.

If none, enter “0”.

NUMBER OF CHILDREN UNDER AGE 18

(0-30)

ALL

A13. Which of the following best describes your current living arrangement?

Please consider the housing you spent the most time at in the last month.

Select one only

 I live alone 1

 I live with parents or guardians 2

 I live with a spouse or partner. 3

 I live with other relatives 4

 I live with roommates or unrelated others 5

 I live in a group home with others 6

 Some other arrangement (SPECIFY) 99

STRING (250)

ALL

A14. Do you self-identify as a person with a disability?

m Yes 1

m No 2

m Prefer not to say 3

ALL

A15. Were you enrolled in or attending any school since [CURRENT DATE – 1 YEAR], prior to enrolling in [SCC4 PROGRAM]at [SCC4 COMMUNITY COLLEGE]?

m Yes 1

m No 0

If A15 = 1

A16. Where were you enrolled in school?

m [SCC4 COMMUNITY COLLEGE] 1

m A different college or university 2

m A high school 3

m Somewhere else (SPECIFY) 99

(STRING 150)

ALL

A17. What is the highest degree or level of school that you have completed? (NTEWS Survey)

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

m High school diploma 2

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

m Some college credit, no degree 4

m Vocational certificate, certification, or diploma (for example, cosmetology, automotive repair) (SPECIFY) 5

(STRING 150)

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

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

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

B. SELF-REPORTED INTEREST IN RECEIVING SUPPORT SERVICES

ALL

B1. The next set of questions will ask about your interest in getting support services from [SCC4 COMMUNITY COLLEGE].

ALL

B2. How did you hear about the [SCC4 PROGRAM] program at [SCC4 COMMUNITY COLLEGE]?

Select all that apply

o Someone at [SCC4 COMMUNITY COLLEGE] 1

o Someone at another college (for example, an advisor or instructor) 2

o Someone at high school (for example a counselor or teacher) 3

o Family member, friend, or colleague 4

o My employer 5

o A workforce board, labor union, or other workforce group 6

o Another organization in my community 7

o Print, radio, or TV 8

o Online (for example, websites and blogs, social media, email, or web advertising) 9

o Information session or event (either online or in-person) 10

o Somewhere else (SPECIFY) 99

(STRING 250)

ALL

B3. Why are you pursuing training from [SCC4 COMMUNITY COLLEGE]?

Select all that apply

o I want to have the right skills for my first job 1

o I want to advance in my current job 2

o I want to get a better job in my current field 3

o I am looking to enter a new field 4

o I am currently unemployed and looking to find employment 5

o Other (SPECIFY) 99

STRING (250)

ALL

B4. Are you interested in getting help from [SCC4 COMMUNITY COLLEGE] with any of the following?

This help could be provided directly by SCC4 program staff.

	Yes	No	I’m not sure
a. Career navigation and coaching on topics such as career exploration and career readiness skills	1 🔾	2 🔾	3 🔾
b. Finding a job	1 🔾	2 🔾	3 🔾
c. Interview preparation skills	1 🔾	2 🔾	3 🔾
d. Financial literacy training or support (for example, training on money management)	1 🔾	2 🔾	3 🔾
e. Tutoring	1 🔾	2 🔾	3 🔾
f. Academic advising and counseling	1 🔾	2 🔾	3 🔾
g. Financial assistance with transportation	1 🔾	2 🔾	3 🔾
h. Financial assistance to help pay bills	1 🔾	2 🔾	3 🔾
i. Financial assistance for employment related costs (for example, uniforms or exam fees)	1 🔾	2 🔾	3 🔾
j. Strategies to balance school and other life responsibilities	1 🔾	2 🔾	3 🔾
k. Mental health services	1 🔾	2 🔾	3 🔾
l. Other service or services [SPECIFY]	1 🔾	2 🔾	3 🔾
STRING (150)

FILL ROW BELOW IF YES SELECTED IN B4

B5. How important is it for you to get this help?

