CDC REPRODUCTIVE HEALTH ASSESSMENT QUESTIONNAIRE
Version 04-28-2011
CDC REPRODUCTIVE HEALTH ASSESSMENT QUESTIONNAIRE
Women of Reproductive Age
001 QUESTIONNAIRE IDENTIFICATION NUMBER |____|____|____|____|
START TIME: ________
002 STATE |____|____| (provide locally appropriate categories)
003 SITE
|____|____| (provide locally appropriate categories)
004 TYPE OF SITE _____________________
Result codes: 1-Home; 2-Shelter; 3-FEMA Trailer; 4- Store; 5-Other ______________
005 TYPE OF DISASTER ___________________
Result codes: 1-Earthquake; 2-Fire; 3-Flood; 4-Hurricane; 5-Tornado, 6-Other ______________
006 DATE OF DISASTER: ___ ___/ ___ ___/___ ___ ___ ___
Day
Month
Year
007 INTERVIEWER: Initials [____|____|____]
008 DATE OF INTERVIEW: ___ ___/ ___ ___/___ ___ ___ ___
Day
Month
Year
009 CHECKED BY SUPERVISOR: Initials [____|____|____]
1
CDC REPRODUCTIVE HEALTH ASSESSMENT QUESTIONNAIRE
Version 04-28-2011
SECTION 1: Background Characteristics
INTERVIEWER READS: I would like to begin by asking you some general questions about your background and your current
living arrangements. Please remember that your responses are kept confidential and will have no bearing on any aide,
services, or assistance that you may be receiving from the government or other organizations.
Q101
What is your age?
Age in years [__|__]
[BRFFS – 12.1; HS Criteria]
Q102
Are you Hispanic or Latina?
Q103
[BRFFS – 12.2]
Which one of the following would you say
is your race?
READ ALL – choose only one response
[BRFFS 12.3; HS Criteria]
Q104
What is the highest grade or year of school
you completed?
READ ONLY IF NECESSARY
[BRFSS 12.8; HS Criteria]
Q105
Which of the following describes your
current marital status?
READ ALL – choose only one response
[BRFSS 12.6; HS Criteria]
Q106
How damaged was your home by the
disaster?
READ ALL – choose only one response
Q107
Q108
Since the disaster, how many times have
you moved? (move = move your day to
day belongings to a new place)
[HS Criteria]
Where are you living now? Please provide
county and state.
Don’t know 88
No Response 99
Yes 1
No 2
Don’t know 8
No Response 9
White 1
Black or African American 2
Asian 3
Native Hawaiian or Other Pacific Islander 4
American Indian or Alaska Native 5
Other (specify) ______________ 6
Don’t know 8
No Response 9
Never attended school or only kindergarten 1
Grades 1 through 8 (Elementary) 2
Grades 9 through 11 (Some high school) 3
Grade 12 or GED (High school graduate) 4
College 1 to 3 years (Some college or technical school) 5
College 4 years or more (College graduate) 6
Don’t know 8
No Response 9
Married 1
Divorced 2
Widowed 3
Separated 4
Never Married 5
OR
A member of an unmarried couple 6
Don’t know
No Response
My home was not damaged
Minor (Living areas of dwelling still livable)
Major (Living areas of dwelling are not livable)
Destroyed
Don’t know
No Response
8
9
1
2
3
4
8
9
Number of moves [__|__]
Don’t know 88
No Response 99
County__________________
State [__|__]
Don’t know 88
No Response 99
2
CDC REPRODUCTIVE HEALTH ASSESSMENT QUESTIONNAIRE
Q109
What best describes your current
residence?
House, condo, or apartment 01
Staying with friends or family 02
FEMA trailer 03
Mobile home 04
Automobile or RV 05
Shelter 06
Hotel 07
Homeless 08
Other (specify) ____________ 09
Don’t know 88
No Response 99
Babies (<1 year) [__|__]
Children and teenagers (1-17 years) [__|__]
Adults (18 - 64 years) [__|__]
Older Adults (≥65 years) [__|__]
READ ONLY IF NECESSARY
Q110
Counting you, how many people live in
your current residence?
[PRAMS adapted – P12]
Q111
Q112
Q113
Just before the disaster, what was your
monthly household income before taxes?
Include your income, your husband’s or
partner’s income, and any other income
you may have received. (All information
will be kept private and will not affect any
services you are now getting.)
[PRAMS adapted - 54]
What is your current monthly household
income before taxes? Include your
income, your husband’s or partner’s
income, and any other income you may
have received (All information will be kept
private and will not affect any services you
are now getting.)
