ANNUAL SURVEY OF REFUGEES
MODE TEST QUESTIONNAIRE
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to test the Annual Survey of Refugees (ASR) in an online format to inform future administrations of the ASR, which is designed to learn how refugees adapt to life in the U.S. Public reporting burden for this collection of information is estimated to average 45 minutes per respondent, including any time you needed to collect information to be able to answer our questions. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. If you have any comments on this collection of information, please contact Office of Refugee Resettlement at [email protected].
GLOBAL PROGRAMMING NOTES:
MODE= Web
SAMPSOURCE= CLIENT SUPPLIED LIST
Except for screening questions, allow respondents to skip all other survey questions without a response.
Message to show on the web if skipped:
Your answers to these questions are very important to us. Please take a moment to respond to the question below. If you prefer not to answer, click the “Next” button.
The body of the page (question area) should be white.
Question text should be in larger font than response options.
Question numbers will be removed before going live.
Preferred fonts – Arial, Helvetica, or Verdana.
Do not show any Section titles (ex – Demographics, etc.)
Languages – allow respondent to pick among the following language preferences:
English
Dari
Ukrainian
Kiswahili
Arabic
Sgaw Karen
Spanish
99 (DO NOT READ) Refused has been removed for all questions for this web version
Please code any skipped/left blank web response for a question a respondent saw as a “999”.
Please locate ‘Finish Survey Later’ button to bottom of screen..
Set auto-suspend for web surveys at 30 minutes of inactivity
IF ENTERING VIA WEBSITE AND SECURE ACCESS CODE:
Welcome to the Annual Survey of Refugees.
[LANGUAGE SELECTION]
I would like to complete the survey in English.
Me gustaría completar la encuesta en Español.
[in Dari]
[in Ukrainian]
[in Kiswahili]
[in Arabic]
[in Sgaw Karen]
You will need the materials we mailed to you to start the survey. All the information that you provide will remain completely private.
Enter the 7-digit Secure Access Code on the materials we mailed you.
Secure Access Code __ __ __ __ __ __
Thank you for considering participating in the Annual Survey of Refugees. Before we begin, we have a few quick questions for you.
[Note that participants will all go into the screening questions that follow.]
IF ENTERING VIA QR CODE:
Welcome to the Annual Survey of Refugees.
Thank you for considering participating in the Annual Survey of Refugees. Before we begin, we have a few quick questions for you.
Are you…. INSERT FULL NAME?
Yes
No
IF Q1=2 – Please provide the mailed letter or postcard to INSERT FULL NAME who lives or stays at [ADDRESS]. Thank you.
(ASK IF Q1=1)
Did you enter the US since October 2017 as a refugee?
Yes
No
(ASK IF Q2 =2, BLANK)
What year did you arrive in the U.S.?
ENTER
IF Q3= SAMPLE FISCAL YEAR GO TO INTRO
(ASK IF Q3=BLANK)
Did you arrive in the U.S. between 2017 and 2022?
Yes
No
(ASK IF Q4=BLANK)
What year were you born?
ENTER
IF Q5= SAMPLE BIRTH YEAR GO TO INTRO
(ASK IF Q5=BLANK)
What is your age?
ENTER
IF Q6= SAMPLE AGE GO TO INTRO
(SHOW IF Q2=1 OR Q3 = SAMPLE FISCAL YEAR OR Q5= SAMPLE BIRTH YEAR OR Q6= SAMPLE AGE)
You are invited to participate in a voluntary study to inform improvements to the Annual Survey of Refugees, which is an annual survey that collects information on how refugees adapt to life in the U.S. It is funded by the Office of Refugee Resettlement and is being conducted by two research organizations, the Urban Institute and SSRS.
If you agree, you will answer some questions about you and your family - your education, work, community, and access to help and healthcare. It takes about 45 minutes, but it’s sometimes shorter and we will send you a $30 gift card to thank you for participating.
Before you start, you need to know a few things:
You don’t have to answer any questions you don’t want to.
You can stop the survey at any time.
The answers you give will be kept private and will not have your name on them.
Your responses will be combined with those of other refugees for analysis.
Your decision to participate or not participate in the study will not affect your access to social services and benefits.
Finally, there is very little risk associated with your participation because of the care we take to keep your name and your answers safe. There are no direct benefits to you, but you will help the Office of Refugee Resettlement understand how to improve the Annual Survey of Refugees.
If you have any comments about this survey, you can send your comments to the Office of Refugee Resettlement at [email protected] or call and leave a message at 202-401-9246.
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. The OMB number for this information collection is 0970-0355 and the expiration date is 10/31/2027
<1> I understand and agree to participate in the Annual Survey of Refugees.
<2> I do not want to participate in the Annual Survey of Refugees.
We would like to start by asking you a few questions about each person who lives in your home, or who is staying or visiting there and has no other home.
Q1 AND Q1A CANNOT BE LEFT BLANK [IF RESPONDENT DOES NOT COMPLETE THEM, THEY WILL BE EXITED FROM THE SURVEY]
(ASK ALL)
[PN: ALLOW UP TO 10 NAMES TO BE ENTERED.]
Q1. Including yourself, how many people are living or staying at this address? Please include family members as well as others not related to you who live in your home.
Enter Number: ________ [RANGE: 1-99]
(ASK IF Q1>1)
Q1A. Not counting you, start with your oldest family members and tell us the names of each family member who lives there. Also include those who usually live here but are temporarily absent.
( If you do not want to provide names of family members in the household, we are only using the name to refer to the correct person in later questions. So, just a first name or initials are fine.)
________
01 [AUTO-POPULATE RESPONDENT NAME]
02 [RECORD HH MEMBER #2 IF APPLICABLE]
03 [RECORD HH MEMBER #3 IF APPLICABLE]
04 [RECORD HH MEMBER #4 IF APPLICABLE]
05 [RECORD HH MEMBER #5 IF APPLICABLE]
06 [RECORD HH MEMBER #6 IF APPLICABLE]
07 [RECORD HH MEMBER #7 IF APPLICABLE]
08 [RECORD HH MEMBER #8 IF APPLICABLE]
09 [RECORD HH MEMBER #9 IF APPLICABLE]
10 [RECORD HH MEMBER #10 IF APPLICABLE]
99 NO OTHER HH MEMBERS
[PN: ASK Q2 for each member named in Q1a, including the respondent. COLLECT Q2 FOR ALL HH FAMILY MEMBERS BEFORE MOVING TO Q3]
[PN: AUTOPOPULATE Q2(a) WITH CODE 01 – SELF]
Q2(a-j). What is (INSERT NAME)’s relationship to you?
