1820-NEW Youth and Parent Consent Form and Survey

Appendix C

Youth and Parent Consent Form and Survey

Youth and Parent Consent Form and Survey

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 1820-NEW. Public reporting burden for this collection of information is estimated to average 0.25 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is voluntary. If you have any comments concerning the accuracy of the time estimate, suggestions for improving this individual collection, or if you have comments or concerns regarding the status of your individual form, application or survey, please contact Diandrea Bailey, PhD, U.S. Department of Education, Office of Special Education and Rehabilitative Services, Rehabilitation Services Administration, 400 Maryland Avenue SW, Washington, DC 20202 directly.

February 5, 2025

Programming Fills

Fill	Source / Condition	First Used at Question #:
[yourself/themself]	“yourself” IF Q1=1; “themself” IF Q1=2 OR 3	Q4
[Do you/Does FNAME]	"Do you" IF Q1=1; "Does [Q3 FIRST NAME]" IF Q1=2 OR 3	Q4
[are you/is FNAME]	"are you" IF Q1=1; "is [Q3 FIRST NAME]" IF Q1=2 OR 3	A1
[you attend/FNAME attends]	"you attend" IF Q1=1; "[Q3 FIRST NAME] attends" IF Q1=2 OR 3	A2
[you/FNAME]	"you" IF Q1=1; "FNAME”" IF Q1=2 OR 3	A2
[your/FNAME’s]	"your" IF Q1=1; "[Q3 FIRST NAME]'s" IF Q1=2 OR 3	Q2
[Have you/Has FNAME]	"Have you" IF Q1=1; "Has [Q3 FIRST NAME]" IF Q1=2 OR 3	B4
[you/them]	"you" IF Q1=1; “them” IF Q1=2 OR 3	B11
[you are/FNAME is]	"you are" IF Q1=1; "[Q3 FIRST NAME] is" IF Q1=2 OR 3	B3
[How old are you?/What is FNAME’s age?]	"How old are you?" IF Q1=1; "What is [Q3 FIRST NAME]'s age?" IF Q1=2 OR 3	E1

Q. INTRODUCTION AND CONSENT

Consent to participate in the Pathways to Partnerships National Evaluation

ALL COMPLETING VIA WEB VERSION

SCREENREADER. Do you want to take this survey in a format that is accessible to screen readers?

m Yes…………………………………………1 GOTO screen reader compatible version

m No,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 2 GOTO OVER18

ALL

OVER18. Before you start the survey, are you 18 years of age or older?

MARK ONE ONLY

m Yes……………………………………………………………………………..1 GOTO Q1

m No, I am under 18 years of age……………………………………2 GOTO UNDER18

IF OVER18 = 2

UNDER18. A parent or guardian must complete this survey for participants under age 18. If your parent or guardian is available now, please use the back button to allow them to change the previous answer and then complete the survey. If your parent or guardian is not available at this time, let the person who shared the survey with you know so they can follow-up with them. Thank you for your time. [GOTO END]

if over18=1

Q1. Who is completing this survey?

MARK ONE ONLY

m I am a parent or guardian completing it on behalf of my child 2

m I am completing it about myself or with help 1

m Someone else is completing the survey 3

I understand that:

1. The U.S. Department of Education, Rehabilitation Services Administration is funding 20 state vocational rehabilitation or education agencies to collaborate so they can improve access to transition services for children and youth with disabilities.

2. The goal of the projects is to create easy access to services for youth with disabilities through partnerships that can help improve their education and employment outcomes.

3. Mathematica and its partner M. Davis and Company are conducting a national evaluation of the projects.

4. I, or my parent or guardian, will be asked to answer a survey as I enroll in the project.

5. If I choose to respond to this survey, I will be part of a research study about the project in my state.

6. There will be no cost to me to be in the study.

7. I do not have to take part if I do not want to. I do not need to answer any questions if I do not want to. I can choose to no longer be in this study at any time.

The personally identifiable information (PII) requested on this form is collected as authorized by Consolidated Appropriations Act, 2022, P.L. 117-103 Rehabilitation Services, March 15, 2022. 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. Your responses will be combined with the responses of other respondents and no individual names will be reported. While there are no direct benefits to participants and participation is voluntary, your participation will help us learn how states can help increase employment for people with disabilities. 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 have any questions or concerns about this study, please contact Mathematica survey staff at XXX-XXX-XXXX or ffy23dif@mathematica-mpr.com. If you have any questions or concerns about your rights as a study participant, please contact the WCG Institutional Review Board at (609) 945-0101.

