Title of Proposed Information Collection

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.

-----------------------------------------------------------------------

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!