Form ORR-9 Annual Survey

OMB Number: 0970-0033

Expiration Date: XX/XX/XXXX

QUESTIONNAIRE FOR

ANNUAL SURVEY

OF

REFUGEES

NOTE: For the re-interview cases, items Q.1a thru Q.1k should only be used for verification. In addition, items marked

with asterisk, Q.2a*, Q.2b*, Q.3a* Q.3d*, Q.4a*, Q.4c*, and Q.4d* should not be re-administered. Refer to

ASR Training Manual.

Office of Refugee Resettlement

Administration for Children and Families

Department of Health and Human Services

ASR-1

ENGLISH

Arrington Dixon and Associates, Inc. 2401 Shannon Place, SE Washington, D.C. (202) 889-0123

INTRODUCTORY STATEMENT

We are with Arrington Dixon and Associates, Inc. We are calling in connection with a survey that we are conducting

for the U.S. Office of Refugee Resettlement concerning the adjustment to life in the United States of refugees and certain

other recent immigrants.

About two weeks ago we sent you a letter describing this survey. As indicated in that letter, any information that you

give us will be held in confidence and will be used for statistical purposes only. Today we would like to talk to you

further about your life in this country.

If you have no questions, we would like to proceed with the interview.

ORR-9

Public reporting burden for this collection of information is estimated to average 40 minutes per response, including

the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of

information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of

information unless it displays a currently valid OMB Control Number.

Send comments regarding this burden estimate or any other aspect of this collection of information, including

suggestions for reducing this burden, to: Reports Clearance Office, Administration for Children and Families,

Department of Health and Human Services, 370 L'Enfant Promenade, Washington, D.C. 20447; and to: Office of

Management and Budget, Paperwork Reduction Project, OMB Control Number 0970-0033, Washington, D.C. 20403.

Arrington Dixon and Associates, Inc. 2401 Shannon Place, SE Washington, D.C. (202) 889-0123

EN-2

Household ID Number _________________________

Interviewer's Name _________________________ Code ___/ ___/ ___

Date of Interview _________________________

Time Interview Started _________________________ AM PM

ATTEMPTS TO CONTACT INTERVIEWEE

1. _________________ 5. __________________ 9. _________________

2. _________________ 6. __________________ 10. _________________

3. _________________ 7. __________________

4. _________________ 8. __________________

TOTAL NUMBER OF ATTEMPTS TO CONTACT INTERVIEWEE _______________

NAME OF RESPONDENT

Last Middle First

CURRENT ADDRESS

Street# Street Name Apt.#

City State Zip Code

TELEPHONE (_______) ______________________________

Area Code

Arrington Dixon and Associates, Inc. 2401 Shannon Place, SE Washington, D.C. (202) 889-0123

EN-3

Q.1 We would like to start by asking you a few questions about each person who lives here, or who is staying or

visiting here and has no other home. Let us start with the person who has overall responsibility, that is the

person in whose name your home is rented, owned, or is being bought: the head of the household. (RECORD

ANSWERS ON ATTACHED HOUSEHOLD CONTROL CHART).

a. What is the name of the Head of the household, and of each of the other members of the

household? (PROBE: ARE THERE OTHER PERSONS WHO USUALLY LIVE HERE

BUT ARE TEMPORARILY ABSENT?)

FOR EACH HOUSEHOLD MEMBER ASK (VERIFY):

b. What is ... relationship to the head of household?

c. What is ... current marital status?

01 Now married (note: spouse need not live in household)

02 Divorced

03 Legally separated

04 Never married

05 Widowed

06 Other (SPECIFY)_______________

d. What was ... age at last birthday?

e. What was ... date of birth?

f. Is ... male or female?

g. What is ... country of birth?

h. What is ... country of citizenship?

i. What is ... ethnic origin?

j. What month and year did ... enter the U.S. to stay?

k. In what State did ... originally resettle?

Arrington Dixon and Associates, Inc. 2401 Shannon Place, SE Washington, D.C. (202) 889-0123

EN-4

Now I want to ask some questions only of persons in your household who are 16 years old or older.

Q.2a* How many years of schooling did ... complete before coming to the U.S.?

Q.2b* What was the highest degree or certificate that ... obtained before coming to the U.S.?

