Download:
pdf |
pdfAppendix C
OMB #:
Expiration Date:
Cluster/Project/Case:______/_____
Household Questionnaire
Quality Control for Rental Assistance Subsidies
HUD Contract #: GS-23F-9777H
Task Order #: C-CHI-00829, CHI-T0001
ORC Macro
11785 Beltsville Drive
Calverton, MD 20705-3119
July 14, 2006
Data Collector will select the case from the list of sample cases.
A. BACKGROUND
System will enter:
Cluster/Project/Case: __ __/__ __ __/__ __
Quality Control Month [QCM]: ___ ___/___ ___
MONTH YEAR
Date of Interview: __ __/___ ___/___ ___
MONTH DAY YEAR
Time Interview Began: ___ ___:___ ___ AM PM
Respondent: ________________________________
Introductory statement to respondent:
All of the questions I will be asking you are about your situation in [QCM]. It may be that
things have changed since then, but I am interested in knowing only about your situation in
[QCM].
First, I’d like to ask you some questions about each of the people who lived in your
household during [QCM].
General Instructions to Data Collector
The following standards should be used if the respondent does not know the response to a
question:
Questions Requiring a Yes/No Response.
Enter “Z”
Birth dates.
Enter 99/99/9999
Income Dollar Amounts.
Enter 9's until the entire field is completed
Note to Reader:
This document has been designed to portray the automated questionnaire used to interview the tenant
during the household interview. It is not designed to be used as a paper data collection instrument. All
household interviews for the HUDQC studies are conducted using laptop computers.
ORC Macro HUDQC Household Questionnaire
2
July 14, 2006
B. HOUSEHOLD COMPOSITION
1.
Let’s start with the head of the household. Who is the head of this household?
SKIP TO Q. 5.
2.
What is his/her name?
3.
CODE HOUSEHOLD MEMBER IN 50058/59.
Household Member Status:
L = Listed on Form 50058/59
N = New Member
Z = Not in household anymore
4.
What is your/his/her relationship to [head of household]?
*
PROBE UNTIL YOU RECEIVE ENOUGH INFORMATION TO SELECT THE
CORRECT RELATIONSHIP CODE. REMEMBER TO ASK IF ADULTS (OTHER
THAN SPOUSE OR CO-HEAD) ARE FULL-TIME STUDENTS.
Relationship Codes: S = Spouse
E = Full-time Student 18+
K = Co-head
L = Live-in Aide
Y = Other Youth Under 18
A = Other Adult
F = Foster Child/Adult
IF RELATIONSHIP CODE = L, SKIP TO Q. 14.
IF RELATIONSHIP = S, Y, OR F SKIP TO Q. 6.
5.
Were you/Was [hh member] attending school in [QCM]?
Student Codes:
FT = Full Time
PT = Part Time
0 = No
Z = Don’t Know
IF NO, SKIP TO Q. 6.
5a.
IF STUDENT STATUS IS NOT ALREADY VERIFIED WITH ACCEPTABLE
VERIFICATION, ASK: May I see a document that supports your/[hh member’s]
school attendance in [QCM]?
RECORD THE TYPE AND DATE OF VERIFICATION.
Verification Codes for F-T Student:
2 School Enrollment Documents
4 Other
0 None
1 Letter from the Registrar’s Office or School Official
3 Verbal Information form the Registrar’s Office or School Official
5b. IF RESPONDENT IS NOT ABLE TO VERIFY SCHOOL ATTENDANCE, SAY:
We need to verify school attendance for [hh member]. Can you tell me the address,
contact person and phone number of the school?
6.
What is his/her/your date of birth?
6a.
IF DATE OF BIRTH IS NOT ALREADY VERIFIED WITH ACCEPTABLE
VERIFICATION, ASK: May I see a document that supports your/[hh member’s] date
of birth?
RECORD THE TYPE AND DATE OF VERIFICATION.
ORC Macro HUDQC Household Questionnaire
3
July 14, 2006
Verification Codes for Date of Birth:
0 None
3 (age 62 or older) Letter from SSI or SSA
4 Baptismal Certificate
7 (under age of 18) Adoption Paper/Custody Agreement
1 Birth Certificate
5 Census Record
8 INS Card
2 Driver’s License
6 Military ID
9 Other
IF RELATIONSHIP CODE = F, SKIP TO Q. 14.
7.
Are you/Is [hh member] a United States citizen?
IF NO, SKIP TO Q. 8.
IF DON’T KNOW, SKIP TO Q. 10.
IF YES, ENTER “EC” AND ASK:
Citizenship Codes: EC = U.S. Citizen
7a.
EN = Legal Alien
IN = Illegal Alien
xx = Not applicable
Z = Don’t Know
IF CITIZENSHIP IS NOT ALREADY VERIFIED WITH ACCEPTABLE
VERIFICATION, ASK: May I see a document that supports your/[hh member’s]
citizenship status?
RECORD THE TYPE AND DATE OF VERIFICATION.
Verification Codes for Citizenship: 0 None
1 Birth Certificate
3 US Passport
4 Official Citizenship Papers
6 INS Card
7 INS System Verification (SAVE)
9 Other
2 Voter’s Registration
5 Resident Card
8 Baptismal Certificate
SKIP TO QUESTION Q. 10.
8.
Do you/Does [hh member] have legal immigration status?
IF NO, ENTER “IN” AND SKIP TO Q. 10.
IF YES, ENTER “EN” AND ASK:
8a.
What is your/[hh member’s] Alien Registration number?
8b. IF IMMIGRATION STATUS IS NOT ALREADY VERIFIED WITH
ACCEPTABLE VERIFICATION, ASK: May I see a document that supports
your/[hh member’s] citizenship status?
RECORD THE TYPE AND DATE OF VERIFICATION.
9.
Question deleted.
10.
What is your/[hh member’s] Social Security number?
10a. IF SOCIAL SECURITY NUMBER IS NOT ALREADY VERIFIED WITH
ACCEPTABLE VERIFICATION, ASK: May I see a document that supports
your/[hh member’s] social security number?
RECORD THE TYPE AND DATE OF VERIFICATION.
Verification Codes for SSN: 0 None
3 Letter from INS stating SSN has been assigned
5 Verbal Information from SSA
ORC Macro HUDQC Household Questionnaire
1 SS card
2 Letter/Benefit Statement from SSA
4 Certification that no SSN Assigned
6 Verbal Information from INS
7 Other
4
July 14, 2006
11.
Were you/Was [hh member] a person with disabilities in QCM?
11a. IF DISABILITY STATUS IS NOT ALREADY VERIFIED WITH ACCEPTABLE
VERIFICATION, ASK: May I see a document that verifies you/[hh member] was a
person with disabilities in [QCM]?
RECORD THE TYPE AND DATE OF VERIFICATION.
Verification Codes for Disability Status:
2 Other Proof of SSI/SSA disability
4 Letter from VA Stating 100% Disability
0 None
1 Letter from SSI or SSA
3 Letter from Professional Verifying Disability
5 Other
11b. IF RESPONDENT IS NOT ABLE TO VERIFY DISABILITY, SAY: We need to
verify disability status for [you/hh member]. Can you tell me the address, contact
person and phone number of the person who can verify [your/hh member’s]
disability?
12.
During [QCM], were you/was [hh member] temporarily or permanently living away from
home?
IF NO, SKIP TO Q. 14.
13. Why were you/was [hh member] living away from home?
Reasons for Temporarily Living Away from Home:
3 = Employment
4 = in Foster Care
14.
1 = Attending School
6 = Other
2 = Military
8 = Don’t Know
Was anyone else living here in [QCM]?
IF YES, GO BACK TO Q. 2.
IF NO, SKIP TO SECTION C.
REVIEW LIST WITH RESPONDENT.
IF DIFFERENT THAN FILE DATA, RESOLVE DISCREPANCIES.
ORC Macro HUDQC Household Questionnaire
5
July 14, 2006
B-ADD ON. STUDENTS
ASK THESE QUESTIONS FOR ALL HOUSEHOLD MEMBERS WHERE THE
RESPONSE TO Q. B 5 IS YES, AND THE STUDENT IS UNDER 24 YEARS OLD
These next questions ask about the members of your household who are students.
1. What type of institution did you/the student attend in {QCM}?
Student Status:
1 = High School
4 = Other Institution of Higher Education
2 = College or University
3 = Vocational School
5 = Other, but not an Institution of Higher Education
Z = Don’t Know
IF CODE 1 OR 5, SKIP TO SECTION C.
2. Did your/the student’s parent or guardian live in the unit with you/the student?
IF YES, SKIP TO SECTION C.
3. During [QCM], were you/was the student married?
IF YES, SKIP TO SECTION C.
4. Did you/the student have a dependent child living in the unit with you?
IF YES, SKIP TO SECTION C.
5. Were you/was the student a Veteran?
IF YES, SKIP TO SECTION C.
6. When did you/the student begin living away from your/his/her parent or guardian?
IF MORE THAN A YEAR PRIOR TO THE QCM, SKIP TO SECTION C.
7. Were you/was the student claimed as a dependent on your/his/her parent or guardian’s
income taxes during [QCM]?
8. Were your/the student’s parent(s) or guardian providing financial help in [QCM]?
IF YES, RECORD DETAIL IN GIFTS AND CONTRIBUTIONS SECTION
9. We need to collect information about your/the student’s parent or guardian’s income. To the
extent you can, please answer the following questions.
10. Information Regarding the Student’s Father or Legal Guardian
10a. What is your/the student’s father’s (or guardian’s) full name?
ALLOW AN OPTION FOR THE USER TO INDICATE THE RESPONDENT
DOESN’T KNOW THE STUDENT’S FATHER OR LEGAL GUARDIAN, AND
ORC Macro HUDQC Household Questionnaire
6
July 14, 2006
ANOTHER OPTION TO INDICATE THE RESPONDENT HAS NO INFORMATION
REGARDING THE STUDENT’S FATHER OR LEGAL GUARDIAN. IF EITHER
OPTION IS SELECTED SKIP TO Q. 11.
10b. Did your/the student’s father/guardian have income from employment during [QCM]?
IF NO, SKIP TO Q. 10e.
10c. Who was his employer? RECORD EMPLOYER NAME AND AS MUCH
ADDRESS INFORMATION AS AVAILABLE
10d. Approximately how much did student’s father/guardian earn in a month? ALLOW
ROOM FOR COMMENTS AS WELL AS A DOLLAR FIGURE
10e. Did your/the student’s father/guardian have income from sources other than
employment?
IF NO, SKIP TO Q. 11.
10f. What source of income did your/the student’s father/guardian have? RECORD
SOURCE AND AS MUCH DESCRIPTION AND ADDRESS INFORMATION AS
AVAILABLE
10g. Approximately how much did student’s father/guardian received from that source of
income in a month? ALLOW ROOM FOR COMMENTS AS WELL AS A
DOLLAR FIGURE
10h. Did your/the student’s father/guardian have income from any other source?
IF NO, SKIP TO Q. 11.
10i. What other source of income did your/the student’s father/guardian have? RECORD
SOURCE AND AS MUCH DESCRIPTION AND ADDRESS INFORMATION AS
AVAILABLE
10j. Approximately how much did student’s father/guardian receive from that source of
income in a month? ALLOW ROOM FOR COMMENTS AS WELL AS A
DOLLAR FIGURE
REPEAT QUESTIONS 10h THROUGH 10j UNTIL THE RESPONSE TO 10h IS NO.
