Survey number ______
Community Health Survey 1
Instructions to Survey interviewers/ CHA Team:
You may change this survey in any way. You may add or remove questions. It is
just a guide for you. All questions have been pretested and reviewed for accuracy.
So, before changing the wording of the questions, we encourage you to seek
professional advice on questionnaire design.
You must have demographic questions in your survey to be able to tell how
representative your survey sample is. Use these questions to compare your sample
population to your county’s population (from the US Census estimates for that
year). The demographic categories in this survey match the categories from the
2010 Census questions to make your comparisons easier.
Instructions for the interviewers are in red type. Do not read these instructions out
loud when administering the surveys. If these surveys will be self-administered,
you may want to simplify the directions.
Questions similar to or exactly like those from the Behavioral Risk Factor
Surveillance System (BRFSS) 2010 are in blue type. You may take these
questions out of your CHA survey if you have recent county-level BRFSS data
for these questions. Recent data includes data from the year before your
Community Health Assessment is due. Ex: If your CHA is due in December 2011
and you have BRFSS 2010 data for your county, do not include these questions in
your community survey.
This survey explores all of the Healthy Carolinians 2020 focus areas. Questions
that gather information about one or more of the focus areas are noted with
HC2020: Focus Area. If these surveys will be self-administered, you may
want to remove this notation.
Key to Focus Area Abbreviations:
C Cross-cutting
CD Chronic Disease
EH Environmental Health
I Injury
ID/FI Infectious Disease/Foodborne Illnesses
MH Mental Health
MIH Maternal and Infant Health
OH Oral Health
PAN Physical Activity and Nutrition
SA Substance Abuse
SDH Social Determinants of Health
STD/UP STDs/Unintended Pregnancy
T Tobacco
Survey number ______
Community Health Survey 2
2011 Granville-Vance District Community Health Survey
Read the following section to each potential participant:
(Show badges.) Hello, I am _______ and this is ________ representing the Granville-
Vance District Health Department. We are conducting a survey of our county to learn
more about the health and quality of life in Vance County. The Health Department
and the Granville-Vance Community Health Assessment Partners will use the results
of this survey to help address the major health and community issues in our county.
May I come forward to talk to you more about it?
Your address was one of many randomly selected from our county. The survey is
completely voluntary, and it should take about 20 minutes to complete. Your answers
will be completely confidential. The information you give us will not be linked to you in
any way. If you complete this survey, we will enter your name into a drawing for
gift cards and other prizes in early July, and give you a small bag of helpful
information and a few handy items today. Here is an information card for you to
look at while you think about it. (Give the person the ¼ page information card)
Would you like to participate? _____Yes _____ No
(If no, stop the survey here and thank the person for his or her time.)
Eligibility
Do you live in Vance County? _____Yes _____ No
(If no, stop the survey here and thank the person for his or her time.)
Have you participated in this year’s survey already?
_____Yes _____ No _____ Not sure
(If yes or not sure, stop the survey here and thank the person for his or her time.)
If they are able to do the survey, SAY: If there is anything that we ask or say that
you do not understand, or you would like further explanation about any item, please
do not hesitate to ask.
Survey number ______
Community Health Survey 3
Vance County Community Health Survey
PART 1: Quality of Life Statements
Please tell us whether you “strongly disagree”, “disagree”, “neutral”, “agree” or
“strongly agree” with each of the next 6 statements.
HC2020: SDH
Statements
Circle the number that best
represents the person’s opinion of
each statement below.
Strongly Strongly
Disagree Disagree Neutral Agree Agree
1. How do you feel about this statement, “There
is good healthcare in Vance County”?
Consider the cost and quality, number of options, and
availability of healthcare in the county.
1 2 3 4 5
2. How do you feel about this statement,
“Vance County is a good place to raise children”?
Consider the quality and safety of schools and child
care programs, after school programs, and places to
play in this county.
1 2 3 4 5
3. How do you feel about this statement,
“Vance County is a good place to grow old”?
Consider the county’s elder-friendly housing,
transportation to medical services, recreation, and
services for the elderly.
1 2 3 4 5
4. How do you feel about this statement, “There
is plenty of economic opportunity in Vance
County”? Consider the number and quality of jobs,
job training/higher education opportunities, and
availability of affordable housing in the county.
1 2 3 4 5
5. How do you feel about this statement,
“Vance County is a safe place to live”?
Consider how safe you feel at home, in the workplace,
in schools, at playgrounds, parks, and shopping centers
in the county.
