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17 2017 OMB ENG TRACKCHANGES and highlighted
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8
ENGLISH
Cycle 839, FALL 20157
OMB NO. 1205-0453
COUNTY
EXPIRATION DATE: XX/XX/20XX
39
FARM WORKER ID
[FOR OFFICE USE ONLY]
[REV. Mar 17, 2017]
NATIONAL AGRICULTURAL WORKERS SURVEY - 20175 (“NAWS”)
CS2
DATE:
/
/
[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 and Evaluation, ETA,
Department of Labor, Room N5641, 200 Constitution Avenue, N.W., Washington, D.C. 20210.
1
[REV. Mar 17, 2017]
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HOUSEHOLD GRID
___ ___ ___ ___ ___
892 ___ ___ ___ __
County
A1
*A2 A3 A5
A6
**A7
A9
**A10
A8
A4
***A31
A32-33
A34-35
A11
A13
Farmworker ID
A12
HA15
*****HA16
HA17
*****HA18
ONLY FOR SPOUSE AND CHILDREN UNDER 22 YEARS OLD
NAME
R
E
L
A
T
I
O
N
S
E
X
M
A
R
I
T
A
L
S
T
A
T
U
S
HIGHEST GRADE
LEVEL [FOR
MINORS INCLUDE
PRE-SCHOOL
MONTH
COUNTRY
(“PS”) AND
AND
COUNTRY
BIRTH
KINDER (“K”)
SCHOOL
YEAR
OF
DATE
[ ASK
[CODE]
FIRST
BIRTH
MM/YY
ONLY
[CODE]
ENTERED
FARM
U.S.?
WORKER FOR
HIGHEST
DEGREE
OBTAINED. ]
A. (FARMWORKER)
[ASK ALL IN
A1]:
DOES S/HE
LIVE WITH
YOU NOW?
IF NOT,
WHERE?
[STATE and
COUNTRY]
LAST 12
IF
MONTHS,
NOT
HAVE YOU
HERE,
TRAVELED TO
WHY
DO FW (OR
NOT?
DONE FW IN
__
OTHER CITY)?
C
IF YES,
O
[NAME]
D
TRAVELED OR
E
JOINED WITH
YOU?
PRIOR 12
MONTHS TO
(A32-33), HAD
YOU
TRAVELED TO ANY U.S.
DO FW (OR
SCHOOL
LAST
DONE FW IN
12
OTHER CITY)?
IF YES,
MONTHS?
[NAME]
TRAVELED OR
JOINED WITH
YOU?
[For each
“NO” in
And the When?
“HA15"]
last
(Last
Why did
In the last year [LAST 12 MONTHS],
ANY
time,
time)
[NAME
has [NAME of (spouse) (child)]
U.S.
where [ENTER
ANY
in
FW
used any type of health care
did
‘within” “HA15"]
U.S.
LAST
service from doctors nurses,
WORK
[NAME] NUMBER not use
12
NOW? dentists, clinics or hospitals for...
health
go?
OF
MON
MONTHS services?
THS?
[ENTER
[ENTER AGO:
CODES]
CODES] 1 TO 12]
HG: _______
M
F
S
M
O
/
HD: _______
Y
Y
Y
N
N
N
NOTE: ILLNESS BELOW
INCLUDES: Physical,
mental, substance
abuse, alcohol,
depression, victim of
violence, etc.
/
B.
S
M
M
F
Y
Y
Y
Y
N
N
N
N
Y
Y
/
/
O
N
N
C.
S
/
Y
M
M
N
O
1 = SPOUSE/COMMON LAW SPOUSE
2 = OWN CHILD, DEPENDENT OR ADOPTED
3 = SIBLING
4 = PARENT
5 = GRANDCHILD
6 = OTHER RELATIVE (COUSINS, UNCLES, ETC.)
95= DK (DON’T KNOW)
96 = RF REFUSE)
97 = OTHER: ___
Y
Y
Y
Y
/
F
*CODES FOR A2 (RELATIONSHIP):
Y
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
99= NOT ANSWERED
N
N
***CODES FOR A31
7= SOUTHEAST ASIA (INDONESIA, CAMBODIA, 1 =
VIETNAM, LAOS, THAILAND)
8= PACIFIC ISLANDS (THE PHILIPPINES, GUAM, 2 =
FIJI, ETC.)
9= ASIA (CHINA, JAPAN, KOREA, ETC.)
3=
95= DK (DON’T KNOW)
96 = RF REFUSE)
97 = OTHER: ___
N
NO CHILD CARE IN THIS
LOCATION
NO HOUSING IN THIS
LOCATION
CHILD IN SCHOOL,
AFFECTED IF MOVED
95= DK (DON’T KNOW)
96 = RF REFUSE)
97 = OTHER: ___
N
a illness?
YES
NO
D/K
b. injury?:
YES
NO
D/K
c. routine or preventive
YES
care?:
NO
D/K
d. dental treatment or
preventive care?:
YES
NO
D/K
a illness?:
YES
NO
D/K
b. injury?:
YES
NO
D/K
c. routine or preventive
YES
care?:
NO
D/K
d. dental treatment or
preventive care?:
NO
D/K
****CODES FOR HA16
1=
2=
3=
4=
5=
6=
7=
COMMUNITY/MIGRANT HEALTH
CENTER
PRIVATE MEDICAL CLINIC/
DOCTOR’S OFFICE
HOSPITAL
EMERGENCY ROOM
MIGRANT HEALTH CLINIC
CHIROPRACTOR OR NATUROPATH
DENTIST
95= DK (DON’T KNOW)
96 = RF REFUSE)
97 = OTHER: ___
2
YES
*****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= DK (DON’T KNOW)
96 = RF REFUSE)
97 = OTHER: ___
[REV. Mar 17, 2017]
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HOUSEHOLD GRID
___ ___ ___ ___ ___
892 ___ ___ ___ __
County
A1
NAME
*A2 A3 A5
R
E
L
A
T
I
O
N
S
E
X
M
A
R
I
T
A
L
S
T
A
T
U
S
A6
**A7
A9
**A10
A8
HIGHEST GRADE
LEVEL [FOR
MINORS INCLUDE
PRE-SCHOOL
(“PS”) AND
MONTH
COUNTRY
COUNTRY KINDER (“K”)
AND
BIRTH
SCHOOL
[ ASK ONLY
OF
YEAR
DATE
[CODE]
FARM
BIRTH
FIRST
MM/YY
WORKER
[CODE]
ENTERED
FOR
U.S.?
HIGHEST
DEGREE
OBTAINED. ]
A4
[ASK ALL IN
A1]:
DOES S/HE
LIVE WITH
YOU NOW?
IF NOT,
WHERE?
[STATE and
COUNTRY]
***A31
IF
NOT
HERE,
WHY
NOT?
__
C
O
D
E
A32-33
LAST 12
A34-35
PRIOR 12
MONTHS,
HAVE YOU
TRAVELED TO
DO FW (OR
DONE FW IN
OTHER CITY)?
IF YES,
[NAME]
TRAVELED OR
JOINED WITH
YOU?
A11
A13
Y
M
M
F
Y
Y
N
O
N
N
Y
Y
Y
N
N
N
E.
S
/
Y
M
M
Y
Y
Y
Y
Y
/
F
N
O
N
N
N
N
N
F.
S
/
M
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.)
95= DK (DON’T KNOW)
96 = RF REFUSE)
97 = OTHER: ___
Y
Y
Y
Y
N
N
N
N
Y
Y
/
F
** 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
95= DK (DON’T KNOW)
96 = RF REFUSE)
97 = OTHER: _____ _
99= NOT ANSWERED
N
***CODES FOR A31
7= SOUTHEAST ASIA (INDONESIA, CAMBODIA, 1 =
VIETNAM, LAOS, THAILAND)
8= PACIFIC ISLANDS (THE PHILIPPINES, GUAM, 2 =
FIJI, ETC.)
9= ASIA (CHINA, JAPAN, KOREA, ETC.)
