Survey Instrument

Annual Survey of Refugees

Annual Survey Refugees Updated Questionnaire for OMB - English FINAL

Survey Instrument

OMB: 0970-0033

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Questionnaire for Annual Survey Of Refugees - 2012

OMB Number: 0970-0033

Expiration Date: 02/28/2019

QUESTIONNAIRE AND CODING ANSWER SHEETS

FOR

ANNUAL SURVEY OF REFUGEES

NOTE: For the re-interview cases, items Q.1a thru Q.1k should only be used for verification. In addition, items marked with an asterisk, Q.2a*, Q.2b, Q.3a*-- Q.3d*, 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

ENGLISH

INTRODUCTORY STATEMENT

Hello. My name is ____________. I am calling on behalf of the Office of Refugee Resettlement regarding a survey we are conducting about the adjustment to life in the United States of refugees and other recent immigrants.

Recently, we sent you a letter describing this survey and asking for your participation. Any information you give us will be held in confidence and will be used for statistical purposes only. Your participation in this interview is completely voluntary.

If you have some time now, I’d like to proceed with the interview.

ORR-9

Public reporting burden for this collection of information is estimated to average 30 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 Human Services, 330 C ST SW, Washington D.C. 20201; and to: Office of Management and Budget, Paperwork Reduction Project, OMB Control Number 0970-0033, Washington D.C. 20403.

TRACKING AND VALIDATION FORM

Household ID Number _________________________

Interviewer's Name _________________________ Code ___/ ___/ ___

Date of Interview _______/ ______/ ______

Month Day Year

Time Interview Started _______: _______ AM PM

Hours Minutes

ATTEMPTS TO CONTACT INTERVIEWEE

1. _________________ 5. _____________________

2. _________________ 6. _____________________

3. _________________ 7. _____________________

4. _________________ 8. _____________________

TOTAL NUMBER OF ATTEMPTS TO CONTACT INTERVIEWEE _______

NAME OF RESPONDENT

_______________________________________________________________________

Last Middle First

CURRENT ADDRESS

_______________________________________________________________________

Street# Street Name Apt.#

_______________________________________________________________________

City State Zip Code

E-MAIL ADDRESS:__________________________________

TELEPHONE (_______) ______________________________

Area Code

TRACKING AND VALIDATION FORM

Household ID Number _________________________

Interviewer's Name _________________________ Code ___/ ___/ ___

Date of Interview _______/ ______/ ______

Month Day Year

Time Interview Started _______: _______ AM PM

Hours Minutes

ATTEMPTS TO CONTACT INTERVIEWEE

1. _________________ 5. _____________________

2. _________________ 6. _____________________

3. _________________ 7. _____________________

4. _________________ 8. _____________________

TOTAL NUMBER OF ATTEMPTS TO CONTACT INTERVIEWEE_______

NAME OF RESPONDENT

________________________________________________________________________

Last Middle First

CURRENT ADDRESS

________________________________________________________________________

Street# Street Name Apt.#

________________________________________________________________________

City State Zip Code

E-MAIL ADDRESS:__________________________________

TELEPHONE (_______) ______________________________

Area Code

HOUSEHOLD ID# ______ USE HOUSEHOLD CONTROL CHART

Q.1 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, which 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).

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?

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?

What is ... ethnic origin?

j. What month and year did ... enter the U.S. to stay?

k. In what State did ... originally resettle?

USE THE HOUSEHOLD CONTROL CHART

Now I want to ask some questions only of persons in your household who are 16 years old or older.

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

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

Q.2b* What was the highest degree or certificate that ... obtained 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) DK / (-8) RA / (-7) NA

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?)

01 Not employed (skip to Q.3d)

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

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

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

Q.3c* What were the most important activities or duties in this job?

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

Q.3d* Was ... in a prison or reeducation camp prior to coming to the U.S.?

01 No

02 Yes How long was ... there?

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

Household ID#

Q.2a*

How many years?

(-1) If 1 year or less

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

__________

years

-1

-9 -8 -7

__________

years

-1

-9 -8 -7

__________

years

-1

-9 -8 -7

__________

years

-1

-9 -8 -7

__________

years

-1

-9 -8 -7

Q.2b*

(01) None

(02) Primary

(03) Training in refugee camp

(04) Technical school certification

(05) Secondary

(06) University degree

(07) Medical degree

(08) Other (SPECIFY)

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

__________

-9 -8 -7

__________

-9 -8 -7

__________

-9 -8 -7

__________

-9 -8 -7

__________

-9 -8 -7

Q.3a*

FOLLOW SKIP PATTERN

(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

__________

-9 -8 -7

__________

-9 -8 -7

__________

-9 -8 -7

__________

-9 -8 -7

__________

-9 -8 -7

Q.3b*

What kind of work (activities)?

