Field Test of the National Household Food Acquisition and Purchase Survey

APPENDIX O
HOUSEHOLD INTERVIEW #2

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SECTION A. NON-FOOD EXPENDITURES
We’re going to start with some questions about your household expenses.

CASE ID:__________

A1. Are your living quarters …
[SIPP]

HOUSEHOLD INTERVIEW #2

(1) Owned or being bought by you or someone in your household 
SKIP TO A2
(2) Rented, or
(3) Occupied without paying rent?  SKIP TO A4
(77) REFUSED  SKIP TO A1b
(99) DON’T KNOW  SKIP TO A1b

INTRODUCTION

As you may remember, this study is designed to help the U.S. Department
of Agriculture understand households’ food choices and America’s food
needs. To understand households’ food choices, we need to gather detailed
information about households’ financial situations. In this interview I’ll ask
you about household expenses, income, and assets – which include things
you own or money you may have saved.

A1a. How much did (you/your household) pay for rent last month?
$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

Taking part in this study is voluntary - you can skip any question you do not
want to answer or that makes you feel uncomfortable. Your decision will
not affect any benefits or services you may receive from any other
government agency, now or in the future. The information you give us is
strictly confidential and will be used only for statistical purposes. It will take
about 30 minutes to answer these questions.

A1b. Is this public housing – that is, is it owned by a local public housing
authority or other public agency? DO NOT INCLUDE MILITARY
HOUSING [SIPP]
(1) YES  SKIP TO A4
(0) NO
(77) REFUSED  SKIP TO A4
(99) DON’T KNOW  SKIP TO A4

I’d like to continue now unless you have any questions for me.

A1c. Is the rent here subsidized by the Federal, State, or Local
government? By that I mean, is the government paying part of the
cost? DO NOT INCLUDE MILITARY HOUSING

REMIND RESPONDENTS AS NEEDED: Your best guess is all that is needed. You don’t
need to make precise calculations or look through your financial information.

(1) YES SKIP TO A4
(0) NO  SKIP TO A4
(77) REFUSED  SKIP TO A4
(99) DON’T KNOW SKIP TO A4

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A2c. How much do you pay for homeowner’s insurance?
$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

A2. How much is (your/your household’s) monthly mortgage payment?
INTERVIEWER: IF HOUSE IS PAID OFF, ENTER ZERO.
$|__|__|__|__|.|__|__|
(77) REFUSED  SKIP TO A2b
(99) DON’T KNOW  SKIP TO A2b

ASK IF NECESSARY: Is that per month, per quarter, per year?
(1) PER MONTH
(2) PER QUARTER
(3) PER YEAR
(4) TWICE PER YEAR
(5) OTHER
(77) REFUSED
(99) DON’T KNOW

A2a. Does that include your Real Estate taxes and homeowner’s
insurance?
(1) YES  SKIP TO A3
(0) NO
(77) REFUSED
(99) DON’T KNOW

A3. (Are you/Is your household) required to pay condominium fees or
Home Owner’s Association fees for general maintenance or
management services?

A2b. How much do you pay for real estate taxes?
$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

(1) YES
(0) NO  SKIP TO A4
(77) REFUSED  SKIP TO A4
(99) DON’T KNOW  SKIP TO A4

ASK IF NECESSARY: Is that per month, per quarter, or per year?
(1) PER MONTH
(2) PER QUARTER
(3) PER YEAR
(4) TWICE PER YEAR
(5) OTHER
(77) REFUSED
(99) DON’T KNOW

A3a. How much do you pay for condominium fees?
$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW
ASK IF NECESSARY: Is that per month, per quarter, per year?
(1) PER MONTH
(2) PER QUARTER
(3) PER YEAR
(4) TWICE PER YEAR
(5) OTHER
(77) REFUSED
(99) DON’T KNOW
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A4. The next questions are about utility bills, telephone bills, and internet
expenses. Do you consider any portion of (your / your household’s)
utility, telephone, or internet expenses to be business expenses?

