OMB No. 1121-0111: Approval Expires 7/31/2006

FORM

(9-16-2004)

U.S. DEPARTMENT OF COMMERCE

NATIONAL CRIME 

VICTIMIZATION SURVEY 

ITEMS FILLED AT START OF INTERVIEW

10a.

1. Field representative identification

201

Code Name

1 Unit in sample the previous enumeration period – Fill 3

2 Unit in sample first time this period – SKIP to 4

2. Unit status

202

1 Same household interviewed the previous enumeration

3. Household status – Mark first box that applies.

203

2 Replacement household since the previous enumeration

3

4

Noninterview the previous enumeration 

Other – Specify

4. Line number of household respondent

____________ Go to page 2

Use of telephone (cc item 26a and b)

AFTER INTERVIEW – TRANSCRIBE FROM CONTROL CARD

5. Group Quarters (GQ) type code

____________

204

1 Owned or 

being bought

6. Tenure (cc item 8a)

206 2 Rented

for cash

3 No cash

rent

1 Urban

7. Land use (cc item 9)

207 2 Rural

X Item blank

8. Farm sales (cc item 10)

208 1 $1,000 or more 2 Less than $1,000

9. Type of living quarters (cc items 11c and 11d)

Housing unit

1

2

3

4

5

House, apartment, flat

HU in nontransient hotel, motel, etc.

HU permanent in transient hotel, motel, etc.

HU in rooming house

209

Mobile home or trailer with no permanent room added

7 HU not specified above – Describe

6 Mobile home or trailer with one or more permanent rooms added

OTHER unit

8 Quarters not HU in rooming or boarding house

9 Unit not permanent in transient hotel, motel, etc.

10 Unoccupied site for mobile home, trailer, or tent

Student quarters in college dormitory

OTHER unit not specified above – Describe

11

12

1 Phone in unit ...................

2 Phone in common area (hallway, etc.) ....

Phone in another unit (neighbor, friend, etc.)

Work/office phone ................

No phone – SKIP to 11a

3

4

5

10b. Is phone interview acceptable? (cc item 26d)

Fill 10b

210

211 1 Yes 2 No 3 Refused to give number

11a. Number of housing units in structure (cc item 27a)

1

2

3

1 – SKIP to 11c

2

3

213

4

5

6

4

5–9

10+

7 Mobile home/trailer –

SKIP to 11c

8 Only OTHER units

11b.

Restricted access (cc item 27c)

1 Yes 3 DK

12a. Household Income (cc item 28)

214

8

9

10

20,000 – 24,999

25,000 – 29,999

30,000 – 34,999

ITEMS FILLED DURING AND/OR AFTER INTERVIEW

13. Proxy information – Fill for all proxy interviews

a. Proxy interview obtained 

for Line No.

b. Reason

(Enter

code)

c. Reason

(Enter

code)

301 302 303

Name Line No.

304 305 306

307 308 309

310 311 312

Codes for item 13c

FILL INTER-COMM

14. Type Z noninterview

a. Interview not

obtained for

Line No.

b. Proxy respondent

313

315

317

319

314

316

318

320

Complete 17—28 for each Line No. in 14a

Codes for item 14b

FILL

INTERCOMM

15a. Household members 12 years of age and OVER

____________ Total number 321

15b. Household members UNDER 12 years of age

____________ Total number 322 0 None

15d. Crime Incident Reports filled

____________ Total number of NCVS-2s filled 323 0 None

Fill BOUNDING INFORMATION

N

C

V

S

1

2 No Item blank

6

7

1

2

3

4

5

Less than $5,000

$5,000 – 7,499

7,500 – 9,999

10,000 – 12,499

12,500 – 14,999

12c. Public Housing (cc item 8c)

1 Yes (public 

housing)

219

12d. Manager Verification of Public Housing (cc item 8d)

Unable to verify

1

2

Public housing 

Not public housing

220

3

4

CATI/Telephone

Other – Specify

NCVS-1 BASIC SCREEN QUESTIONNAIRE

12b. College/University (cc item 8b)

1 Yes 2 No

Able to verify

218

X

X Item blank

X Item blank

No (not public 

housing)

2

b. Reason (Enter code)

16. Changes in Household Composition (cc item 25a)

a. Line No.

324

326

328

330

15,000 – 17,499

17,500 – 19,999

11

12

13

14

35,000 – 39,999

40,000 – 49,999

50,000 – 74,999

75,000 and over

325

327

329

331

Only transcribe

changes discovered

during the current

enumeration

BEFORE INTERVIEW – TRANSCRIBE FROM CONTROL CARD

ACTING AS COLLECTING AGENT FOR THE

BUREAU OF JUSTICE STATISTICS

U.S. DEPARTMENT OF JUSTICE

Control number

PSU Segment/Suffix

AFTER INTERVIEW – TRANSCRIBE FROM CONTROL CARD – Cont.

3– TA and won’t return before closeout

American Indian Reservation or American Indian Lands

(cc item 8e)

221 1 Yes 2 No

12e.

Economics and Statistics Administration

U.S. CENSUS BUREAU

212

6 – Office use only

3 – Physically/ 

mentally 

unable to 

answer—no 

proxy available 

4 – TA and no proxy 

available . . . .

1 – Never available

NOTICE – We are conducting this survey under the authority of Title 13, United States Code, NCVS-1

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

Code, also requires us to keep all information about you and your household strictly confidential.

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.

205

2 – Refused ....

5 – Other ......

Location of phone – Mark first box that applies.

1–12–13 years old and parent refused permission for self interview

2– Physically/mentally unable to answer

11c.

222 Gated or walled community 1 Yes 2 No X Item blank

Building with restricted access 1 Yes 2 No X Item blank

Direct outside access (cc item 27b)

USCENSUSBUREAU

223

Sample 

designation/Suffix

Serial/

Suffix

15c. Number of Type Z noninterview household members 

12 years of age and OVER

____________ Total number 332 0 None

HH No. Spinoff

Indicator
HOUSEHOLD RESPONDENT’S PERSONAL CHARACTERISTICS

17. NAME (of household respondent)

Last

First

Type of interview

Line

No.

401

1

2

3

4

Per. – Self-respondent

Tel. – Self-respondent

Per. – Proxy

Tel. – Proxy

18. 19.

Fill 13 on cover page ________

Line No.

29.

33a.

Date of interview 501

If unsure, ASK OR VERIFY –

How long have you lived at this address? 

(Enter number of months OR years.)

____________ Months (1-11) – SKIP to 33b 505

OR

____________ Years (Round to nearest whole year) – 

Fill Check Item A

506

5 years or more – SKIP to 34

Less than 5 years – Ask 33b

CHECK

ITEM A

How many years are entered in 33a?

33b. Altogether, how many times have you moved in the last 

5 years, that is, since _________________, 20 ___? ____________ Number of times 508

Page 2 FORM NCVS-1 (9-16-2004)

402

AFTER INTERVIEW – TRANSCRIBE FROM CONTROL CARD

20.

Relationship to

reference

person

21.

Age last

birthday

22a.

Marital status 

THIS survey 

period

22b.

Marital

status LAST

survey period

23.

Sex

24.

Armed

Forces

member

25.

Educational

attainment

28.

Race

27.

