Alternative Housing Pilot Program Evaluation Baseline Survey

Mississippi Alternative Housing Program Questionnaire

The U.S. Department of Housing and Urban Development (HUD) is evaluating the Mississippi Alternative Housing Program (MAHP) for FEMA. It is a requirement of the grant that the Mississippi Emergency Management Agency (MEMA) assist with this evaluation.

• If you are selected to receive an MAHP unit, the federal government needs to know how living in the unit affects you. This will allow FEMA and HUD to make better decisions about how to respond to future disasters.

The information obtained through this survey will be used as baseline information to compare your responses to a follow-survey that will be conducted approximately two years from now. It is important that you respond to the later survey in addition to this baseline survey. The results from these surveys will be used to determine if the AHPP houses should be used as housing after future disasters.

Public reporting burden for this collection of information is estimated to average 25 minutes per response. This agency may not collect this information, and you are not required to complete this Form, unless it displays a currently valid OMB control number. The OMB Control Number for this survey is 2528-0248, expiring on 4/30/2008. This collection is authorized by 12.U.S.C. 1701z-1, which authorizes HUD to undertake studies of this type.

Sensitive Information: Your individual responses will be maintained securely and will only be seen by the researchers working on this project. If you have any questions about this survey, please contact Erin Wilson at 301-634-1776.

When you fill out this form, please indicate your answer by circling the number next to the response you want to select or filling in the blank boxes provided for your answer.

Please fill in the following information about yourself and how you can be contacted:

1. First Name

2. Last Name:

3. Date of birth:

Month Day Year

4. FEMA Registration Number:

5. Please provide the address of where you are currently living:

	Address:					Apt. #:
	City:		State:		Zipp:

6a. If possible, please provide us with up to three phone numbers where we might be able to reach you or another household member if we need to ask you a question. Please also tell us what phone it is (for example, “My mobile phone”, “Home Phone”, “Work Phone”, “My Husband/Wife’s mobile phone”).

Area Code Number

Phone Number 1:

-

Whose Phone?

Area Code Number

Phone Number 2:

-

Whose Phone?

Area Code Number

Phone Number 3:

-

Whose Phone?

6b. If possible, please provide us with up to three email addresses where we might be able to reach you or another household member if we need to ask you a question. Please also tell us whose email address it is.

Email 1:		@
Whose email?

Email 2:		@
Whose email?

Email 3:		@
Whose email?

Please provide us the following information about yourself. Please circle the number next to your response.

7. Are you Male or Female?

	1	Male
	2	Female

8a. What ethnicity do you consider yourself?

	1	Hispanic or Latino
	2	Not Hispanic or Latino

8b.What race do you consider yourself? You may indicate more than one.

	1	American Indian or Alaska Native
	2	Asian
	4	Black or African American
	5	Native Hawaiian or Other Pacific Islander
	6	White

9. What is the highest degree or level of school you have completed? (select only one)

	1	Nusery School to 6th grade or no schooling
	2	7th to 12th grade - NO DIPLOMA
	3	High School Graduate or Equivalent (for example, GED)
	4	Some College
	5	Associates Degree
	6	Bachelors Degree
	7	Masters Degree, Doctorate Degree, or other Professional Degree (for example, MD, DDS, DVM, LLB, JD)

Now we would like to know something about who currently lives with you.

10. How many people do you live with? Please write the number in the box below.

11. Please provide the information for each person that lives with you in the table below.:

First Name	Last Name	Age	Gender (M/F)	Relationship to you	Currently Living with you? (Y/N)

12. Do you or anyone in the household have a physical disability or condition that limits one or more basic activity such as walking, climbing stairs, reaching, lifting, or carrying? Please circle the number of your response. If you select yes, please answer question 12a as well.

	1	Y es	12a. Is anyone in a wheelchair or otherwise unable to climb stairs at all?
	2	No		1	Y es
				2	N o

13. Do you or anyone in the household have a sensory disability such as blindness or deafness?

	1	Yes
	2	No

The next set of questions ask about your income in the past month and generally what resources you are depending on to support yourself. This information is important for understanding what impact the AHPP program might have.

14a. Are you currently:

	1	Employed full-time (30 hours of work per week or more)
	2	Employed part-time (less than 30 hours per week)
	3	Self-employed
	4	Unemployed Looking for Work
	5	Not working for pay (retired, disabled, taking care of family, etc...)

14b. How many of the people your household (including yourself) are employed full-time or part-time?

