Florida Agricultural Workers Survey 2009

ENGLISH
OMB NO.: XXXX-XXXX
EXPIRATION DATE: XX/XX/XX
(REV. 1/15/09)

County

Farm Worker ID
[For Office Use Only]

Florida Agricultural Workers Survey 2009
CS2

/

Date:

/
[For Office Use Only]

CS5

Crop:

Crop Code

CS6

Task:

Task Code

Language During Interview:
Location of Interview:

GN:

ID:

GN Referred to:

If GN Referred to Contractor, Grower or Other,
Write Information

9

Contractor?

9

Other Grower?

9

Other? ______________________________

u

Name:
Address

Telephone:

(

)

-

Worker Is Actually Employed By?: 9 1 Grower 9 2 Contractor Number of Production Workers
Type of Work?:

9 1 Field Work

9 2 Nursery

9 3 Packing House

9 7 Other

Farm Worker's Name:
Local Address:
Telephone:

(

)

Interviewer's Name:
CP5 Time Began:

CS9 Interviewer's ID
:

9 AM
9 PM

CP6 Time Ended:

:

9 AM
9 PM

Public reporting burden for the collection of information is estimated to average 75 minutes per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden to: the Office of Information
Management, Department of Labor, Room N-1301, 200 Constitution Avenue, NW, Washington, DC 20210; and to: the Office
of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503.

(REV. 1/15/09) Farm Worker Survey

page 2

REFER TO QUESTIONS IN THE FOLLOWING SECTION

Household Grid
County:

(Farmworker)

A16

Birth Date
MM/YY

Country of
Birth
[Code]

Highest
Grade
Level

Country
School
[Code}

Month and
Year First
Entered U.S.?

[Ask All In A1]: Does S/He Live
With You Now? If Not, Where?
[State/Country]

Last 12 Months,
[Name] Joined You
When Traveled for
FW?

/

S
M
O

/

S
M
O

/

S
M
O

/

S
M
O

/

S
M
O

/

F
M
F
M
F
M
F
H.

A4

S
M
O

M

G.

A8

/

F

F.

**A10

S
M
O

M

E.

A9

/

F

D.

**A7

S
M
O

M

C.

A6

M
F

B.

A5
Marital

A.

A3
Gender

Name

*A2
Relation
[Code]

A1

M
F

*Codes for A2 (Relationship)
1=Spouse/Common Law Spouse
2=Own Child, Dependent or Adopted
3=Sibling
4=Parent
5=Grandchild
6=Other Relative (Cousins, Uncles, etc...)
7=Other: _________________________________

Farmworker ID:

/

Y

Y

N

N

Y

Y

N

N

Y

Y

N

N

Y

Y

N

N

Y

Y

N

N

Y

Y

N

N

Y

Y

N

N

**Codes for A7 and A10 (Countries and Regions)
1=U.S.A.
2=Puerto Rico
3=Mexico
4=Central America
5=South America
6=Caribbean

7=Southeast Asia (Indonesia, Cambodia, Vietnam, Laos, Thailand)
8=Pacific Islands (The Philippines, Guam, Fiji, etc...)
9=Asia (China, Japan, Korea, etc...)
97=Other: ________________________________
99=Not Answered

(REV. 1/15/09) Farm Worker Survey

page 3

REFER TO QUESTIONS IN THE FOLLOWING SECTION

Household Grid
County:

A16

Birth Date
MM/YY

Country of
Birth
[Code]

Highest
Grade
Level

Country
School
[Code}

Month and
Year First
Entered U.S.?

[Ask All In A1]: Does S/He Live
With You Now? If Not, Where?
[State/Country]

Last 12 Months,
[Name] Joined You
When Traveled for
FW?

/

S
M
O

/

S
M
O

/

S
M
O

/

S
M
O

/

S
M
O

/

F
M
F
M
F
M
F
P.

A4

S
M
O

M

O.

A8

/

F

N.

**A10

S
M
O

M

M.

A9

/

F

L.

**A7

S
M
O

M

K.

A6

M
F

J.

A5
Marital

I.

A3
Gender

Name

*A2
Relation
Code

A1

M
F

*Codes for A2 (Relationship)
1=Spouse/Common Law Spouse
2=Own Child, Dependent or Adopted
3=Sibling
4=Parent
5=Grandchild
6=Other Relative (Cousins, Uncles, etc...)
7=Other: _________________________________

Farmworker ID:

Y

Y

N

N

Y

Y

N

N

Y

Y

N

N

Y

Y

N

N

Y

Y

N

N

Y

Y

N

N

Y

Y

N

N

Y

Y

N

N

**Codes for A7 and A10 (Countries and Regions)
1=U.S.A.
2=Puerto Rico
3=Mexico
4=Central America
5=South America
6=Caribbean

7=Southeast Asia (Indonesia, Cambodia, Vietnam, Laos, Thailand)
8=Pacific Islands (The Philippines, Guam, Fiji, etc...)
9=Asia (China, Japan, Korea, etc...)
97=Other: ________________________________
99=Not Answered

(REV. 1/15/09) Farm Worker Survey

page 4

[The Following Questions Refer To Other Individuals Who Live With
The Worker and Were Not Mentioned In The "Household Grid"]
A15

Other than those you have already mentioned, how many people live with you now?
A20
...your
relatives?

Out of those (Total in "A15"), how many are:

a.

...adults?

b.

...children?

c.

...do not know age?

A16
...doing
FW?

Total
A17
How many
are doing
NF?

A18
How many
NW?

(18 years or older?)
(17 years or younger?)

Insurance Questions About Respondent and His/Her Family
(Individuals In The "Household Grid")
A21

A23

Who has Health (Medical) Insurance in your family (in the U.S.A.)?

Who Pays For It?
[Use Codes.]

How about...

a.

...you (farm worker)?

[Only for Children: If yes, ask how many of the children under
and over 18 year old have insurance. Match total number with
Family Grid.]

9 0 No

Mark All That Apply

91

92

9 7Don't Know

95

9 6:

9 0 No

91

92

95

9 6:

91

92

95

9 6:

93

94

93

94

93

94

9 1 Yes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

b.

...your spouse?

9 1 Yes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9 7 Don't Know
c.

...your children?

A21c2

9 0 No

A24
(a) How many under 18 yrs.?

9 1 Yes, All Have It (Ask A23)
(b) How many over 18 yrs.?

9 2 Yes, Some Have It
9 7 Don't Know
Codes for "A23" (Who Pays?):

1 = I Pay

3 = My Employer

5 = Government

2 = My Spouse

4 = My Spouse's Employer

6 = Other:
________________________

(REV. 1/15/09) Farm Worker Survey

page 5

B4 In the last 2 years, has anyone in your household (from
"Family Grid") - excluding yourself - attended training,
special classes or schools in the U.S.? [READ ALL
CHOICES. MARK ALL THAT APPLY.]:

G7 [ONLY for those BORN OUTSIDE the U.S.A.] In your
home country, do you own or are you buying any of the
following items? [READ ALL CHOICES. MARK ALL THAT
APPLY.]:

9 a.

9 a.
9 b.
9 c.
9 d.
9 e.
9 f.
9

9 d.
9 f.
9 j.
9 k.
9 l.
9 n.
9

Adult Education such as English/ESL/Adult Basic
Education/Citizenship?
Job training?
GED (High School Equivalency)?
Migrant Education
Head Start?
Migrant Head Start?
Other?
Don't Know.

G4 In the last 2 years, have you or anyone in your
household received benefits or used the services of any
of the following social programs? [READ CHOICES. MARK
ALL THAT APPLY.]:

9 p.
9 b.
9 c.
9 d.
9 e.
9 f.
9 g.
9 h.
9 i.
9 j.
9 k.
9 l.
9 m.
9 n.
9

Temporary Assistance for Needy Families (TANF)?
Food Stamps?
Disability Insurance?
Unemployment Insurance?
Social Security?
Veteran's Pay?
General Assistance/Welfare?
Low Income Housing?
Public Health Clinic?
Medicaid?
WIC?
Disaster Relief?
Legal Services?
Other?
Don't Know.

G6 Do you own or are you buying any of the following items
in the U.S.? [READ CHOICES. MARK ALL THAT APPLY.]:

9 a.
9 b.
9 c.
9 d.
9 e.
9 f.
9

A Plot of Land?
A House?
A Mobile Home?
A Car or Truck?
A Business?
Other?
None.

A Plot of Land?
A House?
A Mobile Home?
A Car or Truck?
A Business?
Other?
None.

B1 Which of the following describes you? [READ ALL CHOICES.
CHECK ONLY ONE.]:

9 1.
9 2.
9 3.
9 5.
9 4.
9 7.

Mexican-American?
Mexican?
Chicano?
Puerto Rican?
Other Hispanic?
Not Hispanic or Latino?

B2 Which of the following do you consider yourself? [READ
ALL CHOICES. MARK ALL THAT APPLY.]:

9 1.
9 2.
9 4.
9 5.
9 6.
9 7.

White?
Black or African American?
American Indian/Alaskan Native, Indigenous?
Asian?
Native Hawaiian or Pacific Islander?
Other?

B3 Have you received any job training or attended any of the
following special classes or school in the U.S.? [READ ALL
CHOICES. MARK ALL THAT APPLY.]:

9 a.
9 b.
9 c.
9 d.
9 e.
9 f.
9 g.
9 h.
9 i.
9 j.
9

English/ESL?
Citizenship?
Literacy?
Job Training?:
GED/High School Equivalency?
College or University?
Adult Basic Education?
Even Start?
Migrant Education?
Other?
None.

(REV. 1/15/09) Farm Worker Survey

page 6

[IF FOREIGN BORN, ASK]
B18

Where were you born? In what...

(d)
...State?
(Department)

(e)
...Municipality
(Equivalent)?

(f)
...Town
(or City)?

B16

When you lived in your country,
did you work in...

G1
G2
G3

...Agriculture [FW]?
...Non-Agriculture [NF]?
...Part Farm and Part Non-Farm [FW
and NF]
...Never Worked?
Not Applicable [Only for those born
in the U.S.]

G5
G8

B17 - 18
Before coming to the USA, you lived
in what...
(B17)
...Country?

(B18)
...State
(or Department)?

LANGUAGE SECTION
B7 How well do you speak English? [READ CHOICES. MARK
ONLY ONE RESPONSE.]:
9 1. Not At All?
9 3. Somewhat?
9 2. A Little?
9 4. Well?

