XI APPENDICES
D.
Questionnaire
(THIS SECTION TO BE
COMPLETED BY GARDEN STATE COALITION)
|
Information
Column
1. Document ID
[1]
2. Study
ID
. [2] |
(INTERVIEWER: COMPLETE THIS SECTION BEFORE BEGINNING INTERVIEW)
| 3. Date of Interview
|
Month ______ |
[3] |
|
Day
________ |
[4] |
|
Year ______ |
[5] |
|
ZONE ______ |
[6] |
| 4. Interviewers first name |
_______________________ |
[7] |
| 5. Time began |
_______________________ |
[8] |
[ INTRODUCTION]
Hello, my name is _____________ and I am working with the
[organization name]. [Organization name] runs a number of youth and
young adult programs. We are interviewing young adults 21 years of
age and under in (Insert City) to better understand their housing
and living conditions so that we can better plan our youth programs.
All of the information you provide will be kept confidential. We can
provide you a small token of our appreciation for participating in
this interview. Would you be able to take five minutes of your time
to answer a few questions?
Have you completed an interview for this study before?
YES
[01] [INELIGIBLE FOR INTERVIEW]
NO
[02] [INTERVIEWER GO
TO Q. 6]
DONT KNOW
[96] [INTERVIEWER GO
TO Q. 6]
REFUSED TO ANSWER
[97] [TRY TO RESCHEDULE OR TRY TO GO TO
6]
BACKGROUND QUESTIONS
[INTERVIEWERS OBSERVATIONS; IF UNSURE ASK Q. 7.]
6. What is your gender?
MALE
[01]
FEMALE
[02]
7. What is your ethnic background?
BLACK, AFRICAN
AMERICAN
[01]
HISPANIC
[02]
ASIAN OR PACIFIC ISLANDER
[03]
WHITE, CAUCASIAN
[04]
AMERICAN INDIAN, ESKIMO, OR ALEUT
. [05]
OTHER __________________________
[06]
8. What is your date of birth? [RECORD MONTH, DATE, YEAR]
_____
M |
/______
D |
/_____
Y |
If refused to answer, estimate the respondents age
UNDER 18 YEARS OF AGE
[01]
18 TO 21 YEARS OF AGE
[02]
9. What city, County, and
State did you live in with your parents, relatives or guardians?
___________________________ CITY
___________________________ COUNTY
___________________________ STATE
10. Are you currently attending school?
YES
. [01]
NO
[02]
REFUSED TO ANSWER
[97]
11. What is the highest grade you have completed? [WRITE IN
GRADE]
______________ GRADE IN SCHOOL
12. Have you ever lived away from your parents and guardians?
YES
..
[01]
NO
[02]
[INTERVIEWER GO TO Q.18]
REFUSED TO ANSWER
.. [97]
13. On how many different occasions have you done this?
14. In the last year have you ever lived away from your parents or
guardians?
YES
[01]
NO
. [02]
15. Currently, how long have you been living away from your parents
or guardians?
_______________YEARS_______________MONTHS
IF NO TO #14 CHECK:CURRENTLY LIVING WITH
PARENTS
..[02]
16. In total, over the years, how long have you lived away from your
parents or guardians?
_________________YEARS_______________MONTHS
17. Why were (are) you living away from parents or guardians?
RUN
AWAY
THROWN
OUT
LEFT HOME AFTER THE AGE OF 18
RECENTLY RELEASED FROM
DETENTION CENTER
RECENTLY RELEASED FROM
PRISON
PARENTS
INCARCERATED
.
PARENTS HOMELESS
.
PARENTS
MOVED
.
.
OTHER________________________
REFUSED TO
ANSWER
|
[01]
[02]
[03]
[04]
[05]
[06]
[07]
[08]
[09]
[97] |
18. Do you presently support yourself?
YES
[01]
NO
... [02] [INTERVIEWER
GO TO Q. 20]
REFUSED TO ANSWER
[97]
19. How do you support yourself? [WRITE ALL RESPONSES GIVEN]
20. Do you presently have any means by which you can pay for
housing?
YES
[01]
NO
. [02]
REFUSED TO ANSWER
[97]
21. Have you seen a
medical care provider (doctor) in the last year?