01 None

02 Primary

03 Training in refugee camp

04 Technical school certification

05 Secondary (or high school diploma)

06 University degree (other than medical)

07 Medical degree

08 Other (SPECIFY) ______________

(-9) DK/ (-8) RA/ (-7) NA

Q.3a* Before coming to the U.S., was ...: (If in a refugee camp prior to the U.S., what type of employment did the

person hold before that?)

01 Not employed (skip to Q.3d)

02 Civil servant (civilian in local or national government)

03 In the military

04 Employee in private sector

05 Self-employed

06 Student

07 Other (SPECIFY) ___________________

(-9) DK/ (-8) RA/ (-7) NA

Q.3b* What kind of work (activities) did ... perform before coming to the U.S.? (e.g., lawyer, typist, farmer, teacher,

electrician, student)

Q.3c* What were the most important activities or duties in this job?

Q.3d* Was ... in a prison or reeducation camp prior to coming to the U.S.?

01 No

Yes. How long was ... there?

(-9) DK/ (-8) RA/ (-7) NA

Arrington Dixon and Associates, Inc. 2401 Shannon Place, SE Washington, D.C. (202) 889-0123

PK (-7) DONT KNOW RA (-8) REFUSE TO ANSWER NA (-7) NOT APPLICABLE

EN-5

Q.4a* At the time of arrival in the U.S., how well did ... speak English?

01 Very well

02 Well

03 Not well

04 Not at all

(-9) DK/ (-8) RA/ (-7) NA

Q.4b How well does ... speak English now?

01 Very well

02 Well

03 Not well

04 Not at all

(-9) DK/ (-8) RA/ (-7) NA

Q.4c* Before coming to the U.S. did ... have any English language instruction?

01 No (skip to Q.4e)

02 Yes

(-9) DK/ (-8) RA/ (-7) NA

Q.4d* (If yes to Q.4c) Altogether how many weeks did ... attend English language instruction before coming to the

U.S.?

Q.4e Within the past 12 months, has ... attended an English language training program?

01 No (skip to Q.5a)

02 Yes

(-6) High school student (skip to Q.5a)

(-9) DK/ (-8) RA/ (-7) NA

Q.4f Within the past 12 months, how many weeks did ... attend English language training?

Q.4g Within the past 12 months, did the English language class that ... attended in the U.S. meet every day or less

frequently?

01 Every day

02 2 to 6 times a week

03 Once a week

(-9) DK/ (-8) RA/ (-7) NA

Q.4h Within the past 12 months, how many hours a day was ... in English language training?

Q.4j Is ... currently enrolled in an English language training program?

01 No

02 Yes

(-9) DK/ (-8) RA/ (-7) NA

Q.4k What type of organization gave the English language training program? (Most recent program if more than

one)

School or university

Employer program

Religious organization

Refugee service agency (state/local government)

Refugee mutual assistance association (MAA)

Private individual/group

Other (SPECIFY)________________

(-9) DK/ (-8) RA/ (-7) NA

Arrington Dixon and Associates, Inc. 2401 Shannon Place, SE Washington, D.C. (202) 889-0123

PK (-7) DONT KNOW RA (-8) REFUSE TO ANSWER NA (-7) NOT APPLICABLE

EN-6

Q.5a Did ... work at a job anytime last week?

01 No (skip to Q.11a)

02 Yes (go to Q.5b)

(-9) DK/ (-8) RA/ (-7) NA (skip to Q.11a)

(FOR PERSONS WHO WORKED LAST WEEK)

Q.5b Did ... work at more than one job last week?

01 No (skip to Q.6a)

02 Yes (go to Q.5c)

(-9) DK/ (-8) RA/ (-7) NA (skip to Q.6a)

Q.5c How many jobs did ... work at last week?

Q.6a How many hours did ... work at his/her primary job last week? (Primary job means the job worked at for the

greatest number of hours)

Q.6b How many hours did ... work at all jobs last week?

Q.7 How much money per hour did ... receive at his/her primary job last week?

(If knows hourly wage, skip Q.8a & Q8b. If not, continue with Q.8a.)

Q.8a How much did ... earn before taxes from that job?

Q.8b On what basis is that amount computed?

01 Weekly

02 Bi-weekly

03 Monthly

04 Yearly

If ... worked at second job last week, ask Q.9 If ... worked only one job last week, skip to Q.18a

(SECOND JOB ONLY)

Q.9 How much money per hour did ... receive from his/her second job last week?

(If knows hourly wage, skip to Q.18a. If not, continue with Q.10a)

Q.10a How much did ... earn before taxes from that job?

