Form Appendix A Appendix A Baseline Survey

Plan for Evaluation of the Trade Adjustment Assistance Program

Appendix A-Baseline Survey.final

Plan for Evaluation of the Trade Adjustment Assistance Program

OMB: 1205-0460

Document [doc]

Download: doc | pdf

APPENDIX A

BASELINE SURVEY INSTRUMENT

OMB Approval No.:

Expiration Date:

6066-220

TRADE ADJUSTMENT

ASSISTANCE STUDY (TAA)

BASELINE SURVEY

SECTION A – INTRODUCTION AND SCREENING

DIAL THE NUMBER ON THE CATI SCREEN

A1. May I speak with [fill SAMPLE MEMBER NAME]?

<1> YES [GO TO A3a OR A3b]

<2> NOT A GOOD TIME, SCHEDULE CALLBACK [GO TO CALL BACK SCREEN]

<3> REFUSED [GO TO REFUSAL SCREEN]

<4> NEED MORE INFORMATION [GO TO A2]

<5> SAMPLE MEMBER NO LONGER LIVES THERE/WRONG NUMBER [GO TO A7]

<6> “DO NOT CALL LIST” MENTIONED [GO TO CORRESPONDING

TEXT IN THE FAQs]

A2. I’m calling from Mathematica Policy Research and we’re conducting a survey for the U.S. Department of Labor. [fill SAMPLE MEMBER NAME] participated in a program funded by the Department of Labor and I need to speak to [fill HIM/HER] about [fill HIS/HER] experiences.

<1> CONTINUE

<2> NOT A GOOD TIME, SCHEDULE CALLBACK [GO TO CALL BACK SCREEN]

<3> REFUSED [GO TO REFUSAL SCREEN]

<4> “DO NOT CALL LIST” MENTIONED [GO TO CORRESPONDING

TEXT IN THE FAQs]

<5> NEED MORE INFORMATION [GO TO MORE INFORMATION SCREEN]

A3a. READ IF RESPONDENT IS A TAA SAMPLE MEMBER:

My name is (NAME) and I’m calling from Mathematica Policy Research in Princeton, New Jersey. Recently, we sent you a letter about a survey we are conducting for the U.S. Department of Labor. We are calling people who received unemployment insurance and who were eligible to receive Trade Adjustment Assistance or NAFTA-TAA services. The purpose of the survey is to improve services to people who are eligible for Trade Adjustment Assistance services. The interview takes about 30 minutes and we will mail you a check for $25 when the survey is completed.

<1> CONTINUE

<2> NOT A GOOD TIME, SCHEDULE CALLBACK [GO TO CALL BACK SCREEN]

<3> REFUSED/NOT INTERESTED [GO TO REFUSAL SCREEN]

<4> NOT SURE ABOUT DOING THE SURVEY/HAS QUESTIONS

<5> DON’T KNOW WHAT WE’RE TALKING ABOUT/NEVER

PARTICIPATED IN TAA

<6> NEVER COLLECTED UNEMPLOYMENT

<7> “DO NOT CALL LIST” MENTIONED [GO TO CORRESPONDING TEXT IN THE

FAQs]

A3b. READ IF RESPONDENT IS A COMPARISON GROUP SAMPLE MEMBER:

My name is (NAME) and I’m calling from Mathematica Policy Research in Princeton, New Jersey. Recently, we sent you a letter about a survey we are conducting for the U.S. Department of Labor. We are calling people who established claims for unemployment benefits. The purpose of the survey is to improve services to people who collect unemployment insurance. The interview takes about 30 minutes and we will mail you a check for $25 when the survey is completed.

<1> CONTINUE

<2> NOT A GOOD TIME, SCHEDULE CALLBACK [GO TO CALL BACK SCREEN]

<3> REFUSED/NOT INTERESTED [GO TO REFUSAL SCREEN]

<4> NOT SURE ABOUT DOING THE SURVEY/HAS QUESTIONS

<5> DON’T KNOW WHAT WE’RE TALKING ABOUT

<6> NEVER COLLECTED UNEMPLOYMENT

<7> “DO NOT CALL LIST” MENTIONED [GO TO CORRESPONDING TEXT IN THE

FAQs]

A4. To get started I need to verify that I am speaking with the correct person. Could you please tell me your date of birth?

IF NECESSARY: READ DOB ALOUD AND CONFIRM.

RECORD: | | |/| | |/| | | | | [GO TO A6]

month day year

<r> REFUSED [ASK A5]

A5. What are the last four digits of your social security number?

IF NECESSARY: READ LAST 4-DIGITS ALOUD.

<d> DON’T KNOW

<r> REFUSED

A6. CATI SCREEN: SHOW DOB OR LAST 4 DIGITS OF SS# FROM UI CLAIMS RECORDS.

INTERVIEWER: DO THE DOB OR THE LAST FOUR SSN DIGITS MATCH SAMPLE INFO?

<1> YES [GO TO B1]

<0> NO [GO TO A9]

A7. I’m calling [fill SAMPLE MEMBER] on behalf of the U.S. Department of Labor to conduct a survey about government programs that provide services to people. Can you give me a telephone number where (he/she) can be reached?

RECORD: | | | |-| | | |-| | | | |

area code number

<0> NO/DOES NOT KNOW NUMBER

<r> NO/REFUSED

A8. Let me give you a toll-free number where [fill SAMPLE MEMBER] can reach someone to complete the survey and receive $25 for participation. The toll-free number is xxx‑xxx‑xxxx. Thank you. [END]

A9. I am sorry. Before I continue with the interview I will need to check our records further. Thank you for your time.

END

MORE INFORMATION SCREENS/FREQUENTLY ASKED QUESTIONS (FAQs).

WHAT IS THE PURPOSE OF THE STUDY?

For TAA group. Our goal is to learn about the training and employment experiences of workers who lost their jobs for trade-related reasons and who were eligible for Trade Adjustment Assistance (TAA) or NAFTA-TAA services. This study is very important for improving the services provided by the TAA and Unemployment Insurance systems.

For Comparison group. Our goal is to learn about the training and employment experiences of workers who received unemployment benefits. This study is very important for improving the services provided by the Unemployment Insurance system.

FOR THE TAA GROUP. I AM NO LONGER IN TAA TRAINING/I NEVER PARTICIPATED IN TAA/I NEVER HEARD OF TAA.

We are calling people whom the U.S. Department of Labor were notified to be eligible to receive Trade Adjustment Assistance or NAFTA-TAA services, even if these people never actually received services, are no longer receiving services, or never heard of the TAA program. Your responses and views are important in that it helps us gain perspective from those who participated in the TAA program as well as from those who did not.

IF DISSATISFIED WITH TAA TRAINING PROGRAM.

I understand. Your comments will be especially important to the research. The U.S. Department of Labor wants to have feedback from people who were satisfied and people who were dissatisfied with their experiences.

I NEVER RECEIVED UNEMPLOYMENT BENEFITS/I NEVER COLLECTED UNEMPLOYMENT.

According to [fill STATE] Unemployment Insurance Agency records, you filed for unemployment benefits on [fill INITIAL UI CLAIM DATE].

I DON’T COLLECT UNEMPLOYMENT BENEFITS ANYMORE/I COLLECTED THEM FOR A VERY SHORT TIME.

We are calling a group of people who collected benefits during the past two years. The interview goes very quickly.

I’M DISSATISFIED WITH MY UNEMPLOYMENT BENEFITS.

I understand. Your comments will be especially important to the research. The U.S. Department of Labor needs to hear from people who were satisfied and people who were dissatisfied with their experiences while collecting unemployment benefits.

MORE INFORMATION SCREENS - continued

IF DISSATISFIED WITH LOCAL UNEMPLOYMENT AGENCIES SAY.

HOW DID YOU GET MY NAME?

Your name was randomly selected from among persons in the state of [fill STATE] who began receiving TAA training in 2004-2005.

IS THE SURVEY CONFIDENTIAL?

Your responses are protected from disclosure by federal statue (P.L. 107-347, Title V Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA). Your answers will be combined with those of others and your name will never be used in reporting the results of the study. Your answers to questions will not affect your eligibility for any public program.

I DON’T HAVE THE TIME.

We can do the survey in more than one call, if necessary. I’d like to begin now and do as much as we can. Then, if you need to stop, I can call you back at your convenience to finish. Or, I can schedule a more convenient time to call you back. Which do you prefer?

WHAT HAPPENS IF I DON’T PARTICIPATE IN THE SURVEY?

Your participation is voluntary and will not affect your eligibility to receive unemployment or other benefits. However, your experience and opinions are very important to the success and improvement of programs that help unemployed workers find jobs.

I’M NOT INTERESTED.

Let me reassure you that we are not selling anything. The questions we ask are designed to help the U.S. Department of Labor improve services to people who are unemployed and seeking jobs. There are no right or wrong answers. We’re interested in your experiences and opinions. Your answers will be combined with those of others and your name will never be included in any report.

HOW LONG WILL THIS TAKE?

The length of the interview is different for different people, but it usually takes about 30 minutes.

MORE INFORMATION SCREENS - continued

WHO GAVE YOU THE AUTHORITY TO CONDUCT THE STUDY?

This study is being sponsored by the U.S. Department of Labor and has been approved by the U.S. Office of Management and Budget under OMB approval xxxx‑xxxx. Without this approval we would not be able to conduct this survey. Questions regarding any aspect of this survey may be directed to the U.S. Department of Labor, Office of Policy Development, Evaluation and Research, Room N‑5637, Washington, DC 20210 (Paperwork Reduction Project xxxx‑xxxx).

WILL I BE PAID?

Yes, we will mail you a check in the amount of $25 within 6 weeks of completing the survey.

WILL THERE BE A REPORT ON THE FINDINGS THAT I CAN READ? WHERE/WHEN CAN I SEE A PUBLISHED REPORT ABOUT THE NATIONAL EVALUATION OF THE TAA PROGRAM?

Survey results will be reported in several interim reports in 2005 and 2006. The evaluation’s final report won’t be finalized until 2008. Once these reports are cleared by the U.S. Department of Labor for public release, they will be available at the MPR Web address at www.mathematica-mpr.com.

WHAT ARE YOU GOING TO DO FOR ME NOW? ARE YOU GOING TO HELP ME FIND A JOB? ARE YOU GOING TO SEND ME FOR MORE TRAINING?

Mathematica Policy Research is a private, independent research firm. Our firm is conducting an evaluation for the U.S. Department of Labor, and this survey is part of this evaluation. Our staff, however, are NOT directly involved in the provision of unemployment compensation, job search assistance or training services. If you need further assistance, you should contact the appropriate program staff in your local area.

I’M ON THE NATIONAL “DO NOT CALL LIST/REGISTRY.” WHY ARE YOU CALLING ME?

I understand how the law may be confusing, but legitimate research calls are not included in the law that applies to telemarketing calls. Lawmakers recognize the value of legitimate research and the need for the public to participate. We will not sell you anything, nor will we ask for money. Your privacy will be respected, and your cooperation is appreciated.

I can provide you with a Web site address so you can get more information on who is included and excluded on the do not call list. The Web address is www.donotcall.gov.

SECTION B – UI CLAIM DATE AND HISTORY

B1. The first few questions I have are about the dates of your unemployment benefits. According to [fill STATE’s] Unemployment Insurance Agency records, you filed for unemployment benefits on or about [fill UI CLAIM DATE]. Is that correct?

<1> YES [GO TO CATI INSTRUCTIONS BEFORE B3]

<0> NO

<d> DON’T KNOW

<r> REFUSED

B2. When around [fill UI CLAIM DATE], did you file for or start collecting unemployment benefits?

PROBE: If you filed more than once during that period, please tell me about the first of those times that you filed for benefits.

PROBE, IF NECESSARY: Did you file for or start collecting unemployment benefits between 2004 and 2005?

RECORD MONTH, DAY, AND YEAR. IF SAMPLE MEMBER CANNOT GIVE EXACT DATE, PROBE FOR BEGINNING (CODE DAY 1), MIDDLE (CODE DAY 15), OR END OF MONTH (CODE DAY 30).

[CATI: REPLACE SAMPLE DATA UI CLAIM DATE WITH THIS DATE FOR SUBSEQUENT QUESTIONS.]

(2004-2005)

| | | / | | | / | | | | | [GO TO CATI INSTRUCTIONS BEFORE B3]

MONTH DAY YEAR

<x> DID NOT FILE/COLLECT [THANKS AND END]

<d> DON’T KNOW

<r> REFUSED [THANKS AND END]

CATI CHECK: IF COMPARISON SAMPLE GO TO B7.

