Enc. 5 Recruitment Screener
Generic Clearance for Questionnaire Pretesting Research
Enclosure 5_Recruitment Screener
2016 NYCHVS Spanish Translation Research
OMB: 0607-0725
NYCHVS Screener
Hello, I’m _____________ from the Census Bureau.
Thank you for contacting us about participating in one of our studies.
I just need to get a little bit of background information to start.
Auto filled: ID Number
Auto filled: Last Contact Date
Auto filled: Eligible Date
What is your name?
First name: [ ]
Last name(s): [ ]
ASK/CONFIRM IF NOT OBVIOUS: Are you male or female?
o Male
o Female
In what year were you born? ________ (Must be 18 years or older to participate; Before June/July 1998)
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, or Native Hawaiian or other Pacific Islander?
(Allow up to 3 answers)
[] White
[] Black or African American
[] American Indian or Alaska Native
[] Asian
[] Native Hawaiian or other Pacific Islander
With regard to your culture, do you consider yourself indigenous?
o Yes
o No
Were you born in the United States or in another country?
o United States SKIP TO Q8
o Another country
7a. In what country were you born? _____________
7b. How long have you been in the United States? ______________
7c. Were any of your other household members born in the U.S.?
o Yes
o No
7d. Did you complete your schooling in the U.S. or in another country?
o United States SKIP TO Q8
o Another country
7e. In what country did you complete your schooling? ____________
What is the highest grade of school you have completed, or the highest degree you have received?
(do not read categories to respondent)
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.)
Other (specify)________________
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 SKIP TO Q10
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? [IF OUTSIDE NYC, INELIGIBLE. THANK AND END]
Do you own or rent your home?
o Rent
o Own SKIP TO Q13
Is your rent stabilized?
o Rent Stabilized
o Non-regulated
What type of home do you [rent/own]?
o Apartment
o Condominium
o Cooperative
o Town House
o Single Family House?
Are there any vacant homes in your building?
o Yes
o No SKIP TO Q15
14a. IF YES: Can you tell me more about the vacant homes in your building? How many are there, and where are they located in relation to your home?
Specify:_________________________________________________________________
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?
[ ]
For each of the [ANSWER TO Q15 + ANSWER TO Q16] people that live in your household, I’d like to ask you their relationship to you. I don’t need their names – just their relationship to you.
Don’t read
[ ] Opposite sex husband/wife
[ ] Same sex husband/wife
[ ] Opposite sex unmarried partner
[ ] Same sex unmarried partner
[ ] Son or daughter
[ ] Brother or sister
[ ] Father or mother
[ ] Granchild
[ ] Parent-in-law
[ ] Son-in-law or daughter-in-law
[ ] Other relative (specify: ___________)
[ ] Housemate or roommate
[ ] Roomer or boarder
[ ] Landlord
[ ] Other nonrelative (specify: ____________)
What is your native language or languages?
[ ] Spanish
[ ] English
[ ] Other (Specify:______________)
[IF NOT MENTIONED AT Q18] Do you speak any indigenous language?
o Yes (Specify:__________)
o No
Do either of your parents speak an indigenous language?
o Yes (Specify:__________)
o No
The Census Bureau does interviews and focus groups in many different languages. I’d like to start by asking you about your Spanish. How well do you speak Spanish?
O Very well
O Well
O Not well
O Not at all
How well do you read Spanish?
O Very well
O Well
O Not well
O Not at all
[IF NEEDED: It’s not necessary that you speak English to participate in one of our studies, but I need to ask you a few questions about English now.] How well do you speak English?
O Very well
O Well
O Not well
O Not at all
How well do you read English?
O Very well
O Well
O Not well
O Not at all
Would you say you speak Spanish better than English, English better than Spanish, or both about equally well?
O Spanish better than English
O English better than Spanish
O Both about equally well
When you have a choice between English and Spanish, do you typically participate in surveys or fill out forms in…?
O Spanish
O English
O Both equally often
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 [ ]
What is your daytime telephone number?
[Probe for all 3 phone numbers]
Mobile ([ ]) [ ] – [ ]
Home (if not mobile) ([ ]) [ ] – [ ]
Work (if any) ([ ]) [ ] – [ ] EXT.[ ]
30a. IF PROVIDED MOBILE NUMBER: If you are eligible to participate in a study, we may send you a text message to remind you of your appointment. Can you receive text messages, or do you prefer not receive them?
If you are eligible to participate in a study, we may send you an email confirmation with directions to the interview location. What is the e-mail address we could use when sending directions?
[ ]
Is your household’s annual income …
o Less than $15,000?
o $15,000 to $25,000?
o $25,000 to$50,000?
o $50,000 to $100,000?
o More than $100,000?
Are you currently receiving public assistance in the United Sates from any source, including the U.S. Government or any State, county, city, or municipality (other than emergency medical treatment) such as SNAP, WIC, TANF, etc.?
o Yes (SPECIFY: What type of public assistance?_________________ (list all programs))
o No
THANK AND END OR SCHEDULE AS APPROPRIATE.
| 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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