B20
When you were a
child, in what
language did adults
speak to you at
home?
[CHECK ALL THAT
APPLY.]:

U

B8 How well do you read English? [READ CHOICES. MARK ONLY
ONE RESPONSE.]:
9 1. Not At All?
9 3. Somewhat?
9 2. A Little?
9 4. Well?

B21
And now, as an adult, what languages can you speak?

[For each checked answer, ask]:
[CHECK
ALL THAT
APPLY]

U

B22
And now, how well do you
speak it? [READ CHOICES.
MARK ONLY ONE PER CHECK]:

B23
And now, how well do you read
it? [READ CHOICES. MARK ONLY
ONE PER CHECK]:

B24
In which language
do you believe you
are most dominant
(comfortable
conversing)?
[CHECK ONLY ONE.]

U

a.

ENGLISH

b.

SPANISH

9 2.
9 3.
9 4.

A Little?
Somewhat?
Well?

9 1.
9 2.
9 3.
9 4.

Not At All?
A Little?
Somewhat?
Well?

c.

CREOLE

9 2.
9 3.
9 4.

A Little?
Somewhat?
Well?

9 1.
9 2.
9 3.
9 4.

Not At All?
A Little?
Somewhat?
Well?

d.

MIXTEC

9 2.
9 3.
9 4.

A Little?
Somewhat?
Well?

9 1.
9 2.
9 3.
9 4.

Not At All?
A Little?
Somewhat?
Well?

e.

KANJOBAL

9 2.
9 3.
9 4.

A Little?
Somewhat?
Well?

9 1.
9 2.
9 3.
9 4.

Not At All?
A Little?
Somewhat?
Well?

f.

ZAPOTEC

9 2.
9 3.
9 4.

A Little?
Somewhat?
Well?

9 1.
9 2.
9 3.
9 4.

Not At All?
A Little?
Somewhat?
Well?

z.

OTHER:

9 2.
9 3.
9 4.

A Little?
Somewhat?
Well?

9 1.
9 2.
9 3.
9 4.

Not At All?
A Little?
Somewhat?
Well?

(REV. 1/15/09) Farm Worker Survey

page 7

B10 In what month and year did you first do any farm work in
the U.S. (First time FW in the U.S.)?
[ASK FOR MONTH AND YEAR.]:
Month

/

Year

B11 Approximately how many years have you done farmwork
in the U.S.? [COUNT ANY YEAR IN WHICH 15 DAYS OR MORE
WERE WORKED]:

D33a While you are working for this grower/contractor, what
type of payment arrangement do you have for your
living quarters? [IF PAYMENT IS ONLY FOR UTILITIES,
CONSIDER IT FREE. DO NOT READ CHOICES. MARK ONLY
ONE]:

9 10. I (or I and my family) receive FREE housing from my
employer. [SKIP TO D34a]

9 3. I Pay for housing provided by My Employer. (I pay
directly or through wage deduction.)

Years

9 5. I Pay for housing provided by the Government, a
charity, or other non-work related institution.

B12 Approximately how many years have you done
non-farmwork in the U.S.? [COUNT ANY YEAR IN WHICH 15
DAYS OR MORE WERE WORKED.]

9 11. I Do Not Pay Rent. (I or family member own the
house or live for free with friends or relatives.) [SKIP TO
D34a]

9 12. I Rent from Non-Employer (relative or non-relative).

Years

9 97.
B13 When was the last time your parents did hired farm-work
in the U.S.?
9 0. Never?
9 1. Now/Within Last Year?
9 2. One to Five Years Ago?
9 3. Six to 10 Years Ago?
9 4. Over 11 Years Ago?
9 7. Don't Know?

B26-27

...And where were your parents born? In what...

...Country?:
(B26a) Father?:

(B27a) Mother?:

[Ask Questions Below Only For Foreign Country in "B26a"
and "B27a"]:...
...State ( or Department or Equivalent)?:
(B26b) Father?:

B27b) Mother?:

...Municipality (or District or Equivalent)?:
(B26c) Father?:

(B27c) Mother?:

...Town (or City)?:
(B26d) Father?:

(B27d) Mother?:

(REV. 1/15/09) Farm Worker Survey

D50

page 8

At this location, how much do you pay for housing
(including housing for your family, if they live with you)?

9 1.
per week

$

,

$

,

.

or
per day

$

,

.

9 2.

Don't know. taken out of my paycheck.

9 3.

Don't know/Don't remember, but not taken out of my
paycheck.

9 7.

Where are your living quarters located?
[READ CHOICES. MARK ONLY ONE.]

9 1.

Off-farm in property not owned or administered by
your present employer?

9 2.

Off-farm in property owned or administered by your
present employer?

9 3.

On-farm of the grower for whom you currently work?

9 7.

Other?

D54

How many of the following do you have in your current
living quarters (dwelling)?

.

or
per month

D35

a. Bedrooms?

Other.

b. Bathrooms?
c. Kitchen?

D34a In what type of living quarters do you live now (housing
structure at this location)?
[READ CHOICES. MARK ONLY ONE.]
Is it a...

f. Other Rooms?
D52

How many people, in total, sleep in these rooms?
[VERIFY RESPONSE BY ADDING TOTAL NUMBER GIVEN IN
THE HOUSEHOLD GRID PLUS TOTAL IN A15. IF ANSWERS
DO NOT MATCH, MAKE APPROPRIATE CHANGES.]

9 1.

Mobile home?

9 2.

Single-family home (detached)?

9 3.

Duplex, triplex, etc...(attached, own parking space with
direct access to home)?

9 4.

Apartments (two or more in a building, shared parking
spaces)?

9 5.

Dormitory or barracks?

During the past 12 months, where have your children,
12 and under, been while your work in U.S. farmwork?

9 6.

Campsite or tent?

[CHECK ALL THAT APPLY.]

9 7.

Motel or hotel?

9 1.

9 8.

Without shelter, "homeless" (includes "sleeping in a
car")? [SKIP TO D36A]

9 13. With my spouse/other family.

9 97. Other?

D36a

[FOR PARENTS OF CHILDREN 12 OR YOUNGER.]

They've stayed at home alone, at least sometimes.

9 14. With a neighbor/babysitter, migrant head start, head
start, migrant education, daycare center, etc...

9 11. With me in the fields.
9 12. Other:

((REV. 1/15/09) Farm Worker Survey

page 9

Work Grid

REFER TO QUESTIONS IN THE FOLLOWING SECTION

REPORT FROM PRESENT TO PERIOD COVERING JANUARY 1, 2008

C15

PER. &SUB-PER.NO.

GR
CO
[FW
Only]

C6

C8

NF?
NW?
AB?

C3

C4

EMPLOYER'S NAME

FW?
UNEMPLOYMENT
RECEIVED?

C1-C2

County:

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

(FARM WORK, NONFARM WORK, AND
WORK ABROAD)

CROP

Farmworker ID:

C5

C9

C10

WRITE ACTIVITY
OR TASK WHILE
FW AND NF

DATES FOR
PERIODS OF
FW, NF,
NW, AB

# OF
WORK

COUNTY NAME

DAYS
PER
WEEK?

[IF IN A BORDER
COUNTY,

[USE CODES FOR
*NW AND **AB]

FROM

TO

FW & NF

C11

CITY

C12

ASK IF COMMUTE FROM
MEXICO]

C7

C16

***FW

WERE

AND NF:

YOUR
SPOUSE AND
KIDS
WITH
YOU?

WHY
LEFT?
[CODES]

SPOUSE
CHILDREN
ALL
NO

COMMUTE FROM
MEXICO TO DO FW?
Y
N

SPOUSE
CHILDREN
ALL
NO

COMMUTE FROM
MEXICO TO DO FW?
Y
N

SPOUSE
CHILDREN
ALL
NO

COMMUTE FROM
MEXICO TO DO FW?
Y
N

SPOUSE
CHILDREN
ALL
NO

COMMUTE FROM
MEXICO TO DO FW?
Y
N

SPOUSE
CHILDREN
ALL
NO

COMMUTE FROM
MEXICO TO DO FW?
Y

C-5 Activity Codes: Only for "NW" (In the U.S.A.)
[Write Activity for FW and NF]
201 = Looking for FW and NF Work
202 = Looking for Farm Work
203 = Looking for NF Work
204 = Waiting for Recall Notice (After Layoff)
205 = Waiting for Start of Season
206 = Family Responsibilities/Work in Home

C13

STATE / COUNTRY

[C1-C2 FOR OFFICE USE ONLY]

207 = In School
208 = Laid-up Due to Injury
209 = In-transit Between Jobs
210 = Vacation
211 = Did Not Look for Work
212 = Other: (Specify in Grid)

** C-5 Activity Codes: Only for "AB" (While in a
Foreign Country or Abroad)
311 = FW in Family Ranch
312 = FW-Hired
320 = NF in Own Business: (Specify in Grid)
341 = NF in "Maquila"
359 = NF - Other: (Specify in Grid)
361 = NW - Medical Treatment
362 = NW - Vacation
369 = NW - Other: (Specify in Grid)

N

*** C-7 Codes: Why Left "FW" and "NF"?
1 = Laid-Off/End of Season
2 = Fired
3 = Family Responsibilities
4 = School
5 = Moved
6 = Health Reason
7 = Vacation

8 = Retired
10 = Quit
11 = Change Jobs
9 = Other (Specify):

(REV. 1/15/09) Farm Worker Survey

page 10

Work Grid

REFER TO QUESTIONS IN THE FOLLOWING SECTION

REPORT FROM PRESENT TO PERIOD COVERING JANUARY 1, 2008

C15

PER. &SUB-PER.NO.

GR
CO
[FW
Only]

C6

C8

FW?
NF?
NW?
AB?

C3

C4

EMPLOYER'S NAME
UNEMPLOYMENT
RECEIVED?

C1-C2

County:

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

(FARM WORK, NONFARM WORK, AND
WORK ABROAD)

CROP

Farmworker ID:

C5

C9

C10

WRITE ACTIVITY
OR TASK WHILE
FW AND NF

DATES FOR
PERIODS OF
FW, NF,
NW, AB

# OF
WORK

COUNTY NAME

DAYS
PER
WEEK?