01 Self
02 Husband or wife
03 Unmarried partner
04 Biological son or daughter
05 Adopted son or daughter
06 Stepson or stepdaughter
07 Brother or sister
08 Father or mother
09 Grandchild
10 Parent-in-law
11 Son-in-law or daughter-in-law
12 Foster child
13 Other relative
16 Other
98 Don’t know
(FOR ONLY THOSE WITH Q2(a-j)=01-13, I.E., FAMILY MEMBERS, ASK Q3 TO Q4B BEFORE MOVING TO Q5).
INSERT “Now we’d like to get some information on your family living with you” ONLY FOR Q3B, I.E. THE SECOND FAMILY MEMBER
Q3(a-j). (Now we’d like to get some information on your family living with you). [Are you/Is (INSERT NAME)] male or female?
01 Male
02 Female
98 Don’t know
(ASK ALL)
Q4A(a-j). What is (your/INSERT NAME)’s age?
(Please report babies as age 0 when the child is less than 1 year old)
___________ [RANGE 1-110]
000 Less than one year
998 Don’t know
DO NOT SHOW “000 Less than one year” to RESPONDENT (Q4Aa).
(ASK ALL)
Q4B(a-j). What year [were you/was [INSERT NAME]] born?
1 ENTER 4-DIGIT YEAR
8 Don’t know
[PN: IF Q4A_1<16 OR Q4B_1 YEAR<2005 PLEASE DISPLAY “To confirm, you said your age is [INSERT AGE FROM Q4A_1] and your date of birth is [INSERT DATE OF BIRTH FROM Q4B_1].” IF YES, PROCEED, IF NO, GO BACK TO Q4A_1)
[PN: STARTING WITH RESPONDENT, ASK Q6 THROUGH Q9 FOR EACH FAMILY MEMBER in Q2 (if Q2a-j<14).]
(ASK ALL)
[PN: START WITH RESPONDENT, ASK Q6 TO Q11; THEN AUTO-POPULATE AS APPROPRIATE FOR FAMILY MEMBERS Q2(a-j)<14 USING RESPONDENT’S RESPONSES]
Q6(a-j). What is (YOUR/INSERT NAME)’s country of birth?
01 United States
02 Afghanistan
03 Bhutan
04 Burma
05 Burundi
06 Cuba
07 Democratic Republic of the Congo
08 Eritrea
09 Ethiopia
10 Iran
11 Iraq
12 Jordan
13 Kenya
14 Malaysia
15 Nepal
16 Rwanda
17 Somalia
18 Sudan
19 Syria
20 Tanzania
21 Thailand
22 Uganda
23 Ukraine
24 Armenia
25 Moldova
26 Pakistan
27 Palestine
28 Republic of South Sudan
29 Oman
97 Other (SPECIFY) _______________
98 Don’t know
[PN: 01 UNITED STATES CANNOT BE ENTERED FOR PA]
(ASK OF RESPONDENT ONLY AND IF Q6=2-97 )
[PN: IF Q6_1=1 DO NOT ASK Q6(B-J). IF Q6_1=2-99 ASK Q6(B-J) FOR REMAINING FAMILY MEMBERS]
Q6_1. Were all family members of this household born in [INSERT COUNTRY NAME FROM Q6]?
01 Yes
02 No
98 Don’t know
[PN: IF YES TO Q6_1 (Q6_1=1), THEN AUTOPOPULATE Q6 FOR ALL FAMILY MEMBERS AND DO NOT ASK Q6 FOR THE FAMILY MEMBERS]
(ASK ALL BUT RESPONDENT IF Q6=02-99. RESPONDENT DOES NOT GET Q7.)
[PN: AUTO-POPULATE FOR FAMILY MEMBERS Q2(a-0)<14 WITH RESPONDENT RESPONSE IF Q7_1 =1]
Q7( b-j). Did [insert name] enter as a refugee?
01 Yes
02 No
98 Don’t know
[PN: IF Q7_1=1 DO NOT ASK Q7(B-J) FOR THE FAMILY MEMBERS Q2(a-j)<14. IF Q7_1=2-99 ASK Q7(B-J) FOR REMAINING FAMILY MEMBERS]
Q7_1. Did all members of this household arrive in the U.S. as a refugee?
01 Yes
02 No
98 Don’t know
(ASK IF Q6=02-99)
[PN: AUTO-POPULATE FOR FAMILY MEMBERS B-J IE, Q2(A-J)<14 USING RESPONDENT’S Q8a RESPONSE IF Q8_1=1]
Q8(a-j). In what year did (YOU/INSERT NAME) arrive in the U.S.?
01 [ENTER 4-DIGIT YEAR]
98 Don’t know
(ASK OF RESPONDENT ONLY AND IF YEAR PROVIDED IN Q8)
[PN: IF Q8_1=1 DO NOT ASK Q8(B-J). ]
Q8_1. Did all members of this household arrive in the U.S. in [INSERT YEAR FROM Q8]?
01 Yes
02 No
98 Don’t know
(ASK IF Q6=02-99)
[PN: AUTO-POPULATE Q9 FOR FAMILY MEMBERS B-J WITH Q2(A-J)<14 USING RESPONDENT’S Q9a RESPONSE if Q9_1=1]
Q9(a-j). In what state did [YOU/insert name] originally resettle?
State, Specify_____________ [PN: SHOW STATE LIST]
[PN: AUTO-POPULATE Q9 FOR FAMILY MEMBERS B-J WITH Q2(A-J)<14 USING RESPONDENT’S Q9a RESPONSE if Q9_1=1]
Q9A(a-j). In what city did [YOU/insert name] originally resettle?
City, Specify_______________
(ASK OF RESPONDENT ONLY AND IF Q9 IS NOT DK/REF (RESPONDENT GIVES STATE)
[PN: ]
Q9_1. When first arriving in the U.S., did all family members of this household originally resettle in [INSERT STATE NAME FROM Q9]?
