Form H-100 New York City Housing and Vacancy Survey

Place a check mark ( ✓) in

beside the respondent.

1. HOUSEHOLD ROSTER
a. What are the names of all persons living or staying
here? Start with the ADULT who owns or rents this
apartment (house). (Enter that name under PERSON 1 below.)
• Include anyone staying here with no other home
• Include anyone who usually lives here but is
temporarily away traveling or at school
• Include lodgers, boarders, babies, etc.
b. Is . . . male or female?
c. How old is . . . ? (Enter whole years ONLY.)
01

PERSON 1 – Reference Person (owner/renter)

a. Last name

First name

b. Sex
1
2

02

c. Age
Male
Female

PERSON 2

a. Last name

First name

b. Sex
1
2

03

c. Age
Male
Female

PERSON 3

a. Last name

First name

b. Sex
1
2

04

c. Age
Male
Female

PERSON 4

a. Last name

First name

b. Sex
1
2

05

c. Age
Male
Female

PERSON 5

a. Last name

First name

b. Sex
1
2

06

c. Age
Male
Female

PERSON 6

a. Last name

First name

b. Sex
1
2

07

c. Age
Male
Female

PERSON 7

a. Last name

First name

b. Sex
1
2

c. Age
Male
Female

Use continuation form for additional persons.

H-100 FLAP (4-18-2016)

FORM H-100 (4-18-2016)

OMB No. 0607-0757: Approval Expires xx/xx/xxxx
U.S. DEPARTMENT OF COMMERCE
Economic and Statistics Administration

U.S. CENSUS BUREAU
ACTING AS COLLECTING AGENT FOR

NEW YORK CITY

NOTICE – Your answers will be held in strict
confidence and will be seen only by persons
sworn to uphold the confidentiality of Census
Bureau information.

A. NAME

NEW YORK CITY HOUSING
AND VACANCY SURVEY

CODE

B. DATE OF INTERVIEW

QUESTIONNAIRE – 2017

2017

(IF THIS FORM IS FOUND, PLEASE CALL 1–800–991–2520)

C. RECORD OF VISITS
(Additional spaces on page 26)
Date
Time
Remarks
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.

Fill items D through J by observing the condition of the
building containing the sample unit as you approach it and
walk inside. – Mark (X) all that apply in D through G.

1
2
3
4
5
6

007
008
009
010
011

2
3
4
5

1

035

6

2
3
4
5

1

022

6

2
3
4
5

Vacant unit – Mark (X) one

Broken or missing windows
Rotted/loose window frames/sashes
Boarded-up windows
None of these problems with windows
Unable to observe windows

Loose, broken, or missing stair railings
Loose, broken, or missing steps
None of these problems with stairways
No interior steps or stairways
No exterior steps or stairways
Unable to observe stairways

3
4
5

1

032

N. SAMPLE UNIT

Sagging or sloping floors
Slanted or shifted doorsills or door frames
Deep wear in floors causing depressions
Holes or missing flooring
None of these problems with floors
Unable to observe floors

033

2

11

No

12
13

J. WHEELCHAIR ACCESSIBILITY
036

037

1. Street entry and inner lobby entry (width 32")
1
Accessible
3
Unable to observe
building entrance
2
Inaccessible
2. Elevator (door width 36", cab depth 51")
1
3
Unable to observe elevator
Accessible
2
4
No elevator
Inaccessible
3. Residential unit entrance (width 32")

038

1
2

Accessible
Inaccessible

Unit damaged by fire
Building boarded-up
List procedure applied
No such address (house number/street)
Other – Explain in "Notes" area on page 11

10

windows on this street? – Include sample unit building
Yes

Questionnaire complete

01

Questionnaire not complete
02
Refused
03
No one home
04
Temporarily absent – 1 month or longer
05
Other – Explain in "Notes" area on page 11
06
Demolished
07
Condemned
08
Nonresidential
09
Merged with another unit – Give address below

Dilapidated – Go to I
Not dilapidated –
If not dilapidated
2
Sound
Deteriorating
3

1

– SKIP to question 1 on page 2.

Always mark (X) one box. If an interview is not taken,
explain why in the "Notes" area on page 11.

I. Are there any buildings with broken or boarded-up
024

⎫
to question 59
⎬ SKIP
on page 23
⎭

Ask–
M. How many people live or stay here?
Include anyone without a usual home elsewhere.

H. CONDITION
023

Superintendent
Rental office/agent
Real estate agent/broker
Owner
Other – Specify

1
2

G. FLOORS
017
018
019
020
021

Occupied unit – Go to M

030

F. STAIRWAYS (exterior and interior)
012
013
014
015
016

Vacant

2

Name

Missing bricks, siding, or other outside wall material
Sloping or bulging outside walls
Major cracks in outside walls
Loose or hanging cornice, roofing, or other material
None of these problems with walls
Unable to observe walls

E. WINDOWS
1

Occupied

1

L. RESPONDENT

D. EXTERNAL WALLS
001
002
003
004
005
006

K. OCCUPANCY STATUS
025

3

Unable to observe
residential unit entrance

14

Complete after an occupied unit interview.

O. FORM TYPE
034

One form only

1

2

First of two forms

OFFICE USE ONLY
026

TS

027

A

028

B

039

C

Section I – OCCUPIED UNITS

d. How is . . .

e. Is . . . of Spanish or
Hispanic origin?

related to . . .
(reference
person) (person
on Line 1)?

(If "Yes", read the
categories and mark (X)
the appropriate box;
otherwise mark (X)
"No.")

Show Flashcard I
and enter the
appropriate code
in the box below.

1
2
3

R

4
5

Reference person

6

7

1
2
3
4
5
6

7

1
2
3
4
5
6

7

1
2
3
4
5
6

7

1
2
3
4
5
6

7

1
2
3
4
5
6

7

1
2
3
4
5
6

7

Page 2

f. What is . . .’s
race? Select
one or more
categories
from the
flashcard.
Show Flashcard II
and mark (X) all
that apply, OR
mark (X) box 12
only and print race.

No
Puerto Rican
Dominican
Cuban
South/Central American
Mexican-American,
Mexican, Chicano
Other Spanish/Hispanic

01

07

02

08

03

09

04

10

05

11

06

12

No
Puerto Rican
Dominican
Cuban
South/Central American
Mexican-American,
Mexican, Chicano
Other Spanish/Hispanic

01

07

02

08

03

09

04

10

05

11

06

12

No
Puerto Rican
Dominican
Cuban
South/Central American
Mexican-American,
Mexican, Chicano
Other Spanish/Hispanic

01

07

02

08

03

09

04

10

05

11

06

12

No
Puerto Rican
Dominican
Cuban
South/Central American
Mexican-American,
Mexican, Chicano
Other Spanish/Hispanic

01

07

02

08

03

09

04

10

05

11

06

12

No
Puerto Rican
Dominican
Cuban
South/Central American
Mexican-American,
Mexican, Chicano
Other Spanish/Hispanic

01

07

02

08

03

09

04

10

05

11

06

12

No
Puerto Rican
Dominican
Cuban
South/Central American
Mexican-American,
Mexican, Chicano
Other Spanish/Hispanic

01

07

02

08

03

09

04

10

05

11

06

12

No
Puerto Rican
Dominican
Cuban
South/Central American
Mexican-American,
Mexican, Chicano
Other Spanish/Hispanic

01

07

02

08

03

09

04

10

05

11

06

12

These next two questions may seem
like ones I asked before, but I must
ask them to double check.
(Don’t ask for
persons under 15)

g. Does . . . have

h. Does . . . have
a parent in the
household?

a spouse or
unmarried
partner in the
household?
(If "Yes", enter person
number of spouse or
partner; otherwise
mark (X) "No".)

No
Under 15
(If "Yes", enter person
number of spouse or
partner; otherwise
mark (X) "No".)

No
Under 15
(If "Yes", enter person
number of spouse or
partner; otherwise
mark (X) "No".)

No
Under 15
(If "Yes", enter person
number of spouse or
partner; otherwise
mark (X) "No".)

No
Under 15
(If "Yes", enter person
number of spouse or
partner; otherwise
mark (X) "No".)

No
Under 15
(If "Yes", enter person
number of spouse or
partner; otherwise
mark (X) "No".)

