Weatherization Assistance Program Evaluation

Weatherization Assistance Program Evaluation

S4 Occupant Survey for OMB

Weatherization Assistance Program Evaluation

OMB: 1910-5151

Document [doc]
Download: doc | pdf




OMB Control Number: 1910-5151



OCCUPANT SURVEY



This data is being collected to conduct a survey of occupants about their experiences with the Weatherization Assistance Program and benefits they believe they have received from the program.  The data you supply will be used to describe occupant satisfaction with the program as well as changes in energy education and non-energy benefits provided by the program.


Public reporting burden for this collection of information is estimated to average two hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Office of the Chief Information Officer, Records Management Division, IM-11, Paperwork Reduction Project (1910-5151), U.S. Department of Energy, 1000 Independence Ave SW, Washington, DC, 20585-1290; and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Project (1910-5151), Washington, DC  20503.


Lastly, all of the information obtained from this survey will be protected and will remain confidential. The data will be analyzed in such a way that the information provided cannot be associated back to you or your household. Your answers will not be shared with or reported back to anyone within the agency that served you or your state.


PRE-WEATHERIZATION SURVEY

{INTERVIEWER:STATE PRIOR TO PRE-WEATHERIZATION SURVEY ONLY}I will need to ask these questions of the adult in the household most involved with the weatherization of the home or the head of the household. Am I speaking to the right person?


POST-WEATHERIZATION SURVEY

{INTERVIEWER: VERIFY RESPONDENT IS THE SAME RESPONDENT FROM THE PRE-WEATHERIZATION SURVEY}Before we begin, I need to verify that this is the same person who completed this survey before your home received weatherization services. Am I speaking to the same person?


PLEASE RECORD RESPONDENT’S NAME, GENDER and AGE


Name Gender Age



Main Respondent:




1. How long have you lived in your current home?

{If less than one year} Enter: _________ months

Enter: _________ years


1a. {IF RESPONDENT HAS LIVED IN THE HOME < ONE YEAR} Has ANY OTHER ADULT living in the household lived in the home for more than one year?

  1. Yes

  2. No

{IF YES} Name ______________________

{IF NO: STOP SURVEY}


PART I. Energy Consumption, Non-Energy Impacts, Health and Demographics


2. Are you currently…?

  1. Married

  2. Divorced

  3. Widowed

  4. Separated

  5. Never married

  6. A member of an unmarried couple

  7. Refused

3. What is the highest degree or level of school you have completed?

  1. No Schooling Completed

  2. Kindergarten to grade 12 (No Diploma)

  3. High school diploma or GED

  4. Some college, no degree

  5. Associate’s degree (for example: AA, AS)

  6. Bachelor’s degree (for example: BA, BS)

  7. Master’s degree (for example: MA, MS, MBA)

  8. Professional degree (for example: MD, JD)

  9. Doctorate degree (for example: PhD, EdD)

  10. Refused

4. Do you consider yourself to be of Hispanic or Latino

origin, such as Mexican, Puerto Rican, Cuban, or other Spanish background?

  1. Yes

  2. No

  3. Don’t know/Not Sure

  4. Refused




5. Which describes your race? You can select one or more categories.

  1. White

  2. Black or African-American

  3. American Indian or Alaska Native

  4. Asian

  5. Native Hawaiian or Other Pacific Islander

  6. Other (if volunteered)

  7. Hispanic or Latino (if volunteered)

  8. Refused


5a. {IF MORE THAN ONE} Which ONE of these groups best represents your

race? You can select one or more categories.

  1. White

  2. Black or African-American

  3. American Indian or Alaska Native

  4. Asian

  5. Native Hawaiian or Other Pacific Islander

  6. Other (if volunteered)

  7. Hispanic or Latino (if volunteered)

  8. Refused


6. Were you born a citizen of the United States or did you become a citizen of the United States through naturalization?

  1. Born

  2. Naturalized

  3. Neither

  4. Refused


In this next section, I will be asking you about your home and your use of energy.


7. Do you rent or own your current residence?

  1. Rent

  2. Own

  3. Neither (Please describe the housing agreement).

________________________________________________________________________

8. Which of the following best describes the location of your home? Do you live in a city, a

town, the suburbs, or in a rural area?

  1. City

  2. Town

  3. Suburbs

  4. Rural

  5. Don’t Know/Not Sure

  6. Refused



9. In the past 12 months has anyone in your household owned or had the regular use of any cars,

trucks, vans, sports-utility-vehicles or similar vehicles? DO NOT INCLUDE MOTORCYCLES

OR MOPEDS.

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused


INTERVIEWER: “REGULAR USE” means the vehcile is kept at home AND is available for some personal use.


10. Thinking of the area where you live, in the past 12 months, have members of your household had regular access to public transportation? {PROBE: buses, trolley buses, trains, trams, rapid transit (metro/subway/underground), water taxi/ferries, free transportation offered by community services agencies, Medicaid covered transportation…)

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused


11. Which of the following do you believe best describes your current home? Is it a… (INTERVIEWER: DEFINE EACH HOUSING TYPE IF NEEDED)

  1. Single-family detached house

  2. a Single-family attached house,

  3. an Apartment building with 2-4 units,

  4. an Apartment building with 5 or more units, or

  5. a Mobile home?


12. How many bedrooms do you have in your home? [Include bedrooms in finished attics or

finished basements.] ______________


13. Now think about other rooms in your home besides bedrooms and bathrooms. Not including

unfinished areas, hallways, and closets, how many other rooms are there in your home?

__________________


16. Is your home heated during the winter?

  1. Yes (SKIP to Q17)

  2. No

  3. Don’t Know/Not Sure

  4. Refused


16a. {IF NO}You have just told me that you don’t heat your home during the winter. Just to clarify, is it that you have heating equipment but don’t use it, or does your home just not have any heating equipment?

  1. Have equipment, but don’t use it (SKIP to Q8)

  2. Don’t have any heating equipment

  3. Don’t Know/Not Sure

  4. Refused


17. Last winter, did you heat all # (sum from Q12 ad Q13) rooms?

  1. Yes (SKIP to Q18)

  2. No

  3. Don’t Know/Not Sure

  4. Refused

17a. How many of those rooms were not heated last winter?

Enter the number ___________


18. Is any air conditioning equipment used in your home?

  1. Yes (SKIP to Q19)

  2. No

  3. Don’t Know/Not Sure

  4. Refused


18a. (IF NO) Just to clarify, do you have air conditioning equipment but don’t use it, or does your home just not have any air conditioning equipment?

  1. Have equipment, but don’t use it (SKIP to Q 20)

  2. Don’t have any air conditioning equipment

  3. Don’t Know/Not Sure

  4. Refused


19. Last summer, did you air condition all # (sum Q12 and Q13) rooms?

(1) Yes (SKIP to Q20)

(2) No

  1. Don’t Know/Not Sure

  2. Refused

19a.How many of those rooms were not cooled last summer?

Enter the number ___________


20. Is any part of your home over a crawl space with exposed dirt as the floor?

  1. Yes

  2. No

  3. Don’t Know/Not sure

  4. Refused


21. Is any part of your home over a basement?

  1. Yes

  2. No (SKIP TO 22)

  3. Don’t Know/Not Sure

  4. Refused


21a. Do you use your basement for living space? That is, do you use it for work, play or sleep?

  1. Yes

  2. No (SKIP to Q22)

  3. Don’t Know/Not Sure

  4. Refused


21b. Is the basement warm enough to be used as a living space in the winter?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused


21c. Is the basement cool enough to be used as a living space in the summer?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused

22. An attic is an area directly below the roof, accessible by stairs, with space for you to stand

upright and easily move about. Does your home have an attic?

  1. Yes

  2. No (SKIP to Q23)

  3. Don’t Know/Not Sure

  4. Refused


22a. Do you use the attic for living space? That is, do you use it for work, play or sleep?

  1. Yes

  2. No (SKIP to Q23)

  3. Don’t Know/Not Sure

  4. Refused


22b. Is the attic warm enough to be used as a living space in the winter?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused

22c. Is the attic cool enough to be used as a living space in the summer?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused



23. Does your home have a garage that is attached to or part of your home?

  1. Yes

  2. No (SKIP to 24)

  3. Don’t Know/Not Sure

  4. Refused


23a. Do you warm up your vehicle in your garage?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused


23b. Have you or anyone else living in your home observed the smell of vehicle exhaust inside your home?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused


I have some questions about heating your home.

