Form 3 Roster Questions for Group 2

Group 2 Roster-Latest Revision 5/26/17

Participant ID #: |___|___|___|___|___|___|___|___|___|___| American Community Survey Roster (Group 2: Income and WW)

	Respondent	Person 2	Person 3	Person 4	Person 5	Person 6
1. I am going to be asking some questions about everyone ages 15 or older 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 age 15 or older who is 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, stepson or stepdaughter, OR foster son or daughter?		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 BIRTH MONTH/DAY/YEAR.	___/___/____	___/___/____	___/___/____	___/___/____	___/___/____	___/___/____
4b. What is (your/<Name>'s) age? (What is your best estimate of (your/<Name>'s) age?)	________	________	________	________	________	________
5a. <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  Go to 6a	 Yes  No  Go to 6a	 Yes  No  Go to 6a	 Yes  No  Go to 6a	 Yes  No  Go to 6a	 Yes  No  Go to 6a
5b. <Are you/Is (Name)> Mexican, Mexican American, or Chicano; Puerto Rican; Cuban; or of another other Hispanic, Latino, or Spanish origin; (for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on?)	Mexican, Mexican American, Chicano Puerto Rican  Cuban  Another Hispanic, Latino, or Spanish origin; (for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on)	Mexican, Mexican American, Chicano Puerto Rican  Cuban  Another Hispanic, Latino, or Spanish origin; (for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on)	Mexican, Mexican American, Chicano Puerto Rican  Cuban  Another Hispanic, Latino, or Spanish origin; (for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on)	Mexican, Mexican American, Chicano Puerto Rican  Cuban  Another Hispanic, Latino, or Spanish origin; (for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on)	Mexican, Mexican American, Chicano Puerto Rican  Cuban  Another Hispanic, Latino, or Spanish origin; (for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on)	Mexican, Mexican American, Chicano Puerto Rican  Cuban  Another Hispanic, Latino, or Spanish origin; (for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on)
5b_SKIP IF PERSON HAS A RESPONSE OF “ANOTHER HISPANIC, LATINO, OR SPANISH ORIGIN” IN 5B, ASK 5C FOR THAT PERSON. OTHERWISE, GO TO 6A.
5c. What is that origin? (For example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on.)	________	________	________	________	________	________
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.

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