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NOTICE – We are conducting this survey under the authority of Title 13, United States Code,
Section 8. Section 9 of this law requires us to keep all information about you and your household
strictly confidential. We may use this information only for statistical purposes. Also, Title 42,
Section 3732, United States Code, authorizes the Bureau of Justice Statistics, Department of
Justice, to collect information using this survey. Title 42, Sections 3789g and 3735, United States
Code, also requires us to keep all information about you and your household strictly confidential.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless such collection displays a valid OMB number.
NCVS-1
Economics and Statistics Administration
U.S. CENSUS BUREAU
ACTING AS COLLECTING AGENT FOR THE
BUREAU OF JUSTICE STATISTICS
U.S. DEPARTMENT OF JUSTICE
NATIONAL CRIME
VICTIMIZATION SURVEY
BEFORE INTERVIEW – TRANSCRIBE FROM CONTROL CARD
Control number
PSU
Segment/Suffix
Sample
Serial/
designation/Suffix Suffix
HH No. Spinoff
Indicator
U.S. DEPARTMENT OF COMMERCE
FORM
(9-16-2004)
NCVS-1 BASIC SCREEN QUESTIONNAIRE
AFTER INTERVIEW – TRANSCRIBE FROM CONTROL CARD – Cont.
12a. Household Income (cc item 28)
ITEMS FILLED AT START OF INTERVIEW
1.
214
Field representative identification
Code
Name
1
2
3
201
4
2.
202
3.
203
4.
Unit status
1
Unit in sample the previous enumeration period – Fill 3
Unit in sample first time this period – SKIP to 4
2
Household status – Mark first box that applies.
1
Same household interviewed the previous enumeration
2
Replacement household since the previous enumeration
3
Noninterview the previous enumeration
Other – Specify
4
5
218
5.
205
6.
206
7.
207
8.
208
9.
209
219
Tenure (cc item 8a)
1
Owned or
being bought
Land use (cc item 9)
1
Urban
11
12
220
Rented
for cash
2
Rural
No cash
rent
3
No
Less than $1,000
2
1
2
3
1 – SKIP to 11c
2
3
3
4
5
6
11b. Direct outside access
213
1
Yes
2
No
223
Yes (public
housing)
1
2
No (not public
housing)
Item blank
Able to verify
X
Unable to verify
Public housing
Not public housing
3
4
CATI/Telephone
Other – Specify
1
Yes
2
No
3
7
8
304
305
306
307
308
309
310
311
312
Codes for item 13c
1–12–13 years old and parent refused permission for self interview
2– Physically/mentally unable to answer FILL INTER-COMM
3– TA and won’t return before closeout
14. Type Z noninterview
a. Interview not
b. Reason
Yes
Yes
321
Fill 10b
USCENSUSBUREAU
2
No
No
X
X
(Enter
code)
FILL
INTERCOMM
____________ Total number
15b. Household members UNDER 12 years of age
322
____________ Total number
0
None
15c. Number of Type Z noninterview household members
332
Mobile home/trailer –
SKIP to 11c
Only OTHER units
2
Codes for item 14b
1 – Never available
2 – Refused . . . .
3 – Physically/
314
mentally
unable to
answer—no
316
proxy available
4 – TA and no proxy
318
available . . . .
5 – Other . . . . . .
320
6 – Office use only
Complete 17—28 for each Line No. in 14a
obtained for
Line No.
15a. Household members 12 years of age and OVER
(cc item 27b)
DK X Item blank
Gated or walled community 1
Building with restricted access 1
(Enter
code)
Line No.
303
317
Refused to give number
4
5–9
10+
Name
302
315
11c. Restricted access (cc item 27c)
222
1
No
301
313
11a. Number of housing units in structure (cc item 27a)
212
Item blank
view obtained
for Line No.
10b. Is phone interview acceptable? (cc item 26d)
2
2
13. Proxy information – Fill for all proxy interviews
a. Proxy interb. Proxy respondent
c. Reason
OTHER unit
Quarters not HU in rooming or boarding house
Unit not permanent in transient hotel, motel, etc.
Unoccupied site for mobile home, trailer, or tent
Student quarters in college dormitory
OTHER unit not specified above – Describe
Yes
Yes
ITEMS FILLED DURING AND/OR AFTER INTERVIEW
2
Use of telephone (cc item 26a and b)
Location of phone – Mark first box that applies.
1
Phone in unit . . . . . . . . . . . . . . . . . . .
Phone in common area (hallway, etc.) . . . .
2
3
Phone in another unit (neighbor, friend, etc.)
Work/office phone . . . . . . . . . . . . . . . .
4
No phone – SKIP to 11a
5
1
14
12e. American Indian Reservation or American Indian Lands
319
211
13
(cc item 8e)
Type of living quarters (cc items 11c and 11d)
Housing unit
1
House, apartment, flat
HU in nontransient hotel, motel, etc.
2
HU permanent in transient hotel, motel, etc.
3
HU in rooming house
4
Mobile home or trailer with no permanent room added
5
6
Mobile home or trailer with one or more permanent rooms added
7
HU not specified above – Describe
10
12
12d. Manager Verification of Public Housing (cc item 8d)
221
Farm sales (cc item 10)
X
Item blank 1 $1,000 or more
9
210
X
2
Group Quarters (GQ) type code
____________
35,000 – 39,999
40,000 – 49,999
50,000 – 74,999
75,000 and over
11
12c. Public Housing (cc item 8c)
____________ Go to page 2
8
10a.
1
1
AFTER INTERVIEW – TRANSCRIBE FROM CONTROL CARD
15,000 – 17,499
17,500 – 19,999
20,000 – 24,999
25,000 – 29,999
30,000 – 34,999
12b. College/University (cc item 8b)
Line number of household respondent
204
Less than $5,000 6
7
$5,000 – 7,499
7,500 – 9,999
8
9
10,000 – 12,499
12,500 – 14,999 10
Item blank
Item blank
12 years of age and OVER
____________ Total number
0
None
0
None
15d. Crime Incident Reports filled
323
____________ Total number of NCVS-2s filled
16. Changes in Household Composition (cc item 25a)
a. Line No.
b. Reason (Enter code)
324
325
326
327
328
329
330
331
N
C
V
S
Only transcribe
changes discovered
during the current
enumeration
Fill BOUNDING INFORMATION
HOUSEHOLD RESPONDENT’S PERSONAL CHARACTERISTICS
17.
18.
NAME (of household respondent)
19.
Type of interview
Line
No.
Last
401
Per. – Self-respondent
Tel. – Self-respondent
Per. – Proxy
Tel. – Proxy Fill 13 on cover page
1
First
402
2
3
4
________
Line No.
AFTER INTERVIEW – TRANSCRIBE FROM CONTROL CARD
20.
21.
(cc 13b)
Relationship to
reference
person
(cc 17)
(cc 18)
Age last Marital status
birthday THIS survey
period
403
22a.
404
22b.
23.
24.
(From previous (cc 19)
enumeration)
Sex
Marital
status LAST
survey period
405
406
25.
26.
(cc 20)
(cc 21)
(cc 22)
Armed Educational Attending
Forces attainment school
member
407
408
409
27.
28.
(cc 23)
Hispanic
origin
(cc 24)
Race
413
412
411
Mark (X) all that
apply.
*
01
02
03
04
05
06
07
08
09
10
11
Husband
Wife
________
Son
Age
Daughter
Father
Mother
Brother
Sister
Other relative
Nonrelative
Ref. person
29.
1
2
3
4
5
Married
Widowed
Divorced
Separated
Never
married
1
2
3
4
5
6
Married
Widowed
Divorced
Separated
Never
married
Not interviewed
last
survey
period
1
2
M
F
1
2
Yes
No
0
____________
Highest level
completed
1
2
3
4
Regular
school
College/
University
Trade
school
Vocational
school
None of
the
above
schools
Yes
No
1
2
1
2
3
4
5
6
White
Black/African
American
American
Indian/Alaska
Native
Asian
Native
Hawaiian/Other
Pacific Islander
Other – Specify
501
Date of interview
Month
Day
Year
MOBILITY QUESTIONS
Before we get to the crime questions, I have some
questions that are helpful in studying where and why
crimes occur.
33a.
If unsure, ASK OR VERIFY –
How long have you lived at this address?
(Enter number of months OR years.)
505
OR
506
CHECK
ITEM A
33b.
____________ Months (1-11) – SKIP to 33b
____________ Years (Round to nearest whole year) –
Fill Check Item A
5 years or more – SKIP to 34
Less than 5 years – Ask 33b
How many years are entered in 33a?
Altogether, how many times have you moved in the last
5 years, that is, since _________________, 20 ___?
508
____________ Number of times
BUSINESS OPERATED FROM SAMPLE ADDRESS
34.
