Form ASEC Questionnaire ASEC Questionnaire ASEC Questionnaire

Annual Social and Economic Supplement to the Current Population Survey

Attachment A - Items Booklet

Annual Social and Economic Supplement

OMB: 0607-0354

Document [doc]
Download: doc | pdf

Attachment A

2013 Annual Social and Economic Supplement

Items Booklet - Feb/March/April 2013












2013 ANNUAL SOCIAL AND ECONOMIC SUPPLEMENT

CPS FIELD REPRESENTATIVE / CATI INTERVIEWER


ITEMS BOOKLET










































This document does not contain any Title 13 data or other Personally Identifiable Information. All data are fictitious and any resemblance to actual data is coincidental. Consistent with Field Division Policy, any names referenced in practice interviews or other exercises are not meant to refer to any actual businesses, schools, group quarters, or persons, especially any current or former Census Bureau employees.

MOVER ITEMS



HH32b


Did (you/name of reference person) live at this address during the week of November 19, 2012?


1 Yes

2 No



HH32d


Did any of the following household members live here during the week of

November 19, 2012?


  1. Yes

  2. No




FAMILY INCOME



S_FAMINC


Which category represents the total combined income of all members of this FAMILY during the past 12 months?


This includes money from jobs, net income from business, farm or rent, pensions, dividends, interest, social security payments and any other money income received by members of this family who are 15 years of age or older?


1 Less than $5,000 9 30,000 to 34,999

2 5,000 to 7,499 10 35,000 to 39,999

3 7,500 to 9,999 11 40,000 to 49,999

4 10,000 to 12,499 12 50,000 to 59,999

5 12,500 to 14,999 13 60,000 to 74,999

6 15,000 to 19,999 14 75,000 to 99,999

7 20,000 to 24,999 15 100,000 to 149,000

8 25,000 to 29,999 16 150,000 to more

INCDKR


Is the combined income of all members of this FAMILY during the past 12 months above or below $75,000?


  1. Above

  2. Below



INTRODUCTION


Pr_incom


?[F1] Importance of responding

Wording of introduction is optional.


The questions you just answered were about your job and economic status last week. The next set of questions ask about your job and economic status last year.


1 Enter 1 to Continue




WORK EXPERIENCE


Q29a


Did (name/you) work at a job or business at any time during 2012?


  1. Yes

  2. No


Q29b


Did (you/he/she) do any temporary, part-time, or seasonal work even

for a few days during 2012?


  1. Yes

  2. No

Q30


Even though (name/you) did not work in 2012, did (you/he/she) spend any time trying to find a job or on layoff?


  1. Yes

  2. No


Q31


How many different weeks (was/were) (name/you) looking for work or on layoff from a job?


 (01-52) Number of weeks


________________


Q32


What was the main reason (you/he/she) did not work in 2012?


Read categories if necessary


  1. Ill, or disabled and unable to work

  2. Retired

  3. Taking care of home or family

  4. Going to school

  5. Could not find work

  6. Doing something else


Q33


During 2012 in how many weeks did (name/you) work even for a few hours?
Include paid vacation and sick leave as work.

(01-52) Number of weeks

Enter 97 if respondent can only answer in months


________________

Q33mon


 Enter number of months worked

(1-12)


________________


Q33ver


Then (name/you) worked about (number) weeks. Is that correct?


  1. Yes

          1. 2 No – back to Q33 and obtain estimate


Q35


Did (name/you) lose any full weeks of work in 2012 because (you/he/she)

(were/was) on layoff from a job or lost a job?

Number of weeks worked in 2012: (number)


  1. Yes

              1. 2 No

              2. 7 Mistake made in number of weeks worked last year - Specify in Q35SP


Q35SP


Specify mistake made in number of weeks worked last year


_________________________________________________


Q36


You said (name/you) worked about (number) (week/weeks).

How many OF THE REMAINING (number) WEEKS (was/were)
(you/he/she) looking for work or on layoff from a job?

Enter 0 for none


________________


Q37


Were the (number) weeks (name/you) (was/were) looking for work or on layoff all in one stretch?


  1. Yes – one stretch

  2. No – two stretches

  3. No – 3 or more stretches


Q38


What was the main reason (name/you) (was/were) not working or looking for work in the remaining weeks of 2012?


Read list only if respondent is having difficulty answering the question

  1. Ill, or disabled and unable to work

  2. Taking care of home or family

  3. Going to school

  4. Retired

  5. No work available

  6. Other   (Specify - Q38sp)


Q38sp


 Enter verbatim response


_________________________________________________


Q39

For how many employers did (name/you) work in 2012?
If more than one at the same time, only count it as one employer.

  1. One

  2. Two

  3. Three or more


Q41


In the (one week/weeks) that (name/you) worked, how many hours did (you/he/she) (work that week?/usually work per week?)

Enter number of hours


________________

Q43


During 2012, were there one or more weeks in which (name/you) worked less than 35 hours?


Exclude time off with pay because of holidays, vacation, days off, or sickness.

  1. Yes

  2. No


Q44


In the weeks that (name/you) worked, how many weeks did (name/you) work less than 35 hours in 2012?


 Number of weeks worked in 2012: (number)
(Number of weeks was reported in item Q33)

(1-52)


________________


Q45


What was the main reason (name/you) worked less than 35 hours per week?


 Read list only if respondent is having difficulty answering the question

  1. Could not find a full time job

  2. Wanted to work part time or only able to work part time

  3. Slack work or material shortage

  4. Other reason

Q46


What was (name's/your) longest job during 2012?


Was it:

(IO1NAM:) (name of employer)

(IO1IND:) (kind of business or industry)

(IO1OCC:) (occupation)

(IO1DT:) (duties)

CLASS OF WORKER: (PRIVATE/FEDERAL GOVERNMENT/STATE GOVERNMENT/LOCAL GOVERNMENT/WORKING WITHOUT PAY IN FAMILY BUS./SELF EMPLOYED--INCORPORATED/SELF EMPLOYED--UNINCORPORATED)


  1. Same as listed

  2. Different job


Q47a


For whom did (name/you) work (?/at) (blank/(your/his/her) (blank/longest job during 2012?))

Name of Company, business, organization or other employer

      

(blank/( IO1NAM:) (entry)

The current employer is pre-filled in the Form Pane below. Press ENTER if Same)


(blank/ If longest job last year is military job, enter Armed Forces)


(blank/ Enter N for no work done at all during 2012)


_________________________________________________


Q47b


What kind of business or industry is this?

For example: TV and radio manufacturing, retail shoe store, farm


(blank/( IO1IND:) (entry)

The current business or industry type is pre-filled in the Form Pane below. Press ENTER if Same)


(blank/ If longest job last year is military job, enter NA)


_________________________________________________

Q47b1


Is this business or organization mainly manufacturing, retail trade, wholesale trade, or something else?


(blank/( IO1MFG:) (entry)

The current business or organization type is pre-filled in the Form Pane below. Press ENTER if Same)


(blank/ If longest job last year is military job, enter 4)


  1. Manufacturing

  2. Retail

  3. Wholesale trade

  4. Something else


Q47c


What kind of work (was/were) (you/he/she) doing?

For example: Electrical Engineer, Stock Clerk, Typist

(blank/( IO1OCC:) (entry)

The current occupation is pre-filled in the Form Pane below. Press ENTER if Same)


(blank/ If longest job last year is military job, enter Armed Forces)


_________________________________________________


Q47d1


What were (your/his/her) most important activities or duties?

For example: Types, keeps account books, files, sells cars, operates printing press, finishes concrete.


(blank/( IO1DT:) (entry)

The current job description is pre-filled in the Form Pane below. Press ENTER if Same)


(blank/ If longest job last year is military job, enter NA)


_________________________________________________

Q47d2


What were (your/his/her) most important activities or duties?

For example: Types, keeps account books, files, sells cars, operates printing press, finishes concrete.


(blank/( IO1DT:) (entry)

The current job description is pre-filled in the Form Pane below. Press ENTER if Same)


(blank/ If longest job last year is military job, enter NA)


_________________________________________________


Q47E1


 Ask Only If Necessary


(Were/Was) (you/he/she) employed by government, by a PRIVATE company, a nonprofit organization, or (was/were) ( you/he/she) self-employed or working in a family business?


  1. Government

  2. Private for profit company

  3. Non profit organization including tax exempt and charitable organizations

  4. Self employed

  5. Working in family business


Q47E1a


Would that be the federal, state, or local government?


  1. Federal

  2. State

  3. Local (county, city, township)


Q47E1b


Was this business incorporated?


  1. Yes

  2. No

Q47E1c

(Were/Was) (you/name) the owner of the business?


  1. Yes

  2. No


Q4788


Counting all locations where (this employer/(name/you)) (operates/operate), what is the total number of persons who work for ((name's/your) employer)/name/you))?


Read categories if necessary


  1. under 10

  2. 10-49

  3. 50-99

  4. 100-499

  5. 500-999

  6. 1,000+



EARNED INCOME


Q48aa


How much did (name/you) earn from this employer before taxes and other deductions during 2012?


Enter dollar amount

Enter 0 for none

________________


Q48aap


Read if necessary


Is this a weekly, every other week, twice a month, monthly, or yearly amount?

  1. Weekly

  2. Every other week (bi-weekly)

  3. Twice a month

  4. Monthly

7 Yearly

Q48a1


For how many (weekly/every other week/twice a month/monthly) pay periods did (name/you) earn (fill from Q48aa) from this employer in 2012?


(1-12/1-24/1-26/1-52)


________________


Q48aC2


Do not read to the respondent.

The annual rate appears out of range. The total annual earnings entered is (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q48aV


According to my calculations (name/you) earned (total) altogether from this employer in 2012 before deductions. Does that sound about right?


  1. Yes

  2. No


Q48a2


What is your best estimate of (name's/your) correct total amount of earnings from this employer during 2012 before deductions?


PREVIOUS ENTRIES: Q48aa: (amount) 

Q48aap: (periodicity)

Q48a1: (number of pay periods)

Enter dollar amount


________________


Q48a3


Does this amount include all tips, bonuses, overtime pay, or commissions (name/you) may have received from this employer in 2012?


  1. Yes

  2. No


Q48aad


How much did (name/you) earn in tips, bonuses, overtime pay, or commissions from this employer in 2012?


Enter dollar amount


________________ 


Q48b


What were (name's/your) net earnings from this business/farm after expenses during 2012?


If response is "Broke Even" then enter 1

Enter "0" for None

If response is "Lost Money" press enter

Enter dollar amount


________________


Q48b_char


Enter “L” for Lost Money

________________


Q48BL


  Enter amount of money lost in 2012

  Enter annual amount only


________________


Q48bp


Is this a weekly, every other week, twice a month, monthly, quarterly, or yearly amount?


  1. Weekly

  2. Every other week

  3. Twice a month

  4. Monthly

  5. Quarterly

  1. Yearly


Q48B1A


Do not read to the respondent.

The annual rate appears out of range. The total annual business loss entered is (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q48B1B


Do not read to the respondent.

