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pdfOMB Number: 0970-0033
Expiration Date: 08/31/2012
QUESTIONNAIRE AND CODING ANSWER SHEETS
FOR
ANNUAL SURVEY OF REFUGEES
NOTE:
For the re-interview cases, items Q.1a thru Q.1k should only be used for verification. In addition, items
marked with an asterisk, Q.2a*, Q.2b, Q.3a*-- Q.3d*, Q.4a*, Q.4c*, and Q.4d* should not be readministered. Refer to ASR Training Manual.
Office of Refugee Resettlement
Administration for Children and Families
Department of Health and Human Services
ASR-1
ENGLISH
Questionnaire for Annual Survey Of Refugees - 2012
INTRODUCTORY STATEMENT
Hello. My name is ____________. I am calling on behalf of the Office of Refugee Resettlement
regarding a survey we are conducting about the adjustment to life in the United States of
refugees and other recent immigrants.
Recently, we sent you a letter describing this survey and asking for your participation. Any
information you give us will be held in confidence and will be used for statistical purposes only.
Your participation in this interview is completely voluntary.
If you have some time now, I’d like to proceed with the interview.
ORR-9
Public reporting burden for this collection of information is estimated to average 40 minutes per
response, including the time for reviewing instructions, gathering and maintaining the data needed,
and reviewing the collection of information. An agency may not conduct or sponsor, and a person is
not required to respond to, a collection of information unless it displays a currently valid OMB
Control Number.
Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to: Reports Clearance Office, Administration for
Children and Families, Department of Health and Human Services, 370 L’Enfant Promenade,
Washington D.C. 20447; and to: Office of Management and Budget, Paperwork Reduction Project,
OMB Control Number 0970-0033, Washington D.C. 20403.
2
Questionnaire for Annual Survey Of Refugees - 2012
TRACKING AND VALIDATION FORM
Household ID Number _________________________
Interviewer's Name _________________________ Code ___/ ___/ ___
Date of Interview _______/ ______/ ______
Month Day
Year
Time Interview Started
_______: _______ AM PM
Hours Minutes
ATTEMPTS TO CONTACT INTERVIEWEE
1. _________________ 5. _____________________
2. _________________ 6. _____________________
3. _________________ 7. _____________________
4. _________________ 8. _____________________
TOTAL NUMBER OF ATTEMPTS TO CONTACT INTERVIEWEE _______
NAME OF RESPONDENT
_______________________________________________________________________
Last
Middle
First
CURRENT ADDRESS
_______________________________________________________________________
Street#
Street Name
Apt.#
_______________________________________________________________________
City
State
Zip Code
E-MAIL ADDRESS:__________________________________
TELEPHONE (_______) ______________________________
Area Code
3
Questionnaire for Annual Survey Of Refugees - 2012
TRACKING AND VALIDATION FORM
Household ID Number _________________________
Interviewer's Name _________________________ Code ___/ ___/ ___
Date of Interview _______/ ______/ ______
Month Day
Year
Time Interview Started
_______: _______ AM PM
Hours Minutes
ATTEMPTS TO CONTACT INTERVIEWEE
1. _________________ 5. _____________________
2. _________________ 6. _____________________
3. _________________ 7. _____________________
4. _________________ 8. _____________________
TOTAL NUMBER OF ATTEMPTS TO CONTACT INTERVIEWEE_______
NAME OF RESPONDENT
________________________________________________________________________
Last
Middle
First
CURRENT ADDRESS
________________________________________________________________________
Street#
Street Name
Apt.#
________________________________________________________________________
City
State
Zip Code
E-MAIL ADDRESS:__________________________________
TELEPHONE (_______) ______________________________
Area Code
4
Questionnaire for Annual Survey Of Refugees - 2012
HOUSEHOLD ID# ______
Q.1
USE HOUSEHOLD CONTROL CHART
We would like to start by asking you a few questions about each person who lives here, or who is
staying or visiting here and has no other home. Let us start with the person who has overall
responsibility, which is the person in whose name your home is rented, owned, or is being
bought: the head of the household.
(RECORD ANSWERS ON ATTACHED HOUSEHOLD CONTROL CHART).
a. What is the name of the Head of the household, and of each of the other members of the
household?
(PROBE: ARE THERE OTHER PERSONS WHO USUALLY LIVE HERE BUT ARE
TEMPORARILY ABSENT?)
FOR EACH HOUSEHOLD MEMBER ASK (VERIFY):
b. What is ... relationship to the head of household?
c. What is ... current marital status?
01 - Now married (note: spouse need not live in household)
02 - Divorced
03 - Legally separated
04 - Never married
05 - Widowed
06 - Other (SPECIFY) _______________
d. What was ... age at last birthday?
e. What was ... date of birth?
f.
Is ... male or female?
g. What is ... country of birth?
h. What is ... country of citizenship?
i.
What is ... ethnic origin?
j.
What month and year did ... enter the U.S. to stay?
k. In what State did ... originally resettle?
5
Questionnaire for Annual Survey Of Refugees - 2012
USE THE HOUSEHOLD CONTROL CHART
6
Questionnaire for Annual Survey Of Refugees - 2012
Now I want to ask some questions only of persons in your household who are 16 years old or older.
Q.2a* How many years of schooling did ... complete before coming to the U.S.?
(-9) DK / (-8) RA / (-7) NA
Q.2b* What was the highest degree or certificate that ... obtained before coming to the
U.S.?
01
02
03
04
05
06
07
08
None
Primary
Training in refugee camp
Technical school certification
Secondary (or high school diploma)
University degree (other than medical)
Medical degree
Other (SPECIFY) ______________
(-9) DK / (-8) RA / (-7) NA
Q.3a* Before coming to the U.S., was ...: (If in a refugee camp prior to the U.S., what
type of employment did the person hold before that?)
01
02
03
04
05
06
07
Not employed (skip to Q.3d)
Civil servant (civilian in local or national government)
In the military
Employee in private sector
Self-employed
Student
Other (SPECIFY) ___________________
(-9) DK / (-8) RA / (-7) NA
Q.3b* What kind of work (activities) did ... perform before coming to the U.S.? (e.g., lawyer, typist,
farmer, teacher, electrician, student)
(-9) DK / (-8) RA / (-7) NA
Q.3c* What were the most important activities or duties in this job?
(-9) DK / (-8) RA / (-7) NA
Q.3d* Was ... in a prison or reeducation camp prior to coming to the U.S.?
01
02
No
Yes
How long was ... there?
(-9) DK / (-8) RA / (-7) NA
7
Questionnaire for Annual Survey Of Refugees - 2012
Household ID#
Q.2a*
How many years?
(-1) If 1 year or less
(-9) DK / (-8) RA / (-7) NA
Q.2b*
(01) None
(02) Primary
(03) Training in refugee camp
(04) Technical school certification
(05) Secondary
(06) University degree
(07) Medical degree
(08) Other (SPECIFY)
(-9) DK / (-8) RA / (-7) NA
Q.3a*
FOLLOW SKIP PATTERN
(01) Not employed (skip to Q.3d)
(02) Civil servant...
(03) In the military
(04) Employee in private sector
(05) Self-employed
(06) Student
(07) Other (SPECIFY)
(-9) DK / (-8) RA / (-7) NA
Q.3b*
What kind of work (activities)?
(-9) DK / (-8) RA / (-7) NA
Q.3c*
Most important duties/activities
(-9) DK / (-8) RA / (-7) NA
Q.3d*
(01) No
(02) Yes. How long was ... there?
