Form AHS-101AR AHS Screener Questionnaire

OMB No. 0607-0809: Approval Expires 04/30/2010

AHS-101AR

U.S. DEPARTMENT OF COMMERCE

FORM
(9-28-2005)

Economics and Statistics Administration

U.S. CENSUS BUREAU

AGE RESTRICTED LIVING SCREENER QUESTIONNAIRE
AMERICAN HOUSING SURVEY
Control Nos.:

CASEID:
FACILITY INFORMATION

Hello. I am ________________ from the US Census Bureau.
(Here is my ID card.)
The U.S. Census Bureau is testing a new method for updating
its address lists for facilities that may contain housing units
designed for an older population. We will use this information
to ensure that these types of units will be more accurately
represented in future censuses and surveys.

Name:
Address:

Information you provide will be kept confidential and used
for statistical purposes only, as required by Title 13,
United States Code, Section 9. The Census Bureau cannot
publish or release information that would identify any
individual. The Congress has imposed criminal sanctions
(up to five years imprisonment and/or up to $250,000 fine)
if any person sworn to uphold the confidentiality of your
information violates the provisions of Title 13.

Contact person:
Contact phone number:
UNIT INFORMATION
Address:

I would like to speak with the person or one of the people
who knows where people live or stay at this address.
Would that be you, or should I speak with someone else?
This voluntary collection should take about 6 minutes. I
can provide you with an address at the end of the interview
to which written comments or suggestions about this
procedure can be directed.

FACILITY AND UNIT INFORMATION
1.

May I have your name please?

2.

What is your job title?

Same as on label

OR

3a. Is this (read facility name and address on the label)?

Yes – Skip to 4

3b. Was this address ever (read facility name and address
on the label)?

Yes – Make necessary corrections on the label
1

4.

5.

6.

No – End interview. Read thank you statement
on the reverse side. Then mark item 13,
code 37 “Out of Universe”

The following questions are about the
BUILDING that contains (read unit address). How
many living quarters/apartments/residences are
there in that building?

One
2–4

Is there more than one building in this
complex?

Yes
2

Do any of the buildings have 5 or more
units/apartments in them?

No

}

Go to 5

5–9
10–19
20–29
30–39
40–49
50 or more

}

No – End interview. Read thank you statement
on the reverse side. Then mark item 13,
code 37 “Out of Universe”
Yes

3

No – End interview. Read thank you statement
on the reverse side. Then mark item 13,
code 37 “Out of Universe”

7a. Does the BUILDING containing (read unit address)
provide special services? By special services I
mean residents live independently and are
generally self-sufficient, but CAN get some help
with at least some of the following:
• meals, transportation, or housekeeping within
the unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• managing finances, using the telephone, or
shopping, and/or . . . . . . . . . . . . . . . . . . . . . . . .
• personal care such as bathing, eating, moving
about, dressing, or toilet use? . . . . . . . . . . . . .

Yes – Skip to item 8

No

Yes – Skip to item 8

No

Yes – Skip to item 8

No

b. What is its current use?
4

Continue on the back.

USCENSUSBUREAU

Skip to 7a

8a. Was the BUILDING containing (read unit address)
built before 1990?
8b. Was this BUILDING originally used as private
residential housing?

Yes
No – Skip to 9
5

Yes, private – End interview. Read thank you
statement below. Then mark item 13,
code 37 “Out of Universe”
No, something else – Specify

9. The next questions are about (read unit address)
itself. Now I would like to ask about this
particular unit. Is (read unit address) a unit for
hospice, skilled nursing, dementia, or
Alzheimers patients?

6

No

10a. Do the residents of this unit live separately
from all the other occupants of the building?

Yes
7

10b. Do the residents of this unit have direct access
to their unit from the outside or through a
common or public hall?

11. Are the residents of this unit free to move
about the public areas of the building and to
leave the facility anytime they wish?

Yes – End interview. Read thank you statement
below. Then mark item 13, code 14
(Type B – OTHER unit)

No – End interview. Read thank you statement
below. Then mark item 13, code 14
(Type B – OTHER unit)
Yes

8

No – End interview. Read thank you statement
below. Then mark item 13, code 14
(Type B – OTHER unit)

9

Yes – Read thank you statement below. Then
mark item 13, code 1 (Unit eligible)

10

No – Read thank you statement below. Then mark
item 13, code 14 (Type B – OTHER unit)

THANK YOU STATEMENT
Thank you for your help. The Census Bureau uses this type of information to select samples that represent
the diversity of conditions in our country. The samples are used to conduct studies on a variety of
subjects, such as employment, income, health care, and housing.

INTERVIEW RESULTS
12. Incomplete screening Interview:
2

Partial interview – Specify

Refused
Unable to locate (Call office, determine if PV
needed.)
Other – Specify

4

5

1

Unit eligible for AHS interview at time of
screening. (Did not get screened out by questions and
FR believes it meets all requirements.)

▲

▲

Type A

3

13. Outcome from screening Interview:

Type B (Unit NOT eligible now but status may change
in the future.)

12

Permanent or temporary business or
commercial storage
OTHER unit or staff quarters
Occupancy prohibited
Interior exposed to the elements
Type B not classified above – Specify

14
15
16
17

▲

Type C (Unit out of universe for AHS sample, will
always be INELIGIBLE for AHS interview.)

30

Demolished or disaster loss
Building or mobile home moved
Out of universe (Describe type of facility in notes.)

31
37

NOTES: (Describe any unusual circumstances, explain why you feel unit does not meet requirements for age restricted living
even if answers indicate that it does. Conversely, if the unit did not meet the requirements, and you think it should be included,
explain why you feel the unit should be included.

FORM AHS-101AR (9-28-2005)