We need your help!!! This is a chance for you to help other youth in foster care! The federal government is requiring all states to collect information on youth in foster care and the life skills services they receive which you may know as Chafee Services. Youth are being surveyed at age 17, 19, and 21 regardless of whether they are still in foster care to see if the services have made a difference in their life. If you are receiving this letter, it is because you took the survey at age 17. The information is being compiled in the National Youth in Transition Database. The questions being asked are being asked in every state with the same wording. The information from the surveys is being used to improve the services youth receive while they are in care. The survey should take approximately 20 minutes to complete. Your experiences are important to us and we hope to learn about them while you are in care and when you leave care. Your participation is voluntary and is not connected to any services that you receive. If there is a question that you feel uncomfortable answering, you may check “Declined” for that question. We hope that you will take a few minutes to answer the questions. The information from the surveys is confidential and is only being used by individuals involved with the National Youth in Transition Database. Any data shared is not associated with an individual but is looking at a region and state view. We thank you for your participation and willingness to improve services for older youth in Missouri’s foster care program.

Contact Information:

Please provide us with your contact information so we can get in touch with you in the future. We will only use this contact information to connect with you for the purpose of the survey. The survey results are being used to assist youth with needs as they transition out of foster care. We will be in touch again when you are 19 and/or 21 with another survey.

Personal Contact Information:

Name (First, Last)
Street Address
City, State, Zip Code
Phone Number - Home
Phone Number - Cell
Email Address (please print clearly)

Just in case you move or change your phone number, we would like you to include the contact information for three people who would know how to reach you. We won’t ask these people for any other information about you, and the answers you share with us will not be shared with them. These individuals are your supports and should be someone who is like family to you.

Permanent Connections:

Contact Person Name (First, Last)
Relationship To You
Street Address
City, State, Zip Code
Phone Number
Email Address (please print clearly)

Contact Person Name (First, Last)
Relationship To You
Street Address
City, State, Zip Code
Phone Number
Email Address (please print clearly)

Contact Person Name (First, Last)
Relationship To You
Street Address
City, State, Zip Code
Phone Number
Email Address (please print clearly)

If we are not able to reach you through your contact information, we would like to search other databases that we have access to with your permission such as food stamps or MO HealthNet. If you are willing for us to do this if we cannot locate you for the survey, we ask that you read the consent below and sign it.

Consent to Access Administrative Data

Agreement to Permit the Use of Administrative Data for Tracking and Location

I,	(print name), authorize Missouri Children’s

Division to review various kinds of administrative records (e.g. department of motor vehicle records, public assistance records, educational records, child welfare records, unemployment insurance wage records, credit bureau records, vital statistics records, and criminal justice records) that might contain information that could be used to locate and contact me for follow-up interviews for the National Youth In Transition Database Survey when I am 19 and 21 years old.

I understand that by signing this agreement I am voluntarily authorizing Missouri Children’s Division to review the aforementioned records. This agreement will expire when I reach the age of 22.

Signature:

Date:

National Youth in Transition Database Survey

You have the option of completing the survey on-line by typing in the text below in to a web browser address bar: http://dssapp.dss.mo.gov/fcwNYTDSurvey/index.asp?respID= (plus DCN needs to be checked)

What is your name? (please print your name below)

Name: _________________________

What is the date that you answered the survey questions (please write the date below)

Date: __________________________

Instructions:

For questions 1-22, please check only one answer.

Currently are you employed full-time?

(For example, do you work 35 hours or more a week at one or more jobs?)

Yes ☐	No ☐	Declined ☐

Currently are you employed part-time?

(For example, do you work 1 to 34 hours per week at one or more jobs?)

Yes ☐	No ☐	Declined ☐

In the past year, did you complete an apprenticeship, internship, or other on-the-job training, either paid or unpaid?

(This question is asking if you had a job that you learned a trade or skill such as welding, office skills, or customer service and you learned the skill from an experienced person whether you were paid or unpaid for the work.)

Yes ☐	No ☐	Declined ☐

Currently are you receiving Social Security payments (Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI) or dependents’ payments)?

(These are payments from the government to meet basic needs for food, clothing, and shelter of a person with a disability. You could be receiving these payments because of a parent or guardian’s disability or your own.)

