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77.wpd
7
ENGLISH
Cycle 77, FALL 2013
OMB NO. 1205-0453
COUNTY
EXPIRATION DATE: 10/31/2015
7
FARM WORKER ID
[FOR OFFICE USE ONLY]
[REV. Sep 20, 2013]
NATIONAL AGRICULTURAL WORKERS SURVEY - 2013 (“NAWS”)
CS2
DATE:
/
/
[FOR OFFICE USE ONLY]
CROP CODE
CS5
CROP:
CS6 TASK:
TASK CODE
LANGUAGE DURING INTERVIEW: __________________
GN:
ID:
IF GN REFERRED TO CONTRACTOR, GROWER OR OTHER,
WRITE INFORMATION)
NAME :
_______________________________________
ADDRESS:
_______________________________________
TELEPHONE:
(_________)___________-________________
GN REFERRED TO:
9 “CONTRACTOR”?:
9 OTHER GROWER?
9 OTHER?:_______
WORKER IS ACTUALLY EMPLOYED BY?: 9 1 GROWER
9 2 CONTRACTOR
TYPE OF WORK?: 91 FIELD WORK
92 NURSERY
93 PACKING HOUSE
97 OTHER:________
FARM WORKER’S NAME:
LOCAL ADDRESS:
TELEPHONE:
INTERVIEWER’S
NAME:
CP5 TIME BEGAN:
CS9 INTERVIEWER’S ID:
:
9 AM
9 PM
CP6 TIME ENDED:
:
9 AM
9 PM
Notwithstanding any other provision of law, no person is required to respond to nor shall a person be subject to a
penalty for failure to comply with a collection of information subject to the requirements of the Paperwork
Reduction Act unless that collection of information displays a currently valid Office of Management and Budget
control number. Public reporting burden for this collection of information, which is voluntary, is estimated to
average 1 hour (or 60 minutes) per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Send comments regarding this burden estimate to the Office of Policy, Development and Evaluation, ETA,
Department of Labor, Room N5641, 200 Constitution Avenue, N.W., Washington, D.C. 20210.
1
[REV. Sep 20, 2013]
S:\4. Questionnaire\2013\CYCLE77\ENGLISHCY77\Oct29ENG2013CY77.wpd
HOUSEHOLD GRID
___ ___ ___ ___ ___
77 ___ ___ ___ __
County
A1
NAME
A.
(FARMWORKER)
*A2 A3 A5
R
E
L
A
T
I
O
N
S
E
X
M
F
B.
M
F
C.
M
F
D.
M
F
E.
M
F
F.
M
F
G.
M
F
M
A
R
I
T
A
L
S
T
A
T
U
S
A6
/
S
M
O
/
**A10
A8
A4
/
S
M
O
/
S
M
O
/
1 = SPOUSE/COMMON LAW SPOUSE
2 = OWN CHILD, DEPENDENT OR ADOPTED
3 = SIBLING
4 = PARENT
5 = GRANDCHILD
6 = OTHER RELATIVE (COUSINS, UNCLES, ETC.)
7 = OTHER: __________________________
A32-33
LAST 12
MONTHS,
HAVE YOU
IF
TRAVELED
NOT
TO DO FW
HERE,
(OR DONE
WHY NOT? FW IN
__
OTHER
C
CITY)? IF
O
YES,
D
[NAME]
TRAVELED
E
OR
JOINED
WITH
YOU?
Farmworker ID
A34-35
A11
PRIOR 12
MONTHS TO
(A3-33),
HAD YOU
TRAVELED
TO DO FW
(OR DONE
FW IN
OTHER
CITY)?
IF YES,
[NAME]
TRAVELED
OR JOINED
WITH YOU?
A12
A13
ANY U.S. ANY
ANY U.S.
FW
SCHOOL U.S.
LAST 12 WORK LAST 12
MONTHS? NOW? MONTHS?
Y
Y
Y
N
N
N
Y
Y
Y
Y
N
N
N
N
/
Y
Y
Y
Y
N
N
N
N
/
Y
Y
Y
Y
N
N
N
N
Y
Y
Y
Y
N
N
N
N
Y
Y
Y
Y
N
N
N
N
/
/
/
/
*CODES FOR A2 (RELATIONSHIP):
[ASK ALL IN A1]:
DOES S/HE LIVE WITH
YOU NOW?
IF NOT, WHERE?
[STATE/COUNTRY]
***A31
/
/
S
M
O
S
M
O
A9
HIGHEST
MONTH
GRADE LEVEL COUNTRY
AND
BIRTH COUNTRY [FOR MINORS SCHOOL
YEAR
DATE OF BIRTH INCLUDE PRE- [CODE]
FIRST
MM/YY [CODE] SCHOOL (“PS”)
ENTERED
AND KINDER
U.S.?
(“K”)
S
M
O
S
M
O
**A7
Y
Y
Y
Y
N
N
N
N
/
** CODES FOR A7 AND A10 (COUNTRIES AND REGIONS):
1= U.S.A.
2= PUERTO RICO
3= MEXICO
4= CENTRAL AMERICA
5= SOUTH AMERICA
6= CARIBBEAN
7= SOUTHEAST ASIA (INDONESIA, CAMBODIA, VIETNAM,
LAOS, THAILAND)
8= PACIFIC ISLANDS (THE PHILIPPINES, GUAM, FIJI, ETC.)
9= ASIA (CHINA, JAPAN, KOREA, ETC.)
97= OTHER: _________________
99= NOT ANSWERED
2
FW
NF
NW
FW
NF
NW
FW
NF
NW
FW
NF
NW
FW
NF
NW
FW
NF
NW
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
***CODES FOR A31
1=
2=
3=
7=
NO CHILD CARE IN THIS
LOCATION
NO HOUSING IN THIS LOCATION
CHILD IN SCHOOL, AFFECTED
IF MOVED
OTHER: _________________
[REV. Sep 20, 2013]
S:\4. Questionnaire\2013\CYCLE77\ENGLISHCY77\Oct29ENG2013CY77.wpd
HOUSEHOLD GRID
___ ___ ___ ___ ___ 77 ___ ___ ___ __
County
A1
NAME
H.
*A2 A3 A5
R
E
L
A
T
I
O
N
S
E
X
M
F
I.
M
F
J.
M
F
K.
M
F
L.
M
F
M.
M
F
N.
M
F
O.
M
F
M
A
R
I
T
A
L
S
T
A
T
U
S
A6
A9
**A10
A8
A4
HIGHEST
MONTH
GRADE LEVEL
AND
BIRTH COUNTRY [FOR MINORS COUNTRY
YEAR
DATE OF BIRTH INCLUDE PRE- SCHOOL
FIRST
MM/YY [CODE] SCHOOL (“PS”) [CODE]
ENTERED
AND KINDER
U.S.?
(“K”)
S
M
O
/
S
M
O
/
S
M
O
/
S
M
O
/
S
M
O
**A7
/
S
M
O
/
S
M
O
/
*CODES FOR A2 (RELATIONSHIP):
1 = SPOUSE/COMMON LAW SPOUSE
2 = OWN CHILD, DEPENDENT OR ADOPTED
3 = SIBLING
4 = PARENT
5 = GRANDCHILD
6 = OTHER RELATIVE (COUSINS, UNCLES, ETC.)
7 = OTHER: __________________________
A32-33
LAST 12
IF
MONTHS,
NOT
HERE,
FOR FW,
WHY NOT?
[NAME]
__
C
TRAVELED
O
OR
D
JOINED
WITH
E
YOU?
Farmworker ID
A34-35
A11
Y
Y
Y
N
N
N
N
Y
Y
Y
Y
N
N
N
N
/
Y
Y
Y
Y
N
N
N
N
Y
Y
Y
Y
N
N
N
N
/
/
Y
Y
Y
Y
N
N
N
N
/
Y
Y
Y
Y
N
N
N
N
Y
Y
Y
Y
N
N
N
N
Y
Y
Y
Y
N
N
N
N
/
/
/
** CODES FOR A7 AND A10 (COUNTRIES AND REGIONS):
1= U.S.A.
2= PUERTO RICO
3= MEXICO
4= CENTRAL AMERICA
5= SOUTH AMERICA
6= CARIBBEAN
7= SOUTHEAST ASIA (INDONESIA, CAMBODIA, VIETNAM,
LAOS, THAILAND)
8= PACIFIC ISLANDS (THE PHILIPPINES, GUAM, FIJI, ETC.)
9= ASIA (CHINA, JAPAN, KOREA, ETC.)
97= OTHER: _________________
99= NOT ANSWERED
3
A12
A13
PRIOR 12
MONTHS TO
(A32-32),
ANY U.S. ANY
ANY U.S.
FOR FW,
SCHOOL U.S.
FW
LAST 12 WORK LAST 12
[NAME]
MONTHS? NOW? MONTHS?
TRAVELED
OR JOINED
WITH YOU?
Y
/
/
S
M
O
[ASK ALL IN A1]:
DOES S/HE LIVE WITH
YOU NOW?
IF NOT, WHERE?
[STATE/COUNTRY]
***A31
FW
NF
NW
FW
NF
NW
FW
NF
NW
FW
NF
NW
FW
NF
NW
FW
NF
NW
FW
NF
NW
FW
NF
NW
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
***CODES FOR A31
1=
2=
3=
7=
NO CHILD CARE IN THIS
LOCATION
NO HOUSING IN THIS LOCATION
CHILD IN SCHOOL, AFFECTED
IF MOVED
OTHER: _________________
[REV. Sep 20, 2013]
S:\4. Questionnaire\2013\CYCLE77\ENGLISHCY77\Oct29ENG2013CY77.wpd
[ASK ONLY TO RESPONDENTS WHO - IN FAMILY GRID- HAVE CHILDREN UNDER 6 YEARS OLD
WHO HAVE BEEN OR ARE CURRENTLY IN THE U.S.A.]
