Screener

Screener_NCVS Mail Materials.docx

Generic Clearance for Questionnaire Pretesting Research

Screener

OMB: 0607-0725

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Cognitive Interview Participant Telephone Screener – NCVS Mail Materials


Hello, I’m _____________ from the Census Bureau. Thank you for contacting us about participating in our research study for the National Crime Victimization Survey. I just need to get a little bit of background information to start.


  • ID Number:

  • Contact Date:



  1. What is your name?

First name:

Last name:



  1. (Ask if not obvious) Are you male or female?

o Male

o Female



  1. In what year were you born?


  1. Are you employed by the Federal Government? (if federal contractor, mark NO)

o Yes

o No



  1. Who is the person most likely to receive and open the mail for your household?

o Self

o Another person





  1. In what city, state, and ZIP code do you currently live?

City: State: Zip:




  1. How did you hear about this research opportunity?

  • E-mail link

  • Census Bureau employee

  • Friend or family member (but not a Census Bureau employee)

  • Facebook

  • Craigslist

  • Google advertisement

  • Flyer

  • Newspaper advertisement

  • Other – specify:



  1. Have you participated in any research studies with the U.S. Census Bureau?

o Yes

o No



  1. What is your daytime telephone number?



  1. What is the e-mail address we should use when sending directions to our office, should you qualify?




  1. Are you a United States citizen? You do not have to be a U.S. citizen to participate in our studies.

o Yes

o No



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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleSlight changes to participate
AuthorDawn V Nelson
File Modified0000-00-00
File Created2021-01-22

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