01 Yes
02 No
98 Don’t know
(ASK ALL)
[PN: AUTO-POPULATE FOR PERSONS B-J USING RESPONDENT’S Q10A RESPONSE IF Q10_1=1]
Q10(a-j). What is (YOUR/INSERT NAME)’s ethnic origin?
[FOR BLANGUAGE = DARI PLEASE SHOW THE FOLLOWING CODES]
Pashtun
Hazara
Tajik
Uzbek
97 OTHER (SPECIFY) _______________
98 ) Don’t know
[FOR BLANGUAGE = UKRAINIAN PLEASE SHOW THE FOLLOWING CODES]
Ukrainian
Russian
97 OTHER (SPECIFY) _______________
98 Don’t know
[FOR BLANGUAGE = KISWAHILI PLEASE SHOW THE FOLLOWING CODES]
Bembe/Bemba/Mbembe
Banyamulenge/Banyamulengue
Mkongo
Tutsi
Hutu
Mushi
Bantu
Luba
97 OTHER (SPECIFY) _______________
98 ) Don’t know
[FOR BLANGUAGE = ARABIC PLEASE SHOW THE FOLLOWING CODES]
Arab
Kurd
Chaldean
Siryac
97 OTHER (SPECIFY) _______________
98 Don’t know
[PN: SHOW LIST BASED ON RESPONDENT LANGUAGE]
[PN: IF BLANGUAGE = BLANK, SHOW ETHNICITY LIST BASED ON CURRENT SURVEY LANGAUGE]
(ASK OF RESPONDENT ONLY AND IF Q10=1-97)
[PN: IF Q10_1=1 DO NOT ASK Q10(B-J).
Q10_1. Are all family members of this household of [INSERT ETHNIC ORIGIN FROM Q10a] origin?
01 Yes
02 No
98 Don’t know
(ASK ALL)
[PN: AUTO-POPULATE Q11 FOR FAMILY MEMBERS B-J FOR WHOM Q2(A-J)<14 USING RESPONDENT’S Q11a RESPONSE IF Q11_1=1]
Q11(a-j). What is [YOUR/insert name]'s race or ethnicity?
[PN: ALLOW MULTIPLE RESPONSES – CODE 98 MUTUALLY EXCLUSIVE]
[MARK ALL THAT APPLY]
01 White
02 Black or African American
03 Asian
04 Middle Eastern or North African
05 American Indian or Alaska Native
06 Latino/Hispanic
97 Other (Specify) _______________
98 Don’t know
(ASK OF RESPONDENT ONLY AND IF Q11=1-97)
[PN: IF Q11_1=1 DO NOT ASK Q11(B-J). Q11_1. Are all family members of this household [INSERT RACE FROM Q11a]?
01 Yes
02 No
98 Don’t know
(ASKED OF RESPONDENT ONLY)
Q5. What is your current marital status?
01 Now married, spouse living in household
02 Now married, spouse not living in household
03 Divorced or separated
04 Never married
05 Widowed
97 Other (SPECIFY) _______________
[PN: Q13 AND 14 ARE ONLY ASKED OF THE RESPONDENT]
(ASK OF RESPONDENT ONLY)
Q13. How many states have you lived in since you arrived in the U.S.?
________ [PN: RANGE 1-97]
[ASK IF Q13>1 ]
Q14. What was the reason for your first move from the initial state where you were resettled? Was it for…
[MARK ALL THAT APPLY]
Economic opportunity, such as employment
02 To be closer to family or friends
03 To live in a place where there are more people from your home country
04 Affordable housing
97 Other
(ASK ALL)
Q17. Just before coming to the U.S. were you living in a refugee camp?
01 Yes
02 No
(ASK IF Q17=1 )
Q18. How long did you live in a refugee camp?
Your whole life ( born in the camp)
03 ___________ years (RECORD NUMBER OF YEARS) [PN: RANGE 1-96]
Less than a year
(ASK ALL)
Q19. What was your work status in your home country? Were you…
NOTE: This could be the work status before you had to flee or faced persecution.
Not working for pay includes being too young, a student, too old or any other reason for not working for pay
01 Not working for pay
02 Working for paid jobs, SPECIFY occupation:__________
03 Self-employed ( business, profession, or own farm)
04 OTHER
98 Don’t know
[ASK IF Q19=1]
Q20. What is the main reason you were not working for pay in your home country?
Too young to work or still in school
02 Taking care of children or family
03 Elderly (past retirement age)
04 Safety concerns
05 Poor health or disability
06 Lack of work authorization
07 No jobs available
08 Other
ACQ1. When you first arrived in the United States as a refugee, were you sent to any of the following US military bases?
01 Fort August in Alaska
02 Fort Relief in Nebraska
03 Fort Rosewood in Idaho
04 I was not sent to any of the above
98 Don’t Know
These next questions are about your ability to speak in English
(ASK ALL)
Q23. When you arrived in the U.S., how well did you speak English:
01 Very well
02 Well
03 Not well
04 Not at all
(ASK ALL)
Q24. How well do you speak English now:
01 Very well
02 Well
03 Not well
04 Not at all
(ASK ALL)
Q25. Since arriving in the US, have you ever taken any ESL or English classes, either online or in a classroom?
01 Yes
02 No
(ASK IF Q25=01)
Q26. Where have you taken ESL or English classes in the U.S.?
[PN: ALLOW MULTIPLE RESPONSES]
[MARK ALL THAT APPLY]
01 At work
02 At a local school or college
03 At a library
04 At a church or other religious organization
05 At a refugee resettlement organization
97 Other
(ASK ALL)
Q27. What challenges, if any, have you had taking ESL or English classes in the US?
[PN: ALLOW MULTIPLE RESPONSES – CODE 11 MUTUALLY EXCLUSIVE]
[MARK ALL THAT APPLY]
Cost of classes
Too busy with work responsibilities
Too busy with child care or family responsibilities
Lack of knowledge on classes available
Lack of transportation
Poor health or disability
11 NO CHALLENGES
Next are some questions about any programs or classes you may have taken here in the U.S. other than studying English.
(ASK ALL)
Q28. Since arriving in the US, have you participated in a program to prepare you for a job, either online or in a classroom?
NOTE: This includes job training classes or programs, job search training or interview and resume preparation.
01 Yes
02 No
(ASK IF Q28=01)
Q29. Where did you take this job preparation program in the U.S.?