Now I’d like to ask you some questions about child care. There are many places and persons that take care of
children while parents work. Parents use childcare or a neighbor’s home; other times the kids stay at home with
their mother, siblings or other relatives...
[IF MSHS (“a”) WAS NOT MENTIONED IN “HS1",
HS1. ...Now that you’re working here in [NAME OF
ASK HS4]: ...
LOCALITY], how have you arranged for your child
(-dren) to be taken care of while you work (FW)?
HS4. ...Have you ever heard of MSHS?
Please tell me all the types of child care arrangements
you have used [IF ONLY ONE RESPONSE, PROBE FOR 9 0 NO [EXPLAIN MSHS. MENTION LOCAL MSHS
MORE. CHECK ALL THAT APPLY]
NAMES, IF STILL “NO,” SKIP TO “A15"
NEXT SECTION]
9 a. MSHS
9 1 YES
9 b. Spouse
9 c. Child(-ren)’s older sibling(s).Age(s)?:___ ___ ___
9 d. Other relatives (not spouse or child(-dren)’s older
siblings)
9 e. Out of home (DAYCARE / CENTER / BABYSITTER)
9 f. Friends / Neighbors
9 g. Take them to the field (FW)
9 z. Other (specify): _______________
HS2.
HS5. Has/Have your child(-dren) ever used MSHS?
(When?)
9 0 NO
[ASK ONLY “HS6"]
9 1 YES. NOW, IN THIS LOCATION [SKIP TO “HS7"]
9 2 YES. NOT NOW, BUT WITHIN THE LAST 12
MONTHS. [ASK HS6 AND HS7]
9 3 YES. BUT, MORE THAN 12 MONTHS [ASK ONLY
“HS6"]
[IF MORE THAN ONE ANSWER IN HS1, ASK]: Which
one do you use most often during an average work
week (FW)? [ENTER LETTER CODE IN HS1]:
----------------------------------------------------------HS3. [ASK ALL] Why do you use this type (the most) while
doing FW? [CHECK ALL THAT APPLY]
9 a.
9 b.
9 c.
9 d.
9 e.
9 f.
9 z.
Trust
Flexible / Convenient hours
Convenient location
Culturally compatible (same language, food, staff, etc.)
Prepares child for school (e.g., English)
Don’t know (e.g., spouse decides)
Other (specify):_________________
HS6. Why aren’t you (or your spouse) using MSHS
at this location? [CHECK ALL THAT APPLY]
9 a.
9 b.
Prefer own child care arrangements
No MSHS in this area
9 c.
9 d.
9 e.
9 f.
9 g.
9 h.
9 i.
MSHS not open entire season (FOR FW)
9 z.
Inconvenient hours
MSHS full (applied, but no openings)
Applied, but did not qualify
Does not serve infants / older children
Do not like it. Specify: ___________________
Do not qualify. (Specify) Why?:
_______________________________________
Other (specify): _________________
HS7. [ASK QUESTIONS IN REFERENCE TO CHILDREN WHO USE/ USED MSHS IN THE LAST 12 MONTHS]
a
b
c
d
e
f
CHILD(-REN) WHO
USE/USED MSHS
[ENTER NAMES]
1
2
DATE LAST USED
MSHS?
(MONTH/YEAR)
START:
_______ / _______
END:
_______ / _________
START:
_______ / _______
END:
_______ / _________
LOCATION
(CITY/STATE)?
NAME OF
CENTER?
CITY:
______________
STATE:
______________
CITY:
______________
STATE:
______________
CODES FOR “e”:
1 = PREVIOUS MSHS REFERRED US
2 = RECRUITER FROM MSHS CONTACTED US
3 = SOCIAL WORKER (AGENCY, CLINIC, ETC.) REFERRED ME (SPOUSE)
4
HOW DID YOU LEARN [INTERVIEWER: CHECK
ABOUT MSHS?
IF CENTER IN “d” is in
[ENTER CODE]
MSHS LIST]
9 0 NO
9 1 YES
9 0 NO
9 1 YES
4 = SAW A FLYER WITH MSHS INFORMATION
5 = A RELATIVE/FRIEND TOLD US ABOUT IT
6 = OTHER:_____________________________
[REV. Oct 29, 2013]
S:\4. Questionnaire\2013\CYCLE77\ENGLISHCY77\Oct29ENG2013CY77.wpd
[THE FOLLOWING QUESTIONS REFER TO OTHER INDIVIDUALS WHO LIVE WITH THE WORKER AND
WERE NOT MENTIONED IN THE “HOUSEHOLD GRID”!]
A15 Other than those you have already mentioned, how many people live with you now?
TOTAL
Out of those (TOTAL IN “A15” ), ...
...how many are: ...
A20
... your
relatives?
A16
... doing
FW?
A17
A18
How many
How many
are doing NF?
NW?
a. ...ADULTS?
(18 YEARS OR OLDER)?
b. ...CHILDREN?
(17 YEARS OR YOUNGER)?
c. ...DO NOT KNOW AGE?
INSURANCE QUESTIONS ABOUT RESPONDENT AND HIS/HER FAMILY
(INDIVIDUALS IN THE “HOUSEHOLD GRID”) [DESCRIBE/EXPLAIN “HEALTH INSURANCE”]
A21
A23
Who pays for it?
In the U.S.A.,... Who has Health (Medical) Insurance in your family? ...
How about...
[ONLY FOR CHILDREN: IF YES, ASK HOW MANY OF THE CHILDREN [USE CODES. MARK ALL
UNDER AND OVER 18 YRS. OLD HAVE INSURANCE. MATCH TOTAL THAT APPLY]
NUMBER WITH FAMILY GRID]
a. ...you (farm
worker)?
b. ...your spouse?
90
NO
91
YES
97
DON’T KNOW
90
NO
91
YES
97
DON’T KNOW
A21c2
9 0 NO
91
92
95
9 6:
91
92
95
9 6:
91
92
95
9 6:
93
94
93
94
93
94
A24
(a) How many under 18 yrs?:
9 1 YES, ALL HAVE IT [ASK A23]
c. ...your
children?
9 2 YES, ONLY
SOME HAVE IT
(b) How many over 18 yrs?:
9 7 DON’T KNOW
CODES FOR “A23” (WHO PAYS?):
1= I PAY
3= MY EMPLOYER
5= GOVERNMENT
2= MY SPOUSE
4= MY SPOUSE’S EMPLOYER
6= OTHER:
5
[REV. Oct 29, 2013]
S:\4. Questionnaire\2013\CYCLE77\ENGLISHCY77\Oct29ENG2013CY77.wpd
B4 In the last 2 years [LAST 24 MONTHS], has
anyone in your household (from “Family
Grid”)- excluding yourself - participated in,
attended or received any training, special
classes or schools in the U.S.? [READ
G7 [ASK “G7" ONLY FOR THOSE BORN
OUTSIDE THE U.S.A.] ...And in your home
country, do you own or are you buying any of
the following items? [READ CHOICES.
CHECK ALL THAT APPLY]: ...
CHOICES. CHECK ALL THAT APPLY]: ...
9 a. ...Adult Education such as English/
ESL/Adult Basic Education/ Citizenship?
9 d. ...Job training?:
9 f. ...GED (High School Equivalency)?
9 j. ...Migrant Education?
9 k. ...Head Start?
9 l. ...Migrant Head Start?
9 n. ...Other?:
9
Don’t know
9 a.
9 b.
9 c.
9 d.
9 e.
9 f.
9
B1 [ASK ALL] Which of the following describes
you? [READ CHOICES. CHECK ONLY ONE]: ...
91
92
93
95
94
97
G4 In the last 2 years [LAST 24 MONTHS], have
you or anyone in your household received
benefits or used the services of any of the
following social programs? [READ CHOICES.
CHECK ALL THAT APPLY]: ...
9 p.
9 b.
9 c.
9 d.
9 e.
9 f.
9 g.
9 h.
9 i.
9 j.
9 k.
9 l.
9 m.
9 n.
9
...(TANF) Temporary assistance for
needy families?
...Food stamps?
...Disability insurance?
...Unemployment insurance?
...Social Security?
...Veteran’s pay?
...General assistance/welfare?
...Low income housing?
...Public Health Clinic?
...Medicaid?
...WIC?
...Disaster Relief?
...Legal Services?
...Other?:
Don’t know
G6 Do you own or are you buying any of the
following items in the U.S.? [READ CHOICES.
...MEXICAN-AMERICAN?
...MEXICAN?
...CHICANO?
...PUERTO RICAN?
...OTHER HISPANIC?:
...NOT HISPANIC OR LATINO?
B2 Which of the following do you consider
yourself? [READ CHOICES EXCEPT
“OTHER.” MARK ONE OR MORE RESPONSE]: ...
91
92
94
95
96
...White?
...Black or African American?
...American Indian/Alaska Native?
...Asian?
...Native Hawaiian or Pacific Islander?
9 7 ...Other?:
B3 Have you ever participated in, attended or
received any job training or attended any of
the following special classes or school in the
U.S.? [READ CHOICES. CHECK ALL THAT
APPLY]: ...
CHECK ALL THAT APPLY]: ...
9 a.
9 b.
9 c.
9 d.
9 e.
9 f.
9
...a plot of land?
...a house?