ENTER 'C' FOR A COMBINED EXPENSE
A5b. IF COMBINED EXPENSE (A5a=C), ASK: What was combined with
[UTILITY]? CHECK ALL THAT APPLY

(1) YES
(0) NO
(77) REFUSED
(99) DON’T KNOW

(4) BOTTLED OR TANK GAS
(1) ELECTRICITY
(3) FUEL OIL
(2) NATURAL OR UTILITY GAS
(5) OTHER FUELS INCLUDING WOOD
(6) PIPED-IN WATER
(7) SEWERAGE MAINTENANCE
(8) TRASH/GARBAGE COLLECTION
(9) WATER SOFTENING SERVICE
(10) SEPTIC TANK CLEANING
(11) NONE
(12) NO MORE ENTRIES

A5. In [LAST MONTH], (did you / did you or any members of your
household) receive any bills for any of the following utilities, fuels, or
services? Please remember to include any bills you receive or pay online
or have automatically deducted. Do not include bills for business
properties.
READ EACH ITEM ON LIST. CHECK ALL THAT APPLY
(1) Electricity
(2) Natural or utility gas
(3) Fuel oil
(4) Bottled or tank gas
(5) Other fuels including wood
(6) Piped-in water
(7) Sewerage maintenance
(8) Trash/garbage collection
(9) Water softening service
(10)Septic tank cleaning
(11)NONE
(12)NO MORE ENTRIES

A5c. IF A4=1, ASK: Is any part of that deducted as a business expense?
(1) YES
(0) NO  SKIP TO A6
(77) REFUSED  SKIP TO A6
(99) DON’T KNOW  SKIP TO A6
A5d. What percentage is deducted as a business expense?
|__|__|__| PERCENT OR $|__|__|__|.__|__| DOLLARS
(77) REFUSED
(99) DON’T KNOW

FOR EACH ITEM CHECKED ASK A5a – A5c
A5a. How much were you billed for [UTILITY] in [LAST MONTH]?
$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW
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A6. What types of telephone services (did you / did you or other members
of your household) have in [LAST MONTH]?

A6c. IF A4=1, ASK: Is any of that deducted as a business expense?
(1) YES
(0) NO  SKIP TO A7, IF NO CELL (A6≠1) SKIP TO A8
(77) REFUSED  SKIP TO A7, IF NO CELL (A6≠1) SKIP TO A8
(99) DON’T KNOW  SKIP TO A7, IF NO CELL (A6≠1) SKIP TO A8

CHECK ALL THAT APPLY
(1) Cell phone
(2) Landline
(3) Voice over Internet
(4) Pre-paid long distance telephone cards
(5) Pre-paid cell phone minutes
(77) REFUSED  SKIP TO A11
(99) DON’T KNOW  SKIP TO A11

A6d. What percentage is deducted?
|__|__|__| PERCENT
(77) REFUSED
(99) DON’T KNOW

A6a. ASK IF LANDLINE, ELSE SKIP TO A7: Does your bill for home
telephone service include any of the following?

IF CELL PHONE (A6=1) AND NO LANDLINE (A6≠2) ASK A7 OR IF A6a≠4

A7. Is your bill for cell phone service combined with any of the following?

CHECK ALL THAT APPLY

CHECK ALL THAT APPLY

(1) Internet access (including broadband, DSL, and dial-up)
(2) Cable or satellite television service
(3) Non-telephone rentals or purchases such as a modem
(4) ASK IF A6=1: Cell phone
(5) MISC. COMBINED (UNABLE TO SPECIFY/DON’T KNOW)
(6) NONE
(77) REFUSED
(99) DON’T KNOW

(1) Internet access (including broadband, DSL, and dial-up)
(2) Cable or satellite television service
(3) Non-telephone rentals or purchases such as a modem
(4) DO NOT USE
(5) MISC. COMBINED (UNABLE TO SPECIFY/DON’T KNOW)
(6) NONE
(77) REFUSED
(99) DON’T KNOW

A6b. How much were you billed in [LAST MONTH] for your home phone
(and cable/internet/cell phone/misc services)? Please remember
to include any bills you receive or pay online or have automatically
deducted. Do not include any unpaid charges from a previous
billing period. PROBE: Your best guess is fine.

