Roster

Attachment N ACS Cog Test CAI Roster_revised_042516.doc

Generic Clearance for Questionnaire Pretesting Research

Roster

OMB: 0607-0725

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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.




6


File Typeapplication/msword
AuthorCensus
Last Modified ByElizabeth Poehler
File Modified2016-04-26
File Created2016-04-26

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