No
Under 15
(If "Yes", enter person
number of spouse or
partner; otherwise
mark (X) "No".)

No
Under 15

(If "Yes", enter
person number(s) of
parent(s); otherwise
mark (X) "No".)

No
(If "Yes", enter
person number(s) of
parent(s); otherwise
mark (X) "No".)

No
(If "Yes", enter
person number(s) of
parent(s); otherwise
mark (X) "No".)

No
(If "Yes", enter
person number(s) of
parent(s); otherwise
mark (X) "No".)

No
(If "Yes", enter
person number(s) of
parent(s); otherwise
mark (X) "No".)

No
(If "Yes", enter
person number(s) of
parent(s); otherwise
mark (X) "No".)

No
(If "Yes", enter
person number(s) of
parent(s); otherwise
mark (X) "No".)

No
FORM H-100 (4-18-2016)

Section I – OCCUPIED UNITS – Continued

2a. Is there anyone now living in this apartment
(house) that came here within the past five
years from a homeless situation such as a
shelter, transitional center, or hotel?

b. Who are they? (Fill in for the persons who
answered "Yes" to 2a above.)
Refer to the roster, page 2, and enter the person
number(s) starting in box 055.

050

1
2

Yes – GO to 2b
No – SKIP to 3

055

056

057

058

059

060

061

062

063

064

065

066

The following questions (3 through 11c) refer to the reference person (the person listed under PERSON 1).

3. Where was the most recent place . . .
(reference person) lived for six months or more
before moving into this apartment (house)?
(Show Flashcard III to respondent and have him/her
select an answer. Then mark (X) the appropriate box.)

IN NEW YORK CITY, SAME BUILDING
051

01
02

Always lived in this unit
Another unit in the same building

IN NEW YORK CITY, OTHER BUILDING
NOTE – If the respondent indicates that the reference
person has always lived in the SAME unit that he/she
currently lives in, don’t mark (X) box 01 unless you are
certain. Many people may feel as though they have
lived in a unit forever, but it’s rare. The reference
person had to live there since birth. Be sure to probe.

03
04
05
06
07

Bronx
Brooklyn
Manhattan
Queens
Staten Island

OUTSIDE OF NEW YORK CITY
08
09
10
11
12
13
14
15
16

17
18
19
20
21
22
23

24
25
26

FORM H-100 (4-18-2016)

New York, New Jersey, Connecticut
Other State
Puerto Rico
Dominican Republic
Caribbean (other than Puerto Rico or
Dominican Republic)
Mexico
Central America, South America
Canada
Armenia, Azerbaijan, Belarus, Estonia,
Georgia, Kazakhstan, Kyrgyzstan, Latvia,
Lithuania, Moldova, Russia, Tajikistan,
Turkmenistan, Ukraine, or Uzbekistan
Other European countries
China, Hong Kong, Taiwan
Korea
India
Pakistan, Bangladesh
Philippines
Southeast Asia (Cambodia, Laos, Malaysia, Myanmar
(Burma), Singapore, Thailand, Vietnam)
Other Asia
Africa
All other countries – Specify

Page 3

Section I – OCCUPIED UNITS – Continued

4a. In what year did . . . (reference person) move

Year

into this apartment (house)?

If 1971 – GO to 4b
If any other year – SKIP to 5

052

b. Ask only if reference person moved here in 1971.
Did . . . (reference person) move here on or after
July 1 in 1971?

053

1
2

5. Are you the first occupant(s) of this
apartment (house) since its construction,
gut rehabilitation, or creation through
conversion or sub-division?
CHECK
ITEM A

054

1
2
3

Yes, on or after July 1 in 1971
No, before July 1 in 1971
Yes, first occupants
No, previously occupied
Don’t know

REFER TO QUESTION 4a ABOVE
Moved here 2014 or later – GO to question 6
Moved here 2013 or earlier – SKIP to question 7 on page 5

6. What is the main reason . . . (reference person)

EMPLOYMENT

moved from his/her previous residence?
Mark (X) ONLY one box.

110

01
02
03
04
05
06

Job transfer/new job
Retirement
Looking for work
Commuting reasons
To attend school
Other financial/employment reason

FAMILY
07
08
09
10
11
12

13
14

Needed larger house or apartment
Widowed
Separated/divorced
Newly married
Moved to be with or closer to relatives
Family size decreased (except widowed/
separated/divorced)
Wanted to establish separate household
Other family reason

NEIGHBORHOOD
15
16
17
18
19

Neighborhood overcrowded
Change in racial or ethnic composition
of neighborhood
Wanted this neighborhood/better
neighborhood services
Crime or safety concerns
Other neighborhood reason

HOUSING
20
21
22
23
24
25
26
27
28

Wanted to own residence
Wanted to rent residence
Wanted less expensive residence/difficulty
paying rent or mortgage
Wanted better quality residence
Evicted
Poor building condition/services
Harassment by landlord
Needed housing accessible for persons with
mobility impairments
Other housing reason

OTHER
29
30
31
32
33

Page 4

Displaced by urban renewal, highway
construction, or other public activity
Displaced by private action (other than eviction)
Schools
Natural disaster/fire
Any other – Specify

FORM H-100 (4-18-2016)

Section I – OCCUPIED UNITS – Continued

7. Place of birth

a. . . .

b. . . . ’s

(reference
person) born?

Show Flashcard IV to respondent.
➤

Where was

07. New York City (responses 03-07 on Flashcard IV)

111

(reference
person’s)
father born?
112

07

c. . . . ’s
(reference
person’s)
mother born?
113

07

07

09. U.S., Outside New York City (responses 08 or 09
on Flashcard IV) . . . . . . . . . . . . . . . . . . . . . . . . .

09

09

09

10. Puerto Rico . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10

10

10

11. Dominican Republic . . . . . . . . . . . . . . . . . . . . . .

11

11

11

12. Caribbean (other than Puerto Rico or
Dominican Republic) . . . . . . . . . . . . . . . . . . . . . .

12

12

12

13. Mexico . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13

13

13

14. Central America, South America . . . . . . . . . . . . .

14

14

14

15. Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15

15

15

16. Armenia, Azerbaijan, Belarus, Estonia, Georgia,
Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Moldova,
Russia, Tajikistan, Turkmenistan, Ukraine, or
Uzbekistan . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

16

16

16

17. Other European countries . . . . . . . . . . . . . . . . . .

17

17

17

18. China, Hong Kong, Taiwan . . . . . . . . . . . . . . . . .

18

18

18

19. Korea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19

19

19

20. India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20

20

20

21. Pakistan, Bangladesh . . . . . . . . . . . . . . . . . . . . .

21

21

21

22. Philippines . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

22

22

22

23. Southeast Asia (Cambodia, Laos, Malaysia, Myanmar
(Burma), Singapore, Thailand, Vietnam) . . . . . . . . .

23

23

23

24. Other Asia . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

24

24

24

25. Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25

25

25

26. All other countries – Specify . . . . . . . . . . . . . . . .

26

– Specify

1

No
Yes, a condominium
Yes, a cooperative
Don’t know

26

– Specify

26

– Specify

Mark (X) box 07 above for categories 03-07 on
Flashcard IV. Mark (X) box 09 for categories 08 and 09
on Flashcard IV.

8. Is this apartment (house) part of a condominium
or cooperative building or development?

114

2

A condominium is a building or development with
individually owned apartments or houses having
commonly owned areas and grounds. A cooperative
or "co-op" is a building or development that is owned
by its shareholders.

3
4

9a. Is this apartment (house) owned or being
bought by . . . (reference person) or someone
else in this household?

b. Does . . . (reference person) or someone else in
this household own cooperative shares for
this apartment (house)?

115

1
0

129

1
2
3

c. Does . . . (reference person) pay cash rent for
this apartment (house) or does he/she
occupy it rent free?
CHECK
ITEM B

116

2
3

Yes, owned or being bought – SKIP to 11a
No – GO to 9b
Yes – SKIP to 11a
⎫
No
⎬ GO to 9c
Don’t know ⎭
Pay cash rent – GO to Check Item B
Occupy rent free – SKIP to 20

REFER TO QUESTION 8 ABOVE
Condominium (box 2 marked) ⎫ GO to 10a
⎬
Cooperative (box 3 marked) ⎭
All other renter occupied (box 1 or 4 marked) – SKIP to 20

10a. Did . . . (reference person) live here and pay
cash rent at the time this building became a
condominium or cooperative?

