Household Interview

OMB #: 2528-0203

FY 2013 Household Questionnaire

Quality Control for Rental Assistance Subsidy Determinations

HUD Contract #: GS-23F-9777H

Task Order #: DU208WP-13-T-00002

ICF International

11785 Beltsville Drive

Calverton, MD 20705-3119

Updated October 18, 2013

Notes to Reader:

1. This document has been designed to portray the automated questionnaire used to interview the tenant during the household interview. It is not designed to be used as a paper data collection instrument. All household interviews for the HUDQC studies are conducted using laptop computers.

2. Explanation of fonts used:

   1. ALL CAPS NON-BOLD font are used for instructions to the Field Interviewrs.

   2. Small Caps and Bold font are used for section titles.

   3. Sentence case non-bold fonts are used for actual question texts that the Field Interviewers read verbatim.

   4. Sentence case, bold and slightly smaller font are prepolulated data or selections that appear on the screen.

   5. ALL CAPS BOLD font are used to denote logics and skip patterns built into the software.

   6. (ALL CAPS, BLUE, & IN PARENTHESIS) fonts are used to indicate the field name in the software.

3. Items in tables are the selection options provided for the respective questions.

4. Verification for all items will be requested during the Household Interview. Depending on the item, they may be requested after questions about individual items have been asked, or after specific sections have been completed. Whenever the verification questions are asked in the software, it will be denoted by: VERIFICATION SCREEN in this transcript.

In each VERIFICATION SCREEN, the Field Interviewer will be prompted to say: “Please provide a document that shows the name, address and phone number of the organization (or person) that we can contact if we need to verify the information you just told me about.”

If the tenant provides appropriate documents to verify the information, the name, address, and phone number of the individual or institution will be abstracted from the document provided, and the document will be scanned. The only exception to this rule have to do with verification of Social Security Number, Date of Birth, and Citizenship Status. These items will only be verified during the household interview if there are no verification documents found in the tenant file during data abstraction. If they do need to be verified during the household interview, the Field Interviewer will review the document, enter the information from the document into the software, and indicate the type of document that was provided. The Field Interviewers will not scan verification documents for these three items. The logic behind the verification screen and a template of the VERIFICATION SCREEN is available in Exhibit 1 and Exhibit 2 at the end of this document).

If the tenant has no document to verify the information, the Field Interviewer will be prompted to ask: “Please tell me the name, address and phone number of the person who can verify this information."

5. The Quality Control Month (QCM) is the month and year for which data are collected. The QCM is used in conducting the household interview—all information requested from the tenant is as of the QCM. The QCM is based on the rent calculation date, the effective date and type of action.

BEFORE BEGINNING THE INTERVIEW, READ THE CONSENT TO INTERVIEW FORM TO THE TENANT AND SIGN IT.

ONCE YOU HAVE READ THE CONSENT TO INTERVIEW FORM TO THE TENANT AND SIGNED IT, PRESS ANY KEY TO BEGIN THE INTERVIEW.

SELECT THE HOUSEHOLD MEMBER WHO IS RESPONDING TO THE HOUSEHOLD QUESTIONNAIRE. IF THE RESPONDENT’S NAME IS NOT ON THE LIST, SELECT “OTHER.”

A. Background

System will prepopulate: Cluster: __ __ Project:__ __ __ Case: __ __

Quality Control Month [QCM]: ___ ___/___ ___ ___ ___

Date of Visit (MM/DD/YYYY): __ __/___ ___/___ ___ ___ ___

Time Interview Begins: ___ ___:___ ___

Respondent Line Number: ____ (HRESP)

Other Interviewee Name and Relationship: ______________________________(HINTOTHER)

All of the questions I will be asking you are about your situation in [QCM]. It may be that things have changed since then, but I am interested in knowing only about your situation in [QCM].

First, I’d like to ask you some questions about each of the people who lived in your household during [QCM].

PRESS ENTER TO CONTINUE

B. Household Composition

1. Let’s start with the head of the household. Who is the head of this household? (HB1)

	Line of household member
1	(name of first member)
	Each member is listed in the order they were recorded on the 50058/59
	Other

CHECK [HH MEMBER’S] STATUS IN [QCM]. (HB2)

	Status compared with forms 58/59
L	Listed on form 58/59
N	New member
Z	Not in household in QCM

IF HHM 1 SKIP TO Q. 5.(HB4S)

IF HHM’S 2, 3, ETC. WHO ARE LISTED ON THE 50058/50059, SKIP TO Q. 4 (HB4)

IF THE MEMBER IS NOT ON THE LIST, SELECT ‘OTHER’, AND PROCEED BY ENTERING THE REQUESTED INFORMATION.

IF HH MEMBER IS LISTED ON THE 50058/59 AND STATUS = Z, SKIP TO Q.19 (HB12AM)

2. What is his/her name? (HB1)

   	Line of household member
   1	(name of first member)
   	Each member is listed in the order they were recorded on the 50058/59
   	Other

3. CHECK [HH MEMBER’S] STATUS IN [QCM]. (HB2)

	Status compared with forms 58/59
L	Listed on form 58/59
N	New member
Z	Not in household in QCM

IF STATUS = N, ENTER THE NEW MEMBER’S NAME (HB3)

4. What is [hh member’s] relationship to [you/head of household]? (HB4)

* PROBE: IF THE RESPONSE DOES NOT CLEARLY MATCH ONE OF THE LISTED OPTIONS; THEN ASK THE TENANT IF THE RELATIONSHIP FITS ANY OF THEM

	Relationship to head
A	Other adult
E	Full time student 18 and over
F	Foster child/foster adult
H	Head of household
K	Co-head
L	Live-in aide
S	Spouse
Y	Youth under 18

IF RELATIONSHIP CODE = L, SKIP TO Q. 14. (HB14)
IF RELATIONSHIP = Y, SKIP TO Q. 7. (HB5M)

5. Were you/Was [hh member] attending school in [QCM]? (HB4S)

IF YES, Confirm whether a part time of full time student.

	Student status
0	Not a student
1	F-T student
2	P-T student

IF NOT A STUDENT, SKIP TO Q.7.(HB5M)

6. May I see a document that supports [your/hh member’s] school attendance in [QCM]? (HB4SV)

	Verification code for student
0	None
1	Letter from the registrar’s office or school official
2	School enrollment documents
3	Verbal info. from the registrar’s office or school official
4	Other

VERIFICATION SCREEN

7. What is his/her/your birthday? ENTER MM/DD/YYYY (HB5M/D/Y)

IF THE DAY IS NOT CLEAR THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END – 28, 30, OR 31).

8. IF DATE OF BIRTH IS NOT ALREADY VERIFIED WITH ACCEPTABLE VERIFICATION, ASK: May I see a document that supports your/[hh member’s] date of birth? (HB5V)

   	Date of birth verification
   0	None
   1	Birth Certificate
   2	Driver’s License
   3	(Age 62 or older) Letter from SSI /SSA
   4	Baptismal certificate
   5	Census record
   6	Military ID
   7	(Under age of 18) Adoption Paper or Custody Agreement
   8	USCIS Permanent Resident Card
   9	Other official document

9. Are you/Is [hh member] a United States citizen? (HB6)

	United states citizen
N	No
Y	Yes
Z	Don’t Know

IF NO or DON’T KNOW, SKIP TO Q. 11. (HB7)

10. IF CITIZENSHIP IS NOT ALREADY VERIFIED WITH ACCEPTABLE VERIFICATION, ASK: May I see a document that supports your/[hh member’s] citizenship status? (HB8V)

	Citizenship verification
0	None
1	Birth Certificate
2	Voter’s Registration
3	Copy of US Passport
4	Official Citizenship Papers
5	USCIS Permanent Resident Card
6	USCIS Work Permit (EAD)
7	SAVE - USCIS system verification
8	Baptismal papers
9	Other official document

SKIP TO QUESTION Q. 14. (HB9)

11. Do you/Does [hh member] have legal immigration status? (HB7)

	Legal immigration status
N	No
Y	Yes
Z	Don’t Know

IF NO or don’t know, SKIP TO Q.14 (HB9)

12. What is your/[hh member’s] Alien Registration number? (HB8)

13. IF IMMIGRATION STATUS IS NOT ALREADY VERIFIED WITH ACCEPTABLE VERIFICATION, ASK: May I see a document that supports your/[hh member’s] citizenship or legal immigration status? (HB8V)

14. What is your/[hh member’s] Social Security number? (HB9)

15. IF SOCIAL SECURITY NUMBER IS NOT ALREADY VERIFIED WITH ACCEPTABLE VERIFICATION, ASK: May I see a document that supports your/[hh member’s] social security number? (HB9V)

    	Social security number verification
    0	None
    1	SS Card
    2	Letter/benefit statement from SSA
    3	Letter from SAVE-USCIS stating SSN has been assigned
    4	Certification that no SSN assigned
    5	Verbal information from SSA
    6	Verbal information from SAVE-USCIS
    7	Other: Driver’s License, ID Card, Payroll Stubs, Form 1099, Life Insurance Policy Policy, Court Records

16. Were you/ Was [hh member] a person with disabilities in QCM? (HB10)

	Disabled
N	No
Y	Yes
Z	Don’t Know

17. IF NO OR DON”T KNOW: SKIP TO Q18. (HB11)IF YES: May I see a document that verifies you/[hh member] are a person with disabilities? (HB10V)

	Verification code for disability
0	None
1	Letter from SSI or SSA
2	Other proof of SSI/SSA disability
3	Letter from professional verifying disability
5	Other

IF THE TENANT HAS NO DOCUMENT TO VERIFY THE INFORMATION: Please tell me the name, address and phone number of the person who can verify this information.

18. During [QCM], were you/was [hh member] temporarily or permanently living away from home? (HB11)

	Temporariliy living away
N	No
Y	Yes
Z	Don’t Know

IF NO or don’t know SKIP TO Q. 23 (HB14)

19. When did [you /hh member] start living away from home? MM/DD/YYYY (HB12AM/D/Y)

20. Why [were you/was hh member] living away from home? (HB12)

ENTER CODE, THEN RECORD RESPONSE

	Reason living away
1	Attending school
2	Military
3	Employment
4	In foster care
6	Other
8	Don’t Know

RECORD TEXT RESPONSE: _________________________________________

21. Did you /[hh member] live away from home the entire time between [QCM] through [QCM+12 months]? (HB13A)

	Living away 12 months after QCM
N	No
Y	Yes
Z	Don’t Know

IF YES, GO TO Q. 23. (HB14)

22. When did you/[HH MEMBER] return home as a permanent household member? MM/DD/YYYY (HB13BM/D/Y)

Note: Questions 18 through 22 will also be asked if a household member was listed on the 50058/59, but the respondent said the member was not living in the home during the QCM.

23. Was anyone else living in the household in [QCM]? (HB14)

IF YES, GO BACK TO Q. 2. (HB1)

IF NO, HDCS conducts a check to see if all members on the 50058/59 were accounted for during the interview. If all members are accounted for, SKIP TO SECTION C.

IF ALL MEMBERS ARE NOT ACCOUNTED FOR, HDCS WILL DISPLAY THE MESSAGE: THE NUMBER OF HOUSEHOLD MEMBERS LISTED ON THE 50058/59 DOES NOT MATCH THE NUMBER ENTERED IN THE INTERVIEW. SELECT YES, AND ASK SPECIFICALLY ABOUT THE MEMBER THAT THE RESPONDENT DIDN’T MENTION. HDCS GOES BACK TO QUESTION 2.

B-Add on. Students

ASK THESE QUESTIONS FOR ALL HOUSEHOLD MEMBERS WHERE THE RESPONSE TO Q. B 5 (HB4S) IS NOT EQUAL TO ‘0’ (NOT A STUDENT), AND THE STUDENT IS UNDER 24 YEARS OLD

The next questions ask about students in the household. I will ask questions about each student separately. (HB25)

SELECT A HOUSEHOLD MEMBER FROM THE LIST

	Household member
Mem # of each student	Name of each student

1. What type of institution were you/was the student attending? (HB21)

	What type of institution was the student attending?
1	High School
2	College or University
3	Vocational School
4	Other Institution of Higher Education
5	Other, but not an Institution of Higher Education
Z	Don‘t Know

IF CODE 1 OR 5, ask about the next student; if no more students, SKIP TO SECTION C.

2. Did your/the student’s parent or guardian live in the unit with you/him? (HB22)

PROBE: We are interested in who lived in the unit for which assistance is being provided—the primary residence. Did both you/[hh member] and your/[hh member’s] parents live in the same unit even if you/[the student] temporarily lived on campus?

	Did (your /the student’s) parent or guardian live in the unit with you/the student?
1	Yes
2	No

IF YES, ask about the next student; if no more students, SKIP TO SECTION C.

3. During [QCM], were you/was [hh member] married? (HB23)

	Was the Student married?
1	Yes
2	No

IF YES, ask about the next student; if no more students, SKIP TO SECTION C.

4. Did you/[hh member] have a dependent child living in the unit with you/him? (HB24)

	Did you /the student have a dependent child living in the unit with you?
1	Yes
2	No

IF YES, ask about the next student; if no more students, SKIP TO SECTION C.

5. Are you/is [hh member] a Veteran? (HB25)

	Was the Student a Veteran?
1	Yes
2	No

IF YES, ask about the next student; if no more students, SKIP TO SECTION C.

6. When did you/[hh member] begin living away from your/his/her parent or guardian? (HB26)

IF MORE THAN A YEAR PRIOR TO THE QCM, ask about the next student; if no more students, SKIP TO SECTION C.

7. Were you/was [hh member] claimed as a dependent on your/his/her parent or guardian’s income taxes during [QCM]? (HB27)

   	Claimed as a dependent
   1	Yes
   2	No

8. Were your/the student’s parent(s) or guardian providing financial help in [QCM]? (HB28)

	Guardian providing help
1	Yes
2	No

IF YES, RECORD DETAIL IN GIFTS AND CONTRIBUTIONS SECTION

9. We need to collect information about your/[hh member’s] parent or guardian’s income. To the extent you can, please answer the following questions.

10. Do you have any information regarding the income received by [hh member’s] father or legal guardian? (HB210)

	Student’s Father or Legal Guardian
1	Info Available
2	No Info Available
3	Don’t Know

IF NO INFORMATION AVAILABLE OR DON’T KNOW, SKIP TO Q. 11. (HB211)

10a. What is your/[HH member’s] father’s (or guardian’s) full name? (HB210A)

IF THE RESPONDENT DOESN’T KNOW, TYPE DON’T KNOW.