IF TRA INDICATED IN TAA SAMPLE MEMBER’S DATA ASK B3, OTHERWISE GO TO B3a.

B3. Unemployment Insurance Agency records for the state of [fill STATE] show that you also collected TRA, or Trade Readjustment Allowances, which were monetary benefits that you received after exhausting your basic unemployment insurance. These records indicate that you started receiving these TRA benefits on or about [fill TRA CLAIM DATE]. Is that correct?

<1> YES [GO TO B5]

<0> NO [GO TO B4]

<x> NEVER COLLECTED TRA [GO TO B7]

<d> DON’T KNOW

<r> REFUSED

B3a. Have you received TRA or Trade Readjustment Allowances since [fill B1/B2 UI CLAIM DATE]? These are monetary benefits that you may have received after exhausting your basic unemployment insurance.

<1> YES

<0> NO, NEVER COLLECTED TRA [GO TO B7]

<d> DON’T KNOW

<r> REFUSED

B4. When around [fill TRA CLAIM DATE], did you start collecting TRA or Trade Readjustment Allowances?

CATI NOTE: THE FILL DATE IS ONLY RELEVANT FOR THOSE WITH TRA INDICATED IN SAMPLE MEMBER’S DATA—I.E., THOSE WITH B3 = <0>,<d>, <r>

THIS DATE BECOMES TRA DATE, REPLACING DATE FROM SAMPLE INFORMATION.

RECORD: | | |/| | |/| | | | |

month day year

<x> NEVER COLLECTED [GO TO B7]

<d> DON’T KNOW

<r> REFUSED

B5. When did you stop receiving TRA benefits?

RECORD MONTH, DAY, AND YEAR. IF SAMPLE MEMBER CANNOT GIVE EXACT DATE, PROBE FOR BEGINNING (CODE DAY 1), MIDDLE (CODE DAY 15), OR END OF MONTH (CODE DAY 30).

RECORD: | | |/| | |/| | | | |

month day year

<n> CURRENTLY RECEIVING/DID NOT STOP [GO TO C1]

<d> DON’T KNOW

<r> REFUSED

B6. Why did you stop collecting TRA benefits?

<1> BENEFITS RAN OUT/EXHAUSTED

<2> RE-EMPLOYED/FOUND A JOB/STARTED OWN BUSINESS

<3> DID NOT COMPLETE TRAINING

<4> WAIVER EXPIRED/DISQUALIFIED

<5> VOLUNTARILY OUT OF LABOR FORCE

<6> ILLNESS/DISABILITY

<7> TOO MUCH TROUBLE/HASSLE DEALING WITH/REACHING TAA/TRA/UI

OFFICE

<8> DID NOT WANT TRA ANYMORE

<9> MOVED

<10> WAS NOT ELIGIBLE FOR TRA IN THE FIRST PLACE/DENIED BENEFITS/

NEVER COLLECTED

<11> STILL COLLECTING

<12> OTHER (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

GO TO C1

B7. When did you stop receiving unemployment insurance benefits? When did your UI benefits run out?

RECORD MONTH, DAY, AND YEAR. IF SAMPLE MEMBER CANNOT GIVE EXACT DATE, PROBE FOR BEGINNING (CODE DAY 1), MIDDLE (CODE DAY 15), OR END OF MONTH (CODE DAY 30).

RECORD: | | |/| | |/| | | | |

month day year

<n> CURRENTLY RECEIVING/DID NOT STOP [GO TO C1]

<d> DON’T KNOW

<r> REFUSED

B8. Why did you stop collecting unemployment insurance benefits from your initial claim filed around [fill INITIAL CLAIM DATE]?

<1> BENEFITS RAN OUT/EXHAUSTED

<2> RE-EMPLOYED/FOUND A JOB/STARTED OWN BUSINESS

<4> DISQUALIFIED

<5> VOLUNTARILY OUT OF LABOR FORCE/WENT TO SCHOOL

<6> ILLNESS/DISABILITY

<7> TOO MUCH TROUBLE/HASSLE DEALING WITH/REACHING UI OFFICE

<8> DID NOT WANT UI ANYMORE

<9> MOVED

<10> WAS NOT ELIGIBLE FOR UI IN THE FIRST PLACE/DENIED BENEFITS/

NEVER COLLECTED [TERMINATE INTERVIEW]

<11> STILL COLLECTING

<12> OTHER (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

SECTION C – PRE-UI EMPLOYMENT

PART I: INFORMATION ON THE JOB THAT LED TO THE UI CLAIM/TAA ELIGIBILITY

C1. Now, I’d like to ask you about the job you had just before you filed for unemployment benefits in [fill B1/B2 UI CLAIM DATE]. What kind of company did you work for at that time—what did they make, do, or sell?

PROBE, IF NECESSARY: What was the major product or service of the job you had that made you eligible to collect unemployment insurance benefits.

<1> (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

CATI: IF COMPARISON GROUP SAMPLE, GO TO C3

C2. IF TAA SAMPLE ASK: My records indicate that you worked at [fill NAME OF COMPANY FROM SAMPLE]. Is this correct?

<1> YES [GO TO C4]

<0> NO

<d> DON’T KNOW

<r> REFUSED

C3. What was the name of this company? Who was your employer?

<1> (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

C4. What was your job title? What did you do there?

FOR EXAMPLE: ELECTRICAL ENGINEER, STOCK CLERK, SEWING MACHINE OPERATOR, LONG HAUL TRUCK DRIVER, SHORT HALL TRUCK DRIVER.

<1> (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

C5. Did you belong to a union on that job?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

C6. About how many employees did this company have in your location?

PROBE: Please consider only the location where you worked. Your best estimate is fine.

| | | |,| | | | RECORD NUMBER [GO TO C7]

<d> DON’T KNOW

<r> REFUSED

C6a. Would you say the number was . . .

<1> under 10 employees,

<2> 10 to under 50,

<3> 50 to under 100,

<4> 100 to under 500,

<5> 500 to under 1,000,

<6> 1,000 to under 2,500, or

<7> 2,500 or more employees?

<n> SELF-EMPLOYED

<d> DON’T KNOW

<r> REFUSED

C7. When did you first start working for [fill C2/C3 EMPLOYER NAME]?

ADJUST DATE, IF NECESSARY.

PROBE: Your best estimate would be fine.

CATI: DATE MUST BE BEFORE CLAIM DATE.

| | | / | | | / | | | | | [GO TO C9]

MONTH DAY YEAR

<d> DON’T KNOW

<r> REFUSED

C8. Would you say you first started working for that employer less than three years ago or three or more years ago?

<1> LESS THAN 3 YEARS AGO

<2> 3 OR MORE YEARS AGO

<d> DON’T KNOW

<r> REFUSED

C9. And what was the last date that you worked on that job before you applied for unemployment insurance benefits around [fill INITIAL CLAIM DATE]?

PROBE, IF NECESSARY: How long before [fill INITIAL CLAIM DATE] did that job end?

DATE SHOULD BE BEFORE INITIAL CLAIM DATE, BUT MAY NOT BE.

| | | / | | | / | | | | |

MONTH DAY YEAR

<d> DON’T KNOW

<r> REFUSED

CATI: ALWAYS FILL C9 DATE, IF KNOWN, FOR JOB END DATE. IF UNKNOWN, USE B1/B2 UI CLAIM DATE.

C10. How many hours per week, including regular overtime hours, did you usually work on that job?

(1-80)

| | | HOURS PER WEEK

<d> DON’T KNOW

<r> REFUSED

C11. And how much did you usually make, before taxes and other deductions, when that job ended? Please include tips, commissions, bonuses, and regular overtime.

IF STILL AT JOB, PROBE: What was your rate of pay when you lost the job just before you filed for benefits?

ACCEPT MOST CONVENIENT PAY PERIOD.

$ | | | |,| | | |.| | |

<1> PER HOUR

<2> PER WEEK

<3> ONCE EVERY TWO WEEKS

<4> TWICE A MONTH

<5> PER MONTH

<6> PER YEAR

<7> IN-KIND ONLY

<8> OTHER (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

C12. Were any of the following benefits available to you at that job?

INTERVIEWER: CODE “YES” IF AVAILABLE, BUT NOT USED.

	YES	NO	DON’T KNOW	REFUSED
a. Health insurance or membership in an HMO or PPO plan?	1	0	d	r
b. Paid vacation?	1	0	d	r
c. Paid holidays?	1	0	d	r
d. Paid sick leave?	1	0	d	r
e. Retirement or pension benefits?	1	0	d	r

C13. Why did you stop working at that job: were you laid off, did you quit, retire, were you fired, or was there some other reason?

PROBE: The time just before you filed for unemployment benefits around [fill INITIAL CLAIM DATE].

PROBE ANY “OTHER REASON” (FOR EXAMPLE, LACK OF WORK, COMPANY/PLANT MOVED/CLOSED, REORGANIZATION, LABOR DISPUTE) FOR TYPE OF JOB SEPARATION): What was the reason?

CODE ONE ONLY

<1> LAID OFF (INCLUDE JOB COMPLETED/TEMP. WORK/SEASONAL WORK/WORK PERIOD

ENDED/REORGANIZATION/DOWNSIZING/COMPANY SOLD/COMPANY MOVED/

COMPANY WENT OUT OF BUSINESS/END OF TERM IN SERVICE/ENLISTMENT UP)

<2> QUIT [GO TO C18]

<3> RETIRED [GO TO C21]

<4> FIRED [GO TO C19]

<5> ILLNESS/PREGNANCY/LEAVE OF ABSENCE

<6> STRIKE

<7> STILL WORKING BUT REDUCED HOURS

<8> INJURY ON JOB

<9> OTHER (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

C14. Which of the following best describes the reason that you were laid off?

CODE ONE ONLY

<1> The company moved or closed

<2> The plant or facility moved or closed

<3> Your job or shift was eliminated

<4> There was a lack of work

<5> There was a strike, or

<6> Was there some other reason? (SPECIFY) [specify]

<7> EMPLOYER SAID RESPONDENT COULDN’T

DO JOB ANYMORE [GO TO C21]

<d> DON’T KNOW

<r> REFUSED

C15. At the time that you were laid off, did you expect to go back to that job?

PROBE: Did you think it would be a temporary layoff?

<1> YES

<0> NO [GO TO C17]

<d> DON’T KNOW

<r> REFUSED

C16. When you were laid off, were you given a specific date of return to work?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

C17. [IF C15 = “0” SAY: “Even though you did not expect it at the time you were laid off”], did you actually go back to that job?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

GO TO C21

C18. Which of the following best describes the reason that you quit?

INTERVIEWER: READ ALL CHOICES BEFORE ACCEPTING ONE ANSWER

<1> Health, personal, or family reasons,

<2> To accompany spouse,

<3> Unsatisfactory working arrangements or you disliked the job,

<4> You knew the plant or company was going to close or move, [GO TO C21]

<5> Commuting became too difficult or expensive,

<6> You moved away,

<7> You changed careers/went back to school, or

<8> Was there some other reason? (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

GO TO C21

C19. What was the main reason why you were fired?

INTERVIEWER: READ ALL CHOICES BEFORE ACCEPTING ONE ANSWER

<1> Employer said you were not working or were not doing job well

<2> Employer said you couldn’t do job anymore

<3> Absences, arrive late, or leave early

<4> Dispute with employer

<5> Labor dispute

<6> Job eliminated or company reorganization

<7> Salary too high and company cutting expenses, or

<8> Was there some other reason? (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

C20. How long before you were fired, did your employer officially notify you that this would happen?

INTERVIEWER: RECORD NUMBER AND MARK CODE.

| | | NUMBER

<0> NO ADVANCE NOTICE

<1> DAYS

<2> WEEKS

<d> DON’T KNOW

<r> REFUSED

C21. When that job ended, did you receive severance pay, a buyout or some other payment?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

C22. And when that job ended, did you look for work?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

PART II: EMPLOYMENT DURING THE 3 YEARS PRIOR TO THE PRE-UI CLAIM JOB

CATI: CY = CALENDAR YEAR OF JOB END YEAR.

C23. The next few questions are about your employment and earnings experiences before you left your job at [fill C2/C3 EMPLOYER NAME] in [fill JOB END MONTH/YEAR]?

About how many jobs did you have between [fill CY-3] and [fill CY-1]? Please include your job at [fill C2/C3 EMPLOYER NAME] in your response.

| | | NUMBER

<d> DON’T KNOW

<r> REFUSED

CATI: CAN’T BE “0.”

C24. What were your total earnings from all paid jobs you had in [fill (CY-1)]?

