UPDATES HIGHLIGHTED: AFI 36-Month Follow-up Questionnaire

ASSETS FOR INDEPENDENCE (AFI)

PROGRAM EVALUATION

INSTRUMENT 1

AFI Follow-up Questionnaire

*Note for review: This 36-month questionnaire has been updated to reflect the change in time period, but otherwise remains the same as the previously approved 12-month follow-up survey. In this document, all updates are highlighted in yellow to indicate a change between the previously approved follow-up survey and the 36-month survey submitted for review.

Table of Contents

1. Demographics 1

2. Financial Service Use 4

3. Current Residence 8

4. Employment 10

5. Household Income and Expenses 13

6. Financial Experience and Assets 16

7. Debts 21

8. Material Hardship 23

9. Social Engagement and Outlook 25

10. Locating Information 29

THE PAPERWORK REDUCTION ACT OF 1995:  Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Before beginning the follow-up interview, the interviewer will read the participant the Follow-Up Survey Introduction, which is included in this package as Attachment I.

1. Demographics

F_Demo1. To confirm I’m speaking with the correct person, please tell me your year of birth. INTERVIEWER: DID RESPONDENT REPORT [FILL DOB]?

1. YEAR CONFIRMED

2. YEAR DIFFERS [ASK TO SPEAK WITH THE PERSON NAMED AS THE RESPONDENT AT BASELINE]

F_Demo2. During your last interview that took place on [FILL: INTERVIEW DATE BASELINE_DT/FIRSTYR_DT], you reported that the highest level of education you completed was [FILL: EDUCATION LEVEL]. Is that still correct?

1. Yes

2. No

F_Demo3. [IF F_DEMO2=NO] What is the highest level of school you have now completed or the highest degree you have now received?

1. Grade 1 to 11 (with fill in for highest grade completed)

2. 12th grade – no diploma

3. GED or alternative credential

4. Regular high school diploma

5. Some college credit, but less than one year of college credit

6. 1 or more years of college credit, but no degree

7. Associate’s degree (for example, AA or AS)

8. License or certificate (for example real estate, medical technician, beautician)

9. Bachelor’s degree or higher (for example, BA or BS)

F_Demo5. During your last interview, your home address was [FILL: ADDRESS]. Are you still living there?

1. Yes

2. No

F_Demo6. [IF F_DEMO5=NO] What is your current home address, including zip code?

ADDRESS

CITY, STATE ZIP

F_Demo7. Which of the following best describes your current marital status? Are you…

1. Currently Married

2. Never married

3. Separated

4. Divorced

5. Widowed

F_Demo8. [IF STATUS=2-5 for F_Demo7] Are you living with a partner?

1. Yes

2. No

F_Demo9. I would like to review the adults we recorded as living or staying with you during your last interview. For each one, let me know if he or she is still there with you. “Living at your address” means every other adult who considers it their current primary residence, or who stays there at least three nights per week, every week. [First/next,] we recorded a [male/female] named [First name] who was your [FILL: relationship]. Is [he/she] still with you at least half-time?

1. Yes

2. No

F_Demo10. Is there anybody else 18 years of age or older living or staying at this address at least three nights per week, every week not including yourself?

1. Yes (loop collect information in grid)

2. No

F_Demo11. How many children under the age of 6 live or stay at this address at least three nights per week, every week? Please include biological, adopted, foster, step and any other children under age 6.

__________________

RANGE: 0-15 [SOFT CHECK IF 6 OR MORE]

F_Demo12. How many children ages 6 to 17 live or stay at this address least three nights per week, every week? Please include biological, adopted, foster, step and any other children between ages of 6 to 17.

__________________

RANGE: 0-15 [SOFT CHECK IF 6 OR MORE]

F_Demo13. [IF F_Demo11>0 or F_Demo12>0]

For how many of the children in the household are you or your spouse/partner legal guardians? ________

RANGE: 0-20 [SOFT CHECK IF 6 OR MORE]

Demo14a. Do you or your spouse/partner have any biological children under age 18 who do NOT live with you at least three nights per week?

1. Yes

2. No

Demo14b. [If Demo10a=YES] How many biological children under age 18 do NOT live with you or your spouse/partner at least three nights per week?

