[Federal Register Volume 60, Number 57 (Friday, March 24, 1995)]
[Notices]
[Pages 15589-15595]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: X95-40324]
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DEPARTMENT OF LABOR
Office of the Secretary
Title of Proposed Information Collection
AGENCY: Office of the Secretary, Labor.
ACTION: To permit collection of information on the needs of enrollees
of the Senior Community Service Employment Program so it is available
in time for the White House Conference on Aging and for reauthorization
of the Older Americans Act.
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SUMMARY: The Employment and Training Administration, Department of
Labor, in carrying out its responsibilities under the Paperwork
Reduction Act (44 U.S.C. Chapter 35, 5 CFR 1320 [53 FR 16618, May 10,
1988]), is submitting a brief description of the need for the
information to be collected, including the use to which it is planned
to be put.
DATES: The Employment and Training Administration has requested an
expedited review of this submission under the Paperwork Reduction Act;
the Office of Management and Budget (OMB) review of this proposed
survey has been requested to be completed by March 29, 1995.
FOR FURTHER INFORMATION CONTACT:
Comments and questions regarding the Senior Community Service
Employment Program Needs Assessment should be directed to Mr. Kenneth
A. Mills, Departmental Clearance Officer, Office of Information
Resource Management Policy, U.S. Department of Labor, 200 Constitution
Avenue, NW., Room N-1301, Washington, DC 20210, 202 219-5095. Comments
should also be sent to OMB, Office of Information and Regulatory
Affairs, Attn: OMB Desk Officer for ETA, NEOB Room 10235, Washington,
DC 20503, 202 395-7316. Any member of the public who wants to comment
on the information collection request which has been submitted to OMB
should advise Mr. Mills of this intent at the earliest possible date.
Average Burden Hours/Minutes per Response: 30 minutes.
Frequencey of Response: One-time.
Number of Respondents: 2,000.
Total Annual Burden Hours: 1,000.
Total Annual Responses: 2,000.
Affected Public: Individuals or households.
Respondents Obligation to Reply: Voluntary.
Signed at Washington, DC this 20th day of March 1995.
Theresa M. O'Malley,
Acting Departmental Clearance Officer.
Appendix--Supporting Statement for Paperwork Reduction Act Submissions
A. Justification
1. Circumstances that make the collection of information necessary.
There are two events which make the collection of the information
necessary. The first is the White House Conference on Aging. It would
be useful to have information on individuals enrolled in the Senior
Community Service Employment Program in time for recommendations/
resolutions to be based on factual information.
This survey instrument would provide solid information on the needs
of SCSEP enrollees. The second is the reauthorization of the Older
Americans Act. The subcommittee has informally indicated they plan
hearings in late May/early June. The information would provide positive
hard data about the needs of the enrollees as insights to the programs
success in meeting those needs.
2. How collected, by whom, how frequently, and for what purpose the
information is to be used. This request is for a one-time collection.
As indicated above the information will be used for two purposes--the
White House Conference on Aging and the [[Page 15590]] Reauthorization
of the Older Americans Act.
The data would be collected by grantee staff taking the
questionnaire to the enrollees work site for completion. The enrollee
would seal the envelop after completion and it would be returned to the
Department for compiling and interpreting by Defense Technologies
Incorporated.
The current collection of data on the SCSEP is very limited to
summary data which cannot be analyzed to provide insights to the
enrollees needs for individual cohorts.
3. Information technology used to reduce burden, as well as any
technical or legal obstacles to reducing burden. This is a one-time
request which is to be completed by the enrollee and not the grantee.
The individuals selected will be representative of the universe of
enrollees in the SCSEP. Although the actual collection itself does not
lend itself to automation, the questionnaire has been set up in a
manner which expedites the imputing and analysis of the data.
4. Similar information already available. There is no other similar
data being collected involving the SCSEP enrollees.
5. Impact on small businesses or other small entities. This ICR
does not involve small businesses.