1 2 3 4 5
6. How do you feel about this statement, “There
is plenty of help for people during times of need in
Vance County”?
Consider social support in this county: neighbors,
support groups, faith community outreach, community
organizations, and emergency monetary assistance.
1 2 3 4 5
Survey number ______
Community Health Survey 4
PART 2: Community Improvement
Read: The next set of questions will ask about community problems, issues,
and services that are important to you. Remember your choices will not be
linked to you in any way.
7. HC2020: EH, SDH, I, MH
Please look at this list of community issues. (Give person the sheet of community
issues.) In your opinion, which one issue most affects the quality of life in Vance
County? (Please choose only one.) If there is a community problem that you
consider the most important and it is not on this list, please let me know and I will
write it in. If you would like, I can read these out loud as you think about them.
(Read health problems if they prefer to have them read.)
___ Pollution (air, water, land)
___ Dropping out of school
___ Low income/poverty
___ Homelessness
___ Lack of/ inadequate health insurance
___ Hopelessness
___ Discrimination/ racism
___ Lack of community support
___ Drug and Alcohol Abuse
___ Neglect and abuse (Specify type)
___ Elder abuse ___ Child Abuse
___ Domestic Violence
___ Teen Pregnancy
___ Violent crime (murder, assault, etc.)
___ Theft
___ Rape/sexual assault
___ Other: __________________
___ No opinion
8. HC2020: PAN, SDH, I, MH
(Give the person a list of services.) In your opinion, which one of the following
services needs the most improvement in your neighborhood or community?
(Please choose only one.) If there is a service that you think needs improvement
that is not on this list, please let me know and I will write it in. If you would like,
I can read these out loud as you think about them. (Read health problems aloud.)
___ Animal control
___ Child care options
___ Elder care options
___ Services for disabled people
___ More affordable health services
___ Better/ more healthy food choices
___ More affordable/better housing
___ Availability of employment
___ Higher paying employment
___ Number of health care providers
What kind? ______________
___ Culturally appropriate health services
___ Drug and Alcohol Abuse Prevention
___ Counseling/ mental health/ support groups
___ Drug and Alcohol Abuse Treatment
___ Better/ more recreational facilities
(parks, trails, community centers, etc.)
___ Healthy family activities
___ Positive teen activities
___ Transportation options
___ Road maintenance
___ Road safety
___ Other: __________________
___ None
Survey number ______
Community Health Survey 5
Part 3. Health Information
9. HC2020: PAN, SA, I, MH, MIH, OH, STD/UP, ID/FI, T
In your opinion, which one health behavior do people in your own community
need more information about? (Please suggest only one.) (DO NOT read the
options. Mark only the one they say. IF they cannot think of one, give them the list
and offer to read the choices; explain we can write in other answers.
___Going to a dentist for check-ups / preventive care
___ Going to the doctor for yearly check-ups and screenings
___ Getting prenatal care during pregnancy
___Getting flu shots and other vaccines
___ Quitting smoking / Tobacco use prevention
___ Domestic violence prevention
___ Rape/ sexual abuse prevention
___ Caring for family members with special needs/ disabilities
___ Preventing pregnancy /sexually transmitted disease (safe sex)
___ Substance abuse prevention (ex: drugs and alcohol)
___ Preparing for an emergency/ disaster
____ Other: _________________
__ None
10. Where do you get most of your health-related information? Please choose only
one. (DO NOT read the options. Mark only the one they say. IF they cannot think of
one, give them the list, offer to read the choices; explain we can write in others.
Choose only one please.)
____ Friends and family ____ Hospital
____ Doctor/nurse ____ Health department
____ Pharmacist ____ Help lines
____ Church ____ Books/magazines
____ Internet ____ Other _____
____ My child’s school
11. What health topic(s)/ disease(s) would you like to learn more about?
(Write in all suggestions.)
________________________________________________________________________
12. Do you have children between the ages of 9 and 19 for which you are the
caretaker? (Includes step-children, grandchildren, or other relatives.)
