Neighborhood Crime Survey

Research to support the National Crime Victimization Survey (NCVS)

Appendix C - Mail Survey Instruments

Pretest of a Mail Survey Instrument under the National

OMB: 1121-0325

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1121-0325 can be found here:

2015-10-27 - Reinstatement without change of a previously approved collection

Document [pdf]

Download: pdf | pdf

Appendix C ‐ Survey Instruments
1. Incident Level Instrument
2. Person Level Instrument

OMB No 121-0325
Expires XX/XX/XXXX

Neighborhood
Crime Survey
A Survey Sponsored by
The Bureau of Justice Statistics

Title 42, Section 3732, United States Code, authorizes the Bureau of Justice Statistics, Department of Justice, to collect information
using this survey and requires us to keep all information about you and your household strictly confidential. Under the Paperwork
Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid
OMB number. The valid OMB control number for this information collection is 1121-0325. Comments regarding any other aspect
of this data collection may be sent to, to DOJ Clearance Officer, Bureau of Justice Statistics, 810 Seventh Street, NW Washington,
DC 20531 or by calling toll-free 1-888-380-0050.



Please use a black or blue pen to complete this form.



Mark
to indicate your answer. If you want to
change your answer, darken the box
and mark
the correct answer.



These questions will ask how you feel about the safety
of your neighborhood.

5. How safe do you think children are in your community?
Always safe
Mostly safe
Sometimes safe
Rarely safe
Never safe
6. In the last 3 years, do you believe your community has:
Become safer
Stayed the same
Become less safe
Don’
t
k
now

1. On the whole, how much of the time is the community
where you live safe?
Always safe
Mostly safe
Sometimes safe
Rarely safe
Never safe



2. Is there any place within a mile of your home where you
would be afraid to walk alone at night?
Yes
No

T
he
s
e
ne
x
t
que
s
t
i
ons
wi
l
l
a
s
k
a
bout
c
ont
a
c
t
y
ou’
v
e
ha
d
with your local police department.

7. While living at this address, have you ever contacted
the local police department for assistance?
Yes
No  GO TO 9

3. How often does fear of crime prevent you from doing
things you would like to do?
Very often
Somewhat often
Rarely
Never

8. If so, how satisfied were you with the police response?
Very satisfied
Mostly satisfied
Somewhat satisfied
Not at all satisfied

4. When you leave your home, how often do you think
about it being broken into or vandalized while you're
away?

9. How would you rate the job the local police department
is doing in your community?
Excellent

Very often
Somewhat often
Rarely
Never

Good
Fair
Poor
Don’
t
k
now

Draft

NCVS_2015_Pilot_Incident_Level_v8
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

These questions will help us learn more about your 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.

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.
The information you provide below will help you with some questions later, please list yourself as Adult 1.
Adult 1

Adult 2

Adult 3

Adult 4

First Name
Age
Gender

Male
Female

Is this adult
Hispanic or
Latino?

Yes, Hispanic or
Latino
No, not Hispanic
or Latino

White

Black or African
American
Asian

American Indian
or Alaska Native
Native Hawaiian
or Other Pacific
Islander

What is this
adult's race?
(Mark all
that apply)

Draft

NCVS_2015_Pilot_Incident_Level_v8
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Section A: Violent Crimes

Your Household: Continued


E. Do you own or rent the place where you're living?
Own
Rent

A 'violent crime' is when another person who is
physically present with you does something unlawful to
you or another household member.
‐
‐
Vi
ol
e
nt
c
r
i
me
s
may
hav
e
happe
ne
d
at
home
,
on
t
he
street, at work or school, or anywhere else.

Some other arrangement
F. How many years have you lived at this address?

‐
‐
I
nc
l
ude
c
r
i
me
s
whe
r
e
t
he
of
f
e
nde
r
was
s
ome
one
y
ou
know, a stranger, or even a family member.

Mark if less than one year
years

1. In the past 12 months, were you or anyone else you
listed attacked, mugged, or threatened with violence?
Yes

G. How many cars, vans, trucks, SUVs, or other motor
vehicles have you or anyone you listed owned in the
past 12 months?

Include those that are no longer owned.

2. In the past 12 months, did anyone ATTEMPT to attack
you or anyone else you listed?

Mark if none

Yes
number of vehicles


No
3. In the past 12 months, did anyone force you or anyone
else you listed to have sex with them, or to engage in
unwant
ed
s
ex
‐
r
el
a
t
ed
ac
t
i
v
i
t
y
?
Yes

Continue answering questions about violent crimes in
the next column.

No
4. In the past 12 months, did anyone ATTEMPT to force you
or anyone else you listed to have sex with them, or to
e
ng
a
g
e
i
n
unwant
ed
s
ex
‐
r
el
a
t
ed
ac
t
i
v
i
t
y
?
Yes
No


If you marked 'YES' for any question above (1, 2, 3, or 4),
continue with question 5 on the next page. Otherwise
skip to Section B on page 9.

Draft

NCVS_2015_Pilot_Incident_Level_v8
39060

Violent Crimes:
Most Recent Incident
You reported that you or someone else you listed
experienced a violent crime in the past 12 months.
Please start with the most recent incident.

8. Where did it happen?
I
n
t
he
v
i
c
t
i
m’
s
home
or
y
a
r
d

If there were none, please go to Section B on page 9.

I
n
t
he
v
i
c
t
i
m’
s
nei
g
hbor
hood,
but
not
t
he
i
r
home or yard
Somewhere else in this city

5. In what month and year did the most recent violent
crime happen?

Outside of this city
9. Was the victim confronted by the offender?

month

By confronted, we mean that the offender approached
the victim, or had some contact with the victim.

year

Yes

6. Who did this happen to? Write in the first name and
adult number of the person(s) this happened to from
question D on page 2.
Later questions will refer to this person or these persons
as the "victim."
First Name

No
10. How well did the victim know the offender?
If there was more than one victim or offender, answer for
the offender the victim knew the best.
Well known

A casual acquaintance  GO TO 12
By sight only  GO TO 12
Victim did not know the offender(s)  GO TO 12
11. How did the victim know that offender?
Spouse at time of incident
E
x
‐
s
pous
e
a
t
t
i
me
of
i
nc
i
de
nt
7. What happened?
Provide as many details as you can recall, such as: where
it happened, who was attacked, what injuries occurred,
and what (if anything) was stolen.