________RANGE: 0-20 [SOFT CHECK IF 6 OR MORE]

2. Financial Service Use

F_FS1. (ADD)IF CONTROL GROUP, ASK: In the past 12 months Since [BASELINE_DT/FIRSTYR_DT], when you most recently completed our survey, have you participated in any individual development account, or IDA program? An IDA program is a matched savings program.

1. Yes

2. No [SKIP TOF_FS3]

F_FS2. [F_FS1=YES] What was the name of that program?

F_FS3. [FOR CONTROL/TREATMENT, ASK] In the past 12 months Since [BASELINE_DT/FIRSTYR_DT], did you participate in any…

	Yes	No	IF YES… How many hours?
a. (ADD) Financial education classes or training seminars where someone explained how to manage your money	1	2
b. (ADD) Home ownership counseling programs where someone explained how to save to buy a home?	1	2
c. Credit counseling programs where someone explained how to manage the money you owe?	1	2
d. (ADD) Small business counseling program where someone explained how to develop a small business plan?	1	2

FS3a. In the past 12 months Since [BASELINE_DT/FIRSTYR_DT], did you receive any…

	Yes	No	IF YES… How much?
a. home ownership financial assistance or down payment program where you received money toward a home purchase? This does not include any funds you may have borrowed that you will need to pay back.	1	2
b. educational assistance or grants. This does not include any funds you may have borrowed that you will need to pay back.	1	2
c. small business financial assistance programs where you received money to start a business? This does not include any funds you may have borrowed that you will need to pay back.	1	2

F_FS4. [FOR ALL TREATMENTS AND FOR CONTROLS WHO ANSWER YES TO F_FS1: FOR EACH ENDORSEMENT FOR F_FS3 a-e, ASK] Did you receive these services from [FILL NAME OF HOST IDA PROGRAM FOR TREATMENTS OR FILL IDA PROGRAM NAME FOR CONTROLS BASED ON RESPONSE TO F_FS2] or from another program?”

1. [FILL IDA PROGRAM NAME: HOST PROGRAM FOR TREATMENTS OR F_FS2 RESPONSE FOR CONTROLS]

2. Another program

3. Both

F_FS5. [IF TREATMENT GROUP] In the past 12 months, did Have you opened an IDA account at FILL SITE?

1. Yes

2. No

F_FS6. [F_FS5=NO] What is the main reason that you haven’t yet opened didn’t open an IDA account? Would you say it was due to….

1. Not having enough time

2. Not having enough money

3. Transportation problems

4. Family problems

5. Not wanting to participate in the program

6. Other [specify]

GO TO NEXT SECTION

F_FS7. During the past 12 months Since [BASELINE_DT/FIRSTYR_DT], did you make a matched withdrawal of savings from your IDA account?

1. Yes

2. No

F_FS8. (ADD) [IF F_FS7=YES] What did you use your IDA matched withdrawals for? [CHECK ALL THAT APPLY.]

	Yes	No
a. home purchase?	1	2
b. home repair or improvement?	1	2
c. primary or secondary education, post-secondary education, job training, or technical education?	1	2
d. business start-up or development?	1	2

F_FS9. [IF F_FS7=NO] Did you withdraw any of your IDA funds without receiving a match?

1. Yes

2. No

F_FS10. [IF F_FS7=YES OR F_FS9=YES] Did you withdraw all of your savings or only some of your savings?

1. All

2. Some

F_FS11. [If F_FS9=YES] Why did you withdraw your savings without receiving a match?

1. To make up for lost income

2. For basic living expenses

3. For house repairs or to buy an appliance

4. For medical expenses

5. For car repairs

6. For school or childcare expenses

7. For special gifts or luxuries

8. Other (Volunteered Specify)

F_FS12. [IF F_FS7=YES OR F_FS9=YES] Is your account now closed?

1. Yes

2. No

3. Current Residence

The next questions are about your housing situation.

CR1. How would you describe your current home? Is it…

1 A single family home

2 An attached home such as an apartment, condo, town house, or duplex

3 A trailer, or

4 Something else

CR1.1 Describe the dwelling where you live.

SPECIFY

CR2. (ADD4 Hous 3a) Do you own or rent the (IF CR1=3 FILL: trailer) home you currently live in? By own, we mean you hold a mortgage on the home or have a deed to the home.