[IF IN A BORDER
COUNTY,

[USE CODES FOR
*NW AND **AB]

FROM

TO

FW & NF

C11

CITY

C12

ASK IF COMMUTE FROM
MEXICO]

C7

C16

***FW

WERE

AND NF:

YOUR
SPOUSE AND
KIDS
WITH
YOU?

WHY
LEFT?
[CODES]

SPOUSE
CHILDREN
ALL
NO

COMMUTE FROM
MEXICO TO DO FW?
Y
N

SPOUSE
CHILDREN
ALL
NO

COMMUTE FROM
MEXICO TO DO FW?
Y
N

SPOUSE
CHILDREN
ALL
NO

COMMUTE FROM
MEXICO TO DO FW?
Y
N

SPOUSE
CHILDREN
ALL
NO

COMMUTE FROM
MEXICO TO DO FW?
Y
N

SPOUSE
CHILDREN
ALL
NO

COMMUTE FROM
MEXICO TO DO FW?
Y

C-5 Activity Codes: Only for "NW" (In the U.S.A.)
[Write Activity for FW and NF]
201 = Looking for FW and NF Work
202 = Looking for Farm Work
203 = Looking for NF Work
204 = Waiting for Recall Notice (After Layoff)
205 = Waiting for Start of Season
206 = Family Responsibilities/Work in Home

C13

STATE / COUNTRY

[C1-C2 FOR OFFICE USE ONLY]

207 = In School
208 = Laid-up Due to Injury
209 = In-transit Between Jobs
210 = Vacation
211 = Did Not Look for Work
212 = Other: (Specify in Grid)

** C-5 Activity Codes: Only for "AB" (While in a
Foreign Country or Abroad)
311 = FW in Family Ranch
312 = FW-Hired
320 = NF in Own Business: (Specify in Grid)
341 = NF in "Maquila"
359 = NF - Other: (Specify in Grid)
361 = NW - Medical Treatment
362 = NW - Vacation
369 = NW - Other: (Specify in Grid)

N

*** C-7 Codes: Why Left "FW" and "NF"?
1 = Laid-Off/End of Season
2 = Fired
3 = Family Responsibilities
4 = School
5 = Moved
6 = Health Reason
7 = Vacation

8 = Retired
10 = Quit
11 = Change Jobs
9 = Other (Specify):

(REV. 1/15/09) Farm Worker Survey

page 11

Work Grid

REFER TO QUESTIONS IN THE FOLLOWING SECTION

REPORT FROM PRESENT TO PERIOD COVERING JANUARY 1, 2008

C15

PER. &SUB-PER.NO.

GR
CO
[FW
Only]

C6

C8

FW?
NF?
NW?
AB?

C3

C4

EMPLOYER'S NAME
UNEMPLOYMENT
RECEIVED?

C1-C2

County:

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

(FARM WORK, NONFARM WORK, AND
WORK ABROAD)

CROP

C5

C9

C10

WRITE ACTIVITY
OR TASK WHILE
FW AND NF

DATES FOR
PERIODS OF
FW, NF,
NW, AB

# OF
WORK

COUNTY NAME

DAYS
PER
WEEK?

[IF IN A BORDER
COUNTY,

[USE CODES FOR
*NW AND **AB]

FROM

TO

FW & NF

C11

CITY

C12

ASK IF COMMUTE FROM
MEXICO]

C13

C7

C16

***FW

WERE

AND NF:

YOUR
SPOUSE AND
KIDS
WITH
YOU?

WHY
LEFT?
[CODES]

SPOUSE
CHILDREN
ALL
NO

COMMUTE FROM
MEXICO TO DO FW?
Y
N

SPOUSE
CHILDREN
ALL
NO

COMMUTE FROM
MEXICO TO DO FW?
Y
N

SPOUSE
CHILDREN
ALL
NO

COMMUTE FROM
MEXICO TO DO FW?
Y
N

SPOUSE
CHILDREN
ALL
NO

COMMUTE FROM
MEXICO TO DO FW?
Y
N

SPOUSE
CHILDREN
ALL
NO

COMMUTE FROM
MEXICO TO DO FW?
Y
N

C-5 Activity Codes: Only for "NW" (In the U.S.A.)
[Write Activity for FW and NF]
201 = Looking for FW and NF Work
202 = Looking for Farm Work
203 = Looking for NF Work
204 = Waiting for Recall Notice (After Layoff)
205 = Waiting for Start of Season
206 = Family Responsibilities/Work in Home

Farmworker ID:

STATE / COUNTRY

[C1-C2 FOR OFFICE USE ONLY]

207 = In School
208 = Laid-up Due to Injury
209 = In-transit Between Jobs
210 = Vacation
211 = Did Not Look for Work
212 = Other: (Specify in Grid)

** C-5 Activity Codes: Only for "AB" (While in a
Foreign Country or Abroad)
311 = FW in Family Ranch
312 = FW-Hired
320 = NF in Own Business: (Specify in Grid)
341 = NF in "Maquila"
359 = NF - Other: (Specify in Grid)
361 = NW - Medical Treatment
362 = NW - Vacation
369 = NW - Other: (Specify in Grid)

*** C-7 Codes: Why Left "FW" and "NF"?
1 = Laid-Off/End of Season
2 = Fired
3 = Family Responsibilities
4 = School
5 = Moved
6 = Health Reason
7 = Vacation

8 = Retired
10 = Quit
11 = Change Jobs
9 = Other (Specify):

(REV. 1/15/09) Farm Worker Survey

page 12

Work Grid

REFER TO QUESTIONS IN THE FOLLOWING SECTION

REPORT FROM PRESENT TO PERIOD COVERING JANUARY 1, 2008

C15

PER. &SUB-PER.NO.

GR
CO
[FW
Only]

C6

C8

FW?
NF?
NW?
AB?

C3

C4

EMPLOYER'S NAME
UNEMPLOYMENT
RECEIVED?

C1-C2

County:

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

(FARM WORK, NONFARM WORK, AND
WORK ABROAD)

CROP

Farmworker ID:

C5

C9

C10

WRITE ACTIVITY
OR TASK WHILE
FW AND NF

DATES FOR
PERIODS OF
FW, NF,
NW, AB

# OF
WORK

COUNTY NAME

DAYS
PER
WEEK?

[IF IN A BORDER
COUNTY,

[USE CODES FOR
*NW AND **AB]

FROM

TO

FW & NF

C11

CITY

C12

ASK IF COMMUTE FROM
MEXICO]

C7

C16

***FW

WERE

AND NF:

YOUR
SPOUSE AND
KIDS
WITH
YOU?

WHY
LEFT?
[CODES]

SPOUSE
CHILDREN
ALL
NO

COMMUTE FROM
MEXICO TO DO FW?
Y
N

SPOUSE
CHILDREN
ALL
NO

COMMUTE FROM
MEXICO TO DO FW?
Y
N

SPOUSE
CHILDREN
ALL
NO

COMMUTE FROM
MEXICO TO DO FW?
Y
N

SPOUSE
CHILDREN
ALL
NO

COMMUTE FROM
MEXICO TO DO FW?
Y
N

SPOUSE
CHILDREN
ALL
NO

COMMUTE FROM
MEXICO TO DO FW?
Y

C-5 Activity Codes: Only for "NW" (In the U.S.A.)
[Write Activity for FW and NF]
201 = Looking for FW and NF Work
202 = Looking for Farm Work
203 = Looking for NF Work
204 = Waiting for Recall Notice (After Layoff)
205 = Waiting for Start of Season
206 = Family Responsibilities/Work in Home

C13

STATE / COUNTRY

[C1-C2 FOR OFFICE USE ONLY]

207 = In School
208 = Laid-up Due to Injury
209 = In-transit Between Jobs
210 = Vacation
211 = Did Not Look for Work
212 = Other: (Specify in Grid)

** C-5 Activity Codes: Only for "AB" (While in a
Foreign Country or Abroad)
311 = FW in Family Ranch
312 = FW-Hired
320 = NF in Own Business: (Specify in Grid)
341 = NF in "Maquila"
359 = NF - Other: (Specify in Grid)
361 = NW - Medical Treatment
362 = NW - Vacation
369 = NW - Other: (Specify in Grid)

N

*** C-7 Codes: Why Left "FW" and "NF"?
1 = Laid-Off/End of Season
2 = Fired
3 = Family Responsibilities
4 = School
5 = Moved
6 = Health Reason
7 = Vacation

8 = Retired
10 = Quit
11 = Change Jobs
9 = Other (Specify):

(REV. 1/15/09) Farm Worker Survey

page 13

Work Grid

REFER TO QUESTIONS IN THE FOLLOWING SECTION

Report from December 31, 2007 to First Work in the U.S.

C15

C6

GR

FW?

EMPLOYER'S NAME

CO

NF?

(FARM WORK, NON-FARM WORK,
AND WORK ABROAD)

[FW Only]

NW?
AB?

C8

UNEMPLOYMENT
RECEIVED?

PER. AND
SUB-PER. NO.

C1-C2

County:

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

C3

C4

CROP

C5

C9

C11

WRITE ACTIVITY OR TASK WHILE
FW AND NF

DATES FOR
Periods of
FW, NF,
NW, AB

CITY

[USE CODES FOR *NW AND
**AB]

From

* C-5 Activity Codes: Only for "NW" (In the U.S.A.)
[Write Activity for FW and NF]
201 = Looking for FW and NF Work
202 = Looking for Farm Work
203 = Looking for NF Work
204 = Waiting for Recall Notice (After Layoff)
205 = Waiting for Start of Season
206 = Family Responsibilities/Work in Home

Farmworker ID:

207 = In School
208 = Laid-up Due to Injury
209 = In-transit Between Jobs
210 = Vacation
211 = Did Not Look for Work
212 = Other: (Specify in Grid)

To

** C-5 Activity Codes: Only for "AB" (While in a
Foreign Country or Abroad)
311 = FW in Family Ranch
312 = FW-Hired
320 = NF in Own Business: (Specify in Grid)
341 = NF in "Maquila"
359 = NF - Other: (Specify in Grid)
361 = NW - Medical Treatment
362 = NW - Vacation
369 = NW - Other: (Specify in Grid)

C13

STATE / COUNTRY

[C1-C2 FOR OFFICE USE ONLY]

(REV. 1/15/09) Farm Worker Survey

page 14

Work Grid

REFER TO QUESTIONS IN THE FOLLOWING SECTION

Report from December 31, 2007 to First Work in the U.S.

