Veterans Homelessness Prevention Demonstration
Task Order Number
Contract Number C-CHI-01115T-0001
Paperwork Reduction Act Submission for Veterans Homelessness Prevention Demonstration Evaluation Focus Groups and Telephone Survey
Part A: Justification
Evaluation of the Veterans Homelessness Prevention Demonstration
Interviewer: Please fill out any blanks on this page before you begin the interview. CATI will already have filled in the site and R ID number [delete if CATI fills it all in]
Interviewer Name: _______________________________
VHPD Site |
R ID Number |
Interview Date |
Start Time |
End Time |
1 – Utica/NY 2 – Tampa/FL 3 – Austin/TX 4 – San Diego/CA 5 – Tacoma/WA |
__________ |
___ / ___ / ___ |
____: _____ |
____: _____ |
Instructions to interviewer are in pink
Instructions pertaining to CATI programming are in yellow
Hi, my name is ______________. I am calling from Silber & Associates, a research firm based in Baltimore. I am calling to ask you some questions about your situation now that you have begun to participate in the [PROGRAM NAME]. Thank you for allowing [PROGRAM NAME] to send us your name and contact information, and for taking the time to speak with me today. We will be talking for about 25-30 minutes. As you may remember, [PROGRAM NAME] told you that someone would be contacting you shortly to hear about how things have been going for you and what brought you to the program.
HUD, the VA, and the Department of Labor, the federal partners sponsoring [PROGRAM NAME], are very interested in helping veterans avoid homelessness. They hope to learn from your experiences with the Veterans Homelessness Prevention Program about the ways the program might be able to help you deal with the situation you are in. I’ll ask you a series of questions about your living situation (housing, who lives with you), income and employment, health and well-being, things that are making it hard at present for you to get stable housing, and ways you think your military experiences may be affecting your living situation. You will probably have answered many of the same questions for [PROGRAM NAME] and the [VAMC NAME], but please bear with us as the information you give us will be used to understand in greater depth the situation that some veterans may find themselves in, where they are in danger of losing their housing or may already have lost it.
Your participation in this study will help the federal partners to improve programs for veterans like you across the country. Your participation is completely voluntary; you may stop the interview at any time. If any question makes you feel uncomfortable, you can refuse to answer that question. The information you provide will be kept confidential and only used for this study. The collection of this information has been approved by the Office of Management and Budget. Right now, let me verify a few things:
I’m going to be asking you questions that refer to [PROGRAM NAME]. These questions will work best if I can use the names that you call the agencies that are part of the program. Could you please tell me what you call:
The VA medical center where you may get health care___________________
The program that provides rent assistance and other help with housing and benefits_______________________________________
The Worksource Center that you may use for help finding work or improving your job situation__________________________________
CATI will insert appropriate name as follows: 1a for PN-VA; 1b for PN-HL; 1c for PN-DOL.
What is the address where you are currently living?
Street__________________________________________________________
City_________________________________ Zip code_______________
Is that the address we should use to send you the $40 we will pay you for your participation in this interview?
Yes 1
No 0
4a. If no, to what address should we send payment
Street__________________________________________________________
City_________________________________ Zip code_______________
---------------------------------------------------------------------------------------------------------------
SECTION A. HOUSING AT VHPD PROGRAM ENTRY AND HOUSING HISTORY
I’d like to ask you a few questions first about your living situation.
A1 At the time you began filling out your application for [PN-HL], were you living in your own place—that is, a house or apartment that you rented, and the lease was in your name or you and your spouse/partner’s names jointly?
YES (ASK A1a) 1
NO (SKIP TO A2) 0
DON’T KNOW 7
REFUSED 8
A1a. Did you own that place, or did you rent it?
Own it 1
Rent it 2
DON’T KNOW 7
REFUSED 8
SKIP TO A4
A2. Was it someone else’s place, for instance, the place of your parents, other relatives, or friends?
YES (ASK A2a) 1
NO (SKIP TO A3) 0
DON’T KNOW 7
REFUSED 8
A2a. Did you pay rent to the people whose place it was?
YES 1
NO 0
DON’T KNOW 7
REFUSED 8
SKIP TO A4.
A3 Could you tell me, then, which one of the following best describes your living situation at the time you began filling out your application for [PN-HL]? I’ll start reading some possibilities—stop me when I read the one where you were staying when you starting filling out your [PN-HL] application. [INTERVIEWER: READ OPTIONS UNTIL R INDICATES THE RIGHT ONE, AND MARK THAT ANSWER]
An emergency shelter or domestic violence shelter |
01 |
A voucher hotel or motel (paid for by a homeless or government program) |
02 |
Housing paid for by the VA’s Grant & Per Diem program |
03 |
A transitional housing program |
04 |
Anywhere not meant for habitation—e.g., a car, truck, RV, or trailer; an abandoned building, in parks, on the streets, in camping grounds, anywhere outside |
05 |
A hotel or motel you paid for yourself |
06 |
A VA residential drug or alcohol treatment program—only for vets |
07 |
A residential drug or alcohol treatment program for anyone—not just for vets |
08 |
A VA hospital |
09 |
Any other hospital—i.e., not a hospital run by the VA |
10 |
Jail or prison |
11 |
A permanent housing program for people with disabilities who have been homeless, with services and caseworkers to help you keep your housing |
12 |
OTHER SPECIFY: __________________________ |
13 |
Don’t Know |
97 |
Refused |
98 |
A4 How long had you been living or staying in that place at the time you began filling out your application for [PN-HL]?
Less than 1 month 1
1 to 3 months 2
4 to 6 months 3
7 to 12 months 4
1 year or more 5
Don’t Know 7
Refused 8
A5. Is that where you are living now?
YES (SKIP TO A8) 1
NO 0
DON’T KNOW 7
REFUSED 8
A5a. Please describe the place you are living now. Is that your own place—that is, a house or apartment that you rent, and the lease is in your name or you and your spouse/partner’s names jointly.
YES (ASK A5a1) 1
NO (SKIP TO A6) 60
DON’T KNOW 7
REFUSED 8
A5a1. Do you own that place, or do you rent it?
Own it 1
Rent it 2
DON’T KNOW 7
REFUSED 8
SKIP TO A8
A6. Is it someone else’s place, for instance, the place of your parents, other relatives, or friends?
YES (ASK A6a) 1
NO (SKIP TO A7) 0
DON’T KNOW 7
REFUSED 8
A6a. Do you pay rent to the people whose place it is?
YES 1
NO 0
DON’T KNOW 7
REFUSED 8
SKIP TO A8
A7 Could you tell me, then, which one of the following best describes where you are living at the present time? I’ll start reading some possibilities—stop me when I read the one where you are staying now. [INTERVIEWER: START READING OPTIONS, STOP WHEN R INDICATES THE RIGHT ONE, AND MARK THAT ANSWER]
An emergency shelter or domestic violence shelter |
01 |
A voucher hotel or motel (paid for by a homeless or government program) |
02 |
Housing paid for by the VA’s Grant & Per Diem program |
03 |
A transitional housing program |
04 |
Anywhere not meant for habitation—e.g., a car, truck, RV, or trailer; an abandoned building, in parks, on the streets, in camping grounds, anywhere outside |
05 |
A hotel or motel you paid for yourself |
06 |
A VA residential drug or alcohol treatment program—only for vets |
07 |
A residential drug or alcohol treatment program for anyone—not just for vets |
08 |
A VA hospital |
09 |
Any other hospital—i.e., not a hospital run by the VA |
10 |
Jail or prison |
11 |
A permanent housing program for people with disabilities who have been homeless, with services and caseworkers to help you keep your housing |
12 |
OTHER SPECIFY: __________________________ |
13 |
Don’t Know |
97 |
Refused |
98 |
SKIP TO A10
A8. Can you tell me about the house, apartment, or living space you live in now. Overall, how would you describe the condition of your current house, apartment, or 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 7
REFUSED 8
A9. Excluding kitchens, bathrooms and hallways, how many rooms does the unit have? _____
IF A4 = 5 AND A5 = 1, SKIP TO A20
OTHERWISE, ASK A10
A10. Were you still in the military 12 months ago—that would be [INSERT MONTH AND YEAR]?
YES 1
NO (SKIP TO A14) 0
DON’T KNOW 7
REFUSED 8
A10a. How long ago did you leave or were you discharged from the military?
Less than 1 month 1
1 to 3 months 2
4 to 6 months 3
7 up to 12 months 4
Don’t Know 7
Refused 8
A11 Please think about the first place you lived after you left the military. Was it your own place—that is, a house or apartment that you rented, and the lease was in your name or you and your spouse/partner’s names jointly?
YES (ASK A11a) 1
NO (SKIP TO A12) 0
DON’T KNOW 7
REFUSED 8
A11a. Did you own that place, or did you rent it?
Own it 1
Rent it 2
DON’T KNOW 7
REFUSED 8
SKIP TO A17
A12. Was it someone else’s place, for instance, the place of your parents, other relatives, or friends?
YES (ASK A12a) 1
NO (SKIP TO A13) 0
DON’T KNOW 7
REFUSED 8
A12a. Did you pay rent to the people whose place it was?
YES 1
NO 0
DON’T KNOW 7
REFUSED 8
SKIP TO A17
A13 Could you tell me, then, which one of the following best describes the first place you lived after you left the military. I’ll start reading some possibilities—stop me when I read the one where you stayed right after you left the military. [INTERVIEWER: START READING OPTIONS, STOP WHEN R INDICATES THE RIGHT ONE, AND MARK THAT ANSWER]
An emergency shelter or domestic violence shelter |
01 |
A voucher hotel or motel (paid for by a homeless or government program) |
02 |
Housing paid for by the VA’s Grant & Per Diem program |
03 |
A transitional housing program |
04 |
Anywhere not meant for habitation—e.g., a car, truck, RV, or trailer; an abandoned building, in parks, on the streets, in camping grounds, anywhere outside |
05 |
A hotel or motel you paid for yourself |
06 |
A VA residential drug or alcohol treatment program—only for vets |
07 |
A residential drug or alcohol treatment program for anyone—not just for vets |
08 |
A VA hospital |
09 |
Any other hospital—i.e., not a hospital run by the VA |
10 |
Jail or prison |
11 |
A permanent housing program for people with disabilities who have been homeless, with services and caseworkers to help you keep your housing |
12 |
OTHER SPECIFY: __________________________ |
13 |
Don’t Know |
97 |
Refused |
98 |
SKIP TO A17.
A14. Please think of the place where you were living or staying 12 months ago—that would be in [INSERT MONTH AND YEAR]? Was it your own place—that is, a house or apartment that you rented, and the lease was in your name or you and your spouse/partner’s names jointly?
YES (ASK A14a) 1
NO (SKIP TO A15) 0
DON’T KNOW 7
REFUSED 8
A14a. Did you own that place, or did you rent it?
Own it 1
Rent it 2
DON’T KNOW 7
REFUSED 8
SKIP TO A17
A15. Was it someone else’s place, for instance, the place of your parents, other relatives, or friends?
YES (ASK A15a) 1
NO (SKIP TO A16) 0
DON’T KNOW 7
REFUSED 8
A15a. Did you pay rent to the people whose place it was?
YES 1
NO 0
DON’T KNOW 7
REFUSED 8
SKIP TO A17.
A16 Could you tell me, then, which one of the following best describes the place where you were living or staying 12 months ago—that would be in [INSERT MONTH AND YEAR]? I’ll start reading some possibilities—stop me when I read the one where you lived 12 months ago. [INTERVIEWER: START READING OPTIONS, STOP WHEN R INDICATES THE RIGHT ONE, AND MARK THAT ANSWER]
An emergency shelter or domestic violence shelter |
01 |
A voucher hotel or motel (paid for by a homeless or government program) |
02 |
Housing paid for by the VA’s Grant & Per Diem program |
03 |
A transitional housing program |
04 |
Anywhere not meant for habitation—e.g., a car, truck, RV, or trailer; an abandoned building, in parks, on the streets, in camping grounds, anywhere outside |
05 |
A hotel or motel you paid for yourself |
06 |
A VA residential drug or alcohol treatment program—only for vets |
07 |
A residential drug or alcohol treatment program for anyone—not just for vets |
08 |
A VA hospital |
09 |
Any other hospital—i.e., not a hospital run by the VA |
10 |
Jail or prison |
11 |
A permanent housing program for people with disabilities who have been homeless, with services and caseworkers to help you keep your housing |
12 |
OTHER SPECIFY: __________________________ |
13 |
Don’t Know |
97 |
Refused |
98 |
SKIP TO A19
A17. Can you tell me about the house, apartment, or living space you lived in[after you left the military / 12 months ago]. Overall, how would you describe the condition of your current house, apartment, or 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 7
REFUSED 8
A18. Excluding kitchens, bathrooms and hallways, how many rooms did the unit have? _____
A19 Including the place you are living now, how many different places have you lived [since you left the military / during the past 12 months],
2 places 2
3 places 3
4 places 4
5 or more places 5
Don’t Know 7
Refused 8
A19a. Other than the place you are living now, we’d like to know all the types of places you lived or stayed [since you left the military / during the past 12 months] During that time, did you live or stay in any of the following places? [READ RESPONSES AND MARK “YES” OR “NO” FOR ALL THAT APPLY.]