...a mobile home?
...a car/truck?
...a business?
...other?:
None
9 d.
9 a.
9 b.
9 c.
9 e.
9 f.
9 g.
9 h.
9 i.
9 j.
9
...a plot of land?
...a house?
...a mobile home?
...a car/truck?
...a business?
...other?:
None
6
...Job training?:
...English/ESL?
...Citizenship?
...Literacy?
...GED, High School Equivalency?
...College or University?
...Adult Basic Education?
...Even Start?
...Migrant Education?
...Other?:
None
[REV. Oct 29, 2013]
S:\4. Questionnaire\2013\CYCLE77\ENGLISHCY77\Oct29ENG2013CY77.wpd
[IF FOREIGN BORN, ASK];
B16. When you lived in your
B18. Where were you born? In what...
(d)
...STATE?:
(DEPARTMENT)
(e)
...MUNICIPALITY
(EQUIVALENT)?:
(f)
...TOWN (OR
CITY)?:
country, did you work
in...
9 1 ...AGRICULTURE [FW]?
9 2 ...NON-AGRICULTURE
[NF]?
9 3 ...PART FARM AND PART
NON-FARM [FW AND NF]?
9 5 ...NEVER WORKED?
9 8 NOT APPLICABLE [ONLY
FOR THOSE BORN IN THE
U.S.]
B17-18.
Before coming to the USA, you
lived in what...
(B17)
...COUNTRY?:
(B18)
...STATE (OR
DEPARTMENT)?:
LANGUAGE SECTION
B7 How well do you speak English? [READ
CHOICES. MARK ONLY ONE RESPONSE]: ...
91
...Not at all? 9 3
...Somewhat?
92
...A little?
94
...Well?
B20
When you were a
child, in what
languages did adults
speak to you at
home? [CHECK ALL
THAT APPLY]
U
a
b
c
d
e
f
z
B8 How well do you read English? [READ
CHOICES. MARK ONLY ONE RESPONSE]: ...
9 1 ...Not at all?
9 3 ...Somewhat?
9 2 ...A little?
9 4 ...Well?
B21
B24
And now, as an adult, what languages can you speak?
In which
language do you
believe you are
most dominant
(comfortable)
conversing?
[FOR EACH CHECKED ANSWER, ASK]:
[CHECK
B22
B23
ALL THAT
And now, how well do you
And now, how well do you
APPLY]
speak it? [READ CHOICES.
read it? [READ CHOICES.
U
MARK ONLY ONE PER CHECK]: MARK ONLY ONE PER CHECK]: [CHECK ONE] U
ENGLISH
SPANISH
9 2 ...A LITTLE?
9 3 ...SOMEWHAT?
9 4 ...WELL?
91
92
93
94
...NOT AT ALL?
...A LITTLE?
...SOMEWHAT?
...WELL?
CREOLE
9 2 ...A LITTLE?
9 3 ...SOMEWHAT?
9 4 ...WELL?
91
92
93
94
...NOT AT ALL?
...A LITTLE?
...SOMEWHAT?
...WELL?
MIXTEC
9 2 ...A LITTLE?
9 3 ...SOMEWHAT?
9 4 ...WELL?
91
92
93
94
...NOT AT ALL?
...A LITTLE?
...SOMEWHAT?
...WELL?
KANJOBAL
9 2 ...A LITTLE?
9 3 ...SOMEWHAT?
9 4 ...WELL?
91
92
93
94
...NOT AT ALL?
...A LITTLE?
...SOMEWHAT?
...WELL?
ZAPOTEC
9 2 ...A LITTLE?
9 3 ...SOMEWHAT?
9 4 ...WELL?
91
92
93
94
...NOT AT ALL?
...A LITTLE?
...SOMEWHAT?
...WELL?
OTHER:
9 2 ...A LITTLE?
9 3 ...SOMEWHAT?
9 4 ...WELL?
91
92
93
94
...NOT AT ALL?
...A LITTLE?
...SOMEWHAT?
...WELL?
7
[REV. Oct 29, 2013]
S:\4. Questionnaire\2013\CYCLE77\ENGLISHCY77\Oct29ENG2013CY77.wpd
B10 In what month and year did you first do
D33a
any farm work in the U.S.? (First time FW
in the U.S.) [ASK FOR MONTH AND
YEAR]
/
MONTH /
YEAR
B11 Approximately how many years have you
done farmwork in the U.S.? [COUNT ANY
YEAR IN WHICH 15 DAYS OR MORE
WERE WORKED].
years
9 10 I (OR I AND MY FAMILY) RECEIVE FREE
HOUSING FROM MY EMPLOYER. [SKIP TO
D34A]
93
I PAY FOR HOUSING PROVIDED BY MY
EMPLOYER. (I PAY DIRECTLY OR THROUGH
WAGE DEDUCTION).
95
I PAY FOR HOUSING PROVIDED BY THE
GOVERNMENT, A CHARITY, OR OTHER
NON-WORK RELATED INSTITUTION.
B12 Approximately how many years have you
done non-farmwork in the U.S.? [COUNT
ANY YEAR IN WHICH 15 DAYS OR
MORE WERE WORKED]
years
While you are working for this grower/
contractor, what type of payment arrangement
do you have for your living quarters? [IF
PAYMENT IS ONLY FOR UTILITIES,
CONSIDER IT FREE. DO NOT READ
CHOICES. MARK ONLY ONE]:
9 11 DO NOT PAY RENT. (I OR FAMILY MEMBER
OWN THE HOUSE OR LIVE FOR FREE WITH
FRIENDS OR RELATIVES) [SKIP TO D34A]
9 12 I RENT FROM NON-EMPLOYER (RELATIVE
OR NON-RELATIVE)
B13 When was the last time your parents did
hired farm-work in the U.S.?
9 97 OTHER:
90
91
92
93
94
97
D50 At this location how much do you pay for
B26-27
NEVER
NOW / WITHIN LAST YEAR
ONE TO FIVE YEARS AGO
SIX TO TEN YEARS AGO
OVER 11 YEARS AGO
DON’T KNOW
housing (including housing for your family, if
they live with you)?
91
...And where were your parents born?
...In what...
...COUNTRY?:
(B26a)
FATHER:
(B27a)
MOTHER?:
[ASK QUESTIONS BELOW ONLY FOR FOREIGN
COUNTRY in “B26a” and “B27a”]: ...
...STATE (OR DEPARTMENT OR EQUIVALENT)?:
(B26b) FATHER:
(B27b) MOTHER?:
FATHER:
(B27c)
MOTHER?:
...TOWN (OR CITY) ?
(B26d) FATHER:
(B27d)
MOTHER?:
,
.
or
per month $
,
.
or
per day
,
.
$
9 2 DON'T KNOW, TAKEN OUT OF MY
PAYCHECK
9 3 DON'T KNOW/DON'T REMEMBER, BUT
NOT TAKEN OUT OF MY PAYCHECK
9 7 OTHER:
...MUNICIPALITY (OR DISTRICT OR EQUIVALENT)?:
(B26c)
per week $
8
[REV. Oct 29, 2013]
S:\4. Questionnaire\2013\CYCLE77\ENGLISHCY77\Oct29ENG2013CY77.wpd
D34a In what type of living quarters do you live
now (housing structure at this location)?
[READ CHOICES. MARK ONLY ONE]:
D54
How many of the following do you have in
your current living quarters (dwelling)...
9 a. ...Bedrooms?:
...Is it a (an)...
9 b. ...Bathrooms?:
9 1 ...Mobile home?
9 2 ...Single-family home (detached)?
9 c. ...Kitchens?:
9 3 ...Duplex, triplex, etc. (attached, own parking
space with direct access to home)?
9 f. ...Other rooms?:
9 4 ...Apartments (two or more in a building,
shared parking spaces)?
D52 How many people total sleep in these
rooms? [VERIFY RESPONSE BY
ADDING TOTAL NUMBER GIVEN IN
HOUSEHOLD GRID PLUS TOTAL IN
A15. IF ANSWERS DO NOT MATCH
MAKE APPROPRIATE CHANGES]
9 5 ...Dormitory or barracks?
9 6 ...Campsite or tent?
9 7 ...Motel or hotel?
9 8 ...Without shelter, “homeless.” (Includes
“sleeping in a car”)? [SKIP TO D36a]
9 97
...Other:
D36a [FOR PARENTS OF CHILDREN 12 YEARS
OLD OR YOUNGER] I already asked you
about the daycare arrangements for your
children under 6 years old here in (NAME
OF LOCATION)...How about in all the
places you’ve lived in the past 12
MONTHS, where have all your children
12 years old or younger stayed while
you are working (FW in the USA)?
D35 Where are your living quarters located?
[READ CHOICES. MARK ONLY ONE]: ...
9 1 ...Off farm in property not owned or
administered by your present employer?
9 2 ...Off farm in property owned or administered
by your present employer?
[CHECK ALL THAT APPLY]
91
9 3 ...On farm of the grower you currently work
for?
THEY'VE STAYED HOME ALONE, AT
LEAST SOMETIMES
9 13 WITH MY SPOUSE, OTHER FAMILY
9 7 ...Other?:
9 14 WITH A NEIGHBOR / BABYSITTER,
MIGRANT HEAD START, HEAD START,
MIGRANT EDUCATION, DAYCARE
CENTER, ETC.