10b. Did your/[hh member’s] parent/guardian have income from employment during [QCM]? (HB210B)

	Father/guardian have income from employment
1	Yes
2	No
3	Don’t know

IF NO, SKIP TO Q. 10e. (HB210E)

10c. Who was his employer? (HB210BOTHOTHER)

10d. Approximately how much did [hh member’s] parent/guardian earn in a month? (HB210D)

ENTER AMOUNT. IF UNKNOWN, ENTER 99999

10e. Did your/[hh member’s] parent/guardian have income from sources other than employment? (HB210E)

	Father’s other source
1	Yes
2	No
3	Don’t know

IF NO, SKIP TO Q. 11. (HB211)

10f. What source of income did he have? (HB210EOTHOTHER)

RECORD THE SOURCE AND AS MUCH DESCRIPTION AND ADDRESS INFORMATION AS AVAILABLE

10g. Approximately how much did [hh member’s] parentguardian receive from that source of income in a month? (HB210G)

ENTER AMOUNT. IF UNKNOWN, ENTER 99999

10h. Did your/[hh member’s] parent/guardian have income from any other source? (HB210H)

	Father other source
1	Yes
2	No

IF NO, SKIP TO Q. 11. (HB211)

10i. What other source of income did he have? (HB210HOTHOTHER)

RECORD THE SOURCE AND AS MUCH DESCRIPTION AND ADDRESS INFORMATION AS AVAILABLE

10j. Approximately how much did your/[hh member’s] parent/guardian receive from that source of income in a month? (HB210J)

ENTER AMOUNT. IF UNKNOWN, ENTER 99999

11. Do you have any information regarding the income received by another of [hh member’s] parent/ legal guardian? (HB211)

	Information about mother
1	Info Available
2	No Info Available
3	Don’t Know

IF NO, SKIP TO verification screen

11a. What is your/[hh member’s] mother’s (or guardian’s) full name? (HB211A)

IF THE RESPONDENT DOES NOT KNOW THE NAME, TYPE DON’T KNOW

11b. Did your/[hh member’s] parent/guardian have income from employment? (HB211B)

	Mother employed
1	Yes
2	No

IF NO, SKIP TO Q. 11e. (HB211E)

11c. Who was her employer? (HB211BOTHOTHER)

RECORD THE EMPLOYER’S NAME AND AS MUCH ADDRESS INFORMATION AS AVAILABLE

11d. Approximately how much did your/[hh member’s] parent/guardian earn in a month? (HB211D)

ENTER AMOUNT. IF UNKNOWN, ENTER 99999

11e. Did your/[hh member’s] parent/guardian have income from sources other than employment? (HB211E)

	Mother other income
1	Yes
2	No

IF NO, SKIP TO verification screen

11f. What source of income did she have? (HB211F)

RECORD THE SOURCE AND AS MUCH DESCRIPTION AND ADDRESS INFORMATION AS AVAILABLE

11g. Approximately how much did your/[hh member’s] parent/guardian receive from that source of income in a month? (HB211G)

ENTER AMOUNT. IF UNKNOWN, ENTER 99999

11h. Did your/[hh member’s] parent/guardian have income from any other source? (HB211H)

	Mother other income source
1	Yes
2	No

IF NO, SKIP TO verification screen

11i. What other source of income did she have? (HB211I)

RECORD THE SOURCE AND AS MUCH DESCRIPTION AND ADDRESS INFORMATION AS AVAILABLE

11j. Approximately how much did your/[hh member’s] parent/guardian receive from that source of income in a month? (HB211J)

ENTER AMOUNT. IF UNKNOWN, ENTER 99999

VERIFICATION SCREEN

12. REPEAT Q. 1 THROUGH 12 FOR EACH HOUSEHOLD MEMBER WHERE THE RESPONSE TO Q. B 5 (HB4S) IS YES, AND THE STUDENT IS 18-24 YEARS OLD

C. Employment

These next questions are about income from employment. I am not asking about self employment such as baby-sitting, or other work you do at home.

1. During [QCM], were you/was [hh member] doing any work for pay? (HD3)

Did you expect to work at other jobs during the year that you did not have during [QCM]^a.

	Current/future work
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 14. (HD34)

2. Can you tell me the name of the company and the kind of work you/[hh member ] did? WE WANT TO KNOW IF THE TENANT WORKED REGULARLY, SPORADICALLY, OR SEASONALLY. (OTHOTH3)

RECORD THE NAME OF THE COMPANY/ORGANIZATION OR OTHER TEXTUAL EXPLANATIONS.

3. When did you /[hh member] start that job? ENTER MM/DD/YYYY (HD5M/D/Y)

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, 0R 31).

3a. Were you/was [hh member] paid on a regular basis? Such as hourly, weekly, monthly, etc? (HD6A)

	Paid on a regular basis
1	Yes
2	No

IF YES, SKIP TO Q. 5. (HD6)

4. I need to figure out how much you/[hh member] made during [QCM through QCM plus 11 months]. Can you tell me what you expected to be paid during that period?

5. Now I’d like to know how much you /[hh member] expected to be/were making on that job in [QCM]. I’m asking about your/[hh members] earnings and not other money you /[hh member] may have received to help pay for things like transportation or uniforms. How much did/were you /[was hh member] expect to make/making on that job from regular wages or salary? Do not include tips, commissions, or bonuses you have received in that amount. (HD6)

PROBE: FOR THE GROSS INCOME AMOUNT—THAT IS INCOME EARNED BEFORE REMOVING ANY TAXES, DEDUCTION ETC.

6. How often were you /[hh member] expect to be/paid that? (HD7)

	Pay frequency
1	Annually
4	Quarterly
6	Every two months
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly
90	Hourly
91	Pieces
92	Daily

IF HOURLY:

6a. About how many hours did you/[hh member] expect to work each week? (HD8)

6b. About how many weeks did you/[hh member] expect to work during the year? (HD10)

IF DAILY:

6a. About how many days did you/[hh member] expect to work each week? (HD9)

6b. About how many weeks did you/[hh member] expect to work during the year? (HD10)

IF PIECEWORK:

6a. About how many hours did you/[hh member] expect to work each week? (HD8)

6b. About how many weeks did you/[hh member] expect to work during the year? (HD10)

7. Do you have any reason to believe the income you just told me about should be excluded when determining the amount of rent you should pay?

If yes:

Please tell me the name of the organization that funded this income.

	Excluded Income Source
1	Federal work-study program (if HHM student)
2	Americorp
3	Job Training Partnership Act (JTPA)
4	Workforce Investment Act
5	VISTA
6	Older American Act
7	RSVP
8	Foster Grandparents
9	Senior Campanions Program
11	Resident Service Stipend
26	Census Bureau
96	Other excluded

VERIFICATION SCREEN

8. Did you/[hh member] expect the rate of pay to change during the year? (HD11)

	Rate of pay change
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 9. (HD17)

8a. When did you/[hh member] expect the income to change? ENTER MM/DD/YYYY (HB12M/D/Y)

IF THE DAY IS NOT CLEAR THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31).

8b. What did you/[hh member] expect your new rate of pay to be? (HD13)

9. Did you/[hh member] expect to receive any overtime pay? (HD17)

	Expected overtime pay
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 11. (HD25)

9a. What was/did you expect your/[hh member’s] hourly overtime rate of pay to be? (HD18)

9b. About how many hours of overtime did you/[hh member] expect to work each week? (HD19)

9c. About how many weeks during the year did you/[hh member] expect to make that much? (HD20)

10. Did you expect your/[hh member’s] rate of overtime pay to change during the year? (HD21)

	Expect rate of overtime to change
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 11. (HD25)

10a. When did you/[hh member] expect the income to change? ENTER MM/DD/YYYY (HD22M/D/Y)

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31).

10b. What did you/[hh member] expect your new rate of overtime pay to be? (HD23)

10c. About how many weeks during the year did you/[hh member] expect to make that much? (HD24)

11. Did you/[hh member] expect to receive tips? (HD25)

	Expect to receive tips
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 12. (HD28)

11a. About how much did you/[hh member] expect to make in tips each week? (HD26)

11b. About how many weeks during the year did you/[hh member] expect to make that much? (HD27)

12. Did you/[hh member] expect to receive bonuses? (HD28)

	Expect to receive bonuses
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 13. (HD31)

12a. About how often did you/[hh member] expect to receive a bonus? (HD30)

	Frequency of bonuses
1	Annually
4	Quarterly
6	Every two months
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

12b. About how much did you/[hh member] expect to receive each time you got a bonus? (HD29)

13. Did you/[hh member] expect to receive commissions? (HD31)

	Expect to receive commissions
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 14. (HD34)

13a. About how much did you/[hh member] expect to receive in commissions each month? (HD32)

13b. About how many months during the year did you/[hh member] expect to make that much? (HD33)

13c. Do you believe this source of income should have been counted when determining the amount of rent your household paid? (HD33A)

	Should have been counted
N	No
Y	Yes
Z	Don’t Know

IF NO, enter why the tenant thinks this income should not be counted?

14. Were you/[was hh member] doing/expecting to do any work for which you received any goods or benefits, such as food or clothing? (HD34)

	Received anything in goods or benefits
N	No
Y	Yes
Z	Don’t Know

IF NO/DON’T KNOW AND RESPONSE TO Q. 1 WAS YES, SKIP TO Q. 15. (HD40)

IF NO/DON’T KNOW AND RESPONSE TO Q. 1 WAS NO, REPEAT QUESTIONS STARTING WITH Q. 1 ASKING ABOUT INCOME FROM EXPECTED JOBS THAT HE/SHE DID NOT HAVE IN [QCM].

IF YES AND RESPONSE TO Q. 1 WAS YES, SKIP TO Q. 14b.

14a. Could you give me the name, address, and phone number of the person who provided the goods and benefits? (part of HD34)

14b. What was the value of those things? (HD35)

14c. When did you/ [hh member] expect to start receiving them? ENTER MM/DD/YYYY (HD36M/D/Y)

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31).

14d. How often did you/[hh member] expect to receive them? (HD37)

	Frequency of receiving goods
1	Annually
4	Quarterly
6	Every two months
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

PROBE: Once a week? Every month? Every 3 months?

14e. Did you/[hh member] expect to continue to receive them during the full year? (HD38)

	Expect continue receiving goods
N	No
Y	Yes
Z	Don’t Know

IF YES, SKIP TO q.15. (HD40)

14f. When did you expect that income to change? ENTER MM/DD/YYYY (HD39M/D/Y)

IF THE DAY IS NOT CLEAR THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31).

15. Were you/[hh member] working at any other jobs in [QCM] or have any other kind of employment income—for example, piece-work or jobs you/[hh member] were/was paid for on a day or half-day basis, like cleaning or child care? (HD40)

Did you expect to work at other jobs during the year that you did not have during [QCM], or expect to have any other kind of employment income—for example, piece-work or jobs you would be paid on a day or half-day basis, like cleaning or child care?

	Any other job
N	No
Y	Yes
Z	Don’t Know

IF YES, REPEAT Q. 2 THROUGH 15.

Questions about FUTURE income—REPEAT QUESTIONS STARTING WITH QUESTION 1 ABOUT INCOME FROM EXPECTED JOBS THAT HE/SHE DID NOT HAVE DURING QCM.

IF NO, AND there are OTHER ADULT HOUSEHOLD MEMBERS, GO TO Q. 1.

IF NO, AND there are no more OTHER ADULT HOUSEHOLD MEMBERS, GO TO section D.

D. Military Pay

1. During [QCM], were you/[was hh member] serving in the military—the Army, Navy, Marines, Air Force, or Coast Guard? (HE2)

	Serving in military
N	No
Y	Yes
Z	Don’t Know

IF YES, SKIP TO Q. 9. (HE4)

2. Were you/[was hh member] in the reserves or National Guard during [QCM]? (HE3)

	Serving in national guard
N	No
Y	Yes
Z	Don’t Know

IF NO: IF OTHER ADULT HH MEMBERS, GO TO Q. 1.
IF NO OTHER ADULT HH MEMBERS, SKIP TO SECTION E.

3. When did you/[hh member] start serving? (HE4M/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

4. How much pay did you/[hh member] expect to receive from your/his/her service in the reserves or Guard:For weekend drills? (HE4)

5. How many times per year did you/[hh member] expect to receive that amount? (HE5)

6. For 2-week summer camp? (HE8)

7. For any other reserve or guard activity? (HE9)

8. How many times per year did you/[hh member] expect to receive that amount? (HE10)

SKIP TO Q. 12. (HE15)

9. When did you /[hh member] start serving? (HE4) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

10. How much regular pay, not including any allowances or special pay, were you/[was hh member] receiving? (HE4)

11. How often did you/[hh member] get that amount? (HE6)

    	Frequency military pay
    1	Annually
    12	Monthly
    24	Twice a month
    26	Every two weeks
    52	Weekly

12. During [QCM], were you/[ was hh member] receiving:

A monthly housing allowance? (HE15)

	Receive housing allowance
N	No
Y	Yes
Z	Don’t Know

IF YES: How much was your/his/her monthly housing allowance? (HE16)

13. A monthly food allowance? (HE17)

	Receive food allowance
N	No
Y	Yes
Z	Don’t Know

IF YES: How much was your/his/her monthly food allowance? (HE18)

14. Hostile Fire Pay? (HE29)

	Receive Hostile Fire Pay?
N	No
Y	Yes
Z	Don’t Know

IF YES: How much was your/his/her hostile fire pay? (HE30)

15. Were you (was HH member)receiving any other allowances from the military? DO NOT INCLUDE HOSTILE FIRE OR IMMINENT DANGER PAY OR HAZARDOUS DUTY PAY (COMBAT PAY) (HE19)

NOTE: HAZARDOUS DUTY PAY IS NOT INCLUDED AS INCOME.

	Other allowance
N	No
Y	Yes
Z	Don’t Know

IF NO: SKIP TO Q18. (HE22)

IF YES:

16. What was the amount of that allowance? (HE20)

17. How often did you/[hh member] receive that amount? (HE21)

    	How often allowance was received
    1	Annually
    4	Quarterly
    6	Every two months
    12	Monthly
    24	Twice a month
    26	Every two weeks
    52	Weekly
    99	Don’t know

18. Did you/[hh member] expect any of the amounts of pay or allowances to change during the year? (HE22)

	Expect changes during the year
N	No
Y	Yes
Z	Don’t Know

IF NO, GO TO Verification screen

19. Which pay did you/[hh member] expect would change? (HE23)

    	Expected pay to change
    BP	Base pay
    FA	Food allowance
    HA	Housing allowance
    OA	Other allowances
    RA	Reserve activity
    SC	Summer camp
    WD	Weekend drills

20. What did you/[hh member] expect your new rate of pay to be? (HE24)

21. How often did you/[hh member] expect to be receiving that amount? (HE25)

    	Frequency receiving that amount
    1	Annually
    12	Monthly
    24	Twice a month
    26	Every two weeks
    52	Weekly

22. When was the amount expected to change? (HE26M/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

VERIFICATION SCREEN

IF NO OTHER ADULT HH MEMBERS, SKIP TO SECTION F.

REPEAT Q. 1 THROUGH 15 FOR EACH ADULT HH MEMBER

E. Self-Employment

1. Other than the salaries you already told me about, in [QCM], did anyone in the household get income by working for him- or herself, or from owning a business? For example babysitting, catering, or driving a cab?

Do not include income already recorded.

	Any HH member own a business
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 7. (HP10)

2. What kind of work was it? (HP2)

IF THE HOUSEHOLD HAS MORE THAN ONE SOURCE OF SELF-EMPLOYMENT, THEN ASK THE TENANT TO TALK ABOUT THEM ONE AT A TIME.

3. Which member of your household received that income? (HP3)

	HH member
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

4. What was your/ [hh members] gross income in [QCM]? (HP4)

IF “NOTHING,” ENTER “0”; THEN SKIP TO Q. 7. (HP10)

5. How many times a year did you [hh member] get this amount? (HP5)

5a. That means that you [hh member] made [income], [frequency] times a year. That equals to [annualized amount] for a 12 month period. Is that right? (HP5A)

	Confirm annual income
N	No
Y	Yes

IF NO, GO BACK TO Q. 4 (HP4)

6. Did you [hh member] expect to continue getting that amount for the full year? (HP6)

	Expect same amount for full year
N	No
Y	Yes
Z	Don’t Know

IF YES, SKIP TO Q. 8.
IF NO:

6a. When did you [hh member] expect the amount to change? (HP7M/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

6b. How much gross income did you [hh member] expect to make then? (HP8)

6c. How many times per year did you [hh member] expect to receive that amount? (HP9)

That means that you [hh member] made [income], [frequency] times a year which equals [annualized amount] for a 12 month period. Is that right? (HP9A)

	Confirm annual amount
N	No
Y	Yes

IF NO, GO BACK TO Q. 6b (HP8)

If Yes, SKIP TO Q. 8. (HP15A)

7. In [QCM], was anyone living in the household expecting to get income later on during the year by working for him- or herself or owning a business? For example, babysitting, catering, housekeeping, or driving a cab. (HP10)

	Expecting some income from business
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO SECTION. F

IF YES:

7a. Which member of your household expected to receive that income? (HP11)

7b. What kind of work was it? (HP10A)

7c. Which member of your household expected to receive that income? (HP11)

	HH member expected business income
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

7d. When did you[hh member] expect this income to begin? (HP12M/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

7e. How much did you [hh member] expect to receive then? (HP13)

7f. How often did you [hh member] expect to receive that amount? (HP14)

	Expected business income frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

Business Expenses

8. These next few questions are about expenses related to [type of self employment].
Did you/[hh member] expect to have any expenses related to (type of employment).
For example, diapers, food supplies, beauty supplies, insurance, tolls, gas, or other expenses? (HP15A)

	Materials and supplies payments
N	No
Y	Yes
Z	Don’t Know

IF YES: How much did you [hh member] expect all the expenses associated with (type of self employment) to amount to for the full year? (HP15B)

Probe: For all types of related expenses and record the total.