3=
NO CHILD CARE IN THIS
LOCATION
NO HOUSING IN THIS
LOCATION
CHILD IN SCHOOL,
AFFECTED IF MOVED
95= DK (DON’T KNOW)
96 = RF REFUSE)
97 = OTHER: ___
N
a illness?
YES
NO
D/K
b. injury?:
YES
NO
D/K
c. routine or preventive
YES
care?:
NO
D/K
d. dental treatment or
preventive care?:
YES
NO
D/K
a illness ?:
YES
NO
D/K
b. injury?:
YES
NO
D/K
c. routine or preventive
YES
care?:
NO
D/K
d. dental treatment or
preventive care?:
YES
NO
D/K
a illness?:
YES
NO
D/K
b. injury?:
YES
NO
D/K
c. routine or preventive
YES
care?:
NO
D/K
d. dental treatment or
preventive care?:
NO
D/K
YES
****CODES FOR HA16
1=
2=
3=
4=
5=
6=
7=
COMMUNITY/MIGRANT HEALTH
CENTER
PRIVATE MEDICAL CLINIC/
DOCTOR’S OFFICE
HOSPITAL
EMERGENCY ROOM
MIGRANT HEALTH CLINIC
CHIROPRACTOR OR NATUROPATH
DENTIST
95= DK (DON’T KNOW)
96 = RF REFUSE)
97 = OTHER: ___
3
*****HA16
HA17
*****HA18
[For each
And the When?
“NO” in
(Last
last
“HA15"]
ANY
In the last year [LAST 12 MONTHS], time,
time)
Why did
U.S.
has [NAME of (spouse) (child)]
[NAME
[ENTER
ANY
where
FW
in
‘within”
U.S.
used
any
type
of
health
care
did
LAST
“HA15"]
WORK
service from doctors nurses,
[NAME] NUMBER
12
not use
NOW?
OF
go?
MON
dentists, clinics or hospitals for...
health
MONTHS services?
THS?
[ENTER
AGO:
[ENTER
CODES] 1 TO 12] CODES]
/
/
HA15
ONLY FOR SPOUSE AND CHILDREN UNDER 22 YEARS OLD
MONTHS TO
(A32-33), HAD
YOU
TRAVELED TO
ANY U.S.
DO FW (OR
DONE FW IN SCHOOL
LAST
OTHER CITY)?
12
IF YES,
MONTHS?
[NAME]
TRAVELED OR
JOINED WITH
YOU?
D.
S
Farmworker ID
A12
*****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= DK (DON’T KNOW)
96 = RF REFUSE)
97 = OTHER: ___
[REV. Mar 17, 2017]
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[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?)
[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"]
[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.
9 c.
9 d.
9 e.
9 f.
9 g.
9 h.
9 i.
Prefer own child care arrangements
No MSHS in this area
MSHS not open entire season (FOR FW)
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?:
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)
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. Mar 17, 2017]
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[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 are How many
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
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
CHOICES. CHECK ALL THAT APPLY]: ...
...Adult Education such as English/ ESL/Adult Basic Education/
9 a.
Citizenship?
...Job training?:
9 d.
...GED (High School Equivalency)?
9 f.
...Migrant Education?
9 j.
...Head Start?
9 k.
...Migrant Head Start?
9 l.
...Other?:
9 n.
Don’t know
9
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]: ...
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
D36a [FOR PARENTS OF CHILDREN 12 YEARS OLD OR
B1 [ASK ALL] Which of the following describes you? [READ
YOUNGER] I already asked you about the daycare
CHOICES. CHECK ONLY ONE]: ...
arrangements for your children under 6 years old
here in (NAME OF LOCATION)...How about in all the
9 1 ...MEXICAN-AMERICAN?
places you’ve lived in the past 12 MONTHS, where
9 2 ...MEXICAN?
have all your children 12 years old or younger stayed
9 3 ...CHICANO?
while you are working (FW in the USA)? [CHECK ALL 9 5 ...PUERTO RICAN?
THAT APPLY]
9 4 ...OTHER HISPANIC?:
9 7 ...NOT HISPANIC OR LATINO?
THEY'VE STAYED HOME ALONE, AT LEAST
SOMETIMES
B2
Which of the following do you consider yourself? [READ
9 13 WITH MY SPOUSE, OTHER FAMILY
CHOICES EXCEPT “OTHER.” MARK ONE OR
9 14 WITH A NEIGHBOR / BABYSITTER, MIGRANT HEAD
START, HEAD START, MIGRANT EDUCATION, DAYCARE
MORE RESPONSE]: ...
CENTER, ETC.
9 11 WITH ME IN THE FIELDS
9 1 ...White?
9 12 OTHER:
9 2 ...Black or African American?
G4 In the last 2 years [LAST 24 MONTHS], have you or
9 4 ...American Indian/Alaska Native?
anyone in your household received benefits or used
9 5 ...Asian?
the services of any of the following social programs?
9 6 ...Native Hawaiian or Pacific Islander?
91
[READ CHOICES. CHECK ALL THAT APPLY]: ...
9 r.
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
G6
9 7 ...Other?:
Welfare (general assistance) or TANF
(Temporary Assistance for Needy
Families)?
...(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 Advice or Services?
...Other?:
Don’t know
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]: ...
9 d.
9 a.
9 b.
9 c.
9 e.
9 f.
9 g.
9 h.
9 i.
9 j.
9
Do you own or are you buying any of the following
items in the U.S.? [READ CHOICES. CHECK ALL
THAT APPLY]: ...
9 j. ...a house or a mobile home?
9 b. ...a house?
9 c. ...a mobile home?
9 d. ...a car/truck?
9 e. ...a business?
9 f. ...other?:
9 x 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. Mar 17, 2017]
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[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?
98
B17-18.
Before coming to the USA, you
lived in what...
(B17)
...COUNTRY?:
(B18)
...STATE (OR
DEPARTMENT)?:
NOT APPLICABLE [ONLY FOR
THOSE BORN IN THE U.S.]
LANGUAGE SECTION
B7 How well do you speak English? [READ
CHOICES. MARK ONLY ONE RESPONSE]: ...
...Not at all? 9 3
...Somewhat?
91
...A little?
...Well?
92
94
B20
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
And now, as an adult, what languages can you speak?
When you were a
child, in what
languages did
[CHECK
[FOR EACH CHECKED ANSWER, ASK]:
adults speak to you
ALL THAT
at home? [CHECK
APPLY]
ALL THAT APPLY]
U
a
b
c
d
e
f
z
U
B22
B23
And now, how well do you
speak it? [READ CHOICES.
And now, how well do
you read it? [READ
MARK ONLY ONE PER
CHECK]:
CHOICES. MARK ONLY
ONE PER CHECK]:
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?
ENGLISH
7
B24
In which language do
you believe you are
most dominant
(comfortable)
conversing?
[CHECK ONE. If fully
bilingual, enter and
circle both] U
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S:\4. Questionnaire\2017\OMB SENT TO DANIEL 2017\MAR 17 2017 OMB ENG TRACKCHANGES and highlighted changes.wpd
B10 In what month and year did you first do any farm
D33a
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
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
D34A65]
farmwork in the U.S.? [COUNT ANY YEAR IN
WHICH 15 DAYS OR MORE WERE WORKED].
years
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
B13 When was the last time your parents did hired
9 11 DO NOT PAY RENT. (I OR FAMILY MEMBER
OWN THE HOUSE OR LIVE FOR FREE WITH
FRIENDS OR RELATIVES) D34A65]
farm-work in the U.S.?
90
91
92
93
94
97
B26-27
NEVER
NOW / WITHIN LAST YEAR
ONE TO FIVE YEARS AGO
SIX TO TEN YEARS AGO
OVER 11 YEARS AGO
DON’T KNOW
...And where were your parents born? ...In
what...
...COUNTRY?:
(B26a)
FATHER:
(B27a)
9 12 I RENT FROM NON-EMPLOYER (RELATIVE
OR NON-RELATIVE)
9 97 OTHER:
D50 At this location how much do you pay for housing
(including housing for your family, if they live with
you)?
