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pdfAppendix C.
Follow Up Survey Instrument
OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
Evaluation of the Rapid Re-Housing for Families Demonstration Program Follow up Survey—
DRAFT
INTRODUCTION............................................................................................................................... 1
SECTION A. HOUSEHOLD COMPOSITION.................................................................................... 2
SECTION B. CURRENT HOUSING ................................................................................................. 9
SECTION C. INCOME AND EMPLOYMENT.................................................................................. 14
SECTION D. HOUSING COSTS ..................................................................................................... 18
SECTION E. HOUSING BARRIERS ............................................................................................... 21
SECTION F. EDUCATION ............................................................................................................. 22
SECTION G. FOOD SECURITY/HUNGER..................................................................................... 23
SECTION H. FAMILY WELL-BEING.............................................................................................. 24
SECTION I. HEALTH ...................................................................................................................... 27
SECTION J. CLOSING ................................................................................................................... 28
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
C-i
OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
INTRODUCTION
Hi, my name is ______________. I am calling from Abt Associates Inc., a research firm
based in Massachusetts. You may remember that while you were enrolled in [Program Name], you
were told that HUD was studying the type of assistance you were receiving, sometimes referred to as
Rapid Rehousing. At the time, you agreed to participate in the study and you were told that someone
would be contacting you a year after you left the program to hear about how things have been going
for you. HUD is very interested in how the Rapid Rehousing Program may have helped you deal with
the situation you were in. I am calling to ask you some questions about your situation since you left
___________ [Program Name] in [Month/Year of Program Exit].
I’d like to remind you that your participation is completely voluntary, and all of your answers
will be kept confidential. Nothing you say can be traced back to you, nor can your participation affect
any housing subsidy you may be receiving. Your name will never be linked to your answers.
If you are still willing to participate in the interview, I’ll ask you a series of questions about
who lives with you, your neighborhood, housing, employment, and health. Your participation in this
study will help HUD to improve programs for families like yours across the country. At the end of your
interview, we will verify your address so we can send you $25 for your participation.
Intro Q1.
Is it okay to proceed with the interview? It will take about 25 minutes.
YES ................................................................................................ 1
THIS IS NOT A GOOD TIME........................................................... 2
[End Interview and reschedule for another time.]
NOT INTERESTED ........................................................................ 3
[End Interview, and thank person for their time.]
Thank you for agreeing to continue with the interview. I’d like to start by asking you about the people in
your family. First, I’ll ask you about people in your family who live with you now. Then, I will ask about
those who are part of your family but do not live with you now.
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
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OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
SECTION A. HOUSEHOLD COMPOSITION
A1.
How many adults, that is, people who are 18 years old or older, in your family are living with
you right now?
NUMBER OF ADULTS........................................... ______________
REFUSED...................................................................................... -2
DON’T KNOW ................................................................................ -1
CAPI: IF GREATER THAN 0 GO TO A1a; ELSE SKIP TO A2
A1a.
Please tell me the first names of the adults in your family who live with you right
now. Do not include yourself. By adult, I mean people who are 18 years old or
older.
A1a1.
A1a2.
CAPI: LOOP UNTIL NAMES COLLECTED FOR NUMBER OF ADULTS REPORTED IN A1a
A2.
How many children in your family are living with you right now? By children I mean
people 17 years old or younger.
NUMBER OF CHILDREN....................................... ______________
REFUSED...................................................................................... -2
DON’T KNOW ................................................................................ -1
CAPI: IF GREATER THAN 0 GO TO A2a; ELSE SKIP TO A3
A2a.
Please tell me the first names of the children in your family who live with you right
now. By children I mean people 17 years old or younger.
A2a1.
A2a2.
A2a3.
CAPI: LOOP UNTIL NAMES COLLECTED FOR NUMBER OF CHILDREN REPORTED IN A2
A3.
Do you have a spouse, partner, or significant other who is not living with you right now?
YES ................................................................................................ 1
NO .................................................................................................. 2
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
CAPI: IF “YES” GO TO A3a; ELSE GO TO A4.
A3a.
What is the first name of your spouse/partner/significant other who is part of your
family but is not living with you right now?
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
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OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
NAME____________________________________________________
(spouse or partner who is part of family but not living with Respondent right now)
A4.
Do you have any of your own children who are part of your family but are not living with you
right now? By children I mean people 17 years old or younger. Please do not include
children 18 years old or older.
YES ................................................................................................ 1
NO .................................................................................................. 2
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
CAPI: IF “YES” GO TO A4a; ELSE SKIP TO A5
A4a.
How many of your own children are not living with you now? By children I mean
people 17 years old or younger. Please do not include children 18 years old or
older.
NUMBER OF CHILDREN
______________
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
CAPI: IF GREATER THAN 0 GO TO A4b; ELSE SKIP TO A5
A4b.
Now, can you please tell the first name(s) of any of your children who are part of your
family but are not living with you right now. By children I mean people 17 years
old or younger. Please do not include children 18 years old or older. Do not
include yourself.
A4b1.
A4b2.
A4b3.
CAPI: LOOP UNTIL NAMES COLLECTED FOR NUMBER OF CHILDREN REPORTED IN A4a
A5.
Has your household remained the same during the past year, that is, are all the people who
lived with you were getting help from the RRHP [PROGRAM NAME] last year, living with you
now?
YES ................................................................................................ 1
NO .................................................................................................. 2
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
CAPI: IF “NO” GO TO A5a; ELSE SKIP TO A6
A5a.