[PN: ALLOW MULTIPLE RESPONSES ]
[MARK ALL THAT APPLY]
01 At work
02 At a local school or college
03 At a library
04 At a church or other religious organization
05 At a refugee resettlement organization
97 Other
(ASK ALL)
[PN: BEGIN WITH Q30a to Q34 FOR RESPONDENT, AND THEN ASK Q30B-J to Q33B-J FOR FAMILY MEMBERS FOR WHOM Q2(a-j)<14 IF Q4=16-110,998,999 AND Q7=1,98,99;)]
Q30(a-j). What was the highest degree or level of school that [YOU/INSERT NAME] completed before coming to the U.S.?
01 No schooling
02 Primary or elementary school
03 Lower secondary school (or middle school)
04 Upper secondary school (or high school)
05 Some technical or vocational training
06 Some university classes but did not attain degree
07 University (bachelor's degree)
08 Advanced degree (master's, PhD, or professional degree)
09 Religious school
97 Other (SPECIFY)__________________
(ASK IF Q30(a-j) > 01)
Q31(a-j). Has [YOUR/INSERT NAME’s] education, degree, or certificate earned outside the U.S. been:
01 Fully recognized in the U.S.
02 Partially recognized
03 Not at all recognized in the U.S.
98 Don’t know
Q32(a-j). Since arriving in the U.S., (have you/has [INSERT NAME]) pursued a degree or certificate by attending school, community college, or college, with classes either online or in a classroom?
NOTE: THIS SHOULD INCLUDE ANY DEGREE OR CERTIFICATE {YOU/THEY} HAVE BEGUN AND NOT NECESSARILY COMPLETED; THIS SHOULD NOT INCLUDE ESL OR ENGLISH CLASSES, JOB TRAINING WITH NO PROFESSIONAL CERTIFICATE, OR OTHER CLASSES THAT ARE NOT ASSOCIATED WITH A DEGREE OR CERTIFICATE
01 Yes
02 No
98 Don’t know
(ASK IF Q32 (a-j)=01)
Q33(a-j). At what level was/is (your/[INSERT NAME]’s) degree or certificate program. Was/is it:
NOTE: THIS SHOULD NOT INCLUDE ESL, JOB TRAINING WITH NO PROFESSIONAL CERTIFICATE, OR OTHER PROGRAMS NOT LISTED BELOW
01 GED or high school equivalency
02 Professional certificate
03 Associate's degree
04 Bachelor's degree
05 An advanced degree ( master's, PhD, or professional)
97 OTHER
(ASK ALL) [PN: ASK ONLY OF THE RESPONDENT; SKIP TO Q35 FOR FAMILY MEMBERS]
Q34 What challenges, if any, have you had getting training or education (not counting ESL or English classes)?
[PN: ALLOW MULTIPLE RESPONSES – CODE 11, 97 MUTUALLY EXCLUSIVE]
[MARK ALL THAT APPLY]
Cost of classes
Too busy with work responsibilities
Too busy with child care or family responsibilities
Lack of knowledge on classes available
Lack of transportation
Poor health or disability
07 Other
11 No challenges
97 NOT APPLICABLE
[PN: ASK Q35-Q43 FOR FAMILY MEMBERS A-J FOR WHOM Q2(A-J)<14 IF Q4=16-110,998,999 AND Q7=1,98,99; START WITH RESPONDENT, THEN CYCLE THROUGH Q35-Q43 FOR EACH FAMILY MEMBER 16+ YRS OLD.
IF Q4=16-110,998,999 AND Q7=1,98,99 AND Q20=3,5 SKIP THIS SECTION FOR THE RESPONDENT AND ONLY CYCLE THROUGH Q35-Q43 FOR EACH FAMILY MEMBER 16+ YRS OLD.
IF THERE ARE MORE THAN 4 FAMILY MEMBERS WHO ARE 16+ AND ELIGIBLE, Q35-Q43 SHOULD BE ASKED OF 4 RANDOMLY SELECTED FAMILY MEMBERS WHO ARE 16+ AND ELIGIBLE. QUESTIONS SHOULD BE ASKED OF THE SAME 4 MEMBERS]
IF ONLY RESPONDENT IS ELIGIBLE FOR THIS SECTION INSERT ‘you’
IF RESPONDENT AND FAMILY MEMBERS ARE ELIGIBLE FOR THIS SECTION INSERT ‘you and other family members of your household’
IF Q4=16-110,998,999 AND Q7=1,98,99 AND Q20=3 or 5 ONLY INSERT “other family members of your household”
This next part of the survey is about (you/ you and other family members of your household/other family members of your household): [fill in the names of those eligible based on the screening/HH roster].
First we will ask about [your/[INSERT NAME]’s] employment in the last week and month.
(ASK ALL)
Q35(a-j). Last week, did [you/INSERT NAME] work for pay at a job or business?
01 Yes
02 No
98 Don’t know
(ASK Q38(a-j) IF Q35(a-j)=02; ELSE SKIP TO Q40)
Q38(a-j). During the last 4 weeks, (have you/has [INSERT NAME]) been actively looking for work?
01 Yes
02 No
98 Don’t know
(ASK IF Q38(a-j)=02)
Q39(a-j). Why (have you/has [INSERT NAME]) not been looking for work?
[PN: ALLOW MULTIPLE RESPONSES – CODE 98 MUTUALLY EXCLUSIVE]
[MARK ALL THAT APPLY]
Has a job but was temporarily absent for any reason (e.g., illness, bad weather, vacation, labor-management disputes)
Poor health or disability
03 Limited English ability
04 Attending school or training
05 Providing child care or family caregiving
06 Is elderly (past retirement age)
07 Lack of transportation
OTHER
98 Don’t know
(ASK IF Q35(a-j)=02 AND Q39(a-j) NOT EQUAL 01)
Q39A(a-j). Although [you/INSERT NAME] did not work last week, did [you/INSERT NAME] have a job or business at any time in the past year?
01 Yes
02 No
98 Don’t know
(ASK IF Q35(a-j)=01or Q39(a-j)=01 or Q39A(a-j)=01)
Q45(a-j). What kind of work do /does [you/INSERT NAME] do, that is, what is [your/INSERT NAME]’S occupation? For example: plumber, typist, or farmer.