117

1
2
3

Yes
No
Don’t know

b. When this apartment (house) became a
condominium or cooperative was it done
through a non-eviction plan?
Under a non-eviction plan, tenants can NOT be
evicted for NOT buying their unit.
FORM H-100 (4-18-2016)

118

1
2
3

Yes
⎫
No
⎬ SKIP to 20
Don’t know ⎭
Page 5

Section I – OCCUPIED UNITS – Continued

11a. In what year did . . . (reference person) acquire

Year

this apartment (house)?
119

b. Before . . . (reference person) acquired this
apartment (house) was it owned and
occupied by another household, rented
by . . . (reference person), rented by another
household, or never previously occupied?

120

1
2
3
4
5

c. Before . . . (reference person) acquired this
apartment (house) was it part of a
condominium or cooperative building or
development?
CHECK
ITEM C

121

1
2
3

Owned and occupied by another household
Rented by reference person
Rented by another household
Never previously occupied
Don’t know
Yes
No
Don’t know

REFER TO QUESTION 11a ABOVE
Acquired 2012 or later – GO to 12a
Acquired 2011 or earlier – SKIP to 13

12a. What was the purchase price for this
apartment (house)?

b. What was the down payment for this
apartment (house)?

122

$ _______________ .

123

0

124

$ _______________ .

125

0

126

$ _______________ .

127

1

00

Don’t know
00

Don’t know

13. What is the value of this apartment (house);
that is, in your opinion, how much would it
currently sell for if it were on the market?

00

14. Is there a mortgage, home equity loan, or
similar loan on this apartment (house) or is
this apartment (house) owned free and
clear?

2

Mortgage, home equity, or similar loan
Owned free and clear – SKIP to Check Item D

15a. What are the current monthly mortgage or
loan payments on this apartment (house)?
Include payments on first, second, home
equity loan, and any other mortgages.

128

$ _______________ .

b. When did the most recent mortgage or loan

Month

on this apartment (house) originate?

recent mortgage or loan on this apartment
(house)?
CHECK
ITEM D

Per month

Year

133

c. What is the current interest rate on the most

00

134

135

.

%

REFER TO QUESTION 8 ON PAGE 5
Condominium (box 2 marked) ⎫
⎬ GO to 16
Cooperative (box 3 marked) ⎭
All other owner occupied (box 1 or 4 marked) – SKIP to 18a

16. What are the monthly condominium or co-op
maintenance fees for this apartment
(house)? Exclude payments for any
mortgages (loans) on this unit.
CHECK
ITEM E

130

$ _______________ .

00

REFER TO QUESTION 1c ON PAGE 2 FOR EACH PERSON
With any household member age 62 or over – GO to 17
No household member age 62 or over – SKIP to 18a

17. Is any household member receiving a Senior
Citizen Carrying Charge Increase Exemption
as part of the SCRIE program?
(Senior Citizen Rent Increase Exemption)

140

1
2
3

Yes
No
Don’t know

18a. Is the fire and liability insurance premium for
this apartment (house) paid separately?
(Separately means not included in the mortgage or
loan payment or the condominium or co-op
maintenance fee.)

141

1
2
3

Yes – GO to 18b
No, included in mortgage or loan ⎫
payment
⎬ SKIP to 19a
No insurance
⎭

b. What was the cost of fire and liability
insurance for 2016?

Page 6

142

$ _______________ .

00

FORM H-100 (4-18-2016)

Section I – OCCUPIED UNITS – Continued

19a. Are the real estate taxes for this apartment
(house) paid separately?

144

2

(Separately means not included in the mortgage or
loan payment or the condominium or co-op
maintenance fee.)

b. What were the real estate taxes for 2016?

1

3

145

Yes – GO to 19b
No, included in mortgage
or loan payment
No, included in condominium
or maintenance fee

$ _______________ .

⎫
⎬ SKIP to 20
⎭

00

NOTE – Questions 20–22a, 23a and 23b pertain to the building. Be certain to mark (X) the same box in each
question for all forms within the same building.

20.

How many units are in this building?

146

01
02

If the respondent doesn’t know, canvass the
building and count the units.

03
04
05
06
07
08
09
10
11
12
13
14

If owner occupied, mark "Yes" without asking.

21.

147

Does the owner of this building live in this
building?

22a. How many stories are in this building?

1
2
3

148

01
02

Count the basement if there are people living in it.

03
04
05
06
07
08
09

b. On what floor is this unit?
Enter the 2-digit floor number or mark (X) box "0"
if basement unit. Enter the lowest floor number if
on more than one floor.

23a. Is there a passenger elevator in this building?

0

172

149

passenger elevator without going up or
down any steps or stairs?

173

1

1
2
3

c. Is it possible to go from the sidewalk to this
unit without going up or down any steps or
stairs?

171

1
2
3

24a. How many rooms are in this apartment
(house)? Do not count bathrooms, porches,
balconies, halls, foyers, or half-rooms.

150

1
2
3
4
5
6
7
8

b. Of these rooms, how many are bedrooms?

151

01
02
03
04
05
06
07
08
09

FORM H-100 (4-18-2016)

Yes
No
Don’t know
One – SKIP to 23c
Two
Three
Four
Five
6 to 10
11 to 20
21 to 40
41 or more
Basement
Floor

2

b. Is it possible to go from the sidewalk to a

1 unit without business
1 unit with business
2 units without business
2 units with business
3 units
4 units
5 units
6 to 9 units
10 to 12 units
13 to 19 units
20 to 49 units
50 to 99 units
100 to 199 units
200 or more units

Yes
No – SKIP to 23c
Yes
No
Don’t know
Yes
No
Don’t know
One – SKIP to 25a
Two
Three
Four
Five
Six
Seven
Eight or more
None
One
Two
Three
Four
Five
Six
Seven
Eight or more
Page 7

Section I – OCCUPIED UNITS – Continued

25a. Does this apartment (house) have complete
plumbing facilities; that is, hot and cold
piped water, a flush toilet, and a bathtub or
shower?

152

0
1
2

b. Are these facilities for the exclusive use of
this household or are they also for use by
another household?

c. Was there any time in the last three months
when all the toilets in this apartment (house)
were not working for six consecutive hours?

153

3
4

154

1
2
3

26a. Does this apartment (house) have complete
kitchen facilities? Complete kitchen
facilities include a sink with piped water, a
range or cookstove, and a refrigerator.

155

0
1
2
3

b. Are these facilities for the exclusive use of
this household or are they also for use by
another household?

c. Are all the kitchen facilities in your
apartment (house) functioning?
(Sink, range/cookstove, and refrigerator)

27. How is this apartment (house) heated – by

156

4
5

157

1
2

158

fuel oil, utility gas, electricity, or with
some other fuel?

1
2
3
4
5

28. I have some questions about utility costs.
a. (1) Do you pay for your own electricity?

159

1
2
3

Yes, has complete plumbing facilities – GO to 25b
No, has some but not all facilities in this
apartment (house) – SKIP to 25c
No plumbing facilities in this apartment
(house) – SKIP to 26a
For the exclusive use of this household
Also for use by another household
Yes
No
No toilet in this apartment (house)
Yes has complete kitchen facilities – GO to 26b
No, has some but not all facilities in this
apartment (house) – SKIP to 26c
No kitchen facilities in this apartment
⎫
(house), but facilities available in building ⎬ SKIP
to 27
⎭
No kitchen facilities in this building
For the exclusive use of this household
Also for use by another household
Yes, all are functioning
No, one or more is not working at all
Fuel oil
Utility gas
Electricity
Other fuel (including CON ED steam)
Don’t know
Yes – GO to 28a(2)
Yes, but combined with gas – Ask for separate
estimates; if not possible SKIP to 28c
No, included in rent, condominium or
other fee – SKIP to 28b(1)

(2) What is the average MONTHLY cost?

b. (1) Do you pay for your own gas?

160

$ _______________ .

161

1
2
3

00

Yes – GO to 28b(2)
No, included in rent,
⎫
condominium or other fee ⎬ SKIP to 28d(1)
⎭
No, gas not used

(2) What is the average MONTHLY cost?
162

$ _______________ .