PROBE: Please include any part-time, self-employment, temporary jobs, odd jobs, side jobs, under-the-table jobs, or other types of paid jobs that you had.

$ | | | |,| | | | PER YEAR [GO TO D1]

IF CAN’T GIVE EXACT TOTAL EARNINGS, ASK: About how much did you make, before taxes and other deductions, for all your paid jobs in [fill (CY-1)]?

$ | | | |,| | | |.| | |

<1> PER HOUR

<2> PER WEEK

<3> ONCE EVERY TWO WEEKS

[GO TO D1]

<4> TWICE A MONTH

<5> PER MONTH

<6> PER YEAR

<7> IN-KIND ONLY

<8> OTHER (SPECIFY) [specify]

[GO TO C25]

<d> DON’T KNOW

<r> REFUSED

C25. Would you say your total earnings in [fill (CY-1)] were less than $30,000 or $30,000 or more?

<1> LESS THAN $30,000 [GO TO C27]

<2> $30,000 OR MORE

<d> DON’T KNOW

<r> REFUSED

C26. Would you say they were . . .

<1> $30,000 to under $45,000,

<2> $45,000 to under $60,000,

<3> $60,000 to under $75,000,

<4> $75,000 to under $90,000,

<5> $90,000 to under $105,000, or

<6> $105,000 or more?

<d> DON’T KNOW

<r> REFUSED

GO TO D1

C27. Would you say they were . . .

<1> less than $5,000,

<2> $5,000 to under $10,000,

<3> $10,000 to under $15,000,

<4> $15,000 to under $20,000,

<5> $20,000 to under $25,000, or

<6> $25,000 to under $30,000?

<d> DON’T KNOW

<r> REFUSED

SECTION D – RAPID RESPONSE

D1. When your job at [fill C3 EMPLOYER] ended, did someone come to your place of work or talk with you at another location about how to file for unemployment insurance claims and to describe the reemployment services available in your community?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

D2. Who talked to you? Was it . . .

READ ALL ITEMS.

CODE ALL THAT APPLY

<1> your employer,

<2> One-Stop Career Center, [fill NAME OF ONE-STOP CENTER NAME],

or Rapid Response staff,

<3> unemployment insurance staff,

<4> state employment services staff,

<5> TAA staff,

<6> union representatives, or

<7> someone else? (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

SECTION E – NOTIFICATION OF TRADE ADJUSTMENT ASSISTANCE

ELIGIBILITY/KNOWLEDGE OF TAA/APPLICATION

CATI: ASK THIS SECTION OF THE TAA SAMPLE ONLY.

PART I: Notification of TAA Eligibility

E1. Now I would like to ask you about the TAA or Trade Adjustment Assistance Program. You may also know it as NAFTA-TAA or ATAA. These are government programs which offer assistance to workers who have lost their jobs because of trade with foreign countries.

How did you first find out about the TAA program?

PROBE: NAFTA stands for North American Free Trade Agreement. ATAA stands for Alternative Trade Adjustment Assistance. You may also know it as the Trade Act.

IF “AT WORK,” ANSWERED, PROBE BY ASKING: Did you find out through a meeting at your employer or by seeing a notice posted, a letter, or did you hear about it from your co‑workers or through your union? CODE ANSWER.

CODE ALL THAT APPLY. READ LIST IF NECESSARY.

<1> MEETING AT FORMER EMPLOYER

<2> CO-WORKERS

<3> NOTICE POSTED AT WORK

<4> EMPLOYMENT/JOB SERVICE OFFICE

<5> UNEMPLOYMENT OFFICE/UNEMPLOYMENT STAFF

<6> ONE-STOP CENTER

<7> FRIENDS (NOT CO-WORKERS)

<8> NEWSPAPERS/RADIO/TV/INTERNET

<9> UNION REPRESENTATIVE

<10> LETTER

<11> SCHOOL

<12> NEVER FOUND OUT ABOUT TAA [GO TO F1]

<13> OTHER (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

E2. CATI: IF “<10> LETTER” CODED IN E1, ASK:

Was the letter from . . .

<1> the state of [fill STATE NAME], [GO TO E4]

<2> your union,

<3> your employer, or

<4> some other organization? (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

E3. Did you also get a letter from the state saying that you might be eligible for Trade Adjustment Assistance benefits?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

E4. When did you receive this letter? Was it . . .

<1> before the layoff, or [GO TO E6]

<2> after you were laid off?

[GO TO E6]

<d> DON’T KNOW

<r> REFUSED

E5. Did you receive the letter . . .

<1> within a month after you were laid off,

<2> one to six months after you were laid off, or

<3> six months or longer after layoff?

<d> DON’T KNOW

<r> REFUSED

E6. Did you attend a TAA orientation or meet with a TAA representative to find out more about TAA?

PROBE: Did you have a meeting with a TAA representative where you were told about all of the services you may be eligible for?

<1> YES

<0> NO [GO TO E8]

<d> DON’T KNOW

<r> REFUSED

E7. Where did this meeting take place? Was it . . .

READ ALL ANSWERS BEFORE ACCEPTING ANSWER(S).

<1> at the state unemployment or employment office

or One-Stop Career Center,

<2> at your former employer,

<3> at your union’s office,

<4> by telephone, or

<5> at some other location? (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

PART II: KNOWLEDGE OF TAA SERVICES

CATI: IF B3a = “NO,” “DK” OR “R,” ASK E8.

OTHERWISE GO TO CATI CHECK BEFORE E9.

E8. Were you told or did you know that under the Trade Adjustment Assistance program, you could be eligible to receive TRA payments after you used up your unemployment insurance benefits?

PROBE: This is supplemental unemployment insurance payments.

PROBE: TRA stands for Trade Readjustment Allowance.

<1> YES

<0> NO

[GO TO E10]

<d> DON’T KNOW

<r> REFUSED

CATI: IF TRA SAMPLE, OR B3a = “YES” OR E8 = “YES,” ASK E9:

E9. Were you aware that in order to get TRA benefits you had to enter a training program or receive a waiver by a specific deadline?

PROBE: This deadline was about 8 to 16 weeks or 2 to 4 months after your layoff.

PROBE: A waiver excuses you from having to take part in training, in order to maintain eligibility for TRA.

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

E10. Were you told or did you know that under the Trade Adjustment Assistance program that you might have been eligible for [INSERT a – d]?

		CODE YES OR NO FOR EACH
		YES	NO	DON’T KNOW	REFUSED
a.	training paid for by TAA to acquire new skills?	1	0	d	r
b.	having your travel and living expenses paid if you attended a training program in another area?	1	0	d	r
c.	having your travel and living expenses paid while you looked for work in another area?	1	0	d	r
d.	having your moving expenses paid if you got a job in another area?	1	0	d	r

PART III: APPLICATION FOR TAA SERVICES

E11. Did you complete an application form to determine your eligibility, or otherwise formally apply for TAA or TRA services?

<1> YES, RESPONDENT APPLIED

<2> YES, EMPLOYER/UNION/STATE REPRESENTATIVE

APPLIED FOR RESPONDENT (INTERVIEWER NOTE: RESPONDENT

VOLUNTEERS THIS INFORMATION)

<0> NO

<d> DON’T KNOW

<r> REFUSED

E12. Why did you apply for TAA? What about the program interested you the most?

INTERVIEWER: CODE ALL THAT APPLY

<1> TRAINING/SCHOOLING

<2> HCTC (HEALTH CARE TAX CREDIT)

<3> ATAA (ALTERNATIVE TAA)

<4> TRA BENEFITS

<5> JOB SEARCH OR RELOCATION ALLOWANCES

<6> ALL OF THE ABOVE

<7> OTHER (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

GO TO F1

E13. Why didn’t you apply for TAA services?

<1> WASN’T INTERESTED IN TRAINING

<2> GOT A JOB/BEGAN WORKING

<3> DIDN’T THINK I WOULD BE ELIGIBLE

<4> RECALLED TO WORK BY FORMER EMPLOYER

<5> EXPECTED TO BE RECALLED BY FORMER EMPLOYER

<6> DIDN’T KNOW HOW TO APPLY FOR TAA SERVICES

<7> RULES TOO COMPLICATED

<8> MOVED/LEFT THE AREA

<9> OTHER (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

SECTION F – REEMPLOYMENT SERVICES

F1. After you left your job at [fill C2/C3 EMPLOYER NAME], did you receive any of the following services at a local unemployment office, One-Stop Career Center or other organization providing reemployment services: (INSERT a – g)

CATI: ROTATE START

	SERVICES	YES	NO	DON’T KNOW	REFUSED
a.	Assistance in searching for work?	1	0	d	r
b.	Referrals to jobs or employers?	1	0	d	r
c.	Help with your resume?	1	0	d	r
d.	Information on how to change careers?	1	0	d	r
e.	Tests to see what jobs you were qualified or suited for?	1	0	d	r
f.	Labor market information about what occupations were in demand in your local area?	1	0	d	r
g.	Information on education or job training programs?	1	0	d	r

F2. Did you ever receive counseling to help you determine if training was appropriate?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

F3. Did you ever receive counseling to help you select a training program or provider?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

F4. How many meetings did you have with your counselor to help you make a training decision?

| | | # OF MEETINGS

<d> DON’T KNOW

<r> REFUSED

CATI: IF ONE OR MORE SERVICES IN F1 ANSWERED “YES,” OR F2 OR F3 ANSWERED “YES,” ASK F5. OTHERWISE GO TO F6.

F5. Where did you receive the majority of these services? Was it at . . .

CODE ONE ONLY

<1> the state unemployment or employment office, One-Stop Career Center,

or [fill ONE-STOP CENTER NAME],

<2> another government agency,

<3> your employer,

<4> a school, training provider, college or university,

<5> a placement agency,

<6> Internet, or

<7> some other location? [specify]

<d> DON’T KNOW

<r> REFUSED

F6. Did you receive a letter stating that you needed to participate in a reemployment service to receive unemployment insurance benefits?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

F7. Did you receive payment for travel and living expenses while you attended a training program in another area?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

F8. How much did you receive in total for this?

$ | |,| | | | ROUND TO THE NEAREST DOLLAR AMOUNT

<d> DON'T KNOW

<r> REFUSED

F9. Did you receive payment for travel and living expenses while you looked for work in another area?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

F10. How much did you receive in total for this?

$ | |,| | | | ROUND TO THE NEAREST DOLLAR AMOUNT

<d> DON'T KNOW

<r> REFUSED

F11. Did you receive payment for moving expenses if you got a job in another area?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

F12. How much did you receive in total for this?

$ | |,| | | | ROUND TO THE NEAREST DOLLAR AMOUNT

<d> DON'T KNOW

<r> REFUSED

CATI: IF ONE OR MORE SERVICES IN F1 ANSWERED “YES,” OR F2 OR F3 ANSWERED “YES,” ASK:

F13. Thinking about all the services we’ve discussed, how helpful (was/were) the service(s) you received in [fill TASK]? Would you say the service(s) (was/were) very helpful, moderately helpful, a little bit helpful, or not at all helpful?

TASKS

VERY HELPFUL

MODERATELY

HELPFUL

LITTLE

BIT

HELPFUL

NOT

AT ALL

HELPFUL

STILL IN SCHOOL/

TRAINING

DON’T

KNOW

REFUSED

finding a job?

identifying a suitable education or training program?

SECTION G – EDUCATION AND TRAINING SERVICES

G1-G18 OMITTED IN BASELINE

G19. Now I’d like to ask you about education and job training programs and courses you may have attended since [fill JOB END DATE]. Please include training programs that helped you learn job skills or prepare for an occupation, as well as general educational programs, such as regular high school, adult basic education or GED courses, and college.

Since you left your job at [fill C3 COMPANY NAME], did you participate in any education and training programs and courses?

<1> YES [GO TO G21]

<0> NO

<d> DON’T KNOW

<r> REFUSED

G20. Why didn’t you participate in any education and training?

<1> GOT A JOB/BEGAN WORKING

<2> COULD NOT AFFORD TRAINING

<3> SUITABLE TRAINING NOT AVAILABLE/

COULDN’T GET INTO TRAINING I WANTED

<4> NOT INTERESTED/CHOSE NOT TO PARTICIPATE/

DID NOT WANT TO PURSUE TRAINING

<5> COST/MONEY/FINANCIAL REASONS

<6> HEALTH ISSUES/SICK

<7> FAMILY ISSUES/CHILD CARE

<8> TRANSPORTATION PROBLEMS

<9> OTHER (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

GO TO I1

G21. How many different education and training programs did you enroll in since [fill JOB END DATE]?

