Wave 5 Topical Mod Wave 5 Topical Modules Items Booklet

Items Booklet for
Specification:
Section: Work Schedule TM

WSEMPCT

Mark One Only
How many employers did [fill HESHE] work
for during a typical week?
COUNT SELF-EMPLOYED AS ONE EMPLOYER
(1)
(2)
(3)

1
2
3+

@

WSHRS1

Enter Number
How many hours per day did [fill HESHE]
work that week for [fill EMPBUSARR(<1>)]?
ROUND PARTIAL HOURS TO THE NEAREST WHOLE HOUR
@ Hours

WSDYS1

Enter Number
How many days did [fill HESHE] work during that week for
[Fill EMPBUSARR(<1>)]?
[r]H[n]
@ Days

WSWHDY1

Multiple Entry
Which days of the week were these?
[r]H[n]
ENTER ALL THAT APPLY
ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
@1

Friday, July 24, 2009

Monday through Friday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
All seven days
@2

@3

@4

@5

@6

@7

@8

Page 1 of 42

Survey:
Section: Work Schedule TM

Items Booklet

Mark One Only

WSVER1

DO NOT READ TO RESPONDENT
[fill EMPBUSARR(<1>)]
The number of days of the week listed as work days [if DAY1(<1>) is <1>]
Sunday
[endif]
[if DAY1(<2>) is <1>]
Monday
[endif]
[if DAY1(<3>) is <1>]
Tuesday
[endif]
[if DAY1(<4>) is <1>]
Wednesday
[endif]
[if DAY1(<5>) is <1>]
Thursday
[endif]
[if DAY1(<6>) is <1>]
Friday
[endif]
[if DAY1(<7>) is <1>]
Saturday
[endif]
appears to be inconsistent with the previously reported total
number of days worked during the week - [fill WSDYS1].
Probe to correct the days of the week worked and/or
total number of days worked.
IF THERE IS NO INCONSISTENCY, ENTER "P" TO PROCEED.
IF THERE IS AN INCONSISTENCY, BACK UP (F1) TO CORRECT
THE APPROPRIATE ANSWER(S).
@
Multiple Entry

WSBEG1

During that week, at what time of day did
[fill HESHE] begin work most days for [fill EMPBUSARR(<1>)]?
@1 : @2

@3

(1) A.M.
(2) P.M.
(3) Noon
(4) Midnight

Multiple Entry

WSEND1

At what time of day did [fill HESHE]
end work most days?
@1 : @2

Page 2 of 42

@3

(1) A.M.
(2) P.M.
(3) Noon
(4) Midnight

Friday, July 24, 2009

Items Booklet

Survey:
Section: Work Schedule TM

WSHMWK1

Mark One Only

As part of the work schedule for that week, were
there any days when [fill HESHE] worked only at home for
[if EMPBUSARR(<1>) eq or EMPBUSARR(<1>) eq ][fill
HISHER] [endif][fill EMPBUSARR(<1>)]?
(1)
(2)

Yes
No

@

WSHOM1

Multiple Entry
Which days of the week were these?
ENTER ALL THAT APPLY
ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
@1

Monday through Friday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
All seven days
@2

@3

@4

@5

@6

@7

@8

Mark One Only

WSJOB1

SHOW FLASHCARD Z
Which of the following best describes [fill HISHER]
work schedule at this job?
(1)
(2)
(3)
(4)
(5)
(6)
(7)

Regular daytime schedule
Regular evening shift
Regular night shift
Rotating shift (one that changes regularly from days to evenings or nights)
Split shift (one consisting of two distinct periods each day)
Irregular schedule (one that changes from day to day)
Other (specify)

@

Friday, July 24, 2009

Page 3 of 42

Survey:
Section: Work Schedule TM

Items Booklet

WSMNR1

Mark One Only
What is the MAIN reason [fill HESHE] worked [fill TEMP]?
DO NOT READ ANSWER CATEGORIES
VOLUNTARY
(1)
(2)
(3)
(4)
(5)

REASONS
Better child care arrangements
Better Pay
Better arrangements for care of other family members
Allows time for school
Other voluntary reasons

INVOLUNTARY REASONS
(6) Could not get any other job
(7) Requirement of the job
(8) Other involuntary reasons
@

WSHRS2

Enter Number
How many hours per day did [fill HESHE]
work that week for [fill EMPBUSARR(<2>)]?
ROUND PARTIAL HOURS TO THE NEAREST WHOLE HOUR
@ Hours

WSDYS2

Enter Number
How many days did [fill HESHE] work during that week?
[r]H[n]
@ Days

WSWHDY2

Multiple Entry
Which days of the week were these?
[r]H[n]
ENTER ALL THAT APPLY
ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
@1

Page 4 of 42

Monday through Friday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
All seven days
@2

@3

@4

@5

@6

@7

@8

Friday, July 24, 2009

Items Booklet

Survey:
Section: Work Schedule TM

WSVER2

Mark One Only
DO NOT READ TO RESPONDENT
[fill EMPBUSARR(<2>)]
The number of days of the week listed as work days [if DAY2(<1>) is <1>]
Sunday
[endif]
[if DAY2(<2>) is <1>]
Monday
[endif]
[if DAY2(<3>) is <1>]
Tuesday
[endif]
[if DAY2(<4>) is <1>]
Wednesday
[endif]
[if DAY2(<5>) is <1>]
Thursday
[endif]
[if DAY2(<6>) is <1>]
Friday
[endif]
[if DAY2(<7>) is <1>]
Saturday
[endif]
appears to be inconsistent with the previously reported total
number of days worked during the week - [fill WSDYS2].
Probe to correct the days of the week worked and/or
total number of days worked.
IF THERE IS NO INCONSISTANCY, ENTER "P" TO PROCEED.
IF THERE IS AN INCONSISTANCY, BACK UP (F1) TO CORRECT
THE APPROPRIATE ANSWER(S).
@

WSBEG2

Multiple Entry
During that week, at what time of day did
[fill HESHE] begin work most days for [fill EMPBUSARR(<2>)]?
@1 : @2

@3

(1)
(2)
(3)
(4)

A.M.
P.M.
Noon
Midnight

WSEND2

Multiple Entry
At what time of day did [fill HESHE]
end work most days?
@1 : @2

Friday, July 24, 2009

@3

(1)
(2)
(3)
(4)

A.M.
P.M.
Noon
Midnight

Page 5 of 42

Survey:
Section: Work Schedule TM

Items Booklet

WSHMWK2

Mark One Only

As part of the work schedule for that week, were there
any days when [fill HESHE] worked only at home for[if EMPBUSARR(<2>) eq
or EMPBUSARR(<2>) eq ] [fill HISHER][endif] [fill EMPBUSARR(<2>)]?
(1)
(2)

Yes
No

@

WSHOM2

Multiple Entry
Which days of the week were these?
ENTER ALL THAT APPLY
ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
@1

Monday through Friday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
All seven days
@2

@3

@4

@5

@6

@7

@8

Mark One Only

WSJOB2

SHOW FLASHCARD Z
Which of the following best describes [fill HISHER]
work schedule at this job?
(1)
(2)
(3)
(4)
(5)
(6)
(7)

Regular daytime schedule
Regular evening shift
Regular night shift
Rotating shift (one that changes regularly from days to evenings or nights)
Split shift (one consisting of two distinct periods each day)
Irregular schedule (one that changes from day to day)
Other (specify)

@

Page 6 of 42

Friday, July 24, 2009

Items Booklet

Survey:
Section: Work Schedule TM
Mark One Only

WSMNR2

What is the MAIN reason [fill HESHE] worked [fill TEMP]?
DO NOT READ ANSWER CATEGORIES
VOLUNTARY
(1)
(2)
(3)
(4)
(5)

REASONS
Better child care arrangements
Better Pay
Better arrangements for care of other family members
Allows time for school
Other voluntary reasons

INVOLUNTARY REASONS
(6) Could not get any other job
(7) Requirement of the job
(8) Other involuntary reasons
@

Friday, July 24, 2009

Page 7 of 42

Survey:
Section: Child Care

Items Booklet

Mark One Only

CHC1_HRWKSCH

About how many hours per WEEK did [fill TEMPNAME] usually spend in
school last month?
ENTER (V) FOR HOURS VARIED
ENTER (N) FOR NOT ENROLLED
@

