Households: M - Household Survey
NSLP/SBP Access, Participation, Eligibility, and Certification Study
rev062112 Attachment M.1-Household Survey
Households: M - Household Survey
OMB: 0584-0530
M.1
HOUSEHOLD SURVEY
OMB
Approval No.: 0584-0530
Approval
Expires:
NATIONAL SCHOOL LUNCH AND SCHOOL BREAKFAST PROGRAM ACCESS, PARTICIPATION, ELIGIBILITY, AND CERTIFICATION STUDY (APEC-II)
HOUSEHOLD QUESTIONNAIRE
April 23, 2012
-
CASE ID NUMBER: | | | | | | | | |
DATE: | | | / | | | / | 2 | 0 | 1 | |
MONTH DAY YEAR
INTERVIEWER ID NUMBER: | | | | | |
TIME INTERVIEW BEGAN: | | |:| | | AM 1
HOUR MINUTE PM 2
According
to the Paperwork Reduction Act of 1995, no persons are required to
respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this
information collection is 0584-0530. The time required to complete
this information collection is estimated to average 45 minutes per
response, including the time to review instructions, search existing
data resources, gather the data needed, and complete and review the
information collection.
SECTION A: INTRODUCTION |
A1. INTRODUCTION WHEN CALLING TO MAKE AN APPOINTMENT: Hello, my name is INTERVIEWER’S FULL NAME and I am calling on behalf of the U.S. Department of Agriculture’s National School Meals Study. We recently sent (you/PARENT FROM APPLICATION FORM) a letter describing the study. I would like to schedule an appointment with (you/PARENT FROM APPLICATION FORM/the parent of TARGET CHILD) to come to (your/his/her) home and interview (you/him/her) about (your/his/her) experience with the school meal programs. May I speak with (him/her)?
INTERVIEWER: ATTEMPT APPOINTMENT. MENTION $25.00 GIFT CARD TO PARENT.
IF APPOINTMENT MADE—RECORD ON CONTACT
SHEET AND POLITELY THANK RESPONDENT AND
TERMINATE CALL (RECORD ON CONTACT SHEET) 1
WANTS TO KNOW MORE ABOUT THE STUDY (GO TO A2) 2
DID NOT GET LETTER—VERIFY
ADDRESS AND OFFER TO BRING
OR SEND LETTER (RECORD OUTCOME ON CONTACT SHEET) 3
HOW DID YOU GET MY NAME OR NUMBER (GO TO A3) 4
DO INTERVIEW NOW (TELEPHONE ONLY) (GO TO B1) 5
TARGET CHILD DECEASED (GO TO B7) 6
PARENT FROM APPLICATION
FORM DECEASED (GO TO B7) 7
NOT INTERESTED—RECORD ON
CONTACT SHEET AND TERMINATE
CALL (RECORD ON CONTACT SHEET) 8
A2. The U.S. Department of Agriculture is interested in learning about parents’ participation in the school meal program. In order to do this we have selected a sample of students who participate in, or whose parents applied for, the school meal program, and we would like to talk to the parents of those students to find out about their experiences with the meal program and their children’s participation. TARGET CHILD was randomly selected. The interview usually takes about 45 minutes, and we give you a $25.00 gift card when it has been completed. When would be a good time to schedule the interview in your home?
IF APPOINTMENT MADE—RECORD
ON CONTACT SHEET AND POLITELY
THANK RESPONDENT AND
TERMINATE CALL 1
NOT INTERESTED—RECORD
SITUATION ON CONTACT SHEET
AND POLITELY TERMINATE CALL 2
A3. We got your name from lists of parents who applied to the school meal program for this school year. We randomly selected TARGET CHILD and would like to interview (her/his) parents about their experiences with the meal program. The interview usually takes about 45 minutes and we will give you a $25.00 gift card when it has been completed. When would be a good time to schedule the interview at your home?
IF APPOINTMENT MADE—RECORD
ON CONTACT SHEET AND POLITELY
THANK RESPONDENT AND
TERMINATE CALL 1
NOT INTERESTED—RECORD
SITUATION ON CONTACT SHEET
AND POLITELY TERMINATE CALL 2
A4. INTRODUCTION WHEN AT RESPONDENT’S HOME: Hello, may I speak to PARENT FROM APPLICATION FORM? My name is INTERVIEWER’S FULL NAME and I am here on behalf of the U.S. Department of Agriculture’s National School Meals Study. The study will help the USDA understand people’s experiences with the programs and their children’s participation in school meal programs.
WHEN PARENT ON APPLICATION FORM PRESENT: We are interviewing parents of children who attend school in the DISTRICT school district. You were selected at random to participate in this survey because you participate in or applied for school lunch or breakfast for TARGET CHILD. You will be given a $25.00 gift card for completing the survey.
Participation in this study is voluntary and will not affect any benefits you may be receiving. All information is private and will not be used in any way that could identify you or your child. I would like to begin the interview now.
YES (GO TO B1) 1
NOT A GOOD TIME, SCHEDULE REVISIT 2
REFUSED OR NOT INTERESTED—
RECORD SITUATION ON CONTACT
AND TERMINATE INTERVIEW 3
NOT SURE ABOUT DOING
THE SURVEY OR HAS
QUESTIONS (GO TO A5) 4
NAMED PERSON NOT AVAILABLE
OR NOT CORRECT—RECORD
SITUATION ON CONTACT SHEET
AND TERMINATE INTERVIEW 5
NO LONGER HAS CUSTODY
OF FOSTER CHILD—ATTEMPT
INTERVIEW 6
STUDENT RESIDES IN GROUP HOME—
ATTEMPT INTERVIEW 7
SAMPLED CHILD NOW LIVES WITH
ANOTHER PARENT OR GUARDIAN—
ATTEMPT INTERVIEW 8
TARGET CHILD DECEASED (GO TO B7) n
A5. INFORMATION SCREEN FOR NSLP AND SBP APEC-II STUDY
WHAT IS THE PURPOSE OF THE STUDY?
The U.S. Department of Agriculture is interested in learning about children’s participation in school food programs and perceptions of meal program quality.
MY CHILD DOES NOT EAT SCHOOL MEALS
Even if your child has never eaten a school breakfast or lunch, we need information on why you do not participate. This will help us understand how the school breakfast and lunch programs are working in your school district.
HOW DID YOU GET MY NAME? WHY SHOULD I PARTICIPATE?
Families with children enrolled in your child’s school district were randomly selected from a list provided by your child’s school who receive or applied for meal benefits. The information you provide will help provide an accurate picture of households’ experiences with the school meal program.
AM I REQUIRED TO PARTICIPATE?
Your participation in the survey is entirely voluntary and it will not affect you or your child’s eligibility for school meals or any other programs. You may refuse to answer any question during the interview. However, your experiences and opinions are very important for the study and for the program’s success. I will give you a gift card worth $25.00 when the interview has been completed.
I HAVE OTHER CHILDREN WHO ATTEND SCHOOL IN THE DISTRICT, BUT YOU DID NOT NAME THEM
We have only identified one enrolled child to ask questions about for each household that we are contacting in the district. For the purposes of this survey, all the questions we ask you refer to TARGET CHILD.
I DO NOT HAVE THE TIME FOR THE SURVEY
I understand how valuable your time is. This survey will only take about 45 minutes, we can try to do it now or if this time is not convenient, I can arrange to come back at a better time for you.
I AM NOT SATISFIED WITH THE SCHOOL MEAL PROGRAM
That is a good reason to do the survey. Your comments will be especially important because the U.S. Department of Agriculture is interested in the different perspectives of people who use or have used the school meal program in the past.
IS THE SURVEY PRIVATE?
Yes. All of the information we collect in the survey is completely private to the full extent allowed by law and will be used for research purposes only. Your answers will be combined with the answers of other survey participants and will never be linked to your name or your child’s name in any reports.
HOW LONG WILL THE SURVEY TAKE?
The length of the interview is different for different people, but it usually takes about 40 to 45 minutes.
WHY CAN’T YOU DO THE INTERVIEW BY TELEPHONE OR WHY DO YOU HAVE TO COME TO MY HOME?
Some of the survey questions may require you to look up information, which would take too much time over the telephone. The interviewer will also need to look at some documents as part of the survey.
WHAT IS THE INTERVIEW ABOUT?
The person who interviews you may ask you about participation in the school breakfast and school lunch programs, perceptions of school meals, and household size and income. Remember, all information is completely private. The information you provide will not affect the meal reimbursements your school receives or your child’s eligibility to receive school meal benefits.
WHY ARE YOU ASKING ABOUT INCOME?
Income information will help document how accurately school districts run the school meal programs. We will be asking you for your permission to examine income and eligibility records. Your permission is important to the success of this study. Remember, all information is completely private. The information you provide will not affect the meal reimbursements your school receives or your child’s eligibility to receive school meal benefits.
WHO WILL COME TO MY HOME?
An interviewer who works for (Mathematica)(DIR) will come to your home on the date and time you agreed to. The interviewer will have an identification badge stating that she or he works for (Mathematica)(DIR).
WHEN WILL I RECEIVE MY PAYMENT?
The (Mathematica)(DIR) interviewer will give you your gift card after the completion of the interview.
SECTION B: ENROLLMENT STATUS |
B1. CODE WITHOUT ASKING IF KNOWN OR ASK: Is TARGET CHILD male or female?
MALE 1
FEMALE 2
DOES NOT KNOW d
REFUSED r
B2. Does TARGET CHILD currently attend TARGET SCHOOL?
YES (GO TO B5) 1
NO 0
DOES NOT KNOW (GO TO D0) d
REFUSED (GO TO D0) r
B3. What school does (she/he) attend now?
SCHOOL NAME AND ADDRESS
CHILD DROPPED OUT OF SCHOOL 1
CHILD DECEASED (GO TO B7) 2
DOES NOT KNOW d
REFUSED r
B4. When did (she/he) stop attending TARGET SCHOOL?
| | | / | | | / | | |
MONTH DAY YEAR
DOES NOT KNOW d
REFUSED r
B5. When did (she/he) begin attending TARGET SCHOOL this school year?
PROBE: By “this school year” I mean the current school year 2012-2013.
PROBE: Was that in the beginning, middle, or the end of the month? IF BEGINNING ENTER 5, IF MIDDLE ENTER 15, IF END ENTER 25.
| | | / | | | / | | | (GO TO D0)
MONTH DAY YEAR
FIRST DAY OF SCHOOL (GO TO D0) f
NEVER ATTENDED THIS YEAR n
DOES NOT KNOW (GO TO D0) d
REFUSED (GO TO D0) r
B6. INTERVIEWER: IF B5 EQUALS “NEVER ATTENDED THIS YEAR” THEN TERMINATE INTERVIEW AND REPORT DISPOSITION TO YOUR SUPERVISOR. FOR ALL OTHER SITUATIONS, PROCEED TO D1 AND CONDUCT INTERVIEW.
B7. I am very sorry to hear about your loss. Thank you for your time. We will not do an interview. INTERVIEWER TERMINATE CALL.
NO SECTION C IN THIS DOCUMENT
SECTION D: PARTICIPATION IN SCHOOL LUNCH AND BREAKFAST PROGRAMS |
D0. INTERVIEWER: CHECK B2. HAS TARGET CHILD LEFT TARGET SCHOOL? DOES B2 EQUAL “0”?
YES (GO TO D71) 1
NO 0
D1. The next questions are about the meals TARGET CHILD eats at school.
I am going to ask you whether your child had a school breakfast or lunch (yesterday/Friday) and then ask about each day during the previous week. By school breakfast or lunch, I mean the meals your child’s school provides to students under the School Breakfast and School Lunch Program. School meals are meals that are on the menu for (free/a single price), as opposed to individual foods, such as salads, meats, and desserts, that are priced and bought separately.
Did (she/he) attend school (yesterday/last Friday)?
YES 1
NO (GO TO D9a) 0
DOES NOT KNOW (GO TO D9a) d
REFUSED (GO TO D9a) r
D2. INTERVIEWER: CHECK CONTACT SHEET. DOES TARGET CHILD’S SCHOOL HAVE A SCHOOL BREAKFAST PROGRAM (SBP)?
YES 1
NO (GO TO D5) 0
DOES NOT KNOW (GO TO D5) d
REFUSED (GO TO D5) r
D3. Did TARGET CHILD eat breakfast at school (yesterday/Friday)? Include breakfast served on the school bus.
YES 1
NO (GO TO D5) 0
DOES NOT KNOW (GO TO D5) d
REFUSED (GO TO D5) r
D4. Was that the school breakfast, or did your child get breakfast in some other way?
PROBE: By school breakfast we mean the meal received from the School Breakfast Program which consists of a set of food items from the menu that were either free or, if paid for, was purchased for a single price, as opposed to individual foods that are priced and bought separately.
HAD SCHOOL BREAKFAST (GO TO D5) 1
HAD SOMETHING ELSE 0
DOES NOT KNOW d
REFUSED r
D5. INTERVIEWER: CHECK CONTACT SHEET. DOES TARGET CHILD’S SCHOOL HAVE A SCHOOL LUNCH PROGRAM (SLP)?
YES 1
NO (GO TO D9a) 0
DOES NOT KNOW (GO TO D9a) d
REFUSED (GO TO D9a) r
NO D6 IN THIS DOCUMENT
D7. Did (she/he) eat lunch at school (yesterday/last Friday)?
YES 1
NO (GO TO D9a) 0
DOES NOT KNOW (GO TO D9a) d
REFUSED (GO TO D9a) r
D8. Was that the school lunch, or did your child get lunch in some other way?
PROBE: By school lunch we mean the meal received from the School Lunch Program which consists of a set of food items from the menu that were either free or, if paid for, was purchased for a single price, as opposed to individual foods that are priced and bought separately.
HAD SCHOOL LUNCH 1
HAD SOMETHING ELSE 0
DOES NOT KNOW d
REFUSED r
D9a. CODE WITHOUT ASKING IF KNOWN:
When was the last full week of school?
LAST WEEK 1
FROM | | | | | | TO | | | | | |
DAY MONTH DAY MONTH
DOES NOT KNOW d
REFUSED r
D9b. Now please think about the last full week of school—that would be (Monday through Friday last week/from Monday—DATE to Friday—DATE). I will ask you about whether TARGET CHILD ate (breakfast/lunch/breakfast or lunch) at school each day and what was eaten. (Here is a menu of the food offered in school to help you recall what (she/he) may have had.)
Did (she/he) attend school (last Monday/on Monday, DATE)?
YES 1
NO (GO TO D17) 0
DOES NOT KNOW (GO TO D17) d
REFUSED (GO TO D17) r
D10. INTERVIEWER: CHECK CONTACT SHEET. DOES TARGET CHILD’S SCHOOL HAVE A SCHOOL BREAKFAST PROGRAM (SBP)?
YES 1
NO (GO TO D13) 0
DOES NOT KNOW (GO TO D13) d
REFUSED (GO TO D13) r
D11. Did TARGET CHILD eat breakfast at school (last Monday/on Monday, DATE)?
YES 1
NO (GO TO D13) 0
DOES NOT KNOW (GO TO D13) d
REFUSED (GO TO D13) r
D12. Was that the school breakfast, or did your child get breakfast in some other way?
PROBE: By school breakfast we mean the meal received from the School Breakfast Program which consists of a set of food items from the menu that were either free or, if paid for, was purchased for a single price, as opposed to individual foods that are priced and bought separately.
HAD SCHOOL BREAKFAST (GO TO D13) 1
HAD SOMETHING ELSE 0
DOES NOT KNOW d
REFUSED r
D13. INTERVIEWER: CHECK CONTACT SHEET. DOES TARGET CHILD’S SCHOOL HAVE A SCHOOL LUNCH PROGRAM (SLP)?
YES 1
NO (GO TO D17) 0
DOES NOT KNOW (GO TO D17) d
REFUSED (GO TO D17) r
NO D14 IN THIS DOCUMENT
D15. Did (she/he) eat lunch at school (last Monday/on Monday, DATE)?
YES 1
NO (GO TO D17) 0
DOES NOT KNOW (GO TO D17) d
REFUSED (GO TO D17) r
D16. Was that the school lunch, or did your child get lunch in some other way?
PROBE: By school lunch we mean the meal received from the School Lunch Program which consists of a set of food items from the menu that were either free or, if paid for, was purchased for a single price, as opposed to individual foods that are priced and bought separately.
HAD SCHOOL LUNCH (GO TO D18) 1
HAD SOMETHING ELSE 0
DOES NOT KNOW d
REFUSED r
D17. Did (she/he) attend school (last Tuesday/on Tuesday, DATE)?
YES 1
NO (GO TO D25) 0
DOES NOT KNOW (GO TO D25) d
REFUSED (GO TO D25) r
D18. INTERVIEWER: CHECK CONTACT SHEET. DOES TARGET CHILD’S SCHOOL HAVE A SCHOOL BREAKFAST PROGRAM (SBP)?
YES 1
NO (GO TO D21) 0
DOES NOT KNOW (GO TO D21) d
REFUSED (GO TO D21) r
D19. Did (she/he) eat breakfast at school (last Tuesday/on Tuesday, DATE)?
YES 1
NO (GO TO D21) 0
DOES NOT KNOW (GO TO D21) d
REFUSED (GO TO D21) r
D20. Was that the school breakfast, or did your child get breakfast in some other way?
PROBE: By school breakfast we mean the meal received from the School Breakfast Program which consists of a set of food items from the menu that were either free or, if paid for, was purchased for a single price, as opposed to individual foods that are priced and bought separately.
HAD SCHOOL BREAKFAST (GO TO D21) 1
HAD SOMETHING ELSE 0
DOES NOT KNOW d
REFUSED r
D21. INTERVIEWER: CHECK CONTACT SHEET. DOES TARGET CHILD’S SCHOOL HAVE A SCHOOL LUNCH PROGRAM (SLP)?
YES 1
NO (GO TO D25) 0
DOES NOT KNOW (GO TO D25) d
REFUSED (GO TO D25) r
NO D22 IN THIS DOCUMENT
D23. Did (she/he) eat lunch at school (last Tuesday/on Tuesday, DATE)?
YES 1
NO (GO TO D25) 0
DOES NOT KNOW (GO TO D25) d
REFUSED (GO TO D25) r
D24a. Was that the school lunch, or did your child get lunch in some other way?
PROBE: By school lunch we mean the meal received from the School Lunch Program which consists of a set of food items from the menu that were either free or, if paid for, was purchased for a single price, as opposed to individual foods that are priced and bought separately.
HAD SCHOOL LUNCH (GO TO D26) 1
HAD SOMETHING ELSE 0
DOES NOT KNOW d
REFUSED r
D25. Did (she/he) attend school (last Wednesday/on Wednesday, DATE)?
YES 1
NO (GO TO D33) 0
DOES NOT KNOW (GO TO D33) d
REFUSED (GO TO D33) r
D26. INTERVIEWER: CHECK CONTACT SHEET. DOES TARGET CHILD’S SCHOOL HAVE A SCHOOL BREAKFAST PROGRAM (SBP)?
YES 1
NO (GO TO D29) 0
DOES NOT KNOW (GO TO D29) d
REFUSED (GO TO D29) r
D27. Did (she/he) eat breakfast at school (last Wednesday/on Wednesday, DATE)?
YES 1
NO (GO TO D29) 0
DOES NOT KNOW (GO TO D29) d
REFUSED (GO TO D29) r
D28a. Was that the school breakfast, or did your child get breakfast in some other way?
PROBE: By school breakfast we mean the meal received from the School Breakfast Program which consists of a set of food items from the menu that were either free or, if paid for, was purchased for a single price, as opposed to individual foods that are priced and bought separately.
HAD SCHOOL BREAKFAST (GO TO D29) 1
HAD SOMETHING ELSE 0
DOES NOT KNOW d
REFUSED r
D29. INTERVIEWER: CHECK CONTACT SHEET. DOES TARGET CHILD’S SCHOOL HAVE A SCHOOL LUNCH PROGRAM (SLP)?
YES 1
NO (GO TO D33) 0
DOES NOT KNOW (GO TO D33) d
REFUSED (GO TO D33) r
NO D30 IN THIS DOCUMENT
D31. Did (she/he) eat lunch at school (last Wednesday/on Wednesday, DATE)?
YES 1
NO (GO TO D33) 0
DOES NOT KNOW (GO TO D33) d
REFUSED (GO TO D33) r
D32a. Was that the school lunch, or did your child get lunch in some other way?
PROBE: By school lunch we mean the meal received from the School Lunch Program which consists of a set of food items from the menu that were either free or, if paid for, was purchased for a single price, as opposed to individual foods that are priced and bought separately.
HAD SCHOOL LUNCH (GO TO D34) 1
HAD SOMETHING ELSE 0
DOES NOT KNOW d
REFUSED r
D33. Did (she/he) attend school (last Thursday/on Thursday, DATE)?
YES 1
NO (GO TO D41) 0
DOES NOT KNOW (GO TO D41) d
REFUSED (GO TO D41) r
D34. INTERVIEWER: CHECK CONTACT SHEET. DOES TARGET CHILD’S SCHOOL HAVE A SCHOOL BREAKFAST PROGRAM (SBP)?
YES 1
NO (GO TO D37) 0
DOES NOT KNOW (GO TO D37) d
REFUSED (GO TO D37) r
D35. Did (she/he) eat breakfast at school (last Thursday/on Thursday, DATE)?
YES 1
NO (GO TO D37) 0
DOES NOT KNOW (GO TO D37) d
REFUSED (GO TO D37) r
D36a. Was that the school breakfast, or did your child get breakfast in some other way?
PROBE: By school breakfast we mean the meal received from the School Breakfast Program which consists of a set of food items from the menu that were either free or, if paid for, was purchased for a single price, as opposed to individual foods that are priced and bought separately.
