Survey Instrument

Questionnaire
for Annual Survey of Refugees
Questionnaire for Annual Survey of Refugees - Year 4

OMB Number: 0970-0033
OMB Number:
0970-0033
Expiration Date
xx/xx/xxxx

Expiration Date: 12/31/2006

QUESTIONNAIRE FOR
ANNUALSURVEY
OF
REFUGEES
NOTE: For the re-interview cases, items Q.la thru Q.Ik should only be used for verification . In
addition, items marked with asterisk, Q2a*, Q.26*, Q .3a*-Q3d*, Q.4a*, Q.4c*, and
Q.4d* should not be re-administered. Refer to ASR Training Manual.
Office of Refugee Resettlement
Administration for Children and Families
Department of Health and Human Services
ASR-1

INTRODUCTORY STATEMENT
We are with DB Consulting Group, Inc. We are calling in connection with a survey that we are
conducting for the U .S . Office of Refugee Resettlement concerning the adjustment to life in the
United States of refugees and certain other recent immigrants.
About two weeks ago we sent you a letter describing this survey. As indicated in that letter, any
information that you give us will be held in confidence and will be used for statistical purposes only .
Today we would like to talk to you further about your life in this country.
If you have no questions, we would like to proceed with the interview .
ORR-9
Public reporting burden for this collection of information is estimated to average 40 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 .
Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to : Reports Clearance Office, Administration for
Children and Families, Department of Health and Hunan Services, 370 L'Enfant Promenade,
Washington, D .C . 20447 ; and to: Office of Management and Budget, Paperwork Reduction Project,
OMB Control Number 0970-0033, Washington, D .C . 20403 .

ENGLISH

DB Consulting Group, Inc

Questionnaire for Annual Survey of Refugees

Questionnaire for Annual Survey of Refugees

Questionnaire for Annual Survey of Refugees - Year 4

Questionnaire for Annual Survey of Refugees-Year 4

TRACKING AND VALIDATION FORM
Household ID Number

TRACKING AND VALIDATION FORM
Household ID Number

Interviewer's Name

Code

Date of Interview

/

/

/

Interviewer's Name

/

Code

Date of Interview

Month Day Year

/

I

I

/

Month Day Year

Time Interview Started

AM PM
. Hours Minutes

Time Interview Started

ATTEMPTS TO CONTACT INTERVIEWEE

AM PM
. Hours Minutes

ATTEMPTS TO CONTACT INTERVIEWEE

1.

5.

9.

1.

5.

9.

2.

6.

10.

2.

6.

10 .

3.

7.

3.

7.

4.

8.

4.

8.

TOTAL NUMBER OF ATTEMPTS TO CONTACT INTERVIEWEE

TOTAL NUMBER OF ATTEMPTS TO CONTACT INTERVIEWEE

NAME OF RESPONDENT

NAME OF RESPONDENT

Last

Middle

First

CURRENT ADDRESS

Last

Middle

First

CURRENT ADDRESS

Street#

Street Name

City

State

Apt.#
Zip Code

TELEPHONE

Street#

Street Name

City

State

Apt.#
Zip Code

TELEPHONE ~)

DB Consulting Group, Inc

DB Consulting Group, Inc

Questionnaire for Annual Survey of Refugees

Questionnaire for Annual Survey of Refugees- Year 4

HOUSEHOLD ID# USE

Questionnaire for Annual Survey of Refugees
Questionnaire for Annual Survey of Refugees - Year 4

HOUSEHOLD CONTROL CHART

We would like to start by asking you a few questions about each person who lives here, or who
is staying or visiting here and has no other home. Let us start with the person who has overall
responsibility, that is the person in whose name your home is rented, owned, or is being
bought: the head of the household. (RECORD ANSWERS ON ATTACHED HOUSEHOLD
CONTROL CHART) .
a.

What is the name of the Head of the household, and of each of the other members of the
household?
(PROBE: ARE THERE OTHER PERSONS WHO USUALLY LIVE HERE BUT ARE
TEMPORARILY ABSENT?)
FOR EACH HOUSEHOLD MEMBER ASK (VERIFY) :

b . What is . . . relationship to the head of household?
c. What is . . . current marital status?

Use the Household Control Chart

01 Now married (note : spouse need not live in household)
02 Divorced
03 Legally separated
04 Never married
05 Widowed
06 Other (SPECIFY)
d. What was . . . age at last birthday?
e. What was ... date of birth?
f. Is . . . male or female?
g. What is . . . country of birth?
h. What is . . . country of citizenship?
i . What is .. . ethnic origin?
j . What month and year did . .. enter the U.S . to stay?
k. In what State did . . . originally resettle?

DB Consulting Group, Inc

DB Consulting Group, Inc

Questionnaire for Annual Survey of Refugees
Questionnaire for Annual Survey of Refugees-Year 4
Now I want to ask some questions only of persons in your household who are 16 years old or older.

Questionnaire for Annual Survey of Refugees
Questionnaire for Annual Survey of Refugees-Year 4

Q .2b* What was the highest degree or certificate that . . . obtained before coming to the U.S
.?

HOUSEHOLDID#
Q.2a*Howmany years?
(-1) if 1 year or less
-9 DK/ -8 RA/ -7 NA
Q.2b*

Q.3a* Before coming to the U.S ., was . . . : (If in a refugee camp prior to the U.S., what type of
employment did the person hold before that?)

(0 1) None
(02) Primary
(03) Training in refugee camp
(04) Technical school
certification
(05) Secondary (or high school
diploma)
(06) University degree (other
than medical)
(07) Medical degree
(08) Other (SPECIFY)
-9 DK/ -8 RA / -7 NA
Q.3a*
FOLLOW SHIP PATTERN

Q .2a* How many years of schooling did . . . complete before coming to the U .S
.?

01
None
02
Primary
03
Training in refugee camp
04
Technical school certification
05
Secondary (or high school diploma)
06
University degree (other than medical)
07
Medical degree
08
Other (SPECIFY)
(-9) DKI (-8) RA/ (-7) NA

01
Not employed (skip to Q3d)
02
Civil servant (civilian in local or national government)
03
In the military
04
Employee in private sector
05
Self-employed
06
Student
07
Other (SPECIFY)
(-9) DK/ (-8) RA/ (-7) NA

(01) Not employed (skip to Q .3d)
(02) Civil servant. . .
(03) In the military
(04) Employee in private sector
(05) Self-employed
(06) Student
(07) Other (SPECIFY)
-9 DK / -8 RA / -7 NA

1
- years
-1
-9-8-7

2
- years
-1
-9-8-7

3
- years
-1
-9-8-7

01
02
03
04

01
02
03
04

05
06
07
08
-9-8-7

07

01
02
03
04
05
06
-9-8-7

Q .3b* What kind of work (activities) did . . . perform before coming to the U .S .? (e .g., lawyer, typist,
farmer, teacher, electrician, student)

Q3b*
(-9) DK / (-8) RA / (-7) NA

Q3c* What were the most important activities or duties in this job?

Q3c*
(-9) DK / (-8) RA / (-7) NA

Q3d* Was . . . in a prison or reeducation camp prior to coming to the U .S
.?