(-1) If 1 week or less
(-9) DK / (-8) RA / (-7) NA
1
2
3
4
5
__________
years
-1
__________
years
-1
__________
years
-1
__________
years
-1
__________
years
-1
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
02
03
04
05
06
07
__________
08
01
02
03
04
05
06
07
__________
08
01
02
03
04
05
06
07
__________
08
01
02
03
04
05
06
07
__________
08
01
02
03
04
05
06
07
__________
08
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
02
03
04
05
06
__________
07
01
02
03
04
05
06
__________
07
01
02
03
04
05
06
__________
07
01
02
03
04
05
06
__________
07
01
02
03
04
05
06
__________
07
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
__________
__________
_________
__________
_________
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
__________
__________
__________
__________
__________
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
__________
02
weeks
01
__________
02
weeks
01
__________
02
weeks
01
__________
02
weeks
01
__________
02
weeks
-1
-1
-1
-1
-1
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
8
Questionnaire for Annual Survey Of Refugees - 2012
Q.4a* At the time of arrival in the U.S., how well did ... speak English?
01
02
03
04
Very well
Well
Not well
Not at all
(-9) DK / (-8) RA / (-7) NA
Q.4b
How well does ... speak English now?
01
02
03
04
Very well (skip to Q.4c)
Well (skip to Q4.c)
Not well
Not at all
(-9) DK / (-8) RA / (-7) NA
Q.4ba (If 03 or 04 from Q. 4b) If English is not spoken, how does … communicate with service
providers?
01
02
03
04
Relatives
Interpreter
Neighbors
Other (SPECIFY)
(-9) DK / (-8) RA / (-7) NA
Q.4c* Before coming to the U.S. did ... have any English language instruction?
01
02
No (skip to Q.4e)
Yes
(-9) DK / (-8) RA / (-7) NA
Q.4d* (If yes to Q.4c) Altogether how many weeks did ... attend English language instruction before
coming to the U.S.?
(-9) DK / (-8) RA / (-7) NA
9
Questionnaire for Annual Survey Of Refugees - 2012
Household ID# 1
Q.4a*
1
(01) Very well
(02) Well
(03) Not well
(04) Not at all
01
02
03
04
(-9) DK / (-8) RA / (-7) NA
Q.4b
FOLLOW SKIP PATTERN
3
4
5
01
02
03
04
01
02
03
04
01
02
03
04
01
02
03
04
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
(01) Very well (skip to Q.4c)
(02) Well (skip to Q.4c)
(03) Not well
(04) Not at all
01
02
03
04
01
02
03
04
01
02
03
04
01
02
03
04
01
02
03
04
(-9) DK / (-8) RA / (-7) NA
Q.4ba
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
02
03
___________
04
01
02
03
___________
04
01
02
03
___________
04
01
02
03
___________
04
01
02
03
__________
04
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
02
01
02
01
02
01
02
01
02
-9 -8 -7
-9 -8 -7
9 -8 -7
-9 -8 -7
-9 -8 -7
__________
weeks
__________
weeks
__________
weeks
__________
weeks
__________
weeks
-1
-1
-1
-1
-1
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
(01) Relatives
(02) Interpreter
(03) Neighbors
(04) Other (SPECIFY)
(-9) DK / (-8) RA / (-7) NA
Q.4c*
FOLLOW SKIP PATTERN
(01) No (skip to Q.4e)
(02) Yes
(-9) DK / (-8) RA / (-7) NA
Q.4d*
How many weeks?
(-1) If 1 week or less
(-9) DK / (-8) RA / (-7) NA
2
10
Questionnaire for Annual Survey Of Refugees - 2012
Q.4e
Within the past 12 months, has ... attended an English language training program?
01
02
(-6)
No (skip to Q.5a)
Yes
High school student (skip to Q.5a)
(-9) DK / (-8) RA / (-7) NA
Q.4f
Within the past 12 months, how many weeks did ... attend English language training?
(-9) DK / (-8) RA / (-7) NA
Q.4g
Within the past 12 months, did the English language class that ... attended in the U.S. meet every
day or less frequently?
01
02
03
Every day
2 to 6 times a week
Once a week
(-9) DK / (-8) RA / (-7) NA
Q.4h
Within the past 12 months how many hours a day was ... in English language training?
Q.4j
Is ... currently enrolled in an English language training program?
01
02
No
Yes (skip to Q.4k)
(-9) DK / (-8) RA / (-7) NA
Q.4ja If not currently enrolled in an English language training program, why not?
01
02
03
04
Daycare constraints
Transportation constraints
Time constraints
Other (SPECIFY)
(-9) DK / (-8) RA / (-7) NA
11
Questionnaire for Annual Survey Of Refugees - 2012
Household ID#
Q.4e
FOLLOW SKIP PATTERN
1
2
3
4
5
(01) No (skip to Q.5a)
(02) Yes
(-6) High School Student
(skip to Q.5a)
01
02
-6
01
02
-6
01
02
-6
01
02
-6
01
02
-6
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
How many weeks?
__________
weeks
__________
weeks
__________
weeks
__________
weeks
__________
weeks
(-1) If 1 week or less
-1
-1
-1
-1
-1
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
02
03
01
02
03
01
02
03
01
02
03
01
02
03
(-9) DK / (-8) RA / (-7) NA
Q.4h
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
How many hours per day?
__________
hours
__________
hours
__________
hours
__________
hours
__________
hours
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
02
01
02
01
02
01
02
01
02
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
02
01
02
01
02
01
02
01
02
(-9) DK / (-8) RA / (-7) NA
Q.4f
(-9) DK / (-8) RA / (-7) NA
Q.4g
(01) Every day
(02) 2 to 6 times weekly
(03) Once a week
(-9) DK / (-8) RA / (-7) NA
Q.4j
FOLLOW SKIP PATTERN
(01) No
(02) Yes (skip to Q.4k)
(-9) DK / (-8) RA / (-7) NA
Q.4ja
(01) Daycare constraints
(02) Transportation
constraints
(03) Time constraints
(04) Other (SPECIFY)
(-9) DK / (-8) RA / (-7) NA
03
__________
04
-9 -8 -7
03
__________
04
-9 -8 -7
12
03
__________
04
-9 -8 -7
03
__________
04
-9 -8 -7
03
__________
04
-9 -8 -7
Questionnaire for Annual Survey Of Refugees - 2012
Q.4k
What type of organization gave the English language training program? (Most recent program if
more than one)
01
02
03
04
05
06
07
School or university
Employer program
Religious organization
Refugee service agency (state/local government)
Refugee Mutual Assistance Association (MAA)
Private individual/group
Other (SPECIFY) ________________
(-9) DK / (-8) RA / (-7) NA
Q.5a
Did ... work at a job anytime last week?
01
02
No (skip to Q.11a)
Yes
(-9) DK / (-8) RA / (-7) NA (skip to Q.11a)
[FOR PERSONS WHO WORKED LAST WEEK]
Q.5b
Did ... work at more than one job last week?
01
02
No (skip to Q.6a)
Yes
(-9) DK / (-8) RA / (-7) NA (skip to Q.6a)
Q.5c
How many jobs did ... work at last week?
(-9) DK / (-8) RA / (-7) NA
Q.6a
How many hours did ... work at his/her primary job last week? (Primary job means the job
worked at for the greatest number of hours)
(-9) DK / (-8) RA / (-7) NA
Q.6b
How many hours did ... work at all jobs last week?
(-9) DK / (-8) RA / (-7) NA
Q.7
How much money per hour did ... receive at his/her primary job last week? (If knows hourly
wage, skip Q.8a & Q8b. If not, continue with Q.8a.)