Does anyone in this household operate a business from
this address?
530
1
2
35.
Page 2
PERSONAL – Fill by observation.
TELEPHONE – Ask.
Is there a sign on the premises or some
other indication to the general public that a
business is operated from this address?
531
1
2
Yes – Go to 35
No – SKIP to 36a
Yes (Recognizable business)
No (Unrecognizable business)
FORM NCVS-1 (9-16-2004)
HOUSEHOLD RESPONDENT’S SCREEN QUESTIONS
36a.
I’m going to read some examples that will give you an
idea of the kinds of crimes this study covers.
As I go through them, tell me if any of these
happened to you in the last 6 months, that is
since __________ ______, 20 ____.
Briefly describe incident(s)
Was something belonging to YOU stolen, such as –
(a) Things that you carry, like luggage, a wallet,
purse, briefcase, book –
(b) Clothing, jewelry, or cellphone –
(c) Bicycle or sports equipment –
(d) Things in your home – like a TV, stereo, or tools
(e) Things outside your home such as a garden
hose or lawn furniture –
(f) Things belonging to children in the household –
(g) Things from a vehicle, such as a package,
groceries, camera, or CDs –
OR
(h) Did anyone ATTEMPT to steal anything
belonging to you?
36b.
MARK OR ASK –
Did any incidents of this type happen to you?
532
1
2
36c.
Yes – What happened?
Describe above
No – SKIP to 37a
How many times?
533
Number of times (36c)
37a.
37b.
(Other than any incidents already mentioned,)
has anyone –
(a) Broken in or ATTEMPTED to break into your
home by forcing a door or window, pushing
past someone, jimmying a lock, cutting a
screen, or entering through an open door or
window?
(b) Has anyone illegally gotten in or tried to get
into a garage, shed, or storage room?
OR
(c) Illegally gotten in or tried to get into a hotel or
motel room or vacation home where you were
staying?
MARK OR ASK –
Did any incidents of this type happen to you?
Briefly describe incident(s)
534
1
2
37c.
Yes – What happened?
Describe above
No – SKIP to 38
How many times?
535
Number of times (37c)
FORM NCVS-1 (9-16-2004)
Page 3
HOUSEHOLD RESPONDENT’S SCREEN QUESTIONS
38.
What was the TOTAL number of cars, vans, trucks,
motorcycles, or other motor vehicles owned by you or
any other member of this household during the last
6 months? Include those you no longer own.
536
0
1
2
3
4
39a.
During the last 6 months, (other than any incidents
already mentioned,) (was the vehicle/were any of
the vehicles) –
None – SKIP to 40a
1
2
3
4 or more
Briefly describe incident(s)
(a) Stolen or used without permission?
(b) Did anyone steal any parts such as a tire, car
stereo, hubcap, or battery?
(c) Did anyone steal any gas from (it/them)?
OR
(d) Did anyone ATTEMPT to steal any vehicle or parts
attached to (it/them)?
39b.
MARK OR ASK –
Did any incidents of this type happen to you?
537
1
2
39c.
Yes – What happened?
Describe above
No – SKIP to 40a
How many times?
538
Number of times (39c)
40a.
(Other than any incidents already mentioned,)
since __________ ______, 20 ____, were you attacked
or threatened OR did you have something stolen
from you –
Briefly describe incident(s)
(a) At home including the porch or yard –
(b) At or near a friend’s, relative’s, or
neighbor’s home –
(c) At work or school –
(d) In places such as a storage shed or laundry
room, a shopping mall, restaurant, bank, or
airport –
(e) While riding in any vehicle –
(f) On the street or in a parking lot –
(g) At such places as a party, theater, gym,
picnic area, bowling lanes, or while fishing
or hunting –
OR
(h) Did anyone ATTEMPT to attack or ATTEMPT
to steal anything belonging to you from any of
these places?
40b.
MARK OR ASK –
Did any incidents of this type happen to you?
539
1
2
40c.
Yes – What happened?
Describe above
No – SKIP to 41a
How many times?
540
Number of times (40c)
Page 4
FORM NCVS-1 (9-16-2004)
HOUSEHOLD RESPONDENT’S SCREEN QUESTIONS
41a.
(Other than any incidents already mentioned,)
has anyone attacked or threatened you in any
of these ways (Exclude telephone threats) –
Briefly describe incident(s)
(a) With any weapon, for instance, a gun or
knife –
(b) With anything like a baseball bat, frying
pan, scissors, or stick –
(c) By something thrown, such as a rock or
bottle –
(d) Include any grabbing, punching, or choking,
(e) Any rape, attempted rape or other type of
sexual attack –
(f) Any face to face threats –
OR
(g) Any attack or threat or use of force by anyone
at all? Please mention it even if you are not
certain it was a crime.
41b.
MARK OR ASK –
Did any incidents of this type happen to you?
541
1
2
41c.
Yes – What happened?
Describe above
No – SKIP to 42a
How many times?
542
Number of times (41c)
42a.
People often don’t think of incidents committed
by someone they know. (Other than any incidents
already mentioned,) did you have something
stolen from you OR were you attacked or
threatened by (Exclude telephone threats) –
(a) Someone at work or school –
(b) A neighbor or friend –
(c) A relative or family member –
Briefly describe incident(s)
(d) Any other person you’ve met or known?
42b.
MARK OR ASK –
Did any incidents of this type happen to you?
543
1
2
42c.
Yes – What happened?
Describe above
No – SKIP to 43a
How many times?
544
Number of times (42c)
43a.
Incidents involving forced or unwanted sexual
acts are often difficult to talk about. (Other than
any incidents already mentioned,) have you been
forced or coerced to engage in unwanted sexual
activity by –
Briefly describe incident(s)
(a) Someone you didn’t know before –
(b) A casual acquaintance –
OR
(c) Someone you know well?
43b.
MARK OR ASK –
Did any incidents of this type happen to you?
545
1
2
43c.
Yes – What happened?
Describe above
No – SKIP to 44a
How many times?
546
Number of times (43c)
FORM NCVS-1 (9-16-2004)
Page 5
HOUSEHOLD RESPONDENT’S SCREEN QUESTIONS
44a.
During the last 6 months, (other than any
incidents already mentioned,) did you call the
police to report something that happened to YOU
which you thought was a crime?
Briefly describe incident(s)
547
1
2
548
Yes – What happened?
Describe above
No – SKIP to 45a
OFFICE USE ONLY
*
CHECK
ITEM B
44b.
Look at 44a. If unsure, ASK, otherwise, mark without
asking. Were you (was the respondent) attacked or
threatened, or was something stolen or an
attempt made to steal something that
belonged to you (the respondent) or another
household member?
549
1
2
Yes – Ask 44b
No – SKIP to 45a
How many times?
550
Number of times (44b)
45a.
During the last 6 months, (other than any
incidents already mentioned,) did anything which
you thought was a crime happen to YOU, but you
did NOT report to the police?
Briefly describe incident(s)
551
1
2
552
Yes – What happened?
Describe above
No – SKIP to INTRO 1 at top of
page 7
OFFICE USE ONLY
*
CHECK
ITEM C
45b.
Look at 45a. If unsure, ASK, otherwise, mark without
asking. Were you (was the respondent) attacked or
threatened, or was something stolen or an
attempt made to steal something that
belonged to you (the respondent) or another
household member?
553
1
2
Yes – Ask 45b
No – SKIP to INTRO 1 at top of
page 7
How many times?
554
Number of times (45b)
NOTES
Page 6
FORM NCVS-1 (9-16-2004)
HOUSEHOLD RESPONDENT’S IDENTITY THEFT QUESTIONS
FIELD REPRESENTATIVE – Read introduction.
INTRO 1: The next few questions are related to identity theft. They refer to episodes of identity theft discovered by you or
anyone in your household during the last 6 months.
45c.
Since
, 20
, have you
or anyone in your household discovered that
someone –
(a) Used or attempted to use any existing credit
cards or credit card numbers without permission
to place charges on an account? . . . . . . . . . .
(b) Used or attempted to use any existing accounts
other than a credit card account – for example, a
wireless telephone account, bank account or
debit/check cards – without the account holder’s
permission to run up charges or to take money
from accounts? . . . . . . . . . . . . . . . . . . . . . .
(c) Used or attempted to use personal information
without permission to obtain NEW credit cards or
loans, run up debts, open other accounts, or
otherwise commit theft, fraud, or some other
crime? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CHECK
ITEM C1
45d.
45e.
45f.
107
1
Yes
2
No
3
Don’t know
108
1
Yes
2
No
3
Don’t know
109
1
Yes
2
No
3
Don’t know
1
None (no entries of Yes) – SKIP to Check Item D
One or more times – Ask 45d
Look at 45c. How many times is box 1 (Yes)
marked in 45c?