C15

C6

GR

FW?

CO

NF?

[FW
Only]

NW?
AB?

C8

UNEMPLOYMENT
RECEIVED?

PER. AND
SUB-PER. NO.

C1-C2

County:

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

C3
EMPLOYER'S NAME
(FARM WORK, NON-FARM
WORK, AND WORK
ABROAD)

C4

CROP

C5

C9

C11

WRITE ACTIVITY OR
TASK WHILE FW AND NF

DATES FOR
Periods of
FW, NF,
NW, AB

CITY

[USE CODES FOR *NW
AND **AB]

From

* C-5 Activity Codes: Only for "NW" (In the U.S.A.)
[Write Activity for FW and NF]
201 = Looking for FW and NF Work
202 = Looking for Farm Work
203 = Looking for NF Work
204 = Waiting for Recall Notice (After Layoff)
205 = Waiting for Start of Season
206 = Family Responsibilities/Work in Home

Farmworker ID:

207 = In School
208 = Laid-up Due to Injury
209 = In-transit Between Jobs
210 = Vacation
211 = Did Not Look for Work
212 = Other: (Specify in Grid)

To

** C-5 Activity Codes: Only for "AB" (While in a
Foreign Country or Abroad)
311 = FW in Family Ranch
312 = FW-Hired
320 = NF in Own Business: (Specify in Grid)
341 = NF in "Maquila"
359 = NF - Other: (Specify in Grid)
361 = NW - Medical Treatment
362 = NW - Vacation
369 = NW - Other: (Specify in Grid)

C13

STATE / COUNTRY

[C1-C2 FOR OFFICE USE ONLY]

(REV. 1/15/09) Farm Worker Survey

page 15

Work Grid

REFER TO QUESTIONS IN IN THE FOLLOWING SECTION

Report from December 31, 2007 to First Work in the U.S.

C15

C6

GR

FW?

CO

NF?

[FW
Only]

NW?
AB?

C8

UNEMPLOYMENT
RECEIVED?

PER. AND
SUB-PER. NO.

C1-C2

County:

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

C3
EMPLOYER'S NAME
(FARM WORK, NON-FARM
WORK, AND WORK
ABROAD)

C4

CROP

C5

C9

C11

WRITE ACTIVITY OR
TASK WHILE FW AND NF

DATES FOR
Periods of
FW, NF,
NW, AB

CITY

[USE CODES FOR *NW
AND **AB]

From

* C-5 Activity Codes: Only for "NW" (In the U.S.A.)
[Write Activity for FW and NF]
201 = Looking for FW and NF Work
202 = Looking for Farm Work
203 = Looking for NF Work
204 = Waiting for Recall Notice (After Layoff)
205 = Waiting for Start of Season
206 = Family Responsibilities/Work in Home

Farmworker ID:

207 = In School
208 = Laid-up Due to Injury
209 = In-transit Between Jobs
210 = Vacation
211 = Did Not Look for Work
212 = Other: (Specify in Grid)

To

** C-5 Activity Codes: Only for "AB" (While in a
Foreign Country or Abroad)
311 = FW in Family Ranch
312 = FW-Hired
320 = NF in Own Business: (Specify in Grid)
341 = NF in "Maquila"
359 = NF - Other: (Specify in Grid)
361 = NW - Medical Treatment
362 = NW - Vacation
369 = NW - Other: (Specify in Grid)

C13

STATE / COUNTRY

[C1-C2 FOR OFFICE USE ONLY]

(REV. 1/15/09) Farm Worker Survey

page 16

Work Grid

REFER TO QUESTIONS IN IN THE FOLLOWING SECTION

Report from December 31, 2007 to First Work in the U.S.

C15

C6

GR

FW?

CO

NF?

[FW
Only]

NW?
AB?

C8

UNEMPLOYMENT
RECEIVED?

PER. AND
SUB-PER. NO.

C1-C2

County:

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

C3
EMPLOYER'S NAME
(FARM WORK, NON-FARM
WORK, AND WORK
ABROAD)

C4

C5

C9

C11

CROP

WRITE ACTIVITY OR
TASK WHILE FW AND NF
[USE CODES FOR *NW
AND **AB]

DATES FOR
Periods of
FW, NF,
NW, AB

CITY

From

* C-5 Activity Codes: Only for "NW" (In the U.S.A.)
[Write Activity for FW and NF]
201 = Looking for FW and NF Work
202 = Looking for Farm Work
203 = Looking for NF Work
204 = Waiting for Recall Notice (After Layoff)
205 = Waiting for Start of Season
206 = Family Responsibilities/Work in Home

Farmworker ID:

207 = In School
208 = Laid-up Due to Injury
209 = In-transit Between Jobs
210 = Vacation
211 = Did Not Look for Work
212 = Other: (Specify in Grid)

To

** C-5 Activity Codes: Only for "AB" (While in a
Foreign Country or Abroad)
311 = FW in Family Ranch
312 = FW-Hired
320 = NF in Own Business: (Specify in Grid)
341 = NF in "Maquila"
359 = NF - Other: (Specify in Grid)
361 = NW - Medical Treatment
362 = NW - Vacation
369 = NW - Other: (Specify in Grid)

C13

STATE / COUNTRY

[C1-C2 FOR OFFICE USE ONLY]

(REV. 1/15/09) Farm Worker Survey

page 17

Work Grid

REFER TO QUESTIONS IN IN THE FOLLOWING SECTION

Report from December 31, 2007 to First Work in the U.S.

C1-C2

County:

C15

C6

GR

FW?

C8

[FW
Only]

NW?
AB?

UNEMPLOYMENT
RECEIVED?

PER. AND
SUB-PER. NO.

NF?
CO

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

C3
EMPLOYER'S NAME
(FARM WORK, NON-FARM
WORK, AND WORK
ABROAD)

C4

C5

C9

C11

CROP

WRITE ACTIVITY OR
TASK WHILE FW AND NF
[USE CODES FOR *NW
AND **AB]

DATES FOR
Periods of
FW, NF,
NW, AB

CITY

From

* C-5 Activity Codes: Only for "NW" (In the U.S.A.)
[Write Activity for FW and NF]
201 = Looking for FW and NF Work
202 = Looking for Farm Work
203 = Looking for NF Work
204 = Waiting for Recall Notice (After Layoff)
205 = Waiting for Start of Season
206 = Family Responsibilities/Work in Home

Farmworker ID:

207 = In School
208 = Laid-up Due to Injury
209 = In-transit Between Jobs
210 = Vacation
211 = Did Not Look for Work
212 = Other: (Specify in Grid)

To

** C-5 Activity Codes: Only for "AB" (While in a
Foreign Country or Abroad)
311 = FW in Family Ranch
312 = FW-Hired
320 = NF in Own Business: (Specify in Grid)
341 = NF in "Maquila"
359 = NF - Other: (Specify in Grid)
361 = NW - Medical Treatment
362 = NW - Vacation
369 = NW - Other: (Specify in Grid)

C13

STATE / COUNTRY

[C1-C2 FOR OFFICE USE ONLY]

(REV. 1/15/09) Farm Worker Survey

page 18

Work Grid

REFER TO QUESTIONS IN IN THE FOLLOWING SECTION

Report from December 31, 2007 to First Work in the U.S.

C1-C2

County:

C15

C6

GR

FW?

C8

UNEMPLOYMENT
RECEIVED?

PER. AND
SUB-PER. NO.

NF?
CO
[FW
Only]

NW?

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

GR

FW
NF

Y

CO

NW
AB

N

AB?

C3
EMPLOYER'S NAME
(FARM WORK, NON-FARM
WORK, AND WORK
ABROAD)

C4

CROP

C5

C9

C11

WRITE ACTIVITY OR
TASK WHILE FW AND NF

DATES FOR
Periods of
FW, NF,
NW, AB

CITY

[USE CODES FOR *NW
AND **AB]

From

* C-5 Activity Codes: Only for "NW" (In the U.S.A.)
[Write Activity for FW and NF]
201 = Looking for FW and NF Work
202 = Looking for Farm Work
203 = Looking for NF Work
204 = Waiting for Recall Notice (After Layoff)
205 = Waiting for Start of Season
206 = Family Responsibilities/Work in Home

Farmworker ID:

207 = In School
208 = Laid-up Due to Injury
209 = In-transit Between Jobs
210 = Vacation
211 = Did Not Look for Work
212 = Other: (Specify in Grid)

To

** C-5 Activity Codes: Only for "AB" (While in a
Foreign Country or Abroad)
311 = FW in Family Ranch
312 = FW-Hired
320 = NF in Own Business: (Specify in Grid)
341 = NF in "Maquila"
359 = NF - Other: (Specify in Grid)
361 = NW - Medical Treatment
362 = NW - Vacation
369 = NW - Other: (Specify in Grid)

C13

STATE / COUNTRY

[C1-C2 FOR OFFICE USE ONLY]

(REV. 1/15/09) Farm Worker Survey

page 19

D2 [If Non-Farm Job Listed On Work Grid] For your most
recent non-farm (NF) employer, how many hours per
week did you work on average?
Hours

D3 [If Non-Farm Job Listed] For your most recent
non-farm employer (NF), how much were you paid
per week on average?
$

,

.

Current Farm Job
Now I am going to ask you some questions about the
crop/task your are CURRENTLY performing for the
EMPLOYER through whom we contacted you. [FIRST PERIOD
IN WORK GRID]:
D4 How many hours did you work last week at your
current farm job?

D61

Were you paid by [READ CHOICES. MARK ONE
RESPONSE.]

9 1.
9 2.
9 3.
9 4.
9 5.
9 6.

Payroll Check?
Personal Check?
Cash and Check?
Other Check?
Cash?
Other?

D62

Did you get a receipt?

9 0.

No

D7

For what time period was that payment?

9 1.
9 2.
9 3.
9 4.
9 7.

One Day?
One Week?
Two Weeks?
One Month?
Other?

D8

How many hours did you work during that period (in
D7)

Hours

9 1.

Yes

Hours
[D5 TO D8: IF SHE/HE HAS NOT RECEIVED PAYMENT YET FOR
CURRENT CROP, ASK FOR ESTIMATES] Can you tell me how
you were paid and the amount your employer paid you on
your last pay day?

