2 Roster Questions for Group 1

Generic Clearance for Questionnaire Pretesting Research

Attachment G Interviewer Administered Roster Questions (Group 1)

ACS Respondent Burden Cognitive Testing

OMB: 0607-0725

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Group 1 Roster-Latest Revision 5/24/17

Participant ID #: |___|___|___|___|___|___|___|___|___|___| American Community Survey Roster (Group 1: YRNAT/YOE)



Respondent

Person 2

Person 3

Person 4

Person 5

Person 6

1. I am going to be asking some questions about everyone who is living or staying at this address. First, let’s start with you. What is your name?


(What is the name of the next person living or staying here?)





Name or initials:

_________________





Name or initials:

_________________





Name or initials:

_________________





Name or initials:

_________________





Name or initials:

_________________





Name or initials:

_________________

ROSTER AND DEMOGRAPHICS

ASK AS TOPIC-BASED, THAT IS, ASK QUESTION FOR EACH PERSON BEFORE MOVING TO NEXT QUESTION.


READ ONLY ONCE: Now I would like to ask you some basic questions about people in this household.


2. ASK OR VERIFY: How is <Name> related to you?

Husband or wife

Son or daughter

Brother or sister

Father or mother

Grandchild

Parent-in-law

Son-in-law or daughter-in-law

Other relative

Roomer or boarder

Housemate or roommate

Unmarried partner

Foster child

Other nonrelative


IF RESPONSE IS “SON” OR “DAUGHTER” ASK FIRST BEFORE SELECTING ANSWER CATEGORY:

Is <Name> your biological son or daughter, adopted son or daughter, OR stepson or stepdaughter?



Husband or wife

Biological Son/Daughter

Adopted Son/Daughter

 Stepson/
Stepdaughter

Brother/Sister

Father/Mother

Grandchild

Parent-in-law

Son-in-law/daughter-in-law

Other relative

Roomer/Boarder

Housemate/ Roommate

Unmarried partner

Foster child

Other non-relative

Husband or wife

Biological Son/Daughter

Adopted Son/Daughter

 Stepson/
Stepdaughter

Brother/Sister

Father/Mother

Grandchild

Parent-in-law

Son/daughter-law

Other relative

Roomer/Boarder

Housemate/ Roommate

Unmarried partner

Foster child

Other non-relative

Husband or wife

Biological Son/Daughter

Adopted Son/Daughter

 Stepson/
Stepdaughter

Brother/Sister

Father/Mother

Grandchild

Parent-in-law

Son/daughter-law

Other relative

Roomer/Boarder

Housemate/ Roommate

Unmarried partner

Foster child

Other non-relative

Husband or wife

Biological Son/Daughter

Adopted Son/Daughter

 Stepson/
Stepdaughter

Brother/Sister

Father/Mother

Grandchild

Parent-in-law

Son/daughter-law

Other relative

Roomer/Boarder

Housemate/ Roommate

Unmarried partner

Foster child

Other non-relative

Husband or wife

Biological Son/Daughter

Adopted Son/Daughter

 Stepson/
Stepdaughter

Brother/Sister

Father/Mother

Grandchild

Parent-in-law

Son/daughter-law

Other relative

Roomer/Boarder

Housemate/ Roommate

Unmarried partner

Foster child

Other non-relative

3. ASK OR VERIFY: Are you male or female?

(How about <Name>?)

Or ask: (Is <Name> male or female?)

Male

Female


Male

Female


Male

Female


Male

Female


Male

Female


Male

Female


4a. What is (your/<Name>'s) date of birth?

ENTER MONTH/DAY/YEAR OF BIRTH.


___/___/____


___/___/____


___/___/____


___/___/____


___/___/____


___/___/____

4b. What is (your/<Name>'s) age?


(What is your best estimate of (your/<Name>'s) age?)



________




________




________




________




________




________


5. <Are you/Is (Name)> of Hispanic, Latino, or Spanish origin?

(How about <Name>?)

Or ask: (Is <Name> of Hispanic, Latino, or Spanish origin?)

Yes

No


Yes

No


Yes

No


Yes

No


Yes

No


Yes

No


6a. I'm going to read a list of race categories. You may choose one or more races. For this survey, Hispanic origin is not a race.


(Are you/Is <Name>) White; Black or African American; American Indian or Alaska Native; Asian; Native Hawaiian or Other Pacific Islander; or Some other race?




White

 Black or African American

 American Indian or Alaska Native

 Asian

 Native Hawaiian or Other Pacific Islander

 Some other race


White

 Black or African American

 American Indian or Alaska Native

 Asian

 Native Hawaiian or Other Pacific Islander

 Some other race


White

 Black or African American

 American Indian or Alaska Native

 Asian

 Native Hawaiian or Other Pacific Islander

 Some other race


White

 Black or African American

 American Indian or Alaska Native

 Asian

 Native Hawaiian or Other Pacific Islander

 Some other race


White

 Black or African American

 American Indian or Alaska Native

 Asian

 Native Hawaiian or Other Pacific Islander

 Some other race


White

 Black or African American

 American Indian or Alaska Native

 Asian

 Native Hawaiian or Other Pacific Islander

 Some other race



6b. Thank you. Please give me just a moment to review your answers.




3


File Typeapplication/msword
AuthorCensus
Last Modified ByKathryn A Cheza (CENSUS/ACSO FED)
File Modified2017-06-09
File Created2017-06-09

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