(1-10)

| | | #

<d> DON’T KNOW

<r> REFUSED

CATI: ALLOW FOR 5 PROGRAMS. ASK G22 ACROSS FIRST, THEN ASK G23‑G41 FOR EACH PROGRAM.

(FIRST SCHOOL OR TRAINING

PROGRAM AFTER JOB END DATE)

(SECOND SCHOOL OR TRAINING

PROGRAM AFTER JOB END DATE)

G22. What (is/are) the name(s) of the training and education program(s) you attended since [fill JOB END DATE], starting with the first one you attended?

What’s the next program you attended?

G23. When did you start attending [fill PROGRAM/THE FIRST/SECOND] program after [fill JOB END DATE]?

| | |/| | |/| | | | |

month day year

DON’T KNOW d

REFUSED r

| | |/| | |/| | | | |

month day year

DON’T KNOW d

REFUSED r

G24. And when did you stop attending (the/that) program?

| | |/| | |/| | | | |

month day year

STILL IN PROGRAM n

DON’T KNOW d

REFUSED r

| | |/| | |/| | | | |

month day year

STILL IN PROGRAM n

DON’T KNOW d

REFUSED r

G25. How many hours per week (did/do) you attend that program?

PROBE: Include only hours of instruction.

| | | HOURS PER WEEK

DON’T KNOW d

REFUSED r

| | | HOURS PER WEEK

DON’T KNOW d

REFUSED r

G26. While at [fill G22 NAME] (are/were) you being trained in some skill or occupation, or (are/were) you taking a general education program?

SKILL/OCCUPATION (GO TO G28) 1

GENERAL EDUCATION 2

DON’T KNOW (GO TO G30) d

REFUSED (GO TO G30) r

SKILL/OCCUPATION (GO TO G28) 1

GENERAL EDUCATION 2

DON’T KNOW (GO TO G30) d

REFUSED (GO TO G30) r

GO TO G29

G27. What kind of general education (are/were) you taking? (Is/Was) it . . .

INTERVIEWER: READ CATEGORIES.

CODE ONE ONLY

regular high school, 1

GED classes, 2

ESL-English as a second

language, 3

non-credit adult education, 4

a two-year program at a

community college, 5

a four-year program at a college

or university, 6

a graduate or professional

program, or 7

something else? (SPECIFY) [specify] 8

DON’T KNOW d

REFUSED r

regular high school, 1

GED classes, 2

ESL-English as a second

language, 3

non-credit adult education, 4

a two-year program at a

community college, 5

a four-year program at a college

or university, 6

a graduate or professional

program, or 7

something else? (SPECIFY) [specify] 8

DON’T KNOW d

REFUSED r

G28. What kind of job (are/were) you being trained for or what (are/were) you learning to do in that program?

PROBE FOR SPECIFICS.

(THIRD SCHOOL OR TRAINING

PROGRAM AFTER JOB END DATE)

(FOURTH SCHOOL OR TRAINING

PROGRAM AFTER JOB END DATE)

(FIFTH SCHOOL OR TRAINING

PROGRAM AFTER JOB END DATE)

| | |/| | |/| | | | |

month day year

DON’T KNOW d

REFUSED r

| | |/| | |/| | | | |

month day year

DON’T KNOW d

REFUSED r

| | |/| | |/| | | | |

month day year

DON’T KNOW d

REFUSED r

| | |/| | |/| | | | |

month day year

STILL IN PROGRAM n

DON’T KNOW d

REFUSED r

| | |/| | |/| | | | |

month day year

STILL IN PROGRAM n

DON’T KNOW d

REFUSED r

| | |/| | |/| | | | |

month day year

STILL IN PROGRAM n

DON’T KNOW d

REFUSED r

| | | HOURS PER WEEK

DON’T KNOW d

REFUSED r

| | | HOURS PER WEEK

DON’T KNOW d

REFUSED r

| | | HOURS PER WEEK

DON’T KNOW d

REFUSED r

SKILL/OCCUPATION (GO TO G28) 1

GENERAL EDUCATION 2

DON’T KNOW (GO TO G30) d

REFUSED (GO TO G30) r

SKILL/OCCUPATION (GO TO G28) 1

GENERAL EDUCATION 2

DON’T KNOW (GO TO G30) d

REFUSED (GO TO G30) r

SKILL/OCCUPATION (GO TO G28) 1

GENERAL EDUCATION 2

DON’T KNOW (GO TO G30) d

REFUSED (GO TO G30) r

GO TO G29

regular high school, 1

GED classes, 2

ESL-English as a second

language, 3

non-credit adult education, 4

a two-year program at a

community college, 5

a four-year program at a college

or university, 6

a graduate or professional

program, or 7

something else? (SPECIFY) [specify] 8

DON’T KNOW d

REFUSED r

GO TO G29

regular high school, 1

GED classes, 2

ESL-English as a second

language, 3

non-credit adult education, 4

a two-year program at a

community college, 5

a four-year program at a college

or university, 6

a graduate or professional

program, or 7

something else? (SPECIFY) [specify] 8

DON’T KNOW d

REFUSED r

GO TO G29

regular high school, 1

GED classes, 2

ESL-English as a second

language, 3

non-credit adult education, 4

a two-year program at a

community college, 5

a four-year program at a college

or university, 6

a graduate or professional

program, or 7

something else? (SPECIFY) [specify] 8

DON’T KNOW d

REFUSED r

GO TO G29

(FIRST SCHOOL OR TRAINING

PROGRAM AFTER JOB END DATE)

(SECOND SCHOOL OR TRAINING

PROGRAM AFTER JOB END DATE)

G29. (Are/Were) you attending this program mainly to prepare yourself for a new occupation or mainly to improve yourself in your occupation when you worked at [fill C3 COMPANY NAME]?

PREPARE FOR NEW OCCUPATION 1

IMPROVE SELF IN OCCUPATION 2

NEITHER 3

BOTH 4

DON’T KNOW d

REFUSED r

PREPARE FOR NEW OCCUPATION 1

IMPROVE SELF IN OCCUPATION 2

NEITHER 3

BOTH 4

DON’T KNOW d

REFUSED r

G30. Where (do/did) you go to get that training?

CODE ONE ONLY

(READ CHOICES IF NECESSARY)

PRIVATE COMPANY THAT

PROVIDES TRAINING?

(SPECIFY) [specify] 1

COMMUNITY COLLEGE/

2 YEAR COLLEGE 2

4 YEAR COLLEGE OR UNIVERSITY 3

VOCATIONAL TRAINING CENTER 4

ADULT ED/COMMUNITY SCHOOL/

ADULT HS/NIGHT SCHOOL 5

COMMUNITY BASED ORGANIZATION

OR OTHER NON-PROFIT PRIVATE

AGENCY 6

BUSINESS SCHOOL 7

COMPANY 8

SOME PLACE ELSE?

(SPECIFY) [specify] 9

DON’T KNOW d

REFUSED r

PRIVATE COMPANY THAT

PROVIDES TRAINING?

(SPECIFY) [specify] 1

COMMUNITY COLLEGE/

2 YEAR COLLEGE 2

4 YEAR COLLEGE OR UNIVERSITY 3

VOCATIONAL TRAINING CENTER 4

ADULT ED/COMMUNITY SCHOOL/

ADULT HS/NIGHT SCHOOL 5

COMMUNITY BASED ORGANIZATION

OR OTHER NON-PROFIT PRIVATE

AGENCY 6

BUSINESS SCHOOL 7

COMPANY 8

SOME PLACE ELSE?

(SPECIFY) [specify] 9

DON’T KNOW d

REFUSED r

G31. How much (does/did) the program cost?

PROBE: Please provide the cost of program participation, regardless of who paid for it.

PROBE IF ASKED: Include the cost of books, uniforms, and travel.

$ | | |,| | | |

DON’T KNOW (GO TO G32) d

REFUSED (GO TO G32) r

$ | | |,| | | |

DON’T KNOW (GO TO G32) d

REFUSED (GO TO G32) r

C31a. Is this amount the . . .

total cost of the program, 1

the cost per semester, (RECORD #

OF SEMESTERS

| | |) 2

the cost per year, or (RECORD #

OF YEARS

| | |) 3

for some other period

of time? (RECORD #

OF UNITS

| | |) 4

(SPECIFY) [specify]

total cost of the program, 1

the cost per semester, (RECORD #

OF SEMESTERS

| | |) 2

the cost per year, or (RECORD #

OF YEARS

| | |) 3

for some other period

of time? (RECORD #

OF UNITS

| | |) 4

(SPECIFY) [specify]

(THIRD SCHOOL OR TRAINING

PROGRAM AFTER JOB END DATE)

(FOURTH SCHOOL OR TRAINING

PROGRAM AFTER JOB END DATE)

(FIFTH SCHOOL OR TRAINING

PROGRAM AFTER JOB END DATE)

PREPARE FOR NEW OCCUPATION 1

IMPROVE SELF IN OCCUPATION 2

NEITHER 3

BOTH 4

DON’T KNOW d

REFUSED r

PREPARE FOR NEW OCCUPATION 1

IMPROVE SELF IN OCCUPATION 2

NEITHER 3

BOTH 4

DON’T KNOW d

REFUSED r

PREPARE FOR NEW OCCUPATION 1

IMPROVE SELF IN OCCUPATION 2

NEITHER 3

BOTH 4

DON’T KNOW d

REFUSED r

PRIVATE COMPANY THAT

PROVIDES TRAINING?

(SPECIFY) [specify] 1

COMMUNITY COLLEGE/

2 YEAR COLLEGE 2

4 YEAR COLLEGE OR UNIVERSITY 3

VOCATIONAL TRAINING CENTER 4

ADULT ED/COMMUNITY SCHOOL/

ADULT HS/NIGHT SCHOOL 5

COMMUNITY BASED ORGANIZATION

OR OTHER NON-PROFIT PRIVATE

AGENCY 6

BUSINESS SCHOOL 7

COMPANY 8

SOME PLACE ELSE?

(SPECIFY) [specify] 9

DON’T KNOW d

REFUSED r

PRIVATE COMPANY THAT

PROVIDES TRAINING?

(SPECIFY) [specify] 1

COMMUNITY COLLEGE/

2 YEAR COLLEGE 2

4 YEAR COLLEGE OR UNIVERSITY 3

VOCATIONAL TRAINING CENTER 4

ADULT ED/COMMUNITY SCHOOL/

ADULT HS/NIGHT SCHOOL 5

COMMUNITY BASED ORGANIZATION

OR OTHER NON-PROFIT PRIVATE

AGENCY 6

BUSINESS SCHOOL 7

COMPANY 8

SOME PLACE ELSE?

(SPECIFY) [specify] 9

DON’T KNOW d

REFUSED r

PRIVATE COMPANY THAT

PROVIDES TRAINING?

(SPECIFY) [specify] 1

COMMUNITY COLLEGE/

2 YEAR COLLEGE 2

4 YEAR COLLEGE OR UNIVERSITY 3

VOCATIONAL TRAINING CENTER 4

ADULT ED/COMMUNITY SCHOOL/

ADULT HS/NIGHT SCHOOL 5

COMMUNITY BASED ORGANIZATION

OR OTHER NON-PROFIT PRIVATE

AGENCY 6

BUSINESS SCHOOL 7

COMPANY 8

SOME PLACE ELSE?

(SPECIFY) [specify] 9

DON’T KNOW d

REFUSED r

$ | | |,| | | |

DON’T KNOW (GO TO G32) d

REFUSED (GO TO G32) r

$ | | |,| | | |

DON’T KNOW (GO TO G32) d

REFUSED (GO TO G32) r

$ | | |,| | | |

DON’T KNOW (GO TO G32) d

REFUSED (GO TO G32) r

total cost of the program, 1

the cost per semester, (RECORD #

OF SEMESTERS

| | |) 2

the cost per year, or (RECORD #

OF YEARS

| | |) 3

for some other period

of time? (RECORD #

OF UNITS

| | |) 4

(SPECIFY) [specify]

total cost of the program, 1

the cost per semester, (RECORD #

OF SEMESTERS

| | |) 2

the cost per year, or (RECORD #

OF YEARS

| | |) 3

for some other period

of time? (RECORD #

OF UNITS

| | |) 4

(SPECIFY) [specify]

total cost of the program, 1

the cost per semester, (RECORD #

OF SEMESTERS

| | |) 2

the cost per year, or (RECORD #

OF YEARS

| | |) 3

for some other period

of time? (RECORD #

OF UNITS

| | |) 4

(SPECIFY) [specify]

(FIRST SCHOOL OR TRAINING

PROGRAM AFTER JOB END DATE)

(SECOND SCHOOL OR TRAINING

PROGRAM AFTER JOB END DATE)

G32. (Do/Did) you or your family pay for all, some, or none of this training?

