ASSETS FOR INDEPENDENCE (AFI)
PROGRAM EVALUATION
INSTRUMENT 1
AFI Baseline Questionnaire
Table of Contents
6. Household Income and Expenses 13
7. Financial Experience and Assets 16
THE PAPERWORK REDUCTION ACT OF 1995: Public reporting burden for this collection of information is estimated to average 30 minutes per response (though the total information collection burden for the baseline and follow-up questionnaires is 60 minutes), 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.
Explanatory Notes
This questionnaire has been developed for the Assets for Independence (AFI) program evaluation. Two AFI grantees will be selected to participate in the evaluation. A research sample of AFI-eligible households will be enrolled in conjunction with normal intake procedures used by the participating grantees.
Program operational procedures will differ at each intake site. We expect that program staff will screen potential participants for AFI eligibility using a paper form. Once they screen someone as project-eligible, they will create a case for the participant in the site management system. As part of this computer entry process, the site administrator (a member of the on-site intake staff of the AFI project) will confirm the respondent’s language, will obtain the respondent’s informed consent to participate in the evaluation, and (for those who consent) will launch the self-administered baseline questionnaire on a laptop computer. Once the demographic section begins, the participant will answer questions independently in a private setting.
After completion of the baseline questionnaire, each respondent will be randomly assigned (via software within the site management system) to the treatment group or to the control group. Cases in the treatment group are allowed to receive IDA services, while cases in the control group are not allowed to receive IDA services, but can access non-IDA services offered by the site.
Start-up and Informed Consent
Intro1. SITE ADMINISTRATOR: IS RESPONDENT ABLE TO PROCEED WITH THE INFORMED CONSENT AND BASELINE SURVEY IN ENGLISH?
1. Yes [USE CONSENT FORM IN ENGLISH]
2. No [USE TRANSLATION OF CONSENT FORM (Spanish or other)]
AT THIS POINT ADMINISTER INFORMED CONSENT.
Demo1a. Please provide the following information about yourself:
First
and Last |
Birth
Date |
Current
Marital |
Gender |
Ethnicity – Hispanic/Latino (Select
one or more) |
Race |
First Name
Last Name
|
MM DD YYYY |
1 Married, now 2 Never Married 3 Separated 4 Widowed 5 Divorced IF STATUS =2-5: Are you living with a partner? 1 Yes 2 No |
1 Male 2 Female |
1 Mexican, Mexican American, Chicano/a 2 Puerto Rican 3 Cuban 4 Another Hispanic, Latino/a or Spanish origin 5 Not Hispanic or Latino/a, or Spanish origin |
1 White 2 Black or African American 3 American Indian or Alaska Native 4 Asian Indian 5 Chinese 6 Filipino 7 Japanese 8 Korean 9 Vietnamese 10 Other Asian 11 Native Hawaiian 12 Guamanian or Chamorro 13 Samoan 14 Other Pacific Islander |
Demo1b. Please provide the following information about yourself:
Do
you speak a language other than English at home? |
IF
YES… How well do you speak English? |
IF
YES… How well do you read English? |
1 Yes 2 No |
1 Very Well 2 Well 3 Not Well 4 Not at All |
1 Very Well 2 Well 3 Not Well 4 Not at All |
Demo2. (SIPP W1 Section C –EDUCA) What is the highest level of school you have completed or the highest degree you have received?
Grade 1 to 11 (with fill in for highest grade completed)
12th grade – no diploma
GED or alternative credential
Regular high school diploma
Some college credit, but less than one year of college credit
1 or more years of college credit, but no degree
Associate’s degree (for example, AA or AS)
License or certificate (for example real estate, medical technician, beautician)
Bachelor’s degree or higher (for example, BA or BS)
Demo4. What is your current home address, including zip code?
ADDRESS
CITY, STATE ZIP
Demo5. Household size (# adults)
Not including yourself, how many people 18 years of age or older are currently living at your address? “Living at your address” means every other adult who considers it their current primary residence, or who stays there at least three nights per week, every week.
_________________________
NUMBER: [RANGE 0-20]
Demo6. [IF Demo5>0] Please provide the following information about the [next oldest adult in your household]:
ANSWER DEMO6 AND DEMO7 FOR EACH ADULT IN HOUSEHOLD.
