3 Flash Cards

Generic Clearance for Questionnaire Pretesting Research

Enclosure 4_Flash Cards

NYCHVS Cognitive Interviews

OMB: 0607-0725

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A3








1. Husband/wife
2. Son/daughter (own, adopted, step, foster child)
3. Brother/sister (stepbrother/sister)
4. Father/mother
5. Father-in-law/mother-in-law
6. Grandchild
7. Grandparent
8. Other relative (cousin, nephew, etc)
9. Roomer/boarder
10. Unmarried partner
11. Housemate/roommate
12. Other non-relative

A4










1. No
2. Puerto Rican
3. Dominican
4. Cuban
5. South/ Central American
6. Mexican-American, Mexican, Chicano
7.
Other Spanish/ Hispanic







A5











1. White
2. Black or African American
3. American Indian or Alaska Native
4. Asian
5. Native Hawaiian or Other Pacific Islander









A6










  1. Chinese

  2. Asian Indian

  3. Filipino

  4. Korean

  5. Japanese

  6. Vietnamese

  7. Something else









F62.1





1. GED program
2. College undergraduate years (freshman to senior)
3. Graduate or professional school beyond a bachelor's degree (for example: MA or PhD program, or medical or law school)
4. Occupational, vocational, or apprenticeship program
5. Literacy or ESL program









A33,A34, A35

1. New York City
2. U.S. outside of New York City
3.
Puerto Rico
4. Dominican Republic
5. Caribbean (oter than Puerto Rico or Dominican Republic
6. Mexico
7. Central/ South America
8. Canada
9. Armenia, Azerbaijan, Belarus, Estonia, Georgia, Kazakhstan, Kyrgystan, Latvia, Lithuania, Moldova, Russia, Tajikistan, Turkmenistan, Ukraine, or Uzbekistan
10.
Other European countries
11. China, Hong Kong, Taiwan
12. Korea
13. India
14. Pakistan, Bangladesh
15. Philippines
16. Southeast Asia (Cambodia, Laos, Malaysia, Myanmar (Burma), Singapore, Thailand, Vietnam)
17. Other Asia
18. Africa
19. All other countries – specify

B4







1. NYC program or grant
2. Federal program or grant
3. Federal homebuyer loan
4. Non-Profit assistance
5. Gift or other personal loan













B8





1. First Mortgage
2. Second Mortage
3. Home Equity Loan
4. Home Equity Credit Line
5. Reverse Mortgage
6. Other













B23






1. Principal
2. Interest
3. Property Taxes
4. Homeowners' Insurance














B18


1. Mortgage refinanced for the option to suspend or temporarily reduce mortgage payments


2. Mortgage refinanced to receive cash or increase the outstanding balance of the loan


3. Mortgage refinanced to increase the payment period


4. Mortgage refinanced to reduce the payment period


5. Mortgage refinanced to reduce the monthly payment


6. Mortgage refinanced to get a lower interest rate


7. Anything other reason





B31





1. Roof
2. Boiler
3. Pipes
4. Electrical equipment
5. Mold
6. Asbestos
7. Lead
8. Exterior (cladding, siding, or windows)
9. Foundation/basement









B36







1. Electricity
2. Cooking Gas
3. Heat
4. Water/Sewer
5. Other
6. None
7. All utilities are included in the rent or condo/coop fees







F5



1. One or more utility
2. Landline telephone
3. Cell phone
4. Cable / Internet
5. Other
6. None















B47





  1. The people who live here pay the full rent


  1. Another person pays part or all of the rent




  1. Another program pays part or all of the rent


  1. Both another person and a program pay part or all of the rent



  1. The landlord is not owed rent for this apartment







B48





  1. Section 8/Housing Choice Voucher


  1. Shelter Allowance/City FEPS


  1. SCRIE/DRIE


  1. Other assistance that pays part of my rent











B50







  1. A family member or another person


  1. An employer of someone in the household


  1. Other















C7





  1. Yes, complete kitchen facilities


2. No, some but not all facilities


3. No kitchen facilities in this apartment (house) but facilities available in building


4. No kitchen facilities in building













C4





  1. Yes, complete plumbing facilities


  1. No, some but not all facilities


  1. No plumbing facilities

















C39







1. Very Severe
2. Serious
3. Moderate
4. Slight













C27







1. Yes, central air conditioning
2. Yes, one or more window air conditioners
3. No















C19





1. Most days
2. Some days
3. A few days
4. Never
5. I did not live here during that time















C44





1. Issues are resolved quickly
2. Issues are resolved adequately
3. Issues take a long time to resolve
4. Issues are not resolved















C47, C48





1.. A big problem
2. Somewhat of a problem
3. Not a problem
4. I do not see this in my building














M43



  1. Less than 1 year


  1. 1 year


  1. More that 1 but less than 2 years


  1. 2 years


  1. Other


  1. My lease expired but I am still living here


  1. No lease









M14





1. Husband/wife
2. Son/daughter (own, adopted, step, foster child)
3. Brother/sister (stepbrother/sister)
4. Father/mother
5. Father-in-law/mother-in-law
6. Grandchild
7. Grandparent
8. Other relative (cousin, nephew, etc)
9. Roomer/boarder
10. Unmarried partner
11. Housemate/roommate
12. Other non-relative