91
MOTHER?:
per week
[ASK QUESTIONS BELOW ONLY FOR FOREIGN
COUNTRY in “B26a” and “B27a”]: ...
or
per month $
...STATE (OR DEPARTMENT OR EQUIVALENT)?:
(B26b) FATHER:
(B27b) MOTHER?:
or
per day
...MUNICIPALITY (OR DISTRICT OR EQUIVALENT)?:
(B26c)
FATHER:
...TOWN (OR CITY) ?
(B26d) FATHER:
(B27c)
(B27d)
8
$
,
.
,
.
,
.
92
DON'T KNOW, TAKEN OUT OF MY PAYCHECK
93
DON'T KNOW/DON'T REMEMBER, BUT NOT
TAKEN OUT OF MY PAYCHECK
97
OTHER:
MOTHER?:
MOTHER?:
$
[REV. Mar 17, 2017]
D65
S:\4. Questionnaire\2017\OMB SENT TO DANIEL 2017\MAR 17 2017 OMB ENG TRACKCHANGES and highlighted changes.wpd
Do you live in a labor camp or Migrant
Center? [IF YES, PROBE: WHO OWNS OR RUNS IT?]
D54
9 0 NO
9 1 YES, labor camp run by a grower or labor contractor
9 2 YES, labor camp run by migrant center or public
How many of the following do you
have in your current living quarters
(dwelling)...
9 a. ...Bedrooms?:
agency
9 b. ...Bathrooms?:
9 3 YES, labor camp run by another person/group
Specify: __________________
9 c. ...Kitchens?:
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)...
9 f. ...Other rooms?:
D52 How many people total sleep in these
rooms? [VERIFY RESPONSE BY ADDING
9 1 ...Mobile home?
9 2 ...Single-family home (detached)?
9 3 ...Duplex, triplex, etc. (attached, own parking
space with direct access to home)?
9 4 ...Apartments (two or more in a building,
shared parking spaces)?
5
...Dormitory or barracks?
9
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:
D35b
TOTAL NUMBER GIVEN IN HOUSEHOLD
GRID PLUS TOTAL IN A15. IF ANSWERS
DO NOT MATCH MAKE APPROPRIATE
CHANGES]
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]
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?
91
9 5 ...On farm or next to or adjacent to a farm
owned by the grower you currently work for?
9 13 WITH MY SPOUSE, OTHER FAMILY
THEY'VE STAYED HOME ALONE, AT
LEAST SOMETIMES
9 14 WITH A NEIGHBOR / BABYSITTER,
MIGRANT HEAD START, HEAD START,
MIGRANT EDUCATION, DAYCARE
CENTER, ETC.
9 6 ...On a farm or next to or adjacent to a farm
NOT owned by the grower you currently work
for?
9 7 ...Other?:
9 11 WITH ME IN THE FIELDS
9 12 OTHER:
9
[REV. Mar 17, 2017]
S:\4. Questionnaire\2017\OMB SENT TO DANIEL 2017\MAR 17 2017 OMB ENG TRACKCHANGES and highlighted changes.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
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
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
Farmworker ID
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
C1-C2
County
REPORT FROM FIRST PERIOD COVERING OCTOBER 01, 2014 TO PRESENT
RECEIVED
UNEMPLOYMENT?
[C1-C2 FOR OFFICE USE ONLY]
___ ___ ___ ___ ___ 892 ___ ___ ___ ___
***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. Mar 17, 2017]
S:\4. Questionnaire\2017\OMB SENT TO DANIEL 2017\MAR 17 2017 OMB ENG TRACKCHANGES and highlighted changes.wpd
WORK GRID
[C1-C2 FOR OFFICE USE ONLY]
___ ___ ___ ___ ___
County
892 ___ ___ ___ ___
Farmworker ID
C15
C3
GR
EMPLOYER’S
NAME (FARM
WORK, NONFARM WORK
AND WORK
ABROAD)
C4
C5
CROP
WRITE
ACTIVITY OR
TASK WHILE
FW AND NF
[USE CODES
FOR *NW
AND**AB]
C6
C9
NW?
AB?
GR
FW
NF
Y
CO
NW
AB
GR
FW
NF
FW?
PER.
AND
SUB
PER.
NO.
C8
RECEIVED
UNEMPLOYMENT?
C1-C2
CO
[FW
ONLY]
NF?
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
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]
C13
C7
STATE/COUNTRY
REPORT FROM FIRST PERIOD COVERING OCTOBER 01, 20164 TO PRESENT
***FW
AND
NF:
WHY
LEFT?
SPOUSE
CHILDREN
ALL
NO
SPOUSE
CHILDREN
ALL
NO
Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
SPOUSE
CHILDREN
ALL
NO
Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
SPOUSE
CHILDREN
ALL
NO
Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
SPOUSE
CHILDREN
ALL
NO
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
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
97
= RETIRED
= QUIT
= CHANGE JOBS
= OTHER
(SPECIFY):
[REV. Mar 17, 2017]
S:\4. Questionnaire\2017\OMB SENT TO DANIEL 2017\MAR 17 2017 OMB ENG TRACKCHANGES and highlighted changes.wpd
WORK GRID
___ ___ ___ ___ ___
County
[C1-C2 FOR OFFICE USE ONLY]
892 ___ ___ ___ ___
Farmworker ID
C15
C3
C4
C5
C6
FW?
NF?
CROP
WRITE
ACTIVITY OR
TASK WHILE
FW AND NF
[USE CODES
FOR *NW AND
**AB]
NW?
AB?
GR
FW
NF
Y
CO
NW
AB
GR
FW
NF
GR
PER.
AND
SUB
PER.
NO.
C8
RECEIVED
UNEMPLOYMENT?
C1-C2
CO
[FW
ONLY]
EMPLOYER’S
NAME FOR:
FW, NF AND
WORK AB
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
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, 20164 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
8 = RETIRED
SEASON
10 = QUIT
2 = FIRED
11 = CHANGE JOBS
3 = FAMILY
97 = OTHER
RESPONSIBILITIES
(SPECIFY):
4 = SCHOOL
5 = MOVED
6 = HEALTH REASON
7 = VACATION
[REV. Mar 17, 2017]
S:\4. Questionnaire\2017\OMB SENT TO DANIEL 2017\MAR 17 2017 OMB ENG TRACKCHANGES and highlighted changes.wpd
WORK GRID
___ ___ ___ ___ ___
County
[C1-C2 FOR OFFICE USE ONLY]
892 ___ ___ ___ ___
Farmworker ID
C15
C3
C4
C5
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?
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
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
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)
C8
C9
DATES FOR PERIODS OF
FW,NF, NW,AB
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, 20164 TO PRESENT
***FW
AND
NF:
WHY
LEFT?
SPOUSE
CHILDREN
ALL
NO
N/A
COMMUTE FROM
MEXICO TO DO FW?
Y
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
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]
Y
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
97
=
=
=
=
RETIRED
QUIT
CHANGE JOBS
OTHER
(SPECIFY):
[REV. Mar 17, 2017]
S:\4. Questionnaire\2017\OMB SENT TO DANIEL 2017\MAR 17 2017 OMB ENG TRACKCHANGES and highlighted changes.wpd
D1 In the year before last [FROM OCTOBER
D61 Were you paid by [READ CHOICES. MARK
ONE RESPONSE]:...
20143 TO OCTOBER 20154, YEAR BEFORE
1
...PAYROLL
CHECK? 9 4 ...OTHER CHECK?
9
THE ONE COVERED IN WORK GRID], how
many months did you do (FW) in the U.S.? [1 9 2 ...PERSONAL CHECK? 9 5 ...CASH?
DAY OR MORE PER MONTH EQUALS 1 MONTH]
9 3 ...CASH AND CHECK? 9 6 ...OTHER:
months
D62 Did you get a receipt?
D2 [IF NON-FARM JOB LISTED ON WORK GRID]:
9 0 NO
9 1 YES
For your most recent non-farm (NF) employer,
how many hours per week did you work on
D7 For what time period was that payment?
average?
