Various Demographic Area Pretesting Activities

March 25, 2013

SCREENING QUESTIONNAIRE FOR RESPONDENT DATABASE

Introduction: Hello, I’m __________ from the Census Bureau. Thanks for calling us about participating in one of our surveys. I just need to get a little bit of background information to start.

1. What is your name? ________________________________

2. What is your daytime phone number?

(______) ______-_________

3. Are you employed by the federal government?

1 [ ] Yes Explain that this person cannot participate in our research and end interview.
2 [ ] No

4. (IF NECESSARY) Are you male or female?

1 [ ] Male
2 [ ] Female

5. What is your date of birth? __________________ (MONTH/DAY/YEAR)

6. Are you now married, widowed, divorced, separated or have you never been married?

1 [ ] Married

2 [ ] Widowed

3 [ ] Divorced

4 [ ] Separated

5 [ ] Never been married

7. What is the highest grade of school you have completed, or the highest degree you have received?

1 [ ] Never completed any school
2 [ ] Completed ninth grade or below
3 [ ] Some high school
4 [ ] Completed high school, or received a GED
5 [ ] Vocational training beyond high school
6 [ ] Some college < ask 7a >
7 [ ] Completed college < ask 7a >
8 [ ] Master’s degree < ask 7b >

9 [ ] Doctorate or Professional degree < ask 7b >

7a. Did you receive any scholarships or loans for your college studies?

1 [ ] Yes 2 [ ] No

7b. Did you receive any scholarships or loans for your graduate studies?

1 [ ] Yes 2 [ ] No

8. Do you consider yourself to be of Hispanic or Spanish origin?

1 [ ] Yes, Hispanic or Spanish origin

2 [ ] No

9. Choose one or more of the following races:

1 [ ] White
2 [ ] Black or African American
3 [ ] Asian
4 [ ] American Indian or Alaska Native
5 [ ] Native Hawaiian or other Pacific Islander

10. Is English your native language?

1 [ ] Yes 2 [ ] No

11a. Are you currently working for pay full-time, part-time, or are you not working for pay at this time?

1 [ ] Full-time
2 [ ] Part-time
3 [ ] Not working for pay – skip to question 12

11b. Are you self-employed?

1 [ ] Yes 2 [ ] No

11c. What is your job title or job description? (IF NECESSARY: WHAT KIND OF WORK DO YOU DO AT YOUR JOB?)

______________________________________________________________________________

11d. Is your job related to any of the following fields: computer science, math, life sciences, physical sciences, social sciences, engineering or health sciences?

1 [ ] Yes 2 [ ] No

11e. Have you changed jobs in last 2 years?

1 [ ] Yes 2 [ ] No

12. Do you currently have more than one job?

1 [ ] Yes 2 [ ] No

13. Do you contribute to more than one retirement plan, including 401(k)s, IRAs, or pension plans?

1 [ ] Yes 2 [ ] No

14. Are you disabled or unable to work for health reasons?

1 [ ] Yes 2 [ ] No

15. Is your household’s annual income…

1. Above $25,000?

1 [ ] Yes 2 [ ] No – skip to 13

2. Is it above $50,000?

1 [ ] Yes 2 [ ] No – skip to 13

3. Is it above $100,000?

1 [ ] Yes 2 [ ] No – skip to 13

16. How many people 18 or older live in your household, including yourself? _______

16a. (If necessary:) Are they all related?

1 [ ] Yes 2 [ ] No

17. Do you have any problems doing any daily activities like dressing, walking or lifting?

1 [ ] Yes 2 [ ] No

18. Do you own or rent the place where you currently live?

1 [ ] Own 2 [ ] Rent

19. Is the place where you currently live (owned/rented) in your name or in the name of someone else in your
household?

1 [ ] Respondent’s name 2 [ ] Other person’s name

20. How many people younger than eighteen live in your household? _________

IF NO CHILDREN UNDER 18, SKIP TO QUESTION 18

21. What are the ages of each of the children younger than eighteen living in your household?

_____ _____ _____ _____ _____ _____

21a. Do any of these children have special needs or disabilities?

1 [ ] Yes 2 [ ] No

22. Did anyone move out of your household or into your household in the last 12 months?

1 [ ] Yes 2 [ ] No

23. Do you live in a single family home, a townhouse or duplex, an apartment, or another type of housing?

1 [ ] Single family home
2 [ ] Townhouse or duplex
3 [ ] Apartment
4 [ ] Other

24. Do you live within 10 or so miles of a body of water, such as a bay, ocean, lake, or river?

1 [ ] Yes 2 [ ] No

25. Do you have any pets in your household?

1 [ ] Yes 2 [ ] No

26. Do you use the internet for…

Online banking?
1 [ ] Yes 2 [ ] No

Online shopping?
1 [ ] Yes 2 [ ] No

Email?
1 [ ] Yes 2 [ ] No

27. How often do you use the internet?

[ ] Rarely/Never [ ] Daily [ ] Weekly [ ] Monthly [ ] Yearly

28. How did you hear about the survey?

1 [ ] Newspaper ad 2-19 __________________

2 [ ] Flyer

3 [ ] An organization the person is a member of ________________________

4 [ ] Friend or colleague / word of mouth

5 [ ] Some other way (specify)_____________________________________________

6 [ ] Recruitment Table

29. Have you participated in any cognitive testing or questionnaires with ACS (American Community Survey) in the past? (internet or mail)

[ ] Yes [ ] No

30. If necessary, would you be able to come to our facility in Suitland, MD to be interviewed?

[ ] Yes [ ] No [ ] Possibly

31. (If #29 is NO) Have you tested questionnaires before, either for the Census Bureau of any other company?

[ ] Yes [ ] No

32. What city or town do you live in? ______________________________________________

33. Are you a U.S. citizen ? [ ] Yes [ ] No

34. Do you have a smartphone? [ ] Yes [ ] No

35. Does anyone in your household have a bank account? [ ] Yes [ ] No

36. Have you had any type of contact with the police within the last 12 months?

If yes – Tell me about the contact with the police

Traffic Stop –Street Stop- Other (voluntary contact)

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