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OMB No. 1121-0111: Approval Expires 7/31/2006
NOTICE – We are conducting this survey under the authority of Title 13, United States Code,
Section 8. Section 9 of this law requires us to keep all information about you and your household
strictly confidential. We may use this information only for statistical purposes. Also, Title 42,
Section 3732, United States Code, authorizes the Bureau of Justice Statistics, Department of
Justice, to collect information using this survey. Title 42, Sections 3789g and 3735, United States
                                                                                                      FORM   NCVS-1
                                                                                                      (9-16-2004)
                                                                                                                                                U.S. DEPARTMENT OF COMMERCE
                                                                                                                                                          Economics and Statistics Administration


                                                                                                                                ACTING AS COLLECTING AGENT FOR THE
                                                                                                                                                                     U.S. CENSUS BUREAU             N
                                                                                                                                                                                                    C
Code, also requires us to keep all information about you and your household strictly confidential.                                 BUREAU OF JUSTICE STATISTICS
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless such collection displays a valid OMB number.
                                                                                                                                  U.S. DEPARTMENT OF JUSTICE

  BEFORE INTERVIEW – TRANSCRIBE FROM CONTROL CARD                                                                            NATIONAL CRIME
Control number                                                                                                            VICTIMIZATION SURVEY
PSU              Segment/Suffix               Sample             Serial/
                                              designation/Suffix Suffix
                                                                                HH No. Spinoff
                                                                                       Indicator
                                                                                                             NCVS-1 BASIC SCREEN QUESTIONNAIRE
                                                                                                      AFTER INTERVIEW – TRANSCRIBE FROM CONTROL CARD – Cont.
                                                                                                                                                                                                    V
1.
                 ITEMS FILLED AT START OF INTERVIEW
          Field representative identification
                                                                                                      12a. Household Income (cc item 28)
                                                                                                       214          1     Less than $5,000 6     15,000 – 17,499        11     35,000 – 39,999
                                                                                                                                                                                                    S
                                                                                                                    2     $5,000 – 7,499   7     17,500 – 19,999        12     40,000 – 49,999
          Code          Name
  201                                                                                                               3      7,500 – 9,999   8     20,000 – 24,999        13     50,000 – 74,999
                                                                                                                    4     10,000 – 12,499  9     25,000 – 29,999        14     75,000 and over
2.        Unit status                                                                                               5     12,500 – 14,999 10     30,000 – 34,999
  202      1
           2
               Unit in sample the previous enumeration period – Fill 3
               Unit in sample first time this period – SKIP to 4
                                                                                                      12b. College/University (cc item 8b)
                                                                                                       218          1     Yes                         2    No                                       1
3.        Household status – Mark first box that applies.                                             12c. Public Housing (cc item 8c)
  203      1  Same household interviewed the previous enumeration                                      219          X     Item blank     1     Yes (public          2        No (not public
           2  Replacement household since the previous enumeration                                                                             housing)                      housing)
           3  Noninterview the previous enumeration                                                   12d. Manager Verification of Public Housing (cc item 8d)
           4  Other – Specify                                                                          220          X    Item blank
4.        Line number of household respondent                                                                       Able to verify                    Unable to verify
                                                                                                                    1     Public housing              3    CATI/Telephone
  204             ____________ Go to page 2                                                                         2     Not public housing          4    Other – Specify
      AFTER INTERVIEW – TRANSCRIBE FROM CONTROL CARD
5.        Group Quarters (GQ) type code
                                                                                                      12e. American Indian Reservation or American Indian Lands
                                                                                                               (cc item 8e)
  205         ____________                                                                             221          1     Yes                         2    No
6.        Tenure (cc item 8a)                                                                                   ITEMS FILLED DURING AND/OR AFTER INTERVIEW
  206      1  Owned or                    2       Rented        3        No cash
              being bought                        for cash               rent                         13. Proxy information – Fill for all proxy interviews
7.        Land use (cc item 9)                                                                          a. Proxy inter- b. Proxy respondent                 c. Reason
                                                                                                               view obtained                                                         (Enter
  207      1  Urban                       2       Rural                                                        for Line No.              Name                   Line No.             code)
8.        Farm sales (cc item 10)                                                                      301                                                302                    303
  208      X  Item blank 1 $1,000 or more                            2        Less than $1,000         304                                                305                    306

9.        Type of living quarters (cc items 11c and 11d)                                               307                                                308                    309
              Housing unit                                                                             310                                                311                    312
  209      1  House, apartment, flat
           2  HU in nontransient hotel, motel, etc.                                                     Codes for item 13c
           3  HU permanent in transient hotel, motel, etc.                                              1–12–13 years old and parent refused permission for self interview
                                                                                                        2– Physically/mentally unable to answer FILL INTER-COMM
           4  HU in rooming house
                                                                                                        3– TA and won’t return before closeout
           5  Mobile home or trailer with no permanent room added
           6  Mobile home or trailer with one or more permanent rooms added                           14. Type Z noninterview
           7  HU not specified above – Describe                                                         a. Interview not  b. Reason                 Codes for item 14b
                                                                                                               obtained for                  (Enter 1 – Never available
                                                                                                               Line No.                      code)  2 – Refused . . . .
                  OTHER unit                                                                                                                        3 – Physically/
            8     Quarters not HU in rooming or boarding house                                         313                            314               mentally                         FILL
                  Unit not permanent in transient hotel, motel, etc.                                                                                    unable to
            9
                                                                                                                                                        answer—no                        INTER-
                  Unoccupied site for mobile home, trailer, or tent                                    315                            316                                                COMM
          10                                                                                                                                            proxy available
          11      Student quarters in college dormitory                                                                                             4 – TA and no proxy
                                                                                                       317                            318               available . . . .
          12      OTHER unit not specified above – Describe
                                                                                                                                                    5 – Other . . . . . .
                                                                                                       319                            320           6 – Office use only
          Use of telephone (cc item 26a and b)
                                                                                                                        Complete 17—28 for each Line No. in 14a
10a.      Location of phone – Mark first box that applies.
  210      1  Phone in unit . . . . . . . . . . . . . . . . . . .
                                                                                                      15a. Household members 12 years of age and OVER
           2  Phone in common area (hallway, etc.) . . . .                                             321      ____________ Total number
                                                                                       Fill 10b
           3  Phone in another unit (neighbor, friend, etc.)                                          15b. Household members UNDER 12 years of age
           4  Work/office phone . . . . . . . . . . . . . . . .
                                                                                                       322      ____________ Total number                                        0      None
           5  No phone – SKIP to 11a
10b. Is phone interview acceptable? (cc item 26d)                                                     15c. Number of Type Z noninterview household members
                                                                                                               12 years of age and OVER
  211       1     Yes      2      No      3       Refused to give number                               332      ____________ Total number                                        0     None
11a. Number of housing units in structure (cc item 27a)                                               15d. Crime Incident Reports filled
  212       1     1 – SKIP to 11c          4      4       7     Mobile home/trailer –                  323      ____________ Total number of NCVS-2s filled                      0     None
            2     2                        5      5–9           SKIP to 11c
            3     3                        6      10+     8     Only OTHER units                      16. Changes in Household Composition (cc item 25a)
                                                                                                        a. Line No.  b. Reason (Enter code)
11b. Direct outside access                       (cc item 27b)
                                                                                                       324                         325                               Only transcribe
  213       1     Yes      2      No       3       DK X Item blank                                                                                                   changes discovered
                                                                                                       326                         327                               during the current
11c. Restricted access (cc item 27c)                                                                                                                                 enumeration
                                                                                                       328                         329
  222     Gated or walled community 1                   Yes     2        No    X     Item blank
  223     Building with restricted access 1             Yes     2        No    X     Item blank        330                         331

USCENSUSBUREAU                                                                                                                  Fill BOUNDING INFORMATION
HOUSEHOLD RESPONDENT’S PERSONAL CHARACTERISTICS

17.     NAME (of household respondent)                                                     18.         Type of interview                                      19.
                                                                                                                                                              Line
                                                                                                                                                              No.
Last                                                                                             401                                                           402

                                                                                             1     Per. – Self-respondent
First                                                                                        2     Tel. – Self-respondent
                                                                                             3     Per. – Proxy
                                                                                                                                                             ________
                                                                                             4     Tel. – Proxy Fill 13 on cover page                        Line No.

                                      AFTER INTERVIEW – TRANSCRIBE FROM CONTROL CARD
20.                  21.          22a.              22b.               23.       24.             25.              26.              27.         28.
(cc 13b)             (cc 17)  (cc 18)               (From previous (cc 19)       (cc 20) (cc 21)   (cc 22)                         (cc 23)     (cc 24)
Relationship to      Age last Marital status        enumeration)   Sex           Armed Educational Attending                       His-        Race
reference            birthday THIS survey           Marital                      Forces attainment school                          panic
person                        period                                                                                                           Mark (X) all that
                                                    status LAST                  member                                            origin
                                                                                                                                               apply.
                                                    survey period

 403                   404            405               406                407       408          409                 411              413         412
                                                                                                                                                    *
01      Husband                   1     Married     1     Married      1     M   1     Yes                        0     Regular    1     Yes   1        White
02      Wife                      2     Widowed     2     Widowed      2     F   2     No                               school     2     No    2        Black/African
03      Son            ________   3     Divorced    3     Divorced                               ____________     1     College/                        American
04      Daughter         Age      4     Separated   4     Separated                               Highest level         Univer-                3        American
                                                                                                   completed            sity                            Indian/Alaska
05      Father                    5     Never       5     Never
                                        married           married                                                 2     Trade                           Native
06      Mother                                                                                                          school
                                                          Not inter-                                                                           4        Asian
07      Brother                                     6
                                                                                                                        Voca-
                                                          viewed                                                  3                            5        Native
08      Sister                                                                                                          tional                          Hawaiian/Other
                                                          last
09      Other relative                                    survey                                                        school                          Pacific Islander
10      Nonrelative                                       period                                                  4     None of                6        Other – Specify
11      Ref. person                                                                                                     the
                                                                                                                        above
                                                                                                                        schools




29.       Date of interview                                                                501
                                                                                                        Month         Day               Year

                                                              MOBILITY QUESTIONS
          Before we get to the crime questions, I have some
          questions that are helpful in studying where and why
          crimes occur.
          If unsure, ASK OR VERIFY –
33a.      How long have you lived at this address?                                         505         ____________ Months (1-11) – SKIP to 33b
          (Enter number of months OR years.)                                                                OR

                                                                                           506         ____________ Years (Round to nearest whole year) –
                                                                                                                   Fill Check Item A

 CHECK
 ITEM A                                                                                                    5 years or more – SKIP to 34
                  How many years are entered in 33a?
                                                                                                           Less than 5 years – Ask 33b


33b.      Altogether, how many times have you moved in the last
                                                                                           508
          5 years, that is, since _________________, 20 ___?                                           ____________ Number of times

                                            BUSINESS OPERATED FROM SAMPLE ADDRESS

34.       Does anyone in this household operate a business from
          this address?                                                                    530         1   Yes – Go to 35
                                                                                                       2   No – SKIP to 36a

          PERSONAL – Fill by observation.
          TELEPHONE – Ask.                                                                 531         1   Yes (Recognizable business)
35.       Is there a sign on the premises or some                                                      2   No (Unrecognizable business)
          other indication to the general public that a
          business is operated from this address?




                                                                                                                                                   FORM NCVS-1 (9-16-2004)
Page 2
HOUSEHOLD RESPONDENT’S SCREEN QUESTIONS
 36a.     I’m going to read some examples that will give you an     Briefly describe incident(s)
          idea of the kinds of crimes this study covers.
          As I go through them, tell me if any of these
          happened to you in the last 6 months, that is
          since __________ ______, 20 ____.
          Was something belonging to YOU stolen, such as –
          (a) Things that you carry, like luggage, a wallet,
              purse, briefcase, book –
         (b) Clothing, jewelry, or cellphone –
         (c) Bicycle or sports equipment –
          (d) Things in your home – like a TV, stereo, or tools
          (e) Things outside your home such as a garden
              hose or lawn furniture –
          (f) Things belonging to children in the household –
          (g) Things from a vehicle, such as a package,
              groceries, camera, or CDs –
              OR
          (h) Did anyone ATTEMPT to steal anything
              belonging to you?




