Various Demographic Pretesting Activities

Generic Clearence for Questionnaire Pretesting Research

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Various Demographic Pretesting Activities

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ANSWER SHEET - Record Income Sources and Amounts for Household Adults Aged 15 and Older
Person 1 (15+):
name__________

Person 2 (15+):
name__________

Person 3 (15+):
name__________

Person 4 (15+):
name__________

Person 5 (15+):
name__________

Person 6 (15+):
name__________

Income source:
Earned income
.00

.00

.00

.00

.00

.00

.00

.00

.00

.00

.00

.00

Total:
+ amount
+ amount

.00

.00

.00

.00

.00

.00

Income total:

.00

.00

.00

.00

.00

.00

w/ tips/bonuses/etc.
net bus./farm earnings

Total:

w/ tips/bonuses/etc.

Total:

other work
tips/bonuses/etc.
other businses earning

Unemployment/
Workers comp.

Total:

.00

.00

.00

.00

.00

.00

supplemental unempl.

Total:

.00

.00

.00

.00

.00

.00

union unemploy.

Total:

.00

.00

.00

.00

.00

.00

workers compensation

Total:

.00

.00

.00

.00

.00

.00

Unemp. total:

.00

.00

.00

.00

.00

.00

Social Security

Total:

.00

.00

.00

.00

.00

.00

Child's Social Security

Total:

.00

.00

.00

.00

.00

.00

Soc. Sec total:

.00

.00

.00

.00

.00

.00

Supplemental Security
Income

Total:

.00

.00

.00

.00

.00

.00

Child's SSI

Total:

.00

.00

.00

.00

.00

.00

.00

.00

.00

.00

.00

.00

SSI total:

1

name 1: ________

name 2: ________

name 3: ________

name 4: ________

name 5: ________

name 6: ________

Public Assistance

Total:

.00

.00

.00

.00

.00

.00

SNAP (Food Stamps)

Total:

.00

.00

.00

.00

.00

.00

Veteran's payments

Total:

.00

.00

.00

.00

.00

.00

Veteran's payments 2

Total:

.00

.00

.00

.00

.00

.00

Vet. total:

.00

.00

.00

.00

.00

.00

.00

.00

.00

.00

.00

.00

WIC

Survivor benefits

Total:

Survivor benefits 2

Total:

.00

.00

.00

.00

.00

.00

Survivor benefits 3

Total:

.00

.00

.00

.00

.00

.00

Surv. total:

.00

.00

.00

.00

.00

.00

Disability income

Total:

.00

.00

.00

.00

.00

.00

Disability income 2

Total:

.00

.00

.00

.00

.00

.00

Disability income 3

Total:

.00

.00

.00

.00

.00

.00

Disabil. total:

.00

.00

.00

.00

.00

.00

Retirement Accounts

value

.00

.00

.00

.00

.00

.00

Retirement/Pension
Income

Total:

.00

.00

.00

.00

.00

.00

retirement/pension 2

Total:

.00

.00

.00

.00

.00

.00

retirement/pension 3

Total:

.00

.00

.00

.00

.00

.00

.00

.00

.00

.00

.00

.00

Retir. total:

2

name 1: ________

name 2: ________

name 3: ________

name 4: ________

name 5: ________

name 6: ________

retirement assets

value

.00

Interest (retirement)

Total:

.00

.00

.00

.00

.00

.00

non-retirement assets

value

.00

.00

.00

.00

.00

.00

Interest (non-retirmt)

Total:

.00

.00

.00

.00

.00

.00

Dividends (retirement)

value

.00

.00

.00

.00

.00

.00

Dividends (retirement)

Total:

.00

.00

.00

.00

.00

.00

Dividends (non-retrmt)

value

.00

.00

.00

.00

.00

.00

Dividends (non-retrmt)

Total:

.00

.00

.00

.00

.00

.00

Property Income

Total:

.00

.00

.00

.00

.00

.00

Education Assistance

Pell total:

.00

.00

.00

.00

.00

.00

Other education

Total:

.00

.00

.00

.00

.00

.00

Educ. total:

.00

.00

.00

.00

.00

.00

Child Support

Total:

.00

.00

.00

.00

.00

.00

Alimony payments

Total:

.00

.00

.00

.00

.00

.00

Financial Assistance

Total:

.00

.00

.00

.00

.00

.00

Other money income

Total:

.00

.00

.00

.00

.00

.00

Other money income2

Total:

.00

.00

.00

.00

.00

.00

Other total:

.00

.00

.00

.00

.00

.00

Total:

.00

.00

.00

.00

.00

.00

Any energy assistance

.00

.00

.00

.00

.00

3


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