00

IMPORTANT – SKIP 28c unless the respondent cannot provide separate estimates for electricity and gas, and pays a
combined bill. If separate estimates are available, fill 28a(2) and 28b(2), leave 28c blank, and SKIP to 28d(1).

c. What is your combined average electricity
and gas payment each month?

d. (1) Do you pay your own water and sewer
charges?

163

$ _______________ .

164

1
2

00

⎫
⎬
⎭

Fill this ONLY when
separate estimates
cannot be given.

Yes – GO to 28d(2)
No, included in rent, condominium or other fee or
no charge – SKIP to 28e(1)

(2) What is the total YEARLY cost?

e. (1) Do you pay for your own oil, coal,
kerosene, wood, steam, etc.?

165

$ _______________ .

166

1
2
3

00

Yes – GO to 28e(2)
No, included in rent,
⎫
condominium or other fee ⎬ SKIP to Check Item F
No, these fuels not used ⎭

(2) What is the total YEARLY cost?
167

Page 8

$ _______________ .

00
FORM H-100 (4-18-2016)

Section I – OCCUPIED UNITS – Continued
REFER TO QUESTION 9 ON PAGE 5

CHECK
ITEM F

Owner occupied (question 9a, box 1 marked)
⎫
Owns co-op shares (question 9b, box 1 marked) ⎬ SKIP to 32a
⎭
Occupy rent free (question 9c, box 3 marked)
Pay cash rent (question 9c, box 2 marked) – GO to 29

29. What is the length of the lease on this
apartment (house); that is, the total time
from when the lease began until it will
expire?

181

Less than 1 year
1 year
More than 1 but less than 2 years
2 years
More than 2 years
No lease
Don’t know

1
2
3
4
5
6
7

30. What is the MONTHLY rent?
(If rent is paid other than monthly, refer to the
manual on how to convert it.)

182

$ _______________ .

00

Per month

31a. Is any part of the monthly rent for this apartment (house) paid by any of the following
government programs, either to a member of this household or directly to the landlord?

(1) Federal Section 8 certificate or voucher
program . . . . . . . . . . . . . . . . . . . . . . . . . . .

(2) Senior Citizen Rent Increase
Exemption (SCRIE)

.................

(3) Public assistance shelter allowance . .

(4) Another Federal housing subsidy
program

...........................

(5) Another state or city housing
subsidy program . . . . . . . . . . . . . . . . . . . .

541

184

542

543

544

1

Yes

2

No

3

Don’t know

1

Yes

2

No

3

Don’t know

1

Yes

2

No

3

Don’t know

1

Yes

2

No

3

Don’t know

1

Yes – Specify

2

No

3

Don’t know

b. Of the (amount from question 30 above) rent you
reported, how much is paid out of pocket
by this household?
(Out of pocket means the money your household pays
for rent over and above any shelter allowance or other
government housing subsidy.)

FORM H-100 (4-18-2016)

547

$ _______________ .
0

00

None
(If amount reported in 31b is not equal to 30,
verify that at least one form of subsidy in 31a
is marked "Yes"; if amount reported in 31b is
equal to 30 but any subsidy is marked "Yes",
verify that someone in household receives a
rental subsidy.)

Page 9

Section I – OCCUPIED UNITS – Continued

32a. Now, I would like to ask some questions
about the condition of this apartment
(house).
At any time during this winter, was there
a breakdown in your heating equipment;
that is, was it completely unusable for 6
consecutive hours or longer?

b. How many times did that happen?

185

0
1

186

2
3
4
5

33. During this winter when your regular
heating system was working, did you, at
any time, have to use additional sources of
heat because your regular system did not
provide enough heat? Additional sources
may be the kitchen stove, a fireplace, or a
portable heater.

187

1
2

Yes – GO to 32b
No – SKIP to 33

One
Two
Three
Four or more times
Yes
No

34. Does your apartment (house) have
functioning air conditioning? Would you
say central air conditioning, one or more
window air conditioners, or no air
conditioning?
NOTE: Central air takes priority over window units.

35a. At any time in the last 90 days have you
seen any mice or rats, or signs of mice or
rats in this building?

b. During the past month, about how many
cockroaches did you see in this
apartment (house) on a typical day?

197

1
2
3
4

188

1
2

571

1
2
3
4
5

c. Is this building serviced by an
exterminator regularly, only when
needed, irregularly, or not at all?

189

1
2
3
4
5

36a. Does this apartment (house) have open
cracks or holes in the interior walls or
ceiling? Do not include hairline cracks.

b. Does this apartment (house) have holes in
the floors?

37a. Is there any broken plaster or peeling paint
on the ceiling or inside walls?

190

1
2

191

1
2

192

0
1

b. Is the area of broken plaster or peeling
paint larger than 81⁄2 inches by 11 inches?

193

3

Show unfolded Fact Sheet or Survey Letter to
demonstrate the 81⁄2 x 11 size.

38. Has water leaked into your apartment
(house) in the last 12 months, excluding
leaks resulting from your own plumbing
fixtures backing up or overflowing?

2

194

1
2

Yes, central air conditioning
Yes, one or more window air conditioners
No
Don’t know/Not sure
Yes
No

None
1 to 5
6 to 19
20 or more
Don’t know/Not sure
Regularly
Only when needed
Irregularly
Not at all
Don’t know
Yes
No

Yes
No
Yes – GO to 37b
No – SKIP to 38

Yes
No

Yes
No

We are also interested in the condition of
your neighborhood.

39. How would you rate the physical condition
of the residential structures in this
NEIGHBORHOOD – would you say they are
on the whole excellent, good, fair, or poor?

196

1
2
3
4

Excellent
Good
Fair
Poor

Now, in order to better understand the housing situation in the city, we need to learn
something about the income, employment, and education level of each household member.

INTERVIEWER: Continue with questions for each person on page 12.
Page 10

FORM H-100 (4-18-2016)

Section I – OCCUPIED UNITS – Continued
Notes

INTERVIEWER: Continue with questions for each person on page 12.
FORM H-100 (4-18-2016)

Page 11

Section I – OCCUPIED UNITS – Continued
CHECK ITEM G

40a. Did . . . work
at any time
last week?

Ask questions
40a–51b of ALL
household members
age 15 and above.
Refer to question 1c
on page 2 for each
person’s age.

601
1

2

1

2

15 years or older –
Ask questions
40a–51b

1

Under 15 – SKIP to
Check Item H on
page 20

2

1

2

15 years or older –
Ask questions
40a–51b

1

Under 15 – SKIP to
Check Item H on
page 20

2

2

15 years or older –
Ask questions
40a–51b

1

Under 15 – SKIP to
Check Item H on
page 20

2

2

15 years or older –
Ask questions
40a–51b

1

Under 15 – SKIP to
Check Item H on
page 20

2

1

2

15 years or older –
Ask questions
40a–51b

1

Under 15 – SKIP to
Check Item H on
page 20

2

2

Yes – Full or part-time
(includes helping without
pay in family business)

15 years or older –
Ask questions
40a–51b

1

Under 15 – SKIP to
Check Item H on
page 20

2

213

Yes – Full or part-time
(includes helping without
pay in family business)

214

Yes – Full or part-time
(includes helping without
pay in family business)

215

Yes – Full or part-time
(includes helping without
pay in family business)

216

Yes – Full or part-time
(includes helping without
pay in family business)

15 years or older –
Ask questions
40a–51b

1

Under 15 – SKIP to
Check Item H on
page 20

2

217

Yes – Full or part-time
(includes helping without
pay in family business)
No – Did not work (or did
only own housework,
school work, or volunteer
work) – SKIP to 41

Yes, on vacation,
temporary illness,
labor dispute,
etc. – SKIP to 45a

3

No

1

Yes, on layoff

2

Yes, on vacation,
temporary illness,
labor dispute,
etc. – SKIP to 45a

3

No

Yes – SKIP
to 44

2

No

1

Yes – SKIP
to 44

2

No

233

1

Yes, on layoff

2

Yes, on vacation,
temporary illness,
labor dispute,
etc. – SKIP to 45a

3

No

1

Yes – SKIP
to 44

2

No

234

1

Yes, on layoff

2

Yes, on vacation,
temporary illness,
labor dispute,
etc. – SKIP to 45a

3

No

1

Yes – SKIP
to 44

2

No

235

1

Yes, on layoff

2

Yes, on vacation,
temporary illness,
labor dispute,
etc. – SKIP to 45a

3

No

1

Yes – SKIP
to 44

2

No

236

1

Yes, on layoff

2

Yes, on vacation,
temporary illness,
labor dispute,
etc. – SKIP to 45a

3

No

227

Hours – SKIP
to 45a

1

232

226

Hours – SKIP
to 45a

No – Did not work (or did
only own housework,
school work, or volunteer
work) – SKIP to 41

2

225

Hours – SKIP
to 45a

No – Did not work (or did
only own housework,
school work, or volunteer
work) – SKIP to 41

Yes, on layoff

224

Hours – SKIP
to 45a

No – Did not work (or did
only own housework,
school work, or volunteer
work) – SKIP to 41

1

223

Hours – SKIP
to 45a

No – Did not work (or did
only own housework,
school work, or volunteer
work) – SKIP to 41

207

Page 12

been doing
anything to
find work
during the
last four
weeks?