1. Own

2. Rent

3. Other

CR3. [If CR2=OTHER]  How would you describe your current housing situation?

1. Living with family such as parents, in-laws, brother, or sister

2. Living with a friend

3. Neither

CR4. [If CR3=NEITHER] What is your current living situation?

_________________________

DESCRIBE

CR5. [If CR2=OTHER]  Do you help pay for the rent or mortgage of the place where you are living?

1. Yes

2. No

CR6. (SIPP - HOME5) [IF CR2=RENT or CR5=YES..on average] Excluding any rent subsidies, how much do you [or your spouse/partner] currently pay in monthly rent?

CR7. When did you begin living in your current home? Please indicate month (if known) and year

_________________________

MM/YYYY

CR8. (ADD4 modified - HOUS4) [ASK IF CR2=OWN] What was the total price of the house [if CR1=3, FILL: trailer home] when you [IF DEMO5>0, FILL: or others in your household] purchased it?

$_____ Amount (0 – 999,999)

CR9. (ADD4 - MORT1) [IF CR2=OWN] Do you [or your spouse/partner] currently owe money on home mortgage loans for this house?

1. Yes

2. No

CR10. (ADD4 - MORT3) [IF CR8=Yes] How much do you owe on home mortgage loans?

$______ AMOUNT (1 – 999,999)

CR11. [IF CR2=OWN] How much would the home be worth if you were to sell it today?

CR12. (ADD4 - MORT4) [If CR8=YES] How much do you currently pay each month in mortgage payments?

$______ AMOUNT (1 – 10,000)

CR13. (ADD4 modified) On average, how much additional money do you pay each month for gas, water, electricity, and heating oil?

$________________

4. Employment

The next questions are about your employment.

E1. (slightly modified PSID-BCDE1) Are you currently working now, looking for work, retired, keeping house, a student, or doing something else?

1. Working now

2. Temporarily laid off, sick, or maternity leave

3. Unemployed

4. Retired

5. Disabled, permanently or temporarily

6. Keeping house

7. Student

8. Something else

E2. [IF E1=3] Are you currently looking for work?

1. Yes

2. No

E3. (PSID-BCDE3) [If E1=2-8] Are you doing any work for money now?

1. Yes

2. No

E4. (PSID-BCDE3A) [If E3=NO] Have you done any work for money in the past 12 months?

1. Yes

2. No (GO TO NEXT SECTION)

E5. (PSID-modified BCDE14B) [IF E1=1 or E3=1]How many weeks did you were you employed at any job in the past 12 months? Please include weeks that were covered by paid vacation or disability.

E6. (PSID-BC22) People who are self-employed find their own work or sales, or carry on a trade or business. Are you self-employed?

E6.1 (If E6=yes) Do you employ other workers?

E6.2 (If E6.1=yes) How many workers do you employ?

E7. Are you working for any company as a paid employee?

1. Yes

2. No

E8. [IF E7=YES] How many employers do you currently work for?

(If >1, then use the term “main job” where appropriate in subsequent questions)

NOTE: If E8>1, ANSWER E10-E17 for up to 2 secondary jobs.

E9. How many hours per week do you usually work at all jobs combined?

E10. [IF E8>1] How many hours per week do you usually work (if E8>1; FILL at all jobs combined)? If your hours vary from week to week, report the average.

E11. In what month and year did you begin working at your current (fill main/secondary) job?

MONTH:________ YEAR:________________

E12. (PSID-BC29) On your (main/secondary) job, are you salaried, paid by the hour, or something else?

1. Salaried

2. Salary+commission

3. Paid by hour

4. Hour+tips

5. Hourly+commission

6. Other

E13. (PSID-BC38) [If E12=6] How is that?

1. Piecework, hourly+piecework/production

2. Commission

3. Self-employed, farmer, “profits” – draw on account

4. By the job/day/mile

5. other

E14. (PSID-BC30) [If E12=1 or 2] (On your main/secondary job) How much is your salary?

_________________________

(ENTER amount and time unit)

PER HOUR

PER DAY

PER WEEK

PER MONTH

ETC.

E15. (PSID-BC33) [If E12=3, 4, or 5] (On your main/secondary job) What is your hourly wage rate for your regular work time?