11. Information regarding the student’s mother or legal guardian.
11a. What is your/the student’s mother’s (or guardian’s) full name?
ALLOW AN OPTION FOR THE USER TO INDICATE THE RESPONDENT
DOESN’T KNOW, AND ANOTHER OPTION TO INDICATE THE RESPONDENT
HAS NO INFORMATION REGARDING THE STUDENT’S MOTHER OR LEGAL
GUARDIAN. IF EITHER OPTION IS SELECTED SKIP TO Q. 12.
ORC Macro HUDQC Household Questionnaire
7
July 14, 2006
11b. Did your/the student’s mother/guardian have income from employment?
IF NO, SKIP TO Q. 11e.
11c.Who was her employer? RECORD EMPLOYER NAME AND AS MUCH
ADDRESS INFORMATION AS AVAILABLE
11d. Approximately how much did student’s mother/guardian earn in a month? ALLOW
ROOM FOR COMMENTS AS WELL AS A DOLLAR FIGURE
11e. Did your/the student’s mother/guardian have income from sources other than
employment?
IF NO, SKIP TO Q. 12.
11f. What source of income did your/the student’s mother/guardian have? RECORD
SOURCE AND AS MUCH DESCRIPTION AND ADDRESS INFORMATION AS
AVAILABLE
11g. Approximately how much did student’s mother/guardian received from that source of
income in a month? ALLOW ROOM FOR COMMENTS AS WELL AS A
DOLLAR FIGURE
11h. Did your/the student’s mother/guardian have income from any other source?
IF NO, SKIP TO Q. 12.
11i. What other source of income did your/the student’s mother/guardian have? RECORD
SOURCE AND AS MUCH DESCRIPTION AND ADDRESS INFORMATION AS
AVAILABLE
11j. Approximately how much did student’s mother/guardian receive from that source of
income in a month? ALLOW ROOM FOR COMMENTS AS WELL AS A
DOLLAR FIGURE
REPEAT QUESTIONS 11h THROUGH 11j UNTIL THE RESPONSE TO 11h IS NO.
12. REPEAT Q. 1 THROUGH 9 FOR EACH HOUSEHOLD MEMBER WHERE THE
RESPONSE TO Q. B 5 IS YES, AND THE STUDENT IS UNDER 24 YEARS OLD.
ORC Macro HUDQC Household Questionnaire
8
July 14, 2006
C. EMPLOYMENT
These next questions are about income from employment. I am not asking about self
employment such as baby-sitting, driving a cab, or other work you do at home.
1.
During [QCM], were you/[hh member] doing any work for pay?
IF YES, ENTER HH MEM. #.
IF NO, SKIP TO Q. 30.
2.
Please give me the name of the company and the kind of work you/[hh member ] did. WE
WANT TO KNOW IF THE TENANT WORKED REGULARLY, SPORADICALLY, OR
SEASONALLY.
3.
When did you /[hh member] start that job?
3a.
Were you paid on a regular basis, such as hourly, weekly, monthly, etc?
IF NO, SKIP TO Q. 8A.
4.
I’d like to know how much you /[hh member] were making on that job in [QCM]. I’m
asking about earnings and not other money you /[hh member] may get to help pay for
things like transportation or uniforms. How much were you /[hh member] making on that
job . . .
From regular wages or salary? Do not include tips, commissions, or bonuses in that
amount.
5.
How often were you /[hh member] paid that?
Frequency Codes:
IF HOURLY:
01 = Annually
24 = Twice a month
91 = Pieces
04 = Quarterly
26 = Every Two Weeks
92 = Daily:
06 = Every Two Months
52 = Weekly
12 = Monthly
90 = Hourly
6. About how many hours did you/[hh member] expect to work
each week?
8. About how many weeks did you/[hh member] expect to work
during the year?
IF DAILY:
7. About how many days did you/[hh member] expect to work
each week?
8. About how many weeks did you/[hh member] expect to work
during the year?
ORC Macro HUDQC Household Questionnaire
9
July 14, 2006
IF PIECEWORK: 6.
8.
How many pieces per week did you/[hh member] expect to
be paid for?
About how many weeks did you/[hh member] expect to
work during the year?
SKIP TO Q. 9.
8a.
I need to figure out how much you made during [QCM through QCM plus 11 months].
Can you tell me what you expected to be paid during that period?
9.
IF EMPLOYMENT IS NOT ALREADY VERIFIED WITH THIRD PARTY IN
WRITING VERIFICATION ASK: We need to verify the income information you just told
me about.
Can you tell me the address, contact person and phone number for the employer?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER VERIFICATION
INFORMATION.
10. Did you/[hh member] expect the rate of pay to change during the year?
IF NO, SKIP TO Q. 13.
13.
11.
When did you/[hh member] expect the income to change?
12.
What did you/[hh member] expect your new rate of pay to be?
Did you/[hh member] expect to receive any overtime pay?
IF NO, SKIP TO Q. 21.
14. What was your/[hh member’s] hourly overtime rate of pay?
15. About how many hours of overtime did you/[hh member] expect to work each week?
16. About how many weeks during the year did you/[hh member] expect to make that
much?
17. Did you expect your/[hh member’s] rate of overtime pay to change during the year?
IF NO, SKIP TO Q. 21.
18. When did you/[hh member] expect that change to take place?
19.
What did you/[hh member] expect your new rate of overtime pay to be?
20.
About how many weeks during the year did you/[hh member] expect to make
that much?
ORC Macro HUDQC Household Questionnaire
10
July 14, 2006
21.
Did you/[hh member] expect to receive tips?
IF NO, SKIP TO Q. 24.
22. About how much did you/[hh member] expect to make in tips each week?
23. About how many weeks during the year did you/[hh member] expect to make that
much?
24.
Did you/[hh member] expect to receive bonuses?
IF NO, SKIP TO Q. 27.
25. About how often did you/[hh member] expect to receive a bonus?
26. About how much did you/[hh member] expect to receive each time you got a bonus?
27.
Did you/[hh member] expect to receive commissions?
IF NO, SKIP TO Q. 30.
28. About how much did you/[hh member] expect to receive in commissions each
month?
29. About how many months during the year did you/[hh member] expect to make that
much?
30.
Were you/[was hh member] doing any work for which you received any goods or benefits,
such as food or clothing?
IF NO AND RESPONSE TO Q. 1 WAS YES, SKIP TO Q. 37.
IF NO AND RESPONSE TO Q. 1 WAS NO, REPEAT QUESTIONS STARTING
WITH Q. 1 ASKING ABOUT INCOME FROM EXPECTED JOBS THAT HE/SHE
DID NOT HAVE IN QCM.
IF YES AND RESPONSE TO Q. 1 WAS YES, SKIP TO Q. 32.
31. Please give me the name, telephone number, and address of the company you were
working for.
32. What was the value of the things you [hh member] received?
33. When did you/[hh member] start receiving them?
34. How often did you/[hh member] receive them?
PROBE: Once a week? Every month? Every 3 months?
IF FREQUENCY IS ANNUAL, SKIP TO Q. 37.
ORC Macro HUDQC Household Questionnaire
11
July 14, 2006
35. Did you/[hh member] expect to continue to receive them during the full year?
IF NO: 36. When did you expect it to change?
37.
Were you/[hh member] working at any other jobs in [QCM] or have any other kind of
employment income—for example, piece-work or jobs you/[hh member] were/was paid for
on a day or half-day basis, like cleaning or child care?
IF YES, REPEAT Q. 2 THROUGH 37.
FUTURE—REPEAT QUESTIONS STARTING WITH QUESTION 1 ABOUT INCOME
FROM EXPECTED JOBS THAT HE/SHE DID NOT HAVE DURING QCM.
IF NO, AND OTHER ADULT HOUSEHOLD MEMBERS, GO TO Q. 1.
ORC Macro HUDQC Household Questionnaire
12
July 14, 2006
D. TRAINING AND SELF-SUFFICIENCY PROGRAMS
These next questions help us determine whether you are entitled to a disregard from your earned
income because of special circumstances.
1.
IF PROJECT TYPE = OWNER ADMINISTERED, OR VOUCHER AND MEMBER
IS NOT DISABLED, SKIP TO Q. 23.
IF RESPONSE TO Q. C-3 (JOB START DATE) IS PRIOR TO THE DATE OF
ADMISSION TO THE PROGRAM (ITEM 2H ON THE 50058 FORM), SKIP TO
Q. 4.
IF RESPONSE TO Q. C-3 (JOB START DATE) IS MORE THAN 24 MONTHS
PRIOR TO QCM SKIP TO Q. 4.
Before you [hh member] started working, were you [hh member] unemployed for at least
12 months?
IF NO, SKIP TO Q. 4.
2.
What was your source of income prior to starting employment? Include income from
all sources such as TANF, pensions, Social Security, etc.
3.
What was the monthly amount of your [hh member’s] income prior to starting
employment?
SKIP TO Q. 23.
4.
Did you participate in a self-sufficiency or other job training program in the two years prior
to [QCM]?
IF NO, SKIP TO Q. 13.
5.
When did you [hh member] begin participating in that program?
6.
When did you [hh member] stop participating in that program?
IF JOB START DATE IS AFTER THE MEMBER STOPPED PARTICIPATING IN
THAT PROGRAM, SKIP TO Q. 13.
IF JOB START DATE FALLS BETWEEN THE DATE THE MEMBER BEGAN
PARTICIPATING AND STOPPED PARTICIPATING IN THAT PROGRAM, SKIP
TO Q. 11.
7.
Did you [hh member] receive an increase in pay while you [hh member] were
participating in the program?
IF NO, SKIP TO Q. 13.
ORC Macro HUDQC Household Questionnaire
13
July 14, 2006
8.
When did you [hh member] receive the first increase in pay while you were [hh
member was] participating in the program?
9.
What was your [hh member’s] monthly income prior to receiving that increase in
pay?
SKIP TO Q. 13.
10. Question Deleted
11. What was your source of income before starting employment? Include income from
all sources such as TANF, pensions, Social Security, etc.
12. What was your [hh member’s] monthly income prior to starting your [hh member’s]
job?
13.
Have you [hh member] ever received assistance, benefits or services through TANF?
IF NO, SKIP TO Q. 23.
14. When did you [hh member] begin receiving assistance, benefits, or services through
TANF?
15. When did you [hh member] stop receiving assistance, benefits, or services through
TANF?
IF MORE THEN 30 MONTHS PRIOR TO QCM, SKIP TO Q. 23.
IF JOB START DATE (RESPONSE TO Q. C-3) IS AFTER 6 MONTHS FROM
WHEN THE MEMBER STOPPED RECEIVING ASSISTANCE, SKIP TO Q. 23.
16. Can you tell me the name of the TANF agency, the address, the name of a person to
contact, and their telephone number?
IF JOB START DATE FALLS BETWEEN THE DATE THE MEMBER BEGAN
RECEIVING ASSISTANCE AND SIX MONTHS AFTER THE MEMBER
STOPPED RECEIVING ASSISTANCE, SKIP TO Q. 21.
17. Did you [hh member] receive an increase in pay while you [hh member] were
receiving assistance through TANF or within 6 months after you [hh member] last
received assistance through TANF?
