Various Demographic Pretesting Activities

Generic Clearence for Questionnaire Pretesting Research

omb1107ASECenc3

Various Demographic Pretesting Activities

OMB: 0607-0725

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SHOW CARD: Which of these sources of income did you or other household members receive in calendar year 2010?

Source of income

Earnings from a job, or your own business or a family business or farm

Unemployment benefits from State or federal unemployment, Supplemental unemployment, Union unemployment or strike benefits, or workers compensation or unemployment insurance

Income or lump-sum payments from retirement accounts or pensions: Include 401(k), 403(b), KEOGH or IRA accounts, and pensions from an employer or union

Social Security benefits for yourself or on behalf of children or other family members

Supplemental Security Income (SSI): Federal, state or local assistance provided to low-income seniors, and blind or disabled people of any age

Disability income such as company or union disability, government employee disability, U.S. Railroad retirement disability, accident or disability insurance payments, and so on

Survivor benefits such as estates, trusts or insurance annuities, or widow’s pensions

Veterans payments such as service connected disability compensation, survivor benefits, veteran’s pension or educational assistance for self or children

Interest or dividends from mutual funds, stocks, bonds and retirement accounts such as 401(k), 403(b), KEOGH or IRA accounts

State or county public assistance (welfare) for yourself or on behalf of children: Include welfare assistance programs such as TANF, AFDC, general or emergency assistance, diversion payments, assistance from Bureau of Indian Affairs, etc

Food stamps (SNAP benefit card), School lunch programs, WIC assistance for yourself or on behalf of children or other household members

Child support or alimony payments

Education assistance for tuition, fees, books or living expenses

Property income including rental income or royalties



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