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pdfAppendix A:
Adult Survey
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Section 1: Household Roster (HRS)
Section 2: Outlook and Social Networks (HSN)
Section 3: Housing Consumption and Mobility (HHC)
Section 4: Neighborhoods (HNB)
Section 5: Education and Training (HED)
Section 6: Employment and Earnings (HEM)
Section 7: Income and Assistance (HIN)
Section 8: Savings and Assets (HSA)
Section 9: Physical Health (HPH)
Section 10: Substance Abuse (HSU)
Section 11: K6 (HK6)
Section 12: Mental Health Screener (HSC)
Section 13: Depression (HDE)
Section 14: Mania (HMA)
Section 15: Panic Disorder (HPD)
Section 16: Generalized Anxiety Disorder (HGA)
Section 17: Intermittent Explosive Disorder (HIE)
Section 18: Victimization and PTSD (HCV)
Section 19: Mental Health Services (HSR)
Section 20: Parent Report on Youth (HPY)
Section 21: Respondent Report of Household Outcomes (HHO)
Section 22: Relationships, Fathers and Parenting (HRL)
Section 23: Decision Making (HDM)
Section 24: Contact Information (HCI)
National Bureau of Economic Research
University of Michigan - ISR
Appendices
Moving to Opportunity
Final Impact Evaluation
Adult Questionnaire
National Bureau of Economic Research
University of Michigan
2008-2009
Interviewer: Obtain written consent and read the following statement before
beginning the interview:
“Before we begin this interview, let me assure you that this interview is
completely confidential and voluntary. If we come to any question that you
do not want to answer, just let me know and we will go on to the next
question.”
MTO Adult Qnaire
Page A-1
Adult Questionnaire
A_Section 01: Household Roster
The adult respondent survey will begin with a roster to take stock of who is currently living in the
household, and to collect information on the residential status of members who resided in the MTO
household at time of enrollment. Information from the baseline survey, the 1997 and 2000 canvases
and the Interim survey about household membership will be pre-loaded. Information will be updated
for existing household members, and information about new members will be collected.
Preload: All people in the baseline household and all other people reported as living with R at the time of
last contact
To begin, I need to get a list of the people that live with you in this household – including their name, age,
race or ethnicity, and relationship to you. Let’s start with you.
HRS1. Person ID: _________________________________
HRS2.
First Name: ________________________________
HRS3. Last Name: _________________________________
HRS4: Is [Name] living with you now?
Yes .............................................. 1
No ............................................... 5 (GO TO HRS11)
Deceased ..................................... 7 (GO TO NEXT PERSON)
HRS5. What is (his/her) relationship to you?
BIRTH CHILD ........................... ................. 1
ADOPTED CHILD..................... ................. 2
STEP CHILD.............................. ................. 3
GRANDCHILD .......................... ................. 4
FOSTER CHILD ........................ ................. 5
OTHER CHILD.......................... ................. 6
SPOUSE ..................................... ................. 7
PARTNER (ROMANTIC) ......... ................. 8
FRIEND (NOT ROMANTIC) .... ................. 9
PARENT..................................... ................. 10
SIBLING..................................... ................. 11
COUSIN ..................................... ................. 12
OTHER RELATIVE................... ................. 13
OTHER NONRELATIVE .......... ................. 14
HEAD OF HOUSEHOLD.......... ................. 96
HRS6. Is [Name] male or female?
Male ............................................ 1
Female......................................... 2
HRS7. What is [Name’s] date of birth?
Date: _______________________ (GO TO HRS8)
DK................................................. (GO TO HRS7a)
RF.................................................. (GO TO HRS7a)
MTO Adult Qnaire
1 A-2
Page
HRS7a. What is (your/his/her) current age?
Age: ______________________ (GO TO HRS8)
DK................................................. (GO TO HRS7b)
RF.................................................. (GO TO HRS7b)
HRS7b. Do you think [Name] is under 18, or 18 years old or older?
Under 18........................................ 1
18 Older......................................... 2
[ Questions HRS8 and HRS9 about race / ethnicity have been deleted ]
HRS10. [IF PERSON IS UNDER 18]: Does [Name’s] biological father live in this household?
Yes ..................................................................................1
No....................................................................................5
¾ [GO TO NEXT PERSON, OR NEXT SECTION]
HRS11. In what month and year did [Name] move out of your household?
Month: ______________ Year: _______________
¾ [IF PERSON IS UNDER 18, ASK HRS12a. IF OVER 18, ASK HRS12b.]
HRS12a_Youth. Who is [Name] living with now?
Living with R or deceased..............................................0
Living with mother and father........................................1
Living with mother.........................................................2
Living with father...........................................................3
Living with other relatives
(including as foster child) ...........................................4
Incarcerated (as an adult) ...............................................5
Juvenile detention center ................................................6
In nursing home or institution ........................................7
In foster care (non relative) ............................................8
Boarding school (not college) ........................................9
College dorm, or apartment at college ...........................10
Homeless ........................................................................11
Other (specify)__________________............................12
HRS12b_Adult. Who is [Name] living with now?
Living with R or deceased .............................................0
Living in own household................................................1
Incarcerated ....................................................................2
In nursing home or institution ........................................3
In military.......................................................................4
Homeless ........................................................................5
Halfway house................................................................6
Other (specify) ________________...............................7
Revised 08/08/07
A_Section 02: OUTLOOK AND SOCIAL NETWORKS (HSN)
HSN1.
Taken all together, how would you say things are these days would you say that you are very happy, pretty
happy, or not too happy?
VERY HAPPY
1
PRETTY HAPPY
2
NOT TOO HAPPY
3
REFUSED
7
DON’T KNOW
8
HSN2.
Considering your child/children's lives in general these days, how happy or unhappy would you say you
are, on the whole... very happy, pretty happy, or not too happy?
VERY HAPPY
1
PRETTY HAPPY
2
NOT TOO HAPPY
3
REFUSED
7
DON’T KNOW
8
(RB) Next I am going to read a few statements. For each, please tell me if you agree a lot, agree a little,
neither agree nor disagree, disagree a little, or disagree a lot. Please be as honest and accurate as you can
throughout. Try not to let your response to one statement influence your responses to other statements.
There are no "correct" or "incorrect" answers. Answer according to your own feelings, rather than how you
think "most people" would answer.
HSN3.
I hardly ever expect things to go my way.
MTO Adult Qnaire
AGREE A LOT
1
AGREE A LITTLE
2
NEITHER AGREE NOR DISAGREE
3
DISAGREE A LITTLE
4
DISAGREE A LOT
5
REFUSED
7
DON’T KNOW
8
Page A-4
Revised 08/08/07
HSN4.
I rarely count on good things happening to me.
AGREE A LOT
1
AGREE A LITTLE
2
NEITHER AGREE NOR DISAGREE
3
DISAGREE A LITTLE
4
DISAGREE A LOT
5
REFUSED
7
DON’T KNOW
8
HSN5.
Overall, I expect more good things to happen to me than bad.
MTO Adult Qnaire
AGREE A LOT
1
AGREE A LITTLE
2
NEITHER AGREE NOR DISAGREE
3
DISAGREE A LITTLE
4
DISAGREE A LOT
5
REFUSED
7
DON’T KNOW
8
Page A-5
Revised 08/08/07
HSN6.
We would also like to learn some more about what you did and how you felt yesterday. . Specifically we
are wondering how your day went and how you felt at [RANDOMLY SELECTED TIME] yesterday.
What were you doing at [RANDOMLY SELECTED TIME]? (Please check all that apply)
[commuting; working; shopping; preparing food; doing housework; taking care of your children; eating;
praying / worshipping / meditating; socializing; watching TV; nap / resting; computer / Internet / email;
relaxing; on the phone; intimate relations; exercising; other (please specify)
MTO Adult Qnaire
COMMUTING
1
WORKING
2
SHOPPING
3
PREPARING FOOD
4
DOING HOUSEWORK
5
TAKING CARE OF YOUR CHILDREN
6
EATING
7
PRAYING/WORSHIPPING/MEDITATING
8
SOCIALIZING
9
WATCHING TV
10
NAP/RESTING
11
COMPUTER/INTERNET/EMAIL
12
RELAXING
13
ON THE PHONE
14
INTIMATE RELATIONS
15
EXERCISING
16
OTHER (SPECIFY)
95
REFUSED (SKIP TO HSN14)
97
DON’T KNOW (SKIP TO HSN14)
98
Page A-6
Revised 08/08/07
HSN7.
[Note to interviewer: if only one activity chosen then skip]. Which activity above would you consider the
main activity at [RANDOMLY SELECTED TIME], that is, the activity that took up the most time?
COMMUTING
1
WORKING
2
SHOPPING
3
PREPARING FOOD
4
DOING HOUSEWORK
5
TAKING CARE OF YOUR CHILDREN
6
EATING
7
PRAYING/WORSHIPPING/MEDITATING
8
SOCIALIZING
9
WATCHING TV
10
NAP/RESTING
11
COMPUTER/INTERNET/EMAIL
12
RELAXING
13
ON THE PHONE
14
INTIMATE RELATIONS
15
EXERCISING
16
OTHER (SPECIFY)
95
REFUSED
DON’T KNOW
HSN8.
At what time did this main activity [INSERT NAME OF MAIN ACTIVITY] begin?
Time: _______________
REFUSED
DON’T KNOW
HSN9.
At what time did this main activity end?
Time: _______________
REFUSED
DON’T KNOW
MTO Adult Qnaire
Page A-7
Revised 08/08/07
HSN10.
Where were you?
AT HOME
1
AT WORK
2
SOMEONE ELSE’S HOUSE IN THE NEIGHBORHOOD
3
SOMEWHERE ELSE IN THE NEIGHBORHOOD
4
SOMEWHERE ELSE (SPECIFY)
5
REFUSED
7
DON’T KNOW
8
HSN11.
Were you interacting with anyone? (including on the phone, in a teleconference,etc.)
YES
1
NO
5
REFUSED
7
DON’T KNOW
8
HSN12.
If you were interacting with someone, who was it? (check all that apply)
MTO Adult Qnaire
SPOUSE / SIGNIFICANT OTHER
1
MY CHILDREN
2
FRIENDS
3
PARENTS / RELATIVES
4
CO-WORKERS
5
BOSS
6
CLIENTS / CUSTOMERS
7
OTHER PEOPLE NOT LISTED
8
REFUSED
97
DON’T KNOW
98
Page A-8
Revised 08/08/07
HSN13.
Please rate each feeling on the scale given. A rating of 0 means that you did not experience that feeling at
all. A rating of 6 means that this feeling was a very important part of the experience. Please circle the
number between 0 and 6 that best describes how you felt.
0
1
2
3
4
5
6
RF
DK
6
7
8
5
6
7
8
4
5
6
7
8
3
4
5
6
7
8
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8
0
1
2
3
4
5
6
7
8
HSN13h.
Angry / hostile
0
1
2
3
4
5
6
7
8
HSN13i.
Worried/anxious
0
1
2
3
4
5
6
7
8
HSN13j.
Enjoying myself
0
1
2
3
4
5
6
7
8
HSN13k.
Criticized/put down
0
1
2
3
4
5
6
7
8
HSN13l.
Tired
0
1
2
3
4
5
6
7
8
HSN13a.
Impatient for it to end
0
1
2
3
4
5
HSN13b.
Happy
0
1
2
3
4
HSN13c.
Frustrated/annoyed
0
1
2
3
HSN13d.
Depressed/blue
0
1
2
HSN13e.
Competent/capable
0
1
HSN13f.
Hassled/pushed around
0
HSN13g.
Warm/friendly
MTO Adult Qnaire
Page A-9
Revised 08/08/07
HSN14.
Now I'd like to ask you a few questions about your friends or other people who are close to you.
About how many close friends do you have these days? These are people you feel at ease with, can talk to
about private matters, or call on for help. Would you say that you have no close friends, one or two, three
to five, six to ten, or more than ten?
NO CLOSE FRIENDS
1
1 OR 2 CLOSE FRIENDS
2
3 TO 5 CLOSE FRIENDS
3
6 TO 10 CLOSE FRIENDS
4
MORE THAN 10 CLOSE FRIENDS
5
REFUSED
7
DON’T KNOW
8
HSN15. (RB)
The next few questions are about ALL your friends. Some people have friends who mostly know one
another. Other people have friends who don’t know one another.
Would you say that: all your friends know one another, most of your friends know one another, only a few
friends know one another, or none of your friends know one another?
ALL YOUR FRIENDS KNOW ONE ANOTHER
1
MOST OF YOUR FRIENDS KNOW ONE ANOTHER
2
ONLY A FEW OF YOUR FRIENDS KNOW ONE ANOTHER
3
NONE OF YOUR FRIENDS KNOW ONE ANOTHER
4
NO FRIENDS (SKIP TO HSN19)
5
REFUSED
7
DON’T KNOW
8
HSN16. (RB)
How many of your friends live in the same neighborhood as you?
MTO Adult Qnaire
ALL
1
MOST
2
SOME
3
A FEW
4
NONE
5
REFUSED
7
DON’T KNOW
8
Page A-10
Revised 08/08/07
(RB)
ALL
HSN17a.
Thinking about everyone that you
would count as a friend, not just your
close friends, About how many have
graduated from college -- -- none,
only a few, some, most, or all?
HSN17b.
About how many earn more than
$30,000 a year?
HSN17c.
About how many work full-time?
HSN17d.
About how many would you say are
a different race or ethnicity than you?
MOST
SOME
A FEW
NONE
REF
DK
1
2
3
4
5
7
8
1
2
3
4
5
7
8
1
2
3
4
5
7
8
1
2
3
4
5
7
8
HSN18.
Of your friends who have graduated from college, about how many of these would you count as a close
friend?
NONE
1
1 OR 2 CLOSE FRIENDS
2
3 TO 5 CLOSE FRIENDS
3
6 TO 10 CLOSE FRIENDS
4
MORE THAN 10 CLOSE FRIENDS
5
REFUSED
7
DON’T KNOW
8
HSN18a.
How many of these people live in your current neighborhood?
MTO Adult Qnaire
NONE
1
1 OR 2 IN NEIGHBORHOOD
2
3 TO 5 IN NEIGHBORHOOD
3
6 TO 10 IN NEIGHBORHOOD
4
MORE THAN 10 IN NEIGHBORHOOD
5
REFUSED
7
DON’T KNOW
8
Page A-11
Revised 08/08/07
HSN19. (RB)
Here is a list of some of the ways in which people are connected to each other. Some people can be
connected to you in more than one way. How is/are your friend(s) in your neighborhood connected to you?
♦[ CHECK ALL THAT APPLY.]
THROUGH…
FAMILY/ RELATIVES
1
YOUR CHILD/YOUR CHILD'S SCHOOL
2
YOUR NEIGHBORHOOD (CURRENT OR FORMER)
3
YOUR WORK / SPOUSE'S WORK
4
CHURCH
5
A GROUP YOU BELONG TO
7
FROM YOUR CHILDHOOD
8
OTHER (Specify)
9
REFUSED
97
DON’T KNOW
98
HSN20.
The next two questions are about friends and relatives. During the past thirty days, about how often have
you had friends or relatives over to your home: every day; several days a week; twice a week; about once a
week; 2-3 times in the past month; once in the past month; or not at all in the past month?
MTO Adult Qnaire
EVERY DAY (INCLUDES 6-7 TIMES A WEEK)
1
SEVERAL DAYS A WEEK (INCLUDES 3-5 TIMES A WEEK)
2
TWICE A WEEK
3
ABOUT ONCE A WEEK
4
2 OR 3 TIMES IN THE PAST MONTH
5
ONCE IN THE PAST MONTH
6
NOT AT ALL IN THE PAST MONTH
7
REFUSED
97
DON’T KNOW
98
Page A-12
Revised 08/08/07
HSN21.
During the past thirty days, about how often have you visited with friends or relatives at their homes?
EVERY DAY (INCLUDES 6-7 TIMES A WEEK)
1
SEVERAL DAYS A WEEK (INCLUDES 3-5 TIMES A WEEK)
2
TWICE A WEEK
3
ABOUT ONCE A WEEK
4
2 OR 3 TIMES IN THE PAST MONTH
5
ONCE IN THE PAST MONTH
6
NOT AT ALL IN THE PAST MONTH
7
REFUSED
97
DON’T KNOW
98
[CHECKPOINT: IF NO MOVES, SKIP TO HSN29:]
HSN22.
Thinking about your neighborhood now, are you living in the same neighborhood as when you lived at
[BASELINE ADDRESS] or living in a different neighborhood?
SAME (SKIP TO HSN29)
1
DIFFERENT
2
REFUSED (SKIP TO HSN29)
7
DON’T KNOW (SKIP TO HSN29)
8
HSN23.
Do you still have friends in your old neighborhood, where you lived at [BASELINE ADDRESS]?
MTO Adult Qnaire
YES
1
NO (SKIP TO HSN29)
5
REFUSED (SKIP TO HSN29)
7
DON’T KNOW (SKIP TO HSN29)
8
Page A-13
Revised 08/08/07
HSN24.
How often do you go back to visit friends in that old neighborhood?
EVERY DAY (INCLUDES 6-7 TIMES A WEEK)
1
SEVERAL DAYS A WEEK (INCLUDES 3-5 TIMES A WEEK)
2
TWICE A WEEK
3
ABOUT ONCE A WEEK
4
2-3 TIMES A MONTH
5
ONCE A MONTH
6
A COUPLE OF TIMES A YEAR
7
NEVER
8
REFUSED
97
DON’T KNOW
98
HSN25.
How often do your friends from that old neighborhood visit you?
EVERY DAY (INCLUDES 6-7 TIMES A WEEK)
1
SEVERAL DAYS A WEEK (INCLUDES 3-5 TIMES A WEEK)
2
TWICE A WEEK
3
ABOUT ONCE A WEEK
4
2-3 TIMES A MONTH
5
ONCE A MONTH
6
A COUPLE OF TIMES A YEAR
7
NEVER
8
REFUSED
97
DON’T KNOW
98
HSN26.
Thinking about your current set of friends, how many of these people have you been friends with for at
least [SURVEY YEAR MINUS YEAR OF RANDOM ASSIGNMENT]?
MTO Adult Qnaire
NONE (SKIP TO HSN29)
1
1 OR 2
2
3 TO 5
3
6 TO 10
4
MORE THAN 10
5
REFUSED
7
DON’T KNOW
8
Page A-14
Revised 08/08/07
HSN27.
How often do you go visit these friends?
EVERY DAY (INCLUDES 6-7 TIMES A WEEK)
1
SEVERAL DAYS A WEEK (INCLUDES 3-5 TIMES A WEEK)
2
TWICE A WEEK
3
ABOUT ONCE A WEEK
4
2-3 TIMES A MONTH
5
ONCE A MONTH
6
A COUPLE OF TIMES A YEAR
7
NEVER
8
REFUSED
97
DON’T KNOW
98
HSN28.
How often do these friends come visit you?
EVERY DAY (INCLUDES 6-7 TIMES A WEEK)
1
SEVERAL DAYS A WEEK (INCLUDES 3-5 TIMES A WEEK)
2
TWICE A WEEK
3
ABOUT ONCE A WEEK
4
2-3 TIMES A MONTH
5
ONCE A MONTH
6
A COUPLE OF TIMES A YEAR
7
NEVER
8
REFUSED
97
DON’T KNOW
98
HSN29. (RB)
[RECORD “UNSURE” IF ANSWER IS BETWEEN LIKELY AND UNLIKELY; DK IF DOES
NOT UNDERSTAND THE QUESTION.]
VERY
LIKELY
HSN29a.
If a group of neighborhood children were
skipping school and hanging out on a street
corner, how likely is it that your neighbors
would do something about it? Very likely,
likely, unsure, unlikely, or very unlikely.
HSN29b.
If some children were spray-painting
graffiti on a local building, how likely is it
that your neighbors would do something
about it?
MTO Adult Qnaire
LIKELY
UNSURE
UNLIKELY
VERY UNLIKELY
RF
DK
1
2
3
4
5
7
8
1
2
3
4
5
7
8
Page A-15
Revised 08/08/07
HSN30.
How often do you stop to chat with a neighbor in the street or hallway? Would you say almost every day;
once a week; once a month; a few times a year; or almost never?
ALMOST EVERY DAY (INCLUDES 4-7 DAYS A WEEK)
1
ONCE A WEEK (INCLUDES 1-3 DAYS A WEEK)
2
ONCE A MONTH (INCLUDES 1-3 TIMES AS MONTH)
3
A FEW TIMES A YEAR
4
ALMOST NEVER
5
REFUSED
7
DON’T KNOW
8
HSN31.
In the past 12 months, how often have you gone to church or attended other religious services? Never in the
past 12 months; several times in the past 12 months; once a month; once a week; or more than once a
week?
NEVER IN PAST 12 MONTHS (SKIP TO HSN35)
1
SEVERAL TIMES IN PAST 12 MONTHS (INCLUDES 1-11 TIMES)
2
ONCE A MONTH (INCLUDES 1-3 TIMES A MONTH)
3
ONCE A WEEK (INCLUDES1-3 DAYS A WEEK)
4
MORE THAN ONCE A WEEK
5
[IF VOLUNTEERED]: NO CHURCH OR PLACE OF WORSHIP (SKIP TO
HSN35)
6
REFUSED (SKIP TO HSN35)
7
DON’T KNOW (SKIP TO HSN35)
8
HSN32.
Do you attend church or other religious services in this neighborhood, your old neighborhood at
BASELINE ADDRESS, or somewhere else?
THIS NEIGHBORHOOD
1
OLD NEIGHBORHOOD AT BASELINE ADDRESS
2
SOMEWHERE ELSE
3
REFUSED
7
DON’T KNOW
8
HSN33.
How many years have you been attending this church?
Number of Years _____
REFUSED
DON’T KNOW
MTO Adult Qnaire
Page A-16
Revised 08/08/07
HSN34.
In the past 12 months, have you taken part in any sort of activity with people at your church or place of
worship other than attending services? This might include teaching Sunday school, serving on a
committee, attending choir rehearsal, retreat, or other things.
YES
1
NO
5
REFUSED
7
DON’T KNOW
8
HSN35.
Now I’d like to know about your role in your community. In the past twelve months. Have you gotten
together informally with, or worked with others in this community to try to deal with some community
issue or problem?
YES
1
NO (SKIP TO HSN37)
5
REFUSED (SKIP TO HSN37)
7
HSN36.
Do you recall what the issue was?
Specify: ____________________________________
REFUSED
DON’T KNOW
HSN37.
In the past twelve months, have you attended a meeting of any local government board or council that deals
with community problems and issues?
YES
1
NO
5
REFUSED
7
DON’T KNOW
8
HSN38.
In the past twelve months, did you contact a public official or some other person of influence in the
community to discuss a community issue or problem?
MTO Adult Qnaire
YES
1
NO
5
REFUSED
7
DON’T KNOW
8
Page A-17
Revised 08/08/07
HSN39.
In any election, some people are not able to vote because they are sick or busy or have some other reason,
and others do not want to vote. Did you happen to vote in any election as part of the 2008 Presidential race?
[options includes: primary election and general election]
YES (SKIP TO NEXT SECTION)
1
NO
5
REFUSED
7
DON’T KNOW
8
HSN40.
Are you currently registered to vote?
YES
MTO Adult Qnaire
1
NO
5
REFUSED
7
DON’T KNOW
8
Page A-18
Revised 08/11/07
A_Section 03: Housing Consumption and Mobility
We want to understand how the places you’ve lived may have affected you and your family. So I’m going to ask
you some questions about the different places you’ve lived since (YEAR OF RANDOM ASSIGNMENT). As you
know, we have been keeping in touch with you over the years, but we want to make sure that we have all the right
information.
♦ [Show the respondent all addresses we had an active contact and the estimated dates at those addresses.
First address is baseline address and last address is current address.]
HHC1.
First let me ask, is this [CORE MOVE ADDRESS] the first place that you moved to after (YEAR OF RANDOM
ASSIGNMENT)?
Yes ................................... 1 (GO TO HHC2)
No..................................... 5
DK.................................... (GO TO HHC2)
RF..................................... (GO TO HHC2)
HHC1a.
If not, what should the address be?
♦ [Correct the core address or insert the new address into the series. If R doesn’t recall address, get
the city, state, and nearest major intersection].
HHC2.
I would like to confirm the year and month that you left (FIRST ADDRESS).
___________MONTH LEFT ADDRESS
____________YEAR LEFT ADDRESS
DON’T KNOW
REFUSED
MOVE SERIES
♦ [Repeated until current address is reached]
HHC3.
What is the main reason you moved away from (THIS ADDRESS)? Did you leave because the landlord evicted
you, your landlord would not renew your lease, the rent increased and you couldn’t afford it, your expenses
increased and you couldn’t afford rent, or was there some other reason?
THE LANDLORD EVICTED YOU ................................................1 (GO TO HHC4)
YOUR LANDLORD WOULD NOT RENEW YOUR LEASE.......2 (GO TO HHC4)
THE RENT INCREASED AND YOU COULDN’T AFFORD IT ..3 (GO TO HHC4)
YOUR EXPENSES INCREASED AND YOU COULDN’T
AFFORD RENT................................................................................4 (GO TO HHC4)
OTHER .............................................................................................5 (GO TO HHC3A)
DON’T KNOW (GO TO HHC4)
REFUSED (GO TO HHC4)
MTO Adult Qnaire
Page A-19
Revised 08/11/07
HHC3a.
What was the main reason you moved?
LOST JOB OR ENDED JOB ........................................................................................................................1
WAS DOING DRUGS ..................................................................................................................................2
PROBLEMS WITH LANDLORD ...............................................................................................................3
PROBLEMS WITH NEIGHBORS/PEOPLE IN NEIGHBORHOOD..........................................................4
UNIT FAILED SECTION 8 INSPECTION..................................................................................................5
SECTION 8 TERMINATED.........................................................................................................................6
RESPONDENT OR CHILD WERE ABUSED/VIOLENCE IN THE HOUSEHOLD.................................7
CHANGE IN FAMILY STATUS (GAINED OR LOST A FAMILY MEMBER, DIVORCE, MARRY)...8
MOVED IN WITH PARTNER/BOYFRIEND/GIRLFRIEND.....................................................................9
WANTED TO BE CLOSER TO FORMER NEIGHBORHOOD .................................................................10
WANTED TO BE CLOSER TO FAMILY ...................................................................................................11
DON’T KNOW
REFUSED
HHC4.
Did you next move to [NEXT ADDRESS]?
Yes ................................... 1 (GO TO HHC5)
No..................................... 5
DK
RF
HHC4a.
What address did you move to?
♦ [Correct the address or insert the new address into the series. If R doesn’t recall address, get the city, state,
and nearest major intersection].
HHC5.
During the time between when you lived at [PREVIOUS ADDRESS] and [THIS ADDRESS], we would like to
know if there was a time when you did not have your own place to stay?
Yes ................................... 1
No..................................... 5 (GO TO NOTE AFTER HHC6a)
DK.................................... (GO TO NOTE AFTER HHC6a)
RF..................................... (GO TO NOTE AFTER HHC6a)
YES
HHC5a.
(When you did not have your own place
to stay,) Did you stay with a relative?
HHC5b.
Did you stay with a friend?
HHC5c.
Did you stay in a shelter?
♦[INTERVIEWER: A SHELTER IS:
A homeless shelter, emergency shelter,
or domestic violence shelter]
MTO Adult Qnaire
NO
DK
REF
1
2
D
R
1
2
D
R
1
2
D
R
Page A-20
Revised 08/11/07
YES
HHC5d.
Did you stay on the street?
HHC5e.
Did you stay in a place not meant for
sleeping like an abandoned building; a
car or van; or a movie theater or
laundromat?
NO
DK
REF
1
2
D
R
1
2
D
R
♦ IF NO TO ALL OF THESE, SKIP TO NOTE AFTER HHC6a
HHC6.
How long were you without a place of your own?
Less than one month............................................................................................... 1
More than one month but less than a year .............................................................. 2
More than a year..................................................................................................... 3
Don’t Know
Refused
HHC6a.
At that time were (SAMPLED CHILDREN) with you or living somewhere else?
Living with you ...................................................................................................... 1
Living somewhere else........................................................................................... 2
Don’t Know
Refused
Note: ♦Return to HHC3, and repeat until HHC3-HHC6a has been asked for current address.
HHC7.
I’d like you compare all of the neighborhoods where you’ve since (YEAR OF RANDOM ASSIGNMENT)
♦[ Instruction: show corrected calendar with all addresses as a reminder].
Looking back at all of these addresses you have lived [SHOW LIST OF ADDRESSES], which of these addresses’
neighborhood did you like the best?
___________________________________________
DON’T KNOW
REFUSED
MTO Adult Qnaire
Page A-21
Revised 08/11/07
HHC7a.
What is the main thing you liked about this neighborhood?
SAFER ......................................................................................................................... 1
FEWER PROBLEMS WITH GANGS/DRUGS ......................................................... 2
BETTER OR BIGGER APARTMENT....................................................................... 3
UNIT IN BETTER CONDITION................................................................................ 4
UNIT IS AFFORDABLE ............................................................................................ 5
CLOSER TO FRIENDS .............................................................................................. 6
CLOSER TO FAMILY................................................................................................ 7
CLOSER TO JOB........................................................................................................ 8
SCHOOLS BETTER ................................................................................................... 9
CLOSER TO PUBLIC TRANSPORTATION ............................................................ 10
CHANGE IN MARTIAL STATUS/ROMANTIC STATUS ...................................... 11
OTHER (SPECIFY).................................................................................................... 12
DON’T KNOW
REFUSED
HCH8.
Which addresses’ neighborhood did you like the least?
___________________________________________
DON’T KNOW
REFUSED
HHC8a.
What was the main thing you didn’t like about this neighborhood?
NOT SAFE................................................................................................................... 1
MORE PROBLEMS WITH GANGS/DRUGS ........................................................... 2
WORSE OR SMALLER APARTMENT .................................................................... 3
UNIT IN WORSE CONDITION................................................................................. 4
UNIT IS UNAFFORDABLE....................................................................................... 5
FARTHER FROM FRIENDS...................................................................................... 6
FARTHER FROM FAMILY....................................................................................... 7
FARTHER FROM JOB ............................................................................................... 8
SCHOOLS WORSE .................................................................................................... 9
FARTHER FROM PUBLIC TRANSPORTATION ................................................... 10
OTHER (SPECIFY)..................................................................................................... 11
DON’T KNOW
REFUSED
HHC9.
♦ (SKIP IF THIS ADDRESS = BASELINE)
Now I'd like you to think about when you rented/bought this house/apartment. How did you find this place?
FROM A LISTING GIVEN BY THE HOUSING AUTHORITY......................... 1
NONPROFIT OR COMMUNITY GROUP........................................................... 2
ADVERTISEMENT IN NEWSPAPER OR INTERNET...................................... 3
REAL ESTATE AGENT/BROKER...................................................................... 4
FRIEND OR FAMILY MEMBER ........................................................................ 5
DRIVING BY/SAW SIGN .................................................................................... 6
OTHER (SPECIFY)............................................................................................... 7
DON’T KNOW
REFUSED
MTO Adult Qnaire
Page A-22
Revised 08/11/07
HHC10.
There are many reasons why people choose to move to certain neighborhoods. What would you say was the main
reason you moved to your current neighborhood?
SAFER ......................................................................................................................... 1
FEWER PROBLEMS WITH GANGS/DRUGS ......................................................... 2
BETTER OR BIGGER APARTMENT....................................................................... 3
UNIT IN BETTER CONDITION................................................................................ 4
UNIT IS AFFORDABLE ............................................................................................ 5
CLOSER TO FRIENDS .............................................................................................. 6
COSER TO FAMILY .................................................................................................. 7
CLOSER TO JOB........................................................................................................ 8
SCHOOLS BETTER ................................................................................................... 9
CLOSER TO PUBLIC TRANSPORTATION ............................................................ 10
LANDLORD ACCEPTED VOUCHER...................................................................... 11
ONLY PLACE I LOOKED ......................................................................................... 12
OTHER (SPECIFY)..................................................................................................... 13
DON’T KNOW
REFUSED
HHC11a.
Now I would like to know some more about your current house/apartment. Do you...
Rent your home or apartment?
Yes ................................... 1 (GO TO HHC12a)
No..................................... 5
DK
RF
HHC11b.
Own your own home?
Yes ................................... 1 (GO TO HHC12b)
No..................................... 5
DK
RF
HHC11c.
Live with family or friends and pay part of the rent or mortgage?
Yes ................................... 1 (GO TO HHC12a)
No..................................... 5
DK
RF
HHC11d.
Live with family or friends and do not pay rent?
Yes ................................... 1 (GO TO HHC13)
No..................................... 5
DK
RF
MTO Adult Qnaire
Page A-23
Revised 08/11/07
HHC11e.
Live in a group shelter?
Yes ................................... 1 (GO TO HHC12c)
No..................................... 5
DK
RF
HHC11f.
Live in some other housing arrangement?
Specify ________________________ (GO TO HHC13)
DK
RF
HHC12a.
Altogether in the month just passed, what did you pay in rent? We are interested only in knowing your part of the
payment.
______________________________________ (GO TO HHC13)
DK
RF
HHC12b.
Altogether in the month just passed, what was the amount you paid to the bank or mortgage company?
ENTER dollar amount $ _ _ _,_ _ _
DK
RF
(GO TO HHC13)
HHC12c.
Do you have your own room or do you share a room with other people?
Yes ................................... 1 (GO TO HHC13)
No..................................... 5
DK
RF
HHC13.
Not including bathrooms and hallways, how many rooms are there in your house or apartment?
ENTER NUMBER OF ROOMS__________
IF 9 OR MORE ROOMS, ENTER ‘9’
DK
RF
MTO Adult Qnaire
Page A-24
Revised 08/11/07
HHC14.
Overall, how would you describe the condition of your current house/apartment? Would you say it was in excellent,
good, fair, or poor condition?
Excellent..........................................1
Good................................................2
Fair ..................................................3
Poor .................................................4
DK
RF
BIG
PROB.
SMALL
PROB.
NO PROB.
AT ALL
1
2
HHC15b.
Plumbing that doesn't work?
1
HHC15c.
Rats or mice?
DK
RF
3
D
R
2
3
D
R
1
2
3
D
R
HHC15d.
Cockroaches?
1
2
3
D
R
HHC15e.
Broken locks or no locks on the door to your unit?
1
2
3
D
R
HHC15f.
Broken windows or windows without screens?
1
2
3
D
R
HHC15g.
A heating system that does not work?
1
2
3
D
R
HHC15a.
Now I am going to ask you some questions about
problems that people have in some homes or apartments.
Where you live now, how much of a problem are…
Walls with peeling paint or broken plaster? [Would you
say they are a big problem, a small problem or no
problem at all?]
CHECKPOINT:
IF HHC15a IS CODED ‘1’ OR ‘2’ (BIG OR SMALL PROBLEM) Æ GO TO HHC16a
ALL OTHERS Æ GO TO NEXT CHECKPOINT
HHC16a.
Does the house or apartment have any area of peeling paint or broken plaster bigger than 8 inches by 11 inches?
(the size of a standard letter)
Yes ..................................................1
No....................................................5
DK
RF
MTO Adult Qnaire
Page A-25
Revised 08/11/07
CHECKPOINT:
IF HHC15b IS CODED ‘1’ OR ‘2’ (BIG OR SMALL PROBLEM) Æ GO TO HHC16b
ALL OTHERS Æ GO TO NEXT CHECKPOINT
HHC16b.
In the last 3 months, was there any time when all the toilets in the home were not working and you had no working
toilet in the home for 6 hours or longer? (“while household was living here” if less than 3 months)
Yes……………………………………..1
No………………………………………5
DK
RF
HHC16c.
Is water leaking today from any kitchen or bathroom sink or drain pipe?
Yes……………………………………….1
No………………………………………..5
DK
RF
CHECKPOINT:
IF HHC15c IS CODED ‘1’ OR ‘2’ (BIG OR SMALL PROBLEM) Æ GO TO HHC16d
ALL OTHERS Æ GO TO NEXT CHECKPOINT
HHC16d.
Did you see a rat anywhere in your building or outside around the grounds this week?
Yes ..................................................1
No....................................................5
DK
RF
CHECKPOINT:
IF HHC15d IS CODED ‘1’ OR ‘2’ (BIG OR SMALL PROBLEM) Æ GO TO HHC16e
ALL OTHERS Æ GO TO NEXT CHECKPOINT.
HHC16e.
Have you seen many cockroaches in your home this week?
Yes ..................................................1
No....................................................5
DK
RF
MTO Adult Qnaire
Page A-26
Revised 08/11/07
CHECKPOINT:
IF HHC15g IS CODED ‘1’ OR ‘2’ (BIG OR SMALL PROBLEM) Æ GO TO HHC16f
ALL OTHERS Æ GO TO HHC17
HHC16f.
During this past winter, was there any time when this house/apartment was so cold for 24 hours or more that it
caused anyone in your household discomfort?
Yes ..................................................1
No....................................................5 (GO TO HHC17)
DK (GO TO HHC17)
RF (GO TO HHC17)
HHC16g.
Was that because the heating system broke down, you could not pay your utility bill, to keep costs down, or some
other reason?
Heating system broke down ........................................ 1
Could not pay utility bill ............................................. 2
Keep costs down.......................................................... 3
Some other reason ....................................................... 4
DK
RF
HHC17.
Does your house/apartment have significant problems with mold on walls or ceilings, for example in your
bathroom?
Yes ..................................................1
No....................................................5
DK
RF
HHC18.
Does the house or apartment have any walls, ceilings, or floors with serious problems like sagging, leaning, buckling
or large holes?
Yes ..................................................1
No....................................................5
DK
RF
(IF BASELINE=CURRENT ADDRESS, GO TO PAYMENT DIFFICULTIES CHECKPOINT)
MTO Adult Qnaire
Page A-27
Revised 08/11/07
HHC19.
Some people get housing assistance that requires them to complete re-certifications by reporting income and who
lives with them to determine the amount of rent they pay. One of those programs is the housing voucher program,
also sometimes called Section 8, which gives a renter the right to choose where they live and it helps pay the rent.
Does your household have a housing voucher?
Yes ..................................................1
No....................................................5 (GO TO HHC19b)
DK (GO TO HHC19b)
RF (GO TO HHC19b)
HHC19a.
(If HHC19 = YES)
Can your household use its housing voucher to move to another location?
Yes ..................................................1 (GO TO HHC20)
No....................................................5
DK
RF
HHC19b.
Is the housing authority your landlord?
Yes ..................................................1 (GO TO HHC20)
No....................................................5
DK
RF
HHC19c.
(If HHC19 = NO & HHC19b = NO)
Do you currently live in some other type of housing where your landlord requires you to prove your income each
year?
Yes ..................................................1 (GO TO HHC20)
No....................................................5
DK
RF
HHC19d.
(IF HHC19 = NO & (HHC19b and HHC19c = NO))
People stop getting housing assistance (either public housing or section 8 vouchers) for different reasons. What
would you say was the main reason you are no longer getting assistance?
NO LONGER ELIGIBLE BECAUSE INCOME IS TOO HIGH.................................1
PURCHASED HOME ..................................................................................................2
GOT MARRIED/MOVED IN WITH PARTNER........................................................3
EVICTED BY LANDLORD ........................................................................................4
TERMINATED FROM PROGRAM/BROKE RULES ETC. ......................................5
RELOCATED FROM PUBLIC HOUSING AND
COULD NOT MOVE BACK .......................................................................................6
OTHER (SPECIFY:_____________________________) ...........................................7
DK
RF
MTO Adult Qnaire
Page A-28
Revised 08/11/07
HHC19e.
Since you stopped getting housing assistance, have you tried to get a new housing voucher, Section 8, or applied to
move back into public housing?
Yes ..................................................1
No....................................................5 (GO TO HHC20)
DK (GO TO HHC20)
RF (GO TO HHC20)
HHC19f.
Are you currently on a waiting list for housing assistance?
Yes ..................................................1
No....................................................5
DK
RF
HHC20 CHECKPOINT.
¾
¾
¾
(IF HHC11a = YES [RENTER], GO TO HHC20a. ASK QUESTIONS IN ‘RENTER’ COLUMN.
(IF HHC11b= YES [HOMEOWNER], GO TO HHC20b. ASK QUESTIONS IN ‘OWNER’ COLUMN.
(IF HHC11c, d, e, f = YES, DK, OR RF: SKIP TO NEXT SECTION OF SURVEY)
RENTERS:
HHC20a.
How many months in the past 12 months were you more
than 15 days late paying your rent?
_________# MONTHS LATE WITH RENT
DK
RF
OWNERS:
HHC20b.
How many months in the past 12 months were you more
than 15 days late paying your mortgage?
_________# MONTHS LATE WITH MORTGAGE
DK
RF
H20c.
In the last 12 months, has your current or previous
landlord ever threatened to evict you for nonpayment of
rent?
YES
NO
DK
RF
HHC20d.
In the last 12 months, has your current or previous bank
ever threatened to foreclose on your mortgage?
YES
NO
DK
RF
HHC21.
Now I have some questions about your utilities. Do you
pay for your own electricity or is that included in the
rent?
PAY OWN ELECTRICITY…..1
INCLUDED IN RENT………...2 (GO TO HHC20)
DK (GO TO HHC20)
RF (GO TO HHC20)
HHC21a.
How much was the electric bill last month?
________DOLLARS FOR ELECTRICITY
DK
RF
MTO Adult Qnaire
HHC21a.
How much was the electric bill last month?
________DOLLARS FOR ELECTRICITY
DK
RF
Page A-29
Revised 08/11/07
RENTERS:
HHC22.
Do you pay for your own gas or is that included in the
rent?
PAY OWN GAS…………1
INCLUDED IN RENT..….2 (GO TO CKPT)
DK (GO TO CKPT)
RF (GO TO CKPT)
OWNERS:
HHC22a.
How much was the gas bill last month?
HHC22a.
How much was the gas bill last month?
_________ DOLLARS FOR GAS
DK
RF
_________ DOLLARS FOR GAS
DK
RF
CHECKPOINT:
IF HHC21 = 1 OR HHC22 = 1, THEN ASK HHC23.
OTHERS, GO TO NEXT SECTION.
ASK HHC23
HHC23.
People sometimes have trouble paying their utility bills on time. How many months out of the last 12 were you
more than 15 days late paying your electric, gas, or water bill?
Enter number of months _______________________
DK
RF
CHECKPOINT:
IF HHC23 IS CODED 1-12, Æ ASK HHC23a.
IF CODED “0”, DK OR REFUSED, Æ GO TO NEXT SECTION.
HHC23a.
Did you receive a notice that your gas, water, or electricity would be shut off if you did not pay your bill?
Yes ..................................................1
No....................................................5
DK
RF
HHC23b.
In the past 12 months, was your gas, water, or electricity ever shut off for nonpayment?
Yes ..................................................1
No....................................................5
DK
RF
MTO Adult Qnaire
Page A-30
Revised 08/11/07
HHC23c.
For the most recent time you were late making the payment, why were you late paying? Did you forget about the
bill, was the bill higher than usual, or did you run out of money?
FORGOT ABOUT BILL ....................................1
BILL WAS HIGHER THAN NORMAL............2
RAN OUT OF MONEY......................................3
OTHER (SPECIFY)............................................4
DK
RF
MTO Adult Qnaire
Page A-31
Revised 08/11/07
A_Section 04: Neighborhoods
HNB1.
Which of the following statements best describes how satisfied you are with your neighborhood? Would
you say you are very satisfied, somewhat satisfied, in the middle, somewhat dissatisfied, or very
dissatisfied with your neighborhood?
Very satisfied
1
Somewhat satisfied
2
In the middle
3
Somewhat dissatisfied
4
Very dissatisfied
5
Don’t know
Refused
HNB2.
Now I would like to ask you about problems that occur in some neighborhoods. I will
read you a series of questions, and for each please tell me if it is a big problem, a small
problem, or not a problem in your neighborhood. In your neighborhood, how big of a
problem is…
Big
Problem
HNB2a.
Litter or trash on the streets or sidewalk? Is
it a big problem, a small problem or no
problem?
Small
Problem
No
Problem
DK
RF
1
2
3
D
R
1
2
3
D
R
HNB2c.
People drinking in public?
1
2
3
D
R
HNB2d.
Abandoned buildings?
1
2
3
D
R
HNB2e.
Groups of people just hanging out?
1
2
3
D
R
HNB2f.
Police not coming when called?
1
2
3
D
R
HNB2b.
How big of a problem is graffiti or writing on the
walls?
MTO Adult Qnaire
Page A-32
Revised 08/11/07
HNB3.
Have you seen people using or selling illegal drugs in your neighborhood during the past 30 days?
Yes
1
No (SKIP TO HNB6)
5
Don’t know (SKIP TO HNB6)
D
Refused (SKIP TO HNB6)
R
HNB4.
How often have you seen someone using drugs in your neighborhood in the past 30 days? Would you say
almost every day, once a week, or once or twice in the past 30 days, or didn’t see anyone using ?
Almost every day (includes 4-7 days a week)
1
Once a week (includes 1-3 days a week)
2
Once or twice in the past 30 days (includes 1-3 times in 30 days)
3
Didn’t see anyone using
4
Don’t know
Refused
HNB5.
How often have you seen someone selling drugs in your neighborhood in the past 30 days? Would you say
almost every day, once a week, or once or twice in the past 30 days, or didn’t your see anyone selling ?
Almost every day (includes 4-7 days a week)
1
Once a week (includes 1-3 days a week)
2
Once or twice in the past 30 days (includes 1-3 times in 30 days)
3
Didn’t see anyone using
4
Don’t know
Refused
HNB6.
Now I have a few questions about discrimination. Sometimes people feel like they are discriminated
against, or treated badly or differently because of their race or ethnicity. Can you think of one or more
occasions in the last 6 months when you felt you were treated unfairly because of your race or ethnicity in
the following places? How about…
HNB6a.
In a store where you were shopping or a restaurant where you
wanted to eat?
HNB6b.
In your own neighborhood?
HNB6c.
At your child's school?
HNB6d.
In dealing with the police, such as a traffic accident?
MTO Adult Qnaire
Yes
No
DK
RF
1
5
D
R
1
5
D
R
1
5
D
R
1
5
D
R
Page A-33
Revised 08/11/07
HNB7.
Sometimes people feel like they are discriminated against, or treated badly or differently because they
might not have quite as much money as other people, or because of the way they dress or talk. Can you
think of one or more occasions in the last 6 months when you felt you were treated unfairly in the following
places because of how much money your family has or the way you dress or talk? How about…
Yes
No
1
5
D
R
HNB7b.
In your own neighborhood?
1
5
D
R
HNB7c.
At your child's school?
1
5
D
R
HNB7d.
In dealing with the police, such as a traffic accident?
1
5
D
R
HNB7a.
In a store where you were shopping or a restaurant where you
wanted to eat?
DK
RF
HNB8.
How long does it take you to get to the nearest bus or train stop?
LESS THAN 15 MINUTES
1
15-30 MINUTES
2
31-45 MINUTES
3
46 MINUTES TO 1 HOUR
4
MORE THAN 1 HOUR
5
DON’T KNOW
REFUSED
________________________________________________________________________
HNB9a.
Now I would like to get a sense of how safe you think your neighborhood is. How safe do you feel on the
streets near your home during the day? Would you say very safe, safe, unsafe, or very unsafe?
VERY SAFE
1
SAFE
2
UNSAFE
3
VERY UNSAFE
4
DON’T KNOW
REFUSED
______________________________________________________________________________________
MTO Adult Qnaire
Page A-34
Revised 08/11/07
HNB9b.
How safe do you feel on the streets near your home at night? Would you say very safe, safe, unsafe, or
very unsafe?
VERY SAFE
1
SAFE
2
UNSAFE
3
VERY UNSAFE
4
DON’T KNOW
REFUSED
MTO Adult Qnaire
Page A-35
Revised 08/11/07
A_Section 05: Education & Training
HED1.
Now I’d like to talk about your educational background. What is the highest grade or year of regular
school that you have completed and gotten credit for?
♦ ENTER GRADE: ________________
FIRST YEAR OF COLLEGE........................................ 13
SECOND YEAR OF COLLEGE................................... 14
THIRD YEAR OF COLLEGE ...................................... 15
FOURTH YEAR OF COLLEGE................................... 16
FIFTH YEAR OF COLLEGE........................................ 17
SIXTH YEAR OF COLLEGE....................................... 18
SEVENTH YEAR OF COLLEGE................................. 19
EIGHTH YEAR OF COLLEGE OR MORE................. 20
DON’T KNOW
REFUSED
HED2a.
Do you have a high school diploma or a GED?
GED ............................................................................... 1
HIGH SCHOOL DIPLOMA.......................................... 2
BOTH............................................................................. 3
NEITHER....................................................................... 4
DON’T KNOW
REFUSED
HED2b.
Do you have a college degree?
YES ................................................................................ 1
NO.................................................................................. 5 (GO TO HED3a)
DON’T KNOW.............................................................. D (GO TO HED3a)
REFUSED...................................................................... R (GO TO HED3a)
HED2c.
What is the highest degree you have received?
Associate degree in college -- Occupational/vocational program .......................... 1
Associate degree in college -- Academic program................................................. 2
Bachelor's degree (For example: BA, AB, BS)...................................................... 3
Master's degree (For example: MA, MS, MEng, MEd, MSW, MBA) .................. 4
Professional School Degree (For example: MD, DDS, DVM, LLB, JD) ............. 5
Doctorate degree (For example: PhD, EdD) ......................................................... 6
Don’t know
Refused
MTO Adult Qnaire
Page A-36
Revised 08/11/07
HED3a.
Now I would like to ask you about any regular school or any training you may have had in the past 2 years.
Have you participated in any additional regular schooling or in some other type of schooling or training
program that lasted at least two weeks that was designed to help you find a job, improve your job skills, or
learn a new job?
Yes ................................................................................. 1
No................................................................................... 5 (GO TO HEM1)
Don’t Know.................................................................... D (GO TO HEM1)
Refused........................................................................... R (GO TO HEM1)
HED3b.
What kind of schooling or training was that?
♦ ENTER ALL THAT APPLY
GENERAL EQUIVALENCY DIPLOMA (GED)............................................................... 1
ENGLISH AS A SECOND LANGUAGE........................................................................... 2
COMPUTER TRAINING.................................................................................................... 3
WORK STUDY PROGRAM............................................................................................... 4
CERTIFICATION OR TRAINING IN A HEALTH CARE FIELD ................................... 5
REGULAR SCHOOLING................................................................................................... 6
OTHER (SPECIFY) ______________________________ ................................................ 7
DON’T KNOW
REFUSED
HED3c.
How many weeks did you participate in schooling or training in the past 24 months?
♦ ENTER number of weeks: ________________________
DON’T KNOW
REFUSED
HED3d.
During those weeks, how many hours a week did you usually spend in schooling or training?
♦ ENTER number of hours: ____________________________
DON’T KNOW
REFUSED
HED3e.
Are you currently participating in schooling or training?
Yes ................................................................................. 1
No................................................................................... 5
Don’t know
Refused
MTO Adult Qnaire
Page A-37
Revised 08/12/07
A_Section 06: Employment & Earnings
HEM1_C1.
Last week, did you do any work for pay?
Yes .............................................................................. 1(GO TO HEM3)
No................................................................................ 5
If Volunteered, Retired................................................ 6 (GO TO HEM21)
If Volunteered, Disabled ............................................. 7 (GO TO HEM20)
If Volunteered, Unable to Work.................................. 8 (GO TO HEM20)
Don’t Know................................................................. (GO TO HEM22)
Refused........................................................................ (GO TO HEM22)
HEM2_C2.
(RB) What is the main reason that you did not work for pay last week?
Retired......................................................................... 1 (GO TO HEM21)
Disabled ...................................................................... 2 (GO TO HEM20)
Unable to Work ........................................................... 3 (GO TO HEM20)
Has Job But Temporarily Absent ................................ 4 (GO TO HEM3)
Couldn’t Find Any Work ............................................ 5 (GO TO HEM22)
Child Care Problems ................................................... 6 (GO TO HEM22)
Family Responsibilities ............................................... 7 (GO TO HEM22)
In School or Other Training ........................................ 8 (GO TO HEM22)
Waiting For a New Job to Begin ................................. 9 (GO TO HEM22)
Other (Specify): ___________________.................... 10 (GO TO HEM22)
Don’t Know................................................................. 98 (GO TO HEM22)
Refused........................................................................ 99 (GO TO HEM22)
HEM3_C3.
Last week, did you have more than one job, including part-time and weekend work?
Yes .............................................................................. 1
No................................................................................ 5
Don’t know
Refused
HEM4_C4.
How many hours per week do you usually work at your (main) job? (By main job, we mean the one at
which you usually work the most hours.)
HOURS PER WEEK: __________ (GO TO HEM4b)
DON’T KNOW (GO TO HEM4a)
REFUSED (GO TO HEM4a)
HEM4a_C4a.
Do you usually work 35 hours or more per week at your (main) job?
Yes .............................................................................. 1
No................................................................................ 5
Hours Vary.................................................................. 7
Don’t know
Refused
______________________________________________________________________________________
MTO Adult Qnaire
Page A-38
Revised 08/12/07
CHECKPOINT:
IF MORE THAN ONE JOB (HEM3=YES), Æ ASK HEM4b.
OTHERS Æ GO TO HEM5.
HEM4b.
How many hours per week do you usually work at your other job(s)?
HOURS PER WEEK: __________
DON’T KNOW
REFUSED
HEM5.
Now I have a few questions about the (main) job at which you worked last week. Were you employed by
government, by a private company, a nonprofit organization, or were you self-employed (or working in the
family business)?
Government................................................................. 1
A Private for Profit Company ..................................... 2
A Nonprofit Organization
(inclu tax exempt and charitable organizations)..... 3
Self Employed............................................................. 4
Working in the Family Business ................................. 5
Don’t know
Refused
HEM5a_C5.
What kind of business or industry is this? What do they make or do where you work?
________________________________________________
________________________________________________
DON’T KNOW
REFUSED
HEM5b_C5a.
Is this business or organization mainly manufacturing, retail trade, wholesale trade, or something else?
Manufacturing ..........................................................................................1
Retail Trade..............................................................................................2
Wholesale Trade.......................................................................................3
Something Else (Specify): ____________________................................4
Don’t know
Refused
HEM6_C6.
What kind of work do you do, that is, what is your occupation? For example, plumber, typist, farmer.
______________________________________________
DON’T KNOW
REFUSED
MTO Adult Qnaire
Page A-39
Revised 08/12/07
HEM7_C7.
What are your usual duties or activities at this job? For example, typing, keeping account books, filing,
selling cars, operating, printing press, laying brick.
_____________________________________________
_____________________________________________
DON’T KNOW
REFUSED
HEM8_C8.
When did you first start working [at your main job]?
♦ ENTER MM/YYYY
_ _/_ _ _ _
DON’T KNOW
REFUSED
HEM9_C9.
For your (main) job, what is the easiest way for you to report your total earnings before taxes or other
deductions: hourly, weekly, annually, or on some other basis?
Hourly ......................................................................................................1
Daily.........................................................................................................2
Weekly .....................................................................................................3
Biweekly (every 2 weeks) ........................................................................4
Twice Monthly .........................................................................................5
Monthly....................................................................................................6
Annually...................................................................................................7
Per Unit (Specify Unit Type): __________________ ............................8
Other: (Specify): ____________________________ . ............................9
Don’t know
Refused
HEM10_C10.
Do you usually receive overtime pay, tips, or commissions (at your main job)?
Yes .............................................................................. 1
No................................................................................ 5
Don’t know
Refused
INTERVIEWER CHECKPOINT – REFER TO HEM9
IF EARNING = HOURLY ...................... (GO TO HEM13)
(HEM9 = ‘1’)
IF EARNING = DAILY, WEEKLY, BIWEEKLY, TWICE MONTHLY, MONTHLY,
ANNUALLY ................ (GO TO HEM11)
(HEM9 = ( ‘2’, ‘3’, ‘4’, ‘5’, ‘6’, ‘7’))
IF EARNING = PER UNIT...................... (GO TO HEM12a)
(HEM9 = ‘8’)
IF EARNING = OTHER, DK, RF............ (GO TO HEM15)
(HEM9 = (‘9’, ‘DK’, ‘RF’))
MTO Adult Qnaire
Page A-40
Revised 08/12/07
HEM11_C11.
(Including overtime pay, tips, and commissions), what are your usual (daily / weekly / biweekly / monthly /
annual) earnings on [this] job, before taxes or other deductions?
♦ ENTER dollar amount:
$ _ _ _,_ _ _._ _
Don’t know
Refused
INTERVIEWER CHECKPOINT – REFER TO HEM9
IF EARNING = DAILY ........................................ (GO TO HEM11a)
(HEM9 = ‘2’)
IF EARNING = WEEKLY, BIWEEKLY, TWICE MONTHLY,
MONTHLY................................. (GO TO HEM15)
(HEM9 = (‘3’, ‘4’, ‘5’, ‘6’)
IF EARNING = ANNUALLY............................... (GO TO HEM12)
(HEM9 = ‘7’)
HEM11a_C11a.
How many days a week do you usually work?
NUMBER OF DAYS: __________
Don’t know
Refused
HEM12_C12.
How many weeks a year do you get paid for?
NUMBER OF WEEKS: ______________ (GO TO HEM15)
Don’t know
Refused
HEM12a_C12a.
INTERVIEWER CHECKPOINT – REFER TO HEM9 and HEM10
IF EARNING IS ‘PER UNIT’ AND OVERTIME IS ‘YES’
(HEM9_C9 = ‘8’ AND HEM10_C10 = ‘1’)……………... ..............1 (GO TO HEM12d)
IF EARING IS ‘PER UNIT’ AND OVERTIME IS (‘NO’, ‘DK’, ‘RF’)
(HEM9_C9 = ‘8’ AND HEM10_C10 = (‘5’, ‘DK’, ‘RF’)...................2 (GO TO HEM12b)
HEM12b_C12b.
What is your rate of pay per [UNIT] (on this job)?
♦ ENTER dollar amount: $ _ _ _,_ _ _._ _
Don’t Know................................................................. 9999998 (GO TO HEM15)
Refused........................................................................ 9999999 (GO TO HEM15)
MTO Adult Qnaire
Page A-41
Revised 08/12/07
HEM12c_C12c.
For how many [UNIT]’s are you usually paid per week (on this job)?
♦ NUMBER OF UNITS: ______________
Don’t know
Refused
(GO TO HEM15)
HEM12d_C12d.
Excluding overtime pay, tips, and commissions, what is your rate of pay per [UNIT] (on this job)?
DOLLAR AMOUNT: $ _ _ _,_ _ _._ _
Don’t know
Refused
HEM12e_C12e.
For how many [UNIT]’s are you usually paid per week at this rate?
NUMBER OF UNITS: _____________
Don’t know
Refused
HEM12g_C12g.
(At your main job,) how much do you usually receive just in overtime pay, tips, commissions, before taxes
or other deductions?
DOLLAR AMOUNT: $ _ _ _,_ _ _._ _
Don’t Know................................................................. 998 (GO TO HEM12i)
Refused........................................................................ 999 (GO TO HEM12i)
HEM12h_C12h.
Is that ...
Per Hour ...................................................................... 1
Per Day........................................................................ 2
Per Week ..................................................................... 3
Per Month.................................................................... 4
Per Year....................................................................... 5
Per Unit (Specify Unit Type): _______________ ...... 6
Other (Specify): ___________________.................... 7
Don’t know
Refused
MTO Adult Qnaire
Page A-42
Revised 08/12/07
HEM12i_C12i.
CHECKPOINT
IF EARNING IS ‘PER UNIT’ AND OVERTIME IS ‘YES’ AND
OVERTIME IS ‘PAID PER DAY’………...……...……...1 (GO TO HEM12l)
(HEM9 = ‘8’ AND HEM10 =‘1’ AND HEM12h = ‘2’)
IF EARING IS ‘PER UNIT’ AND OVERTIME IS ‘YES’AND
OVERTIME IS ‘PAID PER UNIT’ …………...…...……2 (GO TO HEM12j)
(HEM9 = ‘8’ AND HEM10 = ‘1’ AND HEM12h = ’6’)
IF EARING IS ‘PER UNIT’ AND OVERTIME IS ‘YES’ AND
OVERTIME IS ‘PAID PER HOUR’ ……………………3 (GO TO HEM12k)
(HEM9 = ‘8’ AND HEM10 = ‘1’ AND HEM12h =’1’)
IF EARING IS ‘PER UNIT’ AND OVERTIME IS ‘YES’ AND
OVERTIME IS (‘PAID PER WEEK’,’PER MONTH’,
’PER YEAR’,‘OTHER’, ‘DK’ or ‘RF’) ……………..…..4 (GO TO HEM15)
(HEM9 = ‘8’ AND HEM10 = ‘1’ AND HEM12h =(‘3’,’4’,‘5’,’7’,‘DK’ or ‘RF’))
HEM12j_C12j.
For how many [UNIT]’s are you usually paid per week at this rate?
NUMBER OF UNITS: ___________ (GO TO HEM15)
Don’t know (GO TO HEM15)
Refused (GO TO HEM15)
HEM12k_C12k.
How many hours do you usually work per week at this rate?
HOURS PER WEEK: ___________ (GO TO HEM15)
Don’t know (GO TO HEM15)
Refused (GO TO HEM15)
HEM12l_C12l.
How many days per week do you usually work at this rate?
DAYS PER WEEK: __________ (GO TO HEM15)
Don’t know (GO TO HEM15)
Refused (GO TO HEM15)
HEM13_C13.
CHECKPOINT
IF EARNING IS ‘HOURLY’ AND OVERTIME IS ‘YES’
(HEM9 = ‘1’ AND HEM10 =‘1’)……………………………………1 (GO TO HEM14a)
IF EARING IS ‘HOURLY’ AND OVERTIME IS (‘NO’, ‘DK’, ‘RF’)
(HEM9 = ‘1’ AND HEM10 = (‘5 ‘ or ‘DK’ or ‘RF’)………………2 (GO TO HEM13a)
HEM13a_C13a.
What is your hourly rate of pay (on this job)?
DOLLAR AMOUNT: $ _,_ _ _._ _ (GO TO HEM15)
Don’t know (GO TO HEM15)
Refused (GO TO HEM15)
MTO Adult Qnaire
Page A-43
Revised 08/12/07
HEM14a_C14a.
Excluding overtime pay, tips and commissions, what is your hourly rate of pay (on this job)?
DOLLAR AMOUNT: $_,_ _ _._ _
Don’t know
Refused
HEM14b_C14b.
How many hours do you usually work per week at this rate?
HOURS PER WEEK: _______________
Don’t know
Refused
HEM14c_C14c.
(At your main job,) how much do you usually receive just in overtime pay, tips, commissions before taxes
or other deductions?
DOLLAR AMOUNT: $_ _ _,_ _ _._ _
Don’t know
Refused
HEM14d_C14d.
Is that…
Per Hour ........................................................ 1 (GO TO HEM14e)
Per Day.......................................................... 2 (GO TO HEM14e)
Per Week ....................................................... 3 (GO TO HEM15)
Per Month...................................................... 4 (GO TO HEM15)
Per Year......................................................... 5 (GO TO HEM15)
Per Unit (Specify): ______________............ 6 (GO TO HEM14e)
Other (Specify): _______________.............. 7 (GO TO HEM15)
Don’t Know .................................................. 8 (GO TO HEM15)
Refused ......................................................... 9 (GO TO HEM15)
HEM14e_C14e.
How many days/units/hours do you usually work per week at this rate?
♦ ENTER days/units/hours per week: _____________
Don’t know
Refused
MTO Adult Qnaire
Page A-44
Revised 08/12/07
HEM15a_C15a.
Through your employer are you eligible for any of the following benefits? By eligible we mean the benefit
is available for you now, even if you decided to not receive it or have not needed it.
Health Insurance?
Yes .............................................................................. 1
No................................................................................ 5
Don’t know
Refused
HEM15b_C15b.
Sick Leave?
Yes .............................................................................. 1
No................................................................................ 5
Don’t know
Refused
HEM15c_C15c.
Paid Vacation?
Yes .............................................................................. 1
No................................................................................ 5
Don’t know
Refused
HEM16_C16.
I’d like to ask you how you found the (main) job you have now. What is the most important source of
information you used to find this job?
[FIELD CODE RESPONSE INTO ONE OF THE FOLLOWING CATEGORIES.]
A Friend, Relative, or Acquaintance ........................... 1
A Government Employment Agency .......................... 2 (GO TO HEM18)
A Private Employment Agency................................... 3 (GO TO HEM18)
Checking Directly With My Employer ....................... 4 (GO TO HEM18)
A Referral From A Job Training Program .................. 5 (GO TO HEM18)
The Newspaper............................................................ 6 (GO TO HEM18)
A School Employment Service ................................... 7 (GO TO HEM18)
A Computer Search ..................................................... 8 (GO TO HEM18)
Church......................................................................... 9 (GO TO HEM18)
Community Center ...................................................... 10 (GO TO HEM18)
Other (Specify): ___________________________ .... 11 (GO TO HEM18)
Don’t Know................................................................. .98 (GO TO HEM18)
Refused........................................................................ .99(GO TO HEM18)
HEM17_C17.
Did this person live in the same neighborhood as you at the time you got the job?
Yes .............................................................................. 1
No................................................................................ 5
Don’t know
Refused
MTO Adult Qnaire
Page A-45
Revised 08/12/07
HEM18_C18.
(RB) How did you usually get to work last week?
♦ PROBE: For one used for most distance
♦ CHECK ALL THAT APPLY
Car, Truck, or Van ...................................................... 1
Bus or Trolley Bus ...................................................... 2
Streetcar or Trolley Car............................................... 3
Subway or Elevated..................................................... 4
Railroad....................................................................... 5
Ferryboat ..................................................................... 6
Taxicab........................................................................ 7
Motorcycle .................................................................. 8
Bicycle ........................................................................ 9
Walked ........................................................................ 10
Worked at Home ......................................................... 11
Other Method .............................................................. 12
Don’t know
Refused
HEM19_C19.
How many minutes did it usually take you to get from home to work last week?
♦ ENTER number of minutes: ____________ (GO TO HEM28)
Don’t know (GO TO HEM28)
Refused (GO TO HEM28)
HEM20_C20.
Do you have a disability that prevents you from accepting any kind of work during the next six months?
Yes .............................................................................. 1 (GO TO HEM28)
No................................................................................ 5 (GO TO HEM22)
Don’t Know................................................................. 8 (GO TO HEM22)
Refused........................................................................ 9 (GO TO HEM22)
HEM21_C21.
Do you currently want a job, either full-time or part-time?
Yes or Maybe, It Depends........................................... 1 (GO TO HEM22)
No................................................................................ 5 (GO TO HEM28)
Don’t Know................................................................. 8 (GO TO HEM28)
Refused........................................................................ 9 (GO TO HEM28)
HEM22_C22.
Have you been doing anything to find work during the past four weeks?
Yes .............................................................................. 1
No................................................................................ 5 (GO TO HEM28)
Retired......................................................................... 6 (GO TO HEM28)
Disabled ...................................................................... 7 (GO TO HEM28)
Unable To Work.......................................................... 8 (GO TO HEM28)
Don’t Know................................................................. (GO TO HEM28)
Refused........................................................................ (GO TO HEM28)
MTO Adult Qnaire
Page A-46
Revised 08/12/07
HEM23_C23.
(RB) What are all the things you have done to find work during the past four weeks?
♦ CHECK ALL THAT APPLY
Contacted Employer(s)............................................................................................................. 1
Contacted Public Employment Agency Programs/Courses ..................................................... 2
Contacted Private Employment Agency .................................................................................. 3
Contacted Friends or Relatives ................................................................................................ 4
Interviewed for a Job................................................................................................................ 5
Contacted School/University Employer Center ....................................................................... 6
Sent Out Resumes/Filled out Applications .............................................................................. 7
Checked Union/Professional Registers .................................................................................... 8
Placed or Answered Ads .......................................................................................................... 9
Looked at Ads Directly ............................................................................................................ 10
Attended Job Training.............................................................................................................. 11
Nothing..................................................................................................................................... 12
Other (Specify): ___________________________________ ................................................. 13
Don’t know
Refused
HEM26_C26.
Last week, could you have started a job if one had been offered?
Yes .............................................................................. 1 (GO TO HEM28)
No................................................................................ 5
Don’t know (GO TO HEM28)
Refused (GO TO HEM28)
HEM27_C27.
Why is that?
Waiting For New Job to Begin.................................................................1
Own Temporary Illness............................................................................2
Going to School .......................................................................................3
Other (Specify):__________________________ ....................................4
Don’t know
Refused
HEM28_C28.
Now I am going to ask you about any other paid employment you have had in the past 2 years (other than
the job we jus discussed). This should include any paid employment you have now. Please tell me about
any work you have had as an employee, that is, work you had in an ongoing relationship with a particular
employer. For example, working in a supermarket or restaurant would be work as an employee.
In the past 2 years, have you done any (other) work at all for which you were paid?
Yes .............................................................................. 1
No................................................................................ 5 (GO TO HEM35)
Don’t Know................................................................. 8 (GO TO HEM35)
Refused........................................................................ 9 (GO TO HEM35)
MTO Adult Qnaire
Page A-47
Revised 08/12/07
HEM28a_C28a.
Please tell me the name of your most recent (other) employer.
_______________________________ [DO NOT ENTER IDENTIFYING INFORMATION.]
Don’t know
Refused
HEM29_C29.
What kind of work did you usually do for this employer?
[RECORD TYPE OR WORK FOR EMPLOYER. IF RESPONDENT WORKS FOR A
TEMPORARY AGENCY, REFER TO THAT AS ONE JOB.]
Please describe: __________________________________
Don’t know
Refused
HEM30_C30.
When did you first start working for this employer?
♦ ENTER MONTH AND YEAR
Don’t know
Refused
_ _/_ _ _ _
HEM31_C31.
Are you currently working for this employer?
Yes ....................................................................... 1 (GO TO HEM33)
No......................................................................... 5
Don’t know (GO TO HEM33)
Refused (GO TO HEM33)
HEM32_C32.
When did you stop working for this employer?
♦ ENTER MONTH AND YEAR
Don’t know
Refused
_ _/_ _ _ _
HEM33_C33.
How much (do/did) you usually earn per week from this employer?
♦ ENTER DOLLAR AMOUNT: $ _,_ _ _._ _
Don’t know
Refused
HEM34_C34.
How many hours per week (do/did) you usually work for this employer?
♦ ENTER HOURS PER WEEK: ________________
Don’t know
Refused
MTO Adult Qnaire
Page A-48
Revised 08/12/07
HEM35_C35.
During the past month, did you do any small jobs (other than any already mentioned) to bring in extra
money like babysitting, home repairs, mowing lawns, house cleaning, cooking, or things like that?
Yes .............................................................................. 1
No................................................................................ 5 (GO TO HEM36)
Don’t Know................................................................. 8 (GO TO HEM36)
Refused........................................................................ 9 (GO TO HEM36)
HEM35a_C35a.
How many hours do you usually work a week at these small jobs?
♦ ENTER NUMBER OF HOURS: ____________________
Don’t know
Refused
HEM36.
INTERVIEWER CHECKPOINT –
SPOUSE OR PARTNER LIVING IN THE HOUSEHOLD Æ CONTINUE WITH HEM36a
NO SPOUSE OR PARTNER Æ GO TO NEXT SECTION
HEM36a_C36a.
Last week, did [HUSBAND OR OTHER COHABITING ADULT MALE] do any work for pay?
Yes .............................................................................. 1(GO TO HEM38)
No................................................................................ 5
If Volunteered, Retired................................................ 6 (GO TO HEM53)
If Volunteered, Disabled ............................................. 7 (GO TO HEM52)
If Volunteered, Unable to Work.................................. 8 (GO TO HEM52)
Don’t Know................................................................. (GO TO HEM54)
Refused........................................................................ (GO TO HEM54)
HEM37_C37.
(RB) What is the main reason that he did not work for pay last week?
Retired......................................................................... 1 (GO TO HEM53)
Disabled ...................................................................... 2 (GO TO HEM52)
Unable to Work ........................................................... 3 (GO TO HEM52)
Has Job But Temporarily Absent ................................ 4 (GO TO HEM38)
Couldn’t Find Any Work ............................................ 5 (GO TO HEM54)
Child Care Problems ................................................... 6 (GO TO HEM54)
Family Responsibilities ............................................... 7 (GO TO HEM54)
In School or Other Training ........................................ 8 (GO TO HEM54)
Waiting For a New Job to Begin ................................. 9 (GO TO HEM54)
Other (Specify):___________________..................... 10 (GO TO HEM54)
Don’t Know................................................................. 98 (GO TO HEM54)
Refused........................................................................ 99 (GO TO HEM54)
MTO Adult Qnaire
Page A-49
Revised 08/12/07
HEM38_C38.
Last week, did he have more than one job, including part-time and weekend work?
Yes .............................................................................. 1
No................................................................................ 5
Don’t know
Refused
HEM39_C39.
How many hours per week does he usually work at his (main) job? (By main job, we mean the one at
which he usually works the most hours.)
♦ ENTER number of hours per week: __________ (GO TO CHECKPOINT AFTER HEM39a)
Don’t know (GO TO HEM39a)
Refused (GO TO HEM39a)
HEM39a_C39a.
Does he usually work 35 hours or more per week at his (main) job?
Yes .............................................................................. 1
No................................................................................ 5
Hours Vary.................................................................. 7
Don’t know
Refused
INTERVIEWER CHECKPOINT—REFER TO HEM38
IF R WORKS MORE THAN ONE JOB (HEM38 = YES) ………(GO TO HEM39b)
ALL OTHERS…………………………………………………... (GO TO HEM40)
HEM39b.
How many hours per week does he usually work at his other job(s)?
♦ ENTER NUMBER OF HOURS PER WEEK: ___________________
Don’t know
Refused
HEM40_C40.
Now I have a few questions about the (main) job at which [HUSBAND OR OTHER COHABITING
ADULT MALE] worked last week. What kind of business or industry is this? What do they make or do
where he works?
____________________________________________
____________________________________________
Don’t know
Refused
MTO Adult Qnaire
Page A-50
Revised 08/12/07
HEM40a_C40a.
Is this business or organization mainly manufacturing, retail trade, wholesale trade, or something else?
Manufacturing ..........................................................................................1
Retail Trade..............................................................................................2
Wholesale Trade.......................................................................................3
Something Else (Specify): ____________________ ...............................4
Don’t know
Refused
HEM41_C41.
What kind of work does he do, that is, what is his occupation? For example, plumber, typist, farmer.
___________________________________________
___________________________________________
Don’t know
Refused
HEM42_C42.
What are his usual duties or activities at this job? For example: typing, keeping account books, filing,
selling cars, operating printing press, laying brick.
____________________________________________
____________________________________________
Don’t know
Refused
HEM43_C44.
For his [main] job, what is the easiest way for you to report his total earnings before taxes or other
deductions: hourly, weekly, annually, or on some other basis?
Hourly ......................................................................................................1
Daily.........................................................................................................2
Weekly .....................................................................................................3
Biweekly (every 2 weeks) ........................................................................4
Twice Monthly .........................................................................................5
Monthly....................................................................................................6
Annually...................................................................................................7
Per Unit (Specify Unit Type): _________________ .. ............................8
Other: (Specify): ___________________________ ... ............................9
Don’t know
Refused
HEM44_C45.
Does he usually receive overtime pay, tips, or commissions (at main job)?
Yes .............................................................................. 1
No................................................................................ 5
Don’t know
Refused
MTO Adult Qnaire
Page A-51
Revised 08/12/07
INTERVIEWER CHECKPOINT – REFER TO HEM44
IF EARNING = HOURLY ...................... (GO TO HEM48)
(HEM44 = ‘1’)
IF EARNING = DAILY, WEEKLY, BIWEEKLY, TWICE MONTHLY, MONTHLY,
ANNUALLY .............................................................. (GO TO HEM45)
(HEM44 = ( ‘2’, ‘3’, ‘4’, ‘5’, ‘6’, ‘7’))
IF EARNING = PER UNIT ...................... (GO TO HEM47a)
(HEM44 = ‘8’)
IF EARNING = OTHER, DK, RF............ (GO TO HEM50)
(HEM44 = (‘9’, ‘DK’, ‘RF’))
HEM45_C46.
(Including overtime pay, tips, and commissions), what are [SPOUSE’S OR COHABITING ADULT
MALE’S] usual (daily/weekly/biweekly/monthly/annual) earnings on (this) job, before taxes or other
deductions?
♦ ENTER DOLLAR AMOUNT: $ _ _ _,_ _ _._ _
Don’t know
Refused
INTERVIEWER CHECKPOINT – REFER TO HEM44
IF EARNING = DAILY .......................................................... (GO TO HEM46a)
(HEM44 = ‘2’)
IF EARNING = WEEKLY, BIWEEKLY, TWICE MONTHLY, MONTHLY
........................................................................ (GO TO HEM47a)
(HEM44 = (‘3’, ‘4’, ‘5’, ‘6’))
IF EARNING = ANNUALLY................................................. (GO TO HEM50)
(HEM44 = ‘7’)
HEM46a.
How many days a week does he usually work?
♦ ENTER NUMBER OF DAYS: ________________
Don’t know
Refused
HEM47a_C47.
How many weeks a year does he get paid for?
♦ ENTER NUMBER OF WEEKS: ___________(GO TO HEM50)
Don’t know
Refused
MTO Adult Qnaire
Page A-52
Revised 08/12/07
CHECKPOINT
IF EARNING IS ‘PER UNIT’ AND OVERTIME IS ‘YES’
(HEM44 = ‘8’ AND HEM45 = ‘1’) ..................................1 (GO TO HEM47d)
IF EARING IS ‘PER UNIT’ AND OVERTIME IS (‘NO’, ‘DK’, ‘RF’)
(HEM44 = ‘8’ AND HEM45 = (‘5’, ‘DK’, ‘RF’) ............2 (GO TO HEM47b)
HEM47b_C47b.
What is [SPOUSE OR OTHER COHABITING ADULT MALE]‘s rate of pay per [UNIT] (on this job)?
♦ ENTER DOLLAR AMOUNT: $ _ _ _,_ _ _._ _
Don’t Know................................................................. 9999998 (GO TO HEM50)
Refused........................................................................ 9999999 (GO TO HEM50)
HEM47c_C47c.
For how many [UNIT]’s is [SPOUSE OR OTHER COHABITING ADULT MALE] usually paid per week
(on this job)?
♦ ENTER number of units: __________................... (GO TO HEM50)
Don’t know
Refused
HEM47d_C47d.
Excluding overtime pay, tips and commissions, what is [SPOUSE OR OTHER COHABITING ADULT
MALE]’s rate of pay per [UNIT] (on this job)?
♦ ENTER DOLLAR AMOUNT: $ _,_ _ _._ _
Don’t know
Refused
HEM47e_C47e.
For how many [UNIT]’s is [SPOUSE OR OTHER COHABITING ADULT MALE] usually paid per week
at this rate?
♦ ENTER NUMBER OF UNITS: ______________
Don’t know
Refused
HEM47g_C47g.
At his main job, how much does [SPOUSE OR OTHER COHABITING ADULT MALE] usually receive
just in overtime pay, tips, commissions, before taxes or other deductions?
♦ ENTER DOLLAR AMOUNT: $ _ _,_ _ _._ _
Don’t know
Refused
MTO Adult Qnaire
Page A-53
Revised 08/12/07
HEM47h_C47h.
Is that …
Per Hour ...................................................................... 1
Per Day........................................................................ 2
Per Week ..................................................................... 3
Per Month.................................................................... 4
Per Year....................................................................... 5
Per Unit ....................................................................... 6
Other (Specify):___________________..................... 7
Don’t know
Refused
CHECKPOINT
IF EARNING IS ‘PER UNIT’ AND OVERTIME IS ‘YES’
AND OVERTIME IS ‘PAID PER DAY’)
(HEM44 = ‘8’ AND HEM45 =‘1’ AND HEM47h = ‘2’)............................... 1 (GO TO
HEM47j)
IF EARING IS ‘PER UNIT’ AND OVERTIME IS ‘YES’
AND OVERTIME IS ‘PAID PER UNIT’
(HEM44 = ‘8’ AND HEM45 = ‘1’ AND HEM47h = ’6’)............................. 2 (GO TO
HEM47i)
IF EARING IS ‘PER UNIT’ AND OVERTIME IS ‘YES’
AND OVERTIME IS ‘PAID PER HOUR’
(HEM44 = ‘8’ AND HEM45 = ‘1’ AND HEM47h =’1’).............................. 3 (GO TO
HEM47k)
IF EARING IS ‘PER UNIT’ AND OVERTIME IS ‘YES’
AND OVERTIME IS (‘PAID PER WEEK’,’PER MONTH’,’PER
YEAR‘,’OTHER’, ‘DK’ or ‘RF’)
(HEM44 = ‘8’ AND HEM45 = ‘1’ AND HEM47h =(‘3’,’4’,‘5’,’7’,‘DK’ or ‘RF’))
....................................................................................................................................4 (GO TO
HEM50)
HEM47i_C57j.
For how many [UNIT]’s is [SPOUSE OR OTHER COHABITING ADULT MALE] usually paid per week
at this rate?
♦ ENTER NUMBER OF UNITS: ___________ ..... (GO TO HEM50)
Don’t know
Refused
HEM47j_C47l.
How many days per week does [SPOUSE OR OTHER COHABITING ADULT MALE] usually work at
this rate?
♦ ENTER HOURS PER WEEK: ______________________ (GO TO HEM50)
Don’t know
Refused
MTO Adult Qnaire
Page A-54
Revised 08/12/07
HEM47k_C47k.
How many hours does he usually work per week at this rate?
♦ ENTER DAYS PER WEEK: _______________ (GO TO HEM50)
Don’t know (GO TO HEM50)
Refused (GO TO HEM50)
HEM48_C48.
CHECKPONT
IF EARNING IS ‘HOURLY’ AND OVERTIME IS ‘YES’
(HEM44 = ‘1’ AND HEM45 =‘1’) ....................................................... 1 (GO TO HEM49a)
IF EARING IS ‘HOURLY’ AND OVERTIME IS (‘NO’, ‘DK’, ‘RF’)
(HEM44 = ‘1’ AND HEM45 = (‘5 ‘ or ‘DK’ or ‘RF’) ...................... 2 (GO TO HEM48a)
HEM48a_C48a.
What is [SPOUSE OR OTHER COHABITING ADULT MALE]’s hourly rate of pay (on this job)?
♦ ENTER DOLLAR AMOUNT: $ _,_ _ _._ _ ... (GO TO HEM50)
Don’t know (GO TO HEM50)
Refused (GO TO HEM50)
HEM49a_C49a.
Excluding overtime pay, tips and commissions, what is his hourly rate of pay (on this job)?
♦ ENTER DOLLAR AMOUNT: $ _,_ _ _._ _
Don’t know
Refused
HEM49b_C49b.
How many hours does he usually work per week at this rate?
♦ ENTER HOURS PER WEEK: ______________________
Don’t know
Refused
HEM49c_C49c.
(At main job), how much does [SPOUSE OR OTHER COHABITING ADULT MALE] usually receive
just in overtime, tips, commissions, before taxes or other deductions?
♦ ENTER DOLLAR AMOUNT: $ _ _ _,_ _ _._ _
Don’t know
Refused
MTO Adult Qnaire
Page A-55
Revised 08/12/07
HEM49d_C49d.
Is that ...
Per Hour ...................................................................... 1 (GO TO HEM49e)
Per Day........................................................................ 2 (GO TO HEM49e)
Per Week ..................................................................... 3 (GO TO HEM50)
Per Month.................................................................... 4 (GO TO HEM50)
Per Year....................................................................... 5 (GO TO HEM50)
Per Unit (Specify):_________________..................... 6 (GO TO HEM49e)
Other (Specify):___________________..................... 7 (GO TO HEM50)
Don’t Know................................................................. 8 (GO TO HEM50)
Refused........................................................................ 9 (GO TO HEM50)
HEM49e_C49e.
How many day/unit/hours does he usually work per week at this rate?
♦ ENTER DAYS/UNITS/HOURS PER WEEK: _________________
Don’t know
Refused
HEM50_C53.
How did [SPOUSE OR OTHER COHABITING ADULT MALE] usually get to work last week?
♦ PROBE: For one used for most distance
♦ CHECK ALL THAT APPLY
Car, Truck, or Van ...................................................... 1
Bus or Trolley Bus ...................................................... 2
Streetcar or Trolley Car............................................... 3
Subway or Elevated..................................................... 4
Railroad....................................................................... 5
Ferryboat ..................................................................... 6
Taxicab........................................................................ 7
Motorcycle .................................................................. 8
Bicycle ........................................................................ 9
Walked ........................................................................ 10
Worked at Home ......................................................... 11
Other Method .............................................................. 12
Don’t know
Refused
HEM51_C54.
How many minutes did it usually take him to get from home to work last week?
♦ ENTER number of minutes: ____________
Don’t know
Refused
(GO TO next module)
MTO Adult Qnaire
Page A-56
Revised 08/12/07
HEM52_C55.
Does he have a disability that prevents him from accepting any kind of work during the next six months?
Yes .............................................................................. 1 (GO TO next module)
No................................................................................ 5
Don’t Know................................................................. 8
Refused........................................................................ 9
HEM53_C56.
Does he currently want a job, either full-time or part-time?
Yes or Maybe, It Depends........................................... 1
No................................................................................ 5 (GO TO next module)
Don’t Know................................................................. 8 (GO TO next module)
Refused........................................................................ 9 (GO TO next module)
HEM54_C57.
Has [SPOUSE OR OTHER COHABITING ADULT MALE] been doing anything to find work during the
past four weeks?
Yes .............................................................................. 1
No................................................................................ 5 (GO TO next module)
Retired......................................................................... 6 (GO TO next module)
Disabled ...................................................................... 7 (GO TO next module)
Unable to Work ........................................................... 8 (GO TO next module)
Don’t Know................................................................. (GO TO next module)
Refused........................................................................ (GO TO next module)
HEM55_C58.
(RB) What are all the things he has done to find work during the past four weeks?
♦ ENTER ALL THAT APPLY
Contacted Employer(s)......................................................................................................1
Contacted Public Employment Agency Programs/Courses ..............................................2
Contacted Private Employment Agency ...........................................................................3
Contacted Friends or Relatives .........................................................................................4
Interviewed for a Job.........................................................................................................5
Contacted School/University Employer Center ................................................................6
Sent Out Resumes/Filled out Applications .......................................................................7
Checked Union/Professional Registers .............................................................................8
Placed or Answered Ads ...................................................................................................9
Looked at Ads Directly .....................................................................................................10
Attended Job Training.......................................................................................................11
Nothing..............................................................................................................................12
Other (Specify): ___________________________________ ..........................................13
Don’t know
Refused
MTO Adult Qnaire
Page A-57
Revised 08/12/07
HEM56_C61.
Last week, could he have started a job if one had been offered?
Yes .............................................................................. 1 (GO TO next module)
No................................................................................ 5
Don’t Know................................................................. 8 (GO TO next module)
Refused........................................................................ 9 (GO TO next module)
HEM57_C62.
Why is that?
Waiting for New Job to Begin..................................... 1
Own Temporary Illness............................................... 2
Going to School .......................................................... 3
Other (Specify): ___________________.................... 4
Don’t know
Refused
MTO Adult Qnaire
Page A-58
Revised 08/13/07
A_Section 07: Income & Public Assistance
HIN1.
Are you or your (child/children) now receiving help from the Supplemental Security Income program,
called SSI?
Yes ..................................................1
No....................................................5
DK
RF
INTERVIEWER CHECKPOINT – REFER TO HOUSEHOLD LISTING
IF NO CHILDREN IN HOUSEHOLD, GO TO HIN3
HIN2.
Is the SSI for you or for your (child/children)?
Respondent......................................1
Child (ren) .......................................2
Both.................................................3
DK...................................................D
RF....................................................R
HIN3.
In what month and year did [you /your child/your children]start receiving SSI benefits?
♦ ENTER MM/YYYY
_ _/_ _ _ _
(IF BOTH R AND CHILD ARE RECEIVING SSI, ASK FOR THE MONTH AND YEAR
THE FIRST PERSON TO RECEIVE SSI STARTED RECEIVING IT.)
DON’T KNOW
REFUSED
HIN4.
Workers sometimes receive a tax refund check—early in the year —from the Earned Income Tax Credit or
because they overpaid taxes in the previous year. Did you receive a tax refund check from the federal
government in 2008?
(PROBE IF NECESSARY: During calendar year 2008 did you receive
a federal income tax refund for the 2007 tax year?)
Yes ..................................................1
No....................................................5 (GO TO HIN5)
DK...................................................D (GO TO HIN5)
RF....................................................R (GO TO HIN5)
MTO Adult Qnaire
Page A-59
Revised 08/13/07
HIN4a.
How much was your tax refund?
♦ ENTER DOLLAR AMOUNT
$ _,_ _ _
(IF R SAYS REFUND WAS ‘LARGER THAN $10,000’ CODE 9999)
DON’T KNOW
REFUSED
HIN4b. What was the main thing you spent your refund on?
[INTERVIEWER: DO NOT READ CATEGORIES]
Savings ............................................ ..........................................................................1
Pay Off Credit Card Bill or Other Loan .....................................................................2
Pay Other Bills ................................ ..........................................................................3
Purchase Household Furnishings, Appliances, Clothing............................................4
Purchase/Repair Car........................ ..........................................................................5
Get New Apartment ........................ ..........................................................................6
School Tuition................................. ..........................................................................7
Other (Specify):_________________________________ ........................................8
DK
RF
HIN5.
(RB) What kind of health insurance or health care coverage do you have for yourself?
♦ CHECK ALL THAT APPLY
Private Health Insurance Plan From Employer or Workplace ..........................................1
Private Health Insurance Plan Purchased Directly ............................................................2
Private Health Insurance Plan Through A State or Local
Government or Community Program ........................................................................3
Medicaid ...........................................................................................................................4
Medicare.......................................... .................................................................................5
Military Health Care/VA or Champus/Tricare/Champ-VA ..............................................6
Single Service Plan (e.g. Dental, Vision, Prescriptions) ...................................................7
No Coverage of Any Type .............. .................................................................................8
Other (Specify): ____________________________________
DK
RF
HIN6.
Are you or your (child/children) regularly receiving welfare benefits now?
[INTERVIEWER: DO NOT ACCEPT “FOOD STAMPS,” “SSI,” “MEDICAID,” OR
“WIC.” ]
[INTERVIEWER: ACCEPT LOCAL NAMES FOR TANF]
Yes ..................................................1
No....................................................5
DK
RF
MTO Adult Qnaire
Page A-60
Revised 08/13/07
HIN7.
Are you or your (child/children) now receiving Food Stamps?
Yes ..................................................1
No....................................................5
DK
RF
HIN8.
Which of these statements best describes the food eaten in your household in the last 12 months: we
always had enough to eat, sometimes we did not have enough to eat, or, often, we did not have enough to
eat?
Always Enough to Eat................................... 1
Sometimes Not Enough to Eat ...................... 2
Often Not Enough to Eat............................... 3
DK
RF
HIN9.
How much do you (and everyone else in your family) spend on food that you use at home in an average
week?
[INTERVIEWER: IF RESPONDENT LIVES WITH NON-FAMILY MEMBERS, OR
AMOUNT SEEMS UNREASONABLY HIGH OR LOW, PROBE: “Is that only your/your
family’s share of the food?”]
♦ ENTER DOLLAR AMOUNT AND UNIT
$ _,_ _ _._ _ PER: day…..1 week…..2
year……4
DON’T KNOW
REFUSED
month……3
HIN10.
Do you have any food delivered to the door which isn’t included in that?
Yes ..................................................1 (GO TO HIN11)
No....................................................5 (GO TO HIN12)
DK...................................................D (GO TO HIN12)
RF....................................................R (GO TO HIN12)
HIN11. How much do you spend on that food?
♦ ENTER DOLLAR AMOUNT AND UNIT
$ _,_ _ _._ _
PER:
day…..1 week…..2
year……4
month……3
DON’T KNOW
REFUSED
MTO Adult Qnaire
Page A-61
Revised 08/13/07
HIN12.
About how much do you (and everyone else in your family) spend eating out?
♦ ENTER DOLLAR AMOUNT AND UNIT
$ _,_ _ _._ _
PER:
day…..1
year……4
week…..2
month……3
DON’T KNOW
REFUSED
INTERVIEWER CHECKPOINT
If NO CHILDREN IN HOUSEHOLD Æ (GO TO HIN14)
HIN13.
About how many days per week do you and your (child/children) all eat dinner together?
♦ ENTER NUMBER OF DAYS _____________
DON’T KNOW
REFUSED
HIN14.
How much did you earn from all your employers before taxes and deductions during 2007?
♦ ENTER DOLLAR AMOUNT
$ _ _,_ _ _
(GO TO HIN16)
(IF R SAYS ‘INCOME OF $99,999 OR MORE’, CODE 99999)
DK...................................................D (GO TO HIN14a)
RF....................................................R (GO TO HIN14a)
HIN14a.
Would it amount to $10,000 or more?
Yes ..................................................1
No....................................................5 (GO TO HIN14e)
DK...................................................D (GO TO HIN14e)
RF....................................................R (GO TO HIN14e)
HIN14b.
Would it amount to $20,000 or more?
Yes ..................................................1
No....................................................5 (GO TO HIN14d)
DK...................................................D (GO TO HIN14d)
RF....................................................R (GO TO HIN14d)
MTO Adult Qnaire
Page A-62
Revised 08/13/07
HIN14c.
Would it amount to $25,000 or more?
Yes ..................................................1 (GO TO CHECKPOINT)
No....................................................5 (GO TO CHECKPOINT)
DK...................................................D (GO TO CHECKPOINT)
RF....................................................R (GO TO CHECKPOINT)
HIN14d.
Would it amount to $15,000 or more?
Yes ..................................................1 (GO TO CHECKPOINT)
No....................................................5 (GO TO CHECKPOINT)
DK...................................................D (GO TO CHECKPOINT)
RF....................................................R (GO TO CHECKPOINT)
HIN14e.
Would it amount to $5,000 or more?
Yes ..................................................1
No....................................................5
DK...................................................D
RF....................................................R
INTERVIEWER CHECKPOINT
IF THERE IS NO SPOUSE/PARTNER IN THE HOUSEHOLD Æ (GO TO HIN15)
ALL OTHERS Æ (GO TO HIN16)
HIN15.
About how much money did you receive from the (father/fathers) of all of your children in the past 12
months?
♦ ENTER dollar amount
$ _ _,_ _ _ (GO TO HIN16)
(IF R SAYS ‘CHILD SUPPORT OF $99,999 OR MORE’, CODE 99999)
DK...................................................(GO TO HIN15a)
RF....................................................(GO TO HIN15a)
HIN15a.
I just need to have a range. Can you tell me if it was . . .
____________________________________
HIN16.
How much income did you receive from all other sources during 2007? Please include any money from the
government such as welfare, SSI, unemployment benefits, Social Security, money from any businesses you
have, money from alimony, help from friends or relatives, and any other money income received.
♦ ENTER DOLLAR AMOUNT
$ _ _,_ _ _
(IF R SAYS ‘INCOME OF $99,999 OR MORE’, CODE 99999)
DON’T KNOW
REFUSED
MTO Adult Qnaire
Page A-63
Revised 08/13/07
INTERVIEWER CHECKPOINT
IF RESPONDENT LIVES ALONE Æ (GO TO NEXT SECTION)
HIN17.
What is the total combined income of all members of this household during the year 2007? Please include
money from jobs, work on the side, welfare, SSI, help from your family and friends, and any other money
income received by you or any other household member.
♦ ENTER dollar amount $ _ _, _ _ _ (GO TO NEXT MODULE)
(IF R SAYS ‘INCOME OF $99,999 OR MORE’, CODE 99999)
DK...................................................D (GO TO HIN17a)
RF....................................................R (GO TO HIN17a)
HIN17a.
Would it amount to $10,000 or more?
Yes ..................................................1
No....................................................5 (GO TO HIN17e)
DK...................................................D (GO TO HIN17e)
RF....................................................R (GO TO HIN17e)
HIN17b.
Would it amount to $20,000 or more?
Yes ..................................................1
No....................................................5 (GO TO HIN17d)
DK...................................................D (GO TO HIN17d)
RF....................................................R (GO TO HIN17d)
HIN17c.
Would it amount to $25,000 or more?
Yes ..................................................1 (GO TO next module)
No....................................................5 (GO TO next module)
DK...................................................D (GO TO next module)
RF....................................................R (GO TO next module)
HIN17d.
Would it amount to $15,000 or more?
Yes ..................................................1 (GO TO next module)
No....................................................5 (GO TO next module)
DK...................................................D (GO TO next module)
RF....................................................R (GO TO next module)
MTO Adult Qnaire
Page A-64
Revised 08/13/07
HIN17e.
Would it amount to $5,000 or more?
Yes ..................................................1
No....................................................5
DK...................................................D
RF....................................................R
MTO Adult Qnaire
Page A-65
Revised 08/13/07
A_Section 08: Savings & Assets
HSA1.
Do you currently have any checking accounts, savings accounts, or any other type of bank account at any
type of institution?
Yes ..................................................1
No....................................................5 (GO TO HSA2)
Don’t Know..................................... (GO TO HSA3)
Refused............................................ (GO TO HSA3)
HSA1a.
About how much is in these accounts all together?
♦ ENTER DOLLAR AMOUNT $ _ _ _,_ _ _
(GO TO HSA3)
Don’t Know.....................................(GO TO HSA1b)
Refused............................................(GO TO HSA1b)
HSA1b.
(RB) Would it be…
A. $0; none
B. $1 - $99
C. $100 - $199
D. $200 - $299
E. $300 - $399
F. $400 - $499
G. $500 - $999
H. $1,000 - $1,999
I. $2,000 - $2,999
J. $3,000 - $3,999
K. $4,000 - $4,99 9
L. $5,000 - $9,999
M. $10,000 - $14,999
N. $15,000 - $19,999
O. $20,000 - $24,999
P. $25,000 - $29,999
Q. $30,000 - $39,999
R. $40,000 - $49,999
S. $50,000 - $59, 999
T. $60,000 - $74,999
U. $75,000 - $99,999
V. $100,000 - $124,999
W. $125,000 - $149,999
X. $150,000 - $199,999
Y. $200,000 - $249,999
Z. $250,000 or more
ENTER LETTER ___________ (GO TO HSA3)
DON’T KNOW (GO TO HSA3)
REFUSED (GO TO HSA3)
HSA2.
What is the most important reason you don’t have a bank account?
Don’t write enough checks to make it worthwhile...................................1
Minimum balance is too high...................................................................2
Don’t like dealing with banks ..................................................................3
Service charges are too high.....................................................................4
No bank has convenient hours or locations..............................................5
Some other reason (specify): ___________________ .............................6
Don’t Know
Refused
MTO Adult Qnaire
Page A-66
Revised 08/13/07
HSA3.
Do you have any savings or keep money for a while in any other type of account, or any other place
including savings held as cash in your house or somewhere else?
Yes ..................................................1 (GO TO HSA3a)
No....................................................5 (GO TO HSA4)
Don’t Know..................................... (GO TO HSA4)
Refused............................................ (GO TO HSA4)
HSA3a.
What would that be?
PLEASE SPECIFY:_____________________________
Don’t Know
Refused
HSA3b.
About how much would these other savings be worth?
♦ ENTER DOLLAR AMOUNT $ _ _ _,_ _ _
Don’t Know
Refused
HSA4.
In what year did you buy your home?
♦ ENTER YEAR_____________
Don’t Know
Refused
HSA5.
What was the purchase price of your present home?
♦ ENTER DOLLAR AMOUNT$ _ _ _,_ _ _ (GO TO HSA6)
Don’t Know..............................................................................................(GO TO HSA5a)
Refused.....................................................................................................(GO TO HSA5a)
HSA5a.
(RB)Was it …
A. $0; none
B. $1 - $99
C. $100 - $199
D. $200 - $299
E. $300 - $399
F. $400 - $499
G. $500 - $999
H. $1,000 - $1,999
I. $2,000 - $2,999
J. $3,000 - $3,999
K. $4,000 - $4,99 9
L. $5,000 - $9,999
M. $10,000 - $14,999
N. $15,000 - $19,999
O. $20,000 - $24,999
P. $25,000 - $29,999
Q. $30,000 - $39,999
R. $40,000 - $49,999
S. $50,000 - $59, 999
T. $60,000 - $74,999
U. $75,000 - $99,999
V. $100,000 - $124,999
W. $125,000 - $149,999
X. $150,000 - $199,999
Y. $200,000 - $249,999
Z. $250,000 or more
ENTER LETTER ___________
Don’t Know
Refused
MTO Adult Qnaire
Page A-67
Revised 08/13/07
HSA6.
If you were to sell your house today, how much would it be worth?
♦ ENTER DOLLAR AMOUNT $ _ _ _,_ _ _ (GO TO HSA7)
Don’t Know..............................................................................................(GO TO HSA6a)
Refused.....................................................................................................(GO TO HSA6a)
HSA6a.
(RB) Would it be …
A. $0; none
B. $1 - $99
C. $100 - $199
D. $200 - $299
E. $300 - $399
F. $400 - $499
G. $500 - $999
H. $1,000 - $1,999
I. $2,000 - $2,999
J. $3,000 - $3,999
K. $4,000 - $4,99 9
L. $5,000 - $9,999
M. $10,000 - $14,999
N. $15,000 - $19,999
O. $20,000 - $24,999
P. $25,000 - $29,999
Q. $30,000 - $39,999
R. $40,000 - $49,999
S. $50,000 - $59, 999
T. $60,000 - $74,999
U. $75,000 - $99,999
V. $100,000 - $124,999
W. $125,000 - $149,999
X. $150,000 - $199,999
Y. $200,000 - $249,999
Z. $250,000 or more
ENTER LETTER ___________
Don’t Know
Refused
HSA7.
Do you own this home outright or do you have any mortgages or land contracts on the property?
Own Outright ........................................................................................... 1(GO TO HSA8)
Has Mortgage and/or Land Contract ........................................................2
Don’t Know.............................................................................................. (GO TO HSA8)
Refused..................................................................................................... (GO TO HSA8)
HSA7a.
How much do you still owe on all the loans taken out for your home?
♦ ENTER DOLLAR AMOUNT $ _ _ _,_ _ _ (GO TO HSA8)
Don’t Know..............................................................................................(GO TO HSA7b)
Refused.....................................................................................................(GO TO HSA7b)
HSA7b.
(RB) Is it:
A. $0; none
B. $1 - $99
C. $100 - $199
D. $200 - $299
E. $300 - $399
F. $400 - $499
G. $500 - $999
H. $1,000 - $1,999
I. $2,000 - $2,999
J. $3,000 - $3,999
K. $4,000 - $4,99 9
L. $5,000 - $9,999
M. $10,000 - $14,999
N. $15,000 - $19,999
O. $20,000 - $24,999
P. $25,000 - $29,999
Q. $30,000 - $39,999
R. $40,000 - $49,999
S. $50,000 - $59, 999
T. $60,000 - $74,999
U. $75,000 - $99,999
V. $100,000 - $124,999
W. $125,000 - $149,999
X. $150,000 - $199,999
Y. $200,000 - $249,999
Z. $250,000 or more
ENTER LETTER ___________
Don’t Know
Refused
MTO Adult Qnaire
Page A-68
Revised 08/13/07
HSA8.
Do (you/you and your household) own a car or truck, or other motor vehicle that runs and can be driven on
the road?
Yes ..................................................1
No....................................................5 (GO TO HSA10)
Don’t Know..................................... (GO TO HSA10)
Refused............................................ (GO TO HSA10)
HSA9.
Thinking about the vehicles that (you/you and your household) own, did you borrow money or get
financing to purchase any of your vehicles?
Yes ..................................................1
No....................................................5 (GO TO HSA10)
Don’t Know..................................... (GO TO HSA10)
Refused............................................ (GO TO HSA10)
HSA9a.
About how much, if anything, do (you/you and your household) still owe on all of your vehicle loans?
♦ ENTER DOLLAR AMOUNT $ _ _,_ _ _ (GO TO HSA10)
Don’t Know..............................................................................................(GO TO HSA9b)
Refused.....................................................................................................(GO TO HSA9b)
HSA9b.
(RB) Would you say it was ….
A. $0; none
B. $1 - $99
C. $100 - $199
D. $200 - $299
E. $300 - $399
F. $400 - $499
G. $500 - $999
H. $1,000 - $1,999
I. $2,000 - $2,999
J. $3,000 - $3,999
K. $4,000 - $4,99 9
L. $5,000 - $9,999
M. $10,000 - $14,999
N. $15,000 - $19,999
O. $20,000 - $24,999
P. $25,000 - $29,999
Q. $30,000 - $39,999
R. $40,000 - $49,999
S. $50,000 - $59, 999
T. $60,000 - $74,999
U. $75,000 - $99,999
V. $100,000 - $124,999
W. $125,000 - $149,999
X. $150,000 - $199,999
Y. $200,000 - $249,999
Z. $250,000 or more
ENTER LETTER ___________
Don’t Know
Refused
HSA10.
Do you or anyone in your household have any student loans?
Yes ..................................................1
No....................................................5 (GO TO HSA11)
Don’t Know (GO TO HSA11)
Refused (GO TO HSA11)
MTO Adult Qnaire
Page A-69
Revised 08/13/07
HSA10a.
About how much do you (or your household) still owe on your student loans?
♦ ENTER DOLLAR AMOUNT $ _ _ _,_ _ _
Don’t Know
Refused
HSA11.
Do you have a valid driver’s license?
Yes ..................................................1
No....................................................5
Don’t Know
Refused
HSA12.
Do (you/you and anyone in your household) have any unpaid medical bills?
Yes ..................................................1
No....................................................5 (GO TO HSA13)
Don’t Know..................................... (GO TO HSA13)
Refused............................................ (GO TO HSA13)
HSA12a.
About how much do (you/you and your household) still owe on your medical bills?
♦ ENTER DOLLAR AMOUNT $ _ _ _,_ _ _
(GO TO HSA13)
Don’t Know..............................................................................................(GO TO HSA12b)
Refused.....................................................................................................(GO TO HSA12b)
HSA12b.
(RB) Would it be …
A. $0; none
B. $1 - $99
C. $100 - $199
D. $200 - $299
E. $300 - $399
F. $400 - $499
G. $500 - $999
H. $1,000 - $1,999
I. $2,000 - $2,999
J. $3,000 - $3,999
K. $4,000 - $4,99 9
L. $5,000 - $9,999
M. $10,000 - $14,999
N. $15,000 - $19,999
O. $20,000 - $24,999
P. $25,000 - $29,999
Q. $30,000 - $39,999
R. $40,000 - $49,999
S. $50,000 - $59, 999
T. $60,000 - $74,999
U. $75,000 - $99,999
V. $100,000 - $124,999
W. $125,000 - $149,999
X. $150,000 - $199,999
Y. $200,000 - $249,999
Z. $250,000 or more
ENTER LETTER ___________
Don’t Know
Refused
HSA13.
Do you have any credit or charge cards? Including major credit cards like, Visa or MasterCard, or charge
cards from a store or gas station such as Sears or Mobil?
Yes ..................................................1
No....................................................5 (GO TO HSA15)
Don’t Know..................................... (GO TO HSA15)
Refused............................................ (GO TO HSA15)
MTO Adult Qnaire
Page A-70
Revised 08/13/07
HSA14. About how much do (you/you and your household) currently owe on all your credit and charge
cards?
♦ ENTER DOLLAR AMOUNT $ _ _ _,_ _ _ (GO TO HSA15)
Don’t Know..............................................................................................(GO TO HSA14a)
Refused.....................................................................................................(GO TO HSA14a)
HSA14a.
(RB) Would it be …
A. $0; none
B. $1 - $99
C. $100 - $199
D. $200 - $299
E. $300 - $399
F. $400 - $499
G. $500 - $999
H. $1,000 - $1,999
I. $2,000 - $2,999
J. $3,000 - $3,999
K. $4,000 - $4,99 9
L. $5,000 - $9,999
M. $10,000 - $14,999
N. $15,000 - $19,999
O. $20,000 - $24,999
P. $25,000 - $29,999
Q. $30,000 - $39,999
R. $40,000 - $49,999
S. $50,000 - $59, 999
T. $60,000 - $74,999
U. $75,000 - $99,999
V. $100,000 - $124,999
W. $125,000 - $149,999
X. $150,000 - $199,999
Y. $200,000 - $249,999
Z. $250,000 or more
ENTER LETTER ___________
Don’t Know
Refused
HSA15.
Now I’d like to ask you about the types of financial services you use. In the past 30 days, where did you
cash most of your checks?
♦ PROBE: “any other places” once
♦ ENTER ALL THAT APPLY
At a bank ..................................................................................................1
At your work place...................................................................................2
At a check cashing outlet .........................................................................3
Through an insurance broker....................................................................4
Through a friend or family member .........................................................5
In a supermarket.......................................................................................6
At a restaurant, bar, or in any other kind of store.....................................7
Didn’t cash any checks.............................................................................8
Other (specify): ________________________........................................9
Don’t Know
Refused
HSA16.
If you needed to borrow $500 for three months, is there some person (or place) you could borrow it from?
Yes ...........................................................................................................1
No.............................................................................................................5 (GO TO HSA19)
Would Not Borrow...................................................................................6 (GO TO HSA19)
Don’t Know.............................................................................................. (GO TO HSA19)
Refused..................................................................................................... (GO TO HSA19)
MTO Adult Qnaire
Page A-71
Revised 08/13/07
HSA17.
Where would you go first?
Friends or family ...............................................................................................................1
A finance company ...........................................................................................................2
A payday loan at a check cashing outlet ...........................................................................3
Someone in my neighborhood who lends out
money and charges interest...........................................................................................4
A community loan fund (or church loan fund)..................................................................5
A cash advance on my credit card.....................................................................................6
A bank (or savings bank, savings & loan, or credit union) ...............................................7
A pawn shop......................................................................................................................8
A furniture store ................................................................................................................9
I would not borrow............................................................................................................10
Other (specify):_________________________________ ..............................................11
Don’t Know
Refused
HSA18.
