Assessment Of Native American, Alaska Native, And Native Hawaiian Housing Needs

A
SSESSMENT OF NATIVE AMERICAN, ALASKA NATIVE, AND NATIVE HAWAIIAN HOUSING NEEDS

PAPERWORK REDUCTION ACT SUBMISSION

JULY 14, 2011

Assessment of Native American and

Alaska Native Housing Needs

Household Survey: In-Person Interview

DRAFT v13

Field Interviewer Name:
Field Interview ID #:
Interview Date:
Start Time:		AM PM
Finish Time:		AM PM

Is this an Indian Housing Block Grant assisted unit?  If YES, identify whether: Check one	YES  NO
Currently Assisted Stock (CAS) Mutual Help
Currently Assisted Stock (CAS) Rental
IHBG Ownership
IHBG Rental

Affix Survey Case ID label here

Household Screener

INTERVIEWER READ: “Hello, my name is (name of interviewer) from NORC at the University of Chicago. (SHOW NORC ID CARD.) I am here to see if you received our letter about the Assessment of American Indian, Alaska Native, and Native Hawaiian Housing Needs Survey.

IF YES: Do you have any questions about the survey? May I tell you more about the survey?

IF NO: Here is a copy of the letter and some information about the project. Should I leave the materials and come back at a later time or could I answer any questions you may have at this time?

S1. I would like to speak with the person who owns/rents this home OR his/her spouse or partner. Are you that person?	YES I am the owner/renter If YES, go to S1a and then ask question S1b. YES I am the spouse/partner of the owner/renter If YES, go to S1a and then ask question S1e. NO If NO, go to S2 Don’t know REFUSED If respondent does not speak English, then indicate here the need for a translator. Stop the screening and contact the Field Manager for further direction. _______Respondent is in need of a translator
S1a. If YES: BRIEFLY COVER THE FOLLOWING POINTS WITH THE RESPONDENT: Purpose of the survey Request to interview them Respondent incentive Answer any questions/concerns	COMMENTS:
FOR OWNER/RENTER S1b. Since the purpose of this survey is to understand the housing needs of Native Americans, how do you (owner/renter) identify your racial/ethnic background? I am going to read the categories to you. Please choose one or more of the following races you consider yourself to be. (Mark all that apply)	American Indian or Alaska Native Native Hawaiian or other Pacific Islander White Black or African American Asian Other (SPECIFY): __________________________ Don’t know Refused If the owner/renter is American Indian or Alaska Native, continue to question S1c. If the owner/renter is NOT American Indian or Alaska Native, then ask question S1d.
S1c. I see that you (owner/renter) have identified yourself as American Indian or Alaska Native. Are you an enrolled member of a tribe?	Yes No Don’t know Refused Continue with question S1h.
S1d. I see that you (owner/renter) have identified yourself as NOT American Indian or Alaska Native; can you tell me the racial/ethnic background of your (spouse/partner)?	I do not have a spouse/partner If the owner/renter does not have a spouse/partner, then thank the person you are speaking with and end the interview. Contact the Field Manager for further directions. STOP. American Indian or Alaska Native Native Hawaiian or other Pacific Islander White Black or African American Asian Other (SPECIFY): __________________________ Don’t know Refused If the spouse/partner of the owner/renter is American Indian or Alaska Native, skip to question S1f. You will need to speak with the spouse/partner of the owner/renter to complete the Screener and arrange/conduct the interview. If the spouse/partner is available: introduce yourself and the study, and cover points in S1a. Then continue with S1f. If the spouse/partner is not available: Skip to S2. If the spouse/partner is not American Indian or Alaska native, then thank the person you are speaking with and end the interview. Contact the Field Manager for further directions. STOP.
FOR SPOUSE/PARTNER S1e. Since the purpose of this survey is to understand the housing needs of Native Americans, how do you (spouse/partner) identify your racial/ethnic background? I am going to read the categories to you. Please choose one or more of the following races you consider yourself to be. (Mark all that apply)	American Indian or Alaska Native Native Hawaiian or other Pacific Islander White Black or African American Asian Other (SPECIFY): __________________________ Don’t know Refused If the spouse/partner is American Indian or Alaska Native, continue with question S1f. If the spouse/partner is NOT American Indian or Alaska Native, then ask question S1g.
S1f. I see that you (spouse/partner) have identified yourself as American Indian or Alaska Native. Are you (spouse/partner) an enrolled member of a tribe?	Yes No Don’t know Refused Skip to question S1h.
S1g. I see that you (spouse/partner) have identified yourself as NOT American Indian or Alaska Native; can you tell me the racial/ethnic background of the (owner/renter)?	American Indian or Alaska Native Native Hawaiian or other Pacific Islander White Black or African American Asian Other (SPECIFY): __________________________ Don’t know Refused If the spouse/partner indicates that the owner/renter IS American Indian or Alaska Native, continue with question S1h. If the spouse/partner indicates that the owner /renter is NOT American Indian or Alaska Native, then thank the person you are speaking with and end the interview. Contact the Field Manager for further directions. STOP.
S1h. Do you have any additional questions about the survey? When would be the best time for me to come back to conduct the interview? Is now a good time?	Now is a good time. Date Time AM/PM (circle) Go to Informed Consent, next page -> Come back at another time. BEST DATE/TIME FOR INTERVIEW: Date Time AM/PM (circle) Continue with S2. -> I would prefer that someone else speak for me. Continue with S3.
S2. IF NO: When would be a good time to do the interview? OBTAIN CONTACT INFORMATION AND COME BACK ANOTHER DAY.	Name of owner/renter or spouse/partner: _____________________________________________________ Best date/time to speak with respondent: Date Time AM/PM (circle) Phone number: __________________________________
S3. IF NEED FOR PROXY: If for some reason, the owner/renter OR spouse/partner is unable to participate in an interview, then ask who the best person (i.e., the one who is most knowledgeable about family housing) would be able to participate.	First name of proxy: _____________________________ Relationship to owner/renter: _________________ Phone number: __________________________________ Reason owner/renter cannot participate: _______________________________________________________

Informed Consent

Hello, my name is ­­­­­­­­­­­­­­__________________________ [INTERVIEWER NAME].

I am from [INDICATE WHERE FROM] and I am [INDICATE TRIBAL AFFILIATION, if applicable].

I work with NORC at the University of Chicago to conduct this survey of housing needs.

As you may have learned from the [ADVANCE LETTER SENT/MATERIALS SHARED/TRIBAL LETTER/COMMUNITY PRESENTATION HELD], this survey is conducted to help understand the housing needs of American Indian and Alaska Native families. It is sponsored by the Department of Housing and Urban Development and being conducted across Indian Country.

Your participation is very important to the success of this survey. This survey is voluntary, which means that you don’t have to participate and you can decide not to answer any specific questions. There are no consequences for choosing not to participate or not to answer any question. You also may end the interview at any point. You will receive a [CASH GIFT/ GIFT CARD/VOUCHER] as a token of appreciation for participating in the survey. The interview will take about 45 minutes.

The information you provide will be confidential, and will not be shared with anyone except for research staff working on the study. This includes anything that can identify you such as your name, address, or telephone number. Everyone who works on this survey has signed a legal document stating they will not reveal any of your personal information and can be severely penalized if they do.

The survey will ask you about how many people live in your household, the features of the housing unit you live in (such as the number of rooms, electricity, and heat), your preferences for an ideal housing unit, your thoughts on homeownership and renting, your attitudes about tribally-assisted housing, your reasons for living on Indian Land, and the costs of housing. Finally, at the end of the interview I will make some observations about the condition of the housing unit, such as whether repairs are needed and things like that. The interview will take about 45 minutes.

