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CYCLE 102, Spring 2022
OMB Nº. 1205-0453
1
0 2
COUNTY FIPS
EXPIRATION DATE: 01/31/2023
[Revised Nov.15, 2021]
FARM WORKER ID
[FOR OFFICE USE ONLY]
NATIONAL AGRICULTURAL WORKERS SURVEY - 2022
CS2
DATE:
CS5
CROP:
/
/
(“NAWS”)
[FOR OFFICE USE ONLY]
CROP CODE
CS6 TASK:
TASK CODE
LANGUAGE DURING INTERVIEW: __________________
GN:
ID:
IF GN REFERRED TO CONTRACTOR, GROWER OR OTHER,
WRITE INFORMATION)
NAME :
_______________________________________
ADDRESS:
_______________________________________
TELEPHONE:
(_________)___________-________________
GN REFERRED TO:
9 “CONTRACTOR”?:
9 OTHER GROWER?
9 OTHER?:_______
WORKER IS ACTUALLY EMPLOYED BY?:
9 1 GROWER
9 2 CONTRACTOR
92 NURSERY
93 PACKING HOUSE
97 OTHER:________
TYPE OF WORK?: 91 FIELD WORK
FARM WORKER’S NAME:
TELEPHONE:
INTERVIEWER’S
NAME:
CP5 TIME BEGAN:
CS9 INTERVIEWER’S ID:
:
9 AM
9 PM
CP6 TIME ENDED:
:
9 AM
9 PM
Notwithstanding any other provision of law, no person is required to respond to nor shall a person be subject to a
penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction
Act unless that collection of information displays a currently valid Office of Management and Budget control
number. Public reporting burden for this collection of information, which is voluntary, is estimated to average 45
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. Send comments
regarding this burden estimate to the Office of Policy Development, Evaluation and Research, ETA, Department of
Labor, Room N5641, 200 Constitution Avenue, N.W., Washington, D.C. 20210.
HOUSEHOLD GRID
A1
NAME
A. (FARMWORKER)
*A2
R
E
L
A
T
I
O
N
A3
S
E
X
M
F
B.
A5
M
A
R
I
T
A
L
S
T
A
T
U
S
S
M
O
A6
B
I
R
T
H
D
A
Y
MM
/
YY
**A7
C
O
U
N
T
R
Y
A9
**A10
HIGHEST
C
GRADE
O
LEVEL
U
[FOR
N
MINORS
T
INCLUDE
R
PREY
SCHOOL
(“PS”) AND
S
B KINDER (“K”)
C
I
[ASK
H
R
ONLY
O
T
WORKER
O
H
FOR
L
[COD HIGHEST
[COD
E]
DEGREE
E]
OBTAINED. ]
A8
MONTH
AND
YEAR
FIRST
E
N
T
E
R
E
D
Y
Y
Y
N
N
N
Y
Y
Y
Y
N
N
N
N
Y
Y
Y
Y
N
N
N
N
/
HD: _______
S
/
NF
/
F
O
D.
NW
S
FW
M
M
/
/
F
Y
Y
Y
Y
N
N
N
N
NF
O
E.
NW
S
M
M
/
Y
Y
Y
N
N
N
N
NW
Y
Y
Y
Y
FW
N
N
N
N
NF
O
M
F
S
M
/
/
O
*CODES FOR A2 (RELATIONSHIP):
1 = SPOUSE/COMMON LAW SPOUSE
2 = OWN CHILD, DEPENDENT OR ADOPTED
3 = SIBLING
4 = PARENT
5 = GRANDCHILD
6 = OTHER RELATIVE (COUSINS, UNCLES, ETC.)
95= DK (DON’T KNOW)
96= RF (REFUSE)
7= OTHER::__________________
** CODES FOR A7 AND A10 (COUNTRIES AND REGIONS):
1= U.S.A.
8= PACIFIC ISLANDS (THE
2= PUERTO RICO
PHILIPPINES, GUAM, FIJI, ETC.)
3= MEXICO
9= ASIA (CHINA, JAPAN, KOREA,
4= CENTRAL AMERICA
ETC.)
5= SOUTH AMERICA
95= DK (DON’T KNOW)
6= CARIBBEAN
96= RF (REFUSE)
7= SOUTH EAST ASIA (INDONESIA, CAMBODIA,
97=OTHER:________
VIETNAM, LAOS, THAILAND)
2
FW
Y
/
F
F.
NW
FW
M
M
FW
NF
/
/
O
C.
A4
***A31
A32-33
A34-35
A11
A36
[ASK ALL
IF
LAST 12
PRIOR 12
ANY
ANY
MONTHS,
IN A1]:
NOT
MONTHS
U.S.
U.S.
DOES
HERE, TRAVELED TO (A32-33), SCHOOL WORK
S/HE LIVE WITH YOU NOW?
WHY TO DO FW TRAVELED LAST
LAST
IF NOT, WHERE? [STATE and NOT? (OR DONE TO DO FW
12
12
FW IN
COUNTRY]
_
(OR DONE MONTHS MONTHS
OTHER
C
FW IN
?
?
CITY)?
O
OTHER
IF YES,
D
CITY)?
[NAME]
E
IF YES,
TRAVELED
[NAME]
OR JOINED TRAVELED
WITH YOU? OR JOINED
WITH YOU?
HG: _______
/
S
M
102 ___ ___ ___ __
Farmworker ID
U.S.?
M
F
___ ___ ___ ___ ___
County
NF
NW
***CODES FOR A31
1 = NO CHILD CARE IN THIS LOCATION
2 = NO HOUSING IN THIS LOCATION
3 = CHILD IN SCHOOL, AFFECTED IF
MOVED
95= DK (DON’T KNOW)
96= RF (REFUSE)
7= OTHER: _______
HOUSEHOLD GRID
A1
NAME
*A2
R
E
L
A
T
I
O
N
A3
S
E
X
G.
A5
A6
**A7
A9
**A10
A8
M
A
R
I
T
A
L
B
I
R
T
H
D
A
Y
C
O
U
N
T
R
Y
HIGHEST
GRADE
LEVEL
[FOR
MINORS
INCLUDE
PRESCHOOL
(“PS”) AND
KINDER
(“K”)
C
O
U
N
T
R
Y
MONTH
AND
YEAR
S
T
A
T
U
S
MM
/
YY
B
I
R
T
H
[CODE]
S
C
H
O
O
L
[ASK
ONLY
WORKER
FOR HIGHEST
DEGREE
OBTAINED. ] [COD
E]
FIRST
E
N
T
E
R
E
D
U.S.?
M
S
/
M
***A31
A34-35
A11
A36
LAST 12
MONTHS,
TRAVELED
TO DO FW
(OR DONE
FW IN
OTHER
CITY)?
IF YES,
[NAME]
TRAVELED
OR JOINED
WITH YOU?
PRIOR 12
MONTHS TO
(A32-33),
TRAVELED
TO DO FW
(OR DONE
FW IN
OTHER
CITY)?
IF YES,
[NAME]
TRAVELED
OR JOINED
WITH YOU?
ANY
U.S.
S
C
H
O
O
L
LAST
12
M
O
N
T
H
S?
ANY
U.S.
WORK
Y
Y
Y
Y
N
N
N
N
[ASK ALL
IF
IN A1]:
NOT
DOES
S/HE LIVE WITH YOU NOW?
H
IF NOT, WHERE? [STATE
E
and
R
COUNTRY]
E,
WHY
NOT
?
_
C
O
D
E
A32-33
102___ ___ ___ __
Farmworker ID
/
/
O
H.
A4
County
LAST
12
M
O
N
T
H
S?
FW
S
M
F
___ ___ ___ ___ ___
M
Y
Y
Y
Y
N
N
N
N
Y
Y
Y
Y
N
N
N
N
Y
Y
Y
N
N
N
/
F
O
NF
NW
FW
NF
NW
I.
S
M
/
M
F
/
O
J.
M
S
F
M
/
/
FW
NF
Y
NW
FW
NF
N
O
S
K.
NW
FW
M
Y
M
1 = SPOUSE/COMMON LAW SPOUSE
2 = OWN CHILD, DEPENDENT OR ADOPTED
3 = SIBLING
4 = PARENT
5 = GRANDCHILD
6 = OTHER RELATIVE (COUSINS, UNCLES, ETC.)
95= DK (DON’T KNOW)
96= RF (REFUSE)
7 = OTHER:__________________
Y
Y
N
N
N
NF
F
*CODES FOR A2 (RELATIONSHIP):
Y
/
/
O
** CODES FOR A7 AND A10 (COUNTRIES AND REGIONS):
1= U.S.A.
2= PUERTO RICO
3= MEXICO
4= CENTRAL AMERICA
5= SOUTH AMERICA
6= CARIBBEAN
7= SOUTHEAST ASIA (INDONESIA, CAMBODIA,
VIETNAM, LAOS, THAILAND)
8= PACIFIC ISLANDS (THE PHILIPPINES, GUAM,
FIJI, ETC.)
9= ASIA (CHINA, JAPAN, KOREA, ETC.)
95= DK (DON’T KNOW)
96= RF (REFUSE)
97=OTHER: ________
3
NW
N
***CODES FOR A31
1 = NO CHILD CARE IN THIS LOCATION
2 = NO HOUSING IN THIS LOCATION
3 = CHILD IN SCHOOL, AFFECTED IF MOVED
95= DK (DON’T KNOW)
96= RF (REFUSE)
7 = OTHER:: _______
[THESE QUESTIONS REFER TO OTHER INDIVIDUALS WHO LIVE WITH THE WORKER AND WERE NOT MENTIONED IN THE
“HOUSEHOLD GRID”!]: A15 Other than those you have already mentioned, how many people live with you now?:
... TOTAL:
A20 ...your
Out of those (TOTAL IN “A15” ), ...how many are: ...
a.
...ADULTS? (18 YEARS OR OLDER)?
b.
...CHILDREN? (17 YEARS OR YOUNGER)?
c.
relatives?
A16
...doing FW?
...DO NOT KNOW AGE?
INSURANCE QUESTIONS ABOUT RESPONDENT AND HIS/HER FAMILY
(INDIVIDUALS IN THE “HOUSEHOLD GRID”) [DESCRIBE/EXPLAIN “HEALTH INSURANCE”]
A21
A23
In the U.S.A.,... Who has Health (Medical) Insurance in your family? ...
How about...
a. ...you
(farmworker)?
b. ...your
spouse?
[CHILDREN UNDER
AND OVER 18 YRS.
OLD. MATCH TOTAL
WITH FAMILY GRID]
C. ...your
children?
