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pdfNeighborhood Crime Survey
A Survey Sponsored by
The Bureau of Justice Statistics
Start Here
These first questions will help us learn more about this household and who lives at this address.
The person who knows the most about the people who live at this address should complete this
questionnaire.
Please use a pen with black or blue ink if possible.
Answer the questions by marking a box or writing in a number.
A. Including you, how many people age 18 or older live at this address? Include family members,
roommates, and boarders.
Write in the number:
people 18 and older
B. How many children aged 12 to 17 live at this address?
children 12 to 17 years old
C. And how many children aged 11 or younger live at this address, including babies?
children 11 years old or younger
D. Starting with yourself, complete each column below for each person age 18 or older living at this
address. Write in each person’s name, age, and check the box for his/her gender, ethnicity and race.
The information you provide below will help you with some questions later, Please list yourself as Person 1.
Person 1
Person 2
Person 3
Person 4
Name
Age
Gender
Is this person
Hispanic or Latino?
□ Male
□ Female
□ Yes, Hispanic
or Latino
□ No, not
□
□
What is this
person’s race?
□
□
Hispanic or
Latino
White
Black or
African
American
Asian
Some other
race
□ Male
□ Female
□ Yes, Hispanic
or Latino
□ No, not
□
□
□
□
Hispanic or
Latino
White
Black or
African
American
Asian
Some other
race
□ Male
□ Female
□ Yes, Hispanic
or Latino
□ No, not
□
□
□
□
Hispanic or
Latino
White
Black or
African
American
Asian
Some other
race
□ Male
□ Female
□ Yes, Hispanic
or Latino
□ No, not
□
□
□
□
Hispanic or
Latino
White
Black or
African
American
Asian
Some other
race
About Your Household
► These questions will help us learn more about this
household.
A. Personal Crimes
► A ‘personal crime’ is when another person who is
physically present with you does something
unlawful to you or another household member.
- Personal crimes may have happened at home,
on the street, at work or school, or anywhere
else.
E. Is this house…
Owned or being bought,
Rented, or
Occupied by some other arrangement?
F. How many years have you lived at this address?
- Include crimes where the offender was someone
you know, a stranger, or even a family member
► The questions below will ask whether you or
anyone you listed have experienced different
types of personal crimes in the past 12 months.
Mark if less than one year
1.
years
G. How many cars, vans, trucks, SUV’s, or other
motor vehicles have you or anyone you listed
owned in the past 12 months?
2.
Include those that are no longer owned.
number of vehicles
3.
Yes
No
In the past 12 months, did anyone attempt
to attack you or anyone else you listed?
Mark if none
► Continue answering questions about personal
crimes in the next column.
In the past 12 months, were you or anyone
else you listed attacked, mugged, or
threatened with violence?
Yes
No
In the past 12 months, did anyone force
you or anyone else you listed to have sex
with them, or to engage in unwanted sexrelated activity including attempts?
Yes
No
► If you said ‘no’ to questions 1, 2, and 3, please
go to Section B on page 8. Otherwise continue
with question 4 on the next page.
Personal Crimes:
Most Recent Incident
You reported that you or someone else you listed
experienced a personal crime in the past 12
months. These next questions will collect more
information about the most recent personal crime.
If there was more than one, please start with the
most recent incident. If there were none, please go
to Section B on page 8.
4. In what month and year did the most recent
personal crime happen?
month
year
5. Who did this happen to?
Write in the number of the person from Page 2.
Later questions will refer to this person as the
“victim.”
person number from question D
6. What happened?
Please describe it in your own words.
8. Did the victim know the person or any of the
persons who committed the crime?
Even if it was more than one person, we will call this
the “offender.”
Yes
No GO TO 11
9. How well did the victim know the offender?
If there was more than one person, answer for the
one the victim knew the best.
By sight only GO TO 11
A casual acquaintance GO TO 11
Well known
10. How did the victim know that offender?
Spouse at time of incident
Ex-spouse at time of incident
Parent or step parent
Own child or step-child
Brother or sister
Boyfriend or girlfriend
Friend
Some other relationship
11. Did the offender have a weapon such as a gun
or a knife, or something to use as a weapon?
7. Where did it happen?
In the victim’s home or yard
In the victim’s neighborhood
Somewhere else in [LOCAL AREA]
Outside of [LOCAL AREA]
Yes
No
12. Did the offender attack the victim?
Yes GO TO 15
No
13. Did the offender ATTEMPT to attack the victim?
Yes GO TO 15
No
14. Did the offender threaten the victim with harm
in any way?
Yes
No
15. Did the victim experience any type of unwanted
sexual contact such as forced or coerced
sexual intercourse, or any other sexual assault,
including attempts?
Yes
No GO TO 19
16. Was the victim forced or coerced to have sexual
intercourse?