Apart from the $500 you would repay them, how much would they charge you to borrow the money?
Nothing, No charge ..................................................................................1 (GO TO HSA19)
Percent…………......................................................................................2 (GO TO HSA18a)
Dollar amount……...................................................................................3 (GO TO HSA18b)
Other ………............................................................................................4 (GO TO HSA18c)
Don’t Know .............................................................................................D (GO TO HSA19)
Refused.....................................................................................................R (GO TO HSA19)
HSA18a.
What percent would you have to pay to borrow the $500?
♦ ENTER PERCENTAGE AMOUNT _______ . ____% (GO TO HSA19)
Don’t Know (GO TO HSA19)
Refused (GO TO HSA19)
HSA18b.
How many dollars would you have to pay to borrow the $500?
♦ ENTER DOLLAR AMOUNT $ ________ (GO TO HSA19)
Don’t Know (GO TO HSA19)
Refused (GO TO HSA19)
HSA18c.
Other (specify):
__________________________________________________
Don’t Know
Refused
MTO Adult Qnaire
Page A-72
Revised 08/13/07
HSA19.
How often does your household have to borrow money to pay bills?
Never........................................................................................................1
Rarely .......................................................................................................2
Occasionally.............................................................................................3
Frequently ................................................................................................4
All the time...............................................................................................5
Don’t Know
Refused
HSA20.
How often does your household put off buying something you need because you don't have money?
Never........................................................................................................1
Rarely .......................................................................................................2
Occasionally.............................................................................................3
Frequently ................................................................................................4
All the time...............................................................................................5
Don’t Know
Refused
HSA21.
In the past 12 months, have (you/you or anyone in your household) filed for personal bankruptcy?
Yes ...........................................................................................................1
No.............................................................................................................5
Don’t Know
Refused
MTO Adult Qnaire
Page A-73
Revised 08/07/07
A_Section 09: PHYSICAL HEALTH (HPH)
HPH1.
Now I’d like to ask you some questions about your health. Would you say your health in general is excellent, very good, good,
fair, or poor?
EXCELLENT
1
VERY GOOD
2
GOOD
3
FAIR
4
POOR
5
REFUSED
7
DON’T KNOW
8
HPH2.
To help people say how good or bad their health state is, we have drawn a scale (rather like a thermometer) on which the best
state you can imagine is marked 100 and the worst state you can imagine is marked 0. We would like you to indicate on this
scale how good or bad your own health is today, in your opinion. Please do this by drawing a line from the box below to
whichever point on the scale indicates how good or bad youth health state is today.
Scaled Health State Ranking: _______________________
DK
RF
HPH3.
Have you ever been told by a doctor or other health professional that you had asthma?
YES
1
NO (GO TO HPH5)
5
REFUSED (GO TO HPH5)
7
DON’T KNOW (GO TO HPH5)
8
HPH4.
During the past 12 months, have you had an episode of asthma or an asthma attack?
YES
1
NO
5
REFUSED
7
DON’T KNOW
8
HPH5.
During the past 12 months, have you had a wheezing or whistling sound in your chest?
MTO Adult Qnaire
YES
1
NO (GO TO HPH6a)
5
REFUSED (GO TO HPH6a)
7
DON’T KNOW (GO TO HPH6a)
8
Page A-74
Revised 08/07/07
HPH6.
How many attacks of wheezing or whistling have you had in your chest during the past 12 months?
NUMBER OF ATTACKS ________________________
DON’T KNOW
-1
REFUSED
-2
HPH6a.
Have you ever been told by a doctor or other health professional that you had hypertension, also called high blood pressure?
YES
1
NO (GO TO HPH7)
2
REFUSED (GO TO HPH7)
7
DON’T KNOW (GO TO HPH7)
8
HPH6b.
Were you told on two or more different visits that you had hypertension, also called high blood pressure?
YES
1
NO
2
REFUSED
7
DON’T KNOW
8
HPH6c.
Was any medication ever prescribed by a doctor to help you lower your blood pressure?
YES
1
NO (GO TO HPH7)
2
REFUSED
7
DON’T KNOW
8
HPH6d.
Are you now taking prescribed medicine for your high blood pressure?
MTO Adult Qnaire
YES
1
NO
2
REFUSED
7
DON’T KNOW
8
Page A-75
Revised 08/07/07
YES
HPH7a.
The next few questions are about health problems you might have
had at any time in your life. Have you ever had any of the
following: Arthritis or rheumatism?
NO
REFUSED
DON’T
KNOW
1
2
7
8
HPH7b.
Chronic back or neck problems?
1
2
7
8
HPH7c.
Frequent or severe headaches?
1
2
7
8
HPH7d.
Any other chronic pain?
1
2
7
8
HPH7e.
A stroke?
1
2
7
8
HPH7f.
A heart attack?
1
2
7
8
1
2
7
8
1
2
7
8
1
2
7
8
1
2
7
8
HPH7k.
HIV infection or AIDS?
1
2
7
8
HPH7l.
Epilepsy or seizures?
1
2
7
8
HPH7m.
Cancer?
1
2
7
8
HPH7g.
Did a doctor or other health professional ever tell you that you
had any of the following illnesses: Heart disease?
HPH7h.
Any other chronic lung disease, like COPD or emphysema?
HPH7i.
Diabetes or high blood sugar?
HPH7j.
An ulcer in your stomach or intestine?
[INTERVIEWER INSTRUCTION: (SEE HPH7a - HPH7m SERIES)
CIRCLE ALL ENDORSED CONDITIONS IN HPH7a - HPH7m SERIES IN LEFT COLUMN BELOW AND ON THE
FOLLOWING TWO PAGES. THEN ASK FOLLOW-UP QUESTIONS TO THE RIGHT IN SEQUENCE ONE ITEM
AT A TIME. IF NO CONDITIONS WERE ENDORSED, GO TO HPH10.]
MTO Adult Qnaire
Page A-76
Revised 08/07/07
HPH8.
How old were you the
first time you had
(DX)?
HPH9.
Did you still have (DX) or receive any treatment for (it/ them) at any time
during the past 12 months?
YES
(1)
NO
(5)
DK
(8)
RF
(9)
8
9
GO TO HPH8
FOR NEXT DX
OR HPH10
GO TO HPH8
FOR NEXT DX
OR HPH10
8
9
GO TO HPH8
FOR NEXT DX
OR HPH10
GO TO HPH8
FOR NEXT DX
OR HPH10
8
9
GO TO HPH8
FOR NEXT DX
OR HPH10
GO TO HPH8
FOR NEXT DX
OR HPH10
HPH8a.
ARTHRITIS OR
RHEUMATISM
______________
YEARS
HPH8b.
HPH9b.
5
BACK OR NECK
PROBLEMS
1
______________
YEARS
GO TO HPH8 FOR
NEXT DX OR HPH10
HPH8c.
GO TO
HPH8 FOR
NEXT DX
OR HPH10
HPH9c.
5
FREQUENT OR
SEVERE
HEADACHES
1
______________
YEARS
GO TO HPH8 FOR
NEXT DX OR HPH10
HPH8d.
GO TO
HPH8 FOR
NEXT DX
OR HPH10
HPH9d.
5
(ANY OTHER)
CHRONIC PAIN
______________
YEARS
1
GO TO HPH8 FOR
NEXT DX OR HPH10
GO TO
HPH8 FOR
NEXT DX
OR HPH10
HPH8e.
STROKE
______________
YEARS
DK..................998
RF ..................999
GO TO HPH8 FOR
NEXT DX OR HPH10
HPH8f.
HEART ATTACK
______________
YEARS
DK..................998
RF ..................999
GO TO HPH8 FOR
NEXT DX OR HPH10
MTO Adult Qnaire
Page A-77
Revised 08/07/07
HEART DISEASE
HPH8g.
______________
YEARS
DK..................998
RF ..................999
GO TO HPH8 FOR
NEXT DX OR HPH10
CHRONIC LUNG
DISEASE
HPH8h.
______________
YEARS
DK..................998
RF ..................999
GO TO HPH8 FOR
NEXT DX OR HPH10
DIABETES OR
HIGH BLOOD
SUGAR
HPH8i.
______________
YEARS
HPH9i.
5
1
GO TO HPH8 FOR
NEXT DX OR HPH10
HPH8j.
GO TO GO
TO HPH8
FOR NEXT
DX OR
HPH10
8
9
GO TO HPH8
FOR NEXT DX
OR HPH10
GO TO HPH8
FOR NEXT DX
OR HPH10
8
9
GO TO HPH8
FOR NEXT DX
OR HPH10
GO TO HPH8
FOR NEXT DX
OR HPH10
HPH9j.
5
(AN/THE) ULCER
______________
YEARS
HIV (INFECTION)
HPH8k.
______________
YEARS
DK..................998
RF ..................999
1
GO TO HPH8 FOR
NEXT DX OR HPH10
GO TO GO
TO HPH8
FOR NEXT
DX OR
HPH10
GO TO HPH8 FOR
NEXT DX OR HPH10
EPILEPSY OR
SEIZURES
HPH8l.
______________
YEARS
DK..................998
RF ..................999
GO TO HPH8 FOR
NEXT DX OR HPH10
CANCER
MTO Adult Qnaire
HPH8m.
______________
YEARS
DK..................998
RF ..................999
Page A-78
Revised 08/07/07
HPH10.
Is there a place where you usually go to when you are sick or need advice about your health?
YES
1
THERE IS NO PLACE (GO TO HPH12)
2
THERE IS MORE THAN ONE PLACE
3
REFUSED (GO TO HPH12)
7
DON’T KNOW (GO TO HPH12)
8
HPH10a.
What kind of place is it? A clinic, doctor’s office, emergency room, or some other place?
[INTERVIEWER: IF MORE THAN 1 PLACE, PROBE FOR THE ONE RESPONDENT GOES TO MOST OFTEN]
CLINIC OR HEALTH CENTER
1
DOCTOR’S OFFICE OR HMO
2
HOSPITAL EMERGENCY ROOM
3
HOSPITAL OUTPATIENT DEPARTMENT
4
SOME OTHER PLACE
5
DOESN’T GO TO ONE PLACE MOST OFTEN
6
REFUSED
7
DON’T KNOW
8
HPH11.
Is that [FILL] the same place you usually go when you need routine or preventative care, such as a physical examination or
check up?
MTO Adult Qnaire
YES (GO TO HPH13)
1
NO
2
REFUSED
7
DON’T KNOW
8
Page A-79
Revised 08/07/07
HPH12.
What kind of place do you USUALLY go to when you need routine or preventive care, such as a physical examination or
check-up?
CLINIC OR HEALTH CENTER
1
DOCTOR’S OFFICE OR HMO
2
HOSPITAL EMERGENCY ROOM
3
HOSPITAL OUTPATIENT DEPARTMENT
4
SOME OTHER PLACE
5
DOESN’T GET PREVENTATIVE CARE ANYWHERE
0
DOESN’T GO TO ONE PLACE MOST OFTEN
6
REFUSED
7
DON’T KNOW
9
HPH13.
About how long has it been since you last saw or talked to a doctor or other health care professional about your own health?
NEVER
0
6 MONTHS OR LESS
1
MORE THAN 6 MONTHS, BUT NOT MORE THAN 1 YEAR
AGO
MORE THAN ONE YEAR, BUT NOT MORE THAN 2 YEARS
AGO
MORE THAN 2 YEARS, BUT NOT MORE THAN 5 YEARS
AGO
2
3
4
MORE THAN FIVE YEARS AGO
5
REFUSED
7
DON’T KNOW
9
HPH14.
Is there a place where YOUR CHILDREN usually go when (he / she / they) (is / are) sick or you need advice about (his / her /
their) health?
MTO Adult Qnaire
YES
1
THERE IS NO PLACE (GO TO HPH16)
2
THERE IS MORE THAN ONE PLACE
3
REFUSED (GO TO HPH16)
7
DON’T KNOW (GO TO HPH16)
8
Page A-80
Revised 08/07/07
HPH15.
What kind of place do your children go to most often – a clinic, doctor’s office, emergency room, or some other kind of place?
[INTERVIEWER: IF MORE THAN 1 PLACE, PROBE FOR THE ONE RESPONDENT GOES TO MOST OFTEN]
CLINIC OR HEALTH CENTER
1
DOCTOR’S OFFICE OR HMO
2
HOSPITAL EMERGENCY ROOM
3
HOSPITAL OUTPATIENT DEPARTMENT
4
SOME OTHER PLACE
5
DOESN’T GO TO ONE PLACE MOST OFTEN
6
REFUSED
7
DON’T KNOW
8
HPH16.
In the past 12 months, have you had any accidents or injuries that required medical attention?
YES
1
NO
2
REFUSED
7
DON’T KNOW
8
HPH17.
During the past 12 months, ABOUT how many days did illness or injury keep you in bed more than half of the day? (include
days while an overnight patient in a hospital)
____________ (0-365 Days)
DK
RF
HPH18.
During the PAST 12 MONTHS, how many times have you gone to a HOSPITAL EMERGENCY ROOM about
your own health? (This includes emergency room visits that resulted in a hospital admission.)
MTO Adult Qnaire
NEVER
0
ONCE
1
2-3 TIMES
2
4-5 TIMES
3
6-7 TIMES
4
8-9 TIMES
5
10-12 TIMES
6
13-15 TIMES
7
16 OR MORE TIMES
8
REFUSED
97
DON’T KNOW
98
Page A-81
Revised 08/07/07
HPH19.
[Were you/has anyone in the family been] hospitalized OVERNIGHT in the past 12 months? Do not include an
overnight stay in the emergency room.
YES
1
NO (SKIP TO HPH23)
2
REFUSED (SKIP TO HPH23)
7
DON’T KNOW (SKIP TO HPH23)
8
HPH20.
Who was in the hospital overnight? Anyone else?
NEED RESPONSE CATEGORIES FOR THIS QUESTION
1
REFUSED
7
DON’T KNOW
8
HPH21.
How many different times did [you/person] stay in the hospital overnight or longer DURING THE PAST 12
MONTHS?
ONCE
1
2-3 TIMES
2
4-5 TIMES
3
6-7 TIMES
4
8-9 TIMES
5
10-12 TIMES
6
13-15 TIMES
7
16 OR MORE TIMES
8
REFUSED
97
DON’T KNOW
98
HPH22.
Altogether how many nights [were you/was ALIAS] in the hospital DURING THE PAST 12 MONTHS?
MTO Adult Qnaire
ONCE
1
2-3 TIMES
2
4-5 TIMES
3
6-7 TIMES
4
8-9 TIMES
5
10-12 TIMES
6
13-15 TIMES
7
16 OR MORE TIMES
8
REFUSED
97
DON’T KNOW
98
Page A-82
Revised 08/07/07
HPH23.
During the past 12 months, was there any time when you or your children needed medical care but did not get it?
YES
1
NO (GO TO HPH24)
2
REFUSED (GO TO HPH24)
7
DON’T KNOW (GO TO HPH24)
8
There are many reasons people do not get medical care. During the past 12 months, did you or your children not get care for
any of the following reasons:
YES
NO
RF
DK
HPH23a.
You couldn’t afford it.
1
2
7
8
HPH23b.
You didn’t have transportation.
1
2
7
8
HPH23c.
You didn’t know whom to see.
1
2
7
8
HPH23d.
You couldn’t go because you had to work or take care of
family members or friends?
1
2
7
8
HPH24.
How would you describe the condition of your natural teeth? Excellent, very good, good, fair, poor, or no natural teeth?
MTO Adult Qnaire
EXCELLENT
0
VERY GOOD
1
GOOD
2
FAIR
3
POOR
4
NO NATURAL TEETH
5
REFUSED
7
DON’T KNOW
8
Page A-83
Revised 08/07/07
HPH25.
About how long has it been since you last saw a dentist?
NEVER
0
6 MONTHS OR LESS
1
MORE THAN 6 MONTHS, BUT NOT MORE THAN 1 YEAR
AGO
MORE THAN ONE YEAR, BUT NOT MORE THAN 2 YEARS
AGO
MORE THAN 2 YEARS, BUT NOT MORE THAN 5 YEARS
AGO
2
3
4
MORE THAN FIVE YEARS AGO
5
REFUSED
7
DON’T KNOW
8
HPH26.
The next questions are about activities you might do during a typical day. Does your health now limit you in
these activities? If so, how much?
Yes,
Yes,
No, not
RF
DK
limited
limited
limited
a lot
a little
at all
HPH26a.
Vigorous activities, such as running, lifting heavy
objects, participating in strenuous sports
1
2
3
7
8
1
2
3
7
8
HPH26c.
Lifting or carrying groceries.
1
2
3
7
8
HPH26d.
Climbing several flights of stairs
1
2
3
7
8
HPH26e.
Climbing one flight of stairs
1
2
3
7
8
HPH26f.
Bending, kneeling, or stooping
1
2
3
7
8
HPH26g.
Walking more than a mile
1
2
3
7
8
HPH26h.
Walking several blocks
1
2
3
7
8
HPH26i.
Walking one block
1
2
3
7
8
HPH26j.
Bathing or dressing yourself
1
2
3
7
8
HPH26b.
Moderate activities, such as moving a table, pushing
a vacuum cleaner, bowling, or playing golf.
MTO Adult Qnaire
Page A-84
Revised 08/07/07
HPH28.
During the past 4 weeks, have you had any of the following problems with your work or other regular daily
activities as a result of your physical health?
YES
NO
RF
DK
HPH28a.
Cut down on the amount of time you spent on work or
other activities.
1
2
7
8
HPH28b.
Accomplished less than you would like.
1
2
7
8
HPH28c.
Were limited in the kind of work or other activities.
1
2
7
8
1
2
7
8
HPH28d.
Had difficulty performing the work or other activities
(for example, it took extra effort).
HPH29.
The next questions are about moderate and vigorous physical activity.
In a usual week, do you do moderate activities 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?
YES
1
NO (GO TO HPH30)
2
REFUSED (GO TO HPH30)
7
DON’T KNOW (GO TO HPH30)
8
HPH29a.
How many times per week do you do these moderate activities (for at least 10 minutes at a time)?
NUMBER OF TIMES PER WEEK _______________
DON’T KNOW
97
REFUSED
98
HPH30.
In a usual week, do you do vigorous activities for at least 10 minutes at a time, such as running, aerobics, heavy yard work, or
anything else that causes large increases in breathing or heart rate?
MTO Adult Qnaire
YES
1
NO (GO TO HPH31)
2
REFUSED (GO TO HPH31)
7
DON’T KNOW (GO TO HPH31)
8
Page A-85
Revised 08/07/07
HPH30a.
How many times per week do you do these vigorous activities (for at least 10 minutes at a time)?
NUMBER OF TIMES PER WEEK _______________
DON’T KNOW
97
REFUSED
98
HPH31.
In a typical week, how many hours do you watch television?
LESS THAN 2 HOURS A WEEK
1
3 TO 10 HOURS A WEEK
2
11 TO 20 HOURS A WEEK
3
21 TO 30 HOURS A WEEK
4
31 TO 40 HOURS A WEEK
5
40 HOURS OR MORE A WEEK
6
DON’T KNOW
-1
REFUSED
-2
HPH32.
Do you use a computer at home?
YES
1
NO (GO TO HPH33)
2
REFUSED (GO TO HPH33)
7
DON’T KNOW (GO TO HPH33)
8
HPH32a.
In a typical week, how many hours total do you use a computer?
MTO Adult Qnaire
NONE
1
LESS THAN 1 HOUR A WEEK
2
1 TO 3 HOURS A WEEK
3
4 TO 6 HOURS A WEEK
4
7 TO 9 HOURS A WEEK
5
10 HOURS OR MORE A WEEK
6
DON’T KNOW
-1
REFUSED
-2
Page A-86
Revised 08/07/07
HPH33.
How frequently do you use the Internet at any location?
NONE
1
LESS THAN 1 HOUR A WEEK
2
1 TO 3 HOURS A WEEK
3
4 TO 6 HOURS A WEEK
4
7 TO 9 HOURS A WEEK
5
10 HOURS OR MORE A WEEK
6
DON’T KNOW
-1
REFUSED
-2
HPH34.
What time did you wake up this morning?
Time Woke Up:_____________________
DON’T KNOW
-1
REFUSED
-2
HPH35.
What time did you go to bed last night?
Time Went to Bed:_____________________
DON’T KNOW
-1
REFUSED
-2
HPH36.
In a typical week, how many times do you eat fruit? (Do not count fruit juice.)
Suggest using RB for this series.
MTO Adult Qnaire
I DO NOT TYPICALLY EAT FRUIT
1
1 TO 3 TIMES
2
4 TO 6 TIMES
3
1 TIME PER DAY
4
2 TIMES PER DAY
5
3 TIMES PER DAY
6
4 TIMES OR MORE PER DAY
7
DON’T KNOW
-1
REFUSED
-2
Page A-87
Revised 08/07/07
HPH37.
In a typical week, how many times do you eat vegetables other than french fries or potato chips?
I DO NOT TYPICALLY EAT VEGETABLES
1
1 TO 3 TIMES
2
4 TO 6 TIMES
3
1 TIME PER DAY
4
2 TIMES PER DAY
5
3 TIMES PER DAY
6
4 TIMES OR MORE PER DAY
7
DON’T KNOW
-1
REFUSED
-2
HPH38.
How often did you drink regular, carbonated SODA OR SOFT DRINKS that contain sugar?
I DO NOT TYPICALLY DRINK SODA OR SOFT DRINKS
1
1 TO 3 TIMES
2
4 TO 6 TIMES
3
1 TIME PER DAY
4
2 TIMES PER DAY
5
3 TIMES PER DAY
6
4 TIMES OR MORE PER DAY
7
DON’T KNOW
-1
REFUSED
-2
HPH39.
How often did you eat salty snacks, such as potato chips, pretzels, or popcorn?
MTO Adult Qnaire
I DO NOT TYPICALLY EAT SALTY SNACKS
1
1 TO 3 TIMES
2
4 TO 6 TIMES
3
1 TIME PER DAY
4
2 TIMES PER DAY
5
3 TIMES PER DAY
6
4 TIMES OR MORE PER DAY
7
DON’T KNOW
-1
REFUSED
-2
Page A-88
Revised 08/07/07
HPH40.
How often did you eat sweet snacks, such as cookies, chocolate bars, or candy?
I DO NOT TYPICALLY EAT SWEET SNACKS
1
1 TO 3 TIMES
2
4 TO 6 TIMES
3
1 TIME PER DAY
4
2 TIMES PER DAY
5
3 TIMES PER DAY
6
4 TIMES OR MORE PER DAY
7
DON’T KNOW
-1
REFUSED
-2
HPH41.
On how many of the past seven days did you eat food from a fast food place, McDonalds, Kentucky Fried Chicken, Pizza Hut,
Taco Bell, or a local fast food restaurant?
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days
DON’T KNOW
REFUSED
0
1
2
3
4
5
6
7
-1
-2
HPH42.
Now I’d like to take a short break and actually take your blood pressure. Once we are done, we will resume the interview by
asking a few follow-up questions.
[INTERVIEWER: ENTER BLOOD PRESSURE EQUIPMENT NUMBER] _______
HPH43.
How many hours has it been since you had your last meal?
MTO Adult Qnaire
NUMBER OF HOURS: ________
1
DON’T KNOW
-1
REFUSED
-2
Page A-89
Revised 08/07/07
HPH44.
INTERVIEWER: [RECORD ROOM TEMPERATURE HERE]
______________FAHRENHEIT
DK
RF
HPH44a.
[ DID THE RESPONDENT SMOKE AT ANY TIME DURING THIS INTERVIEW?]
YES
1
NO
2
REFUSED
7
DON’T KNOW
8
HPH45.
[INTERVIEWER: RECORD BLOOD PRESSURE MEASUREMENT HERE. IF LARGE CUFF TOO SMALL, TAKE
PRESSURE ON FOREARM. IF FOR ANY REASON YOU ARE UNABLE TO TAKE MEASUREMENT, ENTER 1]
HPH45sys
HPH45Ddia
HPH45plse
SYSTOLIC BLOOD PRESSURE: _____________mmHg
REFUSED
DON’T KNOW
DIASTOLIC BLOOD PRESSURE: _____________mmHg
REFUSED
DON’T KNOW
PULSE: _____________beats/min
REFUSED
DON’T KNOW
HPH45a.
[INTERVIEWER: WHICH CUFF DID YOU USE?]
MTO Adult Qnaire
ADULT (ONE TUBE)
1
LARGE (TWO TUBES)
2
FOREARM
3
REFUSED
7
DON’T KNOW
8
Page A-90
Revised 08/07/07
HPH45b.
Now I need to take another blood pressure reading.
[INTERVIEWER: RECORD SECOND BLOOD PRESSURE READING HERE]
HPH45bsys
HPH45bdia
SYSTOLIC BLOOD PRESSURE: _____________mmHg
REFUSED
DON’T KNOW
DIASTOLIC BLOOD PRESSURE: _____________mmHg
REFUSED
DON’T KNOW
HPH45c.
[[CAPI PROGRAMMER: CALCULATE THE AVERAGE OF TWO BLOOD PRESSURE READINGS FROM
HPH45b AND HPH45c: IF AVERAGE BLOOD PRESSURE FALLS INTO “HIGH CATEGORY, CONTINUE.
OTHERWISE SKIP TO HPH46]
In order to make sure we have measured your blood pressure accurately, we will continue with the next set of questions, and at
the end of the interview, I will ask you to let us take your blood pressure measurement again.
[THANK THE RESPONDENT, SKIP TO HPH46]
HPH45csys
HPH45cdia
SYSTOLIC BLOOD PRESSURE: _____________mmHg
REFUSED
DON’T KNOW
DIASTOLIC BLOOD PRESSURE: _____________mmHg
REFUSED
DON’T KNOW
[INTERVIEWER: EXPLAIN TO RESPONDENT]:
In order to make sure that we have measured your blood pressure accurately, we will continue with the next set of questions but
at the end of the interview, I will ask you to let me take your blood pressure measurement again. [GO TO HPH46]
HPH45d.
[CAPI PROGRAMMER DISPLAY AVERAGE OF TWO BLOOD PRESSURE READINGS.]
HPH45e.
[INTERVIEWER: IF AVERAGE BLOOD PRESSURE READING IS NORMAL, HAND RESPONDENT THE CARD
WITH HIS/HER BLOOD PRESSURE INFORMATION AND EXPLAIN. ALSO INCLUDE:]
Here’s a sheet with the readings I took. It also has information about what blood pressure shows.
HPH46.
HEIGHT MEASUREMENT
HPH47.
WEIGHT MEASUREMENT
MTO Adult Qnaire
___________ FT _____________IN
DK
RF
_____________ POUNDS
DK
RF
Page A-91
Revised 08/07/07
[QUESTIONS FOR DRIED BLOOD SPOTS (DBS) MARKERS]
HPH48.
Do you have any reason to think you’re pregnant?
YES
1
NO
2
REFUSED
7
DON’T KNOW
8
HPH49.
What is the date when you last menstrual period began?
Date: _____________________
REFUSED
7
DON’T KNOW
8
HPH50.
In the last week, have you had a cough, runny nose, sore throat, fever, diarrhea, or any other type of infection?
NO
0
COUGH
1
RUNNY NOSE
2
SORE THROAT
3
FEVER
4
DIARRHEA
5
OTHER INFECTION (SPECIFY)
95
REFUSED
97
DON’T KNOW
98
HPH51.
Regarding your current medication use: In the past 24 hours, have you taken aspirin or aspirin-containing medications
including cold and allergy medications or headache powders? (Some examples of those include Anacin, Aspirin, BC,
Backache Relief Extra Strength, Bayer, Excedrin, Goody’s, Pain Relief, Pain Reliever Added Strength, Vanquish)
MTO Adult Qnaire
YES
1
NO
2
REFUSED
7
DON’T KNOW
8
Page A-92
Revised 08/07/07
HPH52.
In the past 24 hours, have you used any prescription medications? Please think about any prescription medications
whether or not they were prescribed to you.
YES
1
NO
2
REFUSED
7
DON’T KNOW
8
HPH53.
At what time did you last drink or eat anything except for water?
Time: _____________________
REFUSED
7
DON’T KNOW
8
HPH54.
At what time did you last drink a caffeinated beverage (such as coffee, tea, or soda)?
Time: _____________________
REFUSED
7
DON’T KNOW
8
HPH55.
At what time did you last smoke cigarettes, cigars, a pipe or use chewing tobacco?
Time: _____________________
REFUSED
DON’T KNOW
7
8
[ GO TO next module]
MTO Adult Qnaire
Page A-93
Revised 08/07/07
SECTION I: SEVERE BLOOD PRESSURE
[A SECOND SET OF BLOOD PRESSURE READINGS ARE TAKEN AT THE END OF THE ADULT INTERVIEW
IF AVERAGE BLOOD PRESSURE IS HIGH]
HPH_I2.
[INTERVIEWER: IF RESPONDENT’S BLOOD PRESSURE WAS OUT OF THE ACCEPTED RANGE IN
HPH45d, CONTINUE WITH HPH_I2b.]
HPH_I2a.
[CAPI PROGRAMMER: RECORD TIME STAMP OF TIME OF DAY]
HPH_I2b.
Now I’d like to take your blood pressure again.
[INTERVIEWER: RECORD BLOOD PRESSURE MEASUREMENT HERE]
HPH_I2bSYS
HPH_I2bDIA
SYSTOLIC BLOOD PRESSURE: _____________mmHg
REFUSED
DON’T KNOW
DIASTOLIC BLOOD PRESSURE: _____________mmHg
REFUSED
DON’T KNOW
HPH_I2c.
[INTERVIEWER: TAKE AN ADDITIONAL BP MEASUREMENT. RECORD MEASUREMENT HERE]
HPH_I2cSYS
HPH_I2cDIA
SYSTOLIC BLOOD PRESSURE: _____________mmHg
REFUSED
DON’T KNOW
DIASTOLIC BLOOD PRESSURE: _____________mmHg
REFUSED
DON’T KNOW
HPH_I2d.
[CAPI PROGRAMMER: CALCULATE AVERAGE OF ALL FOUR BLOOD PRESSURE READINGS IN HPH_F16,
HPH_F16b, HPH_I2b and HPH_I2c AND DISPLAY]
HPH_I2dSYS
HPH_I2dDIA
MTO Adult Qnaire
AVERAGE SYSTOLIC BLOOD PRESSURE: _____________mmHg
REFUSED
DON’T KNOW
AVERAGE DIASTOLIC BLOOD PRESSURE: _____________mmHg
REFUSED
DON’T KNOW
Page A-94
Revised 08/07/07
HPH_I2e.
[INTERVIEWER: FILL IN THE INFORMATION (DATE, NUMBER OF READINGS, AVERAGE SYSTOLIC AND
DIASTOLIC READINGS) AT THE TOP OF THE BLOOD PRESSURE READING FORM AND HAND IT TO THE
RESPONDENT]
Thank you. Here’s a sheet with an average of all the readings I took. It also has information about what blood pressure shows.
[ GO TO NEXT MODULE]
MTO Adult Qnaire
Page A-95
Revised 08/09/07
A_Section 10: Substance Abuse (HSU)
HSU1_U1
First, I would like to ask you about smoking habits. Have you ever smoked a cigarette?
YES
1
NO (GO TO HSU4_U4)
5
REFUSED (GO TO HSU4_U4)
7
DON’T KNOW (GO TO HSU4_U4)
8
HSU2_U2
During the past 30 days, on how many days did you smoke a cigarette?
♦ENTER NUMBER:____________
1
0 (GO TO HSU4_U4)
5
REFUSED (GO TO HSU4_U4)
7
DON’T KNOW (GO TO HSU4_U4)
8
HSU3_U3
When you smoked a cigarette during the past 30 days, how many cigarettes did you usually smoke each
day?
♦ENTER NUMBER _ _ _
RF
DK
HSU4_U4
Next I would like to ask you some questions about drinking alcoholic beverages, including beer, wine, or
liquor. Have you ever had a drink of alcoholic beverage? By a drink we mean a can or bottle of beer, a
glass of wine, a mixed drink, or a shot of liquor.
MTO Adult Qnaire
YES
1
NO (GO TO HSU9_U9)
5
REFUSED (GO TO HSU9_U9)
7
DON’T KNOW (GO TO HSU9_U9)
8
Page A-96
Revised 08/09/07
HSU5_U5
During the past 30 days, on how many days did you have one or more drinks of an alcoholic beverage?
♦ENTER NUMBER _ _ _
0 (GO TO HSU9_U9)
REFUSED (GO TO HSU9_U9)
7
DON’T KNOW (GO TO HSU9_U9)
8
HSU6_U6
In the last 30 days, on the days that you drank alcohol, about how many drinks did you usually have?
♦ENTER DAYS _ _ _
RF
DK
HSU7_U7
On how many days did you have 5 or more drinks on the same occasion during the same time or within
hours of each other?
♦ENTER DAYS _ _ _
RF
DK
HSU8_U8
In the last 30 days, how many days have you had something alcoholic to drink, such as beer, wine, or hard
liquor right before or during school or work hours?
♦ENTER DAYS _ _ _
RF
DK
HSU9_U9
Have you ever used marijuana – that is grass or pot – in your lifetime?
MTO Adult Qnaire
YES
1
NO (GO TO HSU12_U12)
5
REFUSED (GO TO HSU12_U12)
7
DON’T KNOW (GO TO HSU12_U12)
8
Page A-97
Revised 08/09/07
HSU10_U10
On how many days have you used marijuana in the last 30 days?
♦ENTER DAYS _ _ _ (IF 0 DAYS, GO TO HSU12)
RF
DK
HSU11_U11
In the last 30 days, how many times have you used marijuana right before or during school or work hours?
♦ENTER DAYS _ _ _
RF
DK
HSU12_U12
Excluding marijuana and alcohol, have you ever used any other drugs like cocaine or crack or heroin, or
any other substance not prescribed for you by a doctor, in order to get high or to achieve an altered state?
YES
1
NO (GO TO HSU15)
5
REFUSED (GO TO HSU15)
7
DON’T KNOW (GO TO HSU15)
8
HSU13_U13
During the past 12 months, about how many times have you used any of these drugs or other substances?
♦ENTER NUMBER _ _ _
REFUSED
7
DON’T KNOW
8
HSU14_U14
Have you ever sold or helped sell marijuana, hashish or other drugs such as heroin, cocaine, or LSD?
MTO Adult Qnaire
YES
1
NO
5
REFUSED
7
DON’T KNOW
8
Page A-98
Revised 08/09/07
CHECKPOINT:
IF HSU4_U4 IS CODED 5(NO), DK or RF………………….(GO TO CHECKPOINT (HSU20))
HSU15
The following questions are about your drinking. For each of the five questions, please indicate the most
appropriate response as it applied to your drinking in the last month.
Do you think your use of alcohol was out of control?
NEVER/ALMOST NEVER
0
SOMETIMES
1
OFTEN
2
ALWAYS/NEARLY ALWAYS
3
RF
DK
HSU16
Did the prospect of missing a chance to drink make you anxious or worried?
NEVER/ALMOST NEVER
0
SOMETIMES
1
OFTEN
2
ALWAYS/NEARLY ALWAYS
3
RF
DK
HSU17
Did you worry about your use of alcohol?
NEVER/ALMOST NEVER
0
SOMETIMES
1
OFTEN
2
ALWAYS/NEARLY ALWAYS
3
RF
DK
MTO Adult Qnaire
Page A-99
Revised 08/09/07
HSU18
Did you wish you could stop?
NEVER/ALMOST NEVER
0
SOMETIMES
1
OFTEN
2
ALWAYS/NEARLY ALWAYS
3
RF
DK
HSU19
How difficult did you find it to stop or go without drinking?
NOT DIFFICULT
0
QUITE DIFFICULT
1
VERY DIFFICULT
2
IMPOSSIBLE
3
RF
DK
CHECKPOINT (SeeHSU_U9, HSU_U12)
IF (HSU9_U9 IS CODED 1 (YES)) OR
(HSU12_U12 IS CODED 1 (YES))…………………………….(GO TO HSU20a)
OTHERS………………………………………………………….. (GO TO NEXT SECTION)
HSU20a
The following questions are about your drug use. For each, please tell me if this happened nearly always,
often, sometimes, or almost never.
Do you think your use of (drug) was out of control?
NEVER/ALMOST NEVER
0
SOMETIMES
1
OFTEN
2
ALWAYS/NEARLY ALWAYS
3
RF
DK
MTO Adult Qnaire
Page A-100
Revised 08/09/07
HSU20b
Did the prospect of missing a fix make you anxious or worried?
NEVER/ALMOST NEVER
0
SOMETIMES
1
OFTEN
2
ALWAYS/NEARLY ALWAYS
3
RF
DK
HSU20c
Did you worry about your use of (drug)?
NEVER/ALMOST NEVER
0
SOMETIMES
1
OFTEN
2
ALWAYS/NEARLY ALWAYS
3
RF
DK
HSU20d
Did you wish you could stop?
NEVER/ALMOST NEVER
0
SOMETIMES
1
OFTEN
2
ALWAYS/NEARLY ALWAYS
3
RF
DK
HSU20e
How difficult did you find it to stop or go without (drug)?
NOT DIFFICULT
0
QUITE DIFFICULT
1
VERY DIFFICULT
2
IMPOSSIBLE
3
RF
DK
MTO Adult Qnaire
Page A-101
Revised 08/07/07
A_Section 11: K-6 INDEX PLUS TRANQUILITY (HK6)
ALL OF
THE TIME
MOST OF
THE TIME
SOME
OF THE
TIME
A
LITTLE
OF THE
TIME
NONE
OF THE
TIME
RF
DK
Now I am going to ask you some
questions about feelings that you may
have experienced during the past 30
days. How much of the time during
the past 30 days have you felt…
HK61.
So sad that nothing could cheer you
up?
1
2
3
4
5
7
8
HK62.
Nervous?
1
2
3
4
5
7
8
HK63
Restless or fidgety?
1
2
3
4
5
7
8
HK64
Hopeless?
1
2
3
4
5
7
8
HK65
That everything was an effort?
1
2
3
4
5
7
8
HK66
Worthless?
1
2
3
4
5
7
8
HK67
Calm and peaceful?
1
2
3
4
5
7
8
MTO Adult Qnaire
Page A-102
Revised 08/07/07
A_Section 12: MENTAL HEALTH SCREENER (HSC)
HSC1_SC20.
The next questions are going to require you to think back over
your entire life. Please take your time and think carefully
before answering. INTERVIEWER: READ FOLLOWING
QUESTIONS SLOWLY
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
GO TO
HSC3_SC20_1
Have you ever in your life had an attack of fear or panic when
all of a sudden you felt very frightened, anxious, or uneasy?
HSC2_SC20a.
Have you ever had an attack when all of a sudden
• you became very uncomfortable,
• you either became short of breath, dizzy, nauseous, or
• your heart pounded,
• or you thought that you might lose control, die, or go
crazy?
HSC3_SC20_1.
Have you ever in your life had attacks of anger when all of a
sudden you lost control and broke or smashed something worth
more than a few dollars?
HSC4_SC20_2.
Have you ever had attacks of anger when all of a sudden you lost
control and hit or tried to hurt someone?
HSC5_SC20_3.
Have you ever had attacks of anger when all of a sudden you lost
control and threatened to hit or hurt someone?
HSC6_SC21.
Have you ever in your life had an episode lasting several days
or longer when most of the day you felt sad, empty or
depressed?
HSC7_SC22.
Have you ever had an episode lasting several days or longer
when most of the day you were very discouraged about how
things were going in your life?
HSC8_SC23.
Have you ever had an episode lasting several days or longer
when you lost interest in most things you usually enjoy like
work, hobbies, and personal relationships?
MTO Adult Qnaire
GO TO
HSC6_SC21
1
Page A-103
Revised 08/07/07
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
5
8
1
GO TO
HSC11_SC26
GO TO
HSC11_SC26
GO TO
HSC11_SC2
6
1
5
8
9
1
5
8
9
5
8
9
5
8
9
HSC9_SC24.
Some people have episodes lasting several days or longer when
they feel much more excited and full of energy than usual.
Their minds go too fast. They talk a lot. They are very restless
or unable to sit still and they sometimes do things that are
unusual for them, such as driving too fast or spending too
much money. Have you ever had a period like this lasting
several days or longer?
HS10_SC25.
Have you ever had an episode period lasting several days or
longer when most of the time you were very irritable, grumpy,
or in a bad mood?
HSC11_SC25a.
Have you ever had an episode lasting several days or longer
when most of the time you were so irritable that you either
started arguments, shouted at people, or hit people?
HSC12_SC26.
Did you ever have a time in your life when you were a
“worrier” – that is, when you worried a lot more about things
than other people with the same problems as you?
HSC13_SC26a.
Did you ever have a time in your life when you were much
more nervous or anxious than most other people with the same
problems as you?
9
GO TO
CHECKPOINT
1
GO TO
CHECKPOINT
HSC14_SC26b.
Did you ever have a period lasting one month or longer when
you were anxious and worried most days?
1
CHECKPOINT: FOLLOW SKIP FOR FIRST ENDORSED ITEM
HSC6_SC21 IS CHECKED .................................... 1
GO TO HDE1_D1
HSC7_SC22 IS CHECKED .................................... 2
GO TO HDE2_D2
HSC8_SC23 IS CHECKED .................................... 3
GO TO HDE3_D9
HSC9_SC24 IS CHECKED .................................... 4
GO TO HMA1_M1
HSC11_SC25a IS CHECKED ................................ 5
GO TO HMA4_M5
HSC1_SC20 IS CHECKED .................................... 7
GO TO HPD1_PD1_INTRO 1
HSC2_SC20a IS CHECKED .................................. 8
GO TO HPD1_PD1_INTRO 2
HSC12_SC26 IS CHECKED .................................. 12
GO TO HGA1_G1_INTRO 1
HSC13_SC26a IS CHECKED ............................... 13
GO TO HGA1_G1_INTRO 2
HSC14_SC26b IS CHECKED................................ 14
GO TO HGA1_G1_INTRO 3
HSC3_SC20_1 IS CHECKED ................................ 15
GO TO NEXT CHECKPOINT (SC37)
HSC4_SC20_2 IS CHECKED ................................ 16
GO TO HIE1_IED3_INTRO 4
HSC5_SC20_3 IS CHECKED ................................ 17
GO TO HIE1_IED3_INTRO 5
ALL OTHERS .......................................................... 18
GO TO HCV1
MTO Adult Qnaire
Page A-104
Revised 08/07/07
CHECKPOINT (SC37):
HSC4_SC20_2 IS CHECKED ..............................1
GO TO HIE1_IED3_INTRO 1
HSC5_SC20_3 IS CHECKED ..............................2
GO TO HIE1_IED3_INTRO 2
ALL OTHERS .......................................................3
GO TO HIE1_IED3_INTRO 3
MTO Adult Qnaire
Page A-105
Revised 08/07/07
A_Section 13: DEPRESSION (HDE)
HDE1_D1
A few moments ago, you mentioned having episodes that lasted several days or longer when you felt sad, empty, or
depressed most of the day. During episodes of this sort, did you ever feel discouraged about how things were going in
your life?
Yes ..................................................1
No....................................................5 (GO TO HDE1b_D1b)
DK................................................... (GO TO HDE1b_D1b)
RF.................................................... (GO TO HDE1b_D1b)
HDE1a_D1a
During the episodes of being sad, empty, or depressed, did you ever lose interest in most things like work, hobbies, and
other things you usually enjoy?
Yes .............................................................................. 1 (GO TO HDE4_D12)
No................................................................................ 5 (GO TO HDE4_D12)
DK............................................................................... (GO TO HDE4_D12)
RF................................................................................ (GO TO HDE4_D12)
♦ INTERVIEWER INSTRUCTION:
¾ IF HDE1a_D1a IS CODED 1 (YES), THEN READ “sad/discouraged/uninterested”
¾ IF HDE1a_D1a IS CODED 5 (NO), DK OR RF, THEN READ “sad/discouraged”
HDE1b_D1b
During the episodes of being sad, empty, or depressed, did you ever lose interest in most things like work, hobbies, and
other things you usually enjoy?
Yes .............................................................................. 1 (GO TO HDE4_D12)
No................................................................................ 5 (GO TO HDE4_D12)
DK............................................................................... (GO TO HDE4_D12)
RF................................................................................ (GO TO HDE4_D12)
♦INTERVIEWER INSTRUCTION:
¾ IF HDE1b_D1b IS CODED 1 (YES), THEN READ “sad/uninterested”
¾ IF HDE1b_D1b IS CODED 5 (NO), DK OR RF, THEN READ “sad”
HDE2_D2
A few moments ago, you mentioned having episodes that lasted several days or longer when you felt discouraged about
how things were going in your life. During episodes of this sort, did you ever lose interest in most things like work,
hobbies, and other things you usually enjoy?
Yes .............................................................................. 1 (GO TO HDE4_D12)
No................................................................................ 5 (GO TO HDE4_D12)
DK............................................................................... (GO TO HDE4_D12)
RF................................................................................ (GO TO HDE4_D12)
♦INTERVIEWER INSTRUCTION:
¾ IF HDE2_D2 IS CODED 1 (YES), THEN READ “discouraged/uninterested”
¾ IF HDE2_D2 IS CODED 5 (NO), DK OR RF, THEN READ “discouraged”
MTO Adult Qnaire
1
Page A-106
Revised 08/07/07
HDE3_D9
A few moments ago you mentioned having episodes that lasted several days or longer when you felt discouraged about
how things were going in your life. During episodes of this sort, did you ever lose interest in most things like work,
hobbies, and other things you usually enjoy?
Yes .............................................................................. 1
No................................................................................ 5
DK
RF
♦INTERVIEWER INSTRUCTION: READ “uninterested”
HDE4_D12
Did you ever have an episode of being sad, discouraged, or uninterested in things that lasted most of the day, early every
day, for two weeks or longer?
Yes .............................................................................. 1
No................................................................................ 5 (GO TO HDE19_D88)
DK............................................................................... (GO TO HDE19_D88)
RF................................................................................ (GO TO HDE19_D88)
HDE5_D16
Think of times lasting two weeks or longer when (this problem/these problems) with your mood (was/were) most severe
and frequent. During those times, did your feelings of sadness, discouragement, or lack of interest usually last less than
one hour a day, between 1 and 3 hours, between 3 and 5 hours, or more than 5 hours?
Less than 1 hour...............................................................1 (GO TO HDE19_D88)
Between 1 and 3 hours ....................................................2
Between 3 and 5 hours ....................................................3
More than 5 hours............................................................4
DK
RF
HDE6_D22
Please think of an episode of being sad, discouraged, or uninterested in things lasting two weeks or longer when you also
had other problems at the same time, such as changes in sleep, appetite, the ability to concentrate and remember, feelings
of low self worth, and other problems. Is there one particular episode of this sort that stands out in your mind as the
worst one you ever had?
♦ INTERVIEWER: READ SLOWLY
Yes ...................................................................................1
No.....................................................................................5 (GO TO HDE6d_D22c)
DK.................................................................................... (GO TO HDE6d_D22c)
RF .................................................................................... (GO TO HDE6d_D22c)
MTO Adult Qnaire
2
Page A-107
Revised 08/07/07
HDE6a_D22a
How old were you when that worst episode started?
♦ ENTER number of years of age____________________
DK
RF
HDE6b_D22b
How long did that worst episode last?
♦ ENTER length of duration
DK............................................................................... (GO TO HDE7_D24)
RF................................................................................ (GO TO HDE7_D24)
HDE6c_D22b
♦ ENTER unit of time
Days ............................................................................ 1 (GO TO HDE7_D24)
Weeks.......................................................................... 2 (GO TO HDE7_D24)
Months......................................................................... 3 (GO TO HDE7_D24)
Years ........................................................................... 4 (GO TO HDE7_D24)
DK............................................................................... (GO TO HDE7_D24)
RF................................................................................ (GO TO HDE7_D24)
HDE6d_D22c
Then think of the last time you had a bad episode of being sad, discouraged, or uninterested in things like this. How old
were you when that last episode occurred?
♦ ENTER age________________________
DK...............................................................................
RF................................................................................
HDE6e_D22d
How long did that episode last?
♦ ENTER length of duration________________________
DK............................................................................... (GO TO HDE7_D24)
RF................................................................................ (GO TO HDE7_D24)
HDE6f_D22d
♦ ENTER unit of time
Days ............................................................................ 1
Weeks.......................................................................... 2
Months......................................................................... 3
Years ........................................................................... 4
MTO Adult Qnaire
3
Page A-108
Revised 08/07/07
HDE7_D24.
(RB, PG 5. FOR EACH ITEM ENDORSED, ASK R TO MARK IT IN THE RB.)
Look at page 5 in your booklet. In answering the next questions, think about the episode of two weeks or longer
during that episode when your sadness, discouragement, and loss of interest and other problems were most severe and
frequent. During that period, which of the following problems did you have most of the day nearly every day?
YES
(1)
NO
(5)
DK
(8)
RF
(9)
HDE7a_D24a.
Did you feel sad, empty, or depressed most of the day nearly every day during that
episode of two weeks?
1
5
8
9
HDE7b_D24c.
During that episode of two weeks, did you feel discouraged about how things
were going in your life most of the day nearly every day?
1
5
8
9
1
5
8
9
1
5
8
9
HDE7c_D24e.
During that episode of two weeks, did you lose interest in almost all things like
work and hobbies and things you like to do for fun?
HDE7d_D24f.
Did you feel like nothing was fun even when good things were happening?
INTERVIEWER CHECKPOINT: (SEE HDE7a_D24a-HDE7d_D24f)
ONE OR MORE RESPONSES CODED ‘1’ ............................ 1
ALL OTHERS........................................................................... 2
(RB, PG 5-6. FOR EACH ITEM ENDORSED, ASK R TO
MARK IT IN THE RB.)
HDE9a_D26a.
Did you have a much smaller appetite than usual nearly every
day during that period of two weeks?
HDE9b_D26b.
Did you have a much larger appetite than usual nearly every
day?
HDE9c_D26c.
Did you gain weight without trying to during that period of two
weeks?
(GO TO HDE19_D88)
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
GO TO
HDE9d_D26e
5
8
9
1
5
8
9
1
GO TO
HDE9e_D26g
5
8
9
IF R REPORTS BEING PREGNANT OR GROWING,
CODE "NO"
MTO Adult Qnaire
4
Page A-109
Revised 08/07/07
(RB, PG 5-6. FOR EACH ITEM ENDORSED, ASK R TO
MARK IT IN THE RB.)
HDE9d_D26e.
Did you lose weight without trying to?
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
GO TO
HDE9g_D26j
5
8
1
5
8
9
1
GO TO
HDE9i_D26l
5
8
9
1
5
8
9
1
5
8
9
GO TO
HDE9k_D26n
GO TO
HDE9k
_D26n
GO TO
HDE9k
_D26n
1
GO TO
5
GO TO
8
GO TO
9
GO TO
HDE9m_D26p
HDE9m _D26p
HDE9m
_D26p
HD9Em
_D26p
1
5
8
9
GO TO
HDE9m_D26p
GO TO
HDE9m
_D26p
GO TO
HDE9m
_D26p
1
5
8
9
1
5
8
9
IF R REPORTS BEING ON A DIET OR PHYSICALLY
ILL, CODE "NO"
HDE9e_D26g.
Did you have a lot more trouble than usual either falling asleep,
staying asleep, or waking too early nearly every night during that
period of two weeks?
HDE9f_D26h.
Did you sleep a lot more than usual nearly every night during
that period of two weeks?
HDE9g_D26j.
Did you feel tired or low in energy nearly every day during that
period of two weeks even when you had not been working very
hard?
HDE9h_D26k.
Did you have a lot more energy than usual nearly every day
during that period of two weeks?
HDE9i_D26l.
Did you talk or move more slowly than is normal for you nearly
every day?
HDE9j_D26m.
Did anyone else notice that you were talking or moving slowly?
HDE9k_D26n.
Were you so restless or jittery nearly every day that you paced up
and down or couldn't sit still?
HDE9l_D26o.
Did anyone else notice that you were restless?
HDE9m_D26p.
Did your thoughts come much more slowly than usual or seem
mixed up nearly every day during that period of two weeks?
MTO Adult Qnaire
5
9
Page A-110
Revised 08/07/07
(RB, PG 5-6. FOR EACH ITEM ENDORSED, ASK R TO
MARK IT IN THE RB.)
HDE9n_D26r.
Did you have a lot more trouble concentrating than is normal for
you nearly every day?
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
GO TO
HDE11_D28
5
8
9
1
GO TO
HDE11_D28
5
8
9
5
8
9
HDE9o_D26s.
Were you unable to make up your mind about things you
ordinarily have no trouble deciding about?
HDE9p_D26t.
Did you lose your self-confidence?
HDE9q_D26u.
Did you feel that you were not as good as other people nearly
every day?
HDE9r_D26w.
Did you feel guilty nearly every day?
HDE9s_D26aa.
Did you often think a lot about death, either your own, someone
else’s, or death in general?
HDE9t_D26bb.
During that period, did you ever think that it would be better if
you were dead?
HDE9u_D26cc.
Did you think about committing suicide?
1
GO TO
HDE11_D28
HDE10_D27
INTERVIEWER CHECKPOINT (See HDE7_D24 – HDE9_D26w)
¾ IF AT LEAST ONE ‘1’ (YES) RESPONSE IN HDE7a_D24a –HDE7b_D24c
............................................................................................................. INCREMENT COUNT BY ONE.
¾ IF AT LEAST ONE ‘1’ RESPONSE IN HDE7c_D24e – HDE7d_D24f,
..................................................................................................................INCREMENT COUNT BY ONE.
¾
INCREMENT COUNT BY ONE FOR EACH ‘1’ RESPONSE IN HDE9a_D26a – HDE9r_D26w.
COUNT EQUALS THREE OR MORE...............................................1
ALL OTHERS ........................................................................................2
MTO Adult Qnaire
6
(GO TO HDE19_D88)
Page A-111
Revised 08/07/07
HDE11_D28
You mentioned having a number of the problems I just asked you about. How much did your sadness, discouragement,
or lack of interest and these other problems interfere with either your work, your social life, or your personal
relationships during that episode– not at all, a little, some, a lot, or extremely?
Not at all ........................................................................................................1
A Little...........................................................................................................2
Some ..............................................................................................................3
A Lot..............................................................................................................4
Extremely.......................................................................................................5
DK............................................................................................................
RF.............................................................................................................
HDE12_D17
How severe was your emotional distress during those times -- mild, moderate, severe, or very severe?
Mild..................................................................................1
Moderate..........................................................................2
Severe ..............................................................................3
Very Severe .....................................................................4
DK...............................................................................
RF................................................................................
HDE13_D18
How often, during those times, was your emotional distress so severe that nothing could cheer you up -- often, sometimes,
rarely, or never?
Often ..............................................................................................................1
Sometimes .....................................................................................................2
Rarely.............................................................................................................3
Never..............................................................................................................4
DK............................................................................................................
RF.............................................................................................................
INTERVIEWER CHECKPOINT ( See HDE11_D28, HDE12_D17, HDE13_D18)
If (HDE11_D28 Equals (‘3’,’4’,or ‘5’)) OR (HDE12_D17 Equals (‘2’,’3’, or ‘4’))
OR (HDE13_D18 Equals (‘1’ or ‘2’)) .....................................................(Continue with HDE14_D37)
If None of Those Things is True ............................................................(GO TO HDE19_D88)
HDE14_D37
Think of the very first time in your life you had an episode lasting two-weeks or longer when most of the day nearly
every day you felt sad, discouraged, or uninterested and also had some of the other problems we just reviewed. Can you
remember your exact age?
Yes ...........................................................................................................1
No.............................................................................................................5 (GO TO HDE15b_D37b)
DK............................................................................................................ (GO TO HDE15b _D37b)
RF............................................................................................................. (GO TO HDE15b _D37b)
MTO Adult Qnaire
7
Page A-112
Revised 08/07/07
HDE14a_D37a.
(IF NEC: How old were you?)
♦ ENTER age ..........................................................................................(GO TO HDE15_D38)
DK............................................................................................................(GO TO HDE15_D38)
RF.............................................................................................................(GO TO HDE15_D38)
HDE14b_D37b
About how old were you (the first time you had an episode of this sort)?
♦ INTERVIEWER: IF “ALL MY LIFE” OR “AS LONG AS I CAN REMEMBER,”
PROBE: Was it before you first started school?
IF NOT YES,
PROBE: Was it before you were a teenager?
♦ ENTER age____________________________
Before Started School...............................................................................4
Before Teenager .......................................................................................12
Not Before Teenager ................................................................................13
HDE15_D38
Did you have an episode of being sad, discouraged, uninterested with some of the other problems (on pages 5-6) lasting
two weeks or longer at any time in the past 12 months?
Yes ...........................................................................................................1
No.............................................................................................................5 (GO TO HDE17_D38c)
DK............................................................................................................ (GO TO HDE17_D38c)
RF............................................................................................................. (GO TO HDE17_D38c)
HDE15a_D38a
How recently – in the past month, two to six months ago, or more than six months ago?
Past Month ...............................................................................................1
2-6 Months Ago .......................................................................................2
More Than 6 months Ago ........................................................................3
DK............................................................................................................
RF.............................................................................................................
HDE16_D38b.
About how many days out of the last 365 were you in an episode?
♦ ENTER number of days____________ .................. (GO TO HDE18_D88)
DK............................................................................... (GO TO HDE18_D88)
RF................................................................................ (GO TO HDE18_D88)
MTO Adult Qnaire
8
Page A-113
Revised 08/07/07
HDE17_D38c
How old were you the last time you had one of these episodes?
♦ ENTER age___________________________
DK............................................................................................................
RF.............................................................................................................
HDE18_D88
INTERVIEWER CHECKPOINT (SEE HSC1_SC20, HSC2_SC20a, HSC9_SC24, HSC11_SC25a, HSC12_SC26,
HSC13_SC26a, HSC14_SC26b):
♦ INTERVIEWER: FOLLOW SKIP FOR FIRST ENDORSED ITEM.
HSC9_SC24 Equals ‘1’.................................................................. 1 (GO TO HMA1_M1)
HSC11_SC25a Equals ‘1’.............................................................. 2 (GO TO HMA5_M5)
HSC1_SC20 Equals ‘1’ ..................................................................... 3 (GO TO HPD1_PD1_INTRO 1)
HSC2_SC20a Equals ‘1’ ................................................................... 4 (GO TO HPD1_PD1_INTRO 2)
HSC12_SC26 Equals ‘1’ ................................................................... 5 (GO TO HGA1_G1_INTRO 1)
HSC13_SC26a Equals‘1’ .................................................................. 6 (GO TO HGA1_G1_INTRO 2)
HSC14_SC26b Equals ‘1’ ................................................................. 7 (GO TO HGA1_G1_INTRO 3)
ALL OTHERS................................................................................... 8 (GO TO CHECKPOINT HIE1)
MTO Adult Qnaire
9
Page A-114
Revised 08/07/07
A_Section 14: MANIA (HMA)
HMA1_M1
Earlier in the interview you mentioned having an episode lasting four days or longer when you felt much more excited
and full of energy than usual and your mind went too fast. People who have episodes like this often have changes in their
thinking and behavior at the same time, like being more talkative, needing very little sleep, being very restless, going on
buying sprees, and behaving in ways they would normally think are inappropriate. Did you ever have any of these
changes during your episodes of being excited and full of energy?
♦ INTERVIEWER: READ SLOWLY
Yes ....................................................................1 (GO TO HMA2_M3)
No......................................................................5 (GO TO CHECKPOINT HMA1a)
DK..................................................................... (GO TO CHECKPOINT HMA1a)
RF ..................................................................... (GO TO CHECKPOINT HMA1a)
HMA1a. INTERVIEWER CHECKPOINT (SEE HCS10a_SC25a)
HSC10a_SC25a IS CODED 1 ...................... 1 (GO TO HM4_M5)
ALL OTHERS............................................... 2 (GO TO HM15_M54)
HMA2_M3
Please think of the one episode when you were very excited and full of energy and you had the largest number of changes
like these at the same time. Is there one episode of this sort that stands out in your mind?
Yes ....................................................................1
No......................................................................5 (GO TO HMA2d_M3c)
DK..................................................................... (GO TO HMA2d_M3c)
RF ..................................................................... (GO TO HMA2d_M3c)
HMA2a_M3a
How old were you when that episode occurred?
♦ ENTER age________________
DK.....................................................................
RF .....................................................................
HMA2b_M3b
How long did that episode last?
♦ ENTER length of duration_____________________
DK..................................................................... (GO TO HMA2d_M3c)
RF ..................................................................... (GO TO HMA2d_M3c)
MTO Adult Qnaire
1
Page A-115
Revised 08/07/07
HMA2c_M3b
♦ ENTER unit of time__________________
Hours.................................................................1
Days ..................................................................2
Weeks ...............................................................3
Months ..............................................................4
Years .................................................................5
DK..................................................................... (GO TO HMA3_M4)
RF ..................................................................... (GO TO HMA3_M4)
HMA2d_M3c
Then think of the most recent time you had an episode like this. How old were you when that most recent episode
occurred?
♦ ENTER age___________________
DK.....................................................................
RF .....................................................................
HMA2e_M3d
How long did that episode last?
♦ ENTER length of duration________________________
DK..................................................................... (GO TO HMA3_M4)
RF ..................................................................... (GO TO HMA3_M4)
HMA2f_M3d
♦ ENTER unit of time
Hours.................................................................1
Days ..................................................................2
Weeks ...............................................................3
Months ..............................................................4
Years .................................................................5
HMA3_M4
During that episode, which of the following behavior changes did you experience: were you so irritable or grouchy that you
started arguments, shouted at people, or hit people?
Yes ....................................................................1
No......................................................................5
DK.....................................................................
RF .....................................................................
(GO TO HMA7a_M7a)
MTO Adult Qnaire
2
Page A-116
Revised 08/07/07
HMA4_M5
Earlier in the interview you mentioned having episodes lasting four days or longer when you became so irritable or
grouchy that you started arguments, shouted at people, or hit people. People who have episodes of irritability like this
often have changes in their thinking and behavior at the same time, like being more talkative, needing very little sleep,
being very restless, going on buying sprees and behaving in ways they would normally think are inappropriate. Did you
ever have any of these changes during your episodes of being very irritable or grouchy?
♦ INTERVIEWER: READ SLOWLY
Yes ....................................................................1
No......................................................................5 (GO TO HMA15_M54)
DK..................................................................... (GO TO HMA15_M54)
RF ..................................................................... (GO TO HMA15_M54)
HMA5_M6
Please think of the episode of four days or more when you were very irritable or grouchy and you had the largest number of
changes like these at the same time. Is there one episode of this sort that stands out in your mind?
Yes ....................................................................1
No......................................................................5 (GO TO HMA6d_M6c)
DK..................................................................... (GO TO HMA6d_M6c)
RF ..................................................................... (GO TO HMA6d_M6c)
HMA6a_M6a
How old were you when that episode occurred?
♦ ENTER age_______________________
DK.....................................................................
RF .....................................................................
HMA6b_M6b
How long did that episode last?
♦ ENTER length of duration_________________________
DK..................................................................... (GO TO HMA7a_M7a)
RF ..................................................................... (GO TO HMA7a_M7a)
HMA6c_M6b
♦ ENTER unit of time
Hours.................................................................1
Days ..................................................................2
Weeks ...............................................................3
Months ..............................................................4
Years .................................................................5
DK
RF
(GO TO HMA7a_M7a)
MTO Adult Qnaire
3
Page A-117
Revised 08/07/07
HMA6d_M6c
Then think of the most recent time you had an episode like this. How old were you when that most recent episode
occurred?
♦ ENTER age_________________________
DK.....................................................................
RF .....................................................................
HMA6e_M6d
How long did that episode last?
♦ ENTER length of duration________________________
DK..................................................................... (GO TO HMA7a_M7a)
RF ..................................................................... (GO TO HMA7a_M7a)
HMA6f_M6d
♦ ENTER unit of time
Hours.................................................................1
Days ..................................................................2
Weeks ...............................................................3
Months ..............................................................4
Years .................................................................5
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
HMA7a_M7a.
During that episode, which of the following changes did you experience:
Did you become so restless or fidgety that you paced up and down or couldn’t
stand still?
(KEY PHRASE: being restless)
HMA7b_M7b.
Were you a lot more interested in sex than usual, or did you want to have sexual
encounters with people you wouldn’t ordinarily be interested in?
(KEY PHRASE: having a lot more interest in sex than usual)
HMA7c_M7c.
Did you become overly friendly or outgoing with people?
MTO Adult Qnaire
4
Page A-118
Revised 08/07/07
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
HMA7d_M7d.
(During that episode, which of the following changes did you experience:)
Did you do anything else that wasn’t usual for you - - like talking about things you
would normally keep private, or acting in ways that you’d usually find
embarrassing?
(KEY PHRASE: behaving inappropriately)
HMA7e_M7e.
Did you try to do things that were impossible to do, like taking on large amounts
of work?
(KEY PHRASE: trying to accomplish unrealistic goals)
HMA7f_M7f.
Did you talk a lot more than usual or feel a need to keep talking all the time?
(KEY PHRASE: talking a lot more than usual)
HMA7g_M7g.
Did you constantly keep changing your plans or activities?
(KEY PHRASE: constantly changing plans)
HMA7h_M7h.
Did you find it hard to keep your mind on what you were doing?
(KEY PHRASE: hard to keep your mind on things)
HMA7i_M7i.
Did your thoughts seem to jump from one thing to another or race through your
head so fast you couldn’t keep track of them?
(KEY PHRASE: thoughts racing)
HMA7j_M7j.
Did you sleep far less than usual and still not get tired or sleepy?
(KEY PHRASE: sleeping far less than usual)
HMA7k_M7k.
Did you get involved in foolish investments or schemes for making money?
(KEY PHRASE: getting involved in foolish schemes)
HMA7l_M7l.
Did you spend so much more money than usual that it caused you to have
financial trouble?
(KEY PHRASE: getting into financial trouble)
MTO Adult Qnaire
5
Page A-119
Revised 08/07/07
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
HMA7m_M7m.
(During that episode, which of the following changes did you experience:)
Did you do reckless things like driving too fast, staying out all night, or having
casual or unsafe sex?
(KEY PHRASE: doing risky things)
HMA7n_M7n.
Did you have a greatly exaggerated sense of self-confidence or believe you could
do things you really couldn’t do?
(KEY PHRASE: having too much self-confidence)
HMA7o_M7o.
Did you have the idea that you were actually someone else, or that you had a
special connection with a famous person that you really didn’t have?
(KEY PHRASE: believing you were someone else or somehow connected to
a famous person)
HMA8_M8 (See HMA7a_M7a – HMA7o_M7o)
THREE OR MORE RESPONSES CODED ‘1’ (YES) ..... …..1
ALL OTHERS.................................................................... ….. 2 (GO TO HMA15_M54)
HMA9_M9
Let me review. You had episodes when you were very (excited and full of energy/irritable or grouchy) and also had
some problems like (KEY PHRASE OF 3 “YES” RESPONSES IN HM7 SERIES). How much did these episodes ever
interfere with either your work, your social life, or your personal relationships – not at all, a little, some, a lot, or
extremely?
Not at all............................................................................. 1 (GO TO HMA15_M54)
A Little ............................................................................... 2 (GO TO HMA15_M54)
Some................................................................................... 3
A Lot .................................................................................. 4
Extremely ........................................................................... 5
DK...........................................................................................
RF ...........................................................................................
HMA10_M9b
Did other people say anything or worry about the way you were acting?
Yes ....................................................................1
No......................................................................5
DK...........................................................................................
RF ...........................................................................................
MTO Adult Qnaire
6
Page A-120
Revised 08/07/07
HMA11_M18
Think of the very first time in your life you had an episode lasting four days or longer when you became very
(excited and full of energy/irritable or grouchy) and also had some of the behavior changes you just reported. Can you
remember your exact age?
Yes ....................................................................1
No......................................................................5 (GO TO HMA11b_M18b)
DK..................................................................... (GO TO HMA11b_M18b)
RF ..................................................................... (GO TO HMA11b_M18b)
HMA11a_M18a
(How old were you?)
♦ ENTER age ________________
(GO TO HMA12_M19)
DK.................................... (GO TO HMA12_M19)
RF..................................... (GO TO HMA12_M19)
HMA11b_M18b
About how old were you the first time you had an episode of this sort?
♦ INTERVIEWER: IF “ALL MY LIFE” OR “AS LONG AS I CAN REMEMBER,”
PROBE: Was it before you first started school?
IF NOT YES, PROBE: Was it before you were a teenager?
♦ ENTER age________________________
Before Started School......................................................... 4
Before Teenager ................................................................. 12
Not Before Teenager .......................................................... 13
HMA12_M19
Did you have one of these episodes at any time in the past 12 months?
Yes ..................................................................................... 1
No....................................................................................... 5 (GO TO HMA14_M9d)
DK...................................................................................... (GO TO HMA14_M9d)
RF....................................................................................... (GO TO HMA14_M9d)
HMA13_M19c
How many weeks in the past 12 months were you in one of these episodes?
♦ ENTER number of weeks________________________(GO TO HMA15_M54)
DK...................................................................................... (GO TO HMA15_M54)
RF....................................................................................... (GO TO HMA15_M54)
MTO Adult Qnaire
7
Page A-121
Revised 08/07/07
HMA14_M19d
How old were you the last time you had one of these episodes?
♦ ENTER age________________________
DK
RF
CHECKPOINT_HMA15_M54 (See HSC1_SC20, HSC2_SC20a, HSC12_SC26, HSC12a_SC26a,
HSC12b_SC26b)
♦ FOLLOW SKIP FOR FIRST ENDORSED ITEM.
HSC1_SC20 Equals ‘1’ ...........................................................................1 (GO TO HPD1a_PD1 INTRO 1)
HSC2_SC20a Equals ‘1’ .........................................................................2 (GO TO HPD1b_PD1 INTRO 2)
HSC12_SC26 Equals ‘1’ .........................................................................6 (GO TO HG1a_G1 INTRO 1)
HSC12a_SC26a Equals ‘1’ .....................................................................7 (GO TO HG1b_G1 INTRO 2)
HSC12b_SC26b Equals ‘1’.....................................................................8 (GO TO HG1c_G1 INTRO 3)
ALL OTHERS ........................................................................................9 (GO TO CHECKPOINT HIED1)
MTO Adult Qnaire
8
Page A-122
Revised 08/06/07
A_Section 15: PANIC DISORDER (HPD)
HPD1_PD1_INTRO 1
Earlier you mentioned having attacks of fear or panic
when all of a sudden you felt very frightened, anxious,
or uneasy. Think of a bad attack like that. During that
attack, which of the following problems did you have?
HPD1_PD1_INTRO 2
Earlier you mentioned having attacks when all of a sudden
you had several problems like being short of breath, your
heart pounding or feeling dizzy, and being afraid you would
die or go crazy. Think of a bad attack like that. During that
attack, which of the following problems did you have?
SKIP TO HPD2 AFTER FOUR “YES” RESPONSES
HPD1a_PD1a.
Did your heart pound or race?
(KEY PHRASE: heart racing)
HPD1b_PD1b.
Were you short of breath?
(KEY PHRASE: being short of breath)
HPD1c_PD1c.
Did you have nausea or discomfort in your stomach?
(KEY PHRASE: having nausea)
HPD1d_PD1d.
Did you feel dizzy or faint?
(KEY PHRASE: feeling dizzy)
HPD1e_PD1e.
Did you sweat?
(KEY PHRASE: sweating)
HPD1f_PD1f.
Did you tremble or shake?
(KEY PHRASE: trembling)
HPD1g_PD1g.
Did you have a dry mouth?
(KEY PHRASE: having a dry mouth)
HPD1h_PD1h.
Did you feel like you were choking?
(KEY PHRASE: choking)
HPD1i_PD1i.
Did you have pain or discomfort in your chest?
(KEY PHRASE: having discomfort in your chest)
HPD1j_PD1j.
Were you afraid that you might lose control of yourself or go crazy?
(KEY PHRASE: fearing that you might lose control of yourself)
MTO Adult Qnaire
1
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
Page A-123
Revised 08/06/07
HPD1k_PD1k.
Did you feel that you were “not really there”, like you were watching a movie
of yourself?
(KEY PHRASE: feeling unreal)
HPD1l_PD1l.
Did you feel that things around you were unreal or like a dream?
(KEY PHRASE: feeling that things around you were unreal)
HPD1m_PD1m.
Were you afraid that you might pass out?
(KEY PHRASE: fearing that you might pass out)
HPD1n_PD1n.
Were you afraid that you might die?
(KEY PHRASE: fearing that you might die)
HPD1o_PD1o.
Did you have hot flushes or chills?
(KEY PHRASE: having hot flushes)
HPD1p_PD1p.
Did you have numbness or tingling sensations?
(KEY PHRASE: having numbness)
1
GO TO
HPD1_P
D1m
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
HPD2_PD2 (See HPD1_PD1 SERIES)
COUNT OF # “YES” RESPONSES: ___________
SKIP INSTRUCTION:
ZERO TO THREE RESPONSES.......................................... 1(GO TO HPD17_PD66)
ALL OTHERS ....................................................................... 2
HPD3_PD3
During your attacks did the problems like (PARENTHETICAL PHRASE OF FIRST THREE YES RESPONSES IN HPD1
SERIES) begin suddenly and reach their peak within ten minutes after the attacks began?
(♦IF NECESSARY ASK: Did they begin within ten minutes after the start of the attack?)
Yes .................................................. 1
(IF VOL)Sometimes ....................... 3
No ................................................... 5
MTO Adult Qnaire
2
Page A-124
Revised 08/06/07
HPD4_PD4
About how many of these sudden attacks have you had in your entire lifetime?
♦ ENTER number of attacks_____________________
If R Reports More Than 900.................................................. 900
If R Reports “More Than I Can Remember ........................... 995
DK ...................................................................................
RF ....................................................................................
CHECKPOINT (HPD5)
HPD4_PD4 Equals ‘1’ ................................. 1
ALL OTHERS............................................. 2
(GO TO HPD17_PD66)
(GO TO HPD5_PD9)
HPD5_PD9
Can you remember your exact age the very first time you had one of these attacks?
Yes .................................................. 1
No ................................................... 5 (GO TO HPD5b_PD9b)
DK .................................................. (GO TO HPD5b _PD9b)
RF ................................................... (GO TO HPD5b _PD9b)
HPD5a_PD9a
(♦ INTERVIEWER: IF NECESSARY: How old were you?)
♦ ENTER age __________________________
(GO TO HPD6_PD10)
HPD5b_PD9b
About how old were you?
♦ INTERVIEWER: IF “ALL MY LIFE” OR “AS LONG AS I CAN REMEMBE,”
PROBE: Was it before you first started school?
IF NOT YES, PROBE: Was it before you were a teenager?
♦ ENTER age_______________________
Before Started School ..................................................4
Before Teenager...........................................................12
Not Before Teenager....................................................13
MTO Adult Qnaire
3
Page A-125
Revised 08/06/07
HPD6_PD10
Did you have one of these attacks at any time in the past 12 months?
Yes...................................................................................1
No ....................................................................................5 (GO TO HPD6d_PD10d)
DK ................................................................................... (GO TO HPD6d _PD10d)
RF .................................................................................... (GO TO HPD7a_PD13a)
HPD6a_PD10a
How recently – in the past month, between two and six months ago, or more than six months ago?
Past Month.......................................................................1
Between two and six months ago ...................................2
More than six months ago...............................................3
DK ...................................................................................
RF ....................................................................................
HPD6b_PD10b
How many weeks in the past 12 months did you have at least one attack?
♦ ENTER number of weeks________________________
DK ...................................................................................
RF ....................................................................................
HPD6c_PD10c
And how many attacks in all did you have in the past 12 months?
♦ ENTER number of attacks________________________ (GO TO HPD7a_PD13a)
DK ...............................................................................(GO TO HPD7a _PD13a)
RF ................................................................................(GO TO HPD7a _PD13a)
HPD6d_PD10d
How old were you the last time you had one of these attacks?
♦ ENTER age____________________
DK ...................................................................................
RF ....................................................................................
MTO Adult Qnaire
4
Page A-126
Revised 08/06/07
HPD7_PD13.
After having one of these attacks, did you ever have any of the following
Experiences:
HPD7a_PD13a.
A month or more when you often worried that you might have another
attack?
HPD7b_PD13b.
A month or more when you worried that something terrible might happen
because of the attacks, like having a car accident, having a heart attack, or
losing control?
HPD7c_PD13c.
A month or more when you changed your everyday activities because of the
attacks?
HPD7d_PD13d.
A month or more when you avoided certain situations because of fear about
having another attack?
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
5
8
9
5
8
9
5
8
9
GO TO HPD8
_PD17
1
GO TO HPD8
_PD17
1
GO TO HPD8
_PD17
1
GO TO HPD8
__PD17
HPD8_PD17
Attacks of this sort can occur in three different situations. The first is when the attacks occur unexpectedly “out of the
blue.” The second is when a person has an unreasonably strong fear. For example, some people have a terrible fear of
bugs or of heights or of being in a crowd. The third is when a person is in real danger, like a car accident or a bank robbery.
The next question is about how many of your attacks occurred in each of these three kinds of situations. Did you ever have
an attack that occurred unexpectedly “out of the blue?”
Yes...................................................................................1
No ....................................................................................5 (GO TO HPD9_PD18)
DK ................................................................................... (GO TO HPD9_PD18)
RF .................................................................................... (GO TO HPD9_PD18)
HPD8a_PD17a
About how many attacks in your lifetime occurred unexpectedly “out of the blue?”
♦ ENTER number of attacks______________________
If R Reports More Than 900.................................................. 900
If R Reports “More Than I Can Remember” ...............995
DK ...................................................................................
RF ....................................................................................
HPD9_PD18
About how many attacks in your lifetime occurred in situations where you were not in real danger, but where you had an
unreasonably strong fear of the situations?
♦ ENTER number of attacks______________________________
If R Reports More Than 900.................................................. 900
If R Reports “More Than I Can Remember” ...............995
DK ...................................................................................
RF ....................................................................................
MTO Adult Qnaire
5
Page A-127
Revised 08/06/07
HPD10_PD19
About how many attacks in your lifetime occurred in situations where you were in real danger?
♦ INTERVIEWER: IF R THOUGHT THERE WAS REAL DANGER EVEN THOUGH IT TURNED OUT NOT
TO BE DANGEROUS CODE “REAL DANGER.”
♦ ENTER number of attacks________________________
If R Reports More Than 900.................................................. 900
If R Reports “More Than I Can Remember” ...............995
DK ...................................................................................
RF ....................................................................................
CHECKPOINT (PD20)
HPD8_PD17 Equals ‘1’ ..............................................1 (GO TO HPD11_PD20a)
ALL OTHERS............................................................2 (GO TO HPD17_PD66)
HPD11_PD20a (See HPD9_PD18 – HPD10_PD19)
(HPD9_PD18 Equals ‘0’) AND (HPD10_PD19 Equals ‘0’) ................ 1(GO TO HPD13_PD22)
ALL OTHERS........................................................................................ 2 (GO TO HPD12_PD21)
HPD12_PD21
How old were you (when you had the attack/the first time you had an attack) “out of the blue” for no obvious reason?
♦ INTERVIEWER: IF “ALL MY LIFE” OR “AS LONG AS I CAN REMEMBER,”
PROBE: Was it before you first started school?
IF NOT YES, PROBE: Was it before you were a teenager?
♦ ENTER age _________
Before Started School ..................................................4
Before Teenager...........................................................12
Not Before Teenager....................................................13
DK ...................................................................................
RF ....................................................................................
HPD13_PD22
How much did (this/these) unexpected “out of the blue” attack(s) or worry about having another attack ever interfere with
either your work, your social life, or your personal relationships – not at all, a little, some, a lot, or extremely?
Not at All .....................................................................1
A Little.........................................................................2
Some ............................................................................3
A Lot............................................................................4
Extremely.....................................................................5
DK ...................................................................................
RF ....................................................................................
MTO Adult Qnaire
6
Page A-128
Revised 08/06/07
CHECKPOINT (PD33)
HPD11_PD20a Equals ‘1’ ..........................................1 (GO TO HPD17_PD66)
ALL OTHERS............................................................2 (GO TO NEXT CHECKPOINT (PD35))
CHECKPOINT (PD35)
HPD6_PD10 Equals ‘1’ ..............................................1 (GO TO HPD14_PD36)
ALL OTHERS............................................................2 (GO TO HPD17_PD66)
HPD14_PD36
How many unexpected “out of the blue” attacks did you have in the past 12 months?
♦ ENTER number of attacks____________________________
DK ...................................................................................
RF ....................................................................................
CHECKPOINT (PD37)
HPD14_PD36 Equals “0”, “DK” or “RF” ..................1
HPD14_PD36 Equals “1” ...........................................2 (GO TO HPD16_PD38)
ALL OTHERS............................................................3 (GO TO HPD15b_PD37b)
HPD15a_PD37a
How old were you the last time you had an unexpected “out of the blue” attack?
♦ ENTER age ________________________
DK ...................................................................................
RF ....................................................................................
(GO TO HPD17_PD66)
HPD15b_PD37b
About how many weeks in the past 12 months did you have at least one of these attacks?
♦ ENTER number of weeks ___________________________
DK ...................................................................................
RF ....................................................................................
HPD16_PD38
How recently – in the past month, between two and six months ago, or more than six months ago?
Past Month.......................................................................1
Between two and six months ago ...................................2
More than six months ago...............................................3
DK ...................................................................................
RF ....................................................................................
MTO Adult Qnaire
7
Page A-129
Revised 08/06/07
HPD17_PD66 (See HSC12_SC26, HSC13_SC26a, HSC14_SC26b):
♦ INTERVIEWER: FOLLOW SKIP FOR FIRST ENDORSED ITEM.
HSC12_SC26 Equals ‘1’..............................................................................4 (GO TO HGA1_G1 INTRO 1)
HSC13_SC26a Equals ‘1’ ...........................................................................5 (GO TO HGA1_G1 INTRO 2)
HSC14_SC26b Equals ‘1’ ...........................................................................6 (GO TO HGA1_G1 INTRO 3)
ALL OTHERS.............................................................................................7 (GO TO HIE1_IED1)
MTO Adult Qnaire
8
Page A-130
Revised 08/07/07
A_Section 16: GENERALIZED ANXIETY DISORDER SECTION (HGA)
HGA1_G1_INTRO 1.
(RB)
Earlier you mentioned having a time in
your life when you were "a worrier".
The next questions are about that time.
Looking at your
booklet, what sorts of things were you
worried or nervous or anxious about
during that time?
HGA1_G1_INTRO 2.
(RB)
Earlier you mentioned having a time in
your life when you were much more
nervous or anxious than most other
people. The next questions are about
that time. Looking at your booklet,
what sorts of things were you nervous
or anxious about during that time?
HGA1_G1_INTRO 3.
(RB)
Earlier you mentioned having a period
lasting one month or longer when you
were anxious or worried most days.
The next questions are about that time.
Looking at your
booklet, what sorts of things were you
anxious or worried about during that
time?
PROBE FOR UP TO THREE EXAMPLES: Anything else [that made you (worried or anxious/nervous or
anxious/anxious or worried)]?
CIRCLE ALL MENTIONS.
DIFFUSE WORRIES
EVERYTHING .......................................................................................................................... 1
NOTHING IN PARTICULAR .................................................................................................. 2
PERSONAL PROBLEMS
FINANCES................................................................................................................................. 3
SUCCESS AT SCHOOL OR WORK ....................................................................................... 4
SOCIAL LIFE............................................................................................................................. 5
LOVE LIFE ................................................................................................................................ 6
RELATIONSHIPS AT SCHOOL OR WORK ......................................................................... 7
RELATIONSHIPS WITH FAMILY......................................................................................... 8
PHYSICAL APPEARANCE ..................................................................................................... 9
PHYSICAL HEALTH................................................................................................................ 10
MENTAL HEALTH .................................................................................................................. 11
SUBSTANCE USE .................................................................................................................... 12
OTHER PERSONAL PROBLEMS (SPECIFY) ...................................................................... 13
PHOBIC AND OBSESSIVE-COMPULSIVE SITUATIONS
SOCIAL PHOBIAS
(E.G., MEETING PEOPLE AFTER MOVING TO A NEW TOWN) ............................ 14
AGORAPHOBIA (E.G., LEAVING HOME ALONE AFTER A DIVORCE)....................... 15
SPECIFIC PHOBIAS
(E.G., FEARS OF BUGS, HEIGHTS, OR CLOSED SPACES)...................................... 16
OBSESSIONS (E.G., WORRY ABOUT GERMS).................................................................. 17
COMPULSIONS (E.G., REPETITIVE HANDWASHING) ................................................... 18
NETWORK PROBLEMS
BEING AWAY FROM HOME OR APART FROM LOVED ONES..................................... 19
THE HEALTH OR WELFARE OF LOVED ONES - FIRST MENTION ............................. 20
THE HEALTH OR WELFARE OF LOVED ONES - SECOND MENTION ........................ 21
THE HEALTH OR WELFARE OF LOVED ONES - THIRD MENTION............................ 22
OTHER NETWORK PROBLEMS (SPECIFY) ....................................................................... 23
MTO Adult Qnaire
Page A-131
Revised 08/07/07
SOCIETAL PROBLEMS
CRIME / VIOLENCE ................................................................................................................ 24
THE ECONOMY ...................................................................................................................... 25
THE ENVIRONMENT (E.G., GLOBAL WARMING, POLLUTION).................................. 26
MORAL DECLINE OF SOCIETY
(E.G., COMMERCIALISM, DECLINE OF THE FAMILY) .......................................... 27
WAR / REVOLUTION.............................................................................................................. 28
OTHER SOCIETAL PROBLEMS (SPECIFY)........................................................................ 29
OTHER PROBLEMS (SPECIFY)
FIRST (SPECIFY)..................................................................................................................... 30
SECOND (SPECIFY)................................................................................................................ 31
THIRD (SPECIFY) ............................................................................................................. 32
HGA2_G3.
Do you think your (worry or anxiety/nervousness or anxiety/anxiety or worry) was ever excessive or
unreasonable or a lot stronger than it should have been?
YES .................................... 1
NO ...................................... 5
DK ......................................
RF .......................................
HGA3_G4.
How often did you find it difficult to control your (worry or anxiety/nerves or anxiety/anxiety or worry) -- often,
sometimes, rarely, or never?
OFTEN............................... 1
SOMETIMES .................... 2
RARELY............................ 3
NEVER .............................. 4
DK ......................................
RF .......................................
HGA4_G4a.
How often were you so nervous or worried that you could not think about anything else, no matter how hard you
tried -- often, sometimes, rarely, or never?
OFTEN.......................................1
SOMETIMES ............................2
RARELY....................................3
NEVER ......................................4
DK ..............................................
RF ...............................................
MTO Adult Qnaire
Page A-132
Revised 08/07/07
INTERVIEWER CHECKPOINT: (SEE HGA4, HGA4a)
HGA4 EQUALS ‘1’ OR ‘2’ OR HGA4a EQUALS ‘1’ OR ‘2’....... 1
ALL OTHERS ................................................................................... 2 (GO TO IED1, NEXT
SECTION)
HGA5a_G5.
What is the longest period of months or years in a row you ever had when you were (worried or anxious/nervous
or anxious/anxious or worried) most days?
IF VOL “WHOLE LIFE” OR “AS LONG AS I CAN REMEMBER,”
CODE 995 YEARS
PROBE DK: Did you ever have a period that lasted 6 months or longer?
(IF NOT) Did you ever have a period that lasted 1 month or longer?
___________
NUMBER
DK ......................................
RF .......................................
HGA5b_G5.
CIRCLE UNIT OF TIME: MONTHS…1
YEARS…2
CHECKPOINT_HGA6_G6.
INTERVIEWER CHECKPOINT: (SEE HGA5)
LESS THAN 1 MONTH............................................ 1
1 TO 5 MONTHS ....................................................... 2
ALL OTHERS ............................................................ 3
GO TO IED1, NEXT SECTION
GO TO CHECKPOINT_HGA7_G7
GO TO CHECKPOINT_HGA8_G8
CHECKPOINT_ HGA7_G7.
INTERVIEWER INSTRUCTION: ASK ABOUT “PERIODS LASTING ONE MONTH OR LONGER” FOR
THE REMAINDER OF THE SECTION
(GO TO HGA7_G9)
CHECKPOINT_ HGA8_G8.
INTERVIEWER INSTRUCTION: ASK ABOUT “PERIODS LASTING SIX MONTHS OR LONGER” FOR
THE REMAINDER OF THE SECTION
(GO TO HGA7_G9)
MTO Adult Qnaire
Page A-133
Revised 08/07/07
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
HGA7b_G9b.
Did you often get tired easily?
1
5
8
9
HGA 7c_G9c.
Were you often more irritable than usual?
1
5
8
9
1
5
8
9
HGA7e_G9e.
Did you often have tense, sore, or aching muscles?
1
5
8
9
HGA7f_G9f.
Did you often have trouble falling or staying asleep?
1
5
8
9
YES
(1)
NO
(5)
DK
(8)
RF
(9)
HGA8a_G10a.
Did your heart often pound or race?
1
5
8
9
HGA8b_G10b.
Did you often sweat?
1
5
8
9
HGA8c_G10c.
Did you often tremble or shake?
1
5
8
9
HGA8d_G10d.
Did you often have a dry mouth?
1
5
8
9
HGA8e_G10e.
Were you sad or depressed most of the time?
1
5
8
9
HGA7a_G9a.
Think of your worst period lasting (one month / six months) or longer when you
were (worried or anxious/nervous or anxious/anxious or worried): During that
episode, did you often have any of the following associated problems:
Did you often feel restless, keyed up, or on edge?
HGA 7d_G9d.
Did you often have difficulty concentrating or keeping your mind on what you
were doing?
CHECKPOINT_ HGA9_G11.
INTERVIEWER CHECKPOINT: (SEEH HGA7, HGA8)
ZERO RESPONSES CODED ‘1’ IN HGA7 AND HGA8 SERIES ........................ 1 GO TO IED1, NEXT
SECTION
ZERO RESPONSES CODED ‘1’ IN HGA8 SERIES .............................................. 2 GO TO
CHECKPOINT_ HGA14
FOUR OR MORE RESPONSES CODED ‘1’ IN HGA7 AND HGA8 SERIES .... 3 GO TO HGA11
ALL OTHERS ........................................................................................................... 4 GO TO HGA10
MTO Adult Qnaire
Page A-134
Revised 08/07/07
CHECKPOINT_ HGA9_G12.
INTERVIEWER CHECKPOINT: (SEE HGA7)
TWO OR MORE RESPONSES CODED ‘1’ IN HGA7 SERIES ......1
GO TO HGA11
ALL OTHERS .....................................................................................2
GO TO IED1, NEXT
SECTION
HGA10.
INTERVIEWER QUERY: TOTAL NUMBER RESPONSES
CODED ‘1’ IN HGA7SERIES IS __________
YES
(1)
NO
(5)
DK
(8)
RF
(9)
CODED ‘1’ IN HGA8 SERIES IS __________
GO TO HGA11 AS SOON AS FIVE RESPONSES CODED ‘1’ IN
HGA7, HGA8, HGA10 SERIES
HGA10a_G13a.
Did you often feel dizzy or lightheaded?
1
5
8
9
HGA10b_G13b.
Were you often short of breath?
1
5
8
9
HGA10c_G13c.
Did you often feel like you were choking?
1
5
8
9
HGA10d_G13d.
Did you often have pain or discomfort in your chest?
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
HGA10e_G13e.
Did you often have pain or discomfort in your stomach?
GO TO
HGA10g_G13g
HGA10f_G13f.
Did you often have nausea?
HGA10g_G13g.
Did you often feel that you were unreal?
GO TO HGA10i
_G13i
HGA10h_G13h.
Did you often feel that things around you were unreal?
HGA10i_G13i.
Were you often afraid that you might lose control or go crazy?
GO TO
HGA10k_G13k
HGA10j_G13j.
Were you often afraid that you might pass out?
1
5
8
9
HGA10k_G13k.
Were you often afraid that you might die?
1
5
8
9
1
5
8
9
HGA10l_G13l.
Did you often have hot flushes or chills?
MTO Adult Qnaire
Page A-135
Revised 08/07/07
HGA10m_G13m.
Did you often have numbness or tingling sensations?
1
5
8
9
HGA10n_G13n.
Did you often feel like you had a lump in your throat?
1
5
8
9
1
5
8
9
HGA10o_G13o.
Were you easily startled?
CHECKPOINT_ HGA13_G14.
INTERVIEWER CHECKPOINT: (SEE HGA7, HGA8, HGA10)
TWO OR MORE RESPONSES CODED ‘1’ IN HGA7 SERIES ............................ 1
THREE OR MORE RESPONSES CODED ‘1’ IN HGA7, HGA8, HGA10 SERIES…………2
ALL OTHERS...................................................................................................... 3 (GO TO IED1,
NEXT SECTION)
HGA11_G15.
How much emotional distress did you ever experience because of your (worry or anxiety/nervousness or
anxiety/anxiety or worry) – no distress, mild distress, moderate distress, severe distress, or very severe distress?
NO ...................................... 1
MILD.................................. 2
MODERATE ..................... 3
SEVERE............................. 4
VERY SEVERE ................ 5
DK ......................................
RF .......................................
HGA12_G17.
How much did your (worry or anxiety/nervousness or anxiety/anxiety or worry) ever interfere with either your
work, your social life, or your personal relationships – not at all, a little, some, a lot, or extremely?
NOT AT ALL .................... 1
A LITTLE .......................... 2
SOME................................. 3
A LOT ................................ 4
EXTREMELY ................... 5
DK ......................................
RF .......................................
MTO Adult Qnaire
(GO TO CHECKPOINT_ HGA12)
Page A-136
Revised 08/07/07
HGA12a_G17.
How often were you unable to carry out your daily activities because of your (worry or anxiety/nervousness or
anxiety/anxiety or worry) -- often, sometimes, rarely, or never?
OFTEN............................... 1
SOMETIMES .................... 2
RARELY............................ 3
NEVER .............................. 4
DK
RF
CHECKPOINT_HGA12_G17.
INTERVIEWER CHECKPOINT: (SEE HGA11, HGA12)
HGA11 EQUALS ‘3’, ‘4’, OR ‘5’ OR HGA12 EQUALS ‘3’, ‘4’, OR ‘5’........... 1
ALL OTHERS ........................................................................................................... 2 (GO TO HED1,
NEXT SECTION)
HGA13_G26.
Think of the very first time in your life you had an episode lasting (one month / six months) or longer when
(you were worried or anxious most days/you were nervous or anxious most days/you were anxious or worried
most days) and also had some of the other problems we just reviewed. Can you remember your exact age?
YES ................................................... 1
NO ..................................................... 5
DON’T KNOW ................................ 8
REFUSED......................................... 9
(GO TO HGA13b_G26)
(GO TO HGA13b_G26)
(GO TO HGA13b_G26)
HGA13a_G26a.
(IF NEC: How old were you?)
__________ AGE
(GO TO HGA14_G27)
DON’T KNOW ................. 998
REFUSED.......................... 999
(GO TO HGA14_G27)
(GO TO HGA14_G27)
HGA13b_G26b.
About how old were you?
¾ IF “ALL MY LIFE” OR “AS LONG AS I CAN REMEMBER,”
PROBE: Was it before you first started school?
¾
IF NOT YES, PROBE: Was it before you were a teenager?
__________ YEARS OLD
BEFORE STARTED SCHOOL ..................... 4
BEFORE TEENAGER.................................... 12
NOT BEFORE TEENAGER .......................... 13
WHOLE LIFE OR DON’T KNOW ............... 998
REFUSED........................................................ 999
MTO Adult Qnaire
Page A-137
Revised 08/07/07
HGA14_G27.
Did you have an episode of being (worried or anxious/nervous or anxious/anxious or worried), lasting at least
one month or longer, in the past 12 months?
YES .................................... 1
NO ...................................... 5
DON’T KNOW ................. 8
REFUSED.......................... 9
GO TO HGA14b_G27b)
GO TO HGA14b_G27b)
GO TO HGA14b_G27b)
HGA14b_G27b.
How many months in the past 12 months were you in an episode of this sort?
_________________ MONTHS
DON’T KNOW ................................ 98
REFUSED......................................... 99
(GO TO IED1, NEXT SECTION)
HGA14c_G27c.
How old were you the last time you had one of these episodes?
_____________ YEARS OLD
GO TO IED1, NEXT SECTION
MTO Adult Qnaire
Page A-138
Revised 08/08/07
A_Section 17: INTERMITTENT EXPLOSIVE DISORDER (HIE)
INTERVIEWER CHECKPOINT IED1:
HSC3_SC20.1 IS CODED “1” (YES)......................... 1
GO TO CHECKPOINT IED2
HSC4_SC20.2 IS CODED “1” (YES)......................... 2
GO TO HIE1_IED3 INTRO 4
HSC5_SC20.3 IS CODED “1” (YES)......................... 3
GO TO HIE1_IED3 INTRO 5
ALL OTHERS............................................................. 4
GO TO NEXT SECTION
INTERVIEWER CHECKPOINT IED2:
HSC4_SC20.2 IS CODED “1” (YES)......................... 1
GO TO HIE1_IED3 INTRO 1
HSC5_SC20.3 IS CODED “1” (YES)......................... 2
GO TO HIE1_IED3 INTRO 2
ALL OTHERS............................................................. 3
GO TO HIE1_IED3 INTRO 3
HIE1_IED3.
INTRO 1.
Earlier in the interview
you mentioned having
attacks of anger when
all of a sudden you lost
control and either broke
or smashed something
of value or you hit or
hurt someone. The next
few questions are about
those attacks.
Approximately how
many times in your life
have you had an attack
of this sort, (READ
SLOWLY) when you
lost control and either
broke something, hurt
someone, or threatened
to hurt someone?
HIE1_IED3.
INTRO 2.
Earlier in the interview
you mentioned having
attacks of anger when
all of a sudden you lost
control and either broke
or smashed something
of value or you
threatened to hit or hurt
someone. The next few
questions are about
those attacks.
Approximately how
many times in your life
have you had an attack
of this sort, (READ
SLOWLY) when you
lost control and either
broke something or
threatened to hurt
someone?
HIE1_IED3.
INTRO 3.
Earlier in the
interview you
mentioned having
attacks of anger when
all of a sudden you
lost control and broke
or smashed something
of value. The next few
questions are about
those attacks.
Approximately how
many times in your
life have you had an
attack of this sort,
(READ SLOWLY)
when you lost control
and either broke or
smashed something?
HIE1_IED3.
INTRO 4.
Earlier in the interview
you mentioned having
attacks of anger when
all of a sudden you lost
control and hit or hurt
someone. The next few
questions are about
those attacks.
Approximately how
many times in your life
have you had an attack
of this sort, (READ
SLOWLY) when you
lost control and either
hurt someone or
threatened to hurt
someone?
HIE1_IED3.
INTRO 5.
Earlier in the interview
you mentioned having
attacks of anger when all
of a sudden you lost
control and threatened to
hit or hurt someone. The
next few questions are
about those attacks.
Approximately how many
times in your life have you
had an attack of this sort,
(READ SLOWLY) when
you lost control and
threatened to hurt
someone?
CODE RESPONSES GREATER THAN 9997 AS 9997
______________ ATTACKS
DON’T KNOW............................. 998
REFUSED..................................... 999
MTO Adult Qnaire
Page A-139
Revised 08/08/07
INTERVIEWER CHECKPOINT IED4.:
HIED1_IED3 EQUALS ‘0’-‘2’ .................................. 1
ALL OTHERS............................................................. 2
GO TO NEXT SECTION
HIE2_IED5.
Did these anger attacks sometimes occur without a good reason?
YES .................................. 1
NO.................................... 5
DK
RF
GO TO HIE4_IED6
HIE3_IED5a.
Did the attacks sometimes occur in situations where most people would not have had an anger attack?
YES..........................................1
NO ...........................................5
DK
RF
GO TO HIE4_IED6
HIE3a_IED5b.
During those attacks, did you sometimes get a lot more angry than most people would have been in the
same situation.
YES..........................................1
NO ...........................................5
DON’T KNOW .......................8
REFUSED ...............................9
GO TO NEXT SECTION
GO TO NEXT SECTION
GO TO NEXT SECTION
HIE4_IED6.
Did you have times before these attacks when you felt such a strong impulse to let loose or blow-up that you
couldn't resist it no matter how hard you tried?
YES .................................. 1
NO.................................... 5
DK
RF
HIE5_IED7.
How often was your anger out of control during your typical attacks -- all of the time, most of the time,
sometimes, rarely, or never?
ALL OF THE TIME ................................. 1
MOST OF THE TIME .............................. 2
SOMETIMES............................................ 3
RARELY................................................... 4
NEVER .................................................... 5
DK
RF
MTO Adult Qnaire
Page A-140
Revised 08/08/07
INTERVIEWER CHECKPOINT IED8.
HIE4_IED6 EQUALS ‘1’........................................... 1
HIE5_IED7 EQUALS ‘1’-‘4’ .................................... 2
ALL OTHERS............................................................. 3
GO TO NEXT SECTION
HIE6_IED9.
Some people only have anger attacks when they drink alcohol or use drugs. Did your anger attacks usually
occur when you had been drinking or using drugs?
YES .................................. 1
NO.................................... 5
DON’T KNOW ............... 8
REFUSED ....................... 9
GO TO HIE7_IED11
GO TO HIE7_IED11
GO TO HIE7_IED11
HIE6a_IED9a.
Did you ever have anger attacks when you had not been drinking or using drugs?
YES............................................... 1
NO ................................................ 5
DON’T KNOW ............................ 8
REFUSED .................................... 9
GO TO NEXT SECTION
GO TO NEXT SECTION
GO TO NEXT SECTION
HIE7_IED11.
Some people only have anger attacks when they are sad or depressed. Did your anger attacks usually occur
during periods of time when you were sad or depressed?
YES .................................. 1
NO.................................... 5
DON’T KNOW ............... 8
REFUSED ....................... 9
GO TO CHECKPOINT IED12
GO TO CHECKPOINT IED12
GO TO CHECKPOINT IED12
HIE7a_IED11a.
Did you ever have anger attacks at times you were not sad or depressed?
YES ...................................................1
NO.....................................................5
DK
RF
INTERVIEWER CHECKPOINT IED12.:
HSC3_SC20._ IS CHECKED ................... 1
HSC4_SC20_2 IS CHECKED .................. 2
GO TO HIE9_IED15
ALL OTHERS........................................... 3
GO TO HIE10_IED16
MTO Adult Qnaire
Page A-141
Revised 08/08/07
HIE8_IED13.
Think about all the things you ever damaged or broke during your anger attacks. What is the approximate
combined repair cost or replacement value of all these things?
CODE RESPONSES GREATER THAN $9,997 AS $9,997
$______________
DK
RF
INTERVIEWER CHECKPOINT IED14.
HSC4_SC2_.2 EQUALS ‘1’..................... 1
ALL OTHERS........................................... 2
GO TO HIE10_IED16
HIE9_IED15.
About how many times during your anger attacks did you ever hurt someone badly enough that they needed
medical attention?
CODE RESPONSES GREATER THAN 997 AS 997
______________
DK
RF
TIMES
HIE10_IED16.
How much did your anger attacks ever interfere with either your work, your social life, or your personal
relationships -- not at all, a little, some, a lot, or extremely?
NOT AT ALL ........................................... 1 GO TO HIE11_IED17
A LITTLE ................................................. 2
SOME ....................................................... 3
A LOT ....................................................... 4
EXTREMELY .......................................... 5
DK
RF
HIE11_IED17.
How often did you feel guilty or embarrassed or regretful in the days or weeks after your attacks -- all of the
time, most of the time, sometimes, rarely, or never?
ALL OF THE TIME ................................. 1
MOST OF THE TIME .............................. 2
SOMETIMES............................................ 3
RARELY................................................... 4
NEVER .................................................... 5
DK
RF
MTO Adult Qnaire
Page A-142
Revised 08/08/07
HIE12_IED18.
Think of the very first time in your life you had an anger attack. Can you remember your exact age when that
attack occurred?
YES .................................. 1
NO.................................... 5
DON’T KNOW ............... 8
REFUSED ....................... 9
GO TO HIE12b_IED18b
GO TO HIE12b _IED18b
GO TO HIE12b _IED18b
HIE12a_IED18a.
(IF NEC: How old were you)?
______________ YEARS OLD
GO TO HIE13_IED22
DON’T KNOW...............................998 GO TO HIE13_IED22
REFUSED.......................................999 GO TO HIE13_IED22
HIE12b_IED18b.
About how old were you?
______________ YEARS OLD
IF "ALL MY LIFE" OR "AS LONG AS I CAN REMEMBER,"
PROBE: Was it before you first started school?
IF NO, PROBE: Was it before you were a teenager?
BEFORE STARTED SCHOOL.................................4
BEFORE TEENAGER ..............................................12
NOT BEFORE TEENAGER .....................................13
WHOLE LIFE OR DON’T KNOW...........................998
REFUSED..................................................................999
HIE13_IED22.
How many anger attacks did you have in the past 12 months?
______________ ATTACKS
DK
RF
HIE13a_IED22a.
How old were you the last time you had an anger attack?
______________ YEARS OLD
GO TO NEXT SECTION
DON’T KNOW...............................998 GO TO NEXT SECTION
REFUSED.......................................999 GO TO NEXT SECTION
MTO Adult Qnaire
Page A-143
Revised 08/08/07
HIE14_IED23.
About how many weeks in the past twelve months did you have at least one of these attacks?
______________
DK
RF
WEEKS
HIE15_IED24.
And how many attacks in total did you have during the past twelve months?
CODE RESPONSES GREATER THAN 997 AS 997
______________
DK
RF
ATTACKS
GO TO NEXT SECTION
MTO Adult Qnaire
Page A-144
Revised 08/08/07
A_Section 18: Victimization and PTSD (HCV)
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
HCV8_PT14.
Were you ever badly beaten up by a spouse or romantic partner?
1
5
8
9
HCV9_PT15.
Were you ever badly beaten up by anyone else?
1
5
8
9
HCV10_PT16.
Were you ever mugged, held up, or threatened with a weapon?
1
5
8
9
1
5
8
9
HCV1_PT1. (RB, PG 40)
In the next part of the interview, we ask about very stressful
events that might have happened in our life. First, did you ever
participate in combat, either as a member of a military, or as a
member of an organized non-military group?
HCV2_PT8.
Were you ever involved in a life-threatening automobile
accident?
HCV3_PT9.
Did you ever have any other life-threatening accident, including
on your job?
HCV4_PT10.
Were you ever involved in a major natural disaster, like a
devastating flood, hurricane, or earthquake?
HCV5_PT11.
Were you ever in a man-made disaster, like a fire started by a
cigarette, or a bomb explosion?
HCV6_PT12.
Did you ever have a life-threatening illness?
HCV7_PT13.
As a child, were you ever badly beaten up by your parents or the
people who raised you?
HCV11_PT17.
The next two questions are about sexual assault. The first is
about rape. We define this as someone either having sexual
intercourse with you or penetrating your body with a finger or
object when you did not want them to, either by threatening you
or using force, or when you were so young that you didn’t know
what was happening. Did this ever happen to you?
MTO Adult Qnaire
Page A-145
Revised 08/08/07
HCV12_PT18.
Other than rape, were you ever sexually assaulted, where someone
touched you inappropriately, or when you did not want them to?
HCV13.
Have you ever been chased when you thought the person chasing
you would hurt you?
HCV14.
Have you ever been hit, slapped, punched or beaten up, even if you
were not beaten up very badly?
HCV15.
Has anyone ever stolen your purse, wallet, or snatched your
jewelry?
HCV16.
Did anyone ever try to break into your home?
HCV17_PT20.
Did someone very close to you ever die unexpectedly; for
example, they were killed in an accident, murdered, committed
suicide, or had a fatal heart attack at a young age?
HCV18_PT21.
Did you ever have a son or daughter who had a life-threatening
illness or injury?
HCV19_PT22.
Did anyone very close to you ever have an extremely traumatic
experience, like being kidnapped, tortured or raped?
HCV20_PT22_1
When you were a child, did you ever witness serious physical
fights at home, like when your father beat up your mother?
HCV21_PT23.
Did you ever see someone being badly injured or killed, or
unexpectedly see a dead body?
HCV22_PT27.
Did you ever experience any other extremely traumatic or lifethreatening event that I haven’t asked about yet?
MTO Adult Qnaire
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
GO TO
HCV23
_PT55
GO TO
HCV23
_PT56
GO TO
HCV23
_PT56
GO TO
HCV23
_PT56
Page A-146
Revised 08/08/07
HCV23_PT55a.
Briefly, what was the one most traumatic event that you have not told me about?
REFUSED ...................................9 GO TO CHECKPOINT HCV23_PT56
RECORD BRIEF DESCRIPTION OF EVENT:______________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Descriptor:
HCV23_PT56.
INTERVIEW CHECKPOINT:
R REPORTED ONLY AT LEAST ONE EVENT TYPE,
HCV7_PT13 THROUGH HCV12_PT18........................................................ 1
ALL OTHERS...................................................................................................... 2
GO HCV28a
HCV24.
You said you had been [crime experience]. When was the last time this happened? (Was this within the past 12 months?
Was this within the past 6 months?)
Within the past 6 months.................1
Within the past 12 months...............2
Over a year ago................................3
DON’T KNOW ...............................8
REFUSED .......................................9
HCV25.
Were the police informed, or did they find out about this incident in any way?
YES..................................................1
NO....................................................5
DON’T KNOW ...............................8
REFUSED .......................................9
HCV26.
As far as you know, was anyone arrested or were charges brought against anyone in connection with this incident?
YES..................................................1
NO....................................................5
DON’T KNOW ...............................8
REFUSED .......................................9
MTO Adult Qnaire
Page A-147
Revised 08/08/07
HCV27.
You said you had been [violent crime experience] during the past 12 months. The last time this happened, where did it
happen? (RECORD VERBATIM AND CHECK ALL THAT APPLY)
_____________________________________________
_____________________________________________
_____________________________________________
Inside home......................................1
In someone else’s home ..................2
At school..........................................3
Somewhere else in neighborhood ...4
Outside neighborhood .....................5
Don’t know ......................................8
Refused ............................................9
HCV27a.
