Appendix E

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YCLE58.wpd

ENGLISH
Cycle 58, SUMMER 2007
OMB NO.: 1205-0453
EXPIRATION DATE: January 31, 2008

5
COUNTY

8

FARM WORKER ID
[FOR OFFICE USE ONLY]

(REV.5/1/07)

NATIONAL AGRICULTURAL WORKERS SURVEY - 2007 (“NAWS”)
CS2

DATE:

/

/
[FOR OFFICE USE ONLY]

CROP CODE
CS5

CROP:

CS6 TASK:

TASK CODE

LANGUAGE DURING INTERVIEW: __________________
LOCATION OF INTERVIEW: ________________________
GN:

ID:
IF GN REFERRED TO CONTRACTOR, GROWER OR OTHER,
WRITE INFORMATION)
NAME :
_______________________________________
ADDRESS:
_______________________________________
TELEPHONE:
(_________)___________-________________

GN REFERRED TO:

9 “CONTRACTOR”?:
9 OTHER GROWER?
9 OTHER?:_______

WORKER IS ACTUALLY EMPLOYED BY?:
TYPE OF WORK?: 91 FIELD WORK

9 1 GROWER

92 NURSERY

9 2 CONTRACTOR

93 PACKING HOUSE

97 OTHER:________

FARM WORKER’S
NAME:
LOCAL ADDRESS:
TELEPHONE:
INTERVIEWER’S
NAME:
CP5 TIME BEGAN:

CS9 INTERVIEWER’S
ID:

:

9 AM
9 PM

CP6 TIME ENDED:

:

9 AM
9 PM

Public reporting burden for the collection of information is estimated to average between 50 and 65 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing this burden, to the Office of Information Management,
Department of Labor, Room N-1301, 200 Constitution Avenue, N.W., Washington, D.C. 20210; and to the Office of
Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

1

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HOUSEHOLD GRID

REFER TO QUESTIONS IN SECTION A:

58 ___ ___ ___ __

___ ___ ___ ___ ___
County

NAME

A.

S
E
X

F
M
F
C.

M
F

D.

M
F

E.

M
F

F.

M
F

G.

M
F

H.

A6

**A7

A9

**A10

A8

HIGHEST
GRADE LEVEL
MONTH
BIRTH COUNTRY [FOR MINORS COUNTRY AND YEAR
DATE OF BIRTH INCLUDE PRE- SCHOOL
FIRST
MM/YY [CODE]
SCHOOL
[CODE]
ENTERED
(“PS”) AND
U.S.?
KINDER (“K”)

A4

A16

M
F

S
M
O

/

S
M
O

/

S
M
O

/

S
M
O

/

S
M
O

/

S
M
O

/

S
M
O

/

S
M
O

/

A12

A13

A30

Y

/

N

Y

Y

Y

N

N

N

Y

Y

Y

N

N

N

/

/
Y

Y

Y

N

N

N

/
Y

Y

Y

N

N

N

/
Y

Y

Y

N

N

N

Y

Y

Y

N

N

N

Y

Y

Y

N

N

N

/

/

/

*CODES FOR A2 (RELATIONSHIP):
1 = SPOUSE/COMMON LAW SPOUSE
2 = OWN CHILD, DEPENDENT OR ADOPTED
3 = SIBLING
4 = PARENT
5 = GRANDCHILD
6 = OTHER RELATIVE (COUSINS, UNCLES, ETC.)
7 = OTHER: __________________________

Farmworker ID
A11

LAST 12
[UNDER 18]
[ASK ALL IN A1]:
MONTHS,
ANY U.S.
ANY
ANY U.S.
LAST 12
DOES S/HE LIVE WITH YOU
[NAME]
SCHOOL
U.S.
FW LAST MONTHS, EVER
NOW?
JOINED
LAST 12 WORK
12
ACCOMPANIED
IF NOT, WHERE?
YOU WHEN
MONTHS? NOW? MONTHS?
YOU TO THE
[STATE/COUNTRY]
TRAVELED
FIELD?
FOR FW?

(FARMWORKER)
M

B.

MARITAL

*A2 A3 A5

RELATION
[CODE]

A1

FW
NF
NW
FW
NF
NW
FW
NF
NW
FW
NF
NW
FW
NF
NW
FW
NF
NW
FW
NF
NW

Y

Y

N

N

Y

Y

N

N

Y

Y

N

N

Y

Y

N

N

Y

Y

N

N

Y

Y

N

N

Y

Y

N

N

** CODES FOR A7 AND A10 (COUNTRIES AND REGIONS):
1= U.S.A.
2= PUERTO RICO
3= MEXICO
4= CENTRAL AMERICA
5= SOUTH AMERICA
6= CARIBBEAN

2

7= SOUTHEAST ASIA (INDONESIA, CAMBODIA, VIETNAM, LAOS,
THAILAND)
8= PACIFIC ISLANDS (THE PHILIPPINES, GUAM, FIJI, ETC.)
9= ASIA (CHINA, JAPAN, KOREA, ETC.)
97= OTHER: _________________
99= NOT ANSWERED

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HOUSEHOLD GRID

REFER TO QUESTIONS IN SECTION A:

___ ___ ___ ___ ___

58 ___ ___ ___ ___

County

I.

A3

S
M
O

/

S
M
O

/

S
M
O

/

S
M
O

/

S
M
O

/

S
M
O

/

S
M
O

/

S
M
O

/

M

M
F

L.

M
F

M.

M
F

N.

M
F

O.

M
F

P.

M
F

**A7

A9

**A10

A8

A4

A16

A11

HIGHEST
GRADE
LAST 12
MONTH
[ASK ALL IN A1]:
LEVEL [FOR
AND
MONTHS,
ANY U.S.
BIRTH COUNTRY
DOES S/HE LIVE WITH
COUNTRY
MINORS
[NAME]
YEAR
SCHOOL
DATE OF BIRTH
SCHOOL
YOU NOW? IF NOT,
INCLUDE
JOINED YOU LAST 12
FIRST
MM/YY [CODE]
WHERE?
[CODE]
PRE-SCHOOL
ENTERED
WHEN
MONTHS?
[STATE/COUNTRY]
(“PS”) AND
U.S.?
TRAVELED
KINDER (“K”)
FOR FW?

M

F
K.

A6

S
E
X

F
J.