(-9) DK / (-8) RA / (-7) NA
13
Questionnaire for Annual Survey Of Refugees - 2012
Household ID#
Q.4k
1
2
3
4
5
(01) School or university
(02) Employer program
(03) Religious organization
(04) Refugee service agency
(05) Refugee Mutual Assistance
Association
(06) Private individual/group
(07) Other (SPECIFY)
01
02
03
04
05
01
02
03
04
05
01
02
03
04
05
01
02
03
04
05
01
02
03
04
05
06
06
06
06
06
07
07
07
07
07
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
02
01
02
01
02
01
02
01
02
9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
02
01
02
01
02
01
02
01
02
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
__________
# of jobs
__________
# of jobs
__________
# of jobs
__________
# of jobs
__________
# of jobs
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
__________
# of hours
__________
# of hours
__________
# of hours
__________
# of hours
__________
# of hours
(-9) DK / (-8) RA / (-7) NA
Q.6b
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
How many hours? (all jobs)
__________
# of hours
__________
# of hours
__________
# of hours
__________
# of hours
__________
# of hours
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
$_____/hour
$_____/hour
$_____/hour
$_____/hour
$_____/hour
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
(-9) DK / (-8) RA / (-7) NA
Q.5a
FOLLOW SKIP PATTERN
(01) No (skip to Q.11a)
(02) Yes
(-9) DK / (-8) RA / (-7) NA
Q.5b
FOLLOW SKIP PATTERN
(01) No (skip to Q.6a)
(02) Yes
(-9) DK / (-8) RA / (-7) NA (skip to
Q.6a)
Q.5c
How many jobs?
(-9) DK / (-8) RA / (-7) NA
Q.6a
How many hours? (primary job)
(-9) DK / (-8) RA / (-7) NA
Q.7
FOLLOW SKIP PATTERN
(If knows hourly wage, skip Q.8a &
Q.8b. If not, continue with Q.8a)
(-9) DK / (-8) RA / (-7) NA
14
Questionnaire for Annual Survey Of Refugees - 2012
Q.8a
How much did ... earn before taxes from that job?
(-9) DK / (-8) RA / (-7) NA
Q.8b
On what basis is that amount computed?
01
02
03
04
Weekly
Bi-weekly
Monthly
Annually
(-9) DK / (-8) RA / (-7) NA
(IF ... WORKED AT SECOND JOB LAST WEEK, GO TO Q.9)
(IF ... WORKED ONLY ONE JOB LAST WEEK, SKIP TO Q.18a)
[SECOND JOB ONLY]
Q.9
How much money per hour did ... receive from his/her second job last week? (If knows hourly
wage, skip to Q.18a. If not, continue with Q.10a)
(-9) DK / (-8) RA / (-7) NA
Q.10a How much did ... earn before taxes from that job?
(-9) DK / (-8) RA / (-7) NA
Q.10b On what basis is that amount computed?
01
02
03
04
Weekly
Bi-weekly
Monthly
Yearly
(-9) DK / (-8) RA / (-7) NA
(IF … ANSWERED Q.10b, SKIP TO Q.18a)
15
Questionnaire for Annual Survey Of Refugees - 2012
Household ID#
Q.8a
How much before taxes from that job?
(-9) DK / (-8) RA / (-7) NA
Q.8b
(01) Weekly
(02) Bi-weekly
(03) Monthly
(04) Yearly
1
2
3
4
5
________
$
-9 -8 -7
________
$
-9 -8 -7
________
$
-9 -8 -7
________
$
-9 -8 -7
________
$
-9 -8 -7
01
02
03
04
01
02
03
04
01
02
03
04
01
02
03
04
01
02
03
04
9 -8 -7
-9 -8 -7
-9 -8 -7
(-9) DK / (-8) RA / (-7) NA
-9 -8 -7
-9 -8 -7
(IF ... WORKED AT SECOND JOB LAST WEEK, ASK Q.9)
(IF...WORKED ONLY ONE JOB LAST WEEK, SKIP TO Q.18a)
Q.9
FOLLOW SKIP PATTERN
(If knows hourly wage, skip to Q.18a. If
not, continue with Q.10a)
Hourly wage?
(-9) DK / (-8) RA / (-7) NA
Q.10a
How much before taxes from that job?
(-9) DK / (-8) RA / (-7) NA
Q.10b
FOLLOW SKIP PATTERN
(If … answered Q.10b, skip to Q.18a)
(01) Weekly
(02) Bi-weekly
(03) Monthly
(04) Yearly
(-9) DK / (-8) RA / (-7) NA
_______
$ per hour
_______
$ per hour
________
$ per hour
________
$ per hour
_______
$ per hour
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
________
$
-9 -8 -7
_________
$
-9 -8 -7
_________
$
-9 -8 -7
_________
$
-9 -8 -7
_________
$
-9 -8 -7
01
02
03
04
01
02
03
04
01
02
03
04
01
02
03
04
01
02
03
04
-9 -8 -7
9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
16
Questionnaire for Annual Survey Of Refugees - 2012
Q.11a Has ... ever worked since coming to the U.S. to stay?
01
02
Never worked in the U.S. (skip to Q.13)
Yes - How many weeks has it been since ... had a job?
(-9) DK / (-8) RA / (-7) NA (skip to Q.12)
Q.11b (If yes to Q.11a, answer Q.11b. Otherwise skip to Q.12)
Since coming to the U.S., in how many weeks has ... ever worked?
(-9) DK / (-8) RA / (-7) NA
Q.12
Was ... temporarily absent or on layoff from a job or business last week?
01
02
Temporarily absent
On layoff
(-9) DK / (-8) RA / (-7) NA
Q.13
Has ... been looking for work during the last 4 weeks?
01
02
No (skip to Q.17)
Yes
(-9) DK / (-8) RA / (-7) NA (skip to Q.17)
Q.14
What has ... done to find a job? Has he/she checked with (multiple answers may be given):
01
02
03
04
05
06
07
08
09
10
Nothing
Refugee Mutual Assistance Association (MAA)
Refugee service agency
Public employment agency
Private employment agency
Advertisements
Sponsor
Other refugees
Friends who are not refugees
Other (SPECIFY) _____________
(-9) DK / (-8) RA / (-7) NA
17
Questionnaire for Annual Survey Of Refugees - 2012
Household ID#
Q.11a
FOLLOW SKIP PATTERN
1
2
3
4
5
(01) Never worked in the U.S. (skip to Q.13)
01
01
01
01
01
________
02
weeks
_________
02
weeks
_________
02
weeks
_________
02
weeks
-1
-1
-1
-1
-1
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
_________
weeks
_________
weeks
_________
weeks
_________
weeks
_________
weeks
-1
-1
-1
-1
-1
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
02
01
02
01
02
01
02
01
02
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
02
01
02
01
02
01
02
01
02
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
02
03
04
05
06
07
08
09
_________
10
01
02
03
04
05
06
07
08
09
_________
10
01
02
03
04
05
06
07
08
09
_________
10
01
02
03
04
05
06
07
08
09
_________
10
01
02
03
04
05
06
07
08
09
_________
10
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
(02) Yes. How many weeks since ... had a
job?
(-1) If 1 week or less
(-9) DK / (-8) RA / (-7) NA (skip to Q.12)
Q.11b
How many weeks?
(-1) If less than 1 week
(-9) DK / (-8) RA / (-7) NA
Q.12
(01) Temporarily absent
(02) On layoff
(-9) DK / (-8) RA / (-7) NA
Q.13
FOLLOW SKIP PATTERN
(01) No (skip to Q.17)
(02) Yes
(-9) DK / (-8) RA / (-7) NA (skip to Q.17)
Q.14
(01) Nothing
(02) Refugee Mutual Assistance Association
(03) Refugee service agency
(04) Public employment agency
(05) Private employment agency
(06) Advertisements
(07) Sponsor
(08) Other refugees
(09) Friends who are not refugees
(10) Other (SPECIFY)
(-9) DK / (-8) RA / (-7) NA
18
________
02
weeks
Questionnaire for Annual Survey Of Refugees - 2012
Q.15
How many weeks has ... been looking for a job?