D9

Now - WITH YOUR CURRENT EMPLOYER - you already
told me that the crop you are currently working is:

D10

And you told me that - WITH YOUR CURRENT
EMPLOYER - the task you are now doing is:

D11

Are you paid:

9 1.
9 2.
9 3.

By the Hour?
By the Piece? [SKIP TO D13]
Combination Hourly Wage and Piece Rate? [ASK
D12 THROUGH D18]
Salary or Other? [SKIP TO D19]

D5 After Taxes
$

,

.

D6 Before Taxes
$

,

.

9 4.
D12

How much per hour (to the nearest cent)? [IF PAID
ONLY BY THE HOUR, ENTER AMOUNT AND SKIP TO D20.
IF COMBINATION, ENTER AMOUNT AND CONTINUE WITH
D13]:
$

.

Per Hour

(REV. 1/15/09) Farm Worker Survey

page 20

D13

[IF PAID BY THE PIECE] Are you paid as an individual
or by the crew? [IF THE ANSWER IS "CREW", ASK
QUESTIONS D14 TO D18 CONSISTENTLY IN REFERENCE
TO THE CREW.]

9 1.

Individual

9 2.

Crew

D14

[IF CREW PIECE RATE] How many people are in your
crew? [ONE IS NOT A POSSIBLE ANSWER.]

[SKIP TO D15]

D15

[IF BY PIECE] How do they pay you/your crew [i.e.,
UNIT OF MEASURE; SUCH AS BOX, BIN, BUCKET,
etc...]?

D16

[IF BY PIECE] How many of these (in D15 e.g.,
boxes, bins, buckets, etc...] you/your crew do in an
average day?

D20

In the last 12 months, aside from your wages, have
you received (do you receive) any money bonus
from your current employer?

9 0.

No [SKIP TO D22]

9 1.

Yes

9 2.

Don't Know [SKIP TO D22]

D21

[IF PAID A BONUS] How and when do you receive
the money bonus? [READ CHOICES. MARK ALL
THAT APPLY.]

9 g.
9 a.
9 b.
9 c.
9 d.
9 e.
9 f.

Retention (Return or Rehire) Bonus?
Holiday Bonus?
Incentive Bonus (rewards)?
Dependent on Grower Profit?
End of Season Bonus?
Money for Transportation?
Other?

D63

How much money bonus have you been given
(Total in the last 12 months with current employer)?
$

D17

[IF BY PIECE] How many hours per day do you/your
crew work on average at this task?

[IF BY PIECE] How much do "they" pay you/your
crew on average for each (box, bin, bucket, etc...in
D15)?
$

D19

,

If you are injured at work or get sick as a result of
your work, does your employer provide health
insurance or pay for your health care?

9 0.
9 1.
9 7.

No
Yes
Don't Know

D23

If you are injured at work or get sick as a result of
your work, do you get any payment while you are
recuperating (i.e., "workers' compensation")?

9 0.
9 1.
9 7.

No
Yes
Don't Know

D24

If you are injured or get sick off the job (e.g., at
home), does your employer provide health
insurance or pay for your health care? [WHETHER
OR NOT THE WORKER TAKES IT OR USES IT.]

9 0.
9 1.
9 7.

No
Yes
Don't Know

.

[IF PAID BY SALARY, OR OTHER] Explain fully how
and how much you are paid (salary or other).
Explain thoroughly the method and amount of
payment. [USE BACK OF PAGE IF NEEDED.]

(REV. 1/15/09) Farm Worker Survey

.

D22

Hours

D18

,

page 21

D26

Are you covered by unemployment insurance if you
lose this job?

D37a How far is your current job from your current
residence?

9 0.
9 1.
9 7.

No
Yes
Don't Know

D27

How many years have you worked for this
employer? [ONE DAY/PER YEAR = ONE YEAR]

9 1.
9 2.
9 3.
9 4.
9 5.
9 6.

I'm located at the job.
Within 9 miles.
10 - 24 miles.
25 - 49 miles.
50 - 74 miles.
75 or more miles.

D37

At your current job, how do you usually get to work?
[READ CHOICES. MARK ONE.]

9 1.
9 2.
9 5.

Drive car? [SKIP TO D39a]
Walk?
[SKIP TO D39a]
Public transportation (bus, train, etc...)? [SKIP TO
D39a]
Labor bus, truck, van?
"Raitero"?
Ride with others (share ride)?
Other?

Years
D28

Do you work for (current employer) year round or
on a seasonal basis?

9 0.
9 1.
9 7.

Year Round
Seasonal
Don't Know

D29

[IF WORKED ON A SEASONAL BASIS] Does this
employer keep in contact with you about future
employment? [READ CHOICES. MARK ALL THAT
APPLY.]

[SKIP TO D30]
(first time) [SKIP TO D30]

9 a.
9 b.
9 c.
9 d.
9 e.
9 f.
9

Yes, before leaving at the end of the season?
Yes, by letter (written message)?
Yes, by phone/in person?
Yes, by someone else?
No, you contact employer?
Other?
Don't Know.

D30

How did you get this job? [DO NOT READ CHOICES.
MARK ONLY ONE RESPONSE.]

9 1.
9 4.
9 5.

I applied for the job on my own.
I was recruited by a grower or his foreman.
I was recruited by farm labor contractor or his
foreman.
9 6. I was referred by the employment service.
9 7. I was referred by the welfare office.
9 8. I was referred by relative/friend/workmate.
9 9. I was referred by labor union.
9 10. Day Laborer/Picked Up at shape up.
9 97. Other:

9 6.
9 8.
9 4.
9 7.

D38a Do you have to use the transport (in D37)? (Is it
mandatory or obligatory)?

9 0.

No

9 1.

D38

Do you pay a fee to (responsible in D37 and/or
"raiteros") for rides to work?

9 0.

No

9 1.

Yes

Yes

9 2. Yes, Just for gas

D39a At your current job, who pays for the equipment you
use at work? [READ CHOICES. MARK ONLY ONE.]

9 1.
9 2.
9 3.
9 5.
9 6.
9 10.
9 11.

Don't need any equipment?
(You) pay all?
The grower/contractor pays all?
A friend/relative pays some or all?
(You) pay some?
(You) pay only for replacement of damaged tools?
The grower/contractor provides you with tools, but
you prefer to buy/bring your own?
9 12. The grower/contractor provides some and you have
to bring/buy the rest?
9 97. Other?

(REV. 1/15/09) Farm Worker Survey

Now I'm going to ask you some questions about your
individual and family income for last year (2007).
G1

What was your total income last year - in 2007 - in
U.S. dollars [U.S. EARNINGS ONLY FOR FW AND NF]?
[READ OR SHOW CHOICES. MARK ONLY ONE.]

9 0.
9 1.
9 2.
9 3.
9 4.
9 5.
9 6.
9 7.
9 8.
9 9.
9 10.
9 11.
9 12.
9 13.
9 14.
9 15.
9 97

Did not work AT ALL in 2007.
Less than 500
500 to 999
1,000 to 2,499
2,500 to 4,999
5,000 to 7,499
7,500 to 9,999
10,000 to 12,499
12,500 to 14,999
15,000 to 17,499
17,500 to 19,999
20,000 to 24,999
25,000 to 29,999
30,000 to 34,999
35,000 to 39,999
Over 40,000
Don't remember (Don't know).

G2

How much of that income was from agricultural
employment (U.S. earnings only)? [READ OR
SHOW CHOICES. MARK ONLY ONE.]

9 0.
9 1.
9 2.
9 3.
9 4.
9 5.
9 6.
9 7.
9 8.
9 9.
9 10.
9 11.
9 12.
9 13.
9 14.
9 15.
9 97

Did not work in FW in 2007.
Under 500
500 to 999
1,000 to 2,499
2,500 to 4,999
5,000 to 7,499
7,500 to 9,999
10,000 to 12,499
12,500 to 14,999
15,000 to 17,499
17,500 to 19,999
20,000 to 24,999
25,000 to 29,999
30,000 to 34,999
35,000 to 39,999
Over 40,000
Don't remember (Don't know).

page 22

G3

What was your family's total income last year - in
2007 - in U.S. dollars [U.S. earnings FW and NF for
all in "Family Grid"]? [READ OR SHOW CHOICES.
MARK ONLY ONE.]

9 0.
9 1.
9 2.
9 3.
9 4.
9 5.
9 6.
9 7.
9 8.
9 9.
9 10.
9 11.
9 12.
9 13.
9 14.
9 15.
9 97

We did not work AT ALL in 2007.
Under 500
500 to 999
1,000 to 2,499
2,500 to 4,999
5,000 to 7,499
7,500 to 9,999
10,000 to 12,499
12,500 to 14,999
15,000 to 17,499
17,500 to 19,999
20,000 to 24,999
25,000 to 29,999
30,000 to 34,999
35,000 to 39,999
Over 40,000
Don't remember (Don't know).

E1

At any time during the last 2 years (in the U.S.),
were you covered by a union contract while doing
farm work (FW)?

9 0.
9 1.
9 7.

No
Yes
Don't Know

E2

How long do you expect to continue doing farm
work (in the U.S.)? [READ CHOICES. MARK ONLY
ONE.]

9 1.
9 2.
9 3.
9 4.
9 5.
9 7.
E4

9 0.
9 1.
9 7.

Less than one year.
One to three years.
Four to five years.
Over five years.
Over five years/as long as I am able.
Other?
Could you get a U.S. non-farm (NF) job within a
month?
No
Yes
Don't know.

(REV. 1/15/09) Farm Worker Survey

page 23

SCREENING FOR INJURY SUPPLEMENT
[INTERVIEWER...ONLY IF THE RESPONDENT SEEMS HISITANT TO TALK ABOUT INJURIES, e.g., BECAUSE HE/SHE IS FEARFUL,
SHOULD YOU REMIND THE RESPONDENT THAT ALL THE INFORMATION HE/SHE SHARES WITH YOU IS CONFIDENTIAL. USE YOUR
JUDGEMENT ABOUT REMINDING THE INTERVIEWER ABOUT CONFIDENTIALITY AT ANY POINT WHILE ADMINISTERING THIS
SUPPLEMENT.

