Employers - Point of Contact Questions

U:\NAWS2017\OMB DRAFTS 2016-2017\OMB
CleanDraft7EnglishMAR 17 2017.wpd

ENGLISH
Cycle 89, FALL 2017
OMB NO. 1205-0453

8

9

COUNTY FIPS

FARM WORKER ID
[FOR OFFICE USE ONLY]

EXPIRATION DATE: XX/XX/20XX
[REV. Mar 10, 2017]

NATIONAL AGRICULTURAL WORKERS SURVEY - 2017
CS2

DATE:

/

(“NAWS”)

/
[FOR OFFICE USE ONLY]

CROP CODE
CS5

CROP:
TASK CODE

CS6 TASK:
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:
INTER
VIEWER’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, Evaluation and Research,
ETA, Department of Labor, Room N5641, 200 Constitution Avenue, N.W., Washington, D.C. 20210.

HOUSEHOLD GRID

[REV. Mar 10, 2017]

___ ___ ___ ___ ___

89 ___ ___ ___
Farmworker ID

County
A1

NAME

*A2 A3 A5
M
R
A
E
R
L
I
A
T
T
A
I
L
O S
N E S
X T
A
T
U
S

A6
B
I
R
T
H
D
A
Y

**A7
C
O
U
N
T
R
Y

A9
**A10
A8
A4
HIGHEST
C
MONTH [ASK ALL
IN A1]:
GRADE
O
AND
LEVEL
DOES
U
YEAR
[FOR
S/HE LIVE
N
MINORS
WITH YOU
T
FIRST
INCLUDE
R
NOW?
PREIF NOT,
Y
E
SCHOOL
WHERE?
N
(“PS”) AND
S
T
[STATE and
B
KINDER
COUNTRY]
C
E
MM
I
(“K”)
[ASK
H
R
/
R
ONLY
O
E
YY
T
WORKER
O
D
H
FOR HIGHEST
L
[CODE]
DEGREE
OBTAINED. ] [CODE] U.S.?

***A31

A32-33
LAST 12
MONTHS,
TRAVELED
TO DO FW
(OR DONE
FW IN
OTHER
WHY CITY)?
NOT IF YES,
?
[NAME]
_ TRAVELED
C
OR
O
JOINED
D
WITH
E
YOU?
IF
NOT
H
E
R
E,

A34-35
A11
PRIOR 12 ANY
MONTHS U.S.
TO (A32-33), S
TRAVELED C
TO DO FW
H
(OR DONE
O
FW IN
O
OTHER
L
CITY)?
LAST
IF YES,
12
[NAME]
M
TRAVELED O
OR JOINED N
WITH YOU? T
H
S?

HA15
*****HA16
HA17
*****HA18
A13
ONLY FOR SPOUSE AND CHILDREN UNDER 22 YEARS OLD
ANY
U.S.
And
When?
FW
the
(Last [For each
LAST
last
time) “NO” IN
In the USA, in the LAST 12
12
time,
[Enter “HA15"]
MONTHS,
M
where ‘within” Why did
has [NAME of (spouse) (child)]
O
did
number [NAME]
used any type of health care
N
not
[NAME]
of
service from doctors nurses,
T
go?
months access
dentists, clinics or hospitals
H
health
ago]:
[ENTER
S?
1
care?
for...
CODE]
[ENTER
TO
12]
CODES]

A. (FARMWORKER)
M
F

S
M
O

HG: _______
/

Y

Y

Y

N

N

N

NOTE: Explain that
ILLNESS below refers to:
“A physical illness, as
well as a mental health
problem or substance
abuse.”

/
HD: _______

B.
S
M
M
F

/

Y

Y

Y

Y

Y

N

N

N

N

N

/

O

C.

a. illness?:

Y
DK

N
RF

b. injury?:

Y
DK

N
RF

c. routine or

Y
DK

N
RF

d. dental treatment or Y
DK
preventive care?:

N
RF

a. illness?:

Y
DK

N
RF

b. injury?:

Y
DK

N
RF

c. routine or

Y
DK

N
RF

d. dental treatment or Y
DK
preventive care?:

N
RF

preventive care?:

/
S
M
M
F
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.)
95= RF (REFUSE)
96= DK (DON’T KNOW)
97=OTHER::__________________

Y

Y

Y

Y

Y

N

N

N

N

N

/

** CODES FOR A7 AND A10 (COUNTRIES AND REGIONS):
1= U.S.A.
8= PACIFIC ISLANDS
2= PUERTO RICO
(THE PHILIPPINES,
3= MEXICO
GUAM, FIJI, ETC.)
4= CENTRAL AMERICA
9= ASIA (CHINA,
5= SOUTH AMERICA
JAPAN, KOREA,
6= CARIBBEAN
ETC.)
7= SOUTH EAST ASIA
95= RF (REFUSE)
(INDONESIA, CAMBODIA,
96= DK (DON’T KNOW)
VIETNAM, LAOS, THAILAND) 97=OTHER:________

***CODES FOR A31
1 = NO CHILD CARE IN
THIS LOCATION
2 = NO HOUSING IN THIS
LOCATION
3 = CHILD IN SCHOOL,
AFFECTED IF MOVED
95= RF (REFUSE)
96= DK (DON’T KNOW)
97=OTHER: _______

2

__

preventive care?:

****CODES FOR HA16
1 = COMMUNITY/MIGRANT HEALTH
CENTER
2 = PRIVATE MEDICAL CLINIC/ DOCTOR’S
OFFICE
3 = HOSPITAL
4 = EMERGENCY ROOM
7 = DENTIST
95= RF (REFUSE)
96= DK (DON’T KNOW)
97=OTHER:__________

*****CODES FOR HA 18

a=
b=
c=
d=
e=
f=
g=

Did not know where to go
No transportation
Too far away
Health Center not open when needed
No need to go / Does not get sick
Too expensive
No insurance

95= RF (REFUSE)
96= DK (DON’T KNOW)
97=OTHER: ______________

HOUSEHOLD GRID

[REV. Mar 10, 2017]

___ ___ ___ ___ ___
County

A1

NAME

*A2 A3

R
E
L
A
T
I
O
N

S
E
X

A5

A6

**A7

A9

**A10

A8

M
A
R
I
T
A
L

B
I
R
T
H
D
A
Y

C
O
U
N
T
R
Y

HIGHEST
GRADE
LEVEL
[FOR
MINORS
INCLUDE
PRESCHOOL
(“PS”) AND
KINDER
(“K”)

C
O
U
N
T
R
Y

MONTH
AND
YEAR

S
T
A
T
U
S

MM
/
YY

B
I
R
T
H

S
C
H
O
O
L

[ASK
ONLY
WORKER
FOR HIGHEST
[CODE]
DEGREE
OBTAINED. ] [CODE]

FIRST
E
N
T
E
R
E
D
U.S.?

A4

***A31

A32-33

A34-35

A11

[ASK ALL
IF
LAST 12
PRIOR 12 ANY
MONTHS U.S.
IN A1]:
NOT MONTHS,
DOES
TRAVELED TO (A32-33), S
S/HE LIVE
H TO DO FW TRAVELED C
H
WITH YOU
E (OR DONE TO DO FW
O
NOW?
R
(OR DONE
FW IN
O
FW IN
IF NOT,
E,
OTHER
L
OTHER
WHERE?
WHY CITY)?
LAST
[STATE and NOT IF YES,
CITY)?
IF YES,
12
COUNTRY]
?
[NAME]
M
_ TRAVELED
[NAME]
TRAVELED O
C
OR
O
JOINED OR JOINED N
WITH YOU? T
D
WITH
H
E
YOU?
S?

A13

HA15

*****HA16

a. illness?:
S
M
F
O

Y

Y

Y

Y

N

N

N

N

N

E.
/
S
M

Y

Y

Y

Y

Y

N

N

N

N

N

Y

Y

Y

Y

N

N

/

M
F
O

F.
/
S
M

Y

/

M
F

N
N

N

O

*CODES FOR A2 (RELATIONSHIP):

** CODES FOR A7 AND A10 (COUNTRIES AND
REGIONS):

1 = SPOUSE/COMMON LAW SPOUSE
2 = OWN CHILD, DEPENDENT OR ADOPTED
3 = SIBLING
4 = PARENT
5 = GRANDCHILD
6 = OTHER RELATIVE (COUSINS, UNCLES,
ETC.)
95= RF (REFUSE)
96= DK (DON’T KNOW)
97=OTHER:__________________

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.)
95= RF (REFUSE)
96= DK (DON’T KNOW)
97=OTHER: ________

Y
DK
Y
DK

N
RF
N
RF

c. routine or preventive Y
care?:
DK

N
RF

d. dental treatment or
preventive care?:

N
RF
N
RF
N
RF
N
RF
N
RF
N
RF
N
RF
N
RF
N
RF

b. injury?:

Y
/

/

***CODES FOR A31
1 = NO CHILD CARE IN THIS
LOCATION
2 = NO HOUSING IN THIS
LOCATION
3 = CHILD IN SCHOOL,
AFFECTED IF MOVED
95= RF (REFUSE)
96= DK (DON’T KNOW)
97=OTHER:: _________

3

HA17

*****HA18

ANY
ONLY FOR SPOUSE AND CHILDREN UNDER 22 YEARS OLD
And
When?
U.S.
the
(Last [For each
FW
last
time) “NO” IN
LAST
In the USA, in the LAST 12
time,
[Enter “HA15"]
12
where ‘within” Why did
MONTHS, has [NAME of (spouse)
M
did
number [NAME]
O (child)] used any type of health care
not
N
service from doctors nurses,
[NAME]
of
dentists, clinics or hospitals for...
go? months access
T
H
ago]:
health
care?
1
S?
[ENTER
CODE]
TO
[ENTER
CODES]
12]

D.