HAD SCHOOL BREAKFAST (GO TO D37) 1
HAD SOMETHING ELSE 0
DOES NOT KNOW d
REFUSED r
D37. INTERVIEWER: CHECK CONTACT SHEET. DOES TARGET CHILD’S SCHOOL HAVE A SCHOOL LUNCH PROGRAM (SLP)?
YES 1
NO (GO TO D41) 0
DOES NOT KNOW (GO TO D41) d
REFUSED (GO TO D41) r
NO D38 IN THIS DOCUMENT
D39. Did (she/he) eat lunch at school (last Thursday/on Thursday, DATE)?
YES 1
NO (GO TO D41) 0
DOES NOT KNOW (GO TO D41) d
REFUSED (GO TO D41) r
D40a. Was that the school lunch, or did your child get lunch in some other way?
PROBE: By school lunch we mean the meal received from the School Lunch Program which consists of a set of food items from the menu that were either free or, if paid for, was purchased for a single price, as opposed to individual foods that are priced and bought separately.
HAD SCHOOL LUNCH (GO TO D41) 1
HAD SOMETHING ELSE 0
DOES NOT KNOW d
REFUSED r
D41. INTERVIEWER: IS THE INTERVIEW BEING ADMINISTERED ON A MONDAY OR ON THE WEEKEND? DID WE ALREADY ASK ABOUT FRIDAY AT QUESTIONS D1 THROUGH D8?
YES (GO TO D50) 1
NO 0
D42. Did (she/he) attend school (last Friday/on Friday, DATE)?
YES 1
NO (GO TO D50) 0
DOES NOT KNOW (GO TO D50) d
REFUSED (GO TO D50) r
D43. INTERVIEWER: CHECK CONTACT SHEET. DOES TARGET CHILD’S SCHOOL HAVE A SCHOOL BREAKFAST PROGRAM (SBP)?
YES 1
NO (GO TO D46) 0
DOES NOT KNOW (GO TO D46) d
REFUSED (GO TO D46) r
D44. Did (she/he) eat breakfast at school (last Friday/on Friday, DATE)?
YES 1
NO (GO TO D46) 0
DOES NOT KNOW (GO TO D46) d
REFUSED (GO TO D46) r
D45a. Was that the school breakfast, or did your child get breakfast in some other way?
PROBE: By school breakfast we mean the meal received from the School Breakfast Program which consists of a set of food items from the menu that were either free or, if paid for, was purchased for a single price, as opposed to individual foods that are priced and bought separately.
HAD SCHOOL BREAKFAST (GO TO D46) 1
HAD SOMETHING ELSE 0
DOES NOT KNOW d
REFUSED r
D46. INTERVIEWER: CHECK CONTACT SHEET. DOES TARGET CHILD’S SCHOOL HAVE A SCHOOL LUNCH PROGRAM (SLP)?
YES 1
NO (GO TO D50) 0
DOES NOT KNOW (GO TO D50) d
REFUSED (GO TO D50) r
NO D47 IN THIS DOCUMENT
D48. Did (she/he) eat lunch at school (last Friday/on Friday, DATE)?
YES 1
NO (GO TO D50) 0
DOES NOT KNOW (GO TO D50) d
REFUSED (GO TO D50) r
D49a. Was that the school lunch, or did your child get lunch in some other way?
PROBE: By school lunch we mean the meal received from the School Lunch Program which consists of a set of food items from the menu that were either free or, if paid for, was purchased for a single price, as opposed to individual foods that are priced and bought separately.
HAD SCHOOL LUNCH (GO TO D50) 1
HAD SOMETHING ELSE 0
DOES NOT KNOW d
REFUSED r
D50. INTERVIEWER: CHECK CONTACT SHEET. DOES THE TARGET CHILD’S SCHOOL HAVE A SCHOOL BREAKFAST PROGRAM (SBP)?
YES 1
NO (GO TO D60) 0
DOES NOT KNOW (GO TO D60) d
REFUSED (GO TO D60) r
D51. INTERVIEWER: DID THE TARGET CHILD PARTICIPATE IN THE SBP ON ANY DAY IN THE TARGET WEEK? ARE ANY QUESTIONS D4, D12, D20, D28, D36, AND D45 EQUAL TO “1”?
YES (GO TO D55) 1
NO 0
D52. You just mentioned that TARGET CHILD did not get the school breakfast on any day (she/he) attended school (last week/during the last week (she/he) went to school). Why didn’t (she/he) get the school breakfast (last week/during that week)?
AFTER RESPONSE, SAY: Were there other reasons why (she/he) did not eat the school breakfast (last week/that week)?
PROBE: The complete school breakfast.
CIRCLE ALL
THAT APPLY
EATS BREAKFAST AT HOME 1
BRINGS BREAKFAST FROM HOME 2
DOES NOT LIKE THE FOOD AT SCHOOL 3
NOT ENOUGH TIME TO EAT AT SCHOOL 4
CHILD DOES NOT EAT BREAKFAST 5
ON A DIET 6
DOES NOT LIKE WAITING IN LINE 7
CHILD THINKS ONLY NEEDY CHILDREN
EAT SCHOOL BREAKFASTS 8
CHILD DOES NOT EAT SCHOOL BREAKFAST
BECAUSE FRIENDS DO NOT EAT IT 9
NOT IN SCHOOL THAT WEEK/
OUT SICK ALL WEEK 10
LATE FOR SCHOOL EVERY DAY
THAT WEEK 11
HAD EARLY MORNING CLASSES
THAT WEEK 12
CHILD OR PARENT TOO EMBARRASSED
TO PARTICIPATE 13
OTHER (SPECIFY) 14
DOES NOT KNOW d
REFUSED r
D53. INTERVIEWER: IS THERE MORE THAN ONE ANSWER TO D52?
YES 1
NO (GO TO D59) 0
D54. What is the most important reason (she/he) did not get the school breakfast (last/that) week?
EATS BREAKFAST AT HOME 1
BRINGS BREAKFAST FROM HOME 2
DOES NOT LIKE THE FOOD AT SCHOOL 3
NOT ENOUGH TIME TO EAT AT SCHOOL 4
CHILD DOES NOT EAT BREAKFAST 5
ON A DIET 6
DOES NOT LIKE WAITING IN LINE 7
CHILD THINKS ONLY NEEDY CHILDREN
EAT SCHOOL BREAKFASTS 8
CHILD DOES NOT EAT SCHOOL BREAKFAST
BECAUSE FRIENDS DO NOT EAT IT 9
NOT IN SCHOOL THAT WEEK/
OUT SICK ALL WEEK 10
LATE FOR SCHOOL EVERY DAY
THAT WEEK 11
HAD EARLY MORNING CLASSES
THAT WEEK 12
CHILD OR PARENT TOO EMBARRASSED
TO PARTICIPATE 13
OTHER (SPECIFY) 14
DOES NOT KNOW d
REFUSED r
GO TO D59 |
D55. INTERVIEWER: DID THE TARGET CHILD GET THE SCHOOL BREAKFAST ON EVERY DAY (SHE/HE) ATTENDED SCHOOL IN THE TARGET WEEK? WHEN D9b EQUALS “1” DOES D12 EQUAL “1” AND WHEN D17 EQUALS “1” DOES D20 EQUAL “‘1” AND WHEN D25 EQUALS “1” DOES D28 EQUAL “1” AND WHEN D33 EQUALS “1” DOES D36 EQUAL “1” AND WHEN D42 EQUALS “1” DOES D45 EQUAL “1”?
YES (GO TO D60) 1
NO 0
D56. You mentioned that TARGET CHILD did not get the school breakfast every day (she/he) attended school (last week/during (her/his) last week in school). Why didn’t (she/he) get the school breakfast every day (she/he) went to school that week?
AFTER RESPONSE, SAY: Were there any other reasons?
CIRCLE ALL
THAT APPLY
ATE BREAKFAST AT HOME 1
BROUGHT BREAKFAST FROM HOME 2
DOES NOT ALWAYS LIKE THE
FOOD SERVED 3
WAS NOT IN SCHOOL ON THAT
OR THOSE DAYS/OUT SICK 4
WAS LATE FOR SCHOOL 5
HAD EARLY MORNING CLASSES
OR PROGRAMS 6
EARLY DISMISSAL OR STUDENT LEFT
SCHOOL EARLY 7
SCHOOL CLOSED ALL DAY 8
OTHER (SPECIFY) 9
DOES NOT KNOW d
REFUSED r
D57. INTERVIEWER: IS THERE MORE THAN ONE ANSWER TO D56?
YES 1
NO (GO TO D59) 0
D58. What is the most important reason (she/he) did not get the school breakfast on those days?
ATE BREAKFAST AT HOME 1
BROUGHT BREAKFAST FROM HOME 2
DOES NOT ALWAYS LIKE THE
FOOD SERVED 3
WAS NOT IN SCHOOL ON THAT
OR THOSE DAYS/OUT SICK 4
WAS LATE FOR SCHOOL 5
HAD EARLY MORNING CLASSES
OR PROGRAMS 6
EARLY DISMISSAL OR STUDENT LEFT
SCHOOL EARLY 7
SCHOOL CLOSED ALL DAY 8
OTHER (SPECIFY) 9
DOES NOT KNOW d
REFUSED r
NO D59 IN THIS DOCUMENT
D60. INTERVIEWER: CHECK CONTACT SHEET. DOES THE TARGET CHILD’S SCHOOL HAVE A NATIONAL SCHOOL LUNCH PROGRAM (NSLP)?
YES 1
NO (GO TO D70) 0
DOES NOT KNOW (GO TO D70) d
REFUSED (GO TO D70) r
D61. INTERVIEWER: DID THE TARGET CHILD PARTICIPATE IN THE NSLP ON ANY DAYS IN THE TARGET WEEK? ARE ANY QUESTIONS D8, D16, D24, D32, D40, AND D49 EQUAL TO “1”?
YES (GO TO D65) 1
NO 0
D62. You mentioned that TARGET CHILD did not get the school lunch on any day (she/he) attended school. Why didn’t (she/he) get the school lunch (last week/during that week)?
AFTER RESPONSE, SAY: Were there any other reasons why (she/he) did not eat the school lunch (last week/that week)?
PROBE: The complete school lunch.
CIRCLE ALL
THAT APPLY
PREFERS TO BRING LUNCH FROM HOME 1
EATS LUNCH AT HOME 2
DOES NOT LIKE THE FOOD AT SCHOOL 3
NOT ENOUGH TIME TO EAT AT SCHOOL 4
CHILD DOES NOT EAT LUNCH 5
ON A DIET 6
DOES NOT LIKE WAITING IN LINE 7
CHILD THINKS ONLY NEEDY CHILDREN
EAT SCHOOL LUNCHES 8
CHILD DOES NOT EAT SCHOOL LUNCH
BECAUSE FRIENDS DO NOT EAT IT 9
NOT IN SCHOOL THAT WEEK/
SICK ALL WEEK 10
LATE FOR SCHOOL EVERY DAY THAT WEEK 11
HAD CLASSES DURING LUNCH PERIOD
THAT WEEK 12
CHILD OR PARENT TOO EMBARRASSED
TO PARTICIPATE 13
OTHER (SPECIFY) 14
DOES NOT KNOW d
REFUSED r
D63. INTERVIEWER: IS THERE MORE THAN ONE ANSWER IN D62?
YES 1
NO (GO TO D69) 0
D64. What is the most important reason (she/he) did not get the school lunch (last/that) week?
PREFERS TO BRING LUNCH FROM HOME 1
EATS LUNCH AT HOME 2
DOES NOT LIKE THE FOOD AT SCHOOL 3
NOT ENOUGH TIME TO EAT AT SCHOOL 4
CHILD DOES NOT EAT LUNCH 5
ON A DIET 6
DOES NOT LIKE WAITING IN LINE 7
CHILD THINKS ONLY NEEDY CHILDREN
EAT SCHOOL LUNCHES 8
CHILD DOES NOT EAT SCHOOL LUNCH
BECAUSE FRIENDS DO NOT EAT IT 9
NOT IN SCHOOL THAT WEEK/
OUT SICK ALL WEEK 10
LATE FOR SCHOOL EVERY DAY THAT WEEK 11
HAD CLASSES DURING LUNCH PERIOD
THAT WEEK 12
CHILD OR PARENT TOO EMBARRASSED
TO PARTICIPATE 13
OTHER (SPECIFY) 14
DOES NOT KNOW d
REFUSED r
GO TO D69 |
D65. INTERVIEWER: DID THE TARGET CHILD GET THE SCHOOL LUNCH ON EVERY DAY (SHE/HE) ATTENDED SCHOOL IN TARGET WEEK? WHEN D9b EQUALS “1” DOES D16 EQUAL “1” AND WHEN D17 EQUALS “1” DOES D24 EQUAL “1” AND WHEN D25 EQUALS “1” DOES D32 EQUAL “1” AND WHEN D33 EQUALS “1” DOES D40 EQUAL “1” AND WHEN D42 EQUALS “1” DOES D49 EQUAL “1”?
YES (GO TO D70) 1
NO 0
D66. You mentioned that TARGET CHILD did not get the school lunch every day (she/he) attended school (last week/during (her/his) last week in school). Why did (she/he) not get the school lunch every day (she/he) went to school (last/that) week?
AFTER RESPONSE, SAY: Were there any other reasons?
CIRCLE ALL
THAT APPLY
ATE LUNCH AT HOME 1
BROUGHT LUNCH FROM HOME 2
DOES NOT ALWAYS LIKE THE
FOOD SERVED 3
WAS NOT IN SCHOOL ON THAT
OR THOSE DAYS/OUT SICK 4
WAS LATE FOR SCHOOL 5
HAD EARLY MORNING CLASSES
OR PROGRAMS 6
EARLY DISMISSAL OR STUDENT LEFT
SCHOOL EARLY 7
SCHOOL CLOSED ALL DAY 8
OTHER (SPECIFY) 9
DOES NOT KNOW d
REFUSED r
D67. INTERVIEWER: IS THERE MORE THAN ONE ANSWER TO D66?
YES 1
NO (GO TO D69) 0
D68. What is the most important reason (she/he) did not get the school lunch on those days?
ATE LUNCH AT HOME 1
BROUGHT LUNCH FROM HOME 2
DOES NOT ALWAYS LIKE THE FOOD SERVED 3
WAS NOT IN SCHOOL ON THAT
OR THOSE DAYS/OUT SICK 4
WAS LATE FOR SCHOOL 5
HAD EARLY MORNING CLASSES OR PROGRAMS 6
EARLY DISMISSAL OR STUDENT LEFT
SCHOOL EARLY 7
SCHOOL CLOSED ALL DAY 8
OTHER (SPECIFY) 9
DOES NOT KNOW d
REFUSED r
NO D69 IN THIS DOCUMENT
D70. INTERVIEWER: DID THE TARGET CHILD HELP THE RESPONDENT WITH THE
QUESTIONS ON MEALS EATEN AT SCHOOL?
YES (GO TO E1) 1
NO (GO TO E1) 0
D71. I am going to ask you how often your child usually had school breakfast or lunch each week when TARGET CHILD was going to TARGET SCHOOL. By school breakfast or lunch, I mean the meals your child’s school provides to students under the School Breakfast and School Lunch Program. School meals are meals that include a set of food items from the menu that were either free or, if paid for, was purchased for a single price, as opposed to individual foods (such as salads, meats, or desserts) that are priced and bought separately.
When TARGET CHILD was going to TARGET SCHOOL, how many days in an average week did (he/she) eat a school breakfast?
| | NUMBER OF SCHOOL BREAKFASTS
NONE, DID NOT EAT BREAKFAST/
SCHOOL BREAKFAST 0
D72. And when TARGET CHILD was going to TARGET SCHOOL, how many days in an average week did (he/she) eat a school lunch?
| | NUMBER OF SCHOOL LUNCHES
NONE, DID NOT EAT LUNCH/
SCHOOL LUNCH 0
SECTION E: PERCEPTIONS OF SCHOOL MEALS |
INTERVIEWER: THE FOLLOWING QUESTIONS ARE ABOUT THE EXPERIENCES WITH SCHOOL MEALS AT TARGET SCHOOL, PROMPT AS NEEDED
E1. The next questions are about TARGET CHILD’S satisfaction with school meals at TARGET SCHOOL. How satisfied is/was TARGET CHILD with how the food tastes? Overall is/was (she/he) very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied?
PROBE: How satisfied do you think (she/he) is/was with the food’s taste?
VERY SATISFIED 1
SOMEWHAT SATISFIED 2
SOMEWHAT DISSATISFIED 3
VERY DISSATISFIED 4
CHILD NEVER EATS SCHOOL
MEALS (GO TO G1) n
DOES NOT KNOW d
REFUSED r
E2. How satisfied is/was (she/he) with the amount or size of the portions of food (she/he) is/was given in school meals? Would you say very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied?
PROBE: How satisfied do you think (she/he) is/was with the amount served?
VERY SATISFIED 1
SOMEWHAT SATISFIED 2
SOMEWHAT DISSATISFIED 3
VERY DISSATISFIED 4
DOES NOT KNOW d
REFUSED r
E3. Overall, how satisfied is/was TARGET CHILD with the food (she/he) gets in school?
PROBE: Very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied?
PROBE: Overall, how satisfied do you think (she/he) is/was?
VERY SATISFIED 1
SOMEWHAT SATISFIED 2
SOMEWHAT DISSATISFIED 3
VERY DISSATISFIED 4
DOES NOT KNOW d
REFUSED r
E4. The next questions are about your satisfaction with school meals. How satisfied are you with the healthfulness of the food TARGET CHILD is/was served at school?
PROBE: Very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied?
VERY SATISFIED 1
SOMEWHAT SATISFIED 2
SOMEWHAT DISSATISFIED 3
VERY DISSATISFIED 4
DOES NOT KNOW d
REFUSED r
E5. Overall, how satisfied are/were you with TARGET CHILD’S school’s food program?
PROBE: Very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied?
VERY SATISFIED 1
SOMEWHAT SATISFIED 2
SOMEWHAT DISSATISFIED 3
VERY DISSATISFIED 4
DOES NOT KNOW d
REFUSED r
NO SECTION F IN THIS DOCUMENT
SECTION G: HOUSEHOLD COMPOSITION |
G1. Next, I would like to ask you about the people you live with. How many people live with you not including yourself? Please include babies, small children, people who are not related to you, and people who are temporarily away, for example, at school or in a hospital.
INTERVIEWER: IF TRANSIENT HOUSEHOLDER(S), INCLUDE ALL WHO SLEEP THERE HALF THE MONTH OR MORE.
| | | PEOPLE IN HOUSEHOLD
NONE OR LIVES ALONE (GO TO G15) 0
DOES NOT KNOW d
REFUSED r
G1a. CODE IF OBVIOUS OR ASK: Does TARGET CHILD live with you?
YES 1
NO 0
DOES NOT KNOW d
REFUSED r
INTERVIEWER: NUMBER OF PERSONS LISTED AT G2 MUST EQUAL NUMBER IN G1. |
G2. (Besides TARGET CHILD), Please tell me the first name of everyone else who lives with you.
PROBE: Who else lives with you?
RECORD TARGET CHILD’S FIRST NAME THEN RECORD NAMES OF ALL OTHER HOUSEHOLD MEMBERS ACROSS THE GRID FIRST, THEN ASK G3 THROUGH G14 FOR EACH PERSON. |
_________________________ TARGET CHILD
TARGET CHILD NOT CURRENTLY LIVING IN HOUSEHOLD (GO TO NAME #2) 0
|
_________________________ NAME #2
|
_________________________ NAME #3
|
G3. What is NAME's relationship to you?
CODE COHABITEE'S CHILD AND OTHER CHILDREN WHO ARE NOT NATURAL, ADOPTED, STEP, OR FOSTER, BUT FOR WHOM THE RESPONDENT TAKES RESPONSIBILITY, AS "OTHER CUSTODIAL CHILD." |
NATURAL CHILD 1 STEPCHILD OR ADOPTED CHILD 2 OTHER CUSTODIAL CHILD 3 FOSTER CHILD 4 |
NATURAL CHILD 1 STEPCHILD OR ADOPTED CHILD 2 OTHER CUSTODIAL CHILD 3 FOSTER CHILD 4 |
NATURAL CHILD 1 STEPCHILD OR ADOPTED CHILD 2 OTHER CUSTODIAL CHILD 3 FOSTER CHILD 4 |
SPOUSE OR DOMESTIC PARTNER 5 BOYFRIEND, GIRLFRIEND, OR PARTNER 6 PARENT 7 STEPPARENT 8 GRANDPARENT OR GREAT-GRANDPARENT 9 AUNT, UNCLE, GREAT-AUNT, OR GREAT-UNCLE 10 |
SPOUSE OR DOMESTIC PARTNER 5 BOYFRIEND, GIRLFRIEND, OR PARTNER 6 PARENT 7 STEPPARENT 8 GRANDPARENT OR GREAT-GRANDPARENT 9 AUNT, UNCLE, GREAT-AUNT, OR GREAT-UNCLE 10 |
SPOUSE OR DOMESTIC PARTNER 5 BOYFRIEND, GIRLFRIEND, OR PARTNER 6 PARENT 7 STEPPARENT 8 GRANDPARENT OR GREAT-GRANDPARENT 9 AUNT, UNCLE, GREAT-AUNT, OR GREAT-UNCLE 10 |
|
|
SIBLING (BROTHER OR SISTER) 11 NEPHEW OR NIECE 12 |
SIBLING (BROTHER OR SISTER) 11 NEPHEW OR NIECE 12 |
SIBLING (BROTHER OR SISTER) 11 NEPHEW OR NIECE 12 |
|
COUSIN 13 GRANDCHILD 14 |
GRANDCHILD 14 |
GRANDCHILD 14 |
|
OTHER RELATIVE OR IN-LAW 15 NON-RELATIVE (INCLUDING ROOMER OR BOARDER) 16 OTHER (SPECIFY) 17
DOES NOT KNOW d REFUSED r |
OTHER RELATIVE OR IN-LAW 15 NON-RELATIVE (INCLUDING ROOMER OR BOARDER) 16 OTHER (SPECIFY) 17
DOES NOT KNOW d REFUSED r |
OTHER RELATIVE OR IN-LAW 15 NON-RELATIVE (INCLUDING ROOMER OR BOARDER) 16 OTHER (SPECIFY) 17
DOES NOT KNOW d REFUSED r |
G4. CODE SEX. IF NECESSARY, ASK: Is NAME female or male? |
FEMALE 1
MALE 2 |
FEMALE 1
MALE 2 |
FEMALE 1
MALE 2 |
NO G5 or G6 IN THIS DOCUMENT |
|||
G7. INTERVIEWER: IS NAME A CHILD? DOES G3 EQUAL “01,” “02,” “03,” “04,” “11”, “12,” “13”, OR “14”? |
YES 1
NO (GO TO G9) 0 |
YES 1
NO (GO TO G9) 0 |
YES 1
NO (GO TO G9) 0 |
G8. What is (her/his) date of birth? |
|___|___|/|___|___|/|___|___| MONTH DAY YEAR DOES NOT KNOW d REFUSED r GO TO G10 |
|___|___|/|___|___|/|___|___| MONTH DAY YEAR DOES NOT KNOW d REFUSED r GO TO G10 |
|___|___|/|___|___|/|___|___| MONTH DAY YEAR DOES NOT KNOW d REFUSED r GO TO G10 |
G9. How old is (he/she)?
