Roster

Attachment N: All Groups Roster Only - Latest Revision 3/21/16

Participant ID #: |___|___|___|___|___|___|___|___|___|___| American Community Survey Roster

Respondent

Person 2

Person 3

Person 4

Person 5

Person 6

1a. I am going to be asking some questions about everyone who is living or staying at this address. First let's create a list of the people, starting with you. What is your name? (What is the name of the next person living or staying here?)

Full Name: _________________

Full Name: _________________

Full Name: _________________

Full Name: _________________

Full Name: _________________

Full Name: _________________

ROSTER AND DEMOGRAPHICS Ask as topic-based, that is, ask question for each person before moving to next question. READ ONLY ONCE: (Next we need to record each person’s relationship to you.) 2. How is <Name> related to you? ASK OR VERIFY: Is <Name> your- Husband or wife Son or daughter Brother or sister Father or mother Grandchild Parent-in-law Son-in-law or daughter-in-law Other relative Roomer or boarder Housemate or roommate Unmarried partner Foster child Other nonrelative IF RESPONSE IS “SON” OR “DAUGHTER” ASK FIRST BEFORE SELECTING ANSWER CATEGORY:: Is <Name> your biological son or daughter, adopted son or daughter, OR stepson or stepdaughter?

Husband or wife Biological Son/Daughter Adopted Son/Daughter  Stepson/ Stepdaughter Brother/Sister Father/Mother Grandchild Parent-in-law Son/daughter-law Other relative Roomer/Boarder Housemate/ Roommate Unmarried partner Foster child Other non-relative

Husband or wife Biological Son/Daughter Adopted Son/Daughter  Stepson/ Stepdaughter Brother/Sister Father/Mother Grandchild Parent-in-law Son/daughter-law Other relative Roomer/Boarder Housemate/ Roommate Unmarried partner Foster child Other non-relative

Husband or wife Biological Son/Daughter Adopted Son/Daughter  Stepson/ Stepdaughter Brother/Sister Father/Mother Grandchild Parent-in-law Son/daughter-law Other relative Roomer/Boarder Housemate/ Roommate Unmarried partner Foster child Other non-relative

Husband or wife Biological Son/Daughter Adopted Son/Daughter  Stepson/ Stepdaughter Brother/Sister Father/Mother Grandchild Parent-in-law Son/daughter-law Other relative Roomer/Boarder Housemate/ Roommate Unmarried partner Foster child Other non-relative

Husband or wife Biological Son/Daughter Adopted Son/Daughter  Stepson/ Stepdaughter Brother/Sister Father/Mother Grandchild Parent-in-law Son/daughter-law Other relative Roomer/Boarder Housemate/ Roommate Unmarried partner Foster child Other non-relative

UNRELATED HOUSEHOLD CHECK: IS ENTIRE HOUSEHOLD UNRELATED (relationships for ALLhousehold members are “ Roomer/Boarder”,” Housemate/Roommate”,” Foster child”, or “ Other non-relative“) ?  Yes  No

3. ASK OR VERIFY: Are you male or female? (How about <NAME OF ADDITIONAL HOUSEHOLD MEMBERS>? Or ask: Is <NAME OF ADDITIONAL HOUSEHOLD MEMBERS> male or female?)

 Male  Female

 Male  Female

 Male  Female

 Male  Female

 Male  Female

 Male  Female

4a. What is (your/<Name>'s) date of birth? ENTER MONTH/DAY/YEAR OF BIRTH.

___/___/____

___/___/____

___/___/____

___/___/____

___/___/____

___/___/____

4b. What is (your/<Name>'s) age? (What is your best estimate of (<Name>'s/your) age?)

________

________

________

________

________

________

5a. <Are you/Is (Name)> of Hispanic, Latino, or Spanish origin?

 Yes  No  Go to 6a

5b. <Are you/Is (Name)> Mexican, Mexican American, or Chicano; Puerto Rican; Cuban; or of another other Hispanic, Latino, or Spanish origin; for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on?

Mexican, Mexican American, Chicano Puerto Rican  Cuban  Another Hispanic, Latino, or Spanish origin; for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on?

Mexican, Mexican American, Chicano Puerto Rican  Cuban  Another Hispanic, Latino, or Spanish origin; for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on?

Mexican, Mexican American, Chicano Puerto Rican  Cuban  Another Hispanic, Latino, or Spanish origin; for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on?

Mexican, Mexican American, Chicano Puerto Rican  Cuban  Another Hispanic, Latino, or Spanish origin; for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on?

Mexican, Mexican American, Chicano Puerto Rican  Cuban  Another Hispanic, Latino, or Spanish origin; for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on?

Mexican, Mexican American, Chicano Puerto Rican  Cuban  Another Hispanic, Latino, or Spanish origin; for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on?

