Control Number
Tester Type
Week
Site
Test Type
Tester ID
City
State
Zip Code (00000)
Perceived Race / Ethnicity
Sex / Gender
Age Group
Primary Person Who Provided Info
Were you able to meet with an agent to discuss housing options?
If you were not able to meet with an agent, why not?
If no units were available, were you offered to be placed on a waiting list?
After you conveyed your sexual orientation and/or household composition to the a
During your visit, did the agent comment on or make reference to any of the foll
If the agent made a comment on or made reference to any of the following: Fair H
Please specify what other personal information volunteered by you, requested by
The agent said that he/she would contact you
The agent invited you to call him/her
Other (specify)
If other, please specify
This form is complete
Personal information volunteered by you, requested by the agent, or not obtained
Items necessary for application process: Application form?
Items necessary for application process: Credit check?
Items necessary for application process: Criminal background check?
Did the agent provide you with: Business Card
Did the agent provide you with: Brochure
Did the agent provide you with: Listings
Did the agent provide you with: Floor Plan
Did the agent provide you with: Rental/Lease Agreement
Did the agent provide you with: Gift
If the agent provided other, specify
Did the agent provide you with: Other
How many TOTAL units were you told were available that had at least your minimum
How many TOTAL units did you inspect? (Model units inspected may be included in
Did the agent make any comments on your qualifications to rent (i.e., renters in
If the agent made any comments on your qualifications to rent, what was the comm
Did the agent provide you with: Food and/or Beverage
Did you meet with the agent:
Items necessary for application process: Co-signer?
Did the agent give you an application to take with you?
Did the agent make any comments about race or ethnicity?
If the agent made any comments about race or ethnicity, what was the comment?
Did the agent make any comments about your household/household composition?
If the agent made any comments about your household/household composition, what
Were arrangements for future contact made?
Perceived Sexual Orientation of Agent
Perceived Sexual Orientation
Did you obtain information about housing?
If you did not obtain information about housing, why not? Proceed to Section 3 a
If you indicated other as the reason for not obtaining information about housing
Were you able to obtain an appointment?
If you were unable to obtain an appointment, why not?
If you indicated other as the reason you were unable to obtain an appointment, p
Day of the appointment
Date of appointment (mm/dd/yyyy)
Time of appointment (hh:mm)
Location of meeting – specific type (e.g., agent’s office or address of specific
Agent comments re: building/neighborhood: Noise
Agent comments re: building/neighborhood: Safety
Agent comments re: building/neighborhood: Schools
Agent comments re: building/neighborhood: Maintenance/ Services
Did you clearly convey your sexual orientation to the agent with whom you discus
If you did not clearly convey your sexual orientation to the agent with whom you
Please describe how and when you conveyed your sexual orientation:
After you conveyed your sexual orientation to the agent, were you told that ther
Did the agent make any comments about persons who are lesbian, gay or transgende
If the agent make any comments about persons who are lesbian, gay or transgender
Only for Transgender Testers: For this test, were you instructed by your Test Co
If you did not clearly convey your transgender identity to the agent with whom y
If you did clearly convey your transgender identity to the agent with whom you d
Did you clearly convey your sexual orientation to the person you reached at the
If after you conveyed your sexual orientation and/or household composition to th
Please indicate what language you used to reference your partner/spouse:
How many actual available units were inspected?
How many model units or other units (similar to the actual available unit) were
For safety reasons or otherwise, was it necessary for you to prematurely end you
If for safety reasons or otherwise, was it necessary for you to prematurely end
Only for Transgender Testers: After you conveyed your transgender identity to th
If Yes: did you clearly convey your transgender identity to the agent with whom
At what point in the conversation did you convey your transgender identity to th
If you indicated other as the point in the conversation when you conveyed your t
Did the agent ask about or make reference to your gender/gender expression/trans
If the agent asked about or made reference to your gender/gender expression/tran
If Yes, please also describe how you responded to the agent’s inquiry or referen
At what point in the conversation did the agent ask about or make reference to g
If you indicated other as the point in the conversation when the agent ask about