The information you provide will be help in the national understanding of housing conditions and needs for Native Americans and Alaska Natives living in tribal areas and villages. It will be used along with data collected across the country to inform policy in ways that help tribes improve housing conditions.

The information that you provide will be kept private. You will not be quoted by name and no names will be included in the summary reports. A report will be shared with the tribe/native village at a later date. It will summarize the findings, without giving names or other information that would identify you or the tribe/native village.

If you have questions about your rights as a survey participant, please call the IRB Human Subjects Protection hotline, toll-free, at (866) 309-0542. You may also email xxx@norc.org or visit www.norc.org.

Do I have your permission to begin the interview?

• IF YES, Let’s begin. [Certain tribes may require written consent]

• IF NO, ask:

Are there any questions I can answer for you?

_________________________________________________________________________________________________

_________________________________________________________________________________________________

What is the reason you prefer not doing the interview?

_________________________________________________________________________________________________

_________________________________________________________________________________________________

When is a good time to come back?

Date: ____/____/________ Time: ____:____ ____ AM/PM (circle)

1. Household Composition ¹

INTERVIEWER READ: “In this interview, I am going to ask you some questions about you and your family, and the people that live with you in order to better understand your housing needs. This interview is anonymous, meaning that your name does not appear anywhere on this form.”

If PROXY is used: “If you are speaking for someone else, please remember to answer the questions from the owner’s/renter’s perspective. Feel free to consult with him/her or to not answer any questions if you’re not comfortable answering.”

A1. To begin, can you tell me how long you have lived here? IF RESIDENT HAS BEEN IN RESIDENCE FOR LESS THAN 1 YEAR THEN INDICATE NUMBER OF MONTHS. IF RESIDENT HAS BEEN IN RESIDENCE FOR 1 1/2 YEARS THEN INDICATE 1 YEAR 6 MONTHS. DO NOT ROUND UP.	______ years _____ months
A2. How many people are living or staying at this address? 2 READ THE INSTRUCTIONS TO THE RIGHT ALOUD TO RESPONDENT SO THEY KNOW WHO TO INCLUDE AND WHO NOT TO INCLUDE. AFTER GOING THROUGH THIS SECTION AND DESCRIBING EVERYONE STAYING HERE: IF THE NUMBER OF PERSONS THE RESPONDENT DESCRIBES IS HIGHER THAN THE NUMBER THEY GIVE FOR THIS QUESTION, CHANGE THE NUMBER HERE TO THE HIGHER NUMBER. IF THE NUMBER OF PERSONS RESPONDENTS DESCRIBES IS LOWER THAN THE NUMBER OF PERSONS THEY GIVE HERE, THEN MENTION THAT AND ASK IF THEY HAVE LEFT SOMEONE OUT. IF THEY HAVE OMITTED SOMEONE, ADD THE PERSON IN THE APPROPRIATE TABLE. IF THEY JUST GAVE THE WRONG NUMBER HERE, THEN CORRECT IT.	Number of people: _____ INCLUDE everyone who lives or stays here now or will be living or staying here for more than 2 months. INCLUDE yourself if you are living here or will be living here f or more than 2 months. INCLUDE anyone else staying here who does not have another place to stay, even if they are here for 2 months or less. INCLUDE any children age 17 or younger who are temporarily living away from home at boarding school or with family or friends but for whom this address is their permanent residence. INCLUDE any children age 17 or younger who regularly split their time between this address and another parent, grandparents or other family members INCLUDE any of your children age 18 and over who are away at college but for whom this address is their permanent residence. INCLUDE anyone that is temporarily away and taking part in subsistence activities (e.g., hunting, gathering, fish camp, herding, etc.).
A3. Do you have a spouse/partner?	YES NO Don’t know REFUSED If YES, continue with question A3a. If NO/DK/REF, skip to question A4. →
A3a. Do you and he/she live together?	YES NO Don’t know REFUSED Continue with question A4.
A4. Do you have any children?	YES NO Don’t know REFUSED If YES, continue with question A4a. If NO/DK/REF, skip to question A6. →
A4a. Do any of your children live with you? Please include children of all ages who live here. Include children age 17 or younger who are away temporarily at boarding school or with family or friends but for whom this is their permanent residence, or who regularly split their time between this address and another parent, grandparents, or other family members. Also include children age 18 or over who are away at college but for whom this is their permanent residence.	YES NO Don’t know REFUSED If YES, continue with question A4b. If NO/DK/REF, skip to question A5. →
A4b. If yes, how many of these children live with you?	2 3 4 5 or more Continue with question A4c.

A4c. For each child who lives with you, please tell me his or her gender, age, whether he or she is American Indian or Alaska Native, his or her tribal affiliation, and how long he or she has lived with you. Also, please tell me whether this child splits his/her time between living with you and in another household OR if he/she is away at school. IF CHILD IS AN INFANT (2 YEARS OF AGE OR LESS), THEN INDICATE AGE IN MONTHS. OTHERWISE MARK IN YEARS. IF CHILD HAS BEEN IN RESIDENCE FOR LESS THAN 1 YEAR THEN INDICATE NUMBER OF MONTHS. IF CHILD HAS BEEN IN RESIDENCE FOR 1 ½ YEARS THEN INDICATE 1 YEAR 6 MONTHS. DO NOT ROUND UP. IF CHILD SPLITS TIME WITH THEM AND OTHER FAMILY MEMBER(S), INDICATE YES FOR “SPLIT TIME.” PROVIDE OVERALL LENGTH OF TIME WITH THEM. DON’T TAKE OUT PERIODS THEY ARE AWAY. IF CHILD IS AWAY AT SCHOOL, INDICATE YES FOR “AWAY AT SCHOOL.” PROVIDE OVERALL LENGTH OF TIME WITH THEM. DON’T TAKE OUT PERIODS THEY ARE AWAY.
√		Male (M)/ Female (F)	Age DK R	AI/ AN YES NO DK R	If AIAN, what is Tribal affiliation? DK R	Length of time living with you DK R	Split time? YES NO	Away at school? YES NO
	Child #1					_____ ______ years months
	Child #2					_____ ______ years months
	Child #3					_____ ______ years months
	Child #4					_____ ______ years months
	Child #5					_____ ______ years months
	Child #6					_____ ______ years months
	Child #7					_____ ______ years months
	Child #8					_____ ______ years months

A5. Do you have any grandchildren?						YES NO Don’t know REFUSED If YES, continue with question A5a and A5b. If NO/DK/REF, skip to question A6. →
A5a. Do any of your grandchildren live with you?  Please include grandchildren above the age 18 and grandchildren age 17 or younger age 17 or younger who are away temporarily at boarding school or with family or friends but for whom this is their permanent residence or who regularly split their time between this address and parents, other grandparents, or other family members.						YES NO Don’t know REFUSED
A5b. If yes, how many of these grandchildren live with you?						1 2 3 4 5 or more Continue with question A5c.
A5c. For each grandchild who lives with you, please tell me his or her gender, age, whether he or she is American Indian or Alaska Native, his or her tribal affiliation, and how long he or she has lived with you. Also, please tell me whether this grandchild splits his/her time between living with you or another household OR if he/she is away at school. IF GRANDCHILD IS AN INFANT (2 YEARS OF AGE OR LESS), THEN INDICATE AGE IN MONTHS; OTHERWISE MARK IN YEARS. IF GRANDCHILD HAS BEEN IN RESIDENCE FOR LESS THAN 1 YEAR THEN INDICATE NUMBER OF MONTHS. IF GRANDCHILD HAS BEEN IN RESIDENCE FOR 1 1/2 YEARS THEN INDICATE 1 YEAR 6 MONTHS. DO NOT ROUND UP. IF GRANDCHILD SPLITS TIME WITH THEM AND OTHER FAMILY MEMBER(S), INDICATE YES FOR “SPLIT TIME.” PROVIDE OVERALL LENGTH OF TIME WITH THEM. DON’T TAKE OUT PERIODS THEY ARE AWAY. IF GRANDCHILD IS AWAY AT SCHOOL, INDICATE YES FOR “AWAY AT SCHOOL.” PROVIDE OVERALL LENGTH OF TIME WITH THEM. DON’T TAKE OUT PERIODS THEY ARE AWAY.
√		Male (M)/ Female (F)	Age DK R	AI/ AN YES NO DK R	If AI/AN, what is Tribal affiliation? DK R		Length of time living with you DK R	Split time? YES NO	Away at school? YES NO
	Grandchild #1						_____ ______ years months
	Grandchild #2						_____ ______ years months
	Grandchild #3						_____ ______ years months
	Grandchild #4						_____ ______ years months
	Grandchild #5						_____ ______ years months
	Grandchild #6						_____ ______ years months
	Grandchild #7						_____ ______ years months
	Grandchild #8						_____ ______ years months