6. Consequence to Federal program or policy activities if the
collection is not conducted or is conducted less frequently. If the
data is not collected, it will not be possible to utilize the results
for analyzing the needs of the enrollees for either the White House
Conference on Aging or in the Reauthorization of the Older Americans
Act. In addition, if the data is not collected, it will not be possible
to use it for internal discussions about how to best meet the needs of
the enrollees at the community level.
7. Special circumstances that require the collection to be
conducted in a manner inconsistent with the general information
collection guidelines in 5 CFR 1320.6 (e.g., payment to respondents,
disclosure of proprietary information, etc.). This request is
consistent with 5 CFR 1320.6.
8. Consultations with persons outside the agency to obtain their
views on the availability of data, frequency of collection, the clarity
of instructions and record keeping, disclosure, or reporting format (if
any), and on the data elements to be recorded, disclosed, or reported.
The Department consulted widely with all the organizations dealing with
older workers, including the National Association of the State Units on
Aging, the American Association of Retired Persons, Green Thumb,
National Association for Hispanic Elderly, the National Caucus and
Center on Black Aged, the National Council on Aging, the National
Indian Council on Aging, the National Pacific/Asian Center on Aging,
the National Urban League, the National Council of Senior Citizens, and
the U.S. Department of Agriculture's Forest Service.
All organizations listed have been provided the opportunity to
suggest modifications or revisions to questions. The development of the
questionnaire grew out of an effort by one of the grantee
organizations, Green Thumb, Inc., to obtain information which could be
summarized and submitted to describe the needs of enrollees of the
Senior Community Service Employment Program at a series of three mini-
White House Conference on Aging meetings. Based upon the
recommendations of other grantee organizations, it was agreed that a
more thorough collection effort could provide valuable representative
information for a variety of purposes. This is a one-time request which
does not require multiple collections by grantees or contacts with
enrollees.
9. Confidentiality provided to respondents and the basis for the
assurance in statute, regulation, or agency policy. The individual
enrollee will receive a cover letter that will explain that the
information is provided on a voluntary basis and the responses will be
handled on a confidential basis. To ensure that this occurs, the
enrollee will seal the envelop provided after completion. No one will
know which responses are attributable to a specific individual.
10. Sensitive nature of questions. The proposed questionnaire does
not contain questions on such topics as sexual behavior and attitudes,
religious beliefs, and other matters that are commonly considered
private.
11. Estimates of cost.
a. Federal Government. The cost to the Federal Government will be
as follows:
(1) Printing. 2,000 Questionnaires .03 per page x 16 pages=$960.
(2) Support Staff required for Compiling/Mailing. 10 hours x GS-7
salary of $13.46/hour=134.60.
(3) Analysis. $12,000 for Defense Technologies Inc. to input the
data and determine significance of data.
b. Grantee. The costs to the grantee will be minimal since they
must send some one to the individual's work site to assess the progress
being made by the enrollee. This visit would coincide with the delivery
of the questionnaire.
c. Enrollee. This questionnaire will be completed at the work site.
There will be no cost to the enrollee.
12. Estimates of the burden of the collection of information.
a. Number of Respondents. 2,000.
b. Frequency of Response. Once.
c. Annual Burden. 30 minutes x 2,000 enrollees=1,000 hours. Time
requirements were based on a pre-test of the survey instrument.
13. Amendments to existing collections. This is a new data
collection for ETA that will count as a +1,000 PC hours towards ETA's
Information Collection Budget (ICB).
14. Plans for publication. Not Applicable. Information collected
will be used for policy recommendations and program operations.
B. Collections of Information Employing Statistical Methods
1. Sampling method. The information would be collected using
accepted statistical sampling techniques. A three-part process will be
employed involving three strata--States, minority national sponsors,
and the remaining national sponsors. All participants would have some
chance of being selected under the proposed sample design. Before
beginning the process of selecting the sample, it was determined that a
sample of 2,000 respondents would be required to provide sufficient
data to generalize conclusions to the SCSEP population. This decision
was driven somewhat by the need to obtain a sample size sufficiently
large for minority populations (American Indian, Asian-Pacific
Islanders and Hispanics) which formed less than 15 percent of the total
number of older workers served by the program.