Please describe the change in your household composition since last
year: (CIRCLE ALL THAT APPLY)
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
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OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
GOT MARRIED/PARTNER MOVED IN ........................................... 1
GOT DIVORCED/SEPARATED/PARTNER MOVED OUT ............... 2
MOVED INTO HOUSE OF FAMILY OR FRIEND............................. 3
MOVED OUT OF HOUSE THAT YOU PREVIOUSLY SHARED
WITH ANOTHER FAMILY OR FRIEND ........................................... 4
HAD A BABY .................................................................................. 5
BROUGHT BACK CHILD(REN) WHO HAD BEEN LIVING OUTSIDE
THE HOME ..................................................................................... 6
CHILD(REN) WHO HAD BEEN LIVING WITH RESPONDENT LEFT
THE HOME ..................................................................................... 7
SOMEONE IN THE HOUSEHOLD DIED ........................................ .8
SOMEONE IN THE HOUSEHOLD MOVED TO AN INSTITUTIONAL
SETTING ........................................................................................ 9
OTHER (SPECIFY ________________________)........................ 10
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
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OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
Now, I would like to ask you some questions about you and the family members who are living with you now. Let’s start with you and then move to the
adult(s) with you. [COMPLETE THE ROSTER FIRST FOR RESPONDENT, THEN FOR FAMILY MEMBERS LIVING IN CURRENT UNIT. CAPI WILL
INCLUDE A CHECK THAT EVERYONE NAMED IN A1a AND A2a IS ASKED ABOUT IN ROSTER. MORE COLUMNS WILL BE ADDED AS
NEEDED. SKIP ADULTS IF A1 = 0 AND SKIP CHILDREN IF A2 = 0]
RESPONDENT
ADULT FAMILY MEMBER 1 (A1a1)
CHILD FAMILY MEMBER 2 (A2a1)
CHILD FAMILY MEMBER 3 (A2a2)
MALE............................................... 1
FEMALE.......................................... 2
DON’T KNOW................................ -1
REFUSED ...................................... -2
____ years old
DON’T KNOW................................ -1
REFUSED
-2
HUSBAND OR WIFE ..................... 1
LOVER/PARTNER ......................... 2
CHILD .............................................. 3
STEP-CHILD .................................. 4
FOSTER CHILD ............................. 5
CHILD OF LOVER/PARTNER ...... 6
SON- OR
DAUGHTER-IN-LAW ..................... 7
MOTHER OR FATHER.................. 8
STEP-PARENT............................... 9
MOTHER- OR FATHER-IN-LAW
OR PARTNER'S PARENT...........10
GRANDPARENT ..........................11
BROTHER OR SISTER ...............12
BROTHER- OR
SISTER-IN-LAW ...........................13
GRANDCHILD ..............................14
OTHER RELATIVE.......................15
DON’T KNOW................................-1
REFUSED ......................................-2
MALE............................................... 1
FEMALE .......................................... 2
DON’T KNOW................................-1
REFUSED ......................................-2
____ years old
DON’T KNOW................................-1
REFUSED
-2
HUSBAND OR WIFE......................1
LOVER/PARTNER .........................2
CHILD ..............................................3
STEP-CHILD ..................................4
FOSTER CHILD..............................5
CHILD OF LOVER/PARTNER.......6
SON- OR
DAUGHTER-IN-LAW......................7
MOTHER OR FATHER ..................8
STEP-PARENT ...............................9
MOTHER- OR FATHER-IN-LAW
OR PARTNER'S PARENT ...........10
GRANDPARENT ..........................11
BROTHER OR SISTER ...............12
BROTHER- OR
SISTER-IN-LAW ...........................13
GRANDCHILD ..............................14
OTHER RELATIVE.......................15
DON’T KNOW ................................-1
REFUSED ......................................-2
MALE ...............................................1
FEMALE ..........................................2
DON’T KNOW ................................-1
REFUSED ......................................-2
____ years old
DON’T KNOW ................................-1
REFUSED
-2
HUSBAND OR WIFE ......................1
LOVER/PARTNER..........................2
CHILD ..............................................3
STEP-CHILD ..................................4
FOSTER CHILD ..............................5
CHILD OF LOVER/PARTNER .......6
SON- OR
DAUGHTER-IN-LAW ......................7
MOTHER OR FATHER ..................8
STEP-PARENT ...............................9
MOTHER- OR FATHER-IN-LAW
OR PARTNER'S PARENT .......... 10
GRANDPARENT.......................... 11
BROTHER OR SISTER............... 12
BROTHER- OR
SISTER-IN-LAW........................... 13
GRANDCHILD.............................. 14
OTHER RELATIVE ...................... 15
DON’T KNOW ............................... -1
REFUSED...................................... -2
MALE ...............................................1
FEMALE...........................................2
DON’T KNOW ............................... -1
REFUSED...................................... -2
____ years old
DON’T KNOW ............................... -1
REFUSED
-2
A6. What is [A1a1/A2a1]’s
relationship to you?
A7. Is [R/A1a1/A2a1] male
or female?
A8. What is
[R/A1a1/A2a1]’s Age
right now?
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
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OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
A9. Does [R/A1a1/A2a1]
have any disabilities
that require any special
housing features such
as wheelchair access?
A10. ASK IF [A2a1] IS 15
OR UNDER: Was there
any time in the past
year when [CHILD] did
not live with you?
A11. ASK IF [A2a1] IS 15
OR UNDER:
Please tell me all of the
different places that
[A2a1] has lived when
s/he did not live with
you. Did [A2a1] live …
[MARK ALL THAT
APPLY.]
A12. ASK IF [A2a1] IS 5
YEARS OLD OR
OLDER. Did [A2a1]
attend school during
the school year? Is
[A2a1] currently
attending school?
RESPONDENT
ADULT FAMILY MEMBER 1 (A1a1)
CHILD FAMILY MEMBER 2 (A2a1)
CHILD FAMILY MEMBER 3 (A2a2)
YES ................................................. 1
NO ................................................... 2
DON’T KNOW................................ -1
REFUSED ...................................... -2
YES.................................................. 1
NO.................................................... 2
DON’T KNOW................................-1
REFUSED ......................................-2
YES..................................................1
NO....................................................2
DON’T KNOW ................................-1
REFUSED ......................................-2
YES ..................................................1
NO ....................................................2
DON’T KNOW ............................... -1
REFUSED...................................... -2
YES..................................................1
NO....................................................2
DON’T KNOW ................................-1
REFUSED ......................................-2
YES ..................................................1
NO ....................................................2
DON’T KNOW ............................... -1
REFUSED...................................... -2
With his/her other parent ................1
With your Own parents or
in-laws.............................................2
With other relatives .........................3
In foster care ...................................4
How long in foster care?
________months/days
With his/her other parent ................1
With your Own parents or
in-laws.............................................2
With other relatives .........................3
In foster care....................................4
How long in foster care?
________months//days
Other: ______________ ................5
DON’T KNOW ................................-1
REFUSED ......................................-2
YES..................................................1
NO....................................................2
DON’T KNOW ................................-1
REFUSED ......................................-2
Other: ______________.................5
DON’T KNOW ............................... -1
REFUSED...................................... -2
YES ..................................................1
NO ....................................................2
DON’T KNOW ............................... -1
REFUSED...................................... -2
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
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OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
Now I’d like to ask you about your spouse/partner/significant other OR children who are part of your family but who are not with you now. [Next,
complete the roster for people mentioned in A3 and A4b, spouse/partner/significant other OR children who R considers part of the family but
who are not living with R. MORE COLUMNS WILL BE ADDED AS NEEDED. SKIP ADULTS IF A3 = “NO” AND SKIP CHILDREN IF A4A = 0]
A13. What is [A3a/A4b1’s]
relationship to you?
