Roster

5

CPS Roster Questionnaire for Civic Engagement and Volunteerism Supplement

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

Q1-5. Ask 1^st HH member. Record information on Household Roster.

1. 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? Lets start with you.

2. MCHILD I have listed . . . [READ NAMES]

Have I missed any babies or small children?

1 Yes (who is that? Add to roster)

2 No

3. MAWAY

Have I missed anyone who usually lives here but is away now -traveling, at school, or in a hospital?

1 Yes (who is that? Add to roster)

2 No

4. MBOARDER

Have I missed any lodgers, boarders, or persons you employ who live here?

1 Yes (who is that? Add to roster)

2. No

5. OWNRENT

What is the name of the person or one of the persons who owns or rents that home?

For Q 6 - 7 complete each question for every household member before moving to the next question.

6. SEX

What is [your/[NAME]’s] sex?

1. Male

2. Female

7. REL [SHOW FLASHCARD]

How is [NAME] related to you?

1. Opposite sex spouse (husband/wife)

2. Opposite sex unmarried partner

3. Same sex spouse (husband/wife)

4.Same sex unmarried partner

5. Child

6. Grandchild

7. Parent

8. Brother/ sister

9. Other relative (aunt, uncle, cousin, in law)

10. Foster child

11. Housemate/roommate

12. Roomer/boarder

13. Other nonrelative

14. DK

15. REF

99. self

Complete questions 8 AND 9 before moving to the next person. Complete the set of questions for everyone in the household before moving to Q10.

8. AGE What is [your/NAME’s] date of birth?

9. OVER18 [IF NAME’S DOB IS UNKNOWN] Is [NAME] over 18?

1 Yes (who is that? Add to roster)

2. No

For Q10 complete for everyone in the household before moving to Q11 HISPA.

10. EDUCATION [SHOW FLASHCARD]

What is the highest level of school [you have /[NAME has]]

completed or the highest degree [you have/[NAME has]] received?

1. 1^st, 2^nd , 3^rd, or 4^th grade

2. 5^th or 6^th grade

3. 7^th or 8^th grade

4. 9^th grade

5. 10^th grade

6. 11^th grade

7. 12^th grade, no diploma

8. High school graduate-high school diploma or equivalent

9. Some college – no diploma

10. Associates degree- occupational / vocational program

11. Associates degree- academic program

12. Bachelors degree (BA, BS, AB)

13. Master’s degree (MS,MA, MBA, MEd, MEng,MSW)

14. Professional degree (MD,DDS,DMV,LLB, JD)

15. Doctorate degree (PhD, EdD)

Complete questions 11-13 before moving to the next person. Complete the set of questions for everyone in the household before moving to Q14 RACEA.

11. Hisp A [Are/is] [You/NAME] Spanish, Hispanic , or Latino?

1. Yes

   

2. No

3. DK Skip to 14 RACEA

4. REF

12. HISPB (Are/Is)(you/NAME) Mexican, Mexican American, Chicano, Puerto Rican, Cuban American, or some other Spanish, Hispanic, or Latino Group?

1. Mexican

2. Mexican American

3. Chicano Skip to 14. RACEA

4. Puerto Rican

5. Cuban American

6. Some Other Proceed to 13. O_HISP

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

Complete questions 14-15 before moving to the next person. Complete the set of questions for everyone in the household before moving to Q16 DIS1.

14. RACEA I am going to read you a list of five race categories. Please choose one or

more races that (you/NAME) (consider yourself/ 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

4. Asian

5. Native Hawaiian or Other Pacific Islander

6. Other – DO NOT READ > Proceed to 15. RACEB

15. RACEB What is your race?

Questions 16 to 27 is household-based and should only be asked once.

We want to learn about people who have physical, mental, or emotional conditions that cause serious difficulty with their daily activities.

16. DIS1 Is anyone deaf or does anyone have serious difficulty hearing?

1. Yes Proceed to 17.DIS1WHO

   

2. No

3. DK Skip to 18. DIS2

4. REF

17. DIS1WHO Who is that? Anyone else?

18. DIS2 Is anyone blind or does anyone have serious difficulty seeing, even when wearing glasses?

1. Yes Proceed to 19.DIS2WHO

   

2. No

3. DK Skip to 20. DIS3

4. REF

19. DIS2WHO Who is that? Anyone else?

20. DIS3 Because of a physical, mental, or emotional condition, does anyone have serious difficulty concentrating, remembering, or making decisions?

1. Yes Proceed to 21.DIS3WHO

   

2. No

3. DK Skip to 22. DIS4

4. REF

21. DIS3WHO Who is that? Anyone else?

22. DIS4 Does anyone] have serious difficulty walking or climbing stairs?

1. Yes Proceed to 23.DIS4WHO

   

2. No

3. DK Skip to 24. DIS5

4. REF

23. DIS4WHO Who is that? Anyone else?

24. DIS5 Does anyone have difficulty dressing or bathing?

1. Yes Proceed to 25.DIS5WHO

   

2. No

3. DK Skip to 26. DIS6

4. REF

25. DIS5WHO Who is that? Anyone else?

26. DIS6 Because of a physical, mental, or emotional condition, does anyone have difficulty doing errands alone such as visiting a doctor's office or shopping?

1. Yes Proceed to 27.DIS6WHO

   

2. No

3. DK Go to CEV questions

4. REF

27. DIS6WHO Who is that? Anyone else?