Q.3d*
(01) No
Yes . How long was . . . there?

weeks

(-1) if 1 week or less
(-9) DK / (-8) RA / (-7) NA

-9-8-7

01

No
Yes . How long was . . . there?

DB Consulting Group, Inc

01

4
- years
-1
-9-8-7

5
- years
-1
-9-8-7

01
02
03
04

01
02
03
04

01
02
03
04

05

05

05

05

06

06

06

06

07
08
-9-8-7

07

01
02
03
04
05
06
-9-8-7

07
08
-9-8-7

07

01
02
03
04
05
06
-9-8-7

_

07
08
-9-8-7

07

01
02
03
04
05
06
-9-8-7

07
08
-9-8-7

07

01
02
03
04
05
06
-9-8-7

01

01

01

01

weeks
-1
-9-8-7

weeks
-1
-9-8-7

weeks
-1
-9-8-7

weeks
-1
-9-8-7

DB Consulting Group, Inc

Questionnaire for Annual Survey of Refugees

Questionnaire for Annual Survey of Refugees

Questionnaire for Annual Survey of Refugees - Year 4

QAa* At the time of arrival in the U.S ., how well did . .. speak English?
01 Very well
02 Well
03 Not well
04 Not at all
(-9) DK/ (-8) RA/ (-7) NA

Questionnaire for Annual Survey of Refugees-Year 4

HOUSEHOLD 1D#
QAa*

(01)Very well
(02) W ell
(03) Not well
(04) Not at all
(-9) DK / (-8) RA / (-7) NA

1
01
02
03
04
-9-8-7

2

01
02
03
04
-9-8-7

-- 3

01
02
03
04
-9-8-7

0©
01
01
02
02
03
03
04
04
-9-8-7
-9-8-7

Q.4b How well does .. . speak English now?
01 Very well
02 Well
03 Not well
04 Not at all
(-9) DK/ (-8) RA/ (-7) NA

Q.4b (0 1) Very well
(02) Well
(03) Not well
(04) Not at all
(-9) DK / (-8) RA / (-7) NA

01
02
03
04
-9-8-7

01
02
03
04
-9-8-7

01
02
03
04
-9-8-7

01
02
03
04
-9-8-7

01
02
03
04
-9-8-7

QAc* Before coming to the U.S . did . .. have any English language instruction?
01 No (skip to Q.4e)
02 Yes
(-9) DK/ (-8) RA/ (-7) NA

Q.4c*FOLLOW SKI' PATTERN
(01) No
(skip to Q.4e)
(02) Yes
(-9) DK / (-8) RA / (-7) NA

01
02
-9-8-7

01
02
-9-8-7

01
02
-9-8-7

01
02
-9-8-7

01
02
-9-8-7

Q.4d* (Uyes to Q.4c) Altogether how many weeks did . ., attend English language instruction before
coming to the U.S .?

QAd* How many weeks?
(-1) if 1 week or less
(-9) DK / (-8) RA / (-7) NA
Q.4e FOLLOW SKIP PATTERN
(01) No
(skip to Q.5a)
(02) Yes
(-6) High School Student
(slip to Q.5a)
-9 DK / -8 RA / - NA
Q.4f How many weeks?
(-1) if 1 week or less
(-9) DK / (-8) RA / (-7) NA
Q.4g (01)Everyday
(02) 2 to 6 times weekly
(03) Once a week
(-9) DK / (-8) RA / (-7) NA
Q.4h How many hours per day?
(-9) DK / (-8) RA / (-7) NA

wks
-1
-9-8-7

wks
-1
-9-8-7

wks
-1
-9-8-7

wks
-1
-9-8-7

01
02
-6
-9-8-7

01
02
-6
-9-8-7

01
02
-6
-9-8-7

01
02
-6
-9-8-7

01
02
-6
-9-8-7

wks
-1
-9-8-7
01
02
03
-9-8-7
bra
-g
-8 -7

wks
-1
-9-8-7
01
02
03
-9-8-7

wks
-1
-9-8-7
01
02
03
-9-8-7
hrs
-q
-8 -7

wks
-1
-9-8-7
01
02
03
-9-8-7

-q
-g -7

wks
-1
-9-8-7
01
02
03
-9-8-7
bra

-9
-8 -7

-9
-8 -7

01
02
-9-8-7

01
02
-9-8-7

01
02
-9-8-7

01
02
-9-8-7

01
02
-9-8-7

01
02
03
04
05
06

01
02
03
04
05
06

01
02
03
04
05
06

01
02
03
04
05
06

01
02
03
04
05
06

Q.4e Within the past 12 months, has .. . attended an English language training program?
01 No (skip to Q.5a)
02 Yes
(-6) High school student (skip to Q.5a)
(-9) DK/ (-8) RA/ (-7) NA
Q.4f Within the past 12 months, how many weeks did .., attend English language training?
Q.4g Within the past 12 months, did the English language class that . . . attended in the U.S . meet every day
or less frequently?
01
Every day
02
2 to 6 times a week
03
Once a week
(-9) DK/ (-8) RA/ (-7) NA
QAh Within the past 12 months, how many hours a day was . . . in English language training?
QAj Is . ., currently enrolled in an English language training program?
01 No
02 Yes
(-9) DK/ (-8) RA/ (-7) NA
QAk
What type of organization gave the English language training program? (Most recent
program if more than one) 01
School or university
02
Employer program
03
Religious organization
04
Refugee service agency (state/local government)
05
Refugee mutual assistance association (MAA)
06
Private individual/group
07
Other (SPECIFY)
DB Consulting Group, Inc

Q.4i (01) No
(02) Yes
(-9)DK/(-8) RA (-7) NA
Q.4k (01) School or university
program
(02)Employer
(03) Religious organization
(04) Refugee service agency (gov't)
(05) Refugee mutual assistance assn
(06) Private individual/group
(07) Other (SPECIFY)
-9 DK / -8 RA / -7 NA

07

-9-8-7

hrs

07

-9-8-7

DB Consulting Group, Inc

07

-9-8-7

07

-9-8-7

wks
-1
-9-8-7

hrs

07

-9-8-7

Questionnaire for Annual Survey of Refugees

Questionnaire for Annual Survey of Refugees- Year 4

Q.5a

Did . . . work at a job anytime last week?
Ol
No (skip to Q. I la)
02
Yes (go to Q.5b)
(-9) DK/ (-8) RA/ (-7) NA (skip to Q.1 Is)

(FOR PERSONS WHO WORKED LAST WEEK)
Q.5b
Did . . . work at more than onejob last week?
Ol
No (skip to Q .6a)
02
Yes (go to Q.5c)
(-9) DK/ (-8) RA/ (-7) NA (skip to Q.6a)
Q.5c

How many jobs did ... work at last week?

