NW Participant Screening Form
Email address *
Date of Application *
Name *
Your answer
Phone *
Your answer
Preferred Method of Contact *
Are you able & willing to commit to 1 year? *
Specific days/times that do not work for you?
Are you currently employed? *
If employed?
Your answer
If employed, how many hours are worked per week?
Hourly wage or salary $:
Your answer
If not employed, are you eligible to work?
Total monthly $ income from all sources: *
Your answer
Degree Completion Specifics (Certification/Degree): *
15. Marital status: *
Total # of members in household: *
How would you describe your childcare situation? *
Are your children (2+ years old) currently in accredited child care/after school care? *
Do you have healthcare? *
Which apply to your healthcare? Please check all that apply.
Do your children have health care? *
Which apply to your children's healthcare? Please check all that apply.
Do you currently have stable housing? *
If yes, do you own or rent?
If yes, what is your monthly payment?
Do you receive rent rebate? *
Do you receive public housing assistance (HUD)? *
Do you receive privatized public housing assistance? *
Do you use Section 8 vouchers? *
23. Do you have reliable transportation? *
If yes, what are your methods of transportation?
If no, is it possible to gain transportation within 60 days?
24. Do you have auto insurance required by the state of MO? *
25. Do you have a valid ID or driver's license? *
If no, has it been:
If revoked/suspended, please explain:
Your answer
Have you ever been convicted of a felony? *
Have you ever been convicted of a misdemeanor? *
Do you have any legal pending court cases? *
Do you have any pending legal matters (adoption, divorce, etc)? *
MISSOURI STATE UNIVERSITY CONSENT FORM FOR RESEARCH PARTICIPATION: Please review the following information regarding your involvement in MSU's research component of this project. Study Title: Northwest Project Program Evaluation Principal Investigator: Amy Blansit, Instructor of Kinesiology, Missouri State University (MSU), Director Northwest Project & Christina Ryder, Instructor of Sociology, MSU. Missouri State University is conducting an evaluation of the Northwest Project, which you are a potential participant in. This form has important information about the reason for doing this study, what we will ask you to do if you decide to be in this study, and the way we would like to use information about you if you choose to be in the study. Why are you doing this study? The purpose of the study is to determine the extent to which the Northwest Project increases participants’ opportunities for economic stability and self-sufficiency. What will I do if I choose to be in this study? You will be asked to complete a brief participant screening survey at the beginning of your participation in the Northwest Project, an intake form if you are selected, and follow-up surveys when you complete participation in the Northwest Project. Study time: Study participation will vary depending on whether you are selected to participate in the Northwest Project. For those who are not selected, you will spend approximately ten minutes completing a participant screening form. For those who are selected, you will spend approximately two hours over the course of twenty four months (two years). Study location: Surveys will be administered to you by a representative of The Fairbanks, participating agencies, and case management workers. What are the possible risks or discomforts? Your participation in this study does not involve any physical or emotional risk to you beyond that of everyday life. However, while the researchers will do their best to maintain your confidentiality there may be times when specific information about you will need to be shared with program directors and/or service providers in order to make improvements to the services you receive. What are the possible benefits for me or others?You are not likely to have any direct benefit from being in this research study, with the exception of possible adjustments to increase the effectiveness of programming you receive. This study is designed to learn more about the effectiveness of the Northwest Project. The study results will be used to improve Northwest Project program delivery and may be used to help other people in the future. How will you protect the information you collect about me, and how will that information be shared? Results of this study may be used in publications and presentations. Your study data will be handled as confidentially as possible. If results of this study are published or presented, individual names and other personally identifiable information will not be used. The only people who will have access to identifying information will be the principal investigator, who will keep identifying information stored on paper in a locked file cabinet at The Fairbanks, and possibly service providers, if your responses lead to changes in your programming. No identifying information will be shared with the general public or with law enforcement. Financial Information: Participation in this study will involve no cost to you. You will not be paid for participating in this study. What are my rights as a research participant?Participation in this study is required to be eligible for receiving services through the Northwest Project. You do not have to answer any question(s) you do not want to answer. Who can I contact if I have questions or concerns about this research study? If you have questions, you are free to ask them now. If you have questions later, you may contact Amy Blansit at 417-720-1890, or at ablansit@missouristate.edu. Consent: I have read this form and the research study has been explained to me. I have been given the opportunity to ask questions and my questions have been answered. If I have additional questions, I have been told whom to contact. I agree to participate in the research study described above and will receive a copy of this consent form. *
Is there any additional information you would like us to know? If yes, please include information below.
Your answer
I answered these questions to the best of my ability. Electronic Signature of Accuracy: *
Your answer
Date of Signature: *
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