Q.10b On what basis is that amount computed?

01 Weekly

02 Bi-weekly

03 Monthly

04 Yearly

(Skip to Q.18a)

Arrington Dixon and Associates, Inc. 2401 Shannon Place, SE Washington, D.C. (202) 889-0123

PK (-7) DONT KNOW RA (-8) REFUSE TO ANSWER NA (-7) NOT APPLICABLE

EN-7

Q.11a Has ... ever worked since coming to the U.S. to stay?

01 Never worked in the U.S. (skip to Q.13)

Yes -- How many weeks has it been since ... had a job?

(-9) DK/(-8) RA/ (-7) NA (skip to Q.12)

Q.11b (If yes to 11a, otherwise skip to Q.12) Since coming to the U.S., in how many weeks has ... ever worked?

Q.12 Was ... temporarily absent or on layoff from a job or business last week?

01 No

02 Yes

(-9) DK/ (-8) RA/ (-7) NA

Q.13 Has ... been looking for work during the last 4 weeks?

01 No (skip to Q.17)

02 Yes

(-9) DK/ (-8) RA/ (-7) NA (skip to Q.17)

Q.14 What has ... done to find a job? Has he/she checked with: (multiple answer may be given)

01 Nothing

02 Refugee mutual assistance association (MAA)

03 Refugee service agency

04 Public employment agency

05 Private employment agency

06 Advertisements

07 Sponsor

08 Other refugees

09 Friends (not refugees)

11 Other (SPECIFY)_____________

Q.15 How many weeks has ... been looking for a job?

Q.16 What caused ... to begin looking for work? (multiple answer may be given)

01 New arrival in the U.S.

02 Lost job

03 Quit job

04 Finished school

05 Training ended

06 Moved to a new area

07 Medical problem ended

08 Other (SPECIFY)

09 Eligibility for cash and/or medical assistance ended

(Skip to Q.18a IF WORKED; OR to Q.24a IF NEVER WORKED)

Q.17 Why is ... not looking for a job? (multiple answer may be given)

01 Limited English

02 Attending school or training

03 Poor health or handicap

04 Child care or family responsibilities

05 Believes no work is available

06 Tried to find work but couldn't

08 Age

07 Other (SPECIFY)______________

Go to Q.24a if never worked

Arrington Dixon and Associates, Inc. 2401 Shannon Place, SE Washington, D.C. (202) 889-0123

PK (-7) DONT KNOW RA (-8) REFUSE TO ANSWER NA (-7) NOT APPLICABLE

EN-8

Q.18a In the last year, how many weeks did ... work?

Q.18b How many hours per week did ... usually work?

Q.18c What were ...'s total earnings before taxes from all jobs in the past 12 months?

Q.18d When did ... get his/her first job in the U.S.?

Q.18e Did the income that ... received from his/her first job disqualify ... from receiving cash assistance (such as RCA,

AFDC/TANF, or GA)?

01 No

02 Yes

03 Was not receiving cash assistance at that time

(-9) DK/ (-8) RA/ (-7) NA

Q.19b What kind of business or industry is this? (e.g., hospital, electronic parts manufacturing, social service

agency)

Q.19c What kind of work does(did) .. perform? (e.g., nurse, assembly line worker, typist, supervisor)

Q.20 Is (was) ... a:

01

02

03

04

05

06

07

Employee of a private company, business, or individual (go to Q.22a)

Federal government employee (go to Q.22a)

State government employee (go to Q.22a)

Local government employee (go to Q.22a)

Self-employed (go to Q.21)

Working without pay in family business (skip to Q.24a)

Other (SPECIFY) _____________

(-9) DK/ (-8) RA/ (-7) NA

Q.21 [IF SELF-EMPLOYED]

a. What kind of business is it? (e.g., restaurant, tailor shop, grocery store)

b. How many other refugees does ... employ?

c. How many total employees does ... have?