_________________________

(ENTER amount)

E16. (PSID-BC36) [If E12=4] (On your main/secondary job) How much are your tips, on average?

_________________________

(ENTER amount and time unit)

E17. (PSID-BC37) [If E10=2 or 5] (On your main/secondary job) How much is your commission, on average?

_________________________

(ENTER amount and time unit)

E18. [IF ONE OR MORE OTHER ADULTS IN HOUSEHOLD] Is any other adult in your household employed?

NOTE: Show grid of other adults and allow a check employment section column with yes/no responses.

5. Household Income and Expenses

The next questions are about your household income and selected expenses.

HI1. (ISIS modified) In the past month, did you or anyone in your household have income or benefits from any of the following sources?

	Yes	No
a. Job earnings?	1	2
b. WIC?	1	2
c. Food stamps (also known as Supplemental Nutrition Assistance Program--SNAP)?	1	2
d. Free or reduced price school lunch program?	1	2
e. SSI or Supplemental Security Income	1	2
f. Public assistance or welfare (not including WIC or food stamps)?	1	2
g. Housing choice voucher (known as Section 8) or public housing?	1	2
h. Energy assistance	1	2
i. Child care subsidy	1	2
j. Medicaid or the Children’s Health Insurance Program	1	2
k. Unemployment insurance?	1	2
l. Worker’s compensation, disability?	1	2
m. Receive child support (official or unofficial)?	1	2
o. Receive from family and friends? (outside the household)	1	2

HIa. DISPLAY INCOME AND BENEFIT OPTIONS WHERE RESPONDENT SELECTED YES IN HI1: About how much did you or anyone in your household receive from the following sources in the past month?	Amount in the Past Month	Don’t Know/Refused
a. Job earnings?	$
b. WIC?	$
c. Food stamps (also known as Supplemental Nutrition Assistance Program--SNAP)?	$
d. Free or reduced price school lunch program?	$
e.  SSI or Supplemental Security Income	$
f. Public assistance or welfare (not including WIC or food stamps)?	$
g. Housing choice voucher (known as Section 8) or public housing?	$
h. Energy assistance	$
i. Child care subsidy	$
k. Unemployment insurance?	$
l. Worker’s compensation, disability?	$
m. Receive child support (official or unofficial)?	$
o. Receive from family and friends? (outside the household)	$

HI2a. In the past month, did you or anyone in your household pay child support, official or unofficial?

HI2b. In the past month, did you or anyone in your household give money to family or friends living outside your household?

H13a. [IF H12a = yes] In the past month, how much did you or anyone in your household pay for child support, official or unofficial?

Don’t know/Refused options will be allowed if respondent does not know amount or range.

H13b. [IF H12b = yes] In the past month, how much did you or anyone in your household give to family or friends living outside your household?

Don’t know/Refused options will be allowed if respondent does not know amount or range.

HI4. (ADD4 - INAS2) What was the total combined income of your household in FILL PREVIOUS CALENDAR YEAR? Please include money from jobs, net income from business, farm or rent, pensions, dividends, welfare, social security payments and any other money income received by you or any other member of your household.

$ ________ Amount – (0 – 500,000)

HI5. [IF HI3=REF OR DK] Please provide your best estimate of your total combined household income in [FILL PREVIOUS CALENDAR YEAR].

1. $0

2. $1 to $9,999

3. $10,000 to $14,999

4. $15,000 to $19,999

5. $20,000 to $24,999

6. $25,000 to $29,999

7. $30,000 to $34,999

8. $35,000 to $39,999

9. $40,000 to $44,999

10. $45,000 to $49,999

11. $50,000 to $59,999

12. $60,000 to $69,999

13. $70,000 to $79,999

14. $80,000 or over

Don’t know/Refused options will be allowed if respondent does not know amount or range.

6. Financial Experience and Assets

The next questions ask about your financial and life experiences in the past year.

FE1. Did you or anyone else in the household experience any of the following in the past 12 months since [BASELINE_DT/FIRSTYR_DT]?