Yes GO TO 19
No
17. Was there an attempt to force or coerce sexual
intercourse from the victim?
Yes GO TO 19
No
18. Was the victim sexually assaulted in some other
way?
No
No GO TO 21
Yes
No
21. Did anyone report this crime to the police?
Yes
No GO TO 24
23. What did the police do while they were there?
Mark all that apply.
Took a report
Searched/looked around
Took evidence (e.g. fingerprints)
Questioned witnesses or suspects
Promised to investigate
Arrested someone
Something else
24. Was anything stolen or taken during this
incident?
Yes
No GO TO 26
Mark all that apply.
Yes
20. Did the victim stay overnight in a hospital as a
result of these injuries?
25. What was stolen or taken?
Yes
19. Did the victim suffer any injuries as a result of
this incident?
22. Did the police come once the incident was
reported to them?
Yes
No
Something the victim had in their possession or
on their person (e.g. purse, wallet, or cell phone)
Something someone else had in their
possession or on their person (e.g. their purse,
wallet, or cell phone)
A motor vehicle that the victim was in or near
Something else
26. Other than this incident, did another personal
crime happen to you or someone else you
listed in the past 12 months?
Yes Continue with the next most recent
personal crime
No Please go to Section B, page 8
Personal Crimes:
Next Most Recent Incident
These questions are about the next most recent
personal crime that happened to you or someone
else you listed in the past 12 months. If there were
no other personal crimes, please go to Section B on
page 8.
27. In what month and year did the next most
recent personal crime happen?
month
year
28. Who did this happen to?
Write in the number of the person from Page 2.This
is the” victim.”
person number from question D.
29. What happened?
Please describe it in your own words.
30. Where did it happen?
In the victim’s home or yard
In the victim’s neighborhood
Somewhere else in (LOCAL AREA)
Outside of (LOCAL AREA)
31. Did the victim know the person or any of the
persons who committed the crime?
Even if it was more than one person, we will call this
the “offender.”
Yes
No GO TO 34
32. How well did the victim know the offender?
If there was more than one person, answer for the
one the victim knew the best.
By sight only GO TO 34
A casual acquaintance GO TO 34
Well known
33. How did the victim know that offender?
Spouse at time of incident
Ex-spouse at time of incident
Parent or step parent
Own child or step-child
Brother or sister
Boyfriend or girlfriend
Friend
Some other relationship
34. Did the offender have a weapon such as a gun
or a knife, or something to use as a weapon?
Yes
No
35. Did the offender attack the victim?
Yes GO TO 38
No
36. Did the offender ATTEMPT to attack the victim?
Yes GO TO 38
No
37. Did the offender threaten the victim with harm
in any way?
Yes
No
38. Did the victim experience any type of unwanted
sexual contact such as forced or coerced
sexual intercourse, or any other sexual assault,
including attempts?
Yes
No GO TO 42
39. Was the victim forced or coerced to have
sexual intercourse?
Yes GO TO 42
No
40. Was there an attempt to force or coerce sexual
intercourse from the victim?
Yes GO TO 42
No
41. Was the victim sexually assaulted in some
other way?
Yes
No
42. Did the victim suffer any injuries as a result of
this incident?
Yes
Yes
No
44. Did anyone report this crime to the police?
No GO TO 47
Mark all that apply.
Took a report
Searched/looked around
Took evidence (e.g. fingerprints)
Questioned witnesses or suspects
Promised to investigate
Arrested someone
Something else
47. Was anything stolen or taken during this
incident?
Yes
No GO TO 49
48. What was stolen or taken?
Mark all that apply.
Something the victim had in their possession or
on their person (e.g. purse, wallet, or cell phone)
Something someone else had in their
possession or on their person (e.g. their purse,
wallet, or cell phone)
A motor vehicle that the victim was in or near
Something else
49. Other than this incident, did another personal
crime happen to you or someone else you
listed in the past 12 months?
Yes Continue with the next most recent
personal crime
No Please go to Section B, page 8
Yes
No
Yes
46. What did the police do while they were there?
No GO TO 44
43. Did the victim stay overnight in a hospital as a
result of these injuries?
45. Did the police come once the incident was
reported to them?
Personal Crimes:
Third Most Recent Incident
50. Other than the incidents that you have already
reported, in what month and year did the third
most recent personal crime happen?
month
year
51. Who did this happen to?
Write in the number of the person from Page 2.
Personal Crimes:
Fourth Most Recent Incident
55. Other than the incidents that you have already
reported, in what month and year did the fourth
most recent personal crime happen?
month
year
56. Who did this happen to?
Write in the number of the person from Page 2.
person number from question D.
person number from question D.
52. What happened?
Please describe it in your own words.
57. What happened?
Please describe it in your own words.