Parent or step parent
Own
c
hi
l
d
or
s
t
e
p‐
c
hi
l
d
Brother or sister
Boyfriend or girlfriend
Friend
Some other relationship
12. Did the offender have a weapon such as a gun or a
knife, or something to use as a weapon?
Yes
No
Don’
t
k
now
13. Did the offender attack the victim?
Yes  GO TO 16 on the next page
No

Draft

NCVS_2015_Pilot_Incident_Level_v8
39060

14. Did the offender ATTEMPT to attack the victim?
Yes



22. Did anyone report this crime to the police?
Yes

GO TO 16

15. Did the offender threaten the victim with harm in any
way?

Yes

16. Did the victim experience any type of unwanted sexual
contact such as forced or coerced sexual intercourse, or
any other sexual assault, including any attempted sexual
contact by force?

Took a report
Searched/looked around
Took evidence (e.g. fingerprints)
Questioned witnesses or suspects

17. Was the victim forced or coerced to have sexual
intercourse?

Promised to investigate
Arrested someone

GO TO 20

Something else

I don't know what the police did

18. Was there an attempt to force or coerce sexual
intercourse from the victim?


GO TO 25

Mark all that apply.

No  GO TO 20

Yes



24. What did the police do while they were there?

Yes



GO TO 25

23. Did the police come once the incident was reported to
them?

Yes



25. Was anything stolen or taken during this incident?

GO TO 20

Yes

19. Was the victim sexually assaulted in some other way?



GO TO 27

26. What was stolen or taken?

Yes

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

20. Did the victim suffer any injuries as a result of this
incident?
Yes
No  GO TO 22 in the next column
21. Did the victim stay overnight in a hospital as a result of
these injuries?

Something else
27. Other than this incident, did another violent crime
happen to you or someone else you listed in the past 12
months?

Yes
No

Yes  Continue with the next most recent violent
crime
No



GO TO Section B, page 9

Draft

NCVS_2015_Pilot_Incident_Level_v8
39060

Violent Crimes:
Next Most Recent Incident
These questions are about the next most recent violent
crime that happened to you or someone else you listed in
the past 12 months.

31. Where did it happen?
I
n
t
he
v
i
c
t
i
m’
s
home
or
y
a
r
d
I
n
t
he
v
i
c
t
i
m’
s
nei
g
hbor
hood,
but
not
t
he
i
r
home or yard
Somewhere else in this city

If there were no other violent crimes, please go to Section
B on page 9.

Outside of this city

28. In what month and year did the next most recent
violent crime happen?

32. Was the victim confronted by the offender?
By confronted, we mean that the offender approached
the victim, or had some contact with the victim.

month

year

Yes
No

29. Who did this happen to? Write in the first name and
adult number of the person(s) this happened to from
question D on page 2.
Later questions will refer to this person or these persons
as the "victim."
First Name

33. How well did the victim know the offender?
If there was more than one victim or offender, answer for
the offender the victim knew the best.
Well known

A casual acquaintance  GO TO 35
By sight only  GO TO 35
Victim did not know the offender(s)  GO TO 35
34. How did the victim know that offender?
Spouse at time of incident
E
x
‐
s
pous
e
a
t
t
i
me
of
i
nc
i
de
nt
Parent or step parent

30. What happened?
Provide as many details as you can recall, such as: where
it happened, who was attacked, what injuries occurred,
and what (if anything) was stolen.

Own
c
hi
l
d
or
s
t
e
p‐
c
hi
l
d
Brother or sister
Boyfriend or girlfriend
Friend
Some other relationship
35. Did the offender have a weapon such as a gun or a
knife, or something to use as a weapon?
Yes
No
Don’
t
k
now
36. Did the offender attack the victim?
Yes  GO TO 39 on the next page
No

Draft

NCVS_2015_Pilot_Incident_Level_v8
39060

37. Did the offender ATTEMPT to attack the victim?

45. Did anyone report this crime to the police?

Yes  GO TO 39
No

Yes
No  GO TO 48
46. Did the police come once the incident was reported to
them?

38. Did the offender threaten the victim with harm in any
way?
Yes

Yes

No  GO TO 48

39. Did the victim experience any type of unwanted sexual
contact such as forced or coerced sexual intercourse, or
any other sexual assault, including any attempted sexual
contact by force?

47. What did the police do while they were there?
Mark all that apply.
Took a report
Searched/looked around

Yes
No



Took evidence (e.g. fingerprints)

GO TO 43

Questioned witnesses or suspects

40. Was the victim forced or coerced to have sexual
intercourse?

Promised to investigate
Arrested someone

Yes  GO TO 43
No

Something else
I don't know what the police did

41. Was there an attempt to force or coerce sexual
intercourse from the victim?
Yes



48. Was anything stolen or taken during this incident?

GO TO 43

Yes

No  GO TO 50

42. Was the victim sexually assaulted in some other way?

49. What was stolen or taken?

Yes

Mark all that apply.

43. Did the victim suffer any injuries as a result of this
incident?
Yes
No



GO TO 45 in the next column

Something else

44. Did the victim stay overnight in a hospital as a result of
these injuries?

50. Other than this incident, did another violent crime
happen to you or someone else you listed in the past 12
months?

Yes
No

Yes  Continue with the next most recent violent
crime
No  GO TO Section B, page 9

Draft

NCVS_2015_Pilot_Incident_Level_v8
39060

Violent Crimes:
Fourth Most Recent Incident

Violent Crimes:
Third Most Recent Incident
51. Other than the incidents that you have already
reported, in what month and year did the third most
recent violent crime happen?

month

56. Other than the incidents that you have already
reported, in what month and year did the fourth most
recent violent crime happen?

year

month

52. Who did this happen to? Write in the first name and
adult number of the person(s) this happened to from
question D on page 2.
First Name

year

57. Who did this happen to? Write in the first name and
adult number of the person(s) this happened to from
question D on page 2.
#

First Name

53. What happened?

58. What happened?

Provide as many details as you can recall, such as: where
it happened, who was attacked, what injuries occurred,
and what (if anything) was stolen.