FILL IN BLANK BOXES WITH ZEROES. |
A. YEARS. |___|___| B. MONTHS |___|___|
|
A. YEARS. |___|___| B. MONTHS |___|___| |
A. YEARS. |___|___| B. MONTHS |___|___| |
_________________________ NAME #4
|
_________________________ NAME #5
|
_________________________ NAME #6
|
_________________________ NAME #7
|
NATURAL CHILD 1 STEPCHILD OR ADOPTED CHILD 2 OTHER CUSTODIAL CHILD 3 FOSTER CHILD 4 |
NATURAL CHILD 1 STEPCHILD OR ADOPTED CHILD 2 OTHER CUSTODIAL CHILD 3 FOSTER CHILD 4 |
NATURAL CHILD 1 STEPCHILD OR ADOPTED CHILD 2 OTHER CUSTODIAL CHILD 3 FOSTER CHILD 4 |
NATURAL CHILD 1 STEPCHILD OR ADOPTED CHILD 2 OTHER CUSTODIAL CHILD 3 FOSTER CHILD 4 |
SPOUSE OR DOMESTIC PARTNER 5 BOYFRIEND, GIRLFRIEND, OR PARTNER 6 PARENT 7 STEPPARENT 8 GRANDPARENT OR GREAT-GRANDPARENT 9 AUNT, UNCLE, GREAT-AUNT, OR GREAT-UNCLE 10 |
SPOUSE OR DOMESTIC PARTNER 5 BOYFRIEND, GIRLFRIEND, OR PARTNER 6 PARENT 7 STEPPARENT 8 GRANDPARENT OR GREAT-GRANDPARENT 9 AUNT, UNCLE, GREAT-AUNT, OR GREAT-UNCLE 10 |
SPOUSE OR DOMESTIC PARTNER 5 BOYFRIEND, GIRLFRIEND, OR PARTNER 6 PARENT 7 STEPPARENT 8 GRANDPARENT OR GREAT-GRANDPARENT 9 AUNT, UNCLE, GREAT-AUNT, OR GREAT-UNCLE 10 |
SPOUSE OR DOMESTIC PARTNER 5 BOYFRIEND, GIRLFRIEND, OR PARTNER 6 PARENT 7 STEPPARENT 8 GRANDPARENT OR GREAT-GRANDPARENT 9 AUNT, UNCLE, GREAT-AUNT, OR GREAT-UNCLE 10 |
SIBLING (BROTHER OR SISTER) 11 NEPHEW OR NIECE 12 |
SIBLING (BROTHER OR SISTER) 11 NEPHEW OR NIECE 12 |
SIBLING (BROTHER OR SISTER) 11 NEPHEW OR NIECE 12 |
SIBLING (BROTHER OR SISTER) 11 NEPHEW OR NIECE 12 |
COUSIN 13 GRANDCHILD 14 |
COUSIN 13 GRANDCHILD 14 |
COUSIN 13 GRANDCHILD 14 |
COUSIN 13 GRANDCHILD 14 |
OTHER RELATIVE OR IN-LAW 15 NON-RELATIVE (INCLUDING ROOMER OR BOARDER) 16 OTHER (SPECIFY) 17
DOES NOT KNOW d REFUSED r |
OTHER RELATIVE OR IN-LAW 15 NON-RELATIVE (INCLUDING ROOMER OR BOARDER) 16 OTHER (SPECIFY) 17
DOES NOT KNOW d REFUSED r |
OTHER RELATIVE OR IN-LAW 15 NON-RELATIVE (INCLUDING ROOMER OR BOARDER) 16 OTHER (SPECIFY) 17
DOES NOT KNOW d REFUSED r |
OTHER RELATIVE OR IN-LAW 15 NON-RELATIVE (INCLUDING ROOMER OR BOARDER) 16 OTHER (SPECIFY) 17
DOES NOT KNOW d REFUSED r |
FEMALE 1
MALE 2 |
FEMALE 1
MALE 2 |
FEMALE 1
MALE 2 |
FEMALE 1
MALE 2 |
YES 1
NO (GO TO G9) 0 |
YES 1
NO (GO TO G9) 0 |
YES 1
NO (GO TO G9) 0 |
YES 1
NO (GO TO G9) 0 |
|___|___|/|___|___|/|___|___| MONTH DAY YEAR DOES NOT KNOW d REFUSED r GO TO G10 |
|___|___|/|___|___|/|___|___| MONTH DAY YEAR DOES NOT KNOW d REFUSED r GO TO G10 |
|___|___|/|___|___|/|___|___| MONTH DAY YEAR DOES NOT KNOW d REFUSED r GO TO G10 |
|___|___|/|___|___|/|___|___| MONTH DAY YEAR DOES NOT KNOW d REFUSED r GO TO G10 |
A. YEARS. |___|___| B. MONTHS |___|___|
|
A. YEARS. |___|___| B. MONTHS |___|___|
|
A. YEARS. |___|___| B. MONTHS |___|___| |
A. YEARS. |___|___| B. MONTHS |___|___| |
G2. (Besides TARGET CHILD), Please tell me the first name of everyone else who lives with you.
PROBE: Who else lives with you?
RECORD TARGET CHILD’S FIRST NAME THEN RECORD NAMES OF ALL OTHER HOUSEHOLD MEMBERS ACROSS THE GRID FIRST, THEN ASK G3 THROUGH G14 FOR EACH PERSON. |
_________________________ NAME #8
|
_________________________ NAME #9
|
_________________________ NAME #10
|
G3. What is NAME's relationship to you?
CODE COHABITEE'S CHILD AND OTHER CHILDREN WHO ARE NOT NATURAL, ADOPTED, STEP, OR FOSTER, BUT FOR WHOM THE RESPONDENT TAKES RESPONSIBILITY, AS "OTHER CUSTODIAL CHILD." |
NATURAL CHILD 1 STEPCHILD OR ADOPTED CHILD 2 OTHER CUSTODIAL CHILD 3 FOSTER CHILD 4 |
NATURAL CHILD 1 STEPCHILD OR ADOPTED CHILD 2 OTHER CUSTODIAL CHILD 3 FOSTER CHILD 4 |
NATURAL CHILD 1 STEPCHILD OR ADOPTED CHILD 2 OTHER CUSTODIAL CHILD 3 FOSTER CHILD 4 |
SPOUSE OR DOMESTIC PARTNER 5 BOYFRIEND, GIRLFRIEND, OR PARTNER 6 PARENT 7 STEPPARENT 8 GRANDPARENT OR GREAT-GRANDPARENT 9 AUNT, UNCLE, GREAT-AUNT, OR GREAT-UNCLE 10 |
SPOUSE OR DOMESTIC PARTNER 5 BOYFRIEND, GIRLFRIEND, OR PARTNER 6 PARENT 7 STEPPARENT 8 GRANDPARENT OR GREAT-GRANDPARENT 9 AUNT, UNCLE, GREAT-AUNT, OR GREAT-UNCLE 10 |
SPOUSE OR DOMESTIC PARTNER 5 BOYFRIEND, GIRLFRIEND, OR PARTNER 6 PARENT 7 STEPPARENT 8 GRANDPARENT OR GREAT-GRANDPARENT 9 AUNT, UNCLE, GREAT-AUNT, OR GREAT-UNCLE 10 |
|
|
SIBLING (BROTHER OR SISTER) 11 NEPHEW OR NIECE 12 |
SIBLING (BROTHER OR SISTER) 11 NEPHEW OR NIECE 12 |
SIBLING (BROTHER OR SISTER) 11 NEPHEW OR NIECE 12 |
|
COUSIN 13 GRANDCHILD 14 |
COUSIN 13 GRANDCHILD 14 |
COUSIN 13 GRANDCHILD 14 |
|
OTHER RELATIVE OR IN-LAW 15 NON-RELATIVE (INCLUDING ROOMER OR BOARDER) 16 OTHER (SPECIFY) 17
DOES NOT KNOW d REFUSED r |
OTHER RELATIVE OR IN-LAW 15 NON-RELATIVE (INCLUDING ROOMER OR BOARDER) 16 OTHER (SPECIFY) 17
DOES NOT KNOW d REFUSED r |
OTHER RELATIVE OR IN-LAW 15 NON-RELATIVE (INCLUDING ROOMER OR BOARDER) 16 OTHER (SPECIFY) 17
DOES NOT KNOW d REFUSED r |
G4. CODE SEX. IF NECESSARY, ASK: Is NAME female or male? |
FEMALE 1
MALE 2 |
FEMALE 1
MALE 2 |
FEMALE 1
MALE 2 |
NO G5 or G6 IN THIS DOCUMENT |
|||
G7. INTERVIEWER: IS NAME A CHILD? DOES G3 EQUAL “01,” “02,” “03,” “04,” “11”, “12,” “13”, OR “14”? |
YES 1
NO (GO TO G9) 0 |
YES 1
NO (GO TO G9) 0 |
YES 1
NO (GO TO G9) 0 |
G8. What is (her/his) date of birth? |
|___|___|/|___|___|/|___|___| MONTH DAY YEAR DOES NOT KNOW d REFUSED r GO TO G10 |
|___|___|/|___|___|/|___|___| MONTH DAY YEAR DOES NOT KNOW d REFUSED r GO TO G10 |
|___|___|/|___|___|/|___|___| MONTH DAY YEAR DOES NOT KNOW d REFUSED r GO TO G10 |
G9. How old is (he/she)?
FILL IN BLANK BOXES WITH ZEROES. |
A. YEARS. |___|___| B. MONTHS |___|___|
|
A. YEARS. |___|___| B. MONTHS |___|___| |
A. YEARS. |___|___| B. MONTHS |___|___| |
_________________________ NAME #11
|
_________________________ NAME #12
|
_________________________ NAME #13
|
_________________________ NAME #14
|
NATURAL CHILD 1 STEPCHILD OR ADOPTED CHILD 2 OTHER CUSTODIAL CHILD 3 FOSTER CHILD 4 |
NATURAL CHILD 1 STEPCHILD OR ADOPTED CHILD 2 OTHER CUSTODIAL CHILD 3 FOSTER CHILD 4 |
NATURAL CHILD 1 STEPCHILD OR ADOPTED CHILD 2 OTHER CUSTODIAL CHILD 3 FOSTER CHILD 4 |
NATURAL CHILD 1 STEPCHILD OR ADOPTED CHILD 2 OTHER CUSTODIAL CHILD 3 FOSTER CHILD 4 |
SPOUSE OR DOMESTIC PARTNER 5 BOYFRIEND, GIRLFRIEND, OR PARTNER 6 PARENT 7 STEPPARENT 8 GRANDPARENT OR GREAT-GRANDPARENT 9 AUNT, UNCLE, GREAT-AUNT, OR GREAT-UNCLE 10 |
SPOUSE OR DOMESTIC PARTNER 5 BOYFRIEND, GIRLFRIEND, OR PARTNER 6 PARENT 7 STEPPARENT 8 GRANDPARENT OR GREAT-GRANDPARENT 9 AUNT, UNCLE, GREAT-AUNT, OR GREAT-UNCLE 10 |
SPOUSE OR DOMESTIC PARTNER 5 BOYFRIEND, GIRLFRIEND, OR PARTNER 6 PARENT 7 STEPPARENT 8 GRANDPARENT OR GREAT-GRANDPARENT 9 AUNT, UNCLE, GREAT-AUNT, OR GREAT-UNCLE 10 |
SPOUSE OR DOMESTIC PARTNER 5 BOYFRIEND, GIRLFRIEND, OR PARTNER 6 PARENT 7 STEPPARENT 8 GRANDPARENT OR GREAT-GRANDPARENT 9 AUNT, UNCLE, GREAT-AUNT, OR GREAT-UNCLE 10 |
SIBLING (BROTHER OR SISTER) 11 NEPHEW OR NIECE 12 |
SIBLING (BROTHER OR SISTER) 11 NEPHEW OR NIECE 12 |
SIBLING (BROTHER OR SISTER) 11 NEPHEW OR NIECE 12 |
SIBLING (BROTHER OR SISTER) 11 NEPHEW OR NIECE 12 |
COUSIN 13 GRANDCHILD 14 |
COUSIN 13 GRANDCHILD 14 |
COUSIN 13 GRANDCHILD 14 |
COUSIN 13 GRANDCHILD 14 |
OTHER RELATIVE OR IN-LAW 15 NON-RELATIVE (INCLUDING ROOMER OR BOARDER) 16 OTHER (SPECIFY) 17
DOES NOT KNOW d REFUSED r |
OTHER RELATIVE OR IN-LAW 15 NON-RELATIVE (INCLUDING ROOMER OR BOARDER) 16 OTHER (SPECIFY) 17
DOES NOT KNOW d REFUSED r |
OTHER RELATIVE OR IN-LAW 15 NON-RELATIVE (INCLUDING ROOMER OR BOARDER) 16 OTHER (SPECIFY) 17
DOES NOT KNOW d REFUSED r |
OTHER RELATIVE OR IN-LAW 15 NON-RELATIVE (INCLUDING ROOMER OR BOARDER) 16 OTHER (SPECIFY) 17
DOES NOT KNOW d REFUSED r |
FEMALE 1
MALE 2 |
FEMALE 1
MALE 2 |
FEMALE 1
MALE 2 |
FEMALE 1
MALE 2 |
YES 1
NO (GO TO G9) 0 |
YES 1
NO (GO TO G9) 0 |
YES 1
NO (GO TO G9) 0 |
YES 1
NO (GO TO G9) 0 |
|___|___|/|___|___|/|___|___| MONTH DAY YEAR DOES NOT KNOW d REFUSED r GO TO G10 |
|___|___|/|___|___|/|___|___| MONTH DAY YEAR DOES NOT KNOW d REFUSED r GO TO G10 |
|___|___|/|___|___|/|___|___| MONTH DAY YEAR DOES NOT KNOW d REFUSED r GO TO G10 |
|___|___|/|___|___|/|___|___| MONTH DAY YEAR DOES NOT KNOW d REFUSED r GO TO G10 |
A. YEARS. |___|___| B. MONTHS |___|___|
|
A. YEARS. |___|___| B. MONTHS |___|___|
|
A. YEARS. |___|___| B. MONTHS |___|___| |
A. YEARS. |___|___| B. MONTHS |___|___| |
G10. INTERVIEWER: CHECK G8 AND G9: IS NAME FIVE TO 18 YEARS OLD? |
YES 1
NO (GO TO G13) 0
|
YES 1
NO (GO TO G13) 0
|
YES 1
NO (GO TO G13) 0
|
G11. Is NAME currently attending school?
INTERVIEWER: IF TARGET CHILD, CODE WITHOUT ASKING. |
YES 1
NO (GO TO G13) 0
DOES NOT KNOW (GO TO G13) d
REFUSED (GO TO G13) r
|
YES 1
NO (GO TO G13) 0
DOES NOT KNOW (GO TO G13) d
REFUSED (GO TO G13) r
|
YES 1
NO (GO TO G13) 0
DOES NOT KNOW (GO TO G13) d
REFUSED (GO TO G13) r
|
G12. What grade is (she/he) in?
NOTE: IF CHILD IS BETWEEN GRADES, CODE GRADE SHE OR HE WILL BE ENTERING. |
|___|___| GRADE OR
PRESCHOOL p
KINDERGARTEN k
UNGRADED u
DOES NOT KNOW d
REFUSED r |
|___|___| GRADE OR
PRESCHOOL p
KINDERGARTEN k
UNGRADED u
DOES NOT KNOW d
REFUSED r |
|___|___| GRADE OR
PRESCHOOL p
KINDERGARTEN k
UNGRADED u
DOES NOT KNOW d
REFUSED r |
G13. Did NAME live with you in MONTH? |
YES 1
NO 0
DOES NOT KNOW d
REFUSED r
|
YES 1
NO 0
DOES NOT KNOW d
REFUSED r
|
YES 1
NO 0
DOES NOT KNOW d
REFUSED r
|
G14. INTERVIEWER: CHECK G2. IS THERE ANOTHER PERSON TO ASK ABOUT? |
YES (GO TO G2, NAME 2) 1
NO (GO TO G15) 0
|
YES (GO TO G2, NAME 3) 1
NO (GO TO G15) 0
|
YES (GO TO G2, NAME 4) 1
NO (GO TO G15) 0
|
YES 1
NO (GO TO G13) 0
|
YES 1
NO (GO TO G13) 0
|
YES 1
NO (GO TO G13) 0
|
YES 1
NO (GO TO G13) 0
|
YES 1
NO (GO TO G13) 0
DOES NOT KNOW (GO TO G13) d
REFUSED (GO TO G13) r
|
YES 1
NO (GO TO G13) 0
DOES NOT KNOW (GO TO G13) d
REFUSED (GO TO G13) r
|
YES 1
NO (GO TO G13) 0
DOES NOT KNOW (GO TO G13) d
REFUSED (GO TO G13) r
|
YES 1
NO (GO TO G13) 0
DOES NOT KNOW (GO TO G13) d
REFUSED (GO TO G13) r
|
|___|___| GRADE OR
PRESCHOOL p
KINDERGARTEN k
UNGRADED u
DOES NOT KNOW d
REFUSED r
|
|___|___| GRADE OR
PRESCHOOL p
KINDERGARTEN k
UNGRADED u
DOES NOT KNOW d
REFUSED r
|
|___|___| GRADE OR
PRESCHOOL p
KINDERGARTEN k
UNGRADED u
DOES NOT KNOW d
REFUSED r
|
|___|___| GRADE OR
PRESCHOOL p
KINDERGARTEN k
UNGRADED u
DOES NOT KNOW d
REFUSED r
|
YES 1
NO 0
DOES NOT KNOW d
REFUSED r
|
YES 1
NO 0
DOES NOT KNOW d
REFUSED r
|
YES 1
NO 0
DOES NOT KNOW d
REFUSED r
|
YES 1
NO 0
DOES NOT KNOW d
REFUSED r
|
YES (GO TO G2, NAME 5) 1
NO (GO TO G15) 0
|
YES (GO TO G2, NAME 6) 1
NO (GO TO G15) 0
|
YES (GO TO G2, NAME 7) 1
NO (GO TO G15) 0
|
YES (GO TO G2, NAME 8) 1
NO (GO TO G15) 0
|
G10. INTERVIEWER: CHECK G8 AND G9: IS NAME FIVE TO 18 YEARS OLD? |
YES 1
NO (GO TO G13) 0
|
YES 1
NO (GO TO G13) 0
|
YES 1
NO (GO TO G13) 0
|
G11. Is NAME currently attending school?
INTERVIEWER: IF TARGET CHILD, CODE WITHOUT ASKING. |
YES 1
NO (GO TO G13) 0
DOES NOT KNOW (GO TO G13) d
REFUSED (GO TO G13) r
|
YES 1
NO (GO TO G13) 0
DOES NOT KNOW (GO TO G13) d
REFUSED (GO TO G13) r
|
YES 1
NO (GO TO G13) 0
DOES NOT KNOW (GO TO G13) d
REFUSED (GO TO G13) r
|
G12. What grade is (she/he) in?
