CAI_V1_Group 3

Attachment Q: Version 1, Group 3 Questions – Last Revision 4/20/16

American Community Survey

Cognitive Test

Interviewer-administered Survey

Version 1, Group 3

March 28, 2016

Participant ID #: |___|___|___|___|___|___|___|___|___|___|

DETAILED QUESTIONS—PERSON 1

13. What is your ancestry or ethnic origin? (For example: Italian, Jamaican, African-American, Cambodian, Cape Verdean, Norwegian, Dominican, French Canadian, Haitian, Korean, Lebanese, Polish, Nigerian, Mexican, Taiwanese, Ukrainian and so on.)	_________________________________ _________________________________
14a. Do you speak a language other than English at home?	 Yes  No  Go to 15a
14b. What is this language? (For example: Korean, Italian, Spanish, Vietnamese)	_________________________________
14c. How well do you speak English – very well, well, not well, not at all?	 Very well  Well  Not well  Not at all
15a. Did you live in this <house/apartment/mobile home/unit> 1 year ago?	 Yes  Go to 29a  No
15b. Did you live in the United States, Puerto Rico, or another country?	 United States  Puerto Rico  Another country
15b-SKIP IF PERSON ANSWERED “UNITED STATES” OR “PUERTO RICO”, GO TO QUESTION 15D. OTHERWISE GO TO 15C.
15c. What was the foreign country?	________________ Country  Go to 29a
15d. What was the street address?	_________________________________
15e. What was the city or town?	____________________________City
15e-SKIP IF PERSON ANSWERED “PUERTO RICO” IN QUESTION 15B, GO TO QUESTION 15G. OTHERWISE GO TO 15F.
15f. What was the state? ENTER THE STATE ABBREVIATION	__________________________ State
15g. What was the ZIP code?	_______________________ZIP
IF PERSON DID NOT ANSWER “PUERTO RICO” IN QUESTION 15B, ASK: 15h. What was the county? IF PERSON ANSWERED “PUERTO RICO” IN QUESTION 15B, ASK: 15h. What was the municipio?	__________________County/Municipio

29a. Now, I am going to ask a series of questions about employment…

LAST WEEK, did you work for pay at a job or business?

(Include any work even if you worked only 1 hour, or helped without pay in a family business or farm for 15 hours or more, or were on active duty in the Armed Forces.)

 Yes  go to 30a

 No

29b. LAST WEEK, did you do ANY work for pay, even for as little as one hour?

 Yes

 No  go to 35a

30a. The next few questions deal with where you worked LAST WEEK and how you got there.

LAST WEEK, at what location did you work?

What is the address – number and street name?

(If you worked at more than one address or location, give the address or location where you worked most LAST WEEK.

If you do not know the exact street address, give a description of the location such as the building name or the nearest street or intersection.

For example: Town Center Mall, 1st National Bank, Reno Airport, 2nd Ave. and 4th St.)

_____________________________

Number and Street Name

30b. What was the city or town?

City

30c. What was the state?

ENTER THE STATE ABBREVIATION

State

30d. What was the ZIP code?

ZIP code

30e. What was the county?

30f. Is the work inside the limits of (<name of city>/that city or town)?

 Yes

 No

31. LAST WEEK, how did you USUALLY get to work?

(If you usually used more than one method of transportation during the trip, report the one used for most of the distance.)

 Car, truck, or van

 Bus

 Subway or elevated rail

 Commuter rail or long-distance train

 Light rail, streetcar, or trolley

 Ferryboat

 Taxicab

 Motorcycle

 Bicycle

 Walked

 Worked from home  go to 39a

 Other method

INSTRUCTION M

IF RESPONSE TO QUESTION 31 IS “CAR, TRUCK, OR VAN”, GO TO QUESTION 32.

OTHERWISE GO TO QUESTION 33.

32. LAST WEEK, how many people including yourself usually rode to work together?

____

33. LAST WEEK, what time did your trip to work usually begin?

(What hour?)

(How many minutes past the hour?)

(Was that AM or PM?)

Hour Minute

__ : __ a.m.

 p.m.