9 11 WITH ME IN THE FIELDS
9 12 OTHER:
9
[REV. Oct 29, 2013]
S:\4. Questionnaire\2013\CYCLE77\ENGLISHCY77\Oct29ENG2013CY77.wpd
REMINDER FOR INTERVIEWER:
BEFORE BEGINNING WITH “THE WORK GRID” ASK FOR “NW” AND “AB” PERIODS: “DURING THE LAST 12 MONTHS, FOR 5 OR MORE
DAYS ...HAVE YOU BEEN ILL OR SICK? ...HAVE YOU BEEN UNEMPLOYED? ...HAVE YOU TRAVELED OUT OF THE COUNTRY?” [USE THE
AFFIRMATIVE RESPONSES TO PROBE AND DOCUMENT DATES HERE OR DURING THE QUESTIONS IN THE “WORK GRID”]:
WORK GRID
___ ___ ___ ___ ___ 77 ___ ___ ___ ___
County
[C1-C2 FOR OFFICE USE ONLY]
Farmworker ID
C15
C3
C4
C5
C6
NW?
AB?
FW
NF
Y
FW?
GR
PER.
AND
SUB
PER.
NO.
CO
[FW
ONLY]
EMPLOYER’S
NAME ( FARM
WORK, NONFARM WORK
AND WORK
ABROAD)
CROP
WRITE
ACTIVITY OR
TASK WHILE
FW AND NF
[USE CODES
FOR *NW
AND**AB]
NF?
GR
CO
NW
AB
GR
FW
NF
CO
NW
AB
GR
FW
NF
CO
NW
AB
GR
FW
NF
NW
AB
CO
* C-5 ACTIVITY CODES: ONLY FOR “NW” (IN THE U.S.A.)
[WRITE ACTIVITY FOR FW AND NF]
201 = LOOKING FOR FW AND NF
WORK
202 = LOOKING FOR FARM
WORK
203 = LOOKING FOR NF WORK
204 = WAITING FOR RECALL
NOTICE(AFTER LAYOFF)
205 = WAITING FOR START OF
SEASON
C8
RECEIVED
UNEMPLOYMENT?
C1-C2
206 = FAMILY RESPONSIBILITIES/
WORK IN HOME
207 = IN SCHOOL
208 = LAID UP DUE TO INJURY
209 = IN-TRANSIT BETWEEN JOBS
210 = VACATION
211 = DID NOT LOOK FOR WORK
212 = OTHER: (SPECIFY IN GRID)
C9
C10
DATES FOR PERIODS OF
FW, NF, NW, AB
FROM:
TO:
# OF
WORK
DAYS
PER
WEEK?
FW & NF
C11
C12
CITY
COUNTY NAME
[IF IN A BORDER
COUNTY ASK IF
COMMUTE FROM
MEXICO]
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
** C-5 ACTIVITY CODES: ONLY FOR “AB”
(WHILE IN A FOREIGN COUNTRY OR ABROAD):
311 = FW IN FAMILY RANCH
312 = FW-HIRED
320 = NF IN OWN BUSINESS: (SPECIFY IN
GRID)
341 = NF IN “MAQUILA”
359 = NF- OTHER: (SPECIFY IN GRID)
361 = NW - MEDICAL TREATMENT
362 = NW - VACATION
369 = NW - OTHER: (SPECIFY IN GRID)
10
C13
C7
C16
STATE/COUNTRY
REPORT FROM FIRST PERIOD COVERING OCTOBER 01, 2012 TO PRESENT
***FW
AND
NF:
WHY
LEFT?
WERE YOUR
SPOUSE
AND KIDS
WITH YOU?
[CODES]
SPOUSE
CHILDREN
ALL
NO
SPOUSE
CHILDREN
ALL
NO
SPOUSE
CHILDREN
ALL
NO
SPOUSE
CHILDREN
ALL
NO
*** C-7 CODES: WHY LEFT “FW” AND “NF”?
1 = LAID OFF/END OF
SEASON
2 = FIRED
3 = FAMILY
RESPONSIBILITIES
4 = SCHOOL
5 = MOVED
6 = HEALTH REASON
7 = VACATION
8 = RETIRED
10 = QUIT
11 = CHANGE JOBS
9 = OTHER
(SPECIFY):
[REV. Oct 29, 2013]
S:\4. Questionnaire\2013\CYCLE77\ENGLISHCY77\Oct29ENG2013CY77.wpd
WORK GRID
[C1-C2 FOR OFFICE USE ONLY]
___ ___ ___ ___ ___
County
77 ___ ___ ___ ___
Farmworker ID
C15
C3
C4
C5
CROP
WRITE
ACTIVITY OR
TASK WHILE
FW AND NF
[USE CODES
FOR *NW
AND**AB]
C6
PER.
AND
SUB
PER.
NO.
CO
[FW
ONLY]
EMPLOYER’S
NAME (FARM
WORK, NONFARM WORK
AND WORK
ABROAD)
GR
FW
NF
Y
NF?
CO
NW
AB
GR
FW
NF
CO
NW
AB
GR
FW
NF
CO
NW
AB
GR
FW
NF
CO
NW
AB
GR
FW
NF
CO
NW
AB
* C-5 ACTIVITY CODES: ONLY FOR “NW” (IN THE U.S.A.)
[WRITE ACTIVITY FOR FW AND NF]
201 = LOOKING FOR FW AND NF
WORK
202 = LOOKING FOR FARM
WORK
203 = LOOKING FOR NF WORK
204 = WAITING FOR RECALL
NOTICE(AFTER LAYOFF)
205 = WAITING FOR START OF
SEASON
C9
NW?
AB?
FW?
GR
C8
RECEIVED
UNEMPLOYMENT?
C1-C2
206 = FAMILY RESPONSIBILITIES/
WORK IN HOME
207 = IN SCHOOL
208 = LAID UP DUE TO INJURY
209 = IN-TRANSIT BETWEEN
JOBS
210 = VACATION
211 = DID NOT LOOK FOR WORK
212 = OTHER: (SPECIFY IN GRID)
C10
DATES FOR PERIODS OF
FW, NF, NW, AB
FROM:
TO:
# OF
WORK
DAYS
PER
WEEK?
FW & NF
C11
C12
CITY
COUNTY NAME
[IF IN A BORDER
COUNTY ASK IF
COMMUTE FROM
MEXICO]
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
** C-5 ACTIVITY CODES: ONLY FOR “AB”
(WHILE IN A FOREIGN COUNTRY OR
ABROAD):
311 = FW IN FAMILY RANCH
312 = FW-HIRED
320 = NF IN OWN BUSINESS: (SPECIFY IN
GRID)
341 = NF IN “MAQUILA”
359 = NF- OTHER: (SPECIFY IN GRID)
361 = NW - MEDICAL TREATMENT
362 = NW - VACATION
369 = NW - OTHER: (SPECIFY IN GRID)
11
C13
C7
STATE/COUNTRY
REPORT FROM FIRST PERIOD COVERING OCTOBER 01, 2012 TO PRESENT
***FW
AND
NF:
WHY
LEFT?
C16
WERE
YOUR
SPOUSE
AND KIDS
WITH YOU?
[CODES]
SPOUSE
CHILDREN
ALL
NO
SPOUSE
CHILDREN
ALL
NO
SPOUSE
CHILDREN
ALL
NO
SPOUSE
CHILDREN
ALL
NO
SPOUSE
CHILDREN
ALL
NO
*** C-7 CODES: WHY LEFT “FW” AND “NF”?
1 = LAID OFF/END OF SEASON 8 = RETIRED
2 = FIRED
10 = QUIT
11 = CHANGE JOBS
3 = FAMILY
RESPONSIBILITIES
9 = OTHER
4 = SCHOOL
(SPECIFY):
5 = MOVED
6 = HEALTH REASON
7 = VACATION
[REV. Oct 29, 2013]
S:\4. Questionnaire\2013\CYCLE77\ENGLISHCY77\Oct29ENG2013CY77.wpd
WORK GRID
___ ___ ___ ___ ___
County
[C1-C2 FOR OFFICE USE ONLY]
77 ___ ___ ___ ___
Farmworker ID
C15
C3
C4
C5
C6
FW?
NF?
CROP
WRITE
ACTIVITY OR
TASK WHILE
FW AND NF
[USE CODES
FOR *NW AND
**AB]
GR
PER.
AND
SUB
PER.
NO.
CO
[FW
ONLY]
EMPLOYER’S
NAME FOR:
FW, NF AND
WORK AB
NW?
AB?
FW
NF
Y
GR
CO
NW
AB
GR
FW
NF
CO
NW
AB
GR
FW
NF
CO
NW
AB
GR
FW
NF
CO
NW
AB
GR
FW
NF
CO
NW
AB
* C-5 ACTIVITY CODES: ONLY FOR “NW” (IN THE U.S.A.)
[WRITE ACTIVITY FOR FW AND NF]
201 = LOOKING FOR FW AND NF
WORK
202 = LOOKING FOR FARM
WORK
203 = LOOKING FOR NF WORK
204 = WAITING FOR RECALL
NOTICE(AFTER LAYOFF)
205 = WAITING FOR START OF
SEASON
C8
RECEIVED
UNEMPLOYMENT?
C1-C2
206 = FAMILY RESPONSIBILITIES/
WORK IN HOME
207 = IN SCHOOL
208 = LAID UP DUE TO INJURY
209 = IN-TRANSIT BETWEEN JOBS
210 = VACATION
211 = DID NOT LOOK FOR WORK
212 = OTHER: (SPECIFY IN GRID)
C9
C10
DATES FOR PERIODS OF
FW , NF, NW, AB
FROM:
TO:
# OF
WORK
DAYS
PER
WEEK?