A19a1. In my own place (lease was in your name or you owned it) Y/N/DK/Ref
A19a2. In someone else’s place (relative, partner, or friend) Y/N/DK/Ref
A19a3. In a shelter for homeless people/victims of domestic violence Y/N/DK/Ref
A19a4. In my car/truck, abandoned building, somewhere outside, or a place not meant for habitation Y/N/DK/Ref
Don’t Know 7
Refused 8
IF R IS NOT HOMELESS NOW AND HAS NOT BEEN HOMELESS DURING LAST 12 MONTHS, ASK A20 [I.E., R NEVER GOT TO QUESTIONS A3, A7, A12, OR A15]
OTHERWISE, IF R HAS BEEN HOMELESS IN THE LAST 12 MONTHS, SKIP TO A21 [I.E., R ANSWERED 01 THROUGH 12 TO QUESTIONS A3, A7, A12, OR/AND A15]
A20 Have you ever been homeless—that is, living or sleeping in an emergency shelter, transitional housing program, your car or truck, anywhere outside, or in another place not meant for human habitation.
YES (ask A21) 1
NO (SKIP TO SECTION B) 0
Don’t Know 7
Refused 8
A21 How often have you been homeless in your lifetime—that is, living or sleeping in an emergency shelter, transitional housing program, your car or truck, anywhere outside, or in another place not meant for human habitation?
Once 1
Twice 2
Three times 3
Four or more times 4
Don’t Know 7
Refused 8
A22 How old were you the first time you were homeless? [INTERVIEWER if R uncertain, read “by homeless, I mean living or sleeping in an emergency shelter, transitional housing program, your car or truck, anywhere outside, or in another place not meant for human habitation]
Eleven or younger 0
12-15 (SKIP TO A23) 1
16-17 (SKIP TO A23) 2
18-19 3
20-24 4
25-34 5
35 or older 6
Don’t Know 7
Refused 8
A22a. Did that first time happen…
Before you joined the military, reserves, or National Guard? 1
While you were in the military, reserves, or National Guard? 2
After you were discharged from the military, reserves, or National Guard? 3
Don’t Know 7
Refused 8
A23 Altogether, what would you say is the total number of days, weeks, months, or years that you have been homeless in your life? [INTERVIEWER: INSERT NUMBER IN A23a and then the unit (days/weeks/months) in A23b.]
. A23a NUMBER OF [DAYS/WEEKS/MONTHS/YEARS] ______________
DON’T KNOW 997
REFUSED 998
A23b RECORD UNIT OF TIME:
DAYS 1
WEEKS 2
MONTHS 3
YEARS 4
DON’T KNOW 7
REFUSED 8
A24 Thinking about the (various) time(s) you were homeless, can you tell me about the things that happened to cause you to lose your housing or become homeless? (ASK QUESTION, RECORD ANSWERS, PROBE FOR “ANYTHING ELSE,” BUT DON’T READ ALL THE ANSWERS).
|
|
Yes |
No |
|
RENT / FINANCIAL ISSUES |
|
|
A |
You couldn’t pay the rent |
1 |
0 |
B |
The rent increased and you couldn’t afford to pay it |
1 |
0 |
C |
Someone who paid the rent/mortgage stopped paying it |
1 |
0 |
D |
You lost your job or your job ended or your hours were cut substantially |
1 |
0 |
E |
Someone else in your household lost their job or their job ended or their hours were cut substantially |
1 |
0 |
F |
You lost welfare or another cash assistance benefit |
1 |
0 |
|
FORCED OUT BY SOMEONE ELSE |
|
|
G |
You were pushed out or kicked out |
1 |
0 |
H |
People you were staying with asked you to leave |
1 |
0 |
I |
The landlord made you leave or you were evicted |
1 |
0 |
J |
You didn’t get along with people there |
|
|
K |
You, or your children, were abused or beaten or there was violence in the household |
|
|
L |
The bank foreclosed on your house |
1 |
0 |
M |
The landlord was foreclosed on, and all tenants had to leave |
1 |
0 |
N |
Your house or apartment was condemned or destroyed (e.g., fire, flood, tornado, earthquake) |
1 |
0 |
|
HEALTH ISSUES |
|
|
O |
You became sick or disabled (other than ARC/AIDS/HIV related) |
1 |
0 |
P |
It was ARC/AIDS/HIV related |
1 |
0 |
Q |
You were drinking |
1 |
0 |
R |
You were doing drugs |
1 |
0 |
S |
You went into the hospital or treatment program |
1 |
0 |
T |
You were pregnant or just had a baby |
1 |
0 |
U |
You were released, dismissed, or discharged from the institution or treatment program where you were staying |
1 |
0 |
V |
Wanted to get away from someone else’s drug / alcohol use |
1 |
0 |
|
OTHER REASONS |
|
|
W |
No room, too crowded |
1 |
0 |
X |
You went into the military |
1 |
0 |
Y |
You went to jail or prison |
1 |
0 |
Z |
You left town |
1 |
0 |
AA |
Other Specify: _________________________________ |
1 |
0 |
DON’T KNOW 7
REFUSED 8
SECTION B. HOUSEHOLD COMPOSITION
Now I’d like to ask you some questions about the people you have lived or stayed with during the past 12 months / since you left the military—that would be since [INSERT MONTH AND YEAR].
B1 Do you live alone now?
YES 1
NO (SKIP TO B2) 0
DON’T KNOW 7
REFUSED 8
B1a. Have you lived alone for ALL of the last 12 months / since you left the military?
YES 1
NO (SKIP TO B2) 0
DON’T KNOW 7
REFUSED 8
If both B1 and B1a are “yes,” skip to B7.
B2. Thinking about where you were living 12 months ago / since you left the military—that would be since [INSERT MONTH AND YEAR], could you tell me the people you were living with at that time? [Mark all that apply]
B2a. Your children (if asked, “including someone else’s children
you were responsible for”) Y/N/DK/Ref
How Many? ____________
B2b. Someone else’s children (not your responsibility) Y/N/DK/Ref
How Many? ____________
B2c. Your spouse Y/N/DK/Ref
B2d. Your boyfriend, girlfriend, or partner Y/N/DK/Ref
B2e. Your parent(s) or your spouse/partner/boy/girlfriend’s parent(s) Y/N/DK/Ref
B2f. Other relatives of yours or your spouse/partner/boy/girlfriend’s Y/N/DK/Ref
B2g. Friends Y/N/DK/Ref
B2h. Roommates Y/N/DK/Ref
B2i. Lodger(s), Boarder(s), anyone else Y/N/DK/Ref
B2j. How many adults and how many children would that be, in total, counting yourself?
# adults (18 and older) _______________
# children (17 and younger) ___________
B3. Do you still live with all the same people you did 12 months ago / when you left the military, and no one else?
YES (SKIP TO B5) 1
NO (i.e., lives with more/fewer/different people—ASK B4) 0
DON’T KNOW 7
REFUSED 8
B4. Please tell me all the people you live with now. [Mark all that apply]
B4a. Your children (if asked, “including someone else’s children
you were responsible for”) Y/N/DK/Ref
How Many? ____________
B4b. Someone else’s children (not your responsibility) Y/N/DK/Ref
How Many? ____________
B4c. Your spouse Y/N/DK/Ref
B4d. Your boy/girlfriend/partner Y/N/DK/Ref
B4e. Your parent(s) or your spouse/partner/boy/girlfriend’s parent(s) Y/N/DK/Ref
B4f. Other relatives of yours or your spouse/partner/boy/girlfriend’s Y/N/DK/Ref
B4g. Friends Y/N/DK/Ref
B4h. Roommates Y/N/DK/Ref
B4i. Lodger(s), Boarder(s), anyone else Y/N/DK/Ref
B4j. How many adults and how many children would that be, in total, counting yourself?
# adults (18 and older) _______________
# children (17 and younger) ___________
B5. Between the time 12 months ago / when you left the military and now, have you lived with any people who are not with you now and also were not with you 12 months ago / when you left the military—that is, is there anyone you have lived with, even for a little while, between then and now, who has not been mentioned yet?
YES (ASK B5a) 1
NO (SKIP to B6) 0
DON’T KNOW 7
REFUSED 8
B5a. Who would that be?
B5a1. Your children (if asked, “including someone else’s children
you were responsible for”) Y/N/DK/Ref
How Many? ____________
B5a2. Someone else’s children (not your responsibility) Y/N/DK/Ref
How Many? ____________
B5a3. Your spouse Y/N/DK/Ref
B5a4. Your boy/girlfriend/partner Y/N/DK/Ref
B5a5. Your parent(s) or your spouse/partner/boy/girlfriend’s parent(s) Y/N/DK/Ref
B5a6. Other relatives of yours or your spouse/partner/boy/girlfriend’s Y/N/DK/Ref
B5a7. Friends Y/N/DK/Ref
B5a8. Roommates Y/N/DK/Ref
B5a9. Lodger(s), Boarder(s), anyone else Y/N/DK/Ref
IF R LIVES WITH AT LEAST 1 CHILD NOW FOR WHOM S/HE HAS RESPONSIBILITY (B4A = YES), ASK B6.
OTHERWISE, SKIP TO B7.
B6. Thinking about the children who live with you now and for whom you have responsibility, how many of them are
B6a. Aged 0 (newborn) through 5?
NUMBER OF CHILDREN ______________
DON’T KNOW 7
REFUSED 8
B6b. Aged 6 through 17?
NUMBER OF CHILDREN ______________
DON’T KNOW 7
REFUSED 8
B6c. Adults—that is, aged 18 or older?
NUMBER OF CHILDREN ______________
DON’T KNOW 7
REFUSED 8
B7. Do you have any children of your own, ages 0 through 17, who do NOT live with you now?
YES (ASK B7a) 1
NO 0
DON’T KNOW 7
REFUSED 8
B7a. NUMBER OF CHILDREN ______________
DON’T KNOW 7
REFUSED 8
B8. Do you have a spouse who does NOT live with you now?
YES 1
NO 0
DON’T KNOW 7
REFUSED 8
SECTION C: HOUSING BARRIERS
Next, I’d like to ask about some things that sometimes make people move from the place they live, or make it difficult to keep their housing, or to find a place to live if they have lost the housing they used to have.
IF A4 IS 1, 2, 3, OR 4, START AT C1
IF A4 IS 5, START AT C2
C1. People may change the place they live for many reasons. I’m going to read you a list of some of those reasons. Thinking about the time(s) you moved during the past 12 months, please tell me if something was a major reason, minor reason, or not a reason at all why you moved.
|
Major Reason |
Minor Reason |
Not a Reason |
DK |
Ref |
|
|
|
|
|
|
C1a. To get better schools for my children |
2 |
1 |
0 |
7 |
8 |
C1b. Change in marital / romantic status |
2 |
1 |
0 |
7 |
8 |
C1c. Better transportation |
2 |
1 |
0 |
7 |
8 |
C1d. Wanted a better, apartment or house |
2 |
1 |
0 |
7 |
8 |
C1e. Want a bigger apartment or house |
2 |
1 |
0 |
7 |
8 |
C1f. To get or change job / to be near my job |
2 |
1 |
0 |
7 |
8 |
C1g. To get away from drugs, gangs, or other unsafe activities |
2 |
1 |
0 |
7 |
8 |
C1h. To be near my family |
2 |
1 |
0 |
7 |
8 |
C1i. Did not get along with landlord |
2 |
1 |
0 |
7 |
8 |
C1j. Did not get along with other people there |
2 |
1 |
0 |
7 |
8 |
C1k. Change in rent/unit too expensive |
2 |
1 |
0 |
7 |
8 |
C1l. Utilities were too expensive |
2 |
1 |
0 |
7 |
8 |
C1m. Unit failed section 8 inspection |
2 |
1 |
0 |
7 |
8 |
C1n. Got a section 8 subsidy |
2 |
1 |
0 |
7 |
8 |
C1o. Moved into public housing |
2 |
1 |
0 |
7 |
8 |
C1p. Personal safety/domestic violence |
2 |
1 |
0 |
7 |
8 |
C1q. Entered a residential treatment program |
2 |
1 |
0 |
7 |
8 |
C1r. Asked to leave by the people whose place it was |
2 |
1 |
0 |
7 |
8 |
C1s. Evicted—formal eviction by landlord |
2 |
1 |
0 |
7 |
8 |
C1t. Other |
2 |
1 |
0 |
7 |
8 |
|
|
|
|
|
|
DON’T KNOW |
7 |
|
|
|
|
REFUSED |
8 |
|
|
|
|
C2. Many things may make it difficult for people to keep the housing they have. I’m going to read a number of reasons why people might have trouble keeping their housing. Please tell me if you think this has been a big problem, a small problem, or no problem for you during the past 12 months.