2
Was the misuse of – (the credit card account(s)/any
existing account(s) other than credit cards/personal
information or new account(s)) one episode or more
than one episode of identity theft?
110
Did these episodes of identify theft occur separately
or at the same time?
111
Which episode of identity theft was most recently
discovered?
112
1
2
1
2
1
2
3
One – SKIP to 45g
More than one
Separately
At the same time – SKIP to 45g
Existing credit cards
Existing accounts other than a credit card
Personal information to obtain new accounts
INTRO 2: The following questions refer only to the most recent discovery of identity theft by you or anyone in your
household.
45g.
How did you become aware of the identity theft?
Mark (X) all that apply.
113
1
*
2
3
4
5
6
7
8
9
45h.
45i.
45j.
What was the total dollar amount of the credit,
loans, cash, services, and anything else the person
obtained while misusing (the credit card
account(s)/any existing accounts other than credit
cards/personal information or new account(s))?
Has the misuse of – (the credit card account(s)/any
existing accounts other than credit cards/personal
information or new account(s)) stopped (e.g. you or
a household member closed a checking account)?
Is the misuse of – (the credit card account(s)/any
existing accounts other than credit cards/personal
information or new account(s)) still causing
problems for you or any other household member?
For example, are you still spending time clearing up
credit accounts or your credit report?
FORM NCVS-1 (9-16-2004)
114
$
X
0
115
1
2
3
116
Block was placed on a credit card or other existing account
Money missing from account or charges placed on an
account
Contacted by a credit bureau, collection agency, credit card
company or other company about late/unpaid bills
Contacted by a bank
Noticed that a credit card, check book, etc. was missing
Notified by a law enforcement agency
Denied credit or a loan
Noticed an error in a credit report
Other – Specify
1
2
3
.00
Amount taken
Don’t know
None
Yes
No
Don’t know
Yes – SKIP to 45l
No
Don’t know
Page 7
HOUSEHOLD RESPONDENT’S IDENTITY THEFT QUESTIONS
45k.
How much time did it take to resolve ALL PROBLEMS
associated with the misuse of – (the credit card
account(s)/any existing account(s) other than credit
cards/personal information or new account(s)) after
the misuse was discovered?
Less than one month:
117
____________ Days
OR
1 – 6 Months:
45l.
As a result of (any of) the misuse of (the credit card
account(s)/any existing account(s) other than credit
cards/personal information or new account(s))
discovered in the last 6 months, have you or anyone
in your household . . .
118
____________ Months
X
Don’t know days or months
119
1
*
2
10
Been turned down for a loan?
Had banking problems?
Had problems with credit card accounts?
Had phone or utilities cut off or been denied new
service?
Had to pay higher interest rates on credit cards,
loans, etc.
Been turned down for insurance or had to pay
higher rates?
Been contacted by a debt collector or creditor?
Been the subject of a civil suit or judgment?
Been the subject of a criminal investigation,
warrant, proceeding, or conviction?
Had some other problems?– Specify
11
No problems
3
4
(Read answer categories 1–10)
5
Mark (X) all that apply.
6
7
8
9
CHECK
ITEM C2
Briefly summarize the identity theft that occurred
against the respondent or another household member.
HOUSEHOLD RESPONDENT’S CHECK ITEMS D AND E
CHECK
ITEM D
Who besides the respondent was present when the
screen questions were asked? (If telephone
interview, mark box 1 only.)
555
*
1
2
3
4
5
6
7
8
CHECK
ITEM E
Telephone interview – SKIP to 46a
Personal interview – Mark all that apply.
No one besides respondent present
Respondent’s spouse
HHLD member(s) 12+, not spouse
HHLD member(s) under 12
Nonhousehold member(s)
Someone was present – Can’t say who
Don’t know if someone else present
If self-response interview, SKIP to 46a
Did the person for whom this interview was taken
help the proxy respondent answer any screen
questions?
556
1
2
3
Yes
No
Person for whom interview taken not present
HOUSEHOLD RESPONDENT’S VANDALISM SCREEN QUESTIONS
46a.
Now I’d like to ask about ALL acts of vandalism that may have been committed during the last 6 months
against YOUR household. Vandalism is the deliberate, intentional damage to or destruction of household
property. Examples are breaking windows, slashing tires, and painting graffiti on walls.
Since __________ ______, 20 ____, has anyone intentionally
damaged or destroyed property owned by you or
someone else in your household?
(EXCLUDE any damage done in conjunction with
incidents already mentioned.)
46b.
What kind of property was damaged or destroyed
in this/these act(s) of vandalism? Anything else?
Continue asking "Anything else?" until you get a "No" response.
Mark (X) all property that was damaged or destroyed by
vandalism during reference period.
557
2
558
1
*
2
3
4
5
6
7
8
9
Page 8
1
Yes
No – SKIP to Check Item G
on page 11
Motor vehicle (including parts)
Bicycle (including parts)
Mailbox
House window/screen/door
Yard or garden (trees, shrubs, fence, etc.)
Furniture, other household goods
Clothing
Animal (pet, livestock, etc.)
Other – Specify
FORM NCVS-1 (9-16-2004)
HOUSEHOLD RESPONDENT’S VANDALISM SCREEN QUESTIONS
46c.
What kind of damage was done in this/these
act(s) of vandalism? Anything else?
Continue asking "Anything else?" until you get a "No" response.
Mark (X) all kinds of damage by vandals that occurred
during reference period.
559
1
*
2
3
4
5
6
7
46d.
What was the total dollar amount of the damage
caused by this/these act(s) of vandalism during the
last 6 months? (Use repair costs if the property was
repaired.)
560
46e.
Was the damage under $100 or $100 or more?
(INCLUDE total amount for all incidents of
vandalism during the last 6 months.)
CHECK
ITEM F1
Look at 46a. If unsure, ASK, otherwise, mark without
asking. In the vandalism just mentioned, were
you (was the respondent) attacked or threatened,
or was something stolen or an attempt made
to steal something that belonged to you (the
respondent) or another household member?
(other than any incident(s) already
mentioned)
$
X
(EXCLUDE any damage done in incidents already
mentioned.)
0
561
Broken glass: window, windshield,
glass in door, mirror
Defaced: marred, graffiti, dirtied
Burned: use of fire, heat or explosives
Drove into or ran over with vehicle
Other breaking or tearing
Injured or killed animals
Other – Specify
1
2
3
.
00 – SKIP to Check
Item F1
Don’t know
No cost – SKIP to Check Item F1
Under $100
$100 or more
Don’t know
Briefly describe incident(s)
562
1
2
46f.
How many times?
Yes – What happened?
Describe above
No – SKIP to 46g
563
Number of times (46f)
NOTES
FORM NCVS-1 (9-16-2004)
Page 9
HOUSEHOLD RESPONDENT’S HATE CRIME SCREEN QUESTIONS
46g.
Hate crimes or crimes of prejudice or bigotry occur
when (an offender/offenders) target(s) people because
of one or more of their characteristics or religious
beliefs.
Do you have any reason to suspect the vandalism just
discussed was a hate crime or crime of prejudice or
bigotry?
46h.
3
Yes – Ask 46h
No . . . . . . .
Don’t know . . SKIP to Check Item G
564
1
Yes
2
586
1
2
An offender/Offenders can target people for a variety of
reasons, but we are only going to ask you about a few
today. Do you suspect the offender(s) targeted you
because of...
(a) Your race? . . . . . . . . . . . . . . . . . . . . . . . . . . .
(b) Your religion? . . . . . . . . . . . . . . . . . . . . . . . . .
565
1
Yes
2
No
No
(c) Your ethnic background or national origin (for
example, people of Hispanic origin)? . . . . . . . .
566
1
Yes
2
No
3
Don’t know
(d) Any disability (by this I mean physical, mental, or
developmental disabilities) you may have? . . . .
567
1
2
No
3
Don’t know
568
1
Yes
Yes
2
No
3
Don’t know
569
1
Yes
2
No
3
Don’t know
587
1
Yes – Specify
2
No
3
Don’t know
1
Yes – Specify
2
No
3
Don’t know
(e) Your gender? . . . . . . . . . . . . . . . . . . . . . . . . .
(f) Your sexual orientation? . . . . . . . . . . . . . . . . .
3
3
Don’t know
Don’t know
If "Yes," SAY – (by this we mean homosexual,
bisexual, or heterosexual)
46i.
Some offenders target people because they
associate with certain people or the (offender
perceives/offenders perceive) them as having
certain characteristics or religious beliefs.
Do you suspect you were targeted because of...
(a) Your association with people who
have certain characteristics or
religious beliefs (for example, a
multiracial couple)? . . . . . . . . . . . . . . . . . . .