PAID FOR ALL (GO TO G35) 1

PAID FOR SOME 2

PAID FOR NONE (GO TO G34) 3

DON’T KNOW d

REFUSED r

PAID FOR ALL (GO TO G35) 1

PAID FOR SOME 2

PAID FOR NONE (GO TO G34) 3

DON’T KNOW d

REFUSED r

G33. How much (do/did) you or your family pay for this training?

$ | |,| | | | <1> Total cost

<2> Semester

DK d <3> Year

REF r <4> Other

$ | |,| | | | <1> Total cost

<2> Semester

DK d <3> Year

REF r <4> Other

G34. Who (else) (pays/paid) for this training?

CIRCLE ALL THAT APPLY

TAA BENEFITS/TRADE ACT 1

OTHER GOVERNMENT AGENCY 2

WIA 3

ITA VOUCHER 4

EMPLOYER 5

PRIVATE ORGANIZATION OR

SCHOLARSHIP FUND 6

PELL GRANT 7

VA (VETERANS) ASSISTANCE 8

OTHER? (SPECIFY) [specify] 9

DON’T KNOW d

REFUSED r

TAA BENEFITS/TRADE ACT 1

OTHER GOVERNMENT AGENCY 2

WIA 3

ITA VOUCHER 4

EMPLOYER 5

PRIVATE ORGANIZATION OR

SCHOLARSHIP FUND 6

PELL GRANT 7

VA (VETERANS) ASSISTANCE 8

OTHER? (SPECIFY) [specify] 9

DON’T KNOW d

REFUSED r

G35. INTERVIEWER: CHECK G24. IS RESPONDENT STILL IN PROGRAM?

YES (GO TO G41) 1

NO 0

YES (GO TO G41) 1

NO 0

G36. Did you complete the program?

PROBE: Did you receive a certificate or degree?

YES 1

NO (GO TO G38) 0

NO SPECIFIC

COMPLETION (GO TO G40) 2

DON’T KNOW d

REFUSED r

YES 1

NO (GO TO G38) 0

NO SPECIFIC

COMPLETION (GO TO G40) 2

DON’T KNOW d

REFUSED r

GO TO G40

G37. Did you receive a certificate, degree or license for completing the [fill PROGRAM/COURSE NAME]?

YES 1

NO 0

DON’T KNOW d

REFUSED r

YES 1

NO 0

DON’T KNOW d

REFUSED r

(THIRD SCHOOL OR TRAINING

PROGRAM AFTER JOB END DATE)

(FOURTH SCHOOL OR TRAINING

PROGRAM AFTER JOB END DATE)

(FIFTH SCHOOL OR TRAINING

PROGRAM AFTER JOB END DATE)

PAID FOR ALL (GO TO G35) 1

PAID FOR SOME 2

PAID FOR NONE (GO TO G34) 3

DON’T KNOW d

REFUSED r

PAID FOR ALL (GO TO G35) 1

PAID FOR SOME 2

PAID FOR NONE (GO TO G34) 3

DON’T KNOW d

REFUSED r

PAID FOR ALL (GO TO G35) 1

PAID FOR SOME 2

PAID FOR NONE (GO TO G34) 3

DON’T KNOW d

REFUSED r

$ | |,| | | | <1> Total cost

<2> Semester

DK d <3> Year

REF r <4> Other

$ | |,| | | | <1> Total cost

<2> Semester

DK d <3> Year

REF r <4> Other

$ | |,| | | | <1> Total cost

<2> Semester

DK d <3> Year

REF r <4> Other

TAA BENEFITS/TRADE ACT 1

OTHER GOVERNMENT AGENCY 2

WIA 3

ITA VOUCHER 4

EMPLOYER 5

PRIVATE ORGANIZATION OR

SCHOLARSHIP FUND 6

PELL GRANT 7

VA (VETERANS) ASSISTANCE 8

OTHER? (SPECIFY) [specify] 9

DON’T KNOW d

REFUSED r

TAA BENEFITS/TRADE ACT 1

OTHER GOVERNMENT AGENCY 2

WIA 3

ITA VOUCHER 4

EMPLOYER 5

PRIVATE ORGANIZATION OR

SCHOLARSHIP FUND 6

PELL GRANT 7

VA (VETERANS) ASSISTANCE 8

OTHER? (SPECIFY) [specify] 9

DON’T KNOW d

REFUSED r

TAA BENEFITS/TRADE ACT 1

OTHER GOVERNMENT AGENCY 2

WIA 3

ITA VOUCHER 4

EMPLOYER 5

PRIVATE ORGANIZATION OR

SCHOLARSHIP FUND 6

PELL GRANT 7

VA (VETERANS) ASSISTANCE 8

OTHER? (SPECIFY) [specify] 9

DON’T KNOW d

REFUSED r

YES (GO TO G41) 1

NO 0

YES (GO TO G41) 1

NO 0

YES (GO TO G41) 1

NO 0

YES 1

NO (GO TO G38) 0

NO SPECIFIC

COMPLETION (GO TO G40) 2

DON’T KNOW d

REFUSED r

YES 1

NO (GO TO G38) 0

NO SPECIFIC

COMPLETION (GO TO G40) 2

DON’T KNOW d

REFUSED r

YES 1

NO (GO TO G38) 0

NO SPECIFIC

COMPLETION (GO TO G40) 2

DON’T KNOW d

REFUSED r

GO TO G40

YES 1

NO 0

DON’T KNOW d

REFUSED r

YES 1

NO 0

DON’T KNOW d

REFUSED r

YES 1

NO 0

DON’T KNOW d

REFUSED r

(FIRST SCHOOL OR TRAINING

PROGRAM AFTER JOB END DATE)

(SECOND SCHOOL OR TRAINING

PROGRAM AFTER JOB END DATE)

G38. What was the main reason that you stopped attending (the/that) program?

CODE ONE ONLY

NOT INTERESTED/DIDN’T

LIKE PROGRAM 1

DIDN’T THINK IT WOULD HELP

TO FIND JOB 2

FOUND JOB/REEMPLOYED 3

STARTED (OTHER) SCHOOL/

TRAINING 4

DECIDED DIDN’T WANT JOB 5

ILLNESS/PREGNANCY 6

CHILD CARE/FAMILY

TRANSPORTATION/

LOGISTICAL PROBLEMS 7

PERSONAL PROBLEMS 8

POOR GRADES 9

COULDN’T AFFORD TO CONTINUE 10

COURSES OR PROGRAM

POORLY TAUGHT 11

OTHER? (SPECIFY) [specify] 12

DON’T KNOW d

REFUSED r

NOT INTERESTED/DIDN’T

LIKE PROGRAM 1

DIDN’T THINK IT WOULD HELP

TO FIND JOB 2

FOUND JOB/REEMPLOYED 3

STARTED (OTHER) SCHOOL/

TRAINING 4

DECIDED DIDN’T WANT JOB 5

ILLNESS/PREGNANCY 6

CHILD CARE/FAMILY

TRANSPORTATION/

LOGISTICAL PROBLEMS 7

PERSONAL PROBLEMS 8

POOR GRADES 9

COULDN’T AFFORD TO CONTINUE 10

COURSES OR PROGRAM

POORLY TAUGHT 11

OTHER? (SPECIFY) [specify] 12

DON’T KNOW d

REFUSED r

G39. NO QUESTION G39 IN THIS VERSION.

G40. How useful is (the/that) program to you in your current job? Is it useful, somewhat useful, or is it not useful?

USEFUL 1

SOMEWHAT USEFUL 2

NOT USEFUL 3

TOO SOON TO KNOW 4

NO CURRENT JOB n

DON’T KNOW d

REFUSED r

USEFUL 1

SOMEWHAT USEFUL 2

NOT USEFUL 3

TOO SOON TO KNOW 4

NO CURRENT JOB n

DON’T KNOW d

REFUSED r

G41. INTERVIEWER: CHECK G22. IS THERE ANOTHER PROGRAM?

YES (GO TO G23) 1

NO (GO TO I1) 0

YES (GO TO G23) 1

NO (GO TO I1) 0

(THIRD SCHOOL OR TRAINING

PROGRAM AFTER JOB END DATE)

(FOURTH SCHOOL OR TRAINING

PROGRAM AFTER JOB END DATE)

(FIFTH SCHOOL OR TRAINING

PROGRAM AFTER JOB END DATE)

NOT INTERESTED/DIDN’T

LIKE PROGRAM 1

DIDN’T THINK IT WOULD HELP

TO FIND JOB 2

FOUND JOB/REEMPLOYED 3

STARTED (OTHER) SCHOOL/

TRAINING 4

DECIDED DIDN’T WANT JOB 5

ILLNESS/PREGNANCY 6

CHILD CARE/FAMILY

TRANSPORTATION/

LOGISTICAL PROBLEMS 7

PERSONAL PROBLEMS 8

POOR GRADES 9

COULDN’T AFFORD TO CONTINUE 10

COURSES OR PROGRAM

POORLY TAUGHT 11

OTHER? (SPECIFY) [specify] 12

DON’T KNOW d

REFUSED r

NOT INTERESTED/DIDN’T

LIKE PROGRAM 1

DIDN’T THINK IT WOULD HELP

TO FIND JOB 2

FOUND JOB/REEMPLOYED 3

STARTED (OTHER) SCHOOL/

TRAINING 4

DECIDED DIDN’T WANT JOB 5

ILLNESS/PREGNANCY 6

CHILD CARE/FAMILY

TRANSPORTATION/

LOGISTICAL PROBLEMS 7

PERSONAL PROBLEMS 8

POOR GRADES 9

COULDN’T AFFORD TO CONTINUE 10

COURSES OR PROGRAM

POORLY TAUGHT 11

OTHER? (SPECIFY) [specify] 12

DON’T KNOW d

REFUSED r

NOT INTERESTED/DIDN’T

LIKE PROGRAM 1

DIDN’T THINK IT WOULD HELP

TO FIND JOB 2

FOUND JOB/REEMPLOYED 3

STARTED (OTHER) SCHOOL/

TRAINING 4

DECIDED DIDN’T WANT JOB 5

ILLNESS/PREGNANCY 6

CHILD CARE/FAMILY

TRANSPORTATION/

LOGISTICAL PROBLEMS 7

PERSONAL PROBLEMS 8

POOR GRADES 9

COULDN’T AFFORD TO CONTINUE 10

COURSES OR PROGRAM

POORLY TAUGHT 11

OTHER? (SPECIFY) [specify] 12

DON’T KNOW d

REFUSED r

USEFUL 1

SOMEWHAT USEFUL 2

NOT USEFUL 3

TOO SOON TO KNOW 4

NO CURRENT JOB n

DON’T KNOW d

REFUSED r

USEFUL 1

SOMEWHAT USEFUL 2

NOT USEFUL 3

TOO SOON TO KNOW 4

NO CURRENT JOB n

DON’T KNOW d

REFUSED r

USEFUL 1

SOMEWHAT USEFUL 2

NOT USEFUL 3

TOO SOON TO KNOW 4

NO CURRENT JOB n

DON’T KNOW d

REFUSED r

YES (GO TO G23) 1

NO (GO TO I1) 0

YES (GO TO G23) 1

NO (GO TO I1) 0

YES (GO TO G23) 1

NO (GO TO I1) 0

SECTION H – JOBS SINCE PRE-CLAIM JOB

H1. The next questions are about the jobs you’ve held since working at [fill C3 COMPANY NAME]. Please include part-time and full-time jobs, and jobs in which you were self-employed.

Are you currently working?

<1> YES [GO TO H4]

<0> NO

<d> DON’T KNOW

<r> REFUSED

H2. What are you currently doing? ACCEPT MULTIPLE ANSWERS

<1> GOING TO SCHOOL/PARTICIPATING IN AN EDUCATION

OR TRAINING PROGRAM

<2> LOOKING FOR WORK

<3> CARING FOR CHILDREN/OTHER FAMILY MEMBERS

<4> ILL/DISABLED

<5> RETIRED

<6> NOT LOOKING FOR WORK

<7> NOTHING

<d> DON’T KNOW

<r> REFUSED

H3. Have you worked since [fill C9 MONTH/YEAR OR UI CLAIM MONTH/YEAR OTHERWISE]?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

H4. How many different jobs have you had since [fill C9 DATE OR INITIAL CLAIM MONTH/YEAR]?