IF NO, SKIP TO Q. 23.
18. When did you [hh member] receive the first increase in pay while you were [hh
member was] receiving assistance through TANF or within 6 months after you
[hh member] last received assistance from TANF?
ORC Macro HUDQC Household Questionnaire
14
July 14, 2006
19.
What was your source of income prior to receiving that increase in pay?
PROBE: Income from all sources?
20.
What was the monthly amount of your [hh member’s] income prior to receiving
that increase in pay?
SKIP TO Q. 23.
21. What was your source of income prior to starting employment?
PROBE: Income from all sources?
22. What was the monthly amount of your [hh member’s] income prior to starting that
job?
ORC Macro HUDQC Household Questionnaire
15
July 14, 2006
ASK ALL EMPLOYED HOUSEHOLD MEMBERS IN ALL PROGRAMS
These next questions are about training programs you or other household members have
participated in.
23.
During [QCM], were you/[was hh member] enrolled in or expect to be enrolled in a
training program?
IF YES, ENTER HH MEM. #.
IF NO, SKIP TO SECTION E.
24. When did you [hh member] expect to complete the program?
25. What is the name of the training program?
26. Do you know who ran that program?
IF YES, WHO?
27. Do you know who funded that program?
IF YES, SELECT: STATE, CITY, FEDERAL, HUD, OTHER, DON’T KNOW
28. We need to verify the training program you just told me about. Can you tell me the
address, contact person and phone number for that training program?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER
VERIFICATION INFORMATION.
29. When did you/[hh member] enroll in this training?
30. What was the source of your/[hh member’s] income prior to entering the training
program?
31. What was the monthly amount of that income?
PROBE FOR EMPLOYMENT INCOME, OR TANF.
32. Did you/[hh member] have a second source of income prior to entering the training
program?
IF YES, RECORD SOURCE OF INCOME.
ENTER NAME, ADDRESS, TELEPHONE FOR SOURCE OF INCOME.
33. What was the monthly amount of that income?
ORC Macro HUDQC Household Questionnaire
16
July 14, 2006
E.
MILITARY PAY
1.
During [QCM], were you/[hh member] serving in the military—the Army, Navy, Marines,
Air Force, or Coast Guard?
IF YES, ENTER HH MEM. # AND SKIP TO Q. 9.
2.
Were you/[hh member] in the reserves or National Guard during [QCM]?
IF NO: IF OTHER ADULT HH MEMBERS, GO TO Q. 1.
IF NO OTHER ADULT HH MEMBERS, SKIP TO SECTION F.
3.
When did you start serving?
4.
How much pay did you/[hh member] expect to receive during the year from your service
in the reserves or Guard:
For weekend drills?
5.
How many times per year did you/[hh member] expect to receive that amount?
6.
For 2-week summer camp?
7.
For any other reserve or guard activity?
8.
How many times per year did you/[hh member] expect to receive that amount?
SKIP TO Q. 12.
9.
When did you start serving?
10.
How much regular pay, not including any allowance or special pay, were you/[hh member]
receiving?
11.
How often did you/[hh member] get that amount?
Frequency Codes:
12.
01 = Annually
12 = Monthly
24 = Twice a Month
26 = Every Two Weeks
52 = Weekly
During [QCM], were you/[hh member] receiving:
A monthly housing allowance?
IF YES: 13. How much was your/[hh member’s] monthly housing allowance?
14. A monthly food allowance?
IF YES: 15. How much was your/[hh member’s] monthly food allowance?
ORC Macro HUDQC Household Questionnaire
17
July 14, 2006
16. Were you receiving any other allowance from the military? Do not include Hostile
Fire or Imminent Danger pay (combat pay) in that amount.
NOTE: HAZARDOUS DUTY PAY IS NOT INCLUDED AS INCOME.
IF YES: 17. What was the amount of that allowance?
DO NOT INCLUDE ANY AMOUNT FOR HOSTILE FIRE OR
IMMINENT DANGER PAY (COMBAT PAY)
18. How often did you/[hh member] get that amount?
19.
Did you/[hh member] expect any of the amounts of pay or allowances to change during the
year?
IF NO, GO TO Q. 24.
20. Which pay did you/[hh member] expect would change?
Pay Codes: BP Base Pay
WD Weekend Drills
HA Housing Allowance
SC Summer Camp
FA Food Allowance
RA Reserve Activity (Other Reserves)
OA Other Allowances
21. What did you/[hh member] expect your new pay to be?
22. How often did you/[hh member] expect to be receiving that amount?
23. When was the amount expected to change?
24. We need to verify the income information you just told me about.
Can you tell me the name, address, contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER
VERIFICATION INFORMATION.
Verification Codes:
0 - None
3 – Documentation
rd
1 - 3 Party in Writing
4 - Self Declaration
rd
2 - 3 party Verbal
9 - Other
IF NO OTHER ADULT HH MEMBERS, SKIP TO SECTION F.
REPEAT Q. 1 THROUGH 24 FOR EACH ADULT HH MEMBER.
ORC Macro HUDQC Household Questionnaire
18
July 14, 2006
F.
UNEMPLOYMENT COMPENSATION
1.
During [QCM], were you/[hh member] receiving unemployment compensation payments?
IF, YES ENTER HH MEM. #.
IF NO AND OTHER ADULT HH MEMBERS, REPEAT Q. 1.
IF NO AND NO OTHER ADULT HH MEMBERS, SKIP TO SECTION G.
2.
How much unemployment compensation were you/[hh member] receiving?
3.
How often did you/[hh member] get that amount?
Frequency Codes:
4.
12 = Monthly
24 = Twice a Month
26 = Every Two Weeks
We need to verify the income information you just told me about.
Can you tell me the Name, Address, Contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER VERIFICATION
INFORMATION.
Verification Codes:
5.
01 = Annually
52 = Weekly
0 - None
3 - Documentation
rd
1 - 3 Party in Writing
4 - Self Declaration
rd
2 - 3 party Verbal
9 - Other
In [QCM], did you/[hh member] expect to receive that same amount of unemployment
compensation benefits for the full year?
IF YES AND OTHER ADULT HH MEMBERS, REPEAT Q. 1.
IF YES AND NO OTHER ADULT HH MEMBERS, SKIP TO SECTION G.
IF NO: 6. When was the amount expected to change?
7. How much did you/[hh member] expect to receive then?
8. How often did you/[hh member] expect to receive that amount?
IF NO OTHER ADULT HH MEMBERS, SKIP TO SECTION G.
ASK Q. 1 THROUGH 8 FOR EACH ADULT HH MEMBER.
ORC Macro HUDQC Household Questionnaire
19
July 14, 2006
G. WORKERS’ COMPENSATION
1.
During [QCM], were you/[hh member] receiving workers’ compensation payments?
IF YES, ENTER HH MEM.#.
IF NO AND OTHER ADULT HH MEMBERS, REPEAT Q. 1.
IF NO AND NO OTHER ADULT HH MEMBERS, SKIP TO SECTION H.
2.
How much workers’ compensation were you/[hh member] receiving?
3.
How often did you/[hh member] get that amount?
Frequency Codes:
4.
12 = Monthly
52 = Weekly
24 = Every Two Months
We need to verify the income information you just told me about.
Can you tell me the Name, Address, Contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER VERIFICATION
INFORMATION.
Verification Codes:
5.
01 = Annually
26 =Twice a Week
0 - None
3 - Documentation
rd
1 - 3 Party in Writing
4 - Self Declaration
rd
2 - 3 party Verbal
9 - Other
In [QCM], did you/[hh member] expect to receive the same amount of workers’
compensation benefits for the full year?
IF YES AND OTHER ADULT HH MEMBERS, REPEAT Q. 1.
IF YES AND NO OTHER ADULT HH MEMBERS, SKIP TO SECTION H.
IF NO: 6. When was the amount expected to change?
7. How much did you/[hh member] expect to receive then?
8. How often did you/[hh member] expect to receive that amount?
IF NO OTHER ADULT HH MEMBERS, SKIP TO SECTION H.
ASK Q. 1 THROUGH 8 FOR EACH ADULT HH MEMBER.
ORC Macro HUDQC Household Questionnaire
20
July 14, 2006
H. SOCIAL SECURITY AND SSI BENEFITS
1.
During [QCM], were you [or anyone living here] receiving Social Security or SSI benefits?
*
IF NO, PROBE: Social Security includes retirement, disability, and survivors’ benefits—
benefits paid to the children or spouse of a deceased family member. SSI—Supplemental
Security Income—benefits include payments to people who are elderly or disabled.
IF NO, SKIP TO SECTION I.
2.
Who was receiving the benefit (whose name was the benefit in)?
3.
What is the gross monthly amount of the benefit? The gross amount is the benefit amount
before any deductions such as Medicare are taken out.
4.
Was the benefit for Social Security retirement, or disability benefits, or survivors’ benefits,
or was it for SSI (Supplemental Security Income)?
Type Codes:
5.
SR = Social Security Retirement
SD = Disability
SS = Survivor
ST = SSI State Amount
SO = SSI Old Age
SI = SSI Disability
SN = Respondent Doesn’t Know
Does this include an amount for payments that you should have received earlier but were
postponed for some reason?
IF NO, SKIP TO Q. 7.
6.
How much is the amount for the postponed payments?
7.
Which members of the family are the benefits for?
8.
We need to verify the benefit information you just told me about.
Can you tell me the name, address, contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER VERIFICATION
INFORMATION.
Verification Codes:
9.
0 - None
3 - Documentation
rd
1 - 3 Party in Writing
4 - Self Declaration
rd
2 - 3 party Verbal
9 - Other
In [QCM], did you [hh member] expect the benefits would continue for the full year?
IF YES, SKIP TO Q. 13.
ORC Macro HUDQC Household Questionnaire
21
July 14, 2006
IF NO: 10. When was the amount expected to change?
11. How much did you expect to receive then?
12. What type of benefits did you expect to receive (Social Security retirement,
disability, or survivors’ benefits, or SSI (Supplemental Security Income)
benefits)?
13.
Did you [or anyone living in the house] receive any other Social Security or SSI benefits
during [QCM]?
IF YES, REPEAT Q. 2 THROUGH 13.
IF NO, SKIP TO SECTION I.
Before I go on, let me review these benefits you (and your family) receive from Social Security.
*
PROBE FOR DUPLICATION.
ORC Macro HUDQC Household Questionnaire
22
July 14, 2006
I.
VETERANS’ DISABILITY BENEFITS
1.
During [QCM], were you/[hh member] receiving disability benefit payments from the
Veterans’ Administration?
IF YES, ENTER HH MEM. #.
IF NO AND OTHER ADULT HH MEMBERS, REPEAT Q. 1.
IF NO AND NO OTHER ADULT HH MEMBERS, SKIP TO SECTION J.
2.
What is the percentage of your/[hh member’s] disability?
3.
What was the amount of the Veteran’s disability benefit payment?
4.
How often did you/[hh member] get that amount?
Frequency Codes:
5.
12 = Monthly
52 = Weekly
24 = Twice a Month
We need to verify the benefit information you just told me about.
Can you tell me the name, address, contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER VERIFICATION
INFORMATION.
Verification Codes:
6.