588
(b) The offender(s)’s perception of your
characteristics or religious beliefs (for
example, the offender(s) thought you
were Jewish because you went into a
synagogue)? . . . . . . . . . . . . . . . . . . . . . . . .
589
590
CHECK
ITEM F2
46j.
Are one or more boxes marked "Yes" in 46h
OR 46i?
Do you have any evidence that this vandalism was a
hate crime or crime of prejudice or bigotry?
Yes – Ask 46j
No – SKIP to Check Item G
591
1
2
If "No" or "Don’t know," ASK –
3
Yes – Ask 46k
No . . . . . . . .
Don’t know . . . SKIP to Check Item G
Did the offender(s) say something, write anything,
or leave anything behind at the crime scene that
would suggest you were targeted because of your
characteristics or religious beliefs?
Page 10
FORM NCVS-1 (9-16-2004)
HOUSEHOLD RESPONDENT’S HATE CRIME SCREEN QUESTIONS
46k.
The next questions ask about the evidence you have
that makes you suspect this vandalism was a hate
crime or a crime of prejudice or bigotry. As I read
the following questions, please tell me if any of the
following happened:
(a) Did the offender(s) make fun of you, make
negative comments, use slang, hurtful words, or
abusive language? . . . . . . . . . . . . . . . . . . . .
592
1
Yes
2
No
3
Don’t know
(b) Were any hate symbols present at the crime
scene to indicate the offender(s) targeted you for
a particular reason (for example, a swastika,
graffiti on the walls of a temple, a burning cross,
or written words)? . . . . . . . . . . . . . . . . . . . .
593
1
Yes
2
No
3
Don’t know
(c) Did a police investigation confirm the offender(s)
targeted you (for example, did the offender(s)
confess a motive, or did the police find books,
journals, or pictures that indicated the offender(s)
(was/were) prejudiced against people with certain
characteristics or religious beliefs)? . . . . . . .
594
1
Yes
2
No
3
Don’t know
(d) Do you know if the offender(s) (has/have)
committed similar hate crimes or crimes of
prejudice or bigotry in the past? . . . . . . . . . . .
595
1
Yes
2
No
3
Don’t know
(e) Did the vandalism occur on or near a holiday,
event, location, gathering place, or building
commonly associated with a specific group (for
example, at the Gay Pride March or at a
synagogue, Korean church, or gay bar)? . . . . .
596
1
Yes
2
No
3
Don’t know
(f) Have other hate crimes or crimes of prejudice or
bigotry happened to you or in your area/
neighborhood where people have been targeted?
597
1
Yes
2
No
3
Don’t know
(g) Do your feelings, instincts, or perception lead you
to suspect this vandalism was a hate crime or
crime of prejudice or bigotry, but you do not have
enough evidence to know for sure? . . . . . . . .
598
1
Yes
2
No
3
Don’t know
HOUSEHOLD RESPONDENT’S CHECK ITEM G
CHECK
ITEM G
Transcribe "number of times" entry for each
of the following:
No entries transcribed below – Go to Check
Item H
(a) Screen Question, Item 36c, page 3
____________ Number of times (36c)
(b) Screen Question, Item 37c, page 3
____________ Number of times (37c)
(c) Screen Question, Item 39c, page 4
____________ Number of times (39c)
(d) Screen Question, Item 40c, page 4
____________ Number of times (40c)
(e) Screen Question, Item 41c, page 5
____________ Number of times (41c)
(f) Screen Question, Item 42c, page 5
____________ Number of times (42c)
(g) Screen Question, Item 43c, page 5
____________ Number of times (43c)
(h) Screen Question, Item 44b, page 6
____________ Number of times (44b)
(i) Screen Question, Item 45b, page 6
____________ Number of times (45b)
(j) Vandalism Screen Question, Item 46f, page 9
____________ Number of times (46f)
FIELD REPRESENTATIVE – After completing Check Item G, fill a separate crime incident report for each screen
question that has an entry of 1 or more. Do this before marking Check Item H.
FORM NCVS-1 (9-16-2004)
Page 11
HOUSEHOLD RESPONDENT’S EMPLOYMENT QUESTIONS
Be sure to fill any incident reports before marking Check Item H.
CHECK
ITEM H
47a.
1
Is the respondent 16 years or older?
Did you have a job or work at a business LAST WEEK?
(Do not include volunteer work or work around the house.)
2
576
(If farm or business operator in household, ask about
unpaid work.)
47b.
47c.
48a.
ASK OR VERIFY –
Did you have a job or work at a business DURING THE
LAST 6 MONTHS?
Did that (job/work) last 2 consecutive weeks
or more?
ASK OR VERIFY –
Which of the following best describes your job?
PERSONAL INTERVIEW (Show flashcard)
1
2
577
1
2
578
1
2
579
TELEPHONE INTERVIEW – Were you employed
in the (Read main headings until you get a yes.
Then read answer categories) –
Mark (X) only one category.
Yes – Ask 47a
No – SKIP to Check Item I
Yes – SKIP to 48a
No – Ask 47b
Yes – Ask 47c
No – SKIP to Check Item I
Yes – Ask 48a
No – SKIP to Check Item I
Medical Profession – As a –
1
Physician
Nurse
2
Technician
3
Other – Specify
4
Mental Health Services Field – Are your duties –
5
Professional (Social worker/psychiatrist)
Custodial care
6
Other – Specify
7
Teaching Profession – Were you employed in a –
8
Preschool
Elementary
9
10
Junior high or middle school
High school
11
College or university
12
Technical or industrial school
13
Special education facility
14
Other – Specify
15
Law Enforcement or Security Field – Were you
employed as a –
16
Law enforcement officer
Prison or jail guard
17
Security guard
18
Other – Specify
19
Retail Sales – Were you employed as a –
Convenience or liquor store clerk
Gas station attendant
21
Bartender
22
Other – Specify
23
20
Transportation Field – Were you employed as a –
Bus driver
Taxi cab driver
25
Other – Specify
26
OR
Something else – Specify
27
24
48b.
ASK OR VERIFY –
Is your job with (Read answer categories) –
580
1
2
3
4
48c.
48d.
If box 12 is marked in 48a, mark without asking.
Are you employed by a college or university?
581
While working at your job, do you work mostly in
(Read answer categories) –
582
1
2
1
2
3
4
CHECK
ITEM I
Is this the last household member to be
interviewed?
A private company, business, or individual for wages?
The Federal government?
A State, county, or local government?
Yourself (Self-employed) in your own business,
professional practice, or farm?
Yes
No
A city?
Suburban area?
Rural area?
Combination of any of these?
Yes – Ask or verify Control Card items.
Then END interview.
No – Ask or verify Control Card items. See note below before
interviewing next household member.
FIELD REPRESENTATIVE – If the next household member to be interviewed is under 18, tell the household respondent
that you will be asking the same questions you just asked him/her.
Page 12
FORM NCVS-1 (9-16-2004)
INDIVIDUAL’S PERSONAL CHARACTERISTICS
17.
18.
NAME
19.
Type of interview
Line
No.
Last
401
Per. – Self-respondent
Tel. – Self-respondent
Per. – Proxy
Fill 13 on cover page
Tel. – Proxy
Noninterview – Fill 19 – 28 on this page. Also
fill 14 and adjust item 15c on cover page.
1
First
402
2
3
4
5
________
Line No.
AFTER INTERVIEW – TRANSCRIBE FROM CONTROL CARD
20.
21.
(cc 13b)
Relationship to
reference
person
(cc 17)
(cc 18)
Age last Marital status
birthday THIS survey
period
403
22a.
404
22b.
23.
24.
(From previous (cc 19)
enumeration)
Sex
Marital
status LAST
survey period
405
406
25.
26.
(cc 20)
(cc 21)
(cc 22)
Armed Educational Attending
Forces attainment school
member
407
408
409
27.
28.
(cc 23)
Hispanic
origin
(cc 24)
Race
Mark (X) all that
apply.
411
413
412
*
01
02
03
04
05
06
07
08
09
10
11
Husband
Wife
________
Son
Age
Daughter
Father
Mother
Brother
Sister
Other relative
Nonrelative
Ref. person
29.
1
2
3
4
5
Married
Widowed
Divorced
Separated
Never
married
1
2
3
4
5
6
Married
Widowed
Divorced
Separated
Never
married
Not interviewed
last
survey
period
1
2
M
F
1
2
Yes
No
0
____________
Highest level
completed
1
2
3
4
Regular
school
College/
University
Trade
school
Vocational
school
None of
the
above
schools
Yes
No
1
2
1
2
3
4
5
6
White
Black/African
American
American
Indian/Alaska
Native
Asian
Native
Hawaiian/Other
Pacific Islander
Other – Specify
501
Date of interview
Month
Day
Year
MOBILITY QUESTIONS
Before we get to the crime questions, I have one or two
questions that are helpful in studying where and why
crimes occur.