A7a. How much were you billed in [LAST MONTH] for your cell phone
(and cable/internet/cell phone/misc services)? Please remember
to include any bills you receive or pay online or have automatically
deducted. Do not include any unpaid charges from a previous
billing period. PROBE: Your best guess is fine.

$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW
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A7b. IF A4=1, ASK: Is any of that deducted as a business expense?
A10a. How much were you billed in [LAST MONTH]? Do not include any
unpaid charges from a previous billing period. PROBE: Your best
guess is fine.

(1) YES
(0) NO  SKIP TO A8
(77) REFUSED  SKIP TO A8
(99) DON’T KNOW  SKIP TO A8

$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

A7c. What percentage is deducted?

A10.1 In [LAST MONTH], (did you / did you or any members of your
household) have any expenses for internet not already reported?

|__|__|__| PERCENT
(77) REFUSED
(99) DON’T KNOW

(1) YES
(0) NO  SKIP TO A11
(77) REFUSED  SKIP TO A11
(99) DON’T KNOW  SKIP TO A11

A8. ASK IF PREPAID CARDS (A6=4), ELSE SKIP TO A9: In [LAST MONTH], how
much did (you/your household) pay for pre-paid long distance
telephone cards/minutes?
$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

A10.1.a. How much were you billed in [LAST MONTH]? Do not include
any unpaid charges from a previous billing period. PROBE: Your
best guess is fine.
$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

A9. ASK IF PREPAID CELL PHONE (A6=5), ELSE SKIP TO A10: In [LAST
MONTH], how much did (you/your household) pay for pre-paid cell
phone minutes, not already reported?

A11. Now I am going to ask you some questions about health insurance and
medical expenses.

$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

(Do you/Does anyone in your household) pay for health insurance?
This includes health insurance that you buy on your own and health
insurance deducted from your paycheck. By health insurance, we
mean insurance that pays for a doctor’s services, hospital care, or
any other type of medical service.

A10. In [LAST MONTH], (did you / did you or any members of your
household) have any expenses for cable or satellite TV, not already
reported?
(1) YES
(0) NO  SKIP TO A11
(77) REFUSED  SKIP TO A11
(99) DON’T KNOW  SKIP TO A11

(1) YES
(0) NO  SKIP TO A12
(77) REFUSED  SKIP TO A12
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A12. In [LAST MONTH], (did you / did you or any members of your
household) make any payments for the following medical expenses?
We are asking about your out-of-pocket costs including insurance copays and deductibles. Do not include expenses paid for or reimbursed
by insurance. CHECK ALL THAT APPLY.

(99) DON’T KNOW  SKIP TO A12
A11a. How much is paid for health insurance?
$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

(1) Eye examinations, treatment, surgery, or purchase of eye glasses or
contact lenses
(2) Dental care
(3) Hospital room or hospital services
(4) Physician services or services by medical professionals other than
physicians
(5) Lab tests or x-rays
(6) Care in convalescent or nursing homes, or care for invalids,
convalescents, handicapped, or elderly persons in the home
(7) Adult day care centers
(8) Hearing aids
(9) Prescription drugs
(10) Rental or purchase of supportive or convalescent equipment
(11) Rental or purchase of medical or surgical equipment for general
use
(12) Other medical care and services
(0) NONE  SKIP TO A15

A11b. ASK IF NECESSARY: Is that weekly, every other week, two times
per month, once per month, annually or once per year?
(1) WEEKLY
(2) EVERY OTHER WEEK OR BI-WEEKLY
(3) TWO TIMES PER MONTH
(4) ONCE PER MONTH
(5) QUARTERLY
(6) TWICE PER YEAR
(7) ANNUALLY OR ONCE PER YEAR
(77) REFUSED
(99) DON’T KNOW

FOR EACH CHECKED ITEM:
A12a. What was the total amount that (you / your household) paid for
[CARE/SERVICE/ITEM] in [LAST MONTH]? PROBE: Your best guess
is fine.
$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

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A14. (Do you/Does anyone in your household) pay court ordered Child
Support?