IF Q1 = 1

For participants age 18 and older:

By choosing “yes” you agree that you have read and understood the information above and that you are willing to take this survey.

m Yes

m No

IF Q1 = 2 or 3

For participants younger than age 18, a parent or guardian should complete this form and the survey.

If you have more than one child enrolling for services, please complete a separate consent and survey for each child.

By choosing “yes” you agree that you have read and understood the information above and that you are willing to take this survey on behalf of your child.

m Yes

m No

ALL

Please note that this survey is intended to learn about children and youth with a wide range of disabilities. If any question is not a good fit for you or your child's circumstances, please answer to best of your ability.

if Q1 = 2 or 3

Q2. Please record the name of the person you are completing the survey for below.

Their name will be kept confidential and will not be linked to answers in any reports we create.

(STRING 30)

[FIRST NAME]

(STRING 1)

[MIDDLE INITIAL]

(STRING 30)

[LAST NAME]

If Q1=1

FILL: IF Q1 = 1, "your"; IF Q1 = 2 OR 3, "FNAME’S".

Q3. What is [your/FNAME’S] month and year of birth?

|__|__| / |__|__|__|__|

MM/YYYY

PROGRAMMER BOX

Validation check to confirm that name and dob do not match respondents who have already completed the survey

ALL

FILL: IF Q1 = 1, "do you”/”yourself”; IF Q1 = 2 OR 3, "does NAME"/”themself”.

Q4. [Are you/is FNAME]:

o Female 1

o Male 2

NO RESPONSE M

1. Education

ALL

FILL: IF Q1 = 1, "are you"/”you”/”are”; IF Q1 = 2 OR 3, "is FNAME"/”FNAME’/”is”

NLTS BL Parent

A1. What grade [are you/is FNAME] in this year?

If [you/FNAME] [are/is] currently on summer break, please select the grade you just completed.

m 4th grade 1

m 5th grade 2

m 6th grade 3

m 7th grade 4

m 8th grade 5

m 9th grade 6

m 10th grade 7

m 11th grade 8

m 12th grade 9

m Enrolled in high school and taking college courses at the same time 10

m Enrolled in a college or trade school 11 [SKIP TO B1]

m Something else (Specify) 12 [SKIP TO B1]

m Not currently enrolled in school 13 [SKIP TO B1]

NO RESPONSE M [skip to B1]

Ask if: IF A1 = 1-12

FILL: IF Q1 = 1, "you attend"/”you”/”you”; IF Q1 = 2 OR 3, "FNAME attends"/”FNAME”/”they”/”is”.

NLTS Parent – B3 (modified response options)

A2. Which of the following best describes the school [you attend/FNAME attends] this year?

• If [you/FNAME] attended more than 1 school this year, please select the most recent school.

• If [you/FNAME] attended more than 1 school at the same time, please select the school where [you/they] spent the most time.

• If [you/FNAME] [are/is] currently on summer break, please select the type of school you just completed.

Select one only

m A traditional school that serves students with and without disabilities 1

m A school that serves only students with disabilities 2

m Home schooling by a parent 3

m Something else 4

NO RESPONSE M

IF A1 = 1-10

FILL: IF Q1 = 1, "Do you"; IF Q1 = 2 OR 3, "Does FNAME".

(PROMISE – II.A1, modified)

A3. [Do you/Does FNAME] receive special education services or have an IEP (Individualized Education Program)?

“IEP” stands for an Individualized Education Program. Every year, there is an IEP meeting with [your family/your child], the teachers [you/your child] [work/works] with, and anyone outside of school that [you/your child] might meet with regularly, such as a case manager or counselor. This meeting is to talk about [your/your child’s] progress in school and [your/your child’s] goals for the future. If you are 16 or older, the meeting also includes goals for what you will do after high school, and how you can achieve those goals.

m Yes 1

m No 0

m Don’t know d

NO RESPONSE M

IF A1 = 1-12

FILL: IF Q1 = 1, "Do you"; IF Q1 = 2 OR 3, "Does FNAME".

(PROMISE – II.A2, modified)

A4. [Do you/Does FNAME] have a Section 504 plan?

A Section 504 plan, which falls under civil-rights law, gives students extra help to be successful in school. Such help may include accommodations such as more time on tests or sitting in the front of the classroom.

m Yes 1

m No 0

m Don’t know d

NO RESPONSE M

2. Service use

ALL

FILL: IF Q1 = 1, "your"; IF Q1 = 2 OR 3, "FNAME".

