OMB Clearance Number: 2528-0337
Expires: XX/XX/XXXX
Attachment F.1: The Home Assessment Survey Baseline
If you require information to be presented in an accessible format or reasonable accommodations to participate in this study, please contact us with any specific requests by calling XXX-XXX-XXXX or emailing XXXX@XXXX.XXX. If you require language assistance to participate in this study, please contact us with any specific language assistance requests or needs.
Paperwork Reduction Act Burden Statement
This collection of information is voluntary and will be used to evaluate the US Department of Housing and Urban Development’s Community Choice Demonstration. Public reporting burden for this collection of information is estimated to average 15 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. The OMB number for this collection is OMB 2528-0337 which expires on XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to NAME at XXXX@XXXXX.XXX or call XXX-XXX-XXXX.
Privacy Act Statement
Authority: Section 502 of the Housing and Urban Development Act of 1970 (Public Law 91-609) (12 U.S.C. §§ 1701z-1; 1701z-2(d) and (g)).
Purpose: Evaluation of the Community Choice Demonstration (CCD).
Routine Use: The information will be used for the purpose set forth above and may be provided to Congress or other Federal, state, and local agencies, when determined necessary.
Disclosure: Records will be used for research and statistical analysis and will not be used to make decisions that affect the rights, benefits, or privileges of specific individuals.
SORN ID: Community Choice Demonstration Evaluation Data Files, HUD/PDR-09
Thank you for agreeing to participate in the Home Assessment study. Your participation is voluntary. You can feel free to skip any questions that you do not wish to answer. If you want to skip a question, just let me know and we’ll move on to the next item. Your answers will be kept private. They will be used for research purposes only. Your name will never be linked to your responses in any reports. You do not need to disclose any medical or disability related information if you do not wish to, but if you do disclose that information it will not be shared with anyone or used in any way to impact your eligibility for any public program or activity.
This survey should take up to 15 minutes to complete. If you have any questions about the study or about this survey, please contact XXXX, the Abt Associates Survey Director, at XXXX@abtassoc.com or call the study’s toll-free number XXX-XXX-XXXX.
Do you or do any of the residents in your housing unit smoke?
☐ Yes
☐ No
☐ Don‘t know
☐ Prefer not to answer
1A. [If Q1 response is Yes] What do you or others that you live with smoke? (Check all that apply)
☐ Tobacco cigarettes, cigars or pipes
☐ E-Cigarettes, including vapes
☐ Hookah
☐ Other tobacco products
☐ Other non-tobacco products
☐ Don‘t know
☐ Prefer not to answer
1B. [If Q1 response is Yes] How often do you or someone living with you smoke inside the housing unit?
☐ Multiple times a day
☐ Once a day
☐ A few times a week
☐ Once a week or less
☐ Never
☐ Don‘t know
☐ Prefer not to answer
In the last 3 months, have any visitors to your household smoked tobacco inside your housing unit?
☐ Yes
☐ No
☐ Don‘t know
☐ Prefer not to answer
In the last 3 months, how often has secondhand tobacco smoke (i.e., smoke inhaled involuntarily) entered inside your housing unit from somewhere else in or around the building?
☐ Daily
☐ Weekly
☐ A few times a month
☐ Never
☐ Don‘t know
☐ Prefer not to answer
3A. Excluding secondhand tobacco smoke, do you smell other types of smoke from your neighbors’ housing units?
☐ Yes
☐ No
☐ Don‘t know
☐ Prefer not to answer
Do you have a dog, cat, or other pet with fur that you allow inside?
☐ Yes
☐ No
☐ Don‘t know
☐ Prefer not to answer
4A. [If Q4 response is Yes] Is your pet allowed on the furniture such as on the bed or on couches?
☐ Yes
☐ No
☐ Don‘t know
☐ Prefer not to answer
How often do you cook in the housing unit using your stove?
☐ Multiple times a day
☐ Once a day
☐ A few times a week
☐ Once a week or less
☐ Never or no stove
☐ Don‘t know
☐ Prefer not to answer
Is there a working fume hood that vents your stove?
☐ Yes
☐ No
☐ Don‘t know
☐ Prefer not to answer
6A. [If Q6 response is Yes] Fume hoods that are vented to the outside carry air through a pipe to the exterior of the housing unit. Fume hoods that are not vented to the outside recirculate filtered air back into your kitchen. Where does your fume hood vent to?
☐ Vents to the outside
☐ Does not vent to the outside
☐ I don’t know how it vents
☐ Prefer not to answer
Do you have a gas stove?
☐ Yes
☐ No
☐ Don’t know
☐ Prefer not to answer
Please indicate how often you currently see the pests, or signs of pests, listed below in your housing unit by checking one box for each pest.
|
Never |
Less than once a week |
Once a week |
More than once a week |
Don’t know |
Prefer not to answer |
Cockroaches |
☐ |
☐ |
☐ |
☐ |
☐
|
☐ |
Mice |
☐ |
☐ |
☐ |
☐ |
☐
|
☐ |
Rats |
☐ |
☐ |
☐ |
☐ |
☐
|
☐ |
In the past 3 months, have you, an exterminator, or your landlord used any pest control measures (pesticides, traps, baits, gels, etc.) to control any of the following in your housing unit? (Check all that apply):
☐ Cockroaches
☐ Mice
☐ Rats
☐ Other insects/pests (e.g., bed bugs, ants): _________
☐ None of the above
☐ Don’t know/Not sure
☐ Prefer not to answer
How do you cool your housing unit? (Check all that apply)
☐ Central A/C
☐ Window A/C (or portable free-standing unit)
☐ Fans
☐ Evaporative cooler
☐ Open window
☐ Other: ______________
☐ Don’t know
☐ Prefer not to answer
10a. [If Q10 response is Central A/C or Window A/C] In the past 3 months, has the air conditioning (A/C) system in your housing unit been working properly?