State Strata. An initial determination was made that ten States
would provide a sufficient number of States to be representative of all
States. Since the allocation of slots to States represents 22 percent
of the total, a rounded figure of 20 percent was applied to the total
sample to derive a State sample of 400 respondents. The number of cases
was equally divided between the ten States selected or 40 respondents
per State selected. Then the States were arrayed by the number of slots
provide to each and the cumulative number of slots was posted
throughout the list. This was followed by selecting a skip interval of
1,500. This was based on the total number of slots in all of the States
(14,901 rounded to 15,000) and 10 States (15,000 slots divided by 10
States=1,500 skip interval). A random start number between 1 and 1,500
was selected to identify the first State. For example, if the random
number was [[Page 15591]] 200, the State with a cumulative range that
included the number 200 would be selected. Subsequent selections were
made by adding 200 to the random start number. The result was to select
the following State clusters:
CA, NY, TX, OH, NJ, MO, HI, AL, MD & VI=400 cases National Strata.
As noted above, 20 percent of the sample was assigned to the States;
therefore, the remaining 80 percent of the sample was assigned to the
national sponsors in line with the number of SCSEP slots allocated to
them. The selection of the National Sponsors followed a two-part
process. Each sponsor was treated as a stratum. Three minority grantees
were designated as certainty strata to ensure that a sufficient number
of hits would occur. Each of the three minority grantees was assigned a
sample size of 100 respondents. The remainder of the sample was
assigned to the other national sponsors on a proportional basis. This
resulted in the following sample:
Certainty Strata 100 each=300 cases (minority sponsors)
Proportional sample range 437-53 cases (remaining national sponsors)
depending on no. of slots per grantee=1300 total cases
Estimation procedure. The results of the survey will be reported as
proportions (expressed as percentages). For example, for question one,
xx.x% of the respondents were with the SCSE Program 5 years of more,
yy.y% were with the program more than 2 years but less than 5 years,
etc.
1. Sample Proportions. A sample proportion (p) for each survey item
category is computed by:
[GRAPHIC][TIFF OMITTED]TN24MR95.009
where x is a random variable that equals 1 if the ith sample respondent
selects the particular category and equals 0 otherwise, and n is the
sample size.
The variance is a measure of variability, that is, the different
values that a sample statistic like the proportion can have, given the
size of the sample and the true (population) proportion. Because the
population proportion is unknown, it is estimated by the sample
proportion, p. The estimated variance of p, V(p), is computed by:
V(p)=[(p(1-p))/(n-1)]*[1-(n/N)] [2].
The term [1-(n/N)] is the finite population correction factor,
which takes into account the reduction in the sampling variance
attributable to the proportion of the population that is sampled.
2. Cluster Samples. A two-stage sample was selected for the State
sponsors. The primary sampling units (PSU) were selected with
probabilities proportional to size (pps). A fixed number of 40 cases
were selected from each of the PSU's in the second stage in order to
maintain a constant overall sampling fraction. The estimated proportion
for a sample selected pps is:
[GRAPHIC][TIFF OMITTED]TN24MR95.003
where pi is the sample proportion for cluster i, given by [1], and
m is the number of clusters (PSU) selected in the first stage.
The estimated variance of ppps is:
[GRAPHIC][TIFF OMITTED]TN24MR95.004
The finite correction factor has been omitted because the overall
sampling fraction of 400/15,000 has a negligible effect on the
variance.
3. Stratified Samples. Survey respondents are selected from several
organizations, which are treated as strata for the purposes of
estimating survey statistics. Because a sample of 100 cases is selected
from three minority organizations, the sample is not proportional for
all national strata. The estimates are therefore weighted to reflect
the contribution of each strata to the national estimate. Weights are
computed by the formula:
Wh=Nh/N [5],
where Nh is the size of the strata (the number of members for
national sponsor h) and N is the total number of members for all of the
national sponsors.
The weighted proportion is computed by:
[GRAPHIC][TIFF OMITTED]TN24MR95.005
where ph is the sample proportion for stratum h, given by [1].