ASK A13 IF HOUSEHOLD CONTAINS A CHILD UNDER AGE 12, ELSE GO TO A14
A13. (Do you/Does anyone in your household) pay for child care? This
includes child care centers, family day care homes, and after-school
programs.

(1) YES
(0) NO  SKIP TO A15
(77) REFUSED  SKIP TO A15
(99) DON’T KNOW  SKIP TO A15

(1) YES
(0) NO  SKIP TO A14
(77) REFUSED  SKIP TO A14
(99) DON’T KNOW  SKIP TO A14

A14a. How much is paid for child support?
$|__|__|__|__|.|__|__|
(77) REFUSED  SKIP TO A15
(99) DON’T KNOW  SKIP TO A15

A13a. How much is paid for child care?
$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

A14b. ASK IF NECESSARY: Is that weekly, every other week, two times
per month, once per month, annually or once per year?

A13b. ASK IF NECESSARY: Is that weekly, every other week, two times
per month, once per month, annually or once per year?

(1) WEEKLY
(2) EVERY OTHER WEEK OR BI-WEEKLY
(3) TWO TIMES PER MONTH
(4) ONCE PER MONTH
(5) QUARTERLY
(6) TWICE PER YEAR
(7) ANNUALLY OR ONCE PER YEAR
(8) WHEN I CAN
(77) REFUSED
(99) DON’T KNOW

(1) WEEKLY
(2) EVERY OTHER WEEK OR BI-WEEKLY
(3) TWO TIMES PER MONTH
(4) ONCE PER MONTH
(5) QUARTERLY
(6) TWICE PER YEAR
(7) ANNUALLY OR ONCE PER YEAR
(77) REFUSED
(99) DON’T KNOW

Now I am going to ask about education expenses. Please include any
payments made by you or a member of your household. Include payments
you made online or had automatically deducted.

A13c. (Do you/Does anyone in your household) pay for child care so
that someone in your household can work, look for work, or
attend a training program?
(1) YES
(0) NO  SKIP TO A14
(77) REFUSED  SKIP TO A14
(99) DON’T KNOW  SKIP TO A14

A15. Did (you / anyone in your household) have educational expenses in the
past 12 months?
(1) YES
(0) NO  SKIP TO A17
(77) REFUSED  SKIP TO A17
(99) DON’T KNOW  SKIP TO A17
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A16b. IF COMBINED EXPENSE (A16a = C), ASK: What was combined
with that education expense? CHECK ALL THAT APPLY
(3) FOOD OR BOARD WHILE ATTENDING SCHOOL
(2) HOUSING WHILE ATTENDING SCHOOL
(7) OTHER SCHOOL RELATED EXPENSES NOT ALREADY REPORTED
(4) PRIVATE SCHOOL BUS SERVICE
(6) PURCHASE OF SCHOOL BOOKS, SUPPLIES, OR EQUIPMENT
WHICH HAS NOT (ALREADY BEEN REPORTED
(5) TEST PREPARATION OR TUTORING SERVICES
(1) TUITION
(0) NO MORE ENTRIES
(66) MISC COMBINED (UNABLE TO SPECIFY/DON’T KNOW)
(77) REFUSED
(99) DON’T KNOW

A16. Thinking about these education expenses,
in the past 12 months, (did you / did you or any members of your
household) pay for any of these expenses:
CHECK ALL THAT APPLY.
(1) Tuition for elementary through high school, college, or vocational
school?
(2) Housing while attending school?
(3) Food or board while attending school?
(4) Private school bus service?
(5) Test preparation or tutoring services?
(6) Purchase of school books, supplies, or equipment?
(7) Other school related expenses?
(0) NONE OF THESE  SKIP TO A17
(77) REFUSED  SKIP TO A17
(99) DON’T KNOW  SKIP TO A17