Hispanic

origin

403

01

02

03

04

05

06

07

08

09

10

11

Husband

Wife

Son

Daughter

Father

Mother

Brother

Sister

Other relative

Nonrelative

Ref. person

________

Age

405

1

2

3

4

5

Married

Widowed

Divorced

Separated

Never

married

406

1

2

3

4

5

Married

Widowed

Divorced

Separated

Never

married

Not interviewed

last

survey

period

6

407

1

2

M

F

408

1

2

Yes

No

413

1

2

Yes

No

404

____________

Highest level 

completed

409 412

1

2

White

American

Indian/Alaska

Native

Asian

Other – Specify

4

6

26.

Attending

school

411

1 College/

University

Trade

school

Vocational

school

4 None of

the

above

schools

2

3

(cc 13b) (cc 17) (cc 18) (From previous

enumeration)

(cc 19) (cc 20) (cc 21) (cc 22) (cc 24) (cc 23)

Month Day Year

Regular 

school

0

MOBILITY QUESTIONS

BUSINESS OPERATED FROM SAMPLE ADDRESS

34. Does anyone in this household operate a business from

this address?

35. Is there a sign on the premises or some

other indication to the general public that a

business is operated from this address?

PERSONAL – Fill by observation.

TELEPHONE – Ask.

1

2

Yes – Go to 35

No – SKIP to 36a

530

1

2

Yes (Recognizable business)

No (Unrecognizable business)

531

Before we get to the crime questions, I have some

questions that are helpful in studying where and why

crimes occur.

Black/African

American

Native

Hawaiian/Other

Pacific Islander

5

3

*

Mark (X) all that

apply.
HOUSEHOLD RESPONDENT’S SCREEN QUESTIONS

36a. I’m going to read some examples that will give you an

idea of the kinds of crimes this study covers.

Page 3

Was something belonging to YOU stolen, such as –

(a) Things that you carry, like luggage, a wallet,

purse, briefcase, book –

As I go through them, tell me if any of these

happened to you in the last 6 months, that is

since __________ ______, 20 ____.

(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 –

(h) Did anyone ATTEMPT to steal anything

belonging to you?

OR

36b. Did any incidents of this type happen to you?

MARK OR ASK –

36c. How many times?

37a. (Other than any incidents already mentioned,)

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?

(c) Illegally gotten in or tried to get into a hotel or

motel room or vacation home where you were

staying?

(b) Has anyone illegally gotten in or tried to get

into a garage, shed, or storage room?

OR

37b. Did any incidents of this type happen to you?

MARK OR ASK –

37c. How many times?

Briefly describe incident(s)

1

Yes – What happened? 

532

Number of times (36c)

533

No – SKIP to 38

2

Describe above

Briefly describe incident(s)

534 1

Number of times (37c)

535

2

FORM NCVS-1 (9-16-2004)

Yes – What happened? 

No – SKIP to 37a

Describe above
HOUSEHOLD RESPONDENT’S SCREEN QUESTIONS

39a.

38. What was the TOTAL number of cars, vans, trucks,

motorcycles, or other motor vehicles owned by you or

any other member of this household during the last 

6 months? Include those you no longer own.

During the last 6 months, (other than any incidents

already mentioned,) (was the vehicle/were any of

the vehicles) –

Page 4

(a) Stolen or used without permission?

(Other than any incidents already mentioned,)

since __________ ______, 20 ____, were you attacked

or threatened OR did you have something stolen

from you –

(b) Did anyone steal any parts such as a tire, car

stereo, hubcap, or battery?

(c) Did anyone steal any gas from (it/them)?

(d) Did anyone ATTEMPT to steal any vehicle or parts

attached to (it/them)?

OR

39b. Did any incidents of this type happen to you?

MARK OR ASK –

39c. How many times?

40a.

(a) At home including the porch or yard –

(c) At work or school –

(b) At or near a friend’s, relative’s, or

neighbor’s home –

OR

40b. Did any incidents of this type happen to you?

MARK OR ASK –

40c. How many times?

0

1

2

3

4

None – SKIP to 40a

1

2

3

4 or more

536

Briefly describe incident(s)

537 1 Yes – What happened?

Number of times (39c)

538

2 No – SKIP to 40a

Describe above

539 1 Yes – What happened? 

Number of times (40c)

540

2 No – SKIP to 41a

Describe above

(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 –

Briefly describe incident(s)

(h) Did anyone ATTEMPT to attack or ATTEMPT

to steal anything belonging to you from any of

these places?

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

Page 5

(Other than any incidents already mentioned,)

has anyone attacked or threatened you in any

of these ways (Exclude telephone threats) –

41a.

(a) With any weapon, for instance, a gun or

knife –

(c) By something thrown, such as a rock or

bottle –

(b) With anything like a baseball bat, frying

pan, scissors, or stick –

OR

41b. Did any incidents of this type happen to you?

MARK OR ASK –

41c. How many times?

Briefly describe incident(s)

541 1 Yes – What happened?

Number of times (41c)

542

2 No – SKIP to 42a

Describe above

(d) Include any grabbing, punching, or choking,

(e) Any rape, attempted rape or other type of

sexual attack –

(f) Any face to face threats –

(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.

People often don’t think of incidents committed

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) –

42a.

(a) Someone at work or school –

(c) A relative or family member –

(b) A neighbor or friend –

42b. Did any incidents of this type happen to you?

MARK OR ASK –

42c. How many times?

Briefly describe incident(s)

543 1 Yes – What happened?

Number of times (42c)

544

2 No – SKIP to 43a

Describe above

(d) Any other person you’ve met or known?

Incidents involving forced or unwanted sexual

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 –

43a.

(a) Someone you didn’t know before –

(c) Someone you know well?

(b) A casual acquaintance –

43b. Did any incidents of this type happen to you?

MARK OR ASK –

43c. How many times?

Briefly describe incident(s)

545 1 Yes – What happened?

Number of times (43c)

546

2 No – SKIP to 44a

Describe above

OR

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

Page 6

During the last 6 months, (other than any

incidents already mentioned,) did you call the

police to report something that happened to YOU

which you thought was a crime?

44a. Briefly describe incident(s)

547 1 Yes – What happened?

2 No – SKIP to 45a

Describe above

44b. How many times?

548

*

OFFICE USE ONLY

CHECK

ITEM B Look at 44a. If unsure, ASK, otherwise, mark without

asking. 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?

1

2

Yes – Ask 44b 

No – SKIP to 45a

549

Number of times (44b)

550

During the last 6 months, (other than any

incidents already mentioned,) did anything which

you thought was a crime happen to YOU, but you

did NOT report to the police?

45a. Briefly describe incident(s)

551 1 Yes – What happened?

No – SKIP to INTRO 1 at top of

page 7

2

Describe above

45b. How many times?

552

*

OFFICE USE ONLY

CHECK

ITEM C Look at 45a. If unsure, ASK, otherwise, mark without

asking. 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?

1

2

553 Yes – Ask 45b 

NOTES

554

Number of times (45b)

No – SKIP to INTRO 1 at top of

page 7

FORM NCVS-1 (9-16-2004)
Page 7

HOUSEHOLD RESPONDENT’S IDENTITY THEFT QUESTIONS

FIELD REPRESENTATIVE – Read introduction.

Did these episodes of identify theft occur separately

or at the same time?

45e.

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.

FORM NCVS-1 (9-16-2004)

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

to place charges on an account? .......... 107 1 Yes 2 No 3 Don’t know

(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

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

crime? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

108 1 Yes 2 No 3 Don’t know

109 1 Yes 2 No 3 Don’t know

CHECK

ITEM C1 Look at 45c. How many times is box 1 (Yes)

marked in 45c?