9 1 ONE DAY? 9 4 ONE MONTH?
OTHER?:
9 2 ONE WEEK?
97
9 3 TWO WEEKS?
hours
D3 [IF NON-FARM JOB LISTED] For your most
recent non-farm employer (NF), how much
were
you paid per week on average?
$
,
D8 How many hours did you work during that
period (in D7)?
.
hours
==============================
CURRENT FARM JOB
D9 ...Now - with your current employer - you
Now I am going to ask you some questions about
already told me that the crop you are
the FW you are CURRENTLY performing for
currently working is:...
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
[D5 TO D8: IF SHE/HE HAS NOT RECEIVED PAYMENT D11 Are you paid: ...
YET FOR CURRENT CROP, ASK FOR ESTIMATES]:
9 1 ...BY THE HOUR?
Can you tell me how you were paid and the
9 2 ...BY THE PIECE? [SKIP TO D13]
amount your employer paid you on your last pay
9 3 ...COMBINATION HOURLY WAGE AND
day?
PIECE RATE? [ASK D12 THRU D18]
9 4 ...SALARY OR OTHER? [SKIP TO D19]
D5
After taxes:
$
D6
,
.
D12
PAID ONLY BY THE HOUR, ENTER AMOUNT
AND SKIP TO D20. IF COMBINATION, ENTER
AMOUNT AND CONTINUE WITH D13]:
Before taxes:
$
,
How much per hour (to nearest cent)? [IF
.
$
14
.
PER HOUR
[REV. Mar 17, 2017]
S:\4. Questionnaire\2017\OMB SENT TO DANIEL 2017\MAR 17 2017 OMB ENG TRACKCHANGES and highlighted changes.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]
[IF PAID A BONUS]: How and when do
you receive the money bonus? [READ
CHOICES. MARK ALL THAT APPLY]:...
D21
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.]?
...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
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
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
90
91
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]:
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? [WHETHER OR NOT THE
WORKER TAKES IT OR USES IT]
90
91
97
15
NO
YES
DON’T KNOW
[REV. Mar 17, 2017]
S:\4. Questionnaire\2017\OMB SENT TO DANIEL 2017\MAR 17 2017 OMB ENG TRACKCHANGES and highlighted changes.wpd
D26 Are you covered by unemployment
D37a
insurance if 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
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
D28 Do you work for (current employer) year
round or on a seasonal basis?
Year round
90
9 1 Seasonal
Don’t Know
97
to work? [READ CHOICES. MARK ONE]:...
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?:
D29 [IF WORKED ON A SEASONAL BASIS] Does this
employer keep in contact with you about
future employment? [READ CHOICES. MARK
ALL THAT APPLY]: ...
9 a. ... Yes, before leaving at the end of the
season?
9 b. ... No, you contact employer?
9 c. ... Other?:
Don’t know
9
How far is your current job from your
current residence?
D38a
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?
D30 How did you get this job? [DO NOT READ
CHOICES. MARK ONLY ONE RESPONSE]
90
91
92
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:
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
(20164)”...
G1C
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 97
G3C What was your family’s total income last
year - in 2014 - in U.S. dollars [U.S.
earnings for FW AND NF for all in “FAMILY
GRID”]? [READ OR SHOW CHOICES.
...What was your total personal income last year MARK ONLY ONE]
in 2014 - in U.S. dollars [U.S. earnings only FOR
FW AND NF]? [READ OR SHOW CHOICES.
DID NOT WORK AT ALL IN 20164
90
MARK ONLY ONE]
LESS THAN 1,000
9 21
1,000 TO 2,449
9 22
DID NOT WORK AT ALL IN 20164
2
2,500 TO 4,999
9
LESS THAN 1,000
3
5,000 TO 7,499
9
1,000 TO 2,449
7,500 TO 9,999
94
2,500 TO 4,999
5,000 TO 7,499
10,000 TO 12,499
95
7,500 TO 9,999
12,500 TO 14,999
96
10,000 TO 12,499
15,000 TO 17,499
97
12,500 TO 14,999
8
17,500 TO 19,999
9
15,000 TO 17,499
9
20,000 TO 22,499
9
17,500 TO 19,999
10
22,500
TO 24,999
9
20,000 TO 22,499
22,500 TO 24,999
25,000 TO 27,499
9 11
25,000 TO 27,499
27,500 TO 29,999
9 12
27,500 TO 29,999
30,000 TO 32,499
9 13
30,000 TO 32,499
32,500 TO 34,999
9 14
32,500 TO 34,999
15
35,000 TO 37,499
9
35,000 TO 37,499
16
37,500 TO 39,999
9
37,500 TO 39,999
40,000 TO 44,999
9 17
40,000 TO 44,999
45,000 TO 54,999
9 18
45,000 TO 54,999
55,000 TO 59,999
55,000 TO 59,999
9 19
60,000 OR MORE
60,000 OR MORE
9 20
DON’T REMEMBER (DON’T KNOW)
DON’T REMEMBER (DON’T KNOW)
9 97
G2C How much of that income [in “G1A”] was from
agricultural employment (U.S. earnings only for FW)?
E1
[READ / 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 97
DID NOT WORK AT ALL IN 20164
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
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
DON’T REMEMBER (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
[REV. Mar 17, 2017]
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SCREENING FOR INJURY SUPPLEMENT
[INTERVIEWER: ...ONLY IF THE RESPONDENT SEEMS HESITANT TO TALK ABOUT INJURIES (e.g.,
BECAUSE HE/SHE IS FEARFUL, SHOULD YOU REMIND THE RESPONDENT THAT ALL THE INFORMATION
HE/SHE SHARES WITH YOU IS CONFIDENTIAL. USE YOUR JUDGMENT ABOUT REMINDING THE
INTERVIEWER ABOUT CONFIDENTIALITY AT ANY POINT WHILE ADMINISTERING THIS SUPPLEMENT].
“I would like to ask you some questions about injuries or accidents that you may have had in the
last 12 months while doing work in the United States. These includes injuries or accidents that
happened while your were doing farm work (FW), and it also includes work or employment you may
have had in a non-agricultural job (NF), such as working in construction, landscaping, at a hotel or
restaurant, or any other job. These injuries or accidents doing farm work (“FW”) or non-agricultural
work (“NF”) could have also been things like:...
...injuries from a car accidente traveling to and from work;
...cutting yourself with a sharp tool or knife;
...hurting yourself lifting heavy objects, such as crates;
...hurting yourself by falling, for example falling off a ladder or crate, or tripping in the field; or
...getting sick from working too long in the hot sun, being bitten or stung by an insect, or breathing
pesticides while working in the fields.”
...In the past 12 months, have you had any injury or accident that made you...
NLS01
...unable to work for at least 4 hours?
90
91
NLS02
NLS03
NO
YES
...unable to work as hard as you normally
do for at least 4 hours? [or were assigned
a different job (or different task) that was
easier because the injury prevented you
from doing the first job (or task)]
NLS04
...use any type of first aid, such as a
bandage to stop bleeding or antiseptic to
clean a wound (or ice packs for a bruise,
etc.) or seek medical treatment at a clinic
or from a nurse or doctor?
NO
90
YES
91
...take strong medicine, except aspirin
(or Tylenol or Ibuprofen), to allow you
to keep working?
9 0 NO
9 1 YES
90
91
NO
YES
INTERVIEWER:...
...IF THE RESPONDENT ANSWERED “NO”
TO ALL OF THE PREVIOUS QUESTIONS
(NLS01 TO NLS04), SKIP TO NEXT SECTION
(“EP", PAGE 19).
NL1E
...IF THE RESPONDENT ANSWERED “YES”
TO ANY OF THE PREVIOUS QUESTIONS
(NLS01 TO NLS04), ASK NL1E
HOW MANY OF THESE TYPES OF INJURIES HAVE YOU HAD?