NOTE: IF CHILD IS BETWEEN GRADES, CODE GRADE SHE OR HE WILL BE ENTERING. |
|___|___| GRADE OR
PRESCHOOL p
KINDERGARTEN k
UNGRADED u
DOES NOT KNOW d
REFUSED r |
|___|___| GRADE OR
PRESCHOOL p
KINDERGARTEN k
UNGRADED u
DOES NOT KNOW d
REFUSED r |
|___|___| GRADE OR
PRESCHOOL p
KINDERGARTEN k
UNGRADED u
DOES NOT KNOW d
REFUSED r |
G13. Did NAME live with you in MONTH? |
YES 1
NO 0
DOES NOT KNOW d
REFUSED r
|
YES 1
NO 0
DOES NOT KNOW d
REFUSED r
|
YES 1
NO 0
DOES NOT KNOW d
REFUSED r
|
G14. INTERVIEWER: CHECK G2. IS THERE ANOTHER PERSON TO ASK ABOUT? |
YES (GO TO G2, NAME 9) 1
NO (GO TO G15) 0
|
YES (GO TO G2, NAME 10) 1
NO (GO TO G15) 0
|
YES (GO TO G2, NAME 11) 1
NO (GO TO G15) 0
|
YES 1
NO (GO TO G13) 0
|
YES 1
NO (GO TO G13) 0
|
YES 1
NO (GO TO G13) 0
|
YES 1
NO (GO TO G13) 0
|
YES 1
NO (GO TO G13) 0
DOES NOT KNOW (GO TO G13) d
REFUSED (GO TO G13) r
|
YES 1
NO (GO TO G13) 0
DOES NOT KNOW (GO TO G13) d
REFUSED (GO TO G13) r
|
YES 1
NO (GO TO G13) 0
DOES NOT KNOW (GO TO G13) d
REFUSED (GO TO G13) r
|
YES 1
NO (GO TO G13) 0
DOES NOT KNOW (GO TO G13) d
REFUSED (GO TO G13) r
|
|___|___| GRADE OR
PRESCHOOL p
KINDERGARTEN k
UNGRADED u
DOES NOT KNOW d
REFUSED r
|
|___|___| GRADE OR
PRESCHOOL p
KINDERGARTEN k
UNGRADED u
DOES NOT KNOW d
REFUSED r
|
|___|___| GRADE OR
PRESCHOOL p
KINDERGARTEN k
UNGRADED u
DOES NOT KNOW d
REFUSED r
|
|___|___| GRADE OR
PRESCHOOL p
KINDERGARTEN k
UNGRADED u
DOES NOT KNOW d
REFUSED r
|
YES 1
NO 0
DOES NOT KNOW d
REFUSED r
|
YES 1
NO 0
DOES NOT KNOW d
REFUSED r
|
YES 1
NO 0
DOES NOT KNOW d
REFUSED r
|
YES 1
NO 0
DOES NOT KNOW d
REFUSED r
|
YES (GO TO G2, NAME 12) 1
NO (GO TO G15) 0
|
YES (GO TO G2, NAME 13) 1
NO (GO TO G15) 0
|
YES (GO TO G2, NAME 14) 1
NO (GO TO G15) 0
|
YES (GO TO G2, NEXT NAME) 1
NO (GO TO G15) 0
|
G15. Did anyone (else) not currently in this household live with you in MONTH?
YES 1
NO (GO TO G29) 0
DOES NOT KNOW (GO TO G29) d
REFUSED (GO TO G29) r
G16. How many other people lived with you in MONTH? Please do not count any of the household members you already told me about.
| | | ADDITIONAL HOUSEHOLD MEMBERS
G17. Please tell me the first name(s) of the other (person/people) who lived with you in MONTH, who no longer live with you.
PROBE: Who else lived with you then?
RECORD NAMES OF ALL OTHER HOUSEHOLD MEMBERS ACROSS GRID FIRST, THEN ASK G18 THROUGH G28 FOR EACH PERSON. |
____________________________
NAME #1
|
____________________________
NAME #2 |
____________________________
NAME #3 |
G18. What is NAME's relationship to you?
CODE COHABITEE'S CHILD AND OTHER CHILDREN WHO ARE NOT NATURAL, ADOPTED, STEP, OR FOSTER BUT FOR WHOM THE RESPONDENT TAKES RESPONSIBILITY, AS "OTHER CUSTODIAL CHILD." |
NATURAL CHILD 1 STEPCHILD OR ADOPTED CHILD 2 OTHER CUSTODIAL CHILD 3 FOSTER CHILD 4 |
NATURAL CHILD 1 STEPCHILD OR ADOPTED CHILD 2 OTHER CUSTODIAL CHILD 3 FOSTER CHILD 4 |
NATURAL CHILD 1 STEPCHILD OR ADOPTED CHILD 2 OTHER CUSTODIAL CHILD 3 FOSTER CHILD 4 |
SPOUSE OR DOMESTIC PARTNER 5 BOYFRIEND, GIRLFRIEND, OR PARTNER 6 PARENT 7 STEPPARENT 8 GRANDPARENT OR GREAT-GRANDPARENT 9 AUNT, UNCLE, GREAT-AUNT, OR GREAT-UNCLE 10 |
SPOUSE OR DOMESTIC PARTNER 5 BOYFRIEND, GIRLFRIEND, OR PARTNER 6 PARENT 7 STEPPARENT 8 GRANDPARENT OR GREAT-GRANDPARENT 9 AUNT, UNCLE, GREAT-AUNT, OR GREAT-UNCLE 10 |
SPOUSE OR DOMESTIC PARTNER 5 BOYFRIEND, GIRLFRIEND, OR PARTNER 6 PARENT 7 STEPPARENT 8 GRANDPARENT OR GREAT-GRANDPARENT 9 AUNT, UNCLE, GREAT-AUNT, OR GREAT-UNCLE 10 |
|
|
SIBLING (BROTHER OR SISTER) 11 NEPHEW OR NIECE 12 |
SIBLING (BROTHER OR SISTER) 11 NEPHEW OR NIECE 12 |
SIBLING (BROTHER OR SISTER) 11 NEPHEW OR NIECE 12 |
|
COUSIN 13 GRANDCHILD 14 |
COUSIN 13 GRANDCHILD 14 |
COUSIN 13 GRANDCHILD 14 |
|
OTHER RELATIVE OR IN-LAW 15 NON-RELATIVE (INCLUDING ROOMER OR BOARDER) 16 OTHER (SPECIFY) 17
DOES NOT KNOW d REFUSED r |
OTHER RELATIVE OR IN-LAW 15 NON-RELATIVE (INCLUDING ROOMER OR BOARDER) 16 OTHER (SPECIFY) 17
DOES NOT KNOW d REFUSED r |
OTHER RELATIVE OR IN-LAW 15 NON-RELATIVE (INCLUDING ROOMER OR BOARDER) 16 OTHER (SPECIFY) 17
DOES NOT KNOW d REFUSED r |
G19. CODE SEX. IF NECESSARY, ASK: Is NAME female or male? |
FEMALE 1 MALE 2 |
FEMALE 1 MALE 2 |
FEMALE 1 MALE 2 |
NO G20 or G21 IN THIS DOCUMENT |
|||
G22. INTERVIEWER: IS NAME A CHILD? DOES G18 EQUAL “01,” “02,” “03,” “04,” “11”, “12,” “13”, OR “14”? |
YES 1
NO (GO TO G24) 0 |
YES 1
NO (GO TO G24) 0 |
YES 1
NO (GO TO G24) 0 |
G23. What is (her/his) date of birth? |
|___|___|/|___|___|/|___|___| MONTH DAY YEAR DOES NOT KNOW d REFUSED r |
|___|___|/|___|___|/|___|___| MONTH DAY YEAR DOES NOT KNOW d REFUSED r |
|___|___|/|___|___|/|___|___| MONTH DAY YEAR DOES NOT KNOW d REFUSED r |
|
GO TO G25 |
GO TO G25 |
GO TO G25 |
G24. How old is (she/he)?
FILL IN BLANK BOXES WITH ZEROES. |
A. YEARS. |___|___|
B. MONTHS |___|___|
|
A. YEARS. |___|___|
B. MONTHS |___|___|
|
A. YEARS. |___|___|
B. MONTHS |___|___|
|
G25. INTERVIEWER: CHECK G23 AND G24: IS NAME FIVE TO 18 YEARS OLD? |
YES 1
NO (GO TO G28) 0
|
YES 1
NO (GO TO G28) 0 |
YES 1
NO (GO TO G28) 0 |
G26. Did NAME attend school during MONTH? |
YES 1
NO (GO TO G28) 0
DOES NOT KNOW (GO TO G28) d
REFUSED (GO TO G28) r
|
YES 1
NO (GO TO G28) 0
DOES NOT KNOW (GO TO G28) d
REFUSED (GO TO G28) r |
YES 1
NO (GO TO G28) 0
DOES NOT KNOW (GO TO G28) d
REFUSED (GO TO G28) r |
G27. What grade was (she/he) in?
NOTE: IF CHILD IS BETWEEN GRADES, CODE GRADE HE OR SHE WILL BE ENTERING. |
|___|___| GRADE OR
PRESCHOOL p
KINDERGARTEN k
UNGRADED u
DOES NOT KNOW d
REFUSED r
|
|___|___| GRADE OR
PRESCHOOL p
KINDERGARTEN k
UNGRADED u
DOES NOT KNOW d
REFUSED r |
|___|___| GRADE OR
PRESCHOOL p
KINDERGARTEN k
UNGRADED u
DOES NOT KNOW d
REFUSED r |
G28. INTERVIEWER: CHECK G17. IS THERE ANOTHER PERSON TO ASK ABOUT? |
YES (GO TO G17, NAME 2) 1
NO (GO TO G29) 0
|
YES (GO TO G17, NAME 3) 1
NO (GO TO G29) 0 |
YES (GO TO G17, NAME 4 ON SUPPLEMENTAL FORM) 1
NO (GO TO G29) 0 |
G29. INTERVIEWER: IS THE TARGET CHILD A FOSTER CHILD? DOES G3 EQUAL “4” FOR PERSON NUMBER 1?
YES (GO TO G34) 1
NO (GO TO G30) 0
G30. In TARGET MONTH, did you (or your spouse/partner) pay any household expenses or provide any financial support to [fill EACH CHILD 18 OR UNDER]?
YES (GO TO G32) 1
NO 0
DOES NOT KNOW d
REFUSED r
G31. In TARGET MONTH, did [NAME OF EACH HH MEMBER OVER 18] pay any household expenses or provide any financial support to [fill EACH REMAINING CHILD 18 OR UNDER]?
YES 1
NO 0
DOES NOT KNOW d
REFUSED r
G32. In TARGET MONTH, did you (or your spouse/partner) pay any household expenses or provide any financial support to [NAME OF EACH HH MEMBER OVER 18]?
YES (GO TO H1b) 1
NO 0
DOES NOT KNOW d
REFUSED r
G33. In TARGET MONTH, did [NAME OF EACH HH MEMBER OVER 18] pay any household expenses or provide any financial support to you?
YES 1
NO 0
DOES NOT KNOW d
REFUSED r
ALL GO TO H1b
G34. Who has legal responsibility for [TARGET CHILD]?
FILL ALL NAMES FROM G2 AND G17 1
SOMEONE OUTSIDE THE HOUSEHOLD 2
AN AGENCY 3
OTHER (SPECIFY) 4
_________________________________________
DOES NOT KNOW d
REFUSED r
SECTION H: INCOME AND EARNINGS SOURCES |
H0a. INTERVIEWER: IS THE TARGET CHILD A FOSTER CHILD? DOES G3 EQUAL “4” FOR PERSON NUMBER 1?
YES 1
NO (GO TO H1b) 0
H0b. Next, I would like to ask you about the types of income TARGET CHILD may have had in TARGET MONTH. (I realize these questions may seem personal, but they are important to understanding the school food program application process and the needs of families whose children are enrolled in the DISTRICT NAME school district.) I would like to assure you that all of your responses are strictly private.
How much was TARGET CHILD’s personal income in TARGET MONTH?
PROBE: By “personal income,” we mean money received for a child’s personal use.
$ | |,| | | |
DOES NOT KNOW d
REFUSED r
-
GO TO K4
H1b. Next, I would like to ask you about sources of income you and your household may have had in TARGET MONTH. (I realize these questions may seem personal, but they are important to understanding the school food program application process and the needs of families whose children are enrolled in the DISTRICT NAME school district.) I would like to assure you that all of your responses are strictly private.
H1c. INTERVIEWER: RECORD TARGET CHILD’S NAME IN FIRST COLUMN IN H1d IF 16 YEARS OR YOUNGER. THEN CHECK G8 AND G9 AND G23 AND G24 AND RECORD NAME(S) OF ANY OTHER HOUSEHOLD MEMBERS AGE 16 YEARS OR YOUNGER IN SUBSEQUENT COLUMNS WHERE G30 OR G31 HAVE A “YES” ABOUT THAT HH MEMBER.
H1d. RECORD NAME(S) |
____________________________ TARGET CHILD
|
____________________________ CHILD 2
|
____________________________ CHILD 3
|
H1e. During MONTH, did (TARGET CHILD/NAME) have any income from child support, Social Security, persons outside the household, or any other source? |
YES 1
NO (GO TO H1h) 0
DOES NOT KNOW (GO TO H1h) d
REFUSED (GO TO H1h) r |
YES 1
NO (GO TO H1h) 0
DOES NOT KNOW (GO TO H1h) d
REFUSED (GO TO H1h) r |
YES 1
NO (GO TO H1h) 0
DOES NOT KNOW (GO TO H1h) d
REFUSED (GO TO H1h) r |
H1f. What was the source of that income?
AFTER RESPONSE, SAY: Were there other sources of income?
CIRCLE ALL THAT APPLY |
CHILD SUPPORT 1
SOCIAL SECURITY OR DISABILITY SURVIVORS’ BENEFITS 2
PERSONS OUTSIDE THE HOUSEHOLD 3
OTHER (SPECIFY) 4
DOES NOT KNOW (GO TO H1h) d
REFUSED (GO TO H1h) r |
CHILD SUPPORT 1
SOCIAL SECURITY OR DISABILITY SURVIVORS’ BENEFITS 2
PERSONS OUTSIDE THE HOUSEHOLD 3
OTHER (SPECIFY) 4
DOES NOT KNOW (GO TO H1h) d
REFUSED (GO TO H1h) r |
CHILD SUPPORT 1
SOCIAL SECURITY OR DISABILITY SURVIVORS’ BENEFITS 2
PERSONS OUTSIDE THE HOUSEHOLD 3
OTHER (SPECIFY) 4
DOES NOT KNOW (GO TO H1h) d
REFUSED (GO TO H1h) r |
H1g1. How much was received in child support in MONTH? |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
H1g2. How much was received in Social Security in MONTH? |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
H1g3. How much was received from persons outside the household in MONTH? |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
H1g4. How much was received from OTHER IN H1d in MONTH? |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
H1h. INTERVIEWER: IS THERE ANOTHER PERSON 16 OR YOUNGER TO ASK ABOUT? |
YES (GO TO H1e, CHILD 2) 1
NO (GO TO H2) 0
|
YES (GO TO H1e, CHILD 3) 1
NO (GO TO H2) 0
|
YES (GO TO H1e, CHILD 4) 1
NO (GO TO H2) 0
|
____________________________ CHILD 4
|
____________________________ CHILD 5
|
____________________________ CHILD 6
|
____________________________ CHILD 7
|
|
|
|
|
YES 1
NO (GO TO H1h) 0
DOES NOT KNOW (GO TO H1h) d
REFUSED (GO TO H1h) r |
YES 1
NO (GO TO H1h) 0
DOES NOT KNOW (GO TO H1h) d
REFUSED (GO TO H1h) r |
YES 1
NO (GO TO H1h) 0
DOES NOT KNOW (GO TO H1h) d
REFUSED (GO TO H1h) r |
YES 1
NO (GO TO H2) 0
DOES NOT KNOW (GO TO H2) d
REFUSED (GO TO H2) r |
CHILD SUPPORT 1
SOCIAL SECURITY OR DISABILITY SURVIVORS’ BENEFITS 2
PERSONS OUTSIDE THE HOUSEHOLD 3
OTHER (SPECIFY) 4
DOES NOT KNOW (GO TO H1h) d
REFUSED (GO TO H1h) r |
CHILD SUPPORT 1
SOCIAL SECURITY OR DISABILITY SURVIVORS’ BENEFITS 2
PERSONS OUTSIDE THE HOUSEHOLD 3
OTHER (SPECIFY) 4
DOES NOT KNOW (GO TO H1h) d
REFUSED (GO TO H1h) r |
CHILD SUPPORT 1
SOCIAL SECURITY OR DISABILITY SURVIVORS’ BENEFITS 2
PERSONS OUTSIDE THE HOUSEHOLD 3
OTHER (SPECIFY) 4
DOES NOT KNOW (GO TO H1h) d
REFUSED (GO TO H1h) r |
CHILD SUPPORT 1
SOCIAL SECURITY OR DISABILITY SURVIVORS’ BENEFITS 2
PERSONS OUTSIDE THE HOUSEHOLD 3
OTHER (SPECIFY) 4
DOES NOT KNOW (GO TO H2) d
REFUSED (GO TO H2) r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | |,| | | |
DOES NOT KNOW d
REFUSED r |
YES (GO TO H1e, CHILD 5) 1
NO (GO TO H2) 0
|
YES (GO TO H1e, CHILD 6) 1
NO (GO TO H2) 0
|
YES (GO TO H1e, CHILD 7) 1
NO (GO TO H2) 0
|
GO TO H2
|
H2. INTERVIEWER: LIST THE RESPONDENT’S FIRST NAME IN COLUMN ONE OF THE GRID ON THE NEXT PAGE AND THEIR SPOUSE/DOMESTIC PARTNER IN COLUMN TWO, THEN LIST IN SUBSEQUENT COLUMNS THE FIRST NAMES OF ALL HOUSEHOLD MEMBERS AGE 17 OR OLDER WHO LIVED WITH (HIM/HER) DURING THE TARGET MONTH, INCLUDING THE TARGET CHILD IF AGE 17 OR OLDER. INCLUDE ALL ADULTS LISTED AT G2 THAT HAVE A “YES” RESPONSE TO G13 AND ALL ADULTS LISTED IN G17, WHERE G32 OR G33 HAVE A “YES” ABOUT THAT HH MEMBER. THEN CONTINUE TO H2a.
H2a. INTERVIEWER: RECORD THE MONTH AND YEAR FOR WHICH THE INCOME QUESTIONS ARE ASKED.
| | | / | | |
MONTH YEAR
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
H3. During MONTH, did (you/NAME) work at a job for pay? Please include paid work or salary received from your own business or military service. PROBE: Please do not include profit or loss from your own farm or business. |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
H4. My next questions are about other kinds of income (you/NAME) may have received during MONTH.
During MONTH, did (you/NAME) receive income from unemployment compensation? |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
H5. During MONTH, did (you/NAME) receive income from worker’s compensation?
PROBE: During MONTH? |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
H5a. During MONTH, did (you/NAME) receive income from strike benefits?
PROBE: During MONTH? |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
H6. During MONTH, did (you/NAME) receive income from Social Security or railroad retirement?
PROBE: During MONTH? |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
H7. Income from private pensions, annuities, or survivor’s benefits?
PROBE: During MONTH? |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
H7a. During MONTH, did (you/NAME) receive military cash benefits such as housing, food, or clothing allowances? Please do not include combat pay.
PROBE: During MONTH? |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
H8. Income from Veteran’s benefits?
PROBE: During MONTH?
|
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
H9. During MONTH, did (you/NAME) receive government disability benefits from supplemental Security Income or SSI?
PROBE: During MONTH? |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
H9a. Income from private disability benefits?
PROBE: During MONTH? |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
|
|
|
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r
|
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
|
____________________________ RESPONDENT | | | |
____________________________ PERSON NUMBER | | | |
____________________________ PERSON NUMBER | | | |
H10. Alimony payments?
PROBE: During MONTH? |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
H11. Child support payments?
PROBE: During MONTH? |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
H12. Income from interest and dividends?
PROBE: During MONTH? |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
H13. During MONTH, did (you/NAME) receive rental income?
PROBE: Income (you/ NAME) received from others in the form of rent.
PROBE: During MONTH? |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
H14. Profit or loss from (your/her/his) own nonfarm business, partnership, or professional practice?
PROBE: During MONTH? |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
H15. Income or loss from (your/her/his) own farm?
PROBE: During MONTH? |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
H16. Did (you/NAME) receive financial aid for college students? Please exclude money used for tuition, books and fees, but include money used for room and board.
PROBE: During MONTH? |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
H17. During MONTH, did (you/NAME) receive income from money withdrawn from savings?
PROBE: During MONTH?
PROBE: Personal savings.
|
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
H18. Income from regular contributions from persons outside the household, for example, cash gifts from friends or family?
PROBE: During MONTH?
|
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
H19. Any other cash income, such as net royalties, income from trusts, prize winnings, or bonuses?
PROBE: During MONTH?
|
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
____________________________ PERSON NUMBER | | | |
____________________________ PERSON NUMBER | | | |
____________________________ PERSON NUMBER | | | |
____________________________ PERSON NUMBER | | | |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
YES 1 NO 0 DOES NOT KNOW d REFUSED r |
|
____________________________ RESPONDENT | | |
|
____________________________ PERSON NUMBER | | |
|
____________________________ PERSON NUMBER | | |
|
H20. General assistance? Please do not include TANF or SNAP benefits, which I will ask about later.
PROBE: During MONTH? |
YES 1
NO 0
DOES NOT KNOW d
REFUSED r
|
YES 1
NO 0
DOES NOT KNOW d
REFUSED r |
YES 1
NO 0
DOES NOT KNOW d
REFUSED r |
H21. Did (you/NAME) receive a non-military housing subsidy?
PROBE: During MONTH? |
YES 1
NO 0
DOES NOT KNOW d
REFUSED r |
YES 1
NO 0
DOES NOT KNOW d
REFUSED r |
YES 1
NO 0
DOES NOT KNOW d
REFUSED r |
H22. Black lung benefits?
PROBE: During MONTH? |
YES 1
NO 0
DOES NOT KNOW d
REFUSED r |
YES 1
NO 0
DOES NOT KNOW d
REFUSED r |
YES 1
NO 0
DOES NOT KNOW d
REFUSED r |
H23. Did (you/NAME) receive any other kind of public assistance during MONTH? Please do not include TANF or SNAP benefits which we will talk about later. |
YES 1
NO (GO TO H24) 0
DOES NOT KNOW (GO TO H24) d
REFUSED (GO TO H24) r |
YES 1
NO (GO TO H24) 0
DOES NOT KNOW (GO TO H24) d
REFUSED (GO TO H24) r |
YES 1
NO (GO TO H24) 0
DOES NOT KNOW (GO TO H24) d
REFUSED (GO TO H24) r |
H23a. What kind of public assistance did (you/NAME) receive?