1

2

None (no entries of Yes) – SKIP to Check Item D

One or more times – Ask 45d

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

household.

Was the misuse of – (the credit card account(s)/any

existing account(s) other than credit cards/personal

information or new account(s)) one episode or more

than one episode of identity theft?

45d.

1

2

3

Existing credit cards 

Existing accounts other than a credit card

Personal information to obtain new accounts

110

Mark (X) all that apply.

1

2

One – SKIP to 45g

More than one

111 1

2

Separately

At the same time – SKIP to 45g

45f. Which episode of identity theft was most recently

discovered?

112

45g. How did you become aware of the identity theft? 113 1 Block was placed on a credit card or other existing account

6

7

8

9

Money missing from account or charges placed on an

account

Contacted by a credit bureau, collection agency, credit card

company or other company about late/unpaid bills 

Contacted by a bank

Noticed that a credit card, check book, etc. was missing

Notified by a law enforcement agency

Denied credit or a loan

Noticed an error in a credit report

Other – Specify

3

4

5

2

45h. What was the total dollar amount of the credit,

loans, cash, services, and anything else the person

obtained while misusing (the credit card

account(s)/any existing accounts other than credit

cards/personal information or new account(s))?

$ .00 Amount taken

X Don’t know

0 None

Yes 

No

Don’t know

115

114

Has the misuse of – (the credit card account(s)/any

existing accounts other than credit cards/personal

information or new account(s)) stopped (e.g. you or

a household member closed a checking account)?

45i.

Is the misuse of – (the credit card account(s)/any

existing accounts other than credit cards/personal

information or new account(s)) still causing

problems for you or any other household member?

For example, are you still spending time clearing up

credit accounts or your credit report?

45j. Yes – SKIP to 45l

No

Don’t know

116

1

2

3

1

2

3

*
Page 8

HOUSEHOLD RESPONDENT’S IDENTITY THEFT QUESTIONS

FORM NCVS-1 (9-16-2004)

CHECK 

ITEM E

HOUSEHOLD RESPONDENT’S CHECK ITEMS D AND E

1 

2 

3 

1

Yes 

No 

Person for whom interview taken not present

2 

3 

4 

5 

6 

7 

8

Telephone interview – SKIP to 46a 

Personal interview – Mark all that apply.

If self-response interview, SKIP to 46a

555

No one besides respondent present 

Respondent’s spouse 

HHLD member(s) 12+, not spouse 

HHLD member(s) under 12 

Nonhousehold member(s) 

Someone was present – Can’t say who 

Don’t know if someone else present

CHECK 

ITEM D Who besides the respondent was present when the

screen questions were asked? (If telephone

interview, mark box 1 only.) *

556

11 No problems

45l. As a result of (any of) the misuse of (the credit card

account(s)/any existing account(s) other than credit

cards/personal information or new account(s))

discovered in the last 6 months, have you or anyone

in your household . . . 

(Read answer categories 1–10)

Mark (X) all that apply.

119

*

1 

2 

3 

4

Been turned down for a loan? 

Had banking problems? 

Had problems with credit card accounts? 

Had phone or utilities cut off or been denied new

service? 

Been turned down for insurance or had to pay

higher rates? 

Been contacted by a debt collector or creditor? 

Been the subject of a civil suit or judgment? 

Been the subject of a criminal investigation,

warrant, proceeding, or conviction? 

Had some other problems?– Specify 

6

7 

8 

9

10

CHECK 

ITEM C2 Briefly summarize the identity theft that occurred

against the respondent or another household member.

X Don’t know days or months

Less than one month:

____________ Days 117

OR

____________ Months 118

1 – 6 Months:

45k. How much time did it take to resolve ALL PROBLEMS

associated with the misuse of – (the credit card

account(s)/any existing account(s) other than credit

cards/personal information or new account(s)) after

the misuse was discovered?

Had to pay higher interest rates on credit cards,

loans, etc.

5

HOUSEHOLD RESPONDENT’S VANDALISM SCREEN QUESTIONS

46a.

1

2

3

4

5

6

7

Motor vehicle (including parts)

Bicycle (including parts)

Mailbox

House window/screen/door

Yard or garden (trees, shrubs, fence, etc.)

Furniture, other household goods

Clothing

Animal (pet, livestock, etc.)

558

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.

46b. What kind of property was damaged or destroyed

in this/these act(s) of vandalism? Anything else?

Since __________ ______, 20 ____, has anyone intentionally

damaged or destroyed property owned by you or

someone else in your household? 1

2

557 Yes

8

9 Other – Specify

*

Mark (X) all property that was damaged or destroyed by

vandalism during reference period.

Continue asking "Anything else?" until you get a "No" response. 

(EXCLUDE any damage done in conjunction with

incidents already mentioned.)

No – SKIP to Check Item G 

on page 11

Did the person for whom this interview was taken

help the proxy respondent answer any screen

questions?
HOUSEHOLD RESPONDENT’S VANDALISM SCREEN QUESTIONS

Page 9

1 Broken glass: window, windshield,

glass in door, mirror

46c. What kind of damage was done in this/these 559 act(s) of vandalism? Anything else?

2

3

4

5

6

Defaced: marred, graffiti, dirtied

Burned: use of fire, heat or explosives

Drove into or ran over with vehicle

Other breaking or tearing

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

last 6 months? (Use repair costs if the property was

repaired.)

46f. How many times?

560 $ .

– SKIP to Check

Item F1

X

0

Don’t know

No cost – SKIP to Check Item F1

46e. Was the damage under $100 or $100 or more? 1

2

3

Under $100

$100 or more

Don’t know

561

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)

Briefly describe incident(s)

562 1 Yes – What happened?

2 No – SKIP to 46g

Describe above

Number of times (46f)

563

CHECK

ITEM F1

00

Mark (X) all kinds of damage by vandals that occurred

during reference period.

Continue asking "Anything else?" until you get a "No" response. 

(INCLUDE total amount for all incidents of

vandalism during the last 6 months.)

(EXCLUDE any damage done in incidents already

mentioned.)

NOTES

FORM NCVS-1 (9-16-2004)
Page 10

CHECK

ITEM F2 Are one or more boxes marked "Yes" in 46h

OR 46i?

Yes – Ask 46j

No – SKIP to Check Item G

46g.

1 Yes 2 No

587 1 2 No

3 Don’t know

3 Don’t know

HOUSEHOLD RESPONDENT’S HATE CRIME SCREEN QUESTIONS

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

discussed was a hate crime or crime of prejudice or

bigotry?

Yes – Ask 46h

No . . . . . . .

Don’t know . .

1

2

3

586

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? ...........................

(b) Your religion? .........................

(c) Your ethnic background or national origin (for

example, people of Hispanic origin)? ........

(e) Your gender? .........................

(f) Your sexual orientation? .................

If "Yes," SAY – (by this we mean homosexual,

bisexual, or heterosexual)

(d) Any disability (by this I mean physical, mental, or

developmental disabilities) you may have? ....

1 Yes 2 No 3 Don’t know

1 Yes 2 No 3 Don’t know

1 Yes 2 No 3 Don’t know

1 Yes 2 No 3 Don’t know

1 Yes 2 No 3 Don’t know

564

565

566

567

568

569

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)? ...................

(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)? ........................

