Form 1 SEE-Socio Econonic Status-Occup-Eng

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PRA (0925-0584). Do not return the completed form to this address.

OMB#: 0925-0584
Exp. xx/xx/xxxx

HCHS/SOL- Socio Economic/Occupation Questionnaire
FORM CODE: SEE
VERSION: 1, 12/17/2013

ID NUMBER:

Contact
Occasion

0

2

SEQ #

ADMINISTRATIVE INFORMATION

0a.

/

Completion Date:

/

0b.

Staff ID:

Instructions: Enter the answer given by the participant for each response. Use the CDART Notelog window to code
'Don’t know/refused, Missing, etc.' for those questions that do not list these as an option.

A. Assets
1. Is your house, apartment, or mobile home…?
Owned by you or someone in the household free and
clear without a mortgage or loan
1
Owned by you or someone in the household
with a mortgage or loan

2

Rented

3

Occupied without payment

4

2. Do you have a bank account (for example, savings, checking), mortgage loan or credit card with a bank
in the U.S. or Puerto Rico?
No

0

Yes

1

Don’t know/Not sure

2

Refused

9

B. Annual Household Income
3. Counting the income of all the members of your household, was your household income for the year…
(Include all money received from all sources)
Less than $30,000

1

 GO TO QUESTION 3

$30,000 or more

2

 GO TO QUESTION 4

4. Is that income…

Less than $10,000

1

$10,001-$15,000

2

$15,001-$20,000

3

$20,001-$25,000

4

$25,001-$29,999

5

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FORM CODE: SEE
VERSION: 1 12/17/2013

ID NUMBER:

5. Is that income…

$30,000-$40,000

1

$40,001-$50,000

2

$50,001-$75,000

3

$75,001-$100,000

4

Contact
Occasion

0

2

SEQ #

More than $100,000 5
6. How many people, including yourself, were supported by this income during the year?
Number of people
C. Occupation
7. In the past 12 months, did you have any paid employment?

Yes

1

No 0

Go to Question 111

8. In the past 12 months, how many months did you work?
Number of months

For less than one month record 11

9. When you were working during the past 12 months, in an average month, how many full-time
jobs (30 or more hours/week) did you have?
Number of full-time job(s)
9a.

if=0, Go to Question 10

On average, how many hours per week did you work in those full-time jobs?
Total average hours per week in full-time job(s)

10. When you were working during the past 12 month, in an average month, how many part-time
jobs (less than 30 hours/week) did you have?
Number of part-time job(s)
10a.

if=0, Go to Question 111

On average, how many hours a week did you work in those part -time jobs?
Total average hours per week in part-time job(s) END Questionnaire

Participants with NO paid employment
11. Were you looking for any kind of paid work at any time in the past 12 months?
Yes
10a.

1

No 0

Go to Question 13

If yes, how long have you been looking for work?

SEE-Socio Economic Status-Occupation_12-17-2013.docx

Number of months

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FORM CODE: SEE
VERSION: 1 12/17/2013

ID NUMBER:

Contact
Occasion

0

2

SEQ #

12. What was the main reason you did not work for pay in the past 12 months (Check only one)?
Retired

1

Going to school

2

Homemaker

3

Unable to work for health reasons 4
Disabled
5
On layoff/unemployed
Other:

6
7

Specify:
D. Education
13. Have you been involved in any educational or training program since the first SOL examination?

Yes

1

No 0

Go to Question 15

14. What was the highest grade/level of education achieved? If exact level is not listed, mark the closest
equivalent. (Mark only one)
Elementary/primary school (includes grades 1 – 5)
1
Middle school/junior high (includes grades 6 – 8)
2
High School/preparatory school
3
Trade school/vocational school
4
University/college
5
Other
6
If other, please specify:

SEE-Socio Economic Status-Occupation_12-17-2013.docx

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