☐ Yes
☐ No or the system is not working
☐ Don’t know
☐ Haven’t used system in past 3 months
☐ Prefer not to answer
During the winter, how is your housing unit heated? (Check all that apply)
☐ Radiators
☐ Baseboard heater
☐ Forced hot air (vents, central heat)
☐ Electric space heater
☐ Kerosene space heater
☐ Fireplace/wood-burning stove
☐ Other: ______________
☐ Don’t know
☐ Prefer not to answer
11a. In the past 3 months, have the heating systems in your housing unit been working properly? If multiple appliances are used to heat your home and any part of the house was heated, answer Yes even if one appliance was broken.
☐ Yes
☐ No system is working
☐ Don’t know
☐ Haven’t used system in past 3 months
☐ Prefer not to answer
Do you currently have issues with leaky pipes (including under the sink) or water coming into your housing unit? If so, have you reported them to your landlord?
☐ Yes, reported to landlord
☐ Yes, not reported
☐ No
☐ Don’t know
☐ Prefer not to answer
In the past 3 months, have you seen or smelled any mold in your housing unit? If so, have you reported it to your landlord?
☐ Yes, reported to landlord
☐ Yes, not reported
☐ No
☐ Don’t know
☐ Prefer not to answer
13A. [If Q13 response is Yes] Where in your housing unit was the mold located? (Check all that apply)
☐ Bathroom
☐ Children’s Bedroom
☐ Other Bedroom
☐ Basement
☐ Kitchen
☐ Other room: ____________
☐ Don’t know
☐ Prefer not to answer
How often do you burn incense or candles in your housing unit?
☐ Daily
☐ A few times a week
☐ Once a week or less
☐ Once a month
☐ Never
☐ Don’t know
☐ Prefer not to answer
Now I have some questions about the health of people in your housing unit.
(IF NEEDED: Please remember that your responses to these questions will be kept confidential. If you prefer not to answer any questions, just let me know and we’ll move to the next question.)
Have you ever been told by a doctor or other health professional (like a nurse) that a child in your housing unit has any of the following respiratory conditions? (Check all that apply)
☐ Asthma
☐ Bronchitis
☐ Respiratory allergies
☐ Other respiratory condition (for example, cystic fibrosis or chronic sinusitis):
☐ None of the above
☐ Don’t know
☐ Prefer not to answer
[Ask if Q15 response includes Asthma, Bronchitis, Respiratory allergies, or “Other”; if None, DK, or Prefer not to answer, skip to END] What is the first name of the child with this/these condition(s)? If there is more than one child with these conditions, what is the name of the child who has asthma? If both children or neither child have asthma, what is the name of the child whose conditions are the worst? You can also choose to use a nickname.
Child’s First Name:
☐ Prefer not to answer [If selected, read in “this child”]
[Focus further questions in the interview on this child.]
[If Q15 response includes Asthma] During the past 3 months, has [name of child] had an episode of asthma or an asthma attack?
☐ Yes
☐ No [SKIP TO Q20]
☐ Don’t know [SKIP TO Q20]
☐ Prefer not to answer [SKIP TO Q20]
17A. [If Q17 response is Yes] How many episodes or attacks? ____ Enter number of episodes/attacks
☐ Don’t know
☐ Prefer not to answer
[If Q17 response is Yes] During the past 3 months, did [name of child] visit an emergency room or urgent care center because of their asthma?
☐ Yes
☐ No
☐ Don’t know
☐ Prefer not to answer
[If Q17 response is Yes] In the past 3 months, how many days of school did [name of child] miss due to an episode of asthma or an asthma attack?
☐ Less than 1 day
☐ 1-5 days
☐ 6-10 days
☐ 11 -15 days
☐ More than 15 days
☐ Home schooled
☐ Did not go to school in the past 3 months for other reasons
☐ None
☐ Don’t know
☐ Prefer not to answer
[If Q15 response includes Bronchitis, Respiratory allergies, or “Other” response; otherwise skip to Q21] How many times has [name of child] had symptoms from [if Q15=Bronchitis, read “Bronchitis”, if Q15=Respiratory allergies, read “Respiratory allergies” “or” if Q15=other, read in “[Other text]”] in the past 3 months?
☐ None
☐ Once
☐ Twice
☐ Three times
☐ More than three times
☐ Don’t know
☐ Prefer not to answer
[If Q15 response includes any illness other than asthma; otherwise skip to Q22] During the past 3 months, how many times did [name of child] go to the emergency room because of [ [if Q15=Bronchitis, read “Bronchitis”, if Q15=Respiratory allergies, read “Respiratory allergies” “or” if Q15=other, read in “[Other text]”]
☐ None
☐ Once
☐ Twice
☐ More than twice
☐ Not applicable
☐ Don’t know
☐ Prefer not to answer
[If Q20 response is anything other than “None”] How long has it been since [name of child] last had any symptoms from [if Q15=Bronchitis, read “Bronchitis”, if Q15=Respiratory allergies, read “Respiratory allergies” “or” if Q15=other, read in “[Other text]”]?
☐ Less than 1 day ago
☐ 1-6 days ago
☐ 1 week to less than 1 months ago
☐ 1 month to less than 2 months
☐ 2 months to less than 3 months
☐ Not applicable
☐ Don’t know
☐ Prefer not to answer
Those are all of the questions I have. Thank you for completing this survey. As a reminder, we will contact you in a year to conduct the follow-up Home Assessment.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Shelley Phillips |
| File Modified | 0000-00-00 |
| File Created | 2024-10-27 |