The last time this happened, who did this to you?
Parent ...............................................1
Sibling..............................................2
Other relative ...................................3
Best friend........................................4
Classmate.........................................5
Friend/Acquaintance .......................6
Neighbor ..........................................7
Teacher.............................................8
Stranger............................................9
Gang member ..................................10
Police Officer...................................11
Spouse/Partner/girl(boy)friend........12
Other (specify)................................13
Don’t know ......................................98
Refused ............................................99
HCV28a.
Please tell me if any of the following this have happened to
anyone who lived with you during the past 6 months.
Was anyone’s purse, wallet, or jewelry snatched from them?
HCV28b.
Was anyone threatened with a knife or gun?
HCV28c.
Was anyone beaten up or assaulted?
HCV28d.
Was anyone stabbed or shot?
MTO Adult Qnaire
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
Page A-148
Revised 08/08/07
HCV29_PT61.
INTERVIEWER CHECKPOINT:
R REPORTED ONLY ONE EVENT TYPE,
HCV1_PT1 THROUGH HCV22_PT27 OR HCV28a THROUGH HCV28d……………..1
(GO TO HCV29_PT62_INTRO2)
R REPORTED TWO OR THREE EVENT TYPES,
HCV1_PT1 THROUGH HCV22_PT27 OR HCV28a THROUGH HCV28d……………..2
(GO TO HCV29_PT62_INTRO3)
R REPORTED FOUR OR MORE EVENT TYPES,
HCV1_PT1 THROUGH HCV22_PT27 OR HCV28a THROUGH HCV28d……………..2
(GO TO HMH_PT62 INTRO4)
ALL OTHERS…………………………………………………………………………………..3
(GO TO NEXT SECTION)
HCV29_PT62_INTRO 2.
Let me review. You experienced
(NUMBER) (KEY PHRASE OF
EVENT TYPE). After an experience
like this, people sometimes have
problems like upsetting memories or
dreams, feeling emotionally distant or
depressed, trouble sleeping or
concentrating, and feeling jumpy or
easily startled. Did you have any of
these reactions after [(either/any)
[EVENT TYPE]/ of these experiences]?
HCV29_PT62_INTRO 3.
Let me review. You had (two/ three)
different types of traumatic events:
[KEY PHRASES OF ALL EVENT
TYPES] (and a private event). After
experiences like these, people
sometimes have problems like upsetting
memories or dreams, feeling
emotionally distant or depressed,
trouble sleeping or concentrating, and
feeling jumpy or easily startled. Did
you have any of these reactions after
any of the traumatic experiences you
have gone through?
YES .................................... 1
NO...................................... 5
DON’T KNOW ................. 8
REFUSED.......................... 9
MTO Adult Qnaire
HCV29_PT62_INTRO 4.
Let me review. You had quite a few
different traumatic experiences, like:
[KEY PHRASES OF 3 EVENT
TYPES] (and a private event). After
experiences like these, people
sometimes have problems like upsetting
memories or dreams, feeling
emotionally distant from or depressed,
trouble sleeping or concentrating, and
feeling jumpy or easily startled. Did
you have any of these reactions after
any of the traumatic experiences you
have gone through?
(GO TO NEXT SECTION)
(GO TO NEXT SECTION)
(GO TO NEXT SECTION)
Page A-149
Revised 08/08/07
HCV30_PT64.
Of the [experiences you mentioned to me / NUMBER times (EVENT TYPEs) happened] which one caused you the most
problems like upsetting memories or dreams, feeling emotionally distant, trouble sleeping or concentrating, or feeling
jumpy or easily startled. That is, which one experience caused the largest number or most severe problems?
IF NEC: REVIEW ENDORSED EVENTS.
(IF “DON’T KNOW,” PROBE: Which of these very upsetting events happened most recently?)
DON’T KNOW.................................998
REFUSED .........................................999
RECORD WORST EVENT:
____________ NUMBER OF EVENT
HCV30a_PT64a.
NOTE AGE AT TIME OF WORST EVENT:
[IF NEC: How old were you when that (happened/ started)?]
____________ YEARS OLD
DON’T KNOW..................998
REFUSED ..........................999
INTERVIEWER: SEE HCV30_PT64, THEN PROBE:
HCV31_PT67.
[FOR ONGOING EVENTS] During the period of time when (WORST
EVENT) was happening repeatedly, did you ever feel terrified or very
frightened?
[ALL OTHERS] Were you terrified or very frightened at the time
(WORST EVENT)?
YES
(1)
NO
(5)
DK
(8)
RF
(9)
5
8
9
5
8
9
5
8
9
5
8
9
1
GO TO
HCV32
_PT68
HCV31a_PT67a. Did you feel helpless?
1
GO TO
HCV32
_PT68
HCV31b_PT67b.
Did you feel shocked or horrified?
1
GO TO
HCV32
_PT68
HCV31c_PT67c.
Did you feel numb?
1
GO TO
HCV32
_PT68
MTO Adult Qnaire
Page A-150
Revised 08/08/07
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
HCV32_PT68. (RB)
In the weeks, months, or years after the (event / this experienced ended
/ WORST EVENT), did you try not to think about it (what happened)?
(IF YES: Please make a checkmark by reaction 1.)
(KEY PHRASE: tried not to think about it)
HCV33_PT69.
Did you purposely stay away from places, people, or activities that
reminded you of (it / the event / this experience/ WORST EVENT)?
(IF YES: Please make a checkmark by reaction 2.)
(KEY PHRASE: stayed away from reminders of it)
HCV34_PT70.
Were you ever unable to remember some important parts of what
happened?
IF VOL “UNCONSCIOUS,” “KNOCKED OUT,” OR
“HEAD INJURY,” CODE NO.
(IF YES: Please make a checkmark by reaction 3.)
[KEY PHRASE: were unable to remember part(s) of it]
HCV35_PT71.
Did you lose interest in doing things you used to enjoy?
(IF YES: Please make a checkmark by reaction 4.)
(KEY PHRASE: lost interest in things you used to enjoy)
HCV36_PT72.
Did you feel emotionally distant or cut-off from other people?
(IF YES: Please make a checkmark by reaction 5.)
(KEY PHRASE: felt distant from other people)
HCV37_PT73.
Did you have trouble feeling normal feelings like love, happiness, or
warmth toward other people?
(IF YES: Please make a checkmark by reaction 6.)
(KEY PHRASE: had trouble feeling normal feelings)
MTO Adult Qnaire
Page A-151
Revised 08/08/07
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
HCV38_PT74.
Did you feel you had no reason to plan for the future because you
thought it would be cut short?
(IF YES: Please make a checkmark by reaction 7.)
(KEY PHRASE: felt you had no reason to plan for the
future)
HCV39_PT75.
INTERVIEWER CHECKPOINT: (SEE HCV32_PT68 – HCV38_PT74)
ZERO “YES” RESPONSES IN HCV32_PT68 – HCV38_PT74 .............1 (GO TO NEXT SECTION)
ALL OTHERS...............................................................................................2 (GO TO HCV39_PT86)
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
HCV39_PT86. (RB)
Did you ever have repeated unwanted memories of (it / the event / this
experience / WORST EVENT) – that is, you kept remembering it even
when you didn’t want to?
(IF YES: Please make a checkmark by reaction 8 in the
booklet.)
(KEY PHRASE: had unwanted memories)
HCV40_PT87.
Did you ever have repeated unpleasant dreams about (it/ the event/ this
experience/ WORST EVENT)?
(IF YES: Please make a checkmark by reaction 9 in the
booklet.)
(KEY PHRASE: had unpleasant dreams)
HCV41_PT88.
Did you have flashbacks – that is, suddenly act or feel as if (it/ the
event/ this experience/ WORST EVENT) were happening all over
again?
(IF YES: Please make a checkmark by reaction 10 in the
booklet.)
(KEY PHRASE: had flashbacks)
MTO Adult Qnaire
Page A-152
Revised 08/08/07
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
HCV42_PT89.
Did you get very upset when you were reminded of (it/ the event/ this
experience/ WORST EVENT)?
(IF YES: Please make a checkmark by reaction 11 in the
booklet.)
HCV43_PT90.
When you were reminded of (it/ the event/ this experience/ WORST
EVENT), did you ever have physical reactions like sweating, your
heart racing, or feeling shaky?
(IF YES: Please make a checkmark by reaction 12 in the
booklet.)
(KEY PHRASE: had physical reactions)
HCV44_PT91.
INTERVIEWER CHECKPOINT: (SEE HCV39_PT86 – HCV43_PT90)
ZERO “YES” RESPONSES IN HCV39_PT86 – HCV43_PT90…………1(GO TO NEXT SECTION)
ALL OTHERS ……………………………………………………………..2 (GO TO HCV44_PT102)
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
HCV44_PT102. (RB)
During the time (this event/ this experience/ WORST EVENT)
affected you most, did you have trouble falling or staying asleep?
(IF YES: Please make a checkmark by reaction 13.)
(KEY PHRASE: had sleep problems)
HCV45_PT103.
Were you more irritable or short-tempered than you usually are?
(IF YES: Please make a checkmark by reaction 14.)
(KEY PHRASE: were irritable)
HCV46_PT104.
Did you have more trouble concentrating or keeping your mind on
what you were doing?
(IF YES: Please make a checkmark by reaction 15.)
(KEY PHRASE: had trouble concentrating)
MTO Adult Qnaire
Page A-153
Revised 08/08/07
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
HCV47_PT105.
Were you much more alert or watchful, even when there was no real
need to be?
(IF YES: Please make a checkmark by reaction 16.)
(KEY PHRASE: were more alert or watchful)
HCV48_PT106.
Were you more jumpy or easily startled by ordinary noises?
(IF YES: Please make a checkmark by reaction 17.)
(KEY PHRASE: were jumpy or easily startled)
HCV49_PT107.
INTERVIEWER CHECKPOINT: (SEE HCV44_PT102 – HCV48_PT106)
ZERO “YES” RESPONSES IN HCV44_PT102 – HCV48_PT106 .........1 (GO TO NEXT SECTION)
ALL OTHERS……………………………………………………………2 (GO TO HCV49_PT110)
HCV49_PT110.
You had quite a few reactions, such as (FIRST KEY PHRASE FOR EACH OF THE 3 SETS OF REACTIONS REPORTED
IN HCV32_PT68 – HCV38_PT74, HCV39_PT86 – HCV43_PT90, HCV44_PT102 - HCV48_PT106). For about how
many days, weeks, months, or years did you continue to have any of these reactions?
(IF VOL “IT’S STILL GOING ON,” PROBE: How long has it been so far?)
(IF DK, PROBE, “Was it at least a month?” IF YES, CODE 97 BELOW.)
___________ DURATION NUMBER
“AT LEAST A MONTH” ...............97
DON’T KNOW ...............................98
REFUSED .......................................99
HCV49a_PT110.
CIRCLE UNIT OF TIME: DAYS 1.................WEEKS ............2
MONTHS....3
YEARS ....4
HCV50_PT111.
INTERVIEWER CHECKPOINT: (SEE HCV49_PT110)
LESS THAN ONE MONTH (30 DAYS) OF REACTIONS IN HCV49_PT110 ……1
(GO TO NEXT SECTION)
ALL OTHERS ………………………………………………………………………..2 (GO TO HCV50_PT113)
MTO Adult Qnaire
Page A-154
Revised 08/08/07
HCV50_PT113.
Think of the time when these reactions were most frequent and intense. How often did they occur – less than once a month,
one to two times a month, three to five times a month, six to ten times a month, or more than ten times a month?
LESS THAN ONCE A MONTH ..................1
ONE TO TWO TIMES A MONTH..............2
THREE TO FIVE TIMES A MONTH ........3
SIX TO TEN TIMES A MONTH .................4
MORE THAN TEN TIMES A MONTH ......5
DON’T KNOW .............................................8
REFUSED .....................................................9
(GO TO NEXT SECTION)
(GO TO HCV51_PT114)
(GO TO HCV51_PT114)
(GO TO HCV51_PT114)
(GO TO HCV51_PT114)
(GO TO HCV51_PT114)
(GO TO HCV51_PT114)
HCV51_PT114.
How much distress did these reactions cause you – none, mild, moderate, severe, or very severe distress?
NONE ...............................................................1
MILD ................................................................2
MODERATE....................................................3
SEVERE ...........................................................4
VERY SEVERE...............................................5
DON’T KNOW ...............................................8
REFUSED .......................................................9
HCV52_PT115.
How much did these reactions disrupt or interfere with your normal, daily life – not at all, a little, some, a lot, or
extremely?
NOT AT ALL...................................................1
A LITTLE.........................................................2
SOME ...............................................................3
A LOT...............................................................4
EXTREMELY..................................................5
DON’T KNOW ...............................................8
REFUSED .......................................................9
HCV53_PT116.
INTERVIEWER CHECKPOINT: (SEE HCV51_PT114, HCV52_PT115)
RESPONSES CODED 3-5 IN HCV51_PT114 or HCV52_PT115................. 1(GO TO HCV53_PT261)
ALL OTHERS...................................................................................................... 2(GO TO NEXT SECTION)
HCV53_PT261. (RB: REFER R TO THE LIST OF SXS BEFORE ASKING THIS QUESTION)
The next question is about whether in the past 12 months you had any of these reactions associated with any traumatic
event that ever happened to you in your entire life. Did you have any reactions of this sort over the past 12 months?
YES ................................ 1
NO .................................. 5
DON’T KNOW .............. 8
REFUSED ...................... 9
MTO Adult Qnaire
(GO TO NEXT SECTION)
(GO TO NEXT SECTION)
(GO TO NEXT SECTION)
Page A-155
Revised 08/08/07
HCV54_PT263.
About how many weeks altogether in the past 12 months did you have any of these reactions?
__________ NUMBER OF WEEKS
DON’T KNOW ..............................................98
REFUSED ......................................................99
HCV55_PT264.
INTERVIEWER CHECKPOINT: (SEE HCV54_PT263)
ZERO TO THREE WEEKS IN HCV54_PT263………………1 (GO TO NEXT SECTION)
ALL OTHERS…………………………………………………..2
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
HCV59_PT273.
Did you have any trouble falling or staying asleep during that month?
1
5
8
9
HCV60_PT274.
Were you more jumpy or more easily startled by ordinary noises?
1
5
8
9
1
5
8
9
HCV55_PT269.
Please think of the 30-day period in the past 12 months when these reactions to
[WORST 12-MONTH EVENT / these events / these experiences] were most
frequent and intense. During that month, did you lose interest in doing things
you used to enjoy?
HCV56_PT270.
Did you feel emotionally distant or cut off from other people during that month?
HCV57_PT271.
Did you have trouble feeling normal feelings like love, happiness, or warmth
toward other people?
HCV58_PT272.
Did you feel you had no reason to plan for the future because you thought it
would be cut short?
HCV61_PT275.
Did you purposely stay away from places, people or activities that reminded
you of [WORST 12-MONTH EVENT] / these events)?
MTO Adult Qnaire
Page A-156
Revised 08/09/07
A_Section 19: Services (HSR)
HSR1.
In the past 12 months have you received any sort of professional counseling or therapy for problems with your emotions,
nerves, mental health, or use of alcohol or drugs?
YES .................................................. 1
NO ................................................... 5 ( GO TO HSR5)
DK ................................................... ( GO TO HSR5)
RF ..................................................... ( GO TO HSR5)
HSR1a.
What kind of professional did you see?
♦[ SELECT ALL THAT APPLY]
PSYCHIATRIST......................................................................... 01
PSYCHOLOGIST ....................................................................... 02
SOCIAL WORKER .................................................................... 03
MENTAL HEALTH COUNSELOR........................................... 04
PSYCHOTHERAPIST ................................................................ 05
MARRIAGE OR FAMILY COUNSELOR ................................ 06
DRUG OR ALCOHOL COUNSELOR ...................................... 07
PRIMARY CARE DOCTOR
(E.G., INTERNIST, FAMILY DOCTOR, GP) ........... 08
OTHER MEDICAL DOCTOR
(E.G., CARDIOLOGIST, GYNECOLOGIST) ........... 09
OTHER HEALTH CARE PROVIDER
(E.G., NURSE, OCCUPATIONAL THERAPIST)..... 10
RELIGIOUS COUNSELOR
(E.G., MINISTER, PRIEST, RABBI) ......................... 11
HEALER
(E.G., HERBALIST, CHIROPRACTOR,
SPIRITUALIST) .............................................. 12
ANY OTHER KIND OF PROFESSIONAL............................... 13
DON’T KNOW
REFUSED
HSR2.
How many sessions of psychological counseling or therapy have you received in the past 12 months?
________ (NUMBER OF SESSIONS)
DK
RF
HSR3.
How many minutes did [this session/these sessions] last (on average)?
LESS THAN 5 MINUTES........................................................ 1
5-10 MINUTES......................................................................... 2
11-20 MINUTES....................................................................... 3
21-40 MINUTES....................................................................... 4
41-60 MINUTES....................................................................... 5
MORE THAN 60 MINUTES.................................................... 6
DK
RF
MTO Adult Qnaire
Page A-157
Revised 08/09/07
HSR5.
In the past 12 months have you taken a prescription medicine for problems with your emotions, nerves, mental health, or use of
alcohol or drugs?
YES .................................................. 1
NO ................................................... 5 ( GO TO HSR8)
DK ................................................... ( GO TO HSR8)
RF ..................................................... ( GO TO HSR8)
HSR5a.
Who wrote the prescription for you?
♦SELECT ALL THAT APPLY
PSYCHIATRIST......................................................................... 1
PRIMARY CARE DOCTOR
(E.G., INTERNIST, FAMILY DOCTOR, GP)............... 2
OTHER MEDICAL DOCTOR
(E.G., CARDIOLOGIST, GYNECOLOGIST) ............... 3
NURSE OR PHYSICIAN ASSISTANT..................................... 4
THE PRESCRIPTION WAS WRITTEN FOR
SOMEONE ELSE AND THAT PERSON
GAVE IT TO YOU ........................................................ 5
DK
RF
HSR6.
About how many days out of 365 in the past year did you make a prescription medication for these problems?
________ Days
DK
RF
[CHECKPOINT (SEE HSR1 AND HSR5): ]
(HSR1 IS CODED NO/DK/RF) AND (HSR5 IS CODED NO/DK/R)........(GO TO HSR7)
ALL OTHERS ..............................................................................................(GO TO NEXT SECTION)
HSR7.
Was there a time in the past 12 months when you felt that you might need to see a professional because of problems with your
emotions, nerves, mental health, or your use of alcohol or drugs?
YES .................................................. 1
NO ................................................... 5 ( GO TO NEXT SECTION)
DK ................................................... ( GO TO NEXT SECTION)
RF ..................................................... ( GO TO NEXT SECTION)
MTO Adult Qnaire
Page A-158
Revised 08/09/07
HSR8.
What were your reasons for not seeing a professional?
♦[SELECT ALL THAT APPLY]
PROBLEM NOT SERIOUS OR GOT BETTER.........................................................................01
DID NOT THINK TREATMENT WOULD HELP .....................................................................02
WANTED TO HANDLE PROBLEM ON OWN ........................................................................03
TOO EXPENSIVE .....................................................................................................................04
PROBLEMS WITH TRANSPORTATION OR SCHEDULING ................................................05
THOUGHT IT WOULD TAKE TOO MUCH TIME OR WAS INCONVENIENT...................06
UNSURE WHERE TO GO OR WHO TO SEE...........................................................................07
NOT SATISFIED WITH AVAILABLE SERVICES ..................................................................08
COULD NOT GET AN APPOINTMENT...................................................................................09
EMBARRASSED OR WORRIED ABOUT STIGMA................................................................10
OTHER (SPECIFY) ___________ ..............................................................................................11
DK.
RF
MTO Adult Qnaire
Page A-159
Revised 08/09/07
A_Section 20: PARENT ON YOUTH (HPY)
**SEQUENCE WILL BE COMPLETED FOR EACH CHILD WHO WAS IN THE HOUSEHOLD AT
BASELINE WHO ARE STILL IN THE HOUSEHOLD AT TIME OF FOLLOW-UP.
HPY1
At the beginning of this interview we asked you about household members who lived with you at the time
you applied to be in this study about 10 or more years ago. Here we want to know more about the
schooling of the children that were living with you at that time.
I’d like to start by discussing [CHILD]’s educational progress.
What is the highest grade or year of school that [CHILD] has ever completed?
_____________________ HIGHEST GRADE COMPLETED (1-12)
(13)= ONE YEAR OF COLLEGE
(14)= TWO YEARS OF COLLEGE
(15) = THREE YEARS OF COLLEGE
(16) = FOUR YEARS OF COLLEGE
(94) = DID NOT COMPLETE ANY GRADE
(97) = REFUSED
(98) = DON’T KNOW
HPY2
Has (he/she) received a regular high school diploma? Do not include a GED.
YES (SKIP TO HPY3a)
1
NO
2
DON’T KNOW
REFUSED
HPY3
Has (he/she) received a GED?
YES
1
NO (SKIP TO HPY8)
2
DON’T KNOW
REFUSED
HPY3a
[CHILD] currently enrolled in college?
YES
1
NO
2
DON’T KNOW
REFUSED
MTO Adult Qnaire
Page A-160
Revised 08/09/07
HPY4
When was [CHILD] last enrolled in high school?
ENTER DATE: ______/_____
Month Year
DK
RF
HPY5
Is [CHILD] in school now?
YES (SKIP TO HPY9)
1
NO
2
IF VOLUNTEERED: HOME-SCHOOLED (SKIP TO
HPY8)
3
ON SUMMER VACATION(SKIP TO HPY9)
4
REFUSED (SKIP TO HPY8)
7
DON’T KNOW (SKIP TO HPY8)
8
HPY6
Why doesn’t [CHILD] attend school?
[IF CHILD’S SCHOOL IS ON SUMMER VACATION GO BACK TO HPOY5 AND SELECT
“ON SUMMER VACATION”]
HEALTH PROBLEMS
DROPPED OUT OF SCHOOL BECAUSE OF FINANCIAL
PROBLEMS/HAD TO WORK
DROPPED OUT OF SCHOOL BECAUSE DIDN’T LIKE
SCHOOL
1
2
3
EXPELLED OR SUSPENDED
4
PARENTAL DECISION
5
PREGNANCY/CHILDBIRTH
6
WORKING PART TIME
7
WORKING FULL TIME
8
OTHER (SPECIFY) ________________
95
DON’T KNOW
REFUSED
MTO Adult Qnaire
Page A-161
Revised 08/09/07
[IF AGE < 15, SKIP TO HPY8]
HPY7
Has (he/she) received a GED?
YES
1
NO
2
DON’T KNOW
REFUSED
HPY8
When was [CHILD] last enrolled in school?
ENTER DATE: ______/_____
Month Year
DK
RF
HPY9
What is the full name of the school [CHILD] (is attending/ most recently attended)?
FULL NAME OF SCHOOL:
___________________________
DK
RF
5
HPY10
Is this school…
A Regular public school
1
A Magnet public school
2
A Charter public school
3
A Vocational public school
4
A Regular private school
5
A Religious or Parochial school
6
Special Education School or Program
7
Enrichment/Gifted and Talented Program or School
8
College or university
9
Other special program or school. (SPECIFY)
________________________________________________
95
Don’t know
Refused
MTO Adult Qnaire
Page A-162
Revised 08/09/07
HPY11
Where is this school located?
ON ______________________________________
NEAR THE CORNER OF ___________________
__________________CITY
DK
RF
HPY12
For which grades did child attend this school?
[CHECK ALL THAT APPLY]
1ST GRADE
1
2
nd
2 GRADE
3
RD
4
TH
5
TH
6
TH
7
TH
8
TH
9
TH
3
GRADE
4
GRADE
5
GRADE
6
GRADE
7
GRADE
8
GRADE
9
GRADE
10
10
TH
11
TH
12
TH
GRADE
11
GRADE
12
GRADE
13
1ST YEAR OF COLLEGE
14
2ND YEAR OF COLLEGE
15
3RD YEAR OF COLLEGE
16
4TH YEAR OF COLLEGE
17
DON’T KNOW
REFUSED
MTO Adult Qnaire
Page A-163
Revised 08/09/07
HPY13
Has [CHILD] ever repeated a grade?
YES
1
NO (SKIP TO HPY15)
2
REFUSED (SKIP TO HPY15)
7
DON’T KNOW (SKIP TO HPY15)
8
HPY14
Which grade(s) did [CHILD]
repeat?
[IF YES:]
HPY14a
Did [CHILD] repeat [GRADE] in the same
school?
YES
K
1
2
3
4
5
6
7
8
9
10
11
12
[CHECK ALL
THAT APPLY]
1
2
3
4
5
6
7
8
9
10
11
12
13
----------->
IF YES ->
IF YES ->
IF YES ->
IF YES ->
IF YES ->
IF YES ->
IF YES ->
IF YES ->
IF YES ->
IF YES ->
IF YES ->
IF YES ->
IF YES ->
YES
NO
RF
DK
1
2
7
8
1
2
7
8
1
2
7
8
1
2
7
8
1
2
7
8
1
2
7
8
1
2
7
8
1
2
7
8
1
2
7
8
1
2
7
8
1
2
7
8
1
2
7
8
1
2
7
8
HPY15
Has [CHILD] ever been suspended or expelled?
YES
1
NO (SKIP TO HPY16)
2
REFUSED (SKIP TO HPY16)
7
DON’T KNOW (SKIP TO HPY16)
8
HPY15a
Has this happened during the past 2 years?
YES
1
NO
2
DON’T KNOW
REFUSED
MTO Adult Qnaire
Page A-164
Revised 08/09/07
ASK HPY16a-HPY16d FOR EACH
SCHOOL ATTENDED
HPY16a
What is the full name of the school
[CHILD] attended before
[SCHOOL NAME LAST
MENTIONED]?
HPY16b
Was this school a...
HPY16c
Where was this school located?
Can you give me the name of the
street on which it was located?
PROBE: What was the nearest
cross-street?
What city is that?
HPY16d
For which grade(s) did [CHILD]
attend this school?
CHECK ALL THAT APPLY
MTO Adult Qnaire
SCHOOL 2
SCHOOL 3
____________________
ATTENDED NO OTHER
SCHOOL (IF CHILD’S AGE IS
<18 THEN SKIP TO J17,
DK
RF
____________________
ATTENDED NO OTHER
SCHOOL (IF CHILD’S AGE IS
<18 THEN SKIP TO J17,
DK
RF
Regular Public School
Magnet Public School
Charter Public School
Vocational Public School
Regular Private School
Religious or Parochial School
Special Education School
Enrichment/gifted & Talented
School or Program
Other Special Program or
School (Specify)
________________
DK
RF
Regular Public School
Magnet Public School
Charter Public School
Vocational Public School
Regular Private School
Religious or Parochial School
Special Education School
Enrichment/gifted & Talented
School or Program
Other Special Program or
School (Specify)
________________
DK
RF
1
2
3
4
5
6
7
8
95
ON ___________________
ON ___________________
NEAR THE CORNER OF
______________________
NEAR THE CORNER OF
______________________
IN THE CITY OF
__________________
DK
RF
IN THE CITY OF
__________________
DK
RF
K
1
2
3
4
5
6
7
1
2
3
4
5
6
7
8
8
9
10
11
12
DK
RF
9
10
11
12
13
K
1
2
3
4
5
6
7
1
2
3
4
5
6
7
8
9
10
11
12
DK
RF
9
10
11
12
13
8
Page A-165
1
2
3
4
5
6
7
8
95
Revised 08/09/07
HPY16e_J16e.
[INTERVIEWER: SKIP TO HPY16a FOR NEXT SCHOOL IF GRADE HISTORY IS NOT
COMPLETE]
HPY16f
Were there any other schools that
[CHILD] attended between
[BEGINNING OF GRADE
HISTORY] and [HIGHEST GRADE
ATTENDED IN J12]?
YES…………….1 (SKIP TO
J16a NEXT SCHOOL)
NO …………..…5
DK
RF
YES…………….1 (SKIP TO J16a
NEXT SCHOOL)
NO …………..…5
DK
RF
HPY17
During the past two years, has anyone from [CHILD’S] school asked someone to come in and talk about
problems [CHILD] was having with schoolwork or behavior?
YES
1
NO
2
DON’T KNOW
REFUSED
HPY18
During the past 2 years, has [CHILD] gone to a special class for gifted students or done advanced work in
any subjects?
YES
1
NO
2
REFUSED
7
DON’T KNOW
8
YES
HPY19a
During the past 2 years, has [CHILD]
gone to a special class or school or gotten
special help in school for learning
problems?
HPY19b
(During the past 2 years, has [CHILD]
gone to a special class or school or gotten
special help in school for) behavioral or
emotional problems?
MTO Adult Qnaire
NO
RF
DK
1
2
7
8
1
2
7
8
Page A-166
Revised 08/09/07
CHECKPOINT
IF (HPOY19a = NO/DK/RF) AND (HPOY19b = NO/DK/RF), Æ GO TO HPY21.
ALL OTHERS, Æ GO TO HPY20.
HPY20
How often has [CHILD] received any special services for these problems—almost every day, once a week,
once a month, a few times a year, or only once or twice in the past two years?
ALMOST EVERY DAY (INCLUDES 3-5 DAYS A WEEK)
1
ONCE A WEEK (INCLUDES 1-2 DAYS A WEEK)
2
ONCE A MONTH (INCLUDES 1-3 TIMES A MONTH)
3
A FEW TIMES A YEAR (INCLUDES 3-4 TIMES A YEAR)
4
ONLY ONCE OR TWICE IN THE PAST 2 YEARS
5
DON’T KNOW
REFUSED
HPY21.
Now I’d like to ask you about your involvement in your children’s schooling.
How satisfied are you with the education that [CHILD] has received up to now? Now I’d like to ask you
about your involvement in your children’s schooling.
Very satisfied........................................................ 1
Somewhat satisfied............................................... 2
Not at all satisfied................................................. 3
Don’t know
Refused
YES
HPY22a
In the past 12 months, have you or another adult who
lives with you gone to a general meeting or school
event at your [CHILD’S] school, like a back-toschool night, parent/teacher organization meeting or
sports event?
HPY22b
In the past 12 months, have you or another adult who
lives with you been a volunteer or worked at your
[CHILD’S] school, been on a school committee or
club outside of school?
MTO Adult Qnaire
NO
NO CHILD IN
SCHOOL
PAST 12
MONTHS
1
2
3
1
2
3
DK
RF
Page A-167
Revised 08/09/07
NOT
TRUE
SOMEWHAT
TRUE
VERY
TRUE
DK
RF
1
2
3
8
9
HPY23b.
(This child) has many worries, often seems worried.
1
2
3
8
9
HPY23c.
(He/She) is often unhappy, depressed, or tearful.
1
2
3
8
9
1
2
3
8
9
1
2
3
8
9
HPY23a.
The next questions are about this CHILD’S behavior. I
will read a series of statements, and for each , please tell me
if the statement is not true, somewhat true, or very true of
[CHILD].
This child is generally obedient, usually does what adults
request.
HPY23d.
(He/She) gets along better with adults than with others
his/her own age.
HPY23e.
(He/She) sees tasks through to the end, has a good attention
span.
HPY24.
Overall, do you think [CHILD] has difficulties in one or more of the following areas: emotions,
concentration, behavior or being able to get along with other people? Would you say he/she has severe
difficulties, definite difficulties, minor difficulties, or no difficulties in one or more of these areas?
Yes-severe difficulties................................... 1
Yes-definite difficulties................................. 2
Yes-minor difficulties ................................... 3
No.................................................................. 5
Don’t Know
Refused
MTO Adult Qnaire
Page A-168
Revised 08/09/07
HPY25
About how long has it been since [CHILD] last saw or talked to a doctor or other health care professional
about (his/her) health? Would you say six months or less, more than six months but not more than one year
ago, more than one year but not more than three years ago, more than three years ago, or never?
6 months or less
1
More than 6 months, but not more than 1 year ago
2
More than 1 year, but not more than 3 years ago
3
More than 3 years
4
Never
5
Don’t Know
Refused
HPY26.
During the past [TIME SINCE RANDOM ASSIGNMENT], that is, since [DATE OF RANDOM
ASSIGNMENT], has there ever been anytime lasting a month or more when [CHILD] did not live with
you?
Yes ................................................................ 1
No.................................................................. 5 (SKIP TO NEXT SECTION)
Don’t Know (SKIP TO NEXT SECTION)
Refused (SKIP TO NEXT SECTION)
HPY27a.
When was the first time [CHILD] lived somewhere else – in what month and year did (he/she) begin to live
away?
ENTER:_______/________
Month Year
DK
RF
HPY27b.
And, when did (he/she) come back to live with you?
ENTER:_______/________
Month Year
[IF VOL: STILL LIVING AWAY]
DK
RF
MTO Adult Qnaire
Page A-169
Revised 08/09/07
HPY27c.
Where was (he/she) living during that time?
Maternal grandparents................................... 1
Other maternal relatives ................................ 2
Child’s own father......................................... 3
Paternal relatives ........................................... 4
Foster home................................................... 5
Alone / with friends / with partner ................ 6
In school / college ......................................... 7
In jail ............................................................. 8
In the military................................................ 9
In the hospital ............................................... 10
Rrunaway ...................................................... 11
With step parent ............................................ 12
With other relative......................................... 13
In Job Corps .................................................. 14
Adopted......................................................... 15
Just moved back with R ................................ 16
Shelter ........................................................... 17
Other ............................................................. 18
DK
RF
MTO Adult Qnaire
Page A-170
Revised 08/09/07
HPY27d.
Why was CHILD living (with/in) ARRANGEMENT?
Personal reasons:
Behavioral problems ............................................ 1
Problems of mother (drugs, alcohol, in jail)......... 2
Health problems of child ...................................... 3
Health problems of mother................................... 4
Financial problems of mother............................... 5
Unsuitable housing arrangement .......................... 6
Homelessness ....................................................... 7
Child taken away by state..................................... 8
Put in foster home ................................................ 9
Mother could not care for child ............................ 10
Permanent alternative arrangements:
Thought child would be better off
with friends or relatives................................. 11
Put child up for adoption ...................................... 12
Child wanted to live with father ........................... 13
Father awarded custody........................................ 14
Age of child issues:
Child is grown adult ............................................. 15
Child is away at school......................................... 16
Other = R does not know where child is
Child in jail........................................................... 17
Iimmigration related issue .................................... 18
Reason related to move ........................................ 19
Child kidnapped ................................................... 20
Shared custody ..................................................... 21
Family just helping out......................................... 22
Away at camp....................................................... 23
Other .................................................................... 24
DK
RF
MTO Adult Qnaire
Page A-171
Revised 08/03/07
A_Section 21: Adult Report on Other Household Members
These next questions ask about other members of your household, their education and employment, their
marital status, whether they have children, and their health.
♦ INSTRUCTIONS: WORK DOWN GRID, ASKING QUESTIONS FOR EACH PERSON AGE 18+
LIVING IN THE HOUSEHOLD.
ENTER FIRST NAME OF
EACH PERSON
HHO1.
Is this person in school now?
HHO2.
Has (he/she) graduated from
high school or does (he/she)
have a GED?
HHO3.
Has (he/she) ever attended
any college?
HHO4.
Is (he/she) now working fulltime or part-time?
HHO5.
Does (he/she) have a physical
health problem that keeps
him/her from doing normal
activities like walking, getting
dressed, household or
working?
HHO6.
Does (he/she) have any
chronic physical disability
like cancer, a heart problem or
any other serious health
problem?
MTO Adult Qnaire
Person #1
Person #2
Person #3
Person #4
Yes………..1
No………….5
DK
RF
Yes………..1
No………….5
DK
RF
Yes………..1
No………….5
DK
RF
Yes………..1
No………….5
DK
RF
GED…………..1
High School…..2
Neither………..3
DK
RF
GED…………..1
High School…..2
Neither………..3
DK
RF
GED…………..1
High School…..2
Neither………..3
DK
RF
GED…………..1
High School…..2
Neither………..3
DK
RF
Yes………..1
No………….5
DK
RF
Yes………..1
No………….5
DK
RF
Yes………..1
No………….5
DK
RF
Yes………..1
No………….5
DK
RF
Full time………..1
Part time…………2
Not working……..3
DK
RF
Full time………..1
Part time…………2
Not working……..3
DK
RF
Full time………..1
Part time…………2
Not working……..3
DK
RF
Full time………..1
Part time…………2
Not working……..3
DK
RF
Yes………..1
No………….5
DK
RF
Yes………..1
No………….5
DK
RF
Yes………..1
No………….5
DK
RF
Yes………..1
No………….5
DK
RF
Yes………..1
No………….5
DK
RF
Yes………..1
No………….5
DK
RF
Yes………..1
No………….5
DK
RF
Yes………..1
No………….5
DK
RF
Page A-172
Revised 08/03/07
HHO7.
(Does (he/she) have an)
alcohol or drug problem?
HHO8.
(Does (he/she) have)
Depression or other serious
chronic mental health
problem?
HHO9a.
Has (he/she) smoked a
cigarette in the past 30 days?
HHO9b.
When he/she smoked a
cigarette during the past 30
days, how many cigarettes did
(he/she) usually smoke each
day?
HHO10.
♦ ASK OR VERIFY:
What is (his/her) marital
status?
HHO11.
How many children has
(he/she) had?
HHO12.
In what year was (his/her)
(first) child born?
HHO13.
During the prior 12 months,
has (he/she) been arrested,
convicted of a crime or put in
jail?
Person #1
Person #2
Person #3
Person #4
Yes………..1
No………….5
DK
RF
Yes………..1
No………….5
DK
RF
Yes………..1
No………….5
DK
RF
Yes………..1
No………….5
DK
RF
Yes………..1
No………….5
DK
RF
Yes………..1
No………….5
DK
RF
Yes………..1
No………….5
DK
RF
Yes………..1
No………….5
DK
RF
Yes…1
No….5 [GT HHO10]
DK [GO TO HHO10]
RF [GO TO HHO10]
Yes…1
No….5 [GT HHO10]
DK [GO TO HHO10]
RF [GO TO HHO10]
Yes…1
No….5 [GT HHO10]
DK [GO TO HHO10]
RF [GO TO HHO10]
Yes…1
No….5 [GT HHO10]
DK [GO TO HHO10]
RF [GO TO HHO10]
________# OF
CIGARETTES
DK
RF
________# OF
CIGARETTES
DK
RF
________# OF
CIGARETTES
DK
RF
________# OF
CIGARETTES
DK
RF
Single………..…..1
Married………….2
Divorced…………3
Widowed…………4
DK
RF
Single………..…..1
Married………….2
Divorced…………3
Widowed…………4
DK
RF
Single………..…..1
Married………….2
Divorced…………3
Widowed…………4
DK
RF
Single………..…..1
Married………….2
Divorced…………3
Widowed…………4
DK
RF
________# OF
CHILDREN
DK
RF
________# OF
CHILDREN
DK
RF
________# OF
CHILDREN
DK
RF
________# OF
CHILDREN
DK
RF
IF NONE OR DK/RF,
GO TO HH013.
IF NONE OR DK/RF,
GO TO HH013.
IF NONE OR DK/RF,
GO TO HH013.
IF NONE OR DK/RF,
GO TO HH013.
________YEAR 1ST
CHILD BORN
DK
RF
CHECK ALL
THAT APPLY:
________YEAR 1ST
CHILD BORN
DK
RF
CHECK ALL
THAT APPLY:
________YEAR 1ST
CHILD BORN
DK
RF
CHECK ALL
THAT APPLY:
________YEAR 1ST
CHILD BORN
DK
RF
CHECK ALL
THAT APPLY:
Arrested………….1
Convicted………..2
Put In
Jail……………….3
Neither……….….4
DK
RF
Arrested………….1
Convicted………..2
Put In
Jail……………….3
Neither……….….4
DK
RF
Arrested………….1
Convicted………..2
Put In
Jail……………….3
Neither……….….4
DK
RF
Arrested………….1
Convicted………..2
Put In
Jail……………….3
Neither……….….4
DK
RF
♦ GO TO HHO1 FOR NEXT PERSON OR NEXT SECTION
MTO Adult Qnaire
Page A-173
Revised 08/03/07
A_Section 22: Relationships & Parenting (HRL)
HRL1.
In this next section I am going to ask you about your adult relationships and parenting.
Are you currently married or in a serious relationship?
Yes ............................ 1
No.............................. 5
Don’t know ............... 8
Refused .................... 9
GO TO HRL2
GO TO HRL3
GO TO HRL3
GO TO HRL10
HRL2.
How long have you been married or in this relationship?
Less than a year...............................1
About 2 years ..................................2
More than 2 years............................3
DK
RF
HRL3.
About how many romantic relationships did you have in the past 12 months that lasted for at least one
month?
_______ # of Relationships………………………GO TO CHECKPIONT HRL3b.
Don’t know..................... ASK HRL3a
Refused.............................ASK HRL3a
HRL3a
I just need to have a range. Can you tell me if it was 1-5 relationships, 6-10 relationships, 11-15
relationships, or more than 15 relationships?
1-5 Relationships
6-10 Relationships
11-15 Relationships
More than 15 relationships
DK
RF
1
2
3
4
HRL3b. CHECKPOINT
¾ IF HRL1 IS CODED 1 (R IS MARRIED), GO TO HRL4
¾ IF HRL1 IS CODED 5 (R NOT MARRIED), GO TO HRL10
MTO Adult Qnaire
Page A-174
Revised 08/03/07
HRL4.
Now I’m going to ask you a few questions about your current relationship. All things considered, on a
scale from 1 to 7, where 1 is “completely unhappy” and 7 is “completely happy”, how happy are you with
your current relationship?
Completely unhappy
Moderately unhappy
Slightly happy
Not happy or unhappy
Slightly happy
Moderately happy
Completely happy
DK
RF
1
2
3
4
5
6
7
ALL
HRL5a.
The following statements describe the way some people
feel about their spouse or partner, and their relationship in
general. Please indicate whether each of the following
happens all of the time, most of the time, some of the
time, or none of the time.
Our arguments get very heated.
MOST
SOME
NONE
1
2
3
4
HRL5b.
My partner/spouse and I have similar views about what
is important in life.
1
2
3
4
HRL5c.
I am satisfied with the way we handle our problems and
disagreements.
1
2
3
4
1
2
3
4
HRL5d.
My partner/spouse expresses love and affection toward
me.
DK
RF
8
9
8
9
8
9
8
9
HRL6.
Now we are going to ask a set of questions about CHILD (pre-loaded, randomly selected child aged 10 to
20, lived in household at baseline, and currently living in household).
In the past week, have you and [CHILD] talked about things he/she is doing at school, school work or
grades?
Yes ................................... 1
No..................................... 5
DK
RF
MTO Adult Qnaire
Page A-175
Revised 08/03/07
HRL7.
How often did someone help [CHILD] with his/her homework? Would you say five or more times a week,
3 to 4 times a week, 1 to 2 times a week, less than once a week, or never?
Never................................ 1
Less than once/week ........ 2
1 to 2 times/week ............. 3
3 to 4 times/week ............. 4
5 or more times/week ....... 5
DK
RF
HRL8.
How often do you or another adult in the household check to make sure CHILD has completed his/her
homework? Less than once a month, about once a month, a few times a month, or at least a few times a
week?
Less than once/month......................... 1
About once/month.............................. 2
Few times/month................................ 3
At least a few times/week................... 4
DK
RF
HRL9.
During this school year, have you or another adult in your household taken it upon yourself to contact
(CHILD’s) teacher or school for any reason having to do with (CHILD)?
Yes ................................... 1
No..................................... 5
DK
RF
HRL9a.
Why did you contact (CHILD)’s school?
♦ PROBE: Anything else?
♦ CODE ALL THAT APPLY
To report an absence or tardiness ...............................................1
To discuss problems the child is having at school .....................2
To request special placement or services ...................................3
To request evaluation by a specialist..........................................4
To request a specific teacher ......................................................5
To check on CHILD’s progress .................................................6
To ask about homework problems .............................................7
Other (specify) ..........................................................................8
DK
RF
MTO Adult Qnaire
Page A-176
Revised 08/03/07
HRL10.
Children sometimes do things that are wrong, disobey, or make their parents angry. We would like to
know what you have done when your [AGE OF CHILD] year old child did something wrong or made you
upset or angry. I am going to read a list of things you might have done in the past year and I would like you
to tell me whether you have: done it once in the past year, done it twice in the past year, 3-5 times, 6-10
times, 11-20 times, or more than 20 times in the past year. If you haven’t done it in the past year but have
done it before that, I would like to know this, too.
(When CHILD did something
wrong or made you angry, how
often did you…)
HRL10a.
Explain why something was
wrong?
HRL10b.
Sent [CHILD] to[his/her] room,
took away privileges, or
grounded [him/her]?
HRL10c.
Called [CHILD] dumb or lazy or
some other name like that, or
threatened to hit [him/her], but
did not actually do it?
HRL10d.
Shouted, yelled, screamed,
swore or cursed at [CHILD]?
HRL10e.
Said you would send [CHILD]
away or kick [CHILD] out of
the house?
HRL10f.
Spanked or hit [CHILD]
11Once 1-2/yr 3-5/yr6-10/yr 20
Not in Never
20+/yr past yr happened DK
RF
1
2
3
4
5
6
7
8
D
R
1
2
3
4
5
6
7
8
D
R
1
2
3
4
5
6
7
8
D
R
1
2
3
4
5
6
7
8
D
R
1
2
3
4
5
6
7
8
D
R
1
2
3
4
5
6
7
8
D
R
HRL11.
Is [CHILD] allowed to be in public places without adult supervision?
Yes ............................ 1
No.............................. 5
DK
RF
HRL12.
In the last month [if on vacation: in which s/he was in school], after school, has [CHILD] always come
directly to your home and stayed home until dinner time?
YES ........................... 1 (GO TO HRL 14)
NO............................. 5
DK
RF
MTO Adult Qnaire
Page A-177
Revised 08/03/07
HRL13.
In the last month [if on vacation: in which s/he was in school], how often has (he/she) done that?
Almost every day ......................................... 1
A few times a week ...................................... 2
Once a week ................................................. 3
Less than once a week.................................. 4
Never............................................................ 5
DK
RF
HRL14.
Where is this [CHILD] usually in the evenings?
Home, supervised......................................... 1
Home, unsupervised..................................... 2
Somewhere else, supervised......................... 3
Somewhere else, unsupervised..................... 4
DK
RF
HRL15.
Please tell me whether you make rules about how late [CHILD] can stay out at night, or does [CHILD]
decide for him/herself?
Parent makes rules........................................ 1
Child decides for self ................................... 2
Child and parent decide jointly .................... 3
DK
RF
HRL16.
Does [CHILD] have a curfew or set time to be home on school nights?
IF CHILD IS NOT CURRENTLY IN SCHOOL, PROBE FOR LAST TIME CHILD WAS
ENROLLED IN SCHOOL.
Yes ............................................................... 1
No................................................................. 5
(If vol): Not out on school nights ............... 7
DK
RF
HRL17.
Does [CHILD] have a curfew on weekend nights?
Yes ............................................................... 1
No................................................................. 5
(If vol): Not out on school nights ............... 7
DK
RF
MTO Adult Qnaire
Page A-178
Revised 08/03/07
CHECKPOINT
¾ IF HRL16 IS CODED 7 (NOT OUT ON SCHOOL NIGHTS) GO TO HRL19.
¾ OTHERS, ASK HRL18.
HRL18.
In a typical week, how late does [CHILD] stay out on school nights (Monday to Thursday)?
IF R GIVES HALF HOUR, ROUND UP (E.G., “8:30” IS CODED “NO LATER THAN
9:00”)
No later than 8:00......................................... 1
No later than 9:00......................................... 2
No later than 10:00....................................... 3
No later than 11:00....................................... 4
No later than 12:00 midnight ....................... 5
As late as he/she wants................................. 6
DK
RF
HRL19.
How many of [CHILD's] close friends do you know by sight and by first and last name? All, most, about
half, only a few, or none?
All ................................................................ 1
Most ............................................................. 2
About half .................................................... 3
Only a few.................................................... 4
None of them................................................ 5
(If vol): No close friends .............................. 6
DK
RF
MTO Adult Qnaire
Page A-179
A_Section 23. Decision Making
HDM1
Are there any big expenses that you think you will have to pay for in the next five to ten years, such as educational
expenses, purchase of a new car, health care costs, support for other family members, or anything else?
YES.........................1
NO ..........................5 (GO TO HDM4a)
DK ........................(GO TO HDM4a)
RF .......................(GO TO HDM4a)
HDM2.
How much thought have you given to how you will meet those expenses?
A LOT.....................1
SOME .....................2
A LITTLE...............3
HARDLY ANY ......4
DK
RF
HDM3
Are you saving for those expenses now?
YES.........................1
NO ..........................5
DK
RF
HDM4a
Suppose a relative of yours calls to say they just inherited some money and part of it should be yours. Because of
the way their inheritance is being distributed, they can either send you some money now, or a larger amount of
money later, which they would send to you on your next birthday. Suppose that you trust this person to send what
they promise, and that you do not expect to get a birthday present from this relative other than this money.
Would you rather they mailed you $100 tomorrow or $120 on your next birthday?
$100 TOMORROW..........................1
$200 ON NEXT BIRTHDAY ..........5
DK
RF
HDM4b
Suppose you get a letter from the government saying you are getting an extra tax refund. You can choose between
getting the refund now, or a larger refund one month from now.
Would you rather they sent $100 tomorrow or $110 one month from now?
$100 TOMORROW...................................... 1 (GO TO HDM4e)
$110 ONE MONTH FROM NOW .............. 2
DK
RF
MTO Adult Qnaire
Page A-180
HDM4c
Now suppose the choice were between $100 now and $105 one month from now. Would you rather they sent $100
tomorrow or $105 one month from now?
$100 TOMORROW...................................... 1 (GO TO HDM5a)
$105 ONE MONTH FROM NOW .............. 2
DON’T KNOW (GO TO HDM5a)
REFUSED (GO TO HDM5a)
HDM4d
Now suppose the choice were between $100 now and $101 one month from now. Would you rather they sent $100
tomorrow or $101 one month from now?
$100 TOMORROW...................................... 1
$101 ONE MONTH FROM NOW .............. 2
DON’T KNOW
REFUSED
(GO TO HDM5a)
HDM4e
Now suppose the choice were between $100 now and $115 one month from now. Would you rather they sent $100
tomorrow or $115 one month from now?
$100 TOMORROW...................................... 1
$115 ONE MONTH FROM NOW .............. 2 (GO TO HDM5a)
DON’T KNOW (GO TO HDM4.2e)
REFUSED (GO TO HDM5a)
HDM4f
Now suppose the choice were between $100 now and $120 one month from now. Would you rather they sent $100
tomorrow or $120one month from now?
$100 TOMORROW...................................... 1
$120 ONE MONTH FROM NOW .............. 2
DK
RF
HDM5a
Suppose that a new company moves into your area and offers you a part-time job that you would be willing and able
to take for one month. This company offers you two different ways of being paid. The first way is a salary that
would guarantee you $300. The second way would tie your earnings to how well the company as a whole does that
month. The second way is possibly better paying, but the income is less certain.
There is a 50-50 chance the second way would pay $600, and a 50-50 chance that it would pay $200. Which way of
getting paid would you choose – earning $300 for sure, or an equal chance of earning either $600 or $200.
$300 FOR SURE .......................................... 1 (GO TO HDM5d)
EARNING EITHER $600 OR $200 ............ 2
DON’T KNOW ......................................... (GO TO HDM5d)
REFUSED .................................................. (GO TO HDM6)
MTO Adult Qnaire
Page A-181
HDM5b
Now suppose there is a 50-50 chance the second way would pay $600, and a 50-50 chance that it would pay $150.
Which way of getting paid would you choose – earning $300 for sure, or an equal chance of earning either $600 of
$150?
$300 FOR SURE .......................................... 1 (GO TO HDM6)
EARNING EITHER $600 OR $150 ............ 2
DON’T KNOW (GO TO HDM6)
REFUSED (GO TO HDM6)
HDM5c.
Now suppose there is a 50-50 chancethe second way would pay $600, and a 50-50 chance that it would pay $75.
Which way of getting paid would you choose – earning $300 for sure, or an equal chance of earning either $600 or
$75?
$300 FOR SURE .......................................... 1 (GO TO HDM6)
EARNING EITHER $600 OR $75 .............. 2 (GO TO HDM6)
DON’T KNOW .......................................... (GO TO HDM6)
REFUSED .................................................. (GO TO HDM6)
HDM5d.
Now suppose there is a 50-50 chance the second way would pay $600 and 50-50 chance that it would pay $240.
Which way of getting paid would you choose – earning $300 for sure, or an equal chance of earning either $600 or
$240?
$300 FOR SURE .......................................... 1
EARNING EITHER $600 OR $240 ............ 2 (GO TO HDM6)
DON’T KNOW ......................................... (GO TO HDM5e)
REFUSED ................................................... (GO TO HDM6)
HDM5e.
Now suppose there is a 50-50 chance the second way would pay $600 and 50-50 chance that it would pay $270.
Which way of getting paid would you choose – earning $300 for sure, or an equal chance of earning either $600 or
$270?
$300 FOR SURE .......................................... 1
EARNING EITHER $600 OR $270 ............ 2
DON’T KNOW
REFUSED
MTO Adult Qnaire
Page A-182
HDM6.
How do you see yourself: Are you generally a person who is fully prepared to take risks or do you try to avoid
taking risks? If 0 means you always avoid taking risks and 10 means you are always fully prepared to take risks,
where on a 0 to 10 scale would you place yourself?
(IF NEC: You can give me any number between 0 and 10)
0
1
2
3
4
5
6
7
8
9
10
DK
RF
ALWAYS AVOID TAKING RISKS
FULLY PREPARED TO TAKE RISKS
HDM7a.
(RB) Now I want to ask you about trusting different groups of people. First, thinking about people in your
immediate family, generally speaking would you say you can trust them a lot, trust them some, trust them only a
little or not trust them at all?
A LOT........................................................... 1
SOME ........................................................... 2
ONLY A LITTLE......................................... 3
NOT AT ALL ............................................... 4
DK
RF
HDM7b.
(RB) How about people in your neighborhood, would you say you can trust them a lot, some, only a little or not at
all?
A LOT........................................................... 1
SOME ........................................................... 2
ONLY A LITTLE......................................... 3
NOT AT ALL ............................................... 4
DK
RF
HDM7c
(RB) How about other people in general? (would you say you can trust them a lot, some, only a little or not at all?)
A LOT........................................................... 1
SOME ........................................................... 2
ONLY A LITTLE......................................... 3
NOT AT ALL ............................................... 4
DK
RF
MTO Adult Qnaire
Page A-183
HDM8a.
(RB) Next, I’m going to read a list of institutions. For each one, please tell me whether you feel that you can trust
them a lot, some, only a little or not at all. First the police department in your area, do you feel you can trust them a
lot, some, only a little or not at all?
A LOT........................................................... 1
SOME ........................................................... 2
ONLY A LITTLE......................................... 3
NOT AT ALL ............................................... 4
DK
RF
HDM8b.
How about the public schools in your area? (do you feel you can trust them a lot, some, only a little or not at all?)
A LOT........................................................... 1
SOME ........................................................... 2
ONLY A LITTLE......................................... 3
NOT AT ALL ............................................... 4
DK
RF
HDM8c.
How about the city or local government? (do you feel you can trust them a lot, some, only a little or not at all?)
A LOT........................................................... 1
SOME ........................................................... 2
ONLY A LITTLE......................................... 3
NOT AT ALL ............................................... 4
DK
RF
HDM9.
Generally speaking, would you say that most people can be trusted or that you can’t be too careful in life?
MOST PEOPLE CAN BE TRUSTED ......... 1
CAN’T BE TOO CAREFUL........................ 2
OTHER (DEPENDS)…................................ 3
DK
RF
HDM10.
How often do you lend money to friends: More than once a week, about once a week, about once a month, or once a
year or less?
MORE THAN ONCE A WEEK................... 1
ABOUT ONCE A WEEK ............................ 2
ABOUT ONCE A MONTH ......................... 3
ONCE A YEAR OR LESS ........................... 4
DK
RF
MTO Adult Qnaire
Page A-184
HDM11.
How often do you lend things you own to your friends?
MORE THAN ONCE A WEEK................... 1
ABOUT ONCE A WEEK ............................ 2
ABOUT ONCE A MONTH ......................... 3
ONCE A YEAR OR LESS ........................... 4
DK
RF
HDM12.
As part of our study of how MTO participants make decisions, we are pleased to be able to offer you a small amount
of additional survey compensation. This compensation is available in two forms. Either a check for $20 that we
will put in the mail tomorrow or a check for $25 that we could put in the mail on your next birthday. Which would
you prefer -- $20 sent tomorrow, or $25 sent on your next birthday?
$20 SENT TOMORROW............................. 1
$25 ON NEXT BIRTHDAY ........................ 2
DK
RF
MTO Adult Qnaire
Page A-185
A_Section 24. Contact Information (HCI)
HCI1
To continue to help the government learn how to improve housing programs, it is very important that we
talk to people periodically to see how things are going. Since people often move, we would like to ask you
for the names of friends or relatives who usually keep in touch with you. We would contact these people
only if we were unable to reach you at your current phone number. We would ask them only for your
address and telephone information.
(IF NO CONTACT PERSON INFORMATION AVAIALBLE FROM PREVIOUS CONTACTS: Please
give me the name of three people who do not live with you and who will know how to reach you if we need
to contact you again to verify this interview or to ask a few additional questions.)
(IF CONTACT INFORMATION AVAILABLE: In the past you gave us information on the following
three people. I would like to make sure that we have the most current information for them, and that they
are the best people to use to find you.)
HC2
UPDATE OR COLLECT INFORMATION FOR CONTACT PERSON #1
NAME
RELATIONSHIP TO R
ADDRESS
PHONE NUMBER
HC3
UPDATE OR COLLECT INFORMATION FOR CONTACT PERSON #2
NAME
RELATIONSHIP TO R
ADDRESS
PHONE NUMBER
HC4
UPDATE OR COLLECT INFORMATION FOR CONTACT PERSON #3
NAME
RELATIONSHIP TO R
ADDRESS
PHONE NUMBER
MTO Adult Qnaire
Page A-186
Moving to Opportunity
Final Impact Evaluation
Youth Questionnaire
National Bureau of Economic Research
University of Michigan
2008-2009
Interviewer: Obtain written parent consent and youth assent/consent, and
read the following statement before beginning the interview:
“Before we begin this interview, let me assure you that this interview is
completely confidential and voluntary. If we come to any question that you
do not want to answer, just let me know and we will go on to the next
question.”
Moving to Opportunity
Final Impact Evaluation
Youth Questionnaire
National Bureau of Economic Research
University of Michigan
2008-2009
Interviewer: Obtain written parent consent and youth assent/consent, and
read the following statement before beginning the interview:
“Before we begin this interview, let me assure you that this interview is
completely confidential and voluntary. If we come to any question that you
do not want to answer, just let me know and we will go on to the next
question.”
MTO Youth Qnaire
Page B-1
Revised 08/09/07
Youth Questionnaire
B_Section 01: Youth Household Listing (YHL)
YHS1.
[INTERVIEWER: ENTER R’S LIVING ARRANGEMENT]
With parent(s) .......................... 1
In own house/apartment ........... 2
In a dorm .................................. 3
Military..................................... 4
Other (Specify)__________..... 5
Don’t Know .............................
Refused ....................................
(GO TO YHS2)
(GO TO YHS2)
(GO TO NEXT SECTION)
(GO TO NEXT SECTION)
(GO TO YHS2)
(GO TO YHS2)
(GO TOYHS2)
YHS2.
To begin, I need to get a list of the people that live with you in this household – including their name, age,
and relationship to you. Let’s start with you.
YHS3.
First Name: ________________________________
YHS4.
What is (his/her) relationship to you?
BIRTH CHILD ........................... ................. 1
ADOPTED CHILD..................... ................. 2
STEP CHILD.............................. ................. 3
GRANDCHILD .......................... ................. 4
FOSTER CHILD ........................ ................. 5
OTHER CHILD.......................... ................. 6
SPOUSE ..................................... ................. 7
PARTNER (ROMANTIC) ......... ................. 8
FRIEND (NOT ROMANTIC) .... ................. 9
PARENT..................................... ................. 10
SIBLING..................................... ................. 11
COUSIN ..................................... ................. 12
OTHER RELATIVE................... ................. 13
OTHER NONRELATIVE .......... ................. 14
DON’T KNOW
REFUSED
YHS5.
Is [Name] male or female?
Male ............................................ 1
Female......................................... 2
Don’t Know
Refused
YHS6.
What is (your/his/her) current age?
Age: ______________________
Don’t Know
Refused
MTO Youth Qnaire
Page B-2
Revised 08/09/07
B_Section 02: SOCIAL NETWORKS (YSN)
YSN1.
About how many friends do you have who you either hang out with, talk to on the phone or get together with
socially?
NUMBER OF FRIENDS_____________________
YSN2.
About how many CLOSE FRIENDS do you have these days? These are people you feel at ease or hang out with,
and, can talk to about private matters, or call on for help. Would you say that you have no close friends, one or two,
three to five, six to ten, or more than ten?
NO CLOSE FRIENDS
1
1 OR 2 CLOSE FRIENDS
2
3 TO 5 CLOSE FRIENDS
3
6 TO 10 CLOSE FRIENDS
4
MORE THAN 10 CLOSE FRIENDS
5
DK
RF
YSN3.
Thinking about the friends with whom you spend most of your time. What age group are they in? Are they about
your age, one or two years older than you, three to five years older than you, or more than five years older than you?
YOUNGER THAN ME
1
ROUGHLY MY AGE GROUP
2
ONE TO TWO YEARS OLDER THAN ME
3
THREE TO FIVE YEARS OLDER THAN ME
4
MORE THAN FIVE YEARS OLDER THAN ME
5
DK
RF
MTO Youth Qnaire
Page B-3
Revised 08/09/07
YSN4.
During the hours when you are not at school, how often do you either talk on the phone, hang out, or get together
with this [friend/these friends]—most every day, a few times a week, a few times a month, about once a month, or
less than once a month?
MOST EVERY DAY (INCLUDES 5-7 TIMES PER WEEK)
1
A FEW TIMES A WEEK (INCLUDES 2-4 TIMES PER WEEK)
2
A FEW TIMES A MONTH (INCLUDES 2-4 TIMES PER
MONTH/1 TIME PER WEEK)
3
ABOUT ONCE A MONTH
4
LESS THAN ONCE A MONTH
5
NEVER (IF VOLUNTEERED)
6
DK
RF
YSN5.
Among the close friends you hang out with, how important is it to:
VERY
IMPORTANT
SOMEWHAT
IMPORANT
NOT AT ALL
IMPORTANT
REF
DK
YSN5a.
Attend class regularly
1
2
3
7
8
YSN5b.
Get good grades
1
2
3
7
8
YSN5c.
Study
1
2
3
7
8
YSN5d.
Continue their education past high
chool
1
2
3
7
8
YSN5e.
Do community work or volunteer
1
2
3
7
8
YSN6.
Which of the following things does/has your close friend do/done?
(Do/does your close friends ever….)
YSN6a.
Get involved in school activities like school clubs,
teams, or projects?
YSN6b.
Use marijuana or other drugs?
MTO Youth Qnaire
YES
NO
REF
DK
1
2
7
8
1
2
7
8
Page B-4
Revised 08/09/07
(Do/does your close friends ever….)
YSN6c.
Carry a knife, gun, or weapon?
YES
NO
REF
DK
1
2
7
8
YSN6d.
Drop out of school
1
2
7
8
YSN6e.
Had or fathered a baby?
1
2
7
8
NUMBER
DK
REF
_______
-1
-2
YSN6g.
How many use marijuana or other drugs?
_______
-1
-2
YSN6h.
How many carry a gun, knife, or weapon?
_______
-1
-2
YSN6i.
How many dropped out of school?
_______
-1
-2
YSN6j.
How many had or fathered a baby?
_______
-1
-2
YSN6f.
Out of the friends you just told me about, how many ever do each of
the following things. How many get involved in school activities
like school clubs, teams, or projects?
YSN7.
How often is each of the following true for you?
VERY
OFTEN
SOMEWHAT
OFTEN
NOT AT
REFUSED
ALL
OFTEN
YSN7a.
I speak proper English, even with my
friends outside school.
1
2
3
7
8
YSN7b.
People would describe my behavior as
ghetto
1
2
3
7
8
MTO Youth Qnaire
DON’T
KNOW
Page B-5
Revised 08/09/07
YSN8.
The next few questions are about all your friends. Some people have friends who mostly know one another. Other
people have friends who don’t know one another. Would you say that: all your friends know one another; most of
your friends know one another, only a few of your friends know one another, or none of your friends know one
another?
ALL YOUR FRIENDS KNOW ONE ANOTHER
1
MOST OF YOUR FRIENDS KNOW ONE ANOTHER
2
ONLY A FEW OF YOUR FRIENDS KNOW ONE ANOTHER
3
NONE OF YOUR FRIENDS KNOW ONE ANOTHER
4
NO FRIENDS (GO TO W10)
5
REFUSED
7
DON’T KNOW
8
YSN9.
Did you meet or know our friends through school, relatives, the neighborhood, a club or group you belong to, or
other friends?
[ IWER: CHECK ALL THAT APPLY]
FAMILY/RELATIVES
IN YOUR (CURRENT/LAST) SCHOOL
1
2
YOUR NEIGHBORHOOD (CURRENT OR FORMER)
3
WORK
4
CHURCH
5
A GROUP YOU BELONG TO
6
FROM MY EARLY CHILDHOOD
7
OTHER: ______________________________
95
YSN10.
How many of your current friends were also your friends when you were [AGE at RANDOM ASSIGNMENT]?
__________Number (IF NONE, GO TO YSN13)
YSN11a.
The next few questions are about your friends from when you were [AGE AT RANDOM ASSIGNMENT]
During the past year, how many of these friends have come to visit you?
__________Number
MTO Youth Qnaire
Page B-6
Revised 08/09/07
YSN11b.
During the past year, how many of these friends did you visit?
________Number
Most
every
day
A few
times a
week
A few
times a
month
About
once a
month
Less
than
once a
month
Never
Ref
DK
YSN12a.
During the past year, how often
have you visited these friends –
almost every day, a few times a
week, a few times a month, about
once a month, less than once a
month, or never?
1
2
3
4
5
6
7
8
YSN12b.
During the past year, how often
have they come to visit you?
1
2
3
4
5
6
7
8
YSN13.
How many of your close friends live in your neighborhood?
NONE
1
SOME
2
ABOUT HALF
3
MOST
4
ALL
5
DK
RF
YSN14.
Many churches, synagogues, and other places of worship have special activities for teenagers—such as youth groups,
Bible classes, or choir. In the past 12 months, how often did you attend such youth activities: Did you go once a week
or more, once a month or more but less than once a week, less than once a month, or never?
ONCE A WEEK OR MORE
1
ONCE A MONTH OR MORE (BUT LESS THAN ONCE A WEEK)
2
LESS THAN ONCE A MONTH
3
NEVER
4
DK
RF
MTO Youth Qnaire
Page B-7
Revised 08/09/07
YSN15.
At my house, we watch news on the TV and talk about it.
ALL OF THE TIME
1
SOME OF THE TIME
2
HARDLY EVER
3
NEVER
4
DK
RF
YSN16.
Now I have some questions about how you think about yourself. How strongly do you agree or disagree with these
statements?
Strongly
Agree
Disagree Strongly
DK
RF
Agree
Disagree
YSN16a.
I don’t have enough control over the
direction my life is taking
1
2
3
4
5
6
YSN16b.
Every time I try to get ahead, something
or somebody stops me.
1
2
3
4
5
6
YSN16c.
In my life, good luck is more important
than hard work for success
1
2
3
4
5
6
YSN16d.
My plans hardly ever work out, so
planning only makes me unhappy
1
2
3
4
5
6
YSN16e.
When I make plans, I am almost certain I
can make them work.
1
2
3
4
5
6
YSN16f.
Chance and luck are very important for
what happens in my life
1
2
3
4
5
6
YSN16g.
I am just as smart as others my age
1
2
3
4
5
6
YSN16h.
I find it hard to make friends
1
2
3
4
5
6
YSN16i.
I have a lot of friends
1
2
3
4
5
6
YSN16j.
I am really easy to like
1
2
3
4
5
6
MTO Youth Qnaire
Page B-8
Revised 08/09/07
Strongly
Agree
YSN16k.
I don’t know whether I like a new outfit
until I find out what my friends think of it.
1
Agree
2
Disagree
3
Strongly
Disagree
DK
4
5
RF
6
YSN17.
Most people think about how other people see them. How do you think other people see you?
Not At All
Sometimes
Very
DK
RF
YSN17a.
As Popular
1
2
3
4
5
YSN17b.
As Athletic
1
2
3
4
5
YSN17c.
Socially Active
1
2
3
4
5
YSN17d.
Good Student
1
2
3
4
5
YSN17e.
Important
1
2
3
4
5
YSN17f.
Trouble Maker
1
2
3
4
5
YSN17g.
As Part of the leading crowd
1
2
3
4
5
YSN17h.
As Not Fitting In Any Group
1
2
3
4
5
MTO Youth Qnaire
Page B-9
Revised 08/11/07
Section 03: NEIGHBORHOOD (YNB)
YNB1.
Taken all together, how would you say things are these days. Would you say that you are very happy, pretty
happy, or not too happy?
VERY HAPPY
1
PRETTY HAPPY
2
NOT TOO HAPPY
3
DON’T KNOW
REFUSED
YNB2.
We would like to learn some more about what you did and how you felt yesterday. Not all days are the same –
some are better, some are worse, and others are pretty typically. Specifically, we are wondering how your day
went and how you felt at [RANDOMLY SELECTED TIME] yesterday.
What were you doing at [RANDOMLY SELECTED TIME]? (Please check all that apply)
MTO Youth Qnaire
COMMUTING
1
WORKING
2
SHOPPING
3
PREPARING FOOD
4
DOING HOUSEWORK
5
TAKING CARE OF YOUR CHILDREN
6
EATING
7
PRAYING/WORSHIPPING/MEDITATING
8
SOCIALIZING
9
WATCHING TV
10
NAP/RESTING
11
COMPUTER/INTERNET/EMAIL
12
RELAXING
13
ON THE PHONE
14
INTIMATE RELATIONS
15
EXERCISING
16
OTHER (SPECIFY)
95
REFUSED (SKIP TO YNB14)
97
DON’T KNOW (SKIP TO YNB14)
98
Page B-10
Revised 08/11/07
YNB3.
[NOTE TO INTERVIEWER: IF ONLY ONE ACTIVITY CHOSEN, THEN SKIP.]
Which activity above would you consider the main activity at [RANDOMLY SELECTED TIME], that is, the
activity that took up the most time?
COMMUTING
1
WORKING
2
SHOPPING
3
PREPARING FOOD
4
DOING HOUSEWORK
5
TAKING CARE OF YOUR CHILDREN
6
EATING
7
PRAYING/WORSHIPPING/MEDITATING
8
SOCIALIZING
9
WATCHING TV
10
NAP/RESTING
11
COMPUTER/INTERNET/EMAIL
12
RELAXING
13
ON THE PHONE
14
INTIMATE RELATIONS
15
EXERCISING
16
OTHER (SPECIFY)
95
DON’T KNOW
REFUSED
YNB4.
At what time did [INSERT NAME OF MAIN ACTIVITY] begin?
Time: _______________
DON’T KNOW
REFUSED
YNB5.
At what time did [INSERT NAME OF MAIN ACTIVITY] end?
Time: _______________
DON’T KNOW
REFUSED
MTO Youth Qnaire
Page B-11
Revised 08/11/07
YNB6.
Where were you while you were [INSERT NAME OF MAIN ACTIVITY]?
AT HOME
1
AT SCHOOL/WORK
2
SOMEONE ELSE’HS HOUSE IN NEIGHBORHOOD
3
SOMEWHERE ELSE IN THE NEIGHBORHOOD
4
SOMEWHERE ELSE
5
DON’T KNOW
REFUSED
YNB7.
Were you interacting with anyone? (including on the phone)
YES
1
NO (SKIP TO YNB9)
5
DON’T KNOW
REFUSED
YNB8.
If you were interacting with someone, who was it? (check all that apply)
SPOUSE / SIGNIFICANT OTHER
1
MY CHILDREN
2
FRIENDS
3
PARENTS / RELATIVES
4
CO-WORKERS
5
BOSS
6
CLIENTS / CUSTOMERS
7
OTHER PEOPLE NOT LISTED
8
DON’T KNOW
REFUSED
MTO Youth Qnaire
Page B-12
Revised 08/11/07
YNB9
Please rate each feeling on the scale given. A rate of 0 means that you did not experience that feeling at all. A
rating of 6 means that this feeling was a very important part of the experience. Please give me the number
between 0 and 6 that best describes how you felt.
0
1
2
3
4
5
6
RF
DK
6
7
8
5
6
7
8
4
5
6
7
8
3
4
5
6
7
8
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8
0
1
2
3
4
5
6
7
8
YNB9h.
Angry / hostile
0
1
2
3
4
5
6
7
8
YNB9i.
Worried/anxious
0
1
2
3
4
5
6
7
8
YNB9j.
Enjoying myself
0
1
2
3
4
5
6
7
8
YNB9k.
Criticized/put down
0
1
2
3
4
5
6
7
8
YNB9l.
Tired
0
1
2
3
4
5
6
7
8
YNB9a.
Impatient for it to end
0
1
2
3
4
5
YNB9b.
Happy
0
1
2
3
4
YNB9c.
Frustrated/annoyed
0
1
2
3
YNB9d.
Depressed/blue
0
1
2
YNB9e.
Competent/capable
0
1
YNB9f.
Hassled/pushed around
0
YNB9g.
Warm/friendly
MTO Youth Qnaire
Page B-13
Revised 08/11/07
YNB10.
Now I’d like to talk about the neighborhood you live in. Which of the following statements best describes how
satisfied you are with your neighborhood? Would you say you are very satisfied, somewhat satisfied, somewhat
dissatisfied, or very dissatisfied?
Very satisfied
1
Somewhat satisfied
2
In the middle
3
Somewhat dissatisfied
4
Very dissatisfied
5
Don’t know
Refused
YNB11a.
Now I would like to get a sense of how safe you think your neighborhood is. On the streets near your home
during the day, would you say very safe, safe, unsafe, or very unsafe?
Very Safe
1
Safe
2
Unsafe
3
Very Unsafe
4
Don’t Know
Refused
YNB11b.
On the streets near your home at night? Very safe, safe, unsafe, or very unsafe?
Very Safe
1
Safe
2
Unsafe
3
Very Unsafe
4
Don’t Know
Refused
MTO Youth Qnaire
Page B-14
Revised 08/11/07
YNB12.
Now I have a few questions about discrimination. Sometimes people feel like they are discriminated against, or
treated badly or differently because of their race or ethnicity. Can you think of one or more occasions in the last
6 months when you felt you were treated unfairly because of your race or ethnicity in the following places?
How about…
YES
NO
REF
DK
YNB12a.
At your school or work?
1
2
7
8
YNB12b.
At a neighborhood playground or recreation program?
1
2
7
8
YNB12c.
In a store where you were shopping or a restaurant where you
wanted to eat?
1
2
7
8
YNB12d.
When you met someone for the first time?
1
2
7
8
YNB12e.
In dealing with the police, such as a traffic accident?
1
2
7
8
YNB13.
Sometimes people feel they are discriminated against, or treated badly or differently because they might not
have quite as much money as other people, or because of the way they dress or talk. Can you think of one or
more occasions in the last 6 months when you felt you were treated unfairly because of how much money your
family has or the way you dress or talk? How about…
YES
NO
REF
DK
YNB13a.
At your school or work?
1
2
7
8
YNB13b.
At a neighborhood playground or recreation program?
1
2
7
8
1
2
7
8
1
2
7
8
1
2
7
8
YNB13c.
In a store where you were shopping or a restaurant where
you wanted to eat?
YNB13d.
When you met someone for the first time?
YNB13e.
In dealing with the police, such as a traffic accident?
YNB14.
Have you seen people using or selling illegal drugs in your neighborhood during the past 30 days?
MTO Youth Qnaire
YES
1
NO (SKIP TO YNB16 )
2
REFUSED (SKIP TO YNB16)
7
DON’T KNOW (SKIP TO YNB16)
8
Page B-15
Revised 08/11/07
YNB15a.
How often have you seen someone using drugs in your neighborhood in the past 30 days? Would you say
almost every day, once a week, or once or twice in the past 30 days, or didn’t see any using?
ALMOST EVERY DAY (INCLUDES 4-7 DAYS A WEEK)
1
ONCE A WEEK (INCLUDES 1-3 DAYS A WEEK)
2
ONCE OR TWICE IN THE PAST 30 DAYS (INCLUDES 1-3
TIMES IN 30 DAYS)
DIDN’T SEE ANY USING
3
4
REFUSED
DON’T KNOW
YNB15b.
How often have you seen someone selling drugs in your neighborhood in the past 30 days? Would you say
almost every day, once a week, or once or twice in the past 30 days, or you didn’t see any selling?
ALMOST EVERY DAY (INCLUDES 4-7 DAYS A WEEK)
1
ONCE A WEEK (INCLUDES 1-3 DAYS A WEEK)
2
ONCE OR TWICE IN THE PAST 30 DAYS (INCLUDES 1-3
TIMES IN 30 DAYS)
DIDN’T SEE ANY SELLING
3
4
REFUSED
DON’T KNOW
YNB16.
How often do people make unwanted or rude comments to you?
NEVER
1
A COUPLE OF TIMES EACH YEAR
2
A COUPLE OF TIMES EACH MONTH
3
ONCE OR TWICE A WEEK
4
EVERY DAY
5
REFUSED
DON’T KNOW
MTO Youth Qnaire
Page B-16
Revised 08/11/07
YNB17.
How often do people give you sexual attention that you do not want?
NEVER
1
A COUPLE OF TIMES EACH YEAR
2
A COUPLE OF TIMES EACH MONTH
3
ONCE OR TWICE A WEEK
4
EVERY DAY
5
REFUSED
DON’T KNOW
YNB18.
How often are you afraid to go places because you worry about unwanted attention or pressure?
NEVER
1
A COUPLE OF TIMES EACH YEAR
2
A COUPLE OF TIMES EACH MONTH
3
ONCE OR TWICE A WEEK
4
EVERY DAY
5
REFUSED
DON’T KNOW
MTO Youth Qnaire
Page B-17
Revised 08/12/07
Section 04: EDUCATION and TRAINING (YED)
YED1.
The first set of questions are about your educational experiences. Are you currently attending or enrolled in
regular school?
[INTERVIEWER: REGULAR SCHOOL IS ONE THAT OFFERS AN ACADEMIC DIPLOMA OR
DEGREE; E.G., ELEMENTARY SCHOOL, HIGH SCHOOL, COLLEGE, GRADUATE SCHOOL,
LAW SCHOOL, OR NURSING PROGRAM LEADING TO AN RN DEGREE. NOT INCLUDED AS
REGULAR SCHOOL ARE: TRAINING AT A TECHNICAL INSTITUTE, LICENSE TRADE
PROGRAMS, ETC, UNLESS THE CREDITS OBTAINED ARE TRANSFERABLE TO A REGULAR
SCHOOL AND COULD COUNT TOWARD AN ACADEMIC DIPLOMA OR DEGREE.]
Yes
1
No (SKIP TO YED3)
2
ON SUMMER VACATION
3
REFUSED (SKIP TO YED3)
7
DON’T KNOW (SKIP TO YED3)
8
YED2.
Are you attending school full-time or part-time?
FULL-TIME
1
PART-TIME
2
REFUSED
7
DON’T KNOW
8
YED2a.
What grade or year of school are you currently attending?
Grade: ________
[IF GRADE 12 OR LESS, SKIP TO YED5. IF ABOVE 12TH GRADE, CODE AS FOLLOWS]:
MTO Youth Qnaire
FIRST YEAR OF COLLEGE
13
SECOND YEAR OF COLLEGE
14
THIRD YEAR OF COLLEGE
15
FOURTH YEAR OF COLLEGE
16
VOCATIONAL/TRADE SCHOOL
17
OTHER (SPECIFY): ____________
95
REFUSED (SKIP TO YED5)
97
DON’T KNOW (SKIP TO YED5)
98
Page B-18
Revised 08/12/07
YED2b.
Are you attending a two-year college, a four-year college, or a trade or business school?
TWO-YEAR PROGRAM
1
FOUR-YEAR PROGRAM
2
TRADE SCHOOL
3
BUSINESS SCHOOL
4
OTHER (SPECIFY): ____________
95
REFUSED
97
DON’T KNOW
98
YED3.
When were you last enrolled in regular school—what was the month and year?
__________/__________
Month (MM) Year (YYYY)
DON’T KNOW
-1
REFUSED
-2
NEVER ENROLLED (SKIP TO YED30)
-3
YED4.
What is the main reason you left at that time?
RECEIVED DEGREE, COMPLETED COURSE WORK
EXPELLED/SUSPENDED
GOT MARRIED
PREGNANT
SCHOOL WAS TOO DANGEROUS
POOR GRADES
DID NOT LIKE SCHOOL/TIRED OF SCHOOL
OFFERED JOB
ENTERED MILITARY
FINANCIAL DIFFICULTIES, COULDN’T AFFORD TO GO
CHILD CARE RESPONSIBILITIES
HOME RESPONSIBILITIES
MOVED AWAY FROM SCHOOL
DIDN’T GET ALONG WITH OTHER STUDENTS
MY FRIENDS HAD DROPPED OUT OF SCHOOL
HAD A PROBLEM WITH DRUGS OR ALCOHOL
BECAME THE FATHER/MOTHER OF A BABY
HAD A HEALTH PROBLEM
OTHER (SPECIFY) ____________
REFUSED
DON’T KNOW
MTO Youth Qnaire
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
95
97
98
Page B-19
Revised 08/12/07
YED5.
The next few questions ask about life in (high) school. If you are not currently in (high) school, please think
about the time when you were last in (high) school when answering these questions.
During the school year, how often [have you been/were] you late for school?
Never (LESS THAN ONCE A MONTH)
Once a month
Once every two weeks (2-3 TIMES A MONTH)
Once a week (4-5 TIMES A MONTH)
Several times a week (2-4 TIMES A WEEK)
Everyday (5 TIMES A WEEK)
REFUSED
DON’T KNOW
1
2
3
4
5
6
7
8
YED6.
During the school year, how many days were you absent from school?
NUMBER OF DAYS ABSENT ____________
REFUSED
-1
DON’T KNOW
-2
YED7.
During the school year, how many times did you cut classes or skip school?
Never
1
Once a month
2
Once every two weeks (2-3 TIMES A MONTH)
3
Once a week (4-5 TIMES A MONTH)
4
Several times a week (2-4 TIMES A WEEK)
5
Everyday (5 TIMES A WEEK)
6
REFUSED
7
DON’T KNOW
8
YED8.
Which of the following happened the last time you cut classes or skipped school?
MTO Youth Qnaire
THE SCHOOL DID NOT DO ANYTHING
1
SOMEONE FROM SCHOOL CALL MY HOME
2
SOMEONE FROM SCHOOL VISITED MY HOME
3
THE SCHOOL SENT A LETTER TO MY HOME
4
THE SCHOOL MADE ME SEE A COUNSELOR
5
OTHER (SPECIFY): ______________________________
95
REFUSED
97
DON’T KNOW
98
Page B-20
Revised 08/12/07
YED9.
(RB) Overall, what grades did you receive [last year/the last full year of school you completed]?
MOSTLY A’S (90-100)
1
ABOUT HALF A’S AND HALF B’S (85-89)
2
MOSTLY B’S (80-84)
3
ABOUT HALF B’S AND HALF C’S (75-79)
4
MOSTLY C’S (70-74)
5
ABOUT HALF C’S AND HALF D’S (65-69)
6
MOSTLY D’S (60-64)
7
MOSTLY BELOW D (BELOW 60)
8
OTHER (SPECIFY) _______________
95
REFUSED
97
DON’T KNOW
98
YED10.
What is the lowest grade you could get without your parents getting upset?
MOSTLY A’S (90-100)
1
ABOUT HALF A’S AND HALF B’S (85-89)
2
MOSTLY B’S (80-84)
3
ABOUT HALF B’S AND HALF C’S (75-79)
4
MOSTLY C’S (70-74)
5
ABOUT HALF C’S AND HALF D’S (65-69)
6
MOSTLY D’S (60-64)
7
MOSTLY BELOW D (BELOW 60)
8
THEY WOULD NEVER GET UPSET _______________
9
REFUSED
97
DON’T KNOW
98
YED11.
What average grade did you receive [last year/last full year of school you completed] in each of these subjects?
A
B
C
D
Below D
DK
RF
YED11a. Math
YED11b. English
YED11c. Social Studies
YED11d. Science
MTO Youth Qnaire
Page B-21
Revised 08/12/07
YED12.
Have you ever taken/Did you ever take] any classes in algebra, geometry, or other advanced math?
YES
1
NO (SKIP TO YED13)
2
REFUSED (SKIP TO YED13)
7
DON’T KNOW (SKIP TO YED13)
8
YED12a.
(RB) What subjects are you taking or have you completed in math?
[INTERVIEWER: CHECK ALL THAT APPLY]
ALGEBRA I
1
GEOMETRY
2
ALGEBRA II
3
TRIGONOMETRY
4
PRE-CALCULUS OR ADVANCED ALGEBRA
5
CALCULUS
6
OTHER (SPECIFY): ______________________________
95
REFUSED
97
DON’T KNOW
98
NO OTHER MENTIONS
0
YED13.
Thinking about [your school/when you were last in school], in general, how much do you agree with each of the
following statements about your school and teachers:
STRONGLY
AGREE
AGREE
DISAGREE
STRONGLY
DISAGREE
RF
DK
YED13a.
The teachers [are/were] interested in
students. Do you strongly agree, agree,
disagree, or strongly disagree?
1
2
3
4
7
8
YED13b.
Students get along well with teachers.
1
2
3
4
7
8
YED13c.
In this school, students get teased if they
study hard to get good grades.
1
2
3
4
7
8
YED13d.
Disruptions by other students [get/got] in the
way of my learning.
1
2
3
4
7
8
YED13e.
There [is/was] a lot of cheating on tests and
assignments.
1
2
3
4
7
8
MTO Youth Qnaire
Page B-22
Revised 08/12/07
STRONGLY
AGREE
AGREE
DISAGREE
STRONGLY
DISAGREE
RF
DK
YED13f.
Discipline [is/was] fair.
1
2
3
4
7
8
YED13g.
I [feel/felt] safe at this school.
1
2
3
4
7
8
YED13h.
Misbehaving students (at my school) often
get away with it.
1
2
3
4
7
8
YED13i.
In class, I often feel “put down” by my
teachers.
1
2
3
4
7
8
YED14.
Overall about how much total time do you spend on homework each week, both in and out of school? Mark “in
school” or “out of school.”
In school
Out of School
None
1 hour or less
2-3 hours
4-6 hours
7-9 hours
10-12 hours
13-15 hours
Over 15
hours
DK
RF
YED15.
About how much homework are you assigned on a typical school night evening?
MTO Youth Qnaire
None
1
Less than 1 hour
2
2 to 3 hours
3
More than 3 hours
4
REFUSED
7
DON’T KNOW
8
Page B-23
Revised 08/12/07
YED16.
When homework is assigned, how much do you usually complete?—never assigned, none of it, some of it, most
of it, all, all plus some extra?
Never assigned
1
None of it
2
Some of it
3
Most of it
4
All
5
All plus some extra
6
REFUSED
7
DON’T KNOW
8
YED17.
In a typical day, how many class periods do you spend in study hall—none, one, 2, 3, 4, over 4?
None ................................................................................0
One ..................................................................................1
2.......................................................................................2
3.......................................................................................3
4.......................................................................................4
Don’t know
Refused
YED18.
How much additional reading [do/did] you do each week on your own outside of school—not in connection
with schoolwork? Do not count any assigned reading.
NUMBER OF HOURS: ___________ (SKIP TO YED19)
DON’T KNOW
REFUSED
-1
-2
YED18a.
Which of these is closest to the amount of time you usually [spend/spent] reading on your own outside of school
or work each week? 1-4 hours, 5-9 hours, 10-14 hours, 15-19 hours, 20 or more hours per week?
MTO Youth Qnaire
1-4 HOURS PER WEEK
1
5-9 HOURS PER WEEK
2
10-14 HOURS PER WEEK
3
15-19 HOURS PER WEEK
4
20 OR MORE HOURS PER WEEK
5
REFUSED
7
DON’T KNOW
8
Page B-24
Revised 08/12/07
YED19.
Do you currently use a computer at home?
YES
1
NO
2
REFUSED
7
DON’T KNOW
8
YED20.
In the past month, how frequently have you used the internet at any location?
Never/Rarely .........................................................................................1
Less than once a week ..............................................................................2
Once or twice a week ...............................................................................3
Every day or almost every day .................................................................4
Don’t know
Refused
[IF AGE IS LESS THAN 15, SKIP TO YED23]
YED21.
(Did you take/Have you taken) any of the Advanced Placement — or AP — exams?
[INTERVIEWER: AP EXAMS ARE USED BY COLLEGES TO GRANT CREDIT AND
PLACEMENT, AND ARE ADMINISTERED BY THE COLLEGE BOARD WITH THE
EDUCATIONAL TESTING SERVICE]
YES
1
NO
2
REFUSED
7
DON’T KNOW
8
YED22.
Have you ever taken the SAT or ACT test?
MTO Youth Qnaire
YES
1
NO
2
REFUSED
7
DON’T KNOW
8
Page B-25
Revised 08/12/07
YED23.
(Have/had) you ever been in any of the following kinds of courses or programs in high school?
YES
NO
RF
DK
YED23a.
Remedial English?
(sometimes called basic or essential)
1
2
7
8
YED23b.
Remedial mathematics?
(sometimes called basic or essential)
1
2
7
8
1
2
7
8
1
2
7
8
1
2
7
8
YED23c.
Any special class or special help for any
emotional, physical or mental condition?
YED23d.
A vocational course?
YED23e.
A program for the gifted and talented?
YED24.
Please mark one for each activity you (have/had) participated in (this/most recent) school year.
PARTCIPATED
PARTICIPATED
AS AN
OFFICER/
LEADER
RF
DK
2
3
4
7
8
1
2
3
4
7
8
YED24c.
Academic clubs (Art,
Computer, Engineering,
Debate/Forensics, foreign
languages, Science, Math,
Psychology, Philosophy
Club, etc.)
1
2
3
4
7
8
YED24d.
Any other club or group
(band, drama,
racial/ethnic/cultural group)
1
2
3
4
7
8
SCHOOL
DOES
NOT
HAVE
DID NOT
PARTICIPATE
YED24a.
School sponsored sports
(baseball, basketball,
football, soccer, hockey,
etc.)
1
YED24b.
Student government or
honor society
MTO Youth Qnaire
Page B-26
Revised 08/12/07
YED25.
Have you held a leadership position in any activity, club or group in school?
Yes...................................................................................1
No ....................................................................................5
DK
RF
YED26.
As things stand now, how far in school do you think you will get?
[NOTE to interviewer: Skip “less than high school” if youth is high school graduate YED2a > 12.]
Less than high school graduation
1
High school graduation only
2
VOCATIONAL, TRADE, OR BUSINESS SCHOOL AFTER HIGH SCHOOL
Less than two years of school
3
Two years or more of school
4
A degree from a vocational, trade, or business school
5
COLLEGE PROGRAM
Less than two years of college
6
Two or more years of college (including two-year degree)
7
Finish college (four- or five-year degree)
8
GRADUATE OR PROFESSIONAL SCHOOL
Master’s degree or equivalent
9
Ph.D., M.D., or other professional degree
10
DOES NOT APPLY
95
REFUSED
97
DON’T KNOW
98
MTO Youth Qnaire
Page B-27
Revised 08/12/07
YED27.
How far in school do you think your mother wants you to go?
Less than high school graduation
1
High school graduation only
2
VOCATIONAL, TRADE, OR BUSINESS SCHOOL AFTER HIGH SCHOOL
Less than two years of school
3
Two years or more of school
4
A degree from a vocational, trade, or business school
5
COLLEGE PROGRAM
Less than two years of college
6
Two or more years of college (including two-year degree)
7
Finish college (four- or five-year degree)
8
GRADUATE OR PROFESSIONAL SCHOOL
Master’s degree or equivalent
9
Ph.D., M.D., or other professional degree
10
DOES NOT APPLY
95
REFUSED
97
DON’T KNOW
98
YED28.
Who has influenced you the most on any decisions about courses you take in school or your future schooling
and education?
Mother .............................................................................1
Father...............................................................................2
Stepparent........................................................................3
Brothers or sisters ............................................................4
Other relatives .................................................................5
Teachers ..........................................................................6
Coach...............................................................................7
Guidance counselor .........................................................8
Advisor or school principal .............................................9
Friends at school..............................................................10
Young adults you admire.................................................11
Other leaders in the community.......................................12
No One ............................................................................13
DK
RF
MTO Youth Qnaire
Page B-28
Revised 08/12/07
YED29.
In a typical week how much time do you spend on other activities?
NEVER
LESS THAN
ONCE A
WEEK
ONCE/
TWICE A
WEEK
EVERY
DAY
RF
DK
1
2
3
4
7
8
1
2
3
4
7
8
YED29c.
Hanging out in the neighborhood, at
the basketball court or local park
1
2
3
4
7
8
YED29d.
Hanging out at home or in the yard
1
2
3
4
7
8
YED29e.
Shopping at a mall, or store
1
2
3
4
7
8
YED29a.
Youth groups or recreational sports,
classes or other lessons
YED29b.
Volunteer work or community
service or other types of community
activities
YED30.
[ASK ONLY OF 17-20 YEAR OLDS; IF AGE 10-16, SKIP TO Next section]: Now I would like to ask you
about other types of schooling and training you may have had.
[Other than your regular school, which we’ve already talked about], in the last two years, have you participated
in any training program that lasted at last two weeks that was designed to help you find a job, improve your job
skills, or learn a new job?
YES
1
NO (SKIP TO NEXT SECTION)
2
REFUSED (SKIP TO NEXT SECTION)
7
DON’T KNOW (SKIP TO NEXT SECTION)
8
YED31.
What kind of training was that? (RECORD VERBATIM)
MTO Youth Qnaire
GENERAL EQUIVALENCY DIPLOMA (GED)
1
ENGLISH AS A SECOND LANGUAGE
2
COMPUTER TRAINING
3
WORK STUDY PROGRAM
4
CERITIFICATION OR TRAINING IN A HEALTH CARE FIELD
5
OTHER [SPECIFY] __________________________________
95
REFUSED
97
DON’T KNOW
98
NO OTHER MENTIONS
0
Page B-29
Revised 08/12/07
YED32.
How many weeks in total did you participate in training in the last two years?
NUMBER OF WEEKS: ______________
DON’T KNOW
-1
REFUSED
-2
YED33.
During those weeks, how many hours a week did you usually spend in training?
NUMBER OF HOURS: _______________
DON’T KNOW
-1
REFUSED
-2
YED33a.
Are you currently participating in training?
MTO Youth Qnaire
YES
1
NO
2
REFUSED
7
DON’T KNOW
8
Page B-30
Revised 08/09/07
SECTION 05: EMPLOYMENT (YEM)
INTERVIEWER CHECKPOINT – REFER TO Household Listing
IF YOUTH 10-14: (GO TO next module)
IF YOUTH 15-20: (GO TO YEM1)
YEM1.
Now I’d like to ask a few questions about any jobs you may have. Last week, did you do any work for pay?
Yes ............................................................................... 1(GO TO YEM3)
No ................................................................................5
If Volunteered, Disabled.............................................. 7 (GO TO YEM13)
If Volunteered, Unable to Work .................................. 8 (GO TO YEM13)
DK ............................................................................... D (GO TO YEM13)
RF ................................................................................ R (GO TO YEM13)
________________________________________________________________
YEM2.
(RB) What is the main reason that you did not work for pay last week?
Disabled ....................................................................... 2
Unable to Work............................................................ 3
Has Job But Temporarily Absent................................. 4
Couldn’t Find Any Work ............................................. 5
Child Care Problems .................................................... 6
Family Responsibilities................................................ 7
In School or Other Training......................................... 8
Waiting For a New Job to Begin.................................. 9
Other (Specify)____________________..................... 10
DK
RF
(GO TO YEM13)
YEM3.
Last week, did you have more than one job, including part-time and weekend work?
Yes .................................... 1
No ..................................... 5
DK
RF
YEM4.
How many hours per week do you usually work at your (main) job? (By main job, we mean the one at which
you usually work the most hours.)
Hours Each Week: ________________....................... 1 (GO TO YEM5)
Hours Vary Each Week ............................................... 7
DK ............................................................................... D
RF ................................................................................ R
MTO Youth Qnaire
1
Page B-31
Revised 08/09/07
YEM4a.
Do you usually work 35 hours or more per week at your main job?
Yes .................................................. 1
No ................................................... 5
Hours Vary...................................... 7
DK
RF
INTERVIEWER CHECKPOINT – Refer to YEM3
IF MORE THAN ONE JOB (YEM3= ‘YES’), ASK YEM4b
IF ONLY ONE JOB (YEM3=‘NO’,‘D’,‘R’), GO TO YEM5
YEM4b.
How many hours per week do you work at your other job(s)?
HOURS PER WEEK: __________
DON’T KNOW
REFUSED
YEM5.
When did you first start working (at your main job)?
♦ ENTER MONTH AND YEAR
DK
RF
_ _/_ _ _ _
YEM6.
For your (main) job, what is the easiest way for you to report your total earnings before taxes or other deductions:
hourly, weekly, annually, or on some other basis?
Hourly .......................................................................... 1
Daily ............................................................................ 2
Weekly......................................................................... 3
Biweekly (every 2 weeks)............................................ 4
Twice Monthly............................................................. 5
Monthly........................................................................ 6
Annually ...................................................................... 7
Per Unit (Specify Unit Type)_________ ..................... 8
Other (Specify)___________________....................... 9
DK
RF
YEM7.
Do you usually receive overtime pay, tips, or commissions (at your main job)?
Yes .................................... 1
No ..................................... 5
DK
RF
MTO Youth Qnaire
2
Page B-32
Revised 08/09/07
INTERVIEWER CHECKPOINT – REFER TO YEM6
IF EARNING = HOURLY ...................... (GO TO YEM10)
(YEM6 = ‘1’)
IF EARNING = DAILY, WEEKLY, BIWEEKLY, TWICE MONTHLY, MONTHLY, ANNUALLY
(YEM6 = (‘2’, ‘3’, ‘4’, ‘5’, ‘6’, ‘7’)....... (GO TO YEM8)
IF EARNING = PER UNIT
(YEM6 = ‘8’) ......................................... (GO TO YEM9b)
IF EARNING = OTHER, DK, RF
(YEM6 = (‘9’, ‘.D’ or ‘.R’).................... (GO TO YEM12)
YEM8.
(Including overtime pay, tips, and commissions), what are your usual (daily/weekly/biweekly/twice
monthly/monthly/annual) earnings on (this) job, before taxes or other deductions?
♦ ENTER DOLLAR AMOUNT: $_____________
DK
RF
YEM8a.
(IF RATE OF PAY IS DAILY): How many days a week do you usually work?
♦ ENTER NUMBER OF DAYS ___________
DK
RF
YEM9.
How many weeks a year do you get paid for?
♦ ENTER NUMBER OF WEEKS ____________ (GO TO YEM12)
DK
RF
INTERVIEWER CHECKPOINT – REFER TO YEM6, YEM7
IF EARNING IS ‘PER UNIT’ AND OVERTIME IS ‘YES’
(YEM6 = ‘8’ AND YEM7= ‘1’)……………... ....1 (GO TO YEM9d)
IF EARING IS ‘PER UNIT’ AND OVERTIME IS (‘NO’, ‘DK’ or ‘RF’)
(YEM6 = ‘8’ AND YEM7= (‘5’, ‘.D’ or ‘.R’).................2 (GO TO YEM9b)
YEM9b.
What is your rate of pay per unit of (on this job)?
♦ ENTER DOLLAR AMOUNT
DK
RF
MTO Youth Qnaire
$ ___________
3
Page B-33
Revised 08/09/07
INTERVIEWER CHECKPOINT – REFER TO YEM9b
IF RATE OF PAY PER UNIT > 0
(YEM9b > ‘0’) ...................................................... (GO TO YEM9c)
IF RATE OF PAY PER UNIT = ‘0’, ‘DK’ or ‘RF’
(YEM9b = (‘0’, ‘.D’ or ‘.R’)................................ (GO TO YEM12)
YEM9c.
For how many units are you usually paid per week (on this job)?
♦ ENTER NUMBER OF UNITS _________
DK
RF
YEM9d.
(Excluding overtime pay, tips, and commissions) What is your rate of pay per unit of (on this job)?
♦ ENTER DOLLAR AMOUNT $___________
DK
RF
INTERVIEWER CHECKPOINT – REFER TO YEM9d
IF RATE OF PAY PER UNIT > 0
(YEM9d > ‘0’) ...................................................... (GO TO YEM9e)
IF RATE OF PAY PER UNIT = (‘0’, ‘DK’ or ‘RF’)
(YEM9d = (‘0’, ‘.D’ or ‘.R’)................................ (GO TO YEM9g)
YEM9e.
For how many units are you usually paid per week (on this job/at this rate)?
♦ ENTER NUMBER OF UNITS _________
DK .................................... D (GO TO YEM12)
RF ..................................... R (GO TO YEM12)
YEM9g.
(At your main job,) how much do you usually receive just in overtime pay, tips, commissions, before taxes or
other deductions?
♦ ENTER DOLLAR AMOUNT $____________
DK
RF
INTERVIEWER CHECKPOINT – REFER TO YEM9g
IF AMOUNT OF OVERTIME PAY, TIPS, COMMISSIONS > ‘0’
(YEM9g > ‘0’) ................................................... (GO TO YEM9h)
IF AMOUNT OF OVERTIME PAY, TIPS, COMMISSIONS = (‘0’, ‘.D’, ‘.R’)
(YEM9g = (‘0’, ‘.D’ or ‘.R’)............................... (GO TO YEM12)
MTO Youth Qnaire
4
Page B-34
Revised 08/09/07
YEM9h.
Is that per hour, per day, per week, per month, per year, per unit, or something else?
Per Hour.......................................... 1
Per Day ........................................... 2
Per Week......................................... 3
Per Month ....................................... 4
Per Year .......................................... 5
Per Unit........................................... 6
Other (Specify)_________.............. 7
DK
RF
INTERVIEWER CHECKPOINT – REFRE TO YEM6, YEM7, YEM9h
YEM6 = ‘8’ AND YEM7 = ‘1’ AND YEM9h = ‘2’ .................................................1
(GO TO YEM9l)
YEM6 = ‘8’ AND YEM7 = ‘1’ AND YEM9h = ‘6’ .................................................2
(GO TO YEM9j)
YEM6 = ‘8’ AND YEM7 = ‘1’ AND YEM9h = ‘1’) ...............................................3
(GO TO YEM9k)
YEM6 = ‘8’ AND YEM7 = ‘1’
AND YEM9h = (‘3’, ‘4’, ‘5’, ‘7’, ‘.D’ or ‘.R’).............................................4
(GO TO YEM12)
YEM9j.
For how many days/units are you usually paid per week at this rate?
♦ ENTER NUMBER OF DAYS OR UNITS ___________
DK
RF
(GO TO YEM12)
YEM9k.
How many hours do you usually work per week at this rate?
♦ ENTER HOURS PER WEEK ___________ (GO TO YEM12)
DK .................................................. D (GO TO YEM12)
RF ................................................... R (GO TO YEM12)
YEM9l.
How many days per week do you usually work at this rate?
♦ ENTER DAYS PER WEEK _____________
DK
RF
(GO TO YEM12)
MTO Youth Qnaire
5
Page B-35
Revised 08/09/07
YEM10 CHECKPOINT
IF EARNING IS ‘HOURLY’ AND OVERTIME IS ‘YES’
(YEM6 = ‘1’ AND YEM7 =‘1’)...................................................................1 (GO TO YEM11a)
IF EARING IS ‘HOURLY’ AND OVERTIME IS (‘NO’, ‘DK’ or ‘RF’)
(YEM6 = ‘1’ AND YEM7 = (‘5 ‘,’.D’ or ‘.R’)) ..........................................2
(GO TO YEM10a)
YEM10a.
What is your hourly rate of pay (on this job)?
♦ ENTER dollar amount _____________
DK
RF
(GO TO YEM12)
YEM11a.
Excluding overtime pay, tips and commissions what is your hourly rate of pay (on this job)?
♦ ENTER DOLLAR AMOUNT $____________
DK
RF
YEM11b.
How many hours do you usually work per week at this rate?
♦ ENTER HOURS PER WEEK __________
DK
RF
YEM11c.
(At your main job,) how much do you usually receive just in overtime pay, tips, commissions, before taxes or
other deductions?
♦ ENTER DOLLAR AMOUNT $_____________
DK
RF
INTERVIEWER CHECKPOINT – REFER TO YEM11c
IF AMOUNT OF OVERTIME PAY, TIPS, COMMISSIONS > ‘0’
(YEM11c > ‘0’) ..........................................................................1 (GO TO YEM11d)
IF AMOUNT OF OVERTIME PAY, TIPS, COMMISSIONS = (‘0’, ‘.D’, ‘.R’)
(YEM11c = (‘0’, ‘.D’ or ‘.R’)......................................................2 (GO TO YEM12)
MTO Youth Qnaire
6
Page B-36
Revised 08/09/07
YEM11d.
Is that per hour, per day, per week, per month, per year, per unit, or something else?
Per Hour.......................................... 1 (GO TO YEM11e)
Per Day ........................................... 2 (GO TO YEM11e)
Per Week......................................... 3 (GO TO YEM12)
Per Month ....................................... 4 (GO TO YEM12)
Per Year .......................................... 5 (GO TO YEM12)
Per Unit........................................... 6 (GO TO YEM11e)
Other (Specify)_________.............. 7 (GO TO YEM12)
DK .................................................. D (GO TO YEM12)
RF ................................................... R (GO TO YEM12)
YEM11e.
For how many (units/days/hours) are you usually paid per week at this rate?
♦ ENTER UNIT/DAY/HOUR PER WEEK _____________
DK
RF
YEM12
(RB) I’d like to ask you how you found the (main) job you have now. What is the most important source of
information you used to find this job?
A Friend, Relative, or Acquaintance............. .............. 1
A Government Employment Agency............ .............. 2
A Private Employment Agency ...... ............. .............. 3
Checking Directly With Employer . ............. .............. 4
A Referral from A Job Training Program ..... .............. 5
The Newspaper ............................... ............. .............. 6
A School Employment Service ....... ............. .............. 7
A Computer Search......................... ............. .............. 8
Church............................................. ............. .............. 9
Community Center.......................... ............. .............. 10
Other (Specify)_____________________.... .............. 11
DK
RF
(GO TO YEM17)
YEM13. Have you been doing anything to find work during the past four weeks?
Yes ....................................1
No .....................................5 (GO TO YEM17)
Disabled ............................7 (GO TO YEM17)
Unable to Work.................8 (GO TO YEM17)
DK ....................................D (GO TO YEM17)
RF .....................................R (GO TO YEM17)
MTO Youth Qnaire
7
Page B-37
Revised 08/09/07
YEM14
(RB) What are all the things you have done to find work during the past four weeks?
♦ ENTER ALL THAT APPLY
Contacted Employer(s) ......................................................................................................... 1
Contacted Public Employment Agency Programs/Courses .................................................. 2
Contacted Private Employment Agency ............................................................................... 3
Contacted Friends or Relatives ............................................................................................. 4
Interviewed for a Job ............................................................................................................ 5
Contacted School/University Employer Center .................................................................... 6
Sent out Resumes/Filled out Applications ............................................................................ 7
Checked Union/Professional Registers ................................................................................. 8
Placed or Answered Ads....................................................................................................... 9
Looked at Ads....................................................................................................................... 10
Attended Job Training........................................................................................................... 11
Nothing ................................................................................................................................. 12
Other (Specify) ..................................................................................................................... 13
DK
RF
YEM15.
Last week, could you have started a job if one had been offered?
Yes .................................... 1 (GO TO YEM17)
No ..................................... 5
DK .................................... D (GO TO YEM17)
RF ..................................... R (GO TO YEM17)
YEM16.
Why is that?
Waiting For New Job to Begin ......................................................... 1
Own Temporary Illness..... ............................................................... 2
Going To School............... ............................................................... 3
Other (Specify)______________________...................................... 4
DK
RF
MTO Youth Qnaire
8
Page B-38
Revised 08/09/07
YEM17.
Now I am going to ask you about any other paid employment you have had in the past 2 years (other than the job
we just discussed). This should include any paid employment you have now. Please tell me about any work you
have had as an employee, that is, work you had in an ongoing relationship with a particular employer. For
example, working in a supermarket or restaurant would be work as an employee.
In the past 2 years, have you done any/are you doing (other) work as an employee for which you were paid?
Yes .................................... 1
No ..................................... 5 (GO TO YEM24)
DK .................................... D (GO TO YEM24)
RF ..................................... R (GO TO YEM24)
YEM17a.
Now I am going to ask a few questions about the most recent (other) employer you had in the past 2 years. Please
tell me the name of your most recent (other) employer?
______________________________
DK
RF
YEM18.
What kind of work did you usually do for this employer?
[RECORD TYPE OF WORK FOR EMPLOYER. IF RESPONDENT WORKS FOR A
TEMPORARY AGENCY, REFER TO THAT AS ONE JOB]
Please describe: __________________________________________________________________
__________________________________________________________________
YEM19.
When did you first start working for this employer?
♦ ENTER MONTH AND YEAR _________ / ________
DK
RF
YEM20.
Are you currently working for this employer?
Yes .................................... 1 (GO TO YEM22)
No ..................................... 5
DK .................................... D (GO TO YEM22)
RF ..................................... R (GO TO YEM22)
YEM21.
When did you stop working for this employer?