Hours per week
Enter Number

CHC2_HRWKJOB

About how many hours per WEEK did [fill TEMPNAME] usually
spend looking for a job last month?
ENTER (V) FOR HOURS VARIED
ENTER (N) FOR DID NOT LOOK FOR A JOB LAST MONTH
@

Hours per week
Multiple Entry

CHC3_CKD1

SHOW FLASHCARD AA
During a typical week last month, please tell me if [fill TEMPNAME]
used any of the following individuals or arrangements to look after
[fill CHILDNAME1] on a regular basis. By regular basis,
I mean at least ONCE A WEEK during the PAST MONTH.
(1) Yes
(2) No
[r]H[n]
NOT ALL FLASHCARD CATEGORIES MAY APPEAR BELOW. ONLY VALID
CATEGORIES FOR RESPONDENT ARE LISTED ON THE SCREEN.
[if WORKRSLR eq <1>]
@1 Child's other parent or stepparent?
@2 Did [fill TEMPNAME] care for [fill CHILDNAME1] while
[fill TEMPNAME] [fill WASWERE] [fill CCTEMP]?[endif]
@3 Brother or sister age 15 or older?
@4 Brother or sister under age 15?
@5 Grandparent?
@6 Any other relative?
@7 Family day care provider caring for 2 or more children outside
of [fill PTEMPNAME] home?
@8 A child care or day care center?
@9 A nursery or preschool?
@10 A federally supported Head Start program?
@11 A non-relative such as a friend, neighbor, sitter, nanny,
or aupair?
Mark One Only

CHC5_WHEPAR1

Did [fill CHILDNAME1] 's other parent/stepparent care for
[fill HIMHERG] in [fill CHILDNAME1]'s home, the other
parent's home, another person's home, or someplace else?
MARK ONLY ONE
(1)
(2)
(3)
(4)

Child's home
Other parent's home (parent doesn't live with child)
Another person's home
Someplace else

@
Enter Number

CHC6_PARHRSA

How many hours per WEEK did [fill CHILDNAME1]'s other parent
or stepparent usually care for [fill HIMHERG]?
@
Page 8 of 42

Hours
Friday, July 24, 2009

Items Booklet

Survey:
Section: Child Care
Enter Number

CHC7_PARHRS1

Of those [fill CHC6_PARHRSA] hours per week that
[fill CHILDNAME1]'s other parent/stepparent
cared for [fill HIMHERG], how many of them were while
[fill TEMPNAME] [fill WASWERE] [fill CCTEMP]?
@

Hours
Mark One Only

CHC8_WHSELF1

In which of the following places did [fill TEMPNAME] care for
[fill CHILDNAME1], in [fill PTEMPNAME] home, at work or school,
or someplace else?
MARK ONLY ONE
(1)
(2)
(3)

In [fill PTEMPNAME] home
At work or at school
Someplace else

@
Enter Number

CHC9_SELFHR1

How many hours per WEEK did [fill TEMPNAME] care for
[fill CHILDNAME1] on a regular basis while
[fill TEMPNAME] [fill WASWERE] [fill CCTEMP]?
@

Hours
Mark One Only

CHC10_WHSB15A

Did [fill CHILDNAME1]'s brother or sister age 15 or over
care for [fill HIMHERG] in [fill CHILDNAME1]'s home, some other home,
or someplace else?
MARK ONLY ONE
PROBE: Where was [fill CHILDNAME1] cared for most of the time?
(1)
(2)
(3)

Child's home
Other home
Someplace else

@
Enter Number

CHC11_WHSBHRA

How many hours per WEEK did [fill CHILDNAME1]'s brother or
sister age 15 or over usually care for [fill HIMHERG]?
@

Hours
Enter Number

CHC12_HRSB15A

Of those [fill CHC11_WHSBHRA] hours per week that [fill CHILDNAME1]'s
brother or sister age 15 or over cared for [fill HIMHERG],
how many of them [fill WASWERE] while [fill TEMPNAME] [fill WASWERE]
[fill CCTEMP]?
@

Friday, July 24, 2009

Hours

Page 9 of 42

Survey:
Section: Child Care

Items Booklet

Mark One Only

CHC13_WHSB14A

Did [fill CHILDNAME1]'s brother or sister UNDER age 15 care for
[fill HIMHERG] in [fill CHILDNAME1]'s home, some other home,
or someplace else?
MARK ONLY ONE
(1)
(2)
(3)

Child's home
Other home
Someplace else

@
Enter Number

CHC14_SB14HR

How many hours per WEEK did [fill CHILDNAME1]'s brother or
sister UNDER age 15 usually care for [fill HIMHERG]?
@

Hours
Enter Number

CHC15_HRSB14A

Of those [fill CHC14_SB14HR] hours per week that
[fill CHILDNAME1]'s brother or sister UNDER age 15 cared for
[fill HIMHERG], how many of them were while [fill TEMPNAME]
[fill WASWERE] [fill CCTEMP]?
@

Hours
Mark One Only

CHC16_WHGRAN1

Did [fill CHILDNAME1]'s grandparent or set of grandparents
usually care for [fill HIMHERG] in [fill CHILDNAME1]'s
home, the grandparent's home, or someplace else?
MARK ONLY ONE
(1)
(2)
(3)

Child's home
Grandparent's home
Someplace else

@
Enter Number

CHC17_GRANHRA

How many hours per WEEK did [fill CHILDNAME1]'s grandparent or
set of grandparents usually care for [fill CHILDNAME1]?
@

Hours
Enter Number

CHC18_HRGRAN1

Of those [fill CHC17_GRANHRA] hours per week that [fill CHILDNAME1]'s
grandparent or set of grandparents cared for [fill HIMHERG],
how many of them were while [fill TEMPNAME] [fill WASWERE]
[fill CCTEMP]?
@

Page 10 of 42

Hours

Friday, July 24, 2009

Items Booklet

Survey:
Section: Child Care
Mark One Only

CHC19_PAYGRA1

When [fill CHILDNAME1] was cared for by [fill HISHERG] grandparent(s),
did [fill TEMPNAME] or [fill PTEMPNAME] family usually make any
money payment for this arrangement?
(1)
(2)

Yes
No

@
Enter Number

CHC20_AMTGRA1

In a typical WEEK last month, how much did [fill TEMPNAME]
or [fill PTEMPNAME] family pay [fill CHILDNAME1]'s grandparent
or grandparents to watch [fill HIMHERG]?
IF PAYMENT COVERS MORE THAN ONE CHILD IN THIS HOUSEHOLD, ASK
RESPONDENT TO SPLIT AMOUNT BETWEEN CHILDREN
$ @ PER WEEK
Mark One Only

CHC21_WHRELA1

Did this other relative usually care for [fill CHILDNAME1] in
[fill CHILDNAME1]'s home, the relative's home or someplace else?
MARK ONLY ONE
(1)
(2)
(3)

Child's home
Other relative's home
Someplace else

@
Enter Number

CHC22_RELAHRA

How many hours per WEEK did this other relative usually care for
[fill CHILDNAME1]?
@

Hours
Enter Number

CHC23_RELAHR1

Of those [fill CHC22_RELAHRA] hours per week that [fill CHILDNAME1]'s
other relative cared for [fill HIMHERG], how many of them were
while [fill TEMPNAME] [fill WASWERE] [fill CCTEMP]?
@

Hours
Mark One Only

CHC24_PAYREL1

When [fill CHILDNAME1] was cared for by this other relative, did
[fill TEMPNAME] or [fill PTEMPNAME] family usually make any money
payment for this arrangement?
(1)
(2)

Yes
No

@

Friday, July 24, 2009

Page 11 of 42

Survey:
Section: Child Care

Items Booklet

Enter Number

CHC25_AMTREL1

In a typical WEEK last month, how much did [fill TEMPNAME] or
[fill PTEMPNAME] family pay [fill CHILDNAME1]'s other relative to watch
[fill HIMHERG]?
IF PAYMENT COVERS MORE THAN ONE CHILD IN THIS HOUSEHOLD, ASK
RESPONDENT TO SPILT AMOUNT BETWEEN CHILDREN
$ @ PER WEEK
Enter Number

CHC26_HRSFAMA

How many hours per WEEK was [fill CHILDNAME1] usually cared for
in family day care?
@

Hours
Enter Number

CHC27_HRSFAM1

Of those [fill CHC26_HRSFAMA] hours that [fill CHILDNAME1] was
cared for in family day care, how many of them were while
[fill TEMPNAME] [fill WASWERE] [fill CCTEMP]?
@