The estimated variance of pw is:
[GRAPHIC][TIFF OMITTED]TN24MR95.006
Note: V(ph)=is given by equation [2] or [4] as appropriate
[7]. Degree of accuracy needed for the purpose described in the
justification. 95 percent confidence intervals for survey estimators
are constructed by 1.96*sqrt[V()],
where is an estimator such as pw and
sqrt[V()] is the square root of the estimated variance of
.
2. Procedures for the collection of information.
a. Sample selection. The Department would provide instructions to
the grantees involved on how to select a sample from among their
records using a random numbering table.
b. How delivered. The sponsor's representative (either staff or
enrollees) would hand-carry the questionnaire to the host agency
community service assignment site for completion by the participant or
with the assistance of the sponsor's representative.
c. How collected: The SCSEP participants would return the
questionnaire to the sponsor's representative after completion or if
the participant is not functionally literate, the sponsor's
representative would verbally administer the questionnaire on site.
This would ensure responses are obtained from the SCSEP participant in
a timely manner. Note: since the questions are almost entirely
objective, interview bias should not be a major concern.
d. How provided to the Department of Labor. The sponsor would
insert the completed questionnaires in an envelop and return them to
the Department without any attempt to analyze the individual
questionnaires.
3. Methods to maximize response rates and to deal with issues of
non-response. As indicated above, the questionnaires will be hand-
delivered to the enrollee work site and completed while the project
worker is discussing enrollee progress with the host agency. The
response rate is anticipated to be 90 percent or better based on a
pretest in which all respondents completed and returned the
questionnaires.
4. Tests of procedures or methods to be undertaken. An informal
pretest of twenty individuals was undertaken to ensure that the
questionnaire could be easily understood.
[[Page 15592]] 5. Individuals consulted on the design of the
questionnaire and/or statistical methodology.
Lawrence Crecy............ 202-637-8400 National Caucus and Center for Black Aged.
Donald Davis.............. 202-637-8400 National Council on the Aging.
Michael Flor.............. 206-624-1221 National Asian-Pacific Center on Aging.
Dorinda Fox............... 202-624-9507 National Council of Senior Citizens.
Robert Mizerak............ 212-310-9120 National Urban League.
Glenn Northup............. 202-434-2277 American Association of Retired Persons.
Henry Rodriquez........... 213-487-1922 Association Nacional Pro Personas Mayores.
Andrea Wooten............. 703-522-7272 Green Thumb, Inc.
Robert Casady............. 202-606-7370 Bureau of Labor Statistics.
Roberta Sanster........... 202-606-7517 Bureau of Labor Statistics.
U.S. Department of Labor,
Employment and Training Administration, 200 Constitution Avenue,
NW., Washington, DC 20210
Dear Enrollee: Welcome to the Department of Labor's White House
Conference on Aging Needs Assessment Team!
The enclosed questionnaire has been developed to determine the
employment and training, health, and housing related needs of the
Senior Community Service Employment Program (SCSEP) enrollees. You
play a critical role in the first comprehensive needs assessment of
SCSEP enrollees. No one is required to complete this questionnaire.
You are being asked to complete it voluntarily. However, your
responses are important to us since you were selected on a
statistically random basis. This means your responses represent
hundreds of other enrollees' needs as well as your own. We are
asking you to complete the survey so we can learn how to meet more
effectively your needs and the needs of others like you.
Please answer each question by circling the number of the
response which most accurately reflects your situation. There are no
right or wrong answers. Just answer the question honestly. Your name
will not be on the survey, so no one will know what answers you
give. If you have any questions at any time during the survey,
please direct them to the individual who provided this questionnaire
to you.
The results of the survey will be shared with the delegates to
the White House Conference on Aging in May 1995. In addition, the
summary data will be provided to all of the organizations operating
SCSEP programs. This will enable them to determine what local
resources in the community can be brought to bear on the needs
identified through this process.
We estimate that it will take an average of 30 minutes per
respondent to complete this questionnaire. If you have any comments
regarding this estimate or any other aspect of the questionnaire,
including suggestions for reducing the time needed to respond, send
them to the Division of Older Worker Programs, Department of Labor,
200 Constitution Avenue, NW., Room C4524, Washington, DC 20210 and/
or the Office of IRM Policy, Department of Labor, Room N-1301, 200
Constitution Avenue, NW., Washington, DC 20210 (Paperwork Reduction
Project 1225-XXXX).