Questionnaire for Annual Survey of Refugees

Questionnaire for Annual Survey of Refugees-Year 4

Household ID#
Q.sa FOLLOW SKIP PATTERN
(01) No (skip to Q .lla)
(02) Yes
(-9) DK / (-8 RA / (-7) NA

1

2

-3

4

5

Ol
02
-9-8-7

Q.5b FOLLOW SHIP PATTERN
(01) No (skip to Q.6a)
(02) Yes
(-9) DK I (-8) RA / (-7) NA

01
02
-9-8-7

Ol
02
-9-8-7

Ol
02
-9-8-7

Ol
02
-9-8-7

01
02
-9-8-7

Ol
02
-9-8-7

Ol
02
-9-8-7

Ol
02
-9-8-7

Ol
02
-9-8-7

Q.5cHowmany jobs?
(-9) DK / (-8) RA / (-7) NA

_#ofjobs
-9-8-7

_#ofjobs
-9-8-7

_#ofjobs
-9-8-7

_#ofjobs
-9-8-7

_#ofjobs
-9-8-7

Q.6a flow many hours?
(primary job)
(-9) DK I (-8) RA I (-7) NA

# of
hours
-9-8-7
# of
hours
-9-8-7

_# of
hours
-9-8-7
# of
hours
-9_8_7

_# of
hours
-9-8-7
_# of
hours
-9-8-7

_# of
hours
-9-8-7
# of
hours
_9_8_7

_# of
hours
-9-8-7
_# of
hours
-9-8-7

Q .6a

How many hours did . . . work at his/her primary job last week? (Primary job means the job
worked at for the greatest number of hours)

Q .66

How many hours did . . . work at all jobs last week?

Q.6b How many hours? (all jobs)
(-9) DK / (-8) RA / (-7) NA

Q .7

How much money per hour did . . . receive at his/her primary job last week?
(Ifknows hourly wage, slap Q.8a & Q8b . Ifnot, continue with Q.8a)

Q.7 FOLLOW SKIP PATTERN
(if knows wage, skip to Q.9 or
$ /hour
$
/hour
$
/hour
$
/hour
Q.18a)
-9-8-7
-9-8-7
--9-8-7
_9-8 -7
-9 DK 1 -8 RA / -7 NA
Q.8a
$
$
$
$
-9 DK / -8 RA I - NA
-9-8-7
9-8-7
-48-7
-9-8-7
Q.8b
(01) Weekly
0l
0l
0l
0l
(02) Biweekly
02
02
02
02
(03) Monthly
03
03
03
03
(04) Yearly
04
04
04
04
-9 DK I -8 RA / - NA
-9-8-7
-9-8-7
-9-8-7
-9-8-7
IF... WORKED_
ONLY ONE JOB LAST WEE SHIP TO .18a
Q.9 FOLLOW SHIP PATTERN

Q .8a
Q .8b

How much did . . . earn before taxes from that job?
On what basis is that amount computed?
Ol
Weekly
02
Bi-weekly
03
Monthly
04
Yearly
If. ., worked at secondjob last weep ask
Q .9If. . . worked only onejob last week, slap to Q. 18a

(SECOND JOB ONLY)
Q.9
How much money per hour did . . . receive from his/her second job last week?
(If knows hourly wage, skip to Q. 18a. Ifnot continue with Q.IOa)
Q.l0a

How much did . .. cam before taxes from that job?

Q.IOb

On what basis is that amount computed?
01
Weekly
02
Bi-weekly
03
Monthly
04
Yearly
(Skip to Q. 18a)
DB Consulting Group, Inc

(Ifknows hourly wage, skip to
Q. 18a)

-9 DK / -8 RA I - NA
Q.10a
-9 DK 1 -8 RA/- NA
Q.10b FOLLOW SHIP PATTERN
Skip to question Q.18a
(0 l) Weekly
(02) Biweekly
(03) Monthly
(04) Yearly
-9 DK / -8 RA / -7 NA

$
$

/hour
-9-8-7
-9 -8 -7

$_/hour
-9-8-7
$
-9-8-7

0l
02
03
04
-9-8-7

0l
02
03
04
-9-8-7

DB Consulting Group, Inc

$
$

/hour
-9-8-7
-9-8 -7
01
02
03
04
-9-8-7

$
$

/hour
-9-8-7
-9-8-7
01
02
03
04
-9-8-7

$
$

/hour
-9-8-7
-9-8 -7
0l
02
03
04
-9-8-7

$
$

/hour
-9-8-7
-9-8-7
0l
02
03
04
-9-8-7

Questionnaire for Annual Survey of Refugees
Questionnaire for Annual Survey of Refugees - Year 4
Q.1la

Has . .. ever worked since coming to the U.S . to stay?
01
Never worked in the U.S. (skip to Q.13)
02
Yes -How many weeks has it been since . ., had a job?
(-9) DKI(-8) RA/ (-7) NA (skip to Q.12)

Q.llb

(Ifyes to Ila, otherwise skip to Q.12)
Since coming to the U.S ., in how many weeks has . .. ever worked?

Q.12

Was . . . temporarily absent or on layoff from a job or business last week?
01
No
02
Yes
(-9) DK/ (-8) RA/ (-7) NA

Q.13

Has .. . been looking for work during the last 4 weeks?
01
No (skip to. 17)
02
Yes
(-9) DKI (-8) RA/ (-7) NA (skip to Q.17)

Q.14

Q.15
Q.16

Q.17

What has . . . done to find a job? Has he/she checked with : (multiple answer may be given)
01
Nothing
02
Refugee mutual assistance association (MAA)
03
Refugee service agency
04
Public employment agency
05
Private employment agency
06
Advertisements
07
Sponsor
08
Other refugees
09
Friends (not refugees)
1I
Other (SPECIFY)
How many weeks has . . . been looking for a job?

What caused .. . to begin looking for work? (multiple answer may be given)
01
New arrival in the U.S.
02
Lostjob
03
Quitjob
04
Finished school
05
Training ended
06
Moved to a new area
07
Medical problem ended
08
Other (SPECIFY)
09
Eligibility for cash and/or medical assistance ended
(Skip to Q.18a1FWORKED, OR to Q.24a1FNEVER WORKED)
Why is . . . not looking for a job? (multiple answer may be given)
01
Limited English
02
Attending school or training
03
Poor health or handicap
04
Child care or family responsibilities
05
Believes no work is available
06
Tried to find work but couldn't
08
Age
05
Other (SPECIFY)
06
Go to Q.24a if never worked
DB Consulting Group, Inc

Questionnaire for Annual Survey of Refugees
Questionnaire for Annual Survey of Refugees-Year 4
Q.Ila FOLLOW SKIP PATTERN
(01) Never worked in the U.S. (skip to Q.13)
Yes. How many weeks since . ., had a job?
(-1) if l week or less
-9 DK/ -8 RA I -7 NA ski to .12
Q.llb How many weeks?
(-1) if less than 1 week
-9 DKI -8 RA/ -7 NA
Q.12 (01)
No
(02)
Yes
-9 DK I (-8) RA / (-7) NA
Q.13 (01) No
(skip to Q.17)
(02) Yes
-9 DK I -8 RA / - NA ski to .1
Q.14 (01)Nothing
(02) Refugee mutual assistance assoc.
(03) Refugee service agency
(04) Public employment agency
(05) Private employment agency
(06) Advertisements
(07) Sponsor
(08) Other refugees
(09) Friends (not refugees)
(11) Other (SPECIFY)
(-9 ) DK / (-8) RA / (-7) NA
Q.15 How many weeks?
(-1) if less than 1 week
-9 DK/ -8 RA/ - NA
Q.16 (01) New arrival in the U.S .
(02) Lost job
(03) Quit job
(04) Finished school
(05) Training ended
(06) Moved to new area
(07) Medical problem ended
(08) Other (SPECIFY)
(09) Eligibility for cash/medical . ., ended
(-9 ) DK / (-8) RA / (-7) NA
.l7 (0 l) Limited English
(02) Attending school or training
(03)Poor health orhandicap
(04) Child care / family responsibilities
(05) Believes no work is available
(06) Tried to find work but couldn't
(08) Age
(07) Other (SPECIFY)
(-9 ) DK / (-8) RA I (-7) NA
Go to .24a IF NEVER WORKED