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

__________

-9 -8 -7

__________

-9 -8 -7

_________

-9 -8 -7

__________

-9 -8 -7

_________

-9 -8 -7

Q.3c*

Most important duties/activities

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

__________

-9 -8 -7

__________

-9 -8 -7

__________

-9 -8 -7

__________

-9 -8 -7

__________

-9 -8 -7

Q.3d*

(01) No

(02) Yes. How long was ... there?

(-1) If 1 week or less

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

__________

weeks

-1

-9 -8 -7

__________

weeks

-1

-9 -8 -7

__________

weeks

-1

-9 -8 -7

__________

weeks

-1

-9 -8 -7

__________

weeks

-1

-9 -8 -7

Q.4a* 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

Q.4b How well does ... speak English now?

01 Very well (skip to Q.4c)

02 Well (skip to Q4.c)

03 Not well

04 Not at all

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

Q.4ba (If 03 or 04 from Q. 4b) If English is not spoken, how does … communicate with service providers?

01 Relatives

02 Interpreter

03 Neighbors

04 Other (SPECIFY)

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

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

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

Household ID# 1

Q.4a*

(01) Very well
(02) Well

(03) Not well

(04) Not at all

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

-9 -8 -7

Q.4b

FOLLOW SKIP PATTERN

(01) Very well (skip to Q.4c)

(02) Well (skip to Q.4c)

(03) Not well

(04) Not at all

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

-9 -8 -7

Q.4ba

(01) Relatives

(02) Interpreter

(03) Neighbors

(04) Other (SPECIFY)

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

___________
04

-9 -8 -7

___________

-9 -8 -7

___________

-9 -8 -7

___________

-9 -8 -7

__________

-9 -8 -7

Q.4c*

FOLLOW SKIP PATTERN

(01) No (skip to Q.4e)

(02) Yes

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

-9 -8 -7

9 -8 -7

-9 -8 -7

Q.4d*

How many weeks?

(-1) If 1 week or less

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

__________

weeks

-1

-9 -8 -7

__________

weeks

-1

-9 -8 -7

__________

weeks

-1

-9 -8 -7

__________

weeks

-1

-9 -8 -7

__________

weeks

-1

-9 -8 -7

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?

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

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

Q.4h Within the past 12 months how many hours a day was ... in English language training?

Q.4j Is ... currently enrolled in an English language training program?

01 No

02 Yes (skip to Q.4k)

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

Q.4ja If not currently enrolled in an English language training program, why not?

01 Daycare constraints

02 Transportation constraints

03 Time constraints

04 Other (SPECIFY)

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

Household ID#

Q.4e

FOLLOW SKIP PATTERN

(01) No (skip to Q.5a)

(02) Yes

(-6) High School Student

(skip to Q.5a)

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

-6

-9 -8 -7

-6

-9 -8 -7

-6

-9 -8 -7

-6

-9 -8 -7

-6

-9 -8 -7

Q.4f

How many weeks?

(-1) If 1 week or less

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

__________

weeks

-1

-9 -8 -7

__________

weeks

-1

-9 -8 -7

__________

weeks

-1

-9 -8 -7

__________

weeks

-1

-9 -8 -7

__________

weeks

-1

-9 -8 -7

Q.4g

(01) Every day

(02) 2 to 6 times weekly

(03) Once a week

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

-9 -8 -7

Q.4h

How many hours per day?

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

__________

hours

-9 -8 -7

__________

hours

-9 -8 -7

__________

hours

-9 -8 -7

__________

hours

-9 -8 -7

__________

hours

-9 -8 -7

Q.4j

FOLLOW SKIP PATTERN

(01) No

(02) Yes (skip to Q.4k)

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

-9 -8 -7

Q.4ja

(01) Daycare constraints

(02) Transportation

constraints

(03) Time constraints

(04) Other (SPECIFY)

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

__________

-9 -8 -7

__________

-9 -8 -7

__________

-9 -8 -7

__________

-9 -8 -7

__________

-9 -8 -7

Q.4k 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) ________________

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

Q.5a Did ... work at a job anytime last week?

01 No (skip to Q.11a)

02 Yes

(-9) DK / (-8) RA / (-7) NA (skip to Q.11a)

[FOR PERSONS WHO WORKED LAST WEEK]

Q.5b Did ... work at more than one job last week?

01 No (skip to Q.6a)

02 Yes

(-9) DK / (-8) RA / (-7) NA (skip to Q.6a)

Q.5c How many jobs did ... work at last week?

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

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)

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

Q.6b How many hours did ... work at all jobs last week?

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

Q.7 How much money per hour did ... receive at his/her primary job last week? (If knows hourly wage, skip Q.8a & Q8b. If not, continue with Q.8a.)