Yes – Specify

589 1 2 Yes – Specify No 3 Don’t know

46j. Do you have any evidence that this vandalism was a

hate crime or crime of prejudice or bigotry?

If "No" or "Don’t know," ASK – 

1

2

3

591

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?

SKIP to Check Item G

Yes – Ask 46k 

No . . . . . . . .

Don’t know . . . SKIP to Check Item G

588

590

FORM NCVS-1 (9-16-2004)
Page 11

CHECK 

ITEM G Transcribe "number of times" entry for each

of the following:

(a) ____________ Number of times (36c)

(h)

(i)

No entries transcribed below – Go to Check

Item H

____________ Number of times (37c)

____________ Number of times (39c)

____________ Number of times (40c)

____________ Number of times (41c)

____________ Number of times (42c)

____________ Number of times (43c)

____________ Number of times (44b)

____________ Number of times (45b)

____________ Number of times (46f)

(f)

(g)

(j)

(b)

(c)

(d)

(e)

Screen Question, Item 36c, page 3 

Screen Question, Item 39c, page 4 

Screen Question, Item 40c, page 4 

Screen Question, Item 41c, page 5 

Screen Question, Item 42c, page 5 

Screen Question, Item 43c, page 5 

Screen Question, Item 44b, page 6 

Screen Question, Item 45b, page 6 

Screen Question, Item 37c, page 3 

Vandalism Screen Question, Item 46f, page 9

HOUSEHOLD RESPONDENT’S CHECK ITEM G

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.

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? ....................

(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)? ....................

(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)? .......

(d) Do you know if the offender(s) (has/have)

committed similar hate crimes or crimes of

prejudice or bigotry in the past? ...........

(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)? .....

(f) Have other hate crimes or crimes of prejudice or

bigotry happened to you or in your area/

neighborhood where people have been targeted?

(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? ........

592 1 Yes 2 No 3 Don’t know

593 1 Yes 2 No 3 Don’t know

594 1 Yes 2 No 3 Don’t know

595 1 Yes 2 No 3 Don’t know

596 1 Yes 2 No 3 Don’t know

597 1 Yes 2 No 3 Don’t know

598 1 Yes 2 No 3 Don’t know

FORM NCVS-1 (9-16-2004)
1

2

3

4

Physician

Nurse

Technician

Other – Specify

579

Did you have a job or work at a business LAST WEEK?

(Do not include volunteer work or work around the house.)

47a.

576 1

2

Yes – SKIP to 48a 

No – Ask 47b

Did you have a job or work at a business DURING THE

LAST 6 MONTHS?

47b.

ASK OR VERIFY – 577

578 1

2

1

2

Yes – Ask 47c

No – SKIP to Check Item I

Yes – Ask 48a

No – SKIP to Check Item I

Did that (job/work) last 2 consecutive weeks

or more?

47c.

48a. Which of the following best describes your job?

ASK OR VERIFY – Medical Profession – As a –

Mental Health Services Field – Are your duties –

Teaching Profession – Were you employed in a –

Law Enforcement or Security Field – Were you

employed as a –

Retail Sales – Were you employed as a –

Transportation Field – Were you employed as a –

Something else – Specify

5

6

7

Professional (Social worker/psychiatrist)

Custodial care

Other – Specify

8

9

Preschool

Elementary

Junior high or middle school

High school

College or university

Technical or industrial school

Special education facility 

Other – Specify

10

11

12

13

14

15

Law enforcement officer

Prison or jail guard

Security guard

Other – Specify

16

17

18

19

Convenience or liquor store clerk

Gas station attendant

Bartender

Other – Specify

20

21

22

23

Bus driver

Taxi cab driver

Other – Specify

24

25

26

27

OR

(If farm or business operator in household, ask about

unpaid work.)

PERSONAL INTERVIEW (Show flashcard)

TELEPHONE INTERVIEW – Were you employed

in the (Read main headings until you get a yes.

Then read answer categories) –

Mark (X) only one category.

CHECK

ITEM H Is the respondent 16 years or older?

1

2

Yes – Ask 47a

No – SKIP to Check Item I

HOUSEHOLD RESPONDENT’S EMPLOYMENT QUESTIONS

CHECK

ITEM I Is this the last household member to be

interviewed?

Yes – Ask or verify Control Card items.

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.

48b. Is your job with (Read answer categories) –

ASK OR VERIFY – 580 1 A private company, business, or individual for wages?

2

3

4

The Federal government?

A State, county, or local government?

Yourself (Self-employed) in your own business,

professional practice, or farm?

While working at your job, do you work mostly in

(Read answer categories) –

48d. 1

2

3

4

A city?

Suburban area?

Rural area?

Combination of any of these?

582

If box 12 is marked in 48a, mark without asking.

48c.

581 1

2

Yes

Are you employed by a college or university? No

Be sure to fill any incident reports before marking Check Item H.

Page 12 FORM NCVS-1 (9-16-2004)
INDIVIDUAL’S PERSONAL CHARACTERISTICS

Noninterview – Fill 19 – 28 on this page. Also

fill 14 and adjust item 15c on cover page.

5

17. NAME

Last

First

Type of interview

Line

No.

401

1

2

3

4

Per. – Self-respondent 

Tel. – Self-respondent 

Per. – Proxy 

Tel. – Proxy

18. 19.

Fill 13 on cover page ________

Line No.

402

AFTER INTERVIEW – TRANSCRIBE FROM CONTROL CARD

29.

33a.

Date of interview 501

If unsure, ASK OR VERIFY –

How long have you lived at this address? 

(Enter number of months OR years.)

____________ Months (1-11) – SKIP to 33b 505

OR

____________ Years (Round to nearest whole year) – 

Fill Check Item A

506

5 years or more – SKIP to 36a

Less than 5 years –Ask 33b

CHECK

ITEM A

How many years are entered in 33a?

33b. Altogether, how many times have you moved in the last 

5 years, that is, since _________________, 20 ___? ____________ Number of times 508

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.

20.

Relationship to

reference

person

21.

Age last

birthday

22a.

Marital status 

THIS survey 

period

22b.

Marital

status LAST

survey period

23.

Sex

24.

Armed

Forces

member

25.

Educational

attainment

28.

Race

27.

Hispanic

origin

01

02

03

04

05

06

07

08

09

10

11

Husband

Wife

Son

Daughter

Father

Mother

Brother

Sister

Other relative

Nonrelative

Ref. person

________

Age

1

2

3

4

5

Married

Widowed

Divorced

Separated

Never

married

1

2

3

4

5

Married

Widowed

Divorced

Separated

Never

married

Not interviewed

last

survey

period

6

1

2

M

F

1

2

Yes

No

1

2

Yes

No

____________

Highest level 

completed

1

2

White

American

Indian/Alaska

Native

Asian

Other – Specify

4

6

26.

Attending

school

1 College/

University

Trade

school

Vocational

school

4 None of

the

above

schools

2

3

(cc 13b) (cc 17) (cc 18) (From previous

enumeration)

(cc 19) (cc 20) (cc 21) (cc 22) (cc 24) (cc 23)

Regular 

school

0

Black/African

American

Native

Hawaiian/Other

Pacific Islander

5

3

403 404 405 406 407 408 409 411 413 412

*

Mark (X) all that

apply.

Page 13 FORM NCVS-1 (9-16-2004)
Page 14

INDIVIDUAL’S SCREEN QUESTIONS

36a. I’m going to read some examples that will give you an

idea of the kinds of crimes this study covers.

