NYTD Baseline - Nevada Cohort 5

INSTRUCTIONS

Click here to review instructions for taking the Nevada Baseline Survey

Did you review the instructions? *

Yes

GENERAL CONTACT INFORMATION

a. First name *

b. Middle initial

c. Last Name *

d. Nickname or other name or names that you are commonly known by

e. Gender *

f. Date of Birth *

Year

Month

Day

_____________________________________________________________________________________________________________ HOME ADDRESS

g. Address *

h. City *

i. State *

j. Zip Code *

_____________________________________________________________________________________________________________ MAILING ADDRESS (IF DIFFERENT. IF THE SAME, SKIP DOWN TO HOME PHONE) Do you have your mail sent somewhere other than what you listed above? Some people might list a P.O. Box, for example. If you live away at college, you might list a parent’s address as a mailing address, if you prefer to have mail sent there.

k. Address

l. City

m. State

n. Zip Code

_____________________________________________________________________________________________________________

o. Home Phone (please include area code and do not include spaces or dashes)

p. Cell Phone (please include area code and do not include spaces or dashes)

q. E-mail address

s. Caseworker Name

t. UNITY Person ID

u. If you were not living in Nevada on your 17th birthday, what state were you in

v. Please provide the first and last name of a friend or family member who you think would be able to reach you

w. Phone number of that friend or family member

x. E-mail address of that friend or family member

EMPLOYMENT

a. Currently are you employed full-time? *

b. Currently are you employed part-time?

OTHER SOURCES OF INCOME

b. Currently are you using a scholarship, grant, stipend, student loan, voucher, or other type of educational financial aid to cover any educational expenses? *

Select YES if you are currently receiving scholarships, grants, student loan or stipends to pay for your education, whether the money comes from your state, the Federal Government, or a private scholarship or loan source. Your educational expenses could include tuition, housing, books and supplies, or transportation costs that are required to obtain your education.

c. Currently are you receiving any periodic and/or significant financial resources or support from another source not previously indicated and excluding paid employment? *

Select YES if you are currently receiving financial support from someone else. This could be from your biological family, foster or adoptive family or even another supportive adult or friend. Select YES if you receive funds from a legal settlement. Also, select YES if you receive child support payments for YOURSELF). DO NOT INCLUDE occasional gifts, such as birthday or graduation checks or small donations of food or personal incidentals, child care assistance, or other financial help that does not benefit you directly in supporting yourself. Also, do not include child support if you have a child.

d. Currently are you receiving ongoing welfare payments from the government to support your basic needs? *

Select YES if you are currently receiving ongoing welfare payments from the government to support your basic needs. Does not include payments or subsidies for unemployment insurance, child care subsidies, education assistance, food stamps or housing assistance.

e. Currently are you receiving public food assistance? *

Select YES if you are currently receiving public food assistance such as food stamps, which are government-issued coupons or debit cards that can be used to buy food. Public food assistance also includes assistance from the Women, Infants and Children (WIC) program.

f. Currently are you receiving any sort of housing assistance from the government such as living in public housing or receiving a housing voucher? *

Select YES if you currently live in public housing, which is rental housing where the government covers a portion of the rent for eligible individuals and families. This does not include payments from the foster care or child welfare agency for room and board payments, such as money through your Independent Living or Transitional Living program to pay for housing.

EDUCATION

a. What is the highest educational degree or certification that you have received? *

Choose the highest degree or certification from the list. They are listed in order, from lowest degree (the ones that usually take the least amount of time to complete) to the highest degree. If you have not yet earned one of the degrees, then select “None of the Above.”

b. Currently are you enrolled in and attending high school, GED classes, post-high school vocational training, or college? *

Select YES if you are enrolled in and attending school. Select yes if you are enrolled in school but you’re not currently attending because you are on summer break. Do not select yes if you have future plans to attend school, but have not yet signed up.

HOUSING

a. Have you ever been homeless? *

LIFESTYLE QUESTIONS

a. Have you ever referred yourself or has someone else referred you for an alcohol or drug abuse assessment or counseling? *

b. Have you ever been confined in a jail, prison, correctional facility, or juvenile or community detention facility, in connection with allegedly committing a crime? *

“Allegedly” means that you were accused of a crime, even if you were never convicted. Answer YES to this question if you have ever spent ANY amount of time in a jail, prison, correctional facility, or juvenile or community detention facility because someone suspected that you committed a crime. DO NOT count times you may have visited any of these places for a school field trip or to visit someone you know.

c. Have you ever given birth or fathered any children that were born? *

d. If you responded yes to the previous question, were you married to the child's other parent at the time each child was born?

ACCESS TO HEALTH CARE

a. Currently are you on Medicaid? *

b. Currently do you have health insurance, other than medicaid? *

Select YES if you have other health insurance through a company or organization other than Medicaid. This could include health insurance provided by a parent, through your employer, or a plan that you pay for yourself. This also could include access to free health care through a college, Indian Tribe, or other source. If you responded yes to this question, please answer questions c., d., & e. below. If you don't have health insurance other than medicaid, please respond with 'not applicable' to the next 3 questions.

c. Does your health insurance include coverage for medical services?

d. Does your health insurance include coverage for mental health services?

e. Does your health insurance include coverage for prescription drugs?

By hitting 'Submit NYTD Survey', I understand that this information is for the National Youth in Transition Database and will be provided to the state of Nevada and will be used to collect information with a goal of helping to improve the system.

NYTD Baseline - Nevada Cohort 5

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