When trying to keep the housing you have/had, is/was … |
Big |
Small problem |
No problem at all |
DON’T KNOW |
REF |
C2a. Not having enough income to pay rent a... |
3 |
2 |
1 |
7 |
8 |
C2b. Not having enough income to pay for utilities a … |
3 |
2 |
1 |
7 |
8 |
C2c. Owing too much back rent or utilities … |
3 |
2 |
1 |
7 |
8 |
C2d. Not being currently employed a… |
3 |
2 |
1 |
7 |
8 |
C2e. Sudden loss of income a … |
3 |
2 |
1 |
7 |
8 |
C2f. Sudden illness of you or other earner a … |
3 |
2 |
1 |
7 |
8 |
C2g. Loss of essential household member through divorce, separation, death a … |
3 |
2 |
1 |
7 |
8 |
C2h. Having conflicts with people you live with a … |
3 |
2 |
1 |
7 |
8 |
C2i. Having trouble with drugs or alcohol a … |
3 |
2 |
1 |
7 |
8 |
C2j. Having emotional problems, depression a … |
3 |
2 |
1 |
7 |
8 |
C2k. Having too many people living in the same place a … |
3 |
2 |
1 |
7 |
8 |
C2l. Fearing eviction because people staying where you are aren’t on the lease |
3 |
2 |
1 |
7 |
8 |
C2m. Violence among the people you live with a… |
3 |
2 |
1 |
7 |
8 |
C2n. Trouble with your neighbors a… |
3 |
2 |
1 |
7 |
8 |
C2o. Violence in the neighborhood in general a … |
3 |
2 |
1 |
7 |
8 |
C2p. Having problems with police a… |
3 |
2 |
1 |
7 |
8 |
C3. Once a person loses housing, many things may make it hard to find another place to live. I’m going to read a number of reasons why people might have trouble finding housing. Please tell me if you think this is a big problem, small problem, or no problem at all for you.
When trying to find a place to live is … |
Big |
Small problem |
No problem at all |
DON’T KNOW |
REF |
C3a. Not having enough income to pay rent a... |
3 |
2 |
1 |
7 |
8 |
C3b. Not having enough money to pay a security or utility deposit or first/last month’s rent a… |
3 |
2 |
1 |
7 |
8 |
C3c. Lack of transportation to look for units a… |
3 |
2 |
1 |
7 |
8 |
C3d. Poor credit history a… |
3 |
2 |
1 |
7 |
8 |
C3e. Racial discrimination a… |
3 |
2 |
1 |
7 |
8 |
C3f. Not being currently employed a… |
3 |
2 |
1 |
7 |
8 |
C3g. No rent history a… |
3 |
2 |
1 |
7 |
8 |
C3h. No local rent history or recently moved to community a… |
3 |
2 |
1 |
7 |
8 |
C3i. No references from past landlords a… |
3 |
2 |
1 |
7 |
8 |
C3j. A past eviction(s) a… |
3 |
2 |
1 |
7 |
8 |
C3k. Problems with past landlords a… |
3 |
2 |
1 |
7 |
8 |
C3l. Past lease violations a… |
3 |
2 |
1 |
7 |
8 |
C3m. Having problems with police a… |
3 |
2 |
1 |
7 |
8 |
C3n. Having a criminal record or background a… |
3 |
2 |
1 |
7 |
8 |
C3o. Having a felony drug record, a… |
3 |
2 |
1 |
7 |
8 |
C3p. Having three or more children in the household a… |
3 |
2 |
1 |
7 |
8 |
C3q. Having teenagers in the household a… |
3 |
2 |
1 |
7 |
8 |
C3r. Someone in the household under 21 years old a… |
3 |
2 |
1 |
7 |
8 |
C3s. Someone in the household that has a disability a… |
3 |
2 |
1 |
7 |
8 |
C3t. Being a veteran a … |
3 |
2 |
1 |
7 |
8 |
C3u. The type of military discharge you have a … |
3 |
2 |
1 |
7 |
8 |
SECTION D. EDUCATION AND TRAINING
D1. At the time you began to fill out your application for [PN-HL], what was the highest grade or school did you complete and get credit for?
Grade (1-12): ____________________
GED 1
High school diploma 2
Some college or 2-year degree 3
Finished 4-year degree 4
Master’s degree or equivalent 5
Other 6
DON’T KNOW 7
REFUSED 8
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 97
REFUSED 98
UNRETRIEVABLE/MISSING 99
D2. At the time you began to fill out your application for [PN-HL], did you have any type of vocational license or certification from a training or educational program?
YES 1
NO 0
DON’T KNOW 7
REFUSED 8
D3. Are you now participating in any additional schooling or training program that (has) 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 0
DON’T KNOW 7
REFUSED 8
D4. What kind of schooling or training is that? [MARK ALL THAT APPLY]
D4a. Regular schooling leading to a degree (AA, BA, etc.) Y/N/DK/Ref
D4b. Regular schooling leading to a vocational or professional
license or certification Y/N/DK/Ref
D4c. General equivalency diploma (GED) Y/N/DK/Ref
D4d. English as a second language (ESL) Y/N/DK/Ref
D4e. Computer training Y/N/DK/Ref
D4f. Apprenticeship / on-the-job training Y/N/DK/Ref
D4g. Vocational rehabilitation Y/N/DK/Ref
D4h. OTHER Y/N/DK/Ref
DON’T KNOW 7
REFUSED 8
D5. Did _________________ help you get that schooling / training? [Insert each program name in turn]
D5a. [PN-HL] Y/N/DK/Ref
D5b. [PN-VA] Y/N/DK/Ref
D5c. [PN-DOL] Y/N/DK/Ref
D5d. Other agency Y/N/DK/Ref
SECTION E. INCOME AND EMPLOYMENT
E1. Have you received any income from any source in past 30 days?
YES 1
NO (SKIP TO E6) 0
REFUSED 7
DON’T KNOW 8
E2. In the past 30 days, have you received any income from … (IF YES:) How much did you receive in the past 30 days?
|
NO |
YES |
AMOUNT |
E2a. Income from a job |
0 |
1 |
$_____________ |
E2b. Unemployment Insurance |
0 |
1 |
$_____________ |
E2c. Supplemental Security Income (SSI) |
0 |
1 |
$_____________ |
E2d. Social Security Disability Income (SSDI) |
0 |
1 |
$_____________ |
E2e. Service-connected psychiatric disability pension /payment from the VA |
0 |
1 |
$_____________ |
E2f. Service-connected non-psychiatric disability pension /payment from the VA |
0 |
1 |
$_____________ |
E2g. Non-service-connected veteran’s pension |
0 |
1 |
$_____________ |
E2h. Private disability insurance |
0 |
1 |
$_____________ |
E2i. Worker’s compensation |
0 |
1 |
$_____________ |
E2i. Compensated work therapy (CWT) |
0 |
1 |
$_____________ |
E2k. Temporary Assistance for Needy Families (TANF) (or use local program name) |
0 |
1 |
$_____________ |
E2l. General Assistance (GA) (or use local program name) |
0 |
1 |
$_____________ |
E2m. Retirement income from Social Security |
0 |
1 |
$_____________ |
E2n. Income from investments or assets |
0 |
1 |
$_____________ |
E2o. Pension from a former civilian job |
0 |
1 |
$_____________ |
E2p. Child support |
0 |
1 |
$_____________ |
E2q. Alimony or other spousal support |
0 |
1 |
$_____________ |
E2r. Other source |
0 |
1 |
$_____________ |
E3. In the past 30 days, did the GI Bill, an education or training allowance from the VA, or a scholarship or grant provide you with income or resources that you could use to cover expenses?
YES 1
NO 0
REFUSED 7
DON’T KNOW 8
E4. [IF OTHER ADULTS IN THE HOUSEHOLD [B2j = 2+ adults], ASK: Did any other adults in your household / in the household where you live receive any income in the past 30 days?
YES 1
NO 0
REFUSED 7
DON’T KNOW 8
E4a. If YES to E4, ASK: How many other adults who live with you received any income in the past 30 days? _______
E4b. Ask E4b if E4a. > 0: What was the total income received by other adults in your household in the past 30 days? _______
IF DON’T KNOW, OR REFUSED, Ask in ranges:---such as:
1 Under $500
2 $500 - < $750
3 $750 - <$1000
4 $1000-<$1500
5 $1500-<$2000
6 $2000 or more
E5. 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.
|
NO |
YES |
Amount of monthly assistance
|
E5a. Food Stamps (officially called Supplemental Nutrition Assistance Program (SNAP) |
0 |
1 |
$___________ |
E5b. Medicaid health insurance program (or use local name) |
0 |
1 |
|
E5c. Medicare health insurance program (or use local name) |
0 |
1 |
|
E5d. State Children’s Health Insurance Program (or use local name) |
0 |
1 |
|
E5e. WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) |
0 |
1 |
$___________ |
E5f. Veteran’s Administration (VA) Medical Services |
0 |
1 |
|
E5g. TANF Child Care services (or use local name) |
0 |
1 |
|
E5h. Other child care services |
0 |
1 |
|
E5i. TANF transportation services (or use local name) |
0 |
1 |
|
E5j. Other transportation services |
0 |
1 |
|
E5k. Other TANF-funded services (or use local name) |
0 |
1 |
|
E5l. Health Insurance from work |
0 |
1 |
|
E5m. Health insurance from a place you used to work |
0 |
1 |
|
E5n. Health insurance you pay for yourself |
0 |
1 |
|
E5o. Temporary rental assistance |
0 |
1 |
$___________ |
E5p. Other source |
0 |
1 |
$___________ |
E6. Did _________________ help you access those benefits? [Insert each program name in turn]
E6a. [PN-HL] Y/N/DK/Ref
E6b.[PN-VA] Y/N/DK/Ref
E6c. [PN-DOL] Y/N/DK/Ref
Now I’d like to ask a few questions about any jobs you may have.
E7. Last week, did you do any work for pay?
YES (SKIP TO E12b) 1
NO 0
DON’T KNOW 7
REFUSED 8
E8. Have you been doing anything to find work during the past four weeks?
YES 1
NO 0
DON’T KNOW 7
REFUSED 8
E9. What is the main reason that you did not work for pay or look for work last week? [Wait for respondent to answer and mark only one]
Unable to work because of housing problems 01
Unable to work for health reasons related to military service 02
Unable to work for health reasons unrelated to military service 03
Has job but temporarily absent/seasonal work 04
Couldn’t find any work 05
Couldn’t find a job that pays enough 06
Child care problems 07
Family responsibilities 08
In school or other training 09
Waiting for a new job to begin 10
Had enough money from other sources 11
Retired 12
Disabled 13
Other (specify): ______________________________ 95
DON’T KNOW 97
REFUSED 98
E10. Have you been referred to [PN-DOL] to help you find work?
YES 1
NO 0
DON’T KNOW 7
REFUSED 8
E11. Do you have a disability that limits or prevents you from working?
YES (ASK E11a) 1
NO 0
DON’T KNOW 7
REFUSED 8
E11a. Is this disability related to your military service?
YES 1
NO 0
DON’T KNOW 7
REFUSED 8
E12. When did you last work for pay, including in the military?
__ __/__ __ __ __ Month/Year
DON’T KNOW (ASK E12a) 7
REFUSED 8
E12a. About how long ago was it that you last worked for pay? Would it be longer than one year? Longer than two years?
Number of months ______
Number of years _______
DON’T KNOW 7
REFUSED 8
E12b. [ASK IF ANSWER TO E11/11a IS LESS THAN 1 YEAR] During the [past 12 months / since you left the military], how much of the time have you had a job or done some work for pay?
All or almost all of the time 5
Most of the time 4
About half of the time 3
Some of the time 2
Almost none or none of the time 1
DON’T KNOW 7
REFUSED 8
DO NOT ASK E13 IF DATE OF DAY LAST WORKED FOR PAY IS DATE LEFT MILITARY. DO NOT ASK E14 IF DATE LAST WORKED FOR PAY IS 3 OR MORE MONTHS AGO.
E13. Have you worked for pay since leaving the military, Reserves, or National Guard?
YES 1
NO 0
DON’T KNOW 7
REFUSED 8
E14. Were you working for pay at the time you began filling out your application for [PN-HL]?
YES 1
NO 0
DON’T KNOW 7
REFUSED 8
IF E7 = 0, THEN SKIP TO E18
E15. When did you first start working at your job?
__ __/__ __ __ __ Month/Year
DON’T KNOW (ASK E15a) 7
REFUSED 8
E15a. About how long have you been working at that job?
Number of months ______
Number of years _______
DON’T KNOW 7
REFUSED 8
E15b. [ASK IF E15a = 2 MONTHS OR LESS] Did _________________ help you get that job? [Insert each program name in turn, record answer]
E6a. [PN-HL] Y/N/DK/Ref
E6b.[PN-VA] Y/N/DK/Ref
E6c. [PN-DOL] Y/N/DK/Ref
E16. Last week, did you have more than one job, including part-time and weekend work?
YES 1
NO 0
DON’T KNOW 7
REFUSED 8
E17. How many hours per week do you usually work at your main job? By main job, I mean the one at which you usually work the most hours.
NUMBER OF HOURS________________ 1-84
DON’T KNOW 97
REFUSED 98
E16a. Do you usually work 35 hours or more per week at your main job?
YES 1
NO 0
DON’T KNOW 7
REFUSED 8
E18. How old were you when you first worked for pay?