A17. In the past 12 months, did (you/any member of your household) pay
for season passes or membership in …CHECK ALL THAT APPLY.
(1) Health clubs, fitness centers, or gyms?
(2) Swimming pools?
(3) Golf courses or tennis clubs?
(4) Ski areas?
(5) Weight loss centers?
(6) Little League, Pop Warner, or other youth sports teams?
(7) Other sports and recreational organizations?
(0) NONE  SKIP TO A18
(77) REFUSED  SKIP TO A18
(99) DON’T KNOW  SKIP TO A18

FOR EACH CHECKED ITEM IN A16 ASK:
A16a. How much was paid for [EDUCATION EXPENSE] in the past 12
months? Do not include expenses that will be reimbursed.
$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW
ENTER 'C' FOR A COMBINED EXPENSE

FOR EACH ITEM CHECKED IN A17:
A17a. What was the total cost for [MEMBERSHIP] in the past 12
months?
$|__|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW
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A20. How much (do you/does your household) pay in car/truck payments
for [YEAR] [MAKE] [MODEL]?

A18. How many cars, trucks, minivans, vans or SUVs (do you/ does your
household) have? Do not include vehicles used entirely for business.

$|__|__|__|__|.|__|__|

|__|__| NUMBER
(0) NONE  SKIP TO A26
(77) REFUSED  SKIP TO A26
(99) DON’T KNOW  SKIP TO A26

(77) REFUSED
(99) DON’T KNOW
A20a. ASK IF NECESSARY: What period is covered by each payment?

A18a. What are the years, makes, and models of each vehicle?
# Year

Make

(0) WEEK
(1) 2 WEEKS
(2) MONTH
(3) QUARTER
(4) SEMIANNUALLY
(5) ANNUALLY
(6) ONE TIME PAYMENT
(7) OTHER, SPECIFY: _______________________
(77) REFUSED
(99) DON’T KNOW

Model

1
2
3
(77) REFUSED
(99) DON’T KNOW
FOR EACH VEHICLE ASK:
A19. (Do you/Does your household) own or lease the [YEAR] [MAKE]
[MODEL]?

ASK IF A17 = 0, 77, 99
A21. (Do you / Does your household) have any automobile expenses?
(1) YES
(0) NO  SKIP TO A26
(77) REFUSED  SKIP TO A26
(99) DON’T KNOW  SKIP TO A26

(1) OWN
(2) LEASE SKIP TO A20
(77) REFUSED
(99) DON’T KNOW

A22. What is (your / your household’s) average monthly expense for
gasoline and other fuels (including gasohol) for all vehicles?

A19a. How much is owed on [YEAR] [MAKE] [MODEL]?
$|__|__|__|__|.|__|__|
(0) NOTHING SKIP TO A22
(77) REFUSED
(99) DON’T KNOW

$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

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A25. In [LAST MONTH], did (you/you or any member of your household)
have expenses for local tolls or electronic toll passes? Do not include
tolls incurred on a vacation trip, or business expenses that will be
reimbursed or deducted.

A22a. If A4 = 1, ASK, What percentage of that is counted as a business
expense?
|__|__|__| PERCENT
(77) REFUSED
(99) DON’T KNOW

(1) YES
(0) NO SKIP TO B1
(77) REFUSED  SKIP TO B1
(99) DON’T KNOW SKIP TO B1

A23. What is (your / your household’s) average monthly expense for
automobile insurance? Do not include insurance paid on vehicles used
for a business.

A25a. How much was paid for tolls in [LAST MONTH]?

$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

A24. In [LAST MONTH], did (you/you or any member of your household)
have expenses for parking, such as parking meters, garage rental or
parking lot fees? Do not include expenses that are part of your home
ownership or rental costs, or business expenses that will be reimbursed
or deducted.

A26. What is (your / your household’s) average monthly expense for public
transportation?

(1) YES
(0) NO SKIP TO A25
(77) REFUSED  SKIP TO A25
(99) DON’T KNOW SKIP TO A25

$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

A24a. How much was paid for parking in [LAST MONTH]?
$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

SECTION B. EARNED INCOME
IF HH SIZE = 1
The next questions are about the types of income you receive.
[SIPP]CONFIRM LIST OF HH MEMBERS WORKING FOR PAY, IF NONE, SKIP
TO B5.
IF HH SIZE > 1
The next questions are about the types of income received by all
members of your household. Earlier this week you told us who in your
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household is working for pay. [SIPP]CONFIRM LIST OF HH MEMBERS
WORKING FOR PAY, IF NONE, SKIP TO B5.