01 = Annually
26 = Every Two Weeks
0 - None
3 - Documentation
rd
1 - 3 Party in Writing
4 - Self Declaration
rd
2 - 3 party Verbal
9 - Other
In [QCM], did you/[hh member] expect to receive the same amount of Veterans’ disability
benefits payments for the full year?
IF YES AND OTHER ADULT HH MEMBERS, REPEAT Q. 1.
IF YES AND NO OTHER ADULT HH MEMBERS, SKIP TO SECTION J.
IF NO: 7. When did you/[hh member] expect it to change?
8. How much did you/[hh member] expect to receive then?
9. How often did you/[hh member] expect to receive that amount?
REPEAT Q. 1 THROUGH 9 FOR EACH ADULT HH MEMBER.
ORC Macro HUDQC Household Questionnaire
23
July 14, 2006
J.
PRIVATE OR PUBLIC RETIREMENT BENEFITS (OTHER THAN SOCIAL
SECURITY)
1.
During [QCM], did you/[hh member] receive retirement income from any private or
government retirement plan?
IF YES, ENTER HH MEM. #.
IF NO AND OTHER ADULT HH MEMBERS, REPEAT Q. 1.
IF NO AND NO OTHER ADULT HH MEMBERS, SKIP TO SECTION K.
2.
From what company or agency were you/[hh member] receiving retirement pay?
Type Codes:
PR = Private
XT = Government
MR = Military
3.
How much retirement income were you/[hh member] receiving?
4.
How often did you/[hh member] get that amount?
Frequency Codes:
5.
12 = Monthly
52 = Weekly
24 = Twice a Month
We need to verify the benefit information you just told me about.
Can you tell me the name, address, contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER VERIFICATION
INFORMATION.
Verification Codes:
6.
01 = Annually
26 = Every Two Weeks
DK = Don’t Know
0 - None
3 - Documentation
rd
1 - 3 Party in Writing
4 - Self Declaration
rd
2 - 3 party Verbal
9 - Other
Did you/[hh member] expect to continue receiving that amount for the full year?
IF YES AND OTHER ADULT HH MEMBERS, REPEAT Q. 1.
IF YES AND NO OTHER ADULT HH MEMBERS, SKIP TO SECTION K.
IF NO: 7. When was the amount expected to change?
8. How much did you/[hh member] expect to receive then?
9. How often did you/[hh member] expect to receive that amount?
10.
In [QCM], were you/[hh member] receiving retirement benefits from any other sources?
IF YES, REPEAT Q. 2 THROUGH 10 FOR EACH SOURCE.
IF NO AND OTHER ADULT HH MEMBERS, REPEAT Q. 1 THROUGH 10.
IF NO AND NO OTHER ADULT HH MEMBERS, SKIP TO SECTION K.
ORC Macro HUDQC Household Questionnaire
24
July 14, 2006
K. TEMPORARY ASSISTANCE TO NEEDY FAMILIES (TANF)
1.
During [QCM], did you [or anyone living here] receive financial assistance for children
from TANF? This used to be called AFDC – Aid to Families with Dependent Children,
and is now called TANF—Temporary Assistance to Needy Families
*
NOTE THAT DIFFERENT STATES MAY USE DIFFERENT TERMS TO IDENTIFY
THE TANF PROGRAM
*
DO NOT INCLUDE AMOUNTS FOR ASSISTANCE SUCH AS FOOD STAMPS,
MEDICAL ASSISTANCE, OR LIEAP PAYMENTS. RECORD THESE ITEMS UNDER
THE “OTHER WELFARE” SECTION
IF NO, SKIP TO Q. 22.
2.
Whose name was the benefit in?
3.
What was the amount of the assistance in [QCM]?
4.
Who was this assistance for?
5.
How often did you/[hh member] expect to receive that amount?
Frequency Codes:
6.
01 = Annually
26 = Every Two Weeks
12 = Monthly
52 = Weekly
24 = Twice a Month
Is that the regular amount that you/[hh member] should receive or was the regular amount
reduced for some reason?
IF REGULAR AMOUNT, SKIP TO Q. 8.
7.
Why was the regular amount reduced?
Reason No Longer Receiving TANF Codes:
1 = Accused of fraud
2 = Did not meet all the Family Self Sufficiency Requirements
3 = Did not meet other welfare requirements
4 = Followed All Requirements, but Time for Getting Job Ran out
5 = Unable to find a job even after complying with rules
6 = Increased Income
7 = Fewer family members receiving assistance
96 = Other
99 = Don’t Know
7a.
What was the benefit amount before the reduction?
ORC Macro HUDQC Household Questionnaire
25
July 14, 2006
8.
In [QCM], did [you/hh member] expect this assistance to continue for the full year?
IF YES, SKIP TO Q. 12.
IF NO: 9. When was the amount expected to change?
10. How much did you [hh member] expect to receive then?
11. How often did you [hh member] expect to receive that amount?
12.
In [QCM], did the assistance you just told me about include an amount for child support?
IF YES, SKIP TO Q. 20.
13.
In [QCM], did you [hh member] receive a separate amount, from the welfare agency, for
child support?
IF NO, SKIP TO Q. 20.
14. How much child support were you [hh member] receiving in [QCM]?
15. How often did you [hh member] receive that amount?
16.
In [QCM], did you [hh member] expect to receive that same amount of child support
payments for the full year?
IF YES, SKIP TO Q. 20.
IF NO: 17. When was the amount expected to change?
18. How much did you [hh member] expect to receive then?
19. How often did you [hh member] expect to receive that amount?
20.
We need to verify the benefit information you just told me about.
Can you tell me the name, address, contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER VERIFICATION
INFORMATION.
Verification Codes:
21.
0 - None
3 - Documentation
rd
1 - 3 Party in Writing
4 - Self Declaration
rd
2 - 3 party Verbal
9 - Other
Is anyone else living here receiving TANF benefits?
IF YES, REPEAT Q. 2 THROUGH 21.
IF NO, SKIP TO SECTION L.
ORC Macro HUDQC Household Questionnaire
26
July 14, 2006
22.
Even though no one is receiving TANF now, we also need to know if anyone ever received
TANF. At any time during the time you were receiving housing assistance, did you
(anyone living here) receive TANF?
IF NO, SKIP TO SECTION L.
23.
Who received TANF financial assistance?
24.
Why aren’t you/[hh member] still receiving TANF benefits?
25.
How much were your/[hh member’s] monthly TANF benefits?
26.
When did you/[hh member] stop receiving TANF benefits?
27.
Did you (anyone living here) start receiving a new source of income or receive an increase
in an existing source of income after the TANF benefits were stopped?
IF NO, SKIP TO Q. 30.
28. What was the source of that income?
29
30.
What was the monthly amount of the increase or new source of income?
Did anyone else living here receive TANF benefits while getting housing assistance?
IF YES, REPEAT Q. 22 THROUGH 30.
IF NO, SKIP TO SECTION L.
ORC Macro HUDQC Household Questionnaire
27
July 14, 2006
L.
OTHER WELFARE
1.
During [QCM], other than TANF were you [or anyone living here] receiving benefits from
the local social service office [public welfare office] or a private charitable agency (other
than TANF)
IF NO, SKIP TO SECTION M.
2.
Who was receiving this assistance?
3.
What type of benefit was it?
Type Codes:
4.
AG = Aged
EA = Emergency Assistance
PA = Out of Pocket Expenses
BL = Blind
GA = General Assistance
RA = Rental Assistance
DI = Disabled
OW = Other
TI = “Transitional” Income
11 = LIEAP
21 = Food Stamps
MA = Medical Assistance
(Not Medicare or Medicaid)
What agency provided the benefit?
Agency Codes:
1 = State-public
2 = Local-public
3 = Private Agency
6 = Other
5.
How much were you [hh member] receiving in [QCM]?
6.
How often were you [hh member] receiving that amount?
Frequency Codes:
7.
26 = Every Two Weeks
52 = Weekly
We need to verify the benefit information you just told me about.
Can you tell me the name, address, contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER VERIFICATION
INFORMATION.
Verification Codes:
8.
01 = Annually
12 = Monthly
24 = Twice a Month
8 = Don’t Know
0 - None
3 - Documentation
rd
1 - 3 Party in Writing
4 - Self Declaration
rd
2 - 3 party Verbal
9 - Other
In [QCM], did you [hh member] expect to receive that same amount of welfare
payments for the full year?
IF YES, SKIP TO Q. 12.
IF NO: 9. When did you [hh member] expect it to change?
10. How much did you [hh member] expect to receive then?
11. How often did you [hh member] expect to receive that amount?
ORC Macro HUDQC Household Questionnaire
28
July 14, 2006
12.
Is anyone else living here receiving other welfare benefits?
IF YES, REPEAT Q. 2 THROUGH 12.
IF NO, SKIP TO SECTION M.
ORC Macro HUDQC Household Questionnaire
29
July 14, 2006
M. CHILD SUPPORT
IF NO CHILDREN, SKIP TO SECTION N.
These next questions are about child support payments that you [or any household member]
received directly from an absent parent or child support agency.
1.
Do any of the children living here (other than foster children) have a father or mother who
is living somewhere else?
IF NO, SKIP TO SECTION N.
2.
During [QCM], were you [or any other household member] receiving child support from an
absent parent or child support agency? By this I mean payments that came to you [or other
household member] directly, not payments received from TANF.
IF NO, SKIP TO Q. 10.
3.
Whose name was the child support payment in?
3a.
Which child/ren was the child support for?
4.
How much were you [was hh member] getting in [QCM]?
5.
How often were you [was hh member] getting that amount?
Frequency Codes:
6.
01 = Annually
12 = Monthly
24 = Twice a Month
26 = Every Two Weeks
52 = Weekly
Did you [hh member] expect to continue receiving that amount for the full year?
IF YES, SKIP TO Q. 12.
IF NO: 7. When did you [hh member] expect the amount to change?
8. How much did you [hh member] expect to receive then?
9. How often did [hh member] you expect to receive that amount?
SKIP TO Q. 12.
10.
Do you [Does hh member] have a court order that requires the father/mother to make child
support payments?
IF YES, SKIP TO Q. 12.
11.
Have you [Has hh member] gone to court to try to get a court order?
ORC Macro HUDQC Household Questionnaire
30
July 14, 2006
12.
[Besides regular child support,] Does the child(ren)’s father/mother give you [hh member]
any extra money or things for the children on a regular basis— other than their birthdays or
holidays?
*
IF NO, PROBE: Not even helping to pay for their diapers, clothes, or buying them
things?
IF NO, SKIP TO SECTION N.
12a. Who received this extra money or things?
12b. Which child/ren was the extra money or things for?
13.
About how much would you say he/she spends on them during a typical month?
14.
We need to verify the income information you just told me about.
Can you tell me the name, address, contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER VERIFICATION
INFORMATION.
Verification Codes:
15.
0 - None
3 - Documentation
rd
1 - 3 Party in Writing
4 - Self Declaration
rd
2 - 3 party Verbal
9 - Other
Does anyone else living here receive child support benefits directly from the absent
father/mother (not through TANF)?
IF YES, REPEAT Q. 3 THROUGH 15.
IF NO, SKIP TO SECTION N.
ORC Macro HUDQC Household Questionnaire
31
July 14, 2006
N. REGULAR GIFTS AND CONTRIBUTIONS (OTHER THAN FROM AN ABSENT
PARENT)
1.