Age in years ________________ 12-60
DON’T KNOW 97
REFUSED 98
E19. Since you were 16 years old, how much of your life have you had a job or done some work for pay, including your time in the military, reserves, or National Guard?
All or almost all of the time 5
Most of the time 4
About half of the time 3
Some of the time 2
Almost none or none of the time 1
DON’T KNOW 7
REFUSED 8
E20. [ASK IF ANSWER TO E15a IS LESS THAN 1 YEAR] During the past 12 months / since you left the military, how much of the time have you had a job or done some work for pay?
All or almost all of the time 5
Most of the time 4
About half of the time 3
Some of the time 2
Almost none or none of the time 1
DON’T KNOW 7
REFUSED 8
SECTION F: HOUSING COSTS
Now I’d like to talk about how much you pay each month for housing.
IF A5 = 1 AND A1a = 1, THEN SKIP TO F8
IF A5 = 2, AND A5a1 = 1, THEN SKIP TO F8
F1. IF RENTERS: What is the total rent on the place you are staying—the rent on the lease, not just what you and your household pay?
PER MONTH: $__ __ __ __ .00 (FOUR DIGITS, ROUNDED TO DOLLAR)
(EXPECTED RANGE = $1-3000)
DON’T KNOW (ASK F1a) -2
REFUSED (ASK F1a) -1
F1a. Can you give me a range? Is the full monthly rent payment:
Under $500 per month 1
$500 - < $750 2
$750 - < $1000 3
$1000 - < $1500 4
$1500 - < $2000 5
More than $2000 per month 6
DON’T KNOW 7
REFUSED 8
F2. In the month just past, what did you and your family pay in rent? We are interested only in knowing the amount of the rent payment that you and your family 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 = $1-3000)
DON’T KNOW (ASK F2a) -2
REFUSED (ASK F2a) -1
F2a. Can you give me a range? Is your own family’s monthly rent payment:
Under $500 per month 1
$500 - < $750 2
$750 - < $1000 3
$1000 - < $1500 4
$1500 - < $2000 5
More than $2000 per month 6
DON’T KNOW 7
REFUSED 8
F3. Do you receive any assistance to pay rent from the government or from some other program?
YES (ask F4) 1
NO (skip to F5) 0
DON’T KNOW 7
REFUSED 8
F4. Is this assistance from [PN-HL], public housing, a Section 8 Voucher, Project-based Section 8, VASH, temporary rent assistance (up to 24 months), or some other type of assistance?
[PN-HL] 1
Public housing 2
Section 8 voucher 3
Project based section 8 4
A VASH voucher through the VA 5
Temporary rent assistance through the VA—(e..g., SSVF, Grant & Per Diem) 6
Temporary rent assistance (up to 24 months, e.g., HPRP, TANF, a transitional
housing program for homeless people, 7
Other 8
DON’T KNOW 97
REFUSED 98
F5. IF OTHER ADULTS IN THE HOUSEHOLD, BASED ON HOUSEHOLD COMPOSITION QUESTION ABOVE (IF B2j # of Adults > 1), ASK: Thinking about the other adult(s) living with you or you are living with, did any of them contribute any money toward rent or utilities?
YES (ask F5a) 1
NO 0
DON’T KNOW 7
REFUSED 8
F5a. What is the total amount these other adults paid toward rent or utilities in the past 30 days? _______
IF DON’T KNOW, OR REFUSED, Ask in ranges: Such as…
Under $200
$300 - < $400
$400 - <$600
$700-<$1000
$1000 or more
F6. Did any adults who do not live with you or in the place you are staying contribute any money toward rent or utilities in the past 30 days?
YES (ASK F6a) 1
NO 0
DON’T KNOW 7
REFUSED 8
F6a. What is the total amount these other adults paid toward your rent in the past 30 days? _______
IF DON’T KNOW, OR REFUSED, Ask in ranges: Such as…
Under $200
$300 - < $400
$400 - <$600
$700-<$1000
$1000 or more
F7. In the last 12 months, has there been a time when you were unable to pay rent? [INTERVIEWER—if asked, clarify—“two weeks into the the month when it was due”]
YES (ASK F7a) 1
NO 0
DON’T KNOW 7
REFUSED 8
F7a. How often did this happen?
Once 1
Twice 2
Three or more times 3
DON’T KNOW 7
REFUSED 8
SKIP TO F9
F8. IF OWNERS: 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 and your household 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)
DON’T KNOW (ASK F8a) -2
REFUSED (ASK F8a) -1
F8a. Can you give me a range? Is your monthly mortgage payment:
Under $500 per month 1
$500 - < $750 2
$750 - < $1000 3
$1000 - < $1500 4
$1500 - < $2000 5
More than $2000 per month 6
DON’T KNOW 7
REFUSED 8
F9. Do you pay for any utilities that are not included as part of the [RENT/MORTGAGE] that you pay? By utilities, I mean electricity, heating oil, gas or propane, and water, but NOT telephone and cable services.
YES (ask F10) 1
NO 0
DON’T KNOW 7
REFUSED 8
F10. 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)
DON’T KNOW (ASK F10a) -2
REFUSED (ASK F10a) -1
F10a. Can you tell me the range for your monthly utility payment? Was it…
Under $500 per month 1
$500 - < $750 2
$750 - < $1000 3
$1000 - < $1500 4
$1500 - < $2000 5
More than $2000 per month 6
DON’T KNOW 7
REFUSED 8
F11. In the last 12 months, has there been a time when you were unable to pay utility bills—that is, electricity, heating oil, gas or propane, and water, but NOT telephone and cable services. [INTERVIEWER—if asked, clarify—“by the middle of the month when it was due”]
YES (ASK F11a) 1
NO 0
DON’T KNOW 7
REFUSED 8
F11a. How often did this happen?
Once 1
Twice 2
Three or more times 3
DON’T KNOW 7
REFUSED 8
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.
|
Often true |
Sometimes true |
Never true |
DK |
REF |
G1a. We worried whether our food would run out before we got money to buy more. |
3 |
2 |
1 |
7 |
8 |
G1b. The food we bought just didn't last, and we didn't have money to get more. |
3 |
2 |
1 |
7 |
8 |
G1c. We couldn't afford to eat balanced meals. |
3 |
2 |
1 |
7 |
8 |
G2. 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 (Skip to G4) 0
DON’T KNOW 7
REFUSED 8
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 3
SOME MONTHS BUT NOT EVERY MONTH 2
ONE OR TWO MONTHS 1
DON’T KNOW 7
REFUSED 8
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 0
DON’T KNOW 7
REFUSED 8
G5. In the last 12 months, were you ever hungry but didn’t eat because you couldn’t afford enough food?
YES 1
NO 0
DON’T KNOW 7
REFUSED 8
SECTION H: FAMILY HEALTH AND WELL-BEING
H1. 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 7
REFUSED 8
H2. Please tell me about any health problems you may be experiencing at this time (read and check all that apply)
H2a. Chest infection, cold, cough, bronchitis Y/N/DK/Ref
H2b. Pneumonia Y/N/DK/Ref
H2c. Tuberculosis Y/N/DK/Ref
H2d. Joint problems, arthritis, rheumatism Y/N/DK/Ref
H2e. Problem walking, lost limb, other physical handicap or disability Y/N/DK/Ref
H2f. High blood pressure Y/N/DK/Ref
H2g. Heart disease, stroke Y/N/DK/Ref
H2h. Diabetes, high sugar Y/N/DK/Ref
H2i. Gonorrhea, syphilis, herpes, Chlamydia, other STDs (NOT AIDS) Y/N/DK/Ref
H2j. HIV/AIDS Y/N/DK/Ref
H2k. Serious depression Y/N/DK/Ref
H2l. Serious anxiety or tension Y/N/DK/Ref
H2m. Being easily startled, not being able to relax your guard Y/N/DK/Ref
H2n. Trouble understanding, concentrating, or remembering Y/N/DK/Ref
H2o. Trouble sleeping Y/N/DK/Ref
H2p. Trouble controlling anger or violent behavior Y/N/DK/Ref
H2q. Symptoms of post-traumatic stress disorder (PTSD) Y/N/DK/Ref
H2r. Trouble with use of alcohol or drugs Y/N/DK/Ref
H2s. Problems dealing with the results of head injury/traumatic brain injury (TBI) Y/N/DK/Ref
H2t. Experiencing serious thoughts of suicide Y/N/DK/Ref
H2u. Cancer Y/N/DK/Ref
H2v. OTHER 95
DON’T KNOW 97
REFUSED 98
H3. Has _________________ been helping you with any of these health problems? [Insert each program name]
H3a. [PN-HL] Y/N/DK/Ref
H3b. [PN-VA] Y/N/DK/Ref
H3c. [PN-DOL] Y/N/DK/Ref
IF NO CHILDREN LIVING WITH R (B4A = NO), SKIP TO SECTION I
The next few questions are about your children aged 17 and younger who live with you now.
H4. Overall, how would you rate the health of these child(ren) during the past month (that is the past 30 days)?
Excellent 1
Very good 2
Good 3
Fair 4
Poor 5
DON’T KNOW 7
REFUSED 8
H5. Do any of your minor children who live with you have disabilities that require, or will require, any special school services?
Yes 1
No 0
DON’T KNOW 7
REFUSED 8
H6. Do any of your minor children who live with you have disabilities that require any special housing accommodations?
Yes 1
No 0
DON’T KNOW 7
REFUSED 8
IF B6B GE 1, ASK H7A
IF B6B = 0, SKIP TO SECTION I
H7. Earlier [B6b] you said you had _____ of your own children aged 6 to 17. I’d like to ask you a few questions about them.
H7a. I’d like to ask you about your school-age children who live with you—that is, child(ren) in your household who are aged 6 through 17. Are all of these children attending school now?
Yes, all of them (SKIP TO H7b) 2
Some are, and some are not 1
No, none of them are attending school 0
DON’T KNOW 7
REFUSED 8
H7b. Have they been attending school throughout the most recent school year?
Yes, all of them have been attending 3
Some have been and some have not been attending 2
No, none of them have been attending school 1
Don’t know about one or more kids because she/he/they doesn’t/don’t live with me 0
DON’T KNOW 7
REFUSED 8
H7c. [Ask if H7b. is 3 or 2] Over the past 12 months, how many different schools has each child attended?
Each child has attended only 1 school the whole year 1
One or more children has attended 2 different schools during the year 2
One or more children has attended 3 or more different schools during the year 3
Don’t know about one or more kids because she/he/they haven’t lived with me all year 4
DON’T KNOW 7
REFUSED 8
IF H7A = 1 OR 0, OR H7B = 2 OR 1, ASK H8.
OTHERWISE, SKIP TO SECTION I
H8. There may be many reasons why children are not able to attend school. Please tell me which of the following have been true for your children over the past 12 months:
H8a. Took time to enroll them after moving Y/N/DK/Ref
H8b. Took time to get the proper documents together (e.g., immunizations) Y/N/DK/Ref
H8c. Transportation too hard to arrange Y/N/DK/Ref
H8d. Child(ren) sick a lot Y/N/DK/Ref
H8e. Other children at school treat my child(ren) badly Y/N/DK/Ref
H8f. Child(ren) moving back and forth between parents Y//N/DK/Ref
H8g. OTHER Y/N/DK/Ref
DON’T KNOW 7
REFUSED 8
SECTION I: VETERAN STATUS/MILITARY EXPERIENCE
I1. Have you ever been on active-duty military services in the Armed Forces of the United States or ever been in the United States military Reserves or the National Guard? Active duty does not include training in the reserves or National Guard.
Yes, on active duty in the Armed Forces of the US in the past, but not now 2
Yes, active duty, in the Reserves or National Guard only 1
No 0
DON’T KNOW 7
REFUSED 8
I2. When did you serve on active duty in the U.S. Armed Forces, Reserves, or National Guard? (Interviewer: Ask for month and year and mark all that apply.)
I2a. Persian Gulf: August 1990 to current Y/N/DK/Ref
I2b. May 1975 to July 1990 Y/N/DK/Ref
I2c. Vietnam era (August 1964-April 1975) Y/N/DK/Ref
I2d. February 1955-July 1964 Y/N/DK/Ref
I2e. Korean conflict (June 1950-January 1955) Y/N/DK/Ref
I2f. January 1947 to May 1950 Y/N/DK/Ref
I2g. World War II (December 1941 to December 1946) Y/N/DK/Ref
I2h. December 1918 to November 1941 Y/N/DK/Ref
I2i. World War I (April 1917-November 1918) Y/N/DK/Ref
I3. Did you serve in the theatre of operations for any of the following military conflicts? That is, did you serve within the geographic proximity of the military conflict. We’ll ask next if you were exposed to conflict itself?
13a. World War II Y/N/DK/Ref
13b. Korean War Y/N/DK/Ref
13c. Vietnam War Y/N/DK/Ref
13d. Persian Gulf War (Operation Desert Storm) Y/N/DK/Ref
13e. Afghanistan (Operation Enduring Freedom) Y/N/DK/Ref
13f. Iraq (Operation Iraqi Freedom) Y/N/DK/Ref
13g. Iraq (Operation New Dawn) Y/N/DK/Ref
13h. Other peace-keeping operations or military interventions (such as
Lebanon, Panama, Somalia, Bosnia, Kosovo) Y/N/DK/Ref
I4. During your military service, were you ever in or exposed to combat?