The annual rate appears out of range. The total annual business income entered is (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q48b2


What is your best estimate of (name's/your) ANNUAL net earnings from this business/farm after expenses in 2012?


PREVIOUS ENTRIES:  Q48b: (amount) 

Q48bp: (periodicity)

Enter dollar amount


________________


Q48b2L


What is your best estimate of (name's/your) ANNUAL net LOSS from this business/farm after expenses in 2012?

PREVIOUS ENTRIES:  Q48bL: (amount) 

Q48bp: (periodicity)

Enter dollar amount


________________


Q48b3


What were (name's/your) net earnings from this business/farm during the FIRST quarter of 2012?


If response is "Broke Even" then enter 1

Enter "0" for None

If response is “Lost Money” press enter

Enter dollar amount


________________

Q48b3_char


Enter "L" for Lost Money


________________


Q48B3L


Enter amount of money lost in the first quarter of 2012.


________________


Q48b4


What were (name's/your) net earnings from this business/farm during the SECOND quarter of 2012?


If response is "Broke Even" then enter 1

Enter "0" for None

If response is "Lost Money" press enter

Enter dollar amount


________________


Q48b4_char


Enter "L" for Lost Money


________________


Q48B4L


Enter amount of money lost in the second quarter of 2012.


________________


Q48b5


What were (name's/your) net earnings from this business/farm during the THIRD quarter of 2012?


If response is "Broke Even" then enter 1

Enter "0" for None

If response is "Lost Money" press enter

Enter dollar amount


________________

Q48b5_char


Enter "L" for Lost Money


________________


Q48B5L


Enter amount of money lost in the third quarter of 2012.


________________


Q48b6


What were (name's/your) net earnings from this business/farm during the FOURTH quarter of 2012?


If response is "Broke Even" then enter 1

Enter "0" for None

If response is "Lost Money" press enter

Enter dollar amount


________________


Q48b6_char


Enter "L" for Lost Money


________________


Q48B6L

Enter amount of money lost in the fourth quarter of 2012.


________________


Q48b7


Does this amount include all tips, bonuses, overtime pay, or commissions (name/you) may have received from this business in 2012?


  1. Yes

  2. No


Q48bad


How much did (name/you) earn in tips, bonuses, overtime pay, or commissions

in 2012?


 Enter dollar amount


________________

Q49a


Did (name/you) earn money from any other work (you/he/she) did during 2012?

  1. Yes

  2. No


Q49b1d


How much did (name/you) earn from all other employers before taxes and other deductions during 2012?


 Enter dollar amount

 Enter “0” for None


________________


Q49b1p


Read if necessary


Is this a weekly, every other week, twice a month, monthly, or yearly amount?

  1. Weekly

  2. Every other week (bi-weekly)

  3. Twice a month

  4. Monthly

7 Yearly


Q49B11


For how many (weekly/every other week/twice a month/monthly) pay periods did (name/you) earn (fill from Q49b1d) from all other employers in 2012?


(1-12/1-24/1-26/1-52)


________________

Q49B1C


Do not read to the respondent.

The total annual earnings entered from all other employers is (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q49B1V


According to my calculations (name/you) earned (total) altogether from all other employers in 2012.  Does that sound about right?


  1. Yes

  2. No


Q49B12


What is your best estimate of (name's/your) correct total amount of earnings from all other employers during 2012?


PREVIOUS ENTRIES:  Q49b1d: (amount)

Q49b1p: (periodicity)

Q49b11: (number of pay periods)

 

Enter dollar amount


________________


Q49b13


Does this amount include all tips, bonuses, overtime pay, or commissions (name/you) may have received from all other employers in 2012?


  1. Yes

  2. No


Q49B1A


How much did (name/you) earn in tips, bonuses, overtime pay, or commissions from all other employers in 2012?


Enter dollar amount


________________


Q49b2


How much did (name/you) earn from (blank/any other businesses of) (your/his/her) (own/own business) after expenses?


If response is "Broke Even" then enter 1

Enter "0" for None

If response is "Lost Money" press enter

Enter annual amount only


________________


Q49b2_char


Enter "L" for Lost Money


________________


Q49b3


 Enter annual amount lost only


____________


Q49b4


How much did (name/you) earn from (your/his/her) farm after expenses?


If response is "Broke Even" then enter 1 

Enter "0" for None 

If response is "Lost money" press enter

Enter annual amount only


_______________


Q49b4_char


Enter "L" for Lost Money


________________


Q49b5


Enter annual amount lost only


________________

UNEMPLOYMENT AND WORKERS COMPENSATION



Q51A1


At any time during 2012 did (name/you) receive any State or Federal unemployment compensation?

  1. Yes

  2. No


Q51A1p


What is the easiest way for you to tell us (name's/your) State or Federal unemployment compensation; weekly, every other week, twice a month, monthly, or yearly?

  1. Weekly

  2. Every other week (bi-weekly)

  3. Twice a month

  4. Monthly

7 Yearly


Q51A11


How much did (name/you) receive (weekly/every other week/ twice a month/monthly/ ) in State or Federal unemployment compensation during 2012?


Enter dollar amount 


________________


Q51A1C


Do not read to the respondent.

The annual rate appears out of range. The total State or Federal unemployment compensation received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q51A12


How many (weekly/every other week/ twice a month/monthly) payments did (name/you) receive from State or Federal unemployment compensation during 2012?


 (1-12/1-24/1-26/1-52)


________________


Q51A13


According to my calculations (name/you) received (total) altogether from State or Federal unemployment compensation during 2012. Does that sound about right?


  1. Yes

  2. No


Q51A14


What is your best estimate of the correct total amount (name/you) received from State or Federal unemployment compensation during 2012?


PREVIOUS ENTRIES:  Q51A11: (amount)
  Q51A1p: (periodicity)
  Q51A12: (number of pay periods)

Enter dollar amount 


________________

 

Q51A2


At any time during 2012 did (name/you) receive any Supplemental Unemployment Benefits (SUB)?


  1. Yes

  2. No


Q51A2p


What is the easiest way for you to tell us (name's/your) Supplemental Unemployment Benefits; weekly, every other week, twice a month, monthly, or yearly?

  1. Weekly

  2. Every other week (bi-weekly)

  3. Twice a month

  4. Monthly

7 Yearly


Q51A21


How much did (name/you) receive (weekly/every other week/twice a month/

monthly/ ) in Supplemental Unemployment Benefits during 2012?

Enter dollar amount 


_____________


Q51A2C


Do not read to the respondent.

The annual rate appears out of range. The total Supplemental Unemployment Benefits received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q51A22


How many (weekly/every other week/twice a month/ monthly) payments did (name/you) receive from Supplemental Unemployment Benefits during 2012?


(1-12/1-24/1-26/1-52)


________________


Q51A23


According to my calculations (name/you) received (total) altogether from Supplemental Unemployment Benefits during 2012. Does that sound about right?


  1. Yes

  2. No

Q51A24


What is your best estimate of the correct total amount (name/you) received from Supplemental Unemployment Benefits during 2012?


 PREVIOUS ENTRIES:  Q51A21: (amount)
Q51A2p: (periodicity)
Q51A22: (number of pay periods)

Enter dollar amount


________________


Q51A3


At any time during 2012 did (name/you) receive any Union Unemployment or Strike Benefits?


  1. Yes

  2. No


Q51A3p


What is the easiest way for you to tell us (name's/your) Union Unemployment or Strike Benefits; weekly, every other week, twice a month, monthly, or yearly?

  1. Weekly

  2. Every other week (bi-weekly)

  3. Twice a month

  4. Monthly

7 Yearly


Q51A31


How much did (name/you) receive (weekly/every other week/ twice a month/ monthly/ ) in Union Unemployment or Strike Benefits during 2012?


 Enter dollar amount


________________


C251A3


Do not read to the respondent.

The annual rate appears out of range. The total Union Unemployment or Strike Benefits received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q51A32


How many (weekly/every other week/ twice a month/ monthly) payments did (name/you) receive from Union Unemployment or Strike Benefits during 2012?

(1-12/1-24/1-26/1-52)


________________


Q51A33


According to my calculations (name/you) received  (total) altogether from Union Unemployment or Strike Benefits during 2012. Does that sound about right?


  1. Yes

  2. No


Q51A34


What is your best estimate of the correct total amount (name/you) received from Union Unemployment or Strike Benefits during 2012?


 PREVIOUS ENTRIES:  Q51A31: (amount)
Q51A3p: (periodicity)
Q51A32: (number of pay periods)

Enter dollar amount

________________


Q52a


During 2012 did (name/you) receive any Worker’s Compensation payments or other payments as a result of a job related injury or illness?


Exclude sick pay and disability retirement.


  1. Yes

  2. No

Q52b


What was the source of these payments?


  1. State Worker's Compensation

  2. Employer or employer's insurance

  3. Own insurance

  4. Other


Q52cp


What is the easiest way for you to tell us (name's/your)Worker’s Compensation; weekly, every other week, twice a month, monthly, or yearly?

  1. Weekly

  2. Every other week (bi-weekly)

  3. Twice a month

  4. Monthly

7 Yearly


Q52c1


How much did (name/you) receive (weekly/every other week/ twice a month/ monthly/ ) in Worker’s Compensation during 2012?


 Enter dollar amount


________________


Q52cC2


Do not read to the respondent.

The annual rate appears out of range. The total worker's compensation received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q52c2


How many (weekly/every other week/ twice a month/ monthly) payments did (name/you) receive from Worker’s Compensation during 2012?

(1-12/1-24/1-26/1-52)


________________

Q52c3


Then (name/you) received (total) altogether from Worker’s Compensation

during 2012. Does that sound about right?


  1. Yes

  2. No


Q52c4


What is your best estimate of the correct total amount (name/you)
received from Worker’s Compensation during 2012?

PREVIOUS ENTRIES:  Q52c1: (amount)
Q52cp: (periodicity)
Q52c2: (number of pay periods)
 Enter dollar amount


________________




SOCIAL SECURITY


Q56a


During 2012 did (you/ anyone in this household) receive any Social Security payments from the U.S. Government?


  1. Yes

  2. No


Q56b


 Read only if necessary


Who received Social Security payments either for themselves or as combined payments with other family members?

Enter Line Number Of Parent Or Guardian For Payments Made To
Children Under Age 15
Enter all that apply, separate using the space bar or a comma.


Enter persons line number (1-16)

Q56dp


What is the easiest way for you to tell us (name's/your) Social Security payment; monthly, quarterly, or yearly?


4 Monthly

5 Quarterly

7 Yearly


Q56d


How much did (name/you) receive (monthly/quarterly/ ) in Social Security payments in 2012?


 Enter dollar amount 

 If already included in amount reported for another household member, press Enter


________________


Q56d_Char


Enter <A> for Already included


________________


Q56d1


What is the amount of the Social Security payment (name/you) received last month?


Enter dollar amount 


________________


Q56d2


For how many (months/quarters) did (name/you) receive Social Security in 2012?

(1-4; 1-12)


________________


Q56d3


Is this $(amount from Q56d/amount from Q56d1) before or after the Medicare part B monthly deduction?