"I would like to ask you some questions about injuries or accidents that you may have had while doing farm work in the
United States. These injuries include a car accident while traveling to and from work.
They could also be things like...
...
...
...
...

cutting yourself with a sharp tool or knife;
hurting yourself lifting heavy objects, such as crates;
hurting yourself by falling, for example, falling off a ladder or crate, ortripping in the field; or
getting sick from working too long in the hot sun, being bitten or stung by an insect, or breathing pesticides while
working in the fields."

...

In the past 12 months, have you had any injury or accident that made you...

NLS03

NLS02

...Use any typ of first aid, such as a bandage to
stop bleeding or antiseptic to clean a would (or ice
packs for a bruise, etc.) or seek medical treatment
at a clinic or from a nurse or doctor?

G

0

No

G

1

Yes

...Unable to work as hard as you normally do for
at least 4 hours? [or were assigned a different
job (or different task) that was easier because the
injury prevented your from doing the first job (or
task)]

NLS01

NLS04

...Unable to work for at least 4 hours?

G

0

No

G

1

Yes

...Take strong medicine, except aspirin (or
Tylenol or ibuprofen), to allow you to keep
working?

G

0

No

G

0

No

G

1

Yes

G

1

Yes

INTERVIEWER...
...IF THE RESPONDENT ANSWERED "NO" TO ALL OF
THE PREVIOUS QUESTIONS (NSL01 - NLS04),
SKIP TO NEXT SECTION ("NP1f", PAGE 24).

...IF THE RESPONDENT ANSWERED "YES" TO ANY
OF THE PREVIOUS QUESTIONS (NLS01 - NLS04),
ASK NL1E

NL1E How many of these types of injuries have you had

[INTERVIEWER: WRITE HERE ANY SPONTANEOUS RESPONSE RELATED TO AN INJURY OR INJURIES (e.g., TYPE OF INJURIES AND
DATES) SO YOU CAN REFER TO IT WHEN COMPLETING THE "INJURY SUPPLEMENT"]:

CONTINUE WITH NEXT SECTION ("NP1f) UNTIL COMPLETION OF QUESTIONNAIRE,
THEN COMPLETE "INJURY / ACCIDENT - SUPPLEMENT QUESTIONNAIRE"]

(REV. 1/15/09) Farm Worker Survey

page 24

NP - Handling Pesticides (in the U.S.A.)
NP1f.

In the last 12 months, have you loaded, mixed, or applied pesticides?

9 0. No . . . u

[SKIP TO "SECTION NT2a"]

9 1. YES
P10
Which of the following classes of pesticides have you
loaded, mixed, or applied in the last 12 months (in
the U.S.A, doing FW)?

P11

P12

P13

[If YES:]
When was
the last time?

NAME OF CROP?

[IF WITHIN THE
LAST 30 DAYS IN

(MONTH / YEAR)
a.

...Insecticide?

P11]
HOW MANY DAYS?

9 0. No x
9 1. Yes u

b.

...Herbicide?

9 0. No x
9 1. Yes u

c.

...Fungicide?

9 0. No x
9 1. Yes u

d.

...Rodenticide?

9 0. No x
9 1. Yes u

z.

f.

...Other. Specify:
_____________

9 0. No x

...Don't know the type?

9 0. No x

9 1. Yes u

9 1. Yes u

NT - TRAINING AND INSTRUCTIONS
NT2a.

And...in the last 12 months, with your current employer, has anyone given you training or instructions in
the safe use of pesticides (through video, audio, cassette, classroom lectures, written material, informal
talks, or by any other means)?

9 0. No
9 1.
YES

(REV. 1/15/09) Farm Worker Survey

page 25

NMS - Musculoskeletal
INTERVIEWER: TO BEGIN, ASK ALL QUESTIONS IN 1ST
During the last 12 months [From
(month of last year) until now (month
of current year)], have you had pain
or discomfort in your:

x
(MS1-6)
NMS1 -

Did you have this
pain/discomfort for Five (5) or
more consecutive days? [If
yes, ask how many days.]

a.

b.

Back?

9 0. No

x

9 1. Yes

u

NMS2 -

What type of
activity were
you doing
when this
pain/discomf
ort began?

9 FW
9 NF
9 NW

Shoulder/Neck?

9 0. No

x

9 1. Yes

u

9 FW
9 NF
9 NW

NMS3 - Elbow/Arm?

9 0. No

x

9 1. Yes

u

9 FW
9 NF
9 NW

NMS4 - Hand/Wrist/Finger?

9 0. No

x

9 1. Yes

u

9 FW
9 NF
9 NW

NMS5 - Legs/Feet/Toes?
(Lower Extremities)
9 0. No
x

9 1. Yes

9 FW
9 NF
9 NW

u

NMS6 - Other?

9 0. No

x

9 1. Yes

u

A Little

9 FW
9 NF
9 NW

COLUMN.]

How severe
was this
pain/discomfort
?

How long did you work
with this
pain/discomfort?

How many days did you
NOT WORK because of
this pain/discomfort?

d.

e.

[Show scale
below.]

c.

u

9 1. A little.
9 2. A lot.
9 3. Unbearable

9
9
9
9
9

1. Less than 1 day
2. Days:
3. Weeks:
4. Months:
7. Don't Know

9
9
9
9
9

1. Less than 1 day
2. Days:
3. Weeks:
4. Months:
7. Don't Know

u

9 1. A little.
9 2. A lot.
9 3. Unbearable

9
9
9
9
9

1. Less than 1 day
2. Days:
3. Weeks:
4. Months:
7. Don't Know

9
9
9
9
9

1. Less than 1 day
2. Days:
3. Weeks:
4. Months:
7. Don't Know

u

9 1. A little.
9 2. A lot.
9 3. Unbearable

9
9
9
9
9

1. Less than 1 day
2. Days:
3. Weeks:
4. Months:
7. Don't Know

9
9
9
9
9

1. Less than 1 day
2. Days:
3. Weeks:
4. Months:
7. Don't Know

u

9 1. A little.
9 2. A lot.
9 3. Unbearable

9
9
9
9
9

1. Less than 1 day
2. Days:
3. Weeks:
4. Months:
7. Don't Know

9
9
9
9
9

1. Less than 1 day
2. Days:
3. Weeks:
4. Months:
7. Don't Know

u

9 1. A little.
9 2. A lot.
9 3. Unbearable

9
9
9
9
9

1. Less than 1 day
2. Days:
3. Weeks:
4. Months:
7. Don't Know

9
9
9
9
9

1. Less than 1 day
2. Days:
3. Weeks:
4. Months:
7. Don't Know

u

9 1. A little.
9 2. A lot.
9 3. Unbearable

9
9
9
9
9

1. Less than 1 day
2. Days:
3. Weeks:
4. Months:
7. Don't Know

9
9
9
9
9

1. Less than 1 day
2. Days:
3. Weeks:
4. Months:
7. Don't Know

9 0. No
9 1. Yes, days:

9 0. No
9 1. Yes, days:

9 0. No
9 1. Yes, days:

9 0. No
9 1. Yes, days:

9 0. No
9 1. Yes, days:

9 0. No
9 1. Yes, days:

A Lot

Unbearable

(REV. 1/15/09) Farm Worker Survey

page 26

NS - Sanitation Section
The following questions refer to sanitation at your job with your current FW employer.
Does your current employer provide Every Day:
NS1 -

Provides (potable) clean drinking water and
disposable cups?

9 0.
9 1.
9 2.
9 7.

A Toilet (Every Day)?

NS4 -

No water, No cups.
Yes, water only.
Yes, water and disposable cups.
Don't know.

9 0. No
9 1. Yes
9 7. Don't know.

NS9 -

(Provides) water to wash hands (EVERY Day)?

9 0. No
9 1. Yes
9 7. Don't know.

NH - Individual Personal Health History (Lifetime)
INTERVIEWER: FIRST ASK ALL QUESTIONS IN 1ST
a.
Have you ever - in your whole life
- been told by a doctor or nurse that
you have the following conditions:

b.

c.

Are you currently
taking medication
for this condition?

In the last 12 months, in the U.S.
and/or abroad, have you seen a
doctor or nurse for (condition in NH
Column)? [If answer is "YES" for the
U.S. and "AB", mark both.]

9 0. No

q

9 0. No
9 1. Yes, in the U.S.A.
9 2. Yes, "AB":

x
NH1 - Asthma?

NH2 - Diabetes?

NH3 - High Blood Pressure?

NH4 - Tuberculosis?

NH5 - Heart Disease

NH6 - Urinary Tract Infections?

NH10 - Other?

9 0. No

COLUMN.]

9 1. Yes

u

9 1. Yes

q

9 0. No

x

9 0. No

q

9 1. Yes

u

9 1. Yes

q

9 0. No

x

9 0. No

q

9 1. Yes

u

9 1. Yes

q

9 0. No

x

9 0. No

q

9 1. Yes

u

9 1. Yes

q

9 0. No

x

9 0. No

q

9 1. Yes

u

9 1. Yes

q

9 0. No

x

9 0. No

q

9 1. Yes

u

9 1. Yes

q

9 0. No

x

9 0. No

q

9 1. Yes

u

9 1. Yes

q

9 0. No
9 1. Yes, in the U.S.A.
9 2. Yes, "AB":
9 0. No
9 1. Yes, in the U.S.A.
9 2. Yes, "AB":
9 0. No
9 1. Yes, in the U.S.A.
9 2. Yes, "AB":
9 0. No
9 1. Yes, in the U.S.A.
9 2. Yes, "AB":
9 0. No
9 1. Yes, in the U.S.A.
9 2. Yes, "AB":
9 0. No
9 1. Yes, in the U.S.A.
9 2. Yes, "AB":

(REV. 1/15/09) Farm Worker Survey

page 27

NQ - Quality of and Access to Health Care Section
[INTERVIEWER: I WOULD LIKE TO ASK YOU A FEW FINAL QUESTIONS ABOUT HEALTH CARE IN GENERAL. YOU MAY HAVE GIVEN ME
SOME OF THIS INFORMATION ALREADY, BUT I WOULD LIKE TO MAKE SURE IT IS CORRECT.]

NQ1

In the last TWO YEARS [SINCE (MONTH) OF 2 YEARS
AGO UNTIL NOW (MONTH) OF CURRENT YEAR], in the
U.S., have you used any type of health care
services from doctors, nurses, dentists, clinics, or
hospitals?

9 0.
9 1.

No
Yes

NQ3

And the last time you used the health care provider,
where did you go (what kind of place was it)?