Yes (ask I4a) 1
No 0
DON’T KNOW 7
REFUSED 8
I4a. Were you ever exposed to unfriendly or friendly fire?
Yes, a lot 2
Yes, a little 1
No 0
DON’T KNOW 7
REFUSED 8
14b. During your military service, how many times were you deployed to serve in combat?
0-1 deployments ..............................................................................................................1
2-3 deployments...............................................................................................................2
More than 3 deployments.................................................................................................3
DON’T KNOW..................................................................................................................7
REFUSED........................................................................................................................8
I5. In total, how many years of active duty military service did you serve?
__________ years
DON’T KNOW 7
REFUSED 8
I6. When were you discharged from the military, Reserves, or National Guard?
____/______ date, in month/year
DON’T KNOW 7
REFUSED 8
I7. When you were discharged from military service, what kind of discharge did you receive (Mark only one)
An honorable discharge 1
A general discharge, under honorable conditions 2
A general discharge, under other than honorable conditions 3
A bad conduct discharge 4
A dishonorable discharge 5
An uncharacterized or other discharge 6
DON’T KNOW 7
REFUSED 8
I8. Think of the greatest challenges you faced when re-entering civilian life after you left the military. Was [insert each option I8a. – I8k in turn] a challenge?
I8a. Finding a job, or getting your old job back Y/N/DK/Ref
I8b. Finding an affordable place to live Y/N/DK/Ref
I8c. Dealing with physical illnesses and conditions Y/N/DK/Ref
I8d. Getting through physical therapy/rehabilitation Y/N/DK/Ref
I8e. Getting used to my new physical limitations Y/N/DK/Ref
I8f. Letting down your guard, learning to relate to the world without constant
vigilance / expectation of danger Y/N/DK/Ref
I8g. Dealing with emotional problems Y/N/DK/Ref
I8h. Getting used to living with your family again Y/N/DK/Ref
I8i. Finding your place—seemed like there was no place for you any more,
You couldn’t reconnect Y/N/DK/Ref
I8j. Lack of social supports Y/N/DK/Ref
I8k. Something else [SPECIFY:__________________________] Y/N/DK/Ref
I8l. No challenges, haven’t had any problems 0
I9. After leaving the military, what period of time did you find the hardest to get through?
Right after being discharged 4
About six months to a year after being discharged 3
More than a year after being discharged 2
No time was hard, haven’t had any problems 1
DON’T KNOW 7
REFUSED 8
I10. Do you think military service increased your risk for becoming homeless or having trouble keeping your housing after you left the military, decreased your risk, or had no effect?
Increased very much (ask I10a) 5
Increased somewhat (ask I10a) 4
Had no effect 3
Decreased somewhat (ask I10a) 2
Decreased very much (ask I10a) 1
DON’T KNOW 7
REFUSED 8
I10a. What aspects of your military experience do you think were the most important in increasing or decreasing your risk of losing housing or becoming homeless?
_________________________________________________________________________
SECTION J: DEMOGRAPHICS
I have a few more questions about you.
J1. What is your ethnic background? Are you:
Hispanic or Latino, or 1
Not Hispanic or Latino? 0
DON’T KNOW 7
REFUSED 8
J2. What is your race? Do you think of yourself as: [Mark all that apply]
IF VOLUNTEERED: MULTIRACIAL, 1
Alaska Native or American Indian, 2
Asian, 3
Black or African American, 4
Native Hawaiian or Other Pacific Islander, or 5
White 6
OTHER (SPECIFY_______________) 96
DON’T KNOW 97
REFUSED 98
J3. INTERVIEWER: RECORD RESPONDENT’S GENDER:
MALE / FEMALE [query or interviewer observation]
J4. What is your Date of Birth?
____ _____ month
____ ____ date
____ ____ ____ ____ year
[CATI WILL PROMPT IF CURRENT YEAR IS GIVEN FOR BIRTH YEAR—TO ASK AGAIN FOR BIRTH YEAR—IF R CANNOT RECALL BIRTH YEAR, WILL ASK HOW OLD ARE YOU NOW?]
J5. What is your marital status?
Now married 5
Widowed 4
Divorced 3
Separated 2
Never married 1
DON’T KNOW 7
REFUSED 8
SECTION K: CONTACT INFORMATION
Thank you very much for your time today. To help us be able to get back in touch with you in the future, we would like to collect the names, telephone numbers and addresses of three people who will always know how to reach you. Please tell me about people who live at different addresses. This information will be kept strictly confidential and will only be used if we are unable to contact you.
K1. Could you tell us the name of someone who does not live with you and will always know how to contact you?
Yes 1
No 0
DON’T KNOW 7
REFUSED 8
CONTACT #1:
K2. What is his/her first name?
K2a. What is his/her middle name?
K2b. What is his/her last name?
K2c. Does his/her name have a suffix?
K3. What is (his/her) street address?
K3a. Is there a complex/building name?
K3b. Is there an apartment number?
K3c. In what city?
K3d. In what state?
K3e. What is the zip code?
K4. What is (his/her) home phone number, starting with the area code?
Telephone # with area code: (_______) ________-________
K5. What is (his/her) cell phone number, starting with the area code?
Telephone # with area code: (_______) ________-________
K6. What is (his/her) email address?
K7 What is (his/her) relationship to you?
Friend 1
Relative [SPECIFY RELATIONSHIP] 2
OTHER (SPECIFY______________________________) 95
DON’T KNOW 97
REFUSED 98
CONTACT #2:
K8. Could you tell us the name of a second person who does not live with you and will always know how to contact you?
Yes 1
No (SKIP TO CLOSING) 2
DON’T KNOW 7
REFUSED 8
K9. What is his/her first name?
K9a. What is his/her middle name?
K9b. What is his/her last name?
K9c. Does his/her name have a suffix?
K10. What is (his/her) street address?
K10a. Is there a complex/building name?
K10b. Is there an apartment number?
K10c. In what city?
K10d. In what state?
K10e. What is the zip code?
K11. What is (his/her) home phone number, starting with the area code?
Telephone # with area code: (_______) ________-________
K12. What is (his/her) cell phone number, starting with the area code?
Telephone # with area code: (_______) ________-________
K13. What is (his/her) email address?
K14. What is (his/her) relationship to you?
Friend 1
Relative [SPECIFY RELATIONSHIP] 2
OTHER (SPECIFY______________________________) 95
DON’T KNOW 97
REFUSED 98
CONTACT #3:
K15. Could you tell us the name of a third person who does not live with you and will always know how to contact you?
Yes 1
No (SKIP TO CLOSING) 2
DON’T KNOW (SKIP TO CLOSING) 7
REFUSED (SKIP TO CLOSING) 8
K16. What is his/her first name?
K16a. What is his/her middle name?
K16b. What is his/her last name?
K16c. Does his/her name have a suffix?
K17. What is (his/her) street address?
K17a. Is there a complex/building name?
K17b. Is there an apartment number?
K17c. In what city?
K17d. In what state?
K17e. What is the zip code?
K18. What is (his/her) home phone number, starting with the area code?
Telephone # with area code: (_______) ________-________
K19. What is (his/her) cell phone number, starting with the area code?
Telephone # with area code: (_______) ________-________
K20. What is (his/her) email address?
K21. What is (his/her) relationship to you?
Friend 1
Relative [SPECIFY RELATIONSHIP] 2
OTHER (SPECIFY______________________________) 95
DON’T KNOW 97
REFUSED 98
CLOSING: Thank you very much for your time today and for helping us with this study. Your answers and those of people like you will help shape programs to continue the types of help you have received from [PROGRAM NAME].
Evaluation of the Veterans Homelessness Prevention Demonstration
Interviewer: Please fill out any blanks on this page before you begin the interview. CATI will already have filled in the site and R ID number [delete if CATI fills it all in]
Interviewer Name: _______________________________
VHPD Site |
R ID Number |
Interview Date |
Start Time |
End Time |
1 – Utica/NY 2 – Tampa/FL 3 – Austin/TX 4 – San Diego/CA 5 – Tacoma/WA |
__________ |
___ / ___ / ___ |
____: _____ |
____: _____ |
CATI insert the following information in the right places in the follow-up, based on answers to baseline interview
Date of baseline interview [or do we want this to be the date of VHPD enrollment?]
Date that VHPD rent subsidy ended
Type of place at baseline—own place, s/o else’s place, homeless
Where R is living—same location as at baseline, or different location
R lived alone at baseline, or with others (if homeless w/o family, then “alone”)
If R had school-age children living in household at baseline, how many?___________
Instructions to interviewer are in pink
Instructions pertaining to CATI programming are in yellow
[READ ALOUD] Hi, my name is ______________. I’m calling from Silber & Associates, a research firm based in Baltimore. As you’ll recall, we talked on [INSERT DATE of baseline interview], just as you were enrolling in [PROGRAM NAME], about your situation and your housing needs. I’m talking to people such as yourself who have participated in a program to help veterans keep their housing, or get back into housing if they have lost it. We are interested in learning about how things are for you now, and how [PROGRAM NAME] may have helped, or still be helping, you and your family.
As before, I’ll be asking you a series of questions about your living situation (housing, who lives with you), income and employment, health and well-being, and anything that may be making it hard at present for you to stay stably housed. I’ll also be asking you about the [PROGRAM NAME] you participated in, and the ways you think the program has affected your current situation.
HUD, the VA, and the Department of Labor, the federal partners sponsoring [PROGRAM NAME], are very interested in helping veterans avoid homelessness. They hope to learn from your experiences with the [PROGRAM NAME] about the ways they might be able to help veterans who find themselves in need of help keep their housing. Your participation in this study will help the VA and HUD to improve programs for veterans like you across the country. Your participation is completely voluntary; you may stop the interview at any time. If any question makes you feel uncomfortable, you can refuse to answer that question. The information you provide will be kept confidential and only used for this study. The collection of this information has been approved by the Office of Management and Budget.
SECTION A. HOUSING NOW AND SINCE BASELINE
A1. I see that you are living in [the same place as/a different place than—CATI fill in] you were when we last talked. Is the place where you are living now your own place, someone else’s place, or something else? [If asked, “something else” could be a shelter, transitional housing program, hospital, treatment program, or car/vehicle, outdoors, place not meant for habitation]
Living in SAME PLACE as baseline that is
OWN PLACE (ASK A2) 1
SOMEONE ELSE’S PLACE (ASK A2) 2
SOMETHING ELSE (ASK A2) 3
Living in DIFFERENT PLACE than at baseline that is
OWN PLACE (SKIP TO A3) 4
SOMEONE ELSE’S PLACE (SKIP TO A3) 5
SOMETHING ELSE (SKIP TO A3) 6
DON’T KNOW 7
REFUSED 8
A2. Have you (and your family) been living here the whole time since we last talked, which was in__[ INSERT MONTH AND YEAR OF BASELINE INTERVIEW]__?
YES (IF A1 = 1 OR 2, SKIP TO SECTION B; OTHERWISE, ASK A3) 1
NO 0
DON’T KNOW 7
REFUSED 8
A3 How long have you lived or stayed in the place you are living now?
Less than 1 month 1
1 to 3 months 2
3 to 6 months 3
6 to 12 months 4
More than 12 months 5
Don’t Know 7
Refused 8
A4 Please describe the place you are living now. Is that your own place—that is, a house or apartment that you rent, and the lease is in your name or you and your spouse/partner’s names jointly.
YES (ASK A4a) 1
NO (SKIP TO A5) 0
DON’T KNOW 7
REFUSED 8
A4a. Do you own that place, or are you renting it?
Own it 1
Rent it 2
DON’T KNOW 7
REFUSED 8
SKIP TO A7
A5. Was it someone else’s place, for instance, the place of your parents, other relatives, or friends?
YES (ASK A5a) 1
NO (SKIP TO A6) 0
DON’T KNOW 7
REFUSED 8
A5a. Did you pay rent to the people whose place it was?
YES 1
NO 0
DON’T KNOW 7
REFUSED 8
SKIP TO A7.
A6 Could you tell me, then, which one of the following best describes where you are living at the present time? [INTERVIEWER: start reading options, stop when R indicates the right one, and mark that answer]
An emergency shelter or domestic violence shelter |
01 |
A voucher hotel or motel (paid for by a homeless or government program) |
02 |
Housing paid for by the VA’s Grant & Per Diem program |
03 |
A transitional housing program |
04 |
Anywhere not meant for habitation—e.g., a car, truck, RV, or trailer; an abandoned building, in parks, on the streets, in camping grounds, anywhere outside |
05 |
A hotel or motel you paid for yourself |
06 |
A VA residential drug or alcohol treatment program—only for vets |
07 |
A residential drug or alcohol treatment program for anyone—not just for vets |
08 |
A VA hospital |
09 |
Any other hospital—i.e., not a hospital run by the VA |
10 |
Jail or prison |
11 |
A permanent housing program for people with disabilities who have been homeless, with services and caseworkers to help you keep your housing |
12 |
OTHER SPECIFY: __________________________ |
13 |
Don’t Know |
97 |
Refused |
98 |
A7. 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 7
REFUSED 8
A8. Excluding kitchens, bathrooms and hallways, how many rooms does the unit have? _____
A9 Including the place you lived when we last talked [that is, since [INSERT DATE] and the place you are living now, how many different places have you lived?
