The following is a list of questions in DYB pertaining to student level information. It is organized by page in DYB.

Student Profile

Name: __________________________________________

  • What is the student’s sex?
  • Female
  • Male  
  • Other/Intersex

Birth Date: _______________________
With what race and/or origin does the student identify?

  • White
    • Enter origin such as German, Irish, Lebanese, etc. _______________________________
  • Black or African American
    • Enter origin such as African American, Haitian, Nigerian, etc. __________________________________
  • Hispanic, Latino, or Spanish Origin
    • Enter origin such as Mexican, Mexican American, Puerto Rican, Cuban, Columbian, etc. ___________________________________
  • American Indian or Native Alaskan
    • Enter origin such as Navajo, Mayan, Tingit, etc. _________________________________
  • Asian or South Asian
    • Enter origin such as Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Hmong Laotian, Thai, Pakistani, etc. __________________________________________
  • Native Hawaiian or other Pacific Islander
    • Enter origin such as Native Hawaiian, Guamanian or Chamorro, Samoan, Fijian, etc.________________________________
  • Other race or origin
    • Enter other race or origin ___________________________________________________

What is the student’s marital status?

  • Married
  • Single       
  • Widowed      
  • Divorced
  • Civil Union    
  • Partner/Cohabitating
  • Unknown

Was this student a parent or primary caregiver at entry to YouthBuild?

  • Parent
  • Primary Caregiver
  • Both parent and primary caregiver
  • Neither

Is this student currently homeless or have they been homeless in the last year?

  • Currently homeless    
  • Homeless in past year     
  • Neither
  • Unknown

Has the student ever been in foster care?

  • Currently in foster care  
  • Aged out of or no longer in foster care     
  • Never in foster care
  • Unknown

Is this student economically disadvantaged?

  • Yes
  • No    

Is the student an English language learner?

  • Yes
  • No    

Does the student identify as LGBTQ?

  • Yes
  • No
  • Unknown

Was the student employed for any part of the 6 months before entry into YouthBuild?

  • Yes
  • No        
  • Unknown

If this student enrolls in postsecondary education will they be a first generation enrollee?  

  • Yes
  • No
  • Unknown

Does this student identify as having a disability?

  • Yes
  • No
  • Unknown

Is this student registered to vote? (asked if over 18 years old)

  • Yes
  • No        
  • Not Eligible to Vote
  • Unknown

Criminal Justice

Was this student a youth or adult offender before entry into YouthBuild?

  • Youth Offender
  • Adult Offender
  • Both Youth and Adult Offender
  • Neither  
  • Unknown

What was the student’s most recent release date (if known)? __________________

What was the student’s court involvement at entry into YouthBuild (if involved at entry)?

  • On parole/probation    
  • In detention/incarcerated    
  • Case pending    
  • None

What was the level of the most serious offense (if involved at entry)?

  • Felony
  • Misdemeanor
  • Non-Criminal Offense
  • Unknown

Did this student become court involved after entering YouthBuild? (question asked at exit)

  • Convicted of a new crime
  • Parole / Probation Revoked
  • No involvement 
  • Unknown

If selected Convicted of new crime or Parole / Probation revoked: What was the date of the student’s court involvement incident? ____________

Enrollment

Enrollment Date: ___________________________
Exit Reason:

  • Successful Exit    
  • Left program to return to high school    
  • Chose to leave before meeting requirements for completion    
  • Was asked to leave for disciplinary reasons    
  • Moved from target area of program    
  • Left for medical reasons
  • Incarcerated    
  • Left to care for an ill or disabled family member    
  • Active reservist called to military duty    
  • Deceased
  • Left for other reasons

Exit Date: _________________________
Exit Additional Details: ______________________________________________________________________
Return Date (if applicable): ___________________________
Student’s Email Address: (asked at exit) _________________________________
What was the student’s attendance percentage during the program? (asked at exit) ______
How many hours of community service did the student participate in during YouthBuild? (asked at exit) ____________________

Contact Information

Student’s Email Address: __________________________________________________
Phone Number: _________________________________
Street Address: _______________________________________________________________________
City: ______________________________________    
State: ___________
Twitter: __________________________________________________
Facebook: ________________________________________________

Education Profile

How many years was the student out of school before enrolling in YouthBuild? __________________________

Reading Grade Level
Grade Level: ________________________    Test Date: __________________ (Pre-test)
Grade Level: ________________________    Test Date: __________________ (Post-test)

Math Grade Level
Grade Level: ________________________    Test Date: __________________ (Pre-test)
Grade Level: ________________________    Test Date: __________________ (Post-test)

Diploma and High School Equivalency
Educational Credential at Entry:

  • High School Diploma
  • High School Equivalency
  • No Credential

Educational Credential Earned After Entry

  • High School Diploma        
  • GED
  • HISET
  • TASC    
  • Other Equivalency    
  • None

Educational Credential date (if awarded after entry): ________________________________

Post Secondary Goals
Initial Desired PSE Credential

  • Associates Degree
  • Bachelor’s Degree    
  • Graduate/Professional Degree
  • Certificate
  • Apprenticeship Placement
  • Employment only  

Post Secondary Prep Achievements (questions asked at exit)
Did this student earn post secondary credits at your program?