33a.
If unsure, ASK OR VERIFY –
How long have you lived at this address?
(Enter number of months OR years.)
505
OR
506
CHECK
ITEM A
33b.
FORM NCVS-1 (9-16-2004)
____________ Years (Round to nearest whole year) –
Fill Check Item A
5 years or more – SKIP to 36a
Less than 5 years –Ask 33b
How many years are entered in 33a?
Altogether, how many times have you moved in the last
5 years, that is, since _________________, 20 ___?
____________ Months (1-11) – SKIP to 33b
508
____________ Number of times
Page 13
INDIVIDUAL’S SCREEN QUESTIONS
36a.
I’m going to read some examples that will give you an
idea of the kinds of crimes this study covers.
Briefly describe incident(s)
As I go through them, tell me if any of these
happened to you in the last 6 months, that is since
__________ ______, 20 ____.
Was something belonging to YOU stolen, such as –
(a) Things that you carry, like luggage, a wallet,
purse, briefcase, book –
(b) Clothing, jewelry, or cellphone –
(c) Bicycle or sports equipment –
(d) Things in your home – like a TV, stereo, or tools –
(e) Things from a vehicle, such as a package, groceries,
camera, or CDs –
OR
(f) Did anyone ATTEMPT to steal anything
belonging to you?
36b.
MARK OR ASK –
Did any incidents of this type happen to you?
532
1
2
▼
36c.
Yes – What happened?
Describe above
No – SKIP to 40a
How many times?
533
Number of times (36c)
40a.
(Other than any incidents already mentioned,)
since __________ ______, 20 ____, were you attacked
or threatened OR did you have something stolen
from you –
Briefly describe incident(s)
(a) At home including the porch or yard –
(b) At or near a friend’s, relative’s, or neighbor’s
home –
(c) At work or school –
(d) In places such as a storage shed or laundry
room, a shopping mall, restaurant, bank, or
airport –
(e) While riding in any vehicle –
(f) On the street or in a parking lot –
(g) At such places as a party, theater, gym,
picnic area, bowling lanes, or while fishing
or hunting –
OR
(h) Did anyone ATTEMPT to attack or ATTEMPT to
steal anything belonging to you from any of
these places?
40b.
MARK OR ASK –
Did any incidents of this type happen to you?
539
1
2
▼
40c.
Yes – What happened?
Describe above
No – SKIP to 41a
How many times?
540
Number of times (40c)
Page 14
FORM NCVS-1 (9-16-2004)
INDIVIDUAL’S SCREEN QUESTIONS
41a.
(Other than any incidents already mentioned,)
has anyone attacked or threatened you in any of
these ways (Exclude telephone threats) –
Briefly describe incident(s)
(a) With any weapon, for instance, a gun or
knife –
(b) With anything like a baseball bat, frying pan,
scissors, or stick –
(c) By something thrown, such as a rock or
bottle –
(d) Include any grabbing, punching, or choking,
(e) Any rape, attempted rape or other type of
sexual attack –
(f) Any face to face threats –
OR
(g) Any attack or threat or use of force by anyone
at all? Please mention it even if you are not
certain it was a crime.
41b.
MARK OR ASK –
Did any incidents of this type happen to you?
541
1
2
How many times?
▼
41c.
Yes – What happened?
Describe above
No – SKIP to 42a
542
Number of times (41c)
42a.
People often don’t think of incidents committed
by someone they know. (Other than any incidents
already mentioned,) did you have something
stolen from you OR were you attacked or
threatened by (Exclude telephone threats) –
Briefly describe incident(s)
(a) Someone at work or school –
(b) A neighbor or friend –
(c) A relative or family member –
(d) Any other person you’ve met or known?
42b.
MARK OR ASK –
Did any incidents of this type happen to you?
543
1
2
How many times?
▼
42c.
Yes – What happened?
Describe above
No – SKIP to 43a
544
Number of times (42c)
43a.
43b.
Incidents involving forced or unwanted sexual
acts are often difficult to talk about. (Other than
any incidents already mentioned,) have you been
forced or coerced to engage in unwanted sexual
activity by –
(a) Someone you didn’t know before –
(b) A casual acquaintance –
OR
(c) Someone you know well?
MARK OR ASK –
Did any incidents of this type happen to you?
Briefly describe incident(s)
545
1
2
How many times?
▼
43c.
Yes – What happened?
Describe above
No – SKIP to 44a
546
Number of times (43c)
FORM NCVS-1 (9-16-2004)
Page 15
INDIVIDUAL’S SCREEN QUESTIONS
44a.
During the last 6 months, (other than any
incidents already mentioned,) did you call the
police to report something that happened to YOU
which you thought was a crime?
Briefly describe incident(s)
547
1
2
548
OFFICE USE ONLY
*
CHECK
ITEM B
44b.
Yes – What happened?
Describe above
No – SKIP to 45a
Look at 44a. If unsure, ASK, otherwise, mark without asking.
Were you (was the respondent) attacked or
threatened, or was something stolen or an
attempt made to steal something that belonged to
you (the respondent) or another household member?
549
1
2
Yes – Ask 44b
No – SKIP to 45a
How many times?
550
Number of times (44b)
45a.
During the last 6 months, (other than any
incidents already mentioned,) did anything which
you thought was a crime happen to YOU, but you
did NOT report to the police?
Briefly describe incident(s)
551
1
2
552
Yes – What happened?
Describe above
No – SKIP to Check Item D below
OFFICE USE ONLY
*
CHECK
ITEM C
45b.
Look at 45a. If unsure, ASK, otherwise, mark without
asking. Were you (was the respondent) attacked or
threatened, or was something stolen or an
attempt made to steal something that belonged
to you (the respondent) or another household
member?
553
1
2
Yes – Ask 45b
No – SKIP to Check Item D below
How many times?
554
Number of times (45b)
INDIVIDUAL’S CHECK ITEMS D, E, AND G
CHECK
ITEM D
Who besides the respondent was present when the
screen questions were asked? (If telephone interview,
mark box 1 only.)
555
*
1
2
3
4
5
6
7
8
CHECK
ITEM E
If self-response interview, SKIP to Check Item G
Did the person for whom this interview was taken help
the proxy respondent answer any screen questions?
556
1
2
3
CHECK
ITEM G
Transcribe "number of times" entry for each of the following:
Telephone interview – SKIP to Check Item G
Personal interview – Mark all that apply.
No one besides respondent present
Respondent’s spouse
HHLD member(s) 12+, not spouse
HHLD member(s) under 12
Nonhousehold member(s)
Someone was present – Can’t say who
Don’t know if someone else present
Yes
No
Person for whom interview taken not present
No entries transcribed below – Go to Check Item H
(a) Screen Question, Item 36c, page 14
____________ Number of times (36c)
(b) Screen Question, Item 40c, page 14
____________ Number of times (40c)
(c) Screen Question, Item 41c, page 15
____________ Number of times (41c)
(d) Screen Question, Item 42c, page 15
____________ Number of times (42c)
(e) Screen Question, Item 43c, page 15
____________ Number of times (43c)
(f) Screen Question, Item 44b, page 16
____________ Number of times (44b)
(g) Screen Question, Item 45b, page 16
____________ Number of times (45b)
FIELD REPRESENTATIVE – After completing Check Item G, fill a separate crime incident report for each screen question that has an entry
of 1 or more. Do this before marking Check Item H.
Page 16
FORM NCVS-1 (9-16-2004)
INDIVIDUAL’S EMPLOYMENT QUESTIONS
Be sure to fill any incident reports before marking Check Item H.
CHECK
ITEM H
47a.
1
Is the respondent 16 years or older?
2
Did you have a job or work at a business LAST WEEK?
(Do not include volunteer work or work around the house.)
(If farm or business operator in household, ask about
unpaid work.)
576
1
2
Yes – Ask 47a
No – SKIP to Check Item I
Yes – SKIP to 48a
No – Ask 47b
ASK OR VERIFY –
47b.
Did you have a job or work at a business DURING THE
LAST 6 MONTHS?
47c.
Did that (job/work) last 2 consecutive weeks
or more?
577
1
2
578
1
2
Yes – Ask 47c
No – SKIP to Check Item I
Yes – Ask 48a
No – SKIP to Check Item I
ASK OR VERIFY –
48a.
Which of the following best describes your job?
PERSONAL INTERVIEW (Show flashcard)
579
TELEPHONE INTERVIEW –Were you employed
in the (Read main headings until you get a yes.
Then read answer categories) –
Medical Profession – As a –
1
Physician
Nurse
2
Technician
3
Other – Specify
4
Mental Health Services Field – Are your duties –
5
Professional (Social worker/psychiatrist)
Custodial care
6
Other – Specify
7
Mark (X) only one category.