9 1.
9 2.
9 3.
9 4.
9 5.
9 6.
9 7.
9 8.
9 10.
9 97.

Community Health Center?
Private Medical Doctor's Office/Private Clinic?
Healer/"Curandero"?
Hospital
Emergency Room?
Migrant Health Clinic?
Chiropractor or Naturopath's Office?
Dentist?
Other?
Don't Know.

NQ5

u [SKIP TO NQ8]

And, the last time you used the health care
provider, who paid the majority of the cost?

9 1.
9 2.
9 3.
9 4.
9 5.
9 8.
9 9.

I paid the bill out of "my own pocket".
Medicaid / Medicare?
Public clinic - Did not charge.
Employer provided health plan.
Self or family bought individual health plan.
Billed, but did not pay.
Worker's Compensation.

9 6.

Other Plan:

9 7.

Combination of:

NQ10 [ASK ALL]: ...When you need to get health care in
the USA, what are the main difficulties you face?
[CHECK ALL THAT APPLY.]

9 m. I do not know. I've never needed it.
9 l.
I'm "undocumented" / "no papers" (That's why they
9 a.
9 b.
9 c.
9 d.
9 e.
9 f.
9 g.
9 h.
9 i.
9 j.
9

don't treat me well).
No transportation, too far away.
Don't know where services are available.
Health center not open when needed.
They don't provide the services I need.
They don't speak my language.
They don't treat me with respect; I don't feel
welcomed.
The don't understand my problems.
I'll lose my job.
Too expensive, no insurance.
Other?
No difficulties.

NQ1a How about in a foreign country (e.g. Mexico),
have you used any type of health service in the
last two years? [IF YES, ASK AND ENTER COUNTRY.]

9 0.

No

9 1.

Yes, in:
(NAME OF COUNTRY)

(REV. 1/15/09) Farm Worker Survey

page 28

GENERAL HEALTH (MG)

FAMILY WORRYING AND CONCERNS (MF)

MG1

In general, how would you describe your health?
Would you say... [READ OPTIONS]

MF1

How difficult is it for you to be separated from your
family? Would you say... [Read Options]

G
G
G
G
G
G

EXCELLENT?
GOOD?
FAIR?
POOR?
DON'T KNOW.
REFUSED.

G
G
G
G
G
G

NOT AT ALL DIFFICULT?
SOMEWHAT (MORE OR LESS)?
VERY DIFFICULT?
NOT SEPARATED FROM FAMILY.
DON'T KNOW.
REFUSED.

1
2
3
4
7
6

0
1
2
3
7
6

WORK LIMITATIONS (MW)
MW1

Do you have any PHYSICAL problem that LIMITS your
work?

MW3

In the last 12 months, ABOUT how many days have you MISSED
WORK because of a work-related injury?

G 0

NO

G 1

G 1

YES

G 7

DON'T KNOW

G 7

DON'T KNOW

G 6

REFUSED

G 6

REFUSED

G 5

OTHER:

G 5

OTHER:

MW2

Do you have any MENTAL or EMOTIONAL problem that
LIMITS your work?

MW4

And in the last 12 months, ABOUT how many days have you WORKED
while INJURED or ILL because of a work-related illness or injury?

G 0

NO

G 1

G 1

YES

G 7

DON'T KNOW

G 7

DON'T KNOW

G 6

REFUSED

G 6

REFUSED

G 5

OTHER:

G 5

OTHER:

DAYS

DAYS

DECISIONS LATITUDE (MD)
0

1

2

3

7

6

5

NEVER

SOMETIMES

VERY OFTEN

ALWAYS

DON'T KNOW

REFUSED

DOESN'T UNDERSTAND

1 ...do you have a lot of say about what happens on
your job?

G

G

G

G

G

G

G

2 ...does your job require a high level of skill?

G

G

G

G

G

G

G

3 ...do you have the freedom to decide how you do
your farmwork?

G

G

G

G

G

G

G

4 ...does your job require you to be creative?

G

G

G

G

G

G

G

"In your current FW...how often...

JOB DEMANDS (MJ)
0

1

2

3

7

6

5

NEVER

SOMETIMES

VERY OFTEN

ALWAYS

DON'T KNOW

REFUSED

DOESN'T UNDERSTAND

G

G

G

G

G

G

G

G

G

G

G

G

G

G

"In your current FW...how often...
1

...does your job in farmwork require you to work
very hard?

2 ...are you asked to do an excessive
amount of work?

(REV. 1/15/09) Farm Worker Survey

page 29
CESD - SHORT FORM (MC)

[FIRST READ INSTRUCTIONS AND ASK ALL QUESTIONS IN FIRST COLUMN. MARK RESPONSES IN SECOND COLUMN "MC",
THEN, ASK "MCDAYS" FOR EACH "YES" RESPONSE IN SECOND COLUMN "MC"]
The next set of items are about your mood.
Different people experience their moods in different
ways, so some of the items may sound similar, but
I need to ask them. In the past seven (7) days,
have you felt...

MC
____________
[Check All Responses]

MCDAYS
______________________
How many of the past 7 days did you
feel...[SYMPTOM IN CES1] for MOST of the day? [If
respondent asks "What do you mean by most?",
answer: "Whatever "most" means to you]
[Write Number of Days]

1

2

3

4

5

6

7

8

9

10

...that you enjoyed life?

...happy?

...that everything you did was an effort?

...restless in your sleep?

...lonely?

...that people were unfriendly?

...sad?

...that people disliked you?

...that you could not get going?

...depressed?

G 0 No
G 1 Yes

q

G 0 No
G 1 Yes

q

G 0 No
G 1 Yes

q

G 0 No
G 1 Yes

q

G 0 No
G 1 Yes

q

G 0 No
G 1 Yes

q

G 0 No
G 1 Yes

q

G 0 No
G 1 Yes

q

G 0 No
G 1 Yes

q

G 0 No
G 1 Yes

q

Job Insecurity (MI)
MI1

Are you afraid that you could be fired from this farm job?

MI2

How easy would it be to find another job, FW or NF
where you would earn at least as much as you earn
now? ...Would you say...

G 0

No

G 1

Not at all easy? (Difficult)

G 1

Yes

G 2

Somewhat easy?

G 7

Don't Know

G 3

Very easy?

G 6

Refused

G 7

Don't Know

G 6

Refused

(REV. 1/15/09) Farm Worker Survey

page 30

NSK - Skin
INTERVIEWER: FIRST ASK ALL QUESTIONS IN 1ST

COLUMN.]

Document only "Dermatitis-Related" Problems
The following questions regarding skin refer to the last 12 months, from [Month] of [Last Year] until now {Month] of [Current Year].

x

4.

Have you had any skin problems such as redness, inflammation,
discoloration, or rash on your:

9 FW

NSK1 - Hands?

9 0. No x

The last time you had this
skin problem, what were you
working on?

9 1. Yes u

u

9 NF
9 NW
9 FW

NSK2 - Arms?

9 0. No x

9 1. Yes u

u

9 NF
9 NW
9 FW

NSK3 - Face?

9 0. No x

9 1. Yes u

u

9 NF
9 NW
9 FW

NSK6 - Torso?

9 0. No x

9 1. Yes u

u

9 NF
9 NW
9 FW

NSK7 - Feet/Legs?

9 0. No x

9 1. Yes u

u

9 NF
9 NW
9 FW

NSK4 - Any other part of your body?

9 0. No x

9 1. Yes

u

9 NF
9 NW

u

FW Only
1.

(FW) Crop?

2. (FW) Task?

(REV. 1/15/09) Farm Worker Survey

page 31

INTERVIEWER:

PLEASE CHECK IF RESPONDENT
QUALIFIES FOR THE INJURY SUPPLEMENT!
CHECK PAGE 23
(SCREENING SECTION)

(REV. 1/15/09) Farm Worker Survey

page 32

L - Legal Status
[WE ARE INTERESTED IN KNOWING WHETHER ANY OF THE FOLLOWING APPLY TO YOU.
US, WILL KNOW YOUR RESPONSE.]

L1

What is your current legal status in the U.S.? [READ CHOICES, IF
NECESSARY.]

9 1.
9 2.

9 3.

9 4.

9 5.

I am a U.S. citizen by birth.

u[SKIP TO NEXT PAGE]

I am a naturalized U.S. citizen (foreign born, naturalized). [Ask:
"Before becoming a naturalized U.S. citizen, under which program
did you apply to obtain your permanent residence?" (Possible
answers in L2: 1-9, 97) Then ask: L4-1, L4-2 and L4-3].
Permanent resident/Green Card (right to reside and work in the
U.S.). [Ask: L2, "Under which program did you apply?" (Possible
answers in L2: 1-9, 97). Then ask: L4-1 and L4-2].
Border crossing card/Commuter Card (right to cross the border
and work in the U.S.). [Ask: L2, "Under which program did you
apply?"] (Possible answers in L2: 9, 12, 13, and 97). Then ask:
L3, L4-1 and L4-2].
Pending status (without documents, applied, awaiting official
decision) [Ask: L2, "Under which program did you apply?"
(Possible answers in L2: 1-9, 97). Then ask: L3 and L4-1].

PLEASE BE ASSURED THAT NO ONE, BESIDES

L2

PROGRAMS [DO NOT READ OPTIONS.]

9 1.

Amnesty under 5 year program.

9 2.

Amnesty under SAW (90 day) program.

9 3.

Cuban/Haitian entrant.

9 4.

Spousal petition program/Family unity.

9 5.

Labor certification program.

9 6.

Registry program.

9 7.

Political asylum.

9 8.

Refugee.

9 9.

Protective status (temporary).

9 10. Guest worker program [bracero].
9 11. Student.

9 6.

Undocumented (application denied/did not apply to any
programs). (Possible answers, "None".) [SKIP TO NEXT PAGE].

9 7.

Temporary resident/Non Immigrant Visa (only for specified
time). [Ask: L2, "Under which program did you apply?"] (Possible
answers in L2: 10 - 97). Then ask: L3 and L4-1].

9 12. Tourist.

9 8.

Other. [If relevant and appropriate, Ask : L2, L3, L4-1, L4-2 and
L4-3; then skip to next page.]:

L3

Do you have general work authorization? 9 0. No

9 1. Yes

9 13. Border crossing card/"passport"
9 97. Other.
9 99. Not answered.