          MARK OR ASK –
 36b.     Did any incidents of this type happen to you?                                            532   1   Yes – What happened?
                                                                                                                   Describe above
                                                                                                         2   No – SKIP to 37a

 36c.     How many times?
                                                                                                   533
                                                                                                             Number of times (36c)

 37a.     (Other than any incidents already mentioned,)             Briefly describe incident(s)
          has anyone –
          (a) Broken in or ATTEMPTED to break into your
              home by forcing a door or window, pushing
              past someone, jimmying a lock, cutting a
              screen, or entering through an open door or
              window?
          (b) Has anyone illegally gotten in or tried to get
              into a garage, shed, or storage room?
             OR
          (c) Illegally gotten in or tried to get into a hotel or
              motel room or vacation home where you were
              staying?




          MARK OR ASK –
 37b.     Did any incidents of this type happen to you?                                            534   1   Yes – What happened?
                                                                                                                   Describe above
                                                                                                         2   No – SKIP to 38

 37c.     How many times?
                                                                                                   535
                                                                                                             Number of times (37c)


FORM NCVS-1 (9-16-2004)
                                                                                                                                     Page 3
HOUSEHOLD RESPONDENT’S SCREEN QUESTIONS
38.      What was the TOTAL number of cars, vans, trucks,
         motorcycles, or other motor vehicles owned by you or                                  536   0   None – SKIP to 40a
         any other member of this household during the last                                          1   1
         6 months? Include those you no longer own.                                                  2   2
                                                                                                     3   3
                                                                                                     4   4 or more


39a.     During the last 6 months, (other than any incidents    Briefly describe incident(s)
         already mentioned,) (was the vehicle/were any of
         the vehicles) –
         (a) Stolen or used without permission?
         (b) Did anyone steal any parts such as a tire, car
             stereo, hubcap, or battery?
         (c) Did anyone steal any gas from (it/them)?
            OR
         (d) Did anyone ATTEMPT to steal any vehicle or parts
             attached to (it/them)?




         MARK OR ASK –
39b.     Did any incidents of this type happen to you?                                         537   1   Yes – What happened?
                                                                                                               Describe above
                                                                                                     2   No – SKIP to 40a


39c.     How many times?
                                                                                               538
                                                                                                         Number of times (39c)


40a.     (Other than any incidents already mentioned,)          Briefly describe incident(s)
         since __________ ______, 20 ____, were you attacked
         or threatened OR did you have something stolen
         from you –
         (a) At home including the porch or yard –
         (b) At or near a friend’s, relative’s, or
             neighbor’s home –
         (c) At work or school –
         (d) In places such as a storage shed or laundry
             room, a shopping mall, restaurant, bank, or
             airport –
         (e) While riding in any vehicle –
         (f) On the street or in a parking lot –
         (g) At such places as a party, theater, gym,
             picnic area, bowling lanes, or while fishing
             or hunting –
            OR
         (h) Did anyone ATTEMPT to attack or ATTEMPT
             to steal anything belonging to you from any of
             these places?



         MARK OR ASK –
40b.     Did any incidents of this type happen to you?                                         539   1   Yes – What happened?
                                                                                                               Describe above
                                                                                                     2   No – SKIP to 41a


40c.     How many times?
                                                                                               540
                                                                                                         Number of times (40c)

                                                                                                                     FORM NCVS-1 (9-16-2004)
Page 4
HOUSEHOLD RESPONDENT’S SCREEN QUESTIONS
 41a.     (Other than any incidents already mentioned,)         Briefly describe incident(s)
          has anyone attacked or threatened you in any
          of these ways (Exclude telephone threats) –
          (a) With any weapon, for instance, a gun or
              knife –
          (b) With anything like a baseball bat, frying
              pan, scissors, or stick –
          (c) By something thrown, such as a rock or
              bottle –
          (d) Include any grabbing, punching, or choking,
          (e) Any rape, attempted rape or other type of
              sexual attack –
          (f) Any face to face threats –
             OR
          (g) Any attack or threat or use of force by anyone
              at all? Please mention it even if you are not
              certain it was a crime.




          MARK OR ASK –
 41b.     Did any incidents of this type happen to you?                                        541   1   Yes – What happened?
                                                                                                               Describe above
                                                                                                     2   No – SKIP to 42a

 41c.     How many times?
                                                                                               542
                                                                                                         Number of times (41c)

 42a.     People often don’t think of incidents committed       Briefly describe incident(s)
          by someone they know. (Other than any incidents
          already mentioned,) did you have something
          stolen from you OR were you attacked or
          threatened by (Exclude telephone threats) –
          (a) Someone at work or school –
          (b) A neighbor or friend –
          (c) A relative or family member –
          (d) Any other person you’ve met or known?




          MARK OR ASK –
 42b.     Did any incidents of this type happen to you?                                        543   1   Yes – What happened?
                                                                                                               Describe above
                                                                                                     2   No – SKIP to 43a

 42c.     How many times?
                                                                                               544
                                                                                                         Number of times (42c)

 43a.     Incidents involving forced or unwanted sexual         Briefly describe incident(s)
          acts are often difficult to talk about. (Other than
          any incidents already mentioned,) have you been
          forced or coerced to engage in unwanted sexual
          activity by –
          (a) Someone you didn’t know before –
          (b) A casual acquaintance –
             OR
          (c) Someone you know well?




          MARK OR ASK –
 43b.     Did any incidents of this type happen to you?                                        545   1   Yes – What happened?
                                                                                                               Describe above
                                                                                                     2   No – SKIP to 44a

 43c.     How many times?
                                                                                               546
                                                                                                         Number of times (43c)

FORM NCVS-1 (9-16-2004)
                                                                                                                                 Page 5
HOUSEHOLD RESPONDENT’S SCREEN QUESTIONS
44a.     During the last 6 months, (other than any                      Briefly describe incident(s)
         incidents already mentioned,) did you call the
         police to report something that happened to YOU
         which you thought was a crime?




                                                                                                       547   1   Yes – What happened?
                                                                                                                       Describe above
                                                                                                             2   No – SKIP to 45a

                                                                       548
                                                                                                                   OFFICE USE ONLY
                                                                       *
 CHECK          Look at 44a. If unsure, ASK, otherwise, mark without
 ITEM B         asking. Were you (was the respondent) attacked or                                      549   1   Yes – Ask 44b
                threatened, or was something stolen or an                                                    2   No – SKIP to 45a
                attempt made to steal something that
                belonged to you (the respondent) or another
                household member?
44b.     How many times?



                                                                                                       550
                                                                                                                 Number of times (44b)
45a.     During the last 6 months, (other than any                      Briefly describe incident(s)
         incidents already mentioned,) did anything which
         you thought was a crime happen to YOU, but you
         did NOT report to the police?




                                                                                                       551   1   Yes – What happened?
                                                                                                                       Describe above
                                                                                                             2   No – SKIP to INTRO 1 at top of
                                                                                                                      page 7
                                                                       552
                                                                                                                   OFFICE USE ONLY
                                                                       *
 CHECK          Look at 45a. If unsure, ASK, otherwise, mark without
 ITEM C         asking. Were you (was the respondent) attacked or                                      553   1   Yes – Ask 45b
                threatened, or was something stolen or an                                                    2   No – SKIP to INTRO 1 at top of
                attempt made to steal something that                                                                  page 7
                belonged to you (the respondent) or another
                household member?
45b.     How many times?


                                                                                                       554
                                                                                                                 Number of times (45b)
NOTES




Page 6                                                                                                                       FORM NCVS-1 (9-16-2004)
HOUSEHOLD RESPONDENT’S IDENTITY THEFT QUESTIONS

   FIELD REPRESENTATIVE – Read introduction.

   INTRO 1: The next few questions are related to identity theft. They refer to episodes of identity theft discovered by you or
            anyone in your household during the last 6 months.


45c.     Since                         , 20      , have you
         or anyone in your household discovered that
         someone –
         (a) Used or attempted to use any existing credit
             cards or credit card numbers without permission                    107   1   Yes                 2   No                 3    Don’t know
             to place charges on an account? . . . . . . . . . .

         (b) Used or attempted to use any existing accounts
             other than a credit card account – for example, a
             wireless telephone account, bank account or
             debit/check cards – without the account holder’s
             permission to run up charges or to take money                      108   1   Yes                 2   No                 3    Don’t know
             from accounts? . . . . . . . . . . . . . . . . . . . . . .

         (c) Used or attempted to use personal information
             without permission to obtain NEW credit cards or
             loans, run up debts, open other accounts, or
             otherwise commit theft, fraud, or some other                       109   1   Yes                 2   No                 3    Don’t know
             crime? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
  CHECK
  ITEM C1           Look at 45c. How many times is box 1 (Yes)                        1   None (no entries of Yes) – SKIP to Check Item D
                    marked in 45c?                                                    2   One or more times – Ask 45d

 45d.     Was the misuse of – (the credit card account(s)/any                   110   1   One – SKIP to 45g
          existing account(s) other than credit cards/personal                        2   More than one
          information or new account(s)) one episode or more
          than one episode of identity theft?

 45e.     Did these episodes of identify theft occur separately                 111   1   Separately
          or at the same time?                                                        2   At the same time – SKIP to 45g

 45f.     Which episode of identity theft was most recently                     112   1   Existing credit cards
          discovered?                                                                 2   Existing accounts other than a credit card
                                                                                      3   Personal information to obtain new accounts

   INTRO 2: The following questions refer only to the most recent discovery of identity theft by you or anyone in your
            household.

 45g.     How did you become aware of the identity theft?                       113   1   Block was placed on a credit card or other existing account
                                                                                 *    2   Money missing from account or charges placed on an
          Mark (X) all that apply.                                                        account
                                                                                      3   Contacted by a credit bureau, collection agency, credit card
                                                                                          company or other company about late/unpaid bills
                                                                                      4   Contacted by a bank
                                                                                      5   Noticed that a credit card, check book, etc. was missing
                                                                                      6   Notified by a law enforcement agency
                                                                                      7   Denied credit or a loan
                                                                                      8   Noticed an error in a credit report
                                                                                      9   Other – Specify




 45h.     What was the total dollar amount of the credit,
          loans, cash, services, and anything else the person                   114   $                             .00    Amount taken
          obtained while misusing (the credit card                                    X   Don’t know
          account(s)/any existing accounts other than credit
          cards/personal information or new account(s))?                              0   None


 45i.     Has the misuse of – (the credit card account(s)/any                   115   1   Yes
          existing accounts other than credit cards/personal
          information or new account(s)) stopped (e.g. you or                         2   No
          a household member closed a checking account)?                              3   Don’t know

 45j.     Is the misuse of – (the credit card account(s)/any                    116   1   Yes – SKIP to 45l
          existing accounts other than credit cards/personal
          information or new account(s)) still causing                                2   No
          problems for you or any other household member?                             3   Don’t know
          For example, are you still spending time clearing up
          credit accounts or your credit report?




FORM NCVS-1 (9-16-2004)                                                                                                                           Page 7
HOUSEHOLD RESPONDENT’S IDENTITY THEFT QUESTIONS
45k.     How much time did it take to resolve ALL PROBLEMS                        Less than one month:
         associated with the misuse of – (the credit card
         account(s)/any existing account(s) other than credit              117    ____________ Days
         cards/personal information or new account(s)) after
         the misuse was discovered?                                                    OR
                                                                                  1 – 6 Months:

                                                                           118    ____________ Months
                                                                                  X   Don’t know days or months

45l.     As a result of (any of) the misuse of (the credit card            119    1   Been turned down for a loan?
         account(s)/any existing account(s) other than credit
         cards/personal information or new account(s))                     *      2   Had banking problems?
         discovered in the last 6 months, have you or anyone                      3   Had problems with credit card accounts?
         in your household . . .                                                  4   Had phone or utilities cut off or been denied new
                                                                                      service?
         (Read answer categories 1–10)                                            5   Had to pay higher interest rates on credit cards,
                                                                                      loans, etc.
         Mark (X) all that apply.                                                 6   Been turned down for insurance or had to pay
                                                                                      higher rates?
                                                                                  7   Been contacted by a debt collector or creditor?
                                                                                  8   Been the subject of a civil suit or judgment?
                                                                                  9   Been the subject of a criminal investigation,
                                                                                      warrant, proceeding, or conviction?
                                                                                 10   Had some other problems?– Specify


                                                                                 11   No problems

 CHECK            Briefly summarize the identity theft that occurred
 ITEM C2          against the respondent or another household member.