A6. Is there anyone else, other than your [spouse/partner, child(ren), and grandchild(ren)] who is related to you by birth or marriage that is living in your household? Include all of the people who usually stay here, but are away temporarily, on business trips, vacations, at school, temporarily in a hospital and such.	YES NO Don’t know REFUSED If YES, continue with question 6a and 6b. If NO/DK/REF, skip to question 7. →
A6a. If yes, how many other relatives live in your household?	2 3 4 5 or more
A6b. I would like to ask you about the other family member(s) that live(s) here with you. Can you tell me their relationship to you? I would also like to ask how long she or he has been living with you, and whether she or he is a child age 17 or younger. Let’s begin with the women and girls and then I will ask about the men and boys. INTERVIEWER: Check the box next to the type of relative. If more than one, enter the number in the “If more than 1:” column. If there are multiple relatives (such as sisters), enter the longest time of all the sisters. IF RELATIVE IS AN INFANT (2 YEARS OF AGE OR LESS), THEN INDICATE AGE IN MONTHS; OTHERWISE MARK IN YEARS. IF RELATIVE HAS BEEN IN RESIDENCE FOR LESS THAN 1 YEAR THEN INDICATE NUMBER OF MONTHS. IF RELATIVE HAS BEEN IN RESIDENCE FOR 1 1/2 YEARS THEN INDICATE 1 YEAR 6 MONTHS. DO NOT ROUND UP. IF RELATIVE SPLITS TIME WITH THEM AND OTHER FAMILY MEMBER(S), INDICATE YES FOR “SPLIT TIME.” PROVIDE OVERALL LENGTH OF TIME WITH THEM. DON’T TAKE OUT PERIODS THEY ARE AWAY. IF RELATIVE IS AWAY AT SCHOOL, INDICATE YES FOR “AWAY AT SCHOOL.” PROVIDE OVERALL LENGTH OF TIME WITH THEM. DON’T TAKE OUT PERIODS THEY ARE AWAY.

√	Relationship	If more than 1:		Is this person(s) age 17 or younger? YES NO DK R			Length of time living with you DK R	Split time? YES NO		Away at school? YES NO
	Mother	NA					_____ ______ years months
	Grandmother						_____ ______ years months
	Sister						_____ ______ years months
	Aunt						_____ ______ years months
	Cousin (female)						_____ ______ years months
	Niece						_____ ______ years months
	Foster daughter						_____ ______ years months
	Mother-in-law						_____ ______ years months
	Sister-in-law						_____ ______ years months
	Other female relative (SPECIFY):						_____ ______ years months
	Father						_____ ______ years months
	Grandfather						_____ ______ years months
	Brother						_____ ______ years months
	Uncle						_____ ______ years months
	Cousin (male)						_____ ______ years months
	Nephew						_____ ______ years months
	Foster son						_____ ______ years months
	Father-in-law						_____ ______ years months
	Brother-in-law						_____ ______ years months
	Other male relative (SPECIFY):						_____ ______ years months
	Other (SPECIFY):						_____ ______ years months
	Other (SPECIFY):						_____ ______ years months
A7. Is there anyone else, unrelated to you by birth or marriage, living in your household?					YES NO Don’t know REFUSED If YES, continue with question A7a and A7b. If NO/DK/REF, skip to question A8. →
A7a. If yes, how many persons that are not related to you live in your household?						3 4 5 or more
A7b. Can you tell me this person’s relationship to you? I would also like to ask how long she or he has been living with you, and whether she or he is a child age 17 or younger. IF THEY SAY THEY ARE A RELATIVE, THEN ENTER THAT PERSON IN TABLE A6b ABOVE FOR RELATIVES. ALSO, CHANGE THE RESPONSE TO QUESTION A6 (IF NECESSARY), AND CHANGE THE NUMBER IN A6a. IF NOT A RELATIVE, CONTINUE. INTERVIEWER: Check the box next to the type of relationship. If more than one, enter the number next to the person identified. IF PERSON IS AN INFANT (2 YEARS OF AGE OR LESS), THEN INDICATE AGE IN MONTHS; OTHERWISE MARK IN YEARS. IF PERSON HAS BEEN IN RESIDENCE FOR LESS THAN 1 YEAR THEN INDICATE NUMBER OF MONTHS. IF PERSON HAS BEEN IN RESIDENCE FOR 1 1/2 YEARS THEN INDICATE 1 YEAR 6 MONTHS. DO NOT ROUND UP. IF PERSON SPLITS TIME WITH THEM AND OTHER FAMILY MEMBER(S), INDICATE YES FOR “SPLIT TIME.” PROVIDE OVERALL LENGTH OF TIME WITH THEM. DON’T TAKE OUT PERIODS THEY ARE AWAY. IF PERSON IS AWAY AT SCHOOL, INDICATE YES FOR “AWAY AT SCHOOL.” PROVIDE OVERALL LENGTH OF TIME WITH THEM. DON’T TAKE OUT PERIODS THEY ARE AWAY.
√	Relationship	If more than 1:	Is this person(s) age 17 or younger? YES NO DK R				Length of time living with you DK R		Split time? YES NO	Away at school? YES NO
	Friend						_____ ______ years months
	Foster child						_____ ______ years months
	Boarder						_____ ______ years months
	Roommate						_____ ______ years months
	Landlord						_____ ______ years months
	Other (SPECIFY):						_____ ______ years months
	Other (SPECIFY):						_____ ______ years months
	Other (SPECIFY):						_____ ______ years months

A8. In your opinion, are there more people staying here than can live comfortably in this unit?

YES NO Don’t know REFUSED

A9. Of all the people who are living here, is anyone living with you because they had to leave where they were living and had no other place to stay?

YES NO Don’t know REFUSED If YES, ask question A10. If NO, skip to next section. → If DON’T KNOW or REFUSED ask A10.

A10. Would any of these people move to a separate house or apartment if they could?

YES NO Don’t know REFUSED If YES, continue with question A10a. If NO/DK/REF, skip to next section. →

A10a. Which ones? INDICATE THE PERSON ON THE LIST. FOR EACH PERSON IDENTIFIED, ASK QUESTION A10b, GIVE THE RESPONDENT SHOWCARD X AND RECORD THE RESPONSE.

A10b. Are any of them currently looking for housing? If YES, continue with question A10c. If NO/DK/REF, skip to question A11.

A10c. If yes, do they expect to move within the next 60 days?

YES

NO

DK

R

YES

NO

DK

R

Child(ren):

Grandchild(ren):

Relative(s):

Non-relative(s):

A11. Of the people who you mentioned, let’s see, that would be [MENTION ALL THE PERSONS NOTED ABOVE], what is the most important factor preventing each of them from moving into their own house or apartment at this time? RECORD ONE RESPONSE ONLY FOR EACH PERSON.