5b_SKIP IF PERSON HAS A RESPONSE OF “ANOTHER HISPANIC, LATINO, OR SPANISH ORIGIN” IN 5B, ASK 5C FOR THAT PERSON. OTHERWISE GO TO 6A.

5c. What is that origin? For example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on.

________

________

________

________

________

________

COMPLETE ALL PARTS OF QUESTION 6 (A-I) FOR EACH PERSON BEFORE MOVING ON TO THE NEXT PERSON. 6a. I'm going to read a list of race categories. You may choose one or more races. For this survey, Hispanic origin is not a race. (Are you/Is <Name>) White; Black or African American; American Indian or Alaska Native; Asian; Native Hawaiian or Other Pacific Islander; or Some other race?

White  Black or African American  American Indian or Alaska Native  Asian  Native Hawaiian or Other Pacific Islander  Some other race

White  Black or African American  American Indian or Alaska Native  Asian  Native Hawaiian or Other Pacific Islander  Some other race

White  Black or African American  American Indian or Alaska Native  Asian  Native Hawaiian or Other Pacific Islander  Some other race

White  Black or African American  American Indian or Alaska Native  Asian  Native Hawaiian or Other Pacific Islander  Some other race

White  Black or African American  American Indian or Alaska Native  Asian  Native Hawaiian or Other Pacific Islander  Some other race

White  Black or African American  American Indian or Alaska Native  Asian  Native Hawaiian or Other Pacific Islander  Some other race

6A–SKIP IF PERSON HAS A RESPONSE OF “AMERICAN INDIAN OR ALASKA NATIVE” IN 6A, ASK 6B FOR THAT PERSON. OTHERWISE GO TO 6B-SKIP.

6b. What is (/your /<Name>’s) enrolled or principal tribe?

________

________

________

________

________

________

6B–SKIP IF PERSON HAS A RESPONSE OF “ASIAN” IN 6A, ASK 6C FOR THAT PERSON. OTHERWISE GO TO 6D-SKIP.

6c. You may choose one or more Asian groups. <Are you/Is (Name)/> Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or another Asian group, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on?

Asian Indian  Chinese  Filipino Japanese  Korean  Vietnamese  Other Asian

Asian Indian  Chinese  Filipino Japanese  Korean  Vietnamese  Other Asian

Asian Indian  Chinese  Filipino Japanese  Korean  Vietnamese  Other Asian

Asian Indian  Chinese  Filipino Japanese  Korean  Vietnamese  Other Asian

Asian Indian  Chinese  Filipino Japanese  Korean  Vietnamese  Other Asian

Asian Indian  Chinese  Filipino Japanese  Korean  Vietnamese  Other Asian

6C–SKIP IF PERSON HAS A RESPONSE OF “OTHER ASIAN” IN 6C, ASK 6D FOR THAT PERSON. OTHERWISE GO TO 6D-SKIP.

6d. What is that other Asian group? For example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on.

________

________

________

________

________

________

6D–SKIP IF PERSON HAS A RESPONSE OF “NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER” IN 6A, ASK 6E FOR THAT PERSON. OTHERWISE GO TO 6E-SKIP.

6e. You may choose one or more Pacific Islander groups. (Are you/ Is <Name>) Native Hawaiian; Guamanian or Chamorro; Samoan; or another Pacific Islander group, for example, Fijian, Tongan, and so on?

Native Hawaiian  Guamanian or Chamorro  Samoan  Other Pacific Islander

Native Hawaiian  Guamanian or Chamorro  Samoan  Other Pacific Islander

Native Hawaiian  Guamanian or Chamorro  Samoan  Other Pacific Islander

Native Hawaiian  Guamanian or Chamorro  Samoan  Other Pacific Islander

Native Hawaiian  Guamanian or Chamorro  Samoan  Other Pacific Islander

Native Hawaiian  Guamanian or Chamorro  Samoan  Other Pacific Islander

6E–SKIP IF PERSON HAS A RESPONSE OF “OTHER PACIFIC ISLANDER” IN 6E, ASK 6F FOR THAT PERSON. OTHERWISE GO TO 6F-SKIP.

6f. What is that other Pacific Islander group? For example, Fijian, Tongan, and so on.

___________

___________

___________

___________

___________

___________

6F–SKIP IF PERSON HAS A RESPONSE OF “SOME OTHER RACE OR ORIGIN” IN 6A, ASK 6G FOR THAT PERSON. OTHERWISE GO TO 6H.

6g. What is (your/<Name>’s) other race group?

___________

___________

___________

___________

___________

___________

6h. Thank you. Please give me just a moment to review your answers. STOP HERE. GO TO PERSON SELECTION THEN PROBES.

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