(1-10)

| | | # OF JOBS SINCE PRE-UI CLAIM JOB

<d> DON’T KNOW

<r> REFUSED

JOB 1

JOB 2

H5. Please tell me the name of the (other) companies, organizations, and people you’ve worked for since your job ended around [fill JOB END DATE], starting with the most recent job that you had.

TREAT A JOB INTERRUPTED BY TWO OR MORE UNPAID WEEKS AS SEPARATE JOBS, EVEN IF IT IS WITH THE SAME EMPLOYER. IF SEPARATION IS LESS THAN TWO WEEKS, TREAT AS ONE JOB.

PROBE: What’s the next job you had since [fill INITIAL CLAIM DATE]?

(SPECIFY) [specify] 1

DON’T KNOW d

REFUSED r

(SPECIFY) [specify] 1

DON’T KNOW d

REFUSED r

H6. When did you start working for [fill JOB NAME]?

RECORD MONTH, DAY, AND YEAR. IF SAMPLE MEMBER CANNOT GIVE EXACT DATE, PROBE FOR BEGINNING (CODE DAY 1), MIDDLE (CODE DAY 15), OR END OF MONTH (CODE DAY 30).

INTERVIEWER: DATE USUALLY WILL BE AFTER PRE UI CLAIM JOB BUT IT MAY NOT BE.

(2004-2005)

| | | / | | | / | | | | |

MONTH DAY YEAR

DON’T KNOW d

REFUSED r

(2004-2005)

| | | / | | | / | | | | |

MONTH DAY YEAR

DON’T KNOW d

REFUSED r

H7. When did that job end?

RECORD MONTH, DAY, AND YEAR. IF SAMPLE MEMBER CANNOT GIVE EXACT DATE, PROBE FOR BEGINNING (CODE DAY 1), MIDDLE (CODE DAY 15), OR END OF MONTH (CODE DAY 30).

(2004-2005)

| | | / | | | / | | | | |

MONTH DAY YEAR

STILL AT JOB n

DON’T KNOW d

REFUSED r

(2004-2005)

| | | / | | | / | | | | |

MONTH DAY YEAR

STILL AT JOB n

DON’T KNOW d

REFUSED r

JOB 3

JOB 4

(SPECIFY) [specify] 1

DON’T KNOW d

REFUSED r

(SPECIFY) [specify] 1

DON’T KNOW d

REFUSED r

(2004-2005)

| | | / | | | / | | | | |

MONTH DAY YEAR

DON’T KNOW d

REFUSED r

(2004-2005)

| | | / | | | / | | | | |

MONTH DAY YEAR

DON’T KNOW d

REFUSED r

(2004-2005)

| | | / | | | / | | | | |

MONTH DAY YEAR

STILL AT JOB n

DON’T KNOW d

REFUSED r

(2004-2005)

| | | / | | | / | | | | |

MONTH DAY YEAR

STILL AT JOB n

DON’T KNOW d

REFUSED r

JOB 1

JOB 2

H8. How did you find (this/that) job?

PROBE: How did you hear about it?

CODE ONE ONLY

RECALL BY FORMER EMPLOYER 1

STATE EMPLOYER AGENCY/

STATE JOB SERVICE 2

PRIVATE EMPLOYMENT AGENCY 3

FRIENDS AND RELATIVES 4

WANT ADS 5

DIRECTLY WITH EMPLOYER 6

UNION 7

SELF-EMPLOYED 8

THROUGH SCHOOL 9

INTERNET, INTERNET JOB

SERVICE, TV 10

OTHER (SPECIFY) [specify] 11

DON’T KNOW d

REFUSED r

RECALL BY FORMER EMPLOYER 1

STATE EMPLOYER AGENCY/

STATE JOB SERVICE 2

PRIVATE EMPLOYMENT AGENCY 3

FRIENDS AND RELATIVES 4

WANT ADS 5

DIRECTLY WITH EMPLOYER 6

UNION 7

SELF-EMPLOYED 8

THROUGH SCHOOL 9

INTERNET, INTERNET JOB

SERVICE, TV 10

OTHER (SPECIFY) [specify] 11

DON’T KNOW d

REFUSED r

H9. What kind of company is [fill JOB]—what do they make, sell, or do?

(SPECIFY) [specify] 1

DON’T KNOW d

REFUSED r

(SPECIFY) [specify] 1

DON’T KNOW d

REFUSED r

H10. What (do/did) you do there—what (is/was) your job?

PROBE: What (are/were) your most important duties at (this/that) job?

(SPECIFY) [specify] 1

DON’T KNOW d

REFUSED r

(SPECIFY) [specify] 1

DON’T KNOW d

REFUSED r

H11. (Do/Did) you belong to a union on this job?

YES 1

NO 0

DON’T KNOW d

REFUSED r

YES 1

NO 0

DON’T KNOW d

REFUSED r

JOB 3

JOB 4

RECALL BY FORMER EMPLOYER 1

STATE EMPLOYER AGENCY/

STATE JOB SERVICE 2

PRIVATE EMPLOYMENT AGENCY 3

FRIENDS AND RELATIVES 4

WANT ADS 5

DIRECTLY WITH EMPLOYER 6

UNION 7

SELF-EMPLOYED 8

THROUGH SCHOOL 9

INTERNET, INTERNET JOB

SERVICE, TV 10

OTHER (SPECIFY) [specify] 11

DON’T KNOW d

REFUSED r

RECALL BY FORMER EMPLOYER 1

STATE EMPLOYER AGENCY/

STATE JOB SERVICE 2

PRIVATE EMPLOYMENT AGENCY 3

FRIENDS AND RELATIVES 4

WANT ADS 5

DIRECTLY WITH EMPLOYER 6

UNION 7

SELF-EMPLOYED 8

THROUGH SCHOOL 9

INTERNET, INTERNET JOB

SERVICE, TV 10

OTHER (SPECIFY) [specify] 11

DON’T KNOW d

REFUSED r

(SPECIFY) [specify] 1

DON’T KNOW d

REFUSED r

(SPECIFY) [specify] 1

DON’T KNOW d

REFUSED r

(SPECIFY) [specify] 1

DON’T KNOW d

REFUSED r

(SPECIFY) [specify] 1

DON’T KNOW d

REFUSED r

YES 1

NO 0

DON’T KNOW d

REFUSED r

YES 1

NO 0

DON’T KNOW d

REFUSED r

JOB 1

JOB 2

H12. How many hours per week, including regular overtime hours (do/did) you usually work on (this/that) job?

(1-120)

| | | | # HOURS PER WEEK

DON’T KNOW d

REFUSED r

(1-120)

| | | | # HOURS PER WEEK

DON’T KNOW d

REFUSED r

H13. How much (are/were) you making before taxes and other deductions (when you left that job)? Please include tips, commissions, bonuses, and regular overtime.

INTERVIEWER: ACCEPT MOST CONVENIENT PAY PERIOD. IF NECESSARY, CONFIRM PAY PERIOD.

$ | | | |,| | | |.| | |

ENTER TIME PERIOD:

PER HOUR 1

PER WEEK 2

ONCE EVERY TWO WEEKS 3

TWICE A MONTH 4

PER MONTH 5

PER YEAR 6

IN-KIND ONLY 7

OTHER (SPECIFY) [specify] 8

NOT YET PAID n

DON’T KNOW d

REFUSED r

$ | | | |,| | | |.| | |

ENTER TIME PERIOD:

PER HOUR 1

PER WEEK 2

ONCE EVERY TWO WEEKS 3

TWICE A MONTH 4

PER MONTH 5

PER YEAR 6

IN-KIND ONLY 7

OTHER (SPECIFY) [specify] 8

NOT YET PAID n

DON’T KNOW d

REFUSED r

H14. (Are/Were) any of the following benefits available to you at [fill JOB]?

INTERVIEWER: IF BENEFITS WILL BE AVAILABLE TO SAMPLE MEMBER AFTER A STANDARD PROBATIONARY PERIOD, CODE YES, EVEN IF NOT USED.

YES NO DK RF

a. Health insurance or

membership in an

HMO or PPO

plan? 1 0 d r

b. Paid vacation? 1 0 d r

c. Paid holidays? 1 0 d r

d. Paid sick leave? 1 0 d r

e. Retirement or

pension benefits? 1 0 d r

YES NO DK RF

a. Health insurance or

membership in an

HMO or PPO

plan? 1 0 d r

b. Paid vacation? 1 0 d r

c. Paid holidays? 1 0 d r

d. Paid sick leave? 1 0 d r

e. Retirement or

pension benefits? 1 0 d r

H15. INTERVIEWER: CHECK H7. IS CODE “n,” STILL AT JOB, CIRCLED?

YES (GO TO NEXT

JOB OR CATI INSTRUCTIONS

BEFORE H19) 1

NO 0

YES (GO TO NEXT

JOB OR CATI INSTRUCTIONS

BEFORE H19) 1

NO 0

JOB 3

JOB 4

(1-120)

| | | | # HOURS PER WEEK

DON’T KNOW d

REFUSED r

(1-120)

| | | | # HOURS PER WEEK

DON’T KNOW d

REFUSED r

$ | | | |,| | | |.| | |

ENTER TIME PERIOD:

PER HOUR 1

PER WEEK 2

ONCE EVERY TWO WEEKS 3

TWICE A MONTH 4

PER MONTH 5

PER YEAR 6

IN-KIND ONLY 7

OTHER (SPECIFY) [specify] 8

NOT YET PAID n

DON’T KNOW d

REFUSED r

$ | | | |,| | | |.| | |

ENTER TIME PERIOD:

PER HOUR 1

PER WEEK 2

ONCE EVERY TWO WEEKS 3

TWICE A MONTH 4

PER MONTH 5

PER YEAR 6

IN-KIND ONLY 7

OTHER (SPECIFY) [specify] 8

NOT YET PAID n

DON’T KNOW d

REFUSED r

YES NO DK RF

a. Health insurance or

membership in an

HMO or PPO

plan? 1 0 d r

b. Paid vacation? 1 0 d r

c. Paid holidays? 1 0 d r

d. Paid sick leave? 1 0 d r

e. Retirement or

pension benefits? 1 0 d r

YES NO DK RF

a. Health insurance or

membership in an

HMO or PPO

plan? 1 0 d r

b. Paid vacation? 1 0 d r

c. Paid holidays? 1 0 d r

d. Paid sick leave? 1 0 d r

e. Retirement or

pension benefits? 1 0 d r

YES (GO TO NEXT

JOB OR CATI INSTRUCTIONS

BEFORE H19) 1

NO 0

YES (GO TO NEXT

JOB OR CATI INSTRUCTIONS

BEFORE H19 1

NO 0

JOB 1

JOB 2

H16. Why did you stop working at that job—were you laid off, did you quit, retire, were you fired, or was there some other reason?

LAID OFF (INCLUDE JOB COMPLETED/

TEMP. WORK/SEASONAL WORK/WORK

PERIOD ENDED/REORGANIZATION/

DOWNSIZING/COMPANY SOLD/

COMPANY MOVED/COMPANY WENT

OUT OF BUSINESS/END OF TERM IN

SERVICE/ENLISTMENT UP) 1

QUIT 2

RETIRED 3

FIRED 4

ILLNESS/PREGNANCY/

LEAVE OF ABSENCE 5

STRIKE 6

INJURY ON JOB 7

OTHER (SPECIFY) [specify] 8

DON’T KNOW d

REFUSED r

LAID OFF (INCLUDE JOB COMPLETED/

TEMP. WORK/SEASONAL WORK/WORK

PERIOD ENDED/REORGANIZATION/

DOWNSIZING/COMPANY SOLD/

COMPANY MOVED/COMPANY WENT

OUT OF BUSINESS/END OF TERM IN

SERVICE/ENLISTMENT UP) 1

QUIT 2

RETIRED 3

FIRED 4

ILLNESS/PREGNANCY/

LEAVE OF ABSENCE 5

STRIKE 6

INJURY ON JOB 7

OTHER (SPECIFY) [specify] 8

DON’T KNOW d

REFUSED r

H17. When that job ended, did you . . .

CODE ALL THAT APPLY

look for work, 1

begin working somewhere else, 2

attend an education or

training program, 3

continue working at a different job, or 4

do something else? (SPECIFY) [specify] 5

DON’T KNOW d

REFUSED r

look for work, 1

begin working somewhere else, 2

attend an education or

training program, 3

continue working at a different job, or 4

do something else? (SPECIFY) [specify] 5

DON’T KNOW d

REFUSED r

H18. CATI: DID RESPONDENT HAVE MORE THAN ONE POST-CLAIM JOB? IS H4 > 1?

