ACS Methods Panel

American Community Survey Methods Panel Tests

Attachment L3 -- Content Test Question Wording

ACS Methods Panel

OMB: 0607-0936

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Attachment L3 - Content Test Question Wording

2016 Content Test Question Wording
TABLE OF CONTENTS
Mode
TELEPHONE SERVICE
COMPUTER AND INTERNET

2-4

Paper ▪ CAPI ▪ Internet

5-12

Paper ▪ CATI/CAPI ▪ Internet

RELATIONSHIP

13-15

Paper ▪ CATI/CAPI ▪ Internet

HISPANIC ORIGIN/RACE

16-30

Paper ▪ CATI/CAPI ▪ Internet

HEALTH INSURANCE

31-39

Paper ▪ CATI/CAPI ▪ Internet

PREMIUM AND SUBSIDIES

40-43

Paper ▪ CATI/CAPI ▪ Internet

JOURNEY TO WORK: COMMUTING MODE

44-46

Paper ▪ CATI/CAPI ▪ Internet

JOURNEY TO WORK: TIME LEFT FOR WORK

47-48

Paper ▪ CATI/CAPI ▪ Internet

NUMBER OF WEEKS WORKED

49-51

Paper ▪ CATI/CAPI ▪ Internet

CLASS OF WORKER

52-60

Paper ▪ CATI/CAPI ▪ Internet

INDUSTRY AND OCCUPATION

61-64

Paper ▪ CATI/CAPI ▪ Internet

RETIREMENT INCOME

65-70

Paper ▪ CATI/CAPI ▪ Internet▪ *CFU

1
Note that there are multiple versions for CATI/CAPI wording in Round 1. The version that best resembles Round 2 wording appears in the tables below.
*The Retirement income topics is the only topic that includes a different series of questions for the Content Follow-up (CFU) than what is asked in the Content Test Interview. These questions are included in a
separate table.

TELEPHONE SERVICE
(Back to Table of Contents)

TELEPHONE SERVICE
PAPER VERSION
2014 CURRENT WORDING

ROUND 1 ENGLISH

ROUND 2 ENGLISH

Version 1
At this house, apartment, or mobile
home – do you or any member of this
household have telephone service from
which you can both make and receive
calls? Include service for regular
telephones (land lines), cell phones, and
other methods of communication such as
voice over Internet.

At this house, apartment, or mobile
home – do you or any member of this
household have telephone service
from which you can both make and
receive calls? Include voice service
from a telephone company, cell or
mobile phone provider, cable company,
or any other voice provider.

Yes
No

Version 2
At this house, apartment, or mobile
home – do you or any member of this
household have telephone service from
which you can both make and receive
calls? Include voice service from the
telephone company, cell phone provider,
cable company or any other voice
provider.

FINAL WORDING
Version 1
Can you or any member of this
household both make and receive
phone calls when at this house,
apartment or mobile home?
Yes
No
Version 2
Can you or any member of this
household both make and receive
phone calls when at this house,
apartment or mobile home?
Include calls using cell phones, land
lines, or other phone devices.
Yes
No

Yes
No

TELEPHONE SERVICE

CAPI VERSION
2014 CURRENT WORDING
, do you or any member of
this household own or use a desktop,
laptop, or notebook computer?
Yes
No

At this , do you or any member of
this household own or use a desktop or
laptop computer?
Yes
No

At this ,
do you or any member of this household own
or use a desktop, laptop, netbook, or
notebook computer?
Yes
No

At this , Do you or any member of
this household own or use a
smartphone?
Yes
No

At this , Do you or any member of
this household own or use a tablet or
other portable wireless computer?
Yes
No

At this , Do you or any member of
this household own or use a
smartphone?
Yes
No

At this ,
Do you or any member of this household own
or use a handheld computer, smart mobile
phone, or other handheld wireless computer?

At this , Do you or any member of
this household own or use a tablet or
other portable wireless computer that is
carried or worn?
Yes
No

At this , Do you or any member of
this household own or use some other
type of computer?
Yes
No

At this , Do you or any member of
this household own or use a tablet or
other portable wireless computer?
Yes
No

What is this other type of computer?
________

At this , Do you or any member of
this household own or use some other
type of computer?
Yes
No

Yes
No
At this ,
Do you or any member of this household own
or use some other type of computer?
Yes
No

At this , Do you or any member of
this household own or use some other
type of computer?
Yes
No

What is this other type of computer? ________

What is this other type of computer?
________

What is this other type of computer?
________
----------------------------------------------------------------

--------------------------------------------------------

-------------------------------------------------------

COMPUTER AND INTERNET
2014 CURRENT WORDING

ROUND 1 ENGLISH

At this ,
do you or any member of this household
access the Internet?
Yes
No

At this , do you or any member of
this household connect to the Internet?
Yes
No

At this ,
Do you or any member of this household
access the Internet with or without a
subscription to an Internet service?
With a subscription to an Internet service
Without a subscription to an Internet service

At this , Do you or any member of
this household connect to the Internet
with or without a plan purchased from an
Internet service provider?
With a plan purchased from an Internet
service provider
Without a plan purchased from an
Internet service provider

At this ,
do you or any member of this household
subscribe to the Internet using a dial-up
service?
Yes
No
At this ,
Do you or any member of this household
subscribe to the Internet using a DSL service?
Yes
No
At this ,
Do you or any member of this household
subscribe to the Internet using a cable-modem
service?
Yes
No
At this ,
Do you or any member of this household
subscribe to the Internet using a fiber-optic
service?

ROUND 2 ENGLISH
At this , do you or any member of
this household pay for a plan for a
smartphone or mobile device to access
the Internet and make phone calls?
Yes (Skip to Internet Access)
No

At this , do you or any member of
this household access the Internet?
Yes
No (Skip next question)

-------------------------------------------------------At this , do you or any member of
this household access the Internet using a
mobile broadband or data plan for a
computer, a smartphone or other device?
Yes
No

At this , Do you or any member of
this household pay a cell phone company
or Internet service provider to access the
Internet?
Yes
No
-------------------------------------------------------At this , do you or any member of
this household access the Internet using
mobile broadband Internet service for a
smartphone or other mobile device?
Yes
No

At this , Do you or any member of
this household access the Internet using a
broadband or high speed connection
installed in this

At this , Do you or any member of
this household access the Internet using
broadband or high speed Internet service
installed in this

FINAL WORDING
At this , do you or any member of
this household have access to the
Internet?
Yes
No (Skip to vehicle question)
At this , Do you or any member of
this household pay a cell phone company
or Internet service provider to access the
Internet?
Yes
No (Skip to vehicle question)

------------------------------------------------------Do you or any member of this household
access the Internet using a cellular data
plan for a smartphone or other mobile
device?
Yes
No

Do you or any member of this household
access the Internet using a broadband or
high speed Internet service such as cable,
fiber optic, or DSL service installed in this
?

COMPUTER AND INTERNET
2014 CURRENT WORDING
Yes
No
At this ,
Do you or any member of this household
subscribe to the Internet using a mobile
broadband plan for a computer or a cell
phone?
Yes
No
At this ,
Do you or any member of this household
subscribe to the Internet using a satellite
Internet service?
Yes
No
At this ,
Do you or any member of this household
subscribe to the Internet using some other
service?
Yes
No
What is this other type of Internet service?
________

ROUND 1 ENGLISH

ROUND 2 ENGLISH

?
Yes
No

,
such as cable, fiber optic, or DSL service?
Yes
No

At this , Do you or any member of
this household access the Internet using a
satellite Internet service?
Yes
No

At this , Do you or any member of
this household access the Internet using a
dial-up service?
Yes
No

At this , Do you or any member of
this household access the Internet using a
dial-up Internet service?
Yes
No

At this , Do you or any member of
this household access the Internet using
some other service?
Yes
No

What is this other type of Internet
service? ________

FINAL WORDING
Yes
No

Do you or any member of this household
access the Internet using a satellite
Internet service installed in this
?
Yes
No
Do you or any member of this household
access the Internet using a dial-up
Internet service installed in this
?
Yes
No
Do you or any member of this household
access the Internet using some other
service?
Yes
No

What is this other type of Internet
service? ________

COMPUTER AND INTERNET

INTERNET VERSION
2014 CURRENT WORDING

FINAL WORDING

At this – do you
or any member of this household own or use any of the
following computers? Exclude GPS devices, digital music
players, and devices with only limited computer
capabilities, for example: household appliances.

At this – do
you or any member of this household own or use any
of the following types of computers?

Desktop, laptop, netbook, or notebook computer
(Yes/No)

Smartphone (Yes/No)

Desktop or laptop (Yes/No)

Tablet or other portable wireless computer (Yes/No)
Handheld computer, smart mobile phone, or other
handheld wireless computer (Yes/No)

Some other type of computer (Yes/No)
Specify_______________

Some other type of computer (Yes/No)
Specify _______________
At this – do you
or any member of this household access the Internet?
Yes, with a subscription to an Internet service
Yes, without a subscription to an internet service
No Internet access at this

At this – do you
or any member of this household subscribe to the
Internet using –
Dial-up Service? (Yes/No)
DSL service? (Yes/No)
Cable modem service? (Yes/No)
Fiber-optic service? (Yes/No)
Mobile broadband plan for a computer or a cell phone?
(Yes/No)
Satellite Internet service? (Yes/No)
Some other service? (Yes/No)
Specify service ________

At this – do
you or any member of this household have access to
the Internet?
Yes, by paying a cell phone company or Internet service
provider
Yes, without paying a cell phone company or Internet
service provider (SKIP next question)
No access to the Internet at this house, apartment, or
mobile home (SKIP next question)

Do you or any member of this household have access
to the Internet using a –
Cellular data plan for a smartphone or other mobile
device? (Yes/No)
Broadband (high speed) Internet service, such as
cable, fiber optic, or DSL service installed in this
? (Yes/No)

COMPUTER AND INTERNET
2014 CURRENT WORDING

FINAL WORDING
Satellite Internet service installed in this
? (Yes/No)
Dial-up Internet service installed in this
? (Yes/No)
Some other service? (Yes/No)
Specify service ________

RELATIONSHIP
(Back to Table of Contents)

RELATIONSHIP
PAPER VERSION
2014 CURRENT WORDING

ROUND 1 ENGLISH
Not in cognitive testing. This
item was field tested in the
2013 questionnaire design
test.

ROUND 2 ENGLISH

FINAL WORDING

Not in cognitive testing. This
item was field tested in the
2013 questionnaire design
test.

How is this person related to Person 1? Mark
(X) ONE box.
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
Same-sex husband/wife/spouse
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
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
Foster child
Other nonrelative

RELATIONSHIP

CATI/CAPI VERSION
2014 CURRENT WORDING
CAPI:
How related to <(reference
person)/you>?
Husband or wife
Son or daughter (CATI ONLY)
Biological son or daughter (CAPI ONLY)
Adopted son or daughter (CAPI ONLY)
Stepson or stepdaughter (CAPI ONLY)
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
CATI:
biological
son or daughter, adopted son or daughter, stepson or
stepdaughter, OR foster son or daughter?
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Foster son or daughter

ROUND 1 ENGLISH
Not in cognitive testing.
This item was field
tested in the 2013
questionnaire design
test.

ROUND 2 ENGLISH
Not in cognitive testing.
This item was field tested
in the 2013 questionnaire
design test.