Was something belonging to YOU stolen, such as –

(a) Things that you carry, like luggage, a wallet,

purse, briefcase, book –

As I go through them, tell me if any of these

happened to you in the last 6 months, that is since

__________ ______, 20 ____.

(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 –

(f) Did anyone ATTEMPT to steal anything

belonging to you?

OR

36b. Did any incidents of this type happen to you?

MARK OR ASK –

36c. How many times?

40a.

(a) At home including the porch or yard –

OR

40b. Did any incidents of this type happen to you?

MARK OR ASK –

40c. How many times?

Briefly describe incident(s)

1

532

Number of times (36c)

533

2

Describe above

539

Number of times (40c)

540

(Other than any incidents already mentioned,)

since __________ ______, 20 ____, were you attacked

or threatened OR did you have something stolen

from you –

(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 –

(h) Did anyone ATTEMPT to attack or ATTEMPT to

steal anything belonging to you from any of

these places?

Briefly describe incident(s)

▼ ▼

No – SKIP to 41a

Yes – What happened?

1

2

Describe above

No – SKIP to 40a

Yes – What happened?

FORM NCVS-1 (9-16-2004)
Page 15

INDIVIDUAL’S SCREEN QUESTIONS

(Other than any incidents already mentioned,)

has anyone attacked or threatened you in any of

these ways (Exclude telephone threats) –

41a.

(a) With any weapon, for instance, a gun or

knife –

(c) By something thrown, such as a rock or

bottle –

(b) With anything like a baseball bat, frying pan,

scissors, or stick –

OR

41b. Did any incidents of this type happen to you?

MARK OR ASK –

41c. How many times?

Briefly describe incident(s)

541 1 Yes – What happened?

Number of times (41c)

542

2 No – SKIP to 42a

Describe above

(d) Include any grabbing, punching, or choking,

(e) Any rape, attempted rape or other type of

sexual attack –

(f) Any face to face threats –

(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.

People often don’t think of incidents committed

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) –

42a.

(a) Someone at work or school –

(c) A relative or family member –

(b) A neighbor or friend –

42b. Did any incidents of this type happen to you?

MARK OR ASK –

42c. How many times?

Briefly describe incident(s)

543 1 Yes – What happened?

Number of times (42c)

544

2 No – SKIP to 43a

Describe above

(d) Any other person you’ve met or known?

Incidents involving forced or unwanted sexual

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 –

43a.

(a) Someone you didn’t know before –

(c) Someone you know well?

(b) A casual acquaintance –

43b. Did any incidents of this type happen to you?

MARK OR ASK –

43c. How many times?

Briefly describe incident(s)

545 1 Yes – What happened?

Number of times (43c)

546

2 No – SKIP to 44a

Describe above

OR

▼ ▼ ▼

FORM NCVS-1 (9-16-2004)
Page 16

44a. Briefly describe incident(s)

547 1 Yes – What happened?

2 No – SKIP to 45a

Describe above

44b. How many times?

548

* OFFICE USE ONLY

CHECK

ITEM B Look at 44a. If unsure, ASK, otherwise, mark without asking.

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?

1

2

Yes – Ask 44b 

No – SKIP to 45a

549

Number of times (44b)

550

45a. Briefly describe incident(s)

551 1 Yes – What happened?

2 No – SKIP to Check Item D below

Describe above

How many times?

552

*

OFFICE USE ONLY

CHECK

ITEM C Look at 45a. If unsure, ASK, otherwise, mark without

asking. 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?

1

2

553

Number of times (45b)

554

During the last 6 months, (other than any

incidents already mentioned,) did you call the

police to report something that happened to YOU

which you thought was a crime?

During the last 6 months, (other than any

incidents already mentioned,) did anything which

you thought was a crime happen to YOU, but you

did NOT report to the police?

INDIVIDUAL’S SCREEN QUESTIONS

45b.

FORM NCVS-1 (9-16-2004)

CHECK 

ITEM E

INDIVIDUAL’S CHECK ITEMS D, E, AND G

1 

2 

3 

1

Yes 

No 

Person for whom interview taken not present

2 

3 

4 

5 

6 

7 

8

Telephone interview – SKIP to Check Item G

Personal interview – Mark all that apply.

Did the person for whom this interview was taken help

the proxy respondent answer any screen questions?

555

No one besides respondent present 

Respondent’s spouse 

HHLD member(s) 12+, not spouse 

HHLD member(s) under 12 

Nonhousehold member(s) 

Someone was present – Can’t say who 

Don’t know if someone else present

CHECK 

ITEM D

If self-response interview, SKIP to Check Item G

Who besides the respondent was present when the

screen questions were asked? (If telephone interview,

mark box 1 only.) *

CHECK

ITEM G

____________ Number of times (36c)

____________ Number of times (40c)

____________ Number of times (41c)

____________ Number of times (42c)

____________ Number of times (43c)

____________ Number of times (44b)

____________ Number of times (45b)

Transcribe "number of times" entry for each of the following:

(a)

(f)

(g)

(b)

(c)

(d)

(e)

Screen Question, Item 36c, page 14

Screen Question, Item 41c, page 15

Screen Question, Item 42c, page 15

Screen Question, Item 43c, page 15

Screen Question, Item 44b, page 16

Screen Question, Item 45b, page 16

Screen Question, Item 40c, page 14

No entries transcribed below – Go to Check Item H

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.

556

Yes – Ask 45b 

No – SKIP to Check Item D below
INDIVIDUAL’S EMPLOYMENT QUESTIONS

Page 17

CHECK

ITEM H Is the respondent 16 years or older?

1

2

3

4

Physician

Nurse

Technician

Other – Specify

579

1

2

Yes – Ask 47a

No – SKIP to Check Item I

Did you have a job or work at a business LAST WEEK?

(Do not include volunteer work or work around the house.)

47a.

576 1

2

Yes – SKIP to 48a 

No – Ask 47b

Did you have a job or work at a business DURING THE

LAST 6 MONTHS?

47b.

ASK OR VERIFY –

577

578 1

2

1

2

Yes – Ask 47c

No – SKIP to Check Item I

Yes – Ask 48a

No – SKIP to Check Item I

Did that (job/work) last 2 consecutive weeks

or more?

47c.

48a. Which of the following best describes your job?

ASK OR VERIFY –

Medical Profession – As a –

Mental Health Services Field – Are your duties –

Teaching Profession – Were you employed in a –

Law Enforcement or Security Field – Were you

employed as a –

Retail Sales – Were you employed as a –

Transportation Field – Were you employed as a –

Something else – Specify

5

6

7

Professional (Social worker/psychiatrist)

Custodial care

Other – Specify

8

9

Preschool

Elementary

Junior high or middle school

High school

College or university

Technical or industrial school

Special education facility 

Other – Specify

10

11

12

13

14

15

Law enforcement officer

Prison or jail guard

Security guard

Other – Specify

16

17

18

19

Convenience or liquor store clerk

Gas station attendant

Bartender

Other – Specify

20

21

22

23

Bus driver

Taxi cab driver

Other – Specify

24

25

26

27

OR

Be sure to fill any incident reports before marking Check Item H.

PERSONAL INTERVIEW (Show flashcard)

TELEPHONE INTERVIEW –Were you employed 

in the (Read main headings until you get a yes. 

Then read answer categories) –

Mark (X) only one category.