FW:
NF:
[INTERVIEWER: Write here any spontaneous response related to an injury or injuries (e.g., type of
injuries and dates) so you can refer to it when completing the “Injury Supplement”]:
CONTINUE WITH NEXT SECTION (“NEW EPA”) UNTIL COMPLETION OF QUESTIONNAIRE,
THEN COMPLETE “INJURY / ACCIDENT -SUPPLEMENT QUESTIONNAIRE”!!!
18
SECTION
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EP. NEWSENT
EPA
TO DANIEL
VERSION
2017\MAR 17 2017 OMB ENG TRACKCHANGES and highlighted changes.wpd
EP1. When was the last time you worked two (2) EP2. On the first day of the consecutive days, at
[REV. Apr 21, 2015]
consecutive days? [If worked yesterday,
what time did you arrive to work?
enter yesterday’s date as 1st Day]
___________:____________ AM/PM
a. First day [MM/DD/Year]: _____/_____/_____
b. Second day [MM/DD/Year]: _____/_____/_____ 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
first day?
“a”] the first day?
d
How long did you work
How long were you idle (e.g.,
doing [TASK in “b”] with rest, break, lunch, etc.)
[CROP in “a”]?
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? [MARK ANSWER]
(or first day?) [CHECK ONE]
YES NO D/K
YES
NO
1 PANTS
2
LONG SLEEVE
SHIRT
SHORT SLEEVE
3 SHIRT
4
OTHER:
---------------
EP7.
WASHED?
G YES
G NO
G YES
G NO
G YES
G NO
G YES
G NO
[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?
19
__b. short sleeve shirt __c.pants?
[REV. Mar 17, 2017]
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NMS - MUSCULOSKELETAL: [INTERVIEWER: FIRST ASK ALL FIRST COLUMN QUESTIONS]
During the last 12
months [from June
2014 until now (current
month)], have you had
pain or discomfort in
your...
What type of
work were you
doing when this
pain/discomfort
began?
NMS (1 TO 6)
...BACK?
90
91
NO
YES
NMS2
...SHOULDER /
NECK?
90
91
a.
9 FW
NMS1
NO
YES
NMS3
...ELBOW / ARM?
NO
9 1 YES
90
[If NF, ask:] What type of
TASK were you doing?
[If FW, ask:] What type of
TASK and CROP were you
working on?
f.
“FW”: CROP AND TASK:
9 NW
“NF”: OCCUPATION AND
INDUSTRY:
9 FW
“FW”: CROP AND TASK:
9 NW
“NF”: OCCUPATION AND
INDUSTRY:
9 FW
“FW”: CROP AND TASK:
NMS4
9 FW
“FW”: CROP AND TASK:
...HAND/WRIST/FING
ER?
9 NF
9 NW
NMS5
9 FW
“FW”: CROP AND TASK:
...LEGS / FEET /
TOES?
9 NF
91
90
91
NO
YES
NMS6
...OTHER?
90
91
NO
YES
A LITTLE
NO
YES:
“NF”: OCCUPATION AND
INDUSTRY:
9 FW
“FW”: CROP AND TASK:
NO
YES:
90
92
A LOT
NO
YES:
90
A LITTLE
92
A LOT
NO
YES:
A LITTLE
92
A LOT
NO
YES:
“NF”: OCCUPATION AND
INDUSTRY:
UNBEARABLE
91
A LITTLE
92
A LOT
UNBEARABLE
91
A LITTLE
92
A LOT
DAYS 9 3
90
UNBEARABLE
91
DAYS 9 3
90
UNBEARABLE
91
DAYS 9 3
91
9 NF
c.
A LITTLE
DAYS 9 3
91
9 NW
9 NW
90
91
“NF”: OCCUPATION AND
INDUSTRY:
91
DAYS 9 3
91
9 NF
9 NW
NO
YES
NO
YES:
90
91
9 NF
How severe was How long did you work How many days did you
this
with this
NOT WORK because of this
pain/discomfort? pain/discomfort?
pain/discomfort?
[SHOW SCALE
BELOW]
b.
91
9 NF
“NF”: OCCUPATION AND
INDUSTRY:
90
Did you have this
pain/discomfort
for FIVE (5) or
more consecutive
days?
[If “YES”, ask]:
How many
DAYS?
UNBEARABLE
91
A LITTLE
92
A LOT
93
UNBEARABLE
d.
e.
9 LESS THAN A DAY
9 DAYS:
9 WEEKS:
9 MONTHS:
9 DON’T KNOW
9 LESS THAN A DAY
9 DAYS:
9 WEEKS:
9 MONTHS:
9 DON’T KNOW
9 LESS THAN A DAY
9 DAYS:
9 WEEKS:
9 MONTHS:
9 DON’T KNOW
9 LESS THAN A DAY
9 DAYS:
9 WEEKS:
9 MONTHS:
9 DON’T KNOW
9 LESS THAN A DAY
9 DAYS:
9 WEEKS:
9 MONTHS:
9 DON’T KNOW
9 LESS THAN A DAY
9 DAYS:
9 WEEKS:
9 MONTHS:
9 DON’T KNOW
9 LESS THAN A DAY
9 DAYS:
9 WEEKS:
9 MONTHS:
9 DON’T KNOW
9 LESS THAN A DAY
9 DAYS:
9 WEEKS:
9 MONTHS:
9 DON’T KNOW
9 LESS THAN A DAY
9 DAYS:
9 WEEKS:
9 MONTHS:
9 DON’T KNOW
9 LESS THAN A DAY
9 DAYS:
9 WEEKS:
9 MONTHS:
9 DON’T KNOW
9 LESS THAN A DAY
9 DAYS:
9 WEEKS:
9 MONTHS:
9 DON’T KNOW
9 LESS THAN A DAY
9 DAYS:
9 WEEKS:
9 MONTHS:
9 DON’T KNOW
DAYS
A LOT
UNBEARABLE
20
[REV. Mar 17, 2017]
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NP – HANDLING PESTICIDES
(IN THE U.S.A.)
NP1f. In the last 12 months, have you
loaded, mixed or applied pesticides?
NS – SANITATION SECTION
“The following questions refer to sanitation
at your job with your current FW employer:
...
9 0 NO
9 1 YES
NT – TRAINING AND INSTRUCTIONS
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)?
... Does your current employer provide
EVERY DAY...
NS1 ... (potable) clean drinking water and
disposable cups?
90
91
92
97
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
21
[REV. Mar 17, 2017]
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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: ...
a.
b.
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
9 0 NO
9 0 NO
9 1 YES
9 1 YES
NH4
...TUBERCULOSIS?
NH5
...HEART DISEASE?
NH6
...URINARY TRACT
INFECTIONS?
NH10
...OTHER?:
9 0 NO
9 0 NO
9 1 YES
9 1 YES
22
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. Mar 17, 2017]
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NQ5 And, ...the last time you used a health care
provider, who helped pay for the cost?
[CHECK ALL THAT APPLY]
NQ – QUALITY OF AND ACCESS TO HEALTH
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.
91
92
93
94
95
98
99
96
NQ1
9 7 Combination of:
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
NQ10 [ASK ALL]: ...When you NEED to get health
care in the USA what are the main difficulties
you face? [CHECK ALL THAT APPLY]
9 m.
NQ3b ...And the last time you used the health care 9 l.
provider, where did you go (what kind of
place was it)?
9 a.
9 b.
9 1 COMMUNITY HEALTH CENTER/
9 c.
9 2 PRIVATE MEDICAL DOCTOR’S
9 d.
OFFICE/PRIVATE CLINIC
9 e.
9 3 HEALER/ “CURANDERO”
9 f.
9 4 HOSPITAL
9 g.
9 5 EMERGENCY ROOM
9 h.
9 6 MIGRANT HEALTH CLINIC
9 i.
9 7 CHIROPRACTOR OR NATUROPATH’S
9 j.