9 0 NO
9 1 YES
9 95 DON’T KNOW
9 0 NO
9 1 YES
9 95 DON’T KNOW
Who pays for it?
[USE CODES. MARK ALL
THAT APPLY]
91 92 93 94 95
97
9 6:
91
92
93
94
92
93
94
95
9 6:
A21c2
A24
(a) How many under 18 yrs?:
9 0 NO
9 1 YES, ALL HAVE IT [ASK A23]
(b) How many over 18 yrs?:
9 2 YES, ONLY SOME HAVE IT
91
95
9 6:
9 95 DON’T KNOW
CODES FOR “A23” (WHO PAYS?):
1= I PAY
2= MY SPOUSE
3= MY EMPLOYER
4= MY SPOUSE’S EMPLOYER
5= GOVERNMENT
7 = PARENT’(S’) INSURANCE
6 = OTHER:
G4 In the last 2 years [LAST 24 MONTHS], have you or anyone in your
household received benefits or used the services of any of the
following social programs? [READ CHOICES. CHECK ALL THAT
APPLY]: ...
9 r.
...Welfare (general assistance) or TANF (Temporary
Assistance for Needy Families)?
9 b. ...Food stamps?
9 c. ...Disability insurance?
9 d. ...Unemployment insurance?
9 s. ..Additional benefits related to COVID-19?
9 e. ...Social Security?
9 h. ...Low income housing?
9 i.
...Public Health Clinic?
9 j.
...Medicaid?
9 k. ...WIC?
9 l. ...Disaster Relief
9 m. ... Legal Advice or Services
9 n. ...Other?:
9 ...None
9 ...Don’t know
D36a [FOR PARENTS OF CHILDREN 12 YEARS OLD OR
YOUNGER]: ...in all the places you’ve lived in the USA in
the past 12 MONTHS, where have all your children 12
years old or younger stayed while you are working (FW
in the USA)? [CHECK ALL THAT APPLY]
91
9 13
9 14
9 15
9 16
9 17
9 11
9 12
4
They've stayed home alone, at least sometimes
With my spouse, other family
With a neighbor or babysitter
Migrant head start, Head start
School or pre-school
Other migrant education
With me in the fields
OTHER:
D65 Do you live in a labor camp or Migrant Center? [IF
YES, PROBE: WHO OWNS OR RUNS IT?]
90
91
92
93
D35b
NO
YES, labor camp run by a grower or labor
contractor
YES, labor camp run by migrant center or public
agency
YES, labor camp run by another person/group
Specify: __________________
Where are your living quarters located?
[READ CHOICES. MARK ONLY ONE]: ...
91
...OFF FARM IN PROPERTY NOT OWNED OR
ADMINISTERED BY YOUR PRESENT EMPLOYER?
9 2 ...OFF FARM IN PROPERTY OWNED OR ADMINISTERED
BY YOUR PRESENT EMPLOYER?
9 5 ...ON FARM OR NEXT TO OR ADJACENT TO A FARM
OWNED BY THE GROWER YOU CURRENTLY WORK
FOR?
9 6 ...ON A FARM OR NEXT TO OR ADJACENT TO A FARM
NOT OWNED BY THE GROWER YOU CURRENTLY WORK
FOR?
9 97 ...OTHER?:
D34b
In what type of living quarters do you live
now (housing structure at this location)? [READ
CHOICES. MARK ONLY ONE]: ...Is it a (an)...
91
92
94
...MOBILE HOME?
...SINGLE-FAMILY HOME (DETACHED)?
...APARTMENTS (TWO OR MORE IN A BUILDING,
SHARED PARKING SPACES)?
9 97 ...OTHER:
D54
How many of the following do you have in your
current living quarters (dwelling)...
9 a.
...Bedrooms?:
9 b.
...Bathrooms?:
9 c.
...Kitchens?:
9 f.
...Other rooms?:
D52
How many people total sleep in these rooms?
[VERIFY RESPONSE BY ADDING TOTAL NUMBER
GIVEN IN HOUSEHOLD GRID PLUS TOTAL IN A15.
IF ANSWERS DO NOT MATCH, MAKE
APPROPRIATE CHANGES]
D33a
While you are working for this grower/ contractor, what
type of payment arrangement do you have for your
living quarters? [IF PAYMENT IS ONLY FOR UTILITIES,
CONSIDER IT FREE. DO NOT READ. MARK ONE]:
9 10 I (OR I AND MY FAMILY) RECEIVE FREE HOUSING FROM
MY EMPLOYER. [SKIP TO D66]
9 3 I PAY FOR HOUSING PROVIDED BY MY EMPLOYER. (I
PAY DIRECTLY OR THROUGH WAGE DEDUCTION).
9 5 I PAY FOR HOUSING PROVIDED BY THE GOVERNMENT,
A CHARITY, OR OTHER NON-WORK RELATED
INSTITUTION.
9 11 DO NOT PAY RENT. (I OR FAMILY MEMBER OWN THE
HOUSE OR LIVE FOR FREE WITH FRIENDS OR
RELATIVES) [SKIP TO G6. ASK IF BUYING OTHERS]
9 12 I RENT FROM NON-EMPLOYER (RELATIVE OR NONRELATIVE)
9 97 OTHER:
D50
At this location how much do you pay for housing
(including housing for your family if they live with you)?
91
per week
$
or
per month $
or
per day
$
92
93
97
,
.
,
.
,
.
DON'T KNOW, TAKEN OUT OF MY PAYCHECK
DON'T KNOW/DON'T REMEMBER, BUT NOT TAKEN OUT
OF MY PAYCHECK
OTHER:
D66 [If in employer-provided housing]: Over the past 12
months, what safety practices have been in place to prevent
COVID-19 (or spread of infectious disease) in the housing? (READ
OPTIONS and MARK RESPONSES]:
9 a. individual rooms
9 b. single beds (no bunk beds)
9 c. information about COVID-19 or infectious disease
prevention
9 d. a separate place to isolate sick workers
9 other:
9 none
G6 Do you own or are you buying any of the following items
in the U.S.? [READ OPTIONS/MARK ALL “YES” RESPONSES]
9 a. ...a plot of land?
9 h. ...a type of housing, such as a house, mobile home,
condominium, or apartment?
9 d. ...any kind of vehicle, such as a car or truck?:
9 f. ...other?:
9 None
5
E2
D37a How far is your current job from your current
residence?
91
I'M LOCATED AT THE JOB
92
WITHIN 9 MILES
93
10-24 MILES
94
25-49 MILES MILES
95
50-74 MILES
96
75 MILES OR MORE
91
93
95
97
9 1 ...DRIVE CAR?
9 2 ...WALK [SKIP TO B10]
9 5 ...PUBLIC TRANSPORTATION (BUS, TRAIN, ETC.)?
[SKIP TO B10]
9 6 ...LABOR BUS, TRUCK, VAN?
9 8 ...“RAITERO”:?
9 4 ...RIDE WITH OTHERS (SHARES RIDE)?
9 7 ...OTHER?:
B1
B10
...MEXICAN?
9 3 ...CHICANO?
9 5..PUERTO RICAN?
9 4 ...OTHER HISPANIC?:
9 7 ...NOT HISPANIC OR LATINO?
B2 Which of the following do you consider yourself?
[READ CHOICES EXCEPT “OTHER.” MARK ONE OR
MORE RESPONSES]: ...
9 1 White?
9 2 Black or African American?
9 4 American Indian/Alaska Native?
9 5 .Asian?
9 6 Native Hawaiian or Pacific
Islander?
9 7 ...Other?:
Do you pay a fee to (responsible in D37 and/or
"raiteros") for rides to work?
B3 Have you ever participated in, attended or received any
job training or attended any of the following special
classes or school in the U.S.? [READ CHOICES.
CHECK ALL THAT APPLY]: ...
NO
YES, A FEE
YES, JUST FOR GAS
In what month and year did you first do any farm work
in the U.S.? (First time FW in the U.S.) [ASK FOR
MONTH/ YEAR]
MONTH
/
/
Approximately how many years have you done nonfarmwork in the U.S.? [COUNT ANY YEAR IN WHICH
15 DAYS OR MORE WERE WORKED]
years
B13
9 a.
9b
9 c.
9 d.
9 e.
9 f.
9 g.
9 i.
9 j.
9
YEAR
B11 Approximately how many years have you done
farmwork in the U.S.? [COUNT ANY YEAR IN WHICH 15
DAYS OR MORE WERE WORKED].
years
B12
[ASK ALL] Which of the following describes you?
[READ CHOICES. CHECK ONLY ONE]: ...
9 1 ...MEXICAN-AMERICAN? 9 2
D38a Do you have to use the transport (in D37) (IS IT
MANDATORY OR OBLIGATORY)?
9 0 NO
9 1 YES
90
91
92
LESS THAN ONE YEAR 9 2 ONE TO THREE YEARS
FOUR TO FIVE YEARS 9 4 OVER FIVE YEARS
OVER FIVE YEARS/ AS LONG AS I AM ABLE
E4. Could you get a U.S. non-farm job (NF) within a
month?
9 7 DON’T KNOW
9 0 NO 9 1 YES
D37 At your current job, how do you usually get to work?
[READ CHOICES. MARK ONE]:...
D38
How long do you expect to continue doing farm work
(FW in the U.S.)? [READ CHOICES. MARK ONLY ONE]
When was the last time your parents did hired farmwork in the U.S.?
90
NEVER
9 1 NOW / WITHIN LAST YEAR
92
ONE TO FIVE YEARS AGO
9 3 SIX TO TEN YEARS AGO
94
OVER 10 YEARS AGO 9 7
DON’T KNOW
B4
In the last 2 years [LAST 24 MONTHS], has anyone in
your household (from “Family Grid”)- excluding
yourself - participated in, attended or received any
training, special classes or schools in the U.S.? [READ
CHOICES. CHECK ALL THAT APPLY]: ...
9 a. English/ ESL
9 b. Citizenship?
9 c. Literacy?
9 d. Job training?:
9 e. GED (High School Equivalency)?
9 j. College or university?
9 g. Basic adult education?
9 i.
Migrant Education?
9 k. Head Start?
9 l.
9 n.
9
9
7
...English/ESL?
...Citizenship?
...Literacy?
...Job training:
...GED, High School Equivalency?
...College or University?
...Adult Basic Education?
...Migrant Education?
...Other?:
None
Migrant Head Start?
Other?:
Don’t know
None
[IF FOREIGN BORN, ASK];
Where were you born? In
what...
B18.
(d) ...STATE?:
(DEPARTMENT)
B26-27
(e) ...MUNICIPALITY
(EQUIVALENT)?:
B16.
When you lived in your country, did
you work in...