15a. Please check ALL of your HOUSEHOLD’S sources of income in the past month: (you may check more than one)

	1	Wages, salary, commissions, bonuses or tips from a job
	2	Self-employment income
	3	Interest, dividends, net rental income, royalty income, or income from estates and trust
	4	Social Security or Railroad Retirement
	5	Supplemental Security Income (SSI)
	6	Alimony or Child Support
	7	Any public assistance or welfare payments from the state or local welfare office (including TANF, but NOT including Food Stamps)
	8	Food Stamps
	9	Retirement, survivor, or disability pensions (NOT including Social Security)
	10	Unemployment Compensation
	11	No income in past month
	12	Other

15b. What is your household’s total monthly income last month from all of the sources checked above. MONTHLY HOUSEHOLD INCOME:

$ .00

16. In the past month, have you or anyone in your household had to use savings, insurance proceeds, state repair grant, or credit card debt in order to cover your living expenses? (check all that apply)

	1	Yes, savings
	2	Yes, insurance proceeds from your homeowner or renters policy
	3	Yes, state grants program for hurricane victims
	4	Yes, new credit card or other debt (that you did not pay off this month)
	5	No

17. In the past month, have you lived in housing or received financial assistance from family, friends, or a charitable organization (such as a church or the Red Cross)? (check all that apply)

	1	Yes, living with friends or family (or in a house provided by friends or family)
	2	Yes, friends or family provided some financial help
	3	Yes, living in housing provided by charitable organization (including a homeless shelter)
	4	Yes, charitable organization provided some financial help
	5	No

Please tell us something about the house or apartment you lived in immediately before the Hurricane.

18. What was the address of the home you lived in before the Hurricane?

	Address:					Apt. #:
	City:		State:		Zip:

19. What type of building did you live in? (select only one)

	1	A Mobile Home on my own land
	2	A Mobile Home on leased land (in a “trailer park”)
	3	A one-family house detached from any other house
	4	A one-family house attached to one or more houses (duplex, row house)
	5	A building with 2 to 4 apartments or condominiums
	6	A building with 5 or more apartments or condominiums
	7	Hotel or Motel
	8	Homeless Shelter
	9	Homeless - living on the street
	10	Other (such as boat, RV, van, etc.)

20. What best describes the level of damage your home sustained?

	1	Destroyed or more than 50 percent damaged. The house was washed away or damaged so badly that it is uninhabitable without major reconstruction.
	2	Major Damage - 20 to 50 percent damaged. The house needed substantial repairs such as a new roof and repair of most walls and fixtures.
	3	Moderate Damage - 5 to 20 percent damaged. One or more rooms in the house needed substantial repairs but other rooms were relatively undamaged.
	4	Low Damage - 1 to 5 percent damaged. The home had limited damage such as roof shingles blown off, damaged siding, or minor water damage.
	5	No Damage
	98	Don’t Know
	7	Homeless before the hurricane

21. Did you own or rent?

	1	Own or buying
	2	R ent
	3	Other (such as homeless) (skip to question 31)
			21a. Pre-hurricane, how much were you paying in monthly rent?
				$ .00	(skip to question 31)

Answer questions 22 to 30 ONLY if you or someone else in the household OWNED OR WAS BUYING the house or condominium you lived in immediately prior to the Hurricane. Otherwise, SKIP to question 31.

22a. How much do you estimate the home you lived in was worth before the storm?

	$ .00			or range:	$ .00	to	$ .00
		98	Don’t Know

22b. Do you or the person that owned the home still own the home that was damaged?

	1	Yes
	2	N o	If you no longer own the home, what happened to the house?
			1	Lender foreclosed (skip to question 31)
			2	Sold it (skip to question 31)
			3	Other (specify, then skip to question 31) ___________________________________________

23. If you still own the home, do you have a mortgage on the damaged home?

	1	Yes
	2	No (skip to question 25)

24. For owners with a mortgage on the house, are you up-to-date on your monthly payments?

	1	Yes
	2	No, lender is not requiring me to pay currently
	3	No, lender has indicated I am delinquent in my payments
	4	No, lender is in the process of foreclosing

25. How much is it estimated that it will cost to repair your home?

	$ .00			or range:	$ .00	to	$ .00
		98	Don’t Know

26. What percent of the estimated cost to repair has the insurance company said it would cover?

	1	All
	2	More than half
	3	Some, but less than half
	4	None, wrong type of insurance or insurance company will not pay
	5	None, did not have insurance
	98	Don’t Know

27. Please indicate what programs you have been approved to receive assistance from because your home was damaged in the storm.

	Approved	Denied	Pending	Did not apply
	1	2	3	4	FEMA Housing Assistance Repair Grants
	1	2	3	4	State Disaster Recovery Grant (tailor to each state)
	1	2	3	4	SBA Disaster Recovery Loans
	1	2	3	4	Private Bank or Mortgage Company Financing
	1	2	3	4	Other Program

28. Do you plan to repair/rebuild your home?

	1	Yes
	2	N o	If you do not plan on repairing or rebuilding your, what are you planning to do with it?
			1	Sell it (skip to question 31)
			2	Nothing (skip to question 31)

29. If you are planning to repair or rebuild, what is the status of the rebuilding?

	1	Completed
	2	Construction started and will be completed in less than 6 months
	3	Construction has just begun
	4	Plan to start construction within 6 months
	5	Plan to start construction within 1 year
	6	Do not know when construction might start

30. When construction is completed, do you expect to move back into your rebuilt home?

	1	Yes
	2	No

Now, please tell us something about your current housing.

31. How many different places have you lived for a week or longer since the hurricane that caused you to leave your house? For example, if you lived in a shelter, moved to a motel, and then received a FEMA travel trailer, that would be “3”.

