ࡱ> X[UVW~g {bjbj٘ .@1 & & & & &4&4&4&8op4&;l&,++++,, --8;;;;;;$=|@3;] &-,,--3; & &++4;000-X &+ &+-80--80034+0L,`-38;0;3,^A`-^A4^A &54--0-----3;3;&/---;----^A--------- $: MICHIGAN NATIONAL YOUTH IN TRANSTION DATABASE (NYTD)OUTCOMES SURVEYMichigan Department of Human ServicesNOTE: Survey due within 45 days after the youths 17th birthday. It must be entered online at: https://www.mdhs.michigan.gov/nytd/INFORMATION ON YOUTH DEPARMENT OF HUMAN SERVICES STAFF TO COMPLETEName of Youth (First and Last):Youth Survey ID Number: FORMTEXT       FORMTEXT      DHS County Name and/or Private Agency Name: FORMTEXT      INFORMATION ON YOUTH CONTACT PERSONContact information of a friend or family member who the youth thinks will be able to reach them in the future:Name:Phone:Email Address: FORMTEXT       FORMTEXT       FORMTEXT      SURVEY ADMINISTRATORPlease enter the contact information for the person administering this survey:Name (First and Last):Relationship to Youth: FORMTEXT       FORMTEXT      Name of Agency (If Applicable): FORMTEXT      Mailing Address: FORMTEXT      Phone Number:Email Address: FORMTEXT       FORMTEXT      Survey administrator, please indicate (with a check mark) the status of the youth and the survey; FORMCHECKBOX Youth participated in the survey. FORMCHECKBOX Youth declined to complete the survey. FORMCHECKBOX Youth is incapacitated. FORMCHECKBOX Youth has AWOLP status. FORMCHECKBOX Youth is deceased. FORMCHECKBOX Incarcerated FORMCHECKBOX Unable to locate/Invite only allowable for youth follow-up survey. FORMCHECKBOX Parent declined, only allowable if the youth has not reached the age of majority. Definitions: Youth is incapacitated The youth has a permanent or temporary mental or physical condition that prevents him or her from participating in the outcomes data collection. Youth has AWOLP status A youth in foster care is known to have run away or be missing from his or her foster care placement. Death The youth died prior to his or her participation in the outcomes data collection. Date the survey was administered (The survey administration date is the date on which the youth provided answers to the survey. For example, the youth gave answers to the survey on January 1st and their worker inputs the data on February 1st. The Survey Administration Date is January 1st.RESEARCH PARTICIPATION INFORMATION AND CONSENT FORM Study Name: National Youth in Transition Database (NYTD) Outcome Survey Survey Administrator, please read the information below to the youth and/or have youth read the information. This consent form may contain words that you do not understand. Please ask you caseworker to explain any words that you do not clearly understand. You may think about if before making you decision. What is this survey about? The Michigan Department of Human Services is administering a survey to older youth in foster care as a part of a national research study. The name of the survey is the Michigan National Youth in Transition Database (NYTD) Outcomes Survey. Your participation in the study will help to measure states success in preparing youth for the transition from foster care to independent living. You are being asked to participate because you are 17 years old and currently in foster care. What am I being asked to do? If you agree to take part in this study, you will be asked to complete a survey that contains questions about your financial independence, education, connections with adults, experience with homelessness, parenting status, social behaviors and access to health insurance. There are approximately 22 questions in the survey and it will take about 15 minutes for you to finish. The consent form offers you the option to accept or decline participation in taking the survey. You may ask questions about the study. You should sign the consent form only after you have had all of your questions answered and you understand what is being asked of you. Will you share my answers with anyone? This is not anonymous survey. The answers you provide will be kept in the DHS database called SWSS. A had copy of your answers to the survey may be kept in your DHS case file. DHS staff persons will have access to the survey answers. Your answers will be sent to the US government foster care agency but the Michigan Department of Human Services will use a special code, not your name when your answers are sent. The results of this survey will only be published for foster youth as a group. When the results of this survey are studied or discussed, your name will not be connected to the data. Your name will not be used in any reports or discussions about the results of the survey. Do I have to take this survey? You do not have to take this survey. Your participation is voluntary. No one will blame you or criticize you if you decide not to participate. There are no costs or financial risks to you if you decide not to participate in the survey. If you choose to take the survey you do not need to complete all of the questions. If you begin the survey, leave the site and return to finish it at a later time, your previously selected answers