9 1 ...AGRICULTURE [FW]?
9 2 ...NON-AGRICULTURE [NF]?
9 3 ...PART FARM AND PART NON-FARM [FW AND
NF]?
9 5 ...NEVER WORKED?
B17-18. Before coming to the USA, you lived
in what...
(B17)...COUNTRY?:
(B18)...STATE (OR
DEPARTMENT)?:
...And where were your parents born? ...In what...
a. ...COUNTRY?
b. ...STATE (OR EQUIVALENT)
(B26) FATHER:
(B27) MOTHER?:
LANGUAGE SECTION
B7
How well do you speak English? [READ CHOICES. MARK
ONLY ONE RESPONSE]: ...
91
...Not at all?
93
...Somewhat?
94
...Well?
92
...A little?
B20
When you were a child, in
what languages did adults
speak to you
B8 How well do you read English? [READ CHOICES. MARK ONLY
ONE RESPONSE]:
9 3 ...Somewhat?
9 1 ...Not at all?
9 4 ...Well?
9 2 ...A little?
B21
And now, as an adult, what languages can you speak?
at home?
[CHECK
Check all that apply:
ALL THAT B22 And now, how well do
APPLY]
you speak it?
[FOR EACH CHECKED ANSWER, ASK]:
READ CHOICES. MARK
ONLY ONE PER CHECK]:
c CREOLE
d MIXTEC
e KANJOBAL
f ZAPOTEC
z OTHER:
92
93
94
92
93
94
92
93
94
92
93
94
...A LITTLE?
...SOMEWHAT?
...WELL?
...A LITTLE?
...SOMEWHAT?
...WELL?
...A LITTLE?
...SOMEWHAT?
...WELL?
...A LITTLE?
...SOMEWHAT?
...WELL?
92
93
94
...A LITTLE?
...SOMEWHAT?
...WELL?
92
93
94
...A LITTLE?
...SOMEWHAT?
...WELL?
8
believe you are most
B23 And now, how well do
you read it?
dominant (comfortable)
[READ CHOICES. MARK
ONLY ONE PER CHECK]:
conversing? [CHECK ONE. If
fully bilingual enter and check
both]
a ENGLISH
b SPANISH
B24
In which language do you
91
92
93
94
...NOT AT ALL?
...A LITTLE?
...SOMEWHAT?
...WELL?
91
92
93
94
...NOT AT ALL?
...A LITTLE?
...SOMEWHAT?
...WELL?
91
92
93
94
...NOT AT ALL?
...A LITTLE?
...SOMEWHAT?
...WELL?
91
92
93
94
...NOT AT ALL?
...A LITTLE?
...SOMEWHAT?
...WELL?
91
92
93
94
...NOT AT ALL?
...A LITTLE?
...SOMEWHAT?
...WELL?
91
92
93
94
...NOT AT ALL?
...A LITTLE?
...SOMEWHAT?
...WELL?
REMINDER: BEFORE BEGINNING WITH “THE WORK GRID” ASK FOR “NW” AND “AB” PERIODS: “DURING THE LAST 12 MONTHS, FOR 5 OR MORE DAYS ...HAVE YOU BEEN ILL OR
SICK? ...HAVE YOU BEEN UNEMPLOYED? ...HAVE YOU TRAVELED OUT OF THE COUNTRY?” [USE THE “YES” RESPONSES TO PROBE AND DOCUMENT DATES HERE OR DURING THE QUESTIONS IN THE “WORK GRID”]:
C4
WORK GRID
REPORT FROM FIRST PERIOD COVERING FEBRUARY 1, 2021 TO PRESENT
C5
C6
C8
C9
C10
FW
PER.
AND
SUB
PER.
NO.
GR
CO
[FW
ONLY]
EMPLOYER’S NAME
(FARM WORK, NONFARM WORK AND
WORK ABROAD)
CROP
WRITE
ACTIVITY OR TASK WHILE FW,
AB and NF [USE CODES FOR
*NW ONLY]
NF
NW
AB
GR
FW
NF
CO
NW
AB
RECEIVED
UNEMPLOYMENT?
[C1-C2 FOR OFFICE USE ONLY]
C1-C2 C15
C3
DATES FOR PERIODS
OF
FW, NF, NW, AB
FROM:
TO:
# OF
WORK
DAYS
PER
WEEK?
FW, NF,
AB
NW
AB
GR
FW
NF
CO
NW
AB
FW
NF
GR
CO
NW
AB
FW
NF
GR
CO
NW
AB
* C-5 ACTIVITY CODES: ONLY FOR “NW” (IN THE U.S.A.)
[WRITE ACTIVITY FOR FW, NF, AB]
207 =
208 =
STATE
and
***FW, NF,
&
AB:
WHY
LEFT?
COUNTRY
[CODE]
Y
COMMUTE FROM
MEXICO TO DO FW?
N
Y
Y
CO
205 =
206 =
CITY
COUNTY NAME
[IF IN A BORDER
COUNTY ASK IF
COMMUTE FROM
MEXICO]
N
FW
NF
GR
201 =
202 =
203 =
204 =
____________ ___ 102_____________ ___ ___ ___ ___
County
Farmworker ID
C11
C12
C13
C7
LOOKING FOR FW AND NF WORK
LOOKING FOR FARM WORK
LOOKING FOR NF WORK
WAITING FOR RECALL NOTICE(AFTER
LAYOFF)
WAITING FOR START OF SEASON
FAMILY RESPONSIBILITIES/ WORK IN
HOME
IN SCHOOL
LAID UP DUE TO INJURY
209 = IN-TRANSIT BETWEEN JOBS
210 = VACATION
211 = DID NOT LOOK FOR WORK
212 = OTHER: (SPECIFY IN GRID)
213= WAITING FOR COVID SITUATION TO
IMPROVE
214= CHILDCARE DUE TO COVID
215=SICK WITH COVID
216=NO WORK AVAILABLE DUE TO COVID
217 = WAITING FOR COVID TEST RESULTS
218 = QUARANTINING DUE TO COVID EXPOSURE
COMMUTE FROM
MEXICO TO DO FW?
N
Y
N
Y
COMMUTE FROM
MEXICO TO DO FW?
N
Y
N
Y
COMMUTE FROM
MEXICO TO DO FW?
N
Y
N
Y
COMMUTE FROM
MEXICO TO DO FW?
N
Y
** C-5 ACTIVITY CODES: ONLY FOR “AB” (WHILE
IN A FOREIGN COUNTRY OR ABROAD):
311= WORK IN OWN/FAMILY FARM
320= NF IN OWN BUSINESS (SPECIFY IN GRID)
341= NF IN “MAQUILA”
359= NF OTHER (SPECIFY IN GRID)
361 = NW - MEDICAL TREATMENT
362 = NW - VACATION
369 = NW - OTHER: (SPECIFY IN GRID)
370 = NW- WAITING FOR COVID SITUATION TO
IMPROVE
9
N
*** C-7 CODES: WHY LEFT “FW”, “NF”, & “AB”?
1 = LAID OFF/END OF SEASON
2 = FIRED
3 = FAMILY RESPONSIBILITIES
4 = SCHOOL
5 = MOVED
6 = HEALTH REASON
7 = VACATION
8 = RETIRED
10 = QUIT
11 = CHANGE JOBS
12 = NO WORK DUE TO COVID-19
13= CHILDCARE DUE TO COVID
14= SICK WITH COVID
15 = STOPPED WORKING TO AVOID
COVID
9 = OTHER (SPECIFY):
______________-
WORK GRID
C4
REPORT FROM FIRST PERIOD COVERING FEBRUARY 1, 2021 TO PRESENT
C5
C6
C8
C9
C10
FW
GR
PER.
EMPLOYER’S NAME
AND
(FARM WORK, NONSUB
CO
FARM WORK AND
PER. [FW
WORK ABROAD)
NO. ONLY]
CROP
WRITE
ACTIVITY OR TASK WHILE
FW, AB and NF [USE CODES
FOR *NW ONLY]
FW
NF
CO
NW
AB
GR
FW
NF
CO
NW
AB
GR
FW
NF
CO
NW
AB
N
FW
NF
Y
NW
AB
N
NW
AB
* C-5 ACTIVITY CODES: ONLY FOR “NW” (IN THE U.S.A.)
[WRITE ACTIVITY FOR FW, NF, AB]
LOOKING FOR FW AND NF WORK
LOOKING FOR FARM WORK
LOOKING FOR NF WORK
WAITING FOR RECALL NOTICE(AFTER
LAYOFF)
WAITING FOR START OF SEASON
FAMILY RESPONSIBILITIES/ WORK IN HOME
IN SCHOOL
LAID UP DUE TO INJURY
209 =
IN-TRANSIT BETWEEN JOBS
210 =
VACATION
211 =
DID NOT LOOK FOR WORK
212 =
OTHER: (SPECIFY IN GRID)
213= WAITING FOR COVID SITUATION TO
IMPROVE
214= CHILDCARE DUE TO COVID
215=SICK WITH COVID
216=NO WORK AVAILABLE DUE TO COVID
217 = WAITING FOR COVID TEST RESULTS
218 = QUARANTINING (COVID)
C12
COUNTY NAME
[IF IN A BORDER
COUNTY ASK IF
COMMUTE FROM
MEXICO]
STATE
and
___ _
C7
***FW,
NF &
AB:
WHY
LEFT?
COUNTRY
[CODE]
COMMUTE FROM
MEXICO TO DO FW?
Y
N
COMMUTE FROM
MEXICO TO DO FW?
N
NW
AB
CO
TO:
CITY
102 ___ ___
Farmworker ID
C13
Y
CO
GR
FROM:
# OF
WORK
DAYS
PER
WEEK?
FW, NF,
AB
N
FW
NF
FW
NF
DATES FOR
PERIODS OF
FW, NF, NW, AB
County
C11
Y
GR
CO
205 =
206 =
207 =
208 =
NW
AB
GR
GR
201 =
202 =
203 =
204 =
NF
RECEIVED
UNEMPLOYMENT?
[C1-C2 FOR OFFICE USE ONLY]
C1-C2 C15
C3
Y
N
Y
COMMUTE FROM
MEXICO TO DO FW?
N
Y
N
Y
COMMUTE FROM
MEXICO TO DO FW?
Y
N
COMMUTE FROM
MEXICO TO DO FW?
Y
N
Y
COMMUTE FROM
MEXICO TO DO FW?