First
and Last |
Birth
Date |
Current
Marital |
Gender |
Relationship
to the Respondent |
Ethnicity – Hispanic/Latino (Select
one or more) |
Race |
First Name
Last Name
|
MM DD YYYY IF MISSING, ASK AGE |
1 Married 2 Widowed 3 Divorced 4 Separated 5 Never married
|
1 Male 2 Female |
1 Spouse 2 Unmarried partner 3 Father/Mother 4 Brother/Sister 5 Other relative 6 Other Non relative |
1 Mexican, Mexican American, Chicano/a 2 Puerto Rican 3 Cuban 4 Another Hispanic, Latino/a or Spanish origin 5 Not Hispanic or Latino/a, or Spanish origin |
1 White 2 Black or African American 3 American Indian or Alaska Native 4 Asian Indian 5 Chinese 6 Filipino 7 Japanese 8 Korean 9 Vietnamese 10 Other Asian 11 Native Hawaiian 12 Guamanian or Chamorro 13 Samoan 14 Other Pacific Islander |
PROGRAMMER: DISPLAY ROSTER AND ADMINISTER DEMO7 BELOW.
Demo7. Is there anybody else 18 years of age or older living or staying at your address?
1. Yes (ANSWER DEMO6)
2. No (ANSWER DEMO8a)
Demo8a. How many children under the age of 6 live or stay at your address? Include each child for whom your address is their current primary residence, or who lives there at least three days per week, every week. Please include biological, adopted, foster, step and any other children under age 6.
__________________
RANGE: 0-15 [SOFT CHECK IF 6 OR MORE]
Demo8b. How many children ages 6 to 17 live or stay at your address? Please include biological, adopted, foster, step and any other children between ages of 6 to 17.
__________________
RANGE: 0-15 [SOFT CHECK IF 6 OR MORE]
Demo9. [If Demo8a>0 or Demo8b>0] For how many of the children in the household are you or your spouse/partner legal guardians?
________RANGE: 0-20 [SOFT CHECK IF 6 OR MORE]
Demo10a. Do you or your spouse/partner have any biological children under age 18 who do NOT live with you at least three days a week?
1. Yes
2. No
Demo10b. [If Demo10a=YES] How many biological children under age 18 do NOT live with you or your spouse/partner at least three days a week?
________RANGE: 0-20 [SOFT CHECK IF 6 OR MORE]
FS1. (ADD) Within the past 12 months, have you opened an individual development account (IDA) as a participant in an IDA program? An IDA program is a matched savings program.
1. Yes (ANSWER FS2)
2. No (ANSWER FS3)
FS2. At any time in the past, have you received a matched contribution for your savings as a participant in an IDA program?
1. Yes
2. No
FS3. In the past 12 months, did you participate in any…
|
Yes |
No |
IF YES… How many hours? |
a. (ADD) financial education classes or training seminars where someone explained how to manage your money |
1 |
2 |
|
b. (ADD) home ownership counseling programs where someone explained how to save to buy a home? |
1 |
2 |
|
c. credit counseling programs where someone explained how to manage the money you owe? |
1 |
2 |
|
d. (ADD) Small business counseling program where someone explained how to develop a small business plan? |
1 |
2 |
|
FS3a. In the past 12 months, did you receive any…
|
Yes |
No |
IF YES… How much? |
a. home ownership financial assistance or down payment assistance program where you received money toward a home purchase? This does not include any funds you may have borrowed that you will need to pay back. |
1 |
2 |
|
b. educational assistance or grants. This does not include any funds you may have borrowed that you will need to pay back. |
1 |
2 |
|
c. small business financial assistance programs where you received money to start a business? This does not include any funds you may have borrowed that you will need to pay back. |
1 |
2 |
|
The next questions are about your housing situation.
CR1. How would you describe your current home? Is it…
1 A single family home
2 An attached home such as an apartment, condo, town house, or duplex
3 A trailer, or
4 Something else
CR1.1 Describe the dwelling where you live.
SPECIFY
CR2. (ADD4 Hous 3a) Do you own or rent the (IF CR1=3 FILL: trailer) home you currently live in? By own, we mean you hold a mortgage on the home or have a deed to the home.
Own
Rent
Other
CR3. [If CR2=OTHER] How would you describe your current housing situation?
Living with family such as parents, in-laws, brother, or sister
Living with a friend
Neither
CR4. [If CR3=NEITHER] What is your current living situation?