Note: If more than one occupation, choose the principal occupation
________ (record occupation)
98 Don’t know
(ASK IF Q35(a-j)=01OR Q39(a-j)=1 OR Q39A(a-j)=1)
Q40(a-j). What was (your/[INSERT NAME]'s) hourly wage at your/his/her primary job?
$________ (RANGE: 0-96)
These next questions are about (your/INSERT NAME’s) work over the past year.
(ASK IF Q35(a-j)=01or Q39(a-j)=01 or Q39A(a-j)=01)
Q42(a-j). In the past year, how many weeks did [you/INSERT NAME] work, even for a few hours, including paid vacation, paid sick leave, and military service?
________ (RANGE: 0-52)
98 Don’t know
(ASK IF Q35(a-j)=01or Q39(a-j)=01 or Q39A(a-j)=01)
Q43(a-j). In the past year, how many hours per week did [you/INSERT NAME] usually work?
________ (RANGE: 0-168)
998 Don’t know
[PN: ASK Q46-Q48 AND Q50-Q56 FOR FAMILY MEMBERS A-J FOR WHOM Q2(A-J)<14 IF Q4=16-110,998,999 AND Q7=1,98,99; START WITH RESPONDENT, THEN CYCLE THROUGH Q35-48 AND Q50-56 FOR EACH FAMILY MEMBER 16+ YRS OLD.
IF Q4=16-110,998,999 AND Q7=1,98,99 AND Q20=3,5 SKIP THIS SECTION FOR THE RESPONDENT AND ONLY CYCLE THROUGH Q46-Q48 AND Q50-Q56 FOR EACH FAMILY MEMBER 16+ YRS OLD.
IF THERE ARE MORE THAN 4 FAMILY MEMBERS WHO ARE 16+ AND ELIGIBLE, Q46-Q48 AND Q50-Q56 SHOULD BE ASKED OF 4 RANDOMLY SELECTED FAMILY MEMBERS WHO ARE 16+ AND ELIGIBLE. QUESTIONS SHOULD BE ASKED OF THE SAME 4 MEMBERS]
IF ONLY RESPONDENT IS ELIGIBLE FOR THIS SECTION INSERT ‘you’
IF RESPONDENT AND FAMILY MEMBERS ARE ELIGIBLE FOR THIS SECTION INSERT ‘you and other family members of your household’
IF Q4=16-110,998,999 AND Q7=1,98,99 AND Q20=3 or 5 ONLY INSERT “other family members of your household”]
These next questions are about your/INSERT NAME’s work since arriving in the US (in [INSERT ARRIVAL YEAR FROM RESPONSE IN Q8 A-J IF AVAILABLE]).
(ASK IF Q39A(a-0)=02)
Q46(a-j). Since arriving in the US, have you/has [INSERT NAME] ever worked for pay since coming to the U.S.?
01 Yes
02 No
98 Don’t know
(ASK IF Q46(a-j)=02AND Q38(a-j) NOT EQUAL 01)
Q47(a-j). Since arriving in the U.S., (have you/has [INSERT NAME]) ever actively looked for work?
01 Yes
02 No
98 Don’t know
(ASK ALL)
Q48(a-j). Have you/Has [INSERT NAME] faced any of the following challenges in finding a job in the US?
[PN: ALLOW MULTIPLE RESPONSES – CODE 98 MUTUALLY EXCLUSIVE]
[MARK ALL THAT APPLY]
01 Limited English ability
02 Low literacy in own language
03 Not knowing how to find a job
04 Employers not recognizing qualifications or work experience from outside the US
05 Childcare or family responsibilities
06 Poor health or disability
07 Lack of transportation
08 Other
98 Don’t know
[NEXT SECTION ONLY IF HAS EVER WORKED IN THE US (IF Q35(a-j)=1 OR Q39(a-j)=1 OR Q39A(a-j)=1 OR Q46(a-j)=1)]
Now think about (your/INSERT NAME’s) first job that (you/he/she) got in the U.S.
(ASK Q49 ONLY OF THE RESPONDENT)
Q49a. Who was the most helpful to you in getting your first job in the U.S.?
01 Got it yourself
02 Friends or relatives
03 Case worker/Refugee resettlement organization
97 OTHER
(ASK IF Q35(a-j)=1 OR Q39(a-j)=1 OR Q39A(a-j)=1 OR Q46(a-j)=1)
Q50(a-j). What kind of work did [you/INSERT NAME] do in that first job [you/INSERT NAME] had in the U.S., that is, what was [your/INSERT NAME]’s occupation? ( For example: plumber, typist, or farmer.)
_______ (RECORD RESPONSE)
98 Don’t know
(ASK IF Q35(a-j)=1 OR Q39(a-j)=1 OR Q39A(a-j)=1 OR Q46=1)
Q51(a-j). Did that first job come with health insurance benefits?
01 Yes
02 No
98 Don’t know
(ASK IF Q35(a-j)=1 OR Q39(a-j)=1 OR Q39A(a-j)=1 OR Q46(a-j)=1)
Q52(a-j). Is (your/[INSERT NAME]’s) current or most recent job the same as that first job in the U.S.?
That means working for the same employer and still having the same work title.
01 Yes
02 No
98 Don’t know
SECOND LINE SHOULD BE IN A LIGHTER COLOR.
ASK IF Q35(a-j)=1 OR Q39(a-j)=1 OR Q39A(a-j)=1 OR Q46(a-j)=1)
Q53(a-j): Does your/[INSERT NAME]’s current or most recent job correspond to your/[INSERT NAME]’s level of education?
01 Your/his/her level of education is higher than what is required by you/his/her job.
02 Your/his/her level of education is matched to what is required by your/his/her job.
03 Your/his/her job requires a higher level of education.
ASK IF Q35(a-j)=1 OR Q39(a-j)=1 OR Q39A(a-j)=1 OR Q46(a-j)=1)
Q54(a-j): Overall, how would you describe your/[INSERT NAME]’s skills in relation to what is required to do in your/[INSERT NAME]’s current or most recent job?
01 Your/his/her skills are higher than what is required by your/his/her job
02 Your/his/her skills are matched to what is required by your/his/her job
03 Some of your/his/her skills need to be further developed for your/his/her job
ASK IF Q35(a-j)=1 OR Q39(a-j)=1 OR Q39A(a-j)=1 OR Q46(a-j)=1)
Q55(a-j): Does your/[INSERT NAME]’s current or most recent job come with health insurance benefits?