N
Y
** C-5 ACTIVITY CODES: ONLY FOR “AB” (WHILE IN A
FOREIGN COUNTRY OR ABROAD):
311= WORK IN OWN/FAMILY FARM
320= NF IN OWN BUSINESS (SPECIFY IN GRID)
341= NF IN “MAQUILA”
359= NF OTHER (SPECIFY IN GRID)
361 =
NW - MEDICAL TREATMENT
362 =
NW - VACATION
369 =
NW - OTHER: (SPECIFY IN GRID)
370 =
NW- WAITING FOR COVID SITUATION TO IMPROVE
WORK GRID
10
N
*** C-7 CODES: WHY LEFT “FW”, “NF”, & “AB”?
1=
LAID OFF/END OF SEASON
2=
FIRED
3=
FAMILY RESPONSIBILITIES
4=
SCHOOL
5 = MOVED
6=
HEALTH REASON
7 = VACATION
8 = RETIRED
10 = QUIT
11 = CHANGE JOBS
___
12 = NO WORK DUE TO COVID-19 13=
CHILDCARE DUE TO COVID
14= SICK WITH COVID
15 = STOPPED WORKING TO AVOID COVID
9 = OTHER (SPECIFY):
___ ___ ______
102___ ___ __
C4
REPORT FROM FIRST PERIOD COVERING FEBRUARY 01, 2021 TO PRESENT
C5
C6
C8
C9
FW
GR
PER.
AND
SUB
CO
PER. [FW
NO. ONLY]
EMPLOYER’S NAME (
FARM WORK, NONFARM WORK AND
WORK ABROAD)
CROP
WRITE
ACTIVITY OR TASK WHILE FW,
AB and NF [USE CODES FOR
*NW ONLY]
NF
NW
AB
FW
NF
GR
NW
AB
CO
GR
FW
NF
CO
NW
AB
GR
FW
NF
CO
NW
AB
RECEIVED
UNEMPLOYMENT?
[C1-C2 FOR OFFICE USE ONLY]
C3
C1-C2 C15
DATES FOR
PERIODS OF
FW, NF, NW, AB
FROM:
TO:
C10
# OF
WORK
DAYS
PER
WEEK?
FW, NF,
AB
Y
NW
AB
CO
FW
NF
GR
NW
AB
CO
FW
NF
GR
NW
AB
CO
* C-5 ACTIVITY CODES: ONLY FOR “NW” (IN THE U.S.A.)
[WRITE ACTIVITY FOR FW, NF, AB]
201 =
202 =
203 =
204 =
205 =
206 =
207 =
208 =
LOOKING FOR FW AND NF WORK
LOOKING FOR FARM WORK
LOOKING FOR NF WORK
WAITING FOR RECALL NOTICE(AFTER
LAYOFF)
WAITING FOR START OF SEASON
FAMILY RESPONSIBILITIES/ WORK IN
HOME
IN SCHOOL
LAID UP DUE TO INJURY
209 = IN-TRANSIT BETWEEN JOBS
210 = VACATION
211 = DID NOT LOOK FOR WORK
212 = OTHER: (SPECIFY IN GRID)
213= WAITING FOR COVID SITUATION
TO IMPROVE
214= CHILDCARE DUE TO COVID
215=SICK WITH COVID
216=NO WORK AVAILABLE DUE TO COVID
217 = WAITING FOR COVID TEST RESULTS
COUNTY NAME
[IF IN A BORDER
COUNTY ASK IF
COMMUTE FROM
MEXICO]
Y
C13
STATE
and
COUNTRY
C7
***FW,
NF & AB:
WHY
LEFT?
[CODE]
N
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
Y
FW
NF
CITY
Farmworker ID
C12
COMMUTE FROM
MEXICO TO DO FW?
N
Y
GR
County
C11
COMMUTE FROM
MEXICO TO DO FW?
Y
N
N
Y
COMMUTE FROM
MEXICO TO DO FW?
N
Y
Y
N
COMMUTE FROM
MEXICO TO DO FW?
N
Y
Y
N
COMMUTE FROM
MEXICO TO DO FW?
N
Y
** C-5 ACTIVITY CODES: ONLY FOR “AB” (WHILE IN A
FOREIGN COUNTRY OR ABROAD):
311= WORK IN OWN/FAMILY FARM
320= NF IN OWN BUSINESS (SPECIFY IN GRID)
341= NF IN “MAQUILA”
359= NF OTHER (SPECIFY IN GRID)
361 = NW - MEDICAL TREATMENT
362 = NW - VACATION
369 = NW - OTHER: (SPECIFY IN GRID)
370 = NW- WAITING FOR COVID SITUATION TO IMPROVE
N
*** C-7 CODES: WHY LEFT “FW”, “NF”, & “AB”?
1 = LAID OFF/END OF SEASON
2 = FIRED
3 = FAMILY RESPONSIBILITIES
4 = SCHOOL
5 = MOVED
6 = HEALTH REASON
7 = VACATION
8 = RETIRED
10 = QUIT
11 = CHANGE JOBS
12 = NO WORK DUE TO COVID-19
13= CHILDCARE DUE TO COVID
14= SICK WITH COVID
15 = STOPPED WORKING TO AVOID
COVID
9 = OTHER (SPECIFY):
218 = QUARANTINING (COVID)
WORK GRID
11
___ ___ ___ ___ ___
102 ___ ___ ___ ___
PER.
AND
SUB
PER.
NO.
GR
CO
[FW
ONLY]
C4
REPORT FROM FIRST PERIOD COVERING FEBRUARY 1, 2021 TO PRESENT
C5
C6
C8
C9
C10
FW
?
EMPLOYER’S NAME (
FARM WORK, NONFARM WORK AND
WORK ABROAD)
CROP
WRITE
ACTIVITY OR TASK WHILE NF?
FW, AB and NF [USE
CODES FOR *NW ONLY] NW
?
AB?
GR
FW
NF
CO
NW
AB
GR
FW
NF
CO
NW
AB
GR
FW
NF
CO
NW
AB
FW
NF
GR
NW
AB
CO
FW
NF
GR
NW
AB
CO
FW
NF
GR
NW
AB
CO
* C-5 ACTIVITY CODES: ONLY FOR “NW” (IN THE U.S.A.)
[WRITE ACTIVITY FOR FW, NF, AB]
201 =
202 =
203 =
204 =
205 =
206 =
207 =
208 =
LOOKING FOR FW AND NF WORK
LOOKING FOR FARM WORK
LOOKING FOR NF WORK
WAITING FOR RECALL NOTICE(AFTER
LAYOFF)
WAITING FOR START OF SEASON
FAMILY RESPONSIBILITIES/ WORK IN
HOME
IN SCHOOL
LAID UP DUE TO INJURY
209 = IN-TRANSIT BETWEEN JOBS
210 = VACATION
211 = DID NOT LOOK FOR WORK
212 = OTHER: (SPECIFY IN GRID)
213= WAITING FOR COVID SITUATION
TO IMPROVE
214= CHILDCARE DUE TO COVID
215=SICK WITH COVID
216=NO WORK AVAILABLE DUE TO COVID
217 = WAITING FOR COVID TEST RESULTS
218 = QUARANTINING(COVID)
RECEIVED
UNEMPLOYMENT?
[C1-C2 FOR OFFICE USE ONLY]
C1-C2 C15
C3
DATES FOR
PERIODS OF
FW, NF, NW, AB
FROM:
TO:
# OF
WORK
DAYS
PER
WEEK?
FW, NF,
AB
County
C11
CITY
C12
Farmworker ID
C13
COUNTY NAME
[IF IN A BORDER
COUNTY ASK IF
COMMUTE FROM
MEXICO]
STATE
and
C7
***FW,
NF & AB
NF:
WHY
LEFT?
COUNTRY
[CODE]
Y
COMMUTE FROM
MEXICO TO DO FW?
N
Y
N
Y
COMMUTE FROM
MEXICO TO DO FW?
N
Y
N
Y
COMMUTE FROM
MEXICO TO DO FW?
N
Y
N
Y
COMMUTE FROM
MEXICO TO DO FW?
N
Y
N
Y
COMMUTE FROM
MEXICO TO DO FW?
N
Y
N
Y
COMMUTE FROM
MEXICO TO DO FW?
N
Y
** C-5 ACTIVITY CODES: ONLY FOR “AB” (WHILE IN A
FOREIGN COUNTRY OR ABROAD):
311= WORK IN OWN/FAMILY FARM
320= NF IN OWN BUSINESS (SPECIFY IN GRID)
341= NF IN “MAQUILA”
359= NF OTHER (SPECIFY IN GRID)
361 = NW - MEDICAL TREATMENT
362 = NW - VACATION
369 = NW - OTHER: (SPECIFY IN GRID)
370 = NW- WAITING FOR COVID SITUATION TO IMPROVE
12
N
*** C-7 CODES: WHY LEFT “FW”, “NF”, & “AB”?
1 = LAID OFF/END OF SEASON
2 = FIRED
3 = FAMILY RESPONSIBILITIES
4 = SCHOOL
5 = MOVED
6 = HEALTH REASON
7 = VACATION
8 = RETIRED
10 = QUIT
11 = CHANGE JOBS
12 = NO WORK DUE TO COVID-19
13= CHILDCARE DUE TO COVID
14= SICK WITH COVID
15 = STOPPED WORKING TO AVOID
COVID
9 = OTHER (SPECIFY):
D1 In the year before last (FROM OCTOBER 2019
D30 How did you get this job? [DO NOT READ CHOICES. MARK
TO OCTOBER 2020) [YEAR BEFORE THE ONE
ONLY ONE RESPONSE]
COVERED IN WORK GRID], how many months
did you do (FW) in the U.S.? [1 DAY OR MORE
9 1 I APPLIED FOR THE JOB ON MY OWN
PER MONTH EQUALS 1 MONTH]
months
D2 [IF NON-FARM JOB LISTED ON WORK GRID]: For
your most recent non-farm (NF) employer, how
many hours per week did you work on
average?
hours
94
95
96
97
98
99
9 10
I WAS RECRUITED BY A GROWER OR HIS FOREMAN
I WAS RECRUITED BY FARM LABOR CONTRACTOR OR HIS
FOREMAN
I WAS REFERRED BY THE EMPLOYMENT SERVICE
I WAS REFERRED BY THE WELFARE OFFICE
I WAS REFERRED BY RELATIVE / FRIEND / WORKMATE
I WAS REFERRED BY LABOR UNION
DAY LABORER / PICKED UP AT SHAPE UP
9 97 Other:
D3 [IF NON-FARM JOB LISTED] For your most recent
non-farm employer (NF), how much were
you paid per week on average?
$
,
NP – HANDLING PESTICIDES (IN THE U.S.A.)
NP1f.
.
90
D27 How many years have you worked for this
(FW) employer? [ONE DAY/PER YEAR=ONE
YEAR]
years
D22
In the last 12 months, have you loaded, mixed or applied
pesticides?