Just those 2 places 1
3 places 2
4 places 3
5 or more places 4
Don’t Know 7
Refused 8
If R is not homeless now and has not been homeless since baseline interview, SKIP TO A14
Otherwise, if R was homeless at baseline interview or has been homeless since then, ASK A10 and A11
A10. Since we last talked, have you spent any time living or sleeping in any of the following places? [READ LIST AND MARK ALL THAT APPLY]
An emergency shelter or domestic violence shelter |
Y/N/DK/Ref |
A voucher hotel or motel (paid for by a homeless or government program) |
Y/N/DK/Ref |
Housing paid for by the VA’s Grant & Per Diem program |
Y/N/DK/Ref |
A transitional housing program |
Y/N/DK/Ref |
Anywhere not meant for habitation—e.g., a car, truck, RV, or trailer; an abandoned building, in parks, on the streets, in camping grounds, anywhere outside |
Y/N/DK/Ref |
A hotel or motel you paid for yourself |
Y/N/DK/Ref |
A VA residential drug or alcohol treatment program—only for vets |
Y/N/DK/Ref |
A residential drug or alcohol treatment program for anyone—not just for vets |
Y/N/DK/Ref |
A VA hospital |
Y/N/DK/Ref |
Any other hospital—i.e., not a hospital run by the VA |
Y/N/DK/Ref |
Jail or prison |
Y/N/DK/Ref |
A permanent housing program for people with disabilities who have been homeless, with services and caseworkers to help you keep your housing |
Y/N/DK/Ref |
OTHER SPECIFY: __________________________ |
Y/N/DK/Ref |
Don’t Know |
97 |
Refused |
98 |
A11. Thinking about the (various) time(s) you were homeless, can you tell me about the things that happened to cause you to lose your housing or become homeless? (INTERVIEWER: ASK QUESTION, RECORD ANSWERS, PROBE FOR “ANYTHING ELSE,” BUT DON’T READ ALL THE ANSWERS).
|
|
Yes |
No |
|
RENT / FINANCIAL ISSUES |
|
|
A |
You couldn’t pay the rent |
1 |
0 |
B |
The rent increased and you couldn’t afford to pay it |
1 |
0 |
C |
Someone who paid the rent/mortgage stopped paying it |
1 |
0 |
D |
You lost your job or your job ended or your hours were cut substantially |
1 |
0 |
E |
Someone else in your household lost their job or their job ended or their hours were cut substantially |
1 |
0 |
F |
You lost welfare or another cash assistance benefit |
1 |
0 |
|
FORCED OUT BY SOMEONE ELSE |
|
|
G |
You were pushed out or kicked out |
1 |
0 |
H |
People you were staying with asked you to leave |
1 |
0 |
I |
The landlord made you leave / you were evicted |
1 |
0 |
J |
You didn’t get along with people there |
1 |
1 |
K |
You, or your children, were abused or beaten or there was violence in the household |
1 |
1 |
L |
The bank foreclosed on your house |
1 |
0 |
M |
The landlord was foreclosed on, and all tenants had to leave |
1 |
0 |
N |
Your house or apartment was condemned or destroyed (e.g., fire, flood, tornado, earthquake) |
1 |
0 |
|
HEALTH ISSUES |
|
|
O |
You became sick or disabled (other than ARC/AIDS/HIV related) |
1 |
0 |
P |
It was ARC/AIDS/HIV related |
1 |
0 |
Q |
You were drinking |
1 |
0 |
R |
You were doing drugs |
1 |
0 |
S |
You went into the hospital or treatment program |
1 |
0 |
T |
You were pregnant or just had a baby |
1 |
0 |
U |
You were released, dismissed, or discharged from the institution or treatment program where you were staying |
1 |
0 |
V |
Wanted to get away from someone else’s drug / alcohol use |
1 |
0 |
|
OTHER REASONS |
|
|
W |
No room, too crowded |
1 |
0 |
X |
You went into the military |
1 |
0 |
Y |
You went to jail or prison |
1 |
0 |
Z |
You left town |
1 |
0 |
AA |
Other Specify: _________________________________ |
1 |
0 |
DON’T KNOW 7
REFUSED 8
A14. Since you began participating in [PN-HL], have you received any of the following types of assistance from that program…? [INTERVIEWER: read each option, record answer]
A14a. Paying off rent arrears—back rent you owed Y/N/DK/Ref
A14b. Paying deposit on different apartment Y/N/DK/Ref
A14c. Paying one or more month’s rent going forward Y/N/DK/Ref
A14d. Helping negotiate with current or new landlord Y/N/DK/Ref
A14e. Paying utility bill arrears—what you owed for old utility bills Y/N/DK/Ref
A14f. Negotiating with utility companies to set up a repayment schedule I could
handle, and/or lower my rate for the future Y/N/DK/Ref
A14g. Paying some or all of the costs of moving into a new place Y/N/DK/Ref
A14h. Helping get furniture and furnishings Y/N/DK/Ref
A15. [ASK if any “yeses” to A14] Did you get what you needed from the services you’ve just mentioned?
Yes, helped very much 2
Yes, helped somewhat 1
No, did not help 0
DON’T KNOW 7
REFUSED 8
SECTION B. HOUSEHOLD COMPOSITION
Now I’d like to ask you some questions about the people you have lived or stayed with since we last talked. That would be since [INSERT MONTH AND YEAR].
B1 Do you live alone now?
YES 1
NO (SKIP TO B2) 0
DON’T KNOW 7
REFUSED 8
B1a. Have you lived alone since we last talked?
YES 1
NO 0
DON’T KNOW 7
REFUSED 8
If both B1 and B1a are “yes,” skip to Section C. IF B1=1 and b1a=0 then skil to B4
B2. When we last talked, in [INSERT DATE], you were living with:---[CATI, insert the people R lived with]. Do you still live with exactly the same people—nobody new, nobody left?
YES (SKIP TO SECTION C) 1
NO 0
DON’T KNOW 7
REFUSED 8
B3. Since some things have changed, I’d like to know who lives in the household where you are staying now? [Mark all that apply]
B3a. Your children (if asked, “including someone else’s children
you were responsible for”) Y/N/DK/Ref
How Many? ____________
B3b. Someone else’s children (if asked, those that are not your responsibility) Y/N/DK/Ref
How Many? ____________
B3c. Your spouse Y/N/DK/Ref
B3d. Your boy/girlfriend/partner Y/N/DK/Ref
B3e. Your parent(s) or your spouse/partner/boy/girlfriend’s parent(s) Y/N/DK/Ref
B3f. Other relatives of yours or your spouse/partner/boy/girlfriend’s Y/N/DK/Ref
B3g. Friends Y/N/DK/Ref
B3h. Roommates Y/N/DK/Ref
B3i. Lodger(s), Boarder(s), anyone else Y/N/DK/Ref
B3a1. How many adults and how many children would that be, in total, counting yourself?
# adults (18 and older) _______________
# children (17 and younger) ___________
B4. Between the time we last talked and now, have you lived with any people who are not with you now and also were not with you when we last talked—that is, is there anyone you have lived with, even for a little while, between the time we last talked and now, who has not been mentioned yet?
YES (ASK B4A) 1
NO (SKIP to SECTION C) 0
DON’T KNOW 7
REFUSED 8
B4a. Who would that be?
B4a. Your children (if asked, “including someone else’s children
you were responsible for”) Y/N/DK/Ref
How Many? ____________
B4b. Someone else’s children (if asked, those that are not your responsibility) Y/N/DK/Ref
How Many? ____________
B4c. Your spouse Y/N/DK/Ref
B4d. Your boy/girlfriend/partner Y/N/DK/Ref
B4e. Your parent(s) or your spouse/partner/boy/girlfriend’s parent(s) Y/N/DK/Ref
B4f. Other relatives of yours or your spouse/partner/boy/girlfriend’s Y/N/DK/Ref
B4g. Friends Y/N/DK/Ref
B4h. Roommates Y/N/DK/Ref
B4i. Lodger(s), Boarder(s), anyone else Y/N/DK/Ref
SECTION C: HOUSING BARRIERS
Next, I’d like to ask about some things that sometimes make people change the place where they are living, or make it difficult for some people to keep their housing, or to find a place to live if they have lost the housing they used to have.
If A1 is 1 or 2, start at C2
If A2 is 3, 4, 5, 6, DK, or Refused, start at C1
C1. People may change the place they live for many reasons. I’m going to read you a list of some of those reasons. Thinking about the time(s) you moved since we last talked—that would be in [INSERT DATE]—please tell me if something was a major reason, minor reason, or not a reason at all why you moved. [IF R MOVED MORE THAN ONCE, REASONS COULD APPLY TO ONE OR MORE OF THE MOVES.]
|
Major Reason |
Minor Reason |
Not a Reason |
DK |
Ref |
|
|
|
|
|
|
C1a. To get better schools for my children |
2 |
1 |
0 |
7 |
8 |
C1b. Change in marital / romantic status |
2 |
1 |
0 |
7 |
8 |
C1c. Better transportation |
2 |
1 |
0 |
7 |
8 |
C1d. Wanted a better, apartment/house |
2 |
1 |
0 |
7 |
8 |
C1e. Want a bigger apartment/house |
2 |
1 |
0 |
7 |
8 |
C1f. To get or change job / to be near my job |
2 |
1 |
0 |
7 |
8 |
C1g. To get away from drugs, gangs, or other unsafe activities |
2 |
1 |
0 |
7 |
8 |
C1h. To be near my family |
2 |
1 |
0 |
7 |
8 |
C1i. Did not get along with landlord |
2 |
1 |
0 |
7 |
8 |
C1j. Did not get along with other people there |
2 |
1 |
0 |
7 |
8 |
C1k. Change in rent/unit too expensive |
2 |
1 |
0 |
7 |
8 |
C1l. Utilities were too expensive |
2 |
1 |
0 |
7 |
8 |
C1m. Unit failed section 8 inspection |
2 |
1 |
0 |
7 |
8 |
C1n. Got a section 8 subsidy |
2 |
1 |
0 |
7 |
8 |
C1o. Moved into public housing |
2 |
1 |
0 |
7 |
8 |
C1p. Personal safety/domestic violence |
2 |
1 |
0 |
7 |
8 |
C1q. Entered a residential treatment program |
2 |
1 |
0 |
7 |
8 |
C1r. Asked to leave by the people whose place it was |
2 |
1 |
0 |
7 |
8 |
C1s. Evicted—formal eviction by landlord |
2 |
1 |
0 |
7 |
8 |
C1t. Other |
2 |
1 |
0 |
7 |
8 |
|
|
|
|
|
|
DON’T KNOW |
7 |
|
|
|
|
REFUSED |
8 |
|
|
|
|
Next, I’d like to ask about some things that make it difficult at times for some people to keep their housing, or to find a place to live if they have lost the housing they used to have.
C2. Many things may make it difficult for people to keep the housing they have. I’m going to read a number of reasons why people might have trouble keeping their housing. Please tell me if you think this has been a big problem, a small problem, or no problem for you since we last talked---that would be in [insert month and year, or “about ____ months ago”].
When trying to keep the housing you have/had, is/was … |
Big |
Small problem |
No problem at all |
DON’T KNOW |
REF |
C2a. Not having enough income to pay rent a... |
3 |
2 |
1 |
7 |
8 |
C2b. Not having enough income to pay for utilities a … |
3 |
2 |
1 |
7 |
8 |
C2c. Owing too much back rent or utilities a … |
3 |
2 |
1 |
7 |
8 |
C2d. Not being currently employed a… |
3 |
2 |
1 |
7 |
8 |
C2e. Sudden loss of income a … |
3 |
2 |
1 |
7 |
8 |
C2f. Sudden illness of you or other earner a … |
3 |
2 |
1 |
7 |
8 |
C2g. Loss of essential household member through divorce, separation, death a … |
3 |
2 |
1 |
7 |
8 |
C2h. Having conflicts with people you live with a … |
3 |
2 |
1 |
7 |
8 |
C2i. Having trouble with drugs or alcohol a … |
3 |
2 |
1 |
7 |
8 |
C2j. Having emotional problems, depression a … |
3 |
2 |
1 |
7 |
8 |
C2k. Having too many people living in the same place a … |
3 |
2 |
1 |
7 |
8 |
C2l. Fearing eviction because people staying where you are aren’t on the lease |
3 |
2 |
1 |
7 |
8 |
C2m. Violence among the people you live with a… |
3 |
2 |
1 |
7 |
8 |
C2n. Trouble with your neighbors a… |
3 |
2 |
1 |
7 |
8 |
C2o. Violence in the neighborhood in general a … |
3 |
2 |
1 |
7 |
8 |
C2p. Having problems with police a… |
3 |
2 |
1 |
7 |
8 |
If A1 is 1 or 2, SKIP to SECTION D
Otherwise, ASK C3
C3. Once a person loses housing, many things may make it hard to find another place to live. I’m going to read a number of reasons why people might have trouble finding housing. Please tell me if you think this is a big problem, small problem, or no problem at all for you since we last talked---that would be since [insert month and year, or “about ____ months ago”].
