Attachment XI Shuttle Form - English

Consumer Price Index Housing Survey

ATT_XI_Housing Shuttle Form - English.xlsb

OMB: 1220-0163

Document [xlsb]
Download: xlsb | pdf
Consumer Price Index: Housing Update Form
PLEASE DELETE OR DESTROY AFTER USE

OMB No. 1220-0163



BLS Contact: <Data Collector's Name>



Contact Phone: <Data Collector's Phone #>



Contact Fax: <Data Collector's Fax #>



Contact Email: <Data Collector's Email>



Please Return Form By: <Date>



Number of Units: 1



Address:
Unit:
Is this house/apartment occupied by the owner or is it rented? <Select>
Is this house/apartment Public Housing?



<Select Yes or No>
If Yes, Is it owned or operated by a government agency?



<Select Yes or No>
Is this house/apartment part of an assisted living program?



<Select Yes or No>
If Yes, Does the program provide ADL assistance to an occupant of this house/apartment?



<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?
Bedrooms:
<#>
Full Baths:
<#>
Half Baths:
<#>
Other Rooms (E.g., Kitchen, Living Room, Finished Basement, etc.):
<#>
Total:
0
In what year was this structure built? If the exact year is not known, the decade sufficient.



<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?



<Select Yes or No>
If Yes, How long is the current lease agreement?



<Select>
If Yes, and longer than month-to-month, in what month and year did the current lease start?



<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?



<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?



<Enter Amount>



Total Rent:
$-
Does this rent include any optional extra charges? <Select Yes or No>
If Yes, what is the amount of the extra charge?



<Enter Amount>
What is this extra charge for?



<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?



<Select Yes or No>
If Yes, how much is the charge for electricity for this house?



<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?



<Enter Amount>
If Window A/C, how many does this unit have?



<Enter Amount>
How many are provided by the Landlord?



<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?



<Select Yes or No>
If Yes, how much is the charge for the heat fuel this house?



<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?



<Select Yes or No>
If Yes, how much is the charge for the hot water fuel this house?



<Enter Amount>
Please verify the house/apartment's structure type.



<Select>
If this is a multi unit structure, is there an elevator?



<Select Yes or No>
For future data collection, would you prefer to be contacted by phone or email?



<Select>
What is your preferred contact time? (E.g. weekdays between noon and 3:00PM)



<Enter Contact Time>
What is the best phone number or email address to contact you?



<Enter Phone or Email>
Is there someone else that can answer these questions in the future, if you cannot be reached?



<Select Yes or No>
If Yes, what is this manager/authorized representative's name?



<Enter Manager/Rep.'s Name>
What is this manager/authorized representative's phone number or email?



<Enter Phone or Email>
What is this manager/authorized representative's preferred contact time?



<Enter Contact Time>






Additional Information: The tenant's name is only used to denote occupancy changes, and is not required.
Respondent Comments:








File Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet

© 2025 OMB.report | Privacy Policy