(-9) DK/ (-8) RA/ (-7) NA

Arrington Dixon and Associates, Inc. 2401 Shannon Place, SE Washington, D.C. (202) 889-0123

PK (-7) DONT KNOW RA (-8) REFUSE TO ANSWER NA (-7) NOT APPLICABLE

EN-9

[FOR EMPLOYEE ONLY]

Q.22a What did ... do to find this job? Did he/she check with:

01 Voluntary agency (agency that helped with initial U.S. resettlement)

02 Refugee mutual assistance association (MAA)

03 Refugee service agency

04 Public Employment Agency

05 Private Employment Agency

06 Advertisements

07 Sponsor

08 Other refugees

09 Friends (not refugees)

111 Religious Institution

112 College/Job Training

113 Self

114 Relative

11 Other (SPECIFY)_____________

(-9) DK/ (-8) RA/ (-7) NA

Q.24a Within the past 12 months, has...attended any job-training program?

01 No (skip to Q.25a)

02 Yes

(-9) DK/ (-8) RA/ (-7) NA

Q.24b How many weeks did that training last?

Q.24c Did the job-training class meet every day or less frequently?

01 Every day

02 2 to 6 times a week

03 Once a week

Q.24d How many hours a day did the job-training class meet?

Q.24e For what kind of work (occupation) did this training prepare ...? (e.g., electronics assembler, welder, typist,

nurse, childcare provider)

Arrington Dixon and Associates, Inc. 2401 Shannon Place, SE Washington, D.C. (202) 889-0123

PK (-7) DONT KNOW RA (-8) REFUSE TO ANSWER NA (-7) NOT APPLICABLE

EN-10

Q.25a Within the past 12 months, has ... attended school or university (other than to take English language training

or the job-training class indicated in the previous question)?

01 No (skip to Q.26b)

02 Yes

(-9) DK/ (-8) RA/ (-7) NA

Q.25b Was ... attending school or university in order to obtain a degree or certificate?

01 No (skip to Q.26b)

02 Yes

(-9) DK/ (-8) RA/ (-7) NA

Q.25c What degree or certificate was ... attempting to earn?

01 High school certificate or equivalency

02 Associate degree

03 Bachelor's degree

04 Master's or Doctorate degree

05 Professional school degree (e.g., MD, LLB, DDS)

06 Other (SPECIFY) ___________

(-9) DK/ (-8) RA/ (-7) NA

Q.25d Has ... received this degree or certificate?

01 No (skip to Q.26b)

02 Yes

(-9) DK/ (-8) RA/ (-7) NA

Q.25e In what year did ... receive this degree or certificate?

Q.26b How many months has ... lived at this residence?

Q.26c Did ... live at this residence a year ago?

01 No

02 Yes (skip to Q.27a)

(-9) DK/ (-8) RA/ (-7) NA

Q.26d Did ... live in this state a year ago?

01 No

02 Yes (skip to Q.27a)

(-9) DK/ (-8) RA/ (-7) NA

Q.26e In which state did ... live a year ago?

01 Not in the U.S. (skip to Q.27a)

Specify state

(-9) DK/ (-8) RA/ (-7) NA

Q.26f What was the primary reason that ... moved to this state?

Arrington Dixon and Associates, Inc. 2401 Shannon Place, SE Washington, D.C. (202) 889-0123

PK (-7) DONT KNOW RA (-8) REFUSE TO ANSWER NA (-7) NOT APPLICABLE

EN-11

Q.27a (For persons in the U.S. 12 months or longer): Has ... applied to adjust his/her immigration status to that of

a permanent U.S. resident?

01 No (skip to Q.27c)

02 Yes (ask Q.27b)

(-9) DK/ (-8) RA/ (-7) NA

Q.27b When did ... apply for adjustment to permanent resident status? (If application date is given, skip to Q.28)

Q.27c Does ... plan to adjust his/her immigration status in the future?

01 No

02 Yes

03 Did not know he/she had to apply to become a permanent resident

Q.28 Does this person have a physical, mental, or other health condition that has lasted for 6 or more months and which:

a. Limits the kind or amount of work this person can do at a job?

01 No

02 Yes

b. Prevents this person from working at a job?

01 No

02 Yes

Q.29a During the past 12 months, how were ...'s medical expenses paid? (may indicate more than one)

01 No medical expenses

02 Self or household members

03 Other relatives or friends

04 Sponsor/sponsoring agency

05 Religious organization

06 Medicaid or Refugee medical assistance

07 Other government source

08 Insurance through own employment (e.g., Blue Cross)

09 Insurance through family member's employment

11 Other source (SPECIFY) __________________

Q.29b What is ... usual source of medical care?

01 No regular source

02 Private physician

03 Emergency room at a hospital

04 Health clinic

05 Folk healer

06 Other (SPECIFY)__________________

Q.29c Was there any time in the past 12 months when ... was not covered either by refugee medical assistance,

Medicaid, or private health insurance?