____ Yes ____ No (skip to question #14)
____ (Do not read.) Refused to answer (skip to question #14)
Survey number ______
Community Health Survey 6
13. HC2020: PAN, SA, I, MH, OH, STD/UP, CD, T
Which of the following health topics do you think your child/children need(s)
more information about? (Read list. Allow time for a yes or no following each
item. Check all that apply.)
a.___ Dental hygiene f.___ Tobacco k.___ Reckless driving/speeding
b.___ Sexual intercourse g.___ STDs l.___ Mental health issues
c.___ Eating Disorders h.___ Nutrition m.___ Suicide prevention
d.___ Asthma management i.___ Alcohol n. Other ________________
e.___ Diabetes management j.___ Drug Abuse o. ___ None of the above
PART 4: Personal Health
These next questions are about your own personal health. Remember, the answers
you give for this survey will not be linked to you in any way.
14. HC2020: C
Would you say that, in general, your health is…
(Read choices and ask them to choose only one.)
_____ Excellent ____ Fair
_____ Very good ____ Poor
_____ Good ____ Don’t know/Not sure
_____ (Do not read.) Refused to answer
If the person being interviewed starts talking about a family member’s health problems… I am
sorry to hear about that. Maybe some of the answers you give today will help us and our community
leaders address some of these types of issues. Right now we’d like to focus just on your own health.
15. HC2020: CD, PAN, MH
Have you ever been told by a doctor, nurse, or other health professional that you
have any of the health conditions I am going to read?
(DK= Don’t know/ Not sure; R= Refuse to answer)
a. Asthma ____ Yes ____ No ____ DK ____R
b. Depression or anxiety ____ Yes ____ No ____ DK ____R
c. High blood pressure ____ Yes ____ No ____ DK ____R
d. High cholesterol ____ Yes ____ No ____ DK ____R
e. Diabetes (not during pregnancy) ____ Yes ____ No ____ DK ____R
f. Osteoporosis ____ Yes ____ No ____ DK ____R
g. Overweight/Obesity ____ Yes ____ No ____ DK ____R
h. Angina/ heart disease ____ Yes ____ No ____ DK ____R
i. Cancer ____ Yes ____ No ____ DK ____R
Survey number ______
Community Health Survey 7
16. HC2020: MH
In the past 30 days, have there been any days when feeling sad or worried
kept you from going about your normal business?
____ Yes ____ No
____ Don’t know/ Not sure _____ (Do not read.) Refused to answer
17. HC2020: I, CD
In the past 30 days, have you had any physical pain or health problems that
made it hard for you to do your usual activities such as driving, working around
the house, or going to work?
____ Yes _____ No
____ Don’t know/ Not sure _____ (Do not read.) Refused to answer
18. HC2020: PAN
Now I will ask about your fitness. During a normal week, other than in your
regular job, do you engage in any physical activity or exercise that lasts at least a
half an hour?
____ Yes ____ No (Skip to question #21)
____ Don’t know/ Not sure ____ (Do not read.) Refused to answer
(Skip to question #21 for Don’t know or Refused to answer)
19. HC2020: PAN
Since you said yes, how many times do you exercise or engage in physical activity
during a normal week? _______ (Write number)
(If you exercise more than once a day, count each separate physical activity that lasts
for at least a half hour to be one “time.”)
20. HC2020: PAN
Where do you go to exercise or engage in physical activity? Check all that apply.
a.____ YMCA d.____ Private gym
b.____ Park e.____ Home
c.____ Public Recreation Center f.____ Other: _____________
Skip to question #22
Survey number ______
Community Health Survey 8
21. HC2020: PAN Since you said “no”, what are the reasons you do not exercise for
at least a half hour during a normal week? You can give as many of these reasons
as you need to. (DO NOT read the options. Mark only the ones they say. If they
really can’t think of one, then mark I don’t know.)
a.____ My job is physical or hard labor
b.____ Exercise is not important to me.
c.____ I don’t have access to a facility that has
the things I need, like a pool, golf course,
or a track.
d.____ I don’t have enough time to exercise.
e.____ I would need child care & I don’t have it.
f.____ I don’t know how to find exercise
partners.
g.____ I don’t like to exercise.
h.____ It costs too much to exercise
i. ____ There is no safe place to exercise.
j. ____ I’m too tired to exercise.
k.____ I’m physically disabled.
l. ____ I don’t know
m. ____Other __________
22. HC2020: PAN
Not counting lettuce salad or potato products, think about how often you eat fruits and
vegetables in an average week… (It is easier for most people to work up to the amount in a week.
Start with 1) Do you eat fruit? 2) How often? 3) If an apple represents a serving, how many in a
typical day do you have? This should get you to how many in a week. Then do the same for veggies.