FW & NF
C11
C12
CITY
COUNTY
[IF IN A BORDER
COUNTY ASK IF
COMMUTE FROM
MEXICO]
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
** C-5 ACTIVITY CODES: ONLY FOR “AB”
(WHILE IN A FOREIGN COUNTRY OR ABROAD):
311 =
312 =
320 =
341 =
359 =
361 =
362 =
369 =
FW IN FAMILY RANCH
FW-HIRED
NF IN OWN BUSINESS: (SPECIFY IN GRID)
NF IN “MAQUILA”
NF- OTHER: (SPECIFY IN GRID)
NW - MEDICAL TREATMENT
NW - VACATION
NW - OTHER: (SPECIFY IN GRID)
12
C13
C7
STATE/COUNTRY
REPORT FROM FIRST PERIOD COVERING OCTOBER 01, 2012 TO PRESENT
***FW
AND
NF:
WHY
LEFT?
C16
WERE
YOUR
SPOUSE
AND KIDS
WITH YOU?
[CODES]
SPOUSE
CHILDREN
ALL
NO
SPOUSE
CHILDREN
ALL
NO
SPOUSE
CHILDREN
ALL
NO
SPOUSE
CHILDREN
ALL
NO
SPOUSE
CHILDREN
ALL
NO
*** C-7 CODES: WHY LEFT “FW” AND “NF”?
8 = RETIRED
1 = LAID OFF/END OF
SEASON
10 = QUIT
2 = FIRED
11 = CHANGE JOBS
3 = FAMILY
9 = OTHER
RESPONSIBILITIES
(SPECIFY):
4 = SCHOOL
5 = MOVED
6 = HEALTH REASON
7 = VACATION
[REV. Oct 29, 2013]
S:\4. Questionnaire\2013\CYCLE77\ENGLISHCY77\Oct29ENG2013CY77.wpd
WORK GRID
___ ___ ___ ___ ___
County
[C1-C2 FOR OFFICE USE ONLY]
77 ___ ___ ___ ___
Farmworker ID
C15
C3
C4
C5
C8
C9
DATES FOR PERIODS OF
FW,NF, NW,AB
NW?
AB?
GR
FW
NF
Y
CO
NW
AB
GR
FW
NF
CO
NW
AB
GR
FW
NF
CO
NW
AB
GR
FW
NF
CO
NW
AB
GR
FW
NF
CO
NW
AB
FW?
GR
PER.
AND
SUB
PER.
NO.
CO
[FW
ONLY]
C6
EMPLOYER
(FARM WORK,
NON-FARM AND
ABROAD JOB)
CROP
ACTIVITY OR
TASK WHILE
FW AND NF
[USE CODES
FOR *NW AND
**AB]
NF?
* C-5 ACTIVITY CODES: ONLY FOR “NW” (IN THE U.S.A.)
[WRITE ACTIVITY FOR FW AND NF]
201 = LOOKING FOR FW AND NF
WORK
202 = LOOKING FOR FARM
WORK
203 = LOOKING FOR NF WORK
204 = WAITING FOR RECALL
NOTICE(AFTER LAYOFF)
205 = WAITING FOR START OF
SEASON
206 = FAMILY RESPONSIBILITIES/
WORK IN HOME
207 = IN SCHOOL
208 = LAID UP DUE TO INJURY
209 = IN-TRANSIT BETWEEN JOBS
210 = VACATION
211 = DID NOT LOOK FOR WORK
212 = OTHER: (SPECIFY IN GRID)
FROM:
C10
TO:
# OF
WORK
DAYS
PER
WEEK?
FW & NF
C11
C12
CITY
COUNTY
[IF IN A BORDER
COUNTY ASK IF
COMMUTE FROM
MEXICO]
C13
C7
STATE/COUNTRY
C1-C2
RECEIVED
UNEMPLOYMENT?
REPORT FROM FIRST PERIOD COVERING OCTOBER 01, 2012 TO PRESENT
***FW
AND
NF:
WHY
LEFT?
SPOUSE
CHILDREN
ALL
NO
N/A
SPOUSE
CHILDREN
ALL
NO
N/A
Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
SPOUSE
CHILDREN
ALL
NO
N/A
Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
SPOUSE
CHILDREN
ALL
NO
N/A
Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
SPOUSE
CHILDREN
ALL
NO
N/A
Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
** C-5 ACTIVITY CODES: ONLY FOR “AB”
(WHILE IN A FOREIGN COUNTRY OR ABROAD):
311 = FW IN FAMILY RANCH
312 = FW-HIRED
320 = NF IN OWN BUSINESS: (SPECIFY IN
GRID)
341 = NF IN “MAQUILA”
359 = NF- OTHER: (SPECIFY IN GRID)
361 = NW - MEDICAL TREATMENT
362 = NW - VACATION
369 = NW - OTHER: (SPECIFY IN GRID)
13
WERE
YOUR
SPOUSE
AND KIDS
WITH YOU?
[CODES]
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
C16
*** C-7 CODES: WHY LEFT “FW” AND “NF”?
1 = LAID OFF/END OF
SEASON
2 = FIRED
3 = FAMILY
RESPONSIBILITIES
4 = SCHOOL
5 = MOVED
6 = HEALTH REASON
7 = VACATION
8
10
11
9
=
=
=
=
RETIRED
QUIT
CHANGE JOBS
OTHER
(SPECIFY):
[REV. Sep 20, 2013]
S:\4. Questionnaire\2013\CYCLE77\ENGLISHCY77\Oct29ENG2013CY77.wpd
D1 In the year before last [FROM OCTOBER 2011 TO D61
OCTOBER 2012, YEAR BEFORE THE ONE COVERED
IN WORK GRID], how many months did you do
(FW) in the U.S.? [1 DAY OR MORE PER
MONTH EQUALS 1 MONTH]
9 1 ...PAYROLL CHECK?
9 2 ...PERSONAL CHECK?
9 3 ...CASH AND CHECK?
months
90
NO
91
YES
D7 For what time period was that payment?
hours
D3 [IF NON-FARM JOB LISTED] For your most
recent non-farm employer (NF), how much were
you paid per week on average?
,
9 4 ...OTHER CHECK?
9 5 ...CASH?
9 6 ...OTHER:
D62 Did you get a receipt?
D2 [IF NON-FARM JOB LISTED ON WORK GRID]:
For your most recent non-farm (NF) employer,
how many hours per week did you work on
average?
$
Were you paid by [READ CHOICES.
MARK ONE RESPONSE]:...
9 1 ONE DAY?
9 4 ONE MONTH?
9 2 ONE WEEK? 9 7 OTHER?:
9 3 TWO WEEKS?
D8 How many hours did you work during that
period (in D7)?
.
hours
==============================
D9 ...Now - with your current employer - you
already told me that the crop you are
currently working is:...
CURRENT FARM JOB
Now I am going to ask you some questions about
the FW you are CURRENTLY performing for
the EMPLOYER through whom we contacted you
[INCLUDED IN A WORK GRID PERIOD].
D4 How many hours did you work last week at
your current farm job?
D10
And you told me that - with your current
employer - the task you are now doing is:
hours
D11 Are you paid: ...
[D5 TO D8: IF SHE/HE HAS NOT RECEIVED
PAYMENT YET FOR CURRENT CROP, ASK FOR
ESTIMATES]: Can you tell me how you were paid
9 1 ...BY THE HOUR?
9 2 ...BY THE PIECE? [SKIP TO D13]
9 3 ...COMBINATION HOURLY WAGE AND
PIECE RATE? [ASK D12 THRU D18]
9 4 ...SALARY OR OTHER? [SKIP TO D19]
and the amount your employer paid you on your
last pay day?
D5
After taxes:
$
D6
,
D12
.
Before taxes:
$
,
How much per hour (to nearest cent)? [IF
PAID ONLY BY THE HOUR, ENTER
AMOUNT AND SKIP TO D20. IF
COMBINATION, ENTER AMOUNT AND
CONTINUE WITH D13]:
.
$
14
.
PER HOUR
[REV. Sep 20, 2013]
S:\4. Questionnaire\2013\CYCLE77\ENGLISHCY77\Oct29ENG2013CY77.wpd)
In the last 12 months, aside from your
wages, have you received (do you receive)
any money bonus from your current
employer?
D20
D13 [IF PAID BY THE PIECE]: Are you paid as an
individual or by the crew? [IF THE ANSWER
IS "CREW", ASK QUESTIONS D14 to D18
CONSISTENTLY IN REFERENCE TO THE
CREW]
91
92
INDIVIDUAL [SKIP TO D15]
CREW
9 0 NO [SKIP TO D22]
9 1 YES
9 7 DON’T KNOW [SKIP TO D22]
D14 [IF CREW PIECE RATE]: How many people
are in your crew? [ONE IS NOT A POSSIBLE
ANSWER]
9 g.
9 a.
9 b.
9 c.
9 d.
9 e.
9 f.
D15 [IF BY PIECE]: How do they pay you/your
crew [i.e., UNIT OF MEASURE SUCH AS
BOX, BIN, BUCKET, ETC.]?
D16 [IF BY PIECE]: How many of these (in D15
[IF PAID A BONUS]: How and when do you
receive the money bonus? [READ
CHOICES. MARK ALL THAT APPLY]:...
D21
...retention (return or rehire) bonus?
...holiday bonus?
...incentive bonus (rewards)?
...dependent on grower profit?
...end of season bonus?
...money for transportation?
...Other?:
How much money bonus have you been
given (TOTAL last 12 months with current
employer)?
D63
e.g., boxes, bins, buckets, etc.) you/your
crew do in an average day?