♦ ENTER MONTH AND YEAR _________ / ________
DK
RF
MTO Youth Qnaire
9
Page B-39
Revised 08/09/07
YEM22.
How much (do/did) you usually earn per week from this employer?
♦ ENTER DOLLAR AMOUNT $_________
DK
RF
YEM23.
How many hours per week (do/did) you usually work for this employer?
♦ ENTER NUMBER OF HOURS ____________
DK
RF
YEM24.
During the past month have you worked as a freelancer – doing things like babysitting or mowing lawns – or
worked by yourself, for example, running your own business?
Yes .................................... 1
No ..................................... 5 (GO TO next module)
DK .................................... D (GO TO next module)
RF ..................................... R (GO TO next module)
YEM24a.
In the last month, how many hours did you do this type of work?
♦ ENTER HOURS PER MONTH _____________
DK
RF
YEM24b.
In the past month, approximately how much did you earn doing this type of work?
♦ ENTER DOLLAR AMOUNT $___________
DK
RF
MTO Youth Qnaire
10
Page B-40
Revised 08/09/07
B_Section 06: YOUTH PHYSICAL HEALTH (YPH)
YPH1.
Now I’d like to ask you some questions about your health. In general, how is your health: excellent, very good,
good, fair, or poor?
EXCELLENT
1
VERY GOOD
2
GOOD
3
FAIR
4
POOR
5
REFUSED
7
DON’T KNOW
8
YPH2.
Have you ever been told by a doctor or other health professional that you had asthma?
YES
1
NO (SKIP TO YPH4)
2
REFUSED (SKIP TO YPH4)
7
DON’T KNOW (SKIP TO YPH4)
8
YPH3.
During the past 12 months, have you had an episode of asthma or an asthma attack?
YES
1
NO
2
REFUSED
DON’T KNOW
YPH3a.
During the past three months, have you used prescription inhalers? Do not include over-the-counter inhalers like
Primatene Mist.
YES
1
NO
2
REFUSED
DON’T KNOW
MTO Youth Qnaire
Page B-41
Revised 08/09/07
YPH4.
During the past 12 months, have you had a wheezing or whistling sound in your chest?
YES
1
NO (SKIP TO YPH9)
2
REFUSED (SKIP TO YPH9)
7
DON’T KNOW (SKIP TO YPH9)
8
YPH5.
How many attacks of wheezing or whistling have you had in your chest during the past 12 months?
NUMBER OF ATTACKS _______________
REFUSED
DON’T KNOW
YPH6.
During the past 12 months, how many times have you gone to the doctor’s office or the
for one or more of these attacks of wheezing or whistling?
hospital emergency room
NUMBER OF TIMES _________
REFUSED
DON’T KNOW
YPH7.
During the past 12 months, how much did you limit your usual activities due to wheezing or whistling? Would you
say…
Not at all
1
A little
2
A fair amount
3
A moderate amount
4
A lot
5
Refused
Don’t Know
YPH8.
During the past 12 months, how many days of work and school did you miss due to wheezing or whistling?
NUMBER OF DAYS MISSED SCHOOL/WORK ____________ (SKIP TO YPH9)
DON’T KNOW
-1
REFUSED (SKIP TO YPH9)
-2
MTO Youth Qnaire
Page B-42
Revised 08/09/07
YPH8a. [INTERVIEWER: PROBE]
Is that …
Zero days
1
1-7 days
2
8-30 days
3
31 days or more
4
Refused
Don’t Know
YPH9. Height Measurement
____ feet ____ inches
Refused
Don’t Know
YPH10.
Weight Measurement
_________ pounds
Refused
Don’t Know
YPH11.
In the past year have you had a routine physical examination?
YES
1
NO (SKIP TO YPH12)
2
DON’T KNOW (SKIP TO YPH12)
7
REFUSED (SKIP TO YPH12)
8
YPH11a.
Where did you have this examination? [CHECK ALL THAT APPLY]
Private doctor’s office
1
Community health clinics
2
School
3
Hospital
4
OTHER (SPECIFY) _____________________________
95
Refused
Don’t Know
MTO Youth Qnaire
Page B-43
Revised 08/09/07
YPH12.
How would you describe the condition of your teeth: excellent, very good, good, fair or poor?
Excellent
1
Very good
2
Good
3
Fair
4
Poor
5
Has no natural teeth
6
Refused
Don’t Know
YPH13.
In the past year have you had a dental examination by a dentist or hygienist?
YES (GO TO YPH15)
1
NO
2
DON’T KNOW
7
REFUSED
8
YPH14.
In the past year, what kept you from seeing a health professional when you really needed to? If there was more than
one reason, choose more than one answer.
Didn’t know whom to go see
1
Had no transportation
2
No one available to go along
3
Parent or guardian would not go along
4
Didn’t want parents to know
5
Difficult to make appointment
6
Afraid of what the doctor would say or do
7
I thought the problem would go away
8
Couldn’t pay
9
Didn’t have time
10
Too embarrassed
11
Thought the doctor would report something to the police
or other legal authorities
12
Didn’t think the doctor could help
13
OTHER (SPECIFY) _____________________________
95
Refused
Don’t Know
MTO Youth Qnaire
Page B-44
Revised 08/09/07
YPH15.
In the past 12 months, have you had any accidents or injuries that required medical attention?
YES
1
NO (SKIP TO YPH18)
2
REFUSED (SKIP TO YPH18)
7
DON’T KNOW (SKIP TO YPH18)
8
YPH16.
How many such accidents or injuries requiring medical attention have you had in the past 12 months?
NUMBER OF ACCIDENTS/INJURIES: ________________
DON’T KNOW (SKIP TO YPH18)
-1
REFUSED (SKIP TO YPH18)
-2
YPH17.
What was the cause of [that/the first/the second/etc.] accident or injury requiring medical attention?
[INTERVIEWER: REPEAT FOR UP TO 4 INJURIES. IF NECESSARY, PROBE]
How did it happen?
1st Accident/
Injury
1
2nd Accident/
Injury
1
3rd Accident/
Injury
1
4th Accident/
Injury
1
Other Sports-Related (E.G. Basketball,
Football, Volleyball, Cheerleading)
2
2
2
2
Other Kids Including Fights
3
3
3
3
Other Falls
4
4
4
4
External Factor (Broken Glass, Needle, Nail,
Car)
5
5
5
5
Other (Specify)
______________________________
95
95
95
95
Refused
97
97
97
97
Don’t Know
98
98
98
98
Cycling Or Skating
YPH18.
Other than [that/those] already mentioned have you had any serious accident or injury during the past 12 months
which limited your usual activities but did not require medical attention?
MTO Youth Qnaire
YES
1
NO (SKIP TO YPH20)
2
REFUSED (SKIP TO YPH20)
7
DON’T KNOW (SKIP TO YPH20)
8
Page B-45
Revised 08/09/07
YPH19.
How many of these accidents or injuries did you have during the past 12 months? Remember, these are ones that
did not require medical attention but did limit your usual activities.
NUMBER OF ACCIDENTS/INJURIES
____________
DON’T KNOW (SKIP TO YPH20)
-1
REFUSED (SKIP TO YPH20)
-2
YPH20.
What was the cause of [that/the first/the second/etc.] accident or injury not requiring medical attention?
[INTERVIEWER: REPEAT FOR UP TO 4 INJURIES. IF NECESSARY, PROBE] How did it happen?
1st Accident/
Injury
1
2nd Accident/
Injury
1
3rd Accident/
Injury
1
4th Accident/
Injury
1
Other Sports-Related (E.G. Basketball,
Foorball, Volleyball, Cheerleading)
2
2
2
2
Other Kids Including Fights
3
3
3
3
Other Falls
4
4
4
4
External Factor (Broken Glass, Needle,
Nail, Car)
5
5
5
5
Other (Specify)
______________________________
95
95
95
95
REFUSED
97
97
97
97
DON’T KNOW
98
98
98
98
Cycling Or Skating
YPH21.
The next few quests are about health problems you might have had at any time in your life. Have you ever had any
of the following: Headaches, chronic back or neck problems, frequent or very bad headaches or other chronic pain?
YES
1
NO
2
REFUSED
DON’T KNOW
MTO Youth Qnaire
Page B-46
Revised 08/09/07
YPH22.
Did a doctor or other health professional ever tell you that you have/had diabetes or high blood sugar, or a serious
stomach or bowel problem like an ulcer or colitis?
YES
1
NO
2
REFUSED
DON’T KNOW
YPH23.
Now I’d like to ask about the exercise you get. On how many of the past seven days did you exercise or participate
in physical activity for at least 20 minutes that made you sweat and breathe hard, such as basketball, soccer, running,
swimming, fast bicycling, fast dancing, or similar aerobic activities.
NUMBER OF DAYS: ________________
DON’T KNOW
-1
REFUSED
-2
YPH24.
On how many of the past seven days did you participate in physical activity for at least 30 minutes that did not make
you sweat and breathe hard, such as fast walking, slow bicycling, skating, pushing a lawn mower, or mopping
floors?
NUMBER OF DAYS: _______________
DON’T KNOW
-1
REFUSED
-2
YPH25.
In a typical week, how many times do you eat fruit? (Do not count fruit juice.)
MTO Youth Qnaire
I do not typically eat fruit
1
1 to 3 times per week
2
4 to 6 times per week
3
1 time per day
4
2 times per day
5
3 times per day
6
4 times or more per day
7
DON’T KNOW
-1
REFUSED
-2
Page B-47
Revised 08/09/07
YPH26.
In a typical week, how many times do you eat vegetables other than French fries or potato chips?
I do not typically eat vegetables
1
1 to 3 times per week
2
4 to 6 times per week
3
1 time per day
4
2 times per day
5
3 times per day
6
4 times or more per day
7
DON’T KNOW
-1
REFUSED
-2
YPH27.
In a typical week, how often do you drink regular, carbonated SODA OR SOFT DRINKS that contain sugar? Do
NOT include diet soda.
(DO NOT include diet or sugar-free fruit drinks. DO NOT include juices or tea in cans. DO NOT include diet
mineral water or diet flavored waters.)
MTO Youth Qnaire
I do not typically drink soda or soft drinks
1
1 to 3 times per week
2
4 to 6 times per week
3
1 time per day
4
2 times per day
5
3 times per day
6
4 times or more per day
7
DON’T KNOW
-1
REFUSED
-2
Page B-48
Revised 08/09/07
YPH28.
How often did you eat salty snacks, such as potato chips, pretzels, or popcorn?
I do not typically eat salty snacks
1
1 to 3 times per week
2
4 to 6 times per week
3
1 time per day
4
2 times per day
5
3 times per day
6
4 times or more per day
7
DON’T KNOW
-1
REFUSED
-2
YPH29.
How often did you eat sweet snacks, such as cookies, chocolate bars, or candy?
I do not typically eat sweet snacks
1
1 to 3 times per week
2
4 to 6 times per week
3
1 time per day
4
2 times per day
5
3 times per day
6
4 times or more per day
7
DON’T KNOW
-1
REFUSED
-2
YPH30.
On how many of the past seven days did you eat at a fast food type place—McDonald’s, Kentucky Fried Chicken,
Pizza Hut, Taco Bell, etc.?
MTO Youth Qnaire
0 days
0
1 day
1
2 days
2
3 days
3
4 days
4
5 days
5
6 days
6
7 days
7
DON’T KNOW
-1
REFUSED
-2
Page B-49
Revised 08/09/07
YPH31.
On a typical weeknight, what time do you usually go to bed?
Type in time in this format HH:MM A for AM or HH:MM P for PM. midnight is 12:00 A and noon is 12:00 P
TIME _________
DON’T KNOW
-1
REFUSED
-2
YPH32.
On a typical weeknight, what time do you usually get up?
TIME _________
DON’T KNOW
-1
REFUSED
-2
YPH33.
In a typical week, how many hours do you watch television or DVDs?
Less than 2 hours per week
1
3 to 10 hours per week
2
11 to 20 hours per week
3
21 to 30 hours per week
4
31 to 40 hours per week
5
More than 40 hours per week
6
DON’T KNOW
97
REFUSED
98
YPH34.
In a typical week, how many hours total do you use a computer, or play computer or video games?
MTO Youth Qnaire
None
1
Less than 1 hour a week
2
1 to 3 hours a week
3
4 to 6 hours a week
4
7 to 9 hours a week
5
10 hours or more a week
6
DON’T KNOW
97
REFUSED
98
Page B-50
Revised 08/08/07
Section 07: K-6 INDEX PLUS TRANQUILITY (YK6)
ALL OF
THE TIME
MOST OF
THE TIME
SOME
OF THE
TIME
A
LITTLE
OF THE
TIME
NONE
OF THE
TIME
RF
DK
Now I am going to ask you some
questions about feelings that you may
have experienced during the past 30
days. How much of the time during
the past 30 days have you felt…
YK61.
So sad that nothing could cheer you
up?
1
2
3
4
5
7
8
YK62.
Nervous?
1
2
3
4
5
7
8
YK63
Restless or fidgety?
1
2
3
4
5
7
8
YK64
Hopeless?
1
2
3
4
5
7
8
YK65
That everything was an effort?
1
2
3
4
5
7
8
YK66
Worthless?
1
2
3
4
5
7
8
YK67
Calm and peaceful?
1
2
3
4
5
7
8
MTO Youth Qnaire
Page B-51
Revised 08/08/07
VERY TRUE
SOMEWHAT
TRUE
NOT TRUE
RF
DK
The next questions are about this your
general behavior. For each item below,
please circle the appropriate number
indicating whether the statement is not true,
somewhat true, or very true.
YK68
Are you generally obedient? Do you usually
do what adults request?
YK69
Do you have many worries? Do you often
feel worried?
YK610
Are you often unhappy, depressed, or
tearful?
YK611
Do you get along better with adults than
with people your own age?
YK612
Do you see tasks through to the end? Do
you have a good attention span?
MTO Youth Qnaire
1
2
3
7
8
1
2
3
7
8
1
2
3
7
8
1
2
3
7
8
1
2
3
7
8
Page B-52
Revised 08/09/07
Section 08: Youth Mental Health Screener (YSC)
INTERVIEWER: READ FOLLOWING QUESTIONS SLOWLY
YSC1_SC20.
The next questions are going to require you to think back over your
entire life. Please take your time and think carefully before
answering. (INTERVIEWER: READ THE NEXT SENTENCE
SLOWLY ) Have you ever in your life had an attack of fear or panic
when all of a sudden you felt very frightened, nervous, or uneasy?
YSC2_SC20a.
Have you ever had an attack when all of a sudden
• you became very uncomfortable,
• you became short of breath, dizzy, sick to your stomach, or
• your heart beat very fast, or
• you thought that you might lose control, die, or go crazy?
YSC3_SC20_1.
Have you ever in your life had attacks of anger when all of a sudden
you lost control and broke or smashed something worth more than a
few dollars?
YSC4_SC20_2.
Have you ever had attacks of anger when all of a sudden you lost
control and hit or tried to hurt someone?
YSC5_SC20_3.
Have you ever had attacks of anger when all of a sudden you lost
control and threatened to hit or hurt someone?
YSC6_SC21.
Have you ever in your life had a time lasting a few days or longer
when most of the day you felt sad, empty or depressed?
YSC7_SC22.
Have you ever had a time lasting a few days or longer when most of
the day you felt very discouraged or hopeless about how things were
going in your life?
YSC8_SC23.
Have you ever had a time lasting a few days or longer when you lost
interest and became bored with most things you usually enjoy like
work, hobbies, and personal relationships?
YSC9_SC24.
Some people have times lasting anywhere between a few hours and a
few weeks when they feel much more excited and full of energy than
usual. Their minds go too fast. They talk a lot. They are very
restless or unable to sit still and they sometimes do things that are
unusual for them, such as taking many risks or spending too much
money. Have you ever had a time like this lasting several hours or
longer?
MTO Youth Qnaire
YES
(1)
NO
(5)
DK
(8)
RF
(9)
5
8
9
1
5
8
9
1
5
8
9
5
8
9
5
8
9
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
GO TO
YSC3
_SC20_1
1
GO TO
YSC6
_SC21
1
1
Page B-53
Revised 08/09/07
INTERVIEWER: READ FOLLOWING QUESTIONS SLOWLY
YSC10_SC25.
Have you ever had a time lasting a few days or longer when most of
the time you were very irritable, grouchy, or in a cranky mood?
YSC10a_SC25a.
Have you ever had a time lasting anywhere between a few hours and
a few weeks when most of the time you were so irritable or grouchy
that you either started arguments, shouted a lot, or hit people?
YSC11_SC26.
Did you ever have a time in your life when you were a “worrier” –
that is, when you worried a lot more about things than other people
with the same problems as you?
YSC11a_SC26a.
Did you ever have a time in your life when you were much more
nervous or anxious than most other people with the same problems
as you?
YSC11b_SC26b.
Did you ever have a time lasting one month or longer when you
were anxious and worried most days?
YES
(1)
NO
(5)
DK
(8)
RF
(9)
5
8
9
1
GO TO
YSC11
_SC26
GO TO
YSC11
_SC26
GO TO
YSC11
_SC26
1
5
8
9
1
5
8
9
5
8
9
5
8
9
GO TO
YSC12
_SC31
1
GO TO
YSC12
_SC31
1
YSC12_SC31.
The next question is about concentration problems that usually start before the age of seven. These problems include
not being able to keep your mind on what you are doing, losing interest very quickly in games or work, trouble
finishing what you started without being distracted, and not listening when people spoke to you. During your first
years at school—say between the ages of kindergarten and second grade -- was there ever a period lasting six months
or longer when you had a lot more trouble with problems of this sort than most children?
YES.................................................................. 1
NO.................................................................... 5
DON’T KNOW ............................................... 8
REFUSED ....................................................... 9
YSC13_SC32.
Some young kids are very restless and fidgety and so impatient that they often interrupt people and have trouble
waiting their turn. Did you ever have a time before the age of seven lasting six months or longer when you were like
that?
YES.................................................................. 1
NO.................................................................... 5
DON’T KNOW ............................................... 8
REFUSED ....................................................... 9
MTO Youth Qnaire
Page B-54
Revised 08/09/07
YSC14_SC33.
Did you ever have a period lasting six months or longer when you often did things that got you in trouble with adults
such as losing your temper, arguing or talking back to adults, refusing to do what your teachers or parents asked you
to do, annoying people on purpose, or being grouchy or irritable?
YES.................................................................. 1
NO.................................................................... 5
DON’T KNOW ............................................... 8
REFUSED ....................................................... 9
YSC15_SC33_1.
Many children and teenagers go through periods when they do things adults don’t want them to do, like lying,
stealing, or breaking rules. Did you ever go through a period during your childhood or teenage years when you did
any of these things?
YES.................................................................. 1
NO.................................................................... 5
DON’T KNOW ............................................... 8
REFUSED ....................................................... 9
GO TO YSC14_SC36
YSC16_SC33_2.
Did you ever go through a period where you either broke into cars, set fires, or destroyed property on purpose?
YES.................................................................. 1
NO.................................................................... 5
DON’T KNOW ............................................... 8
REFUSED ....................................................... 9
GO TO YSC18_SC36
YSC17_SC33_3.
Did you ever run away from home, or repeatedly play hooky from school, or often stay out much later at night than you
were supposed to?
YES.................................................................. 1
NO.................................................................... 5
DON’T KNOW ............................................... 8
REFUSED ....................................................... 9
MTO Youth Qnaire
Page B-55
Revised 08/09/07
YSC18_SC36.
INTERVIEWER CHECKPOINT: (SEE YSC1_SC20, YSC2_SC20a, YSC6_SC21, YSC7_SC22, YSC8_SC23,
YSC9_SC24, YSC10a_SC25a, YSC11_SC26, YSC11a_SC26a, YSC11b_SC26b)
FOLLOW SKIP FOR FIRST ENDORSED ITEM.
YSC6_SC21 EQUALS ‘1’ ................................................1
YSC7_SC22 EQUALS ‘1’ ................................................2
YSC8_SC23 EQUALS ‘1’ ................................................3
YSC9_SC24 EQUALS ‘1’ ................................................4
YSC10a_SC25a EQUALS ‘1’ ..........................................5
YSC1_SC20 EQUALS ‘1’ ................................................7
YSC1a_SC20a EQUALS ‘1’ ............................................8
YSC11_SC26 EQUALS ‘1’ ..............................................12
YSC11a_SC26a EQUALS ‘1’ ..........................................13
YSC11b_SC26b EQUALS ‘1’..........................................14
ALL OTHERS ................................................................ 15
MTO Youth Qnaire
GO TO YDE1_D1, NEXT SECTION
GO TO YDE2_D2
GO TO YDE3_D9
GO TO YMA1_M1
GO TO YMA4_M5
GO TO YPD1_PD1 INTRO 1
GO TO YPD1_PD1 INTRO 2
GO TO YGA1_G1 INTRO 1
GO TO YGA1_G1 INTRO 2
GO TO YGA1_G1 INTRO 3
GO TO CHECKPOINT IE1
Page B-56
Revised 08/07/07
Section 09: DEPRESSION (YDE)
YDE1_D1
A few moments ago, you mentioned having episodes that lasted several days or longer when you felt sad, empty, or
depressed most of the day. During episodes of this sort, did you ever feel discouraged about how things were going in
your life?
Yes ..................................................1
No....................................................5 (GO TO YDE1b_D1b)
DK................................................... (GO TO YDE1b_D1b)
RF.................................................... (GO TO YDE1b_D1b)
YDE1a_D1a
During the episodes of being sad, empty, or depressed, did you ever lose interest in most things like work, hobbies, and
other things you usually enjoy?
Yes .............................................................................. 1 (GO TO YDE4_D12)
No................................................................................ 5 (GO TO YDE4_D12)
DK............................................................................... (GO TO YDE4_D12)
RF................................................................................ (GO TO YDE4_D12)
♦ INTERVIEWER INSTRUCTION:
¾ IF YDE1a_D1a IS CODED 1 (YES), THEN READ “sad/discouraged/uninterested”
¾ IF YDE1a_D1a IS CODED 5 (NO), DK OR RF, THEN READ “sad/discouraged”
YDE1b_D1b
During the episodes of being sad, empty, or depressed, did you ever lose interest in most things like work, hobbies, and
other things you usually enjoy?
Yes .............................................................................. 1 (GO TO YDE4_D12)
No................................................................................ 5 (GO TO YDE4_D12)
DK............................................................................... (GO TO YDE4_D12)
RF................................................................................ (GO TO YDE4_D12)
♦INTERVIEWER INSTRUCTION:
¾ IF YDE1b_D1b IS CODED 1 (YES), THEN READ “sad/uninterested”
¾ IF YDE1b_D1b IS CODED 5 (NO), DK OR RF, THEN READ “sad”
YDE2_D2
A few moments ago, you mentioned having episodes that lasted several days or longer when you felt discouraged about
how things were going in your life. During episodes of this sort, did you ever lose interest in most things like work,
hobbies, and other things you usually enjoy?
Yes .............................................................................. 1 (GO TO YDE4_D12)
No................................................................................ 5 (GO TO YDE4_D12)
DK............................................................................... (GO TO YDE4_D12)
RF................................................................................ (GO TO YDE4_D12)
♦INTERVIEWER INSTRUCTION:
¾ IF YDE2_D2 IS CODED 1 (YES), THEN READ “discouraged/uninterested”
¾ IF YDE2_D2 IS CODED 5 (NO), DK OR RF, THEN READ “discouraged”
MTO Youth Qnaire
1
Page B-57
Revised 08/07/07
YDE3_D9
A few moments ago you mentioned having episodes that lasted several days or longer when you felt discouraged about
how things were going in your life. During episodes of this sort, did you ever lose interest in most things like work,
hobbies, and other things you usually enjoy?
Yes .............................................................................. 1
No................................................................................ 5
DK
RF
♦INTERVIEWER INSTRUCTION: READ “uninterested”
YDE4_D12
Did you ever have an episode of being sad, discouraged, or uninterested in things that lasted most of the day, early every
day, for two weeks or longer?
Yes .............................................................................. 1
No................................................................................ 5 (GO TO YDE19_D88)
DK............................................................................... (GO TO YDE19_D88)
RF................................................................................ (GO TO YDE19_D88)
YDE5_D16
Think of times lasting two weeks or longer when (this problem/these problems) with your mood (was/were) most severe
and frequent. During those times, did your feelings of sadness, discouragement, or lack of interest usually last less than
one hour a day, between 1 and 3 hours, between 3 and 5 hours, or more than 5 hours?
Less than 1 hour...............................................................1 (GO TO YDE19_D88)
Between 1 and 3 hours ....................................................2
Between 3 and 5 hours ....................................................3
More than 5 hours............................................................4
YDE6_D22
Please think of an episode of being sad, discouraged, or uninterested in things lasting two weeks or longer when you also
had other problems at the same time, such as changes in sleep, appetite, the ability to concentrate and remember, feelings
of low self worth, and other problems. Is there one particular episode of this sort that stands out in your mind as the
worst one you ever had?
♦ INTERVIEWER: READ SLOWLY
Yes ...................................................................................1
No.....................................................................................5 (GO TO YDE6d_D22c)
DK.................................................................................... (GO TO YDE6d_D22c)
RF .................................................................................... (GO TO YDE6d_D22c)
YDE6a_D22a
How old were you when that worst episode started?
♦ ENTER number of years of age____________________
MTO Youth Qnaire
2
Page B-58
Revised 08/07/07
YDE6b_D22b
How long did that worst episode last?
♦ ENTER length of duration
YDE6c_D22b
♦ ENTER unit of time
Days ............................................................................ 1 (GO TO YDE7_D24)
Weeks.......................................................................... 2 (GO TO YDE7_D24)
Months......................................................................... 3 (GO TO YDE7_D24)
Years ........................................................................... 4 (GO TO YDE7_D24)
DK............................................................................... (GO TO YDE7_D24)
RF................................................................................ (GO TO YDE7_D24)
YDE6d_D22c
Then think of the last time you had a bad episode of being sad, discouraged, or uninterested in things like this. How old
were you when that last episode occurred?
♦ ENTER age________________________
YDE6e_D22d
How long did that episode last?
♦ ENTER length of duration________________________
YDE6f_D22d
♦ ENTER unit of time
Days ............................................................................ 1
Weeks.......................................................................... 2
Months......................................................................... 3
Years ........................................................................... 4
YDE7_D24.
(RB, PG 5. FOR EACH ITEM ENDORSED, ASK R TO MARK IT IN THE RB.)
Look at page 5 in your booklet. In answering the next questions, think about the episode of two weeks or longer
during that episode when your sadness, discouragement, and loss of interest and other problems were most severe and
frequent. During that period, which of the following problems did you have most of the day nearly every day?
YES
(1)
NO
(5)
DK
(8)
RF
(9)
YDE7a_D24a.
Did you feel sad, empty, or depressed most of the day nearly every day during that
episode of two weeks?
1
5
8
9
YDE7b_D24c.
During that episode of two weeks, did you feel discouraged about how things
were going in your life most of the day nearly every day?
1
5
8
9
MTO Youth Qnaire
3
Page B-59
Revised 08/07/07
YDE7c_D24e.
During that episode of two weeks, did you lose interest in almost all things like
work and hobbies and things you like to do for fun?
YDE7d_D24f.
Did you feel like nothing was fun even when good things were happening?
1
5
8
9
1
5
8
9
INTERVIEWER CHECKPOINT: (SEE YDE7a_D24a-YDE7d_D24f)
ONE OR MORE RESPONSES CODED ‘1’ ............................ 1
ALL OTHERS........................................................................... 2
(RB, PG 5-6. FOR EACH ITEM ENDORSED, ASK R TO
MARK IT IN THE RB.)
YDE9a_D26a.
Did you have a much smaller appetite than usual nearly every
day during that period of two weeks?
YDE9b_D26b.
Did you have a much larger appetite than usual nearly every
day?
YDE9c_D26c.
Did you gain weight without trying to during that period of two
weeks?
(GO TO YDE19_D88)
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
GO TO
YDE9d_D26e
5
8
9
1
5
8
9
1
GO TO
YDE9e_D26g
5
8
9
1
5
8
9
1
GO TO
YDE9g_D26j
5
8
1
5
8
9
1
GO TO
YDE9i_D26l
5
8
9
IF R REPORTS BEING PREGNANT OR GROWING,
CODE "NO"
YDE9d_D26e.
Did you lose weight without trying to?
IF R REPORTS BEING ON A DIET OR PHYSICALLY
ILL, CODE "NO"
YDE9e_D26g.
Did you have a lot more trouble than usual either falling asleep,
staying asleep, or waking too early nearly every night during that
period of two weeks?
YDE9f_D26h.
Did you sleep a lot more than usual nearly every night during
that period of two weeks?
YDE9g_D26j.
Did you feel tired or low in energy nearly every day during that
period of two weeks even when you had not been working very
hard?
MTO Youth Qnaire
4
Page B-60
9
Revised 08/07/07
(RB, PG 5-6. FOR EACH ITEM ENDORSED, ASK R TO
MARK IT IN THE RB.)
YDE9h_D26k.
Did you have a lot more energy than usual nearly every day
during that period of two weeks?
YDE9i_D26l.
Did you talk or move more slowly than is normal for you nearly
every day?
YDE9j_D26m.
Did anyone else notice that you were talking or moving slowly?
YDE9k_D26n.
Were you so restless or jittery nearly every day that you paced up
and down or couldn't sit still?
YDE9l_D26o.
Did anyone else notice that you were restless?
YDE9m_D26p.
Did your thoughts come much more slowly than usual or seem
mixed up nearly every day during that period of two weeks?
YDE9n_D26r.
Did you have a lot more trouble concentrating than is normal for
you nearly every day?
YDE9o_D26s.
Were you unable to make up your mind about things you
ordinarily have no trouble deciding about?
YDE9p_D26t.
Did you lose your self-confidence?
YDE9q_D26u.
Did you feel that you were not as good as other people nearly
every day?
YDE9r_D26w.
Did you feel guilty nearly every day?
YDE9s_D26aa.
Did you often think a lot about death, either your own, someone
else’s, or death in general?
YDE9t_D26bb.
During that period, did you ever think that it would be better if
you were dead?
MTO Youth Qnaire
5
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
GO TO
YDE9k_D26n
8
GO TO
YDE9k
_D26n
9
GO TO
YDE9k
_D26n
1
GO TO
5
GO TO
8
GO TO
9
GO TO
YDE9m_D26p
YDE9m _D26p
YDE9m
_D26p
HD9Em
_D26p
1
5
8
9
GO TO
YDE9m_D26p
GO TO
YDE9m
_D26p
GO TO
YDE9m
_D26p
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
GO TO
YDE11_D28
5
8
9
1
GO TO
YDE11_D28
5
8
9
Page B-61
Revised 08/07/07
(RB, PG 5-6. FOR EACH ITEM ENDORSED, ASK R TO
MARK IT IN THE RB.)
YES
(1)
YDE9u_D26cc.
Did you think about committing suicide?
1
GO TO
YDE11_D28
NO
(5)
DK
(8)
RF
(9)
5
8
9
YDE10_D27
INTERVIEWER CHECKPOINT (See YDE7_D24 – YDE9_D26w)
¾ IF AT LEAST ONE ‘1’ (YES) RESPONSE IN YDE7a_D24a –YDE7b_D24c
............................................................................................................. INCREMENT COUNT BY ONE.
¾ IF AT LEAST ONE ‘1’ RESPONSE IN YDE7c_D24e – YDE7d_D24f,
..................................................................................................................INCREMENT COUNT BY ONE.
¾
INCREMENT COUNT BY ONE FOR EACH ‘1’ RESPONSE IN YDE9a_D26a – YDE9r_D26w.
COUNT EQUALS THREE OR MORE...............................................1
ALL OTHERS ........................................................................................2
(GO TO YDE19_D88)
YDE11_D28
You mentioned having a number of the problems I just asked you about. How much did your sadness, discouragement,
or lack of interest and these other problems interfere with either your work, your social life, or your personal
relationships during that episode– not at all, a little, some, a lot, or extremely?
Not at all ........................................................................................................1
A Little...........................................................................................................2
Some ..............................................................................................................3
A Lot..............................................................................................................4
Extremely.......................................................................................................5
YDE12_D17
How severe was your emotional distress during those times -- mild, moderate, severe, or very severe?
Mild..................................................................................1
Moderate..........................................................................2
Severe ..............................................................................3
Very Severe .....................................................................4
YDE13_D18
How often, during those times, was your emotional distress so severe that nothing could cheer you up -- often, sometimes,
rarely, or never?
Often ..............................................................................................................1
Sometimes .....................................................................................................2
Rarely.............................................................................................................3
Never..............................................................................................................4
MTO Youth Qnaire
6
Page B-62
Revised 08/07/07
INTERVIEWER CHECKPOINT ( See YDE11_D28, YDE12_D17, YDE13_D18)
If(YDE11_D28 Equals (‘3’,’4’,or ‘5’)) OR (YDE12_D17 Equals (‘2’,’3’, or ‘4’))
OR (YDE13_D18 Equals (‘1’ or ‘2’)).........................................................(Continue with YDE14_D37)
If None of Those Things is True ............................................................(GO TO YDE19_D88)
YDE14_D37
Think of the very first time in your life you had an episode lasting two-weeks or longer when most of the day nearly
every day you felt sad, discouraged, or uninterested and also had some of the other problems we just reviewed. Can you
remember your exact age?
Yes ...........................................................................................................1
No.............................................................................................................5 (GO TO YDE15b_D37b)
DK............................................................................................................ (GO TO YDE15b _D37b)
RF............................................................................................................. (GO TO YDE15b _D37b)
YDE14a_D37a.
(IF NEC: How old were you?)
♦ ENTER age ..........................................................................................(GO TO YDE15_D38)
DK............................................................................................................(GO TO YDE15_D38)
RF.............................................................................................................(GO TO YDE15_D38)
YDE14b_D37b
About how old were you (the first time you had an episode of this sort)?
♦ INTERVIEWER: IF “ALL MY LIFE” OR “AS LONG AS I CAN REMEMBER,”
PROBE: Was it before you first started school?
IF NOT YES,
PROBE: Was it before you were a teenager?
♦ ENTER age____________________________
Before Started School...............................................................................4
Before Teenager .......................................................................................12
Not Before Teenager ................................................................................13
YDE15_D38
Did you have an episode of being sad, discouraged, uninterested with some of the other problems (on pages 5-6) lasting
two weeks or longerat any time in the past 12 months?
Yes ...........................................................................................................1
No.............................................................................................................5 (GO TO YDE17_D38c)
DK............................................................................................................ (GO TO YDE17_D38c)
RF............................................................................................................. (GO TO YDE17_D38c)
MTO Youth Qnaire
7
Page B-63
Revised 08/07/07
YDE15a_D38a
How recently – in the past month, two to six months ago, or more than six months ago?
Past Month ...............................................................................................1
2-6 Months Ago .......................................................................................2
More Than 6 months Ago ........................................................................3
YDE16_D38b.
About how many days out of the last 365 were you in an episode?
♦ ENTER number of days____________ .................. (GO TO YDE18_D88)
DK............................................................................... (GO TO YDE18_D88)
RF................................................................................ (GO TO YDE18_D88)
YDE17_D38c
How old were you the last time you had one of these episodes?
♦ ENTER age___________________________
YDE18_D88
INTERVIEWER CHECKPOINT (SEE YSC1_SC20, YSC2_SC20a, YSC9_SC24, YSC11_SC25a, YSC12_SC26,
YSC13_SC26a, YSC14_SC26b):
♦ INTERVIEWER: FOLLOW SKIP FOR FIRST ENDORSED ITEM.
YSC9_SC24 Equals ‘1’ .................................................................. 1(GO TO YMA1_M1)
YSC11_SC25a Equals ‘1’ .............................................................. 2(GO TO YMA5_M5)
YSC1_SC20 Equals ‘1’...................................................................... 4 (GO TO YPD1_PD1_INTRO 1)
YSC2_SC20a Equals ‘1’ ................................................................... 4 (GO TO YPD1_PD1_INTRO 2)
YSC12_SC26 Equals ‘1’ ................................................................... 9 (GO TO YGA1_G1_INTRO 1)
YSC13_SC26a Equals‘1’ .................................................................. 10(GO TO YGA1_G1_INTRO 2)
YSC14_SC26b Equals ‘1’ ................................................................. 11(GO TO YGA1_G1_INTRO 3)
ALL OTHERS................................................................................... 12(GO TO YIE1_IED3)
MTO Youth Qnaire
8
Page B-64
Revised 08/07/07
Section 10: MANIA (YMA)
YMA1_M1
Earlier in the interview you mentioned having an episode lasting four days or longer when you felt much more excited
and full of energy than usual and your mind went too fast. People who have episodes like this often have changes in their
thinking and behavior at the same time, like being more talkative, needing very little sleep, being very restless, going on
buying sprees, and behaving in ways they would normally think are inappropriate. Did you ever have any of these
changes during your episodes of being excited and full of energy?
♦ INTERVIEWER: READ SLOWLY
Yes ....................................................................1 (GO TO YMA2_M3)
No......................................................................5 (GO TO CHECKPOINT YMA1a)
DK..................................................................... (GO TO CHECKPOINT YMA1a)
RF ..................................................................... (GO TO CHECKPOINT YMA1a)
YMA1a.
INTERVIEWER CHECKPOINT (SEE HCS10a_SC25a)
HSC10a_SC25a IS CODED 1 (YES)……………….(GO TO HM4_M5)
ALL OTHERS………………………………………..(GO TO HM15_M54)
YMA2_M3
Please think of the one episode when you were very excited and full of energy and you had the largest number of changes
like these at the same time. Is there one episode of this sort that stands out in your mind?
Yes ....................................................................1
No......................................................................5 (GO TO YMA2d_M3c)
DK..................................................................... (GO TO YMA2d_M3c)
RF ..................................................................... (GO TO YMA2d_M3c)
YMA2a_M3a
How old were you when that episode occurred?
♦ ENTER age________________
YMA2b_M3b
How long did that episode last?
♦ ENTER length of duration_____________________
YMA2c_M3b
♦ ENTER unit of time__________________
Hours.................................................................1
Days ..................................................................2
Weeks ...............................................................3
Months ..............................................................4
Years .................................................................5
DK..................................................................... (GO TO YMA3_M4)
RF ..................................................................... (GO TO YMA3_M4)
MTO Youth Qnaire
1
Page B-65
Revised 08/07/07
YMA2d_M3c
Then think of the most recent time you had an episode like this. How old were you when that most recent episode
occurred?
♦ ENTER age___________________
YMA2e_M3d
How long did that episode last?
♦ ENTER length of duration________________________
YMA2f_M3d
♦ ENTER unit of time
Hours.................................................................1
Days ..................................................................2
Weeks ...............................................................3
Months ..............................................................4
Years .................................................................5
YMA3_M4
During that episode, which of the following behavior changes did you experience: were you so irritable or grouchy that you
started arguments, shouted at people, or hit people?
Yes ....................................................................1
No......................................................................5
(GO TO YMA7a_M7a)
YMA4_M5
Earlier in the interview you mentioned having episodes lasting four days or longer when you became so irritable or
grouchy that you started arguments, shouted at people, or hit people. People who have episodes of irritability like this
often have changes in their thinking and behavior at the same time, like being more talkative, needing very little sleep,
being very restless, going on buying sprees and behaving in ways they would normally think are inappropriate. Did you
ever have any of these changes during your episodes of being very irritable or grouchy?
♦ INTERVIEWER: READ SLOWLY
Yes ....................................................................1
No......................................................................5 (GO TO YMA15_M54)
DK..................................................................... (GO TO YMA15_M54)
RF ..................................................................... (GO TO YMA15_M54)
MTO Youth Qnaire
2
Page B-66
Revised 08/07/07
YMA5_M6
Please think of the episode of four days or more when you were very irritable or grouchy and you had the largest number of
changes like these at the same time. Is there one episode of this sort that stands out in your mind?
Yes ....................................................................1
No......................................................................5 (GO TO YMA6d_M6c)
DK..................................................................... (GO TO YMA6d_M6c)
RF ..................................................................... (GO TO YMA6d_M6c)
YMA6a_M6a
How old were you when that episode occurred?
♦ ENTER age_______________________
YMA6b_M6b
How long did that episode last?
♦ ENTER length of duration_________________________
YMA6c_M6b
♦ ENTER unit of time
Hours.................................................................1
Days ..................................................................2
Weeks ...............................................................3
Months ..............................................................4
Years .................................................................5
DK
RF
(GO TO YMA7a_M7a)
YMA6d_M6c
Then think of the most recent time you had an episode like this. How old were you when that most recent episode
occurred?
♦ ENTER age_________________________
YMA6e_M6d
How long did that episode last?
♦ ENTER length of duration________________________
MTO Youth Qnaire
3
Page B-67
Revised 08/07/07
YMA6f_M6d
♦ ENTER unit of time
Hours.................................................................1
Days ..................................................................2
Weeks ...............................................................3
Months ..............................................................4
Years .................................................................5
YMA7_M7.
During that episode, which of the following changes did you experience:
YMA7a_M7a.
Did you become so restless or fidgety that you paced up and down or couldn’t
stand still?
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
(KEY PHRASE: being restless)
YMA7b_M7b.
Were you a lot more interested in sex than usual, or did you want to have sexual
encounters with people you wouldn’t ordinarily be interested in?
(KEY PHRASE: having a lot more interest in sex than usual)
YMA7c_M7c.
Did you become overly friendly or outgoing with people?
YMA7d_M7d.
Did you do anything else that wasn’t usual for you - - like talking about things you
would normally keep private, or acting in ways that you’d usually find
embarrassing?
(KEY PHRASE: behaving inappropriately)
YMA7e_M7e.
Did you try to do things that were impossible to do, like taking on large amounts
of work?
(KEY PHRASE: trying to accomplish unrealistic goals)
YMA7f_M7f.
Did you talk a lot more than usual or feel a need to keep talking all the time?
(KEY PHRASE: talking a lot more than usual)
YMA7g_M7g.
Did you constantly keep changing your plans or activities?
(KEY PHRASE: constantly changing plans)
MTO Youth Qnaire
4
Page B-68
Revised 08/07/07
YMA7_M7.
During that episode, which of the following changes did you experience:
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
YMA7h_M7h.
Did you find it hard to keep your mind on what you were doing?
(KEY PHRASE: hard to keep your mind on things)
YMA7i_M7i.
Did your thoughts seem to jump from one thing to another or race through your
head so fast you couldn’t keep track of them?
(KEY PHRASE: thoughts racing)
YMA7j_M7j.
Did you sleep far less than usual and still not get tired or sleepy?
(KEY PHRASE: sleeping far less than usual)
YMA7k_M7k.
Did you get involved in foolish investments or schemes for making money?
(KEY PHRASE: getting involved in foolish schemes)
YMA7l_M7l.
Did you spend so much more money than usual that it caused you to have
financial trouble?
(KEY PHRASE: getting into financial trouble)
YMA7m_M7m.
Did you do reckless things like driving too fast, staying out all night, or having
casual or unsafe sex?
(KEY PHRASE: doing risky things)
YMA7n_M7n.
Did you have a greatly exaggerated sense of self-confidence or believe you could
do things you really couldn’t do?
(KEY PHRASE: having too much self-confidence)
YMA7o_M7o.
Did you have the idea that you were actually someone else, or that you had a
special connection with a famous person that you really didn’t have?
(KEY PHRASE: believing you were someone else or somehow connected to
a famous person)
MTO Youth Qnaire
5
Page B-69
Revised 08/07/07
YMA8_M8 (See YMA7a_M7a – YMA7o_M7o)
THREE OR MORE RESPONSES CODED ‘1’ (YES) ..... …..1
ALL OTHERS.................................................................... ….. 2 (GO TO YMA15_M54)
YMA9_M9
Let me review. You had episodes when you were very (excited and full of energy/irritable or grouchy) and also had
some problems like (KEY PHRASE OF 3 “YES” RESPONSES IN HM7 SERIES). How much did these episodes ever
interfere with either your work, your social life, or your personal relationships – not at all, a little, some, a lot, or
extremely?
Not at all............................................................................. 1 (GO TO YMA15_M54)
A Little ............................................................................... 2 (GO TO YMA15_M54)
Some................................................................................... 3
A Lot .................................................................................. 4
Extremely ........................................................................... 5
YMA10_M9b
Did other people say anything or worry about the way you were acting?
Yes ....................................................................1
No......................................................................5
YMA11_M18
Think of the very first time in your life you had an episode lasting four days or longer when you became very
(excited and full of energy/irritable or grouchy) and also had some of the behavior changes you just reported. Can you
remember your exact age?
Yes ....................................................................1
No......................................................................5 (GO TO YMA11b_M18b)
DK..................................................................... (GO TO YMA11b_M18b)
RF ..................................................................... (GO TO YMA11b_M18b)
YMA11a_M18a
(How old were you?)
♦ ENTER age ________________
(GO TO YMA12_M19)
DK.................................... (GO TO YMA12_M19)
RF..................................... (GO TO YMA12_M19)
MTO Youth Qnaire
6
Page B-70
Revised 08/07/07
YMA11b_M18b
About how old were you the first time you had an episode of this sort?
♦ INTERVIEWER: IF “ALL MY LIFE” OR “AS LONG AS I CAN REMEMBER,”
PROBE: Was it before you first started school?
IF NOT YES, PROBE: Was it before you were a teenager?
♦ ENTER age________________________
Before Started School......................................................... 4
Before Teenager ................................................................. 12
Not Before Teenager .......................................................... 13
YMA12_M19
Did you have one of these episodes at any time in the past 12 months?
Yes ..................................................................................... 1
No....................................................................................... 5 (GO TO YMA14_M9d)
DK...................................................................................... (GO TO YMA14_M9d)
RF....................................................................................... (GO TO YMA14_M9d)
YMA13_M19c
How many weeks in the past 12 months were you in one of these episodes?
♦ ENTER number of weeks________________________(GO TO YMA15_M54)
DK...................................................................................... (GO TO YMA15_M54)
RF....................................................................................... (GO TO YMA15_M54)
YMA14_M19d
How old were you the last time you had one of these episodes?
♦ ENTER age________________________
DK
RF
CHECKPOINT_YMA15_M54 (See YSC1_SC20, YSC2_SC20a, YSC12_SC26, YSC12a_SC26a,
YSC12b_SC26b)
♦ FOLLOW SKIP FOR FIRST ENDORSED ITEM.
YSC1_SC20 Equals ‘1’ ...........................................................................1 (GO TO YPD1a_PD1 INTRO 1)
YSC2_SC20a Equals ‘1’ .........................................................................2 (GO TO YPD1b_PD1 INTRO 2)
YSC12_SC26 Equals ‘1’ .........................................................................6 (GO TO YGA1a_G1 INTRO 1)
YSC12a_SC26a Equals ‘1’ .....................................................................7 (GO TO YGA1b_G1 INTRO 2)
YSC12b_SC26b Equals ‘1’.....................................................................8 (GO TO YGA1c_G1 INTRO 3)
ALL OTHERS ........................................................................................9 (GO TO YIE1_IE1)
MTO Youth Qnaire
7
Page B-71
Revised 08/06/07
Section 11: PANIC DISORDER (YPD)
YPD1_PD1_INTRO 1
Earlier you mentioned having attacks of fear or panic
when all of a sudden you felt very frightened, anxious,
or uneasy. Think of a bad attack like that. During that
attack, which of the following problems did you have?
YPD1_PD1_INTRO 2
Earlier you mentioned having attacks when all of a sudden
you had several problems like being short of breath, your
heart pounding or feeling dizzy, and being afraid you would
die or go crazy. Think of a bad attack like that. During that
attack, which of the following problems did you have?
SKIP TO YPD2 AFTER FOUR “YES” RESPONSES
YPD1a_PD1a.
Did your heart pound or race?
(KEY PHRASE: heart racing)
YPD1b_PD1b.
Were you short of breath?
(KEY PHRASE: being short of breath)
YPD1c_PD1c.
Did you have nausea or discomfort in your stomach?
(KEY PHRASE: having nausea)
YPD1d_PD1d.
Did you feel dizzy or faint?
(KEY PHRASE: feeling dizzy)
YPD1e_PD1e.
Did you sweat?
(KEY PHRASE: sweating)
YPD1f_PD1f.
Did you tremble or shake?
(KEY PHRASE: trembling)
YPD1g_PD1g.
Did you have a dry mouth?
(KEY PHRASE: having a dry mouth)
YPD1h_PD1h.
Did you feel like you were choking?
(KEY PHRASE: choking)
YPD1i_PD1i.
Did you have pain or discomfort in your chest?
(KEY PHRASE: having discomfort in your chest)
YPD1j_PD1j.
Were you afraid that you might lose control of yourself or go crazy?
(KEY PHRASE: fearing that you might lose control of yourself)
MTO Youth Qnaire
1
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
Page B-72
Revised 08/06/07
YPD1k_PD1k.
Did you feel that you were “not really there”, like you were watching a movie
of yourself?
(KEY PHRASE: feeling unreal)
YPD1l_PD1l.
Did you feel that things around you were unreal or like a dream?
(KEY PHRASE: feeling that things around you were unreal)
YPD1m_PD1m.
Were you afraid that you might pass out?
(KEY PHRASE: fearing that you might pass out)
YPD1n_PD1n.
Were you afraid that you might die?
(KEY PHRASE: fearing that you might die)
YPD1o_PD1o.
Did you have hot flushes or chills?
(KEY PHRASE: having hot flushes)
YPD1p_PD1p.
Did you have numbness or tingling sensations?
(KEY PHRASE: having numbness)
1
GO TO
YPD1_P
D1m
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
YPD2_PD2 (See YPD1_PD1 SERIES)
COUNT OF # “YES” RESPONSES: ___________
SKIP INSTRUCTION:
ZERO TO THREE RESPONSES.......................................... 1(GO TO YPD17_PD66)
ALL OTHERS ....................................................................... 2
YPD3_PD3
During your attacks did the problems like (PARENTHETICAL PHRASE OF FIRST THREE YES RESPONSES IN YPD1
SERIES) begin suddenly and reach their peak within ten minutes after the attacks began?
(♦IF NECESSARY ASK: Did they begin within ten minutes after the start of the attack?)
Yes .................................................. 1
(IF VOL)Sometimes ....................... 3
No ................................................... 5
YPD4_PD4
About how many of these sudden attacks have you had in your entire lifetime?
♦ ENTER number of attacks_____________________
If R Reports More Than 900.................................................. 900
If R Reports “More Than I Can Remember ........................... 995
DK ...................................................................................
RF ....................................................................................
MTO Youth Qnaire
2
Page B-73
Revised 08/06/07
CHECKPOINT (YPD5)
YPD4_PD4 Equals ‘1’ ................................. 1
ALL OTHERS............................................. 2
(GO TO YPD17_PD66)
(GO TO YPD5_PD9)
YPD5_PD9
Can you remember your exact age the very first time you had one of these attacks?
Yes .................................................. 1
No ................................................... 5 (GO TO YPD5b_PD9b)
DK .................................................. (GO TO YPD5b _PD9b)
RF ................................................... (GO TO YPD5b _PD9b)
YPD5a_PD9a
(♦ INTERVIEWER: IF NECESSARY: How old were you?)
♦ ENTER age __________________________
(GO TO YPD6_PD10)
YPD5b_PD9b
About how old were you?
♦ INTERVIEWER: IF “ALL MY LIFE” OR “AS LONG AS I CAN REMEMBE,”
PROBE: Was it before you first started school?
IF NOT YES, PROBE: Was it before you were a teenager?
♦ ENTER age_______________________
Before Started School ..................................................4
Before Teenager...........................................................12
Not Before Teenager....................................................13
YPD6_PD10
Did you have one of these attacks at any time in the past 12 months?
Yes...................................................................................1
No ....................................................................................5 (GO TO YPD6d_PD10d)
DK ................................................................................... (GO TO YPD6d _PD10d)
RF .................................................................................... (GO TO YPD7a_PD13a)
YPD6a_PD10a
How recently – in the past month, between two and six months ago, or more than six months ago?
Past Month.......................................................................1
Between two and six months ago ...................................2
More than six months ago...............................................3
DK ...................................................................................
RF ....................................................................................
MTO Youth Qnaire
3
Page B-74
Revised 08/06/07
YPD6b_PD10b
How many weeks in the past 12 months did you have at least one attack?
♦ ENTER number of weeks________________________
DK ...................................................................................
RF ....................................................................................
YPD6c_PD10c
And how many attacks in all did you have in the past 12 months?
♦ ENTER number of attacks________________________ (GO TO YPD7a_PD13a)
DK ...............................................................................(GO TO YPD7a _PD13a)
RF ................................................................................(GO TO YPD7a _PD13a)
YPD6d_PD10d
How old were you the last time you had one of these attacks?
♦ ENTER age____________________
DK ...................................................................................
RF ....................................................................................
YPD7_PD13.
After having one of these attacks, did you ever have any of the following
experiences:
YPD7a_PD13a.
A month or more when you often worried that you might have another
attack?
YPD7b_PD13b.
A month or more when you worried that something terrible might happen
because of the attacks, like having a car accident, having a heart attack, or
losing control?
YPD7c_PD13c.
A month or more when you changed your everyday activities because of the
attacks?
YPD7d_PD13d.
A month or more when you avoided certain situations because of fear about
having another attack?
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
5
8
9
5
8
9
5
8
9
GO TO YPD8
_PD17
1
GO TO YPD8
_PD17
1
GO TO YPD8
_PD17
1
GO TO YPD8
__PD17
YPD8_PD17
Attacks of this sort can occur in three different situations. The first is when the attacks occur unexpectedly “out of the
blue.” The second is when a person has an unreasonably strong fear. For example, some people have a terrible fear of
bugs or of heights or of being in a crowd. The third is when a person is in real danger, like a car accident or a bank robbery.
The next question is about how many of your attacks occurred in each of these three kinds of situations. Did you ever have
an attack that occurred unexpectedly “out of the blue?”
MTO Youth Qnaire
4
Page B-75
Revised 08/06/07
Yes...................................................................................1
No ....................................................................................5 (GO TO YPD9_PD18)
DK ................................................................................... (GO TO YPD9_PD18)
RF .................................................................................... (GO TO YPD9_PD18)
YPD8a_PD17a
About how many attacks in your lifetime occurred unexpectedly “out of the blue?”
♦ ENTER number of attacks______________________
If R Reports More Than 900.................................................. 900
If R Reports “More Than I Can Remember” ...............995
DK ...................................................................................
RF ....................................................................................
YPD9_PD18
About how many attacks in your lifetime occurred in situations where you were not in real danger, but where you had an
unreasonably strong fear of the situations?
♦ ENTER number of attacks______________________________
If R Reports More Than 900.................................................. 900
If R Reports “More Than I Can Remember” ...............995
DK ...................................................................................
RF ....................................................................................
YPD10_PD19
About how many attacks in your lifetime occurred in situations where you were in real danger?
♦ INTERVIEWER: IF R THOUGHT THERE WAS REAL DANGER EVEN THOUGH IT TURNED OUT NOT
TO BE DANGEROUS CODE “REAL DANGER.”
♦ ENTER number of attacks________________________
If R Reports More Than 900.................................................. 900
If R Reports “More Than I Can Remember” ...............995
DK ...................................................................................
RF ....................................................................................
CHECKPOINT (PD20)
YPD8_PD17 Equals ‘1’ ..............................................1 (GO TO YPD11_PD20a)
ALL OTHERS............................................................2 (GO TO YPD17_PD66)
YPD11_PD20a (See YPD9_PD18 – YPD10_PD19)
(YPD9_PD18 Equals ‘0’) AND (YPD10_PD19 Equals ‘0’) ................. 1(GO TO YPD13_PD22)
ALL OTHERS........................................................................................ 2 (GO TO YPD12_PD21)
MTO Youth Qnaire
5
Page B-76
Revised 08/06/07
YPD12_PD21
How old were you (when you had the attack/the first time you had an attack) “out of the blue” for no obvious reason?
♦ INTERVIEWER: IF “ALL MY LIFE” OR “AS LONG AS I CAN REMEMBER,”
PROBE: Was it before you first started school?
IF NOT YES, PROBE: Was it before you were a teenager?
♦ ENTER age _________
Before Started School ..................................................4
Before Teenager...........................................................12
Not Before Teenager....................................................13
DK ...................................................................................
RF ....................................................................................
YPD13_PD22
How much did (this/these) unexpected “out of the blue” attack(s) or worry about having another attack ever interfere with
either your work, your social life, or your personal relationships – not at all, a little, some, a lot, or extremely?
Not at All .....................................................................1
A Little.........................................................................2
Some ............................................................................3
A Lot............................................................................4
Extremely.....................................................................5
CHECKPOINT (PD33)
YPD11_PD20a Equals ‘1’ ..........................................1 (GO TO YPD17_PD66)
ALL OTHERS............................................................2 (GO TO NEXT CHECKPOINT (PD35))
CHECKPOINT (PD35)
YPD6_PD10 Equals ‘1’ ..............................................1 (GO TO YPD14_PD36)
ALL OTHERS............................................................2 (GO TO YPD17_PD66)
YPD14_PD36
How many unexpected “out of the blue” attacks did you have in the past 12 months?
♦ ENTER number of attacks____________________________
DK ...................................................................................
RF ....................................................................................
CHECKPOINT (PD37)
YPD14_PD36 Equals “0”, “DK” or “RF”...................1
YPD14_PD36 Equals “1”............................................2 (GO TO YPD16_PD38)
ALL OTHERS............................................................3 (GO TO YPD15b_PD37b)
MTO Youth Qnaire
6
Page B-77
Revised 08/06/07
YPD15a_PD37a
How old were you the last time you had an unexpected “out of the blue” attack?
♦ ENTER age ________________________
DK ...................................................................................
RF ....................................................................................
(GO TO YPD17_PD66)
YPD15b_PD37b
About how many weeks in the past 12 months did you have at least one of these attacks?
♦ ENTER number of weeks ___________________________
DK ...................................................................................
RF ....................................................................................
YPD16_PD38
How recently – in the past month, between two and six months ago, or more than six months ago?
Past Month.......................................................................1
Between two and six months ago ...................................2
More than six months ago...............................................3
DK ...................................................................................
RF ....................................................................................
YPD17_PD66 (See YSC12_SC26, YSC13_SC26a, YSC14_SC26b):
♦ INTERVIEWER: FOLLOW SKIP FOR FIRST ENDORSED ITEM.
YSC12_SC26 Equals ‘1’..............................................................................4 (GO TO YGA1_G1 INTRO 1)
YSC13_SC26a Equals ‘1’............................................................................5 (GO TO YGA1_G1 INTRO 2)
YSC14_SC26b Equals ‘1’............................................................................6 (GO TO YGA1_G1 INTRO 3)
ALL OTHERS.............................................................................................7 (GO TO YIE1_IED1)
MTO Youth Qnaire
7
Page B-78
Revised 08/07/07
Section 12: GENERALIZED ANXIETY DISORDER SECTION (YGA)
YGA1_G1_INTRO 1.
(RB)
Earlier you mentioned having a time in
your life when you were "a worrier".
The next questions are about that time.
Looking at your booklet, what sorts of
things were you worried or nervous or
anxious about during that time?
YGA1_G1_INTRO 2.
(RB)
Earlier you mentioned having a time in
your life when you were much more
nervous or anxious than most other
people. The next questions are about
that time. Looking at your booklet,
what sorts of things were you nervous
or anxious about during that time?
YGA1_G1_INTRO 3.
(RB)
Earlier you mentioned having a period
lasting one month or longer when you
were anxious or worried most days.
The next questions are about that time.
Looking at your booklet, what sorts of
things were you anxious or worried
about during that time?
PROBE FOR UP TO THREE EXAMPLES: Anything else [that made you (worried or anxious/nervous or
anxious/anxious or worried)]?
CIRCLE ALL MENTIONS.
DIFFUSE WORRIES
EVERYTHING .......................................................................................................................... 1
NOTHING IN PARTICULAR .................................................................................................. 2
PERSONAL PROBLEMS
FINANCES................................................................................................................................. 3
SUCCESS AT SCHOOL OR WORK ....................................................................................... 4
SOCIAL LIFE............................................................................................................................. 5
LOVE LIFE ................................................................................................................................ 6
RELATIONSHIPS AT SCHOOL OR WORK ......................................................................... 7
RELATIONSHIPS WITH FAMILY......................................................................................... 8
PHYSICAL APPEARANCE ..................................................................................................... 9
PHYSICAL HEALTH................................................................................................................ 10
MENTAL HEALTH .................................................................................................................. 11
SUBSTANCE USE .................................................................................................................... 12
OTHER PERSONAL PROBLEMS (SPECIFY) ...................................................................... 13
PHOBIC AND OBSESSIVE-COMPULSIVE SITUATIONS
SOCIAL PHOBIAS
(E.G., MEETING PEOPLE AFTER MOVING TO A NEW TOWN) ............................ 14
AGORAPHOBIA (E.G., LEAVING HOME ALONE AFTER A DIVORCE)....................... 15
SPECIFIC PHOBIAS
(E.G., FEARS OF BUGS, HEIGHTS, OR CLOSED SPACES)...................................... 16
OBSESSIONS (E.G., WORRY ABOUT GERMS).................................................................. 17
COMPULSIONS (E.G., REPETITIVE HANDWASHING) ................................................... 18
NETWORK PROBLEMS
BEING AWAY FROM HOME OR APART FROM LOVED ONES..................................... 19
THE HEALTH OR WELFARE OF LOVED ONES - FIRST MENTION ............................. 20
THE HEALTH OR WELFARE OF LOVED ONES - SECOND MENTION ........................ 21
THE HEALTH OR WELFARE OF LOVED ONES - THIRD MENTION............................ 22
OTHER NETWORK PROBLEMS (SPECIFY) ....................................................................... 23
SOCIETAL PROBLEMS
CRIME / VIOLENCE ................................................................................................................ 24
THE ECONOMY ...................................................................................................................... 25
THE ENVIRONMENT (E.G., GLOBAL WARMING, POLLUTION).................................. 26
MTO Youth Qnaire
Page B-79
Revised 08/07/07
MORAL DECLINE OF SOCIETY
(E.G., COMMERCIALISM, DECLINE OF THE FAMILY) .......................................... 27
WAR / REVOLUTION.............................................................................................................. 28
OTHER SOCIETAL PROBLEMS (SPECIFY)........................................................................ 29
OTHER PROBLEMS (SPECIFY)
FIRST (SPECIFY)..................................................................................................................... 30
SECOND (SPECIFY)................................................................................................................ 31
THIRD (SPECIFY) ............................................................................................................. 32
YGA2_G3.
Do you think your (worry or anxiety/nervousness or anxiety/anxiety or worry) was ever excessive or
unreasonable or a lot stronger than it should have been?
YES .................................... 1
NO ...................................... 5
DK ......................................
RF .......................................
YGA3_G4.
How often did you find it difficult to control your (worry or anxiety/nerves or anxiety/anxiety or worry) -- often,
sometimes, rarely, or never?
OFTEN............................... 1
SOMETIMES .................... 2
RARELY............................ 3
NEVER .............................. 4
DK ......................................
RF .......................................
YGA4_G4a.
How often were you so nervous or worried that you could not think about anything else, no matter how hard you
tried -- often, sometimes, rarely, or never?
OFTEN.......................................1
SOMETIMES ............................2
RARELY....................................3
NEVER ......................................4
DK .......................
RF
INTERVIEWER CHECKPOINT: (SEE YGA4, YGA4a)
YGA4 EQUALS ‘1’ OR ‘2’ OR YGA4a EQUALS ‘1’ OR ‘2’ ....... 1
ALL OTHERS ................................................................................... 2 (GO TO NEXT
SECTION)
MTO Youth Qnaire
Page B-80
Revised 08/07/07
YGA5a_G5.
What is the longest period of months or years in a row you ever had when you were (worried or anxious/nervous
or anxious/anxious or worried) most days?
IF VOL “WHOLE LIFE” OR “AS LONG AS I CAN REMEMBER,”
CODE 995 YEARS
PROBE DK: Did you ever have a period that lasted 6 months or longer?
(IF NOT) Did you ever have a period that lasted 1 month or longer?
___________
DK
RF
NUMBER
YGA5b_G5.
CIRCLE UNIT OF TIME: DAYS…1
DK
RF
WEEKS…2
MONTHS…3
YEARS…4
CHECKPOINT_YGA6_G6.
INTERVIEWER CHECKPOINT: (SEE YGA5)
LESS THAN 1 MONTH............................................ 1
1 TO 5 MONTHS ....................................................... 2
ALL OTHERS ............................................................ 3
GO TO NEXT SECTION
GO TO CHECKPOINT_YGA7_G7
GO TO CHECKPOINT_YGA8_G8
CHECKPOINT_YGA7_G7.
INTERVIEWER INSTRUCTION: ASK ABOUT “PERIODS LASTING ONE MONTH OR LONGER” FOR
THE REMAINDER OF THE SECTION
(GO TO YGA7_G9)
CHECKPOINT_YGA8_G8.
INTERVIEWER INSTRUCTION: ASK ABOUT “PERIODS LASTING SIX MONTHS OR LONGER” FOR
THE REMAINDER OF THE SECTION
(GO TO YGA7_G9)
YGA7a_G9a.
Think of your worst period lasting (one month / six months) or longer when you
were (worried or anxious/nervous or anxious/anxious or worried): During that
episode, did you often have any of the following associated problems:
Did you often feel restless, keyed up, or on edge?
YGA7b_G9b.
Did you often get tired easily?
MTO Youth Qnaire
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
Page B-81
Revised 08/07/07
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
YGA7e_G9e.
Did you often have tense, sore, or aching muscles?
1
5
8
9
YGA7f_G9f.
Did you often have trouble falling or staying asleep?
1
5
8
9
YES
(1)
NO
(5)
DK
(8)
RF
(9)
YGA8a_G10a.
Did your heart often pound or race?
1
5
8
9
YGA8b_G10b.
Did you often sweat?
1
5
8
9
YGA8c_G10c.
Did you often tremble or shake?
1
5
8
9
YGA8d_G10d.
Did you often have a dry mouth?
1
5
8
9
YGA8e_G10e.
Were you sad or depressed most of the time?
1
5
8
9
YGA 7c_G9c.
Were you often more irritable than usual?
YGA 7d_G9d.
Did you often have difficulty concentrating or keeping your mind on what you
were doing?
CHECKPOINT_ YGA9_G11.
INTERVIEWER CHECKPOINT: (SEEH YGA7, YGA8)
ZERO RESPONSES CODED ‘1’ IN YGA7 AND YGA8 SERIES ........................ 1 GO TO NEXT
SECTION
ZERO RESPONSES CODED ‘1’ IN YGA8 SERIES .............................................. 2 GO TO
CHECKPOINT_ YGA14
FOUR OR MORE RESPONSES CODED ‘1’ IN YGA7 AND YGA8 SERIES..... 3 GO TO YGA11
ALL OTHERS ........................................................................................................... 4 GO TO YGA10
CHECKPOINT_ YGA9_G12.
INTERVIEWER CHECKPOINT: (SEE YGA7)
TWO OR MORE RESPONSES CODED ‘1’ IN YGA7 SERIES ......1
(GO TO YGA11)
ALL OTHERS .....................................................................................2
(GO TO NEXT
SECTION)
MTO Youth Qnaire
Page B-82
Revised 08/07/07
YGA10.
INTERVIEWER QUERY: TOTAL NUMBER RESPONSES
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
YGA10b_G13b.
Were you often short of breath?
1
5
8
9
YGA10c_G13c.
Did you often feel like you were choking?
1
5
8
9
YGA10d_G13d.
Did you often have pain or discomfort in your chest?
1
5
8
9
GO TO
YGA10g_G13g
5
8
9
1
5
8
9
GO TO YGA10i
_G13i
5
8
9
1
5
8
9
1
5
8
9
CODED ‘1’ IN YGA7SERIES IS __________
CODED ‘1’ IN YGA8 SERIES IS __________
GO TO YGA11 AS SOON AS FIVE RESPONSES CODED ‘1’ IN
YGA7, YGA8, YGA10 SERIES
YGA10a_G13a.
Did you often feel dizzy or lightheaded?
YGA10e_G13e.
Did you often have pain or discomfort in your stomach?
YGA10f_G13f.
Did you often have nausea?
YGA10g_G13g.
Did you often feel that you were unreal?
YGA10h_G13h.
Did you often feel that things around you were unreal?
YGA10i_G13i.
Were you often afraid that you might lose control or go crazy?
1
1
GO TO
YGA10k_G13k
YGA10j_G13j.
Were you often afraid that you might pass out?
1
5
8
9
YGA10k_G13k.
Were you often afraid that you might die?
1
5
8
9
YGA10l_G13l.
Did you often have hot flushes or chills?
1
5
8
9
YGA10m_G13m.
Did you often have numbness or tingling sensations?
1
5
8
9
YGA10n_G13n.
Did you often feel like you had a lump in your throat?
1
5
8
9
1
5
8
9
YGA10o_G13o.
Were you easily startled?
MTO Youth Qnaire
Page B-83
Revised 08/07/07
CHECKPOINT_ YGA13_G14.
INTERVIEWER CHECKPOINT: (SEE YGA7, YGA8, YGA10)
TWO OR MORE RESPONSES CODED ‘1’ IN YGA7 SERIES ............................ 1
THREE OR MORE RESPONSES CODED ‘1’ IN YGA7, YGA8, YGA10 SERIES…………2
ALL OTHERS...................................................................................................... 3 (GO TO
NEXT SECTION)
YGA11_G15.
How much emotional distress did you ever experience because of your (worry or anxiety/nervousness or
anxiety/anxiety or worry) – no distress, mild distress, moderate distress, severe distress, or very severe distress?
NO ...................................... 1
MILD.................................. 2
MODERATE ..................... 3
SEVERE............................. 4
VERY SEVERE ................ 5
DK
RF
YGA12_G17.
How much did your (worry or anxiety/nervousness or anxiety/anxiety or worry) ever interfere with either your
work, your social life, or your personal relationships – not at all, a little, some, a lot, or extremely?
NOT AT ALL .................... 1
A LITTLE .......................... 2
SOME................................. 3
A LOT ................................ 4
EXTREMELY ................... 5
DK
RF
(GO TO CHECKPOINT_ YGA10)
YGA12a_G17a.
How often were you unable to carry out your daily activities because of your (worry or anxiety/nervousness or
anxiety/anxiety or worry) -- often, sometimes, rarely, or never?
OFTEN............................... 1
SOMETIMES .................... 2
RARELY............................ 3
NEVER .............................. 4
DK
RF
CHECKPOINT_YGA12_G17.
INTERVIEWER CHECKPOINT: (SEE YGA11, YGA12)
YGA11 EQUALS ‘3’, ‘4’, OR ‘5’ OR YGA12 EQUALS ‘3’, ‘4’, OR ‘5’ ........... 1
ALL OTHERS ........................................................................................................... 2 (GO TO
NEXT SECTION)
MTO Youth Qnaire
Page B-84
Revised 08/07/07
YGA13_G26.
Think of the very first time in your life you had an episode lasting (one month / six months) or longer when
(you were worried or anxious most days/you were nervous or anxious most days/you were anxious or worried
most days) and also had some of the other problems we just reviewed. Can you remember your exact age?
YES ................................................... 1
NO ..................................................... 5
DON’T KNOW ................................ 8
REFUSED......................................... 9
(GO TO YGA13b_G26)
(GO TO YGA13b_G26)
(GO TO YGA13b_G26)
YGA13a_G26a.
(IF NEC: How old were you?)
__________ AGE
(GO TO YGA14_G27)
DON’T KNOW ................. 998
REFUSED.......................... 999
(GO TO YGA14_G27)
(GO TO YGA14_G27)
YGA13b_G26b.
About how old were you?
¾ IF “ALL MY LIFE” OR “AS LONG AS I CAN REMEMBER,”
PROBE: Was it before you first started school?
¾
IF NOT YES, PROBE: Was it before you were a teenager?
__________ YEARS OLD
BEFORE STARTED SCHOOL ..................... 4
BEFORE TEENAGER.................................... 12
NOT BEFORE TEENAGER .......................... 13
WHOLE LIFE OR DON’T KNOW ............... 998
REFUSED........................................................ 999
YGA14_G27.
Did you have an episode of being (worried or anxious/nervous or anxious/anxious or worried), lasting at least
one month or longer, in the past 12 months?
YES .................................... 1
NO ...................................... 5
DON’T KNOW ................. 8
REFUSED.......................... 9
GO TO YGA14b_G27b)
GO TO YGA14b_G27b)
GO TO YGA14b_G27b)
YGA14b_G27b.
How many months in the past 12 months were you in an episode of this sort?
_________________ MONTHS
DON’T KNOW ................................ 98
REFUSED......................................... 99
(GO TO NEXT SECTION)
MTO Youth Qnaire
Page B-85
Revised 08/07/07
YGA14c_G27c.
How old were you the last time you had one of these episodes?
_____________ YEARS OLD
DK
RF
GO TO NEXT SECTION
MTO Youth Qnaire
Page B-86
Revised 08/08/07
Section 13: INTERMITTENT EXPLOSIVE DISORDER (YIE)
INTERVIEWER CHECKPOINT IED1:
YSC3_SC20.1 IS CODED “1” (YES) ......................... 1
GO TO CHECKPOINT IED2
YSC4_SC20.2 IS CODED “1” (YES) ......................... 2
GO TO YIE1_IED3 INTRO 4
YSC5_SC20.3 IS CODED “1” (YES) ......................... 3
GO TO YIE1_IED3 INTRO 5
ALL OTHERS............................................................. 4
GO TO NEXT SECTION
INTERVIEWER CHECKPOINT IED2:
YSC4_SC20.2 IS CODED “1” (YES) ......................... 1
GO TO YIE1_IED3 INTRO 1
YSC5_SC20.3 IS CODED “1” (YES) ......................... 2
GO TO YIE1_IED3 INTRO 2
ALL OTHERS............................................................. 3
GO TO YIE1_IED3 INTRO 3
YIE1_IED3.
INTRO 1.
Earlier in the interview
you mentioned having
attacks of anger when
all of a sudden you lost
control and either broke
or smashed something
of value or you hit or
hurt someone. The next
few questions are about
those attacks.
Approximately how
many times in your life
have you had an attack
of this sort, (READ
SLOWLY) when you
lost control and either
broke something, hurt
someone, or threatened
to hurt someone?
YIE1_IED3.
INTRO 2.
Earlier in the interview
you mentioned having
attacks of anger when
all of a sudden you lost
control and either broke
or smashed something
of value or you
threatened to hit or hurt
someone. The next few
questions are about
those attacks.
Approximately how
many times in your life
have you had an attack
of this sort, (READ
SLOWLY) when you
lost control and either
broke something or
threatened to hurt
someone?
YIE1_IED3. INTRO
3.
Earlier in the
interview you
mentioned having
attacks of anger when
all of a sudden you
lost control and broke
or smashed something
of value. The next few
questions are about
those attacks.
Approximately how
many times in your
life have you had an
attack of this sort,
(READ SLOWLY)
when you lost control
and either broke or
smashed something?
YIE1_IED3.
INTRO 4.
Earlier in the interview
you mentioned having
attacks of anger when
all of a sudden you lost
control and hit or hurt
someone. The next few
questions are about
those attacks.
Approximately how
many times in your life
have you had an attack
of this sort, (READ
SLOWLY) when you
lost control and either
hurt someone or
threatened to hurt
someone?
YIE1_IED3.
INTRO 5.
Earlier in the interview
you mentioned having
attacks of anger when all
of a sudden you lost
control and threatened to
hit or hurt someone. The
next few questions are
about those attacks.
Approximately how many
times in your life have you
had an attack of this sort,
(READ SLOWLY) when
you lost control and
threatened to hurt
someone?
CODE RESPONSES GREATER THAN 9997 AS 9997
______________ ATTACKS
DON’T KNOW............................. 998
REFUSED..................................... 999
MTO Youth Qnaire
Page B-87
Revised 08/08/07
INTERVIEWER CHECKPOINT IED4.:
YIED1_IED3 EQUALS ‘0’-‘2’ .................................. 1
ALL OTHERS............................................................. 2
GO TO NEXT SECTION
YIE2_IED5.
Did these anger attacks sometimes occur without a good reason?
YES .................................. 1
NO.................................... 5
DK
RF
GO TO YIE4_IED6
YIE3_IED5a.
Did the attacks sometimes occur in situations where most people would not have had an anger attack?
YES..........................................1
NO ...........................................5
DK
RF
GO TO YIE4_IED6
YIE3a_IED5b.
During those attacks, did you sometimes get a lot more angry than most people would have been in the
same situation.
YES..........................................1
NO ...........................................5
DON’T KNOW .......................8
REFUSED ...............................9
GO TO NEXT SECTION
GO TO NEXT SECTION
GO TO NEXT SECTION
YIE4_IED6.
Did you have times before these attacks when you felt such a strong impulse to let loose or blow-up that you
couldn't resist it no matter how hard you tried?
YES .................................. 1
NO.................................... 5
DK
RF
YIE5_IED7.
How often was your anger out of control during your typical attacks -- all of the time, most of the time,
sometimes, rarely, or never?
ALL OF THE TIME ................................. 1
MOST OF THE TIME .............................. 2
SOMETIMES............................................ 3
RARELY................................................... 4
NEVER .................................................... 5
DK
RF
MTO Youth Qnaire
Page B-88
Revised 08/08/07
INTERVIEWER CHECKPOINT IED8.
YIE4_IED6 EQUALS ‘1’........................................... 1
YIE5_IED7 EQUALS ‘1’-‘4’ .................................... 2
ALL OTHERS............................................................. 3
GO TO NEXT SECTION
YIE6_IED9.
Some people only have anger attacks when they drink alcohol or use drugs. Did your anger attacks usually
occur when you had been drinking or using drugs?
YES .................................. 1
NO.................................... 5
DON’T KNOW ............... 8
REFUSED ....................... 9
GO TO YIE7_IED11
GO TO YIE7_IED11
GO TO YIE7_IED11
YIE6a_IED9a.
Did you ever have anger attacks when you had not been drinking or using drugs?
YES............................................... 1
NO ................................................ 5
DON’T KNOW ............................ 8
REFUSED .................................... 9
GO TO NEXT SECTION
GO TO NEXT SECTION
GO TO NEXT SECTION
YIE7_IED11.
Some people only have anger attacks when they are sad or depressed. Did your anger attacks usually occur
during periods of time when you were sad or depressed?
YES .................................. 1
NO.................................... 5
DON’T KNOW ............... 8
REFUSED ....................... 9
GO TO CHECKPOINT IED12
GO TO CHECKPOINT IED12
GO TO CHECKPOINT IED12
YIE7a_IED11a.
Did you ever have anger attacks at times you were not sad or depressed?
YES ...................................................1
NO.....................................................5
DK
RF
INTERVIEWER CHECKPOINT IED12.:
YSC3_SC20_1 IS CHECKED .................. 1
YSC4_SC20_2 IS CHECKED .................. 2
GO TO YIE9_IED15
ALL OTHERS........................................... 3
GO TO YIE10_IED16
MTO Youth Qnaire
Page B-89
Revised 08/08/07
YIE8_IED13.
Think about all the things you ever damaged or broke during your anger attacks. What is the approximate
combined repair cost or replacement value of all these things?
CODE RESPONSES GREATER THAN $9,997 AS $9,997
$______________
DK
RF
INTERVIEWER CHECKPOINT IED14.
YSC4_SC20_2 EQUALS ‘1’ .................... 1
ALL OTHERS........................................... 2
GO TO YIE10_IED16
YIE9_IED15.
About how many times during your anger attacks did you ever hurt someone badly enough that they needed
medical attention?
CODE RESPONSES GREATER THAN 997 AS 997
______________
DK
RF
TIMES
YIE10_IED16.
How much did your anger attacks ever interfere with either your work, your social life, or your personal
relationships -- not at all, a little, some, a lot, or extremely?
NOT AT ALL ........................................... 1 GO TO YIE11_IED17
A LITTLE ................................................. 2
SOME ....................................................... 3
A LOT ....................................................... 4
EXTREMELY .......................................... 5
DK
RF
YIE11_IED17.
How often did you feel guilty or embarrassed or regretful in the days or weeks after your attacks -- all of the
time, most of the time, sometimes, rarely, or never?
ALL OF THE TIME ................................. 1
MOST OF THE TIME .............................. 2
SOMETIMES............................................ 3
RARELY................................................... 4
NEVER .................................................... 5
DK
RF
MTO Youth Qnaire
Page B-90
Revised 08/08/07
YIE12_IED18.
Think of the very first time in your life you had an anger attack. Can you remember your exact age when that
attack occurred?
YES .................................. 1
NO.................................... 5
DON’T KNOW ............... 8
REFUSED ....................... 9
GO TO YIE12b_IED18b
GO TO YIE12b _IED18b
GO TO YIE12b _IED18b
YIE12a_IED18a.
(IF NEC: How old were you)?
______________ YEARS OLD
GO TO YIE13_IED22
DON’T KNOW...............................998 GO TO YIE13_IED22
REFUSED.......................................999 GO TO YIE13_IED22
YIE12b_IED18b.
About how old were you?
______________ YEARS OLD
IF "ALL MY LIFE" OR "AS LONG AS I CAN REMEMBER,"
PROBE: Was it before you first started school?
IF NO, PROBE: Was it before you were a teenager?
BEFORE STARTED SCHOOL.................................4
BEFORE TEENAGER ..............................................12
NOT BEFORE TEENAGER .....................................13
WHOLE LIFE OR DON’T KNOW...........................998
REFUSED..................................................................999
YIE13_IED22.
How many anger attacks did you have in the past 12 months?
______________ ATTACKS
DK
RF
YIE13a_IED22a.
How old were you the last time you had an anger attack?
______________ YEARS OLD
GO TO NEXT SECTION
DON’T KNOW...............................998 GO TO NEXT SECTION
REFUSED.......................................999 GO TO NEXT SECTION
MTO Youth Qnaire
Page B-91
Revised 08/08/07
YIE14_IED23.
About how many weeks in the past twelve months did you have at least one of these attacks?
______________
DK
RF
WEEKS
YIE15_IED24.
And how many attacks in total did you have during the past twelve months?
CODE RESPONSES GREATER THAN 997 AS 997
______________
DK
RF
ATTACKS
YIE16. INTERVIEWER CHECKPOINT: (SEE YSC12_SC31, YSC13_SC32)
FOLLOW SKIP FOR THE FIRST ENDORSED ITEM:
YSC12_SC31 EQUALS ‘1’ ..................... 1 GO TO YAD1_AD1, NEXT SECTION
YSC13_SC32 EQUALS ‘1’ ..................... 2 GO TO YAD3b_AD29, NEXT SECTION
ALL OTHERS ......................................... 3 GO TO OD1
MTO Youth Qnaire
Page B-92
Revised 08/09/07
Section 14: ATTENTION-DEFICIT / HYPERACTIVITY DISORDER (YAD)
(IF NEC: Very Frequently, often,
once in a while, or never?)
YAD1a_AD1a1.
Earlier in the interview you mentioned
having a time that began before the
age of seven when you had a lot more
trouble than most people with
concentration or attention. The next
questions are about that time. How
often did you have the following
problems during that time:
How often did you lose things like
assignments or books or other things
you needed? Very frequently, often,
once in a while, or never?
(KEY PHRASE: often losing things)
YAD1b_AD1b1.
How often did you make a lot of
careless mistakes in your homework,
work, or other activities?
Very
Frequently
Often
Once in a
While
Never
DK
RF
(1)
(2)
(3)
(4)
(8)
(9)
1
2
3
4
8
9
1
2
3
4
8
9
1
2
3
4
8
9
1
2
3
4
8
9
(KEY PHRASE: making lots of
careless mistakes)
YAD1c_AD1c1.
How often did you forget what you
were supposed to be doing or what
you had planned to do?
(KEY PHRASE: being forgetful)
YAD1d_AD1d1.
How often did people say that you did
not seem to be listening when they
spoke to you?
(KEY PHRASE: being told by
others that you didn’t seem
to listen to them)
CHECKPOINT_YAD1d1_AD1d.1.
INTERVIEWER CHECKPOINT: (SEE YAD1a_AD1a1-YAD1d_AD1d1)
ONE TO FOUR RESPONSES CODED ‘1’ or ‘2’ ....................... 1
ALL OTHERS................................................................................. 2
YAD3b_AD29
MTO Youth Qnaire
GOTO
Page B-93
Revised 08/09/07
YAD1e_AD1e1.
How often did you quickly lose
interest in games you were playing or
in work you were doing at home or at
school?
1
2
3
4
8
9
(KEY PHRASE: quickly losing
interest in activities)
CHECKPOINT_YAD1e1_AD1e.1.
INTERVIEWER CHECKPOINT: (SEE YAD1a_AD1a1-YAD1e_AD1e1)
TWO TO FIVE RESPONSES CODED ‘1’ or ‘2’ ........................ 1
ALL OTHERS................................................................................. 2
YAD1f_AD1f1.
How often were you unable to keep
your mind on what you were doing if
things were going on nearby?
1
2
3
GO TO YAD3b_AD29
4
8
9
(KEY PHRASE: being easily
distracted)
CHECKPOINT_YAD1f1_AD1f.1.
INTERVIEWER CHECKPOINT: (SEE YAD1a_AD1a1-YAD1f_AD1f1)
THREE TO FIVE RESPONSES CODED ‘1’ or ‘2’ .................... 1
SIX RESPONSES CODED ‘1’ or ‘2’ ............................................ 2
ALL OTHERS................................................................................. 3
GO TO YAD2_AD3
GO TO YAD3b_AD29
YAD1g_AD1g1.
How often did you dislike, stay away
from, or put off doing things that
required a lot of concentration?
(KEY PHRASE: disliking, avoiding,
or putting off doing things
that required a lot of
concentration)
MTO Youth Qnaire
1
2
3
4
8
9
Page B-94
Revised 08/09/07
Very
Frequently
(1)
Often
Once in a
While
(3)
(2)
CHECKPOINT_YAD1g1_AD1g.1.
INTERVIEWER CHECKPOINT: (SEE YAD1a_AD1a1-YAD1g_AD1g1)
FOUR TO FIVE RESPONSES CODED ‘1’ or ‘2’ ...................... 1
SIX RESPONSES CODED ‘1’ or ‘2’ ............................................ 2
ALL OTHERS................................................................................. 3
YAD1h_AD1h1.
How often did you get confused when
you had to make plans or decide the
order in which to do things?
1
2
3
Never
DK
RF
(4)
(8)
(9)
GO TO YAD2_AD3
GO TO YAD3b_AD29
4
8
9
(KEY PHRASE: getting confused
when you had to make plans)
CHECKPOINT_YAD1h1_AD1h.1.
INTERVIEWER CHECKPOINT: (SEE YAD1a_AD1a1-YAD1h_AD1h1)
FIVE RESPONSES CODED ‘1’ or ‘2’.......................................... 1
SIX RESPONSES CODED ‘1’ or ‘2’ ............................................ 2
ALL OTHERS................................................................................. 3
YAD1i_AD1i1.
How often did you leave chores,
homework or other work unfinished
even when you meant to get them
done?
1
2
3
GO TO YAD2_AD3
GO TO YAD3b_AD29
4
8
9
(KEY PHRASE: leaving important
jobs or homework undone)
CHECKPOINT_YAD1o_AD2.
INTERVIEWER CHECKPOINT: (SEE YAD1a_AD1a1-YAD1i_AD1i1)
** SIX OR MORE ‘1’ OR ‘2’ RESPONSES IN YAD1a-i ......................................1
ALL OTHERS..........................................................................................................2 GO TO YAD3b_AD29
YAD2_AD3.
You had several concentration and attention problems, such as (KEY PHRASES FOR FIRST 3 ITEMS CODED ‘1’
OR ‘2’ IN YAD1 SERIES). Can you remember your exact age the very first time in your life when you
had any of these problems for six months or longer?
YES......................................1
NO .......................................5
DON’T KNOW...................8
REFUSED ...........................9
MTO Youth Qnaire
GO TO YAD2b_AD3b
GO TO YAD2b_AD3b
GO TO YAD2b_AD3b
Page B-95
Revised 08/09/07
YAD2a_AD3a.
(IF NEC: How old were you?)
__________ YEARS OLD
GO TO YAD3_AD4
DON’T KNOW.................998
REFUSED.........................999
GO TO YAD3_AD4
GO TO YAD3_AD4
YAD2b_AD3b.
About how old were you the first time (you had any of these problems)?
¾
¾
¾
IF DON’T KNOW, PROBE: Can you remember what grade you were in at school?
IF “ALL MY LIFE” OR “AS LONG AS I CAN REMEMBER,” PROBE: Was it before you were seven?
IF NOT YES, PROBE: Was it before your teens?
__________ YEARS OLD
OR
__________ GRADE
BEFORE SEVEN YEARS OLD....................6
NOT BEFORE SEVEN YEARS OLD ...........8
BEFORE TEENS .............................................12
NOT BEFORE TEENS....................................13
WHOLE LIFE ..................................................996
DON’T KNOW................................................998
REFUSED ........................................................999
YAD3_AD4.
Did you still have a lot of problems with concentration and attention during the past 12 months?
YES....................................................1
NO......................................................5
DON'T KNOW..................................8
REFUSED .........................................9
GO TO YAD3b_AD29
YAD3a_AD4a.
How old were you the last time you had six months or longer when you had a lot of problems with concentration or
attention?
__________ YEARS OLD
DON’T KNOW ................998
REFUSED ........................999
YAD3b_AD29.
INTERVIEWER CHECKPOINT: (SEE YSC13_SC32)
YSC13_SC32 EQUALS ‘1’..... 1
ALL OTHERS........................... 2
MTO Youth Qnaire
GO TO YOD1, NEXT SECTION
Page B-96
Revised 08/09/07
(IF NEC: Very frequently, often,
once in a while, or never?)
YAD4a_AD30a1.
(IF YSC12_SC31 EQUALS ‘1’:
You also mentioned earlier in the
interview/ IF YSC13_32 EQUALS
‘1’: Earlier in the interview you
mentioned) having a time that began
before the age of seven when you
had a lot more trouble than most
people with being very restless,
fidgety, or impatient. How often did
you have the following problems
during that time:
Very
Frequently
(1)
Often
Never
DK
RF
(2)
Once in a
While
(3)
(4)
(8)
(9)
1
2
3
4
8
9
1
2
3
4
8
9
1
2
3
4
8
9
1
2
3
4
8
9
How often were you often very
active even when you were not
supposed to be – for example,
climbing on things or running around
even after being asked to keep still?
Very frequently, often, once in a
while, or never?
(KEY PHRASE: being very active
when you were not supposed to be)
YAD4b_AD30b1.
How often did you feel very
restless?
(KEY PHRASE: often feeling
very restless)
YAD4c_AD30c1.
How often were you “on the go,”
usually taking very little time to
rest?
(KEY PHRASE: being “on the
go” without taking time to rest)
YAD4d_AD30d1.
How often did you have trouble
playing quietly or doing quiet
activities like reading for more than
a few minutes at a time?
(KEY PHRASE: having trouble
playing quietly)
MTO Youth Qnaire
Page B-97
Revised 08/09/07
(IF NEC: Very frequently, often,
once in a while, or never?)
YAD4e_AD30e1.
How often did you usually fidget or
squirm a great deal when you were
sitting down?
Very
Frequently
(1)
Often
Never
DK
RF
(2)
Once in a
While
(3)
(4)
(8)
(9)
1
2
3
4
8
9
1
2
3
4
8
9
(KEY PHRASE: fidgeting or
squirming a lot)
YAD4f_AD30f1.
How often did you get up from your
seat when you were not supposed to
–
like at dinner, at school or
–
at religious services?
(KEY PHRASE: getting up from
your seat when you were not
supposed to)
CHECKPOINT_YAD4f1_AD30f.1.
INTERVIEWER CHECKPOINT: (SEE YAD4a_AD30a1-YAD4f_AD30f1)
ONE TO FIVE RESPONSES CODED ‘1’ OR ‘2’ ....................... 1
SIX RESPONSES CODED ‘1’ OR ‘2’.......................................... 2
ALL OTHERS................................................................................. 3
SECTION
GO TO YAD5_AD32
GO TO YOD1, NEXT
YAD4g_AD30g1.
How often did you talk a lot more
than other people your age?
1
2
3
4
8
9
(KEY PHRASE: being very
talkative)
CHECKPOINT_YAD4g_AD30g.1.
INTERVIEWER CHECKPOINT: (SEE YAD4a_AD30a1-YAD4g_AD30g1)
TWO TO FIVE RESPONSES CODED ‘1’ OR ‘2’ ...................... 1
SIX RESPONSES CODED ‘1’ OR ‘2’.......................................... 2
ALL OTHERS................................................................................. 3
SECTION
GO TO YAD5_AD32
GO TO YOD1, NEXT
YAD4h_AD30h1.
How often did you blurt out answers
to other people’s questions even
before they finished speaking?
(KEY PHRASE: interrupting
people by blurting out answers to
their questions before they were
done speaking)
MTO Youth Qnaire
1
2
3
4
8
9
Page B-98
Revised 08/09/07
(IF NEC: Very frequently, often,
once in a while, or never?)
Very
Frequently
(1)
Often
Once in a
While
(3)
Never
(2)
(4)
CHECKPOINT_YAD4h_AD30h.1.
INTERVIEWER CHECKPOINT: (SEE YAD4a_AD30a1-YAD4h_AD30h1)
THREE TO FIVE RESPONSES CODED ‘1’ or ‘2’ .................... 1
SIX RESPONSES CODED ‘1’ or ‘2’ ............................................ 2
ALL OTHERS................................................................................. 3
SECTION
YAD4i_AD30i1.
How often did you interrupt people
or join other people’s conversations
without being asked to do so?
1
2
3
DK
RF
(8)
(9)
GO TO YAD5_AD32
GO TO YOD1, NEXT
4
8
9
(KEY PHRASE: interrupting
conversations )
YAD4i_AD30i.1.
INTERVIEWER CHECKPOINT: (SEE YAD4a_AD30a1-YAD4i_AD30i1)
FOUR TO FIVE RESPONSES CODED ‘1’ or ‘2’ ....................... 1
SIX RESPONSES CODED ‘1’ or ‘2’ ............................................ 2
ALL OTHERS................................................................................. 3
SECTION
YAD4j_AD30j1.
How often did you try to join games
or other activities that were already
happening?
1
2
3
GO TO YAD5_AD32
GO TO YOD1, NEXT
4
8
9
(KEY PHRASE: interrupting
games or other activities )
CHECKPOINT_YAD4j_AD30j.1.
INTERVIEWER CHECKPOINT: (SEE YAD4a_AD30a1-YAD4j_AD30j1)
FIVE RESPONSES CODED ‘1’ or ‘2’.............................1
SIX RESPONSES CODED ‘1’or ‘2’ ................................2 GO TO YAD5_AD32
ALL OTHERS....................................................................3 GO TO YOD1, NEXT SECTION
YAD4k_AD30k1.
How often did you have a lot of
trouble waiting your turn – for
example, how often was it very hard
for you to wait in a line or to wait for
a teacher to call on you in class
before you spoke out loud?
1
2
3
4
8
9
(KEY PHRASE: having trouble
waiting your turn)
MTO Youth Qnaire
Page B-99
Revised 08/09/07
CHECKPOINT_YAD4l_AD31.
INTERVIEWER CHECKPOINT: (SEE YAD4a_AD30a1-YAD4k_AD30k1)
** 3 OR MORE RESPONSES CODED ‘1’ OR ‘2’ IN
YAD4a_AD30a1-YAD4k_AD30k1 ........................................................... 1
ALL OTHERS ............................................................................................... 2 GO TO YOD1, NEXT SECTION
_______________________________________________________________________________________________
YAD5_AD32.
You mentioned several problems with restlessness and impatience, such as (KEY PHRASES FOR FIRST 3 ITEMS
CODED ‘1’ OR ‘2’ IN YAD_AD30a1-YAD_AD30k1). Can you remember your exact age the very first time in
your life when you had any of these problems for six months or longer?
YES.....................................1
NO.......................................5
DON’T KNOW..................8
REFUSED ..........................9
GO TO YAD5b_AD32b
GO TO YAD5b_AD32b
GO TO YAD5b_AD32b
YAD5a_AD32a.
(IF NEC: How old were you?)
__________ YEARS OLD GO TO YAD6_AD33
DON’T KNOW...............998
REFUSED .......................999
GO TO YAD6_AD33
GO TO YAD6_AD33
YAD5b_AD32b.
About how old were you the first time (you had any of these problems)?
¾
¾
¾
IF DON’T KNOW, PROBE: Can you remember what grade you were in at school?
IF “ALL MY LIFE” OR “AS LONG AS I CAN REMEMBER,” PROBE: Was it before you were seven?
IF NOT YES, PROBE: Was it before your teens?
__________ YEARS OLD
OR
__________ GRADE
BEFORE SEVEN YEARS OLD ................6
NOT BEFORE SEVEN YEARS OLD........8
BEFORE TEENS .........................................12
NOT BEFORE TEENS................................13
WHOLE LIFE ..............................................996
DON’T KNOW ............................................998
REFUSED.....................................................999
YAD6_AD33.
Did you still have a lot of problems with restlessness or impatience during the past 12 months?
YES....................................................1
NO......................................................5
DON'T KNOW..................................8
REFUSED .........................................9
MTO Youth Qnaire
GO TO YOD1, NEXT SECTION
Page B-100
Revised 08/09/07
YAD6a_AD33a.
How old were you the last time you had six months or longer when you had these problems?
__________ YEARS OLD
DON’T KNOW ..............998
REFUSED.......................999
GO TO YOD1, NEXT SECTION
MTO Youth Qnaire
Page B-101
Revised 08/09/07
Section 15: Youth Oppositional Defiant Disorder & Behavioral Problems Index (YOD)
OFTEN
TRUE
YOD1a
I am going to read a list of items that
describe feelings or thoughts people
sometimes have. For each item that
describes you now or in the past six
months, please tell me if it is often true,
sometimes true, or not true of you.
SOMETIMES
TRUE
NOT
TRUE
REFUSED
DON’T
KNOW
8
1
2
3
7
I have trouble concentrating or paying
attention.
YOD1b
I lie or cheat.
1
2
3
7
8
YOD1c
I tease others a lot.
1
2
3
7
8
YOD1d
I disobey my parents.
1
2
3
7
8
YOD1e
I have trouble sitting still.
1
2
3
7
8
YOD1f
I have a hot temper.
1
2
3
7
8
YOD1g
I would rather be alone than with
others.
1
2
3
7
I hang around with kids who get into
trouble.
1
2
3
7
YOD1i
I disobey at school.
1
2
3
7
8
YOD1j
I don’t get along with other kids.
1
2
3
7
8
YOD1k
I have trouble getting along with
teachers.
1
2
3
7
8
YOD1h
8
8
YOD1l.
INTERVIEWER CHECKPOINT: (SEE YSC14_SC33)
YSC14_SC33 IS CODED ‘1’.................1 GO TO YOD2_OD1
ALL OTHERS.........................................2 GO TO NEXT SECTION
YOD2_OD1.
YES
(1)
YOD2a_OD1b.
Earlier in the interview you mentioned a time lasting six months or longer when
you often did things that got you in trouble with adults. Which of the following
things did you do during that time:
Did you often argue with or “talk back” to adults?
1
GO TO
YOD2c
_OD1e
NO
(5)
DK
(8)
RF
(9)
5
8
9
(KEY PHRASE: often argued with adults)
MTO Youth Qnaire
Page B-102
Revised 08/09/07
YOD2b_OD1d.
Did you often refuse to follow directions from adults like your parents, teacher, or
boss?
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
8
9
8
9
8
9
8
9
(KEY PHRASE: refused to follow directions)
CHECKPOINT_YOD2b1_OD1d.1.
INTERVIEW CHECKPOINT: (SEE YOD1d, YOD1f, YOD1i & YOD2a_OD1b – YOD2b_OD1d
FOUR RESPONSES CODED ‘1’ ..................................................1
ALL OTHERS .................................................................................2
GO TO YOD3_OD3
YOD2c_OD1e.
Were you angry a lot of the time?
1
5
(KEY PHRASE: were angry a lot)
CHECKPOINT_YOD2c1_OD1e.1.
INTERVIEW CHECKPOINT: (SEE YOD1d, YOD1f, YOD1i & YOD2a_OD1b – YOD2c_OD1e
FOUR RESPONSES CODED ‘1’ ..................................................1
ALL OTHERS .................................................................................2
GO TO YOD3_OD3
YOD2d_OD1f.
Did you often feel you were being taken advantage of or treated unfairly?
1
5
(KEY PHRASE: felt like you were being treated unfairly)
CHECKPOINT_YOD2d1_OD1f.1.
INTERVIEW CHECKPOINT: (SEE YOD1d, YOD1f, YOD1i & YOD2a_OD1b – YOD2d_OD1f
FOUR RESPONSES CODED ‘1’ ..................................................1
ZERO RESPONSES CODED ‘1’ ..................................................2
ALL OTHERS .................................................................................3
GO TO YOD3_OD3
GO TO NEXT SECTION
YOD2e_OD1g.
Did you annoy people on purpose by doing or saying things just to bother them?
1
5
(KEY PHRASE: annoyed people on purpose)
CHECKPOINT_YOD2e1_OD1g.1.
INTERVIEW CHECKPOINT: (SEE YOD1d, YOD1f, YOD1i & YOD2a_OD1b – YOD2e_OD1g
FOUR RESPONSES CODED ‘1’ ..................................................1
ALL OTHERS .................................................................................2
GO TO YOD3_OD3
YOD2f_OD1h.
Did you blame others for your mistakes or bad behavior?
1
5
(KEY PHRASE: blamed others for your mistakes or bad behavior)
MTO Youth Qnaire
Page B-103
Revised 08/09/07
YES
(1)
NO
(5)
DK
(8)
RF
(9)
8
9
8
9
8
9
CHECKPOINT_YOD2f1_OD1h.1.
INTERVIEW CHECKPOINT: (SEE YOD1d, YOD1f, YOD1i & YOD2a_OD1b – YOD2f_OD1h
FOUR RESPONSES CODED ‘1’ ..................................................1
ALL OTHERS .................................................................................2
GO TO YOD3_OD3
YOD2g_OD1i.
Did you do mean things to “pay people back” for things they did that you didn’t
like?
(KEY PHRASE: did mean things to get back at people)
1
5
CHECKPOINT_YOD2g1_OD1i.1.
INTERVIEW CHECKPOINT: (SEE YOD1d, YOD1f, YOD1i & YOD2a_OD1b – YOD2g_OD1i
FOUR RESPONSES CODED ‘1’ ..................................................1
ALL OTHERS .................................................................................2
GO TO YOD3_OD3
YOD2h_OD1j.
Did you easily get mad at the way people treated you?
1
5
(KEY PHRASE: easily took offense)
CHECKPOINT_YOD2h1_OD1j.1.
INTERVIEW CHECKPOINT: (SEE YOD1d, YOD1f, YOD1i & YOD2a_OD1b – YOD2h_OD1j
FOUR RESPONSES CODED ‘1’ ..................................................1
ALL OTHERS .................................................................................2
GO TO YOD3_OD3
YOD2i_OD1k.
Were you easily annoyed by others?
1
5
(KEY PHRASE: were easily annoyed by others)
YOD2j_OD2.
INTERVIEWER CHECKPOINT: (SEE YOD1d, YOD1f, YOD1i & YOD2a_OD1b –
YOD2i_OD1k)
FOUR OR MORE “YES” RESPONSES IN
YOD1d, YOD1f, YOD1i & YOD2a-i ..................................................1
ALL OTHERS.........................................................................................2
GO TO NEXT SECTION
YOD3_OD3.
You mentioned several things – such as, you (KEY PHRASES FOR 3 ITEMS ENDORSED IN YOD1d, YOD1f,
YOD1i & YOD2a-i). Think of the very first time in your life you had six months or longer of feeling or acting like
this. Can you remember your exact age?
YES .................................1
NO...................................5
DON’T KNOW .............8
REFUSED .....................9
MTO Youth Qnaire
GO TO YOD3b_OD3b
GO TO YOD3b_OD3b
GO TO YOD3b_OD3b
Page B-104
Revised 08/09/07
YOD_OD3a.
(IF NEC: How old were you?)
__________ YEARS OLD
GO TO YOD4_OD4
DON’T KNOW..................998 GO TO YOD4_OD4
REFUSED ..........................999 GO TO YOD4_OD4
YOD3b_OD3b.
About how old were you (the first time you had a period of this sort)?
¾
IF DON’T KNOW, PROBE: Can you remember what grade you were in at school?
¾
IF “ALL MY LIFE” OR “AS LONG AS I CAN REMEMBER,” PROBE: Was it before
you first started school?
¾
IF NOT YES, PROBE: Was it before you were a teenager?
__________ YEARS OLD
OR
__________ GRADE
BEFORE STARTED SCHOOL ................... 4
BEFORE TEENAGER ................................. 12
WHOLE LIFE OR DON’T KNOW.............. 998
REFUSED..................................................... 999
YOD4_OD4.
Did you still feel or act like this during the past 12 months?
YES....................................................1
NO......................................................5
DON'T KNOW..................................8
REFUSED .........................................9
GO TO NEXT SECTION
YOD4a_OD4a.
How old were you the last time you had six months or longer when you felt or acted like this?
__________ YEARS OLD
DON’T KNOW ................998
REFUSED ........................999
GO TO NEXT SECTION
MTO Youth Qnaire
Page B-105
Revised 08/09/07
Section 16: Youth Risky Behavior & Conduct Disorder (YRB)
YRB1_U1
First I would like to ask you about smoking habits. Have you ever smoked a cigarette?
YES
1
NO (SKIP TO YRB4_U4)
2
REFUSED (SKIP TO YRB4_U4)
DON’T KNOW (SKIP TO YRB4_U4)
YRB2_U2.
During the past 30 days, on how many days did you smoke a cigarette?
NUMBER OF DAYS SMOKED CIGARETTES__________
(IF 0, SKIP TO YRB4_U4)
DON’T KNOW (SKIP TO YRB4_U4)
REFUSED (SKIP TO YRB4_U4)
YRB3_U3.
When you smoked a cigarette during the past 30 days, how many cigarettes did you usually smoke each day?
(IF NEC: A PACK CONTAINS 20 CIGARETTES)
NUMBER OF CIGARETTES EACH DAY ____________
_____DON’T KNOW
_____REFUSED
YRB4_U4.
Next I would like to ask you some questions about drinking alcoholic beverages, including beer, wine, or liquor.
Have you ever had a drink of alcoholic beverage? By a drink we mean a can or bottle of beer, a glass of wine, a
mixed drink, or a shot of liquor. Do not include childhood sips that you might have had from an older person’s
drink.
YES
1
NO (SKIP TO YRB9_U9)
2
REFUSED (SKIP TO YRB9_U9)
DON’T KNOW (SKIP TO YRB9_U9)
YRB5_U5.
During the past 30 days, on how many days did you have one or more drinks of an alcoholic beverage?
NUMBER OF DAYS DRANK ALCOHOL____________
(IF 0, SKIP TO YRB9_U9)
DON’T KNOW (SKIP TO YRB9_U9)
REFUSED (SKIP TO YRB9_U9)
MTO Youth Qnaire
Page B-106
Revised 08/09/07
YRB6_U6.
In the last 30 days, on the days that you drank alcohol, about how many drinks did you usually have?
NUMBER OF ALCOHOLIC BEVERAGES PER DAY ____________
_____DON’T KNOW
_____REFUSED
YRB7_U7.
On how many days did you have 5 or more drinks on the same occasion during the past 30 days? By occasion, we
mean at the same time or within hours of each other.
NUMBER OF DAYS HAD 5+ ALCOHOLIC BEVERAGES ___________
_____DON’T KNOW
_____REFUSED
YRB8_U8.
In the last 30 days, how many days have you had something alcoholic to drink, such as beer, wine or hard liquor
right before or during school or work hours?
NUMBER OF DAYS DRANK BEFORE OR DURING SCHOOL/WORK ____________
_____DON’T KNOW
_____REFUSED
YRB9_U9.
Have you ever used marijuana — that is grass or pot — in your lifetime?
YES
1
NO (SKIP TO YRB12_U12)
2
REFUSED (SKIP TO YRB12_U12)
DON’T KNOW (SKIP TO YRB12_U12)
YRB10_U10.
On how many days have you used marijuana in the last 30 days?
NUMBER OF DAYS USED MARIJUANA ________ (IF 0, SKIP TO YRB12_U12)
DON’T KNOW (SKIP TO YRB12_U12)
REFUSED (SKIP TO YRB12_U12)
YRB11_U11.
In the last 30 days, how many times have you used marijuana right before or during school or work hours?
NUMBER OF DAYS USED MARIJUANA BEFORE OR
DURING SCHOOL/WORK__________
_____DON’T KNOW
_____REFUSED
MTO Youth Qnaire
Page B-107
Revised 08/09/07
YRB12_U12.
Excluding marijuana and alcohol, have you ever used any other drugs like cocaine or crack or heroin, or any other
substance not prescribed for you by a doctor, in order to get high or to achieve an altered state?
YES
1
NO (SKIP TO YRB14_U14)
2
____REFUSED (SKIP TO YRB14_U14)
____DON’T KNOW (SKIP TO YRB14_U14)
YRB13_U13.
During the past 12 months, how many times have you used any of these drugs or other substances?
NUMBER OF TIMES TOOK DRUGS (EXCLUDING
MARIJUANA AND ALCOHOL)____________
_____DON’T KNOW
_____REFUSED
YRB14_U14.
Have you ever sold or helped sell marijuana, hashish or other drugs such as heroin, cocaine, or LSD?
YES
1
NO (SKIP TO YRB19_U19)
2
___REFUSED (SKIP TO YRB19_U19)
___DON’T KNOW (SKIP TO YRB19_U19)
YRB15_U15.
During the past 12 months, how many times have you sold or helped sell marijuana, hashish, or other hard drugs?
NUMBER OF TIMES SOLD DRUGS____________
____DON’T KNOW
____REFUSED
YRB16_U19.
Are there any gangs in your neighborhood or where you go to school?
YES
1
NO
2
DK
RF
MTO Youth Qnaire
Page B-108
Revised 08/09/07
YRB17_U20.
Do any of your brothers, sisters, cousins, or friends belong to a gang?