Then ask: Do you drink juice? If yes, Is it 100% fruit juice?... BE SURE to check how much at 1 time)
►How many cups per week of fruits and vegetables would you say you eat? ◄
(One apple or 12 baby carrots equal one cup) (Write # of cups in the space provided.)
a. Number of cups of fruit _____ c. ____ Never eat fruit
b. Number of cups of vegetables _____ d.____ Never eat vegetables
e. Number of cups 100% fruit juice _____ f. ____ Never drink 100% fruit juice
If you get questions about lettuce salad: Lettuce salad is the typical “house salad” with iceberg
lettuce, or the salad mixes you get at the store or fast food restaurants, even with meat on top.
If you get questions about potato products: Potato products are French fries, baked
potatoes, hash browns, mashed potatoes ~ anything made from white potatoes.
In case you get this question:
For the purposes of this study, ketchup is not considered a vegetable.
23. HC2020: T
Have you been exposed to secondhand smoke in the past year?
___ Yes ___(Do not read.) Refused to answer (Skip to question #25)
___No (Skip to question #25) ___Don’t know/ Not sure (Skip to question #25)
Survey number ______
Community Health Survey 9
24. HC2020: T
If yes, where do you think you are exposed to secondhand smoke most often?
(Check only one place)(Wait for the answer and if they don’t know what to say,
read the list).
a.____ Home e.____ School
b.____ Workplace f.____ Other: ________________________
c.____ Hospitals .
d.____ Restaurants
25. HC2020: T
Do you currently smoke? (Include regular smoking in social settings.)
____Yes ____ No (If no, skip to question #27)
_____ (Do not read.) Refused to answer
26. HC2020: T
If yes, where would you go for help if you wanted to quit?
(DO NOT read the options. Choose only one.
If they cannot think of one, mark I don’t know)
a.____ Quit Line NC
b.____ Doctor
c.____ Church
d.____ Pharmacy
e.____ Private counselor/therapist
f.____ Health Department
g.____ I don’t know
h.____ Other: ____________________
i.____ NA; I don’t want to quit
27. HC2020: ID/FI
Now I will ask you questions about your personal flu vaccines. An influenza/flu
vaccine can be a “flu shot” injected into your arm or spray like “FluMist” which
is sprayed into your nose.
►During the past 12 months, have you had a seasonal flu vaccine?◄
____ Yes, flu shot
____ Yes, flu spray
____ Yes, both
____ No
____ Don’t know / Not sure
____ Refused to answer (Do not read.)
Survey number ______
Community Health Survey 10
Part 5. Access to Care/ Family Health
28. Where do you go most often when you are sick? (DO NOT read the options.
Mark only the one they say. If they cannot think of one, read: Here are some
possibilities. Read responses. Choose only one please.)
_____ Doctor's office _____ Medical Clinic
_____ Health department _____ Urgent Care Center
______ Hospital Other:_______________ ______ Refused to answer
29. HC2020: C
Do you have health insurance? If yes, What is your primary health insurance
plan? (This is the plan which pays the medical bills first, or pays most of the
medical bills). (Please choose only one.)
[Note: The State Employee Health Plan is also called the “North Carolina Teacher’s and
Employee Health Plan.”
Medicare is a federal health insurance program for people 65 and older, or some younger
people with disabilities.
Medicaid is a state health insurance program for families and individuals with limited
financial resources or special circumstances.]
a. ___ The State Employee Health Plan
b. ___ Blue Cross and Blue Shield of North Carolina
c. ___ Other private health insurance plan purchased from employer or workplace
d. ___ Other private health insurance plan purchased directly from an insurance company
e.___ Medicare
f.___ Medicaid or Carolina ACCESS or Health Choice 55
g.___ The military, Tricare, CHAMPUS, or the Veteran’s Administration (VA)
h.___ The Indian Health Service
i. ___ Other (government plan)
j. ___ No health plan of any kind
Do not read: k.___ Don't know/Not sure l. ___ Refused to answer
30. HC2020: C, OH
In the past 12 months, did you have a problem getting the health care you
needed for you personally or for a family member from any type of health care
provider, dentist, pharmacy, or other facility?
____ Yes ____ (Do not read.) Refused to answer (Skip to question #33)
____ No (Skip to question #33) ____ Don’t know/ Not sure (Skip to question #33)
Survey number ______
Community Health Survey 11
31. HC2020: C
Since you said “yes”… What type of provider or facility did you, or your family
member, have trouble getting health care from?
You can choose as many of these as you need to. If there was a provider that you tried to
see but we do not have listed here, please tell me and I will write it in. (Read Providers.)