A14. Is [A3a/A4b1] male or
female?
A15. What is [A3a/A4b1]’s
age right now?
A16. Does [A3a/A4b1] have
any disabilities that
require any special
housing features such
as wheelchair access?
A17. ASK IF [A4b1] IS 15
OR UNDER: How long
has it been since
[A5b1] lived with you?
FAMILY MEMBER 5 (A3)
FAMILY MEMBER 6 (A4b1)
FAMILY MEMBER 7 (A4b2)
FAMILY MEMBER 8 (A4b3)
HUSBAND OR WIFE ..................... 1
LOVER/PARTNER ......................... 2
CHILD.............................................. 3
STEP-CHILD ................................. 4
FOSTER CHILD ............................. 5
CHILD OF LOVER/PARTNER ...... 6
DON’T KNOW................................ -1
REFUSED ...................................... -2
MALE............................................... 1
FEMALE.......................................... 2
DON’T KNOW................................ -1
REFUSED ...................................... -2
___ years old
DON’T KNOW................................ -1
REFUSED
-2
YES ................................................. 1
NO ................................................... 2
DON’T KNOW................................ -1
REFUSED ...................................... -2
HUSBAND OR WIFE ..................... 1
LOVER/PARTNER ......................... 2
CHILD .............................................. 3
STEP-CHILD .................................. 4
FOSTER CHILD ............................. 5
CHILD OF LOVER/PARTNER ...... 6
DON’T KNOW................................-1
REFUSED ......................................-2
MALE............................................... 1
FEMALE .......................................... 2
DON’T KNOW................................-1
REFUSED ......................................-2
___ years old
DON’T KNOW................................-1
REFUSED
-2
YES.................................................. 1
NO.................................................... 2
DON’T KNOW................................-1
REFUSED ......................................-2
HUSBAND OR WIFE......................1
LOVER/PARTNER..........................2
CHILD ..............................................3
STEP-CHILD ..................................4
FOSTER CHILD..............................5
CHILD OF LOVER/PARTNER.......6
DON’T KNOW ................................-1
REFUSED ......................................-2
MALE ...............................................1
FEMALE ..........................................2
DON’T KNOW ................................-1
REFUSED ......................................-2
___ years old
DON’T KNOW ................................-1
REFUSED
-2
YES ..................................................1
NO....................................................2
DON’T KNOW ................................-1
REFUSED ......................................-2
HUSBAND OR WIFE ......................1
LOVER/PARTNER..........................2
CHILD ..............................................3
STEP-CHILD ..................................4
FOSTER CHILD ..............................5
CHILD OF LOVER/PARTNER .......6
DON’T KNOW ............................... -1
REFUSED...................................... -2
MALE................................................1
FEMALE...........................................2
DON’T KNOW ............................... -1
REFUSED...................................... -2
___ years old
DON’T KNOW ............................... -1
REFUSED
-2
YES ..................................................1
NO ....................................................2
DON’T KNOW ............................... -1
REFUSED...................................... -2
_______ Year(s)
______ Month(s)
DON’T KNOW................................-1
REFUSED
-2
[A5b1] has never lived with R .......-3
_______ Year(s)
______ Month(s)
DON’T KNOW ................................-1
REFUSED
-2
[A5b2] has never lived with R .......-3
_______ Year(s)
______ Month(s)
DON’T KNOW ............................... -1
REFUSED
-2
[A5b3] has never lived with R....... -3
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
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OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
FAMILY MEMBER 5 (A3)
A18. ASK IF [A3a/A4b1] IS
15 OR UNDER:
Please tell where the
[A3a/A4b1] is currently
living, while not with
you.
A19. ASK IF [A3a/A4b1] IS
15 OR UNDER. Have
you done anything to
try to get [A3a/A4b1] to
move back in with you?
A20. ASK IF [A3a/A4b1] IS
15 OR UNDER:
What would you say
has been the total
amount of time
[A3a/A4b1] has spent
living apart from you?
FAMILY MEMBER 6 (A4b1)
FAMILY MEMBER 7 (A4b2)
FAMILY MEMBER 8 (A4b3)
With his/her other parent................ 1
With your own parents or
in-laws ............................................ 2
With other relatives......................... 3
In foster care ................................... 4
How long has [E5a2] been in
foster care?
________months/years/days
With his/her other parent ................1
With your own parents or
in-laws.............................................2
With other relatives .........................3
In foster care ...................................4
How long has [E5a3] been in
foster care?
________months/years/days
With his/her other parent ................1
With your own parents or
in-laws .............................................2
With other relatives .........................3
In foster care....................................4
How long has [E5a4] been in
foster care?
________months/years/days
Other: ______________ ................ 5
YES.................................................. 1
NO.................................................... 2
DON’T KNOW................................-1
REFUSED ......................................-2
Other: ______________ ................5
YES ..................................................1
NO....................................................2
DON’T KNOW ................................-1
REFUSED ......................................-2
Other: ______________.................5
YES ..................................................1
NO ....................................................2
DON’T KNOW ............................... -1
REFUSED...................................... -2
_______ Year(s)
_______ Year(s)
_______ Year(s)
______ Month(s)
______ Month(s)
______ Month(s)
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
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OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
SECTION B. CURRENT HOUSING
B1
Which one of the following best describes your current living situation?
Would you say you live in…
YES
NO
REF
DK
B1a.
A house or apartment that you rent. That is the lease is in your name, or you
and your spouse/partner’s names jointly. This does not include your parent’s or
guardian’s home or apartment
1
2
-2
-1
B1b.
A house or apartment that you own. That is the mortgage is in your name. This
does not include your parent’s or guardian’s home or apartment
1
2
-2
-1
B1c.
Your partner’s (boy/girlfriends/fiancé, significant other’s) place. Your name is
NOT on the lease.
1
2
-2
-1
B1d.
A friend or relative’s house or apartment, and you are paying part of the rent
[PROBE: THIS INCLUDES YOUR PARENT’S or GUARDIAN’S HOUSE OR
APARTMENT OR OTHER FRIEND OR RELATIVE’S APARTMENT]
1
2
-2
-1
B1e.
A friend or relative’s house or apartment, but you are not paying part of the
rent [PROBE: THIS INCLUDES YOUR PARENT’S or GUARDIAN’S HOUSE OR
APARTMENT OR OTHER FRIEND OR RELATIVE’S APARTMENT]
1
2
-2
-1
CAPI: IF B1a, B1b, B1c, B1d, or B1e =Yes SKIP TO B2;
Otherwise, continue down B1f through B1q until a yes response is reached.
B1f.