$
D17 [IF BY PIECE]: How many hours per day
D22
you/your crew work on average at this task?
hours
,
If you are injured at work or get sick as a
result of your work, does your employer
provide health insurance or pay for your
health care?
90
91
D18 [IF BY PIECE]: How much do “they” pay
you/your crew on average for each (box bin,
bucket, etc. In D15)?
.
NO
YES
97
DON’T KNOW
D23 If you are injured at work or get sick as a
$
,
result of your work, do you get any payment
while you are recuperating (i.e., “workers'
compensation”)?
.
D19 [IF PAID BY SALARY, OR OTHER]: Explain
fully how and how much you are
paid (salary or other). Explain thoroughly
the method and amount of payment.
[USE BACK OF PAGE IF NEEDED]:
90
91
NO
YES
97
DON’T KNOW
D24 If you are injured or get sick off the job
(e.g., at home), does your employer provide
health insurance or pay for your health care?
[USE BACK OF PAGE IF NEEDED]
[WHETHER OR NOT THE WORKER TAKES IT
OR USES IT]
90
91
97
15
NO
YES
DON’T KNOW
[REV. Sep 20, 2013]
S:\4. Questionnaire\2013\CYCLE77\ENGLISHCY77\Oct29ENG2013CY77.wpd
D26 Are you covered by unemployment insurance if D37a
you lose this job?
90
91
NO
YES
91
92
93
94
95
96
9 7 DON’T KNOW
D27 How many years have you worked for this
employer? [ONE DAY/PER YEAR=ONE YEAR]
years
work? [READ CHOICES. MARK ONE]:...
round or on a seasonal basis?
9 1 ...DRIVE CAR? [SKIP TO D39a]
9 2 ...WALK [SKIP TO D39a]
9 5 ...PUBLIC TRANSPORTATION (BUS, TRAIN,
ETC.)? [SKIP TO D39a]
9 6 ...LABOR BUS, TRUCK, VAN?
9 8 ...“RAITERO”:?
9 4 ...RIDE WITH OTHERS (SHARES RIDE)?
9 7 ...OTHER?:
9 0 YEAR ROUND [SKIP TO D30]
9 1 SEASONAL
9 7 DON’T KNOW (FIRST TIME) [SKIP TO D30]
D29 [IF WORKED ON A SEASONAL BASIS] Does
this employer keep in contact with you about
future employment? [READ CHOICES. MARK
ALL THAT APPLY]: ...
D38a
91
94
I APPLIED FOR THE JOB ON MY OWN
I WAS RECRUITED BY A GROWER OR HIS
FOREMAN
9 5 I WAS RECRUITED BY FARM LABOR
CONTRACTOR OR HIS FOREMAN
9 6 I WAS REFERRED BY THE EMPLOYMENT
SERVICE
9 7 I WAS REFERRED BY THE WELFARE
OFFICE
9 8 I WAS REFERRED BY RELATIVE / FRIEND /
WORKMATE
9 9 I WAS REFERRED BY LABOR UNION
9 10 DAY LABORER / PICKED UP AT SHAPE UP
9 97 Other:
Do you have to use the transport (in D37) (IS
IT MANDATORY OR OBLIGATORY)?
9 0 NO
9 1 YES
D38 Do you pay a fee to (responsible in D37 and/or
"raiteros") for rides to work?
90
91
92
D30 How did you get this job? [DO NOT READ
CHOICES. MARK ONLY ONE RESPONSE]
I'M LOCATED AT THE JOB
WITHIN 9 MILES
10-24 MILES
25-49 MILES MILES
50-74 MILES
75 OR MORE
D37 At your current job, how do you usually get to
D28 Do you work for (current employer) year
9 a. ... Yes, before leaving at the end of the
season?
9 b. ... Yes, by letter (written message)?
9 c. ... Yes, by phone/in person?
9 d. ... Yes, by someone else?
9 e. ... No, you contact employer?
9 f. ... Other?:
9
Don’t know
How far is your current job from your current
residence?
D39a
91
92
93
95
NO
YES, A FEE
YES, JUST FOR GAS
At your current job, who pays for the
equipment you use at work? [READ
CHOICES. MARK ONLY ONE]:...
...DON'T NEED ANY EQUIPMENT?
...(YOU) PAY ALL?
...THE GROWER/CONTRACTOR PAYS ALL?
...A FRIEND / RELATIVE PAYS SOME OR
ALL?
9 6 ...(YOU) PAY SOME?
910 ...(YOU) PAY ONLY FOR REPLACEMENT OF
DAMAGED TOOLS?
911 ... THE GROWER/CONTRACTOR PROVIDES
YOU WITH TOOLS, BUT YOU PREFER TO
BUY/BRING YOUR OWN?
912 ...THE GROWER/CONTRACTOR PROVIDES
SOME AND YOU HAVE TO BRING/BUY THE
REST?
9 97 ...OTHER?:
16
“Now I’m going to ask you some questions about your
individual and family income for last year (2012)”...
G3B
G1B ...What was your total personal income last year - in
2012 - in U.S. dollars [U.S. earnings only FOR FW AND NF]?
[READ OR SHOW CHOICES. MARK ONLY ONE]
90
91
92
93
94
95
96
97
98
99
9 10
9 11
9 12
9 13
9 14
9 15
9 16
9 17
9 18
9 19
9 20
9 97
What was your family’s total income last
year - in 2012 - in U.S. dollars [U.S.
earnings for FW AND NF for all in “FAMILY
GRID”]? [READ OR SHOW CHOICES.
MARK ONLY ONE]
90
91
92
93
94
95
96
97
98
99
9 10
9 11
9 12
9 13
9 14
9 15
9 16
9 17
9 18
9 19
9 20
9 97
DID NOT WORK AT ALL IN 2012
LESS THAN 2,500
2,500 TO 4,999
5,000 TO 7,499
7,500 TO 9,999
10,000 TO 12,499
12,500 TO 14,999
15,000 TO 17,499
17,500 TO 19,999
20,000 TO 22,499
22,500 TO 24,999
25,000 TO 27,499
27,500 TO 29,999
30,000 TO 32,499
32,500 TO 34,999
35,000 TO 37,499
37,500 TO 39,999
40,000 TO 44,999
45,000 TO 54,999
55,000 TO 59,999
60,000 OR MORE
DON’T REMEMBER (DON’T KNOW)
G2B How much of that income [in “G1A”] was from
agricultural employment (U.S. earnings only for FW)?
DID NOT WORK AT ALL IN 2012
LESS THAN 2,500
2,500 TO 4,999
5,000 TO 7,499
7,500 TO 9,999
10,000 TO 12,499
12,500 TO 14,999
15,000 TO 17,499
17,500 TO 19,999
20,000 TO 22,499
22,500 TO 24,999
25,000 TO 27,499
27,500 TO 29,999
30,000 TO 32,499
32,500 TO 34,999
35,000 TO 37,499
37,500 TO 39,999
40,000 TO 44,999
45,000 TO 54,999
55,000 TO 59,999
60,000 OR MORE
DON’T REMEMBER (DON’T KNOW)
[READ / SHOW CHOICES. MARK ONLY ONE]
90
91
92
93
94
95
96
97
98
99
9 10
9 11
9 12
9 13
9 14
9 15
9 16
9 17
9 18
9 19
9 20
9 97
E1
DID NOT WORK AT ALL IN 2012
LESS THAN 2,500
2,500 TO 4,999
5,000 TO 7,499
7,500 TO 9,999
10,000 TO 12,499
12,500 TO 14,999
15,000 TO 17,499
17,500 TO 19,999
20,000 TO 22,499
22,500 TO 24,999
25,000 TO 27,499
27,500 TO 29,999
30,000 TO 32,499
32,500 TO 34,999
35,000 TO 37,499
37,500 TO 39,999
40,000 TO 44,999
45,000 TO 54,999
55,000 TO 59,999
60,000 OR MORE
DON’T REMEMBER (DON’T KNOW)
At any time during the last 2 years (in the
U.S.), were you covered by a union
contract while doing farm work (FW)?
9 0 NO
9 1 YES
9 7 DON’T KNOW
E2
How long do you expect to continue doing
farm work (FW in the U.S.)? [READ
CHOICES. MARK ONLY ONE]
91
92
93
94
95
LESS THAN ONE YEAR
ONE TO THREE YEARS
FOUR TO FIVE YEARS
OVER FIVE YEARS
OVER FIVE YEARS/ AS LONG AS I AM
ABLE
9 7 OTHER?:
E4 Could you get a U.S. non-farm job (NF)
within a month?
9 0 NO
9 1 YES
9 7 DON’T KNOW
17
SECTION EP. NEW EPA VERSION
S:\4. Questionnaire\2013\CYCLE77\ENGLISHCY77\Oct29ENG2013CY77.wpd
[REV. Sep 24, 2013]
When was the last time you worked two (2)
consecutive days? [If worked yesterday,
enter yesterday’s date as 1st Day]
EP1.
a. First day [MM/DD/Year]:
_____/_____/_____
b. Second day [MM/DD/Year]: _____/_____/_____
EP2.
On the first day of the consecutive days, at
what time did you arrive to work?
___________:____________ AM/PM
EP3. And...what time did you leave work [First day]?
__________:____________ AM/PM
[If “First day” is more than 15 days from today, skip to
EP7, otherwise continue with EP2]:
EP4. TIME SPENT DOING CROP/TASK ON THE FIRST DAY [REFER TO FIRST DAY IN “EP1a”]
a
b
c
What crops did
What tasks were you
you work with the doing with [crops in “a”]
first day?
the first day?
d
How long did you work
doing [TASK in “b”] with
[CROP in “a”]?