If you are injured at work or get sick as a
result of your work, does your employer
provide health insurance or pay for your
health care?
90
NO
NO
9 1 YES
NT – TRAINING AND INSTRUCTIONS
NT2a. In the last 12 months, with your current employer, has
anyone given you training or instructions in the safe use of
pesticides (through video, audio, cassette, classroom
lectures, written material, informal talks or by any other
means)?
90
NO
9 1 YES
NS – SANITATION SECTION
“The following questions refer to sanitation at your job with your
D23 If you are injured at work or get sick as a
current FW employer: ... Does your current employer provide EVERY
result of your work, do you get any
DAY...
91
YES
97
DON’T KNOW
payment while you are recuperating (i.e.,
“workers' compensation”)?
NS1 ... (potable) clean drinking water and disposable cups?
90
91
D24
NO
YES
97
DON’T KNOW
If you are injured or get sick off the job
(e.g., at home), does your employer
provide health insurance or pay for your
health care? [WHETHER OR NOT THE
WORKER TAKES IT OR USES IT]
90
91
D26
NO
YES
90
92
NO WATER, NO CUPS
9 1 YES, WATER ONLY
YES, WATER AND DISPOSABLE CUPS 9 7 DON’T KNOW
NS4 ... a toilet (EVERY DAY)?
9 0 NO
9 1 YES
NS9
97
DON’T KNOW
... (provide) water to wash hands (EVERY DAY)?
9 0 NO
9 1 YES
97
DON’T KNOW
NV1. In the last 12 months, with your current farm employer, which
safety practices were in place to prevent the spread of COVID-19 or
other infectious diseases at the workplace?
Are you covered by unemployment insurance [READ CHOICES AND MARK ALL MENTIONED]
97
DON’T KNOW
if you lose this job?
90
91
NO
YES
97
DON’T KNOW
9 a. Masks were required of all workers
9 b. Workers had to stay six feet apart when possible
9 c. Soap or sanitizer to clean hands was provided
9 d. Vaccinations were required
9 e.Signs were posted in a language that I can understand
9 f. COVID-19 prevention training was offered (in preferred language)
9 z. Other:
9 None
13
CURRENT FARM JOB
Now I am going to ask you some questions about
the FW you are CURRENTLY performing for
the EMPLOYER through whom we contacted you
[INCLUDED IN A WORK GRID PERIOD].
D4
D11
9 1 ...BY THE HOUR?
9 2 ...BY THE PIECE? [SKIP TO D13]
9 3 ...COMBINATION HOURLY WAGE AND PIECE
RATE? [ASK D12 THRU D18]
9 4 ...SALARY OR OTHER? [SKIP TO D19]
How many hours did you work last week at
your current farm job?
D12
hours
[D5 TO D8: IF SHE/HE HAS NOT RECEIVED PAYMENT YET
FOR CURRENT CROP, ASK FOR ESTIMATES]: Can you tell
me how you were paid and the amount your employer
paid you on your last pay day?
$
,
$
D61
.
9 4 ...OTHER CHECK?
9 5 ...CASH?
9 6 ...OTHER:
INDIVIDUAL [SKIP TO D15]
CREW
[IF CREW PIECE RATE]: How many people are in
your crew? [ONE IS NOT A POSSIBLE ANSWER]
D15
[IF BY PIECE]: How do they pay you/your
crew [i.e., UNIT OF MEASURE SUCH AS BOX, BIN,
BUCKET, ETC.]?
Did you get a receipt?
NO
91
YES
9 4 ONE MONTH?
9 7 OTHER?:
How many of these (in D15 e.g., boxes,
bins, buckets, etc.) you/your crew do in an average
day?
D16
[IF BY PIECE]:
D17
[IF BY PIECE]: How many hours per day you/your
For what time period was that payment?
crew work on average at this task?
How many hours did you work during that period (in
D7)?
hours
D18
hours
D9
[IF PAID BY THE PIECE]: Are you paid as an
individual or by the crew? [IF THE ANSWER IS
D14
Were you paid by [READ CHOICES. MARK ONE
RESPONSE]:...
9 1 ONE DAY?
9 2 ONE WEEK?
9 3 TWO WEEKS?
D8
per hour
.
91
92
,
90
D7
ONLY BY THE HOUR, ENTER AMOUNT AND SKIP TO
“G1C.” IF COMBINATION, ENTER AMOUNT AND
CONTINUE WITH D13]:
"CREW", ASK QUESTIONS D14 to D18
CONSISTENTLY IN REFERENCE TO THE CREW]
.
9 1 ...PAYROLL CHECK?
9 2 ...PERSONAL CHECK?
9 3 ...CASH AND CHECK?
D62
D13
Before taxes:
D6
How much per hour (to nearest cent)? [IF PAID
$
After taxes:
D5
Are you paid: ...
...Now - with your current employer - you already
told me that the crop you are currently working is:...
$
D19
D10 And you told me that - with your current employer -
the task you are now doing is:
[IF BY PIECE]: How much do “they” pay you/your
crew on average for each (box bin, bucket, etc. In
D15)?
,
[IF PAID BY SALARY, OR OTHER]: Explain fully how and
how much you are paid (salary or other). Explain
thoroughly the method and amount of payment. [USE
BACK OF PAGE IF NEEDED]:
15
.
“Now I’m going to ask you some questions about your individual and family income for last year (2021)...
G1C ...What was your total personal income
last year - in 2021- in U.S. dollars [U.S.
earnings only FOR FW AND NF]?
[READ OR SHOW CHOICES. MARK ONLY ONE]
90
9 21
9 22
92
93
94
95
96
97
98
99
9 10
9 11
9 12
9 13
9 14
9 15
9 16
9 17
9 18
9 19
9 20
9 97
9 96
DID NOT WORK AT ALL IN 2021
LESS THAN 1,000
1,000 TO 2,449
2,500 TO 4,999
5,000 TO 7,499
7,500 TO 9,999
10,000 TO 12,499
12,500 TO 14,999
15,000 TO 17,499
17,500 TO 19,999
20,000 TO 22,499
22,500 TO 24,999
25,000 TO 27,499
27,500 TO 29,999
30,000 TO 32,499
32,500 TO 34,999
35,000 TO 37,499
37,500 TO 39,999
40,000 TO 44,999
45,000 TO 54,999
55,000 TO 59,999
60,000 OR MORE
DK (DON’T KNOW)
RF (REFUSE)
G2C How much of that income [in “G1C”] was
from agricultural employment (U.S.
earnings only for FW)? [READ OR SHOW
CHOICES. MARK ONLY ONE]
90
9 21
9 22
92
93
94
95
96
97
98
99
9 10
9 11
9 12
9 13
9 14
9 15
9 16
9 17
9 18
9 19
9 20
9 97
9 96
DID NOT WORK AT ALL IN 2021
LESS THAN 1,000
1,000 TO 2,449
2,500 TO 4,999
5,000 TO 7,499
7,500 TO 9,999
10,000 TO 12,499
12,500 TO 14,999
15,000 TO 17,499
17,500 TO 19,999
20,000 TO 22,499
22,500 TO 24,999
25,000 TO 27,499
27,500 TO 29,999
30,000 TO 32,499
32,500 TO 34,999
35,000 TO 37,499
37,500 TO 39,999
40,000 TO 44,999
45,000 TO 54,999
55,000 TO 59,999
60,000 OR MORE
DK (DON’T KNOW)
RF (REFUSE)
16
G3C What was your family’s total income last
year - in 2021- in U.S. dollars [U.S.
earnings for FW AND NF for all in “FAMILY
GRID”]? [READ OR SHOW CHOICES.
MARK ONLY ONE]
90
9 21
9 22
92
93
94
95
96
97
98
99
9 10
9 11
9 12
9 13
9 14
9 15
9 16
9 17
9 18
9 19
9 20
9 97
9 96
DID NOT WORK AT ALL IN 2021
LESS THAN 1,000
1,000 TO 2,449
2,500 TO 4,999
5,000 TO 7,499
7,500 TO 9,999
10,000 TO 12,499
12,500 TO 14,999
15,000 TO 17,499
17,500 TO 19,999
20,000 TO 22,499
22,500 TO 24,999
25,000 TO 27,499
27,500 TO 29,999
30,000 TO 32,499
32,500 TO 34,999
35,000 TO 37,499
37,500 TO 39,999
40,000 TO 44,999
45,000 TO 54,999
55,000 TO 59,999
60,000 OR MORE
DK (DON’T KNOW)
RF (REFUSE)
a.
NH - PERSONAL HEALTH - LIFE HISTORY [ASK ALL]:
b. Are you currently taking
c. In the last 12 months, in the U.S. and/or abroad, have you seen a
medication, for this
doctor or nurse for (condition “YES” in COLUMN “a”)? [IF ANSWER IS
“YES” FOR THE U.S. AND “AB” MARK BOTH]
condition (in ”a”), that was
prescribed by a medical
provider?
Have you ever – in your whole life -- been told by a doctor or
nurse (health practicioner) that you have the following
condition...
...heart disease?
NH5
9 1 YES:
90
NO
9 96 RF
91
YES
9 0 NO
9 1 YES:
90
NO
9 95 DK
9 96 RF
91
YES
90
NO
91
YES
90
NO
9 95 DK
...asthma?
NH1
...cancer?
NH8
90
NO
9 95 DK
91
YES:
9 96
RF
a.
And have you ever -- in your
whole life – been told by a
doctor or nurse that you
have...
NH3 ...high
blood pressure?
9 0 NO
9 1 YES
9 95 DK
9 96 RF
NH12
...high cholesterol?
9 0 NO
9 1 YES
9 95 DK
9 96 RF
TYPE OF CANCER?
9 0 NO
9 1 YES, IN THE U.S.A.
9 2 YES, “AB”:
NAME OF COUNTRY
9 0 NO
9 1 YES, IN THE U.S.A.
9 2 YES, “AB”:
90
91
92
NAME OF COUNTRY
NO
YES, IN THE U.S.A.
YES, “AB”:
NAME OF COUNTRY
NH – INDIVIDUAL PERSONAL HEALTH HISTORY (LIFETIME) [INTERVIEWER: FIRST ASK ALL QUESTIONS IN FIRST COLUMN.]
g.
d.
e.
f.
b.
...ever been
tested for this
condition?
90
NO
91
YES
9 95 DK
90
NO
91
YES
9 95 DK
What was the outcome
(result, the last time)?
91
92
93
94
9 95
91
92
93
NORMAL
PREHYPERTENSION
HIGH
DID NOT RECEIVE IT
DK (FORGOT)
NORMAL
BORDERLINE
HIGH
9 4 DIDN’T RECEIVE IT
9 95 DK (FORGOT)
When was the last
test taken?