(If farm or business operator in household, ask about

unpaid work.)

CHECK

ITEM I Is this the last household member to be

interviewed?

48b. Is your job with (Read answer categories) –

ASK OR VERIFY –

580 1 A private company, business, or individual for wages?

2

3

4

The Federal government?

A State, county, or local government?

Yourself (Self-employed) in your own

business, professional practice, or farm?

While working at your job, do you work mostly in

(Read answer categories) –

48d.

1

2

3

4

A city?

Suburban area?

Rural area?

Combination of any of these?

582

Yes – END interview. 

If box 12 is marked in 48a, mark without asking. 48c. Are you employed by a college or university? Yes

No

581 1

2

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.

No – See note below before interviewing next 

household member.

FORM NCVS-1 (9-16-2004)
Page 18

INDIVIDUAL’S PERSONAL CHARACTERISTICS

17. NAME

Last

First

Type of interview

Line

No.

401

1

2

3

4

Per. – Self-respondent 

Tel. – Self-respondent 

Per. – Proxy 

Tel. – Proxy

18. 19.

Fill 13 on cover page ________

Line No.

402

AFTER INTERVIEW – TRANSCRIBE FROM CONTROL CARD

29.

33a.

Date of interview 501

If unsure, ASK OR VERIFY –

How long have you lived at this address? 

(Enter number of months OR years.)

____________ Months (1-11) – SKIP to 33b 505

OR

____________ Years (Round to nearest whole year) – 

Fill Check Item A

506

5 years or more – SKIP to 36a

Less than 5 years –Ask 33b

CHECK

ITEM A

How many years are entered in 33a?

33b. Altogether, how many times have you moved in the last 

5 years, that is, since _________________, 20 ___? ____________ Number of times 508

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.

20.

Relationship to

reference

person

21.

Age last

birthday

22a.

Marital status 

THIS survey 

period

22b.

Marital

status LAST

survey period

23.

Sex

24.

Armed

Forces

member

25.

Educational

attainment

28.

Race

27.

Hispanic

origin

01

02

03

04

05

06

07

08

09

10

11

Husband

Wife

Son

Daughter

Father

Mother

Brother

Sister

Other relative

Nonrelative

Ref. person

________

Age

1

2

3

4

5

Married

Widowed

Divorced

Separated

Never

married

1

2

3

4

5

Married

Widowed

Divorced

Separated

Never

married

Not interviewed

last

survey

period

6

1

2

M

F

1

2

Yes

No

1

2

Yes

No

____________

Highest level 

completed

1

2

White

American

Indian/Alaska

Native

Asian

Other – Specify

4

6

26.

Attending

school

1 College/

University

Trade

school

Vocational

school

4 None of

the

above

schools

2

3

(cc 13b) (cc 17) (cc 18) (From previous

enumeration)

(cc 19) (cc 20) (cc 21) (cc 22) (cc 24) (cc 23)

Regular 

school

0

Black/African

American

Native

Hawaiian/Other

Pacific Islander

5

3

403 404 405 406 407 408 409 411 413 412

*

Mark (X) all that

apply.

FORM NCVS-1 (9-16-2004)

Noninterview – Fill 19 – 28 on this page. Also

fill 14 and adjust item 15c on cover page.

5
Page 19

INDIVIDUAL’S SCREEN QUESTIONS

36a. I’m going to read some examples that will give you an

idea of the kinds of crimes this study covers.

Was something belonging to YOU stolen, such as –

(a) Things that you carry, like luggage, a wallet,

purse, briefcase, book –

As I go through them, tell me if any of these

happened to you in the last 6 months, that is since

__________ ______, 20 ____.

(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 –

(f) Did anyone ATTEMPT to steal anything

belonging to you?

OR

36b. Did any incidents of this type happen to you?

MARK OR ASK –

36c. How many times?

40a.

(a) At home including the porch or yard –

OR

40b. Did any incidents of this type happen to you?

MARK OR ASK –

40c. How many times?

Briefly describe incident(s)

1

532

Number of times (36c)

533

2

Describe above

539

Number of times (40c)

540

(Other than any incidents already mentioned,)

since __________ ______, 20 ____, were you attacked

or threatened OR did you have something stolen

from you –

(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 –

(h) Did anyone ATTEMPT to attack or ATTEMPT to

steal anything belonging to you from any of

these places?

Briefly describe incident(s)

▼ ▼

No – SKIP to 41a

Yes – What happened?

1

2

Describe above

No – SKIP to 40a

Yes – What happened?

FORM NCVS-1 (9-16-2004)
Page 20

INDIVIDUAL’S SCREEN QUESTIONS

(Other than any incidents already mentioned,)

has anyone attacked or threatened you in any of

these ways (Exclude telephone threats) –

41a.

(a) With any weapon, for instance, a gun or

knife –

(c) By something thrown, such as a rock or

bottle –

(b) With anything like a baseball bat, frying pan,

scissors, or stick –

OR

41b. Did any incidents of this type happen to you?

MARK OR ASK –

41c. How many times?

Briefly describe incident(s)

541 1 Yes – What happened?

Number of times (41c)

542

2 No – SKIP to 42a

Describe above

(d) Include any grabbing, punching, or choking,

(e) Any rape, attempted rape or other type of

sexual attack –

(f) Any face to face threats –

(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.

People often don’t think of incidents committed

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) –

42a.

(a) Someone at work or school –

(c) A relative or family member –

(b) A neighbor or friend –

42b. Did any incidents of this type happen to you?

MARK OR ASK –

42c. How many times?

Briefly describe incident(s)

543 1 Yes – What happened?

Number of times (42c)

544

2 No – SKIP to 43a

Describe above

(d) Any other person you’ve met or known?

Incidents involving forced or unwanted sexual

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 –

43a.

(a) Someone you didn’t know before –

(c) Someone you know well?

(b) A casual acquaintance –

43b. Did any incidents of this type happen to you?

MARK OR ASK –

43c. How many times?

Briefly describe incident(s)

545 1 Yes – What happened?

Number of times (43c)

546

2 No – SKIP to 44a

Describe above

OR

▼ ▼ ▼

FFORM NCVS-1 (9-16-2004)
Page 21

44a. Briefly describe incident(s)

547 1 Yes – What happened?

2 No – SKIP to 45a

Describe above

44b. How many times?

548

* OFFICE USE ONLY

CHECK

ITEM B Look at 44a. If unsure, ASK, otherwise, mark without asking.

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?

1

2

Yes – Ask 44b 

No – SKIP to 45a

549

Number of times (44b)

550

45a. Briefly describe incident(s)

551 1 Yes – What happened?

2 No – SKIP to Check Item D below

Describe above

How many times?

552

*

OFFICE USE ONLY

CHECK

ITEM C Look at 45a. If unsure, ASK, otherwise, mark without

asking. 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?

1

2

553

Number of times (45b)

554

During the last 6 months, (other than any

incidents already mentioned,) did you call the

police to report something that happened to YOU

which you thought was a crime?

During the last 6 months, (other than any

incidents already mentioned,) did anything which

you thought was a crime happen to YOU, but you

did NOT report to the police?

INDIVIDUAL’S SCREEN QUESTIONS

45b.

FORM NCVS-1 (9-16-2004)

CHECK 

ITEM E

INDIVIDUAL’S CHECK ITEMS D, E, AND G

1 

2 

3 

1

Yes 

No 

Person for whom interview taken not present

2 

3 

4 

5 

6 

7 

8

Telephone interview – SKIP to Check Item G

Personal interview – Mark all that apply.