[PRAMS adapted - 54]
What type of health insurance did you
have just before the disaster?
CIRCLE ALL MENTIONED
[PRAMS adapted – 2]
Q114
What type of health insurance do you have
now?
CIRCLE ALL MENTIONED
[PRAMS adapted - 2]
Version 04-28-2011
1=MENTIONED
Total number of people [__|__]
Don’t know 88
No Response 99
Less than $800 1
$800 to $1199 2
$1200 to $1599 3
$1600 to $1999 4
$2000 to $2999 5
$3000 to $3999 6
$4000 or more 7
Don’t know 8
No Response 9
Less than $800 1
$800 to $1199 2
$1200 to $1599 3
$1600 to $1999 4
$2000 to $2999 5
$3000 to $3999 6
$4000 or more 7
Don’t know 8
No Response 9
2=NOT MENTIONED
No health insurance 1
2
Medicaid (or state program name) 1
2
Health insurance or HMO (you or partner’s work or military)
1
2
Other (specify)____________________________ 1
2
Don’t know 1
2
No Response 1
2
1=MENTIONED
2=NOT MENTIONED
No health insurance 1
2
Medicaid (or state program name) 1
2
Health insurance or HMO (you or partner’s work or military)
1
2
Other (specify)____________________________ 1
2
Don’t know 1
2
No Response 1
2
3
CDC REPRODUCTIVE HEALTH ASSESSMENT QUESTIONNAIRE
Version 04-28-2011
SECTION 2: Pregnant Women
Q201
To your knowledge, are you currently
pregnant?
Yes
No
Don’t know
No Response
[BRFSS – 12.20]
1
2
8
9
Q301
Q301
Q301
INTERVIEWER READS: Now I am going to ask you a few questions about your pregnancy.
Q202 How far along are you in your pregnancy?
Months [__|__] and Weeks [__|__]
Enter months and weeks OR weeks
OR
Weeks [__|__]
[RHA toolkit adapted – 204]
Don’t know 88
No Response 99
Q203
How many weeks or months pregnant
were you when you had your first visit for
prenatal care? Do not count a visit that
was only for a pregnancy test or only for
WIC.
Months [__|__] and Weeks [__|__]
OR
Weeks [__|__]
Q205
I have not seen anyone for prenatal care 00
Don’t know 88
No Response 99
Enter months and weeks OR weeks
[PRAMS – 16; HS Criteria]
Q204
Are you currently seeing someone for
prenatal care?
Yes
No
Don’t know
No Response
[RHA toolkit adapted – 205]
Q205
Have any of these things kept you from
getting prenatal care at all or as early as
you wanted? For each item, answer true if
it is a reason that you haven’t gotten
prenatal care when you wanted during
your current pregnancy or false if it is not a
reason or does not apply to you.
CIRCLE TRUE OR FALSE FOR ALL
[PRAMS adapted – 18]
Q206
Has prenatal care been more difficult for
you to get because of the disaster?
1=TRUE
1
2
8
9
2=FALSE
Couldn’t get an appointment when you wanted one 1 2
Not enough money or insurance to pay for visits 1 2
No transportation to get to the clinic or doctor’s office 1 2
Had too many other things going on 1 2
Couldn’t take time off from work or school 1 2
Didn’t have your Medicaid (or state Medicaid name) card
1 2
No one to take care of children or other family members
1 2
Didn’t want prenatal care 1 2
Didn’t know where to go to receive care 1 2
The wait time in the office was too long 1 2
Other (specify) ___________________ 1 2
Don’t know 1 2
No Response 1 2
Yes 1
If yes, why_______________________________________
No 2
Don’t know 8
No Response 9
4
CDC REPRODUCTIVE HEALTH ASSESSMENT QUESTIONNAIRE
Q207
Do you have any of the following health
problems that require ongoing care which
started before or during this pregnancy?
READ ALL – circle all that apply
[PRAMS adapted – 23 & 24]
1=YES
Version 04-28-2011
2=NO
Q502
Q502
Q502
Q502
Q502
High blood sugar (diabetes or gestational diabetes) 1 2
Vaginal bleeding 1 2
Asthma 1 2
Kidney or bladder (urinary tract) infection 1 2
Severe nausea, vomiting or dehydration 1 2
High blood pressure, hypertension (including pregnancyinduced hypertension) preeclampsia or toxemia 1 2
Heart problems 1 2
Other (specify) ___________________ 1 2
Don’t know 1 2
No Response 1 2
Q502
Q502
Q502
Q502
Q502
5
CDC REPRODUCTIVE HEALTH ASSESSMENT QUESTIONNAIRE
Version 04-28-2011
SECTION 3: Post Partum Women & Their Infants
Q301
Q302
Have you given birth to a baby who is
currently six months old or younger?