M35



  1. Cost of the apartment [house]

  2. What I am able to pay at this time

  3. Ability to remain in the home safely and securely

  4. Physical condition of the apartment [house]

  5. Size of the apartment [house]

  6. Apartment amenities (dishwasher, laundry, balcony, etc)

  7. Physical condition of the building

  8. Building amenities (elevator, laundry, gym, etc)

  9. Neighborhood amenities (parks, museums, stores, etc)

  10. Neighborhood safety

  11. The time it takes to get to work

  12. School quality

  13. Proximity of family and friends





M37







  1. Within the next month


  1. More than a month, but in the next six months


  1. More than six months, but in the next year


  1. More than a year, but in the next two years


  1. More than two years








E11







  1. Yes, could have gone to work


  1. No, because of own temporary illness


  1. No, because of all other reasons (in school, etc.)













E5

PRIVATE SECTOR EMPLOYEE

  1. For-profit company or organization

  2. 2. Non-profit organization (including tax-exempt and charitable organizations)

GOVERNMENT EMPLOYEE

  1. Local government (for example: city or county school district)

  2. State government (including state colleges/universities)

  3. Active duty U.S. Armed Forces or Commissioned Corps

  4. Federal government civilian employee

SELF-EMPLOYED OR OTHER

7. Owner of non-incorporated business, professional practice, or farm

8. Owner of incorporated business, professional practice, or farm

9. Worked without pay in a for-profit family business or farm for 15 hours or more per week

E17



  1. Wages, salary, tips, bonuses, or commissions

  2. Income from self-employment such as a free-lancer or contractor, net real estate income including short-term rental of part or all of your apartment/home, or income from a business that is not incorporated

  3. Disability benefits including SSI, SSDI, or a disability pension

  4. Retirement income including Social Security or

  5. Survivor benefits for [person] or [person] on behalf of others

  6. Regular payments from dividends, annuities, stipends, estates, trusts, or royalties

  7. Child support, alimony, or similar

  8. Unemployment





F4





  1. Dental


  1. Preventive care / check-up


  1. Mental health


  1. Treatment or diagnosis of illness or health condition


  1. Prescription drugs











P1





  1. Supplemental Nutrition Assistance Program (SNAP)


  1. Temporary Assistance for Needy Families (TANF)


  1. Women, Infants and Children (WIC)















F10




1. Insurance through a current or former employer or union (of this person or another family member)
2. Insurance purchased directly from an insurance company (by this person or another family member)
3. Medicare, for people 65 and older, or people with certain disabilities
4. Medicaid, Medical Assistance or any kind of government-assistance plan for those with low incomes or a disability
5. TRICARE or other military health care
6. VA (including those who have ever used or enrolled for VA health care)
7. Indian Health Service
8. Any other type of health insurance or health coverage plan - Specify_________







N25-N3







  1. Strongly agree


  1. Agree


  1. Neither agree nor disagree


  1. Disagree


  1. Strongly disagree













N4







  1. Very safe


  1. Safe


  1. Neither safe nor unsafe


  1. Unsafe


  1. Very unsafe











N5







1. Not worried at all
2. A little worried
3. Somewhat worried
4. Very worried
5. Extremely worried













F18



1. Student Loan
2. Car Loans
3. Loans from relatives and friends
4. Credit Card
5. Medical Bills
6. Legal Bills
7. Other













F54



  1. Checking account


  1. Savings account


  1. Equity in a business


  1. Car


  1. Property other than your own home


  1. Retirement plan


  1. Educational savings account


  1. Other Investments


  1. Anything else of value more than $5,000


  1. None





F62





  1. Nursery school, preschool


  1. Head Start


  1. Early Head Start


  1. Universal Pre-K


  1. Kindergarten


  1. Grade 1 through 12











F68




1. A relative who took care of him/her in your home


2. A relative who took care of him/her in someone else’s home


3. A non-relative who took care of him/her in your home


4. A non-relative who took care of him/her in someone else’s home


5. A child-care or day-care center, preschool, or nursery school that was not
Early Head Start or Head Start


6. Early Head Start or Head Start







N13, N14, N15, N16, N17







  1. A big problem



  1. Somewhat of a problem



  1. Not a problem



  1. I do not see this in my neighborhood















M21-M26, M32-M33







1. Current home

2. Previous home

3. About the same



M27-M28







1. Current building

2. Previous building

3. About the same



M29-M31







1. Current neighborhood

2. Previous neighborhood

3. About the same



F14-F16







1. Often true

2. Sometimes true

3. Never true



E35









1. No, has not attended in the last 3 months

2. Yes, public school

3. Yes, private school, home school



A41







1. Very well

2. Well

3. Not well

4. Not at all



F59









  1. More than my home value



  1. About right



  1. Less than my home value



E6







1. U.S. Army

2. U.S. Navy

3. U.S. Air Force

4. U.S. Marine Corps

5. U.S. Coast Guard



A32





1. Never served in the military

2. Only on active duty for training in the Reserves or National Guard

3. Now on active duty

4. On active duty in the past, but not now

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