A permanent housing program with services to help you keep your housing (on
site or coming to you)
1
2
-2
-1
B1g.
A transitional housing program
1
2
-2
-1
B1h.
A voucher hotel or motel
1
2
-2
-1
B1i.
A hotel or motel you pay for yourself
1
2
-2
-1
B1j
A residential drug or alcohol treatment program
1
2
-2
-1
B1k.
Jail or prison
1
2
-2
-1
B1l.
A domestic violence shelter
1
2
-2
-1
B1m.
An emergency shelter
1
2
-2
-1
B1n.
A car or other vehicle
1
2
-2
-1
B1o.
An abandoned building
1
2
-2
-1
B1p.
Anywhere outside [PROBE: STREETS, PARKS, ETC.] IF YES: SKIP TO B4
1
2
-2
-1
B1q.
OTHER SPECIFY: __________________________ IF YES: SKIP TO B4
1
2
-2
-1
Don’t Know..................................................................................... -1
Refused ......................................................................................... -2
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
C-9
OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
B2
Is this the same unit you lived in while you were receiving rental assistance from [name of
program]?
YES ................................................................................................ 1
NO .................................................................................................. 2
Don’t Know..................................................................................... -1
Refused ......................................................................................... -2
CAPI: IF B2 IS “NO” GO TO B2a; ELSE SKIP TO B3
B2a.
How long have you lived in this unit?
Years ________
Months_______
B2b.
How many different places have you lived in during the past year? ______
B2c.
Why did you move out of the place you lived in at the end of the [program name]?
SELECT ALL THAT APPLY – AND RANK AS MAJOR/MINOR REASON.
BECAUSE THAT WAS PART OF THE PROGRAM’S DESIGN ............................01
TO GET BETTER SCHOOLS FOR MY CHILDREN ..............................................02
CHANGE IN MARITAL / ROMANTIC STATUS ......................................................03
BETTER TRANSPORTATION .................................................................................04
WANTED A BETTER, APARTMENT/HOUSE ........................................................05
WANT A BIGGER APARTMENT/HOUSE...............................................................06
TO GET OR CHANGE JOB / TO BE NEAR MY JOB.............................................07
TO GET AWAY FROM DRUGS AND GANGS OR OTHER UNSAFE
ACTIVITIES................................................................................................................08
TO BE NEAR MY FAMILY ........................................................................................09
DID NOT GET ALONG WITH LANDLORD .............................................................10
CHANGE IN RENT/UNIT TOO EXPENSIVE ..........................................................11
UTILITIES WERE TOO EXPENSIVE.......................................................................12
UNIT FAILED SECTION 8 SPECTION....................................................................13
GOT A SECTION 8 SUBSIDY ..................................................................................14
MOVED INTO PUBLIC HOUSING ...........................................................................15
PERSONAL SAFETY/DOMESTIC VIOLENCE.......................................................16
OTHER: (SPECIFY): _____________.....................................................................95
DON’T KNOW ............................................................................................................ -1
REFUSED .................................................................................................................. -2
Major
Reason
1
1
1
1
1
1
1
1
Minor
Reason
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
C-10
OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
B3.
IF B2 = NO: Was there ever a time during the past year (that is, since MONTH/YEAR) when
you did not have your own place to stay?
IF B2 = YES: was there ever a time during the past year that you temporarily left your own
place (other than for vacation).
YES ................................................................................................ 1
NO .................................................................................................. 2
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
CAPI: IF B3 = YES GO TO B4; ELSE SKIP TO B6
B4.
During the past year, when you did not have your own place to stay, we would like to know
about any places where you stayed. Did you…
YES
NO
REF
DK
B4a.
Stay with a relative?
1
2
7
8
B4b.
Stay with a friend?
1
2
7
8
B4c.
Stay in a shelter?*
1
2
7
8
B4d.
Stay on the street?
1
2
7
8
*INTERVIEWER: A SHELTER IS A HOMELESS SHELTER, EMERGENCY SHELTER, OR
DOMESTIC VIOLENCE SHELTER]
CAPI: ASK ONLY IF BASED ON A2a/A4b ABOVE RESPONDENT HAS CHILDREN AGES 17 OR
YOUNGER, OTHERWISE SKIP TO B6
B5.
During the time when you did not have your own place to stay in the past year, did LIST
EACH CHILD’S NAME FROM A2a AND A4b… live with you ..
All of the time .................................................................................. 1
Part of the time................................................................................ 2
Not at all.......................................................................................... 3
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
REPEAT FOR ALL CHILDREN.
B6.
IF B2 = YES; Did you ever receive help from an agency to pay your rent so you could stay in
your own place?
YES ................................................................................................ 1
NO .................................................................................................. 2
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
C-11
OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
B7.
IF B6 =YES: How much and how many times did you receive help?
Total $ amount_____________
Total number of times received assistance______________
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
B8.
I have some questions about the house/apartment/living space you live in now. Overall, how
would you describe the condition of your current house/apartment/living space? Would you
say it was in excellent, good, fair, or poor condition?
EXCELLENT .................................................................................. 1
GOOD ............................................................................................ 2
FAIR .............................................................................................. 3
POOR ............................................................................................ 4
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
B9.
Excluding kitchens, bathrooms and hallways, how many rooms does the unit have?_____
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
B10.
IF B1a = YES i.e. FOR RENTERS: How satisfied are you with building maintenance? Are
you:
Completely satisfied ........................................................................ 1
Partly satisfied................................................................................. 2
Dissatisfied...................................................................................... 3
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
Not applicable ................................................................................ -3
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
C-12
OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
B11.
B11a
B11b.
B11c.
B11d.
B11e.
B11f.
B11g.
B11h.
B11i.
B11j.
B11k
B11l.
B11m.
Now I am going to ask you some questions about problems that people have in some homes/apartments/ living spaces. Since you moved in to
your current unit, have you had any of the following housing quality issues:
Did not live
there during
Yes
No
REF
DK
relevant time
Did water ever leak into your housing unit directly from the outside—for example,
1
2
-3
-2
-1
through the roof, outside walls, basement or any closed windows or skylights?
Now about water leaks from INSIDE. Did water leak in -- from broken pipes or water
1
2
-3
-2
-1
heaters, backed up plumbing, or other equipment failure inside the unit?
How about the floors in this housing unit. Are any holes in the floors big enough for
1
2
-3
-2
-1
someone to catch their foot on? (ABOUT 4 INCHES ACROSS; ABOUT THE HEIGHT
OF A SOUP CAN)
People sometimes have problems with cracks or holes in their home's floors, walls, or
1
2
-3
-2
-1
ceilings -- not little hairline cracks or nail holes, but OPEN cracks or holes. In the INSIDE
walls or ceilings of this housing unit, are there any open holes or cracks wider than
the edge of a dime?