YES
[01]
NO
. [02]
REFUSED TO ANSWER
[97]
22. Where did you go the last time that you needed medical
attention?
Now I would like to ask you a few questions about places you may
have stayed in the past.
23. Have you ever been in foster care?
YES
..
[01]
CURRENTLY IN FOSTER CARE
[02]
NO
[03]
[INTERVIEWER GO TO Q. 26]
REFUSED TO ANSWER
[97]
24 How long have you been/were you in foster care?
__________YEARS_______ MONTHS
25. How long ago was that?
______YEARS _______MONTHS
26. Have you ever been in juvenile detention?
YES
. [01]
NO
[02]
[INTERVIEWER GO TO Q. 29]
REFUSED TO ANSWER
.. [97]
27. How long were you in
juvenile detention?
______________YEARS__________MONTHS
28. How long ago was that?
________ YEARS _________ MONTHS
29. Have you ever been in prison/jail?
YES
. [01]
NO
[02] [INTERVIEWER
GO TO Q. 32]
REFUSED TO ANSWER [97]
30. How long were you in
prison/jail?
___________YEARS___________MONTHS
31. How long ago was that?
_______YEARS _______ MONTHS
32. I want you to think
back to where you stayed or spent your nights in the last week. I
will read you a number of places you could have stayed or spent your
nights. Could you let me know if you stayed or spent your nights at
any of these places during the last week? [READ CATEGORIES]
|
Place of
Sleep or rest |
Yes |
No |
|
1. Someone elses house,
apartment or room
|
|
|
|
2. Your own house, apartment
or room (includes foster and adult group homes)
|
|
|
|
3. A hotel or motel (place
with rooms that you pay for yourself)
|
|
|
|
4. A room paid for by a
voucher
|
|
|
|
5. A place of business (all
night movie, bar, laundromat, all night restaurant, etc.)
|
|
|
|
6. A transportation site (bus
station, airport, path)
|
|
|
|
7. Anywhere outside (on the
street, in a park, on a bench, etc.)
|
|
|
|
8. A car, bus, van or other
vehicle (including abandoned vehicle)
|
|
|
|
9. A detention center, jail
|
|
|
|
10. An abandoned building
|
|
|
|
11. An institution, a
hospital, detox
|
|
|
|
12. An emergency shelter
|
|
|
|
13. A transitional
shelter/housing
|
|
|
|
14. A program that offers
permanent housing for homeless people.
|
|
|
33. In which of these places did you spend the most time?
34. This time I want you to think back to where you stayed the week
that started Monday, November 20th. That happened to be Thanksgiving
week. Over the week or those seven days that was a part of
Thanksgiving week, could you tell me all the places where you stayed
or spent the night? Again, I will read you a number of places you
could have stayed or spent your nights. Could you let me know if you
stayed or spent your nights at any of these places during the
Thanksgiving week? (READ CATEGORIES)
|
Place of
Sleep or rest |
Yes |
No |
|
1. Someone elses house,
apartment or room
|
|
|
|
2. Your own house, apartment
or room (includes foster and adult group homes)
|
|
|
|
3. A hotel or motel (place
with rooms that you pay for yourself)
|
|
|
|
4. A room paid for by a
voucher
|
|
|
|
5. A place of business (all
night movie, bar, laundromat, all night restaurant, etc.)
|
|
|
|
6. A transportation site (bus
station, airport, path)
|
|
|
|
7. Anywhere outside (on the
street, in a park, on a bench, etc.)
|
|
|
|
8. A car, bus, van or other
vehicle (including abandoned vehicle)
|
|
|
|
9. A detention center, jail
|
|
|
|
10. An abandoned building
|
|
|
|
11. An institution, a
hospital, detox
|
|
|
|
12. An emergency shelter
|
|
|
|
13. A transitional
shelter/housing
|
|
|
|
14. A program that offers
permanent housing for homeless people.
|
|
|
35. In which of these places did you spend the most time?
Finally we have one additional question which we use as one way to
check on duplicate interviews.
36. Would you care to share with us your mothers first name?
RECORD TIME INTERVIEW ENDED. _____________________
THANK YOU FOR TAKING THE TIME FOR THE INTERVIEW