Did the person for whom this interview was taken help

the proxy respondent answer any screen questions?

555

No one besides respondent present 

Respondent’s spouse 

HHLD member(s) 12+, not spouse 

HHLD member(s) under 12 

Nonhousehold member(s) 

Someone was present – Can’t say who 

Don’t know if someone else present

CHECK 

ITEM D

If self-response interview, SKIP to Check Item G

Who besides the respondent was present when the

screen questions were asked? (If telephone interview,

mark box 1 only.) *

CHECK

ITEM G

____________ Number of times (36c)

____________ Number of times (40c)

____________ Number of times (41c)

____________ Number of times (42c)

____________ Number of times (43c)

____________ Number of times (44b)

____________ Number of times (45b)

Transcribe "number of times" entry for each of the following:

(a)

(f)

(g)

(b)

(c)

(d)

(e)

Screen Question, Item 36c, page 19

Screen Question, Item 41c, page 20

Screen Question, Item 42c, page 20

Screen Question, Item 43c, page 20

Screen Question, Item 44b, page 21

Screen Question, Item 45b, page 21

Screen Question, Item 40c, page 19

No entries transcribed below – Go to Check Item H

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.

556

Yes – Ask 45b 

No – SKIP to Check Item D below
INDIVIDUAL’S EMPLOYMENT QUESTIONS

Page 22

CHECK

ITEM H Is the respondent 16 years or older?

1

2

3

4

Physician

Nurse

Technician

Other – Specify

579

1

2

Yes – Ask 47a

No – SKIP to Check Item I

Did you have a job or work at a business LAST WEEK?

(Do not include volunteer work or work around the house.)

47a.

576 1

2

Yes – SKIP to 48a 

No – Ask 47b

Did you have a job or work at a business DURING THE

LAST 6 MONTHS?

47b.

ASK OR VERIFY –

577

578 1

2

1

2

Yes – Ask 47c

No – SKIP to Check Item I

Yes – Ask 48a

No – SKIP to Check Item I

Did that (job/work) last 2 consecutive weeks or

more?

47c.

48a. Which of the following best describes your job?

ASK OR VERIFY –

Medical Profession – As a –

Mental Health Services Field – Are your duties –

Teaching Profession – Were you employed in a –

Law Enforcement or Security Field – Were you

employed as a –

Retail Sales – Were you employed as a –

Transportation Field – Were you employed as a –

Something else – Specify

5

6

7

Professional (Social worker/psychiatrist)

Custodial care

Other – Specify

8

9

Preschool

Elementary

Junior high or middle school

High school

College or university

Technical or industrial school

Special education facility 

Other – Specify

10

11

12

13

14

15

Law enforcement officer

Prison or jail guard

Security guard

Other – Specify

16

17

18

19

Convenience or liquor store clerk

Gas station attendant

Bartender

Other – Specify

20

21

22

23

Bus driver

Taxi cab driver

Other – Specify

24

25

26

27

OR

Be sure to fill any incident reports before marking Check Item H.

PERSONAL INTERVIEW (Show flashcard)

TELEPHONE INTERVIEW – Were you employed in 

the (Read main headings until you get a yes. 

Then read answer categories) –

Mark (X) only one category.

(If farm or business operator in household, ask about

unpaid work.)

CHECK

ITEM I Is this the last household member to be

interviewed?

48b. Is your job with (Read answer categories) –

ASK OR VERIFY –

580 1 A private company, business, or individual for wages?

2

3

4

The Federal government?

A State, county, or local government?

Yourself (Self-employed) in your own

business, professional practice, or farm?

While working at your job, do you work mostly in (Read

answer categories) –

48d.

1

2

3

4

A city?

Suburban area?

Rural area?

Combination of any of these?

582

Yes – END interview. 

If box 12 is marked in 48a, mark without asking. 48c. Are you employed by a college or university? Yes

No

581 1

2

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.

No – See note below before interviewing next 

household member.

FORM NCVS-1 (9-16-2004)
Page 23

INDIVIDUAL’S PERSONAL CHARACTERISTICS

17. NAME

Last

First

Type of interview

Line

No.

401

1

2

3

4

Per. – Self-respondent 

Tel. – Self-respondent 

Per. – Proxy 

Tel. – Proxy

18. 19.

Fill 13 on cover page ________

Line No.

402

AFTER INTERVIEW – TRANSCRIBE FROM CONTROL CARD

29.

33a.

Date of interview 501

If unsure, ASK OR VERIFY –

How long have you lived at this address? 

(Enter number of months OR years.)

____________ Months (1-11) – SKIP to 33b 505

OR

____________ Years (Round to nearest whole year) – 

Fill Check Item A

506

5 years or more – SKIP to 36a

Less than 5 years –Ask 33b

CHECK

ITEM A

How many years are entered in 33a?

33b. Altogether, how many times have you moved in the last 

5 years, that is, since _________________, 20 ___? ____________ Number of times 508

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.

20.

Relationship to

reference

person

21.

Age last

birthday

22a.

Marital status 

THIS survey 

period

22b.

Marital

status LAST

survey period

23.

Sex

24.

Armed

Forces

member

25.

Educational

attainment

28.

Race

27.

Hispanic

origin

01

02

03

04

05

06

07

08

09

10

11

Husband

Wife

Son

Daughter

Father

Mother

Brother

Sister

Other relative

Nonrelative

Ref. person

________

Age

1

2

3

4

5

Married

Widowed

Divorced

Separated

Never

married

1

2

3

4

5

Married

Widowed

Divorced

Separated

Never

married

Not interviewed

last

survey

period

6

1

2

M

F

1

2

Yes

No

1

2

Yes

No

____________

Highest level 

completed

1

2

White

American

Indian/Alaska

Native

Asian

Other – Specify

4

6

26.

Attending

school

1 College/

University

Trade

school

Vocational

school

4 None of

the

above

schools

2

3

(cc 13b) (cc 17) (cc 18) (From previous

enumeration)

(cc 19) (cc 20) (cc 21) (cc 22) (cc 24) (cc 23)

Regular 

school

0

Black/African

American

Native

Hawaiian/Other

Pacific Islander

5

3

403 404 405 406 407 408 409 411 413 412

*

Mark (X) all that

apply.

FORM NCVS-1 (9-16-2004)

Noninterview – Fill 19 – 28 on this page. Also

fill 14 and adjust item 15c on cover page.

5
Page 24

INDIVIDUAL’S SCREEN QUESTIONS

36a. I’m going to read some examples that will give you an

idea of the kinds of crimes this study covers.

Was something belonging to YOU stolen, such as –

(a) Things that you carry, like luggage, a wallet,

purse, briefcase, book –

As I go through them, tell me if any of these

happened to you in the last 6 months, that is since

__________ ______, 20 ____.

(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 –

(f) Did anyone ATTEMPT to steal anything

belonging to you?

OR

36b. Did any incidents of this type happen to you?

MARK OR ASK –

36c. How many times?

40a.

(a) At home including the porch or yard –

OR

40b. Did any incidents of this type happen to you?

MARK OR ASK –

40c. How many times?

Briefly describe incident(s)

1

532

Number of times (36c)

533

2

Describe above

539

Number of times (40c)

540

(Other than any incidents already mentioned,)

since __________ ______, 20 ____, were you attacked

or threatened OR did you have something stolen

from you –

(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 –

(h) Did anyone ATTEMPT to attack or ATTEMPT to

steal anything belonging to you from any of

these places?

