AHS Screener AHS Screener

May 17, 2016

RECRUITING QUESTIONNAIRE

1a. [If work full time or part time] How many days to you commute to work in a typical week?

1 [ ] 0 days – go to question 2
2 [ ] 1 day
3 [ ] 2 days
4 [ ] 3 days
5 [ ] 4 days
6 [ ] 5 days
7 [ ] 6 days
8 [ ] 7 days

1b. [If work full time or part time] How do you usually commute to work?
Mark all that apply.

1 [ ] Drive own car
2 [ ] Carpool
3 [ ] Metro/Train
4 [ ] Bus
5 [ ] Bike
6 [ ] Walk
7 [ ] Other ________________________________

1c. [If 1b = Drive or Carpool] How many people, including yourself, usually rode to work in that vehicle?

________________________________

1d. [If 1b = Drive or Carpool ] Do you pay any tolls on the way to work?

1 [ ] Yes 2 [ ] No

1e. [If 1b = Drive, Carpool, Metro/Train, or Bus] Do you pay to park on your way to work?

1 [ ] Yes 2 [ ] No

1f. [If 1b = Metro/Train or bus] Do you receive a stipend for public transportation from your employer?

1 [ ] Yes 2 [ ] No

1g. [If 1b = Other] Do you use a Taxi or car service to get to work?

1 [ ] Yes 2 [ ] No

2. [If living in a single family home, townhome, or duplex] Do you have a basement?

1 [ ] Yes 2 [ ] No

3. [If living in an apartment or condo] How many stories are in your building?

1 [ ] Yes 2 [ ] No

4. Have you moved in the past 2 years?

1 [ ] Yes 2 [ ] No

5. What do you use to heat your home?
Mark all that apply.

1 [ ] Forced warm-air furnace
2 [ ] Steam or hot water system
3 [ ] Electric heat pump
4 [ ] Built-in electric baseboard, electric coils
5 [ ] Floor, wall, other pipeless furnace
6 [ ] VENTED room heaters
7 [ ] UNVENTED room heaters
8 [ ] Portable electric heaters
9 [ ] Woodburning, pot belly, Franklin stove
10 [ ] Fireplace w/ inserts
11 [ ] Fireplace w/o inserts
12 [ ] Other
13 [ ] None
14 [ ] Cooking stove

6a. Do you currently have a mortgage or loan for your home?

1 [ ] Yes 2 [ ] No

6b. [if 6a = yes] How many mortgages or loans do you have on your home?

1 [ ] 1 mortgage
2 [ ] 2 mortgages
3 [ ] 3 mortgages
4 [ ] 4 mortgages
5 [ ] 5 mortgages
6 [ ] 6 mortgages
7 [ ] 7+ mortgages

6c. [if 1 mortgage read “Does your” else read “Do any of your”] mortgage(s) or loan(s) have an interest rate that can change with market rates, known as an "adjustable rate" mortgage or ARM?

1 [ ] Yes 2 [ ] No

6d. Has the interest rate of (any of) your “adjustable rate” mortgage(s) or loan(s) ever been fixed for more than one year, or [is it/are any of them] currently fixed?

1 [ ] Yes 2 [ ] No

7. Do you have flood insurance?

1 [ ] Yes 2 [ ] No

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