A5

MARITAL
STATUS

NAME

*A2

RELATION
[CODE]

A1

Y

Y

N

N

N

Y

Y

Y

N

N

N

Y

Y

Y

N

N

N

Y

Y

Y

N

N

N

Y

Y

Y

N

N

N

Y

Y

Y

N

N

N

Y

Y

Y

N

N

N

Y

Y

Y

N

N

N

/

/

/

/

/

/

/

*CODES FOR A2 (RELATIONSHIP):
1 = SPOUSE/COMMON LAW SPOUSE
2 = OWN CHILD, DEPENDENT OR ADOPTED
3 = SIBLING
4 = PARENT
5 = GRANDCHILD
6 = OTHER RELATIVE (COUSINS, UNCLES, ETC.)
7 = OTHER: __________________________

Y
/

Farmworker ID
A12

A13

A30

[UNDER 18]
ANY
LAST 12
ANY U.S. FW
U.S.
MONTHS, EVER
LAST 12
WORK
ACCOMPANIED
MONTHS?
NOW?
YOU TO THE
FIELD?
FW
NF
NW
FW
NF
NW
FW
NF
NW

Y

Y

N

N

Y

Y

N

N

Y

Y

N

N

FW
NF
NW

Y

Y

N

N

FW
NF
NW

Y

Y

N

N

FW
NF
NW

Y

Y

N

N

Y

Y

N

N

Y

Y

N

N

FW
NF
NW
FW
NF
NW

** CODES FOR A7 AND A10 (COUNTRIES AND REGIONS):
1= U.S.A.
2= PUERTO RICO
3= MEXICO
4= CENTRAL AMERICA
5= SOUTH AMERICA
6= CARIBBEAN

3

7= SOUTHEAST ASIA (INDONESIA, CAMBODIA, VIETNAM, LAOS,
THAILAND)
8= PACIFIC ISLANDS (THE PHILIPPINES, GUAM, FIJI, ETC.)
9= ASIA (CHINA, JAPAN, KOREA, ETC.)
97= OTHER: _________________
99= NOT ANSWERED

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[THE FOLLOWING QUESTIONS REFER TO OTHER INDIVIDUALS WHO LIVE WITH THE WORKER
AND WERE NOT MENTIONED IN THE “HOUSEHOLD GRID”!]
A15 Other than those you have already mentioned, how many people live with you now?
TOTAL

Out of those (TOTAL IN “A15” ), ...
...how many are: ...

A20
... your
relatives?

A16
... doing
FW?

A17
A18
How many
How many
are doing NF?
NW?

a. ...adults?
(18 years or older)?
b. ...children?
(17 years or younger)?
c. ...do not know age?

INSURANCE QUESTIONS ABOUT RESPONDENT AND HIS/HER FAMILY
(INDIVIDUALS IN THE “HOUSEHOLD GRID”)
A21

A23

Who has Health (Medical) Insurance in your family (in the U.S.A.)? ...
Who pays for it?
[ONLY FOR CHILDREN: IF YES, ASK HOW MANY OF THE CHILDREN [USE CODES. MARK ALL
How about...
UNDER AND OVER 18 YRS. OLD HAVE INSURANCE. MATCH TOTAL THAT APPLY]
NUMBER WITH FAMILY GRID]

a. ...you (farm
worker)?

b. ...your spouse?

90

NO

91

YES

97

DON’T KNOW

90

NO

91

YES

97

DON’T KNOW
A21c2

9 0 NO
9 1 YES, ALL HAVE IT [ASK

c. ...your
children?

92

95

9 6:

91

92

95

9 6:

91

92

95

9 6:

93

94

93

94

93

94

A24
(a) How many under 18 yrs?:

A23]

9 2 YES, ONLY
SOME HAVE IT

91

(b) How many over 18 yrs?:

9 7 DON’T KNOW

CODES FOR “A23” (WHO PAYS?):
1= I PAY

3= MY EMPLOYER

5= GOVERNMENT

2= MY SPOUSE

4= MY SPOUSE’S EMPLOYER

6= OTHER:

4

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B4 In the last 2 years, has anyone in your
G7 [ONLY FOR THOSE BORN OUTSIDE THE
U.S.A.] ...And in your home country, do you
household (from “Family Grid”)- excluding
own or are you buying any of the following
yourself - attended, training, special classes
items? [READ CHOICES. MARK ALL THAT APPLY]: ...
or schools in the U.S.? [READ CHOICES. MARK ALL
THAT APPLY]: ...

9 a. ...Adult Education such as English/
ESL/Adult Basic Education/ Citizenship?
9 d. ...Job training?:
9 f. ...GED (High School Equivalency)?
9 j. ...Migrant Education?
9 k. ...Head Start?
9 l. ...Migrant Head Start?
9 n. ...Other?:
9
Don’t know

9 a.
9 b.
9 c.
9 d.
9 e.
9 f.
9

B1 Which of the following describes you?

9 b.
9 c.
9 d.
9 e.
9 f.
9 g.
9 h.
9 i.
9 j.
9 k.
9 l.
9 m.
9 n.
9

...(TANF) Temporary assistance for
needy families?
...Food stamps?
...Disability insurance?
...Unemployment insurance?
...Social Security?
...Veteran’s pay?
...General assistance/welfare?
...Low income housing?
...Public Health Clinic?
...Medicaid?
...WIC?
...Disaster Relief?
...Legal Services?
...Other?:
Don’t know

91
92
93
95
94
97
B2

...Mexican-American?
...Mexican?
...Chicano?
...Puerto Rican?
...Other Hispanic?:
...Not Hispanic or Latino?
Which of the following do you consider
yourself? [READ CHOICES. MARK ONLY ONE
RESPONSE]: ...

9 1 ...White?
9 2 ...Black or African American?
9 4 ...American Indian/Alaskan Native,
Indigenous?
9 5 ...Asian?
9 6 ...Native Hawaiian or Pacific Islander?
9 7 ...Other?:

B3 Have you attended any of the following
special classes or school in the U.S.? [READ
CHOICES. MARK ALL THAT APPLY]: ...

G6 Do you own or are you buying any of the
following items in the U.S.? [READ CHOICES.

9 a.
9 b.
9 c.
9 d.
9 e.
9 f.
9 g.
9 h.
9 i.
9 j.
9

MARK ALL THAT APPLY]: ...

9 a.
9 b.
9 c.
9 d.
9 e.
9 f.
9

[READ

CHOICES. MARK ONLY ONE]: ...

G4 In the last 2 years, have you or anyone in
your household received benefits or used
the services of any of the following social
programs? [READ CHOICES. MARK ALL THAT APPLY]: ...

9 p.

...a plot of land?
...a house?
...a mobile home?
...a car/truck?
...a business?
...other?:
None

...a plot of land?
...a house?
...a mobile home?
...a car/truck?
...a business?
...other?:
None

5

...English/ESL?
...Citizenship?
...Literacy?
...Job training?:
...GED, High School Equivalency?
...College or University?
...Adult Basic Education?
...Even Start?
...Migrant Education?
...Other?:
None

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LANGUAGE SECTION

B7 How well do you speak English? [READ
CHOICES. MARK ONLY ONE RESPONSE]: ...
9 1 ...Not at all? 9 3
...Somewhat?
9 2 ...A little?
94
...Well?

B8 How well do you read English? [READ
CHOICES. MARK ONLY ONE RESPONSE]: ...
9 1 ...Not at all?
9 3 ...Somewhat?
9 2 ...A little?
9 4 ...Well?

B20
B21
When you were a child, in And now, as an adult, what languages can you speak?
what languages did adults
speak to you at home?
[FOR EACH CHECKED ANSWER, ASK]:
[CHECK ALL THAT APPLY] [CHECK
B22
B23
ALL
And
now,
how
well
do
you
And
now,
how
well do you
U THAT
read it? [READ CHOICES.
APPLY] speak it? [READ
CHOICES. MARK ONLY MARK ONLY ONE PER
U
ONE PER CHECK]:
CHECK]:

B24
In which language
do you believe you
are most dominant
(comfortable)
conversing?
[CHECK ONLY ONE]
U

a ENGLISH

b SPANISH

9 2 ...a little?
9 3 ...somewhat?
9 4 ...well?