Yes
No
Don’t know
No Response
1
2
8
9
Were you pregnant when the disaster
occurred?
Yes
No
Don’t know
No Response
1
2
8
9
Q401
Q401
Q401
INTERVIEWER READS: Now I will ask you questions about this baby and about care for you following the birth of this baby.
Q303 How much did the baby weigh at birth?
Pounds [__|__]
[HS Criteria]
Q304
Ounces [__|__]
Don’t know 88
No Response 99
Yes 1
No 2
Don’t know 8
No Response 9
Was the baby born more than 3 weeks
before his or her due date?
[PRAMS adapted – 10; HS Criteria]
Q305
Q306
Since your baby was born, have you had a
postpartum checkup for yourself? (A
postpartum checkup is the regular checkup
a woman has after she gives birth.)
[PRAMS – L8]
Did any of these things keep you from
getting a postpartum checkup? For each
item, answer true if it was a reason that
you didn’t get a postpartum checkup after
your most recent delivery or false if it was
not a reason or did not apply to you.
CIRCLE TRUE OR FALSE FOR ALL
[New question – responses adapted from
PRAMS 18]
Q307
Was getting a postpartum checkup more
difficult for you because of the disaster?
Yes
No
Don’t know
No Response
1=TRUE
1
2
8
9
2=FALSE
Didn’t know a postpartum checkup was recommended 1 2
Couldn’t get an appointment when you wanted one 1 2
Not enough money or insurance to pay for visit 1 2
No transportation to get to the clinic or doctor’s office 1 2
Couldn’t take time off from work or school 1 2
Didn’t have your Medicaid (or state Medicaid name) card
1 2
No one to take care of children or other family members 1 2
Had too many other things going on 1 2
Didn’t know where to go to receive care 1 2
The wait time in the office was too long 1 2
Other (specify) ___________________ 1 2
Don’t know 1 2
No Response 1 2
Yes 1
If yes, why________________________________
No 2
Don’t know 8
No Response 9
6
Q307
Q308
Q308
CDC REPRODUCTIVE HEALTH ASSESSMENT QUESTIONNAIRE
Q308
Has your baby had a checkup with a
doctor since he or she was born?
Q309
Did any of these things keep your baby
from having a checkup with a doctor when
you wanted one? For each item, answer
true if it was a reason that kept your baby
from having a well-baby checkup when you
wanted one or false if it was not a reason
or did not apply to you.
CIRCLE TRUE OR FALSE FOR ALL
[PRAMS adapted – X2]
Q310
Was it more difficult for you to get a
checkup with a doctor for your baby
because of the disaster?
Version 04-28-2011
Yes
No
Don’t know
No Response
1=TRUE
1
2
8
9
2=FALSE
Not enough money or insurance to pay for it
No transportation to the clinic or doctor’s office
No one to take care of children or other family members
Couldn’t get an appointment
Baby was too sick to go for routine care
The wait time in the office was too long
Didn’t know where to go to receive care
Had too many things other things going on
Other (specify) ___________________
Don’t know
No Response
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
Yes 1
If yes, why ______________________________________
No 2
Don’t know 8
No Response 9
Q311
Are you currently breastfeeding or feeding
pumped milk to your baby?
Yes
No
Don’t know
No Response
[PRAMS – 46]
Q312
Did you have difficulty getting formula for
your baby because of the disaster?
I did not need formula (exclusively breastfed)
No, I did not have difficulty getting formula
Yes, I had difficulty getting formula
Don’t know
No Response
READ ALL – choose only one response
Q313
Did you have difficulty getting clean water
to mix formula or clean bottles for feeding
because of the disaster?
READ ALL - choose all that apply
1=YES
1
2
8
9
1
2
3
8
9
2=NO
I did not use formula or bottles
No, I did not have difficulty
Yes, I needed water for formula
Yes, I needed water to clean bottles
Don’t know
No Response
1
1
1
1
1
1
2
2
2
2
2
2
7
CDC REPRODUCTIVE HEALTH ASSESSMENT QUESTIONNAIRE
Version 04-28-2011
SECTION 4: Family Planning
INTERVIEWER READS: Now I am going to ask you questions about preventing pregnancy. We understand that these
questions are personal and want to assure you again that your answers will be kept confidential.