34. LAST WEEK, how many minutes did it usually take you to get from home to work?

ENTER A ONE-WAY COMMUTE TIME FOR THE PERSON’S DAILY COMMUTE FROM HOME TO WORK LAST WEEK.

___ Minutes

INSTRUCTION N

IF RESPONSE TO QUESTION 29B IS “NO” ASK QUESTION 35A.

OTHERWISE, GO TO QUESTION 39A.

35a. LAST WEEK, were you on layoff from a job?

 Yes  go to 35c

 No

35b. LAST WEEK, were you TEMPORARILY absent from a job or business because of vacation, temporary illness, maternity leave, other family or personal reasons, bad weather, etc.?

 Yes  go to 38

 No  go to 36

35c. Have you been informed that you will be recalled to work within the next 6 months OR been given a date to return to work?

 Yes  go to 37a

 No

36. During the LAST 4 WEEKS, have you been ACTIVELY looking for work?

 Yes

 No  go to 38

37a. LAST WEEK, could you have started a job if offered one (or returned to work if recalled)?

 Yes  go to 38

 No

37b. Why was that?

Own temporary illness

Going to school or some other reason

38. When did you last work, even for a few days?

 Within the past 12 months

 Between 1 and 5 years ago  go to Instruction O

Over 5 years ago or never worked  go to Instruction O

The next few questions ask about work in the past 52 weeks, that is from <Current date, year -1> to today.

39a. Over the past 52 weeks, that is since one year ago today, did you work EVERY week? Count paid vacation, paid sick leave, and military service as work.

 Yes  go to 40

 No

39b. Over the past 52 weeks, that is since one year ago today, how many WEEKS did you work? Include paid time off and include weeks when (you/Name) only worked for a few hours.

Weeks

Would rather answer in months  go to 39c

39c. How many months have you worked since one year ago today?

Include paid time off and weeks when you only worked for a few hours.

Convert respondent’s answer from months to weeks using the table to the right and enter calculation below table. Use this cacluation for the fill in question 39d to verify.

Months

nths	Weeks	Months	Weeks
			
			
			
			
			
			

____ Weeks

39d. Then you worked about (fill calculated number) of weeks. Is that right?

 Yes

 No = go to 39c

40. Over the past 52 weeks, that is since one year ago today, in the weeks you worked, how many hours did you usually work each week?

Usual hours each week

INSTRUCTION O

If there is another person to collect detail person data for, Continue to person 2.

Otherwise, end interview.

DETAILED QUESTIONS—PERSON 2

13. What is <Name>’s ancestry or ethnic origin? (For example: Italian, Jamaican, African-American, Cambodian, Cape Verdean, Norwegian, Dominican, French Canadian, Haitian, Korean, Lebanese, Polish, Nigerian, Mexican, Taiwanese, Ukrainian and so on.)	_________________________________ _________________________________
14a. Does <Name> speak a language other than English at home?	 Yes  No  Go to 15a
14b. What is this language? (For example: Korean, Italian, Spanish, Vietnamese)	_________________________________
14c. How well does <Name> speak English – very well, well, not well, not at all?	 Very well  Well  Not well  Not at all
14c-SKIP IF PERSON IS LESS THAN ONE YEAR OLD, GO TO INSTRUCTION O ON PAGE 13. OTHERWISE GO TO QUESTION 15A.
15a. Did <Name> live in this <house/apartment/mobile home/unit> 1 year ago?	 Yes  Go to 29a  No
15b. Did <Name> live in the United States, Puerto Rico, or another country?	 United States  Puerto Rico  Another country  Yes, in the same house as Person 1= goto 29a Person 1 address is located on Page 5.
15b-SKIP IF PERSON ANSWERED “UNITED STATES” or “PUERTO RICO” , GO TO QUESTION 15D. OTHERWISE GO TO 15C.
15c. What was the foreign country?	_________________________ Country
15d. What was the street address?	_________________________________
15e. What was the city or town?	_________________________________
15e-SKIP IF PERSON ANSWERED “PUERTO RICO” IN QUESTION 15B, GO TO QUESTION 15G. OTHERWISE GO TO 15F.
15f. What was the state? ENTER THE STATE ABBREVIATION	__________________________ State
15g. What was the ZIP code?	_______________________ ZIP
IF PERSON DID NOT ANSWER “PUERTO RICO” IN QUESTION 15B, ASK: 15h. What was the county? IF PERSON ANSWERED “PUERTO RICO” IN QUESTION 15B, ASK: 15h. What was the municipio?	_______________________ County/Municipio
15h-SKIP IF PERSON IS LESS THAN FIFTEEN YEARS OLD, GO TO INSTRUCTION O ON PAGE 13. OTHERWISE GO TO QUESTION 29A.