Were you [or anyone living here] receiving any (other) money or gifts on a regular basis
from people who do not live here? PROBE: Does someone who does not live here help
you with any of your bills—your utilities, or groceries, or help pay for the babysitting or
day care?
IF NO, SKIP TO SECTION O.
2.
Which household member was receiving these gifts or money?
3.
Who has been helping you [hh member] out?
4.
What kinds of things has he/she been giving you [hh member]?
PROBE FOR GROCERIES, UTILITY BILLS, CAR PAYMENTS, GROCERIES,
ETC.
5.
About how often does he/she give you [hh member][gift]? About how often does he/she
pay for [item]?
Frequency Codes:
01 = Annually
12 = Monthly
24 = Every Two Weeks
26 = Twice a Month
52 = Weekly
6.
What is the value of [gift/item]?
7.
We need to verify the income information you just told me about.
Can you tell me the Name, Address, Contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER VERIFICATION
INFORMATION
. Verification Codes:
8.
0 - None
3 - Documentation
rd
1 - 3 Party in Writing
4 - Self Declaration
rd
2 - 3 party Verbal
9 - Other
Did you [hh member] receive any other gifts or money from that source?
IF YES, GO BACK TO Q. 4
9.
Was anyone else helping you [hh member] with gifts or paying for expenses?
IF YES, GO BACK TO Q. 2.
IF NO, SKIP TO SECTION O.
ORC Macro HUDQC Household Questionnaire
32
July 14, 2006
O. ALIMONY
IF ALL ADULT HOUSEHOLD MEMBERS ARE LIVING WITH SPOUSE, SKIP
TO SECTION P.
These next questions are about alimony—payments that are made by a separated or
divorced husband or wife to help support the other spouse. Alimony is different from child
support payments that are used to support children.
1.
Are there any household members living here who receive alimony?
IF NO, SKIP TO SECTION P.
2.
Which household member?
QUESTIONS 3 THROUGH 5 WERE DELETED.
6.
How much were you [was hh member] receiving from your [his/her] former husband
[wife]?
7.
How often were you [hh member] getting that amount?
Frequency Codes:
8.
26 = Every Two Weeks
52 = Weekly
We need to verify the income information you just told me about.
Can you tell me the Name, Address, Contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER VERIFICATION
INFORMATION.
Verification Codes:
9.
01 = Annually
12 = Monthly
24 = Twice a Month
0 - None
3 - Documentation
rd
1 - 3 Party in Writing
4 - Self Declaration
rd
2 - 3 party Verbal
9 - Other
Did you [hh member] expect to continue getting that amount for the full year?
IF YES, SKIP TO Q. 13.
IF NO: 10. When did you [hh member] expect it to change?
11. How much did you [hh member] expect to receive then?
12. How often did you [hh member] expect to receive that amount?
13.
Are there other adult household members who have been married, but are not living with
their spouse in the household?
IF YES, GO BACK TO Q. 2.
IF NO, SKIP TO SECTION P.
ORC Macro HUDQC Household Questionnaire
33
July 14, 2006
P.
SELF EMPLOYMENT
1.
Other than the salaries you already told me about, in [QCM], did you [or anyone in your
family] get income by working for yourself, or from owning a business? For example
babysitting, catering, or driving a cab? DO NOT COUNT INCOME ALREADY
RECORDED.
IF NO, SKIP TO SECTION Q.
2.
What kind of work was it?
3.
Which member of your household received that income?
4.
What was your [hh members] gross income in [QCM]?
IF “NOTHING,” ENTER “0"; THEN SKIP TO Q. 10.
5.
How many times a year did you [hh member] get that amount?
5a.
CONFIRM THE ANNUAL INCOME REPORTED BY THE RESPONDENT.
This means you [hh member] expected to make ____________ during the 12 month period
following [QCM]. Is that correct?
6.
Did you [hh member] expect to continue getting that amount for the full year?
IF YES, SKIP TO Q. 15.
IF NO: 7. When did you [hh member] expect the amount to change?
8. How much gross income did you [hh member] expect to receive then?
9. How many times per year did you [hh member] expect to receive that
amount?
SKIP TO Q. 15.
10.
In [QCM], were you [hh member] expecting to get some income by working for yourself or
owning your own business later on during the year?
IF NO, SKIP TO SECTION Q.
IF YES: 11. Which member of your household expected to receive that income?
12. When did you/he/she expect to begin receiving that amount?
13. How much did you [hh member] expect to receive then?
14. How often did you [hh member] expect to receive that amount?
ORC Macro HUDQC Household Questionnaire
34
July 14, 2006
Business Expenses
15a. These next few questions are about expenses related to (type of self employment).
Did you/[hh member] expect to have any expenses related to (type of employment).
For example, diapers, food supplies, beauty supplies, insurance, tolls, gas, or other
expenses?
IF YES: b.
How much did you [hh member] expect all the expenses associated with
(type of self employment) to amount to for the full year?
PROBE FOR ALL TYPES OF RELATED EXPENSES AND RECORD THE TOTAL.
16a. Did you [hh member] have any expenses associated with the space you use for this
business?
IF YES: b.
How much did you [hh member] expect that expense to amount to for the
full year?
17a. Did you [hh member] have any interest payments on loans for (type of employment).?
IF YES: b.
How much did you [hh member] expect those payments to amount to for
the full year?
18a. Did you [hh member] have any depreciation? expenses?
IF YES: b.
How much did you [hh member] expect that expense to amount to for the
full year?
19a. Did you [hh member] have any other expenses?
IF NO, GO TO Q. 21.
IF YES: b. How much did you [hh member] expect that expense to amount to for the
full year?
20.
Deleted
21.
Were you or any other family members receiving or expecting to receive other income
from working for yourself or owning your own business?
IF YES, GO BACK TO Q. 2.
ORC Macro HUDQC Household Questionnaire
35
July 14, 2006
Q. INCOME FROM RENTAL PROPERTY
1.
Do you [or anyone living here] own property that you rent out to others?
IF NO, SKIP TO SECTION R.
2.
What is the address of this property?
Rental Property Income
3.
During [QCM], were you [was anyone living here] getting rental income from the
property?
IF NO, SKIP TO Q. 12.
4.
Which family member was getting this income?
5.
In [QCM] who was renting the property and paying the rent?
RECORD NAME, ADDRESS, AND PHONE.
6.
How much rental income were you [hh member] getting? Please tell me the full amount of
rent, without deducting any of the expenses.
7.
How often were you [hh member] getting that amount?
Frequency Codes:
8.
01 = Annually
12 = Monthly
24 =Twice a Month
26 = Every Two Weeks
52 = Weekly
Did you [hh member] expect to continue getting that amount for the full year?
IF YES, SKIP TO Q. 17.
IF NO: 9. When did you [hh member] expect it to change?
10. How much did you [hh member] expect to receive then?
11. How often did you [hh member] expect to receive that amount?
SKIP TO Q. 17.
12.
In [QCM], were you [hh member] expecting to get rental income from this property during
the year?
IF NO, SKIP TO SECTION R.
ORC Macro HUDQC Household Questionnaire
36
July 14, 2006
IF YES: 13. Which member of your household expected to receive that income?
14. When did you [hh member] expect that income to begin?
15. How much did you [hh member] expect to receive then?
16. How often did you [hh member] expect to receive that amount?
Rental Property Expenses
17.
Now I’d like you to think about typical rental expenses on this property. I’m going to read
a list of expenses and I’d like you to tell me the amount of each expense that you were [hh
member was] responsible for paying and how often you had that expense. Also, tell me
whether you expected these expenses to change, and if so what changes you [hh member]
expected during the year.
a.
Were you [hh member] responsible to pay for maintenance?
IF NO, ENTER 0, AND SKIP TO Q. 18.
IF YES: b. What were your [hh member’s] average monthly costs for
maintenance?
c. In [QCM] were you [hh member] expecting that amount to change
significantly?
IF NO, ENTER 0, AND SKIP TO Q. 18.
IF YES: d. What did you [hh member] expect the new average
monthly amount to be?
e. When did you [hh member] expect it to change?
18.
a.
Were you responsible to pay for electricity?
IF NO, ENTER 0, AND SKIP TO Q. 19.
IF YES: b. What were your [hh member’s] average monthly costs for electricity?
c. In [QCM] were you [hh member] expecting that amount to change
significantly?
IF NO, ENTER 0, AND SKIP TO Q. 19.
IF YES: d. What did you [hh member] expect the new average
monthly amount to be?
e. When did you [hh member] expect it to change?
19.
a.
Were you [hh member] responsible to pay for heating, such as gas or oil?
IF NO, ENTER 0, AND SKIP TO Q. 20.
ORC Macro HUDQC Household Questionnaire
37
July 14, 2006
IF YES: b. What were your [hh member’s] average monthly costs for heating?
c. In [QCM] were you [hh member] expecting that amount to change
significantly?
IF NO, ENTER 0, AND SKIP TO Q. 20.
IF YES: d. What did you [hh member] expect the new average
monthly amount to be?
e. When did you [hh member] expect it to change?
20.
a.
Were you [hh member] responsible to pay for water?
IF NO, ENTER 0, AND SKIP TO Q. 21.
IF YES: b. What were your [hh member’s] average monthly costs for water?
c. In [QCM] were you [hh member] expecting that amount to change
significantly?
IF NO, ENTER 0, AND SKIP TO Q. 21.
IF YES: d. What did you [hh member] expect the new average
monthly amount to be?
e. When did you [hh member] expect it to change?
21.
a.
Were you [hh member] responsible to pay for other utilities?
IF NO, ENTER 0, AND SKIP TO Q. 22.
IF YES: b. What were your [hh member’s] average monthly costs for other
utilities?
c. In [QCM] were you [hh member] expecting that amount to change
significantly?
IF NO, ENTER 0, AND SKIP TO Q. 22.
IF YES: d. What did you expect the new average monthly amount
to be?
e. When did you [hh member] expect it to change?
22.
a.
Were you [hh member] responsible for paying for insurance?
IF NO, ENTER 0, AND SKIP TO Q. 23.
IF YES: b. What were your [hh member’s] average monthly costs for insurance?
c. In [QCM] were you [hh member] expecting that amount to change
significantly?
IF NO, ENTER 0, AND SKIP TO Q. 23.
ORC Macro HUDQC Household Questionnaire
38
July 14, 2006
IF YES: d. What did you [hh member] expect the new amount to
be?
e. When did you [hh member] expect it to change?
23.
a.
Were you [hh member] responsible for paying for real estate taxes?
IF NO, ENTER 0, AND SKIP TO Q. 24.
IF YES: b. What were your [hh member’s] average monthly costs for Real Estate
Taxes?
c. In [QCM] were you [hh member] expecting that amount to change
significantly?
IF NO, ENTER 0, AND SKIP TO Q. 24.
IF YES: d. What did you [hh member] expect the new amount to
be?
e. When did you [hh member] expect it to change?
24.
a.
Were you responsible for paying for mortgage payments?
IF NO, ENTER 0, AND SKIP TO Q. 25.
IF YES: b. What were your [hh member’s] average monthly costs for mortgage
payments?
c. In [QCM] were you [hh member] expecting that amount to change
significantly?
IF NO, ENTER 0, AND SKIP TO Q. 25.
IF YES: d. What did you [hh member] expect the new amount to
be?
e. When did you [hh member] expect it to change?