Q401
Have you had your tubes tied or has your
husband or partner had a vasectomy?
Yes
No
Don’t know
No Response
1
2
8
9
Q402
Just before the disaster, were you or your
husband or partner using any birth control
method to keep from getting pregnant? Some
things people do to keep from getting
pregnant include not having sex at certain
times [rhythm] or withdrawal, and using birth
control methods such as the pill, condoms,
vaginal ring, or IUD.
Yes
No
Don’t know
No Response
1
2
8
9
Q403
At any point in time since the disaster, has it
been more difficult to get your birth control
method?
Q501
Q404
Q404
Q404
Yes 1
If yes, why______________________________
No 2
Don’t know 8
No Response 9
Q404
1
2
3
8
9
Q406
I am not having sex 1 2
I want to get pregnant 1 2
I am pregnant now 1 2
I don’t want to use birth control 1 2
My husband or partner doesn’t want to use anything
1 2
I don’t think I can get pregnant (sterile) 1 2
I can’t pay for birth control 1 2
Other (specify)____________________ 1 2
Don’t know 1 2
No Response 1 2
Q501
Q501
Q501
Q501
Are you or your husband or partner doing
anything now to keep from getting pregnant?
Yes
No
No, I do not have a husband or partner
Don’t know
No Response
[PRAMS - 51]
Q405
What are your reasons or your husband’s or
partner’s reasons for not doing anything now
to keep from getting pregnant now?
CIRCLE ALL MENTIONED
[PRAMS – 52]
1=MENTIONED
Q501
Q501
Q501
2=NOT MENTIONED
Q501
Q501
Q501
Q501
Q501
Q501
8
CDC REPRODUCTIVE HEALTH ASSESSMENT QUESTIONNAIRE
Q406
What kind of birth control method are you or
your husband or partner using now to keep
from getting pregnant?
CIRCLE ALL MENTIONED
[PRAMS – E1]
Q407
Where did you last obtain your birth control
method?
[RHA Toolkit adapted – 313]
CHOOSE THE PRIMARY LOCATION
1=MENTIONED
Version 04-28-2011
2=NOT MENTIONED
Pill
Condoms
Injection once every 3 months (Depo-Provera®)
Contraceptive implant (Implanon®)
Contraceptive patch (OrthoEvra®)
Diaphragm, cervical cap, or sponge
Vaginal ring (NuvaRing® or others)
IUD (including Mirena®)
Rhythm method or natural family planning
Withdrawal (pulling out)
Not having sex (abstinence)
Emergency contraception (“morning after” pill)
Other (specify)__________________
Don’t know
No Response
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Private doctor’s office
HMO facility
Community health clinic
Public health clinic
Family planning/Planned Parenthood
Hospital or urgent care center
Pharmacy/store
Other(specify)__________________
Don’t know
No Response
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Q501
Q501
Q501
01
02
03
04
05
06
07
08
88
99
9
CDC REPRODUCTIVE HEALTH ASSESSMENT QUESTIONNAIRE
Version 04-28-2011
SECTION 5: Family Stressors, Risk Behaviors, and Needs
INTERVIEWER READS: Disasters can be very stressful for women and their families. These next questions are about things
that may have happened to you or your family. We understand that these questions are personal and that some may be
difficult for you to answer. Please remember that your answers will be kept confidential and that we can stop and take a break
at any time.
Q501
Do you have any of the following health
problems that require ongoing care?