When trying to find a place to live is … |
Big |
Small problem |
No problem at all |
DON’T KNOW |
REF |
C3a. Not having enough income to pay rent a... |
3 |
2 |
1 |
7 |
8 |
C3b. Not having enough money to pay a security or utility deposit or first/last month’s rent a… |
3 |
2 |
1 |
7 |
8 |
C3c. Lack of transportation to look for units a… |
3 |
2 |
1 |
7 |
8 |
C3d. Poor credit history a… |
3 |
2 |
1 |
7 |
8 |
C3e. Racial discrimination a… |
3 |
2 |
1 |
7 |
8 |
C3f. Not being currently employed a… |
3 |
2 |
1 |
7 |
8 |
C3g. No rental history a… |
3 |
2 |
1 |
7 |
8 |
C3h. No local rent history or recently moved to community a… |
3 |
2 |
1 |
7 |
8 |
C3i. No references from past landlords a… |
3 |
2 |
1 |
7 |
8 |
C3j. A past eviction(s) a… |
3 |
2 |
1 |
7 |
8 |
C3k. Problems with past landlords a… |
3 |
2 |
1 |
7 |
8 |
C3l. Past lease violations a… |
3 |
2 |
1 |
7 |
8 |
C3m. Having problems with police a… |
3 |
2 |
1 |
7 |
8 |
C3n. Having a criminal record or background a… |
3 |
2 |
1 |
7 |
8 |
C3o. Having a felony drug record, a… |
3 |
2 |
1 |
7 |
8 |
C3p. Having three or more children in the household a… |
3 |
2 |
1 |
7 |
8 |
C3q. Having teenagers in the household a… |
3 |
2 |
1 |
7 |
8 |
C3r. Someone in the household under 21 years old a… |
3 |
2 |
1 |
7 |
8 |
C3s. Someone in the household that has a disability a… |
3 |
2 |
1 |
7 |
8 |
C3t. Being a veteran a … |
3 |
2 |
1 |
7 |
8 |
C3u. The type of military discharge you have a … |
3 |
2 |
1 |
7 |
8 |
SECTION D. EDUCATION AND TRAINING
D1. Have you completed any school since we last talked---that would be in [insert month and year, or “about ____ months ago”]. If yes, what grade or school did you complete and get credit for? [MARK ONLY NEW COMPLETIONS. IF NONE, MARK “DID NOT COMPLETE ANY MORE EDUCATION]
Did not complete any more education 0
GED 1
High school diploma 2
Some college or 2-year degree 3
Finished 4-year degree 4
Master’s degree or equivalent 5
Other 6
DON’T KNOW 7
REFUSED 8
D2. Since we last talked, have you completed a vocational, trade, or business program?
Yes (ask D3) 1
No (skip to D5) 0
DON’T KNOW 7
REFUSED 8
D3. What kind of schooling or training was that? [INTERVIEWER: MARK ALL THAT APPLY]
D3a. Regular schooling leading to a degree (AA, BA, etc.) Y/N/DK/Ref
D3b. Regular schooling leading to a vocational or professional
license or certification Y/N/DK/Ref
D3c. General equivalency diploma (GED) Y/N/DK/Ref
D3d. English as a second language (ESL) Y/N/DK/Ref
D3e. Computer training Y/N/DK/Ref
D3f. Apprenticeship / on-the-job training Y/N/DK/Ref
D3g. Vocational rehabilitation Y/N/DK/Ref
D3h. OTHER Y/N/DK/Ref
DON’T KNOW 7
REFUSED 8
D4. Did _________________ help you get that schooling / training? [Insert each program name in turn]
D4a. [PN-HL] Y/N/DK/Ref
D4b. [PN-VA] Y/N/DK/Ref
D4c. [PN-DOL] Y/N/DK/Ref
D4d. Other agency Y/N/DK/Ref
D5. Are you now participating in any additional schooling or training program that (has) lasted at least two weeks that was designed to help you find a job, improve your job skills, or learn a new job?
YES (ask D6) 1
NO (skip to Section E) 0
DON’T KNOW 7
REFUSED 8
D6. What kind of schooling or training is that? [MARK ALL THAT APPLY]
D6a. Regular schooling leading to a degree (AA, BA, etc.) Y/N/DK/Ref
D6b. Regular schooling leading to a vocational or professional
license or certification Y/N/DK/Ref
D6c. General equivalency diploma (GED) Y/N/DK/Ref
D6d. English as a second language (ESL) Y/N/DK/Ref
D6e. Computer training Y/N/DK/Ref
D6f. Apprenticeship / on-the-job training Y/N/DK/Ref
D6g. Vocational rehabilitation Y/N/DK/Ref
D6h. OTHER Y/N/DK/Ref
DON’T KNOW 7
REFUSED 8
D7. Did _________________ help you get that schooling / training? [Insert each program name in turn]
D7a. [PN-HL] Y/N/DK/Ref
D7b. [PN-VA] Y/N/DK/Ref
D7c. [PN-DOL] Y/N/DK/Ref
D7d. Other agency Y/N/DK/Ref
SECTION E. INCOME AND EMPLOYMENT
E1. Have you received any income from any source in past 30 days?
YES 1
NO (SKIP TO E6) 0
REFUSED 7
DON’T KNOW 8
E2. In the past 30 days, have you received any income from … (IF YES:) How much did you receive in the past 30 days?
|
NO |
YES |
AMOUNT |
E2a. Income from a job |
0 |
1 |
$_____________ |
E2b. Unemployment Insurance |
0 |
1 |
$_____________ |
E2c. Supplemental Security Income (SSI) |
0 |
1 |
$_____________ |
E2d. Social Security Disability Income (SSDI) |
0 |
1 |
$_____________ |
E2e. Service-connected psychiatric disability pension /payment from the VA |
0 |
1 |
$_____________ |
E2f. Service-connected non-psychiatric disability pension /payment from the VA |
0 |
1 |
$_____________ |
E2g. Non-service-connected veteran’s pension |
0 |
1 |
$_____________ |
E2h. Private disability insurance |
0 |
1 |
$_____________ |
E2i. Worker’s compensation |
0 |
1 |
$_____________ |
E2i. Compensated work therapy (CWT) |
0 |
1 |
$_____________ |
E2k. Temporary Assistance for Needy Families (TANF) (or use local program name) |
0 |
1 |
$_____________ |
E2l. General Assistance (GA) (or use local program name) |
0 |
1 |
$_____________ |
E2m. Retirement income from Social Security |
0 |
1 |
$_____________ |
E2n. Income from investments or assets |
0 |
1 |
$_____________ |
E2o. Pension from a former civilian job |
0 |
1 |
$_____________ |
E2p. Child support |
0 |
1 |
$_____________ |
E2q. Alimony or other spousal support |
0 |
1 |
$_____________ |
E2r. Other source |
0 |
1 |
$_____________ |
E3. In the past 30 days, did the GI Bill, an education or training allowance from the VA, or a scholarship or grant provide you with income or resources that you could use to cover expenses?
YES 1
NO 0
REFUSED 7
DON’T KNOW 8
E4. Since you began participating in [PN-HL], have you received any of the following types of assistance from that program…? [INTERVIEWER: read each option, record answer]
E4a. Helping to get food stamps, child care, TANF, other public benefits Y/N/DK/Ref
E4b. Connecting to [PN-DOL] to help with employment Y/N/DK/Ref
E4c. Help from [PN-VA] to get any allowances, grants, or other support that
the VA has for veterans Y/N/DK/Ref
E4d. Any other help to increase your income or resources Y/N/DK/Ref
E5. [If any “yeses” to E4] Did you get what you needed from the services you’ve just mentioned?
Yes, helped very much 2
Yes, helped somewhat 1
No, did not help 0
DON’T KNOW 7
REFUSED 8
E6. [IF OTHER ADULTS IN THE HOUSEHOLD [B3a1 = 2+ adults]: Did any other adults in your household / the household where you are staying receive any income in the past 30 days?
YES 1
NO (SKIP TO E7) 0
REFUSED 7
DON’T KNOW 8
E6a. If YES to E4 ASK:, How many other adults in your household / the household where you are staying received any income in the past 30 days? _______
E6b. IF E4a > 0, ASK: What is the total income received by other adults in the household in the past 30 days? _______
IF DON’T KNOW, OR REFUSED, Ask in ranges::
Under $500
$500 - < $750
$750 - <$1000
$1000-<$1500
$1500-<$2000
$2000 or more
E7. In the past 30 days, did you or anyone in the 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.
|
NO |
YES |
Amount of monthly assistance
|
E7a. Food Stamps (officially called Supplemental Nutrition Assistance Program (SNAP) |
0 |
1 |
$___________ |
E7b. Medicaid health insurance program (or use local name) |
0 |
1 |
|
E7c. Medicare health insurance program (or use local name) |
0 |
1 |
|
E7d. State Children’s Health Insurance Program (or use local name) |
0 |
1 |
|
E7e. WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) |
0 |
1 |
$___________ |
E7f. Veteran’s Administration (VA) Medical Services |
0 |
1 |
|
E7g. TANF Child Care services (or use local name) |
0 |
1 |
|
E7h. Other child care services |
0 |
1 |
|
E7i. TANF transportation services (or use local name) |
0 |
1 |
|
E7j. Other transportation services |
0 |
1 |
|
E7k. Other TANF-funded services (or use local name) |
0 |
1 |
|
E7l. Health Insurance from work |
0 |
1 |
|
E7m. Health insurance from a place you used to work |
0 |
1 |
|
E7n. Health insurance you pay for yourself |
0 |
1 |
|
E7o. Temporary rental assistance |
0 |
1 |
$___________ |
E7p. Other source |
0 |
1 |
$___________ |
Now I’d like to ask a few questions about any jobs you may have.
E8. Last week, did you do any work for pay?
YES (SKIP TO E16) 1
NO 0
DON’T KNOW 7
REFUSED 8
E9. Have you been doing anything to find work during the past four weeks?
YES 1
NO 0
DON’T KNOW 7
REFUSED 8
E10. What is the main reason that you did not work for pay or look for work last week? [Wait for respondent to answer and mark only one
Unable to work because of housing problems 01
Unable to work for health reasons related to military service 02
Unable to work for health reasons unrelated to military service 03
Has job but temporarily absent/seasonal work 04
Couldn’t find any work 05
Couldn’t find a job that pays enough 06
Child care problems 07
Family responsibilities 08
In school or other training 09
Waiting for a new job to begin 10
Had enough money from other sources 11
Retired 12
Disabled 13
Other (specify): ______________________________ 95
DON’T KNOW 97
REFUSED 98
E11. Do you have a disability that limits or prevents you from working?
YES (ASK E11a) 1
NO 0
DON’T KNOW 7
REFUSED 8
E11a. Is this disability related to your military service?
YES 1
NO 0
DON’T KNOW 7
REFUSED 8
E12. When we last talked, you were [working / not working – CATI insert]. Since that time,
E12a. [ASK IF R WAS NOT WORKING AT BASELINE INTERVIEW] Have you done any work for pay since we last talked?
YES (ASK E13) 1
NO 0
DON’T KNOW 7
REFUSED 8
E12b. [ASK IF R WAS WORKING AT BASELINE INTERVIEW] How long has it been since you last worked for pay?
Number of months ______
DON’T KNOW 7
REFUSED 8
E13. Since we last talked, how much of the time have you had a job or done some work for pay?
All or almost all of the time 5
Most of the time 4
About half of the time 3
Some of the time 2
Almost none or none of the time 1
DON’T KNOW 7
REFUSED 8
E14. Since you began participating in [PN-HL], have you received any of the following types of assistance from any of the agencies that participate in the program…? [INTERVIEWER: read each option, record answer]
E14a. Helping with resume writing, presenting self to potential employers Y/N/DK/Ref
E14b. Job counseling—what would be good jobs for me, what skills I need
to develop, etc. Y/N/DK/Ref
E14c. Helping with specific skills or training needed for jobs (e.g., computers,
job training) Y/N/DK/Ref
E14d. Making job lists available to me, referring me to specific jobs Y/N/DK/Ref
E14e. Clothing, uniforms, equipment needed for specific jobs Y/N/DK/Ref
E14f. Referrals to specific jobs Y/N/DK/Ref
E14g. Anything else job-related Y/N/DK/Ref
E15. [If any “yeses” to E14] Did you get what you needed from the services you’ve just mentioned?
Yes, helped very much 2
Yes, helped somewhat 1
No, did not help 0
DON’T KNOW 7
REFUSED 8
SKIP to SECTION F
E16. When did you first start working at your job?
__ __/__ __ __ __ Month/Year
DON’T KNOW (ASK E16a) 7
REFUSED 8
E16a. About how long have you been working at that job?
Number of months ______
Number of years _______
DON’T KNOW 7
REFUSED 8
E17. Last week, did you have more than one job, including part-time and weekend work?