01
wks
-1
-9-8-7

wks
-1
-9-8-7
01
02
-9-8-7
01
02
-9-8-7
01
02
03
04
05
06
07
08
09
1I

-9-8-7
wks

-1
-9-8-7
01
02
03
04
05
06
07
08
09
-9-8-7
01
02
03
04
05
06
08
07-9 -8 -7

01

01

01

01

1
-9-8-7

-t
-9-8-7

-1
-9-8-7

-1
-9-8-7

wks

wks

wks

wks

wks
-1
-9-8-7
01
02
-9-8-7
01
02
-9-8-7

wks
-1
-9-8-7
01
02
-9-8-7
01
02
-9-8-7

wks
-1
-9-8-7
01
02
-9-8-7
01
02
-9-8-7

wks
-1
-9-8-7
01
02
-9-8-7
01
02
-9-8-7

01
02
03
04
05
06
07
08
09
1l

01
02
03
04
05
06
07
08
09
11

01
02
03
04
05
06
07
08
09
11

01
02
03
04
05
06
07
08
09
11

-9-8-7

-9-8-7

-9-8-7

-9-8-7

wks

-1
-9-8-7
01
02
03
04
05
06
07
0809
-9-8-7

01
02
03
04
05
06
08
079 -8 -7

DB Consulting Group, Inc

wks

08

-1
-9-8-7
01
02
03
04
05
06
07

09
-9-8-7
01
02
03
04
05
06
08
0
4-87
-

wks

-1
-9-8-7
01
02
03
04
05
06
07
0809
-9-8-7
01
02
03
04
05
06
08
079 -8 -7

wks
-1
-9-8-7
01
02
03
04
05
06
07
0809
-9-8-7
01
02
03
04
05
06
08
07 -9-8-7

Questionnaire for Annual Survey of Refugees

Questionnaire for Annual Survey of Refugees - Year 4

Questionnaire for Annual Survey of Refugees

Questionnaire for Annual Survey of Refugees- Year 4

(FOR ALL PERSONS WHO HAD WORKED IN THE U .S . -- IF DID NOT WORK LAST
WEEK ASK ABOUT LAST JOB),
GO TO 0.24a IF INDIVIDUAL NEVER WORKED IN THE U.S .
Q.18a In the last year, how many weeks did . .. work?

Household 1D #
.18a How many weeks?
(-1) if less than 1 week
(-9 ) DK / (-8) RA I (-7) NA

Q.18b How many hours per week did . . . usually work?

Q.18b How many hours per wk?
(-9 ) DK / (-8) RA / (-7) NA
Q,18c
Total Earnings for last 12 months
-9 DK / -8 RA / -7 N
Q.18d
Date of First Job
-9 DK / -8 RA I -7 NA
Q.18e(01)No
(02) Yes
(03) was not receiving cash
assistance .. .
(-9 ) DK / (-8) RA / (-7) NA

Q.18c

What were .. .'s total earnings before taxes from all jobs in the past 12 months?

Q.18d When did . . . get his/her firstjob in the U.S .?
Q.18e

Did the income that . . . received from his/her first job disqualify . . .
from receiving cash assistance (such as RCA, AFDCITANF, o r GA)?
01
No
02
Yes
03
Was not receiving cash assistance at that time
(-9) DK/ (-8) RA/ (-7) NA

Q,19b What kind of business or industry is this?
(e.g., hospital, electronic parts manufacturing, social service agency)

Q.19b
(-9 ) DK / (-8) RA / (-7) NA

Q.19c

What kind of work does(did) .. perform?
(e .g., nurse, assembly line worker, typist, supervisor)

Q .19c
(-9 ) DK / (-8) RA / (-7) NA

Q.20

Is (was) . . . a:
01
Employee of a private company, business, or individual (go to Q.22a)
02
Federal government employee (go to Q.22a)
03
State government employee (go to Q.22a)
04
Local government employee o to .22a
05
Self-employed (go to Q.21)
06
Working without pay in family business (skip to Q .24a)
07
Other (SPECIFY)
(-9) DK/ (-8) RA/ (-7) NA

Q .21 [IF SELF-EMPLOYED]

DID

a What kind of business is it? (e.g., restaurant, tailor shop, grocery store)
b . How many other refugees does . . . employ?
c . How many total employees does . . . have?
(-9) DK/ (-8) RA/ (-7) NA

1F
NOT WORK LAST WEEK, ASK ABOUT LAST JOB. GO TO Q.24a, IF NEVER
WORKED IN THE U.S.
DB Consulting Group, Inc

Q .20 FOLLOW SKIP PATTERN
(01) Employee of a private
company go to Q. 22a
(02) Federal government employee
go to Q.22a
(03) State government employee
go to Q.22a
(04) Local government employee
go to Q.22a
(05) Self-employed go to Q.21
(06) Working without pay in
family business
go to Q.24a
(07) Other (SPECIFY)
-9 DK / (-8) RA / (4) NA
Q.21 a. What kind of business is it?
b . How many other refugees does
. . . employ?
c. How many total employees does
. . .have?
-9 DK / (-8) RA / (4) NA

1

2

wks

-1
-9-8-7
hrshvk
-9-8-7
$

3

wks

wks

-1
-9-8-7

-1
-9-8-7

hrs/wk
-9-8-7

hrs/wk
-9-8-7

$

$

4
_wks
-1
-9-8-7

5
_wks
-1
-9-8-7

hrs/wk
-9-8-7
$

hrslwk
-9-8-7
$

-9-8-7
I
MIv1YYYY
-9-8-7
01
02
03

-9-8-7
_l
MIv1YYPY
-9-8-7
01
02
03

-9-8-7
l
MMYYYY
-9-8-7
01
02
03

-9-8-7
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Mb1YYYY
-9-8-7
01
02
03

-9-8-7
I_
MMYYYY
-9-8-7
01
02
03

-9-8-7

-9-8-7

-9-8-7

-9-8-7

-9-8-7

01

01

01

01

01

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02

02

02

02

03

03

03

03

03

04

04

04

04

04

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06

05
06

05
06

05
06

05
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07

-9-8-7

a.
b.

#ref

c.

#empl

07
a
b.

-9-8-7
#ref

c. -#empl

DB Consulting Group, Inc

07

-9-8-7

07

-9-8-7

07

-9-8-7

a.
b.

#ref

a.
b.

#ref

a.
b.

#ref

c.

#empl

c.

#empl

c.