01 Yes
02 No
98 Don’t know
(ASK IF Q35(a-j)=1 OR Q39A(a-j)=1 OR Q39A(a-j)=1 OR Q46(a-j)=1)
Q56(a-j). Does [your/[INSERT NAME]'s] current or most recent job provide a higher hourly wage than your/his/her first job in the US?
01 Yes
02 No
98 Don’t know
ACQ2. What month is it today?
01 August
02 September
03 October
04 November
98 Don’t Know
[PN: SHIFT BACK HERE TO ASKING ONLY ABOUT THE RESPONDENT, NOT ALL ELIGIBLE FAMILY ADULTS]
Now the following questions ask about your family and how you support yourselves.
(ASK ALL)
Q57. Approximately, what was your family's average monthly net household income in the past year, that is, the money left over after taxes are removed?
Note: Please provide the average monthly income, not the yearly income.
________ [RANGE: 0-99997]
99998 Don’t know
(ASK IF Q57=98 OR Q57=99)
Q57A.
(IF Q57=99998: It is hard to estimate this, but)
(IF
Q57=99999: This can be a sensitive question, but)
Would you be
able to tell us if your average monthly net household income was:
01 Less than $2300
02 More than $2300
98 Don’t know
(ASK IF Q57A=01)
Q57B. And would you say it was
01 Less than $1200
02 More than $1200
03 About that amount
98 Don’t know
(ASK IF Q57B=01)
Q57C. And would you say it was
01 Less than $300
02 More than $300
03 About that amount
98 Don’t know
(ASK IF Q57B=02)
Q57D. And would you say it was
01 Less than $1800
02 More than $1800
03 About that amount
98 Don’t know
(ASK IF Q57A=02)
Q57E. And would you say it was
01 Less than $3300
02 More than $3300
03 About that amount
98 Don’t know
(ASK IF Q57E=01)
Q57F. And would you say it was
01 Less than $2700
02 More than $2700
03 About that amount
98 Don’t know
(ASK IF Q57E=02)
Q57G. And would you say it was
01 Less than $4500
02 More than $4500
03 About that amount
98 Don’t know
(ASK ALL)
Q58. Was your family able to pay its monthly living expenses last month?
(Note: By living expenses we mean paying for your housing, utilities, transportation, and other bills)
Yes
No
Don’t know
Next are some questions about your family’s receipt of different government benefits.
(ASK ALL)
Q60. In the past year, have one or more persons in your family received food stamps? This is when the government gives you vouchers that you exchange for food, also known as “SNAP”.
Note: Food stamps, now known the Supplemental Nutrition Assistance Program (SNAP), are vouchers issued by the government for low income families or individuals that can be exchanged for food. (IF PROGRAM NAME IS NOT ‘SNAP’ INSERT This program is also known as (INSERT STATE SPECIFIC NAME) in your state.)
01 Yes
02 No
98 Don’t know
SET HASCHILDREN=1 if ANY Q4a (B-J)=0-17
SET HASCHILDRENUNDER20 if there are children under age of 20 and over the age of 5 and respondent is their parent or guardian (IF ANY Q2(a-j)=4,5,6,12 AND ANY Q4a(a-j)=6 -19)]
(ASK IF THERE ARE CHILDREN <18 in the Household; IF ANY Q4a (B-J)=0-17)
Q61. In the past year, have one or more persons in your family received TANF, also known in your state as [INSERT PROGRAM NAME BASED ON SAMPLE STATE] This is when the government provides cash assistance to families with children to help pay for food, shelter, utilities, and non-medical expenses.
Note: TANF is a federally-funded program run by states that provides limited cash assistance to extremely low-income parents and their children. TANF provides financial assistance to help pay for food, shelter, utilities, and expenses other than medical. Each state in the U.S. has a different name for its TANF program.
01 Yes
02 No
98 Don’t know
(ASK ALL)
Q62. In the past year, have one or more persons in your family received “SSI” or Supplemental Security Income? This is when the government provides cash assistance to the elderly and disabled.
( Note: Supplemental Security Income (SSI) is a U.S. government program that provides stipends to low income people who are either aged 65 or older, blind, or disabled.)
01 Yes
02 No
98 Don’t know
(ASK ALL)
Q63. In the past year, have one or more persons in your family received income from General Assistance or other welfare? This is when the government assists adults in meeting their basic needs for housing, utilities, personal needs, and transportation.
01 Yes
02 No
98 Don’t know
(ASK ALL)
Q64. In the past year, have you or anyone in your family received any other government supports, from federal, state, or local government?
01 Yes, (SPECIFY) ___________
02 No
98 Don’t know
(ASK ALL)
Q65. To what extent do people in your community share your cultural background (that is, sharing the same culture, ethnic group, language, or religion)? Is it:
01 All or most
02 About half
03 Only a few
04 None
98 Don’t know
(ASK ALL)
Q66. Have you visited the home of any friends or neighbors of your same cultural background, or have any visited your home?
01 Yes
02 No
98 Don’t know
(ASK ALL)
Q67. Have you visited the home of any friends or neighbors of a different cultural background, or have any visited your home?
01 Yes
02 No
98 Don’t know
(ASK IF Q67=01)
Q68. How did you meet this person (or these people) (of a different cultural background)?
[PN: ALLOW MULTIPLE RESPONSES ]
[MARK ALL THAT APPLY]
01 Through work
02 Through children's school
03 In the neighborhood
04 Through friends or relatives
05 Through church or other religious organization
(ASK ALL)
Q69. Which, if any, kinds of groups or organizations have you participated in? Have you participated in: Group related to children's school? (like the PTA or parents' volunteering groups?
Yes
No
Q69b. Have you participated in: Church or other religious organization or group?
01 Yes
02 No
Q69c. Have you participated in: Community or ethnic organization or club?
01 Yes
02 No
Q69d. Have you participated in: Sports club or team?
01 Yes
02 No
Q69e. Have you participated in: Any other group?