9 1...not at all?
9 2...a little?
9 3...somewhat?
9 4...well?

c CREOLE

9 2 ...a little?
9 3 ...somewhat?
9 4 ...well?

9 1...not at all?
9 2...a little?
9 3...somewhat?
9 4...well?

d MIXTEC

9 2 ...a little?
9 3 ...somewhat?
9 4 ...well?

9 1...not at all?
9 2...a little?
9 3...somewhat?
9 4...well?

e KANJOBAL

9 2 ...a little?
9 3 ...somewhat?
9 4 ...well?

9 1...not at all?
9 2...a little?
9 3...somewhat?
9 4...well?

f ZAPOTEC

9 2 ...a little?
9 3 ...somewhat?
9 4 ...well?

9 1...not at all?
9 2...a little?
9 3...somewhat?
9 4...well?

z OTHER:

9 2 ...a little?
9 3 ...somewhat?
9 4 ...well?

9 1...not at all?
9 2...a little?
9 3...somewhat?
9 4...well?

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

B12 Approximately how many years have you done
non-farmwork in the U.S.? [COUNT ANY YEAR
IN WHICH 15 DAYS OR MORE WERE WORKED]
years

MONTH

/
/

YEAR

B11 Approximately how many years have you done
farmwork in the U.S.? [COUNT ANY YEAR IN
WHICH 15 DAYS OR MORE WERE
WORKED].

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

90
91
92
93
94
97

years

6

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

(REV.9/4/07)

B16

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[IF FOREIGN BORN] When you lived
in your country (outside the U.S.), did
you work in ... [READ CHOICES. MARK

D33a While you are working for this grower/
contractor, what type of payment
arrangement do you have for your living
quarters? [IF PAYMENT IS ONLY FOR
UTILITIES, CONSIDER IT FREE. DO NOT READ
CHOICES. MARK ONLY ONE]:

ONLY ONE RESPONSE.]:...

9 1 ...Agriculture [FW]?
9 2 ...Non-agriculture [NF]?
9 3 ...Part farm and part non-farm [FW
and NF]?
9 5 ...Never worked?
9 8 Not applicable [ONLY FOR THOSE
BORN IN THE U.S.]

B17

[IF FOREIGN BORN] In what country
(outside of the U.S.) did you live before
coming here (to the U.S.)?

B18 [IF FOREIGN BORN] Before coming
to the United States, in what state/
department/ province [OF COUNTRY IN
B17] did you live?

9 10 I (OR I AND MY FAMILY) RECEIVE FREE
HOUSING FROM MY EMPLOYER. [SKIP
TO D34A]

93

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

95

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

9 11 DO NOT PAY RENT. (I OR FAMILY
MEMBER OWN THE HOUSE OR LIVE
FOR FREE WITH FRIENDS OR
RELATIVES) [SKIP TO D34A]
9 12 I RENT FROM NON-EMPLOYER
(RELATIVE OR NON-RELATIVE)
9 97 OTHER:
D50 At this location how much do you pay for
housing (including housing for your family, if
they live with you)?

B18a. Were you born there [NAME OF
STATE, DEPARTMENT OR PROVINCE
IN B18]?

90
91

91

NO
YES [SKIP TO D33a]

B18b. [IF NOT BORN IN (NAME) OF B18],
Where were you born? [NAME OF
STATE, DEPARTMENT OR PROVINCE IN
FOREIGN COUNTRY]

per week $

,

.

or
per month $

,

.

or
per day

,

.

$

9 2 DON'T KNOW, TAKEN OUT OF MY
PAYCHECK
9 3 DON'T KNOW/DON'T REMEMBER, BUT
NOT TAKEN OUT OF MY PAYCHECK
9 7 OTHER:

7

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D34a In what type of living quarters do you live
now (housing structure at this location)?

D53

In your current living quarters, how many
rooms are used for sleeping?

[READ CHOICES. MARK ONLY ONE]:

...Is it a...
D52 How many people total sleep in these
rooms? [VERIFY RESPONSE BY ADDING

9 1 ...Mobile home?

TOTAL NUMBER GIVEN IN HOUSEHOLD GRID
PLUS TOTAL IN A15. IF ANSWERS DO NOT
MATCH MAKE APPROPRIATE CHANGES]

9 2 ...Single-family home (detached)?
9 3 ...Duplex, triplex, etc. (attached, own parking
space with direct access to home)?
9 4 ...Apartments (two or more in a building,
shared parking spaces)?

D36a [FOR PARENTS OF CHILDREN 12 OR
YOUNGER] During the past 12
MONTHS, where have your children, 12
and under, been while you work in U.S.
farm work? [CHECK ALL THAT APPLY]

9 5 ...Dormitory or barracks?
9 6 ...Campsite or tent?
9 7 ...Motel or hotel?
9 8 ...Without shelter, “homeless.” (Includes
“sleeping in a car”)? [SKIP TO D36a]
9 97

91

Other:

THEY'VE STAYED HOME ALONE, AT
LEAST SOMETIMES

9 13 WITH MY SPOUSE, OTHER FAMILY
D35 Where are your living quarters located?

9 14 WITH A NEIGHBOR / BABYSITTER,
MIGRANT HEAD START, HEAD START,
MIGRANT EDUCATION, DAYCARE
CENTER, ETC.

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

9 1 ...Off farm in property not owned or
administered by your present employer?

9 11 WITH ME IN THE FIELDS

9 2 ...Off farm in property owned or administered
by your present employer?

9 12 OTHER:

9 3 ...On farm of the grower you currently work
for?
9 7 ...Other?:

8

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WORK GRID

REFER TO QUESTIONS IN THE FOLLOWING SECTION

___ ___ ___ ___ ___
County

[C1-C2 FOR OFFICE USE ONLY]

58 ___ ___ ___ ___
Farmworker ID

C15

C3

C4

C5

C6

NW?
AB?
FW
NF

Y

FW?
GR
PER.
AND
SUB
PER.
NO.

CO
[FW
ONLY]

EMPLOYER’S
NAME ( FARM
WORK, NONFARM WORK
AND WORK
ABROAD)

CROP

WRITE
ACTIVITY OR
TASK WHILE
FW AND NF
[USE CODES
FOR *NW
AND**AB]

GR

NF?

CO

NW
AB

GR

FW
NF

CO

NW
AB

GR

FW
NF

CO

NW
AB

GR

FW
NF

CO

NW
AB

GR

FW
NF

CO

NW
AB

* C-5 ACTIVITY CODES: ONLY FOR “NW” (IN THE U.S.A.)
[WRITE ACTIVITY FOR FW AND NF]
201 = LOOKING FOR FW AND NF
WORK
202 = LOOKING FOR FARM WORK
203 = LOOKING FOR NF WORK
204 = WAITING FOR RECALL
NOTICE(AFTER LAYOFF)
205 = WAITING FOR START OF
SEASON

C8
RECEIVED
UNEMPLOYMENT?