                                      HOUSEHOLD RESPONDENT’S CHECK ITEMS D AND E
 CHECK            Who besides the respondent was present when the          555    1   Telephone interview – SKIP to 46a
 ITEM D           screen questions were asked? (If telephone                          Personal interview – Mark all that apply.
                  interview, mark box 1 only.)                             *
                                                                                  2   No one besides respondent present
                                                                                  3   Respondent’s spouse
                                                                                  4   HHLD member(s) 12+, not spouse
                                                                                  5   HHLD member(s) under 12
                                                                                  6   Nonhousehold member(s)
                                                                                  7   Someone was present – Can’t say who
                                                                                  8   Don’t know if someone else present

 CHECK            If self-response interview, SKIP to 46a
 ITEM E
                  Did the person for whom this interview was taken         556    1   Yes
                  help the proxy respondent answer any screen                     2   No
                  questions?                                                      3   Person for whom interview taken not present

                              HOUSEHOLD RESPONDENT’S VANDALISM SCREEN QUESTIONS
46a.     Now I’d like to ask about ALL acts of vandalism that may have been committed during the last 6 months
         against YOUR household. Vandalism is the deliberate, intentional damage to or destruction of household
         property. Examples are breaking windows, slashing tires, and painting graffiti on walls.

         Since __________ ______, 20 ____, has anyone intentionally
         damaged or destroyed property owned by you or
         someone else in your household?                                                      557    1    Yes
                                                                                                     2    No – SKIP to Check Item G
         (EXCLUDE any damage done in conjunction with                                                          on page 11
         incidents already mentioned.)

46b.     What kind of property was damaged or destroyed                    558    1   Motor vehicle (including parts)
         in this/these act(s) of vandalism? Anything else?
                                                                           *      2   Bicycle (including parts)
         Continue asking "Anything else?" until you get a "No" response.          3   Mailbox
         Mark (X) all property that was damaged or destroyed by                   4   House window/screen/door
         vandalism during reference period.                                       5   Yard or garden (trees, shrubs, fence, etc.)
                                                                                  6   Furniture, other household goods
                                                                                  7   Clothing
                                                                                  8   Animal (pet, livestock, etc.)
                                                                                  9   Other – Specify




Page 8                                                                                                                              FORM NCVS-1 (9-16-2004)
HOUSEHOLD RESPONDENT’S VANDALISM SCREEN QUESTIONS
 46c.     What kind of damage was done in this/these                        559   1    Broken glass: window, windshield,
          act(s) of vandalism? Anything else?                                          glass in door, mirror
                                                                            *
          Continue asking "Anything else?" until you get a "No" response.         2    Defaced: marred, graffiti, dirtied
          Mark (X) all kinds of damage by vandals that occurred                   3    Burned: use of fire, heat or explosives
          during reference period.                                                4    Drove into or ran over with vehicle
                                                                                  5    Other breaking or tearing
                                                                                  6    Injured or killed animals
                                                                                  7    Other – Specify



 46d.     What was the total dollar amount of the damage
          caused by this/these act(s) of vandalism during the                     $                             00 – SKIP to Check
                                                                            560                             .        Item F1
          last 6 months? (Use repair costs if the property was
          repaired.)
                                                                                  X    Don’t know
          (EXCLUDE any damage done in incidents already                           0    No cost – SKIP to Check Item F1
          mentioned.)

 46e.     Was the damage under $100 or $100 or more?                        561   1    Under $100
          (INCLUDE total amount for all incidents of                              2    $100 or more
          vandalism during the last 6 months.)                                    3    Don’t know

 CHECK                                                                       Briefly describe incident(s)
 ITEM F1            Look at 46a. If unsure, ASK, otherwise, mark without
                    asking. In the vandalism just mentioned, were
                    you (was the respondent) attacked or threatened,
                    or was something stolen or an attempt made
                    to steal something that belonged to you (the
                    respondent) or another household member?
                    (other than any incident(s) already
                    mentioned)
                                                                                                            562   1   Yes – What happened?
                                                                                                                           Describe above
                                                                                                                  2   No – SKIP to 46g

 46f.     How many times?
                                                                                                            563
                                                                                                                      Number of times (46f)
  NOTES




FORM NCVS-1 (9-16-2004)                                                                                                                       Page 9
HOUSEHOLD RESPONDENT’S HATE CRIME SCREEN QUESTIONS

46g.   Hate crimes or crimes of prejudice or bigotry occur
       when (an offender/offenders) target(s) people because
       of one or more of their characteristics or religious
       beliefs.

       Do you have any reason to suspect the vandalism just                   586   1   Yes – Ask 46h
       discussed was a hate crime or crime of prejudice or
       bigotry?                                                                     2   No . . . . . . .
                                                                                    3   Don’t know . . SKIP to Check Item G



46h.   An offender/Offenders can target people for a variety of
       reasons, but we are only going to ask you about a few
       today. Do you suspect the offender(s) targeted you
       because of...

       (a) Your race? . . . . . . . . . . . . . . . . . . . . . . . . . . .   564   1   Yes             2    No                 3       Don’t know
       (b) Your religion? . . . . . . . . . . . . . . . . . . . . . . . . .   565   1   Yes             2    No                 3       Don’t know
       (c) Your ethnic background or national origin (for
           example, people of Hispanic origin)? . . . . . . . .               566   1   Yes             2    No                 3       Don’t know
       (d) Any disability (by this I mean physical, mental, or
           developmental disabilities) you may have? . . . .                  567   1   Yes             2    No                 3       Don’t know
       (e) Your gender? . . . . . . . . . . . . . . . . . . . . . . . . .     568   1   Yes             2    No                 3       Don’t know
        (f) Your sexual orientation? . . . . . . . . . . . . . . . . .        569   1   Yes             2    No                 3       Don’t know
           If "Yes," SAY – (by this we mean homosexual,
           bisexual, or heterosexual)



46i.   Some offenders target people because they
       associate with certain people or the (offender
       perceives/offenders perceive) them as having
       certain characteristics or religious beliefs.

       Do you suspect you were targeted because of...

       (a) Your association with people who
           have certain characteristics or
           religious beliefs (for example, a
           multiracial couple)? . . . . . . . . . . . . . . . . . . .         587   1   Yes – Specify   2    No                 3       Don’t know

                                                                              588



       (b) The offender(s)’s perception of your
           characteristics or religious beliefs (for
           example, the offender(s) thought you
           were Jewish because you went into a
           synagogue)? . . . . . . . . . . . . . . . . . . . . . . . .        589   1   Yes – Specify   2    No                 3       Don’t know

                                                                              590




CHECK
ITEM F2          Are one or more boxes marked "Yes" in 46h                              Yes – Ask 46j
                 OR 46i?                                                                No – SKIP to Check Item G


46j.   Do you have any evidence that this vandalism was a
       hate crime or crime of prejudice or bigotry?                           591   1   Yes – Ask 46k
                                                                                    2   No . . . . . . . .
       If "No" or "Don’t know," ASK –                                               3   Don’t know . . . SKIP to Check Item G

       Did the offender(s) say something, write anything,
       or leave anything behind at the crime scene that
       would suggest you were targeted because of your
       characteristics or religious beliefs?




                                                                                                                                    FORM NCVS-1 (9-16-2004)
Page 10
HOUSEHOLD RESPONDENT’S HATE CRIME SCREEN QUESTIONS
 46k.    The next questions ask about the evidence you have
         that makes you suspect this vandalism was a hate
         crime or a crime of prejudice or bigotry. As I read
         the following questions, please tell me if any of the
         following happened:
         (a) Did the offender(s) make fun of you, make
             negative comments, use slang, hurtful words, or
             abusive language? . . . . . . . . . . . . . . . . . . . .       592    1     Yes               2    No                 3   Don’t know

         (b) Were any hate symbols present at the crime
             scene to indicate the offender(s) targeted you for
             a particular reason (for example, a swastika,
             graffiti on the walls of a temple, a burning cross,
             or written words)? . . . . . . . . . . . . . . . . . . . .      593    1     Yes               2    No                 3   Don’t know

         (c) Did a police investigation confirm the offender(s)
             targeted you (for example, did the offender(s)
             confess a motive, or did the police find books,
             journals, or pictures that indicated the offender(s)
             (was/were) prejudiced against people with certain
             characteristics or religious beliefs)? . . . . . . .            594    1     Yes               2    No                 3   Don’t know

         (d) Do you know if the offender(s) (has/have)
             committed similar hate crimes or crimes of
             prejudice or bigotry in the past? . . . . . . . . . . .         595    1     Yes               2    No                 3   Don’t know

         (e) Did the vandalism occur on or near a holiday,
             event, location, gathering place, or building
             commonly associated with a specific group (for
             example, at the Gay Pride March or at a
             synagogue, Korean church, or gay bar)? . . . . .                596    1     Yes               2    No                 3   Don’t know

         (f) Have other hate crimes or crimes of prejudice or
             bigotry happened to you or in your area/
             neighborhood where people have been targeted?                   597    1     Yes               2    No                 3   Don’t know

         (g) Do your feelings, instincts, or perception lead you
             to suspect this vandalism was a hate crime or
             crime of prejudice or bigotry, but you do not have
             enough evidence to know for sure? . . . . . . . .               598    1     Yes               2    No                 3   Don’t know


                                            HOUSEHOLD RESPONDENT’S CHECK ITEM G
  CHECK
  ITEM G            Transcribe "number of times" entry for each                           No entries transcribed below – Go to Check
                    of the following:                                                     Item H

                    (a) Screen Question, Item 36c, page 3                               ____________ Number of times (36c)
                    (b) Screen Question, Item 37c, page 3                               ____________ Number of times (37c)
                    (c) Screen Question, Item 39c, page 4                               ____________ Number of times (39c)
                    (d) Screen Question, Item 40c, page 4                               ____________ Number of times (40c)
                    (e) Screen Question, Item 41c, page 5                               ____________ Number of times (41c)
                    (f) Screen Question, Item 42c, page 5                               ____________ Number of times (42c)
                   (g) Screen Question, Item 43c, page 5                                ____________ Number of times (43c)
                   (h) Screen Question, Item 44b, page 6                                ____________ Number of times (44b)
                    (i) Screen Question, Item 45b, page 6                               ____________ Number of times (45b)
                    (j) Vandalism Screen Question, Item 46f, page 9                     ____________ Number of times (46f)

                      FIELD REPRESENTATIVE – After completing Check Item G, fill a separate crime incident report for each screen
                                             question that has an entry of 1 or more. Do this before marking Check Item H.




FORM NCVS-1 (9-16-2004)                                                                                                                      Page 11
HOUSEHOLD RESPONDENT’S EMPLOYMENT QUESTIONS
  Be sure to fill any incident reports before marking Check Item H.
 CHECK                                                                          1   Yes – Ask 47a
 ITEM H         Is the respondent 16 years or older?                            2   No – SKIP to Check Item I

 47a.   Did you have a job or work at a business LAST WEEK?
        (Do not include volunteer work or work around the house.)        576    1   Yes – SKIP to 48a
        (If farm or business operator in household, ask about                   2   No – Ask 47b
        unpaid work.)

        ASK OR VERIFY –                                                  577    1   Yes – Ask 47c
 47b.   Did you have a job or work at a business DURING THE                     2   No – SKIP to Check Item I
        LAST 6 MONTHS?