Thanks for your assistance.
Sincerely,
Charles L. Atkinson,
Chief, Division of Older Worker Programs.
U.S. Department of Labor--Employment and Training Administration
White House Conference on Aging--Needs Assessment Survey
The Department of Labor needs your help in completing this
survey so we can learn how to better meet your needs and the needs
of others like you. Completion of the questionnaire will take
approximately 30 minutes of your time. The survey is voluntary--you
are not required to complete it. However, your responses to the
questionnaire are valuable and your participation will be greatly
appreciated. The contents of your questionnaire will be treated
confidentially. When you have completed the questionnaire--please
seal it in the envelope provided. Thank you very much for taking the
time to fill it.
Section I. Work Profile
1. How long have you been in the Senior Community Service
Employment Program/Title V (circle the number of your answer)?
1 Less than 6 months
2 More than 6 months but less than 2 years
3 More than 2 years but less than 5 years
4 5 years or more
2. Did you work in paid employment, before enrollment in Title V
(circle the number of your answer)?
1 In the last 3 months
2 More than 3 months but less than 6 months ago
3 More than 6 months but less than 1 year ago
4 More than 1 year ago
5 I have never worked for pay
If your answer was #5, skip to question #5.
3. In your last job before enrollment in Title V, you received
on-the-job training (circle the number of your answer.)
1 Yes
2 No
4. Did you leave your last paying job before enrollment in Title
V because (circle the number of your answer)?
1 You retired from work
2 You were laid off/terminated
3 You resigned/quit
4 You were ill
5 You were disabled
6 other, please explain ____________________
5. In 1995, you want to (circle the number(s) of the two most
important responses for your answer.)
1 Learn new skills
2 Continue your assignment with the Senior Community Service
Employment Program
3 Spend time on personal interests
4 Help my community
5 Get a job off the Senior Community Service Employment Program
6 Join an employment related training program
7 Other, please explain ____________________
6. Do you currently worry about money (circle the number of your
answer)?
1 Daily
2 Several times a week
3 Several times a month
4 Monthly
5 Few times a year
7. Are you currently able to pay your bills on time (circle the
number of your answer)?
1 Rarely
2 Some of the time
3 Most of the time
8. Excluding the Senior Community Service Employment Program,
are you currently employed (circle the number of your answer)?
1 Not at all
2 Less than 10 hours each week
3 Between 10-24 hours each week
4 More than 24 hours each week
9. Do you want to work (circle the number of your answer)?
1 Less than 10 hours each week, skip to question #11
2 Between 10-24 hours each week skip to question #11
3 More than 24 hours each week skip to question #11
4 Not at all
10. At this time, the main reason you do not want to work is
(circle the number of your answer.)
1 You have other obligations, such as care giving, etc.
2 You have sufficient income
3 You have other interests
4 You are ill
5 You are disabled
6 Other, please explain ____________________
[[Page 15593]] 11. When employers offer jobs in your community,
do you feel they hire older workers (circle the number of your
answer)?
1 Rarely or none of the time
2 Some of the time
3 Most of the time
12. In the past month, have you applied for a paying job in your
community (circle the number of your answer)?
1 Not at all
2 1-9 times
3 10-19 times
4 20 or more times
13. How did you learn previously about job openings (circle all
of the numbers that apply for your answers)?
1 The newspaper
2 Radio
3 Television
4 Local employment services
5 Friends or relatives
6 Other, please explain ____________________
14. Would you like to be employed in the following type of job
(circle the number of your top two choices for your answer)
1 Clerical/office
2 Mechanical/technical
3 Public service
4 Manufacturing
5 Agriculture
6 Sales
7 Health care
8 Home care
9 Child care
10 Food service
11 Education
12 Other, please explain ____________________
15. Do you currently receive any of the following benefits?
(circle all of the numbers that apply for your answer.)