_________________________
DESCRIBE
CR5. [If CR2=OTHER] Do you help pay for the rent or mortgage of the place where you are living?
Yes
No
CR6. (SIPP - HOME5) [IF CR2=RENT or CR5=YES..on average] Excluding any rent subsidies, how much do you [or your spouse/partner] currently pay in monthly rent?
CR7. When did you begin living in your current home? Please indicate month (if known) and year
_________________________
MM/YYYY
CR8. (ADD4 modified - HOUS4) [ASK IF CR2=OWN] What was the total price of the house [if CR1=3, FILL: trailer home] when you [IF DEMO5>0, FILL: or others in your household] purchased it?
$_____ Amount (0 – 999,999)
CR9. (ADD4 - MORT1) [IF CR2=OWN] Do you [or your spouse/partner] currently owe money on home mortgage loans for this house?
Yes
No
CR10. (ADD4 - MORT3) [IF CR8=Yes] How much do you owe on home mortgage loans?
$______ AMOUNT (1 – 999,999)
CR11. [IF CR2=OWN] How much would the home be worth if you were to sell it today?
CR12. (ADD4 - MORT4) [If CR8=YES] How much do you currently pay each month in mortgage payments?
$______ AMOUNT (1 – 10,000)
CR13. (ADD4 modified) On average, how much additional money do you pay each month for gas, water, electricity, and heating oil?
$________________
The next questions are about your employment.
E1. (slightly modified PSID-BCDE1) Are you currently working now, looking for work, retired, keeping house, a student, or doing something else?
Working now
Temporarily laid off, sick, or maternity leave
Unemployed
Retired
Disabled, permanently or temporarily
Keeping house
Student
Something else
E2. [IF E1=3] Are you currently looking for work?
Yes
No
E3. (PSID-BCDE3) [If E1=2-8] Are you doing any work for money now?
Yes
No
E4. (PSID-BCDE3A) [If E3=NO] Have you done any work for money in the past 12 months?
Yes
No (GO TO NEXT SECTION)
E5. (PSID-modified BCDE14B) [IF E1=1 or E3=1]How many weeks did you were you employed at any job in the past 12 months? Please include weeks that were covered by paid vacation or disability.
E6. (PSID-BC22) People who are self-employed find their own work or sales, or carry on a trade or business. Are you self-employed?
E6.1 (If E6=yes) Do you employ other workers?
E6.2 (If E6.1=yes) How many workers do you employ?
E7. Are you working for any company as a paid employee?
Yes
No
E8. [IF E7=YES] How many employers do you currently work for?
(If >1, then use the term “main job” where appropriate in subsequent questions)
NOTE: If E8>1, ANSWER E10-E17 for up to 2 secondary jobs.
E9. How many hours per week do you usually work at all jobs combined?
E10. [IF E8>1] How many hours per week do you usually work (if E8>1; FILL at all jobs combined)? If your hours vary from week to week, report the average.
E11. In what month and year did you begin working at your current (fill main/secondary) job?
MONTH:________ YEAR:________________
E12. (PSID-BC29) On your (main/secondary) job, are you salaried, paid by the hour, or something else?
Salaried
Salary+commission
Paid by hour
Hour+tips
Hourly+commission
Other
E13. (PSID-BC38) [If E12=6] How is that?
Piecework, hourly+piecework/production
Commission
Self-employed, farmer, “profits” – draw on account
By the job/day/mile
other
E14. (PSID-BC30) [If E12=1 or 2] (On your main/secondary job) How much is your salary?
_________________________
(ENTER amount and time unit)
PER HOUR
PER DAY
PER WEEK
PER MONTH
ETC.
E15. (PSID-BC33) [If E12=3, 4, or 5] (On your main/secondary job) What is your hourly wage rate for your regular work time?
_________________________
(ENTER amount)
E16. (PSID-BC36) [If E12=4] (On your main/secondary job) How much are your tips, on average?
_________________________
(ENTER amount and time unit)
E17. (PSID-BC37) [If E10=2 or 5] (On your main/secondary job) How much is your commission, on average?
_________________________
(ENTER amount and time unit)
E18. [IF ONE OR MORE OTHER ADULTS IN HOUSEHOLD] Is any other adult in your household employed?
NOTE: Show grid of other adults and allow a check employment section column with yes/no responses.
The next questions are about your household income and selected expenses.