  1. After Deduction

  2. Before Deduction


Q56d4


Were there any changes since last year in your monthly payments?


  1. Yes

  2. No


Q56dC2


Do not read to the respondent.

The annual rate appears out of range. The total Social Security received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q56d5


According to my calculations (name/you) received $(total) altogether from Social Security in 2012. Does that sound about right?


  1. Yes

  2. No


Q56d6


What is your best estimate of the correct amount (name/you) received in Social Security during 2012?

PREVIOUS ENTRIES: (amount)
Q56dp: (periodicity)
  Q56d2: (number of pay periods)
  Q56d3: (amount added per month)
Q56d4: (cost of living subtracted per month)
Enter dollar amount 


________________


SSR


What were the reasons (name/you) (was/were) getting Social Security in 2012?


Enter all that apply, separate using the space bar or a comma.

Probe: Any Other Reason?


  1. Retired

  2. Disabled

  3. Widowed

  4. Spouse

  5. Surviving child

  6. Dependent child

  7. On behalf of surviving, dependent, or disabled children

  8. Other


SSRs


 Specify other reason


________________________________________________


SSC


Which children under age 15 were receiving Social Security in 2012?


Probe: Anyone Else?

Enter all that apply, separate using the space bar or a comma.

Enter 0 if none listed

Enter 96 for All persons


 Enter persons line number (1-16)

SSCR


What were the reasons (Child's name/the children) (was/were) getting Social Security in 2012?


Enter all that apply, separate using the space bar or a comma.

Probe: Any Other Reason?

  1. Disabled child/children

  2. Surviving child/children

  3. Dependent child/children

4 Other

SOCIAL SECURITY FOR CHILDREN


Q56f


Did anyone in this household receive any Social Security income in 2012 that we have not already counted on behalf of children in this household?


 Includes all children under 19 years of age

 Social Security Income previously reported will appear here


LN  Name  Amount reported in Q56d amount


  1. Yes

  2. No


Q56g


Read only if necessary


Who received these Social Security payments?

Enter line number of parent or guardian
Enter all that apply, separate using the space bar or a comma.

Probe: Anyone Else?


Enter persons line number (1-16)


Q56ip


What is the easiest way for you to tell us (name's/your) Social Security payment for children in this household; monthly, quarterly, or yearly?


4 Monthly

5 Quarterly

7 Yearly


Q56i


How much did (name/you) receive (monthly/quarterly/ ) in Social Security payments for children in this household in 2012?


Enter dollar amount 

If already included in amount reported for another household member, press Enter


________________


Q56i_Char


Enter A for Already included


________________


Q56i1


What is the amount of the Social Security payment (name/you) received for children in this household last month?

 Enter dollar amount 


________________


Q56i2


For how many (months/quarters) did (name/you) receive Social Security in 2012?


 (1-4; 1-12)


________________


Q56i3


Was the cost of living increase the only change which occurred in monthly payments for children in this household?


  1. Yes

  2. No


Q56iC2


Do not read to the respondent.

The annual rate appears out of range. The total Social Security received for children in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q56i4


According to my calculations (name/you) received $(total) altogether for children in this household from Social Security in 2012. Does that sound about right?


  1. Yes

  2. No


Q56i5


What is your best estimate of the correct amount (name/you) received in Social Security for children in this household during 2012?

 Previous entries: (amount)
  Q56ip: (periodicity)
Q56i2: (number of pay periods)
Q56i3: (cost of living subtracted per month)

Enter dollar amount


________________


CSS


Which children under age 19 were receiving Social Security in 2012?


 Probe: Anyone Else?

 Enter all that apply, separate using the space bar or a comma.

Enter 0 if none listed

Enter 96 for All persons


Enter persons line number (1-16)


CRSS


What were the reasons (Child’s name/the children) (was/were) getting Social Security in 2012?

Enter all that apply, separate using the space bar or a comma.

Probe: Any Other Reason?

  1. Disabled child/children

  2. Surviving child/children

  3. Dependent child/children

  4. Other

SUPPLEMENTAL SECURITY INCOME (SSI)


Q57a


During 2012 did (you/ anyone in this household) receive:

any SSI payments, that is, Supplemental Security Income?


Note: SSI are assistance payments to low-income aged, blind and disabled persons, and come from state or local welfare offices, the Federal government, or both.


  1. Yes

  2. No


Q57b


Read only if necessary


 Who received SSI?


Supplemental Security Income

Enter all that apply, separate using the space bar or a comma.

Probe: Anyone Else?


Enter persons line number (1-16)


Q57cp


What is the easiest way for you to tell us (name's/your) Supplemental Security Income payment; monthly, quarterly, or yearly?


4 Monthly

5 Quarterly

7 Yearly


Q57c


How much did (name/you) receive (monthly/ quarterly/ ) in Supplemental Security Income payments in 2012?


Enter dollar amount 


________________


Q57c1


What is the amount of the Supplemental Security Income payment (name/you) received last month?

Enter dollar amount


________________


Q57c2


For how many (months/quarters) did (name/you) receive Supplemental Security Income in 2012?


(1-4; 1-12)


________________


Q57c3


Was the cost of living increase the only change which occurred in monthly payments?


  1. Yes

  2. No


Q57cC2


Do not read to the respondent.

The annual rate appears out of range. The total Supplemental Security Income received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q57c4


According to my calculations (name/you) received $(total) altogether from Supplemental Security Income in 2012. Does that sound about right?


  1. Yes

  2. No


Q57c5


What is your best estimate of the correct amount (name/you) received in Supplemental Security Income during 2012?


Previous entries: (amount)

Q57cp: (periodicity)
Q57c2: (number of pay periods)
Q57c3: (amount subtracted per month)

Enter Dollar Amount


________________


SSIR


What were the reasons (name/you) (was/were) getting Supplemental Security Income in 2012?

Enter all that apply, separate using the space bar or a comma.

Probe: Any Other Reason?


  1. Disabled

  2. Blind

  3. On behalf of a disabled child

  4. On behalf of a blind child

  5. Other

SSIC


Which children under age 15 were receiving Supplemental Security Income in 2012?


Probe: Anyone Else?

Enter all that apply, separate using the space bar or a comma.

Enter 0 if none listed
Enter 96 for All persons


Enter persons line number (1-16)


SUPPLEMENTAL SECURITY INCOME FOR CHILDREN


Q57d


Did anyone in this household receive any Supplemental Security Income in 2012 that we have not already counted on behalf of children in this household?


Includes all children under 18 years of age 

SSI previously reported will appear here


LN  Name  Amount for Q57C amount


  1. Yes

  2. No


Q57e


Read only if necessary


 Who received these Supplemental Security Income payments?


Enter line number of parent or guardian

Enter all that apply, separate using the space bar or a comma.

Probe: Anyone Else?


Enter persons line number (1-16)


Q57ip


What is the easiest way for you to tell us the Supplemental Security
Income (name/you) received on behalf of children?

4 Monthly

5 Quarterly

7 Yearly


Q57i


How much did (name/you) receive (monthly/ quarterly/ ) in Supplemental Security
Income on behalf of children in 2012?

Enter dollar amount


________________



Q57i1


What is the amount of the Supplemental Security Income payment (name/you)

received on behalf of children last month?

Enter dollar amount 


________________


Q57i2


For how many (months/quarters) did (name/you) receive Supplemental Security Income on behalf of children in 2012?


(1-4;1-12)


________________


Q57i3


Was the cost of living increase the only change which occurred in monthly payments?


  1. Yes

  2. No


Q57iC2


Do not read to the respondent.

The annual rate appears out of range. The total Supplemental Security Income received on behalf of children in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q57i4


According to my calculations (name/you) received $(total) altogether from Supplemental Security Income on behalf of children in 2012.

Does that sound about right?


  1. Yes

  2. No


Q57i5


What is your best estimate of the correct amount (name/you) received in Supplemental Security Income on behalf of children during 2012?


PREVIOUS ENTRIES: (amount)
Q57ip: (periodicity)
Q57i2: (number of pay periods)
Q57i3: (amount subtracted per month)

 Enter dollar amount 


________________


RSSI


What were the reasons (name/you) (was/were) getting Supplemental Security Income on behalf of children in 2012?


 Enter all that apply, separate using the space bar or a comma.

Probe: Any Other Reason?


  1. On behalf of a disabled child/children

  2. On behalf of a blind child/children

  3. Other


CSSI


Which children under age 18 were receiving Supplemental Security Income

in 2012?


Probe: Anyone Else?

Enter all that apply, separate using the space bar or a comma.

Enter 0 if none listed

Enter 96 for All persons

Enter persons line number (1-16)



PUBLIC ASSISTANCE


Q59A88


At any time during 2012, even for one month, did (you/ anyone in this household) receive any CASH assistance from a state or county welfare program such as

(State Program Name)?


Include cash payments from:

welfare or welfare-to-work programs,

(State Program Name and/or acronyms),

Temporary Assistance for Needy Families program (TANF),

Aid to Families with Dependent Children (AFDC),

General Assistance/Emergency Assistance program,

Diversion Payments,

Refugee Cash and Medical Assistance program,

General Assistance from Bureau of Indian Affairs, or

Tribal Administered General Assistance.

Do not include food stamps/Supplemental Nutrition Assistance Program (SNAP) benefits, SSI, energy assistance, WIC, School meals, or transportation, childcare, rental, or education assistance.


  1. Yes

  2. No


Q59A89


Just to be sure, in 2012, did anyone receive CASH assistance from a state or county welfare program, on behalf of CHILDREN in the household?


  1. Yes

  2. No


Q59b_88 


Who received this CASH assistance?


Enter line number

Enter all that apply, separate using the space bar or a comma.

Probe: Anyone Else?


Enter persons line number (1-16)

Q59C8


From what type of program did (name/you) receive the CASH assistance? Was it a welfare or welfare-to-work program such as (State Program Name), General Assistance, Emergency Assistance, or some other program?


Enter all that apply, separate using the space bar or a comma.

Probe: Any Other Program?


  1. (State Program Name)/welfare/AFDC

  2. General Assistance

  3. Emergency Assistance/short-term cash assistance

  4. Some other program (specify)


Q59C8s


What type of program?

_________________________________________________


Q59ep


What is the easiest way for you to tell us (name's/your) CASH assistance payments; weekly, every other week, twice a month, monthly, or yearly?


  1. Weekly

  2. Every other week (bi-weekly)

  3. Twice a month

  4. Monthly

7 Yearly


Q59e


During 2012, how much CASH assistance did (name/you) receive (per week/every other week/twice a month/ monthly/ )?


 Enter dollar amount


___________


Q59e2


How many (weekly/every other week/ twice a month/ monthly) cash assistance payments did (name/you) receive in 2012?


(1-12; 1-52)


________________

Q57eC2


Do not read to the respondent.

The annual rate appears out of range. The total cash assistance received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q59e3


According to my calculations (name/you) received $(total) altogether in cash assistance from a state or county program in 2012. Does that sound about right?


  1. Yes

  2. No


Q59e4


What is your best estimate of the correct amount of cash assistance
(name/you) received during 2012?