M

89 ___ ___ ___ __
Farmworker ID

Y
DK
a. illness?:
Y
DK
b. injury?:
Y
DK
c. routine or preventive Y
care?:
DK
d. dental treatment or
Y
preventive care?:
DK
a. illness?:
Y
DK
b. injury?:
Y
DK
c. routine or preventive Y
care?:
DK
d. dental treatment or
Y
preventive care?:
DK

****CODES FOR HA16

*****CODES FOR HA 18

1=

a = Did not know where to go
b = No transportation
c = Too far away
d = Health Center not open when needed
e = No need to go / Does not get sick
f = Too expensive
g= No insurance
95= RF (REFUSE)
96= DK (DON’T KNOW)
97=OTHER: ______________

COMMUNITY/MIGRANT HEALTH
CENTER
2 = PRIVATE MEDICAL CLINIC/
DOCTOR’S OFFICE
3 = HOSPITAL
4 = EMERGENCY ROOM
7 = DENTIST
95= RF (REFUSE)
96= DK (DON’T KNOW)
97=OTHER: ________

HOUSEHOLD GRID

[REV. Mar 10, 2017]

___ ___ ___ ___ ___
County

A1

NAME

*A2

R
E
L
A
T
I
O
N

A3

S
E
X

A5

A6

**A7

A9

**A10

A8

A4

***A31

A32-33

A34-35

A11

A13

M
A
R
I
T
A
L

B
I
R
T
H
D
A
Y

C
O
U
N
T
R
Y

HIGHEST

C

MONTH

[ASK ALL

IF

LAST 12

PRIOR 12

ANY

ANY

GRADE
LEVEL
[FOR
MINORS
INCLUDE
PRESCHOOL
(“PS”) AND
KINDER
(“K”)

O
U
N
T
R
Y

AND
YEAR

S
T
A
T
U
S

MM
/
YY

B
I
R
T
H
[CODE]

S
C
H
O
O
L

[ASK
ONLY
WORKER
FOR HIGHEST
[CODE]
DEGREE
OBTAINED. ]

FIRST
E
N
T
E
R
E
D
U.S.?

MONTHS U.S. U.S.
IN A1]:
NOT MONTHS,
FW
DOES
TRAVELED TO (A32-33), S
S/HE LIVE
H TO DO FW TRAVELED C LAST
12
H
WITH YOU
E (OR DONE TO DO FW
M
O
(OR DONE
NOW?
R
FW IN
O
O
FW IN
IF NOT,
E,
OTHER
N
L
WHERE?
WHY CITY)?
OTHER
T
LAST
CITY)?
[STATE and NOT IF YES,
H
12
COUNTRY]
?
IF YES,
[NAME]
S?
M
[NAME]
_ TRAVELED
C
TRAVELED O
OR
O
JOINED OR JOINED N
D
WITH YOU? T
WITH
H
E
YOU?
S?

G.

HA15

*****HA16

S
M
F

/

O

Y

Y

Y

Y

Y

N

N

N

N

N

c. routine or preventive Y
care?:
DK

N
RF

d. dental treatment or
preventive care?:

Y
DK

N
RF

a. illness?:

Y
DK
Y
DK

N
RF
N
RF

Y
DK

N
RF

Y
DK

N
RF

Y
DK
Y
DK

N
RF
N
RF

Y
DK

N
RF

Y
DK

N
RF

b. injury?:

H.
/
S
M
M

Y

Y

Y

Y

Y

N

N

N

N

N

/

F
O

I.

b. injury?:
c. routine or preventive
care?:
d. dental treatment or
preventive care?:
a. illness?:

/
S
M
M

Y

Y

Y

Y

Y

N

N

N

N

N

/

F
O

*CODES FOR A2 (RELATIONSHIP):

** CODES FOR A7 AND A10 (COUNTRIES AND REGIONS):

1 = SPOUSE/COMMON LAW SPOUSE
2 = OWN CHILD, DEPENDENT OR
ADOPTED
3 = SIBLING
4 = PARENT
5 = GRANDCHILD
6 = OTHER RELATIVE (COUSINS,
UNCLES, ETC.)__________________
95= RF (REFUSE)
96= DK (DON’T KNOW)
97=OTHER::__________________

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.)
95= RF (REFUSE)
96= DK
97 = OTHER:___________________

***CODES FOR A31
1 = NO CHILD CARE IN
THIS LOCATION
2 = NO HOUSING IN
THIS LOCATION
3 = CHILD IN SCHOOL,
AFFECTED IF
MOVED
95= RF (REFUSE)
96= DK
97 = OTHER:__________
4

*****HA18

And When?
the
(Last [For each
“NO” IN
last
time)
time, [Enter “HA15"]
In the USA, in the
LAST 12 MONTHS, has [NAME of where ‘within”
(spouse) (child)] used any type of
did number Why did
of
[NAME]
health care service from doctors [NAME]
nurses, dentists, clinics or
go? months
not
access
hospitals for...
ago]:
1
health
[ENTER
care?
CODE]
TO
12]
[ENTER
CODES]

Y
DK
Y
DK

/

HA17

ONLY FOR SPOUSE AND CHILDREN UNDER 22 YEARS OLD

a. illness?:

M

89 ___ ___ ___ __

Farmworker ID

b. injury?:
c. routine or preventive
care?:
d. dental treatment or
preventive care?:

N
RF
N
RF

****CODES FOR HA16

*****CODES FOR HA 18

1 = COMMUNITY/MIGRANT HEALTH CENTER
2 = PRIVATE MEDICAL CLINIC/ DOCTOR’S OFFICE
3 = HOSPITAL
4 = EMERGENCY ROOM
7 = DENTIST
95= RF (REFUSE)
96= DK (DON’T KNOW)
97=OTHER: ________

a=
b=
c=
d=
e=
f=
g=

Did not know where to go
No transportation
Too far away
Health Center not open when needed
No need to go / Does not get sick
Too expensive
No insurance

95= RF (REFUSE)
96= DK (DON’T KNOW)
97=OTHER:______________

[REV. Mar 10, 2017]

U:\NAWS2017\OMB DRAFTS 2016-2017\OMB CleanDraft7EnglishMAR 17 2017.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", ASK
HS1. ...Now that you’re working here in [NAME OF
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): _______________

HS5. Has/Have your child(-dren) ever used MSHS?
(When?)
[ASK ONLY “HS6"]
9 0 NO
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"]

HS2.

[IF MORE THAN ONE ANSWER IN HS1, ASK]: Which one
HS6. Why aren’t you (or your spouse) using MSHS
do you use most often during an average work week
at this location? [CHECK ALL THAT APPLY]
(FW)? [ENTER LETTER CODE IN HS1]:
Prefer own child care arrangements
9 a.
----------------------------------------------------------No MSHS in this area
9 b.
MSHS not open entire season (FOR FW)
9 c.
HS3. [ASK ALL] Why do you use this type (the most) while
doing FW? [CHECK ALL THAT APPLY]
9 d. Inconvenient hours
MSHS full (applied, but no openings)
9 e.
9 a. Trust
Applied, but did not qualify
9 f.
9 b. Flexible / Convenient hours
g.
Does not serve infants / older children
9
9 c. Convenient location
9 h. Do not like it. Specify: ___________________
9 d. Culturally compatible (same language, food, staff, etc.)
Do not qualify. (Specify) Why?:
9 i.
9 e. Prepares child for school (e.g., English)
_______________________________________
9 f. Don’t know (e.g., spouse decides)
Other (specify): _________________
9 z.
9 z. 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)
5

HOW DID YOU LEARN [INTERVIEWER: CHECK IF
ABOUT MSHS?
CENTER IN “d” is in MSHS
[ENTER CODE]
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. Mar 10, 2017]

[THESE 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: ...
a.

...ADULTS? (18 YEARS OR OLDER)?

b.

...CHILDREN? (17 YEARS OR YOUNGER)?

A20 ...your

relatives?

A16

...doing FW?

...DO NOT KNOW AGE?

c.

INSURANCE QUESTIONS ABOUT RESPONDENT AND HIS/HER FAMILY
(INDIVIDUALS IN THE “HOUSEHOLD GRID”) [DESCRIBE/EXPLAIN “HEALTH INSURANCE”]
A21

A23

In the U.S.A.,... Who has Health (Medical) Insurance in your family? ...
How about...
9 0 NO
a. ...you
9 1 YES
(farmworker)?
9 95 DON’T KNOW
9 0 NO
b. ...your
9 1 YES
spouse?
9 95 DON’T KNOW
[CHILDREN UNDER
AND OVER 18 YRS.
OLD. MATCH TOTAL
WITH FAMILY GRID]
C.

...your
children?

