4 Economic

ID NUMBER:

FORM CODE: ECE VERSION: A 7/04/07

Contact Occasion

SEQ #

OMB#: 0925-XXXX

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 02 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

H

OMB#: 0925-XXXX

Exp. XX/XXXX

CHS/SOL Economic Questionnaire

ID NUMBER:

FORM CODE: ECE VERSION: A 7/04/07

Contact Occasion

SEQ #

Acrostic:

Administrative Information

0a. Completion Date: // 0b. Staff ID:

Month Day Year

Instructions: Mark the appropriate box for the response. Unless instructed, mark ONLY one response.

A. Assets

1. Is your house, apartment, or mobile home…?

Owned by you or someone in the household free

and clear---without a mortgage or loan 1

Owned by you or someone in the household

---with a mortgage or loan 2

Rented 3

Occupied without payment 4

B. Annual Household Income

2. Counting the income of all the members of your household, was your household income for the year…

(Include all money received from all sources)

Less than $30,000 1  GO TO QUESTION 3 $30,000 or more 2  GO TO QUESTION 4

3. Is that income… Less than $10,000 1

$10,001-$15,000 2

$15,001-$20,000 3

$20,001-$25,000 4

$25,001-$29,999 5

4. Is that income… $30,000-$40,000 1

$40,001-$50,000 2

$50,001-$75,000 3

$75,001-$100,000 4

More than $100,000 5

5. How many people, including yourself, were supported by this income during the year?

Number of people

C. SES Ladder

Here is a picture of a ladder. Think of this ladder as representing where people stand in the United States. At the top of the ladder are the people who are the best off – those who have the most money, the most education and the most respected jobs. At the bottom are the people who are the worst off – who have the least money, least education, and the least respected jobs or no job. The higher up you are on this ladder, the closer you are to the people at the very top; the lower you are, the closer you are to the people at the very bottom.

6. Where would you place yourself on this ladder? Please show the step where you think you stand at this time in your life, relative to other people in the United States.

Economic Form (ECE) Page 2 of 2