9. Now I need to ask you about very specific types of expenses. When responding to these questions, do not include expenses you already told me about.

9a. Did you [hh member] have any expenses associated with office space expenses (HP16A)

Probe: This would include rooms used for baby sitting, beauty shop, office space, etc.

	Office space payments
N	No
Y	Yes
Z	Don’t Know

IF YES: how much did you [hh member] expect that expense to amount to for the full year? (HP16B)

9b. Did you [hh member] have any interest payments on loans for (type of employment)? (HP17A)

	Interests payments
N	No
Y	Yes
Z	Don’t Know

IF YES: How much did you [hh member] expect that expense to amount to for the full year? (HP17B)

9c. Did you [hh member] have any depreciation expenses? (HP18A)

	Depreciation payments
N	No
Y	Yes
Z	Don’t Know

IF YES: How much did you [hh member] expect that expense to amountfor the full year? (HP18B)

9d. Did you [hh member] have any other business related expenses? (HP19A)

	Other expenses 1 payments
N	No
Y	Yes
Z	Don’t Know

IF NO, GO TO Q. 10.

IF YES:

a. What type of expense was this? ENTER THE TYPE OF EXPENSE (HP19AB)

b. How much did you [hh member] expect that expense to amount to for the full year? (HP19B)

9e. Did you [hh member] have any other business related expenses? (HP20A)

	Other expenses 2 payments
N	No
Y	Yes
Z	Don’t Know

IF YES:

How much did you [hh member] expect that expense to amount to for the full year? (HP20B)

VERIFICATION SCREEN

10. Were you (or other household members) receiving or expecting to receive other income from working for yourself or owning your own business? HP22

	Anyone else has a family business
N	No
Y	Yes
Z	Don’t Know

IF YES, GO BACK TO Q. 2.

F. Training and Earned Income Disregard

These next questions help us determine whether you[hh member] are entitled to a disregard from your earned income because of special circumstances.

1. IF PROGRAM TYPE = OWNER ADMINISTERED, OR VOUCHER AND MEMBER IS NOT DISABLED, SKIP TO Q. 23. (HD51)

IF RESPONSE TO Q. C-3 (JOB START DATE) IS PRIOR TO THE DATE OF ADMISSION TO THE PROGRAM (item 2h on the 50058 form), SKIP TO Q. 4. (HD81)

IF RESPONSE TO Q. C-3 (JOB START DATE) IS MORE THAN 24 MONTHS PRIOR TO QCM SKIP TO Q. 4. (HD81)

NOTE: IF THE HOUSEHOLD MEMBER HAS MORE THAN ONE JOB, HDCS USES THE 1^ST JOB RECORDED FOR THAT MEMBER.

Before you [hh member] started working, were you [hh member] unemployed for at least 12 months? (HD78)

	Unemployed for at least 12 months
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 4. (HD81)

2. What was your source of income prior to starting employment? (HD79)

INCLUDE INCOME FROM SOURCES SUCH AS TANF, DISABILITY, PENSION, AND SOCIAL SECURITY INCOME. PRESS ENTER AND PROVIDE INFORMATION ABOUT SOURCE.

3. What was the monthly amount of your [hh member’s] income prior to starting employment? (HD80)

IF OTHER EMPLOYED HOUSEHOLD MEMBERS, RETURN TO Q. 1 FOR NEXT MEMBER; OTHERWISE SKIP TO Q. 23. (HD51)

4. Did you participate in a self-sufficiency or other job training program between [QCM minus 2 years] and [QCM]? (HD81)

	Completed self-sufficiency training
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 12. (HD90)

5. When did you [hh member] begin participating in that program? ENTER MM/DD/YYYY (HD82M/D/Y)

NOTE: THE START DATE MUST BE BEFORE OR DURING THE QCM.

IF THE DAY IS NOT CLEAR THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

6. When did you [hh member] stop participating in that program? (HD83M/D/Y)

IF JOB START DATE IS AFTER THE MEMBER STOPPED PARTICIPATING IN THAT PROGRAM, SKIP TO Q. 12. (HD90)

IF JOB START DATE FALLS BETWEEN THE DATE THE MEMBER BEGAN PARTICIPATING AND STOPPED PARTICIPATING IN THAT PROGRAM, SKIP TO Q. 11. (HD89)

7. Did you [hh member] receive an increase in pay while you [hh member] were participating in the program? (HD84)

	Received increase while in training
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 12. (HD90)

8. When did you [hh member] receive the first increase in pay? ENTER MM/DD/YYYY (HD85M/D/Y)

NOTE: THIS DATE (HD85M/D/Y) MUST FALL BETWEEN HD82M/D/Y AND HD83M/D/Y.

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

9. What was your [hh member’s] monthly income prior to receiving that increase in pay? (HD87)

SKIP TO Q. 12. (HD90)

10. What was your source of income before starting employment? (HD89OTHOTHER)

INCLUDE INCOME FROM SOURCES SUCH AS TANF, DISABILITY, PENSION, AND SOCIAL SECURITY INCOME. PRESS ENTER AND PROVIDE INFORMATION ABOUT THE SOURCE.

11. What was your [hh member’s] monthly income prior to starting your job? (HD89)

12. Have you [has hh member] ever received assistance, benefits or services through TANF? [Formerly known as AFDC] (HD90)

	Ever received TANF assistance
N	No
Y	Yes
Z	Don’t Know

IF NO, AND THERE ARE OTHER EMPLOYED HOUSEHOLD MEMBERS, RETURN TO Q. 1 FOR NEXT MEMBER; OTHERWISE SKIP TO Q. 23. (HD90)

13. When did you [hh member] begin receiving assistance, benefits, or services through TANF? ENTER MM/DD/YYYY (HD 91M/D/Y)

IF THE DAY IS NOT CLEAR THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

14. When did you [hh member] stop receiving assistance, benefits, or services through TANF? ENTER MM/DD/YYYY (HD 92M/D/Y)

ENTER 99 IF NO END DATE.

IF THE DAY IS NOT CLEAR THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

IF MORE THEN 30 MONTHS PRIOR TO QCM, AND THERE ARE OTHER EMPLOYED HOUSEHOLD MEMBERS, RETURN TO Q. 1 FOR NEXT MEMBER; OTHERWISE SKIP TO Q. 23. (HD51)

IF JOB START DATE (RESPONSE TO Q. C-3) IS AFTER 6 MONTHS FROM WHEN THE MEMBER STOPPED RECEIVING ASSISTANCE, AND THERE ARE OTHER EMPLOYED HOUSEHOLD MEMBERS, RETURN TO Q. 1 FOR NEXT MEMBER; OTHERWISE SKIP TO Q. 23. (HD51)

15. Please tell me the name of the TANF agency, the address, the name of a person to contact, and their telephone number? (HD92 OTHOTHER)

IF JOB START DATE IS BEFORE THE MEMBER BEGAN RECEIVING ASSISTANCE, SKIP TO Q. 21. (HD98)

16. Did you [hh member] receive an increase in pay while you [hh member] were receiving assistance through TANF or within 6 months after you [hh member] last received assistance through TANF? (HD93)

IF NO, AND THERE ARE OTHER EMPLOYED HOUSEHOLD MEMBERS, RETURN TO Q. 1 FOR NEXT MEMBER; OTHERWISE SKIP TO Q. 23. (HD51)

17. When did you [hh member] receive the first increase in pay while you were [hh member was] receiving assistance through TANF or within 6 months after you [hh member] Last received assistance from TANF? (HD94)

IF THE DAY IS NOT CLEAR THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

18. What was your source of income prior to receiving that increase in pay? (HD95)

PRESS ENTER AND PROVIDE INFORMATION ABOUT SOURCE

PROBE: Income from all sources?

19. What was the monthly amount of your [hh member’s] income prior to receiving that increase in pay? (HD96)

IF OTHER EMPLOYED HOUSEHOLD MEMBERS, RETURN TO Q. 1 FOR NEXT MEMBER; OTHERWISE SKIP TO Q. 23. (hd51)

20. What was your [hh member’s] source of income prior to starting employment? (HD97)

INCLUDE INCOME FROM SOURCES SUCH AS TANF, DISABILITY, PENSION AND SOCIAL SECURITY INCOME.

21. What was the monthly amount of your [hh member’s] income prior to starting that job? (HD98)

IF OTHER EMPLOYED HOUSEHOLD MEMBERS, RETURN TO Q. 1 FOR NEXT MEMBER; OTHERWISE GO TO Q. 23. (hd51)

Employment Training Programs

These next questions are about training programs ANY household members have participated in.

22. During [QCM], were you/[was hh member] enrolled in or expected to bein a training program? (HD51)

	Enrolled in training program
N	No
Y	Yes
Z	Don’t Know

IF NO, AND THERE IS ANOTHER EMPLOYED HOUSEHOLD MEMBER, RETURN TO Q. 23 (HD51); OTHERWISE SKIP TO SECTION G

23. When did you [hh member] expect to complete the program? ENTER MM/DD/YYYY (HD53M/D/Y)

IF THE DAY IS NOT CLEAR THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

25. Can you tell me the name of the training program? (HD55OTHOTHER)

26. Do you know who ran that program? (HD55)

IF YES, record the sponsor’s name.

27. Do you know who funded that program? (HD56)

if no, skip to q. 28. (vERIFICATION SCREEN)

5a. What agency funded the program? (HD 56A)

	Program funded by
1	State
2	City
3	Federal
4	HUD
5	Other
6	Don’t know

VERIFICATION SCREEN:

29. When did you/[hh member] enroll in this training program? ENTER MM/DD/YYYY (HD57M/D/Y)

IF THE DAY IS NOT CLEAR THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

30. What was the source of your/[hh member’s] income prior to entering the training program? (HD58A)

PRESS ENTER AND RECORD SOURCE OF INCOME

31. What was the monthly amount of that income? (HD58B)

PROBE FOR EMPLOYMENT INCOME, TANF.

32. Did you/[hh member] have a second source of income prior to entering the training program? (HD59A)

	Source of second income prior to training
N	No
Y	Yes
Z	Don’t Know

IF YES, RECORD SOURCE OF INCOME.
ENTER NAME, ADDRESS TELEPHONE FOR the SOURCE OF INCOME.

What was the name, address and telephone for that second source of income? (Other)

33. What was the monthly amount of that income? (HD59B)

IF THERE IS ANOTHER EMPLOYED HOUSEHOLD MEMBER, RETURN TO Q. 23 (HD51); OTHERWISE SKIP TO SECTION G

G. Unemployment Compensation

1. During [QCM], were you/[was hh member] receiving unemployment compensation payments? (HF2)

	Receiving unemployment compensation
N	No
Y	Yes
Z	Don’t Know

IF NO AND OTHER ADULT HH MEMBERS, REPEAT Q. 1.
IF NO AND NO OTHER ADULT HH MEMBERS, SKIP TO SECTION H.

2. How much unemployment compensation were you/[was hh member] receiving? (HF3)

3. How often did you/[hh member] get that amount? (HF4)

	Compensation frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

VERIFICATION SCREEN

4. In [QCM], did you/[hh member] expect to receive the same amount of unemployment compensation benefits for the full year? (HF5)

	Expect same amount for full year
N	No
Y	Yes
Z	Don’t Know

IF YES AND OTHER ADULT HH MEMBERS, REPEAT Q. 1.
IF YES AND NO OTHER ADULT HH MEMBERS, SKIP TO SECTION H.
IF NO:

5. When was the amount expected to change? (HF6M/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

6. How much did you/[hh member] expect to receive then? (HF7)

7. How often did you/[hh member] expect to receive that amount? (HF8)

	New compensation frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

IF NO OTHER ADULT HH MEMBERS, SKIP TO SECTION H.

ASK Q. 1 THROUGH 8 FOR EACH ADULT HH MEMBER.

H. Workers’ Compensation

1. During [QCM], were you/[was hh member] receiving workers’ compensation payments? (HG2)

IF NO AND OTHER ADULT HH MEMBERS, REPEAT Q. 1. (HG2)
IF NO AND NO OTHER ADULT HH MEMBERS, SKIP TO SECTION I.

2. How much workers’ compensation were you/[was hh member] receiving? (HG3)

3. How often did you/[hh member] get that amount? (HG4)

	Workers’ compensation frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

VERIFICATION SCREEN

5. In [QCM], did you/[hh member] expect to receive the same amount of workers’ compensation benefits for the full year? (HG5)

IF YES AND OTHER ADULT HH MEMBERS, REPEAT Q. 1.
IF YES AND NO OTHER ADULT HH MEMBERS, SKIP TO SECTION I.
IF NO:

6. When was the amount expected to change? (HG6M/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

7. How much did you/[hh member] expect to receive then? (HG7)

8. How often did you/[hh member] expect to receive that amount? (HG8)

	New workers’ compensation frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

IF NO OTHER ADULT HH MEMBERS, SKIP TO SECTION I.

ASK Q. 1 THROUGH 8 FOR EACH ADULT HH MEMBER.

I. Social Security and SSI Benefits

1. During [QCM], was anyone living here receiving Social Security or SSI benefits? (HH1)

IF NO, PROBE: Social Security includes retirement, disability, and survivors’ benefits—benefits paid to the children or spouse of a deceased family member. SSI—Supplemental Security Income—benefits include payments to people who are elderly or disabled.

IF NO, SKIP TO SECTION J

2. Who was receiving the benefit (whose name was the benefit in)? (HH4)

SELECT THE MEMBER

	Household member receiving check
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

3. What was the gross monthly amount of the benefit? Note: The gross amount is the benefit amount before any deductions such as Medicare are taken out. (HH5)

4. Was the benefit for Social Security retirement, or disability, or survivors’ benefits, or was it for SSI (Supplemental Security Income)?

PROBE: Is this disability or retirement? (HH6)

	Type of benefit
SR	Social security retirement
SD	Disability
SS	Survivor
SO	SSI old age
SI	SSI disability
ST	SSI state amount
SN	Don’t know

5. Does this include an amount for payments that you [hh member] should have received earlier but were postponed for some reason? (HH6A)

	Include postponed payments
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 7. (HH7A)

6. How much is the amount for the postponed payments? (HH6B)

7. a. Who was this assistance for? (HH7A)

SELECT THE FIRST MEMBER FOR WHOM THE BENEFITS WERE PAID

	First beneficiary member
98	NO BENEFICIARIES
1	First1 Last1
2	First2 Last2
3	First3 Last3

b. Select the name of the second beneficiary, or No More Beneficiaries if this benefit is not for any other household members. (HH7B)

	Second beneficiary member
98	NO BENEFICIARIES
2	First2 Last2
3	First3 Last3

c. Select the name of the third beneficiary, or No More Beneficiaries if this benefit is not for any other household members. (HH7C)

	Third beneficiary member
98	NO BENEFICIARIES
3	First3 Last3

Note: HDCS allows for 10 beneficiaries for the same benefit.