231

222

Hours – SKIP
to 45a

No – Did not work (or did
only own housework,
school work, or volunteer
work) – SKIP to 41

206

607
1

212

205

606

42. Has . . .

TEMPORARILY
absent or on
layoff from a job
last week?

221

Hours – SKIP
to 45a

No – Did not work (or did
only own housework,
school work, or volunteer
work) – SKIP to 41

204

605
1

Yes – Full or part-time
(includes helping without
pay in family business)

203

604
1

211

202

603

41. Was . . .

hours did . . .
work last
week at all
jobs?
(Subtract time off;
add overtime or
extra hours worked)

201

602

b. How many

1

Yes – SKIP
to 44

2

No

237

1

Yes, on layoff

2

Yes, on vacation,
temporary illness,
labor dispute,
etc. – SKIP to 45a

3

No

1

Yes – SKIP
to 44

2

No

FORM H-100 (4-18-2016)

Section I – OCCUPIED UNITS – Continued

43. What is

44. When did . . .

the main
reason
. . . is not
looking
for work?

last work at
his/her job or
business?

1
2
3
4

631

5

2017
⎫ GO
2016
⎬ to
45a
2012–2015 ⎭
2011 or earlier ⎫ SKIP
⎬ to
Never worked ⎭ 49b

242

Show
Flashcard V
and enter the
code.

1
2
3
4

632
5

2017
⎫ GO
2016
⎬ to
45a
2012–2015 ⎭
2011 or earlier ⎫ SKIP
⎬ to
Never worked ⎭ 49b

243

Show
Flashcard V
and enter the
code.

1
2
3

633

4
5

2017
⎫ GO
2016
⎬ to
45a
2012–2015 ⎭
2011 or earlier ⎫ SKIP
⎬ to
Never worked ⎭ 49b

244

Show
Flashcard V
and enter the
code.

1
2
3

634

4
5

2017
⎫ GO
2016
⎬ to
45a
2012–2015 ⎭
2011 or earlier ⎫ SKIP
⎬ to
Never worked ⎭ 49b

245

Show
Flashcard V
and enter the
code.

1
2
3

635

4
5

2017
⎫ GO
2016
⎬ to
45a
2012–2015 ⎭
2011 or earlier ⎫ SKIP
⎬ to
Never worked ⎭ 49b

246

Show
Flashcard V
and enter the
code.

1
2
3

636

4
5

2017
⎫ GO
2016
⎬ to
45a
2012–2015 ⎭
2011 or earlier ⎫ SKIP
⎬ to
Never worked ⎭ 49b

247

Show
Flashcard V
and enter the
code.

1
2
3
4

637
5

FORM H-100 (4-18-2016)

45a. For whom did . . .
work?
Print the name of the
company, employer,
business, or branch of
armed services if on
active duty.

241

Show
Flashcard V
and enter the
code.

The following questions ask about the job worked last week.
If . . . had more than one job, describe the one . . . worked the most hours.
If . . . didn’t work, refer to the most recent job since 2012.

2017
⎫ GO
2016
⎬ to
45a
2012–2015 ⎭
2011 or earlier ⎫ SKIP
⎬ to
Never worked ⎭ 49b

b. What kind of

c. Is this mainly

business or
industry is this?
For example: health
care, retail, financial,
construction.

Describe the main
activity at location
where employed.

manufacturing,
wholesale
trade, retail
trade, or
something
else?
251
1
2
3
4

Describe the main
activity at location
where employed.

252
1
2
3
4

Describe the main
activity at location
where employed.

1

3
4

1

3
4

1

3
4

Manufacturing
Wholesale trade
Retail trade
Other (service,
construction,
government, etc.)

256
1
2
3
4

Describe the main
activity at location
where employed.

Manufacturing
Wholesale trade
Retail trade
Other (service,
construction,
government, etc.)

255

2

Describe the main
activity at location
where employed.

Manufacturing
Wholesale trade
Retail trade
Other (service,
construction,
government, etc.)

254

2

Describe the main
activity at location
where employed.

Manufacturing
Wholesale trade
Retail trade
Other (service,
construction,
government, etc.)

253

2

Describe the main
activity at location
where employed.

Manufacturing
Wholesale trade
Retail trade
Other (service,
construction,
government, etc.)

Manufacturing
Wholesale trade
Retail trade
Other (service,
construction,
government, etc.)

257
1
2
3
4

Manufacturing
Wholesale trade
Retail trade
Other (service,
construction,
government, etc.)
Page 13

Section I – OCCUPIED UNITS – Continued

46a. What kind of work

b. What are . . .’s usual

47. What type of business or

was . . . doing; that
is, what’s his/her
occupation?

activities at this job?

organization does . . . work at?

For example:
registered nurse, retail
salesperson,
accountant, electrician.

For example: patient care,
selling clothing, filing
taxes, wiring lighting.

Read all categories unless the answer
is apparent from the information given
in question 45, then mark (X) the
appropriate box.

261

271

281

1
2
3
4
5
6

262

272

282

1
2
3
4
5
6

263

273

283

1

2
3
4
5
6

264

274

284

1

2
3
4
5
6

265

275

285

1

2
3
4
5
6

266

276

286

1

2
3
4
5
6

267

277

287

1
2
3
4
5
6

Page 14

Private FOR PROFIT company, business, or
individual for wages, salary, or commission
Private NOT-FOR-PROFIT, tax-exempt, or
charitable organization
Government – Federal
Government – State or local (city, borough, etc.)
Self-employed in own incorporated or
unincorporated business or professional practice
Working without pay in family business
Private FOR PROFIT company, business, or
individual for wages, salary, or commission
Private NOT-FOR-PROFIT, tax-exempt, or
charitable organization
Government – Federal
Government – State or local (city, borough, etc.)
Self-employed in own incorporated or
unincorporated business or professional practice
Working without pay in family business
Private FOR PROFIT company, business, or
individual for wages, salary, or commission
Private NOT-FOR-PROFIT, tax-exempt, or
charitable organization
Government – Federal
Government – State or local (city, borough, etc.)
Self-employed in own incorporated or
unincorporated business or professional practice
Working without pay in family business
Private FOR PROFIT company, business, or
individual for wages, salary, or commission
Private NOT-FOR-PROFIT, tax-exempt, or
charitable organization
Government – Federal
Government – State or local (city, borough, etc.)
Self-employed in own incorporated or
unincorporated business or professional practice
Working without pay in family business
Private FOR PROFIT company, business, or
individual for wages, salary, or commission
Private NOT-FOR-PROFIT, tax-exempt, or
charitable organization
Government – Federal
Government – State or local (city, borough, etc.)
Self-employed in own incorporated or
unincorporated business or professional practice
Working without pay in family business
Private FOR PROFIT company, business, or
individual for wages, salary, or commission
Private NOT-FOR-PROFIT, tax-exempt, or
charitable organization
Government – Federal
Government – State or local (city, borough, etc.)
Self-employed in own incorporated or
unincorporated business or professional practice
Working without pay in family business
Private FOR PROFIT company, business, or
individual for wages, salary, or commission
Private NOT-FOR-PROFIT, tax-exempt, or
charitable organization
Government – Federal
Government – State or local (city, borough, etc.)
Self-employed in own incorporated or
unincorporated business or professional practice
Working without pay in family business
FORM H-100 (4-18-2016)

Section I – OCCUPIED UNITS – Continued

48a. How many weeks did . . .

b. How many hours did . . .

work in 2016?

usually work each
week in 2016?