Hours
Mark One Only

CHC28_PAYFAM1

When [fill CHILDNAME1] was cared for in family day care, did
[fill TEMPNAME] or [fill PTEMPNAME] family usually make any money
payment for this arrangement?
(1)
(2)

Yes
No

@
Enter Number

CHC29_AMTFAM1

In a typical WEEK last month, how much did [fill TEMPNAME] or
[fill PTEMPNAME] family pay for family day care for [fill CHILDNAME1]?
IF PAYMENT COVERS MORE THAN ONE CHILD IN THIS HOUSEHOLD, ASK
RESPONDENT TO SPLIT AMOUNT BETWEEN CHILDREN
$ @ PER WEEK
Mark One Only

CHC30_WHDAYC1

When [fill CHILDNAME1] was cared for in this child care or day
care center, was that at [fill PTEMPNAME] work or school, at a
church or religious organization, or someplace else?
MARK ONLY ONE
(1)
(2)
(3)

At work or at school
At a church or religious organization
Someplace else, including working at the child care or day
care center

@

Page 12 of 42

Friday, July 24, 2009

Items Booklet

Survey:
Section: Child Care
Enter Number

CHC31_DYHRA1

How many hours per WEEK was [fill CHILDNAME1] cared for in
this child care or day care center?
@

Hours
Enter Number

CHC32_HRDAYC1

Of those [fill CHC31_DYHRA1] hours per week that [fill CHILDNAME1]
was cared for in this child care center, how many of them were
while [fill TEMPNAME] [fill WASWERE] [fill CCTEMP]?
@

Hours
Mark One Only

CHC33_PAYDAY1

When [fill CHILDNAME1] was cared for in this child care or day care
center, did [fill TEMPNAME] or [fill PTEMPNAME] family usually
make any money payment for this arrangement?
(1)
(2)

Yes
No

@
Enter Number

CHC34_AMTDAY1

In a typical WEEK last month, how much did [fill TEMPNAME]
or [fill PTEMPNAME] family pay the child care or day care center
to care for [fill CHILDNAME1]?
IF PAYMENT COVERS MORE THAN ONE CHILD IN THIS HOUSEHOLD,
ASK RESPONDENT TO SPLIT AMOUNT BETWEEN CHILDREN
$ @ PER WEEK
Mark One Only

CHC35_WHNURS1

When [fill CHILDNAME1] attended nursery or preschool, was this at
[fill PTEMPNAME] work or school, at a church or religious organization,
or someplace else?
MARK ONLY ONE
(1)
(2)
(3)

At work or at school
At a church or religious organization
Someplace else, including working at the child care or day
care center

@
Enter Number

CHC36_NURHRSA

How many hours per WEEK does [fill CHILDNAME1] attend nursery or
preschool?
@

Friday, July 24, 2009

Hours

Page 13 of 42

Survey:
Section: Child Care

Items Booklet

Enter Number

CHC37_HRNURS1

Of those [fill CHC36_NURHRSA] hours per week that [fill CHILDNAME1]
attended nursery or preschool, how many of them were while
[fill TEMPNAME] [fill WASWERE] [fill CCTEMP]?
@

Hours
Mark One Only

CHC38_PAYNUR1

When [fill CHILDNAME1] attended this nursery or preschool, did
[fill TEMPNAME] or [fill PTEMPNAME] family usually make any money
payment for this arrangement?
(1)
(2)

Yes
No

@
Enter Number

CHC39_AMTNUR1

In a typical WEEK last month, how much did [fill TEMPNAME] or
[fill PTEMPNAME] family pay for [fill CHILDNAME1] to attend nursery
or preschool?
IF PAYMENT COVERS MORE THAN ONE CHILD IN THIS HOUSEHOLD,
ASK RESPONDENT TO SPLIT AMOUNT BETWEEN CHILDREN
$ @ PER WEEK
Enter Number

CHC40_HEADHRA

How many hours per WEEK does [fill CHILDNAME1] usually attend
Head Start?
@

Hours
Enter Number

CHC41_HRSTAR1

Of those [fill CHC40_HEADHRA] hours per week that [fill CHILDNAME1]
attended Head Start, how many of them were while
[fill TEMPNAME] [fill WASWERE] [fill CCTEMP]?
@

Hours
Mark One Only

CHC42_PAYSTA1

When [fill CHILDNAME1] attended Head Start, did [fill TEMPNAME] or
[fill PTEMPNAME] family usually make any money payment for this
arrangement?
(1)
(2)

Yes
No

@

Page 14 of 42

Friday, July 24, 2009

Items Booklet

Survey:
Section: Child Care
Enter Number

CHC43_AMTSTA1

In a typical WEEK last month, how much did [fill TEMPNAME]
or [fill PTEMPNAME] family pay for [fill CHILDNAME1]
to attend Head Start?
IF PAYMENT COVERS MORE THAN ONE CHILD IN THIS HOUSEHOLD,
ASK RESPONDENT TO SPLIT AMOUNT BETWEEN CHILDREN
$ @ PER WEEK
Mark One Only

CHC44_WHOTHE1

Did this non-relative usually care for [fill CHILDNAME1] in
[fill CHILDNAME1]'s home, the non-relative's home, or someplace else?
MARK ONLY ONE
(1)
(2)
(3)

Child's home
The non-relative's home
Someplace else

@
Enter Number

CHC45_OTHRHRA

How many hours per WEEK did this non-relative usually care for
[fill CHILDNAME1]?
@

Hours
Enter Number

CHC46_HROTHE1

Of those [fill CHC45_OTHRHRA] hours per week that [fill CHILDNAME1] was
cared for by this non-relative, how many of them were while
[fill TEMPNAME] [fill WASWERE] [fill CCTEMP]?
@

Hours
Mark One Only

CHC47_PAYOTH1

When [fill CHILDNAME1] was cared for by this non-relative, did
[fill TEMPNAME] or [fill PTEMPNAME] family usually make any money
payment for this arrangement?
(1)
(2)

Yes
No

@
Enter Number

CHC48_AMTOTH1

In a typical WEEK last month, how much did [fill TEMPNAME]
or [fill PTEMPNAME] family pay this non-relative to care for
[fill CHILDNAME1]?
IF PAYMENT COVERS MORE THAN ONE CHILD IN THIS HOUSEHOLD,
ASK RESPONDENT TO SPLIT AMOUNT BETWEEN CHILDREN
$ @ PER WEEK

Friday, July 24, 2009

Page 15 of 42

Survey:
Section: Child Care

Items Booklet

CHC49_CKD2

Multiple Entry
SHOW FLASHCARD AA
During a typical week last month, please tell me if [fill TEMPNAME]
used any of the following individuals or arrangements to look after
[fill CHILDNAME1] on a regular basis. By regular basis,
I mean at least ONCE A WEEK during the PAST MONTH.
[r]H[n]
NOT ALL FLASHCARD CATEGORIES MAY APPEAR BELOW. ONLY VALID
CATEGORIES FOR RESPONDENT ARE LISTED ON THE SCREEN.
(1) Yes
(2) No
[if WORKRSLR eq <1>]
@1 Child's other parent or stepparent?
@2 Did [fill TEMPNAME] care for [fill CHILDNAME1] while
[fill TEMPNAME] [fill WASWERE] [fill CCTEMP]?[endif]
@3 Brother or sister age 15 or older?
@4 Brother or sister under age 15?
@5 Grandparent?
@6 Any other relative?
@7 Family day care provider caring for 2 or more children
outside of [fill PTEMPNAME] home?
@8 A child care or day care center?
@9 Organized sports, including practices?
@10 Lessons (music, art, dance, language, computer)?
@11 Clubs (boys/girls clubs, scouts, and other organizations)?
@12 Before or after school care programs?
@13 A non-relative such as a friend, neighbor, sitter, nanny,
or aupair?
Mark One Only

CHC51_WHEPAR2

Did [fill CHILDNAME1] 's other parent/stepparent care for
[fill HIMHERG] in [fill CHILDNAME1]'s home, the other parent's
home, another person's home, or someplace else?
MARK ONLY ONE
(1)
(2)
(3)
(4)

Child's home
Other parent's home (parent doesn't live with child)
Another person's home
Someplace else

@
Enter Number

CHC52_PARHR2A

How many hours per WEEK did [fill CHILDNAME1]'s other parent or
stepparent usually care for [fill HIMHERG]?
@

