United South End Settlements
S.T.E.P 12-month Survey
If you need this translated into another language, or have any questions, please contact us at STEP@USES.org.
Si necesitas la información en otro idioma o ayuda para completar el formulario, por favor contactar directamente a step@uses.org.
First Name
Last Name
Email
Phone
Have you moved in the past three months?
Yes
No
If you have moved in the past three months,
please include your new address:
Street Address
City
State
Zip code
Enrollment Status
Applied
Page 2: your home & neighborhood
Which best describes your housing type?
Public Housing (housing developments and income-restricted housing)
Subsidized Housing (Project-based)
Voucher (section 8, MRVP)
Private (market rate)
Unsure
Which best describes your housing stability?
Stable (rent)
Stable (own)
Semi-Stable (Transitional Housing or at risk of losing stable housing)
Unstable (homeless, temporary or emergency housing)
Would you like assistance finding stable housing?
Yes
No
How safe do you feel on the streets near your home during
the day
?
Very safe
Mostly safe
Somewhat safe
Mostly unsafe
Very unsafe
How safe do you feel on the streets near your home
at night
?
Very safe
Mostly safe
Somewhat safe
Mostly unsafe
Very unsafe
Page 3: financial capabilities & monthy expenses
Financial Capabilities:
One component of the S.T.E.P. program that we'll measure is any impact it has on financial capabilities - the ability to: increase credit scores, increase savings, decrease debts, and secure access to all eligible benefits.
What is your current Credit Score
Current amount in savings (EXCLUDING retirement and college savings)
Debt owed (credit cards)
Debt owed (car loans)
Debt owed (student loans)
Other debt owed
What type of debt for 'other'?
Total Debt Owed
Public Benefits (i.e., SNAP)
I am receiving the maximum public benefits I am eligible for
I am receiving public benefits and am unsure if I am receiving maximum amount eligible for
I am not receiving public benefits
Which benefits do you receive? Select all that apply.
EA
EAEDC
EITC
Energy Assistance
Mass Health
P-EBT
SNAP
SSI
Social Security
Subsidized childcare
Subsidized housing
SSDI
TAFDC
Transportation
Unemployment insurance
VA Benefit
WIC
Other
.
Please describe Other benefit
Page 4: reliable childcare, employment, income
Do you have reliable childcare for your children when USES (ECE, club48, Camp Hale) is not open?
Yes
No
N/A - I don't need childcare outside of USES's hours
Would you like help finding reliable childcare?
Yes
No
N/A - I don't need childcare outside of USES's hours
What is your employment status?
Not working
Part-time
Full-time
Multiple part-time (less than full)
Multiple part-time (equal to or more than full)
Retired
Stay at home parent/guardian
Has your employment changed in the past 3 months?
Yes
No
Job
Add Jobs here. Select 'Add another response' below to add additional jobs
Position/Job TItle
Employer
Job Type
Full-time
Part-time
Number of hours a week usually worked at this job
How long have you worked for this job? (i.e 3 months, 2 years, etc.)
Total compensation (pay) from this job per month ($)
Seasonal / Temp / YR
Temporary
Seasonal
Year round
Job Satisfaction
Seeking new work
Seeking internal promotion
Satisfied with job
Loves job
Prefers not to answer
How long have you been unemployed?
Never worked
Less than 6 months
6 months - 1 year
1-2 years
2-3 years
3+ years
Please choose which best describes you
Looking for work
Not looking for work
If you are unemployed OR looking for other work, please share what barriers you are facing to employment?
Select all that apply
Suitable work is unavailable or hard to find
Lack necessary skills or qualifications
Lack transportation to or from work
Own illness or disability
Unable to find affordable or accessible childcare
Caring for elderly relative(s)
Attending school
Choose to stay at home to raise child(ren)
Personal or family responsibilities
Gave up looking for work
Other
Not applicable
If selected other, please share
What are some things you have done in the last 4 weeks to find employment?
Do you want support searching for a job?
