Form Internet Screener Internet Screener Internet Screener
Generic Clearance for Questionnaire Pretesting Research
FY16_Recruitment_Screener_Internet_Participate (updated 10-7) Spanish additions in red OMB submission version
FY16 Generic Screeners
OMB: 0607-0725
CSM Universal Internet Screener (for Fiscal Year 2016)
Full screener will be translated into Spanish. Questions in red will only appear in the Spanish version.
Landing page.
By completing and submitting this participant form, your name will be added to our participant database.
We will contact you via the information provided if you are eligible to participate in a study.
To be considered for participation in our studies it is important that you complete all of the required fields on this form with accurate information. The more information you provide, the easier it is to match you for a study.
Your information is kept completely confidential and will not be sold or given to any third-party vendor.
What is your name?
First name: [ ]
Last name: [ ]
Are you male or female?
o Male
o Female
In what year were you born?
Are you of Hispanic, Latino, or Spanish origin?
o Yes
o No
What is your race? Please select one or more.
[] White
[] Black or African American
[] American Indian or Alaska Native
[] Asian
[] Native Hawaiian or other Pacific Islander
What is the highest grade of school you have completed, or the highest degree you have received?
Less than high school
Completed high school
Some college, no degree
Associate’s degree (AA/AS)
Bachelor’s Degree (BA/BS)
Post-Bachelor's degree (For example MA, MS, Ph.D, JD, etc.)
6a. Were you born in the United States or in another country?
o United States
o Another country
If another country:
5b. In what country were you born?
5c. How long have you been in the United States?
5d. Were any of your other household members born in the U.S.?
5e. Did you complete your schooling in the U.S. or in another country?
o United States
o Another country
If another country:
5f. In what country did you complete your schooling?
Are you working for pay full-time, part-time, or are you not working for pay at this time?
o Full-time
o Part-time
o Not working for pay at this time
a. What is your current job title or job description?
[ ]
Are you employed by the Federal Government? (if federal contractor, mark NO)
o Yes
o No
In what city, state, and ZIP code do you currently live?
How many people age 18 or older currently live in your household, INCLUDING yourself?
[ ]
How many people younger than 18 currently live in your household?
[ ]
Do you speak a language other than English at home?
o Yes
o No
What language or languages do you speak at home? Please select one or more.
[ ] Spanish
[ ] Chinese
[ ] Korean
[ ] Vietnamese
[ ] Arabic
[ ] Russian
[ ] Other [ ]
11a.Do you speak any dialect or indigenous language?
o Yes
o No
11b. With regard to your culture, do you consider yourself indigenous?
o Yes
o No
Do you own a cell phone?
o Yes
o No
Some cell phones are called “smartphones” because of certain features they have. Is your cell phone a smartphone, such as an iPhone, Android, Blackberry or Windows phone, or are you not sure?
Do you own a desktop or laptop computer, or both?
o Desktop computer
o Laptop computer
o Both desktop and laptop computer
o Neither
Do you own a tablet computer such as an iPad, Samsung Galaxy Tab, Google Nexus, or Kindle Fire?
o Yes
o No
Do you have at least one year of Internet experience?
o Yes
o No
How often do you use the Internet either on a computer or on a mobile device like a smartphone or tablet?...Several times a day, about once a day, a few times a week, a few times a month, a few times a year?
Several times a day
About once a day
A few times a week
A few times a month
A few times a year
Not at all
Name two things you do on the Internet besides e-mail.
Research
Social media/communication (Facebook, Twitter, Craigslist)
Shopping
Banking or paying bills online
Music / movies / videos
Gaming
News
Travel (directions/reservations)
Employment
Other
c. If you were asked to do a survey, would you rather complete it on paper, over the phone, or online?
How did you hear about this research opportunity?
E-mail link
Census Bureau employee
Friend or family member (but not a Census Bureau employee)
Craigslist
Google advertisement
Flyer
Newspaper advertisement
Other – specify[ ]
Have you participated in any research studies with the U.S. Census Bureau?
o Yes
o No
Would you be willing to come to our office in Suitland, Maryland, to participate in a research study?
o Yes
o No
What is your daytime telephone number?
Mobile ([ ]) [ ] – [ ]
Home (if not mobile) ([ ]) [ ] – [ ]
Work (if any) ([ ]) [ ] – [ ] EXT.[ ]
What is the e-mail address we should use when sending directions to our office, should you qualify for a study?
[ ]
What is your household’s annual income?
o Less than $15,000
o $15,001 to $25,000
o $25,001 to-$50,000
o $50,001 to $100,000
o More than $100,000
Are you a United States citizen? You do not have to be a U.S. citizen to participate in our studies.
o Yes
o No
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Slight changes to participate |
| Author | Dawn V Nelson |
| File Modified | 0000-00-00 |
| File Created | 2021-01-28 |
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