Hours
Enter Number

CHC53_PARHRS2

Of those [fill CHC52_PARHR2A] hours per week that
[fill CHILDNAME1]'s other parent/stepparent cared for [fill HIMHERG],
how many of them were while [fill TEMPNAME] [fill WASWERE] [fill CCTEMP]?
@

Page 16 of 42

Hours

Friday, July 24, 2009

Items Booklet

Survey:
Section: Child Care

CHC54_WHSELF2

Mark One Only
In which of the following places did [fill TEMPNAME]
care for [fill CHILDNAME1], in [fill PTEMPNAME] home, at work or school,
or someplace else?
MARK ONLY ONE
(1)
(2)
(3)

In [fill PTEMPNAME] home
At work or at school
Someplace else

@
Enter Number

CHC55_SELFHR2

How many hours per WEEK did [fill TEMPNAME] care for
[fill CHILDNAME1] on a regular basis while [fill TEMPNAME]
[fill WASWERE] [fill CCTEMP]?
@

Hours
Mark One Only

CHC56_WHSB15B

Did [fill CHILDNAME1]'s brother or sister age 15 or over care for
[fill HIMHERG] in [fill CHILDNAME1]'s home, some other home,
or someplace else?
MARK ONLY ONE
PROBE: Where was [fill CHILDNAME1] cared for most of the time?
(1)
(2)
(3)

Child's home
Other home
Someplace else

@
Enter Number

CHC57_WHSBHRB

How many hours per WEEK did [fill CHILDNAME1]'s brother or sister
age 15 or over usually care for [fill HIMHERG]?
@

Hours
Enter Number

CHC58_HRSB15B

Of those [fill CHC57_WHSBHRB] hours per week that [fill CHILDNAME1]'s
brother or sister age 15 or over cared for [fill HIMHERG],
how many of them [fill WASWERE] while [fill TEMPNAME]
[fill WASWERE] [fill CCTEMP]?
@

Friday, July 24, 2009

Hours

Page 17 of 42

Survey:
Section: Child Care

Items Booklet

Mark One Only

CHC59_WHSB14B

Did [fill CHILDNAME1]'s brother or sister UNDER age 15 care for
[fill HIMHERG] in [fill CHILDNAME1]'s home, some other home, or
someplace else?
MARK ONLY ONE
(1)
(2)
(3)

Child's home
Other home
Someplace else

@
Enter Number

CHC60_SB14HB

How many hours per WEEK did [fill CHILDNAME1]'s brother or sister
UNDER age 15 usually care for [fill HIMHERG]?
@

Hours
Enter Number

CHC61_HRSB14B

Of those [fill CHC60_SB14HB] hours per week that [fill CHILDNAME1]'s
brother or sister UNDER age 15 cared for [fill HIMHERG], how many
of them were while [fill TEMPNAME] [fill WASWERE] [fill CCTEMP]?
@

Hours
Mark One Only

CHC62_WHGRAN2

Did [fill CHILDNAME1]'s grandparent or set of grandparents usually
care for [fill HIMHERG] in [fill CHILDNAME1]'s home, the
grandparent's home, or someplace else?
IF GRANDPARENT(S) LIVE WITH CHILD, ENTER (1) CHILD'S HOME
MARK ONLY ONE
(1)
(2)
(3)

Child's home
Grandparent's home
Someplace else

@
Enter Number

CHC63_GRANHRB

How many hours per WEEK did [fill CHILDNAME1]'s grandparent or
set of grandparents usually care for [fill CHILDNAME1]?
@

Hours
Enter Number

CHC64_HRGRAN2

Of those [fill CHC63_GRANHRB] hours per week that [fill CHILDNAME1]'s
grandparent or set of grandparents cared for [fill HIMHERG],
how many of them were while [fill TEMPNAME] [fill WASWERE]
[fill CCTEMP]?
@

Page 18 of 42

Hours

Friday, July 24, 2009

Items Booklet

Survey:
Section: Child Care
Mark One Only

CHC65_PAYGRA2

When [fill CHILDNAME1] was cared for by [fill HISHERG] grandparent(s),
did [fill TEMPNAME] or [fill PTEMPNAME] family usually make any
money payment for this arrangement?
(1)
(2)

Yes
No

@
Enter Number

CHC66_AMTGRA2

In a typical WEEK last month, how much did [fill TEMPNAME]
or [fill PTEMPNAME] family pay [fill CHILDNAME1]'s grandparent or
grandparents to watch [fill HIMHERG]?
IF PAYMENT COVERS MORE THAN ONE CHILD IN THIS HOUSEHOLD, ASK
RESPONDENT TO SPLIT AMOUNT BETWEEN CHILDREN.
$ @ PER WEEK
Mark One Only

CHC67_WHRELA2

Did this other relative usually care for [fill CHILDNAME1] in
[fill CHILDNAME1]'s home, the relative's home or someplace else?
MARK ONLY ONE
(1)
(2)
(3)

Child's home
Other relative's home
Someplace else

@
Enter Number

CHC68_RELHRB

How many hours per WEEK did this other relative usually care
for [fill CHILDNAME1]?
@

Hours
Enter Number

CHC69_RELAHR2

Of those [fill CHC68_RELHRB] hours per week that [fill CHILDNAME1]'s
other relative cared for [fill HIMHERG], how many of them were
while [fill TEMPNAME] [fill WASWERE] [fill CCTEMP]?
@

Hours
Mark One Only

CHC70_PAYREL2

When [fill CHILDNAME1] was cared for by this other relative,
did [fill TEMPNAME] or [fill PTEMPNAME] family usually make any
money payment for this arrangement?
(1)
(2)

Yes
No

@

Friday, July 24, 2009

Page 19 of 42

Survey:
Section: Child Care

Items Booklet

Enter Number

CHC71_AMTREL2

In a typical week last month, how much did [fill TEMPNAME]
or [fill PTEMPNAME] family pay [fill CHILDNAME1]'s other relative
to watch [fill HIMHERG]?
IF PAYMENT COVERS MORE THAN ONE CHILD IN THIS HOUSEHOLD, ASK
RESPONDENT TO SPLIT AMOUNT BETWEEN CHILDREN.
$ @ PER WEEK
Enter Number

CHC72_HRSFAMB

How many hours per WEEK was [fill CHILDNAME1] usually cared
for in family day care?
@

Hours
Enter Number

CHC73_HRSFAM2

Of those [fill CHC72_HRSFAMB] hours that [fill CHILDNAME1] was cared
for in family day care, how many of them were while [fill TEMPNAME]
[fill WASWERE] [fill CCTEMP]?
@

Hours
Mark One Only

CHC74_PAYFAM2

When [fill CHILDNAME1] was cared for in family day care, did
[fill TEMPNAME] or [fill PTEMPNAME] family usually make any money
payment for this arrangement?
(1)
(2)

Yes
No

@
Enter Number

CHC75_AMTFAM2

In a typical WEEK last month, how much did [fill TEMPNAME]
or [fill PTEMPNAME] family pay for family day care for
[fill CHILDNAME1]?
IF PAYMENT COVERS MORE THAN ONE CHILD IN THIS HOUSEHOLD, ASK
RESPONDENT TO SPLIT AMOUNT BETWEEN CHILDREN.
$ @ PER WEEK
Mark One Only

CHC76_WHDAYC2

When [fill CHILDNAME1] was cared for in this child care or
day care center, was that at [fill PTEMPNAME] work or school,
at a church or religious organization, or someplace else?
MARK ONLY ONE
(1)
(2)
(3)

At work or at school
At a church or religious organization
Someplace else, including working at the child care or day
care center

@

Page 20 of 42

Friday, July 24, 2009

Items Booklet

Survey:
Section: Child Care
Enter Number

CHC77_DYHRA2

How many hours per WEEK was [fill CHILDNAME1] cared for in this
child care or day care center?
@

Hours
Enter Number

CHC78_HRDAYC2

Of those [fill CHC77_DYHRA2] hours per week that [fill CHILDNAME1]
was cared for in this child care center, how many of them were
while [fill TEMPNAME] [fill WASWERE] [fill CCTEMP]?
@

Hours
Mark One Only

CHC79_PAYDAY2

When [fill CHILDNAME1] was cared for in this child care or day
care center, did [fill TEMPNAME] or [fill PTEMPNAME] family
usually make any money payment for this arrangement?
(1)
(2)