HI1. (ISIS modified) In the past month, did you or anyone in your household have income or benefits from any of the following sources?
|
Yes |
No |
a. Job earnings? |
1 |
2 |
b. WIC? |
1 |
2 |
c. Food stamps (also known as Supplemental Nutrition Assistance Program--SNAP)? |
1 |
2 |
d. Free or reduced price school lunch program? |
1 |
2 |
e. SSI or Supplemental Security Income |
1 |
2 |
f. Public assistance or welfare (not including WIC or food stamps)? |
1 |
2 |
g. Housing choice voucher (known as Section 8) or public housing? |
1 |
2 |
h. Energy assistance |
1 |
2 |
i. Child care subsidy |
1 |
2 |
j. Medicaid or the Children’s Health Insurance Program |
1 |
2 |
k. Unemployment insurance? |
1 |
2 |
l. Worker’s compensation, disability? |
1 |
2 |
m. Receive child support (official or unofficial)? |
1 |
2 |
o. Receive from family and friends? (outside the household) |
1 |
2 |
HIa. DISPLAY INCOME AND BENEFIT OPTIONS WHERE RESPONDENT SELECTED YES IN HI1: About how much did you or anyone in your household receive from the following sources in the past month? |
Amount in the Past Month |
Don’t Know/Refused |
a. Job earnings? |
$ |
|
b. WIC? |
$ |
|
c. Food stamps (also known as Supplemental Nutrition Assistance Program--SNAP)? |
$ |
|
d. Free or reduced price school lunch program? |
$ |
|
e. SSI or Supplemental Security Income |
$ |
|
f. Public assistance or welfare (not including WIC or food stamps)? |
$ |
|
g. Housing choice voucher (known as Section 8) or public housing? |
$ |
|
h. Energy assistance |
$ |
|
i. Child care subsidy |
$ |
|
k. Unemployment insurance? |
$ |
|
l. Worker’s compensation, disability? |
$ |
|
m. Receive child support (official or unofficial)? |
$ |
|
o. Receive from family and friends? (outside the household) |
$ |
|
HI2a. In the past month, did you or anyone in your household pay child support, official or unofficial?
HI2b. In the past month, did you or anyone in your household give money to family or friends living outside your household?
H13a. [IF H12a = yes] In the past month, how much did you or anyone in your household pay for child support, official or unofficial?
$ ________ Amount – (0 – 10,000)
Don’t know/Refused options will be allowed if respondent does not know amount or range.
H13b. [IF H12b = yes] In the past month, how much did you or anyone in your household give to family or friends living outside your household?
$ ________ Amount – (0 – 100,000)
Don’t know/Refused options will be allowed if respondent does not know amount or range.
HI4. (ADD4 - INAS2) What was the total combined income of your household in FILL PREVIOUS CALENDAR YEAR? Please include money from jobs, net income from business, farm or rent, pensions, dividends, welfare, social security payments and any other money income received by you or any other member of your household.
$ ________ Amount – (0 – 500,000)HI5. [IF HI4=REF OR DK] Please provide your best estimate of your total combined household income in [FILL PREVIOUS CALENDAR YEAR].
$0
$1 to $9,999
$10,000 to $14,999
$15,000 to $19,999
$20,000 to $24,999
$25,000 to $29,999
$30,000 to $34,999
$35,000 to $39,999
$40,000 to $44,999
$45,000 to $49,999
$50,000 to $59,999
$60,000 to $69,999
$70,000 to $79,999
$80,000 or over
Don’t know/Refused options will be allowed if respondent does not know amount or range.
The next questions ask about your financial and life experiences in the past year.
FE1. Did you or anyone else in the household experience any of the following in the past 12 months?
|
Yes |
No |
a. marriage |
1 |
2 |
b. divorce |
1 |
2 |
c. birth of a child |
1 |
2 |
d. health condition that affected your ability to work |
1 |
2 |
e. start a new job |
1 |
2 |
f. lose a job |
1 |
2 |
g. change jobs |
1 |
2 |
h. experience a wage increase |
1 |
2 |
i. experience a wage decrease |
1 |
2 |
j. experience an increase in the hours worked |
1 |
2 |
k. experience a decrease in the hours worked |
1 |
2 |
l. pay off or pay down a debt |
1 |
2 |
n. incur a major unexpected expense (e.g., car repair, home repair, or medical expense) |
1 |
2 |
The next questions ask about the value of assets that you own….