A21c2

9 0 NO

Who pays for it?
[USE CODES. MARK ALL THAT APPLY]

91 92

93

94

9 5 9 97:
91 92
95

93

94

9 97:

A24

(a) How many under 18 yrs?:

91 92

93

94

9 1 YES, ALL HAVE IT [ASK A23]
9 2 YES, ONLY SOME HAVE IT

(b) How many over 18 yrs?:

9 5 9 97:

9 95 DON’T KNOW
1= I PAY
2= MY SPOUSE
G4

CODES FOR “A23” (WHO PAYS?):
3= MY EMPLOYER
5= GOVERNMENT
4= MY SPOUSE’S EMPLOYER
97= OTHER:

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 r.

...Welfare (general assistance) or TANF (Temporary
Assistance for Needy Families)?
9 b. ...Food stamps?
9 c. ...Disability insurance?
9 d. ...Unemployment insurance?
9 e. ...Social Security?
9 h. ...Low income housing?
...Public Health Clinic?
9 i.
...Medicaid?
9 j.
9 k. ...WIC?
9 l. ...Disaster Relief
9 m. ... Legal Advice or Services
9 n. ...Other?:
Don’t know
9
9 none

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)? [CHECK ALL THAT APPLY]
9 1 They've stayed home alone, at least sometimes
9 13 With my spouse, other family
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:

6

[REV. Mar 10, 2017]

Do you live in a labor camp or Migrant Center? [IF

D65

D33a

YES, PROBE: WHO OWNS OR RUNS IT?]

90
91
92
93

NO
YES, labor camp run by a grower or labor
contractor
YES, labor camp run by migrant center or public
agency
YES, labor camp run by another person/group
Specify: __________________

Where are your living quarters located?

D35b

[READ CHOICES. MARK ONLY ONE]: ...

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 10 I (OR I AND MY FAMILY) RECEIVE FREE HOUSING
FROM MY EMPLOYER. [SKIP TO B10]

9 3 I PAY FOR HOUSING PROVIDED BY MY EMPLOYER. (I
PAY DIRECTLY OR THROUGH WAGE DEDUCTION).

9 5 I PAY FOR HOUSING PROVIDED BY THE
GOVERNMENT, A CHARITY, OR OTHER NON-WORK
RELATED INSTITUTION.

...OFF FARM IN PROPERTY NOT OWNED OR
ADMINISTERED BY YOUR PRESENT EMPLOYER?
9 11 DO NOT PAY RENT. (I OR FAMILY MEMBER OWN
...OFF FARM IN PROPERTY OWNED OR
THE HOUSE OR LIVE FOR FREE WITH FRIENDS OR
ADMINISTERED BY YOUR PRESENT EMPLOYER?
RELATIVES) [SKIP TO B10]
...ON FARM OR NEXT TO OR ADJACENT TO A FARM
OWNED BY THE GROWER YOU CURRENTLY WORK
9 12 I RENT FROM NON-EMPLOYER (RELATIVE OR NONRELATIVE)
FOR?
...ON A FARM OR NEXT TO OR ADJACENT TO A FARM
9 97 OTHER:
NOT OWNED BY THE GROWER YOU CURRENTLY
WORK FOR?
...OTHER?:

91

92
95

96

9 97

D50

D34b

In what type of living quarters do you live
now (housing structure at this location)? [READ
CHOICES. MARK ONLY ONE]: ...Is it a (an)...

At this location how much do you pay for
housing (including housing for your family, if
they live with you)?

91
per week

91
92
94
9 97

...MOBILE HOME?
...SINGLE-FAMILY HOME (DETACHED)?
...APARTMENTS (TWO OR MORE IN A BUILDING,
SHARED PARKING SPACES)?
...OTHER:

How many of the following do you have in
your current living quarters (dwelling)...

D54

9 a.

...Bedrooms?:

9 b.

...Bathrooms?:

9 c.

...Kitchens?:

9 f.

...Other rooms?:

,

.

or
per month $

,

.

or
per day

,

.

92
93
97
G6

$

$

DON'T KNOW, TAKEN OUT OF MY PAYCHECK
DON'T KNOW/DON'T REMEMBER, BUT NOT
TAKEN OUT OF MY PAYCHECK
OTHER:
Do you own or are you buying any of the following
item in the U.S.? [READ OPTIONS. MARK ALL “YES”
RESPONSES]

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]

...a plot of land?
...a type of housing, such as a house, mobile
home, condominium, or apartment?
9 d. ...any kind of vehicle, such as a car or truck?:
9 f. ...other?:
9 h.
9 l.

9

7

None

[REV. Mar 10, 2017]

How far is your current job from your current
residence?

D37a

91
92
93
94
95
96

B13 When was the last time your parents did hired
farm-work in the U.S.?

I'M LOCATED AT THE JOB
WITHIN 9 MILES
10-24 MILES
25-49 MILES MILES
50-74 MILES
75 MILES OR MORE

90
91
92
93
9 4

97
E2

At your current job, how do you usually get to
work? [READ CHOICES. MARK ONE]:...

D37

9 1 ...DRIVE CAR? [SKIP TO B10]
9 2 ...WALK [SKIP TO B10]
9 5 ...PUBLIC TRANSPORTATION (BUS, TRAIN,
ETC.)? [SKIP TO B10]
9 6 ...LABOR BUS, TRUCK, VAN?
9 8 ...“RAITERO”:?
9 4 ...RIDE WITH OTHERS (SHARES RIDE)?
9 7 ...OTHER?:

9 0 NO

E4

90
91
92

Could you get a U.S. non-farm job (NF) within a
month?
9 0 NO
9 1 YES
9 7 DON’T KNOW

9 1 YES

Do you pay a fee to (responsible in D37 and/or
"raiteros") for rides to work?

D38

How long do you expect to continue doing farm
work (FW in the U.S.)? [READ CHOICES. MARK
ONLY ONE]

9 1 LESS THAN ONE YEAR
9 2 ONE TO THREE YEARS
9 3 FOUR TO FIVE YEARS
9 4 OVER FIVE YEARS
9 5 OVER FIVE YEARS/ AS LONG AS I AM ABLE
9 7 OTHER?:

Do you have to use the transport (in D37) (IS IT
MANDATORY OR OBLIGATORY)?

D38a

NEVER
NOW / WITHIN LAST YEAR
ONE TO FIVE YEARS AGO
SIX TO TEN YEARS AGO
OVER 11 YEARS AGO
DON’T KNOW

B1

[ASK ALL]

Which of the following describes you?

[READ CHOICES. CHECK ONLY ONE]: ...

NO
YES, A FEE
YES, JUST FOR GAS

91
92
93
95
94
97

B10 In what month and year did you first do any
farm work in the U.S.? (First time FW in the
U.S.) [ASK FOR MONTH AND YEAR]

...MEXICAN-AMERICAN?
...MEXICAN?
...CHICANO?
...PUERTO RICAN?
...OTHER HISPANIC?:
...NOT HISPANIC OR LATINO?

B2 Which of the following do you consider yourself?
MONTH

/
/

[READ CHOICES EXCEPT “OTHER.” MARK ONE OR MORE
RESPONSES]: ...

YEAR

91
92
94
95
96
97

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

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

8

...White?
...Black or African American?
...American Indian/Alaska Native?
...Asian?
...Native Hawaiian or Pacific Islander?
...Other?:

[REV. Mar 10, 2017]

[IF FOREIGN BORN, ASK];
Where were you born? In what...

B18.

(e) ...MUNICIPALITY
(d) ...STATE?:
(DEPARTMENT) (EQUIVALENT)?:

B16.

(f) ...TOWN (OR 9 1
92
CITY)?:
93
95

B26-27

When you lived in your
country, did you work in...

B17-18. Before coming to the USA, you
lived in what...

...AGRICULTURE [FW]?
...NON-AGRICULTURE [NF]?
...PART FARM AND PART
NON-FARM [FW AND NF]?
...NEVER WORKED?

(B17)...COUNTRY?:

(B18)...STATE (OR
DEPARTMENT)?:

...And where were your parents born? ...In what...
...COUNTRY?

STATE (OR EQUIVALENT)

MUNICIPALITY (OR EQUIVALENT)

TOWN (OR CITY)

(B26a) FATHER:
(B27a) MOTHER?:

LANGUAGE SECTION
B7

How well do you speak English?

B8

B20

9 1 ...Not at all?
9 2 ...A little?

B21

[CHECK
ALL THAT

B22 And

to you at home?

APPLY]

do you speak it?

U

U

B24

[FOR EACH CHECKED ANSWER, ASK]:

now, how well

B23 And

now, how well

[READ CHOICES. MARK ONLY

ONLY ONE PER CHECK]:

ONE PER CHECK]:

ONE. If fully bilingual,
enter and check both] U

93

92
93
94
92
93
94
92

e KANJOBAL

93
94
92

f ZAPOTEC

93
94
92

z OTHER:

dominant (comfortable)

[READ CHOICES. MARK

94

d MIXTEC

believe you are most

conversing? [CHECK

92

c CREOLE

In which language do you

do you read it?

a ENGLISH

b SPANISH

9 3 ...Somewhat?
9 4 ...Well?

And now, as an adult, what languages can you speak?

When you were a child,
in what languages
did adults speak
[CHECK ALL THAT
APPLY]

How well do you read English?
[READ CHOICES. MARK ONLY ONE RESPONSE]: ...