Yes
No

@
Enter Number

CHC80_AMTDAY2

In a typical WEEK last month, how much did [fill TEMPNAME]
or [fill PTEMPNAME] family pay the child care or day care center to
care for [fill CHILDNAME1]?
IF PAYMENT COVERS MORE THAN ONE CHILD IN THIS HOUSEHOLD, ASK
RESPONDENT TO SPLIT AMOUTN BETWEEN CHILDREN.
$

@ PER WEEK
Mark One Only

CHC81_WHSPOR2

Did [fill CHILDNAME1] usually participate in organized sports
at school or someplace else?
MARK ONLY ONE
(1)
(2)

At school
Someplace else

@
Enter Number

CHC82_WHSPORA

How many hours per WEEK did [fill CHILDNAME1] participate in
organized sports?
@

Hours
Enter Number

CHC83_HRSPOR2

Of those [fill CHC82_WHSPORA] hours per week that [fill CHILDNAME1]
participated in organized sports, how many of them were while
[fill TEMPNAME] [fill WASWERE] [fill CCTEMP]?
@

Friday, July 24, 2009

Hours

Page 21 of 42

Survey:
Section: Child Care

Items Booklet

Mark One Only

CHC84_PAYSPOR

Did [fill TEMPNAME] or [fill PTEMPNAME] family usually make any
money payment for [fill CHILDNAME1] to participate in these
organized sports?
(1)
(2)

Yes
No

@
Enter Number

CHC85_AMTSPO2

In a typical WEEK last month, how much did [fill TEMPNAME] or
[fill PTEMPNAME] family pay for [fill CHILDNAME1] to participate
in these organized sports?
IF PAYMENT COVERS MORE THAN ONE CHILD IN THIS HOUSEHOLD, ASK
RESPONDENT TO SPLIT AMOUNT BETWEEN CHILDREN.
$

@

PER WEEK
Mark One Only

CHC86_WHLESS2

When [fill CHILDNAME1] took lessons, did these usually take place at
school or someplace else?
MARK ONLY ONE
(1)
(2)

At school
Someplace else

@
Enter Number

CHC87_HRLESSA

For about how many hours per WEEK was [fill CHILDNAME1]
taking lessons?
@

Hours
Enter Number

CHC88_HRLESS2

Of those [fill CHC87_HRLESSA] hours per week that [fill CHILDNAME1] was
taking lessons, how many of them were while [fill TEMPNAME]
[fill WASWERE] [fill CCTEMP]?
@

Hours
Mark One Only

CHC89_PAYLES2

Did [fill TEMPNAME] or [fill PTEMPNAME] family usually make any
money payment for [fill CHILDNAME1] to take these lessons?
(1)
(2)

Yes
No

@

Page 22 of 42

Friday, July 24, 2009

Items Booklet

Survey:
Section: Child Care

CHC90_AMTLES2

Enter Number
In a typical WEEK last month, how much did [fill TEMPNAME] or
[fill PTEMPNAME] family pay for [fill CHILDNAME1] to take these lessons?
IF PAYMENT COVERS MORE THAN ONE CHILD IN THIS HOUSEHOLD, ASK
RESPONDENT TO SPLIT AMOUNT BETWEEN CHILDREN.
$

@

PER WEEK
Mark One Only

CHC91_WHCLUB2

When your child participated in this club, were the meetings held
at school or someplace else?
MARK ONLY ONE
(1)
(2)

At school
Someplace else

@
Enter Number

CHC92_WHCLUBA

How many hours per WEEK did [fill CHILDNAME1] spend at
club meetings?
@

Hours
Enter Number

CHC93_HRCLUB2

Of those [fill CHC92_WHCLUBA] hours per week that [fill CHILDNAME1]
spent at club meetings, how many of them were while
[fill TEMPNAME] [fill WASWERE] [fill CCTEMP]?
@

Hours
Mark One Only

CHC94_PAYCLU2

Did [fill TEMPNAME] or [fill PTEMPNAME] family usually make any
money payment for [fill CHILDNAME1] to belong to this club or clubs?
(1)
(2)

Yes
No

@
Enter Number

CHC95_AMTCLU2

In a typical WEEK last month, how much did [fill TEMPNAME] or
[fill PTEMPNAME] family pay for [fill CHILDNAME1] to belong to
this club or clubs?
IF PAYMENT COVERS MORE THAN ONE CHILD IN THIS HOUSEHOLD, ASK
RESPONDENT TO SPLIT AMOUNT BETWEEN CHILDREN.
$

Friday, July 24, 2009

@ PER WEEK

Page 23 of 42

Survey:
Section: Child Care

Items Booklet

Mark One Only

CHC96_WHSCHO2

When [fill CHILDNAME1] went to these before or after school care
programs, was that at [fill PTEMPNAME] work or school, your child's
school, or someplace else?
MARK ONLY ONE
(1)
(2)
(3)

At work or school
At child's school
Someplace else

@
Enter Number

CHC97_WHSCHOA

About how many hours per WEEK did [fill CHILDNAME1] spend at these
before or after school care programs?
@

Hours
Enter Number

CHC98_HRSCHO2

Of those [fill CHC97_WHSCHOA] hours per week that [fill CHILDNAME1]
spent at these before or after school care programs, how many of them
were while [fill TEMPNAME] [fill WASWERE] [fill CCTEMP]?
@

Hours
Mark One Only

CHC99_PAYSCH2

Did [fill TEMPNAME] or [fill PTEMPNAME] family usually make any money
payment for [fill CHILDNAME1] to attend these before or after school
care programs?
(1)
(2)

Yes
No

@
Enter Number

CHC100_AMTSCH2

In a typical WEEK last month, how much did [fill TEMPNAME] or
[fill PTEMPNAME] family pay for [fill CHILDNAME1] to attend these
before or after school care programs?
IF PAYMENT COVERS MORE THAN ONE CHILD IN THIS HOUSEHOLD, ASK
RESPONDENT TO SPLIT AMOUNT BETWEEN CHILDREN.
$ @ PER WEEK
Mark One Only

CHC101_WHOTHE2

Did this non-relative usually care for [fill CHILDNAME1] in
[fill CHILDNAME1]'s home, the non-relative's home, or someplace else?
MARK ONLY ONE
(1)
(2)
(3)

Child's home
The non-relative's home
Someplace else

@

Page 24 of 42

Friday, July 24, 2009

Items Booklet

Survey:
Section: Child Care

CHC102_OTHHRB

Enter Number
How many hours per WEEK did this non-relative usually care for
[fill CHILDNAME1]?
@

Hours

CHC104_HROTHE2

Enter Number
Of those [fill CHC102_OTHHRB] hours per week that [fill CHILDNAME1] was
cared for by this non-relative, how many of them were while
[fill TEMPNAME] [fill WASWERE] [fill CCTEMP]?
@

Hours
Mark One Only

CHC105_PAYOTH2

When [fill CHILDNAME1] was cared for by this non-relative, did
[fill TEMPNAME] or [fill PTEMPNAME] family usually make any money
payment for this arrangement?
(1)
(2)

Yes
No

@
Enter Number

CHC106_AMTOTH2

In a typical WEEK last month, how much did [fill TEMPNAME] or
[fill PTEMPNAME] family pay this non-relative to care for
[fill CHILDNAME1]?
IF PAYMENT COVERS MORE THAN ONE CHILD IN THIS HOUSEHOLD, ASK
RESPONDENT TO SPLIT AMOUNT BETWEEN CHILDREN.
$

@

PER WEEK
Mark One Only

CHC107_SCHOOWK

Did [fill CHILDNAME1] usually attend [fill TEMP2] last month?
(1)
(2)

Yes
No

@
Enter Number

CHC108_HRSCHWK

About how many hours per WEEK was [fill CHILDNAME1] usually in
school last month?
BE SURE RESPONDENT GIVES WEEKLY HOURS IN SCHOOL
@

Hours per week
Enter Number

CHC109_HRSCHOO

Of those [fill CHC108_HRSCHWK] hours per week that [fill CHILDNAME1]
was at school, how many of them were while [fill TEMPNAME]
[fill WASWERE] [fill CCTEMP]?
BE SURE RESPONDENT GIVES WEEKLY HOURS IN SCHOOL.
@
Friday, July 24, 2009