FINAL WORDING
CAPI:
How related to <(reference
person)/you>?
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
Same-sex husband/wife/spouse
Same-sex unmarried partner
Son or daughter (CATI ONLY)
Biological son or daughter (CAPI ONLY)
Adopted son or daughter (CAPI ONLY)
Stepson or stepdaughter (CAPI ONLY)
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
Foster child
Other nonrelative
CATI:
biological
son or daughter, adopted son or daughter, OR stepson or
stepdaughter?
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
Foster son or daughter

RELATIONSHIP

INTERNET VERSION
2014 CURRENT WORDING
How is (Name) related to (Reference person)?
Husband or wife
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
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

FINAL WORDING
How is (Name) related to (Reference person)?
Opposite-sex husband/wife/spouse
Opposite-sex unmarried partner
Same-sex husband/wife/spouse
Same-sex unmarried partner
Biological son or daughter
Adopted son or daughter
Stepson or stepdaughter
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
Foster child
Other nonrelative
Conditions under which a follow-up screen should appear:
The sex reported for this person and the reference person do not match the relationship category chosen. There
are 4 relationship categories to which this applies:
1. Opposite sex husband/wife/spouse
2. Same sex husband/wife/spouse
3. Opposite sex unmarried partner
4. Same sex unmarried partner
st
rd
So if this person is reported as the 1 or 3 category above, but the reference person and this person are
reported to have the same sex value (both=1 or both=2), then the check should come up. Conversely, if this
nd
th
person is reported to have the 2 or 4 category above, but the reference person and this person are reported
as different sex values (one=1 and the other=2) then the check should come up.
Edit check wording:
Please confirm that your answers are correct. [NAME] is recorded as [REFERENCE PERSON]’s [RELATIONSHIP
CATEGORY]. Is that correct?
is recorded as . Is that correct?
is recorded as . Is that correct?

HISPANIC ORIGIN/RACE
(Back to Table of Contents)

HISPANIC ORIGIN/RACE
PAPER VERSION
2014 CURRENT WORDING

ROUND 1 ENGLISH

ROUND 2 ENGLISH

FINAL WORDING

Version 1
 NOTE: Please answer BOTH Question 5
about Hispanic origin and Question 6
about race. For this survey, Hispanic
origins are not races.

Is Person 1 of Hispanic, Latino, or Spanish
origin? Mark (X) one or more boxes.
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish
origin – Print origin(s), for example,
Salvadoran, Dominican, Colombian, and so
on. ________

Is Person 1 of Hispanic, Latino, or Spanish
origin? Mark all boxes that apply AND print
origins. Note, you may report more than one
group.

----------------------------------------------------

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish
origin – Print details, for example,
Salvadoran, Dominican, Colombian, etc.
________________________________

What is Person 1’s race? Mark (X) one or
more boxes.
White – Print origin(s), for example, German,
Lebanese, Egyptian, and so on. ________
Black or African Am. – Print origin(s), for
example, African American, Jamaican,
Nigerian, and so on. ________
American Indian or Alaska Native – Print
name of enrolled or principal tribe(s), for
example, Navajo Nation, Mayan, Chevak
Native Village, and so on. ________

What is Person 1’s race? Mark all boxes
that apply AND print origins in the spaces
below. Note, you may report more than one
group.
White – Print details, for example, German,
Lebanese, Egyptian, etc.
________________________________

Black or African Am. – Print details, for
example, African American, Jamaican,

HISPANIC ORIGIN/RACE
2014 CURRENT WORDING

ROUND 1 ENGLISH
Chinese
Filipino
Asian Indian
Vietnamese
Korean
Japanese
Other Asian – Print origin(s), for example,
Pakistani, Cambodian, Hmong, and so on.
________
Native Hawaiian
Samoan
Guamanian or Chamorro
Other Pacific Islander – Print origin(s), for
example Tongan, Fijian, Marshallese, and so
on. ________
Some other race – Print race(s) or origin(s).
________

ROUND 2 ENGLISH

FINAL WORDING
Nigerian, etc.
________________________________

American Indian or Alaska Native – Print
name of enrolled or principal tribe(s), for
example, Navajo Nation, Mayan, Native
Village of Barrow Inupiat Traditional
Government, etc.
________________________________

Chinese
Filipino
Asian Indian
Vietnamese
Korean
Japanese
Other Asian – Print details, for example,
Pakistani, Cambodian, Hmong, etc.
________________________________

Native Hawaiian
Samoan
Chamorro
Other Pacific Islander – Print details, for
example, Tongan, Fijian, Marshallese, etc.
________________________________

Some other race – Print race(s) or origin(s).
________________________________

HISPANIC ORIGIN/RACE
2014 CURRENT WORDING

ROUND 1 ENGLISH

ROUND 2 ENGLISH

FINAL WORDING

Version 2
What is Person 1’s race or origin? Mark (X)
one or more boxes AND print the specific
race(s) and/or origin(s).

Which categories describe Person 1?
Mark all boxes that apply AND print
details in the spaces below.

Version 2
Which categories describe Person 1? Mark
all boxes that apply AND print details in the
spaces below.

White – Print origin(s), for example,
German, Irish, English, and so on. ________

White – Print details, for example,
German, Irish, English. ________

White – Print details, for example, German,
Irish, English, etc. ________

Hispanic, Latino, or Spanish origin – Print
origin(s), for example, Mexican or Mexican
American, Puerto Rican, Colombian, and so
on. ________

Hispanic, Latino, or Spanish origin –
Print details, for example, Mexican or
Mexican American, Puerto Rican,
Colombian. ________

Black or African Am. – Print origin(s), for
example, African American, Jamaican,
Nigerian, and so on. ________

Black or African Am. – Print details,
for example, African American,
Jamaican, Nigerian. ________

Asian – Print origin(s), for example, Chinese,
Asian Indian, Vietnamese, and so on.
________

Asian – Print details, for example,
Chinese, Asian Indian, Vietnamese.
________

American Indian or Alaska Native – Print
name of enrolled or principal tribe(s), for
example, Navajo Nation, Mayan, Chevak
Native Village, and so on. ________

American Indian or Alaska Native –
Print details, for example, Navajo
Nation, Mayan, Chevak Native
Village. ________

Middle Eastern or North African – Print
origin(s), for example, Lebanese, Iranian,
Egyptian, and so on. ________

Middle Eastern or North African –
Print details, for example, Lebanese,
Iranian, Egyptian. ________

Native Hawaiian or Other Pacific Islander –
Print origin(s), for example, Native Hawaiian,
Guamanian or Chamorro, Fijian, and so on.
________

Native Hawaiian or Other Pacific
Islander – Print details, for example,
Native Hawaiian, Guamanian or
Chamorro, Fijian. ________

Native Hawaiian or Other Pacific Islander –
Print details, for example, Native Hawaiian,
Chamorro, Fijian,etc. ________

Some other race or origin – Print race(s)
and/or origin(s). ________

Some other race or origin – Print
details. ________

Some other race, ethnicity, or origin – Print
details. ________

Hispanic, Latino, or Spanish origin – Print
details, for example, Mexican or Mexican
American, Puerto Rican, Colombian, etc.
________
Black or African Am. – Print details, for
example, African American, Jamaican,
Nigerian, etc. ________
Asian – Print details, for example, Chinese,
Asian Indian, Vietnamese, etc.________
American Indian or Alaska Native – Print
name(s) of enrolled or principal tribe(s), for
example, Navajo Nation, Mayan, Native
Village of Barrow Inupiat Traditional
Government, etc. ________
Middle Eastern or North African – Print
details, for example, Lebanese, Iranian,
Egyptian, etc. ________

HISPANIC ORIGIN/RACE

CATI/CAPI VERSION
2014 CURRENT WORDING
(First time question asked)
CAPI: Please look at Card B.
of Hispanic, Latino, or
Spanish origin?
Yes
No
(Subsequent persons)
?> of Hispanic, Latino, or
Spanish origin?
Yes
No
Mexican, Mexican
American, or Chicano; Puerto Rican; Cuban;
or of another Hispanic, Latino, or Spanish
origin; for example, Argentinean,
Colombian, Dominican, Nicaraguan,
Salvadoran, Spaniard, and so on?
Mexican, Mexican American, or Chicano
Puerto Rican
Cuban
Another Hispanic, Latino, or Spanish origin
(For example, Argentinean, Colombian,
Dominican, Nicaraguan, Salvadoran,
Spaniard, and so on)
What is that origin? (For example,
Argentinean, Colombian, Dominican,
Nicaraguan, Salvadoran, Spaniard, and so
on.) ________

ROUND 1 ENGLISH

ROUND 2 ENGLISH

FINAL WORDING

CATI: I’m going to read a list of races and
origins. You may choose one or more.

CATI: I’m going to read a list of categories.
You may choose all that apply.

CAPI: Please look at Card C and choose one or
more races or origins.

White; Hispanic,
Latino, or Spanish origin; Black or African
American; Asian; American Indian or
Alaska Native; Middle Eastern or North
African; Native Hawaiian or Other Pacific
Islander; or Some other race or origin?

VERSION 1
of Hispanic, Latino, or
Spanish origin?
Yes
No

White; Hispanic, Latino,
or Spanish origin; Black or African American;
Asian; American Indian or Alaska Native;
Middle Eastern or North African; Native
Hawaiian or Other Pacific Islander; or Some
other race or origin?

CAPI: Please look at Card B and choose all
categories that apply.

CAPI:
(Card C shows what is listed below)

CAPI:
(Card B shows what is listed below)

Choose one or more races or origins.

Choose all categories that apply.

White – For example, German, Irish, English,
and so on.
Hispanic, Latino, or Spanish origin – For
example, Mexican or Mexican American,
Puerto Rican, Colombian, and so on.
Black or African American – For example,
African American, Jamaican, Nigerian, and so
on.
Asian – For example, Chinese, Asian Indian,
Vietnamese, and so on.
American Indian or Alaska Native – For
example, Navajo Nation, Mayan, Chevak
Native Village, and so on.
Middle Eastern or North African – For
example, Lebanese, Iranian, Egyptian, and so
on.
Native Hawaiian or Other Pacific Islander –

White – For example, German, Irish,
English.
Hispanic, Latino, or Spanish origin – For
example, Mexican or Mexican American,
Puerto Rican, Colombian.
Black or African American – For example,
African American, Jamaican, Nigerian.
Asian – For example, Chinese, Asian Indian,
Vietnamese.
American Indian or Alaska Native – For
example, Navajo Nation, Mayan, Chevak
Native Village.
Middle Eastern or North African – For
example, Lebanese, Iranian, Egyptian.
Native Hawaiian or Other Pacific Islander –
For example Native Hawaiian, Guamanian
or Chamorro, Fijian.

CATI: You may choose one or more
origins. Mexican,
Mexican American, Chicano; Puerto Rican;
Cuban; or of some other Hispanic, Latino, or
Spanish origin?
Mexican, Mexican American, or Chicano
Puerto Rican
Cuban
Another Hispanic, Latino, or Spanish origin
What is that origin or origins? (For example,
Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc.)
________
CAPI: Please look at Card B and choose one
or more origins.
Mexican, Mexican
American, Chicano; Puerto Rican; Cuban; or
of some other Hispanic, Latino, or Spanish
origin?
(Card B shows what is listed below)
Mexican, Mexican American, or Chicano
Puerto Rican
Cuban
Another Hispanic, Latino, or Spanish origin
(For example, Salvadoran, Dominican,

HISPANIC ORIGIN/RACE
2014 CURRENT WORDING
---------------------------------------------------------CATI: I'm going to read a list of race
categories. You may choose one or more
races.
CAPI: Please look at Card C and choose one
or more races.