How long were you idle (e.g.,
rest, break, lunch, etc.)
during [TIME in “c”]?
1
Hour(s):
Minutes:
Hour(s):
Minutes:
2
Hour(s):
Minutes:
Hour(s):
Minutes:
3
Hour(s):
Minutes:
Hour(s):
Minutes:
4
Hour(s):
Minutes:
Hour(s):
Minutes:
5
Hour(s):
Minutes:
Hour(s):
Minutes:
EP5. SHOWER/BATH
“Due to busy schedules or limited access to washing facilities, it is not always possible for one to take a shower or
bath right after work.”
EP5. After your first work day [Date in EP1a] were you able to bathe/shower (soap and water)?
0 __NO
1__YES: When?: [MM/DD/YEAR]: ______/_____/_____ TIME:_______:__________ AM/PM
Where?: [Check one]:
___Work ___Home
___Other (specify):__________
EP6. CLOTHING ARTICLES
“It is also recognized that workers do not always have enough working clothes or enough time or money
for washing their work clothes as often as they might like, and that some articles of clothing are not
washed as often as others”
a
b
What clothing articles did you
wear on the first day?
c
[REFER TO “YES” AND “NO” ITEMS IN “b”]
...Are you wearing (or did you
wear) any of the same clothing ...Which of those clothing articles were
articles you wore on yesterday washed (soap and water) before you
wore them (today) again? [CHECK
(or first day?) [CHECK ONE]
ANSWER]
YES NO D/K
YES
NO
1 PANTS
WASHED
G YES
G NO
2
LONG SLEEVE
SHIRT
G YES
G NO
3
SHORT
SLEEVE SHIRT
G YES
G NO
4
OTHER:
---------------
G YES
G NO
EP7.
[Ask this question only if answers to “EP6c" are “YES” to (all): “c1, c2 and c3”, otherwise skip to
section “NP”]
Have you ever had to wear the same shirt or pants (without washing them) when doing FW?
0__NO 1__YES: Which one?:
__a. long sleeve shirts?
18
__b. short sleeve shirt __c.pants?
[REV. Sep 20, 2013]
S:\4. Questionnaire\2013\CYCLE77\ENGLISHCY77\Oct29ENG2013CY77.wpd
NP – HANDLING PESTICIDES
(IN THE U.S.A.)
NS – SANITATION SECTION
NP1f. In the last 12 months, have you
loaded, mixed or applied pesticides?
“The following questions refer to sanitation
at
your job with your current FW employer: ...
9 0 NO
9 1 YES
... Does your current employer provide
EVERY DAY...
NS1 ... (potable) clean drinking water and
disposable cups?
NT – TRAINING AND INSTRUCTIONS
90
91
92
97
NT2a. In the last 12 months, with your
current employer, has anyone given
you training or instructions in the
safe use of pesticides (through video,
audio, cassette, classroom lectures,
written material, informal talks or by
any other means)?
NO WATER, NO CUPS
YES, WATER ONLY
YES, WATER AND DISPOSABLE CUPS
DON’T KNOW
NS4 ... a toilet (EVERY DAY)?
9 0 NO
9 1 YES
9 7 DON’T KNOW
9 0 NO
9 1 YES
NS9
... (provide) water to wash hands
(EVERY DAY)?
9 0 NO
9 1 YES
9 7 DON’T KNOW
19
[REV. Oct 29, 2013]
S:\4. Questionnaire\2013\CYCLE77\ENGLISHCY77\Oct29ENG2013CY77.wpd
NH – INDIVIDUAL PERSONAL HEALTH HISTORY (LIFETIME)
[INTERVIEWER: FIRST ASK ALL QUESTIONS IN FIRST COLUMN.]
Have you ever -- in your
whole life – been told by a
doctor or nurse that you
have the following
conditions: ...
b.
a.
c.
Are you currently In the last 12 months, in the U.S.
taking medication and/or abroad, have you seen a
for this condition? doctor or nurse for (condition in
NH1 to NH10 COLUMN)? [IF ANSWER
IS “YES” FOR THE U.S. AND “AB”
MARK BOTH]
NH1
...ASTHMA?
9 0 NO
9 0 NO
9 1 YES
9 1 YES
NH2
...DIABETES?
9 0 NO
9 0 NO
9 1 YES
9 1 YES
NH3
...HIGH BLOOD
PRESSURE?
9 0 NO
9 0 NO
9 1 YES
9 1 YES
9 0 NO
9 0 NO
9 1 YES
9 1 YES
9 0 NO
9 0 NO
9 1 YES
9 1 YES
NH4
...TUBERCULOSIS?
NH5
...HEART DISEASE?
NH6
...URINARY TRACT
INFECTIONS?
9 0 NO
9 0 NO
9 1 YES
9 1 YES
NH10
...OTHER?:
9 0 NO
9 0 NO
9 1 YES
9 1 YES
20
9 0 NO
9 1 YES, IN THE U.S.A.
9 2 YES, “AB”:
9 0 NO
9 1 YES, IN THE U.S.A.
9 2 YES, “AB”:
9 0 NO
9 1 YES, IN THE U.S.A.
9 2 YES, “AB”:
9 0 NO
9 1 YES, IN THE U.S.A.
9 2 YES, “AB”:
9 0 NO
9 1 YES, IN THE U.S.A.
9 2 YES, “AB”:
9 0 NO
9 1 YES, IN THE U.S.A.
9 2 YES, “AB”:
9 0 NO
9 1 YES, IN THE U.S.A.
9 2 YES, “AB”:
[REV. Sep 20, 2013]
S:\4. Questionnaire\2013\CYCLE77\ENGLISHCY77\Oct29ENG2013CY77.wpd
NQ5 And, ...the last time you used the health care
provider, who paid the majority of the cost?
NQ – QUALITY OF AND ACCESS TO HEALTH
9 1 I PAID THE BILL OUT OF “MY OWN
POCKET”
9 2 MEDICAID / MEDICARE
9 3 PUBLIC CLINIC DID NOT CHARGE
9 4 EMPLOYER PROVIDED HEALTH PLAN
9 5 SELF OR FAMILY BOUGHT INDIVIDUAL
HEALTH PLAN
9 8 BILLED, BUT DID NOT PAY
9 9 WORKER’S COMPENSATION
9 6 OTHER:
CARE SECTION
[INTERVIEWER]: I would like to ask you a few
final questions about health care in general. You
may have given me some of this information
already, but I would like to make sure it is correct.
NQ1
In the last TWO YEARS [LAST 24 MONTHS],
in the U.S.A., have you used any type of
health care services from doctors, nurses,
dentists, clinics, or hospitals?
90
91
NO [SKIP TO NQ10]
YES
9 7 COMBINATION OF:
NQ10 [ASK ALL]: ...When you NEED to get health
care in the USA what are the main difficulties
you face? [CHECK ALL THAT APPLY]
NQ3b ...And the last time you used the health care 9 m.
provider, where did you go (what kind of
9 l.
place was it)?
91
COMMUNITY HEALTH CENTER/
92
PRIVATE MEDICAL DOCTOR’S
OFFICE/PRIVATE CLINIC
93
HEALER/ “CURANDERO”
94
HOSPITAL
95
EMERGENCY ROOM
96
MIGRANT HEALTH CLINIC
97
CHIROPRACTOR OR NATUROPATH’S
OFFICE
98
9 g.
9 h.
9 i.
9 j.
I do not know. I’ve never needed it
I’m “undocumented” / “no papers” (that’s
why they don’t treat me well)
No transportation, too far away
Don’t know where services are available
Health Center not open when needed
They don’t provide the services I need
They don’t speak my language
They don’t treat me with respect / I don’t feel
welcomed
They don’t understand my problems
I’ll lose my job
Too expensive/ no insurance
Other:
9
No difficulties / No problems
9 a.
9 b.
9 c.
9 d.
9 e.
9 f.
DENTIST
9 10 OTHER:
9 97 DON’T KNOW
NQ1a.
(How about) In a foreign country (e.g.
Mexico), Have you used any type of health
service in the last two years [LAST 24
MONTHS] [IF “YES,” ASK AND ENTER
COUNTRY]
90
NO
91
YES, IN:
[NAME OF COUNTRY]
21
[REV. Sep 20, 2013]
S:\4. Questionnaire\2013\CYCLE77\ENGLISHCY77\Oct29ENG2013CY77.wpd
LEGAL STATUS
We are interested in knowing whether any of the following apply to you. Please be assured that no one
besides us will know your response.
L1
What is your current legal status in the U.S.? [READ CHOICES IF L2
NECESSARY]
9 1 I AM A U.S. CITIZEN BY BIRTH [SKIP TO NEXT PAGE]
9 2 I AM A NATURALIZED U.S. CITIZEN (FOREIGN BORN,
NATURALIZED). (ASK: “BEFORE BECOMING A
NATURALIZED U.S. CITIZEN, UNDER WHICH PROGRAM
DID YOU APPLY TO OBTAIN YOUR PERMANENT
RESIDENCE?”) [POSSIBLE ANSWERS IN L2: 1 - 9, 97).