59. Did anyone report this crime to the police?
Yes
54. Did anyone report this crime to the police?

Yes

60. Other than this incident, did another violent crime
happen to you or someone else you listed in the past 12
months?
Yes

No
55. Other than this incident, did another violent crime
happen to you or someone else you listed in the past 12
months?

No  GO TO Section B on the next page
61. You've already described four violent crimes. Other than
those incidents, how many more violent crimes
happened to you or some else you listed in the past 12
months?

Yes  Continue with the next most recent
violent crime in the next column
No  GO TO Section B on the next page

additional violent crime incidents
Draft

NCVS_2015_Pilot_Incident_Level_v8
39060

Section B:
T
hef
t
a
nd
Br
ea
k
‐
i
ns
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.

65. In the past 12 months, was anything stolen from this
house or apartment, from the yard, or from any other
building that is part of your home, like a garage or
shed?

Do not include any incidents you reported in the previous
section as a violent crime.

Yes
No

62. In the past 12 months, did you or others in this household
have anything stolen?

66. In the past 12 months, so far as you know, did anyone
ATTEMPT to steal something that belonged to you or
others in this household?

‐
I
t
c
oul
d
hav
e
be
e
n
s
ome
t
hi
ng
y
ou
we
ar
or
c
ar
r
y
,
l
i
k
e
a
wallet or purse, watch, or jewelry.

Yes
No

‐
I
t
c
oul
d
hav
e
be
e
n
el
e
c
t
r
oni
c
e
qui
pme
nt
,
l
i
k
e
a
phone,
tablet, or MP3 player.

67. In the past 12 months, did anyone break into this home,
or attempt to break in, whether or not anything was
stolen?

Yes
No

Yes

63. In the past 12 months, was a car or other motor vehicle
stolen or used without permission?

Yes



If you marked 'YES' for any of these questions (62
through 67), continue with the next page. Otherwise
skip to Section C on page 14.

64. In the past 12 months, was anything stolen from a car?
‐
I
t
c
oul
d
hav
e
be
e
n
hubc
aps
or
ot
he
r
par
t
s
,
a
r
adi
o
or
stereo, gasoline, personal items, or anything else.
Yes
No

Draft

NCVS_2015_Pilot_Incident_Level_v8
39060

T
hef
t
a
nd
Br
ea
k
‐
i
ns
:
Most Recent Incident
T
hes
e
nex
t
ques
t
i
ons
ar
e
a
bout
a
t
hef
t
or
br
ea
k
‐
i
n
t
ha
t
happened to you or others in this household in the past 12
months. If there was more than one, please start with the
most recent.

72. Did the offender ATTEMPT to get inside the home,
structure, or building?
Yes
No  GO TO 74

I
f
t
her
e
wer
e
no
t
hef
t
s
or
br
eak
‐
i
ns
,
pl
ea
s
e
g
o
t
o
S
ec
t
i
on
C
on page 14.

73. Was there any evidence, such as a broken lock or
broken window, that the offender(s) got in by force or
tried to get in by force?

68. In what month and year did the most recent incident
happen?

Yes
No

month

74. Was something stolen or taken without permission that
belonged to you or others in this household?

year

69. What happened?

Yes  GO TO 76
No

Provide as many details as you can recall, such as: where it
happened, and what was stolen.

75. Did the offender ATTEMPT to take something that
belonged to you or others in this household?
Yes
No
76. Was a car or other motor vehicle stolen during this
incident?
Yes  GO TO 78
No
77. Did anyone ATTEMPT to steal a car or other motor
vehicle?
Yes
No
78. What was the total value of the property that was
taken?

70. Where did it happen?
In this home or yard

79. Did you or anyone else report this incident to the
police?

In this neighborhood
Somewhere else in this city

Yes

Outside of this city


.00

If the incident occurred in this home continue with
question 71, otherwise go to question 74 in the next
column.

8
0.Di
d
a
not
her
t
hef
t
or
br
ea
k
‐
i
n
happen
t
o
y
ou
or
ot
her
s
in this household in the past 12 months?

71. Did the offender actually get inside the home, structure,
or building?

Yes  GO TO 81 on the next page
No  GO TO Section C on page 14

Yes  GO TO 73 in the next column
No
Draft

NCVS_2015_Pilot_Incident_Level_v8
39060

T
hef
t
a
nd
Br
ea
k
‐
i
ns
:
Next Most Recent Incident
T
hes
e
a
r
e
a
bout
t
he
nex
t
mos
t
r
ec
ent
t
hef
t
or
br
ea
k
‐
i
n
i
n
the past 12 months.

85. Did the offender ATTEMPT to get inside the home,
structure, or building?
Yes

I
f
t
her
e
wer
e
no
t
hef
t
s
or
br
eak
‐
i
ns
,
pl
ea
s
e
g
o
t
o
S
ec
t
i
on
C
on page 14.

81. In what month and year did the next most recent
incident happen?



GO TO 87

86. Was there any evidence, such as a broken lock or broken
window, that the offender(s) got in by force or tried to
get in by force?
Yes

month

year

82. What happened?

87. Was something stolen or taken without permission that
belonged to you or others in this household?

Provide as many details as you can recall, such as: where it
happened, and what was stolen.

Yes  GO TO 89
No
88. Did the offender ATTEMPT to take something that
belonged to you or others in this household?
Yes
No
89. Was a car or other motor vehicle stolen during this
incident?
Yes  GO TO 91
No
90. Did anyone ATTEMPT to steal a car or other motor
vehicle?
Yes
No
91. What was the total value of the property that was
taken?

83. Where did it happen?
In this home or yard

In this neighborhood
Somewhere else in this city

92. Did you or anyone else report this incident to the
police?

Outside of this city


.00

Yes

If the incident occurred in this home continue with
question 84, otherwise go to question 87 in the next
column.

No
9
3.Di
d
a
not
her
t
hef
t
or
br
ea
k
‐
i
n
happen
t
o
y
ou
or
ot
her
s
in this household in the past 12 months?

