AI Screener AI Screener

PARTICIPANT SCREENER

American Indians and Indigenous Mexican, Central, and South Americans

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’d like to talk 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 one 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 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. Do you have heritage with any indigenous groups of people from Mexico, Central America, or South America?

a. No  SKIP TO Q.9

b. Yes (IF YES) What is that group(s)? ___________________

Can you speak the language of your indigenous group now, or did you speak the language of your group as a child?

a. No  SKIP TO Q.13

b. Yes (IF YES) What is that language(s)? ____________________  SKIP TO Q.13

9. What is/are your tribe(s), pueblo(s) or rancheria(s)? You can identify more than one.

a._________________________________

____Federally recognized ____State-recognized ____Neither

b._________________________________

____Federally recognized ____State-recognized ____Neither

c._________________________________

____Federally recognized ____State-recognized ____Neither

10. Are you enrolled in any tribe(s), pueblo(s), or rancheria(s)?

____Yes – Which ones? ______________________ _______________________

____No

____I don’t know

11. At this time, what is your level of engagement with your main tribe?

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 in tribal affairs

d. Not active in a tribal affairs

12. Do you live on a reservation for most of the year?

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

_____ No

12a. (IF YES, ASK) Do you live on the reservation of which you are tribally associated or enrolled?

____Yes ____No

12b. (IF YES or OCCASIONAL, ASK) In what city and state is the reservation located?

Name of city or town and state:_________________________  SKIP TO Q.13

12c. (IF NO, ASK) What city and state do you live in for most of the year?

Name of city or town and state:______________________________

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

a. No

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

14. 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

13a. (If American Indian or Alaska Native) What is your mother’s tribe? You can say more than one _______________________

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

a. No

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

16. 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

16a. (If American Indian or Alaska Native) What is your father’s tribe? You can say more than one _______________________

17. 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

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

19. 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? ______________________

20. Did someone in your tribe ask you or nominate you to participate in this research study interview?

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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