24.{IF NO TO HEAT FROM PREVIOUS SECTION SKIP TO COOLING}Let’s start with the

main source of heating in your home. Please tell me which type of heating equipment

provides most of the heat for your home. Remember to include portable heaters, fireplaces,

heating stoves and cooking stoves.

  1. Heat pump

  2. Central furnace with ducts to individual rooms

  3. Steam/Hot water system with radiators or pipes in each room

  4. Built-in electric units in each room installed in walls, ceilings, baseboards, or floors

  5. Built-in floor/wall pipeless furnace

  6. Built-in room heater burning gas, oil, or kerosene

  7. Heating stove burning wood, coal, or coke

  8. Portable heaters

  9. Fireplace

  10. Cooking stove used to heat your home as well as to cook

  11. Some other equipment (Specify __________________)




25. Does the main heating equipment for your home also heat any other apartments, condos, households, businesses, or farm buildings?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused




26. What is the main fuel used for heating your home? That is, which fuel is the one that

provides the most heat for your home?

  1. Electricity

  2. Natural gas from underground pipes

  3. Propane (bottled gas)

  4. Fuel oil

  5. Kerosene

  6. Wood

  7. Biomass

  8. Solar or Wind

  9. Geothermal

  10. District steam

  11. Some other fuel (Specify __________)


27. You told me that [EQUIPM] is the main source of heat in your home. In the past 12 months,

did you use any other types of heating equipment? Remember to include portable heaters,

fireplaces, heating stoves and cooking stoves. CHECK ALL THAT APPLY

  1. No other equipment

  2. Heat pump

  3. Central furnace with ducts to individual rooms

  4. Steam/Hot water system with radiators or pipes in each room

  5. Built-in electric units in each room installed in walls, ceilings, baseboards, or floors

  6. Built-in floor/wall pipeless furnace

  7. Built-in room heater burning gas, oil, or kerosene

  8. Heating stove burning wood, coal, coke, or biomass (such as pellets or corn)

  9. Portable heaters

  10. Fireplace

  11. Cooking stove used to heat your home as well as to cook

  12. Some other equipment (Specify __________________)


28. What fuel does the [FILL: EQUIPAUX] use?

  1. Electricity

  2. Natural gas from underground pipes

  3. Propane (bottled gas)

  4. Fuel oil

  5. Kerosene

  6. Wood

  7. Biomass (wood pellets or corn)

  8. Solar or Wind

  9. Geothermal

  10. District steam

  11. Some other fuel (Specify __________)


29. { IF YES WIND OR SOLAR FOR EITHER MAIN OR OTHER FUELS USED}

Do you have any on-site system that generates electricity such as a solar system or a small

wind turbine?

  1. Yes

  2. No (SKIP to Q30)

  3. Don’t Know/Not Sure

  4. Refused

29a. What type of on-site system do you have?

  1. Solar or Photovoltaic system

  2. Small wind turbine

  3. Combined Heat and Power system

  4. Other . Please specify____________

29b. Is your on-site system connected to the grid?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused

30. {IF YES HEATING STOVE}Which statement best describes your heating stove?

  1. Manufactured before 1992

  2. Energy Star

  3. Neither

  4. Don’t Know/Not Sure

  5. Refused

31. {IF YES FIREPLACE}Does this fireplace have a flue to the outside or is it entirely self-contained?

  1. Flue to the outside

  2. Flueless (self-contained)

  3. Don’t Know/Not Sure

  4. Refused


32. {IF YES HEATING STOVE OR FIREPLACE}In the past 12 months how often did you have to burn garbage, cardboard, plastics, foam, colored ink, magazines, boxes, or wrappers to keep warm?

  1. Never

  2. Once

  3. Sometimes

  4. Often

  5. Most of the winter

  6. Don’t Know/Not Sure

  7. Refused


33. {IF YES HEATING STOVE OR FIREPLACE}In the past 12 months how often did you have to burn coated, painted, or pressure-treated wood, driftwood, plywood, particle board, or any wood with glue in it to keep warm?

  1. Never

  2. Once

  3. Sometimes

  4. Often

  5. Most of the winter

  6. Don’t Know/Not Sure

  7. Refused


34. {IF YES HEATING STOVE OR FIREPLACE}In the past 12 months how often did you have to burn wet, rotted, diseased, or moldy wood

to keep warm?

  1. Never

  2. Once

  3. Sometimes

  4. Often

  5. Most of the winter

  6. Don’t Know/Not Sure

  7. Refused


35. What fuel does the cooking stove and/or oven use? CHECK ALL THAT APPLY

  1. Electricity

  2. Natural gas from underground pipes

  3. Propane (bottled gas)

  4. Fuel oil

  5. Kerosene

  6. Wood

  7. Some other fuel (Specify __________)

  8. No working stove or oven in the home


36. Is an exhaust fan that vents to the outside used regularly when cooking in your kitchen?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused


37. In the past 12 months how often have you used your oven to heat your house?

(1) Never

(2) Rarely

(3) Sometimes

(4) Frequently

(5) All the time

(6) Don’t Know/Not Sure

(7) Refused


38. Does your household use a microwave oven?

  1. Yes

  2. No (SKIP to 39)

  3. Don’t Know/Not Sure

  4. Refused

38a. Which answer best describes how frequently your household uses the microwave to prepare hot meals and snacks in a typical week?

  1. Used to cook or reheat most meals and snacks

  2. Used to cook or reheat about half of meals and snacks

  3. Used to cook or reheat a few meals and snacks

  4. Used very little

  5. Don’t Know/Not Sure

  6. Refused

39. Does your heating system have an air filter?

(1) Yes

(2) No (SKIP to 40)

(3) Don’t know/Not Sure

(4) Refused


39a. Is the air filter in your heating system a High Efficiency Particulate Arresting (HEPA) filter?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused


39b. Approximately, how often does someone in your household change (or clean) the air filter in your heating system?

(1) Monthly

(2) Every three months

(3) Every six months

(4) Once a year

(5) Once every two years

(6) Don’t change (or clean) it

(7) Air filter is changed by service company

(8) Don’t Know/Not Sure

(9) Refused


40. {IF YES FURNACE} Do you know when was the last time your furnace received maintenance service by a furnace contractor to ensure optimum and safe operation?

(1) Yes

(2) No (SKIP to Q41)

(3) Refused




40a. How many years and months ago did this occur? _______________


41. Do you have a CO (or carbon monoxide) monitor in your house?

(1) Yes

(2) No (SKIP to Q 42)

(3) Don’t know/Not Sure

(4) Refused


41a. Is your CO monitor currently working?

(1) Yes

(2) No

(3) Don’t know/Not Sure

(4) Refused


42. Do you have one or more smoke detectors in your house?

(1) Yes

(2) No (SKIP to Q43)

(3) Don’t know/Not Sure

(4) Refused


42a. How many smoke detectors are there in your house?

Enter Number __________

  1. Don’t Know/Not Sure

  2. Refused

42b. How many of these smoke detectors are currently working?

Enter Number __________

  1. Don’t Know/Not Sure

  2. Refused

43. In the past 12 months how many times has the fire department been called to put out a fire in your home during the past year? _________


44. In the past 12 months did any fire start in your home as a result of using an

alternate heating source, such as space heaters, electric blankets, your kitchen stove or oven, heating stove, furnace, or your fireplace?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused


45. In the past 12 months, how many individuals needed medical attention because of fire?


Enter Number_______



Now I have some questions about cooling you home.


46. (IF NO TO AIR CONDITIONING FROM PREVIOUS SECTION SKIP TO CEILING FAN USE Q47) Central air conditioning requires that the system have ducts to carry the cooled air to the individual rooms. These ducts may also carry warm air for space heating. Does your home have ducts like these?

  1. Yes

  2. No


    (SKIP to 47)

  3. Don’t Know/Not Sure

  4. Refused


46a. Does the central air conditioning equipment that cools your home also cool any other

apartments, condos, households, businesses, or farm buildings?

  1. Yes

  2. No


46b. Which of the statements shown best describes the way your central air conditioning system

was used last summer?

  1. Not used at all (if volunteered)

  2. Turned on only a few days or nights when really needed

  3. Turned on quite a bit

  4. Turned on just about all summer


47. Which of the following statements best describes the way your household used the

most used window/wall air conditioning unit last summer?