1 Social Security Retirement
2 Medicare premiums, special programs paying deductibles and co-
payments
3 Subsidized Housing
4 Medicaid
5 Social Security Disability
6 Supplemental Security Income (SSI)
7 Other, please explain ____________________
8 None of the above
16. If you started working outside of SCSEP, would any of the
following benefits you are now receiving change? (circle the
numbers(s) of the two major benefits lost for both ``a.'' and ``b.''
below.)
a. Work Related Benefits
1 Sick leave
2 Annual leave
3 Paid holidays
4 You do not know
b. Government Subsidized Benefits
5 Rent costs increase
6 SSI check reduced or cutoff
7 Food stamps reduced or cutoff
8 Lose Medicaid
9 You do not know
10 Not applicable
Section II. Health Profile
17. Your physical health since you began your participation in
the Senior Community Service Employment Program has shown (circle
the number of your answer)
1 No improvement
2 Some improvement
3 A great deal of improvement
4 None
5 Your health was good when you started the program
18. Your personal outlook since participating in the Senior
Community Service Employment Program, has shown (circle the number
of your answer)
1 No improvement
3 Some improvement
4 A great deal of improvement
5 None
6 Your personal outlook was good when you started the program
19. Most of the time, when you are sick or injured you (circle
the number of your answer.)
1 Go to a private doctor
2 Go to the emergency room
3 Go to a clinic
4 Treat yourself
5 Do nothing
6 Other, please explain ____________________
20. Your last visit to the doctor was (circle the number of your
answer.)
1 1 to 3 month(s) ago
2 4 to 6 months ago
3 7 to 12 months ago
4 More than 12 months ago
5 Rarely visit a doctor
21. The doctor you go to is (circle the number of your answer.)
1 0 to 10 miles away
2 11 to 20 miles away
3 21 to 40 miles away
4 Over 40 miles away
5 You do not go to a doctor
22. Do you go to the dentist (circle the number of your answer)?
1 Rarely
2 Only when you have a problem
3 Every six months
4 Once a year
23. Do you use (circle the number(s) of all responses that apply
for your answer)?
1 Eyeglasses/contact lens
2 Hearing aids
3 Dentures
4 Cane/walker/wheelchair
5 Other, please explain ____________________
6 None
24. Do you use Doctor prescribed medication (circle the number
of your answer)?
1 Daily
2 Several times a week
3 Several times a month
4 Monthly
5 A few times a year or less
25. You need new/additional (circle the number(s) of all
responses that apply for your answer.)
1 Eyeglasses/contact lens
2 Hearing aids
3 Dentures
4 Cane/walker/wheelchair
5 Other, please explain ____________________
26. For 1994, your medical costs were (circle the number of your
answer.)
1 All paid for by insurance or other methods
2 Partially paid for by insurance or other methods
3 Paid almost entirely by you
27. For 1994, your prescription drug costs were (circle the
number of your answer.)
1 All paid for by insurance or other methods
2 Partially paid for by insurance or other methods
3 Paid almost entirely by you
28. For 1994, you had medical coverage through (circle the
number(s) of all responses that apply for your answer.)
1 Private insurance
2 Medicare
3 Medicaid
4 VA medical care
5 Other, please explain ____________________
6 You do not have medical coverage
29. Are you responsible for taking care of a family member(s)
(circle the number of your answer)?
1 Daily
2 Several times a week
3 Several times a month
4 Monthly
5 A few times a year or less
30. Do you take care of the following family member(s) or others
(circle the number(s) of all responses that apply for your
answers(s))?
1 Child(ren)
2 Adult(s)
3 Disabled/ill child(ren)
4 Disabled/ill adult(s)
5 A friend/neighbor
6 You do not take care of family member(s), skip to
question #32
31. Do you need help taking care of family members or others
(circle the number of your answer)?
1 Daily
2 Once or twice a week
3 Several times a month
4 Once a month or less
32. Each night, do you go to bed hungry (circle the number of
your answer.)
1 Yes
2 No
33. Do you practice physical exercise (circle the numbers for
all responses that apply for your answer)?
1 Almost never (any exercise)
2 Once or twice a week (slow walking or similar exercise)
3 Three or more times a week (slow walking or similar exercise)
4 Once or twice a week (aerobic level exercise)
5 Three or more times a week (aerobic level exercise)
34. Presently, are you satisfied with your life (circle the
number of your answer)?