YES (GO TO H6) 1

NO (GO TO H19 CATI

INSTRUCTIONS) 0

YES (GO TO H6) 1

NO (GO TO H19 CATI

INSTRUCTIONS) 0

JOB 3

JOB 4

LAID OFF (INCLUDE JOB COMPLETED/

TEMP. WORK/SEASONAL WORK/WORK

PERIOD ENDED/REORGANIZATION/

DOWNSIZING/COMPANY SOLD/

COMPANY MOVED/COMPANY WENT

OUT OF BUSINESS/END OF TERM IN

SERVICE/ENLISTMENT UP) 1

QUIT 2

RETIRED 3

FIRED 4

ILLNESS/PREGNANCY/

LEAVE OF ABSENCE 5

STRIKE 6

INJURY ON JOB 7

OTHER (SPECIFY) [specify] 8

DON’T KNOW d

REFUSED r

LAID OFF (INCLUDE JOB COMPLETED/

TEMP. WORK/SEASONAL WORK/WORK

PERIOD ENDED/REORGANIZATION/

DOWNSIZING/COMPANY SOLD/

COMPANY MOVED/COMPANY WENT

OUT OF BUSINESS/END OF TERM IN

SERVICE/ENLISTMENT UP) 1

QUIT 2

RETIRED 3

FIRED 4

ILLNESS/PREGNANCY/

LEAVE OF ABSENCE 5

STRIKE 6

INJURY ON JOB 7

OTHER (SPECIFY) [specify] 8

DON’T KNOW d

REFUSED r

look for work, 1

begin working somewhere else, 2

attend an education or

training program, 3

continue working at a different job, or 4

do something else? (SPECIFY) [specify] 5

DON’T KNOW d

REFUSED r

look for work, 1

begin working somewhere else, 2

attend an education or

training program, 3

continue working at a different job, or 4

do something else? (SPECIFY) [specify] 5

DON’T KNOW d

REFUSED r

YES (GO TO H6) 1

NO (GO TO H19 CATI

INSTRUCTIONS) 0

YES (GO TO H6) 1

NO (GO TO H19 CATI

INSTRUCTIONS) 0

CATI CHECK: IF MORE THAN 2 JOBS IN QUESTION H4, CONTINUE ASKING SAME SERIES OF QUESTIONS ABOUT ALL 5 JOBS.

CATI: ASK ONLY OF TAA SAMPLE.

CATI: CHECK A4 (OR UI SAMPLE DATA IF A4 WAS REFUSED).

IF SAMPLE MEMBER WAS BORN EARLIER THAN 1955, ASK H19.

H19. Were you told or did you know that under the TAA program, instead of retraining, you might have been eligible to receive a wage supplement at a new job, if that job paid less than your job at [fill C3 COMPANY NAME]?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

CATI: IF E11 = 1 OR 2, ASK H20, OTHERWISE GO TO I1

H20. Did you apply for this benefit?

<1> YES [GO TO H22]

<0> NO

<d> DON’T KNOW

<r> REFUSED

H21. Why didn’t you apply?

CODE ALL THAT APPLY

<1> NOT ENOUGH MONEY TO BE WORTHWHILE

<2> WANTED TRAINING

<3> COULD NOT FIND A JOB

<4> OTHER (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

GO TO I1

H22. Did you receive the wage supplement?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

H23. How much did you receive in total?

$ | | | |,| | | |

<d> DON’T KNOW

<r> REFUSED

SECTION I – MARITAL STATUS

I1. Now I have some general questions. At the time you left your job at [fill C3 COMPANY] in [fill JOB END DATE], were you married, living together unmarried, separated, divorced, widowed, or had you never been married?

<1> MARRIED

<2> LIVING TOGETHER UNMARRIED

<3> SEPARATED

<4> DIVORCED

<5> WIDOWED

<6> NEVER MARRIED

<d> DON’T KNOW

<r> REFUSED

I2. Was your (spouse/partner) working for pay when you left your job around [fill JOB END DATE]?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

SECTION J – PRE- AND POST-CLAIM INCOME

(OTHER THAN UI BENEFITS)

The next questions are about other sources of income and support besides unemployment benefits that you may have received during the calendar year before you left your job at [fill C3 EMPLOYER]. These questions will go very quickly.

CATI: CY = CALENDAR YEAR THE PERSON LEFT THEIR PRE-UI JOB, - MEANS “MINUS” THE NUMBER OF YEAR(S) INDICATED.

J1. In [fill CY-1], did you or anyone else in your household receive food stamp benefits?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED [GO TO SPECIAL REFUSE SCREEN]

J REF. THIS ITEM SHOULD BE PROGRAMMED LIKE AN INFO SCREEN.

CATI: IF AMOUNTS RECEIVED ARE REFUSED FOR ANY SOURCE, SAY:

Your answers to these questions will help the researchers better understand the problems people face when they are unemployed. Neither your name nor any other information that would identify you is kept with your answers. Could you provide your best estimate?

J2. In [fill CY-1], did you or anyone else in your household receive cash assistance from [fill LOCAL TANF NAME] or welfare, Supplemental Security Income (SSI), Social Security Retirement, Disability, or Survivors Benefits (SSA) or General Assistance (GA)?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

J3. What was the total income for you and all the members of your household, before taxes and other deductions in [fill CY-1]? Please include all of the sources of income we’ve talked about, plus any others you may have had.

PROBE, IF NEEDED: Include sources such as self-employment, regular jobs, and earnings from odd side jobs, under-the-table jobs, and other activities, social security, pensions, rent, interest and dividends, unemployment compensation, welfare, other public assistance, food stamps, child support, and money from any other sources. Your best estimate is fine.

$ | | | |,| | | | [GO TO J7] <1> PER MONTH

<2> PER YEAR

<d> DON’T KNOW

<r> REFUSED

INTERVIEWER: ACCEPT A “DON’T KNOW” ANSWER WITHOUT PRESSING RESPONDENT FOR AN ANSWER. GO TO RANGES IN J4 TO

GET INCOME AMOUNT.

J4. Would you say your household income in that year was less than $30,000 or $30,000 or more?

<1> LESS THAN $30,000 [GO TO J6]

<2> $30,000 OR MORE

<d> DON’T KNOW

<r> REFUSED

J5. Would you say it was . . .

<1> $30,000 to under $45,000,

<2> $45,000 to under $60,000,

<3> $60,000 to under $75,000,

<4> $75,000 to under $90,000,

<5> $90,000 to under $105,000, or

<6> $105,000 or more?

<d> DON’T KNOW

<r> REFUSED

GO TO J7

J6. Would you say it was . . .

<1> less than $5,000,

<2> $5,000 to under $10,000,

<3> $10,000 to under $15,000,

<4> $15,000 to under $20,000,

<5> $20,000 to under $25,000, or

<6> $25,000 to under $30,000?

<d> DON’T KNOW

<r> REFUSED

HOUSING

J7. At the time you left your job at [fill C2/C3 EMPLOYER NAME], did you (and your (spouse/partner)) own the residence where you lived?

<1> YES [GO TO J9]

<0> NO

<d> DON’T KNOW

<r> REFUSED

J8. Did you rent, did you live rent-free, or did you have some other kind of arrangement?

CODE ONE ONLY

<1> RENTED (INCLUDING RENT PAID

TO ANOTHER HOUSEHOLD MEMBER)

<2> OCCUPIED RENT FREE

<3> OCCUPIED FOR SERVICES

<4> PUBLIC HOUSING

<5> OTHER (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

J9. Now I would like to ask you similar questions about other sources of income and support besides unemployment benefits that you may have received since you left your job at [fill C3 COMPANY]. These questions will also go very quickly. Please remember I’m asking about income after you left your job at [fill WITH C3 COMPANY].

PENSION

Since [fill JOB END MONTH/YEAR], did you or anyone else in your household receive pension benefits from a private or government employer or from a 401K or IRA account?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

J10. Since [fill JOB END MONTH/YEAR], for approximately how many months did you receive pension benefits?

| | | # OF MONTHS

<1> ALL THE MONTHS

<d> DON’T KNOW

<r> REFUSED

J11. How much was received each month since [fill JOB END DATE]?

IF VARIED, PROBE: Please tell me the average amount received.

$ | | |,| | | | PER MONTH

<d> DON’T KNOW

<r> REFUSED

FOOD STAMP BENEFITS

J12. READ STEM IF NECESSARY: Since [fill JOB END MONTH/YEAR], did you or anyone else in your household receive . . .

food stamp benefits?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

J13. Since [fill JOB END MONTH/YEAR], for approximately how many months did you or anyone else in your household receive food stamp benefits?

| | | # OF MONTHS

<1> ALL THE MONTHS

<d> DON’T KNOW

<r> REFUSED

J14. How much was received each month since [fill JOB END DATE]?

IF VARIED, PROBE: Please tell me the average amount received.

$ | | |,| | | | PER MONTH

<d> DON’T KNOW

<r> REFUSED

CASH ASSISTANCE

J15. READ STEM IF NECESSARY: Since [fill JOB END MONTH/YEAR], did you or anyone else in your household receive . . .

Cash assistance from [fill LOCAL TANF NAME] or welfare, Supplemental Security Income (SSI), Social Security Retirement, Disability, or Survivors Benefits (SSA) or General Assistance (GA)?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

J16. Since [fill JOB END MONTH/YEAR], for approximately how many months did you or anyone else in your household receive cash assistance?

| | | # OF MONTHS

<1> ALL THE MONTHS

<d> DON’T KNOW

<r> REFUSED

J17. How much was received each month since [fill JOB END MONTH/YEAR]?

IF VARIED, PROBE: Please tell me the average amount received.

$ | | |,| | | | PER MONTH

<d> DON’T KNOW

<r> REFUSED

J18. What was the total income for you and all the members of your household, before taxes and other deductions in [fill INTERVIEW YEAR-1]? Please include all of the sources of income we’ve talked about, plus any others you may have had.

$ | | | |,| | | | [GO TO K1] <1> PER MONTH

<2> PER YEAR

<d> DON’T KNOW

<r> REFUSED

INTERVIEWER: ACCEPT A “DON’T KNOW” ANSWER WITHOUT PRESSING RESPONDENT FOR AN ANSWER. GO TO RANGES TO GET INCOME AMOUNT.

J19. Would you say your household income in [fill INTERVIEW YEAR-1] was less than $30,000 or $30,000 or more?

<1> LESS THAN $30,000 [GO TO J21]

<2> $30,000 OR MORE

<d> DON’T KNOW

<r> REFUSED

J20. Would you say it was . . .

<1> $30,000 to under $45,000,

<2> $45,000 to under $60,000,

<3> $60,000 to under $75,000,

<4> $75,000 to under $90,000,

<5> $90,000 to under $105,000, or

<6> $105,000 or more?

<d> DON’T KNOW

<r> REFUSED

GO TO K1

J21. Would you say it was . . .

<1> less than $5,000,

<2> $5,000 to under $10,000,

<3> $10,000 to under $15,000,

<4> $15,000 to under $20,000,

<5> $20,000 to under $25,000, or

<6> $25,000 to under $30,000?

<d> DON’T KNOW

<r> REFUSED

SECTION K – HEALTH STATUS AND HEALTH INSURANCE

K1. Now I have some questions about your health and health care insurance.

Would you say your health in general is . . .

<1> excellent,

<2> good,

<3> fair, or

<4> poor?

<d> DON’T KNOW

<r> REFUSED

K2. Thinking back to the time you left your job at [fill C3 EMPLOYER], how was your health back then? Was it . . .

<1> excellent,

<2> good,

<3> fair, or

<4> poor?

<d> DON’T KNOW

<r> REFUSED

K3. Do you have a physical, emotional, or other health condition that limits the amount of work you could do?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

K4. What kind of work-limiting health problems do you have? Do you have . . . (READ a – e)

	YES	NO	DON’T KNOW	REFUSED
a. a physical disability or illness?	1	0	d	r
b. an emotional or mental health problem?	1	0	d	r
c. a problem with drugs or alcohol?	1	0	d	r
d. a learning disability?	1	0	d	r
e. any other problems? (SPECIFY) [specify]	1	0	d	r

CATI: FOR EACH “YES” ANSWER IN K4, ASK:

K5. For how long have you had this problem?

INTERVIEWER: IF RESPONDENT SAYS “MY WHOLE LIFE,” ENTER R’s AGE AS

NUMBER AND CODE “3” FOR YEARS.