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

Household ID#

Q.4k

(01) School or university

(02) Employer program

(03) Religious organization

(04) Refugee service agency

(05) Refugee Mutual Assistance

Association

(06) Private individual/group

(07) Other (SPECIFY)

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

-9 -8 -7

Q.5a

FOLLOW SKIP PATTERN

(01) No (skip to Q.11a)

(02) Yes

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

9 -8 -7

-9 -8 -7

Q.5b

FOLLOW SKIP PATTERN

(01) No (skip to Q.6a)

(02) Yes

(-9) DK / (-8) RA / (-7) NA (skip to Q.6a)

-9 -8 -7

Q.5c

How many jobs?

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

__________

# of jobs

-9 -8 -7

__________

# of jobs

-9 -8 -7

__________

# of jobs

-9 -8 -7

__________

# of jobs

-9 -8 -7

__________

# of jobs

-9 -8 -7

Q.6a

How many hours? (primary job)

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

Q.6b

How many hours? (all jobs)

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

Q.7

FOLLOW SKIP PATTERN

(If knows hourly wage, skip Q.8a & Q.8b. If not, continue with Q.8a)

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

$_____/hour

-9 -8 -7

$_____/hour

-9 -8 -7

$_____/hour

-9 -8 -7

$_____/hour

-9 -8 -7

$_____/hour

-9 -8 -7

Q.8a How much did ... earn before taxes from that job?

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

Q.8b On what basis is that amount computed?

01 Weekly

02 Bi-weekly

03 Monthly

04 Annually

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

(IF ... WORKED AT SECOND JOB LAST WEEK, GO TO Q.9)

(IF ... WORKED ONLY ONE JOB LAST WEEK, SKIP 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. If not, continue with Q.10a)

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

Q.10a How much did ... earn before taxes from that job?

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

Q.10b On what basis is that amount computed?

01 Weekly

02 Bi-weekly

03 Monthly

04 Yearly

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

(IF … ANSWERED Q.10b, SKIP TO Q.18a)

Household ID#

Q.8a

How much before taxes from that job?

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

________

-9 -8 -7

________

-9 -8 -7

________

-9 -8 -7

________

-9 -8 -7

________

-9 -8 -7

Q.8b

(01) Weekly

(02) Bi-weekly

(03) Monthly

(04) Yearly

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

-9 -8 -7

9 -8 -7

-9 -8 -7

(IF ... WORKED AT SECOND JOB LAST WEEK, ASK Q.9)

(IF...WORKED ONLY ONE JOB LAST WEEK, SKIP TO Q.18a)

Q.9

FOLLOW SKIP PATTERN

(If knows hourly wage, skip to Q.18a. If not, continue with Q.10a)

Hourly wage?

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

_______

$ per hour

-9 -8 -7

_______

$ per hour

-9 -8 -7

________

$ per hour

-9 -8 -7

________

$ per hour

-9 -8 -7

_______

$ per hour

-9 -8 -7

Q.10a

How much before taxes from that job?

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

________

-9 -8 -7

_________

-9 -8 -7

_________

-9 -8 -7

_________

-9 -8 -7

_________

-9 -8 -7

Q.10b

FOLLOW SKIP PATTERN

(If … answered Q.10b, skip to Q.18a)

(01) Weekly

(02) Bi-weekly

(03) Monthly

(04) Yearly

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

-9 -8 -7

9 -8 -7

-9 -8 -7

Q.11a 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) DK / (-8) RA / (-7) NA (skip to Q.12)

Q.11b (If yes to Q.11a, answer Q.11b. Otherwise skip to Q.12)

Since coming to the U.S., in how many weeks has ... ever worked?

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

Q.12 Was ... temporarily absent or on layoff from a job or business last week?

01 Temporarily absent

02 On layoff

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

Q.13 Has ... been looking for work during the last 4 weeks?

01 No (skip to Q.17)

02 Yes

(-9) DK / (-8) RA / (-7) NA (skip to Q.17)

Q.14 What has ... done to find a job? Has he/she checked with (multiple answers 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 who are not refugees

10 Other (SPECIFY) _____________

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

Household ID#

Q.11a

FOLLOW SKIP PATTERN

(01) Never worked in the U.S. (skip to Q.13)

(02) Yes. How many weeks since ... had a

job?

(-1) If 1 week or less

(-9) DK / (-8) RA / (-7) NA (skip to Q.12)

________

02
weeks

-1

-9 -8 -7

_________

weeks

-1

-9 -8 -7

_________

weeks

-1

-9 -8 -7

_________

weeks

-1

-9 -8 -7

________

weeks

-1

-9 -8 -7

Q.11b

How many weeks?