Hours per week
Page 25 of 42

Survey:
Section: Child Care

Items Booklet

Mark One Only

CHC110_SELFCA1

Sometimes it is difficult to make arrangements to look after children
all of the time. During a typical week last month, did
[fill CHILDNAME1] care for [fill SELFG] for even a small amount of
time?
(1)
(2)

Yes
No

@
Enter Number

CHC111_KIDSHR1

About how many hours per WEEK did [fill CHILDNAME1] usually care
for [fill SELFG]?
BE SURE RESPONDENT GIVES WEEKLY HOURS OF CARE
ENTER (L) FOR LESS THAN ONE HOUR
@

Hours per week
Enter Number

CHC112_KIDSHR2

Of those [fill CHC111_KIDSHR1] hours per week that [fill CHILDNAME1] cared
for [fill SELFG], how many of them were while [fill TEMPNAME]
[fill WASWERE] [fill CCTEMP]?
BE SURE RESPONDENT GIVES WEEKLY HOURS OF CARE
ENTER (L) FOR LESS THAN ONE HOUR
@

Hours per week
Mark One Only

CHC113_DAYCHAN

Thinking now about the arrangements used last MONTH, were any
changes made in the child care arrangements used for
[fill CHILDNAME1] at that time, even for less than a day, because
[fill HISHERG] usual child care provider was not available?
INCLUDE BOTH UNEXPECTED AND ANTICIPATED LOSSES OF CHILD CARE
PROVIDERS SUCH AS SCHOOL CLOSINGS AND TEMPORARY ILLNESS OF THE
PROVIDER EVEN FOR PART OF THE DAY
(1)
(2)

Yes
No

@
Mark One Only

CHC114_PAYHELP

Did anyone help [fill TEMPNAME] pay for all or part of the cost of
any child care arrangements for [fill CHILDNAME1]?
By this I mean a government agency, an employer, a relative, or a friend.
(1)
(2)
(3)

Yes
No
Did not use any arrangements

@

Page 26 of 42

Friday, July 24, 2009

Items Booklet

Survey:
Section: Child Care

CHC115_WHOPAID

Multiple Entry
Who or what agency helped pay for this arrangement?
MARK ALL THAT APPLY
ENTER (N) FOR NO MORE
(1)
(2)
(3)
(4)
@1

Government (Federal, state, or local government agency,
or welfare office)
Child's other parent
Employer
Other (specify)
@2

@3

@4

CHC116_SPECIF1

Multiple Entry
Specify the exact "OTHER" person or agency that helped pay for this
arrangement.
@1

CHC117_SATIS

Mark One Only
How satisfied [fill AREIS] [fill TEMPNAME] with [fill HISHER]
current arrangement(s) for [fill CHILDNAME1]?
(1)
(2)
(3)
(4)
(5)

Very satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Very dissatisfied

@

CHC118_LIST

Mark One Only
Are you currently on a waiting list for a child care arrangement for
[fill CHILDNAME1]?
(1)
(2)

Yes
No

@
Mark One Only

CHC119_WORKMORE

Are problems in obtaining child care preventing [fill TEMPNAME] from
[if FLAGC lt <1> and ENROLL ne <1>]working?[else][if FLAGC ge <1> or ENROLL ne <1>]working
more hours?[else][if ENROLL eq <1> and FLAGC lt <1>]going to school more hours?[else][if ENROLL eq <1>
and FLAGC ge <1>]working more hours?[endif][endif][endif][endif]
(1)
(2)

Yes
No

@

Friday, July 24, 2009

Page 27 of 42

Survey:
Section: Child Care

Items Booklet

Multiple Entry

CHC120_TIMEAMT

Considering all of [fill PTEMPNAME] children, how much time,
if any, was lost in total from [fill TEMP3] last month either
because of failures in child care arrangements or because
[fill TEMPNAME] could not find a child care provider?
READ IF NECESSARY: Is that hours, days, weeks, or months?
ENTER (N) FOR NONE OR NO MORE
@1 Number
(1)
(2)
(3)
(4)

Hours
Days
Weeks
Months

@2

Page 28 of 42

Friday, July 24, 2009

Items Booklet

Survey:
Section: Annual Income and Retirement Accounts
Mark One Only

AIRA002_BUS97A

Earlier you told me [fill TEMPNAME]
operated (Read all business names during
2009). Did [fill TEMPNAME] own and
operate any other businesses during 2009?
(1)
(2)

Yes
No

@
Mark One Only

AIRA003_BUS97B

Did [fill TEMPNAME] own and operate any businesses during 2009?
(1)
(2)

Yes
No

@
Multiple Entry

AIRA004_BUSNAM

What was the name of these businesses?
ENTER (N) AFTER LAST BUSINESS
Business
Business
Business
Business
Business

1:
2:
3:
4:
5:

@1
@2
@3
@4
@5

Multiple Entry

AIRA006_TWOBUS

Businesses listed in prior interviews
[roster begin bus]
BUSINESS NAME = [fill I_ALLBUS:l]
[roster end bus]
Businesses listed this interview
[if AIRA004_BUSNAM@1 valid] [fill AIRA004_BUSNAM@1] [endif]
[if AIRA004_BUSNAM@2 valid] [fill AIRA004_BUSNAM@2] [endif]
[if AIRA004_BUSNAM@3 valid] [fill AIRA004_BUSNAM@3] [endif]
[if AIRA004_BUSNAM@4 valid] [fill AIRA004_BUSNAM@4] [endif]
[if AIRA004_BUSNAM@5 valid] [fill AIRA004_BUSNAM@5] [endif]
Which two of the busineses yielded the largest net incomes
during 2009?
ENTER (N) IF NO SECOND BUSINESS
ENTER (N) AFTER LAST BUSINESS
Business 1 @1
Business 2 @2

Friday, July 24, 2009

Page 29 of 42

Survey:
Section: Annual Income and Retirement Accounts
Mark One Only

Items Booklet

AIRA007_BS1FRM

[if AIRA006_TWOBUS@1 valid]
BUSINESS1 = [fill AIRA006_TWOBUS@1]
[endif]
What was the form of this (business/practice) - was it a sole
proprietorship, a partnership, or a corporation?
(1)
(2)
(3)

Sole proprietorship
Partnership
Corporation

@
Mark One Only

AIRA008_BS1LOC

Was this business primarily located in [fill PTEMPNAME] own
home or somewhere else?
(1)
(2)

Own home
Somewhere else

@
Mark One Only

AIRA010_BS1OWN

Were any other members of this household part owners of this
(business/practice)?
(1)
(2)

Yes
No

@
Multiple Entry

AIRA011_BS1WHO

Which other household members were owners?
ENTER LINE NUMBER OF PERSON
@1
@2

Person
Person
Mark One Only

AIRA013_BS1HH

Was this (business/practice) owned entirely by members of this
household?
(1)
(2)

Yes
No

@
Enter Number

AIRA014_BS1PCT

What percentage of this (business/practice) was owned by members of
this household?
@

Page 30 of 42

Percent

Friday, July 24, 2009

Items Booklet

Survey:
Section: Annual Income and Retirement Accounts
Enter Number

AIRA015_BS1PTO

What percentage of this (business/practice) did [fill TEMPNAME] own
in [fill HISHER] own name?
@

Percent
Enter Number

AIRA016_BS1PCT

What were the gross receipts of this (business/practice) in 2009?
@

Dollars
Enter Number

AIRA017_BS1EXP

What were the total expenses of this (business/practice) in 2009?
@

Dollars
Multiple Entry

AIRA021_BS1NET

What was [fill PTEMPNAME] net income from this (business/practice)
in 2009?
Please use records if they are available. (Obtain estimate if
necessary.)
ENTER (N) FOR NONE OR NO MORE
@1
@2

Profit
OR
Loss
Mark One Only

AIRA024_BS1OTH

Apart from the net income already reported for [fill TEMPNAME],
did other household owners receive any net income in 2009 from
this (business/practice)?
(1)
(2)

Yes
No

@
Multiple Entry

AIRA025_BS1AMT

What was the amount of net income that was
received by [FILL NAME(AIRA011_BS1WHO@1)]?
ENTER

(N) FOR NONE OR NO MORE
@1
@2

Profit
OR
Loss
Multiple Entry

AIRA026_BS1NTO

What was the amount of net income that was
received by [FILL NAME(AIRA011_BS1WHO@2)]?
ENTER (N)FOR NONE OR NO MORE
@1
@2