Where was Are you currently taking
medication, for this
the test
condition (in “a”), that
taken?:
*[USE CODE]
was prescribed by a
medical provider?
9 1 0 TO 12 months
9 2 13 TO 24 MONTHS
9 3 2 TO 5 YRS
9 4 MORE THAN 5 YRS
9 95 DK (FORGOT)
9 1 0 TO 12 months
9 2 13 TO 24 MONTHS
9 3 2 TO 5 YRS
9 4 MORE THAN 5 YRS
9 95 DK (FORGOT)
90
NO
91
YES
90
NO
91
YES
c.
In the last 12 months, in the
U.S. and/or abroad, have
you seen a doctor or nurse
for (condition in “a”)?
90
NO
91
YES, IN THE U.S.A.
92
YES, “AB”:
90
NO
91
92
YES, IN THE U.S.A.
YES, “AB”:
*CODES FOR ( COLUMN “g” ): NH3 - NH12 - NH13
1 = COMMUNITY/MIGRANT HEALTH CENTER
2 = PRIVATE MEDICAL DOCTOR’S OFFICE/PRIVATE CLINIC
3 = HOSPITAL
4 = EMERGENCY ROOM
5 DENTIST
6 PHARMCY
17
7 TESTING SITE
97 = OTHER: __________
95 = DK
96 = RF
CONTINUATION OF NH – INDIVIDUAL PERSONAL HEALTH HISTORY (LIFETIME) [INTERVIEWER: FIRST ASK ALL QUESTIONS IN FIRST COLUMN.]
a.
And how about these other conditions,
have you ever -- in your whole life –
been told by a doctor or nurse that you
have the following conditions...
NH2
[IF
AN
...diabetes?
9 0 NO
9 1 YES
9 95 DK
9 96 RF
RESPONDENT IS A WOMAN, AND
SWER IS “YES” ASK]:
Was it diagnosed during pregnancy?:
9 0 NO
9 1 YES
9 95 DK
NH6
NO
YES
DK
9 96 RF
...tuberculosis?
9 0 NO
9 1 YES
9 95 RF
NH15 ...COVID-19?
9 0 NO
9 1 YES
9 95 RF
9 96 RF
NH10
...other?:
90
91
9 95 RF
NORMAL
91
0 TO 12 MONTHS
92
HIGH SUGAR LEVEL
92
13 TO 24 MONTHS
9 1 YES
93
LOW SUGAR LEVEL
93
2 TO 5 YEARS
9 95 DK
94
DIDN’T RECEIVE IT
94
MORE THAN 5 YRS
9 95
DK (FORGOT)
90
NO
90
NO
9 1 YES
9 95 DK
90
NO
9 1 YES
9 96 RF
NO
YES:
9 95 DK
90
NO
9 1 YES
9 95 DK
9 0 NO
9 1 YES
9 96 RF
f.
When was the last test taken?
91
9 96 RF
...urinary tract infection?
90
91
9 95
NH4
e.
d.
What was the outcome (result) of
...ever been
the last test?
tested for
this
condition?
9 95 DK
*Codes for column “g”
1
COMMUNITY/MIGRANT HEALTH CENTER
2
PRIVATE CLINIC OR DOCTOR’S OFFICE
9 95
DK (FORGOT)
91
92
94
9 95
NORMAL
ABNORMAL
DIDN’T RECEIVE IT
DK (FORGOT)
91
92
POSITIVE
NEGATIVE
94
DIDN’T RECEIVE IT
9 95
DK (FORGOT)
91
92
POSITIVE
NEGATIVE
94
DIDN’T RECEIVE IT
9 95
DK (FORGOT)
91
92
94
9 95
POSITIVE
NEGATIVE
DIDN’T RECEIVE IT
DK (FORGOT)
g.
Where was
the test
taken?:
*[ENTER
CODE]
9 1 0 TO 12 MONTHS
9 2 13 TO 24 MONTHS
9 3 2 TO 5 YRS
9 4 MORE THAN 5 YRS
9 95 DK (FORGOT)
9 1 0 TO 12 MONTHS
9 2 13 TO 24 MONTHS
9 3 2 TO 5 YRS
9 4 MORE THAN 5 YRS
9 95 DK (FORGOT)
9 1 0 TO 3 MONTHS
9 2 4 TO 6 MONTHS
9 3 7 TO 10 MONTHS
9 4 MORE THAN 10 MONTHS
9 95 DK (FORGOT)
91
92
93
94
9 95
0 TO 12 MONTHS
13 TO 24 MONTHS
2 TO 5 YRS
MORE THAN 5 YRS
DK (FORGOT)
5 DENTIST
6 PHARMACY
7 COMMUNITY TESTING SITE
95 = DK
3 HOSPITAL
4 EMERGENCY ROOM
18
b.
Are you currently
taking medication,
for this condition
(in “a”), that was
prescribed by a
medical provider?
c.
In the last 12 months, in the U.S.
and/or abroad, have you seen a doctor
or nurse for this condition (in “a”)? [IF
ANSWER IS “YES” FOR THE U.S. AND
“AB” MARK BOTH]
90
NO
90
NO
91
YES, IN THE U.S.A.
91
YES
92
YES, “AB”:
90
NO
90
NO
91
YES, IN THE U.S.A.
91
YES
92
YES, “AB”:
90
90
NO
NO
91
YES, IN THE U.S.A.
91
YES
92
YES, “AB”:
90
90
NO
NO
91
YES, IN THE U.S.A.
91
YES
92
YES, “AB”:
90
NO
91
YES
90
91
92
NO
YES, IN THE U.S.A.
YES, “AB”:
96 = RF
97 OTHER: ____________
HA – QUALITY OF AND ACCESS TO HEALTH CARE SECTION
HA1 [INTERVIEWER ]: Now, I would like to ask you a few questions about health care services that you may have used in the last 12 months. [FIRST ASK QUESTIONS IN THE FIRST COLUMN. READ
OPTIONS & MARK ALL RESPONSES] ...In the LAST YEAR (12 MONTHS) in the USA, have you used any type of health care service (including telehealth) from doctors, nurses, dentists, clinics, or
hospitals: ...
NOTE: EXPLAIN THAT ILLNESS
BELOW REFERS TO: “A physical
illness, as well as a mental health
problem or substance abuse.”
9 a ...FOR ILLNESS?
9 0 NO: [ASK HA7]
9 95 DK
91
9 1.
9 2.
9 3.
9 95
YES
9 96 RF
9 96 RF
9 d ...FOR DENTAL TREATMENT
(DUE TO PROBLEM WITH
TEETH)?
9 0 NO:[ASK HA7] 9 1 YES
9 95 DK
9 96 RF
9 e ...FOR ROUTINE DENTAL
CLEANING/CHECK-UP?
9 0 NO:[ASK HA7] 9 1 YES
9 95 DK
9 96 RF
*CODES FOR “HA2”
1 COMMUNITY/MIGRAN 5 DENTIST
T HEALTH CENTER
6 Telehealth
2 PRIVATE CLINIC OR w/community/
DOCTOR’S OFFICE
migrant center
3 HOSPITAL
8 Telehealth
4 EMERGENCY ROOM w/private doctor or
97=OTHER:
clinic
____________
95 = DK
96 = RF
When (last time)?
9 2. 2 TO 6 MONTHS
9 3. 7 TO 12 MONTHS
9 95 DK
9 c ...FOR ROUTINE OR PREVENTIVE
CARE?
9 0 NO:[ASK HA7] 9 1 YES
9 95 DK
HA3
9 1. LAST MONTH
YES
9 96 RF
9 b ...FOR INJURY?
9 0 NO:[ASK HA7]
9 95 DK
91
*HA2
...And where
did you go
(last time)?
*[ENTER
CODES]
1
2
3
4
5
LAST MONTH
2 TO 6 MONTHS
7 TO 12 MONTHS
DK
9 1.
9 2.
9 3.
9 95
LAST MONTH
2 TO 6 MONTHS
7 TO 12 MONTHS
DK
9 1.
9 2.
9 3.
9 95
LAST MONTH
2 TO 6 MONTHS
7 TO 12 MONTHS
DK
9 1.
9 2.
9 3.
9 95
LAST MONTH
2 TO 6 MONTHS
7 TO 12 MONTHS
DK
**HA4
HA5 In general, how satisfied were YOU with the
***HA6
****HA7
Did you get any help to
care YOU received at your LAST visit for
Why weren’t you
[If “NO” in “HA1",
pay for the cost of that
(“YES” in HA2)? [ASK ALL OPTIONS, MARK
(completely) very
ask]: Why have you
health service?***[
ONE ]: Were you...
satisfied with the
not used the health
“YES” OR “NO”, ASK
health care received at services for [“NO”
HOW IT WAS PAID.
that visit?
in “HA1"]
ENTER CODES THAT
**[ENTER CODE]
[ ENTER CODES]
APPLY]:
9 0 NO:
[ENTER CODES]
9 1 YES:
[ENTER CODES]
91
92
93
...VERY SATISFIED?
9 0 NO:
[ENTER CODES]
9 1 YES:
[ENTER CODES]
91
92
93
...VERY SATISFIED?
91
92
93
...VERY SATISFIED?
91
92
93
...VERY SATISFIED?
91
92
93
...VERY SATISFIED?