Do the walls on the inside of this housing unit have any areas of peeling paint or broken
1
2
-3
-2
-1
plaster that are bigger than 8 inches by 11 inches? (THE SIZE OF A STANDARD
BUSINESS LETTER)
Have you ever seen signs of mice or rats inside your housing unit ? (EXCLUDE
1
2
-3
-2
-1
RATS/MICE KEPT AS PETS OR SNAKE FOOD OR OTHERWISE DELIBERATELY
BROUGHT INSIDE)
Does this housing unit have a complete kitchen for exclusive use of the unit? (To have
1
2
-3
-2
-1
complete kitchen facilities, the unit must have a sink, refrigerator, and (range, cookstove,
microwave, or built-in cooking burners) in the kitchen
Does this unit have complete plumbing facilities that are for exclusive use of the unit?
1
2
-3
-2
-1
(To have complete plumbing facilities, the unit must have exclusive use of hot and cold
running water, a toilet, and a bathtub/shower in the bathroom).
Last winter, for any reason, was your housing unit so cold for 24 hours or more that it
1
2
-3
-2
-1
was uncomfortable?
B11i1. IF YES: Did that happen more than once?
-3
-2
-1
Is all the electrical wiring in the finished areas of this home concealed in the walls?
1
2
-3
-2
-1
Have the fuses blown or breakers been tripped more than twice in the past year?
1
2
-3
-2
-1
Has the toilet been broken for at least 6 hours more than once?
1
2
-3
-2
-1
Is the main source of heat for your unit an UNVENTED room heaters burning kerosene,
1
2
-3
-2
-1
gas, or oil?
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
C-13
OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
B12.
Which of the following statements best describes how satisfied you are with your
neighborhood? Would you say you are...
Very satisfied .................................................................................. 1
Somewhat satisfied ......................................................................... 2
In the middle ................................................................................... 3
Somewhat dissatisfied..................................................................... 4
Very dissatisfied .............................................................................. 5
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
B13.
Now I would like to ask you about problems that occur in some neighborhoods. In your
neighborhood, how big of a problem is…
B13a.
B13b.
B13c.
B13d.
B13e.
B13f.
B13g.
B13h.
B13i.
B13j.
B13k.
Litter or trash on the
streets or sidewalk?
People drinking in public?
Abandoned buildings?
Groups of people just
hanging out?
Police not coming when
called?
People using or selling
illegal drugs?
Fighting in which a
weapon was used?
Violent arguments
between neighbors?
Gang fights?
Sexual assaults or rapes?
Robberies or muggings?
Big problem
1
Small
Problem
2
No Problem
3
REF
-2
DK
-1
1
1
1
2
2
2
3
3
3
-2
-2
-2
-1
-1
-1
1
2
3
-2
-1
1
2
3
-2
-1
1
2
3
-2
-1
1
2
3
-2
-1
1
1
1
2
2
2
3
3
3
-2
-2
-2
-1
-1
-1
SECTION C. INCOME AND EMPLOYMENT
C1.
Have you received any income from any source in past 30 days?
YES ................................................................................................ 1
NO .................................................................................................. 2
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
CAPI: IF C1 = “NO” SKIP TO C3; ELSE GO TO C2.
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
C-14
OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
C2.
In the past 30 days, have you received any income from … (IF YES:) How much did you
receive in the past 30 days?
C2a.
C2b.
C2c.
C2d.
C2e.
C2f.
C2g.
C2h.
C2i.
C2j.
C2k.
C2l.
C2m.
C2n.
C2o.
C3.
Income from a job
Unemployment Insurance
Supplemental Security Income
(SSI)
Social Security Disability
Income (SSDI)
Veteran’s disability payment
Private disability insurance
Worker’s compensation
Temporary Assistance for
Needy Families (TANF) (or use
local program name)
General Assistance (GA) (or
use local program name)
Retirement income from Social
Security
Veteran’s pension
Pension from a former job
Child support
Alimony or other spousal
support
Other source
NO
1
1
1
YES
2
2
2
AMOUNT
$_____________
$_____________
$_____________
1
2
$_____________
1
1
1
1
2
2
2
2
$_____________
$_____________
$_____________
$_____________
1
2
$_____________
1
2
$_____________
1
1
1
1
2
2
2
2
$_____________
$_____________
$_____________
$_____________
1
2
$_____________
IF OTHER PERSONS 15 OR OLDER IN THE HOUSEHOLD, BASED ON A8, ASK: Did any
other persons who live with you in your unit receive any income in the past 30 days?
YES ................................................................................................ 1
NO .................................................................................................. 2
REFUSED....................................................................................... 7
DON’T KNOW ................................................................................. 8
IF NO, SKIP TO C4
C3a.
If YES, How many other persons who live with you in your unit received any income?
_______
C3b.
What is the total income received by other persons in your household in the past 30
days? _______
IF DON’T KNOW, OR REFUSED, Ask in ranges:
Under $100 ..................................................................................... 1
$100 - < $200.................................................................................. 2
$200 - <$300 .................................................................................. 3
$300-<$400 .................................................................................... 4
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
C-15
OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
C3c.
Did any of these persons contribute any money toward rent?
YES ................................................................................................ 1
NO .................................................................................................. 2
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
IF NO, DON’T KNOW OR REFUSED SKIP TO C5
C3d.
What is the total amount these other persons paid toward your rent in the past 30
days? _______
IF DON’T KNOW, OR REFUSED, Ask in ranges:
Under $100 ..................................................................................... 1
$100 - < $200.................................................................................. 2
$200 - <$300 .................................................................................. 3
$300-<$400 .................................................................................... 4
SKIP TO C5
C4.
Did any other persons who do not live with you contribute any money toward your rent in the
past 30 days?
YES ................................................................................................ 1
NO .................................................................................................. 2
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
IF NO, DON’T KNOW OR REFUSED SKIP TO C5
C4a.
What is the total amount these other persons paid toward your rent in the past 30
days? _______
IF DON’T KNOW, OR REFUSED, Ask in ranges:
Under $100 ..................................................................................... 1
$100 - < $200.................................................................................. 2
$200 - <$300 .................................................................................. 3
$300-<$400 .................................................................................... 4
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
C-16
OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
C5.
In the past 30 days, did you or anyone in your household receive (or are you on) any of the
following benefits: … (IF YES:) How much did you receive in the past 30 days? JUST ASK
AMOUNT FOR THE MARKED ONES.
c5a.
c5b.
c5c.
c5d.
c5e.
c5f.
c5g.
c5h.
c5i.
c5j.
c5k.
c5l.
c5m.
c5n.