 47c.   Did that (job/work) last 2 consecutive weeks                     578    1   Yes – Ask 48a
        or more?                                                                2   No – SKIP to Check Item I

        ASK OR VERIFY –                                                         Medical Profession – As a –
 48a.   Which of the following best describes your job?                  579    1  Physician
                                                                                2  Nurse
        PERSONAL INTERVIEW (Show flashcard)
                                                                                3  Technician
        TELEPHONE INTERVIEW – Were you employed                                 4  Other – Specify
        in the (Read main headings until you get a yes.
        Then read answer categories) –                                          Mental Health Services Field – Are your duties –
        Mark (X) only one category.                                             5  Professional (Social worker/psychiatrist)
                                                                                6  Custodial care
                                                                                7  Other – Specify
                                                                                Teaching Profession – Were you employed in a –
                                                                                8  Preschool
                                                                                9  Elementary
                                                                               10  Junior high or middle school
                                                                               11  High school
                                                                               12  College or university
                                                                               13  Technical or industrial school
                                                                               14  Special education facility
                                                                               15  Other – Specify
                                                                                Law Enforcement or Security Field – Were you
                                                                                employed as a –
                                                                               16  Law enforcement officer
                                                                               17  Prison or jail guard
                                                                               18  Security guard
                                                                               19  Other – Specify
                                                                                Retail Sales – Were you employed as a –
                                                                               20   Convenience or liquor store clerk
                                                                               21   Gas station attendant
                                                                               22   Bartender
                                                                               23   Other – Specify
                                                                                Transportation Field – Were you employed as a –
                                                                               24   Bus driver
                                                                               25   Taxi cab driver
                                                                               26   Other – Specify
                                                                                     OR
                                                                               27   Something else – Specify

        ASK OR VERIFY –                                                  580    1   A private company, business, or individual for wages?
 48b.   Is your job with (Read answer categories) –                             2   The Federal government?
                                                                                3   A State, county, or local government?
                                                                                4   Yourself (Self-employed) in your own business,
                                                                                    professional practice, or farm?

        If box 12 is marked in 48a, mark without asking.                 581    1   Yes
 48c.   Are you employed by a college or university?                            2   No

 48d.   While working at your job, do you work mostly in                 582    1   A city?
        (Read answer categories) –                                              2   Suburban area?
                                                                                3   Rural area?
                                                                                4   Combination of any of these?

 CHECK          Is this the last household member to be                             Yes – Ask or verify Control Card items.
 ITEM I         interviewed?                                                              Then END interview.
                                                                                    No – Ask or verify Control Card items. See note below before
                                                                                         interviewing next household member.


                  FIELD REPRESENTATIVE – If the next household member to be interviewed is under 18, tell the household respondent
                                         that you will be asking the same questions you just asked him/her.
Page 12                                                                                                                        FORM NCVS-1 (9-16-2004)
INDIVIDUAL’S PERSONAL CHARACTERISTICS
 17.     NAME                                                                                 18.       Type of interview                                      19.
                                                                                                                                                               Line
                                                                                                                                                               No.
 Last                                                                                             401                                                           402

                                                                                              1     Per. – Self-respondent
 First                                                                                        2     Tel. – Self-respondent
                                                                                              3     Per. – Proxy
                                                                                                                          Fill 13 on cover page               ________
                                                                                              4     Tel. – Proxy                                              Line No.
                                                                                              5     Noninterview – Fill 19 – 28 on this page. Also
                                                                                                    fill 14 and adjust item 15c on cover page.
                                   AFTER INTERVIEW – TRANSCRIBE FROM CONTROL CARD
20.                       21.      22a.              22b.               23.       24.             25.              26.              27.         28.
(cc 13b)                  (cc 17)  (cc 18)           (From previous (cc 19)       (cc 20) (cc 21)   (cc 22)                         (cc 23)     (cc 24)
Relationship to           Age last Marital status    enumeration)   Sex           Armed Educational Attending                       His-        Race
reference                 birthday THIS survey       Marital                      Forces attainment school                          panic       Mark (X) all that
person                             period            status LAST                  member                                            origin      apply.
                                                     survey period

  403                      404         405               406                407       408          409                 411              413         412
                                                                                                                                                     *
01       Husband                   1     Married     1     Married      1     M   1     Yes                        0     Regular    1     Yes   1        White
02       Wife                      2     Widowed     2     Widowed      2     F   2     No                               school     2     No    2        Black/African
03       Son            ________   3     Divorced    3     Divorced                               ____________     1     College/                        American
04       Daughter         Age      4     Separated   4     Separated                               Highest level         Univer-                3        American
                                                                                                    completed            sity                            Indian/Alaska
05       Father                    5     Never       5     Never
                                         married           married                                                 2     Trade                           Native
06       Mother                                                                                                          school
                                                           Not inter-                                                                           4        Asian
07       Brother                                     6
                                                                                                                         Voca-
                                                           viewed                                                  3                            5        Native
08       Sister                                                                                                          tional                          Hawaiian/Other
                                                           last
09       Other relative                                    survey                                                        school                          Pacific Islander
10       Nonrelative                                       period                                                  4     None of                6        Other – Specify
11       Ref. person                                                                                                     the
                                                                                                                         above
                                                                                                                         schools




 29.       Date of interview                                                                501
                                                                                                         Month          Day              Year

                                                               MOBILITY QUESTIONS
           Before we get to the crime questions, I have one or two
           questions that are helpful in studying where and why
           crimes occur.
           If unsure, ASK OR VERIFY –
 33a.      How long have you lived at this address?                                         505         ____________ Months (1-11) – SKIP to 33b
           (Enter number of months OR years.)                                                                OR

                                                                                            506         ____________ Years (Round to nearest whole year) –
                                                                                                                     Fill Check Item A

  CHECK
  ITEM A                                                                                                    5 years or more – SKIP to 36a
                    How many years are entered in 33a?
                                                                                                            Less than 5 years –Ask 33b


 33b.      Altogether, how many times have you moved in the last
                                                                                            508
           5 years, that is, since _________________, 20 ___?                                           ____________ Number of times




FORM NCVS-1 (9-16-2004)                                                                                                                                        Page 13
INDIVIDUAL’S SCREEN QUESTIONS
36a.   I’m going to read some examples that will give you an      Briefly describe incident(s)
       idea of the kinds of crimes this study covers.
       As I go through them, tell me if any of these
       happened to you in the last 6 months, that is since
       __________ ______, 20 ____.
       Was something belonging to YOU stolen, such as –
       (a) Things that you carry, like luggage, a wallet,
           purse, briefcase, book –
       (b) Clothing, jewelry, or cellphone –
       (c) Bicycle or sports equipment –
       (d) Things in your home – like a TV, stereo, or tools –
       (e) Things from a vehicle, such as a package, groceries,
           camera, or CDs –
          OR
       (f) Did anyone ATTEMPT to steal anything
           belonging to you?




       MARK OR ASK –
36b.   Did any incidents of this type happen to you?                                             532   1   Yes – What happened?
                                                                                                                 Describe above
                                                                                                       2   No – SKIP to 40a




                                                                                                                                         ▼
36c.   How many times?
                                                                                                 533
                                                                                                           Number of times (36c)

40a.   (Other than any incidents already mentioned,)              Briefly describe incident(s)
       since __________ ______, 20 ____, were you attacked
       or threatened OR did you have something stolen
       from you –
       (a) At home including the porch or yard –
       (b) At or near a friend’s, relative’s, or neighbor’s
           home –
       (c) At work or school –
       (d) In places such as a storage shed or laundry
           room, a shopping mall, restaurant, bank, or
           airport –
       (e) While riding in any vehicle –
       (f) On the street or in a parking lot –
       (g) At such places as a party, theater, gym,
           picnic area, bowling lanes, or while fishing
           or hunting –
          OR
       (h) Did anyone ATTEMPT to attack or ATTEMPT to
           steal anything belonging to you from any of
           these places?




       MARK OR ASK –
40b.   Did any incidents of this type happen to you?                                             539   1   Yes – What happened?
                                                                                                                 Describe above
                                                                                                       2   No – SKIP to 41a
                                                                                                                                         ▼




40c.   How many times?
                                                                                                 540
                                                                                                           Number of times (40c)
Page 14                                                                                                                FORM NCVS-1 (9-16-2004)
INDIVIDUAL’S SCREEN QUESTIONS
 41a.     (Other than any incidents already mentioned,)         Briefly describe incident(s)
          has anyone attacked or threatened you in any of
          these ways (Exclude telephone threats) –
          (a) With any weapon, for instance, a gun or
              knife –
          (b) With anything like a baseball bat, frying pan,
              scissors, or stick –
          (c) By something thrown, such as a rock or
              bottle –
          (d) Include any grabbing, punching, or choking,
          (e) Any rape, attempted rape or other type of
              sexual attack –
          (f) Any face to face threats –
              OR
          (g) Any attack or threat or use of force by anyone
              at all? Please mention it even if you are not
              certain it was a crime.




          MARK OR ASK –
 41b.     Did any incidents of this type happen to you?                                        541   1   Yes – What happened?
                                                                                                               Describe above
                                                                                                     2   No – SKIP to 42a

 41c.     How many times?




                                                                                                                                     ▼
                                                                                               542
                                                                                                         Number of times (41c)

 42a.     People often don’t think of incidents committed       Briefly describe incident(s)
          by someone they know. (Other than any incidents
          already mentioned,) did you have something
          stolen from you OR were you attacked or
          threatened by (Exclude telephone threats) –
          (a) Someone at work or school –
          (b) A neighbor or friend –
          (c) A relative or family member –
          (d) Any other person you’ve met or known?




          MARK OR ASK –
 42b.     Did any incidents of this type happen to you?                                        543   1   Yes – What happened?
                                                                                                               Describe above
                                                                                                     2   No – SKIP to 43a

 42c.     How many times?
                                                                                                                                     ▼




                                                                                               544
                                                                                                         Number of times (42c)

 43a.     Incidents involving forced or unwanted sexual         Briefly describe incident(s)
          acts are often difficult to talk about. (Other than
          any incidents already mentioned,) have you been
          forced or coerced to engage in unwanted sexual
          activity by –
          (a) Someone you didn’t know before –
          (b) A casual acquaintance –
              OR
          (c) Someone you know well?




          MARK OR ASK –
 43b.     Did any incidents of this type happen to you?                                        545   1   Yes – What happened?
                                                                                                               Describe above
                                                                                                     2   No – SKIP to 44a

 43c.     How many times?
                                                                                                                                     ▼




                                                                                               546
                                                                                                         Number of times (43c)

FORM NCVS-1 (9-16-2004)                                                                                                          Page 15
INDIVIDUAL’S SCREEN QUESTIONS
44a.   During the last 6 months, (other than any                                 Briefly describe incident(s)
       incidents already mentioned,) did you call the
       police to report something that happened to YOU
       which you thought was a crime?




                                                                                                                547   1   Yes – What happened?
                                                                                                                                Describe above
                                                                                                                      2   No – SKIP to 45a
                                                                                548
                                                                                                                            OFFICE USE ONLY
                                                                                 *
 CHECK          Look at 44a. If unsure, ASK, otherwise, mark without asking.
 ITEM B         Were you (was the respondent) attacked or                                                       549   1   Yes – Ask 44b
                threatened, or was something stolen or an
                attempt made to steal something that belonged to                                                      2   No – SKIP to 45a
                you (the respondent) or another household member?

44b.   How many times?
                                                                                                                550
                                                                                                                          Number of times (44b)

45a.   During the last 6 months, (other than any                                 Briefly describe incident(s)
       incidents already mentioned,) did anything which
       you thought was a crime happen to YOU, but you
       did NOT report to the police?




                                                                                                                551   1   Yes – What happened?
                                                                                                                                Describe above
                                                                                                                      2   No – SKIP to Check Item D below
                                                                                552
                                                                                                                            OFFICE USE ONLY
                                                                                 *
 CHECK          Look at 45a. If unsure, ASK, otherwise, mark without
 ITEM C         asking. Were you (was the respondent) attacked or                                               553   1   Yes – Ask 45b
                threatened, or was something stolen or an
                attempt made to steal something that belonged                                                         2   No – SKIP to Check Item D below
                to you (the respondent) or another household
                member?