VERIFICATION SCREEN

9. In [QCM], did you [hh member] expect the benefits would continue for the full year? (HH8)

	Expect benefits to continue
N	No
Y	Yes
Z	Don’t Know

IF YES, SKIP TO Q. 13. (HH1)

IF NO:

10. When was the amount expected to change? (HH9M/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

11. How much did you [hh member] expect to receive then? (HH10)

12. What type of benefits did you [hh member] expect to receive (Social Security retirement, disability, or survivors’ benefits, or SSI (Supplemental Security Income) benefits)? (HH11)

	Type of benefit expect to change
SR	Social Security retirement
SD	Disability
SS	Survivor
SO	SSI old age
SI	SSI disability
ST	SSI state amount
SN	Don’t know

13. Did anyone living in this house receive other Social Security or SSI benefits during [QCM]? (HH1)

IF YES, REPEAT Q. 2 THROUGH 13.
IF NO, SKIP TO SECTION J.

J. Veterans’ Disability Benefits

1. During [QCM], were you/[was hh member] receiving disability benefit payments from the
Veteran’s Administration? (HI2)

	Receiving disability benefits
N	No
Y	Yes
Z	Don’t Know

IF NO AND OTHER ADULT HH MEMBERS, REPEAT Q. 1.
IF NO AND NO OTHER ADULT HH MEMBERS, SKIP TO SECTION K.

2. What is the percentage of your/[hh member’s] disability? (HI3)

3. What was the amount of the disability payments? (HI4)

4. How often did you/[hh member] get that amount? (HI5)

	Disability frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

5. Was this benefit a deferred disability benefit received in a lump sum or in prospective monthly payments? By deferred disability benefit, I mean a benefit that was due to you [hh member] at an earlier time, but that you [hh member] didn’t receive until a later date. (H15A)

	Prospective regular payments or lump sum
Y	Yes
N	No
Z	Don’t Know

VERIFICATION SCREEN

6. In [QCM], did you/[hh member] expect to receive the same amount of Veterans’ disability benefits payments for the full year? (HI6)

	Expect same amount for full year
N	No
Y	Yes
Z	Don’t Know

IF YES AND OTHER ADULT HH MEMBERS, REPEAT Q. 1.
IF YES AND NO OTHER ADULT HH MEMBERS, SKIP TO SECTION K.
IF NO:

7. When did you/[hh member] expect it to change? (HI7M/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

8. How much did you/[hh member] expect to receive then? (HI8)

9. How often did you/[hh member] expect to receive that amount? (HI9)

	New disability frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

REPEAT Q. 1 THROUGH 9 FOR EACH ADULT HH MEMBER.

K. Private or Public Retirement Benefits (Other Than Social Security)

1. During [QCM], did you/[hh member] receive retirement income from any private or
government retirement plan? (HJ2)

	Receiving retirement income
N	No
Y	Yes
Z	Don’t Know

IF NO AND OTHER ADULT HH MEMBERS, REPEAT Q. 1.
IF NO AND NO OTHER ADULT HH MEMBERS, SKIP TO SECTION L.

2. From what type of company or agency were you/[was hh member] receiving retirement pay? (HJ4)

	Agency receiving retirement from
MR	Military Retirement
PR	Private Retirement
VD	Veterans’s Disability
X2	Don’t know/None

3. How much retirement income were you/[was hh member] receiving? (HJ5)

4. How often did you/[hh member] get that amount? (HJ6)

	Retirement frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

VERIFICATION SCREEN

5. Did you/[hh member] expect to continue receiving that amount for the full year? (HJ7)

	Expect same amount for full year
N	No
Y	Yes
Z	Don’t Know

IF YES AND OTHER ADULT HH MEMBERS, REPEAT Q. 1.
IF YES AND NO OTHER ADULT HH MEMBERS, SKIP TO SECTION l
IF NO:

5a. When was the amount expected to change? (HJ8M/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

5b. How much did you/[hh member] expect to receive then? (HJ9)

5c. How often did you/[hh member] expect to receive that amount? (HJ10)

	New retirement frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

6. In [QCM], were you/[was hh member] receiving retirement benefits from any other sources? (HJ11)

	Retirement from other sources
N	No
Y	Yes
Z	Don’t Know

IF YES, REPEAT Q. 2 THROUGH 10 FOR EACH SOURCE.
IF NO AND OTHER ADULT HH MEMBERS, REPEAT Q. 1 THROUGH 6.
IF NO AND NO OTHER ADULT HH MEMBERS, SKIP TO SECTION L.

L. Temporary Assistance to Needy Families (TANF)

1. During [QCM], did anyone living here receive financial assistance for children from TANF? (HK1)

THIS USED TO BE CALLED AFDC (AID TO FAMILIES WITH DEPENDENT CHILDREN), AND IS NOW CALLED TANF (TEMPORARY ASSISTANCE TO NEEDY FAMILIES). DIFFERENT STATES MAY USE DIFFERENT NAMES TO IDENTIFY THE TANF PROGRAM. DO NOT INCLUDE AMOUNTS FOR ASSISTANCE SUCH AS FOOD STAMPS, MEDICAL ASSISTANCE, AND LIEAP PAYMENTS. RECORD THOSE ITEMS UNDER THE “OTHER WELFARE” SECTION

	Introduction to section
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 13. (hkk2)

2. Whose name was the benefit in? (HK2)

SELECT THE MEMBER

	Household member
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

3. What was the amount of assistance in [QCM]? (HK3)

4. a. Who was this assistance for? (HK4A)

SELECT THE FIRST MEMBER FOR WHOM THE BENEFITS WERE PAID

	TANF for HH member 1
98	NO BENEFICIARIES
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

b. Select the name of the second beneficiary, or No More Beneficiaries if this benefit is not for any other household members. (HK4B)

	TANF for HH member 2
98	NO BENEFICIARIES
2	First2 Last2
3	First3 Last3
4	First4 Last4

c. Select the name of the third beneficiary, or No More Beneficiaries if this benefit is not for any other household members. (HK4C)

	TANF for HH member 3
98	NO BENEFICIARIES
3	First3 Last3
4	First4 Last4

Note: HDCS allows for 10 beneficiaries for the same benefit.

5. How often did you/[hh member] expect to receive that amount? (HK5)

	TANF assistance frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

6. Is that the regular amount that you/[hh member] should receive or was the regular amount reduced for some reason? (HK6)

	Regular amount reduced
0	Reduced
1	Regular
8	Don’t know

IF REGULAR AMOUNT, SKIP TO Q. 8. (hk8)

7. Why was the regular amount reduced? (HK7)

	Reason amount was reduced
1	Accused of fraud
2	Did not meet all the Family Self-Sufficiency Requirements
3	Did not meet other welfare requirements
4	Followed all requirements but time for getting job run out
5	Unable to find a job even after complying with rules
6	Increase income
7	Fewer family members receiving assistance
8	Other
9	Don’t Know

IF RESPONSE IS CODE 4 to 9 , SKIP TO Q. 8. (HK8)

7a. What was the benefit amount before the reduction? (HK7A)

8. In [QCM], did [you/hh member] expect this assistance to continue for the full year? (HK8)

	Expect TANF continue for full year
N	No
Y	Yes
Z	Don’t Know

IF YES, SKIP TO Q. 19. (vERIFICATION sCREEN hlink11x)
IF NO:

9. When was the amount expected to change? (HK9M/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

10. How much did you [hh member] expect to receive then? (HK10)

11. How often did you [hh member] expect to receive that amount? (HK11)

	New TANF frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

VERIFICATION SCREEN

12. Was anyone else living here receiving TANF benefits in [QCM]? (HK20)

	Anyone else receiving TANF
N	No
Y	Yes
Z	Don’t Know

IF YES, REPEAT Q. 2 THROUGH 12.
IF NO, SKIP TO SECTION M.

13. Even though no one was receiving TANF in QCM we still need to know if anyone has ever received TANF. At any point while receiving housing assistance, did anyone in this household receive TANF? (HKK2)

	Received TANF financial assistance
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO SECTION m.

14. Who was receiving this assistance? (HKK3)

    	Member who received TANF benefits
    1	First1 Last1
    2	First2 Last2
    3	First3 Last3
    4	First4 Last4

15. Why aren’t you/[hh member] still receiving TANF benefits? (HKK4)

    	Why aren’t receiving benefits anymore
    1	Fraud
    2	Did not meet welfare FSS requirements
    3	Did not meet other welfare requirements
    4	Followed all requirements but time for getting job run out
    5	Unable to find a job even after complying with rules
    6	Increaseincome
    7	Fewer family members receiving assistance
    96	Other
    99	Don’t Know

16. How much were your/[hh member’s] monthly TANF benefits? (HKK5)

VERIFICATION SCREEN

14. When did you/[hh member] stop getting TANF benefits? (HKK6M/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

18. Did you [hh member] or any other household member start receiving a new source of income or receive an increase in an existing source of income after the TANF benefits were stopped? (HKK7)

	Household member receiving a new source of income
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 21. (hkk2)

19. What was the source of that income? (HKK8)

PRESS ENTER AND RECORD RESPONSE

20. What was the monthly amount of the increase or new source of income? (HKK9)

21. Did anyone else living here receive TANF benefits while getting housing assistance? (HKK2)

	Received TANF financial assistance
N	No
Y	Yes
Z	Don’t Know

IF YES, REPEAT Q. 13 THROUGH 21.
IF NO, SKIP TO SECTION M.

M. Other Welfare

1. During [QCM], other than TANF was anyone living here receiving benefits from the local social service office, public welfare office,or private charitable agency? (HL1)

IF NO, SKIP TO SECTION N.

	Anyone receiving benefits from public welfare
N	No
Y	Yes
Z	Don’t Know

2. Which household member received benefits? (HL2)

	Household member
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

3. What type of benefit was it? (HL3)

	Type of benefit
TI	Transitional income
AG	Aged
DI	Disabled
BL	Blind
GA	General assistance
EA	Emergency assistance
WO	Other
RA	Rental assistance
PA	Out of pocket expense to participate in public program
11	LIEAP
21	Food Stamps
MA	Medical Assistance (Not Medicare or Medicaid)

4. What type of agency provided the benefit? (HL4)

	Agency providing welfare benefit
1	State public
2	Local public
3	Private agency
6	Other
8	Don’t know

5. How much were you [was hh member] receiving in [QCM]? (HL6)

6. How often were you [was hh member] receiving that amount? (HL7)

	Welfare benefit frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

VERIFICATION SCREEN

7. In [QCM], did you [hh member] expect to receive that same amount of assistance
payments for the full year? (HL8)

	Expect same amount for full year
N	No
Y	Yes
Z	Don’t Know

IF YES, SKIP TO Q. 11. (hl12)
IF NO:

8. When did you [hh member] expect it to change? (HL9M/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

9. How much did you [hh member] expect to receive then? (HL10)

10. How often did you [hh member] expect to receive that amount? (HL11)

	Expected welfare frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

11. Was anyone else living here receiving other welfare benefits in [QCM]? (HL12)

	Anyone else receiving welfare benefits
N	No
Y	Yes
Z	Don’t Know

IF YES, REPEAT Q. 2 THROUGH 10.
IF NO, SKIP TO SECTION N.

N. Child Support

IF NO CHILDREN, SKIP TO SECTION O.

These next questions are about child support payments that you [or anyone else living here] received directly from an absent parent, or through a child support or TANF agency.

1. Do any of the children living here (other than foster children) have a father or mother who is living somewhere else? (HM1)

	Child having parent living away
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO SECTION o.

2. During [QCM], was any household member receiving child support from an absent parent, or child support or TANF agency? (HM2)

	Receiving child support
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 10. (hm10)

3. Which household member received the child support payments? (HM3A1)

	HH member
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

3a. Which child was the support for? (HM3B1 )

	Child 1 support was for
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

3b. HDCS repeats -“Which child was the support for? “ Until the user selects “No More Beneficiaries” (HM3B2)

	Child 2 support was for
98	NO MORE BENEFICIARIES
2	First2 Last2
3	First3 Last3
4	First4 Last4

4. How much were you [was hh member] getting in [QCM]? (HM4)

5. How often were you [was hh member] getting that amount? (HM5)

	Child support frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

6. Did [you/ hh member] expect to continue receiving that amount for the full year? (HM6)

	Expect same amount for full year
N	No
Y	Yes
Z	Don’t Know

IF YES, SKIP TO Q. 12. (hm12)
IF NO:

6a. When did [you/ hh member] it to change? (HM7D)

ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

7. How much did you [you/ hh member] expect to receive then? (HM8)

8. How often did [you/ hh member] you expect to receive that amount? (HM9)

	Future child support frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

9. From where did the child support come?

	Child Support Source
1	Absent Parent
2	Child Support Agency
3	TANF Agency

SKIP TO Q. 12. (hm12)

10. Do [you/or any other household member] have a court order that required the father/mother to make child support payments? (HM10)

	Court order requiring child support
N	No
Y	Yes
Z	Don’t Know

IF YES, SKIP TO Q. 12. (hm12)

11. Has anyone in the household gone to court to try to get a court order? (HM11)

	Gone to court to get court order
N	No
Y	Yes
Z	Don’t Know

12. Besides holiday and birthday gifts, in [QCM] did the absent parent give any extra money or things for the child(ren) on a regular basis? (HM12)

	Extra money on regular basis
N	No
Y	Yes
Z	Don’t Know

IF NO, PROBE: Not even helping to pay for their diapers, clothes, or buying them things?

IF NO, AND nO TO Q. 2, SKIP TO SECTION O.

iF NO AND YES TO Q.2, SKIP TO vERIFICATION SCREEN

12a. Which household member received money or other things? (HM12A1)

	HHM that received money/other things
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

12b. (1)Which child/ren was the extra money or things for? (HM12B1)

NAME OF THE FIRST CHILD FOR WHOM THE MONEY OR OTHER THINGS WERE FOR.

	Child 1 support was for
98	No Recipients
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

(2). Select the name of the second child for whom the money or other things were for. Or select No More Beneficiaries if this support is not for any other household members. (HM12B2)

	Child 2 support was for
98	No More Recipients
2	First2 Last2
3	First3 Last3
4	First4 Last4

(3) Select the name of the third child for whom the money or other things were for. Or select No More Beneficiaries if this support is not for any other household members. (HM12B3)

	Child 3 support was for
98	No More Recipients
3	First3 Last3
4	First4 Last4

13. About how much would you say he/she spends on them during a typical month? (HM13)

VERIFICATION SCREEN

14. Was anyone else living here receiving child support benefits directly from the absent father/mother, child support, TANF agency? (HM14)

IF YES, REPEAT Q. 3 THROUGH 14.
IF NO, SKIP TO SECTION o.

	Anyone else receiving child support
N	No
Y	Yes
Z	Don’t Know

O. Regular Gifts and Contributions

1. In [QCM], was anyone living here receiving any (other) money or gifts on a regular basis from people who do not live here? PROBE: Did someone who did not live here help pay any bills—utilities, or groceries, or help pay for babysitting or day care? (HN1)

IF NO, SKIP TO SECTION p.

2. Who was the money or gifts for? (HN2)

	HH member
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

3 Who was helping you/[hh member] out? (HN3)

RECORD NAME

4. What kinds of things was he/she giving you/[hh member]? (HN4)

PROBE FOR GROCERIES, UTILITY BILLS, CAR PAYMENTS, ETC.

5. About how often was he/she giving or paying you/[hh member] for [gift/item]? (HN5)

	Gifts/money frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

6. What was the value of [gift/item]? (HN6)

VERIFICATION SCREEN

7. Did you [hh member] receive any other gifts or money from that source? (HN7)

	Receive any other gifts/money
N	No
Y	Yes
Z	Don’t Know

IF YES, GO BACK TO Q. 4 (hn4)

8. Was anyone else helping any household members with gifts or paying for expenses? (HN8)

	Anyone else receive gifts/money
N	No
Y	Yes
Z	Don’t Know

IF YES, GO BACK TO Q. 2.
IF NO, SKIP TO SECTION P.