	Very important	Important	Slightly important	Not at all important
a. Career navigation and coaching on topics such as career exploration and career readiness skills	1 🔾	2 🔾	3 🔾	4 🔾
b. Finding a job	1 🔾	2 🔾	3 🔾	4 🔾
c. Interview preparation skills	1 🔾	2 🔾	3 🔾	4 🔾
d. Financial literacy training or support	1 🔾	2 🔾	3 🔾	4 🔾
e. Tutoring	1 🔾	2 🔾	3 🔾	4 🔾
f. Academic advising and counseling	1 🔾	2 🔾	3 🔾	4 🔾
g. Transportation	1 🔾	2 🔾	3 🔾	4 🔾
h. Financial assistance to help pay bills	1 🔾	2 🔾	3 🔾	4 🔾
i. Financial assistance for employment related costs (for example, uniforms or exam fees)	1 🔾	2 🔾	3 🔾	4 🔾
j. Strategies to balance school and other life responsibilities	1 🔾	2 🔾	3 🔾	4 🔾
k. Mental health services	1 🔾	2 🔾	3 🔾	4 🔾
l. Other service or services [SPECIFY]	1 🔾	2 🔾	3 🔾	4 🔾
(STRING 150)

C. EMPLOYMENT AND BENEFITS

all

[CUrrent year]

C1. The next set of questions will ask about your jobs and income over the past two years.

Have you worked for pay at any time over the past 2 years? That is, from [CURRENT YEAR – 2 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.

m Yes 1

m No 0 Go to C14

C1 = 1

[CUrrent year]

C2. How many jobs have you had during the past 2 years, that is, between [CURRENT YEAR – 2 YEARS] to [CURRENT YEAR]?

Your best guess is fine.

(1-100) NUMBER OF JOBS

C1 = 1

C3. 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.

m Yes 1

m No 0

C3 = 0

C4. In what month and year did you last work for pay?

Your best guess is fine.

MONTH YEAR

(1-12) (1950-Current year)

C3 = 1

C5. Do you currently have more than one job for pay?

m Yes 1

m No 0

C1 = 1

C6. [IF C3 = 1 and C5 = 0]: The next set of questions are about your current job.

[IF C3 = 1 and C5 = 1]: The next set of questions are about your current job.

If you currently work at more than one job, please answer these questions about the job where you work the most hours.

[IF C3 = 0]: The next set of questions are about your most recent job.

If you worked at more than one job, please answer these questions about the job where you worked the most hours.

C1 = 1

C7. [IF C3 = 1]: Where are you currently working?

Please list the name of the company or employer, or if you are self-employed.

[IF C3 = 0]: Where did you most recently work?

Please list the name of the company or employer, or if you were self-employed.

m Self-employed 1

(STRING 150)

C1 = 1

C8. [IF C3 = 1]: In what industry is your current job?

[IF C3 = 0]: In what industry was your most recent job?

m Advanced manufacturing 1

m Aerospace 2

m Agriculture 3

m Automotive 4

m Aviation 5

m Clean or renewable energy 6

m Construction 7

m Education 8

m Entertainment 9

m Financial Services 10

m Forestry 11

m Health Care 12

m Hospitality 13

m Information Technology 14

m Legal 15

m Retail 16

m Security/Law enforcement 17

m Telecommunications or broadband infrastructure 18

m Transportation 19

m Non-Sector Specific 20

m Something else 99

(STRING 150)

C1 = 1

C9. [IF C3 = 1]: What is the name of your title at your current job?

If you currently work at more than one job, please answer these questions about the job where you work the most hours.

[IF C3 = 0]: What was the name of your title at your most recent job?

If you worked at more than one job, please answer this question about the job where you worked the most hours.

(STRING 250)

C1 = 1

C10. [If C3 = 1]: What do you do at your current job?

Please enter a description of the work that you do. (Modified, PROMISE 60-Month Y2_C_A9, P18M IX.A7/YTD36M-II.B3)

[IF C3 = 0]: What did you do at your most recent job? Please enter a description of the work that you did.

(STRING 150)

C1 = 1

C11. [IF C3 = 1]: How much do you get paid before taxes and deductions, at your current job(s)? If you work more than one job, please report your total income across jobs.

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

[IF C3 = 0]: How much did you get paid before taxes and deductions, at your most recent job?

If your pay varied, please provide an average amount. If you were paid per job or for completing a particular task, please enter the total amount you usually made per week or per month while doing this type of work.

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

(0-999,999.99) AMOUNT

m Per hour 1

m Per week 2

m Every month 3

m Once every two weeks 4

m Twice a month 5

m Once per year 6

m By day/daily 7

m Other way (SPECIFY) 99

(STRING 100)

m I don’t know d

C1 = 1

C12. [IF C3 = 1 and C5 = 1]: Across all of your current jobs, how many hours do you think you usually work per week?