(-9) DK / (-8) RA / (-7) NA
Q.16
What caused ... to begin looking for work? (multiple answers may be given)
01
02
03
04
05
06
07
08
09
New arrival in the U.S.
Lost job
Quit job
Finished school
Training ended
Moved to a new area
Medical problem ended
Other (SPECIFY) _____________
Eligibility for cash and/or medical assistance ended
(-9) DK / (-8) RA / (-7) NA
(SKIP TO Q.18a IF WORKED OR SKIP TO Q.24a IF NEVER WORKED)
Q.17
Why is ... not looking for a job? (multiple answers may be given)
01
02
03
04
05
06
08
07
Limited English
Attending school or training
Poor health or handicap
Child care or family responsibilities
Believes no work is available
Tried to find work but couldn’t
Age
Other (SPECIFY) ______________
(-9) DK / (-8) RA / (-7) NA
(SKIP TO Q.24a IF NEVER WORKED)
19
Questionnaire for Annual Survey Of Refugees - 2012
1
2
3
4
5
_________
weeks
_________
weeks
_________
weeks
_________
weeks
_________
weeks
-1
-1
-1
-1
-1
(-9) DK / (-8) RA / (-7) NA
Q.16
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
(01) New arrival in the U.S.
(02) Lost job
(03) Quit job
(04) Finished school
(05) Training ended
(06) Moved to a new area
(07) Medical problem ended
01
02
03
04
05
06
07
_________
08
01
02
03
04
05
06
07
_________
08
01
02
03
04
05
06
07
_________
08
01
02
03
04
05
06
07
_________
08
01
02
03
04
05
06
07
_________
08
09
09
09
09
09
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
02
03
04
05
06
08
_________
07
01
02
03
04
05
06
08
_________
07
01
02
03
04
05
06
08
_________
07
01
02
03
04
05
06
08
_________
07
01
02
03
04
05
06
08
_________
07
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
Household ID#
Q.15
How many weeks?
(-1) If less than 1 week
(08) Other (SPECIFY)
(09) Eligibility for cash/medical ended
(-9) DK / (-8) RA / (-7) NA
Q.17
(01) Limited English
(02) Attending school or training
(03) Poor health or handicap
(04) Child care or family responsibilities
(05) Believes no work is available
(06) Tried to find work but couldn’t
(08) Age
(07) Other (SPECIFY)
(-9) DK / (-8) RA / (-7) NA
(skip to q.24a if never worked)
20
Questionnaire for Annual Survey Of Refugees - 2012
[FOR ALL PERSONS WHO HAD WORKED IN THE U.S. -- IF DID NOT WORK LAST WEEK,
ASK ABOUT LAST JOB. GO TO Q.24a IF INDIVIDUAL NEVER WORKED IN THE U.S.]
Q.18a In the last year, how many weeks did ... work?
(-9) DK / (-8) RA / (-7) NA
Q.18b How many hours per week did ... usually work?
(-9) DK / (-8) RA / (-7) NA
Q.18c What were ...'s total earnings before taxes from all jobs in the past 12 months?
(-9) DK / (-8) RA / (-7) NA
Q.18d When did ... get his/her first job in the U.S.?
(-9) DK / (-8) RA / (-7) NA
Q.18e Did the income that ... received from his/her first job disqualify... from receiving cash assistance
(such as RCA,TANF, or GA)?
01
02
03
No
Yes
Was not receiving cash assistance at that time
(-9) DK / (-8) RA / (-7) NA
21
Questionnaire for Annual Survey Of Refugees - 2012
Household ID#
Q.18a
1
2
3
4
5
__________
weeks
__________
weeks
__________
weeks
__________
weeks
__________
weeks
-1
-1
-1
-1
-1
(-9) DK / (-8) RA / (-7) NA
Q.18b
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
How many hours per week?
__________
hrs/wk
__________
hrs/wk
__________
hrs/wk
__________
hrs/wk
__________
hrs/wk
(-9) DK / (-8) RA / (-7) NA
Q.18c
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
Total earnings for last 12
months
________
$
________
$
________
$
________
$
________
$
(-9) DK / (-8) RA / (-7) N
Q.18d
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
____/ _____
Month Year
____/ _____
Month Year
____/ _____
Month Year
____/ _____
Month Year
____/ _____
Month Year
(-9) DK / (-8) RA / (-7) NA
Q.18e
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
(01) No
(02) Yes
(03) Was not receiving cash
assistance at that time
01
02
03
01
02
03
01
02
03
01
02
03
01
02
03
(-9) DK / (-8) RA / (-7) NA
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
How many weeks?
(-1) If less than 1 week
Date of first job
22
Questionnaire for Annual Survey Of Refugees - 2012
[FOR ALL PERSONS WHO HAD WORKED IN THE U.S. -- IF DID NOT WORK LAST WEEK,
ASK ABOUT LAST JOB. GO TO Q.24a IF INDIVIDUAL NEVER WORKED IN THE U.S.]
Q.19b What kind of business or industry is this?
(e.g., hospital, electronic parts manufacturing, social service agency)
(-9) DK / (-8) RA / (-7) NA
Q.19c What kind of work does (did)… perform?
(e.g., nurse, assembly line worker, typist, supervisor)
(-9) DK / (-8) RA / (-7) NA
Q.20
Is (was) ... a:
01
02
03
04
05
06
07
Employee of a private company, business, or individual (skip to Q.22a)
Federal government employee (skip to Q.22a)
State government employee (skip to Q.22a)
Local government employee (skip to Q.22a)
Self-employed (go to Q.21)
Working without pay in family business (skip to Q.24a)
Other (SPECIFY) _____________
(-9) DK / (-8) RA / (-7) NA
Q.21 [IF SELF-EMPLOYED]
a.
b.
c.
What kind of business is it? (e.g., restaurant, tailor shop, grocery store)
How many other refugees does ... employ?
How many total employees does ... have?
(-9) DK / (-8) RA / (-7) NA
23
Questionnaire for Annual Survey Of Refugees - 2012
1
2
3
4
5
__________
__________
__________
__________
__________
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
__________
__________
__________
__________
__________
(-9) DK / (-8) RA / (-7) NA
Q.20
FOLLOW SKIP PATTERN
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
(01) Employee of a private
company (skip to Q.22a)
01
01
01
01
01
(02) Federal government
employee (skip to Q.22a)
02
02
02
02
02
(03) State government employee
( skip to Q.22a)
03
03
03
03
03
(04) Local government employee
( skip to Q.22a)
04
04
04
04
04
(05) Self-employed (go to Q.21)
05
05
05
05
05
(06) Working without pay in
family business (skip to
Q.24a)
06
06
06
06
06
__________
07
__________
07
__________
07
__________
07
__________
07
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
(a) What kind of business is it?
__________
a
_________
a
___________
a
__________
a
__________
a
(b) How many other refugees
does … employ?
_______#ref
b
_______#ref
b
_______#ref
b
_______#ref
b
______#ref
b
(c) How many total employees
does ... have?
_____#emp
c
_____#emp
c
_____#emp
c
_____#emp
c
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
Household ID#
Q.19b
What kind of business/industry?
(-9) DK / (-8) RA / (-7) NA
Q.19c
What kind of work?