YES
1
NO
2
DK
RF
YRB18_U21.
Have you ever belonged to a gang?
YES
1
NO (SKIP TO YRB19_U22)
2
REFUSED (SKIP TO YRB19_U22))
DON’T KNOW (SKIP TO YRB19_U22)
YRB18a_U21a
In the past 12 months, have you been a member of a gang?
YES
1
NO
2
DK
RF
YRB19_U22
Have you ever had sexual intercourse, that is, made love, had sex, or gone all the way?
YES
1
NO (SKIP TO YRB31a)
2
REFUSED (SKIP TO YRB31a)
DON’T KNOW (SKIP TO YRB31a)
YRB20_U23
How old were you when you had sexual intercourse for the first time?
AGE: ____________ YEARS
DK
RF
YRB21_U24
How many partners have you had sexual intercourse with in the past 12 months — that is since this time last year?
NUMBER OF PARTNERS PAST YEAR _______________
DK
RF
MTO Youth Qnaire
YRB22_U25
Page B-109
Revised 08/09/07
The last time you had sexual intercourse, did you or your partner use a condom?
YES
1
NO
2
REFUSED
DON’T KNOW
YRB23_U26
The last time you had sexual intercourse, did you or your partner use any other method to prevent pregnancy?
YES
1
2
NO
REFUSED
DON’T KNOW
CHECKPOINT:
R IS FEMALE: Æ CONTINUE WITH YUB24_U27
R IS MALE Æ GO TO YRB28_U31
YRB24_U27
Have you ever been pregnant? Consider all pregnancies, even if no child was born.
YES
1
NO (SKIP TO YRB31a)
2
REFUSED (SKIP TO YRB31a)
DON’T KNOW (SKIP TO YRB31a)
YRB25_U28
Are you pregnant now?
YES
1
NO
2
REFUSED
DON’T KNOW
YRB26_U29
(Not counting a current pregnancy) How many times have you been pregnant? Please include pregnancies that did
not result in live births.
NUMBER OF TIMES ____________
____DON’T KNOW
_____REFUSED
YRB27_U30
Now we would like to ask about the outcomes of your previous pregnancies. How many of your pregnancies have
resulted in children born alive to you?
MTO Youth Qnaire
Page B-110
Revised 08/09/07
NUMBER OF PREGNANCIES WITH LIVE BIRTHS ___________
(IF 0 SKIP TO YRB31a, OTHERWISE SKIP TO YRB31_U34)
DON’T KNOW (SKIP TO YRB31a)
REFUSED (SKIP TO YRB31a)
CHECKPOINT:
R IS FEMALE: Æ GO TO YRB31_U34
R IS MALE Æ CONTINUE WITH YRB28_U31
YRB28_U31
Have you ever gotten someone pregnant?
YES
1
NO (SKIP TO YRB31_U34)
2
REFUSED (SKIP TO YRB31_U34)
DON’T KNOW (SKIP TO YRB31_U34)
YRB28a_U31a
How many times have you gotten someone pregnant?
NUMBER OF TIMES ___________
(IF 0, SKIP TO YRB31a)
DON’T KNOW
REFUSED
YRB29_U32
Is someone pregnant with your child now?
YES
1
NO
2
REFUSED
DON’T KNOW
YRB30_U33
How many children have you ever fathered? Please only count live births and do not count current pregnancy.
NUMBER OF CHILDREN ___________
DON’T KNOW
REFUSED
MTO Youth Qnaire
Page B-111
Revised 08/09/07
YRB31_U34
Now I’d like to ask you about cash assistance for which some families receive money on a regular basis. For
example, they may get a monthly check. Some people call this assistance "welfare," AFDC, TANF or "public aid."
I will use the word “welfare.” Are you or your (child/children) regularly receiving welfare benefits now?
YES
1
NO
2
REFUSED
DON’T KNOW
YRB32
Which of these three is most effective for pregnancy prevention?
CONDOM
1
WITHDRAWAL
2
BIRTH CONTROL PILL
3
DON’T KNOW
REFUSED
YRB33
Which of these three is most effective for prevention of STDs?
CONDOM
1
WITHDRAWAL
2
BIRTH CONTROL PILL
3
_____DON’T KNOW
_____REFUSED
YRB33a.
INTERVIEWER CHECKPOINT: (SEE YSC15_SC33_1, YSC16_SC33_2, YSC17_SC33_3, YRB14_U14)
YSC15_SC33.1 IS CODED ‘1’ OR YSC16_SC33.2 IS CODED ‘1’ OR
YSC17_SC33.3 IS CODED ‘1’.................1 GO TO YRB34_CD1
YRB14_U14 IS CODED ‘1’......................2 GO TO YRB49a
ALL OTHERS............................................3 GO TO YRB53
MTO Youth Qnaire
Page B-112
Revised 08/09/07
YES
(1)
NO
(2)
DK
(8)
RF
(9)
1
5
8
9
YRB34b_CD1i
… when you often skipped school without permission?
1
5
8
9
YRB34c_CD1k
… when you ran away from home overnight more than once?
1
5
8
9
YRB34d_CD1c
… when you shoplifted or stole something worth at least $20?
1
5
8
9
1
5
8
9
YRB34a_CD1h
You mentioned earlier that you had a time in your life when you did
things adults don’t like young people to do. The next questions are
about those things. Was there ever a time…
…when you often stayed out three hours or more later at night than your
parents wanted?
YRB34e_CD1b
… when you often got out of doing things you were supposed to do by
fooling people or lying to them?
YRB34f.
INTERVIEWER CHECKPOINT: (SEE YRB34a-e)
FIVE RESPONSES CODED ‘5’..................................................................1
ALL OTHERS...............................................................................................2
YRB35a_CD1a
… when you often told lies to trick people into giving you things or
doing what you wanted them to do?
YRB35b_CD1d
… when you stole money or other things from your parents or the other
people you lived with?
YRB35c_CD1e
… when you broke into someone’s locked car, or a locked home or
building?
YRB35d_CD1f
… when you set a fire to try to cause serious damage?
YRB35e_CD1g
… when you deliberately damaged someone’s property by doing
something like breaking windows, slashing tires, vandalizing, or writing
graffiti on buildings?
YRB35f_CD1j
… when you ran away from home and stayed away for at least four
days?
MTO Youth Qnaire
GO TO YRB53
YES
(1)
NO
(2)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
5
8
9
1
Page B-113
Revised 08/09/07
YRB36_CD7
You answered “yes” to (NUMBER OF “YES” RESPONSES IN YRB34/YRB35 SERIES) of the questions I just
asked about. Think of the very first time in your life you did (that type of behavior/ either of those behaviors/ any of
those behaviors]. Can you remember your exact age?
YES ....................................... 1
NO......................................... 5
DON’T KNOW ......................
REFUSED...............................
(GO TO YRB36a_CD7b)
(GO TO YRB36b_CD7c)
(GO TO YRB36b_CD7c)
(GO TO YRB36b_CD7c)
YRB36a_CD7b.
(IF NEC: How old were you?)
__________Years Old
DON’T KNOW
REFUSED
GO TO YRB37_CD9
GO TO YRB37_CD9
GO TO YRB37_CD9
YRB36b_CD7c.
About how old were you the first time [you did (that type of behavior/ either of those behaviors/ any of those
behaviors)]?
IF “DON’T KNOW”, PROBE: Can you remember what grade you were in at school?
[IF “ALL MY LIFE” OR “AS LONG AS I CAN REMEMBER,” PROBE: Was it before you first started
school?
IF NOT YES, PROBE] : Was it before you were a teenager?
__________ YEARS OLD
OR
BEFORE STARTED SCHOOL
BEFORE TEENAGER
NOT BEFORE TEENAGER
DON’T KNOW
REFUSED
__________ GRADE
6
12
13
YRB37_CD9
Did you do (that type of behavior/ either of those behaviors/ any of those behaviors) during the past 12 months?
YES ....................................... 1 (GO TO YRB41_CD10)
NO......................................... 5
DON’T KNOW
REFUSED
YRB37a_CD9a
How old were you the last time you did (that type of behavior/ either of those behaviors/ any of those behaviors)?
__________ YEARS OLD
DK
RF
MTO Youth Qnaire
Page B-114
Revised 08/09/07
YRB38_CD10.
About how many years altogether did you do (that type of behavior/ either of those behaviors/ any of those behaviors)?
________ NUMBER OF YEARS
DK
RF
YRB39
About how many times during the past 12 months did you do (that type of behavior / either of those behaviors / any
of those behaviors) during the past 12 months?
________NUMBER OF TIMES
DK
RF
YRB40_CD11
How much did (this behavior/ these behaviors) ever cause problems with either your school work, your job, or your
relationships with family or friends – not at all, a little, some, a lot, or extremely?
NOT AT ALL
A LITTLE
SOME
A LOT
EXTREMELY
DON’T KNOW
REFUSED
1
2
3
4
5
YRB40a_CD11a
How often during that time were you unable to carry out your daily activities or to take care of yourself because of (this
behavior/these behaviors) – often, sometimes, not very often, never?
OFTEN
SOMETIMES
NOT VERY OFTEN
NEVER
DON’T KNOW
REFUSED
MTO Youth Qnaire
1
2
3
4
Page B-115
Revised 08/09/07
YRB41a_CD16a
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
GO TO
YRB41_CD
16h
5
8
9
1
5
8
9
1
5
8
9
YRB41a_CD16a
Here is another set of questions about things adults don’t like young
people to do. These questions all involve aggressive behavior. Was
there ever a time…
…when you often “bullied,” threatened, or frightened people,
including smaller or younger children?
YRB41b_CD16b
… when you repeatedly got involved in physical fights?
YRB41c_CD16c
… when you used a weapon on another person, like a baseball bat,
glass bottle, knife, gun, or brick?
YRB41d_CD16d
… when you were physically cruel to an animal and hurt it on
purpose?
(IF NEC: This does not include hunting or getting rid of pests like
rodents or insects.)
YRB41e_CD16e
… when you were physically cruel to a person and hurt them on
purpose?
YRB41f_CD16f
… when you forced someone to give you something like money,
jewelry, or clothing by threatening them or hurting them?
1
YRB41g_CD16g
… when you stole someone’s purse, wallet, luggage, package or bag
by grabbing it from them? (IF NEC: This does not include stealing
from someone who wasn’t aware of the theft, such as stealing a piece
of luggage when the owner wasn’t watching.)
YRB41h_CD16h
… when you made anyone do something sexual by either forcing,
intimidating, or threatening them?
YRB41i_CD17.1. INTERVIEWER CHECKPOINT: (SEE YRB41a_CD16a – YRB41h_CD16h)
ONE OR MORE RESPONSES CODED ‘1’ .................................. 1
ALL OTHERS .................................................................................. 2
GO TO YRB47_CD32
YRB42_CD18
You answered “yes” to (NUMBER OF “YES” RESPONSES IN YRB44 SERIES) type(s) of aggressive behavior.
Think of the very first time in your life when you did (that type of behavior/ either of those behaviors / any of those
behaviors). Can you remember your exact age?
YES ....................................... 1
NO......................................... 5 (GO TO YRB39b_CD7c)
DON’T KNOW (GO TO YRB45b_CD18c)
REFUSED (GO TO YRB45b_CD18c)
MTO Youth Qnaire
Page B-116
Revised 08/09/07
YRB42a_CD18b
(IF NEC: How old were you?)
ENTER AGE: ________________
TO YRB46_CD20
YRB42b_CD18c
About how old were you the first time [you engaged in (that type of aggressive behavior/ either of those aggressive
behaviors/ any of those aggressive behaviors)]?
[IF DON’T KNOW, PROBE: Can you remember what grade you were in at school?]
[IF “ALL MY LIFE” OR “AS LONG AS I CAN REMEMBER,” PROBE: Was it before you first started school?
IF NOT YES, PROBE: Was it before you were a teenager?]
__________ YEARS OLD
BEFORE STARTED SCHOOL
BEFORE TEENAGER
NOT BEFORE TEENAGER
DON’T KNOW
REFUSED
OR
__________ GRADE
6
12
13
YRB43_CD20
Did you do (that type of behavior/ either of those behaviors/ any of those behaviors) during the past 12 months?
YES ....................................... 1 GO TO YRB47_CD21
NO......................................... 5
DK
RF
YRB43a_CD20a
How old were you the last time you did (that type of behavior/ either of those behaviors/ any of those behaviors)?
__________ YEARS OLD
DK
RF
YRB44_CD21
About how many years altogether did you do (that type of behavior/ either of those behaviors/ any of those behaviors)?
________ NUMBER OF YEARS
DK
RF
YRB45
About how many times during the past 12 months did you do (that type of behavior / either of those behaviors / any
of those behaviors)?
______NUMBER OF TIMES
DK
RF
MTO Youth Qnaire
Page B-117
Revised 08/09/07
YRB46_CD22
How much did (this behavior/ these behaviors) ever cause problems with either your school work, your job, or your
relationships with family or friends – not at all, a little, some, a lot, or extremely?
NOT AT ALL
A LITTLE
SOME
A LOT
EXTREMELY
DON’T KNOW
REFUSED
1
2
3
4
5
YRB47_CD32
Were you ever suspended or expelled from school as a result of your behavior?
YES
NO
DON’T KNOW
REFUSED
1
5
YRB48_CD33
Were you ever fired from a job because of your behavior?
YES
NO
DON’T KNOW
REFUSED
1
5
YRB49a
You said you have done something in the past that is against the law. When was the LAST time that you [MOST
SERIOUS ILLEGAL ACTIVITY RESPONDENT REPORTS FROM YRB14, YRB34d, YRB35c-e, YRB41c, or
YRB41e-h]?
__ __ MONTH
__ __ __ __ YEAR
YRB49b
Did this happen in the neighborhood or somewhere else?
IN THE NEIGHBORHOOD .........................1 GO TO YRB49d
SOMEWHERE ELSE ...................................2 GO TO YRB49c
DON’T KNOW .............................................3 GO TO YRB49d
REFUSED .....................................................4 GO TO YRB49d
YRB49c
Where did this happen?
AT SCHOOL
AT A PARK/PLAYGROUND
AT A STORE/RESTAURANT
IN A CAR
DON’T KNOW
REFUSED
MTO Youth Qnaire
1
2
3
4
Page B-118
Revised 08/09/07
YRB49d
Who were the people you were with?
1
2
FRIENDS
FAMILY MEMBERS
OTHER (Specify:______________)
DON’T KNOW
REFUSED
YRB49e
How long have you known this person/these people?
_____________ NUMBER
UNIT OF TIME:
DAYS.....................1
WEEKS..................2
MONTHS...............3
YEARS ..................4
YRB49f
Did the police talk to you about this?
YES
NO
DON’T KNOW
REFUSED
1
5
YRB49g
Did the police arrest you or charge you with an offense?
YES
1
NO
5
DON’T KNOW
REFUSED
YRB50_CD37
Were you ever in trouble with the police as a result of your behavior?
YES ....................................... 1
NO......................................... 5 (GO TO YRB51_CD38)
(GO TO YRB51_CD38)
DON’T KNOW
REFUSED
(GO TO YRB51_CD38)
YRB50a_CD37a
How old were you the first time (you got into trouble with the police as a result of your behavior)?
______________ YEARS OLD
DK
RF
YRB51_CD38
Were you ever arrested (because of your behavior)?
YES ....................................... 1
NO......................................... 5 (GO TO YRB53)
DON’T KNOW (GO TO YRB53)
REFUSED (GO TO YRB53)
MTO Youth Qnaire
Page B-119
Revised 08/09/07
YRB52_CD39
Were you ever sent to jail, prison, or a juvenile correction facility because of your behavior?
YES ....................................... 1
NO......................................... 5 (GO TO YRB53)
DON’T KNOW (GO TO YRB53)
REFUSED (GO TO YRB53)
YRB52a_CD39a
How old were you the first time (you were sent to jail, prison, or a juvenile correction facility for your behavior)?
______________ YEARS OLD
DK
RF
YRB52b_CD39b
How long did you stay in any of these facilities altogether?
_____________ NUMBER
DK (GO TO YRB53)
RF (GO TO YRB53)
YRB5c_CD39c
UNIT OF TIME:
DAYS.....................1
WEEKS..................2
MONTHS...............3
YEARS ..................4
YRB53
What is the percent chance that you would be arrested if you stole a car?
________________ PERCENT
DK
RF
YRB54
Suppose you were arrested for stealing a car, what is the percent chance that you would serve time in jail?
________________ PERCENT
DK
RF
GO TO NEXT SECTION
MTO Youth Qnaire
Page B-120
Revised 08/09/07
Section 17: POST-TRAUMATIC STRESS DISORDER (YCV)
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
YCV7_PT14.
Were you ever badly beaten up by a spouse or romantic partner?
1
5
8
9
YCV8_PT15.
Were you ever badly beaten up by anyone else?
1
5
8
9
YCV9_PT16.
Were you ever mugged, held up, or threatened with a weapon?
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
YCV1_PT8.
Were you ever involved in a life-threatening automobile accident?
YCV2_PT9.
Did you ever have any other life- threatening accident, including on your
job?
YCV3_PT10.
Were you ever involved in a major natural disaster, like a devastating
flood, hurricane, or earthquake?
YCV4_PT11.
Were you ever in a man-made disaster, like a fire started by a cigarette, or
a bomb explosion?
YCV5_PT12.
Did you ever have a life-threatening illness?
YCV6_PT13.
As a child, were you ever badly beaten up by your parents or the people
who raised you?
YCV10_PT17.
The next two questions are about sexual assault. The first is about rape.
We define this as someone either having sexual intercourse with you or
penetrating your body with a finger or object when you did not want them
to, either by threatening you or using force, or when you were so young
that you didn’t know what was happening. Did this ever happen to you?
YCV11_PT18.
Other than rape, were you ever sexually assaulted, where someone touched
you inappropriately, or when you did not want them to?
YCV12.
Have you ever been chased when you thought the person chasing you
would hurt you?
YCV13.
Have you ever been hit, slapped, punched or beaten up, even if you were
not beaten up very badly?
MTO Youth Qnaire
Page B-121
Revised 08/09/07
YCV14.
Has anyone ever stolen your purse, wallet, or snatched your jewelry?
1
5
8
9
YCV15.
Did anyone ever try to break into your home?
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
GO TO
YCV23
_PT55a
5
GO
TO
CKPT
PT56
8
GO
TO
CKPT
PT56
9
GO TO
CKPTP
T56
YCV16_PT20.
Did someone very close to you ever die unexpectedly; for example, they
were killed in an accident, murdered, committed suicide, or had a fatal
heart attack at a young age?
YCV17_PT22.
Did anyone very close to you ever have an extremely traumatic
experience, like being kidnapped, tortured or raped?
YCV18_PT22_1.
When you were a child, did you ever witness serious physical fights at
home, like when your father beat up your mother?
YCV19_PT23.
Did you ever see someone being badly injured or killed, or unexpectedly
see a dead body?
YCV20_PT27.
Did you ever experience any other extremely traumatic or life-threatening
event that I haven’t asked about yet?
YCV21_PT55a. Briefly, what was the one most traumatic event that you have not told me about?
REFUSED ................................... 9 GO TO CHECKPOINT (PT56)
RECORD BRIEF DESCRIPTION OF EVENT:______________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
INTERVIEW CHECKPOINT (PT56):
R REPORTED ONLY AT LEAST ONE EVENT TYPE,
YCV7_PT13 THROUGH YCV12_PT18 ........................................................ 1
ALL OTHERS..................................................................................................... 2
MTO Youth Qnaire
GO TO YCV26a
Page B-122
Revised 08/09/07
YCV22.
You said you had been [VIOLENT CRIME EXPERIENCE/MULTIPLE VIOLENT CRIME EXPERIENCES]. When
was the last time [THIS/ONE OF THESE EVENTS] happened?
Past 6 months...................................1
Past 12 months.................................2
Over a year ago................................3
DON’T KNOW ...............................8
REFUSED .......................................9
YCV23.
Were the police informed, or did they find out about this incident in any way?
YES..................................................1
NO....................................................5
DON’T KNOW ...............................8
REFUSED .......................................9
YCV24.
As far as you know, was anyone arrested or were charges brought against anyone in connection with this incident?
YES..................................................1
NO....................................................5
DON’T KNOW ...............................8
REFUSED .......................................9
YCV25.
You said you had been [VIOLENT CRIME EXPERIENCE]. The last time this happened, where did it happen?
(Record answer verbatim and circle all that apply).
_____________________________________________
_____________________________________________
_____________________________________________
Inside home......................................1
In someone else’s home ..................2
At school..........................................3
Somewhere else in neighborhood ...4
Outside neighborhood .....................5
Don’t know ......................................8
Refused ............................................9
MTO Youth Qnaire
Page B-123
Revised 08/09/07
YCV25a.
The last time this happened, who did this to you?
Parent ...............................................1
Sibling..............................................2
Other relative ...................................3
Best friend........................................4
Classmate.........................................5
Friend/Acquaintance .......................6
Neighbor ..........................................7
Teacher.............................................8
Stranger............................................9
Gang member ..................................10
Police Officer...................................11
Spouse/Partner/girl(boy)friend........12
Other (specify)................................13
Don’t know ......................................98
Refused ............................................99
YCV26a.
Please tell me if any of the following have happened to anyone who
lived with you during the past months? Was anyone’s purse, wallet or
jewelry snatched from them?
YCV26b.
Was anyone threatened with a knife or gun?
YCV26c.
Was anyone beaten up or assaulted?
YCV26d.
Was anyone stabbed or shot?
MTO Youth Qnaire
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
Page B-124
Revised 08/09/07
CHECKPOINT_YCV26e_PT61.
INTERVIEWER CHECKPOINT:
R REPORTED ONLY ONE EVENT TYPE, YCV1_PT8 THROUGH YCV20_PT27 OR YCV26a
THROUGH YCV26d ...................................................................... 1 GO TO YCV27_PT62 INTRO2
R REPORTED TWO OR THREE EVENT TYPES, YCV1_PT8 THROUGH YCV20_PT27 OR YCV26a
THROUGH YCV26d ...................................................................... 2 GO TO YCV27_PT62 INTRO3
R REPORTED FOUR OR MORE EVENT TYPES, YCV1_PT8 THROUGH YCV20_PT27 OR YCV26a
THROUGH YCV26d ..................................................................... 3 GO TO YCV27_PT62 INTRO4
ALL OTHERS
............................................................................. 4 GO TO NEXT SECTION
YCV27_PT62 INTRO 2.
Let me review. You experienced
(NUMBER) (KEY PHRASE OF
EVENT TYPE). After an experience
like this, people sometimes have
problems like upsetting memories or
dreams, feeling emotionally distant or
depressed, trouble sleeping or
concentrating, and feeling jumpy or
easily startled. Did you have any of
these reactions after [(either/any)
[EVENT TYPE]/ of these experiences]?
YCV27_PT62 INTRO 3.
Let me review. You had (two/ three)
different types of traumatic events:
[KEY PHRASES OF ALL EVENT
TYPES] (and a private event). After
experiences like these, people
sometimes have problems like upsetting
memories or dreams, feeling
emotionally distant or depressed,
trouble sleeping or concentrating, and
feeling jumpy or easily startled. Did
you have any of these reactions after
any of the traumatic experiences you
have gone through?
YES.....................................1
NO ......................................5
DON’T KNOW..................8
REFUSED ..........................9
YCV27_PT62 INTRO 4.
Let me review. You had quite a few
different traumatic experiences, like:
[KEY PHRASES OF 3 EVENT
TYPES] (and a private event). After
experiences like these, people
sometimes have problems like upsetting
memories or dreams, feeling
emotionally distant from or depressed,
trouble sleeping or concentrating, and
feeling jumpy or easily startled. Did
you have any of these reactions after
any of the traumatic experiences you
have gone through?
GO TO NEXT SECTION
GO TO NEXT SECTION
GO TO NEXT SECTION
YCV28_PT62_2
Did you ever in your life talk to a medical doctor or other professional about (this problem / any of these problems)?
(By professional we mean psychologists, counselors, spiritual advisors, herbalists, acupuncturists, and other healing
professionals).
YES.....................................1
NO.......................................5
MTO Youth Qnaire
Page B-125
Revised 08/09/07
YCV29_PT64.
Of the [experiences you mentioned to me / NUMBER times (EVENT TYPEs) happened] which one caused you the
most problems like upsetting memories or dreams, feeling emotionally distant, trouble sleeping or concentrating, or
feeling jumpy or easily startled. That is, which one experience caused the largest n umber or most severe problems?
¾
IF NEC: REVIEW ENDORSED EVENTS.
¾
(IF “DON’T KNOW,” PROBE: Which of these very upsetting events happened most recently?)
DON’T KNOW.................................998
REFUSED .........................................999
RECORD WORST EVENT:
____________ NUMBER OF EVENT
YCV29a_PT64a.
NOTE AGE AT TIME OF WORST EVENT: [IF NEC: How old were you when that (happened/ started)?]
____________ YEARS OLD
DON’T KNOW..................998
REFUSED ..........................999
INTERVIEWER: SEE YCV29_PT64, THEN PROBE:
YCV30_PT67.
[FOR “ONGOING” EVENTS: During the period of time when
(WORST EVENT) was happening repeatedly, did you ever feel terrified
or very frightened?]
[ALL OTHERS: Were you terrified or very frightened at the time
(WORST EVENT)?]
YCV30a_PT67a.
Did you feel helpless?
YCV30b_PT67b.
Did you feel shocked or horrified?
MTO Youth Qnaire
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
5
8
9
5
8
9
GO TO
YCV31_
PT68
1
GO TO
YCV31_
PT68
1
GO TO
YCV31_
PT68
Page B-126
Revised 08/09/07
YCV30c_PT67c.
Did you feel numb?
1
GO TO
YCV31_
PT68
5
8
9
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
YCV31_PT68.
(RB)
In the weeks, months, or years after (the event/ this experience ended/
WORST EVENT), did you try not to think about (it/ what happened)?
(IF YES: Please make a checkmark by reaction 1.)
(KEY PHRASE: tried not to think about it)
YCV32_PT69.
Did you purposely stay away from places, people or activities that
reminded you of (it/ the event/ this experience/ WORST EVENT)?
(IF YES: Please make a checkmark by reaction 2.)
(KEY PHRASE: stayed away from reminders of it)
YCV33_PT70.
Were you ever unable to remember some important parts of what
happened?
IF VOL “UNCONSCIOUS,” “KNOCKED OUT,” OR
“HEAD INJURY,” CODE NO.
(IF YES: Please make a checkmark by reaction 3.)
[KEY PHRASE: were unable to remember part(s) of it]
YCV34_PT71.
Did you lose interest in doing things you used to enjoy?
(IF YES: Please make a checkmark by reaction 4.)
(KEY PHRASE: lost interest in things you used to enjoy)
YCV35_PT72.
Did you feel emotionally distant or cut-off from other people?
(IF YES: Please make a checkmark by reaction 5.)
(KEY PHRASE: felt distant from other people)
YCV36_PT73.
Did you have trouble feeling normal feelings like love, happiness, or
warmth toward other people?
(IF YES: Please make a checkmark by reaction 6.)
MTO Youth Qnaire
Page B-127
Revised 08/09/07
(KEY PHRASE: had trouble feeling normal feelings)
YCV37_PT74.
Did you feel you had no reason to plan for the future because you
thought it would be cut short?
(IF YES: Please make a checkmark by reaction 7.)
1
5
8
9
(KEY PHRASE: felt you had no reason to plan for the
future)
INTERVIEWER CHECKPOINT (PT75)
ZERO “YES” RESPONSES IN YCV31_PT68 – YCV37_PT74............................ 1 GO TO NEXT SECTION
ALL OTHERS............................................................................................................. 2 GO TO YCV38_PT86
YCV38_PT86.
(RB)
Did you ever have repeated unwanted memories of (it/ the event/ this
experience/ WORST EVENT) – that is, you kept remembering it even
when you didn’t want to?
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
(IF YES: Please make a checkmark by reaction 8.)
(KEY PHRASE: had unwanted memories)
YCV39_PT87.
Did you ever have repeated unpleasant dreams about (it/ the event/ this
experience/ WORST EVENT)?
(IF YES: Please make a checkmark by reaction 9.)
(KEY PHRASE: had unpleasant dreams)
YCV40_PT88.
Did you have flashbacks – that is, suddenly act or feel as if (it/ the
event/ this experience/ WORST EVENT) were happening all over
again?
(IF YES: Please make a checkmark by reaction 10.)
(KEY PHRASE: had flashbacks)
YCV41_PT89.
Did you get very upset when you were reminded of (it/ the event/ this
experience/ WORST EVENT)?
MTO Youth Qnaire
Page B-128
Revised 08/09/07
(IF YES: Please make a checkmark by reaction 11.)
(KEY PHRASE: got really upset when reminded of it)
YCV42_PT90.
When you were reminded of (it/ the event/ this experience/ WORST
EVENT), did you ever have physical reactions like sweating, your
heart racing, or feeling shaky?
1
5
8
9
(IF YES: Please make a checkmark by reaction 12.)
(KEY PHRASE: had physical reactions)
INTERVIEWER CHECKPOINT (PT91)
ZERO “YES” RESPONSES IN YCV38_PT86 – YCV42_PT90............... 1 GO TO NEXT SECTION
ALL OTHERS ............................................................................................... 2 GO TO YCV43_PT102
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
YCV43_PT102.
(RB)
During the time (this event/ this experience/ WORST EVENT)
affected you most, did you have trouble falling or staying asleep?
(IF YES: Please make a checkmark by reaction 13.)
(KEY PHRASE: had sleep problems)
YCV44_PT103.
Were you more irritable or short-tempered than you usually are?
(IF YES: Please make a checkmark by reaction 14.)
(KEY PHRASE: were irritable)
YCV45_PT104.
Did you have more trouble concentrating or keeping your mind on
what you were doing?
(IF YES: Please make a checkmark by reaction 15.)
(KEY PHRASE: had trouble concentrating)
YCV46_PT105.
Were you much more alert or watchful, even when there was no real
need to be?
(IF YES: Please make a checkmark by reaction 16.)
(KEY PHRASE: were more alert or watchful)
MTO Youth Qnaire
Page B-129
Revised 08/09/07
YCV47_PT106.
Were you more jumpy or easily startled by ordinary noises?
(IF YES: Please make a checkmark by reaction 17.)
1
5
8
9
(KEY PHRASE: were jumpy or easily startled)
INTERVIEWER CHECKPOINT (PT107)
ZERO “YES” RESPONSES IN YCV43_PT102 – YCV47_PT106.....................1
ALL OTHERS..........................................................................................................2
GO TO NEXT SECTION
GO TO YCV48_PT110
YCV48_PT110.
You had quite a few reactions, such as (FIRST KEY PHRASE FOR EACH OF THE 3 SETS OF REACTIONS
REPORTED IN YCV31_PT68 – YCV37_PT74, YCV38_PT86 – YCV39_PT90, YCV43_PT102 YCV47_PT106). For about how many days, weeks, months, or years did you continue to have any of these reactions?
(IF VOL “IT’S STILL GOING ON,” PROBE: How long has it been so far?)
(IF DK, PROBE, “Was it at least a month?” IF YES, CODE 97 BELOW.)
___________ DURATION NUMBER
CIRCLE UNIT OF TIME: DAYS....1
WEEKS....2
MONTHS....3
YEARS ....4
“AT LEAST A MONTH” ...............97
DON’T KNOW ...............................98
REFUSED .......................................99
_______________________________________________________________________________________________
YCV49a_PT110.
CIRCLE UNIT OF TIME: DAYS 1.................WEEKS ............2
MONTHS....3
YEARS ....4
INTERVIEWER CHECKPOINT (PT111)
LESS THAN ONE MONTH (30 DAYS) OF REACTIONS IN
YCV48_PT110......................................................................................... 1 GO TO NEXT SECTION
ALL OHERS ........................................................................................... 2 GO TO YCV48_PT113
YCV49_PT113.
Think of the time when these reactions were most frequent and intense. How often did they occur – less than once a
month, one to two times a month, three to five times a month, six to ten times a month, or more than ten times a
month?
LESS THAN ONCE A MONTH ..................1
ONE TO TWO TIMES A MONTH..............2
THREE TO FIVE TIMES A MONTH ........3
SIX TO TEN TIMES A MONTH .................4
MORE THAN TEN TIMES A MONTH ......5
DON’T KNOW .............................................8
REFUSED .....................................................9
(GO TO NEXT SECTION)
(GO TO YCV50_PT114)
(GO TO YCV50_PT114)
(GO TO YCV50_PT114)
(GO TO YCV50_PT114)
(GO TO YCV50_PT114)
(GO TO YCV50_PT114)
YCV50_PT114.
How much distress did these reactions cause you – none, mild, moderate, severe, or very severe distress?
MTO Youth Qnaire
Page B-130
Revised 08/09/07
NONE ...............................................................1
MILD ................................................................2
MODERATE....................................................3
SEVERE ...........................................................4
VERY SEVERE...............................................5
DON’T KNOW ...............................................8
REFUSED .......................................................9
YCV51_PT115.
How much did these reactions disrupt or interfere with your normal, daily life – not at all, a little, some, a lot, or
extremely?
NOT AT ALL...................................................1
A LITTLE.........................................................2
SOME ...............................................................3
A LOT...............................................................4
EXTREMELY..................................................5
DON’T KNOW ...............................................8
REFUSED .......................................................9
INTERVIEWER CHECKPOINT (PT116)
RESPONSES CODED 3-5 IN YCV50_PT114 OR IN YCV51_PT115 .......... 1 GO TO YCV52_PT261
ALL OTHERS...................................................................................................... 2 GO TO NEXT SECTION
YCV52_PT261. (RB: REFER R TO THE LIST OF SXS BEFORE ASKING THIS QUESTION).
The next question is about whether in the past 12 months you had any of these reactions associated with any
traumatic event that ever happened to you in your entire life. Did you have any reactions of this sort over the past
12 months?
YES ................................ 1
NO .................................. 5
DON’T KNOW .............. 8
REFUSED ...................... 9
GO TO NEXT SECTION
GO TO NEXT SECTION
GO TO NEXT SECTION
YCV53_PT263.
About how many weeks altogether in the past 12 months did you have any of these reactions? (You can use any
number between 0 and 52.)
__________ NUMBER OF WEEKS
DON’T KNOW ..............................................98
REFUSED ......................................................99
INTERVIEWER CHECKPOINT PT264
ZERO TO THREE WEEKS IN YCV53_PT263.......1 GO TO NEXT SECTION
ALL OTHERS.............................................................2
MTO Youth Qnaire
Page B-131
Revised 08/09/07
YES
(1)
NO
(5)
DK
(8)
RF
(9)
1
5
8
9
1
5
8
9
1
5
8
9
1
5
8
9
YCV58_PT273.
Did you have any trouble falling or staying asleep during that month?
1
5
8
9
YCV59_PT274.
Were you more jumpy or more easily startled by ordinary noises?
1
5
8
9
1
5
8
9
YCV54_PT269.
Please think of the 30-day period in the past 12 months when these reactions
were most frequent and intense. During that month, did you lose interest in
doing things you used to enjoy?
YCV55_PT270.
Did you feel emotionally distant or cut off from other people during that month?
YCV56_PT271.
Did you have trouble feeling normal feelings like love, happiness, or warmth
toward other people?
YCV57_PT272.
Did you feel you had no reason to plan for the future because you thought it
would be cut short?
YCV60_PT275.
Did you purposely stay away from places, people or activities that reminded
you of [(WORST 12-MONTH EVENT)]/ these events]?
MTO Youth Qnaire
Page B-132
Revised 08/09/07
Section 18: YOUTH REPORTS ON PARENTS AND PARENTING (YOP)
YOP1
How many adults do you have in your life who you feel comfortable talking to about personal problems?
NUMBER OF ADULTS ___________________
DON’T KNOW
-1
REFUSED
-2
YOP2
How many adults do you have in your life who care a lot about how you turn out and who will help you if you
get into trouble?
NUMBER OF ADULTS ___________________
DON’T KNOW
-1
REFUSED
-2
YOP3
(RB) Who are the adult(s) who you go to first to talk about personal problems or who will help you if you get
into trouble? Check all that apply.
Mother....................................................... 1
Father ........................................................ 2
Stepparent.................................................. 3
Brothers or sisters...................................... 4
Other relatives ........................................... 5
Teachers .................................................... 6
Coach ........................................................ 7
Guidance counselor................................... 8
Advisor or school principal ....................... 9
Other leaders in the community ................ 10
No one ....................................................... 11
DK
RF
YOP4
(RB) Of all the people you know personally, young or adult, think about the person you admire the most. How
would you describe this person? [Check all that apply.]
Honest ....................................................... 1
Popular ...................................................... 2
Dresses Well ............................................. 3
Intelligent .................................................. 4
Makes a lot of money................................ 5
Has an important job ................................. 6
Has a college degree.................................. 7
Good at sports ........................................... 8
I do not admire anyone.............................. 9
DK
RF
MTO Youth Qnaire
Page B-133
Revised 08/09/07
YOP5
What is your relationship to that person?
A friend ..................................................... 1
My mother or father .................................. 2
A relative................................................... 3
Boyfriend/girlfriend .................................. 4
Other ......................................................... 5
DK
RF
YOP6
Now we would like to know about your relationship with your mother, or with the adult most responsible for
taking care of you or who knows the most about your activities. Do you live with your mother?
YES (SKIP TO YOP8)
1
NO
2
MOTHER DECEASED
3
REFUSED
7
DON’T KNOW
8
YOP7
Who is the adult who lives with you and knows the most about your activities?
MTO Youth Qnaire
FATHER (SKIP TO YOP12)
1
GRANDMOTHER
2
AUNT
3
SISTER
4
FOSTER MOTHER
5
STEP MOTHER
6
COUSIN
7
FRIEND
8
SPOUSE/(BOY)/GIRLFRIEND
9
NO ADULT LIVES WITH YOUTH (SKIP TO YOP12)
10
OTHER (SPECIFY): ___________________
95
REFUSED (SKIP TO YOP12)
97
DON’T KNOW (SKIP TO YOP12)
98
Page B-134
Revised 08/09/07
YOP8
When you think about how your [CAREGIVER] acts toward you, in general, would you say your
[CAREGIVER] is very supportive, somewhat supportive, or not very supportive?
VERY SUPPORTIVE
1
SOMEWHAT SUPPORTIVE
2
NOT VERY SUPPORTIVE
3
REFUSED
7
DON’T KNOW
8
NOTHING
JUST A
LITTLE
SOME
THINGS
MOST
THINGS
EVERY
-THING
RF
DK
YOP9a
(RB) How much does your [CAREGIVER]
know about your close friends, that is, who
they are? Do you think (she/he) knows
nothing, just a little, some things, most
things or everything?
1
2
3
4
5
7
8
YOP9b
(RB) (How much does your [CAREGIVER]
know) About who you are with when you
are not at home?
1
2
3
4
5
7
8
YOP9c
(RB) (How much does your
[CAREGIVER] know) About who your
teachers are [who your teachers were when
you were last enrolled in school] and what
you (are/were) doing in school?
1
2
3
4
5
7
8
NEVER
RARELY
SOMETIMES
OFTEN
RF
DK
YOP10a
(RB) How often does your (CAREGIVER)
Limit privileges because of poor grades—
often, sometimes, rarely, or never?
1
2
3
4
7
8
YOP10b
(RB) (How often does your
[CAREGIVER]) Check on whether you
have done your homework?
1
2
3
4
7
8
YOP10c
(RB) (How often does your
[CAREGIVER]) Help you with your
homework?
1
2
3
4
7
8
YOP10d
(RB) (How often does your
[CAREGIVER]). Limit the amount of time
you go out with friends on school nights?
1
2
3
4
7
8
MTO Youth Qnaire
Page B-135
Revised 08/09/07
NEVER
RARELY
SOMETIMES
OFTEN
RF
DK
YOP10e
(RB) (How often does your
[CAREGIVER]) Require you to do work or
chores around the home?
1
2
3
4
7
8
YOP10f
(How often does your [CAREGIVER]),
Limit you from leaving home to hang out
with your friends?
1
2
3
4
7
8
[IF FATHER IS PRIMARY CAREGIVER, SKIP TO YOP15]
YOP11
Did your (CAREGIVER) ever have a problem with drinking alcohol, or using drugs?
YES
1
NO (SKIP TO YOP15)
2
REFUSED (SKIP TO YOP15)
7
DON’T KNOW (SKIP TO YOP15)
8
YOP12
Now I’d like to talk with you about your father. When you were growing up, in general, was he very
supportive, somewhat supportive, or not very supportive of you?
MTO Youth Qnaire
VERY SUPPORTIVE
1
SOMEWHAT SUPPORTIVE
2
NOT VERY SUPPORTIVE
DOESN’T SEE FATHER (SKIP TO YOP11 )
3
4
FATHER DECEASED (SKIP TO YOP11)
5
REFUSED
7
DON’T KNOW
8
Page B-136
Revised 08/09/07
YOP12a
In the past 12 months, how often have you seen your father – almost every day, once a week, once a month, a
few times, or never in the past 12 months?
Never in the past 12 months
1
A few times
2
Once a month
Once a week
3
Almost every day
5
LIVED IN SAME HOUSEHOLD
6
REFUSED
7
DON’T KNOW
8
4
YOP13
How far in school do you think your father wants you to go?
Less than high school graduation
1
High school graduation only
2
VOCATIONAL, TRADE, OR BUSINESS SCHOOL AFTER HIGH
SCHOOL
Less than two years of school
3
Two years or more of school
4
A degree from a vocational, trade, or business school
5
COLLEGE PROGRAM
Less than two years of college
6
Two or more years of college (including two-year degree)
7
Finish college (four- or five-year degree)
8
GRADUATE OR PROFESSIONAL SCHOOL
MTO Youth Qnaire
Master’s degree or equivalent
9
Ph.D., M.D., or other professional degree
10
REFUSED
97
DON’T KNOW
98
Page B-137
Revised 08/09/07
YOP14
KNOWS
NOTHING
KNOWS
JUST A
LITTLE
KNOWS
SOME
THINGS
KNOWS
MOST
THINGS
KNOWS
EVERYTHING
RF
DK
YOP14a
(RB) How much does your father know
about your close friends, that is, who
they are? Do you think he knows
nothing, knows just a little, knows some
things, knows most things, or knows
everything?
1
2
3
4
5
7
8
YOP14b
(RB) (How much does your father
know) About who you are with when
you are not at home?
1
2
3
4
5
7
8
2
3
4
5
7
8
YOP14c
(RB) (How much does your father
know) About who your teachers are
[who your teachers were when you were
last enrolled in school] and what you
are/were doing in school?
1
YOP15
In a typical week, what (is/was) the latest you (can/could) stay out on school nights (Sunday through
Thursday)?
MTO Youth Qnaire
NOT ALLOWED OUT
1
NO LATER THAN 8:00
2
NO LATER THAN 9:00
3
NO LATER THAN 10:00
4
NO LATER THAN 11:00
5
NO LATER THAN 12:00
6
AS LATE AS I WANT
7
REFUSED
97
DON’T KNOW
98
Page B-138
Revised 08/09/07
YES
NO
DK
RF
YOP16a
If your parent or parents found out that you had come home an hour
late for no good reason, would (he/she/they) discuss it calmly with
you?
1
5
8
9
YOP16b
(If your parent or parents found out that you had come home an hour
late for no good reason, would (he/she/they)) Ignore it, pretend that
it didn’t happen or let you get away with it?
1
5
8
9
YOP16c
(If your parent or parents found out that you had come home an hour
late for no good reason, would (he/she/they)) Sulk, pout, or give you
the silent treatment?
1
5
8
9
YOP16d
(If your parent or parents found out that you had come home an hour
late for no good reason, would (he/she/they)) Take away a privilege,
ground you, or give you a chore?
YOP16e
(If your parent or parents found out that you had come home an hour
late for no good reason, would (he/she/they)) Make threats that
won’t be kept?
1
5
8
9
1
5
8
9
YOP16f
(If your parent or parents found out that you had come home an hour
late for no good reason, would (he/she/they)) Yell, shout, or scream
at you?
1
5
8
9
YOP16g
(If your parent or parents found out that you had come home an hour
late for no good reason, would (he/she/they)) Use physical
punishment?
1
5
8
9
MTO Youth Qnaire
Page B-139
Revised 08/10/07
Section 19: Youth Decision Making (YDM)
Very
low
YDM1a
(RB) Think about how you see your
future. What are the chances that You
will live to age 35? Would you say
very low, low, about 50-50, high, or
very high?
YDM1b
What are the chances that you will
complete college by age 35?
YDM1c
(What are the chances that) You will
find a stable, well-paid job as an adult?
Low
About
50-50
High
Very
high
REFUSED
DON’T
KNOW
1
2
3
4
5
7
8
1
2
3
4
5
7
8
1
2
3
4
5
7
8
YDM2
Do you expect your life as an adult to be much like your own family, better than your own family, or worse than
your own family?
MUCH LIKE YOUR OWN FAMILY ........................1
BETTER THAN YOUR OWN FAMILY ...................2
WORSE THAN YOUR OWN FAMILY ....................3
DON’T KNOW
REFUSED
YDM3
The next questions are about what you think your chances to get ahead will be like. How much do you agree or
disagree with the following statements ....
(RB) As an adult, I will have just as much chance to succeed as people from other neighborhoods. Do you strongly
agree, agree, disagree, or strongly disagree?
STRONGLY AGREE..................................................1
AGREE........................................................................2
DISAGREE. ................................................................3
STRONGLY DISAGREE. ..........................................4
DON’T KNOW
REFUSED
MTO Youth Qnaire
Page B-140
Revised 08/10/07
YDM4
(RB) Most people in my neighborhood will be better off than me.
STRONGLY AGREE..................................................1
AGREE........................................................................2
DISAGREE. ................................................................3
STRONGLY DISAGREE. ..........................................4
DON’T KNOW
REFUSED
YDM5a
Suppose that after having helped a relative with some chores, they offer to send you a small amount of money in
return for your help. They tell you that they can either send you something now, or send you a little more if you are
willing to wait one month. If they pay you now, they will put $20 in the mail tomorrow. If they pay you one month
from now, they will send you slightly more than that. Suppose that you trust them to pay you what they promise,
when they promise it.
Would you rather they mailed you $20 tomorrow or $23 one month from now?
$20 TOMORROW.......................................................1 (GO TO YDM5D)
$23 ONE MONTH FROM NOW................................2
DK (GO TO YDM5D)
RF (GO TO YDM6)
YDM5b
Now suppose the choice were between $20 now and $22 one month from now. Would you rather they mailed you
$20 tomorrow or $22 one month from now?
$20 TOMORROW.......................................................1 (GO TO YDM6)
$22 ONE MONTH FROM NOW ...............................2
DK (GO TO YDM6)
RF (GO TO YDM6)
YDM5c
Now suppose the choice were between $20 now and $21 one month from now. Would you rather they mailed you
$20 tomorrow or $21 one month from now?
$20 TOMORROW.......................................................1 (GO TO YDM6)
$21 ONE MONTH FROM NOW ...............................2 (GO TO YDM6)
DK ............................................................................... (GO TO YDM6)
RF ............................................................................... (GO TO YDM6)
YDM5d
Now suppose the choice were between $20 now and $24 one month from now. Would you rather they mailed you
$20 tomorrow or $24 one month from now?
$20 TOMORROW ......................................................1
$24 ONE MONTH FROM NOW................................2 (GO TO YDM6)
DK ............................................................................... (GO TO YDM5E)
RF ................................................................................ (GO TO YDM6)
MTO Youth Qnaire
Page B-141
Revised 08/10/07
YDM5e
Now suppose the choice were between $20 now and $25 one month from now. Would you rather they mailed you
$20 tomorrow or $25 one month from now?
$20 TOMORROW.......................................................1
$25 ONE MONTH FROM NOW ...............................2
DK
RF
YDM6
Suppose a relative of yours calls to say they just inherited some money and part of it should be yours. Because of
the way their inheritance is being distributed, they can either send you some money now, or a larger amount of
money later, which they would send to you on your next birthday. Suppose that you trust this person to send what
they promise, and that you do not expect to get a birthday present from this relative other than this money.
Would you rather they mailed you $50 tomorrow or $60 on your next birthday?
$50 TOMORROW ......................................................1
$60 ON NEXT BIRTHDAY ......................................2
DK
RF
YDM7a
Suppose you have a choice between two, equally good summer jobs. The first would pay you $600 for the summer
for sure. The second job would pay you an amount that depends on how the company as a whole did for the
summer. It is possibly better paying, but your earnings will be less certain.
There is a 50-50 chance that the second job will pay $1200, and a 50-50 chance it will pay $400. Which would you
choose – the job that pays $600 for sure, or the job with an equal chance of paying either $1200 or $400?
JOB THAT PAYS $600 FOR SURE ..................................................................... 1 (GO TO YDM7D)
JOB WITH AN EQUAL CHANCE OF PAYING EITHER $1200 OR $400 ....... 2
DON’T KNOW .................................................................................................... (GO TO YDM7D)
REFUSED .......................................................................................................... (GO TO YDM8A)
YDM7b
Now suppose there is a 50-50 chance that the second job will pay $1200, and a 50-50 chance that it will pay $300.
Which would you choose – the job that pays $600 for sure, or the job with an equal chance of paying either $1200 or
$300?
JOB THAT PAYS $600 FOR SURE .................................................................... 1 (GO TO YDM8A)
JOB WITH AN EQUAL CHANCE OF PAYING $1200 OR $300 ...................... 2
DON’T KNOW...................................................................................................... (GO TO YDM8A)
REFUSED .......................................................................................................... (GO TO YDM8A)
YDM7c
Now suppose there is a 50-50 chance that the second job will pay $1200, and a 50-50 chance that it will pay $150.
Which would you choose – the job that pays $600 for sure, or a job with an equal chance of paying either $1200 or
$150?
JOB THAT PAYS $600 FOR SURE ..................................................................... 1 (GO TO YDM8A)
JOB WITH AN EQUAL CHANCE OF PAYING $1200 OR $150 ...................... 2 (GO TO YDM8A)
DON’T KNOW ..................................................................................................... (GO TO YDM8A)
REFUSED .......................................................................................................... (GO TO YDM8A)
MTO Youth Qnaire
Page B-142
Revised 08/10/07
YDM7d
Now suppose there is a 50-50 chance that the second job will pay $1200, and a 50-50 chance that it will pay $480.
Which would you choose – the job that pays $600 for sure, or a job with an equal chance of paying either $1200 or
$480?
JOB THAT PAYS $600 FOR SURE .................................................................... 1
JOB WITH AN EQUAL CHANCE OF PAYING $1200 OR $480 ...................... 2 (GO TO YDM8A)
DON’T KNOW...................................................................................................... (GO TO YDM7E)
REFUSED .......................................................................................................... (GO TO YDM8a)
YDM7e
Now suppose there is a 50-50 chance that the second job will pay $1200, and a 50-50 chance that it will pay $540.
Which would you choose – the job that pays $600 for sure, or a job with an equal chance of paying either $1200 or
$540?
JOB THAT PAYS $600 FOR SURE ..................................................................... 1
JOB WITH AN EQUAL CHANCE OF PAYING $1200 OR $540 ...................... 2
DON’T KNOW
REFUSED
YDM8a
(RB) Now, I want to ask you about trusting different groups of people. First, thinking about people in your
immediate family, generally speaking would you say you can trust them a lot, trust them some, trust them only a
little or not trust them at all?
A LOT ......................................................................... 1
SOME ......................................................................... 2
ONLY A LITTLE ....................................................... 3
NOT AT ALL ............................................................. 4
DON’T KNOW
REFUSED
YDM8b
(RB) How about people in your neighborhood? (would you say you can trust them a lot, trust them some, trust them
only a little or not trust them at all?)?
A LOT ......................................................................... 1
SOME ......................................................................... 2
ONLY A LITTLE ....................................................... 3
NOT AT ALL ............................................................. 4
DON’T KNOW
REFUSED
YDM8c
(RB) How about other people in general? (would you say you can trust them a lot, trust them some, trust them only
a little or not trust them at all?)?
A LOT ......................................................................... 1
SOME ......................................................................... 2
ONLY A LITTLE ....................................................... 3
NOT AT ALL ............................................................. 4
DON’T KNOW
REFUSED
MTO Youth Qnaire
Page B-143
Revised 08/10/07
YDM8d
(RB) Next, I’m going to ask about trust in institutions. How about the police department in your area, do you feel
you can trust them a lot, some, only a little or not at all?
A LOT ......................................................................... 1
SOME ......................................................................... 2
ONLY A LITTLE ....................................................... 3
NOT AT ALL ............................................................. 4
DON’T KNOW
REFUSED
YDM9
Generally speaking, would you say that most people can be trusted or that you can’t be too careful in life?
MOST PEOPLE CAN BE TRUSTED........................ 1
CAN’T BE TOO CAREFUL ...................................... 2
(IF R VOLUNTEERS) OTHER (DEPENDS ............ 3
DON’T KNOW
REFUSED
YDM10
(RB) Next, I am going to read you a list of statements and for each, please tell me if you strongly agree, agree,
disagree, or strongly disagree? I trust the people I hang around with at school.
STRONGLY AGREE ................................................. 1
AGREE. ...................................................................... 2
DISAGREE................................................................. 3
STRONGLY DISAGREE........................................... 4
DON’T KNOW
REFUSED
YDM11
(RB) I trust other students at my school, even if I don’t know them.
STRONGLY AGREE ................................................. 1
AGREE. ...................................................................... 2
DISAGREE................................................................. 3
STRONGLY DISAGREE........................................... 4
DON’T KNOW
REFUSED
Thank you for completing the MTO survey and achievement tests for this important HUD study.
YDM12. [ASKED ONLY OF YOUTH 13-20 RANDOMLY SELECTED TO PARTICIPATE IN DECISION
MAKING EXERCISE]
With some additional support from several private foundations we are pleased to be able to offer you a small amount
of additional compensation that is available in two forms. Either a check for $20 that we will put in the mail
tomorrow or a check for $25 that we could put in the mail on your next birthday. Which would you prefer -- $20
sent tomorrow, or $25 sent on your next birthday?
$20 SENT TOMORROW............................. 1
$25 ON NEXT BIRTHDAY ........................ 2
DON’T KNOW
REFUSED
Section 20. Contact Information (YCI)
YCI1
To continue to help the government learn how to improve housing programs, it is very important that we
talk to people periodically to see how things are going. Since people often move, we would like to ask you
for the names of friends or relatives who usually keep in touch with you. We would contact these people
only if we were unable to reach you at your current phone number. We would ask them only for your
address and telephone information.
(IF NO CONTACT PERSON INFORMATION AVAIALBLE FROM PREVIOUS CONTACTS: Please
give me the name of three people who do not live with you and who will know how to reach you if we need
to contact you again to verify this interview or to ask a few additional questions.)
(IF CONTACT INFORMATION AVAILABLE: In the past you gave us information on the following
three people. I would like to make sure that we have the most current information for them, and that they
are the best people to use to find you.)
YC2
UPDATE OR COLLECT INFORMATION FOR CONTACT PERSON #1
NAME
RELATIONSHIP TO R
ADDRESS
PHONE NUMBER
YC3
UPDATE OR COLLECT INFORMATION FOR CONTACT PERSON #2
NAME
RELATIONSHIP TO R
ADDRESS
PHONE NUMBER
YC4
UPDATE OR COLLECT INFORMATION FOR CONTACT PERSON #3
NAME
RELATIONSHIP TO R
ADDRESS
PHONE NUMBER
MTO Youth Qnaire
Page B-145
Appendix C:
Early Childhood Longitudinal Survey (ECLS)
Education Achievement Assessment
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page C-1
Early Childhood Longitudinal Survey, Grades 5 and 8
Youth Assessment of Math and Reading Achievement
With supplementation of NELS items
MTO Final Evaluation
Youth who are ages 10 to 20 at the end of 2007, and who were members of the MTO core
households, will be administered the U.S. Department of Education’s Early Childhood
Longitudinal Study of Kindergartners in 1998 (ECLS) 5th and 8th grade reading and math
tests. The eighth grade ECLS test will be each further supplemented by four items from
reading and math achievement assessments taken from the 10th and 12th grade
assessments of the U.S. Department of Education’s National Education Longitudinal
Study of youth who were 8th graders in 1988 (NELS). Note that permission has already
been obtained from the U.S. Department of Education to use these items from NELS.
The MTO reading and math assessments will be administered as part of our MTO youth
survey data collection. Each youth will be administered both the Reading (Language and
Literacy) and Math (Quantitative Skills and Mathematical Thinking) tests. Testing of
children aged 10 to 20 is expected to take up to 45 minutes.
The ECLS tests proposed for MTO have been administered to a national probability
sample of what was initially 22,000 children in about 800 public and 200 private schools
at entry to kindergarten in fall 1988. At each point of data collection, children are given
cognitive, as well as socio-emotional, assessments. The U.S. Department of Education’s
National Center for Education Statistics (NCES) and Westat (under subcontract to
NCES) conduct detailed analyses in pilot and pre-testing phases to examine the
psychometric characteristics of the achievement tests. Examination of psychometric
properties begins early during the pilot phases of each round of testing. During this pilot
phase researchers ensure that tests are capturing appropriate content levels for each grade,
consistently measure longitudinal growth in learning and achievement, that individual
items can discriminate knowledge and consistently align with level of performance of
other items and that the tests have enough variation in difficulty to protect against floor
and ceiling effects i.e. that the items are not so easy or so hard that there is no variation in
test results. The ECLS fifth grade test represents the sixth round of data collection and
took place during the spring of 2004 when approximately 90 percent of the ECLS-K
sampled children were in fifth grade. Psychometric characteristics of the ECLS fifth
grade test are detailed in Pollack et al., (2007). Pre-testing of the ECLS eighth grade test
are in progress.
The content areas for reading in the 5th grade test include basic skills, vocabulary, initial
understanding, developing interpretation, personal reflection, and critical stance. These
content areas are identical to the U.S. Department of Education’s National Assessment of
Education Progress (NAEP), usually referred to as the “nation’s report card,” with the
addition of vocabulary and basic skills. The mathematics test specifications are primarily
based on the Mathematics Framework for the 1996 NAEP (NAGB 1996a), which is in
turn derived from the curriculum standards from the Commission on Standards for
School Mathematics of the National Council of Teachers of Mathematics [NCTM]
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page C-2
(1989). The math content areas includes number sense, properties and operations,
measurement, geometry and spatial sense, data analysis statistics and probability,
patterns, algebra and functions.
The format of the fifth-grade assessment is similar to that of prior rounds with a short
routing test that is used to determine the difficulty of the second stage achievement test
form that youth are then asked to complete. This type of assessment that tailors the
specific questions that children are asked to their performance on earlier achievement
items is known as an “adaptive test.” An assessor presents the questions to the child and
enters responses into a computer for each individually administered assessment (or, for
the eighth grade tests, assessors will score the routing test by using a template that is
place over the score sheet).
Psychometrically, adaptive tests such as those administered in ECLS are more efficient
than “one form fits all” tests, since the information that is generated per unit of testing
time is greater (Lord 1980). The reason is that we do reduce the amount of time spent
asking questions of children that are either too difficult or too easy for them given their
current academic capabilities. Adaptive testing also minimizes the potential for floor and
ceiling effects, which can impact measurement of gain in longitudinal studies. Floor
effects occur when some children’s ability level is below the minimum level that is asked
about on the test (e.g., imagine administering the AP physics exam to a sample of first
graders), which can prevent low-performing children from demonstrating their true gains
in knowledge when they are retested. Similarly, ceiling effects result in failure to measure
the gains in achievement of high-performing children whose abilities are beyond the most
difficult test questions (imagine administering a first grade math assessment to a sample
of high school AP physics students). Adaptive testing relies on item response theory
(IRT) assumptions in order to place children who have taken different test forms on the
same vertical achievement score scale, which is facilitated in part by the fact that there is
some overlap in items across the different test form levels. The underlying assumption of
IRT is that a test taker’s probability of answering an item correctly is a function of his or
her ability level for the construct being measured and of one or more characteristics of
the test item itself. Additional discussion of IRT may be found Pollack et al. (2005).
Analyses of the 5th grade test show that 26% took the low form, 49% took the middle
form and 25% took the high form, indicating relatively even distribution of appropriate
difficulty level. Reading assessment reliabilities (that is, the correlation in scores of
children who were asked to take the test multiple times) were equal to 0.82, 0.72 and 0.76
on the low, middle and high form of the test, respectively. Roughly one-third of the 5th
grade sample took each level of the second stage math form. Math reliabilities were
0.78, 0.58, and 0.75, respectively.
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page C-3
Appendix D
Physical Measurements
Blood Spot Collection
Page D-1
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Blood Pressure
Height, Weight Measurement
Blood Spot Collection
IWER: Text in bold and italics is to be read to the respondent. Normal text is interviewer instructions
or questions that are to be answered by you.
IWER: Mark an ‘X’ by each measurement for which R is eligible.
______ Blood Pressure
______ Height and Weight
______ Blood Spot Collection
IWER: Before beginning the physical measurements you must have a signed consent form from the
Respondent.
Page D-2
National Bureau of Economic Research
University of Michigan – ISR
Appendices
BLOOD PRESSURE
Equipment needed:
Blood Pressure monitor
Batteries
IWER: Did the R sign the Physical Measures consent form? (Circle one.)
1 ............YES - Consent signed → continue
5.............NO - Consent not signed → do not complete this measure and answer the question in the box below
“Now let’s talk about the first activity. I’d like to measure your blood pressure measure using this monitor
and cuff which I will secure around your left arm. I would like to take three blood pressure measures. I
will ask you to relax and remain seated during the measurements. First, I will place the cuff on your left
arm. Once the cuff is placed appropriately on your arm and we are ready to begin, I’ll ask you to lay your
arm on a flat surface palm facing up so that the center of your upper arm is at the same height as your
heart. I will then press the Start button. The cuff will inflate and deflate automatically.”
IWER: Demonstrate the test.
“Do you have a rash, a cast, edema (swelling) in the arm, open sores or wounds, or significant bruise where
the blood pressure cuff will contact?” (IWER: Circle one.)
1 ............YES – do not complete this measure and answer question in box below
5 ............NO – continue
“Do you understand the directions for this test?” (IWER: Circle one.)
1 ............YES – continue
5 ............NO - do not complete this measure and answer question in box below
“Do you feel it would be safe for you to do this test? (IWER: Circle one.)
1 ............YES – continue
5 ............NO - do not complete this measure and answer question in box below
IWER: Why didn’t R complete the blood pressure test? (Circle all that apply.)
1 .........R felt it would not be safe
2 .........IWER felt it would not be safe
3 .........R refused or was not willing to complete the test
4 .........R tried but was unable to complete test
5 .........R did not understand the instructions
6 .........R has a rash, a cast, edema, open sores or wounds, or significant bruise where the blood cuff would
contact R’s arm
97 .......Other (Specify) _____________________________________
Go To Next Measurement
Page D-3
INSTRUCTIONS FOR ADMINISTERING BLOOD PRESSURE TEST:
1)
Insert Arm Cuff plug into jack on the side of the monitor.
2)
Instruct R to remove bulky clothing from upper left arm.
3)
Instruct R to sit in a chair with his/her feet flat on the floor and place his/her upper arm on a table.
4)
Place the cuff on the R’s left arm approximately ½” above the elbow. Position the green marker over the
brachial artery on the inside of the arm.
5)
Press the sewn hook material firmly against the side of the cuff. The cuff should make direct contact
with the Rs skin. The R should easily be able to fit his/her index finger between the cuff and the arm.
6)
Instruct the R to rest their arm comfortably on a support (like a table) with palm facing upward so the
cuff is at the same level as the heart.
7)
Press the ON/OFF button and instruct the R to remain still. When the ♥ symbol appears on the display,
press the START button. The cuff will begin to inflate automatically. Numbers will appear on the
display and the ♥ symbol will blink.
8)
The cuff will then automatically deflate. The monitor will first display the SYSTOLIC and DIASTOLIC
readings. RECORD time of Reading and both SYSTOLIC and DIASTOLIC Readings in chart below.
Record the pulse identified by the letter P.
9)
Press the ON/OFF button to repeat the measure. The cuff does not need to be removed or loosened in
between readings.
10) Allow approximately 45 seconds to 1 minute between readings and repeat steps 4-9 a second time.
IWER: Record measurements in chart: (Enter 993 in first systolic reading if R tried but was unable to do it.
Enter 999 if R chose not to do it.). Enter information into CAPI.
Measurement
#
Time of Reading
Systolic Reading Diastolic Reading
Pulse
1
__ __:__ __ am/pm
mmHg
mmHg
P
2
__ __:__ __ am/pm
mmHg
mmHg
P
IWER: Which arm was used to conduct the measurements? (Circle one.)
1 .........Left arm
2 .........Right arm
IWER: How compliant was R during this measurement? (Circle one.)
1 .........R was fully compliant
2 .........R was prevented from fully complying due to illness, pain, or other symptoms or discomforts
3 .........R was not fully compliant, but no obvious reason for this.
IWER: What was R’s position for this test? (Circle one.)
1 .........Standing
2 .........Sitting
3 .........Lying down
IWER: Did the R smoke, exercise, consume alcohol or food within the 30 minutes prior to completing the
blood pressure test? (Circle one.)
1 ............Yes
2 ...............No
Page D-4
National Bureau of Economic Research
University of Michigan – ISR
Appendices
INSTRUCTIONS FOR MEASURING HEIGHT AND WEIGHT:
Equipment needed:
Adhesive tape, tape measure
Scale and batteries
“Next, I would like to measure your height and weight using this scale. I will ask you to stand up against
the wall, and I will measure your height. Then I will ask you to step on the scale and I will record your
weight.”
“Do you understand the directions for this test?” (IWER: Circle one.)
1 .........YES – continue
5 .........NO - do not complete this measure and answer question in box below
“Do you feel it would be safe for you to do this test?” (IWER: Circle one.)
1 .........YES – continue
5 .........NO - do not complete this measure and answer question in box below
1. Locate best place for measuring height and weight:
a. The surface should be flat, even, and smooth. A hard floor such as wood, linoleum, concrete,
or tile is ideal. A low pile carpet may also be used.
b. There must be a wall or doorframe next to the appropriate surface. It should be flat so the
respondent can stand against it, and you can put a self-adhesive note on it.
c. The location should be private enough so the respondent feels comfortable and confidentiality
isn’t compromised. However, you and the respondent should feel safe.
2. Ask respondent to remove shoes and stand near the wall.
3. Place adhesive tape on the wall at the level of the respondent’s head.
4. Ask respondent to stand up against the wall as straight as comfortable, with his or her heels and
shoulders as close to the wall as comfortable.
5. Place the rafter’s square on the respondent’s head so it rests lightly or just touches the head. Put the
widest edge along the head, with diagonal edge facing away from the wall.
6. Make a mark on the self-adhesive note underneath the wide edge of the rafter’s square, and ask the
respondent to step away from the wall.
7. Measure from the floor to the mark and record it in the booklet.
8. Remove adhesive from the wall.
9. Record respondent’s height: __________FEET
__________INCHES
10. Place scale on the floor
11. Ask respondent to remove shoes and heavy objects from his/her pockets.
12. Ask respondent to step on scale and record weight: ____________ POUNDS
13. If respondent did not complete height or weight, indicate reason in box below.
Page D-5
National Bureau of Economic Research
University of Michigan – ISR
Appendices
IWER: Why didn’t R complete the height measurement? (Circle all that apply.)
1 ............R felt it would not be safe
2 ............IWER felt it would not be safe
3 ............R refused or was not willing to complete the test
4 ............R tried but was unable to complete test
5 ............R did not understand the instructions
97 ..........Other (Specify)_______________
IWER: Why didn’t R complete the weight measurement? (Circle all that apply.)
1 ............R felt it would not be safe
2 ............IWER felt it would not be safe
3 ............R refused or was not willing to complete the test
4 ............R tried but was unable to complete test
5 ............R did not understand the instructions
6 ............R’s weight exceeded the capacity of the scale (330 pounds)
97 ..........Other (Specify)_______________
Enter information into the computer.
Page D-6
National Bureau of Economic Research
University of Michigan – ISR
Appendices
IWER: Before beginning the blood spot collection you must have a signed consent form from the
Respondent.
BLOOD SAMPLE COLLECTION
Equipment needed:
Cholesterol and A1c Collection Kit (Lab Authorization Form; Blood Collection Card,
Foil Blood Sample Return Bag with Desiccant; Lancet; Alcohol Prep; Sterile Gauze
Pad; Adhesive Bandage; Preaddressed, Prepaid Mailing Envelope)
In-home cholesterol test kit
IWER: Did the R sign the Blood Sample consent form? (Circle one.)
1 .........YES - Consent signed → continue
5 .........NO - Consent not signed → do not complete this measure and answer the question in the box
below
“Do you have hemophilia or are you taking any medications that thin your blood, also called
anticoagulants?” (IWER: Circle one.)
1 .........Yes - do not complete this measure and answer question in box below
5 .........No – continue
IWER: Explain directions for the test.
“Do you understand the directions for this test?” (IWER: Circle one.)
1 .........YES – continue
5 .........NO - do not complete this measure and answer question in box below
“Do you feel it would be safe for you to do this test?” (IWER: Circle one.)
1 .........YES – continue
5 .........NO - do not complete this measure and answer question in box below
IWER: Why didn’t R complete the blood spot assay? (Circle all that apply.)
1 ............R felt it would not be safe
2 ............IWER felt it would not be safe
3 ............R refused or was not willing to complete the test
4 ............R tried but was unable to complete test
5 ............R did not understand the instructions
6 ............R has hemophilia or is on medication that thins the blood (anticoagulant)
97 ..........Other (Specify)_______________
Page D-7
National Bureau of Economic Research
University of Michigan – ISR
Appendices
INSTRUCTIONS FOR BLOOD SAMPLE COLLECTION
1) Remove all parts of the Blood Collection Kit and place on a hard, clean, and dry surface (If any item is
opened or broken, do not use).
2) Place labels on the signed consent form, both copies of the two lab authorization forms, and the blood
collection card. Write the date and time of the blood collection on the lab authorization forms, and in this
booklet (chart below).
3) Put on a pair of latex gloves.
4) Clean the R’s finger with the Alcohol Prep pad and make sure the R’s finger is dry before proceeding.
5) While holding the R’s hand, place the lancet on the side of the pad of the R’s middle or ring finger.
6) Prick the finger with the lancet. If necessary, instruct the R to gently squeeze his/her finger from the base
several times for a large drop of blood.
7) With the sterile gauze pad, wipe away the first drop of blood.
8) When the next large drop of blood is formed, place the first drop of blood on the in-home cholesterol test
strip and insert into the machine. Record the reading in CAPI. Record the reading on results card and give
to the respondent.
9) When the next large drop of blood is formed, gently touch the drip to the center of one of the circles printed
on the blood collection card. If a single drop of blood does not completely fill a circle, you may add
additional drops beside the first until the circle is filled. Try not to overlap the drops. If the blood should
“pool” on the surface of the card, gently tap the card to break the surface tension of the blood and allow it to
flow through to the card below.
10) Once the R completely fills one of the circles, assist the R with filling the other two circles on the form.
11) Provide the R with a band-aid
12) Place or ask the R to place the used gauze pad, alcohol wipe, wrappers and lancet in the plastic bag and
discard in the garbage.
13) Allow the blood sample to air dry for 10 to 15 minutes.
14) Tear off the blood sample return bag at the notch and open the bag.
15) Insert the blood collection card into the bag and reseal the bag. Note: The desiccant pack must remain in the
bag.
16) Place the sealed return bag and the top copy of the lab authorization forms into prepaid mailing envelope.
17) Iwer, mail the envelope as soon as possible.
IWER: Record date and time of specimen collection in chart:
Specimen #
Date
1
Time
am/pm
Page D-8
National Bureau of Economic Research
University of Michigan – ISR
Appendices
IWER: Did R complete this test? (Circle one).
1 ............Yes
3 ............R tried but was unable to complete test
9 ............R chose not to do test
IWER: Who pricked the R’s finger(s)? (Select all that apply.)
1 ............IWER pricked the R’s finger(s)
2 ............R pricked own finger(s)
3 ............Someone else pricked R’s finger(s) (Specify relationship to R:___________________)
IWER: Did the R fill all three circles with blood? (Circle one).
1 ............Yes
2 ............No
IWER: How many times did the R’s finger need to be pricked in order to fill the circles? (Circle one).
1 ............One time
2 ............Two times
3 ............Two times but the R was unable to fill all three circles with blood
IWER: Did any problems occur during the collection of the blood sample?
1 ............R became light-headed, fainted, or nauseous
2 ............R had difficulty getting finger to stop bleeding
3 ............R experienced pain
97 ..........Other (Specify:____________________________________)
IWER: How compliant was R during this measurement? (Circle one.)
1 ............R was fully compliant
2 ............R was prevented from fully complying due to illness, pain, or other symptoms or discomforts
3 ............R did not appear to be fully compliant, but no obvious reason for this.
Page D-9
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Appendix E
Language Assessment
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page E-1
Appendix E
Language Assessment
We will examine MTO impacts on language outcomes by asking and transcribing two new
open ended questions and a reading passage to the adult and youth MTO surveys for a sub-set
of survey respondents, as well as transcribing questions already on the draft surveys. Table E.1
presents minimum detectable effects (MDEs) for different language outcomes for different
candidate sample sizes for our MTO language exercise. The power calculations focus on four
grammatical or phonological measures that have shown the most pronounced differences across
social class lines in a previous study of language patterns in Detroit:1 absence of third singular
present tense –s (“He sing a lot”), copula absence (“He happy”), multiple negation (“He didn’t
do nothing”), as well as medial and final th as f, t or missing (“teef” rather than “teeth”).
The MDE calculations suggest that obtaining language measures from 500 youth and 500 adults
(250 from each of the experimental and control groups) would provide reasonable power to
detect MTO impacts on key language outcomes. For example with language measures for a
sample of 500 youth, we would be able to detect MTO effects on missing third person singular
–s (“He sing a lot”) of around 13% of the control mean, which is smaller than the observed
difference between lower-and upper-working-class youth 10-17 in a Detroit study (Wolfram,
1969) . For adults the MDE for missing third person singular with a sample of 500 would be
22% of the control mean, which would not quite give us enough precision to be confident of
detecting the sort of difference in this measure that was observed between black lower- and
upper-working class adults in Wolfram’s Detroit study (57% versus 51%). However the MDEs
that we expect to have with our MTO study for other language measures such as copula
absence, multiple negation and medial and final th as f, t or missing (33%, 18% and 23% of the
control means, respectively) are about the same size or smaller than the observed differences
between lower- and upper-working class African-American adults in Detroit (equal to 29%,
48% and 33%, respectively). Put differently, collecting language measures even from a subsample of our MTO adult and youth survey sample frames should provide us with adequate
statistical power to detect reasonable MTO program impacts on most of our key language
measures of interest for both adults and youth.
To reach the target sample, a subset of randomly pre-selected 750 MTO adults and 750 youth
will be asked to respond to two of the following three language tasks: an open-ended ”danger
of death” question, an open-ended “code switching” question, that examines the ability of
respondents to use “mainstream” language patterns regardless of their own normal daily
vernacular, or reading a short passage below. With 750 people being asked to complete two of
these three language tasks, we will have analytic samples of 500 respondents for each of the
three language measures.
Open ended question on danger of death: Were you ever in a situation where you were
in serious danger of being killed? Where you said to yourself, ‘This is it?’ (If the person
has no “danger or death” experience: What was the most stressful experience that you
ever lived through? What helped you get through it? What is the scariest thing that has
ever happened to you ?)
1
Specifically, these data come from differences in language patterns observed between lower- and upper-working class
informants in Wolfram’s (1969) Detroit study.
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page E-2
Open ended question to understand code switching: “Imagine that there is a proposal to
close a school that your child attends or a park in your neighborhood that you or your
children or relatives use. What would you say to the local public school board or city
council to argue against closing the school or park?”
Short reading passage: Ray and His Cat Come Back
On Friday, I was in Aunt Cindy's store,
And Ray was with the same old cat that I saw before.
Ray said, "Matt, my cat wants a treat!"
Ray grabbed Matt's chips and let his cat eat.
Ray said, "Those chips are stale!
I see that you bought them on sale."
The cat spit out the chips and jumped in Ray's coat.
Poor little Matt had his heart in his throat
Next Ray turned around and he looked at me.
My blood began to boil, I thought "Yo, who is he?"
Ray said, "You may be bad but I am the worst,
And my mean old cat keeps a super class thirst"
I said, "I don't want to listen to your cat moan.
Here's five cents so it can buy its own."
Ray snatched the can right out of my hand.
He poured the coke all over the ground,
And said, "Cat, it is time to get down."
The cat slipped down and started to drink.
I brought my knee back, and then kicked the can-Right at the cat and told it to SCRAM!
But the cat came back to try to score.
I said to Ray, "Oh, your cat wants more?"
I gave a little whistle and opened the door.
Ray screamed, "Wait! What's that coming at me?"
I said, "That's my dog, Black, you'll certainly see.
Don't worry Ray it's no big deal
I'll count to three and Black has his meal."
When I got to two, Ray and his cat ran.
Ray really fell for my new cat plan.
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page E-3
Table E.1 MDEs for MTO Language Outcomes, by Sample Size
Factor
Sample Size
Age
Group
Mean
Prevalence
MDE as
% of
mean
missing third person singular –s
500
Youth
0.79
12.91%
missing third person singular –s
750
Youth
0.79
10.54%
missing third person singular –s
1000
Youth
0.79
9.13%
missing third person singular –s
1500
Youth
0.79
7.45%
500
Youth
0.66
17.98%
copula absence
copula absence
750
Youth
0.66
14.68%
copula absence
1000
Youth
0.66
12.71%
copula absence
1500
Youth
0.66
10.38%
10.52%
multiple negation
500
Youth
0.85
multiple negation
750
Youth
0.85
8.59%
multiple negation
1000
Youth
0.85
7.44%
multiple negation
1500
Youth
0.85
6.07%
medial and final th as f, t, or missing
500
Youth
0.8
12.52%
medial and final th as f, t, or missing
750
Youth
0.8
10.22%
medial and final th as f, t, or missing
1000
Youth
0.8
8.85%
medial and final th as f, t, or missing
1500
Youth
0.8
7.23%
missing third person singular -s
500
Adult
0.57
21.75%
missing third person singular -s
750
Adult
0.57
17.76%
missing third person singular -s
1000
Adult
0.57
15.38%
missing third person singular -s
1500
Adult
0.57
12.56%
500
Adult
0.38
31.99%
26.12%
copula absence
copula absence
750
Adult
0.38
copula absence
1000
Adult
0.38
22.62%
copula absence
1500
Adult
0.38
18.47%
17.98%
multiple negation
500
Adult
0.66
multiple negation
750
Adult
0.66
14.68%
multiple negation
1000
Adult
0.66
12.71%
multiple negation
1500
Adult
0.66
10.38%
medial and final th as f, t, or missing
500
Adult
0.55
22.65%
medial and final th as f, t, or missing
750
Adult
0.55
18.50%
medial and final th as f, t, or missing
1000
Adult
0.55
16.02%
medial and final th as f, t, or missing
1500
Adult
0.55
13.08%
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page E-4
Appendix F:
Item by Item Justification
Adult Survey
National Bureau of Economic Research
University of Michigan – ISR
Appendices
HOUSEHOLD SCREENER1
Question
Item
Number
HRS1
[MEMBER #] Person ID
HRS2
First Name
HRS3
Last Name
HRS4
In household now? Yes, no, deceased
HRS5
Relationship to respondent: Birth child, adopted child, Stepchild,
Grandchild, Foster child, Other child (not specified), Spouse,
Partner (romantically involved), Friend (not romantically
involved), Parent, Sibling, Cousin, Other relative (not specified),
Other nonrelative (not specified), Head of household
HRS6
Gender
HRS7
Birth date
(race / ethnicity questions HRS 8 and 9 deleted)
HRS10
HRS11
HRS12
Biological father in household? Yes, no, deceased
Date moved out
Current location: Living with R, Living in own HH, Living with
mother, Living with father, Living with other relative, Incarcerated,
In nursing home, In military, Other, In foster care (for children),
Half way house, Homeless, Boarding school, College dorm
1
Source
Justification/Notes
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
The adult respondent survey will begin with a roster to take stock
of who is currently living in the household, and to collect
information on the residential status of members who resided in
the MTO household at time of enrollment. Information from the
baseline survey, the 1997 and 2000 canvasses and the interim
survey about household membership will be pre-loaded.
Information about new members will be newly collected at time of
the long-term survey. These items provide valuable information
to create several outcomes of interest including whether or not the
adult respondent is married or living with a partner, the number of
children in the household, whether the household is multigenerational. Finally, these questions about household
membership will serve as filters for subsequent items in the survey
such as spousal employment, and adult respondent reports of
household outcomes.
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
Information on individual identifying information and basic demographics will be pre-loaded for baseline and interim household members. New members of the
“current” household will be defined as people who slept in the home 2 or more nights per week over the past month.
OUTLOOK & SOCIAL NETWORK
Question
Item
Number
HSN1
[HAPPINESS]
Taken all together, how would you say things are these days would
you say that you are very happy, pretty happy, or not too happy?
Source
Justification/Notes
GSS
Happiness measures have been shown to be correlated with selfreported health, sociability and extraversion, sleep quality,
happiness of close relatives, and recent positive changes of
circumstances. Individual happiness has been shown to be
affected similarly by changes in both income of locality and
personal income. The greatest of these effects are often felt by
those who socialize more in their localities potentially because of
the greater salience of income differences to the individual. Some
research has suggested that income rank in one’s peer group may
have a more pronounced effect on happiness. In addition, we are
considering asking respondents how life has turned out for their
children and not just for themselves. This seems particularly
relevant to MTO because many of the families wanted to move to
provide a better life for their children.
OUTLOOK & SOCIAL NETWORK
Question
Item
Number
HSN2
Considering your child/children's lives in general these days, how
happy or unhappy would you say you are, on the whole... very
happy, pretty happy, or not too happy?
HSN3
HSN4
HSN5
HSN6
GSS, modified
circumstances. Individual happiness has been shown to be
affected similarly by changes in both income of locality and
personal income. The greatest of these effects are often felt by
those who socialize more in their localities potentially because of
the greater salience of income differences to the individual. Some
research has suggested that income rank in one’s peer group may
have a more pronounced effect on happiness. In addition, we are
considering asking respondents how life has turned out for their
children and not just for themselves. This seems particularly
relevant to MTO because many of the families wanted to move to
provide a better life for their children.
Optimism/pessimism measures relate to how a person tends to
think about their future outcomes. These measures have been
linked to a number of outcomes that are relevant to MTO. They
are associated better adjustment to and coping ability and higher
levels of academic achievement, as well as higher levels of careerrelated goals.
Because overall happiness (above) is sometimes perceived in
context of comparing oneself to one’s neighbors, there is the
possibility that MTO moves may have improved the quality of the
daily lives of families but they respond in turn by raising their
standards (perhaps in part because they are now surrounded by
more affluent families). So their lives may in fact be “better” but
they might not perceive or express this consciously because they
are now comparing themselves to a more affluent, "happier" set of
neighbors. To test daily happiness in addition to overall
happiness, the U-index method proposed by Kahneman and
Krueger is designed to circumvent the potential overall happiness
conundrum by trying to measure instead the quality of the
everyday experiences that MTO families enjoy.
LOT-R
We would also like to learn some more about what you did and how
you felt yesterday. . Specifically we are wondering how your day
went and how you felt at [RANDOMLY SELECTED TIME]
yesterday.
Kahneman and
Krueger, 2004
HSN9
HSN10
Where were you?
HSN8
Justification/Notes
[OPTIMISM]
7. I hardly ever expect things to go my way.
9. I rarely count on good things happening to me.
10. Overall, I expect more good things to happen to me than bad.
What were you doing at [RANDOMLY SELECTED TIME]?
(Please check all that apply)
[commuting; working; shopping; preparing food; doing housework;
taking care of your children; eating; praying / worshipping /
meditating; socializing; watching TV; nap / resting; computer /
Internet / email; relaxing; on the phone; intimate relations;
exercising; other (please specify)
[Note to interviewer: if only one activity chosen then skip]. Which
activity above would you consider the main activity at
[RANDOMLY SELECTED TIME], that is, the activity that took up
the most time?
At what time did this main activity [INSERT NAME OF MAIN
ACTIVITY] begin?
At what time did this main activity end?
HSN7
Source
MTO Adult Item Table
Kahneman and
Krueger, 2004
Kahneman and
Krueger, 2004
Kahneman and
Krueger, 2004
Kahneman and
Krueger, 2004
This series of questions has been shortened for MTO, which will
be examined by the original authors, Kahneman and Krueger, for
their feedback. These questions serve to evoke recent memories
about specific activities engaged in and measure the proportion of
time respondents face in an unpleasant state (versus a pleasant
state).
Page F-2
OUTLOOK & SOCIAL NETWORK
Question
Item
Number
HSN11
Were you interacting with anyone? (including on the phone, in a
teleconference, etc.)
HSN12
If you were interacting with someone, who was it? (check all that
apply)
[spouse / significant other; my children; friends; parents / relatives;
co-workers; boss; clients / customers; other people not listed]
HSN13
Please rate each feeling on the scale given. A rating of 0 means that
you did not experience that feeling at all. A rating of 6 means that
this feeling was a very important part of the experience. Please
circle the number between 0 and 6 that best describes how you felt.
Impatient for it to end
Happy
Frustrated / annoyed
Depressed / blue
Competent / capable
Hassled / pushed around
Warm / friendly
Angry / hostile
Worried / anxious
Enjoying myself
Criticized / put down
Tired
HSN14
[FRIENDS]
About how many CLOSE friends do you have these days? These
are people you feel at east with, can talk to about private matters, or
call on for help. Would you say that you have no close friends, one
or two, three to five, six to ten, or more than ten?
HSN15
The next few questions are about ALL your friends. Some people
have friends who mostly know one another. Other people have
friends who don’t know one another.
Would you say that: all your friends know one another, most of your
friends know one another, only a few friends know one another, or
none of your friends know one another?
HSN16
How many of your friends live in the same neighborhood as you?
HSN17a
HSN17b
HSN17c
Thinking about everyone that you would count as a friend, not just
your close friends, About how many have graduated from college --- none, only a few, some, most, or all?
About how many earn more than $30,000 a year?
About how many work full-time?
MTO Adult Item Table
Source
Justification/Notes
Kahneman and
Krueger, 2004
Kahneman and
Krueger, 2004
Kahneman and
Krueger, 2004
MTO Interim
MTO Interim
These questions concern the formation of new friendships and
maintenance of old ones. They support analyses of degree of
social isolation, the breadth of the respondent’s social network,
and the degree of support available from friends after a lowpoverty move. The questions measure various aspects of social
networks, including the respondent’s integration into the new
community, the density of the community links, and the level and
the type of information available to the respondent. These
questions also obtain information on whether respondents know as
friends people who could be role models for educational
achievement or economic self-sufficiency.
MTO Interim
MTO Interim
MTO Interim
Original
Page F-3
OUTLOOK & SOCIAL NETWORK
Question
Item
Number
HSN17d
About how many would you say are a different race or ethnicity
than you?
HSN18
Of your friends who have graduated from college, about how many
of these would you count as a CLOSE friend?
HSN18a
How many of these people live in your current neighborhood?
HSN19
Here is a list of some of the ways in which people are connected to
each other. Some people can be connected to you in more than one
way. How is/are your friend(s) in your neighborhood connected to
you? Check all that apply. (THROUGH: FAMILY/ RELATIVES,
YOUR CHILD/YOUR CHILD'S SCHOOL, YOUR
NEIGHBORHOOD (CURRENT OR FORMER), YOUR WORK /
SPOUSE'S WORK, CHURCH, A GROUP YOU BELONG TO,
FROM CHILDHOOD, OTHER)
HSN20
[FRIENDS AND RELATIVES]
The next two questions are about friends and relatives. During the
past thirty days, about how often have you had friends or relatives
over to your home? Every day; several days a week; twice a week;
about once a week; 2-3 times in the past month; once in the past
month; or not at all in the past month?
HSN21
During the past thirty days, about how often have you visited with
friends or relatives at their homes?
HSN22
[TIES TO OLD NEIGHBORHOOD]
Thinking about your neighborhood now, are you living in the same
neighborhood as when you lived at [BASELINE ADDRESS] or
living in a different neighborhood?
HSN23
Do you still have friends in your old neighborhood, where you lived
at [BASELINE ADDRESS]?
HSN24
How often do you go back to visit friends in that old neighborhood?
Source
SCCBS,
modified
Original
Original
GSS, modified
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
HSN25
How often do your friends from that old neighborhood visit you?
MTO Interim
HSN26
Thinking about your current set of friends, how many of these
people have you been friends with for at least [survey year minus
year of random assignment]?
How often do you go visit these friends?
How often do these friends come visit you?
Original
HSN27
HSN28
MTO Adult Item Table
Justification/Notes
These questions measure the degree to which respondents who
moved through MTO perceive that they moved away from the
neighborhoods of high-poverty public housing developments and
the extent to which they remain tied to those areas through
personal relationships. It is hypothesized that, the closer or more
numerous the ties back to the origin neighborhoods, the less
respondents will be influenced by—or take advantage of—the
differences offered by low-poverty areas.
Original
Original
Page F-4
OUTLOOK & SOCIAL NETWORK
Question
Item
Number
HSN29
[COLLECTIVE EFFICACY]
[INTERVIEWER, HAND RESPONDENT CARD WITH
RESPONSE CATEGORIES. RECORD “UNSURE” IF ANSWER
IS BETWEEN LIKELY AND UNLIKELY; DK IF DOES NOT
UNDERSTAND THE QUESTION.
HSN29a
If a group of neighborhood children were skipping school and
hanging out on a street corner, how likely is it that your neighbors
would do something about it? Very likely, likely, unsure, unlikely,
or very unlikely.
HSN29b
HSN30
HSN31
HSN32
HSN33
HSN34
HSN35
HSN36
HSN37
If some children were spray-painting graffiti on a local building,
how likely is it that your neighbors would do something about it?
[NEIGHBORS]
How often do you stop to chat with a neighbor in the street or
hallway? Would you say almost every day; once a week; once a
month; a few times a year; or almost never?
[CHURCH]
In the past 12 months, how often have you gone to church or
attended other religious services? Never in the past 12 months;
several times in the past 12 months; once a month; once a week; or
more than once a week?
Do you attend church or other religious services in this
neighborhood, your old neighborhood at BASELINE ADDRESS, or
somewhere else?
How many years have you been attending this church?
In the past 12 months, have you taken part in any sort of activity
with people at your church or place of worship other than attending
services? This might include teaching Sunday school, serving on a
committee, attending choir rehearsal, retreat, or other things.
[POLITICAL PARTICIPATION]
Now I’d like to know about your role in your community. In the past
twelve months, have you gotten together informally with others in
the community to try to deal with some community issue or
problem?
Do you recall what the issue was?
In the past twelve months, have you attended a meeting of any local
government board or council that deals with community problems
and issues?
MTO Adult Item Table
Source
Justification/Notes
These questions measure the adult’s view of the level of
community monitoring of youth. One of the major theories of
community-level change is that low-poverty neighborhoods
socialize their youth differently than poor neighborhoods, toward
achievement and learning, and away from anti-social behavior.
MTO Interim
MTO Interim
MTO Interim
MTO Interim
These questions provide a measure of civic engagement—the
respondent’s involvement with the larger community. While
engagement is not a middle-class phenomenon (there are many
examples of well-organized, activist communities in working-class
and poor neighborhoods), here we wish to see whether those who
have moved to low-poverty areas are becoming engaged with
these communities.
Original
Original
SCCBS,
modified
Citizen
Participation
Study
Original
Citizen
Participation
Study
The inclusion of political participation items tests the hypothesis
that escaping troubled and resource-poor neighborhoods also
enables poor people to escape conditions that inhibit their
involvement in the activities of democratic citizenship—from
voting in local, state, and national elections to working
collectively with others to address community problems.
Page F-5
OUTLOOK & SOCIAL NETWORK
Question
Item
Number
HSN38
In the past twelve months, did you contact a public official or some
other person of influence in the community to discuss a community
issue or problem?
HSN39
In any election, some people are not able to vote because they are
sick or busy or have some other reason, and others do not want to
vote. Did you happen to vote in as part of the 2008 Presidential
race? [options include: primary elections; general election]
HSN40
Are you currently registered to vote?
HOUSING CONSUMPTION & MOBILITY
Question
Item
Number
INTRO
We want to understand how the places you’ve lived may have
affected you and your family. So I’m going to ask you some
questions about the different places you’ve lived since (YEAR OF
RANDOM ASSIGNMENT). As you know, we have been keeping
in touch with you over the years, but we want to make sure that we
have all the right information.
HHC1
HHC1a
HHC2
[Show the respondent all addresses we had an ACTIVE contact and
the estimated dates at those addresses. First address is baseline
address and last address is current address.]
CORE ADDRESS SERIES
First let me ask, is this [CORE MOVE ADDRESS] the first place
that you moved to after (YEAR OF RANDOM ASSIGNMENT)?
[if yes, skip to HHC2]
If not, what should the address be? [Correct the core address or
insert the new address into the series. If R doesn’t recall address,
get the city, state, and nearest major intersection].
I would like to confirm the year and month that you left (FIRST
ADDRESS).
MOVE SERIES
MTO Adult Item Table
Source
Justification/Notes
Detroit Area
Study
CPS, voting and
registration
supplement
2000, modified
CPS, voting and
registration
supplement
2000, modified
Source
Justification/Notes
Original
We want to verify each of the R’s locations since core move so as
to analyze respondents’ mobility patterns over time.
Original
Original
Original
Original, based
on MTO Interim
and HOPE VI
Panel Study
This series of questions combines items from the MTO Interim
and HOPE VI Panel Study surveys to create a comprehensive item
asking about reasons for moving to and from locations, and
(where applicable) moving from the initial low-poverty location.
Page F-6
HOUSING CONSUMPTION & MOBILITY
Question
Item
Number
HHC3
What is the main reason you moved away from (THIS ADDRESS)?
Did you leave because:
(a) the landlord evicted you
(b) your landlord would not renew your lease
(c) the rent increased and you couldn’t afford it
(d) your expenses increased and you couldn’t afford rent
(e) other
[If a-d, skip to HHC4]
HHC3a
What was the main reason you moved? [open ended response with
pre-codes]
-Lost job or ended job
-Was doing drugs
-Problems with landlord
-Problems with neighbors/people in neighborhood
-Unit failed Section 8 inspection
-Section 8 terminated
-Respondent or child were abused/violence in the household
-Change in family status (gained or lost a family member,
divorce, marry)
-Moved in with partner/boyfriend/girlfriend
-Wanted to be closer to former neighborhood
-Wanted to be closer to family
-Refused
-Don’t know
HHC4
Did you next move to [NEXT ADDRESS]? [if yes, skip to HHC5]
HHC4a
What address did you move to? [Correct the core address or insert
the new address into the series. If R doesn’t recall address, get the
city, state, and nearest major intersection].
HHC5
During the time between when you lived at [PREVIOUS
ADDRESS] and [THIS ADDRESS], we would like to know if there
was a time when you did not have your own place to stay?[if NO,
skip to note after HHC6a]
MTO Adult Item Table
Source
Justification/Notes
MTO Interim,
modified
MTO Interim,
modified
Original
Original
MTO Interim
These questions measure housing security. Are sample members
able to maintain their own housing units? If not, are they
doubling-up with other families and experiencing spells of
homelessness?
Page F-7
HOUSING CONSUMPTION & MOBILITY
Question
Item
Number
[IF YES] When you did not have your own place stay, did you....
HHC5a
-Stay with a relative?
HHC5b
-Stay with a friend?
HHC5c
-Stay in a shelter? [INTERVIEWER: A SHELTER IS: A
homeless shelter, emergency shelter, or domestic violence
shelter]
HHC5d
-Stay on the street?
HHC5e
-Stay in a place not meant for sleeping like an abandoned
building, car or van, movie theater, or laundromat?
IF NO TO ALL OF THESE, SKIP TO NOTE AFTER HHC6a
HHC6
How long were you without a place of your own?
-less than one month
-more than one month but less than a year
-more than a year
HHC6a
At that time were (SAMPLED CHILDREN) with you or living
somewhere else?
NOTE
Return to HHC3, and repeat until HHC3-HHC6a have been asked
for current address
BEST AND WORST NEIGHBORHOODS
HHC7
I’d like you compare all of the neighborhoods where you’ve since
(YEAR OF RANDOM ASSIGNMENT) (show corrected calendar
with all addresses as a reminder).
Source
Justification/Notes
MTO Interim,
modified
Original
MTO Interim,
modified
Original
Original, based
on MTO Interim
and HOPE VI
Panel Study
Original
These questions combine items from the MTO Interim and HOPE
VI Panel surveys to create a comprehensive set of questions
asking about reasons for moving to and from locations, and (where
applicable) moving from the initial low-poverty location.
Looking back at all of these addresses you have lived, which of
these addresses’ NEIGHBORHOOD did you like the BEST?
MTO Adult Item Table
Page F-8
HOUSING CONSUMPTION & MOBILITY
Question
Item
Number
HHC7a
What is the MAIN thing you LIKED about this neighborhood?
[open ended with precodes]
HHC8
HHC8a
HHC9
-SAFER
-FEWER PROBLEMS WITH GANGS/DRUGS
-BETTER OR BIGGER APARTMENT
-UNIT IN BETTER CONDITION
-UNIT IS AFFORDABLE
-CLOSER TO FRIENDS
-CLOSER TO FAMILY
-CLOSER TO JOB
-SCHOOLS BETTER
-CLOSER TO PUBLIC TRANSPORTATION
-CHANGE IN MARTIAL STATUS/ROMANTIC STATUS
-OTHER
Which addresses’ NEIGHBORHOOD did you like the LEAST?
What was the MAIN thing you didn’t like about this neighborhood?
[open ended with precodes]
-NOT SAFE
-MORE PROBLEMS WITH GANGS/DRUGS
-WORSE OR SMALLER APARTMENT
-UNIT IN WORSE CONDITION
-UNIT IS UNAFFORDABLE
-FARTHER FROM FRIENDS
-FARTHER FROM FAMILY
-FARTHER FROM JOB
-SCHOOLS WORSE
-FARTHER FROM PUBLIC TRANSPORTATION
-OTHER
SEARCHING FOR CURRENT ADDRESS
(SKIP IF THIS ADDRESS = BASELINE) Now I'd like you to
think about when you rented/bought this house/apartment. How did
you find this place? [PRECODES:]
-From a listing given by the housing authority
-Nonprofit or community group
-Advertisement in newspaper or internet
-Real estate agent/broker
-Friend or family member
-DRIVING BY/SAW SIGN
-Other
MTO Adult Item Table
Source
Justification/Notes
Original, based
on MTO Interim,
HOPE VI Panel
Study , and
3CITYMTO
The goal of this question is to understand how and why
respondents are making choices about neighborhoods.
The goal of this question is to understand respondents’
motivations for choosing specific neighborhoods.
Original
Original, based
on MTO Interim,
HOPE VI Panel
Study, and
3CITYMTO
AHS modified,
3CITYMTO
The goal of this question is to understand how respondents search
for housing after original core move assistance.
Page F-9
HOUSING CONSUMPTION & MOBILITY
Question
Item
Number
HHC10
There are many reasons why people choose to move to certain
neighborhoods. What would you say was the main reason you
moved to your current neighborhood? [PRECODES:]
-SAFER
-FEWER PROBLEMS WITH GANGS/DRUGS
-BETTER OR BIGGER APARTMENT
-UNIT IN BETTER CONDITION
-UNIT IS AFFORDABLE
-CLOSER TO FRIENDS
-CLOSER TO FAMILY
-CLOSER TO JOB
-SCHOOLS BETTER
-CLOSER TO PUBLIC TRANSPORTATION
-LANDLORD ACCEPTED VOUCHER
-ONLY PLACE I LOOKED
-OTHER
CURRENT HOUSING UNIT
HHC11a
Now I would like to know some more about your current
house/apartment. Do you...
…rent your home or apartment? (If yes, skip to HHC12a)
HHC11b
…own your own home? (If yes, skip to HHC12b)
HHC11c
…live with family or friends and pay part of the rent or mortgage?
(If yes, skip to HHC12a)
HHC11d
…live with family or friends and do not pay rent? (If yes, skip to
HHC13)
HHC11e
…live in a group shelter? (If yes, skip to HHC12c)
HHC11f
…live in some other housing arrangement? (specify_______) (If
yes, skip to HHC13)
HHC12a
Altogether in the month just passed, what did you pay in rent? We
are interested only in knowing your part of the payment. (skip to
HHC13)
HHC12b
Altogether in the month just passed, what was the amount you paid
to the bank or mortgage company? (skip to HHC13)
HHC12c
Do you have your own room or do you share a room with other
people? (skip to HHC13)
MTO Adult Item Table
Source
Justification/Notes
MTO Interim,
modified
The goal of this question is to understand respondents’
motivations for choosing specific neighborhoods.
MTO Interim
These questions measure housing security. Are sample members
able to maintain their own housing units? If not, are they
doubling-up with other families and experiencing homelessness?
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
Page F-10
HOUSING CONSUMPTION & MOBILITY
Question
Item
Number
HHC13
Not including bathrooms and hallways, how many rooms are there
in your house or apartment?
-one
-two
-three
-four
-five
-six or more
-refused
-don’t know
HHC14
Overall, how would you describe the condition of your current
house/apartment? Would you say it was in excellent, good, fair, or
poor condition?
HHC15a
Now I am going to ask you some questions about problems that
people have in some homes or apartments. Where you live now,
how much of a problem are…
HHC15b
HHC15c
HHC15d
HHC15e
HHC15f
HHC15g
HHC16a
HHC16b
HHC16c
HHC16d
HHC16e
Walls with peeling paint or broken plaster? [Would you say they are
a big problem, a small problem or no problem at all?]
Plumbing that doesn't work?
Rats or mice?
Cockroaches
Broken locks or no locks on the door to your unit?
Broken windows or windows without screens?
A heating system that does not work?
(If HHC15a big or small problem then ask): Does the house or
apartment have any area of peeling paint or broken plaster bigger
than 8 inches by 11 inches? (the size of a standard letter)
(If HHC15b big or small problem then ask): In the last 3 months,
was there any time when all the toilets in the home were not
working and you had no working toilet in the home for 6 hours or
longer? (“while household was living here” if less than 3 months)
(If HHC15b big or small problem then ask): Is water leaking today
from any kitchen or bathroom sink or drain pipe?
(If HHC15c If big or small problem then ask): Did you see a rat
anywhere in your building or outside around the grounds this week?
(If HHC15d If big or small problem then ask): Have you seen many
cockroaches in your home this week?
MTO Adult Item Table
Source
Justification/Notes
MTO Interim
The purpose of this question is to determine whether respondents
are living in overcrowded housing.
MTO Interim
These questions assess housing quality and compares them to
AHS benchmarks
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
AHS
The purpose of these items is to get more detailed information
about specific housing quality problems.
AHS
AHS
AHS
AHS
Page F-11
HOUSING CONSUMPTION & MOBILITY
Question
Item
Number
HHC16f
(If HHC15g big or small problem then ask): During this past winter,
was there any time when this house/apartment was so cold for 24
hours or more that it caused anyone in your household discomfort?
HHC16g
(If HHC16f=YES): Was that because the heating system broke
down, you could not pay your utility bill, to keep costs down, or
some other reason?
HHC17
Does your house/apartment have significant problems with mold on
walls or ceilings, for example in your bathroom?
HHC18
Does the house or apartment have any walls, ceilings, or floors with
serious problems like sagging, leaning, buckling or large holes?
HOUSING ASSISTANCE
(IF BASELINE=CURRENT ADDRESS, SKIP HHC19
QUESTIONS, SYSTEM SHOULD AUTOMATICALLY CODE
PERSON AS BEING IN PUBLIC HOUSING)
HHC19
Some people get housing assistance that requires them to complete
re-certifications by reporting income AND who lives with them to
determine the amount of rent they pay. One of those programs is the
housing voucher program, also sometimes called Section 8, which
gives a renter the right to choose where they live AND it helps pay
the rent. Does your household have a housing voucher?
HHC19a
IF HHC19= YES
Can your household use its housing voucher to move to another
location? (If yes, then SKIP to HHC20)
HHC19b
IF HHC19 = NO
Is the housing authority your landlord? (If yes, then SKIP to
HHC20)
HHC19c
IF HHC19 = NO & HHC19b = NO
Do you currently live in some other type of housing where your
landlord requires you to prove your income each year? (If yes, then
SKIP to HHC20)
MTO Adult Item Table
Source
Justification/Notes
AHS
AHS
AHS
AHS
ORCM,
modified
This sequence of questions concerns housing assistance status and
exits from housing assistance. Housing assistance status concerns
the cost to the federal government of any ongoing subsidies.
MTO may also provide useful data on exits from assisted status.
These items provide a check on PIC data, which can be inaccurate
and out of date, especially regarding residents who have lost
assistance.
ORCM,
modified
ORCM,
modified
ORCM,
modified
Page F-12
HOUSING CONSUMPTION & MOBILITY
Question
Item
Number
HHC19d
IF HHC19 = NO & HHC19b = NO & HHC19c NO
People stop getting housing assistance (either public housing or
section 8 vouchers) for different reasons. What would you say was
the main reason you are no longer getting assistance?
-NO LONGER ELIGIBLE BECAUSE INCOME IS TOO
HIGH
-PURCHASED HOME
-GOT MARRIED/MOVED IN WITH PARTNER
-EVICTED BY LANDLORD
-TERMINATED FROM PROGRAM/BROKE RULES ETC.
-RELOCATED FROM PUBLIC HOUSING AND COULD
NOT MOVE BACK
-OTHER (SPECIFY:_____________________________)
HHC19e
Since you stopped getting housing assistance, have you tried to get a
new housing voucher, Section 8, or applied to move back into public
housing?
HHC19f
IF HHC19e = YES
Are you currently on a waiting list for housing assistance?
PAYMENT DIFFICULTIES
(IF HHC11a = YES [RENTER], THEN ASK HHC20a THROUGH
HHC23c, SKIPPING HHC20b and HHC20d)
(IF HHC11b= YES [HOMEOWNER], THEN ASK HHC20b,
HHC20d, and HHC21a, HHC22a, and HHC 23 SERIES)
(IF HHC11c, d, e, f = YES, SKIP TO NEXT SECTION OF
SURVEY)
HHC20a
How many months in the past 12 months were you more than 15
days late paying your rent?
HHC20b
How many months in the past 12 months were you more than 15
days late paying your mortgage?
HHC20c
In the last 12 months, has your current or previous landlord ever
threatened to evict you for nonpayment of rent?
HHC20d
In the last 12 months, has your current or previous bank ever
threatened to foreclose on your mortgage?
HHC21
Now I have some questions about your utilities. Do you pay for
your own electricity or is that included in the rent?
HHC21a
(IF HHC21 = "Pay own electricity") How much was the electric bill
last month?
HHC22
Do you pay for your own gas or is that included in the rent?
MTO Adult Item Table
Source
Justification/Notes
MTO Interim
Original
Original
MTO Interim
MTO Interim
Current housing expenditures may reflect the effects of the
transition from public housing to Section 8 vouchers on families’
finances. The transition to Section 8 with the MTO move or to
renting/owning without housing assistance later may lead to
substantial changes in housing expenditures and burden. This, in
turn, could lead to housing or food insecurity and other financial
problems.
The purpose of these questions is to understand whether financial
hardship might be placing respondents at risk of housing
instability.
MTO Interim
MTO Interim
MTO Interim
MTO Interim,
modified
MTO Interim,
modified
The purpose of these questions is to understand whether
respondents are experiencing financial hardship that might be
placing them at risk for housing instability.
Page F-13
HOUSING CONSUMPTION & MOBILITY
Question
Item
Number
HHC22a
(IF HHC22 = "Pay own gas") How much was the gas bill last
month?
HHC23
IF PAY OWN ELECTRICITY OR GAS:
People sometimes have trouble paying their utility bills on time.
How many months out of the last 12 were you more than 15 days
late paying your electric, gas, or water bill?
HHC23a
IF HHC23 IS > 0
Did you receive a notice that your gas, water, or electricity would be
shut off if you did not pay your bill?
HHC23b
In the past 12 months, was your gas, water, or electricity ever shut
off for nonpayment?
HHC23c
For the most recent time you were late making the payment, why
were you late paying?
- Forgot about bill
- Bill was higher than normal
- Ran out of money
- Other
NEIGHBORHOODS
Question
Item
Number
HNB1
Which of the following statements best describes how satisfied you
are with your neighborhood? Would you say that you are very
satisfied, somewhat satisfied, in the middle, somewhat dissatisfied,
or very dissatisfied with your neighborhood?
HNB2
Now I would like to ask you about problems that occur in some
neighborhoods. I will read a series of questions, and for each please
tell me if it is a big problem, a small problem, or not a problem in
your neighborhood. In your neighborhood, how big of a problem
is…
HNB2a
Litter or trash on the streets or sidewalk? Is it a big problem, a small
problem, or no problem?
HNB2b
How big of a problem is graffiti or writing on the walls?
HNB2c
People drinking in public?
HNB2d
Abandoned buildings?
HNB2e
Groups of people just hanging out?
HNB2f
Police not coming when called?
MTO Adult Item Table
Source
Justification/Notes
MTO Interim,
modified
MTO Interim,
modified
MTO Interim
MTO Interim
Original
Source
Justification/Notes
MTO Interim
As a mediating factor, greater neighborhood satisfaction may
reduce housing mobility and lengthen exposure to low-poverty
neighborhoods, thereby influencing impacts on virtually all of the
outcomes considered in the study.
Questions about neighborhood problems related to graffiti or
people hanging out are relevant for understanding how MTO
might affect perceptions of safety, and more generally research
within criminology provides some (conflicting) evidence about the
degree to which “disorder” contributes to the prevalence of
criminal activity. Given the importance of crime and gangs to
MTO families in their decisions to sign up for the program,
questions about disorder and other neighborhood problems are
also relevant for understanding how and why MTO may affect
how satisfied adults are with their neighborhoods, which is also
directly measured by a survey question in this module.