PREVIOUS ENTRIES:  Q59e: (amount)

Q59ep: (periodicity)

Q59e2: (number of pay periods)

Enter dollar amount 


________________


Q59f


Was the cash assistance for adults AND children, or JUST children?


  1. Both adults AND children

  2. Children only

  3. Adults only


Q59g


(Who/Which children) in your household was the cash assistance for?

 

Probe: Anyone Else?

Enter all that apply, separate using the space bar or a comma.

Enter 0 if none listed

Enter 96 for All persons


Enter persons line number (1-16)

VETERANS PAYMENTS


Q60A88


At any time during 2012 did (you/ anyone in this household) receive:

Any Veterans’ (VA) payments?


 Include assistance received by children of veterans


  1. Yes

  2. No


Q60b_88


 Read only if necessary

Who received Veterans’ (VA) payments either for themselves or as combined payments with other family members?

 Enter all that apply, separate using the space bar or a comma.

Probe: Anyone Else?


Enter persons line number (1-16)

Q60C8


What type of Veterans' payment did (name/you) receive?


 Read list only if respondent is having difficulty answering the question.

Enter all that apply, separate using the space bar or a comma.

Probe: Any Other Payments?


  1. Service-connected disability compensation

  2. Survivor Benefits

  3. Veterans’ Pension

  4. Educational assistance (including assistance received by children of veterans)

  5. Other Veterans’ payments


Q60D88


(Are/Is) (name/you) required to fill out an annual income questionnaire for the Department of Veterans' Affairs?

  1. Yes

  2. No


Q60V1P


What is the easiest way for you to tell us (name's/your) (fill from first answer in Q60c8); weekly, every other week, twice a month, monthly, or yearly?


  1. Weekly

  2. Every other week (bi-weekly)

  3. Twice a month

  4. Monthly

7 Yearly


Q60V1


How much did (name/you) receive (weekly/every other week/ twice a month/monthly/ ) before deductions in (fill from first answer in Q60c8) in 2012?


Enter dollar amount


________________


Q60V12


How many (weekly/every other week/ twice a month/monthly) payments did (name/you) receive in (fill from first answer in Q60c8) in 2012?


(1-52)


________________


Q60V1C


Do not read to the respondent.

The annual rate appears out of range. The total (fill from first answer in Q60c8) received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q60V13


According to my calculations (name/you) received (total) dollars altogether from (fill from first answer in Q60c8) in 2012. Does that sound about right?


  1. Yes

  2. No


Q60V14


What is your best estimate of the correct amount (name/you) received in Veteran's benefits during 2012?


PREVIOUS ENTRIES:  Q60V1:  (amount) 

Q60V1P: (periodicity)

Q60V12:  (number of pay periods)

 Enter dollar amount

________________


Q60V2P


What is the easiest way for you to tell us (name's/your) (fill from second answer in Q60c8); weekly, every other week, twice a month, monthly, or yearly?

1 Weekly

2 Every other week (bi-weekly)

  1. Twice a month

  2. Monthly

7 Yearly


Q60V2


How much did (name/you) receive (weekly/every other week/ twice a month/monthly/ ) before deductions in (fill from second answer in Q60c8) in 2012?


Enter dollar amount


________________


Q60V22


How many (weekly/every other week/ twice a month/monthly) payments did (name/you) receive in (fill from second answer in Q60c8) in 2012?


(1-52)


________________


Q60V2C


Do not read to the respondent.

The annual rate appears out of range. The total (fill from second answer in Q60c8) received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q60V23


According to my calculations (name/you) received (total) dollars altogether from

(fill from second answer in Q60c8) in 2012. Does that sound about right?


  1. Yes

  2. No


Q60V24


What is your best estimate of the correct amount (name/you) received in

(fill from second answer in Q60c8) during 2012?


PREVIOUS ENTRIES:  Q60V2:  (amount)

Q60V2P: (periodicity)

Q60V22: (number of pay periods)


Enter dollar amount

________________




SURVIVOR BENEFITS


Q58A


Did (you/ anyone in this household) receive any survivor benefits in 2012 such as

widow’s pensions, estates, trusts, insurance annuities, or any other survivor benefits

(other than Social Security/ other than VA benefits/ other than Social Security or

VA benefits)?


  1. Yes

  2. No


Q58b


Read only if necessary

 

Who received this income?


Enter all that apply, separate using the space bar or a comma.

Probe: Anyone Else?


Enter persons line number (1-16)


Q58C


What was the source of this income?


Asking About: (name/name- -CURRENT RESPONDENT) 

Read list if respondent is having difficulty answering the question

Enter all that apply, separate using the space bar or a comma.

Probe: Any Other Source?



2 Company or union survivor pension (INCLUDE PROFIT SHARING)

  1. Federal Government survivor (CIVIL SERVICE) pension

  2. U.S. Military retirement survivor pension

  3. State or Local government survivor pension

  4. U.S. Railroad retirement survivor pension

  5. Worker's compensation survivor pension

  6. Black Lung survivor pension

  7. Regular payments from estates or trusts

  8. Regular payments from annuities or paid-up insurance policies

11 Other or don't know (SPECIFY) - ENTER LAST


Q58Cs1


Specify other source of income as survivor or widow

Enter "Survivor Benefits" if the answer is "Don't Know"


________________________________________________


Q58E1P


What is the easiest way for you to tell us (name's/your) (fill from first answer

in Q58C or Q58Cs1); weekly, every other week, twice a month, monthly,

or yearly?


  1. Weekly

  2. Every other week

  3. Twice a month

  4. Monthly

7 Yearly


Q58E1


How much did (name/you) receive (weekly/every other week/twice a month/

monthly/ ) in (fill from first answer in Q58C or Q58Cs1) in 2012?


Enter dollar amount


________________



Q58E12


How many (weekly/every other week/twice a month/monthly) payments did

(name/you) receive in (fill from first answer in Q58C or Q58Cs1) in 2012?


 (1-52)


________________



Q58E1C


Do not read to the respondent.

The annual rate appears out of range. The total (fill from first answer in Q58C or Q58Cs1) received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q58E13


According to my calculations (name/you) received (total) altogether from
(fill from first answer in Q58C or Q58Cs1) in 2012. Does that sound about right?

  1. Yes

  2. No


Q58E14


What is your best estimate of the correct amount (name/you) received from (fill from first answer in Q58C or Q58Cs1) during 2012?


PREVIOUS ENTRIES:  Q58E1: (amount)
Q58E1P: (periodicity)
Q58E12: (number of pay periods)
 Enter dollar amount


________________


Q58E2P


What is the easiest way for you to tell us (name's/your) (fill from second answer in Q58C or Q58Cs1); weekly, every other week, twice a month, monthly, or yearly?


  1. Weekly

  2. Every other week

  3. Twice a month

  4. Monthly

7 Yearly


Q58E2


How much did (name/you) receive (weekly/every other week/twice a month/ monthly/ ) in (fill from second answer in Q58C or Q58Cs1) in 2012?


Enter dollar amount


________________


Q58E22


How many (weekly/every other week/twice a month/monthly) payments did (name/you) receive in (fill from second answer in Q58C or Q58Cs1) in 2012?


 (1-52)


________________


Q58E2C


Do not read to the respondent.

The annual rate appears out of range. The total (fill from second answer in Q58C or Q58Cs1) received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q58E23


According to my calculations (name/you) received (total) altogether from

(fill from second answer in Q58C or Q58Cs1) in 2012.


Does that sound about right?


  1. Yes

  2. No


Q58E24


What is your best estimate of the correct amount (name/you) received from (fill from second answer in Q58C or Q58Cs1) during 2012?


 PREVIOUS ENTRIES: Q58E2: (amount)

Q58E2P: (periodicity)

Q58E22: (number of pay periods)


Enter dollar amount


________________


Q58E3P


What is the easiest way for you to tell us (name's/your) (fill from third answer in Q58C or Q58Cs1); weekly, every other week, twice a month, monthly, or yearly?

  1. Weekly

  2. Every other week

  3. Twice a month

  4. Monthly

7 Yearly


Q58E3


How much did (name/you) receive (weekly/every other week/twice a month/ monthly/ ) in (fill from third answer in Q58C or Q58Cs1) in 2012?


 Enter dollar amount


________________


Q58E32


How many (weekly/every other week/ twice a month/ monthly) payments did (name/you) receive in (fill from third answer in Q58C or Q58Cs1) in 2012?


 (1-52)


________________


Q58E3C


Do not read to the respondent.

The annual rate appears out of range. The total (fill from third answer in Q58C or Q58Cs1) received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q58E33


According to my calculations (name/you) received (total) altogether from (fill from third answer in Q58C or Q58Cs1) in 2012. Does that sound about right?


  1. Yes

  2. No


Q58E34


What is your best estimate of the correct amount (name/you) received from (fill from third answer in Q58C3 or Q58Cs1) during 2012?


PREVIOUS ENTRIES: Q58E3: (amount)
Q58E3P: (periodicity)
Q58E32: (number of pay periods)

Enter dollar amount

_______________


DISABILITY INCOME



Q59A


(Do you/Does anyone in the household) have a health problem or disability which prevents (you/them) from working or which limits the kind or amount of work (you/they) can do?


  1. Yes

  2. No


Q59b

 Read only if necessary


Who is that?


 Enter all that apply, separate using the space bar or a comma.

Probe: Anyone Else?


Enter persons line number (1-16)

 

Q60a


(Did you/Is there anyone in this household who) ever (retire or leave/ retired or left) a job for health reasons?


  1. Yes

  2. No


Q60b


 Read only if necessary

Who is that?


 Enter all that apply, separate using the space bar or a comma.

 Probe: Anyone Else?


Enter persons line number (1-16)

Q61b


Did (name/you) receive any income in 2012 as a result of (your/his/her) health problem (other than Social Security/ other than VA benefits/ other than Social Security or VA benefits) ?


(blank/If amount was reported previously as compensation from a job related injury or illness, then enter precode 2)

(blank/Amount previously reported in (Q52CT) was $(amount))



  1. Yes

  2. No



Q61c


What was the source of this income?


Asking About: (name) (blank/- -CURRENT RESPONDENT)

Enter all that apply, separate using the space bar or a comma.

Probe: Any Other Reason?


  1. Worker’s compensation

  2. Company or union disability

  3. Federal Government (CIVIL SERVICE) disability

  4. U.S. Military retirement disability

  5. State or Local government employee disability

  6. U.S. Railroad retirement disability

  7. Accident or disability insurance

  8. Black Lung miner’s disability

  9. State temporary sickness

  10. Other or don’t know – Specify – Enter last


Q61Cs1


Specify other source from health problem or disability

Enter "Other Health Problem/Disability" if the answer is "Don't Know"


_____________________________________________


Q61E1P


What is the easiest way for you to tell us (name's/your) (first answer from Q61c or Q61cs1) payments; weekly, every other week, twice a month, monthly, or yearly?


