MM slash DD slash YYYY
This number can be found in the survey request letter or provided to you from your case worker.
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6. I here by give consent to participate in the survey.
If you have declined to participate, please proceed to the end of the survey and click on the "SUBMIT" button.
7. Are You Currently Employed Full time?(Required)
As of today, do you work 35 hours or more per week at one or more jobs?
8. Are You Currently Employed Part-time?(Required)
As of today, do you work at least 1 hour but no more than 34 hours per week at one or more jobs?
9. In the past year, did you complete an apprenticeship, internship, or other on-the-job training, either paid or unpaid?(Required)
In the past year, did you complete an apprenticeship, internship, or other on-the-job training for which you were paid or unpaid, that helped you acquire employment related skills? Some examples: specific trade skills such as carpentry or auto mechanics, or office skills such as word processing or use of office equipment.
10. Currently are you receiving social security payments (Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), or dependents’ payments)?(Required)
As of today, are you receiving payments from SSI or SSDI, either directly, or as a beneficiary?
11. Currently are you using a scholarship, grant, stipend, student loan, voucher, or other type of educational financial aid to cover any educational expenses?(Required)
As of today, are you receiving any of the following payments to aid your education: a scholarship, ETV voucher, grant, stipend, student loan, tuition or fee waiver, or other type of educational financial aid?
12. Currently are you receiving ongoing welfare payments (TANF) from the government to support your basic needs?(Required)
As of today, are you receiving TANF (Temporary Assistance for Needy Families)?
13. Currently are you receiving public food assistance?(Required)
As of today, are you receiving food assistance from the government such as SNAP/food stamps, EBT, or WIC? This does not include assistance such as a food pantry.
14. Currently are you receiving any sort of housing assistance from the government, such as living in public housing or receiving a housing voucher?(Required)
As of today, are you living in public housing or receiving an FUP or Section 8 voucher?
15. Currently are you receiving any periodic and/or significant financial resources or support from another source not previously indicated and excluding paid employment?(Required)
As of today, are you receiving any other support not listed above, including payments from a spouse or family member (biological, foster or adoptive), child support that you receive for yourself, or funds from a legal settlement. NOTE: This does NOT include occasional gifts, such as birthday or graduation checks or small donations of food or personal incidentals, child care subsidies, child support for your own child or other financial help that does not benefit you directly in supporting yourself.
16. What is the highest educational degree or certification that you have received?(Required)
Vocational certificate: a document stating that you have received education or training that qualifies you for a particular job, e.g., auto mechanics or cosmetology. Vocational license: a document that indicates that the State or local government recognizes you as a qualified professional in a particular trade or business. An Associate’s degree is generally a two-year degree from a community college, and a Bachelor’s degree is a four-year degree from a college or university. Higher degree: indicates a graduate degree, such as a Masters or Doctorate degree. None of the above: means that the you have not received any of the above educational certifications.
17. Currently are you enrolled in and attending high school, GED classes, post-high school vocational training, or college?(Required)
As of today, are you enrolled and attending classes, even if school is out of session (e.g., spring break, summer vacation, etc.)? This includes: high school, GED classes, or post secondary vocational training or college.
18 Currently is there at least one adult in your life, other than your caseworker, to whom you can go for advice or emotional support?(Required)
As of today, do you have an adult connection? This is someone that you can easily access either by telephone or in person for advice or guidance when you have a decision to make or a problem to solve, or for companionship to share personal achievements. This can include, but is not limited to, adult relatives, parents or foster parents. Do NOT include: spouses, partners, boyfriends or girlfriends and current caseworkers.
19. In the past two years, were you homeless at any time?(Required)
“Homelessness” is considered as not having a regular or adequate place to live and includes: living in a car, living on the street, living in a homeless shelter, or another temporary living situation like “couch surfing.”
20 In the past two years, did you refer yourself, or has someone else referred you for an alcohol or drug abuse assessment or counseling?(Required)
Alcohol or drug abuse assessment is a process designed to determine if someone has a problem with alcohol or drug use.
21. In the past two years, were you confined in a jail, prison, correctional facility, or juvenile or community detention facility, in connection with allegedly committing a crime?(Required)
In the past two years were you confined in a jail, prison, correctional facility, or juvenile or community detention facility because you committed, or were accused of committing a crime?
22. In the past two years, did you give birth or father any children that were born?(Required)
If you are a male completing this survey, and you do not know if you have fathered a child that was born, answer “No.”
23. If you responded yes to the previous question, were you married to the child’s other parent at the time each child was born?(Required)
An answer of “Yes” on this question indicates that at the time that each of your children was born, you were married to the other parent of the child.
24. Currently are you on MassHealth?(Required)
As of today, are you receiving MassHealth coverage (or your State’s medical assistance coverage if you currently are living outside of Massachusetts)?
25. Currently do you have health insurance, other than MassHealth?
‘‘Health insurance’’ other than MassHealth or Medicaid means having a third party pay for all or part of health care. You might have health insurance such as group coverage offered by your employer or your school, or an individual policy that covers medical and/or mental health care and/or prescription drugs, or you might be covered under your parents’ insurance. This also could include access to free health care through a college, Indian Tribe, or other source?
26. Does your health insurance include coverage for medical services?
‘‘Health insurance’’ other than MassHealth or Medicaid means having a third party pay for all or part of health care. You might have health insurance such as group coverage offered by your employer or your school, or an individual policy that covers medical and/or mental health care and/or prescription drugs, or you might be covered under your parents’ insurance. This also could include access to free health care through a college, Indian Tribe, or other source?
27. Does your health insurance include coverage for mental health services?
If you answered “Yes” to having health insurance with medical coverage (item 26), is all or part of the cost for mental health care services, such as counseling or therapy included in your health insurance coverage? Answer “Yes” if you have MassHealth through DCF.
28. Does your health insurance include coverage for prescription drugs?
If you answered “Yes” to having health insurance with medical coverage (item 26), is all or part of the cost for mental health care services, such as counseling or therapy included in your health insurance coverage? Answer “Yes” if you have MassHealth through DCF.