will not be saved. Once you select the submit button your survey will be submitted and you will not be able to access it or change your answers. Will someone try to contact me later? You may be contacted acted again (at age 19) and then 2 years later (at age 21) for follow-up surveys. The follow-up surveys will have similar questions to this survey. What if I have questions about the survey? If you have questions or concerns about the survey now or in the future, please contact: DHS Caseworker/Private Agency CaseworkerDHS Central Office Youth ServicesName:235 S. Grand Ave., Suite 415Lansing, MI 48909Phone Number:Fax: 517-335-7789Email Address:Phone: 517-241-9865CONSENT Your signature is your agreement to participate in this study. If there is any part of the form that is unclear to you be sure to ask questions about it. Do not sign the form until you get the answers to all of your questions. I have read the consent form and understand the information about the survey. All of my questions about the survey have been answered. I agree to participate in this survey.Printed name of the youthSignature of the youthDatePrinted name of the person conducting informed consent discussionSignature of the person conducting informed consent discussion Michigan NYTD Outcomes SurveyName of Youth (First and Last):Youth Survey ID Number: FORMTEXT       FORMTEXT      Current Age of Youth:Date of Birth:Survey Date:DHS County Office Name and/or Private Agency Name:Employment and On-the Job TrainingIf someone is employed  full-time, they are working at least 35 hours per week at one or more jobs.1)Currently, are you employed full-time? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX DeclinedIf someone is employed part-time, they are working between 1 and 34 hours per week at one or more jobs.2)Currently, are you employed full-time? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX DeclinedThis next question asks about programs that provide on-the-job training. This training might include trade skills such as carpentry or auto mechanics, or office skills such as word processing or the use of office equipment.3)In the past year, did you complete an apprenticeship, internship or other on-the-job training, either paid or unpaid? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX DeclinedFinancial SupportAfter exiting foster care, sometimes eligible foster care youth receive social security payments. These are payments from the government to meet basic needs for food, clothing and shelter of a person with a disability. You may be receiving these payments because of a parent or guardians disability, rather than your own disability.4)Currently, are you receiving social security payments (Supplemental Security Income SSI, Social Security Disability Insurance SSDI, or dependents payments)? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX DeclinedStudents often receive financial aid to help with education expenses. Scholarships, grants and stipends are funds awarded to help with expenses related to obtaining an education. A student loan is a government-guaranteed, low-interest loan for students who have finished high school.5)Current, are you using a scholarship, grant, stipend, student loan, voucher or other type of education financial aid to cover any education expenses? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Declined Financial support can come from your family as well. This type of support could be from your biological, foster or adoptive family. It could be child support that you receive or duns from a legal settlement. It does not include occasional gifts such as birthday or graduation checks. It also does not include small donations of food or personal items, child care subsidies, child support for your child or other financial support that does not benefit you directly in supporting yourself.6)Currently, are you receiving ongoing welfare payments from the government to support your basic needs (state emergency relief [SER], FIP [cash assistance])? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Declined FORMCHECKBOX N/A answer only allowable if you are still in foster care.7)Currently, are you receiving public food assistance (FAP, Bridge card, food stamps)? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Declined FORMCHECKBOX N/A answer only allowable if you are still in foster care.8)Currently, are you receiving any sort of housing assistance from the government, such as living in public housing or receiving a housing voucher? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Declined FORMCHECKBOX N/A answer only allowable if you are still in foster care.9)Currently, are you receiving any periodic and/or significant financial resources or support from another source not previously indicated and excluding paid employment? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX DeclinedEducation and Training10)What is the highest educational degree or certification that you have received? FORMCHECKBOX High school diploma/GED. FORMCHECKBOX Vocational certificate. FORMCHECKBOX Vocational license. FORMCHECKBOX Associates degree. (e.g., A.A.) FORMCHECKBOX Bachelors degree. (e.g., B.A. or B.S.) FORMCHECKBOX Higher degree. FORMCHECKBOX None of the above.Definitions: Vocational Certificate a document stating that a person has received education or training that qualifies him or her for a particular job, e.g., auto mechanic or cosmetology. Vocational License a document that indicates that the state or local government recognizes an individual as a qualified professional in a particular trade or business. Associates degree generally a two-year degree from a community college. Bachelors degree a four-year degree from a college or university. Higher degree a graduate degree, such as a Masters or Doctorate degree. None of the above the youth has not received any of the above educational certificates.11)Currently, are you enrolled in and attending high school, GED classes, post-high school vocational training, or college? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX DeclinedNote: If you are enrolled in and attending school that is currently out of session (spring break, summer vacation), then you are still considered enrolled in and attending an educational program. Personal Relationships and Living CircumstancesThis question asks about connections to adults in your life. It refers to an adult that you can go to for advice or guidance when you have to make a decision, when you need help solving a problem, or when you want to share something good that has happened to you. The adult might be a relative, parent, or foster parent or someone else who is close to you (for example a minster or a teacher). The adult must be someone that you can easily reach, either by telephone or in person. The adult would not include: a spouse, partner, boyfriend/girlfriend, or current caseworker.12)Currently, is there at least one adult in your life, other than your caseworker, to whom you can go to for advice or emotional support? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX DeclinedThe next question is about homelessness. Homelessness means that you had no regular or adequate place to live. This includes living in a car or on the street, staying in a homeless or other temporary shelter or sleeping on a friends or relatives couch on a temporary basis.13)Have you ever been homeless? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX DeclinedThis question is about alcohol and drug abuse assessment and counseling. Alcohol or drug abuse assessment is a process designed to determine if someone has a problem with alcohol or drug use. You could have decided to seek alcohol or drug abuse assessment or counseling yourself (self-referral) or someone else like a social worker, school staff, physician, mental health worker, foster parent, or other adult might have referred you to alcohol/drug assessment or counseling.14)Have you ever referred yourself or has someone else referred you for an alcohol or drug abuse assessment or counseling? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Declined15)Have you ever been confined in a jail, prison, correctional facility, or juvenile or community detention facility, in connection with allegedly committing a crime? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX DeclinedThe next question asks about giving birth or fathering children. If you are female, the question refers to giving birth to at least one child that was born. If you are male, the question refers to fathering at least one child that was born. If you are male and you do not know if you have fathered a child, answer No.16)Have you ever given birth of fathered any children that were born? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Declined17)If you responded yes to the previous question, were you married to the childs other parent at the time each child was born? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX DeclinedHealth Care CoverageThe next question asks about Medicaid a health insurance program funded by the government.18)Currently, are you on Medicaid? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Declined The next several questions ask about other health insurance. Health insurance is when a third party pays for all or part of health care. You might be covered under your parents health insurance policy. You might have health insurance such as group coverage offered by your employer or your college. Your might have an individual policy that covers medical, mental health care, or prescription drugs. 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FORMCHECKBOX Declined20)Does your health insurance include coverage for medical services? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX Dont know FORMCHECKBOX Declined21)Does your health insurance include coverage for mental health services? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX Dont know FORMCHECKBOX Declined22)Does your health insurance include coverage for prescription drugs? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX Dont know FORMCHECKBOX DeclinedThank you for taking the survey.     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