  1. Weekly

  2. Every other week

  3. Twice a month

  4. Monthly

7 Yearly


Q61E1


How much did (name/you) receive (weekly/ every other week/ twice a month/ monthly/ ) before deductions in (first answer from Q61c or Q61cs1) payments in 2012?


 Enter dollar amount


_______________


Q61E12


How many (weekly/ every other week/ twice a month/ monthly) payments did
(name/you) receive in (first answer from Q61c or Q61cs1) payments in 2012?

Disability income source #1 (1-12; 1-52)

_______________


Q61E1C


Do not read to the respondent.

The annual rate appears out of range. The total (fill from first answer in Q61c or Q61cs1) payments received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q61E13


According to my calculations (name/you) received (total) dollars altogether from
(first answer from Q61c or Q61cs1) payments in 2012. Does that sound about right?


  1. Yes

  2. No

Q61E14


What is your best estimate of the correct amount (name/you) received from (first answer from Q61c or Q61cs1) payments during 2012?


PREVIOUS ENTRIES: Q61E1: (amount)
Q61E1P: (periodicity)
Q61E12: (number of pay periods)
Enter dollar amount


_______________


Q61E2P


What is the easiest way for you to tell us (name's/your) (second fill from Q61c or Q61cs1) payments; weekly, every other week, twice a month, monthly, or yearly?


  1. Weekly

  2. Every other week

  3. Twice a month

  4. Monthly

7 Yearly


Q61E2


How much did (name/you) receive (weekly/every other week/ twice a month/ monthly) before deductions in (second answer from Q61c or Q61cs1)
payments in 2012?

Enter dollar amount


_______________


Q61E22


How many (weekly/every other week/ twice a month/ monthly) payments did (name/you) receive in (second answer from Q61c or Q61cs1) payments in 2012?


 Disability income payment source #2 (1-12; 1-52)


_______________


Q61E2C


Do not read to the respondent.

The annual rate appears out of range. The total (fill from second answer in Q61c or Q61cs1) payments received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q61E23


According to my calculations (name/you) received (total) dollars altogether

from (second answer from Q61c or Q61cs1) payments in 2012. Does that

sound about right?


  1. Yes

  2. No



Q61E24


What is your best estimate of the correct amount (name/you) received from (second fill from Q61c or Q61cs1) payments during 2012?


PREVIOUS ENTRIES:  Q61E2: (amount)
Q61E2P: (periodicity)
Q61E22: (number of pay periods)


 Enter dollar amount


_______________




RETIREMENT AND PENSIONS



Q62A


During 2012 did (you/ anyone in this household) receive any pension or retirement income from a previous employer or union, or any other type of retirement income (other than Social Security/ other than VA benefits/ other than Social Security or VA benefits) ?


  1. Yes

  2. No


Q62b


Read only if necessary


Who received pension or retirement income?


 Enter all that apply, separate using the space bar or a comma.

 Probe: Anyone Else?


Enter persons line number (1-16)



Q62C


What was the source of (name's/your) income?


 Enter all that apply, separate using the space bar or a comma.

 Probe: Any Other pension or retirement income?


  1. Company or union pension (INCLUDE PROFIT SHARING)

  2. Federal Government (CIVIL SERVICE) retirement

  3. U.S. Military retirement

  4. State or Local government pension

  5. U.S. Railroad Retirement

  6. Regular payments from annuities or paid up insurance policies

  7. Regular payments from IRA, KEOGH, 401(k), 403(b), and 457(b) and (f) accounts

  8. Other sources or don’t know – Specify – Enter last


Q62Cs1


 Enter other source of pension or retirement income

 Enter "Other Pension Or Retirement" if the answer is "Don't Know"


_____________________________________________


Q62E1P


What is the easiest way for you to tell us (name's/your) (first answer from Q62c or Q62cs1); weekly, every other week, twice a month, monthly, or yearly?


  1. Weekly

  2. Every other week

  3. Twice a month

  4. Monthly

7 Yearly

Q62E1


How much did (name/you) receive (weekly/every other week/ twice a month/ monthly/ ) in (first answer from Q62c or Q62cs1) in 2012?


 Enter dollar amount


_______________


Q62E12


How many (weekly/every other week/ twice a month/ monthly) payments did (name/you) receive in (first answer from Q62c or Q62cs1) in 2012?


 Pension/Retirement #1 (1-12; 1-52)


_______________


Q62E1C


Do not read to the respondent.

The annual rate appears out of range. The total (fill from first answer in Q62c or Q62cs1) payments received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q62E13


According to my calculations (name/you) received (total) dollars altogether from (first answer from Q62c or Q62cs1) in 2012. Does that sound about right?


  1. Yes

  2. No


Q62E14


What is your best estimate of the correct amount (name/you) received in (first answer from Q62c or Q62cs1) during 2012?


PREVIOUS ENTRIES: Q62E1: (amount)
Q62E1P: (periodicity)
  Q62E12: (number of pay periods)

Enter dollar amount


_______________


Q62E2P


What is the easiest way for you to tell us (name's/your) (second answer from Q62c or Q62cs1); weekly, every other week, twice a month, monthly, or yearly?


  1. Weekly

  2. Every other week

  3. Twice a month

  4. Monthly

7 Yearly


Q62E2


How much did (name/you) receive (weekly/every other week/ twice a month/ monthly/ ) in (second answer from Q62c or Q62cs1) in 2012?


Enter dollar amount


_______________


Q62E22


How many (weekly/every other week/ twice a month/ monthly) payments did (name/you) receive in (second answer from Q62c or Q62cs1) in 2012?


 Pension/Retirement #2 (1-12; 1-52)


_______________


Q62E2C


Do not read to the respondent.

The annual rate appears out of range. The total (fill from second answer in Q62c or Q62cs1) payments received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q62E23


According to my calculations (name/you) received (total) dollars altogether from (second answer from Q62c or Q62cs1) in 2012. Does that sound about right?


  1. Yes

  2. No



Q62E24


What is your best estimate of the correct amount (name/you) received in (second answer from Q62c or Q62cs1) during 2012?


PREVIOUS ENTRIES:  Q62E2: (amount)
Q62E2P: (periodicity)
Q62E22: (number of pay periods)

Enter dollar amount

_______________


Q62E3P


What is the easiest way for you to tell us (name's/your) (third answer from Q62c or Q62cs1); weekly, every other week, twice a month, monthly, or yearly?


  1. Weekly

  2. Every other week

  3. Twice a month

  4. Monthly

7 Yearly


Q62E3


How much did (name/you) receive (weekly/every other week/ twice a month/ monthly/) in (third answer from Q62c or Q62cs1) in 2012?

 Enter dollar amount


_______________


Q62E32


How many (weekly/every other week/ twice a month/ monthly) payments did (name/you) receive in (third answer from Q62c or Q62cs1) in 2012?


 Pension/Retirement #3 (1-12; 1-52)


_______________


Q62E3C


Do not read to the respondent.

The annual rate appears out of range. The total (fill from third answer in Q62c or Q62cs1) payments received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q62E33


According to my calculations (name/you) received (total) dollars altogether from
(third answer fromQ62c or Q62cs1) in 2012. Does that sound about right?


  1. Yes

  2. No


Q62E34


What is your best estimate of the correct amount (name/you) received in (third answer from Q62c or Q62cs1) during 2012?


 PREVIOUS ENTRIES:  Q62E3: (amount)
Q62E3P: (periodicity)
Q62E32: (number of pay periods)

Enter dollar amount


_______________



INTEREST



Q63A1


At anytime during 2012 did (you/ anyone in this household):

Have money in any kind of money market fund, interest earning checking account, or savings account?


  1. Yes

  2. No


Q63A2


At anytime during 2012 did (you/ anyone in this household):

Have any savings bonds?

  1. Yes

  2. No

Q63A3

At anytime during 2012 did (you/ anyone in this household):

Have any treasury notes, IRAs, certificates of deposit, or any other investments which pay interest?

1 Yes

2 No


Q63b


Ask only if necessary


Which members of this household ages 15 and over had (interest earning accounts or money market funds/savings bonds/treasury notes, IRAs, CDs, or any other investments which pay interest)?


Include each person in cases of joint accounts or ownership

 Enter all that apply, separate using the space bar or a comma.

 Probe: Anyone Else?

 

Enter persons line number (1-16)


Q63c


How much did (name/you) receive in interest from these sources during 2012, including even small amounts reinvested or credited to accounts?

 Only include interest received from U.S. Savings Bonds cashed during 2012

 Separate amounts for joint ownership

If already included in amount reported for another household member, press Enter

Enter dollar amount 


_______________


Q63c_Char


Enter A for "Already Included"


_______________


Q63cp


Read if necessary


Is this a weekly, every other week, twice a month, monthly, quarterly,
every 6 months, or yearly amount?

  1. Weekly

  2. Every other week

  3. Twice a month

  4. Monthly

  5. Quarterly

  6. Every 6 months

  7. Yearly


Q63c2


How many (weekly/ every other week/ twice a month/ monthly/ quarterly/ every 6 months) payments did (name/you) receive in interest income in 2012?


 (1-2; 1-52)


_______________


Q63cC2


Do not read to the respondent.

The annual rate appears out of range. The total interest income received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q63c3


According to my calculations (name/you) received (total) dollars altogether from
interest income in 2012. Does that sound about right?


  1. Yes

  2. No


Q63c4


What is your best estimate of the correct amount (name/you) received from interest payments during 2012?


PREVIOUS ENTRIES: Q63c: (amount)
Q63cp: (periodicity)
Q63c2: (number of pay periods)

 Enter dollar amount


_______________



DIVIDENDS


Q64A


At anytime during 2012 did (anyone in this household ages 15 and over/you) own any shares of stock in corporations (PAUSE) or any mutual fund shares?


  1. Yes

  2. No


Q64b


Ask only if necessary


Which members of this household?


Include each person in case of joint accounts or ownership

Enter all that apply, separate using the space bar or a comma.

Probe: Anyone Else


Enter persons line number (1-16)


Q64c


How much did (name/you) receive in dividends from stocks (or mutual funds) during 2012, including dividends that were reinvested?

 

 Separate amounts for joint ownership

 If already included in amount reported for another household member, press Enter

   Enter "0" for None

   Enter dollar amount


_______________

Q64c_Char


Enter <A> for Already included


_______________


Q64cp


Read if necessary


Is this a weekly, every other week, twice a month, monthly, quarterly,
every 6 months, or yearly amount?

  1. Weekly

  2. Every other week

  3. Twice a month

  4. Monthly

  5. Quarterly

  6. Every 6 months

  7. Yearly


Q64c2


How many (weekly/every other week/ twice a month/ monthly/ quarterly/ every 6 months) payments did (name's/your) receive in dividends from stocks (or mutual funds) in 2012?


(1-2; 1-52)


_______________


Q64cC2


Do not read to the respondent.

The annual rate appears out of range. The total dividend payments received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q64c3


According to my calculations (name/you) received (total) dollars altogether from
dividend payments in 2012. Does that sound about right?


  1. Yes

  2. No

Q64c4


What is your best estimate of the correct amount (name/you) received from dividend payments during 2012?