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
Page F-14
NEIGHBORHOODS
Question
Item
Number
HNB3
Have you seen people USING or SELLING illegal drugs in your
neighborhood during the past 30 days? (IF NO, SKIP TO HNB6)
HNB4
How often have you seen someone USING drugs in your
neighborhood in the past 30 days? Would you say almost every day,
once a week, or once or twice in the past 30 days, or didn’t see any
using?
HNB5
How often have you seen someone SELLING drugs in your
neighborhood in the past 30 days? Would you say almost every day,
once a week, or once or twice in the past 30 days, or you didn’t see
any selling?
HNB6
HNB7b
Now I have a few questions about discrimination. Sometimes
people feel like they are discriminated against, or treated badly or
differently because of their race or ethnicity. Can you think of one
or more occasions in the last 6 months when you felt you were
treated unfairly because of your race or ethnicity in the following
places? How about…
In a store where you were shopping or a restaurant where you
wanted to eat?
In your own neighborhood?
At your child’s school?
In dealing with the police, such as a traffic accident?
Sometimes people feel like they are discriminated against, or treated
badly or differently because they might not have quite as much
money as other people, or because of the way they dress or talk.
Can you think of one or more occasions in the last 6 months when
you felt you were treated unfairly in the following places because of
how much money your family has or the way you dress or talk?
How about…
In a store where you were shopping or a restaurant where you
wanted to eat?
In your own neighborhood?
HNB7c
At your child’s school?
HNB7d
In dealing with the police, such as a traffic accident?
HNB6a
HNB6b
HNB6c
HNB6d
HNB7
HNB7a
MTO Adult Item Table
Source
Justification/Notes
MTO Interim
We would like to distinguish between prevalence of drug use in
the neighborhood versus prevalence of drug distribution. Drug
use in the community may signal the prevalence of anti-social
norms and perhaps the quality of local policing, and may influence
the probability that MTO participants use drugs themselves. But
most criminologists believe that drug market activity is more
strongly linked than is drug use to the risk of violence, and areas
where drug selling is more common may put youth at elevated risk
for involvement in drug selling themselves (while areas where
drug use is common but drug distribution is not may not have the
same influences on MTO youth involvement with drug selling).
Respondent perceptions of discrimination are both an outcome of
interest in their own right and a mediating factor for other
outcomes. As a mediating factor, discrimination is an important
aspect of the social environment. If living in a low-poverty
neighborhood increases the experience of discrimination, it may
limit the adult’s integration into the community and the level of
interaction with other adults, thereby influencing virtually all of
the outcomes considered in the study. It may also serve as an
indicator of overall social isolation of MTO families.
MTO Interim,
modified
MTO Interim,
modified
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim,
modified
Because MTO generated more pronounced changes in
neighborhood socio-economic than racial composition,
discrimination by social class may be a more important concern
for MTO families than discrimination by race.
MTO Interim,
modified
MTO Interim,
modified
MTO Interim,
modified
MTO Interim,
modified
Page F-15
NEIGHBORHOODS
Question
Item
Number
HNB8
How long would it take you to get to the nearest bus or train stop?
Source
Justification/Notes
MTO Interim
HNB9a
MTO Interim
Ease of access to neighborhood essentials like shopping and to
local amenities such as parks or playgrounds may be reduced by
moves to low-poverty neighborhoods, because of their residential
character and lower density. This could reduce employment
opportunities and the respondent’s satisfaction with the
neighborhood, making a subsequent move more likely.
Alternatively, if employment opportunities are better in lowpoverty areas, families may be better able to afford cars,
improving their access to these activities and amenities.
These questions measure fear of crime and crime victimization in
the current neighborhood. In prior research with the MTO sample,
fear of crime and victimization were identified as factors with
pervasive effects on families’ lives, strongly motivating them to
move. The MTO intervention may greatly reduce victimization
and fear, improving the adult’s willingness to interact with the
community. A greater sense of safety may also influence parenting
style and therefore children’s activities. Reduced stress and fear
may also affect mental health (e.g., reduced anxiety and
depression), with consequent impacts on employability. Thus,
families’ sense of safety and exposure to crime and violence can
be expected to act as mediating factors in a number of areas.
HNB9b
Now I would like to get a sense of how safe you think your
neighborhood is. How safe do you feel on the streets near your
home during the day?, Would you say very safe, safe, unsafe, or
very unsafe?
How safe do you feel on the streets near your home at night? Would
you say very safe, safe, unsafe, or very unsafe?
EDUCATION & TRAINING
Question
Item
Number
HED1
Now I would like to talk to you about your educational background.
What is the highest grade or year of regular school that you have
completed and gotten credit for?
HED2a
Do you have a high school diploma or a GED?
HED2b
Do you have a college degree?
HED2c
What is the highest degree you have received?
HED3a
Now I would like to ask you about any regular school or any
training you may have had in the past 2 years. Have you
participated in any additional regular schooling or in some other
type of schooling or training program that lasted at least two weeks
that was designed to help you find a job, improve your job skills, or
learn a new job?
HED3b
What kind of schooling or training was that?
MTO Adult Item Table
MTO Interim
Source
Justification/Notes
MTO Interim
The MTO treatment may affect whether adults have furthered their
educations after the move, either through formal educational
opportunities or through job training. Measuring this outcome
directly as part of the final MTO evaluation will capture human
capital investment that has taken place since the interim
evaluation.
Adults may gain exposure to more educated role models and to
social norms that place higher value on educational and career
advancement. Their mental health may improve (reduced
depression, stress, anxiety), increasing their capacity or desire to
invest in human capital. They may gain access to institutions that
have more educational resources. Greater safety in their new
neighborhoods may require less intense monitoring of their
MTO Interim
Original
Original
MTO Interim,
modified
MTO Interim
Page F-16
EDUCATION & TRAINING
Question
Item
Number
HED3c
How many weeks did you participate in schooling or training in the
past 24 months?
HED3d
During those weeks, how many hours a week did you usually spend
in schooling or training?
HED3e
Are you currently participating in schooling or training?
EMPLOYMENT & EARNINGS
Question
Item
Number
HEM1
Last week, did you do any work for pay?
HEM2
[IF NO] What is the main reason that you did not work for pay last
week?
HEM3
Last week, did you have more than one job, including part-time and
weekend work?
HEM4
How many hours per week do you usually work at your [main] job?
(By main job, we mean the one at which you usually work the most
hours.)
HEM4a
Do you usually work 35 hours or more per week at your [main] job?
HEM4b
[IF HEM3=YES] How many hours per week do you usually work at
your other job(s)?
HEM5
Now I have a few questions about the (main) job at which you
worked last week. Were you employed by government, by a private
company, a nonprofit organization, or were you self employed (or
working in the family business)? [government; private for profit
company; nonprofit organization including tax exempt and
charitable organizations; self employed; working in the family
business]
HEM5a
What kind of business or industry is this? What do they make or do
where you work?
HEM5b
Is this business or organization mainly manufacturing, retail trade,
wholesale trade, or something else?
HEM6
What kind of work do you do, that is, what is your occupation? For
example, plumber, typist, farmer.
HEM7
What are your usual duties or activities at this job? For example,
typing, keeping account books, filing, selling cars, operating,
printing press, laying brick.
HEM8
When did you first start working [at your main job]?
MTO Adult Item Table
Source
Justification/Notes
MTO Interim,
modified
MTO Interim
children, allowing the adults to pursue self-improvement.
Job training programs in particular may provide adults with skills
that facilitate entry into the labor force or help them obtain better
jobs, important determinants of self-sufficiency.
MTO Interim
Source
Justification/Notes
MTO Interim
MTO Interim
These questions are a slightly modified version of the standard
Current Population Survey (CPS) questions designed to measure
current labor market status, hours of work, occupation, industry,
and rate of pay. Several questions have been added to take better
account of the casual, sporadic employment typical of a lowincome population. This sequence will allow us to estimate
impacts on all the standard measures of labor market status and
activity (e.g., employment and unemployment, weekly hours and
earnings, hourly wage rate). Moves to low-poverty neighborhoods
can be expected to influence these outcomes because the
availability and type of jobs in such neighborhoods are
substantially different than those in high-poverty neighborhoods
and because the supply of low-wage labor competing for such jobs
may be smaller. Respondents who move to low-poverty areas may
also be more motivated and/or able to work than those who remain
in public housing, because the social norms and role models in
higher-income neighborhoods are likely to be more supportive of
work. Other factors that may affect the employment and earnings
of the MTO families include the greater safety and reduced stress
levels of low-poverty neighborhoods and more
supportive/effective welfare-to-work programs.
If it important to ask this series of questions as part of the final
MTO evaluation because the long-run effects of moving may be
qualitatively different from the short- or intermediate-run effects.
For example, while the loss of informal social networks may make
it initially more difficult for families who move to low-poverty
areas to find jobs this effect should dissipate over time.
Furthermore, the effects of neighborhood characteristics on
MTO Interim
MTO Interim
MTO Interim
CPS
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
Page F-17
EMPLOYMENT & EARNINGS
Question
Item
Number
HEM9
For your [main] job, what is the easiest way for you to report your
total earnings before taxes or other deductions: hourly, weekly,
annually, or on some other basis?
HEM10
Do you usually receive overtime pay, tips, or commissions [at main
job]?
HEM11
(Including overtime pay, tips and commissions), what are your usual
(daily/weekly/ biweekly/monthly/annual) earnings on (this) job,
before taxes or other deductions?
HEM11a
How many days a week do you usually work?
HEM12
How many weeks a year do you get paid for?
HEM12b
[IF HEM9=PER UNIT] What is your rate of pay per [UNIT] (on
this job)?
HEM12c
For how many [UNIT]s are you usually paid per week (on this job)?
HEM12d
Excluding overtime pay, tips, and commissions, what is your rate of
pay per [UNIT] (on this job)?
HEM12e
For how many [UNIT]s are you usually paid per week at this rate?
HEM12g
(At your main job,) how much do you usually receive just in
overtime pay, tips, commissions, before taxes or other deductions?
HEM12h
Is that… per hour/day/week/month/year/unit/other?
HEM12j
[IF HEM 12h=PER UNIT] For how many [UNIT]’s are you usually
paid per week at this rate?
HEM12k
[IF HEM12h=PER HOUR] How many hours do you usually work
per week at this rate?
HEM12l
[IF HEM12h=PER DAY] How many days per week do you usually
work at this rate?
HEM13a
[IF NO OVERTIME] What is your hourly rate of pay (on this job)?
HEM14a
Excluding overtime pay, tips, and commissions, what is your hourly
rate of pay (on this job)?
HEM14b
How many hours do you usually work per week at this rate?
HEM14c
(At your main job) how much do you usually receive just in
overtime pay, tips, and commissions before taxes or other
deductions?
HEM14d
Is that… per hour/day/week/month/year/unit/other?
HEM14e
How many days/units/hours do you usually work per week at this
rate?
HEM15a
Through your employer are you eligible for any of the following
benefits? By eligible we mean the benefit is available for you now,
even if you decided to not receive it or have not needed it. Health
insurance?
MTO Adult Item Table
Source
Justification/Notes
MTO Interim
employment and earnings outcomes may be apparent only after
some threshold level of exposure to those characteristics.
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
Availability of fringe benefits is a key indicator of job quality, as
well as a potentially important component of total compensation.
Any impacts on employment and earnings (see discussion above)
could be expected to affect fringe benefits as well.
Page F-18
EMPLOYMENT & EARNINGS
Question
Item
Number
HEM15b
Sick leave?
HEM15c
Paid vacation?
HEM16
I’d like to ask you how you found the (main) job you have now.
What is the most important source of information you used to find
this job?
HEM17
[IF HEM16=A FRIEND, RELATIVE, OR ACQUAINTANCE] Did
this person live in the same neighborhood as you at the time you got
the job?
Source
MTO Interim
MTO Interim
MTO Interim
MTO Interim
HEM18
HEM19
How did you usually get to work last week?
How many minutes did it usually take you to get from home to work
last week?
MTO Interim
MTO Interim
HEM20
[IF SCREENED IN AT HEM1 OR HEM2] Do you have a disability
that prevents you from accepting any kind of work during the next
six months?
Do you currently want a job, either full-time or part-time?
Have you been doing anything to find work during the past four
weeks?
What are all the things you have done to find work during the past
four weeks?
Last week, could you have started a job if one had been offered?
[IF HEM26=NO] Why is that?
In the past 2 years, have you done any (other) work at all for which
you were paid?
[IF HEM28=YES] Please tell me the name of your most recent
(other) employer. [DO NOT ENTER IDENTIFYING
INFORMATION]
What kind of work did you usually do for this employer?
When did you first start working for this employer?
Are you currently working for this employer?
[IF HEM31=NO] When did you stop working for this employer?
How much (do/did) you usually earn per week from this employer?
How many hours per week (do/did) you usually work for this
employer?
MTO Interim
HEM21
HEM22
HEM23
HEM26
HEM27
HEM28
HEM28a
HEM29
HEM30
HEM31
HEM32
HEM33
HEM34
MTO Adult Item Table
MTO Interim
MTO Interim
Justification/Notes
These questions measure the impact of location on the availability
of social contacts that are useful in finding work, a potential
mediating factor of MTO impacts. Residents of low-poverty areas
are likely to value work more highly, and there may be peer
pressure to work. But in the new neighborhood, the respondent
may not have contacts (social networks) that are useful for finding
employment. It may also be the case that the respondent has
acquired or developed social networks in the new neighborhood
only since the interim MTO evaluation.
These questions measure the impact of location on the availability
of transportation to work, a potential mediating factor of MTO
impacts. Moves to low-poverty areas may either increase or
decrease access to jobs, depending on the geography of the local
community and the relationship between employer locations and
public transportation.
This is the standard CPS sequence of questions to determine
whether the respondent is unemployed according to the BLS
definition and to measure the intensity of job search. We would
expect the same factors discussed above in relation to employment
and earnings also to affect unemployment and job search behavior.
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
This sequence, taken from the NLSY79, will allow estimation of
impacts on hours of work and earnings on a previous job. For
respondents who are currently working, these questions assess
recent changes in employment. For respondents who are currently
out of work, these questions provide estimates of hours of work
and earnings on their most recent job.
Page F-19
EMPLOYMENT & EARNINGS
Question
Item
Number
HEM35
During the past month, did you do any small jobs (other than any
already mentioned) to bring in extra money like babysitting, home
repairs, mowing lawns, house cleaning, cooking, or things like that?
HEM35a
[IF HEM35=YES] How many hours do you usually work a week at
these small jobs?
HEM36a
Last week, did [HUSBAND OR OTHER COHABITING ADULT
MALE] do any work for pay?
HEM37
[IF HEM36a=NO] What is the main reason that he did not work for
pay last week?
HEM38
Last week, did he have more than one job, including part-time and
weekend work?
HEM39
How many hours per week does he usually work at his [main] job?
(By main job, we mean the one at which he usually works the most
hours.)
HEM39a
Does he usually work 35 hours or more per week at his [main] job?
HEM39b
[IF HEM38=YES] How many hours per week does he usually work
at his other job(s)?
HEM40
Now I have a few questions about the (main) job at which
[HUSBAND OR OTHER COHABITING ADULT MALE] worked
last week. What kind of business or industry is this? What do they
make or do where he works?
HEM40a
Is this business or organization mainly manufacturing, retail trade,
wholesale trade, or something else?
HEM41
What kind of work does he do, that is, what is his occupation? For
example, plumber, typist, farmer.
HEM42
What are his usual duties or activities at this job? For example:
typing, keeping account books, filing, selling cars, operating
printing press, laying brick.
HEM43
For his [main] job, what is the easiest way for you to report his total
earnings before taxes or other deductions: hourly, weekly, annually,
or on some other basis?
HEM44
Does he usually receive overtime pay, tips, or commissions [at main
job]?
HEM45
(Including overtime pay, tips, and commissions), what are
[SPOUSE’S OR COHABITING ADULT MALE’S] usual
(daily/weekly/biweekly/monthly/annual) earnings on (this) job,
before taxes or other deductions?
HEM46a
How many days a week does he usually work?
HEM47a
How many weeks a year does he get paid for?
MTO Adult Item Table
Source
Justification/Notes
MTO Interim
These questions will measure the extent of informal employment,
which may be an important source of income for the MTO
population. These types of small, temporary, or casual jobs are
not well covered by the CPS-style employment questions.
MTO Interim
MTO Interim
MTO Interim
The remaining core CPS-style questions on employment and
earnings that we ask of the household head in this section (C1C35a) will also be asked of spouses.
MTO Interim
MTO Interim
MTO Interim
CPS
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
Page F-20
EMPLOYMENT & EARNINGS
Question
Item
Number
HEM47b
What is [SPOUSE OR OTHER COHABITING ADULT MALE]‘s
rate of pay per [UNIT] (on this job)?
HEM47c
For how many [UNIT]’s is [SPOUSE OR OTHER COHABITING
ADULT MALE] usually paid per week (on this job)?
HEM47d
Excluding overtime pay, tips and commissions, what is [SPOUSE
OR OTHER COHABITING ADULT MALE]’s rate of pay per
[UNIT] (on this job)?
HEM47e
For how many [UNIT]’s is [SPOUSE OR OTHER COHABITING
ADULT MALE] usually paid per week at this rate?
HEM47g
At his main job, how much does [SPOUSE OR OTHER
COHABITING ADULT MALE] usually receive just in overtime
pay, tips, commissions, before taxes or other deductions?
HEM47h
Is that… per hour/day/week/month/year/unit/other?
HEM47i
For how many [UNIT]’s is [SPOUSE OR OTHER COHABITING
ADULT MALE] usually paid per week at this rate?
HEM47j
[IF PAID PER DAY] How many days per week does [SPOUSE OR
OTHER COHABITING ADULT MALE] usually work at this rate?
HEM47k
How many hours does he usually work per week at this rate?
HEM48a
What is [SPOUSE OR OTHER COHABITING ADULT MALE]’s
hourly rate of pay (on this job)?
HEM49a
Excluding overtime pay, tips, and commissions, what is his hourly
rate of pay (on this job)?
HEM49b
How many hours does he usually work per week at this rate?
HEM49c
(At main job), how much does [SPOUSE OR OTHER
COHABITING ADULT MALE] usually receive just in overtime,
tips, commissions, before taxes or other deductions?
HEM49d
Is that… per hour/day/week/month/year/unit/other?
HEM49e
How many days/units/hours does he usually work per week at this
rate?
HEM50
How did [SPOUSE OR OTHER COHABITING ADULT MALE]
usually get to work last week?
HEM51
How many minutes did it usually take him to get from home to work
last week?
HEM52
[IF SCREENED IN AT HEM36a or HEM37] Does he have a
disability that prevents him from accepting any kind of work during
the next six months?
HEM53
Does he currently want a job, either full-time or part-time?
HEM54
Has [SPOUSE OR OTHER COHABITING ADULT MALE] been
doing anything to find work during the past four weeks?
MTO Adult Item Table
Source
Justification/Notes
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
Original
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
Page F-21
EMPLOYMENT & EARNINGS
Question
Item
Number
HEM55
What are all the things he has done to find work during the past four
weeks?
HEM56
Last week, could he have started a job if one had been offered?
HEM57
Why is that?
INCOME & PUBLIC ASSISTANCE
Question
Question
Number
HIN1
Are you or your (child/children) now receiving help from the
Supplemental Security Income program, called SSI?
HIN2
Is the SSI for you or for your (child/children)?
HIN3
In what month and year did [you/your child/your children] start
receiving SSI benefits?
HIN4
HIN4a
HIN4b
HIN5
Workers sometimes receive a tax refund check—early in the year —
from the Earned Income Tax Credit or because they overpaid taxes
in the previous year. Did you receive a tax refund check from the
federal government in 2008?
How much was your tax refund?
What was the main thing you spent your refund on?
What kind of health insurance or health care coverage do you have
for yourself?
MTO Adult Item Table
Source
Justification/Notes
MTO Interim
MTO Interim
MTO Interim
Source
Justification/Noes
MTO Interim
These questions measure current receipt of cash assistance from
various sources. Changes in residential location facilitated by
MTO may be expected to affect public assistance (SSI, TANF,
and Food Stamps) in several ways. In the long run, better labor
market opportunities in low-poverty areas are expected to lead to
higher employment rates, greater earnings, and less dependence on
cash benefits. It may also be the case that any short-run
disruptions of social networks caused by initial move that may
have made it more difficult for MTO movers to find work and
arrange (informal) childcare will have dissipated by the time of the
long run evaluation. It may also be the case that MTO movers
will respond to changes in community norms in low-poverty areas,
such as a reduced acceptance of welfare than in public housing,
only after having been exposed to low-poverty neighborhoods for
a sufficiently long period of time.
These questions measure receipt of the EITC or tax refunds in
general. They also ask about the use of the tax refund, as it may
be the case that improved savings or spending opportunities in
low-poverty neighborhoods, or different community norms, will
lead MTO participants to make more productive use of their tax
refunds.
This question measures receipt of Medicare or Medicaid (as well
as coverage by other forms of health insurance). Because
transitions in health care coverage, from public programs to
private insurance, can be difficult to achieve and can lag other
improvements in economic well-being this is an important
indicator for the long-term MTO evaluation. This outcome is
important for distinguishing stages in improved economic
circumstances that may be associated with low-poverty moves.
MTO Interim
MTO Interim
MTO Interim
MTO Interim
Original
MTO Interim
Page F-22
INCOME & PUBLIC ASSISTANCE
Question
Question
Number
HIN6
Are you or your (child/children) regularly receiving welfare benefits
now?
Source
Justification/Noes
MTO Interim
This question measures welfare receipt. Welfare agencies in lowpoverty and suburban areas may have greater resources and be
more effective in moving families from welfare to work. Other
changes hypothesized to result from low-poverty moves (e.g.,
reduced stress, improved mental health, and greater monitoring of
youth by community) are likely to ease parents’ welfare-to-work
transitions. It is important to follow-up on this outcome as part of
the long-term MTO evaluation to evaluate whether improvements
in welfare status were persistent.
HIN7
Are you or your (child/children) now receiving Food Stamps?
MTO Interim
This question measures receipt of benefits and also indicates
whether the working poor have access to Food Stamps. See
justification for other cash assistance (for D1-13).
HIN8
Which of these statements best describes the food eaten in your
household in the last 12 months: we always had enough to eat,
sometimes we did not have enough to eat, or, often, we did not have
enough to eat?
CPS, USDA,
modified
This is a modified version of the Department of Agriculture’s food
sufficiency question. This question is a summary indicator of
whether households are able to meet their food needs. If moves to
lower-poverty neighborhoods improve the economic conditions of
families, food sufficiency should improve. Also, neighborhood
changes that may result from moves to low-poverty
neighborhoods – such as different institutions providing food
support, or differences in the availability and price of foods – may
affect the ability of households to meet these needs.
HIN9
How much do you (and everyone else in your family) spend on food
that you use at home in an average week?
Do you have any food delivered to the door which isn’t included in
that?
How much do you spend on that food?
About how much do you (and everyone else in your family) spend
eating out?
PSID
These questions measure food expenditures by the family. These
questions are complements to the food security questions, and
allow measurement of changes in spending or the mix of spending
on food eaten in and food eaten out for given levels of food
security or income. If grocery staples are available more cheaply
in low-income neighborhoods, households may be able to achieve
similar levels of food security for lower food expenditures.
Changes in economic outcomes may lead to substitution between
meals eaten out and meals eaten at home.
This question provides a measure of family routines and values.
These routines in values could be affected by the routines and
values of neighbors. It could also be the case that reduced levels
of stress or improved mental health could affect these routines.
The data from these questions will be combined to measure both
the respondent’s (household head’s) total income and total
household income. Income is a key measure of economic well-
HIN10
HIN11
HIN12
PSID
PSID
PSID
HIN13
About how many days per week do you and your (child/children) all
eat dinner together?
MTO Interim
HIN14
How much did you earn from all your employers before taxes and
deductions during 2007? [IF HIN14=DK/RF, ASK 14a-e;
OTHERWISE, GO TO HIN15]
MTO Interim
MTO Adult Item Table
Page F-23
INCOME & PUBLIC ASSISTANCE
Question
Question
Number
HIN14a
Would it amount to $10,000 or more?
HIN14b
Would it amount to $20,000 or more?
HIN14c
Would it amount to $25,000 or more?
HIN14d
Would it amount to $15,000 or more?
HIN14e
Would it amount to $5,000 or more?
HIN15
About how much money did you receive from the (father/fathers) of
all of your children in the past 12 months?
HIN15a
[IF HIN15=DK/RF] I just need to have a range. Can you tell me if it
was . . .
HIN16
How much income did you receive from all other sources during
2007? Please include any money from the government such as
welfare, SSI, unemployment benefits, Social Security, money from
any businesses you have, money from alimony, help from friends or
relatives, and any other money income received.
HIN17
What is the total combined income of all members of this household
during the year 2007? Please include money from jobs, work on the
side, welfare, SSI, help from your family and friends, and any other
money income received by you or any other household member. [IF
HIN17=DK/RF, ASK 17a-e; OTHERWISE, GO TO NEXT
SECTION]
HIN17a
Would it amount to $10,000 or more?
HIN17b
Would it amount to $20,000 or more?
HIN17c
Would it amount to $25,000 or more?
HIN17d
Would it amount to $15,000 or more?
HIN17e
Would it amount to $5,000 or more?
SAVINGS & ASSETS
Question
Question
Number
HSA1
Do you currently have any checking accounts, savings accounts, or
any other type of bank account at any type of institution?
HSA1a
[IF HSA1=YES] About how much is in these accounts all together?
HSA1b
[IF HSA1a=DK/RF] Would it be… (respondent booklet with choice
of ranges)
MTO Adult Item Table
Source
Justification/Noes
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
Fragile Families,
Wave 3
Fragile Families,
Wave 3
MTO Interim
being, which may be improved for those who moved to lowpoverty areas through MTO, compared to controls.
To overcome the typical extent of missing data for income
questions, included are a series of probes to bracket the income
level. They will help us approximate labor income and address
possible gaps in income data.
Because income and earnings may only have improved through
MTO after a substantial delay, either due to the initially disruptive
effects of moving, or because economic outcomes may only
improve after consistent, long-term exposure to improved
neighborhood characteristics, it is important to include these
outcome measures in the long-term MTO evaluation.
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
Source
Justification/Notes
SCF, modified
Because it is possible that changes in neighborhood environment
could affect the long-term economic security of MTO participants
by changing their access to and use of financial services, we have
proposed to measure these financial outcomes as part of the final
MTO evaluation. There are, broadly speaking, four categories of
SCF, modified
DAHFS
Page F-24
SAVINGS & ASSETS
Question
Question
Number
HSA2
[IF HSA1=NO] What is the most important reason you don’t have a
bank account?
HSA3
HSA3a
HSA3b
HSA4
HSA5
HSA5a
HSA6
HSA6a
HSA7
HSA7a
HSA7b
HSA8
Do you have any savings or keep money for a while in any other
type of account, or any other place including savings held as cash in
your house or somewhere else?
[IF HSA3=YES] What would that be?
About how much would these other savings be worth?
In what year did you buy your home?
What was the purchase price of your present home?
[IF HSA5=DK/RF] Was it … (respondent booklet with choice of
ranges)
If you were to sell your house today, how much would it be worth?
[IF HSA6=DK/RF] Would it be … (respondent booklet with range
of choices)
Do you own this home outright or do you have any mortgages or
land contracts on the property?
[IF HAS MORTGAGES/LAND CONTRACTS IN HSA7] How
much do you still owe on all the loans taken out for your home?
[IF HSA7a=DK/RF] Is it: (respondent booklet with range of
choices)
Do (you/you and your household) own a car or truck, or other motor
vehicle that runs and can be driven on the road?
MTO Adult Item Table
Source
Justification/Notes
SCF, modified
financial outcomes that are of interest in the context of the MTO
evaluation. The first includes measures of banking and savings.
The second includes asset and debt holdings. The third includes
outcomes of particular interest for the low-income population,
such as the use of alternative financial services and reliance on
peers for financial assistance. And the fourth includes indicators
of financial strain, such as having filed for bankruptcy. Given the
very low incomes of MTO participants, we expect that the firstorder impact of MTO on savings and assets may be simply to
increase use of and access to mainstream financial services and
products, such as by increasing the share of adults with a checking
account. Moves to low-poverty neighborhoods could also lead to
improved financial decisions and behavior if they are associated
with increased access to local branch banking opportunities,
improved information or knowledge about returns or investments,
or exposure to more neighborhood residents who utilize
mainstream financial services.
These questions ask about other savings vehicles besides bank
accounts.
DAHFS,
modified
DAHFS
DAHFS,
modified
DAHFS
DAHFS
DAHFS
These questions ask about home value and mortgage debt for
homeowners.
DAHFS
DAHFS
DAHFS,
modified
DAHFS,
modified
DAHFS
DAHFS,
modified
These questions ask about car ownership and debt on car loans.
Page F-25
SAVINGS & ASSETS
Question
Question
Number
HSA9
[IF HSA8=YES] Thinking about the vehicles that (you/you or your
household) own, did you borrow money or get financing to purchase
any of your vehicles?
HSA9a
[IF HSA9=YES] About how much, if anything, do (you/you and
your household) still owe on all of your vehicle loans?
HSA9b
[IF HSA9a=DK/RF] Would you say it was … (respondent booklet
with range of choices)
HSA10
Do you or anyone in your household have any student loans?
HSA10a
[IF HSA10=YES] About how much do you (or your household) still
owe on your student loans?
HSA11
Do you have a valid driver’s license?
HSA12
HSA12a
HSA12b
HSA13
HSA14
HSA14a
HSA15
HSA16
HSA17
HSA18
HSA18a
HSA18b
HSA18c
HSA19
HSA20
Source
DAHFS
DAHFS
DAHFS
DAHFS
DAHFS
These questions ask about student loans.
MTO Interim
A valid form of identification is often necessary to establish a
savings and asset base.
These questions ask about debt related to medical bills.
Do (you/you or anyone in your household) have any unpaid medical
bills?
[IF HSA12=YES] About how much do (you/you or your household)
still owe on your medical bills?
[IF HSA12a=DK/RF] Would it be… (respondent booklet with range
of choices)
Do you have any credit or charge cards? Including major credit
cards like, Visa or MasterCard, or charge cards from a store or gas
station such as Sears or Mobil?
[IF HSA13=YES] About how much do (you/you and your
household) currently owe on all your credit and charge cards?
[IF HSA14=DK/RF] Would it be … (respondent booklet with range
of choices)
In the past 30 days, where did you cash most of your checks?
DAHFS
If you needed to borrow $500 for three months, is there some person
(or place) you could borrow it from?
Where would you go first?
Apart from the $500 you would repay them, how much would they
charge you to borrow the money?
What percent would you have to pay to borrow the $500?
How many dollars would you have to pay to borrow the $500?
Other (specify) [Note this captures charges for borrowing $500 that
are not reported in percent or dollar terms in previous items]
How often does your household have to borrow money to pay bills?
How often does your household put off buying something you need
because you don't have money?
SFAA
MTO Adult Item Table
Justification/Notes
DAHFS
DAHFS
DAHFS,
modified
These questions ask about credit cards.
DAHFS
DAHFS
SFAA, modified
This question determines the use of financial service providers for
check cashing.
These questions ask about sources of financial support, in the form
of a short-term loan.
SFAA
SFAA
SFAA
SFAA
Original
3 Cities
3 Cities
These questions ask about financial strain.
Page F-26
SAVINGS & ASSETS
Question
Question
Number
HSA21
In the past 12 months, have (you/you or anyone in your household)
filed for personal bankruptcy?
PHYSICAL HEALTH
Question
Question
Number
HPH1
Would you say your health in general is excellent, very good, good,
fair, or poor?
HPH2
To help people say how good or bad their health state is, we have
drawn a scale (rather like a thermometer) on which the best state
you can imagine is marked 100 and the worst state you can imagine
is marked 0. We would like you to indicate on this scale how good
or bad your own health is today, in your opinion. Please do this by
drawing a line from the box below to whichever point on the scale
indicates how good or bad youth health state is today.
HPH3
HPH4
HPH5
HPH6
HPH6a
HPH6b
HPH6c
HPH6d
HPH7a
HPH7b
HPH7c
Have you ever been told by a doctor or other health professional that
you had asthma?
During the past 12 months, have you had an episode of asthma or an
asthma attack?
During the past 12 months, have you had a wheezing or whistling
sound in your chest?
How many attacks of wheezing or whistling have you had in your
chest during the past 12 months?
Have you ever been told by a doctor or other health professional that
you had hypertension, also called high blood pressure?
Were you told on two or more different visits that you had
hypertension, also called high blood pressure?
Was any medication ever prescribed by a doctor to help you lower
your blood pressure?
Are you now taking prescribed medicine for your high blood
pressure?
The next few questions are about health problems you might have
had at any time in your life. Have you ever had any of the following:
arthritis or rheumatism?
Chronic back or neck problems?
Frequent or severe headaches?
MTO Adult Item Table
Source
Justification/Notes
DAHFS
This question asks about personal bankruptcy.
Source
Justification/Notes
MTO Interim
This measures sample members’ general health, one of the key
outcome variables in the study. Findings from the MTO Boston
study suggest that general health status improves with moves to
low-poverty areas. Health status is highly correlated with current
medical conditions and future mortality experience. MTO moves
can affect health outcomes through: reduction in stress associated
with living in a high-poverty area, leading to improvements in
mental health; a safer environment and less need to spend time
monitoring children, allowing more exercise; reduced exposure to
persons engaged in drug use; and greater optimism about the
future, leading to increased use of preventive health care.
These questions measure the incidence of asthma in the study
population. Asthma incidence is known to be higher in highpoverty communities and communities with older housing stock,
possibly due to crowding, poor air quality, stress, and/or exposure
to allergens from cockroaches, mites, mice, and cigarette smoke.
Unlike many other chronic health problems, asthma is highly
sensitive to current environmental conditions; the MTO Boston
research suggests reductions due to moves out of public housing.
Data from these questions will be used with the direct measures of
adult blood pressure. See justification for blood pressure measure
later in this sequence.
EQ5D (Note
permission
required to use;
contact:
userinformations
ervice@euroqol.
org)
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
CIDI
These questions ask about other chronic conditions that might
have been affected by MTO.
CIDI
CIDI
Page F-27
PHYSICAL HEALTH
Question
Question
Number
HPH7d
Any other chronic pain?
HPH7e
A stroke?
HPH7f
A heart attack?
HPH7g
Did a doctor or other health professional ever tell you that you had
any of the following illnesses: Heart disease?
HPH7h
HPH7i
HPH7j
HPH7k
HPH7l
HPH7m
HPH8
HPH9
HPH10
HPH10a
HPH11
HPH12
HPH13
HPH14
HPH15
HPH16
HPH17
Any other chronic lung disease, like COPD or emphysema?
Diabetes or high blood sugar?
An ulcer in your stomach or intestine?
HIV infection or AIDS?
Epilepsy or seizures?
Cancer?
How old were you the first time you had (DX)?
Did you still have (DX) or receive any treatment for (it/them) at any
time during the past 12 months?
Is there a place where you usually go to when you are sick or need
advice about your health?
What kind of place is it? A clinic, doctor’s office, emergency room,
or some other place?
Is that [FILL] the same place you usually go when you need routine
or preventative care, such as a physical examination or check up?
What kind of place do you USUALLY go to when you need routine
or preventive care, such as a physical examination or check-up?
About how long has it been since you last saw or talked to a doctor
or other health care professional about your own health?
Is there a place where YOUR CHILDREN usually go when (he / she
/ they) (is / are) sick or you need advice about (his / her / their)
health?
What kind of place do your children go to most often – a clinic,
doctor’s office, emergency room, or some other kind of place?
In the past 12 months, have you had any accidents or injuries that
required medical attention?
During the past 12 months, ABOUT how many days did illness or
injury keep you in bed more than half of the day? (include days
while an overnight patient in a hospital)
MTO Adult Item Table
Source
Justification/Notes
CIDI
CIDI
CIDI
CIDI
CIDI
CIDI
CIDI
CIDI
CIDI
CIDI
CIDI
CIDI
MTO Interim
MTO Interim
NHIS
The MTO treatment may directly affect health care resources,
including the range of providers and the distance to providers from
home. Changes in these resources may be reflected in
respondents’ use of non-emergency health care services. Health
insurance status is measured earlier in the instrument, access to
care follows these questions.
NHIS
NHIS
MTO Interim
MTO Interim
MTO Interim
(from youth
survey)
NHIS2006
These questions are about access to care, an important mediator of
health outcomes. If MTO produces increased levels of
employment and improvement in quality of jobs, treatment group
members may have greater access to employer-provided access to
care. On the other hand, increased earnings could lead families to
fail to qualify for Medicaid. And some may not be offered (or may
not elect) employer-provided health insurance.
Furthermore, MTO moves away from the urban core may reduce
access to low-cost care. For those who live in the suburbs,
Page F-28
PHYSICAL HEALTH
Question
Question
Number
HPH18
During the past 12 months, how many times have you gone to a
HOSPITAL EMERGENCY ROOM about your own health? (this
includes emergency room visits that resulted in a hospital
admission)
HPH19
[Were you / has anyone in the family] been hospitalized
OVERNIGHT in the past 12 months? Do not include an overnight
stay in the emergency room.
HPH20
Who was in the hospital overnight? Anyone else?
HPH21
How many different times did [you / person] stay in the hospital
overnight or longer DURING THE PAST 12 MONTHS?
HPH22
Altogether how many nights [were you / was ALIAS] in the hospital
DURING THE PAST 12 MONTHS?
HPH23
During the past 12 months, was there any time when you or your
children needed medical care but did not get it?
HPH23a
HPH23b
HPH23c
HPH23d
HPH24
HPH25
HPH26
HPH26a
HPH26b
HPH26c
HPH26d
HPH26e
HPH26f
HPH26g
HPH26h
There are many reasons people do not get medical care. During the
past 12 months, did you or your children not get care for any of the
following reasons:
--You couldn’t afford it?
--You didn’t have transportation?
--You didn’t know whom to see?
-- You couldn’t go because you had to work or take care of family
members or friends?
How would you describe the condition of your natural teeth?
Excellent, very good, good, fair or poor, no natural teeth
About how long has it been since you last saw a dentist?
The next questions are about activities you might do during a typical
day. Does your health now limit you in these activities? If so, how
much?
-Vigorous activities, such as running, lifting heavy objects,
participating in strenuous sports
-Moderate activities, such as moving a table, pushing a vacuum
cleaner, bowling, or playing golf
-Lifting or carrying groceries
-Climbing several flights of stairs
-Climbing one flight of stairs
-Bending, kneeling, or stooping
-Walking more than a mile
-Walking several blocks
MTO Adult Item Table
Source
Justification/Notes
NHIS2006
transportation to a close-by health center (as well as possibly
higher costs for the health services offered there) may prove
obstacles to care. These data will help us understand the reasons
people did not receive care, in order to assess whether any
treatment effects are due to cost, access, or information. These
questions concern both utilization of preventive care and
emergency department visits, as well as routine checkups.
NHIS2006
NHIS2006
NHIS2006
NHIS2006
MTO Interim
MTO Interim
MTO Interim
MTO Interim
Original
NHANES
NHIS
MTO Interim,
modified
SF-36
SF-36
MTO Interim
MTO Interim
SF-36
SF-36
SF-36
SF-36
Access to and use of dental care is an extension of the access to
can utilization of medical care sequence.
These questions measure difficulty with some activities of daily
living and serve as additional indicators of overall health status
(see F1). If the MTO treatment has a positive effect on adults’
overall mental and physical health, we expect that such
improvements will be reflected in improved performance in
activities of daily living. Physical mobility and daily functioning
are also potential mediators of other outcomes. Treatment group
adults in good health may be better able to take advantage of the
opportunities provided in the new neighborhood than those in poor
health and with limited mobility.
Page F-29
PHYSICAL HEALTH
Question
Question
Number
HPH26i
-Walking one block
HPH26j
-Bathing or dressing yourself
HPH28
During the past 4 weeks, have you had any of the following
problems with your work or other regular daily activities as a result
of your physical health?
HPH28a
-Cut down on the amount of time you spent on work or other
activities
HPH28b
-Accomplished less than you would like
HPH28c
-Were limited in the kind of work or other activities
HPH28d
-Had difficulty performing the work or other activities (for example,
it took extra effort)
HPH29
In a usual week, do you do moderate activities 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?
HPH29a
How many times per week do you usually do these moderate
activities (for at least 10 minutes at a time)?
HPH30
In a usual week, do you do vigorous activities for at least 10 minutes
at a time, such as running, aerobics, heavy yard work, or anything
else that causes large increases in breathing or heart rate?
HPH30a
How many times per week do you usually do these vigorous
activities (for at least 10 minutes at a time)?
HPH31
-In a typical week, how many hours do you watch television?
HPH32
Do you use a computer at home?
HPH32a
-In a typical week, how many hours total do you use a computer?
HPH33
How frequently do you use the internet at any location?
HPH34
HPH35
HPH36
HPH37
HPH38
HPH39
HPH40
What time did you wake up this morning?
What time did you go to bed last night?
In a typical week, how many times do you eat fruit? (Do not count
fruit juice.)
In a typical week, how many times do you eat vegetables other than
french fries or potato chips?
How often did you drink regular, carbonated SODA OR SOFT
DRINKS that contain sugar?
How often did you eat salty snacks, such as potato chips, pretzels, or
popcorn?
How often did you eat sweet snacks, such as cookies, chocolate
bars, or candy?
MTO Adult Item Table
Source
Justification/Notes
SF-36
SF-36
SF-36
SF-36
SF-36
SF-36
SF-36
BRFSS,
modified
BRFSS,
modified
BRFSS,
modified
BRFSS,
modified
NLSY97
CPSSEP01
NLSY97
CPSSEP01modified
Original
Original
NLSY97
These questions measure the extent of physical exercise among
sample members, a mediator of overall health. Moves to lowpoverty neighborhood could promote increased exercise due to a
safer physical environment, readier access to recreational space,
less need for parents to supervise children constantly, and thus
more time for adults to devote to their own activities, including
exercise. On the other hand, transitions to employment could limit
the time available for exercise.
These questions ask about inactivity, an additional physical health
indicator.
These questions ask about sleep, an additional physical health
indicator.
These questions are about diet, an additional physical health
indicator.
NLSY97
NHIS
Original, similar
to Add Health
Original, similar
to Add Health
Page F-30
PHYSICAL HEALTH
Question
Question
Number
HPH41
On how many of the past seven days did you eat food from a fast
food place, McDonalds, Kentucky Fried Chicken, Pizza Hut, Taco
Bell, or a local fast food restaurant?
HPH42
[INTERVIEWER: [ ENTER BLOOD PRESSURE EQUIPMENT
NUMBER]
HPH43
How many hours has it been since you had your last meal?
HPH44
INTERVIEWER: [RECORD ROOM TEMPERATURE HERE]
HPH44a
CAPI PROGRAMMER: [ DID THE RESPONDENT SMOKE AT
ANY TIME DURING THIS INTERVIEW?]
HPH45
[INTERVIEWER: RECORD BLOOD PRESSURE
MEASUREMENT HERE. IF LARGE CUFF TOO SMALL, TAKE
PRESSURE ON FOREARM. IF FOR ANY REASON YOU ARE
UNABLE TO TAKE MEASUREMENT, ENTER 1]
HPH45a
INTERVIEWER: WHICH CUFF DID YOU USE?
HPH45b
Now I need to take another blood pressure reading.
[INTERVIEWER: RECORD SECOND BLOOD PRESSURE
READING HERE]
HPH45c
[CAPI PROGRAMMER: CALCULATE THE AVERAGE OF
TWO BLOOD PRESSURE READINGS FROM HPH_F16 AND
HPH_F16b: IF AVERAGE BLOOD PRESSURE FALLS INTO
“HIGH CATEGORY, CONTINUE. OTHERWISE SKIP TO
HPH_F16d] In order to make sure we have measured your blood
pressure accurately, we will continue with the next set of questions,
and at the end of the interview, I will ask you to let us take your
blood pressure measurement again.
HPH45d
[CAPI PROGRAMMER DISPLAY AVERAGE OF TWO BLOOD
PRESSURE READINGS.]
HPH45e
[INTERVIEWER: IF AVERAGE BLOOD PRESSURE READING
IS NORMAL, HAND RESPONDENT THE CARD WITH
HIS/HER BLOOD PRESSURE INFORMATION AND EXPLAIN.
ALSO INCLUDE:]
HPH46
HEIGHT MEASUREMENT
HPH47
WEIGHT MEASUREMENT
MTO Adult Item Table
Source
Justification/Notes
Add Health
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
Elevated blood pressure (hypertension) has a well-known
association with increased risk of cardiovascular disease and is a
particularly acute issue for African-Americans. While blood
pressure has a substantial genetic component, it is also a function
of stress, weight, and activity patterns such as exercise and diet—
all of which could be affected by living in a new neighborhood
with different social norms. Increasing evidence suggests that
variations in the magnitude and timing of blood pressure response
to stress are associated with heightened risk of developing
hypertension and accelerated arteriosclerosis, especially in the
context of low incomes (or high job demands). There is also
considerable evidence of links between distressed psychosocial
states and heightened blood pressure. These are all possible
pathways through which MTO may affect blood pressure.
Using automated sphygmomanometers approved by the American
Association for the Advancement of Medical Instrumentation
Standard (accepted by the FDA as the national standard), we will
directly measure adult blood pressure.
MTO Interim
MTO Interim
MTO Interim
MTO Interim
Data from these questions will be used to measure obesity, a basic
health outcome with higher incidence in low-income populations
in the U.S. Moves to low-poverty neighborhoods may reduce
obesity through several mechanisms: lower incidence of
depression and stress; behavioral changes (like exercise); different
social norms about eating habits. Finally, if moving to lowpoverty neighborhood increases discretionary spending on food,
access to a better diet could also reduce obesity.
Page F-31
PHYSICAL HEALTH
Question
Question
Number
QUESTIONS FOR DRIED BLOOD SPOT (DBS) BIOMARKERS
Source
Add Health
Biomarkers can capture otherwise undetectable changes in longerterm risks of disease outcomes, such as changes in cholesterol
levels that may affect heart attack risk, for example. These
biomarkers would enable us to understand neighborhood effects
on very long-term health outcomes that may not manifest
themselves in detectable health problems even at the time of our
proposed surveys, which will be conducted around 10 years after
random assignment.
Add Health
The biomarkers we are collecting have been demonstrated to be
important predictors of cardiovascular and metabolic diseases and
other long-term health outcomes and have been linked to adult
exercise, diet, obesity and stress, all of which have been shown to
be influenced by MTO in the interim study.
Do you have any reason to think you’re pregnant?
HPH48
HPH49
HPH50
HPH51
HPH52
HPH53
HPH54
HPH55
What is the date when your last menstrual period began?
In the last week, have you had a cough, runny nose, sore throat,
fever, diarrhea, or any other type of infection?
Regarding your current medication use: In the past 24 hours, have
you taken aspirin or aspirin-containing medications including cold
and allergy medications or headache powders? (Some examples of
those include Anacin, Aspirin, BC, Backache Relief Extra Strength,
Bayer, Excedrin, Goody’s, Pain Relief, Pain Reliever Added
Strength, Vanquish)
In the past 24 hours, have you used any prescription medications?
Please think about any prescription medications whether or not they
were prescribed to you.
At what time did you last drink or eat anything except for water?
At what time did you last drink a caffeinated beverage (such as
coffee, tea, or soda)?
At what time did you last smoke cigarettes, cigars, a pipe or use
chewing tobacco?
MENTAL HEALH – SUBSTANCE ABUSE
Question
Question
Number
HSU1_U1
First, I would like to ask you about smoking habits. Have you ever
smoked a cigarette?
HSU2_U2
During the past 30 days, on how many days did you smoke a
cigarette?
HSU3_U3
When you smoked a cigarette during the past 30 days, how many
cigarettes did you usually smoke each day?
HSU4_U4
Next I would like to ask you some questions about drinking
alcoholic beverages, including beer, wine, or liquor. Have you ever
had a drink of alcoholic beverage? By a drink we mean a can or
bottle of beer, a glass of wine, a mixed drink, or a shot of liquor.
HSU5_U5
During the past 30 days, on how many days did you have one or
more drinks of an alcoholic beverage?
MTO Adult Item Table
Justification/Notes
Add Health
Add Health
Add Health
Add Health
Add Health
These questions accompanying the DBS extractions address issues
that can confound the readings of the blood samples.
Add Health
Source
Justification/Notes
Interim
For substance disorders, these questions assess alcohol and drug
abuse and dependence. Both lifetime and 12-month prevalence are
assessed. A number of substance use disorders may have onsets
after the beginning of the MTO experiment, which means that we
will be able to detect effects of the experiment on prevention of
lifetime occurrence of these disorders as well as on course. It is
important to assess lifetime prevalence in an effort to obtain some
information about pre-existing characteristics of respondents that
might modify the success of the intervention.
Interim
Interim
Interim
Interim
Page F-32
MENTAL HEALH – SUBSTANCE ABUSE
Question
Question
Number
HSU6_U6
In the last 30 days, on the days that you drank alcohol, about how
many drinks did you usually have?
HSU7_U7
On how many days did you have 5 or more drinks on the same
occasion during the same time or within hours of each other?
HSU8_U8
In the last 30 days, how many days have you had something
alcoholic to drink, such as beer, wine, or hard liquor right before or
during school or work hours?
HSU9_U9
Have you ever used marijuana – that is grass or pot – in your
lifetime?
HSU10_U10
On how many days have you used marijuana in the last 30 days?
HSU11_U11
In the last 30 days, how many times have you used marijuana right
before or during school or work hours?
HSU12_U12
Excluding marijuana and alcohol, have you ever used any other
drugs like cocaine or crack or heroin, or any other substance not
prescribed for you by a doctor, in order to get high or to achieve an
altered state?
HSU13_U13
During the past 12 months, about how many times have you used
any of these drugs or other substances?
HSU14_U14
Have you ever sold or helped sell marijuana, hashish or other drugs
such as heroin, cocaine, or LSD?
HSU15
The following questions are about your drinking. For each of the
five questions, please indicate the most appropriate response as it
applied to your drinking in the last month.
Do you think your use of alcohol was out of control?
HSU16
Did the prospect of missing a chance to drink make you anxious or
worried?
HSU17
Did you worry about your use of alcohol?
HSU18
Did you wish you could stop?
HSU19
How difficult did you find it to stop or go without drinking?
The following questions are about your drug use. For each of the
five questions, please indicate the most appropriate response as it
applied to your drug use in the last month.
HSU20a
Do you think your use of (drug) was out of control?
HSU20b
Did the prospect of missing a fix make you anxious or worried?
HSU20c
Did you worry about your use of (drug)?
HSU20d
Did you wish you could stop?
HSU20e
How difficult did you find it to stop or go without (drug)?
MTO Adult Item Table
Source
Justification/Notes
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Interim
SDS
SDS
SDS
SDS
SDS
SDS
SDS
SDS
SDS
SDS
Page F-33
MENTAL HEALH – K-6 INDEX PLUS TRANQUILITY
Question
Question
Number
Now I am going to ask you some questions about feelings that you
may have experienced during the past 30 days. How much of the
time during the past 30 days have you felt…
HK61
So sad that nothing could cheer you up?
HK62
Nervous?
HK63
Restless or fidgety?
HK64
Hopeless?
HK65
That everything was an effort?
HK66
Worthless?
HK67
Calm and peaceful?
MENTAL HEALH – NCS SCREENER
Question
Question
Number
HSC1_SC20
The next questions are going to require you to think back over your
entire life. Please take your time and think carefully before
answering. (INTERVIEWER: READ THE NEXT SENTECE
SLOWLY )Have you ever in your life had an attack of fear or panic
when all of a sudden you felt very frightened, anxious, or uneasy?
HSC2_SC20a Have you ever had an attack when all of a sudden: you became very
uncomfortable; you either became short of breath, dizzy, nauseous,
or your heart pounded; or you thought you might lose control, die,
or go crazy?
HSC3_SC20.
Have you ever in your life had attacks of anger when all of a sudden
1
you lost control and broke or smashed something worth more than a
few dollars?
HSC4_SC20.
Have you ever had attacks of anger when all of a sudden you lost
2
control and hit or tried to hurt someone?
HSC5_SC20.
Have you ever had attacks of anger when all of a sudden you lost
3
control and threatened to hit or hurt someone?
HSC6_SC21
Have you ever in your life had an episode lasting several days or
longer when most of the day you felt sad, empty or depressed?
HSC7_SC22
Have you ever had an episode lasting several days or longer when
most of the day you were very discouraged about how things were
going in your life?
HSC8_SC23
Have you ever had an episode lasting several days or longer when
you lost interest in most things you usually enjoy like work,
hobbies, and personal relationships?
MTO Adult Item Table
Source
Justification/Notes
Interim
This series of questions examines the possible stress reduction that
could occur when families move away from dangerous
neighborhoods. This K6 sequence is a measure of general
psychological distress.
Source
Justification/Notes
NCS
In addition to repeating the screening questions that were included
in the interim MTO evaluation, we are including detailed fully
structured assessments of DSM-IV disorders. These assessments
are identical to those used to assess the same disorders in the
recently completed National Comorbidity Survey Replication
(NCS-R), thus providing a nationally representative benchmark to
the MTO results. The diagnostic instrument used is the version of
the World Health Organization’s (WHO) Composite International
Diagnostic Interview (CIDI) that was expanded and updated for
the WHO World Mental Health Survey Initiative. This instrument,
which revised the original CIDI to make diagnoses according to
the definitions and criteria of the DSM-IV, was recently approved
by WHO as the official version of CIDI to be used throughout the
world until the publication of ICD-11 in the year 2011. It is
important to recognize that the CIDI is a fully structured
diagnostic interview. This means that it is designed for use by
trained lay interviewers rather than by clinicians and that clinical
judgments are not required in scoring. However, methodological
research has documented good concordance between diagnoses
made by the CIDI and independent diagnoses made by clinical
interviewers.
Four classes of CIDI DSM-IV disorders are assessed in the MTO
survey: anxiety disorders, mood disorders, impulse-control
disorders, and substance use disorders. The following sections also
NCS
NCS
NCS
NCS
NCS
NCS
NCS
Page F-34
MENTAL HEALH – NCS SCREENER
Question
Question
Number
HSC9_SC24
Some people have episodes lasting several days or longer when they
feel much more excited and full of energy than usual. Their minds
go too fast. They talk a lot. They are very restless or unable to sit
still and they sometimes do things that are unusual for them, such as
driving too fast or spending too much money. Have you ever had a
period like this lasting several days or longer?
HSC10_SC25 Have you ever had an episode period lasting several days or longer
when most of the time you were very irritable, grumpy, or in a bad
mood?
HSC11_SC25 Have you ever had an episode lasting several days or longer when
a
most of the time you were so irritable that you either started
arguments, shouted at people, or hit people?
HSC12_SC26 Did you ever have a time in your life when you were a “worrier” –
that is, when you worried a lot more about things than other people
with the same problems as you?
HSC13_SC26 Did you ever have a time in your life when you were much more
a
nervous or anxious than most other people with the same problems
as you?
HSC14_SC26 Did you ever have a period lasting one month or longer when you
b
were anxious and worried most days?
Source
Justification/Notes
NCS
include an assessment of mental health treatment taken from the
NCS-R, including questions about the occurrence of general
medical, mental health specialty, human services, and
complementary-alternative medical treatment of mental and
substance use disorders, as well as about the content and intensity
of such treatment.
NCS
NCS
NCS
NCS
NCS
MENTAL HEALH – DEPRESSION (57.4% of an MTO-like sample of NCS respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
HDE1_D1
A few moments ago, you mentioned having episodes that lasted
Several studies have found significant associations between living
NCS
several days or longer when you felt sad, empty, or depressed most
in disadvantaged neighborhoods and adverse mental health
of the day. During episodes of this sort, did you ever feel
outcomes, including depression. People living in high-poverty
discouraged about how things were going in your life?
neighborhoods differ in many ways from those in lower-poverty
areas, and only some of those differences can be adequately
HDE1a_D1a
During the episodes of being sad, empty, or depressed, did you ever NCS
measured and controlled for in non-experimental studies. Causal
lose interest in most things like work, hobbies, and other things you
inference is more credible in the setting of a randomized
usually enjoy?
intervention that encourages otherwise identical people to live in
HDE1b_D1b
During the episodes of being sad, empty, or depressed, did you ever NCS
different areas. Moving from a high-poverty neighborhood to a
lose interest in most things like work, hobbies, and other things you
lower-poverty neighborhood is a major life event that in principle
usually enjoy?
may or may not improve mental health and other outcomes. On
HDE2_D2
A few moments ago you mentioned having episodes that lasted
NCS
the one hand, the “social stress model” suggests that relocating to
several days or longer when you felt discouraged about how things
safer, more stable neighborhoods that provide better schooling,
were going in your life. During episodes of this sort, did you ever
housing, and employment opportunities may reduce stressful life
lose interest in most things like work, hobbies, and other things you
events and life difficulties, thereby improving mental health. On
usually enjoy?
MTO Adult Item Table
Page F-35
MENTAL HEALH – DEPRESSION (57.4% of an MTO-like sample of NCS respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
the other hand, moving could result in social or cultural isolation,
HDE3_D9
A few moments ago, you mentioned having episodes that lasted
NCS
which could have adverse effects on mental health. Such moves
several days or longer when you lost interest in most things like
could also negatively affect mental health if self-evaluation is
work, hobbies, and other things you usually enjoy. Did you ever
based in part on relative standing within one’s community, as with
have an episode of this sort that lasted most of the day nearly every
“relative deprivation” models. This series of questions serves as a
day for two weeks or longer?
diagnostic assessment of the CIDI-DSMIV major depression
HDE4_D12
Did you ever have an episode of being sad, discouraged, or
NCS
disorder.
uninterested in things that lasted most of the day, nearly every day,
for two weeks or longer?
HDE5_D16
Think of times lasting two weeks or longer when (this problem/these NCS
problems) with your mood (was/were) most severe and frequent.
During those times, did your feelings of sadness, discouragement, or
lack of interest usually last less than one hour a day, between 1 and
3 hours, between 3 and 5 hours, or more than 5 hours?
HDE6_D22
Please think of an episode of being sad, discouraged, or uninterested NCS
in things lasting two weeks or longer when you also had other
problems at the same time, such as changes in sleep, appetite, the
ability to concentrate and remember, feelings of low self worth, and
other problems. Is there one particular episode of this sort that
stands out in your mind as the worst one you ever had?
HDE6a_D22a How old were you when that worst episode started?
NCS
HDE6b_D22b How long did that worst episode last?
NCS
HDE6c_D22b
HDE6d_D22c Then think of the last time you had a bad episode of being sad,
NCS
discouraged, or uninterested in things like this. How old were you
when that last episode occurred?
HDE6e_D22d How long did that episode last?
NCS
HDE6f_D22d
HDE7_D24
Look at page 5 in your booklet. In answering the next questions,
NCS
think about the episode of two weeks or longer during that episode
when your sadness, discouragement, and loss of interest and other
problems were most severe and frequent. During that period, which
of the following problems did you have most of the day nearly every
day
HDE7a_D24a Did you feel sad, empty, or depressed most of the day nearly every
NCS
day during that period of two weeks?
HDE7b_D24c During that episode of two weeks, did you feel discouraged about
NCS
how things were going in your life most of the day nearly every
day?
HDE7c_D24e During that episode of two weeks, did you lose interest in almost all NCS
things like work and hobbies and things you like to do for fun?
MTO Adult Item Table
Page F-36
MENTAL HEALH – DEPRESSION (57.4% of an MTO-like sample of NCS respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
HDE7d_D24f Did you feel like nothing was fun even when good things were
NCS
happening?
HDE9a_D26a Did you have a much smaller appetite than usual nearly every day
NCS
during that period of two weeks?
HDE9b_D27b Did you have a much larger appetite than usual nearly every day?
NCS
HDE9c_D26c Did you gain weight without trying to during that period of two
NCS
weeks?
HDE9d_D26e Did you lose weight without trying to?
NCS
HDE9e_D26g Did you have a lot more trouble than usual either falling asleep,
NCS
staying asleep, or waking too early nearly every night during that
period of two weeks?
HDE9f_D26h Did you sleep a lot more than usual nearly every night during that
NCS
period of two weeks?
HDE9g_D26j Did you feel tired or low in energy nearly every day during that
NCS
period of two weeks even when you had not been working very
hard?
HDE9h_D26k Did you have a lot more energy than usual nearly every day during
NCS
that period of two weeks?
HDE9i_D26l
Did you talk or move more slowly than is normal for you nearly
NCS
every day?
HDE9j_D26m Did anyone else notice that you were talking or moving slowly?
NCS
HDE9k_D26n Were you so restless or jittery nearly every day that you paced up
NCS
and down or couldn't sit still?
HDE9l_D26o Did anyone else notice that you were restless?
NCS
HDE9m_D26 Did your thoughts come much more slowly than usual or seem
NCS
p
mixed up nearly every day during that period of two weeks?
HDE9n_D26r Did you have a lot more trouble concentrating than is normal for
NCS
you nearly every day?
HDE9o_D26s Were you unable to make up your mind about things you ordinarily
NCS
have no trouble deciding about?
HDE9p_D26t Did you lose your self-confidence?
NCS
HDE9q_D26u Did you feel that you were not as good as other people nearly every
NCS
day?
HDE9r_D26w Did you feel guilty nearly every day?
NCS
HDE9s_D26a Did you often think a lot about death, either your own, someone
NCS
a
else’s, or death in general?
HDE9t_D26b During that episode, did you ever think that it would be better if you NCS
b
were dead?
MTO Adult Item Table
Page F-37
MENTAL HEALH – DEPRESSION (57.4% of an MTO-like sample of NCS respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
HDE9u_D26c Did you think about committing suicide?
NCS
c
HDE11_D28
You mentioned having a number of the problems I just asked you
NCS
about. How much did your sadness, discouragement, or lack of
interest and these other problems interfere with either your work,
your social life, or your personal relationships during that episode–
not at all, a little, some, a lot, or extremely?
HDE12_D17
How severe was your emotional distress during those times -- mild,
NCS
moderate, severe, or very severe?
HDE13_D18
How often, during those times, was your emotional distress so
NCS
severe that nothing could cheer you up -- often, sometimes, rarely,
or never?
HDE14_D37
Think of the very first time in your life you had an episode lasting
NCS
two-weeks or longer when most of the day nearly every day you felt
sad, discouraged, or uninterested and also had some of the other
problems we just reviewed. Can you remember your exact age?
HDE14a/b_D How old were you? or About how old were you (the first time you
NCS
37a/b
had an episode of this sort)?
HDE15_D38
Did you have an episode of being sad, discouraged, uninterested
NCS
with some of the other problems (on pages 5-6) lasting two weeks or
longer at any time in the past 12 months?
HDE15a_D38 How recently – in the past month, two to six months ago, or more
NCS
a
than six months ago?
HDE16_D38b About how many days out of the last 365 were you in an episode?
NCS
HDE17_D38c How old were you the last time you had one of these episodes?
NCS
MENTAL HEALH – MANIA (23.4% of an MTO-like sample of NCS respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
HMA1_M1
Earlier in the interview you mentioned having an episode lasting
NCS
Mania, often associated with bipolar disorder, is associated with
four days or longer when you felt much more excited and full of
psychological distress and depression, which could have been
energy than usual and your mind went too fast. People who have
decreased or increased by an MTO move (see justification for
episodes like this often have changes in their thinking and behavior
depression).
at the same time, like being more talkative, needing very little sleep,
being very restless, going on buying sprees, and behaving in ways
they would normally think are inappropriate. Did you ever have any
of these changes during your episodes of being excited and full of
energy?
MTO Adult Item Table
Page F-38
MENTAL HEALH – MANIA (23.4% of an MTO-like sample of NCS respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
HMA2_M3
Please think of the one episode when you were very excited and full NCS
of energy and you had the largest number of changes like these at
the same time. Is there one episode of this sort that stands out in
your mind?
HMA2a_M3a How old were you when that episode occurred?
NCS
HMA2b_M3b How long did that episode last? (enter number)
NCS
HMA2c_M3b (enter unit of time: hours, days, weeks, months or years)
HMA2d_M3c Then think of the most recent time you had an episode like this.
NCS
How old were you when that most recent episode occurred?
HMA2e_M3d How long did that episode last? (enter number)
NCS
HMA2f_M3d (enter unit of time: hours, days, weeks, months or years)
HMA3_M4
During that episode, which of the following behavior changes did
NCS
you experience: were you so irritable or grouchy that you started
arguments, shouted at people, or hit people?
HMA4_M5
Earlier in the interview you mentioned having episodes lasting four
NCS
days or longer when you became so irritable or grouchy that you
started arguments, shouted at people, or hit people. People who have
episodes of irritability like this often have changes in their thinking
and behavior at the same time, like being more talkative, needing
very little sleep, being very restless, going on buying sprees and
behaving in ways they would normally think are inappropriate. Did
you ever have any of these changes during your episodes of being
very irritable or grouchy?
HMA5_M6
Please think of the episode of four days or more when you were very NCS
irritable or grouchy and you had the largest number of changes like
these at the same time. Is there one episode of this sort that stands
out in your mind?
HMA6a_M6a How old were you when that episode occurred?
NCS
HMA6b_M6b How long did that episode last? (enter number)
NCS
HMA6c_M6b (enter unit of time: hours, days, weeks, months or years)
HMA6d_M6c Then think of the most recent time you had an episode like this.
NCS
How old were you when that most recent episode occurred?
HMA6e_M6d How long did that episode last? (enter number)
NCS
HMA6f_M6d (enter unit of time: hours, days, weeks, months or years)
HMA7a_M7a During that episode, which of the following changes did you
NCS
experience…
Did you become so restless or fidgety that you paced up and down
or couldn’t stand still? (KEY PHRASE: being restless)
MTO Adult Item Table
Page F-39
MENTAL HEALH – MANIA (23.4% of an MTO-like sample of NCS respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
HMA7b_M7b Were you a lot more interested in sex than usual, or did you want to
NCS
have sexual encounters with people you wouldn’t ordinarily be
interested in? (KEY PHRASE: having a lot more interest in sex than
usual)
HMA7c_M7c Did you become overly friendly or outgoing with people?
NCS
HMA7d_M7d Did you do anything else that wasn’t usual for you - - like talking
NCS
about things you would normally keep private, or acting in ways that
you’d usually find embarrassing?
(KEY PHRASE: behaving inappropriately)
HMA7e_M7e Did you try to do things that were impossible to do, like taking on
NCS
large amounts of work? (KEY PHRASE: trying to accomplish
unrealistic goals)
HMA7f_M7f
Did you talk a lot more than usual or feel a need to keep talking all
NCS
the time? (KEY PHRASE: talking a lot more than usual)
HMA7g_M7g Did you constantly keep changing your plans or activities?
NCS
(KEY PHRASE: constantly changing plans)
HMA7h_M7h Did you find it hard to keep your mind on what you were doing?
NCS
(KEY PHRASE: hard to keep your mind on things)
HMA7_M7i
Did your thoughts seem to jump from one thing to another or race
NCS
through your head so fast you couldn’t keep track of them?
(KEY PHRASE: thoughts racing)
HMA7j_M7j
Did you sleep far less than usual and still not get tired or sleepy?
NCS
(KEY PHRASE: sleeping far less than usual)
HMA7k_M7k Did you get involved in foolish investments or schemes for making
NCS
money? (KEY PHRASE: getting involved in foolish schemes)
HMA7l_M7l
Did you spend so much more money than usual that it caused you to NCS
have financial trouble? (KEY PHRASE: getting into financial
trouble)
HMA7m_M7 Did you do reckless things like driving too fast, staying out all night, NCS
m
or having casual or unsafe sex? (KEY PHRASE: doing risky things)
HMA7n_M7n Did you have a greatly exaggerated sense of self-confidence or
NCS
believe you could do things you really couldn’t do?
(KEY PHRASE: having too much self-confidence)
HMA7o_M7o Did you have the idea that you were actually someone else, or that
NCS
you had a special connection with a famous person that you really
didn’t have? (KEY PHRASE: believing you were someone else or
somehow connected to a famous person)
MTO Adult Item Table
Page F-40
MENTAL HEALH – MANIA (23.4% of an MTO-like sample of NCS respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
HMA9_M9
Let me review. You had episodes when you were very (excited and NCS
full of energy/irritable or grouchy) and also had some problems like
(KEY PHRASE OF 3 “YES” RESPONSES IN M7 SERIES). How
much did these episodes ever interfere with either your work, your
social life, or your personal relationships – not at all, a little, some, a
lot, or extremely?
HMA10_M9b Did other people say anything or worry about the way you were
NCS
acting?
HMA11_M18 Think of the very first time in your life you had an episode lasting
NCS
four days or longer when you became very
(excited and full of energy/irritable or grouchy) and also had some
of the behavior changes you just reported. Can you remember your
exact age?
HMA11a/b_
How old were you? or About how old were you the first time you
NCS
M18a/b
had an episode of this sort?
HMA12_M19 Did you have one of these episodes at any time in the past 12
NCS
months?
HMA13_M19 How many weeks in the past 12 months were you in one of these
NCS
c
episodes?
HMA14_M19 How old were you the last time you had one of these episodes?
NCS
d
MENTAL HEALH – PANIC DISORDER (HPD) (50.0% of an MTO-like sample of NCS respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
HPD1_PD1
Earlier you mentioned having attacks of fear or panic when all NCS
Panic disorders are a type of anxiety disorder, which will
INTRO 1
of a sudden you felt very frightened, anxious, or uneasy.
most often have lifetime cases with ages of onset prior to
Think of a bad attack like that. During that attack, which of
the beginning of the MTO experiment. This means that the
the following problems did you have?
influence of the MTO experiment will be on course of illness
rather than on onset. By asking questions about age at first
HPD1_PD1
Earlier you mentioned having attacks when all of a sudden
NCS
onset and most recent onset, MTO’s impact can be greater
INTRO 2
you had several problems like being short of breath, your
evaluated.
heart pounding or feeling dizzy, and being afraid you would
die or go crazy. Think of a bad attack like that. During that
attack, which of the following problems did you have?
HPD1a_PD1a Did your heart pound or race? (KEY PHRASE: heart racing)
NCS
HPD1b_PD1b Were you short of breath? (KEY PHRASE: being short of
NCS
breath)
MTO Adult Item Table
Page F-41
MENTAL HEALH – PANIC DISORDER (HPD) (50.0% of an MTO-like sample of NCS respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
HPD1c_PD1c Did you have nausea or discomfort in your stomach?
NCS
(KEY PHRASE: having nausea)
HPD1d_PD1d Did you feel dizzy or faint? (KEY PHRASE: feeling dizzy)
NCS
HPD1e_PD1e Did you sweat? (KEY PHRASE: sweating)
NCS
HPD1f_PD1f
Did you tremble or shake? (KEY PHRASE: trembling)
NCS
HPD1g_PD1g Did you have a dry mouth? (KEY PHRASE: having a dry
NCS
mouth)
HPD1h_PD1h Did you feel like you were choking? (KEY PHRASE: choking)
NCS
HPD1i_PD1i
Did you have pain or discomfort in your chest? (KEY PHRASE: NCS
having discomfort in your chest)
HPD1j_PD1j
Were you afraid that you might lose control of yourself or go
NCS
crazy? (KEY PHRASE: fearing that you might lose control of
yourself)
HPD1k_PD1k Did you feel that you were “not really there”, like you were
NCS
watching a movie of yourself? (KEY PHRASE: feeling unreal)
HPD1l_PD1l
Did you feel that things around you were unreal or like a
NCS
dream? (KEY PHRASE: feeling that things around you were
unreal)
HPD1m_PD1 Were you afraid that you might pass out? (KEY PHRASE:
NCS
m
fearing that you might pass out)
HPD1n_PD1n Were you afraid that you might die? (KEY PHRASE: fearing
NCS
that you might die)
HPD1o_PD1o Did you have hot flushes or chills? (KEY PHRASE: having hot
NCS
flushes)
HPD1p_PD1p Did you have numbness or tingling sensations? (KEY PHRASE: NCS
having numbness)
HPD3_PD3
During your attacks did the problems like (PARENTHETICAL
NCS
PHRASE OF FIRST THREE YES RESPONSES IN HPD1 SERIES)
begin suddenly and reach their peak within ten minutes after
the attacks began?
NCS
HPD4_PD4
About how many of these sudden attacks have you had in
your entire lifetime?
HPD5_PD9
Can you remember your exact age the very first time you had NCS
one of these attacks?
HPD5a/b_PD How old were you? or About how old were you?
NCS
9a/b
MTO Adult Item Table
Page F-42
MENTAL HEALH – PANIC DISORDER (HPD) (50.0% of an MTO-like sample of NCS respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
HPD6_PD10
Did you have one of these attacks at any time in the past 12
NCS
months?
HPD6a_PD10 How recently – in the past month, between two and six
a
months ago, or more than six months ago?
HPD6b_PD10 How many weeks in the past 12 months did you have at least NCS
b
one attack?
HPD6c_PD10 And how many attacks in all did you have in the past 12
NCS
c
months?
HPD6d_PD10 How old were you the last time you had one of these attacks? NCS
d
HPD7_PD13
After having one of these attacks, did you ever have any of
NCS
the following experiences?
HPD7a_PD13 A month or more when you often worried that you might
NCS
a
have another attack?
HPD7b_PD13 A month or more when you worried that something terrible
NCS
b
might happen because of the attacks, like having a car
accident, having a heart attack, or losing control?
HPD7c_PD13 A month or more when you changed your everyday activities
NCS
c
because of the attacks?
HPD7d_PD13 A month or more when you avoided certain situations
NCS
d
because of fear about having another attack?
HPD8_PD17
Attacks of this sort can occur in three different situations. The NCS
first is when the attacks occur unexpectedly “out of the blue.”
The second is when a person has an unreasonably strong
fear. For example, some people have a terrible fear of bugs
or of heights or of being in a crowd. The third is when a
person is in real danger, like a car accident or a bank robbery.
The next question is about how many of your attacks
occurred in each of these three kinds of situations. Did you
ever have an attack that occurred unexpectedly “out of the
blue?”
HPD8a_PD17 About how many attacks in your lifetime occurred
NCS
a
unexpectedly “out of the blue?”
HPD9_PD18
About how many attacks in your lifetime occurred in situations NCS
where you were not in real danger, but where you had an
unreasonably strong fear of the situations?
MTO Adult Item Table
Page F-43
MENTAL HEALH – PANIC DISORDER (HPD) (50.0% of an MTO-like sample of NCS respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
HPD10_PD19 About how many attacks in your lifetime occurred in situations NCS
where you were in real danger?
HPD12_PD21 How old were you (when you had the attack/the first time
NCS
you had an attack) “out of the blue” for no obvious reason?
HPD13_PD22 How much did (this/these) unexpected “out of the blue”
NCS
attack(s) or worry about having another attack ever interfere
with either your work, your social life, or your personal
relationships – not at all, a little, some, a lot, or extremely?
HPD14_PD36 How many unexpected “out of the blue” attacks did you have
NCS
in the past 12 months?
HPD15a_PD3 How old were you the last time you had an unexpected “out
NCS
7a
of the blue” attack?
HPD15b_PD3 About how many weeks in the past 12 months did you have
NCS
7b
at least one of these attacks?
HPD16_PD38 How recently – in the past month, between two and six
months ago, or more than six months ago?
MENTAL HEALTH – GENERALIZED ANXIETY DISORDER (HGA) (57.8% of an MTO-like sample of NCS respondents screened into this module)
Question
Question
Sourec
Justification/Notes
Number
HGA1_G1
Earlier you mentioned having a time in your life when you
NCS
Because of the documented effects of neighborhood
INTRO 1
were "a worrier". The next questions are about that time.
mobility on general psychological distress, the
Looking at your booklet, what sorts of things were you
generalized anxiety disorder questions will serve to
worried or nervous or anxious about during that time?
evaluate occurrence of episodes over respondents’
HGA1_G1
Earlier you mentioned having a time in your life when you
NCS
lives as well as 12-month prevalence.
INTRO 2
were much more nervous or anxious than most other people.
The next questions are about that time. Looking at your
booklet, what sorts of things were you nervous or anxious
about during that time?
HGA1_G1
Earlier you mentioned having a period lasting one month or
NCS
INTRO 3
longer when you were anxious or worried most days. The
next questions are about that time. Looking at your booklet,
what sorts of things were you anxious or worried about
during that time?
MTO Adult Item Table
Page F-44
MENTAL HEALTH – GENERALIZED ANXIETY DISORDER (HGA) (57.8% of an MTO-like sample of NCS respondents screened into this module)
Question
Question
Sourec
Justification/Notes
Number
HGA2_G3
Do you think your (worry or anxiety/nervousness or
NCS
anxiety/anxiety or worry) was ever excessive or unreasonable
or a lot stronger than it should have been?
HGA3_G4
How often did you find it difficult to control your (worry or
NCS
anxiety/nerves or anxiety/anxiety or worry) -- often,
sometimes, rarely, or never?
HGA4_G4a
How often were you so nervous or worried that you could not NCS
think about anything else, no matter how hard you tried -often, sometimes, rarely, or never?
HGA5a_G5
NCS
What is the longest period of months or years in a row you
ever had when you were (worried or anxious/nervous or
anxious/anxious or worried) most days? (enter number)(enter
unit of time: months, years)
HGA5b_G5
HGA7a_G9a
Think of your worst period lasting (one month / six months)
NCS
or longer when you were (worried or anxious/nervous or
anxious/anxious or worried): During that episode, did you
often have any of the following associated problems:
Did you often feel restless, keyed up, or on edge?
HGA7b_G9b
Did you often get tired easily?
NCS
HGA7c_G9c
Were you often more irritable than usual?
NCS
HGA7d_G9d
Did you often have difficulty concentrating or keeping your
NCS
mind on what you were doing?
HGA7e_G9e
Did you often have tense, sore, or aching muscles?
NCS
HGA7f_G9f
Did you often have trouble falling or staying asleep?
NCS
HGA8a_G10a Did your heart often pound or race?
NCS
HGA8b_G10b Did you often sweat?
NCS
HGA8c_G10c Did you often tremble or shake?
NCS
HGA8d_G10d Did you often have a dry mouth?
NCS
HGA8e_G10e Were you sad or depressed most of the time?
NCS
HGA10a_G13 Did you often feel dizzy or lightheaded?
NCS
a
HGA10b_G13 Were you often short of breath?
NCS
b
HGA10c_G13 Did you often feel like you were choking?
NCS
c
HGA10d_G13 Did you often have pain or discomfort in your chest?
NCS
d
MTO Adult Item Table
Page F-45
MENTAL HEALTH – GENERALIZED ANXIETY DISORDER (HGA) (57.8% of an MTO-like sample of NCS respondents screened into this module)
Question
Question
Sourec
Justification/Notes
Number
HGA10e_G13 Did you often have pain or discomfort in your stomach?
NCS
e
HGA10f_G13 Did you often have nausea?
NCS
f
HGA10g_G13 Did you often feel that you were unreal?
NCS
g
HGA10h_G13 Did you often feel that things around you were unreal?
NCS
h
HGA10i_G13i Were you often afraid that you might lose control or go crazy? NCS
HGA10j_G13 Were you often afraid that you might pass out?
NCS
j
HGA10k_G13 Were you often afraid that you might die?
NCS
k
HGA10l_G13l Did you often have hot flushes or chills?
NCS
HGA10m_G1 Did you often have numbness or tingling sensations?
NCS
3m
HGA10n_G13 Did you often feel like you had a lump in your throat?
NCS
n
HGA10o_G13 Were you easily startled?
NCS
o
HGA11_G15
How much emotional distress did you ever experience
NCS
because of your (worry or anxiety/nervousness or
anxiety/anxiety or worry) – no distress, mild distress,
moderate distress, severe distress, or very severe distress?
HGA12_G17
How much did your (worry or anxiety/nervousness or
NCS
anxiety/anxiety or worry) ever interfere with either your work,
your social life, or your personal relationships – not at all, a
little, some, a lot, or extremely?
HGA12a_G17 How often were you unable to carry out your daily activities
NCS
a
because of your (worry or anxiety/nervousness or
anxiety/anxiety or worry) -- often, sometimes, rarely, or
never?
MTO Adult Item Table
Page F-46
MENTAL HEALTH – GENERALIZED ANXIETY DISORDER (HGA) (57.8% of an MTO-like sample of NCS respondents screened into this module)
Question
Question
Sourec
Justification/Notes
Number
NCS
HGA13_G26
Think of the very first time in your life you had an episode
lasting (one month / six months) or longer when (you were
worried or anxious most days/you were nervous or anxious
most days/you were anxious or worried most days) and also
had some of the other problems we just reviewed. Can you
remember your exact age?
HGA13a/b_G How old were you? or About how old were you?
NCS
26a/b
HGA14_G27
Did you have an episode of being (worried or anxious/nervous NCS
or anxious/anxious or worried), lasting at least one month or
longer, in the past 12 months?
HGA14b_G27 How many months in the past 12 months were you in an
NCS
b
episode of this sort?
HGA14c_G27 How old were you the last time you had one of these
NCS
c
episodes?
MENTAL HEALTH – INTERMITTENT EXPLOSIVE DISORDER (IED) (20.5% of an MTO-like sample of NCS respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
HIE1_IED3_
Earlier in the interview you mentioned having attacks of anger NCS
Intermittent explosive disorder is an impulse-control
INTRO 1
when all of a sudden you lost control and either broke or
disorder, which, like the anxiety disorder, will have ages of
smashed something of value or you hit or hurt someone. The
onset most likely prior to the beginning of MTO. We
next few questions are about those attacks. Approximately
anticipate that MTO will be shown to have a powerful effect
how many times in your life have you had an attack of this
in reducing the persistence and severity of impulse-control
sort, (READ SLOWLY) when you lost control and either broke
disorders, but that intervention effects will be lower among
something, hurt someone, or threatened to hurt someone?
participants with a history of pre-existing severe-persistent
highly comorbid disorders. This is why both entire life and
HIE1_IED3_I Earlier in the interview you mentioned having attacks of anger NCS
12-month histories are tested for.
NTRO 2
when all of a sudden you lost control and either broke or
smashed something of value or you threatened to hit or hurt
someone. The next few questions are about those attacks.
Approximately how many times in your life have you had an
attack of this sort, (READ SLOWLY) when you lost control and
either broke something or threatened to hurt someone?
MTO Adult Item Table
Page F-47
MENTAL HEALTH – INTERMITTENT EXPLOSIVE DISORDER (IED) (20.5% of an MTO-like sample of NCS respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
HIE1_IED3_I Earlier in the interview you mentioned having attacks of anger NCS
NTRO 3
when all of a sudden you lost control and broke or smashed
something of value. The next few questions are about those
attacks. Approximately how many times in your life have you
had an attack of this sort, (READ SLOWLY) when you lost
control and either broke or smashed something?
HIE1_IED3_I Earlier in the interview you mentioned having attacks of anger NCS
NTRO 4
when all of a sudden you lost control and hit or hurt
someone. The next few questions are about those attacks.
Approximately how many times in your life have you had an
attack of this sort, (READ SLOWLY) when you lost control and
either hurt someone or threatened to hurt someone?
HIE1_IED3_I Earlier in the interview you mentioned having attacks of anger NCS
NTRO 5
when all of a sudden you lost control and threatened to hit or
hurt someone. The next few questions are about those
attacks. Approximately how many times in your life have you
had an attack of this sort, (READ SLOWLY) when you lost
control and threatened to hurt someone?
HIE2_IED5
Did these anger attacks sometimes occur without a good
NCS
reason?
HIE3_IED5a
Did the attacks sometimes occur in situations where most
NCS
people would not have had an anger attack?
HIE3a_IED5
During those attacks, did you sometimes get a lot more angry NCS
b
than most people would have been in the same situation.
HIE4_IED6
Did you have times before these attacks when you felt such a NCS
strong impulse to let loose or blow-up that you couldn't resist
it no matter how hard you tried?
HIE5_IED7
How often was your anger out of control during your typical
NCS
attacks -- all of the time, most of the time, sometimes, rarely,
or never?
HIE6_IED9
Some people only have anger attacks when they drink alcohol NCS
or use drugs. Did your anger attacks usually occur when you
had been drinking or using drugs?
HIE6a_IED9
Did you ever have anger attacks when you had not been
NCS
a
drinking or using drugs?
MTO Adult Item Table
Page F-48
MENTAL HEALTH – INTERMITTENT EXPLOSIVE DISORDER (IED) (20.5% of an MTO-like sample of NCS respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
HIE7_IED11
Some people only have anger attacks when they are sad or
NCS
depressed. Did your anger attacks usually occur during
periods of time when you were sad or depressed?
HIE7a_IED1
Did you ever have anger attacks at times you were not sad or NCS
1a
depressed?
HIE8_IED13
Think about all the things you ever damaged or broke during
NCS
your anger attacks. What is the approximate combined repair
cost or replacement value of all these things?
HIE9_IED15
About how many times during your anger attacks did you
NCS
ever hurt someone badly enough that they needed medical
attention?
HIE10_IED1
How much did your anger attacks ever interfere with either
NCS
6
your work, your social life, or your personal relationships -not at all, a little, some, a lot, or extremely?
HIE11_IED1
How often did you feel guilty or embarrassed or regretful in
NCS
7
the days or weeks after your attacks -- all of the time, most of
the time, sometimes, rarely, or never?
HIE12_IED1
Think of the very first time in your life you had an anger
NCS
8
attack. Can you remember your exact age when that attack
occurred?
HIE12a/b_IE How old were you? or About how old were you?
NCS
D18a/b
HIE13a_IED
How many anger attacks did you have in the past 12 months? NCS
22
HIE13a_IED
How old were you the last time you had an anger attack?
NCS
22a
HIE14_IED2
About how many weeks in the past 12 months did you have
NCS
3
at least one of these attacks?
HIE15_IED2
And how many attacks in total did you have during the past
NCS
4
twelve months?
MTO Adult Item Table
Page F-49
MENTAL HEALTH – CRIME VICTIMIZATION & POST-TRAUMATIC STRESS DISORDER (HCV) (75.8% of an MTO-like sample of NCS respondents
screened into this module)
Question
Question
Source
Justification/Notes
Number
HCV Module Overall
HCV1_PT1
In the next part of the interview, we ask about very stressful
NCS
These questions from the NCS module on PTSD ask about
events that might have happened in our life. First, did you
experiences with having been beaten up by one’s parents as
ever participate in combat, either as a member of a military,
a child, and other experiences with violence. However, the
or as a member of an organized non-military group?
NCS questions in the NCS do not ask about some of the
HCV2_PT8
Were you ever involved in a life-threatening automobile
NCS
follow-up details (such as police response) that are of
accident?
interest to us for the long-term MTO survey. As such, the
HCV3_PT9
Did you ever have any other life-threatening accident,
NCS
module adds measures from other surveys (see below).
including on your job?
HCV4_PT10
Were you ever involved in a major natural disaster, like a
NCS
Given that exposure to crime is an important mechanism
devastating flood, hurricane, or earthquake?
through which MTO may affect mental health outcomes of
HCV5_PT11
Were you ever in a man-made disaster, like a fire started by a NCS
participating adults – and in fact is the most important
cigarette, or a bomb explosion?
stated reason why MTO families signed up for the program
HCV6_PT12
Did you ever have a life-threatening illness?
NCS
– these questions will examine individual crime victimization
HCV7_PT13
As a child, were you ever badly beaten up by your parents or
NCS
experience, including information about the circumstances
the people who raised you?
and location of the event as well as the offender.
HCV8_PT14
Were you ever badly beaten up by a spouse or romantic
NCS
Importantly, in addition to questions about general violence
partner?
victimization these questions include items specific to
HCV9_PT15
Were you ever badly beaten up by anyone else?
NCS
violence committed by people known to the respondent, as
HCV10_PT16 Were you ever mugged, held up, or threatened with a
NCS
well as questions intended to capture sexual violence.
weapon?
HCV11_PT17 The next two questions are about sexual assault. The first is
NCS
These questions also include a detailed assessment of
about rape. We define this as someone either having sexual
traumatic life events as well as a separate battery of
intercourse with you or penetrating your body with a finger or
nontraumatic stressful life events. We anticipate that some
object when you did not want them to, either by threatening
of these events will be less prevalent among respondents in
you or using force, or when you were so young that you
the MTO intervention than control groups.
didn’t know what was happening. Did this ever happen to
you?
HCV12_PT18 Other than rape, were you ever sexually assaulted, where
NCS
YCV12-15 & 21-22
someone touched you in appropriately, or when you did not
Because crime, safety, and victimization are important in
want them to?
their own right, and because of the implications they have
HCV13
Have you ever been chased when you thought the person
PHDCN
on a number of other important outcomes, including mental
chasing you would hurt you?
and physical health, these questions expand on those
HCV14
Have you ever been hit, slapped, punched or beaten up, even PHDCN
Interim items related to criminal victimization. The PTSD
if you were not beaten up very badly?
questions in the NCS also do not ask about experiences with
HCV15
Has anyone ever stolen your purse, wallet, or snatched your
Interim,
property crime victimization.
jewelry?
modified
MTO Adult Item Table
Page F-50
MENTAL HEALTH – CRIME VICTIMIZATION & POST-TRAUMATIC STRESS DISORDER (HCV) (75.8% of an MTO-like sample of NCS respondents
screened into this module)
Question
Question
Source
Justification/Notes
Number
HCV16
Did anyone ever try to break into your home?
Interim,
modified
HCV17_PT20 Did someone very close to you ever die unexpectedly; for
NCS
example, they were killed in an accident, murdered,
committed suicide, or had a fatal heart attack at a young age?
HCV18_PT21 Did you ever have a son or daughter who had a lifeNCS
threatening illness or injury?
HCV19_PT22 Did anyone very close to you ever have an extremely
NCS
traumatic experience, like being kidnapped, tortured or
raped?
HCV20_PT22 When you were a child, did you ever witness serious physical
NCS
_1
fights at home, like when your father beat up your mother?
HCV21_PT23 Did you ever see someone being badly injured or killed, or
NCS
unexpectedly see a dead body?
HCV22_PT27 Did you ever experience any other extremely traumatic or life- NCS
threatening event that I haven’t asked about yet?
HCV23_PT55 Briefly, what was the one most traumatic event that you have NCS
a
not told me about?
HCV24
You said you had been [crime experience]. When was the
PHDCN
last time this happened? (Was this within the past 12
months? Was this within the past 6 months?)
HCV25
Were the police informed, or did they find out about this
NCVS
incident in any way?
HCV26
As far as you know, was anyone arrested or were charges
NCVS
brought against anyone in connection with this incident?
HCV27
You said you had been [violent crime experience] during the
PHDCN
past 12 months. The last time this happened, where did it
happen?
HCV27a
The last time this happened, who did this to you?
PHDCN
HCV28a
Please tell me if any of the following this have happened to
Interim,
anyone who lived with you during the past 6 months.
modified
Was anyone’s purse, wallet, or jewelry snatched from them?
HCV28b
Was anyone threatened with a knife or gun?
Interim,
modified
HCV28c
Was anyone beaten up or assaulted?
Interim,
modified
MTO Adult Item Table
Page F-51
MENTAL HEALTH – CRIME VICTIMIZATION & POST-TRAUMATIC STRESS DISORDER (HCV) (75.8% of an MTO-like sample of NCS respondents
screened into this module)
Question
Question
Source
Justification/Notes
Number
HCV28d
Was anyone stabbed or shot?
Interim,
modified
HCV29_PT62 Let me review. You experienced (NUMBER) (EVENT). After
NCS
an experience like this, people sometimes have problems like
upsetting memories or dreams, feeling emotionally distant or
depressed, trouble sleeping or concentrating, and feeling
jumpy or easily startled. Did you have any of these reactions
after (either / any) (EVENT) of these experiences?
HCV30_PT64 Of the [experiences you mentioned to me / NUMBER times
NCS
(EVENT TYPEs) happened] which one caused you the most
problems like upsetting memories or dreams, feeling
emotionally distant, trouble sleeping or concentrating, or
feeling jumpy or easily startled. That is, which one
experience caused the largest number or most severe
problems?
HCV30a_PT6 How old were you when that (happened / started)?
NCS
4a
HCV31_PT67 [FOR ONGOING EVENTS] During the period of time when
NCS
(WORST EVENT) was happening repeatedly, did you ever feel
terrified or very frightened?
[ALL OTHERS] Were you terrified or very frightened at the
time (WORST EVENT)?
HCV31a_PT6 Did you feel helpless?
NCS
7a
HCV31b_PT6 Did you feel shocked or horrified?
NCS
7b
HCV31c_PT6 Did you feel numb?
NCS
7c
HCV32_PT68 In the weeks, months, or years after the (event / this
NCS
experienced ended / WORST EVENT), did you try not to think
about it (what happened)?
HCV33_PT69 Did you purposely stay away from places, people, or activities NCS
that reminded you of (it / the event / this experience/ WORST
EVENT)?
HCV34_PT70 Were you ever unable to remember some important parts of
NCS
what happened?
MTO Adult Item Table
Page F-52
MENTAL HEALTH – CRIME VICTIMIZATION & POST-TRAUMATIC STRESS DISORDER (HCV) (75.8% of an MTO-like sample of NCS respondents
screened into this module)
Question
Question
Source
Justification/Notes
Number
HCV35_PT71 Did you lose interested in doing things you used to enjoy?
NCS
HCV36_PT72 Did you feel emotionally distant or cut-off from other people?
NCS
HCV37_PT73 Did you have trouble feeling normal feelings like love,
NCS
happiness, or warmth towards other people?
HCV38_PT74 Did you feel you had no reason to plan for the future because NCS
you thought it would be cut short?
HCV39_PT86 Did you ever have repeated unwanted memories of (it / the
NCS
event / this experience / WORST EVENT) – that is, you kept
remembering it even when you didn’t want to?
HCV40_PT87 Did you ever have repeated unpleasant dreams about (it / the NCS
event / this experience / WORST EVENT)?
HCV41_PT88 Did you have flashbacks – that is, suddenly act or feel as if (it NCS
/ the event / this experience / WORST EVENT) were
happening all over again?
HCV42_PT89 Did you get very upset when you were reminded of (it / the
NCS
event / this experience / WORST EVENT)?
HCV43_PT90 When you were reminded of (it / the event / this experience / NCS
WORST EVENT), did you ever have physical reactions like
sweating, your heart racing, or feeling shaky?
HCV44_PT01 During the time (this event / this experience / WORST
NCS
2
EVENT) affected you most, did you have trouble falling or
staying asleep?
HCV45_PT10 Were you more irritable or short-tempered than you usually
NCS
3
are?
HCV46_P104 Did you have more trouble concentrating or keeping your
NCS
mind on what you were doing?
HCV47_PT10 Were you much more alert or watchful, even when there was
NCS
5
no real need to be?
HCV48_PT10 Were you more jumpy or easily startled by ordinary noises?
NCS
6
HCV49_PT11 You had quite a few reactions, such as (FIRST KEY PHRASE).
NCS
0
For about how many days, weeks, months, or years did you
HCV49a_PT1 continue to have any of these reactions? (enter number)
(enter unit of time: days, weeks, months, years)
10
MTO Adult Item Table
Page F-53
MENTAL HEALTH – CRIME VICTIMIZATION & POST-TRAUMATIC STRESS DISORDER (HCV) (75.8% of an MTO-like sample of NCS respondents
screened into this module)
Question
Question
Source
Justification/Notes
Number
HCV50_PT11 Think of the time when these reactions were most frequent
NCS
3
and intense. How often did they occur – less than once a
month, one or two times a month, three to five times a
month, six to ten times a month, or more than ten times a
month?
HCV51_PT11 How much distress did these reactions cause you – none,
NCS
4
mild, moderate, severe, or very severe distress?
HCV52_PT11 How much did these reactions disrupt or interfere with your
NCS
5
normal, daily life – not at all, a little, some, a lot, or
extremely?
HCV53_PT26 (RB) The next question is about whether in the past 12
NCS
1
months you had any of these reactions associated with any
traumatic event that ever happened to you in your entire life.
Did you have any reactions of this sort over the past 12
months?
HCV54_PT26 About how many weeks altogether in the past 12 months did
NCS
3
you have any of these reactions?
HCV55_PT26 Please think of the 30-day period in the past 12 months when NCS
9
these reactions to [WORST 12-MONTH EVENT / these events
/ these experiences] were most frequent and intense. During
that month, did you lose interest in doing things you used to
enjoy?
HCV56_PT27 Did you feel emotionally distant or cut off from other people
NCS
0
during that month?
HCV57_PT27 Did you have trouble feeling normal things like love,
NCS
1
happiness, or warmth toward other people?
HCV58_PT27 Did you feel you had no reason to plan for the future because NCS
2
you thought it would be cut short?
HCV59_PT27 Did you have any trouble falling or staying asleep during that
NCS
3
month?
HCV60_PT27 Were you more jumpy or more easily startled by ordinary
NCS
4
noises?
HCV61_PT27 Did you purposely stay away from places, people or activities
NCS
5
that reminded you of [WORST 12-MONTH EVENT] / these
events)?
MTO Adult Item Table
Page F-54
MENTAL HEALH – SERVICES
Question
Question
Number
HSR1
In the past 12 months have you received any sort of professional
counseling or therapy for problems with your emotions, nerves,
mental health, or use of alcohol or drugs?
HSR1a
What kind of professional did you see?
Psychiatrist
Psychologist
Social Worker
Mental Health Counselor
Psychotherapist
Marriage or Family Counselor
Drug or Alcohol Counselor
Primary Care Doctor (e.g., Internist, Family Doctor, GP)
Other Medical Doctor (e.g., Cardiologist, Gynecologist)
Other Health Care Provider (e.g., Nurse, Occupational Therapist)
Religious Counselor (e.g., Minister, Priest, Rabbi)
Healer (e.g., Herbalist, Chiropractor, Spiritualist)
Any other kind of professional
HSR2
How many sessions of psychological counseling or therapy have
you received in the past 12 months?
HSR3
How many minutes did [this/these session(s)] last (on average)?
HSR4
In the past 12 months have you taken a prescription medicine for
problems with your emotions, nerves, mental health, or use of
alcohol or drugs?
HSR5
Who wrote the prescription for you?
HSR6
About how many days out of 365 in the past year did you make a
prescription medication for these problems?
HSR7
Was there a time in the past 12 months when you felt that you might
need to see a professional because of problems with your emotions,
nerves, mental health, or your use of alcohol or drugs?
HSR8
What were your reasons for not seeing a professional?
PARENT REPORT ON YOUTH
Question
Question
Number
MTO Adult Item Table
Source
Justification/Notes
NCS
An important way in which neighborhood context can influence
mental health is by improving access to treatment. This is true
even when, as in MTO, experimental subjects did not receive any
expansion in their health insurance coverage, as health insurance
is a surprisingly weak determinant of obtaining treatment for
mental health problems. This is especially true among mothers of
school-aged children, as the vast majority of the MTO participants
are, as school-based human services professionals play a major
role in promoting free or low-cost treatment for such individuals.
In order to evaluate the role played by expanded treatment and
increased treatment quality in accounting for MTO effects on the
mental health of respondents, these questions serve as an
assessment of mental health treatment. Included are questions
about the occurrence of general medical, mental health specialty,
human services, and complementary-alternative medical treatment
of mental and substance use disorders, as well as about the content
and intensity of such treatment.
NCS
NCS
NCS
NCS
NCS
NCS
NCS
NCS
Source
Justification/Notes
Page F-55
PARENT REPORT ON YOUTH
Question
Question
Number
HPY1
At the beginning of this interview we asked you about household
members who lived with you at the time you applied to be in this
study about 10 or more years ago. Here we want to know more
about the schooling of the children that were living with you at that
time.
**SEQUENCE WILL BE COMPLETED FOR EACH CHILD
WHO WAS IN THE HOUSEHOLD AT BASELINE WHO ARE
STILL IN THE HOUSEHOLD AT TIME OF FOLLOW-UP.
What is the highest grade or year of school [CHILD] has ever
completed?
HPY2
Has (he/she) received a regular high school diploma? Do not
include a GED
HPY3
Has (he/she) received a GED?
HPY3a
Is [CHILD] currently enrolled in college?
HPY4
When was [CHILD] last enrolled in high school?
HPY5
Is [CHILD] in school now?
HPY6
Why doesn’t [CHILD] attend school?
HPY7
Has (he/she) received a GED?
HPY8
When was [CHILD] last enrolled in high school?
HPY9
What is the full name of the school [CHILD] (is attending /most
recently attended)?
HPY10
Is/was this school a…[Regular Public School; Magnet Public
School; Charter Public School; Vocational Public School; Regular
Private School; Religious or Parochial School; Special Education
School; Enrichment/gifted & Talented School or Program; Other
Special Program or School (Specify)]
HPY11
Where is this school located?
HPY12
For which grades did child attend this school?
REPEAT HPY16a-HPY16d FOR EACH SCHOOL ATTENDED
HPY13
Has [CHILD] ever repeated a grade?
HPY14
Which grades did [CHILD] repeat?
HPY14a
IF YES: Did [CHILD] repeat [GRADE] in same school?
HPY15
Has [CHILD] ever been suspended or expelled?
HPY15a
IF YES: Has this happened during the past 2 years?
HPY16a
Source
Justification/Notes
MTO Interim
These questions measure the child’s educational attainment to date
and whether he/she is currently enrolled in school. Combined
with information on the child’s age and school history (see below),
the questions permit analysis of educational progress, an important
child outcome.
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
MTO Interim
This sequence obtains the child’s/youth’s school history. These
will be repeated for all the schools attended since random
assignment in the MTO program. Data on school history are
needed in order to understand whether school changes followed
the residential location changes brought about by the MTO
intervention. If, as hypothesized, schools in low-poverty
neighborhoods will be important in shaping the educational
attainment and economic prospects of MTO children and youth, it
is necessary to know whether they attended those schools or
whether (for a variety of reasons) they were schooled elsewhere
(and where). Identification of schools will allow us to link to rich
data on school performance and student body socioeconomic
characteristics in the school(s) the child/youth is attending/has
attended, factors which might determine the extent to which
schools mediate MTO impacts. Grade retention is a major aspect
of educational progress. However, it may reflect not only the
child’s/youth’s educational efforts and academic achievement but
also differences in the policy and standards of schools located in
lower-poverty neighborhoods, compared to those in higherpoverty neighborhoods.
What is the full name of the school [CHILD] attended before
[SCHOOL NAME LAST MENTIONED]?
MTO Adult Item Table
Page F-56
PARENT REPORT ON YOUTH
Question
Question
Number
HPY16b
Was this school a…[Regular Public School; Magnet Public School;
Charter Public School; Vocational Public School; Regular Private
School; Religious or Parochial School; Special Education School;
Enrichment/gifted & Talented School or Program; Other Special
Program or School (Specify)]
HPY16c
Where was this school located? Can you give me the name of the
street on which it was located? PROBE: What was the nearest
cross-street? What city is that?
HPY16d
For which grade(s) did [CHILD] attend this school?
HPY16e
REPEAT HPY16a-HPY16d FOR EACH SCHOOL ATTENDED
HPY16f
Were there any other schools that [CHILD] attended between
[BEGINNING OF GRADE HISTORY] and [HIGHEST GRADE
ATTENDED IN J12]?
HPY17
During the past two years, has anyone from [CHILD’S] school
asked someone to come in and talk about problems [CHILD] was
having with schoolwork or behavior?
HPY18
During the past 2 years, has [CHILD] gone to a special class for
gifted students or done advanced work in any subjects?
HPY19a
During the past 2 years, has [CHILD] gone to a special class or
school or gotten special help in school for learning problems?
HPY19b
(During the past 2 years, has [CHILD] gone to a special class or
school or gotten special help in school for) behavioral or emotional
problems?
How often has [CHILD] received any special services for these
problems -- almost every day, once a week, once a month, a few
times a year, or only once or twice in the past two years?
Now I’d like to ask you about your involvement in your children’s
schooling. How satisfied are you with the education that [CHILD]
has received up to now? Are you very satisfied, somewhat satisfied,
or not at all satisfied?
HPY20
HPY21
MTO Adult Item Table
Source
Justification/Notes
MTO Interim
The child’s/youth’s academic track (both opportunities for and
involvement in advanced school work) may be affected by moves
to low-poverty neighborhoods. Better schools in more affluent
neighborhoods are more likely to offer advanced classes and
provide more rigorous preparation.
These questions measure whether the child/youth has been
involved in formal special education programming in school and
the intensity of services received. Moving to a low-poverty
community’s school may require adjustments and remedial
intervention to effect the transition. But recent research also
indicates that minority children in predominantly white schools
tend to be over-assigned to special education.
MTO Interim
NELS
These questions assess the degree to which parents are involved in
their child/children’s education. The MTO treatment may affect
the adult’s concern and level of parental support for education
(due to different social norms and improved mental health, among
Page F-57
PARENT REPORT ON YOUTH
Question
Question
Number
HPY22a
In the past 12 months, have you or another adult who lives with you
gone to a general meeting or school event at your [CHILD’S]
school, like a back-to-school night, parent/teacher organization
meeting or sports event?
HPY22b
HPY23a
HPY23b
HPY23c
HPY23d
HPY23e
HPY24
HPY25
HPY26
HPY27a
HPY27b
In the past 12 months, have you or another adult who lives with you
been a volunteer or worked at your [CHILD’S] school, been on a
school committee or club outside of school?
The next questions are about this child’s behavior. I will read a
series of statements, and for each , please tell me if the statement is
not true, somewhat true, or very true of [CHILD].
This child is generally obedient, usually does what adults request.
(This child) has many worries, often seems worried.
(He/She) is often unhappy, depressed, or tearful.
(He/She) gets along better with adults than with others his/her own
age.
(He/She) sees tasks through to the end, has a good attention span.
Overall, do you think [CHILD] has difficulties in one or more of the
following areas: emotions, concentration, behavior or being able to
get along with other people? Would you say he/she has severe
difficulties, definite difficulties, minor difficulties, or no difficulties
in one or more of these areas?
About how long has it been since [CHILD] last saw or talked to a
doctor or other health care professional about (his/her) health?
Would you say 6 months or less, More than 6 months, but not more
than 1 year ago, More than 1 year, but not more than 3 years ago,
More than 3 years, or Never?
During the past [TIME SINCE RANDOM ASSIGNMENT], that is,
since [DATE OF RANDOM ASSIGNMENT], has there ever been
anytime lasting a month or more when [CHILD] did not live with
you?
When was the first time [CHILD] lived somewhere else – in what
month and year did (he/she) begin to live away?
And, when did he / she come back to live with you?
MTO Adult Item Table
Source
Justification/Notes
MTO Interim
other things), which may affect children’s educational outcomes.
SDQ Parent
report for youth
11-17
This brief series serves as a set of behavioral screening questions.
SDQ
SDQ
SDQ
SDQ
NHIS99,
modified
This question measures preventive health care behavior, an
important mediator of child/youth health that may change with
MTO moves.
New Chance
These questions measure where the child has lived since random
assignment (if not with mother) and why. Literature suggests that:
(a) decreased family stability due to mobility leads to increased
probability of having children put in foster care; (b) Increased
safety equates to less violence in the home for children and a
reduced probability of having children put in foster care; or (c)
move to a neighborhood where schools, police, neighbors are
New Chance
New Chance
Page F-58
PARENT REPORT ON YOUTH
Question
Question
Number
HPY27c
Where was (he/she) living during that time? [Maternal grandparents;
other maternal relatives; child’s own father; paternal relatives; foster
home; alone / with friends / with partner; in school / college; in jail;
in the military; in the hospital; runaway; with step parent; with other
relative; in Job Corps; adopted; just moved back with R; shelter;
other]
HPY27d
Why was [CHILD] living (with/in) [ARRANGEMENT]? [Personal
reasons = behavioral problems; problems of mother (drugs, alcohol,
in jail); health problems of child; health problems of mother;
financial problems of mother; unsuitable housing arrangement,
homelessness; child taken away by state, put in foster home; mother
could not care for child; Permanent alternative arrangements =
thought child would be better off with friends or relatives; put child
up for adoption; child wanted to live with father; father awarded
custody; Age of child issues = child is grown adult; child is away at
school; Other = R does not know where child is; child in jail;
immigration related issue; reason related to move; child kidnapped;
shared custody; family just helping out; away at camp; other]
ADULT REPORT ON OTHER HOUSEHOLD MEMBERS
Question
Question
Number
HHO1
These next questions ask about other members of your household,
their education and employment, their marital status, whether they
have children, and their health. [Interviewers will ask this series of
questions for each person age 18+ living in the household]
Is this person in school now?
HHO2
Has (he/she) graduated from high school or does (he/she) have a
GED?
HHO3
Has (he/she) ever attended any college?
HHO4
Is (he/she) now working full-time or part-time?
HHO5
Does he/she have a physical health problem that keeps him/her from
doing normal activities like walking, getting dressed, household or
working?
HHO6
Does (he/she) have any chronic physical disability like cancer, a
heart problem or any other serious health problem?
HHO7
(Does (he/she) have an) Alcohol or drug problem?
MTO Adult Item Table
Source
Justification/Notes
New Chance
more likely to call CPS if there is a problem increases the
probability of children ending up in foster care. Furthermore, with
the huge costs associated with foster care (avg. cost per child per
year = $22,000 (1995)), a big effect here either way will have
policy implications.
New Chance
Source
Justification/Notes
MTO baseline
These items, modeled on a section of the National Comorbidity
Survey, serve to measure the burden of other household members
on respondents. These questions assess financial, caregiver, and
psychological burden stemming from other household members.
MTO baseline
Original
MTO baseline
NCS, ModifiedFamily Burden
NCS, ModifiedFamily Burden
NCS, ModifiedFamily Burden
Page F-59
ADULT REPORT ON OTHER HOUSEHOLD MEMBERS
Question
Question
Number
HHO8
(Does (he/she) have) Depression or other serious chronic mental
health problem?
HHO9a
Has he/she smoked a cigarette in the past 30 days?
HHO9b
When he/she smoked a cigarette during the past 30 days, how many
cigarettes did he/she usually smoke each day?
HHO10
What is (his/her) marital status?