Count paid vacation,
paid sick leave, and
military service.

291

301

Weeks
or
00

Hours

None – SKIP to 49b

292

302

Weeks
or
00

Hours

None – SKIP to 49b

293

303

Weeks
or
00

Hours

None – SKIP to 49b

294

304

Weeks
or
00

Hours

None – SKIP to 49b

295

305

Weeks
or
00

Hours

None – SKIP to 49b

296

306

Weeks
or
00

Hours

None – SKIP to 49b

297

307

Weeks
or
00

Hours

None – SKIP to 49b

FORM H-100 (4-18-2016)

Page 15

Section I – OCCUPIED UNITS – Continued
The following questions are about income received during 2016. If an exact amount is not known,
accept a best estimate. If there was a net loss in b or c, mark the "Loss" box and enter the dollar amount of the loss.

49a. Did . . . earn income

b. Did . . . earn any income from

c. Did . . . receive any interest,

(his/her) own farm or nonfarm
business, proprietorship, or
partnership?

dividends, net rental or
royalty income, or income
from estates and trusts?
Include even small amounts
credited to an account.

from wages, salary,
commissions, bonuses,
or tips?

Yes – How much?
Report net income after
business expenses

Yes – How much from all
jobs? Report the amount
before deductions for taxes,
bonds, dues or other items

00
$ _______________ .
Annual amount – Dollars

331

00

311
312 1

$ _______________ .
Annual amount – Dollars

332 1

No

2

00
$ _______________ .
Annual amount – Dollars

333
313
314 1

$ _______________ .
Annual amount – Dollars

334 1

No

2

316 1

$ _______________ .
Annual amount – Dollars

336 1

No

2

00
$ _______________ .
Annual amount – Dollars

337

318 1

$ _______________ .
Annual amount – Dollars

338 1

No

2

320 1

$ _______________ .
Annual amount – Dollars

340 1

No

2

322 1

$ _______________ .
Annual amount – Dollars

342 1

No

2

00
$ _______________ .
Annual amount – Dollars

343

324 1

Page 16

$ _______________ .
Annual amount – Dollars
No

344 1
2

No
Loss

No
Loss

Yes – How much?
00
$ _______________ .
Annual amount – Dollars

359

360 1

No
Loss

Yes – How much?
00
$ _______________ .
Annual amount – Dollars

361

362 1

No
Loss

00

323

358 1

2

Yes – How much?
Report net income after
business expenses

Yes – How much from all
jobs? Report the amount
before deductions for taxes,
bonds, dues or other items

00
$ _______________ .
Annual amount – Dollars

357

2

00
$ _______________ .
Annual amount – Dollars

341

00

321

No
Loss

Yes – How much?

No
Loss
Yes – How much?
Report net income after
business expenses

Yes – How much from all
jobs? Report the amount
before deductions for taxes,
bonds, dues or other items

356 1

2

00
$ _______________ .
Annual amount – Dollars

339

00

319

00
$ _______________ .
Annual amount – Dollars

355

No
Loss
Yes – How much?
Report net income after
business expenses

Yes – How much from all
jobs? Report the amount
before deductions for taxes,
bonds, dues or other items

No
Loss

Yes – How much?

No
Loss

00

317

354 1

2

Yes – How much?
Report net income after
business expenses

Yes – How much from all
jobs? Report the amount
before deductions for taxes,
bonds, dues or other items

00
$ _______________ .
Annual amount – Dollars

353

2

00
$ _______________ .
Annual amount – Dollars

335

00

315

No
Loss

Yes – How much?

No
Loss
Yes – How much?
Report net income after
business expenses

Yes – How much from all
jobs? Report the amount
before deductions for taxes,
bonds, dues or other items

352 1

No
Loss

00

00
$ _______________ .
Annual amount – Dollars

351

2

Yes – How much?
Report net income after
business expenses

Yes – How much from all
jobs? Report the amount
before deductions for taxes,
bonds, dues or other items

Yes – How much?

No
Loss

Yes – How much?
00
$ _______________ .
Annual amount – Dollars

363

364 1
2

No
Loss

FORM H-100 (4-18-2016)

Section I – OCCUPIED UNITS – Continued

49d. Did . . . receive any Social Security or

49e. Did . . . receive any income from

Railroad Retirement payments? Include
payments as a retired worker, dependent,
or disabled worker.

government programs for Supplemental
Security Income (SSI), Family
Assistance/Temporary Assistance for
Needy Families (TANF), Safety Net, or any
other public assistance or public welfare
payments, including shelter allowance?

Yes – How much?

Yes – How much?
00
$ _______________ .
Annual amount – Dollars

371

372 1

No

00
$ _______________ .
Annual amount – Dollars

391

392 1

Yes – How much?

Yes – How much?
00
$ _______________ .
Annual amount – Dollars

373
374

1

00
$ _______________ .
Annual amount – Dollars

393
394

No

1

00
$ _______________ .
Annual amount – Dollars

376 1

No

00
$ _______________ .
Annual amount – Dollars

395

396

1

Yes – How much?
00
$ _______________ .
Annual amount – Dollars

377

378 1

No

00
$ _______________ .
Annual amount – Dollars

397

398

00
$ _______________ .
Annual amount – Dollars

380 1

No

1

00
$ _______________ .
Annual amount – Dollars

399

400

00
$ _______________ .
Annual amount – Dollars

382 1

No

1

00
$ _______________ .
Annual amount – Dollars

401

402

00
$ _______________ .
Annual amount – Dollars

384 1

No

FORM H-100 (4-18-2016)

No

Yes – How much?

1

Yes – How much?

383

No

Yes – How much?

Yes – How much?

381

No

Yes – How much?

Yes – How much?

379

No

Yes – How much?

Yes – How much?

375

No

No

Yes – How much?
00
$ _______________ .
Annual amount – Dollars

403

404

1

No

Page 17

Section I – OCCUPIED UNITS – Continued

49f. Did . . . receive any income from retirement,

49g. Did . . . receive any income from Veterans’

survivor, or disability pensions? Include
payments from companies, unions, Federal,
State, or local governments and the U.S.
military. Do NOT include Social Security.

(VA) payments, unemployment
compensation, child support, alimony, or
any other regular source of income?
Do NOT include lump-sum payments such
as money from an inheritance or the sale of
a home.

Yes – How much?
00
$ _______________ .
Annual amount – Dollars

411

412 1

Yes – How much?
431
432

No

$ _______________ .
Annual amount – Dollars
1

Yes – How much?
00
$ _______________ .
Annual amount – Dollars

413
414

1

433

$ _______________ .
Annual amount – Dollars
1

00
$ _______________ .
Annual amount – Dollars

416 1

$ _______________ .
Annual amount – Dollars
1

Yes – How much?
00
$ _______________ .
Annual amount – Dollars

417

418 1

00
$ _______________ .
Annual amount – Dollars

420 1

$ _______________ .
Annual amount – Dollars
1

00
$ _______________ .
Annual amount – Dollars

422 1

No

$ _______________ .
Annual amount – Dollars
1

424 1

Page 18

No

No

441
442

00
$ _______________ .
Annual amount – Dollars

00

Yes – How much?

$ _______________ .
Annual amount – Dollars
1

Yes – How much?

423

No

439

Yes – How much?

421

00

Yes – How much?

440

No

No

437

Yes – How much?

419

00

Yes – How much?

438

No

No

435
436

No

00

Yes – How much?

Yes – How much?

415

No

Yes – How much?

434

No

00

00

No

Yes – How much?
443
444

$ _______________ .
Annual amount – Dollars
1

00

No

FORM H-100 (4-18-2016)

Section I – OCCUPIED UNITS – Continued

50a. Are you/Is . . . currently enrolled,

50b. How much school have you/has . . .

either part-time or full time, in any
of these?

completed?
(Show Flashcard VI to respondent and have
him/her select an answer. Then mark (X) the
appropriate box below.)