Profit
OR
Loss

Friday, July 24, 2009

Page 31 of 42

Survey:
Section: Annual Income and Retirement Accounts
Mark One Only

Items Booklet

AIRA027_BS2FRM

[if AIRA006_TWOBUS@2 valid]
BUSINESS2 = [fill AIRA006_TWOBUS@2]
[endif]
What was the form of this (business/practice) - was it a sole
proprietorship, a partnership, or a corporation?
(1)
(2)
(3)

Sole proprietorship
Partnership
Corporation

@
Mark One Only

AIRA028_BS2LOC

Was this business primarily located in [fill PTEMPNAME] own home or
somewhere else?
(1)
(2)

Own home
Somewhere else

@
Mark One Only

AIRA030_BS2OWN

Were any other members of this household part owners of this
(business/practice)?
(1)
(2)

Yes
No

@
Multiple Entry

AIRA031_BS2WHO

Which other household members were owners?
ENTER LINE NUMBER OF PERSON
@1
@2

Person
Person
Mark One Only

AIRA032_BS2HH

Was this (business/practice) owned entirely by members of this
household?
(1)
(2)

Yes
No

@
Enter Number

AIRA033_BS2PCT

What percentage of this business/practice) was owned by members of
this household?
@

Page 32 of 42

Percent

Friday, July 24, 2009

Items Booklet

Survey:
Section: Annual Income and Retirement Accounts
Enter Number

AIRA034_BS2PTO

What percentage of this (business/practice) did [fill TEMPNAME] own
in [fill HISHER] own name?
@

Percent
Enter Number

AIRA035_BS2PCT

What were the gross receipts of this (business/practice) in 2009?
@

Dollars
Enter Number

AIRA036_BS2EXP

What were the total expenses of this (business/practice) in 2009?
@

Dollars
Multiple Entry

AIRA038_BS2NET

What was [fill PTEMPNAME] net income from this (business/practice)
in 2009?
Please use records if they are available. (Obtain estimate if
necessary.)
ENTER FOR (N) FOR NONE OR NO MORE
@1
@2

Profit
OR
Loss
Mark One Only

AIRA040_BS2OTH

Apart from the net income already reported for [fill TEMPNAME],
did other household owners receive any net income in 2009 from
this (business/practice)?
(1)
(2)

Yes
No

@
Multiple Entry

AIRA041_BS2AMT

What was the amount of net income that was
received by [FILL NAME(AIRA031_BS2WHO@1)]?
ENTER (N) FOR NONE OR NO MORE
@1
@2

Profit
OR
Loss
Multiple Entry

AIRA042_BS2NTO

What was the amount of net income that was
received by [FILL NAME(AIRA031_BS2WHO@2)]?
ENTER (N) FOR NONE OR NO MORE
@1
@2

Profit
OR
Loss

Friday, July 24, 2009

Page 33 of 42

Survey:
Section: Annual Income and Retirement Accounts
Multiple Entry

Items Booklet

AIRA052_NETOBS

What was [fill PTEMPNAME] net income from [fill HISHER] other
businesses in 2009?
ENTER (N) FOR NONE OR NO MORE
@1 Profit
OR
@2 Loss
Mark One Only

AIRA053_IRA

[fill C_DODOES] [fill TEMPNAME] have an Individual Retirement
Account, that is, an IRA, in [fill HISHER] own name?
(1)
(2)

Yes
No

@
Mark One Only

AIRA054_IRACON

Did [fill TEMPNAME] make any tax-deductible contributions to
IRA accounts which applied to [fill HISHER] 2009 tax return?
(1)
(2)

Yes
No

@
Enter Number

AIRA055_IRAAMT

How much were [fill PTEMPNAME] tax-deductible contributions to
IRA accounts which applied to [fill HISHER] 2009 tax return?
@

Amount
Mark One Only

AIRA056_IRAWD

Did [fill TEMPNAME] make any withdrawals from [fill HISHER]
IRA accounts during 2009?
(1)
(2)

Yes
No

@
Enter Number

AIRA057_IRAWAT

How much did [fill TEMPNAME] withdraw from IRA accounts during 2009?
@

Amount
Enter Number

AIRA058_IRAERN

Including all IRA accounts in [fill PTEMPNAME] own name, how much
did [fill HISHER] IRA accounts earn during 2009?
ENTER (N) FOR NONE
@

Page 34 of 42

Amount

Friday, July 24, 2009

Items Booklet

Survey:
Section: Annual Income and Retirement Accounts

AIRA059_IRAAST

Multiple Entry
What types of assets did [fill TEMPNAME]
IRA accounts?

have in [fill HISHER]

MARK ALL THAT APPLY
(1)
@1
@2
@3
@4
@5
@6
@7

Yes

(2)

No

Certificates of deposit or other savings certificates
Money market funds
U.S. Government securities
Municipal or corporate bonds
U.S. Savings Bonds
Stocks or mutual fund shares
Other assets
Mark One Only

AIRA060_KEO

[fill C_DODOES] [fill TEMPNAME] have a Keogh account in [fill HISHER]
own name?
(1)
(2)

Yes
No

@
Mark One Only

AIRA061_KEOCON

Did [fill TEMPNAME] make any tax-deductible contributions to a
Keogh account which applied to [fill HISHER] 2009 tax return?
(1)
(2)

Yes
No

@
Enter Number

AIRA062_KEOAMT

How much were [fill PTEMPNAME] tax-deductible contributions to
Keogh accounts which applied to [fill HISHER] 2009 tax return?
@

Amount
Mark One Only

AIRA063_KEOWD

Did [fill TEMPNAME] make any withdrawals from [fill HISHER] Keogh
accounts during 2009?
(1)
(2)

Yes
No

@
Enter Number

AIRA064_KEOWAT

How much did [fill TEMPNAME] withdraw from Keogh accounts
during 2009?
@

Friday, July 24, 2009

Amount

Page 35 of 42

Survey:
Section: Annual Income and Retirement Accounts
Enter Number

Items Booklet

AIRA065_KEOERN

Including all Keogh accounts in [fill PTEMPNAME] own name, how
much did [fill PTEMPNAME] Keogh accounts earn during 2009?
ENTER (N) FOR NONE
@

Amount
Multiple Entry

AIRA066_KEOAST

What type of assets did [fill TEMPNAME] have in [fill HISHER]
Keogh accounts?
MARK ALL THAT APPLY
(1)
@1
@2
@3
@4
@5
@6
@7

Yes

(2)

No

Certificates of deposit or other savings certificates
Money market funds
U.S. Government securities
Municipal or corporate bonds
U.S. Savings Bonds
Stocks or mutual fund shares
Other assets
Mark One Only

AIRA068_401

During 2009, did [fill TEMPNAME] participate in an employee
plan such as a 401k, 403b, or thrift plan? Such a plan allows
employees to defer part of their salary and not have to pay taxes
on their deferred salary until they retire or make a withdrawal.
(1)
(2)

Yes
No

@
Enter Number

AIRA069_401CON

How much did [fill TEMPNAME] contribute to this plan
during 2009?
ENTER (N) FOR NONE
@

Amount
Mark One Only

AIRA070_401WD

Did [fill TEMPNAME] make any withdrawals from [fill HISHER] 401k,
403b, or thrift plan during 2009?
(1)
(2)

Yes
No

@
Enter Number

AIRA072_401WAT

How much did [fill TEMPNAME] withdraw from 401k, 403b, or thrift plan
accounts during 2009?
@

Page 36 of 42

Amount

Friday, July 24, 2009

Items Booklet

Survey:
Section: Annual Income and Retirement Accounts
Enter Number

AIRA073_401ERN

Including all 401k, 403b, or thrift plan accounts in [fill HISHER] own
name, how much did [fill HISHER] 401k, 403b or thrift plan accounts
earn during 2009?
ENTER (N) FOR NONE
@

Amount
Multiple Entry

AIRA074_401AST

What types of assets did [fill TEMPNAME] have in [fill HISHER]
401k, 403b, or thrift plan accounts?
MARK ALL THAT APPLY
(1)
@1
@2
@3
@4
@5

Yes

(2)

No

Money market funds
U.S. Government securities
Municipal or corporate bonds
Stocks or mutual fund shares
Other assets
Mark One Only

ARRECUSE

DO NOT READ TO RESPONDENT
Did respondent use any records when reporting the amount of annual
income received or income received from retirement accounts?
(1)
(2)