____ Dentist
____ General practitioner
____ Eye care/ optometrist/ ophthalmologist
____ Pharmacy/ prescriptions
____ Pediatrician
____ OB/GYN
____ Health department
____ Hospital
____ Urgent Care Center
____ Medical Clinic
____ Specialist (What type?) ________________
32. HC2020: C
Which of these problems prevented you or your family member from getting the
necessary health care?
You can choose as many of these as you need to. If you had a problem that we do
not have written here, please tell me and I will write it in. (Read Problems.)
a. ___ No health insurance.
b. ___ Insurance didn’t cover what I/we needed.
c. ___ My/our share of the cost (deductible/co-pay) was too high.
d. ___ Doctor would not take my/our insurance or Medicaid.
e. ___ Hospital would not take my/our insurance.
f. ___ Pharmacy would not take my/our insurance or Medicaid.
g. ___ Dentist would not take my/our insurance or Medicaid.
h. ___ No way to get there.
i. ___ Didn’t know where to go.
j. ___ Couldn’t get an appointment.
k. ___ The wait was too long.
l. ___ Other: ____________________
Survey number ______
Community Health Survey 12
33. HC2020: MH
If a friend or family member needed counseling for a mental health or a
drug/alcohol abuse problem, who is the first person you would tell them to talk to?
(DO NOT read the options. If they can’t think of anyone, say…
Here are some possibilities. Please choose only one. Read responses.)
a.____ Private counselor or therapist e.____ Doctor
b.____ Support group (e.g., AA. Al-Anon) f.____ Minister/religious official
c.____ School counselor g.____ Mental Health Agency
d.____ Don’t know h.____Other: __________________
i. ____(Do not read) Prefer not to respond
Part 6. Emergency Preparedness
34. Does your household have working smoke and carbon monoxide detectors?
(Mark only one.)
___ Yes, smoke detectors only ___ Yes, carbon monoxide detectors only
___ Yes, both ___ No
___ Don’t know/ Not sure ___ (Do not read.) Refused to answer
35. Does your family have a basic emergency supply kit?
(These kits include water, non-perishable food, any necessary prescriptions, first
aid supplies, flashlight and batteries, non-electric can opener, blanket, etc.)
___ Yes ___ Don’t know/Not sure (Skip to question 37)
___ No (Skip to question 37)
___ (Do not read.) Refused to answer (Skip to question 37)
36. If yes, how many days do you have supplies for? _______ (Write number of days)
37. In a large-scale disaster or emergency, what would be your main way of
communicating with family? (Check only one.) (Do not read choices)
___ a. Regular home phone ___ e. 2-way radio
___ b. Cell phone ___g. Other (describe) ________________
___ c. Email ___ h. Don’t know/ Not sure
___ d. Pager ___ i. (Do not read.) Refused to answer
Survey number ______
Community Health Survey 13
38. What would be your main way of getting information from authorities in a
large-scale disaster or emergency? (Check only one.) (Do not read choices; if they
can’t answer, mark “Don’t know”.
___ a. Television ___ f. Neighbors
___ b. Radio ___g. Text message (emergency alert system)
___ c. Internet ___ h. Other (describe) ________________
___ d. Print media (ex: newspaper) ___ i. Don’t know/ Not sure
___ e. Social networking site ___j. (Do not read.) Refused to answer
39. If public authorities announced a mandatory evacuation from your
neighborhood or community due to a large-scale disaster or emergency, would
you evacuate?
___ Yes (Skip to question #41)
___ No (Go to question #40)
___ Don’t know/ Not sure (Go to question #40)
___ (Do not read.) Refused to answer (Go to question #40)
40. What would be the main reason you might not evacuate if asked to do so?
(Check only one.) (Do not read choices; if they can’t answer, mark “Don’t know”.
___ a. Lack of transportation ___g. Concern about traffic jams & inability
to get out
___ b. Lack of trust in public officials ___h. Health problems (could not be moved)
___ c. Concern about leaving property behind
___ d. Concern about personal safety ___ i. Other (describe) _________________
___ e. Concern about family safety ___ j. Don’t know/ Not sure
___ f. Concern about leaving pets ___k. (Do not read.) Refused to answer
Part 7. Demographic Questions
The next set of questions are general questions about you, which will only be reported as a
summary of all answers given by survey participants. Your answers will remain anonymous.