C1-C2

206 = FAMILY RESPONSIBILITIES/
WORK IN HOME
207 = IN SCHOOL
208 = LAID UP DUE TO INJURY
209 = IN-TRANSIT BETWEEN JOBS
210 = VACATION
211 = DID NOT LOOK FOR WORK
212 = OTHER: (SPECIFY IN GRID)

C9

C10

DATES FOR PERIODS OF
FW, NF, NW, AB

FROM:

TO:

# OF
WORK
DAYS
PER
WEEK?
FW & NF

C11

C12

CITY

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

C13

C7

C16

STATE/COUNTRY

REPORT FROM FIRST PERIOD COVERING JUNE 01, 2006 TO PRESENT

***FW
AND
NF:
WHY
LEFT?

WERE YOUR
SPOUSE
AND KIDS
WITH YOU?

[CODES]

SPOUSE
CHILDREN
ALL
NO

COMMUTE FROM
MEXICO TO DO FW?
Y
N

N

SPOUSE
CHILDREN
ALL
NO

Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N

N

SPOUSE
CHILDREN
ALL
NO

Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N

N

SPOUSE
CHILDREN
ALL
NO

Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N

N

SPOUSE
CHILDREN
ALL
NO

Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N

N
** C-5 ACTIVITY CODES: ONLY FOR “AB” (WHILE IN A
FOREIGN COUNTRY OR ABROAD):
311 =
312 =
320 =
341 =
359 =
361 =
362 =
369 =

FW IN FAMILY RANCH
FW-HIRED
NF IN OWN BUSINESS: (SPECIFY IN GRID)
NF IN “MAQUILA”
NF- OTHER: (SPECIFY IN GRID)
NW - MEDICAL TREATMENT
NW - VACATION
NW - OTHER: (SPECIFY IN GRID)

9

*** C-7 CODES: WHY LEFT “FW” AND “NF”?
1 = LAID OFF/END OF SEASON
2 = FIRED
3 = FAMILY RESPONSIBILITIES
4 = SCHOOL
5 = MOVED
6 = HEALTH REASON
7 = VACATION

8
10
11
9

=
=
=
=

RETIRED
QUIT
CHANGE JOBS
OTHER (SPECIFY):

(REV.9/4/07)

S:\NAWSDOC\CYCLE58\ENGLISHCY58\JUNE13CYCLE58.wpd

WORK GRID

REFER TO QUESTIONS IN THE FOLLOWING SECTION

___ ___ ___ ___ ___

58 ___ ___ ___ ___

County

[C1-C2 FOR OFFICE USE ONLY]

Farmworker ID

C15

C3

C4

C5

C6

C8

C9
DATES FOR PERIODS OF
FW, NF, NW, AB

NW?
AB?

GR

FW
NF

Y

CO

NW
AB

GR

FW
NF

FW?
GR
PER.
AND
SUB
PER.
NO.

CO
[FW
ONLY]

EMPLOYER’S
NAME (FARM
WORK, NONFARM WORK
AND WORK
ABROAD)

CROP

WRITE
ACTIVITY OR
TASK WHILE
FW AND NF
[USE CODES
FOR *NW
AND**AB]

NF?

CO

NW
AB

GR

FW
NF

CO

NW
AB

GR

FW
NF

CO

NW
AB

GR

FW
NF
NW
AB

CO
* C-5 ACTIVITY CODES: ONLY FOR “NW” (IN THE U.S.A.)
[WRITE ACTIVITY FOR FW AND NF]
201 = LOOKING FOR FW AND NF
WORK
202 = LOOKING FOR FARM WORK
203 = LOOKING FOR NF WORK
204 = WAITING FOR RECALL
NOTICE(AFTER LAYOFF)
205 = WAITING FOR START OF
SEASON

206 = FAMILY RESPONSIBILITIES/
WORK IN HOME
207 = IN SCHOOL
208 = LAID UP DUE TO INJURY
209 = IN-TRANSIT BETWEEN JOBS
210 = VACATION
211 = DID NOT LOOK FOR WORK
212 = OTHER: (SPECIFY IN GRID)

FROM:

C10

TO:

# OF
WORK
DAYS
PER
WEEK?
FW & NF

C11

C12

CITY

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

C13

C7

STATE/COUNTRY

C1-C2

RECEIVED
UNEMPLOYMENT?

REPORT FROM FIRST PERIOD COVERING JUNE 01, 2006 TO PRESENT

***FW
AND
NF:
WHY
LEFT?

C16

WERE
YOUR
SPOUSE
AND KIDS
WITH YOU?

[CODES]

SPOUSE
CHILDREN
ALL
NO

COMMUTE FROM
MEXICO TO DO FW?
Y
N

N

SPOUSE
CHILDREN
ALL
NO

Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N

N

SPOUSE
CHILDREN
ALL
NO

Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N

N

SPOUSE
CHILDREN
ALL
NO

Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N

N

SPOUSE
CHILDREN
ALL
NO

Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N

N
** C-5 ACTIVITY CODES: ONLY FOR “AB” (WHILE IN
A FOREIGN COUNTRY OR ABROAD):
311 =
312 =
320 =
341 =
359 =
361 =
362 =
369 =

FW IN FAMILY RANCH
FW-HIRED
NF IN OWN BUSINESS: (SPECIFY IN GRID)
NF IN “MAQUILA”
NF- OTHER: (SPECIFY IN GRID)
NW - MEDICAL TREATMENT
NW - VACATION
NW - OTHER: (SPECIFY IN GRID)

10

*** C-7 CODES: WHY LEFT “FW” AND “NF”?
1 = LAID OFF/END OF SEASON
2 = FIRED
3 = FAMILY RESPONSIBILITIES
4 = SCHOOL
5 = MOVED
6 = HEALTH REASON
7 = VACATION

8
10
11
9

=
=
=
=

RETIRED
QUIT
CHANGE JOBS
OTHER (SPECIFY):

(REV.9/4/07)

S:\NAWSDOC\CYCLE58\ENGLISHCY58\JUNE13CYCLE58.wpd

WORK GRID

REFER TO QUESTIONS IN THE FOLLOWING SECTION

___ ___ ___ ___ ___
County

[C1-C2 FOR OFFICE USE ONLY]

58 ___ ___ ___ ___
Farmworker ID

C15

C3

C4

C5

C6
FW?
NF?

CROP

WRITE
ACTIVITY OR
TASK WHILE
FW AND NF
[USE CODES
FOR *NW AND
**AB]

NW?
AB?

GR

FW
NF

Y

CO

NW
AB

GR

FW
NF

CO

NW
AB

GR

FW
NF

CO

NW
AB

GR

FW
NF

GR
PER.
AND
SUB
PER.
NO.

C8
RECEIVED
UNEMPLOYMENT?