53. Did anyone report this crime to the police?
Yes
No
54. Other than this incident, did another personal
crime happen to you or someone else you listed in
the past 12 months?
Yes Continue with the next most recent
personal crime in the next column
No Please go to Section B on the next page
58. Did anyone report this crime to the police?
Yes
No
59. Other than this incident, did another personal
crime happen to you or someone else you
listed in the past 12 months?
Yes
No Please go to Section B on the next
page
60. You’ve already described four personal crimes.
Other than those incidents, how many more
personal crimes happened to you or some else
you listed in the past 12 months?
additional personal crime incidents
B. Theft and Break-ins
This section will ask about times in the past 12
months where someone may have stolen
something, tried to steal something, or broken into
this home.
64. In the past 12 months, was anything stolen
from this house or apartment, from a yard, or
from any other building, like a garage or
shed, on the property?
Do not include any incidents that have reported in
the previous section as a personal crime.
61. In the past 12 months, did you or anyone else
you listed have anything stolen?
- it could have been something you wear or carry,
like a wallet or purse, watch, or jewelry
- it could have been electronic equipment, like a
phone, tablet, or MP3 player
Yes
No
63. In the past 12 months, was anything stolen
from a car?
- It could have been hubcaps or other parts, a
radio or stereo, gasoline, personal items, or
anything else
Yes
No
Yes
No
66. In the past 12 months, did anyone break into
this home, or attempt to break in, whether or
not anything was stolen?
Yes
No
No
65. In the past 12 months, so far as you know, did
anyone ATTEMPT to steal something that
belonged to you or anyone you listed?
62. In the past 12 months, was a car or other motor
vehicle stolen or used without permission?
Yes
►
Yes
No
If you said “no” to all questions 61 through
66, go to Section C, page 13. Otherwise
continue with the next page.
Theft and Break-ins:
Most Recent Incident
Theses next questions are about a theft or break-in
that happened to you or someone else you listed in
the past 12 months. If there was more than one,
please start with the most recent. If there were no
thefts or break-ins, please go to Section C on page
13.
67. In what month and year did the most recent
incident happen?
month
year
68. What happened?
Please describe it in your own words.
72. Was there any evidence, such as a broken lock or
broken window, that the offender(s) got in by
force/tried to get in by force?
Yes
No
73. Was something stolen or taken without
permission that belonged to you or others who
live at this address?
Yes GO TO 75
No
74. Did the offender ATTEMPT to take something
that belonged to you or others who live at this
address?
Yes
No
75. Was a car or other motor vehicle stolen
during this incident?
69. Where did it happen?
►
In this home or yard
In this neighborhood
Somewhere else in (LOCAL AREA)
Outside of (LOCAL AREA)
If the incident occurred in this home continue with
question 70, otherwise go to question 73.
70. Did the offender actually get inside the home,
structure, or building?
Yes GO TO 71
No
71. Did the offender ATTEMPT to get inside the
home, structure, or building?
Yes
No GO TO 57
Yes GO TO 77
No
76. Did anyone ATTEMPT to steal a car or other
motor vehicle?
Yes
No
77. Did you or anyone else report this crime to
the police?
Yes
No
78. Did another theft or break-in happen to you or
someone else you listed in the past 12
months?
Yes Please go to 79
No Please go to Section C, page 13
Theft and Break-ins:
Next Most Recent Incident
These questions are about the next most recent
theft or break- in in the past 12 months. If there
wasn’t one, please go to Section C on page 13.
79. In what month and year did the next most
recent incident happen?
month
year
80. What happened?
Please describe it in your own words.
84. Was there any evidence, such as a broken lock or
broken window, that the offender(s) got in by
force/tried to get in by force?
Yes
No
85. Was something stolen or taken without
permission that belonged to you or others who
live at this address?
Yes GO TO 87
No
86. Did the offender ATTEMPT to take something
that belonged to you or others who live at this
address?
Yes
No
87. Was a car or other motor vehicle stolen?
81. Where did it happen?
►
In this home or yard
In this neighborhood
Somewhere else in (LOCAL AREA)
Outside of (LOCAL AREA)
If the incident occurred in this home continue with
question 82, otherwise go to question 85.
82. Did the offender actually get inside the home,
structure, or building?
Yes GO TO 84
No
83. Did the offender ATTEMPT to get inside the
home, structure, or building?
Yes
No GO TO 85
Yes GO TO 89
No
88. Did anyone ATTEMPT to steal a car or other
motor vehicle?
Yes
No
89. Did you or anyone else report this crime to
the police?
Yes
No
90. Did another theft or break-in happen to you or
someone else you listed in the past 12
months?
Yes Please go to 91
No Please go to Section C, page 13
Theft and Break-ins:
Third Most Recent Incident
These questions are about the third most recent
theft or break- in in the past 12 months. If there
wasn’t one, please go to Section C on page 13.
91. In what month and year did the third most
recent incident happen?
month
year
92. What happened?
Please describe it in your own words.
96. Was there any evidence, such as a broken lock or
broken window, that the offender(s) got in by
force/tried to get in by force?
Yes
No
97. Was something stolen or taken without
permission that belonged to you or others who
live at this address?
Yes GO TO 99
No
98. Did the offender ATTEMPT to take something
that belonged to you or others who live at this
address?
Yes
No
99. Was a car or other motor vehicle stolen?
93. Where did it happen?
►
In this home or yard
In this neighborhood
Somewhere else in (LOCAL AREA)
Outside of (LOCAL AREA)
If the incident occurred in this home continue with
question 94, otherwise go to question 97.
94. Did the offender actually get inside the home,
structure, or building?
Yes GO TO 96
No
95. Did the offender ATTEMPT to get inside the
home, structure, or building?
Yes
No GO TO 97
Yes GO TO 101
No
100. Did anyone ATTMPET to steal a car or other
motor vehicle?
Yes
No
101. Did you or anyone else report this crime to
the police?
Yes
No
102. Did another theft or break-in happen to you
or someone else you listed in the past 12
months?
Yes Please go to 103
No Please go to Section C, page 13
Theft and Break-ins:
Fourth Most Recent Incident
These questions are about the fourth most recent
theft or break- in in the past 12 months. If there
wasn’t one, please go to Section C on the next page.
103. In what month and year did the fourth most
recent incident happen?
month
108. Was there any evidence, such as a broken lock
or broken window, that the offender(s) got in by
force/tried to get in by force?
Yes
No
109. Was something stolen or taken without
permission that belonged to you or who live at
this address?
Yes GO TO 111
No
year
104. What happened?
Please describe it in your own words.
110. Did the offender ATTEMPT to take something
that belonged to you or others who live at this
address?
Yes
No
111. Was a car or other motor vehicle stolen?
105. Where did it happen?
►
In this home or yard
In this neighborhood
Somewhere else in (LOCAL AREA)
Outside of (LOCAL AREA)
If the incident occurred in this home continue with
question 106, otherwise go to question 109.
106. Did the offender actually get inside the home,
structure, or building?
Yes GO TO 108
No
107. Did the offender ATTEMPT to get inside the
home, structure, or building?
Yes
No GO TO 108
Yes GO TO 113
No
112. Did anyone ATTEMPT to steal a car or other
motor vehicle?
Yes
No
113. Did you or anyone else report this crime to the
police?
Yes
No
114. Did another theft or break-in happen to you or
someone else you listed in the past 12 months?
Yes Please go to 115
No Please go to Section C on the next page
115. You’ve already described four thefts or breakins. Other than those incidents, how many more
thefts or break-ins happened to you or some
else you listed in the past 12 months?
additional thefts or break-ins
C. Other Crimes
These last few questions will ask you about other
kinds of crimes that you or someone else you listed
may have experienced, such as, identity theft or
vandalism.
121. How many times in the last 12 months has
this happened?
Count multiple uses of the account before
discovery as one time.
Do not include any incidents you may have reported
in the previous sections.
116. In the last 12 months has this home or property,
or the property of others who live at this
address been vandalized?
Yes
No GO TO 118
117. How many times in the last 12 months has this
happened?
number of vandalism incidents
118. In the last 12 months have you or anyone you
listed discovered or been told that someone
used or attempted to use any existing credit
cards?
Yes
No GO TO 120
119. How many times in the last 12 months has this
happened?
Count multiple uses of the same card number before
discovery as one time.
number of times
120. In the last 12 months have you or anyone you
listed discovered, or been told that someone
used or attempted to use other accounts
without permission?
Think of accounts such as wireless phones, bank
accounts, or check cards
Yes
No GO TO 122
number of times
122. In the last 12 months have you or anyone
you listed discovered or been told that
someone used or attempted to use personal
information to obtain new credit cards or
loans, or fraud?
Yes
No GO TO 124
123. How many times in the last 12 months has
this happened?
Count multiple times before discovery as one
time.
number of times
124. Finally, which category best fits the total
income of all persons in your household
over the past 12 months?
Include money from jobs or other earnings,
pensions, interest, rent, Social Security
payments, and so on.
$0 to $10,000
$10,001 to $20,000
$20,001 to $30,000
$30,001 to $40,000
$40,001 to $50,000
$50,001 to $60,000
$60,001 to $75,000
$75,001 to $100,000
$100,001 to $150,000
$150,001 or more
► Thank you for completing this survey. Please
return it in the postage-paid envelope provided.
| File Type | application/pdf |
| Author | Douglas Williams |
| File Modified | 2013-05-14 |
| File Created | 2013-05-14 |