Factor preventing each person from moving

Relationship

No housing available in this area

Can’t afford own housing

Waiting for a subsidized unit/on waiting list

No safe places to live available in this area

Other (SPECIFY)

Don’t Know

Refused

Children

Child 1

Child 2

Child 3

Grandchildren

Grandchild 1

Grandchild 2

Grandchild 3

Relatives

Female (Specify):

Female (Specify):

Male (Specify):

Male (Specify):

Non-relative household member

Friend

Foster child

Boarder

Roommate

Landlord

Other (Specify)

Other (Specify):

2. Housing unit characteristics and Conditions³

INTERVIEWER READ: Now I would like to ask some questions about the house/apartment that you live in to get a better understanding about the features of this unit. I will ask you some questions about the rooms, cooking and food storage, electricity, heat, water, and septic systems.

TYPE AND NUMBER OF ROOMS
B1	How many rooms are there in this house/apartment, not counting bathrooms and hallways?	# rooms ______
B2	BEDRMS (p 60) How many bedrooms are there in your house/apartment?	0 1 2 3 4 5 6 7 8 9 Enter 10 for 10 or more
B2a	Are any other rooms in your house/apartment used at night for people to sleep in?	YES NO Don’t know REFUSED If YES, continue with B2b. If NO, go to B3.
B2b	IF YES Which rooms? (SPECIFY)	___________________________________________________
B3	BATHS (p 60) How many full bathrooms? A full bathroom includes a toilet, sink, bathtub and/or shower.	0 1 2 3 4 5 6 7 8 9 Enter 10 for 10 or more
B4	HALFB (p 60) How many half bathrooms? A half bathroom includes a toilet and sink.	0 1 2 3 4 5 6 7 8 9 Enter 10 for 10 or more

COOKING AND FOOD STORAGE
B5	Are your main cooking facilities inside this unit or outside?	Inside unit Outside unit No cooking facilities If INSIDE UNIT, continue with B6 If OUTSIDE UNIT or NO COOKING FACILITIES, skip to question B10
B6	COOKQ (p 71) Does your house/apartment have some type of cooking stove, or a range with an oven—one that is in working order?	YES NO Don’t know REFUSED
B7	BURNERQ Does your house/apartment have any built-in cooking burners that are in working order?	YES NO Don’t know REFUSED
B8	OVENQ (p 72) Does your house/apartment have a microwave oven that is in working order?	YES NO Don’t know REFUSED
B9	CFUELQ (p 72) What fuel is used MOST for cooking—electricity, gas, or something else?	Electricity Gas or liquid propane Kerosene or other liquid fuel Coal or coke Wood Other (SPECIFY): __________________________ No fuel used
B10	REFQ (p 73) Does your house/apartment have a refrigerator that is in working order?	YES NO Don’t know REFUSED
B11	SINKQ Does your house/apartment have a kitchen sink?	YES NO Don’t know REFUSED

ELECTRICITY
B12	Is your house connected to the electric grid, or do you receive your electricity another way (e.g., generator, extension cord to someone else’s house)?	Electric grid Another way Don’t have electricity Don’t know Refused If “Electric grid”, continue with question B13. If “Another way,” skip to question B14. If “Don’t have electricity,” skip to B20.
B13	BUYE2 Do you pay separately for electricity?	Yes No, included in rent, condo fee or other charges Continue with question B15
B14	How do you obtain electricity?	By extension cord from another source Through a generator Other (SPECIFY): __________________________ Skip to HEATING section question B20 ->
B15	NOWIRE1Q (p 99) Is all the electrical wiring in the finished areas of your house/apartment concealed in the walls?	Yes, wiring concealed No, wiring not concealed or not covered No electrical wiring
B16	NOWIRE1Q (p 99) Is the electrical wiring safely contained in protective or metal or plastic coverings? (Exclude appliance cords, extension cords, chandelier cords, phone, antenna, cable TV wires, etc.).	YES NO Don’t know REFUSED
B17	PLUG SV (p 100) Does every room have an electrical outlet or wall plug that works?	YES NO Don’t know REFUSED
B18	IFBLOW (p 100) Have any fuses blown or circuit breakers tripped in the past three months?	YES NO Don’t know REFUSED If YES, continue with B19. If NO/DK/REF, skip to B20.
B19	NUMBLOW (p 100) How many times?	1 2 3 4 5 6 7 Enter 8 for 8 or more

HEAT
B20	HEQUIP = Main heating equipment What is the main source of heat for this unit?	Forced warm-air furnace with ducts and vents to individual rooms Steam or hot water system with radiators OR other system using steam or hot water Electric heat pump Built-in electric baseboard heating or electric coils in floors, ceilings, or walls Floor, wall, or other pipeless furnace built into the building VENTED room heaters burning kerosene, gas, or oil UNVENTED room heaters burning kerosene, gas, or oil Portable electric heaters Woodburning stove, pot belly stove, Franklin stove Fireplace WITH inserts Fireplace WITHOUT inserts Other heating equipment No heating equipment Cooking stove (gas or electric) Not applicable
B21	HFUELA (pp 84-85) What fuel is used MOST for heating your house/apartment?	Electricity Gas or liquid propane Fuel oil Kerosene or other liquid fuel Coal or coke Wood Solar energy Other (SPECIFY): __________________________ None
B22	HCENTA (p 86) Sometimes people have more than one type of heating equipment in their house/apartment. Turning first to questions about your MAIN heating equipment: Is your heating equipment designed to send heat to all or most of the rooms?	YES NO Don’t know REFUSED If YES, continue with question 23 If NO/DK/REF, skip to question 24.
B23	HCENTB (p 86) How does it send heat to the rooms?	Forced air through ducts and vents Steam or hot water through radiators or pipes Electric coils inside the floors, ceilings or walls Some other way
B24	What is the secondary source of heating for your house/apartment?	Forced warm-air furnace with ducts and vents to individual rooms Steam or hot water system with radiators OR other system using steam or hot water Electric heat pump Built-in electric baseboard heating or electric coils in floors, ceilings, or walls Floor, wall, or other pipeless furnace built into the building VENTED room heaters burning kerosene, gas, or oil UNVENTED room heaters burning kerosene, gas, or oil Portable electric heaters Woodburning stove, pot belly stove, Franklin stove Fireplace WITH inserts Fireplace WITHOUT inserts Other heating equipment No heating equipment Cooking stove (gas or electric) Not applicable Do not have secondary source of heating
B25	The next series of questions are about problems that some people have experienced with their homes. We are interested if you have experienced these types of problems too. FREEZEQ (p94) Last winter for any reason was your house/apartment so cold for 24 hours or more that you were uncomfortable?	YES NO Don’t know REFUSED If YES, continue with question B26 If NO/DK/REF, skip to question B30.
B26	IFCOLD (p 94) Was that because the MAIN heating equipment broke down?	YES NO Don’t know REFUSED If NO, skip to B28
B27	NUMCOLD (p95) How many times did the MAIN heating equipment break down for 6 hours or more last winter?	1 2 3 4 5 6 7 Enter 8 for 8 or more
B28	OTHCOLD (p 95) Was it cold for any other reason?	YES NO Don’t know REFUSED If NO, DK or REFUSED, skip to B30
B29	OTHCOLD (p 95) What was the reason?	Enter all that apply: Utility interruption Inadequate heating supply Inadequate insulation Cost of heating Other (SPECIFY): __________________________