45b.   How many times?
                                                                                                                554
                                                                                                                          Number of times (45b)

                                              INDIVIDUAL’S CHECK ITEMS D, E, AND G
 CHECK          Who besides the respondent was present when the                 555   1     Telephone interview – SKIP to Check Item G
 ITEM D         screen questions were asked? (If telephone interview,                       Personal interview – Mark all that apply.
                mark box 1 only.)                                               *
                                                                                      2     No one besides respondent present
                                                                                      3     Respondent’s spouse
                                                                                      4     HHLD member(s) 12+, not spouse
                                                                                      5     HHLD member(s) under 12
                                                                                      6     Nonhousehold member(s)
                                                                                      7     Someone was present – Can’t say who
                                                                                      8     Don’t know if someone else present

 CHECK          If self-response interview, SKIP to Check Item G
 ITEM E         Did the person for whom this interview was taken help           556   1     Yes
                the proxy respondent answer any screen questions?                     2     No
                                                                                      3     Person for whom interview taken not present

 CHECK          Transcribe "number of times" entry for each of the following:               No entries transcribed below – Go to Check Item H
 ITEM G
               (a) Screen Question, Item 36c, page 14                                     ____________ Number of times (36c)
               (b) Screen Question, Item 40c, page 14                                     ____________ Number of times (40c)
               (c) Screen Question, Item 41c, page 15                                     ____________ Number of times (41c)
               (d) Screen Question, Item 42c, page 15                                     ____________ Number of times (42c)
               (e) Screen Question, Item 43c, page 15                                     ____________ Number of times (43c)
                (f) Screen Question, Item 44b, page 16                                    ____________ Number of times (44b)
               (g) Screen Question, Item 45b, page 16                                     ____________ Number of times (45b)

       FIELD REPRESENTATIVE – After completing Check Item G, fill a separate crime incident report for each screen question that has an entry
                              of 1 or more. Do this before marking Check Item H.
Page 16                                                                                                                                FORM NCVS-1 (9-16-2004)
INDIVIDUAL’S EMPLOYMENT QUESTIONS
   Be sure to fill any incident reports before marking Check Item H.
   CHECK                                                                          1    Yes – Ask 47a
   ITEM H           Is the respondent 16 years or older?
                                                                                  2    No – SKIP to Check Item I
 47a.     Did you have a job or work at a business LAST WEEK?
          (Do not include volunteer work or work around the house.)
                                                                           576    1    Yes – SKIP to 48a
          (If farm or business operator in household, ask about
          unpaid work.)                                                           2    No – Ask 47b

          ASK OR VERIFY –
                                                                           577    1    Yes – Ask 47c
 47b.     Did you have a job or work at a business DURING THE                     2    No – SKIP to Check Item I
          LAST 6 MONTHS?
 47c.     Did that (job/work) last 2 consecutive weeks
                                                                           578    1    Yes – Ask 48a
          or more?
                                                                                  2    No – SKIP to Check Item I
          ASK OR VERIFY –
                                                                                  Medical Profession – As a –
 48a.     Which of the following best describes your job?                  579    1  Physician
          PERSONAL INTERVIEW (Show flashcard)                                     2  Nurse
          TELEPHONE INTERVIEW –Were you employed                                  3  Technician
          in the (Read main headings until you get a yes.                         4  Other – Specify
          Then read answer categories) –
                                                                                  Mental Health Services Field – Are your duties –
          Mark (X) only one category.
                                                                                  5  Professional (Social worker/psychiatrist)
                                                                                  6  Custodial care
                                                                                  7  Other – Specify
                                                                                  Teaching Profession – Were you employed in a –
                                                                                  8  Preschool
                                                                                  9  Elementary
                                                                                 10  Junior high or middle school
                                                                                 11  High school
                                                                                 12  College or university
                                                                                 13  Technical or industrial school
                                                                                 14  Special education facility
                                                                                 15  Other – Specify
                                                                                  Law Enforcement or Security Field – Were you
                                                                                  employed as a –
                                                                                 16  Law enforcement officer
                                                                                 17  Prison or jail guard
                                                                                 18  Security guard
                                                                                 19  Other – Specify
                                                                                  Retail Sales – Were you employed as a –
                                                                                 20   Convenience or liquor store clerk
                                                                                 21   Gas station attendant
                                                                                 22   Bartender
                                                                                 23   Other – Specify
                                                                                  Transportation Field – Were you employed as a –
                                                                                 24   Bus driver
                                                                                 25   Taxi cab driver
                                                                                 26   Other – Specify
                                                                                        OR
                                                                                 27    Something else – Specify

          ASK OR VERIFY –
 48b.     Is your job with (Read answer categories) –                      580    1    A private company, business, or individual for wages?
                                                                                  2    The Federal government?
                                                                                  3    A State, county, or local government?
                                                                                  4    Yourself (Self-employed) in your own
                                                                                       business, professional practice, or farm?

          If box 12 is marked in 48a, mark without asking.
 48c.     Are you employed by a college or university?
                                                                           581    1    Yes
                                                                                  2    No
 48d.     While working at your job, do you work mostly in
                                                                           582    1    A city?
          (Read answer categories) –
                                                                                  2    Suburban area?
                                                                                  3    Rural area?
                                                                                  4    Combination of any of these?
   CHECK            Is this the last household member to be
   ITEM I           interviewed?                                                       Yes – END interview.
                                                                                       No – See note below before interviewing next
                                                                                             household member.
       FIELD REPRESENTATIVE – If the current respondent is a parent or legal guardian and the next household member to be interviewed is
                              under 18, tell the current respondent that you will be asking the same questions you just asked him/her.
FORM NCVS-1 (9-16-2004)                                                                                                                    Page 17
Ncvs Questionnaire
Ncvs Questionnaire
Ncvs Questionnaire
Ncvs Questionnaire
Ncvs Questionnaire
Ncvs Questionnaire
Ncvs Questionnaire
Ncvs Questionnaire
Ncvs Questionnaire
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Ncvs Questionnaire