Teaching Profession – Were you employed in a –
8
Preschool
Elementary
9
10
Junior high or middle school
High school
11
College or university
12
Technical or industrial school
13
Special education facility
14
Other – Specify
15
Law Enforcement or Security Field – Were you
employed as a –
16
Law enforcement officer
Prison or jail guard
17
Security guard
18
Other – Specify
19
Retail Sales – Were you employed as a –
Convenience or liquor store clerk
Gas station attendant
21
Bartender
22
Other – Specify
23
20
Transportation Field – Were you employed as a –
Bus driver
Taxi cab driver
25
Other – Specify
26
24
OR
27
48b.
ASK OR VERIFY –
Is your job with (Read answer categories) –
580
1
2
3
4
48c.
48d.
If box 12 is marked in 48a, mark without asking.
Are you employed by a college or university?
581
1
2
While working at your job, do you work mostly in
(Read answer categories) –
582
1
2
3
4
CHECK
ITEM I
Is this the last household member to be
interviewed?
Something else – Specify
A private company, business, or individual for wages?
The Federal government?
A State, county, or local government?
Yourself (Self-employed) in your own
business, professional practice, or farm?
Yes
No
A city?
Suburban area?
Rural area?
Combination of any of these?
Yes – END interview.
No – See note below before interviewing next
household member.
FIELD REPRESENTATIVE – If the current respondent is a parent or legal guardian and the next household member to be interviewed is
under 18, tell the current respondent that you will be asking the same questions you just asked him/her.
FORM NCVS-1 (9-16-2004)
Page 17
INDIVIDUAL’S PERSONAL CHARACTERISTICS
17.
18.
NAME
19.
Type of interview
Line
No.
Last
401
Per. – Self-respondent
Tel. – Self-respondent
Per. – Proxy
Fill 13 on cover page
Tel. – Proxy
Noninterview – Fill 19 – 28 on this page. Also
fill 14 and adjust item 15c on cover page.
1
First
402
2
3
4
5
________
Line No.
AFTER INTERVIEW – TRANSCRIBE FROM CONTROL CARD
20.
21.
(cc 13b)
Relationship to
reference
person
(cc 17)
(cc 18)
Age last Marital status
birthday THIS survey
period
403
22a.
404
22b.
23.
24.
(From previous (cc 19)
Sex
enumeration)
Marital
status LAST
survey period
405
406
25.
26.
(cc 20)
(cc 21)
(cc 22)
Armed Educational Attending
Forces attainment school
member
407
408
409
27.
28.
(cc 23)
Hispanic
origin
(cc 24)
Race
Mark (X) all that
apply.
411
413
412
*
01
02
03
04
05
06
07
08
09
10
11
Husband
Wife
________
Son
Age
Daughter
Father
Mother
Brother
Sister
Other relative
Nonrelative
Ref. person
29.
1
2
3
4
5
Married
Widowed
Divorced
Separated
Never
married
1
2
3
4
5
6
Married
Widowed
Divorced
Separated
Never
married
Not interviewed
last
survey
period
1
2
M
F
1
2
Yes
No
0
____________
Highest level
completed
1
2
3
4
Regular
school
College/
University
Trade
school
Vocational
school
None of
the
above
schools
1
2
Yes
No
1
2
3
4
5
6
White
Black/African
American
American
Indian/Alaska
Native
Asian
Native
Hawaiian/Other
Pacific Islander
Other – Specify
501
Date of interview
Month
Day
Year
MOBILITY QUESTIONS
Before we get to the crime questions, I have one or two
questions that are helpful in studying where and why
crimes occur.
33a.
If unsure, ASK OR VERIFY –
How long have you lived at this address?
(Enter number of months OR years.)
505
OR
506
CHECK
ITEM A
33b.
Page 18
____________ Years (Round to nearest whole year) –
Fill Check Item A
5 years or more – SKIP to 36a
Less than 5 years –Ask 33b
How many years are entered in 33a?
Altogether, how many times have you moved in the last
5 years, that is, since _________________, 20 ___?
____________ Months (1-11) – SKIP to 33b
508
____________ Number of times
FORM NCVS-1 (9-16-2004)
INDIVIDUAL’S SCREEN QUESTIONS
36a.
I’m going to read some examples that will give you an
idea of the kinds of crimes this study covers.
Briefly describe incident(s)
As I go through them, tell me if any of these
happened to you in the last 6 months, that is since
__________ ______, 20 ____.
Was something belonging to YOU stolen, such as –
(a) Things that you carry, like luggage, a wallet,
purse, briefcase, book –
(b) Clothing, jewelry, or cellphone –
(c) Bicycle or sports equipment –
(d) Things in your home – like a TV, stereo, or tools –
(e) Things from a vehicle, such as a package, groceries,
camera, or CDs –
OR
(f) Did anyone ATTEMPT to steal anything
belonging to you?
36b.
MARK OR ASK –
Did any incidents of this type happen to you?
532
1
2
▼
36c.
Yes – What happened?
Describe above
No – SKIP to 40a
How many times?
533
Number of times (36c)
40a.
(Other than any incidents already mentioned,)
since __________ ______, 20 ____, were you attacked
or threatened OR did you have something stolen
from you –
Briefly describe incident(s)
(a) At home including the porch or yard –
(b) At or near a friend’s, relative’s, or neighbor’s
home –
(c) At work or school –
(d) In places such as a storage shed or laundry
room, a shopping mall, restaurant, bank, or
airport –
(e) While riding in any vehicle –
(f) On the street or in a parking lot –
(g) At such places as a party, theater, gym,
picnic area, bowling lanes, or while fishing
or hunting –
OR
(h) Did anyone ATTEMPT to attack or ATTEMPT to
steal anything belonging to you from any of
these places?
40b.
MARK OR ASK –
Did any incidents of this type happen to you?
539
1
2
▼
40c.
Yes – What happened?
Describe above
No – SKIP to 41a
How many times?
540
Number of times (40c)
FORM NCVS-1 (9-16-2004)
Page 19
INDIVIDUAL’S SCREEN QUESTIONS
41a.
(Other than any incidents already mentioned,)
has anyone attacked or threatened you in any of
these ways (Exclude telephone threats) –
Briefly describe incident(s)
(a) With any weapon, for instance, a gun or
knife –
(b) With anything like a baseball bat, frying pan,
scissors, or stick –
(c) By something thrown, such as a rock or
bottle –
(d) Include any grabbing, punching, or choking,
(e) Any rape, attempted rape or other type of
sexual attack –
(f) Any face to face threats –
OR
(g) Any attack or threat or use of force by anyone
at all? Please mention it even if you are not
certain it was a crime.
41b.
MARK OR ASK –
Did any incidents of this type happen to you?
541
1
2
▼
41c.
Yes – What happened?
Describe above
No – SKIP to 42a
How many times?
542
Number of times (41c)
42a.
People often don’t think of incidents committed
by someone they know. (Other than any incidents
already mentioned,) did you have something
stolen from you OR were you attacked or
threatened by (Exclude telephone threats) –
Briefly describe incident(s)
(a) Someone at work or school –
(b) A neighbor or friend –
(c) A relative or family member –
(d) Any other person you’ve met or known?
42b.
MARK OR ASK –
Did any incidents of this type happen to you?
543
1
2
▼
42c.
Yes – What happened?
Describe above
No – SKIP to 43a
How many times?
544
Number of times (42c)
43a.
43b.
Incidents involving forced or unwanted sexual
acts are often difficult to talk about. (Other than
any incidents already mentioned,) have you been
forced or coerced to engage in unwanted sexual
activity by –
(a) Someone you didn’t know before –
(b) A casual acquaintance –
OR
(c) Someone you know well?
MARK OR ASK –
Did any incidents of this type happen to you?
Briefly describe incident(s)
545
1
2
▼
43c.
Yes – What happened?
Describe above
No – SKIP to 44a
How many times?
546
Number of times (43c)
Page 20
FFORM NCVS-1 (9-16-2004)
INDIVIDUAL’S SCREEN QUESTIONS
44a.
During the last 6 months, (other than any
incidents already mentioned,) did you call the
police to report something that happened to YOU
which you thought was a crime?
Briefly describe incident(s)
547
1
2
548
OFFICE USE ONLY
*
CHECK
ITEM B
44b.
Yes – What happened?
Describe above
No – SKIP to 45a
Look at 44a. If unsure, ASK, otherwise, mark without asking.
Were you (was the respondent) attacked or
threatened, or was something stolen or an
attempt made to steal something that belonged to
you (the respondent) or another household member?
549
1
2
Yes – Ask 44b
No – SKIP to 45a
How many times?
550
Number of times (44b)
45a.
During the last 6 months, (other than any
incidents already mentioned,) did anything which
you thought was a crime happen to YOU, but you
did NOT report to the police?