  1. Turned on only a few days or nights when really needed

  2. Turned on quite a bit

  3. Turned on just about all summer

  4. No working window/wall units in home


48. Which of the following statements best describes the way your household used a

Swamp or Evaporative Air Cooler last summer?

  1. Turned on only a few days or nights when really needed

  2. Turned on quite a bit

  3. Turned on just about all summer

  4. No swamp/evaporative air cooler in home.


49. How many ceiling fans does your household have?

Enter Number_________

  1. None (SKIP to Q 50)

  2. Don’t Know/Not Sure

  3. Refused

49a. How many ceiling fans does your household use?

Enter Number of ceiling fans_______

  1. None (SKIP to


    50)

  2. Don’t Know/Not Sure

  3. Refused

49b. Thinking about the ceiling fan that you use the most, how often was this fan used last summer? Is it . . .

  1. Used only a few days or nights, when it’s really needed,

  2. Used quite a bit, or

  3. Used just about all summer?

  4. Not used at all

  5. Don’t Know/Not Sure

  6. Refused


49c. Thinking about the ceiling fan that you use the most, how often was this fan used last winter? Is it . . .

  1. Used only a few days or nights,

  2. Used quite a bit, or

  3. Used just about all winter?

  4. Not used at all

  5. Don’t Know/Not Sure

  6. Refused


50. Opening windows on opposite sides of the house to cool the indoor temperature is called natural cross ventilation. In the past 12 months, has your household used window fans to assist with natural cross ventilation in the warmer months?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused

51. How often are your windows open in the summer?

(1) Never

(2) Rarely

(3) Sometimes

(4) Frequently

(5) All the time

(6) Don’t Know/Not Sure

(7) Refused


52. How often are your windows open in the winter?

(1) Never

(2) Rarely

(3) Sometimes

(4) Frequently

(5) All the time

(6) Don’t Know/Not Sure

(7) Refused


53. Do any large trees shade your home from the afternoon summer sun?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused


54. Do you close the drapes, curtains, shades, and/or blinds during the day to block out the sun during the summer?

(1) Never

(2) Rarely

(3) Sometimes

(4) Frequently

(5) All the time

(6) Don’t Know/Not Sure

(7) Refused


INTERVIEWER INSTRUCTION: RECORD ANY INFORMATION HERE ABOUT THE

AIRCONDITIONING EQUIPMENT IN THIS HOUSING UNIT AND ITS’ USAGE THAT

MIGHT PROVIDE CLARIFICATION TO THE RESPONDENT’S ANSWERS.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________


Now I have some questions on the indoor air temperature of your home.


55. Does your home have a thermostat that controls the heating and/or cooling in your home?

  1. Yes

  2. No (SKIP to Q 64)

  3. Don’t Know

  4. Refused


55a. What equipment does your thermostat control?

(1) Central heating only

(2) Central cooling only

(3) Central heating and cooling

(4) Don’t know




56. Some thermostats can be programmed so that the temperature changes automatically at different times of the day; for example, the heat can be automatically turned down or lowered at night when you go to bed, then automatically adjusted up again in the morning. Is the thermostat that controls your main [heating and/or cooling] equipment programmable?

  1. Yes

  2. No (SKIP to Q57)

  3. Don’t know/Not Sure

  4. Refused


56a. Do you or someone else in your household know how to use the programmable thermostat?

  1. Yes

  2. No (SKIP to Q57)

  3. No, someone who does not live in my home programs the thermostat for use

  4. Don’t know/Not Sure

  5. Refused


56b. Is your thermostat programmed to change the temperature at different times of the day?

  1. Yes

  2. No (SKIP to Q56d)

  3. Don’t know/Not Sure

  4. Refused


56c. Please indicate how the programmable thermostat is used. (Select all that apply.)

  1. Thermostat is automatically adjusted to a lower temperature at night during the winter

  2. Thermostat is automatically adjusted to a lower temperature during the day when no one is home during the winter

  3. Thermostat is automatically adjusted to a higher temperature at night during the summer

  4. Thermostat is automatically adjusted to a higher temperature during the day when no one is home during the summer

  5. Other __________________

  6. Don’t know/Not Sure

  7. Refused


56d. Which statement best describes your programmable thermostat…

  1. It is very easy to use

  2. It is somewhat easy to use

  3. It is neither easy nor difficult to use

  4. It is somewhat difficult to use

  5. It is very difficult to use

  6. Refused


56e. Typically, how often is your programmable thermostat reprogrammed, that is, the time schedule and desired indoor temperature setting changed permanently?

(1) Daily

(2) Weekly

(3) Monthly

(4) Every three months of so

(5) Once a year

(6) Less than once a year

(7) Never

(8) Don’t know/Not Sure

(9) Refused



56f. How often is the current temperature setting “overridden” temporarily and why?

(1) Daily

(2) Weekly

(3) Monthly

(4) Every three months of so

(5) Once a year

(6) Less than once a year

{IF ANSWERED ANY OF THE ABOVE} Please explain why._________

(7) Never

(8) Don’t know/Not Sure

(9) Refused


56g. How often is the “hold” mode used and why?

Daily

(2) Weekly

(3) Monthly

(4) Every three months of so

(5) Once a year

(6) Less than once a year

{IF ANSWERED ANY OF THE ABOVE} Please explain why._________

(7) Never

(8) Don’t know/Not Sure

(9) Refused


56h. Please indicate what features need improvement in your programmable thermostat.

  1. Size of words and numbers?

  2. Ease of programming?

  3. Additional features, such as the energy use in my home?

  4. Being able to change its settings using a cell phone, Internet?

  5. Other features. Please Specify. _________________

  6. Don’t Know/Not Sure

  7. Refused


56i. Is there anyone in your home who doesn’t operate the programmable thermostat? Why? (select all that apply)

  1. It’s too complicated/too difficult

  2. We do not have an instruction manual / Nobody showed us how

  3. We haven’t needed to

  4. Other (Specify)________

  5. Don’t Know/Not Sure

  6. Refused


56j. {IF NO TO 56b. or ANSWERED (7)NEVERTO 56e}Why is your programmable thermostat not programmed to automatically change the temperature? (select all that apply)

  1. We change the temperature manually/don’t need to program

  2. It takes too much effort to use

  3. Household members cannot agree on what temperatures at which to set the thermostat

  4. It is better to always keep the temperature setting always the same. (Why?)

  5. There is always somebody at home

  6. Other (Specify)________

  7. Don’t Know/Not Sure

  8. Refused


57. During the winter, what is the temperature when someone is inside your home during the day? [IF NO ANSWER, PROBE 1: THEN AT WHAT TEMPERATURE IS THE THERMOSTAT SET? PROBE 2: CAN I JUST HAVE YOUR BEST ESTIMATE?]


Enter degrees Fahrenheit________


58. During the winter, what is the temperature when no one is inside your home during the day? [IF NO ANSWER, PROBE 1: THEN AT WHAT TEMPERATURE IS THE THERMOSTAT SET? PROBE 2: CAN I JUST HAVE YOUR BEST ESTIMATE?]


Enter degrees Fahrenheit________



59. During the winter, what is the temperature inside your home at night? [IF NO ANSWER, PROBE 1: THEN AT WHAT TEMPERATURE IS THE THERMOSTAT SET? PROBE 2: CAN I JUST HAVE YOUR BEST ESTIMATE?]


Enter degrees Fahrenheit________


Now I would like you to think about the temperature inside your home when using your central air conditioning equipment last summer. [If NUMTHERM>1: Earlier you reported having [FILL: NUMTHERM] thermostats. For the next questions, if the thermostats are set at different temperatures, only report for the thermostat that affects the rooms where most of the people are.]

60. During the summer, what is the temperature when someone is inside your home during the day? IF NO ANSWER, PROBE 1: THEN AT WHAT TEMPERATURE IS THE THERMOSTAT SET? PROBE 2: WHAT’S YOUR BEST ESTIMATE?


Enter degrees Fahrenheit ________

Air-conditioner Turned Off


61. During the summer, what is the temperature when no one is inside your home during the day? IF NO ANSWER, PROBE 1: THEN AT WHAT TEMPERATURE IS THE THERMOSTAT SET? PROBE 2: WHAT’S YOUR BEST ESTIMATE?


Enter degrees Fahrenheit ________

Air-conditioner Turned Off


62. During the summer, what is the temperature inside your home at night? IF NO ANSWER, PROBE 1: THEN AT WHAT TEMPERATURE IS THE THERMOSTAT SET? PROBE 2: WHAT’S YOUR BEST ESTIMATE?