#empI

Questionnaire for Annual Survey of Refugees

Questionnaire for Annual Survey of Refugees

Questionnaire for Annual Survey of Refugees - Year 4

[FOR EMPLOYEE ONLY]
Q.22a

What did . . . do to fad this job? Did he/she check with:
01
Voluntary agency (agency that helped with initial U.S . resettlement)
02
Refugee mutual assistance association (MAA)
03
Refugee service agency
04
Public Employment Agency
05
Private Employment Agency
06
Advertisements
07
Sponsor
08
Other refugees
09
Friends (not refugees)
111
Religious Institution
112
College/Job Training
113
Self
114
Relative
11
Other (SPECIFY)
(-9) DK/ (-8) RA/ (-7) NA

Q .24a Within the pas t 12 months, has . . .attended any jab training program?
01
No (skip to Q.25a)
02
Yes
(-9) DK/ (-8) RA/ (-7) NA
Q.24b How many weeks did that training last?
Q.24c Did the job-training class meet every day or less frequently?
01
02
03

Every day
2 to 6 times a week
Once a week

Q.24d How many hours a day did the job-training class meet?
Q.24e For what kind of work (occupation) did this training prepare . . .?
(e.g., electronics assembler, welder, typist nurse, childcare provider)

DB Consulting Group, Inc

Questionnaire for Annual Survey of Refugees-Year 4

Household ID#
Q .22a
(01) Voluntary agency
(02) Refugee mutual assistance
association
(03) Refugee service agency
(04) Public Employment Agency
(05) Private Employment Agency
(06) Advertisements
(07) Sponsor
(08) Other refugees
(09) Friends (not refugees)
(111) Religious Organization
(112) College/Job Training
(113) Self
(114) Relative
(11) Other (SPECIFY)
(-9 ) DK / (-8) RA / (-7) NA
Q.24a FOLLOW SHIP PATTERN
(01) No (skip to Q25a)
(02) Yes
(-9 ) DK / (-8) RA / (-7) NA
Q.24b

Q .24c

Q .24d

How many weeks?
(-1) if less than 1 week
(-9 ) DK / (-8) RA I (-7) NA
(0 1) Every day
(02) 2 to 6 times weekly
(03) Once a week
How many hours per day?
(-9 ) DK / (-8) RA / (-7) NA

Q.24e

11

1

2

3

4

5

01
02

01
02

01
02

01
02

01
02

03
04
05
06
07
08
09
Ill
112
113
114

03
04
05
06
07
08
09
111
112
113
114

03
04
05
06
07
08
09
111
112
113
114

03
04
05
06
07
08
09
111
112
113
114

03
04
05
06
07
08
09
ill
112
113
114

11

11

11

11

_9-8-7

_9_8_7

-9-8-7

-9-8-7

-9-8-7

01
02
-9-8-7

01
02
-9-8-7

01
02
-9-8-7

01
02
-9-8-7

01
02
-9-8-7

_wks
-1
-9-8-7

_wks
-1
-9-8-7

wks
-1
-9-8-7

wks
-1
-9-8-7

wks
-1
-9-8-7

01
02
03

01
02
03

01
02
03

01
02
03

01
02
03

hours
-9-8-7

boom
-9-8-7

hours
-9-8-7

hours
-9-8-7

hours
-9 -8 -7

(-9) DK / (-8) RA / (-7) NA

DB Consulting Group, Inc

Questionnaire for Annual Survey of Refugees

Questionnaire for Annual Survey of Refugees

Questionnaire for Annual Survey of Refugees -Year 4

Q.25a

Questionnaire for Annual Survey of Refugees - Year 4

Within the past 12 months, has ... attended school or university (other than to take English language
training or the job-training class indicated in the previous question)?
01
No (skip to Q.266)
02
Yes
(-9) DK/ (-8) -RA/ (-7) NA

Household ID#
Q15a FOLLOW SKIP PATTERN
(01) No (skip to Q.26b)
(02) Yes
-9 DK I -8 RA / - NA

1

2

3

0

5

01
02
-9-8-7

01
02
-9-8-7

01
02
-9-8-7

01
02
-9-8-7

Q.25b

Was . .. attending school or university in order to obtain a degree or certificate?
01
No
(skip to Q.266)
02
Yes
(-9) DK/ (=8) RA/ (-7) NA

Q.25b FOLLOW SKIP PATTERN
(01) No (skip to Q.26b)
(02) Yes
(-9 ) DK I (-8) RA / (-7) NA

01
02
-9-8-7

01
02
-9-8-7

01
02
-9-9-7

01
02
-9-8-7

01
02
-9-8-7

Q.25c

What degree or certificate was . . . attempting to earn?
01
High school certificate or equivalency
02
Associate degree
03
Bachelor's degree
04
Master's or Doctorate degree
05
Professional school degree (e .g ., MD, LLB, DDS)
06
Other (SPECIFY)
(-9) DK/ (-8) RA/ (-7) NA

01

01
02
-9-8-7

01

01

01

01

02
03
04
05

02
03
04
05

02
03
04
05

02
03
04
05

02
03
04
05

06-9-8-7

06
-9-8-7

Q.25c (01) High School certificate or
equivalency
(02) Associate degree
(03)Bachelor's degree
(04) Master's or Doctorate degree
(05) Profess ional school degree
(e.g ., MD)
(06) Other (SPECIFY)
-9 DK / (-8) RA / (4) NA

Q.25d Has . ., received this degree m certificate?
01
No
(skip to Q.26b)
02
Yes
(-9) DK/ (-8) RA/ (-7) NA

Q.25d FOLLOW SKIP PATTERN
(01) No (skip to Q.26b)
(02) Yes
(-9) DK / (-8) RA / (-7) NA

Q.25e In what year did . .. receive this degree or certificate?

Q.25e

Q.26b How many months has . .. lived at thus residence?

Q.266

Q.26c Did ... live at this residence a year ago?
01
No
02
Yes
(skip to Q.27a)
(-9) DK/ (-8) RA/ (-7) NA
Q.26d Did . . . live in this state a year ago?
01
No
02
Yes
(skip to Q.27a)
(-9) DK/ (-8) RA/ (-7) NA
Q.26e In which state did . ., live a year ago?
01
Not in the U.S .
(skip to Q27a)
Specify state
(-9) DK/ (-8) RA/ (-7) NA
Q.26f What was the primary reason that .., moved to this state?