Food Stamps (officially called Supplemental Nutrition
Assistance Program (SNAP)
Medicaid health insurance program (or use local name)
Medicare health insurance program (or use local name)
State Children’s Health Insurance Program (or use
local name)
WIC (Special Supplemental Nutrition Program for
Women, Infants, and Children)
Veteran’s Administration (VA) Medical Services
TANF Child Care services (or use local name)
TANF transportation services (or use local name)
Other TANF-funded services (or use local name)
Health Insurance from work
Health insurance from a place you used to work
Health insurance you pay for yourself
Other source
Temporary rental assistance
NO
YES
1
2
1
1
1
2
2
2
1
2
1
1
1
1
2
2
2
2
1
1
2
2
Amount of monthly
assistance
$___________
$___________
$___________
$___________
Now I’d like to ask a few questions about any jobs you may have.
C6.
Last week, did you do any work for pay?
YES (SKIP TO C9) ........................................................................ 1
NO .................................................................................................. 2
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
C7.
What is the main reason that you did not work for pay last week?
RETIRED ...................................................................................... 01
DISABLED .................................................................................... 02
UNABLE TO WORK...................................................................... 03
HAS JOB BUT TEMPORARILY ABSENT...................................... 04
COULDN’T FIND ANY WORK....................................................... 05
CHILD CARE PROBLEMS ............................................................ 06
FAMILY RESPONSIBILITIES ........................................................ 07
CHILD WITH DISABILITIES THAT REQUIRES FULL TIME ATTENTION ... 08
IN SCHOOL OR OTHER TRAINING ............................................. 09
WAITING FOR A NEW JOB TO BEGIN ........................................ 10
OTHER (SPECIFY): ______________________________ ........... 95
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
C-17
OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
C8.
Have you been doing anything to find work during the past four weeks?
YES ............................................................................................... 1
NO .................................................................................................. 2
RETIRED ........................................................................................ 3
DISABLED ...................................................................................... 4
UNABLE TO WORK........................................................................ 5
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
SKIP TO D1
C9.
When did you first start working at your job?
__ __/__ __ __ __ Month/Year
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
C10.
Through your employer, are you eligible for any of the following benefits? By eligible we
mean the benefit is available for you now, even if you have decided to not receive it or have
not needed it.
C10a. Health insurance?
C10b. Sick leave?
C.10c Paid vacation?
YES
1
1
1
NO
2
2
2
REF
-2
-2
-2
DK
-1
-1
-1
SECTION D. HOUSING COSTS
Now I’d like to talk about how much you pay each month for housing.
D1.
IF RENTERS BASED ON B1a= yes, or B1c=yes, or B1d=yes, or B1i=yes: ALL OTHERS
SKIP TO D4.
In the month just past, what did you and the family you headed pay in rent? We are
interested only in knowing the amount of the rent payment that you or the family you head
paid, not any amount that may have been paid by other people or by a government agency
and not including any utilities that you pay for directly to the utility company.
PER MONTH: $__ __ __ __ .00 (FOUR DIGITS, ROUNDED TO DOLLAR)
(EXPECTED RANGE = $1-3000)
SKIP TO D1b
DON’T KNOW (ASK D1a) .............................................................. -1
REFUSED (ASK D1a) .................................................................... -2
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
C-18
OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
D1a.
Can you give me a range? Is your monthly rent payment:
Between 0 and $200 per month ....................................................... 1
Between $201 and $400.................................................................. 2
Between $401 and $600.................................................................. 3
Between $601 and $800.................................................................. 4
More than $800 per month .............................................................. 5
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
D1b.
What is the total contract rent that is paid to the landlord? That is the rent including
any amount you and your household pay and including any amounts paid by other
people or by a government agency.
PER MONTH: $__ __ __ __ .00 (FOUR DIGITS, ROUNDED TO DOLLAR)
(EXPECTED RANGE = $1-3000)
SKIP TO D2
DON’T KNOW (ASK D1c)............................................................... -1
REFUSED (ASK D1c) .................................................................... -2
D1c.
Can you give me a range? Is the total monthly rent payment:
Between 0 and $200 per month ....................................................... 1
Between $201 and $400.................................................................. 2
Between $401 and $600.................................................................. 3
Between $601 and $800.................................................................. 4
More than $800 per month .............................................................. 5
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
D2.
Are you paying lower rent because you receive assistance from the government, or some
other program to pay part of your rent?
YES (ASK D3)................................................................................. 1
NO (SKIP TO D5)............................................................................ 2
DON’T KNOW (SKIP TO D5).......................................................... -1
REFUSED (SKIP TO D5) ............................................................... -2
D3.
Is this assistance: public housing, a Section 8 Voucher, Project-based Section 8 or some
other type of assistance?
PUBLIC HOUSING.......................................................................... 1
A SECTION 8 VOUCHER ............................................................... 2
PROJECT BASED SECTION 8 ....................................................... 3
OTHER (SPECIFY): _____________ ............................................ 95
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
C-19
OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
SKIP TO D5
D4.
IF OWNERS: (IF THE ANSWER TO B1b = YES. ALL OTHERS SKIP TO E1) In the month
just past, what did you and the family you headed pay for your mortgage? We are interested
only in knowing the amount of the mortgage payment that you or the family you head paid,
not any amount that may have been paid by other people or by a government agency.
PER MONTH: $__ __ __ __ .00 (FOUR DIGITS, ROUNDED TO DOLLAR)
(EXPECTED RANGE = $0-3000)
SKIP TO D5
DON’T KNOW (ASK D4a) .............................................................. -2
REFUSED (ASK D4a) .................................................................... -1
D4a.
Can you give me a range? Is your monthly mortgage payment:
Between 0 and $200 per month ....................................................... 1
Between $201 and $400.................................................................. 2
Between $401 and $600.................................................................. 3
Between $601 and $800.................................................................. 4
More than $800 per month .............................................................. 5
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
D5.
Did you pay for any utilities that are not included as part of the RENT/MORTGAGE that you
pay? By utilities, I mean electricity, heat, gas, and water, but NOT telephone and cable
services.
YES ................................................................................................ 1
NO .................................................................................................. 2
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
D6.
What is the total amount of all utility payments that you and the family you head pay in a
typical month—that is not a month with unusually high or low heat or air conditioning bills?
MONTHLY UTILITIES: $__ __ __ __ .00 (FOUR DIGITS, ROUNDED TO DOLLAR)
(EXPECTED RANGE: $0-1000)
SKIP TO E1
DON’T KNOW (ASK D6a) .............................................................. -1
REFUSED (ASK D6a) .................................................................... -2
D6a.