Yes
No

@

Friday, July 24, 2009

Page 37 of 42

Survey:
Section: Taxes

Items Booklet

Mark One Only

TAX002_FILE

Did [fill TEMPNAME] file a Federal income tax return for
2009?
(1)
(2)

Yes
No

@
Mark One Only

TAX003_COPY

Do you have a copy of [fill PTEMPNAME] tax form or a
worksheet that you could refer to for the next few questions?
(1)
(2)

Yes
No

@
Mark One Only

TAX004_STATUS

What was [fill PTEMPNAME] filing status on [fill HISHER]
2009 Federal tax return?
LINES 1-5 ON FORMS 1040 or 1040A
(1)
(2)
(3)
(4)
(5)

Single taxpayer
Married, filing joint return
Married, filing separately
Unmarried head of household
Qualifying widow(er) with dependent child

@
Enter Number

TAX005_EXEMP

What were the total number of exemptions claimed on
[fill PTEMPNAME] return?
LINE 6d ON FORMS 1040 OR 1040A
Enter number of exemptions: @
Multiple Entry

TAX007_EXEMHH

Besides [fill TEMPNAME], which persons in
this household did [fill TEMPNAME] claim
as an exemption?
ENTER LINE NUMBER OF PERSON COVERED
ENTER (A) FOR ALL PERSONS COVERED
ENTER (N) FOR NONE OR NO MORE
@1 @2 @3 @4 @5 @6 @7 @8 @9 @10
@11 @12 @13 @14 @15 @16 @17 @18 @19 @20
@21 @22 @23 @24 @25 @26 @27 @28 @29 @30

Page 38 of 42

Friday, July 24, 2009

Items Booklet

Survey:
Section: Taxes

TAX008_EXMOUT

Mark One Only
Did [fill TEMPNAME] claim exemptions for any people who lived
outside of [fill HISHER] home for the entire year?
(1)
(2)

Yes
No

@

TAX008B_EXEMNO

Enter Number
How many people who lived outside of the household did
[fill TEMPNAME] claim exemptions for the entire year?
Enter number of persons exemptions outside of the household:

@

TAX009_RELATE

Multiple Entry
What was the relationship of this person/these persons
to [fill TEMPNAME]?
ENTER (N) FOR NONE OR NO MORE
(1)
(2)
(3)
(4)
@1

Parent
Child
Brother/Sister
Other
@2

@3

@4

@5

@6

@7

@8

@9

@10

Mark One Only

TAX011_FORM

Did [fill TEMPNAME] file form 1040, the long form or did
[fill TEMPNAME] file one of the short forms, 1040A or 1040EZ?
(1)
(2)
(3)

Form 1040
Form 1040A
Form 1040EZ

@
Mark One Only

TAX012_SCHEDA

Did [fill TEMPNAME] file a Schedule A, Itemized Deductions,
with [fill HISHER] 2009 tax return?
(1)
(2)

Yes
No

@
Mark One Only

TAX013_SCHEDD

Did [fill TEMPNAME] file Schedule D, Capital Gains and Losses,
with [fill HISHER] 2009 tax return?
(1)
(2)

Yes
No

@

Friday, July 24, 2009

Page 39 of 42

Survey:
Section: Taxes

Items Booklet

Enter Number

TAX017_ITEMIZ

[if TAX004_STATUS eq <2>]
How much were [fill HISHER] (and [fill HISHER] spouse's) itemized
deductions for 2009?
[else]
How much were [fill HISHER] itemized deductions for 2009?
[endif]
LINE 39 OF FORM 1040
Amount: $@
Mark One Only

TAX018_DEPEND

Did [fill TEMPNAME] claim a child and dependent care expense
credit in 2009?
LINE 47 ON FORM 1040; LINE 29 ON FORM 1040A
(1)
(2)

Yes
No

@
Enter Number

TAX019_DEPAMT

What was that amount?
Amount:

$@
Multiple Entry

TAX19B_DPHH

For which persons did you claim this
exemption?
ENTER LINE NUMBER OF PERSON COVERED
ENTER (A) FOR ALL PERSONS COVERED
ENTER (N) FOR NONE OR NO MORE
@1 @2 @3 @4 @5 @6 @7 @8 @9 @10
@11 @12 @13 @14 @15 @16 @17 @18 @19 @20
@21 @22 @23 @24 @25 @26 @27 @28 @29 @30
Mark One Only

TAX020_CREDIT

Did [fill TEMPNAME] claim a credit for the elderly or the
disabled in 2009?
LINE 48 ON FORM 1040; LINE 30 ON FORM 1040A
(1)
(2)

Yes
No

@
Enter Number

TAX021_CRDAMT

What was that amount?
Amount:

Page 40 of 42

$@

Friday, July 24, 2009

Items Booklet

Survey:
Section: Taxes
Enter Number

TAX023_GAINS

[if TAX004_STATUS eq <2>]
How much were [fill PTEMPNAME](and [fill PTEMPNAME] spouse's)
capital gains or losses from the sale or exchange of personal
assets for 2009?
[else]
How much were [fill PTEMPNAME] capital gains or losses from the sale
or exchange of personal assets for 2009?
[endif]
ENTER LOSS AS A NEGATIVE AMOUNT
LINE 13 ON FORM 1040
ENTER (N) FOR NONE
$@
Enter Number

TAX024_AGI

[if TAX004_STATUS eq <2>]
What was [fill PTEMPNAME] (and [fill PTEMPNAME] spouse's)
adjusted gross income in 2009?
[else]
What was [fill PTEMPNAME] adjusted gross income in 2009?
[endif]
ENTER LOSS AS A NEGATIVE AMOUNT
LINE 36 ON FORM 1040; LINE 21 ON FORM 1040A; LINE 4 ON FORM 1040EZ
ENTER (N) FOR NONE
$@
Enter Number

TAX025_TXLIAB

[if TAX004_STATUS eq <2>]
What was [fill PTEMPNAME](and [fill PTEMPNAME] spouse's) net
tax liability in 2009?
[else]
What was [fill PTEMPNAME] net tax liability in 2009?
[endif]
LINE 62 ON FORM 1040; LINE 38 ON FORM 1040A; LINE 10 ON FORM 1040EZ
ENTER (N) FOR NONE
Amount: $@
Mark One Only

TAX027_EARN

Did [fill TEMPNAME] claim an earned income credit on
[fill HISHER] Federal income tax return?
(1)
(2)

Yes
No

@
Enter Number

TAX028_ERNAMT

What was the amount of earned income credit claimed?
LINE 65a ON FORM 1040; LINE 41a ON FORM 1040A;
LINE 8a ON FORM 1040EZ
Amount:

Friday, July 24, 2009

$@

Page 41 of 42

Survey:
Section: Taxes

Items Booklet

Multiple Entry

TX28B_ERNHH

For which persons did you claim this
exemption?
ENTER LINE NUMBER OF PERSON COVERED
ENTER (A) FOR ALL PERSONS COVERED
ENTER (N) FOR NONE OR NO MORE
@1 @2 @3 @4 @5 @6 @7 @8 @9 @10
@11 @12 @13 @14 @15 @16 @17 @18 @19 @20
@21 @22 @23 @24 @25 @26 @27 @28 @29 @30
Mark One Only

TAX032_PROPTX

Did [fill TEMPNAME] pay any property taxes on [fill PTEMPNAME]
residence(s) in 2009?
(1)
(2)

Yes
No

@
Mark One Only

TAX033_PROPAY

Did [fill TEMPNAME] pay these jointly with someone else living
here?
(1)
(2)

Yes
No

@
Multiple Entry

TX34_PROWHO

Who made these joint payments with
[fill TEMPNAME]?
ENTER LINE NUMBER OF PERSON WHO MADE JOINT
PAYMENTS
ENTER (A) FOR ALL PERSONS COVERED
ENTER (N) FOR NONE OR NO MORE
@1 @2 @3 @4 @5 @6 @7 @8 @9 @10
@11 @12 @13 @14 @15 @16 @17 @18 @19 @20
@21 @22 @23 @24 @25 @26 @27 @28 @29 @30
Enter Number

TAX035_PROAMT

What was the property tax bill for [fill PTEMPNAME] residence(s)
in 2009?
LINE 6 OF SCHEDULE A, PROPERTY TAX BILLS; OR OTHER DOCUMENTS
SUCH AS ESCROW SUMMARIES FROM THE MORTGAGE COMPANY
Amount:

Page 42 of 42

$@

Friday, July 24, 2009