	Yes	No
a. marriage	1	2
b. divorce	1	2
c. birth of a child	1	2
d. health condition that affected your ability to work	1	2
e. start a new job	1	2
f. lose a job	1	2
g. change jobs	1	2
h. experience a wage increase	1	2
i. experience a wage decrease	1	2
j. experience an increase in the hours worked	1	2
k. experience a decrease in the hours worked	1	2
l. pay off or pay down a debt	1	2
n. incur a major unexpected expense (e.g., car repair, home repair, or medical expense)	1	2

The next questions ask about the value of assets that you own….

FE2. (SCF) Do you or your spouse/partner own any cars, or any kind of truck, van or sport utility vehicle (SUV)? Do not include motorcycles, tractors, snow blowers, etc. or any vehicles owned by a business.

1. Yes

2. No

FE3. (SCF) [If FE2=YES] Altogether, how many such cars or vehicles do you and your spouse/partner own?

ANSWER F4-F5D FOR EACH VEHICLE

FE4. (SCF) What type of vehicle is it?

1. Car

2. Van/minivan

3. Sport utility vehicle (SUV)

4. Pickup

5. Truck, other than a pickup

6. Other

FE5a. (SCF) What make is the [FILL: car/van/SUV/pickup/truck/vehicle]?

DROP DOWN LIST OF MAKE

FE5b. (SCF) What model is the [FILL car/van/SUV/pickup/truck/vehicle]?

DROP DOWN LIST OF MODEL

FE5c. (SCF) What model year is [[FILL car/van/SUV/pickup/truck/vehicle]?

DROP DOWN LIST OF YEARS

FE5d. How much is owed on that [FILL car/van/SUV/pickup/truck/vehicle]?

$ ________ Amount – (0 – 500,000)

1. $0

2. $1 to $4,999

3. $5,000 to $9,999

4. $10,000 to $14,999

5. $15,000 to $19,999

6. $20,000 to $24,999

7. $25,000 to $29,999

8. $30,000 to $34,999

9. $35,000 or over

Don’t know/Refused options will be allowed if respondent does not know amount or range.

END LOOP

FE6a. (PSID - W10) Do you or spouse/partner currently own part or all of a farm or business?

1. Yes

2. No

3. I don’t know

FE6b. [IF FE6a=YES] How much is owed on that farm or business?

$ ________ Amount – (0 – 500,000)

1. $0

2. $1 to $4,999

3. $5,000 to $9,999

4. $10,000 to $14,999

5. $15,000 to $19,999

6. $20,000 to $24,999

7. $25,000 to $29,999

8. $30,000 to $34,999

9. $35,000 to $39,999

10. $40,000 to $44,999

11. $45,000 to $49,999

12. $50,000 to $59,999

13. $60,000 to $69,999

14. $70,000 to $79,999

15. $80,000 or over

Don’t know/Refused options will be allowed if respondent does not know amount or range.

FE6c. [IF FE6a=YES] How much would it be worth if it were sold today?

$ ________ Amount – (0 – $500,000)

Don’t know/Refused options will be allowed if respondent does not know amount or range.

FE7a. Do you or spouse/partner currently own other real estate, such as a rental property, other houses, or land?

1. Yes

2. No

3. I don’t know

FE7b. [IF FE7a=YES] How much is owed on that other real estate?

$ ________ Amount – (0 – $500,000)

1. $0

2. $1 to $4,999

3. $5,000 to $9,999

4. $10,000 to $14,999

5. $15,000 to $19,999

6. $20,000 to $24,999

7. $25,000 to $29,999

8. $30,000 to $34,999

9. $35,000 to $39,999

10. $40,000 to $44,999

11. $45,000 to $49,999

12. $50,000 to $59,999

13. $60,000 to $69,999

14. $70,000 to $79,999

15. $80,000 or over

Don’t know/Refused options will be allowed if respondent does not know amount or range.

FE7c. [IF FE7a=YES] How much would it be worth if it were sold today?

$ ________ Amount – (0 – $500,000)

Don’t know/Refused options will be allowed if respondent does not know amount or range.

The next questions are about different ways people save money.