[READ CHOICES. MARK ONLY ONE RESPONSE]: ...
...Not at all?
...Somewhat?
91
93
...A little?
...Well?
92
94

93
94

91
92
93
94

...NOT AT ALL?
...A LITTLE?
...SOMEWHAT?
...WELL?

91
92
93
94

...NOT AT ALL?
...A LITTLE?
...SOMEWHAT?
...WELL?

91
92
93
94

...NOT AT ALL?
...A LITTLE?
...SOMEWHAT?
...WELL?

91
92
93
94

...NOT AT ALL?
...A LITTLE?
...SOMEWHAT?
...WELL?

...A LITTLE?
...SOMEWHAT?
...WELL?

91
92
93
94

...NOT AT ALL?
...A LITTLE?
...SOMEWHAT?
...WELL?

...A LITTLE?
...SOMEWHAT?
...WELL?

91
92
93
94

...A LITTLE?
...SOMEWHAT?
...WELL?
...A LITTLE?
...SOMEWHAT?
...WELL?
...A LITTLE?
...SOMEWHAT?
...WELL?
...A LITTLE?
...SOMEWHAT?
...WELL?

9

...NOT AT ALL?
...A LITTLE?
...SOMEWHAT?
...WELL?

[REV. Mar 10, 2017]

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 “YES” RESPONSES TO PROBE AND DOCUMENT DATES HERE OR DURING THE QUESTIONS IN THE “WORK GRID”]:

WORK GRID

___ ___ ___ ___ ___ 89 ___ ___ ___ ___

[C1-C2 FOR OFFICE USE ONLY]
C15

C3

C4

FW?
PER.
AND
SUB
PER.
NO.

GR
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]

NW?
AB?

GR

FW
NF

CO

NW
AB

GR

FW
NF

CO

NW
AB

GR

FW
NF

CO

NW
AB

GR

FW
NF
NW
AB

CO

FW
NF

GR

NW
AB

CO
* C-5 ACTIVITY CODES: ONLY FOR “NW” (IN THE U.S.A.)
[WRITE ACTIVITY FOR FW AND NF]
201 =
202 =
203 =
204 =

NF?

LOOKING FOR FW AND NF WORK
LOOKING FOR FARM WORK
LOOKING FOR NF WORK
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)

RECEIVED
UNEMPLOYMENT?

C1-C2

County
REPORT FROM FIRST PERIOD COVERING OCTOBER 01, 2016 TO PRESENT
C5
C6
C8
C9
C10
C11
DATES FOR
PERIODS OF
FW, NF, NW, AB

FROM:

TO:

# OF
WORK
DAYS
PER
WEEK?
FW &
NF

C12

C13

COUNTY NAME
[IF IN A BORDER
COUNTY ASK IF
COMMUTE FROM
MEXICO]

STATE
and

C7
***FW
AND
NF:
WHY
LEFT?

COUNTRY
[CODE]

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

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 =

CITY

Farmworker ID

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)

10

*** 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
97 = OTHER (SPECIFY):

WORK GRID

[REV. Mar 10, 2017]

___ ___ ___ ___ ___ 89 ___ ___ ___ ___

[C1-C2 FOR OFFICE USE ONLY]
C15

C3

C4

FW?
GR

PER.
AND
CO
SUB
PER. [FW
NO. 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]

NW?
AB?

GR

FW
NF

CO

NW
AB

GR

FW
NF

CO

NW
AB

GR

FW
NF

CO

NW
AB

GR

FW
NF
NW
AB

CO

FW
NF

GR

NW
AB

CO

FW
NF

GR

NW
AB

CO
* C-5 ACTIVITY CODES: ONLY FOR “NW” (IN THE U.S.A.)
[WRITE ACTIVITY FOR FW AND NF]
201 =
202 =
203 =
204 =

NF?

LOOKING FOR FW AND NF WORK
LOOKING FOR FARM WORK
LOOKING FOR NF WORK
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)

RECEIVED
UNEMPLOYMENT?

C1-C2

County
REPORT FROM FIRST PERIOD COVERING OCTOBER 01, 2016 TO PRESENT
C5
C6
C8
C9
C10
C11
DATES FOR
PERIODS OF
FW, NF, NW, AB

FROM:

TO:

# OF
WORK
DAYS
PER
WEEK?
FW & NF

C12

C13

COUNTY NAME
[IF IN A BORDER
COUNTY ASK IF
COMMUTE FROM
MEXICO]

STATE
and

C7
***FW
AND
NF:
WHY
LEFT?

COUNTRY
[CODE]

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

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 =

CITY

Farmworker ID

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)
11

*** 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
97 = OTHER (SPECIFY):

WORK GRID

[REV. Mar 10, 2017]

___ ___ ___ ___ ___

[C1-C2 FOR OFFICE USE ONLY]
C15

PER.
AND
SUB
PER.
NO.

GR

C3

C4

REPORT FROM FIRST PERIOD COVERING OCTOBER 01, 2016 TO PRESENT
C5
C6
C8
C9
C10
C11
FW?

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]

NW?
AB?

GR

FW
NF

CO

NW
AB

GR

FW
NF

CO

NW
AB

GR

FW
NF

CO

NW
AB

GR

FW
NF
NW
AB

CO

FW
NF

GR

NW
AB

CO

FW
NF

GR

NW
AB

CO
* C-5 ACTIVITY CODES: ONLY FOR “NW” (IN THE U.S.A.)
[WRITE ACTIVITY FOR FW AND NF]
201 =
202 =
203 =
204 =

NF?

LOOKING FOR FW AND NF WORK
LOOKING FOR FARM WORK
LOOKING FOR NF WORK
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)

RECEIVED
UNEMPLOYMENT?

C1-C2

89 ___ ___ ___ ___

County

DATES FOR
PERIODS OF
FW, NF, NW, AB

FROM:

TO:

# OF
WORK
DAYS
PER
WEEK?
FW &
NF

CITY

C12

C13

COUNTY NAME
[IF IN A BORDER
COUNTY ASK IF
COMMUTE FROM
MEXICO]

STATE
and

C7
***FW
AND
NF:
WHY
LEFT?

COUNTRY
[CODE]

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

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 =

Farmworker ID

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

*** C-7 CODES: WHY LEFT “FW” AND “NF”?
1=
2=
3=
4=
5=
6=
7=

LAID OFF/END OF SEASON
FIRED
FAMILY RESPONSIBILITIES
SCHOOL
MOVED
HEALTH REASON
VACATION

8 = RETIRED
10 = QUIT
11 = CHANGE JOBS
97 = OTHER (SPECIFY):

WORK GRID

[REV. Mar 10, 2017]

___ ___ ___ ___ ___

[C1-C2 FOR OFFICE USE ONLY]
C15

PER.
AND
SUB
PER.
NO.

GR

C3

C4

REPORT FROM FIRST PERIOD COVERING OCTOBER 01, 2016 TO PRESENT
C5
C6
C8
C9
C10
C11
FW?

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]

NW?
AB?

GR

FW
NF

CO

NW
AB

GR

FW
NF

CO

NW
AB

GR

FW
NF

CO

NW
AB

GR

FW
NF
NW
AB

CO

FW
NF

GR

NW
AB

CO

FW
NF

GR

NW
AB

CO
* C-5 ACTIVITY CODES: ONLY FOR “NW” (IN THE U.S.A.)
[WRITE ACTIVITY FOR FW AND NF]
201 =
202 =
203 =
204 =

NF?

LOOKING FOR FW AND NF WORK
LOOKING FOR FARM WORK
LOOKING FOR NF WORK
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)

RECEIVED
UNEMPLOYMENT?

C1-C2

89 ___ ___ ___ ___

County

DATES FOR
PERIODS OF
FW, NF, NW, AB

FROM:

TO:

# OF
WORK
DAYS
PER
WEEK?
FW &
NF

C12

C13

COUNTY NAME
[IF IN A BORDER
COUNTY ASK IF
COMMUTE FROM
MEXICO]

STATE
and

C7
***FW
AND
NF:
WHY
LEFT?

COUNTRY
[CODE]

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

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 =

CITY

Farmworker ID

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)
13

*** 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
97 = OTHER (SPECIFY):

In the year before last [FROM OCTOBER 2015
D30 How did you get this job? [DO NOT READ CHOICES. MARK
TO OCTOBER 2016, YEAR BEFORE THE ONE
ONLY ONE RESPONSE]
COVERED IN WORK GRID], how many months
did you do (FW) in the U.S.? [1 DAY OR MORE PER
9 1 I APPLIED FOR THE JOB ON MY OWN
MONTH EQUALS 1 MONTH]
9 4 I WAS RECRUITED BY A GROWER OR HIS FOREMAN
months
9 5 I WAS RECRUITED BY FARM LABOR CONTRACTOR OR
D2 [IF NON-FARM JOB LISTED ON WORK GRID]: For
HIS FOREMAN
your most recent non-farm (NF) employer, how 9 6 I WAS REFERRED BY THE EMPLOYMENT SERVICE
many hours per week did you work on
9 7 I WAS REFERRED BY THE WELFARE OFFICE
average?
9 8 I WAS REFERRED BY RELATIVE / FRIEND / WORKMATE
hours
D1

D3

9 9 I WAS REFERRED BY LABOR UNION
9 10 DAY LABORER / PICKED UP AT SHAPE UP
[IF NON-FARM JOB LISTED] For your most recent
9 97 Other:
non-farm employer (NF), how much were
you paid per week on average?
NP – HANDLING PESTICIDES
(IN THE U.S.A.)