New

B1. How confident are you that you know where to go for disability-related services and support to help with [your/FNAME’s] education, employment, or living in the community?

m Very confident 1

m Somewhat confident 2

m Not at all confident 3

NO RESPONSE M [SKIP TO B3]

Ask if: B1 = 1, 2, 3

FILL: IF Q1 = 1, "you need"; IF Q1 = 2 OR 3, "FNAME needs".

New

B2. How hard or easy is it for you to get the education, employment, or other services and supports [you need/FNAME needs]?

m Very easy 1

m Easy 2

m Hard 3

m Very hard 4

NO RESPONSE M

ALL, Present one line per page

FILL: IF Q1 = 1, "you are"; IF Q1 = 2 OR 3, "FNAME is".

FROM PRELOAD: VR NAME(S)

FROM PRELOAD: CIL NAME(S)

FROM PRELOAD: PTIC NAME(S)

New/modeled off NBS section E

B3. Before learning about the services [you are/FNAME is] enrolling in today, had you ever heard of the following agencies or organizations?

	YES	NO
a. Vocational rehabilitation [FILL VR NAME(S))]	1 m	0 m
b. Center for independent living [CIL NAME(S)]	1 m	0 m
c. Parent training and information center [PTIC NAME(S)]?	1 m	0 m

If not b3a=1 then skip to b5

Ask if: B3A = 1, Present on same page as B3A

FILL: IF Q1 = 1, "Have you"; IF Q1 = 2 OR 3, "Has FNAME".

FROM PRELOAD: VR NAME(S)

B4. [Have you/Has FNAME] ever used services from vocational rehabilitation?

In your state the agency is called [FILL VR NAME(S)].

m Yes 1

m No 0

m Don’t know d

NO RESPONSE M

IF NOT B3B=1 THEN SKIP TO B6

Ask if: B3B = 1, Present on same page as B3B

FILL: IF Q1 = 1, "Have you"; IF Q1 = 2 OR 3, "Has FNAME".

FROM PRELOAD: CIL NAME(S)

B5. [Have you/Has FNAME] ever used services from a center for independent living?

In your area some of these centers are called [FILL CIL NAME(S)].

m Yes 1

m No 0

m Don’t know d

NO RESPONSE M

IF NOT B3C=1 THEN SKIP TO B7

Ask if: B3C = 1, Present on same page as B3C

FILL: IF Q1 = 1, "Have you"; IF Q1 = 2 OR 3, "Has FNAME".

FROM PRELOAD: PTIC NAME(S)

B6. [Have you/Has FNAME] ever used services or resources from a parent training and information center?

In your state [this center is/these centers are] called [FILL PTIC NAME(S)].

m Yes 1

m No 0

m Don’t know d

NO RESPONSE M

ALL

NBS B23_3 (modified)

B7. Have you ever used the internet to find information about disability services?

m Yes 1

m No 0

m Don’t know d

NO RESPONSE M

ALL

FILL: IF Q1 = 1, "you have"/”you”/”yourself”; IF Q1 = 2 OR 3, "has FNAME"/”you/FNAME”/”themself”.

These next questions are about services, training, or help [you have/FNAME has] ever received. When answering them, think only about services or help [you/FNAME] received from agencies or people who are not friends or family.

PROMISE 18-month parent survey (modified)

B8a. [Have you/has FNAME] ever had any training to teach [you/FNAME] about how to speak up for [yourself/themself] to get the things [you/FNAME] want[s] or need[s]?

This is sometimes called self-advocacy training.

m Yes 1

m No 0

m Don’t know d

If B8A=0 or d

FILL: IF Q1 = 1, "you"; IF Q1 = 2 OR 3, "FNAME".

B8b. Do you think [you/FNAME] would benefit from self-advocacy training?

m Yes 1

m No 0

m Don’t know d

ALL

FILL: IF Q1 = 1, "Have you"; IF Q1 = 2 OR 3, "Has FNAME".

PROMISE 18-month parent survey (modified)

B9a. [Have you/Has FNAME] ever gotten help learning about how to save and manage money?

m Yes 1

m No 0

m Don’t know d

If B9A=0 or d

FILL: IF Q1 = 1, "you"; IF Q1 = 2 OR 3, "FNAME".

B9b. Do you think [you/FNAME] would benefit from help learning about how to save and manage money?

m Yes 1

m No 0

m Don’t know d

ALL

FILL: IF Q1 = 1, "Have you"; IF Q1 = 2 OR 3, "Has FNAME".