Briefly describe incident(s)
551
1
2
552
Yes – What happened?
Describe above
No – SKIP to Check Item D below
OFFICE USE ONLY
*
CHECK
ITEM C
45b.
Look at 45a. If unsure, ASK, otherwise, mark without
asking. Were you (was the respondent) attacked or
threatened, or was something stolen or an
attempt made to steal something that belonged
to you (the respondent) or another household
member?
553
1
2
Yes – Ask 45b
No – SKIP to Check Item D below
How many times?
554
Number of times (45b)
INDIVIDUAL’S CHECK ITEMS D, E, AND G
CHECK
ITEM D
Who besides the respondent was present when the
screen questions were asked? (If telephone interview,
mark box 1 only.)
555
*
1
2
3
4
5
6
7
8
CHECK
ITEM E
If self-response interview, SKIP to Check Item G
Did the person for whom this interview was taken help
the proxy respondent answer any screen questions?
556
1
2
3
CHECK
ITEM G
Transcribe "number of times" entry for each of the following:
Telephone interview – SKIP to Check Item G
Personal interview – Mark all that apply.
No one besides respondent present
Respondent’s spouse
HHLD member(s) 12+, not spouse
HHLD member(s) under 12
Nonhousehold member(s)
Someone was present – Can’t say who
Don’t know if someone else present
Yes
No
Person for whom interview taken not present
No entries transcribed below – Go to Check Item H
(a) Screen Question, Item 36c, page 19
____________ Number of times (36c)
(b) Screen Question, Item 40c, page 19
____________ Number of times (40c)
(c) Screen Question, Item 41c, page 20
____________ Number of times (41c)
(d) Screen Question, Item 42c, page 20
____________ Number of times (42c)
(e) Screen Question, Item 43c, page 20
____________ Number of times (43c)
(f) Screen Question, Item 44b, page 21
____________ Number of times (44b)
(g) Screen Question, Item 45b, page 21
____________ Number of times (45b)
FIELD REPRESENTATIVE – After completing Check Item G, fill a separate crime incident report for each screen question that has an entry
of 1 or more. Do this before marking Check Item H.
FORM NCVS-1 (9-16-2004)
Page 21
INDIVIDUAL’S EMPLOYMENT QUESTIONS
Be sure to fill any incident reports before marking Check Item H.
CHECK
ITEM H
47a.
1
Is the respondent 16 years or older?
2
Did you have a job or work at a business LAST WEEK?
(Do not include volunteer work or work around the house.)
(If farm or business operator in household, ask about
unpaid work.)
576
1
2
Yes – Ask 47a
No – SKIP to Check Item I
Yes – SKIP to 48a
No – Ask 47b
ASK OR VERIFY –
47b.
Did you have a job or work at a business DURING THE
LAST 6 MONTHS?
47c.
Did that (job/work) last 2 consecutive weeks or
more?
577
1
2
578
1
2
Yes – Ask 47c
No – SKIP to Check Item I
Yes – Ask 48a
No – SKIP to Check Item I
ASK OR VERIFY –
48a.
Which of the following best describes your job?
PERSONAL INTERVIEW (Show flashcard)
579
TELEPHONE INTERVIEW – Were you employed in
the (Read main headings until you get a yes.
Then read answer categories) –
Medical Profession – As a –
Physician
Nurse
2
Technician
3
Other – Specify
4
1
Mental Health Services Field – Are your duties –
Professional (Social worker/psychiatrist)
Custodial care
6
Other – Specify
7
Mark (X) only one category.
5
Teaching Profession – Were you employed in a –
Preschool
Elementary
9
10
Junior high or middle school
High school
11
College or university
12
Technical or industrial school
13
Special education facility
14
Other – Specify
15
8
Law Enforcement or Security Field – Were you
employed as a –
16
Law enforcement officer
Prison or jail guard
17
Security guard
18
Other – Specify
19
Retail Sales – Were you employed as a –
Convenience or liquor store clerk
Gas station attendant
21
Bartender
22
Other – Specify
23
20
Transportation Field – Were you employed as a –
Bus driver
Taxi cab driver
25
Other – Specify
26
24
OR
27
48b.
ASK OR VERIFY –
Is your job with (Read answer categories) –
580
1
2
3
4
48c.
48d.
If box 12 is marked in 48a, mark without asking.
Are you employed by a college or university?
581
1
2
While working at your job, do you work mostly in (Read
answer categories) –
582
1
2
3
4
CHECK
ITEM I
Is this the last household member to be
interviewed?
Something else – Specify
A private company, business, or individual for wages?
The Federal government?
A State, county, or local government?
Yourself (Self-employed) in your own
business, professional practice, or farm?
Yes
No
A city?
Suburban area?
Rural area?
Combination of any of these?
Yes – END interview.
No – See note below before interviewing next
household member.
FIELD REPRESENTATIVE – If the current respondent is a parent or legal guardian and the next household member to be interviewed is
under 18, tell the current respondent that you will be asking the same questions you just asked him/her.
Page 22
FORM NCVS-1 (9-16-2004)
INDIVIDUAL’S PERSONAL CHARACTERISTICS
17.
18.
NAME
19.
Type of interview
Line
No.
Last
401
Per. – Self-respondent
Tel. – Self-respondent
Per. – Proxy
Fill 13 on cover page
Tel. – Proxy
Noninterview – Fill 19 – 28 on this page. Also
fill 14 and adjust item 15c on cover page.
1
First
402
2
3
4
5
________
Line No.
AFTER INTERVIEW – TRANSCRIBE FROM CONTROL CARD
20.
21.
(cc 13b)
Relationship to
reference
person
(cc 17)
(cc 18)
Age last Marital status
birthday THIS survey
period
403
22a.
404
22b.
23.
24.
(From previous (cc 19)
Sex
enumeration)
Marital
status LAST
survey period
405
406
25.
26.
(cc 20)
(cc 21)
(cc 22)
Armed Educational Attending
Forces attainment school
member
407
408
409
27.
28.
(cc 23)
Hispanic
origin
(cc 24)
Race
Mark (X) all that
apply.
411
413
412
*
01
02
03
04
05
06
07
08
09
10
11
Husband
Wife
________
Son
Age
Daughter
Father
Mother
Brother
Sister
Other relative
Nonrelative
Ref. person
29.
1
2
3
4
5
Married
Widowed
Divorced
Separated
Never
married
1
2
3
4
5
6
Married
Widowed
Divorced
Separated
Never
married
Not interviewed
last
survey
period
1
2
M
F
1
2
Yes
No
0
____________
Highest level
completed
1
2
3
4
Regular
school
College/
University
Trade
school
Vocational
school
None of
the
above
schools
1
2
Yes
No
1
2
3
4
5
6
White
Black/African
American
American
Indian/Alaska
Native
Asian
Native
Hawaiian/Other
Pacific Islander
Other – Specify
501
Date of interview
Month
Day
Year
MOBILITY QUESTIONS
33a.
Before we get to the crime questions, I have one or two
questions that are helpful in studying where and why
crimes occur.
If unsure, ASK OR VERIFY –
How long have you lived at this address?
(Enter number of months OR years.)
505
OR
506
CHECK
ITEM A
33b.
FORM NCVS-1 (9-16-2004)
____________ Years (Round to nearest whole year) –
Fill Check Item A
5 years or more – SKIP to 36a
Less than 5 years –Ask 33b
How many years are entered in 33a?
Altogether, how many times have you moved in the last
5 years, that is, since _________________, 20 ___?
____________ Months (1-11) – SKIP to 33b
508
____________ Number of times
Page 23
INDIVIDUAL’S SCREEN QUESTIONS
36a.
I’m going to read some examples that will give you an
idea of the kinds of crimes this study covers.
Briefly describe incident(s)
As I go through them, tell me if any of these
happened to you in the last 6 months, that is since
__________ ______, 20 ____.
Was something belonging to YOU stolen, such as –
(a) Things that you carry, like luggage, a wallet,
purse, briefcase, book –
(b) Clothing, jewelry, or cellphone –
(c) Bicycle or sports equipment –
(d) Things in your home – like a TV, stereo, or tools –
(e) Things from a vehicle, such as a package, groceries,
camera, or CDs –
OR
(f) Did anyone ATTEMPT to steal anything
belonging to you?
36b.
MARK OR ASK –
Did any incidents of this type happen to you?
532
1
2
▼
36c.
Yes – What happened?
Describe above
No – SKIP to 40a
How many times?
533
Number of times (36c)
40a.
