Attachment XI Shuttle Form - English

Consumer Price Index: Housing Update Form
PLEASE DELETE OR DESTROY AFTER USE
	OMB No. 1220-0163
BLS Contact:	<Data Collector's Name>
Contact Phone:	<Data Collector's Phone #>
Contact Fax:	<Data Collector's Fax #>
Contact Email:	<Data Collector's Email>
Please Return Form By:	<Date>
Number of Units:	1
Address:				Unit:
Is this house/apartment occupied by the owner or is it rented?					<Select>
Is this house/apartment Public Housing?					<Select Yes or No>
If Yes, Is it owned or operated by a government agency?					<Select Yes or No>
Is this house/apartment part of an assisted living program?					<Select Yes or No>
If Yes, Does the program provide ADL assistance to an occupant of this house/apartment?					<Select Yes or No>
Is this house/apartment the primary residence of at least one of the occupants?					<Select Yes or No>
Is anyone living in the household a relative of the landlord?					<Select Yes or No>
How many bedrooms, baths, and other rooms are there?
Bedrooms:					<#>
Full Baths:					<#>
Half Baths:					<#>
Other Rooms (E.g., Kitchen, Living Room, Finished Basement, etc.):					<#>
Total:					0
In what year was this structure built? If the exact year is not known, the decade sufficient.					<Enter Year>
Is this house/apartment under rent control?					<Select Yes or No>
When did the person, who has lived in this house the longest, move in?					<Enter Month and Year>
Do you/Does the tenant have a lease or other rental agreement?					<Select Yes or No>
If Yes, How long is the current lease agreement?					<Select>
If Yes, and longer than month-to-month, in what month and year did the current lease start?					<Enter Month and Year>
What is the tenant's name OR initials?					<Enter Name of Occupant>
How much rent are you/is the tenant paying for this house now?					<Enter Amount>
What period of time does that rent cover?					<Select>
Is the rent lower because the Landlord receives a subsidy from a government program such as Section 8?					<Select Yes or No>
If Yes, how much was the subsidy?					<Enter Amount>
Is the rent lower because someone did work for the landlord?					<Select Yes or No>
If Yes, how much was the work reduction?					<Enter Amount>
			Total Rent:		$-
Does this rent include any optional extra charges?					<Select Yes or No>
If Yes, what is the amount of the extra charge?					<Enter Amount>
What is this extra charge for?					<Enter Name of Charge>
Does the Landlord provide free off-street parking?					<Select Yes or No>
Who pays for the water service?					<Select>
Who pays for the sewer service?					<Select>
Who pays for the electricity?					<Select>
If this is paid by the Tenant, is the cost of electricity included in the rent you reported earlier?					<Select Yes or No>
If Yes, how much is the charge for electricity for this house?					<Enter Amount>
What type of A/C equipment does this unit have?					<Select>
If Thru-the-wall A/C, how many does this unit have?					<Enter Amount>
If Window A/C, how many does this unit have?					<Enter Amount>
How many are provided by the Landlord?					<Enter Amount>
What is the primary type of heating fuel used by this unit?					<Select>
Who pays for the heating fuel?					<Select>
If this is paid by the tenant, is the cost of heat fuel included in the rent you reported earlier?					<Select Yes or No>
If Yes, how much is the charge for the heat fuel this house?					<Enter Amount>
What is the primary type of hot water fuel used by this unit?					<Select>
Who pays for the hot water fuel?					<Select>
If this is paid by the tenant, is the cost of hot water fuel included in the rent you reported earlier?					<Select Yes or No>
If Yes, how much is the charge for the hot water fuel this house?					<Enter Amount>
Please verify the house/apartment's structure type.					<Select>
If this is a multi unit structure, is there an elevator?					<Select Yes or No>
For future data collection, would you prefer to be contacted by phone or email?					<Select>
What is your preferred contact time? (E.g. weekdays between noon and 3:00PM)					<Enter Contact Time>
What is the best phone number or email address to contact you?					<Enter Phone or Email>
Is there someone else that can answer these questions in the future, if you cannot be reached?					<Select Yes or No>
If Yes, what is this manager/authorized representative's name?					<Enter Manager/Rep.'s Name>
What is this manager/authorized representative's phone number or email?					<Enter Phone or Email>
What is this manager/authorized representative's preferred contact time?					<Enter Contact Time>
Additional Information:	The tenant's name is only used to denote occupancy changes, and is not required.
						Respondent Comments: