NHIS College Housing Frame Questionnaire Study

Attachment 1: NHIS College Housing Frame Questionnaire

The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).

OMB #0920-0222; Expiration Date: 06/30/2015

Intro Screen

Hello, my name is _____________ from the United States Census Bureau. <Insert college name here> has been selected for sample for the National Health Interview Survey, a nationwide survey that collects information about the general health of the nation. All of the information you provide will remain confidential, and will only be used for statistical purposes. Can you or anyone in your office answer questions about college-owned student housing, such as the names of the dorms, and the number of beds at each dorm?

Yes (Continue to Question 2)

Yes, but not now (Continue to Contact Information)

Yes, but I would prefer to provide this information through email (Go to Collect Through Email Screen)

No, refusal (Go to Thank You – No Information Collected Screen)

No, we don’t offer any student housing (Go to Thank You – No Information Collected Screen)

No, I don’t know that information but someone else does (Continue to Question 1a)

No, phone number isn’t correct (go to Question 1a)

No, need further documentation (Go to Authentication Screen)

No, reached voice mail (Go to Leave Message Screen)

Question 1a

Do you know the phone number of someone who could answer questions about student housing at <insert college name>?

Yes (Fill out Contact Information below)

No, the knowledgeable person exists but is not currently available (Go to Contact Information screen)

No, I don’t know how to reach that person (Go to Thank You – No Information Collected Screen)

Contact Information

Could you provide the name, phone number and a good time to contact him/her?

Contact Person 1:

<Name>

<Phone Number>

<Contact Time>

Contact Person 2:

<Name>

<Phone Number>

If person is unavailable: (Continue to Thank You – No Information Collected Screen)

If person is available, ask to be transferred: (Continue to Intro Screen)

Question 2

Can I please collect the following contact information from you?

< Contact Person Name >

< Contact Person Title >

< Contact Person Office Location >

< Contact Phone Number + Extension, if applicable >

< Email address >

(Continue to Question 3)

Question 3

I will now ask some questions pertaining to information about college-owned dorms located on campus. A register is an up-to-date list of all beds, rooms, or persons at the dorm. If possible, collecting a register where the units are distinguished by beds is preferred. Is there a central location within the college where the registers are stored?

Yes (Go to Question 4)

No (Go to Question 6; if answer is no, will need to collect register info when collecting information about the dorm)

Question 4

Where are the registers located?

Note: This could entail any combination of an address, building name, room number, etc.

< Enter register location >

(Continue to Question 5)

Question 5

Are the units on the registers all beds, rooms, or persons or are they all different for each dorm?

Note: If the designations are different for each dorm, this information will need to be collected individually for each dorm.

Beds

Rooms

Persons

Different

Other <enter designation>

(Continue to Question 6)

Question 6

Can you please provide the name, address, and number of units for each college-owned dorm on campus? If you prefer, I can provide an electronic form for you to fill out and return in an email.

(If respondent says they would like to provide information through email go to Collect Through Email Screen)

<Dorm Name>

<House Number>

<Street Name>

<ZIP Code>

<Maximum Capacity> Note: This should be consistent with the number of units collected in the prior question pertaining to the designation of the units on the registers.

<Location Description> (Only ask for this if House Number/Street Name aren’t filled).

<Register Location> (Only fill if not filled from before)

<Register Designations>

(Continue to Thank You – Information Collected)

Thank You – Information Collected

Thank you very much for your time and cooperation. If a unit is selected to be interviewed at one of these dorms, a U.S. Census Bureau Field Representative will arrive on campus to complete an interview at a later date.

(Continue to Close Out)

Thank You – No Information Collected

Thank you very much for your time.

(Continue to Close Out)

Leave Message

Hello, my name is _________ from the United States Census Bureau. <Insert college name here> has been selected for sample for the National Health Interview Survey, a nationwide survey that collects information about the general health of the nation. All of the information you provide will remain confidential, and will only be used for statistical purposes. I am calling to collect information about the student housing located at <insert college name>. Please give me a call back at <leave telephone number>. Thank you.

Collect Through Email Screen

After this call is complete, I will send you an email containing a form for all information to collect. Can you please provide me with your email address?

<Email Address>

Please send the completed form back within three business days. If there are any questions about the form, please give me a call at (provide phone number). Thank you and have a good day.

The body of the email sent will be the following:

Hello <contact person>,

As mentioned on the phone, <insert college name here> has been selected for sample for the National Health Interview Survey, a nationwide survey that collects information about the general health of the nation. All of the information you provide will remain confidential, and will only be used for statistical purposes. Attached to this email is a form to complete pertaining to student housing at <insert college name here>. Please complete the form and provide it back. If there are any questions about the form, please feel free to ask. Thank you for your cooperation.

(If no response after three business days, send follow up email and/or give the contact person a call. After receiving the email with the completed form, enter the information into this questionnaire and send the following email message to the respondent:

Thank you very much for your cooperation. If a unit is selected to be interviewed at one of these dorms, a U.S. Census Bureau Field Representative will arrive on campus to complete an interview at a later date.)

Below is the questionnaire to collect information about college-owned student housing at <insert college name>. If there are any questions pertaining to the questionnaire, please contact <Person 1> at <phone number> or <email address>, or <Person 2> at <phone number> or <email address>. Thank you for your cooperation.

Please fill in the following contact information:

<Contact Person Name>

<Contact Person Title>

<Contact Person Office Location>

<Contact Person Phone Number> - <Extension>

<Contact Person Email Address>

A register is an up-to-date list of all beds, rooms, or persons at the dorm. If possible, collecting a register where the units are distinguished by beds is preferred. If there is a central location within the college where the registers are stored, please provide it below. If not, the location of the individual dorms will need to be filled in later.

<Register Location>

Note: This could include a combination of address, building name, room number, etc.

How are the units on the registers distinguished?

Beds <>

Rooms <>

Persons <>

Mixed <>

Other <Enter Designation>

Please fill in the following information about all of the college-owned dorms on campus. If necessary, add additional rows to the table to accommodate all the dorms on campus:

Dorm Name	House Number	Street Name	ZIP Code	Maximum Capacity	Register Location (if mixed)	Unit Designations (e.g. beds, rooms, persons)

Thank you very much for your time. Please save the above form and provide it to <person> at <email address>.

Close Out

<Case Complete; fill to ‘Y’ when done with the college>

< Notes >

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