(07) Other (SPECIFY)
(-9) DK / (-8) RA / (-7) NA
Q.21
(-9) DK / (-8) RA / (-7) NA
24
_____#emp
c
-9 -8 -7
Questionnaire for Annual Survey Of Refugees - 2012
[FOR EMPLOYEES ONLY]
Q.22a What did ... do to find this job? Did he/she check with:
01
02
03
04
05
06
07
08
09
10
11
12
13
14
Voluntary agency (agency that helped with initial U.S. resettlement)
Refugee Mutual Assistance Association (MAA)
Refugee service agency
Public employment agency
Private employment agency
Advertisements
Sponsor
Other refugees
Friends (who are not refugees)
Religious organization
College/job training
Self
Relative
Other (SPECIFY) _____________
(-9) DK / (-8) RA / (-7) NA
Q.24a Within the past 12 months, has ...attended any job training program?
01
02
No (skip to Q.25a)
Yes
(-9) DK / (-8) RA / (-7) NA
25
Questionnaire for Annual Survey Of Refugees - 2012
Household ID#
Q.22a
1
2
3
4
5
(01) Voluntary agency
01
01
01
01
01
(02) Refugee Mutual Assistance
Association
02
02
02
02
02
(03) Refugee service agency
03
03
03
03
03
(04) Public employment agency
04
04
04
04
04
(05) Private employment agency
05
05
05
05
05
(06) Advertisements
06
06
06
06
06
(07) Sponsor
07
07
07
07
07
(08) Other refugees
08
08
08
08
08
(09) Friends (who are not refugees)
09
09
09
09
09
(10) Religious organization
10
10
10
10
10
(11) College/Job Training
11
11
11
11
11
(12) Self
12
12
12
12
12
(13) Relative
13
13
13
13
13
(14) Other (SPECIFY)
14
14
14
14
14
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
02
01
02
01
02
01
02
01
02
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
(-9) DK / (-8) RA / (-7) NA
Q.24a
FOLLOW SKIP PATTERN
(01) No (skip to Q.25a)
(02) Yes
(-9) DK / (-8) RA / (-7) NA
26
Questionnaire for Annual Survey Of Refugees - 2012
Q.24b How many weeks did that training last?
(-9) DK / (-8) RA / (-7) NA
Q.24c Did the job-training class meet every day or less frequently?
01
02
03
Every day
2 to 6 times a week
Once a week
(-9) DK / (-8) RA / (-7) NA
Q.24d How many hours a day did the job-training class meet?
(-9) DK / (-8) RA / (-7) NA
Q.24e For what kind of work (occupation) did this training prepare...?
(e.g., electronics assembler, welder, typist, nurse, childcare provider)
(-9) DK / (-8) RA / (-7) NA
27
Questionnaire for Annual Survey Of Refugees - 2012
Household ID#
Q.24b
1
2
3
4
5
________
weeks
_________
weeks
_________
weeks
________
weeks
_________
weeks
-1
-1
-1
-1
-1
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
(01) Every day
01
01
01
01
01
(02) 2 to 6 times weekly
02
02
02
02
02
(03) Once a week
03
03
03
03
03
(-9) DK / (-8) RA / (-7) NA
Q.24d
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
How many hours per day?
_________
hours
_________
hours
_________
hours
_________
hours
_________
hours
(-9) DK / (-8) RA / (-7) NA
Q.24e
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
________
________
________
________
________
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
How many weeks?
(-1) If less than 1 week
(-9) DK / (-8) RA / (-7) NA
Q.24c
What type of training?
(-9) DK / (-8) RA / (-7) NA
28
Questionnaire for Annual Survey Of Refugees - 2012
Q.25a Within the past 12 months, has ... attended school or university (other than to take English
language training or the job-training class indicated in the previous question)?
01
02
No (skip to Q.26b)
Yes
(-9) DK / (-8) RA / (-7) NA
Q.25b Was ... attending school or university in order to obtain a degree or certificate?
01
02
No (skip to Q.26b)
Yes
(-9) DK / (-8) RA / (-7) NA
Q.25c What degree or certificate was ... attempting to earn?
01
02
03
04
05
06
High school certificate or equivalency
Associate degree
Bachelor's degree
Master's or Doctorate degree
Professional school degree (e.g., MD, LLB, DDS)
Other (SPECIFY) ___________
(-9) DK / (-8) RA / (-7) NA
Q.25d Has ... received this degree or certificate?
01
02
No (skip to Q.26b)
Yes
(-9) DK / (-8) RA / (-7) NA
29
Questionnaire for Annual Survey Of Refugees - 2012
Household ID#
Q.25a
FOLLOW SKIP PATTERN
1
2
3
4
5
(01) No (skip to Q.26b)
(02) Yes
01
02
01
02
01
02
01
02
01
02
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
02
01
02
01
02
01
02
01
02
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
01
01
01
01
02
03
04
05
02
03
04
05
02
03
04
05
02
03
04
05
02
03
04
05
06
06
06
06
06
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
02
01
02
01
02
01
02
01
02
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
(-9) DK / (-8) RA / (-7) NA
Q.25b
FOLLOW SKIP PATTERN
(01) No (skip to Q.26b)
(02) Yes
(-9) DK / (-8) RA / (-7) NA
Q.25c
(01) High School certificate or
equivalency
(02) Associate degree
(03) Bachelor's degree
(04) Master's or Doctorate degree
(05) Professional school degree
(e.g., MD)
(06) Other (SPECIFY)
(-9) DK / (-8) RA / (-7) NA
Q.25d
FOLLOW SKIP PATTERN
(01) No (skip to Q.26b)
(02) Yes
(-9) DK / (-8) RA / (-7) NA
30
Questionnaire for Annual Survey Of Refugees - 2012
Q.25e In what year did ... receive this degree or certificate?
(-9) DK / (-8) RA / (-7) NA
Q.26b How many months has ... lived at this residence/neighborhood?
(-9) DK / (-8) RA / (-7) NA
Q.26c Did ... live at this residence a year ago?
01
02
No
Yes
(skip to Q.26ea)
(-9) DK / (-8) RA / (-7) NA
Q.26d Did ... live in this state a year ago?
01
02
No
Yes
(skip to Q.26ea)
(-9) DK / (-8) RA / (-7) NA
Q.26e In which state did … live a year ago?
01
02
Not in the U.S. (skip to Q.26f)
Specify state___________
(-9) DK / (-8) RA / (-7) NA
Q.26ea Did … migrate from a different state?
01
02
No
Yes, if yes when
a. Within the last 90 days
b. Within the last 180 days
c. Within 1year
d. Other
(-9) DK / (-8) RA / (-7) NA
31
Questionnaire for Annual Survey Of Refugees - 2012
Household ID#
Q.25e
1
2
3
4
5
________
YYYY
________
YYYY
________
YYYY
________
YYYY
________
YYYY
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
________
months
________
months
________
months
________
months
________
months
-1
-1
-1
-1
-1
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
02
01
02
01
02
01
02
01
02
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
02
01
02
01
02
01
02
01
02
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
________
State
01
________
State
01
________
State
01
________
State
01
________
State
(-9) DK / (-8) RA / (-7) NA
Q.26ea
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
(01) No
(02) Yes, if yes when
a. Within the last 90 days
b. Within the last 180 days
c. Within 1year
d. Other
01
02
a.
b.
c.
______
d.
01
02
a.
b.
c.
______
d.
01
02
a.
b.
c.
______
d.
01
02
a.
b.
c.
______
d.
01
02
a.
b.
c.
______
d.
(-9) DK / (-8) RA / (-7) NA
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
What year?
(-9 ) DK / (-8) RA / (-7) NA
Q.26b
How many months?