(Read categories and mark (X) all that apply)

663

1
2
3
4
5

6
7

664

1
2
3
4
5

6
7

665

1
2
3
4
5

6
7

666

1
2
3
4
5

6
7

667

1
2
3
4
5

6
7

668

1
2
3
4
5

6
7

669

1
2
3
4
5

6
7

GED program
High school
College
Graduate or professional degree program
Occupational, vocational, or apprenticeship
program

471
01
02
03
04

Literacy or ESL program
No, not enrolled
GED program
High school
College
Graduate or professional degree program
Occupational, vocational, or apprenticeship
program
Literacy or ESL program
No, not enrolled
GED program
High school
College
Graduate or professional degree program
Occupational, vocational, or apprenticeship
program

05

GED program
High school
College
Graduate or professional degree program
Occupational, vocational, or apprenticeship
program
Literacy or ESL program
No, not enrolled
GED program
High school
College
Graduate or professional degree program
Occupational, vocational, or apprenticeship
program

01
02
03
04

05

FORM H-100 (4-18-2016)

No school completed
Up to 6th grade
7th or 8th grade
9th, 10th, 11th, or 12th
grade, but no H.S. diploma
H.S. diploma

06

07
08
09

10

Some college, but no degree
Associate degree
College graduate
Some graduate/professional
training
Graduate/professional degree

07
08
09

10

Some college, but no degree
Associate degree
College graduate
Some graduate/professional
training
Graduate/professional degree

473
01
02
03
04

05

No school completed
Up to 6th grade
7th or 8th grade
9th, 10th, 11th, or 12th
grade, but no H.S. diploma
H.S. diploma

06
07
08
09

10

Some college, but no degree
Associate degree
College graduate
Some graduate/professional
training
Graduate/professional degree

474
01
02
03
04

05

No school completed
Up to 6th grade
7th or 8th grade
9th, 10th, 11th, or 12th
grade, but no H.S. diploma
H.S. diploma

06
07
08
09

10

Some college, but no degree
Associate degree
College graduate
Some graduate/professional
training
Graduate/professional degree

475
01
02
03
04

05

No school completed
Up to 6th grade
7th or 8th grade
9th, 10th, 11th, or 12th
grade, but no H.S. diploma
H.S. diploma

06
07
08
09

10

Some college, but no degree
Associate degree
College graduate
Some graduate/professional
training
Graduate/professional degree

476
01
02
03
04

Literacy or ESL program
No, not enrolled
GED program
High school
College
Graduate or professional degree program
Occupational, vocational, or apprenticeship
program
Literacy or ESL program
No, not enrolled

06

472

Literacy or ESL program
No, not enrolled
GED program
High school
College
Graduate or professional degree program
Occupational, vocational, or apprenticeship
program
Literacy or ESL program
No, not enrolled

No school completed
Up to 6th grade
7th or 8th grade
9th, 10th, 11th, or 12th
grade, but no H.S. diploma
H.S. diploma

05

No school completed
Up to 6th grade
7th or 8th grade

06
07
08

9th, 10th, 11th, or 12th
grade, but no H.S. diploma
H.S. diploma

09

No school completed
Up to 6th grade
7th or 8th grade
9th, 10th, 11th, or 12th
grade, but no H.S. diploma
H.S. diploma

06

10

Some college, but no degree
Associate degree
College graduate
Some graduate/professional
training
Graduate/professional degree

477
01
02
03
04

05

07
08
09

10

Some college, but no degree
Associate degree
College graduate
Some graduate/professional
training
Graduate/professional degree
Page 19

Section I – OCCUPIED UNITS – Continued

51a. In what year did . . . move into this
apartment (house)?
(Do not ask of reference person)

CHECK ITEM H
Is this the last person listed?

If 1971, ask –

b. Did . . . move here on or after
July 1 in 1971?
(Do not ask of reference person)

Yes – GO to 52

R

No – Return to Check Item G on
page 12 for the next person

Reference person

Year
680

Yes – GO to 52
If 1971 – GO to 51b
If any other year – SKIP to Check Item H

51a.

No – Return to Check Item G on
page 12 for the next person

51b. Did . . . move here on or after July 1 in 1971?
695

1
2

Yes, on or after July 1 in 1971
No, before July 1 in 1971

Year
681

Yes – GO to 52
If 1971 – GO to 51b
If any other year – SKIP to Check Item H

51a.

No – Return to Check Item G on
page 12 for the next person

51b. Did . . . move here on or after July 1 in 1971?
696

1
2

Yes, on or after July 1 in 1971
No, before July 1 in 1971

Year
682

Yes – GO to 52
If 1971 – GO to 51b
If any other year – SKIP to Check Item H

51a.

No – Return to Check Item G on
page 12 for the next person

51b. Did . . . move here on or after July 1 in 1971?
697

1
2

Yes, on or after July 1 in 1971
No, before July 1 in 1971

Year
683

Yes – GO to 52
If 1971 – GO to 51b
If any other year – SKIP to Check Item H

51a.

No – Return to Check Item G on
page 12 for the next person

51b. Did . . . move here on or after July 1 in 1971?
698

1
2

Yes, on or after July 1 in 1971
No, before July 1 in 1971

Year
684

Yes – GO to 52
If 1971 – GO to 51b
If any other year – SKIP to Check Item H

51a.

No – Return to Check Item G on
page 12 for the next person

51b. Did . . . move here on or after July 1 in 1971?
699

1
2

Yes, on or after July 1 in 1971
No, before July 1 in 1971

Year
685

Yes – GO to 52
If 1971 – GO to 51b
If any other year – SKIP to Check Item H

51a.

No – Return to Check Item G on
page 12 for the next person

51b. Did . . . move here on or after July 1 in 1971?
990

1
2

Page 20

Yes, on or after July 1 in 1971
No, before July 1 in 1971
FORM H-100 (4-18-2016)

Section I – OCCUPIED UNITS – Continued

52. Does anyone in this household (including

(If any household member 15 or older has
reported income on item 49e, one or more of the
answers to item 52 should be “Yes”.)

children under age 15) receive public
assistance or welfare payments from any
of the following?

a. Temporary Assistance for Needy Families

548

1

Yes

2

No

3

Don’t know

b. Safety Net Assistance . . . . . . . . . . . . . . . . . . . .
c. Supplemental Security Income (SSI),

549

1

Yes

2

No

3

Don’t know

including aid to the blind or disabled . . . . . . .

550

1

Yes

2

No

3

Don’t know

.........................

175

1

Yes

2

No

3

Don’t know

e. Women, Infants and Children (WIC) . . . . . . . . .
..........................
f. Other – Specify

199

1

Yes

2

No

3

Don’t know

551

1

Yes

2

No

3

Don’t know

575

1

Yes
No
Don’t know

(TANF), or Family Assistance . . . . . . . . . . . . . .

d. Supplemental Nutrition Assistance
Program (SNAP)

53a. Is there a land-line telephone in this
apartment (house)? Do not count cellular
phones, or any phone line that is used only
for a computer or fax machine.

2
3

b. How many adults (age 18 and over) in this
household have a cell phone for personal use?

570

(If an individual shares a cell phone, count the adult if
he or she has it for at least one-third of the time.)

54a. Would you say that, in general, your health is
excellent, very good, good, fair, or poor?

Persons
00

574

1
2
3
4
5
6

b. Do you or anyone in your household have any

None

Excellent
Very good
Good
Fair
Poor
Don’t know

3

Yes
No
Don’t know

647

1

Yes

2

No

648

1

Yes

2

No

Mental Health . . . . . . . . . . . . . . . . . . . . .

649

1

Yes

2

No

Treatment or diagnosis of illness or
health condition . . . . . . . . . . . . . . . . . . .

650

1

Yes

2

No

(5) Prescription Drugs . . . . . . . . . . . . . . . .

651

1

Yes

2

No

................

131

1

Yes

2

No

...............

132

1

Yes

2

No

Cell phone . . . . . . . . . . . . . . . . . . . . . . . .

136

1

Yes

2

No

Cable/Internet

....................

137

1

Yes

2

No

............................

138

1

Yes

2

No

medical devices in your home that are
important to health and that require electrical
power to operate?

198

1
2

c. In the last 12 months, did you postpone any
of the following types of health care for
financial reasons?
(Read items 1–5 and mark (X) Yes or No for each.)

(1)
(2)
(3)
(4)

Dental

...........................

Preventive care/check-up

..........

55. In the last 12 months, were any of the
following services interrupted because you
did not have enough money at the time?
(Read items 1–5 and mark (X) Yes or No for each.)