PROMISE 18-month parent survey (modified)

B10a. [Have you/Has FNAME] ever gotten help with learning about or getting into a college or training program, including help with an application, entrance exam, or interview?

m Yes 1

m No 0

m Don’t know d

If B10A=0 or d, Present on same page as B10a

FILL: IF Q1 = 1, "you"; IF Q1 = 2 OR 3, "FNAME".

B10b. Do you think [you/FNAME] would benefit from help learning about colleges or training programs or help applying for schools after high school?

m Yes 1

m No 0

m Don’t know d

ALL

FILL: IF Q1 = 1, "Have you"/”you”/”your”; IF Q1 = 2 OR 3, "Has FNAME"/”them”/”their”

PROMISE 18-month parent survey (modified)

B11a. [Have you/Has FNAME] ever participated in activities to help [you/them] learn about jobs or careers that match [your/their] skills and interests?

m Yes 1

m No 0

m Don’t know d

If B11A=0 or d, Present on same page as B11A

FILL: IF Q1 = 1, "you"/”your”; IF Q1 = 2 OR 3, "FNAME"/”their”.

B11b. Do you think [you/FNAME] would benefit from activities to help [you/FNAME] learn about jobs or careers that match [your/their] skills and interests?

m Yes 1

m No 0

m Don’t know d

ALL

FILL: IF Q1 = 1, "Have you"; IF Q1 = 2 OR 3, "Has FNAME".

PROMISE 18-month parent survey (modified)

B12a. [Have you/Has FNAME] ever gotten help to find a job or get work experience?

m Yes 1

m No 0

m Don’t know d

If B12A=0 or d, Present on same page as B12A

FILL: IF Q1 = 1, "you"; IF Q1 = 2 OR 3, "FNAME".

B12b. Do you think [you/FNAME] would benefit from help finding a job or getting work experience?

m Yes 1

m No 0

m Don’t know d

ALL

FILL: IF Q1 = 1, "Have you"/”you”; IF Q1 = 2 OR 3, "Has FNAME"/”them”.

PROMISE 18-month parent survey (modified)

B13a. [Have you/Has FNAME] ever participated in activities to help [you/them] prepare for having a job, such as work readiness or soft skills training?

Work-readiness or soft-skills training helps people get ready for a job and do well at work. This includes learning how to do the job, how to work with other people, and how to manage your time.

m Yes 1

m No 0

m Don’t know d

If B13A=0 or d, Present on same page as B13A

FILL: IF Q1 = 1, "you"; IF Q1 = 2 OR 3, "FNAME"/”them”.

B13b. Do you think [you/FNAME] would benefit from activities to help [you/them] prepare for having a job, such as work readiness or soft skills training?

m Yes 1

m No 0

m Don’t know d

3. Employment

ALL

FILL: IF Q1 = 1, "Have you"/”you”/”you were”; IF Q1 = 2 OR 3, "Has FNAME"/”FNAME”/”FNAME was”.

PROMISE – IX.A3, modified

C1. [Have you/Has FNAME] ever worked at a job or a business?

Please consider all jobs, even if [you/FNAME] only worked for a short time. Work can be either paid or unpaid jobs, but do not count chores around the house even if [you were/FNAME was] paid to do them.

Select all that apply

q Yes, paid 1

q Yes, unpaid 2

m No 3

m Don’t know d

NO RESPONSE M

IF NOT (C1 = 1 or 2) THEN SKIP TO D1

Ask if: C1 = 1 or 2

FILL: IF Q1 = 1, "you"/”you were”; IF Q1 = 2 OR 3, "FNAME"/”FNAME was”.

PROMISE – IX.A3, modified

C2. Did [you/FNAME] work at a job or a business at any time in the past year?

Please consider all jobs in the past year, even if [you/FNAME] worked for a short time. Work can be either paid or unpaid jobs, but do not count chores around the house even if [you were/FNAME was] paid to do them.

Select all that apply

q Yes, paid 1

q Yes, unpaid 2

m No 3

m Don’t know d

NO RESPONSE M

4. Expectations

ALL

FILL: IF Q1 = 1, "you"; IF Q1 = 2 OR 3, "FNAME".

PROMISE – V.A4

D1. How far do you think [you/FNAME] will get in school? Will [you/FNAME] complete:

m Less than high school (will not graduate or get a GED) 1

m High school diploma 2

m GED 3

m Technical or trade school or apprenticeship 4

m 2- year college 5

m 4- year college 6

m A Master’s, PhD, or other advanced degree 7

NO RESPONSE M

ALL

FILL: IF Q1 = 1, "you are"/”you”; IF Q1 = 2 OR 3, "FNAME is"/”FNAME”.