84. Did the offender actually get inside the home, structure,
or building?

Yes  GO TO 94 on the next page
No  GO TO Section C on page 14

Yes  GO TO 86 in the next column
No

Draft

NCVS_2015_Pilot_Incident_Level_v8
39060

T
hef
t
a
nd
Br
eak
‐
i
ns
:
Third Most Recent Incident
These questions are about the third most recent theft or
br
ea
k
‐
i
n
i
n
t
he
pas
t
12
mont
hs
.

98.

Did the offender ATTEMPT to get inside the home,
structure, or building?
Yes

I
f
t
her
e
wer
e
no
t
hef
t
s
or
br
eak
‐
i
ns
,
pl
ea
s
e
g
o
t
o
S
ec
t
i
on
C
on page 14.

94. In what month and year did the third most recent
incident happen?

99.



GO TO 100

Was there any evidence, such as a broken lock or broken
window, that the offender(s) got in by force or tried to
get in by force?
Yes

month

year

95. What happened?

100. Was something stolen or taken without permission that
belonged to you or others in this household?

Provide as many details as you can recall, such as: where it
happened, and what was stolen.

Yes



GO TO 102

No
101. Did the offender ATTEMPT to take something that
belonged to you or others in this household?
Yes
No
102. Was a car or other motor vehicle stolen during this
incident?
Yes



GO TO 104

No
103. Did anyone ATTEMPT to steal a car or other motor
vehicle?
Yes
No
104. What was the total value of the property that was
taken?

96. Where did it happen?
In this home or yard

In this neighborhood
Somewhere else in this city

105. Did you or anyone else report this incident to the
police?

Outside of this city


.00

Yes

If the incident occurred in this home continue with
question 97, otherwise go to question 100 in the next
column.

No
1
06.Di
d
a
not
her
t
hef
t
or
br
ea
k
‐
i
n
ha
ppen
t
o
y
ou
or
ot
her
s
in this household in the past 12 months?

97. Did the offender actually get inside the home, structure,
or building?

Yes  GO TO 107 on the next page
No  GO TO Section C on page 14

Yes  GO TO 99 in the next column
No

Draft

NCVS_2015_Pilot_Incident_Level_v8
39060

T
hef
t
a
nd
Br
ea
k
‐
i
ns
:
Fourth Most Recent Incident
These questions are about the fourth most recent theft or
br
ea
k
‐
i
n
i
n
t
he
pas
t
12
mont
hs
.

112. Was there any evidence, such as a broken lock or
broken window, that the offender(s) got in by force or
tried to get in by force?

I
f
t
her
e
wer
e
no
t
hef
t
s
or
br
eak
s
‐
i
ns
,
pl
ea
s
e
g
o
t
o
S
ec
t
i
on
C
on page 14.

Yes
No

107. In what month and year did the fourth most recent
incident happen?

month

113. Was something stolen or taken without permission
that belonged to you or others in this household?
Yes  GO TO 115
No

year

108. What happened?

114. Did the offender ATTEMPT to take something that
belonged to you or others in this household?

Provide as many details as you can recall, such as: where
it happened, and what was stolen.

Yes
No
115. Was a car or other motor vehicle stolen during this
incident?
Yes  GO TO 117
No
116. Did anyone ATTEMPT to steal a car or other motor
vehicle?
Yes
No
117. What was the total value of the property that was
taken?

109. Where did it happen?

In this home or yard
In this neighborhood

118. Did you or anyone else report this incident to the
police?
Yes

Somewhere else in this city
Outside of this city


.00

If the incident occurred in this home continue with
question 110, otherwise go to question 113 in the
next column.

119. Di
d
anot
her
t
hef
t
or
br
ea
k
‐
i
n
ha
ppen
t
o
y
ou
or
ot
her
s
in this household in the past 12 months?
Yes  GO TO 120
No  GO TO Section C on the next page

110. Did the offender actually get inside the home,
structure, or building?
Yes  GO TO 112 in the next column
No

1
20.You'
v
e
a
l
r
ea
dy
des
c
r
i
be
d
f
our
t
hef
t
s
or
br
ea
k
‐
i
ns
.
Other than those incidents, how many more thefts or
br
ea
k
‐
i
ns
ha
ppened
t
o
y
ou
or
ot
her
s
i
n
t
hi
s
hous
ehol
d
in the past 12 months?

111. Did the offender ATTEMPT to get inside the home,
structure, or building?
Yes

a
ddi
t
i
ona
l
t
he
f
t
s
or
br
e
a
k
‐
i
ns

No  GO TO 113

Draft

NCVS_2015_Pilot_Incident_Level_v8
39060

Section 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.

126. How many times in the last 12 months has this
happened?
Count multiple uses of an account before discovery as
one time.

Do not include any incidents you may have reported in the
previous sections.

number of times

121. In the last 12 months has this home or the property of
anyone in this household been vandalized?

127. In the last 12 months have you or anyone you listed
discovered or been told that someone used or
attempted to use their personal information to obtain
new credit cards or loans, or for other fraudulent
purposes?
Yes

Think about any vandalism done to your home, or
to any motor vehicles owned by members of this
household in the last 12 months.
Yes
No  GO TO 123

No  GO TO 129

122. How many times in the last 12 months has this
happened?

128. How many times in the last 12 months has this
happened?
Count multiple times before discovery as one time.

number of vandalism incidents

number of times

123. 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



129. Which category best fits the approximate total income
of all persons in your household over the past 12
months?

GO TO 125

Include money from jobs or other earnings, pensions,
interest, rent, Social Security payments, and so on.

124. How many times in the last 12 months has this
happened?
Count multiple uses of the same card number before
discovery as one time.

$0 to $10,000
$10,001 to $20,000
$20,001 to $30,000

number of times

$30,001 to $40,000
$40,001 to $50,000

125. 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?
Include accounts such as cell phones, bank accounts,
debit cards, or check cards.

$50,001 to $60,000
$60,001 to $75,000
$75,001 to $100,000
$100,001 to $150,000
$150,001 or more

Yes
No  GO TO 127 in the next column

130. We may contact some households to clarify answers
and improve the survey. Please provide a telephone
number where we can reach you:

Thank you for completing this survey. Please return it in
t
he
pos
t
a
g
e‐
pa
i
d
env
el
ope
pr
ov
i
ded.