P. Alimony

IF ALL ADULT HOUSEHOLD MEMBERS ARE LIVING WITH SPOUSE, SKIP TO SECTION Q.

These next questions are about alimony—payments that are made by a separated or divorced husband or wife to help support the other spouse. Alimony is different from child support payments that are used to support children.

1. Were there any household members receiving alimony in [QCM]? (HO1)

	Anyone receiving alimony
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO SECTION q.

2. Which household member? (HO2)

Press enter to display household members and select the one that is receiving alimony.

	HH member
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

3. How much were you/[was hh member] receiving from your [his/her] former husband/ wife? (HO6)

4. How often were you [hh member] getting that amount? (HO7)

	Alimony frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

VERIFICATION SCREEN

5. Did you [hh member] expect to continue getting that amount for the full year? (HO8)

	Expect same amount for full year
N	No
Y	Yes
Z	Don’t Know

IF YES, SKIP TO Q. 9. (h012)
IF NO:

6. When did you [hh member] expect it to change? (HO9M/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

7. How much did you [hh member] expect to receive then? (HO10)

8. How often did you [hh member] expect to receive that amount? (HO11)

	Future alimony frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

9. Are there other adult household members who have been married, but whose spouse is not living in the household? (HO12)

	Members married, spouse not in HH
N	No
Y	Yes
Z	Don’t Know

IF YES, GO BACK TO Q. 2.
IF NO, SKIP TO SECTION Q.

Q. Income from Rental Property

1. In [QCM] did anyone living here own property that was rented out to others? (HQ1)

	Own property to rent
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO SECTION R.

2. What is the address of this property? (HQ2)

PRESS ENTER TO DISPLAY THE SCREEN TO RECORD ADDRESS

Rental Property Income

3. During [QCM], was anyone living heregetting rental income from the property? (HQ3)

	Anyone get rental income
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 12. (hq12)

4. Which family member was getting this income? (HQ4)

PRESS ENTER TO DISPLAY HOUSEHOLD MEMBERS, AND SELECT THE ONE RECEIVING THE RENTAL INCOME

	HH member
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

5. In [QCM] who was renting the property and paying the rent? (HQ5)

PRESS ENTER TO DISPLAY A SCREEN TO RECORD NAME, PHONE AND ADDRESS.

6. How much rental income were you [was hh member] getting? Please tell me the full amount of rent, without deducting any of the expenses. (HQ6)

7. How often were you [were hh member] getting that amount? (HQ7)

	Rental income frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

8. Did you [hh member] expect to continue getting that amount for the full year? (HQ8)

	Expect same amount for full year
N	No
Y	Yes
Z	Don’t Know

IF YES, SKIP TO Q. 17. (hq17A)
IF NO:

9. When did you [hh member] expect it to change? (HQ9M/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

10. How much did you [hh member] expect to receive then? (HQ10)

11. How often did you [hh member] expect to receive that amount? (HQ11)

	Future rent income frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

SKIP TO Q. 17. (hq17A)

12. In [QCM], was anyone living here expecting to get rental income from this property during the year? (HQ12)

IF NO, SKIP TO SECTION R.

IF YES:

13. Which family member of your household expected to receive that income? (HQ12A) PRESS ENTER TO DISPLAY THE HOUSEHOLD MEMBERS AND SELECT THE ONE RECEIVING RENTAL INCOME

14. When did you [hh member] expect that income to begin? (HQ14m/d/y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

15. How much did you [hh member] expect to receive then? (HQ15)

16. How often did you [hh member] expect to receive that amount? (HQ16)

	Expected rental income frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

Rental Property Expenses

17. Now I’d like you to think about typical rental expenses on this property. I’m going to read a list of expenses and I’d like you to tell me the amount of each expense that you were [hh member was] responsible for paying and how often you [hh member] had that expense. Also, tell me whether you [hh member] expected these expenses to change, and if so what changes you [hh member] expected during the year.

17a. Were you [was hh member] responsible to pay for maintenance? (HQ17A)

	Responsible for maintenance
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 18. (hq18A)

IF YES:

17b. What were your [hh member’s] average monthly costs for maintenance? (HQ17B)

17c. In [QCM] were you [was hh member] expecting that amount to change significantly? (HQ17C)

	Expected maintenance to change
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 18. (HQ18A)

IF YES:

17d. What did you [hh member] expect the new average monthly amount to be? (HQ17D)

17e. When did you [hh member] expect it to change? (HQ17EM/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

18. Were you [Was hh member] responsible to pay for electricity? (HQ18A)

	Responsible for electricity
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 19. (HQ19A)

IF YES:

18a. What were your [hh member’s] average monthly costs for electricity? (HQ18B)

18b. In [QCM] were you [was hh member] expecting that amount to change significantly? (HQ18C)

	Expected electricity to change
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 19. (HQ19A)

IF YES:

18c. What did you [hh member] expect the new average monthly amount to be? (HQ18D)

18d. When did you [hh member] expect it to change? (HQ18EM/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

19. Were you [Was hh member] responsible to pay for heating, such as gas or oil? (HQ19A)

	Responsible for heating - gas, oil
N	No
Y	Yes
Z	Don’t Know

IF NO, ENTER 0, AND SKIP TO Q. 20. (HQ20A)

IF YES:

19a. What were your [hh member’s] average monthly costs for heating? (HQ19B)

19b. In [QCM] were you [was hh member] expecting that amount to change significantly? (HQ19C)

	Expected heating - gas, oil to change
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 20. (HQ20A)

IF YES:

19c. What did you [hh member] expect the new average monthly amount to be? (HQ19D)

19d. When did you [hh member] expect it to change? (HQ19EM/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

20. Were you [was hh member] responsible to pay for water? (HQ20A)

	Responsible for water
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 21. (HQ21A)

IF YES:

20a. What were your [hh member’s] average monthly costs for water? (HQ20B)

20b. In [QCM] were you [hh member] expecting that amount to change significantly? (HQ20C)

	Expected water to change
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 21. (HQ21A)

IF YES:

20c. What did you [hh member] expect the new average monthly amount to be? (HQ20D)

20d. When did you [hh member] expect it to change? (HQ20E/M/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

21. Were you [was hh member] responsible to pay for other utilities? (HQ21A)

	Responsible for other utilities
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 22. (HQ22A)

IF YES:

21a. What were your [hh member’s] average monthly costs for other utilities? (HQ21B)

21b. In [QCM] were you [was hh member] expecting that amount to change significantly? (HQ21C)

	Expected other utilities to change
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 22. (HQ22A)

IF YES:

21c. What did you [hh member] expect the new average monthly amount to be? (HQ21D)

21d. When did you [hh member] expect it to change? (HQ21EM/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

22. Were you [Was hh member] responsible to pay for insurance? (HQ22A)

	Responsible for insurance
N	No
Y	Yes
Z	Don’t Know

IF NO, ENTER 0, AND SKIP TO Q. 23. (hQ23A)

IF YES:

22a. What were your [hh member’s] average monthly costs for insurance? (HQ22B)

22b. In [QCM] were you [was hh member] expecting that amount to change significantly? (HQ22C)

	Expected insurance to change
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 23. (HQ23A)

IF YES:

22c. What did you [hh member] expect the new amount to be? (HQ22D)

22d. When did you [hh member] expect it to change? (HQ21EM/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

23. Were you [was hh member] responsible to pay for real estate taxes? (HQ23A)

	Responsible for real estate taxes
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 24. (HQ24A)

IF YES:

23a. What were your [was hh member’s] average monthly costs for real estate taxes? (HQ23B)

23b In [QCM] were you [was hh member] expecting that amount to change significantly? (HQ23C)

	Expected real estate taxes to change
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 24. (HQ24A)

IF YES:

23c. What did you [hh member] expect the new amount to be? (HQ23D)

23d. When did you [hh member] expect it to change? (HQ23E/M/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

24. Were you [Was hh member] responsible to pay for mortgage payments? (HQ24A)

	Responsible for mortgage payments
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 25. (HQ25A)

IF YES:

24a. What were your [hh member’s] average monthly costs for mortgage payments? (HQ24B)

24b. In [QCM] were you [was hh member] expecting that amount to change significantly? (HQ24C)

	Expected mortgage payments to change
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 25. (HQ25A)

IF YES:

24c. What did you [hh member] expect the new amount to be? (HQ24D)

24d. When did you [hh member] expect it to change? (HQ24EM/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

25. Were you [Was hh member] responsible to pay for condominium fees? (HQ25A)

	Responsible for condominium fees
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 26. (HQ26A)

IF YES:

25a. What were your [hh member’s] average monthly costs for condominium fees? (HQ25B)

25b. In [QCM] were you [was hh member] expecting that amount to change significantly? (HQ25C)

	Expected condominium fees to change
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 26. (HQ26A)

IF YES:

25c. What did you [hh member] expect the new amount to be? (HQ25D)

25d. When did you [hh member] expect it to change? (HQ25EM/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

26. Were you [Was hh member] responsible to pay for other expenses? (HQ26A)

	Responsible for other 1
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 27. (HQ27A)

IF YES:

26a. What were your [hh member’s] average monthly costs for other expenses? (HQ26B)

26b. In [QCM] were you [was hh member] expecting that amount to change significantly? (HQ26C)

	Expected other 1 to change
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 27. (HQ27A)

IF YES:

26c. What did you [hh member] expect the new amount to be? (HQ26D)

26d. When did you [hh member] expect it to change? (HQ26EM/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

IF RESPONSE TO 26A = NO, SKIP TO VERIFICATION SCREEN Q. 28

27. Were you [was hh member] responsible to pay for any other expenses? (HQ27A)

	Responsible for other 2
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO VERIFICATION SCREEN

IF YES:

27a. What were your [hh member’s] average monthly costs for other expenses? (HQ27B)

27b. In [QCM] were you [was hh member] expecting that amount to change significantly? (HQ27C)

	Expected other 2 to change
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO VERIFICATION SCREEN

IF YES:

27c. What did you [hh member] expect the new amount to be? (HQ27D)

27d. When did you [hh member] expect it to change? (HQ27EM/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

VERIFICATION SCREEN

28. Are there any other household members who own a property to rent to others? (HQ29)

	Any other property for rent
N	No
Y	Yes
Z	Don’t Know

IF YES, REPEAT Q. 2 THROUGH 29.
IF NO, SKIP TO SECTION r.

R. Other Income

1. I’ve asked you about a lot of different kinds of income that this family may be receiving. Is there any other income that I haven’t asked about that this family may have received during [QCM]? For example, lottery winnings that you receive on a regular basis, [If Native American, income from awards by the Indian Claims court,] or any other source? (HS1)

	Any other income
N	No
Y	Yes
Z	Don’t Know

IF NO, AND THERE IS AN UNEARNED INCOME DISCREPANCY, SKIP TO INSTRUCTIONS. .

If no, and there is no discrepancy, skip to section s.

2. Which household member received this income? (HS2)

	HH member
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

3. What type of income was that? (OTHOTH)

Press Enter to display a screen to record the type of income.

What kind of income was that? (HS3A)

	Other income type
LT	Lottery winning
TF	Trust fund
AS	Athletic Scholarship Income
IT	Indian Trust
1	Foster care assistance
2	Student financial assistance
3	Property rebates
4	Grand River Band Ottawa
5	Judgement funds
6	Maine Indian Claims Act
7	Disability assistance for home
8	BIA student assistance
9	Child care block grant
10	Crime assistance
11	LIEAP
12	Medical expense reimbursement
13	Nazi era reparation payments
14	Adoption assistance
15	Income from submarginal land
16	Alaska native claim settlement
17	Exposed to agent orange
18	Spina bifida child of Vietnam Veterans
19	Federated tribes - Yakima / Apache
20	Earned Income Tax Credit
21	SNAP/Food Stamps
22	PASS
23	Monetary Value of groceries by person not living in household
25	Tax rebates provided by the IRS for the EE Stimulus 2008/ARRA onetime $250 recovery payment
96	Additional Other Income

IF SOURCE OF INCOME IS ‘AS’—ATHLETIC SCHOLARSHIP, OR ‘02’—STUDENT FINANCIAL AID:

3a. What was the cost of tuition for [name of student] during the semesters/school sessions immediately prior to and after [QCM]?

IF SOURCE OF INCOME IS ‘ LT’ - LOTTERY WINNINGS, ‘TF’ - TRUST FUND, ‘AS’ - ATHLETIC SCHOLARSHIP, ‘IT’ - INDIAN TRUST OR ‘96’ – ADDITIONAL OTHER INCOME:

NOTE: ITEMS CODED WITH LETTERS ARE SOURCES OF INCOME THAT SHOULD BE INCLUDED; ITEMS CODED WITH NUMBERS ARE EXCLUDED (EXCEPT FOR 96- ADDITIONAL OTHER INCOME). MAKE SURE THE APPROPRIATE SKIP PATTERNS ARE FOLLOWED.

4. How much were you [was hh member] getting? (HS4)

5. How often did you [hh member] get that amount? (HS5)

	Other income frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

VERIFICATION SCREEN

6. In [QCM], did you [hh member] expect to continue getting that amount during the full year? (HS6)

	Expect same amount for full year
N	No
Y	Yes
Z	Don’t Know

IF YES, SKIP TO Q. 10. (HS10)

IF NO:

7. When did you [hh member] expect it to change? (HS7M/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

8. How much did you [hh member] expect to receive then? (HS8)

9. How often did you [hh member] expect to receive that amount? (HS9)

	Future other income frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

10. Is there any other income that I haven’t asked about that anyone living here was getting in [QCM]? (HS10)

	Any other income
N	No
Y	Yes
Z	Don’t Know

IF YES, REPEAT Q. 2 THROUGH 10.

IF NO UNEARNED INCOME DISCREPANCY, SKIP TO SECTION S.

S. Assets

Current Assets

The next questions are about assets such as checking or savings accounts, stocks, bonds, or other valuables that family members own.

1. In [QCM], did anyone living here have:

a. A checking account? (HR1—Occurrence 1 of 17)

	Assets
N	No
Y	Yes
Z	Don’t Know

IF NO, GO TO b.

(1) Who had a checking account? (HR2A)

	Owner 1 of asset
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

(2) Did anyone else have a checking account? (HR2B)

	Owner 2 of asset
98	No one else had this asset
2	First2 Last2
3	First3 Last3
4	First4 Last4

IF YES, SELECT THE HOUSEHOLD MEMBER WHO HAD THE [ITEM].

IF NO, SELECT “No one else had this asset.” REPEAT THIS QUESTION UNTIL THE RESPONSE IS NO.

(3) How many checking accounts did /[hh member] have during [QCM]? (HR2F)

ASK FOR EACH MEMBER WHO HAD A CHECKING ACCOUNT.

b. A savings account? (HR1—Occurrence 2 of 17)

	Assets
N	No
Y	Yes
Z	Don’t Know

IF NO, GO TO c.

(1) Who had a savings account? (HR2A)

	Owner 1 of asset
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

(2) Did anyone else have a savings account? (HR2B)

	Owner 2 of asset
98	No one else had this asset
2	First2 Last2
3	First3 Last3
4	First4 Last4

IF YES, SELECT THE HOUSEHOLD MEMBER WHO HAD THE [ITEM].

IF NO, SELECT “No one else had this asset.” REPEAT THIS QUESTION UNTIL THE RESPONSE IS NO.

(3) How many savings accounts did hh member] have during [QCM]? (HR2F)
ASK FOR EACH MEMBER WHO HAD A SAVINGS ACCOUNT.

c. An IRA-Individual Retirement Account (HR1—Occurrence 3 of 17)

	Assets
N	No
Y	Yes
Z	Don’t Know

IF NO, GO TO d.