(PROMISE – V.A6)

D2. When [you are/FNAME is] 30 years old, how likely do you think it is that [you/FNAME] will be working at a paid job? Do you think [you/FNAME]…

m Definitely will 1

m Probably will 2

m Probably won’t 3

m Definitely won’t 4

NO RESPONSE M

ALL

FILL: IF Q1 = 1, "you are"/”you”/”your”; IF Q1 = 2 OR 3, "FNAME is"/”FNAME”/”their”.

(PROMISE – X1.D2)

D3. When [you are/FNAME is] 30 years old, where do you think [you/they] will be living?

m With parent / guardian(s) 1

m With a sibling or other relative 2

m On [your/ their] own or with a spouse or partner 3

m In a group home or institution 4

m In another living situation 5

NO RESPONSE M

E. Demographics

ALL

FILL: IF Q1 = 1, "your"; IF Q1 = 2 OR 3, "FNAME’s".

OMB

E1. [[Are you]/[Is [NAME]] Hispanic or Latino?

MARK ONLY ONE

m Yes, Hispanic or Latino 1

m No, not Hispanic or Latino 2

NO RESPONSE M

ALL

FILL: IF Q1 = 1, "your"; IF Q1 = 2 OR 3, "FNAME’s".

OMB

E1a. What is [your/NAME’s] race?

MARK ALL THAT APPLY

o Alaska Native or American Indian 1

o Asian 2

o Black or African American 3

o Native Hawaiian or Other Pacific Islander 4

o White 5

NO RESPONSE M

ALL

FILL: IF Q1 = 1, "your"; IF Q1 = 2 OR 3, "FNAME’s".

E2. Is any language other than English regularly used in [your/FNAME’s] home?

m Spanish 1

m Other (Specify) 99

Specify

(STRING)

m No 0

NO RESPONSE M

ALL

FILL: IF Q1 = 1, "your"; IF Q1 = 2 OR 3, ""FNAME’s.

NEW

E3. What is [your/FNAME’s] current zip code?

Specify

(NUM)

NO RESPONSE M

ALL

FILL: IF Q1 = 1, "Do you"; IF Q1 = 2 OR 3, "Does FNAME".

PROMISE – II.A2, modified

E4. [Do you/Does FNAME] receive income from Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) because of a disability?

m Yes 1

m No 0

m Don’t know d

NO RESPONSE M

ALL

FILL: IF Q1 = 1, "Have you"; IF Q1 = 2 OR 3, ""Has FNAME.

NLTS 2012 – D1a, modified

E5. [Have you/Has FNAME] ever been identified as having any of the following?

Select all that apply

q Attention Deficit Disorder (ADD or ADHD) 1

q Autism spectrum disorders 2

q Emotional or behavioral disorder 3

q Hard of hearing/hearing impairment 4

q A learning disability 5

q Intellectual disability 6

q Speech or communication impairment 7

q Physical or orthopedic impairment 8

q Visual impairment/partial sight 9

q Other (Specify) 99

Specify

(STRING)

m Don’t know d

m Never had a health problem/disability 0

NO RESPONSE M

F. Contact information

Mathematica will conduct interviews with some survey respondents in the next year or so. This would involve a call with someone from the study team and having a 30-minute discussion about your experiences. You will receive a $30 gift card as a thank you for completing the interview.

ALL

F1. Would you be interested in participating in an interview sometime in the next year?

m Yes 1

m No 0

NO RESPONSE M

If F1 = 1

F2. Please provide the contact information Mathematica should use to schedule your interview.

First Name: (STRING 50)

Middle Initial:

Last Name: (STRING 50)

Street Address 1: (STRING 50)

Street Address 2: (STRING 10)

City: STRING 50)

State: (STRING 4)

Zip: (STRING 10)

Email address: (STRING 10)

HOME TELEPHONE NUMBER

WORK TELEPHONE NUMBER

CELL NUMBER

IF f1 = 1 AND CELL NUMBER is filled

F3. Would it be ok for Mathematica to send you a text message when they try to contact you for the interview?

m Yes 1

m No 0

NO RESPONSE M

ALL

Thank you for completing the Pathways to Partnerships survey. If you are completing this on someone else’s computer, please return the computer to them.

If you have any questions or concerns, please contact Mathematica staff at ffy23dif@mathematica-mpr.com.

C.1