C1-C2

CO
[FW
ONLY]

EMPLOYER’S
NAME FOR:
FW, NF AND
WORK AB

CO

NW
AB

GR

FW
NF

CO

NW
AB

* C-5 ACTIVITY CODES: ONLY FOR “NW” (IN THE U.S.A.)
[WRITE ACTIVITY FOR FW AND NF]
201 = LOOKING FOR FW AND NF
WORK
202 = LOOKING FOR FARM WORK
203 = LOOKING FOR NF WORK
204 = WAITING FOR RECALL
NOTICE(AFTER LAYOFF)
205 = WAITING FOR START OF
SEASON

206 = FAMILY RESPONSIBILITIES/
WORK IN HOME
207 = IN SCHOOL
208 = LAID UP DUE TO INJURY
209 = IN-TRANSIT BETWEEN JOBS
210 = VACATION
211 = DID NOT LOOK FOR WORK
212 = OTHER: (SPECIFY IN GRID)

C9

C10

DATES FOR PERIODS OF
FW , NF, NW, AB

FROM:

TO:

# OF
WORK
DAYS
PER
WEEK?
FW & NF

C11

C12

CITY

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

C13

C7

STATE/COUNTRY

REPORT FROM FIRST PERIOD COVERING JUNE 01, 2006 TO PRESENT

***FW
AND
NF:
WHY
LEFT?

SPOUSE
CHILDREN
ALL
NO
SPOUSE
CHILDREN
ALL
NO

Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N

N

SPOUSE
CHILDREN
ALL
NO

Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N

N

SPOUSE
CHILDREN
ALL
NO

Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N

N

SPOUSE
CHILDREN
ALL
NO

Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N

N
** C-5 ACTIVITY CODES: ONLY FOR “AB” (WHILE
IN A FOREIGN COUNTRY OR ABROAD):
311 =
312 =
320 =
341 =
359 =
361 =
362 =
369 =

FW IN FAMILY RANCH
FW-HIRED
NF IN OWN BUSINESS: (SPECIFY IN GRID)
NF IN “MAQUILA”
NF- OTHER: (SPECIFY IN GRID)
NW - MEDICAL TREATMENT
NW - VACATION
NW - OTHER: (SPECIFY IN GRID)

11

WERE
YOUR
SPOUSE
AND KIDS
WITH YOU?

[CODES]

COMMUTE FROM
MEXICO TO DO FW?
Y
N

N

C16

*** C-7 CODES: WHY LEFT “FW” AND “NF”?
1 = LAID OFF/END OF SEASON
2 = FIRED
3 = FAMILY RESPONSIBILITIES
4 = SCHOOL
5 = MOVED
6 = HEALTH REASON
7 = VACATION

8
10
11
9

=
=
=
=

RETIRED
QUIT
CHANGE JOBS
OTHER (SPECIFY):

(REV.9/4/07)

S:\NAWSDOC\CYCLE58\ENGLISHCY58\JUNE13CYCLE58.wpd

WORK GRID

REFER TO QUESTIONS IN THE FOLLOWING SECTION

___ ___ ___ ___ ___

58 ___ ___ ___ ___

County

Farmworker ID

[C1-C2 FOR OFFICE USE ONLY]

C15

C3

C4

C5

C8

C9
DATES FOR PERIODS OF
FW,NF, NW,AB

NW?
AB?

GR

FW
NF

Y

CO

NW
AB

GR

FW
NF

CO

NW
AB

GR

FW
NF

CO

NW
AB

GR

FW
NF

CO

NW
AB

GR

FW
NF

CO

NW
AB

FW?

GR
PER.
AND
SUB
PER.
NO.

CO
[FW
ONLY]

C6

EMPLOYER
(FARM WORK,
NON-FARM AND
ABROAD JOB)

CROP

ACTIVITY OR
TASK WHILE
FW AND NF
[USE CODES
FOR *NW AND
**AB]

NF?

* C-5 ACTIVITY CODES: ONLY FOR “NW” (IN THE U.S.A.)
[WRITE ACTIVITY FOR FW AND NF]
201 = LOOKING FOR FW AND NF
WORK
202 = LOOKING FOR FARM WORK
203 = LOOKING FOR NF WORK
204 = WAITING FOR RECALL
NOTICE(AFTER LAYOFF)
205 = WAITING FOR START OF
SEASON

206 = FAMILY RESPONSIBILITIES/
WORK IN HOME
207 = IN SCHOOL
208 = LAID UP DUE TO INJURY
209 = IN-TRANSIT BETWEEN JOBS
210 = VACATION
211 = DID NOT LOOK FOR WORK
212 = OTHER: (SPECIFY IN GRID)

FROM:

C10

TO:

# OF
WORK
DAYS
PER
WEEK?
FW & NF

C11

C12

CITY

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

C13

C7

STATE/COUNTRY

C1-C2

RECEIVED
UNEMPLOYMENT?

REPORT FROM FIRST PERIOD COVERING JUNE 01, 2006 TO PRESENT

***FW
AND
NF:
WHY
LEFT?

SPOUSE
CHILDREN
ALL
NO
N/A
SPOUSE
CHILDREN
ALL
NO
N/A

Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N

N

SPOUSE
CHILDREN
ALL
NO
N/A

Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N

N

SPOUSE
CHILDREN
ALL
NO
N/A

Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N

N

SPOUSE
CHILDREN
ALL
NO
N/A

Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N

N
** C-5 ACTIVITY CODES: ONLY FOR “AB” (WHILE
IN A FOREIGN COUNTRY OR ABROAD):
311 =
312 =
320 =
341 =
359 =
361 =
362 =
369 =

FW IN FAMILY RANCH
FW-HIRED
NF IN OWN BUSINESS: (SPECIFY IN GRID)
NF IN “MAQUILA”
NF- OTHER: (SPECIFY IN GRID)
NW - MEDICAL TREATMENT
NW - VACATION
NW - OTHER: (SPECIFY IN GRID)

12

WERE
YOUR
SPOUSE
AND KIDS
WITH YOU?

[CODES]

COMMUTE FROM
MEXICO TO DO FW?
Y
N

N

C16

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

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

8
10
11
9

=
=
=
=

RETIRED
QUIT
CHANGE JOBS
OTHER (SPECIFY):

(REV.9/4/07)

S:\NAWSDOC\CYCLE58\ENGLISHCY58\JUNE13CYCLE58.wpd

D1 [SHOW CALENDAR] In the year before last
[FROM JUNE 2005 TO JUNE 2006] YEAR
BEFORE THE ONE COVERED IN WORK
GRID], how many months did you
do (FW) in the U.S.? [1 DAY OR MORE PER

D61 Were you paid by [READ CHOICES. MARK
ONE RESPONSE]:...

9 1 ...payroll check?
9 4 ...other check?
9 2 ...personal check? 9 5 ...cash?
9 3 ...cash and check? 9 6 ...other:

MONTH EQUALS 1 MONTH]

months

D62

Did you get a receipt?

D2 [IF NON-FARM JOB LISTED ON WORK GRID]:
9 0 NO
9 1 YES
For your most recent non-farm (NF) employer,
how many hours per week did you work on
D7 For what time period was that payment?
average?
9 1 one day?
9 4 one month?
9 2 one week? 9 7 other?:
hours
9 3 two weeks?
D3 [IF NON-FARM JOB LISTED] For your most
recent non-farm employer (NF), how much were
you paid per week on average?
$

,

D8 How many hours did you work during that
period (in D7)?

.

hours
D9 Now - with your current employer - you
already told me that the crop you are
currently working is:...

CURRENT FARM JOB
Now I am going to ask you some questions about
the crop/task you are CURRENTLY performing for
the EMPLOYER through whom we contacted you
[LAST PERIOD IN WORK GRID].

D10

D4 How many hours did you work last week at
your current farm job?