OFFICE
98
DENTIST
I paid the bill out of “my own pocket”
Medicaid / Medicare
Public clinic did not charge
Employer provided health plan
Self or family bought individual health plan
Billed, but did not pay
Worker’s compensation
Other:
9
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:
No difficulties / No problems
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]
23
NH - PERSONAL HEALTH - LIFE HISTORY [ASK ALL]:
b. Are you currently taking
g. In the last 12 months, in the U.S. and/or abroad, have you seen a
doctor or nurse for (condition “YES” in COLUMN “a”)? [IF ANSWER
medication, for this condition
IS “YES” FOR THE U.S. AND “AB” MARK BOTH]
(in ”a”), that was prescribed by
a medical provider?
a. Have you ever – in your whole life -- been told by a doctor or nurse
(health practicioner) that you have the following condition...
NH5
NH1
...heart disease?
9 0 NO
9 1 YES:
90
NO
9 95 RF
9 96 DK
91
YES
91
90
NO
9 96 DK
91
YES
9 1 YES:
90
NO
91
YES
...asthma?
9 0 NO
9 95 RF
YES:
NH11 ...cancer?
9 0 NO
(TYPE OR KIND OF CANCER?):
9 95 RF
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”:
NO
91
YES, IN THE U.S.A.
92
YES, “AB”:
YES, “AB”:
NH – INDIVIDUAL PERSONAL HEALTH HISTORY (LIFETIME) [INTERVIEWER: FIRST ASK ALL QUESTIONS IN FIRST COLUMN.]
a.
b.
And have you ever -- in your
...ever been
whole life – been told by a
tested for this
doctor or nurse that you have... condition?
NH3 ...high blood pressure?
9 0 NO
9 1 YES
9 95 DK
9 96 RF
NH12 ...high cholesterol?
9 0 NO
9 1 YES
9 95 DK
9 95 RF
90
91
NO
YES
9 95 DK
90
NO
91
YES
9 95 DK
c.
What was the outcome
(result)?
9 1 NORMAL
9 2 PREHYPERTENSION
9 3 HIGH
9 4 DID NOT RECEIVE IT
9 95 DK (FORGOT)
9 1 NORMAL
9 2 BORDERLINE
9 3 HIGH
9 4 DIDN’T RECEIVE IT
9 95 DK (FORGOT)
d.
When was the last test
taken?
e.
f.
g.
Where was Are you currently taking
In the last 12 months, in the
the test
medication, for this condition U.S. and/or abroad, have you
taken?:
(in “a”), that was prescribed
seen a doctor or nurse for
*[USE CODE] by a medical provider?
(condition in “a”)?
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 95 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 95 DK (FORGOT)
90
91
NO
YES
90
NO
91
YES
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 DK
9 1 NORMAL
9 2 ABNORMAL
9 4 DID NOT RECEIVE IT
9 95 (FORGOT)
9 96 RF
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 95 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
24
7 = DENTIST
97 = OTHER: __________
95 = DK
96 = RF
[REV. Mar 17, 2017]
S:\4. Questionnaire\2017\OMB SENT TO DANIEL 2017\MAR 17 2017 OMB ENG TRACKCHANGES and highlighted changes.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...
NH2
f.
When was the last test
taken?
g.
b.
Where was the Are you currently
test taken?:
taking medication, for
*[ENTER
this condition (in “a”),
CODE]
c.
In the last 12 months, in the U.S.
and/or abroad, have you seen a
doctor or nurse for this condition
that was prescribed by (in “a”)? [IF ANSWER IS “YES” FOR
THE U.S. AND “AB” MARK BOTH]
a medical provider?
...diabetes?
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
9 96 RF
NH14
...HIV (AIDS)?
90
91
9 95
NO
90
NO
NH10 ...other?:
9 0 NO
9 1 YES:
13 TO 24 MONTHS
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
94
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 95 DK
90
9 96 RF
92
2 TO 5 YEARS
NO
9 1 YES
9 95 DK
HIGH SUGAR LEVEL
0 TO 12 MONTHS
93
9 1 YES
9 96 RF
92
91
LOW SUGAR LEVEL
9 1 YES
...tuberculosis?
NORMAL
93
9 95 DK
9 0 NO
9 1 YES
9 95 DK
91
9 1 YES
YES
DK
9 96 RF
NH6 ...urinary tract infection?
9 0 NO
9 1 YES
9 95 DK
9 96 RF
NH4
e.
What was the outcome
(result) of the last test?
d.
...ever been
tested for this
condition?
9 95 DK
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
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”:
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 MIGRANT HEALTH CLINIC
6 DENTIST
25
95 = DK
96 = RF
97 OTHER: ____________
[REV. Mar 17, 2017]
S:\4. Questionnaire\2017\OMB SENT TO DANIEL 2017\MAR 17 2017 OMB ENG TRACKCHANGES and highlighted changes.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.”
9 a ...FOR ILLNESS?
9 0 NO: [ASK HA7]
9 95 DK
91
YES
YES
9 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
2
3
4
COMMUNITY/MIGRANT
HEALTH CENTER
PRIVATE CLINIC OR
DOCTOR’S OFFICE
HOSPITAL
EMERGENCY ROOM
HA7
**HA4
When (last time)?
Did you get any
help to pay for the
cost of that health
service?***[ “YES” OR
(kind of place)
*[ENTER
CODES]
9 96 RF
9 b ...FOR INJURY?
9 0 NO:[ASK HA7]
9 95 DK
91
HA3
*HA2
...And where
did you go
(last time)?
5 DENTIST
95 = DK
96 = RF
97=OTHER:
______
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]:
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
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?
2
3
4
5
I paid the bill out of “my own
pocket”
Medicaid / Medicare
Public clinic did not charge
Employer provided health
plan
Self or family bought
individual health plan
6
7
8
95 = DK
96 = RF
97 Other: ________
And in the LAST 12 MONTHS, in the USA, was there ever a time when you wanted HA8
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)
9a
9b
9 0 NO
9 1 YES
9c
9d
1
2
3
4
[ ENTER CODES]
...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]
...SOMEWHAT SATISFIED?[ASK HA6]
...NOT AT ALL SATISFIED? [ASK HA6]
***CODES FOR “HA6"
Billed, but did not pay
Worker’s
compensation
I paid some (copay)
****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]
**CODES FOR “HA4"
1
***HA6
HA5 In general, how satisfied were YOU
COST TOO MUCH
HAD TO WAIT TOO
LONG
LANGUAGE PROBLEM COULD NOT
COMMUNICATE
MISTREATED BY DR.
OR OTHER STAFF
****CODES FOR “HA7"
5
CONDITION DID NOT
IMPROVE AFTER
TREATMENT OR
MEDICATION
6
DR. DID NOT DIAGNOSE OR
TREAT CONDITION
95 = DK
96 = RF
97 OTHER: ____
1 = Did not know where to go
2 = No transportation
3 = Too far away
4 = Health Center not open when needed
5 = No need to go / Does not get sick
6= Too expensive
7= No insurance
95= DK
96= RF
97 = OTHER:___________________
Why could you not get the health care you wanted (or needed)? [CHECK ALL THAT APPLY]
Did not know where to go
No transportation
Too far away
Health Center not open when needed
26
9e
9f
9z
Too expensive
No insurance
Other:
HA9. [ASK ONLY IF “NO” IN ALL“HA1 (a, b, c)" AND “NO” IN “HA7”]
...You said you’ve not used, needed or wanted health care in the last 12 months, in the USA, why have
you not sought health care even for a routine exam?
[CHECK ALL THAT APPLY]
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]
9a
9b
9c
9d
90
91
NO
YES, IN [NAME OF COUNTRY]:
I do not know where to go
No transportation
Too far away
Health Center not open when
needed
9e
9f
9g
9z
Too expensive
No insurance
Do not need to go / Do not get sick
Other:
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_________= ________
27
Nearly every day
3
3
+ __________
DA. DIGITAL ACCESS
DA1 Do you or any member of your family
[“Household Grid”] have access to digital
information sources (i.e., internet, cellular
What devices?
[MARK ALL RESPONSES FOR DEVICES “U”]
phone with internet, etc.)?