READ ALL – circle all that apply
[PRAMS adapted – 23 & 24]
Q502
1=YES
2=NO
High blood sugar (diabetes)
Asthma
Kidney or bladder (urinary tract) infection
High blood pressure, hypertension
Heart problems
Other (specify) ___________________
Don’t know
No Response
Did you experience any of the following
because of the disaster? (READ ALL)
A) You felt like your life was in danger when
the disaster struck
B) You had an illness or an injury
C) A member of your household had an
illness or an injury
D) You walked through floodwater or debris
E) You were without electricity for one week
or longer
F) Someone close to you died in the disaster
G) You saw someone die in the disaster
H) You were living in temporary housing or in
conditions that you were not accustomed to
before
I) You lost personal belongings
J) You were separated from loved ones who
you feel close to
K) You had difficulty getting services or aid
from the government and/or insurance
L) Your husband or partner lost his/her job
M) You lost your job even though you wanted
to go on working
N) You argued with your husband or partner
more than usual
O) You had a lot of bills you couldn’t pay
P) You were in a physical fight
Q) Your husband or partner or you went to jail
R) Someone very close to you had a problem
with drinking or drugs
YES
NO
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
DK/ NR
A)
1……..…2………..…9
B)
C)
1……..…2………..…9
1……..…2………..…9
D)
E)
1……..…2………..…9
1……..…2………..…9
F)
G)
H)
1……..…2…….....…9
1……..…2…….....…9
1……..…2…….....…9
I)
J)
1……..…2…….....…9
1……..…2…….....…9
K)
1……..…2…........…9
L)
M)
1……..…2………..…9
1……..…2………..…9
N)
1……..…2………..…9
O)
P)
Q)
R)
1……..…2………..…9
1……..…2………..…9
1……..…2…….....…9
1……..…2…….....…9
[A-K exposures adapted from Norris, Xiong,
Katrina Focus Groups; L-R stressors PRAMS
adapted]
10
CDC REPRODUCTIVE HEALTH ASSESSMENT QUESTIONNAIRE
Q503
Just before the disaster, how many people
in your household (excluding yourself) did you
have to provide care for on a regular basis?
[GA Survey – adapted CG1)
Q504
Since the disaster, how many people in your
household (excluding yourself) do you have to
provide care for on a regular basis?
[GA Survey – adapted CG1)
Q505
Just before the disaster, did you or your
family ever eat less than you felt you should
because there was not enough money to buy
food?
Version 04-28-2011
Total number of people [__|__]
Don’t know 88
No Response 99
Total number of people [__|__]
Don’t know 88
No Response 99
Yes
No
Don’t know
No Response
1
2
8
9
Yes
No
Don’t know
No Response
1
2
8
9
Never
Rarely
Sometimes
Often
Always
Don’t know
No Response
1
2
3
4
5
8
9
Never
Rarely
Sometimes
Often
Always
Don’t know
No Response
1
2
3
4
5
8
9
Yes
No
Don’t know
No Response
1
2
8
9
[PRAMS adapted – P14]
Q506
Since the disaster, have you or your family
eaten less than you felt you should because
there was not enough money to buy food?
[PRAMS adapted – P14]
Q507
On the scale of 1 to 5 (1=never and
5=always), how often did you feel unsafe in
the place where you lived just before the
disaster?
READ ALL – circle only one response
[PRAMS adapted – P15; HS Criteria]
Q508
On the scale of 1 to 5 (1=never and
5=always), how often have you felt unsafe in
the place where you live since the disaster?
READ ALL – circle only one response
[PRAMS adapted – P15; HS Criteria]
Q509
Since the disaster, have you used any form
of tobacco? (Tobacco includes snuff, chewing
tobacco, cigars, pipe, or cigarettes).
[PRAMS adapted – 27; HS Criteria]
11
CDC REPRODUCTIVE HEALTH ASSESSMENT QUESTIONNAIRE
Q510
Since the disaster, how many alcoholic
drinks have you had in an average week?
(One alcoholic drink is a 12 oz beer, a 5 oz
glass of wine, or a drink with 1 shot of liquor).
[PRAMS adapted – 32a; HS Criteria]
Q511
Q512
Have you had sex with more than one person
since the disaster?
Version 04-28-2011
14 drinks or more a week
7 to 13 drinks a week
4 to 6 drinks a week
1 to 3 drinks a week
Less than 1 drink a week
I have not had an alcoholic drink since then
Don’t know
No Response
1
2
3
4
5
6
8
9
Yes
No
No, I am not sexually active
Don’t know
No Response
1
2
3
8
9
Q514
Yes
No
Don’t know
No Response
1
2
8
9
Q514
Q514
Q514
I have more than one partner
My husband/partner has more than 1 partner
I don’t know my partner’s sexual history
I am having unprotected sex
Many family members/friends have HIV or a STI
I use intravenous drugs
Other ________________
Don’t know
No Response
1
2
3
4
5
6
7
8
9
Do you think you are at risk of getting HIV or
any sexually transmitted infection?
(Chlamydia, Gonorrhea, genital warts, HPV)
Q513
Why do you think that you are at risk of
getting HIV or a sexually transmitted
infection?