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
What is <(Name)’s/your> race?
( White; Black or
African American; American Indian or
Alaska Native; Asian; Native Hawaiian or
Other Pacific Islander; or Some other race?)
How about <(Name)/you?>
You may list one or more tribes.
What is <(Name)'s/ your> enrolled or
principal tribe?
You may choose one or more Asian groups.

ROUND 1 ENGLISH
For example Native Hawaiian, Guamanian or
Chamorro, Fijian, and so on.
Some other race or origin

ROUND 2 ENGLISH
Some other race or origin

Colombian, Guatemalan, Spaniard,
Ecuadorian, etc.)

You said that <(Name) is/you are>:

What is that origin or origins? (For example,
Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc.)
________

You said that <(Name) is/you are>:
WHITE
HISPANIC, LATINO, OR SPANISH
BLACK OR AFRICAN AMERICAN
ASIAN
AMERICAN INDIAN OR ALASKA NATIVE
MIDDLE EASTERN OR NORTH AFRICAN
NATIVE HAWAIIAN OR OTHER PACIFIC
ISLANDER
SOME OTHER RACE
Now, I’m going to collect detailed information
for each race or origin you provided. You may
give one or more origins.
What is <(Name)’s/your> WHITE origin or
origins? For example, German, Irish, English,
and so on. ________

FINAL WORDING

WHITE
HISPANIC, LATINO, OR SPANISH
BLACK OR AFRICAN AMERICAN
ASIAN
AMERICAN INDIAN OR ALASKA NATIVE
MIDDLE EASTERN OR NORTH AFRICAN
NATIVE HAWAIIAN OR OTHER PACIFIC
ISLANDER
SOME OTHER RACE
Now, I’m going to collect detailed
information. You may give more than one
response.
What are <(Name)’s/your> specific
categories for WHITE? For example,
German, Irish, English. ________

What is <(Name)’s/your> HISPANIC, LATINO,
OR SPANISH origin or origins? For example,
Mexican or Mexican American, Puerto Rican,
Colombian, and so on. ________

What are <(Name)’s/your> specific
categories for HISPANIC, LATINO, OR
SPANISH origin? For example, Mexican or
Mexican American, Puerto Rican,
Colombian. ________

What is <(Name)’s/your> BLACK OR AFRICAN
AMERICAN origin or origins? For example,
African American, Jamaican, Nigerian, and so
on. ________

What are <(Name)’s/your> specific
categories for BLACK OR AFRICAN
AMERICAN? For example, African
American, Jamaican, Nigerian. ________

What is <(Name)’s/your> ASIAN origin or
origins? For example, Chinese, Asian Indian,
Vietnamese, and so on. ________

What are <(Name)’s/your> specific
categories for ASIAN? For example,
Chinese, Asian Indian, Vietnamese.

CATI:I’m going to read a list of races. You
may choose one or more races. For this
survey, Hispanic origin is not a race.
CAPI: Please look at Card C and choose one
or more races. For this survey, Hispanic
origin is not a race.
What is <(Name)’s/your> race?
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
You said that <(Name) is/you are>:
WHITE
BLACK OR AFRICAN AMERICAN
AMERICAN INDIAN OR ALASKA NATIVE
ASIAN
NATIVE HAWAIIAN OR OTHER PACIFIC
ISLANDER
SOME OTHER RACE

HISPANIC ORIGIN/RACE
2014 CURRENT WORDING
Asian Indian, Chinese,
Filipino, Japanese, Korean, Vietnamese, or
another Asian group, for example, Hmong,
Laotian, Thai, Pakistani, Cambodian, and so
on?
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian (For example, Hmong, Laotian,
Thai, Pakistani, Cambodian, and so on.)
What is that other Asian group? (For
example, Hmong, Laotian, Thai, Pakistani,
Cambodian, and so on.)
You may choose one or more Pacific
Islander groups.
Native Hawaiian;
Guamanian or Chamorro; Samoan; or
another Pacific Islander group, for example,
Fijian, Tongan, and so on?
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander (For example, Fijian,
Tongan, and so on)

ROUND 1 ENGLISH

ROUND 2 ENGLISH

FINAL WORDING

________
What is <(Name)’s/your> AMERICAN INDIAN
OR ALASKA NATIVE enrolled or principal
tribe? For example, Navajo Nation, Mayan,
Chevak Native Village, and so on. ________
What is <(Name)’s/your> MIDDLE EASTERN
OR NORTH AFRICAN origin or origins? For
example, Lebanese, Iranian, Egyptian, and so
on. ________
What is <(Name)’s/your> NATIVE HAWAIIAN
OR OTHER PACIFIC ISLANDER origin or
origins? For example, Native Hawaiian,
Guamanian or Chamorro, Fijian, and so on.
________
What is <(Name)’s/your> OTHER RACE OR
ORIGIN? ________

What are <(Name)’s/your> specific
categories for AMERICAN INDIAN OR
ALASKA NATIVE? For example, Navajo
Nation, Mayan, Chevak Native Village.
________
What are <(Name)’s/your> specific
categories for MIDDLE EASTERN OR
NORTH AFRICAN? For example, Lebanese,
Iranian, Egyptian. ________
What are <(Name)’s/your> specific
categories for NATIVE HAWAIIAN OR
OTHER PACIFIC ISLANDER? For example,
Native Hawaiian, Guamanian or
Chamorro, Fijian. ________
What are <(Name)’s/your> specific
categories for OTHER RACE OR ORIGIN?
________

Now I’m going to collect detailed
information for each race you provided.
You may give one or more origins.
What is <(Name)’s/your> race?
( White; Black or
African American; American Indian or
Alaska Native; Asian; Native Hawaiian or
Other Pacific Islander; or Some other race?)
How about <(Name)/you?>
What are <(Name)’s/your> WHITE origin or
origins? For example, German, Irish,
English, Italian, Lebanese, Egyptian, etc.
What are <(Name)’s/your> BLACK OR
AFRICAN AMERICAN origin or origins? For
example, African American, Jamaican,
Haitian, Nigerian, Ethiopian, Somali, etc.
What are <(Name)’s/your> AMERICAN
INDIAN OR ALASKA NATIVE enrolled or
principal tribe or tribes? For example,
Navajo Nation, Blackfeet Tribe, Mayan,
Aztec, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo
Community, etc.
You may choose one or more Asian groups.

What is that other Pacific Islander group?
(For example, Fijian, Tongan, and so on.)
What is <(Name)’s/your> other race group?

Chinese, Filipino,
Asian Indian, Vietnamese, Korean,
Japanese, or of some other Asian origin?
Chinese
 Filipino

HISPANIC ORIGIN/RACE
2014 CURRENT WORDING

ROUND 1 ENGLISH

ROUND 2 ENGLISH

FINAL WORDING
 Asian Indian
Vietnamese
 Korean
 Japanese
 Other Asian
What is that other Asian origin or origins?
For example, Pakistani, Cambodian, Hmong,
etc.
You may choose one or more Pacific
Islander groups.
(Is /Are you) Native Hawaiian,
Samoan, Chamorro, or of some other
Pacific Islander origin?
Native Hawaiian
 Samoan
 Chamorro
 Other Pacific Islander
What is that other Pacific Islander origin or
origins? For example, Tongan, Fijian,
Marshallese, etc.
What is (’s/your) other race group
or groups?
VERSION 2
CATI: I’m going to read a list of categories.
You may choose all that apply.
White; Hispanic,
Latino, or Spanish origin; Black or African
American; Asian; American Indian or Alaska
Native; Middle Eastern or North African;

HISPANIC ORIGIN/RACE
2014 CURRENT WORDING

ROUND 1 ENGLISH

ROUND 2 ENGLISH

FINAL WORDING
Native Hawaiian or Other Pacific Islander;
or Some other race, ethnicity, or origin?
CAPI: Please look at Card B and choose all
categories that apply.
CAPI:
(Card B shows what is listed below)
Choose all categories that apply.
White – For example, German, Irish, English,
Italian, Polish, French, etc.
Hispanic, Latino, or Spanish origin – For
example, Mexican or Mexican American,
Puerto Rican, Cuban, Salvadoran,
Dominican, Colombian, etc.
Black or African American – For example,
African American, Jamaican, Haitian,
Nigerian, Ethiopian, Somali, etc.
Asian – For example, Chinese,Filipino, Asian
Indian, Vietnamese, Korean, Japanese, etc.
American Indian or Alaska Native – For
example, Navajo Nation, Blackfeet Tribe,
Mayan, Aztec, Native Village of Barrow
Inupiat Traditional Government, Nome
Eskimo Community, etc.
Middle Eastern or North African – For
example, Lebanese, Iranian, Egyptian,
Syrian, Moroccan, Algerian, etc.
Native Hawaiian or Other Pacific Islander –
For example, Native Hawaiian,
Samoan,Chamorro, Tongan, Fijian,
Marshallese, etc.
Some other race, ethnicity, or origin
You said that <(Name) is/you are>:

HISPANIC ORIGIN/RACE
2014 CURRENT WORDING

ROUND 1 ENGLISH

ROUND 2 ENGLISH

FINAL WORDING
WHITE
HISPANIC, LATINO, OR SPANISH
BLACK OR AFRICAN AMERICAN
ASIAN
AMERICAN INDIAN OR ALASKA NATIVE
MIDDLE EASTERN OR NORTH AFRICAN
NATIVE HAWAIIAN OR OTHER PACIFIC
ISLANDER
SOME OTHER RACE
Now, I’m going to collect detailed
information. You may give more than one
response.
What are <(Name)’s/your> specific
categories for WHITE? For example,
German, Irish, English, Italian, Polish,
French, etc.________
What are <(Name)’s/your> specific
categories for HISPANIC, LATINO, OR
SPANISH origin? For example, Mexican or
Mexican American, Puerto Rican, Cuban,
Salvadoran, Dominican, Colombian, etc.
________
What are <(Name)’s/your> specific
categories for BLACK OR AFRICAN
AMERICAN? For example, African
American, Jamaican, Haitian, Nigerian,
Ethiopian, Somali, etc. ________
What are <(Name)’s/your> specific
categories for ASIAN? For example,
Chinese, Filipino, Asian Indian, Vietnamese,
Korean, Japanese, etc. ________

HISPANIC ORIGIN/RACE
2014 CURRENT WORDING

ROUND 1 ENGLISH

ROUND 2 ENGLISH

FINAL WORDING
What are <(Name)’s/your> specific
categories for AMERICAN INDIAN OR
ALASKA NATIVE? For example, Navajo
Nation, Blackfeet Tribe, Mayan, Aztec,
Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community,
etc. ________
What are <(Name)’s/your> specific
categories for MIDDLE EASTERN OR NORTH
AFRICAN? For example, Lebanese, Iranian,
Egyptian, Syrian, Moroccan, Algerian, etc.
________
What are <(Name)’s/your> specific
categories for NATIVE HAWAIIAN OR
OTHER PACIFIC ISLANDER? For example,
Native Hawaiian, Samoan, Chamorro,
Tongan, Fijian, Marshallese, etc. ________
What are <(Name)’s/your> specific
categories for OTHER RACE, ETHNICITY, OR
ORIGIN? ________