FE2. (SCF) Do you or your spouse/partner own any cars, or any kind of truck, van or sport utility vehicle (SUV)? Do not include motorcycles, tractors, snow blowers, etc. or any vehicles owned by a business.
1. Yes
2. No
FE3. (SCF) [If FE2=YES] Altogether, how many such cars or vehicles do you and your spouse/partner own?
ANSWER F4-F5D FOR EACH VEHICLE
FE4. (SCF) What type of vehicle is it?
Car
Van/minivan
Sport utility vehicle (SUV)
Pickup
Truck, other than a pickup
Other
FE5a. (SCF) What make is the [FILL: car/van/SUV/pickup/truck/vehicle]?
DROP DOWN LIST OF MAKE
FE5b. (SCF) What model is the [FILL car/van/SUV/pickup/truck/vehicle]?
DROP DOWN LIST OF MODEL
FE5c. (SCF) What model year is [[FILL car/van/SUV/pickup/truck/vehicle]?
DROP DOWN LIST OF YEARS
FE5d. How much is owed on that [FILL car/van/SUV/pickup/truck/vehicle]?
$ ________ Amount – (0 – 500,000)
$0
$1 to $4,999
$5,000 to $9,999
$10,000 to $14,999
$15,000 to $19,999
$20,000 to $24,999
$25,000 to $29,999
$30,000 to $34,999
$35,000 or over
Don’t know/Refused options will be allowed if respondent does not know amount or range.
END LOOP
FE6a. (PSID - W10) Do you or spouse/partner currently own part or all of a farm or business?
1. Yes
2. No
3. I don’t know
FE6b. [IF FE6a=YES] How much is owed on that farm or business?
$ ________ Amount – (0 – 500,000)
$0
$1 to $4,999
$5,000 to $9,999
$10,000 to $14,999
$15,000 to $19,999
$20,000 to $24,999
$25,000 to $29,999
$30,000 to $34,999
$35,000 to $39,999
$40,000 to $44,999
$45,000 to $49,999
$50,000 to $59,999
$60,000 to $69,999
$70,000 to $79,999
$80,000 or over
Don’t know/Refused options will be allowed if respondent does not know amount or range.
FE6c. [IF FE6a=YES] How much would it be worth if it were sold today?
$ ________ Amount – (0 – $500,000)
Don’t know/Refused options will be allowed if respondent does not know amount or range.
FE7a. Do you or spouse/partner currently own other real estate, such as a rental property, other houses, or land?
1. Yes
2. No
3. I don’t know
FE7b. [IF FE7a=YES] How much is owed on that other real estate?
$ ________ Amount – (0 – $500,000)
$0
$1 to $4,999
$5,000 to $9,999
$10,000 to $14,999
$15,000 to $19,999
$20,000 to $24,999
$25,000 to $29,999
$30,000 to $34,999
$35,000 to $39,999
$40,000 to $44,999
$45,000 to $49,999
$50,000 to $59,999
$60,000 to $69,999
$70,000 to $79,999
$80,000 or over
Don’t know/Refused options will be allowed if respondent does not know amount or range.
FE7c. [IF FE7a=YES] How much would it be worth if it were sold today?
$ ________ Amount – (0 – $500,000)
Don’t know/Refused options will be allowed if respondent does not know amount or range.
The next questions are about different ways people save money.