And you told me that - with your current
employer - the task you are now doing is:

hours
D11 Are you paid: ...
9 1 ...by the hour?
[D5 TO D8: IF SHE/HE HAS NOT RECEIVED
9 2 ...by the piece? [SKIP TO D13]
PAYMENT YET FOR CURRENT CROP, ASK FOR
9 3 ...combination hourly wage and piece
ESTIMATES]: Can you tell me how you were paid
rate? [ASK D12 THRU D18]
and the amount your employer paid you on your last
9
4
...salary or other? [SKIP TO D19]
pay day?
D5

D12 How much per hour (to nearest cent)? [IF

After taxes:
$

D6

,

PAID ONLY BY THE HOUR, ENTER AMOUNT
AND SKIP TO D20. IF COMBINATION, ENTER
AMOUNT AND CONTINUE WITH D13]:

.

Before taxes:
$

,

$

.

13

.

Per hour

(REV.9/4/07)

S:\NAWSDOC\CYCLE58\ENGLISHCY58\JUNE13CYCLE58.wpd)

D20 In the last 12 months, aside from your
wages, have you received (do you receive)
D13 [IF PAID BY THE PIECE]: Are you paid as
any money bonus from your current
an individual or by the crew? [IF THE
employer?
ANSWER IS "CREW", ASK QUESTIONS D14 to
D18 CONSISTENTLY IN REFERENCE TO THE
CREW]

91
92

9 0 NO [SKIP TO D22]
9 1 YES
9 7 DON’T KNOW [SKIP TO D22]

INDIVIDUAL [SKIP TO D15]
CREW

D14 [IF CREW PIECE RATE]: How many
people are in your crew? [ONE IS NOT A

D21 [IF PAID A BONUS]: How and when do
you receive the money bonus? [READ
CHOICES. MARK ALL THAT APPLY]:...

POSSIBLE ANSWER]

9 g.
9 a.
9 b.
9 c.
9 d.
9 e.
9 f.

D15 [IF BY PIECE]: How do they pay you/your
crew [i.e., UNIT OF MEASURE SUCH AS BOX,
BIN, BUCKET, ETC.]?

...retention (return or rehire) bonus?
...holiday bonus?
...incentive bonus (rewards)?
...dependent on grower profit?
...end of season bonus?
...money for transportation?
...Other?:

D16 [IF BY PIECE]: How many of these (in D15
D63 How much have you been given (TOTAL
e.g., boxes, bins, buckets, etc.) you/your
last 12 months with current employer)?
crew do in an average day?
$

,

.

D17 [IF BY PIECE]: How many hours per day
D22 If you are injured at work or get sick as a
you/your crew work on average at this task?
result of your work, does your employer
provide health insurance or pay for your
hours
health care?
D18 [IF BY PIECE]: How much do “they” pay
you/your crew on average for each (box bin,
bucket, etc. In D15)?
$

,

.

D19 [IF PAID BY SALARY, OR OTHER]:
Explain fully how and how much you are
paid (salary or other). Explain thoroughly
the method and amount of payment.

90
91

NO
YES

97

DON’T KNOW

D23 If you are injured at work or get sick as a
result of your work, do you get any payment
while you are recuperating (i.e., “workers'
compensation”)?

90
91

NO
YES

97

DON’T KNOW

[USE BACK OF PAGE IF NEEDED]:

D24 If you are injured or get sick off the job
(e.g., at home), does your employer provide
health insurance or pay for your health
care? [WHETHER OR NOT THE WORKER
TAKES IT OR USES IT]

90
91
97
(REV. 9/4/07)

NO
YES
DON’T KNOW
S:\NAWSDOC\CYCLE58\ENGLISHCY58\JUNE13CYCLE58.wpd

14

D26 Are you covered by unemployment
insurance if you lose this job?

90
91

No
Yes

D37a How far is your current job from your
current residence?

91
92
93
94
95
96

9 7 Don’t know

D27 How many years have you worked for this
employer? [ONE DAY/PER YEAR=ONE YEAR]
years

D37 At your current job, how do you usually get
to work? [READ CHOICES. MARK ONE]:...

D28 Do you work for (current employer) year
round or on a seasonal basis?

90
91
97

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

9 1 ...Drive car? [SKIP TO D39a]
9 2 ...Walk [SKIP TO D39a]
9 5 ...Public transportation (bus, train, etc.)?

Year round [SKIP TO D30]
Seasonal
Don’t know (first time) [SKIP TO D30]

[SKIP TO D39a]

96
98
94
97

D29 [IF WORKED ON A SEASONAL BASIS AND
LAID OFF WHEN THE SEASON ENDED]

Does this employer keep in contact with you
about future employment? [READ CHOICES.

...Labor bus, truck, van?
...“Raitero”:?
...Ride with others (shares ride)?
...Other?:

D38a Do you have to use the transport (in
D37) (IS IT MANDATORY OR
OBLIGATORY)?

MARK ALL THAT APPLY]: ...

9 a. ... Yes, before leaving at the end of the
season?
9 b. ... Yes, by letter (written message)?
9 c. ... Yes, by phone/in person?
9 d. ... Yes, by someone else?
9 e. ... No, you contact employer?
9 f. ... Other?:
9
Don’t know

9 0 NO

9 1 YES

D38 Do you pay a fee to (responsible in D37
and/or "raiteros") for rides to work?

90
91
92

NO
YES, A FEE
YES, JUST FOR GAS

D30 How did you get this job? [DO NOT READ
CHOICES. MARK ONLY ONE RESPONSE]

D39a At your current job, who pays for the
equipment you use at work? [READ

9 1 I APPLIED FOR THE JOB ON MY OWN
9 4 I WAS RECRUITED BY A GROWER OR HIS

CHOICES. MARK ONLY ONE]:...

91
92
93
95
96
910

...don't need any equipment?
...(you) pay all?
...the grower/contractor pays all?
...a friend/relative pays some or all?
...(you) pay some?
...(you) pay only for replacement of
damaged tools?
911 ... the grower/contractor provides you with
tools, but you prefer to buy/bring your
own?
912 ...the grower/contractor provides some
and you have to bring/buy the rest?
9 97 ...Other?:

FOREMAN

9 5 I WAS RECRUITED BY FARM LABOR
CONTRACTOR OR HIS FOREMAN

9 6 I WAS REFERRED BY THE EMPLOYMENT
9
9

SERVICE
7 I WAS REFERRED BY THE WELFARE
OFFICE
8 I WAS REFERRED BY RELATIVE / FRIEND /
WORKMATE
9 I WAS REFERRED BY LABOR UNION
10 DAY LABORER/PICKED UP AT SHAPE UP

9
9
9 97 Other:

15

(REV.9/4/07)

S:\NAWSDOC\CYCLE58\ENGLISHCY58\JUNE13CYCLE58.wpd

“Now I’m going to aks you some questions
about your individual and family income for
last year (2006)”...

G3 What was your family’s total income last
year - in 2006 - in U.S. dollars [U.S.
EARNINGS FW AND NF FOR ALL IN
“FAMILY GRID”]? [READ OR SHOW

G1 What was your total personal income last
year - in 2006 - in U.S. dollars [U.S. earnings
only FOR FW AND NF]? [READ OR SHOW

CHOICES. MARK ONLY ONE]

90
91
92
93
94
95
96
97
98
99
9 10
9 11
9 12
9 13
9 14
9 15
9 97

CHOICES. MARK ONLY ONE]

90
91
92
93
94
95
96
97
98
99
9 10
9 11
9 12
9 13
9 14
9 15
9 97

did not work AT ALL IN 2006
less than 500
500 to 999
1,000 to 2,499
2,500 to 4,999
5,000 to 7,499
7,500 to 9,999
10,000 to 12,499
12,500 to 14,999
15,000 to 17,499
17,500 to 19,999
20,000 to 24,999
25,000 to 29,999
30,000 to 34,999
35,000 to 39,999
Over 40,000
Don’t remember (Don’t know)

E1

G2 How much of that income was from
agricultural employment (U.S. earnings
only)? [READ/SHOW CHOICES. MARK ONLY

At any time during the last 2 years (in the
U.S.), were you covered by a union
contract while doing farm work (FW)?