(-1) If less than 1 week

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

_________

weeks

-1

-9 -8 -7

_________

weeks

-1

-9 -8 -7

_________

weeks

-1

-9 -8 -7

_________

weeks

-1

-9 -8 -7

_________

weeks

-1

-9 -8 -7

Q.12

(01) Temporarily absent

(02) On layoff

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

-9 -8 -7

Q.13

FOLLOW SKIP PATTERN

(01) No (skip to Q.17)

(02) Yes

(-9) DK / (-8) RA / (-7) NA (skip to Q.17)

-9 -8 -7

Q.14

(01) Nothing

(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 who are not refugees

(10) Other (SPECIFY)

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

_________

-9 -8 -7

_________

-9 -8 -7

_________

-9 -8 -7

_________

-9 -8 -7

_________

-9 -8 -7

Q.15 How many weeks has ... been looking for a job?

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

Q.16 What caused ... to begin looking for work? (multiple answers may be given)

01 New arrival in the U.S.

02 Lost job

03 Quit job

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

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

(SKIP TO Q.18a IF WORKED OR SKIP TO Q.24a IF NEVER WORKED)

Q.17 Why is ... not looking for a job? (multiple answers 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

07 Other (SPECIFY) ______________

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

(SKIP TO Q.24a IF NEVER WORKED)

Household ID#

Q.15

How many weeks?

(-1) If less than 1 week

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

_________

weeks

-1

-9 -8 -7

_________

weeks

-1

-9 -8 -7

_________

weeks

-1

-9 -8 -7

_________

weeks

-1

-9 -8 -7

_________

weeks

-1

-9 -8 -7

Q.16

(01) New arrival in the U.S.

(02) Lost job

(03) Quit job

(04) Finished school

(05) Training ended

(06) Moved to a new area

(07) Medical problem ended

(08) Other (SPECIFY)

(09) Eligibility for cash/medical ended

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

_________

-9 -8 -7

_________

-9 -8 -7

_________

-9 -8 -7

_________

-9 -8 -7

_________

-9 -8 -7

Q.17

(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

(07) Other (SPECIFY)

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

(skip to q.24a if never worked)

_________

-9 -8 -7

_________

-9 -8 -7

_________

-9 -8 -7

_________

-9 -8 -7

_________

-9 -8 -7

[FOR ALL PERSONS WHO HAD WORKED IN THE U.S. -- IF DID NOT WORK LAST WEEK, ASK ABOUT LAST JOB. GO TO Q.24a IF INDIVIDUAL NEVER WORKED IN THE U.S.]

Q.18a In the last year, how many weeks did ... work?

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

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

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

Q.18c What were ...'s total earnings before taxes from all jobs in the past 12 months?

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

Q.18d When did ... get his/her first job in the U.S.?

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

Q.18e Did the income that ... received from his/her first job disqualify... from receiving cash assistance

(such as RCA,TANF, or GA)?

01 No

02 Yes

03 Was not receiving cash assistance at that time

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

Household ID#

Q.18a

How many weeks?

(-1) If less than 1 week

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

__________
weeks

-1

-9 -8 -7

__________
weeks

-1

-9 -8 -7

__________
weeks

-1

-9 -8 -7

__________
weeks

-1

-9 -8 -7

__________
weeks

-1

-9 -8 -7

Q.18b

How many hours per week?

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

__________

hrs/wk

-9 -8 -7

__________

hrs/wk

-9 -8 -7

__________

hrs/wk

-9 -8 -7

__________

hrs/wk

-9 -8 -7

__________

hrs/wk

-9 -8 -7

Q.18c

Total earnings for last 12 months

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

________

-9 -8 -7

________

-9 -8 -7

________

-9 -8 -7

________

-9 -8 -7

________

-9 -8 -7

Q.18d

Date of first job

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

____/ _____

Month Year

-9 -8 -7

____/ _____

Month Year

-9 -8 -7

____/ _____

Month Year

-9 -8 -7

____/ _____

Month Year

-9 -8 -7

____/ _____

Month Year

-9 -8 -7

Q.18e

(01) No

(02) Yes

(03) Was not receiving cash

assistance at that time

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

-9 -8 -7

[FOR ALL PERSONS WHO HAD WORKED IN THE U.S. -- IF DID NOT WORK LAST WEEK, ASK ABOUT LAST JOB. GO TO Q.24a IF INDIVIDUAL NEVER WORKED IN THE U.S.]

Q.19b What kind of business or industry is this?

(e.g., hospital, electronic parts manufacturing, social service agency)

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

Q.19c What kind of work does (did)… perform?

(e.g., nurse, assembly line worker, typist, supervisor)

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

Q.20 Is (was) ... a:

01 Employee of a private company, business, or individual (skip to Q.22a)

02 Federal government employee (skip to Q.22a)

03 State government employee (skip to Q.22a)

04 Local government employee (skip to Q.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]

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

Household ID#

Q.19b

What kind of business/industry?

