Consumer Price Index: Housing Update Form |
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PLEASE DELETE OR DESTROY AFTER USE |
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OMB No. 1220-0163 |
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BLS Contact: |
<Data Collector's Name> |
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Contact Phone: |
<Data Collector's Phone #> |
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Contact Fax: |
<Data Collector's Fax #> |
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Contact Email: |
<Data Collector's Email> |
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Please Return Form By: |
<Date> |
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Number of Units: |
1 |
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Address: |
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Unit: |
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Is this house/apartment occupied by the owner or is it rented? |
<Select> |
Is this house/apartment Public Housing? |
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<Select Yes or No> |
If Yes, Is it owned or operated by a government agency? |
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<Select Yes or No> |
Is this house/apartment part of an assisted living program? |
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<Select Yes or No> |
If Yes, Does the program provide ADL assistance to an occupant of this house/apartment? |
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<Select Yes or No> |
Is this house/apartment the primary residence of at least one of the occupants? |
<Select Yes or No> |
Is anyone living in the household a relative of the landlord? |
<Select Yes or No> |
How many bedrooms, baths, and other rooms are there? |
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Bedrooms: |
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<#> |
Full Baths: |
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<#> |
Half Baths: |
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<#> |
Other Rooms (E.g., Kitchen, Living Room, Finished Basement, etc.): |
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<#> |
Total: |
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0 |
In what year was this structure built? If the exact year is not known, the decade sufficient. |
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<Enter Year> |
Is this house/apartment under rent control? |
<Select Yes or No> |
When did the person, who has lived in this house the longest, move in? |
<Enter Month and Year> |
Do you/Does the tenant have a lease or other rental agreement? |
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<Select Yes or No> |
If Yes, How long is the current lease agreement? |
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<Select> |
If Yes, and longer than month-to-month, in what month and year did the current lease start? |
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<Enter Month and Year> |
What is the tenant's name OR initials? |
<Enter Name of Occupant> |
How much rent are you/is the tenant paying for this house now? |
<Enter Amount> |
What period of time does that rent cover? |
<Select> |
Is the rent lower because the Landlord receives a subsidy from a government program such as Section 8? |
<Select Yes or No> |
If Yes, how much was the subsidy? |
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<Enter Amount> |
Is the rent lower because someone did work for the landlord? |
<Select Yes or No> |
If Yes, how much was the work reduction? |
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<Enter Amount> |
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Total Rent: |
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$- |
Does this rent include any optional extra charges? |
<Select Yes or No> |
If Yes, what is the amount of the extra charge? |
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<Enter Amount> |
What is this extra charge for? |
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<Enter Name of Charge> |
Does the Landlord provide free off-street parking? |
<Select Yes or No> |
Who pays for the water service? |
<Select> |
Who pays for the sewer service? |
<Select> |
Who pays for the electricity? |
<Select> |
If this is paid by the Tenant, is the cost of electricity included in the rent you reported earlier? |
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<Select Yes or No> |
If Yes, how much is the charge for electricity for this house? |
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<Enter Amount> |
What type of A/C equipment does this unit have? |
<Select> |
If Thru-the-wall A/C, how many does this unit have? |
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<Enter Amount> |
If Window A/C, how many does this unit have? |
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<Enter Amount> |
How many are provided by the Landlord? |
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<Enter Amount> |
What is the primary type of heating fuel used by this unit? |
<Select> |
Who pays for the heating fuel? |
<Select> |
If this is paid by the tenant, is the cost of heat fuel included in the rent you reported earlier? |
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<Select Yes or No> |
If Yes, how much is the charge for the heat fuel this house? |
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<Enter Amount> |
What is the primary type of hot water fuel used by this unit? |
<Select> |
Who pays for the hot water fuel? |
<Select> |
If this is paid by the tenant, is the cost of hot water fuel included in the rent you reported earlier? |
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<Select Yes or No> |
If Yes, how much is the charge for the hot water fuel this house? |
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<Enter Amount> |
Please verify the house/apartment's structure type. |
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<Select> |
If this is a multi unit structure, is there an elevator? |
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<Select Yes or No> |
For future data collection, would you prefer to be contacted by phone or email? |
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<Select> |
What is your preferred contact time? (E.g. weekdays between noon and 3:00PM) |
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<Enter Contact Time> |
What is the best phone number or email address to contact you? |
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<Enter Phone or Email> |
Is there someone else that can answer these questions in the future, if you cannot be reached? |
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<Select Yes or No> |
If Yes, what is this manager/authorized representative's name? |
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<Enter Manager/Rep.'s Name> |
What is this manager/authorized representative's phone number or email? |
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<Enter Phone or Email> |
What is this manager/authorized representative's preferred contact time? |
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<Enter Contact Time> |
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Additional Information: |
The tenant's name is only used to denote occupancy changes, and is not required. |
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Respondent Comments: |
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