01 Covered in all months

Yes -- number of months not covered: _______

(-1) Not covered 1 month or less

(-3) Not covered in any month (skip to Q.30a)

Q.29d What type of health insurance coverage did ... have in the past 12 months? (indicate all that apply)

Insurance through own or family member's employment

Private insurance unrelated to employment

Medicaid or refugee medical assistance

Other government health care

Other insurance (SPECIFY)________________

Arrington Dixon and Associates, Inc. 2401 Shannon Place, SE Washington, D.C. (202) 889-0123

PK (-7) DONT KNOW RA (-8) REFUSE TO ANSWER NA (-7) NOT APPLICABLE

EN-12

Now we would like to ask a few questions about the household.

Q.30a FOOD STAMPS - In the past 12 months, have one or more persons in your household received food stamps?

01 No (skip to Q.31a)

02 Yes

(-9) DK/ (-8) RA/ (-7) NA (skip to Q.31a)

Q.30b Who received them? (circle person #s in whose name the assistance was received)

Q.30c What was the total cash value per month? (household)

Q.30d How many months in the past 12 months were food stamps received?

Q.31a AFDC/TANF - In the past 12 months, have one or more persons in your household received cash assistance

through the Aid to Families with Dependent Children (AFDC) program or Temporary Assistance to Needy

Families (TANF) program?

01 No (skip to Q.31f)

02 Yes

(-9) DK/ (-8) RA/ (-7) NA (skip to Q.31f)

Q.31b Which household members received such assistance? (circle person #s in whose name the assistance was

received)

Q.31c What was the cash amount received each month? (household)

Q.31d How many months in the past 12 months was the AFDC or TANF received?

Q.31e In the last month, was AFDC/TANF received?

01 No

02 Yes

(-9) DK/ (-8) RA/ (-7) NA

Q.31f Since coming to the United States, in how many months have one or more persons in your household received

AFDC or TANF?

(A)

(B)

Every month

No months

Number of months: ____________

(-9) DK/ (-8) RA/ (-7) NA

Arrington Dixon and Associates, Inc. 2401 Shannon Place, SE Washington, D.C. (202) 889-0123

PK (-7) DONT KNOW RA (-8) REFUSE TO ANSWER NA (-7) NOT APPLICABLE

EN-13

Q.32a RCA - In the past 12 months, have one or more persons in your household received assistance through the

Refugee Cash Assistance (RCA) program?

01 No (skip to Q.33a)

02 Yes

(-9) DK/ (-8) RA/ (-7) NA (skip to Q.33a)

Q.32b Which household members received such assistance? (circle person #s in whose name the assistance was

received)

Q.32c What was the cash amount received each month? (household)

Q.32d How many months in the past 12 months was RCA received?

Q.32e In the last month, was RCA received?

01 No

02 Yes

(-9) DK/ (-8) RA/ (-7) NA

Q.33a SSI - In the past 12 months, have one or more persons in your household received Supplemental Security

Income (SSI)?

01 No (skip to Q.33f)

02 Yes

(-9) DK/ (-8) RA/ (-7) NA (skip to Q.33f)

Q.33b Which household members received such assistance? (circle person #s in whose name the assistance

was received)

Q.33c What was the cash amount received each month? (household)

Q.33d How many months in the past 12 months was SSI received?

Q.33e In the last month, was SSI received?

01 No

02 Yes

(-9) DK/ (-8) RA/ (-7) NA

Q.33f Since coming to the U.S., in how many months have one or more persons in your household received SSI?

(A) Every month

(B) No months

Number of months: ____________

(-9) DK/ (-8) RA/ (-7) NA

Arrington Dixon and Associates, Inc. 2401 Shannon Place, SE Washington, D.C. (202) 889-0123

PK (-7) DONT KNOW RA (-8) REFUSE TO ANSWER NA (-7) NOT APPLICABLE

EN-14

Q.34a GA - In the past 12 months, have one or more persons in your household received income from General

Assistance (GA)?

01 No (skip to Q.34f)

02 Yes

(-9) DK/ (-8) RA/ (-7) NA (skip to Q.34f)

Q.34b Which household members received such assistance? (circle person #s in whose name the assistance was

received)

Q.34c What was the cash amount received each month? (household)

Q.34d How many months in the past 12 months was GA received?