(1) Who had an IRA account? (HR2A)

	Owner 1 of asset
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

(2) Did anyone else have an IRA account? (HR2B)

	Owner 2 of asset
98	No one else had this asset
2	First2 Last2
3	First3 Last3
4	First4 Last4

IF YES, SELECT THE HOUSEHOLD MEMBER WHO HAD THE [ITEM].

IF NO, SELECT “No one else had this asset.” REPEAT THIS QUESTION UNTIL THE RESPONSE IS NO.

(3) How many IRA accounts did -[hh member] have during [QCM]? (HR2F)
ASK FOR EACH MEMBER WHO HAD AN IRA ACCOUNT.

d. Money in a 401k Fund that you can withdraw? (HR1—Occurrence 4 of 17)

	Assets
N	No
Y	Yes
Z	Don’t Know

IF NO, GO TO e.

(1) Who had a 401K Fund? (HR2A)

	Owner 1 of asset
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

(2) Did anyone else have a 401K Fund? (HR2B)

	Owner 2 of asset
98	No one else had this asset
2	First2 Last2
3	First3 Last3
4	First4 Last4

IF YES, SELECT THE HOUSEHOLD MEMBER WHO HAD THE [ITEM].

IF NO, SELECT “No one else had this asset.” REPEAT THIS QUESTION UNTIL THE RESPONSE IS NO.

(3) How many 401K funds did /[hh member] have during [QCM]? (HR2F)
ASK FOR EACH MEMBER WHO HAD A 401K FUND.

e. Certificates of Deposit (CD’s)? (HR1—Occurrence 5 of 17)

	Assets
N	No
Y	Yes
Z	Don’t Know

IF NO, GO TO f.

(1) Who had the Certificates of Deposit? (HR2A)

	Owner 1 of asset
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

(2) Did anyone else have the Certificates of Deposit? (HR2B)

	Owner 2 of asset
98	No one else had this asset
2	First2 Last2
3	First3 Last3
4	First4 Last4

IF YES, SELECT THE HOUSEHOLD MEMBER WHO HAD THE [ITEM].

IF NO, SELECT “No one else had this asset.” REPEAT THIS QUESTION UNTIL THE RESPONSE IS NO.

(3) How many CD’s did /[hh member] have during [QCM]? (HR2F)
ASK FOR EACH MEMBER WHO HAD A CD.

f. Stocks? (HR1—Occurrence 6 of 17)

	Assets
N	No
Y	Yes
Z	Don’t Know

IF NO, GO TO g.

1. Who had the Stocks? (HR2A)

   	Owner 1 of asset
   1	First1 Last1
   2	First2 Last2
   3	First3 Last3
   4	First4 Last4

2. Did anyone else have the Stocks? (HR2B)

	Owner 2 of asset
98	No one else had this asset
2	First2 Last2
3	First3 Last3
4	First4 Last4

IF YES, SELECT THE HOUSEHOLD MEMBER WHO HAD THE [ITEM].

IF NO, SELECT “No one else had this asset.” REPEAT THIS QUESTION UNTIL THE RESPONSE IS NO.

(3) In how many companies did -/[hh member] own stock in [QCM]? (HR2F)
ASK FOR EACH MEMBER WHO HAD STOCKS.

g. Bonds? (HR1—Occurrence 75 of 17)

	Assets
N	No
Y	Yes
Z	Don’t Know

IF NO, GO TO h.

1. Who had the Bonds? (HR2A)

	Owner 1 of asset
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

( 2) Did anyone else have the Bonds? (HR2B)

	Owner 2 of asset
98	No one else had this asset
2	First2 Last2
3	First3 Last3
4	First4 Last4

IF YES, SELECT THE HOUSEHOLD MEMBER WHO HAD THE [ITEM].

IF NO, SELECT “No one else had this asset.” REPEAT THIS QUESTION UNTIL THE RESPONSE IS NO.

(3) How many bonds did _/[hh member] have during [QCM]? (HR2F)
ASK FOR EACH MEMBER WHO HAD A BOND.

h. Treasury bills (T-bills)? (HR1—Occurrence 8 of 17)

	Assets
N	No
Y	Yes
Z	Don’t Know

IF NO, GO TO i.

1. Who had the Treasury Bills? (HR2A)

   	Owner 1 of asset
   1	First1 Last1
   2	First2 Last2
   3	First3 Last3
   4	First4 Last4

2. Did anyone else have the Treasury Bills? (HR2B)

	Owner 2 of asset
98	No one else had this asset
2	First2 Last2
3	First3 Last3
4	First4 Last4

IF YES, SELECT THE HOUSEHOLD MEMBER WHO HAD THE [ITEM].

IF NO, SELECT “No one else had this asset.” REPEAT THIS QUESTION UNTIL THE RESPONSE IS NO.

(3) How many Treasury Bills did _/[hh member] have during [QCM]? (HR2F)
ASK FOR EACH MEMBER WHO HAD A TREASURY BILL.

i. Money in a Money Market Fund? (HR1—Occurrence 9 of 17)

	Assets
N	No
Y	Yes
Z	Don’t Know

IF NO, GO TO j.

(1) Who had a Money Market Fund? (HR2A)

	Owner 1 of asset
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

(2) Did anyone else have a Money Market Fund? (HR2B)

	Owner 2 of asset
98	No one else had this asset
2	First2 Last2
3	First3 Last3
4	First4 Last4

IF YES, SELECT THE HOUSEHOLD MEMBER WHO HAD THE [ITEM].

IF NO, SELECT “No one else had this asset.” REPEAT THIS QUESTION UNTIL THE RESPONSE IS NO.

(3) How many Money Market accounts did -/[hh member] have during [QCM]? (HR2F)

ASK FOR EACH MEMBER WHO HAD A MONEY MARKET

j. Real estate or other investments? (HR1—Occurrence 10 of 17)

	Assets
N	No
Y	Yes
Z	Don’t Know

IF NO, GO TO k.

1. Who had the Real Estate investment? (HR2A)

   	Owner 1 of asset
   1	First1 Last1
   2	First2 Last2
   3	First3 Last3
   4	First4 Last4

2. Did anyone else have the Real Estate investment? (HR2B)

	Owner 2 of asset
98	No one else had this asset
2	First2 Last2
3	First3 Last3
4	First4 Last4

IF YES, SELECT THE HOUSEHOLD MEMBER WHO HAD THE [ITEM].

IF NO, SELECT “No one else had this asset.” REPEAT THIS QUESTION UNTIL THE RESPONSE IS NO.

(3) How many real estate investments did you/[hh member] have during [QCM]? (HR2F)
ASK FOR EACH MEMBER WHO HAD REAL ESTATE INVESTMENTS.

k. Money in a retirement fund that you could take out without quitting or losing your job? (HR1—Occurrence 11 of 17)

	Assets
N	No
Y	Yes
Z	Don’t Know

IF NO, GO TO l.

(1) Who had a Retirement Fund? (HR2A)

	Owner 1 of asset
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

(2) Did anyone else have a Retirement Fund? (HR2B)

	Owner 2 of asset
98	No one else had this asset
2	First2 Last2
3	First3 Last3
4	First4 Last4

IF YES, SELECT THE HOUSEHOLD MEMBER WHO HAD THE [ITEM].

IF NO, SELECT “No one else had this asset.” REPEAT THIS QUESTION UNTIL THE RESPONSE IS NO.

(3) How many retirement fund accounts did -/[hh member] have during [QCM]? (HR2F)

ASK FOR EACH MEMBER WHO HAD A RETIREMENT FUND.

l. A trust fund that you could withdraw money from? (HR1—Occurrence 12 of 17)

	Assets
N	No
Y	Yes
Z	Don’t Know

IF NO, GO TO m.

(1) Who had a Trust Fund? (HR2A)

	Owner 1 of asset
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

(2) Did anyone else have a Trust Fund? (HR2B)

	Owner 2 of asset
98	No one else had this asset
2	First2 Last2
3	First3 Last3
4	First4 Last4

IF YES, SELECT THE HOUSEHOLD MEMBER WHO HAD THE [ITEM].

IF NO, SELECT “No one else had this asset.” REPEAT THIS QUESTION UNTIL THE RESPONSE IS NO.

(3) How many trust fund accounts did -/[hh member] have during [QCM]? (HR2F)
ASK FOR EACH MEMBER WHO HAD A TRUST FUND.

m. A Keogh Fund that can be withdrawn from? (HR1—Occurrence 13 of 17)

	Assets
N	No
Y	Yes
Z	Don’t Know

IF NO, GO TO n.

(1) Who had a Keogh Fund? (HR2A)

	Owner 1 of asset
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

(2) Did anyone else have a Keogh Fund? (HR2B)

	Owner 2 of asset
98	No one else had this asset
2	First2 Last2
3	First3 Last3
4	First4 Last4

IF YES, SELECT THE HOUSEHOLD MEMBER WHO HAD THE [ITEM].

IF NO, SELECT “No one else had this asset.” REPEAT THIS QUESTION UNTIL THE RESPONSE IS NO.

(3) How many Keogh funds did -/[hh member] have during [QCM]? (HR2F)
ASK FOR EACH MEMBER WHO HAD A KEOGH FUND.

n. Money in a mutual fund? (HR1—Occurrence 14 of 17)

	Assets
N	No
Y	Yes
Z	Don’t Know

IF NO, GO TO o.

(1) Who had a Mutual Fund? (HR2A)

	Owner 1 of asset
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

(2) Did anyone else have a Mutual Fund? (HR2B)

	Owner 2 of asset
98	No one else had this asset
2	First2 Last2
3	First3 Last3
4	First4 Last4

IF YES, SELECT THE HOUSEHOLD MEMBER WHO HAD THE [ITEM].

IF NO, SELECT “No one else had this asset.” REPEAT THIS QUESTION UNTIL THE RESPONSE IS NO.

(3) How many mutual funds did -/[hh member] have during [QCM]? (HR2F)
ASK FOR EACH MEMBER WHO HAD A TRUST FUND.

o. A life insurance policy with a cash value—that is, one that you could borrow against? (HR1—Occurrence 15 of 17)

	Assets
N	No
Y	Yes
Z	Don’t Know

IF NO, GO TO p.

1. Who had Life Insurance? (HR2A)

	Owner 1 of asset
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

2. Did anyone else have Life Insurance? (HR2B)

	Owner 2 of asset
98	No one else had this asset
2	First2 Last2
3	First3 Last3
4	First4 Last4

IF YES, SELECT THE HOUSEHOLD MEMBER WHO HAD THE [ITEM].

IF NO, SELECT “No one else had this asset.” REPEAT THIS QUESTION UNTIL THE RESPONSE IS NO.

(3) How many life insurance policies did /[hh member] have during [QCM]? (HR2F)
ASK FOR EACH MEMBER WHO HAD A LIFE INSURANCE POLICY.

p. Property or other belongings that you were keeping as an investment—such as antiques, coins, or other collections? (HR1—Occurrence 16 of 17)

	Assets
N	No
Y	Yes
Z	Don’t Know

IF NO, GO TO q.

1. Who had Property or other belongings? (HR2A)

   	Owner 1 of asset
   1	First1 Last1
   2	First2 Last2
   3	First3 Last3
   4	First4 Last4

2. Did anyone else have Property or other belongings? (HR2B)

	Owner 2 of asset
98	No one else had this asset
2	First2 Last2
3	First3 Last3
4	First4 Last4

IF YES, SELECT THE HOUSEHOLD MEMBER WHO HAD THE [ITEM].

IF NO, SELECT “No one else had this asset.” REPEAT THIS QUESTION UNTIL THE RESPONSE IS NO.

3. How many properties did [hh member] have during [QCM]? (HR2F)
   ASK FOR EACH MEMBER WHO HAD PROPERTY OR OTHER INVESTMENTS.

q. Other assets I haven’t asked about? (HR1—Occurrence 17 of 17)

	Assets
N	No
Y	Yes
Z	Don’t Know

IF NO AND NO TO 1.a. THROUGH 1.n., SKIP TO Q. 33. (HR18)

1. Who had Other Assets? (HR2A)

   	Owner 1 of asset
   1	First1 Last1
   2	First2 Last2
   3	First3 Last3
   4	First4 Last4

2. Did anyone else have Other Assets? (HR2B)

	Owner 2 of asset
98	No one else had this asset
2	First2 Last2
3	First3 Last3
4	First4 Last4

IF YES, SELECT THE HOUSEHOLD MEMBER WHO HAD THE [ITEM].

IF NO, SELECT “No one else had this asset.” REPEAT THIS QUESTION UNTIL THE RESPONSE IS NO.

(3) How many other assets did /[hh member] have during [QCM]? (HR2F)
ASK FOR EACH MEMBER WHO HAD OTHER ASSETS.

FOR EACH CHECKING AND SAVINGS ACCOUNT, ASK Q. 1 THROUGH Q. 8. IF THERE IS NO CHECKING OR SAVINGS ACCOUNT, SKIP TO QUESTIONS 9. (HR5)

1. In [QCM], how much money did you [hh member] usually keep/have in the [account]? (HR5)

2. Were you [hh member] receiving income from the [account]? (HR6)

	Receiving income from asset
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO vERIFICATION SCREEN
IF YES:

3. How much income did you [hh member] receive from the [account] in [QCM]? (HR7)

4. How often did you [hh member] get that amount? (HR8)

	Asset income frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

VERIFICATION SCREEN:

5. Did you [hh member] get interest on that account? (HR9)

	Getting interest
N	No
Y	Yes
Z	Don’t Know

IF NO,aND MORE ASSETS SKIP TO next asset’s q.1. (HR5)
IF YES:

6. What was the interest rate? (HR10)

ENTER PERCENTAGE. FOR EXAMPLE .01 should BE ENTERED AS 1.0. ENTER 99.99 FOR DON’T KNOW.

IF THIS IS AN OWNER ADMINISTERED CASE ASK THE NEXT TWO QUESTIONS, OTHERWISE SKIP TO THE NEXT ASSET.

7. Was that a joint account with someone outside the household? (HR12)

	Asset owned with someone else
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO NEXT ASSET.

8. What percent of the account was owned by you [hh member]? (HR13)

FOR IRA, 401K, CD’S, STOCKS, BONDS, TREASURY BILLS, RETIREMENT FUND, MONEY MARKET FUNDS, TRUST FUND , KEOGH FUND ASK Q. 9 THROUGH Q. 17. IF THERE ARE NO IRA, 401K, CD’S, STOCKS, BONDS, TREASURY BILLS, RETIREMENT FUND, MONEY MARKET FUNDS, TRUST FUND, OR KEOGH FUND, SKIP TO QUESTIONS 18. (HR5)

In [QCM], how much money did you [hh member] have in the [account/fund]? (HR5)

IF TRUST FUND, SKIP TO VERIFICATION SCREEN

9. Were you/was [hh member] receiving income from the [asset]? (HR6)

	Receiving income from asset
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO VERIFICATION SCREEN
IF YES:

10. How much income did you [hh member] receive from the [asset] in [QCM]? (HR7)

11. How often do/did you [hh member] get that amount? (HR8)

	Asset income frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

VERIFICATION SCREEN:

12. Did you [hh member] get interest on that account? (HR9)

IF NO AND OA, SKIP TO Q. 15. (HR12) If no and not OA, Skip to Q.17. (HR14)
IF YES:

13. What was the interest rate? (HR10)

ENTER THE PERCENTAGE. FOR EXAMPLE .01 should BE ENTERED AS 1.0. ENTER 99.99 FOR DON’T KNOW.

14. Question Removed.

IF THIS IS AN OWNER ADMINISTERED CASE ASK THE NEXT TWO QUESTIONS, OTHERWISE SKIP TO THE NEXT ASSET.