Draft

NCVS_2015_Pilot_Incident_Level_v8
39060

OMB No 121-0325
Expires XX/XX/XXXX

Neighborhood
Crime Survey
A Survey Sponsored by
The Bureau of Justice Statistics



Please use a black or blue pen to complete this form.



Mark
to indicate your answer. If you want to
change your answer, darken the box and mark
the correct answer.



These questions will ask how you feel about the safety of
your neighborhood.

1. On the whole, how much of the time is the community
where you live safe?
Always safe
Mostly safe
Sometimes safe
Rarely safe
Never safe

7. While living at this address, have you ever contacted the
local police department for assistance?
Yes
No  GO TO 8

2. Is there any place within a mile of your home where you
would be afraid to walk alone at night?
Yes
No

7a. If yes, how satisfied were you with the police
response?
Very satisfied
Mostly satisfied

3. How often does fear of crime prevent you from doing things
you would like to do?

Somewhat satisfied
Not at all satisfied

Very often
Somewhat often
Rarely
Never

8. How would you rate the job the local police department is
doing in your community?
Excellent

4. When you leave your home, how often do you think about
it being broken into or vandalized while you're away?

Good
Fair

Very often
Somewhat often
Rarely
Never

Poor
Don’
t
k
now

Draft

NCVS_2015_Pilot_Person_Level_v7
34256

T
hef
t
s
a
nd
Br
ea
k
‐
i
ns



T
he
s
e
que
s
t
i
ons
a
r
e
a
bout
hous
e
hol
d
t
he
f
t
s
a
nd
br
ea
k
‐
i
ns
.
After these questions about your household we will ask
about the individual experiences of each adult living here.

9f. What was stolen?

9. In the last 12 months, did anyone break into your home or
get in without permission?
Yes  GO TO 9a
No  GO TO 10
9a. How many times did this happen in the last 12
months?
number of times
9g. About how much was the value of what was stolen?
9b. When was the most recent time?

$
month

.00

9h. Was any incident like this reported to the police in the
past 12 months?

year

9c. Was someone at home any time in the last 12 months
when someone broke in or entered your home without
permission?

Yes
No
10. In the last 12 months, did anyone try to break into your
home, but not succeed?

Yes  GO TO 9d
No  GO TO 9e

Yes  GO TO 10a
No,
no
at
t
e
mpt
e
d
br
e
a
k
‐
i
ns GO TO 11

9d. When someone was home, did they see the offender?
Yes
No

10a. How
ma
ny
uns
uc
c
es
s
f
ul
br
eak
‐
i
n
a
t
t
empt
s
ha
v
e
y
ou
had in the past 12 months?

9e. Was anything stolen when someone broke in or
entered your home without permission any time in the
last 12 months?

number of attempts

Yes  GO TO 9f
No  GO TO 9h

Draft

NCVS_2015_Pilot_Person_Level_v7
34256

Your Household

10b. When
wa
s
t
he
mos
t
r
ec
ent
uns
uc
c
es
s
f
ul
br
ea
k
‐
i
n
attempt?

13. Do you own or rent the place where you're living?
Own
Rent
Other, describe below

month

year

10c. In the past 12 months, were any of these attempted
br
ea
k
‐
i
ns
r
epor
t
ed
t
o
t
he
pol
i
c
e?
Yes

14. How long have you lived at this address?
1 year or less

Less than 5 years, more than 1 year

11. In the last 12 months, did anyone steal a car, truck,
or other motor vehicle belonging to anyone in your
household?
Yes  GO TO 11a

5 years or more
15. What is this household's approximate combined annual
income?

No  GO TO 12

Less than $10,000
$10,000 to $19,999

11a. About how much was the value of what was stolen?

$20,000 to $39,999

.00

$40,000 to $59,999
$60,000 or more

12. Besides what you told us about earlier, was anything
else stolen from your home, yard or vehicle in the last 12
months?

16. Does anyone in your household own a car, truck, or other
motor vehicle?

Yes  GO TO 12a

Yes

No  GO TO 13

No


12a. What was stolen in the last 12 months?

Continue with the next section for each adult living in this
household. Start with yourself on the next page.

12b. About how much was the value of what was stolen?

.00

Draft

NCVS_2015_Pilot_Person_Level_v7
34256

Adults in this Household
17. How
many
a
dul
t
s
a
g
e
18
a
nd
ol
der
‐
i
nc
l
ude
y
our
s
el
f
‐
l
i
v
e
in this household?

Next Most Recent Crime
‐
When
di
d
i
t
ha
ppen?

Number of people 18 and older
month


You are Adult 1, please answer for each adult in your
household.

year

Please describe what happened, where it happened, and
how many times it happened

Adult 1 (you)
The next questions are about times you may have been
attacked or threatened, had something stolen, or were a
i
nc
l
ude
br
ea
k
‐
i
ns
or
victim of any other type of crime. Don't
other crimes you've already told us about.
If you had no crimes in the last 12 months , please go to
Question 18.



Most Recent Crime
‐
When
di
d
i
t
happen?

Please answer Questions 18 to 29 for yourself (Adult 1)
whether or not you told us about a crime.

18. In the last 12 months, has anyone physically attacked you?
Yes  GO TO 18a

month

No  GO TO 19

year

18a. Did the person(s) who attacked you have a weapon?
Yes  GO TO 18b

Please describe what happened, where it happened, and
how many times it happened

No  GO TO 18c
Don't Know  GO TO 18c
18b. What type of weapon(s) did they have?

18c. In the last 12 months, were you injured during an
attack?
Yes

Next Most Recent Crime
‐
When
di
d
i
t
happen?

No
month

18d. In the last 12 months, was anything stolen from you
during an attack?

year

Please describe what happened, where it happened, and
how many times it happened

Yes
No

Draft

NCVS_2015_Pilot_Person_Level_v7
34256

18e. At the time, what was your relationship with the
person or persons who attacked you?

19e. In the past 12 months, were any of these threats
reported to the police?
Yes

Please mark all that apply.

Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person
18f.

20. In the last 12 months, did anyone force you to have any
type of unwanted sexual activity?
Yes  GO TO 20a
No  GO TO 21

In the past 12 months, were any of these attacks or
attempted attacks reported to the police?

20a. Did the person(s) who forced you to have unwanted
sexual activity have a weapon?