Briefly describe incident(s)

▼ ▼

No – SKIP to 41a

Yes – What happened?

1

2

Describe above

No – SKIP to 40a

Yes – What happened?

FORM NCVS-1 (9-16-2004)
Page 25

INDIVIDUAL’S SCREEN QUESTIONS

(Other than any incidents already mentioned,)

has anyone attacked or threatened you in any of

these ways (Exclude telephone threats) –

41a.

(a) With any weapon, for instance, a gun or

knife –

(c) By something thrown, such as a rock or

bottle –

(b) With anything like a baseball bat, frying pan,

scissors, or stick –

OR

41b. Did any incidents of this type happen to you?

MARK OR ASK –

41c. How many times?

Briefly describe incident(s)

541 1 Yes – What happened?

Number of times (41c)

542

2 No – SKIP to 42a

Describe above

(d) Include any grabbing, punching, or choking,

(e) Any rape, attempted rape or other type of

sexual attack –

(f) Any face to face threats –

(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.

People often don’t think of incidents committed

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) –

42a.

(a) Someone at work or school –

(c) A relative or family member –

(b) A neighbor or friend –

42b. Did any incidents of this type happen to you?

MARK OR ASK –

42c. How many times?

Briefly describe incident(s)

543 1 Yes – What happened?

Number of times (42c)

544

2 No – SKIP to 43a

Describe above

(d) Any other person you’ve met or known?

Incidents involving forced or unwanted sexual

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 –

43a.

(a) Someone you didn’t know before –

(c) Someone you know well?

(b) A casual acquaintance –

43b. Did any incidents of this type happen to you?

MARK OR ASK –

43c. How many times?

Briefly describe incident(s)

545 1 Yes – What happened?

Number of times (43c)

546

2 No – SKIP to 44a

Describe above

OR

▼ ▼ ▼

FORM NCVS-1 (9-16-2004)
Page 26

44a. Briefly describe incident(s)

547 1 Yes – What happened?

2 No – SKIP to 45a

Describe above

44b. How many times?

548

* OFFICE USE ONLY

CHECK

ITEM B Look at 44a. If unsure, ASK, otherwise, mark without asking.

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?

1

2

Yes – Ask 44b 

No – SKIP to 45a

549

Number of times (44b)

550

45a. Briefly describe incident(s)

551 1 Yes – What happened?

2 No – SKIP to Check Item D below

Describe above

How many times?

552

*

OFFICE USE ONLY

CHECK

ITEM C Look at 45a. If unsure, ASK, otherwise, mark without

asking. 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?

1

2

553 Yes – Ask 45b 

Number of times (45b)

554

During the last 6 months, (other than any

incidents already mentioned,) did you call the

police to report something that happened to YOU

which you thought was a crime?

During the last 6 months, (other than any

incidents already mentioned,) did anything which

you thought was a crime happen to YOU, but you

did NOT report to the police?

INDIVIDUAL’S SCREEN QUESTIONS

45b.

FORM NCVS-1 (9-16-2004)

CHECK 

ITEM E

INDIVIDUAL’S CHECK ITEMS D, E, AND G

1 

2 

3 

1

Yes 

No 

Person for whom interview taken not present

2 

3 

4 

5 

6 

7 

8

Telephone interview – SKIP to Check Item G

Personal interview – Mark all that apply.

Did the person for whom this interview was taken help

the proxy respondent answer any screen questions?

555

No one besides respondent present 

Respondent’s spouse 

HHLD member(s) 12+, not spouse 

HHLD member(s) under 12 

Nonhousehold member(s) 

Someone was present – Can’t say who 

Don’t know if someone else present

CHECK 

ITEM D

If self-response interview, SKIP to Check Item G

Who besides the respondent was present when the

screen questions were asked? (If telephone interview,

mark box 1 only.) *

CHECK

ITEM G

____________ Number of times (36c)

____________ Number of times (40c)

____________ Number of times (41c)

____________ Number of times (42c)

____________ Number of times (43c)

____________ Number of times (44b)

____________ Number of times (45b)

Transcribe "number of times" entry for each of the following:

(a)

(f)

(g)

(b)

(c)

(d)

(e)

Screen Question, Item 36c, page 24

Screen Question, Item 41c, page 25

Screen Question, Item 42c, page 25

Screen Question, Item 43c, page 25

Screen Question, Item 44b, page 26

Screen Question, Item 45b, page 26

Screen Question, Item 40c, page 24

No entries transcribed below – Go to Check Item H

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.

556

No – SKIP to Check Item D below
INDIVIDUAL’S EMPLOYMENT QUESTIONS

Page 27

CHECK

ITEM H Is the respondent 16 years or older?

1

2

3

4

Physician

Nurse

Technician

Other – Specify

579

1

2

Yes – Ask 47a

No – SKIP to Check Item I

Did you have a job or work at a business LAST WEEK?

(Do not include volunteer work or work around the house.)

47a.

576 1

2

Yes – SKIP to 48a 

No – Ask 47b

Did you have a job or work at a business DURING THE

LAST 6 MONTHS?

47b.

ASK OR VERIFY –

577

578 1

2

1

2

Yes – Ask 47c

No – SKIP to Check Item I

Yes – Ask 48a

No – SKIP to Check Item I

Did that (job/work) last 2 consecutive weeks or

more?

47c.

48a. Which of the following best describes your job?

ASK OR VERIFY –

Medical Profession – As a –

Mental Health Services Field – Are your duties –

Teaching Profession – Were you employed in a –

Law Enforcement or Security Field – Were you

employed as a –

Retail Sales – Were you employed as a –

Transportation Field – Were you employed as a –

Something else – Specify

5

6

7

Professional (Social worker/psychiatrist)

Custodial care

Other – Specify

8

9

Preschool

Elementary

Junior high or middle school

High school

College or university

Technical or industrial school

Special education facility 

Other – Specify

10

11

12

13

14

15

Law enforcement officer

Prison or jail guard

Security guard

Other – Specify

16

17

18

19

Convenience or liquor store clerk

Gas station attendant

Bartender

Other – Specify

20

21

22

23

Bus driver

Taxi cab driver

Other – Specify

24

25

26

27

OR

Be sure to fill any incident reports before marking Check Item H.

PERSONAL INTERVIEW (Show flashcard)

TELEPHONE INTERVIEW – Were you employed in 

the (Read main headings until you get a yes. 

Then read answer categories) –

Mark (X) only one category.

(If farm or business operator in household, ask about

unpaid work.)

CHECK

ITEM I Is this the last household member to be

interviewed?

48b. Is your job with (Read answer categories) –

ASK OR VERIFY –

580 1 A private company, business, or individual for wages?

2

3

4

The Federal government?

A State, county, or local government?

Yourself (Self-employed) in your own

business, professional practice, or farm?

While working at your job, do you work mostly in (Read

answer categories) –

48d.

1

2

3

4

A city?

Suburban area?

Rural area?

Combination of any of these?

582

Yes – END interview. 

If box 12 is marked in 48a, mark without asking. 48c. Are you employed by a college or university? Yes

No

581 1

2

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.

No – See note below before interviewing next 

household member.

FORM NCVS-1 (9-16-2004)
Page 28

NOTES

FORM NCVS-1 (9-16-2004)