29a. Now, I am going to ask a series of questions about employment…

LAST WEEK, did <Name> work for pay at a job or business?

(Include any work even if <Name> worked only 1 hour, or helped without pay in a family business or farm for 15 hours or more, or was on active duty in the Armed Forces.)

 Yes  go to 30a

 No

29b. LAST WEEK, did <Name> do ANY work for pay, even for as little as one hour?

 Yes

 No  go to 35a

30a. The next few questions deal with where <Name> worked LAST WEEK and how <Name> got there.

LAST WEEK, at what location did <Name> work?

What is the address – number and street name?

(If <Name> worked at more than one address or location, give the address or location where <Name> worked most LAST WEEK.

If <Name> does not know the exact street address, give a description of the location such as the building name or the nearest street or intersection.

For example: Town Center Mall, 1st National Bank, Reno Airport, 2nd Ave. and 4th St.)

_____________________________

Number and Street Name

30b. What was the city or town?

City

30c. What was the state?

ENTER THE STATE ABBREVIATION

State

30d. What was the ZIP code?

ZIP code

30e. What was the county?

County

30f. Is the work location inside the limits of (<name of city>/that city or town)?

 Yes

 No

31. LAST WEEK, how did <Name> USUALLY get to work?

(If <Name> usually used more than one method of transportation during the trip, report the one used for most of the distance.)

 Car, truck, or van

 Bus

 Subway or elevated rail

 Commuter rail or long-distance train

 Light rail, streetcar, or trolley

 Ferryboat

 Taxicab

 Motorcycle

 Bicycle

 Walked

 Worked from home  go to 39a

 Other method

INSTRUCTION M

IF RESPONSE TO QUESTION 31 IS “CAR, TRUCK, OR VAN”, GO TO QUESTION 32.

OTHERWISE GO TO QUESTION 33.

32. LAST WEEK, how many people including <Name> usually rode to work together?

____

33. LAST WEEK, what time did <Name>’s trip to work usually begin?

(What hour?)

(How many minutes past the hour?)

(Was that AM or PM?)

Hour Minutes

__ : __ a.m.

 p.m.

34. LAST WEEK, how many minutes did it usually take <Name> to get from home to work?

ENTER A ONE-WAY COMMUTE TIME FOR THE PERSON’S DAILY COMMUTE FROM HOME TO WORK LAST WEEK.

___ Minutes

INSTRUCTION N

IF RESPONSE TO QUESTION 29B IS “NO” ASK QUESTION 35A.

OTHERWISE, GO TO QUESTION 39A.

35a. LAST WEEK, was <Name> on layoff from a job?

 Yes  go to 35c

 No

35b. LAST WEEK, was <Name> TEMPORARILY absent from a job or business because of vacation, temporary illness, maternity leave, other family or personal reasons, bad weather, etc.?

 Yes  go to 38

 No  go to 36

35c. Has <Name> been informed that <he/she> will be recalled to work within the next 6 months OR been given a date to return to work?

 Yes  go to 37a

 No

36. During the LAST 4 WEEKS, has <Name> been ACTIVELY looking for work?

 Yes

 No  go to 38

37a. LAST WEEK, could <Name> have started a job if offered one (or returned to work if recalled)?

 Yes  go to 38

 No

37b. Why was that?

Own temporary illness

Going to school or some other reason

38. When did <Name> work last work, even for a few days?

 Within the past 12 months

 Between 1 and 5 years ago  go to Instruction O

Over 5 years ago or never worked  go to Instruction O

The next few questions ask about work in the past 52 weeks, that is from <Current date, year -1> to today.

