AN Screener AN Screener

PARTICIPANT SCREENER – Alaska Natives

Participant Name:	Screening Date:
Participant ID Number:	Interview Location:

Hello, my name is [insert name] and I work for Kauffman and Associates on behalf of the U.S. Census Bureau. I am talking to you about an opportunity to participate in research that could help improve U.S. Census forms. We are recruiting participants from different tribal groups, ages, and educational backgrounds to participate in a research study interview. If you meet the criteria and decide to participate, you will receive $40 for your participation. The interview session will take no more than an hour of your time. The session will be audio recorded, and your confidentiality will be protected. Can you take a few minutes to answer a few questions to determine whether you qualify to participate? (IF THE ANSWER IS YES, CONTINUE; IF THE ANSWER IS NO, THANK THE RESPONDENT AND POLITELY END THE CONVERSATION.)

1. Are you available on [INSERT SCHEDULED DATES AND TIMES HERE]?

____Yes ____No - THANK AND END

2. What is your age?

______ IF UNDER 18, THANK AND END

Refuse - THANK AND END

Don't know - THANK AND END

3. When was the last time you participated in a research study interview?

________________________

_____Refuse

_____Never

_____Don’t know

IF LESS THAN 12 MONTHS AGO, REFUSE OR DON'T KNOW: THANK AND

END.

4. About how many research study interviews have you participated in? __________________________

4a. (IF YES) What were the topics of the research study interviews you participated in? _____________________

5. Note gender or confirm if necessary: ____Female ____Male

6. Are you of Hispanic, Latino, or Spanish origin?

a. No

b. Yes (IF YES) What is that origin? ____________________________

7. What is your race? Please select one or more.

(Mark all that apply)

1. White

2. Black or African American

3. American Indian or Alaska Native

4. Asian

5. Native Hawaiian or Other Pacific Islander

6. (DO NOT READ) Some other race

8. What is your village? (You can identify more than one).

_________________________ _________________________

9. Are you associated with one or more tribes? Yes____ No _____

9a. (IF YES) What is(are) the name(s) of these tribe(s)? (You can identify more than one).

___________________________________________________

___________________________________________________

10. Are you a shareholder of one or more ANCSA corporations? Yes____ No _____

10a. (IF YES) What is(are) the name(s) of your corporations(s)?

___________________________________________________

___________________________________________________

11. [ASK IF RESPONDENT HAS NOT PREVIOUSLY REPORTED A COMMUNITY,

ASSOCIATION, OR COUNCIL] Are you a member of a group we have not named, such

as a Community, Association, or Council? Yes____ No _____

11a. (IF YES) What is(are) the name(s) of your group(s)? (You can identify more than one).

___________________________________________________

___________________________________________________

12. Are you enrolled in any tribe(s), village(s), corporation(s), or similar groups?

Yes____ No _____

12a. (IF YES) Which one(s)?

_______________________ Is this federally recognized? Yes____ No _____

_______________________ Is this federally recognized? Yes____ No _____

_______________________ Is this federally recognized? Yes____ No _____

13. [IF A TRIBE, VILLAGE, COMMUNITY, ASSOCIATION, OR COUNCIL IS

REPORTED] At this time, what is your level of engagement with your main [SAY THE TRIBAL ENTITY STATED BY RESPONDENT]?

a. Very active as an elected or appointed leader, council member, or delegate

b. Active, but not an elected or appointed leader, council member, or delegate

c. Occasionally active

d. Not active

14. [IF ANCSA CORPORTATION IS REPORTED] At this time, what is your level of engagement with your main corporation?

a. Very active as an elected or appointed Regional Corporation Officer or Director

b. Active, but not an elected or appointed Regional Corp. Officer or Director

c. Occasionally active

d. Not active

15. Do you live in an Alaskan village for most of the year?

_____Yes, full time ____Occasional visits (social connections and events)

_____ No

15a. (IF YES or Occasional, ASK) What is the name of the village?

_______________  SKIP TO Q.16

15b. (IF NO, ASK) What city or town do you live in for most of the year?

Name of city or town and state:______________________________

16. Is your mother of Hispanic, Latino, or Spanish origin?

a. No

b. Yes (IF YES) What is that origin? ____________________________

17. What is your mother’s race? Please select one or more.

(Mark all that apply)

1. White

2. Black or African American

3. American Indian or Alaska Native

4. Asian

5. Native Hawaiian or Other Pacific Islander

6. (DO NOT READ) Some other race

17a. (If American Indian or Alaska Native) What is your mother’s tribe or village? You can say more than one _______________________

18. Is your father of Hispanic, Latino, or Spanish origin?

a. No

b. Yes (IF YES) What is that origin? ____________________________

19. What is your father’s race? Please select one or more.

(Mark all that apply)

1. White

2. Black or African American

3. American Indian or Alaska Native

4. Asian

5. Native Hawaiian or Other Pacific Islander

6. (DO NOT READ) Some other race

19a. (If American Indian or Alaska Native) What is your father’s tribe or village? You can say more than one _______________________

20. What is the highest grade or level of education you have completed?

____Middle school or less

____Less than high school diploma/GED

____High school diploma/GED

____Some college

____Associate’s degree

____College graduate (does not include associate's degree)

____Graduate/professional degree (MA, MS, MD, JD, PhD, etc.)

____Refuse

____Don't know

21. Please tell us how or where you heard about this study. ________________________

22. Do you know anyone else who is participating or may participate in this study?

a. No

b. Yes (IF YES) How do you know that person? ______________________

23. Did someone in your tribe or village (IF APPLICABLE, or corporation) ask you or nominate you to participate in this interview? ____Yes ____No

a. No

b. Yes (IF YES) Did this person send or tell you any questions you might be asked in this study? _____No _____Yes

Thanks for answering these questions. If you are selected for the interview, we will contact you within the next few days. What is the best way to reach you?

Name:___________________________________ Email:______________________________

Phone #1_________________________________ Phone #2____________________________

Thank you very much!

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