HHO11
How many children has (he/she) had?
HHO12
In what year was (his/her) (first) child born?
HHO13
During the prior 12 months, has (he/she) been arrested, convicted of
a crime or put in jail? [check all that apply]
Arrested; Convicted; Put in jail; Neither
RELATIONSHIPS & PARENTING
Question
Question
Number
HRL1
In this next section, I am going to ask you about your adult
relationships and parenting. Are you currently married or in a
serious relationship?
HRL2
How long have you been married or in this relationship? Less than a
year; About 2 years; More than 2 years
HRL3
About how many romantic relationships did you have in the past 12
months that lasted for at least one month?
HRL3a
I just need to have a range. Can you tell me if it was… (1-5
relationships, 6-10 relationships, 11-15 relationships, or more than
15 relationships?)
HRL4
Now I’m going to ask you a few questions about your current
relationship.
All things considered, on a scale from 1 to 7, where 1 is “completely
unhappy” and 7 is “completely happy”, how happy are you with
your current relationship?
HRL5a
HRL5b
The following statements describe the way some people feel about
their spouse or partner, and their relationship in general. Please
indicate whether each of the following happens all of the time, most
of the time, some of the time, or none of the time.
Our arguments get very heated.
My partner/spouse and I have similar views about what is important
in life.
MTO Adult Item Table
Source
Justification/Notes
NCS, ModifiedFamily Burden
Original
Original
MTO baseline
MTO baseline
MTO baseline
Original
Source
Justification/Notes
Original
There is a long-standing literature documenting influences on
marriage, marital stability and adult relationship quality and mixed
indications of whether living in disadvantaged neighborhoods
affects marriage. MTO provides an opportunity to potentially
unpack confounds of neighborhood disadvantage with individual
level or couple disadvantage and marriage. MTO-induced moves
to lower-poverty areas could improve marriage rates directly, by
expanding the pool of marriageable men or indirectly by
improving mental health or economic self-sufficiency, both of
which can affect search behavior, or increase attractiveness to
potential partners, in the marriage market. Alternatively, any
resulting increase in economic self-sufficiency among MTO
experimental group respondents might result in lower rates of
coupling or marriage, by reducing the need for economic support
by another adult in the household.
Original
FF
FF
NSFH
NSFH / FF /
NLSY, modified
As a mediator of impacts on adult or youth outcomes: Marriage
might foster better mental health as much as mental health might
foster marriage. There is also a growing literature on the positive
associations between growing up with two parents who and youth
development.
NSFH / FF /
NLSY, modified
Page F-60
RELATIONSHIPS & PARENTING
Question
Question
Number
HRL5c
I am satisfied with the way we handle our problems and
disagreements.
HRL5d
My partner/spouse expresses love and affection toward me.
HRL6
HRL7
HRL8
HRL9
HRL9a
HRL10
HRL10a
Now we are going to ask a set of questions about CHILD (preloaded, randomly selected child aged 10 to 20, lived in household at
baseline, and currently living in household).
In the past week, have you and [CHILD] talked about things he/she
is doing at school, school work or grades?
How often did someone help [CHILD] with his/her homework?
Would you say five or more times a week, 3 to 4 times a week, 1 to
2 times a week, less than once a week, or never?
How often do you or another adult in the household check to make
sure CHILD has completed his/her homework? Less than once a
month, about once a month, a few times a month, or at least a few
times a week?
During this school year, have you or another adult in your household
taken it upon yourself to contact (CHILD’s) teacher or school for
any reason having to do with (CHILD)?
Why did you contact (CHILD)’s school? CODE ALL THAT
APPLY. PROBE: Anything else? [to report an absence or tardiness;
to discuss problems the child is having at school; to request special
placement or services; to request evaluation by a specialist; to
request a specific teacher; to check on CHILD’s progress; to ask
about homework problems; other (specify)]
Children sometimes do things that are wrong, disobey, or make their
parents angry. We would like to know what you have done when
your [SAY AGE OF CHILD] year old child did something wrong or
made you upset or angry. I am going to read a list of things you
might have done in the past year and I would like you to tell me
whether you have: done it once in the past year, done it twice in the
past year, 3-5 times, 6-10 times, 11-20 times, or more than 20 times
in the past year. If you haven’t done it in the past year but have done
it before that, I would like to know this, too.
Explain why something was wrong?
MTO Adult Item Table
Source
Justification/Notes
NSFH / FF /
NLSY, modified
NSFH / FF /
NLSY, modified
Add Health
ECLS-K 5th
grade
PHDCN, Wave 3
ECLS-K 5th
grade
One candidate mediating mechanism proposed for explaining
MTO’s effects on children, particularly on youth, is whether MTO
changes parental investments in their children. Additionally,
changes in mental health or marital status could independently or
synergistically affect parenting behavior. MTO adults might also
feel safer in less distressed neighborhoods, or feel less distressed
because of fewer day-to-day hassles, all of which could potentially
improve physical and emotional energy toward better parenting.
Parents also might be happier and feel closer to their children or
more empowered to improve their children’s lives.
ECLS-K 5th
grade
ECLS-K 5th
grade, revised
Straus ParentChild Conflict
Tactic Scale
ECLS-K 5th
grade, revised
Straus ParentChild Conflict
Tactic Scale
Page F-61
RELATIONSHIPS & PARENTING
Question
Question
Number
HRL10b
Sent [CHILD] to [his/her] room, took away privileges or grounded
[him/her]?
HRL10c
Called [CHILD] dumb or lazy or some other name like that, or
threatened to hit [him/her], but did not actually do it?
HRL10d
Shouted, yelled, screamed, swore or cursed at [CHILD]?
HRL10e
Said you would send [CHILD] away or kick [CHILD] out of the
house?
HRL10f
Spanked or hit [CHILD]?
HRL11
Is [CHILD] allowed to be in public places without adult
supervision?
In the last month [if on vacation: in which s/he was in school], after
school, has [CHILD] always come directly to your home and stayed
home until dinner time?
In the last month [if on vacation: in which s/he was in school], how
often has s/he done that?
Where is this [CHILD] usually in the evenings?
Please tell me whether you make rules about how late [CHILD] can
stay out at night, or does [CHILD] decide for him/herself?
Does [CHILD] have a curfew or set time to be home on school
nights?
Does [CHILD] have a curfew on weekend nights?
In a typical week, how late does [CHILD] stay out on school nights
(Monday to Thursday)?
HRL12
HRL13
HRL14
HRL15
HRL16
HRL17
HRL18
MTO Adult Item Table
Source
Justification/Notes
ECLS-K 5th
grade, revised
Straus ParentChild Conflict
Tactic Scale
ECLS-K 5th
grade, revised
Straus ParentChild Conflict
Tactic Scale
ECLS-K 5th
grade, revised
Straus ParentChild Conflict
Tactic Scale
ECLS-K 5th
grade, revised
Straus ParentChild Conflict
Tactic Scale
ECLS-K 5th
grade, revised
Straus ParentChild Conflict
Tactic Scale
PHDCN
PHDCN
PHDCN
MTO Interim
NLSY97
PHDCN
PHDCN
NELS88
Page F-62
RELATIONSHIPS & PARENTING
Question
Question
Number
HRL19
How many of [CHILD’s] close friends do you know by sight and by
first and last name?
DECISION MAKING
Question
Question
Number
HDM1
Are there any big expenses that you think you will have to pay for in
the next five to ten years, such as, such as educational expenses,
purchase of a new car, health care costs, support for other family
members, or anything else?
HDM2
How much thought have you given to how you will meet those
expenses?
HDM3
Are you saving for those expenses now?
HDM4a
Suppose a relative of yours calls to say they just inherited some
money and part of it should be yours. Because of the way their
inheritance is being distributed, they can either send you some
money now, or a larger amount of money later, which they would
send to you on your next birthday. Suppose that you trust this
person to send what they promise, and that you do not expect to get
a birthday present from this relative other than this money.
Would you rather they mailed you $100 tomorrow or that they send
you $120 on your next birthday?
HDM4b
Suppose you get a letter from the government saying you are getting
an extra tax refund. You can choose between getting the refund
now, or a larger refund one month from now.
Would you rather they sent $100 tomorrow, or that they send $110
three months from now?
HDM4c
Now suppose the choice were between $100 now and $105 one
month from now. Would you rather they sent $100 tomorrow or
$105 one month from now?
HDM4d
Now suppose the choice were between $100 now and $101 one
month from now. Would you rather they sent $100 tomorrow or
$101 one month from now?
HDM4e
Now suppose the choice were between $100 now and $115 one
month from now. Would you rather they sent $100 tomorrow or
$115 one month from now?
MTO Adult Item Table
Source
Justification/Notes
PHDCN
Source
Justification/Notes
SCF modified
These questions gauge general attitudes toward the future and
propensity to plan.
Original
SCF modified
Original
This question is intended to uncover rates of time preference.
It is original to the MTO final evaluation. It is written to be
context-rich, and involve choices over modest gains. We propose
to ask ½ of respondents “option 1,” and the other ½ of respondents
“option 2.” In the first option, variation in the distance in time
between the survey date and the respondent’s next birthday will
generate variation in the ranges into which the respondent’s choice
brackets her discount rate. In the second option, we are working
with a fixed time frame.
Original
Original
Original
Original
Page F-63
DECISION MAKING
Question
Question
Number
HDM4f
Now suppose the choice were between $100 now and $120 one
month from now. Would you rather they sent $100 tomorrow or
$120one month from now?
HDM5
Suppose that a new company moves into your area and offers you a
part-time job that you would be willing and able to take for one
month. This company offers you two different ways of being paid.
The first way is a salary that would guarantee you $300. The second
way would tie your earnings to how well the company as a whole
does that month. The second way is possibly better paying, but the
income is less certain.
HDM5a
There is a 50-50 chance the second way would pay $600, and a 5050 chance that it would pay $200. Which way of getting paid would
you choose – earning $300 for sure, or an equal chance of earning
either $600 or $200?
HDM5b
Now suppose the chances were 50-50 that the second way would
pay $600, and a 50-50 chance that it would pay $150. Which way
of getting paid would you choose – earning $300 for sure, or an
equal chance of earning either $600 or $150?
HDM5c
Now suppose the chances were 50-50 that the second way would
pay $600, and a 50-50 chance that it would pay $75. Which way of
getting paid would you choose – earning $300 for sure, or an equal
chance of earning either $600 or $75?
HDM5d
Now suppose the chances were 50-50 that the second way would
pay $600, and 50-50 chance that it would pay $240. Which way of
getting paid would you choose – earning $300 for sure, or an equal
chance of earning either $600 or $240?
HDM5e
Now suppose the chances were 50-50 that the second way would
pay $600, and 50-50 that it would pay $270. Which way of getting
paid would you choose – earning $300 for sure, or an equal chance
of earning either $600 or $270?
HDM6
How do you see yourself: Are you generally a person who is fully
prepared to take risks or do you try to avoid taking risks? If 0 means
you always avoid taking risks and 10 means you are always fully
prepared to take risks, where on a 0 to 10 scale would you place
yourself?
HDM7a
(RB) Now I want to ask you about trusting different groups of
people. First, thinking about people in your immediate family,
generally speaking would you say you can trust them a lot, trust
them some, trust them only a little or not trust them at all?
HDM7b
(RB) How about people in your neighborhood?
MTO Adult Item Table
Source
Justification/Notes
Original
HRS and PSID
modified
These questions are intended to uncover levels of risk aversion.
The risky job choice questions bracket responses by (approximate)
relative risk aversion coefficients of 0.13, 0.27, 0.50, 1.00, and
3.27, assuming CRRA utility.
HRS and PSID
modified
HRS and PSID
modified
HRS and PSID
modified
HRS and PSID
modified
HRS and PSID
modified
SEOP
This question gauges general, self-perceived attitudes toward risk.
GPSTS
These questions ask about trust.
GPSTS
Page F-64
DECISION MAKING
Question
Question
Number
HDM7c
(RB) How about other people in general?
HDM8a
(RB) Next, I m going to read a list of institutions. For each one,
please tell me whether you feel that you can trust them a lot, some,
only a little or not at all. First the police department in your area, do
you feel you can trust them a lot, some, only a little or not at all?
HDM8b
(RB) How about the public schools in your area?
HDM8c
(RB) How about the city or local government?
HDM9
Generally speaking, would you say that most people can be trusted
or that you can’t be too careful in life?
HDM10
How often do you lend money to friends: More than once a week,
about once a week, about once a month, or once a year or less?
HDM11
How often do you lend things you own to your friends?
[EXPERIMENTAL COMPONENT]
HDM12
Each respondent in the time preference experiment subgroup is
offered the following choice:
As part of our study of how MTO participants make choices, we are
pleased to be able to offer you a small amount of additional survey
compensation. This compensation is available in two forms. Either
a check for $20 that we will put in the mail tomorrow or a check for
$25 that we could put in the mail on your next birthday. Which
would you prefer -- $20 sent tomorrow, or $25 sent on your next
birthday?
Source
Justification/Notes
Original
GPSTS
GPSTS
GPSTS
GSS
GLSS
GLSS
Original
The proposed experimental component would offer similar
choices as the survey questions over time preference, but would be
for real stakes, to help generate an independent, and possibly more
credible, measure of the effects of MTO on decision making. A
randomly selected subset of MTO adults would participate in this
experiment.
This choice is designed to uncover rates of time preference. It is
original to the MTO final evaluation. It corresponds with the
survey question on time preference. Variation in the distance in
time between the survey date and the respondent’s next birthday
will generate variation in the ranges into which the respondent’s
choice brackets her discount rate.
CONTACT INFORMATION
MTO Adult Item Table
Page F-65
HCI1
To continue to help the government learn how to improve housing
programs, it is very important that we talk to people periodically to
see how things are going. Since people often move, we would like
to ask you for the names of friends or relatives who usually keep in
touch with you. We would contact these people only if we were
unable to reach you at your current phone number. We would ask
them only for your address and telephone information.
(IF NO CONTACT PERSON INFORMATION AVAIALBLE
FROM PREVIOUS CONTACTS: Please give me the name of three
people who do not live with you and who will know how to reach
you if we need to contact you again to verify this interview or to ask
a few additional questions.)
(IF CONTACT INFORMATION AVAILABLE: In the past you
gave us information on the following three people. I would like to
make sure that we have the most current information for them, and
that they are the best people to use to find you.)
Interviewer will collect/update name, relationship to respondent,
address and telephone number of up to three contact persons.
MTO Adult Item Table
MTO Interim
modified
Contact person information is collected for quality control and
other follow-up activities.
Page F-66
Appendix G:
Item by Item Justification
Youth Survey
National Bureau of Economic Research
University of Michigan – ISR
Appendices
HOUSEHOLD LISTING
Question
Question
Number
YHS1
INTERVIEWER: ENTER R’S LIVING ARRANGEMENT
With parent(s) .......................... 1 (GO TO YHS2)
In own house/apartment ........... 2 (GO TO YHS2)
In a dorm .................................. 3 (GO TO NEXT SECTION)
Military ................................... 4 (GO TO NEXT SECTION)
Other (Specify)__________..... 5 (GO TO YHS2)
YHS2
To begin, I need to get a list of the people that live with you in
this household – including their name, age, and relationship to
you. Let’s start with you.
YHS3
First Name: ________________________________
YHS4
What is (his/her) relationship to you?
BIRTH CHILD ...........................1
ADOPTED CHILD.....................2
STEP CHILD ..............................3
GRANDCHILD ..........................4
FOSTER CHILD.........................5
OTHER CHILD ..........................6
SPOUSE......................................7
PARTNER (ROMANTIC)..........8
FRIEND (NOT ROMANTIC) ....9
PARENT .....................................10
SIBLING.....................................11
COUSIN......................................12
OTHER RELATIVE...................13
OTHER NONRELATIVE
14
YHS5
Is [Name] male or female?
YHS6
What is (your/his/her) current age?
OUTLOOK AND SOCIAL NETWORKS
Question
Question
Number
YSN1
About how many friends do you have who you either hang out
with, talk to on the phone or get together with socially?
MTO Youth Item Table
Source
Justification
Source
Justification/Notes
Interim
These questions measure various aspects of peer influences for
the sampled youth. They ask about the number of friends and
some of the activities (both positive and negative) with which
those friends are involved.
Page G-1
OUTLOOK AND SOCIAL NETWORKS
Question
Question
Number
YSN2
[CLOSE FRIENDS]
About how many CLOSE FRIENDS do you have these days?
These are people you feel at ease or hang out with, can talk to
about private matters, or call on for help. Would you say that
you have no close friends, one or two, three to five, six to ten,
or more than ten?
YSN3
Thinking about all the people with who you spend most of
your time. What age group are they in? younger than me,
roughly my age group, one to two years older than me, three to
five years older than me, more than five years older than me
YSN4
During the hours when you are not at school, how often do
you either talk on the phone, hang out, or get together with
close [friend/these friends]—most every day, a few times a
week, a few times a month, about once a month, or less than
once a month?
YSN5a
Among the close friends you hang out with, how important is it
to:
Attend classes regularly
YSN5b
Get good grades
YSN5c
Study
YSN5d
Continue their education past high school
YSN5e
Do community work or volunteer
YSN6a
Which of the following things does/has your close friend
do/done?
Get involved in school activities like school clubs, teams, or
projects?
YSN6b
Use marijuana or other drugs?
YSN6c
Carry a knife, gun, or weapon?
YSN6d
Dropped out of school?
YSN6e
Had or fathered a baby?
YSN6f
Out of the close friends you just told me about, how many….?
Get involved in school activities like school clubs, teams, or
projects?
YSN6g
Use marijuana or other drugs?
YSN6h
Carry a knife, gun, or weapon?
YSN6i
Have dropped out of school?
MTO Youth Item Table
Source
Justification/Notes
Interim
NELS
NELS analysis shows that spending time with older youth and
adults (relative to youth of the same age) is predictive of
student math and reading achievement, as well as dropout.
Interim
NELS
At Interim, these questions were asked about the respondent’s
friends in general, but for the final evaluation we have focused
the sequence of questions on close friends as this might also
give us better precision in understanding peer sorting
dynamics. Furthermore, NELS analysis shows that these peer
behaviors are predictive of student math and reading
achievement, as well as dropping out of school.
Interim
NELS
NELS
Interim
Interim
Interim
NELS
Page G-2
OUTLOOK AND SOCIAL NETWORKS
Question
Question
Number
YSN6j
Have had or fathered a baby?
YSN7a
How often is each of the following true for you?
I speak proper English, even with my friends outside of school.
YSN7b
People would describe my behavior style as “ghetto.”
YSN8
YSN9
YSN10
YSN11a
YSN11b
YSN12a
YSN12b
YSN13
Source
NELS
Ferguson Tripod
Project
Ferguson Tripod
Project
[ALL FRIENDS]
The next few questions are about all your friends. Some
people have friends who mostly know one another. Other
people have friends who don’t know one another. Would you
say that: all your friends know one another, most of your
friends know one another, only a few friends know one
another, or none of your friends know one another?
Did you meet or know your friends through school, relatives,
the neighborhood, a club or group you belong to, or other
friends? School, relatives, neighborhood, club or group, other
friends, other
Interim
How many of your current friends were also your friends when
you were [AGE AT RANDOM ASSIGNMENT]?
During the past year, how many of these friends have come to
visit you?
During the past year, how many of these did you visit?
During the past year, how often have you visited these friends?
During the past year, how often have they come to visit you?
How many of your close friends live in your neighborhood?
None, some, about half, most, all
Original
MTO Youth Item Table
Original
Justification/Notes
Related to the effort of measuring class discrimination (see
YNB6) is the possibility of analyzing the digital audio-tapes of
the MTO interviews conducted by ISR to measure MTO
impacts on language, and complementary survey questions on
youth perceptions of their language and fit with their social
context. Language is socially constructed and a salient
indicator of the speaker’s socio-economic as well as race or
ethnic background (Labov et al 1968; Wolfram 1969), and so
MTO effects on language could mediate program impacts on
other outcomes by affecting class discrimination. As such, we
propose to include these two items from Ron Ferguson’s
Tripod Project.
YNB15-18b
The items from Interim ascertain peer sorting and capture
duration, by spending some time with the youth respondent to
define old neighborhood and subsequently inquiring about
having and visiting friends in the old neighborhood. However,
missing from the Interim survey was detail on the composition
of friends outside of residence in old or new neighborhood
(e.g., demographic characteristics of friends) and structure or
overlap in friendships, i.e. the extent to which friends know
each other.
Original
Original
Interim
Interim
CASS
Page G-3
OUTLOOK AND SOCIAL NETWORKS
Question
Question
Number
YSN14
Many churches, synagogues, and other places of worship have
special activities for teenagers—such as youth groups, Bible
classes, or choir. In the past 12 months, how often did you
attend such youth activities?
YSN15
At my house, we watch the news on TV and talk about it. All
the time, some of the time, hardly ever, never
YSN16a
How strongly do you agree or disagree with these statements?
[1=strongly agree 2=agree 3=disagree 4=strongly disagree]
I don't have enough control over the direction my life is taking
YSN16b
Every time I try to get ahead, something or somebody stops me
YSN16c
In my life, good luck is more important than hard work for
success
YSN16d
My plans hardly ever work out, so planning only makes me
unhappy
YSN16e
When I make plans, I am almost certain I can make them work
YSN16f
Chance and luck are very important for what happens in my
life
YSN16g
I am just as smart as other students my age
YSN16h
I find it hard to make friends
YSN16i
I have a lot of friends
YSN16j
I am really easy to like
YSN16k
I don’t know whether I like a new outfit until I find out what
my friends think of it.
YSN17a
Most people think about how other people see them. How do
you think other students see you? [not at all, sometimes, very]
- As popular
YSN17b
- As athletic
YSN17c
- Socially active
YSN17d
- Good student
YSN17e
- Important
YSN17f
- Trouble maker
YSN17g
- As part of the leading crowd
YSN17h
- As not fitting in any group
MTO Youth Item Table
Source
Justification/Notes
Interim
This question measures the mediating factor of religious
attendance. The youth’s participation in church-based activity
reveals another aspect of his/her social links and activity.
Ferguson Tripod
Study
NELS
NELS
NELS
This series of items are designed to measure youth self-esteem,
perceptions of fitting in to school and neighborhood
environments, and acquisition of nondominant cultural capital
or ability and receptivity of youth to adapt to new settings.
NELS
NELS
NELS
CASS
CASS
CASS
CASS
CASS
NELS
Page G-4
NEIGHBORHOODS & SOCIAL NETWORKS
Question
Question
Number
YNB1
Taken all together, how would you say things are these days.
Would you say that you are very happy, pretty happy, or not
too happy?
YNB2
We would like to learn some more about what you did and
how you felt yesterday. Not all days are the same – some are
better, some are worse and others are pretty typical.
Specifically, we are wondering how your day went and how
you felt at [RANDOMLY SELECTED TIME] yesterday.
YNB3
YNB4
YNB5
YNB6
YNB7
YNB8
What were you doing at [RANDOMLY SELECTED TIME]?
Which activity above would you consider the main activity at
[RANDOMLY SELECTED TIME], that is, the activity that
took up the most time?
At what time did [INSERT NAME OF MAIN ACTIVITY]
begin?
At what time did [INSERT NAME OF MAIN ACTIVITY]
end?
Where were you while you were [INSERT FIRST
ACTIVITY]? [At home, at school/work, at someone else’s
house in the neighborhood, somewhere else in the
neighborhood, somewhere else]
Were you interacting with anyone (including on the phone)?
If you were interacting with someone, who was it?
MTO Youth Item Table
Source
Justification/Notes
GSS
Kahneman and
Krueger; Day
Reconstruction
Method modified
Because overall happiness (above) is sometimes perceived in
context of comparing oneself to one’s neighbors, there is the
possibility that MTO moves may have improved the quality of
the daily lives of families but they respond in turn by raising
their standards (perhaps in part because they are now
surrounded by more affluent families). So their lives may in
fact be “better” but they might not perceive or express this
consciously because they are now comparing themselves to a
more affluent, "happier" set of neighbors. To test daily
happiness in addition to overall happiness, the U-index method
proposed by Kahneman and Krueger is designed to circumvent
the potential overall happiness conundrum by trying to
measure instead the quality of the everyday experiences that
MTO families enjoy.
This series of questions has been shortened for MTO, which
will be examined by the original authors, Kahneman and
Krueger, for their feedback. These questions serve to evoke
recent memories about specific activities engaged in and
measure the proportion of time respondents face in an
Page G-5
NEIGHBORHOODS & SOCIAL NETWORKS
Question
Question
Number
YNB9
Please rate each feeling on the scale given. A rating of 0
means that you did not experience that feeling at all. A rating
of 6 means that this feeling was a very important part of the
experience. Please give me the number between 0 and 6 that
best describes how you felt.
YNB10
YNB11a
YNB11b
YNB12
YNB12a
YNB12b
YNB9a. Impatient for it to end
YNB9b. Happy
YNB9c. Frustrated/annoyed
YNB9d. Depressed/blue
YNB9e. Competent/capable
YNB9f. Hassled/pushed around
YNB9g. Warm/friendly
YNB9h. Angry/hostile
YNB9i. Worried/anxious
YNB9j. Enjoying myself
YNB9k. Criticized/put down
YNB9l. Tired
Which of the following statements best describes how satisfied
you are with your neighborhood? Would you say you are very
satisfied, somewhat satisfied, in the middle, somewhat
dissatisfied, or very dissatisfied with you neighborhood?
Now I would like to get a sense of how safe you think your
neighborhood is. How safe do you feel on the streets near your
home during the day? Would you say very safe, safe, unsafe
or very unsafe?
How safe do you feel on the streets near your home at night?
Would you say very safe, safe, unsafe or very unsafe?
Now I have a few questions about discrimination. Sometimes
people feel like they are discriminated against, or treated badly
or differently because of their race or ethnicity. Can you think
of one or more occasions in the last 6 months when you felt
you were treated unfairly because of your race or ethnicity in
the following places? How about…
At your school or work?
At a neighborhood playground or recreation program?
MTO Youth Item Table
Source
Justification/Notes
unpleasant state (versus a pleasant state).
Interim
Interim
As a mediating factor, greater neighborhood satisfaction may
reduce mobility and lengthen exposure to low-poverty
neighborhoods. If youth are not satisfied with low-poverty
locations, they may put pressure on the household head to
move, or they may move themselves—either moving in with
friends/relatives or living on their own. Greater satisfaction
with low-poverty locations suggests more adjustment to the
life changes involved.
Interim
Interim
Interim
Interim
Youth perceptions of discrimination are an outcome of direct
interest to the MTO study as well as a mediating factor for
other outcomes, such as mental health (behavior problems) and
social isolation. As a mediating factor, discrimination is an
important aspect of the social environment. Youth may be
subject to particular surveillance by police, storeowners, and/or
neighbors. If living in a low-poverty neighborhood increases
the experience of discrimination, it may limit the youth’s
Page G-6
NEIGHBORHOODS & SOCIAL NETWORKS
Question
Question
Number
YNB12c
In a store where you were shopping or a restaurant where you
wanted to eat?
YNB12d
When you met someone for the first time?
YNB12e
In dealing with the police such as a traffic accident?
YNB13
Now I have a few questions about discrimination. Sometimes
people feel like they are discriminated against, or treated badly
or differently because they might not have quite as much
money as other people or because of the way they dress or talk.
Can you think of one or more occasions in the last 6 months
when you felt you were treated unfairly in the following places
because of how much money your family has or the way you
dress or talk? How about…
YNB13a
At your school or work?
YNB13b
At a neighborhood playground or recreation program?
YNB13c
In a store where you were shopping or a restaurant where you
wanted to eat?
YNB13d
When you met someone for the first time?
YNB13e
In dealing with the police such as a traffic accident?
YNB14
Have you seen people USING or SELLING illegal drugs in
your neighborhood during the past 30 days? (IF NO, SKIP TO
YNB16)
YNB15a
How often have you seen someone USING drugs in your
neighborhood in the past 30 days? Would you say almost every
day, once a week, or once or twice in the past 30 days, or
didn’t see any using?
YNB15b
How often have you seen someone SELLING drugs in your
neighborhood in the past 30 days? Would you say almost
every day, once a week, or once or twice in the past 30 days, or
you didn’t see any selling?
YNB16
YNB17
YNB18
How often do people make unwanted or rude comments to
you? [Never, a couple of times each year, a couple of times
each month, once or twice a week, everyday]
How often do people give you sexual attention that you do not
want?
How often are you afraid to go places because you worry about
unwanted attention or pressure?
MTO Youth Item Table
Source
Justification/Notes
Interim
integration into the community as well as the level of
interaction with other adults and children there, also limiting
exposure to a different set of peer influences and cultural
norms. This may have impacts on virtually all of the outcomes
considered in the study.
The interim MTO survey included a number of questions about
respondent experiences with racial discrimination, although
analyses of these data found few differences across randomlyassigned MTO groups in these measures. However, since MTO
engendered more class than race integration, we will now ask
about class discrimination as well.
Interim
Interim
Interim, modified
Interim, modified
Interim, modified
Interim, modified
Interim, modified
Interim, modified
Interim, modified
Interim, modified
Interim, modified
Maryland
Adolescent
Development in
Context Study
These questions measure the youth’s observations of drug
activity in the neighborhood. These observations may carry a
greater likelihood of involvement with drugs and exposure to
violence. In addition to strongly motivating the parent’s desire
to move, concerns about drug use may affect youths’
willingness to interact with their community. These concerns
may also affect their mental health, with further possible
impacts on educational achievement and/or employability.
Questions YNB7a & 7b split the Interim version of the followup question to YNB7 into two separate questions—one asking
about observing drug use, the other about observing drug
selling.
Previous qualitative interviews with MTO youth in the Boston,
LA and NY sites suggest that female youth in high-poverty
neighborhoods may be subject to harassment that may not
involve the threat of violence but nonetheless affects their
well-being.
Page G-7
EDUCATION AND SCHOOLING
Question
Question
Number
YED1
Are you currently attending or enrolled in regular school?
YED2
Are you attending school full-time or part-time?
YED2a
What grade or year of school are you currently attending?
YED2b
Are you attending a two-year college, a four-year college, or a
trade or business school?
YED3
When were you last enrolled in regular school—what was the
month and year?
YED4
What is the main reason you left at that time?
YED5
YED6
YED7
YED8
YED9
YED10
The next few questions ask about life in school. If you are not
currently in (high) school, please think about the time when
you were last in (high) school when answering these questions.
During the school year, how often [have you been/were] you
late for school?
During the school year, how many days were you absent from
school?
During the school year, how many times did you cut classes or
skip school?
Which of the following happened the last time you cut classes
or skipped school?
-Someone from school called my home
-The school made me see a counselor.
-The school did not do anything.
-The school sent a letter to my home.
-Someone from school visited my home.
Overall, what grades did you receive [last year/the last full
year of school you completed]?
What is the lowest grade you could get without your parents
getting upset?
MTO Youth Item Table
Source
Justification/Notes
Interim
Interim
Interim
Interim
School enrollment is an important mediating factor for the
influence of low-poverty areas on youth. Information to
identify specific schools and locations is gathered in the Parent
on Youth modules of the adult survey
Interim
School leaving is a major educational outcome. These
questions address how long the youth has been out of school
and the reasons he/she left. We will also gain information on
prior spells of leaving for those currently enrolled. The MTO
treatment may affect school leaving in two different ways.
Youth whose schooling changes as a result of an MTO move
may become more engaged in education in a setting where it is
valued more, so that school leaving is reduced. On the other
hand, youth moving from inner-city neighborhoods may get
left behind academically, have other adjustment problems, and
become more likely to leave before graduation.
Interim
Interim
Interim
This series of questions are designed to measure youth school
be school attendance
NELS
NELS
Interim
This question will get youth perspectives on school
disciplinary actions.
CASS
Page G-8
EDUCATION AND SCHOOLING
Question
Question
Number
YED11
What average grade did you receive [last year/the last full year
of school you completed] in each of these subjects
YED12
YED12a
YED13
YED13a
YED13b
YED13c
YED13d
YED13e
YED13f
YED13g
YED13h
YED13i
YED14
YED15
YED16
YED17
YED11a. Math
YED11b. English
YED11c. Social Studies
YED11d. Science
[Have you ever taken/Did you ever take] any classes in
algebra, geometry, or other advanced math?
What subjects are you taking or have you completed in math?
[Algebra I, geometry, algebra II, trigonometry, pre-calculus,
calculus, other]
Thinking about [your school/when you were last in school], in
general, how much do you agree with each of the following
statements about your school and teachers:
The teachers [are/were] interested in students. Do you
strongly agree, agree, disagree, or strongly disagree?
Students get along well with teachers.
In this school, students get teased if they study hard to get
good grades.
Disruptions by other students [get/got] in the way of my
learning.
There [is/was] a lot of cheating on tests and assignments.
Discipline [is/was] fair.
I [feel/felt] safe at this school.
Misbehaving students (at my school) often get away with it.
In class, I often feel “put down” by my teachers.
Overall about how much total time do you spend on homework
each week, both in and out of school?
About how much homework are you assigned on a typical
school night evening?
When homework is assigned, how much do you usually
complete?
In a typical day, how many class periods do you spend in study
hall?
MTO Youth Item Table
Source
Justification/Notes
CASS
This is one of several measures to better understand parental
investment in youth schooling and achievement, as well as
parenting behavior. NELS analysis shows that parental
rewards and punishment are predictive of the achievement test
scores and dropout behavior of low-income students
Interim
These questions about the academic track being followed by
the youth in school use Math as the primary measure of
progress. Self-reported grades will become part of a
composite indicator of school performance.
Interim
Interim
Interim
NELS
The questions from Interim extend the measurement of
engagement in education. The indicators will be combined
into scales of school engagement. Descriptive analyses show
that the additional measures proposed from the NELS are
predictive of reading and math achievement, and dropping out
of school (controlling for prior test assessments, parent’s
education, SES and race).
Ferguson Tripod
StudyTS
Interim
Interim
Interim
Interim
NELS
NELS
NELS
Interim
Ferguson Tripod
Study
NELS
These questions address schoolwork and homework habits.
Youth attention to homework may be affected by the MTO
move through different channels. Youth may spend more time
doing homework because of different norms in the lowpoverty neighborhood and its school, or perhaps because of a
change in parenting and the level of support for education at
home, which may also be affected by a move. Aside from a
change in youth attitude (and behavior) towards homework,
Page G-9
EDUCATION AND SCHOOLING
Question
Question
Number
YED18
How much additional reading [do/did] you do each week on
your own outside of school—not in connection with
schoolwork? Do not count any assigned reading.
[If none skip to YED19.]
YED18a
Which of these is closest to the amount of time you usually
[spend/spent] reading on your own outside of school or work
each week?
[1-4 hours, 5-9 hours, 10-14 hours, 15-19 hours, 20 or more
hours per week]
YED19
Do you currently use a computer at home?
YED20
In the past month, how frequently have you used the internet at
any location?
YED21
[Did you take/Have you taken] any of the Advanced
Source
Justification/Notes
Interim
the amount of time spent on homework may be indicative of a
change the amount of homework different schools assign, the
quality of teaching, or the quality of support from teachers and
parent. Asking about the portion of the assigned homework
the youth usually completes helps us sort and understand this
information. Time spent on reading for pleasure could increase
as a result of the different schools and contact with higher-SES
children and may also be a mediator for improved
achievement.
Interim
CPSSEP01
CPSSEP01,
modified
Interim
Placement (AP) exams?
YED22
YED23
Have you ever taken the SAT or ACT test?
(Have/had) you ever been in any of the following kinds of
courses or programs in school?
Interim
NELS
YED23a
YED23b
YED23c
Remedial English (sometimes called basic or essential)
Remedial Mathematics (sometimes called basic or essential)
Any special class or special help for any emotional, physical
or mental condition
A vocational course
A program for the gifted and talented
Please mark one (1=school does not have; 2=did not
participate; 3=participated; 4=participated as an officer/leader)
for each activity you (have/had) participated in (this/most
recent) school year.
School sponsored sports (baseball, basketball, football, soccer,
hockey, etc.)
Student government or honor society
Academic clubs (Art, Computer, Engineering, Debate, Math
etc.)
Any other club or group (band, drama, racial/ethnic/cultural)
Have you held a leadership position in any activity, club or
group in school?
NELS
NELS
NELS
YED23d
YED23e
YED24
YED24a
YED24b
YED24c
YED24d
YED25
MTO Youth Item Table
NELS
NELS
NELS
NELS
NELS
NELS
NELS
CASS
Page G-10
EDUCATION AND SCHOOLING
Question
Question
Number
YED26
As things stand now, how far in school do you think you will
get?
YED27
How far in school do you think your mother wants you to go?
YED28
Who has influenced you the most on any decisions about
courses you take in school or your future schooling and
education?
YED29
In a typical week how much time do you spend on other
activities? [Read 29a-e]
YED29a
Youth groups or recreational sports, classes or other lessons?
YED29b
Volunteer work or community service or other types of
community activities?
YED29c
Hanging out in the neighborhood, at the basketball court or
local park?
YED29d
Hanging out at home or in the yard?
YED29e
Shopping at a mall, or store?
YED30
Other than your regular school, which we’ve already talked
about,] in the last 2 years, have you participated in any training
program that lasted at least two weeks that was designed to
help you find a job, improve your job skills, or learn a new
job)?
YED31
What kind of training was that?
YED32
How many weeks in total did you participate in training during
the last two years?
YED33
During those weeks, how many hours a week did you usually
spend in training?
YED33a
Are you currently participating in training?
EMPLOYMENT & EARNINGS
Question
Question
Number
YEM1
Now I’d like to ask a few questions about any jobs you may
have. Last week, did you do any work for pay?
YEM2
[If NO to YEM1] What is the main reason that you did not
work for pay last week?
MTO Youth Item Table
Source
Justification/Notes
NELS
NELS
CASS
NELSm
A mother’s educational expectations are predictive of student
math and reading achievement, as well as dropping out of
school, per NELS data analysis. This is a measure of adult
role models in making educational decisions.
These items are designed to measure how youth spend their
time outside of the school day.
NELSm
NELSm
Original
Original
Original
Interim
Interim
Interim
Moves to low-poverty areas may affect the likelihood of a
youth’s participation in job training through differences in peer
pressure and differences in the availability of training
programs. Participation in job training and acquisition of new
skills may be important to facilitate youth transition into the
workforce. Skills provided in the training may help the youth
obtain and hold a job.
Interim
Interim
Source
Justification/Notes
Interim
YEM1-12, 17-24b
These questions are a slightly modified version of the standard
Current Population Survey questions designed to measure
current labor market status, hours of work, occupation,
Interim
Page G-11
EMPLOYMENT & EARNINGS
Question
Question
Number
YEM3
Last week, did you have more than one job, including parttime and weekend work?
YEM4
How many hours per week do you usually work at your (main)
job? (By main job, we mean the one at which you usually
work the most hours.)
YEM4a
Do you usually work 35 hours or more per week at your main
job?
YEM4b
How many hours per week do you usually work at your other
job(s)?
YEM5
When did you first start working (at your main job)?
YEM6
For your (main) job, what is the easiest way for you to report
your total earnings before taxes or other deductions: hourly,
weekly, annually, or on some other basis?
YEM7
Do you usually receive overtime pay, tips, or commissions (at
main job)?
YEM8
(Including overtime pay, tips, and commissions), what are your
usual (weekly/ biweekly/monthly/annual) earnings on (this)
job, before taxes or other deductions?
YEM8a
How many days a week do you usually work?
YEM9
How many weeks a year do you get paid for?
YEM9b
What is your rate of pay per [UNIT] (on this job)
YEM9c
For how many [UNIT]’s are you usually paid per week (on this
job)?
YEM9d
Excluding overtime pay, tips, and commissions, what is you
rate of pay per [UNIT] (on this job)?
YEM9e
For how many [UNIT]’s are you usually paid per week at this
rate?
YEM9g
(At your main job), how much do you usually receive just in
overtime pay, tips, commissions, before taxes or other
deductions?
YEM9h
Is that…
YEM9j
For how many [UNIT]’s are you usually paid per week at this
rate?
YEM9k
How many hours do you usually work per week at this rate?
YEM9l
How many days per week do you usually work at this rate?
YEM10a
What is your hourly rate of pay (on this job)?
MTO Youth Item Table
Source
Justification/Notes
Interim
industry, and rate of pay. Questions have been added to take
better account of the casual, sporadic employment typical of a
low-income population and particularly of its youth. This
sequence will allow estimation of impacts on all the standard
measures of labor market status and activity (e.g., employment
and unemployment, weekly hours and earnings, hourly wage
rate) for youth who have entered the labor market. Moves to
low-poverty neighborhoods can be expected to influence these
outcomes, because the availability and types of jobs in such
neighborhoods are substantially different than those in highpoverty neighborhoods. The supply of low-wage labor
competing for such jobs is also likely to be much smaller.
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Page G-12
EMPLOYMENT & EARNINGS
Question
Question
Number
YEM11a
Excluding overtime pay, tips and commissions, what is you
hourly rate of pay (on this job)?
YEM11b
How many hours do you usually work per week at this rate?
YEM11c
(At your main job,) how much do you usually receive just in
overtime pay, tips, commissions, before taxes or other
deductions?
YEM11d
Is that…
YEM11e
For how many units/days/hours are you usually paid per week
at this rate?
YEM12
I’d like to ask you how you found the (main) job you have
now. What is the most important source of information you
used to find this job?
YEM13
Have you been doing anything to find work during the past
four weeks?
YEM14
What are all the things you have done to find work during the
past four weeks?
YEM15
Last week, could you have started a job if one had been
offered?
YEM16
[If NO to YEM15] Why is that?
YEM17
In the past 2 years, have you done any/are you doing (other)
work as an employee for which you were paid?
YEM17a
Please tell me the name of your most recent (other) employer.
YEM18
What kind of work did you usually do for this employer?
YEM19
Let’s talk about [EMPLOYER-TYPE OF WORK]. When did
you first start working for this employer?
YEM20
Are you currently working for this employer?
YEM21
When did you last stop working for this employer?
YEM22
How much (do/did) you usually earn per week from this
employer?
YEM23
How many hours per week (do/did) you usually work for this
employer?
YEM24
During the past month have you worked as a freelancer—doing
things like babysitting or mowing lawns—or worked by
yourself, for example, running your own business?
YEM24a
In the last month, how many hours did you do this type of
work?
MTO Youth Item Table
Source
Justification/Notes
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Interim
YEM13-23
These questions collect employment history, for use in the
analyses described under YEM1 above.
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Interim
YEM24-24b
These questions measure informal employment, which may be
a more important source of income to youth than to adults. See
YEM1 above for planned analyses.
Page G-13
EMPLOYMENT & EARNINGS
Question
Question
Number
YEM24b
In the past month, approximately how much did you earn
doing this type of work?
PHYSICAL HEALTH
Question
Question
Number
YPH1
Now I’d like to ask you some questions about your health. In
general, how is your health: excellent, very good, good, fair, or
poor?
YPH2
YPH3
YPH3a
YPH4
YPH5
YPH6
YPH7
YPH8
YPH8a
Have you ever been told by a doctor or other health
professional that you had asthma?
During the past 12 months, have you had an episode of asthma
or an asthma attack?
During the past three months, have you used prescription
inhalers? Do not include over-the-counter inhalers like
Primatene Mist.
During the past 12 months, have you had a wheezing or
whistling sound in your chest?
How many attacks of wheezing or whistling have you had in
your chest during the past 12 months?
During the past 12 months, how many times have you gone to
the doctor’s office or the hospital emergency room for one or
more of these attacks of wheezing or whistling?
During the past 12 months, how much did you limit your usual
activities due to wheezing or whistling? Would you say…
During the past 12 months, how many days of work and school
did you miss due to wheezing or whistling?
[PROBE]: Is that…
MTO Youth Item Table
Source
Justification/Notes
Interim
Source
Justification/Notes
Interim
This question measures the general health of sampled youth, a key
outcome variable in the study. Findings from the MTO Boston
study suggest that general health status improves with moves to lowpoverty areas, and health status is highly correlated with current
medical conditions and with future mortality experience. MTO
moves can affect health outcomes through: reduction in stress
associated with living in a high-poverty area, leading to
improvements in mental health; a safer environment; reduced
exposure to persons engaged in drug use; and greater optimism
about the future, leading to increased use of preventive health care.
These questions measure the incidence of asthma among youth in
the study population. Asthma incidence is known to be higher in
high-poverty communities and communities with older housing
stock, possibly due to crowding, poor air quality, stress, and
exposure to allergens from cockroaches, mites, cats, mice, and
cigarette smoke. Children and adolescents are particularly
vulnerable. Unlike many other chronic health problems, asthma is
highly sensitive to current environmental conditions; the MTO
Boston research suggests reductions due to moves out of public
housing. For asthma attacks, our measure follows the standard
practice of combining questions about attacks requiring medical
attention with other episodes of wheezing or whistling in the chest,
in order to avoid confounding neighborhood effects on asthma with
those on access to health services.
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Interim
Page G-14
PHYSICAL HEALTH
Question
Question
Number
YPH9
HEIGHT MEASUREMENT
YPH10
WEIGHT MEASUREMENT
YPH11
YPH11a
YPH12
YPH13
YPH14
YPH15
YPH16
In the past year have you had a routine physical examination?
Where did you have this examination? private doctor’s office,
community health clinic, school, hospital, or some other place
How would you describe the condition of your teeth?
Excellent, very good, good, fair or poor, no natural teeth
In the past year, have you had a dental examination by a dentist
(or hygienist)?
In the past year (if no routine physical or dental exam), what
kept you from seeing a health professional when you needed
to? If there was more than one reason, indicate more than one
answer.
didn’t know whom to go see
had no transportation
no one was available to go along
parent or guardian would not go along
didn’t want parents to know
difficult to make appointment
afraid of what the doctor would say or do
thought the problem would go away
couldn’t pay
didn’t have time
too embarrassed
thought the doctor would report something to the police or
other legal authorities
didn’t think the doctor could help
other
In the past 12 months, have you had any accidents or injuries
that required medical attention?
How many such accidents or injuries requiring medical
attention have you had in the past 12 months?
MTO Youth Item Table
Source
Justification/Notes
Interim
Interim
These will be used to measure obesity, a basic health outcome with
higher incidence in low-income populations in the U.S. Obesity is an
acknowledged problem starting in childhood.
Moves to low-poverty neighborhoods may reduce obesity through
several mechanisms: lower incidence of depression and stress;
behavioral changes (like exercise); different social norms about
eating habits.
These questions expand information on the receipt of and barriers to
routine physical and dental care.
AddHealth
AddHealth
NHANES
AddHealth
AddHealth
Interim
Interim
These questions measure the incidence of accidents and injuries
among youth in the sample. Low-poverty neighborhoods may be
safer in some respects (e.g., better housing, less exposure to
violence) but may encourage more exercise and outdoor play. Thus,
Page G-15
PHYSICAL HEALTH
Question
Question
Source
Number
YPH17
What was the cause of [that/the first/the second/etc.] accident or Interim
requiring medical attention? Probe: How did it happen? Cycling
skating, other sports related, other kids including fights, other fal
external factor (broken glass, needle, nail, car), other
YPH18
(Other than [that/those] already mentioned) have you had any
Interim
serious accident or injury during the past 12 months which
limited your usual activities but did not require medical
attention?
YPH19
How many of these accidents or injuries did you have during
Interim
the past 12 months? Remember, these are ones that did not
require medical attention but did limit your usual activities.
YPH20
What was the cause of [that/the first/the second/etc.] accident
Interim
or injury not requiring medical attention? Probe: How did it
happen? Cycling or skating, other sports related, other kids
including fights, other falls, external factor (broken glass,
needle, nail, car), other
YPH21
The next few questions are about health problems you might
NCS-A
have had at any time in your life. Have you ever had any of
the following: Headaches, Chronic back or neck problems,
Frequent or very bad headaches, other chronic pain?
YPH22
Did a doctor or other health professional ever tell you that you
NCS-A
have/had diabetes or high blood sugar, or a serious stomach or
bowel problems, like an ulcer or colitis?
YPH23
On how many of the past seven days did you exercise or
Interim
participate in physical activity for at least 20 minutes that made
you sweat and breathe hard, such as basketball, soccer,
running, swimming, fast bicycling, fast dancing, or similar
aerobic activities?
YPH24
On how many of the past seven days did you participate in
Interim
physical activity for at least 30 minutes that did not make you
sweat or breathe hard, such as fast walking, slow bicycling,
skating, pushing a lawn mower, or mopping floors?
YPH25
In a typical week, how many times do you eat fruit? (Do not
NLSY97
count fruit juice.)
YPH26
In a typical week, how many times do you eat vegetables other NLSY97
than french fries or potato chips?
YPH27
How often did you drink regular, carbonated SODA OR SOFT NHIS
MTO Youth Item Table
Justification/Notes
the causes of accidents and injuries may change as a result of the
MTO treatment.
These questions tap into chronic conditions that may be triggered by
environmental factors, including stress.
These questions will complement data on obesity and help analyze
whether eating habits actually change with location. Differences
could arise from income but could also be due to the availability and
marketing of different types of foods or exposure to different norms
– all of which could be influenced by MTO. While nutrition has
Page G-16
PHYSICAL HEALTH
Question
Question
Number
DRINKS that contain sugar?
YPH28
How often did you eat salty snacks, such as potato chips,
pretzels, or popcorn?
YPH29
How often did you eat sweet snacks, such as cookies,
chocolate bars, or candy?
YPH30
On how many of the past seven days did you eat food from a
fast food place, McDonalds, Kentucky Fried Chicken, Pizza
Hut, Taco Bell, or a local fast food restaurant?
On a typical weeknight, what time do you usually go to bed?
On a typical weeknight, what time do you usually get up?
YPH31
YPH32
YPH33
YPH34
In a typical week, how many hours do you watch television or
DVDs?
In a typical week, how many hours total do you use a
computer, or play computer or video games?
Source
Original,
similar to
Add Health
Original,
similar to
Add Health
Add Health
AddHealth
AddHealth
NLSY97
Justification/Notes
been identified by the Surgeon General as a leading health indicator
in its own right, it is also an important mediator for other outcomes
such as obesity.
Note that items 25-26 replace an Interim measure that asked about
fruits and vegetables together.
These questions can serve a dual purpose as a way of measuring
sleep as well as implicit indicators of parental monitoring via
enforcement of sleep routines.
These inactivity questions implicitly supplement the exercise
questions above.
NLSY97modified
MENTAL HEALTH- K-6 INDEX & TRANQUILITY & STRENGTHS & DIFFICULTIES QUESTIONNAIRE
Question
Question
Source
Justification/Notes
Number
YK61
Now I am going to ask you some questions about feelings that
Interim
This series of questions examines the possible stress reduction
you may have experienced during the past 30 days. How much
that could occur when families move away from dangerous
of the time during the past month have you felt…
neighborhoods. This K6 sequence is a measure of general
So sad that nothing could cheer you up?
psychological distress.
YK62
Nervous?
YK63
Restless or fidgety?
YK64
Hopeless?
YK65
That everything was an effort?
YK66
Worthless?
YK67
Calm and peaceful?
MTO Youth Item Table
Page G-17
MENTAL HEALTH- K-6 INDEX & TRANQUILITY & STRENGTHS & DIFFICULTIES QUESTIONNAIRE
Question
Question
Source
Justification/Notes
Number
YK68
The next questions are about this your general behavior. For
SDQ
each item below, please circle the appropriate number
indicating whether the statement is not true, somewhat true, or
very true.
Are you generally obedient? Do you usually do what adults
request?
YK69
Do you have many worries? Do you often feel worried?
YK610
Are you often unhappy, depressed, or tearful?
YK611
Do you get along better with adults than with people your own
age?
YK612
Do you see tasks through to the end? Do you have a good
attention span?
MENTAL HEALTH – SCREENER
Question
Question
Number
YSC1_SC20
The next questions are going to require you to think back
over your entire life. Please take your time and think
carefully before answering. (INTERVIEWER: READ THE
NEXT SENTENCE SLOWLY )Have you ever in your life
had an attack of fear or panic when all of a sudden you felt
very frightened, anxious, or uneasy?
YSC2_SC20a
Have you ever had an attack when all of a sudden: you
became very uncomfortable; you either became short of
breath, dizzy, nauseous, or your heart pounded; or you
thought you might lose control, die, or go crazy?
YSC3_SC20_1
Have you ever in your life had attacks of anger when all of a
sudden you lost control and broke or smashed something
worth more than a few dollars?
YSC4_SC20_2
Have you ever had attacks of anger when all of a sudden you
lost control and hit or tried to hurt someone?
YSC5_SC20_3
Have you ever had attacks of anger when all of a sudden you
lost control and threatened to hit or hurt someone?
MTO Youth Item Table
Source
Justification/Notes
NCS-A
In addition to repeating the screening questions that were
included in the interim MTO evaluation, we are including
detailed fully structured assessments of DSM-IV disorders.
These assessments are identical to those used to assess the
same disorders in the recently completed National
Comorbidity Survey Adolescent (NCS-A), thus providing a
nationally representative benchmark to the MTO results.
The diagnostic instrument used is the version of the World
Health Organization’s (WHO) Composite International
Diagnostic Interview (CIDI) that was expanded and
updated for the WHO World Mental Health Survey
Initiative. This instrument, which revised the original CIDI
to make diagnoses according to the definitions and criteria
of the DSM-IV, was recently approved by WHO as the
official version of CIDI to be used throughout the world
until the publication of ICD-11 in the year 2011. It is
important to recognize that the CIDI is a fully structured
NCS-A
NCS-A
NCS-A
NCS-A
Page G-18
MENTAL HEALTH – SCREENER
Question
Question
Number
YSC6_SC21
Have you ever in your life had an episode lasting several
days or longer when most of the day you felt sad, empty or
depressed?
YSC7_SC22
Have you ever had an episode lasting several days or longer
when most of the day you were very discouraged or hopeless
about how things were going in your life?
YSC8_SC23
Have you ever had an episode lasting several days or longer
when you lost interest and became bored with most things
you usually enjoy like work, hobbies, and personal
relationships?
YSC9_SC24
Some people have episodes lasting several days or longer
when they feel much more excited and full of energy than
usual. Their minds go too fast. They talk a lot. They are
very restless or unable to sit still and they sometimes do
things that are unusual for them, such as driving too fast or
spending too much money. Have you ever had a period like
this lasting several days or longer?
YSC10_SC25
Have you ever had an episode lasting several days or longer
when most of the time you were very irritable, grumpy, or in
a cranky mood?
YSC10a_SC25a
Have you ever had an episode lasting several days or longer
when most of the time you were so irritable that you either
started arguments, shouted at people, or hit people?
YSC11_SC26
Did you ever have a time in your life when you were a
“worrier” – that is, when you worried a lot more about things
than other people with the same problems as you?
YSC11a_SC26a
Did you ever have a time in your life when you were much
more nervous or anxious than most other people with the
same problems as you?
YSC11b_SC26b
Did you ever have a period lasting one month or longer when
you were anxious and worried most days?
MTO Youth Item Table
Source
Justification/Notes
NCS-A
diagnostic interview. This means that it is designed for use
by trained lay interviewers rather than by clinicians and
that clinical judgments are not required in scoring.
However, methodological research has documented good
concordance between diagnoses made by the CIDI and
independent diagnoses made by clinical interviewers.
Four classes of CIDI DSM-IV disorders are assessed in the
MTO survey: anxiety disorders, mood disorders, impulsecontrol disorders, and substance use disorders. The
following sections also include an assessment of mental
health treatment taken from the NCS-A, including
questions about the occurrence of general medical, mental
health specialty, human services, and complementaryalternative medical treatment of mental and substance use
disorders, as well as about the content and intensity of such
treatment.
NCS-A
NCS-A
NCS-A
NCS-A
NCS-A
NCS-A
NCS-A
NCS-A
Page G-19
MENTAL HEALTH – SCREENER
Question
Question
Number
YSC12_SC31
The next question is about concentration problems that
usually start before the age of seven. These problems include
not being able to keep your mind on what you were doing,
losing interest very quickly in games or work, trouble
finishing what you started without being distracted, and not
listening when people spoke to you. During your first years
at school—say between the ages of 5 and 7 -- was there ever
a period lasting six months or longer when you had a lot
more trouble with problems of this sort than most children?
YSC13_SC32
Some young kids are very restless and fidgety and so
impatient that they often interrupt people and have trouble
waiting their turn. Did you ever have a time before the age of
seven lasting six months or longer in your childhood when
you were like that?
YSC14_SC33
Did you ever have a period lasting six months or longer when
you often did things that got you in trouble with adults such
as losing your temper, arguing or talking back to adults,
refusing to do what your teachers or parents asked you to do,
annoying people on purpose, or being grouchy or irritable?
YSC15_SC33_1
Many children and teenagers go through periods when they
do things adults don’t want them to do, like lying, stealing, or
breaking rules. Did you ever go through a period during your
childhood or teenage years when you did any of these things?
YSC16_SC33_2
Did you ever go through a period when you either broke into
cars, set fires, or destroyed property on purpose?
YSC17_SC33_3
Did you ever run away from home, or repeatedly play hooky
from school, or often stay out much later at night than you
were supposed to?
MTO Youth Item Table
Source
Justification/Notes
NCS-A
NCS-A
NCS-A
NCS-A
NCS-A
NCS-A
Page G-20
MENTAL HEALTH – DEPRESSION (68.1% of an MTO-like sample of NCS-A respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
YDE1_D1
A few moments ago, you mentioned having episodes that
NCS-A
Several studies have found significant associations between
lasted several days or longer when you felt sad, empty, or
living in disadvantaged neighborhoods and adverse mental
depressed most of the day. During episodes of this sort, did
health outcomes, including depression. People living in highyou ever feel discouraged about how things were going in
poverty neighborhoods differ in many ways from those in
your life?
lower-poverty areas, and only some of those differences can be
adequately measured and controlled for in non-experimental
YDE1a_D1a
During the episodes of being sad, empty, or depressed, did
NCS-A
studies. Causal inference is more credible in the setting of a
you ever lose interest in most things like work,
randomized intervention that encourages otherwise identical
hobbies, and other things you usually enjoy?
people to live in different areas. Moving from a high-poverty
YDE1b_D1b
During the episodes of being sad, empty, or depressed, did
NCS-A
neighborhood to a lower-poverty neighborhood is a major life
you ever lose interest in most things like work,
event that in principle may or may not improve mental health
hobbies, and other things you usually enjoy?
and other outcomes. On the one hand, the “social stress model”
YDE2_D2
A few moments ago you mentioned having episodes that
NCS-A
suggests that relocating to safer, more stable neighborhoods
lasted several days or longer when you felt discouraged
that provide better schooling, housing, and employment
about how things were going in your life. During episodes
opportunities may reduce stressful life events and life
of this sort, did you ever lose interest in most things like
difficulties, thereby improving mental health. On the other
work, hobbies, and other things you usually enjoy?
hand, moving could result in social or cultural isolation, which
could have adverse effects on mental health. Such moves could
YDE3_D9
A few moments ago, you mentioned having episodes that
NCS-A
also negatively affect mental health if self-evaluation is based
lasted several days or longer when you lost interest in most
in part on relative standing within one’s community, as with
things like school, work, hobbies, and other things you
“relative deprivation” models. This series of questions serves
usually enjoy. During episodes of this sort, did you ever
as a diagnostic assessment of the CIDI-DSMIV major
lose interest in most things like work, hobbies, and other
depression disorder.
things you usually enjoy?
YDE4_D12
YDE5_D16
Did you ever have an episode of being sad, discouraged, or
uninterested in things that lasted most of the day, nearly
every day, for two weeks or longer?
Think of times lasting two weeks or longer when (this
problem/these problems) with your mood (was/were) most
severe and frequent. During those times, did your feelings
of sadness, discouragement, or lack of interest usually last
less than one hour a day, between 1 and 3 hours, between 3
and 5 hours, or more than 5 hours?
MTO Youth Item Table
NCS-A
NCS-A
Page G-21
MENTAL HEALTH – DEPRESSION (68.1% of an MTO-like sample of NCS-A respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
YDE6_D22
Please think of an episode of being sad, discouraged, or
NCS-A
uninterested in things lasting (several days/two weeks) or
longer when you also had other problems at the same time,
such as changes in sleep, appetite, the ability to
concentrate and remember, feelings of low self worth, and
other problems. Is there one particular episode of this sort
that stands out in your mind as the worst one you ever had?
YDE6a_D22a
How old were you when that worst episode started?
NCS-A
YDE6b_D22b
How long did that worst episode last?
NCS-A
YDE6d_D22c
Then think of the last time you had a bad episode of being
NCS-A
sad, discouraged, or uninterested in things like this. How
old were you when that last episode occurred?
YDE6e_D22d
How long did that episode last?
NCS-A
YDE7_D24
Look at page 5 in your booklet. In answering the next
NCS-A
questions, think about the episode of (several days/two
weeks) or longer during that episode when your sadness,
discouragement, and loss of interest and other problems
were most severe and frequent. During that period, which of
the following problems did you have most of the day nearly
every day?
YDE7a_D24a
Did you feel sad, empty, or depressed most of the day
NCS-A
nearly every day during that episode of (several days/ two
weeks)?
YDE7b_D24c
During that episode of (several days/ two weeks), did you
NCS-A
feel discouraged about how things were going in your life
most of the day nearly every day?
YDE7c_D24e
During that episode of (several days/ two weeks), did you
NCS-A
lose interest in almost all things like work and hobbies and
things you like to do for fun?
YDE7d_D24f
Did you feel like nothing was fun even when good things
NCS-A
were happening?
YDE9a_D26a
Did you have a much smaller appetite than usual nearly
NCS-A
every day during that period of (several days/ two weeks)?
YDE9b_D26b
Did you have a much larger appetite than usual nearly every NCS-A
day?
YDE9c_D26c
Did you gain weight without trying to during that period of
NCS-A
(several days/ two weeks)?
MTO Youth Item Table
Page G-22
MENTAL HEALTH – DEPRESSION (68.1% of an MTO-like sample of NCS-A respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
YDE9d_D26e
Did you lose weight without trying to?
NCS-A
YDE9e_D26g
Did you have a lot more trouble than usual either falling
NCS-A
asleep, staying asleep, or waking too early nearly every
night during that period of (several days/ two weeks)?
YDE9f_D26h
Did you sleep a lot more than usual nearly every night
NCS-A
during that period of (several days/ two weeks)?
YDE9g_D26j
On most days, did you feel that you didn’t have much
NCS-A
energy?
YDE9h_D26k
Did you have a lot more energy than usual nearly every day NCS-A
during that period of (several days/ two weeks)?
YDE9i_D26l
Did you talk or move more slowly than is normal for you
NCS-A
nearly every day?
YDE9j_D26m
Did anyone else notice that you were talking or moving
NCS-A
slowly?
YDE9k_D26n
Were you so restless or jittery nearly every day that you
NCS-A
paced up and down or couldn't sit still?
YDE9l_D26o
Did anyone else notice that you were restless?
NCS-A
YDE9m_D26p
Did your thoughts come much more slowly than usual or
NCS-A
seem mixed up nearly every day during that period of
(several days/ two weeks)?
YDE9n_D26r
Did you have a lot more trouble concentrating than is
NCS-A
normal for you nearly every day?
YDE9o_D26s
Were you unable to make up your mind about things you
NCS-A
ordinarily have no trouble deciding about?
YDE9p_D26t
Did you lose your self-confidence?
NCS-A
YDE9q_D26u
Did you feel that you were not as good as other people
NCS-A
nearly every day?
YDE9r_D26w
Did you feel guilty nearly every day?
NCS-A
YDE9s_D26aa
Did you often think a lot about death, either your own,
NCS-A
someone else’s, or death in general?
YDE9t_D26bb
During that period, did you ever think that it would be better NCS-A
if you were dead?
YDE9u_D26cc
Did you think about committing suicide?
NCS-A
MTO Youth Item Table
Page G-23
MENTAL HEALTH – DEPRESSION (68.1% of an MTO-like sample of NCS-A respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
YDE11_D28
You mentioned having (two of/a number of) the problems I NCS-A
just asked you about. How much did your sadness,
discouragement, or lack of interest and these other problems
interfere with either your school work, your job, your social
life, or your personal relationships during that episode– not
at all, a little, some, a lot, or extremely?
YDE12_D17
How severe was your emotional distress during those times NCS-A
-- mild, moderate, severe, or very severe?
YDE13_D18
How often, during those times, was your emotional distress
NCS-A
so severe that nothing could cheer you up -- often,
sometimes, rarely, or never?
YDE14_D37
Think of the very first time in your life you had an episode
NCS-A
lasting (several days or longer / two-weeks or longer) when
most of the day nearly every day you felt sad, discouraged,
or uninterested and also had some of the other problems
(you cited on pages 6-7/we just reviewed). Can you
remember your exact age?
YDE14a_D37a
How old were you?
NCS-A
YDE14b_D37b About how old were you (the first time you had an episode
NCS-A
of this sort)?
YDE15_D38
Did you have an episode of being sad, discouraged,
NCS-A
uninterested with some of the other problems (on pages 5-6)
lasting (several days or longer/ two weeks or longer) at any
time in the past 12 months?
YDE15a_D38a
How recently – in the past month, two to six months ago, or NCS-A
more than six months ago?
YDE16_D38b
About how many days out of the last 365 were you in an
NCS-A
episode?
YDE17_D38c
How old were you the last time you had one of these
NCS-A
episodes?
MTO Youth Item Table
Page G-24
MENTAL HEALTH – MANIA (41.0% of an MTO-like sample of NCS-A respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
YMA1_M1
Earlier in the interview you mentioned having an episode
NCS-A
Mania, often associated with bipolar disorder, is associated
lasting four days or longer when you felt much more excited
with psychological distress and depression, which could have
and full of energy than usual and your mind went too fast.
been decreased or increased by an MTO move (see
People who have episodes like this often have changes in
justification for depression).
their thinking and behavior at the same time, like being
more talkative, needing very little sleep, being very restless,
going on buying sprees, and behaving in ways they would
normally think are inappropriate. Did you ever have any of
these changes during your episodes of being excited and full
of energy?
YMA2_M3
Please think of the one episode when you were very excited NCS-A
and full of energy and you had the largest number of
changes like these at the same time. Is there one episode of
this sort that stands out in your mind?
YMA2a_M3a
How old were you when that episode occurred?
NCS-A
YMA2b_M3b
How long did that episode last?
NCS-A
YMA2d_M3c
Then think of the most recent time you had an episode like
NCS-A
this. How old were you when that most recent episode
occurred?
YMA2e_M3d
How long did that episode last?
NCS-A
YMA3_M4
During that episode, which of the following behavior
NCS-A
changes did you experience: were you so irritable or
grouchy that you started arguments, shouted at people, or
hit people?
YMA4_M5
Earlier in the interview you mentioned having episodes
NCS-A
lasting four days or longer when you became so irritable or
grouchy that you started arguments, shouted at people, or
hit people. People who have episodes of irritability like this
often have changes in their thinking and behavior at the
same time, like being more talkative, needing very little
sleep, being very restless, going on buying sprees and
behaving in ways they would normally think are
inappropriate. Did you ever have any of these changes
during your episodes of being very irritable or grouchy?
MTO Youth Item Table
Page G-25
MENTAL HEALTH – MANIA (41.0% of an MTO-like sample of NCS-A respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
YMA5_M6
Please think of the episode of four days or more when you
NCS-A
were very irritable or grouchy and you had the largest
number of changes like these at the same time. Is there one
episode of this sort that stands out in your mind?
YMA6_M6a
How old were you when that episode occurred?
NCS-A
YMA6b_M6b
How long did that episode last?
NCS-A
YMA6d_M6c
Then think of the most recent time you had an episode like
NCS-A
this. How old were you when that most recent episode
occurred?
YMA6e_M6d
How long did that episode last?
NCS-A
YMA7_M7
During that episode, which of the following changes did
NCS-A
you experience?
YMA7a_M7a
Did you become so restless or fidgety that you paced up and NCS-A
down or couldn’t stand still? (KEY PHRASE: being
restless)
YMA7b_M7b
Were you a lot more interested in sex than usual, or did you NCS-A
want to have sexual encounters with people you wouldn’t
ordinarily be interested in? (KEY PHRASE: having a lot
more interest in sex than usual)
YMA7c_M7c
Did you become overly friendly or outgoing with people?
NCS-A
YMA7d_M7d
Did you do anything else that wasn’t usual for you - - like
NCS-A
talking about things you would normally keep private, or
acting in ways that you’d usually find embarrassing?
(KEY PHRASE: behaving inappropriately)
YMA7e_M7e
Did you try to do things that were impossible to do, like
NCS-A
taking on large amounts of work? (KEY PHRASE: trying to
accomplish unrealistic goals)
YMA7f_M7f
Did you talk a lot more than usual or feel a need to keep
NCS-A
talking all the time? (KEY PHRASE: talking a lot more
than usual)
YMA7g_M7g
Did you constantly keep changing your plans or activities?
NCS-A
(KEY PHRASE: constantly changing plans)
YMA7h_M7h
Did you find it hard to keep your mind on what you were
NCS-A
doing? (KEY PHRASE: hard to keep your mind on things)
MTO Youth Item Table
Page G-26
MENTAL HEALTH – MANIA (41.0% of an MTO-like sample of NCS-A respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
YMA7i_M7i
Did your thoughts seem to jump from one thing to another
NCS-A
or race through your head so fast you couldn’t keep track of
them? (KEY PHRASE: thoughts racing)
YMA7j_M7j
Did you sleep far less than usual and still not get tired or
NCS-A
sleepy? (KEY PHRASE: sleeping far less than usual)
YMA7k_M7k
Did you get involved in foolish investments or schemes for
NCS-A
making money? (KEY PHRASE: getting involved in
foolish schemes)
YMA7l_M7l
Did you spend so much more money than usual that it
NCS-A
caused you to have financial trouble? (KEY PHRASE:
getting into financial trouble)
YMA7m_M7m
Did you do reckless things like driving too fast, staying out
NCS-A
all night, or having casual or unsafe sex? (KEY PHRASE:
doing risky things)
YMA7n_M7n
Did you have a greatly exaggerated sense of self-confidence NCS-A
or believe you could do things you really couldn’t do?
(KEY PHRASE: having too much self-confidence)
YMA7o_M7o
Did you have the idea that you were actually someone else,
NCS-A
or that you had a special connection with a famous person
that you really didn’t have? (KEY PHRASE: believing you
were someone else or somehow connected to a famous
person)
YMA9_M9
Let me review. You had episodes when you were very
NCS-A
(excited and full of energy/irritable or grouchy) and also had
some problems like (KEY PHRASE OF 3 “YES”
RESPONSES IN M7 SERIES). How much did these
episodes ever interfere with either your school work, your
job, your social life, or your personal relationships – not at
all, a little, some, a lot, or extremely?
YMA10_M9b
Did other people say anything or worry about the way you
NCS-A
were acting?
YMA11_M18
Think of the very first time in your life you had an episode
NCS-A
lasting four days or longer when you became very
(excited and full of energy/irritable or grouchy) and also had
some of the behavior changes you just reported. Can you
remember your exact age?
YMA11a_M18a How old were you?
NCS-A
MTO Youth Item Table
Page G-27
MENTAL HEALTH – MANIA (41.0% of an MTO-like sample of NCS-A respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
YMA11b_M18b About how old were you the first time you had an episode
NCS-A
of this sort?
YMA12_M19
Did you have one of these episodes at any time in the past
NCS-A
12 months?
YMA13_M19c
How many weeks in the past 12 months were you in one of
NCS-A
these episodes?
YMA14_M19d
How old were you the last time you had one of these
NCS-A
episodes?
MENTAL HEALTH – PANIC DISORDER (PD) (44.8% of an MTO-like sample of NCS-A respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
YPD1_PD1_
Earlier you mentioned having attacks of fear or panic
Panic disorders are a type of anxiety disorder that may have
NCS-A
INTRO 1
when all of a sudden you felt very frightened, anxious, or
developed since the time of random assignment for these youth
uneasy. Think of a bad attack like that. During that attack,
now age 10 to 20 (0 to 10 at random assignment). The
which of the following problems did you have?
improvement in safety for the younger children in the
treatment group compared to the control group may be a key
YPD1_PD1_
Earlier you mentioned having attacks when all of a sudden NCS-A
element in reducing the likelihood of developing an anxiety
INTRO 2
you had several problems like being short of breath, your
disorder.
heart pounding or feeling dizzy, and being afraid you
would die or go crazy. Think of a bad attack like that.
During that attack, which of the following problems did
you have?
YPD1a_PD1a
Did your heart pound or race? (KEY PHRASE: heart
NCS-A
racing)
YPD1b_PD1b
Were you short of breath? (KEY PHRASE: being short of NCS-A
breath)
YPD1c_PD1c
Did you have nausea or discomfort in your stomach?
NCS-A
(KEY PHRASE: having nausea)
YPD1d_PD1d
Did you feel dizzy or faint? (KEY PHRASE: feeling
NCS-A
dizzy)
YPD1e_PD1e
Did you sweat? (KEY PHRASE: sweating)
NCS-A
YPD1f_PD1f
Did you tremble or shake? (KEY PHRASE: trembling)
NCS-A
YPD1g_PD1g
Did you have a dry mouth? (KEY PHRASE: having a dry
NCS-A
mouth)
MTO Youth Item Table
Page G-28
MENTAL HEALTH – PANIC DISORDER (PD) (44.8% of an MTO-like sample of NCS-A respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
YPD1h_PD1h
Did you feel like you were choking? (KEY PHRASE:
NCS-A
choking)
YPD1i_PD1i
Did you have pain or discomfort in your chest? (KEY
NCS-A
PHRASE: having discomfort in your chest)
YPD1j_PD1j
Were you afraid that you might lose control of yourself or
NCS-A
go crazy? (KEY PHRASE: fearing that you might lose
control of yourself)
YPD1k_PD1k
Did you feel that you were “not really there”, like you
NCS-A
were watching a movie of yourself? (KEY PHRASE:
feeling unreal)
YPD1l_PD1l
Did you feel that things around you were unreal or like a
NCS-A
dream? (KEY PHRASE: feeling that things around you
were unreal)
YPD1m_PD1m
Were you afraid that you might pass out? (KEY PHRASE: NCS-A
fearing that you might pass out)
YPD1n_PD1n
Were you afraid that you might die? (KEY PHRASE:
NCS-A
fearing that you might die)
YPD1o_PD1o
Did you have hot flushes or chills? (KEY PHRASE:
NCS-A
having hot flushes)
YPD1p_PD1p
Did you have numbness or tingling sensations? (KEY
NCS-A
PHRASE: having numbness)
YPD3_PD3
During your attacks did the problems like
NCS-A
(PARENTHETICAL PHRASE OF FIRST THREE YES
RESPONSES IN PD1 SERIES) begin suddenly and reach
their peak within ten minutes after the attacks began?
NCS-A
YPD4_PD4
About how many of these sudden attacks have you had in
your entire lifetime?
YPD5_PD9
Can you remember your exact age the very first time you
NCS-A
had one of these attacks?
YPD5a/b_PD9a/
How old were you? or About how old were you?
NCS-A
b
YPD6_PD10
Did you have one of these attacks at any time in the past
NCS-A
12 months?
YPD6a_PD10a
How recently – in the past month, between two and six
NCS-A
months ago, or more than six months ago?
MTO Youth Item Table
Page G-29
MENTAL HEALTH – PANIC DISORDER (PD) (44.8% of an MTO-like sample of NCS-A respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
YPD6b_PD10b
How many weeks in the past 12 months did you have at
NCS-A
least one attack?
YPD6c_PD10c
And how many attacks in all did you have in the past 12
NCS-A
months?
YPD6d_PD10d
How old were you the last time you had one of these
NCS-A
attacks?
YPD7_PD13
After having one of these attacks, did you ever have any of NCS-A
the following experiences?
YPD7a_PD13a
A month or more when you often worried that you might
NCS-A
have another attack?
YPD7b_PD13b
A month or more when you worried that something
NCS-A
terrible might happen because of the attacks, like having a
car accident, having a heart attack, or losing control?
YPD7c_PD13c
A month or more when you changed your everyday
NCS-A
activities because of the attacks?
YPD7d_PD13d
A month or more when you avoided certain situations
NCS-A
because of fear about having another attack?
YPD8_PD17
Attacks of this sort can occur in three different situations.
NCS-A
The first is when the attacks occur unexpectedly “out of
the blue.” The second is when a person has an
unreasonably strong fear. For example, some people have
a terrible fear of bugs or of heights or of being in a crowd.
The third is when a person is in real danger, like a car
accident or a bank robbery. The next question is about how
many of your attacks occurred in each of these three kinds
of situations. Did you ever have an attack that occurred
unexpectedly “out of the blue?”
YPD8a_PD17a
About how many attacks in your lifetime occurred
NCS-A
unexpectedly “out of the blue?”
YPD9_PD18
About how many attacks in your lifetime occurred in
NCS-A
situations where you were not in real danger, but where
you had an unreasonably strong fear of the situations?
YPD10_PD19
About how many attacks in your lifetime occurred in
NCS-A
situations where you were in real danger?
YPD12_PD21
How old were you (when you had the attack/the first time
NCS-A
you had an attack) “out of the blue” for no obvious reason?
MTO Youth Item Table
Page G-30
MENTAL HEALTH – PANIC DISORDER (PD) (44.8% of an MTO-like sample of NCS-A respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
YPD13_PD22
How much did (this/these) unexpected “out of the blue”
NCS-A
attack(s) or worry about having another attack ever
interfere with either your work, your social life, or your
personal relationships – not at all, a little, some, a lot, or
extremely?
YPD14_PD36
How many unexpected “out of the blue” attacks did you
NCS-A
have in the past 12 months?
YPD15a_PD37a
How old were you the last time you had an unexpected
NCS-A
“out of the blue” attack?
YPD15b_PD37b About how many weeks in the past 12 months did you
NCS-A
have at least one of these attacks?
YPD16_PD38
How recently – in the past month, between two and six
NCS-A
months ago, or more than six months ago?
MENTAL HEALTH – GENERALIZED ANXIETY DISORDER (GAD) (63.4% of an MTO-like sample of NCS-A respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
YGA1_G1_
Earlier you mentioned having a time in your life when you
NCS-A
Because of the documented effects of neighborhood mobility
INTRO 1
were "a worrier". The next questions are about that time.
on general psychological distress, the generalized anxiety
Looking at your booklet, what sorts of things were you
disorder questions will serve to evaluate occurrence of
worried or nervous or anxious about during that time?
episodes over respondents’ lives as well as 12-month
prevalence.
YGA1_G1_
Earlier you mentioned having a time in your life when you
NCS-A
INTRO 2
were much more nervous or anxious than most other
people. The next questions are about that time. Looking at
your booklet, what sorts of things were you nervous or
anxious about during that time?
YGA1_G1_
Earlier you mentioned having a period lasting one month or NCS-A
INTRO 3
longer when you were anxious or worried most days. The
next questions are about that time. Looking at your booklet,
what sorts of things were you anxious or worried about
during that time?
YGA2_G3
Do you think your (worry or anxiety/nervousness or
NCS-A
anxiety/anxiety or worry) was ever excessive or
unreasonable or a lot stronger than it should have been?
MTO Youth Item Table
Page G-31
MENTAL HEALTH – GENERALIZED ANXIETY DISORDER (GAD) (63.4% of an MTO-like sample of NCS-A respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
YGA3_G4
How often did you find it difficult to control your (worry or NCS-A
anxiety/nerves or anxiety/anxiety or worry) -- often,
sometimes, rarely, or never?
YGA4_G4a
How often were you so nervous or worried that you could
NCS-A
not think about anything else, no matter how hard you tried
-- often, sometimes, rarely, or never?
YGA5a_G5
What is the longest period of months or years in a row you
NCS-A
ever had when you were (worried or anxious/nervous or
anxious/anxious or worried) most days? (enter number)
YGA5b_G5
(enter unit of time: months, years)
YGA7a_G9a
Think of your worst period lasting (one month / six months) NCS-A
or longer when you were (worried or anxious/nervous or
anxious/anxious or worried): During that episode, did you
often have any of the following associated problems:
Did you often feel restless, keyed up, or on edge?
YGA7b_G9b
Did you often get tired easily?
NCS-A
YGA7c_G9c
Were you often more irritable than usual?
NCS-A
YGA7d_G9d
Did you often have difficulty concentrating or keeping your NCS-A
mind on what you were doing?
YGA7e_G9e
Did you often have tense, sore, or aching muscles?
NCS-A
YGA7f_G9f
Did you often have trouble falling or staying asleep?
NCS-A
YGA8a_G9a
Did your heart often pound or race?
NCS-R
YGA8b_G9b
Did you often sweat?
NCS-R
YGA8c_G9c
Did you often tremble or shake?
NCS-R
YGA8d_G9d
Did you often have a dry mouth?
NCS-R
YGA8e_G9e
Were you sad or depressed most of the time?
NCS-R
YGA10a_G13a
Did you often feel dizzy or lightheaded?
NCS-R
YGA10b_G13b
Were you often short of breath?
NCS-R
YGA10c_G13c
Did you often feel like you were choking?
NCS-R
YGA10d_G13d
Did you often have pain or discomfort in your chest?
NCS-R
YGA10e_G13e
Did you often have pain or discomfort in your stomach?
NCS-R
YGA10f_G13f
Did you often have nausea?
NCS-R
YGA10g_G13g
Did you often feel that you were unreal?
NCS-R
YGA10h_G13h
Did you often feel that things around you were unreal?
NCS-R
YGA10i_G13i
Were you often afraid that you might lose control or go
NCS-R
crazy?
MTO Youth Item Table
Page G-32
MENTAL HEALTH – GENERALIZED ANXIETY DISORDER (GAD) (63.4% of an MTO-like sample of NCS-A respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
YGA10j_G13j
Were you often afraid that you might pass out?
NCS-R
YGA10k_G13k
Were you often afraid that you might die?
NCS-R
YGA10l_G13l
Did you often have hot flushes or chills?
NCS-R
YGA10m_G13m
Did you often have numbness or tingling sensations?
NCS-R
YGA10n_G13n
Did you often feel like you had a lump in your throat?
NCS-R
YGA10o_G13o
Were you easily startled?
NCS-R
YGA11_G15
How much emotional distress did you ever experience
NCS-A
because of your (worry or anxiety/nervousness or
anxiety/anxiety or worry) – no distress, mild distress,
moderate distress, severe distress, or very severe distress?
YGA12_G17
How much did your (worry or anxiety/nervousness or
NCS-A
anxiety/anxiety or worry) ever interfere with either your
school work, your job, your social life, or your personal
relationships – not at all, a little, some, a lot, or extremely?
YGA12a_G17a
How often were you unable to carry out your daily activities NCS-A
because of your (worry or anxiety/nervousness or
anxiety/anxiety or worry) -- often, sometimes, rarely, or
never?
YGA13_G26
Think of the very first time in your life you had an episode
NCS-A
lasting (one month / six months) or longer when (you were
worried or anxious most days/you were nervous or anxious
most days/you were anxious or worried most days) and also
had some of the other problems we just reviewed. Can you
remember your exact age?
YGA13a/b_G26a/ How old were you? or About how old were you?
NCS-A
b
YGA14_G27
Did you have an episode of being (worried or
NCS-A
anxious/nervous or anxious/anxious or worried), lasting at
least one month or longer, in the past 12 months?
YGA14b_G27b
How many months in the past 12 months were you in an
NCS-A
episode of this sort?
YGA14c_G27c
How old were you the last time you had one of these
NCS-A
episodes?
MENTAL HEALTH – INTERMITTENT EXPLOSIVE DISORDER (IED) (33.1% of an MTO-like sample of NCS-A respondents screened into this module)
MTO Youth Item Table
Page G-33
Question
Number
YIE1_IED3_
INTRO 1
YIE1_IED3_
INTRO 2
YIE1_IED3_
INTRO 3
YIE1_IED3_
INTRO 4
YIE1_IED3_
INTRO 5
YIE2_IED5
MTO Youth Item Table
Question
Source
Justification/Notes
Earlier in the interview you mentioned having attacks of
anger when all of a sudden you lost control and either broke
or smashed something of value or you hit or hurt someone.
The next few questions are about those attacks.
Approximately how many times in your life have you had
an attack of this sort, (READ SLOWLY) when you lost
control and either broke something, hurt someone, or
threatened to hurt someone?
Earlier in the interview you mentioned having attacks of
anger when all of a sudden you lost control and either broke
or smashed something of value or you threatened to hit or
hurt someone. The next few questions are about those
attacks. Approximately how many times in your life have
you had an attack of this sort, (READ SLOWLY) when you
lost control and either broke something or threatened to hurt
someone?
Earlier in the interview you mentioned having attacks of
anger when all of a sudden you lost control and broke or
smashed something of value. The next few questions are
about those attacks. Approximately how many times in your
life have you had an attack of this sort, (READ SLOWLY)
when you lost control and either broke or smashed
something?
Earlier in the interview you mentioned having attacks of
anger when all of a sudden you lost control and hit or hurt
someone. The next few questions are about those attacks.
Approximately how many times in your life have you had
an attack of this sort, (READ SLOWLY) when you lost
control and either hurt someone or threatened to hurt
someone?
Earlier in the interview you mentioned having attacks of
anger when all of a sudden you lost control and threatened
to hit or hurt someone. The next few questions are about
those attacks. Approximately how many times in your life
have you had an attack of this sort, (READ SLOWLY)
when you lost control and threatened to hurt someone?
Did these anger attacks sometimes occur without a good
reason?
NCS-A
Intermittent explosive disorder is an impulse-control that may
have developed since the time of random assignment for these
youth now age 10 to 20 (0 to 10 at random assignment). . We
anticipate that MTO will be shown to have a powerful effect in
reducing the development of, persistence, and severity of
impulse-control disorders.
NCS-A
NCS-A
NCS-A
NCS-A
Page G-34
MENTAL HEALTH – INTERMITTENT EXPLOSIVE DISORDER (IED) (33.1% of an MTO-like sample of NCS-A respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
YIE3_IED5a
Did the attacks sometimes occur in situations where most
NCS-A
people would not have had an anger attack?
YIE3a_IED5b
During those attacks, did you sometimes get a lot more
NCS-A
angry than most people would have been in the same
situation.
YIE4_IED6
Did you have times before these attacks when you felt such
NCS-A
a strong impulse to let loose or blow-up that you couldn't
resist it no matter how hard you tried?
YIE5_IED7
How often was your anger out of control during your typical NCS-A
attacks -- all of the time, most of the time, sometimes,
rarely, or never?
YIE6_IED9
Some people only have anger attacks when they drink
NCS-A
alcohol or use drugs. Did your anger attacks usually occur
when you had been drinking or using drugs?
YIE6a_IED9a
Did you ever have anger attacks when you had not been
NCS-A
drinking or using drugs?
YIE7_IED11
Some people only have anger attacks when they are sad or
NCS-A
depressed. Did your anger attacks usually occur during
periods of time when you were sad or depressed?
YIE7a_IED11a
Did you ever have anger attacks at times you were not sad
NCS-A
or depressed?
YIE8_IED13
Think about all the things you ever damaged or broke
NCS-A
during your anger attacks. What is the approximate
combined repair cost or replacement value of all these
things?
YIE9_IED15
About how many times during your anger attacks did you
NCS-A
ever hurt someone badly enough that they needed medical
attention?
YIE10_IED16
How much did your anger attacks ever interfere with either
NCS-A
your work, your social life, or your personal relationships -not at all, a little, some, a lot, or extremely?
YIE11_IED17
How often did you feel guilty or embarrassed or regretful in NCS-A
the days or weeks after your attacks -- all of the time, most
of the time, sometimes, rarely, or never?
YIE12_IED18
Think of the very first time in your life you had an anger
NCS-A
attack. Can you remember your exact age when that attack
occurred?
MTO Youth Item Table
Page G-35
MENTAL HEALTH – INTERMITTENT EXPLOSIVE DISORDER (IED) (33.1% of an MTO-like sample of NCS-A respondents screened into this module)
Question
Question
Source
Justification/Notes
Number
YIE12a/b_IED18 How old were you? or About how old were you?
NCS-A
a/b
YIE13_IED22
How many anger attacks did you have in the past 12
NCS-A
months?
YIE13a_IED22a
How old were you the last time you had an anger attack?
NCS-A
YIE14_IED23
About how many weeks in the past 12 months did you
NCS-A
have at least one of these attacks?
YIE15_IED24
And how many attacks in total did you have during the past
NCS-A
twelve months?
MENTAL HEALTH- ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (AD) (23.2% of an MTO-like sample of NCS-A respondents screened into this
module)
Question
Question
Source
Justification/Notes
Number
YAD1a_AD1a1
Earlier in the interview you mentioned that there was a
NCS-A
AD is another anxiety disorder, and as such we expect results
period that began before the age of seven when you had a
similar to those for panic disorder. As with the other disorders,
lot more trouble than most children with concentration or
both lifetime and 12-month histories are ascertained.
attention. The next questions are about that period. How
often did you have each of the following difficulties
during that period:
How often did you lose things like assignments or books
or other things you needed? (KEY PHRASE: losing
things)
YAD1b_AD1b1
How often did you have trouble paying attention to details, NCS-A
or did you make a lot of careless mistakes? (KEY
PHRASE: making lots of careless mistakes)
YAD1c_AD1c1
How often did you forget what you were supposed to be
NCS-A
doing or what you had planned to do? (KEY PHRASE:
being forgetful)
YAD1d_AD1d1
How often did people say that you did not seem to be
NCS-A
listening when they spoke to you? (KEY PHRASE: being
told by others that you didn’t seem to listen to them)
MTO Youth Item Table
Page G-36
MENTAL HEALTH- ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (AD) (23.2% of an MTO-like sample of NCS-A respondents screened into this
module)
Question
Question
Source
Justification/Notes
Number
YAD1e_AD1e1
IF 1-4 ‘VERY FREQUENTLY’ OR ‘OFTEN’
NCS-A
RESPONSES TO YAD1a-d. ELSE SKIP TO YAD4a
How often did you quickly lose interest in games you were
playing or in work you were doing at home or at school?
(KEY PHRASE: quickly losing interest in activities)
YAD1f_AD1f1
IF 2-5 ‘VERY FREQUENTLY’ OR ‘OFTEN’
NCS-A
RESPONSES TO YAD1a-e. ELSE SKIP TO YAD4a
How often were you unable to keep your mind on what
you were doing if things were going on nearby? (KEY
PHRASE: being easily distracted)
YAD1g_AD1g1
IF 3-5 ‘VERY FREQUENTLY’ OR ‘OFTEN’
NCS-A
RESPONSES TO YAD1a-f. IF SIX ‘VERY
FREQUENTLY’ OR ‘OFTEN’ RESPONSES TO
YAD1a-YAD1f, SKIP TO YAD2. ELSE SKIP TO
YAD4a
How often did you avoid, or put off doing things that
required a lot of concentration? (KEY PHRASE:
avoiding, or putting off doing things that required a lot of
concentration)
YAD1h_AD1h1
IF 4-5 ‘VERY FREQUENTLY’ OR ‘OFTEN’
NCS-A
RESPONSES TO YAD1a-g. IF SIX ‘VERY
FREQUENTLY’ OR ‘OFTEN’ RESPONSES TO
YAD1a-g, SKIP TO YAD2. ELSE SKIP TO YAD4a
How often did you get confused when you had to make
plans or decide the order in which to do things? (KEY
PHRASE: getting confused when you had to make plans)
YAD1i_AD1i1
IF 5 ‘VERY FREQUENTLY’ OR ‘OFTEN’
NCS-A
RESPONSES TO YAD1a-YAD1h. IF SIX ‘VERY
FREQUENTLY’ OR ‘OFTEN’ RESPONSES TO
YAD1a-YAD1h, SKIP TO YAD2. ELSE SKIP TO
YAD4a
How often did you leave chores, homework or other work
unfinished even when you meant to get them done, and
understood how to do them? (KEY PHRASE: leaving
important jobs or homework undone)
MTO Youth Item Table
Page G-37
MENTAL HEALTH- ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (AD) (23.2% of an MTO-like sample of NCS-A respondents screened into this
module)
Question
Question
Source
Justification/Notes
Number
YAD2-3a: ONLY IF SIX ‘VERY FREQUENTLY’ OR
‘OFTEN’ RESPONSES TO YAD1a-i. ELSE SKIP TO
YAD4a
YAD2_AD2
You had several concentration and attention difficulties,
NCS-A
such as (KEY PHRASES FOR FIRST 3 ITEMS
ENDORSED IN *YAD1a-i). Can you remember your
exact age the very first time in your life when you had any
of these difficulties for a period of six months or longer?
YAD2a_AD2a
How old were you?
NCS-A
YAD2b_AD2b
About how old were you (when you had any of these
NCS-A
difficulties?
NCS-A
YAD3_AD3
Did you still have a lot of difficulty with concentration and
attention during the past 12 months?
YAD3a_AD3a
How old were you the last time you had a period of six
NCS-A
months or longer when you had a lot of difficulty with
concentration or attention?
YAD4a_AD30a1 Earlier in the interview you mentioned that there was a
NCS-A
period that began before the age of seven when you had a
lot more trouble than most children with being very restless,
fidgety, or impatient. How often did you have each of the
following difficulties during that period:
How often were you very active even when you were not
supposed to be – for example, climbing on things or running
around – even after being asked to keep still? (KEY
PHRASE: being very active when you were not supposed
to be)
YAD4b_AD30b1 How often did you feel very restless? (KEY PHRASE:
NCS-A
often feeling very restless)
YAD4c_AD30c1 How often were you “on the go,” usually taking very little NCS-A
time to rest? (KEY PHRASE: being “on the go” without
taking time to rest)
YAD4d_AD30d1 How often did you have trouble playing quietly or doing
NCS-A
quiet activities like reading or being read to for more than
a few minutes at a time? (KEY PHRASE: having trouble
playing quietly)
MTO Youth Item Table
Page G-38
MENTAL HEALTH- ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (AD) (23.2% of an MTO-like sample of NCS-A respondents screened into this
module)
Question
Question
Source
Justification/Notes
Number
YAD4e_AD30e1 How often did you fidget or squirm when you were sitting NCS-A
down? (KEY PHRASE: fidgeting or squirming a lot)
YAD4f_AD30f1 How often did you get up from your seat when you were
NCS-A
not supposed to – like at dinner, at school or at religious
services? (KEY PHRASE: getting up from your seat when
you were not supposed to)
YAD4g_AD3gf1 IF 1-5 ‘VERY FREQUENTLY’ OR ‘OFTEN’
NCS-A
RESPONSES TO YAD4a-f. IF SIX ‘VERY
FREQUENTLY’ OR ‘OFTEN’ RESPONSES TO
YAD4a-f, SKIP TO YMH74. ELSE SKIP TO NEXT
SECTION
How often were you extremely talkative? (KEY PHRASE:
being very talkative)
YAD4h_AD30h1 IF 2-5 ‘VERY FREQUENTLY’ OR ‘OFTEN’
NCS-A
RESPONSES TO YAD4a-YAD4g. IF SIX ‘VERY
FREQUENTLY’ OR ‘OFTEN’ RESPONSES TO
YMH74a-g, SKIP TO YMH74. ELSE SKIP TO NEXT
SECTION
How often did you blurt out answers to other people’s
questions even before they finished speaking? (KEY
PHRASE: interrupting people by blurting out answers to
their questions before they were done speaking)
YAD4i_AD30i1
IF 3-5 ‘VERY FREQUENTLY’ OR ‘OFTEN’
NCS-A
RESPONSES TO YAD4a-YAD4h. IF SIX ‘VERY
FREQUENTLY’ OR ‘OFTEN’ RESPONSES TO
YMH74a-h, SKIP TO YMH74. ELSE SKIP TO NEXT
SECTION
How often did you interrupt people or abruptly join other
people’s conversations without being asked to do so?
(KEY PHRASE: interrupting conversations )
MTO Youth Item Table
Page G-39
MENTAL HEALTH- ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (AD) (23.2% of an MTO-like sample of NCS-A respondents screened into this
module)
Question
Question
Source
Justification/Notes
Number
YAD4j_AD30j1
IF 4-5 ‘VERY FREQUENTLY’ OR ‘OFTEN’
NCS-A
RESPONSES TO YAD4a-YAD4i. IF SIX ‘VERY
FREQUENTLY’ OR ‘OFTEN’ RESPONSES TO
YMH74a-i, SKIP TO YMH74. ELSE SKIP TO NEXT
SECTION
How often did you try to break into games or interrupt
other activities that were already underway? (KEY
PHRASE: interrupting games / other activities )
YAD4k_AD30k1 IF 5 ‘VERY FREQUENTLY’ OR ‘OFTEN’
NCS-A
RESPONSES TO YAD4a-YAD4j. IF SIX ‘VERY
FREQUENTLY’ OR ‘OFTEN’ RESPONSES TO
YMH74a-j, SKIP TO YMH74. ELSE SKIP TO NEXT
SECTION
How often did you have a lot of trouble waiting your turn
– for example, how often was it very hard for you to wait
in a line or to wait for a teacher to call on you in class
before you spoke out loud? (KEY PHRASE: having
trouble waiting your turn )
YMH5-6a: ONLY IF SIX ‘VERY FREQUENTLY’ OR
‘OFTEN’ RESPONSES TO YAD4a-YAD4k. ELSE SKIP
TO NEXT SECTION
YAD5_AD32
You mentioned several difficulties with restlessness and
NCS-A
impatience, such as (KEY PHRASES FOR 3 ITEMS
ENDORSED IN YAD4a-k). Can you remember your
exact age the very first time in your life when you had any
of these difficulties for a period of six months or longer?
YAD5a_AD32a
How old were you?
NCS-A
YAD5b_AD32b
About how old were you the last time you had any of these NCS-A
difficulties?
NCS-A
YAD6_AD33
Did you still have a lot of difficulty with restlessness or
impatience during the past 12 months?
YAD6a_AD33a
How old were you the last time you had a period of six
NCS-A
months or longer when you had these difficulties?
MTO Youth Item Table
Page G-40
MENTAL HEALTH- BEHAVIORAL PROBLEMS INDEX (BPI) & OPPOSITIONAL DEFIANT DISORDER (ODD)
(All youth ages 13-20 will answer the 11 BPI questions in this module. 40.0% of an MTO-like sample of NCS-A respondents screened into the ODD module.)
Question #
Question
Source
Justification
YOD1a-k replicate the Interim survey’s Behavioral Problem
YOD1a
I have trouble concentrating or pay attention. Is this true or Interim
Index. The index comes from the PHDCN-II and is a subset of
often true, somewhat or sometimes true, or not true of
the index developed by T.M. Achenbach. Because of overlap
you?
with ODD symptom questions, some of the BPI battery is used
YOD1b
I lie or cheat.
to form the skip patterns that come from the NCS-A ODD
YOD1c
I tease others a lot.
module.
YOD1d
I disobey my parents.
YOD1e
I have trouble sitting still.
YOD1f
I have a hot temper.
YOD1g
I would rather be alone than with others.
YOD1h
I hang around with kids who get into trouble.
YOD1i
I disobey at school.
YOD1j
I don't get along with other kids.
YOD1k
I have trouble getting along with teachers.
YOD2a_OD1a IF YSC14_SC33 = ‘YES’. ELSE SKIP TO NEXT
NCS-A
SECTION
Earlier in the interview you mentioned a period of six
months or when you often did things that got you in
trouble with adults. Did you often do each of the
following things during that period:
YOD2b_OD1b
YOD2c_OD1c
YOD2d_OD1d
Did you often argue with or “talk back” to adults? (KEY
PHRASE: often argued with adults)
Did you often refuse to follow directions from adults like
your parents, teacher, or boss? (KEY PHRASE: refused to
follow directions)
IF 4 ‘YES’ RESPONSES TO YOD1d, YOD1f, YOD1i,
and YOD2a-b, SKIP TO YOD3
Were often you angry? (KEY PHRASE: were angry a lot)
IF 4 ‘YES’ RESPONSES TO YOD1d, YOD1f, YOD1i,
YOD2a-c, SKIP TO YOD3
Did you often feel you were being taken advantage of or
treated unfairly? (KEY PHRASE: felt like you were being
treated unfairly)
MTO Youth Item Table
NCS-A
NCS-A
NCS-A
Page G-41
MENTAL HEALTH- BEHAVIORAL PROBLEMS INDEX (BPI) & OPPOSITIONAL DEFIANT DISORDER (ODD)
(All youth ages 13-20 will answer the 11 BPI questions in this module. 40.0% of an MTO-like sample of NCS-A respondents screened into the ODD module.)
Question #
Question
Source
Justification
YOD2e_OD1e IF 4 ‘YES’ RESPONSES TO YOD1d, YOD1f, YOD1i,
NCS-A
AND YOD2a-d, SKIP TO YOD3. IF ZERO ‘YES’
RESPONSES TO YOD1d, YOD1f, YOD1i, AND YOD2ad, SKIP TO NEXT SECTION
Did you often annoy people on purpose by doing or saying
things just to bother them? (KEY PHRASE: annoyed
people on purpose)
YOD2f_OD1f IF 4 ‘YES’ RESPONSES TO YOD1d, YOD1f, YOD1i,
NCS-A
AND YOD2a-e, SKIP TO YOD3.
Did you often blame others for your mistakes or bad
behavior? (KEY PHRASE: blamed others for your
mistakes or bad behavior)
YOD2g_OD1g IF 1-3 ‘YES’ RESPONSES TO YOD1d, YOD1f, YOD1i,
NCS-A
AND YOD2a-f. IF 4 ‘YES’ RESPONSES TO YOD1d,
YOD1f, YOD1i, AND YOD2a-f, SKIP TO YOD3. ELSE
SKIP TO NEXT SECTION.
Did you often do mean things to “pay people back” for
things they did that you didn’t like? (KEY PHRASE: did
mean things to get back at people)
YOD2h_OD1h IF 2-3 ‘YES’ RESPONSES TO YOD1d, YOD1f, YOD1i,
NCS-A
AND YOD2a-g. IF 4 ‘YES’ RESPONSES TO YOD1d,
YOD1f, YOD1i, AND YOD2a-g, SKIP TO YOD3. ELSE
SKIP TO NEXT SECTION.
Did you often easily take offense at the way people treated
you? (KEY PHRASE: easily took offense)
YOD2i_OD1i
IF 3 ‘YES’ RESPONSES TO YOD1d, YOD1f, YOD1i,
NCS-A
AND YOD2a-h. IF 4 ‘YES’ RESPONSES TO YOD1d,
YOD1f, YOD1i, AND YOD2a-h, SKIP TO YOD3. ELSE
SKIP TO NEXT SECTION.
Were you often easily annoyed by others? (KEY PHRASE:
were easily annoyed by others)
YOD3-4a: ONLY IF FOUR ‘YES’ RESPONSES TO
YOD1d, YOD1f, YOD1i, AND YOD2a-i. ELSE SKIP TO
NEXT SECTION
MTO Youth Item Table
Page G-42
MENTAL HEALTH- BEHAVIORAL PROBLEMS INDEX (BPI) & OPPOSITIONAL DEFIANT DISORDER (ODD)
(All youth ages 13-20 will answer the 11 BPI questions in this module. 40.0% of an MTO-like sample of NCS-A respondents screened into the ODD module.)
Question #
Question
Source
Justification
NCS-A
YOD3_OD3
You mentioned several things – such as, you (KEY
PHRASES FOR 3 ITEMS ENDORSED IN YOD1d,
YOD1f, YOD1i, AND YOD2a-i). Think of the very first
time in your life you had a period of six months or longer of
feeling or acting like this. Can you remember your exact
age?
YOD3a_OD3a (IF NEC) How old were you?
NCS-A
YOD3b_OD3b About how old were you (the first time you had a period of
NCS-A
this sort)?
YOD4_OD4
Did you still feel or behave like this during the past 12
NCS-A
months?
YOD4a_OD4a How old were you the last time you had a period of six
NCS-A
months or longer when you felt or behaved like this?
RISKY/DELINQUENT BEHAVIOR & CONDUCT DISORDER
(All youth ages 13-20 will answer all non-NCS-A questions. 63.5% of an MTO-like sample of NCS-A respondents screened into the Conduct Disorder module.)
Question
Question
Source
Justification/Notes
Number
This sequence of questions measures the prevalence and intensity of
YRB1_U1
First, I would like to ask you about smoking habits. Have Interim
tobacco use among sample youth. The teen years are known to be
you ever smoked a cigarette?
the critical time when smoking addiction is established. Studies
YRB2_U2
During the past 30 days, on how many days did you
Interim
have shown that residents of high-poverty neighborhoods are more
smoke a cigarette?
likely to be tobacco-dependent than residents of low-poverty
YRB3_U3
When you smoked a cigarette during the past 30 days,
Interim
neighborhoods. Tobacco use could be affected by moves to lowhow many cigarettes did you usually smoke each day?
poverty neighborhoods through several mechanisms. Reduced
depression or stress could reduce tobacco use; social norms about
tobacco use could change; and/or exposure to cigarette advertising,
particularly advertising targeted at minority groups and located in
high-poverty areas, could decline. Contract to this hypothesis,
however, the interim evaluation found that male youth who moved
to lower poverty had a much higher rate of smoking than control
group youth, making this an important measure to see if this
negative impact of moving to low-poverty continues for the younger
cohort of youth.
YRB4_U4
Next I would like to ask you some questions about
Interim
These questions measure alcohol use and its possible effect on
MTO Youth Item Table
Page G-43
RISKY/DELINQUENT BEHAVIOR & CONDUCT DISORDER
(All youth ages 13-20 will answer all non-NCS-A questions. 63.5% of an MTO-like sample of NCS-A respondents screened into the Conduct Disorder module.)
Question
Question
Source
Justification/Notes
Number
drinking alcoholic beverages, including beer, wine, or
school or work performance. As with tobacco use, residents of
liquor. Have you ever had a drink of alcoholic beverage?
high-poverty neighborhoods are more likely to be alcoholBy a drink we mean a can or bottle of beer, a glass of
dependent than residents of low-poverty neighborhoods. Alcohol
wine, a mixed drink, or a shot of liquor. Do not include
use among youth could be affected by moves to low-poverty
childhood sips that you might have had from an older
neighborhoods through several mechanisms, including reduced
person’s drink.
depression and stress and/or reduced use or pressure for use among
peers.
YRB5_U5
During the past 30 days, on how many days did you have
Interim
one or more drinks of an alcoholic beverage?
YRB6_U6
In the last 30 days, on the days that you drank alcohol,
Interim
about how many drinks did you usually have?
YRB7_U7
On how many days did you have 5 or more drinks on the
Interim
same occasion during the same time or within hours of
each other?
YRB8_U8
In the last 30 days, how many days have you had
Interim
something alcoholic to drink, such as beer, wine, or hard
liquor right before or during school or work hours?
YRB9_U9
Have you ever used marijuana – that is grass or pot – in
Interim
These questions measure exposure to and use of a range of illegal
your lifetime?
drugs and other controlled substances. Q11 measures their possible
effect on school or work performance, while Q14-15 measure the
YRB10_U10
On how many days have you used marijuana in the last 30 Interim
youth’s involvement in drug distribution. All these risky behaviors
days?
are more likely to occur among youth in high-poverty areas and to
YRB11_U11
In the last 30 days, how many times have you used
Interim
be less frequent (although hardly absent) in low-poverty
marijuana right before or during school or work hours?
neighborhoods.
YRB12_U12
Excluding marijuana and alcohol, have you ever used any
Interim
other drugs like cocaine or crack or heroin, or any other
substance not prescribed for you by a doctor, in order to
get high or to achieve an altered state?
YRB13_U13
During the past 12 months, about how many times have
Interim
you used any of these drugs or other substances?
YRB14_U14
Have you ever sold or helped sell marijuana, hashish or
Interim
other drugs such as heroin, cocaine, or LSD?
YRB15_U15
During the past 12 months, how many times have you sold Interim
or helped sell marijuana, hashish, or other hard drugs?
YRB16_U19
Are there any gangs in your neighborhood or where you
Interim
These questions focus specifically on gang activity, involvement of
go to school?
peers, and the youth’s own possible involvement. We would expect
that youth living inlow-poverty neighborhoods would report
YRB17_U20
Do any of your brothers, sisters, cousins, or friends belong Interim
markedly different incidences of gang contact and involvement,
MTO Youth Item Table
Page G-44
RISKY/DELINQUENT BEHAVIOR & CONDUCT DISORDER
(All youth ages 13-20 will answer all non-NCS-A questions. 63.5% of an MTO-like sample of NCS-A respondents screened into the Conduct Disorder module.)
Question
Question
Source
Justification/Notes
Number
to a gang?
unless they continue to be active with peers in their old (highpoverty) neighborhoods. (W 14-15 below measure continued ties.)
YRB18_U21
Have you ever belonged to a gang?
Interim
YRB18a_U21a
In the past 12 months, have you been a member of a gang? Interim
YRB19_U22
Have you ever had sexual intercourse, that is, made love,
Interim
These questions address teen dating, sexual activity and attendant
had sex, or gone all the way?
risks. Age of first sexual activity is likely to be considerably
younger for MTO youth living in high-poverty areas than for those
YRB20_U23
How old were you when you had sexual intercourse for
Interim
who have moved, although this will be affected by whether they
the first time?
continue to be involved with peers in their old (high-poverty)
YRB21_U24
How many partners have you had sexual intercourse with
Interim
neighborhoods. YRB22-23 focus on risk reduction behaviors
in the past 12 months – that is, since this time last year?
directed at sexually transmitted diseases (STDs) and at pregnancy.
YRB22_U25
The last time you had sexual intercourse, did you or your
Interim
Considering the range of ages in this sample (12-19), we would
partner use a condom?
expect sexual activity to be reported by many or most of the older
YRB23_U26
The last time you had sexual intercourse, did you or your
Interim
youth. However, the MTO treatment could affect use of condoms
partner use any other method to prevent pregnancy?
(through educational differences and differences in peer groups) and
would likely reduce risk-taking around pregnancy (due to greater
educational engagement and attainment as well as better
employment opportunities for both young women and men).
YRB24_U27
Have you ever been pregnant? (Consider all pregnancies,
Interim
These questions measure current and past pregnancies and
even if no child was born).
childbearing for young women in the youth sample. Teen
childbearing greatly increases the likelihood of future poverty for
YRB25_U28
Are you pregnant now?