WATER 4
B30	We would like to know about the primary source of water that you use. WATERQ (p 82) Does most of the water for your house/apartment come from a water system, either public or private, from an individual well, or from some other source?	Public or private water system (includes city water) Individual well Spring Cistern Stream or lake Commercial bottled water Other (SPECIFY): _________________________
B31	WATERS (P 84) In your opinion, is the water from this [water source from B30] safe for cooking and drinking?	YES NO Don’t know REFUSED
B32	HOTPIP (P 79) Is there both hot and cold running water anywhere in your house/apartment?	YES NO Don’t know REFUSED
B33a	Do you use [water source from B 30] this water for drinking?	YES NO Don’t know REFUSED If YES, continue with question B 34a If NO go to question B33b
B33b	How do you obtain water for drinking?	Haul water Have water trucked in Link a hose to another dwelling Bottle water at source Other (SPECIFY): _________________________
B34a	Do you use this water for cooking?	YES NO Don’t know REFUSED If YES, continue with question B35a If NO go to question B34b
B34b	How do you obtain water for cooking?	Haul water Have water trucked in Link a hose to another dwelling Bottle water at source Other (SPECIFY): _________________________
B35a	Do you use this water for bathing?	YES NO Don’t know REFUSED If YES, continue with question B36a If NO go to question B35b
B35b	How do you obtain water for bathing?	Haul water Have water trucked in Link a hose to another dwelling Bottle water at source Other (SPECIFY): _________________________
B36a	Do you use this water for cleaning?	YES NO Don’t know REFUSED If YES, continue with question 37a If NO go to question 36b
B36b	How do you obtain water for cleaning?	Haul water Have water trucked in Link a hose to another dwelling Bottle water at source Other (SPECIFY): _________________________
B37a	The next questions are about water leaks, either from OUTSIDE your house/apartment or from INSIDE. LEAK1 (p96) While you have been living here, did water ever leak INTO your house/apartment directly FROM THE OUTSIDE, for example through the roof, outside walls, basement or any closed windows or skylights? 5 Does water leak into this house/apartment from the outside?	Yes No outside water leaks Don’t know REFUSED If YES, continue with question B37b If NO go to question B38a
37b	LEAK2 (p 96) Did water leak in from the outside within the past 12 months, that is, since [date]?	YES NO Don’t know REFUSED
B37c	WHERELK (p97) Did the water come in from…?	Roof Basement Walls or around closed windows or closed doors Somewhere else (SPECIFY):_____________________________
B38a	ILEAK1 (p97) Now about water leaks from INSIDE. Since you’ve lived here, did water leak in from broken pipes or water heaters, backed up plumbing, or on the ceiling, walls, or floor with water that came from another unit?	YES NO Don’t know REFUSED If YES, continue with question 38b If NO go to question 39
B38b	ILEAK2 Did any inside water leaks happen within the past 12 months, that is since [date]?	YES NO Don’t know REFUSED
B38c	WHERELK2 (p 98) Where did the water come from?	Own plumbing fixtures backed up and/or overflowed Pipes leaked (include pipe leaks from other apartments) Broken water heater Other (SPECIFY): _________________________ Unknown

SEPTIC
B39	PUBSEWQ (p 77) Is your house/apartment connected to a public sewer?	YES NO Don’t know REFUSED If Yes, skip to B41
B40	SEWDISQ (p 78) What means of sewage disposal does your house/apartment have?	Septic tank Cesspool Chemical toilet Outhouse or privy Don’t know Other (SPECIFY): ______________________ None
B41	IFSEW (p98) Did the sewage system break down in the past three months?	YES NO Don’t know REFUSED If NO, DK OR REFUSED, SKIP TO B44
B42	How many of these breakdowns lasted 6 hours or more?	1 2 3 4 5 6 7 Enter 8 for 8 or more
B43	Have you had any of the following problems with the septic system during the last 6 months:	Back-ups Surfacing sewage Septic tank collapse Drain field failed Blocked lines Frequent pumping required Smell/stench

B44	TOILETP (p 80) 6 Is there a flush toilet anywhere in your house/apartment?	YES NO Don’t know REFUSED If YES, continue with B44a If NO, go to B45.
B44a	Were there any times during the last three months when the/all the flush toilet(s) in your house/apartment were broken down or backed up for 6 hours or more?	YES NO Don’t know REFUSED
B45	If NO, what type of toilet does this unit have?	Chemical toilet Outhouse/privy Other (SPECIFY): ______________________
B46	IF RESPONDENT INDICATED THE HOUSE/APARTMENT HAS A FULL BATH IN B3, ASK: Earlier you said that you have a full bath. TUB1 (p 79) Does the full bath contain a bathtub or a shower?	YES NO Don’t know REFUSED
B47	SHARPF (p 81) Some people live in neighborhoods where some of the houses don’t have complete plumbing facilities. So, they must use other people’s bathrooms. Does anyone not living in your home, not counting guests or workers, regularly use your plumbing or bathroom?	YES NO Don’t know REFUSED

Interior condition 7
B48	VISIBLE HOLES IN FLOOR HOLES (p 100) How about the floors in your house/apartment, are there any holes in the floors big enough for someone to catch their foot on?	YES NO Don’t know REFUSED
B49	HOLES OR OPEN CRACKS IN WALLS OR CEILING CRACKS (p 100) People sometimes have problems with cracks or holes in the floors, walls, or ceilings, not hairline cracks or nail holes, but OPEN cracks or holes. In the INSIDE walls or ceilings of your house/apartment, are there any OPEN HOLES or CRACKS WIDER THAN THE EDGE OF A DIME?	YES NO Don’t know REFUSED
B50	PEELING PAINT BIGP1 (p 101) Does the inside of your house/apartment have any areas of peeling paint or broken plaster?	YES NO Don’t know REFUSED
B51	BIGP2 (p 101) Are any of these areas bigger than 8 X 11 inches? (PROMPT: That would be about the size of this piece of paper [indicate questionnaire].)	YES NO Don’t know REFUSED
B52	SIGNS OF RATS (OR OTHER VERMIN) EVROD (p 101) Have you ever seen signs of mice or rats INSIDE your house/apartment?	YES NO Don’t know REFUSED

3. Satisfaction with housing⁸

INTERVIEWER READ: Now that you have described the features of the house/apartment, I would like to ask you some questions about your satisfaction with this housing unit.

HOUSING QUALITY
C1	Overall, how would you rate your satisfaction with the house/apartment you live in? Please tell me using a scale of 1-5 scale where 1 is very dissatisfied and 5 is very satisfied.	Very dissatisfied Dissatisfied Neither dissatisfied nor satisfied Satisfied Very satisfied If respondent indicates VERY DISSATISFIED or DISSATISFIED, continue with C1a. If respondent is NEITHER DISSATISFIED NOR SATISFIED, SATISFIED, or VERY SATISFIED, skip to questions C2.
C1a	Why are you dissatisfied? What features of your house/apartment are you dissatisfied with?	Record verbatim response: OPEN END
C2	Do you think the overall physical condition of this house/apartment is unacceptable, acceptable, or excellent? Please choose one response.	Unacceptable Acceptable Excellent If respondent indicates EXCELLENT, go to D1. If respondent indicates UNACCEPTABLE OR ACCEPTABLE, continue with C2a.
C2a	Why do you say that? What problems are there with the physical condition of your house/apartment?	Record verbatim response: OPEN END

4. Culturally-Responsive housing

INTERVIEWER READ: Next I am going to ask you some questions about your housing preferences.

