Screener
Attachment V - Recruitment Eligibility Screeners.docx
Generic Clearance for Questionnaire Pretesting Research
Screener
OMB: 0607-0725
Section 1: CSM Universal Telephone Screener (for Fiscal Year 2017)
Hello, I’m _____________ from the Census Bureau.
Thank you for contacting us about participating in one of our studies.
I just need to get a little bit of background information to start.
Auto filled: ID Number
Auto filled: Last Contact Date
Auto filled: Eligible Date
What is your name?
First name: [ ]
Last name: [ ]
(Ask if not obvious) Are you male or female?
o Male
o Female
In what year were you born?
Are you of Hispanic, Latino, or Spanish origin?
o Yes
o No
What is your race? Please select one or more. White, Black or African American, American Indian or Alaska Native, Asian, or Native Hawaiian or other Pacific Islander?
(Allow up to 3 answers)
[] White
[] Black or African American
[] American Indian or Alaska Native
[] Asian
[] Native Hawaiian or other Pacific Islander
What is the highest grade of school you have completed, or the highest degree you have received?
(do not read categories to respondent)
Less than high school
Completed high school
Some college, no degree
Associate’s degree (AA/AS)
Bachelor’s Degree (BA/BS)
Post-Bachelor's degree (For example MA, MS, Ph.D, JD, etc.)
6a. Were you born in the United States or in another country?
o United States
o Another country
If another country:
5b. In what country were you born?
5c. How long have you been in the United States?
5d. Were any of your other household members born in the U.S.?
5e. Did you complete your schooling in the U.S. or in another country?
o United States
o Another country
If another country:
5f. In what country did you complete your schooling?
Are you working for pay full-time, part-time, or are you not working for pay at this time?
o Full-time (ask both follow-up questions)
o Part-time (ask both follow-up questions)
o Not working for pay at this time (skip to next question)
a. What is your current job title or job description?
[ ]
Are you employed by the Federal Government? (if federal contractor, mark NO)
o Yes
o No
In what city, state, and ZIP code do you currently live?
How many people age 18 or older currently live in your household, INCLUDING yourself?
[ ]
How many people younger than 18 currently live in your household?
[ ]
Do you speak a language other than English at home?
o Yes (ask follow-up question)
o No (skip to next question)
What language or languages do you speak at home? Please select one or more.
[ ] Spanish
[ ] Chinese
[ ] Korean
[ ] Vietnamese
[ ] Arabic
[ ] Russian
[ ] Other - Specify [ ]
11a.Do you speak any dialect or indigenous language?
o Yes
o No
11b. With regard to your culture, do you consider yourself indigenous?
o Yes
o No
Do you own a cell phone?
o Yes (ask follow-up question)
o No (skip to next question)
Some cell phones are called “smartphones” because of certain features they have. Is your cell phone a smartphone, such as an iPhone, Android, Blackberry or Windows phone, or are you not sure?
Do you own a desktop or laptop computer, or both?
o Desktop computer
o Laptop computer
o Both desktop and laptop computer
o Neither
Do you own a tablet computer such as an iPad, Samsung Galaxy Tab, Google Nexus, or Kindle Fire?
o Yes
o No
Do you have at least one year of Internet experience?
o Yes (ask follow-up question)
o No (skip to next question)
How often do you use the Internet either on a computer or on a mobile device like a smartphone or tablet?...Several times a day, about once a day, a few times a week, a few times a month, or a few times a year?
o Several times a day
o About once a day
o A few times a week
o A few times a month
o A few times a year
o Not at all [do not read to respondent]
Name two things you do on the Internet besides e-mail.
[ ]
[ ]
Internet Activity #1:
Research
Social media/communication (Facebook, Twitter, Craigslist)
Shopping
Banking or paying bills online
Music / movies / videos
Gaming
News
Travel (directions/reservations)
Employment
Other
Internet Activity #2:
Research
Social media/communication (Facebook, Twitter, Craigslist)
Shopping
Banking or paying bills online
Music / movies / videos
Gaming
News
Travel (directions/reservations)
Employment
Other
c. If you were asked to do a survey, would you rather complete it on paper, over the phone, or online?
How did you hear about this research opportunity?
E-mail link
Census Bureau employee
Friend or family member (but not a Census Bureau employee)
Craigslist
Google advertisement
Flyer
Newspaper advertisement
Other – specify[ ]
Have you participated in any research studies with the U.S. Census Bureau?
o Yes
o No
Would you be willing to come to our office in Suitland, Maryland, to participate in a research study??
o Yes
o No
What is your daytime telephone number?
[Probe for all 3 phone numbers]
Mobile ([ ]) [ ] – [ ]
Home (if not mobile) ([ ]) [ ] – [ ]
Work (if any) ([ ]) [ ] – [ ] EXT.[ ]
What is the e-mail address we should use when sending directions to our office, should you qualify for a study?
[ ]
Is your household’s annual income …
o Less than $15,000?
o $15,000 to $25,000?
o $25,000 to$50,000?
o $50,000 to $100,000?
o More than $100,000?
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
Section 2: Privacy Risk Tolerance Additional Screener Questions
Do you currently live with anyone who is not related to you (for example, with a roommate or renter)?
Yes
No
Is the place where you currently live…
Owned by you or someone in your household with a mortgage or loan?
Owned by you or someone in your household free and clear (that is, without a mortgage or loan)?
Rented?
Occupied without payment or rent?
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Jenna A Fulton (CENSUS/CSM FED) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |
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