DB Consulting Group, Inc

What year?
(-9 ) DK / (-8) RA / (-7) NA

How many months?
(-1) if less than 1 month
(-9 ) DK I (-8) RA / (-7) NA
Q.26c FOLLOW SKIP PATTERN
(01) No
(02) Yes (skip to Q.27a)
-9 DK / -8 RA / - NA
Q.26d FOLLOW SKIP PATTERN
(01) No
(02) Yes (skip to Q.27a)
(-9 ) DK l (-8) RA / (-7) NA
Q.26e

FOLLOW SKIP PATTERN
(01) Not in the U.S .
(skip to Q.27a)
Specify state
(-9 ) DK / (-8) RA / (-7) NA

06-9-8-7

06-9-8-7

06

-9-8-7

01
02
-9-8-7

01
02
-9-8-7

01
02
-9-8-7

01
02
-9-8-7

01
02
-9-8-7

YYYY
-9-8-7

YYYY
-9-8-7

YYYY
-9-8-7

YYYY
-9-8-7

YYYY
-9-8-7

_months
-1
-9-8-7

_months
-1
-9-8-7

_months
-1
-9-8-7

_months
-1
-9-8-7

_months
-1
-9-8-7

01
02
-9-8-7

01
02
-9-8-7

01
02
-9-8-7

01
02
-9-8-7

01
02
-9-8-7

01
02
-9-8-7

01
02
-9-8-7

01
02
-9-8-7

01
02
-9-8-7

01
02
-9-8-7

01

01

01

01

01

_State
-9-8-7

_State
-9-8-7

_State
-9-8-7

_State
-9-8-7

Q26fIndicate response :
(-9 ) DK / (-S) RA / (-7) NA

DB Consulting Group, Inc

State
-9-8-7

Questionnaire for Annual Survey of Refugees
Questionnaire for Annual Survey of Refugees - Year 4
Q.27a (For persons in the U.S. 12 months or longer): Has .., applied to adjust his/her immigration status to that of a
permanent U.S. resident?
01
No
(skip to Q.27c)
02
Yes
(ask Q.27b)
(-9) DK/ (-8) RA/ (-7) NA
Q,27b When did . ., apply for adjustment to permanent resident status? (Ifapplication date is given, skip to Q.28)
Q.27c

Does . . . plan to adjust his/her immigration status in the future?
01
No
02
Yes
03
Did not know he/she had to apply to become a permanent resident

Q.28 Does this person have a physical, mental, or other health condition that has lasted for 6 or more months and which:
a. Limits the kind or amount of work this person can do at ajob?
01
No
02
Yes
b. Prevents this person from working at a job?
01
No
02
Yes
Q.29a During the past 12 months, how were .. .'s medical expenses paid? (may indicate more than one)
01
No medical expenses
02
Self or household members
03
Other relatives or friends
04
Sponsor/sponsoring agency
05
Religious organization
06
Medicaid or Refugee medical assistance
07
Other government source
08
Insurance through own employment (e.g, Blue Cross)
09
Insurance through family member's employment
II
Other source (SPECIFY)
Q.29b What is . . . usual source of medical care?
01
No regular source
02
Private physician
03
Emergency room at a hospital
04
Health clinic
05
Folk healer
Other
(SPECIFY)
Q.29c Was there any time in the past 12 months when . .. was not covered either by refugee medical assistance, Medicaid, or
private health insurance?
01
Covered in all months
Yes-number of months not covered;
(-1)
Not covered 1 month or less
(-3)
Not covered in any month (skip to Q.30a)
Q.29d What type of health insurance coverage did.. . have in the past 12 months (indicate all that apply)
01
Insurance through own or family member's employment
02
Private insurance unrelated to employment
03
Medicaid or refugee medical assistance
04
Other government health care
05
Other insurance (SPECIFY)
DB Consulting Group, Inc

Questionnaire for Annual Survey of Refugees
Questionnaire for Annual Survey of Refugees-Year 4
Household IN
Q.27a (01) No (skip to Q.27c)
(02) Yes
-9 DK / (-8) RA / (-7) NA

Q.27b What date? (If it is given skip to Q.28)
(-9 ) DK / (-8) RA / (-7) NA

Q.27c (0 1) No
(02) Yes
(03) Did not know sthe had to apply
-9 DK / -8 RA / -7 NA
Q.28a (01) No
(02) Yes
(-9 ) DK / (-8) RA I (-7) NA
Q.28b (01) No
(02) Yes
(-9 ) DK / (-8) RA / (-7) NA

~MMYYYY
-9-8-7
01
02
03
-9-8-7
01
02
-9-8-7

~MMYYYY
-9-8-7
01
02
03
-9-8-7
01
02
-9-8-7

/
MMYYYY
-9-8-7
01
02
03
-9-8-7
01
02
-9-8-7

4
01
02
-9-8-7
I
N04YYYY
-9-8-7
01
02
03
-9-8-7
01
02
-9-8-7

01
02
03
04
05
06
07
08
09

01
02
03
04
05
06
07
08
09

01
02
03
04
05
06
07
08
09

01
02
03
04
05
06
07
08
09

01
02
-9-8-7

Q.29a (01) No medical expenses
(02) Self or household members
(03) Other relatives or friends
(04) Sponsor/sponsoring agency
(05) Religious organization
(06) Medicaid m Refugee Medical Assistance
(07) Other government source
(08) Insurance through own employer
(09) Insurance through family member
(11) Other source (SPECIFY)
(-9 ) DK / (-8) RA / (-7) NA
Q.29b

1
01
02
-9-9-7

(01) No regular source
(02) Private physician
(03) Emergency room at hospital
(04) Health clinic
(05)Folk healer
(06) Other (SPECIFY)
(-9 ) DK / (-8) RA / (-7) NA

11
-9-8-7
01
02
03
04
05

Q.29c FOLLOW SKIP PATTERN
(01) No -- Covered in all 12 months
Yes-- # of months not covered
(-I) if not covered 1 month or less
(-3) Not covered in any month (skip to Q.30a)
(-9 ) DK / (-8) RA / (-7) NA
Q.29d (01) Insurance through own or family .. .
(02) Private insurance unrelated through . . .
(03) Medicaid or refugee medical assistance
(04) Other government health care
(05) Other insurance (SPECIFY)
(-9 ) DK / -8 RA / -7 NA

0
-7
-!T-801
_# mo .
-1
-3
-9-9-7
01
02
03
04
05_
-9-8-7

2
01
02
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01
02
-9-8-7

11
-9-8-7
01
02
03
04
05
06-9-8-7
01
_# mo .
-1
-3
-9-8-7
01
02
03
04
05
-9-8-7

DB Consulting Group, Inc

3
01
02
-9-8-7

01
02
-9-8-7

11

-9-8-7
01
02
03
04
05

01
02
-9-8-7

11

-9-8-7
01
02
03
04
05

01
02
-9-8-7
I
MMYYYY
-9 -8 -7
01
02
03
-9-8-7
01
02
-9-8-7

01
02
03
04
05
06
07
08
09

01
02
-9-8-7

11
-9-8-7

06
-4-8
-7

06
-9-8-7

01
02
03
04
05
06-9-8-7

01
_# mo .
-I
-3
-9-8-7
01
02
03
04
05
-9-8-7

01
_# mo.
-1
-3
-9-8-7
01
02
03
04
05
-9-8-7

01
_# mo.
-1
-3
-9-8-7
01
02
03
04
05
-9-8-7

Questionnaire for Annual Survey of Refugees

Questionnaire for Annual Survey of Refugees

Questionnaire for Annual Survey of Refugees-Year 4

Now we would like to ask a few questions about the household
Q .30a

FOOD STAMPS -In the past 12 months, have one or more persons in your household
received food stamps?
01
No
(skip to Q.31a)
02
Yes
(-9) DKI (-8) RA/ (-7) NA (slap to Q.31a)