Yes

Yes  GO TO 20b
No  GO TO 20c
Don’
t
k
now GO TO 20c

No
19. In the last 12 months, has anyone threatened you with
physical violence?

20b. What type of weapon(s) did they have?

Yes  GO TO 19a
No  GO TO 20
19a. Did the person(s) who threatened you have a
weapon?

20c. In the last 12 months, were you injured during
forced unwanted sexual activity?

Yes  GO TO 19b
No  GO TO 19c
Don’
t
k
now GO TO 19c

Yes
No
20d. At the time, what was your relationship with the
person or persons who forced you to have unwanted
sexual activity?

19b. What type of weapon(s) did they have?

Please mark all that apply.
Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person

19c. In the last 12 months, was anything stolen when you
were threatened?
Yes
No
19d. At the time, what was your relationship with the
person or persons who threatened you with physical
violence?

20e. In the past 12 months, was any of the forced
unwanted sexual activity reported to the police?
Yes

Please mark all that apply.

Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person

21. In the last 12 months, did anyone threaten you with any
type of forced unwanted sexual activity? Include times
when someone threatened or tried to force you but did
not succeed.
Yes  GO TO 21a
No  GO TO 22

Draft

NCVS_2015_Pilot_Person_Level_v7
34256

21a. Did the person(s) who threatened you with forced
unwanted sexual activity have a weapon?
Yes  GO TO 21b
No

22b. About how much was the value of what was stolen?

.00



GO TO 21c
Don’
t
k
now GO TO 21c

22c. In the past 12 months, were any of the other things
stolen reported to the police?

21b. What type of weapon(s) did they have?

Yes
No
23. In the last 12 months, did you have a credit or debit card
stolen or used without your permission?

21c. Were you injured during the threat of forced
unwanted sexual activity?
Yes

Yes
No

24. In the last 12 months, did you have a bank account used
without your permission?
Yes

21d. At the time, what was your relationship with the
person or persons who threatened you with forced
unwanted sexual activity?

Please mark all that apply.

25. In the last 12 months, did anyone steal your private
information or use it to get a credit card or a loan?
Yes

Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person

No
26. In the past 12 months, did you or anyone else tell the
police about any unauthorized use of your financial
accounts or personal information?

21e. In the past 12 months, were any of the threats of
forced unwanted sexual activity reported to the
police?
Yes

Yes
No

27. What is your gender?
Male

22. Besides what you may have told us about earlier, did you
have anything else stolen in the last 12 months? (For
example: cash, a wallet, purse, watch, jewelry, cell phone,
tablet, or anything else that might have been stolen.)
Yes



Female
28. Are you of Hispanic or Latino origin?
Yes, Hispanic or Latino

GO TO 22a

No, not Hispanic or Latino

No  GO TO 23
29. What is your race?
22a. What was stolen in the last 12 months?

Please mark all that apply.
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander

Draft

NCVS_2015_Pilot_Person_Level_v7
34256

Adult 2
If there are no other adults, go to Question 67 on page 16.

Next Most Recent Crime
‐
When
di
d
i
t
ha
ppen?

The next questions are about times Adult 2 may have been
attacked or threatened, had something stolen, or was a
victim of any other type of crime. Don't
i
nc
l
ude
br
ea
k
‐
i
ns
or other crimes you've already told us about.

month

year

Please describe what happened, where it happened, and
how many times it happened

If Adult 2 had no crimes in the last 12 months, please go to
Question 30.
Most Recent Crime
‐
When
di
d
i
t
happen?

month

year

Please describe what happened, where it happened, and
how many times it happened

 Please answer Questions 30

to 41 for Adult 2 whether or not
a crime was reported above for Adult 2.

30. In the last 12 months, has anyone physically attacked
Adult 2?
Yes



GO TO 30a



GO TO 31

30a. Did the person(s) who attacked Adult 2 have a
weapon?
Yes



GO TO 30b

No  GO TO 30c
Don't know  GO TO 30c

Next Most Recent Crime
‐
When
di
d
i
t
happen?

30b. What type of weapon(s) did they have?
month

year

Please describe what happened, where it happened, and
how many times it happened

30c. In the last 12 months, was Adult 2 injured during an
attack?
Yes
No
30d. In the last 12 months, was anything stolen from
Adult 2 during an attack?
Yes
No

Draft

NCVS_2015_Pilot_Person_Level_v7
34256

30e. At the time, what was Adult 2's relationship with the
person or persons who attacked him/her?

31e. In the past 12 months, were any of these threats to
Adult 2 reported to the police?
Yes

Please mark all that apply.

Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person

32. In the last 12 months, did anyone force Adult 2 to have
any type of unwanted sexual activity?

30f. In the past 12 months, were any of these attacks or
attempted attacks on Adult 2 reported to the police?



GO TO 33

GO TO 32b
No  GO TO 32c
Don’
t
k
now GO TO 32c

31. In the last 12 months, has anyone threatened Adult 2 with
physical violence?
No

GO TO 32a

Yes



32a. Did the person(s) who forced Adult 2 to have
unwanted sexual activity have a weapon?

Yes



32b. What type of weapon(s) did they have?

GO TO 31a
GO TO 32

31a. Did the person(s) who threatened Adult 2 have a
weapon?

32c. In the last 12 months, was Adult 2 injured during
forced unwanted sexual activity?

Yes



Yes



GO TO 31b
GO TO 31c
Don’
t
k
now GO TO 31c

32d. At the time, what was Adult 2's relationship with
the person or persons who forced him/her to have
unwanted sexual activity?

31b. What type of weapon(s) did they have?

31c. In the last 12 months, was anything stolen when
Adult 2 was threatened?
Yes
No
31d. At the time, what was Adult 2's relationship with the
person or persons who threatened him/her?

32e. In the past 12 months, was any of the forced
unwanted sexual activity reported to the police?
Yes

Please mark all that apply.

Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person

33. In the last 12 months, did anyone threaten Adult 2 with
any type of forced unwanted sexual activity? Include times
when someone threatened or tried to force Adult 2 but
did not succeed.
Yes  GO TO 33a
No  GO TO 34

Draft

NCVS_2015_Pilot_Person_Level_v7
34256

33a. Did the person(s) who threatened Adult 2 with
forced unwanted sexual activity have a weapon?