9 0 No
9 1 Yes
9 7 Don’t know

ONE]

90
91
92
93
94
95
96
97
98
99
9 10
9 11
9 12
9 13
9 14
9 15
9 97

we did not work AT ALL IN 2006
Under 500
500 to 999
1,000 to 2,499
2,500 to 4,999
5,000 to 7,499
7,500 to 9,999
10,000 to 12,499
12,500 to 14,999
15,000 to 17,499
17,500 to 19,999
20,000 to 24,999
25,000 to 29,999
30,000 to 34,999
35,000 to 39,999
Over 40,000
Don’t remember (Don’t know)

did not work in FW in 2006
Under 500
500 to 999
1,000 to 2,499
2,500 to 4,999
5,000 to 7,499
7,500 to 9,999
10,000 to 12,499
12,500 to 14,999
15,000 to 17,499
17,500 to 19,999
20,000 to 24,999
25,000 to 29,999
30,000 to 34,999
35,000 to 39,999
Over 40,000
Don’t remember (Don’t know)

E2

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

9 1 Less than one year 9 2 One to three
years
9 3 Four to five years
9 4 Over five years
9 5 Over five years/ as 9 7 Other?:
long as I am able

E4 Could you get a U.S. non-farm job (NF)
within a month?

90
91
97

16

No
Yes
Don’t know

(REV.9/4/07)

S:\NAWSDOC\CYCLE58\ENGLISHCY58\JUNE13CYCLE58.wpd

NP – HANDLING PESTICIDES (IN THE U.S.A.)
NP1f. In the last 12 months, have you loaded, mixed or applied pesticides?
90
NO [SKIP TO “SECTION NT2a”]
91
YES
P10

P11

Which of the following classes of
pesticides have you loaded, mixed or
applied in the last 12 months (in the USA,
doing FW)?

a ...Insecticide?
b ...Herbicide?
c

...Fungicide?

d ...Rodenticide?
z

...Other. Specify:_____

f

..Don’t know the type?

90
91
90
91
90
91
90
91
90
91
90
91

P12

[IF YES:] When
was the last
time?
[MONTH/YEAR]

NAME OF
CROP?

P13
[IF WITHIN THE
LAST 30 DAYS IN
P11]

How many
days?

No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes

NT – TRAINING AND INSTRUCTIONS

NT2a.

In the last 12 months, with your current employer, has anyone given you training or
instructions in the safe use of pesticides (through video, audio, cassette, classroom
lectures, written material, informal talks or by any other means)?

90

91

NO

YES

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

NS1 ... (potable) clean drinking water and
disposable cups?
90
91
92
97

NS4 ... a toilet (EVERY DAY)?
90
91
97

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

NS9

... (provide) water to wash hands (EVERY
DAY)?
90
91
97

(REV.9/4/07)

NO
YES
DON’T KNOW

NO
YES
DON’T KNOW

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17

AL. ALCOHOL CONSUMPTION

AL1 In the last 12 months, in a typical week, about how
many alcoholic drinks did you consume? (A drink is
the equivalent of 1 bottle of beer, 1 glass of wine, 1
can or bottle of wine cooler, 1 cocktail or 1 shot or
jigger of liquor). [MARK ONLY ONE]

9 1 Did not drink any alcohol in the past year
9 2 Less than 1 drink (drank some alcohol in the past
year, but less than once a week)

9 3 1-2 drinks per week
9 4 3-4 drinks per week
9 5 5-6 drinks per week
9 6 7-13 drinks per week (between 1 and 2 drinks a day)
9 7 14 or more drinks per week (at least 2 drinks a day)

9 97

Don’t know, not sure, refused [SKIP to NH]

AL2 During the last 12 months, about how often
did you drink five or more alcoholic drinks
in a single day? [MARK ONLY ONE]

91

Never in the past year

92
93
94

1 or 2 times in the last 12 months
3 to 6 times in the last 12 months
7 to 11 times in the last 12 months

95
96

Once a month
2 to 3 times a month

97
98
99

Once a week
2 times a week
3-4 times a week

9 10
9 11

Nearly every day
Every day

9 97

Don’t know, not sure, refused

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

NH1
...asthma?

9 0 NO

9 0 NO

9 1 YES

9 1 YES

NH2
...diabetes?

9 0 NO

9 0 NO

9 1 YES

9 1 YES

NH3
...high blood pressure?

9 0 NO

9 0 NO

9 1 YES

9 1 YES

9 0 NO

9 0 NO

9 1 YES

9 1 YES

9 0 NO

9 0 NO

9 1 YES

9 1 YES

NH4
...tuberculosis?
NH5
...heart disease?

NH6
9 0 NO
...urinary tract infections?
9 1 YES

9 0 NO

NH10
...Other?:

9 0 NO

9 0 NO

9 1 YES

9 1 YES

9 1 YES

(REV.9/4/07)

9 0 NO
9 1 YES, IN THE U.S.A.
9 2 YES, “AB”:
90
91
92

NO
YES, IN THE U.S.A.
YES, “AB”:

90
91
92

NO

90
91
92

NO

90
91
92

NO

90
91
92

NO

90
91
92

NO

YES, IN THE U.S.A.
YES, “AB”:
YES, IN THE U.S.A.
YES, “AB”:
YES, IN THE U.S.A.
YES, “AB”:
YES, IN THE U.S.A.
YES, “AB”:
YES, IN THE U.S.A.
YES, “AB”:

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18

NQ5 And, ...the last time you used the health care
provider, who paid the majority of the cost?
NQ – QUALITY OF AND ACCESS TO HEALTH

91
92
93
94
95

CARE SECTION
[INTERVIEWER]: I would like to ask you a few
final questions about health care in general. You
may have given me some of this information
already, but I would like to make sure it is correct.

I PAID THE BILL OUT OF “MY OWN POCKET”
MEDICAID / MEDICARE
PUBLIC CLINIC DID NOT CHARGE
EMPLOYER PROVIDED HEALTH PLAN
SELF OR FAMILY BOUGHT INDIVIDUAL HEALTH
PLAN
BILLED, BUT DID NOT PAY

98
9 9 WORKER’S COMPENSATION
9 6 OTHER PLAN:
9 7 COMBINATION OF:

NQ1 In the last TWO YEARS [SINCE JUNE
2005, 2 YEARS AGO, UNTIL NOW (JUNE
2007)], in the U.S.A., have you used any
type of health care services from doctors,
nurses, dentists, clinics, or hospitals?

NQ8 [ASK ALL]: ...And here, in the USA, when
you want to get health care, what are the
main difficulties you face? [CHECK ALL THAT
APPLY.]