Questionnaire for Annual Survey of Refugees - Year 4

Household ID#
Q.30a

FOLLOW SHIP PATTERN
(01) No (skip to Q. 31a)
(02) Yes
(-9) DK I (-8) RA I (-7) NA (skip to Q.31a)

Q .30b

Circle #'s from Household Control Chart
(-9) DK I (-8) RA I (-7) NA

Q .30c

Total Cash Value (per month)
(-9 ) DK I (-8) RA I (-7) NA

Q .30d

How many months?
(-9 ) DK I (-8) RA / (-7) NA

-9-8-7

Q .31a

FOLLOW SHIP PATTERN
(01) No (skip to Q.31f
(02) Yes
(-9 ) DK I (-8) RA I (-7) NA (skip to Q
.3-1f

01
02
-9-8-7

Q .31b Which household members received such assistance? (circle person #s in whose name the
assistance was received)

Q31b

Circle #'s from Household Control Chart
(-9 ) DK I (-8) RA / (-7) NA

Q31c What was the cash amount received each month? (household)

Q .31c

Q31d How many months in the past 12 months was the AFDC or TANF received?

Q .31d

Q31e In the last month, was AFDC/TANF received?
01
No
02
Yes
(-9) DKI (-8) RA/ (-7) NA

Total Cash Value (per month)
(-9 ) DK I (-8) RA I (-7) NA
How many months?
(-9 ) DK 1(-8) RA / (-7) NA

Q .31e

(01) No
(02) Yes
(-9 ) DK I (-8) RA / (-7) NA

Q .31f

(A) Every month
(B) No months
Number of months

Q.30b Who received them? (circle person #s in whose name the assistance was received)
Q.30c What was the total cash value per month? (household)
Q.30d How many months in the past 12 months were food stamps received?

Q.31a

Q .31f

AFDC/TANF -In the past 12 months, have one or more persons in your household received
cash assistance through the Aid to Families with Dependent Children (AFDC) program or
Temporary Assistance t o Needy Families (TANF) Program?
01
No
(skip to Q31.0
02
Yes
(-9) DK/ (-8) RA/ (-7) NA (skip to Q.31fl

Since coming to the United States, in how many months have one or more persons in your
household received AFDC or TANF?
(A)
Every month
(B)
No months
Number of months:
(-9) DK/ (-8) RA/ (-7) NA

DB Consulting Group, Inc

01
02
-9-8-7
0102 03 04 05 06 07 08 091011121314151617
-9-8-7
$

-9-8-7
# of months

0102 03 04 05 06 07 08 09 10 1112 13 14 15 16 17
-9-8-7
$

-9-8-7

# of months
-9-8-7
01
02
-9-8-7
A
B
Number of months -9-8--7

DB Consulting Group, Inc

Questionnaire
Questionnairefor
forAnnual
AnnualSurvey
SurveyofofRefugees
Refugees - Year 4
Q .32a

Q .32b

RCA - In the past 12 months, have one or more persons in your household received
assistance through the Refugee Cash Assistance (RCA) program?
01No
(skip to Q.33a)
02
Yes
(-9) DK/ (-8) RA/ (-7) NA (slap to Q.33a)
Which household members received such assistance?

(circle person #s in whose name the assistance was received)

Q.32c What was the cash amount received each month? (household)
Q.32d

How many months in the past 12 months was RCA received?

Q.32e

In the last month, was RCA received?
01
No
02
Yes
(-9) DK/ (-8) RA/ (-7) NA

Q.33a

SSI - In the past 12 months, have one or more persons in your household received
Supplemental Security Income (SSI)?
01
No
(skip to Q.33f)
02
Yes
(-9) DK/ (-8) RA/ (-7) NA (skip to Q.33f0I

Questionnairefor
for Annual
Annual Survey
Surveyof
ofRefugees-Year
Refugees
Questionnaire
4
Household ID#
Q .32a

FOLLOW SKIP PATTERN
(01) No (skip to Q .33a)
(02) Yes
(-9) DK / (-8) RA / (-7) NA (skip to Q.33a)

Q .32b

Circle #'s from Household Control Chart
(-9 ) DK / (-8) RA / (-7) NA

Q32c

Total Cash Value (per month)
(-9 ) DK I (-8) RA / (-7) NA
How many months?
(-9 ) DK / (-8) RA l (-7) NA

Q .32d

01
02
-9-8-7
0102 03 04 05 06 07 08,09 1011121314151617
-9-8-7
$

-9-8-7
-9-8-7

Q .32e

(01) No
(02) Yes
(-9 ) DK / (-8) RA / (-7) NA

01
02
-9-8-7

Q .33a

FOLLOW SKIP PATTERN
(01) No (skip to Q .33Q
(02)Yes
(-9) DK / (-8) RA I (-7) NA (skip to Q.33f)

01
02
-9-8-7

Q.33b Which household members received such assistance? (circle person #s in whose name the
assistance was received)

Q .33b

Q.33c What was the cash amount received each month? (household)

Circle #'s from Household Control Chart
(-9) DK I (-8) RA l (-7) NA

Q .33c

Total Cash Value (per month)
-9 DK / -8 RA / - NA
How many months?
(-9 ) DK / (-8) RA / (-7) NA

Q.33d How many months in the past 12 months was SSI received?
Q.33e In the last month, was SSI received?
01
No
02
Yes
(-9) DK/ (-8) RA/ (-7) NA
Q.33f

Since coming to the U.S ., in how many months have one or more persons in your
household received SSI?
(A) Every month
(B) No months
Number of months :
DB Consulting Group, Inc

Q .33d
Q .33e

(01) No
(02) Yes
(-9 ) DK / (-8) RA / (-7) NA

Q .33f

(A) Every month
(B) No months
Number of months
-9 DK I -8 RA / -

# of months

0102 03 04 05 06 07 08 09 10 1112 13 14 15 16 17
-9-8-7

NA
DB Consulting Group, Inc

$

-9-8-7
-9-8-7

# of months

01
02
-9-8-7
A
B
Number of months _
-9-8-7

Questionnaire for Annual Survey of Refugees

Questionnaire
for Annual Survey of Refugees
Questionnaire

for Annual Survey of Refugees-Year 4

Q34a GA - In the past 12 months, have one or more persons in your household received income
from General Assistance (GA)?
01
No
(skip to Q .341)
02
Yes
(-9) DK/ (-8) RA/ (-7) NA (skip to Q .34f)

Questionnaire for Annual Survey of Refugees - Year 4

Household ID#
Q.34a

FOLLOW SKIP PATTERN
(0 l) No (skip to Q.34f)
(02) Yes
(-9 ) DK I (-8) RA I (-7) NA (skip to Q .34f)

Q34b Which household members received such assistance?
(circle person #s in whose name the assistance was received)

Q34b

Q.34c What was the cash amount received each month? (household)

Circle #'s from Household Control Chart
(-9 ) DK I (-8) RA I (-7) NA

Q.34c

Q34d How many months in the past 12 months was GA received?