25.
a.
Were you responsible for paying for condominium fees?
IF NO, ENTER 0, AND SKIP TO Q. 26.
IF YES: b. What were your [hh member’s] average monthly costs for
condominium fees?
c. In [QCM] were you [hh member] expecting that amount to change
significantly?
IF NO, ENTER 0, AND SKIP TO Q. 26.
IF YES: d. What did you [hh member] expect the new amount to
be?
e. When did you [hh member] expect it to change?
ORC Macro HUDQC Household Questionnaire
39
July 14, 2006
26.
a.
Were you [hh member] responsible for paying for any other expenses?
IF NO, ENTER 0, AND SKIP TO Q. 28.
IF YES: b. What were your [hh member’s] average monthly costs for other
expenses?
c. In [QCM] were you [hh member] expecting that amount to change
significantly?
IF NO, ENTER 0, AND SKIP TO Q. 27.
IF YES: d. What did you [hh member] expect the new amount to
be?
e. When did you [hh member] expect it to change?
27.
a.
Were you [hh member] responsible for paying for any other expenses?
IF NO, ENTER 0, AND SKIP TO Q. 28.
IF YES: b. What were your [hh member’s] average monthly costs for other
expenses?
c. In [QCM] were you [hh member] expecting that amount to change
significantly?
IF NO, ENTER 0, AND SKIP TO Q. 28.
IF YES: d. What did you [hh member] expect the new amount to
be?
e. When did you [hh member] expect it to change?
28.
We need to verify the income information you just told me about.
Can you tell me the Name, Address, Contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER
VERIFICATION INFORMATION.
Verification Codes:
29.
0 - None
3 - Documentation
rd
1 - 3 Party in Writing
4 - Self Declaration
rd
2 - 3 party Verbal
9 - Other
Are there other household members who own property to rent to others?
IF YES, REPEAT Q. 2 THROUGH 29.
IF NO, SKIP TO SECTION R.
ORC Macro HUDQC Household Questionnaire
40
July 14, 2006
R. ASSETS
Current Assets
These next questions are about assets such as checking or savings accounts, stocks, bonds, or
other valuables you (and other family members) own.
1.
In [QCM], did you or anyone living here have:
a.
A checking account? (Code 2)
IF NO, GO TO b.
b.
(1)
Which members have a checking account?
(2)
How many checking accounts do you/does [hh member] have?
ASK FOR EACH MEMBER IDENTIFIED ABOVE.
A savings account? (Code 3)
IF NO, GO TO c.
c.
(1)
Which members have a savings account?
(2)
How many savings accounts do you/does [hh member] have?
ASK FOR EACH MEMBER IDENTIFIED ABOVE.
An IRA-Individual Retirement Account (Code 4)
IF NO, GO TO d.
d.
(1)
Which members have an IRA account?
(2)
How many Individual Retirement Account’s do you/does [hh member] have?
ASK FOR EACH MEMBER IDENTIFIED ABOVE.
Money in a 401k fund or Keogh fund that you can withdraw? (Code 5)
IF NO, GO TO e.
e.
(1)
Which members have money in a 401k fund or Keogh fund?
(2)
How many 401K or Keogh funds do you/does [hh member] have?
ASK FOR EACH MEMBER IDENTIFIED ABOVE.
Certificates of Deposit (CD’s)? (Code 6)
IF NO, GO TO f.
(1)
Which members have CD’s?
(2)
How many CD’s do you/does [hh member] have?
ASK FOR EACH MEMBER IDENTIFIED ABOVE.
ORC Macro HUDQC Household Questionnaire
41
July 14, 2006
f.
Stocks? (Code 7)
IF NO, GO TO g.
g.
(1)
Which members have stocks?
(2)
In how many companies did you/ [hh member] own stock in [QCM]?
ASK FOR EACH MEMBER IDENTIFIED ABOVE.
Bonds? (Code 8)
IF NO, GO TO h.
h.
(1)
Which members have bonds?
(2)
How many bonds do you/does [hh member] have?
ASK FOR EACH MEMBER IDENTIFIED ABOVE.
Treasury bills (T-bills)? (Code 9)
IF NO, GO TO i.
i.
(1)
Which members have treasury bills?
(2)
How many Treasury bills do you/does [hh member] have?
ASK FOR EACH MEMBER IDENTIFIED ABOVE.
Money in a money market fund? (Code 10)
IF NO, GO TO j.
j.
(1)
Which members money in a money market fund?
(2)
How many money market funds do you/does [hh member] have?
ASK FOR EACH MEMBER IDENTIFIED ABOVE.
Real estate or other investments? (Code 11)
IF NO, GO TO k.
k.
(1)
Which members have a real estate or other investments?
(2)
How many real estate or other investments do you/does [hh member] have?
ASK FOR EACH MEMBER IDENTIFIED ABOVE.
Money in a retirement fund that you could take without quitting or losing your job?
(Code 12)
IF NO, GO TO l.
(1)
Which members have money in a retirement fund?
(2)
How many retirement funds do you/does [hh member] have?
ASK FOR EACH MEMBER IDENTIFIED ABOVE.
ORC Macro HUDQC Household Questionnaire
42
July 14, 2006
l.
A trust fund that you could withdraw money from? (Code 13)
IF NO, GO TO m.
m.
(1)
Which members have a trust fund that you could withdraw money from?
(2)
How many trust funds do you/does [hh member] have?
ASK FOR EACH MEMBER IDENTIFIED ABOVE.
A life insurance policy with a cash value—that is, one that you could borrow against?
(Code 14)
IF NO, GO TO n.
n.
(1)
Which members have a life insurance policy with a cash value?
(2)
How many insurance policies do you/does [hh member] have?
ASK FOR EACH MEMBER IDENTIFIED ABOVE.
Property or other belongings that you were keeping as an investment—such as
antiques, coins, or other collections? (Code 15)
IF NO, GO TO o.
o.
(1)
Which members have a property or other belongings that you were keeping as
an investment?
(2)
How many properties or other belongings do you/does [hh member] have?
ASK FOR EACH MEMBER IDENTIFIED ABOVE.
Other assets I haven’t asked about? (Code 99)
IF YES: (1) Which members have other assets?
IF NO AND NO TO 1.a. THROUGH 1.n., SKIP TO Q. 46.
FOR EACH CHECKING AND SAVINGS ACCOUNT, ASK Q. 2 THROUGH Q. 11.
2.
In QCM, how much money did you [hh member] keep in [account]?
3.
Were you [hh member] receiving income from the [account]?
IF NO, SKIP TO Q. 6.
IF YES: 4. How much income did you [hh member] receive from the [account]?
5. How often did you [hh member] get that amount?
6.
We need to verify the asset information you just told me about.
Can you tell me the Name, Address, Contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER VERIFICATION
INFORMATION
ORC Macro HUDQC Household Questionnaire
43
July 14, 2006
7.
Did you [hh member] get interest on that account?
IF NO, SKIP TO Q. 9.
IF YES: 8. What was the interest rate?
9.
What is the account number (or identification number) for the [asset]?
10.
Is that a joint account with someone outside the household?
IF NO, SKIP TO NEXT ASSET.
11. What percent of the account was owned by you [hh member]?
FOR IRA, 401K OR KEOGH, CD’S, STOCKS, BONDS, TREASURY BILLS, MONEY
MARKET FUNDS, AND RETIREMENT FUNDS, ASK Q. 12 THROUGH Q. 22.
12.
In [QCM], what was the value of [asset]? How much money did you [hh member] have in
[account/fund]?
13.
Were you [hh member] receiving income from [asset]?
IF NO, SKIP TO Q. 16.
IF YES: 14. How much income did you [hh member] receive from [asset]?
15. How often do you [hh member] get that amount?
16.
We need to verify the asset information you just told me about.
Can you tell me the Name, Address, Contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER VERIFICATION
INFORMATION.
17.
Did you [hh member] get interest on that account?
IF NO, SKIP TO Q. 19.
IF YES: 18. What was the interest rate?
19.
What is the Account number (or identification number) for the [asset]?
20.
Was the [asset] jointly owned with someone outside the household?
IF NO, SKIP TO Q. 22.
21. What percent of the [asset] was owned by the household?
22.
If you [hh member] were to sell that asset, what would be the cost of selling the asset? For
example, would you have to pay a lawyer’s fee or a penalty, or any other costs?
IF NO COSTS, ENTER 0.
ORC Macro HUDQC Household Questionnaire
44
July 14, 2006
FOR REAL ESTATE, LIFE INSURANCE, AND PROPERTY, ASK Q. 23 THROUGH
Q. 28.
23.
What was the value of [asset]? How much money did you [hh member] have in
[account/fund]?
24.
We need to verify the asset information you just told me about.
Can you tell me the Name, Address, Contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER VERIFICATION
INFORMATION.
25.
What is the Account number (or identification number) for the [asset]?
26.
Was the [asset] jointly owned with someone outside the household?
IF NO, SKIP TO Q. 28.
27. What percent of the [asset] is owned by the household?
28.
If you [hh member] were to sell that asset, what would be the cost of selling the asset? For
example, would you have to pay a lawyer’s fee or a penalty, or any other costs?
IF NO COSTS, ENTER 0.
FOR TRUST FUNDS, ASK Q. 29 THROUGH Q. 36.
29.
What was the value of [asset]? How much money did you [hh member] have in
[account/fund]?
30.
We need to verify the asset information you just told me about.
Can you tell me the name, address, contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER VERIFICATION
INFORMATION.
31.
Did you get interest on that account?
IF NO, SKIP TO Q. 33.
IF YES: 32. What was the interest rate?
33. What is the Account number (or identification number) for the [asset]?
34.
Was the [asset] jointly owned with someone outside the household?
IF NO, SKIP TO Q. 36.
35. What percent of the [asset] is owned by the household?
ORC Macro HUDQC Household Questionnaire
45
July 14, 2006
36.
If you [hh member] were to sell that asset, what would be the cost of selling the asset? For
example, would you have to pay a lawyer’s fee or a penalty, or any other costs?
IF NO COSTS, ENTER 0.
FOR OTHER ASSETS ASK Q. 37 THROUGH Q. 45.
37.
What is the value of [asset]? How much money did you [hh member] have in
[account/fund]?
38.
Were you [hh member] receiving income from [asset]?
IF NO, SKIP TO Q. 41.
IF YES: 39. How much income did you [hh member] receive from [asset]?
40. How often do you [hh member] get that amount?
41.
We need to verify the asset information you just told me about
Can you tell me the name, address, contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER VERIFICATION
INFORMATION.
42.
What is the Account number (or identification number) for the [asset]?
43.
Was the [asset] jointly owned with someone outside the household?
IF NO, SKIP TO Q. 45.
44. What percent of the [asset] was owned by the household?
45.
If you [hh member] were to sell that asset, what would be the cost of selling the asset? For
example, would you have to pay a lawyer’s fee or a penalty, or any other costs?
IF NO COSTS, ENTER 0.
Assets Disposed of in Last 2 Years
These next questions are about assets you [or anyone living here] may have sold or given away.
46.
Now please think back to [2 years before QCM]. Have you [or any household member]
sold any assets or given away any assets since [2 years before QCM]?
IF NO, SKIP TO SECTION S.
47.
What member of the household sold or gave away the asset?
48.
What was that asset?