90
91

NO [SKIP TO NQ8]
YES

9 a. NO TRANSPORTATION, TOO FAR AWAY
9 b. DON’T KNOW WHERE SERVICES ARE

NQ3b ...And the last time you used the health care
provider, where did you go (what kind of
place was it)?

91
92
93
94
95
96
97
98

AVAILABLE

9 c.
9 d.
9 e.
9 f.

COMMUNITY HEALTH CENTER/
PRIVATE MEDICAL DOCTOR’S
OFFICE/PRIVATE CLINIC
HEALER/ “CURANDERO”
HOSPITAL
EMERGENCY ROOM
MIGRANT HEALTH CLINIC
CHIROPRACTOR OR NATUROPATH’S
OFFICE
DENTIST

9 10 OTHER:
9 97 DON’T KNOW

HEALTH CENTER NOT OPEN WHEN NEEDED
THEY DON’T PROVIDE THE SERVICES I NEED
THEY DON’T SPEAK MY LANGUAGE
THEY DON’T TREAT ME WITH RESPECT / I
DON’T FEEL WELCOMED
THEY DON’T UNDERSTAND MY PROBLEMS

9 g.
9 h. I’LL LOSE MY JOB
9 i. TOO EXPENSIVE/ NO INSURANCE
9 j. OTHER:
9
9 l.

NO DIFFICULTIES
I’M “UNDOCUMENTED” / “NO PAPERS” (THAT’S
WHY THEY DON’T TREAT ME WELL)

NQ1a.

(How about) In a foreign country (e.g.
Mexico), have you used any type of
health service IN THE LAST TWO
YEARS [IF “YES,” ASK AND ENTER
COUNTRY]

90

NO

91

YES, in:
[NAME OF COUNTRY]

19

(REV.9/4/07)

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LEGAL STATUS
We are interested in knowing whether any of the following apply to you. Please be assured that no one
besides us will know your response.

L1

What is your current legal status in the U.S.? [READ

L2

CHOICES IF NECESSARY]

PROGRAMS [DO NOT READ
OPTIONS]

9 1 I am a U.S. citizen by birth [SKIP TO NEXT PAGE]

91

Amnesty under 5 year program

9 2 I am a naturalized U.S. citizen (foreign born, naturalized).

92

Amnesty under SAW (90 day)
program

93

Cuban/Haitian entrant

94

Spousal petition
program/Family unity

the U.S.) [ASK L2: “Under which program did you apply?”
(Possible answers: 1 - 9, 97). THEN ASK: L4-1 and L4-2]

95

Labor certification program

9 4 Border crossing card/Commuter Card (right to cross the

96

Registry program

97

Political asylum

98

Refugee

99

Protective status (temporary)

9 10

Guest worker (H2A) program

9 11

Student

9 12

Tourist

9 13

Border crossing card/ “passport”

9 97

Other.

9 99

Not answered

[ASK: “Before becoming a naturalized U.S. citizen, under
which program did you apply to obtain your permanent
residence?” (Possible answers in L2: 1 - 9, 97). THEN ASK:
L4-1, L4-2, and L4-3]

9 3 Permanent resident/Green Card (right to reside and work in

border and work in the U.S.) [ASK L2: “Under which program
did you apply?” (Possible answers: 1 - 9, 97). THEN ASK:
L3, L4-1 and L4-2]

9 5 Pending status (without documents, applied, awaiting official
decision) [ASK L2: “Under which program did you apply?”
(Possible answers: 1- 9, 97). THEN ASK: L3, and L41]

9 6 Undocumented (application denied/did not apply to any
programs) [Possible answers: “None”. SKIP TO NEXT
PAGE]

9 7 Temporary resident-non immigrant Visa (Only for specified
time) [ASK L2: “Under which program did you apply?”
Possible answers: 10 - 97. THEN ASK: L3 and L41]

9 8 Other [If relevant and appropriate ASK L2, L3, L4-1, L4-2,
and L4-3. THEN SKIP TO NEXT PAGE]:

L3 Do you have general work authorization?: 9 0 No

L4
1 When did you apply to the
program (in L2)?

/
(Month) /

9 1 Yes

9 9 Not answered

DATE STATUS BECAME EFFECTIVE:
2 [Only for those who responded
3 [Only for those who
"2,3, or 4" in L1]: When did you
responded "2" in L1]: When
obtain your legal status?
did you obtain your
naturalization/ become a U.S.
citizen?
/

(Year)

9 7 Don’t know

/

(Month) /

(Year)

20

(Month) /

(Year)

Individual Agreement to be a Research Subject
OMB NO.: 1205-0453

Introduction/Purpose
You are invited to participate in this study for the National Institute for Occupational Safety and Health and the
Department of Labor because you are currently working on a farm. The purpose of the study is to learn more
about the living conditions and health of farm workers.
Procedures to be followed
You will be asked to answer some questions about your work history and about your health. The interview will
last approximately 60 minutes.
Risks
Since we will only be asking you questions, there is very little risk to you as a result of being in the study. You
may refuse to answer any question at any time, with no penalty.
Benefits
There are no direct benefits to you from being in the study. But, knowledge gained through this research may
help us learn how to prevent any harmful effects of farm work for workers like you.
Confidentiality
Your answers to the interview will be kept private to the extent allowed by law. This means that the interview
record will be kept in a locked file, and only researchers on the study will be allowed to see it. Your name will
not appear on any reports about the study. (See back of page for details.)
Alternatives to participation
Participating in this study is voluntary and you can quit at any time. You can also choose not to participate in
any part of the study at any time, with no penalty. Whether or not you participate in this study will not affect
benefits and services to which you are normally entitled. You will be paid for the time you are spending in this
interview. However, if you choose not to participate in sections of the interview you may not receive the full
payment. At any time, you may ask the researchers to explain any part of the study.
Who to call with questions
If you have questions about the research study, including questions about your rights as a research subject,
you may call Aguirre International (toll free) at (877) 850-5200. They will refer your questions to Daniel
Carroll at the Department of Labor, at (202) 693-2975.
I have read and understand the statement above. My questions about any unclear or confusing statements
have been answered clearly. I agree to participate in this study as a research subject. I admit that I have
received a copy of this form and $20 for my participation.

------------------------------------------------------------------ ------------------------------------Signature of Subject
Date
(See reverse)

21

In accordance with the Privacy Act of 1974, as amended (5
U.S.C.552a), we are notifying you that this study is authorized by the
U.S. Department of Labor, Employment and Training Administration
(ETA). Your voluntary participation is important to the success of
this study and will enable the ETA to understand the labor market
and living experiences of U.S. farmworkers. Under written
agreement with research organizations, the ETA may release certain
information necessary for research but only after all identifying
information has been removed. Unless required by law, or necessary
for litigation or legal proceedings and except as indicated in this
statement, we will hold all personal identifiers (e.g. name, address,
and social security number) in total confidence and will not release
them.

Public reporting burden for the collection of information is estimated to average 1 hour (or 60
minutes) per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Send comments regarding this burden estimate or any other aspect
of this collection of information, including suggestions for reducing this burden, to the Office of
Information Management, Department of Labor, Room N-1301, 200 Constitution Avenue,
N.W., Washington, D.C. 20210; and to the Office of Information and Regulatory Affairs, Office
of Management and Budget, Washington, D.C. 20503.