(-1) If less than 1 month
(-9) DK / (-8) RA / (-7) NA
Q.26c
FOLLOW SKIP PATTERN
(01) No
(02) Yes (skip to Q.26ea)
(-9) DK / (-8) RA / (-7) NA
Q.26d
FOLLOW SKIP PATTERN
(01) No
(02) Yes (skip to Q.26ea)
(-9) DK / (-8) RA / (-7) NA
Q.26e
FOLLOW SKIP PATTERN
(01) Not in the U.S. (skip to Q.26f)
(02) Specify state__________
32
-9 -8 -7
Questionnaire for Annual Survey Of Refugees - 2012
Q.26f What was the primary reason that ... moved to this state?
01
02
03
04
Employment opportunities
Better public assistance
Reunification with relatives
Other (SPECIFY)__________
(-9) DK / (-8) RA / (-7) NA
Q.26g Does … know or communicate with your neighbors?
01
02
No
Yes
(-9) DK / (-8) RA / (-7) NA
Q.26h Does … participate in their children’s education?
01
02
No
Yes (if yes how)
a. Attend parent- teacher meetings
b. Volunteer your time
c. Help with homework
d. Other____________
(-9) DK / (-8) RA / (-7) NA
Q.26i Given the opportunity, would … move to a different state?
01
02
No
Yes (if yes, for what reasons)
a. Employment opportunity
b. Better public assistance
c. Reunification with relatives
d. Other _____________
(-9) DK / (-8) RA / (-7) NA
33
Questionnaire for Annual Survey Of Refugees - 2012
Household ID#
Q.26f
1
2
3
4
5
01
02
03
________
04
01
02
03
________
04
01
02
03
________
04
01
02
03
________
04
01
02
03
________
04
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
02
01
02
01
02
01
02
01
02
(-9 ) DK / (-8) RA / (-7) NA
Q.26h
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
(01) No
(02) Yes (if yes how)
a. Attend parent- teacher meetings
b. Volunteer your time
c. Help with homework
d. Other __________
01
02
a.
b.
c.
______
d.
01
02
a.
b.
c.
______
d.
01
02
a.
b.
c.
______
d.
01
02
a.
b.
c.
______
d.
01
02
a.
b.
c.
______
d.
(-9 ) DK / (-8) RA / (-7) NA
Q.26i
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
(01) No
(02) Yes(if yes, for what reasons)
a. Employment opportunity
b. Better public assistance
c. Reunification with relatives
d. Other __________
01
02
a.
b.
c.
______
d.
01
02
a.
b.
c.
______
d.
01
02
a.
b.
c.
______
d.
01
02
a.
b.
c.
______
d.
01
02
a.
b.
c.
______
d.
(-9 ) DK / (-8) RA / (-7) NA
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
(01) Employment opportunities
(02) Better public assistance
(03) Reunification with relatives
(04) Other (SPECIFY)
(-9) DK / (-8) RA / (-7) NA
Q.26g
(01) No
(02) Yes
34
-9 -8 -7
Questionnaire for Annual Survey Of Refugees - 2012
Q.27a (For persons in the U.S. 12 months or longer): Has ... applied to adjust his/her immigration status
to that of a permanent U.S. resident?
01
02
No (skip to Q.27c)
Yes (go to Q.27b)
(-9) DK / (-8) RA / (-7) NA
Q.27b When did ... apply for adjustment to permanent resident status? (If application date is given, skip
to Q.28)
(-9) DK / (-8) RA / (-7) NA
Q.27c Does ... plan to adjust his/her immigration status in the future?
01
02
03
No
Yes
Did not know he/she had to apply to become a permanent resident
(-9) DK / (-8) RA / (-7) NA
Q.28
Does this person have a physical, mental, or other health condition that has lasted for 6 or more
months and which:
a. Limits the kind or amount of work this person can do at a job?
01
02
No
Yes
(-9) DK / (-8) RA / (-7) NA
b. Prevents this person from working at a job?
01
02
No
Yes
(-9) DK / (-8) RA / (-7) NA
35
Questionnaire for Annual Survey Of Refugees - 2012
Household ID#
Q.27a
FOLLOW SKIP PATTERN
1
2
3
4
5
(01) No (skip to Q.27c)
(02) Yes (go to Q.27b)
01
02
01
02
01
02
01
02
01
02
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
___/_____
Month/Year
___/_____
Month/Year
___/_____
Month/Year
___/_____
Month/Year
___/_____
Month/Year
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
02
03
01
02
03
01
02
03
01
02
03
01
02
03
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
02
01
02
01
02
01
02
01
02
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
02
01
02
01
02
01
02
01
02
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
(-9 ) DK / (-8) RA / (-7) NA
Q.27b
FOLLOW SKIP PATTERN
What date?
(If application date is given skip
to Q.28)
(-9) DK / (-8) RA / (-7) NA
Q.27c
(01) No
(02) Yes
(03) Did not know he/she had to
apply…
(-9 ) DK / (-8) RA / (-7) NA
Q.28a
(01) No
(02) Yes
(-9) DK / (-8) RA / (-7) NA
Q.28b
(01) No
(02) Yes
(-9 ) DK / (-8) RA / (-7) NA
36
Questionnaire for Annual Survey Of Refugees - 2012
Q.29a During the past 12 months, how were ...'s medical expenses paid? (May indicate more than one)
01
03
03
04
05
06
07
08
09
10
11
12
No medical expenses
Self or household members
Other relatives or friends
Sponsor/sponsoring agency
Religious organization
Medicaid
Refugee Medical Assistance (RMA)
Co-payments
Other government source
Insurance through own employment (e.g., Blue Cross)
Insurance through family member's employment
Other source (SPECIFY) __________________
(-9) DK / (-8) RA / (-7) NA
Q.29b What is ... usual source of medical care?
01
02
03
04
05
06
No regular source
Private physician
Emergency room at a hospital
Health clinic
Folk healer
Other (SPECIFY) __________________
(-9) DK / (-8) RA / (-7) NA
Q.29c In the past 12 months, was … covered either by Refugee Medical Assistance, Medicaid, or
private health insurance?
01
02
(-1)
(-3)
Yes - covered in all months
No - number of months not covered: _______
Not covered 1 month or less
Not covered in any month (skip to Q.30a)
(-9) DK / (-8) RA / (-7) NA
Q.29d What type of health insurance coverage did ... have in the past 12 months?
(indicate all that apply)
01
02
03
04
05
Insurance through own or family member's employment
Private insurance unrelated to employment
Medicaid or Refugee Medical Assistance
Other government health care
Other insurance (SPECIFY) ________________
(-9) DK / (-8) RA / (-7) NA
37
Questionnaire for Annual Survey Of Refugees - 2012
Household ID#
Q.29a
1
2
3
4
5
(01) No medical expenses
(02) Self or household members
(03) Other relatives or friends
(04) Sponsor/sponsoring agency
(05) Religious organization
(06) Medicaid
(07) Refugee Medical Assistance
(08) Co-payments
(09) Other government source
(10) Insurance through own
employment
(11) Insurance through family
member’s employment
(12) Other source (SPECIFY)
01
02
03
04
05
06
07
08
09
10
01
02
03
04
05
06
07
08
09
10
01
02
03
04
05
06
07
08
09
10
01
02
03
04
05
06
07
08
09
10
01
02
03
04
05
06
07
08
09
10
11
11
11
11
11
_________
12
_________
12
_________
12
_________
12
_________
12
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
02
03
04
05
________
06
01
02
03
04
05
________
06
01
02
03
04
05
________
06
01
02
03
04
05
________
06
01
02
03
04
05
________
06
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
_______
02
# months
-1
-3
01
_______
02
# months
-1
-3
01
_______
02
# months
-1
-3
01
________
02
# months
-1
-3
01
________
02
# months
-1
-3
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
01
01
01
01
01
02
02
02
02
02
03
03
03
03
03
04
________
05
04
________
05
04
________
05
04
________
05
04
________
05
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
-9 -8 -7
(-9) DK / (-8) RA / (-7) NA
Q.29b
(01) No regular source
(02) Private physician
(03) Emergency room at a hospital
(04) Health clinic
(05) Folk healer
(06) Other (SPECIFY)
(-9) DK / (-8) RA / (-7) NA
Q.29c
FOLLOW SKIP PATTERN
(01) Yes - Covered in all 12 months
(02) No - # of months not covered
(-1) Not covered 1 month or less
(-3) Not covered in any month (skip to
Q.30a)
(-9) DK / (-8) RA / (-7) NA
Q.29d
(01) Insurance through own or family
member's employment
(02) Private insurance unrelated to
employment
(03) Medicaid or Refugee Medical
Assistance
(04) Other government health care
(05) Other insurance (SPECIFY)
(-9) DK / (-8) RA / (-7) NA
38
Questionnaire for Annual Survey Of Refugees - 2012
Q.30a FOOD STAMPS - In the past 12 months, have one or more persons in your household
received food stamps?
