Depending upon the objectives for the Housing Needs Assessment survey, the local Housing Task Force will choose the most appropriate questions from the following sample mail questionnaire items. Although they could be converted to telephone or personal interview use, the sensitive questions about income levels may produce more complete and accurate data if done by mail. Furthermore, some questions require time for thought or even finding the answer. 

The questionnaire should include a cover letter that emphasizes the importance of the data and assures confidentiality of the responses. Limit the questionnaire to no longer than five full pages or ten half-pages, including only as many items as needed to meet the objectives for the survey. Fill-in-the-blank alternatives are shown for items that would require extra space if all choices were spelled out. 

For the results to be "respectable," a response rate of at least 50% is necessary. To increase the return rate, enclose a self-addressed, stamped envelope. Sending a postcard-thank you/reminder to all respondents one week after the initial mailing will produce additional responses. A final technique to raise the response rate is to send a follow-up letter with another copy of the survey to those who have not responded by the date three weeks after the initial mailing. 

Sources of the items used or adapted here include Hanna, et. al (1991); Illinois Housing Leadership Network (1990); Winter et al (1989); Morris and Goetz (1989); and Tremblay and Dillman (1984). Selected 1990 Census questions are also included to allow you to obtain updated local data for comparison. 

INTRODUCTORY/COVER LETTER TO ACCOMPANY THE SURVEY 

Dear _____ 

Today, our community faces a challenge to provide both jobs and affordable housing for you. To obtain the information necessary to develop policies and programs for ______ (town name), we are studying local housing needs and all factors that affect the availability of housing in this area. 

You are part of a (random) sample of people who live or work in _____ and whose opinions are important to describing our housing situation. To assure that the attitudes and experiences of all local residents and employees are represented, it is very important that each questionnaire be completed and returned. We have assigned each survey an identification number so that we can process the questionnaire when it returns. No names or addresses will be placed on the surveys or used in our housing report. 

When the housing needs assessment is completed, we will be happy to share the results with you. You may receive a summary of our report by writing, "Copy of results requested" on the back of the return envelope, and printing your name and address below it. Please do not put this information on the survey itself. 

If you have questions, feel free to write or call ______ (name, title) during business hours. Thank you so much for your help. 

SAMPLE COVER PAGE: A SURVEY OF THE HOUSING NEEDS OF _____ RESIDENTS 

_____ (City or County Name) is experiencing important housing and economic changes. Yet we don't know exactly what our community's housing needs are. Conducted by ________ (Housing Task Force name, etc.), this survey is designed to identify the housing concerns of residents in this area so that our leaders can develop housing policies and programs that focus first on our most serious issues. 

Please feel free to use the space in the margins to make additional comments. Your ideas are important and will be read and taken into account. 

Thank you for your help. 

Please return the questionnaire to: 

Name 

Address 

Telephone Number 

Instructions: To determine the housing situation in _____, we need information about your housing experience, adequacy, affordability, and assistance and support service needs. 

For each question, please fill in the blank or circle the number that describes your situation or opinion. 

HOUSING EXPERIENCE 

Q-1 Which best describes the building you live in?
1 Mobile or manufactured home on its own lot
2 Mobile or manufactured home in a mobile home park
3 One-family house detached from any other house
4 Townhouse (one-family house attached to one or more houses)
5 Duplex, triplex, or four-plex
6 Building with 5 - 9 apartments
7 Building with 10 - 19 apartments
8 Building with 20 or more apartments
9 Other (explain)____________________________________________ 

Q-2 Is your dwelling (Circle one)
1 Owned by someone in this household buying it with a mortgage or loan
2 Owned by someone in this household free and clear (paid for)
3 Rented for cash rent
4 Occupied rent-free without payment of cash rent 

Q-3 How long have you lived in this home?
______ number of years (If less than one, write number of months here _______) 

Q-4 About when was your home first built? (Circle one)
1 1980 or after
2 1970-79
3 1960-69
4 1950-59
5 1940-49
6 1939 or earlier
7 Don't know 

Q-5 Are you employed outside your city of residence?
1 No
2 Yes 

If yes: 

a. Where do you live? _________________________ (town/county)
b. How many miles do you drive round trip each day to your job? ______ miles 

Q-6 Have you experienced any of the following difficulties in housing yourself or your family? (Circle all that apply)
1 Shortage of affordable rental housing
2 Limited numbers of affordable homes for sale
3 Available, affordable homes are poor quality or too small
4 Don't have enough money for required downpayment on a home
5 Can't qualify for a mortgage at today's interest rates and home prices
6 Trouble qualifying for home financing because of credit rating
7 Finding housing that is both accessible for my disability and affordable
8 Other, explain _________________________ 

Q-6a If you circled any of the above, which ONE was the most important problem? 