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

__________

-9 -8 -7

__________

-9 -8 -7

__________

-9 -8 -7

__________

-9 -8 -7

__________

-9 -8 -7

Q.19c

What kind of work?

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

__________

-9 -8 -7

__________

-9 -8 -7

__________

-9 -8 -7

__________

-9 -8 -7

__________

-9 -8 -7

Q.20

FOLLOW SKIP PATTERN

Employee of a private

company (skip to Q.22a)

(02) Federal government

employee (skip to Q.22a)

(03) State government employee

( skip to Q.22a)

(04) Local government employee

( skip to Q.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

__________

-9 -8 -7

__________

-9 -8 -7

__________

-9 -8 -7

__________

-9 -8 -7

__________

-9 -8 -7

Q.21

(a) What kind of business is it?

(b) How many other refugees

does … employ?

does ... have?

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

__________
a

_______#ref

_____#emp

-9 -8 -7

_________
a

_______#ref

_____#emp

-9 -8 -7

___________
a

_______#ref

_____#emp

-9 -8 -7

__________
a

_______#ref

_____#emp

-9 -8 -7

__________
a

______#ref

_____#emp

-9 -8 -7

[FOR EMPLOYEES ONLY]

Q.22a What did ... do to find 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 (who are not refugees)

10 Religious organization

11 College/job training

12 Self

13 Relative

14 Other (SPECIFY) _____________

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

Q.24a Within the past 12 months, has ...attended any job training program?

01 No (skip to Q.25a)

02 Yes

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

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 (who are not refugees)

(10) Religious organization

(11) College/Job Training

(12) Self

(13) Relative

(14) Other (SPECIFY)

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

-9 -8 -7

Q.24a

FOLLOW SKIP PATTERN

(01) No (skip to Q.25a)

(02) Yes

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

-9 -8 -7

Q.24b How many weeks did that training last?

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

Q.24c Did the job-training class 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

Q.24d How many hours a day did the job-training class meet?

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

Q.24e For what kind of work (occupation) did this training prepare...?

(e.g., electronics assembler, welder, typist, nurse, childcare provider)

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

Household ID#

Q.24b

How many weeks?

(-1) If less than 1 week

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

________

weeks

-1

-9 -8 -7

_________

weeks

-1

-9 -8 -7

_________

weeks

-1

-9 -8 -7

________

weeks

-1

-9 -8 -7

_________

weeks

-1

-9 -8 -7

Q.24c

(01) Every day

(02) 2 to 6 times weekly

(03) Once a week

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

-9 -8 -7

Q.24d

How many hours per day?

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

_________

hours

-9 -8 -7

_________

hours

-9 -8 -7

_________

hours

-9 -8 -7

_________

hours

-9 -8 -7

_________

hours

-9 -8 -7

Q.24e

What type of training?

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

________

-9 -8 -7

________

-9 -8 -7

________

-9 -8 -7

________

-9 -8 -7

________

-9 -8 -7

Q.25a 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.26b)

02 Yes

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

Q.25b Was ... attending school or university in order to obtain a degree or certificate?

01 No (skip to Q.26b)

02 Yes

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

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

Q.25d Has ... received this degree or certificate?

01 No (skip to Q.26b)

02 Yes

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

Household ID#

Q.25a

FOLLOW SKIP PATTERN

(01) No (skip to Q.26b)

(02) Yes

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

-9 -8 -7

Q.25b

FOLLOW SKIP PATTERN

(01) No (skip to Q.26b)

(02) Yes

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

-9 -8 -7

Q.25c

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)

(06) Other (SPECIFY)

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

-9 -8 -7

Q.25d

FOLLOW SKIP PATTERN

(01) No (skip to Q.26b)

(02) Yes

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

-9 -8 -7

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

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

Q.26b How many months has ... lived at this residence/neighborhood?

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

Q.26c Did ... live at this residence a year ago?

01 No

02 Yes (skip to Q.26ea)

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

Q.26d Did ... live in this state a year ago?

01 No

02 Yes (skip to Q.26ea)

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

Q.26e In which state did … live a year ago?

01 Not in the U.S. (skip to Q.26f)

02 Specify state___________

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

Q.26ea Did … migrate from a different state?

No
Yes, if yes when
1. Within the last 90 days
2. Within the last 180 days
3. Within 1year
4. Other

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

Household ID#

Q.25e

What year?

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

________

YYYY

-9 -8 -7

________

YYYY

-9 -8 -7

________

YYYY

-9 -8 -7

________

YYYY

-9 -8 -7

________

YYYY

-9 -8 -7

Q.26b

How many months?

