Indian Housing Block Grant (IHBG) Evaluation

Community Member Questionnaire

INTRODUCTION and INFORMED CONSENT

Public Reporting Burden for this collection of information is estimated to average 10 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.  Response to this collection of information is mandatory to obtain a benefit.  The information requested does not lend itself to confidentiality.  HUD may not conduct or sponsor, and an applicant is not required to respond to a collection of information unless it displays a currently valid OMB control number.

Researchers from ACKCO, Inc., and Abt Associates, Inc. are conducting a study of housing in Indian Country for the Office of Native American Programs at the US Department of Housing and Urban Development. The purpose of the study is to learn more about housing provided through [local IHBG grantee]. As part of this study, we would like you to complete this questionnaire. We are asking people all over the country who live in Indian Country to answer these same questions. Some of the questions ask you about the condition of your housing and how happy you are with your housing. The answers we receive from you and other people who complete the questionnaire will be reported only as a group and used only for research purposes.

Now I’d like to review some statements that indicate you understand what this study is about, that you agree to take part in the study, and get your signature.

I (PRINT NAME:________________________________________________________) understand that by agreeing to complete this survey, I understand the following statements:

• This study is being done by ACKCO, Inc. and Abt Associates, Inc. for the Office of Native American Programs at HUD.

• This survey will ask questions about my housing.

• My participation in this survey is voluntary and I can choose not to answer any questions I am uncomfortable with.

• All of my responses will be kept private, and no one will be able to see my name and answers together.

• Approximately 650 people in Indian Country will be asked to answer these questions.

• In no way does my participation in this survey affect any housing assistance I may or may not receive now, and

• My responses will be used for research purposes only.

• Yes, I understand the above statements and agree to complete this survey.

• No, I do not agree to complete this survey.

__________________ ____________________________________

SIGNATURE DATE

If I have any questions about this study, you may contact Dan Van Otten, the ACKCO Study Director at 1-800-525-2859, extension 156. You may also contact Marianne Beauregard at Abt Associates, 617-349-2852 (a toll call), if you have questions or concerns about your rights as a study participant.

COMMUNITY MEMBER QUESTIONNAIRE

Please check the box next to the response that best reflects your answer. For the questions on the number of people in your household, just put the number in the space provided.

1. Please check the box below that best describes the kind of housing are you currently living in.

• Rental housing unit

• House that I or my partner owns

• Living with family or friends

• Homeless (e.g., living in a homeless shelter, on the streets, or in a car)

• Other housing situation (specify):_____________________________________________

2. Please check the box below that indicates the type of help you currently receive with your housing expenses from [tribal housing agency name]. If you do not receive any help with your housing expenses from [tribal housing agency name], please check that box.

• I live in a house that is owned or managed by [tribal housing name]

• I receive a monthly rental subsidy from [tribal housing name]

• I get help with my utilities from [tribal housing name]

• I purchased my house from [tribal housing name]

• I receive another type housing assistance to pay my rent or utilities (specify):____________________________________

• I do not receive any help with my housing expenses from [tribal housing agency]

3. Overall, how would you describe the condition of your current house or apartment? Please check just one box.

Excellent

Good

Fair

Poor

4. Not including bathrooms and hallways, how many rooms are there in your house/apartment?

1

2

3

4

5

6 +

5. Where you live now, how much of a problem is…

1. Interior walls with peeling paint or broken plaster?

Big problem

Small problem

No problem at all

2. Plumbing that doesn’t work?

Big problem

Small problem

No problem at all

3. Rats or mice?

Big problem

Small problem

No problem at all

4. A heating system that doesn’t work?

Big problem

Small problem

No problem at all

5. A stove or refrigerator that doesn’t work?

Big problem

Small problem

No problem at all

6. Exposed wire or electrical problems?

Big problem

Small problem

No problem at all

7. Too little space?

Big problem

Small problem

No problem at all

6. Thinking about the exterior of your house, do you have any of the following issues:

1. A roof that leaks?

Yes

No

2. Sloping, leaning, or buckling exterior walls?

   Yes

   No

3. Missing or broken windows?

Yes

No

7. On the grounds around your housing unit, do large puddles of water remain for several days after it rains?

Yes

No

8. How safe is the area outside your home at night? Please check the box that describes how safe you think the area is.

Very safe

Safe

Unsafe

Very unsafe

9. Overall, how satisfied are you with your current apartment or house?

Very satisfied

Somewhat satisfied

Neither satisfied nor dissatisfied

Somewhat dissatisfied

Very dissatisfied

10. Not including you, how many people aged 18 or over currently live with you?

Number of people aged 18 and over:______________

11. How many children under the age of 18 currently live with you?

Number of children under the age of 18:_____________

12. Does anyone in the household regularly sleep in a room other than a bedroom because there are not enough bedrooms?

Yes

No

13. Do household members sometimes go elsewhere to sleep because there is not enough space in your house/apartment?

Yes

No

14. About what share of your family income (take home pay) is used for housing expenses? (For example, if your family has about $800 each month in income and your rent and utilities are approximately $200 per month, then you spend about one-fourth--25%--of your income on housing expenses. You would check one-third or less.)

One-third or less (i.e., 33% or less)

One-third to one-half (i.e., 34 to 50%)

One-half to two-thirds (i.e., 51 to 66%)

Over two-thirds (i.e., more than 66%)

15. Where is your home located?

Within the Reservation

Outside Reservation but in the Tribal Service Area

Outside the Tribal Service Area

16. Is your home on Trust Land?

Yes

No

Thank you for completing this Questionnaire. Please return this form to the registration desk.