Yes
No
if yes, USES will reach out to share options for support
Other Income
Please add non-employment related income here. Click the 'Add another response' at the end to record another income source.
Other Income Source
Please select...
Alimony
Child Support
EAEDC
Energy Assistance
Rental Income
SNAP
SSI
Social Security
SSDI
TAFDC
Transportation
Unemployment insurance
Other
$ Amount received per month
Page 5: financial stability
Do you have trouble paying your heating/cooling, water or electricity bill?
Yes
No
Would you like help with this?
Yes
No
Within the last 3
months.
..
Never
Almost never
Sometimes
Fairly often
Very often
...you couldn’t afford to eat balanced meals (proteins, fruits, veggies).
...you couldn't afford hygiene products (i.e., laundry detergent, shampoo)
...one or some people in your household cut the size of their meals or skipped meals because there wasn't enough money for food
...lack of transportation has kept you from medical appointments, work, or from getting things you need
...you have experienced anxiety or stress about paying your bills
...
your housing and/or financial situation has negatively impacted your stress levels, sleep, and/or overall well-being
...Do you have access to adequate medical care for yourself and your dependents?
Yes
No
Would you like help with this?
Yes
No
In the past three months, have you made regular deposits towards your savings?
Yes
No
Do you have a retirement account and are making contributions?
Yes
No
If there's any other context or information you'd like to add regarding financial stability, please feel free to add here:
Page 6: emotional well-being
Below are a list of ways you might have felt or thought. Please select how often you have felt or thought this way over the last six months.
How often have you...
Never
Almost never
Sometimes
Fairly often
Very often
Felt nervous and stressed
Lacked confidence about your ability to handle your personal problems?
Found that you could not cope with all the things you had to do?
Felt difficulties were piling up so high that you could not overcome them?
If there is anything you'd like to add/share on your emotional well-being, please feel free to do so here:
Page 7: children's well-being
Child's Social-Emotional Health
*If you have more than one child in your care, please complete one survey per child. Click 'Add another response' at the button to add additional children.
This response is for child:
Please fill this out based on what you have observed in the past
3 months:
Rarely or Never
Sometimes
Often
Seems nervous, tense, or fearful
Is restless or can't sit still
Purposely tries to hurt children, adults, or animals (for example, by kicking or biting)
Has trouble adjusting to changes
Gets very upset often
Seems very unhappy, sad, or withdrawn
Has trouble falling or staying asleep (at naptime or night)
Is afraid of certain places, animals, or things
Cries or hangs onto you when you try to leave
Not at all worried
A little worried
Worried
Very worried
How worried are you about your child's behavior, emotions, or relationships?
How worried are you about your child's language development?
How worried are you about your child's academic progress?
Does this child have a college savings account?
Yes
No
Have you had difficulty or been unable to pay for your child's school-related field trips?
Yes
No
N/A - This child hasn't yet had field trip opportunities
Have you had to make the decision to not enroll your child in extracurricular activities due to finances? (i.e., sports, dance, etc.)?
Yes
No
N/A - child is too young for extracurricular activities
Has the child been to the dentist in the past 12 months?
Yes
No
N/A - this child is less than 12 months old
If this child is school-age has s/he ever had an IEP (Individual Education Plan)?
Yes
No
N/A (not school age)
Where did the assessment take place?
Inside the school
Outside the school
Both at school and outside of the school
N/A - Child does not have an IEP
Has the child faced expulsion or suspension from school?
Yes
No
Child does not attend school yet
Any other details or clarifying information you'd like to share about this child?
How often do you have time or engage in each activity with your child(ren?)
Everyday
Few times a week
Few times a month
We rarely or do not do this activity
Read books or look at pictures in a book
Tell stories
Play together (i.e., blocks, dolls, outdoor games, etc.)
Out-of-home activities or programs for children (i.e., library story time, play groups)
Eat meals together
Watch movies or shows together
Intentional one-on-one time with activities not listed above
If there's anything you'd like to add about your children's well-being, please feel free to here:
Contact Information