  • 1. OMB No. 1121-0111: Approval Expires 7/31/2006 NOTICE – We are conducting this survey under the authority of Title 13, United States Code, Section 8. Section 9 of this law requires us to keep all information about you and your household strictly confidential. We may use this information only for statistical purposes. Also, Title 42, Section 3732, United States Code, authorizes the Bureau of Justice Statistics, Department of Justice, to collect information using this survey. Title 42, Sections 3789g and 3735, United States FORM NCVS-1 (9-16-2004) U.S. DEPARTMENT OF COMMERCE Economics and Statistics Administration ACTING AS COLLECTING AGENT FOR THE U.S. CENSUS BUREAU N C Code, also requires us to keep all information about you and your household strictly confidential. BUREAU OF JUSTICE STATISTICS According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB number. U.S. DEPARTMENT OF JUSTICE BEFORE INTERVIEW – TRANSCRIBE FROM CONTROL CARD NATIONAL CRIME Control number VICTIMIZATION SURVEY PSU Segment/Suffix Sample Serial/ designation/Suffix Suffix HH No. Spinoff Indicator NCVS-1 BASIC SCREEN QUESTIONNAIRE AFTER INTERVIEW – TRANSCRIBE FROM CONTROL CARD – Cont. V 1. ITEMS FILLED AT START OF INTERVIEW Field representative identification 12a. Household Income (cc item 28) 214 1 Less than $5,000 6 15,000 – 17,499 11 35,000 – 39,999 S 2 $5,000 – 7,499 7 17,500 – 19,999 12 40,000 – 49,999 Code Name 201 3 7,500 – 9,999 8 20,000 – 24,999 13 50,000 – 74,999 4 10,000 – 12,499 9 25,000 – 29,999 14 75,000 and over 2. Unit status 5 12,500 – 14,999 10 30,000 – 34,999 202 1 2 Unit in sample the previous enumeration period – Fill 3 Unit in sample first time this period – SKIP to 4 12b. College/University (cc item 8b) 218 1 Yes 2 No 1 3. Household status – Mark first box that applies. 12c. Public Housing (cc item 8c) 203 1 Same household interviewed the previous enumeration 219 X Item blank 1 Yes (public 2 No (not public 2 Replacement household since the previous enumeration housing) housing) 3 Noninterview the previous enumeration 12d. Manager Verification of Public Housing (cc item 8d) 4 Other – Specify 220 X Item blank 4. Line number of household respondent Able to verify Unable to verify 1 Public housing 3 CATI/Telephone 204 ____________ Go to page 2 2 Not public housing 4 Other – Specify AFTER INTERVIEW – TRANSCRIBE FROM CONTROL CARD 5. Group Quarters (GQ) type code 12e. American Indian Reservation or American Indian Lands (cc item 8e) 205 ____________ 221 1 Yes 2 No 6. Tenure (cc item 8a) ITEMS FILLED DURING AND/OR AFTER INTERVIEW 206 1 Owned or 2 Rented 3 No cash being bought for cash rent 13. Proxy information – Fill for all proxy interviews 7. Land use (cc item 9) a. Proxy inter- b. Proxy respondent c. Reason view obtained (Enter 207 1 Urban 2 Rural for Line No. Name Line No. code) 8. Farm sales (cc item 10) 301 302 303 208 X Item blank 1 $1,000 or more 2 Less than $1,000 304 305 306 9. Type of living quarters (cc items 11c and 11d) 307 308 309 Housing unit 310 311 312 209 1 House, apartment, flat 2 HU in nontransient hotel, motel, etc. Codes for item 13c 3 HU permanent in transient hotel, motel, etc. 1–12–13 years old and parent refused permission for self interview 2– Physically/mentally unable to answer FILL INTER-COMM 4 HU in rooming house 3– TA and won’t return before closeout 5 Mobile home or trailer with no permanent room added 6 Mobile home or trailer with one or more permanent rooms added 14. Type Z noninterview 7 HU not specified above – Describe a. Interview not b. Reason Codes for item 14b obtained for (Enter 1 – Never available Line No. code) 2 – Refused . . . . OTHER unit 3 – Physically/ 8 Quarters not HU in rooming or boarding house 313 314 mentally FILL Unit not permanent in transient hotel, motel, etc. unable to 9 answer—no INTER- Unoccupied site for mobile home, trailer, or tent 315 316 COMM 10 proxy available 11 Student quarters in college dormitory 4 – TA and no proxy 317 318 available . . . . 12 OTHER unit not specified above – Describe 5 – Other . . . . . . 319 320 6 – Office use only Use of telephone (cc item 26a and b) Complete 17—28 for each Line No. in 14a 10a. Location of phone – Mark first box that applies. 210 1 Phone in unit . . . . . . . . . . . . . . . . . . . 15a. Household members 12 years of age and OVER 2 Phone in common area (hallway, etc.) . . . . 321 ____________ Total number Fill 10b 3 Phone in another unit (neighbor, friend, etc.) 15b. Household members UNDER 12 years of age 4 Work/office phone . . . . . . . . . . . . . . . . 322 ____________ Total number 0 None 5 No phone – SKIP to 11a 10b. Is phone interview acceptable? (cc item 26d) 15c. Number of Type Z noninterview household members 12 years of age and OVER 211 1 Yes 2 No 3 Refused to give number 332 ____________ Total number 0 None 11a. Number of housing units in structure (cc item 27a) 15d. Crime Incident Reports filled 212 1 1 – SKIP to 11c 4 4 7 Mobile home/trailer – 323 ____________ Total number of NCVS-2s filled 0 None 2 2 5 5–9 SKIP to 11c 3 3 6 10+ 8 Only OTHER units 16. Changes in Household Composition (cc item 25a) a. Line No. b. Reason (Enter code) 11b. Direct outside access (cc item 27b) 324 325 Only transcribe 213 1 Yes 2 No 3 DK X Item blank changes discovered 326 327 during the current 11c. Restricted access (cc item 27c) enumeration 328 329 222 Gated or walled community 1 Yes 2 No X Item blank 223 Building with restricted access 1 Yes 2 No X Item blank 330 331 USCENSUSBUREAU Fill BOUNDING INFORMATION
  • 2. HOUSEHOLD RESPONDENT’S PERSONAL CHARACTERISTICS 17. NAME (of household respondent) 18. Type of interview 19. Line No. Last 401 402 1 Per. – Self-respondent First 2 Tel. – Self-respondent 3 Per. – Proxy ________ 4 Tel. – Proxy Fill 13 on cover page Line No. AFTER INTERVIEW – TRANSCRIBE FROM CONTROL CARD 20. 21. 22a. 22b. 23. 24. 25. 26. 27. 28. (cc 13b) (cc 17) (cc 18) (From previous (cc 19) (cc 20) (cc 21) (cc 22) (cc 23) (cc 24) Relationship to Age last Marital status enumeration) Sex Armed Educational Attending His- Race reference birthday THIS survey Marital Forces attainment school panic person period Mark (X) all that status LAST member origin apply. survey period 403 404 405 406 407 408 409 411 413 412 * 01 Husband 1 Married 1 Married 1 M 1 Yes 0 Regular 1 Yes 1 White 02 Wife 2 Widowed 2 Widowed 2 F 2 No school 2 No 2 Black/African 03 Son ________ 3 Divorced 3 Divorced ____________ 1 College/ American 04 Daughter Age 4 Separated 4 Separated Highest level Univer- 3 American completed sity Indian/Alaska 05 Father 5 Never 5 Never married married 2 Trade Native 06 Mother school Not inter- 4 Asian 07 Brother 6 Voca- viewed 3 5 Native 08 Sister tional Hawaiian/Other last 09 Other relative survey school Pacific Islander 10 Nonrelative period 4 None of 6 Other – Specify 11 Ref. person the above schools 29. Date of interview 501 Month Day Year MOBILITY QUESTIONS Before we get to the crime questions, I have some questions that are helpful in studying where and why crimes occur. If unsure, ASK OR VERIFY – 33a. How long have you lived at this address? 505 ____________ Months (1-11) – SKIP to 33b (Enter number of months OR years.) OR 506 ____________ Years (Round to nearest whole year) – Fill Check Item A CHECK ITEM A 5 years or more – SKIP to 34 How many years are entered in 33a? Less than 5 years – Ask 33b 33b. Altogether, how many times have you moved in the last 508 5 years, that is, since _________________, 20 ___? ____________ Number of times BUSINESS OPERATED FROM SAMPLE ADDRESS 34. Does anyone in this household operate a business from this address? 530 1 Yes – Go to 35 2 No – SKIP to 36a PERSONAL – Fill by observation. TELEPHONE – Ask. 531 1 Yes (Recognizable business) 35. Is there a sign on the premises or some 2 No (Unrecognizable business) other indication to the general public that a business is operated from this address? FORM NCVS-1 (9-16-2004) Page 2
  • 3. HOUSEHOLD RESPONDENT’S SCREEN QUESTIONS 36a. I’m going to read some examples that will give you an Briefly describe incident(s) idea of the kinds of crimes this study covers. As I go through them, tell me if any of these happened to you in the last 6 months, that is since __________ ______, 20 ____. Was something belonging to YOU stolen, such as – (a) Things that you carry, like luggage, a wallet, purse, briefcase, book – (b) Clothing, jewelry, or cellphone – (c) Bicycle or sports equipment – (d) Things in your home – like a TV, stereo, or tools (e) Things outside your home such as a garden hose or lawn furniture – (f) Things belonging to children in the household – (g) Things from a vehicle, such as a package, groceries, camera, or CDs – OR (h) Did anyone ATTEMPT to steal anything belonging to you? MARK OR ASK – 36b. Did any incidents of this type happen to you? 532 1 Yes – What happened? Describe above 2 No – SKIP to 37a 36c. How many times? 533 Number of times (36c) 37a. (Other than any incidents already mentioned,) Briefly describe incident(s) has anyone – (a) Broken in or ATTEMPTED to break into your home by forcing a door or window, pushing past someone, jimmying a lock, cutting a screen, or entering through an open door or window? (b) Has anyone illegally gotten in or tried to get into a garage, shed, or storage room? OR (c) Illegally gotten in or tried to get into a hotel or motel room or vacation home where you were staying? MARK OR ASK – 37b. Did any incidents of this type happen to you? 534 1 Yes – What happened? Describe above 2 No – SKIP to 38 37c. How many times? 535 Number of times (37c) FORM NCVS-1 (9-16-2004) Page 3
  • 4. HOUSEHOLD RESPONDENT’S SCREEN QUESTIONS 38. What was the TOTAL number of cars, vans, trucks, motorcycles, or other motor vehicles owned by you or 536 0 None – SKIP to 40a any other member of this household during the last 1 1 6 months? Include those you no longer own. 2 2 3 3 4 4 or more 39a. During the last 6 months, (other than any incidents Briefly describe incident(s) already mentioned,) (was the vehicle/were any of the vehicles) – (a) Stolen or used without permission? (b) Did anyone steal any parts such as a tire, car stereo, hubcap, or battery? (c) Did anyone steal any gas from (it/them)? OR (d) Did anyone ATTEMPT to steal any vehicle or parts attached to (it/them)? MARK OR ASK – 39b. Did any incidents of this type happen to you? 537 1 Yes – What happened? Describe above 2 No – SKIP to 40a 39c. How many times? 538 Number of times (39c) 40a. (Other than any incidents already mentioned,) Briefly describe incident(s) since __________ ______, 20 ____, were you attacked or threatened OR did you have something stolen from you – (a) At home including the porch or yard – (b) At or near a friend’s, relative’s, or neighbor’s home – (c) At work or school – (d) In places such as a storage shed or laundry room, a shopping mall, restaurant, bank, or airport – (e) While riding in any vehicle – (f) On the street or in a parking lot – (g) At such places as a party, theater, gym, picnic area, bowling lanes, or while fishing or hunting – OR (h) Did anyone ATTEMPT to attack or ATTEMPT to steal anything belonging to you from any of these places? MARK OR ASK – 40b. Did any incidents of this type happen to you? 539 1 Yes – What happened? Describe above 2 No – SKIP to 41a 40c. How many times? 540 Number of times (40c) FORM NCVS-1 (9-16-2004) Page 4
  • 5. HOUSEHOLD RESPONDENT’S SCREEN QUESTIONS 41a. (Other than any incidents already mentioned,) Briefly describe incident(s) has anyone attacked or threatened you in any of these ways (Exclude telephone threats) – (a) With any weapon, for instance, a gun or knife – (b) With anything like a baseball bat, frying pan, scissors, or stick – (c) By something thrown, such as a rock or bottle – (d) Include any grabbing, punching, or choking, (e) Any rape, attempted rape or other type of sexual attack – (f) Any face to face threats – OR (g) Any attack or threat or use of force by anyone at all? Please mention it even if you are not certain it was a crime. MARK OR ASK – 41b. Did any incidents of this type happen to you? 541 1 Yes – What happened? Describe above 2 No – SKIP to 42a 41c. How many times? 542 Number of times (41c) 42a. People often don’t think of incidents committed Briefly describe incident(s) by someone they know. (Other than any incidents already mentioned,) did you have something stolen from you OR were you attacked or threatened by (Exclude telephone threats) – (a) Someone at work or school – (b) A neighbor or friend – (c) A relative or family member – (d) Any other person you’ve met or known? MARK OR ASK – 42b. Did any incidents of this type happen to you? 543 1 Yes – What happened? Describe above 2 No – SKIP to 43a 42c. How many times? 544 Number of times (42c) 43a. Incidents involving forced or unwanted sexual Briefly describe incident(s) acts are often difficult to talk about. (Other than any incidents already mentioned,) have you been forced or coerced to engage in unwanted sexual activity by – (a) Someone you didn’t know before – (b) A casual acquaintance – OR (c) Someone you know well? MARK OR ASK – 43b. Did any incidents of this type happen to you? 545 1 Yes – What happened? Describe above 2 No – SKIP to 44a 43c. How many times? 546 Number of times (43c) FORM NCVS-1 (9-16-2004) Page 5
  • 6. HOUSEHOLD RESPONDENT’S SCREEN QUESTIONS 44a. During the last 6 months, (other than any Briefly describe incident(s) incidents already mentioned,) did you call the police to report something that happened to YOU which you thought was a crime? 547 1 Yes – What happened? Describe above 2 No – SKIP to 45a 548 OFFICE USE ONLY * CHECK Look at 44a. If unsure, ASK, otherwise, mark without ITEM B asking. Were you (was the respondent) attacked or 549 1 Yes – Ask 44b threatened, or was something stolen or an 2 No – SKIP to 45a attempt made to steal something that belonged to you (the respondent) or another household member? 44b. How many times? 550 Number of times (44b) 45a. During the last 6 months, (other than any Briefly describe incident(s) incidents already mentioned,) did anything which you thought was a crime happen to YOU, but you did NOT report to the police? 551 1 Yes – What happened? Describe above 2 No – SKIP to INTRO 1 at top of page 7 552 OFFICE USE ONLY * CHECK Look at 45a. If unsure, ASK, otherwise, mark without ITEM C asking. Were you (was the respondent) attacked or 553 1 Yes – Ask 45b threatened, or was something stolen or an 2 No – SKIP to INTRO 1 at top of attempt made to steal something that page 7 belonged to you (the respondent) or another household member? 45b. How many times? 554 Number of times (45b) NOTES Page 6 FORM NCVS-1 (9-16-2004)