FE8. (ADD 4 series) Do you or your spouse/partner currently have money in … |
Yes |
No |
[ask if YES to FSI or F_FS1] |
1 |
2 |
b. a checking account? |
1 |
2 |
c. a savings account? |
1 |
2 |
d. a money market account? |
1 |
2 |
e. certificates of deposit or CDs? |
1 |
2 |
f. retirement accounts like IRAs, 401(k), 403(b), or other pension plans at work? |
1 |
2 |
g. special educational accounts for your children? |
1 |
2 |
h. U.S. gov’t savings bonds? |
1 |
2 |
i. stocks, bonds, or mutual funds? |
1 |
2 |
j. other kinds of savings (e.g., saved at home, saved with trusted friends or family members)? What kind of savings is that?____________________ |
1 |
2 |
FE8a. (ADD 4 series) DISPLAY OPTIONS WHERE RESPONDENT SELECTED YES IN FE8: About how much do you or your spouse/partner currently have in the following accounts… |
Current Amount |
Don’t know/Refused |
[ask if YES to FS1 or F_FS1] |
1 |
|
b. a checking account? |
1 |
|
c. a savings account? |
1 |
|
d. a money market account? |
1 |
|
e. certificates of deposit or CDs? |
1 |
|
f. retirement accounts like IRAs, 401(k), 403(b), or other pension plans at work? |
1 |
|
g. special educational accounts for your children? |
1 |
|
h. U.S. gov’t savings bonds? |
1 |
|
i. stocks, bonds, or mutual funds? |
1 |
|
j. other kinds of savings (e.g., saved at home, saved with trusted friends or family members)? What kind of savings is that?____________________ |
1 |
|
FE9. Do you or your spouse partner have a “whole life”, “universal life” or “cash-value” policy? These policies pay a death benefit, but they also build up a value as premiums are paid. Do not include a term insurance policy, which only pays a death benefit.
1. Yes
2. No
FE9b. [If FE9a=YES] What is the total cash value of these policies?
The cash value of a policy is what the insurance company would pay if the policy were surrendered before death? $_________Amount (0-500,000)Don’t know/Refused options will be allowed if respondent does not know amount or range.
The next questions are about loans you may have received…
D1. In the past 12 months, have you or your spouse/partner... |
Yes |
No |
IF YES, “In the past 12 months have you done this…” WITH DROP-DOWN LIST: Once, 2-4 times, 5 or more times |
a. taken out a payday loan or used payday advance services? |
1 |
2 |
|
b. taken out an auto title loan? |
1 |
2 |
|
c. sold items at a pawn shop? |
1 |
2 |
|
d. gone to a check cashing store to cash checks? |
1 |
2 |
|
D2. [ASK IF FE10 a, b, or c=YES] Thinking about the past 12 months, what was the MAIN reason you or your spouse/partner needed to use a payday loan, auto title loan, or a pawn shop? Was it:
1. To make up for lost income
2. For basic living expenses
3. For house repairs or to buy an appliance
4. For medical expenses
5. For car repairs
6. For school or childcare expenses
7. For special gifts or luxuries
8. Other (Volunteered Specify)
The next questions are about how much money you or your spouse/partner currently owe on loans and credit cards IN TOTAL. Please remember to count a bill or loan only once.
D3. (ADD4 series) Do you currently owe any money on… |
Yes |
No |
Approximately how much do you owe in total? |
Don’t know/Refused |
a. educational or school loans? |
1 |
2 |
$ |
|
b. personal loans from banks or credit unions? |
1 |
2 |
$ |
|
c. personal loans from friends or relatives? |
1 |
2 |
$ |
|
d. payday loans? |
1 |
2 |
$ |
|
e. auto title loans? Auto title loans are loans where a car title is used to borrow money for a short period of time. They are NOT loans used to purchase an automobile. |
1 |
2 |
$ |
|
f. store credit loans? |
1 |
2 |
$ |
|
g. credit cards or charge cards? |
1 |
2 |
$ |
|
h. debt consolidation loans or bills owed to collection agencies? |
1 |
2 |
$ |
|
i. installment loans for major purchases like furniture or appliances? |
1 |
2 |
$ |
|
j. medical procedures like surgeries or outpatient procedures? |
1 |
2 |
$ |
|
k. Other, please specify__________________ |
1 |
2 |
$ |
|
The following are some of the specific difficulties people experience with household expenses.
MH1. Getting enough food can be a problem for some people. Which of these statements best describes the food eaten in your household in the past 6 months? Would you say there is . . .
1. Enough of the kinds of food you want
2. Enough but not always the kinds of food you want
3. Sometimes not enough to eat
4. Often not enough to eat
MH2. (ADD4 – ECON2) When it comes to making ends meet, how much help did your household get in the past 12 months from food pantries, churches, family services, or other organizations? Did you get . . .