RECORD VERBATIM |
___________________________
___________________________
___________________________
___________________________
|
___________________________
___________________________
___________________________
___________________________
|
___________________________
___________________________
___________________________
___________________________
|
H24. INTERVIEWER: CHECK H3. IS THERE ANOTHER PERSON TO ASK ABOUT?
|
YES (GO TO H3, NAME 2) 1
NO (GO TO I1) 0
|
YES (GO TO H3, NAME 3) 1
NO (GO TO I1) 0 |
YES (GO TO H3, NAME 4) 1
NO (GO TO I1) 0 |
____________________________ PERSON NUMBER | | |
|
____________________________ PERSON NUMBER | | |
|
____________________________ PERSON NUMBER | | |
|
____________________________ PERSON NUMBER | | |
|
YES 1
NO 0
DOES NOT KNOW d
REFUSED r
|
YES 1
NO 0
DOES NOT KNOW d
REFUSED r |
YES 1
NO 0
DOES NOT KNOW d
REFUSED r |
YES 1
NO 0
DOES NOT KNOW d
REFUSED r |
YES 1
NO 0
DOES NOT KNOW d
REFUSED r |
YES 1
NO 0
DOES NOT KNOW d
REFUSED r |
YES 1
NO 0
DOES NOT KNOW d
REFUSED r |
YES 1
NO 0
DOES NOT KNOW d
REFUSED r |
YES 1
NO 0
DOES NOT KNOW d
REFUSED r |
YES 1
NO 0
DOES NOT KNOW d
REFUSED r |
YES 1
NO 0
DOES NOT KNOW d
REFUSED r |
YES 1
NO 0
DOES NOT KNOW d
REFUSED r |
YES 1
NO (GO TO H24) 0
DOES NOT KNOW (GO TO H24) d
REFUSED (GO TO H24) r |
YES 1
NO (GO TO H24) 0
DOES NOT KNOW (GO TO H24) d
REFUSED (GO TO H24) r |
YES 1
NO (GO TO H24) 0
DOES NOT KNOW (GO TO H24) d
REFUSED (GO TO H24) r |
YES 1
NO (GO TO H24) 0
DOES NOT KNOW (GO TO H24) d
REFUSED (GO TO H24) r |
___________________________
___________________________
___________________________
___________________________
|
___________________________
___________________________
___________________________
___________________________
|
___________________________
___________________________
___________________________
___________________________
|
___________________________
___________________________
___________________________
___________________________
|
YES (GO TO H3, NAME 5) 1
NO (GO TO I1) 0
|
YES (GO TO H3, NAME 6) 1
NO (GO TO I1) 0 |
YES (GO TO H3, NAME 7) 1
NO (GO TO I1) 0 |
YES (GO TO H3, SUPPLEMENT FORM) 1
NO (GO TO I1) 0 |
SECTION I: INCOME AND EARNINGS AMOUNTS |
I1. Next, I would like to ask you about the different amounts of income (you/you and the other adults in your household) received from the sources we just talked about. For each type of income you just reported, I would like to look at documentation you may have just to be sure we get the right amounts. We can take a short break now so you can collect the documentation. The types of documentation I would like to see are check stubs or last year’s income tax return for earnings from jobs, receipts for cash jobs, leave and earnings statements, business records, or award letters. WAIT FOR RESPONDENT TO COLLECT DOCUMENTS THEN PROCEED TO I2a.
INCOME
FROM WORKING AT A JOB FOR PAY |
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I2a. INTERVIEWER: WAS THERE EARNINGS FROM WORKING AT A JOB FOR PAY? DOES H3 EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR I3a) 0 |
YES 1
NO (GO TO NEXT PERSON OR I3a) 0 |
YES 1
NO (GO TO NEXT PERSON OR I3a) 0 |
I2b. How much were (your/ PERSON’s) earnings from paid jobs during MONTH, before taxes and other deductions? That would be (your/PERSON’s) total pay, not the amount that was brought home. Please include tips, commissions, and regular overtime pay. PROBE: Please do not include profits or losses from your own farm or non-farm business, partnership, or professional practice in MONTH. |
$ |___|___|,|___|___|___|
DOES NOT KNOW (GO TO I2e) d
REFUSED (GO TO I2e) r
|
$ |___|___|,|___|___|___|
DOES NOT KNOW (GO TO I2e) d
REFUSED (GO TO I2e) r
|
$ |___|___|,|___|___|___|
DOES NOT KNOW (GO TO I2e) d
REFUSED (GO TO I2e) r
|
I2c. INTERVIEWER: IF TOTAL FOR MONTH NOT GIVEN, ENTER PAY PERIOD, OR PROBE: Was the amount received per hour, per day, per week, twice a month, or every two weeks? |
MONTH (GO TO I2e) 1 WEEK 2 DAY 3 HOUR 4 BI-MONTHLY (TWICE A MONTH) 5 EVERY TWO WEEKS 6 QUARTER (GO TO I2e) 7 YEAR (GO TO I2e) 8 DOES NOT KNOW (GO TO I2e) d REFUSED (GO TO I2e) r |
MONTH (GO TO I2e) 1 WEEK 2 DAY 3 HOUR 4 BI-MONTHLY (TWICE A MONTH) 5 EVERY TWO WEEKS 6 QUARTER (GO TO I2e) 7 YEAR (GO TO I2e) 8 DOES NOT KNOW (GO TO I2e) d REFUSED (GO TO I2e) r |
MONTH (GO TO I2e) 1 WEEK 2 DAY 3 HOUR 4 BI-MONTHLY (TWICE A MONTH) 5 EVERY TWO WEEKS 6 QUARTER (GO TO I2e) 7 YEAR (GO TO I2e) 8 DOES NOT KNOW (GO TO I2e) d REFUSED (GO TO I2e) r |
I2d. How many PERIODS in I2c did (you/PERSON) work in MONTH?
PROBE: Your best estimate is fine. |
|___|___|___| UNITS WORKED DOES NOT KNOW d REFUSED r |
|___|___|___| UNITS WORKED DOES NOT KNOW d REFUSED r |
|___|___|___| UNITS WORKED DOES NOT KNOW d REFUSED r |
I2e. Did (you/PERSON) have any other paid jobs in MONTH? |
YES 1 NO (GO TO I2g) 0 DOES NOT KNOW (GO TO I2g) d REFUSED (GO TO I2g) r |
YES 1 NO (GO TO I2g) 0 DOES NOT KNOW (GO TO I2g) d REFUSED (GO TO I2g) r |
YES 1 NO (GO TO I2g) 0 DOES NOT KNOW (GO TO I2g) d REFUSED (GO TO I2g) r |
I2f. How much did (you/PERSON) earn from those other jobs in MONTH? |
$ |___|___|,|___|___|___| DOES NOT KNOW d REFUSED r |
$ |___|___|,|___|___|___| DOES NOT KNOW d REFUSED r |
$ |___|___|,|___|___|___| DOES NOT KNOW d REFUSED r |
I2g. May I please look at (your/PERSON’s) pay stub(s) that shows the amount you just reported? |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I3a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I3a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I3a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I3a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I3a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I3a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I3a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I3a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I3a) r |
I2h. INTERVIEWER: ENTER TYPE OF DOCUMENT(S).
CODE ALL THAT APPLY |
CHECK STUB 1 INCOME TAX RETURN 2 RECEIPT FOR CASH JOB 3 LEAVE AND EARNINGS STATEMENT 4 BUSINESS RECORDS 5 AWARD LETTER 6 EXPENSE RECEIPT 7 OTHER (SPECIFY) 8
|
CHECK STUB 1 INCOME TAX RETURN 2 RECEIPT FOR CASH JOB 3 LEAVE AND EARNINGS STATEMENT 4 BUSINESS RECORDS 5 AWARD LETTER 6 EXPENSE RECEIPT 7 OTHER (SPECIFY) 8
|
CHECK STUB 1 INCOME TAX RETURN 2 RECEIPT FOR CASH JOB 3 LEAVE AND EARNINGS STATEMENT 4 BUSINESS RECORDS 5 AWARD LETTER 6 EXPENSE RECEIPT 7 OTHER (SPECIFY) 8
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR I3a) 0 |
YES 1
NO (GO TO NEXT PERSON OR I3a) 0 |
YES 1
NO (GO TO NEXT PERSON OR I3a) 0 |
YES 1
NO (GO TO NEXT PERSON OR I3a) 0 |
$ |___|___|,|___|___|___|
DOES NOT KNOW (GO TO I2e) d
REFUSED (GO TO I2e) r
|
$ |___|___|,|___|___|___|
DOES NOT KNOW (GO TO I2e) d
REFUSED (GO TO I2e) r
|
$ |___|___|,|___|___|___|
DOES NOT KNOW (GO TO I2e) d
REFUSED (GO TO I2e) r
|
$ |___|___|,|___|___|___|
DOES NOT KNOW (GO TO I2e) d
REFUSED (GO TO I2e) r
|
MONTH (GO TO I2e) 1 WEEK 2 DAY 3 HOUR 4 BI-MONTHLY (TWICE A MONTH) 5 EVERY TWO WEEKS 6 QUARTER (GO TO I2e) 7 YEAR (GO TO I2e) 8 DOES NOT KNOW (GO TO I2e) d REFUSED (GO TO I2e) r |
MONTH (GO TO I2e) 1 WEEK 2 DAY 3 HOUR 4 BI-MONTHLY (TWICE A MONTH) 5 EVERY TWO WEEKS 6 QUARTER (GO TO I2e) 7 YEAR (GO TO I2e) 8 DOES NOT KNOW (GO TO I2e) d REFUSED (GO TO I2e) r |
MONTH (GO TO I2e) 1 WEEK 2 DAY 3 HOUR 4 BI-MONTHLY (TWICE A MONTH) 5 EVERY TWO WEEKS 6 QUARTER (GO TO I2e) 7 YEAR (GO TO I2e) 8 DOES NOT KNOW (GO TO I2e) d REFUSED (GO TO I2e) r |
MONTH (GO TO I2e) 1 WEEK 2 DAY 3 HOUR 4 BI-MONTHLY (TWICE A MONTH) 5 EVERY TWO WEEKS 6 QUARTER (GO TO I2e) 7 YEAR (GO TO I2e) 8 DOES NOT KNOW (GO TO I2e) d REFUSED (GO TO I2e) r |
|___|___|___| UNITS WORKED DOES NOT KNOW d REFUSED r |
|___|___|___| UNITS WORKED DOES NOT KNOW d REFUSED r |
|___|___|___| UNITS WORKED DOES NOT KNOW d REFUSED r |
|___|___|___| UNITS WORKED DOES NOT KNOW d REFUSED r |
YES 1 NO (GO TO I2g) 0 DOES NOT KNOW (GO TO I2g) d REFUSED (GO TO I2g) r |
YES 1 NO (GO TO I2g) 0 DOES NOT KNOW (GO TO I2g) d REFUSED (GO TO I2g) r |
YES 1 NO (GO TO I2g) 0 DOES NOT KNOW (GO TO I2g) d REFUSED (GO TO I2g) r |
YES 1 NO (GO TO I2g) 0 DOES NOT KNOW (GO TO I2g) d REFUSED (GO TO I2g) r |
$ |___|___|,|___|___|___| DOES NOT KNOW d REFUSED r |
$ |___|___|,|___|___|___| DOES NOT KNOW d REFUSED r |
$ |___|___|,|___|___|___| DOES NOT KNOW d REFUSED r |
$ |___|___|,|___|___|___| DOES NOT KNOW d REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I3a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I3a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I3a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I3a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I3a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I3a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I3a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I3a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I3a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I3a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I3a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I3a) r |
CHECK STUB 1 INCOME TAX RETURN 2 RECEIPT FOR CASH JOB 3 LEAVE AND EARNINGS STATEMENT 4 BUSINESS RECORDS 5 AWARD LETTER 6 EXPENSE RECEIPT 7 OTHER (SPECIFY) 8
|
CHECK STUB 1 INCOME TAX RETURN 2 RECEIPT FOR CASH JOB 3 LEAVE AND EARNINGS STATEMENT 4 BUSINESS RECORDS 5 AWARD LETTER 6 EXPENSE RECEIPT 7 OTHER (SPECIFY) 8
|
CHECK STUB 1 INCOME TAX RETURN 2 RECEIPT FOR CASH JOB 3 LEAVE AND EARNINGS STATEMENT 4 BUSINESS RECORDS 5 AWARD LETTER 6 EXPENSE RECEIPT 7 OTHER (SPECIFY) 8
|
CHECK STUB 1 INCOME TAX RETURN 2 RECEIPT FOR CASH JOB 3 LEAVE AND EARNINGS STATEMENT 4 BUSINESS RECORDS 5 AWARD LETTER 6 EXPENSE RECEIPT 7 OTHER (SPECIFY) 8
|
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I2i. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT. |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I2j. INTERVIEWER: ENTER THE PAY PERIOD OF PAYMENT. |
MONTH (GO TO I2l) 1
WEEK 2
DAY 3
HOUR 4
BI-MONTHLY (TWICE A MONTH) 5
EVERY TWO WEEKS 6
QUARTER (GO TO I2l) 7
YEAR (GO TO I2l) 8
OTHER (SPECIFY) 9
|
MONTH (GO TO I2l) 1
WEEK 2
DAY 3
HOUR 4
BI-MONTHLY (TWICE A MONTH) 5
EVERY TWO WEEKS 6
QUARTER (GO TO I2l) 7
YEAR (GO TO I2l) 8
OTHER (SPECIFY) 9
|
MONTH (GO TO I2l) 1
WEEK 2
DAY 3
HOUR 4
BI-MONTHLY (TWICE A MONTH) 5
EVERY TWO WEEKS 6
QUARTER (GO TO I2l) 7
YEAR (GO TO I2l) 8
OTHER (SPECIFY) 9
|
I2k. INTERVIEWER: ENTER UNITS WORKED FROM I2j. |
|___|___|___| UNITS WORKED
NOT ON DOCUMENT n
|
|___|___|___| UNITS WORKED
NOT ON DOCUMENT n
|
|___|___|___| UNITS WORKED
NOT ON DOCUMENT n
|
I2l. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT. |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
I2m. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I2n. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING I2b, I2c, I2d AND I2f. THEN COMPUTE THE TOTAL MONTHLY AMOUNT USING I2i, I2j, AND I2k. IF THERE IS NO DIFFERENCE, CONTINUE TO NEXT PERSON OR I3a. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I3a. IS THERE ANOTHER PERSON?
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I3a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I3a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I3a) 0
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
MONTH (GO TO I2l) 1
WEEK 2
DAY 3
HOUR 4
BI-MONTHLY (TWICE A MONTH) 5
EVERY TWO WEEKS 6
QUARTER (GO TO I2l) 7
YEAR (GO TO I2l) 8
OTHER (SPECIFY) 9
|
MONTH (GO TO I2l) 1
WEEK 2
DAY 3
HOUR 4
BI-MONTHLY (TWICE A MONTH) 5
EVERY TWO WEEKS 6
QUARTER (GO TO I2l) 7
YEAR (GO TO I2l) 8
OTHER (SPECIFY) 9
|
MONTH (GO TO I2l) 1
WEEK 2
DAY 3
HOUR 4
BI-MONTHLY (TWICE A MONTH) 5
EVERY TWO WEEKS 6
QUARTER (GO TO I2l) 7
YEAR (GO TO I2l) 8
OTHER (SPECIFY) 9
|
MONTH (GO TO I2l) 1
WEEK 2
DAY 3
HOUR 4
BI-MONTHLY (TWICE A MONTH) 5
EVERY TWO WEEKS 6
QUARTER (GO TO I2l) 7
YEAR (GO TO I2l) 8
OTHER (SPECIFY) 9
|
|___|___|___| UNITS WORKED
NOT ON DOCUMENT n
|
|___|___|___| UNITS WORKED
NOT ON DOCUMENT n
|
|___|___|___| UNITS WORKED
NOT ON DOCUMENT n
|
|___|___|___| UNITS WORKED
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I3a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I3a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I3a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I3a) 0
|
UNEMPLOYMENT
COMPENSATION |
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I3a. INTERVIEWER: WAS THERE UNEMPLOYMENT COMPENSATION? DOES H4 EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR I4a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I4a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I4a) 0
|
I3b. How much unemployment compensation did (you/PERSON) receive during MONTH? |
$ |___|___|,|___|___|___|
DOES NOT KNOW (GO TO I3e) d
REFUSED (GO TO 13e) r
|
$ |___|___|,|___|___|___|
DOES NOT KNOW (GO TO I3e) d
REFUSED (GO TO 13e) r |
$ |___|___|,|___|___|___|
DOES NOT KNOW (GO TO I3e) d
REFUSED (GO TO 13e) r |
I3c. INTERVIEWER: ENTER PERIOD COVERED OR ASK: Was that per week, every two weeks, or per month? |
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I3e) 3
DOES NOT KNOW d
REFUSED r |
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I3e) 3
DOES NOT KNOW d
REFUSED r |
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I3e) 3
DOES NOT KNOW d
REFUSED r |
13d. How many PERIODS IN I3c of unemployment compensation did (you/PERSON) receive in MONTH? |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
I3e. May I look at the statement (you/PERSON) received showing the amount of unemployment compensation received in MONTH?
PROBE: The check stub. |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I4a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I4a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I4a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I4a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I4a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I4a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I4a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I4a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I4a) r |
I3f. INTERVIEWER: ENTER TYPE OF DOCUMENT. |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
I3g. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT.
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I3h. INTERVIEWER: ENTER THE PERIOD OF PAYMENT. |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n
|
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n
|
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n
|
I3i. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH. |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR I4a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I4a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I4a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I4a) 0
|
$ |___|___|,|___|___|___|
DOES NOT KNOW (GO TO I3e) d
REFUSED (GO TO 13e) r
|
$ |___|___|,|___|___|___|
DOES NOT KNOW (GO TO I3e) d
REFUSED (GO TO 13e) r |
$ |___|___|,|___|___|___|
DOES NOT KNOW (GO TO I3e) d
REFUSED (GO TO 13e) r
|
$ |___|___|,|___|___|___|
DOES NOT KNOW (GO TO I3e) d
REFUSED (GO TO 13e) r |
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I3e) 3
DOES NOT KNOW d
REFUSED r |
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I3e) 3
DOES NOT KNOW d
REFUSED r |
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I3e) 3
DOES NOT KNOW d
REFUSED r |
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I3e) 3
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I4a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I4a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I4a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I4a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I4a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I4a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I4a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I4a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I4a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I4a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I4a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I4a) r |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n
|
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n
|
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n
|
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I3j. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT. |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
I3k. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I3l. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING I3b, I3c, AND I3d. THEN COMPUTE THE MONTHLY AMOUNT USING I3g, I3h, AND I3i. IF THERE IS NO DIFFERENCE, CONTINUE TO NEXT PERSON OR I4a. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I4a. IS THERE ANOTHER PERSON?
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I4a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I4a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I4a) 0
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I4a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I4a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I4a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I4a) 0
|
WORKER’S
COMPENSATION |
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I4a. INTERVIEWER: WAS WORKER’S COMPENSATION RECEIVED? DOES H5 EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR I5a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I5a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I5a) 0
|
I4b. How much did (you/NAME) receive from worker’s compensation in MONTH?
|
$ |___|___|,|___|___|___|
DOES NOT KNOW d
REFUSED r |
$ |___|___|,|___|___|___|
DOES NOT KNOW d
REFUSED r |
$ |___|___|,|___|___|___|
DOES NOT KNOW d
REFUSED r |
I4c. INTERVIEWER: ENTER PERIOD COVERED OR ASK: Was that per week, every two weeks, or per month? |
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I4e) 3
DOES NOT KNOW d
REFUSED r |
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I4e) 3
DOES NOT KNOW d
REFUSED r |
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I4e) 3
DOES NOT KNOW d
REFUSED r |
14d. How many PERIODS IN I4c of worker’s compensation did (you/PERSON) receive in MONTH? |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
I4e. May I look at the statement (you/PERSON) received showing the amount of worker’s compensation received in MONTH?
PROBE: The check stub. |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I5a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I5a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I5a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I5a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I5a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I5a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I5a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I5a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I5a) r |
I4f. INTERVIEWER: ENTER TYPE OF DOCUMENT. |
STATEMENT 1
CHECK STUB 2
OTHER (SPECIFY) 3
|
STATEMENT 1
CHECK STUB 2
OTHER (SPECIFY) 3
|
STATEMENT 1
CHECK STUB 2
OTHER (SPECIFY) 3
|
I4g. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT.
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR I5a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I5a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I5a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I5a) 0
|
$ |___|___|,|___|___|___|
DOES NOT KNOW d
REFUSED r |
$ |___|___|,|___|___|___|
DOES NOT KNOW d
REFUSED r |
$ |___|___|,|___|___|___|
DOES NOT KNOW d
REFUSED r |
$ |___|___|,|___|___|___|
DOES NOT KNOW d
REFUSED r |
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I4e) 3
DOES NOT KNOW d
REFUSED r |
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I4e) 3
DOES NOT KNOW d
REFUSED r |
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I4e) 3
DOES NOT KNOW d
REFUSED r |
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I4e) 3
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I5a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I5a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I5a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I5a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I5a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I5a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I5a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I5a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I5a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I5a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I5a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I5a) r |
STATEMENT 1
CHECK STUB 2
OTHER (SPECIFY) 3
|
STATEMENT 1
CHECK STUB 2
OTHER (SPECIFY) 3
|
STATEMENT 1
CHECK STUB 2
OTHER (SPECIFY) 3
|
STATEMENT 1
CHECK STUB 2
OTHER (SPECIFY) 3
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I4h. INTERVIEWER: ENTER THE PERIOD OF PAYMENT. |
WEEK 1
TWO WEEKS 2
MONTH 3
OTHER (SPECIFY) 4
NOT ON DOCUMENT n
|
WEEK 1
TWO WEEKS 2
MONTH 3
OTHER (SPECIFY) 4
NOT ON DOCUMENT n
|
WEEK 1
TWO WEEKS 2
MONTH 3
OTHER (SPECIFY) 4
NOT ON DOCUMENT n
|
I4i. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH. |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
I4j. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT. |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
I4k. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I4l. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING I4b, I4c, AND I4d. THEN COMPUTE THE MONTHLY AMOUNT USING I4g, I4h, AND I4i. IF THERE IS NO DIFFERENCE, CONTINUE TO NEXT PERSON OR I5a. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I5a. IS THERE ANOTHER PERSON?