1 Rarely
2 Some of the time
3 Most of the time
35. Do you feel lonely (circle the number of your answer)?
[[Page 15594]] 1 Rarely
2 Some of the time
3 Most of the time
36. Are you sick--requiring bed rest (circle the number of your
answer)?
1 Rarely
2 Some of the time
3 Most of the time
Section III. Household Profile
37. Do you live (circle the number of your answer)?
1 Alone
2 Together with your spouse/domestic partner
3 Together with your child(ren)
4 Together with your grandchild(ren)
5 Together with other relative(s)
6 Together with non-relatives
7 Group home
8 Halfway house
7 Other, please explain ____________________
38. Do you have a pet (circle the number of your answer)?
1 Yes
2 No
39. Including yourself, the number of person(s) that live in
your household is ________
40 Do you live in a (circle the number of your answer)?
1 House
2 Apartment
3 Mobile home
4 Senior citizens housing complex
5 Condominium/town house
6 Group home
7 Halfway house
8 Assisted living facility
9 Subsidized housing
10 Other, please explain ____________________
11 You do not have a housing arrangement
41. Other than SCSEP, do you spend most of your time during the
day (circle the number of your answer)?
1 Working for pay
2 Doing household chores
3 Looking for work
4 Volunteering
5 Participating in social activities
6 Watching TV
7 Reading
8 Caring for family members
9 Caring for non-family members
10 Other, please explain ____________________
42. The place where you live has the following item(s) (circle
the number(s) of all responses that apply for your answer.)
------------------------------------------------------------------------
Good/safe
Available condition
------------------------------------------------------------------------
a. Basics:
Electricity/gas service......................... 1 1
Heater.......................................... 2 2
Indoor plumbing and bath........................ 3 3
Refrigerator.................................... 4 4
Stove........................................... 5 5
Hot water....................................... 6 6
Air conditioner/cooler.......................... 7 7
Telephone....................................... 8 8
c. Appliances:
Washer.......................................... 9 9
Dryer........................................... 10 10
Radio........................................... 11 11
TV.............................................. 12 12
Video Cassette Recorder (VCR)................... 13 13
Microwave....................................... 14 14
Computer........................................ 15 15
Dishwasher...................................... 16 16
d. Security:
Locking doors and windows....................... 17 17
------------------------------------------------------------------------
43. Do you pay the following utility bills (circle the number(s)
of all responses that apply for your answer(s))?
1 Electric
2 Gas/propane
3 Water/sewer
4 Coal/firewood
5 Heating oil
6 Telephone
44. Do you have problems with (circle the number(s) of all
responses that apply for your answer(s))?
1 Mice and/or rats
2 Roaches
3 Other insects and/or pests
4 None of the above
45. The place where you live, do you (circle the number of your
answer)?
1 Own, mortgaged
2 Own, not mortgaged
3 Rent
4 Do not pay for
5 Homeless
46. The place where you live is in (circle the number of your
answer.)
1 Good condition
2 Fair Condition
3 Poor condition
47. When you need to go somewhere do you usually (circle the
number of your answer)?
1 Walk
2 Get a ride from a senior service
3 Take public transportation
4 Drive your car
5 Pay for a ride from someone
6 Ride your bike
7 Take a taxi
8 Borrow/rent a car
9 Other, please explain____________________
48. Do you have a vehicle or automobile in running condition
(circle the number of your answer)?
1 Yes
2 No
49. Do you have a valid drivers' license (circle the number of
your answer)?
1 Yes
2 No Skip to question #54
50. Do you have vehicle insurance which permits you to drive on
public roads (circle the number of your answer)?
1 Yes
2 No
51. Your greatest desires are for (circle the number(s) of the
two most critical items that apply to you for your answers.)
1 Food
2 Housing
3 Companionship
4 Health/dental care
5 Transportation
6 Paid work
7 Money
8 Skills training
9 More education
10 Clothing
52. When you have a problem, do you usually (circle the number
of your answer)?