39a. Over the past 52 weeks, that is since one year ago today, did <Name> work EVERY week? Count paid vacation, paid sick leave, and military service as work.

 Yes  go to 40

 No

39b. Over the past 52 weeks, that is since one year ago today, how many WEEKS did <Name> work? Include paid time off and include weeks when <Name> only worked for a few hours.

Weeks= go to 40

Would rather answer in months = go to 39c

39c. How many months has <Name> worked since one year ago today?

Include paid time off and weeks when <NAME> only worked for a few hours.

Convert respondent’s answer from months to weeks using the table to the right and enter calculation below table. Use this calculation for the fill in question 39d to verify.

Months

nths	Weeks	Months	Weeks
			
			
			
			
			
			

____ Weeks

39d. Then <Name> worked about (fill calculated number) weeks. Is that right?

 Yes

 No = go to 39c to make corrections

40. Over the past 52 weeks, that is since one year ago today, in the weeks <Name> worked, how many hours did <Name> usually work each week?

Usual hours each week

INSTRUCTION O

If PERSON 2 WAS NOT ELIGIBLE TO ANSWER Questions 39 throuth 40, collect detail person data for person 3.

Otherwise, end interview.

DETAILED QUESTIONS—PERSON 3

13. What is <Name>’s ancestry or ethnic origin? (For example: Italian, Jamaican, African-American, Cambodian, Cape Verdean, Norwegian, Dominican, French Canadian, Haitian, Korean, Lebanese, Polish, Nigerian, Mexican, Taiwanese, Ukrainian and so on.)	_________________________________ _________________________________
14a. Does <Name> speak a language other than English at home?	 Yes  No  Go to 15a
14b. What is this language? (For example: Korean, Italian, Spanish, Vietnamese)	_________________________________
14c. How well does <Name> speak English – very well, well, not well, not at all?	 Very well  Well  Not well  Not at all
14c-SKIP IF PERSON IS LESS THAN ONE YEAR OLD, GO TO INSTRUCTION O ON PAGE 19. OTHERWISE GO TO QUESTION 15A.
15a. Did <Name> live in this <house/apartment/mobile home/unit> 1 year ago?	 Yes  Go to 29a  No
15b. Did <Name> live in the United States, Puerto Rico, or another country?	 United States  Puerto Rico  Another country  Yes, in the same house as Person 1 go to 29a Person 1 address is located on Page 5.
15b-SKIP IF PERSON ANSWERED “UNITED STATES”OR “PUERTO RICO”, GO TO QUESTION 15D. OTHERWISE GO TO 15C.
15c. What was the foreign country?	_________________________ Country
15d. What was the street address?	_________________________________
15e. What was the city or town?	_________________________________
15e-SKIP IF PERSON ANSWERED “PUERTO RICO” IN QUESTION 15B, GO TO QUESTION 15G. OTHERWISE GO TO 15F.
15f. What was the state? ENTER THE STATE ABBREVIATION	__________________________ State
15g. What was the ZIP code?	_______________________ ZIP
IF PERSON DID NOT ANSWER “PUERTO RICO” IN QUESTION 15B, ASK: 15h. What was the county? IF PERSON ANSWERED “PUERTO RICO” IN QUESTION 15B, ASK: 15h. What was the municipio?	_______________________ County/Municipio
15h-SKIP IF PERSON IS LESS THAN FIFTEEN YEARS OLD, GO TO INSTRUCTION O ON PAGE 19. OTHERWISE GO TO QUESTION 29A.

29a. Now, I am going to ask a series of questions about employment…

LAST WEEK, did <Name> work for pay at a job or business?

(Include any work even if <Name> worked only 1 hour, or helped without pay in a family business or farm for 15 hours or more, or was on active duty in the Armed Forces.)

 Yes  go to 30a

 No

29b. LAST WEEK, did <Name> do ANY work for pay, even for as little as one hour?

 Yes

 No  go to 35a

30a. The next few questions deal with where <Name> worked LAST WEEK and how <Name> got there.