15. Was the [asset] jointly owned with someone outside the household? (HR12)

	Asset owned with someone else
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 17. (hr14)

16. What percent of the [asset] was owned by the household? (HR13)

17. If you [hh member] were to sell the [asset], what would be the cost of selling or cashing the/that asset? For example, would you/he/she have to pay a lawyer’s fee or a penalty, or any other costs? (HR14)

IF YES, How much?

IF DON’T KNOW, ENTER 99999.

IF NO COSTS, ENTER 0.

FOR MUTUAL FUNDS, REAL ESTATE, LIFE INSURANCE, ASK Q. 18 THROUGH q. 21. IF THERE ARE NO MUTUAL FUNDS, REAL ESTATE, OR LIFE INSURANCE, SKIP TO QUESTIONS 22. (HR5)

18. In [QCM] what was the cash value of your/[hh member] [asset]? (HR5)

IF MUTUAL FUND, ASK Q.9 (HR6)

VERIFICATION SCREEN

IF THIS IS AN OWNER ADMINISTERED CASE ASK THE NEXT TWO QUESTIONS, OTHERWISE SKIP TO THE NEXT ASSET.

19. Was the [asset] jointly owned with someone outside the household? (HR12)

	Asset owned with someone else
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 21. (HR14)

20. What percent of the [asset] is owned by the household? (HR13)

21. If you [hh member] were to sell the [asset], what would be the cost of selling the asset? For example, would you have to pay a lawyer’s fee or a penalty, or any other costs? (HR14)

IF YES, How much?

IF DON’T KNOW, ENTER 99999.

IF NO COSTS, ENTER 0.

FOR RETIREMENT FUNDS, PROPERTY OR OTHER BELONGINGS ASK Q. 22 THROUGH Q. 27. IF THERE ARE NO RETIREMENT FUNDS, PROPERTY OR OTHER BELONGINGS, SKIP TO QUESTIONS 28. (HR5)

22. In QCM what was the value of the [asset]? How much money did you [hh member] have in the [account/fund]? (HR5)

VERIFICATION SCREEN

23. Did you get interest on that account? (HR9)

IF NO, SKIP TO Q. 25. (HR1)
IF YES:

24. What was the interest rate?

IF THIS IS AN OWNER ADMINISTERED CASE ASK THE NEXT TWO QUESTIONS, OTHERWISE SKIP TO THE NEXT ASSET.

25. Was the [asset] jointly owned with someone outside the household? (HR12)

	Asset owned with someone else
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 27. (HR14)

26. What percent of the [asset] is owned by the household? (HR13)

27. If you [hh member] were to sell the [asset], what would be the cost of selling or cashing the asset? For example, would you/he/she have to pay a lawyer’s fee or a penalty, or any other costs? (HR14)

IF YES, How much?

IF DON’T KNOW, ENTER 99999.

IF NO COSTS, ENTER 0.

FOR OTHER ASSETS ASK Q. 28 THROUGH Q. 32. IF THERE ARE NO OTHER ASSETS, SKIP TO QUESTIONS 33. (HR18)

28. What is the value of the [asset]? How much money did you [hh member] have in [account/fund]? (HR5)

29. Were you [hh member] receiving income from [asset]? (HR6)

IF NO, SKIP TO Verification screen
IF YES: 39. How much income did you [hh member] receive from [asset] in [QCM]? (HR7)

40. How often do you [hh member] get that amount? (HR8)

	Asset income frequency
1	Annually
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

. VERIFICATION SCREEN

IF THIS IS AN OWNER ADMINISTERED CASE ASK THE NEXT TWO QUESTIONS, OTHERWISE SKIP TO THE NEXT ASSET.

30. Was the [asset] jointly owned with someone outside the household? (HR12)

	Asset owned with someone else
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 32. (HR14)

31. What percent of the [asset] was owned by the household? (HR13)

32. If you [hh member] were to sell the [asset], what would be the cost of selling or cashing the asset? For example, would you/he/she have to pay a lawyer’s fee or a penalty, or any other costs? (HR14)

IF YES, How much?

IF DON’T KNOW, ENTER 99999.

IF NO COSTS, ENTER 0.

Assets Disposed of in Last 2 Years

These next questions are about assets anyone living in the household may have sold or given away.

33. Now please think back to [2 years before QCM]. Has any household member sold any assets or given away any assets since [2 years before QCM]? (HR18)

	Sold assets Last 2 years
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO SECTION T.

34. What member of the household sold or gave away the asset? (HR19)

	Owner 1 of asset
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

35. What was that asset? (HR20)

	Type of asset
1	Cash
2	Checking
3	Savings
4	IRA
5	401K
6	Certificate of deposit
7	Stocks
8	Bonds
9	Treasury bills
10	Money market fund
11	Real estate
12	Retirement fund
13	Trust fund
14	Keogh fund
15	Mutual fund
16	Life insurance
17	Valuables
96	Other
99	Missing

36. How much did you [hh member] get for it? (HR21)

37. Do you/[does hh member] think it was worth more than that? (HR22)

	Asset worth more than it was sold
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 40. (hr25)

38. How much did you/[hh member] think it was worth? (HR23)

39. Why didn’t you [hh member] get the full value for the asset? (HR24)

PRESS ENTER TO DISPLAY THE SCREEN TO RECORD THE REASON

40. Did you [hh member] have any expenses when disposing of that asset—for example, lawyers, brokers, penalties, or any other costs? (HR25)

	Any expenses in disposing of assets
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 42. (HR27)

41. How much were those expenses? (HR26)

42. Are there any other assets that any household member sold since [two years prior to QCM]? (HR27)

	More assets sold in Last 2 years
N	No
Y	Yes
Z	Don’t Know

IF YES, REPEAT Q. 33 THROUGH 49.
IF NO, GO TO SECTION T.

THE NEXT FEW SECTIONS (SECTION T. THROUGH SECTION V.) ASK QUESTIONS ABOUT EXPENSES. DEPENDING ON THE HOUSEHOLD CHARACTERISTICS SOME OR ALL OF THE EXPENSE SECTIONS MAY BE SKIPPED. THE SKIP LOGIC IS LISTED BELOW.

IF HH HAS CHILDREN UNDER AGE 13, CONTINUE WITH SECTION T.

IF HH HAS NO CHILDREN UNDER 13, BUT IS ELDERLY OR DISABLED, SKIP TO SECTION U.

IF HH HAS NO CHILDREN UNDER 13 AND IS NOT ELDERLY OR DISABLED BUT HAS A DISABLED MEMBER, SKIP TO SECTION V.

IF HH HAS NO CHILDREN UNDER 13, IS NOT ELDERLY OR DISABLED, AND HAS NO DISABLED MEMBER, SKIP TO SECTION X.

T. Child Care Expenses

1. During [QCM], or anyone living here paying anyone for child care? (HT1)

	Paying for child care
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO SECTION U.

2. a. Who was the first child these child care costs were for? (HT2A)

	Child 1
98	No child received child care expenses
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

ENTRY MESSAGE: IF HHM OVER 13 IS SELECTED. THE MEMBER YOU HAVE SELECTED IS NOT A CHILD UNDER AGE 13. IF CHILD CARE COSTS ARE IN FACT INCURRED FOR THIS MEMBER, CONTINUE. IF NOT, CLICK OK, THEN PRESS SHIFT/TAB TO GO BACK AND SELECT ANOTHER HOUSEHOLD MEMBER.

b. Who was the second child these child care costs were for? (HT2B)

	Child 2
98	No other child received child care expenses
2	First2 Last2
3	First3 Last3
4	First4 Last4

IF THESE COSTS WERE ONLY FOR ONE CHILD, SELECT “No other child received child care.”

c. Who was the third child these child care costs were for? (HT2C)

	Child 3
98	No other child received child care expenses
3	First3 Last3
4	First4 Last4

IF THESE COSTS WERE ONLY FOR TWO CHILDREN, SELECT “No other child received child care.”

Note: HDCS allows for 10 household members.

3. Who was the household member paying for the childcare? (HT3)

	HH member paying child care
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

4. Can you tell me the name of the child care provider? (HT4)

PRESS ENTER TO DISPLAY A SCREEN TO ENTER THE NAME OF THE PROVIDER

5. a. Is the provider a household member? (HT5A)

	Is provider a family member
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO q. 6. (HT6)

IF YES, SELECT HIM/HER FROM THE HOUSEHOLD MEMBER LIST

b. Who was the household member providing the child care? (HT5)

	HH member provide child care
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

6. How much were you [was hh member] paying for the child care? I mean costs that you [hh member] paid for and were not reimbursed by an outside source. (HT6)

7. How often did you [hh member] pay that amount? (HT7)

	Pay frequency
1	Annually
4	Quarterly
6	Every two months
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly
90	Hourly
92	Daily

IF HOURLY:

7a. How many hours a week were you [was he/she] paying for child care? (HT8)

7b. How many weeks a year? (HT10)

IF DAILY:

7a. How many days a week were you [was he/she] paying for child care? (HT8)

7b. How many weeks a year? (HT10)

8. Is the amount you [hh member] pay(s) about the same throughout the year? (HT11)

	Same amount throughout the year
N	No
Y	Yes
Z	Don’t Know

*PROBE: Even if school is out or if you’re [he’s/she’s] not working?

IF YES, SKIP TO verification screen

9. About how many months a year do you [does hh member] pay that amount? (HT12)

THE TOTAL NUMBER OF MONTHS FOR WHICH CHILD CARE IS PAID SHOULD NOT EXCEED 12.

10. Do you [does hh member] pay a different amount during other months of the year? (HT13)

	Different amount during other months
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Verification screen
IF YES, REPEAT Q. 6 THROUGH 10.

VERIFICATION SCREEN

11. Why were you [was hh member] paying for child care? (HT14)

	Why paying for child care
1	Working
2	Looking for work
3	Attending school
6	Other

IF WORKING, SKIP TO Q. 16. (ht19)
IF LOOKING FOR WORK, SKIP TO Q. 12. (ht15)
IF ATTENDING SCHOOL, SKIP TO Q. 13. (HT16)

12. How many hours per week did you/[hh member] spend looking for work? (HT15)

SKIP TO Q. 16. (HT19)

13. Where were you [was hh member] going to school? (HT16)

PRESS ENTER TO DISPLAY A SCREEN TO RECORD SCHOOL NAME.

14. About how many hours a week did you [hh member] spend at school and going to and from school? (HT17)

15. About how many weeks a year did you [hh member] expect to go to school? (HT18)

16. In [QCM], did anyone else in the household pay child care costs or did you/[hh member] pay child care costs to someone else? (HT19)

	Anyone else pay child care
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO SECTION U.
IF YES, REPEAT Q. 2 THROUGH 16.

U. Medical Expenses

ELDERLY AND DISABLED HH, CONTINUE WITH SECTION U.

NONELDERLY HH WITH DISABLED MEMBER AND HH MEMBER WORKING IN QCM, SKIP TO SECTION V.

ALL OTHERS, SKIP TO INSTRUCTIONS FOR SECTION X.

These next questions are about this household’s medical expenses that anyone living here was paying during a typical year. Don’t include expenses covered by insurance or paid for by someone not living here.

1. During [QCM] was anyone in this household paying for insurance premiums for health insurance, nursing home insurance, or Medicare? Include any payments anyone in this household made through another agency or employer. (HU1)

	Have health insurance
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 7. (HU7)

2. Which household member paid for this insurance? (HU2)

2a. What type of insurance is this? (HU2B)

	What Type of Insurance
1	Private Health Insurance
2	Nursing Home
3	Dental
4	Medicare (medical and hospital insurance Part A and B)
5	Prescription
6	Medicare Prescription Insurance (Part D)

If the response is code 1, 2, 3, or 5, go to question 2d.

If the response is code 4, or 6, Go TO Question 2e:

2b. Did you/[hh member] pay for the insurance directly or through a company or agency? (HU2B1)

SELECT HOW THE TENANT PAID FOR INSURANCE FROM\ THE LIST BELOW

	How insurance premium was paid
60	Insurance paid directly by household member
66	Insurance paid through employer
67	Insurance (including Medicare) paid through an other unearned income source (e.g., a pension)

IF THE INSURANCE PREMIUM IS DEDUCTED FROM THE GROSS SOCIAL SECURITY BENEFIT, SELECT CODE 67." (HU2b1)

IF PAID DIRECTLY, SKIP TO Q. 3. (HU3)

2c. Were your/[was hh member's] social security benefits reduced to pay for medicare or did you[he/she] pay the premium directly?"

3. Can you tell me the name of the insurance company? (HU3)

PRESS ENTER TO DISPLAY A SCREEN TO ENTER THE INSURANCE COMPANY

4. How much was the insurance premium for this policy? How much did you/[hh member] pay? (HU4)

5. How often did you [hh member] pay that amount? (HU5)

	Pay frequency
01	Annually
02	Semi-annually
04	Quarterly
06	Bimonthly
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

VERIFICATION SCREEN

6. During [QCM], was anyone in the household paying for any other insurance premiums for health insurance, nursing home insurance, or Medicare? (HU6)

	Anyone else pay for medical insurance
N	No
Y	Yes
Z	Don’t Know

IF YES, GO BACK TO Q. 2. (hu2)

7. In [QCM] did anyone in this household pay for visits to a doctor or a clinic, dentist, eye doctor, or any other health care provider on a regular basis? This includes co-pays, but not costs covered by insurance or paid by someone outside the household. (HU7)

	Visits to doctor, dentist, eye doctor or other
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q.17. (HU34)

8. What type of health service was provided? (HU7A)

	Type of health service
1	Doctor or clinic
2	Dentist
3	Eye doctor
4	Other health provider

9. Which household member visited the [health service] on a regular basis? (HU8)

10. Which household member paid for these visits to the [health service]? (HU9)

11. What [health service] did you [hh member] go to? (HU10)

PRESS ENTER TO DISPLAY A SCREEN TO RECORD THE NAME OF THE PROVIDER

12. How often did you [hh member] see the doctor [dentist/eye doctor /other health provider]/go to the clinic? (HU11)

	Frequency of visits
01	Annually
02	Semi-annually
04	Quarterly
06	Bimonthly
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

13. How much did you [hh member] usually pay when you [he/she] saw the doctor [dentist/eye doctor /other health provider]/went to the clinic? (HU12)

VERIFICATION SCREEN

14. Did you [hh member] expect to have those expenses for the full year? (HU13)

	Expect costs for the full year
N	No
Y	Yes
Z	Don’t Know

IF YES; SKIP TO Q.16. (HU15)

IF NO:

15. When did you [hh member] expect that expense to change? (HU14M/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

16. Did anyone else in the household pay for visits to this doctor, clinic, dentist, or eye doctor; or did anyone else in the household pay for visits to any other health care provider? (HU15)

	Anyone else visit for treatment
N	No
Y	Yes
Z	Don’t Know

IF YES, GO BACK TO Q.9. (HU7A)

17. Was any family member living here paying for prescriptions on a regular basis? This includes co-pays but not costs covered by insurance or somebody outside the household. (HU34)

	Prescriptions
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 26. (hu43)

18. Which household member used prescription medicine on a regular basis? (HU35)

19. Which household member paid for these prescriptions? (HU36)

20. What was the name of the pharmacy where the prescriptions were purchased? (HU37)

PRESS ENTER TO DISPLAY A SCREEN TO RECORD THE NAME OF THE PROVIDER

21. How often did you [hh member] refill these prescriptions? (HU38)

22. How much did you [hh member] usually pay for these prescriptions? (HU39)

VERIFICATION SCREEN

23. Did you [hh member] expect to have these expenses for the full year? (HU40)

	Expect costs for the full year
N	No
Y	Yes
Z	Don’t Know

IF YES: SKIP TO Q. 25 (HU42)

IF NO:

24. When did you [hh member] expect that expense to end? (HU41M/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

25. Did anyone else in the household pay for any other prescriptions on a regular basis? This includes co-pays but not costs covered by insurance or somebody outside the household. (HU42)

	Anyone else for prescriptions
N	No
Y	Yes
Z	Don’t Know

IF YES, GO BACK TO Q. 18. (hu35)

26. Was any family member living here paying for any other medical expenses on a regular basis? (HU43)

	Other medical expenses
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q.36. (HU52)

27. Which household member had other medical expenses on a regular basis? (HU44)

28. Which household member paid for these other medical expenses? (HU45)

29. Where did you [hh member] receive these other medical services?

30. Who did you [hh member] pay for those services? (HU45B)

PRESS ENTER TO DISPLAY A SCREEN TO RECORD THE NAME OF THE PROVIDER

SELECT THE MEDICAL EXPENSE CODE (HU46)

	Medical expense codes
01	Services of doctors, nurses, dentists, other health care prof.
02	Services of health care facility (including x-rays & others)
03	Health insurance
05	Prescriptions
06	Non-prescription drugs and medical supplies
07	Eyeglasses
08	Hearing aids
09	Transportation to and from treatment
10	Medical care of permanently institutionalized if on lease
11	Animal services
13	Care providers (including live-in aide)
96	Other medical

31. How often did you [hh member] have that expense? (HU47)

	Frequency of visits
01	Annually
02	Semi-annually
04	Quarterly
06	Bimonthly
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

32. How much did you [hh member] usually pay? (HU48)

VERIFICATION SCREEN

33. Did you [hh member] expect to have these expenses for the full year? (HU49)

	Expect costs for the full year
N	No
Y	Yes
Z	Don’t Know

IF YES: SKIP TO Q. 35 (HU51)

IF NO:

34. When did you [hh member] expect that expense to end? (HU50M/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

35. Did anyone in the household expect to have any other medical expenses on a regular basis? (HU51)

	Anyone else visit for treatment
N	No
Y	Yes
Z	Don’t Know

IF YES, GO BACK TO Q. 27. (hu44)

36. In [QCM], did any household member pay for outstanding medical bills on a regular basis? Do not include expenses you already told me about. (HU52)

	Outstanding bills
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO INSTRUCTIONS ON THE BOTTOM OF NEXT PAGE.