  • 7. HOUSEHOLD RESPONDENT’S IDENTITY THEFT QUESTIONS FIELD REPRESENTATIVE – Read introduction. INTRO 1: The next few questions are related to identity theft. They refer to episodes of identity theft discovered by you or anyone in your household during the last 6 months. 45c. Since , 20 , have you or anyone in your household discovered that someone – (a) Used or attempted to use any existing credit cards or credit card numbers without permission 107 1 Yes 2 No 3 Don’t know to place charges on an account? . . . . . . . . . . (b) Used or attempted to use any existing accounts other than a credit card account – for example, a wireless telephone account, bank account or debit/check cards – without the account holder’s permission to run up charges or to take money 108 1 Yes 2 No 3 Don’t know from accounts? . . . . . . . . . . . . . . . . . . . . . . (c) Used or attempted to use personal information without permission to obtain NEW credit cards or loans, run up debts, open other accounts, or otherwise commit theft, fraud, or some other 109 1 Yes 2 No 3 Don’t know crime? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHECK ITEM C1 Look at 45c. How many times is box 1 (Yes) 1 None (no entries of Yes) – SKIP to Check Item D marked in 45c? 2 One or more times – Ask 45d 45d. Was the misuse of – (the credit card account(s)/any 110 1 One – SKIP to 45g existing account(s) other than credit cards/personal 2 More than one information or new account(s)) one episode or more than one episode of identity theft? 45e. Did these episodes of identify theft occur separately 111 1 Separately or at the same time? 2 At the same time – SKIP to 45g 45f. Which episode of identity theft was most recently 112 1 Existing credit cards discovered? 2 Existing accounts other than a credit card 3 Personal information to obtain new accounts INTRO 2: The following questions refer only to the most recent discovery of identity theft by you or anyone in your household. 45g. How did you become aware of the identity theft? 113 1 Block was placed on a credit card or other existing account * 2 Money missing from account or charges placed on an Mark (X) all that apply. account 3 Contacted by a credit bureau, collection agency, credit card company or other company about late/unpaid bills 4 Contacted by a bank 5 Noticed that a credit card, check book, etc. was missing 6 Notified by a law enforcement agency 7 Denied credit or a loan 8 Noticed an error in a credit report 9 Other – Specify 45h. What was the total dollar amount of the credit, loans, cash, services, and anything else the person 114 $ .00 Amount taken obtained while misusing (the credit card X Don’t know account(s)/any existing accounts other than credit cards/personal information or new account(s))? 0 None 45i. Has the misuse of – (the credit card account(s)/any 115 1 Yes existing accounts other than credit cards/personal information or new account(s)) stopped (e.g. you or 2 No a household member closed a checking account)? 3 Don’t know 45j. Is the misuse of – (the credit card account(s)/any 116 1 Yes – SKIP to 45l existing accounts other than credit cards/personal information or new account(s)) still causing 2 No problems for you or any other household member? 3 Don’t know For example, are you still spending time clearing up credit accounts or your credit report? FORM NCVS-1 (9-16-2004) Page 7
  • 8. HOUSEHOLD RESPONDENT’S IDENTITY THEFT QUESTIONS 45k. How much time did it take to resolve ALL PROBLEMS Less than one month: associated with the misuse of – (the credit card account(s)/any existing account(s) other than credit 117 ____________ Days cards/personal information or new account(s)) after the misuse was discovered? OR 1 – 6 Months: 118 ____________ Months X Don’t know days or months 45l. As a result of (any of) the misuse of (the credit card 119 1 Been turned down for a loan? account(s)/any existing account(s) other than credit cards/personal information or new account(s)) * 2 Had banking problems? discovered in the last 6 months, have you or anyone 3 Had problems with credit card accounts? in your household . . . 4 Had phone or utilities cut off or been denied new service? (Read answer categories 1–10) 5 Had to pay higher interest rates on credit cards, loans, etc. Mark (X) all that apply. 6 Been turned down for insurance or had to pay higher rates? 7 Been contacted by a debt collector or creditor? 8 Been the subject of a civil suit or judgment? 9 Been the subject of a criminal investigation, warrant, proceeding, or conviction? 10 Had some other problems?– Specify 11 No problems CHECK Briefly summarize the identity theft that occurred ITEM C2 against the respondent or another household member. HOUSEHOLD RESPONDENT’S CHECK ITEMS D AND E CHECK Who besides the respondent was present when the 555 1 Telephone interview – SKIP to 46a ITEM D screen questions were asked? (If telephone Personal interview – Mark all that apply. interview, mark box 1 only.) * 2 No one besides respondent present 3 Respondent’s spouse 4 HHLD member(s) 12+, not spouse 5 HHLD member(s) under 12 6 Nonhousehold member(s) 7 Someone was present – Can’t say who 8 Don’t know if someone else present CHECK If self-response interview, SKIP to 46a ITEM E Did the person for whom this interview was taken 556 1 Yes help the proxy respondent answer any screen 2 No questions? 3 Person for whom interview taken not present HOUSEHOLD RESPONDENT’S VANDALISM SCREEN QUESTIONS 46a. Now I’d like to ask about ALL acts of vandalism that may have been committed during the last 6 months against YOUR household. Vandalism is the deliberate, intentional damage to or destruction of household property. Examples are breaking windows, slashing tires, and painting graffiti on walls. Since __________ ______, 20 ____, has anyone intentionally damaged or destroyed property owned by you or someone else in your household? 557 1 Yes 2 No – SKIP to Check Item G (EXCLUDE any damage done in conjunction with on page 11 incidents already mentioned.) 46b. What kind of property was damaged or destroyed 558 1 Motor vehicle (including parts) in this/these act(s) of vandalism? Anything else? * 2 Bicycle (including parts) Continue asking "Anything else?" until you get a "No" response. 3 Mailbox Mark (X) all property that was damaged or destroyed by 4 House window/screen/door vandalism during reference period. 5 Yard or garden (trees, shrubs, fence, etc.) 6 Furniture, other household goods 7 Clothing 8 Animal (pet, livestock, etc.) 9 Other – Specify Page 8 FORM NCVS-1 (9-16-2004)
  • 9. HOUSEHOLD RESPONDENT’S VANDALISM SCREEN QUESTIONS 46c. What kind of damage was done in this/these 559 1 Broken glass: window, windshield, act(s) of vandalism? Anything else? glass in door, mirror * Continue asking "Anything else?" until you get a "No" response. 2 Defaced: marred, graffiti, dirtied Mark (X) all kinds of damage by vandals that occurred 3 Burned: use of fire, heat or explosives during reference period. 4 Drove into or ran over with vehicle 5 Other breaking or tearing 6 Injured or killed animals 7 Other – Specify 46d. What was the total dollar amount of the damage caused by this/these act(s) of vandalism during the $ 00 – SKIP to Check 560 . Item F1 last 6 months? (Use repair costs if the property was repaired.) X Don’t know (EXCLUDE any damage done in incidents already 0 No cost – SKIP to Check Item F1 mentioned.) 46e. Was the damage under $100 or $100 or more? 561 1 Under $100 (INCLUDE total amount for all incidents of 2 $100 or more vandalism during the last 6 months.) 3 Don’t know CHECK Briefly describe incident(s) ITEM F1 Look at 46a. If unsure, ASK, otherwise, mark without asking. In the vandalism just mentioned, were you (was the respondent) attacked or threatened, or was something stolen or an attempt made to steal something that belonged to you (the respondent) or another household member? (other than any incident(s) already mentioned) 562 1 Yes – What happened? Describe above 2 No – SKIP to 46g 46f. How many times? 563 Number of times (46f) NOTES FORM NCVS-1 (9-16-2004) Page 9
  • 10. HOUSEHOLD RESPONDENT’S HATE CRIME SCREEN QUESTIONS 46g. Hate crimes or crimes of prejudice or bigotry occur when (an offender/offenders) target(s) people because of one or more of their characteristics or religious beliefs. Do you have any reason to suspect the vandalism just 586 1 Yes – Ask 46h discussed was a hate crime or crime of prejudice or bigotry? 2 No . . . . . . . 3 Don’t know . . SKIP to Check Item G 46h. An offender/Offenders can target people for a variety of reasons, but we are only going to ask you about a few today. Do you suspect the offender(s) targeted you because of... (a) Your race? . . . . . . . . . . . . . . . . . . . . . . . . . . . 564 1 Yes 2 No 3 Don’t know (b) Your religion? . . . . . . . . . . . . . . . . . . . . . . . . . 565 1 Yes 2 No 3 Don’t know (c) Your ethnic background or national origin (for example, people of Hispanic origin)? . . . . . . . . 566 1 Yes 2 No 3 Don’t know (d) Any disability (by this I mean physical, mental, or developmental disabilities) you may have? . . . . 567 1 Yes 2 No 3 Don’t know (e) Your gender? . . . . . . . . . . . . . . . . . . . . . . . . . 568 1 Yes 2 No 3 Don’t know (f) Your sexual orientation? . . . . . . . . . . . . . . . . . 569 1 Yes 2 No 3 Don’t know If "Yes," SAY – (by this we mean homosexual, bisexual, or heterosexual) 46i. Some offenders target people because they associate with certain people or the (offender perceives/offenders perceive) them as having certain characteristics or religious beliefs. Do you suspect you were targeted because of... (a) Your association with people who have certain characteristics or religious beliefs (for example, a multiracial couple)? . . . . . . . . . . . . . . . . . . . 587 1 Yes – Specify 2 No 3 Don’t know 588 (b) The offender(s)’s perception of your characteristics or religious beliefs (for example, the offender(s) thought you were Jewish because you went into a synagogue)? . . . . . . . . . . . . . . . . . . . . . . . . 589 1 Yes – Specify 2 No 3 Don’t know 590 CHECK ITEM F2 Are one or more boxes marked "Yes" in 46h Yes – Ask 46j OR 46i? No – SKIP to Check Item G 46j. Do you have any evidence that this vandalism was a hate crime or crime of prejudice or bigotry? 591 1 Yes – Ask 46k 2 No . . . . . . . . If "No" or "Don’t know," ASK – 3 Don’t know . . . SKIP to Check Item G Did the offender(s) say something, write anything, or leave anything behind at the crime scene that would suggest you were targeted because of your characteristics or religious beliefs? FORM NCVS-1 (9-16-2004) Page 10
  • 11. HOUSEHOLD RESPONDENT’S HATE CRIME SCREEN QUESTIONS 46k. The next questions ask about the evidence you have that makes you suspect this vandalism was a hate crime or a crime of prejudice or bigotry. As I read the following questions, please tell me if any of the following happened: (a) Did the offender(s) make fun of you, make negative comments, use slang, hurtful words, or abusive language? . . . . . . . . . . . . . . . . . . . . 592 1 Yes 2 No 3 Don’t know (b) Were any hate symbols present at the crime scene to indicate the offender(s) targeted you for a particular reason (for example, a swastika, graffiti on the walls of a temple, a burning cross, or written words)? . . . . . . . . . . . . . . . . . . . . 593 1 Yes 2 No 3 Don’t know (c) Did a police investigation confirm the offender(s) targeted you (for example, did the offender(s) confess a motive, or did the police find books, journals, or pictures that indicated the offender(s) (was/were) prejudiced against people with certain characteristics or religious beliefs)? . . . . . . . 594 1 Yes 2 No 3 Don’t know (d) Do you know if the offender(s) (has/have) committed similar hate crimes or crimes of prejudice or bigotry in the past? . . . . . . . . . . . 595 1 Yes 2 No 3 Don’t know (e) Did the vandalism occur on or near a holiday, event, location, gathering place, or building commonly associated with a specific group (for example, at the Gay Pride March or at a synagogue, Korean church, or gay bar)? . . . . . 596 1 Yes 2 No 3 Don’t know (f) Have other hate crimes or crimes of prejudice or bigotry happened to you or in your area/ neighborhood where people have been targeted? 597 1 Yes 2 No 3 Don’t know (g) Do your feelings, instincts, or perception lead you to suspect this vandalism was a hate crime or crime of prejudice or bigotry, but you do not have enough evidence to know for sure? . . . . . . . . 598 1 Yes 2 No 3 Don’t know HOUSEHOLD RESPONDENT’S CHECK ITEM G CHECK ITEM G Transcribe "number of times" entry for each No entries transcribed below – Go to Check of the following: Item H (a) Screen Question, Item 36c, page 3 ____________ Number of times (36c) (b) Screen Question, Item 37c, page 3 ____________ Number of times (37c) (c) Screen Question, Item 39c, page 4 ____________ Number of times (39c) (d) Screen Question, Item 40c, page 4 ____________ Number of times (40c) (e) Screen Question, Item 41c, page 5 ____________ Number of times (41c) (f) Screen Question, Item 42c, page 5 ____________ Number of times (42c) (g) Screen Question, Item 43c, page 5 ____________ Number of times (43c) (h) Screen Question, Item 44b, page 6 ____________ Number of times (44b) (i) Screen Question, Item 45b, page 6 ____________ Number of times (45b) (j) Vandalism Screen Question, Item 46f, page 9 ____________ Number of times (46f) FIELD REPRESENTATIVE – After completing Check Item G, fill a separate crime incident report for each screen question that has an entry of 1 or more. Do this before marking Check Item H. FORM NCVS-1 (9-16-2004) Page 11