HISPANIC ORIGIN/RACE

INTERNET VERSION
2014 CURRENT WORDING
Is (Name) of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Enter
origin, for example, Argentinean, Colombian, Dominican,
Nicaraguan, Salvadoran, Spaniard, and so on.
__________________________________
What is (Name)’s race? Select one or more boxes. For
this survey, Hispanic origins are not races.
White
Black or African Am.
American Indian or Alaska Native – Enter name of
enrolled or principal tribe.
__________________________________
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian – Enter race, for example, Hmong, Laotian,
Thai, Pakistani, Cambodian, and so on.
__________________________________
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander – Enter race, for example, Fijian,
Tongan, and so on.
__________________________________
Some other race – Enter race.
__________________________________

FINAL WORDING
VERSION 1
Is (NAME) of Hispanic, Latino, or Spanish origin? Select
all boxes that apply AND enter origins. Note, you may
report more than one group.
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin – Enter
details, for example, Salvadoran, Dominican, Colombian,
Guatemalan, Spaniard, Ecuadorian, etc.
__________________________________

What is (NAME)’s race? Select all boxes that apply AND
enter origins in the spaces below. Note, you may report
more than one group.
White – Enter details, for example, German, Irish,
English, Italian, Lebanese, Egyptian, etc.
__________________________________

Black or African Am. – Enter details, for example, African
American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc.
__________________________________

American Indian or Alaska Native – Enter details, for
example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec,
Native Village of Barrow Inupiat Traditional Government,
Nome Eskimo Community, etc.
__________________________________

HISPANIC ORIGIN/RACE
Chinese
Filipino
Asian Indian
Vietnamese
Korean
Japanese
Other Asian – Enter details, for example, Pakistani,
Cambodian, Hmong, etc.
__________________________________
Native Hawaiian
Samoan
Chamorro
Other Pacific Islander – Enter details, for example,
Tongan, Fijian, Marshallese, etc.
__________________________________
Some other race – Enter race or origin
__________________________________

VERSION 2
Which categories describe NAME? Select all boxes that
apply. Note, you may report more than one group.
White – For example, German, Irish, English, Italian,
Polish, French, etc.
Hispanic, Latino, or Spanish origin – For example,
Mexican or Mexican American, Puerto Rican, Cuban,
Salvadoran, Dominican, Colombian, etc.
Black or African Am. – For example, African American,
Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.
Asian – For example, Chinese, Filipino, Asian Indian,
Vietnamese, Korean, Japanese, etc.
American Indian or Alaska Native – For example, Navajo
Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of

HISPANIC ORIGIN/RACE
Barrow Inupiat Traditional Government, Nome Eskimo
Community, etc.
Middle Eastern or North African – For example,
Lebanese, Iranian, Egyptian, Syrian, Moroccan, Algerian,
etc.
Native Hawaiian or Other Pacific Islander – For example,
Native Hawaiian, Samoan, Chamorro, Tongan, Fijian,
Marshallese, etc.
Some other race, ethnicity, or origin
***For each box checked above for the COMBINED
QUESTION, a subsequent screen should appear. Wording
for subsequent screens are listed below ***
Next, we will collect detailed information for each
category selected. Note, you may report more than one
group.
Select all boxes that apply and/or enter details in the
space below.
WHITE
 German
 Irish
 English
 Italian
 Polish
 French
 Enter, for example, Scottish, Norwegian, Dutch, etc.
__________________
Select all boxes that apply and/or enter details in the
space below.
HISPANIC, LATINO, OR SPANISH
Mexican or Mexican American
 Puerto Rican

HISPANIC ORIGIN/RACE

 Cuban
 Salvadoran
 Dominican
 Colombian
 Enter, for example, Guatemalan, Spaniard,
Ecuadorian, etc. _____________

Select all boxes that apply and/or enter details in the
space below.
BLACK OR AFRICAN AMERICAN
 African American
 Jamaican
 Haitian
 Nigerian
 Ethiopian
 Somali
 Enter, for example, Ghanaian, South African,
Barbadian, etc. _____________

Select all boxes that apply and/or enter details in the
space below.
ASIAN
 Chinese
 Filipino
 Asian Indian
 Vietnamese
 Korean
 Japanese
 Enter, for example, Pakistani, Cambodian, Hmong,
etc. _____________
Enter details in the space below.
AMERICAN INDIAN
Enter, for example, Navajo Nation, Blackfeet Tribe,

HISPANIC ORIGIN/RACE
Muscogee (Creek) Nation, etc. _____________
ALASKA NATIVE
Enter, for example, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community,
Orutsararmuit Native Village, etc. _____________
CENTRAL OR SOUTH AMERICAN INDIAN
Enter, for example, Mayan, Aztec, Taino, etc.
_____________
Select all boxes that apply and/or enter details in the
space below.
MIDDLE EASTERN OR NORTH AFRICAN
 Lebanese
 Iranian
 Egyptian
 Syrian
 Moroccan
 Algerian
 Enter, for example, Israeli, Iraqi, Tunisian, etc.
_____________
Select all boxes that apply and/or enter details in the
space below.
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
 Native Hawaiian
 Samoan
 Chamorro
 Tongan
 Fijian
 Marshallese
 Enter, for example, Palauan, Tahitian, Chuukese, etc.
_____________
Enter other details about NAME’s race, ethnicity, or
origin – Enter details _____________

HEALTH INSURANCE
(Back to Table of Contents)

HEALTH INSURANCE
PAPER VERSION
2014 CURRENT WORDING

ROUND 1 ENGLISH

ROUND 2 ENGLISH

FINAL WORDING

Version 1 and 3
Is this person CURRENTLY covered by any
of the following types of health insurance
or health coverage plans? Mark "Yes" or
"No" for EACH type of coverage in items a
– h.

Is this person CURRENTLY covered by
any of the following types of health
insurance or health coverage plans?
Mark "Yes" or "No" for EACH type of
coverage in items a – h.

Is this person CURRENTLY covered by
any of the following types of health
insurance or health coverage plans?
Mark “Yes” or “No” for EACH type of
coverage in items a – h.

Do NOT include plans that cover only one
type of service, such as dental, drug or
vision plans.
a. Insurance through a current or former
employer or union (of this person or
another family member) (Yes/No)
b. Medicare, for people 65 and older, or
people with certain disabilities
(Yes/No)
c. Medicaid, Medical Assistance, or any
kind of state or governmentassistance plan for those with low
income (Yes/No)
d. Insurance purchased directly from an
insurance company or through a State
or Federal Marketplace (by this
person or another family member)
(Yes/No)
e. TRICARE or other military health care
(Yes/No)
f. VA (including those who have ever
used or enrolled for VA health care)
(Yes/No)

Do NOT include plans that cover only one
type of service, such as dental, drug or
vision plans.
a. Insurance through a current or
former employer or union (of this
person or another family member)
(Yes/No)
b. Medicare, for people 65 and older,
or people with certain disabilities
(Yes/No)
c. Medicaid, Medical Assistance, or any
kind of state or governmentassistance plan for those with low
income (Yes/No)
d. Insurance purchased directly from
an insurance company or through a
State or Federal Marketplace,
healthcare.gov, or a similar state
website (by this person or another
family member)
(Yes/No)
e. TRICARE or other military health care
(Yes/No)

Do NOT include plans that cover only one
type of service, such as dental, drug, or
vision plans.
a. Insurance through a current or
former employer or union (of this
person or another family member)
(Yes/No)
b. Medicare, for people 65 and older,
or people with certain disabilities
(Yes/No)
c. Medicaid, Medical Assistance, or any
kind of state- or governmentassistance plan for those with low
income (Yes/No)
d. Insurance purchased directly from
an insurance company or through a
State or Federal Marketplace,
HealthCare.gov, or a similar state
website (by this person or another
family member)
(Yes/No)
e. TRICARE or other military health care
(Yes/No)

HEALTH INSURANCE
2014 CURRENT WORDING

ROUND 1 ENGLISH
g.
h.

Indian Health Service (Yes/No)
Any other type of health insurance
NOT listed above (Yes/No) – Specify
________

Version 2
Is this person CURRENTLY covered by any
of the following types of health insurance
or health coverage plans? Mark "Yes" or
"No" for EACH type of coverage in items a
– h.

ROUND 2 ENGLISH
f.

g.
h.

VA (including those who have ever
used or enrolled for VA health care)
(Yes/No)
Indian Health Service (Yes/No)
Any other type of health insurance
NOT listed above (Yes/No)– Specify
________

FINAL WORDING
f.

g.
h.

VA (including those who have ever
used or enrolled for VA health care)
(Yes/No)
Indian Health Service (Yes/No)
Other type of health coverage NOT
listed above (Yes/No) – Specify
________

a. Insurance through a current or former
employer or union (of this person or
another family member) (Yes/No)
b. Medicare, for people 65 and older, or
people with certain disabilities (Yes/No)
c. Medicaid, Medical Assistance, or any
kind of state or government-assistance
plan for those with low income (Yes/No)
d. Insurance purchased directly from an
insurance company or through a State or
Federal Marketplace or HealthCare.Gov
(by this person or another family
member).
Do NOT include plans that cover only one
type of service, such as dental, drug or
vision plans. (Yes/No)
e. TRICARE or other military health care
(Yes/No)
f. VA (including those who have ever used
or enrolled for VA health care) (Yes/No)
g. Indian Health Service (Yes/No)
h. Any other type of health insurance NOT
listed above (Yes/No)- Specify ________

HEALTH INSURANCE

CATI/CAPI VERSION
2014 CURRENT WORDING
I am now going to ask you some questions
about [your/’s] health insurance
and health coverage.
[Are you/Is ] currently covered by
health insurance through a current or
former employer or union of [yours or
another family member/ or
another family member]?
[Are you/Is ] currently covered by
health insurance purchased directly from an
insurance company by [you or another
family member/ or another
family member]?
I recorded that (you/)
(have/has) both insurance through an
employer or union AND insurance
directly purchased through an insurance
company. These are two different plans,
is that correct?
[Are you/Is ] currently covered by
Medicare, for people age 65 or older or
people with certain disabilities?
[Are you/Is ] currently covered by
Medicaid, Medical Assistance, or any kind
of government-assistance plan for those
with low incomes or a disability?
[Are you/Is ] currently covered by
TRICARE or other military health care?
[Are you/Is ] currently covered
through the Veteran’s Administration or

ROUND 1 ENGLISH

ROUND 2 ENGLISH

FINAL WORDING

I am now going to ask you some questions
about (your/’s) health insurance and
health coverage. Do NOT include plans that
cover only one type of service, such as dental,
drug or vision plans.

I am now going to ask you some questions
about (your/’s) health insurance
and health coverage. Do NOT include plans
that cover only one type of service, such as
dental, drug or vision plans.

I am now going to ask you some questions
about (your/‘s) health insurance
and health coverage. Do NOT include plans
that cover only one type of service, such as
dental, drug or vision plans.

(Are you/Is ) currently covered by
health insurance through a current or former
employer or union of (yours or another family
member/ or another family
member)?

a.(Are you/Is ) currently covered by
health insurance through an employer or
union? Include coverage from current or
former employers or unions of
(yours/his/hers) or another family member.