Enter degrees Fahrenheit ________

Air-conditioner Turned Off



63. Answer the following statements -- true or false:


a. If the thermostat is turned up very high in the winter, my home will get warmer faster.

  1. True

  2. False


b. The thermostat controls the temperature of the air coming from the heating/cooling unit into my home.

  1. True

  2. False


c. The thermostat only senses the temperature in the air in the room where the thermostat is located. It turns the heating unit off when the temperature in the room reaches the temperature on the thermostat setting.

  1. True

  2. False


d. If the thermostat is turned down at night or when no one is home, then more energy is used than saved when your home is heated up again.

  1. True

  2. False



64. In the past 12 months, was your household unable to use any of the following equipment

because it was broken? CHECK ALL THAT APPLY

  1. Main Heating Equipment

  2. Central Air Conditioner

  3. Room Air Conditioner

  4. Don’t Know/Not Sure

  5. Refused


65. Which of the following statements best describes the indoor temperature of your home during the winter:

  1. Very cold

  2. Cold

  3. Comfortable (SKIP)

  4. Hot

  5. Very hot

  6. Other ________________

  7. Refused


66. Which of the following statements best describes the indoor temperature of your home during the summer:

  1. Very cold

  2. Cold

  3. Comfortable (SKIP TO NEXT Q….)

  4. Hot

  5. Very hot

  6. Other ________________

  7. Refused


67. In the past 12 months, has a landlord controlled the temperature inside your home?

(1) Yes

(2) No

(3) Do not have landlord

(4) Don’t Know/Not Sure

(5) Refused


68. In the past 12 months how often did your household keep your home at a temperature that you

felt was unsafe or unhealthy?

  1. Almost every month

  2. Some months

  3. 1 or 2 months

  4. Never

  5. Don’t Know/Not Sure

  6. Refused


69. In the past 12 months, has anyone in the household needed medical attention because your

home was too cold?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused


70. In the past 12 months did anyone in your household need medical attention

because your home was too hot?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused


71. During the past 12 months, how often have you or other members of your household found

your home too drafty? Would you say it is. . .

  1. All the time,

  2. Most of the time,

  3. Some of the time, or

  4. Never

  5. Don’t Know/Not Sure

  6. Refused


The next group of questions is about laundry appliances and water use in your home.


72. Is a clothes washing machine used in your home? Do not include community clothes washers

that are located in the basement or laundry room of your apartment building.

  1. Yes

  2. No (SKIP to Q73)

  3. Refused


72a. In an average week, how many loads of laundry are washed in your clothes washer?

  1. 1 load or less each week

  2. 2 to 4 loads each week

  3. 5 to 9 loads each week

  4. 10 to 15 loads each week

  5. More than 15 loads each week

  6. Don’t Know/Not Sure

  7. Refused


72b. Does your household wash only full loads of laundry?

(1) Always

(2) Most of the time

(3) Some of the time

(4) Never

(5) Don’t know/Not Sure

(6) Refused


72c. What water temperature setting is usually used for the wash cycle of your clothes washer? Is it hot, warm, or cold water?

  1. Hot

  2. Warm

  3. Cold

  4. Don’t Know/Not Sure

  5. Refused


72d. What water temperature setting is usually used for the rinse cycle of your clothes washer? Is it hot, warm, or cold water?

  1. Hot

  2. Warm

  3. Cold

  4. Don’t Know/Not Sure

  5. Refused


73. Do you use a clothes dryer in your home? Do not include community clothes dryers that are

located in the basement or laundry room of your apartment building.

  1. Yes

  2. No (SKIP TO Q74)

  3. Don’t Know/Not Sure

  4. Refused


73a. Does your household dry only full loads of laundry….?

(1) Always

(2) Most of the time

(3) Some of the time

(4) Never

(5) Don’t Know/Not Sure

(6) Refused


73b. Does your clothes dryer vent directly to the outdoors?

  1. Yes

  2. No

  3. Dryer is ventless

  4. Don’t Know/Not Sure

  5. Refused


73c. Do you clean your clothes dryer’s lint filter after every use?

  1. Yes

  2. No

  3. Dryer has not lint filter

  4. Don’t Know/Not Sure

  5. Refused


74. How frequently does your household hang clothes to dry?

(1) Very frequently

(2) Frequently

(3) Infrequently

(4) Very infrequently

(5) Never

(6) Don’t Know/Not Sure

(7) Refused


75. In the last 12 months, has the temperature of your hot water heater been adjusted?

  1. Yes, the temperature is much warmer

  2. Yes, the temperature is warmer

  3. No adjustment has been made to the temperature

  4. Yes, the temperature is cooler

  5. Yes, the temperature is much cooler

  6. Hot water heater was not in working order for the last 12 months

  7. No water heater

  8. Don’t Know/Not Sure

  9. Refused

76. Over the past 12 months, has the duration of the showers taken by household members changed?

(1) Increased a lot

(2) Increased some

(3) No change

(4) Decreased some

(5) Decreased a lot

(6) No Shower

(7) Don’t Know/Not Sure

(8) Refused


77. Does your main bathroom have a ventilation fan in it that works?

(1) Yes

(2) No (SKIP to Q78)

(3) Don’t know/Not Sure (SKIP to Q50)

(4) Refused


77a. How often do you or members of your household operate the fan while showering?

(1) Never

(2) Rarely

(3) Sometimes

(4) Frequently

(5) All the time

(6) Don’t Know/Not Sure

(7) Refused


77b. How long after showering do you or members of your household operate the fan?

(1) Don’t turn the fan on for showers

(2) The fan is turned off when leaving the shower area

(3) A few minutes

(4) Several minutes

(5) Until the steam in the shower area is gone

(6) Don’t know/Not Sure

(7) Refused


78. Electric dehumidifiers remove moisture from the air and are often used in the summer. Is a

dehumidifier used in your home?

  1. Yes

  2. No (SKIP to Q79)

  3. Don’t Know/Not Sure

  4. Refused



78a. In the past 12 months, how many months was the dehumidifier used?

  1. 1 to 3 months, 4 to 6 months,

  2. 7 to 9 months,

  3. 10 to 11 months, but not all year, or is it

  4. Turned on all year long?

  5. Don’t Know/Not Sure

  6. Refused


Now I have some questions about lights inside your home and energy efficiency.


79. How often do you find lights left on in rooms that are not occupied?

(1) Never

(2) Almost never

(3) Sometimes

(4) Most of the time

(5) All the time

(6) Don’t Know/Not Sure

(7) Refused


80. Do members of your household purchase or intentionally seek out and install compact fluorescent bulbs in your home?

(1) Yes

(2) No (SKIP to Q81)

(3) I do not know what compact fluorescent bulbs are (SKIP to Q81)

(4) Don’t know/Not Sure

(5) Refused


80a. How do you dispose of compact fluorescent light bulbs that are broken or no longer working?_

  1. Directly in household garbage

  2. Doubled bagged in plastic in household garbage

  3. Transport to local recycling center

  4. Other (Please Specify)________________

  5. Don’t Know/Not Sure

  6. Refused


81. Are you familiar with the Energy Star label?

  1. Yes

  2. No (SKIP to 82)

  3. Refused


81a. Has your household bought or intentionally installed appliances or consumer electronics that have an Energy Star label?

  1. Yes

  2. No

  3. Don’t know/Not Sure

  4. Refused


82. Do you unplug any appliances like TVs, VCRs, stereos, radios, clocks, or computers to save energy when they are turned off?

(1) Yes

(2) No

(3) Don’t know/Not Sure

(4) Refused


In this next set of questions, I will ask you about other conditions of your home.


83. How much outdoor noise do you hear indoors when the windows are closed?

  1. A great deal

  2. Some

  3. Hardly any

  4. None at all

  5. Don’t know/Not Sure

  6. Refused


84. Please rate the outside appearance of your home:

  1. Very attractive

  2. Attractive

  3. Neither attractive nor unattractive

  4. Unattractive

  5. Very unattractive

  6. Refused


85. Over the past 12 months, how has the property value of your home changed?

  1. Very much higher

  2. Higher

  3. No change

  4. Lower

  5. Very much lower

  6. Not applicable, don’t own the home or live in an apartment

  7. Don’t know/Not Sure

  8. Refused


86. How infested is your home with cockroaches or other insects or spiders?

(1) Extremely infested

(2) Very infested

(3) Somewhat infested

(4) Hardly infested

(5) Not infested at all (SKIP to Q87)

(6) Don’t know/Not Sure

(7) Refused


86a. What have you done about the cockroaches, other insects or spiders?