Q514
Do you feel you currently need any of the
following services? (READ ALL)
YES
NO
DK/ NR
A) Housing
B) Food stamps, WIC vouchers, or money to
buy food
C) School or vocational training
D) Transportation
E) Dental services
F) Medical services
G) Help to quit smoking
H) Help with alcohol or drug problem
I) Help to reduce violence in your home
J) Counseling information for family and/or
personal problems
K) Other (specify)________________
A)
B)
1……..…2………..…9
1……..…2………..…9
C)
D)
E)
F)
G)
H)
I)
J)
1……..…2………..…9
1……..…2………..…9
1……..…2………..…9
1……..…2………..…9
1……..…2………..…9
1……..…2………..…9
1……..…2………..…9
1……..…2………..…9
K)
1………..2….….......9
ASK ONLY IF PREGNANT/POSTPARTUM
L) Help with or information about
breastfeeding
L)
1……..…2………..…9
[PRAMS adapted – V11]
12
CDC REPRODUCTIVE HEALTH ASSESSMENT QUESTIONNAIRE
Q515
In a future disaster, what would be your main
method of getting health information in a
large-scale disaster or emergency?
CHOOSE ONLY ONE RESPONSE
[Communication survey]
Version 04-28-2011
Television
Newspaper
Radio
Magazines
Internet
Billboards or outdoor posters
Health Department
Health care provider
Family or friend
Church or faith-based organizations
Community organizations
Other (specify) __________
Don’t know
No Response
01
02
03
04
05
06
07
08
09
10
11
12
88
99
13
CDC REPRODUCTIVE HEALTH ASSESSMENT QUESTIONNAIRE
Version 04-28-2011
SECTION 6: Violence
INTERVIEWER READS: Now I would like to ask you some questions about physical violence and unwanted sexual
experiences. These are sensitive topics. Some people may feel uncomfortable with these questions. Please remember that we
will continue to make sure that your answers are absolutely confidential. We also want you to know that we can refer you to
someone who can help, if you wish.
Q601
Since the disaster, has your husband or
partner pushed, hit, slapped, kicked, choked
or physically hurt you in any other way?
Yes
No
Don’t know
No Response
1
2
8
9
[RHA toolkit adapted = 823]
Yes
No
Don’t know
No Response
1
2
8
9
Since the disaster did anyone, including
your husband or partner, force you to take
part in touching or any sexual activity when
you did not want to?
Yes
No
Don’t know
No Response
1
2
8
9
Do you believe that these incidents of
violence affected your physical or emotional
health?
Yes
No
Don’t know
No Response
1
2
8
9
Did you see a doctor, counselor, or any
other medical care provider for treatment of
these problems?
Yes
No
Don’t know
No Response
1
2
8
9
[PRAMS=34]
Q602
Q603
Since the disaster has anyone else beaten
you or mistreated you physically?
INSTRUCTION TO INTERVIEWER
 If any violence is reported since the disaster, continue to Q604
 If no violence is reported since the disaster, go to END
Q604
Q605
END
END
END
[RHA toolkit adapted – 811]
14
CDC REPRODUCTIVE HEALTH ASSESSMENT QUESTIONNAIRE
Version 04-28-2011
SECTION 7: Survey Reliability
INTERVIEWER READS: Lastly, I will ask you 4 questions again that I asked you earlier in the questionnaire. We do this to test
the quality of the questions that we have chosen for the questionnaire. Please remember that your responses will have no bearing
on any aide, services, or assistance that you may be receiving from the government or other organizations. Thank you for helping
us with this test of our questions.
Q701
What best describes your current residence?
READ ONLY IF NECESSARY
Q702
Q703
Q704
[Same as Q109]
Just before the disaster, what was your
monthly household income before taxes?
Include your income, your husband’s or
partner’s income, and any other income you
may have received. (All information will be
kept private and will not affect any services
you are now getting.)
[Same as Q111]
To your knowledge, are you currently
pregnant?
[Same as Q201]
Since the disaster, how many people in
your household (excluding yourself) do you
have to provide care for on a regular basis?
[Same as Q504]
House, condo, or apartment 01
Staying with friends or family 02
FEMA trailer 03
Mobile home 04
Automobile or RV 05
Shelter 06
Hotel 07
Homeless 08
Other (specify) ____________ 09
Don’t know 88
No Response 99
Less than $800 1
$800 to $1199 2
$1200 to $1599 3
$1600 to $1999 4
$2000 to $2999 5
$3000 to $3999 6
$4000 or more 7
Don’t know 8
No Response 9
Yes 1
No 2
Don’t know 8
No Response 9
Total number of people [__|__]
Don’t know 88
No Response 99
END TIME: ___________
That is the end of our questionnaire. Thank you very much for taking the time to answer these
questions. We appreciate your help.
15