9 7. Don't Know

9 9. Not Answered

L4 - Date Status Became Effective
1.

When did you apply to the
program (in L2)?

2.

[Only for those who responded
"2", "3", or "4" in L1] When did
you obtain your legal status?

/
Month

3.

[Only for those who responded
"2" in L1] When did you obtain
your naturalization/ become a
U.S. citizen?

/
Year

Month

/
Year

Month

Year

INFORMED CONSENT
INDIVIDUAL AGREEMENT TO BE A RESEARCH PARTICIPANT
OMB NO.: XXXX-XXXX EXPIRATION DATE XX/XX/XX
UFIRB NO. __ XXXX EXPIRATION DATE XX/XX/XX
Protocol Title: Worker Interviews - Assessing Agricultural Labor Risk for Specialty Crops
Please read this consent document carefully before you decide to participate in this study.
Introduction/Purpose:
You are invited to participate in this study for the University of Florida and the U.S. Department of Agriculture
because you are currently working on a farm. The purpose of the study is to learn more about the living
conditions and health of farm workers.
Procedures to be followed:
You will be asked to answer some questions about your work history and about your health. The interview
will last approximately 75 minutes.
Risks:
Since we will only be asking you questions, there is very little risk to you as a result of being in the study. You
may refuse to answer any question at any time, with no penalty.
Benefits:
There are no direct benefits to you from being in the study. But, knowledge gained through this research may
help us learn how to prevent any harmful effects of farm work for workers like you.
Confidentiality:
Your answers to the interview will be kept private to the extent allowed by law. This means that the interview
record will be kept in a locked file, and only researchers on the study will be allowed to see it. Only results
aggregated over numerous individuals will be presented; your name will not appear on any reports about the
study. (See back of page for details.)
Alternatives to participation:
Participating in this study is voluntary, and you can quit at any time. You can also choose not to participate
in any part of the study at any time, with no penalty. Whether or not you participate in this study will not affect
benefits and services to which you are normally entitled. You will be paid for the time you are spending in this
interview. However, if you choose not to participate in major sections of the interview, you may not receive
the full payment. At any time, you may ask the researchers to explain any part of the study.
Whom to call with questions:
If you have questions about the research study, including questions about your rights as a research subject,
you may call Aguirre International [Toll Free] at (877) 850-5200. They will refer your questions to Robert
Emerson at the University of Florida at (352) 392-1881, ext 316.
If you have questions about your rights as a research participant in the study, contact: UFIRB Office, Box
112250, University of Florida, Gainesville, FL 32611-2250; ph (352) 392-0433.
I have read and understand the statement above. My questions about any unclear or confusing statements
have been answered clearly. I agree to participate in this study as a research subject. I admit that I have
received a copy of this form and $15.00 for my participation.

Signature of Participant

Date

Signature of Interviewer

Date

(See reverse)

In accordance with the Privacy Act of 1974, as amended (5 U.S.C.552a),
we are notifying you that this study is authorized by the U.S. Department
of Labor, Employment, and Training Administration (ETA). Your voluntary
participation is important to the success of this study and will enable the
ETA to understand the labor market and living experiences of U.S. farm
workers. Under written agreement with research organizations, the ETA
may release certain information necessary for research, but only after all
identifying information has been removed. Unless required by law, or
necessary for litigation or legal proceedings, and except as indicated in this
statement, we will hold all personal identifiers (e.g. name, address, and
social security number) in total confidence, and will not release them.

Public reporting burden for the collection of information is estimated to average 75 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden to the Office of Information Management, Department of Labor, Room N-1301, 200 Constitution
Avenue, NW, Washington, DC 20210; and to the Office of Information and Regulatory Affairs, Office of
Management and Budget, Washington, DC 20503.

(REV. 12/15/08) Farm Worker Survey

Name of Worker: ______________________________ Farmworker ID:

GGGGGG

SUPPLEMENT ONLY FOR WORKERS WHO SAID "YES" TO ANY OF THE NL QUESTIONS (PAGE 29).
>>> SECTION NL - INJURIES / ACCIDENTS <<<

[NL3 CODES FOR "INJURY LIST"] IN THE LAST 12 MONTHS, HAVE YOU HAD ANY...
9 a.

scrape/abrasion?

9 d.

sprain/strain/torn ligament/traumatic rupture?

9 g.

cut/laceration/puncture/stab/jab?

9 b.

bruise/contusion?

9 e.

broken or fractured bone/crushed/ mangled?

9 h.

burn/blister/scald?

9 c.

amputation/loss of body part?

9 f.

dislocation?

9 i.

insect bite/sting/bitten by animal?

9 j.

other?:_________________

Please describe how you got injured? What happened when you were injured?
INTERVIEWER:

[If there is more than one injury, first write the number corresponding to the incident (i.e., for the first incident write number 1) in the "Injury
Grid" on the next page. Use the following grids for additional incidents and number each one of them. If you need more grids, use "extras"
from other, unused supplements. In each grid, ask and write answers for questions NL3 to NL20.]

IN THE NEXT GRIDS, WRITE IN DETAIL ALL NARRATIVE RESPONSES TO PROMPT QUESTION FROM NL3 TO NL20. AS YOU ASK EACH QUESTION, MARK RESPONSES; AND WHERE
REQUIRED, MARK ITS CORRESPONDING BOX TO ENSURE THAT ALL QUESTIONS ARE ASKED. (i.e., WHAT HAPPENED?; WHAT WERE YOU DOING?; WHAT CAUSED THE
INJURY/ACCIDENT?; WHAT TOOLS OR MACHINERY WERE YOU USING WHEN IT HAPPENED?, etc...)
[USE A SEPARATE GRID FOR EACH INJURY/ACCIDENT]
Codes for NL13
13.

Community Health Center/Hospital/Emergency Room

6.

Migrant Clinic

9.

Dentist

2.

Private Medical Doctor's Office/Private Clinic

7.

Chiropractor/Naturopath's Office

10.

Went to Home County

3.

Healer/"Curandero"/"Sobador"

8.

First Aid at Scene

11.

Other: ___________________

12.

No Medical Treatment

Codes for NL14
1.

Paid out my own pocket

5.

Self or family insurance/Health Plan

11.

Do not remember who paid for it.

2.

Medicaid/Medicare

8.

Billed, but did not pay.

6.

Other: ___________________

3.

No charge.

9.

"Worker's Compensation"

7.

Combination of: ________________

4.

Employer provided Health Plan.

10.

Employer paid "Out-of-Pocket".

Worker's Injury Page -1-

(REV. 12/15/08)

Farmworker ID:

GGGGGG

INJURIES / ACCIDENTS
Incident #

[INTW: THIS GRID IS FOR THE FIRST INJURY/ACCIDENT MENTIONED BY THE INTERVIEWER]
The following questions are about this injury/accident incident. What part(s) of your body was (were) injured and what type(s) of inury(ies) did you have in
this incident? [INTW: SHOW FIGURE. ASK INJURIES, FROM THIS INCIDENT, FOR EACH BODY PART; WRITE ANSWER(S) AND CHECK ALL CODES THAT APPLY (SEE CODES IN
NL1)].

NL3

[BODY PARTS: CODES FOR TYPE OF INJURY LISTED ON PREVIOUS PAGE (IN NL1). READ AND MARK ALL THAT APPLY]:
Part 1

a.

b.

c.

d.

e.

f.

g.

h.

i.

j.

Part 2

a.

b.

c.

d.

e.

f.

g.

h.

i.

j.

Part 3

a.

b.

c.

d.

e.

f.

g.

h.

i.

j.

[NARRATIVE SECTION - {IF YOU NEED MORE SPACE, USE BACK OF PAGE). AFTER ASKING EACH PROMPT-QUESTION, MARK CORRESPONDING BOX]
WHAT HAPPENED?

WHAT WERE YOU DOING?

NL5
When?

NL6
At Current Job?

/

0 No

NL11
Not able to work normally > 4
hours?
0 No

WHERE DID IT HAPPEN?

WHAT CAUSED IT?

NL7
Doing FW?
1 Yes

NL12
Number of days not able to
work normally?

0 No

NAMES OF MACHINES AND/OR TOOLS?

NL8
Crop?

NL9
Task?

NL14
How was it
paid? [Codes]

NL20
Did you receive first aid?

1 Yes

NL13
Where treated? [Enter all, Use
Codes]

1 Yes

DETAILS?

0 No

Worker's Injury Page -2-

1 Yes

(REV. 12/15/08)

Farmworker ID:

GGGGGG

INJURIES / ACCIDENTS
Incident #

[INTW: THIS GRID IS FOR THE FIRST INJURY/ACCIDENT MENTIONED BY THE INTERVIEWER]
The following questions are about this injury/accident incident. What part(s) of your body was (were) injured and what type(s) of inury(ies) did you have in
this incident? [INTW: SHOW FIGURE. ASK INJURIES, FROM THIS INCIDENT, FOR EACH BODY PART; WRITE ANSWER(S) AND CHECK ALL CODES THAT APPLY (SEE CODES IN
NL1)].

NL3

[BODY PARTS: CODES FOR TYPE OF INJURY LISTED ON PREVIOUS PAGE (IN NL1). READ AND MARK ALL THAT APPLY]:
Part 1

a.

b.

c.

d.

e.

f.

g.

h.

i.

j.

Part 2

a.

b.

c.

d.

e.

f.

g.

h.

i.

j.

Part 3

a.

b.

c.

d.

e.

f.

g.

h.

i.

j.

[NARRATIVE SECTION - {IF YOU NEED MORE SPACE, USE BACK OF PAGE). AFTER ASKING EACH PROMPT-QUESTION, MARK CORRESPONDING BOX]
WHAT HAPPENED?

WHAT WERE YOU DOING?

NL5
When?

NL6
At Current Job?

/

0 No

NL11
Not able to work normally > 4
hours?
0 No

WHERE DID IT HAPPEN?

WHAT CAUSED IT?

NL7
Doing FW?
1 Yes

NL12
Number of days not able to
work normally?

0 No

NAMES OF MACHINES AND/OR TOOLS?

NL8
Crop?

NL9
Task?

NL14
How was it
paid? [Codes]

NL20
Did you receive first aid?

1 Yes

NL13
Where treated? [Enter all, Use
Codes]

1 Yes

DETAILS?

0 No

Worker's Injury Page -3-

1 Yes