  • Yes
    • How many post secondary credits did this student earn?
  • No
  • Unknown

Did this student complete a FAFSA while at your program?

  • Yes
  • No
  • Unknown

Did this student take a college placement test?

  • Yes
  • No
  • Unknown

Did the student complete any post secondary applications?

  • Yes
  • No
  • Unknown

Certificates

Certificate Name:

  • NCCER
  • MCCC
  • BPI
  • HBI PACT    
  • CNA
  • PCA
  • HHA
  • Customer Service Excellence
  • CPR/First Aid
  • OSHA 10
  • OSHA 30
  • Driver’s License
  • CDL   
  • HAZMAT    
  • Other

Date Received: ________________________________

If Other:

Certificate Name:  _______________________________________

    • Type:
      • Construction
      • Customer Service
      • Healthcare
      • Hospitality
      • Foundational
      • Other
    • Industry Recognized:
      • Yes
      • No

If NCCER: Please choose any/all NCCER curricula completed:

  • Core Curriculum
  • Weatherization Level 1
  • Weatherization Level 2
  • Your Role in the Green Environment

If BPI: Please choose any/all BPI curricula completed:

  • RBE-WH-ALCI
  • Building Analyst
  • RBE-AA-ALCI

Activities

Activity Type:

  • Barista Training
  • College Bridge Program
  • Internship
  • Mental Toughness 2 (MT2)        
  • Mentoring
  • Policy Committee Member

Activity Start Date: _______________________

If Mentoring:
What kind of mentoring did the student receive?

  • Group
  • Individual    
  • Both

Was the mentor a Youth Opportunity AmeriCorps Mentor?

  • Yes
  • No

If Internship:
Internship Name: ___________________________________________________

Placements

Job Placement
Employer Name: _____________________________________________________________

Start Date: ____________________________________________________________________

End Date (only if job placement has ended):  _______________________________________

Type of Job:

  • Architecture, and engineering
  • Arts, design, entertainment, sports, and media
  • Building and grounds cleaning, and maintenance
  • Business and financial operations
  • Community and social services
  • Computers, Information Technology, Math
  • Construction and extraction
  • Education, training, and library
  • Farming, fishing, and forestry
  • Food preparation and serving related
  • Healthcare support, practitioners, and technical    
  • Installation, Maintenance, and repair    
  • Legal
  • Life, physical, and social science
  • Management
  • Military specific    
  • Office and administrative support
  • Personal care and service
  • Production
  • Protective service
  • Sales and related    
  • Transportation and material moving
  • Unknown job type

Hours:

  • Full Time Employment
  • Part Time Employment    
  • Unknown

Is this placement a green job?

  • Yes
  • No
  • Unknown

What is the starting wage for this student’s placement? ______________________________

Education Placement
What is the name of this Post Secondary Institution or apprenticeship? ____________________________________________

Enrollment Date: ____________________________________

Where is this student getting their continuing education?

  • College or University    
  • Community College
  • Trade School/Non-College Training Program  
  • Registered Apprenticeship Training

Is this placement full time or part time?  

  • Full Time
  • Part Time
  • Unknown

If selected College or University:
Is the college or university a public or private school?

  • Public
  • Private
  • Unknown

Details (If selected College or University, Community College or Trade School / Non-College Training Program):
How many credits has the student earned at this placement? (Asked at exit only of PSE Initiative Programs) ___________________

What credential is the student working towards at this placement?

  • Bachelors Degree
  • Associates Degree
  • Technical Credential
  • Graduate/Professional Degree
  • Apprenticeship Credential    
  • Other
  • Unknown

If selected Registered Apprenticeship Training:
Apprenticeship Details:
What is the training wage for this apprenticeship? ___________________________

In what sector is this apprenticeship?

  • Construction
  • Healthcare   
  • Retail
  • Other

What kind of organization sponsors this apprenticeship?

  • Employers / Industry   
  • Trade Associations   
  • Unions

Followup

Education Placement:

  • Verify
  • Unable to Verify
  • End Placement

If Verify: When did you follow up with the student? _____________

If Unable to Verify: When did you attempt to contact the student? _______________

If End Placement: Date: _____________

What was the result of this educational placement?  

  • Graduated / Completed Successfully
  • Family Care    
  • Pursuing Employment
  • Transferred to another institution    
  • Criminal Justice Involvement
  • Financial Difficulties
  • Other    

If Graduated/Completed Successfully:
What type of degree or credential was earned at this placement?

  • Bachelors Degree
  • Associates Degree
  • Technical Certification    
  • Graduate / Professional Degree
  • Apprenticeship Credential
  • Other

If Bachelors Degree, Associates Degree, Graduate / Professional Degree:
What was the field of study or major for the degree received?

  • STEM
  • Non-STEM
  • Academic
  • Healthcare  
  • Business    
  • Manufacturing
  • Other

If Technical Certification, Apprenticeship Credential, or Other:
What is the name of the credential earned? _________________________

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