D1	Thinking about this house/apartment, can you tell me if each of the following features of your home reflects tribal culture and practices? I am going to read each feature aloud to you.
			Yes Please explain.		No Please explain.	Don’t Know	Refused
D1a	Exterior appearance
D1b	Architectural design
D1c	Floor plan or arrangement of rooms (for example, interior layout of the unit, entry to the unit)
D1d	Number and type of rooms, for example, for weaving; crafts; sewing; tools; curing or storing meat, fish, berries; activities; family gatherings; ceremonies; places for children to study; rooms for extended family, etc.
D1e	Relationship to the land, for example, how it sits on the land, location of the door(s), lot size, etc.
D2	In your opinion, is the tribal housing office doing anything to make new homes or rehabbed/renovated homes more culturally compatible?		Yes Please explain.		No Please explain.	Don’t Know	Refused
D3	In general, does the design of housing in your community take into consideration cultural values or practices?		Yes Please explain.		No Please explain.	Don’t Know	Refused
D4		If you could choose your housing, which would you prefer? Please choose one. 9		An apartment for rent Duplex/townhome for rent Single-family house for rent Duplex/townhome for purchase Single-family house for purchase Manufactured housing/mobile home for rent Manufactured housing/mobile home for purchase

5. Needed services and Amenities

INTERVIEWER READ: I would like to ask you about needed services and amenities in your community.

NEEDED SERVICES/AMENITIES IN YOUR COMMUNITY
E1	Here is a list of services and amenities that are thought of as important for a community. Please look at the list and tell me which five services or amenities are most needed in your community. Interviewer: Hand the respondent SHOWCARD X with the list of responses. Mark five choices.
	Convenience store
	Grocery store (small/large/supermarket) – a store with a full range of fresh and frozen products)
	Gas station
	Bank or credit union
	Medical/health care services
	Dental care
	Mental health counseling and care
	Substance abuse treatment and care
	Laundromat
	Early childhood education/preschool programs
	Primary school (K-8)
	Secondary school (9-12)
	Child care center
	Legal services/assistance
	After-school programs
	Community college (tribal or non-tribal) or other adult education
	Parks or playgrounds
	A recreation or community center
	A library
	Job placement and training services
	Social service office to sign up for/receive benefits (e.g., welfare, social security, disability)
	Emergency assistance (rent, utilities, shelter)
	Food bank/meal assistance/commodities
	Help finding affordable housing
	Public safety/law enforcement patrols
	Tribal government offices
E2	Are there any other amenities or services that are most needed in your community but aren’t on this list? OPEN END.

6. Preferences for homeownership

INTERVIEWER READ: Some people own their houses or apartments and other people rent them.

I would like to ask you some questions about your preferences for owning or renting. I will also ask if you have concerns about potential sale, foreclosure, eviction or evacuation in the near future.

F1	Do you own this home or apartment or are you buying this home or apartment with a lease/purchase or similar plan?	Own Continue with F4 Owners Buying on lease/purchase Continue with F4 Owners Neither Ask question F2
F2	Do you rent or live for free in this house/apartment?	Rent Skip to F9 Renters Live for free Ask question F3
F3	If live for free: Who owns it?	Parent(s) Grandparent(s) Other family member (SPECIFY):_________________________ Friend Other (SPECIFY): __________________________ Skip to F8

FOR OWNERS ONLY
F4	What is the ownership status of the land that your house or unit is on?	Privately owned, non-trust land Allotment land (individual trust land) Land owned by the tribe (whether in trust or not) Don’t know Other (SPECIFY): __________________________
F5	Are you in a home that was built or subsidized by the tribe, HUD, BIA or some other government agency?	YES NO Don’t know REFUSED
F6	Do you currently have a mortgage on your property?	YES NO Don’t know REFUSED
F7	Have you ever applied for a mortgage and had your application denied?	YES NO Don’t know REFUSED If YES, go to question F7a. If NO, go to question F8.
F7a	Why was your mortgage application denied? Please tell me the reasons. Continue with question F8.	Didn’t have a sufficient down payment Don’t make enough money to pay the mortgage Don’t have a job Don’t have a long/good job history My credit score was too low/didn’t have a credit history Too much debt (credit cards, student loans, medical/health care costs) There were issues about the title to the land or property rights I felt I was discriminated against because I am American Indian/Alaska Native Other (SPECIFY): __________________________
F8	Would you prefer to rent your home rather than owning?	I would prefer to rent I would prefer to own Don’t know REFUSED If “rent”, continue with F8a. If “own”, go to F11.
F8a	Why would you rather rent? MARK ALL THAT APPLY	Less expensive than buying/can’t afford to buy Less responsibility/less risk/don't have to worry about maintenance Can move when I want/can be more flexible The market is too poor right now It is easier Don't have to worry about losing value Live on a fixed income Can't afford down payment Some other reason (SPECIFY): ______________ None Don’t Know Refused Skip to F13.

FOR RENTERS ONLY
F9	Have you ever applied for a mortgage and had your application denied?	YES NO Don’t know REFUSED If YES, go to question F9a. If NO, go to question F10.
F9a	Why was your mortgage application denied? Please tell me the reasons. Continue with question F10.	Didn’t have a sufficient down payment Don’t make enough money to pay the mortgage Don’t have a job Don’t have a long/good job history My credit score was too low/didn’t have a credit history Too much debt (credit cards, student loans, medical/health care costs) There were issues about the title to the land or property rights I felt I was discriminated against because I am American Indian/Alaska Native Other (SPECIFY): __________________________
F10	Would you prefer to own your own home rather than renting?	I would prefer to own I would rather rent Don’t know REFUSED If “own”, go to F11. If “rent”, continue with F10a.
F10a	Why would you rather rent? MARK ALL THAT APPLY	Less expensive than buying/can’t afford to buy Less responsibility/less risk/don't have to worry about maintenance Can move when I want/can be more flexible The market is too poor right now It is easier Don't have to worry about losing value Live on a fixed income Can't afford down payment Some other reason (SPECIFY): ______________ None Don’t Know Refused Continue to F11.

F11	ASK PEOPLE WHO SAID THEY WOULD PREFER TO OWN: Sometimes people find it hard to buy their own home. Here’s a list of barriers that prevent people from buying their own home. Please take a look and tell me if any of these reasons apply to you. Interviewer: Hand the respondent SHOWCARD X with the list of responses.	Can’t save enough for a house/can’t afford down payment (down payment) Can't afford the monthly mortgage payment Can’t find a mortgage lender in the area Can’t resolve land rights (property rights) Don’t have collateral to get a loan because my land is held in trust Don’t have a job Don’t have a long/good job history My credit score was too low/didn’t have a credit history Too much debt (credit cards, student loans, medical/health care costs) No houses available in a location I want to live No affordable houses in my area No houses are available for sale or being built that are suitable for me/my family Don’t know how to buy a home/unfamiliar with loan application process, lending terms, or real estate transactions Lenders are more likely to deny applications from American Indian/Alaska Native
F12	Are there any other reasons that you may have found it hard to buy your own home?	Specify: OPEN END

F13	Would you be willing to contribute your own labor or that of a family member to build your house if that made it possible to own your own home?	YES NO Don’t know REFUSED
F14	Have you ever taken a home buyer education class or training? 10	YES NO Don’t know REFUSED Continue with F15.

POTENTIAL SALE, FORECLOSURE, EVICTION OR EVACUATION 11
F15. Can you tell me if any of the following circumstances apply to you? ASK HOMEOWNERS QUESTIONs 15a and 15b. ASK RENTERS QUESTIONS 15c, 15d, 15e, and 15f.
F15a	You plan to sell your home in the next year or two because you can’t afford the mortgage payments or need the money that you have in your home.	YES NO NA Don’t know REFUSED
F15b	Your home is in foreclosure or you expect it to go into foreclosure within the next 60 days. If R is homeowner, skip to G1.	YES NO NA Don’t know REFUSED
F15c	You expect to be evicted from your home within the next 60 days.	YES NO NA Don’t know REFUSED
F15d	[If living in subsidized unit] You expect to be asked to move because you are behind on your payments.	YES NO NA Don’t know REFUSED
F15e	You will be asked to leave your home in the next 60 days so that someone else can move in.	YES NO NA Don’t know REFUSED
F15f	You will have to leave your home in the next 60 days because this residence will be demolished.	YES NO NA Don’t know REFUSED

Living on Indian land

(Reservations, native villages, or tribal service areas – OK only)

INTERVIEWER READ: Now that you have described your preferences for homeownership or renting, I would like to ask you a few questions about why you choose to live on the reservation/native village/ tribal service area (OK only).