Yes ☐	No ☐	Declined ☐

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

(This educational aid could be used for expenses related to gaining an education. A student loan is a government-guaranteed, low-interest loan for students in post-secondary education.)

Yes ☐	No ☐	Declined ☐

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

For example, are you regularly receiving money from one or more of the following:

A spouse/partner

A family member (biological, foster, adoptive)

Child support

Legal settlements

This does not include special occasion gifts or money for small items such as food or personal items.

Yes ☐	No ☐	Declined ☐

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

(Please check one answer.)

☐High school diploma/GED

☐Vocational certificate (document received stating you qualify for a particular job based on your education and training)

☐Vocational license (document received in which the State or local government recognizes you as qualified professional in a particular trade or business)

☐Associate’s degree (for example A.A. – generally two years from a community college)

☐Bachelor’s degree (for example B.A. or B.S. – generally four years from college or university)

☐Higher degree (for example M.A., M.S., PhD., or J.D.)

☐None of the above (you have not received any of the educational certificates listed)

☐Declined

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

(This could include other adult education programs or alternative schools.)

(You are considered enrolled in and attending school if you are attending a school that is currently out of session for spring break, summer vacation, etc.)

Yes ☐	No ☐	Declined ☐

8.1. If you are currently attending high school, GED classes, post-high school vocational training, or college, what year do you expect to graduate? ____________

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?

(This question is talking about an adult who you can go to for advice or guidance when there is 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. This does not include spouses, partners, boyfriends or girlfriends, and current caseworkers. The adult must be easily accessible to you either by telephone or in person.)

Yes ☐	No ☐	Declined ☐

10. In the past two years, were you homeless at any time?

Note: Homeless is defined as not having a regular or adequate place to live.

For example, at any time in the last two years you have:

lived in a car

lived on the street

stayed in a homeless or temporary shelter

Yes ☐	No ☐	Declined ☐

11. In the past two years, did you refer yourself, or had someone else referred you for an alcohol or drug abuse assessment or counseling?

Yes ☐	No ☐	Declined ☐

12. 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?

Yes ☐	No ☐	Declined ☐

13. In the past two years, did you give birth to or father any children that were born?

Yes ☐	No ☐	Declined ☐

If you checked “No” or “Declined”, skip Question #14 and go to Question #15.

14. If you responded “Yes” to the previous question, were you married to the child’s other parent at the time each child was born?

Yes ☐	No ☐	Declined ☐

15. Currently are you on Medicaid?

(In Missouri this is called MO HealthNet and is a health insurance program funded by the government)

Yes ☐	No ☐	Don’t Know ☐	Declined ☐

16. Currently do you have health insurance, other than Medicaid/MO HealthNet?

(You may have group coverage offered through your job or school or be covered through your parents insurance or through an individual policy that pays for part of all of your health care.)

Yes ☐	No ☐	Don’t Know ☐	Declined ☐

If you checked “No”, “Don’t Know”, or “Declined” please go to Question #20 and continue. If you checked “Yes”, please continue on to Question #17.

17. If you answered “Yes” to Question #16, does your health insurance include coverage for medical services? (This refers to health insurance that is NOT Medicaid/Mo Healthnet coverage.)

Yes ☐	No ☐	Don’t Know ☐	Declined ☐

18. If you answered “Yes” to Question #16, does your health insurance include coverage for mental health services? (This refers to health insurance that is NOT Medicaid/MO HealthNet coverage.)

Yes ☐	No ☐	Don’t Know ☐	Declined ☐

19. If you answered “Yes” to Question #16, does your health insurance include coverage for prescription drugs? (This refers to health insurance that is NOT Medicaid/MO HealthNet coverage.)

Yes ☐	No ☐	Don’t Know ☐	Declined ☐

20. Currently are you receiving Temporary Assistance for Needy Families (TANF) payments from the government to support your basic needs?

Yes ☐	No ☐	Declined ☐

21. Currently are you receiving public food assistance?

Yes ☐	No ☐	Declined ☐

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

Yes ☐	No ☐	Declined ☐

Thank you for completing the survey!!!

We appreciate your help!!!

If you did not complete the survey on-line, please return the survey to your case manager (if you are still in care) or in the enclosed envelope.

For more information on the National Youth in Transition Database:

http://dss.mo.gov/cd/chafee/nytd.htm

“Reaching out to Missouri’s youth so that we might touch the future generation.”