(-1) If less than 1 month

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

________

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

Q.26c

FOLLOW SKIP PATTERN

(01) No

(02) Yes (skip to Q.26ea)

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

-9 -8 -7

Q.26d

FOLLOW SKIP PATTERN

(01) No

(02) Yes (skip to Q.26ea)

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

-9 -8 -7

Q.26e

FOLLOW SKIP PATTERN

(01) Not in the U.S. (skip to Q.26f)

(02) Specify state__________

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

________

State

-9 -8 -7

________

State

-9 -8 -7

________

State

-9 -8 -7

________

State

-9 -8 -7

________

State

-9 -8 -7

Q.26ea

(01) No

(02) Yes, if yes when

a. Within the last 90 days

b. Within the last 180 days

c. Within 1year

d. Other

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

______

-9 -8 -7

______

-9 -8 -7

______

-9 -8 -7

c.
______

-9 -8 -7

______

-9 -8 -7

Q.26f What was the primary reason that ... moved to this state?

01 Employment opportunities

02 Better public assistance

03 Reunification with relatives

04 Other (SPECIFY)__________

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

Q.26g Does … know or communicate with your neighbors?

01 No

02 Yes

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

Q.26h Does … participate in their children’s education?

No
Yes (if yes how)

Attend parent- teacher meetings
Volunteer your time
Help with homework
Other____________

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

Q.26i Given the opportunity, would … move to a different state?

No
Yes (if yes, for what reasons)

Employment opportunity
Better public assistance
Reunification with relatives
Other _____________

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

Household ID#

Q.26f

(01) Employment opportunities

(02) Better public assistance

(03) Reunification with relatives

(04) Other (SPECIFY)

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

________

-9 -8 -7

________

-9 -8 -7

________

-9 -8 -7

________

-9 -8 -7

________

-9 -8 -7

Q.26g

(01) No
(02) Yes

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

-9 -8 -7

Q.26h

(01) No

(02) Yes (if yes how)

a. Attend parent- teacher meetings

b. Volunteer your time

c. Help with homework

d. Other __________

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

c.
______

-9 -8 -7

______

-9 -8 -7

c.
______

-9 -8 -7

c.
______

-9 -8 -7

c.
______

-9 -8 -7

Q.26i

(01) No

(02) Yes(if yes, for what reasons)

a. Employment opportunity

b. Better public assistance

c. Reunification with relatives

d. Other __________

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

c.
______

-9 -8 -7

______

-9 -8 -7

______

-9 -8 -7

______

-9 -8 -7

______

-9 -8 -7

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 (go to Q.27b)

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

Q.27b When did ... apply for adjustment to permanent resident status? (If application date is given, skip to Q.28)

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

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

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

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 a job?

01 No

02 Yes

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

b. Prevents this person from working at a job?

01 No

02 Yes

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

Household ID#

Q.27a

FOLLOW SKIP PATTERN

(01) No (skip to Q.27c)

(02) Yes (go to Q.27b)

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

-9 -8 -7

Q.27b

FOLLOW SKIP PATTERN

What date?

(If application date is given skip to Q.28)

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

___/_____

Month/Year

-9 -8 -7

___/_____

Month/Year

-9 -8 -7

___/_____

Month/Year

-9 -8 -7

___/_____

Month/Year

-9 -8 -7

___/_____

Month/Year

-9 -8 -7

Q.27c

(01) No

(02) Yes

(03) Did not know he/she had to

apply…

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

-9 -8 -7

Q.28a

(01) No

(02) Yes

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

-9 -8 -7

Q.28b

(01) No

(02) Yes

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

-9 -8 -7

Q.29a During the past 12 months, how were ...'s medical expenses paid? (May indicate more than one)

01 No medical expenses

Self or household members

03 Other relatives or friends

04 Sponsor/sponsoring agency

Religious organization
Medicaid
Refugee Medical Assistance (RMA)

08 Co-payments

09 Other government source

10 Insurance through own employment (e.g., Blue Cross)

11 Insurance through family member's employment

12 Other source (SPECIFY) __________________

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

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

06 Other (SPECIFY) __________________

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

Q.29c In the past 12 months, was … covered either by Refugee Medical Assistance, Medicaid, or private health insurance?