$

,

.
NP1f.

D27

How many years have you worked for this
employer? [ONE DAY/PER YEAR=ONE YEAR]

90
91

years
D22

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?
NO
90
91

D23

YES

In the last 12 months, have you loaded, mixed or applied
pesticides?

NT2a.

9 95 DON’T KNOW

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”)?

NO
YES

NT – TRAINING AND INSTRUCTIONS
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)?
9 0 NO
9 1 YES
NS – SANITATION SECTION

90
91
D24

NO
YES

9 95 DON’T KNOW

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? [WHETHER OR NOT THE WORKER
TAKES IT OR USES IT]

90
91
D26

NO
YES

9 95

NO
YES

9 95

NS1

... (potable) clean drinking water and disposable cups?

90
91
92
9 95

NO WATER, NO CUPS
YES, WATER ONLY
YES, WATER AND DISPOSABLE CUPS
DON’T KNOW

DON’T KNOW

Are you covered by unemployment insurance
if you lose this job?

90
91

“The following questions refer to sanitation at your job with your
current FW employer: ... Does your current employer provide EVERY
DAY...

NS4

... a toilet (EVERY DAY)?
9 0 NO
9 1 YES
9 95 DON’T KNOW

NS9

... (provide) water to wash hands (EVERY DAY)?
9 0 NO
9 1 YES
9 95 DON’T KNOW

DON’T KNOW

14

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

D11

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]

How many hours did you work last week at
your current farm job?

D12

[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 and the amount your employer
paid you on your last pay day?

D13

,

.

$

,

.

D62

NO

91

[IF CREW PIECE RATE]: How many people are in
your crew? [ONE IS NOT A POSSIBLE ANSWER]

D15

[IF BY PIECE]: How do they pay you/your
crew [i.e., UNIT OF MEASURE SUCH AS BOX, BIN,
BUCKET, ETC.]?

YES

D16

[IF BY PIECE]: How many of these (in D15 e.g., boxes,
bins, buckets, etc.) you/your crew do in an average
day?

D17

[IF BY PIECE]: How many hours per day you/your

For what time period was that payment?
9 1 ONE DAY?
9 2 ONE WEEK?
9 3 TWO WEEKS?

D8

9 4 ONE MONTH?
9 7 OTHER?:

crew work on average at this task?

hours

How many hours did you work during that period
(in D7)?

D18

[IF BY PIECE]: How much do “they” pay you/your

crew on average for each (box bin, bucket, etc. In
D15)?

hours
D9

INDIVIDUAL [SKIP TO D15]
CREW

Did you get a receipt?
90

D7

[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]

D14

Were you paid by [READ CHOICES. MARK ONE
RESPONSE]:...

9 1 ...PAYROLL CHECK?
9 4 ...OTHER CHECK?
9 2 ...PERSONAL CHECK? 9 5 ...CASH?
9 3 ...CASH AND CHECK? 9 6 ...OTHER:

per hour

.

91
92

Before taxes:

D6

D61

$

After taxes:
$

How much per hour (to nearest cent)? [IF PAID
ONLY BY THE HOUR, ENTER AMOUNT AND SKIP TO D22.
IF COMBINATION, ENTER AMOUNT AND CONTINUE WITH
D13]:

hours

D5

Are you paid: ...

...Now - with your current employer - you already
told me that the crop you are currently working is:...

$
D19

D10 And you told me that - with your current employer

- the task you are now doing is:

15

,

.

[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]:

[REV. Mar 10, 2017]

“Now I’m going to ask you some questions about your individual and family income for last year (2016)”...
G1C ...What was your total personal income
last year - in 2016 - in U.S. dollars [U.S.
earnings only FOR FW AND NF]?

G2C How much of that income [in “G1A”] was

from agricultural employment (U.S.
earnings only for FW)? [READ OR SHOW

[READ OR SHOW CHOICES. MARK ONLY ONE]

90
9 21
9 22
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 95
9 96

CHOICES. MARK ONLY ONE]

90
9 21
9 22
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 95
9 96

DID NOT WORK AT ALL IN 2016
LESS THAN 1,000
1,000 TO 2,449
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
DK (DON’T KNOW)
RF (REFUSE)

G3C What was your family’s total income last
year - in 2016 - in U.S. dollars [U.S.
earnings for FW AND NF for all in “FAMILY
GRID”]? [READ OR SHOW CHOICES.
MARK ONLY ONE]

DID NOT WORK AT ALL IN 2016
LESS THAN 1,000
1,000 TO 2,449
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
DK (DON’T KNOW)
RF (REFUSE)

90
9 21
9 22
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 95
9 96

DID NOT WORK AT ALL IN 2016
LESS THAN 1,000
1,000 TO 2,449
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
DK (DON’T KNOW)
RF (REFUSE)

GA-2 Now, I am going to ask you some questions about your health...

Over the last 2 weeks, how often have you been bothered by the
following problems?
1
2

Not at
all

Several days

More than half the days

0

1

2

0

1

2

+ ________

+ __________

...Feeling nervous, anxious or on edge?
...Not being able to stop or control worrying?
(FOR OFFICE CODING: TOTAL SCORE

T_________= ________

16

Nearly every day

3
3
+ __________

[REV. Mar 10, 2017]

U:\NAWS2017\OMB DRAFTS 2016-2017\OMB CleanDraft7EnglishMAR 17 2017.wpd

NH - PERSONAL HEALTH - LIFE HISTORY [ASK ALL]:
b. Are you currently taking
c. In the last 12 months, in the U.S. and/or abroad, have you seen a
a. Have you ever – in your whole life -- been told by a
medication, for this condition (in
doctor or nurse for (condition “YES” in COLUMN “a”)? [IF ANSWER IS
doctor or nurse (health practicioner) that you have the
“YES” FOR THE U.S. AND “AB” MARK BOTH]
”a”), that was prescribed by a
following condition...
medical provider?

...heart disease?

NH5

9 0 NO

9 1 YES:

90

NO

9 95 RF

9 96 DK

91

YES

91

90

NO

91

YES

...asthma?

NH1

9 0 NO
9 95 RF
NH11

YES:

9 96 DK

...cancer?

9 0 NO

9 1 YES:

(TYPE OR KIND OF CANCER?):

9 95 RF

90

NO

91

YES

9 96 DK

90
91
92

NO
YES, IN THE U.S.A.

90

NO

91

YES, IN THE U.S.A.

92
90

YES, “AB”:

91

YES, IN THE U.S.A.

92

YES, “AB”:

YES, “AB”:

NO

NH – INDIVIDUAL PERSONAL HEALTH HISTORY (LIFETIME) [INTERVIEWER: FIRST ASK ALL QUESTIONS IN FIRST COLUMN.]

a.
And have you ever -- in your
whole life – been told by a
doctor or nurse that you have...

b.
...ever been
tested for this
condition?

NH3 ...high

90

blood pressure?

9 0 NO
9 1 YES
9 96 DK
9 95 RF
NH12

...high cholesterol?

9 0 NO
9 1 YES
9 96 DK
9 95 RF

91

NO
YES

9 96 DK

90

NO

91

YES

9 96 DK

c.
What was the outcome
(result)?

9 1 NORMAL
9 2 PREHYPERTENSION
9 3 HIGH
9 4 DID NOT RECEIVE IT
9 96 DK (FORGOT)
9 1 NORMAL
9 2 BORDERLINE
9 3 HIGH
9 4 DIDN’T RECEIVE IT

9 96

DK (FORGOT)

d.
When was the last test
taken?

f.
e.
Where was Are you currently taking
medication, for this condition
the test
taken?:
(in “a”), that was prescribed
*[USE CODE]
by a medical provider?

9 1 0 TO 12 months
9 2 13 TO 24 MONTHS
9 3 2 TO 5 YRS
9 4 MORE THAN 5 YRS
9 96 DK (FORGOT)
9 1 0 TO 12 months
9 2 13 TO 24 MONTHS
9 3 2 TO 5 YRS
9 4 MORE THAN 5 YRS
9 96 DK (FORGOT)

90

NO

91

YES

90

NO

91

YES

g.
In the last 12 months, in the
U.S. and/or abroad, have you
seen a doctor or nurse for
(condition in “a”)?

90

NO

91

YES, IN THE U.S.A.

92

YES, “AB”:

90

NO

91

YES, IN THE U.S.A.

