CARD C
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Individual(s) or family |
Group Living |
Other Place |
Institution |
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Homeless
Other Type of Housing |
Average Grades in High School
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As to Cs
Ungraded
Other (please describe)
Individual Math Courses
General math
Basic math
Vocational math
Elementary algebra
Algebra I
Intermediate algebra
Algebra II
Advanced algebra
Geometry
Trigonometry
Pre-calculus
Calculus
Other advanced math
Other math
Science Courses
Who Provided You with Financial Assistance
Your Parents
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Amount Still Owed on Loans
(A) $1 - 1,000
(B) 1,001 - 2,500
(C) 2,501 - 5,000
(D) 5,001 - 10,000
(E) 10,001 - 25,000
(F) 25,001 - 50,000
(G) More than $50,000
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General introductory course in computer literacy
Word processing course
Computer programming course
Other computer courses
Shop or industrial arts
Home economics
School-to-Work Programs
Activity
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Description
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- combining academic and vocational studies with a job in a related field |
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- working for an employer to learn about a particular occupation or industry |
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- spending time following workers at a work site |
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- being matched with an individual in an occupation |
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- the production of goods or services by students for sale to or use by others |
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- a planned program of study with a defined career focus that links secondary and post-secondary education |
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Reason for Not Working
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Why You Stopped Working
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Why You Left This Job
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Night shift
Day shift
Evening shift
Benefits Some Employers Make Available
Type of Benefit
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Description
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- Insurance that pays some or all of your medical expenses. |
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- Insurance that pays your survivors in the event of your death. |
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- Insurance that helps pay for the care of your teeth. |
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- Leave during the period before and after the birth or adoption of a child for which you ARE paid. |
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- Leave during the period before and after the birth or adoption of a child for which you ARE NOT paid. |
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- A plan that helps you save for or puts money away for your retirement.
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- Allows for scheduling options on your job. |
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- Pays for schooling. |
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- Company provided or subsidized. |
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- Allows employees to purchase company stock at reduced rates. |
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How You Looked for Work
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Main Reason for Not Working
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Reason for Unpaid Vacation/Leave
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(A) $1 - 1,000
(B) 1,001 - 2,500
(C) 2,501 - 5,000
(D) 5,001 - 10,000
(E) 10,001 - 25,000
(F) 25,001 - 50,000
(G) 50,001 - 100,000
(H) 100,001 – 250,000
(I) More than $250,000
How You Looked for a Job
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Some Sources of Occupational Training Programs Include
apprenticeship programs
business schools
company or military training
correspondence courses
cosmetology schools
employer training programs
night schools
nursing courses
vocational or technical institutes or schools
Reason You Enrolled in Training
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Skills Learned From This Training
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Religions
CATHOLIC |
PROTESTANT |
JEWISH |
OTHERS |
NONE/NO RELIGION |
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Amount Received for Unemployment
A B C D E F
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$1 $100 $150 $200 $250 $350 or more------------------>
A. $1 - $100 B. $101 - $150 C. $151 - $200 D. $201 - $250E. $251 - $350 F. More than $350 |
(A) $1 – 100
(B) 101 – 200
(C) 201 – 300
(D) 301 – 400
(E) 401 – 500
(F) 501 – 600
(G) 601 – 700
(H) 701 – 800
(I) 801 – 900
(J) 901 - 1,000
(K) 1,001 - 1,250
(L) More than $1,250
Cost to Purchase Food Items
(A) $1 – 20
(B) 21-40
(C) 41-60
(D) 61-80
(E) 81-100
(F) More than $100
Income after Expenses
(B) $1 - 5,000
(C) $5,001 - 10,000
(D) $10,001 - 25,000
(E) $25,001 - 50,000
(F) $50,001 - 100,000
(G) $100,001 - 250,000
(H) More than $250,000
(A) Lost or Would Lose Money
(A) $1 - 5,000
(B) 5,001 - 10,000
(C) 10,001 - 25,000
(D) 25,001 - 50,000
(E) 50,001 - 100,000
(F) 100,001 - 250,000
(G) More than $250,000
(A) $1 - 1,000
(B) 1,001 - 2,500
(C) 2,501 - 5,000
(D) 5,001 - 10,000
(E) 10,001 - 25,000
(F) 25,001 - 50,000
(G) More than $50,000
(A) $1 – 500
(B) 501 - 1,000
(C) 1,001 - 2,500
(D) 2,501 - 5,000
(E) 5,001 - 7,500
(F) 7,501 - 10,000
(G) More than $10,000
(A) $1 - 1,000
(B) 1,001 - 2,500
(C) 2,501 - 5,000
(D) 5,001 - 10,000
(E) 10,001 - 25,000
(F) 25,001 - 50,000
(G) 50,001 – 100,000
(H) More than 100,000
(A) $1 - 5,000
(B) 5,001 - 10,000
(C) 10,001 - 25,000
(D) 25,001 - 50,000
(E) 50,001 - 100,000
(F) 100,001 - 250,000
(G) 250,001 - 500,000
(H) More than $500,000
(A) $1 - 25,000
(B) 25,001 - 50,000
(C) 50,001 - 100,000
(D) 100,001 - 250,000
(E) 250,001 - 500,000
(F) 500,001 - 1,000,000
(G) More than $1,000,000
Who Loaned You Money?
