Various Demographic Area Pretesting Activities

SCREENER DATE

SCREENING QUESTIONNAIRE FOR SCHOOL CRIME SURVEY

Introduction: Hello, I'm _____________________ from the Census Bureau. Thanks for calling us about participating in a test of one of our surveys. This is a survey of students ages 12-18. Any students who participate will receive $40 to thank them for their time. I just need to get a little bit of background information to determine if your child qualifies to take part.

1) What is your name? ___________________________________________

2) (VERIFY IF ALREADY HAVE THIS INFORMATION) What is your daytime phone number?

(_______)________-_______________

3) How many people between the ages of 12 and 18 live in your household? _______

IF NO CHILDREN 12-18 I'm sorry. Right now we are only testing the survey with students ages 12-18. Thank you for your time.

Any notes:

IF MORE THAN ONE CHILD: Let’s start with the oldest child first.

	Child 1	Child 2	Child 3	Child 4
4. How old is that child? (Verify child is12 -18)
5. What is that child’s name?
6. Is _____ male or female?
7. What grade is _____ in?
8. Is _____ Hispanic?
9. Which one or more of the following races does _____identify with? white black or African American Asian American Indian or Alaska Native Native Hawaiian or other Pacific Islander
10. Does _____ speak English fluently?
11. What city or town does _____ live in?
12. Does _____ attend public school, attend private school, or is [he/she] homeschooled?
13. IF NOT HOMESCHOOLED: How does _____ typically get to/from school each day: by school bus, by walking or by some other mode?
14. Has _____ ever been bullied in school? (That you know of)
15. Has _____ ever bullied another student at school? (That you know of)
16. Does _____ participate in a school sport?
17. Does _____ identify as LGBT? (Lesbian, Gay, Bisexual, or Transgender)?
18. Does _____ have a learning disability? IF YES: 19. What disability does _____ have?
20. Does _____ participate in a school club?
21. If necessary, would you be able to bring _____to our office in Suitland, MD to be interviewed?

IF MORE THAN ONE CHILD: Now let’s talk about the [second/third/fourth] oldest child.

Thank you for answering these questions about your family. Testing the survey takes about 90 minutes, and we will pay your child $40 for their participation. If your child is eligible to participate, we will be calling you to set up a time to test the survey in the next few days.

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