9 0 NO:
[ENTER CODES]
9 1 YES:
[ENTER CODES]
9 0 NO:
[ENTER CODES]
9 1 YES:
[ENTER CODES]
9 0 NO:
[ENTER CODES]
9 1 YES:
[ENTER CODES]
**CODES FOR “HA4"
I paid the bill out of
6 Billed, but did
“my own pocket”
not pay
Medicaid / Medicare
7 Worker’s
Public clinic did not
compensation
charge
8 I paid some (copay)
Employer provided
health plan
95 = DK
Self or family bought
96 = RF
individual health plan
97 Other: ________
1
2
3
4
19
...SOMEWHAT SATISFIED? [ASK HA6]
...NOT AT ALL SATISFIED? [ASK HA6]
...SOMEWHAT SATISFIED? [ASK HA6]
...NOT AT ALL SATISFIED? [ASK HA6]
...SOMEWHAT SATISFIED? [ASK HA6]
...NOT AT ALL SATISFIED? [ASK HA6]
...SOMEWHAT SATISFIED? [ASK HA6]
...NOT AT ALL SATISFIED? [ASK HA6]
...SOMEWHAT SATISFIED? [ASK HA6]
...NOT AT ALL SATISFIED? [ASK HA6]
***CODES FOR “HA6"
COST TOO MUCH 5 CONDITION DID NOT
HAD TO WAIT TOO
IMPROVE AFTER
LONG
TREATMENT OR
LANGUAGE
MEDICATION
PROBLEM 6 DR. DID NOT DIAGNOSE
COULD NOT
OR TREAT CONDITION
COMMUNICATE
95 = DK
MISTREATED BY
96 = RF
DR. OR OTHER
97 OTHER: _____________
STAFF
****CODES FOR “HA7"
Did not know where to go
No transportation
Too far away
Health Center not open when
needed
5 = No need to go / Does not get sick
6= Too expenive
7 = No insurance
8= Fearof COVI D-19
9= No appts due to COVID-19
10= I was sick with COVID-19
11 = I was exposed to COVID and
therefore could not get an appt
95= DK 96= RF
97= OTHER ______________________
1=
2=
3=
4=
HA8: And in the LAST 12 MONTHS, in the USA, was
there ever a time when you wanted or needed health
care, but could not get it? (e.g., for a routine exam, a
dental appointment or because you were injured or
sick)
GA-2
9 0 NO ( ASK HA10)
9 1 YES
9 95 DK
9 96 RF
HA10: [ASK ALL]... (How about) In a foreign country
HA9: Why could you not get the health care you wanted (or
needed)?
(e.g., Mexico), have you used any type of health
service in the last year (LAST 12 MONTHS) [IF
[CHECK ALL THAT APPLY]
9a
9b
9c
9d
9f
9g
Did not know where to go
No transportation
Too far away
Health Center not open when needed
Too expensive
No insurance
9 h Fear of COVID-19
9 i No appts du e to COVID
9 j. I had COVID
9 k. Exposed to COVID
9 z Other:
“YES ,” ASK AND ENTER COUNTRY]
9 0 NO
9 1 YES, NAME OF COUNTRY?:
Now, I am going to ask you some questions about your health...
Over the last 2 weeks, how often have you been bothered by the following problems?
Not at all
Several days
More than half the days
Nearly every day
1
...Feeling nervous, anxious or on edge?
0
1
2
3
2
...Not being able to stop or control worrying?
0
1
2
3
Not at all
Several days
More than half the days
PQ-2 Over the last 2 weeks, how often have you been bothered by the following problems?
Nearly every day
1
...Little interest or pleasure in doing things?
0
1
2
3
2
...Feeling down, depressed, or hopeless?
0
1
2
3
NV2. In the last 12 months, ABOUT how many days did you miss work (stay
home) because you were ill, or because there as a possibility you had an
illness?
91
days
9 0 NONE [skip to NV3]
9 95 DK [skip to NV3]
9 96 RF [skip to NV3]
9 d.
9 e.
9 f.
9 g.
9 h.
9 z.
NV2a. Among the days you missed,how many days have you MISSED WORK
(FW) because you were ill with COVID-19 or because you thought you might
have COVID-19?
91
days
9 0 NONE
9 95 DK
9 96 RF
NV6. Have you received a COVID-19 vaccination in the past 12 months?
9 0
NO
9 1 YES (SKIP TO NV8)
9 95 Don’t Know (SKIP TO NV8)
NV7. Why not? [DO NOT READ CHOICES. MARK ALL MENTIONED THEN SKIP TO DA1]:
9 a.
9 b.
9 c.
9 d.
9 h.
NV3. In the last 12 months, how many days did you work while you were ill?
91
days
9 95 DK [skip to NV4]
Cost of testing
Concerns about immigration status and testing
Not sure what to do if I test positive
Need to be able to work so it does not matter
Fear of losing my job if test is positive
Other:
9 0 NONE [skip to NV4]
9 96 RF [skip to NV4]
Not sure where to get vaccinated
Unsure of safety of vaccines
Worried about side effects
Do not feel it is necessary
Other:
9 e. Concerns about immigration status
9 f. Concerns about costs
9 g. No time to get vaccinated
NV8. Did you receive your vaccine in the U.S.?
NV4. Have you faced barriers to getting tested for COVID-19?
9 0 NO [skip to NV6]
9 1 YES
9 95 Don’t Know
9 0 NO (SKIP TO DA1)
9 1 YES
NV9. Where did you get vaccinated? (MARK ALL THAT APPLY):
9 a. Community/Migrant Health Center 9 d. County or public vaccination event
9 b. Pharmacy
9 e. Private Clinic/Doctor
9 c. Farm or worksite
9 f. Other:
NV5. [If have faced barriers to getting tested for COVID-19]. What have the barriers
been? [DO NOT READ CHOICES. MARK ALL MENTIONED]:
9 a. Not sick so do not need testing
9 b. Unsure where testing locations are in my community
9 c. No testing is available in my community
20
DA. DIGITAL ACCESS
DA1Do you or any member of your family
[“Household Grid”] have access to digital
information sources (i.e., internet,
What devices?
cellular phone with internet, etc.)?
[CHECK WHO IF “YES”]
B.
Spouse?
C.
Children?
9 0 NO 9 1 YES
9 0 NO 9 1 YES
9 0 NO 9 1 YES
D.
Other?:
9 0 NO 9 1 YES
A.
Worker?
DA7.Have you used, or has anyone helped
you use, any digital device to
seek or obtain information
about ...
DA2
Computer
DA3 Cellular phone
with Internet
[MARK RESPONSES FOR DEVICES “U”]
DA4 Cellular phone with Text DA5
Tablet
DA6 Other
[Specify]:
device?
9 0 NO
9 0 NO
9 0 NO
9 1 YES
9 1 YES
9 1 YES
9 0 NO 9 1 YES
9 0 NO 9 1 YES
9 0 NO 9 1 YES
9 0 NO 9 1 YES
9 0 NO 9 1 YES
9 0 NO 9 1 YES
9 0 NO
9 1 YES
9 0 NO
9 1 YES
9 0 NO
9 1 YES
9 0 NO
9 1 YES
9 0 NO
9 1 YES
9 0 NO
9 1 YES
9 0 NO
9 1 YES
9 0 NO 9 1 YES
9 0 NO 9 1 YES
9 0 NO
9 1 YES
9 0 NO
9 1 YES
DA8.
What devices have you used?
[MARK ALL RESPONSES]
DA9.
Who helped you use the
device (in “DA8") to seek or
obtain the information (in
“DA7")? [MARK ALL
RESPONSES:]
a.
...health insurance?
9 0 NO
k.
91
...a telephone or virtual consult with
a doctor/nurse?
9 0NO
g.
YES
91
YES
...health information or a health
problem?
9 0 NO
b....seeking
9 0 NO
c.
90
91
YES
employment?
91
YES
...training and/or education?
NO
91
YES
d....child care?
9 0 NO
e....housing?
9 0 NO
9 1 YES
9 1 YES
9 1.COMPUTER
9 3. CELLULAR PHONE WITH INTERNET
9 2. TABLET
9 4.
CELLULAR PHONE WITH TEXTING
9 1.COMPUTER
9 3. CELLULAR PHONE WITH INTERNET
9 2. TABLET
9 4.
CELLULAR PHONE WITH TEXTING
9 1.COMPUTER
9 3. CELLULAR PHONE WITH INTERNET
9 2. TABLET
9 4.
9 1.COMPUTER
CELLULAR PHONE WITH TEXTING
9 3. CELLULAR PHONE WITH INTERNET
9 2. TABLET
9 4.
9 1.COMPUTER
9 3. CELLULAR PHONE WITH INTERNET
9 2. TABLET
9 4.
9 1.COMPUTER
9 3. CELLULAR PHONE WITH INTERNET
9 2. TABLET
9 4.
9 1.COMPUTER
9 3. CELLULAR PHONE WITH INTERNET
9 2. TABLET
9 4.
CELLULAR PHONE WITH TEXTING
CELLULAR PHONE WITH TEXTING
CELLULAR PHONE WITH TEXTING
CELLULAR PHONE WITH TEXTING
21
9 1.Self
9 2.
Spouse?
9 3. Children? 9 4.
9 1.Self
9 2.
Other?:
9 3. Children? 9 4.
Other?:
9 1.Self
Spouse?
9 2.
Spouse?
9 3. Children? 9 4.
Other?:
9 1.Self
Spouse?
9 2.
9 3. Children? 9 4. Other?:
9 1.Self
9 2. Spouse?
9 3. Children?
9 4. Other?:
9 1.Self
9 2. Spouse?
9 3. Children?
9 1.Self
9 4. Other
?:
9 2. Spouse?
9 3. Children?
9 4. Other
?:
DA7.Have you used, or has anyone helped
DA8. What devices have you used? [MARK ALL RESPONSES. FOR WHERE?
ASK FOR VENUES]
f. ...benefits? [e.g., Unemployment, Social
9 1.COMPUTER
9 3. CELLULAR PHONE WITH INTERNET
9 0 NO
9 2. TABLET
9 4.
9 1.COMPUTER
9 3. CELLULAR PHONE WITH INTERNET
9 2. TABLET
9 4.
you use, any digital device to
seek or obtain information
about ...
Security, food stamps, retirement, etc.]
9 1 YES:
SPECIFY:
h. ....news?
9 0 NO
9 1 YES
i. ...communication/calls?
9 0 NO
9 1 YES
j. entertainment or social networks
(FaceBook, WhatsApp, etc.)?
9 0 NO
9 1 YES
z.
CELLULAR PHONE WITH TEXTING
...other?: [SPECIFY]:
CELLULAR PHONE WITH TEXTING
9 1.COMPUTER
9 3. CELLULAR PHONE WITH INTERNET
9 2. TABLET
9 4.
9 1.COMPUTER
9 3. CELLULAR PHONE WITH INTERNET
9 2. TABLET
9 4.
CELLULAR PHONE WITH TEXTING
CELLULAR PHONE WITH TEXTING
9 1.COMPUTER
9 3. CELLULAR PHONE WITH INTERNET
9 2. TABLET
9 4.
CELLULAR PHONE WITH TEXTING
22
DA9. Who helped you use the device
(in “DA8") to seek or obtain
the information (in “DA7")?
[MARK ALL RESPONSES:]
9 1.Self
9 2. Spouse?
9 3. Children?
9 1.Self
9 2. Spouse?
9 3. Children?
9 1.Self
?:
9 4. Other
?:
9 2. Spouse?
9 3. Children?
9 1. Self
9 4. Other
9 2. Spouse?
9 3. Children?
9 1.Self
9 4. Other
?:
9 4. Other
?:
9 2. Spouse?
9 3. Children?
9 4. Other
?:
LEGAL STATUS
We are interested in knowing whether any of the following apply to you. Please be assured that no one
besides us will know your response.