YES 1
NO 0
DON’T KNOW 7
REFUSED 8
E18. How many hours per week do you usually work at your [main] job? By main job, I mean the one at which you usually work the most hours.
NUMBER OF HOURS________________ 1-84
DON’T KNOW 97
REFUSED 98
E18a. Do you usually work 35 hours or more per week at your [main] job?
YES 1
NO 0
DON’T KNOW 7
REFUSED 8
If E16 or E16a indicates that current job started AFTER baseline interview, ASK E19
Otherwise, SKIP to SECTION F.
E19. Did _________________ help you get your current job, or any job you have had since we last talked? [INTERVIEWER: Insert each program name in turn, record answer]
D19a. [PN-HL] Y/N/DK/Ref
D19b. [PN-VA] Y/N/DK/Ref
D19c. [PN-DOL] Y/N/DK/Ref
D19d. Other agency Y/N/DK/Ref
SECTION F. HOUSING COSTS
Now I’d like to talk about how much you pay each month for housing.
F1. IF RENTERS (If OWNERS skip to F8): What is the total rent on the place you are staying—the rent on the lease, not just what you and your household pay?
PER MONTH: $__ __ __ __ .00 (FOUR DIGITS, ROUNDED TO DOLLAR)
(EXPECTED RANGE = $1-3000)
DON’T KNOW (ASK F1a) -2
REFUSED (ASK F1a) -1
F1a. Can you give me a range? Is the full monthly rent payment:
Under $500 per month 1
$500 - < $750 2
$750 - < $1000 3
$1000 - < $1500 4
$1500 - < $2000 5
More than $2000 per month 6
DON’T KNOW 7
REFUSED 8
F2. In the month just past, what did you (and your family) pay in rent? We are interested only in knowing the amount of the rent payment that you and your family 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 = $1-3000)
DON’T KNOW (ASK F2a) -2
REFUSED (ASK F2a) -1
F2a. Can you give me a range? Is your own family’s monthly rent payment:
Under $500 per month 1
$500 - < $750 2
$750 - < $1000 3
$1000 - < $1500 4
$1500 - < $2000 5
More than $2000 per month 6
DON’T KNOW 7
REFUSED 8
F3. Do you receive any assistance to pay rent from the government or from some other program?
YES (ask F4) 1
NO (skip to F5) 0
DON’T KNOW 7
REFUSED 8
F4. Is this assistance public housing, a Section 8 Voucher, Project-based Section 8, VASH, temporary rent assistance (up to 24 months), or some other type of assistance?
Public housing 1
Section 8 voucher 2
Project based section 8 3
A VASH voucher through the VA 4
Temporary rent assistance through the VA—(e..g., SSVF, Grant & Per Diem) 5
Temporary rent assistance (up to 24 months, e.g., HPRP, TANF, a transitional
housing program for homeless people, 6
Other 7
DON’T KNOW 97
REFUSED 98
F5. IF OTHER ADULTS IN THE HOUSEHOLD, BASED ON B3a1 = 2 or more, ASK, otherwise skip to F6]: Thinking about the other adult(s) living with you/you are living with, did any of them contribute any money toward rent or utilities?
YES (ask F5a) 1
NO 0
DON’T KNOW 7
REFUSED 8
F5a. What is the total amount these other adults paid toward rent or utilities in the past 30 days? _______
IF DON’T KNOW, OR REFUSED, Ask in ranges:
Under $200
$300 - < $400
$400 - <$600
$700-<$1000
$1000 or more
F6. Did any adults who do not live with you/in the place you are staying contribute any money toward rent or utilities in the past 30 days?
YES (ASK F6a) 1
NO 0
DON’T KNOW 7
REFUSED 8
F6a. What is the total amount these other adults paid toward your rent in the past 30 days? _______
IF DON’T KNOW, OR REFUSED, Ask in ranges:
Under $200
$300 - < $400
$400 - <$600
$700-<$1000
$1000 or more
F7. Since we last talked, has there been a time when you (and your immediate family) were unable to pay rent?
YES (ASK F7a) 1
NO 0
DON’T KNOW 7
REFUSED 8
F7a. How often did this happen?
Once 1
Twice 2
Three or more times 3
DON’T KNOW 7
REFUSED 8
SKIP TO F10
F8. IF OWNERS: In the month just past, what did you (and your family) pay for your mortgage? We are interested only in knowing the amount of the mortgage payment that you and your family, 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)
DON’T KNOW (ASK F8a) -2
REFUSED (ASK F8a) -1
F8a. Can you give me a range? Is your monthly mortgage payment:
Under $500 per month 1
$500 - < $750 2
$750 - < $1000 3
$1000 - < $1500 4
$1500 - < $2000 5
More than $2000 per month 6
DON’T KNOW 7
REFUSED 8
F9. Since we last talked, has there been a time when you (and your family) were unable to pay your mortgage payment?
YES (ASK F9a) 1
NO 0
DON’T KNOW 7
REFUSED 8
F9a. How often did this happen?
Once 1
Twice 2
Three or more times 3
DON’T KNOW 7
REFUSED 8
F10. Do you pay for any utilities that are not included as part of the RENT/MORTGAGE that you pay? By utilities, I mean electricity, heating oil, gas or propane, and water, but NOT telephone and cable services.
YES (ask F11) 1
NO (Skip to Section F12) 0
DON’T KNOW 7
REFUSED 8
F11. 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)
DON’T KNOW (ASK F11a) -2
REFUSED (ASK F11a) -1
F11a. Can you tell me the range for your monthly utility payment? Was it…
Under $500 per month 1
$500 - < $750 2
$750 - < $1000 3
$1000 - < $1500 4
$1500 - < $2000 5
More than $2000 per month 6
DON’T KNOW 7
REFUSED 8
F12. Since we last talked, has there been a time when you (and your immediate family) were unable to pay utility bills such as electricity, telephone, or cable?
YES (ASK F12a) 1
NO 0
DON’T KNOW 7
REFUSED 8
F12a. How often did this happen?
Once 1
Twice 2
Three or more times 3
DON’T KNOW 7
REFUSED 8
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.
|
Often true |
Sometimes true |
Never true |
DK |
REF |
G1a. We worried whether our food would run out before we got money to buy more. |
3 |
2 |
1 |
7 |
8 |
G1b. The food we bought just didn't last, and we didn't have money to get more. |
3 |
2 |
1 |
7 |
8 |
G1c. We couldn't afford to eat balanced meals. |
3 |
2 |
1 |
7 |
8 |
G2. 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 0
DON’T KNOW 7
REFUSED 8
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 3
SOME MONTHS BUT NOT EVERY MONTH 2
ONE OR TWO MONTHS 1
DON’T KNOW 7
REFUSED 8
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 0
DON’T KNOW 7
REFUSED 8
G5. In the last 12 months, were you ever hungry but didn’t eat because you couldn’t afford enough food?
YES 1
NO 0
DON’T KNOW 7
REFUSED 8
SECTION H. FAMILY HEALTH AND WELL-BEING
H1. 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 7
REFUSED 8
H2. Please tell me about any health problems you may be experiencing at this time (read and check all that apply)
H2a. Chest infection, cold, cough, bronchitis Y/N/DK/Ref
H2b. Pneumonia Y/N/DK/Ref
H2c. Tuberculosis Y/N/DK/Ref
H2d. Joint problems, arthritis, rheumatism Y/N/DK/Ref
H2e. Problem walking, lost limb, other physical handicap or disability Y/N/DK/Ref
H2f. High blood pressure Y/N/DK/Ref
H2g. Heart disease, stroke Y/N/DK/Ref
H2h. Diabetes, high sugar Y/N/DK/Ref
H2i. Gonorrhea, syphilis, herpes, Chlamydia, other STDs (NOT AIDS) Y/N/DK/Ref
H2j. HIV/AIDS Y/N/DK/Ref
H2k. Serious depression Y/N/DK/Ref
H2l. Serious anxiety or tension Y/N/DK/Ref
H2m. Being easily startled, not being able to relax your guard Y/N/DK/Ref
H2n. Trouble understanding, concentrating, or remembering Y/N/DK/Ref
H2o. Trouble sleeping Y/N/DK/Ref
H2p. Trouble controlling anger or violent behavior Y/N/DK/Ref
H2q. Symptoms of post-traumatic stress disorder (PTSD) Y/N/DK/Ref
H2r. Trouble with use of alcohol or drugs Y/N/DK/Ref
H2s. Problems dealing with the results of head injury / traumatic
brain injury (TBI) Y/N/DK/Ref
H2t. Experiencing serious thoughts of suicide Y/N/DK/Ref
H2u. Cancer Y/N/DK/Ref
H2v. OTHER 95
DON’T KNOW 97
REFUSED 98
H3. Since you began participating in [PN-HL], have you received any of the following types of help for these health problems from any of the agencies that participate in the program…? [INTERVIEWER: read each option, record answer]
H3a. Treatment for specific physical health conditions Y/N/DK/Ref
H3b. Counseling for emotional issues Y/N/DK/Ref
H3c. Counseling, treatment, group supports for substance abuse problems Y/N/DK/Ref
H3d. Help with family relationships Y/N/DK/Ref
H3e. Help with adjustments to civilian life Y/N/DK/Ref
H3f. Help or counseling for/with children, about family relationships,
school, other issues related to your children Y/N/DK/Ref
H3g. Other Y/N/DK/Ref
H4. Has _________________ been helping you with any of these health problems? [Insert each program name in turn]
H4a. [PN-HL] Y/N/DK/Ref
H4b. [PN-VA] Y/N/DK/Ref
H4c. Other agency Y/N/DK/Ref
H4d. Are you getting or did you get what you needed from the service?
Yes, very much 2
Yes, somewhat 1
No 0
DON’T KNOW 7
REFUSED 8
If no children living with R ( B3a/B3b = 0), skip to Section I
The next few questions are about your minor children who live with you—those aged 17 and younger.
H5. Overall, how would you rate the health of your children aged 17 and younger during the past month (that is the past 30 days)?
Excellent 1
Very good 2
Good 3
Fair 4
Poor 5
DON’T KNOW 7
REFUSED 8
H6. Do any of your minor children have disabilities that require, or will require, any special school services?
Yes 1
No 0
DON’T KNOW 7
REFUSED 8
H7. Do any of your minor children have disabilities that require any special housing accommodations?
Yes 1
No 0
DON’T KNOW 7
REFUSED 8
If school-aged kids (baseline, Question B6b GE 1) ask H8
If no school-aged kids (baseline Question B6b = 0), SKIP to SECTION I
H8. When we talked before you said you had [NUMBER PROVIDED IN BASELINE B6b] of your own children aged 6 to 17. I’d like to ask you about these school-age children. Are all of these children attending school now?
Yes, all of them (SKIP TO H8a) 2
Some are, and some are not 1
No, none of them are attending school 0
DON’T KNOW 7
REFUSED 8
H8a. Have they been attending school throughout the most recent school year?
Yes, all of them have been attending 3
Some have been and some have not been attending 2
No, none of them have been attending school 1
Don’t know about one or more kids because she/he/they doesn’t/don’t live with me 0
DON’T KNOW 7
REFUSED 8
H8b. Since we last talked, how many different schools has each child attended?
Each child has attended only 1 school the whole year Y/N/DK/Ref
One or more children has attended 2 different schools during the year Y/N/DK/Ref
One or more children has attended 3 or more different schools
during the year Y/N/DK/Ref
Don’t know about one or more kids because she/he/they
doesn’t/don’t live with me Y/N/DK/Ref
DON’T KNOW 7
REFUSED 8
If H8 = 1 or 0, or H8a = 2 or 1, ask H9.
Otherwise, skip to SECTION I
H9. There may be many reasons why children are not able to attend school. Please tell me which of the following have been true for your children since we last talked in [INSERT DATE]:
H9a. Took time to enroll after moving Y/N/DK/Ref
H9b. Took time to get the proper documents together (e.g., immunizations) Y/N/DK/Ref
H9c. Transportation too hard to arrange Y/N/DK/Ref
H9d. Child(ren) sick a lot Y/N/DK/Ref
H9e. Other children at school treat my child(ren) badly Y/N/DK/Ref
H9f. Child(ren) moving back and forth between parents Y//N/DK/Ref
H9g. OTHER Y/N/DK/Ref
DON’T KNOW 7
REFUSED 8
SECTION I: DEMOGRAPHICS
I have only one more question for you.
I1. Has your marital status changed since we last talked?
YES (ask I1a) 1
NO (skip to end) 0
DON’T KNOW 7
REFUSED 8
I1a. What is your marital status now?
Now married 5
Widowed 4
Divorced 3
Separated 2
Never married 1
DON’T KNOW 7
REFUSED 8
Before we end, let me make sure I know the address where you are currently living…
________________________________________________________
________________________________________________________
Is that the address we should use to send you the $40 we will pay you for your participation in this interview?
Yes 1
No 0
[If no] to what address should we send payment
------------------------------------------------------------------------------------------------------------------------
CLOSING: Thank you very much for your time today. Do you have any questions for me about the study or what happens next?
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | h46776 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |