Baseline Residents Survey

B. Neighborhood Conditions and Safety

C. Services for [Development Name] Residents

D. Physical and Mental Health

E. Household Composition

F. Travel, Education, Employment and Public Assistance

G. Child Well-Being

Child #1

THIS IS THE FIRST OF TWO CHILD SECTIONS- ONE IS FOR YOUNG CHILDREN (<6) AND ONE IS FOR SCHOOL-AGE CHILDREN (6-14).

USING THE HOUSEHOLD ROSTER (SECTION E), IDENTIFY ALL CHILDREN UNDER AGE 6. IF THERE IS ONLY ONE CHILD UNDER 6, SELECT THIS CHILD.

IF MORE THAN ONE CHILD UNDER 6, RANDOMLY SELECT ONE CHILD BY CHOOSING THE CHILD WHOSE FIRST NAME STARTS WITH A LETTER CLOSEST TO THE LETTER “M.” IF ALL THE CHILDREN HAVE NAMES THAT BEGIN WITH THE SAME LETTER, USE THE FIRST TWO LETTERS.

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Baseline Residents Survey

Next I have some questions about different services that you might have received from [CHOICE ORGANIZATION] or another social service agency. We are specifically interested in services you may have received in the past 12 months.

No 0  [SKIP TO C5]

Ref 99  [SKIP TO C5]

____ Rating [1-7]

The next question asks about alcohol use. When I use the word “drink,” I mean either a 4 oz. glass of wine, a 12 oz. can or bottle of beer, or a shot of liquor either alone or in a mixed drink.

Please answer these questions about the vehicle you use most often

I'd like to ask you some questions about your experience with the area's public transit system.

Choice Neighborhoods Evaluation, Phase 1

Appendix A Baseline Residents Survey_FINAL

_________Bedrooms

Thank you for taking the time to speak with me today. On behalf of the Urban Institute, we are conducting a study about the Choice Neighborhoods Initiative, which is designed to help transform the [Focal Development] and improve the [Neighborhood Name] community. We do not work for [the Grantee/property manager] and what you tell me today will not get back to them. The U.S. Department of Housing and Urban Development and the Annie E. Casey Foundation are funding this study to help understand the impact of the Initiative on residents in the neighborhood and in the development being transformed by the Initiative. The factsheet I gave you gives detailed information about the study.

Participation in this study is completely voluntary, but very important to our work. You may choose not to answer any questions and you can stop the interview at any time. Your decision will not affect any housing subsidies, social services, or public benefits you might receive now or in the future.

Everyone working on this research project has promised to protect the privacy of your information and your responses. We will also keep private any information we get from other sources. Only the researchers at HUD and other researchers specifically designated by HUD will see your information. We will keep your information private by:

Keeping all information about you in a locked drawer or in a password-protected computer that is secure;
Only allowing people on a designated research team to look at your information;
Your name will not be kept in the same file with your answers, so no one will know how you answered specific questions;
Not using your name or any other identifying information in our reports;
Summarizing the data of all residents in the study in any reports to make sure your privacy is protected.

You should know, however, that we will have to tell someone if harm to you or to others becomes a concern.

Your interview will be about 45 minutes long, and I will ask you about your current housing and economic situation, your children and other questions. You will receive a $50 gift card for your time.

If you have questions about the study, contact Leah Hendey at the Urban Institute at 202-261-5856. Or write to The Urban Institute, Metropolitan Housing and Communities, 2100 M Street, NW, Washington, DC 20037.

For quality control purposes, these interviews may be monitored or recorded.

Do you have any questions before we begin?

1 YES (ANSWER UNTIL RESPONDENT SATISFIED)

2 NO

8 DON’T KNOW

9 REFUSED

Now that we have talked about the study, I am going to read a statement. Please tell me if you agree to it or not.

“I [FLNAME] agree to participate in this interview.”

1 YES

2 NO

9 REFUSED

Choice Neighborhoods Initiative

Baseline Survey

A. Housing Status, Conditions and Costs

Housing

I’d like to start by asking you about your housing.

Do you live in a house or an apartment?

1	House	8	DON’T KNOW
2	Apartment	9	REFUSED  SKIP to A2

What type of building is it?

1	Single-family detached SKIP to A2
2	Duplex SKIP to A2
3	Rowhouse or townhouse
4	Multi-unit structure (condo or apartment building)
5	Mobile Home SKIP to A2
8	DON’T KNOW SKIP to A2
9	REFUSED  SKIP to A2

How many units are there in your building:

1	1 unit
2	2 to 4 Units
3	5 to 50 units
4	51 or more units
98	DON’T KNOW
99	REFUSED

IF A1A=1,2,5 OR A1A=3 & A1B=1 THEN USE “HOUSE”. ALL OTHER OPTIONS USE “UNIT”

How many separate rooms are in this [unit/house]? Rooms must be separated by built in archways or hallways that extend at leas 6 inches and go from floor to ceiling. Please include bedrooms, kitchens, etc and exclude bathrooms, porches, balconies, foyers, halls or unfinished basements.

_________Rooms

98	DON’T KNOW
99	REFUSED

How many of thse rooms are bedrooms? Count as bedrooms those rooms you would list if this [unit/house] were for sale or rent. If your [unit/house] is an efficiency/studio apartment, then please say “0”

98	DON’T KNOW
99	REFUSED

How many years have you lived at your current address? [CURRENT ADDRESS REFERS TO THE SPECIFIC HOUSE OR UNIT YOU ARE LIVING IN]

________Years [1-96] [IF >2 SKIP TO A5]

97 LESS THAN ONE YEAR

98 DON’T KNOW  SKIP TO A5

99 REFUSED SKIP TO A5

RECORD THE NUMBER OF MONTHS.

________Months [1-12]

98 DON’T KNOW

99 REFUSED

Have you lived any other place since [MONTH]/[YEAR]?

1	Yes SKIP TO A5	8	DON’T KNOW
2	No	9	REFUSED

How many times have you moved since [MONTH]/[YEAR]?

[CAPI/INTERVIEWER: **‘1’ IS NOT AN OPTION ** IF R SAYS ‘1’, THEN PROBE] So, including your move to this (unit/house), how many other times have you moved since then?

________Number of Moves [2-96]

98 DON’T KNOW

99 REFUSED

[IF THE HOUSEHOLD IS IN THE FOCAL DEVELOPMENT SAMPLE AND THE UNIT IS LOCATED IN THE FOCAL DEVELOPMENT: ]How many years have you lived in [DEVNAME] altogether?

________Years [1-96]  SKIP TO A10

97 LESS THAN ONE YEAR

98 DON’T KNOW SKIP TO A10

99 REFUSED  SKIP TO A10

RECORD THE NUMBER OF MONTHS.

________Months [1-12] SKIP TO A8

97 LESS THAN ONE MONTH SKIP TO A8

98 DON’T KNOW SKIP TO A8

99 REFUSEDSKIP TO A8

IF THE HOUSEHOLD IS IN THE NEIGHBORHOOD RESIDENT SAMPLE:

I would like to know some more about your current [house / unit].

Do you own this [house/unit], rent it, or what?

1	Own
2	Buying
3	RentSKIP TO A7
4	Rent to ownSKIP TO A7
5	Buying on contractSKIP TO A7
6	Live here for free
98	DON’T KNOW
99	REFUSED

Is this [house/unit]…

1	Owned by you or someone in this household with a mortgage or loan?
2	Owned by you or someone in this household free and clear (without a mortgage or loan)?
3	Rented for cash rent?
4	Occupied without payment of cash rent?
98	DON’T KNOW
99	REFUSED

Since you were 18 years old, have you ever lived in assisted or public housing?

1	Yes	8	DON’T KNOW SKIP TO A9
2	No SKIP TO A9	9	REFUSED SKIP TO A9

ALL RESIDENTS:

Since you were 18 years old, how many years have you lived in assisted or public housing altogether?

________Years [0-96]

98 DON’T KNOW

99 REFUSED

IF THE HOUSEHOLD IS IN THE FOCAL DEVELOPMENT SAMPLE AND THE UNIT IS LOCATED IN THE FOCAL DEVELOPMENT OR IF THE HOUSEHOLD IS IN THE NEIGHBORHORHOOD SAMPLE AND OWNS THEIR HOME OR LIVES WITH SOMEONE WHO OWNS THE HOME (A5=1 OR A5A=1,2) SKIP TO A14.

Housing Assistance Status

Next, I am going to ask you about housing assistance. Some people get housing assistance that requires them to complete re-certifications by reporting income and who lives with them to determine the amount of rent they pay.

Does your household have a housing voucher?

1	Yes	8	DON’T KNOW  SKIP TO A11
2	No SKIP TO A11	9	REFUSED SKIP TO A11

Can your household use its housing voucher to move to another location?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

Is the housing authority your landlord?

1	Yes  SKIP TO A14	8	DON’T KNOW
2	No	9	REFUSED

Do you currently live in some other type of housing where your landlord requires you to prove your income each year?

1	Yes  SKIP TO A14	8	DON’T KNOW
2	No	9	REFUSED

IF THE HOUSEHOLD IS IN THE NEIGHBORHOOD RESIDENT SAMPLE, SKIP TO A14 OTHERWISE, CONTINUE:

People stop getting housing assistance for different reasons. What would you say was the main reason you are no longer getting assistance?

1	No longer eligible because income is too high
2	Purchased home
3	Got married/moved in with partner
4	Evicted by landlord
5	Terminated from program/ broke rules, etc.
6	Relocated from public housing and cannot move back
97	Other reason  SPECIFY:
98	DON’T KNOW
99	REFUSED

ALL RESIDENTS

Housing Quality

The next series of questions is about problems that some people have experienced with their homes. We are interested in knowing if you have experienced these types of problems in your current home.

Last winter, for any reason, was your house or unit so cold for 24 hours or more that you or members of your household were uncomfortable?

1	Yes	8	DON’T KNOW  SKIP TO A15
2	No SKIP TO A15	9	REFUSED  SKIP TO A15

What was the reason?

1	Utility interruption	98	DON’T KNOW
2	Inadequate heating capacity	99	REFUSED
3	Inadequate insulation
4	Cost of heating
5	Heating equipment breakdown
6	Other  SPECIFY:

Was your home ever COMPLETELY without running water ^since_in - - that is, since ^date?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

In the past 3 months, was there any time when all of your toilets were BROKEN, or STOPPED UP, or otherwise NOT WORKING, so you COULDN'T USE them?

1	Yes	8	DON’T KNOW SKIP TO A17
2	No  SKIP TO A17	9	REFUSED  SKIP TO A17

How many times since ^date ^were_was not working?

________ Times [Enter 8 for 8 or more]

98	DON’T KNOW
99	REFUSED

And how many of those times ^were_was not working for SIX HOURS or MORE?

________ Times [Enter 8 for 8 or more]

98	DON’T KNOW
99	REFUSED

These next questions are about water leaks-either from OUTSIDE your [home/building] or from INSIDE.

While you have been living here, did water ever leak INTO your house or unit directly FROM THE OUTSIDE--for example, through the roof, outside walls, basement or any closed windows or skylights?

1	Yes	8	DON’T KNOW  SKIP TO A18
2	No  SKIP TO A18	9	REFUSED  SKIP TO A18

Did water leak in from the outside within the past 12 months-that is since [MONTH] 2011?

1	Yes	8	DON’T KNOW  SKIP TO A18
2	No  SKIP TO A18	9	REFUSED  SKIP TO A18

Now about water leaks from INSIDE. Since you’ve lived here, did water leak in-from broken pipes or water heaters, backed up plumbing, [another home_apt_living]?

1	Yes	8	DON’T KNOW  SKIP TOA19
2	No  SKIP TOA19	9	REFUSED  SKIP TOA19

Did any inside water leaks happen within the past 12 months that is, since [MONTH] 2011?

1	Yes	8	DON’T KNOW  SKIP TOA19
2	No  SKIP TOA19	9	REFUSED SKIP TOA19

Did the sewage system break down within the past 12 months that is, since [MONTH] 2011?

1	Yes	8	DON’T KNOW  SKIP TO A20
2	No  SKIP TO A20	9	REFUSED  SKIP TO A20

How many of these breakdowns lasted 6 hours or more?

________ Breakdowns [Enter 8 for 8 or more]

98	DON’T KNOW
99	REFUSED

Is all the electrical wiring in the finished areas of your [home/unit] concealed in the walls? Exclude appliance cords, extension cords, chandelier cords, phone, antenna, cable TV wires, etc.

1	Yes, wiring concealed SKIP TOA21	98	DON’T KNOW SKIP TOA21
2	No, wiring not concealed	99	REFUSED  SKIP TOA21
3	No electrical wiring SKIP TOA21

Is the electrical wiring safely contained in protective metal or plastic coverings? Exclude appliance cords, extension cords, chandelier cords, phone, antenna, cable TV wires, etc.

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

Does every room have an electrical outlet or wall plug that works?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

People sometimes have problems with cracks or holes in their floors, walls, or ceilings – not hairline cracks or nail holes, but OPEN cracks or holes.

In the INSIDE walls or ceilings of your house or unit, are there any OPEN HOLES or CRACKS WIDER THAN THE EDGE OF A DIME?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

How about the floors in your [unit/home]-- are any holes in the floors big enough for someone to catch their foot on? (About 4 inches across -- About the height of a soup can)

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

Does the inside of your house or unit have any areas of peeling paint or broken plaster?

1	Yes	8	DON’T KNOW  SKIP TO A25
2	No  SKIP TO A25	9	REFUSED  SKIP TO A25

Are any of these areas bigger than 8 inches by 11 inches? (The size of a standard business letter)

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

Have you seen signs of mice or rats INSIDE your [house/unit] in the past three months- this is since [MONTH] 2012?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

Have you seen signs of cockroaches INSIDE your [house/unit], in the past three months- this is since [MONTH] 2012?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

Have you seen signs of mildew or mold INSIDE your [house/unit], in the past three months- this is since [MONTH] 2012?

1

Yes

8

DON’T KNOW

2

No

9

REFUSED
Are any of the windows in this housing unit damaged or broken?

1

Yes

8

DON’T KNOW

2

No

9

REFUSED

2

Not Applicable
Are any of the doors in this housing unit damaged or broken?

1

Yes

8

DON’T KNOW

2

No

9

REFUSED

2

Not Applicable
[SKIP IF A5=1 OR A5A=1,2] In the past six months, when the owner has to do MAJOR maintenance or repairs: Do they start quickly enough? Would you say…

PROBE: By MAJOR maintenance or repairs, we mean major leaks, flooding, the heater breaking, etc.

[SKIP IF A5=1 OR A5A=1,2] Do they solve the problem quickly once they start?

1	Yes	98	DON’T KNOW
2	No	99	REFUSED
3	Mixed

[SKIP IF A5=1 OR A5A=1,2] In the past sixth months, for MINOR maintenance or repairs: Do they start quickly enough? Would you say….

PROBE: By minor maintenance or repairs we mean appliance malfunctions, small leaks, etc.

[SKIP IF A5=1 OR A5A=1,2] Do they solve the problem quickly once they start?

1	Yes	98	DON’T KNOW
2	No	99	REFUSED
3	Mixed

[SKIP IF A5=1 OR A5A=1,2] Are maintenance staff polite and considerate of your home?

1	Yes	98	DON’T KNOW
2	No	99	REFUSED
3	Mixed

On maintenance of the building, are you completely satisfied, partly satisfied, or dissatisfied?

1	Completely satisfied	8	DON’T KNOW
2	Partly Satisfied	9	REFUSED
3	Dissatisfied
4	Landlord not responsible for this maintenance

On maintenance of the grounds, are you completely satisfied, partly satisfied, or dissatisfied?

1	Completely satisfied	8	DON’T KNOW
2	Partly Satisfied	9	REFUSED
3	Dissatisfied
4	Landlord not responsible for this maintenance

The next question is about your [unit/home] , and how you feel about it, considering everything that we have talked about during this interview.

On a scale of 1 to 10, how would you rate your [unit/home] as a place to live? 10 is best, 1 is worst. Probe: We would like your opinion please.

________ Rating [0-10]

98	DON’T KNOW
99	REFUSED

Rent and Utility Hardship

[SKIP TO A39 IF A6=1,2]Altogether in the month just passed, what did you pay in rent?··We are interested only in knowing your part of the payment.

$ _________amount IF 0 SKIP TO A40

9998	DON’T KNOW SKIP TO A40
9999	REFUSEDSKIP TO A40

Altogether in the month just passed, what was the amount you paid to the bank or mortgage company?

$_____________ amount

9998	DON’T KNOW
9999	REFUSED

How many months in the past 12 months were you more than 15 days late paying your [rent/mortgage]?

________ Months

98	DON’T KNOW
99	REFUSED

In the past 12 months, have you been threatened with eviction or told you were at risk for eviction from your home for any reason?

1	Yes	8	DON’T KNOW  SKIP TO A44
2	No  SKIP TO A44	9	REFUSED  SKIP TO A44

Why were you were threatened with eviction or told you were at risk? Was it because of… [INTERVIEWER: PLEASE READ LIST. CHECK ALL THAT APPLY]

1	Nonpayment of rent or late rent,	98	DON’T KNOW
2	Nonpayment of mortgage by you or someone else	99	REFUSED
3	Absent from unit for 90 or more days,
4	Problems with visitors (stayed more than 7 days or behavior),
5	Damaging unit,
6	Housekeeping violations,
7	One-strike violation,
8	Income increase, or
97	Some other reason?  SPECIFY:

In the past 12 months, have you been evicted from your home for any reason?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

Now I have some questions about your utilities.··Do you pay for your own electricity or is that included in the [rent/mortgage]?

1	Pay own electricity	7	DON’T KNOW
2	Included in rent SKIP TO A46	8	REFUSED

How much was the electric bill last month?

$ Amount

9998	DON’T KNOW
9999	REFUSED

Do you pay for your own gas or is that included in the [rent/mortgage]?

1	Pay own gas	7	DON’T KNOW
2	Included in rent SKIP TO A48	8	REFUSED
3	Do not use gas SKIP TO A48

How much was the gas bill last month?

$ Amount

9998	DON’T KNOW
9999	REFUSED

Do you pay for your own water bill or is that included in the [rent/mortgage]?

1	Pay own electricity	7	DON’T KNOW
2	Included in rentSKIP TO A50	8	REFUSED

How much was the water bill last month?

$ amount

9998	DON’T KNOW
9999	REFUSED

[ SKIP TO B1 IF A44= 2, A46= 2,3, AND A48= 2]

People sometimes have trouble paying their utility bills on time.··How many months out of the last 12 were you more than 15 days late paying your electric, gas, or water bill?

________ Months [IF 0 SKIP TOB1]

98	DON’T KNOW  SKIP TO B1
99	REFUSED  SKIP TO B1

Did you receive a notice that your gas, water, or electricity would be shut off if you did not pay your bill?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

In the past 12 months, was your gas, water, or electricity ever shut off for nonpayment?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

The next set of questions asks about what it’s like to live in your current neighborhood.

In your neighborhood, how much of a problem….

	Big problem		Some problem	No problem at all	DK	REF
Is the quality of schools? Would you say		1	2	3	8	9
Are trash and junk in the parking lots, streets, lawns, and sidewalks?		1	2	3	8	9
Are vacant lots or abandoned homes?		1	2	3	8	9
Is vandalism and graffiti—that is, writing or painting on the walls of the buildings?		1	2	3	8	9
Are poorly lit streets and walkways		1	2	3	8	9
Are poorly maintained streets?		1	2	3	8	9
Are poorly maintained sidewalks?		1	2	3	8	9
Is traffic safety?		1	2	3	8	9
Is irritating noise at any time of day?		1	2	3	8	9
Is homelessness?		1	2	3	8	9
Are groups of people just hanging out?		1	2	3	8	9
Are police not coming when called?		1	2	3	8	9
Are people being attacked or robbed or shootings and violence?		1	2	3	8	9
Are people selling drugs?		1	2	3	8	9
Are people using drugs?		1	2	3	8	9
Are gangs?		1	2	3	8	9
Is rape or other sexual attacks?		1	2	3	8	9
Is prostitution?		1	2	3	8	9
Are people arguing, fighting, or acting threatening?		1	2	3	8	9
Are men treating women badly in public? (physically and verbally)		1	2	3	8	9

Next, I am going to ask you some questions about facilities in your current neighborhood.

A. Have you (or any member of your household) ever used [a(n)]SERVICE/AMENITY] in your neighborhood?

[IF No, SKIP TO NEXT AMENITY]

B. On a scale of 1 to 5 where 1 indicates that you are “very dissatisfied” and 5 indicates that you are “very satisfied”, how dissatisfied or satisfied are you with the [SERVICE/AMENITY]?

Recreation or community center

No 0

Yes 1

DK 98

Ref 99

Very Satisfied........... 5

.................................. 4

.................................. 3

.................................. 2

Very Dissatisfied...…..1

DON’T KNOW …….DK

REFUSED ............REF

Park or playground

No 0

Yes 1

DK 98

Ref 99

Very Satisfied........... 5

.................................. 4

.................................. 3

.................................. 2

Very Dissatisfied...…..1

DON’T KNOW …….DK

REFUSED ............REF

Public library branch

No 0

Yes 1

DK 98

Ref 99

Very Satisfied........... 5

.................................. 4

.................................. 3

.................................. 2

Very Dissatisfied...…..1

DON’T KNOW …….DK

REFUSED ............REF

Sit down or family restaurant

No 0

Yes 1

DK 98

Ref 99

Very Satisfied........... 5

.................................. 4

.................................. 3

.................................. 2

Very Dissatisfied...…..1

DON’T KNOW …….DK

REFUSED ............REF

Do you do your regular food shopping in your neighborhood?

1	Yes	8	DON’T KNOW
2	No  SKIP TO B7	9	REFUSED

On a scale of 1 to 5 where 1 indicates that you are “very dissatisfied” and 5 indicates that you are “very satisfied”, how dissatisfied or satisfied are you with the quality of food?

________ Rating [0-10]

98	DON’T KNOW
99	REFUSED

Is the elementary school closest to this address satisfactory?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

Do you think that this neighborhood is a good place to raise children?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

Safety and Victimization

Now I would like to ask you about safety.

How safe do you feel or would you feel being out alone in the parking lots, the lawns, the street, or sidewalks right outside your [building/house] during the day? Do you feel...

1	Very safe,	8	DON’T KNOW
2	Somewhat safe,	9	REFUSED
3	Somewhat unsafe, or
4	Very unsafe?

How safe do you feel or would you feel being out alone in the parking lots, the lawns, the street, or sidewalks right outside your [building/house] at night? Do you feel...

1

Very safe,

8

DON’T KNOW

2

Somewhat safe,

9

REFUSED

3

Somewhat unsafe, or

4

Very unsafe?
How safe do you feel being alone inside your (unit/house) at night? Do you feel…

1	Very safe,	8	DON’T KNOW
2	Somewhat safe,	9	REFUSED
3	Somewhat unsafe, or
4	Very unsafe?

Please tell me if any of the following things have happened to you or anyone who lives with you in the past six months, that is, since [INSERT MONTH SIX MONTHS PRIOR TO DATE].

	Yes		No	REF	DK
a. Did anyone in your household have their purse, cell phone, wallet, jewelry, or other personal possession snatched from them in the past six months?		1	2	8	9
b. Was anyone in your household threatened with a knife or gun in the last six months?		1	2	8	9
c. Was anyone in your household beaten or assaulted in the last six months?		1	2	8	9
d. Was anyone in your household stabbed or shot in the last six months?		1	2	8	9
e. Was anyone in your household caught in a shootout in the last six months?		1	2	8	9
f. Did bullets come into your (unit/house) in the last six months?		1	2	8	9
g. Did anyone try to break into your home, or attempt to break in, in the last six months?		1	2	8	9

Neighborhood Cohesion

Thinking about the area that you consider your neighborhood, tell me whether you strongly agree, somewhat agree, somewhat disagree or strongly disagree with the following statements.

	Strongly agree,		Somewhat agree,	Somewhat disagree, or	Strongly disagree?	DK	REF
a. People around here are willing to help their neighbors. Would you say you		1	2	3	4	8	9
b. People in this neighborhood share the same values		1	2	3	4	8	9
c. This is a close-knit neighborhood		1	2	3	4	8	9
d. People in this neighborhood can be trusted		1	2	3	4	8	9
e. People in this neighborhood generally get along with each other		1	2	3	4	8	9

How likely is it that your neighbors would do something if they saw the following? Please tell me whether it is very likely, likely, unlikely, or very unlikely that they would do something if they saw:

	Very likely,		Likely,	Unlikely, or	Very unlikely?	DK	REF
a. Children skipping school and hanging out on a street corner? Would you say		1	2	3	4	8	9
b. Children spray-painting graffiti on a local building?		1	2	3	4	8	9
c. Children showing disrespect to an adult?		1	2	3	4	8	9
d. A fight breaks out in front of their home? Would you say		1	2	3	4	8	9
e. The fire station closest to your home was going to be closed down by the city?		1	2	3	4	8	9

How often do you get help or support besides money, like babysitting, lending small appliances, rides, or emotional support from people in your family that do not live with you? Would you say…

1	Often	8	DON’T KNOW SKIP TO B16
2	Sometimes	9	REFUSED SKIP TO B16
3	Rarely SKIP TO B16
4	Never SKIP TO B16

How many of these family members live in the same neighborhood as you? (not in your [unit/house]) Would you say:

1	None of my family members	8	DON’T KNOW
2	A few of my family members	9	REFUSED
3	Many of my family members
4	All or almost all of my family members?

IF THE HOUSEHOLD IS IN THE FOCAL DEVELOPMENT SAMPLE AND THE UNIT IS LOCATED IN THE FOCAL DEVELOPMENT:

How many of these family members live in the same development as you? (not in your unit) Would you say:

1	None of my family members	8	DON’T KNOW
2	A few of my family members	9	REFUSED
3	Many of my family members
4	All or almost all of my family members?

How often do you get help or support besides money from friends? [PROBE: I am talking about things like babysitting, lending small appliances, rides, or emotional support.] Would you say…

1	Often	8	DON’T KNOW SKIP TO B17
2	Sometimes	9	REFUSED SKIP TO B17
3	Rarely SKIP TO B17
4	Never SKIP TO B17

How many of these friends live in the same neighborhood as you? Would you say:

1	None of my friends	8	DON’T KNOW
2	A few of my friends	9	REFUSED
3	Many of my friends
4	All or almost all of my friends?

IF THE HOUSEHOLD IS IN THE FOCAL DEVELOPMENT SAMPLE AND THE UNIT IS LOCATED IN THE FOCAL DEVELOPMENT:

How many of these friends live in the same development as you? Would you say:

1	None of my friends	8	DON’T KNOW
2	A few of my friends	9	REFUSED
3	Many of my friends
4	All or almost all of my friends?

ALL RESIDENTS

About how many people do you know in your neighborhood?

1	None	8	DON’T KNOW
2	One	9	REFUSED
3	Two
4	Three to five
5	Six to ten
6	More than ten

About how many adults that you know in your neighborhood graduated from college? (Would you say all, most, some, a few, or none?)

1	All	8	DON’T KNOW
2	Most	9	REFUSED
3	Some
4	A few
5	None

About how many adults that you know in your neighborhood work full-time? (Would you say all, most, some, a few, or none?)

1	All	8	DON’T KNOW
2	Most	9	REFUSED
3	Some
4	A few
5	None

About how many adults that you know in your neighborhood would you say are a different race or ethnicity than you? (Would you say all, most, some, a few, or none?)

1	All	8	DON’T KNOW
2	Most	9	REFUSED
3	Some
4	A few
5	None

Please tell me if these next statements are true or false:

	True		False	DK	REF
a I am involved in neighborhood or block organizations that deal with neighborhood issues		1	2	8	9
b I have done volunteer work in the last year to benefit my neighborhood.		1	2	8	9

Do you attend religious services inside your neighborhood or outside your neighborhood?

1	Inside my neighborhood	8	DON’T KNOW
2	Outside my neighborhood	9	REFUSED
3	Don’t Attend

Next, I would like to ask you about how much you know about the revitalization projects occurring in your community overall and how satisfied you are with the changes occurring in your community.

In the past 2 years has the city government made important plans for your [development/neighborhood]?

1	Yes	8	DON’T KNOW  SKIP TO B25
2	No  SKIP TO B25	9	REFUSED  SKIP TO B25

Do you believe that these plans will improve your [development/neighborhood]?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

Have you seen notices or heard about public meetings about the future of your [development/neighborhood], in the past two years?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

In the past 2 years, have you attended a meeting associated with Choice Neighborhoods or redevelopment in [Development Name/Neighborhood Name]?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

Please tell me how strongly you agree or disagree with the following statement. I have a say in the plans for how the new [housing development name] will look. Would you say you:

1	Strongly disagree,	8	DON’T KNOW
2	Somewhat disagree,	9	REFUSED
3	Neither Agree nor disagree,
4	Somewhat agree,
5	Or Strongly agree?

How does the future look for this neighborhood? Is this neighborhood likely to:

1	Get Better	8	DON’T KNOW
2	Stay the Same	9	REFUSED
3	Get Worse

The next question is about your neighborhood, and how you feel about it, considering everything that we have talked about during this interview.

How would you rate your neighborhood on a scale of 1 - 10?

10 is best, 1 is worst Probe: We would like your opinion please.

Enter 0 "No Neighborhood" if respondent volunteers this answer

________ Rating [0-10]

98	DON’T KNOW
99	REFUSED

THIS WHOLE SECTION IS ONLY FOR HOUSEHOLDS IN THE FOCAL DEVELOPMENT SAMPLE

The next section asks questions about services that you might have received from the [Choice Organization], housing authority or a social service agency.

Are you currently receiving case management services from [CHOICE ORGANIZATION]?

1	Yes  SKIP TO C3	8	DON’T KNOW  SKIP TO C3
2	No	9	REFUSED  SKIP TO C3

Why are you not receiving services from [CHOICE ORGANIZATION]? Was that because you…[SELECT ONE RESPONSE OPTION ONLY]

1	Moved too far away,	8	DON’T KNOW
2	Were too busy,	9	REFUSED
3	Felt you didn’t need services anymore,
4	The services weren’t helpful,
5	Didn’t like case manager,
6	No longer qualified for case management assistance, or
7	Some other reason?  SPECIFY:

B. Did the staff from [CHOICE ORGANIZATION] tell you about this service?

C. How would you rate this service, class or special help? As not helpful, somewhat helpful, or very helpful?

A. In the last 12 months, have you attended any educational classes or job trainings? PROBE: like a reading class, literacy testing, a GED session or GED testing, any continuing education classes, classes to complete a degree, job skills preparation training on interviewing skills, resume building, computer skills,or on-the-job training.

No 0  [SKIP TO C4]

Yes 1

DK 98  [SKIP TO C4]

Ref 99  [SKIP TO C4]

No 0

Yes 1

DK 98

Ref 99

Not helpful …0

Somewhat helpful 1

Very helpful 2

DK 98

REFUSED ………99

A. Have you participated in any English as a Second Language classes?

Yes 1

DK 98  [SKIP TO C5]

No 0

Yes 1

DK 98

Ref 99

Not helpful 0

Somewhat helpful 1

Very helpful 2

DK 98

REFUSED 99

A. Have you had a meeting with a case manager or attended a workshop to discuss ways for you to remain compliant with your lease or to avoid eviction (not counting paying utilities)?

No 0  [SKIP TO C6]

Yes 1

DK 98  [SKIP TO C6]

Ref 99  [SKIP TO C6]

No 0

Yes 1

DK 98

Ref 99

Not helpful 0

Somewhat helpful 1

Very helpful 2

DK 98

REFUSED 99

A. Have you received help with addressing health concerns? For example: managing an existing health condition or accessing a health care professional.

No 0  [SKIP TO C7]

Yes 1

DK 98  [SKIP TO C7]

Ref 99  [SKIP TO C7]

No 0

Yes 1

DK 98

Ref 99

Not helpful 0

Somewhat helpful 1

Very helpful 2

DK 98

REFUSED 99

A. Have you attended any one-on-one or group counseling sessions?

No 0  [SKIP TO C8]

Yes 1

DK 98  [SKIP TO C8]

Ref 99  [SKIP TO C8]

No 0

Yes 1

DK 98

Ref 99

Not helpful 0

Somewhat helpful 1

Very helpful 2

DK 98

REFUSED 99

A. Have you attended parenting classes?

No 0  [SKIP TO C9]

Yes 1

Don’t have children…97 SKIP TO C11

DK 98  [SKIP TO C9]

Ref 99  [SKIP TO C9]

No 0

Yes 1

DK 98

Ref 99

Not helpful 0

Somewhat helpful 1

Very helpful 2

DK 98

REFUSED 99

A. Have you received help accessing or paying for child care in order to work or attend classes or school?

No 0  [SKIP TO C10]

Yes 1

DK 98  [SKIP TO C10]

Ref 99  [SKIP TO C10]

No 0

Yes 1

DK 98

Ref 99

Not helpful 0

Somewhat helpful 1

Very helpful 2

DK 98

REFUSED 99

A. Have your children attended/ been enrolled in any of the following services or programs: after school programs, mentoring or tutoring services?

No 0

Yes 1

DK 98

Ref 99

No 0

Yes 1

DK 98

Ref 99

Not helpful 0

Somewhat helpful 1

Very helpful 2

DK 98

REFUSED 99

Housing Relocation

The Choice Neighborhood program may require residents of [FOCAL DEVELOPMENT] to be temporarily or permanently relocated. The next section asks questions about different information that you might have received from the housing authority, Choice office, or social service agency about relocation.

A relocation counselor is a person who helps you make decisions about moving out of your current housing development. In the last 2 years did you talk to or meet with a relocation/move-out counselor?

1	Yes	8	DON’T KNOW  SKIP TO C13
2	No  SKIP TO C13	9	REFUSED  SKIP TO C13

How would you rate this service, class or special help? Would you say it was not helpful, somewhat helpful, or very helpful?

1	Not helpful	8	DON’T KNOW
2	Somewhat helpful	9	REFUSED
3	Very helpful

In the last two years, did you attend any workshops on housing choice, school choice, or housekeeping and tenants’ rights and responsibilitiesthat were related to relocation?

1	Yes	8	DON’T KNOW SKIP TO C15
2	No  SKIP TO C15	9	REFUSED  SKIP TO C15

How would you rate this service, class or special help? Would you say it was not helpful, somewhat helpful, or very helpful?

1	Not helpful	8	DON’T KNOW
2	Somewhat helpful	9	REFUSED
3	Very helpful

Did [the housing authority/ developer] provide information about…

	Yes	No	REF	DK
A.Moving to other public developments in [BASELINE CITY]?	1	2	8	9
B. Section 8/housing choice voucher program?	1	2	8	9
C. Homeownership?	1	2	8	9
D. Transportation to look at available units?	1	2	8	9
E. Dealing with a landlord or helping you with a lease?	1	2	8	9
F. Help paying a security deposit or down payment?	1	2	8	9
G.Help with paying for utility hook-up (such as phone, electric, gas)?	1	2	8	9

Do you want to live in the new Choice development after it is fixed up or rebuilt?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

[IF YES] Why do you want to live in the development after it is fixed up or rebuilt? [DO NOT READ. CHECK ALL THAT APPLY]

1	I want to benefit from the changes to the development	5	A relocation counselor suggested this would be the best choice for me
2	I want to live in a mixed-income development	6	Public transportation in this area is very good
3	I don’t want a housing choice voucher	7	My health condition would make it difficult to move somewhere else
4	My friends or family members in the development want to return	8	I am familiar with this area
97	Some other reason  SPECIFY	98	DON’T KNOW
		99	REFUSED

[IF NO] Why don’t you want to live in the development after it is fixed up or rebuilt? [DO NOT READ. CHECK ALL THAT APPLY]

1	The process is too complicated, I want to move and get settled	8	The units in the new development will not match my household needs
2	There is another area of the city I know I would like to move to	9	My health condition means it would be better for me to move away
3	I don’t want to live around other public housing residents any more	10	A relocation counselor suggested this would be the best choice for me
4	I don't like the way that this neighborhood is changing	98	DON’T KNOW
5	I am not eligible to return	99	REFUSED
6	I do not think my household and I will be welcome in the new development
7	I don't know if I can afford to live in the rebuilt development
97	Some other reason  SPECIFY:

[IF Don’t Know ] Can I ask why you answered don't know? [DO NOT READ. CHECK ALL THAT APPLY]

1	I don't know enough about the new development	6	I don't know if my household and I will be welcome in the new development
2	I don't know enough about the relocation process	7	I don't know what would be best for me and my household members
3	I don't know enough about my choices and options I don't really think these changes are going to happen to the development	8	My health condition makes it difficult for me to figure out what to do
4	I have not had enough time to decide what I want	97	Some other reason  SPECIFY:
5	I want to see what my friends and other family members in the development decide to do	98	DON’T KNOW
		99	REFUSED

Some housing developers make rules about who can live in the new Choice development once it is completed.

Has [the housing authority] provided clear information on who is eligible to move into the new CHOICE development?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

Do you think you are eligible to move to a new CHOICE unit?

1	Yes SKIP TO D1	8	DON’T KNOW SKIP TO D1
2	No	9	REFUSED  SKIP TO D1

Why do you think you are not eligible to move to a new CHOICE unit? Do you think it is because…

YES NO DK REF

someone in your household has bad credit 1 2 8 9
someone in your household has a criminal record 1 2 8 9
you are not employed 1 2 8 9
of poor housekeeping 1 2 8 9
you have/had a tenant not on the lease 1 2 8 9
of some other reason (Specify:_________________) 1 2 8 9

The next few questions ask about your health and healthcare.

In general, would you say your health is…

1

Excellent,

8

DON’T KNOW

2

Very good,

9

REFUSED

3

Good,

4

Fair, or

5

Poor?
Is there a place that you usually go to when you are sick or need advice about your health?

1	Yes	8	DON’T KNOW
2	There is NO place  SKIP TO D4	9	REFUSED
3	There is MORE THAN ONE place

What kind of place [is it\do you go to most often]—a clinic, a doctor’s office, an emergency room, or some other place?

[INTERVIEWER: PROBE FOR FACILITY TYPE]

1	Doctor’s office or private clinic (including HMOs)	8	DON’T KNOW
2	Hospital outpatient clinic	9	REFUSED
3	Hospital emergency room
4	Public health department
5	Community health center
6	Doesn’t go to one place most often  SKIP TO Error! Reference source not found.
7	Other  SPECIFY:

Is that place in your neighborhood?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

On a scale of 1 to 5 where 1 indicates that you are “very dissatisfied” and 5 indicates that you are “very satisfied”, how dissatisfied or satisfied are you with your [RESPONSE FROM D3]?

98	DON’T KNOW
99	REFUSED

During the past 12 months, was there any time when you needed any of the following, but didn't get it because you couldn't afford it?

	Yes		No	DK	REF
a.Prescription medicines		1	2	8	9
b.Mental health care or counseling		1	2	8	9
c.Dental care (including check-ups)		1	2	8	9
d.Eyeglasses		1	2	8	9

Are you covered by health insurance or some other kind of health care plan? Include health insurance obtained through employment or purchased directly as well as government programs like Medicare and Medicaid that provide medical care or help pay medical bills.

1	Yes	8	DON’T KNOW  SKIP TO D7
2	No  SKIP TO D7	9	REFUSED  SKIP TO D7

What kind of health insurance or health care coverage do you have for yourself?

1	Private health insurance plan from employer or workplace	98	DON’T KNOW
2	Private health insurance plan purchased directly	99	REFUSED
3	Private health insurance plan through a state or local government or community program
4	Medicaid /[Family Care/Bayou Health/MassHealth]
5	Medicare
7	Military health care /VA or Champus / Tricare /Champ-VA
8	Single service plan (e.g. dental, vision, prescriptions)
9	No coverage of any type
10	Other SPECIFY_____________________

Do you have any illness(es) or recurring health condition(s) that requires regular, ongoing care?

1	Yes	8	DON’T KNOW  SKIP TO D8
2	No  SKIP TO D8	9	REFUSED  SKIP TO D8

What illness(es) or recurring health condition(s) do you have?

[READ OPTIONS AND CHECK ALL THAT APPLY]

1	Arthritis	98	DON’T KNOW
2	Heart Attack (also called myocardial infarction)	99	REFUSED
3	Stroke
4	Emphysema (also known as chronic obstructive pulmonary disease (COPD))
5	Cancer or a Malignancy
7	Asthma
8	hypertension, also called high blood pressure
9	diabetes or sugar diabetes
10	Other SPECIFY__________________________

In the past 12 months, was your physical health ever such a problem that you could not take a job, had to stop working, or could not attend education or training activities?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

On average, how many hours of sleep do you get in a 24-hour period?

________ [01–24 HOURS]

98	DON’T KNOW
99	REFUSED

About how tall are you without shoes? [RECORD IN FEET AND INCHES]

________feet _________inches

998	DON’T KNOW
999	REFUSED

a.Just to confirm, I have recorded that you are ________feet _________inches tall. Is that correct?

[IF RESPONDENT CHANGES HEIGHT, PLEASE CORRECT ABOVE IN D10a]

About how much do you weigh without shoes? [RECORD IN POUNDS]

________pounds

998	DON’T KNOW
999	REFUSED

a. Just to confirm, I have recorded that you are ________pounds. Is that correct?

[IF RESPONDENT CHANGES WEIGHT, PLEASE CORRECT ABOVE IN D11a]

The next questions ask about difficulties you may have doing certain activities because of a health problem. By “health problem,” we mean any physical, mental, or emotional problem or illness (not including pregnancy).

By yourself, and without using any special equipment, how difficult is it for you to…

	Not at all difficult,	Only a little difficult,	Somewhat difficult,	Very difficult, or	You can’t do this at all?	Do not do this activity	DK	REF
a. Walk a quarter of a mile—about 3 city blocks? Would you say this is…	1	2	3	4	5	6	8	9
b.Walk up 10 steps without resting?	1	2	3	4	5	6	8	9
c.Stand or be on your feet for about 2 hours?	1	2	3	4	5	6	8	9
d.Sit for about 2 hours?	1	2	3	4	5	6	8	9
e.Stoop, bend, or kneel?	1	2	3	4	5	6	8	9
f.Reach up over your head?	1	2	3	4	5	6	8	9
g.Lift or carry something as heavy as 10 pounds?	1	2	3	4	5	6	8	9

Smoking and Substance Use

The next few questions ask about cigarette smoking and alcohol use.

Do you NOW smoke cigarettes every day, some days or not at all?

1	Every day	8	DON’T KNOW
2	Some days	9	REFUSED
3	Not at all

In the past 30 days, how often did you usually have at least one drink—nearly every day, three to four days a week, one to two days per week, one to three days a month, less than once a month, or not at all in the past 30 days?

1	Nearly every day	8	DON’T KNOW
2	Three or four days per week	9	REFUSED
3	One or two days per week
4	One to three days per month
5	Less than once a month
6	Not at all in the past 30 days

Mental Health

I have some remaining questions about your health and well-being. It is useful for us to learn how you are feeling, both physically and emotionally.

As with the first part of this survey, your participation is completely voluntary. You can refuse to answer any question at any time. Please remember that this survey is completely confidential, and what you say will not affect your ability to get any government or program benefits now or in the future.

How much of the time during the past month have you ...

	All of the time,		Most of the time,	Some of the time, or	None of the time?	DK	REF
a.Felt nervous? Would you say		1	2	3	4	8	9
b.Felt calm and peaceful?		1	2	3	4	8	9
c.Felt downhearted and blue?		1	2	3	4	8	9
d.Felt happy?		1	2	3	4	8	9
e.Felt so down in the dumps that nothing could cheer you up?		1	2	3	4	8	9

Self-Efficacy

Now, I’d like to ask you some other questions about yourself.

Please tell me how strongly you agree or disagree with the following statements.

[INTERVIEWER: PLEASE READ EACH STATEMENT]

	Strongly disagree,	Somewhat disagree,	Somewhat agree, or	Strongly agree?	DK	REF
a.I will be able to achieve most of the goals that I have set for myself. Do you	1	2	3	4	8	9
b.When facing difficult tasks, I am certain that I will accomplish them.	1	2	3	4	8	9
c. In general, I think that I can obtain outcomes that are important to me.	1	2	3	4	8	9
d.I believe I can succeed at most any endeavor to which I set my mind.	1	2	3	4	8	9
e.I will be able to successfully overcome many challenges. Do you	1	2	3	4	8	9
f. I am confident that I can perform effectively on many different tasks.	1	2	3	4	8	9
g.Compared to other people, I can do most tasks well.	1	2	3	4	8	9
h. Even when things are tough, I can perform quite well.	1	2	3	4	8	9

In order to understand a little about your household, I would like to ask you about each of the people who are currently living in this household including people who are not on the lease. Please remember that the information you give me will not affect your housing status. We are asking for names just to help us keep track during our survey. As we said earlier, we will never connect your name with your answers.

What is your marital status? Are you:

1	Now Married	98	DON’T KNOW
2	Not married, living with partner	99	REFUSED
3	Not married, not living with partner
4	WIDOWED
5	DIVORCED
6	SEPARATED

Please tell me just the first and last name of each person in your household, starting with yourself.

[INTERVIEWER: FOR EACH PERSON IN THE HOUSEHOLD.

IF THE ANSWER IS DON’T KNOW, CODE “DK” OR REFUSED, CODE “RF”]

CODE “DK” OR REFUSED, CODE “RF”.

	A.What is their: First and Last Name INSERT NAME	B.What is their: Relationship to you? spouse/partner son daughter grandchild sibling parent other relative other non-relative	C. What is their: Birthday? mm/dd/yyyy	D. What is their: Sex? Male Female	E.What is their: Ethnicity? Hispanic Not Hispanic	F.What is their: Race? African-American White American Indian or Alaskan Native Asian Native Hawaiian or Pacific Islander Other
1		Self		M F	H NH	AA W AN AS PI OTH:
2		S/P S D GC SI PA OR ONR		M F	SKIP	SKIP
3		S/P S D GC SI PA OR ONR		M F	SKIP	SKIP
4		S/P S D GC SI PA OR ONR		M F	SKIP	SKIP
5		S/P S D GC SI PA OR ONR		M F	SKIP	SKIP
6		S/P S D GC SI PA OR ONR		M F	SKIP	SKIP
7		S/P S D GC SI PA OR ONR		M F	SKIP	SKIP
8		S/P S D GC SI PA OR ONR		M F	SKIP	SKIP
9		S/P S D GC SI PA OR ONR		M F	SKIP	SKIP
10		S/P S D GC SI PA OR ONR		M F	SKIP	SKIP

	G. What country were they born in?PROBE: We are not interested in citizenship. SPECIFY 97. USA 98. DON’T KNOW 99. REFUSED	ASK IF PERSON IS OVER 16 Which of these categories describes [NAME]? Code all that apply Employed In Job Training Temporarily Laid Off Unemployed Retired Permanently Disabled Homemaker Student Other (Specify)	ASK IF PERSON IS BETWEEN 6-18 Are they enrolled in school?
1		SKIP	SKIP
2			YES NO
3			YES NO
4			YES NO
5			YES NO
6			YES NO
7			YES NO
8			YES NO
9			YES NO
10			YES NO

Now I have a few questions about how you get around town and about your education and employment.

Travel

Do you have a valid driver's license?

1	Yes	8	DON’T KNOW SKIP TO F5
2	No  SKIP TO F5	9	REFUSED SKIP TO F5

.[SKIP TO F4 IF Error! Reference source not found.=0] How often would you say you can use the car? Would you say...

1	Whenever you want?	8	DON’T KNOW
2	A few hours a day for you to use?	9	REFUSED
3	4-6 days per week for you to use?
4	1-3 days per week?
5	It depends
6	Other

How many times in the last 3 months has the car failed to get you where you needed to go because of mechanical problems?

______ Times[0–97]

98	DON’T KNOW
99	REFUSED

How many times have you borrowed a car or other vehicle in the last month?

1	None	8	DON’T KNOW
2	1 to 2	9	REFUSED
3	3 to 4
4	5 to 6
5	7 to 8
6	9 to 10
7	More than 10 times

How many days in the last week did you take the bus, train, or [LOCAL TRANSIT NAME] ?

Days [0–7]

98	DON’T KNOW
99	REFUSED

Education

What is the highest grade or level of regular school you have ever completed?

[PROBE IF ANSWER IS H.S. DIPLOMA:] “Do you have a high school diploma or a GED?”

1	8^TH GRADE OR LESS	98	DON’T KNOW
2	9^TH TO 11^TH GRADE	99	REFUSED
3	12^TH GRADE
4	GED  SKIP TO F9
5	HIGH SCHOOL DIPLOMA  SKIP TO F9
6	SOME VOC/TECH/BUSINESS COURSES SKIP TO F8
7	VOC/TECH/BUSINESS CERTIFICATE OR DIPLOMA  SKIP TO F9
8	SOME COLLEGE COURSES  SKIP TO F8
9	ASSOCIATE’S DEGREE (AA, AS)  SKIP TO F9
10	BACHELOR’S DEGREE (BA, BS)  SKIP TO F9
11	SOME GRADUATE/PROFESSIONAL SCHOOL COURSES SKIP TO F8
12	GRADUATE/PROFESSIONAL DEGREE (MA, MS, PHD, EDD, MEDICINE/MD, DENTRISTRY/DDS, LAW/JJ/LLB, ETC.  SKIP TO F9

Have you earned any degrees such as a GED, high school diploma, or technical certificate?

1	Yes	8	DON’T KNOW SKIP TO F9
2	No  SKIP TO F9	9	REFUSED  SKIP TO F9

What is the highest degree you have ever earned?

[PROBE: IF ANSWER IS H.S. DIPLOMA:] Do you have a high school diploma or a GED?

1	GED	8	DON’T KNOW
2	HIGH SCHOOL DIPLOMA	9	REFUSED
3	VOC/TECH/BUSINESS CERTIFICATE OR DIPLOMA
4	ASSOCIATE’S DEGREE (AA, AS)
5	BACHELOR’S DEGREE (BA, BS)
6	GRADUATE PROFESSIONAL DEGREE (MA, MS, PHD, EDD, MEDICINE/MD, DENTISTRY/DDS, LAW/JD/LLB, ETC.

Employment

Next, I have a few questions about work.

Do you currently work for pay?

1	Yes	8	DON’T KNOW  SKIP TO F20
2	No  SKIP TO F20	9	REFUSED  SKIP TO F20

[START OF QUESTIONS FOR THOSE WHO WORK]

Do you currently have more than one job?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

On average, about how many hours a week do you work at your main job? IF NEEDED: By main job we mean the one at which you work the most hours.

1	LESS THAN 20 HOURS A WEEK	8	DON’T KNOW
2	BETWEEN 20 AND 35 HOURS A WEEK	9	REFUSED
3	MORE THAN 35 HOURS A WEEK

Before taxes or other deductions, how much do you make at your main job, including tips and commissions? [INTERVIEWER: IF NEEDED:] By main job we mean the one at which you work the most hours.

$____________amount

991	Hourly	998	DON’T KNOW
992	Daily	999	REFUSED
993	Weekly
994	Bi-weekly
995	Twice a month
996	Monthly
997	Annually

[SKIP IF F10=2] Considering all the jobs you have right now, including self-employment, how many hours per week on average do you work for pay?

[INTERVIEWER: INCLUDE OVERTIME IF R REGULARLY WORKS OVERTIME HOURS ]

______ hours [1–97]

98	DON’T KNOW
99	REFUSED

[SKIP IF F10=2] Before taxes or other deductions, how much are you paid on all your jobs together, including tips and commissions?

[INTERVIEWER: DO NOT PROBE REFUSALS. PROBE ONLY “DON’T KNOW” ANSWERS.]

$______________amount

991	Hourly	998	DON’T KNOW
992	Daily	999	REFUSED
993	Weekly
994	Bi-weekly
995	Twice a month
996	Monthly
997	Annually

How long have you been working at your main job—the job at which you work the most hours?

__________years ___________months

98	DON’T KNOW
99	REFUSED

What city do you work in for your main job?

Name of City:_______________________________

98	DON’T KNOW
99	REFUSED

How do you get to work for your main job? [CHECK ALL THAT APPLY]

1	BUS	98	DON’T KNOW
2	OTHER PUBLIC TRANSPORTATION
3	CAR (OWN CAR)	99	REFUSED
4	CAR (BORROWED CAR)
5	TAXI CAB
6	WALK
7	WORK AT HOME
8	RIDE WITH A FRIEND (CARPOOL)
9	BIKE
97	Other  SPECIFY:

About how long does it usually take you to get to your main job?

___________ MINUTES

998	DON’T KNOW
999	REFUSED

Through your employer, are you eligible for any of the following benefits? By eligible, we mean that the benefit is available to you now, even if you have decided to not receive it or have not needed it. Are you eligible for…

	Yes		No	DK	REF
a.Health insurance?		1	2	8	9
b.Paid sick leave?		1	2	8	9
c Unpaid sick leave or personal leave?……………………………………..		1	2	8	9
d Paid time off for vacation or annual leave?…………………………………..		1	2	8	9
e Retirement program?……………………………………..		1	2	8	9

[SKIP TO F23]

[END OF QUESTIONS FOR THOSE WHO WORK]

[START OF QUESTIONS FOR THOSE WHO DO NOT WORK]

Have you ever worked for pay?

1	Yes	8	DON’T KNOW  SKIP TO F22
2	No  SKIP TO F22	9	REFUSED  SKIP TO F22

How many years has it been since you were last employed either full or part time?

____________years

Less than one year

DON’T KNOW

REFUSED

What is the main reason you are not working? [DO NOT READ. MARK ONE RESPONSE]

1	Temporarily disabled and unable to work	98	DON’T KNOW
2	Permanently disabled and unable to work	99	REFUSED
3	Other health problem
4	Retired or age
5	Taking care of home or family
6	Going to school
7	Cannot find work
8	Changing jobs
9	No need/no desire
10	Business closed/downsized/laid off
11	Moved
12	Couldn’t afford/find childcare
13	Transportation/distance
14	Fired
15	Temp work/finished job/seasonal
16	Quit
17	Ex-offender
18	Not enough skills
97	Other  SPECIFY:

[ASK REMAINING EMPLOYMENT QUESTIONS FOR EVERYONE ]

Have you looked for a job in the past 12 months?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

Public Assistance

The next question asks about different kinds of government benefits.

In the past 12 months, have you or anyone in your household received food stamps (SNAP) or money for food on the EBT card (the Electronic Benefits Transfer card)? This is also known as a [LINK/Louisiana Purchase/ Bay State Access ] Card.

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

Income

I am going to be asking you about your household income, but first, I want to ask you about possible sources of that income… Did you (or anyone in your household) receive any income in the last 12 months from (...)?

	Yes		No	DK	REF
a.Wages or Salary?		1	2	8	9
b.Commissions, bonuses, or tips?		1	2	8	9
c. Self employment income from a business or farm…………………………		1	2	8	9
d. Interest payments, dividends, net rental income, royalty income, or income from estates and trusts?......................................................................		1	2	8	9
e. Social Security or railroad retirement?.........................................................		1	2	8	9
f. Supplemental Security Income or SSI?........................................................		1	2	8	9
g. Other disability pay such as SSDI (Social Security Disability Insurance), a veteran’s disability benefit or workers compensation for a work-related injury?
h. cash from public assistance like the [Illinois TANF \Louisiana FITAP\ Massachusetts TAFDC\ CALWORKS\ WorkFirst]?......................................		1	2	8	9
i. Retirement, survivor, or disability pensions?...............................................		1	2	8	9
j. Other work that you have not yet told me about that you did inside or outside the home such as child care/babysitting, doing hair, cooking, car repair, carpentry, or other jobs like that?.........................................................		1	2	8	9
k. Any other sources of income received regularly such as Veteran’s payments, unemployment compensation, child support, or alimony?.............		1	2	8	9

[ONLY ASK IF F26h=1] How many years in total have you (or this person) received TANF (or Public Aid)?

Prompt: If multiple people within the household receive TANF, please report the maximum number of years for a single person (i.e., do not add the years for the 2+ people)

years [01–96]

997	Less than one year
998	DON’T KNOW
999	REFUSED

Excluding yourself, how many other people living in your household contribute to the total household income? Please income from all of these sources.

People [0-20]

98	DON’T KNOW
99	REFUSED

About how much was your total household income in the last 12 months before taxes? Please include all the sources of income from all members of your household. [DO NOT PROBE REFUSALS. PROBE ONLY “DON’T KNOW” ANSWERS.]

$______________  SKIP TO F30

99998	DON’T KNOW
99999	REFUSED SKIP TO F30

Could you please tell me which category best estimates your total household income in the last 12 months for all sources and all members of your household.

1	Less than $5,000	8	DON’T KNOW
2	$5,000 to $9,999	9	REFUSED
3	$10,000 to $14,999
4	$15,000 to $19,999
5	$20,000 to $29,999
6	$30,000 to $39,999
7	$40,000 to $49,999
8	$50,000 to $59,999
9	$60,000 to $69,999
10	$70,000 to $79,999
11	$80,000 to $89,999
12	$90,000 to $99,999
13	$100,000 or more

Hardship

Now I’m going to read you some statements that people have made about their food situation . For these statements, please tell me whether the statement was often, sometimes, or never true for your family in the last 12 months, that is, since [month] 2011.

The first statement is “we worried whether our food would run out before I got money to buy more.” Was that often, sometimes, or never true for your household in the last 12 months?

1	Often true	8	DON’T KNOW
2	Sometimes true	9	REFUSED
3	Never true

“The food that we bought just didn’t last, and I didn’t have money to get any more.” Was that often, sometimes, or never true for your household in the last 12 months?

1	Often true	8	DON’T KNOW
2	Sometimes true	9	REFUSED
3	Never true

In the past 12 months, did [you or another adult in your family ever cut the size of your meals or skip meals because there wasn’t enough money for food?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

Sometimes families get financial help, either from other people they live with or friends and family outside. Did you get any help like this in the last 12 months?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

How many days per week does [CHILD1] live in your home?

IF NO CHILD UNDER AGE 6, THEN GO TO NEXT SECTION

What grade in school is [CHILD1] attending? FI INFO: IF R SAYS THAT THE CHILD1 IS IN SPECIAL EDUCATION, CODE SPECIAL EDUCATION AND GRADE.

01	Not Attending School	98 DON’T KNOW
02	Attending A Pre-Kindergarten Program (I.E. Head Start, Preschool, Etc.)	99	REFUSED
03	Kindergarten SKIP TO G3
04	First Grade SKIP TO G3
05	Second Grade SKIP TO G3
06	Third Grade SKIP TO G3
07	Fourth Grade SKIP TO G3
08	Ungraded SKIP TO G3
09	Special Education SKIP TO G3

[IF PARENT INDICATED THAT CHILD1 DOES NOT ATTEND SCHOOL OR IS ENROLLED IN PRE-KINDERGARTEN PROGRAM] Where does [CHILD1] spend most of (his/her) time when (he/she) is not with you (or other parent/guardian)?

01	Nursery School
02	Preschool	98	DON’T KNOW
03	Head Start	99	REFUSED
04	Other Pre-Kindergarten Program/ School
05	Childcare center
07	In a childcare home SKIP TO CHILD 2 INTRO
08	In the care of a relative who is not paid SKIP TO CHILD 2 INTRO
09	In the care of a relative who is paid SKIP TO CHILD 2 INTRO
10	In the care of a friend who is not paid SKIP TO CHILD 2 INTRO
11	In the care of a friend who is paid SKIP TO CHILD 2 INTRO
12	There is no other caregiver or place SKIP TO CHILD 2 INTRO

What is the name of [CHILD1]’s [school/nursery school/preschool/Head Start/pre-kindergarten/ child care center]? RECORD ON SEPARATE SHEET

Is [RESPONSE FROM G3] located in your neighborhood?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

How satisfied are you with the job [RESPONSE FROM G3] is doing to educate your child? Are you very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied, or very dissatisfied?

1	Very Satisfied	8	DON’T KNOW
2	Satisfied	9	REFUSED
3	Neither satisfied nor dissatisfied
4	Dissatisfied
5	Very dissatisfied

[IF R INDICATED CHILD1 WAS NOT IN SCHOOL, SKIP TO INTRO FOR CHILD 2]

Now I'd like to ask you about your family's involvement with [CHILD1]’s school.Since the beginning of this school year, (have/has) (you/any adult in your household)...

Thank you for telling us a little bit about CHILD1.

Child #2

This next set of questions asks about issues relevant to children ages 6 to 14.

Shape2

THIS IS THE SECOND OF TWO CHILD SECTIONS- THIS ONE IS FOR SCHOOL-AGE CHILDREN (6-14).

USING THE HOUSEHOLD ROSTER (SECTION E), IDENTIFY ALL CHILDREN BETWEEN AGE 6 AND 14. IF ONLY ONE CHILD BETWEEN 6 AND 14, SELECT THIS CHILD.

IF MORE THAN ONE CHILD BETWEEN 6 AND 14, RANDOMLY SELECT ONE CHILD BY CHOOSING THE CHILD WHOSE FIRST NAME STARTS WITH A LETTER CLOSEST TO THE LETTER “M.” IF ALL THE CHILDREN HAVE NAMES THAT BEGIN WITH THE SAME LETTER, USE THE FIRST TWO LETTERS.

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

IF NO CHILD BETWEEN 6 AND 14, INTERVIEW IS COMPLETE

Child #2 Education

How many days per week does [CHILD2] live in your home?

days [1–7]

8	DON’T KNOW
9	REFUSED

Is CHILD2 enrolled in school?

1	Yes  SKIP TO G11	8	DON’T KNOW
2	No	9	REFUSED

Why is [CHILD2] not attending school this year? [DO NOT READ LIST. RECORD UP TO 3 MENTIONS.]

01	Dislikes school (doesn’t want to go/no interest/friends not going)		98		DON’T KNOW
02	Does poorly in school (poor grades)	99		REFUSED
03	Wasn’t promoted to next grade
04	Doesn’t get along well with teachers/faculty/staff
05	Wants or needs to work/earn money
06	Is pregnant/got someone else pregnant
07	Has had disciplinary trouble in school (suspensions/expulsions/fighting)
08	Physical disability or problem
09	Mental disability or problem
10	Graduated early
11	Got GED
12	Graduated
97	Other  SPECIFY:

When did (he/she) last attend school?

MM _____ YYYY IF TOTAL > 2 YEARS, SKIP TO G12

9998	DON’T KNOW  SKIP TO G11
9999	REFUSED  SKIP TO G11

In the last two years, has [CHILD2] changed schools? Please do not count a change in schools that occurred when the child graduated.

1	Yes	8	DON’T KNOW  SKIP TO G12
2	No  SKIP TO G12	9	REFUSED  SKIP TO G12

Since starting kindergarten, has [CHILD2] repeated any grades?

1	Yes	8	DON’T KNOW  SKIP TO G13
2	No  SKIP TO G13	9	REFUSED  SKIP TO G13

How many times has [CHILD2] repeated a grade?

__________Times

9998	DON’T KNOW
9999	REFUSED

[IF CHILD2 NOT IN SCHOOL, SKIP TO G19]

[ONLY ASK IF CHILD2 IS CURRENTLY ENROLLED IN SCHOOL] What is the name of [CHILD2]’s school? RECORD ON SEPARATE SHEET

[ONLY ASK IF CHILD2 IS ENROLLED IN SCHOOL] How satisfied are you with the job that [RESPONSE FROM G13] is doing to educate your child? Are you very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied, or very dissatisfied?

1	Very Satisfied	8	DON’T KNOW
2	Satisfied	9	REFUSED
3	Neither satisfied nor dissatisfied
4	Dissatisfied
5	Very dissatisfied

[ONLY ASK IF CHILD2 IS ENROLLED IN SCHOOL] We would like to know your child’s grade level in September 2012. What grade level is [CHILD2] in at school?? [DO NOT READ LIST.]

01	Nursery/Preschool	18	Some Voc/Tech/Business courses
02	Pre-kindergarten	19	Voc/Tech/Business certificate
03	Kindergarten	20	Some college courses
04	First grade	98	DON’T KNOW
05	Second grade	99	REFUSED
06	Third grade
07	Fourth grade
08	Fifth grade
09	Sixth grade
10	Seventh grade
11	Eighth grade
12	Ninth Grade
13	Tenth grade
14	Eleventh grade
15	Twelfth grade

[ONLY ASK IF CHILD2 IS ENROLLED IN SCHOOL] Would you describe [CHILD2]’s work at school as . . .

1 Excellent

2 Above Average

3 Average

4 Below Average

5 Failing

8 DON’T KNOW

9 REFUSED

For each of the following statements, please tell me if you think it describes [CHILD2] all of the time, most of the time, some of the time, or none of the time.

	All of the time		Most of the time	Some of the time	Most of the time	NA	DK	REF
a.[CHILD2] cares about doing well in school. Would you say……………………………………..		1	2	3	4	7	8	9
b.[CHILD2] only works on schoolwork when forced to		1	2	3	4	7	8	9
c.[CHILD2] does just enough schoolwork to get by		1	2	3	4	7	8	9
d.[CHILD2] always does homework		1	2	3	4	7	8	9

Now I'd like to ask you about your family's involvement with [CHILD2]’s school.

Since the beginning of this school year, (have/has) (you/any adult in your household)...

	Yes		No	NA	DK	REF
a. Attended a general school meeting, for example, an open house, or a back-to-school night?		1	2	7	8	9
b. Attended a meeting of the parent-teacher organization or association?		1	2	7	8	9
c. Gone to a regularly scheduled parent-teacher conference with (CHILD2)'s teacher?		1	2	7	8	9
d. Attended a school or class event, such as a play, dance, sports event, or science fair because of (CHILD2)?		1	2	7	8	9
e. Served as a volunteer in (CHILD2)’s classroom or elsewhere in the school?		1	2	7	8	9
f. Participated in fundraising for the school?		1	2	7	8	9
g. Served on a school committee?		1	2	7	8	9
h. Met with a guidance counselor in person?		1	2	7	8	9

Child #2 Activities

Where is this child usually in the evenings?··Is [he / she] usually supervised at home, home and not supervised, somewhere else and supervised, or somewhere else and not supervised?

1 Home, supervised

2 Home, unsupervised

3 Somewhere else, supervised

4 Somewhere else, unsupervised

8 DON’T KNOW

9 REFUSED

Some children participate in after-school programs that provide supervision and organized activities. These programs are usually held in a school or a center, and are different from individual activities like sports, scouts, or special lessons.

Is (CHILD2) now attending an after-school program at a school or in a center, either on a scheduled or a drop-in basis?

1	Yes	8	DON’T KNOW  SKIP TO G22
2	No  SKIP TO G22	9	REFUSED  SKIP TO G22

How many days each week does (CHILD2) go to these programs?

________Days [0-5]

98 DON’T KNOW

99 REFUSED

Sometimes children are able to spend time responsible for themselves, either at home or somewhere else, without anyone around to supervise. Not counting times when an adult is at home and (CHILD2) is outside playing, is (CHILD2) responsible for (himself/herself) after school on a regular basis?

1	Yes	8	DON’T KNOW  SKIP TO G24
2	No  SKIP TO G24	9	REFUSED  SKIP TO G24

How many days each week is (CHILD2) responsible for (himself/herself) after school?

________Days [0-5]

98 DON’T KNOW

99 REFUSED

During the past 12 months, how often has your child participated in the following activities?

	Almost every day	About once a week	About once a month	A few times a year	Never	DK	REF
a.Sports team (at school or community center). Would you say	1	2	3	4	5	8	9
b.School club (like student government, language club, choir, or band)	1	2	3	4	5	8	9
c.Recreation club (like Boys and Girls Club)	1	2	3	4	5	8	9
d.Reading for pleasure	1	2	3	4	5	8	9
e.Going to the park or gym	1	2	3	4	5	8	9
f. Doing things with you or another adult family member	1	2	3	4	5	8	9
g. Participating in church, mosque, or temple activities	1	2	3	4	5	8	9
h. Doing homework	1	2	3	4	5	8	9

Does your child play with other children in the neighborhood?

1	Yes	8	DON’T KNOW  SKIP TO G26
2	No  SKIP TO G26	9	REFUSED  SKIP TO G26
3	Not Applicable  SKIP TO G26

Do you interact with the parents of other children in the neighborhood?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED
3	Not Applicable

[ASK ONLY IF RESIDENT STILL LIVES IN FOCAL DEVELOPMENT, EVEN IF THEY HAVE CHANGED UNITS WITHIN THE DEVELOPMENT] Does your child play with other children in the housing development?

1	Yes	8	DON’T KNOW  SKIP TO G27
2	No  SKIP TO G27	9	REFUSED  SKIP TO G27
3	Not Applicable  SKIP TO G27

Do you interact with the parents of other children in the housing development?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED
3	Not Applicable

Child #2 Behavior

Now I’d like you to rate how much each of the following statements describes [CHILD 2].

	Not at all like child		A little like child	Somewhat like child	A lot like child	Completely like child	NA	DK	REF
a.[CHILD2] is usually in a good mood. Would you say this is		1	2	3	4	5	7	8	9
b.[CHILD2] is admired and well-liked by other children. Would you say this is		1	2	3	4	5	7	8	9
c.[CHILD2] shows concern for other people’s feelings. Would you say this is		1	2	3	4	5	7	8	9
d. [CHILD2] shows pride when he/she does something well or learns something new. Would you say this is		1	2	3	4	5	7	8	9
e.[CHILD2] easily calms down after being angry or upset. Would you say this is		1	2	3	4	5	7	8	9
f.[CHILD2] is helpful and cooperative. Would you say this is		1	2	3	4	5	7	8	9

Now I am going to read some statements that describe behavior problems that many children have. Please tell me whether each statement has been often true, sometimes true, or not true of [CHILD2] during the past 3 months. If CHILD2 is not in school, mark ‘NA’ for question G28a and G28b.

	Often true		Sometimes true	Not true	NA	DK	REF
a.[CHILD2] has trouble getting along with teachers. Would you say		1	2	3	7	8	9
b.[CHILD2 is disobedient at school		1	2	3	7	8	9
c.[CHILD2] is disobedient at home		1	2	3	7	8	9
d.[CHILD2] hangs around with kids who get in trouble		1	2	3	7	8	9
e.[CHILD2] bullies or is cruel or mean to others		1	2	3	7	8	9
f.[CHILD2] is restless or overly active, can’t sit still		1	2	3	7	8	9
g.[CHILD2] is unhappy, sad, or depressed		1	2	3	7	8	9

[SKIP IF CHILD IS NOT OLDER THAN 12] Raising children can be difficult these days. In the past 12 months—that is, since [MONTH] 2011—have there ever been any of the following problems with [CHILD2]?

