Recruitment Screener
Enclosure 3_Screener.docx
Generic Clearance for Questionnaire Pretesting Research
Recruitment Screener
OMB: 0607-0725
NYCHVS 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.
Auto filled: ID Number
Auto filled: Last Contact Date
Auto filled: Eligible Date
What is your name?
First name: [ ]
Last name(s): [ ]
In what year were you born? ________ (Must be 18 years or older to participate;)
What is your native language or languages?
[ ] English [SKIP TO Q7]
[ ] Spanish
[ ] Other (Specify:______________) {This is the “target language” referred to in fills below}
[IF NEEDED: It’s not necessary that you speak English to participate in one of our studies, but I need to ask you a few questions about English now.] How well do you speak English?
O Very well NOT ELIGIBLE FOR SPANISH INTERVIEW.
O Well
O Not well
O Not at all
Would you say you speak [Spanish/target language] better than English, English better than [Spanish/target language], or both about equally well?
O Spanish/target language better than English NOT ELIGIBLE FOR ENGLISH INTERVIEW
O English better than Spanish/target language NOT ELIGIBLE FOR SPANISH INTERVIEW
O Both about equally well
When you have a choice between English and [Spanish/target language,] do you typically participate in surveys or fill out forms in…?
O Spanish/target language NOT ELIGIBLE FOR ENGLISH INTERVIEW
O English NOT ELIGIBLE FOR SPANISH INTERVIEW
O Both equally often
Do you identify as male, female, or transgender?
o Male
o Female
o Transgender
Which of the following best represents how you think of yourself?
o Gay or lesbian
o Straight; that is, not gay, lesbian, or bisexual
o Bisexual
o Something else
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
Were you born in the United States or in another country?
o United States SKIP TO Q12
o Another country
a. In what country were you born? _____________
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.)
Other (specify)________________
Are you working for pay full-time, part-time, or are you not working for pay at this time?
o Full-time
o Part-time
o Not working for pay at this time SKIP TO Q14
a. What is your current job title or job description?
[ ]
Are you employed by the Federal Government? (if federal contractor, mark NO)
o Yes - Not eligible to receive incentive payment
o No
In what city, state, and ZIP code do you currently live? [IF OUTSIDE NYC, INELIGIBLE. THANK AND END]
Do you own or rent your home?
o Rent
o Own SKIP TO Q18
Is your rent stabilized?
o Rent Stabilized
o Non-regulated
Is your rent less than $800 a month?
o Less than $800 a month
o $800 or more a month
What type of home do you [rent/own]?
o Apartment
o Condominium
o Cooperative
o Town House
o Single Family House?
About how many years have you lived at your current address? [DON’T READ ANSWER CHOICES ALOUD]
O 2 years or less
O 3 to 24 years
O 25 years or more
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?
[ ]
For each of the [ANSWER TO Q20 + ANSWER TO Q21] people that live in your household, I’d like to ask you their relationship to you. I don’t need their names – just their relationship to you.
Don’t read
[ ] Opposite sex husband/wife
[ ] Same sex husband/wife
[ ] Opposite sex unmarried partner
[ ] Same sex unmarried partner
[ ] Son or daughter
[ ] Brother or sister
[ ] Father or mother
[ ] Granchild
[ ] Parent-in-law
[ ] Son-in-law or daughter-in-law
[ ] Other relative (specify: ___________)
[ ] Housemate or roommate
[ ] Roomer or boarder
[ ] Landlord
[ ] Other nonrelative (specify: ____________)
Are you currently receiving public assistance in the United Sates from any source, including the U.S. Government or any State, county, city, or municipality (other than emergency medical treatment) such as SNAP, WIC, TANF, etc.?
o Yes (SPECIFY: What type of public assistance?_________________ (list all programs))
o No
What is your daytime telephone number?
[Probe for all 3 phone numbers]
Mobile ([ ]) [ ] – [ ]
Home (if not mobile) ([ ]) [ ] – [ ]
Work (if any) ([ ]) [ ] – [ ] EXT.[ ]
3a. IF PROVIDED MOBILE NUMBER: If you are eligible to participate in a study, we may send you a text message to remind you of your appointment. Can you receive text messages, or do you prefer not receive them?
If you are eligible to participate in a study, we may send you an email confirmation with directions to the interview location. What is the e-mail address we could use when sending directions?
[ ]
THANK AND END OR SCHEDULE AS APPROPRIATE.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Slight changes to participate |
| Author | Dawn V Nelson |
| File Modified | 0000-00-00 |
| File Created | 2021-01-16 |
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