Form CPS CIU Roster Que CPS CIU Roster Que CPS CIU Roster Questionnaire

Okay, let’s get started. Please answer the questions as you would if an interviewer had come to your home.

Ask R1 – R9 for 1^st HH member. Record information on Household Roster. Then ask for next HH member. Repeat for every member of HH.

R1. NAME Now I will ask you some questions about the people who live here.

What are the names of all persons living or staying here? Start with the name of the person, or one of the persons, who owns or rents this home.

R2. AGE What is [your/NAME’s] age?

R3. REL IF NOT RESPONDENT: How [are/is] [you/NAME] related to [fill name of person on line 1 of the Household Roster]?

1.  Spouse 7.  Foster Child

2.  Unmarried Partner 8.  Housemate/Roommate

3.  Child 9.  Roomer/Boarder

4.  Grandchild 10.  Other Non-relative

5.  Parent 11.  Dk

6.  Other relative (Aunt, Cousin, 12.  Ref

Nephew, Mother-in-law, etc.)

R4. HISPONA (Are/Is)(Name/You) Spanish, Hispanic or Latino?

1. Yes

   

2. No

3. Don’t Know Go to 7. RACE

4. Refuse

R5. HISPONB (Are/Is)(Name/you) Mexican, Mexican American, Chicano, Puerto Rican, Cuban American, or some other Spanish, Hispanic, or Latino Group?

1. Mexican

2. Mexican American

3. Chicano Go to 7. Race

4. Puerto Rican

5. Cuban American

6. Some Other > Go to 6. S_OROTSP

R6. S_OROTSP What is the name of (your/his/her) other Spanish, Hispanic, or Latino group?

R7. RACEA I am going to read you a list of five race categories. Please choose one or more races that (NAME/you) (considers yourself/consider NAME/considers himself/considers herself) to be: White; Black or African American; American Indian or Alaska Native; Asian; OR Native Hawaiian or Other Pacific Islander.

1. White

2. Black or African American

3. American Indian or Alaska Native Go to Q9. Work

4. Asian

5. Native Hawaiian or Other Pacific Islander

6. Other – DO NOT READ > Go to Q8. RACEB

R8. RACEB What is your race?

R9. WORK (THE WEEK BEFORE LAST/LAST WEEK), did (name/you) do ANY work for (pay/either pay or profit)?

1. Yes

2. No

3. Retired

4. Disabled

5. Unable to work