92

YES, “AB”:

ASK ONLY TO FEMALE RESPONDENT (FOR WOMEN ONLY)
NH13

[FOR WOMEN ONLY]:
Have you ever had a PAP
SMEAR TEST (Papanicolau,
Pap Test, Cervical Cancer
Test, or Smear Test)

90

NO

91

YES

9 95 RF

9 1 NORMAL
9 2 ABNORMAL
9 4 DID NOT RECEIVE IT
9 96 DK (FORGOT)

9 96 DK

9 1 0 TO 12 months
9 2 13 TO 24 MONTHS
9 3 2 TO 5 YRS
9 4 MORE THAN 5 YRS
9 96 DK (FORGOT)

*CODES FOR ( COLUMN “e” ): NH3 - NH12 - NH13
1 = COMMUNITY/MIGRANT HEALTH CENTER
2 = PRIVATE MEDICAL DOCTOR’S OFFICE/PRIVATE CLINIC

3 = HOSPITAL
4 = EMERGENCY ROOM

7 = DENTIST
97 = OTHER: __________

17

95 = DK
96 = RF

[REV. Mar 10, 2017]

U:\NAWS2017\OMB DRAFTS 2016-2017\OMB CleanDraft7EnglishMAR 17 2017.wpd

CONTINUATION OF NH – INDIVIDUAL PERSONAL HEALTH HISTORY (LIFETIME) [INTERVIEWER: FIRST ASK ALL QUESTIONS IN FIRST COLUMN.]
a.

And how about these other
conditions, have you ever -- in
your whole life – been told by a
doctor or nurse that you have
the following conditions...

9 0 NO
9 1 YES
9 95 DK

9 96 RF
[IF RESPONDENT IS A
WOMAN, AND ANSWER IS
“YES” ASK]:

Was it diagnosed during
pregnancy?:

9 0 NO
9 1 YES
9 95 DK

g.

b.

c.

In the last 12 months, in the U.S.
Where was Are you currently
taking medication, for and/or abroad, have you seen a
the test
this condition (in “a”), doctor or nurse for this condition
taken?:
*[ENTER
CODE]

that was prescribed by (in “a”)? [IF ANSWER IS “YES” FOR
THE U.S. AND “AB” MARK BOTH]
a medical provider?

90
91
9 95

NO

NO

DK
NO
YES
DK

9 96 RF

9 96 RF

13 TO 24 MONTHS
2 TO 5 YEARS

9 95 DK

94

DIDN’T RECEIVE IT

94

MORE THAN 5 YRS

9 95

DK (FORGOT)

9 95

DK (FORGOT)

91
92
93
94
9 95

POSITIVE
NEGATIVE
INCONCLUSIVE
DIDN’T RECEIVE IT
DK (FORGOT)

91
92
93
94
9 95

0 TO 12 MONTHS
13 TO 24 MONTHS
2 TO 5 YRS
MORE THAN 5 YRS
DK (FORGOT)

91
92
94
9 95

NORMAL
ABNORMAL
DIDN’T RECEIVE IT
DK (FORGOT)

0 TO 12 MONTHS
13 TO 24 MONTHS
2 TO 5 YRS
MORE THAN 5 YRS
DK (FORGOT)

91
92
9 95

POSITIVE
NEGATIVE
DIDN’T RECEIVE IT
DK (FORGOT)

91
92
94
9 96

POSITIVE
NEGATIVE
DIDN’T RECEIVE IT
DK (FORGOT)

91
92
93
94
9 95
91
92
93
94
9 95
91
92
93
94
9 95

90

NO

9 95 DK

90

NO

9 1 YES
90

NO

9 1 YES
9 96 RF

9 95 DK

90

NO
YES:

9 95 DK

92
93

...other?:

90
91

HIGH SUGAR LEVEL

0 TO 12 MONTHS

LOW SUGAR LEVEL

9 1 YES

...tuberculosis?

9 0 NO
9 1 YES
9 95 RF

92

91

93

9 95 DK
NH4

NORMAL

9 1 YES

YES

...urinary tract infection?

90
91
9 95

90

91

90

NO

90

NO

91

YES, IN THE U.S.A.

91

YES

92

YES, “AB”:

90

NO

90

NO

91

91
92

YES, IN THE U.S.A

YES

90

NO

90

NO

91

YES, IN THE U.S.A.

91

YES

92

YES, “AB”:

90

90

NO

NO

91

YES, IN THE U.S.A.

91

YES

92

YES, “AB”:

9 96 RF

...HIV (AIDS)?

NH14

NH10

f.

When was the last
test taken?

...diabetes?

NH2

NH6

e.

d.

...ever been What was the outcome
(result) of the last test?
tested for
this
condition?

NO

9 1 YES
9 96 RF

9 95 DK

94

0 TO 12 MONTHS
13 TO 24 MONTHS
2 TO 5 YRS
MORE THAN 5 YRS
DK (FORGOT)
0 TO 12 MONTHS
13 TO 24 MONTHS
2 TO 5 YRS
MORE THAN 5 YRS
DK (FORGOT)

90

NO

91

YES

.

YES, “AB”:

90

NO

91

YES, IN THE U.S.A.

92

YES, “AB”:

*CODES FOR COLUMN “g”
1
2

COMMUNITY/MIGRANT HEALTH CENTER
PRIVATE CLINIC OR DOCTOR’S OFFICE

3 HOSPITAL
4 EMERGENCY ROOM

5 DENTIST
95 = DK

18

96 = RF
97 OTHER: ____________

[REV. Mar 10, 2017]

U:\NAWS2017\OMB DRAFTS 2016-2017\OMB CleanDraft7EnglishMAR 17 2017.wpd

HA – QUALITY OF AND ACCESS TO HEALTH CARE SECTION
HA1 [INTERVIEWER ]: Now, I would like to ask you a few questions about health care services that you may have used in the last 12 months. [FIRST ASK QUESTIONS IN THE FIRST COLUMN. READ
OPTIONS AND MARK ALL RESPONSES] ...In the LAST YEAR , (LAST 12 MONTHS), in the USA,...have you used any type of health care service from doctors, nurses, dentists, clinics, or hospitals: ...
NOTE: EXPLAIN THAT ILLNESS
BELOW REFERS TO: “A physical

illness, as well as a mental
health problem or substance
abuse.”

*HA2

**HA4

HA3

*[ENTER
CODES]
9 a ...FOR ILLNESS?
9 0 NO: [ASK HA7]

9 95 DK

9

9

91

YES

96 RF

9 c ...FOR ROUTINE OR
PREVENTIVE CARE?
9 0 NO:[ASK HA7] 9 1 YES

9 95 DK

9 96 RF

9 d ...FOR DENTAL TREATMENT
OR PREVENTIVE CARE?
9 0 NO:[ASK HA7] 9 1 YES

9 95 DK

9 96 RF

*CODES FOR “HA2”
1 COMMUNITY/MIGRANT
HEALTH CENTER
5 DENTIST
2 PRIVATE CLINIC OR
DOCTOR’S OFFICE
95 = DK
3 HOSPITAL
96 = RF
4 EMERGENCY ROOM
97=OTHER:
______

1
2
3
4
5

with the care YOU received at your
LAST visit for (“YES” in HA2)? [ASK
ALL OPTIONS, MARK ONE ]: Were you...

“NO”, ASK HOW IT WAS
PAID. ENTER CODES ALL THAT APPLY]:

91
92
93

...VERY SATISFIED?

9 1.
9 2.
9 3.
9 95

9 0 NO:
LAST MONTH
[ENTER CODES]
2 TO 6 MONTHS
7 TO 12 MONTHS 9 1 YES:
[ENTER CODES]
DK

91
92
93

...VERY SATISFIED?

9 1.
9 2.
9 3.
9 95

9 0 NO:
LAST MONTH
[ENTER CODES]
2 TO 6 MONTHS
9 1 YES:
7 TO 12 MONTHS
[ENTER CODES]
DK

91
92
93

...VERY SATISFIED?

9 1.
9 2.
9 3.
9 95

9 0 NO:
LAST MONTH
[ENTER CODES]
2 TO 6 MONTHS
9 1 YES:
7 TO 12 MONTHS
[ENTER CODES]
DK

91
92
93

...VERY SATISFIED?

**CODES FOR “HA4"
I paid the bill out of “my 6 Billed, but did not
own pocket”
pay
Medicaid / Medicare
7 Worker’s
compensation
Public clinic did not
charge
8 I paid some (copay)
Employer provided
health plan
95 = DK
Self or family bought
96 = RF
97 Other: ________
individual health plan

1
2
3
4

...NOT AT ALL SATISFIED? [ASK HA6]

...SOMEWHAT SATISFIED? [ASK HA6]
...NOT AT ALL SATISFIED? [ASK HA6]

...SOMEWHAT SATISFIED? [ASK HA6]
...NOT AT ALL SATISFIED? [ASK HA6]

...SOMEWHAT SATISFIED? [ASK HA6]
...NOT AT ALL SATISFIED? [ASK HA6]

***CODES FOR “HA6"
COST TOO MUCH
5 CONDITION DID NOT
HAD TO WAIT TOO
IMPROVE AFTER
TREATMENT OR
LONG
LANGUAGE
MEDICATION
PROBLEM - COULD 6 DR. DID NOT DIAGNOSE
OR TREAT CONDITION
NOT COMMUNICATE
MISTREATED BY DR. 95 = DK
OR OTHER STAFF
96 = RF
97 OTHER: ____

And in the LAST 12 MONTHS, in the USA, was there
Why could you not get the health care you wanted (or needed)?
[CHECK ALL THAT APPLY]
ever a time when you wanted or needed health care, but
could not get it? (e.g., for a routine exam, a dental
appointment or because you were injured or sick)
9 0 NO (

9 95 RF

ASK HA10)