1 Talk to someone
2 Work it out yourself
3 Don't know what to do/who to call
4 Visit a family member
5 Receive religious/professional counseling
6 Call crisis intervention
Section IV. Population Profile
53 You are (circle the number of your answer.)
1 Female
2 Male
54. What is your age (circle the number of your answer.)
1 55-59
2 60-64
3 65-74
4 75-79
5 80-84
6 85-89
7 90-94
8 95-99
9 100 or over
55. You are (circle the number of your answer.)
1 Asian American/Pacific Islander
2 Black [not Hispanic]
3 Hispanic
4 Native American/Alaskan Native
5 White [not Hispanic]
6 Other, please explain____________________
56. You are currently (circle the number of your answer.)
1 Single, never married
2 Widowed
3 Married
4 Separated
5 Divorced
6 Other, please explain ____________________
57. For 1994, your total annual household income is (circle the
number of your answer.)
1 $3,000 or less
2 $3,001 to $6,000
3 $6,001 to $9,200
4 $9,201 to $12,300
5 $12,301 to $15,400
6 $15,401 to $18,500
7 Over $18,500
58. You participate in the following food programs (circle the
number(s) of ALL RESPONSES THAT APPLY for your
answer(s).) [[Page 15595]]
1 Food stamps
2 Senior meals (nutrition site or meals-on-wheels)
3 Commodity distribution
4 Food banks
5 Soup kitchen
6 None of the above
59. Your primary source(s) of income is/are (circle the
number(s) of the two major sources of income that apply for your
answer(s).)
1 Senior Community Service Employment Program
2 Paid private/public employment
3 Social Security
4 Supplemental Security Income (SSI)
5 General assistance/welfare (GA)
6 Aid to families with dependent children, including grandparents
(AFDC)
7 Pension
8 Military benefits
9 Money from relatives
10 Food stamps
11 Other, please explain ____________________
60. The highest education level you have completed is (circle
the number of your answer.)
1 8th grade or under
2 9th-12th grade (but did not graduate)
3 High school graduate
4 GED
5 1 to 3 years of college
6 College graduate
7 Postgraduate work
61. Are you (circle the number of your answer)?
1 A citizen or national of the United States
2 An alien lawfully admitted for permanent residence
3 An alien authorized by the Immigration and Naturalization Service
to work in the United States
62. Are you a registered voter (circle the number of your
answer)?
1 Yes
2 No
63. Are you a U.S. military veteran (circle the number of your
answer)?
1 Yes
2 No
64. Do you qualify for U.S. military benefits (circle the number
of your answer)?
1 Yes
2 No
3 Do not know
65. Your activities in the community (circle the number(s) of
all responses that apply for your answer(s.):
------------------------------------------------------------------------
Daily Weekly Monthly Rarely
------------------------------------------------------------------------
You volunteer in your community.... 1 1 1 1
You participate in religious
worship........................... 2 2 2 2
You take part in senior activities. 3 3 3 3
You visit friends and relatives.... 4 4 4 4
Your friends and relatives visit
you............................... 5 5 5 5
------------------------------------------------------------------------
66. You volunteer at the (circle the numbers(s) of all responses
that apply for your answer(s).)
------------------------------------------------------------------------
Daily Weekly Monthly Rarely
------------------------------------------------------------------------
1 Hospital........................ 1 1 1 1
2 Nursing home.................... 2 2 2 2
3 School.......................... 3 3 3 3
4 Library......................... 4 4 4 4
5 Senior center................... 5 5 5 5
6 Other, please explain
____________
7 You do not volunteer
------------------------------------------------------------------------
67. a. Please indicate the State where you live. ____________
b. Please indicate the county where you live. ____________
c. Do you live inside the limits of a city, town, borough, or
village? ______ Yes ______ No. If yes, please provide the name.
____________
68. Please tell us the three most important things we can do to
serve you.
1.---------------------------------------------------------------------
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2.---------------------------------------------------------------------
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3.---------------------------------------------------------------------
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69. Did you complete the questionnaire (circle the number of
your answer)?
1 Without assistance
2 With assistance
Thank you!