FE8. (ADD 4 series) Do you or your spouse/partner currently have money in …	Yes	No
an Individual Development Account (IDA)? [ask if YES to FSI or F_FS1]	1	2
b. a checking account?	1	2
c. a savings account?	1	2
d. a money market account?	1	2
e. certificates of deposit or CDs?	1	2
f. retirement accounts like IRAs, 401(k), 403(b), or other pension plans at work?	1	2
g. special educational accounts for your children?	1	2
h. U.S. gov’t savings bonds?	1	2
i. stocks, bonds, or mutual funds?	1	2
j. other kinds of savings (e.g., saved at home, saved with trusted friends or family members)? What kind of savings is that?____________________	1	2

FE8a. (ADD 4 series) DISPLAY OPTIONS WHERE RESPONDENT SELECTED YES IN FE8: About how much do you or your spouse/partner currently have in the following accounts…	Current Amount	Don’t know/Refused
an Individual Development Account (IDA)? [ask if YES to FS1 or F_FS1]	1
b. a checking account?	1
c. a savings account?	1
d. a money market account?	1
e. certificates of deposit or CDs?	1
f. retirement accounts like IRAs, 401(k), 403(b), or other pension plans at work?	1
g. special educational accounts for your children?	1
h. U.S. gov’t savings bonds?	1
i. stocks, bonds, or mutual funds?	1
j. other kinds of savings (e.g., saved at home, saved with trusted friends or family members)? What kind of savings is that?____________________	1

FE9. Do you or your spouse partner have a “whole life”, “universal life” or “cash-value” policy? These policies pay a death benefit, but they also build up a value as premiums are paid.  Do not include a term insurance policy, which only pays a death benefit.

1. Yes

2. No

FE9b. [If FE9a=YES] What is the total cash value of these policies?

The cash value of a policy is what the insurance company would pay if the policy were surrendered before death? $_________Amount (0-500,000)

Don’t know/Refused options will be allowed if respondent does not know amount or range.

7. Debts

The next questions are about loans you may have received…

D1. In the past 12 months, have you or your spouse/partner...	Yes	No	IF YES, “In the past 12 months have you done this…” WITH DROP-DOWN LIST: Once, 2-4 times, 5 or more times
a. taken out a payday loan or used payday advance services?	1	2
b. taken out an auto title loan?	1	2
c. sold items at a pawn shop?	1	2
d. gone to a check cashing store to cash checks?	1	2

D2. [ASK IF FE10 a, b, or c=YES] Thinking about the past 12 months, what was the MAIN reason you or your spouse/partner needed to use a payday loan, auto title loan, or a pawn shop? Was it:

1. To make up for lost income

2. For basic living expenses

3. For house repairs or to buy an appliance

4. For medical expenses

5. For car repairs

6. For school or childcare expenses

7. For special gifts or luxuries

8. Other (Volunteered Specify)

The next questions are about how much money you or your spouse/partner currently owe on loans and credit cards IN TOTAL. Please remember to count a bill or loan only once.

D3. (ADD4 series) Do you currently owe any money on…	Yes	No	Approximately how much do you owe in total?	Don’t know/Refused
a. educational or school loans?	1	2	$
b. personal loans from banks or credit unions?	1	2	$
c. personal loans from friends or relatives?	1	2	$
d. payday loans?	1	2	$
e. auto title loans? Auto title loans are loans where a car title is used to borrow money for a short period of time. They are NOT loans used to purchase an automobile.	1	2	$
f. store credit loans?	1	2	$
g. credit cards or charge cards?	1	2	$
h. debt consolidation loans or bills owed to collection agencies?	1	2	$
i. installment loans for major purchases like furniture or appliances?	1	2	$
j. medical procedures like surgeries or outpatient procedures?	1	2	$
k. Other, please specify__________________	1	2	$

8. Material Hardship

The following are some of the specific difficulties people experience with household expenses.

MH1. Getting enough food can be a problem for some people.  Which of these statements best describes the food eaten in your household in the past 6 months?  Would you say there is . . .

1. Enough of the kinds of food you want

2. Enough but not always the kinds of food you want

3. Sometimes not enough to eat

4. Often not enough to eat

MH2. (ADD4 – ECON2) When it comes to making ends meet, how much help did your household get in the past 12 months from food pantries, churches, family services, or other organizations? Did you get . . .