G1	I am going to list some reasons people may have for living on this reservation/native village/tribal service area (OK only). How important are these reasons to you? Interviewer: Hand the respondent SHOWCARD X with the list of responses.
		Not important	Important	Very important	NA	DK	REF
G1a	Makes it easy to be an active member of the tribe/community
G1b	Family and friends are all here
G1c	Have always lived here
G1d	Sustaining traditional way of life
G1e	Avoiding discrimination/harassment
G1f	Access to job or business opportunity
G1g	Access to HUD or BIA housing assistance
G1h	Access to health care
G1j	Access to other subsidies/assistance
G1k	Is there any important reason I missed? (SPECIFY: _______________________)

G2	Have you ever lived off the reservation/native village or outside the tribal service area (OK only)?	YES NO Don’t know REFUSED
G2a	How long ago was that?	Within the last 2 years More than 2 years ago
G3	Do members of your immediate or extended family live outside the boundaries of the reservation/native village or tribal service area (OK only)?	YES NO Don’t know REFUSED
G4	Do you plan to live off the reservation/outside the native village or tribal service area in the next year or two?	YES NO Don’t know REFUSED
G5a	What are the major problems that you experience living on Indian Land? Interviewer: Hand the respondent SHOWCARD X with the list of responses. Mark all that apply.	Limited access to jobs or business opportunities Closed environment Tribal and family politics Difficulty accessing services (child care, job training, shopping, recreation) Limited access to health care Limited choice of schools for children Limited access to tribal or state colleges Shortage of affordable housing Limited supply of housing available Poor housing quality Difficulty obtaining a mortgage Crime and safety concerns Presence of gangs Prevalence of domestic violence Presence of alcohol/drug use Limited transportation options
G5b	Is there anything I missed?	Other (SPECIFY:__________________)

H. Attitudes toward tribally-assisted housing

INTERVIEWER READ: I would like your opinion about the quality of tribally assisted housing on the reservation/native village/tribal service area (OK only), and your sense of the federal government and tribal role in providing housing.

H1	INTEVIEWER: ASK ALL RESIDENTS How well does the [INSERT NAME OF TRIBAL HOUSING AUTHORITY] do its share of keeping the units in good condition? Again, please use a scale of 1 to 5, where 1 is a poor job and 5 is an excellent job.
	1 Poor job	2	3		4			5 Excellent job
H2	INTEVIEWER: ASK ALL RESIDENTS How well do residents do their share of keeping the units in good condition? Please use a scale of 1 to 5, where 1 is a poor job and 5 is an excellent job.
	1 Poor job	2	3		4			5 Excellent job
H3	INTEVIEWER: ASK ONLY FOR RESIDENTS OF TRIBALLY-ASSISTED HOUSING. Hand the respondent SHOWCARD X with the list of responses and read the responses aloud. What do you think the [INSERT NAME OF TRIBAL HOUSING AUTHORITY] could do to make its housing more attractive to you? Please tell me.
				YES		NO	Don’t know		REFUSED
H3a	Better locations
H3b	Different types of structures
H3c	Improved external appearance
H3d	Better quality of construction
H3e	Better upkeep of interior of units
H3f	Better upkeep of exterior of units
H3g	Upgraded/newer appliances
H3h	Larger units
H3i	Different configurations of rooms
H3j	Larger lot sizes
H3k	Reduced crime and drug activity in area
H3l	Reduced gang activity in area
H3m	More accessible social services
H3n	Improved landscaping
H3o	Simplified recertification process (proof of eligibility)
H3p	Exterior appearance/architectural design that reflects tribal culture and practices
H3q	Floor plan or arrangement of rooms, e.g., interior layout of the unit, entry to the unit, that reflects tribal culture and practices
H3r	Number and type of rooms, for example, for weaving, crafts, sewing, subsistence activities, storage, family gatherings, ceremonies, places for children to study, rooms for extended family, etc., that reflects tribal culture and practices
H4	INTEVIEWER: ASK ALL RESIDENTS Do people in your community have a say in the way the tribal government runs its housing assistance programs?			YES NO Don’t know REFUSED

I. Household income and housing costs ¹²

INTERVIEWER READ: I would like to ask you a few questions about the sources of financial and non-financial support for your household. I appreciate that our questions are difficult to answer and sometimes seem intrusive. As with other questions in this survey, we want to reassure you that the information you provide to us is kept confidential.

I1	I am going to be asking you about your household income, but first, I want to ask you about possible sources of that income. Did you (or anyone in your household) receive any income in the last 12 months from (...)?		YES		NO	Don’t know	REFUSED
I1a	Wages or salary
I1b	Commissions, bonuses, or tips
I1c	Self-employment income from a business or farm, including proprietorships and partnerships
I1d	Interest payments, dividends, net rental income, royalty income, or income from estates and trusts related to personal investments
I1e	Social Security or railroad retirement
I1f	Supplemental security income (SSI)
I1g	Public assistance, TANF/welfare payments from the state or local welfare office
I1h	Retirement, survivor, or disability pensions (SSDI)
I1i	Other work that you have not yet told me about that you or someone in your household did inside or outside the home such as child care/babysitting, weaving, basket-making, healing, storytelling, cooking, car repair, carpentry, or other jobs like that.
I1j	Any other sources of income received regularly such as Veteran’s payments, unemployment compensation, child support, or alimony
I1k	Tribal sources of income (per capita payment, other)
I1l	Other (SPECIFY):
I1m	No sources of cash income
I2a	Are there any sources of non-monetary support that your household relies on?		YES		NO	Don’t know	REFUSED
I2b		If YES, please describe them:	Subsistence activities (fishing, hunting, farming, gathering, herding) Bartering for goods and services Food distribution/pantries Labor in exchange for room & board Other (SPECIFY): __________________________
I3		Now we have a question about your household’s income during the last calendar year, that is, for [INSERT YEAR]. Again, I understand that our questions are difficult to answer and sometimes seem intrusive. As with other questions in this survey, I want to reassure you that the information you provide to us is kept confidential. Please look at this card. Can you tell me the letter that matches your best estimate of the amount of household income you received last year from the all of the sources mentioned in the question 1? Let me read them back to you. Interviewer: Review income sources from question I1.
		Interviewer: Hand the respondent SHOWCARD X with the list of responses. Ask him/her to point to the response.	Less than $5,000 13 $5,000 to $9,999 $10,000 to $14,999 $15,000 to $19,999 $20,000 to $24,999 $25,000 to $29,999 $30,000 to $34,999 $35,000 to $39,999 $40,000 to $49,999 $50,000 to $59,999 $60,000 to $79,999 $80,000 to $99,999 $100,000 to $119,999 $120,000 or more Don’t know REFUSED
I4		I am going to show you another card. Please look and show the total amount you pay for housing each month, including the rent/mortgage/note payment and all of your utilities? Interviewer: Hand the respondent SHOWCARD X with the list of responses. Ask him/her to point to the response.		Less than $100 14 $100 to $199 $200 to $249 $250 to $299 $300 to $349 $350 to $399 $400 to $449 $450 to $499 $500 to $599 $600 to $699 $700 to $799 $800 to $999 $1,000 to $1,249 $1,250 to $1,499 $1,500 to $1,999 $1,500 to $1,999 $2,500 or more No cash paid for rent/mortgage/ utilities
I4a		Do you pay the same amount each season?		YES NO Don’t know REFUSED If YES, continue with I5. If NO, continue with I4b.
I4b		Interviewer: For questions I4b-I4e, hand the respondent SHOWCARD X with the list of responses. Ask him/her to point to the response. In the winter, tell me the total amount you pay.		Response A-R per I4 above
I4c		In the spring, tell me the total amount you pay.		Response A-R per I4 above
I4d		In the summer, tell me the total amount you pay.		Response A-R per I4 above
I4e		In the fall, please tell me the total amount you pay.		Response A-R per I4 above
I5		After you take care of housing expenses each month—rent/mortgage and utilities—on average over the past year, how much money do you have left to spend on other things? Interviewer: Hand the respondent SHOWCARD X with the list of responses. Ask him/her to point to the response.		Less than $100 15 $100 to $199 $200 to $249 $250 to $299 $300 to $349 $350 to $399 $400 to $449 $450 to $499 $500 to $599 $600 to $699 $700 to $799 $800 to $999 $1,000 to $1,249 $1,250 to $1,499 $1,500 to $1,999 $1,500 to $1,999 $2,500 or more