Can you tell me the range for your monthly utility payment? Was it…
Between 0 and $100 per month ....................................................... 1
Between $101 and $200 ................................................................. 2
Between $201 and $300.................................................................. 3
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
C-20
OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
Between $301and $400................................................................... 4
Between $401and $500................................................................... 5
More than $500 per month .............................................................. 6
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
SECTION E. HOUSING BARRIERS
E1.
Next, I’d like to ask about things that make it difficult at times for some people to keep a place
of their own to live. I’ll read a list of reasons why some people might have trouble keeping
housing. Please tell me if you think this is a big problem, a small problem, or not a problem
at all for you and your family.
E1a. Not having enough income to
pay rent
E1b. Not being currently employed
E1c. Family violence
E1d. Your having problems with police
or a criminal record or background
E1e. Another family member having
problems with police or a criminal
record or background
E1f. Your having a drug problem or a
felony drug record
E1g. Another family member with a
drug problem or a felony drug record
E1h. Having three or more children in
the household
E1i. Having teenagers in the household
E1j. Having an adult in the household
that is frequently sick.
E1k. Having an adult in the household
that has a physical disability that
requires specific housing modifications.
E1l. Having an adult in the household
that has a mental disability.
E1m. Having an adult in the household
with HIV/AIDS
E1n. Having a child in the household
that is frequently sick.
E1o. Having a child in the household
that has a physical disability that
requires specific housing modifications.
E1p. Having a child in the household
that has a mental disability.
Big
problem
1
Small
Problem
2
No
Problem
3
REF
-2
DK
-1
1
1
1
2
2
2
3
3
3
-2
-2
-2
-1
-1
-1
1
2
3
-2
-1
1
2
3
-2
-1
1
2
3
-2
-1
1
2
3
-2
-1
1
1
2
2
3
3
-2
-2
-1
-1
1
2
3
-2
-1
1
2
3
-2
-1
1
2
3
-2
-1
1
2
3
-2
-1
1
2
3
-2
-1
1
2
3
-2
-1
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
C-21
OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
SECTION F. EDUCATION
F1.
When you entered , what is the highest grade or year of regular school
that you have completed and gotten credit for?
GRADE (1-12): ___________________
FIRST YEAR OF COLLEGE.......................................................... 13
SECOND YEAR OF COLLEGE ..................................................... 14
THIRD YEAR OF COLLEGE ......................................................... 15
FOURTH YEAR OF COLLEGE ..................................................... 16
FIFTH YEAR OF COLLEGE .......................................................... 17
SIXTH YEAR OF COLLEGE ......................................................... 18
SEVENTH YEAR OF COLLEGE ................................................... 19
EIGHTH YEAR OF COLLEGE OR MORE ..................................... 20
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
F2.
Did you have (a high school diploma or) a GED? [PROBE FOR GED VS. HIGH SCHOOL
DIPLOMA]
GED................................................................................................ 1
HIGH SCHOOL DIPLOMA .............................................................. 2
BOTH.............................................................................................. 3
NEITHER ........................................................................................ 4
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
F3.
Now I would like to ask you about any regular school or any training you may have had since
you entered/ the Rapid Rehousing Program (this is since, DATE OF ENTRY). Have you
participated in any additional regular schooling or in some other type of schooling or training
program that lasted at least two weeks that was designed to help you find a job, improve your
job skills, or learn a new job?
YES ................................................................................................ 1
NO .................................................................................................. 2
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
IF NO, DON’T KNOW, OR REFUSED SKIP TO G1.
F4.
What kind of schooling or training was that? [INTERVIEWER: CHECK ALL THAT APPLY)
REGULAR SCHOOLING................................................................. 1
GENERAL EQUIVALENCY DIPLOMA (GED).................................. 2
ENGLISH AS A SECOND LANGUAGE ........................................... 3
COMPUTER TRAINING.................................................................. 4
WORK STUDY PROGRAM ............................................................. 5
OTHER (SPECIFY) __________________________________ .... 95
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
C-22
OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
NO OTHER MENTIONS................................................................ 96
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
F5.
Did you get the training while you were in the program, after, or both?
TAKEN DURING THE TIME .......................... 1
TAKEN SINCE PROGRAM EXIT..................................................... 2
BOTH.............................................................................................. 3
SECTION G. FOOD SECURITY/HUNGER
G1.
Now I am going to read you three statements that people have made about their food
situation. Please tell me whether the statement was often, sometimes, or never true for you
and the other members of your household in the last 12 months.
G1a.
G1b.
G1c.
G2.
We worried whether our
food would run out
before we got money to
buy more.
The food we bought just
didn't last, and we didn't
have money to get more.
We couldn't afford to eat
balanced meals.
Often true
1
Sometime
s true
2
Never true
3
REF
-2
DK
-1
1
2
3
-2
-1
1
2
3
-2
-1
In the last 12 months, did you or other adults in your household ever cut the size of your
meals or skip meals because there wasn’t enough money for food?
YES ................................................................................................ 1
NO .................................................................................................. 2
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
IF NO, DON’T KNOW OR REFUSED SKIP TO G4
G3.
How often did this happen—almost every month, some months but not every month, or in
only 1 or 2 months?
ALMOST EVERY MONTH............................................................... 1
SOME MONTHS BUT NOT EVERY MONTH .................................. 2
ONE OR TWO MONTHS ................................................................ 3
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
C-23
OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
G4.
In the last 12 months, did you ever eat less than you thought you should because there
wasn’t enough money to buy food?
YES ................................................................................................ 1
NO .................................................................................................. 2
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
G5.
In the last 12 months, were you ever hungry but didn’t eat because you couldn’t afford
enough food?
YES ................................................................................................ 1
NO .................................................................................................. 2
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
SECTION H. FAMILY WELL-BEING
ASK IF A2>1, ELSE H2.
H1.
About how many days per week do you and your (child/children) all eat dinner together?
NUMBER OF DAYS: ____________
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
ASK IF HAVE ANY CHILDREN BETWEEN AGES 6– 18 BASED ON RESPONSES TO A8; ELSE
SKIP TO I1.
H2.
Now I’d like to ask you about your involvement in your children’s schooling. In the past 12
months, have you or another adult who lives with you gone to any events at your (child/ren)’s
school such as general meeting school, like a back-to-school night, parent/teacher
organization meeting, a school play or sports event?
YES ................................................................................................ 1
NO .................................................................................................. 2
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
ASK FOR EACH CHILD BETWEEN AGES 6– 18:
H3.