37. Which household member was paying outstanding medical bills on a regular basis? (HU53)

38. Who did you [hh member] pay? (HU54)

39. What type of medical expense was it? (HU55)

sELECT THE MEDICAL EXPENSE CODE

	Medical expense codes
01	Services of doctors, nurses, dentists, other health care professionals
02	Services of health care facility(e.g. hospital, clinic) (includes x-rays and other procedures conducted at such facilities)
03	Health insurance
04	Medicare
05	Prescriptions
06	Non-prescription drugs and medical supplies
07	Eyeglasses
08	Hearing aids
09	Transportation to and from treatment
10	Medical care of permanently institutionalized member if included on lease
11	Animal services
12	Outstanding medical bills on a regular basis
13	Care providers (including live-in aide)
14	Medicare prescription Insurance (Part D)
95	None of the above
96	Other Medical

40. How often did you [hh member] have that expense? (HU56)

	Frequency of bills
01	Annually
02	Semi-annually
04	Quarterly
06	Bimonthly
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

41. How much did you [hh member] pay? (HU57)

VERIFICATION SCREEN

42. Did you [hh member] expect to have that expense for the full year? (HU58)

	Expect costs for the full year
N	No
Y	Yes
Z	Don’t Know

IF YES; SKIP TO Q.44. (HU60)

IF NO:

43. When did you [hh member] expect that expense to end? (HU59M/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

44. Did anyone in the household have any other outstanding medical expenses that you, he or she was paying on a regular basis? (HU60)

	Anyone else has outstanding bills
N	No
Y	Yes
Z	Don’t Know

IF YES, GO BACK TO Q. 37. (hu53)

V. Disability Assistance Expenses (not medical)

IF HOUSEHOLD HAS A DISABLED MEMBER AND THE HOUSEHOLD MEMBER IS WORKING DURING QCM, CONTINUE WITH SECTION V.

IF HOUSEHOLD HAS A DISABLED MEMBER, BUT NO ONE IN THE HOUSEHOLD IS WORKING, SKIP TO SECTION X.

IF HOUSEHOLD HAS NO DISABLED MEMBER, SKIP TO SECTION X.

These next questions are about expenses that were incurred to help take care of or support a family member with a disability.

Live-In Aide IF NO LIVE-IN AIDE, SKIP TO Q. 7. (hv7)

1. In [QCM] did anyone in the household pay to have anyone live here? I am asking about the amount someone in the household paid, not amounts paid by insurance or someone not living in the household. (HV1)

	Pay live-in aide
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 7. (hv7)

2. Which household member paid [live-in aide]? (HV2)

	HH member
1	First1 Last1
2	First2 Last2
3	First3 Last3
4	First4 Last4

3. How much did you/[hh member] pay him/her? I’m asking about the amount that you paid, not any amounts that were paid for by insurance or someone else. (HV3)

4. How often did you [hh member] pay that amount? (HV4)

	Live-in aide Pay frequency (codes)
01	Annually
02	Twice a year
04	4 times a year
06	Every other month
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly
96	Other

VERIFICATION SCREEN:

5. Did [live-in aide] stay here all year? (HV5)

	Live-in-aide stay all year
N	No
Y	Yes
Z	Don’t Know

IF YES, SKIP TO Q. 7. (hv7)

6. How many months did he/she live here? (HV6)

Caregiver

7. In [QCM] did anyone in the household pay for anyone else to take care of the household member who was disabled? (HV7)

	Other caregiver
N	No
Y	Yes
Z	Don’t Know

IF NO, SKIP TO Q. 14. (hv15)

8. Which household member paid for that caregiver? (HV8)

SELECT THE HOUSEHOLD MEMBER WHO PAID THE CAREGIVER.

9. Can you tell me the name of the caregiver? (HV9)

PRESS ENTER TO DISPLAY A SCREEN TO RECORD THE PROVIDER’S NAME

10. How much did you [hh member] pay the caregiver? I’m asking about the amount that you [hh member] paid, not any amounts that are paid for by insurance or someone else. (HV10)

11. How often did you [hh member] pay that amount? (HV11)

	Caregiver pay frequency
1	Annually
02	Twice a year
04	4 times a year
06	Every other month
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly
90	Hourly
92	Daily

IF HOURLY:

11a. How many hours a week did the caregiver usually come here? (HV12)

11b. How many days a week did the caregiver usually come here (HV12)

IF DAILY:

11a. How many days a week did the caregiver usually come here? (HV13)

11b. How many weeks a year did the caregiver usually come here? (HV13)

VERIFICATION SCREEN

12. In QCM, did anyone in the household pay for anyone else to take care of the household member who was disabled? (HV14)

	Other caregiver
N	No
Y	Yes
Z	Don’t Know

IF YES, GO BACK TO Q. 8. (hv8)

Special Equipment

14. During [QCM], did members of your family who were living here pay for any special equipment for the household member who was disabled, such as a wheelchair or specially equipped cars or vans? I’m asking about amounts paid by a household member, not amounts paid by insurance or somebody outside the household. (HV15)

	Special equipment
N	No
Y	Yes
Z	Don’t Know

IF NO, go to Discrepancy Screen or END OF INTERVIEW

15. Who paid for the equipment? (HV16)

16. What kind of equipment was it? (HV17)

	Auxiliary to display equipment
3	Van
4	Auxiliary Apparatus
96	Other

ENTER CODE AND TEXTUAL ANSWER

17. Did you [hh member] rent it, buy it (pay the full amount), or were you [hh member] making installment payments? (HV18)

	How was it acquired
1	Paid in full
2	Making installment payments
3	Renting
8	Don’t know

18. When did you [hh member] buy it/start renting it? (HV19M/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

IF PAID IN FULL:

19. How much did it cost? (HV20)

IF INSTALLMENT PAYMENTS OR RENTED:

20. How much were your [hh member’s] payments? (HV21)

21. How often did you [hh member] pay that amount? (HV22)

	Equipment pay frequency
1	Annually
02	Semi-annually
04	Quarterly
06	Bimonthly
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

IF INSTALLMENT PAYMENTS:

22. When will it be paid off? (HV23M/D/Y) ENTER MM/DD/YYYY

IF THE DAY IS NOT CLEAR, THEN ESTIMATE (NEAR BEGINNING = 01, NEAR MIDDLE = 15, NEAR END = 28, 30, OR 31)

Maintenance Cost

23. Did you/[hh member] have any costs for maintenance of this equipment? (HV23A)

	Maintenance costs
N	No
Y	Yes
Z	Don’t know

24. How much were you/[was hh member] paying in maintenance cost during [QCM]? (HV23B)

25. How often did you [hh member] pay that amount? (HV23C)

	Maintenance pay frequency
1	Annually
02	Semi-anually
04	Quarterly
06	Every other month
12	Monthly
24	Twice a month
26	Every two weeks
52	Weekly

VERIFICATION SCREEN

26. Did anyone else in this household use the equipment that was bought for the household member who was disabled? (HV24)

IF NO, SKIP TO Q. 28. (hv26)

27. About what percentage of the time is the equipment used by [disabled hh member]? (HV25)

28. Did any family member living here pay for any other special equipment for [disabled hh member]? (HV26)

	More equipment
N	No
Y	Yes
Z	Don’t know

IF YES, GO BACK TO Q. 15. (hv16)

W. If Respondent Reports No Income

IF RESPONDENT REPORTED THAT HE/SHE HAS NO INCOME—CONTINUE WITH SECTION W.

IF RESPONDENT REPORTED THAT HE/SHE HAS INCOME—SKIP TO CONCLUSION, SECTION X.

You’ve told me you don’t receive any income. How did you manage to get by—how did you get food and other things you need to live?

RECORD RESPONSE:

IF INCOME IS IDENTIFIED THAT SHOULD HAVE BEEN NOTED IN PREVIOUS SECTIONS, ENTER AMOUNTS IN THE APPROPRIATE SECTION.

X. Conclusion

That’s all the questions I have. But before I go, let me take a minute to check that I have all the information I need.

REVIEW VERIFICATION REQUIREMENTS AND OBTAIN SIGNED RELEASE FORMS FOR EACH THIRD-PARTY VERIFICATION TO BE REQUESTED. OBTAIN SIGNED RELEASE FORM COVER LETTERS FOR EACH MEMBER OF THE HOUSEHOLD 18 OR OVER.

PRESS ENTER TO CONTINUE.

Certification of Interview

I completed this interview on _________________ at _________am/pm.

DATE TIME

Signature ______________________________________________

COMPLETE THE NEXT SECTION IMMEDIATELY AFTER THE INTERVIEW.

Y. Interview Setting

1. What language was the interview conducted in? (HZ1)

1 = English; 2 = Spanish; 3 = Russian; 4 = Creole, 5 = Vietnamese; 6 = Chinese; 7 = Sign Language; 8 = Other

2. What is the repondent’s primary language? (HZ2)

1 = English; 2 = Spanish; 3 = Russian; 4 = Creole, 5 = Vietnamese; 6 = Chinese; 7 = Sign Language; 8 = Other

3. Where was the interview conducted? (HZ3)

1 = Home; 2 = Management Office; 3 = Other

IF NOT IN HOME: Explain why the interview was not conducted in the tenant’s home. (HZ3A)

______________________________________________

IF IN HOME: Did you discover information about the tenant that you would not have if the interview had not been conducted in the tenant’s home? (HZ5) Y/N If yes:

Explain this information you discovered and how you discovered it.

_____________________________________________________________________

4. Were any other adults besides the tenant present during the interview? (HZ4) Y/N

IF YES: Explain who the other adults were and why they were present during the interview. (HZ4A)

______

5. Describe any unusual circumstances about this interview. (HZ6A)

Describe any additional unusual circumstances about this interview. (HZ6B)

6. Explain any communication or comprehension issues, such as a child being interviewed, speech impairment, etc.: (HZ7)

End of the Household Interview Module
1	Review Questionnaire
2	Save and Return to the Main Menu

SAVE AND RETURN TO THE MAIN MENU

Exhibit 1.

VERIFICATION SCREEN LOGIC

The VERIFICATION SCREEN will have the following process built into it:

For each item that is provided by the respondent, in response to the questions asked, the field interviewer will be required to enter the third party name, address, and phone number.

The FI will ask the tenant to provide document(s) that can be used to verify the information. The document(s) will be requested for one of two period ranges:

• If the project has elected to use the actual past income provision based on HUD PIH Notice 2013-03^b, verification documents for assets, income and expenses will be asked 17 months prior to the QCM plus the QCM; a total of 18 months.

• If the project has elected to not use the actual past income provision based on HUD PIH Notice 2013-03, verification documents for assets, income and expenses will be asked 1 month prior to the QCM plus the QCM; a total of 2 months.

For each document provided, the system will validate whether the document for the item is for the correct time period, is for the correct household member, contains contact information, and contains a value amount. If all of the above criteria are met, HDCS will instruct the field interviewer to scan this document when the interview is complete. This process will be incorporated into the VERIFICATION SCREEN as shown in Exhibit 2.

Exhibit 2.

VERIFICATION SCREEN

Please provide a document that shows the name, address and phone number of the organization (or person) that we can contact if we need to verify the information you just told me about.

DID THE TENANT PROVIDE A DOCUMENT?  YES  NO

IF YES, ANSWER THE FOLLOWING QUESTIONS BASED ON THE DOCUMENT(S)

• DOES THE DOCUMENT PROVIDED LIST THE CORRECT HOUSEHOLD MEMBER?

 YES  NO

• DOES THE DOCUMENT PROVIDED LIST A DATE BETWEEN [QCM-2 MONTHS OR QCM-17 MONTHS DEPENDING ON IF THE PROJECT HAS ELECTED TO USE THE PAST PROVISION AND THE ITEM IS AN ASSET OR INCOME] AND [QCM]?

 YES  NO

• DOES THE DOCUMENT CONTAIN IDENTIFYING INFORMATION OF THE THIRD PARTY?

 YES  NO

• DOES THE DOCUMENT CONTAIN A DOLLAR AMOUNT?

 YES  NO

IF THE FOUR QUESTIONS LISTED ABOVE ARE ALL ANSWERED AS A YES:

THIS DOCUMENT SHOULD BE SCANNED AT THE END OF THE INTERVIEW.

ENTER NAME, ADDRESS AND PHONE NUMBER OF THE THIRD PARTY BASED ON THE DOCUMENT

NAME:_____________________________

ADDRESS:__________________________

PHONE NUMBER:___________________

IF NO OR IF INFORMATION IDENTIFYING THE THIRD PARTY IS MISSING ON THE DOCUMENT PROVIDED: Please tell me the name, address and phone number of the person who can verify this information.

ENTER NAME, ADDRESS AND PHONE NUMBER OF THE THIRD PARTY

NAME:_____________________________

ADDRESS:__________________________

PHONE NUMBER:___________________

a The household questionnaire is designed so the respondent is asked about employment the household had during the QCM, and then the same questions are repeated for income the household expected to have in the future. The question text for the “future” questions have been highlighted in grey.

b PIH Notice 2013-03 indicates:

• PHAs that choose to use actual past income must use the most recent 12 months of income information available in EIV. Because this EIV report will give actual earnings data verified by a third party, the program participant is no longer required to provide third party documentation (e.g., paystubs, payroll summary report, unemployment monetary benefit notice).

• PHAs must continue to verify income from sources not available in EIV. However, PHAs must use the same time period for both wage and non-wage income. For example, if a PHA uses EIV information from July 2011 to June 2012 for the purpose of verifying income from wages, the PHA must use the same time period for any nonwage income.