Various Pretesting Activities

U.S. DEPARTMENT OF COMMERCE

Economics and Statistics Administration

U.S. CENSUS BUREAU

RESIDENCE HALL STUDY

1. What is your name? Print name below

Last Name

First Name MI

2. What is your current residence hall address? Please complete all that apply

R oom Number Apartment Number

Street Address Number Street Name

C ity State

Z ip Code

3. W hat is your sex? Mark ONE box.

Male Female

4. What is your age, and what is your date of birth? Print numbers in boxes below.

Age Month Day Year of Birth

5. Are you of Hispanic, Latino or Spanish origin?

	No, not of Hispanic, Latino, or Spanish origin
	Yes, Mexican, Mexican Am., Chicano
	Yes, Puerto Rican
	Yes, Cuban
	Y es, another Hispanic, , Latino, or Spanish origin – Print origin, for example Argentinean, Colombian Dominican, Nicaraguan, Salvadoran, Spaniard, and so on

6. What is your race? Mark one or more boxes.

	White
	Black, African Am., or Negro
	Mexican, Mexican Am., Chicano
	A merican Indian or Alaska Native – Print the name of enrolled or principal tribe.
	Asian Indian			Japanese		Native Hawaiian
	Chinese			Korean		Guamanian or Chamorro
	Filipino			Vietnamese		Samoan
	O ther Asian – Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on.					Other Pacific Islander – Print race, for example, Fijian, Tongan, and so o n.
	S ome other race or origin – Print race or origin.

7. Do you live or stay in this residence hall MOST OF THE TIME? Mark ONE box.

Yes

No

8. On April 1, 2010, were you living or staying in this residence hall? Mark ONE box.

Y es (skip to Question 10)

No

9. On April 1, 2010, what type of place did you live or stay at? Mark one box.

H ouse/Apartment /Mobile Home/ Condo/Townhouse Is this the home of one of your parents, guardians or relatives? Yes No College Dorm /Residence Hall Fraternity House /Sorority House/Greek House Military Barracks/ Military Ship Correctional Facility Group home Other – Specify___________________

10. Other than you, how many other residents live in this room?

	None (Go to Question 9)
	1
	2
	3
	4
	Other ___

11. Besides this facility, what is the full address of another place where you sometimes live or stay? Please complete all that apply

Street Address Number Street Name

Apartment Number

Rural route address

C ity

County

State or foreign country

Z ip Code

12. Is the address you provided in Question 11 the home of one of your parents, guardians or relatives?

	Yes
	No

13. In case we need to contact you again, please provide the following contact information:

Primary Phone:
Secondary phone:
E-mail Address:

	Other way of contact – Please specify.

14. What did you think the word ‘facility’ was referring to in all the above questions?

15. Overall, would you say the survey questions were easy or difficult to respond to?

Easy

Difficult

16. Which questions do you think some people would find difficult? Why?

17. Which questions do you think some people would find sensitive? Why?

18. Do you have any final comments or any questions?