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I5a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I5a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I5a) 0
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
WEEK 1
TWO WEEKS 2
MONTH 3
OTHER (SPECIFY) 4
NOT ON DOCUMENT n
|
WEEK 1
TWO WEEKS 2
MONTH 3
OTHER (SPECIFY) 4
NOT ON DOCUMENT n
|
WEEK 1
TWO WEEKS 2
MONTH 3
OTHER (SPECIFY) 4
NOT ON DOCUMENT n
|
WEEK 1
TWO WEEKS 2
MONTH 3
OTHER (SPECIFY) 4
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I5a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I5a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I5a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I5a) 0
|
STRIKE
BENEFITS |
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
a. INTERVIEWER: WAS THERE STRIKE BENEFITS INCOME? DOES H5a EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR I5a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I5a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I5a) 0
|
b. How much did (you/NAME) receive from strike benefits in MONTH? |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
c. INTERVIEWER: ENTER PERIOD COVERED OR ASK: Was that per week, every two weeks, or per month? |
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I5e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I5e) 3
DOES NOT KNOW d
REFUSED r
|
d. How many PERIODS IN C of strike benefits did (you/PERSON) receive in MONTH? |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
e. May I look at the statement (you/PERSON) received showing the amount of striket benefits received in MONTH?
PROBE: The check stub. |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I5a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I5a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I5a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I5a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I5a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I5a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I5a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I5a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I5a) r |
f. INTERVIEWER: ENTER TYPE OF DOCUMENT. |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
g. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT. |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
h. INTERVIEWER: ENTER THE PERIOD OF PAYMENT. |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
i. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH. |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR I5a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I5a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I5a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I5a) 0
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO e) 3
DOES NOT KNOW d
REFUSED r
|
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I5a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I5a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I5a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I5a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I5a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I5a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I5a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I5a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I5a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I5a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I5a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I5a) r |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
j. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT. |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
k. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
l. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING b, c, AND d. THEN COMPUTE THE MONTHLY AMOUNT USING g, h, AND i. IF THERE IS NO DIFFERENCE, CONTINUE TO NEXT PERSON OR I5a. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I5a. IS THERE ANOTHER PERSON?
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I5a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I5a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I5a) 0
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I5a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I5a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I5a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I5a) 0
|
SOCIAL
SECURITY INCOME |
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I5a. INTERVIEWER: WAS THERE SOCIAL SECURITY INCOME? DOES H6 EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR I6a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I6a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I6a) 0
|
I5b. How much did (you/NAME) receive from Social Security or Railroad Retirement in MONTH? |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
I5c. INTERVIEWER: ENTER PERIOD COVERED OR ASK: Was that per week, every two weeks, or per month? |
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I5e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I5e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I5e) 3
DOES NOT KNOW d
REFUSED r
|
15d. How many PERIODS IN I5c of Social Security or Railroad Retirement benefits did (you/PERSON) receive in MONTH? |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
I5e. May I look at the statement (you/PERSON) received showing the amount of Social Security or Railroad Retirement benefits received in MONTH?
PROBE: The check stub. |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I6a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I6a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I6a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I6a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I6a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I6a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I6a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I6a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I6a) r |
I5f. INTERVIEWER: ENTER TYPE OF DOCUMENT. |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
I5g. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT. |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
I5h. INTERVIEWER: ENTER THE PERIOD OF PAYMENT. |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
I5i. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH. |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR I6a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I6a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I6a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I6a) 0
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I5e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I5e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I5e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I5e) 3
DOES NOT KNOW d
REFUSED r
|
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I6a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I6a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I6a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I6a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I6a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I6a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I6a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I6a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I6a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I6a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I6a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I6a) r |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I5j. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT. |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
I5k. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I5l. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING I5b, I5c, AND I5d. THEN COMPUTE THE MONTHLY AMOUNT USING I5g, I5h, AND I5i. IF THERE IS NO DIFFERENCE, CONTINUE TO NEXT PERSON OR I6a. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I6a. IS THERE ANOTHER PERSON?
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I6a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I6a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I6a) 0
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I6a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I6a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I6a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I6a) 0
|
PRIVATE
PENSIONS |
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I6a. INTERVIEWER: WERE THERE PRIVATE PENSIONS? DOES H7 EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR I7a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I7a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I7a) 0
|
I6b. How much did (you/PERSON) receive in private pensions during MONTH? |
$ |___|___|,|___|___|___|
DOES NOT KNOW d
REFUSED r
|
$ |___|___|,|___|___|___|
DOES NOT KNOW d
REFUSED r
|
$ |___|___|,|___|___|___|
DOES NOT KNOW d
REFUSED r
|
I6c. INTERVIEWER: ENTER PERIOD COVERED OR ASK: Was that per week, every two weeks, or per month? |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I6e) 3 DOES NOT KNOW d REFUSED r
|
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I6e) 3 DOES NOT KNOW d REFUSED r
|
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I6e) 3 DOES NOT KNOW d REFUSED r
|
I6d. How many PERIODS IN I6c of private pension payments did (you/PERSON) receive in MONTH? |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
|
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
I6e. May I look at the statement (you/PERSON) received showing the amount of private pension payments received in MONTH?
PROBE: The check stub. |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I7a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I7a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I7a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I7a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I7a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I7a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I7a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I7a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I7a) r |
I6f. INTERVIEWER: ENTER TYPE OF DOCUMENT. |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
I6g. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT. |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
I6h. INTERVIEWER: ENTER THE PERIOD OF PAYMENT. |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
I6i. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH. |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR I7a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I7a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I7a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I7a) 0
|
$ |___|___|,|___|___|___|
DOES NOT KNOW d
REFUSED r
|
$ |___|___|,|___|___|___|
DOES NOT KNOW d
REFUSED r
|
$ |___|___|,|___|___|___|
DOES NOT KNOW d
REFUSED r
|
$ |___|___|,|___|___|___|
DOES NOT KNOW d
REFUSED r
|
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I6e) 3 DOES NOT KNOW d REFUSED r
|
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I6e) 3 DOES NOT KNOW d REFUSED r
|
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I6e) 3 DOES NOT KNOW d REFUSED r
|
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I6e) 3 DOES NOT KNOW d REFUSED r
|
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I7a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I7a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I7a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I7a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I7a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I7a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I7a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I7a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I7a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I7a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I7a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I7a) r |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I6j. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT. |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
I6k. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I6l. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING I6b, I6c, AND I6d. THEN COMPUTE THE MONTHLY AMOUNT USING I6g, I6h, AND I6i. IF THERE IS NO DIFFERENCE, CONTINUE TO NEXT PERSON OR I7a. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I7a. IS THERE ANOTHER PERSON?
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I7a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I7a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I7a) 0
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I7a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I7a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I7a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I7a) 0
|
MILITARY
BENEFITS |
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
a. INTERVIEWER: WERE THERE MILITARY CASH BENEFITS? DOES H7a EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR H8a) 0
|
YES 1
NO (GO TO NEXT PERSON OR H8a) 0
|
YES 1
NO (GO TO NEXT PERSON OR H8a) 0
|
b. How much in military cash benefits did (you/NAME) receive in MONTH? Please do not include combat pay. |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
c. INTERVIEWER: ENTER PERIOD COVERED OR ASK: Was that per week, every two weeks, or per month? |
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO e) 3
DOES NOT KNOW d
REFUSED r
|
d. How many PERIODS IN C of military cash benefits did (you/PERSON) receive in MONTH? |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
e. May I look at the statement (you/PERSON) received showing the amount of military cash benefits received in MONTH?
PROBE: The check stub. |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I8a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I8a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I8a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I8a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I8a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I8a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I8a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I8a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I8a) r |
f. INTERVIEWER: ENTER TYPE OF DOCUMENT. |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
g. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT. |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
h. INTERVIEWER: ENTER THE PERIOD OF PAYMENT. |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
i. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH. |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR H8a) 0
|
YES 1
NO (GO TO NEXT PERSON OR H8a) 0
|
YES 1
NO (GO TO NEXT PERSON OR H8a) 0
|
YES 1
NO (GO TO NEXT PERSON OR H8a) 0
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO e) 3
DOES NOT KNOW d
REFUSED r
|
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I8a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I8a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I8a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I8a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I8a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I8a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I8a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I8a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I8a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I8a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I8a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I8a) r |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
j. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT. |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
k. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
l. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING b, c, AND d. THEN COMPUTE THE MONTHLY AMOUNT USING g, h, AND i. IF THERE IS NO DIFFERENCE, CONTINUE TO NEXT PERSON OR I8a. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I8a. IS THERE ANOTHER PERSON?
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I8a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I8a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I8a) 0
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I8a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I8a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I8a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I8a) 0
|
VETERAN’S
BENEFITS |
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I7a. INTERVIEWER: WERE THERE VETERAN’S BENEFITS? DOES H8 EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR I8a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I8a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I8a) 0
|
I7b. How much in Veteran’s benefits did (you/NAME) receive in MONTH? |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
I7c. INTERVIEWER: ENTER PERIOD COVERED OR ASK: Was that per week, every two weeks, or per month? |
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I7e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I7e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I7e) 3
DOES NOT KNOW d
REFUSED r
|
I7d. How many PERIODS IN I7c of Veteran’s benefits did (you/PERSON) receive in MONTH? |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
I7e. May I look at the statement (you/PERSON) received showing the amount of Veteran’s benefits received in MONTH?
PROBE: The check stub. |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I8a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I8a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I8a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I8a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I8a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I8a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I8a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I8a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I8a) r |
I7f. INTERVIEWER: ENTER TYPE OF DOCUMENT. |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
I7g. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT. |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
I7h. INTERVIEWER: ENTER THE PERIOD OF PAYMENT. |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
I7i. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH. |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR I8a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I8a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I8a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I8a) 0
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I7e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I7e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I7e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO I7e) 3
DOES NOT KNOW d
REFUSED r
|
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I8a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I8a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I8a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I8a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I8a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I8a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I8a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I8a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I8a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I8a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I8a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I8a) r |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I7j. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT. |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
I7k. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I7l. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING I7b, I7c, AND I7d. THEN COMPUTE THE MONTHLY AMOUNT USING I7g, I7h, AND I7i. IF THERE IS NO DIFFERENCE, CONTINUE TO NEXT PERSON OR I8a. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I8a. IS THERE ANOTHER PERSON? |
YES (GO TO NEXT PERSON) 1
NO (GO TO I8a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I8a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I8a) 0
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I8a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I8a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I8a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I8a) 0
|
SSI
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I8a. INTERVIEWER: WAS THERE SSI? DOES H9 EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR I9a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I9a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I9a) 0
|
I8b. How much Supplemental Security Income or SSI did (you/NAME) receive in MONTH? |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
I8c. INTERVIEWER: ENTER PERIOD COVERED OR ASK: Was that per week, every two weeks, or per month? |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I8e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I8e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I8e) 3 DOES NOT KNOW d REFUSED r |
I8d. How many PERIODS IN I8c of SSI did (you/PERSON) receive in MONTH? |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
I8e. May I look at the statement (you/PERSON) received showing the amount of SSI received in MONTH?
PROBE: The check stub. |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I9a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I9a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I9a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I9a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I9a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I9a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I9a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I9a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I9a) r |
I8f. INTERVIEWER: ENTER TYPE OF DOCUMENT. |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
I8g. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT.
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I8h. INTERVIEWER: ENTER THE PERIOD OF PAYMENT. |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
I8i. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH. |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
I8j. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT. |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR I9a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I9a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I9a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I9a) 0
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I8e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I8e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I8e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I8e) 3 DOES NOT KNOW d REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I9a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I9a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I9a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I9a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I9a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I9a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I9a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I9a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I9a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I9a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I9a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I9a) r |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I8k. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I8l. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING I8b, I8c, AND I8d. THEN COMPUTE THE MONTHLY AMOUNT USING I8g, I8h, AND I8i. IF THERE IS NO DIFFERENCE, CONTINUE TO NEXT PERSON OR I9a. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I9a. IS THERE ANOTHER PERSON?
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I9a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I9a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I9a) 0
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I9a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I9a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I9a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I9a) 0
|
PRIVATE
DISABILITY |
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
a. INTERVIEWER: WAS THERE PRIVATE DISABILITY INCOME? DOES H9a EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR H10a) 0
|
YES 1
NO (GO TO NEXT PERSON OR H10a) 0
|
YES 1
NO (GO TO NEXT PERSON OR H10a) 0
|
b. How much did (you/NAME) receive from private disability in MONTH? |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
c. INTERVIEWER: ENTER PERIOD COVERED OR ASK: Was that per week, every two weeks, or per month? |
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO e) 3
DOES NOT KNOW d
REFUSED r
|
d. How many PERIODS IN C of private disability did (you/PERSON) receive in MONTH? |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
e. May I look at the statement (you/PERSON) received showing the amount of private disability received in MONTH?
PROBE: The check stub. |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I10a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I10a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I10a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I10a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I10a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I10a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I10a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I10a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I10a) r |
f. INTERVIEWER: ENTER TYPE OF DOCUMENT. |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
g. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT.
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
h. INTERVIEWER: ENTER THE PERIOD OF PAYMENT. |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
i. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH. |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR H10a) 0
|
YES 1
NO (GO TO NEXT PERSON OR H10a) 0
|
YES 1
NO (GO TO NEXT PERSON OR H10a) 0
|
YES 1
NO (GO TO NEXT PERSON OR H10a) 0
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO e) 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1
EVERY TWO WEEKS 2
MONTH (GO TO e) 3
DOES NOT KNOW d
REFUSED r
|
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I10a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I10a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I10a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I10a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I10a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I10a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I10a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I10a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I10a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I10a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I10a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I10a) r |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
j. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT. |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
k. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
l. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING b, c, AND d. THEN COMPUTE THE MONTHLY AMOUNT USING g, h, AND i. IF THERE IS NO DIFFERENCE, CONTINUE TO NEXT PERSON OR I10a. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I10a. IS THERE ANOTHER PERSON?
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I10a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I10a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I10a) 0
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I10a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I10a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I10a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I10a) 0
|
ALIMONY
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I9a. INTERVIEWER: WAS THERE ALIMONY? DOES H10 EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR I10a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I10a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I10a) 0
|
I9b. How much in alimony payments did (you/NAME) receive in MONTH? |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
I9c. INTERVIEWER: ENTER PERIOD COVERED OR ASK: Was that per week, every two weeks, or per month? |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I9e) 3 OTHER (SPECIFY) (GO TO I9e) 4 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I9e) 3 OTHER (SPECIFY) (GO TO I9e) 4 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I9e) 3 OTHER (SPECIFY) (GO TO I9e) 4 DOES NOT KNOW d REFUSED r |
I9d. How many PERIODS IN I9c of alimony payments did (you/PERSON) receive in MONTH? |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
I9e. May I look at the statement (you/PERSON) received showing the amount of alimony payments received in MONTH?
PROBE: The check stub. |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I10a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I10a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I10a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I10a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I10a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I10a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I10a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I10a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I10a) r |
I9f. INTERVIEWER: ENTER TYPE OF DOCUMENT. |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
I9g. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT.
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I9h. INTERVIEWER: ENTER THE PERIOD OF PAYMENT. |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
I9i. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH. |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
I9j. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT. |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR I10a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I10a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I10a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I10a) 0
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I9e) 3 OTHER (SPECIFY) (GO TO I9e) 4 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I9e) 3 OTHER (SPECIFY) (GO TO I9e) 4 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I9e) 3 OTHER (SPECIFY) (GO TO I9e) 4 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I9e) 3 OTHER (SPECIFY) (GO TO I9e) 4 DOES NOT KNOW d REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I10a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I10a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I10a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I10a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I10a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I10a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I10a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I10a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I10a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I10a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I10a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I10a) r |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I9k. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I9l. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING I9b, I9c, AND I9d. THEN COMPUTE THE MONTHLY AMOUNT USING I9g, I9h, AND I9i. IF THERE IS NO DIFFERENCE, CONTINUE TO NEXT PERSON OR I10a. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I10a. IS THERE ANOTHER PERSON? IS THERE ANOTHER PERSON?
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I10a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I10a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I10a) 0
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I10a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I10a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I10a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I10a) 0
|
CHILD
SUPPORT |
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I10a. INTERVIEWER: WAS THERE CHILD SUPPORT? DOES H11 EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR I11a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I11a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I11a) 0
|
I10b. How much child support payments did (you/NAME) receive in MONTH? |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
I10c. INTERVIEWER: ENTER PERIOD COVERED OR ASK: Was that per week, every two weeks, or per month? |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I10e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I10e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I10e) 3 DOES NOT KNOW d REFUSED r |
I10d. How many PERIODS IN I10c of child support payments did (you/PERSON) receive in MONTH? |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
I10e. May I look at the statement (you/PERSON) received showing the amount of child support payments received in MONTH?
PROBE: The check stub. |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I11a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I11a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I11a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I11a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I11a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I11a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I11a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I11a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I11a) r |
I10f. INTERVIEWER: ENTER TYPE OF DOCUMENT. |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
I10g. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT.
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I10h. INTERVIEWER: ENTER THE PERIOD OF PAYMENT. |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
I10i. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH. |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR I11a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I11a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I11a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I11a) 0
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I10e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I10e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I10e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I10e) 3 DOES NOT KNOW d REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I11a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I11a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I11a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I11a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I11a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I11a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I11a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I11a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I11a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I11a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I11a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I11a) r |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I10j. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT. |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
I10k. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I10l. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING I10b, I10c, AND I10d. THEN COMPUTE THE MONTHLY AMOUNT USING I10g, I10h, AND I10i. IF THERE IS NO DIFFERENCE, CONTINUE TO NEXT PERSON OR I11a. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I11a. IS THERE ANOTHER PERSON?
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I11a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I11a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I11a) 0
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I11a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I11a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I11a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I11a) 0
|
INTEREST
INCOME |
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I11a. INTERVIEWER: WAS THERE INTEREST INCOME? DOES H12 EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR I12a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I12a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I12a) 0
|
I11b. How much income from interest and dividends did (you/NAME) receive in MONTH? |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
I11c. INTERVIEWER: ENTER PERIOD COVERED OR ASK: Was that per week, every two weeks, per month, per quarter or per year? |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I11e) 3 EVERY THREE MONTHS (QUARTERLY) (GO TO I11e) YEAR (GO TO I11e) 5 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I11e) 3 EVERY THREE MONTHS (QUARTERLY) (GO TO I11e) YEAR (GO TO I11e) 5 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I11e) 3 EVERY THREE MONTHS (QUARTERLY) (GO TO I11e) YEAR (GO TO I11e) 5 DOES NOT KNOW d REFUSED r |
111d. How many PERIODS IN I11c of income from interest and dividends did (you/PERSON) receive in MONTH? |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
I11e. May I look at the statement (you/PERSON) received showing the amount of interest and dividends received in MONTH?
PROBE: The check stub. |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I12a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I12a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I12a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I12a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I12a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I12a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I12a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I12a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I12a) r |
I11f. INTERVIEWER: ENTER TYPE OF DOCUMENT. |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
I11g. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT.
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I11h. INTERVIEWER: ENTER THE PERIOD OF PAYMENT. |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
I11i. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH. |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR I12a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I12a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I12a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I12a) 0
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I11e) 3 EVERY THREE MONTHS (QUARTERLY) (GO TO I11e) YEAR (GO TO I11e) 5 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I11e) 3 EVERY THREE MONTHS (QUARTERLY) (GO TO I11e) YEAR (GO TO I11e) 5 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I11e) 3 EVERY THREE MONTHS (QUARTERLY) (GO TO I11e) YEAR (GO TO I11e) 5 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I11e) 3 EVERY THREE MONTHS (QUARTERLY) (GO TO I11e) YEAR (GO TO I11e) 5 DOES NOT KNOW d REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I12a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I12a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I12a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I12a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I12a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I12a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I12a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I12a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I12a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I12a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I12a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I12a) r |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I11j. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT: |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
I11k. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I11l. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING I11b, I11c, AND I11d. THEN COMPUTE THE MONTHLY AMOUNT USING I11g, I11h, AND I11i. IF THERE IS NO DIFFERENCE, CONTINUE TO NEXT PERSON OR I12a. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I12a. IS THERE ANOTHER PERSON?
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I12a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I12a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I12a) 0
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I12a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I12a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I12a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I12a) 0
|
RENTAL
INCOME |
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I12a. INTERVIEWER: WAS THERE RENTAL INCOME? DOES H13 EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR I13a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I13a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I13a) 0
|
I12b. How much rental income did (you/NAME) receive in MONTH? |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
I12c. INTERVIEWER: ENTER PERIOD COVERED OR ASK: Was that per week, every two weeks, or per month? |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I12e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I12e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I12e) 3 DOES NOT KNOW d REFUSED r |
112d. How many PERIODS IN I12c of rental income did (you/PERSON) receive in MONTH? |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
I12e. May I look at the statement (you/PERSON) received showing the amount of rental income received in MONTH?
PROBE: The check stub. |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I13a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I13a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I13a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I13a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I13a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I13a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I13a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I13a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I13a) r |
I12f. INTERVIEWER: ENTER TYPE OF DOCUMENT. |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
I12g. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT. |
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I12h. INTERVIEWER: ENTER THE PERIOD OF PAYMENT. |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
I12i. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH. |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
I12j. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT: |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR I13a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I13a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I13a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I13a) 0
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I12e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I12e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I12e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I12e) 3 DOES NOT KNOW d REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I13a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I13a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I13a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I13a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I13a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I13a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I13a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I13a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I13a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I13a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I13a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I13a) r |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I12k. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I12l. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING I12b, I12c, AND I12d. THEN COMPUTE THE MONTHLY AMOUNT USING I12g, I12h, AND I12i. IF THERE IS NO DIFFERENCE, CONTINUE TO NEXT PERSON OR I13a. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I13a. IS THERE ANOTHER PERSON?