1. No help at all
2. Some help, or
3. A lot of help
MH3. Was there any time in the past 12 months when:
|
Yes |
No |
IF YES: Did this occur in the most recent six months? |
a. you did not pay the full amount of the rent or mortgage because you could not afford it? |
1 |
2 |
Y/N |
b. The bank or mortgage company foreclosed on your mortgage? |
1 |
2 |
Y/N |
c. you were evicted from your home or apartment for not paying the rent or mortgage? |
1 |
2 |
Y/N |
d. you filed in court for personal bankruptcy? |
1 |
2 |
Y/N |
e. you were not able to pay the full amount of the gas, oil, or electricity bills? |
1 |
2 |
Y/N |
f. the gas or electric company turned off service, or the oil company could not deliver oil? |
1 |
2 |
Y/N |
g. the telephone company disconnected service because payments were not made? |
1 |
2 |
Y/N |
h. you or someone else in your household needed to see a doctor or go to the hospital but did not go because you could not afford it? |
1 |
2 |
Y/N |
i. you or someone else in your household needed to see a dentist but did not go because you could not afford it? |
1 |
2 |
Y/N |
j. you or someone else in your household could not fill or postponed filling a prescription for drugs when they were needed because you could not afford it? |
1 |
2 |
Y/N |
MH4. In the past 12 months, have you applied for a loan?
1. Yes
2. No
MH5. [IF MH4=YES] In the past 12 months, have you been turned down for a loan due to a poor credit score?
1. Yes
2. No
Next are some questions about your health, involvement with your community, and future outlook.
General Health |
Poor |
Fair |
Good |
Very |
Excellent |
SE1. In general, would you say your health is… |
0 |
1 |
2 |
3 |
4 |
SE2. (Rosenberg's Self-Esteem Scale) Please tell us if you strongly disagree, disagree, agree, or strongly agree with the following statements.
Outlook |
Strongly Disagree |
Disagree |
Agree |
Strongly Agree |
a. On the whole, I am satisfied with myself. |
1 |
2 |
3 |
4 |
b. At times, I think I am no good at all. |
1 |
2 |
3 |
4 |
c. I feel that I have a number of good qualities. |
1 |
2 |
3 |
4 |
d. I am able to do things as well as most other people. |
1 |
2 |
3 |
4 |
e. I feel I do not have much to be proud of. |
1 |
2 |
3 |
4 |
f. I certainly feel useless at times. |
1 |
2 |
3 |
4 |
g. I feel that I’m a person of worth, at least on an equal plane with others. |
1 |
2 |
3 |
4 |
h. I wish I could have more respect for myself. |
1 |
2 |
3 |
4 |
i. All in all, I am inclined to feel that I am a failure. |
1 |
2 |
3 |
4 |
j. I take a positive attitude toward myself. |
1 |
2 |
3 |
4 |
SE3. (Add CIV_1) During the past 12 months, have you. . .
|
Yes |
No |
a. volunteered, attended an event, or helped raise money for a church, a school, or any other community organization? [If a = Yes] How many times? ____________ (1 – 200) |
1 |
2 |
b. worked on a neighborhood project? [If b = Yes] How many times? ____________ (1 – 200) |
1 |
2 |
SE4. On a scale of 1 to 10, how often do you worry about being able to meet normal monthly living expenses? (1means “never”, 10 means “all the time”)
________ (1 – 10)
SE5. (ADD3-39) Overall, how hard or easy is it to make ends meet? Would you say it is...
Very hard
Hard
Neither hard nor easy
Easy
Very easy
SE6. (ADD3-36) In the past 12 months, has your financial situation gotten better, gotten worse, or stayed the same?
Gotten better
Gotten worse
Stayed the same
SE7. (DAHFS modified) Suppose that your refrigerator breaks down and you have to replace it. When you go to the store, you have the choice between paying now or paying later. If you pay now, the refrigerator will cost $200. If you pay 12 months from now, it will cost more than that. Now suppose your overall income next year will be exactly the same as this year. Would you prefer to pay two hundred dollars now or two hundred ten ($210) dollars a year from now?
$200 NOW (GO TO next section)
$210 ONE YEAR FROM NOW
DK (GO TO next section)
RF (GO TO next section)
SE8. (DAHFS modified) Would you prefer to pay two hundred dollars now or two hundred twenty ($220) dollars a year from now?
$200 NOW (GO TO next section)
$220 ONE YEAR FROM NOW
DK (GO TO next section)
RF (GO TO next section)
SE9. (DAHFS modified) Would you prefer to pay two hundred dollars now or two hundred twenty ($250) dollars a year from now?
$200 NOW (GO TO SE10)
$250 ONE YEAR FROM NOW (GO TO SE11)
DK (GO TO SE10)
RF (GO TO next section)
SE10. (DAHFS modified) Would you prefer to pay two hundred dollars now or two hundred thirty-five ($235) dollars a year from now?