Q-7 In looking for a place to live, do you think you may have been discriminated against for any reason?
1 No
2 Yes 

Q-7a If yes, why do you think you may have been discriminated against? (Circle all that apply)
1 Race or ethnic status
2 Income level
3 My children were not welcome
4 I/we are receiving public assistance
5 Because someone in my household/family is disabled
6 Other, explain ________________________________ 

HOUSING ADEQUACY 

Q-8 Overall, how do you feel about your present housing situation?
1 Very satisfied
2 Satisfied
3 Neither satisfied nor dissatisfied
4 Dissatisfied
5 Very dissatisfied 

Q-9 How many rooms does your house or apartment have? Include the kitchen, but do not count bathrooms, halls, foyers, balconies, porches, unfinished basement rooms, or half-rooms. 

///Communities will choose one of these response methods/// 

Fill in the blank.	ALTERNATE RESPONSE Circle one.
__________ rooms	1 One 2 Two 3 Three 4 Four 5 Five 6 Six  7 Seven or more

Q-10 How many bedrooms are in your home? (How many would you list if the home was on the market for rent or for sale?) 

Fill in the blank.	ALTERNATE RESPONSE Circle one.
___________ bedrooms	1 One 2 Two 3 Three 4 Four 5 Five or more

Q-11 For your family, is the size of your home or apartment? 

1 Just right
2 A little too small
3 A lot too small
4 A little too large
5 A lot too large 

Q-12 Does your home have (Circle all that apply):
1 Cold, piped water
2 Hot, piped water
3 Flush toilet(s)
4 A tub and/or a shower
5 Connection to public/city sewer
6 Connection to septic tank or cesspool
7 Connection to public/city water
8 A well with safe water supply
9 Complete kitchen facilities (range, refrigerator, and sink) 

Q-13 Does your home have (Circle all that apply):
1 At least one entry with only one or no steps
2 Entrance(s) with more than one step
3 Ramped entrance instead of or in addition to steps
4 Front door wide enough for wheelchair passage (at least 32" clear passage)
5 Bathroom door wide enough for wheelchair passage (at least 32" clear)
6 Room to maneuver a wheelchair in the bathroom
7 Room to maneuver a wheelchair in the kitchen
8 Grab rails near the tub or shower
9 Grab rails near the toilet 

Q-14 Please rate the following aspects of your living environment: (Circle numbers) 

	Excellent	Very Good	Good	Fair	Poor
House structural condition	5	4	3	2	1
Exterior appearance of home	5	4	3	2	1
Yard/lot size	5	4	3	2	1
Adequate heating	5	4	3	2	1
Sanitation and safety	5	4	3	2	1
Security from crime	5	4	3	2	1
Quality of neighborhood	5	4	3	2	1
Distance from work	5	4	3	2	1
Occupancy costs	5	4	3	2	1

Q-15 Which one best describes the condition of your home?
1 Excellent, no repairs needed
2 Good, only a few minor repairs needed
3 Adequate, needs many, but mostly minor repairs
4 Poor, needs major repairs
5 Very poor, needs to be torn down 

Q-16 Does your home have any physical deficiencies?
1 No
2 Yes, explain ______________________________________ 

Q-17 Do you agree that this community has any of the following housing problems? 

	Disagree (Not a Problem)	Agree (Minor Problem)	Definitely Agree (A major Problem)	Don't Know
Enough different dwelling types	1	2	3	4
Enough affordable homes for sale	1	2	3	4
Enough affordable rental units	1	2	3	4
Enough subsidized/assisted housing	1	2	3	4
Enough housing for the elderly	1	2	3	4
Too much poor, dilapidated housing	1	2	3	4
Too much vacant/abandoned housing	1	2	3	4

Q-18 Do you feel that city or county funds should be spent to address the above problems?
1 Yes
2 No
3 Don't know 

Q-19 Would you say that it is difficult for the following people to find appropriate and affordable housing in your community? (Circle all that apply)

	Not difficult		Somewhat difficult		Very difficult
Married couples without children	1	2	3	4	5
Married couples with children	1	2	3	4	5
Single parents with children	1	2	3	4	5
Single persons living alone	1	2	3	4	5
People with disabilities	1	2	3	4	5
Older people aged 55-79	1	2	3	4	5
Older people aged 80 or older	1	2	3	4	5