Did [Child] miss more than 15 school days during the past school year?
YES ................................................................................................ 1
NO .................................................................................................. 2
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
IF NO, DON’T KNOW OR REFUSED, SKIP TO H4
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
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OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
H3a.
IF YES, Why?
DO NOT READ LIST. ACCEPT ONE RESPONSE ONLY PER CHILD WHO IS NOT IN
SCHOOL.
HEALTH PROBLEMS.................................................................................. 1
DROPPED OUT OF SCHOOL BECAUSE OF FINANCIAL PROBLEMS/HAD TO WORK 2
DROPPED OUT OF SCHOOL BECAUSE DIDN’T LIKE SCHOOL .............. 3
EXPELLED OR SUSPENDED ..................................................................... 4
PARENTAL DECISION................................................................................ 5
PREGNANCY/CHILDBIRTH ........................................................................ 6
GRADUATED FROM HIGH SCHOOL / EARNED GED................................ 7
INCARCERATED/IN DETENTION FACILITY/BOOT CAMP OR SIMILARLY
INSTITUTIONALIZED .................................................................................. 8
CHILD FACES THREAT OF VIOLENCE/GANG ACTIVITY.......................... 9
LEARNING DISABILITY/REQUIRES SPECIAL SCHOOLING .................... 10
IN MILITARY/MILITARY TRAINING........................................................... 11
WANTED TO JOIN JOB CORPS/JOINED JOB CORPS ............................ 12
HOUSING SITUATION/IN TRANSITION/PROCESS OF MOVING ............. 13
MENTAL HEALTH ..................................................................................... 14
HOME SCHOOLED ................................................................................... 15
HEALTH PROBLEMS................................................................................ 16
OTHER (SPECIFY) ________________ ................................................... 17
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
H4.
Have any of your children [CHILD] ever been suspended or expelled from school?
YES ................................................................................................ 1
NO .................................................................................................. 2
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
IF NO, DON’T KNOW OR REFUSED, SKIP TO H6.
H5.
Has this happened in the past year, that is since you left the RRHP in [PROGRAM EXIT
DATE)?
YES ................................................................................................ 1
NO .................................................................................................. 2
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
H6.
Have you ever been asked by any of your children’s schools [CHILD’S] to come in and talk
about problems your child was having with behavior?
YES ................................................................................................ 1
NO .................................................................................................. 2
DON’T KNOW ................................................................................ -1
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
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OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
REFUSED...................................................................................... -2
IF NO, DON’T KNOW OR REFUSED, SKIP TO H8.
H7.
Has this happened in the past year, that is since you left the RRHP in [PROGRAM EXIT
DATE]?
YES ................................................................................................ 1
NO .................................................................................................. 2
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
H8.
Have any of your children ever gone to a special class for gifted students or done advanced
work in any subjects?
YES ................................................................................................ 1
NO .................................................................................................. 2
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
IF NO, DON’T KNOW OR REFUSED, SKIP TO H10.
H9.
Has this happened in the past year, that is since you left the RRHP in [PROGRAM EXIT
DATE]?
YES ................................................................................................ 1
NO .................................................................................................. 2
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
H10.
Has any of your children gone to a special class or school or gotten special help in school
for…
YES
NO
REF
DK
H10a. Learning problems
1
2
-2
-1
H10b. Behavioral or emotional problems
1
2
-2
-1
IF NO, DON’T KNOW OR REFUSED, SKIP TO I1.
H11.
Has this happened in the past year, that is since you left the RRHP IN [PROGRAM EXIT
DATE]?
YES ................................................................................................ 1
NO .................................................................................................. 2
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
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OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
SECTION I. HEALTH
I1.
Overall, how would you rate your health during the past month (that is the past 30 days)?
Excellent ......................................................................................... 1
Very good ....................................................................................... 2
Good............................................................................................... 3
Fair ................................................................................................. 4
Poor ................................................................................................ 5
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
I2.
In general, has your health been better, worse or about the same in the last year, since you
left the rapid rehousing program [INSERT THE PROGRAM NAME]?
Better .............................................................................................. 1
Worse ............................................................................................. 2
About the same ............................................................................... 3
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
I3.
During the past 30 days, about how often did you feel…
None A little Some Most
of the of the of the of the
Time Time Time Time
REF DK
I3a. Tired out for no good reason?
1
2
3
4
-2
-1
I3b. Nervous?
1
2
3
4
-2
-1
4
I3c. So nervous that nothing could calm you down?
1
2
3
-2
-1
I3d. Hopeless?
1
2
3
4
-2
-1
I3e. Restless or fidgety?
1
2
3
4
-2
-1
1
2
3
4
-2
-1
I3f.
So restless you could not sit still?
I3g. Depressed?
I3h. That everything was an effort?
I4.
I3i.
So sad that nothing could cheer you up?
I3j.
Worthless?
The last set of questions asked about feelings that might have occurred during the past 30
days. Taking them altogether, do you feel better, worse or about the same in the last year,
since you left the rapid rehousing program [INSERT THE PROGRAM NAME]?
Better .............................................................................................. 1
Worse ............................................................................................. 2
About the same ............................................................................... 3
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
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OMB Control Number: xxxx-xxxx
OMB Expiration Date: [date]
ASK IF BASED ON QA2 AND QA4 RESPONDENT HAS CHILDREN, OTHERWISE SKIP TO
SECTION J.
I5.
Overall, how would you rate the health of your children during the past month (that is the past
30 days)?
Excellent ......................................................................................... 1
Very good ....................................................................................... 2
Good............................................................................................... 3
Fair ................................................................................................. 4
Poor ................................................................................................ 5
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
I6.
In general, has the health of your children been better, worse or about the same in the last
year, this is, since you left the rapid rehousing program [INSERT THE PROGRAM NAME]?
Better .............................................................................................. 1
Worse ............................................................................................. 2
About the same ............................................................................... 3
DON’T KNOW ................................................................................ -1
REFUSED...................................................................................... -2
SECTION J. CLOSING
That completes all the specific questions that I have. Is there anything else that you would like to tell
me about your neighborhood, or experiences, or any suggestions that you might have for HUD or
improving housing programs to help families avoid becoming homeless?
________________________________________________________
Please confirm your current address, so we can send you a money order for
$25._____________________________________________________
Thank you for your time.
Rapid Re Housing for Homeless Families Demonstration Program Evaluation – Follow-up Survey Instrument
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| File Type | application/pdf |
| File Title | Microsoft Word - RRHD Follow-up 10-07-10.doc |
| Author | SpellmanB |
| File Modified | 2010-10-07 |
| File Created | 2010-10-07 |