PREVIOUS ENTRIES: Q64c: (amount)
Q64cp: (periodicity)
Q64c2: (number of pay periods)

Enter dollar amount 


_______________




PROPERTY INCOME


Q65A1


During 2012 did (you/ anyone in this household):

Own any land, business property, apartments, or houses which were rented to others?

  1. Yes

  2. No


Q65A2


At anytime during 2012 did (you/ anyone in this household):

Receive income from royalties or from roomers or boarders? (exclude amounts paid by relatives)


  1. Yes

  2. No


Q65A3


At anytime during 2012 did (you/ anyone in this household):

Receive income from estates or trusts? (exclude estates or trusts already reported)


  1. Yes

  2. No


Q65b


Ask only if necessary


Who received this (income/rent) ?


Include each in cases of joint ownership. For self-employed persons, determine if

income was already included

Enter all that apply, separate using the space bar or a comma.
 Probe: Anyone Else?


Enter persons line number (1-16)


Q65c


How much did (name/you) receive in income from rent (blank /, roomers or boarders, estates, trusts, or royalties/, roomers or boarders, or royalties/, estates or trusts) AFTER EXPENSES during 2012?


 Separate amounts for joint ownership if response is "Broke Even" then enter 1.
   Enter dollar amount

If already included in amount reported for another household member,

or if response is "None",

or if response is "Lost Money"

press <Enter> key

_______________


Q65c_Char


Enter "A" for Already included 

Enter "L" for Lost Money

Enter "X" for None


______________


Q65cL


 Enter amount of money lost in 2012.


_______________


Q65cp


Is this a weekly, every other week, twice a month, monthly, quarterly, or yearly amount?


  1. Weekly

  2. Every other week

  3. Twice a month

  4. Monthly

  5. Quarterly

7 Yearly


Q65c2


What is your best estimate of (name's/your) ANNUAL net income from rent (blank/, roomers or boarders, estates, trusts, or royalties/, roomers or boarders, or royalties/, estates or trusts) AFTER EXPENSES in 2012?


 PREVIOUS ENTRIES:  Q65c: (amount)
  Q65cp: (periodicity)

 Enter dollar amount


_______________


Q65cC2


Do not read to the respondent.

The annual rate appears out of range. The total income received from rent ( /roomers or boarders, estates, trusts, or royalties) was (amount) in 2012. Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q65c2L


What is your best estimate of (name’s/your) ANNUAL LOSS from rent (blank/, roomers or boarders, estates, trusts, or royalties/, roomers or boarders, or royalties/, estates or trusts) AFTER EXPENSES in 2012?


 PREVIOUS ENTRIES:  Q65cL: (amount)
  Q65cp: (periodicity)

Enter dollar amount 


_______________

EDUCATION ASSISTANCE


Q66a


During 2012 did (you/ anyone in this household) attend school beyond the high school level including a college, university, or other schools? 

(include vocational, business, or trade schools)


  1. Yes

  2. No


Q66b


Did (you/ anyone in this household) receive any educational assistance for tuition, fees, books, or living expenses during 2012?


 Exclude loans, assistance from household members, and VA educational benefits


  1. Yes

  2. No


Q66c


 Ask only if necessary


Which member received assistance?


Enter all that apply, separate using the space bar or a comma.

Probe: Anyone Else? 


Enter persons line number (1-16)


Q66d


What type of assistance did (name/you) receive?


Exclude assistance from household members

Enter all that apply, separate using the space bar or a comma.

 Probe: Any other assistance?


  1. Pell Grant

  2. Assistance from a welfare or social service office

  3. Some other government assistance

  4. Scholarships, grants, etc.

  5. Other assistance (employers, friends, etc.)

Q69F88


How much did (name/you) receive in Pell Grants during 2012?


Enter annual amount only


________________


Q66HP


What is the easiest way for you to tell us (name's/your) (other/blank ) educational assistance during 2012; weekly, every other week, twice a month, monthly, or yearly?


  1. Weekly

  2. Every other week (bi-weekly)

  3. Twice a month

  4. Monthly

7 Yearly


Q66H


(blank/Aside from the Pell Grant assistance,) (How/how) much did (name/you) receive (weekly/every other week/ twice a month/ monthly/ ) in educational assistance during 2012? 


Enter dollar amount


________________


Q66H2


How many (weekly/every other week/ twice a month/ monthly) payments did (name/you) receive in educational assistance in 2012?


(1-12/1-24/1-26/1-52)


________________


Q66hC2


Do not read to the respondent.

The annual rate appears out of range. The total educational assistance received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.




Q66H3


According to my calculations (name/you) received (total) altogether from educational assistance in 2012. Does that sound about right?


  1. Yes

  2. No


Q66H4


What is your best estimate of the correct amount (name/you) received from educational assistance during 2012?


 Previous entries: Q66h: (amount)

Q66hp: (periodicity)
  Q66h2: (number of pay periods)

Enter dollar amount


________________




CHILD SUPPORT AND ALIMONY


Q70a


During 2012 did (you/ anyone in this household) receive:

Any child support payments?


  1. Yes

  2. No


Q70b


 Read only if necessary


Who received these payments?


Enter all that apply, separate using the space bar or a comma.

Probe: Anyone Else? 


Enter persons line number (1-16)


Q70cp


What is the easiest way for you to tell us (name's/your) child support payments;

weekly, every other week, twice a month, monthly, or yearly?

  1. Weekly

  2. Every other week (bi-weekly)

  3. Twice a month

  4. Monthly

7 Yearly


Q70c


How much did (name/you) receive (weekly/ every other week/ twice a month/ monthly/ ) in child support payments in 2012?


Enter dollar amount 


________________


Q70c2


How many (weekly/every other week/ twice a month/ monthly) child support payments did (name/you) receive in 2012?


 (1-12/1-24/1-26/1-52)


________________


Q70cC2


Do not read to the respondent.

The annual rate appears out of range. The total child support payments received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q70c3


According to my calculations (name/you) received (total) altogether from child support payments in 2012. Does that sound about right?


  1. Yes

  2. No


Q70c4


What is your best estimate of the correct amount (name/you) received from child support payments during 2012?


PREVIOUS ENTRIES: Q70c: (amount)
  Q70cp: (periodicity)
  Q70c2: (number of pay periods)

Enter dollar amount

________________


Q71a

During 2012 did (you/ anyone in this household) receive:

Any alimony payments?


  1. Yes

  2. No


Q71b


Read only if necessary


Who received these payments during 2012?


Enter all that apply, separate using the space bar or a comma.

Probe: Anyone Else?


Enter persons line number (1-16)


Q71cp


What is the easiest way for you to tell us (name's/your) alimony payments;

weekly, every other week, twice a month, monthly, or yearly?

  1. Weekly

  2. Every other week (bi-weekly)

  3. Twice a month

  4. Monthly

7 Yearly


Q71c


How much did (name/you) receive (weekly/every other week/ twice a month/ monthly/ ) in alimony payments in 2012?


Enter dollar amount 


________________


Q71c2


How many (weekly/every other week/ twice a month/ monthly) alimony payments did (name/you) receive in 2012?


(1-12/1-24/1-26/1-52)


________________


Q71cC2


Do not read to the respondent.

The annual rate appears out of range. The total alimony payments received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q71c3


According to my calculations (name/you) received (total) altogether from alimony payments in 2012. Does that sound about right?


  1. Yes

  2. No


Q71c4


What is your best estimate of the correct amount (name/you) received from alimony payments during 2012?


PREVIOUS ENTRIES:  Q71c: (amount)
Q71cp: (periodicity)
Q71c2: (number of pay periods)

 Enter dollar amount

________________

REGULAR FINANCIAL ASSISTANCE


Q72a


During 2012 did (you/ anyone in this household) receive:

(Any other/Any) regular financial assistance from friends

or relatives not living in this household?


Do not include loans


  1. Yes

  2. No


Q72b


Read only if necessary


Who received this assistance?

Enter all that apply, separate using the space bar or a comma.

Probe: Anyone Else?


Enter persons line number (1-16)


Q72cp


What is the easiest way for you to tell us (name's/your) regular financial assistance;

weekly, every other week, twice a month, monthly, or yearly?


  1. Weekly

  2. Every other week (bi-weekly)

  3. Twice a month

  4. Monthly

7 Yearly


Q72c


How much did (name/you) receive (weekly/ every other week/ twice a month/ monthly/ ) in regular financial assistance in 2012?


 Enter dollar amount


________________

Q72c2


How many (weekly/every other week/twice a month/monthly) payments did (name/you) receive in regular financial assistance in 2012?


(1-12/1-24/1-26/1-52)


_______________


Q72cC2


Do not read to the respondent.

The annual rate appears out of range. The total regular financial assistance payments received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q72c3


According to my calculations (name/you) received (total) altogether from regular financial assistance in 2012. Does that sound about right?


  1. Yes

  2. No


Q72c4


What is your best estimate of the correct amount (name/you) received from regular financial assistance during 2012?


PREVIOUS ENTRIES:  Q72c: (amount)
Q72cp: (periodicity)
Q72c2: (number of pay periods)


________________

OTHER MONEY INCOME

Q73A1


During 2012 did (you/ anyone in this household) receive income from:

Hobbies, home businesses, farms, or business interests not already covered?


  1. Yes

  2. No


Q73A1b


Ask only if necessary


Who received this income?


Enter all that apply, separate using the space bar or a comma.

Probe: Anyone Else?


Enter persons line number (1-16)


Q73A1c


What was the source of this income?


 Asking about: (name/you) (name/name- -CURRENT RESPONDENT)


_________________________________________________


Q731P


What is the easiest way for you to tell us (name's/your) income from hobbies, home businesses, farms, or business interests not already covered during 2012;

weekly, every other week, twice a month, monthly, or yearly?


  1. Weekly

  2. Every other week (bi-weekly)

  3. Twice a month

  4. Monthly

7 Yearly

Q731


How much did (name/you) receive (weekly/ every other week/ twice a month/ monthly/ ) in income from hobbies, home businesses, farms, or business interests not already covered during 2012?


 Enter dollar amount


________________



Q7312


How many (weekly/every other week/ twice a month/ monthly) payments did (name/you) receive in income from hobbies, home businesses, farms, or business interests not already covered in 2012?


 (1-12/1-24/1-26/1-52)


________________



Q731C2


Do not read to the respondent.

The annual rate appears out of range. The total income from hobbies, home businesses, farms, or business interests not already covered in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.



Q7313


According to my calculations (name/you) received (total) altogether from hobbies, home businesses, farms, or business interests not already covered in 2012.

Does that sound about right?


  1. Yes

  2. No

Q7314


What is your best estimate of the correct amount (name/you) received in income from hobbies, home businesses, farms, or business interests not already covered during 2012?


PREVIOUS ENTRIES: Q731: (amount)
Q731P: (periodicity)
Q7312: (number of pay periods)

Enter dollar amount 

________________


Q73A2


During 2012 did (you/ anyone in this household) receive income from:

Any severance pay, welfare, emergency assistance, other short-term cash assistance, foster child care payments, or any other money income not already covered?