34b. About how much was the value of what was stolen?

Yes  GO TO 33b
No  GO TO 33c
Don’
t
k
now GO TO 33c

.00

34c. In the past 12 months, were any of the other things
stolen from Adult 2 reported to the police?

33b. What type of weapon(s) did they have?

Yes
No
35. In the last 12 months, did Adult 2 have a credit or debit
card stolen or used without their permission?

33c. Was Adult 2 injured during the threat of forced
unwanted sexual activity?

Yes

36. In the last 12 months, did Adult 2 have a bank account
used without their permission?

33d. At the time, what was Adult 2's relationship with
the person or persons who threatened him/her with
forced unwanted sexual activity?

Yes
No

Please mark all that apply.

37. In the last 12 months, did anyone steal Adult 2's private
information or use it to get a credit card or a loan?

Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person

Yes
No
38. In the past 12 months, did Adult 2 or anyone else tell the
police about any unauthorized use of Adult 2's financial
accounts or personal information?

33e. In the past 12 months, were any of the threats of
forced unwanted sexual activity reported to the
police?

Yes
No

Yes

39. What is Adult 2's gender?

Male

34. Besides what you may have told us about earlier, did
Adult 2 have anything else stolen in the last 12 months?
(For example: cash, a wallet, purse, watch, jewelry, cell
phone, tablet, or anything else that might have been
stolen.)
Yes  GO TO 34a
No  GO TO 35

Female
40. Is Adult 2 of Hispanic or Latino origin?
Yes
No
41. What is Adult 2's race?

34a. What was stolen in the last 12 months?

Please mark all that apply.
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Pacific Islander

Draft

NCVS_2015_Pilot_Person_Level_v7
34256

Adult 3
If there are no other adults, go to Question 67 on page 16.

Next Most Recent Crime
‐
When
di
d
i
t
ha
ppen?

The next questions are about times Adult 3 may have been
attacked or threatened, had something stolen, or was a
victim of any other type of crime. Don't
i
nc
l
ude
br
ea
k
‐
i
ns
or other crimes you've already told us about.

month

year

Please describe what happened, where it happened, and
how many times it happened

If Adult 3 had no crimes in the last 12 months, please go to
Question 42.
Most Recent Crime
‐
When
di
d
i
t
happen?

month

year

Please describe what happened, where it happened, and
how many times it happened

 Please answer Questions 42

to 53 for Adult 3 whether or
not a crime was reported above for Adult 3.

42. In the last 12 months, has anyone physically attacked
Adult 3?
Yes  GO TO 42a
No  GO TO 43
42a. Did the person(s) who attacked Adult 3 have a
weapon?
Yes  GO TO 42b
No  GO TO 42c

‐
When
di
d
i
t
happen?
Next Most Recent Crime

Don't know
month



GO TO 42c

42b. What type of weapon(s) did they have?

year

Please describe what happened, where it happened, and
how many times it happened
42c. In the last 12 months, was Adult 3 injured during an
attack?
Yes
No
42d. In the last 12 months, was anything stolen from
Adult 3 during an attack?
Yes
No

Draft

NCVS_2015_Pilot_Person_Level_v7
34256

42e. At the time, what was Adult 3's relationship with
the person or persons who attacked him/her?

43e. In the past 12 months, were any of these threats to
Adult 3 reported to the police?
Yes

Please mark all that apply.

Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person

44. In the last 12 months, did anyone force Adult 3 to have
any type of unwanted sexual activity?

42f. In the past 12 months, were any of these attacks or
attempted attacks on Adult 3 reported to the police?

Yes



GO TO 44a



GO TO 45

44a. Did the person(s) who forced Adult 3 to have
unwanted sexual activity have a weapon?

Yes

GO TO 44b
No  GO TO 44c
Don’
t
k
now GO TO 44c

No
43. In the last 12 months, has anyone threatened Adult 3 with
physical violence?



44b. What type of weapon(s) did they have?

Yes  GO TO 43a
No  GO TO 44
43a. Did the person(s) who threatened Adult 3 have a
weapon?

44c. In the last 12 months, was Adult 3 injured during
forced unwanted sexual activity?

Yes  GO TO 43b
No  GO TO 43c
Don’
t
k
now GO TO 43c

Yes
No
44d. At the time, what was Adult 3's relationship with
the person or persons who forced him/her to have
unwanted sexual activity?

43b. What type of weapon(s) did they have?

43c. In the last 12 months, was anything stolen when
Adult 3 was threatened?
Yes
No
43d. At the time, what was Adult 3's relationship with the
person or persons who threatened him/her ?

44e. In the past 12 months, was any of the forced
unwanted sexual activity reported to the police?
Yes

Please mark all that apply.

Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person

45. In the last 12 months, did anyone threaten Adult 3 with
any type of forced unwanted sexual activity? Include times
when someone threatened or tried to force Adult 3 but
did not succeed.
Yes



GO TO 45a



GO TO 46

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45a. Did the person(s) who threatened Adult 3 with
forced unwanted sexual activity have a weapon?

46b. About how much was the value of what was stolen?

Yes  GO TO 45b
No  GO TO 45c
Don’
t
k
now GO TO 45c

.00

46c. In the past 12 months, were any of the other things
stolen from Adult 3 reported to the police?

45b. What type of weapon(s) did they have?

Yes
No
47. In the last 12 months, did Adult 3 have a credit or debit
card stolen or used without their permission?

45c. Was Adult 3 injured during the threat of forced
unwanted sexual activity?

Yes

48. In the last 12 months, did Adult 3 have a bank account
used without their permission?

45d. At the time, what was Adult 3's relationship with
the person or persons who threatened him/her with
forced unwanted sexual activity?

Yes
No

Please mark all that apply.

49. In the last 12 months, did anyone steal Adult 3's private
information or use it to get a credit card or a loan?

Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person

Yes
No
50. In the past 12 months, did Adult 3 or anyone else tell the
police about any unauthorized use of Adult 3's financial
accounts or personal information?

45e. In the past 12 months, were any of the threats of
forced unwanted sexual activity reported to the
police?