[CHECK WHO IF “YES”]
DA2 Computer
DA3 Cellular phone with Internet DA4 Cellular phone with Text DA5 Tablet
DA6 Other device?
[Specify]: _________
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
DA8.
helped you use, any digital device to
seek or obtain information about ...
a. ...health or health insurance?
9 0 NO
9 1 YES
b.
90
c.
90
...seeking employment?
NO
9 1 YES
...training and/or education?
NO
9 1 YES
d.
...child care?
9 0 NO
9 1 YES
e.
...housing?
9 0 NO
9 1 YES
f.
90
g.
...benefits? [e.g., Unemployment, Social
Security, food stamps, retirement, etc.]
NO
9 1 YES:
SPECIFY:
...other?: [SPECIFY]:
What devices have you used?
[MARK ALL RESPONSES]
9 a. COMPUTER
Where?:
9 b. TABLET
Where?:
9 c. CELLULAR PHONE WITH INTERNET
9 d.
9 a. COMPUTER
Where?:
9 b. TABLET
Where?:
9 c. CELLULAR PHONE WITH INTERNET
9 d.
9 a. COMPUTER
Where?:
9 b. TABLET
Where?:
CELLULAR PHONE WITH TEXTING
CELLULAR PHONE WITH TEXTING
DA9. Who helped you use the device (in
“DA8") to seek or obtain the
information (in “DA7")? [MARK ALL
RESPONSES:]
9 1.
Self
9 2.
Spouse?
9 3. Children?
9 4.
Other?:
9 1.
Self
9 2.
Spouse?
9 3. Children?
9 4.
Other?:
9 1.
Self
9 2.
Spouse?
9 c. CELLULAR PHONE WITH INTERNET
9 d.
9 3. Children?
9 4.
Other?:
9 a. COMPUTER
9 b. TABLET
Where?:
Where?:
9 1.
Self
9 2.
Spouse?
9 c. CELLULAR PHONE WITH INTERNET
9 d.
Where?:
9 3. Children?
9 1. Self
9 4.
9 2.
Other?:
9 a. COMPUTER
9 b. TABLET
Where?:
CELLULAR PHONE WITH TEXTING
CELLULAR PHONE WITH TEXTING
Spouse?
9 c. CELLULAR PHONE WITH INTERNET
9 d.
9 3. Children?
9 4.
Other?:
9 a. COMPUTER
9 b. TABLET
Where?:
Where?:
9 1.
9 2.
Spouse?
9 c. CELLULAR PHONE WITH INTERNET
9 d.
9 3. Children?
9 4. Other?:
9 a. COMPUTER
9 b. TABLET
Where?:
Where?:
9 1.
Self
9 2.
9 c. CELLULAR PHONE WITH INTERNET
9 d.
9 3. Children?
9 4.
28
CELLULAR PHONE WITH TEXTING
CELLULAR PHONE WITH TEXTING
CELLULAR PHONE WITH TEXTING
Self
Spouse?
Other?:
EDUCATION AND TRAINING
1. In the USA or elsewhere, any other country have you participated in or attended any type of educational program, training or classes that are work-related or important to you in any other way?
They could have been... [Intwr: first ask all items in first column (“a” to “f”) and explain and provide examples for each one;...
[REV. Mar 17, 2017]
[FOR EACH QUESTION, REFER TO
LAST TIME . IF YES, SPECIFY BY
ASKING FOR OCCUPATION AND
INDUSTRY. MARK IF “FW” OR “NF’]
a. ...Worker safety training?
9 0 NO
b
Where (venue
or provider facility)?
[GIVE EXAMPLES.
ENTER CODE]
9 1 YES: 9 FW 9 NF
9 1 USA:
9 heat?
9 pesticide?
9 injuries
9 other?:
9 2 OTHER COUNTRY:
...pesticides?
9 0 NO
2.
9 1 YES: 9 FW:
c ... injuries?
9 0 NO
9 1 YES: 9 FW:
4. Completed?
[ENTER CODES
FOR “NO”]
Year?: ________
9 0 NO Why not?:
9 0 NO Why not?:
9 2 OTHER COUNTRY:
Number of hours?:
________ hrs
9 1 YES
9 1 USA:
9 NF:
d. ...any other safety training?
9 0 NO
9 1 YES: 9 FW: 9 NF:
9 2 OTHER COUNTRY:
9 1 USA:
Year?: ________
Number of hours?:
________ hrs
9 0 NO Why not?:
9 1 YES. How much?: 9 1 YES How?
$ __ __ __ ___. __ __
NO
9 0 NO
9 1 YES
9 2 OTHER COUNTRY:
...English as a Second Language 9 1 USA:
(ESL)?
9 2 OTHER COUNTRY:
NO
9 0 NO Why?:
9 0 NO
9 0 NO Why not?:
9 1 YES How?
9 1 YES. How much?:
$ __ __ __ ___. __ __
9 1 YES
Number of hours?:
90
NO
91
YES. How much?:
9 1 YES How?:
$ __ __ __ ___. __ __
9 1 YES
9 0 NO
9 0 NO Why not?:
9 0 NO Why?:
90
NO
9 1 YES [Specify]:
Number of hours?:
9 0 NO Why not?:
9 0 NO
9 1 YES [Specify]
Number of hours?:
________ hrs
9 1 YES How?
9 1 YES. How much?:
$ __ __ __ ___. __ __
9 1 YES
Year?: ________
9 0 NO Why?:
9 0 NO
9 1 YES [Specify]:
________ hrs
9 0 NO Why?:
9 1 YES. How much?: 9 1 YES How?
$ __ __ __ ___. __ __
9 1 YES [Specify]:
________ hrs
9 1 USA:
90
9 0 NO
________ hrs
Year?: ________
9 1 YES
9 0 NO Why?:
9 1 YES [Specify]:
9 2 OTHER COUNTRY:
f. ...any classes or training for any kind 9 1 USA:
of work?
9 0 NO 9 1 YES: 9 FW 9 NF
9 2 OTHER COUNTRY:
9 0 NO
NO
90
9 0 NO Why not?:
Year?: ________
e.
9 0 NO Why?:
90
9 0 NO
9 1 YES [Specify]:
Year?: ________
e. ...besides “safety training,” any other 9 1 USA:
training received here (current work)
or in any other work you may have
had (OJT)?
9 2 OTHER COUNTRY:
9 0 NO 9 1 YES: 9 FW 9 NF
9 0 NO
7. And this training program,
has it helped (will help) you
for a better job or in any
other way?
[WRITE RESPONSE]
9 1 YES. How much?: 9 1 YES How?:
$ __ __ __ ___. __ __
9 1 YES
Number of hours?:
g. ...GED classes?
9 0 NO
9 1 YES
Year?: ________
6. Did you pay
anything for it?
COUNTRY / VENUE
SPECIFY
SPECIFY
5. Did it lead to a
credential or
license? [Specify]
9 1 YES [Specify]:
Number of hours?:
________ hrs
9 1 USA:
9 NF:
SPECIFY
3.When?
(Dates: Year and
Total hours per
week/day?)
90
9 0 NO Why?:
NO
9 1 YES How?:
9 1 YES
9 1 YES. How much?:
$ __ __ __ ___. __ __
Year?: ________
9 0 NO Why not?: 9 0 NO
9 0 NO
9 0 NO Why?:
Number of hours?:
________ hrs
9 1 YES. How much?:
$ __ __ __ ___. __ __
9 1 YES How?:
9 1 YES
9 1 YES [Specify]
29
f. ...besides school,... basic skills like
9 1 USA:
classes in math, reading and writing?
9 0 NO 9 1 YES
9 2 OTHER COUNTRY:
g. ...other?:
9 FW
9 NF
9 1 USA:
Year?: ________
9 0 NO Why not?: 9 0 NO
Number of hours?:
________ hrs
9 1 YES
90
9 1 YES [Specify]:
9 1 YES. How much?: 9 1 YES How?:
$ __ __ __ ___. __ __
9 0 NO
Year?: ________
9 0 NO Why?:
9 0 NO Why not?:
9 2 OTHER COUNTRY:
9 0 NO Why?:
NO
9 0 NO
9 1 YES [Specify]:
Number of hours?:
________ hrs
9 1 YES
CODES FOR “2"
9 1 YES How?