Yes
No

a. (Are you/Is ) currently covered
by health insurance through an employer
or union? Include coverage from current or
former employers or unions of
(yours/his/hers) or another family member.
Yes
No

(Are you/Is ) currently covered by
Medicare, for people age 65 or older or
people with certain disabilities?
Yes
No

b. (Are you/Is ) currently covered
by Medicare, for people age 65 or older or
people with certain disabilities?
Yes
No

(Are you/Is ) currently covered by
Medicaid, Medical Assistance, or any kind of
state or government-assistance plan for those
with low incomes?
Yes
No

c.(Are you/Is ) currently covered by
Medicaid, Medical Assistance, or any kind
of state or government-assistance plan for
those with low incomes?
Yes
No

c. (Are you/Is ) currently covered
by Medicaid, Medical Assistance, or any
kind of state or government-assistance plan
for those with low incomes?
Yes
No

(Are you/Is ) currently covered by
health insurance purchased directly from an
insurance company or through a State or
Federal Marketplace by (you or another
family member/ or another family
member)?
Yes
No

d.(Are you/Is ) currently covered by
health insurance purchased directly from
an insurance company or through a State or
Federal Marketplace, Healthcare.gov, or a
similar state website by or
another family member?
Yes
No

d.(Are you/Is ) currently covered by
health insurance purchased directly from
an insurance company or through a State or
Federal Marketplace, HealthCare.gov, or a
similar state website by or
another family member?
Yes
No

HEALTH INSURANCE
2014 CURRENT WORDING

ROUND 1 ENGLISH

ROUND 2 ENGLISH

[Fill 2: have you/has ] ever used or
enrolled for VA health care?

I recorded that ( you/) (have/has)
both insurance through an employer or
union AND insurance directly purchased
through an insurance company. These are
two different plans, is that correct?
Yes
No

e.(Are you/Is ) currently covered by
TRICARE or other military health care?
Yes
No

e. (Are you/Is ) currently covered
by TRICARE or other military health care?
Yes
No

f.(Are you/Is ) currently covered
through the VA or (have you/has )
ever used or enrolled for VA health care?
Yes
No

f. (Are you/Is ] currently covered
through the VA or [have you/has ]
ever used or enrolled for VA health care?
Yes
No

g.(Are you/Is ) currently covered
through the Indian Health Service?
Yes
No

g. (Are you/Is ) currently covered
through the Indian Health Service?
Yes
No

h.(Are you/Is ) currently covered by
any other health insurance or health
coverage plan?

Yes
No

h. (Are you/Is ) currently covered
by any other type of health coverage NOT
already mentioned?
Yes
No

What is the name of the health care plan?

What is the name of that health care
coverage?

[Are you/Is ] currently covered
through the Indian Health Service?
[Are you/Is ] currently covered by
any other health insurance or health
coverage plan?
What is the name of the health care plan?

(Are you/Is ) currently covered by
TRICARE or other military health care?
Yes
No
(Are you/Is ] currently covered
through the VA or [have you/has ]
ever used or enrolled for VA health care?
Yes
No
(Are you/Is ) currently covered
through the Indian Health Service?
Yes
No
(Are you/Is ) currently covered by any
other health insurance or health coverage
plan?

Yes
No
What is the name of the health care plan?
Person 2+:
I am now going to ask you some questions
about (your/’s) health
insurance and health coverage. Do NOT
include plans that cover only one type of

FINAL WORDING

[AFTER PARTS B-H, IF YES TO PART A AND
ANY OTHER PLAN]
I recorded that ( you/) (have/has)
insurance through an employer or union
AND (READ PLAN). These are two different
plans, is that correct?
Yes
No

[AFTER PARTS B-H, IF YES TO PART A AND
ANY OTHER PLAN]
I recorded that ( you/) (have/has)
insurance through an employer or union
AND (READ PLAN). Are these two different
plans?
Yes (SKIP to Premiums or Daily Activities, as
applicable)
No

Which of these best describes
(your/’s) plan?

Which of these best describes
(your/‘s) plan?

HEALTH INSURANCE
2014 CURRENT WORDING

ROUND 1 ENGLISH
service, such as dental, drug or vision plans.
(Are you/Is ) currently covered by
health insurance through a current or former
employer or union of (yours or another family
member/ or another family
member)?
Yes
No
Same type as Person 1
Earlier I recorded that < Person 1 Name
is/you are> currently covered by .
(Do you/Does ) have this
same type of health insurance or health
coverage?
Yes
No
I also recorded that (< Person 1 Name> is/you
are) currently covered by . (Do
you/Does ) have this same
type of health insurance or health coverage?
(Are you/Is ) covered by
any other health insurance plan? Do NOT
include plans that cover only one type of
service, such as dental, drug or vision plans.

ROUND 2 ENGLISH

FINAL WORDING

Person 2+:
I am now going to ask you some questions
about (your/’s) health
insurance and health coverage. Do NOT
include plans that cover only one type of
service, such as dental, drug or vision plans.

[AFTER PARTS A-H, IF YES TO BOTH C AND
D]
I recorded that (you/) (have/has)
Medicaid, Medical Assistance, or a state or
government-assistance plan AND health
insurance purchased directly from an
insurance company or through a State or
Federal Marketplace. Are these two
different plans?
Yes (SKIP to Premium)
No

(Are you/Is ) currently covered by
health insurance through an employer or
union? Include coverage from current or
former employers or unions of
(yours/his/hers) or another family member.
Yes
No
Same type as Person 1
[IF SAME TYPE AS PERSON 1]
Earlier I recorded that < Person 1 Name
is/you are> currently covered by . (Do you/Does ) have
this same type of health insurance or
health coverage?
Yes
No
I also recorded that (< Person 1 Name>
is/you are) currently covered by . (Do you/Does ) have this same type of health
insurance or health coverage?
(Are you/Is ) covered by
any other health insurance plan? Do NOT
include plans that cover only one type of

Which of these best describes
(your/‘s) plan?
AFTER PART H, IF “YES” TO BOTH H AND
(any other (a-g) or Specific types):
I recorded that (you/) (have/has)
() and (/another type of
health coverage)? Are these two different
plans?
Yes (SKIP to PREMIUM question)
No
Which of these best describes
(your/‘s) plan?

Person 2+:
I am now going to ask you some questions
about (your/‘s) health
insurance and health coverage. Do NOT
include plans that cover only one type of
service, such as dental, drug or vision plans.

HEALTH INSURANCE
2014 CURRENT WORDING

ROUND 1 ENGLISH

ROUND 2 ENGLISH

FINAL WORDING

service, such as dental, drug or vision plans.

HEALTH INSURANCE

INTERNET VERSION
2014 CURRENT WORDING

FINAL WORDING

Is (Name) CURRENTLY covered by any of the following
types of health insurance or health coverage plans? Select
"Yes" or "No" for EACH type of coverage in items a – h.
a. Insurance through a current or former employer or
union (of this person or another family member)
b. Insurance purchased directly from an insurance
company (by this person or another family member)
c. Medicare, for people 65 and older, or people with
certain disabilities
d. Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low income
or a disability
e. TRICARE or other military health care
f. VA (including those who have ever used or enrolled for
VA health care)
g. Indian Health Service
h. Any other type of health insurance - Specify

Are [is] [you/Name] CURRENTLY covered by any of
the following types of health insurance or health
coverage plans? Select “Yes” or “No” for EACH type
of coverage in items a – h.
Do NOT include plans that cover only one type of
service, such as dental, drug or vision plans.
i. Insurance through a current or former
employer or union (of this person or another
family member) (Yes/No)
j. Medicare, for people 65 and older, or people
with certain disabilities (Yes/No)
k. Medicaid, Medical Assistance, or any kind of
state or government-assistance plan for those
with low income (Yes/No)
l. Insurance purchased directly from an insurance
company or through a State or Federal
Marketplace, HealthCare.gov, or a similar state
website (by this person or another family
member)
(Yes/No)
m. TRICARE or other military health care (Yes/No)
n. VA (including those who have ever used or
enrolled for VA health care) (Yes/No)
o. Indian Health Service (Yes/No)
p. Other type of health coverage NOT listed above
(Yes/No) – Specify ________
Add edit checks as similar to CAI as possible on the
internet version to reduce multi-reporting :
Here are some examples of how it might work:
IF “YES” TO BOTH C AND D Show New Screen after
respondent clicks “Next” on Health Insurance
Screen
You entered that (you/) (have/has)
insurance through Medicaid, Medical Assistance, or
a state or government-assistance plan AND health

HEALTH INSURANCE
2014 CURRENT WORDING

FINAL WORDING
insurance purchased directly from an insurance
company or through a State or Federal Marketplace.
Are these two different plans?
Yes (SKIP to Premium Question)
No
Show on new screen with above question greyed
out:
Which of these best describes (your/‘s)
plan?
__ Medicaid, Medical Assistance, or a state or
government-assistance plan
__ Purchased directly from an insurance company or
through a State or Federal Marketplace
Add edit check to the internet instrument for those
reporting both (h) Other and any other plan type (ag) (Reason: Respondents may select “yes” for a plan
type (a-g) and then provide the name of that plan in
the “Other” category.)
AFTER PART H, IF “YES” TO BOTH H AND (any other
(a-g) or Specific types) show a new screen:
You entered that (you/) (have/has) () and (/another type of health coverage)?
Are these two different plans?
Yes (SKIP to PREMIUM question)
No
Which of these best describes (your/‘s)
plan?
Add edit check to the internet instrument for those
reporting both (a) insurance through an employer

HEALTH INSURANCE
2014 CURRENT WORDING

FINAL WORDING
or union and any other type
[AFTER PARTS B-H, IF YES TO PART A AND ANY
OTHER PLAN]
You entered that (you/) (have/has)
insurance through an employer or union AND
(READ PLAN). Are these two different plans?
Yes (SKIP to Premiums or Daily Activities, as
applicable)
No
Which of these best describes (your/‘s)
plan?
Add skip

PREMIUM AND SUBSIDIES
(Back to Table of Contents)

Premium and Subsidies
PAPER VERSION
2014 CURRENT WORDING
New question- no current
wording

ROUND 1 ENGLISH
Version 1
Is there a monthly premium for this plan? A
monthly premium is a fixed amount of money people
pay each month to have health coverage. It does
not include copays or other expenses such as
prescription drug costs.
Yes
No ➔ SKIP next question
Is the cost of the premium subsidized based on
family income?
Yes
No
Version 2
Is there a monthly premium for this plan?
Yes
No ➔ SKIP next question
Does this person or another family member receive
a tax credit or subsidy based on family income to
help pay the monthly premium?
Yes
No
Version 3
Is there a monthly premium for this plan?
Yes
No ➔ SKIP next question

ROUND 2 ENGLISH
Does this person or another family member
pay a premium for this health insurance
plan? A premium is a fixed amount of money
paid on a regular basis for health coverage. It
does not include copays, deductibles, or other
expenses such as prescription costs.
Yes
No
Based on family income, does this person or
another family member receive financial
assistance through a subsidy or tax credit to
help pay part or all of the cost of the
premium for this plan?
Yes
No

FINAL WORDING
Version 1
Is there a premium for this plan? A premium
is a fixed amount of money paid on a regular
basis for health coverage. It does not include
copays, deductibles, or other expenses such as
prescription costs.
Yes
No -> SKIP subsidy question
Does this person or another family member
receive a tax credit or subsidy based on
family income to help pay the premium?
Yes
No
Version 2