LAST WEEK, at what location did <Name> work?

What is the address – number and street name?

(If <Name> worked at more than one address or location, give the address or location where <Name> worked most LAST WEEK.

If <Name> does not know the exact street address, give a description of the location such as the building name or the nearest street or intersection.

For example: Town Center Mall, 1st National Bank, Reno Airport, 2nd Ave. and 4th St.)

_____________________________

Number and Street Name

30b. What was the city or town?

City

30c. What was the state?

ENTER THE STATE ABBREVIATION

State

30d. What was the ZIP code?

ZIP code

30e. What was the county?

County

30f. Is the work location inside the limits of (<name of city>/that city or town)?

 Yes

 No

31. LAST WEEK, how did <Name> USUALLY get to work?

(If <Name> usually used more than one method of transportation during the trip, report the one used for most of the distance.)

 Car, truck, or van

 Bus

 Subway or elevated rail

 Commuter rail or long-distance train

 Light rail, streetcar, or trolley

 Ferryboat

 Taxicab

 Motorcycle

 Bicycle

 Walked

 Worked from home  go to 39a

 Other method

INSTRUCTION M

IF RESPONSE TO QUESTION 31 IS “CAR, TRUCK, OR VAN”, GO TO QUESTION 32.

OTHERWISE GO TO QUESTION 33.

32. LAST WEEK, how many people including <Name> usually rode to work together?

____

33. LAST WEEK, what time did <Name> ‘s trip to work usually begin?

(What hour?)

(How many minutes past the hour?)

(Was that AM or PM?)

Hour Minutes

__ : __ a.m.

 p.m.

34. LAST WEEK, how many minutes did it usually take <Name> to get from home to work?

ENTER A ONE-WAY COMMUTE TIME FOR THE PERSON’S DAILY COMMUTE FROM HOME TO WORK LAST WEEK.

___ Minutes

INSTRUCTION N

IF RESPONSE TO QUESTION 29B IS “NO” ASK QUESTION 35A.

OTHERWISE, GO TO QUESTION 39A.

35a. LAST WEEK, was <Name> on layoff from a job?

 Yes  go to 35c

 No

35b. LAST WEEK, was <Name> TEMPORARILY absent from a job or business because of vacation, temporary illness, maternity leave, other family or personal reasons, bad weather, etc.?

 Yes  go to 38

 No  go to 36

35c. Has <Name> been informed that <he/she> will be recalled to work within the next 6 months OR been given a date to return to work?

 Yes  go to 37a

 No

36. During the LAST 4 WEEKS, has <Name> been ACTIVELY looking for work?

 Yes

 No  go to 38

37a. LAST WEEK, could <Name> have started a job if offered one (or returned to work if recalled)?

 Yes  go to 38

 No

37b. Why was that?

Own temporary illness

Going to school or some other reason

38. When did <Name> work last work, even for a few days?

 Within the past 12 months

 Between 1 and 5 years ago  go to Instruction O

Over 5 years ago or never worked  go to Instruction O

The next few questions ask about work in the past 52 weeks, that is from <Current date, year -1> to today.

39a. Over the past 52 weeks, that is since one year ago today, did <Name> work EVERY week? Count paid vacation, paid sick leave, and military service as work.

 Yes  go to 40

 No

39b. Over the past 52 weeks, that is since one year ago today, how many WEEKS did <Name> work? Include paid time off and include weeks when <Name> only worked for a few hours.

Weeks= go to 40

Would rather answer in months = go to 39c

39c. How many months has <Name> worked since one year ago today?

Include paid time off and weeks when <Name> only worked for a few hours.

Convert respondent’s answer from months to weeks using the table to the right and enter calculation below table. Use this calculation for the fill in question 39d to verify.

Months

nths	Weeks	Months	Weeks
			
			
			
			
			
			

____ Weeks

39d. Then <Name> worked about (fill calculated number) weeks. Is that right?

 Yes

 No = go to 39c to make corrections

40. Over the past 52 weeks, that is since one year ago today, in the weeks <Name> worked, how many hours did <Name> usually work each week?

Usual hours each week

INSTRUCTION O

end interview.

7