Your family |
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Your spouse’s or partner’s family |
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Informal Care |
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- child is cared for by your live-in spouse or partner who may or may not be the child’s father |
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- child is cared for by your relative or in-law, including the child’s father if the father does not live with the child; this type of care does not include care given by any of your other children |
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- child is cared for by one of your other children |
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- child cares for herself or himself |
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- child is cared for by a baby-sitter, nanny, boyfriend, or friend in the child’s home |
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Formal Care |
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- child is cared for by a non-relative in the non-relative’s home -even if your child is the only one for whom the provider cares |
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- child is cared for in a preschool, Head Start, Montessori, day-care center, nursery school, or other pre-kindergarten program |
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- child attends a kindergarten, elementary, middle, or junior high school |
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- child receives formal care after school |
Relatives who Provide Child Care
Cause of Death
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Heart Attack/Stroke
Accident
Cancer
Old Age
Emphysema
Other (specify)
Relatives (including in-laws)
Type of Relationship
SPOUSE Wife Husband |
PARENTS Mother Father Adoptive Mother Adoptive Father Step-mother Step-father Foster Mother Foster Father
(GREAT) GRANDPARENTS Grandmother (Biological or Social) Grandfather (Biological or Social) Great-grandmother (Biological or Social) Great-grandfather (Biological or Social) Great-great-grandmother Great-great-grandfather
NON-RELATIVES Daughter of Lover/Partner Son of Lover/Partner Roommate Lover/Partner Other Non-relative Mother’s Boyfriend/Partner Father’s Girlfriend/Partner |
IN-LAWS Mother-in-law Father-in-law Sister-in-law Brother-in-law Daughter-in-law Son-in-law Grandmother-in-law Grandfather-in-law Great-grandmother-in-law Great-grandfather-in-law Aunt-in-law Uncle-in-law Cousin-in-law
OTHER RELATIVES Aunt (Biological or Social) Uncle (Biological or Social) Great Aunt Great Uncle Niece (Biological or Social) Step-niece (Biological or Social) Foster-niece (Biological or Social) Adoptive Niece (Biological or Social) Nephew (Biological or Social) Step-nephew (Biological or Social) Foster Nephew (Biological or Social) Adoptive Nephew (Biological or Social) Female Cousin (Biological or Social) Male Cousin (Biological or Social) Other Relative |
CHILDREN Daughter (Biological) Son (Biological) Step-daughter Step-son Adoptive Daughter Adoptive Son Foster Daughter Foster Son
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(GREAT) GRANDCHILDREN Granddaughter (Biological or Social) Grandson (Biological or Social) Great-granddaughter Great-grandson |
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SIBLINGS Sister (Full) Brother (Full) Sister (Half) Brother (Half) Sister (Step) Brother (Step) Sister (Adoptive) Brother (Adoptive) Sister (Foster) Brother (Foster) |
Current Immigration Status
Applicant for naturalization to become U.S. citizen
Have a “Green Card”—Lawful permanent resident of the U.S. (LPR)
Applicant for Lawful permanent residence (LPR)
Refugee/Asylee/Entrant
On temporary visa
Living outside of the U.S. at this time
Other
How Often I Eat Fruit
I do not typically eat fruit
1 to 3 times
4 to 6 times
1 time per day
2 times per day
3 times per day
4 or more times per day
How Often I Eat Vegetables
I do not typically eat vegetables
1 to 3 times
4 to 6 times
1 time per day
2 times per day
3 times per day
4 or more times per day
Health Conditions
Asthma
Cardiovascular or heart condition
Anemia
Diabetes
Cancer
Epilepsy
HIV/AIDS
Sexually transmitted disease other than HIV/AIDS
Other
Disagreement/Agreement Scale
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1 2 3 4 5 6 7
Disagree Disagree Disagree Neither Agree Agree Agree
Strongly Moderately a little Agree a little Moderately Strongly
nor
Disagree
Activities You Engaged In
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Employer-directed travel
Employer-directed training
Meal break
Rest break
Personal business
Normal work activity
Other activity (SPECIFY)
Frequencies
All of the Time
Most of the Time
A Good Bit of the Time
Some of the Time
A Little of the Time
None of the Time
Ladder of Life
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10 Best Possible Life |
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0 Worst Possible Life |
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Dollar Ranges
$1 – 10
11 – 25
26 – 50
51 – 100
101 – 150
151 – 250
More than $250
$0
1 – 5,000
5,001 - 10,000
10,001 - 25,000
25,001 - 50,000
50,001 - 100,000
100,001 - 250,000
More than $250,000
File Type | application/msword |
File Title | Type of Place |
Author | Sanchez-Manuel |
Last Modified By | KINCAID_N |
File Modified | 2010-05-27 |
File Created | 2010-05-27 |