Head of household questionnaire

Attachment E. Domestic VACS Head of Household Questionnaire

For Domestic VACS Adaptation

Form Approved

OMB No: 0920-xxxx
Exp. Date: xx-xx-xxxx

Public Reporting burden of this collection of information is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA  30333; Attn:  PRA (0920-xxxx).

Read to respondent: For the purposes of this survey, the head of household is an adult individual (or emancipated minor) who is responsible for (or shares responsibility for) keeping up the home and caring for those living in it.

H1		RECORD THE TIME THE INTERVIEW BEGAN (00:00):
H2		RECORD THE SEX OF THE RESPONDENT: MALE OR FEMALE Note: this does not need to be asked of participant.	MALE FEMALE		1 2
H3		I would like to start by asking you some questions about yourself: How old are you?	years old: don’T know declined		-98 -99
H4		Does your household have access to: MARK ALL THAT APPLY	smartphone CELL phone (without smartphone/internet capabilities).. DESKTOP OR LAPTOP TABLET OR OTHER WIRELESS COMPUTER CELLULAR DATA PLAN BROADBAND (HIGH SPEED) INTERNET INSTALLED IN HOME DIAL UP INTERNET SERVICE INSTALLED IN HOME don’T know declined		1 2 3 4 5 6 7 -98 -99
H5		How many bedrooms are in this home?	NO. OF BEDROOMS: DON’T KNOW DECLINED		98 99
H6		Now, I would like to ask you about transportation. How many automobiles, meaning cars, vans or trucks are kept at home for use by members of this household? MARK ALL THAT APPLY	ONE TWO THREE FOUR FIVE OR MORE don’T know declined			1 2 3 4 5 -98 -99
H7		What mode(s) of transportation do most members of this household typically use for daily activities? MARK ALL THAT APPLY	CAR, TRUCK, OR VAN BUS TRAIN/SUBWAY/COMMUTER RAIL TAXI, UBER, OR LYFT MOTORCYCLE OR MOTORIZED SCOOTER BICYCLE WALKED OTHER don’T know declined			1 2 3 4 5 6 7 -97 -98 -99
H8		Does any member of this household have a bank account at a bank, credit union or online?	YES NO DON’T KNOW DECLINED		1 2 -98 -99
H9		In the past 12 months, has anyone in the household received outside financial help from a non-government program, or does someone participate in a community based program that provides income, such as micro finance, loan, or community savings group?	YES NO DON’T KNOW DECLINED		1 2 -98 -99
H10		In the past 12 months, how often would you say you or your family were worried or stressed out about having enough money to pay for meals? Would you say very often, often, sometimes, seldom, or never?	VERY OFTEN OFTEN SOMETIMES SELDOM NEVER DON’T KNOW DECLINED		1 2 3 4 5 -98 -99
H11		In the past 12 months, did you or any member of this household receive benefits from the Food Stamp Program or SNAP (Supplemental Nutrition Assistance Program)?	YES NO DON’T KNOW DECLINED		1 2 -98 -99
H12		In the past 12 months, how often have you worried that your total family income would not be enough to meet your family’s expenses and bills? Would you say very often, often, sometimes, seldom, or never?	VERY OFTEN OFTEN SOMETIMES SELDOM NEVER DON’T KNOW DECLINED		1 2 3 4 5 -98 -99
H13		How has your overall financial situation changed over the past 12 months? Would you say it has gotten much worse, slightly worse, not changed, slightly better, or much better?	IT HAS GOTTEN MUCH WORSE IT HAS GOTTEN SLIGHTLY WORSE IT HAS NOT CHANGED IT HAS GOTTEN SLIGHTLY BETTER IT HAS GOTTEN MUCH BETTER DON’T KNOW DECLINED		1 2 3 4 5 -98 -99
H14	Now, I would like to ask you about your family’s experiences with moving. Did you live in this house or apartment one year ago?			YES NO DON’T KNOW DECLINED	1 2 -98 -99		H16 H15 H16
H15	Where did you live one year ago? Were you in a different home in the United States / Puerto Rico or outside the United States / Puerto Rico?			DIFFERENT HOUSE IN THE UNITED STATES OR PUERTO RICO OUTSIDE THE UNITED STATES OR PUERTO RICO DON’T KNOW DECLINED	1 2 -98 -99
	ONLY FOR HOUSEHOLDS WITH 1 OR MORE RESIDENTS LESS THAN 18 YEARS, OTHERWISE SKIP TO H54
H16	Now I will ask you about the health and wellness of the members of your household: In the past year, have any of the adults in the household been ill for 3 or more months?			YES NO DON’T KNOW DECLINED	1 2 -98 -99
H17	Within the past 5 years, has there been a death in the household?			YES NO DON’T KNOW DECLINED	1 2 -98 -99
H18	In the past 12 months, did you ever have to cut the size of the meals in your household because there was not enough food or money?			YES NO DON’T KNOW DECLINED	1 2 -98 -99
H19	In the past 12 months, did people in your household ever skip meals because there was not enough food or money?			YES NO DON’T KNOW DECLINED	1 2 -98 -99
	ONLY ASKED IF PARTICIPANT HAS BEEN SELECTED AND IS LESS THAN 18 YEARS
H20	Is the [AGE] year old [M/F] born on [DOB] currently living in this household because his/her own parent is sick, has died, has moved away, been incarcerated or unable to provide care?			YES, PARENT IS SICK YES, PARENT DIED YES, PARENT MOVED AWAY YES, PARENT INCARCERATED YES, PARENT UNABLE TO PROVIDE CARE NO DON’T KNOW DECLINED	1 2 3 4 5 6 -98 -99
ONLY ASKED IF THERE IS ANOTHER HOUSEHOLD MEMBER LESS THAN 18 YEARS
H21	Are/is the (other) child(ren) living in this household because their own parent is sick, has died, has moved away, been incarcerated or unable to provide care?			YES, PARENT IS SICK YES, PARENT DIED YES, PARENT MOVED AWAY YES, PARENT INCARCERATED YES, PARENT UNABLE TO PROVIDE CARE NO DON’T KNOW DECLINED	1 2 3 4 5 6 -98 -99
ONLY ASKED IF PARTICIPANT HAS BEEN SELECTED AND IS LESS THAN 18 YEARS
H22	Has the [AGE] year old [M/F] born on [DOB] lived outside of family care in the last five years? For example an orphanage, shelter or foster care, detention center or with other relatives/families/friends [Adapt to country context]			YES NO DON’T KNOW DECLINED	1 2 -98 -99		END
ONLY ASKED IF PARTICIPANT HAS BEEN SELECTED AND IS LESS THAN 18 YEARS
H23	Has the [AGE] year old [M/F] born on [DOB] lived on the street, in a homeless shelter, or did not have a permanent residence in the last 5 years? Mark all that apply.			YES, THEY LIVED ON THE STREET YES, THEY LIVED IN A HOMELESS SHELTER YES, THEY DID NOT HAVE A PERMANENT RESIDENCE NO DON’T KNOW DECLINED	1 2 3 4 -98 -99