THEN ASK: L4-1, L4-2, AND L4-3]
93
94
PERMANENT RESIDENT/GREEN CARD (RIGHT TO
RESIDE AND WORK IN THE U.S.) (ASK L2: “UNDER
WHICH PROGRAM DID YOU APPLY?”) [POSSIBLE
ANSWERS: 1 HASTA 9 Y 97). THEN ASK: L4-1 AND L4-2]
91
AMNESTY UNDER 5 YEAR
PROGRAM [“TIME”]
92
AMNESTY UNDER SAW (90 DAY)
PROGRAM [“FW” - “FIELD WORK”]
93
CUBAN/HAITIAN ENTRANT
94
SPOUSAL PETITION
PROGRAM/FAMILY UNITY
95
LABOR CERTIFICATION
PROGRAM
96
REGISTRY PROGRAM
BORDER CROSSING CARD/COMMUTER CARD (RIGHT
TO CROSS THE BORDER AND WORK IN THE U.S.) (ASK 9 7
L2: “UNDER WHICH PROGRAM DID YOU APPLY?”)
[POSSIBLE ANSWERS: 9, 12, 13, Y 97. THEN ASK: L3, L4- 9 8
1 AND L4-2]
99
95
96
97
98
PROGRAMS [DO NOT READ
OPTIONS]
PENDING STATUS (WITHOUT DOCUMENTS, APPLIED,
AWAITING OFFICIAL DECISION) (ASK L2: “UNDER WHICH
PROGRAM DID YOU APPLY?”) [POSSIBLE ANSWERS: 1- 9 10
9, 97. THEN ASK: L3, AND L41]
UNDOCUMENTED (APPLICATION DENIED/DID NOT APPLY 9 11
TO ANY PROGRAMS) [POSSIBLE ANSWERS: “NONE”.
9 12
SKIP TO NEXT PAGE]
POLITICAL ASYLUM
REFUGEE
PROTECTIVE STATUS
(TEMPORARY)
GUEST WORKER PROGRAM
[“BRACERO”]
STUDENT
TOURIST
TEMPORARY RESIDENT - NON IMMIGRANT VISA (ONLY
FOR SPECIFIED TIME) [ASK L2: “UNDER WHICH
PROGRAM DID YOU APPLY?” POSSIBLE ANSWERS: 10 97. THEN ASK: L3 AND L41]
9 13
BORDER CROSSING CARD/
“PASSPORT”
9 97
OTHER:
OTHER [IF RELEVANT AND APPROPRIATE ASK L2, L3,
L4-1, L4-2, AND L4-3. THEN SKIP TO NEXT PAGE]:
9 99
NOT ANSWERED
L3 Do you have general work authorization?:
9 0 NO
9 1 YES
9 7 DON’T KNOW
L4
1 When did you apply to the
program (in L2)?
DATE STATUS BECAME EFFECTIVE:
2 [Only for those who responded
"2,3, or 4" in L1]: When did you
obtain your legal status?
/
(Month)
/
9 9 NOT ANSWERED
3 [Only for those who
responded "2" in L1]: When
did you obtain your
naturalization/ become a U.S.
citizen?
/
(Year)
(Month)
/
/
(Year)
22
(Month)
/
(Year)
JBS International, Inc.
Aguirre Division
555 Airport Boulevard, Suite 400
Burlingame, CA 94010-2002
Phone: 650.373.4900
Fax: 650.348.0260
INDIVIDUAL AGREEMENT TO BE A RESEARCH SUBJECT
OMB CONTROL NUMBER: 1205-0453
INTRODUCTION/PURPOSE
You are invited to participate in this survey for the National Institute for Occupational Safety and
Health and the Department of Labor because you are currently working on a farm. The purpose of the
survey is to learn more about the living conditions and health of farm workers.
PROCEDURES TO BE FOLLOWED
You will be asked to answer some questions about your work history and about your health. The
interview will last approximately 60 minutes.
RISKS
Since we will only be asking you questions, there is very little risk to you as a result of being in the
survey. You may refuse to answer any question at any time, with no penalty.
BENEFITS
There are no direct benefits to you from being in the survey. But, knowledge gained through this
research may help us learn how to prevent any harmful effects of farm work for workers like you.
PRIVACY
Your answers to the interview will be kept private to the extent allowed by law. This means that
the interview record will be kept in a locked file, and only researchers on the survey will be
allowed to see it. Your name will not appear on any reports about the survey. (See back of page
for details.)
ALTERNATIVES TO PARTICIPATION
Participating in this survey is voluntary and you can quit at any time. You can also choose not to
participate in any part of the interview at any time, with no penalty. Whether or not you participate
in this survey will not affect benefits and services to which you are normally entitled. You will be
paid for the time you are spending in this interview. At any time, you may ask the researchers to
explain any part of the survey.
WHO TO CALL WITH QUESTIONS
If you have questions about the research survey, including questions about your rights as a
research subject, you may call Aguirre International (toll free) at 877- SAY-NAWS (or 877-7296297). They will refer your questions to Daniel Carroll at the Department of Labor, at (202) 6932795.
I have read and understand the statement above. My questions about any unclear or confusing
statements have been answered clearly. I agree to participate in this survey as a research
subject. I admit that I have received a copy of this form and $20 for my participation.
-----------------------------------------------------------------Signature of Subject
(See reverse)
------------------------------------Date
In accordance with the Privacy Act of 1974, as amended (5
U.S.C.552a), we are notifying you that this study is authorized by the
U.S. Department of Labor, Employment and Training Administration
(ETA). Your voluntary participation is important to the success of
this study and will enable the ETA to understand the labor market
and living experiences of U.S. farmworkers. Under written
agreement with research organizations, the ETA may release certain
information necessary for research but only after all identifying
information has been removed. Unless required by law, or necessary
for litigation or legal proceedings and except as indicated in this
statement, we will hold all personal identifiers (e.g. name, address,
and social security number) in total confidence and will not release
them.
Notwithstanding any other provision of law, no person is required to respond to nor shall
a person be subject to a penalty for failure to comply with a collection of information
subject to the requirements of the Paperwork Reduction Act unless that collection of
information displays a currently valid Office of Management and Budget control number.
Public reporting burden for this collection of information, which is voluntary, is estimated
to average 1 hour (or 60 minutes) per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. Send comments regarding
this burden estimate to the Office of Policy, Development and Evaluation, ETA,
Department of Labor, Room N5641, 200 Constitution Avenue, N.W., Washington, D.C.
20210.
24
JBS International, Inc.
Aguirre Division
555 Airport Boulevard, Suite 400
Burlingame, CA 94010-2002
Phone: 650.373.4900
Fax: 650.348.0260
INDIVIDUAL AGREEMENT TO BE A RESEARCH SUBJECT
OMB CONTROL NUMBER: 1205-0453
INTRODUCTION/PURPOSE
You are invited to participate in this survey for the National Institute for Occupational Safety and
Health and the Department of Labor because you are currently working on a farm. The purpose
of the survey is to learn more about the living conditions and health of farm workers.
PROCEDURES TO BE FOLLOWED
You will be asked to answer some questions about your work history and about your health. The
interview will last approximately 60 minutes.
RISKS
Since we will only be asking you questions, there is very little risk to you as a result of being in the
survey. You may refuse to answer any question at any time, with no penalty.
BENEFITS
There are no direct benefits to you from being in the survey. But, knowledge gained through this
research may help us learn how to prevent any harmful effects of farm work for workers like you.
PRIVACY
Your answers to the interview will be kept private to the extent allowed by law. This means that
the interview record will be kept in a locked file, and only researchers on the survey will be
allowed to see it. Your name will not appear on any reports about the survey. (See back of page
for details.)
ALTERNATIVES TO PARTICIPATION
Participating in this survey is voluntary and you can quit at any time. You can also choose not to
participate in any part of the interview at any time, with no penalty. Whether or not you participate
in this survey will not affect benefits and services to which you are normally entitled. You will be
paid for the time you are spending in this interview. At any time, you may ask the researchers to
explain any part of the survey.
WHO TO CALL WITH QUESTIONS
If you have questions about the research survey, including questions about your rights as a
research subject, you may call Aguirre International (toll free) at 877- SAY-NAWS (or 877-7296297). They will refer your questions to Daniel Carroll at the Department of Labor, at (202) 6932795.
I have read and understand the statement above. My questions about any unclear or confusing
statements have been answered clearly. I agree to participate in this survey as a research
subject. I admit that I have received a copy of this form and $20 for my participation.
-----------------------------------------------------------------Signature of Subject
(See reverse)
25
------------------------------------Date
In accordance with the Privacy Act of 1974, as amended (5
U.S.C.552a), we are notifying you that this study is authorized by the
U.S. Department of Labor, Employment and Training Administration
(ETA). Your voluntary participation is important to the success of
this study and will enable the ETA to understand the labor market
and living experiences of U.S. farmworkers. Under written
agreement with research organizations, the ETA may release certain
information necessary for research but only after all identifying
information has been removed. Unless required by law, or necessary
for litigation or legal proceedings and except as indicated in this
statement, we will hold all personal identifiers (e.g. name, address,
and social security number) in total confidence and will not release
them.
Notwithstanding any other provision of law, no person is required to respond to nor shall
a person be subject to a penalty for failure to comply with a collection of information
subject to the requirements of the Paperwork Reduction Act unless that collection of
information displays a currently valid Office of Management and Budget control number.
Public reporting burden for this collection of information, which is voluntary, is estimated
to average 1 hour (or 60 minutes) per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. Send comments regarding
this burden estimate to the Office of Policy, Development and Evaluation, ETA,
Department of Labor, Room N5641, 200 Constitution Avenue, N.W., Washington, D.C.
20210.
26
| File Type | application/pdf |
| File Title | S:\4. Questionnaire\2013\CYCLE77\ENGLISHCY77\Oct29ENG2013CY77.wpd |
| Author | jnakamoto |
| File Modified | 2013-10-29 |
| File Created | 2013-10-29 |