49.
How much did you [hh member] get for it?
ORC Macro HUDQC Household Questionnaire
46
July 14, 2006
50.
Do you think it was worth more than that?
IF NO, SKIP TO Q. 53.
51. How much do you think it was worth?
52. Why didn’t you [hh member] get the full value for [the asset]?
53.
Did you [hh member] have any expenses when disposing of that asset—for example,
lawyers, brokers, penalties, or any other costs?
IF NO, SKIP TO Q. 55.
54. How much were those expenses?
55.
Are there any other assets that you [or any household member] sold since [two years prior
to QCM]?
IF YES, REPEAT Q. 47 THROUGH 55.
IF NO, GO TO SECTION S.
ORC Macro HUDQC Household Questionnaire
47
July 14, 2006
S.
OTHER INCOME
1.
I’ve asked you about a lot of different kinds of income that you or your family may be
receiving. Is there any other income that I haven’t asked about that you were [or anyone
living here was] getting in [QCM]? For example, lottery winnings that you receive on a
regular basis, [IF NATIVE AMERICAN, income from awards by the Indian Claims
Court,] or any other source?
IF NO, SKIP TO INSTRUCTIONS ON NEXT PAGE.
2.
Which household member received this income?
3.
What kind of income was that?
RECORD TYPE AND SOURCE OF INCOME.
IF SOURCE OF INCOME IS ‘AS’ – ATHLETIC SCHOLARSHIP, OR ‘02’ –
STUDENT FINANCIAL AID, ASK:
3a. What was the cost of tuition for [name of student] during the semesters/school sessions
immediately prior to and after [QCM]?
IF INCOME IS EXCLUDED, SKIP TO Q. 11.
Type of Income Codes:
Included:
XT Trust Fund
AS Athletic Scholarships
MA Medical Expense Reimbursement
LT Lottery Income
Excluded:
01 Foster Care Assistance
04 Grand Rivers Band of Ottawa
07 Disability Assistance for Home
10 Crime Compensation
14 Adoption Assistance payments
17 Exposed to Agent Orange
20 Earned Income Tax Credit
23 Value of Groceries
99 Excluded
03
06
09
13
16
19
22
95
02
05
08
11
15
18
21
24
Student Financial Aid
Judgment Funds from Claims Court
BIA Student assistance
LIEAP
Income from Submarginal land
Spina Bifida child of Vietnam veteran
Food Stamps
Transitional Assistance Subsidy
4.
How much were you getting?
5.
How often did you get that amount?
Frequency Codes:
01 = Annually
12 = Monthly
24 = Semi-monthly
ORC Macro HUDQC Household Questionnaire
Property Rebates
Maine Indian Claims Act
Child Care Block Grant
Nazi era reparation payments
Alaska native claims settlement
Federated tribes - Yakima/Apache
PASS
None of the Above
26 = Bi-weekly
52 = Weekly
99 = Other
48
July 14, 2006
6.
We need to verify the asset information you just told me about. Can you tell me the Name,
Address, Contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER
VERIFICATION INFORMATION.
Verification Codes:
7.
0 - None
3 - Documentation
rd
1 - 3 Party in Writing
4 - Self Declaration
rd
2 - 3 party Verbal
9 - Other
In [QCM], did you expect to continue getting that amount during the full year?
IF YES, SKIP TO INSTRUCTIONS ON NEXT PAGE.
IF NO: 8. When did you [hh member] expect the amount to change?
9. How much did you [hh member] expect to receive then?
10. How often did you [hh member] expect to receive that amount?
11.
Is there any other income that I haven’t asked about that you were [or anyone living here
was] getting in [QCM]?
IF YES, REPEAT Q. 2 THROUGH 11.
INSTRUCTIONS
IF HH HAS CHILDREN UNDER AGE 13, CONTINUE WITH SECTION T.
IF HH HAS NO CHILDREN UNDER 13, BUT IS ELDERLY OR DISABLED, SKIP TO
SECTION U.
IF HH HAS NO CHILDREN UNDER 13 AND IS NOT ELDERLY OR DISABLED BUT
HAS A DISABLED MEMBER, SKIP TO SECTION V.
IF HH HAS NO CHILDREN UNDER 13, IS NOT ELDERLY OR DISABLED, AND HAS
NO DISABLED MEMBER, SKIP TO INSTRUCTIONS ON P. 60.
ORC Macro HUDQC Household Questionnaire
49
July 14, 2006
T.
CHILD CARE EXPENSES
1.
During [QCM], were you [or anyone living here] paying anyone for child care?
IF NO, SKIP TO SECTION U.
2.
For which children were there child care costs?
3.
Who paid for the child care costs?
4.
Who provided the child care?
5.
Is Provider a household Member?
IF YES, RECORD MEMBER #.
6.
How much were you [or household member] paying for the child care? I mean costs that
you [hh member] paid for and were not reimbursed by an outside source.
7.
How often did you [hh member] pay that amount?
Frequency Codes:
01 = Annually
IF HOURLY: 8.
12 = Monthly
24 = Twice a Month
26 = Every Two Weeks
52 = Weekly
How many hours a week do you [he/she] pay for?
10. How many weeks a year?
IF DAILY:
9.
How many days a week do you [he/she] pay for child care?
10. How many weeks a year?
11.
Is the amount you (hh member} pay(s) about the same throughout the year?
*
PROBE: Even if school is out or if you’re [he’s/she’s] not working?
IF YES, SKIP TO Q. 14.
12. About how many months a year do you [hh member] pay that amount?
13. Do you [hh member] pay a different amount during other months of the year?
IF NO, SKIP TO Q. 14.
IF YES, REPEAT Q. 4 THROUGH 13.
RECORD EACH CHANGE IN CHILD CARE EXPENSE AS A SEPARATE LINE ITEM.
ORC Macro HUDQC Household Questionnaire
50
July 14, 2006
14.
We need to verify the expense information you just told me about.
Can you tell me the Name, Address, Contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER VERIFICATION
INFORMATION.
Verification Codes:
15.
0 - None
3 - Documentation
rd
1 - 3 Party in Writing
4 - Self Declaration
rd
2 - 3 party Verbal
9 - Other
During [QCM], why were you [was hh member] paying for child care?
IF WORKING, SKIP TO Q. 20.
IF LOOKING FOR WORK, SKIP TO Q. 16.
IF ATTENDING SCHOOL, SKIP TO Q. 17.
16.
How many hours per week did you/[hh member] spend looking for work?
SKIP TO Q. 20.
17.
Where were you [was hh member] going to school?
18.
About how many hours a week did you [hh member] spend at school and going to and
from school?
19.
About how many weeks a year did you [hh member] expect to go to school?
20.
Does anyone else in the household pay child care costs?
IF NO, SKIP TO SECTION U.
IF YES, REPEAT Q. 2 THROUGH 20.
ORC Macro HUDQC Household Questionnaire
51
July 14, 2006
U. MEDICAL EXPENSES
ELDERLY AND DISABLED HH, CONTINUE WITH SECTION U.
NONELDERLY HH WITH DISABLED MEMBER AND HH MEMBER
WORKING IN QCM, SKIP TO SECTION V.
ALL OTHERS, SKIP TO INSTRUCTIONS ON P. 60.
These next questions are about your (household’s) medical expenses that you [or someone living
here] were paying for during a typical year—not expenses covered by insurance or paid for by
someone not living here.
1.
In [QCM] were you [or anyone in this household] paying insurance premiums for health
insurance, nursing home insurance, or Medicare? Also include premiums paid for drug
discount card and any payments that you (or anyone in the household) made through an
agency or employer.
IF NO, SKIP TO Q. 8.
2.
Which household member paid for this insurance?
2a.
What type of insurance is this?
Type of Health Insurance:
3 = Dental Health Insurance
1 = Private Health Insurance
4 = Medicare
2 = Nursing Home Insurance
5 = Prescription Coverage
IF TYPE IS MEDICARE, SKIP TO Q. 4.
IF TYPE IS PRIVATE HEALTH INSURANCE, DENTAL INSURANCE, OR
NURSING HOME INSURANCE, SKIP TO Q. 2D.
2b. Is the prescription coverage provided through a Medicare approved prescription drug
discount card?
IF NO, SKIP TO 2d.
2c.
IF YES: May I see a document that describes this card?
RECORD THE TYPE OF DOCUMENT USED TO VERIFY THE MEDICARE
APPROVED PRESCRIPTION DRUG DISCOUNT CARD.
SKIP TO Q. 4.
2d. Did you/[hh member] pay for the insurance directly or through a company or other
agency?
IF PAID DIRECTLY, SKIP TO Q. 3.
ORC Macro HUDQC Household Questionnaire
52
July 14, 2006
2e.
What employer or agency did you/[hh member] pay the health insurance premium
through?
How Insurance Paid:
60 = Insurance paid directly by household member
61 = Nursing Home Insurance paid through employer
67 = Insurance paid through an other unearned income source (e.g., a pension)
3.
What was the name of the insurance provider?
4.
How much was the insurance premium for this policy? How much did [hh member]
pay?
5.
How often did you [household member] pay that amount?
6.
We need to verify the expense information you just told me about.
Can you tell me the name, address, contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER
VERIFICATION INFORMATION.
7.
Did you [or anyone in the household] have any other health, nursing home, or
Medicare insurance?
IF YES, GO BACK TO Q. 2.
8.
In [QCM] did you [or any family member living here] pay for visits to the doctor or clinic,
dentist, eye doctor, or any other health care provider on a regular basis? This includes
copays, but not costs covered by insurance or paid by someone outside the household.
IF NO, SKIP TO Q. 19.
9.
What type of health service was provided?
10. Which household member visited this doctor or clinic on a regular basis?
11. Which household member paid for these visits to the doctor or clinic?
12. What doctor or clinic did you [hh member] go to?
13. How often did you [hh member] see the doctor/go to the clinic?
Frequency Codes:
01 = Annually
06 = Every Two Months
26 = Every Two Weeks
02 = Twice a Year
12 = Monthly
52 = Weekly
04 = 4 Times a year (Quarterly)
24 = Twice a Month
14. How much did you [hh member] usually pay when you [he/she] saw the doctor?
15.
We need to verify the expense information you just told me about.
Can you tell me the name, address, contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER VERIFICATION
INFORMATION.
ORC Macro HUDQC Household Questionnaire
53
July 14, 2006
16. Did you [hh member] expect to have those expenses for the full year?
IF NO:
17. When did you [hh member] expect that expense to change?
18. Did you [or anyone else in the household] pay for visits to this doctor or clinic,
dentist, eye doctor, or any other health care provider?
IF YES, GO BACK TO Q. 9.
19.
Were you [or any family member living here] paying for prescriptions on a regular basis?
IF NO, SKIP TO Q. 29.
20. Which household member used prescription medicine on a regular basis?
21. Which household member paid for these prescriptions?
22. What was the name of the pharmacy where the prescriptions were purchased?
23. How often did you [hh member] refill these prescriptions?
24. How much did you [hh member] usually pay for these prescriptions?
25. We need to verify the expense information you just told me about
Can you tell me the name, address, contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER
VERIFICATION INFORMATION.
26. Did you [hh member] expect to have these expenses for the full year?
IF NO:
27. When did you [hh member] expect that expense to end?
28. Did you [or anyone in the household] pay for any other prescriptions on a regular
basis?