B3. How often (are you/is NAME) paid from your (first/second/third)
job?
(1) DAILY
(2) WEEKLY
(3) EVERY OTHER WEEK OR BI-WEEKLY
(4) TWO TIMES PER MONTH
(5) MONTHLY
(6) OTHER, SPECIFY
(77) REFUSED
(99) DON’T KNOW

ASK B1-B4 FOR EACH EMPLOYED HOUSEHOLD MEMBER AGE 16 AND OLDER, THEN
1
GO TO NEXT PERSON.
IF NO EMPLOYED PERSONS, BEGIN WITH B5.

B1. How many jobs (do you/does NAME) work for pay?
(1) ONE
(2) TWO
(3) THREE
(77) REFUSED
(99) DON’T KNOW

B4. What is the amount of pay that (you/NAME) get per check from
your (first/second/third) job before taxes and any deductions?
PROBE: Your best estimate is fine.

FOR EACH JOB ASK:

$|__|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

B2. How many hours (do you/does NAME) usually work per week or per
month at your (first/second/third) job?

REPEAT B1 TO B4 FOR EACH EMPLOYED PERSON IN HOUSEHOLD.

JOB #1: |__|__|__| HOURS
(1) PER WEEK
(2) PER MONTH
(77) REFUSED
(99) DON’T KNOW
INTERVIEWER: ROUND UP TO WHOLE NUMBER.

1

Age cutoff used by SIPP.

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B5. For the following types of income, just tell me yes or no, did (you /
anyone in your household) receive income from any of the
following in [LAST MONTH]? CHECK ALL THAT APPLY.

SECTION C. UNEARNED INCOME
C1. I have another list of income sources. Again, just tell me yes or no,
did (you / anyone in your household) receive income from any of
the following in [LAST MONTH]? CHECK ALL THAT APPLY

(1) Rental properties?
(2) Roomers or boarders?
(3) Job training, work study, or internship?
(4) Strike benefits?
(5) Workers’ compensation?
(6) Unemployment compensation?
(0) NONE
(77) REFUSED
(99) DON’T KNOW

(1) Social Security Retirement Benefits (SSA)
(2) Social Security Disability Benefits also known as SSDI
(3) Supplemental Security Income or SSI
(4) Temporary Assistance for Needy Families (TANF/STATE NAME)
(5) General Assistance, General Relief, or the GA program
(6) Veteran’s benefits or military allotments
(7) Black Lung Benefits
(8) Child support
(9) Alimony
(10)Foster Care
(11)Pensions, civil service annuities, retirement benefits, survivor’s
benefits, or Railroad Retirement Benefits
(12)Interest, dividends, or capital gains income
(13)Money from a person who is not in your household (not
alimony or child support)
(14)Educational grants, loans, or stipends
(0) NONE SKIP TO C2
(77) REFUSED SKIP TO C2
(99) DON’T KNOW SKIP TO C2

FOR EACH INCOME REPORTED IN B5, ASK:
B5a. How much was received from [INCOME] in [LAST MONTH]?
$|__|__|__|__|__|.|__|__|
(77) REFUSED  SKIP TO B6
(99) DON’T KNOW  SKIP TO B6
B5b. ASK IF NECESSARY: Was that weekly, every other week, two times per
month, or monthly?
(1) DAILY
(2) WEEKLY
(3) EVERY OTHER WEEK OR BI-WEEKLY
(4) TWO TIMES PER MONTH
(5) MONTHLY
(77) REFUSED
(99) DON’T KNOW

C1a. FOR EACH INCOME REPORTED IN C1, ASK: How much was
received from [INCOME] in [LAST MONTH]?
$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW
ENTER ‘C’ FOR A COMBINED INCOME
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C2. (Did you/Did anyone in your household) receive fuel assistance in
the past 12 months such as LIHEAP?