Interim
young women. The MTO treatment is expected to reduce the
YRB26_U29
Not counting a current pregnancy, how many times have
Interim
incidence of both pregnancies and live births among teens who
you been pregnant? Please include pregnancies that did
move to low-poverty areas, as a result of educational differences,
not result in live births.
differences in peer groups, greater educational attainment, and
YRB27_U30
Now we would like to ask about the outcomes of your
Interim
better employment opportunities.
previous pregnancies. How many of your pregnancies
have resulted in children born alive to you?
These questions measure current and past pregnancies resulting
YRB28_U31
Have you ever gotten someone pregnant?
Interim
from the sexual activity of young men in the youth sample. For
YRB28a_U31a
How many times have you gotten someone pregnant?
Interim
reasons noted above, we expect fewer pregnancies and live births if
YRB29_U32
Is someone pregnant with your child now?
Interim
the young men from the MTO treatment group are involved with
YRB30_U33
How many children have you ever fathered? Please only
Interim
their female peers living in low-poverty neighborhoods. But
count live births and do not count current pregnancy.
continued involvement with peers from the old high-poverty
neighborhood may reduce or eliminate such an effect.
YRB31_U34
Now I’d like to ask you about cash assistance for which
Interim
some families receive money on a regular basis. For
example, they may get a monthly check. Some people call
MTO Youth Item Table
Page G-45
RISKY/DELINQUENT BEHAVIOR & CONDUCT DISORDER
(All youth ages 13-20 will answer all non-NCS-A questions. 63.5% of an MTO-like sample of NCS-A respondents screened into the Conduct Disorder module.)
Question
Question
Source
Justification/Notes
Number
this assistance “welfare,” AFDC, TANF, or “public aid.”
I will use the word “welfare.” Are you or your (child /
children) regularly receiving welfare benefits now?
YRB32
Which of these three is most effective for pregnancy
Add Health
These questions are intended to test respondent knowledge of safe
prevention? Condom, withdrawal, birth control pill?
sexual behavior as a mediating factor affected by neighborhood and
peer information.
YRB33
Which of these three is the most effective for prevention
Add Health
of STDs? Condom, withdrawal, birth control pill?
YRB34a_CD1h
Sometimes young people do things that adults don’t want
YRB34a begins the NCS-A Conduct Disorder battery. As above, we
NCS-A
them to do. The next questions are about those things.
expect age of onset to be prior to the beginning of the MTO
Was there ever a time …
experiment and, as such, we expect the effect of the experiment to
… when you often stayed out three hours or more later at
be on course of illness rather than on onset (powerfully reducing the
night than your parents wanted?
persistence and severity of the disorder, especially among MTO
participants without a history of the disorder).
YRB34b_CD1i
… when you often skipped school without permission?
NCS-A
YRB34c_CD1k
… when you ran away from home overnight more than
NCS-A
once?
YRB34d_CD1c
… when you shoplifted or stole something worth at least
NCS-A
$20?
YRB34e_CD1b
… when you often got out of doing things you were
NCS-A
supposed to do by fooling people or lying to them?
IF 5 ‘NO’ RESPONSES TO YRB34a-e & YRB14 =
‘YES’, SKIP TO YRB49a. IF 5 ‘NO’ RESPONSES TO
YRB34a-e & YRB14 = ‘NO’, SKIP TO YRB53
YRB35a_CD1a
… when you often told lies to trick people into giving you NCS-A
things or doing what you wanted them to do?
YRB35b_CD1d
… when you stole money or other things from your
NCS-A
parents or the other people you lived with?
YRB35c_CD1e
… when you broke into someone’s locked car, or a locked NCS-A
home or building?
YRB35d_CD1f
… when you set a fire to try to cause serious damage?
NCS-A
YRB35e_CD1g
… when you deliberately damaged someone’s property by NCS-A
doing something like breaking windows, slashing tires,
vandalizing, or writing graffiti on buildings?
YRB35f_CD1j
… when you ran away from home and stayed away for at
NCS-A
least four days?
YRB36_CD7
You answered “yes” to (NUMBER OF “YES”
NCS-A
MTO Youth Item Table
Page G-46
RISKY/DELINQUENT BEHAVIOR & CONDUCT DISORDER
(All youth ages 13-20 will answer all non-NCS-A questions. 63.5% of an MTO-like sample of NCS-A respondents screened into the Conduct Disorder module.)
Question
Question
Source
Justification/Notes
Number
RESPONSES IN YRB34-35) of the questions I just asked
about. Think of the very first time in your life you did
(that type of behavior / either of those behaviors / any of
those behaviors). Can you remember your exact age?
YRB36a_CD7b
How old were you?
NCS-A
YRB36b_CD7c
About how old were you the first time you did (that type
NCS-A
of behavior / either of those behaviors / any of those
behaviors?)
YRB37_CD9
Did you do (that type of behavior / either of those
NCS-A
behaviors / any of those behaviors) during the past 12
months?
YRB37a_CD9a
How old were you the last time you did (that type of
NCS-A
behavior / either of those behaviors / any of those
behaviors?)
YRB38_CD10
About how many years altogether did you do (that type of NCS-A
behavior / either of those behaviors / any of those
behaviors?)
YRB39
About how many times during the past 12 months did you Original
do (that type of behavior / either of those behaviors / any
of those behaviors) during the past 12 months?
YRB40_CD11
How much did (this behavior / these behaviors) ever cause NCS-A
problems with either your school work, your job, or your
relationships with family or friends – not at all, a little,
some, a lot, or extremely?
YRB40a_CD11a
How often during that time were you unable to carry out
NCS-A
your daily activities or to take care of yourself because (of
this behavior / these behaviors) – often, sometimes, not
very often, never?
YRB41a_CD16a
The next questions are about some other aggressive things NCS-A
adults don’t like young people to do. We want to know if
you ever did any of these things. Did you have a time in
your life when you / was there ever a time when you…
… often “bullied,” threatened, or frightened people,
including smaller or younger children?
YRB41b_CD16b … when you repeatedly got involved in physical fights?
NCS-A
YRB41c_CD16c
… when you used a weapon on another person, like a
NCS-A
MTO Youth Item Table
Page G-47
RISKY/DELINQUENT BEHAVIOR & CONDUCT DISORDER
(All youth ages 13-20 will answer all non-NCS-A questions. 63.5% of an MTO-like sample of NCS-A respondents screened into the Conduct Disorder module.)
Question
Question
Source
Justification/Notes
Number
baseball bat, glass bottle, knife, gun, or brick?
YRB41d_CD16d … when you were physically cruel to an animal and hurt it NCS-A
on purpose? (IF NECESSARY: This does not include
hunting or getting rid of pests like rodents or insects)
YRB41e_CD16e
… when you were physically cruel to a person and hurt
NCS-A
them on purpose?
YRB41f_CD16f
YRB41g_CD16g
YRB41_CD16h
YRB42_CD18
YRB42a_CD18b
YRB42b_CD18c
YRB43_CD20
MTO Youth Item Table
… when you forced someone to give you something like
money, jewelry, or clothing by threatening them or hurting
them?
… when you stole someone’s purse, wallet, luggage, or
package or bag by grabbing it from them? (IF NEC: This
does not include stealing from someone who wasn’t aware
of the theft, such as stealing a piece of luggage when the
owner wasn’t watching)
… when you made anyone do something sexual by either
forcing, intimidating, or threatening them?
IF ZERO ‘YES’ RESPONSES TO YRB41a-h, SKIP TO
YRB47
You answered “yes” to (NUMBER OF “YES”
RESPONSES IN YRB41 SERIES ) type(s) of aggressive
behavior. Think of the very first time in your life when
you did (that type of behavior / either of those behaviors /
any of those behaviors). Can you remember your exact
age?
How old were you?
About how old were you the first time you engaged in
(that type of aggressive behavior / either of those
aggressive behaviors / any of those aggressive behaviors?
Can you remember what grade you were in at school?
Was it before you first started school? Was it before you
were a teenager?
Did you do (that type of behavior / either of those
behaviors / any of those behaviors) during the past 12
months?
NCS-A
NCS-A
NCS-A
NCS-A
NCS-A
NCS-A
NCS-A
Page G-48
RISKY/DELINQUENT BEHAVIOR & CONDUCT DISORDER
(All youth ages 13-20 will answer all non-NCS-A questions. 63.5% of an MTO-like sample of NCS-A respondents screened into the Conduct Disorder module.)
Question
Question
Source
Justification/Notes
Number
YRB43a_CD20a
How old were you the last time you did (that type of
NCS-A
behavior / either of those behaviors / any of those
behaviors?)
YRB44_CD21
About how many years altogether did you do (that type of NCS-A
behavior / either of those behaviors / any of those
behaviors)?
YRB45
About how many times during the past 12 months did you Original
do (that type of behavior / either of those behaviors / any
of those behaviors)?
YRB46_CD22
How much did (this behavior / these behaviors) ever cause NCS-A
problems with either your school work, your job, or your
relationships with family or friends – not at all, a little,
some, a lot, or extremely?
YRB47_CD32
Were you ever suspended or expelled from school as a
NCS-A
result of your behavior?
YRB48_CD33
Were you ever fired from a job because of your behavior? NCS-A
These follow-up questions provide additional information about the
YRB49a
You said you have done something in the past that is
PHDCN
degree to which the criminal justice environment in which MTO
against the law. When was the LAST time that you
youth operate varies across neighborhoods, and the degree to which
[MOST SERIOUS ILLEGAL ACTIVITY
any criminal offending may be rooted in baseline neighborhoods
RESPONDENT REPORTS FROM YRB14, YRB34d,
and social networks as opposed to the new social environments that
YRB35c-e, YRB41c, or YRB41e-h]?
MTO families experience, as a way of learning more about both the
YRB49b
Did this happen in your neighborhood or somewhere else? PHDCN
distributional consequences of MTO and the behavioral mechanisms
YRB49c
If not in neighborhood: Where did this happen?
PHDCN
through which MTO may (or may not) affect anti-social behavior
YRB49d
Who were the people you were with?
PHDCN
over the long term.
YRB49e
How long have you known this person?
PHDCN
YRB49f
Did the police talk to you about this?
PHDCN
YRB49g
Did the police arrest you or charge you with an offense?
NLSY97
YRB50_CD37
Were you ever in trouble with the police as a result of your NCS-A
behavior?
YRB50a_CD37a
How old were you the first time (you got into trouble with NCS-A
the police as a result of your behavior?)
YRB51_CD38
Were you ever arrested (because of your behavior)?
NCS-A
YRB52_CD39
Were you ever sent to jail, prison, or a juvenile correction
NCS-A
facility because of your behavior?
YRB52a_CD39a
How old were you the first time (you were sent to jail,
NCS-A
MTO Youth Item Table
Page G-49
RISKY/DELINQUENT BEHAVIOR & CONDUCT DISORDER
(All youth ages 13-20 will answer all non-NCS-A questions. 63.5% of an MTO-like sample of NCS-A respondents screened into the Conduct Disorder module.)
Question
Question
Source
Justification/Notes
Number
prison, or a juvenile correction facility for your behavior)?
YRB52b_CD39b How long did you stay in any of these facilities altogether? NCS-A
(enter number)
YRB52c_CD39b
(enter unit of time: days, weeks, months, years)
YRB53
What is the percent chance that you would be arrested if
NLSY97
These questions measure a respondent’s perception of the risk of
you stole a car?
illegal activity and supplement the questions in YRB49.
YRB54
Suppose you were arrested for stealing a car, what is the
NLSY97
percent chance that you would serve time in jail?
CRIME VICTIMIZATION & POST-TRAUMATIC STRESS DISORDER (PTSD)
(All youth ages 13-20 will answer non-NCS-A questions. 79.1% of an MTO-like sample of NCS-A respondents screened into the PTSD module.)
Question
Question
Source
Justification/Notes
Number
YCV1_PT8
Were you ever involved in a life-threatening automobile
NCS-A
YCV Module Overall
accident?
These questions from the NCS module on PTSD ask about
experiences with having been beaten up by one’s parents as a child,
YCV2_PT9
Did you ever have any other life-threatening accident,
NCS-A
and other experiences with violence. However, the NCS questions
including on your job?
in the NCS do not ask about some of the follow-up details (such as
YCV3_PT10
Were you ever involved in a major natural disaster, like a
NCS-A
police response) that are of interest to us for the long-term MTO
devastating flood, hurricane, or earthquake?
survey. As such, the module adds measures from other surveys (see
YCV4_PT11
Were you ever in a man-made disaster, like a fire started by NCS-A
below).
a cigarette, or a bomb explosion?
YCV5_PT12
Did you ever have a life-threatening illness?
NCS-A
Given that exposure to crime is an important mechanism through
YCV6_PT13
Were you ever badly beaten up by your parents or the
NCS-A
which MTO may affect mental health outcomes of participating
people who raised you?
youth – and in fact is the most important stated reason why MTO
YCV7_PT14
Were you ever badly beaten up by someone you were
NCS-A
families signed up for the program – these questions will examine
dating or with whom you were romantically involved?
individual crime victimization experience, including information
YCV8_PT15
Were you ever badly beaten up by anyone else?
NCS-A
about the circumstances and location of the event as well as the
YCV9_PT16
Were you ever mugged, held up, or threatened with a
NCS-A
offender. Importantly, in addition to questions about general
weapon?
MTO Youth Item Table
Page G-50
CRIME VICTIMIZATION & POST-TRAUMATIC STRESS DISORDER (PTSD)
(All youth ages 13-20 will answer non-NCS-A questions. 79.1% of an MTO-like sample of NCS-A respondents screened into the PTSD module.)
Question
Question
Source
Justification/Notes
Number
YCV10_PT17
The next two questions are about sexual assault. The first is NCS-A
violence victimization these questions include items specific to
about rape. We define this as someone either having sexual
violence committed by people known to the respondent, as well as
intercourse with you or penetrating your body with a finger
questions intended to capture sexual violence.
or object when you did not want them to, either by
threatening you or using force. Did this ever happen to
These questions also include a detailed assessment of traumatic life
you?
events as well as a separate battery of non-traumatic stressful life
events. We anticipate that some of these events will be less
YCV11_PT18
Other than rape, were you ever sexually assaulted, where
NCS-A
prevalent among respondents in the MTO intervention than control
someone touched you in appropriately, or when you did not
groups.
want them to?
YCV12-15 & 21-22
YCV12
Have you ever been chased when you thought the person
PHDCN
Because crime, safety, and victimization are important in their own
chasing you would hurt you?
right, and because of the implications they have on a number of
YCV13
Have you ever been hit, slapped, punched or beaten up,
PHDCN
other important outcomes, including mental and physical health,
even if you were not beaten up very badly?
these questions expand on those Interim items related to criminal
YCV14
Has anyone ever stolen your purse, wallet, or snatched your Interim,
victimization. The PTSD questions in the NCS also do not ask about
jewelry?
modified
experiences with property crime victimization.
YCV15
Did anyone ever try to break into your home?
Interim,
modified
YCV16_PT20
Did someone very close to you ever die unexpectedly; for
NCS-A
example, they were killed in an accident, murdered,
committed suicide, or had a fatal heart attack at a young
age?
YCV17_PT22
Did anyone very close to you ever have an extremely
NCS-A
traumatic experience, like being kidnapped, tortured or
raped?
YCV18_PT22_1 Did you ever witness serious physical fights at home, like
NCS-A
when your father beat up your mother?
YCV19_PT23
Did you ever see someone being badly injured or killed, or
NCS-A
unexpectedly see a dead body?
YCV20_PT27
Did you ever experience any other extremely traumatic or
NCS-A
life-threatening event that I haven’t asked about yet?
YCV21_PT55a
Briefly, what was the one most traumatic event that you
NCS-A
have not told me about?
YCV22
You said you had been [crime experience]. When was the
NCVS
See YCV12 above.
last time this happened? (Was this within the past 12
months? Was this within the past 6 months?)
MTO Youth Item Table
Page G-51
CRIME VICTIMIZATION & POST-TRAUMATIC STRESS DISORDER (PTSD)
(All youth ages 13-20 will answer non-NCS-A questions. 79.1% of an MTO-like sample of NCS-A respondents screened into the PTSD module.)
Question
Question
Source
Justification/Notes
Number
YCV23
Were the police informed, or did they find out about this
NCVS
incident in any way?
YCV24
As far as you know, was anyone arrested or were charges
NCVS
brought against anyone in connection with this incident?
YCV25
You said you had been [violent crime experience] during
PHDCN
the past 12 months. The last time this happened, where did
it happen?
YCV25a
The last time this happened, who did this to you?
PHDCN
YCV26a
Please tell me if any of the following this have happened to Interim,
The MTO treatment is designed to reduce both involvement and
anyone who lived with you during the past 6 months.
victimization, by fostering moves to low-poverty neighborhoods
modified
Was anyone’s purse, wallet, or jewelry snatched from
where these are lower-probability events. These questions modify
them?
the Interim measures of the youth’s direct involvement in physical
violence and his/her exposure to violence, including victimization,
YCV26b
Was anyone threatened with a knife or gun?
Interim,
by asking about violent episodes involving anyone in the
modified
respondent’s household.
YCV26c
Was anyone beaten up or assaulted?
Interim,
modified
YCV26d
Was anyone stabbed or shot?
Interim,
modified
YCV27_PT62_
Let me review. You experienced (NUMBER) (EVENT).
NCS-A
INTRO 2
After an experience like this, people sometimes have
problems like upsetting memories or dreams, feeling
emotionally distant or depressed, trouble sleeping or
concentrating, and feeling jumpy or easily startled. Did you
have any of these reactions after (either / any) (EVENT) of
these experiences?
YCV27_PT62_
Let me review. You had (two/ three) different types of
NCS-A
INTRO 3
traumatic events: [KEY PHRASES OF ALL EVENT
TYPES] (and a private event). After experiences like
these, people sometimes have problems like upsetting
memories or dreams, feeling emotionally distant or
depressed, trouble sleeping or concentrating, and feeling
jumpy or easily startled. Did you have any of these
reactions after any of the traumatic experiences you have
gone through?
MTO Youth Item Table
Page G-52
CRIME VICTIMIZATION & POST-TRAUMATIC STRESS DISORDER (PTSD)
(All youth ages 13-20 will answer non-NCS-A questions. 79.1% of an MTO-like sample of NCS-A respondents screened into the PTSD module.)
Question
Question
Source
Justification/Notes
Number
YCV27_PT62_
Let me review. You had quite a few different traumatic
NCS-A
INTRO 4
experiences, like: [KEY PHRASES OF 3 EVENT
TYPES] (and a private event). After experiences like
these, people sometimes have problems like upsetting
memories or dreams, feeling emotionally distant from or
depressed, trouble sleeping or concentrating, and feeling
jumpy or easily startled. Did you have any of these
reactions after any of the traumatic experiences you have
gone through?
YCV28_PT62.2
Did you ever in your life talk to a medical doctor or other
NCS-A
professional about (this problem / any of these problems)?
(By professional we mean psychologists, counselors,
spiritual advisors, herbalists, acupuncturists, and other
healing professionals).
YCV29_PT64
Of the [experiences you mentioned to me / NUMBER times NCS-A
(EVENT TYPES) happened] which one caused you the
most problems like upsetting memories or dreams, feeling
emotionally distant, trouble sleeping or concentrating, or
feeling jumpy or easily startled. That is, which one
experience caused the largest n umber or most severe
problems?
YCV29a_PT64a How old were you when that (happened / started)?
NCS-A
YCV30_PT67
[FOR ONGOING EVENTS] During the period of time
NCS-A
when (WORST EVENT) was happening repeatedly, did
you ever feel terrified or very frightened?
[ALL OTHERS] Were you terrified or very frightened at
the time (WORST EVENT)?
YCV30a_PT67a Did you feel helpless?
NCS-A
YCV30b_PT67b Did you feel shocked or horrified?
NCS-A
YCV30c_PT67c Did you feel numb?
NCS-A
YCV31_PT68
In the weeks, months, or years after the (event / this
NCS-A
experienced ended / WORST EVENT), did you try not to
think about it (what happened)?
YCV32_PT69
Did you purposely stay away from places, people, or
NCS-A
activities that reminded you of (it / the event / this
experience/ WORST EVENT)?
MTO Youth Item Table
Page G-53
CRIME VICTIMIZATION & POST-TRAUMATIC STRESS DISORDER (PTSD)
(All youth ages 13-20 will answer non-NCS-A questions. 79.1% of an MTO-like sample of NCS-A respondents screened into the PTSD module.)
Question
Question
Source
Justification/Notes
Number
YCV33_PT70
Were you ever unable to remember some important parts of NCS-A
what happened?
YCV34_PT71
Did you lose interested in doing things you used to enjoy?
NCS-A
YCV35_PT72
Did you feel emotionally distant or cut-off from other
NCS-A
people?
YCV36_PT73
Did you have trouble feeling normal feelings like love,
NCS-A
happiness, or warmth towards other people?
YCV37_PT74
Did you feel you had no reason to plan for the future
NCS-A
because you thought it would be cut short?
YCV38_PT86
Did you ever have repeated unwanted memories of (it / the
NCS-A
event / this experience / WORST EVENT) – that is, you
kept remembering it even when you didn’t want to?
YCV39_PT87
Did you ever have repeated unpleasant dreams about (it /
NCS-A
the event / this experience / WORST EVENT)?
YCV40_PT88
Did you have flashbacks – that is, suddenly act or feel as if
NCS-A
(it / the event / this experience / WORST EVENT) were
happening all over again?
YCV41_PT89
Did you get very upset when you were reminded of (it / the NCS-A
event / this experience / WORST EVENT)?
YCV42_P90
When you were reminded of (it / the event / this experience NCS-A
/ WORST EVENT), did you ever have physical reactions
like sweating, your heart racing, or feeling shaky?
YCV43_PT102
During the time (this event / this experience / WORST
NCS-A
EVENT) affected you most, did you have trouble falling or
staying asleep?
YCV44_PT103
Were you more irritable or short-tempered than you usually NCS-A
are?
YCV45_PT104
Did you have more trouble concentrating or keeping your
NCS-A
mind on what you were doing?
YCV46_PT105
Were you much more alert or watchful, even when there
NCS-A
was no real need to be?
YCV47_PT106
Were you more jumpy or easily startled by ordinary noises? NCS-A
MTO Youth Item Table
Page G-54
CRIME VICTIMIZATION & POST-TRAUMATIC STRESS DISORDER (PTSD)
(All youth ages 13-20 will answer non-NCS-A questions. 79.1% of an MTO-like sample of NCS-A respondents screened into the PTSD module.)
Question
Question
Source
Justification/Notes
Number
YCV48_PT110
You had quite a few reactions, such as (FIRST KEY
NCS-A
PHRASE). For about how many days, weeks, months, or
years did you continue to have any of these reactions?
(enter number)
YCV48a_PT110 (enter unit of time: days, weeks, months, years)
YCV49_PT113
Think of the time when these reactions were most frequent
NCS-A
and intense. How often did they occur – less than once a
month, one or two times a month, three to five times a
month, six to ten times a month, or more than ten times a
month?
YCV50_PT114
How much distress did these reactions cause you – none,
NCS-A
mild, moderate, severe, or very severe distress?
YCV51_PT115
How much did these reactions disrupt or interfere with your NCS-A
normal, daily life – not at all, a little, some, a lot, or
extremely?
YCV52_PT261
(RB) The next question is about whether in the past 12
NCS-A
months you had any of these reactions associated with any
traumatic event that ever happened to you in your entire
life. Did you have any reactions of this sort over the past
12 months?
YCV53_PT263
About how many weeks altogether in the past 12 months
NCS-A
did you have any of these reactions?
YCV54_PT269
Please think of the 30-day period in the past 12 months
NCS-A
when these reactions to [WORST 12-MONTH EVENT /
these events / these experiences] were most frequent and
intense. During that month, did you lose interest in doing
things you used to enjoy?
YCV55_PT270
Did you feel emotionally distant or cut off from other
NCS-A
people during that month?
YCV56_PT271
Did you have trouble feeling normal things like love,
NCS-A
happiness, or warmth toward other people?
YCV57_PT272
Did you feel you had no reason to plan for the future
NCS-A
because you thought it would be cut short?
YCV58_PT273
Did you have any trouble falling or staying asleep during
NCS-A
that month?
MTO Youth Item Table
Page G-55
CRIME VICTIMIZATION & POST-TRAUMATIC STRESS DISORDER (PTSD)
(All youth ages 13-20 will answer non-NCS-A questions. 79.1% of an MTO-like sample of NCS-A respondents screened into the PTSD module.)
Question
Question
Source
Justification/Notes
Number
YCV59_PT274
Were you more jumpy or more easily startled by ordinary
NCS-A
noises?
YCV60_PT275
Did you purposely stay away from places, people or
NCS-A
activities that reminded you of [WORST 12-MONTH
EVENT] / these events)?
YOUTH REPORT ON PARENTS AND PARENTING
Question
Question
Number
YOP1
How many adults do you have in your life who you feel
comfortable talking to about personal problems?
YOP2
How many adults do you have in your life who care a lot about
how you turn out and who will help you if you get into
trouble?
YOP3
(RB) Who are the adult(s) who you go to first to talk about
personal problems or who will help you if you get into trouble?
Check all that apply. [Mother, Father, Stepparent ,
Brothers or sisters, Other relatives, Teachers, Coach, Guidance
counselor, Advisor or school principal, Other leaders in the
community, No one]
YOP4
(RB) Of all of the people you know personally, think about the
person you admire the most. How would you describe this
person? Honest, Popular, Dresses well, Intelligent, Makes a lot
of money, Has an important job, Has a college degree,Good at
sports
YOP5
What is your relationship to that person? Friend,
Mother/father, Relative, Boyfriend/girlfriend
other
YOP6
Now we would like to know about your relationship with your
mother, or with the adult most responsible for taking care of
you or who knows the most about your activities. Do you live
with your mother? [FILTER IF YOUTH LIVING WITH
ADULT RESPONDENT=MOTHER VIA HH ROSTER
SCREENER]
MTO Youth Item Table
Source
Justification/Notes
Interim
One candidate mediating mechanism proposed for explaining
MTO’s effects on children, particularly on youth, is whether MTO
changes parental investments in their children. Additionally,
changes in mental health or marital status could independently or
synergistically affect parenting behavior. MTO adults might also
feel safer in less distressed neighborhoods, or feel less distressed
because of fewer day-to-day hassles, all of which could potentially
improve physical and emotional energy toward better parenting.
Parents also might be happier and feel closer to their children or
more empowered to improve their children’s lives. We will obtain
both parent and youth perspectives on parenting behavior,
particularly since youth disclosure of information to parents about
things like the names of their friends influences parental reporting of
monitoring.
Interim
Original
NELS
NELS
Interim
Parenting, contact with fathers, and access to positive role models
are also proposed hypotheses for understanding MTO’s interim
effects on female vs. male youth. Findings from the MTO interim
evaluation showed that MTO male youth reported higher levels of
father contact and contact with male figures than male youth in the
control group. Findings from the MTO interim evaluation also
suggest that female youth were surrounded and more receptive to
positive adult role models.
Page G-56
YOUTH REPORT ON PARENTS AND PARENTING
Question
Question
Number
YOP7
Who is the adult who lives with you and knows the most about
your activities?
YOP8
When you think about how your [CAREGIVER] acts toward
you, in general, would you say your [CAREGIVER] is very
supportive, somewhat supportive, or not very supportive?
YOP9a
(RB) How much does your [CAREGIVER] know……about
your close friends, that is, who they are? Do you think she/he
knows nothing, just a little, some things, most things, or
everything?
YOP9b
(RB) (How much does your [CAREGIVER] know) about who
you are with when you are not at home?
YOP9c
(RB) (How much does your [CAREGIVER] know) About who
your teachers are [who your teachers were when you were last
enrolled in school] and what you (are/were) doing in school?
YOP10a
(RB) How often does your (CAREGIVER) limit privileges
because of poor grades? Never, rarely, sometimes, often
YOP10b
(RB) (How often does your (CAREGIVER)) Check on
whether you have done your homework?
YOP10c
(RB) (How often does your (CAREGIVER)) Help you with
your homework?
YOP10d
(RB) (How often does your (CAREGIVER)) Limit the amount
of time you go out with friends on school nights?
YOP10e
(RB) (How often does your (CAREGIVER)) Require you to do
work or chores around the home?
YOP10f
(RB) (How often does your (CAREGIVER)( Limit you from
leaving home to hang out with your friends?
YOP11
Did (CAREGIVER) ever have a problem with drinking
alcohol, or using drugs?
YOP12
Now I’d like to talk with you about your father. When you
were growing up, in general, was he very supportive,
somewhat supportive, or not very supportive of you?
YOP12a
In the past 12 months, how often have you seen your father?
YOP13
How far in school do you think your father wants you to go?
MTO Youth Item Table
Source
Justification/Notes
Interim
Interim
Interim
NELS
NELS
NELS
NELS
NELS
NELS
Interim
Interim
Interim
NELS
Page G-57
YOUTH REPORT ON PARENTS AND PARENTING
Question
Question
Number
YOP14a
(RB) How much does your father know about your close
friends, that is, who they are? Do you think he knows nothing,
knows just a little, knows some things, knows most things, or
knows everything?
YOP14b
(RB) (How much does your father know) about who you are
with when you are not at home?
YOP14c
(RB) (How much does your father know) about who your
teachers are [who your teachers were when you were last
enrolled in school] and what you (are/were) doing in school?
YOP15
In a typical week, what (is/was) the latest you (can/could) stay
out on school nights? (Sunday through Thursday)?
YOP16a.
If your parent or parents found out that you had come home an
hour late for no good reason, would (he/she/they) discuss it
calmly with you?
YOP16b.
(If your parent or parents found out that you had come home
an hour late for no good reason, would (he/she/they) ignore it,
pretend that it didn’t happen or let you get away with it
YOP16c.
(If your parent or parents found out that you had come home
an hour late for no good reason, would (he/she/they) sulk, pout,
or give you the silent treatment
YOP16d.
(If your parent or parents found out that you had come home
an hour late for no good reason, would (he/she/they) take away
a privilege, ground you or give you a chore
YOP16e.
(If your parent or parents found out that you had come home
an hour late for no good reason, would (he/she/they) make
threats that won’t be kept
YOP16f
(If your parent or parents found out that you had come home
an hour late for no good reason, would (he/she/they) yell,
shout or scream at you
YOP16g.
(If your parent or parents found out that you had come home
an hour late for no good reason, would (he/she/they) use
physical punishment
MTO Youth Item Table
Source
Justification/Notes
Interim
NELS
NLSY97m
NLSY97m
NLSY97m
NLSY97m
NLSY97m
NLSY97m
NLSY97m
Page G-58
DECISION MAKING
Question
Question
Number
YDM1a
(RB) Think about how you see your future. What are the
chances that: You will live to age 35? Would you say very
low, low, about 50-50, high, or very high?
YDM1b
(RB) What are the chances that you will complete college by
age 35? Would you say very low, low, about 50-50, high, or
very high?
YDM1c
(RB) (What are the chances that) You will find a stable, wellpaid job as an adult?
YDM2
Do you expect your life as an adult to be... Much like your own
family, Better than your own family, Worse than your own
family
YDM3
The next questions are about what you think your chances to
get ahead will be like. How much do you agree or disagree
with the following statements ....
(RB)As an adult, I will have just as much chance to succeed as
people from other neighborhoods. Do you....Strongly agree,
Agree, disagree, strongly disagree
YDM4
Most people in my neighborhood will be better off than me.
Strongly agree, agree, disagree, strongly disagree
YDM5a
Suppose that after having helped a relative with some chores,
they offer to send you a small amount of money in return for
your help. They tell you that they can either send you
something now, or send you a little more if you are willing to
wait one month. If they pay you now, they will put $20 in the
mail tomorrow. If they pay you one month from now, they
will send you slightly more than that. Suppose that you trust
them to pay you what they promise, when they promise it.
Would you rather they mailed you $20 tomorrow or $21 three
months from now?
YDM5b
Now suppose the choice were between $20 now and $22 one
month from now. Would you rather they mailed you $20
tomorrow or $22 three months from now?
YDM5c
Now suppose the choice were between $20 now and $21 one
month from now. Would you rather they mailed you $20
tomorrow or $23 three months from now?
MTO Youth Item Table
Source
Justification/Notes
AddHealth
YDM Module Overall
The specific hypothesis underlying the inclusion of these measures is
that neighborhood characteristics can affect these aspects of decision
making, which can in turn affect socioeconomic outcomes. That is,
decision making processes and attitudes may be an important
mediator through which MTO impacts participant outcomes.
The general approach of the module is to fold the Interim’s future
planning questions into this larger module that measures or elicits
information about future orientation, future plans, risky attitudes,
and altruism and trust. This includes revisions of the items on future
plans, new items on future orientation, and new items on altruism
and trust, all of which will complement proposed measures for the
MTO long-term adult survey.
Interim
Interim
PHDCN
PHDCN
PHDCN
Original
Page G-59
DECISION MAKING
Question
Question
Number
YDM5d
Now suppose the choice were between $20 now and $24 one
month from now. Would you rather they mailed you $20
tomorrow or $24 three months from now?
YDM5e
Now suppose the choice were between $20 now and $25 one
month from now. Would you rather they mailed you $20
tomorrow or $25 three months from now?
YDM6
Suppose a relative of yours calls to say they just inherited some
money and part of it should be yours. Because of the way their
inheritance is being distributed, they can either send you some
money now, or a larger amount of money later, which they
would send to you on your next birthday. Suppose that you
trust this person to send what they promise, and that you do not
expect to get a birthday present from this relative other than
this money.
Would you rather they mailed you $50 tomorrow or that they
send you $60 on your next birthday?
YDM7a
Suppose you have a choice between two, equally good summer
jobs. The first would pay you $600 for the summer for sure.
The second job would pay you an amount that depends on how
the company as a whole did for the summer. It is possibly
better paying, but your earnings will be less certain.
There is a 50-50 chance that the second job will pay $1200, but
there is a 50-50 chance it will pay $400. Which would you
choose – the job that pays $600 for sure, or the job with an
equal chance of paying either $1200 or $400?
YDM7b
Now suppose there is a 50-50 chance that the second job will
pay $1200, but there is a 50-50 chance that it will pay $300.
Which would you choose – the job that pays $600 for sure, or
the job with an equal chance of paying either $1200 or $300?
YDM7c
Now suppose there is a 50-50 chance that the second job will
pay $1200, but there is a 50-50 chance that it will pay $150.
Which would you choose – the job that pays $600 for sure, or a
job with an equal chance of paying either $1200 or $150?
YDM7d
Now suppose there is a 50-50 chance that the second job will
pay $1200, but there is a 50-50 chance that it will pay $480.
Which would you choose – the job that pays $600 for sure, or a
job with an equal chance of paying either $1200 or $480?
MTO Youth Item Table
Source
Justification/Notes
PSIDModified
This question asks about the respondent’s willingness to accept
different (risky) job prospects. Survey items already included in the
risky behavior module (e.g., smoking, drinking and sexual activity)
can serve double-duty as indicators of risk attitudes
PSIDModified
PSIDModified
PSIDModified
Page G-60
YDM7e
YDM8a
YDM8b
YDM8c
YDM8d
YDM9
YDM10
YDM11
YDM12
Now suppose there is a 50-50 chance that the second job will
pay $1200, and a 50-50 chance that it will pay $540. Which
would you choose – the job that pays $600 for sure, or a job
with an equal chance of paying either $1200 or $540?
(RB) Now, I want to ask you about trusting different groups of
people. First, thinking about people in your immediate family,
generally speaking would you say you can trust them a lot,
trust them some, trust them only a little or not trust them at all?
(RB) How about people in your neighborhood?
(RB) How about other people in general?
(RB) Next, I have a question about the police department in
your area. Do you feel you can trust them a lot, some, only a
little or not at all?
Generally speaking, would you say that most people can be
trusted or that you can’t be too careful in life?
(RB) Next, I am going to read you a list of statements and for
each, please tell me if you strongly agree, agree, disagree, or
strongly disagree? I trust the people I hang around with at
school.
I trust other students at my school, even if I don’t know them.
Each randomly-selected sub-set of MTO youth respondents
who are chosen to participate in the time preference
experiment subgroup is offered the following choice:
Thank you for completing the MTO survey and achievement
tests for this important HUD study. With some additional
support from several private foundations we are pleased to be
able to offer you a small amount of additional compensation
that is available in two forms. Either a check for $20 that we
will put in the mail tomorrow or a check for $25 that we could
put in the mail on your next birthday. Which would you prefer
-- $20 sent tomorrow, or $25 sent on your next birthday?
GPSTS
GPSTS
Original
GPSTS
GSS
R. Ferguson
Tripod
R. Ferguson
Tripod,
modified
Original
This choice is designed to uncover rates of time preference. It is
original to the MTO final evaluation. It corresponds with the survey
question on time preference. Variation in the distance in time
between the survey date and the respondent’s next birthday will
generate variation in the ranges into which the respondent’s choice
brackets her discount rate.
CONTACT INFORMATION
Question
Question
Number
YI1
To continue to help the government learn how to improve housing
programs, it is very important that we talk to people periodically to
see how things are going. Since people often move, we would like
to ask you for the names of friends or relatives who usually keep in
touch with you. We would contact these people only if we were
unable to reach you at your current phone number. We would ask
them only for your address and telephone information.
(IF NO CONTACT PERSON INFORMATION AVAIALBLE
FROM PREVIOUS CONTACTS: Please give me the name of three
people who do not live with you and who will know how to reach
you if we need to contact you again to verify this interview or to ask
a few additional questions.)
(IF CONTACT INFORMATION AVAILABLE: In the past you
gave us information on the following three people. I would like to
make sure that we have the most current information for them, and
that they are the best people to use to find you.)
Interviewer will collect/update name, relationship to respondent,
address and telephone number of up to three contact persons.
MTO Youth Item Table
Source
Justification/Notes
MTO Interim
modified
Contact person information is collected for quality control and
other follow-up activities.
Page G-62
Appendix H:
Federal Register Notice
National Bureau of Economic Research
University of Michigan – ISR
Appendices
jlentini on PROD1PC65 with NOTICES
16382
Federal Register / Vol. 72, No. 64 / Wednesday, April 4, 2007 / Notices
Reduction Act. The Department is
soliciting public comments on the
subject proposal.
DATES: Comments Due Date: June 4,
2007.
ADDRESSES: Interested persons are
invited to submit comments regarding
this proposal. Comments should refer to
the proposal by name and/or OMB
Control Number and should be sent to:
Reports Management Liaison Officer,
Office of Policy Development and
Research, Department of Housing and
Urban Development, 451 7th Street,
SW., Room 8234, Washington, DC
20410–5000.
FOR FURTHER INFORMATION CONTACT: Mr.
Michael Blanford, Research Engineer,
Office of Policy Development and
Research, Department of Housing and
Urban Development, 451 7th Street,
SW., Room 8134, Washington, DC
20410–5000. Call (202) 402–5728 for
copies of the proposed forms and other
available documents. (This is not a tollfree number).
SUPPLEMENTARY INFORMATION: The
Department will submit the proposed
information collection to OMB for
review, as required by the Paperwork
Reduction Act of 1995 (44 U.S.C.
Chapter 35, as amended). This Notice is
soliciting comments from members of
the public and affected agencies
concerning the proposed collection of
information to: (1) Evaluate whether the
proposed collection of information is
necessary for the proper performance of
the functions of the agency, including
whether the information will have
practical utility; (2) Evaluate the
accuracy of the agency’s estimate of the
burden of the proposed collection of
information; (3) Enhance the quality,
utility, and clarity of the information to
be collected; and (4) Minimize the
burden of the collection of information
on those who are to respond, including
through the use of appropriate
automated collection techniques or
other forms of information technology
(e.g., permitting electronic submission
of responses).
This Notice also lists the following
information:
Title of Proposal: Humidity
Monitoring Survey.
Description of the need for the
information and proposed use: This
request is for the clearance of a survey
instrument designed to measure the
humidity levels in single family
residences. The purpose of the survey
is: (1) Collect moisture load data to
support research to better understand
the impact of moisture on the durability
of homes; (2) Support the development
of design criteria, such as ASHRAE
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Standard 160P, that will minimize
durability problems associated with
high moisture levels; (3) Investigate the
influence of the interior and exterior
conditions on the moisture level of
typical single family detached homes.
OMB Approval Number: Pending
OMB approval.
Agency form numbers: None.
Members of Affected Public:
Individuals.
Estimation of the total number of
hours needed to prepare the information
collection including number of
respondents, frequency of response, and
hours of response: 70 individuals will
be surveyed in person. Average time to
complete the survey is 20 minutes.
Respondents will be contacted three
times, once every six months. Total
burden hours are 70.
Status of the proposed information
collection: New.
Authority: Section 3506 of the Paperwork
Reduction Act of 1995, 44 U.S.C. Chapter 35,
as amended.
Dated: March 29, 2007.
Darlene F. Williams,
Assistant Secretary for Policy Development
and Research.
[FR Doc. E7–6226 Filed 4–3–07; 8:45 am]
BILLING CODE 4210–67–P
DEPARTMENT OF HOUSING AND
URBAN DEVELOPMENT
[Docket No. FR–5123–N–09]
Notice of Proposed Information
Collection for Public Comment on the
Final Evaluation of the Moving to
Opportunity Program
Office of the Policy
Development and Research, HUD.
ACTION: Notice.
AGENCY:
The proposed information
collection requirement described below
will be submitted to the Office of
Management and Budget (OMB) for
review, as required by the Paperwork
Reduction Act. The Department is
soliciting public comments on the
subject proposal.
DATES: Comments Due Date: June 4,
2007.
SUMMARY:
Interested persons are
invited to submit comments regarding
this proposal. Comments should refer to
the proposal by name and/or OMB
Control Number and should be sent to:
Reports Liaison Officer, Office of Policy
Development and Research, Department
of Housing and Urban Development,
451 7th Street, SW., Room 8234,
Washington, DC 20410.
ADDRESSES:
PO 00000
Frm 00058
Fmt 4703
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FOR FURTHER INFORMATION CONTACT:
Todd M. Richardson, Program
Evaluation Division, Policy
Development and Research, Department
of Housing and Urban Development,
451 7th Street, SW., Room 8140,
Washington, DC 20410–5000. Call (202)
402–5706 (this is not a toll-free number)
or [email protected] for
copies of the proposed forms and other
available documents.
SUPPLEMENTARY INFORMATION: The
Department will submit the proposed
information collection to OMB for
review, as required by the Paperwork
Reduction Act of 1995 (44 U.S.C.
Chapter 35, as amended). This Notice is
soliciting comments from members of
the public and affected agencies
concerning the proposed collection of
information to: (1) Evaluate whether the
proposed collection of information is
necessary for the proper performance of
the functions of the agency, including
whether the information will have
practical utility; (2) Evaluate the
accuracy of the agency’s estimate of the
burden of the proposed collection of
information; (3) Enhance the quality,
utility, and clarity of the information to
be collected; and (4) Minimize the
burden of the collection of information
on those who are to respond, including
through the use of appropriate
automated collection techniques or
other forms of information technology
(e.g., permitting electronic submission
of responses).
This Notice also lists the following
information:
Title of Proposal: Final Evaluation of
the Moving to Opportunity (MTO)
Program.
Description of the need for the
information and proposed use: This
request is for the clearance of several
survey instruments for the Final
Evaluation of the Moving to
Opportunity (MTO) demonstration
program. Authorized by Congress in the
Housing and Community Development
Act of 1992, MTO is a unique
experimental research demonstration
designed to learn whether moving from
a high-poverty neighborhood to a lowpoverty neighborhood significantly
improves the social and economic
prospects of poor families. Families
living in high poverty public and
assisted housing in Baltimore, Boston,
Chicago, Los Angeles and New York
who applied for MTO were randomly
assigned into two treatment groups and
one control group between 1994 and
1998. Families assigned to the treatment
groups were provided Section 8 to allow
them to move out of the high poverty
developments. Families in one of the
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jlentini on PROD1PC65 with NOTICES
Federal Register / Vol. 72, No. 64 / Wednesday, April 4, 2007 / Notices
treatment groups received intensive
mobility counseling and were required
to lease a unit in a neighborhood with
less than ten percent poverty. The other
treatment group families could lease a
unit wherever they chose, but only
received the normal housing authority
counseling. Those families assigned to
the control group did not receive any
Section 8 assistance but continued to
receive project-based assistance.
This data collection is necessary to
measure impacts and mediators
approximately 10 to 14 years after
families were randomly assigned to the
two treatment groups and the control
group. The data are planned to be
collected for the following primary
outcome domains: housing mobility and
assistance; neighborhoods and social
networks, adult education, employment
and earnings; household income and
cash assistance; adult, youth, and child
physical and mental health; youth and
child emotional and social well-being,
including delinquency and risky
behavior; and youth and child
educational performance.
Interviews are estimated to be
completed for 3,900 adult heads of
household using the adult interview
guide and approximately 5,800 youth
between the ages of 10 and 20 using the
youth interview guide. The youth and
children noted above will be
administered a math and reading
achievement assessment. Subject to
final decisions by the research team and
HUD, as well as Institutional Review
Board approval, the interviews will also
include collection of biomarker data via
finger pricks to obtain dried blood spots
of MTO participants. All interviewers
and testing will be conducted in-person
or on the telephone by interviewers
using computer-assisted personal
interviewing (CAPI) or computerassisted telephone interviewing
software to directly input the data into
a computer. Incentive payments will be
made to respondents participating in
this survey in order to ensure a high
response rate. Data gathered will be
used by the National Bureau of
Economic Research to prepare a report
to HUD on the long-term impacts of
MTO. Subject to maintaining the
privacy and confidentiality of
respondents, the data collected will also
be used by academics and HUD policy
analysts to further explore what specific
neighborhood mediating factors
contribute to the neighborhood impact
on outcomes for families and children.
The information will be used by HUD
and Congress to guide future housing
policy in many areas, including housing
mobility assistance and the location and
concentration of assisted housing.
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17:57 Apr 03, 2007
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OMB Control Number: Pending
approval.
Agency form numbers: None.
Members of Affected Public:
Individuals and Households.
Estimation of the total number of
hours needed to prepare the information
collection including number of
respondents, frequency of response, and
hours of response: 3,900 adults at 75
minutes; 5,800 youth with 45 minute
survey and 45 minute achievement test.
One-time response, total 12,910
reporting burden hours.
Status of the proposed information
collection: New.
Authority: Section 3506 of the Paperwork
Reduction Act of 1995, 44 U.S.C. Chapter 35,
as amended.
Dated: March 29, 2007.
Darlene F. Williams,
Assistant Secretary for Policy Development
and Research.
[FR Doc. E7–6227 Filed 4–3–07; 8:45 am]
BILLING CODE 4210–67–P
DEPARTMENT OF THE INTERIOR
Fish and Wildlife Service
Receipt of Applications for Permit
Fish and Wildlife Service,
Interior.
ACTION: Notice of receipt of applications
for permit.
AGENCY:
The public is invited to
comment on the following applications
to conduct certain activities with
endangered species and marine
mammals.
DATES: Written data, comments or
requests must be received by May 4,
2007.
ADDRESSES: Documents and other
information submitted with these
applications are available for review,
subject to the requirements of the
Privacy Act and Freedom of Information
Act, by any party who submits a written
request for a copy of such documents
within 30 days of the date of publication
of this notice to: U.S. Fish and Wildlife
Service, Division of Management
Authority, 4401 North Fairfax Drive,
Room 700, Arlington, Virginia 22203;
fax 703/358–2281.
FOR FURTHER INFORMATION CONTACT:
Division of Management Authority,
telephone 703/358–2104.
SUPPLEMENTARY INFORMATION:
SUMMARY:
Endangered Species
The public is invited to comment on
the following applications for a permit
to conduct certain activities with
PO 00000
Frm 00059
Fmt 4703
Sfmt 4703
16383
endangered species. This notice is
provided pursuant to Section 10(c) of
the Endangered Species Act of 1973, as
amended (16 U.S.C. 1531 et seq.).
Written data, comments, or requests for
copies of these complete applications
should be submitted to the Director
(address above).
Applicant: Devon E. Pearse, NOAANational Marine Fisheries Service,
Southwest Fisheries Science Center,
Santa Cruz, CA, PRT–135127.
The applicant requests a permit to
import biological samples from Orinoco
crocodiles (Crocodylus intermedius) for
the purpose of enhancement of the
species through scientific research. This
notification covers activities conducted
by the applicant for a five-year period.
Applicant: Zoological Society of San
Diego, San Diego, CA, PRT–148347.
The applicant requests a permit to
export biological samples from Southern
white rhinoceros (Ceratotherium simum
simum) and Asian tapir (Tapirus
indicus) for the purpose of enhancement
of the species through scientific
research. This notification covers
activities conducted by the applicant for
a five-year period.
Applicant: Zoological Society of San
Diego, San Diego, CA, PRT–149091.
The applicant requests a permit to
export two live male California condors
(Gymnogyps californianus) to the
Chapultepec Zoo, Mexico for the
purpose of enhancement of the survival
of the species.
Applicant: Milwaukee County
Zoological Gardens, Milwaukee, WI,
PRT–149077.
The applicant requests a permit to
export one male captive-born Central
American tapir (Tapirus bairdii) to the
Africam Safari Zoo, Mexico for the
purpose of enhancement of the species
through captive breeding and
conservation education.
Applicant: Laurie A. Cotroneo, Drexel
University, Pennsylvania, PA, PRT–
149837.
The applicant requests a permit to
import biological samples from
American crocodile (Crocodylus acutus)
for the purpose of enhancement of the
species through scientific research. This
notification covers activities conducted
by the applicant for a five-year period.
Applicant: Wesley A. Miner,
Jacksonville, FL, PRT–148576.
The applicant requests a permit to
import the sport-hunted trophy of one
male bontebok (Damaliscus pygargus
pygargus) culled from a captive herd
maintained under the management
program of the Republic of South Africa,
E:\FR\FM\04APN1.SGM
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Appendix I:
MTO Enrollment Agreement
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Appendix J:
Consent Forms for the Final Evaluation
•
•
•
•
Adult Consent Form
Youth 18-20 Years Old Consent Form
Youth 10-17 Years Old Assent Form
Guardian Consent Form for Youth Under 18 Years Old
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page J-1
OMB Clearance Number:
Expires: mm/dd/yy
Adult Consent Form for the Moving to Opportunity Study
You are invited to take part in a study called Moving to Opportunity (MTO). This study will
help families have a safe place to live. The University of Michigan and the National
Bureau of Economic Research are doing this study for the Department of Housing and
Urban Development (HUD). The study is being paid for by HUD and other government
agencies and foundations. We are talking to over 9,000 people in families that were in
the Moving to Opportunity project about ten years ago, and will ask you to tell us when we
can interview you.
We will ask you questions about your family’s housing, your neighborhood, schooling,
jobs, and health. The interview will take about 75 minutes to do. At the end of the
interview, we will ask you to give a small blood sample by a finger prick, and to have your
height, weight and blood pressure measured. You can do the interview and decide not to
give the blood sample or have the measurements taken. If any part of the interview is
upsetting to you, you can talk with our social worker. You will also be given a list of helpful
telephone numbers and websites that you can go to for help if you need it.
Your answers will be combined with information from HUD and other agencies to tell us
how MTO families are doing now. Your answers to the questions will be kept private.
Your name, address, and telephone number will be kept separate from the answers to the
questions. Only HUD and the research team will see your answers. The information you
give us will be used by researchers for many years.
Your privacy is very important to us. HUD has a Certificate of Confidentiality. This is a
legal document that lets HUD refuse to give out information that could identify you, even if
a court asks for it. Still, if keeping your answers private would put you, someone else, or
your child in serious danger, then we will have to tell government agencies to protect you
or the other person. And, the government may see your information if it audits us; but it,
too, will protect your privacy.
Your participation is voluntary and you may stop the interview at any time. You will not
lose any benefits if you decide not to participate. If you want to stop the interview at any
time, all you have to say is, “I want to stop.” You can answer only questions that you
want to answer. We will pay you [$50/$100] when the interview is over to thank you
for finishing it. If you decide to give a blood spot sample and have your height, weight
and blood pressure taken, you will receive an extra payment of $25.
A supervisor may contact you to check on how well we did and how you felt about the
interview. The supervisor may ask you to do a short follow-up interview.
If you have questions you can ask the interviewer or call the University of Michigan at 1800-759-7947 (English) or 1-800-643-7605 (Spanish). The phones are answered
Monday through Thursday from 9:00 a.m. – 9:00 p.m.; Friday from 9:00 a.m. – 5:00 p.m.,
and Saturday from 12:00 noon to 4:00 p.m. Eastern Time. Please say you are calling
about the MTO study. You will be given a copy of this form.
Consent to Participate
The signature below shows that you have read, or that an interviewer has read to you, the
above information and you agree to participate.
________________________________
Respondent Signature
__________________
Date
Consent to Audio Record
If you agree, we may audio record the interview. The recording will only be used to make
sure the interviewer is doing a good job, and to help us understand how language styles
change in neighborhoods. The recordings are kept private and will be destroyed when
the study is finished. Only University of Michigan employees and people on the MTO
research team are allowed to listen to the recordings. Your signature below shows that
you agree to have your interview recorded. You may still do the interview if you do not
want to have it recorded.
________________________________
Respondent Signature
__________________
Date
OMB Disclaimer
Public reporting burden for this study averages 95 minutes for each adult. This includes the time for
answering the interview questions and completing physical measurements and giving blood samples. This
agency may not collect this information, and you do not have to respond to this survey, unless this form
shows a currently valid OMB control number. HUD will use the information to understand how
neighborhoods affect families and to improve its housing programs.
Sensitive Information
The information collected is sensitive and is protected by the Privacy Act and a Certificate of Confidentiality.
This information is being collected as part of a study of the MTO program originally authorized by Congress
in the Housing and Community Development Act of 1992. The information you give will help HUD find out
what effect MTO has on family safety, health, employment, education, and other outcomes. The
information will be used for research purposes only. HUD will not release your answers outside of HUD for
any other purpose. The Certificate of Confidentiality protects the data from being released for any nonresearch purpose. You are not required to respond to this survey and your benefits will not be affected by
whether or not you respond to the survey.
IRB Clearance
This study has been reviewed by the Institutional Review Board (IRB) at the University of Michigan. If you
have questions about your rights on this study, contact the IRB at 540 E. Liberty Street, Suite 202 in Ann
Arbor MI 48104-2210. The phone number is (734) 936-0933 and email address is [email protected].
OMB Clearance Number:
Expires: mm/dd/yy
Adult Consent Form for Physical Measures and Blood Spot Sampling
for The Moving to Opportunity Study
You are now being asked to have your height and weight measured and your blood
pressure taken, and to provide a small amount of blood from a finger prick. This
information will help us learn more about how the Moving to Opportunity program might
help improve the long-term health of people like you. The dry blood spots are sent to a
lab to get measures of Total cholesterol (TC) and high density lipoprotein (HDL), which
are related to heart disease; Glycosylated hemoglobin, for diabetes; and C-Reactive
protein, for inflammation and related to heart disease. We will also measure Cortisol,
Epstein-Barr virus antibody levels and stress-related hormones that are connected with
many long-term health outcomes.
This part of the study will help researchers understand the connections between health
and things like income and employment. All adults are being asked to have their physical
measurements taken and to give blood spot samples. I understand that if I agree to
participate it means:
a) I understand that I will be asked to have my blood pressure taken, and my
height and weight measured.
b) I understand that I will be asked to provide a small blood sample. My finger will
be pricked and my blood will be collected on a blood spot collection card.
c) I understand that the blood spot collection card will be sent to a laboratory to be
analyzed for Cholesterol (TC and HDL), Glycosylated hemoglobin, C - reactive
protein, and stress-related hormones.
d) I understand that a few drops of my blood will be put in a machine that will test
my cholesterol level in my home.
e) I understand that I will complete these measurements only if I agree to do so.
My participation is voluntary. I am NOT required to do this, and I can stop at
any time.
f) I will receive an extra $25 payment for having my height and weight measured,
my blood pressure taken and giving the blood sample. I will receive [$50/$100]
for completing the interview,,even if I decide not to have my measurements
taken or give the blood sample.
g) My measurements and the results of the blood tests will be kept private in the
same way as the rest of my information. I will not be identified in any reports.
Records will be kept private as much as is allowed by federal, state, and local
law. However, the Institutional Review Board and the MTO research team and
government officials responsible for monitoring this study may see my records.
They will also protect my privacy.
h) HUD has obtained a Certificate of Confidentiality. With this certificate, the
researchers can not be forced to give information that may identify me in any
federal, state, or local civil, criminal, administrative, legislative, or other
proceedings.
i) I will be given a copy of my blood pressure results and will be told if it is above
the normal range. I will be told how to share this information with my family
doctor.
j) I will be given a copy of my cholesterol reading and mailed a copy of my other
blood test results. I will be told if the readings are outside the normal range. I
will be told to share this information with my doctor. I will be told if there was
not enough blood on the card to be analyzed.
k) It will take about 20 minutes to do these measurements.
l) There are no known risks with doing this interview or with taking part in this
study. I may have a small amount of pain from the finger prick. If I get hurt
doing this study, no payment or free medical treatment will be paid by any of
the sponsors of this project.
m) I understand that I will receive the results of my blood tests, and that other
people may also gain from what is learned from this study.
n) I may ask questions at any time and will get truthful answers. I can ask the
interviewer, or call the Survey Director, Nancy Gebler, at the University of
Michigan at (800) 759-7947.
o) I will receive a copy of this form.
The signature below shows that you agree to complete this measurement.
_______________________________
Respondent Signature
________________
Date
OMB Clearance Number:
Expires: mm/dd/yy
Adult Consent Form for Release of Administrative Records
for The Moving to Opportunity Study
Part of our research includes getting information about you from Social Security, welfare,
or other government agencies. The agencies include state departments of labor, local
school districts, and state unemployment insurance agencies. We are asking for your
permission to contact some government and private agencies and ask them for
information about you and your children.
The information will be combined with your survey answers to help us understand how
MTO families are doing now and will help us learn how to help families have a safe place
to live. The information we collect will be used only for research. Only HUD and
members of the MTO research team can see your records. You may still participate in
this study if you do not want these records released.
Here are some examples of the types of information we will ask for:
¾ Records of how much money you earned from your state’s department of labor;
¾ Your children’s school records, including information about how they scored on
achievement tests, their school absences, if they repeated a grade, and how they
are doing in school;
¾ Your and your children’s records from the criminal justice system, including motor
vehicle violations or arrests for other reasons;
¾ Your and your children’s Medicare or Medicaid records;
¾ Your and your children’s participation in TANF, Food Stamps, or other social
programs.
I understand that if I agree to allow MTO researchers to request this information about me
and my children, it means:
a) I understand that NBER will ask for information about me and my children from
agencies like those listed above.
b) I understand that NBER may send a copy of this form to authorize release of
my and my children’s records.
c) I understand that I will sign this form only if I agree to do so. My participation is
voluntary. I am NOT required to do this.
d) The information from my records and my children’s records will be kept private
in the same way as the rest of the interview data. We will not be identified in
any reports. Records will be kept private as much as is allowed by federal,
state, and local law. However, the Institutional Review Board and the MTO
research team and government officials responsible for monitoring this study
may see these records. They will also protect our privacy.
e) HUD has obtained a Certificate of Confidentiality. With this certificate, the
researchers cannot be forced to give out information that may identify me or my
children in any federal, state, or local civil, criminal, administrative, legislative,
or other proceedings.
f) I understand that I will not be paid for allowing records to be released to the
research team.
g) I understand that although I will not receive direct benefit from my participation,
others may gain from what is learned in this study.
h) I may ask questions at any time and will get truthful answers. I can ask the
interviewer, or call the Project Director, Dr. Jens Ludwig, at the University of
Chicago at (773) 702-3242.
i) I will receive a copy of this form.
The signature below shows that you agree to allow agencies to provide your and your
children’s records to the MTO research team, led by researchers from the National
Bureau of Economic Research, Inc. at 1050 Massachusetts Avenue, Cambridge, MA
02138-5398.
________________________________
Respondent Signature
__________________
Date
Respondent Social Security Number: ________________________________
Child’s Name: ______________________ Date of Birth: _____________
Child’s Name: ______________________ Date of Birth: _____________
Child’s Name: ______________________ Date of Birth: _____________
Child’s Name: ______________________ Date of Birth: _____________
OMB Clearance Number:
Expires: mm/dd/yy
Youth Ages 18-20 Consent Form for the Moving To Opportunity Study
You are invited to take part in a study called Moving to Opportunity (MTO). This study
will help families have a safe place to live. The University of Michigan and the National
Bureau of Economic Research are doing this study for the Department of Housing and
Urban Development (HUD). The study is being paid for by HUD and other government
agencies and foundations. We are talking to over 9,000 people in families that were in
the Moving to Opportunity project about ten years ago, and will ask you to tell us when
we can interview you.
During the interview, you will be asked questions about where you live, your schooling
and jobs, your health and any stressful experiences you have had, and risky things you
may do. The interview takes about 1 hour and 45 minutes. We will measure how tall
you are and how much you weigh, and give you a 45 minute achievement test. If any
part of the study upsets you, you can talk with our social worker. We will also give you a
list of helpful telephone numbers that you can call for help if you need it.
Your answers will be put together with information from HUD and other agencies to tell
us how MTO families are doing now. Your answers will be kept private. Information like
your name, address, and telephone number will be kept separate from your answers to
the questions. Only people on the research team will see your answers. The
information you give us will be used by researchers for many years.
Your privacy is very important to us. HUD has a Certificate of Confidentiality. This is
a legal paper that lets HUD refuse to give anyone your name, even if a court asks for it.
Still, if keeping your answers private would put you or someone else in serious danger,
then we will have to tell government agencies to protect you or the other person. And,
the government may see your information if it checks on us, but it, too, will protect your
privacy.
You do not have to do this study. You can stop the interview at any time. You will not
lose any benefits if you decide not to do the interview. If you want to stop, all you have
to say is, “I want to stop.” You can answer only questions that you want to answer. We
will give you [$50/$100] after the interview to thank you for finishing it.
A supervisor may contact you to check on how well we did and how you felt about the
interview. The supervisor may ask you to do a short follow-up interview.
If you have questions about this study, please ask the interviewer or call the University
of Michigan at 1-800-759-7947. Say you are calling about the MTO study. You will be
given a copy this form.
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page J-10
Consent to Participate
Your signature below shows that you have read, or that an interviewer has read to you,
this form and you agree to participate.
________________________________
Respondent Signature
_________________
Date
Consent to Audio Tape
If you agree, we may audio record the interview. The recording will only be used to
make sure the interviewer is doing a good job, and to help us understand how language
styles change in different neighborhoods. The recordings are kept private and will be
destroyed when the study is done. Only University of Michigan employees and people
on the MTO research team are allowed to listen to the recordings. Your signature
below shows that you agree to have the interview recorded. You may still do the
interview if you do not want to have it recorded.
________________________________
Respondent Signature
_________________
Date
OMB Disclaimer
Public reporting burden averages 105 minutes for 18 to 20 year old respondents. This includes the time
for answering the interview questions and doing an achievement test. This agency many not collect this
information, and you do not have to respond to this survey, unless this form shows a current OMB control
number. HUD will use the information to understand how neighborhoods affect families and to improve
its housing programs.
Sensitive Information
The information collected is sensitive and is protected by the Privacy Act and a Certificate of
Confidentiality. This information is being collected as part of a study of the MTO program originally
authorized by Congress in the Housing and Community Development Act of 1992. The information you
give will help HUD find out what effect MTO has had on family safety, health, jobs, schooling, and other
outcomes. The information will be used for research purposes only. HUD will not release your answers
outside of HUD for any other purpose. The Certificate of Confidentiality protects the data from being
released for any non-research purpose. You are not required to respond to this survey and your benefits
will not be affected by whether or not you respond to the survey
IRB Clearance
This research study has been reviewed by the Institutional Review Board (IRB) at the University of
Michigan. If you have questions about your rights on this study, contact the IRB, at 540 E. Liberty Street,
Suite 202, Ann Arbor MI 48104-2210. The phone number is (734) 936-0933. The email address is
[email protected].
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page J-11
OMB Clearance Number:
Expires: mm/dd/yy
Youth Ages 18-20 Consent Form for Release of Administrative Records
for The Moving to Opportunity Study
Part of our research includes getting information about you from Social Security, welfare,
or other government agencies including state departments of labor, local school districts,
and state unemployment insurance agencies. We are asking for your permission to
contact some government and private agencies and obtain information from them about
you.
The information will be put together with your survey answers to help us understand
how MTO families are doing now. The information we collect will used only for research.
Only HUD and members of the MTO research team can see your records. You may still
do the interview if you do not want to have your records released.
Here are some examples of the types of information we will ask for:
¾ Records of how much money you earned from your state’s department of labor;
¾ Your school records, including information from your achievement tests, school
absences, if you repeated a grade, and how you are doing in school;
¾ Your records from the criminal justice system, including motor vehicle violations
or arrests for other reasons;
¾ Your Medicare or Medicaid records;
¾ Your participation in TANF, Food Stamps, or other social programs
I understand that if I agree to allow MTO researchers to request this information about
me, it means:
a) I understand that NBER will ask for information about me from agencies like
those listed above.
b) I understand that NBER may send a copy of this form to authorize release of
my records.
c) I understand that I will sign this form only if I agree to do so. My participation
is voluntary. I do NOT have to do this.
d) The information from my records will be kept private in the same way as the
rest of the interview data. I will not be identified in any reports. Records will
be kept private as much as is allowed by federal, state, and local law.
However, the Institutional Review Board and the MTO research team and
government officials responsible for monitoring this study may see these
records. They will also protect my privacy.
e) HUD has obtained a Certificate of Confidentiality. With this Certificate, the
researchers can not be forced to give information that may identify me in any
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page J-12
f)
g)
h)
i)
federal, state, or local civil, criminal, administrative, legislative, or other
proceedings.
I understand that I will not be paid for letting my records be released to the
research team.
I understand that although I will not receive direct benefit from my
participation, others may gain from what is learned in this study.
I may ask questions at any time and will get truthful answers. I can ask the
interviewer, or contact the Project Director, Dr. Jens Ludwig, at the University
of Chicago: (773) 702-3242.
I will receive a copy of this form.
The signature below shows that you agree to allow agencies to provide your records to
the MTO research team, led by researchers from the National Bureau of Economic
Research, Inc. at 1050 Massachusetts Avenue, Cambridge, MA 02138-5398.
________________________________
Respondent Signature
__________________
Date
Respondent Social Security Number: ________________________________
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page J-13
OMB Clearance Number:
Expires: mm/dd/yy
Youth Age 10-17 Assent for the Moving To Opportunity Study
You are invited to take part in a study called Moving to Opportunity (MTO). This
study will help families have a safe place to live. The University of Michigan and
National Bureau of Economic Research are doing this study for the Department of
Housing and Urban Development (HUD). The study is paid for by HUD and other
government agencies and foundations. We are talking to over 9,000 people in
families that were in the Moving to Opportunity project about ten years ago. With
your parent’s or guardian’s permission, we will ask you when we can interview you.
We will ask you questions about where you live, your schooling and jobs, your health
and any stressful experiences you have had, and risky things you may do. The
interview takes about 1 hour and 45 minutes. We will measure how tall you are and
how much you weigh, and give you a 45-minute achievement test. If any part of the
study upsets you, you can talk with our social worker. We will also give you a list of
helpful telephone numbers that you can call for help if you need it.
Your answers will be put together with information from HUD and other agencies to
tell us how MTO families are doing now. Your answers will be kept private.
Information like your name, address, and telephone number will be kept separate
from your answers to the questions. Only people on the research team will see your
answers. The answers you give us will be used by researchers for many years.
Your privacy is very important to us. HUD has a Certificate of Confidentiality. This
is a legal paper that lets HUD refuse to give anyone your name, even if a court asks
for it. Still, if keeping your answers private would put you, or someone else in serious
danger, then we will have to tell government agencies to protect you or the other
person. And, the government may see your information if it checks on us; but it, too,
will protect your privacy.
You do not have to help us with this study. You can stop the interview at any time.
You will not lose any benefits if you decide not to do the interview. If you want to stop,
all you have to say is, “I want to stop.” You can answer only questions that you want
to answer. We will give you [$50/$100] after the interview is over to thank you
for finishing it.
A supervisor may contact you to check on how well we did and how you felt about the
interview. The supervisor may ask you to do a short follow-up interview.
If you have questions about the MTO study, please ask the interviewer or call the
University of Michigan at 1-800-759-7947. Say you are calling about the MTO study.
You will be given a copy of this form.
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page J-14
Assent to Participate
If you sign your name here it shows that you have read, or that an interviewer has
read to you, this form and you agree to do this interview.
_________________________________
Respondent Signature
________________
Date
Assent to Audio Tape
If you approve, we may record the interview. The recording will be used to make
sure the interviewer is doing a good job, and to help us understand how language
styles change in neighborhoods. The recordings are kept private and will be
destroyed when the study is finished. Only University of Michigan staff and people
on the MTO research team can listen to the recordings. If you sign your name here,
it shows that you agree to have your interview recorded. You may still do the
interview if you do not want to have it recorded.
_________________________________
Respondent Signature
____________________
Date
OMB Disclaimer
Public reporting burden averages 75 minutes for 10 to 12 year olds and about 105 minutes for every 13 to 17 year
old respondent. This includes the time to answer interview questions and take an achievement test. This agency
may not collect this information, and you do not have to respond to this survey, unless this form shows a current
OMB control number. HUD will use the information to understand how neighborhoods affect families and to
improve its housing programs.
Sensitive Information
The information collected is sensitive and is protected by the Privacy Act and a Certificate of Confidentiality. This
information is being collected as part of a study of the MTO program originally authorized by Congress in the
Housing and Community Development Act of 1992. The information you provide will help HUD to understand the
effect MTO has had on family safety, health, jobs, schooling, and other outcomes. The information will be used
for research purposes only. The Certificate of Confidentiality protects the data from being released for any nonresearch purpose. You are not required to respond to this survey and your benefits will not change if you do or do
not answer the survey questions.
IRB Clearance
This study has been reviewed by the Institutional Review Board (IRB) at the University of Michigan. If you have
questions about your rights on this study, contact the IRB at 540 E. Liberty Street, Suite 202 in Ann Arbor MI
48104-2210. The phone number is (734) 936-0933 and email address is [email protected].
National Bureau of Economic Research
University of Michigan – ISR
Appendices
OMB Clearance Number:
Expires: mm/dd/yy
Parents/Guardians of Youth Under Age 18 Consent Form for
Participation in the Moving To Opportunity Study
You children are invited to take part in a study called Moving to Opportunity (MTO).
This study will help families have a safe place to live. The University of Michigan and
the National Bureau of Economic Research are doing this study for the Department of
Housing and Urban Development (HUD). The study is paid for by HUD and other
government agencies and foundations. We are talking to over 9,000 people in
families that took part in the Moving to Opportunity project about ten years ago, and
your children have been selected for this important ten-year follow-up interview.
With your permission, your children will be asked questions about where they live,
their schooling and jobs, physical and mental health, and risky behaviors. The
interview takes about 1 hour and 45 minutes. We will measure their height and weight,
and give them a 45-minute achievement test. If any part of the study upsets your
children, they can talk to our social worker. We will also give them a list of helpful
telephone numbers that they can call for help if needed. Each child will receive a
payment of [$50/$100] to thank them after they complete the interview.
This study will follow strict rules to protect your children’s answers. Each child’s
answers will be kept private. Information like their name, address and telephone
number will be kept separate from their answers to the questions. They will never be
named in any reports about the study. The information they give us will be used by
researchers for many years.
Your children’s privacy is very important to us. HUD has obtained a Certificate of
Confidentiality. This is a legal paper that lets HUD refuse to give out any information
that could identify your children, even if a court asks for it. Still, if keeping your child’s
answers private would put your child, you, or someone else in serious danger; then we
will have to tell government agencies to protect you or the other person. And, the
government may see your child’s information if it checks on us; but it, too, will protect
your and your child’s privacy.
If you or your children have any questions, please ask the interviewer or call the
University of Michigan toll free at: 1-800-759-7947 (English) or 1-800-643-7605
(Spanish). The phones are answered Monday through Thursday, 9:00 a.m. – 9:00
p.m., Friday, 9:00 a.m. – 5:00 p.m., and Saturday, 12:00 noon to 4:00 p.m., Eastern
Time. Please say you are calling about the MTO study. You will get a copy of this
form.
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page J-16
Consent for Child(ren)’s Participation
Your signature below shows that you have read, or that an interviewer has read to you,
the above information and you agree to allow your children to participate.
Child’s Name ___________________ Date of Birth ________________
Child’s Name ___________________ Date of Birth ________________
Child’s Name ___________________ Date of Birth ________________
______________________________
Parent or Guardian Signature
______________
Date
Consent to Audio Tape
If you agree, we may audio record your children’s interviews. The recording will only
be used to make sure the interviewer is doing a good job, and to help us understand
how language styles change in different neighborhoods. The recordings are kept
private and will be destroyed when the study is done. Only University of Michigan
employees and people on the MTO research team are allowed to listen to the
recordings. Your signature below shows that you agree to have the interview
recorded. Your children may still participate in this study if you do not want to have
the interview recorded.
______________________________
Parent or Guardian Signature
______________
Date
OMB Disclaimer
Public reporting burden averages 75 minutes for 10 to 12 year olds and about 105 minutes for 13 to 20 year old
respondents. This includes the time for answering interview questions and completing an achievement test. This
agency may not collect this information and you do have to respond to this survey, unless this form displays a
currently valid OMB control number. HUD will use the information to understand how neighborhoods affect families
and to improve its housing programs.
Sensitive Information
The information collected is sensitive and is protected by the Privacy Act and a Certificate of Confidentiality. This
information is being collected as part of a study of the MTO program originally authorized by Congress in the
Housing and Community Development Act of 1992. The information you give will help HUD find out what effect
MTO has had on family safety, health, employment, education, and other outcomes. The information will be used
for research purposes only. HUD will not disclose or release your responses outside of HUD for any other
purpose. The Certificate of Confidentiality protects the data from being released for any non-research purpose.
You are not required to respond to this survey and your benefits will not be affected by whether or not you respond
to the survey.
IRB Clearance
This study has been reviewed by the Institutional Review Board (IRB) at the University of Michigan. If you have
questions about your rights on this study, contact the IRB at 540 E. Liberty Street, Suite 202 in Ann Arbor MI
48104-2210. The phone number is (734) 936-0933 and the email address is [email protected].
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page J-17
OMB Clearance Number:
Expires: mm/dd/yy
Parent/Guardian Consent Form for Release of Administrative Records
for The Moving to Opportunity Study
Part of our research includes getting information about you and your children from
Social Security, welfare, or other government agencies. The agencies include state
departments of labor, local school districts, and state unemployment insurance
agencies. We are asking for your permission to contact some government and private
agencies and ask them for information from them about you and your children.
The information will be combined with your children’s survey answers to help us
understand how MTO families are doing now and will help us learn how to help
families have a safe place to live. The information we collect will be used only for
research. Only HUD and members of the MTO research team can see your records.
Your children may still participate in this study if you do not want these records
released.
Here are some examples of the types of information we will ask for:
¾ Records of how much money you earned from your state’s department of labor;
¾ Your children’s school records, including information about how they scored on
achievement tests, their school absences, if they repeated a grade, and how
they are doing in school;
¾ Your and your children’s records from the criminal justice system, including
motor vehicle violations or arrests for other reasons;
¾ Your and your children’s Medicare or Medicaid records;
¾ Your and your children’s participation in TANF, Food Stamps, or other social
programs.
I understand that if I agree to let MTO researchers request this added information
about it me and my children, it means:
a) I understand that NBER will ask for information about me and my children
from agencies like those listed above.
b) I understand that NBER may send a copy of this form to authorize release
of my and my children’s records.
c) I understand that I will sign this authorization only if I agree to do so. My
participation is voluntary. I am NOT required to do this.
d) The information obtained from these records will be kept private in the same
way as the rest of the interview data. We will not be identified in any reports.
Records will be kept private as much as is allowed by federal, state, and
local law. However, the Institutional Review Board and the MTO research
team and governmental agencies responsible for monitoring this study may
see these records. They will also protect our privacy.
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page J-18
e) HUD has a Certificate of Confidentiality. With this Certificate, the
researchers cannot be forced to give information that may identify me or my
children in any federal, state, or local civil, criminal, administrative,
legislative, or other proceedings.
f) I understand that my children and I will not be paid for allowing records to be
released to the research team.
g) I understand that although I will not receive direct benefit from my
participation, others may gain from what is learned in this study.
h) I may ask questions at any time and can expect truthful answers. I can ask
the interviewer, or contact the Project Director, Dr. Jens Ludwig, at the
University of Chicago: (773) 702-3242.
i) I will receive a copy of this form.
The signature below shows that you agree to allow agencies to provide your and your
children’s records to the MTO research team, led by researchers from the National
Bureau of Economic Research, Inc. at 1050 Massachusetts Avenue, Cambridge, MA
02138-5398.
________________________________
Respondent Signature
__________________
Date
Respondent Social Security Number: ________________________________
Child’s Name: ______________________ Date of Birth:_____________
Child’s Name: ______________________ Date of Birth:_____________
Child’s Name: ______________________ Date of Birth:_____________
Child’s Name: ______________________ Date of Birth:_____________
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page J-19
Appendix K:
Recruitment Materials and Handouts
• Contact Participant Tracking Card
• Advance Letter to Residents
• Letter for Special Circumstances
o Too Busy Letter
o More Info Letter
o Gatekeeper Letter
o No Contact Letter
• Letter to Authorities
• Letter to Locked Buildings
• Letter to City Government
• MTO Study Fact Brochure
• National Hot Line Directory
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page K-1
INFORMANT REMINDER POSTCARD
UNIVERSITY OF MICHIGAN - INSTITUTE FOR SOCIAL RESEARCH
The next time you hear from:
Please contact us at 1-800-759-7947
with his/her current address and telephone number.
Address:
Phone: (
)
As a token of our appreciation, you will receive a check for $10 if the information
you provide leads us to your friend or relative.
WE NEED YOUR HELP!
University of Michigan - Institute of Social Research
We need help in locating one of your friends or family
members for an important national study.
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page K-2
The U.S. Department of Housing and Urban Development
Moving to Opportunity Demonstration Project
MTO Head of Household Advance Letter
Dear [NAME]
The U.S. Department of Housing and Urban Development (HUD) is contacting families who signed up
for the Moving to Opportunity (MTO) program to find out how they are doing 10 years after the
program started. You and your family became part of this program when a member of your family
applied for the MTO demonstration several years ago. At that time, a member of your family
completed a questionnaire and signed a statement allowing HUD and its researchers to talk to
him/her and his/her family members.
The University of Michigan is helping to conduct this research study for HUD. This study will help
HUD learn how to help families improve their housing situations in the future. You will be asked
questions about your family’s housing and neighborhood, education, employment, and health. The
answers you provide are important to HUD and its research team. You will receive a payment of
[$50/$100] to thank you for your time.
A professional interviewer from the University of Michigan Survey Research Center will be visiting
your neighborhood soon. The interviewer will wear a badge that identifies him/her as an interviewer
for the University of Michigan. Your participation is voluntary. If you agree to participate in this study,
you will be asked to complete a 75-minute survey interview. In order to better understand how
housing programs like MTO might improve the health outcomes of families, at the end of the interview,
you will be asked to provide a blood spot sample via a finger prick and have your blood pressure
measured. The blood spot sample will be analyzed for the measure of cholesterol levels, diabetic
status, cardiovascular and metabolic disease status, and hormones related to stress. If you decide to
provide a blood spot sample our interviewer will provide you with some key results such as for total
cholesterol and tell you whether your levels are above normal and help you figure out what to tell your
family doctor for help.
HUD and the University of Michigan are both very committed to protecting your privacy and can
assure you that your identity and privacy will be protected. You will not be named in any reports
about the study. HUD or people on HUD’s research team may look at your answers, but without your
name attached. HUD will only report results from groups of people, not individuals.
The enclosed brochure tells you more about MTO. You can also call the University of Michigan toll
free 1-800-759-7947 (English) or 1-800-643-7605 (Spanish). The toll-free lines are open Monday
through Thursday, 9:00 a.m. – 9:00 p.m., Friday, 9:00 a.m. – 5:00 p.m., and Saturday, 12:00 noon to
4:00 p.m., Eastern Time. Please refer to the MTO research project when you call. Thank you for
helping us with this important effort.
Sincerely,
Barbara Ward, Survey Manager
Survey Research Center
The University of Michigan
Should you have questions regarding your rights as a research participant, please contact the Institutional Review Board,
540 E. Liberty Street, Suite 202, Ann Arbor, MI 48104-2210, (734)936-0933, email: [email protected].
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page K-3
The U.S. Department of Housing and Urban Development
Moving to Opportunity Demonstration Project
Dear [RESIDENT TOO BUSY],
One of our interviewers recently called on you to ask for your participation in the Moving
to Opportunity (MTO) survey. The University of Michigan is conducting this research
study for the U.S. Department of Housing and Urban Development (HUD). I understand
you have a very busy schedule that makes it difficult to fit in an interview with us.
Because you are so important to the project, I would like to take a moment to explain
some things that might encourage you to find time to talk with us.
HUD has been conducting the MTO demonstration project since 1994. HUD is now
contacting families who signed up for MTO to find out how they are doing 10 years after
the program started. This study will help HUD learn how to help families improve their
housing situation in the future. Therefore, your contribution to this project is extremely
valuable. Without interviews from busy people such as yourself, we would end up with
findings that are biased towards people who have quite a bit of spare time and our
sample would not be representative of the population.
The information you share will be used to inform public policy and assist HUD in
improving the future housing situation. The only way for this project to meet its important
goal is to speak with people like you. Our research team will schedule visits at your
convenience. If you agree to participate, you will receive [$50/$100] for completing a
75-minute survey interview, and an additional $35 for having your blood pressure
measured and providing a small blood spot sample.
Your contribution to this project is very valuable and worthwhile. We understand you are
busy. Our interviewer will try to minimize the amount of time the interview will take.
When our interviewer contacts you again, we hope that you will choose to participate in
this research study. If you would like to suggest a time to reach you, please feel free to
contact the University of Michigan toll free at 1-800-759-7947 (English) or 1-800-6437605 (Spanish). The toll-free lines open Monday through Thursday, 9:00 a.m. – 9:00
p.m., Friday, 9:00 a.m. – 5:00 p.m., and Saturday, 12:00 noon to 4:00 p.m., Eastern
Time. Please refer to the MTO research project when you call. Thank you very much
for your assistance with this important research.
Sincerely,
Barbara Ward, Survey Manager
Survey Research Center
The University of Michigan
Should you have questions regarding your rights as a research participant, please contact the
Institutional Review Board, 540 E. Liberty Street, Suite 202, Ann Arbor, MI 48104-2210,
(734)936-0933, email: [email protected].
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page K-4
The U.S. Department of Housing and Urban Development
Moving to Opportunity Demonstration Project
Dear More Info:
An interviewer from the University of Michigan recently contacted you about participating
in the Moving to Opportunity (MTO) study. I understand that you have some
reservations about participating in the research study or talking with an interviewer.
Because your participation is so important to the success of the study, I would like to
take a moment to give you some more information about the important study.
This research study is being conducted by an experienced team of researchers at the
University of Michigan Survey Research Center and the National Bureau of Economic
Research for the U.S. Department of Housing and Urban Development (HUD). HUD
has been conducting the study of the MTO demonstration program since 1994. Now
HUD is contacting families who signed up for MTO to find out how they are doing 10
years after the program started. HUD wants to learn how to help families improve their
housing situation in the future.
Our interviewers are employees of the University of Michigan and carry U of M Survey
Research Center identification badges. The University is very committed to protecting
the confidentiality of our respondents and we follow very strict university and federal
guidelines regarding protection of respondents. Any identifying information will never be
released.
We are asking respondents to complete a survey interview that will take about 75
minutes, plus consider providing us with a few drops of blood from a finger prick in order
to help better understand how neighborhood and housing programs can help the longterm health outcomes of families. You may complete the interview without giving the
blood spot sample. If you agree to do the interview, you will receive [$50/$100]. If
you agree to provide a blood spot sample and have your blood pressure measured, you
will receive another [$35] and the interviewer will also give you your results from the
blood spot analysis, including your cholesterol level and instructions about how to share
that information with your family doctor.
If you have any questions regarding the research or the time for an interview, please call
us at: 1-800-759-7947 (English) or 1-800-643-7605 (Spanish). The toll-free lines are
open Monday through Thursday, 9:00 a.m. – 9:00 p.m., Friday, 9:00 a.m. – 5:00 p.m.,
and Saturday, 12:00 noon to 4:00 p.m., Eastern Time. Thank you in advance for your
help in completing this important survey effort.
Sincerely,
Barbara Ward, Survey Manager
Survey Research Center
The University of Michigan
Should you have questions regarding your rights as a research participant, please contact the
Institutional Review Board, 540 E. Liberty Street, Suite 202, Ann Arbor, MI 48104-2210,
(734)936-0933, email: [email protected].
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page K-5
The U.S. Department of Housing and Urban Development
Moving to Opportunity Demonstration Project
Dear Gatekeeper:
One of our interviewers recently asked (NAME OF RESPONDENT) to take part in the Moving to
Opportunity (MTO) program study. I understand you had some concerns about your
(RELATIONSHIP TO GATEKEEPER) being interviewed. Because your (RELATIONSHIP)
participation is so important to the success of the study, I would like to take a moment to explain
some things that might ease your concerns.
The University of Michigan is conducting this research study for the U.S. Department of Housing
and Urban Development (HUD). HUD is now contacting families who signed up for MTO to find
out how they are doing 10 years after the program started. This study will help HUD learn how to
help families improve their housing situation in the future.
The MTO interview takes about 75 minutes and contains questions on your (RELATIONSHIP)
housing and neighborhood, education, employment, and health. At the end of the interview, your
(RELATIONSHIP) will also be asked to provide a blood spot sample via a finger prick. The
sample is extremely important for measuring cholesterol levels, diabetic status, cardiovascular
and metabolic disease status, and hormones related to stress. Your (RELATIONSHIP) will
receive [$50/$100] for completing the survey interview, and an additional $35 for having his/her
blood pressure measured and providing a small blood spot sample. All visits will be scheduled at
the convenience of your (RELATIONSHIP).
Your (RELATIONSHIP) is important! Our interviewers are professionally trained to recognize if
the interview is being a burden to the respondent. Your (RELATIONSHIP) may choose to skip
any questions that [he/she] does not want to answer. HUD is very committed to protecting your
privacy. HUD has obtained a Certificate of Confidentiality. This is a legal document that lets
HUD refuse to give out any information that could identify you, even if a court asks for it.
If you have any questions, please call the University of Michigan at: 1-800-759-7947 (English) or
1-800-643-7605 (Spanish). The toll-free lines open Monday through Thursday, 9:00 a.m. – 9:00
p.m., Friday, 9:00 a.m. – 5:00 p.m., and Saturday, 12:00 noon to 4:00 p.m., Eastern Time.
Please refer to the MTO research project when you call. I have asked our interviewer to call on
your (RELATIONSHIP) again. Just tell the interviewer how best to accommodate you and your
(RELATIONSHIP). Thank you very much for your assistance.
Sincerely,
Barbara Ward, Survey Manager
Survey Research Center
The University of Michigan
Should you have questions regarding your rights as a research participant, please contact the Institutional
Review Board, 540 E. Liberty Street, Suite 202, Ann Arbor, MI 48104-2210, (734)936-0933, email:
[email protected].
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page K-6
The U.S. Department of Housing and Urban Development
Moving to Opportunity Demonstration Project
Dear [NAME OF NO CONTACT]:
We mailed a letter to you several weeks ago along with a brochure like the one
enclosed. You and your family became part of the Moving to Opportunity
program study when a member of your family applied for the MTO program
several years ago. The University of Michigan is conducting this research study
for the U.S. Department of Housing and Urban Development (HUD). This study
will help HUD learn how to help families improve their housing situation in the
future.
Our interviewer has tried to contact someone in your household on a number or
occasions, but has been unable to fine anyone at home. We are writing you now
to let you know about this difficulty and to ask for your help in finding a good time
to contact you to set up an appointment for an interview.
We promise that all information and data collected will be used for research
purposes only. Our professionally trained interviewers have taken an oath of
confidentiality and are held to it by the University of Michigan and by their own
pride in their work. Please be assured that any information you provide will be
kept strictly confidential. Your identity and privacy will be protected. You may
skip any of the questions you wish. Most people find that completing the
interview is an interesting and rewarding experience.
If you can suggest a good time for us to reach you, or if you have any questions
about the study, please call the University of Michigan toll free at: 1-800-7597947 (English) or 1-800-643-7605 (Spanish). The toll-free lines are open
Monday through Thursday, 9:00 a.m. – 9:00 p.m., Friday, 9:00 a.m. – 5:00 p.m.,
and Saturday, 12:00 noon to 4:00 p.m., Eastern Time. Please refer to the MTO
research project when you call. Thank you for your help in completing this
important research effort.
Sincerely,
Barbara Ward, Survey Manager
Survey Research Center
The University of Michigan
Should you have questions regarding your rights as a research participant, please contact the
Institutional Review Board, 540 E. Liberty Street, Suite 202, Ann Arbor, MI 48104-2210,
(734)936-0933, email: [email protected].
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page K-7
The U.S. Department of Housing and Urban Development
Moving to Opportunity Demonstration Project
Dear Public Housing Authority Administrator or
Manager of Public Housing Authority Property:
The U.S. Department of Housing and Urban Development (HUD) has been
conducting a study of the Moving to Opportunity (MTO) demonstration program
since 1994. Now HUD is contacting families who signed up for the MTO to find
out how they are doing 10 years after the program started. This letter is to
request your assistance at locating families from your community who have been
participating in this research project.
The last known addresses for many of these families were in your
development(s). Some of the families may have moved due to redevelopment,
vacancy consolidation, or some other reason. Many may have simply changed
phone numbers. To the extent you have this information, we would appreciate if
you could provide current address and telephone numbers for the families
identified by the University of Michigan staff working in your area. Professional
interviewers working for the University of Michigan will be contacting people in
your community to collect information.
The purpose of the MTO research study is to determine the effects of helping
some families who live in public housing or project-based Section 8 housing to
move to different kinds of neighborhoods. As part of the study, it is critical to also
understand what happens to the families that did not move as part of MTO. This
research will help HUD learn how to help families improve their housing situation
in the future.
The University of Michigan is helping to conduct this research study for HUD.
Families who applied for MTO Section 8 assistance agreed to allow researchers
for HUD to follow their lives over a ten-year period. Written consent was
obtained from each household head who applied for MTO, permitting your
agency (and others) to provide locating information and other data about the
family and its members to researchers over that long period of years.
Thank you for your assistance in this important research. Should you have any
questions about this request, please do not hesitate to call me at 202-708-3700,
ext. 5706
Todd M. Richardson, GTR
Office of Policy Development and Research
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page K-8
The U.S. Department of Housing and Urban Development
Moving to Opportunity Demonstration Project
Locked or Gated Community
To Whom It May Concern:
The University of Michigan Survey Research Center (SRC) is conducting the
Moving to Opportunity (MTO) Final Evaluation interviews in your areas. The
University of Michigan is working with the National Bureau of Economic
Research (NBER) and the U.S. Department of Housing and Urban Development
(HUD) to collect information on households that voluntarily joined the MTO
project up to 10 years ago. Professional interviewers from the University of
Michigan Survey Research Center will be contacting people in these
communities in 2008 and 2009.
Families who applied for the MTO program agreed to allow researchers for HUD
to follow their lives over a ten-year period. Written consent was obtained from
each household head who applied for MTO, permitting our interviewers to collect
information and other data about the family and its members for researchers over
the project period. I am hereby requesting that you permit our interviewer to
enter your (complex/building) for the purpose of collecting data.
Participation in this study is voluntary, and residents are so notified prior to the
interviewer’s visit. Our interviewers are professionally trained and wear badges
that identify them as interviewers for the University of Michigan Survey Research
Center. All information collected is confidential and will only be used for research
purposes.
Thank you for your assistance in this important research. Should you have any
questions about this request, please do not hesitate to call the University of
Michigan toll free at: 1-800-759-7947 (English) or 1-800-643-7605 (Spanish)
Monday through Thursday, 9:00 a.m. – 9:00 p.m., Friday, 9:00 a.m. – 5:00 p.m.,
and Saturday, 12:00 noon to 4:00 p.m.
Sincerely,
Barbara Ward, Survey Manager
Survey Research Center
The University of Michigan
Should you have questions regarding your rights as a research participant, please contact the
Institutional Review Board, 540 E. Liberty Street, Suite 202, Ann Arbor, MI 48104-2210,
(734)936-0933, email: [email protected].
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page K-9
The U.S. Department of Housing and Urban Development
Moving to Opportunity Demonstration Project
MTO Letter to City Government
To Whom It May Concern:
The University of Michigan is conducting the Moving to Opportunity (MTO) Final
Evaluation interviews in your area. The University is working with the National
Bureau of Economic Research (NBER) and the U.S. Department of Housing and
Urban Development (HUD) to collect information on households that voluntarily
joined the MTO project up to 10 years ago. Professional interviewers from the
University of Michigan will be contacting people in these communities beginning
in April, 2008 and running through April, 2009.
Families who applied for the MTO program agreed to allow researchers for HUD
to follow their lives over a ten-year period. Written consent was obtained from
each household head who applied for MTO, permitting our interviewers to collect
information and other data about the family and its members for researchers over
that long period of years.
Participation in the study is voluntary, and residents are so notified prior to the
interviewer’s visit. Our interviewers are professionally trained and wear badges
that identify them as interviewers for the University of Michigan. All information
collected is confidential and will only be used for research purposes.
Thank you for your assistance in this important research. Should you have any
questions about this request, please call the University of Michigan toll free at: 1800-759-7947 (English) or 1-800-643-7605 (Spanish). The toll-free lines open
Monday through Thursday, 9:00 a.m. – 9:00 p.m., Friday, 9:00 a.m. – 5:00 p.m.,
and Saturday, 12:00 noon to 4:00 p.m., Eastern Time. Please refer to the MTO
research project when you call.
Sincerely,
Barbara Ward, Survey Manager
Survey Research Center
The University of Michigan
Should you have questions regarding your rights as a research participant, please contact the
Institutional Review Board, 540 E. Liberty Street, Suite 202, Ann Arbor, MI 48104-2210,
(734)936-0933, email: [email protected].
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page K-10
National Bureau of Economic Research
University of Michigan – ISR
Appendices
Page K-11
What is the study about?
The Moving to Opportunity
(MTO) is a program that
studies the effects of using
housing vouchers to help
families move into different
neighborhoods, with the goal
of understanding how to
improve these programs for
families in the future. This
important study is being
conducted by the U.S.
Department of Housing and
Urban Development (HUD).
We are helping HUD carry
out this study.
Why am I being asked to
participate?
HUD is contacting families
who signed up for the
Moving to Opportunity
(MTO) program back in the
1990s to find out how they
are doing 10 years after the
program started. You and
your family became part of
this research study when a
member of your family
applied for the MTO program
several years ago. At that
time, a member of your
family completed a
questionnaire and signed a
statement allowing HUD and
its researchers to talk to
him/her and his/her family
members.
What will I be asked to do
as part of this study?
You will be asked to complete
an interview in your home
and you may be asked to give
permission for your son or
daughter to complete an
interview and a math and
reading assessment. In order
to understand how the
program affects health
outcomes, the interviewer will
measure your height and
weight and take your blood
pressure. You will also be
asked to provide a few drops
of blood obtained from a
finger prick. These blood
spots will be analyzed for
some basic health indicators
such as cholesterol, which is
an important predictor of
heart disease; glycosylated
hemoglobin, a predictor of
someone’s risk for diabetes;
and C-Reactive protein, which
is an indicator of
inflammation and helps
predict heart disease and
other health problems. In
addition we will measure
cortisol, which helps indicate
people’s level of stress that in
turn can affect the ability of
their body’s immune system
to fight off colds and other
problems.
These analyses will allow
researchers to better
understand the connections
between these health
measures and other factors of
interest such as health,
economic and employment
status.
What happens to the
answers?
This study will follow strict
rules to protect your answers.
Your identity and privacy will
be protected. You will never
be named in any reports
about the study. HUD or
people on HUD’s research
team may look at your
answers, but without your
name attached. HUD will
only report results from
groups of people, not
individuals. We will share
some basic health measures
with you at the time of the
interview and mail the other
results of your blood tests to
you about 4-6 weeks after the
interview.
Do I have to participate?
This interview is completely
voluntary. If you are asked to
answer any questions that you
don’t want to answer, just let
your interviewer know and
he/she will go on to the next
question. The answers you
give will be kept confidential.
Who is conducting the
study?
The University of Michigan
and the National Bureau of
Economic Research are
conducting this research study
for HUD. This study will
help HUD learn how to help
families improve their
housing situation in the
future. You will be asked
questions about your family’s
housing and neighborhood,
education, employment, and
health. The answers you
provide are very important to
HUD and its research team.
You will receive [$50/$100]
for completing the
interview. If you decide to
provide a small blood
sample and have your
blood pressure taken, you
will be given an additional
$35. If your child is asked
to participate, he/she will
also be paid [$50/$100] for
completing the interview
and a math and reading
assessment.
Page K-12
Who funds the study?
HUD is paying for the
research. Other sponsors
include the National Institutes
for Health, National Science
Foundation, the Centers for
Disease Control, and the
MacArthur, Spencer and
Smith Richardson
Foundations. [if additional
funding is approved, other agencies
will be listed]
How will the interviews be
completed?
Your interview will be
conducted by a trained
interviewer from the
University of Michigan. The
interview will include
questions about your housing,
neighborhood, living
conditions, education,
employment, and health. It
will last approximately 75
minutes and will be
conducted at a time and place
that is convenient to you.
If your child is asked to
participate, his/her interview
will last about 60 minutes and
the assessment will take
another 45 minutes.
What about my privacy?
We are very committed to
protecting your privacy.
HUD has obtained a
Certificate of
Confidentiality. This is a
legal document that lets HUD
refuse to give out any
information that could
identify you, even if a court
asks for it. However, if
keeping your answers private
would put you, your child, or
someone else in serious
danger, then we will have to
tell government agencies to
protect you or the other
person. Information such as
your name, address, and
telephone number will be
kept in secure files separate
from the answers you
provide. Only HUD and the
research team will see
individual answers to the
interviews.
Ken Dodge, PhD, Duke University
Felton Earls, PhD, Harvard
Ronald Ferguson, PhD, Harvard
Christopher Jencks, MA, Harvard
Terrie Moffitt, PhD, U. Wisconsin
Kathleen Mullan Harris, PhD, UNC
Edgar Olsen, PhD, U. Virginia
Robert Sampson, PhD, Harvard
Lawrence Steinberg, PhD, Temple
Jane Waldfogel, PhD, Columbia
Who do I contact for more
information?
If you have more questions
about the Moving to
Opportunity project, please call
the University of Michigan toll
free at 1-800-759-7947
(English) 1-800-643-7605
(Spanish).
If you wish to speak with
someone at HUD about this
research, contact Todd
Richardson (MTO project
director) at 202-708-3700, ext.
5706.
Moving to Opportunity research
team Members:
Lawrence Katz, PhD, Harvard,,
Principal Investigator
Jens Ludwig, PhD, U. Chicago
Jeffrey Kling, PhD, Brookings
Institution
Ronald Kersler, PhD, Harvard
Medical School
Lisa Gennetian, PhD, Brookings
Institution,
Nancy Gebler, MA, University of
Michigan, Survey Director
Technical Advisory Team:
Lawrence Aber, PhD, NYU
Jeanne Brooks-Gunn, PhD,
Columbia University
Charles Brown, PhD, U. Michigan
Thomas Cook, PhD, Northwestern
Page K-13
National Hotline Directory*
*
This list should not be considered to be a complete list of all community service agencies nor an endorsement of
them.
Organization
American
Council on
Alcoholism
Helpline
US Dept. of
Health and
Human
Services: Center
for Mental,
Substance
Abuse
Prevention
Al-anon/
Alateen
Meeting
Referral
CDC AIDS
Hotline
Rape Abuse and
Incest National
Network
(RAINN)
Big Brothers
Big Sisters of
America
National Legal
Aid and
Defender
Society
Emergency
Food Shelter
National Board
Program
Childhelp USA
National
Domestic
Violence
Hotline
Number
800-527-5344
Hours
M-F
9-5pm
EST
Who they Help
Those seeking information on
treatment for Alcoholism.
How they help
They provide referrals to alcohol
treatment programs nationwide.
They can also send out educational
materials.
24 Hours
7 Days
Those seeking information on
treatment for Alcohol and Drug
Abuse.
They provide referrals to local state
funded and private drug treatment
agencies.
They can also send out information
packets.
800-344-2666
8-6 EST
Alcoholics and their friends
and family.
An operator can direct you to the
meeting locations nearest you.
800-342-AIDS
(800-342-2437)
24 Hours,
7 Days
Any person with questions or
concerns about AIDS or
sexually transmitted disease
They provide referrals to local
clinics that do STD and HIV testing.
They can also provide counseling
about STD risk and transmission.
800-656-4673
24 Hours,
7 Days
Rape and incest victims
215-567-7000
9-5pm
EST
Children who would like to
have a mentor and Adults
looking to be a mentor to a
child.
202-452-0620
9-5pm
EST
Persons seeking free legal
services.
9-5pm
EST
Persons seeking emergency
food, clothing and shelter
When calling this number, you are
automatically transferred to the
nearest rape crisis center in your
area.
Big Brothers Big Sisters of America
is the nation’s largest youth
mentoring organization. The
national office can help you find an
agency near you.
National Legal Aid and Defender
Society will direct you to the nearest
legal aid service in your area. Legal
aid is primarily for people of lower
incomes.
The operator can direct you to the
nearest location in your area that
provides emergency food, clothes
and shelter.
800-729-6686
*Espańol
1-877-767-8432
703-706-9660
800-4-ACHILD
24 Hours,
7 Days
Child abuse victims, offenders,
parents, survivors.
Trained professionals provide short
term counseling, information and
referrals to local agencies. They can
also take reports of suspected child
abuse.
800-799-SAFE
* Espańol:
Ask for Spanish
Operator
24 Hours,
7 Days
Children, parents, friends,
offenders
A crisis line that can provide
immediate help through referrals to
local shelters, counselors and legal
advice.
Page K-14
Boys Town
800-448-3000
24 Hours,
7 Days
Troubled children, parents,
family members
Counselors are available 24 hrs to
give immediate counseling to girls
and boys with any type of problem
including issues with school,
parents, sexuality, abuse, or feelings
of suicide.
National Victim
Center
800-FYI-CALL
(800-394-2255)
All victims of violent crimes
Planned
Parenthood
800-230-PLAN
(800-230-7526)
8:30-5:30
EST
M-F
24 Hours
7 Days
Emergency
Contraceptive
Hotline
888-NOT-2LATE
(888-668-2528)
24 Hours
7 Days
Those seeking information on
Emergency contraception.
America’s Crisis
Pregnancy
Hotline
888-4-OPTIONS
(888-467-8466)
6:3010:00
CST
National
Alliance for the
Mentally Ill
800-950-NAMI
(6264)
10-5pm
EST
Those seeking referrals or
information for any mental
health issue.
The National
Mental Health
Association
Information
Center
United Way
Crisis Line
800-969-NMHA
(6642)
9-5pm
EST
Those seeking referrals or
information for any mental
health issue.
They provide some local referrals
for social service, counseling, legal
and case advocacy.
When you call this number you are
immediately connected to a planned
parenthood in your area.
An automated service provides
referrals to local health care
providers who offer emergency
contraception
They provide counseling and
referrals on pregnancy testing,
abortion, adoption and parenting
services.
NAMI provides referrals to local
counselors, therapists, and support
groups for individuals and families.
They can also answer questions and
send information on any type of
mental health issue.
NMHA provides information on all
types of mental health issues and
gives referrals to support groups, and
inpatient/out patient centers.
800-233-HELP
(4357)
24 Hours
7 Days
Those seeking referrals or
information for any mental
health issue.
Suicide Hotline
800-SUICIDE
Sponsored by
Covenant House
24 Hours
7 Days
Those seeking crisis counseling
Family planning, pelvic exam,
birth control, abortion.
Those seeking Christian
Pregnancy Counseling.
Trained social workers provide
referrals to local agencies,
counselors and mental health
associations. They can also provide
crisis counseling.
They provide referrals to the nearest
local crisis hotlines and services
where counselors are ready to help
24 hours a day.
Page K-15
NAME: «A_sTitle» «A_vFirstName» «A_vMiddleName»
«A_vLastName» «A_sSuffix»
DATE OF TEST: «Date_Blood_Collected»
Dear «A_sTitle» «A_vFirstName» «A_vMiddleName» «A_vLastName» «A_sSuffix»,
Thank you for participating in the Moving To Opportunity Study. The test results of your cholesterol and
hemoglobin A1c tests have been returned from the laboratory. On the enclosed page you will find your
results for your blood pressure readings, cholesterol (both total and HDL cholesterol), and hemoglobin
A1c tests. As you know we cannot provide any medical advice to you. If you have any questions about
these results please contact your doctor.
We look forward to your continued interest and participation in all aspects of this study. If you have
questions about this study, please contact us at 1-800-759-7947.
Sincerely,
Jens Ludwig, Project Director
Nancy Gebler, Survey Director
Should you have questions regarding your rights as a research participant, please contact the Health Sciences Institutional Review Board,
Kate Keever, 540 East Liberty Street, Suite 202, Ann Arbor, MI, 48104-2210, 734-936-0933, email: [email protected].
Blood Pressure Readings:
Time 1:
_____________ / _____________ mmHg
Systolic
Diastolic
Time 2:
_____________ / _____________ mmHg
Systolic
Diastolic
Time 3:
_____________ / _____________ mmHg
Systolic
Diastolic
The American Heart Association recommends a systolic pressure (i.e. top number) of less than 120
mmHg and a diastolic pressure (bottom number) of less than 80 mmHg. The Health and Retirement
Study may not measure blood pressure in the same way that your blood pressure may be measured in your
doctor’s office. However, if your blood pressure is 120/80 mmHg or higher, you should see your
physician or other health professional to recheck this result and consider how to lower it.
Total Blood Cholesterol: «Total Chol Result» mg/dl
The American Heart Association recommends a total cholesterol level of less than 200 mg/dl. If your
total cholesterol is 200 mg/dl or higher you should see your physician or other health professional to
recheck this result and consider how to lower it.
HDL Blood Cholesterol: « HDL Chol Result » mg/dl
The American Heart Association recommends a high-density lipoprotein (HDL) cholesterol level of
greater than 40 mg/dl. If your HDL cholesterol is 40 mg/dl or lower you should see your physician or
other health professional to recheck this result and consider how to increase it.
Hemoglobin A1C: «Blood_Sample_Result»%
The hemoglobin A1c test shows the average amount of sugar in your blood over the last three months.
The American Diabetes Association recommends that the goal of this result should be less than 7%. If
your result is 7% or higher you should see your physician or other health professional to recheck this
result and consider how to lower it.
Blood Spot Error Letter
NAME: «A_sTitle» «A_vFirstName» «A_vMiddleName»
«A_vLastName» «A_sSuffix»
DATE OF TEST: «Date_Blood_Collected»
Dear «A_sTitle» «A_vFirstName» «A_vMiddleName» «A_vLastName» «A_sSuffix»,
Thank you for participating in the Moving To Opportunity Study. We recently received the results of
your blood test from the laboratory. Unfortunately, the lab was unable to analyze your blood sample for
either cholesterol (total and HDL cholesterol), or hemoglobin A1c tests. We apologize that we are unable
to provide you with all of your test results but we truly appreciate your participation in this important
component of the Moving To Opportunity Study.
Your blood pressure measurements taken on the date of the interview are included in the attached letter.
As you know we cannot provide any medical advice to you so if you have any questions about these
results please contact your physician.
We look forward to your continued interest and participation in all aspects of this study. If you have
questions about this study, please contact us at 1-800-759-7947.
Sincerely,
Jens Ludwig, Project Director
Nancy Gebler, Survey Director
Should you have questions regarding your rights as a research participant, please contact the Health Sciences Institutional Review Board,
Kate Keever, 540 East Liberty Street, Suite 202, Ann Arbor, MI, 48104-2210, 734-936-0933, email: [email protected].
Blood Pressure Readings:
Time 1:
_____________ / _____________ mmHg
Systolic
Diastolic
Time 2:
_____________ / _____________ mmHg
Systolic
Diastolic
Time 3:
_____________ / _____________ mmHg
Systolic
Diastolic
The American Heart Association recommends a systolic pressure (i.e. top number) of less
than 120 mmHg and a diastolic pressure (bottom number) of less than 80 mmHg. The
Health and Retirement Study may not measure blood pressure in the same way that your
blood pressure may be measured in your doctor’s office. However, if your blood
pressure is 120/80 mmHg or higher, you should see your physician or other health
professional to recheck this result and consider how to lower it.
Total Blood Cholesterol: «Total Chol Result» mg/dl
The American Heart Association recommends a total cholesterol level of less than 200
mg/dl. If your total cholesterol is 200 mg/dl or higher you should see your physician or
other health professional to recheck this result and consider how to lower it.
HDL Blood Cholesterol: « HDL Chol Result » mg/dl
The American Heart Association recommends a high-density lipoprotein (HDL)
cholesterol level of greater than 40 mg/dl. If your HDL cholesterol is 40 mg/dl or lower
you should see your physician or other health professional to recheck this result and
consider how to increase it.
Hemoglobin A1C: «Blood_Sample_Result»%
The hemoglobin A1c test shows the average amount of sugar in your blood over the last
three months.
The American Diabetes Association recommends that the goal of this result should be
less than 7%. If your result is 7% or higher you should see your physician or other health
professional to recheck this result and consider how to lower it.
| File Type | application/pdf |
| File Title | The Final |
| Author | Hong-Yu Johnson |
| File Modified | 2007-11-19 |
| File Created | 2007-09-05 |