Screener

ATTACHMENT V: TELEPHONE SCREENER

PART A: CBSM Universal Screener

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.

1. What is your name?

First name:_____________________

Last name:_____________________

2. What is your daytime telephone number? [Probe for all 3 phone numbers]

Mobile ([ ]) [ ] – [ ]

Home (if not mobile) ([ ]) [ ] – [ ]

Work (if any) ([ ]) [ ] – [ ] EXT.[ ]

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

City:_____________________

State:_____________________

Zip code:__________________

4. Are you male or female?

• Male

• Female

5. In what year were you born?

6. Are you of Hispanic, Latino, or Spanish origin?

• Yes ( score 1 point)

• No

7. 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 (if white NOT selected, regardless of how many others selected  score 1 point)

• Black or African American

• American Indian or Alaska Native

• Asian

• Native Hawaiian or other Pacific Islander

• Other (specify)

• Refused

8. 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.)

9. Are you working for pay full-time, part-time, or are you not working for pay at this time?

• Full-time (ask follow-up questions 9a and 9b)

• Part-time (ask follow-up questions 9a and 9b)

• Not working for pay at this time (skip to next question)

a. What is your current job title or job description? [open text]

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

• Yes

• No

10. How many people age 18 or older currently live in your household, INCLUDING yourself?

( score 1 point for each person)

11. How many people younger than 18 currently live in your household?

( score 1 point for each person)

12. Do you speak a language other than English at home?

• Yes (ask follow-up question 12a) ( score 1 point)

• No (skip to next question)

1. What language or languages do you speak at home? Please select one or more.

[ ] Spanish

[ ] Chinese

[ ] Korean

[ ] Vietnamese

[ ] Arabic

[ ] Russian

[ ] Other - Specify

13. Do you own a cell phone?

• Yes (ask follow-up questions 11a and 11b)

• No (skip to next question)

1. 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?

2. What type of smartphone do you have?

14. Do you own a desktop or laptop computer, or both?

• Desktop computer

• Laptop computer

• Both desktop and laptop computer

• Neither

15. Do you own a tablet computer such as an iPad, Samsung Galaxy Tab, Google Nexus, or Kindle Fire?

• Yes

• No

16. Do you have at least one year of Internet experience?

• Yes (ask follow-up questions 16a and 16b)

• No (skip to next question)

1. 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?

• Several times a day

• About once a day

• A few times a week

• A few times a month

• A few times a year

• Not at all [do not read to respondent]

2. 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

17. 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

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

• Yes

• No

19. Would you be willing to come to our office in Suitland, Maryland, to participate in a research study?

• Yes

• No

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

21. Is your household’s annual income …

• Less than $15,000? ( score 1 point)

• $15,000 to $25,000? ( score 1 point)

• $25,000 to$50,000?

• $50,000 to $100,000?

• More than $100,000?

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

• Yes

• No

PART B: Undercount of Young Children Supplement

1. Is your home owned, rented or occupied without payment of rent?

1. owned

2. rented ( score 1 point)

3. occupied without payment of rent ( score 1 point)

4. Don’t know/Refused ( score 1 point)

2. What type of home do you live in?

1. House, townhouse or condo

2. Apartment ( score 1 point)

3. Something else ( score 1 point)

4. Don’t know/Refused ( score 1 point)

3. Do any children under age 5 live in your household?

1. Yes ( score 2 points)  3b. How many?____( score 1 point for each person)

2. No

3. Don’t know/refused ( score 2 points)

4. Do any children under age 5 stay at your household, even if it’s just for a night or two?

 Yes ( score 4 points)

 No

 Don’t know/refused ( score 4 points)

5. Do any foster children live or stay at your household, even if it’s just for a night or two?

 Yes ( score 4 points)

 No

 Don’t know/refused ( score 4 points)

6. Is everyone who lives or stays at your household related to each other?

 Yes

 No ( score 4 points)

 Don’t know/Refused ( score 4 points)

7. Has anyone moved in or out of your household recently – say in the last year or so?

 Yes ( score 4 points)

 No

 Don’t know/Refused ( score 4 points)

8. Is anyone in your household the grandparent of a child who lives or stays there sometimes?

 Yes ( score 2 points)

 No

 Don’t know/Refused ( score 2 points)

9. Is anyone in your household the mother of a child who lives or stays there sometimes?

 Yes  ( score 1 point) 9a. How old is the mother? ____(if under 30  score 1 pt)

9b. Is the mother…

 married

 divorced or separated ( score 1 point)

 widowed or ( score 1 point)

 never married? ( score 1 point)

 No

 Don’t know/refused ( score 1 point)

10. Is anyone in your household the father of a child who lives or stays there sometimes?

 Yes  ( score 1 point) 10a. How old is the father? ____(if under 30  score 1 pt)

10b. Is the father…

 married

 divorced or separated ( score 1 point)

 widowed or ( score 1 point)

 never married? ( score 1 point)

 No

 Don’t know/Refused ( score 1 point)

11. Is anyone living or staying at your household temporarily while they find another place to live?

 Yes ( score 4 points)

 No

 Don’t know/Refused ( score 4 points)

"If the census were held today, how likely would you be to fill out the census form?  Extremely likely, Very likely, Somewhat likely, Not too likely, or Not at all likely."

Scoring Algorithm

(more points  higher likelihood the household is at-risk for omitting a young child)

From Part A (Questions from CBSM Universal Screener):

Q6 (Hispanic origin): yes=1 point

Q7 (race): “White” not selected=1 point

Q10 (people 18+): 1 point for each person

Q11 (people under 18): 1 point for each person

Q12 (non-English): yes=1 point

Q21 (hh income): under $25K/year=1 point

From Part B (Questions from UYC-Specific Screener):

Q1 (hh tenure): rented, occupied without payment of rent, D/R=1 point

Q2 (type of home): apartment, condo, other, D/R=1 point

Q3 (children under 5 live there): yes, D/R=2 points

Q3b (how many children under 5): 1 point for each child

Q4 (children under 5 stay there): yes, D/R=4 points

Q5 (foster children): yes, D/R=4 points

Q6 (everyone related): no, D/R=4 points

Q7 (moved in/out recently): yes, D/R=4 points

Q8 (grandparent): yes, D/R=2 points

Q9 (mother): yes, D/R=1 point

Q9a (age of mother): under 30=1point

Q9b (marital status of mother: divorced/widowed/never married=1 point

Q10 (father): yes, D/R=1 point

Q10a (age of father): under 30=1point

Q10b (marital status of father): divorced/widowed/never married=1 point

Q11 (temporary till find other place) : yes, D/R=4 points

Page 14 of 14