In the past 12 months….	Yes	No	NA	DK	REF
a. Has [CHILD2] been suspended, excluded, or expelled from school?	1	2	7	8	9
b. Has [CHILD2] gone to juvenile court?	1	2	7	8	9
c. Has [CHILD2] had a problem with alcohol or drugs?	1	2	7	8	9
d. Has [CHILD2] gotten into trouble with the police?	1	2	7	8	9
e. Has [CHILD2] done something illegal to get money?	1	2	7	8	9
f. Has [CHILD2] been pregnant [or gotten someone else pregnant]	1	2	7	8	9
g. Has [CHILD2] been in a gang?	1	2	7	8	9
h. Has [CHILD2] been arrested?	1	2	7	8	9
i. Has [CHILD2] been in jail or incarcerated?	1	2	7	8	9
j. During the past school year, has a teacher or other school staff contacted you about any schoolwork problems [CHILD2] has had in school?	1	2	7	8	9
k. During the past school year, has a teacher or other school staff contacted you or someone else in the home about any behavioral problems [CHILD2] has had in school?	1	2	7	8	9

Child #2 Health

The following questions are about your child’s health.

Now, I’d like to ask about [CHILD2]’s health status. In general, would you say [CHILD2]’s health is…

1	Excellent,	8	DON’T KNOW
2	Very good,	9	REFUSED
3	Good,
4	Fair, or
5	Poor?

[YOU MAY SKIP READING THIS QUESTION AND CODE AS 996 IF YOU KNOW CHILD2 DID NOT ATTEND SCHOOL AT ALL IN THE PAST 12 MONTHS. Refer to Question G10] During the past 12 months—that is, since [MONTH] 2011—about how many days did [CHILD2] miss school because of illness or injury?

NUMBER OF DAYS	[001–240]	000	NONE
		996	DID NOT GO TO SCHOOL
		998	DON’T KNOW
		999	REFUSED

In the past 12 months, did [CHILD2] receive a physical examination or a well-child check-up?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

About how long has it been since [CHILD2] last saw or talked to a dentist? Include all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists.

1	Never	8	DON’T KNOW
2	6 months or less	9	REFUSED
3	More than 6 months but not more than 1 year ago
4	More than 1 year but not more than 2 years ago
5	More than 2 years but not more than 5 years ago
6	More than 5 years

Where does [CHILD2] usually go for routine medical care?

1	Doctor’s office or private clinic (including HMOs)	8	DON’T KNOW
2	Hospital outpatient clinic	9	REFUSED
3	Hospital emergency room
4	Public health department
5	Community health center
6	No routine medical care
7	Other  SPECIFY:

Has a doctor or other health professional ever said that [CHILD2] has asthma?

1	Yes	8	DON’T KNOW  SKIP TO G38
2	No  SKIP TO G38	9	REFUSED  SKIP TO G38

Does he/she still have symptoms? (coughing, wheezing, shortness of breath)

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

In the past 12 months, has [CHILD2] had an episode of asthma or an asthma attack?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

Has your doctor or a health professional ever said that [CHILD2]…

		Yes	No	DK	REF
a.Had diabetes?	1		2	8	9
b.Had more than 3 ear infections in a year?	1		2	8	9
c.Had autism or other developmental delay?	1		2	8	9
d.Had elevated levels of lead in the blood?	1		2	8	9
e.Had a learning disability?  SPECIFY:	1		2	8	9
f.Had hyperactivity, ADHD, or ADD?	1		2	8	9
g.Was overweight?	1		2	8	9
h.Was underweight, too small or failing to thrive?	1		2	8	9
i.Had anxiety, depression, or other emotional disturbance?	1		2	8	9
j.Had other problems?  SPECIFY:	1		2	8	9
IF ALL ARE “NO,” SKIP to #G40

Do [CHILD2]’s medical, behavioral or other health conditions interfere with his/her ability to do any of the following things? [IF CHILD2 NOT IN SCHOOL, a. IS NA.]

How often does [CHILD2] actively participate in sports, athletics or exercising? Would you say…

1	Never,	8	DON’T KNOW
2	A few times a year,	9	REFUSED
3	1–2 times a month, or
4	Nearly daily?

Does [CHILD2] have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicaid?

1	Yes	8	DON’T KNOW
2	No	9	REFUSED

CONTACT INFORMATION FORM

[To be completed by field locators after end of survey]

Thank you for the time you’ve spent talking with me and for your participation in this study. In order to send your $50 gift card, I need to confirm your name and address.

I have your full name listed as [FLNAME] and spelled as (INTERVIEWER: SPELL NAME). Is that correct? INTERVIEWER, IF R REFUSES, SAY: Please understand that there may be a delay in sending your gift card if we are unable to confirm the correct spelling of your full name.

1	Yes	9	REFUSED
2	No

Corrected Name:______________________________________

Is this your current address? [FULLADD, RCITY, RSTATE, RZIP]

INTERVIEWER: READ ADDRESS TO R, SPELLING EACH WORD.

1	Yes	9	REFUSED
2	No

Corrected Address:

Street: ________________________

City:__________________________

State: _________________________

Zip: __________________________

Is there another address you would like me to use to send your $50 gift card?

1	Yes	9	REFUSED
2	No

What address would you like me to use?

Street: ________________________

City:__________________________

State: _________________________

Zip: __________________________

I also need to confirm your phone number in case we have any questions about the interview.

READ THE PHONE NUMBER. Is this correct?

1	Yes	9	REFUSED
2	No

Corrected Number:_______________________________________

Is this a home, work, or cell phone number?

1	Home	9	REFUSED
2	Work
3	Cell Phone

Is there a cell phone, or additional phone number you would like to provide?

1	Yes	9	REFUSED
2	No

Phone Number:__________________________________________

Is this a home, work, or cell phone number?

1	Home	9	REFUSED
2	Work
3	Cell Phone

In the future, may we call or send a text message to the cell phone number you provided?

1	Yes	9	REFUSED
2	No

Is there a valid e-mail address you would like to provide?

1	Yes	9	REFUSED
2	No

Email Address:_________________________________________ (READ TO CONFIRM)

This study will be going on for a few more years. We are interested in learning what helps people improve their circumstances and what gets in the way of making that happen.

We may want to contact you again in a few years. However, people often move in this length of time. We would like to get the name of one or two other people who know where we could reach you. Many people give their mother or sister’s name. Others give the name of a very close friend. Who would be a good person for us to contact?

PERSON 1:

What is their name? Would you spell that for me?

NAME_____________________________

And what is their relationship to you?

RELATIONSHIP____________________

Where would we contact him/her?

Street: ________________________

City:__________________________

State: _________________________

Zip: __________________________

Is there a phone number?

PHONE NUMBER ____________________

Is there anyone else we can contact?

1	Yes	9	REFUSED
2	No  SKIP TO THANK YOU

PERSON 2:

What is their name? Would you spell that for me?

NAME_____________________________

And what is their relationship to you?

RELATIONSHIP____________________

Where would we contact him/her?

Street: ________________________

City:__________________________

State: _________________________

Zip: __________________________

Is there a phone number?

PHONE NUMBER ____________________

Is there anyone else we can contact?

1	Yes	9	REFUSED
2	No  SKIP TO THANK YOU

PERSON 3:

What is their name? Would you spell that for me?

NAME_____________________________

And what is their relationship to you?

RELATIONSHIP____________________

Where would we contact him/her?

Street: ________________________

City:__________________________

State: _________________________

Zip: __________________________

Is there a phone number?

PHONE NUMBER ____________________

Thank you very much for your time and assistance.

If you have any questions about the study or your gift card, you can contact Tiffany Benefield at DIR, the company in charge of conducting this survey. Her toll-free number is 1-800-863-9964.

Choice Neighborhoods Initiative Residents Survey

Administrative Data Consent Form

[To be completed by field locators after completing contact sheet]

Thank you very much for your time. Your responses will help improve our understanding of the program.

Do we have your permission to access information about you from other sources besides you?

As I explained in the beginning, The Urban Institute is collecting information about the Choice Neighborhoods Initiative to assess the impact of the initiative on residents in the neighborhood and the development being transformed by the initiative. The survey is one important source of information, but we are interested in exploring certain topics more in depth in the future. To support this work, we are asking your permission to link data from administrative records such as employment, public assistance, school, and credit bureau records to your survey responses.

Will the information collected be kept confidential?

This information will not be shared with anyone outside of HUD or a research team designated by HUD. Researchers using the information will follow strict data security procedures as well as sign agreements only to use the information for research purposes. They will keep your information private by:

Not putting your name on any written records except for the administrative data consent form;
Keeping the administrative data consent form separated from your other information;
Keeping all information about you in a locked drawer or in a password-protected computer that is secure;
Not using your name or any other identifying information in any reports;
Summarizing the data of all residents in the study in any reports to make sure your privacy is protected.

How will we use the information collected from you?

The information gathered will be used for purposes of analysis, to write reports, and to contact you for follow-up interviews. Summaries of what we learned from the study may also be presented at conferences, professional meetings, and in written articles. Your name or identifying information will not be part of any report, presentation, article, or public use data file.

Do I have to give you permission to have administrative data about me linked to my questionnaire data?

You may refuse to give us permission to link your administrative data to your survey data. None of your benefits or services will be impacted in any way by your decision. However, linking your administrative data with questionnaire data will give researchers a better understanding of the impact of the Choice Neighborhoods Initiative and your experience during the revitalization of [Neighborhood Name].

Permission to Use Administrative Data

I, _______________________________________ [print your name] authorize the researchers at the Urban Institute, the U.S Department of Housing and Urban Development, and those researchers specifically designated by the U.S Department of Housing and Urban Development to use information collected from the following types of administrative records:

Please indicate your permission by checking the boxes below. If you check the box, it means that you AGREE to give permission for that data.

Employment
Your Children’s School Records
Public Assistance
Credit Bureau
Health
Criminal Justice

This information will be used for research analysis and to assist in efforts to contact me for follow-up interviews.

________________________________ ______________

Signature of Respondent Date

_______________________________ ______________

Signature of DIR Survey Interviewer Date

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	Appendix A Baseline Residents Survey VW 2 21 12
Author	Hailey, Chantal
File Modified	0000-00-00
File Created	2021-01-31

Yes usually,

DON’T KNOW

Not usually,

Very Mixed,

Haven’t needed any,

Or Landlord not responsible for maintenance?