Yes
No

Yes

51. What is Adult 3's gender?

Male

46. Besides what you may have told us about earlier, did
Adult 3 have anything else stolen in the last 12 months?
(For example: cash, a wallet, purse, watch, jewelry, cell
phone, tablet, or anything else that might have been
stolen.)
Yes  GO TO 46a
No  GO TO 47

Female
52. Is Adult 3 of Hispanic or Latino origin?
Yes
No
53. What is Adult 3's race?

46a. What was stolen in the last 12 months?

Please mark all that apply.
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Pacific Islander

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Adult 4
If there are no other adults, go to Question 67 on page 16.

Next Most Recent Crime
‐
When
di
d
i
t
ha
ppen?

The next questions are about times Adult 4 may have been
attacked or threatened, had something stolen, or was a
victim of any other type of crime. Don't
i
nc
l
ude
br
ea
k
‐
i
ns
or other crimes you've already told us about.

month

year

Please describe what happened, where it happened, and
how many times it happened

If Adult 4 had no crimes in the last 12 months, please go to
Question 54.
Most Recent Crime
‐
When
di
d
i
t
happen?

month

year

Please describe what happened, where it happened, and
how many times it happened

 Please answer Questions 54

to 65 for Adult 4 whether or
not a crime was reported above for Adult 4.

54. In the last 12 months, has anyone physically attacked
Adult 4?
Yes  GO TO 54a
No  GO TO 55
54a. Did the person(s) who attacked Adult 4 have a
weapon?
Yes



GO TO 54b

No  GO TO 54c
Don't know  GO TO 54c

Next Most Recent Crime
‐
When
di
d
i
t
happen?

54b. What type of weapon(s) did they have?
month

year

Please describe what happened, where it happened, and
how many times it happened

54c. In the last 12 months, was Adult 4 injured during an
attack?
Yes
No
54d. In the last 12 months, was anything stolen from
Adult 4 during an attack?
Yes
No

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55e. In the past 12 months, were any of these threats to
Adult 4 reported to the police?
Yes

54e. At the time, what was Adult 4's relationship with the
person or persons who attacked him/her?
Please mark all that apply.

Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person

56. In the last 12 months, did anyone force Adult 4 to have
any type of unwanted sexual activity?
Yes  GO TO 56a
No  GO TO 57

54f. In the past 12 months, were any of these attacks or
attempted attacks on Adult 4 reported to the police?

56a. Did the person(s) who forced Adult 4 to have
unwanted sexual activity have a weapon?

Yes

Yes  GO TO 56b
No  GO TO 56c
Don’
t
k
now GO TO 56c

No
55. In the last 12 months, has anyone threatened Adult 4 with
physical violence?
Yes



No 

56b. What type of weapon(s) did they have?

GO TO 55a
GO TO 56

55a. Did the person(s) who threatened Adult 4 have a
weapon?

56c. In the last 12 months, was Adult 4 injured during
forced unwanted sexual activity?

Yes  GO TO 55b
No  GO TO 55c
Don’
t
k
now GO TO 55c

Yes
No
56d. At the time, what was Adult 4's relationship with
the person or persons who forced him/her to have
unwanted sexual activity?

55b. What type of weapon(s) did they have?

55c. In the last 12 months, was anything stolen when
Adult 4 was threatened?
Yes
No
55d. At the time, what was Adult 4's relationship with the
person or persons who threatened him/her?

56e. In the past 12 months, was any of the forced
unwanted sexual activity reported to the police?
Yes

Please mark all that apply.

Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person

57. In the last 12 months, did anyone threaten Adult 4 with
any type of forced unwanted sexual activity? Include times
when someone threatened or tried to force Adult 4 but
did not succeed.
Yes  GO TO 57a
No  GO TO 58

Draft

NCVS_2015_Pilot_Person_Level_v7
34256

57a. Did the person(s) who threatened Adult 4 with
forced unwanted sexual activity have a weapon?

58b. About how much was the value of what was stolen?

Yes  GO TO 57b
No  GO TO 57c
Don’
t
k
now GO TO 57c

.00

58c. In the past 12 months, were any of the other things
stolen from Adult 4 reported to the police?

57b. What type of weapon(s) did they have?

Yes
No
59. In the last 12 months, did Adult 4 have a credit or debit
card stolen or used without their permission?

57c. Was Adult 4 injured during the threat of forced
unwanted sexual activity?

Yes

60. In the last 12 months, did Adult 4 have a bank account
used without their permission?

57d. At the time, what was Adult 4's relationship with
the person or persons who threatened him/her with
forced unwanted sexual activity?

Yes
No

Please mark all that apply.

61. In the last 12 months, did anyone steal Adult 4's private
information or use it to get a credit card or a loan?

Spouse, partner, boyfriend or girlfriend
Former spouse, partner, boyfriend or girlfriend
Other family member or relative
Other friend or acquaintance
Did not know the person

Yes
No
62. In the past 12 months, did Adult 4 or anyone else tell the
police about any unauthorized use of Adult 4's financial
accounts or personal information?

57e. In the past 12 months, were any of the threats of
forced unwanted sexual activity reported to the
police?

Yes
No

Yes

63. What is Adult 4's gender?

Male

58. Besides what you may have told us about earlier, did
Adult 4 have anything else stolen in the last 12 months?
(For example: cash, a wallet, purse, watch, jewelry, cell
phone, tablet, or anything else that might have been
stolen.)
Yes  GO TO 58a
No  GO TO 59

Female
64. Is Adult 4 of Hispanic or Latino origin?
Yes
No
65. What is Adult 4's race?

58a. What was stolen in the last 12 months?

Please mark all that apply.
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Pacific Islander

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Other Adults

Followup

66. Are there more than 4 adults living at your home?

67. We may contact some households to clarify your answers
and to help improve the survey. Please provide a
telephone number where we can reach you:

Yes

 GO TO 66a
No  GO TO 67

66a. Did any of the other adults in this home experience a
crime in the last 12 months?
Yes  GO TO 66b
No  GO TO 67

Thank you.
Please return survey in the
envelope provided.

66b. Please describe the crime(s):

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File Type	application/pdf
File Title	Microsoft Word - cover for Appendix C.docx
Author	giambo_p
File Modified	2014-04-16
File Created	2014-04-16