IF YES, GO BACK TO Q. 19.
28a. Were any of the prescriptions mentioned purchased with a Medicare Approved Drug
Discount card?
IF NO, SKIP TO Q. 29.
IF YES: 28b. For whom were prescriptions purchased with a Medicare
Approved Drug Discount card?
PICK THE MACROLINK ASSOCIATED WITH THAT DISCOUNT CARD. IF
THE TENANT DID NOT MENTION A DRUG DISCOUNT CARD DURING THE
INSURANCE SECTION OF THE INTERVIEW, A NEW MACROLINK NEEDS
TO BE CREATED.
ORC Macro HUDQC Household Questionnaire
54
July 14, 2006
28c. IF A NEW MACRO LINK, May I see a document that describes this card?
RECORD THE TYPE OF DOCUMENT USED TO VERIFY THE MEDICARE
APPROVED PRESCRIPTION DRUG DISCOUNT.
Verification of Discount Card:
01 Copy of the card
03 Other
02 Statement from Medicare
04 Not Verified
28d. Which prescriptions were purchased using the Medicare Approved Drug Discount
Card?
PICK THE MACRO LINK ASSOCIATED WITH THAT PRESCRIPTION/
MACRO LINK.
I am going to ask you about each prescription purchased with a Medicare Approved
Prescription Drug Discount from [insert name of pharmacy] individually.
28e. What prescription did [you/hh member] purchase at [name of pharmacy] using the
Medicare Approved Prescription Drug Discount Card?
ASSIGN A UNIQUE NUMERIC IDENTIFIER FOR EACH PRESCRIPTION
PURCHASED WITH THE MEDICARE APPROVED PRESCRIPTION DRUG
DISCOUNT CARD.
28f. Do you know how much the prescription would have cost if [you/hh member] paid
the full amount? PROBE: This is the amount [you/hh member] would have paid if
insurance would not have covered part of the cost.
28g. IF YES: How much was the full cost?
ENTER THE FULL COST ANNUALLY. SO, IF THE TENANT PURCHASES THE
MEDICATION 4 TIMES A YEAR, MULTIPLY THE AMOUNT BY 4 AND ENTER
THAT AMOUNT.
28h. IF NO: Were any other prescriptions purchased for [you/hh memer] using the
Medicare Approved Prescription Drug Discount Card at this pharmacy?
IF YES, GO BACK TO 28e.
28i. IF NO: Were any other prescriptions purchased using the Medicare Approved
Prescription Drug Discount Card?
IF YES, GO BACK TO 28b.
29.
Were you [or any member of the family living here] paying for any other medical expenses
on a regular basis?
IF NO, SKIP TO Q. 39.
30. Which household member had other medical expenses on a regular basis?
31. Which household member paid for these other medical expenses?
ORC Macro HUDQC Household Questionnaire
55
July 14, 2006
32. Where did you [hh member] receive these other medical services? Who did you pay
for those services?
RECORD PROVIDER AND MEDICAL EXPENSE CODE.
33. How often did you [hh member] have that expense?
34. How much did you [hh member] usually pay?
35. We need to verify the expense information you just told me about.
Can you tell me the Name, Address, Contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER
VERIFICATION INFORMATION.
36. Did you [hh member] expect to have these expenses for the full year?
IF NO: 37.
When did you [hh member] expect that expense to end?
38. Did you [or anyone in the household] expect to have any other medical expenses on a
regular basis?
IF YES, GO BACK TO Q. 30.
39.
During [QCM], did you [or any hh member] pay for outstanding medical bills on a regular
basis?
IF NO, SKIP TO INSTRUCTIONS ON THE BOTTOM OF NEXT PAGE.
40. Which household member was paying outstanding medical bills on a regular basis?
41. Who did you [hh member] pay?
42. What type of medical expense was it?
Medical Expense Codes
01
02
03
04
05
06
07
08
09
10
11
12
13
95
Services of doctors, nurses, dentists, other health care professionals
Services of health care facility (e.g. hospital, clinic) (includes x-rays and other procedures conducted at
such facilities)
Health Insurance
Medicare
Prescriptions
Non-prescription drugs and medical supplies
Eyeglasses
Hearing Aids
Transportation to and from treatment
Medical care of permanently institutionalized household member if included on lease
Animal Services
Outstanding Medical Bills paid on a regular basis
Care Provider Including Live-in Aides
Other Medical
43. How often did you [hh member] have that expense?
ORC Macro HUDQC Household Questionnaire
56
July 14, 2006
44. How much did you [hh member] pay?
45. We need to verify the expense information you just told me about
Can you tell me the Name, Address, Contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER
VERIFICATION INFORMATION
Verification Codes:
rd
0 - None
3 - Documentation
1 - 3 Party in Writing
4 - Self Declaration
rd
2 - 3 party Verbal
9 - Other
46. Did you [hh member] expect to have that expense for the full year?
IF NO:
47. When did you [hh member] expect that expense to end?
48. Did you [or anyone in the household] have any other outstanding medical expenses
that you were paying on a regular basis?
IF YES, GO BACK TO Q. 40.
IF HH HAS A DISABLED MEMBER AND HH MEMBER WORKING IN QCM,
CONTINUE WITH SECTION V.
IF DISABLED HH MEMBER, BUT NO ONE IN HH IS WORKING, SKIP TO
INSTRUCTIONS ON P. 60.
IF HH HAS NO DISABLED MEMBER, SKIP TO INSTRUCTIONS ON P. 60.
ORC Macro HUDQC Household Questionnaire
57
July 14, 2006
V.
DISABILITY ASSISTANCE EXPENSES (NOT MEDICAL)
IF NO LIVE-IN AIDE, SKIP TO Q. 7.
Live-In Aide
1.
IF LIVE-IN AIDE: You told me that [live-in aide] lived here to help care for [hh member].
In [QCM] did you [or someone in this household] pay [him/her]?
IF NO, SKIP TO Q. 7.
2.
Which household member paid [live-in aide]?
3.
How much did you [hh member] pay him/her? I’m asking about the amount that you
[hh member] paid, not any amounts that were paid for by insurance or someone else.
4.
How often did you [hh member] pay that amount?
Frequency Codes:
5.
01 = Annually
06 = Every other month
26 = Every two weeks
02 =Twice a year
12 = Monthly
52 = Weekly
04 = 4 times a year
24 = Twice a month
96 = Other
Did the live-in aide stay here all year?
IF YES, SKIP TO Q. 7.
6.
How many months did he/she live here?
Caregiver
7.
During [QCM] did you [or any household members] pay to have anyone [else] come in to
care for [disabled hh member]?
IF NO, SKIP TO Q. 18.
8.
Which household member paid for that caregiver?
9.
Could you tell me the name of the caregiver?
10.
How much did you [hh member] pay [caregiver]? I’m asking about the amount that you
[hh member] paid, not any amounts that are paid for by insurance or someone else.
11.
How often did you [hh member] pay that amount?
Frequency Codes:
01 = Annually
06 = Every Two Months
26 = Every Two Weeks
02 = Twice a year
12 = Monthly
52 = Weekly
04 = Quarterly
24 = Twice a Month
90 = Hourly
92 = Daily
IF HOURLY: 12. How many hours a week did [caregiver] usually come here?
13. How many weeks a year did [caregiver] usual come here?
ORC Macro HUDQC Household Questionnaire
58
July 14, 2006
IF DAILY:
14. How many days a week did [caregiver] usually come here?
15. How many weeks a year did [caregiver] usual come here?
16. We need to verify the expense information you just told me about.
Can you tell me the address, contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND
OTHER VERIFICATION INFORMATION.
17.
In QCM, did you [hh member] pay for anyone else to care for [disabled member]?
IF YES, GO BACK TO Q. 8.
Special Equipment
18.
During [QCM], did you (or members of your family living here) pay for any special
equipment for [disabled hh member], such as a wheelchair or specially equipped cars or
vans? I am asking about amounts you [hh member] paid; not amounts paid by insurance or
someone outside the household
IF NO, SKIP TO INSTRUCTIONS ON P. 57.
19.
Who paid for the equipment?
20.
What kind of equipment was it?
21.
Did you [hh member] rent it, buy it (pay the full amount), or were you [hh member]
making installment payments?
Payment Type:
22.
1 = Paid in Full
2 = Making Installments
3 = Renting
8 = Don’t Know
When did you [hh member] buy it/start renting it?
PROBE FOR COST OF EQUIPMENT SPECIFICALLY FOR DISABLED MEMBER:
IF BOUGHT: 23. How much did it cost?
IF INSTALLMENT PAYMENTS OR RENTED: 24. How much were your [hh
member’s] payments?
25.
IF INSTALLMENT PAYMENTS: 26.
ORC Macro HUDQC Household Questionnaire
How often did you [hh member]
pay that amount?
When will it be paid off?
59
July 14, 2006
Maintenance Cost
27.
Do you have any costs for maintenance of this equipment?
28.
How much are you paying in maintenance costs during [QCM]?
29.
How often do you pay this amount?
Frequency Codes:
30.
02 = Twice a Year
12 = Monthly
52 = Weekly
04 = 4 Times a year (Quarterly)
24 = Twice a Month
We need to verify the expense information you just told me about.
Can you tell me the Name, Address, Contact person and phone number?
RECORD THE TYPE AND DATE OF VERIFICATION AND OTHER VERIFICATION
INFORMATION.
Verification Codes:
31.
01 = Annually
06 = Every Two Months
26 = Every Two Weeks
0 - None
3 - Documentation
rd
1 - 3 Party in Writing
4 - Self Declaration
rd
2 - 3 party Verbal
9 - Other
Did anyone else in this household use the equipment that was bought for [disabled hh
member]?
IF NO, SKIP TO INSTRUCTIONS ON BOTTOM OF PAGE.
32.
About what percentage of the time is the equipment used by [disabled hh member]?
33.
Did you [or any family member living here] pay for any other special equipment for
[disabled hh member]?
IF YES, GO BACK TO Q. 18.
INSTRUCTIONS
IF RESPONDENT REPORTED THAT HE/SHE HAS NO INCOME—CONTINUE WITH
SECTION W.
IF RESPONDENT REPORTED THAT HE/SHE HAS INCOME—SKIP TO
CONCLUSION, SECTION X.
ORC Macro HUDQC Household Questionnaire
60
July 14, 2006
W. IF RESPONDENT REPORTS NO INCOME
You’ve told me you don’t receive any income. How do you manage to get by—how do you get
food and other things you need to live?
RECORD RESPONSE:
IF INCOME IS IDENTIFIED THAT SHOULD HAVE BEEN NOTED IN PREVIOUS
SECTIONS, ENTER AMOUNTS IN THE APPROPRIATE SECTION.
ORC Macro HUDQC Household Questionnaire
61
July 14, 2006
X.
CONCLUSION
That’s all the questions I have. But before I go, let me take a minute to check that I have all the
information I need.
Certification of Interview
I completed this interview on _________________ at _________am/pm.
DATE
TIME
Signature ______________________________________________
COMPLETE THE NEXT SECTION IMMEDIATELY AFTER THE INTERVIEW.
ORC Macro HUDQC Household Questionnaire
62
July 14, 2006
| File Type | application/pdf |
| File Modified | 2007-01-10 |
| File Created | 2006-08-25 |