Yes - covered in all months
No - number of months not covered: _______

(-1) Not covered 1 month or less

(-3) Not covered in any month (skip to Q.30a)

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

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) ________________

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

Household ID#

Q.29a

(01) No medical expenses

Self or household members
Other relatives or friends
Sponsor/sponsoring agency
Religious organization
Medicaid

(07) Refugee Medical Assistance

(08) Co-payments

(09) Other government source

(10) Insurance through own

employment

(11) Insurance through family

member’s employment

(12) Other source (SPECIFY)

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

_________

-9 -8 -7

_________

-9 -8 -7

_________

-9 -8 -7

_________

-9 -8 -7

_________

-9 -8 -7

Q.29b

(01) No regular source

(02) Private physician

(03) Emergency room at a hospital

(04) Health clinic

(05) Folk healer

(06) Other (SPECIFY)

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

________

-9 -8 -7

________

-9 -8 -7

________

-9 -8 -7

________

-9 -8 -7

________

-9 -8 -7

Q.29c

FOLLOW SKIP PATTERN

(01) Yes - Covered in all 12 months

(02) No - # of months not covered

(-1) Not covered 1 month or less

(-3) Not covered in any month (skip to Q.30a)

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

_______

# months

-1

-3

-9 -8 -7

_______

# months

-1

-3

-9 -8 -7

_______

# months

-1

-3

-9 -8 -7

________

# months

-1

-3

-9 -8 -7

________

# months

-1

-3

-9 -8 -7

Q.29d

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)

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

________

-9 -8 -7

________

-9 -8 -7

________

-9 -8 -7

________

-9 -8 -7

________

-9 -8 -7

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) DK / (-8) RA / (-7) NA (skip to Q.31a)

Q.30b Who received them? (circle Household ID# and person # of the person who received assistance)

Q.30c What was the total cash value per month? (on a household level)

Q.30d How many months in the past 12 months were food stamps received?

Q.30a

FOLLOW SKIP PATTERN

(01) No (skip to Q.31a)

(02) Yes

(-9) DK / (-8) RA / (-7) NA (skip to Q.31a)

-9 -8 -7

Q.30b

Circle # 's from Household Control Chart

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

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17

-9 -8 -7

Q.30c

Total Cash Value (per month)

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

_________________

-9 -8 -7

Q.30d

How many months?

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

________________

# of months

-9 -8 -7

Q.31a TANF - In the past 12 months, have one or more persons in your household received cash assistance through the Temporary Assistance to Needy Families (TANF) Program?

01 No (skip to Q.31f)

02 Yes

(-9) DK / (-8) RA / (-7) NA (skip to Q.31f)

Q.31b Which household members received such assistance? (circle Household ID# and person # of the person who received assistance)

Q.31c What was the cash amount received each month? (on a household level)

Q.31d How many months in the past 12 months was the TANF received?

Q.31e In the last month, was TANF received?

01 No

02 Yes

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

Q.31f Since coming to the United States, in how many months have one or more persons in your household received TANF?

A Every month

B No months

C Number of months:____________

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

Q.31a

FOLLOW SKIP PATTERN

(01) No (skip to Q.31f)

(02) Yes

(-9) DK / (-8) RA / (-7) NA (skip to Q.31f)

-9 -8 -7

Q.31b

Circle # 's from Household Control Chart

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

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17

-9 -8 -7

Q.31c

Total Cash Value (per month)

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

_______________

-9 -8 -7

Q.31d

How many months?

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

________________

# of months

-9 -8 -7

Q.31e

(01) No

(02) Yes

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

-9 -8 -7

Q.31f

(A) Every month

(B) No months

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

_____________

# of months

-9 -8 -7

Q.32a RCA - In the past 12 months, have one or more persons in your household received assistance through the Refugee Cash Assistance (RCA) program?

01 No (skip to Q.33a)

02 Yes

(-9) DK / (-8) RA / (-7) NA (skip to Q.33a)

Q.32b Which household members received such assistance? (circle Household ID# and person # of the person who received assistance)

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

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.32a

FOLLOW SKIP PATTERN

(01) No (skip to Q.33a)

(02) Yes

(-9) DK / (-8) RA / (-7) NA (skip to Q.33a)

-9 -8 -7

Q.32b

Circle # 's from Household Control Chart

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

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17

-9 -8 -7

Q.32c

Total Cash Value (per month)

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

________________

-9 -8 -7

Q.32d

How many months?

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

______________

# of months

-9 -8 -7

Q.32e

(01) No

(02) Yes

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

-9 -8 -7

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.33f)

Q.33b Which household members received such assistance? (circle Household ID#s and person # of the person who received assistance)

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

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

C Number of months: ____________

Q.33a

FOLLOW SKIP PATTERN

(01) No (skip to Q.33f)

(02) Yes

(-9) DK / (-8) RA / (-7) NA (skip to Q.33f)

-9 -8 -7

Q.33b

Circle # 's from Household Control Chart

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

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17

-9 -8 -7

Q.33c

Total Cash Value (per month)

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

_________________

-9 -8 -7

Q.33d

How many months?

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

_____________

# of months

-9 -8 -7

Q.33e

(01) No

(02) Yes

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

-9 -8 -7

Q.33f

(A) Every month

(B) No months

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

_____________

# of months

-9 -8 -7

Q.34a 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.34f)

02 Yes

(-9) DK / (-8) RA / (-7) NA (skip to Q.34f)

Q.34b Which household members received such assistance? (circle Household ID#s and person # of the person who received assistance)

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

Q.34d How many months in the past 12 months was GA received?