$200 NOW (GO TO next section)
$235 ONE YEAR FROM NOW (GO TO next section)
DK (GO TO next section)
RF (GO TO next section)
SE11. (DAHFS modified) Would you prefer to pay two hundred dollars now or three hundred ($300) dollars a year from now?
$200 NOW (GO TO SE12)
$300 ONE YEAR FROM NOW (GO TO next section)
DK (GO TO SE12)
RF(GO TO next section)
SE12. (DAHFS modified) Would you prefer to pay two hundred dollars now or two hundred seventy five ($275) dollars a year from now?
$200 NOW
$275 ONE YEAR FROM NOW
DK
RF
LOC1. Now I'd like to confirm your full name and contact information. Please remember that everything you tell me is voluntary and will be kept confidential in the ways that were explained to you at the beginning of the interview. (ENTER 1 TO CONTINUE)
LOC2. I'd like to verify your name. Is it...[Insert Name] INTERVIEWER: READ NAME AND CORRECT AS NEEDED.
LOC3. Let me verify your address. [Insert Address]
Is this address correct?
1. YES – Go to LOC_4
2. NO – Go to LOC_3a
LOC3a. What is your correct home address? STREET ADDRESS:
_______________________
LOC3b. CITY: ___________________________________
LOC3c. STATE: _________________________________
LOC3d. ZIP CODE: _______________________________
LOC4. What is the best phone number to reach you? In a few weeks, someone may be contacting you to verify the quality of my work. (INTERVIEWER: ENTER THE RESPONDENT'S HOME NUMBER OR THE NUMBER WHERE HE/SHE CAN BE REACHED MOST OFTEN.)
PHONE NUMBER: _______________________________________
LOC4a. Is this your day or evening phone number or both?
1. DAY
2. EVENING
3. BOTH
LOC4b. Is this your home phone number, work phone number, or some other number?
1. HOME NUMBER
2. WORK NUMBER
3. FRIEND/RELATIVE'S NUMBER
4. CELL PHONE / BEEPER / PAGER NUMBER
5. OTHER – Go to LOC_4b1
LOC4b1. SPECIFY OTHER TYPE OF PHONE NUMBER: _______________________
LOC4c. Is there another phone number where you can be reached?
1. YES – Go to LOC_4c1
2. NO – Go to LOC_4d
LOC4c1. Please give me that telephone number.
ALTERNATIVE PHONE NUMBER: _________________
LOC4c2. Is this your day or evening phone number or both?
1. DAY
2. EVENING
3. BOTH
LOC4c3. Is this your home phone number, work phone number, or some other number?
1. HOME NUMBER
2. WORK NUMBER
3. FRIEND/RELATIVE'S NUMBER
4. CELL PHONE / BEEPER / PAGER NUMBER
5. OTHER – Go to LOC_4c4
LOC4c4. INTERVIEWER: SPECIFY OTHER TYPE OF PHONE NUMBER.________________
LOC4d. What is your email address? We will not share it with anyone.
EMAIL:_______________ (ALLOW 70 CHARACTERS)
LOC5. We are collecting contact information on close friends or family members who don't live with participants in case we have problems getting in touch with you. Is there someone who does not live with you who can always reach you?
1. YES – Go to LOC_6
2. NO – Go to LOC_9a
LOC6. What is that person's name?
NAME:________________________________
LOC7. What is this person's relationship to you?
1. SPOUSE OR SIGNIFICANT OTHER
2. PARENT
3. SON/DAUGHTER
4. BROTHER OR SISTER
5. FRIEND
6. OTHER – Go to LOC_7oth
LOC7oth. INTERVIEWER: PLEASE SPECIFY OTHER RELATIONSHIP_____________________
LOC8a. What
is this person's home address? STREET
ADDRESS:
______________________
LOC8b. CITY:______________________________________
LOC8c. STATE: ____________________________________
LOC8d. ZIP CODE: _________________________________
LOC9. What
is this person's telephone number?
___________________
LOC9a. For verification purposes, can I have your date of birth?
________/_________/_________
LOC10. We've reached the end of the interview. Thank you very much for this information and for your participation.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Instructions |
| File Modified | 0000-00-00 |
| File Created | 2021-01-29 |