01 Yes (SPECIFY) _________
02 No
[PN: INCLUDE “Which, if any, kinds of groups or organizations have you participated in?” BEFORE THE QUESTION ON EACH SCREEN Q69b – Q69e] AND ON A SEPARATE LINE
(ASK ALL)
Q70. How welcome do you currently feel in the U.S.? We want to know how welcome you feel in your community today, and not when you first arrived in the
US. Today, do you feel:
01 Very welcome
02 Somewhat welcome
03 Somewhat unwelcome
04 Very unwelcome
98 Don’t know
[PN: ASK Q71 FOR FAMILY MEMBERS FOR WHOM Q2(a-j)<14 IF Q4=16-110,998,999 AND Q7=1,98,99; START WITH RESPONDENT, THEN CYCLE THROUGH Q71 FOR EACH FAMILY MEMBER 16+ YRS OLD. IF THERE ARE MORE THAN 4 FAMILY MEMBERS WHO ARE 16+ AND ELIGIBLE, Q71 SHOULD BE ASKED OF 4 RANDOMLY SELECTED FAMILY MEMBERS WHO ARE 16+ AND ELIGIBLE. QUESTIONS SHOULD BE ASKED OF THE SAME 4 MEMBERS WHO RECEIVE Q35-48 AND Q50-56
Q71. After your first year in the U.S., did [you/[INSERT NAME]] apply for a green card? (become a permanent resident)
01 Yes
02 No
98 Don’t know
(ASK ALL)
Q72: Have you faced any challenges applying for a green card?
01 Yes
02 No
98 Don’t know
(ASK IF Q72=1)
Q72a. What challenges have you had applying for a green card?
[PN: ALLOW MULTIPLE RESPONSES – CODE 98 MUTUALLY EXCLUSIVE]
[MARK ALL THAT APPLY}
Lack of information
Limited English ability
Cost of applying
Medical requirements
Lack of transportation
97 OTHER
98 Don’t know
(ASK ALL)
Q73. Are you currently or are you planning to become a U.S. citizen?
01 Yes, currently a U.S. citizen
02 Yes, planning to become a U.S. citizen
03 No, not planning to become a U.S. citizen
(ASK ALL)
Q74. Do you have a U.S. driver's license?
01 Yes
02 No
The following questions are about where you currently live.
(ASK ALL)
Q77. Is your house or apartment where you currently live…
01 Owned or being bought by someone in the household
02 Rented
97 OTHER
98 Don’t know
(ASK ALL)
Q77A. Is this housing unit in a public housing project, that is, is it owned by a local housing authority or other local public agency?
01 Yes
02 No
98 Don’t know
(ASK ALL)
Q78. How many bedrooms are there in your current apartment or house?
____________(RANGE 0-97)
98 Don’t know
(ASK ALL)
Q79. What is the total monthly rent or housing payment for your home?
Note: WE WANT TO KNOW WHAT THE MONTHLY RENT IS, NOT JUST WHAT YOU CONTRIBUTE EACH MONTH
$________ [RANGE: 0-9997]
9998 Don’t know
Q80. Do you feel safe at night walking alone at night in the city or area where you live?
01 Yes
02 No
98 Don’t know
Q81. How much do you trust your local police?
01 Not at all
02 Somewhat
03 A lot
98 Don’t know
(ASK ALL)
Q82. Discrimination may happen when people are perceived as being different than others. Since coming to the U.S., have you experienced discrimination or been treated unfairly by others because of your ethnicity, race, skin color, culture, language or accent, gender, or religion in any of the following situations?
Q82a. On the street?
01 Yes
02 No
98 Don’t know
Q82b. Since coming to the U.S., have you experienced discrimination or been treated unfairly by others because of your ethnicity, race, skin color, culture, language or accent, gender, or religion: In local businesses?
01 Yes
02 No
98 Don’t know
Q82c. Since coming to the U.S., have you experienced discrimination or been treated unfairly by others because of your ethnicity, race, skin color, culture, language or accent, gender, or religion: At work or when applying for a job or promotion?
01 Yes
02 No
98 Don’t know
Q82d. Since coming to the U.S., have you experienced discrimination or been treated unfairly by others because of your ethnicity, race, skin color, culture, language or accent, gender, or religion: When dealing with police or courts?
01 Yes
02 No
98 Don’t know
Q82e. Since coming to the U.S., have you experienced discrimination or been treated unfairly by others because of your ethnicity, race, skin color, culture, language or accent, gender, or religion: In school or class?
01 Yes
02 No
98 Don’t know
Q82f. Since coming to the U.S., have you experienced discrimination or been treated unfairly by others because of your ethnicity, race, skin color, culture, language or accent, gender, or religion: When looking for a place to live or when renting or buying a home?
01 Yes
02 No
98 Don’t know
Q82g. Since coming to the U.S., have you experienced discrimination or been treated unfairly by others because of your ethnicity, race, skin color, culture, language or accent, gender, or religion: When dealing with health care providers?
01 Yes
02 No
98 Don’t know
Q82h. Since coming to the U.S., have you experienced discrimination or been treated unfairly by others because of your ethnicity, race, skin color, culture, language or accent, gender, or religion: In any other place or situation?
01 Yes
02 No
Don’t know
[PN: INCLUDE “Since coming to the U.S., have you experienced discrimination or been treated unfairly by others because of your ethnicity, race, skin color, culture, language or accent, gender, or religion: ” BEFORE THE QUESTION ON EACH SCREEN Q82a– Q82h] AND ON A SEPARATE LINE
(ASK ALL)
Q84. Have you visited the doctor for a routine physical exam within the past year?
NOTE: A routine physical exam includes “well visit” or preventive care. This can include screenings and checkups; to help prevent health problems before you have any symptoms. They do not include tests or services to monitor or manage a condition or disease once it has been diagnosed.
01 Yes
02 No
98 Don’t know
(ASK ALL)
Q85. If you received any healthcare in the past year, what kind of place was it? Was it from...?
[PN: ALLOW MULTIPLE RESPONSES – CODES 08, 98 MUTUALLY EXCLUSIVE]
[MARK ALL THAT APPLY]
01 A doctor’s office or private clinic
02 A community health center or other public clinic
03 A hospital outpatient department
04 A hospital emergency room
05 An urgent care center
06 A traditional healer from your community such as a dhami, jakhri, or curandero
07 Other
08 Did not receive any healthcare in the past year
98 Don’t know
(ASK ALL)
Q86. Which of the following challenges, if any, did you or family members face in receiving medical care in the past year?