Does this person or another family member
pay a premium for this health insurance
plan? A premium is a fixed amount of money
paid on a regular basis for health coverage. It
does not include copays, deductibles, or other
expenses such as prescription costs.
Yes
No -> SKIP subsidy question

Based on family income, does this person or
another family member receive financial

PREMIUM AND SUBSIDIES
2014 CURRENT WORDING

ROUND 1 ENGLISH

ROUND 2 ENGLISH

Is there a tax credit or subsidy based on family
income to help pay the monthly premium for this
plan?
Yes
No

FINAL WORDING
assistance through a subsidy or tax credit to
help pay part or all of the cost of the
premium for this plan?
Yes
No

CATI/CAPI VERSION
2014 CURRENT WORDING

ROUND 1 ENGLISH

ROUND 2 ENGLISH

FINAL WORDING
41

PREMIUM AND SUBSIDIES
2014 CURRENT WORDING
New question- no current wording

ROUND 1 ENGLISH

ROUND 2 ENGLISH

Is there a monthly premium for this plan?
Yes
No

or another
family member pay a premium for this
health insurance plan? A premium is a
fixed amount of money paid on a
regular basis for health coverage. It
does not include copays, deductibles, or
other expenses such as prescription
costs.
Yes
No

Version 1
If “Yes” in question 15b, 15d, and/or 15h Continue. Otherwise,
SKIP to question 17

Based on family income, or another family member
receive financial assistance through a
subsidy or tax credit to help pay part or
all of the cost of the premium for this
plan?
Yes
No

or another family member receive a tax
credit or subsidy based on family income to help pay the
premium?
Yes
No

Is there a tax credit or subsidy based on
family income to help pay the monthly
premium for this plan?
Yes
No

FINAL WORDING

Is there a premium for this plan? A premium is a fixed amount of
money paid on a regular basis for health coverage. It does not
include copays, deductibles, or other expenses such as
prescription costs.
Yes
No -> SKIP subsidy question

Version 2
If “Yes” in question 15c, 15d, and/or 15h Continue. Otherwise,
SKIP to question 17
or another family member pay a premium
for this health insurance plan? A premium is a fixed amount of
money paid on a regular basis for health coverage. It does not
include copays, deductibles, or other expenses such as
prescription costs.
Yes
No -> SKIP subsidy question
Based on family income, or another family
member receive financial assistance through a subsidy or tax
credit to help pay part or all of the cost of the premium for this
plan?
Yes
No

PREMIUM AND SUBSIDIES

INTERNET VERSION
2014 CURRENT WORDING
New question- no current wording

FINAL WORDING
Version 2
If “Yes” in question 15b, 15d, and/or 15h Continue.
Otherwise, SKIP to question 17
Is there a premium for this plan? A premium is a fixed
amount of money paid on a regular basis for health
coverage. It does not include copays, deductibles, or other
expenses such as prescription costs.
Yes
No -> SKIP subsidy question
Does (Name) or another family member receive a tax
credit or subsidy based on family income to help pay the
premium?
Yes
No
Version 2
If “Yes” in question 15c, 15d, and/or 15h Continue.
Otherwise, SKIP to question 17
Does (Name) or another family member pay a premium for
this health insurance plan? A premium is a fixed amount of
money paid on a regular basis for health coverage. It does
not include copays, deductibles, or other expenses such as
prescription costs.
Yes -> Go To Subsidy Question
No -> add a skip around subsidy Q
Based on family income, does (Name) or another family
member receive financial assistance through a subsidy or
tax credit to help pay part or all of the cost of the premium
for this plan?
Yes
No

JOURNEY TO WORK: COMMUTING MODE
(Back to Table of Contents)

JOURNEY TO WORK: COMMUTING MODE
PAPER VERSION
2014 CURRENT WORDING

ROUND 1 ENGLISH

ROUND 2 ENGLISH

FINAL WORDING

How did this person usually get to
work LAST WEEK? If this person
usually used more than one method of
transportation during the trip, mark
(X) the box of the one used for most of
the distance.

How did this person usually get to
work LAST WEEK? If this person
usually used more than one method of
transportation during the trip, mark (X)
the box of the one used for most of the
distance.

How did this person usually get to
work LAST WEEK? Mark ONEbox for
the method of transportation used for
most of the distance.

__ Car, truck, or van
__ Bus or trolley bus
__ Subway or elevated rail
__ Commuter or long-distance railroad
__ Light rail, streetcar, or trolley
__ Ferryboat
__ Taxicab
__ Motorcycle
__ Bicycle
__ Walked
__ Worked at home➔ SKIP to 39a
__ Other method

__ Car, truck, or van
__ Bus
__ Subway or elevated rail
__ Commuter rail or long-distance
train
__ Light rail, streetcar, or trolley
__ Ferryboat
__ Taxicab
__ Motorcycle
__ Bicycle
__ Walked
__ Worked from home➔ SKIP to 39a
__ Other method

__ Car, truck, or van
__ Bus
__ Subway or elevated rail
__ Long-distance train or commuter
rail
__ Light rail, streetcar, or trolley
__ Ferryboat
__ Taxicab
__ Motorcycle
__ Bicycle
__ Walked
__ Worked from home➔ SKIP to 39a
__ Other method

JOURNEY TO WORK: COMMUTING MODE

CATI/CAPI VERSION
2014 CURRENT WORDING

ROUND 1 ENGLISH

ROUND 2 ENGLISH

FINAL WORDING

CAPI:
LAST WEEK, how did <(Name)/you>
USUALLY get to work?

CAPI:
LAST WEEK, how did <(Name)/you> USUALLY
get to work?

CAPI:
LAST WEEK, how did <(Name)/you>
USUALLY get to work?

(If usually used more
than one method of transportation during
the trip, report the one used for most of the
distance.)

(If usually used more
than one method of transportation during the
trip, report the one used for most of the
distance.)

(If usually used more
than one method of transportation during
the trip, report the one used for most of the
distance.)

(If usually used
more than one method of transportation
during the trip, report the one used for
most of the distance.)

Car, truck, or van
Bus or trolley bus
Streetcar or trolley car
Subway or elevated
Railroad
Ferryboat
Taxicab
Motorcycle
Bicycle
Walked
Worked at home➔ SKIP to weeks worked
question
Other method

Car, truck, or van
Bus or trolley bus
Subway or elevated rail
Commuter or long-distance railroad
Light rail, streetcar, or trolley
Ferryboat
Taxicab
Motorcycle
Bicycle
Walked
Worked at home ➔ SKIP to weeks worked
question
Other method

Car, truck, or van
Bus
Subway or elevated rail
Commuter rail or long-distance train
Light rail, streetcar, or trolley
Ferryboat
Taxicab
Motorcycle
Bicycle
Walked
Worked from home ➔ SKIP to weeks
worked question
Other method

Car, truck, or van
Bus
Subway or elevated rail
Long-distance train or commuter rail
Light rail, streetcar, or trolley
Ferryboat
Taxicab
Motorcycle
Bicycle
Walked
Worked from home ➔SKIP to weeks
worked question
Other method

JOURNEY TO WORK: COMMUTING MODE

INTERNET VERSION
2014 CURRENT WORDING

FINAL WORDING

How did (Name) usually get to work LAST
WEEK? If (Name) usually used more than one
method of transportation during the trip, select
the one used for most of the distance.

How did (Name) usually get to work LAST
WEEK? Select ONE box for the method of
transportation used for most of the
distance.

o
o
o
o
o
o
o
o
o
o
o
o

__ Car, truck, or van
__ Bus
__ Subway or elevated rail
__ Long-distance train or commuter rail
__ Light rail, streetcar, or trolley
__ Ferryboat
__ Taxicab
__ Motorcycle
__ Bicycle
__ Walked
__ Worked from home➔ SKIP to 39a
__ Other method

Car, truck, or van
Bus or trolley bus
Streetcar or trolley car
Subway or elevated
Railroad
Ferryboat
Taxicab
Motorcycle
Bicycle
Walked
Worked at home
Other method

JOURNEY TO WORK: TIME LEFT FOR WORK
(Back to Table of Contents)

JOURNEY TO WORK: TIME LEFT FOR WORK
PAPER VERSION
2014 CURRENT WORDING

ROUND 1 ENGLISH

ROUND 2 ENGLISH

FINAL WORDING

What time did this person usually arrive at
work LAST WEEK?
Hour Minute a.m. p.m.

LAST WEEK, what time did this person’s trip
to work usually begin?
Hour Minute a.m. p.m.

JOURNEY TO WORK: TIME LEFT FOR WORK

CATI/CAPI VERSION
2014 CURRENT WORDING

ROUND 1 ENGLISH

ROUND 2 ENGLISH

FINAL WORDING

LAST WEEK, what time did <(Name)/you>
usually leave for work -- (what hour)?

LAST WEEK, what time did <(Name)/you>
usually arrive at work -- (what hour)?

LAST WEEK, what time did
trip to work usually begin -- (what hour)?

LAST WEEK, what time did
trip to work usually begin? -- (what hour)?

(How many minutes past that hour?)
(Was that AM or PM)?

INTERNET VERSION
2014 CURRENT WORDING
What time did (name) usually leave home
to go to work LAST WEEK?
Hour Minute a.m. p.m.

FINAL WORDING
LAST WEEK, what time did (Name)’s trip to
work usually begin?
Hour Minute a.m. p.m.

NUMBER OF WEEKS WORKED
(Back to Table of Contents)

NUMBER OF WEEKS WORKED
PAPER VERSION
2014 CURRENT WORDING

ROUND 1 ENGLISH
Version 1
During the PAST 12 MONTHS (52 weeks),
did this person work 50 or more weeks?
Count paid time off as work.
Yes
No

ROUND 2 ENGLISH

FINAL WORDING

During the PAST 12 MONTHS (52 weeks),
did this person work 50 or more weeks?
Count paid vacation, paid sick leave, and
military service as work.

During the PAST 12 MONTHS (52
weeks), did this person work
EVERY week? Count paid vacation,
paid sick leave, and military service
as work.

Yes
No

How many weeks DID this person work,
even for a few hours, including paid
vacation, paid sick leave, and military
service?

How many WEEKS did this person work,
even for a few hours, including paid time
off?

weeks ________

Version 2
During the PAST 12 MONTHS (52 weeks),
how many WEEKS did this person work?
Count paid vacation, paid sick leave, and
military service.

Yes SKIP TO QUESTION 39
No
During the PAST 12 MONTHS (52
weeks), how many WEEKS did this
person work? Include paid time off
and include weeks when the
person only worked for a few
hours.
weeks ________

Weeks ________

NUMBER OF WEEKS WORKED

CATI/CAPI VERSION
2014 CURRENT WORDING

ROUND 1 ENGLISH

ROUND 2 ENGLISH

FINAL WORDING

During the PAST 12 MONTHS or 52 weeks,
did <(Name)/you> work 50 or more weeks?
Count paid time off as work.

During the PAST 12 MONTHS or 52 weeks,
did <(Name)/you> work 50 or more
weeks? Count paid time off as work.

During the PAST 12 MONTHS or 52 weeks,
did <(Name)/you> work 50 or more weeks?
Count paid vacation, paid sick leave, and
military service as work.