  1. Yes

  2. No


Q73A2b


Ask only if necessary


Who received this income?


Enter all that apply, separate using the space bar or a comma.

Probe: Anyone Else?


Enter persons line number (1-16)



Q73A2c


What was the source of this income?


Asking about: (name/you) (name/name- -CURRENT RESPONDENT)


_________________________________________________


Q732P


What is the easiest way for you to tell us (name's/your) income from any severance pay, welfare, emergency assistance, other short-term cash assistance, foster child care payments, or any other money income not already covered during 2012; weekly, every other week, twice a month, monthly, or yearly?

  1. Weekly

  2. Every other week (bi-weekly)

  3. Twice a month

  4. Monthly

7 Yearly


Q732


How much did (name/you) receive (weekly/ every other week/ twice a month/ monthly/ ) in income from any severance pay, welfare, emergency assistance,

other short-term cash assistance, foster child care payments, or any other money I income not already covered during 2012?

Enter dollar amount 


________________


Q7322


How many (weekly/every other week/ twice a month/monthly) payments did (name/you) receive in income from any severance pay, welfare, emergency assistance, other short-term cash assistance, foster child care payments, or any other money income not already covered during 2012?


 (1-12/1-24/1-26/1-52)


________________


Q732C2


Do not read to the respondent.

The annual rate appears out of range. The total income from any severance pay, welfare, emergency assistance, other short-term cash assistance, foster child care payments, or any other money not already covered in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.

Q7323


According to my calculations (name/you) received (total) altogether from any severance pay, welfare, emergency assistance, other short-term cash assistance, foster child care payments, or any other money income not already covered during 2012. Does that sound about right?


  1. Yes

  2. No


Q7324


What is your best estimate of the correct amount (name/you) received in income from any severance pay, welfare, emergency assistance, other short-term cash assistance, foster child care payments, or any other money income not already covered during 2012?


PREVIOUS ENTRIES:  Q732: (amount)
  Q732P: (periodicity)
  Q7322: (number of pay periods)

Enter dollar amount 


________________



HEALTH INSURANCE


SHI1


These next questions are about health insurance coverage during the calendar year 2012. The questions apply to ALL persons of ALL ages.


Enter 1 to Continue


SHI2


At any time in 2012, (was/were) (you/ anyone in this household) covered by a health insurance plan provided through (their/your) current or former employer or union?


 Military health insurance will be covered later in another question.


  1. Yes

  2. No

SHI3


Who in this household were policyholders?


 Enter all that apply, separate using the space bar or a comma.

 Probe: Anyone Else?

 

Enter persons line number (1-16)


SHI4


In addition to (name/you) who else in this household was covered by (name’s/your) plan?


 Enter all that apply, separate using the space bar or a comma.
 Enter 0 if no one listed
 Enter 96 for All persons

Probe: Anyone else?


Enter persons line number (1-16)


SHI5


Did (name’s/your) plan cover anyone living outside this household?


  1. Yes

  2. No


SHI6


Did (name’s/your) former or current employer or union pay for all, part, or none of the health insurance premium?


 NOTE: Report here employer's contribution to employee's health insurance premiums, not the employee's medical bills.

  1. All

  2. Part

  3. None


SHI7


At any time during 2012, (was/were) (you/ anyone in this household) covered by a health insurance plan that (you/they) PURCHASED DIRECTLY FROM AN INSURANCE COMPANY, that is, not related to current or past employment?

  1. Yes

  2. No


SHI8


Who in this household were policyholders?


 Enter all that apply, separate using the space bar or a comma.

 Probe: Anyone Else?

 

Enter persons line number (1-16)


SHI9


In addition to (name/you) who else in this household was covered by

(name’s/your) plan?


 Enter all that apply, separate using the space bar or a comma.
 Enter 0 if None listed
 Enter 96 for All persons
 Probe: Anyone else?


Enter persons line number (1-16)


SHI10


Did (name’s/your) plan cover anyone living outside this household?


  1. Yes

  2. No


SHI11


At any time in 2012, (was/were) (you/ anyone in this household) covered by the health insurance plan of someone who does not live in this household?


  1. Yes

  2. No


SHI12


Who was that?


 Enter all that apply, separate using the space bar or a comma.

 Probe: Anyone Else?


Enter persons line number (1-16)


SHI13


At any time in 2012, (was/were) (you/ anyone in this household) covered by Medicare?


Read if necessary: Medicare is the health insurance for persons 65 years old and over OR persons with disabilities.


  1. Yes

  2. No


SHI14


Who was that?


 Enter all that apply, separate using the space bar or a comma.

 Probe: Anyone Else?


Enter persons line number (1-16)


SHI15


At any time in 2012, (was/were) (you/ anyone in this household) covered by Medicaid / (fill state name)?


Read if necessary: Medicaid / (fill state name) is the Government Assistance Program that pays for health care.


  1. Yes

  2. No


SHI16


Who was that?


 Enter all that apply, separate using the space bar or a comma.

 Probe: Anyone Else?


Enter persons line number (1-16)


SHI17


How many months during 2012, (was/were) (name/you) covered by Medicaid/(fill state name)?


 Enter number of months (1-12)


_______________


SHI21


In (state), the (fill state CHIP program name) helps families get health insurance for CHILDREN. (Just to be sure,) Were any of the children in this household covered by that program?


Read if necessary: (fill state CHIP program name) is the name of your state's CHIP program. It is the same as the Children's Health Insurance Program, which helps pay for children's health care.


  1. Yes

  2. No


SHI22


Who was that?


 Enter all that apply, separate using the space bar or a comma.


 Probe: Anyone Else?


Enter persons line number (1-16)


SHI18


At any time in, 2012 (was/were) (you/ anyone in this household) covered by TRICARE, CHAMPVA, VA, military health care, or Indian Health Service?


 NOTE: CHAMPVA is the Civilian Health And Medical Program of the Department of Veteran's Affairs.


  1. Yes

  2. No


SHI19


Who was that?


 Enter all that apply, separate using the space bar or a comma.

 Probe: Anyone Else?

 

Enter persons line number (1-16)


SHI20


What plan (was/were) (name/you) covered by?


Enter all that apply, separate using the space bar or a comma.

Probe: Any Other Plan?


  1. TRICARE

  2. CHAMPVA

  3. VA

  4. Indian Health Service

  5. Other


SHI20s


 Enter other type of plan


_______________


SHIC1


Other than the plans I have already talked about, during 2012, was anyone in this household covered by a health insurance plan [such as the (state-specific name plan) or any other type of plan/of any other type]?

  1. Yes

  2. No


SHIC2


Who has insurance?


 Enter all that apply, separate using the space bar or a comma.

 Probe: Anyone Else?


Enter persons line number (1-16)


SHIC3


What type of health insurance (was/were) (name/you) covered by in 2012?


 Up to six entries allowed

 Probe: Any Other Type Of Plan?


  1. Medicare

  2. Medicaid

  3. TRICARE

  4. CHAMPVA (CHAMPVA IS THE CIVILIAN HEALTH AND MEDICAL

PROGRAM OF THE DEPARTMENT OF VETERAN\'S AFFAIRS)

  1. VA

  2. Military Health Care

  3. Children\'s Health Insurance Program (CHIP)

  4. Indian Health Service

  5. Other government health care

  6. Employer/union provided (policyholder)

  7. Employer/union provided (as dependent)

  8. Privately purchased (policyholder)

  9. Privately purchased (as dependent)

  10. Plan of someone outside the household

  11. Other


SHIC3s


Enter other type of plan

_____________________________________________


SHIC4


I have recorded that (you/read list of names) (were/was) not covered by a health plan at any time during 2012. Is that correct?


  1. Yes

  2. No


SHIC4A


Who should be marked as covered?


 Enter all that apply, separate using the space bar or a comma.

 Probe: Anyone Else?


Enter persons line number (1-16)


SHIC6


What type of health insurance (was/were) (name/you) covered by in 2012?


 Up to six entries allowed

Probe: Any other type of plan?


  1. Medicare

  2. Medicaid

  3. TRICARE

  4. CHAMPVA (CHAMPVA IS THE CIVILIAN HEALTH AND MEDICAL

PROGRAM OF THE DEPARTMENT OF VETERAN\'S AFFAIRS)

  1. VA

  2. Military Health Care

  3. Children\'s Health Insurance Program (CHIP)

  4. Indian Health Service

  5. Other government health care

  6. Employer/union provided (policyholder)

  7. Employer/union provided (as dependent)

  8. Privately purchased (policyholder)

  9. Privately purchased (as dependent)

  10. Plan of someone outside the household

  11. Other


SHIC6s


Enter other type of health insurance covered by in 2012

_____________________________________________




SHI24


An important factor in evaluating a person's or family's health insurance situation is their current health status and/or the current health status of other family members.


Enter 1 to Continue


SHI25


Would you say (name's/your) health in general is excellent, very good, good, fair, or poor?


  1. Excellent

  2. Very good

  3. Good

  4. Fair

  5. Poor



MEDICAL EXPENDITURES


HIPREM

During 2012, about how much did (name/you) pay for health insurance premiums for (yourself/himself/herself) or others in the household, after any reimbursements?


Please include premiums paid for HMOs, Fee for Service Plans,
Commercial Medicare Supplements, or other special purpose plans,
such as vision or dental plans.  Include prescription drug insurance
such as medicare Part D premiums,and Medicare Advantage premiums. 
DO NOT include Medicare Part B premiums.

 Enter dollar amount


________________

OTCMEDAMT

During 2012, about how much was paid for (name/you) for over-the-counter health related products such as aspirin, cold remedies, bandages, first aid supplies, and other items?

Include any amount paid on (your/his/her) behalf by anyone in this household, that was not reimbursed.

 Enter dollar amount

________________

MEDAMT

Aside from over-the-counter items, during 2012, about how much was paid for (name's/your) own medical care, including payments and co-payments for hospital visits, medical providers, dental services, prescription medicine, vision aids, and medical supplies?

Include any amount paid on (your/his/her) behalf by anyone in this household, that was not reimbursed.

 Enter dollar amount


________________


COTCAMT

How about (name)?

During 2012, about how much was paid for (name) for over-the-counter health related products such as aspirin, cold remedies, bandages, first aid supplies, and other items?

Include only amounts paid that were not reimbursed.

 Enter dollar amount


________________

CMEDAMT


Aside from over-the-counter items, during 2012, about how much was paid for (name's) own medical care, including payments and co-payments for hospital visits, medical providers, dental services, prescription medicine, vision aids, and medical supplies?


Include only amounts paid that were not reimbursed.

 Enter dollar amount


________________






EMPLOYER’S PENSION PLAN

Q74a


Other than Social Security did (ANY) employer or union that (name/you) worked for in 2012 have a pension or other type of retirement plan for any of its employees?


  1. Yes

  2. No


Q74b


(Were/Was) (name/you) included in that plan?

  1. Yes

  2. No


SCHOOL LUNCHES


Q80


During 2012 which of the children ages 5 to 18 in this household usually ate a complete lunch offered at school?

Probe: Anyone else?