C1b. ASK IF NECESSARY: Was that weekly, every other week, two times per
month, or monthly?

(1) YES
(0) NO  SKIP TO C3
(77) REFUSED  SKIP TO C3
(99) DON’T KNOW  SKIP TO C3

(1) WEEKLY
(2) EVERY OTHER WEEK OR BI-WEEKLY
(3) TWO TIMES PER MONTH
(4) MONTHLY
(5) QUARTERLY
(77) REFUSED
(99) DON’T KNOW

C2a. How much was received in fuel assistance in the past 12 months?
$|__|__|,__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

C1c. IF COMBINED INCOME (C1a=C), ASK: What was combined with that source
of income? CHECK ALL THAT APPLY

C3. In the past 12 months, did (you/anyone in your household) receive
money from… CHECK ALL THAT APPLY

(1) SOCIAL SECURITY RETIREMENT BENEFITS (SSA)
(2) SOCIAL SECURITY DISABILITY BENEFITS ALSO KNOWN AS SSDI
(3) SUPPLEMENTAL SECURITY INCOME OR SSI
(4) TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF/STATE NAME)
(5) GENERAL ASSISTANCE, GENERAL RELIEF, OR THE GA PROGRAM
(6) VETERAN’S BENEFITS OR MILITARY ALLOTMENTS
(7) BLACK LUNG BENEFITS
(8) CHILD SUPPORT
(9) ALIMONY
(10) FOSTER CARE
(11) PENSIONS, CIVIL SERVICE ANNUITIES, RETIREMENT BENEFITS,
SURVIVOR’S BENEFITS, OR RAILROAD RETIREMENT BENEFITS
(12) INTEREST, DIVIDENDS, OR CAPITAL GAINS INCOME
(13) MONEY FROM A PERSON WHO IS NOT IN YOUR HOUSEHOLD (NOT
ALIMONY OR CHILD SUPPORT)
(14) EDUCATIONAL GRANTS, LOANS, OR STIPENDS
(0) NONE  SKIP TO C2
(77) REFUSED  SKIP TO C2
(99) DON’T KNOW  SKIP TO C2

(1) an insurance settlement
(2) refund of security deposit
(3) lottery winning
(4) trust fund payment
(5) bonus
(0) NONE SKIP TO C4
(77) REFUSED  SKIP TO C4
(99) DON’T KNOW  SKIP TO C4

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C5. IF HOUSEHOLD INCOME >0: Let me make sure that the information
I have about (your / your household) income sources is correct. I
have recorded: [LIST OF INCOME SOURCES]. Is this correct?

ASK C3a FOR EACH SOURCE REPORTED IN C3
C3a. How much was received from [SOURCE] in the past 12 months?
$|__,|__|__|__|,__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

(1) YES  SKIP TO C6
(0) NO
(77) REFUSED  SKIP TO C6
(99) DON’T KNOW  SKIP TO C6

C4. ASK IF NO INCOME REPORTED FOR HOUSEHOLD: Let me make sure
that the information I have is correct. I have not recorded any
sources of income for (you / your household) in [LAST MONTH]. Did
(you / your household) receive any income at all – any financial help
from someone outside the household, any cash or other assistance
from a welfare-type program, any part-time or odd jobs, or anything
else?

C5a. ASK IF NECESSARY: Which ones should not be on the list?
CHECK ALL THAT APPLY ON THE LIST OF INCOME SOURCES
C6. Is anything missing? Did (you / you or anyone in your household)
have any other income sources, such as help from someone outside
this household, from the government or military, from any kind of
work, or from any other source outside this household?

(1) YES
(0) NO  SKIP TO D1
(77) REFUSED  SKIP TO D1
(99) DON’T KNOW  SKIP TO D1

PROBE: It is extremely important to get a complete listing of all income
sources.

C4a. What kind of income? Anything else?
C6a. What kind of income? Anything else?