L2b PROGRAMS [DO NOT READ OPTIONS]:
L1
What is your current legal status in the U.S.? [READ
CHOICES IF NECESSARY]:
91
AMNESTY UNDER 5 YEAR PROGRAM
[“TIME”]
I AM A NATURALIZED U.S. CITIZEN (FOREIGN BORN,
NATURALIZED). (ASK: “BEFORE BECOMING A NATURALIZED
U.S. CITIZEN, UNDER WHICH PROGRAM DID YOU APPLY TO
OBTAIN YOUR PERMANENT RESIDENCE?”) [POSSIBLE
ANSWERS IN L2: 1 - 9, 97). THEN ASK: L4-1, L4-2, AND L4-3]
92
AMNESTY UNDER SAW (90 DAY)
PROGRAM [“FW” - “FIELD WORK”]
93
CUBAN/HAITIAN ENTRANT
94
SPOUSAL PETITION PROGRAM/FAMILY
UNITY
PERMANENT RESIDENT/GREEN CARD (RIGHT TO RESIDE AND
WORK IN THE U.S.) (ASK L2: “UNDER WHICH PROGRAM DID
YOU APPLY?”) [POSSIBLE ANSWERS: 1 HASTA 9 Y 97). THEN
ASK: L4-1 AND L4-2]
95
LABOR CERTIFICATION PROGRAM
96
REGISTRY PROGRAM
97
POLITICAL ASYLUM
91
I AM A U.S. CITIZEN BY BIRTH [SKIP TO NEXT PAGE]
92
93
94
95
96
97
98
BORDER CROSSING CARD/COMMUTER CARD (RIGHT TO
9 8 REFUGEE
CROSS THE BORDER AND WORK IN THE U.S.) (ASK L2: “UNDER
WHICH PROGRAM DID YOU APPLY?”) [POSSIBLE ANSWERS: 9, 9 9 PROTECTIVE STATUS (TEMPORARY)
12, 13, Y 97. THEN ASK: L3, L4-1 AND L4-2]
9 10 GUEST WORKER PROGRAM
[“BRACERO”]
PENDING STATUS (WITHOUT DOCUMENTS, APPLIED, AWAITING
9 11 STUDENT
OFFICIAL DECISION) (ASK L2: “UNDER WHICH PROGRAM DID
YOU APPLY?”) [POSSIBLE ANSWERS: 1- 9, 14, 15 AND 97.
9 12 TOURIST
THEN ASK: L3, AND L41]
9 13 BORDER CROSSING CARD/ “PASSPORT”
UNDOCUMENTED (APPLICATION DENIED/DID NOT APPLY TO
ANY PROGRAMS) [POSSIBLE ANSWERS: “NONE.” SKIP TO
9 14 DACA (Deferred Action for Childhood
NEXT PAGE]
Arrivals.
• Entered USA under 16 yrs. old
TEMPORARY RESIDENT - NON IMMIGRANT VISA (ONLY FOR
before June 15, 2007;
SPECIFIED TIME) [ASK L2: “UNDER WHICH PROGRAM DID YOU
• Under 31 as of June 15, 2012.
APPLY?” POSSIBLE ANSWERS: 10 - 97. THEN ASK: L3 AND L41]
• Have continuously resided in the
USA from June 15, 2007 to the
OTHER [IF RELEVANT AND APPROPRIATE ASK L2, L3, L4-1, L4-2,
present)
AND L4-3. THEN SKIP TO NEXT PAGE]:
9 97 OTHER:
9 99 NOT ANSWERED
L3
Do you have general work authorization?:
9 0 NO
9 1 YES
9 7 DON’T KNOW
L4
1
When did you apply to the 2
program (in L2)?
/
(Month)
/
DATE STATUS BECAME EFFECTIVE:
[Only for those who responded 3
"2,3, or 4" in L1]: When did you
obtain your legal status?
/
(Year)
9 96 REFUSE
[Only for those who
responded "2" in L1]:
When did you obtain your
naturalization/ become a
U.S. citizen?
/
(Month)
/
(Year)
23
(Month)
/
(Year)
JBS International, Inc.
155 Bovet Road, Suite 210
San Mateo, CA 94402-3108
Phone: 650.373.4900
Fax: 650.348.0260
INDIVIDUAL AGREEMENT TO BE A RESEARCH SUBJECT
OMB CONTROL NUMBER: 1205-XXXX
INTRODUCTION/PURPOSE
You are invited to participate in this survey for the Department of Labor because you are currently working on a
farm. The purpose of the survey is to learn more about the employment, living conditions, and the
health of farm workers.
PROCEDURES TO BE FOLLOWED
You will be asked to answer some questions about your work history and about your health. The interview will
last approximately 45 minutes.
RISKS
Since we will only be asking you questions, there is very little risk to you as a result of being in the survey.
You may refuse to answer any question at any time, with no penalty.
BENEFITS
There are no direct benefits to you from being in the survey. Information obtained through this research,
however, may help federal, state, and private farm worker programs improve services to workers like
you.
PRIVACY
Your answers to the interview will be kept private to the extent allowed by law. This means that the interview
record will be kept in a locked file, and only researchers on the survey will be allowed to see it.
Your name will not appear on any reports about the survey. (See back of page for details.)
ALTERNATIVES TO PARTICIPATION
Participating in this survey is voluntary and you can quit at any time. You can also choose not to participate
in any part of the interview at any time, with no penalty. Whether or not you participate in this
survey will not affect benefits and services to which you are normally entitled. You will be paid for
the time you are spending in this interview. At any time, you may ask the researchers to explain any
part of the survey.
WHO TO CALL WITH QUESTIONS
If you have questions about the research survey, including questions about your rights as a research
subject, you may call JBS International (toll free) at 877- SAY-NAWS (or 877-729-6297). They will
refer your questions to Daniel Carroll at the Department of Labor, at (202) 693-2795.
I have read and understand the statement above. My questions about any unclear or confusing statements
have been answered clearly. I agree to participate in this survey as a research subject. I admit that
I have received a copy of this form and $20 for my participation.
-----------------------------------------------------------------Signature of Subject
(See reverse)
------------------------------------Date
In accordance with the Privacy Act of 1974, as amended (5 U.S.C.552a),
we are notifying you that this study is authorized by the U.S. Department of
Labor, Employment and Training Administration (ETA). Your voluntary
participation is important to the success of this study and will enable the
ETA to understand the labor market and living experiences of U.S.
farmworkers. Under written agreement with research organizations, the
ETA may release certain information necessary for research but only after
all identifying information has been removed. Unless required by law, or
necessary for litigation or legal proceedings and except as indicated in this
statement, we will hold all personal identifiers (e.g. name, address, and
social security number) in total confidence and will not release them.
Notwithstanding any other provision of law, no person is required to respond to nor shall a person
be subject to a penalty for failure to comply with a collection of information subject to the
requirements of the Paperwork Reduction Act unless that collection of information displays a
currently valid Office of Management and Budget control number. Public reporting burden for this
collection of information, which is voluntary, is estimated to average 45 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. Send
comments regarding this burden estimate to the Office of Policy Development, Evaluation and
Research, ETA, Department of Labor, Room N5641, 200 Constitution Avenue, N.W., Washington,
D.C. 20210.
JBS International, Inc.
155 Bovet Road, Suite 210
San Mateo, CA 94402-3108
Phone: 650.373.4900
Fax: 650.348.0260
INDIVIDUAL AGREEMENT TO BE A RESEARCH SUBJECT
OMB CONTROL NUMBER: 1205-XXXX
INTRODUCTION/PURPOSE
You are invited to participate in this survey for the Department of Labor because you are currently working
on a farm. The purpose of the survey is to learn more about the employment, living conditions,
and the health of farm workers.
PROCEDURES TO BE FOLLOWED
You will be asked to answer some questions about your work history and about your health. The interview will
last approximately 45 minutes.
RISKS
Since we will only be asking you questions, there is very little risk to you as a result of being in the survey.
You may refuse to answer any question at any time, with no penalty.
BENEFITS
There are no direct benefits to you from being in the survey. Information obtained through this research,
however, may help federal, state, and private farm worker programs improve services to workers like
you.
PRIVACY
Your answers to the interview will be kept private to the extent allowed by law. This means that the interview
record will be kept in a locked file, and only researchers on the survey will be allowed to see it.
Your name will not appear on any reports about the survey. (See back of page for details.)
ALTERNATIVES TO PARTICIPATION
Participating in this survey is voluntary and you can quit at any time. You can also choose not to participate
in any part of the interview at any time, with no penalty. Whether or not you participate in this
survey will not affect benefits and services to which you are normally entitled. You will be paid for
the time you are spending in this interview. At any time, you may ask the researchers to explain any
part of the survey.
WHO TO CALL WITH QUESTIONS
If you have questions about the research survey, including questions about your rights as a research
subject, you may call JBS International (toll free) at 877- SAY-NAWS (or 877-729-6297). They will
refer your questions to Daniel Carroll at the Department of Labor, at (202) 693-2795.
I have read and understand the statement above. My questions about any unclear or confusing statements
have been answered clearly. I agree to participate in this survey as a research subject. I admit that
I have received a copy of this form and $20 for my participation.
-----------------------------------------------------------------Signature of Subject
(See reverse)
Date
26
-------------------------------------
In accordance with the Privacy Act of 1974, as amended (5 U.S.C.552a),
we are notifying you that this study is authorized by the U.S. Department of
Labor, Employment and Training Administration (ETA). Your voluntary
participation is important to the success of this study and will enable the
ETA to understand the labor market and living experiences of U.S.
farmworkers. Under written agreement with research organizations, the
ETA may release certain information necessary for research but only after
all identifying information has been removed. Unless required by law, or
necessary for litigation or legal proceedings and except as indicated in this
statement, we will hold all personal identifiers (e.g. name, address, and
social security number) in total confidence and will not release them.
Notwithstanding any other provision of law, no person is required to respond to nor shall a
person be subject to a penalty for failure to comply with a collection of information subject to the
requirements of the Paperwork Reduction Act unless that collection of information displays a
currently valid Office of Management and Budget control number. Public reporting burden for this
collection of information, which is voluntary, is estimated to average 45 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. Send
comments regarding this burden estimate to the Office of Policy Development, Evaluation and
Research, ETA, Department of Labor, Room N5641, 200 Constitution Avenue, N.W., Washington,
D.C. 20210.
| File Type | application/pdf |
| File Title | S:\4. Questionnaire\2022\CYCLE102\CY102 ENG clean.wpd |
| Author | sallen |
| File Modified | 2021-11-17 |
| File Created | 2021-11-17 |