(1)
(2)
(3)
(4)
(5)

FORM H-100 (4-18-2016)

One or more utility
Land line telephone

Other

Page 21

Section I – OCCUPIED UNITS – Continued

56. Please tell me how strongly you agree or
disagree with the following statements.
(Answer choices: strongly agree, agree,
neither agree nor disagree, disagree,
strongly disagree)
(Please read all answer choices to the respondent for
each statement and mark (X) the appropriate box.)
a. My apartment (house) is affordable to me.

168

1
2
3
4
5

b. My apartment (house) is too expensive
given its condition.

169

1
2
3
4
5

c. My apartment (house) is too expensive
given its location.

183

1
2
3
4
5

CHECK
ITEM I

Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree

REFER TO QUESTION 7a ON PAGE 5 FOR THE REFERENCE PERSON
Born in New York City (box 07 marked) – SKIP to Closing Statement
Born in U.S. outside New York City (box 09 or 10 marked) – SKIP to 58
Born outside U.S. (box 11–26 marked) – GO to 57a

57a. Did . . . (reference person) move to the United

560

States as an immigrant?

1
2

Yes
No

b. In what year did . . . (reference person) move
to the United States?

561

58. In what year did . . . (reference person) move
to New York City? (most recent move if more
than one)

562

CLOSING STATEMENT
Thank you for answering the survey questions. Before I turn it in, I’ll review this form to
make certain I didn’t skip anything. If I did, it would be easier to call you back rather than
return here. Would you please give me your phone number in case I need to follow-up?
Area code
Number
029

_
END INTERVIEW. Fill items N and O on the front cover.

Notes

Page 22

FORM H-100 (4-18-2016)

Section II – VACANT UNITS

59. If this apartment (house) is occupied,
will it be the first occupancy since its
construction, gut rehabilitation, or
creation through conversion or sub-division?

518

1
2
3

Yes, first occupancy
No, previously occupied
Don’t know

NOTE – Questions 60–62a, 63a and 63b pertain to the building. Be certain to mark (X) the same box for each
form in the same building.

60. How many units are in this building?

519

If the respondent doesn’t know, canvass the
building and count the units.

01
02
03
04
05
06
07
08
09
10
11
12
13
14

61. Does the owner of this building live in
this building?

520

1
2
3

62a. How many stories are in this building?

521

Count the basement if there are people living in it.

01
02
03
04
05
06
07
08
09

b. On what floor is this unit?
Enter the 2-digit floor number or mark (X) box "0"
if basement unit. Enter the lowest floor number if
on more than one floor.

63a. Is there a passenger elevator in this
building?

0

554

522

passenger elevator without going up or
down any steps or stairs?

553

1

1
2
3

c. Is it possible to go from the sidewalk to this

555

unit without going up or down any steps or
stairs?

64a. How many rooms are in this apartment
(house)? Do not count bathrooms, porches,
balconies, halls, foyers, or half-rooms.

1
2
3

523

1
2
3
4
5
6
7
8

b. Of these rooms, how many are bedrooms?

524

01
02
03
04
05
06
07
08
09

FORM H-100 (4-18-2016)

Yes
No
Don’t know
One – SKIP to 63c
Two
Three
Four
Five
6 to 10
11 to 20
21 to 40
41 or more
Basement

Floor

2

b. Is it possible to go from the sidewalk to a

1 unit without business
1 unit with business
2 units without business
2 units with business
3 units
4 units
5 units
6 to 9 units
10 to 12 units
13 to 19 units
20 to 49 units
50 to 99 units
100 to 199 units
200 or more units

Yes
No – SKIP to 63c
Yes
No
Don’t know
Yes
No
Don’t know
One – SKIP to 65a
Two
Three
Four
Five
Six
Seven
Eight or more
None
One
Two
Three
Four
Five
Six
Seven
Eight or more

Page 23

Section II – VACANT UNITS – Continued

65a. Does this apartment (house) have complete
plumbing facilities; that is, hot and cold
piped water, a flush toilet, and a bathtub or
shower?

525

0

1

2

Yes, has complete plumbing
facilities – GO to 65b
No, has some but not all facilities
in this apartment (house)
No plumbing facilities in this
apartment (house)

⎫
⎬ SKIP to 66a
⎭

b. Are these facilities for the exclusive use
of the intended occupants of this apartment
(house) or are they also intended for use by
the occupants of another apartment
(house)?

66a. Does this apartment (house) have complete
kitchen facilities? Complete kitchen
facilities include a sink with piped water,
a range or cookstove, and a refrigerator.

526

3

4

527

0

1

2
3

For the exclusive use of the intended
occupants of this apartment (house)
Also intended for use by the occupants of
another apartment (house)
Yes, has complete kitchen
facilities – GO to 66b
No, has some but not all facilities in this
apartment (house)
No kitchen facilities in this apartment
(house), but facilities available in building
No kitchen facilities in this building

⎫
⎬ SKIP
to 67
⎭

b. Are these facilities for the exclusive
use of the intended occupants of this
apartment (house) or are they also
intended for use by the occupants of
another apartment (house)?

528

4

5

For the exclusive use of the intended
occupants of this apartment (house)
Also intended for use by the occupants of
another apartment (house)

67. How is this apartment (house) heated – by
fuel oil, utility gas, electricity, or with some
other fuel?

529

1
2
3
4
5

Fuel oil
Utility gas
Electricity
Other fuel (including CON ED steam)
Don’t know

68. Is this apartment (house) part of a
condominium or cooperative building or
development?

530

1
2
3

A condominium is a building or development with
individually owned apartments or houses having
commonly owned areas and grounds. A cooperative
or "co-op" is a building or development that is owned
by its shareholders.

4

No
Yes, a condominium
Yes, a cooperative
Don’t know

69. How long has this apartment (house)
been vacant?

531

1
2
3
4
5
6

Less than 1 month
1 up to 2 months
2 up to 3 months
3 up to 6 months
6 up to 12 months
1 year or more

70a. Before this apartment (house) became
vacant, was it owner or renter occupied?

532

1
2
3
4

b. Before this apartment (house) became
vacant, was it part of a condominium or
cooperative building or development?

533

1
2
3
4

Owner occupied
Renter occupied
Never previously occupied
Don’t know
No
Yes, a condominium
Yes, a cooperative
Don’t know

Notes

Page 24

FORM H-100 (4-18-2016)

Section II – VACANT UNITS – Continued

71. Is this apartment (house) –
534

2

Available for rent? – SKIP to 73
Available for sale only? – SKIP to Closing
Statement below.

3

Not available for rent or sale? – GO to 72

1

72. What are the reasons that this apartment
(house) is not available for sale or rent?

535

01
02

List all reasons mentioned, and then be sure to
mark (X) ONLY one box for the primary reason.

03
04
05
06
07

08
09

10
11
12

Rented, not yet occupied
Sold, not yet occupied
Unit or building is
undergoing renovation
Unit or building is
awaiting renovation
Being converted to
nonresidential purposes
There is a legal dispute
involving the unit
Being converted or awaiting
conversion to condominium
or cooperative
Held for occasional, seasonal, or
recreational use
The owner cannot rent or sell at
this time due to personal problems
(e.g. age or illness)
Being held pending sale of building
Being held for planned demolition
Held for other reasons – Specify

⎫
⎬
⎭

SKIP to
Closing
Statement
below.

73. What is the MONTHLY asking rent?
(If rent is paid other than monthly, refer to the manual
on how to convert it.)

536

$ _______________ .

00

Per month

INTERVIEWER: If the respondent indicates that the
monthly rent for the vacant unit is based upon the
income of the tenant, ask for a rent range such as
$700–$800. Then enter the midpoint of the range;
in this case $750.
CLOSING STATEMENT
Thank you for answering the survey questions. Before I turn it in, I’ll review this form to
make certain I didn’t skip anything. If I did, it would be easier to call you back rather than
return here. Would you please give me your phone number in case I need to follow-up?
Area code
029

Number

_

END INTERVIEW. Fill item N on the front cover.
Notes

FORM H-100 (4-18-2016)

Page 25

Notes

Page 26

FORM H-100 (4-18-2016)

Notes

FORM H-100 (4-18-2016)

Page 27

C. RECORD OF VISITS (Continued from page 1)
Date

Time

Remarks
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.

FIELD SUPERVISOR
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.

Page 28

FORM H-100 (4-18-2016)