Q-20 What types of housing should your community encourage (more of)? (Circle all that apply and note whether each should be rental and/or owned) 

	Rental	Homeownership
1 Subsidized housing for low income elderly	1	2
2 Subsidized units for nonelderly low income families	1	2
3 Accessible/adaptable housing for disabled persons	1	2
4 Mobile/manufactured homes in mobile home parks	1	2
5 Mobile/manufactured homes on individual house lots	1	2
6 None of the above--adequate housing is available	1	2

HOUSING AFFORDABILITY, PREFERENCES AND COST BURDENS 

Q-21 Are you sharing housing with someone else because you have to in order to afford it?
1 No
2 Yes 

Q-22 If housing that better suits your needs was available, how would you feel about moving or selling your home? 

1 No desire to move/sell 2 Would like to move/sell  3 Definitely want to move/sell  4 Definitely expect to move/sell  5 Definitely plan to move/sell

////Communities may wish to separate this into two different questions: move vs. sell///

Q-23 During the past year, did you try to find better or more affordable housing?
1 No
2 Tried, but not very hard
3 Tried moderately hard
4 Tried very hard 

Q-23 If able to move to other housing you could afford, would you prefer to 
1 Rent
2 Own
3 Other, explain _______________________________ 

Q-24 If you were able to move to other housing, would you consider the following options? (Circle one answer for each) 

	Definitely Not	Probably Not	Not Sure	Probably Yes	Definitely Yes
1 Sharing a home with a non-related person/family	Def-No	Prob-No	Unsure	P-Yes	Def-Yes
2 Buy a mobile home located in a rented space in a park on my own lot	Def-No	Prob-No	Unsure	P-Yes	Def-Yes
3 Buy a mobile home and place	Def-No	Prob-No	Unsure	P-Yes	Def-Yes
4 Buy a duplex and rent out 1/2	Def-No	Prob-No	Unsure	P-Yes	Def-Yes
5 Buy a single-family home	Def-No	Prob-No	Unsure	P-Yes	Def-Yes
6 Buy a townhouse (shares side walls with next house)	Def-No	Prob-No	Unsure	P-Yes	Def-Yes
7 Rent in a duplex	Def-No	Prob-No	Unsure	P-Yes	Def-Yes
8 Rent in a tri- or four-plex	Def-No	Prob-No	Unsure	P-Yes	Def-Yes
9 Rent a single-family house	Def-No	Prob-No	Unsure	P-Yes	Def-Yes
10 Rent an apartment in building with 5+ units	Def-No	Prob-No	Unsure	P-Yes	Def-Yes

Q-25 Which of the above housing options would you most prefer? (Write the number of your choices in the boxes 

Most Prefer

Second Most Prefer

Q-26 Which one of the above would you most dislike? (Write number of choice in box) Most Dislike 

ALTERNATE METHOD OF ASKING ABOUT HOUSING COSTS/INCOME RATIO (COMPARE TO "FILL-IN-THE-BLANK" METHOD ON NEXT PAGE: 

Q-27 What is your housing/income ratio? 1) Add your monthly rent or mortgage payment to your estimated average monthly utility costs, then 2) divide the total monthly housing cost by your monthly income before deductions. The result is: 

1 Less than 30 percent	Example:
2 31 - 40 percent	$300 monthly rent + $50 utilities =
3 41 - 50 percent	$350, divided by $1,000 income = 35%
4 More than 50 percent

IF YOU RENT, please answer these questions: 

Why do you choose to rent? (Circle all that apply)
1 Planning to stay a short time
2 Little or no upkeep required
3 Can't afford to buy a home
4 Other, explain _____________________________________ 

Was a security deposit required when you moved into this unit?
1 Yes, specify the amount $________
2 No 

Fill in the three blanks below and the computer will figure your housing income ratio: 

Approximately how much is your monthly rent? If the rent is cash-free, write zero (0). 

_____________ Dollars 

If not included in the rent payment, how much is the average total monthly cost for heat, electricity, and water/sewer? 

_____________ Dollars 

How much is your household's total monthly income from all jobs and other sources--before deductions? 