32. Please indicate the type of housing you are currently living in:

	1	FEMA travel trailer on my property
	2	FEMA mobile home on my property
	3	FEMA travel trailer in a “group site”
	4	FEMA mobile home in a “group site”

33. What is the MAIN reason you would like an AHPP unit?

	1	To have a LARGER place to live
	2	To have a SAFER place to live
	3	To be CLOSER TO HOME
	4	To have a NEWER place to live
	5	To have a PERMANENT house
	6	Some Other Reason (specify) __________________________________________

We’d like to know a few things about the quality of your current housing and neighborhood.

35. Does your current housing have any of the following problems ...

		Yes	No
	a. Is there mildew, mold, or water damage on any wall, floor, or ceiling?	1	2
	b. Are there any floor problems such as boards, tiles, carpeting or linoleum that are missing, curled, or loose?	1	2
	c. Are there any holes or large cracks where outdoor air or rain can come in?	1	2
	d. In your home, do you smell bad odors such as sewer, natural gas, etc.?	1	2
	e. In the last three months has any bathroom floor been covered by water because of a plumbing problem?	1	2
	f. In the last three months has your toilet not worked for 6 hours or more?	1	2
	g. In the last three months has your electricity not worked for 2 hours or more?	1	2
	h. In cold weather, do you ever need to use your oven to heat your home?	1	2
	i. Do all outside doors and windows have locks that work?	1	2

36. Now, please tell us how satisfied you are with the following neighborhood amenities for your current housing...

		Satisfied	Neither satisfied or unsatisfied	Unsatisfied	Not Applicable or Don’t Know
	a. Distance to your job?	1	2	3	4
	b. Distance to your child/children’s school?	1	2	3	4
	c. Quality of your child/children’s school?	1	2	3	4
	d. Garbage pick-up?	1	2	3	4
	e. Police response?	1	2	3	4
	f. Quality of outdoor space, such as parks?	1	2	3	4
	g. Distance to grocery store?	1	2	3	4
	h. Friendliness of your neighbors?	1	2	3	4
	i. Availability of child care?	1	2	3	4
	j. Availability of health care?	1	2	3	4

Now we’d like to get a sense of how safe you think the area is where you currently live.

37. How safe do you feel…

		Very safe	Safe	Unsafe	Very Unsafe
	a. On the streets near your home during the day?	1	2	3	4
	b. On the streets near your home at night?	1	2	3	4

38. Please tell me if any of the following things has happened to you or anyone who (lives/lived) with you in the past 6 months...

		Yes	No
	a. Was anyone’s purse, wallet, or jewelry snatched from them?	1	2
	b. Was anyone threatened with a knife or a gun?	1	2
	c. Was anyone beaten or assaulted?	1	2
	d. Did someone try to break into your home?	1	2
	e. Was anyone stabbed or shot?	1	2

Several recent studies have shown a relationship between health and housing. To see if the AHPP has any impact on your health, please tell us about your current health.

39. Would you say your health in general is excellent, very good, good, fair, or poor?

	1	Excellent
	2	Very Good
	3	Good
	4	Fair
	5	Poor

40. Have you ever been told by a doctor or other health professional that you have asthma?

	1	Yes
	2	No

Past studies have shown that the where you live and the type of housing you live in can affect how much you exercise and your weight. To see if the AHPP program might have a similar impact, the next questions ask about moderate physical activity and your height and weight. As noted earlier, these data will be used for this study only and averaged with other respondents. Your individual responses will be kept private.

41. In a usual week, do you do moderate activities on three or more days for at least 10 minutes at a time, such as brisk walking, bicycling, vacuuming, gardening, or anything else that cause small increases in breathing or heart rate?

	1	Yes
	2	No

42. About how tall are you without shoes?

Feet

Inches

43. About how much do you weigh without shoes?

Pounds

We also want to know about how you are feeling.

44. How much of the time during the past month have you felt ...

		All of the time	Most of the time	Some of the time	A little of the time	None of the time
	a. So sad that nothing could cheer you up?	1	2	3	4	5
	b. Nervous?	1	2	3	4	5
	c. Restless or fidgety?	1	2	3	4	5
	d. Hopeless?	1	2	3	4	5
	e. That everything was an effort?	1	2	3	4	5
	f. Worthless?	1	2	3	4	5
	g. Calm and peaceful?	1	2	3	4	5

CONTACT INFORMATION

Thank you very much for your time today. To help us be able to get back in touch with you in the future, we would like to collect the names, telephone numbers and addresses of two people who will always know how to reach you. Please tell me about people who live at a different address than you. The information on these surveys will be kept confidential to the extent permitted under the Privacy Act.

45. CONTACT #1:

First Name
Last Name
Street Address
Apt # (if applicable)
City
State
Zip Code

Area Code Number

Phone Number Contact #1:

-

46. CONTACT #2:

First Name
Last Name
Street Address
Apt # (if applicable)
City
State
Zip Code

Area Code Number

Phone Number Contact #2:

-

Thank you for completing this survey. Without your help, we would not know if this program works. Please return this survey to MEMA program staff person before you move into your new unit.

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