9 1 YES. How much?:
$ __ __ __ ___. __ __
CODES FOR “4" “NO, Why not?”
a. Workplace Center
d. Church
a. Too old to study
d. Too tired to continue
g. Applied, didn’t qualify
b. Community Center
e. Adult School
b. Did not learn (Will not learn)
e. No child care
h. “Don’t qualify” didn’t apply
c. Community College
Other:
c. No transportation
f. Too far
i. Other:
[FOR EACH QUESTION, REFER TO LAST
TIME . IF YES, SPECIFY BY ASKING FOR
OCCUPATION AND INDUSTRY. MARK IF
“FW” OR “NF’]
Like...
h. ...English as a Second Language
(ESL)?
9 0 NO
9 1 YES: 9 FW:
9 NF:
SPECIFY
[...continuation: Education and Training...]
ET2. Where (venue
ET3. When? (Dates: Year ET4. Have you
ET5. Have you received ET6.
or provider facility)?
and Total hours per
completed it?
a credential, diploma
Did you pay anything
*[GIVE EXAMPLES.ENTER week/day?)
** [ENTER CODES
or license
for it?
CODE] [FOR OTHER
FOR “NO” AND
[for program ]?
COUNTRY, ENTER
SKIP TO “ET6"]
[Specify]
COUNTRY AND VENUE]
Year?: ________
9 1 USA:
9 0 NO Why not?: 9 0 NO
9 0 NO
Number of hours?:
9 2 OTHER COUNTRY:
_________ hrs
9 1 YES [Specify]
9 1 YES. How much?:
COUNTRY / VENUE
$ __ __ __ ___. __ __
9 1 YES
i. ...besides school,... basic skills like
9 1 USA:
classes in math, reading and writing?
9 0 NO
9 1 YES: 9 FW:
9 NF:
9 2 OTHER COUNTRY:
Year?: ________
9 0 NO Why not?:
90
NO
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 Why?:
9 1 YES How?:
9 0 NO Why?:
9 0 NO
Number of hours?:
________ hrs
9 1 YES
9 1 YES [Specify]:
9 1 YES. How much?:
$ __ __ __ ___. __ __
9 1 YES How?:
SPECIFY
COUNTRY / VENUE
*CODES FOR “ET2": VENUE
**CODES FOR “ET4": “NO, Why not?”
1. WORKPLACE CENTER 3. COMMUNITY COLLEGE 5. ADULT SCHOOL 1. Too old to study
3. No transportation
2. COMMUNITY CENTER 4. CHURCH
97. Other: ______
2. Did not learn (Will not learn) 4.Too tired to continue
30
5. No child care 7. Applied, didn’t qualify
9. Still attending
6. Too far
8. “Don’t qualify” didn’t apply 97. Other: _______
ET8. Have you ever considered (thought about) attending some other kind of
vocational training or special classes to help you improve your skills to
obtain better jobs better pay or change careers, etc.?:
12. If there were any training programs for FARM WORKERS, without any
obstacles, would you consider attending any of them?
9 0 NO
9 0 NO
Why not? [Mark all responses and SKIP TO 13]:
Why not? [Mark all responses]:
9 a.
9 b.
9 c.
9 f.
9 dg.
9 eh.
9 I.
9 j.
9 x.
9 a.
9 b.
9 c.
9 f.
9 g.
9 h.
9 I.
9 j.
9 x.
Too old to study
Did (Will) not learn
No transportation
Too tired to continue
No child care
Too far
Applied, did not qualify
Don’t qualify, did not apply
Other:
9 1 YES
Too old to study
Did (Will) not learn
No transportation
Too tired to continue
No child care
Too far
Applied, did not qualify
Don’t qualify, did not apply
Other:
[ASK ]:
9 1 YES: What kind of training or classes?:
a.
ET9.
Have you heard of training programs for farm workers?:
90
91
NO
YES
b.
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)?:
What kind of training have you heard of?:
90
91
ET11.
And...why would you choose that (in a)?:
[SKIP TO ET12]
[ASK ET10 and ET11]
13.
ET10.
Which training class would you consider attending?
Why did you not attend that training? [Mark all responses]:
9 a.
9 b.
9 c.
9 df.
9 eg.
9 fh.
9 gI.
9 hj.
9 x.
Too old to study
Did (Will) not learn
No transportation
Too tired to continue
No child care
Too far
Applied, did not qualify
Don’t qualify, did not apply
Other:
31
NO
YES. What kind of work?:
PLEASE CHECK
IF RESPONDENT QUALIFIES FOR
THE INJURY SUPPLEMENT!
(CHECK PAGE 18 - SCREENING SECTION)
IF RESPONDENT QUALIFIES,
CONTINUE WITH NEXT SECTION
AND THEN
COMPLETE INJURY SUPPLEMENT
32
[[REV. Mar 17, 2017]
S:\4. Questionnaire\2017\OMB SENT TO DANIEL 2017\MAR 17 2017 OMB ENG TRACKCHANGES and highlighted changes.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 PROGRAMS [DO NOT READ OPTIONS]
NECESSARY]:
AMNESTY UNDER 5 YEAR PROGRAM
91
[“TIME”]
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
95
96
97
98
92
AMNESTY UNDER SAW (90 DAY)
PROGRAM [“FW” - “FIELD WORK”]
93
CUBAN/HAITIAN ENTRANT
94
SPOUSAL PETITION
PROGRAM/FAMILY UNITY
PERMANENT RESIDENT/GREEN CARD (RIGHT TO RESIDE AND
WORK IN THE U.S.) (ASK L2: “UNDER WHICH PROGRAM DID
95
YOU APPLY?”) [POSSIBLE ANSWERS: 1 HASTA 9 Y 97). THEN
ASK: L4-1 AND L4-2]
96
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, L4-1 AND L4-2]
POLITICAL ASYLUM
98
REFUGEE
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)?
/
GUEST WORKER PROGRAM
[“BRACERO”]
STUDENT
9 12
TOURIST
•
•
•
BORDER CROSSING CARD/
“PASSPORT”
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:
9 99
NOT ANSWERED
9 9 NOT ANSWERED
DATE STATUS BECAME EFFECTIVE:
2 [Only for those who responded "2,3, or 3 [Only for those who responded
4" in L1]: When did you obtain your
"2" in L1]: When did you obtain
legal status?
your naturalization/ become a
U.S. citizen?
/
(Month)
PROTECTIVE STATUS (TEMPORARY)
9 11
9 13
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
9 14
L41]
OTHER [IF RELEVANT AND APPROPRIATE ASK L2, L3, L4-1,
L4-2, AND L4-3. THEN SKIP TO NEXT PAGE]:
REGISTRY PROGRAM
97
99
PENDING STATUS (WITHOUT DOCUMENTS, APPLIED,
AWAITING OFFICIAL DECISION) (ASK L2: “UNDER WHICH
9 10
PROGRAM DID YOU APPLY?”) [POSSIBLE ANSWERS: 1- 9, 97.
THEN ASK: L3, AND L41]
UNDOCUMENTED (APPLICATION DENIED/DID NOT APPLY TO
ANY PROGRAMS) [POSSIBLE ANSWERS: “NONE”. SKIP TO
NEXT PAGE]
LABOR CERTIFICATION PROGRAM
/
(Year)
(Month)
/
/
(Year)
(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 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 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
and Evaluation, ETA, Department of Labor, Room N5641, 200 Constitution Avenue, N.W.,
Washington, D.C. 20210.
35
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 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 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
36
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.
37
| File Type | application/pdf |
| File Title | S:\4. Questionnaire\2017\OMB SENT TO DANIEL 2017\MAR 17 2017 OMB ENG TRACKCHANGES and highlighted changes.wpd |
| Author | jnakamoto |
| File Modified | 2017-03-17 |
| File Created | 2017-03-17 |