01
02
No (skip to Q.31a)
Yes
(-9) DK / (-8) RA / (-7) NA (skip to Q.31a)
Q.30b Who received them? (circle Household ID# and person # of the person who received assistance)
Q.30c What was the total cash value per month? (on a household level)
Q.30d How many months in the past 12 months were food stamps received?
39
Questionnaire for Annual Survey Of Refugees - 2012
Q.30a
FOLLOW SKIP PATTERN
(01) No (skip to Q.31a)
(02) Yes
01
02
(-9) DK / (-8) RA / (-7) NA (skip to Q.31a)
Q.30b
-9 -8 -7
Circle # 's from Household Control Chart
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17
(-9) DK / (-8) RA / (-7) NA
Q.30c
-9 -8 -7
Total Cash Value (per month)
_________________
$
(-9) DK / (-8) RA / (-7) NA
Q.30d
-9 -8 -7
How many months?
________________
# of months
(-9) DK / (-8) RA / (-7) NA
-9 -8 -7
40
Questionnaire for Annual Survey Of Refugees - 2012
Q.31a TANF - In the past 12 months, have one or more persons in your household received cash
assistance through the Temporary Assistance to Needy Families (TANF) Program?
01
02
No (skip to Q.31f)
Yes
(-9) DK / (-8) RA / (-7) NA (skip to Q.31f)
Q.31b Which household members received such assistance? (circle Household ID# and person # of the
person who received assistance)
Q.31c What was the cash amount received each month? (on a household level)
Q.31d How many months in the past 12 months was the TANF received?
Q.31e In the last month, was TANF received?
01
02
No
Yes
(-9) DK / (-8) RA / (-7) NA
Q.31f Since coming to the United States, in how many months have one or more persons in your
household received TANF?
A
B
C
Every month
No months
Number of months:____________
(-9) DK / (-8) RA / (-7) NA
41
Questionnaire for Annual Survey Of Refugees - 2012
Q.31a
FOLLOW SKIP PATTERN
(01) No (skip to Q.31f)
(02) Yes
01
02
(-9) DK / (-8) RA / (-7) NA (skip to Q.31f)
Q.31b
-9 -8 -7
Circle # 's from Household Control Chart
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17
(-9) DK / (-8) RA / (-7) NA
Q.31c
Total Cash Value (per month)
-9 -8 -7
_______________
$
(-9) DK / (-8) RA / (-7) NA
Q.31d
-9 -8 -7
How many months?
________________
# of months
(-9) DK / (-8) RA / (-7) NA
Q.31e
-9 -8 -7
(01) No
(02) Yes
01
02
(-9) DK / (-8) RA / (-7) NA
Q.31f
-9 -8 -7
(A) Every month
(B) No months
(C) Number of months
A
B
_____________
C
# of months
(-9) DK / (-8) RA / (-7) NA
-9 -8 -7
42
Questionnaire for Annual Survey Of Refugees - 2012
Q.32a RCA - In the past 12 months, have one or more persons in your household received assistance
through the Refugee Cash Assistance (RCA) program?
01
02
No (skip to Q.33a)
Yes
(-9) DK / (-8) RA / (-7) NA (skip to Q.33a)
Q.32b Which household members received such assistance? (circle Household ID# and person # of the
person who received assistance)
Q.32c What was the cash amount received each month? (on a household level)
Q.32d How many months in the past 12 months was RCA received?
Q.32e In the last month, was RCA received?
01
02
No
Yes
(-9) DK / (-8) RA / (-7) NA
43
Questionnaire for Annual Survey Of Refugees - 2012
Q.32a
FOLLOW SKIP PATTERN
(01) No (skip to Q.33a)
(02) Yes
01
02
(-9) DK / (-8) RA / (-7) NA (skip to Q.33a)
Q.32b
Circle # 's from Household Control Chart
-9 -8 -7
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17
(-9) DK / (-8) RA / (-7) NA
Q.32c
-9 -8 -7
Total Cash Value (per month)
________________
$
(-9) DK / (-8) RA / (-7) NA
Q.32d
-9 -8 -7
How many months?
______________
# of months
(-9) DK / (-8) RA / (-7) NA
Q.32e
-9 -8 -7
(01) No
(02) Yes
01
02
(-9) DK / (-8) RA / (-7) NA
-9 -8 -7
44
Questionnaire for Annual Survey Of Refugees - 2012
Q.33a SSI - In the past 12 months, have one or more persons in your household received
Supplemental Security Income (SSI)?
01
02
No (skip to Q.33f)
Yes
(-9) DK / (-8) RA / (-7) NA (skip to Q.33f)
Q.33b Which household members received such assistance? (circle Household ID#s and person # of the
person who received assistance)
Q.33c What was the cash amount received each month? (on a household level)
Q.33d How many months in the past 12 months was SSI received?
Q.33e In the last month, was SSI received?
01
02
No
Yes
(-9) DK/ (-8) RA/ (-7) NA
Q.33f Since coming to the U.S., in how many months have one or more persons in your household
received SSI?
A
B
C
Every month
No months
Number of months: ____________
45
Questionnaire for Annual Survey Of Refugees - 2012
Q.33a
FOLLOW SKIP PATTERN
(01) No (skip to Q.33f)
(02) Yes
01
02
(-9) DK / (-8) RA / (-7) NA (skip to Q.33f)
Q.33b
Circle # 's from Household Control Chart
-9 -8 -7
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17
(-9) DK / (-8) RA / (-7) NA
Q.33c
-9 -8 -7
Total Cash Value (per month)
_________________
$
(-9) DK / (-8) RA / (-7) NA
Q.33d
-9 -8 -7
How many months?
_____________
# of months
(-9) DK / (-8) RA / (-7) NA
Q.33e
-9 -8 -7
(01) No
(02) Yes
01
02
(-9) DK / (-8) RA / (-7) NA
Q.33f
-9 -8 -7
A
B
_____________
C
# of months
(A) Every month
(B) No months
(C) Number of months
(-9) DK / (-8) RA / (-7) NA
-9 -8 -7
46
Questionnaire for Annual Survey Of Refugees - 2012
Q.34a GA - In the past 12 months, have one or more persons in your household received income from
General Assistance (GA)?
01
02
No (skip to Q.34f)
Yes
(-9) DK / (-8) RA / (-7) NA (skip to Q.34f)
Q.34b Which household members received such assistance? (circle Household ID#s and person # of the
person who received assistance)
Q.34c What was the cash amount received each month? (on a household level)
Q.34d How many months in the past 12 months was GA received?
Q.34e In the last month, was GA received?