During the PAST 12 MONTHS or 52 weeks,
did <(Name)/you> work EVERY week?
Count paid vacation, paid sick leave, and
military service as work.

Yes
No

Yes SKIP NEXT QUESTION
No

How many weeks DID <(Name)/you> work,
even for a few hours, including paid
vacation, paid sick leave, and military
service? Was it:

How many weeks DID <(Name)/you>
work, even for a few hours, including paid
vacation, paid sick leave, and military
service?

How many WEEKS did <(Name)/you> work,
even for a few hours, including paid time
off?

50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less

weeks ________

During the PAST 12 MONTHS or 52 weeks,
how many WEEKS did <(Name)/you> work?
Include paid time off and include weeks
when <(Name)/you> only worked for a few
hours.
weeks ________

NUMBER OF WEEKS WORKED

INTERNET VERSION
2014 CURRENT WORDING
During the PAST 12 MONTHS (52 weeks), did
(Name) work 50 or more weeks? Count paid time
off as work.
•Yes
•No
How many weeks DID (Name) work, even for a few
hours, INCLUDING paid vacation, paid sick leave,
and military service?
• 50 to 52 weeks
• 48 to 49 weeks
• 40 to 47 weeks
• 27 to 39 weeks
• 14 to 26 weeks
• 13 weeks or less

FINAL WORDING
During the PAST 12 MONTHS (52 weeks), did
(Name) work EVERY week? Count paid
vacation, paid sick leave, and military service
as work.
Yes (Skips to next question)
No
During the PAST 12 MONTHS or 52 weeks, how
many WEEKS did (Name) work? Include paid
time off and include weeks when (Name) only
worked for a few hours.
weeks ________

CLASS OF WORKER
(Back to Table of Contents)

CLASS OF WORKER
PAPER VERSION
2014 CURRENT WORDING

ROUND 1 ENGLISH
Version 1
40-45 CURRENT OR MOST RECENT JOB OR
BUSINESS. Describe clearly this person’s
main job activity or business last week. If
this person had more than one job, describe
the one at which this person worked the
most hours. If this person had no job or
business last week, give information for
his/her last job or business.
Which one of the following best describes
this person’s current or most recent job or
business in the past 5 years?
Mark (X) ONE box.
PRIVATE SECTOR employee:
o For-profit company or organization
o Non-profit organization (including taxexempt and charitable organizations)
GOVERNMENT employee:
o Local government (for example: city or
county school district)
o State government (including state
colleges/universities)
o Active duty U.S. Armed Forces or
Commissioned Corps service
o Federal government civilian employee
SELF-EMPLOYED or OTHER:
o Own non-incorporated business,

ROUND 2 ENGLISH

FINAL WORDING

40 DESCRIPTION OF EMPLOYMENT.
The next series of questions is about
the type of employment this person
had last week.

If this person had more than one job,
describe the one at which the most
hours were worked. If this person did
not work last week, describe the
most recent employment in the past
five years.

Which one of the following best
describes this person’s employment
last week or the most recent
employment in the past 5 years?
Mark (X) ONE box.

PRIVATE SECTOR EMPLOYEE
o For-profit company or organization
o Non-profit organization (including
tax-exempt and charitable
organizations)

GOVERNMENT EMPLOYEE
o Local government (for example:
city or county school district)
o State government (including state
colleges/universities)
o Active duty U.S. Armed Forces or

CLASS OF WORKER
2014 CURRENT WORDING

ROUND 1 ENGLISH
professional practice, or farm
o Own incorporated business, professional
practice, or farm
o Worked without pay in a for-profit family
business or farm for 15 hours or more per
week
Version 2
CURRENT OR MOST RECENT JOB OR
BUSINESS. The next series of questions are
about the type of business this person
worked for and the type of work this person
did. If this person had more than one job,
describe the one at which the most hours
were worked. If this person did not work last
week, give information for the last job or
business in the past five years.

ROUND 2 ENGLISH

FINAL WORDING

Commissioned Corps
o Federal government civilian
employee

SELF-EMPLOYED or OTHER:
o Owner of non-incorporated
business, professional practice, or
farm
o Owner of incorporated business,
professional practice, or farm
o Worked without pay in a for-profit
family business or farm for 15
hours or more per week

SELF-EMPLOYED or OTHER
o Owner of non-incorporated
business, professional practice, or
farm
o Owner of incorporated business,
professional practice, or farm
o Worked without pay in a for-profit
family business or farm for 15
hours or more per week

Which one of the following best describes
this person’s current or most recent job or
business in the past 5 years?
Mark (X) one box.
-Employee of a for-profit, private sector
company or organization
-Employee of a non-profit, private sector
organization (including tax-exempt and
charitable organizations)
-Local government employee (for example:
city or county school district)
-State government employee (including
state colleges/universities)
-Active duty U.S. Armed Forces or
Commissioned Corps service
-Federal government civilian employee
-Self-employed in own non-incorporated
business, professional practice, or farm
-Self-employed in own incorporated
business, professional practice, or farm

CLASS OF WORKER
2014 CURRENT WORDING

ROUND 1 ENGLISH

ROUND 2 ENGLISH

FINAL WORDING

-------------------------------------------------

What was the name of this person’s
employer, business, agency, or
branch of the Armed Forces?
________

-Worked without pay in a for-profit family
business or farm for 15 hours or more per
week
-Did not work for pay in the past 5 years (for
example: homemaker, unpaid intern)
-----------------------------------------------------------------------------

----------------------------------------------------------Version 1 and 2
What was the name of this person’s
employer, business, agency, or branch of
the Armed Forces? ________

CLASS OF WORKER

CATI/CAPI VERSION
2014 CURRENT WORDING

ROUND 1 ENGLISH

ROUND 2 ENGLISH

FINAL WORDING

The next series of questions are about the
type of business <(Name)/you> worked
for and the type of work that
did.

The next series of questions are about
the type of business <(Name)/you>
worked for and the type of work that
did.
If <(Name)/you> had more than 1 job,
describe the one at which the most
hours were worked. If <(Name)/you>
did not work last week, give
information for the last job or business
in the past five years.

The next series of questions is about the
type of employment <(Name)/you> had
last week.

[Fill- if worked last week:]
The next series of questions is about the type of
employment <(Name)/you> had last week.

If <(Name)/you> had more than 1 job,
describe the one at which the most
hours were worked. If <(Name)/you>
did not work last week, describe the
most recent employment in the past five
years.

[Fill- If previously reported that this person did
not work last week but worked in the past 5
years:]
The next series of questions is about the type of
employment <(Name)/you> had most recently in
the past 5 years.

I am going to read 5 categories. Please
pick the one that best describes who
<(Name)/you > worked for – a private
organization or company, government,
active duty U.S. Armed Forces or
Commissioned Corps service, selfemployed, or worked without pay in a
for-profit family business.

CATI:
I am going to read 5 categories. Please
pick the one that best describes
<(Name)’s/your> employment – a
private organization or company,
government, active duty U.S. Armed
Forces or Commissioned Corps, selfemployed, or worked without pay in a
for-profit family business or farm.

If <(Name)/you> had more than one job,
describe the one at which the most hours were
worked.

Private company or organization
Government
Active duty U.S. Armed Forces or
Commissioned Corps service
Self-employed
Worked without pay in a for-profit
family business

Private company or organization
Government
Active duty U.S. Armed Forces or
Commissioned Corps
Self-employed
Worked without pay in a for-profit family
business or farm

Was this a for-profit company or nonprofit organization ?
For-profit company
Non-profit organization

Did <(Name)/you> work for a for-profit
company or non-profit organization ?
For-profit company
Non-profit organization

Was this for local, state, or the federal
government?

Did <(Name)/you> work for a local,
state, or federal government?

.(If <(Name)/ you> had more than 1 job,
describe the one at which the most hours
were worked. If <(Name)/you> did not
work last week, give information for the
last job or business in the past five years.)
Let’s start with the first question. I am
going to read 5 categories. Please pick the
one that best describes who
worked for - a
private organization or company,
government, the US Armed Forces (active
duty), self-employed, or working without
pay in a family business.
Private organization or company
Government
US Armed Forces (active duty)
Self-employed
Working without pay in a family business
Was this a non-profit organization or a for
profit company?
Non-profit organization
For-profit company
Was this for Local, State, or the Federal
Government?
Local
State
Federal

CATI:
I am going to read 5 categories. Please
choosethe one that best describes
<(Name)’s/your> employment – a private
organization or company, government, active
duty U.S. Armed Forces or Commissioned Corps,
self-employed, or worked without pay in a forprofit family business or farm.
Private company or organization
Government
Active duty U.S. Armed Forces or Commissioned
Corps
Self-employed
Worked without pay in a for-profit family
business or farm
Did <(Name)/you> work for a for-profit
company or non-profit organization ?
For-profit company
Non-profit organization

CLASS OF WORKER
2014 CURRENT WORDING
Was this self-employment incorporated or
not incorporated?
Incorporated
Not incorporated

ROUND 1 ENGLISH

ROUND 2 ENGLISH

Local
State
Federal

Was <(Name)’s/your> self-employed
business, professional practice or farm
incorporated or not incorporated?
Incorporated
Not incorporated

Was <(Name)’s/your> self-employed
business, professional practice, or farm
incorporated or not incorporated?
Incorporated
Not incorporated

Did <(Name)/you> work without pay in
this for-profit family business or farm
for 15 hours or more per week?
Yes
No

---------------------------------------------------------

-----------------------------------------------------

What was the name of <(Name)'s/your>
company, business or other employer?

What was the name of
<(Name)’s/your> employer, business,
or agency?

CAPI:
Let’s start with the first question. Using
CARD H, which one of the following best
describes <(Name)’s/your>
employment?