1. No help at all

2. Some help, or

3. A lot of help

MH3. Was there any time in the past 12 months when:

	Yes	No	IF YES: Did this occur in the most recent six months?
a. you did not pay the full amount of the rent or mortgage because you could not afford it?	1	2	Y/N
b. The bank or mortgage company foreclosed on your mortgage?	1	2	Y/N
c. you were evicted from your home or apartment for not paying the rent or mortgage?	1	2	Y/N
d. you filed in court for personal bankruptcy?	1	2	Y/N
e. you were not able to pay the full amount of the gas, oil, or electricity bills?	1	2	Y/N
f. the gas or electric company turned off service, or the oil company could not deliver oil?	1	2	Y/N
g. the telephone company disconnected service because payments were not made?	1	2	Y/N
h. you or someone else in your household needed to see a doctor or go to the hospital but did not go because you could not afford it?	1	2	Y/N
i. you or someone else in your household needed to see a dentist but did not go because you could not afford it?	1	2	Y/N
j. you or someone else in your household could not fill or postponed filling a prescription for drugs when they were needed because you could not afford it?	1	2	Y/N

MH4. In the past 12 months, have you applied for a loan?

1. Yes

2. No

MH5. [IF MH4=YES] In the past 12 months, have you been turned down for a loan due to a poor credit score?

1. Yes

2. No

9. Social Engagement and Outlook

Next are some questions about your health, involvement with your community, and future outlook.

General Health	Poor	Fair	Good	Very Good	Excellent
SE1. In general, would you say your health is…	0	1	2	3	4

SE2. (Rosenberg's Self-Esteem Scale) Please tell us if you strongly disagree, disagree, agree, or strongly agree with the following statements.

Outlook	Strongly Disagree	Disagree	Agree	Strongly Agree
a. On the whole, I am satisfied with myself.	1	2	3	4
b. At times, I think I am no good at all.	1	2	3	4
c. I feel that I have a number of good qualities.	1	2	3	4
d. I am able to do things as well as most other people.	1	2	3	4
e. I feel I do not have much to be proud of.	1	2	3	4
f. I certainly feel useless at times.	1	2	3	4
g. I feel that I’m a person of worth, at least on an equal plane with others.	1	2	3	4
h. I wish I could have more respect for myself.	1	2	3	4
i. All in all, I am inclined to feel that I am a failure.	1	2	3	4
j. I take a positive attitude toward myself.	1	2	3	4

SE3. (Add CIV_1) During the past 12 months, have you. . .

	Yes	No
a. volunteered, attended an event, or helped raise money for a church, a school, or any other community organization? [If a = Yes] How many times? ____________ (1 – 200)	1	2
b. worked on a neighborhood project? [If b = Yes] How many times? ____________ (1 – 200)	1	2

SE4. On a scale of 1 to 10, how often do you worry about being able to meet normal monthly living expenses? (1means “never”, 10 means “all the time”)

________ (1 – 10)

SE5. (ADD3-39) Overall, how hard or easy is it to make ends meet?  Would you say it is...

1. Very hard

2. Hard

3. Neither hard nor easy

4. Easy

5. Very easy

SE6. (ADD3-36) In the past 12 months, has your financial situation gotten better, gotten worse, or stayed the same?

1. Gotten better

2. Gotten worse

3. Stayed the same

SE7. (DAHFS modified) Suppose that your refrigerator breaks down and you have to replace it.  When you go to the store, you have the choice between paying now or paying later.  If you pay now, the refrigerator will cost $200.  If you pay 12 months from now, it will cost more than that.  Now suppose your overall income next year will be exactly the same as this year. Would you prefer to pay two hundred dollars now or two hundred ten ($210) dollars a year from now?

1. $200 NOW (GO TO next section)

2. $210 ONE YEAR FROM NOW

3. DK (GO TO next section)

4. RF (GO TO next section)

SE8. (DAHFS modified) Would you prefer to pay two hundred dollars now or two hundred twenty ($220) dollars a year from now?

1. $200 NOW (GO TO next section)

2. $220 ONE YEAR FROM NOW

3. DK (GO TO next section)

4. RF (GO TO next section)

SE9. (DAHFS modified) Would you prefer to pay two hundred dollars now or two hundred twenty ($250) dollars a year from now?

1. $200 NOW (GO TO SE10)

2. $250 ONE YEAR FROM NOW (GO TO SE11)

3. DK (GO TO SE10)

4. RF (GO TO next section)

SE10. (DAHFS modified) Would you prefer to pay two hundred dollars now or two hundred thirty-five ($235) dollars a year from now?