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I13a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I13a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I13a) 0
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I13a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I13a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I13a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I13a) 0
|
NON-FARM
BUSINESS PROFIT OR LOSS |
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I13a. INTERVIEWER: WAS THERE BUSINESS PROFIT OR LOSS? DOES H14 EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR I14a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I14a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I14a) 0
|
I13b. During MONTH, how much profit or loss did (you/PERSONS) have from (your/her/his) own nonfarm business, partnership, or professional practice?
PROBE: Was that profit or loss?
INTERVIEWER: INDICATE IF AMOUNT IS PROFIT OR LOSS. |
$ | |,| | | |,| | | |
PROFIT 1
LOSS 2
DOES NOT KNOW d
REFUSED r
|
$ | |,| | | |,| | | |
PROFIT 1
LOSS 2
DOES NOT KNOW d
REFUSED r
|
$ | |,| | | |,| | | |
PROFIT 1
LOSS 2
DOES NOT KNOW d
REFUSED r
|
I13c. INTERVIEWER: ENTER PERIOD COVERED OR ASK: Was that per week, every two weeks, or per month? |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I13e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I13e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I13e) 3 DOES NOT KNOW d REFUSED r |
113d. How many PERIODS IN I13c of (profit/loss) from (your/PERSON’S) own business did (you/PERSON) realize in MONTH? |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
I13e. May I look at the statement (you/PERSON) received showing the amount of (profit/loss) from (your/PERSON’S) own business in MONTH?
PROBE: The check stub. |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I14a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I14a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I14a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I14a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I14a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I14a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I14a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I14a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I14a) r |
I13f. INTERVIEWER: ENTER TYPE OF DOCUMENT. |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
I13g. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT.
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I13h. INTERVIEWER: ENTER THE PERIOD OF PAYMENT. |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR I14a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I14a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I14a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I14a) 0
|
$ | |,| | | |,| | | |
PROFIT 1
LOSS 2
DOES NOT KNOW d
REFUSED r
|
$ | |,| | | |,| | | |
PROFIT 1
LOSS 2
DOES NOT KNOW d
REFUSED r
|
$ | |,| | | |,| | | |
PROFIT 1
LOSS 2
DOES NOT KNOW d
REFUSED r
|
$ | |,| | | |,| | | |
PROFIT 1
LOSS 2
DOES NOT KNOW d
REFUSED r
|
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I13e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I13e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I13e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I13e) 3 DOES NOT KNOW d REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I14a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I14a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I14a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I14a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I14a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I14a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I14a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I14a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I14a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I14a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I14a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I14a) r |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I13i. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH. |
|___|___| NUMBER OF TIMES RECEIVED
|
|___|___| NUMBER OF TIMES RECEIVED
|
|___|___| NUMBER OF TIMES RECEIVED
|
I13j. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT: |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
I13k. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I13l. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING I13b, I13c, AND I13d. THEN COMPUTE THE MONTHLY AMOUNT USING I13g, I13h, AND I13i. IF THERE IS NO DIFFERENCE, CONTINUE TO NEXT PERSON OR I14a. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I14a. IS THERE ANOTHER PERSON?
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I14a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I14a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I14a) 0
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
|___|___| NUMBER OF TIMES RECEIVED
|
|___|___| NUMBER OF TIMES RECEIVED
|
|___|___| NUMBER OF TIMES RECEIVED
|
|___|___| NUMBER OF TIMES RECEIVED
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I14a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I14a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I14a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I14a) 0
|
FARM
BUSINESS PROFIT OR LOSS |
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I14a. INTERVIEWER: WAS THERE FARM INCOME? DOES H15 EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR I15a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I15a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I15a) 0
|
I14b. During MONTH, how much profit or loss did (you/NAME) realize from (your/her/his) own farm? |
$ | |,| | | |,| | | |
EARNING 1
LOSS 2
MONTH 3
DOES NOT KNOW d
REFUSED r
|
$ | |,| | | |,| | | |
EARNING 1
LOSS 2
MONTH 3
DOES NOT KNOW d
REFUSED r
|
$ | |,| | | |,| | | |
EARNING 1
LOSS 2
MONTH 3
DOES NOT KNOW d
REFUSED r
|
I14c. INTERVIEWER: ENTER PERIOD COVERED OR ASK: Was that per week, every two weeks, or per month? |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I14e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I14e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I14e) 3 DOES NOT KNOW d REFUSED r |
114d. How many PERIODS IN I14c of (profit/loss) from (you/PERSON’s) farm did (you/PERSON) receive in MONTH? |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
I14e. May I look at the statement (you/PERSON) received showing the amount of (profit/loss) from (you/PERSON’S) farm received in MONTH?
PROBE: The check stub. |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I15a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I15a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I15a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I15a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I15a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I15a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I15a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I15a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I15a) r |
I14f. INTERVIEWER: ENTER TYPE OF DOCUMENT. |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
I14g. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT.
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I14h. INTERVIEWER: ENTER THE PERIOD OF PAYMENT. |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR I15a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I15a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I15a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I15a) 0
|
$ | |,| | | |,| | | |
EARNING 1
LOSS 2
MONTH 3
DOES NOT KNOW d
REFUSED r
|
$ | |,| | | |,| | | |
EARNING 1
LOSS 2
MONTH 3
DOES NOT KNOW d
REFUSED r
|
$ | |,| | | |,| | | |
EARNING 1
LOSS 2
MONTH 3
DOES NOT KNOW d
REFUSED r
|
$ | |,| | | |,| | | |
EARNING 1
LOSS 2
MONTH 3
DOES NOT KNOW d
REFUSED r
|
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I14e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I14e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I14e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I14e) 3 DOES NOT KNOW d REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I15a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I15a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I15a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I15a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I15a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I15a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I15a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I15a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I15a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I15a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I15a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I15a) r |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I14i. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH. |
|___|___| NUMBER OF TIMES RECEIVED
|
|___|___| NUMBER OF TIMES RECEIVED
|
|___|___| NUMBER OF TIMES RECEIVED
|
I14j. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT: |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
I14k. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I14l. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING I14b, I14c, AND I14d. THEN COMPUTE THE MONTHLY AMOUNT USING I14g, I14h, AND I14i. IF THERE IS NO DIFFERENCE, CONTINUE TO NEXT PERSON OR I15a. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I15a. IS THERE ANOTHER PERSON?
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I15a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I15a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I15a) 0
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
|___|___| NUMBER OF TIMES RECEIVED
|
|___|___| NUMBER OF TIMES RECEIVED
|
|___|___| NUMBER OF TIMES RECEIVED
|
|___|___| NUMBER OF TIMES RECEIVED
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I15a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I15a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I15a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I15a) 0
|
COLLEGE
FINANCIAL AID
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I15a. INTERVIEWER: WAS THERE COLLEGE FINANCIAL AID? DOES H16 EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR I16a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I16a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I16a) 0
|
I15b. How much financial aid for college students did (you/NAME) receive in MONTH? Please exclude money used for tuition, books and fees, but include money used for room and board. |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
I15c. INTERVIEWER: ENTER PERIOD COVERED OR ASK: Was that per week, every two weeks, or per month? |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I15e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I15e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I15e) 3 DOES NOT KNOW d REFUSED r |
115d. How many PERIODS IN I15c of financial aid for college students did (you/PERSON) receive in MONTH? |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
I15e. May I look at the statement (you/PERSON) received showing the amount of financial aid for college students received in MONTH?
PROBE: The check stub. |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I16a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I16a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I16a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I16a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I16a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I16a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I16a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I16a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I16a) r |
I15f. INTERVIEWER: ENTER TYPE OF DOCUMENT. |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
I15g. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT.
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I15h. INTERVIEWER: ENTER THE PERIOD OF PAYMENT. |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
I15i. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH. |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR I16a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I16a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I16a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I16a) 0
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I15e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I15e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I15e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I15e) 3 DOES NOT KNOW d REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I16a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I16a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I16a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I16a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I16a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I16a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I16a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I16a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I16a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I16a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I16a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I16a) r |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I15j. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT: |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
I15k. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I15l. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING I15b, I15c, AND I15d. THEN COMPUTE THE MONTHLY AMOUNT USING I15g, I15h, AND I15i. IF THERE IS NO DIFFERENCE, CONTINUE TO NEXT PERSON OR I16a. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I16a. IS THERE ANOTHER PERSON?
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I16a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I16a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I16a) 0
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I16a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I16a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I16a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I16a) 0
|
SAVINGS
WITHDRAWAL
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I16a. INTERVIEWER: WAS THERE SAVINGS WITHDRAWAL? DOES H17 EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR I17a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I17a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I17a) 0
|
I16b. How much money did (you/NAME) withdraw from savings in MONTH?
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
I16c. INTERVIEWER: ENTER PERIOD COVERED OR ASK: Was that per week, every two weeks, or per month? |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I16e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I16e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I16e) 3 DOES NOT KNOW d REFUSED r |
116d. How many PERIODS IN I16c did (you/PERSON) withdraw money from savings in MONTH? |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
I16e. May I look at the statement (you/PERSON) received showing the amount of money withdrawn from savings in MONTH?
PROBE: The check stub. |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I17a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I17a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I17a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I17a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I17a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I17a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I17a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I17a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I17a) r |
I16f. INTERVIEWER: ENTER TYPE OF DOCUMENT. |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
I16g. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT.
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I16h. INTERVIEWER: ENTER THE PERIOD OF PAYMENT. |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
I16i. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH. |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR I17a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I17a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I17a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I17a) 0
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I16e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I16e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I16e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I16e) 3 DOES NOT KNOW d REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I17a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I17a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I17a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I17a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I17a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I17a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I17a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I17a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I17a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I17a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I17a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I17a) r |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n
|
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I16j. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT: |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
I16k. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I16l. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING I16b, I16c, AND I16d. THEN COMPUTE THE MONTHLY AMOUNT USING I16g, I16h, AND I16i. IF THERE IS NO DIFFERENCE, CONTINUE TO NEXT PERSON OR I17a. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I17a. IS THERE ANOTHER PERSON?
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I17a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I17a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I17a) 0
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I17a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I17a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I17a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I17a) 0
|
CONTRIBUTIONS
FROM OUTSIDE PERSONS
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I17a. INTERVIEWER: WERE THERE CONTRIBUTIONS FROM OUTSIDE PERSONS? DOES H18 EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR I18a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I18a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I18a) 0
|
I17b. How much income from regular contributions from persons outside the household, for example, cash gifts from friends or family did (you/NAME) receive in MONTH? |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
I17c. INTERVIEWER: ENTER PERIOD COVERED OR ASK: Was that per week, every two weeks, or per month? |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I17e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I17e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I17e) 3 DOES NOT KNOW d REFUSED r |
117d. How many PERIODS IN I17c of regular income contributions did (you/PERSON) receive in MONTH? |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
I17e. May I look at the statement (you/PERSON) received showing the amount of regular income contributions received in MONTH?
PROBE: The check stub. |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I18a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I18a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I18a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I18a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I18a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I18a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I18a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I18a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I18a) r |
I17f. INTERVIEWER: ENTER TYPE OF DOCUMENT. |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
I17g. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT.
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I17h. INTERVIEWER: ENTER THE PERIOD OF PAYMENT. |
WEEK 1
TWO WEEKS 2
MONTH 3
OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1
TWO WEEKS 2
MONTH 3
OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1
TWO WEEKS 2
MONTH 3
OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR I18a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I18a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I18a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I18a) 0
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I17e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I17e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I17e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I17e) 3 DOES NOT KNOW d REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I18a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I18a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I18a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I18a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I18a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I18a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I18a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I18a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I18a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I18a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I18a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I18a) r |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
WEEK 1
TWO WEEKS 2
MONTH 3
OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1
TWO WEEKS 2
MONTH 3
OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1
TWO WEEKS 2
MONTH 3
OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1
TWO WEEKS 2
MONTH 3
OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I17i. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH. |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
I17j. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT: |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
I17k. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I17l. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING I17b, I17c, AND I17d. THEN COMPUTE THE MONTHLY AMOUNT USING I17g, I17h, AND I17i. IF THERE IS NO DIFFERENCE, CONTINUE TO NEXT PERSON OR I18a. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I18a. IS THERE ANOTHER PERSON?
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I18a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I18a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I18a) 0
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I18a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I18a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I18a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I18a) 0
|
OTHER
CASH INCOME
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I18a. INTERVIEWER: WAS THERE OTHER CASH INCOME? DOES H19 EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR I19a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I19a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I19a) 0
|
I18b. How much other cash income, such as net royalties, income from trusts, prize winnings, or bonuses did (you/NAME) receive in MONTH? |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
I18c. INTERVIEWER: ENTER PERIOD COVERED OR ASK: Was that per week, every two weeks, or per month? |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I18e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I18e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I18e) 3 DOES NOT KNOW d REFUSED r |
118d. How many PERIODS IN I18c of other cash income did (you/PERSON) receive in MONTH? |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
I18e. May I look at the statement (you/PERSON) received showing the amount of other cash income received in MONTH?
PROBE: The check stub. |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I19a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I19a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I19a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I19a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I19a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I19a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I19a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I19a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I19a) r |
I18f. INTERVIEWER: ENTER TYPE OF DOCUMENT. |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
I18g. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT.
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I18h. INTERVIEWER: ENTER THE PERIOD OF PAYMENT. |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
I18i. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH. |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR I19a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I19a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I19a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I19a) 0
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I18e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I18e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I18e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I18e) 3 DOES NOT KNOW d REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I19a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I19a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I19a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I19a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I19a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I19a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I19a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I19a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I19a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I19a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I19a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I19a) r |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I18j. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT: |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
I18k. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I18l. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING I18b, I18c, AND I18d. THEN COMPUTE THE MONTHLY AMOUNT USING I18g, I18h, AND I18i. IF THERE IS NO DIFFERENCE, CONTINUE TO NEXT PERSON OR I19a. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I19a. IS THERE ANOTHER PERSON?
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I19a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I19a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I19a) 0
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I19a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I19a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I19a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I19a) 0
|
GENERAL
ASSISTANCE
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I19a. INTERVIEWER: WAS THERE GENERAL ASSISTANCE? DOES H20 EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR I20a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I20a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I20a) 0
|
I19b. How much general assistance money did (you/NAME) receive in MONTH?
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
I19c. INTERVIEWER: ENTER PERIOD COVERED OR ASK: Was that per week, every two weeks, or per month? |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I19e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I19e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I19e) 3 DOES NOT KNOW d REFUSED r |
119d. How many PERIODS IN I19c of general assistance did (you/PERSON) receive in MONTH? |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
I19e. May I look at the statement (you/PERSON) received showing the amount of general assistance received in MONTH?
PROBE: The check stub. |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I20a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I20a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I20a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I20a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I20a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I20a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I20a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I20a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I20a) r |
I19f. INTERVIEWER: ENTER TYPE OF DOCUMENT. |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
I19g. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT.
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I19h. INTERVIEWER: ENTER THE PERIOD OF PAYMENT. |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
I19i. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH. |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR I20a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I20a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I20a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I20a) 0
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I19e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I19e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I19e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I19e) 3 DOES NOT KNOW d REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I20a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I20a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I20a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I20a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I20a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I20a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I20a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I20a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I20a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I20a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I20a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I20a) r |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I19j. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT: |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
I19k. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I19l. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING I19b, I19c, AND I19d. THEN COMPUTE THE MONTHLY AMOUNT USING I19g, I19h, AND I19i. IF THERE IS NO DIFFERENCE, CONTINUE TO NEXT PERSON OR I20a. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I20a. IS THERE ANOTHER PERSON?
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I20a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I20a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I20a) 0
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I20a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I20a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I20a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I20a) 0
|
NON-MILITARY
HOUSEHOLD SUBSIDIES |
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I20a. INTERVIEWER: WAS THERE NON-MILITARY HOUSEHOLD SUBSIDIES? DOES H21 EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR I21a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I21a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I21a) 0
|
I20b. How much did (you/NAME) receive in non-military housing subsidies in MONTH?
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
I20c. INTERVIEWER: ENTER PERIOD COVERED OR ASK: Was that per week, every two weeks, or per month? |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I20e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I20e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I20e) 3 DOES NOT KNOW d REFUSED r |
120d. How many PERIODS IN I20c of non-military housing subsidies did (you/PERSON) receive in MONTH? |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
I20e. May I look at the statement (you/PERSON) received showing the amount of non-military housing subsidies received in MONTH?
PROBE: The check stub. |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I21a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I21a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I21a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I21a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I21a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I21a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I21a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I21a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I21a) r |
I20f. INTERVIEWER: ENTER TYPE OF DOCUMENT. |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
I20g. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT.
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I20h. INTERVIEWER: ENTER THE PERIOD OF PAYMENT. |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
I20i. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH. |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR I21a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I21a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I21a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I21a) 0
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I20e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I20e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I20e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I20e) 3 DOES NOT KNOW d REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I21a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I21a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I21a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I21a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I21a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I21a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I21a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I21a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I21a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I21a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I21a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I21a) r |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I20j. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT: |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
I20k. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I20l. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING I20b, I20c, AND I20d. THEN COMPUTE THE MONTHLY AMOUNT USING I20g, I20h, AND I20i. IF THERE IS NO DIFFERENCE, CONTINUE TO NEXT PERSON OR I21a. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I21a. IS THERE ANOTHER PERSON?
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I21a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I21a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I21a) 0
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I21a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I21a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I21a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I21a) 0
|
BLACK
LUNG DISEASE
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I21a. INTERVIEWER: WAS THERE BLACK LUNG BENEFITS? DOES H22 EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR I22a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I22a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I22a) 0
|
I21b. How much in black lung benefits did (you/NAME) receive in MONTH?
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
I21c. INTERVIEWER: ENTER PERIOD COVERED OR ASK: Was that per week, every two weeks, or per month? |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I21e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I21e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I21e) 3 DOES NOT KNOW d REFUSED r |
121d. How many PERIODS IN I21c of black lung benefits did (you/PERSON) receive in MONTH? |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
I21e. May I look at the statement (you/PERSON) received showing the amount of black lung benefits received in MONTH?
PROBE: The check stub. |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I22a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I22a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I22a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I22a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I22a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I22a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I22a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I22a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I22a) r |
I21f. INTERVIEWER: ENTER TYPE OF DOCUMENT. |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
I21g. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT.
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I21h. INTERVIEWER: ENTER THE PERIOD OF PAYMENT. |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
I21i. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH. |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR I22a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I22a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I22a) 0
|
YES 1
NO (GO TO NEXT PERSON OR I22a) 0
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I21e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I21e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I21e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I21e) 3 DOES NOT KNOW d REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I22a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I22a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I22a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I22a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I22a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I22a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I22a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I22a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I22a) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I22a) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I22a) d REFUSED TO SHOW (GO TO NEXT PERSON OR I22a) r |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r
NOT ON DOCUMENT n |
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I21j. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT: |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
I21k. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I21l. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING I21b, I21c, AND I21d. THEN COMPUTE THE MONTHLY AMOUNT USING I21g, I21h, AND I21i. IF THERE IS NO DIFFERENCE, CONTINUE TO NEXT PERSON OR I22a. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I22a. IS THERE ANOTHER PERSON?
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I22a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I22a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I22a) 0
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I22a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I22a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I22a) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I22a) 0
|
OTHER
PUBLIC ASSISTANCE
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I22a. INTERVIEWER: WAS THERE OTHER PUBLIC ASSISTANCE? DOES H23 EQUAL “YES”? |
YES 1
NO (GO TO NEXT PERSON OR I23) 0
|
YES 1
NO (GO TO NEXT PERSON OR I23) 0
|
YES 1
NO (GO TO NEXT PERSON OR I23) 0
|
I22b. How much did (you/NAME) receive in any other kinds of public assistance during MONTH? Please do not include TANF or SNAP benefits; we will ask about that later. |
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
I22c. INTERVIEWER: ENTER PERIOD COVERED OR ASK: Was that per week, every two weeks, or per month? |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I22e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I22e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I22e) 3 DOES NOT KNOW d REFUSED r |
122d. How many PERIODS IN I22c of other kinds of public assistance did (you/PERSON) receive in MONTH? |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
I22e. May I look at the statement (you/PERSON) received showing the amount of other kinds of public assistance received in MONTH?
PROBE: The check stub. |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I23) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I23) d REFUSED TO SHOW (GO TO NEXT PERSON OR I23) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I23) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I23) d REFUSED TO SHOW (GO TO NEXT PERSON OR I23) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I23) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I23) d REFUSED TO SHOW (GO TO NEXT PERSON OR I23) r |
I22f. INTERVIEWER: ENTER TYPE OF DOCUMENT. |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
I22g. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT.