Q86a. Did you face challenges: Finding a medical provider?
01 Yes
02 No
98 Don’t know
Q86b. Did you face challenges due to: Limited English ability?
01 Yes
02 No
98 Don’t know
Q86c. Did you face challenges due to: Lack of transportation?
01 Yes
02 No
98 Don’t know
Q86d. Did you face challenges due to: Cost of care?
01 Yes
02 No
98 Don’t know
Q86e. Any other challenges?
01 Yes (SPECIFY) _____________
02 No
98 Don’t know
[PN: INCLUDE “Which of the following challenges, if any, did you or family members face in receiving medical care in the past year?” BEFORE THE QUESTION ON EACH SCREEN Q86a – Q86e]
(ASK ALL)
Q87. In the past year, have you or family members delayed seeking medical care because of worry about the costs?
01 Yes
02 No
98 Don’t know
(ASK ALL)
Q88. Would you say that in general your physical health is:
01 Excellent
02 Very Good
03 Good
04 Fair
05 Poor
98 Don’t know
(ASK ALL)
Q89. During the past 30 days, how often did you feel so sad that nothing could cheer you up:
01 All of the time
02 Most of the time
03 Some of the time
04 A little of the time
05 None of the time
98 Don’t know
The next question asks about difficulties you or other family members aged 16 or older may have doing certain activities.
Q88a. When thinking about you and other adult family members in your household,
01 Yes
02 No
98 (DO NOT READ) Don’t Know
99 (DO NOT READ) Refused
Is anyone deaf or has serious difficulty hearing?
Is anyone blind or has serious difficulty seeing even when wearing glasses?
Because of a physical, mental, or emotional condition, does anyone have serious difficulty concentrating, remembering, or making decisions?
Does anyone have serious difficulty walking or climbing stairs?
Because of a physical, mental, or emotional condition, does anyone have difficulty doing errands alone such as visiting a doctor's office or shopping?
[PN: ASK 90-91 FOR FAMILY MEMBERS FOR WHOM Q2(a-j)<14 IF Q4=16-110,998,999 AND Q7=1,98,99; START WITH RESPONDENT, THEN CYCLE THROUGH FOR EACH FAMILY MEMBER 16+ YRS OLD. IF THERE ARE MORE THAN 4 FAMILY MEMBERS WHO ARE 16+ AND ELIGIBLE, SHOULD BE ASKED OF 4 RANDOMLY SELECTED FAMILY MEMBERS WHO ARE 16+ AND ELIGIBLE. QUESTIONS SHOULD BE ASKED OF THE SAME 4 MEMBERS WHO RECEIVE Q35-48 AND Q50-56]
Q90. What kind of health insurance or health care coverage [do you/does [INSERT NAME]] currently have?
( Note: Medicaid and CHIP are federally-funded programs run by states, that provide health care coverage to low-income adults, children, pregnant women, elderly, and people with disabilities. Each state in the U.S. has a different name for its Medicaid and CHIP programs. CHIP is the Children’s Health Insurance Program, which provides health coverage to children)
01 No insurance
02 Insurance through [your/[INSERT NAME]’s] job
03 Insurance through a family member’s job
04 Medicaid, CHIP or Refugee Medical Assistance (RMA) from the government, ( also known in your state as [INSERT PROGRAM NAME BASED ON SAMPLE STATE])
97 Other
98 Don’t know
(ASK ALL)
Q91. About how many months in the past year did [you/[INSERT NAME] have health insurance or health care coverage ?
________ [RANGE: 0-12]
98 Don’t know
[PN: Q92-Q95 should be asked if household roster included any children under age of 20 and over the age of 5 and respondent is their parent or guardian (IF ANY Q2(a-j)=4,5,6,12 AND ANY Q4a(a-j)=6 -19)]
Next are a few questions now about your children.
[PN: ASK QUESTIONS 92-97 ABOUT THE OLDEST CHILD IN THE HOUSEHOLD UNDER AGE OF 20 AND OVER AGE 5]
Q92. Was [INSERT CHILD’S NAME] enrolled in school last year?
01 Yes
02 No
98 Don’t know
ASK Q94 ABOUT THE OLDEST CHILD IN THE HOUSEHOLD UNDER AGE OF 20 AND OVER AGE 5]
Q94. Has [INSERT CHILD’S NAME] ever experienced any of the following problems in school in the U.S.:
[PN: ALLOW MULTIPLE RESPONSES – CODES 06, 98 MUTUALLY EXCLUSIVE]
[MARK ALL THAT APPLY]
01 Child’s limited English ability
02 Inadequate school resources to assist child in achieving English proficiency
03 Teachers not well prepared for children from your culture
04 Discrimination
05 Bullying
06 NO PROBLEMS
97 Or some other problem
98 Don’t know
[PN: IF ANY Q2(B-J)=2 INSERT “and your spouse’s”]
Next is a question about your [if applicable: and your spouse's] interaction with your children’s school and how you engaged during the last school year.
(ASK IF Q92=01, 98, OR 99)
[PN: IF ANY Q2(B-J)=2 INSERT “or your spouse”]
Q95. Did you [or your spouse] attend a school event? ( social, sporting, cultural, or educational activity or event)?
01 Yes
02 No
98 Don’t know
Thank you for completing the survey. We have just a couple more questions for you, and then we will ask for your contact information to send you a $30 gift card to thank you for participating.
PIQ1) How easy or difficult was it for you to complete this survey?
01 Very easy
02 Easy
03 Neither easy nor difficult
04 Difficult
05 Very Difficult
98 Don’t Know
PIQ2) When completing the survey did you run into any problems or recall any questions that were hard to understand?
PIQ3) Do you have suggestions on how we could improve the survey?
(0) No
(1) Yes – What would that be? ______________________
PIQ4) If you were offered the choice between completing this survey online or doing a phone survey with an interviewer in [primary language], which would you prefer?
01 Online survey
02 Phone survey
97 No Preference
98 Don’t Know
Thank you. This is the end of the survey. We would like to send you a $30 gift card to thank you for your participation.
What email address should we send this gift card to?
____________________
Thank you again for your time and participation. You can expect to receive the gift card within [XX] weeks.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Karin Kowalski |
| File Modified | 0000-00-00 |
| File Created | 2024-12-24 |