  1. Nothing

  2. Used insecticides, bug sprays, or poison

  3. Hired an exterminator or other professional

  4. Other. Please specify._________

  5. Don’t Know/Not Sure

  6. Refused

87. How infested is your home with rats or mice?

  1. Extremely infested

(2) Very infested

(3) Somewhat infested

(4) Hardly infested

(5) Not infested at all (SKIP to Q88)

(6) Don’t know/Not Sure

(7) Refused


87a. What have you done about the pests?

  1. Nothing

  2. Used bait or poison

  3. Hired an exterminator or other professional

  4. Other. Please specify._________

  5. Don’t Know/Not Sure

  6. Refused


88. Does your home frequently have a mildew odor or musty smell?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused


89. How often do you observe standing water anywhere in your home?

  1. Never

  2. Rarely

  3. Sometimes

  4. Often

  5. Always

  6. Don’t Know/Not Sure

  7. Refused


90. Have you seen mold in your home in the past 12 months?

  1. Yes

  2. No {SKIP to Q91}

  3. Don’t know/Not Sure

  4. Refused


90a. {If YES MOLD}What have you done about the mold?

  1. Nothing

  2. Cleaned with bleach

  3. Cleaned with other chemical mold remover

  4. Cleaned with natural mold remover (vinegar or natural product)

  5. Air Conditioned

  6. Ventilation (fans)

  7. Used a dehumidifier

  8. Contacted a Professional

  9. Other. Please Specify _________

  1. Don’t know/Not Sure

  2. Refused

Now I would like to ask you a few questions about your energy bills.

Some households may have faced challenges in paying home energy bills. The following

questions ask about challenges your household may have had paying home energy bills or

maintaining heating and cooling equipment. When thinking about these questions, include all of

your experiences in the past 12 months.


91. Some energy utilities and suppliers offer budget payment plans that allow a household to pay

the same amount on the home energy bill each month. In the past 12 months, did your household

use a budget plan for any home energy bill?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused


INTERVIEWER INSTRUCTION: Budget plans are not usually related to late or disconnect notices and are not a way to pay down past due balances.


92. How well do you understand the information on your energy bill other than the amount owed (e.g., information about how much energy your household used during the billing period compared to the same billing period one year ago)?

(1) Very well

(2) Well

(3) Neither well nor not well

(4) Not well

(5) Not well at all

(6) Don’t know/Not Sure

(7) Refused




93. How hard is it to pay your energy bills?

  1. Very hard

  2. Hard

  3. Neither hard or not hard

  4. Not hard

  5. Not hard at all

  6. Don’t know/Not Sure

  7. Refused


94. Has your household ever had to move in the past 5 years because your household could not pay the energy bills?

  1. Yes

  2. No (go to Q20)

  3. Don’t know (go to Q 20)


95. Over the past 12 months, how often has your household not paid energy bills in order to pay other utility bills (PROBE: water/sewage/telephone/Secondary energy fuel type)?

  1. Every month

  2. Every other month

  3. Every few months

  4. Every six months

  5. Once in twelve months

  6. Never

  7. Don’t Know/Not Sure

  8. Refused


96. Over the past 12 months, how often has your household not paid other utilities in order to pay the primary energy bill (PROBE: water/sewage/telephone/Secondary energy fuel type)?

  1. Every month

  2. Every other month

  3. Every few months

  4. Every six months

  5. Once in twelve months

  6. Never (SKIP to Q97)

  7. Don’t Know/Not Sure

  8. Refused


96 a. What utilities were not paid for in order to pay an energy bill? CHECK ALL THAT APPLY.

  1. Water

  2. Sewage

  3. Telephone

  4. Secondary energy fuel type

  5. Other__________

  6. Don’t Know/Not Sure

  7. Refused


97. Over the past 12 months, how often has your household not purchased food in order to pay an energy bill?

  1. Every month

  2. Every other month

  3. Every few months

  4. Every six months

  5. Once in twelve months

  6. Never

  7. Don’t Know/Not Sure

  8. Refused


98. Over the past 12 months, how often has your household not paid energy bills in order to purchase food?

  1. Every month

  2. Every other month

  3. Every few months

  4. Every six months

  5. Once in twelve months

  6. Never

  7. Don’t Know/Not Sure

  8. Refused


99. In the past four weeks, did you or any household member go a whole day and night without eating anything because there was not enough food?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused


100. In the past four weeks, did you worry that your household members would not have nutritious food?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused

101. Some households receive additional assistance to help pay for food. In the past 12 months did you or any members of your household receive food stamps or WIC assistance (Women, Infants, and Children nutrition program)? (ASK ONCE/DO NOT REPEAT QUESTION FOR EACH INDIVIDUAL)

  1. Yes

  2. No; Did not apply

  3. No; Applied for, but rejected

  4. Don’t Know/Not Sure

  5. Refused


102. In the past 5 years have you or anyone in the household experienced any of the following as a result of energy bills? CHECK ALL THAT APPLY.

  1. Eviction from home

  2. Foreclosure on mortgage

  3. Moved in with friends or family

  4. Moved into a shelter or been homeless

  5. Family Separation

  6. Refused


102a. {If YES FAMILY SEPARATION} In what way or ways was the family separated?

  1. Adult partners only separated

  2. One adult partner separated from partner and children

  3. One parent separated from children only

  4. Both parents separated from children

  5. Elder parent or relative separated from family

  6. Refused


103. In the past 12 months how often did your household pay an amount less than what you owed on your home energy bill, because you were unable to afford the whole home energy bill?

  1. Almost every month

  2. Some months

  3. 1 or 2 months

  4. Never

  5. Don’t Know/Not Sure

  6. Refused


104. In the past year, have you used any of the following to assist with paying your energy bill?

  1. Payday loan

  2. Tax Refund Anticipation Loan

  3. Car Title loan

  4. Other type of short term, high-interest loan

  5. Pawn shop

  6. Don’t Know/Not Sure

  7. Refused


104a. {If YES to any of the above}In the past year, in order to pay your home energy bill, how often did you need to use a payday loan, a Tax Refund Anticipation Loan, a car title loan, another type of short-term, high-interest loan, or pawn shop?

  1. Almost every month

  2. Some months

  3. 1 or 2 months

  4. Never

  5. Don’t Know/Not Sure

  6. Refused


105. When home energy bills are not paid on time, it is common for energy utilities and suppliers to send late notices. If the bill is very late, they will send a disconnect, shut-off, or non-delivery notice. How often did you receive a disconnect, shut-off, or non-delivery notice?

  1. Almost every month

  2. Some months

  3. 1 or 2 months

  4. Never (SKIP to Q106)

  5. Don’t Know/Not Sure

  6. Refused


105a. Did you enter into a payment arrangement with your energy utility or supplier in response to the disconnect shut-off, or non-delivery notice?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused


106. In the past 12 months was your electricity or natural gas ever disconnected because you

were unable to pay your home energy bill?

  1. Yes

  2. No (SKIP to Q107)

  3. Don’t Know/Not Sure

  4. Refused


106a. While your electricity or natural gas was disconnected, was there a time when you wanted

to use your main source of heat but were unable to?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused


106b. While your electricity was disconnected, was there a time when you wanted to use

your air conditioner but were unable to?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused


107. In the past 12 months did your fuel oil, kerosene, propane, or wood ever run out because you were unable to pay for a home energy delivery?

  1. Yes

  2. No (SKIP to Q108)

  3. Don’t Know/Not Sure

  4. Refused


107a. When you ran out of your fuel oil, kerosene, propane, or wood was there a time when you

wanted to use your main source of heat but were unable to?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused


Next, I will be asking about health care and coverage.


108. In the past 12 months have you had any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?

  1. Yes (SKIP to Q108b)

  2. No

  3. Refused


108a. {IF NO COVERAGE} According to the information given, you do NOT have health care coverage of any kind. Do you have health insurance or coverage through a plan I might have missed? (INTERVIEWER: REVIEW PLANS IF INFORMANT IS UNSURE.)