Enter all that apply, separate using the space bar or a comma.

Enter 96 for All

Enter 0 for None


Enter persons line number (1-16)



Q83


During 2012 which of the children in this household received free or reduced priced lunches because they qualified for the Federal School Lunch Program?


  Probe: Anyone else?

  Enter all that apply, separate using the space bar or a comma.

  Enter 96 for All

  Enter 0 for None

 

Enter persons line number (1-16)





PUBLIC HOUSING


Q85


Is this public housing, that is, is it owned by a local housing authority or other public agency?


  1. Yes

  2. No


Q86


Are you paying lower rent because the Federal, State, or local government is paying part of the cost?


  1. Yes

  2. No


SPHS8


Is this through Section 8 or through some other government program?


  1. Section 8

  2. Some other government program

  3. Not sure




















FOOD STAMPS/SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)


Q87


Did (you/ anyone in this household) get SNAP (Supplemental Nutrition Assistance Program), food stamps or a food stamp benefit card at any time during 2012?


Do not include WIC benefits.


  1. Yes

  2. No


Q87a


At any time during 2012, even for one month, did (you/ anyone in this household)
receive any food assistance from (State Program name) or a food assistance benefit card (such as State EBT card name)?


Do not include WIC benefits.


  1. Yes

  2. No


Q88


Which of the people now living here were covered by that food assistance

during 2012?


List all household members covered by food assistance regardless of age

   Enter all that apply, separate using the space bar or a comma.

   Enter 96 for All

   Enter 0 for None

   Probe: Anyone else?


Enter persons line number (1-16)


Q90p


What is the easiest way for you to tell us the value of the food assistance:

monthly or yearly?


  1. Monthly

  2. Yearly

  3. Already included with TANF/AFDC payment


Q90

What is the (monthly/ ) value of the food assistance received in 2012?

Enter dollar amount

Q902


How many months was food assistance received in 2012?


 (1-12)


________________



Q90C2


Do not read to the respondent.

The annual rate appears out of range. The total food assistance payments received in 2012 was (amount). Is this a correct entry? If Yes, enter "S" to Suppress. If No, press enter and correct entry.


Q903


According to my calculations (total) was received altogether from food assistance in 2012. Does that sound about right?


  1. Yes

  2. No


Q904


What is your best estimate of the correct amount of food assistance received

during 2012?


PREVIOUS ENTRIES: Q90: (amount)
  Q90p: (periodicity)
Q902: (number of pay periods)

Enter dollar amount 

________________


SWRWIC


At any time during 2012, (was/were) (you/ anyone in this household) on WIC, the Women, Infants, and Children Nutrition Program?


  1. Yes

  2. No





SWRW


Who received WIC for themselves or on behalf of a child?


 Enter all that apply, separate using the space bar or a comma.

Probe: Anyone else?


Enter persons line number (1-16)



ENERGY ASSISTANCE


Q93


The government has an energy assistance program which helps pay heating and cooling costs. This assistance can be received directly by the household or it can be paid directly to the electric company, gas company, or fuel dealer.


In 2012, (have you/has this household) received assistance of this type from the federal, state, or local government?


  1. Yes

  2. No


Q93pr1


Do you remember receiving an additional or unexpected check that was sent during the year to help pay heating or cooling costs?


  1. Yes

  2. No


Q93pr2


Was it used to pay heating or cooling costs?


  1. Yes

  2. No


Q94


Altogether, how much energy assistance has been received in 2012?


Enter annual amount only



MIGRATION


MIGSAM


(Were/Was) (reference person's name/you) living in this house (or apartment) one year ago?


  1. Yes, this house (apt)

  2. No, different house in U.S.

  3. No, outside the U.S.


MIGPLC


Where did (reference person's name/you) live one year ago?


Name of city/town/post office

 Current: (city)
 Enter correct city/town/post office or press ENTER for SAME


_______________

MIGSTA


?[F1]


Where did (reference person's name/you) live one year ago?


 Name of State

 Current: (state)
 Enter W for person living on a ship at sea
 Enter correct State or press ENTER for SAME


_______________


MIGZIP


Where did (reference person's name/you) live one year ago?


  Zip Code
 Current: (zip)
   Enter correct Zip Code or press ENTER for SAME

_______________







MIGCLM


Did (reference person's name/you) live inside the city limits of (place name)?


  1. Yes, inside city limits

  2. No, outside city limits or post office name only


MIGCOU


What (county/parish) is (place name) in? 


 Enter "IND CITY" if an independent city, not a county


_____________________________________________



S_MIGCN1


What country did (reference person's name/you) live in one year ago?


MI1RES


What was [your/name’s] main reason for moving to this house (apartment)?


 The answer categories are separated into the following groups:

FAMILY-RELATED REASONS 1-3

EMPLOYMENT-RELATED REASONS 4-8

HOUSING-RELATED REASONS 9-13

OTHER REASONS 14-18


  1. change in marital status

  2. to establish own household

  3. other family reason

  4. new job or job transfer

  5. to look for work or lost job

  6. to be closer to work/easier commute

  7. retired

  8. other job-related reason

  9. wanted to own home, not rent

  10. wanted new or better house/ apartment

  11. wanted better neighborhood/less crime

  12. wanted cheaper housing

  13. foreclosure/eviction

  14. other housing reason

  15. to attend or leave college

  16. change of climate

  17. health reasons

  18. natural disaster (hurricane, tornado, etc.)

  19. other reason (specify)

MI1s


What was the reason for moving?


_____________________________________________


MIGALL


(There are (number) other persons in this household ages 1 year or over/ ) 
Did (all of these persons/this person) live with (reference person's name/you) (in this house/in City, State/outside the U.S.) one year ago? 



  1. Yes, all lived with (reference person's name/you)

  2. No, some or all did not live with (reference person's name/you)


MIGM


Which of the other members of this household did NOT live with (reference person's name/you) one year ago?


 PROBE: Anyone else?

 Enter all that apply, separate using the space bar or a comma.


Enter persons line number (1-16)


NXTSAM


Did (name/you) live in this house (apartment) one year ago?


  1. Yes , this house

  2. No, different house in U.S.

  3. No, outside the U.S.


NXTPLC


Where did (name/you) live one year ago?


 Name of city/town/post office 

 Current: (city) Enter correct city/town/post office or

 Press ENTER for SAME


_____________________________________________


NXTSTA


?[F1]


Where did (name/you) live one year ago?


 Name of State
   Current: (state)
   Enter correct State or press ENTER for SAME

_____________________________________________


NXTZIP


Where did (name/you) live one year ago?


Zip Code Current: (zip) 

Enter correct zip code or

Press ENTER for SAME


_______________


NXTCLM

Did (name/you) live inside the city limits of (place name)?


  1. Yes, inside city limits

  2. No, outside city limits or post office name only


NXTCOU


What (county/parish) is (place name) in?


Enter "IND CITY" if an independent city, not a county


_____________________________________________


S_NXTCN1


What country did (name/you) live in one year ago?



NX1RES


What was (name’s/your) main reason for moving to this house (apartment)?


 The answer categories are separated into the following groups:

FAMILY-RELATED REASONS 1-3

EMPLOYMENT-RELATED REASONS 4-8

HOUSING-RELATED REASONS 9-13

OTHER REASONS 14-18


  1. change in marital status

  2. to establish own household

  3. other family reason

  4. new job or job transfer

  5. to look for work or lost job

  6. to be closer to work/easier commute

  7. retired

  8. other job-related reason

  9. wanted to own home, not rent

  10. wanted new or better house/ apartment

  11. wanted better neighborhood/less crime

  12. wanted cheaper housing

  13. foreclosure/eviction

  14. other housing reason

  15. to attend or leave college

  16. change of climate

  17. health reasons

  18. natural disaster (hurricane, tornado, etc.)

  19. other reason (specify)


NX1OTH


What was the reason for moving?


_____________________________________________


SUNITS


Ask if necessary


How many housing units are in your building?


  1. Only one

  2. Two

  3. Three or four

  4. Five to nine

  5. Ten or more

PROPERTY VALUE/PRESENCE OF MORTGAGE

VALPROP

About how much do you think this (house and lot/apartment/mobile home)
would sell for if it were for sale?

  Enter dollar amount


________________


MORTYN

Not counting home equity loans, do you or any other member of this household have a mortgage, deed of trust, contract to purchase, or similar debt on THIS property?

1 Yes

2 No

SMORTYN

Do you or any member of this household have a second mortgage or a home equity loan on THIS property?

1 Yes, home equity loan.

2 Yes, second mortgage.

3 Yes, second mortgage and home equity loan.

4 No


CHILD CARE


Q95


Now we want to ask about some of your expenses for children.


Did (you/ anyone in this household) PAY for the care of (your/their) (child/children) while (you/they) worked in 2012?


Include: All child care expenses including preschool and nursery school expenses,
before and after school care, and summer care.
Do not include: cost of kindergarten or grade/elementary school.

  1. Yes

  2. No




Q95A


Which children needed care while their parents worked?


 Enter all that apply, separate using the space bar or a comma.

Probe: Anyone else?

Enter 96 for All persons


Enter persons line number (1-16)


CCFREQ

What is the easiest way for you to tell us how much (you/you and others in this household) paid for child care while (you/they) worked in 2012: weekly, every other week, twice a month, monthly, or yearly?

1 Weekly

2 Every other week

3 Twice a month

4 Monthly

7 Yearly

CCAMT

How much did (you/they) pay for child care?

 Include child care payments made for all children in the household.

 For example, if there are two adults in the household with childcare
expenses use the total paid by both adults.  Do not try to separate
the payments. Record one total for the entire household.


________________

CCNUMPAY

How many (weekly/every other week/twice a month/monthly) payments did (you/they) make during 2012?


________________

CCTOT

Then (you/they) paid (total dollar amount) altogether in child care while (you/they) worked during 2012.  Does that sound about right?

1 Yes

2 No

CCEST

What is your best estimate of the correct amount (you/they) paid for child care while (you/they) worked in 2012?


________________

CHILD SUPPORT PAID

CSPCHILD

Does anyone in this household have any children who lived elsewhere with their other parent or guardian at anytime during 2012?

1 Yes

2 No

CSPWHO

 

Who had children who lived elsewhere? Anyone else?

   Enter line number
  Enter all that apply, separate using the space bar or a comma.


________________

 

CSPREQ

In 2012, (were/was) (name/you) required to pay child support? 

1 Yes

2 No

CSPAMT

How much child support did (name/you) pay in 2012?

  Enter dollar amount

  COUNT ALL FORMS OF CHILD SUPPORTS PAYMENTS, INCLUDING:
...PAYMETNS MADE DIRECTLY TO THE OTHER PARENT/GUARDIAN;
...PAYMENTS MADE THROUGH A COURT OR AGENCY; AND
...PAYMENTS WITHHELD FROM THIS PERSON'S PAYCHECK


________________


0


File Typeapplication/msword
File Title2007 ASEC Items Booklet
Last Modified Bypaska001
File Modified2012-10-12
File Created2012-10-11
© 2024 OMB.report | Privacy Policy