Concluding the interview

I will be sending this document to the NORC central office in Chicago, so that your responses can be included in this important research. An editor will check to see that I have indicated an answer to all of the appropriate questions. If I mistakenly skipped a question, someone from the NORC central office will call you to fill in the missing information. This is standard procedure to ensure that all of the information needed is provided [quality assurance]. All of our central office employees are bound by the same confidentiality rules that I am.

My office may want to verify that I was here. Someone may call you to make sure that I conducted the interview. Please give me your name and telephone number so that my office may contact you.

NAME OF RESPONDENT:
TELEPHONE NUMBER:
ADDRESS:

Interviewer: Thank the respondent for his/her time and give him/her the incentive. Have the respondent sign the receipt.

Now, as I noted at the beginning of the interview, I will take a look at the exterior conditions of this dwelling and fill in some information about the conditions.

FINISH TIME: _____________ AM/PM TRANSFER FINISH TIME TO FRONT COVER

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J. Enumerator observation

Instructions for conducting the housing observation: Once the interview is completed, exit the dwelling and walk around the structure. Record observations regarding the type of structure, the size of the lot it sits on, the general conditions of the exteriors, access to the dwelling, other buildings on the lot, and materials used.

		American Housing Survey (AHS)
J1		Type of structure 16 ISTYPE (p 12) Identify the type of living quarters: Manufactured/mobile home One-unit building, detached from any other building One-unit building, attached to one or more buildings Building with two or more apartments
J2		For mobile home or single family detached: (Confirm with respondent if necessary) LOTQ (p 68) About how large is the [site/lot]? Square feet _________________ Feet by Feet _________________ Whole acres _________________
J2a		LTAC1P (p 69) Would you say that the [site/lot] is more than 1 acre or less than 1 acre? 17 More Less ACRES (p 69) About how many acres? ______
J2b		LTAC10P (p 69) Is it more than 10 acres? More Less
J2c		ESTIMATE (pp 69-70) Could you give me an estimate of dimensions of the lot? ________________________
J3		Observe the exterior condition of the OUTSIDE of the housing unit. (pp 241-243). Indicate whether the following conditions are present or not. If not able to observe, then mark “Not Observed.”
				Yes	No	Not observed
J3a		EMISSR Does the roof have missing shingles or other missing roofing materials?
J3b		EHOLER Does the roof have any holes?
J3c		ESAGR Does the roof’s surface sag or appear uneven?
J3d		EMISSW Does the outside walls have any missing siding, bricks, or other missing wall materials?
J3f		ESLOPEW DO the outside walls slope, lean, buckle or slant?
J3g		EBROKE Are any of the windows broken?
J3h		EBAR Are any of the windows covered with metal bars?
J3i		ECRUMB Are there any holes or open cracks or crumbling in the foundation, in the base on which the building stands?
J4	Access 18		Paved road Well maintained dirt road Poorly maintained dirt road
J5	Other buildings on lot (Mark all that apply)		None Garage/carport Barn or stable Outdoor cooking area Outhouse Living quarters Business Cultural/ceremonial structures (e.g., hogans, tipis, sweat lodges) Other (SPECIFY): __________________________
J6	Exterior materials (Mark all that apply)		Wood or wood siding Aluminum siding Brick Concrete or block Masonite Stucco Other (SPECIFY): __________________________
J7	Roof materials (Mark all that apply)		Asphalt shingles Tar paper Metal Wood Other (SPECIFY): __________________________
J8	Exterior condition THIS QUESTION SEEMS OUT OF SEQUENCE?		Excellent or good Needs minor repairs

1 The roster is adapted from the Family Composition Form (Module 36) for the Health Resources and Services Administration (HRSA) Special Project of National Significance (SPNS) Program Cooperative Agreement Evaluation, developed by The Measurement Group and the SPNS projects. This section of the roster was used to determine history of children, partners, siblings, parents, and extended family and the HIV status of the respondent’s children.

2 Question 2 is from the American Community Survey questionnaire.

3 All questions in this module are derived from the American Housing Survey. Variable names are given as noted and will be used to analyze adequacy of housing per HUD’s Worst Case Housing Needs algorithm. The page number next to the variable pertains to the page number in the 2009 Instrument Items Booklet that lists all questions and items in the AHS survey instrument (there is no paper version of the AHS questionnaire as it is a computer-assisted telephone interview). Questions related to the Interior Conditions are included in this section and were moved from the Enumerator Observations in the 1996 instrument. The topical order was adapted from the 1996 version to allow for a more conversational flow and to address cooking facilities, electricity, and heat first and to introduce more personal topics such as use of water and facilities for bathing later in the interview.

4 Questions B30-B32 are needed to determine adequacy of housing. Questions B33-36 are project developed.

5 May wish to consider the quantity of water that leaks as well (minor or major).

6 NUMTLT variable is needed for the Adequacy of Housing analysis but is not found in the 2009 Instrument Items Booklet, thus TOILETP in B44 may is suggested to serve as a proxy variable.

7 Exposed wiring is addressed in question B15.

8 The wording of the questions 1 and 2 were changed slightly from the 1996 Household Survey and the scaled response sets were simplified. Questions 3 and 4 were adapted from the original survey question to address positive and negative features independently. SHOWCARDS were introduced for these questions to facilitate response.

9 Project-developed question adapted from the North Dakota Statewide Housing Needs Assessment 2004.

10 Project-developed question

11 Project developed question

12 Question 1 regarding sources of household income is derived from the income module of Making Connections Wave I Core survey, which is based on the American Community Survey. Some of the response items have been modified to suit tribal income sources or activities. Question 2 about non-monetary support is a project-developed question to address the prevalence of and reliance on subsistence activities, exchange, and communal sharing. The wording of Question 3 regarding the amount of household income is derived from the National Longitudinal Survey of Youth, 1997 [Measure: Income and earnings items from the National Longitudinal Survey of Youth Round 1(1997) youth questionnaire and parent questionnaire]. The income values are derived from the American Housing Survey-2007.

13 Values derived from the American Housing Survey-2007 Table 2-12, Income Characteristics-Occupied Units, Household Income.

14 Values derived from the American Housing Survey 2007 Table 2-13, Selected Housing Costs – Occupied Units , Monthly Housing Costs.

15 Values derived from the American Housing Survey 2007 Table 2-13, Selected Housing Costs – Occupied Units , Monthly Housing Costs.

16 The 1996 instrument used the following items: Mobile home; Single-family detached; Townhouse; Multifamily building; Other

17 The 1996 instrument used the following items: Lot size: Less than ¼ acre; ¼ to 1 acre; 1 to 10 acres; More than 10 acres

18 Not addressed in AHS. Was in 1996 instrument.