  1. NO/NOT COVERED BY ANY PLAN (SKIP to Q109)

  2. HEALTH INSURANCE PLAN FROM A

  3. CURRENT OR PAST EMPLOYER/

  4. UNION/SCHOOL

  5. A HEALTH INSURANCE PLAN BOUGHT ON

HIS/HER OWN/PROF. ASSN

  1. A PLAN BOUGHT BY SOMEONE WHO

DOES NOT LIVE IN THIS HOUSEHOLD

  1. MEDICARE

  2. MEDICAID/STATE NAME

  3. CHAMPUS/CHAMP-VA, TRICARE, VA,

(10) OTHER MILITARY

(11) INDIAN HEALTH SERVICE

(12) [fill STATE PLAN]

(13) OTHER PLAN [SPECIFY]

(14) DON’T KNOW/NOT SURE

(15) REFUSED


108b. {IF YES COVERAGE}During the past 12 months was there any time that you did not have any health insurance coverage?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused




108c. Does your health plan pay for at least some of the cost of prescription medicines

prescribed by a doctor?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused


109. During the past 12 months, was there any time your household members needed prescription medicines but didn’t get them because you couldn’t afford it?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused


110. Over the past 12 months, how often did members of your household not fill a prescription or took less than the full dose of a prescribed medicine in order to pay the utility bill?

  1. Every month

  2. Every other month

  3. Every few months

  4. Every six months

  5. Once in twelve months

  6. Never

  7. Don’t Know/Not Sure

  8. Refused


111. Over the past 12 months, how frequently has your household not paid energy bills in order to purchase prescription medicines?

  1. Every month

  2. Every other month

  3. Every few months

  4. Every six months

  5. Once in twelve months

  6. Never

  7. Don’t Know/Not Sure

  8. Refused


112. Was there a time in the past 12 months when you needed to see a doctor but could not

because of cost?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused



113. During the past 12 months, have you or other adults in your household had any problems paying medical bills?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused


{Note: Ask these questions of the adult in the household most involved with all the other members of the household because proxy responses are required.}


114. Including yourself, how many people normally live in this household? Do not include

anyone who is just visiting, those away in the military, or children who are away at college.

Enter Number _______________


115. Can you please tell me their first names, gender and age, and your relationship to the person?


First Name Gender Age Relationship In school (Y/N)


Person 1.

Person 2.

Person 3.

Person 4.

Person 5.

Person 6.

Person 7.

Person 8.

Person 9.

Person 10.


116. On a typical week day is there someone at home most or all of the day?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused

For this section, I will be asking health related questions.


117. Now thinking about physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

  1. Number of days______

  2. None

  3. Don’t know / Not sure

  4. Refused


118. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

  1. Number of days_______

  2. None

  3. Don’t know / Not sure

  4. Refused


119. During the past 30 days, for about how many days have you felt you did not get enough rest

or sleep?

  1. Number of days______

  2. None

  3. Don’t know / Not sure

  4. Refused


120. During the past 30 days, for about how many days have you felt very healthy

and full of energy?

  1. Number of days______

  2. None

  3. Don’t know / Not sure

  4. Refused


121. During the past 30 days, for about how many days did poor physical or mental health

keep you from doing your usual activities, such as self-care, work, or recreation?

  1. Number of days _______

  2. None

  3. Don’t know / Not sure

  4. Refused


Next, I am going to ask you whether you have had some particular health

problems in the last 3 months. In the past 3 months, have you had . . .


122. Shortness of breath when lying down, waking up,

or with light work or light

exercise?

  1. Yes

  2. No

  3. Don’t know/Not Sure

  4. Refused


123. Headaches that are either new or more

frequent or severe than ones you have

had before?

  1. Yes

  2. No

  3. Don’t know

  4. Refused

In the past 12 months were you or anyone else in the household ever told by a doctor or health professional that you or they have.. CHECK ALL THAT APPLY


124. Lead poisoning

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused

{IF YES}Please list all individuals, including yourself:

____________________

____________________

____________________


125. Three or more ear infections per year

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused

{IF YES} Please list all individuals, including yourself:

____________________

____________________

____________________


126. Any kind of respiratory allergy

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused

{IF YES} Please list all individuals, including yourself:

____________________

____________________

____________________

127. Flu

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused

{IF YES} Please list all individuals, including yourself:

____________________

____________________

____________________


128. Persistent Cold symptoms lasting more than 14 days (SYMPTOMS INCLUDE COUGHING, SORE THROAT, SNEEZING, SINUS PAIN, CONGESTION, FEVER, FATIGUE, AND HEADACHE)

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused

{IF YES} Please list all individuals, including yourself:

____________________

____________________

____________________

129. Sinus infection or Sinusitis

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused

{IF YES} Please list all individuals, including yourself:

____________________

____________________

____________________


130. Bronchitis

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused

{IF YES} Please list all individuals, including yourself:

____________________

____________________

____________________


131. Have you ever been told by a doctor or other health professional that you have asthma?

    1. Yes

    2. No (SKIP to Q132)

    3. Don’t Know/not sure

    4. Refused


131a. Do you still have asthma?

    1. Yes

    2. No

    3. Don’t Know/Not sure

    4. Refused


131b. During the past 12 months, how many times did you see a doctor or health professional for a routine checkup for your asthma? ______________


READ: Symptoms of asthma include coughing, wheezing, shortness of breath, chest tightness or phlegm production when you have a cold or respiratory infection.


131c. How long has it been since you last had any symptoms of asthma?

    1. Never

    2. Less than one day ago

    3. 1-6 Days ago

    4. 1 week to less than 3 months ago

    5. 3 months to less than 1 year ago

    6. 1 year to less than 3 years ago

    7. 3 years to 5 years ago

    8. More than 5 years ago

    9. Don’t Know/Not sure

    10. Refused


131d. During the past 12 months did you have to stay overnight in the hospital because of asthma?

  1. Yes

  2. No

  3. Don’t know/Not Sure

  4. Refused


131e. Not counting hospitalizations, during the past 12 months, did you go to an emergency room because of asthma?

  1. Yes

  2. No

  3. Don’t know/Not Sure

  4. Refused


These next questions are about cigarette smoking.


132. Which one of the following statements best describes the rules about smoking in your home…

  1. No one is allowed to smoke anywhere inside your home

  2. Smoking is allowed at some places or at sometimes

  3. Smoking is permitted anywhere

  4. Don’t know/Not sure

  5. Refused


133. Have you smoked at least 100 cigarettes in your entire life?

  1. Yes

  2. No

  3. Don’t know/Not sure

  4. Refused


134. Do you now smoke cigarettes every day, some days or not at all?

  1. Everyday

  2. Some days

  3. Not at all

  4. Don’t Know/Not sure

  5. Refused


135. In the past 12 months has anyone in the household been food poisoned from eating food inside your home and therefore went to see a medical professional?

  1. Yes

  2. No

  3. Don’t Know/Not sure

  4. Refused


136. In the past 12 months, has anyone in the household been poisoned by breathing in carbon monoxide, and therefore went to see a medical professional?

  1. Yes

  2. No

  3. Don’t Know/Not sure

  4. Refused


137. In the past 12 months, has anyone in the home been burned from scalding hot water coming out of a faucet or showerhead in your home?

  1. Yes

  2. No (SKIP to Q138)

  3. Don’t Know/Not Sure

  4. Refused


137a. {IF YES BURN}Did you talk to or see a medical professional about this injury?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused


138. I am going to read some statements about health and medical care.

Usually, you go to the doctor as soon as you start to feel bad. Is that:

  1. definitely true,

  2. mostly true,

  3. mostly false, or

  4. definitely false?

  5. Don’t Know/Not Sure

  6. Refused


139. You will do just about anything to avoid going to the doctor. Is that . . .

  1. definitely true,

  2. mostly true,

  3. mostly false, or

  4. definitely false?

  5. Don’t Know/Not Sure

  6. Refused


In this last section I will be asking employment and school related questions.


140. Are you or primary wage earner in the household currently…?

  1. Employed for wages

  2. Self-employed

  3. Out of work for more than 1 year (SKIP to Q140c)

  4. Out of work for less than 1 year (SKIP to Q140c)

  5. A Homemaker (SKIP to Q141)

  6. A Student

  7. Retired (SKIP to Q141)

  8. Unable to work (SKIP to Q141)

  9. Refused


140a. Are you or the primary wage earner in the household employed full-time or part-time?