9 1 YES

9 96 DK

9a
9b
9c
9d

9e
9f
9g
9z

Did not know where to go
No transportation
Too far away
Health Center not open when
needed

19

[ ENTER CODES]

...SOMEWHAT SATISFIED? [ASK HA6]

HA9

HA8

****HA7

Why weren’t you
[If “NO” in “HA1",
(completely)
ask]: Why have you
satisfied with the
not used the health
health care received services for [“NO” in
“HA1"]
at that visit?
**[ENTER CODE]

9 0 NO:
[ENTER CODES]
9 2. 2 TO 6 MONTHS 9 1 YES:
9 3. 7 TO 12 MONTHS [ENTER CODES]
9 95 DK

9 1. LAST MONTH

YES

9 96 RF

9 b ...FOR INJURY?
9 0 NO:[ASK HA7]
95 DK

91

***HA6

HA5 In general, how satisfied were YOU

Did you get any help
...And where
to pay for the cost
did you go
of that health
(last time)? When (last time)?
(kind of place)
service?***[ “YES” OR

No need to go/Do not get sick
Too expensive
No insurance
Other:

****CODES FOR “HA7"
Did not know where to go
No transportation
Too far away
Health Center not open when
needed
5 = No need to go / Does not get sick
6= Too expensive
7= No insurance
1=
2=
3=
4=

95= DK
96= RF
97 = OTHER:___________________

HA10
[ASK ALL]... (How about) In a foreign country (e.g.,

Mexico), have you used any type of health service
in the last year (LAST 12 MONTHS) [IF “YES ,”
ASK AND ENTER COUNTRY]

90
91

NO
YES, IN [NAME OF COUNTRY]:

[REV. Mar 10, 2017]

U:\NAWS2017\OMB DRAFTS 2016-2017\OMB CleanDraft7EnglishMAR 17 2017.wpd

DA. DIGITAL ACCESS
DA1 Do you or any member of your family

[“Household Grid”] have access to digital
information sources (i.e., internet,

What devices?

[MARK RESPONSES FOR DEVICES “U”]

cellular phone with internet, etc.)?
[CHECK WHO IF “YES”]

DA2

Computer

DA3 Cellular phone with Internet DA4 Cellular phone with Text DA5

Tablet

Other device?
[Specify]: _________

DA6

9 1 Worker?
9 2 Spouse?
9 3 Children?

9 0 NO
9 0 NO
9 0 NO

9 1 YES
9 1 YES
9 1 YES

9 0 NO
9 0 NO
9 0 NO

9 1 YES
9 1 YES
9 1 YES

9 0 NO
9 0 NO
9 0 NO

9 1 YES
9 1 YES
9 1 YES

9 0 NO
9 0 NO
9 0 NO

9 1 YES
9 1 YES
9 1 YES

9 0 NO 9 1 YES

9 0 NO

9 1 YES

9 0 NO 9 1 YES

9 0 NO

9 1 YES

9 0 NO 9 1 YES

9 0 NO

9 1 YES

9 4 Other?:

9 0 NO

9 1 YES

9 0 NO

9 1 YES

9 0 NO

9 1 YES

9 0 NO

9 1 YES

9 0 NO 9 1 YES

9 0 NO

9 1 YES

DA7. Have you used, or has anyone helped

DA8.

you use, any digital device to seek or
obtain information about ...

What devices have you used?
[MARK ALL RESPONSES]

DA9.

Who helped you use the device
(in “DA8") to seek or obtain the
information (in “DA7")? [MARK
ALL RESPONSES:]

a.

...health or health insurance?

90
b.

90

NO

91

YES

...seeking employment?
NO

91

YES

c.

...training and/or education?

90

NO

d.

90
e.

90
f.

90
g.

91

YES

...child care?
NO

91

YES

...housing?
NO

91

YES

...benefits? [e.g., Unemployment, Social
Security, food stamps, retirement, etc.]
NO

9 1 YES:
SPECIFY:

...other?: [SPECIFY]:

9 a. COMPUTER

Where?:

9 b. TABLET

Where?:

Self

9 2.

Spouse?

9 c. CELLULAR PHONE WITH INTERNET 9 d. CELLULAR PHONE WITH TEXTING

9 3. Children?

9 4.

Other?:

Where?:
9 a. COMPUTER
Where?:
9 b. TABLET
9 c. CELLULAR PHONE WITH INTERNET 9 d. CELLULAR PHONE WITH TEXTING

9 1.

Self

9 2.

Spouse?

9 3. Children?

9 4.

Other?:

Where?:
9 a. COMPUTER
Where?:
9 b. TABLET
9 c. CELLULAR PHONE WITH INTERNET 9 d. CELLULAR PHONE WITH TEXTING

9 1.

Self

9 2.

Spouse?

9 3. Children?

9 4.

Other?:

Where?:
9 a. COMPUTER
Where?:
9 b. TABLET
9 c. CELLULAR PHONE WITH INTERNET 9 d. CELLULAR PHONE WITH TEXTING

9 1.

Self

9 2.

Spouse?

9 3. Children?

9 4.

Other?:

Where?:
9 a. COMPUTER
Where?:
9 b. TABLET
9 c. CELLULAR PHONE WITH INTERNET 9 d. CELLULAR PHONE WITH TEXTING

9 1.

Self

9 2.

Spouse?

9 3. Children?

9 4.

Other?:

Where?:
9 a. COMPUTER
Where?:
9 b. TABLET
9 c. CELLULAR PHONE WITH INTERNET 9 d. CELLULAR PHONE WITH TEXTING

9 1.

9 2.

Spouse?

9 3. Children?

9 4. Other?:

Where?:
9 a. COMPUTER
Where?:
9 b. TABLET
c.
CELLULAR
PHONE
WITH
INTERNET
9
9 d. CELLULAR PHONE WITH TEXTING

9 1.

Self

9 2.

9 3. Children?

9 4.

20

9 1.

Self

Spouse?
Other?:

EDUCATION AND TRAINING
U:\NAWS2017\OMB DRAFTS 2016-2017\OMB CleanDraft7EnglishMAR 17 2017.wpd
ET1. In the USA or any other country, have you participated in or attended any type of educational program, training or classes that are work-related in FW or NF or important to you in any other way?
Even if not completed. They could have been... [Intwr: first ask all items in first column (“a” to “f”) and explain and provide examples for each one;...
ET6.
ET7. And this training
ET5. Have you
[FOR EACH QUESTION, REFER TO
ET2. Where (venue
ET3. When? (Dates: Year ET4. Have you
program, has it helped (will
LAST TIME . IF YES, SPECIFY BY
or provider facility)?
completed it?
received a credential, Did you pay anything
and Total hours per
for it?
help) you for a better job or in
ASKING FOR OCCUPATION AND
*[GIVE EXAMPLES.ENTER
** [ENTER CODES
diploma or license
week/day?)
CODE] [FOR OTHER COUNTRY,
any other way?
FOR “NO” AND
[for program ]?
INDUSTRY. MARK IF “FW” OR “NF’]
ENTER COUNTRY AND VENUE]
[WRITE RESPONSE]
SKIP TO “ET6"]
[Specify]
...Worker safety training? Like...

[REV. Mar 10, 2017]

a ....heat?

9 0 NO

9 1 YES: 9 FW:

9 1 USA:

Year?: ________

9 0 NO

9 2 OTHER COUNTRY:

Number of hours?:
________ hrs

9 1 YES

9 1 USA:

Year?: ________

9 0 NO

9 2 OTHER COUNTRY:

Number of hours?:
________ hrs

9 1 YES

9 1 USA:

Year?: ________

9 0 NO

9 2 OTHER COUNTRY:

Number of hours?:
________ hrs

9 1 YES

9 1 USA:

Year?: ________

9 0 NO

9 2 OTHER COUNTRY:

Number of hours?:

Why not?:

9 NF:

SPECIFY

9 0 NO

90

9 1 YES [Specify]:

91

9 0 NO

90
91

NO

YES. How much?:
$__ __ __ ___. __ __

9 0 NO
9 1 YES

Why?:
How?

COUNTRY / VENUE

b ...pesticides?

9 0 NO

9 1 YES: 9 FW:
SPECIFY

c ... injuries?
9 0 NO 9 1 YES: 9 FW:

Why not?:

9 NF:

COUNTRY / VENUE

9 NF:

SPECIFY

9 1 YES [Specify]:

NO

9 0 NO
9 1 YES [Specify]:

Why?:

YES. How much?:

$__ __ __ ___. __ __

Why not?:

9 0 NO
9 1 YES

90

NO

9 0 NO

91

YES. How much?:

9 1 YES

How?

Why?:
How?

$__ __ __ ___. __ __

COUNTRY / VENUE

d. ...any other safety training?

90

NO

91

YES: 9 FW:
SPECIFY

________ hrs

COUNTRY / VENUE

e. ...besides “safety training,” any
other training received here
(current work) or in any other
work you may have had (OJT)?

9 0 NO

9 1 YES: 9 FW:

Why not?:

9 NF:

9 NF:

9 1 USA:

Year?: ________

9 2 OTHER COUNTRY:

Number of hours?:
________ hrs

90

9 0 NO
9 1 YES [Specify]:

9 1 YES

91

YES. How much?:
$ __ __ __ ___. __ __

9 0 NO

Why?:

9 1 YES How?:
9 0 NO Why?:

Why not?: 9 0 NO

9 0 NO

NO

9 1 YES [Specify]

9 1 YES

90

NO

91

YES. How much?:
$ __ __ __ ___. __ __

COUNTRY / VENUE

9 1 YES

How?:

SPECIFY

f. ...any classes or training for any
kind of work?