01
02
No
Yes
(-9) DK / (-8) RA / (-7) NA
47
Questionnaire for Annual Survey Of Refugees - 2012
Q.34a
FOLLOW SKIP PATTERN
(01) No (skip to Q.34f)
(02) Yes
01
02
(-9) DK / (-8) RA / (-7) NA (skip to Q.34f)
Q.34b
Circle # 's from Household Control Chart
-9 -8 -7
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17
(-9) DK / (-8) RA / (-7) NA
Q.34c
-9 -8 -7
Total Cash Value (per month)
____________
$
(-9) DK / (-8) RA / (-7) NA
Q.34d
-9 -8 -7
How many months?
_____________
# of months
(-9) DK / (-8) RA / (-7) NA
Q.34e
-9 -8 -7
(01) No
(02) Yes
01
02
(-9) DK / (-8) RA / (-7) NA
-9 -8 -7
48
Questionnaire for Annual Survey Of Refugees - 2012
Q.34f Since coming to the U.S., in how many months have one or more persons in your household
received GA?
A
B
C
Every month
No months
Number of months: ____________
(-9) DK / (-8) RA / (-7) NA
Q.35a CASH - In the past 12 months; have one or more persons in your household received cash
assistance directly from a voluntary agency, sponsor, religious organization, or MAA?
01
02
No (skip to Q.36a)
Yes
(-9) DK / (-8) RA / (-7) NA (skip to Q.36a)
Q.35b What type of organization or person gave such assistance?
01
02
03
04
05
06
Voluntary agency
Religious organization
Refugee Mutual Assistance Association (MAA)
Sponsor
Other individual or family member
Other organization (SPECIFY)
(-9) DK / (-8) RA / (-7) NA
Q.35c Which household members received such assistance? (circle Household ID# and person # of the
person who received assistance)
Q.35d What was the cash amount received each month? (on a household level)
Q.35e How many months in the past 12 months was this private assistance received?
49
Questionnaire for Annual Survey Of Refugees - 2012
Q.34f
(A) Every month
(B) No months
(C) Number of months
A
B
_______
C
# of months
(-9) DK / (-8) RA / (-7) NA
Q.35a
FOLLOW SKIP PATTERN
-9 -8 -7
(01) No (skip to Q.36a)
(02) Yes
01
02
(-9) DK / (-8) RA / (-7) NA (skip to Q.36a)
Q.35b
-9 -8 -7
(01) Voluntary agency
(02) Religious organization
(03) Refugee Mutual Assistance Association
(04) Sponsor
(05) Other individual or family member
(06) Other organization (SPECIFY)
01
02
03
04
05
_______________
06
-9 -8 -7
(-9) DK / (-8) RA / (-7) NA
Q.35c
Circle # 's from Household Control Chart
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17
(-9) DK / (-8) RA / (-7) NA
Q.35d
-9 -8 -7
Total Cash Value (per month)
_______________
$
(-9) DK / (-8) RA / (-7) NA
Q.35e
-9 -8 -7
How many months?
__________
# of months
(-9) DK / (-8) RA / (-7) NA
-9 -8 -7
50
Questionnaire for Annual Survey Of Refugees - 2012
Q.36a OTHER INCOME - Within the past 12 months has anyone in the household received income
from any other source on a regular basis (such as interest from savings accounts, net rental income, child
support, unemployment compensation or retirement income)?
01
02
No (skip to Q.38a)
Yes
(-9) DK / (-8) RA / (-7) NA (skip to Q.38a)
Q.36b Who received the income? (circle Household ID# and person # in whose name income was
received)
Q.36c What was the cash amount received on average each month? (on a household level)
Q.36d How many months was this income received in the past 12 months?
Q.36f What was the source of that income? (multiple answers may be given)
01
02
03
04
05
06
Interest income
Net rental income
Child support
Unemployment compensation
Retirement income
Other (SPECIFY) ___________________
(-9) DK / (-8) RA / (-7) NA
Q.38a Is this house or apartment
01
02
03
Rented for cash rent
Owned by you or someone in this household with or without a mortgage or loan
Occupied without payment of cash rent (skip to Q.38c)
(-9) DK / (-8) RA / (-7) NA
Q.38b How much is the total monthly payment for this housing unit? (For owners, include total
mortgage payment, taxes, insurance and utilities; for renters include rent plus utilities - gas,
electricity and heating oil - if paid separately)
Q.38c Is this housing unit in a public housing project, that is, is it owned by a local housing authority or
other local public agency?
01 No
02 Yes
(-9) DK / (-8) RA / (-7) NA
THAT WAS OUR FINAL QUESTION. THANK YOU VERY MUCH FOR YOUR PARTICIPATION
IN THIS SURVEY.
INTERVIEWER: Remember to answer the questions on the following page.
51
Questionnaire for Annual Survey Of Refugees - 2012
Q.36a
FOLLOW SKIP PATTERN
(01) No (skip to Q.38a)
(02) Yes
01
02
(-9) DK / (-8) RA / (-7) NA (skip to Q.38a)
Q.36b
Circle # 's from Household Control Chart
-9 -8 -7
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17
(-9) DK / (-8) RA / (-7) NA
Q.36c
-9 -8 -7
_______________
$
Total Cash Value (per month)
(-9) DK / (-8) RA / (-7) NA
Q.36d
-9 -8 -7
___________
# of months
How many months?
(-9) DK / (-8) RA / (-7) NA
Q.36f
-9 -8 -7
(01) Interest income
(02) Net rent al income
(03) Child support
(04) Unemployment compensation
(05) Retirement income
(06) Other (SPECIFY)
01
02
03
04
05
___________________________________
06
(-9) DK / (-8) RA / (-7) NA
-9 -8 -7
Q.38a
FOLLOW SKIP PATTERN
(01) Rented for cash rent
(02) Owned by you or someone in this household ...
(03) Occupied without payment or cash rent (skip to
Q.38c)
01
02
03
(-9) DK / (-8) RA / (-7) NA
Q.38b
Rent $
-9 -8 -7
___________
$
-9 -8 -7
(-9) DK / (-8) RA / (-7) NA
Q.38c
(01) No
(02) Yes
01
02
(-9) DK / (-8) RA / (-7) NA
-9 -8 -7
52
Questionnaire for Annual Survey Of Refugees - 2012
FOR INTERVIEWER ONLY
A.
Time Interview Ended _________________________ (Please, use military time)
B.
General Responsiveness of Respondent
01
02
03
04
Willing
Neutral
Reluctant
Other
C.
List Difficulties, if any, With the Interview
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
D. Language in which Interview was Conducted
E. Interviewer's Ethnicity
RS
VN
LA
CB
HM
SP
AH
HA
CN
RO
PL
AN
UP
AR
IR
AF
SO
BU
SR
EN
RS
VN
LA
CB
HM
SP
ET
HA
CN
RO
PL
AN
UP
IZ
IR
AF
SO
BU
SR
Russian
Vietnamese
Laotian
Cambodian
Hmong
Spanish
Amharic
Creole
Chinese
Romanian
Polish
Armenian
Ukrainian
Arabic
Farsi
Afghan
Somalian
Bulgarian
Serbo-Croatian
English
Other (SPECIFY) ________________
Russian
Vietnamese
Lao
Cambodian
Hmong
Cuban/other Hispanic
Ethiopian
Haitian
Chinese
Romanian
Polish
Armenian
Ukrainian
Iraqi
Iranian
Afghan
Somalian
Bulgarian
Serbian
Other (SPECIFY) __________________
END
53
| File Type | application/pdf |
| File Title | Microsoft Word - Questionnaire for OMB - English FINAL 3-14-12.doc |
| Author | Joan Wang |
| File Modified | 2012-03-23 |
| File Created | 2012-03-14 |