41. How old are you? (Mark age category.)
_____ 18 - 19 _____ 35 - 39 _____ 55 - 59 _____ 75 - 79
_____ 20 - 24 _____ 40 - 44 _____ 60 - 64 _____ 80 - 84
_____ 25 - 29 _____ 45 - 49 _____ 65 - 69 _____ 85 or older
_____ 30 - 34 _____ 50 - 54 _____ 70 - 74
_____ (Do not read.) Refused to answer
Survey number ______
Community Health Survey 14
42. Are you Male or Female? (In most cases, this question can be answered by the
interviewer without asking.)
____Male ____Female ____ (Do not read.) Refused to answer
43. a) Are you of Hispanic, Latino, or Spanish origin?
____Yes ____ No (If no, skip to #43)
____ (Do not read.) Refused to answer
b) If yes, are you: (Check all that apply)
_____ Mexican, Mexican American, or Chicano
_____ Puerto Rican
_____ Cuban
_____ Other Hispanic or Latino (please specify)__________
____ (Do not read.) Refused to answer
44. What is your race? (Please check all that apply.)
(If other, please write in the person’s race.)
_____White
_____Black or African American
_____American Indian or Alaska Native (List tribe(s) including Lumbee)________
_____Asian Indian
_____Other Asian including Japanese, Chinese, Korean, Vietnamese, and Filipino/a:
(write in race) ________________
_____Pacific Islander including Native Hawaiian, Samoan, Guamanian/ Chamorro:
(write in race)________________
_____Other race not listed here: (write in race)________________
_____(Do not read.) Refused to answer
45. A. Do you speak a language other than English at home? (If no, skip to #46.)
___Yes ___No
____ (Do not read.) Refused to answer
B. If yes, what language do you speak at home? _________________________
Survey number ______
Community Health Survey 15
46. What is your marital status? (Read categories. Mark only one. No explanation
needed for “other”.)
_____ Never Married/Single _____ Divorced
_____ Married _____ Widowed
_____ Unmarried partner _____ Separated
_____ Other _____ (Do not read.) Refused to answer
47. HC2020: SDH
What is the highest level of school, college or vocational training that you have
finished? (Mark only one.)
_____ Less than 9
th
grade
_____ 9-12
th
grade, no diploma
_____ High school graduate (or GED/ equivalent)
_____ Associate’s Degree or Vocational Training
_____ Some college (no degree)
_____ Bachelor’s degree
_____ Graduate or professional degree
_____ Other: ___________________________
_____ (Do not read.) Refused to answer
48. HC2020: SDH
What was your total household income last year, before taxes? Let me know
which category you fall into. (Read choices. Mark only one.)
_____ Less than $10,000 _____ $35,000 to $49,999
_____ $10,000 to $14,999 _____ $50,000 to $74,999
_____ $15,000 to $24,999 _____ $75,000 to $99,999
_____ $25,000 to $34,999 _____ $100,000 or more
_____ (Do not read.) Refused to answer
49. HC2020: SDH
Including yourself, how many people does this income support? _________
(If you are asked about child support, say: If you are paying child support but
your child is not living with you, this still counts as someone living on your
income.)
Survey number ______
Community Health Survey 16
50. HC2020: SDH
What is your employment status? I will read a list of choices. Let me know
which ones apply to you. (Read choices. Check all that apply.)
a._____ Employed full-time g._____ Disabled
b._____ Employed part-time h._____ Student
c._____ Retired i._____ Homemaker
d._____ Armed forces j._____ Self-employed
e._____ Unemployed for more than 1 year k._____ Unemployed for 1 year or less
f._____ (Do not read.) Refused to answer
51. Do you have access to the Internet?
____ Yes ____ No
____ Don’t know/ Not sure ____ (Do not read.) Refused to answer
52. What is your zip code? (Write only the first 5 digits.) ____________________
(Read) These are all the questions that we have. Thank you so much for taking
the time to complete this survey! THE END.
DO NOT READ, for administrative purposes only. Remove for self-administered surveys:
Based on total household income (#47) and number of people supported (#48).
Percent of Federal Poverty Level = (Income/Guideline*100%) = _____%
[Get conservative estimate by assuming the mean income level for each category in #47
and compare to guideline for number of persons in family.]
The 2010 Poverty Guidelines for the
48 Contiguous States and the District of Columbia
Persons in family
Poverty guideline
1
$10,830
2
14,570
3
18,310
4
22,050
5
25,790
6
29,530
7
33,270
8
37,010
For families with more than 8 persons, add $3,740 for each additional person.