______________ Dollars 

Are you interested in buying a home?
1 No 
2 Yes 

If yes,
What is your affordable price range?___________________ 

If yes,
Would a 10% down payment on a home in that range be a problem?
1 No
2 Yes 

IF YOU OWN (including mobile home owners who rent their lot space), please answer these questions: 

Is this house or apartment part of:
1 A condominium
2 A housing cooperative
3 Neither 

What is the value of your home, that is, how much do you think this house and lot or condominium unit would sell for if it were for sale?
1 Less than $25,000
2 $25,001 - $50,000
3 $50,001 - $75,000
4 $75,001 - $100,000
5 $100,001 - $150,000
6 $150,001 - $200,000
7 $200,001 or more 

About how much is the monthly first mortgage payment (principal, interest, homeowners' insurance, and real estate taxes)? If the mortgage is paid off, please write zero (0). 

_____________ Dollars 

If not included in the house payment, how much is the average total monthly cost for heat, electricity, and water/sewer? 

_____________ Dollars 

How much is your household's total monthly income from all jobs and other sources--before deductions? 

______________ Dollars 

HOUSING ASSISTANCE AND SUPPORT SERVICE NEEDS 

Q-28 Do any of the following conditions interfere with the daily activities of anyone in your household? (Circle all that apply) 

1 Physical disability
2 Developmental disability such as mental retardation
3 Mental health/emotional problem 
4 Alcohol or drug dependence
5 HIV or AIDS-related complex 

Q-29 Does any adult or child in your home have a physical, mental or other health condition lasting for six months or more that: (Circle all that apply) 

1 Interferes with ability to care for personal needs (bathing, dressing) 
2 Makes it difficult to get around inside the the house
3 Limits the kind or amount of work the person can do at a job
4 Prevents this person from working at a job
5 Makes it difficult to get in and out of the house 

Q-30 In the past year, did anyone in your household need or receive outside help (from non-relatives) with any of the following? (Circle all that apply) 

	Needed	Received
Child care services	1	2
Household tasks (such as yardwork or heavy cleaning)	1	2
Personal care (bathing, dressing, etc.)	1	2
Home health assistance	1	2
Meals delivered to your home	1	2
Transportation services	1	2

Q-31 Has anyone in your household received any of the following in the past year? (Circle all that apply)
1 Food stamps
2 Energy assistance
3 Public housing assistance
4 Section 8 housing certificate or housing voucher
5 Have not received subsidized housing assistance, but am on a waiting list 

Finally, we have some questions about your household (for the statistical analysis) 

Q-32 Please list everyone who lives in your household, starting with yourself: 

Who? (e.g., wife, husband, son, daughter, parent, friend)	Age (in years)	Sex (M = Male; F = Female)
1 _______________________________	______	____
2 _______________________________	______	____
3 _______________________________	______	____
4 _______________________________	______	____
5 _______________________________	______	____
6 _______________________________	______	____

Q-33 Which of these best describes your household?
1 One person living alone
2 Married couple with no children
3 Married couple with children
4 Single-parent family
5 Includes at least one person who is unrelated to me
6 Other ________________________________________ 

Q-34 Householders' race and ethnic background (Circle the correct numbers)

	Male householder	Female householder
White	1	1
Black or Negro	2	2
American Indian	3	3
Asian or Pacific Islander	4	4
Hispanic	5	5
Other ____________________	6	6

Q-35 How many people now living in this household work outside the home for pay? 

______ persons 

Q-36 What is the employment status of the householders? (Circle the appropriate numbers) 

	Yourself	Spouse or partner
Employed or self-employed full-time	1	1
Employed or self-employed part-time	2	2
Retired	3	3
Disabled	4	4
Full-time homemaker	5	5
Full-time student	6	6
Unemployed, but looking for work	7	7
Unemployed and not looking for work	8	8
Other, explain	________________	_________________

Q-37 What category best describes your total household income from all sources--before deductions--last year? 

1 Less than $10,000 2 $10,000 - $15,000 3 $15,001 - $20,000 4 $20,001 - $25,000 5 $25,001 - $30,000 6 $30,001 - $35,000 7 $35,001 - $40,000

8 $40,001 - $45,000 9 $45,001 - $50,000 10 $50,000 - $55,000 11 $55,001 - $60,000 12 More than $60,000

Q-38 Did any of your household income over the past year come from (Circle all that apply)
1 Wages or salary 
2 Business or farm income
3 Investment income (from interest, rents, dividends)
4 Retirement income (Social Security, pension, annuities)
5 Disability income
6 Child support payments or alimony
7 Government assistance (AFDC, SSI, welfare or other public assistance)
8 Other, explain ____________________________________ 

   
Iowa State University | ISU Extension | Internet Resources | Search 

...and justice for all. The Iowa Cooperative Extension Service's programs and policies are consistent with pertinent federal and state laws and regulations on nondiscrimination regarding race, color, national origin, religion, sex, age, and disability.