Q34d

Q34e In the last month, was GA received?
01
No
02
Yes
(-9) DK/ (-8) RA/ (-7) NA

Total Cash Value (per month)
-9 DK I -8 RA / -7 NA
How many months?
-9 DK/ -8 RA / -7 NA

Q.34e

(0 1) No
(02) Yes
(-9 ) DK I (-8) RA / (-7) NA

01
02
-9-8-7

Q.34f

(A) Every month
(B) No months
Number of months
(-9 ) DK / (-8) RA / (-7) NA

A
B
Number of months _
-9-8-7

Q .35a

FOLLOW SKD' PATTERN
(01) No (skip to Q36a)
(02) Yes
(-9) DK I (-8) RA l (-7) NA (skip to Q.36a)

01
02
-9-8-7

Q .356

(01) Voluntary agency
(02) Religious organization
(03) Refugee mutual assistance association
(04) Sponsor
(05) Other individual or family member
(06) Other organization (SPECIFY)
(-9 ) DK I (-8) RA l (-7) NA

01
02
03
04
05
06
-9-8-7

Q .35c

Circle #'s from Household Control Chart
(-9 ) DK / (-8) RA / (-7) NA
Total Cash Value (per month)
-9 DK/ -8 RA/ - NA
How many months?
(-9 ) DK I (-8) RA / (-7) NA

Q34f

Q35a

Q35b

Since coming to the U.S., in how many months have one or more persons i n your
household received GA?
(A)
Every month
(B)
No months
Number of months :
(-9) DK/ (-8) RA/ (-7) NA
CASH - In the past 12 months, have one or more persons in your household received cash
assistance directly from a voluntary agency, sponsor, religious organization, or MAA?
01
No
(skip to Q.36a)
02
Yes
(-9) DK/ (-8) RA/ (-7) NA (slap to Q.36a)
What type of organization or person gave such assistance?
01
Voluntary agency
02
Religious organization
03
Refugee mutual assistance association (MAA)
04
Sponsor
05
Other individual or family member
06
Other organization (SPECIFY)
(-9) DK/ (-8) RA/ (-7) NA

1Q.35c Which household members received such assistance?
(circle person #s in whose name the assistance was received
Q.35d What was the cash amount received each month? (household)
Q .35e How many months in the past 12 months was this private assistance received?
DB Consulting Group, Inc

Q35d
Q35e

01
02
-9-8-7
0102 03 04 05 06 07 08 091011121314151617
-9-8-7
$

-9-8-7
-9-8-7

# of months

0102 03 04 05 06 07 08 091011121314151617
-9-8-7
$
-9-8-7
# of months
-9-8-7

DB Consulting Group, Inc

Questionnaire for Annual Survey of Refugees

Questionnaire for Annual Survey of Refugees

Questionnaire for Annual Survey of Refugees-Year 4

Q .36a

OTHER INCOME - Within the past 12 months has anyone in the household received
income from any other source on a regular basis (such as interest from savings accounts, net
rental income, child support, unemployment compensation or retirement income)?
01
No
(skip to Q.38a)
02
Yes
(-9) DK/ (-8) RA/ (-7) NA (skip to Q.38a)

Questionnaire for Annual Survey of Refugees-Year 4

Household ID#
FOLLOW SKIP PATTERN
(01) No (skip to Q.38a)
(02) Yes
(-9) DK I (-8) RA I (-7) NA (skip to Q.38a)

Q.36b

Circle #'s from Household Control Chart
(-9 ) DK / (-8) RA / (-7) NA
Total Cash Value (per month)
-9 DK/ -8 RA/ -7 NA
How many months?
(-9) DK / (-8) RA / (-7) NA

Q36b

Who received the income? (circle person #s in whose name income was received)

Q.36c

What was the cash amount received on average each month? (household)

Q.36c

Q36d

How many months was this income received in the past 12 months?

Q.36d

Q.36f

What was the source of that income? (more than one answer can be giver)
01
Interest income
02
Net rent al income
03
Child support
04
Unemployment compensation
05
Retirement income
06
Other (SPECIFY)
(-9) DK/ (-8) RA/ (-7) NA

Q38a

Q38b

Q.38c

Is this house or apartment
01
Rented for cash rent
02
Owned by you or someone in this household
with or without a mortgage or loan
03
Occupied without payment of cash rent
(-9) DK/ (-8) RA/ (-7) NA
How much is the total monthly payment for this housing unit? (For owners, include total
mortgage payment, taxes, insurance and utilities ; for renters include rent plus utilities - gas,
electricity and heating oil - if paid separately)
Is this housing unit in a public housing project, that is, is it owned by a local housing
authority or other local public agency?
01
No
02
Yes
(-9) DK/ (-8) RA/ (-7) NA

_

Q.36a

Q .36f

Q .38a

(01)Interest income
(02) Net rent al income
(03) Child support
(04) Unemployment compensation
(05) Retirement income
(06) Other (SPECIFY)
(-9 ) DK I (-8) RA / (-7) NA

01
02
-9-8-7
0102 03 04 05 06 07 08 091011121314151617
-9-8-7
$
-9-8-7
# of months
-9-8-7

06

(0 l) Rented for cash rent
(02) Owned by you or someone in this
household . . .
(03) Occupied without payment or cash rent
(04) Other (SPECIFY)
(-9 ) DK / (-8) RA / (-7) NA

Q38b

Rent $
(-9 ) DK I (-8) RA / (-7) NA

Q38c

(01) No
(02) Yes
(-9 ) DK / (-8) RA / (-7) NA

THAT WAS OUR FINAL QUESTION. THANK YOU VERY MUCH FOR YOUR
PARTICIPATION IN THIS SURVEY.
INTERVIEWER: Remember to answer the questions on the following page .

DB Consulting Group, Inc

01
02
03
04
05

DB Consulting Group, Inc

-9-8-7
01
02
03

04

-9-8-7
$

-9-8-7
01
02
-9-8-7

Questionnaire for Annual Survey of Refugees
Questionnaire
forfor
Annual
Survey
ofof
Refugees
Year 3.1
Questionnaire
Annual
Survey
Refugees--Year
4
FOR INTERVIEWER ONLY
A.

Time Interview Ended

B.

General Responsiveness of Respondent
01 Willing
02 Neutral
03
Reluctant
04
List Difficulties, if any, With the Interview

C.

(Please, use military time)

D. Language in which Interview was Conducted
RS
VN
LA
CB
HM
SP
AH
HA
CN
RO
PL
AN
UP
AR
IR
AF
SO
BU
SR
EN

I

E . Interviewer's Ethnic

__ Russian
Vietnamese
Laotian
Cambodian
Hmon
Spanish
Amharic
Creole
Chinese
Romanian
Polish
Armenian
Ukrainian
Arabic
Farsi
Afghan
Somalian
Bul arias
Serbo-Croatian
English

Other (SPECIFY)

RS
VN
LA
CB
HM
SP
ET
HA
CN
RO
PL
AN
UP
IZ
IR
AF
s0
BU
SR
Other (SPECIFY)

END
DB Consulting Group, Inc

Russian
Vietnamese
Lao
Cambodian
Hmon
Cuban/other Hispanic
Ethiopian
Haitian
Chinese
Romanian
Polish
Armenian
Ukrainian
Irrir-j
.
Iranian
Afghan
Somalian
Bulgarian
Serbian