  • 12. HOUSEHOLD RESPONDENT’S EMPLOYMENT QUESTIONS Be sure to fill any incident reports before marking Check Item H. CHECK 1 Yes – Ask 47a ITEM H Is the respondent 16 years or older? 2 No – SKIP to Check Item I 47a. Did you have a job or work at a business LAST WEEK? (Do not include volunteer work or work around the house.) 576 1 Yes – SKIP to 48a (If farm or business operator in household, ask about 2 No – Ask 47b unpaid work.) ASK OR VERIFY – 577 1 Yes – Ask 47c 47b. Did you have a job or work at a business DURING THE 2 No – SKIP to Check Item I LAST 6 MONTHS? 47c. Did that (job/work) last 2 consecutive weeks 578 1 Yes – Ask 48a or more? 2 No – SKIP to Check Item I ASK OR VERIFY – Medical Profession – As a – 48a. Which of the following best describes your job? 579 1 Physician 2 Nurse PERSONAL INTERVIEW (Show flashcard) 3 Technician TELEPHONE INTERVIEW – Were you employed 4 Other – Specify in the (Read main headings until you get a yes. Then read answer categories) – Mental Health Services Field – Are your duties – Mark (X) only one category. 5 Professional (Social worker/psychiatrist) 6 Custodial care 7 Other – Specify Teaching Profession – Were you employed in a – 8 Preschool 9 Elementary 10 Junior high or middle school 11 High school 12 College or university 13 Technical or industrial school 14 Special education facility 15 Other – Specify Law Enforcement or Security Field – Were you employed as a – 16 Law enforcement officer 17 Prison or jail guard 18 Security guard 19 Other – Specify Retail Sales – Were you employed as a – 20 Convenience or liquor store clerk 21 Gas station attendant 22 Bartender 23 Other – Specify Transportation Field – Were you employed as a – 24 Bus driver 25 Taxi cab driver 26 Other – Specify OR 27 Something else – Specify ASK OR VERIFY – 580 1 A private company, business, or individual for wages? 48b. Is your job with (Read answer categories) – 2 The Federal government? 3 A State, county, or local government? 4 Yourself (Self-employed) in your own business, professional practice, or farm? If box 12 is marked in 48a, mark without asking. 581 1 Yes 48c. Are you employed by a college or university? 2 No 48d. While working at your job, do you work mostly in 582 1 A city? (Read answer categories) – 2 Suburban area? 3 Rural area? 4 Combination of any of these? CHECK Is this the last household member to be Yes – Ask or verify Control Card items. ITEM I interviewed? Then END interview. No – Ask or verify Control Card items. See note below before interviewing next household member. FIELD REPRESENTATIVE – If the next household member to be interviewed is under 18, tell the household respondent that you will be asking the same questions you just asked him/her. Page 12 FORM NCVS-1 (9-16-2004)
  • 13. INDIVIDUAL’S PERSONAL CHARACTERISTICS 17. NAME 18. Type of interview 19. Line No. Last 401 402 1 Per. – Self-respondent First 2 Tel. – Self-respondent 3 Per. – Proxy Fill 13 on cover page ________ 4 Tel. – Proxy Line No. 5 Noninterview – Fill 19 – 28 on this page. Also fill 14 and adjust item 15c on cover page. AFTER INTERVIEW – TRANSCRIBE FROM CONTROL CARD 20. 21. 22a. 22b. 23. 24. 25. 26. 27. 28. (cc 13b) (cc 17) (cc 18) (From previous (cc 19) (cc 20) (cc 21) (cc 22) (cc 23) (cc 24) Relationship to Age last Marital status enumeration) Sex Armed Educational Attending His- Race reference birthday THIS survey Marital Forces attainment school panic Mark (X) all that person period status LAST member origin apply. survey period 403 404 405 406 407 408 409 411 413 412 * 01 Husband 1 Married 1 Married 1 M 1 Yes 0 Regular 1 Yes 1 White 02 Wife 2 Widowed 2 Widowed 2 F 2 No school 2 No 2 Black/African 03 Son ________ 3 Divorced 3 Divorced ____________ 1 College/ American 04 Daughter Age 4 Separated 4 Separated Highest level Univer- 3 American completed sity Indian/Alaska 05 Father 5 Never 5 Never married married 2 Trade Native 06 Mother school Not inter- 4 Asian 07 Brother 6 Voca- viewed 3 5 Native 08 Sister tional Hawaiian/Other last 09 Other relative survey school Pacific Islander 10 Nonrelative period 4 None of 6 Other – Specify 11 Ref. person the above schools 29. Date of interview 501 Month Day Year MOBILITY QUESTIONS Before we get to the crime questions, I have one or two questions that are helpful in studying where and why crimes occur. If unsure, ASK OR VERIFY – 33a. How long have you lived at this address? 505 ____________ Months (1-11) – SKIP to 33b (Enter number of months OR years.) OR 506 ____________ Years (Round to nearest whole year) – Fill Check Item A CHECK ITEM A 5 years or more – SKIP to 36a How many years are entered in 33a? Less than 5 years –Ask 33b 33b. Altogether, how many times have you moved in the last 508 5 years, that is, since _________________, 20 ___? ____________ Number of times FORM NCVS-1 (9-16-2004) Page 13
  • 14. INDIVIDUAL’S SCREEN QUESTIONS 36a. I’m going to read some examples that will give you an Briefly describe incident(s) idea of the kinds of crimes this study covers. As I go through them, tell me if any of these happened to you in the last 6 months, that is since __________ ______, 20 ____. Was something belonging to YOU stolen, such as – (a) Things that you carry, like luggage, a wallet, purse, briefcase, book – (b) Clothing, jewelry, or cellphone – (c) Bicycle or sports equipment – (d) Things in your home – like a TV, stereo, or tools – (e) Things from a vehicle, such as a package, groceries, camera, or CDs – OR (f) Did anyone ATTEMPT to steal anything belonging to you? MARK OR ASK – 36b. Did any incidents of this type happen to you? 532 1 Yes – What happened? Describe above 2 No – SKIP to 40a ▼ 36c. How many times? 533 Number of times (36c) 40a. (Other than any incidents already mentioned,) Briefly describe incident(s) since __________ ______, 20 ____, were you attacked or threatened OR did you have something stolen from you – (a) At home including the porch or yard – (b) At or near a friend’s, relative’s, or neighbor’s home – (c) At work or school – (d) In places such as a storage shed or laundry room, a shopping mall, restaurant, bank, or airport – (e) While riding in any vehicle – (f) On the street or in a parking lot – (g) At such places as a party, theater, gym, picnic area, bowling lanes, or while fishing or hunting – OR (h) Did anyone ATTEMPT to attack or ATTEMPT to steal anything belonging to you from any of these places? MARK OR ASK – 40b. Did any incidents of this type happen to you? 539 1 Yes – What happened? Describe above 2 No – SKIP to 41a ▼ 40c. How many times? 540 Number of times (40c) Page 14 FORM NCVS-1 (9-16-2004)
  • 15. INDIVIDUAL’S SCREEN QUESTIONS 41a. (Other than any incidents already mentioned,) Briefly describe incident(s) has anyone attacked or threatened you in any of these ways (Exclude telephone threats) – (a) With any weapon, for instance, a gun or knife – (b) With anything like a baseball bat, frying pan, scissors, or stick – (c) By something thrown, such as a rock or bottle – (d) Include any grabbing, punching, or choking, (e) Any rape, attempted rape or other type of sexual attack – (f) Any face to face threats – OR (g) Any attack or threat or use of force by anyone at all? Please mention it even if you are not certain it was a crime. MARK OR ASK – 41b. Did any incidents of this type happen to you? 541 1 Yes – What happened? Describe above 2 No – SKIP to 42a 41c. How many times? ▼ 542 Number of times (41c) 42a. People often don’t think of incidents committed Briefly describe incident(s) by someone they know. (Other than any incidents already mentioned,) did you have something stolen from you OR were you attacked or threatened by (Exclude telephone threats) – (a) Someone at work or school – (b) A neighbor or friend – (c) A relative or family member – (d) Any other person you’ve met or known? MARK OR ASK – 42b. Did any incidents of this type happen to you? 543 1 Yes – What happened? Describe above 2 No – SKIP to 43a 42c. How many times? ▼ 544 Number of times (42c) 43a. Incidents involving forced or unwanted sexual Briefly describe incident(s) acts are often difficult to talk about. (Other than any incidents already mentioned,) have you been forced or coerced to engage in unwanted sexual activity by – (a) Someone you didn’t know before – (b) A casual acquaintance – OR (c) Someone you know well? MARK OR ASK – 43b. Did any incidents of this type happen to you? 545 1 Yes – What happened? Describe above 2 No – SKIP to 44a 43c. How many times? ▼ 546 Number of times (43c) FORM NCVS-1 (9-16-2004) Page 15
  • 16. INDIVIDUAL’S SCREEN QUESTIONS 44a. During the last 6 months, (other than any Briefly describe incident(s) incidents already mentioned,) did you call the police to report something that happened to YOU which you thought was a crime? 547 1 Yes – What happened? Describe above 2 No – SKIP to 45a 548 OFFICE USE ONLY * CHECK Look at 44a. If unsure, ASK, otherwise, mark without asking. ITEM B Were you (was the respondent) attacked or 549 1 Yes – Ask 44b threatened, or was something stolen or an attempt made to steal something that belonged to 2 No – SKIP to 45a you (the respondent) or another household member? 44b. How many times? 550 Number of times (44b) 45a. During the last 6 months, (other than any Briefly describe incident(s) incidents already mentioned,) did anything which you thought was a crime happen to YOU, but you did NOT report to the police? 551 1 Yes – What happened? Describe above 2 No – SKIP to Check Item D below 552 OFFICE USE ONLY * CHECK Look at 45a. If unsure, ASK, otherwise, mark without ITEM C asking. Were you (was the respondent) attacked or 553 1 Yes – Ask 45b threatened, or was something stolen or an attempt made to steal something that belonged 2 No – SKIP to Check Item D below to you (the respondent) or another household member? 45b. How many times? 554 Number of times (45b) INDIVIDUAL’S CHECK ITEMS D, E, AND G CHECK Who besides the respondent was present when the 555 1 Telephone interview – SKIP to Check Item G ITEM D screen questions were asked? (If telephone interview, Personal interview – Mark all that apply. mark box 1 only.) * 2 No one besides respondent present 3 Respondent’s spouse 4 HHLD member(s) 12+, not spouse 5 HHLD member(s) under 12 6 Nonhousehold member(s) 7 Someone was present – Can’t say who 8 Don’t know if someone else present CHECK If self-response interview, SKIP to Check Item G ITEM E Did the person for whom this interview was taken help 556 1 Yes the proxy respondent answer any screen questions? 2 No 3 Person for whom interview taken not present CHECK Transcribe "number of times" entry for each of the following: No entries transcribed below – Go to Check Item H ITEM G (a) Screen Question, Item 36c, page 14 ____________ Number of times (36c) (b) Screen Question, Item 40c, page 14 ____________ Number of times (40c) (c) Screen Question, Item 41c, page 15 ____________ Number of times (41c) (d) Screen Question, Item 42c, page 15 ____________ Number of times (42c) (e) Screen Question, Item 43c, page 15 ____________ Number of times (43c) (f) Screen Question, Item 44b, page 16 ____________ Number of times (44b) (g) Screen Question, Item 45b, page 16 ____________ Number of times (45b) FIELD REPRESENTATIVE – After completing Check Item G, fill a separate crime incident report for each screen question that has an entry of 1 or more. Do this before marking Check Item H. Page 16 FORM NCVS-1 (9-16-2004)
  • 17. INDIVIDUAL’S EMPLOYMENT QUESTIONS Be sure to fill any incident reports before marking Check Item H. CHECK 1 Yes – Ask 47a ITEM H Is the respondent 16 years or older? 2 No – SKIP to Check Item I 47a. Did you have a job or work at a business LAST WEEK? (Do not include volunteer work or work around the house.) 576 1 Yes – SKIP to 48a (If farm or business operator in household, ask about unpaid work.) 2 No – Ask 47b ASK OR VERIFY – 577 1 Yes – Ask 47c 47b. Did you have a job or work at a business DURING THE 2 No – SKIP to Check Item I LAST 6 MONTHS? 47c. Did that (job/work) last 2 consecutive weeks 578 1 Yes – Ask 48a or more? 2 No – SKIP to Check Item I ASK OR VERIFY – Medical Profession – As a – 48a. Which of the following best describes your job? 579 1 Physician PERSONAL INTERVIEW (Show flashcard) 2 Nurse TELEPHONE INTERVIEW –Were you employed 3 Technician in the (Read main headings until you get a yes. 4 Other – Specify Then read answer categories) – Mental Health Services Field – Are your duties – Mark (X) only one category. 5 Professional (Social worker/psychiatrist) 6 Custodial care 7 Other – Specify Teaching Profession – Were you employed in a – 8 Preschool 9 Elementary 10 Junior high or middle school 11 High school 12 College or university 13 Technical or industrial school 14 Special education facility 15 Other – Specify Law Enforcement or Security Field – Were you employed as a – 16 Law enforcement officer 17 Prison or jail guard 18 Security guard 19 Other – Specify Retail Sales – Were you employed as a – 20 Convenience or liquor store clerk 21 Gas station attendant 22 Bartender 23 Other – Specify Transportation Field – Were you employed as a – 24 Bus driver 25 Taxi cab driver 26 Other – Specify OR 27 Something else – Specify ASK OR VERIFY – 48b. Is your job with (Read answer categories) – 580 1 A private company, business, or individual for wages? 2 The Federal government? 3 A State, county, or local government? 4 Yourself (Self-employed) in your own business, professional practice, or farm? If box 12 is marked in 48a, mark without asking. 48c. Are you employed by a college or university? 581 1 Yes 2 No 48d. While working at your job, do you work mostly in 582 1 A city? (Read answer categories) – 2 Suburban area? 3 Rural area? 4 Combination of any of these? CHECK Is this the last household member to be ITEM I interviewed? Yes – END interview. No – See note below before interviewing next household member. FIELD REPRESENTATIVE – If the current respondent is a parent or legal guardian and the next household member to be interviewed is under 18, tell the current respondent that you will be asking the same questions you just asked him/her. FORM NCVS-1 (9-16-2004) Page 17