1. $200 NOW (GO TO next section)

2. $235 ONE YEAR FROM NOW (GO TO next section)

3. DK (GO TO next section)

4. RF (GO TO next section)

SE11. (DAHFS modified) Would you prefer to pay two hundred dollars now or three hundred ($300) dollars a year from now?

1. $200 NOW (GO TO SE12)

2. $300 ONE YEAR FROM NOW (GO TO next section)

3. DK (GO TO SE12)

4. RF(GO TO next section)

SE12. (DAHFS modified) Would you prefer to pay two hundred dollars now or two hundred seventy five ($275) dollars a year from now?

1. $200 NOW

2. $275 ONE YEAR FROM NOW

3. DK

4. RF

10. Locating Information

LOC1. Now I'd like to confirm your full name and contact information. Please remember that everything you tell me is voluntary and will be kept confidential in the ways that were explained to you at the beginning of the interview. (ENTER 1 TO CONTINUE)

LOC2. I'd like to verify your name. Is it...[Insert Name] INTERVIEWER: READ NAME AND CORRECT AS NEEDED.

LOC3. Let me verify your address. [Insert Address]

Is this address correct?

1. YES – Go to LOC_4

2. NO – Go to LOC_3a

LOC3a. What is your correct home address? STREET ADDRESS:

_______________________

LOC3b. CITY: ___________________________________

LOC3c. STATE: _________________________________

LOC3d. ZIP CODE: _______________________________

LOC4. What is the best phone number to reach you? In a few weeks, someone may be contacting you to verify the quality of my work. (INTERVIEWER: ENTER THE RESPONDENT'S HOME NUMBER OR THE NUMBER WHERE HE/SHE CAN BE REACHED MOST OFTEN.)

PHONE NUMBER: _______________________________________

LOC4a. Is this your day or evening phone number or both?

1. DAY

2. EVENING

3. BOTH

LOC4b. Is this your home phone number, work phone number, or some other number?

1. HOME NUMBER

2. WORK NUMBER

3. FRIEND/RELATIVE'S NUMBER

4. CELL PHONE / BEEPER / PAGER NUMBER

5. OTHER – Go to LOC_4b1

LOC4b1. SPECIFY OTHER TYPE OF PHONE NUMBER: _______________________

LOC4c. Is there another phone number where you can be reached?

1. YES – Go to LOC_4c1

2. NO – Go to LOC_4d

LOC4c1. Please give me that telephone number.

ALTERNATIVE PHONE NUMBER: _________________

LOC4c2. Is this your day or evening phone number or both?

1. DAY

2. EVENING

3. BOTH

LOC4c3. Is this your home phone number, work phone number, or some other number?

1. HOME NUMBER

2. WORK NUMBER

3. FRIEND/RELATIVE'S NUMBER

4. CELL PHONE / BEEPER / PAGER NUMBER

5. OTHER – Go to LOC_4c4

LOC4c4. INTERVIEWER: SPECIFY OTHER TYPE OF PHONE NUMBER.________________

LOC4d. What is your email address? We will not share it with anyone.

EMAIL:_______________ (ALLOW 70 CHARACTERS)

LOC5. We are collecting contact information on close friends or family members who don't live with participants in case we have problems getting in touch with you. Is there someone who does not live with you who can always reach you?

1. YES – Go to LOC_6

2. NO – Go to LOC_9a

LOC6. What is that person's name?

NAME:________________________________

LOC7. What is this person's relationship to you?

1. SPOUSE OR SIGNIFICANT OTHER

2. PARENT

3. SON/DAUGHTER

4. BROTHER OR SISTER

5. FRIEND

6. OTHER – Go to LOC_7oth

LOC7oth. INTERVIEWER: PLEASE SPECIFY OTHER RELATIONSHIP_____________________

LOC8a. What is this person's home address? STREET ADDRESS:
______________________

LOC8b. CITY:______________________________________

LOC8c. STATE: ____________________________________

LOC8d. ZIP CODE: _________________________________

LOC9. What is this person's telephone number?
___________________

LOC9a. For verification purposes, can I have your date of birth?

________/_________/_________

LOC10. We've reached the end of the interview. Thank you very much for this information and for your participation.