  1. Full-time

  2. Part-time

  3. Don’t Know/Not Sure

  4. Refused


140b. How many hours per week do you or the primary wage earner usually work at all of your jobs?

Enter ______ hrs


140c. {IF ANSWERED (3) or (4) to Q140}Have you/Has the primary wage earner looked for work during the last 4 weeks?

(1) Yes

(2) No

  1. Don’t Know/Not Sure

  2. Refused


140d. {IF ANSWERED (3) or (4) to Q140}What is the main reason you were/the primary wage earner was not looking for work during the LAST 4 WEEKS? CHECK ALL THAT APPLY(DO NOT READ LIST)

(1) Believes no work available in line of work or area
(2) Couldn't find any work
(3) Lacks necessary schooling, training, skills or experience
(4) Employers think too young or too old
(5) Other types of discrimination
(6) Can't arrange child care
(7) Family responsibilities
(8) In school or other training
(9) Ill health, physical disability
(10) Transportation problems
(11) Other

  1. Don’t Know/Not Sure

  2. Refused

141. Does a physical, mental or emotional problem NOW keep you or the primary wage earner from working at a job or business?

  1. Yes

  2. No

  3. Don’t know/Not Sure

  4. Refused

142. In the past 12 months did anyone in the household receive income from any of the

following sources?   CHECK ALL THAT APPLY

    1. Supplemental Security Income (SSI)

    2. Welfare payments or case assistance

    3. Veteran’s payments (VA Benefits)

    4. Unemployment Compensation

    5. Don’t Know/Not Sure

    6. Refused

                                                                                                                                               

143. During the past 12 months have you or the primary wage earner had more than one job (or business), including part time, evening, or weekend work?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused


144. {IF ANSWERED (1), (2), (4), or (6) to Q140}Thinking about the last 12 months, is your or the primary wage earner’s main job, where you work(ed) the most amount of hours, considered seasonal?

  1. Yes

  2. No (SKIP to Q145)

  3. Don’t Know/Not Sure

  4. Refused

144a. In what season do you/does the primary wage earner work the least amount of hours?

  1. Winter

  2. Spring

  3. Summer

  4. Fall

145. {IF ASWERED (1) or (2) TO Q 140}In the past 12 months, about how many days of work did you or the primary wage earer miss work at a job or business because of illness or injury (DO NOT INCLUDE MATERITY LEAVE}.

Enter Number________


    1. None

    2. Don’t Know/Not Sure

    3. Refused


146. {IF ASWERED (1) or (2) TO Q 140}In the past 12 months, about how many days of work did you or the primary wage earner miss because of illness or injury of another household member?

Enter Number________


  1. None

  2. Don’t Know/Not Sure

  3. Refused


147. In the past 12 months, about how many days of school have you, the primary wage earner, and/or those in the household enrolled in school, missed because of illness or injury? {IF PRE-SCHOOLER IN HOME}Please tell us about the preschooler who has missed the most number of days. {IF SCHOOL AGED CHILD IN HOME} Please tell us about the school aged child who has missed the most number of days.

Enter Number:

Main Respondent _________ days

      1. Not in School

      2. Don’t Know/Not Sure

      3. Refused

Primary Wage Earner _________ days

  1. Not in School

  2. Don’t Know/Not Sure

  3. Refused

Pres-School Child who has missed the most amount of school_________ days

  1. None

  2. Don’t Know/Not sure

  3. Refused


School Aged child who has missed the most amount of school_________ days

  1. None

  2. Don’t Know/Not sure

  3. Refused


148. {IF STUDENT}In the past 12 months, how frequently did you find it hard to study in your home because of excessive heat or cold?

  1. Very frequently

  2. Frequently

  3. Not frequently or infrequently

  4. Infrequently

  5. Very infrequently

  6. Never

  7. Does not study at home

  8. Don’t Know/Not sure

  9. Refused

149. {IF SCHOOL AGED CHILDREN IN THE HOME}In the past 12 months, how frequently does any school aged child in the home find it hard to study because of excessive heat or cold?

  1. Very frequently

  2. Frequently

  3. Not frequently or infrequently

  4. Infrequently

  5. Very infrequently

  6. Never

  7. Does not study at home

  8. Don’t Know/Not sure

  9. Refused


That is the end of the survey. Thank you for your participation! You will receive your $25 gift card in the mail to compensate you for your time. Could you please verify your mailing address:


Address: __________________________

__________________________

__________________________

__________________________












{INTERVIEWER: ADMINISTER AS A SEPARATE SURVEY POST-WEATHERIZATION}


PART II. Client Satisfaction


{Note: Ask these questions of the adult in the household most involved with the weatherization of the home or the head of the household}


Approximate Date of Weatherization Job: _____________________


1. How long have you known about your local weatherization program?

ENTER THE RESPONSE IN YEARS ___________________


2. How did you find out about your local weatherization program? CHECK ALL THAT APPLY

(1) A call from the weatherization agency

(2) Information received in the mail from the weatherization agency

(3) Local newspaper

(4) Found the program on the Internet

(5) Relative or friend mentioned the weatherization program

(6) Neighbor who had their home weatherized

(7) Agency providing utility assistance such as LIHEAP

(8) Email from an organization with which you are a member

(9) Church

(10) Other (Specify_______________)


3. How long ago did you request that your home be weatherized?

ENTER THE RESPONSE IN YEARS ____________________


4. How satisfied are you with the length of time between your request to have your home weatherized and when it actually was weatherized?

  1. Very satisfied

  2. Satisfied

  3. Not satisfied or dissatisfied

  4. Dissatisfied

(5) Very dissatisfied


5. How easy was it to request that your house be weatherized?

  1. Very easy

  2. Easy

  3. Not easy or difficult

  4. Difficult

  5. Very difficult


6. How easy was it to schedule the initial audit of your home?

(1) Very easy

(2) Easy

(3) Not easy or difficult

(4) Difficult

(5) Very difficult


7. How timely were those who did the initial audit of your home?

(1) Early or On Time

(2) <30 Minutes Late

(3) 30-60 Minutes Late

(4) 1 to 3 Hours Late

(5)More than 4 Hours Late

(6) Did not show up on scheduled day


8. How courteous were those who did the initial audit of your home?

(1) Very Courteous

(2) Courteous

(3) Not Courteous or Rude

(4) Rude

(5) Very Rude


9. How easy was it to schedule the time for the weatherization crew to come to your home?

(1) Very easy

(2) Easy

(3) Not easy or difficult

(4) Difficult

(5) Very difficult


10. How timely was the weatherization crew?

(1) Early or On Time

(2) <30 Minutes Late

(3) 30-60 Minutes Late

(4) 1 to 3 Hours Late

(5)More than 4 Hours Late

(6) Did not show up on scheduled day


11. How courteous was the weatherization crew?

(1) Very Courteous

(2) Courteous

(3) Not Courteous or Rude

(4) Rude

(5) Very Rude

12. How careful of your home and belongings was the weatherization crew?

  1. Very careful

  2. Careful

  3. Neither careful or careless

  4. Careless

  5. Very careless


13. Overall, how clean did the weatherization crew leave the inside of your home?

  1. Very clean

  2. Clean

  3. Neither clean nor dirty

  4. Dirty

  5. Very dirty


13a. Overall, how clean did the weatherization crew leave the outside of your home?

  1. Very clean

  2. Clean

  3. Neither clean nor dirty

  4. Dirty

  5. Very dirty


14. Overall, how satisfied are you with final condition the inside of your home was left in?

  1. Very satisfied

  2. Satisfied

  3. Not satisfied or dissatisfied

  4. Dissatisfied

(5) Very dissatisfied

14a. Overall, how satisfied are you with final condition the outside of your home was left in?