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
I22h. INTERVIEWER: ENTER THE PERIOD OF PAYMENT. |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
YES 1
NO (GO TO NEXT PERSON OR I23) 0
|
YES 1
NO (GO TO NEXT PERSON OR I23) 0
|
YES 1
NO (GO TO NEXT PERSON OR I23) 0
|
YES 1
NO (GO TO NEXT PERSON OR I23) 0
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
$ | | |,| | | |
DOES NOT KNOW d
REFUSED r
|
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I22e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I22e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I22e) 3 DOES NOT KNOW d REFUSED r |
WEEK 1 EVERY TWO WEEKS 2 MONTH (GO TO I22e) 3 DOES NOT KNOW d REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
|___|___| NUMBER OF TIMES RECEIVED
DOES NOT KNOW d
REFUSED r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I23) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I23) d REFUSED TO SHOW (GO TO NEXT PERSON OR I23) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I23) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I23) d REFUSED TO SHOW (GO TO NEXT PERSON OR I23) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I23) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I23) d REFUSED TO SHOW (GO TO NEXT PERSON OR I23) r |
YES 1 DON’T HAVE/ CAN’T FIND (GO TO NEXT PERSON OR I23) 0 DOES NOT KNOW (GO TO NEXT PERSON OR I23) d REFUSED TO SHOW (GO TO NEXT PERSON OR I23) r |
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
STATEMENT 1 CHECK STUB 2 OTHER (SPECIFY) 3
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|,|___|___|___|
NOT ON DOCUMENT n
|
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
WEEK 1 TWO WEEKS 2 MONTH 3 OTHER (SPECIFY) 4
NOT ON DOCUMENT n |
|
________________________________ RESPONDENT | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
I22i. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH. |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
I22j. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT: |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
I22k. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT. |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n |
I22l. INTERVIEWER: COMPUTE THE TOTAL MONTHLY AMOUNT RECEIVED USING I22b, I22c, AND I22d. THEN COMPUTE THE MONTHLY AMOUNT USING I22g, I22h, AND I22i. IF THERE IS NO DIFFERENCE, CONTINUE NEXT PERSON OR TO I23. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO NEXT PERSON OR I23. IS THERE ANOTHER PERSON?
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I23) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I23) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I23) 0
|
I23. INTERVIEWER: IS THERE ANOTHER PERSON TO ASK ABOUT? |
YES (GO TO I2, NAME 2) 1
NO (GO TO J1) 0 |
YES (GO TO I2, NAME 3) 1
NO (GO TO J1) 0 |
YES (GO TO I2, NAME 4) 1
NO (GO TO J1) 0 |
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
________________________________ PERSON NUMBER | | |
|
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| NUMBER OF TIMES RECEIVED
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
|___|___| |___|___| |___|___| MONTH DAY YEAR
NOT ON DOCUMENT n |
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
$ |___|___|___|,|___|___|___|
NOT ON DOCUMENT n
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I23) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I23) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I23) 0
|
YES (GO TO NEXT PERSON) 1
NO (GO TO I23) 0
|
YES (GO TO I2, NAME 2) 1
NO (GO TO J1) 0 |
YES (GO TO I2, NAME 3) 1
NO (GO TO J1) 0 |
YES (GO TO I2, NAME 2) 1
NO (GO TO J1) 0 |
YES (GO TO I2, NAME 3) 1
NO (GO TO J1) 0 |
SECTION J: PUBLIC ASSISTANCE RECEIPT |
J1. The next questions are about participation in other government programs.
During MONTH, did you or anyone else in your household receive (STATE TANF/TANF), Temporary Assistance for Needy Families, also known as cash welfare?
YES 1
NO (GO TO J23) 0
DOES NOT KNOW (GO TO J23) d
REFUSED (GO TO J23) r
J2. Who in your household received (STATE TANF/TANF) benefits in MONTH?
RELATIONSHIP
TO THE CIRCLE ALL
PERSON RESPONDENT THAT APPLY
RESPONDENT 1
PERSON 2: | | | 2
PERSON 3: | | | 3
PERSON 4: | | | 4
PERSON 5: | | | 5
PERSON 6: | | | 6
PERSON 7: | | | 7
PERSON 8: | | | 8
PERSON 9: | | | 9
PERSON 10: | | | 10
PERSON 11: | | | 11
PERSON 12: | | | 12
PERSON 13: | | | 13
PERSON 14: | | | 14
DOES NOT KNOW WHO ELSE (AT LEAST ONE RECIPIENT RECORDED) 15
DOES NOT KNOW d
REFUSED r
J3. INTERVIEWER: DID THE RESPONDENT, SPOUSE, OR CHILDREN/WARDS GET TANF DURING TARGET MONTH? CHECK J2 FOR RELATIONSHIPS CODES 4 AND 5, AND CODES 1, 2, 3, 11, 12, 13 OR 14 WHEN G30 OR G31 HAVE A “YES” FOR THAT HH MEMBER.
YES 1
NO (GO TO J13) 0
J4. How much did [you and your (child/children)/you and your spouse and (child/children)] receive in (STATE TANF/TANF) benefits during MONTH?
$ | |,| | | | TANF
DOES NOT KNOW d
REFUSED r
J5. May I look at the statement you received showing the amount of (STATE TANF/TANF) benefits received in MONTH?
PROBE: The award letter or notification of the amount of (STATE TANF/TANF) benefits you receive.
YES—ALL 1
YES—PARTIAL 2
NO/DOES NOT
HAVE/CAN’T GET
DOCUMENTATION (GO TO J13) 0
DOES NOT KNOW (GO TO J13) d
REFUSED TO SHOW
DOCUMENTATION (GO TO J13) r
J6. INTERVIEWER: ENTER TYPE OF DOCUMENT.
STATEMENT/NOTIFICATION 1
CHECK STUB 2
OTHER (SPECIFY) 3
J7. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT.
$| | |,| | | |
AMOUNT NOT ON DOCUMENT n
J8. INTERVIEWER: ENTER THE PERIOD OF PAYMENT.
WEEK 1
TWO WEEKS 2
MONTH 3
OTHER (SPECIFY) 4
PERIOD NOT ON DOCUMENT n
J9. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH.
| | | | NUMBER OF TIMES RECEIVED
NUMBER OF TIMES NOT ON DOCUMENT n
J10. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT.
| | | | | | | | | PERIOD ENDING DATE
MONTH DAY YEAR
END DATE NOT ON DOCUMENT n
J11. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT.
$| | | |,| | | |
AMOUNT NOT ON DOCUMENT n
J12. INTERVIEWER: COMPUTE THE MONTHLY AMOUNT USING J7, J8, AND J9. COMPARE IT TO THE AMOUNT RECORDED IN J4. IF THERE IS NO MORE THAN $100 DIFFERENCE, OR IF MONTHLY AMOUNT CANNOT BE COMPUTED DUE TO UNAVAILABLE PERIOD, NUMBERS, AMOUNTS, CONTINUE TO J13. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO J13. IF UNRESOLVABLE, CIRCLE CODE AND GO TO J13. CODE RESULT, BELOW.
NO DIFFERENCE OR DIFFERENCE
LESS THAN $100 1
RESOLVED DIFFERENCE(S) TO $100
OR LESS 2
UNRESOLVABLE 3
J13. INTERVIEWER: CHECK J2 FOR OTHER HH MEMBERS WHERE G32 OR G33 HAVE A “YES”. DID OTHER HOUSEHOLD MEMBER(S) RECEIVE TANF DURING TARGET MONTH?
YES 1
NO (GO TO J23) 0
J14. How much in (STATE TANF/TANF) benefits did other members of your household receive in MONTH? (Please do not include the (STATE TANF/TANF) benefits received by you and your spouse.)
$ | | |,| | | | (TANF)
DOES NOT KNOW d
REFUSED r
J15. May I look at the statement showing the amount of (STATE TANF/TANF) benefits other members of your household received in MONTH?
PROBE: The award letter or notification of the amount of (STATE TANF/TANF) benefits received.
YES—ALL 1
YES—PARTIAL 2
NO/DOES NOT HAVE/CAN’T GET
DOCUMENTATION (GO TO J23) 0
DOES NOT KNOW (GO TO J23) d
REFUSED TO SHOW
DOCUMENTATION (GO TO J23) r
J16. INTERVIEWER: ENTER TYPE OF DOCUMENT.
STATEMENT/NOTIFICATION 1
CHECK STUB 2
OTHER (SPECIFY) 3
J17. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT.
$| | |,| | | |
AMOUNT NOT ON DOCUMENT n
J18. INTERVIEWER: ENTER THE PERIOD OF PAYMENT.
WEEK 1
TWO WEEKS 2
MONTH 3
OTHER (SPECIFY) 4
PERIOD NOT ON DOCUMENT n
J19. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH.
| | | NUMBER OF TIMES RECEIVED
NUMBER OF TIMES NOT ON DOCUMENT n
J20. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT.
| | | | | | | | |
MONTH DAY YEAR
END DATE NOT ON DOCUMENT n
J21. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT.
$| | | |,| | | |
AMOUNT NOT ON DOCUMENT n
J22. INTERVIEWER: COMPUTE THE MONTHLY AMOUNT USING J17, J18, AND J19. COMPARE IT TO THE AMOUNT RECORDED IN J14. IF THERE IS NO MORE THAN $100 DIFFERENCE, OR IF MONTHLY AMOUNT CANNOT BE COMPUTED DUE TO UNAVAILABLE PERIOD, NUMBERS, AMOUNTS, CONTINUE TO J23. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO J23. IF UNRESOLVABLE, CIRCLE CODE AND GO TO J23. CODE RESULT, BELOW.
NO DIFFERENCE OR DIFFERENCE
LESS THAN $100 1
RESOLVED DIFFERENCE(S) TO $100
OR LESS 2
UNRESOLVABLE 3
J23. Did you or anyone else in your household receive SNAP benefits during MONTH? Please include electronically transferred benefits.
YES 1
NO (GO TO J46) 0
DOES NOT KNOW (GO TO J46) d
REFUSED (GO TO J46) r
J24. Who in your household received SNAP benefits in MONTH?
RELATIONSHIP
TO THE CIRCLE ALL
PERSON RESPONDENT THAT APPLY
RESPONDENT 1
PERSON 2: | | | 2
PERSON 3: | | | 3
PERSON 4: | | | 4
PERSON 5: | | | 5
PERSON 6: | | | 6
PERSON 7: | | | 7
PERSON 8: | | | 8
PERSON 9: | | | 9
PERSON 10: | | | 10
PERSON 11: | | | 11
PERSON 12: | | | 12
PERSON 13: | | | 13
PERSON 14: | | | 14
DOES NOT KNOW WHO ELSE (AT LEAST ONE RECIPIENT RECORDED) 15
DOES NOT KNOW d
REFUSED r
J25. INTERVIEWER: DID SAMPLE MEMBER, SPOUSE, OR CHILDREN RECEIVE SNAP BENEFITS DURING TARGET MONTH? CHECK J24 FOR RELATIONSHIPS CODES 4 AND 5, AND CODES 1, 2, 3, 11, 12, 13 OR 14 WHEN G30 OR G31 HAVE A “YES” FOR THAT HH MEMBER.
YES 1
NO (GO TO J35) 0
J26. How much did (you/you and your spouse) receive in SNAP benefits in MONTH?
$ | |,| | | | FOOD STAMPS
DOES NOT KNOW d
REFUSED r
J27. May I look at the statement you received showing the amount of SNAP benefits (you/you and your spouse) received in MONTH?
PROBE: The award letter or notification of the amount of SNAP benefits you receive.
YES—ALL 1
YES—PARTIAL 2
NO/DOES NOT HAVE/CAN’T GET
DOCUMENTATION (GO TO J35) 0
DOES NOT KNOW (GO TO J35) d
REFUSED TO SHOW
DOCUMENTATION (GO TO J35) r
J28. INTERVIEWER: ENTER TYPE OF DOCUMENT.
STATEMENT/NOTIFICATION 1
CHECK STUB 2
OTHER (SPECIFY) 3
J29. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT.
$| | |,| | | |
AMOUNT NOT ON DOCUMENT n
J30. INTERVIEWER: ENTER THE PERIOD OF PAYMENT.
WEEK 1
TWO WEEKS 2
MONTH 3
OTHER (SPECIFY) 4
PERIOD NOT ON DOCUMENT n
J31. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH.
| | | NUMBER OF TIMES RECEIVED
NUMBER OF TIMES NOT ON DOCUMENT n
J32. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT.
| | | | | | | | |
MONTH DAY YEAR
END DATE NOT ON DOCUMENT n
J33. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT.
$| | | |,| | | |
AMOUNT NOT ON DOCUMENT n
J34. INTERVIEWER: COMPUTE THE MONTHLY AMOUNT USING J29, J30, AND J31. COMPARE IT TO THE AMOUNT RECORDED IN J26. IF THERE IS NO MORE THAN $100 DIFFERENCE, OR IF MONTHLY AMOUNT CANNOT BE COMPUTED DUE TO UNAVAILABLE PERIOD, NUMBERS, AMOUNTS, CONTINUE TO J35. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO J35. IF UNRESOLVABLE, CIRCLE CODE AND GO TO J35. CODE RESULT, BELOW.
NO DIFFERENCE OR DIFFERENCE
LESS THAN $100 1
RESOLVED DIFFERENCE(S) TO $100
OR LESS 2
UNRESOLVABLE 3
J35. INTERVIEWER: CHECK J24 FOR OTHER HH MEMBERS WHERE G32 OR G33 HAVE A “YES”. DID OTHER HOUSEHOLD MEMBERS RECEIVE SNAP BENEFITS DURING TARGET MONTH?
YES 1
NO (GO TO J46) 0
J36. How much did other members of your household receive in SNAP benefits during MONTH? (Please do not include food stamp benefits received by you and your spouse.)
$ | | |,| | | | FOOD STAMPS
DOES NOT KNOW d
REFUSED r
J37. May I look at the statement showing the amount of SNAP benefits received by other members of your household in MONTH?
PROBE: The award letter or notification of the amount of food stamp benefits received.
YES—ALL 1
YES—PARTIAL 2
NO/DOES NOT HAVE/CAN’T GET
DOCUMENTATION (GO TO J46) 0
DOES NOT KNOW (GO TO J46) d
REFUSED TO SHOW
DOCUMENTATION (GO TO J46) r
J38. INTERVIEWER: ENTER TYPE OF DOCUMENT.
STATEMENT/NOTIFICATION 1
CHECK STUB 2
OTHER (SPECIFY) 3
J39. INTERVIEWER: ENTER AMOUNT SHOWN ON DOCUMENT.
$ | | |,| | | |
AMOUNT NOT ON DOCUMENT n
J40. INTERVIEWER: ENTER THE PERIOD OF PAYMENT.
WEEK 1
TWO WEEKS 2
MONTH 3
OTHER (SPECIFY) 4
PERIOD NOT ON DOCUMENT n
J41. INTERVIEWER: ENTER NUMBER OF TIMES RECEIVED IN MONTH.
| | | NUMBER OF TIMES RECEIVED
NUMBER OF TIMES NOT ON DOCUMENT n
J42. INTERVIEWER: ENTER PERIOD ENDING DATE FROM DOCUMENT.
| | | | | | | | |
MONTH DAY YEAR
END DATE NOT ON DOCUMENT n
J43. INTERVIEWER: ENTER THE YEAR-TO-DATE AMOUNT SHOWN ON THE DOCUMENT.
$| | | |,| | | |
AMOUNT NOT ON DOCUMENT n
J44. INTERVIEWER: COMPUTE THE MONTHLY AMOUNT USING J39, J40, AND J41. COMPARE IT TO THE AMOUNT RECORDED IN J36. IF THERE IS NO MORE THAN $100 DIFFERENCE, OR IF MONTHLY AMOUNT CANNOT BE COMPUTED DUE TO UNAVAILABLE PERIOD, NUMBERS, AMOUNTS, CONTINUE TO J45. IF THERE IS A DIFFERENCE, DISPLAY THE RESULTS AND RESOLVE THE DIFFERENCE WITH THE RESPONDENT, THEN GO TO J45. IF UNRESOLVABLE, CIRCLE CODE AND GO TO J45. CODE RESULT, BELOW.
NO DIFFERENCE OR DIFFERENCE
LESS THAN $100 1
RESOLVED DIFFERENCE(S) TO $100
OR LESS 2
UNRESOLVABLE 3
J45. Did you participate in the Food Distribution Program on Indian Reservations or FDPIR during MONTH?
YES 1
NO 0
DOES NOT KNOW d
REFUSED r
J46. INTERVIEWER: WERE ALL SOURCES OF INCOME DOCUMENTED? CHECK QUESTIONS I2e, I3e, I4e, I5e, I6e, I7e, I8e, I9e, I10e, I11e, I12e, I13e, I14e, I15e, I16e, I17e, I18e, I19e I20e, I21e, I22e, J5, J15, J27, AND J37 FOR ANY QUESTION NOT CODED “1.”
YES (GO TO K1) 1
NO 0
J47. Why are you unable to show me all of the income documents?
CIRCLE ALL
THAT APPLY
REFUSES ON OWN BEHALF/
REFUSES TO SHOW OWN DOCUMENTS 1
REFUSES ON BEHALF OF OTHER
HOUSEHOLD MEMBER(S)/REFUSES
TO SHOW OTHER HOUSEHOLD
MEMBERS’ DOCUMENTS 2
DO NOT HAVE DOCUMENTS 3
CAN’T FIND DOCUMENTS 4
TOO MUCH TROUBLE TO GET/
FIND DOCUMENTS 5
OTHER (SPECIFY) 6
DOES NOT KNOW d
REFUSED r
SECTION K: TOTAL MONTHLY INCOME |
K1. The computer just added up all the income sources you told me about and the total household income in MONTH (including the income of people no longer here) is AMOUNT [TOTAL FROM ALL SOURCES LISTED IN SECTION I]. Does that sound about right?
YES (GO TO K4) 1
NO 0
DOES NOT KNOW (GO TO L1) d
REFUSED (GO TO L1) r
K2. INTERVIEWER: READ OR SHOW RESPONDENT EACH INCOME SOURCE AND AMOUNT AND MAKE ADJUSTMENTS WHERE NEEDED, THEN CONTINUE TO K3.
K3. The revised total income for MONTH is now TOTAL AMOUNT? Does that sound right?
YES 1
NO (GO TO BACK K2 AND
REPEAT PROCEDURES
UNTIL INCOME IS
CORRECT TO THE
RESPONDENT’S
SATISFACTION THEN
CONTINUE TO K4) 0
DOES NOT KNOW d
REFUSED r
K4. Was the TOTAL AMOUNT we just recorded for (your household/TARGET CHILD) in MONTH a usual amount, or was it more or less than the average you expect (your/his/her) monthly income to be this school year?
USUAL AMOUNT (GO TO K6) 1
MORE THAN AVERAGE 2
LESS THAN AVERAGE 3
DOES NOT KNOW (GO TO K6) d
REFUSED (GO TO K6) r
K5. About how much do you expect (your/his/her) usual or normal monthly household income to be over the school year?
$ | | | |,| | | |
DOES NOT KNOW d
REFUSED r
K6. INTERVIEWER: CHECK CONTACT SHEET. IS THE MONTH FOR WHICH INCOME WAS REPORTED THE MONTH HOUSEHOLD SUBMITTED AN APPLICATION?
YES (GO TO L1) 1
NO 0
APPLICATION MONTH NOT AVAILABLE 2
K7. Was the AMOUNT we just recorded for (your household/TARGET CHILD) in MONTH about the same as (your household/his/her) income in APPLICATION MONTH?
YES (GO TO L1) 1
NO 0
DOES NOT KNOW (GO TO L1) d
REFUSED (GO TO L1) r
K8. About how much was (your household/his/her) income in APPLICATION MONTH?
$ | | | |,| | | |
DOES NOT KNOW d
REFUSED r
NO SECTION L IN THIS DOCUMENT
SECTION M: DEMOGRAPHIC CHARACTERISTICS |
M1. Just a few more questions about you. How old are you?
| | | AGE
OR
| | | | | YEAR BORN
DOES NOT KNOW d
REFUSED r
M2. INTERVIEWER: CODE OR ASK: Are you female or male?
FEMALE 1
MALE 2
DOES NOT KNOW d
REFUSED r
M3. Are you currently married, living with a partner to whom you are not married, widowed, divorced, separated, or never married?
CIRCLE ONE
MARRIED 1
LIVING WITH PARTNER TO WHOM
YOU ARE NOT MARRIED 2
WIDOWED 3
DIVORCED 4
SEPARATED 5
SINGLE AND NEVER MARRIED 6
DOES NOT KNOW d
REFUSED r
M4. What is the highest grade or level of school that you have completed?
INTERVIEWER: IF GED, ENTER 12.
| | | HIGHEST GRADE COMPLETED
OTHER (SPECIFY) 0
ASSOCIATES 1
BACHELORS 2
MASTERS 3
Ph.D. 4
LAW DEGREE 5
M.D 6
DOES NOT KNOW d
REFUSED r
M5. Do you consider yourself to be Hispanic or of Latino origin?
PROBE: Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin?
YES 1
NO 0
DOES NOT KNOW d
REFUSED r
M6. Are you American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander or White?
CIRCLE ALL
THAT APPLY
AMERICAN INDIAN OR ALASKA NATIVE 1
ASIAN 2
BLACK OR AFRICAN AMERICAN 3
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER 4
WHITE 5
HISPANIC 6
OTHER (SPECIFY) 7
DOES NOT KNOW d
REFUSED r
M7. Are you a United States citizen?
YES 1
NO 0
DOES NOT KNOW d
REFUSED r
M8. Is TARGET CHILD Hispanic or of Latino origin?
PROBE: Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin?
YES 1
NO 0
DOES NOT KNOW d
REFUSED r
M9. Is (she/he) American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander or White?
CIRCLE ALL
THAT APPLY
AMERICAN INDIAN OR ALASKA NATIVE 1
ASIAN 2
BLACK OR AFRICAN AMERICAN 3
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER 4
WHITE 5
HISPANIC 6
OTHER (SPECIFY) 7
DOES NOT KNOW d
REFUSED r
M10. This is the end of the interview. Thank you very much for participating in our study.
INTERVIEWER: GIVE THE RESPONDENT THE $25.00 GIFT CARD.
TIME INTERVIEW ENDED: | | |:| | | AM 1 HOUR MINUTE PM 2 |
| File Type | application/msword |
| File Title | APEC II HOUSEHOLD SURVEY |
| Subject | CAPI |
| Author | Dorothy Bellow |
| Last Modified By | lywilliams |
| File Modified | 2012-06-27 |
| File Created | 2012-04-23 |
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