9 1 USA:

90

9 2 OTHER COUNTRY:

NO

91

YES: 9 FW:

9 NF:

SPECIFY

9 1 YES: 9 FW:

9 1 USA:
9 NF:

9 2 OTHER COUNTRY:
SPECIFY

9 0 NO

Why not?:

________ hrs
Year?: ________

9 0 NO
9 1 YES [Specify]:

Number of hours?:

COUNTRY / VENUE

g. ...GED classes?

9 0 NO

Year?: ________

9 1 YES
9 0 NO

90

NO

91

YES. How much?:

$ __ __ __ ___. __ __

Why not?:

9 0 NO

90

9 1 YES [Specify]:

91

NO

9 0 NO
9 1 YES
9 0 NO

Why?:

How?:

Why?:

Number of hours?:
________ hrs

COUNTRY / VENUE

9 1 YES

*CODES FOR “ET2": VENUE
1. WORKPLACE CENTER 3. COMMUNITY COLLEGE 5. ADULT SCHOOL
2. COMMUNITY CENTER 4. CHURCH
97. Other: ______

YES. How much?:
$__ __ __ ___. __ __

9 1 YES

How?:

**CODES FOR “ET4": “NO, Why not?”
1. Too old to study
3. No transportation
2. Did not learn (Will not learn) 4.Too tired to continue
21

5. No child care
6. Too far

7. Applied, didn’t qualify
9. Still attending
8. “Don’t qualify” didn’t apply 97. Other: _______

[...continuation: Education and Training...]
[FOR EACH QUESTION, REFER TO
LAST TIME . IF YES, SPECIFY BY
ASKING FOR OCCUPATION AND
INDUSTRY. MARK IF “FW” OR “NF’]
Like...

ET2. Where (venue
or provider facility)?
*[GIVE EXAMPLES.ENTER
CODE] [FOR OTHER COUNTRY,
ENTER COUNTRY AND VENUE]

h. ...English as a Second Language
(ESL)?

9 1 USA:

9 0 NO

9 2 OTHER COUNTRY:

9 1 YES: 9 FW:

9 NF:

i. ...besides school,... basic skills
like classes in math, reading and
writing?

9 1 YES: 9 FW:

and Total hours per
week/day?)

ET4. Have you
completed it?
**[ENTER CODES
FOR “NO” AND
SKIP TO “ET6"]

ET5. Have you received ET6.
a credential, diploma or Did you pay anything
license [for program ]? for it?
[Specify]

9 0 NO

9 0 NO

Number of hours?:
_________ hrs

Why not?:

90

9 1 YES [Specify]

9 1 USA:

Year?: ________

9 2 OTHER COUNTRY:

Number of hours?:

9 NF:
COUNTRY / VENUE

9 0 NO

Why not?:

9 1 YES [Specify]:

9 1 YES

________ hrs

91
90

9 0 NO

Why?:

NO

YES. How much?:
$ __ __ __ ___. __ __

9 1 YES

ET7. And this training
program, has it helped (will
help) you for a better job or
in any other way?
[WRITE RESPONSE]

9 0 NO

Year?: ________

COUNTRY / VENUE

SPECIFY

9 0 NO

ET3. When? (Dates: Year

NO

91

YES. How much?:
$ __ __ __ ___. __ __

9 1 YES
9 0 NO

How?:

Why?:

9 1 YES How?:

SPECIFY
*CODES FOR “ET2": VENUE

**CODES FOR “ET4": “NO, Why not?”

1. WORKPLACE CENTER 3. COMMUNITY COLLEGE 5. ADULT SCHOOL
2. COMMUNITY CENTER 4. CHURCH
97. Other: ______

1. Too old to study
3. No transportation
2. Did not learn (Will not learn) 4.Too tired to continue

5. No child care
6. Too far

7. Applied, didn’t qualify
9. Still attending
8. “Don’t qualify” didn’t apply 97. Other: _______

Have you ever considered (thought about) attending some other kind of
ET12. If there were training programs for FARM WORKERS in this location
vocational training or special classes to help you improve your skills to obtain
(city), of any kind, and there were no obstacles to attend, would you
better jobs, better pay or change careers, etc.?:
attend a program?

ET8.

9 0 NO

9 1 YES:

ET9.

9 a.
9 b.
9 x.

9 1 YES [ASK ]:

What kind of training or classes?:

NO [SKIP TO ET12]

9 1 YES

[ASK ET10 and ET11]

What kind of training have you heard of?:
ET13.

ET11.

Too old to study
Did (Will) not learn
Other: ____

a.

Which training class would you consider attending?

b.

And...why would you choose that (in a)?:

Have you heard of training programs for farm workers?:
90

ET10.

9 0 NO ¿Why not? [Mark all responses and SKIP TO 13]:

Why not? [Mark all responses]:
9 a. Too old to study
9 e. No child care
9 b. Did (Will) not learn
9 f. Too far
9 c. No transportation
9 x. Other: __________________

Why did you not attend that training? [Mark all responses]:

9 a. Too old to study
9 b. Did (Will) not learn
9 c. No transportation

9 d. Too tired to continue 9 g. Applied, did not qualify
9 e. No child care
9 h. Don’t qualify, did not apply
9 f. Too far
9 x. Other: ________________

22

Do you think you are qualified to work in any other job with a
better pay here (current job) or in any other place (employer)?:
90
91

NO
YES. What kind of work?:

[REV. Mar 10, 2017]

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

L2b PROGRAMS [DO NOT READ OPTIONS]:

What is your current legal status in the U.S.? [READ
CHOICES IF NECESSARY]:

91

I AM A U.S. CITIZEN BY BIRTH [SKIP TO NEXT PAGE]

92

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]
BORDER CROSSING CARD/COMMUTER CARD (RIGHT TO
CROSS THE BORDER AND WORK IN THE U.S.) (ASK L2:
“UNDER WHICH PROGRAM DID YOU APPLY?”)
[POSSIBLE ANSWERS: 9, 12, 13, Y 97. THEN ASK: L3, L41 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

97

POLITICAL ASYLUM

98

REFUGEE

99

PROTECTIVE STATUS
(TEMPORARY)

95

PENDING STATUS (WITHOUT DOCUMENTS, APPLIED,
10 GUEST WORKER PROGRAM
AWAITING OFFICIAL DECISION) (ASK L2: “UNDER WHICH 9
[“BRACERO”]
PROGRAM DID YOU APPLY?”) [POSSIBLE ANSWERS: 19, 97. THEN ASK: L3, AND L41]
9 11 STUDENT

96

UNDOCUMENTED (APPLICATION DENIED/DID NOT
APPLY TO ANY PROGRAMS) [POSSIBLE ANSWERS:
“NONE”. SKIP TO NEXT PAGE]

97

98

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 12

TOURIST

9 13

BORDER CROSSING CARD/
“PASSPORT”

9 14

DACA (Deferred Action for Childhood
Arrivals.
• Entered USA under 16 yrs. old before June
15, 2007;
• Under 31 as of June 15, 2012.
• Have continuously resided in the USA
from June 15, 2007 to the present)

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 95 DON’T KNOW
L4

1

When did you apply to the
program (in L2)?

2

DATE STATUS BECAME EFFECTIVE:
[Only for those who responded
"2,3, or 4" in L1]: When did you
obtain your legal status?

/
(Month)

/

9 96 REFUSE

3

[Only for those who
responded "2" in L1]: When
did you obtain your
naturalization/ become a U.S.
citizen?

/
(Year)

(Month)

/

/

(Year)

23

(Month)

/

(Year)

JBS International, Inc.
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 Department of Labor because you are currently working
on a farm. The purpose of the survey is to learn more about the employment, living conditions, and the
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. Information obtained through this research,
however, may help federal, state, and private farm worker programs improve services to 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 JBS International (toll free) at 877- SAY-NAWS (or 877-729-6297). They will refer
your questions to Daniel Carroll at the Department of Labor, at (202) 693-2795.
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, Evaluation and Research, ETA, Department of Labor, Room N5641, 200
Constitution Avenue, N.W., Washington, D.C. 20210.

JBS International, Inc.
555 Airport Boulevard, Suite 400
urlingame, CA 94010-2002
hone: 650.373.4900
ax: 650.348.0260

B
P
F

INDIVIDUAL AGREEMENT TO BE A RESEARCH SUBJECT
OMB CONTROL NUMBER: 1205-0453

INTRODUCTION/PURPOSE
You are invited to participate in this survey for the Department of Labor because you are currently
working on a farm. The purpose of the survey is to learn more about the employment, living
conditions, and the 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. Information obtained through this research,
however, may help federal, state, and private farm worker programs improve services to 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 JBS International (toll free) at 877- SAY-NAWS (or 877-729-6297). They will refer
your questions to Daniel Carroll at the Department of Labor, at (202) 693-2795.
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, Evaluation and Research, ETA, Department of Labor, Room N5641, 200
Constitution Avenue, N.W., Washington, D.C. 20210.