If the hours you usually work vary from week to week, please choose the average number of hours you work per week.

[IF C3 = 1 and C5 = 0]: How many hours do you think you usually work per week?

If the hours you usually work vary from week to week, please choose the average number of hours you work per week.

[IF C3 = 0]: Across all your jobs in the last two years, how many hours do you think you usually worked per week?

If the hours you usually worked varied from week to week, please choose the average number of hours you worked per week.

m Less than 10 hours per week 1

m 10-19 hours per week 2

m 20-29 hours per week 3

m 30-34 hours per week 4

m More than 34 hours per week 5

m I don’t know d

C1 = 1

C13. C3 = 1 Which of the following benefits are available to you at your current job?

C3 = 0 Which of the following benefits were available to you at your most recent job?

Select all that apply

o Health insurance or membership in a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) plan 1

o Paid time off/vacation days 2

o Paid holidays 3

o Paid sick days 4

o Retirement or pension plans (for example, 401(k), 403(b), etc.) 5

o Something else (SPECIFY) 99

m No benefits [are/were] available 0

all

[CUrrent year]

C14. Do you plan to work while you attend [SCC4 PROGRAM]?

m Yes, 35 or more hours per week 1

m Yes, between 20-34 hours per week 2

m Yes, less than 20 hours per week 3

m No 4

m I don’t know d

ALL

C15. During the past year, did you (or anyone in your household) receive income or assistance from any of the following sources? [NextGen]

Select all that apply

o Disability benefits from the Social Security Administration. These are also called Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) 1

o Temporary Assistance for Needy Families (TANF) or [STATE SPECIFIC TANF NAME] 2

o Unemployment Insurance 3

o Worker’s Compensation 4

o Short-term disability 5

o Food Stamps/Supplemental Nutrition Assistance Program (SNAP) /[STATE-SPECIFIC PROGRAM] 6

o Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) 7

o Housing Choice Voucher, also known as Section 8 or Public Housing 8

o Veterans Benefits 9

o Medicaid or [STATE SPECIFIC MEDICAID] or Children’s Health Insurance Program (CHIP) 10

m I don’t know d

m NONE OF THE ABOVE 0

D. CONTACT INFORMATION

ALL

D1. The next set of questions will ask about your contact information. The information you provide will only be used to contact you to complete the surveys. We will not share your contact information with anyone outside of the study team.

ALL

D2. Please fill in your phone number below.

PHONE NUMBER

NO RESPONSE M [SKIP]

SOFT CHECK: IF PHONE NUMBER = NO RESPONSE; Please provide your phone number so we can contact you about additional surveys and study activities. Thank you.

ALL

D3. May we text you about upcoming surveys and other study activities? Message and data rates may apply.

m Yes 1

m No 0

SOFT CHECK: IF NO RESPONSE TO “May we text you…”. This question is important, please provide a response so we know how to best contact you.

ALL

D5. Please provide your mailing address.

(STRING 60)

Street Address Line 1

(STRING 60)

Street Address Line 2

(STRING 60)

City

(STRING 20)

State

(STRING 5)

ZIP

ALL

D6. Lastly, we ask that you please provide some additional contact information in case we are unable to locate you to complete additional surveys in the future. Please provide contact information for one person who will be able to help us get in touch with you to complete the surveys. We will only contact this person if we are not able to reach you to complete a survey. If we contact them, we will not reveal any information about you or the study, other than to say we need to locate you to complete a survey. Their information will be protected with the same privacy assurances as your information. Thank you.

Alternate Contact Name

First Name: (STRING 50)

Last Name: (STRING 50)

CELL NUMBER

NO RESPONSE M [SKIP]

ALL

D7. That is the end of the questions that you need to complete. Thank you for the time you have spent answering them!

Exit Page

FOR THOSE WHO COMPLETED THE SURVEY/CLICKED “SUBMIT”

If you have questions about the survey or your participation in this study, please reach out to your SCC4 program staff or the SCC4 National Evaluation study team at SCC4NationalEval@mathematica-mpr.com.

Your $10 gift card will be sent to you via e-mail within a week to the address you provided in the survey.

IF I1 = 0 (PARTICIPANT DOES NOT AGREE TO PARTICIPATE)

Thank you for your time.