Q.34e In the last month, was GA received?

01 No

02 Yes

(-9) DK/ (-8) RA/ (-7) NA

Q.34f Since coming to the U.S., in how many months have one or more persons in your household received GA?

(A) Every month

(B) No months

Number of months: ____________

(-9) DK/ (-8) RA/ (-7) NA

Q.35a CASH - In the past 12 months, have one or more persons in your household received cash assistance directly

from a voluntary agency, sponsor, religious organization, or MAA?

01 No (skip to Q.36a)

02 Yes

(-9) DK/ (-8) RA/ (-7) NA (skip to Q.36a)

Q.35b What type of organization or person gave such assistance?

01 Voluntary agency

02 Religious organization

03 Refugee mutual assistance association (MAA)

04 Sponsor

05 Other individual or family member

06 Other organization (SPECIFY)

(-9) DK/ (-8) RA/ (-7) NA

Q.35c Which household members received such assistance? (circle person #s in whose name the assistance was

received)

Q.35d What was the cash amount received each month? (household)

Q.35e How many months in the past 12 months was this private assistance received?

Arrington Dixon and Associates, Inc. 2401 Shannon Place, SE Washington, D.C. (202) 889-0123

PK (-7) DONT KNOW RA (-8) REFUSE TO ANSWER NA (-7) NOT APPLICABLE

EN-15

Q.36a OTHER INCOME - Within the past 12 months has anyone in the household received income from any other

source on a regular basis (such as interest from savings accounts, net rental income, child support,

unemployment compensation or retirement income)?

01No (skip to Q.38a)

02 Yes

(-9) DK/ (-8) RA/ (-7) NA (skip to Q.38a)

Q.36b Who received the income? (circle person #s in whose name income was received)

Q.36c What was the cash amount received on average each month? (household)

Q.36d How many months was this income received in the past 12 months?

Q.36f What was the source of that income? ( more than one answer can be given)

01 Interest income

02 Net rental income

03 Child support

04 Unemployment compensation

05 Retirement income

06 Other (SPECIFY)___________________

(-9) DK/ (-8) RA/ (-7) NA

Q.38a Is this house or apartment

01 Rented for cash rent

02 Owned by you or someone in this household with or without a mortgage or loan

03 Occupied without payment of cash rent

(-9) DK/ (-8) RA/ (-7) NA

Q.38b How much is the total monthly payment for this housing unit? (For owners, include total mortgage payment,

taxes, insurance and utilities; for renters include rent plus utilities - gas, electricity and heating oil - if paid

separately)

Q.38c Is this housing unit in a public housing project, that is, is it owned by a local housing authority or other local

public agency?

01 No

02 Yes

(-9) DK/ (-8) RA/ (-7) NA

THAT WAS OUR FINAL QUESTION. THANK YOU VERY MUCH FOR YOUR PARTICIPATION IN THIS

SURVEY.

INTERVIEWER: Remember to answer the questions on the following page.

Arrington Dixon and Associates, Inc. 2401 Shannon Place, SE Washington, D.C. (202) 889-0123

PK (-7) DONT KNOW RA (-8) REFUSE TO ANSWER NA (-7) NOT APPLICABLE

EN-16

FOR INTERVIEWER ONLY

A. Time Interview Ended _________________________ (Please, use military time)

B. General Responsiveness of Respondent

01 Willing

02 Neutral

03 Reluctant

C. List Difficulties, if any, With the Interview

D. Language in which Interview was Conducted E. Interviewer's Ethnicity

RS Russian RS Russian

VN Vietnamese VN Vietnamese

LA Laotian LA Lao

CB Cambodian CB Cambodian

HM Hmong HM Hmong

SP Spanish SP Cuban/other Hispanic

AH Amharic ET Ethiopian

HA Creole HA Haitian

CN Chinese CN Chinese

RO Romanian RO Romanian

PL Polish PL Polish

AN Armenian AN Armenian

UP Ukrainian UP Ukrainian

AR Arabic IZ Iraqi

IR Farsi IR Iranian

AF Afghan AF Afghan

SO Somalian SO Somalian

BU Bulgarian BU Bulgarian

SR Serbo-Croatian SR Serbian

EN English

Other (SPECIFY) __________ Other (SPECIFY) __________

END

Arrington Dixon and Associates, Inc. 2401 Shannon Place, SE Washington, D.C. (202) 889-0123

EN-17