CHECK ALL THAT APPLY FROM EARNED AND UNEARNED
INCOME LISTS [CAPI WILL DISPLAY LIST OF INCOME SOURCES
FROM SECTIONS B AND C]

CHECK ALL THAT APPLY
[CAPI WILL DISPLAY LIST OF INCOME SOURCES FROM SECTIONS
B AND C]

C4b. How much was received from [INCOME SOURCE] in [LAST
MONTH]?
$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

C6b. How much was received from [INCOME SOURCE] in LAST
MONTH?
$|__|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

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D2. ASK FOR EACH HOUSEHOLD MEMBER AGE 16 AND OLDER, THEN
SKIP TO CLOSE: (Do you / Does [NAME]) have money in a checking
or savings account?

SECTION D. ASSETS
The next set of questions is about (your / your household’s) resources or
assets. These include things (you / you or other people in your household)
may own, as well as money you may have saved. This information will help
us better understand the experiences of different groups of people across
the country.

(1) YES
(2) YES, JOINT ACCOUNT ALREADY REPORTED  SKIP TO NEXT PERSON
(0) NO  SKIP TO NEXT PERSON
(77) REFUSED  SKIP TO NEXT PERSON
(99) DON’T KNOW  SKIP TO NEXT PERSON

D1. Do (you/you or anyone in your household) own any of the following
assets? Do you own any . . . (CHECK ALL THAT APPLY)

D2a. What is the total amount that (you / [NAME]) has in checking and
savings accounts?
$|__||__|,|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

(1) Stocks
(2) Bonds
(3) Mutual Funds
(4) Trust Funds
(5) Real Estate other than your primary home
(6) Annuities
(7) Certificates of Deposit (CD)
(8) Other asset worth more than $1,000
(0) NONE SKIP TO D2
(77) REFUSED
(99) DON’T KNOW

SECTION E. LIFE EVENTS
My final questions are about major life events.
E1. Has there been a change in the number of people living in your
household over the past 12 months?
(1) YES
(0) NO  SKIP TO E2
(77) REFUSED  SKIP TO E2
(99) DON’T KNOW  SKIP TO E2

ASK IF HH SIZE > 1, ELSE SKIP D1b.
D1a. FOR EACH TYPE OF ASSET CHECKED IN D3: Who owns [TYPE OF
ASSET]?
CHECK NAME ON ROSTER

E1a. What caused that change? CHECK ALL THAT APPLY.
D1b. What is the dollar value of [TYPE OF ASSET] owned by [you /
NAME]?
PROBE: Your best guess is fine.

(1) BIRTH OF CHILD
(2) NEW STEP, FOSTER OR ADOPTED CHILD
(3) SEPARATION OR DIVORCE
(4) DEATH OF HOUSEHOLD MEMBER
(5) MARRIAGE
(6) NEW PARTNER
(7) OTHER, SPECIFY
(77) REFUSED
(99) DON’T KNOW

$|__|,|__|__||__|,|__|__|__|.|__|__|
(77) REFUSED
(99) DON’T KNOW

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Those are all the questions for this interview. Thank you for the
time you spent answering them.

E2. (Have you or anyone in your / Has anyone in your household or) family
been diagnosed with a major illness or disability in the past 12
months?
(1) YES
(0) NO  SKIP TO E3
(77) REFUSED  SKIP TO E3
(99) DON’T KNOW  SKIP TO E3
SKIP IF HH SIZE = 1
E2a. Was that someone in your household or someone outside your
household?
(1) HOUSEHOLD MEMBER
(2) OUTSIDE HOUSEHOLD
(77) REFUSED
(99) DON’T KNOW
E3. (Have you / Has anyone in your household) changed jobs in the past
12 months?
(1) YES
(0) NO  SKIP TO END
(77) REFUSED  SKIP TO END
(99) DON’T KNOW  SKIP TO END
SKIP IF HH SIZE = 1
E3a. Who was that?
CHECK NAME(S) ON ROSTER. IF ANY NAMES ARE CURRENTLY
EMPLOYED, ASK E3b. ELSE SKIP TO END.
E3b. (Do you/Does NAME) now earn more, less, or about the same as
before changing jobs?
(1) MORE
(2) LESS
(3) ABOUT THE SAME
(77) REFUSED
(99) DON’T KNOW
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