		INDICATE:
	NUMBER	WEEKS	MONTHS	YEARS	DON’T KNOW	REFUSED
a. A physical disability or illness?	\| \| \|	1	2	3	d	r
b. An emotional or mental health problem?	\| \| \|	1	2	3	d	r
c. A problem with drugs or alcohol?	\| \| \|	1	2	3	d	r
d. A learning disability?	\| \| \|	1	2	3	d	r
e. Any other problems? (SPECIFY) [specify]	\| \| \|	1	2	3	d	r

HEALTH INSURANCE COVERAGE

K6. Were you covered by health insurance during the year leading up to the time you left your job at [fill C3 EMPLOYER]?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

K7. Have you been covered by health insurance at any time since you left that job around [fill JOB END DATE]?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

K8. Were you covered by health insurance for the entire period since you left that job?

<1> YES [GO TO K10]

<0> NO

<d> DON’T KNOW

<r> REFUSED

K9. Since [fill JOB END MONTH/YEAR], for approximately how many months were you covered by health insurance?

| | | NUMBER OF MONTHS

<1> ALL THE MONTHS

<d> DON’T KNOW

<r> REFUSED

K10. Since [fill JOB END MONTH/YEAR], what was the main type of health insurance or health coverage that you had?

READ IF NECESSARY.

<1> A HEALTH INSURANCE PLAN FROM YOUR

CURRENT OR FORMER EMPLOYER, UNION, OR SCHOOL,

<2> A HEALTH INSURANCE PLAN FROM YOUR SPOUSE’S

CURRENT OR FORMER EMPLOYER, UNION, OR SCHOOL,

<3> A HEALTH INSURANCE PLAN BOUGHT ON YOUR OWN,

INCLUDING THOSE FROM PROFESSIONAL ASSOCIATIONS,

<4> A HEALTH INSURANCE PLAN PROVIDED BY SOMEONE

WHO DOES NOT LIVE IN YOUR HOUSEHOLD,

<5> MEDICARE, THE HEALTH INSURANCE PLAN FOR PEOPLE

65 YEARS OLD AND OLDER OR PERSONS WITH CERTAIN

DISABILITIES,

<6> MEDICAID, THE GOVERNMENT ASSISTANCE PROGRAM

THAT PAYS FOR HEALTH CARE,

<7> ANOTHER STATE SPECIFIC PLAN,

<8> VA, CHAMPUS, CHAMP-VA, TRICARE, OR SOME

OTHER MILITARY CARE, OR

<9> INDIAN HEALTH SERVICE?

<10> OTHER (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

CATI: ASK K11-K13 ONLY OF TAA SAMPLE.

K11. Were you told or did you know that under the TAA program, you might be eligible for a federal Health Coverage Tax Credit or HCTC, equal to 65 percent of the premiums you would pay for qualified health coverage for you and your family members?

PROBE: A Health Coverage Tax Credit provided to those eligible for TAA services.

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

K12. Did you apply for a Health Coverage Tax Credit?

<1> YES [GO TO K14]

<0> NO

<d> DON’T KNOW

<r> REFUSED

K13. Why didn’t you apply for a Health Coverage Tax Credit?

READ IF NECESSARY.

<1> NOT ELIGIBLE FOR THE TAX CREDIT

<2> DESIRED HEALTH PLAN WAS NOT A QUALIFIED PLAN

<3> ALREADY HAD HEALTH COVERAGE THROUGH MEDICARE

<4> ALREADY HAD HEALTH COVERAGE THROUGH MEDICAID OR S-CHIP

<5> ALREADY HAD HEALTH COVERAGE FROM FORMER EMPLOYER

<6> ALREADY HAD HEALTH COVERAGE FROM SPOUSE’S EMPLOYER

<7> DESIRED HEALTH PLAN WAS STILL TOO EXPENSIVE, EVEN AFTER TAX CREDIT

<8> PROGRAM RULES WERE TOO COMPLICATED/DID NOT UNDERSTAND THEM

<9> WORRIED WOULD NOT GET REIMBURSED

<10> DIDN’T THINK THE TAX CREDITS WOULD LAST LONG ENOUGH

<11> OTHER (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

GO TO K16

K14. Did you ever receive a Health Coverage Tax Credit?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

K15 About how much was the tax credit that you received?

$ | | |,| | | |

<d> DON’T KNOW

<r> REFUSED

K16. During the past 12 months, about how much did (you/your family) spend out-of-pocket for medical care? Do not include the cost of dental care, health insurance premiums, or any costs that were paid by your health insurance.

PROBE: Your best estimate is fine.

PROBE: Include out-of-pocket expenses for prescription drugs, co-payments, and deductibles, but do not include health insurance premiums, dental costs, or any other costs paid by your health insurance.

$ | | |,| | | |

[GO TO L1]

<0> NONE

<d> DON’T KNOW

<r> REFUSED

K17. Would you say you spent . . .

<0> nothing,

<1> less than $500,

<2> $500 to $1,999,

<3> $2,000 to $2,999,

<4> $3,000 to $4,999, or

<5> $5,000 or more?

<d> DON’T KNOW

<r> REFUSED

SECTION L – DEMOGRAPHICS

L1. We’re almost finished. I just have a few final questions. What was the highest diploma or degree you had received at the time you left your job at [fill C3 EMPLOYER] in [fill C9 MONTH/YEAR OR UI CLAIM MONTH/YEAR]?

<0> NONE

<1> LESS THAN HIGH SCHOOL GRADUATE

<2> HIGH SCHOOL DIPLOMA

<3> HIGH SCHOOL EQUIVALENCY/GED

<4> VOCATIONAL/TECHNICAL/BUSINESS

<5> ASSOCIATE’S (2 YEARS)

<6> BACHELOR’S (4 YEARS)

<7> MASTERS

<8> DOCTORATE/Ph.D.

<9> SOME COLLEGE

<10> OTHER (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

L2. Has the highest diploma or degree you have received changed since then?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

L3. What is the highest diploma or degree you currently have?

<0> NONE

<1> LESS THAN HIGH SCHOOL GRADUATE

<2> HIGH SCHOOL DIPLOMA

<3> HIGH SCHOOL EQUIVALENCY/GED

<4> VOCATIONAL/TECHNICAL/BUSINESS

<5> ASSOCIATE’S (2 YEARS)

<6> BACHELOR’S (4 YEARS)

<7> MASTERS

<8> DOCTORATE/Ph.D.

<9> SOME OR MORE COLLEGE

<10> OTHER (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

L4. Do you consider yourself to be of Hispanic or Latino origin, such as Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

L5. What race do you consider yourself? Would you say you are . . .

<1> White,

<2> Black or African American,

<3> American Indian or Alaska Native,

<4> Asian,

<5> Native Hawaiian or Other Pacific Islander, or

<6> some other race? (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

L6. Do you speak a language other than English at home?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

L7. What language other than English do you speak at home?

<1> SPANISH

<2> ASIAN LANGUAGE

<3> FRENCH

<4> OTHER (SPECIFY) [specify]

<d> DON’T KNOW

<r> REFUSED

L8. How well do you speak English?

<1> Very well

<2> Well

<3> Not well

<4> Not at all

<d> DON’T KNOW

<r> REFUSED

L9. INTERVIEWER: CODE WITHOUT ASKING IF KNOWN.

Are you male or female?

<1> MALE

<2> FEMALE

<d> DON’T KNOW

<r> REFUSED

SECTION M – HOUSEHOLD SIZE AND NUMBER OF CHILDREN

M1. How many people, including yourself, lived or stayed with you at the time you left your job at [fill C3 EMPLOYER] in [fill C9 MONTH/YEAR OR UI CLAIM MONTH/YEAR]?

PROBE: Please include people who were temporarily away, for example, at school or in the hospital and people not related to you.

(1-20)

|___|___| PEOPLE IN HOUSEHOLD

<d> DON’T KNOW

<r> REFUSED

M2. How many children under 18 were financially dependent upon you at that time?

(0-20)

|___|___| # CHILDREN UNDER 18

<d> DON’T KNOW

<r> REFUSED

SECTION N – MOBILITY

N1. Now I would like you to think back to [fill C9 MONTH/YEAR OR UI CLAIM MONTH/YEAR]. According to my information, you lived in [fill STATE] at that time. Is that correct?

< 1> YES [GO TO N3]

<0> NO

<d> DON’T KNOW

<r> REFUSED

N2. In what state did you live?

S TATE NAME:

<d> DON’T KNOW

<r> REFUSED

N3. Since then, have you lived, worked, or gone to school or training in a different state or country?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

N3. In what (other) states or countries have you lived, worked, or gone to school in since [fill JOB END DATE]?

PROBE: Do not include vacations or short visits.

OTHER (SPECIFY) [specify]

STATE/COUNTRY 1:___________________________

STATE/COUNTRY 2:___________________________

STATE/COUNTRY 3:___________________________

STATE/COUNTRY 4:___________________________

<d> DON’T KNOW

<r> REFUSED

SECTION O – TRACKING INFORMATION

O1. I would like to thank you for participating in the survey. We plan to contact you again next year and I need to know how to get in touch with you.

O2. INTERVIEWER: IF TELEPHONE NUMBER NOT KNOWN WITH CERTAINTY, ASK IF TELEPHONE NUMBER KNOWN WITH CERTAINTY?

(What is/Is TELEPHONE NUMBER) your telephone number?

TELEPHONE NUMBER SAME AS

SAMPLE INFORMATION 1

NEW TELEPHONE

NUMBER: |__|__|__|-|__|__|__|-|__|__|__|__|

NO TELEPHONE 0

DON’T KNOW d

REFUSED r

O3. Is that number listed in your name or is it in someone else’s?

SAMPLE MEMBER’S 1

OTHER’S 2

O4. Whose telephone is it?

Name

DON’T KNOW d

REFUSED r

O5. What is (his/her/their) address?

___________________________ _____________

House Number/Street Name Apt. #

__________________ _______ ____________

City State ZIP Code

SAME AS SAMPLE MEMBER’S 1

DON’T KNOW d

REFUSED r

GO TO O11

O6. What is (his/her/their) relationship to you?

A. SPOUSE/PARTNER 1

B. MOTHER 2

C. FATHER 3

D. SISTER 4

E. BROTHER 5

F. GRANDMOTHER 6

G. GRANDFATHER 7

H. AUNT 8

I. UNCLE 9

J. FRIEND 10

K. OTHER (SPECIFY) 11

DON’T KNOW d

REFUSED r

O7. Can you give me a number where you can be reached, perhaps a cell phone number?

NEW TELEPHONE

NUMBER: |__|__|__|-|__|__|__|-|__|__|__|__|

NO TELEPHONE 0

DON’T KNOW d

REFUSED r

O8. Whose telephone is that?

Name

DON’T KNOW d

REFUSED r

O9. What is (his/her/their) address?

___________________________ _____________

House Number/Street Name Apt. #

__________________ _______ ____________

City State ZIP Code

DON’T KNOW d

REFUSED r

O10. What is (his/her/their) relationship to you?

CODE ALL THAT APPLY

A. SPOUSE/PARTNER 1

B. MOTHER 2

C. FATHER 3

D. SISTER 4

E. BROTHER 5

F. GRANDMOTHER 6

G. GRANDFATHER 7

H. AUNT 8

I. UNCLE 9

J. FRIEND 10

K. OTHER (SPECIFY) 11

DON’T KNOW d

REFUSED r

O11. In order to mail you your check, I need your correct address. Please give me your permanent address and telephone number.

PROBE: What is the apartment number?

___________________________ _____________

House Number/Street Name Apt. #

__________________ _______ ____________

City State ZIP Code

PHONE NUMBER: |__|__|__|-|__|__|__|-|__|__|__|__|

DON’T KNOW d

REFUSED r

O12. What is the name, address, and telephone number of a relative who will know how to contact you a year from now?

PROBE FOR FULL NAMES, INCLUDING MIDDLE INITIALS.

PROBE FOR SPOUSES’ NAMES.

OTHER RELATIVE’S NAME, ADDRESS, AND TELEPHONE NUMBER

Other Relative’s Full Name

___________________________ _____________

House Number/Street Name Apt. #

__________________ _______ ____________

City State ZIP Code

PHONE NUMBER: |__|__|__|-|__|__|__|-|__|__|__|__|

Spouse’s Name (IF APPLICABLE)

Relationship to Sample Member

DON’T KNOW d

REFUSED r

DOES NOT HAVE OTHER RELATIVES 0

SAME AS SAMPLE MEMBER’S s

NO OTHER CONTACTS n

This is the end of the interview. Thank you very much for your time and cooperation.

Interviewer:_______________________________________

Date: ___________________

hour minute

File Type	application/msword
File Title	Contract No
Author	Tamika Love
Last Modified By	naradzay.bonnie
File Modified	2006-02-17
File Created	2005-02-25