  1. Very satisfied

  2. Satisfied

  3. Not satisfied or dissatisfied

  4. Dissatisfied

  5. Very dissatisfied


15. How easy was it to schedule the final inspection of your home?

(1) Very easy

(2) Easy

(3) Not easy or difficult

(4) Difficult

(5) Very difficult

(6) Final inspection was not done (go to Q18)


16. How timely were those who did the final inspection of your home?

(1) Early or On Time

(2) <30 Minutes Late

(3) 30-60 Minutes Late

(4) 1 to 3 Hours Late

(5)More than 4 Hours Late

(6) Did not show up on scheduled day


17. How courteous were those who did the final inspection of your home?

(1) Very Courteous

(2) Courteous

(3) Not Courteous or Rude

(4) Rude

(5) Very Rude


18. How satisfied are you with the work performed in your home?

  1. Very satisfied

  2. Satisfied

  3. Not satisfied or dissatisfied

  4. Dissatisfied

(5) Very dissatisfied

19. How satisfied are you with any new equipment installed in house?

  1. Very satisfied

  2. Satisfied

  3. Not satisfied or dissatisfied

  4. Dissatisfied

(5) Very dissatisfied

20. Do you feel that other things should have been installed in your home to help you save energy?

  1. Yes

  2. No (go to Q21)


20a. What other things? ______________________


21. How satisfied are you with the energy savings achieved after having your home weatherized?

  1. Very satisfied

  2. Satisfied

  3. Not satisfied or dissatisfied

  4. Dissatisfied

  5. Very dissatisfied

  6. Too soon to tell

  7. Don’t know


22. Did the weatherization agency staff check your home for major repairs (e.g., fixing roof)?

(1) Yes

(2) No (go to Q23)


22a. Were major repairs needed in your home?

  1. Yes

  2. No (go to Q23)


22b. Were major repairs done to your home?

  1. Yes

  2. No

  3. Not yet but expecting repairs to be done


23. Did the weatherization staff ask you about the health of the member(s) of your household?

(1) Yes (go to Q24a)

(2) No


24. Without the weatherization staff asking, did you provide to them any information about the health of the member(s) of your household?

  1. Yes

  2. No (SKIP to Q25)


24a. Were any of the members of your household in need of care that they were not receiving at the time?

  1. Yes

  2. No (go to Q25)


24b. Did the weatherization staff help you to obtain the needed care?

  1. Yes

  2. No


25. Did your weatherization agency refer you to any other housing and/or social service programs?

  1. Yes

  2. No (go to Q26)


25a. What program or programs? ____________________________

26. Did you file a complaint about the weatherization services provided?

(1) Yes

(2) No (go to Q27)


26a. What was the complaint about?____________________


26b. How satisfied are you with the resolution of the situation you complained about?

(1) Very satisfied

(2) Satisfied

(3) Not satisfied or dissatisfied

(4) Dissatisfied

(5) Very dissatisfied


26c. How might the agency have done a better job of resolving your complaint?_______


27. Did you get any information on ways to save energy in your home from the people who weatherized your home?

(1) Yes

(2) No (go to Q33)


28. How much time did the weatherization agency staff talk to you about ways to save energy?

(1) Less than 5 minutes

(2) 5 to 14 minutes

(3)15 to 29 minutes

(4) 30 to 60 minutes

(5) More than one hour


29. How well did you understand what the weatherization agency staff said to you about saving energy?

(1) Very well (go to Q30)

(2) Well (go to Q30)

(3) Neither well or not well (go to Q30)

(4) Not well

(5) Not well at all


29a. Why did you not understand what the weatherization agency staff said?

CHECK ALL THAT APPLY

(1) The staff person did not speak my primary language

(2) The staff person was confusing

(3) The staff person did not speak well

(4) The staff person was hurried

(5) The staff person was boring

(6) I did not get along with the staff person

(7) Other_________________


30. What materials about saving energy did the weatherization agency staff give you? CHECK ALL THAT APPLY

(1) One or more brochures, booklets, or manuals

(2) One or more compact discs (CDs), videos, or DVDs

(3) Hardware kit of weatherization materials

(4) No materials were provided (go to Q31)

(5) Weatherization staff spent time demonstrating how to save energy (go to Q31)


30a. How much time have you spent reading/reviewing the materials about saving energy that the weatherization agency staff gave you?

(1) No time (go to Q31)

(2) Less than 5 minutes

(3) 5 to 14 minutes

(4) 15 to 29 minutes

(5) 30 to 59 minutes

(6) More than one hour


30b. How well did you understand the energy savings materials that the weatherization agency staff gave you?

  1. Very well

  2. Well

  3. Neither well or not well

  4. Not well

  5. Not well at all


30c. How useful have the energy savings materials been to you?

(1) Very useful

(2) Useful

(3) Neither useful or not useful

(4) Not useful

(5) Not very useful


30d. What about the materials were particularly useful? ___________________


30e. How could the materials have been improved for your use? ____________________


31. How satisfied are you with the ways that the weatherization agency provided you with information about saving energy?

  1. Very satisfied

  2. Satisfied

  3. Not satisfied or dissatisfied

  4. Dissatisfied

(5) Very dissatisfied


32. Did you get any information on ways to improve health and safety in your home from the people who weatherized your home?

(1) Yes

(2) No (go to Q38)

33. How much time did the weatherization agency staff talk to you about ways to improve health and safety?

(1) Less than 5 minutes

(2) 5 to 14 minutes

(3) 15 to 29 minutes

(4) 30 to 59 minutes

(5) More than one hour


34. How well did you understand what the weatherization agency staff said to you about improving health and safety?

(1) Very well (go to Q36)

(2) Well (go to Q36)

(3) Neither well or not well (go to Q36)

(4) Not well

(5) Not well at all


34a. Why did you not understand what the weatherization agency staff said?

CHECK ALL THAT APPLY

(1) The staff person did not speak my primary language

(2) The staff person was confusing

(3) The staff person did not speak well

(4) The staff person was hurried

(5) The staff person was boring

(6) I did not get along with the staff person

(7) Other_________________


35. What materials about improving health and safety did the weatherization agency staff give you? CHECK ALL THAT APPLY

(1) One or more brochures, booklets and manuals

(2) One or more compact discs

(3) One or more videos (including DVD’s)

(4) No materials were provided (go to Q36)


35a. How much time have you spent reading/reviewing the materials about improving health and safety that the weatherization agency staff gave you?

(1) No time (go to Q36)

(2) Less than 5 minutes

(3) 5 to 14 minutes

(4) 15 to 29 minutes

(5) 30 to 59 minutes

(6) More than one hour


35b. How well did you understand the improving health and safety materials that the weatherization agency staff gave you?

  1. Very well

  2. Well

  3. Neither well or not well

  4. Not well

  5. Not well at all


35c. How useful have the improving health and safety materials been to you?

(1) Very useful

(2) Useful

(3) Neither useful or not useful

(4) Not useful

(5) Not very useful


35d. What about the materials were particularly useful? ___________________


35e. How could the materials have been improved for your use? ____________________


36. How satisfied are you with the ways that the weatherization agency provided you with information about improving health and safety?

  1. Very satisfied

  2. Satisfied

  3. Not satisfied or dissatisfied

  4. Dissatisfied

(5) Very dissatisfied

37. How could the agency improve the ways that it provides households with information about improving health and safety? ___________________________________


38. What are some of the greatest benefits your household received by participating in the weatherization program? ___________________


39. What suggestions do you have for how the weatherization program can be improved?

________________


40. In the last 12 months, have you informed other people who might be interested in receiving weatherization services of the program?

  1. Yes

  2. No


41. Do you know if these people have had their homes weatherized or are scheduled to have their home weatherized, as a result of your suggestion?

  1. Yes

  2. No


42. Why did you apply for the Weatherization Assistance Program?1

  1. Reduce energy bills

  2. Support environmental efforts to conserve energy

  3. Make home more comfortable

  4. Receive free services

  5. Other

  6. Don’t know


43. Prior to receiving weatherization services, in what ways did your household attempt to weatherize your home?

Please Explain___________________________________________________________________________________________________________________________________________________________________________________________________________________________________


44. Would you say your household is now less likely to move from your current home as a result of weatherization?

  1. Yes

  2. No

  3. Don’t Know/Not Sure

  4. Refused

45. Please rate the chances of your household’s moving during the next 12 months for any reason or combination of reasons:

  1. Very high

  2. High

  3. Medium

  4. Low

  5. Very low

  6. No chance


46. Finally, please rate your overall satisfaction with the weatherization program.

  1. Very satisfied

  2. Satisfied

  3. Not satisfied or dissatisfied

  4. Dissatisfied

  5. Very dissatisfied


That is the end of the survey. Thank you for your participation! You will receive your $10 gift card in the mail to compensate you for your time. Could you please verify your mailing address:


Address: __________________________

__________________________

__________________________

__________________________


1 Ohio REACH

53



File Typeapplication/msword
Authore9r
Last Modified ByBruce Tonn
File Modified2010-09-18
File Created2010-09-18
© 2025 OMB.report | Privacy Policy