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Asking Questions - The Definitive Guide To Questionnaire Design ...

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274 ASKING QUESTIONS<br />

3a. Did you receive any money from interest, dividends, net<br />

rental, or income from estates and trusts?<br />

Yes No<br />

3b. (If Yes): How much did you receive?<br />

$<br />

4a. Did you receive any money from Social Security or<br />

Railroad Retirement?<br />

Yes No<br />

4b. (If Yes): How much did you receive?<br />

$<br />

5a. Did you receive any money from retirement, survivor, or<br />

disability pensions not including Social Security?<br />

Yes No<br />

5b. (If Yes): How much did you receive?<br />

$<br />

6a. Did you receive any money from Supplemental Security<br />

Income (SSI)?<br />

Yes No<br />

6b. (If Yes): How much did you receive?<br />

$<br />

7a. Did you receive any money from public assistance or<br />

welfare payments from the state or local welfare office?<br />

Yes No<br />

7b. (If Yes): How much did you receive?<br />

$<br />

8a. Did you receive any money regularly from any other<br />

source such as alimony, child support, veteran’s payments,<br />

or unemployment compensation?<br />

Yes No

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