(Other than any incidents already mentioned,)
since __________ ______, 20 ____, were you attacked
or threatened OR did you have something stolen
from you –
Briefly describe incident(s)
(a) At home including the porch or yard –
(b) At or near a friend’s, relative’s, or neighbor’s
home –
(c) At work or school –
(d) In places such as a storage shed or laundry
room, a shopping mall, restaurant, bank, or
airport –
(e) While riding in any vehicle –
(f) On the street or in a parking lot –
(g) At such places as a party, theater, gym,
picnic area, bowling lanes, or while fishing
or hunting –
OR
(h) Did anyone ATTEMPT to attack or ATTEMPT to
steal anything belonging to you from any of
these places?
40b.
MARK OR ASK –
Did any incidents of this type happen to you?
539
1
2
▼
40c.
Yes – What happened?
Describe above
No – SKIP to 41a
How many times?
540
Number of times (40c)
Page 24
FORM NCVS-1 (9-16-2004)
INDIVIDUAL’S SCREEN QUESTIONS
41a.
(Other than any incidents already mentioned,)
has anyone attacked or threatened you in any of
these ways (Exclude telephone threats) –
Briefly describe incident(s)
(a) With any weapon, for instance, a gun or
knife –
(b) With anything like a baseball bat, frying pan,
scissors, or stick –
(c) By something thrown, such as a rock or
bottle –
(d) Include any grabbing, punching, or choking,
(e) Any rape, attempted rape or other type of
sexual attack –
(f) Any face to face threats –
OR
(g) Any attack or threat or use of force by anyone
at all? Please mention it even if you are not
certain it was a crime.
41b.
MARK OR ASK –
Did any incidents of this type happen to you?
541
1
2
▼
41c.
Yes – What happened?
Describe above
No – SKIP to 42a
How many times?
542
Number of times (41c)
42a.
People often don’t think of incidents committed
by someone they know. (Other than any incidents
already mentioned,) did you have something
stolen from you OR were you attacked or
threatened by (Exclude telephone threats) –
Briefly describe incident(s)
(a) Someone at work or school –
(b) A neighbor or friend –
(c) A relative or family member –
(d) Any other person you’ve met or known?
42b.
MARK OR ASK –
Did any incidents of this type happen to you?
543
1
2
▼
42c.
Yes – What happened?
Describe above
No – SKIP to 43a
How many times?
544
Number of times (42c)
43a.
43b.
Incidents involving forced or unwanted sexual
acts are often difficult to talk about. (Other than
any incidents already mentioned,) have you been
forced or coerced to engage in unwanted sexual
activity by –
(a) Someone you didn’t know before –
(b) A casual acquaintance –
OR
(c) Someone you know well?
MARK OR ASK –
Did any incidents of this type happen to you?
Briefly describe incident(s)
545
1
2
▼
43c.
Yes – What happened?
Describe above
No – SKIP to 44a
How many times?
546
Number of times (43c)
FORM NCVS-1 (9-16-2004)
Page 25
INDIVIDUAL’S SCREEN QUESTIONS
44a.
During the last 6 months, (other than any
incidents already mentioned,) did you call the
police to report something that happened to YOU
which you thought was a crime?
Briefly describe incident(s)
547
1
2
548
OFFICE USE ONLY
*
CHECK
ITEM B
44b.
Yes – What happened?
Describe above
No – SKIP to 45a
Look at 44a. If unsure, ASK, otherwise, mark without asking.
Were you (was the respondent) attacked or
threatened, or was something stolen or an
attempt made to steal something that belonged to
you (the respondent) or another household member?
549
1
2
Yes – Ask 44b
No – SKIP to 45a
How many times?
550
Number of times (44b)
45a.
During the last 6 months, (other than any
incidents already mentioned,) did anything which
you thought was a crime happen to YOU, but you
did NOT report to the police?
Briefly describe incident(s)
551
1
2
552
Yes – What happened?
Describe above
No – SKIP to Check Item D below
OFFICE USE ONLY
*
CHECK
ITEM C
45b.
Look at 45a. If unsure, ASK, otherwise, mark without
asking. Were you (was the respondent) attacked or
threatened, or was something stolen or an
attempt made to steal something that belonged
to you (the respondent) or another household
member?
553
1
2
Yes – Ask 45b
No – SKIP to Check Item D below
How many times?
554
Number of times (45b)
INDIVIDUAL’S CHECK ITEMS D, E, AND G
CHECK
ITEM D
Who besides the respondent was present when the
screen questions were asked? (If telephone interview,
mark box 1 only.)
555
*
1
2
3
4
5
6
7
8
CHECK
ITEM E
If self-response interview, SKIP to Check Item G
Did the person for whom this interview was taken help
the proxy respondent answer any screen questions?
556
1
2
3
CHECK
ITEM G
Transcribe "number of times" entry for each of the following:
Telephone interview – SKIP to Check Item G
Personal interview – Mark all that apply.
No one besides respondent present
Respondent’s spouse
HHLD member(s) 12+, not spouse
HHLD member(s) under 12
Nonhousehold member(s)
Someone was present – Can’t say who
Don’t know if someone else present
Yes
No
Person for whom interview taken not present
No entries transcribed below – Go to Check Item H
(a) Screen Question, Item 36c, page 24
____________ Number of times (36c)
(b) Screen Question, Item 40c, page 24
____________ Number of times (40c)
(c) Screen Question, Item 41c, page 25
____________ Number of times (41c)
(d) Screen Question, Item 42c, page 25
____________ Number of times (42c)
(e) Screen Question, Item 43c, page 25
____________ Number of times (43c)
(f) Screen Question, Item 44b, page 26
____________ Number of times (44b)
(g) Screen Question, Item 45b, page 26
____________ Number of times (45b)
FIELD REPRESENTATIVE – After completing Check Item G, fill a separate crime incident report for each screen question that has an entry
of 1 or more. Do this before marking Check Item H.
Page 26
FORM NCVS-1 (9-16-2004)
INDIVIDUAL’S EMPLOYMENT QUESTIONS
Be sure to fill any incident reports before marking Check Item H.
CHECK
ITEM H
47a.
1
Is the respondent 16 years or older?
2
Did you have a job or work at a business LAST WEEK?
(Do not include volunteer work or work around the house.)
(If farm or business operator in household, ask about
unpaid work.)
576
1
2
Yes – Ask 47a
No – SKIP to Check Item I
Yes – SKIP to 48a
No – Ask 47b
ASK OR VERIFY –
47b.
Did you have a job or work at a business DURING THE
LAST 6 MONTHS?
47c.
Did that (job/work) last 2 consecutive weeks or
more?
577
1
2
578
1
2
Yes – Ask 47c
No – SKIP to Check Item I
Yes – Ask 48a
No – SKIP to Check Item I
ASK OR VERIFY –
48a.
Which of the following best describes your job?
579
PERSONAL INTERVIEW (Show flashcard)
TELEPHONE INTERVIEW – Were you employed in
the (Read main headings until you get a yes.
Then read answer categories) –
Medical Profession – As a –
Physician
Nurse
2
Technician
3
Other – Specify
4
1
Mental Health Services Field – Are your duties –
Professional (Social worker/psychiatrist)
Custodial care
6
Other – Specify
7
Mark (X) only one category.
5
Teaching Profession – Were you employed in a –
Preschool
Elementary
9
10
Junior high or middle school
High school
11
College or university
12
Technical or industrial school
13
Special education facility
14
Other – Specify
15
8
Law Enforcement or Security Field – Were you
employed as a –
16
Law enforcement officer
Prison or jail guard
17
Security guard
18
Other – Specify
19
Retail Sales – Were you employed as a –
Convenience or liquor store clerk
Gas station attendant
21
Bartender
22
Other – Specify
23
20
Transportation Field – Were you employed as a –
Bus driver
Taxi cab driver
25
Other – Specify
26
24
OR
27
48b.
ASK OR VERIFY –
Is your job with (Read answer categories) –
580
1
2
3
4
48c.
48d.
If box 12 is marked in 48a, mark without asking.
Are you employed by a college or university?
581
1
2
While working at your job, do you work mostly in (Read
answer categories) –
582
1
2
3
4
CHECK
ITEM I
Is this the last household member to be
interviewed?
Something else – Specify
A private company, business, or individual for wages?
The Federal government?
A State, county, or local government?
Yourself (Self-employed) in your own
business, professional practice, or farm?
Yes
No
A city?
Suburban area?
Rural area?
Combination of any of these?
Yes – END interview.
No – See note below before interviewing next
household member.
FIELD REPRESENTATIVE – If the current respondent is a parent or legal guardian and the next household member to be interviewed is
under 18, tell the current respondent that you will be asking the same questions you just asked him/her.
FORM NCVS-1 (9-16-2004)
Page 27
NOTES
Page 28
FORM NCVS-1 (9-16-2004)
| File Type | application/pdf |
| File Title | untitled |
| File Modified | 2008-01-24 |
| File Created | 2004-10-27 |