Form CFS 2030-2 National Youth in Transition Database Follow up Survey - Illinois

Form CFS2030-2 or the "National Youth In Transition Database Follow Up Survey" is a form issued by the Illinois Department of Children and Family Services.

Download a PDF version of the Form CFS2030-2 down below or find it on the Illinois Department of Children and Family Services Forms website.

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CFS 2030-2
Rev 12/2017
State of Illinois
Department of Children and Family Services
NATIONAL YOUTH IN TRANSITION DATABASE
FOLLOW UP SURVEY
Youth's Name:
Date Survey Completed:
Method of Survey Administration: (choose one)
 In-Person (Office)
 In Person (Home)
 Phone
 Mail/Email
Survey Administrator:
 Caseworker
 NYTD Coordinator
 Other
Instructions:
To answer a question, simply X the box next to the correct answer. Please pay attention to the
instructions within the survey. The instructions are intended to help you answer the correct
questions based on the answers you provide.
It is very important that you answer these questions truthfully. The information gathered from
the surveys completed by hundreds of youth will be used to help improve services for youth in
the future. Any answers/information you provide will not be used in any negative manner
towards you. Thank you in advance for your participation and your honesty.
EMPLOYMENT
Q1.
Currently are you employed full-time?
Yes
Declined
No
Q2.
Currently are you employed part-time?
Yes
Declined
No
Q3.
In the past year, did you complete an apprenticeship, internship, or other on-the-job training,
either paid or unpaid?
Yes
Declined
No
OTHER SOURCES OF INCOME
Q4.
Currently are you receiving social security payments (Supplemental Security Income (SSI,
Social Security Disability Insurance (SSDI), or dependents' payments)?
Yes
Declined
No
CFS 2030-2
Rev 12/2017
State of Illinois
Department of Children and Family Services
NATIONAL YOUTH IN TRANSITION DATABASE
FOLLOW UP SURVEY
Youth's Name:
Date Survey Completed:
Method of Survey Administration: (choose one)
 In-Person (Office)
 In Person (Home)
 Phone
 Mail/Email
Survey Administrator:
 Caseworker
 NYTD Coordinator
 Other
Instructions:
To answer a question, simply X the box next to the correct answer. Please pay attention to the
instructions within the survey. The instructions are intended to help you answer the correct
questions based on the answers you provide.
It is very important that you answer these questions truthfully. The information gathered from
the surveys completed by hundreds of youth will be used to help improve services for youth in
the future. Any answers/information you provide will not be used in any negative manner
towards you. Thank you in advance for your participation and your honesty.
EMPLOYMENT
Q1.
Currently are you employed full-time?
Yes
Declined
No
Q2.
Currently are you employed part-time?
Yes
Declined
No
Q3.
In the past year, did you complete an apprenticeship, internship, or other on-the-job training,
either paid or unpaid?
Yes
Declined
No
OTHER SOURCES OF INCOME
Q4.
Currently are you receiving social security payments (Supplemental Security Income (SSI,
Social Security Disability Insurance (SSDI), or dependents' payments)?
Yes
Declined
No
Q5.
Currently are you using a scholarship, grant, stipend, student loan, voucher, or other type of
educational financial aid to cover any educational expenses?
Yes
Declined
No
Q6.
Currently are you receiving ongoing welfare payments from the government to support your
basic needs?
Yes
Declined
No
Q7.
Currently are you receiving public food assistance?
Yes
Declined
No
Q8.
Currently are you receiving any sort of housing assistance from the government, such as
living in public housing or receiving a housing voucher?
Yes
Declined
No
Q9.
Currently are you receiving any periodic and/or significant financial resources or support
from another source not previously indicated and excluding paid employment?
Yes
Declined
No
EDUCATION
Q10.
What is the highest educational degree or certification that you have received?
High school diploma/GED
Bachelor's degree
Vocational certificate
Higher degree
Vocational license
None of the above
Associate's degree
Declined
Q11.
Currently are you enrolled in and attending high school, GED classes, post-high school
vocational training, or college?
Yes
Declined
No
PERMANENT RELATIONSHIPS WITH ADULTS
Q12.
Currently is there at least one adult in your life, other than your caseworker, to whom you can
go for advice or emotional support?
Yes
Declined
No
HOUSING
Q13.
In the past two years, have you ever been homeless?
Yes
Declined
No
RISKY BEHAVIORS
Q14.
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
Declined
No
2
Q15.
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
Declined
No
Q16.
In the past two years, did you give birth to or father any children that were born?
Yes
Declined
No
IF Q16 = YES THEN GO TO Q17
ELSE IF Q16 = NO THEN GO TO Q18
Q17.
Were you married to the child's other parent at the time each child was born?
Yes
Declined
No
ACCESS TO HEALTH CARE
Q18.
Currently are you on Medicaid [or name of the State's medical assistance program under title
XIX]?
Yes
Declined
No
Do not know
Q19.
Currently do you have health insurance, other than Medicaid?
Yes
Declined
No
Do not know
IF Q19 = YES, THEN GO TO Q20
IF Q19 = NO, YOUR SURVEY IS COMPLETE
Q20.
Does your health insurance include coverage for medical services?
Yes
Declined
No
Not applicable
Do not know
Q21.
Does your health insurance include coverage for mental health services?
Yes
Declined
No
Not applicable
Do not know
Q22.
Does your health insurance include coverage for prescription drugs?
Yes
Declined
No
Not applicable
Do not know
END OF SURVEY
WE APPRECIATE YOUR HELP AND COOPERATION
3

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