Q.34e In the last month, was GA received?

01 No

02 Yes

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

Q.34a

FOLLOW SKIP PATTERN

(01) No (skip to Q.34f)

(02) Yes

(-9) DK / (-8) RA / (-7) NA (skip to Q.34f)

-9 -8 -7

Q.34b

Circle # 's from Household Control Chart

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

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17

-9 -8 -7

Q.34c

Total Cash Value (per month)

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

____________

-9 -8 -7

Q.34d

How many months?

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

_____________

# of months

-9 -8 -7

Q.34e

(01) No

(02) Yes

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

-9 -8 -7

Q.34f Since coming to the U.S., in how many months have one or more persons in your household received GA?

A Every month

B No months

C Number of months: ____________

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

Q.35a 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 (skip to Q.36a)

Q.35b 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

Q.35c Which household members received such assistance? (circle Household ID# and person # of the person who received assistance)

Q.35d What was the cash amount received each month? (on a household level)

Q.35e How many months in the past 12 months was this private assistance received?

Q.34f

(A) Every month

(B) No months

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

_______

# of months

-9 -8 -7

Q.35a

FOLLOW SKIP PATTERN

(01) No (skip to Q.36a)

(02) Yes

(-9) DK / (-8) RA / (-7) NA (skip to Q.36a)

-9 -8 -7

Q.35b

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

_______________

-9 -8 -7

Q.35c

Circle # 's from Household Control Chart

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

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17

-9 -8 -7

Q.35d

Total Cash Value (per month)

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

_______________

-9 -8 -7

Q.35e

How many months?

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

__________

# of months

-9 -8 -7

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)

Q.36b Who received the income? (circle Household ID# and person # in whose name income was received)

Q.36c What was the cash amount received on average each month? (on a household level)

Q.36d How many months was this income received in the past 12 months?

Q.36f What was the source of that income? (multiple answers may be given)

01 Interest income

02 Net rental income

03 Child support

04 Unemployment compensation

05 Retirement income

06 Other (SPECIFY) ___________________

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

Q.38a Is this house or apartment

Rented for cash rent
Owned by you or someone in this household with or without a mortgage or loan
Occupied without payment of cash rent (skip to Q.38c)

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

Q.38b 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)

Q.38c 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

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.

Q.36a

FOLLOW SKIP PATTERN

(01) No (skip to Q.38a)

(02) Yes

(-9) DK / (-8) RA / (-7) NA (skip to Q.38a)

-9 -8 -7

Q.36b

Circle # 's from Household Control Chart

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

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17

-9 -8 -7

Q.36c

Total Cash Value (per month)

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

_______________

-9 -8 -7

Q.36d

How many months?

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

___________

# of months

-9 -8 -7

Q.36f

(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

___________________________________

-9 -8 -7

Q.38a

FOLLOW SKIP PATTERN

(01) Rented for cash rent

(02) Owned by you or someone in this household ...

(03) Occupied without payment or cash rent (skip to

Q.38c)

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

-9 -8 -7

Q.38b

Rent $

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

___________

-9 -8 -7

Q.38c

(01) No

(02) Yes

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

-9 -8 -7

FOR INTERVIEWER ONLY

A. Time Interview Ended _________________________ (Please, use military time)

B. General Responsiveness of Respondent

Willing
Neutral
Reluctant
Other

C. List Difficulties, if any, With the Interview

________________________________________________________________________

D. Language in which Interview was Conducted		E. Interviewer's Ethnicity


RS	Russian	RS	Russian
VN	Vietnamese	VN	Vietnamese
LA	Laotian	LA	Lao
CB	Cambodian	CB	Cambodian
HM	Hmong	HM	Hmong
SP	Spanish	SP	Cuban/other Hispanic
AH	Amharic	ET	Ethiopian
HA	Creole	HA	Haitian
CN	Chinese	CN	Chinese
RO	Romanian	RO	Romanian
PL	Polish	PL	Polish
AN	Armenian	AN	Armenian
UP	Ukrainian	UP	Ukrainian
AR	Arabic	IZ	Iraqi
IR	Farsi	IR	Iranian
AF	Afghan	AF	Afghan
SO	Somalian	SO	Somalian
BU	Bulgarian	BU	Bulgarian
SR	Serbo-Croatian	SR	Serbian
EN	English

Other (SPECIFY) ________________		Other (SPECIFY) __________________

END

File Type	application/msword
File Title	OMB Number: 0970-0033
Author	sdavis
Last Modified By	Molly
File Modified	2016-03-21
File Created	2012-03-15