Head of Household Questionnaire

VIOLENCE AGAINST CHILDREN SURVEY – CORE: HOUSEHOLD QUESTIONNAIRE

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
H2

RECORD THE TIME THE INTERVIEW BEGAN (00:00):
RECORD THE SEX OF THE HEAD OF HOUSEHOLD:
MALE OR FEMALE

MALE

1

FEMALE

2

Note: this does not need to be asked of participant.

H3

I would like to start by asking you about yourself:
YEARS OLD:
How old are you?

H4

Now, I will continue by asking you questions about your household.
What is the main source(s) of food for members of your household/
where do you primarily get the food your household needs?

DON’T KNOW

998

DECLINED

999

SUPERMARKET OR LARGE GROCERY
STORE (GIANT FOOD, SAFEWAY, WHOLE
FOODS)
SMALL SUPERMARKET (EDDIE’S, MARS,
FOOD KING)
LIMITED SUPERMARKET (SAVE-A-LOT,
STOP, SHOP, & SAVE, ALDI, ETC.)
CONVENIENCE STORE/GAS STATION
DISCOUNT STORE (FAMILY DOLLAR,
ETC.)
FARMER’S MARKET OR OTHER LOCAL
PRODUCER
RESTAURANTS/DRIVE-THROUGH

H5

3

4
5
6
98

DECLINED

99

Does your household have access to:

SMARTPHONE

A

(Read the response options and choose all responses that apply)

CELL PHONE (WITHOUT
SMARTPHONE/INTERNET CAPABILITIES)

B

DESKTOP OR LAPTOP
TABLET OR OTHER WIRELESS
COMPUTER
A CELLULAR DATA PLAN

D

BROADBAND (HIGH SPEED) INTERNET
INSTALLED IN THE HOME

F

DECLINED

H7A

2

DON’T KNOW

DIAL-UP INTERNET SERVICE INSTALLED
IN THE HOME
DON’T KNOW
H6

1

How many bedrooms are in this home?

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?

C

E

G
Y
Z

NO. OF ROOMS:
DON’T KNOW

98

DECLINED

99

NONE

0

1

1

2

2

H7B

H8

H9

H10

H11

H12

H13

5 OR MORE

5

DON’T KNOW

98

DECLINED

99

What mode(s) of transportation do most members of this household
typically use for daily activities?

CAR, TRUCK OR VAN

A

BUS

B

(Choose all responses that apply)

TRAIN/SUBWAY/COMMUTER RAIL

C

TAXI, UBER, OR LYFT

D

MOTORCYCLE OR MOTORIZED SCOOTER

E

BICYCLE

F

Does any member of this household have a bank account at a bank,
credit union or online?

Does anyone in the household receive financial assistance from a
government program (e.g., Unemployment Insurance, Temporary
Assistance for Needy Families (TANF), Supplemental Security Income
(SSI))?

WALK

G

OTHER (SPECIFY):________________

X

DON’T KNOW

Y

DECLINED

Z

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED
Does anyone in the household receive outside financial help from a non- YES
government program, or does someone participate in a community based NO
program that provides income, such as micro finance, loan, or
DON’T KNOW
community savings group?
DECLINED
In the past 12 months, how often would you say you or your family were VERY OFTEN
worried or stressed out about having enough money to pay for meals?
OFTEN
Would you say very often, often, sometimes, seldom, or never?
SOMETIMES

99
1
2
98
99
1
2
3

SELDOM

4

NEVER

5

DON’T KNOW

98

DECLINED

99

In the past 12 months, did you or any member of this household receive YES
benefits from the Food Stamp Program or SNAP (Supplemental
NO
Nutrition Assistance Program)?
DON’T KNOW

1
2
98

DECLINED

99

Now, I would like to ask you and your family’s experiences with
moving.

YES

1

Have you ever lived in another country?

NO

2
H17

-2-

DON’T KNOW

98

DECLINED

99

H14

What were the main reasons for you living in another country?
(Choose all responses that apply)

BORN ABROAD

A

FAMILY REASONS

B

ECONOMIC / WORK

C

FORCED BY VIOLENCE IN THE FAMILY

D

FORCED BY VIOLENCE IN THE
COMMUNITY
FORCED BY NATURAL DISASTER

H15

H16

Did you live in the United States prior to living in another country?

What were the main reasons for moving from another country to here?
(Choose all responses that apply)

H18

Have you ever lived in another state?

What were the main reasons for you moving from another state to here?
(Choose all responses that apply)

F

FORCED BY OTHER CIRCUMSTANCES

G

DON’T KNOW

Y

DECLINED

Z

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

FAMILY REASONS

A

ECONOMIC / WORK

B

FORCED BY VIOLENCE IN THE FAMILY

C

FORCED BY VIOLENCE IN THE
COMMUNITY
FORCED BY NATURAL DISASTER

H17

E

D
E

FORCED BY OTHER CIRCUMSTANCES

F

DON’T KNOW

Y

DECLINED

Z

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

FAMILY REASONS

A

ECONOMIC / WORK

B

FORCED BY VIOLENCE IN THE FAMILY

C

FORCED BY VIOLENCE IN THE
COMMUNITY
FORCED BY NATURAL DISASTER

D
E

FORCED BY OTHER CIRCUMSTANCES

F

DON’T KNOW

Y

DECLINED

Z

ONLY FOR HOUSEHOLDS WITH 1 OR MORE RESIDENTS LESS THAN 18 YEARS, ELSE SKIP TO H23
H19

H20

H21

Now I will ask you about the health and wellness of the members of your YES
household:
NO

1

In the past year, have any of the adults in the household been ill for 3 or DON’T KNOW
more months?
DECLINED

98

Within the past 5 years, has there been a death in the household?

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

In the past 5 years, did you ever have to cut the size of the meals in your YES
household because there was not enough food or money?
NO
DON’T KNOW

-3-

2

99

1
2
98

H19

H22

In the past 5 years, did people in your household ever skip meals
because there was not enough food or money?

DECLINED

99

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

ONLY ASKED IF PARTICIPANT HAS BEEN SELECTED AND IS LESS THAN 18 YEARS
H23

Is the [AGE] year old [M/F] born on [DOB] currently living in this
household because his/her own parent is sick, has died or has moved
away?

-4-

YES, PARENT IS SICK

1

YES, PARENT DIED

2

YES, PARENT MOVED AWAY

3

YES, PARENT INCARCERATED

4

YES, PARENT UNABLE TO PROVIDE CARE

5

NO

6

DON’T KNOW

98

DECLINED

99

ONLY ASKED IF THERE IS ANOTHER HOUSEHOLD MEMBER LESS THAN 18 YEARS WHO HAS NOT BEEN SELECTED
H24

Are/is the (other) child(ren) living in this household because their own YES, PARENT IS SICK
parent is sick, has died, has moved away, been incarcerated or unable to
provide care?
YES, PARENT DIED

1
2

YES, PARENT MOVED AWAY

3

YES, PARENT INCARCERATED

4

YES, PARENT UNABLE TO PROVIDE CARE

5

NO

6

DON’T KNOW

98

DECLINED

99

ONLY ASKED IF PARTICIPANT HAS BEEN SELECTED AND IS LESS THAN 18 YEARS
H25

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.

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

ONLY ASKED IF PARTICIPANT HAS BEEN SELECTED AND IS LESS THAN 18 YEARS
H26

Has the [AGE] year old [M/F] born on [DOB] lived on the street in the
last 5 years?

-5-

YES

1

NO

2

DON’T KNOW

98

DECLINED

99

H26