Which branch of the Armed Forces work for?
U.S. Army
U.S. Navy
U.S. Air Force
U.S. Marine Corps
U.S. Coast Guard

Which branch of the Armed Forces or
Commissioned Corps did
<(Name)/you> work for?
U.S. Army
U.S. Navy
U.S. Air Force
U.S. Marine Corps
U.S. Coast Guard
U.S. Public Health Service
National Oceanic and Atmospheric
Administration (NOAA)

(Card H shows what is listed below)
For-profit company or organization
[PRIVATE SECTOR EMPLOYEE]
Non-profit organization (including taxexempt and charitable organizations)
[PRIVATE SECTOR EMPLOYEE]
Local government [GOVERNMENT
EMPLOYEE]
State government (including state
colleges/universities) [GOVERNMENT
EMPLOYEE]
Active duty U.S. Armed Forces or
Commissioned Corps [GOVERNMENT
EMPLOYEE]
Federal government civilian employee

FINAL WORDING
Did <(Name)/you> work for a local, state, or
federal government?
Local
State
Federal
Was <(Name)’s/your> self-employed business,
professional practice, or farm incorporated or
not incorporated?
Incorporated
Not incorporated
Did <(Name)/you> work without pay in this forprofit family business or farm for 15 hours or
more per week?
Yes
No
CAPI:
Let’s start with the first question. Using CARD H,
which one of the following best describes
<(Name)’s/your> employment?
(CAPI screenshows what is listed below)
For-profit company or organization [PRIVATE
SECTOR EMPLOYEE]
Non-profit organization (including tax-exempt
and charitable organizations) [PRIVATE SECTOR
EMPLOYEE]
Local government [GOVERNMENT EMPLOYEE]
State government (including state
colleges/universities) [GOVERNMENT
EMPLOYEE]
Active duty U.S. Armed Forces or Commissioned
Corps [GOVERNMENT EMPLOYEE]
Federal government civilian employee

CLASS OF WORKER
2014 CURRENT WORDING

ROUND 1 ENGLISH

ROUND 2 ENGLISH
[GOVERNMENT EMPLOYEE]
Owner of non-incorporated business,
professional practice,or farm [SELFEMPLOYED]
Owner of incorporated business,
professional practice,or farm [SELFEMPLOYED]
Worked without pay in a for-profit
family business or farm for 15 hours or
more per week

FINAL WORDING
[GOVERNMENT EMPLOYEE]
Owner of non-incorporated business,
professional practice, or farm [SELF- EMPLOYED]
Owner of incorporated business, professional
practice, or farm [SELF- EMPLOYED]
Worked without pay in a for-profit family
business or farm for 15 hours or more per week
(Card H shows what is listed below, note grey
headers)
CARD H
Which one of the following best describes this
person’s employment?
(Choose one)
PRIVATE SECTOR EMPLOYEE
For-profit company or organization
Non-profit organization (including taxexempt and charitable organizations)
GOVERNMENT EMPLOYEE
Local government (for example: city or
county school district)
State government (including state
colleges/universities)
Active duty U.S. Armed Forces or
Commissioned Corps
Federal government civilian employee
SELF-EMPLOYED OR OTHER
Owner of non-incorporated business,
professional practice, or farm
Owner of incorporated business,
professional practice, or farm
Worked without pay in a for-profit family
business or farm for 15 hours or more per
week

CLASS OF WORKER
2014 CURRENT WORDING

ROUND 1 ENGLISH

ROUND 2 ENGLISH

FINAL WORDING

-------------------------------------------------------

-----------------------------------------------------------------

What was the name of <(Name)’s/your>
employer, business, or agency?

Which branch of the Armed Forces or
Commissioned Corps did <(Name)/you>
work for?
U.S. Army
U.S. Navy
U.S. Air Force
U.S. Marine Corps
U.S. Coast Guard
U.S. Public Health Service
National Oceanic and Atmospheric
Administration (NOAA)

Which branch of the Armed Forces or
Commissioned Corps did <(Name)/you> work
for?
U.S. Army
U.S. Navy
U.S. Air Force
U.S. Marine Corps
U.S. Coast Guard
U.S. Public Health Service
National Oceanic and Atmospheric
Administration (NOAA)

CLASS OF WORKER

INTERNET VERSION

2014 CURRENT WORDING
The next series of questions are about the type of business
(Name) worked for and the type of work that (he/she/he
or she) did.
Describe clearly (name’s) chief job activity or business last
week. If (name) had more than one job, describe the one at
which (he/she/he or she) worked the most hours. If (name)
had no job or business last week, give information for
(his/her/his or her) last job or business.
Was (name) –
an employee of a PRIVATE FOR-PROFIT company or
business, or of an individual, for wages, salary, or
commissions?
an employee of a PRIVATE NOT-FOR-PROFIT, tax-exempt, or
charitable organization?
a local GOVERNMENT employee (city, county, etc.)?
a state GOVERNMENT employee?
an ACTIVE DUTY U.S. Armed Forces member?
a Federal GOVERNMENT employee (excluding active duty
military)?
SELF-EMPLOYED in own NOT INCORPORATED business,
professional practice, or farm?
SELF-EMPLOYED in own INCORPORATED business,
professional practice, or farm?
working WITHOUT PAY in family business or farm?

FINAL WORDING
COWA [40]
40. DESCRIPTION OF EMPLOYMENT
The next series of questions is about the type of
employment (Name) had last week.
If (Name) had more than one job, describe the one
at which the most hours were worked.
If (Name) did not work last week, describe the most
recent employment in the past five years.
a. Which one of the following best describes
(Name)’s employment last week or the most
recent employment in the past 5 years?
PRIVATE SECTOR EMPLOYEE
For-profit company or organization
Non-profit organization (including taxexempt and charitable organizations)

What was the name of (Name)’s company, business, or
other employer?

GOVERNMENT EMPLOYEE
Local government (for example: city or
county school district)
State government (including state
colleges/universities)
Active duty U.S. Armed Forces or
Commissioned Corps
Federal government civilian employee

Which branch of the Armed Forces does (Name) work for?
U.S. Army
U.S. Navy
U.S. Air Force
U.S. Marine Corps

SELF-EMPLOYED OR OTHER
Owner of non-incorporated business,
professional practice, or farm
Owner of incorporated business, professional
practice, or farm

CLASS OF WORKER
U.S. Coast Guard

Worked without pay in a for-profit family
business or farm for 15 hours or more per
week

-------------------------------------------------------------------INW2 (if COWA not = 5 “Active duty…”) [40b]
b. What was the name of (Name)’s employer,
business, or agency?
| ______________________________|
[60 characters]
INMIL (if COWA= 5 “Active duty...”) [40b]
b. Which branch of the Armed Forces or
Commissioned Corps did (Name) work for?
U.S. Army
U.S. Navy
U.S. Air Force
U.S. Marine Corps
U.S. Coast Guard
U.S. Public Health Service
National Oceanic and Atmospheric
Administration (NOAA)

INDUSTRY AND OCCUPATION
(Back to Table of Contents)

INDUSTRY AND OCCUPATION
PAPER VERSION
2014 CURRENT WORDING

ROUND 1 ENGLISH

ROUND 2 ENGLISH

Version 1
What kind of place was this job or
business? Include the main activity,
product, or service provided at the
location where employed. (For example:
elementary school, women’s clothing
store, fast food restaurant)
_________

What kind of business or industry was
this? Include the main activity,
product, or service provided at the
location where employed. (For
example: elementary school,
residential construction)
_________

Version 2
What kind of business or industry was
this? Include the main activity, product,
or service provided at the location where
employed. Be as specific as possible.
_________
------------------------------------------------------------------------------------

------------------------------------------------------Version 1
What was this person’s main occupation
or title? Be as specific as possible. (For
th
example: 4 grade teacher) ________

FINAL WORDING
What kind of business or industry
was this? Include the main activity,
product, or service provided at the
location where employed. (For
example: elementary school,
residential construction)
_________

----------------------------------------------------------------------------------------------------What was this person’s main
th
occupation? (For example: 4 grade
teacher, entry-level plumber) ________

What was this person’s main
th
occupation? (For example: 4 grade
teacher, entry-level plumber)
________

Version 2
What was this person’s main occupation
or title? Be as specific as possible.
________
-------------------------------------------------------------------------------------------------------------------------------------

-------------------------------------------------------

----------------------------------------------------

INDUSTRY AND OCCUPATION
2014 CURRENT WORDING

ROUND 1 ENGLISH
Version 1
What were this person’s most important
activities or duties? Be as specific as
possible. (For example: instructing and
evaluating students, creating lesson
plans) ________
Version 2
What were this person’s most important
activities or duties? Be as specific as
possible. ________

ROUND 2 ENGLISH

FINAL WORDING

Describe this person’s most important
activities or duties. (For example:
instruct and evaluate students and
create lesson plans, assemble and
install pipe sections and review
building plans for work details)
________

Describe this person’s most
important activities or duties. (For
example: instruct and evaluate
students and create lesson plans,
assemble and install pipe sections and
review building plans for work details)
________
[3 lines for write-in text on paper]

INDUSTRY AND OCCUPATION

CATI/CAPI VERSION
2014 CURRENT WORDING

ROUND 1 ENGLISH

What kind of business or industry was this?

For example: hospital, newspaper
publishing, mail order house, auto engine
manufacturing, bank.
_________

ROUND 2 ENGLISH

FINAL WORDING

What kind of business or industry was
this?

Include the main activity, product, or
service provided at the location where
employed. For example: elementary school,
women’s clothing store, fast food
restaurant.
_________

Include the main activity, product, or
service provided at the location where
employed. For example: elementary
school, residential construction.
_________

Include the main activity, product, or
service provided at the location where
employed. For example: elementary
school, residential construction, oranother
kind of business
_________

------------------------------------------------------------

-----------------------------------------------------------

----------------------------------------------------------

What kind of work < was (Name)/were you>
doing at this job?

What was <(Name)’s/your> main
occupation or title?
Be as specific as possible.
For example: 4th grade teacher________

What was <(Name)’s/your> main
occupation?
For example: 4th grade teacher, entrylevel plumber ________

What was <(Name)’s/your> main
occupation?
For example: 4th grade teacher, entrylevel plumber, or another
occupation________

------------------------------------------------------------

-----------------------------------------------------------

----------------------------------------------------------

What were <(Name)'s/your> most
important activities or duties at this job?
For example: patient care, directing hiring
policies, supervising order clerks, typing and
filing, reconciling financial records.
________

What were <(Name)’s/your> most
important activities or duties?
Be as specific as possible. For example:
instructing and evaluating students,
creating lesson plans________

Describe <(Name)’s/your> most important
activities or duties. For example: instruct
and evaluate students and create lesson
plans, assemble and install pipe sections
and review building plans for work
details.________

For example: registered nurse, personnel
manager, supervisor of order department,
secretary, accountant. ________

INDUSTRY AND OCCUPATION

INTERNET VERSION
2014 CURRENT WORDING
What kind of business or industry was this? Describe
the activity at the location where employed. (For
example: hospital, newspaper publishing, mail order
house, auto engine manufacturing, bank)
Is this business mainly –
manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service, government,
etc.)?
What kind of work was (name) doing at this job? (For
example: registered nurse, personnel manager,
supervisor of order department, secretary, accountant)
What were (Name)’s most important activities or
duties? (For example: patient care, directing hiring
policies, supervising order clerks, typing and filing,
reconciling financial records)

FINAL WORDING
c. What kind of business or industry was this?
Include the main activity, product, or service
provided at the location where employed. (For
example: elementary school, residential
construction)
|_______________________________| [60
characters]
d. Was this mainly -manufacturing?
wholesale trade?
retail trade?
other (agriculture, construction, service,
government, etc.)?
e. What was (Name)’s main occupation? (For
th
example: 4 grade teacher, entry-level plumber)
|_____________________________________|
f. Describe (Name)’s most important activities
or duties. (For example: instruct and evaluate
students in math and create lesson plans,
assemble and install pipe sections and review
building plans for work details)
_____________________________________
|_____________________________________|
|_____________________________________|
|_____________________________________|
[100 characters, bigger box]

RETIREMENT INCOME
(Back to Table of Contents)

RETIREMENT INCOME
PAPER VERSION
2014 CURRENT WORDING

ROUND 1 ENGLISH
Version 1
Retirement, survivor, disability payments,
or retirement account withdrawals or
distributions.
DO NOT include Social Security or amounts
rolled over into other retirement accounts.
Retirement accounts include employer
plans and IRA, Roth IRA, 401(k), 403(b),
SEP, KEOGH, SIMPLE accounts.
Yes
No
TOTAL AMOUNT for past 12
months________

ROUND 2 ENGLISH

FINAL WORDING

Retirement income, pensions, survivor
or disability income.
Include income from a previous employer
or union, or any regular withdrawals or
distributions from IRA, Roth IRA, 401(k),
403(b), or other accounts specifically
designed for retirement.

Do not include Social Security.

Yes
No

TOTAL AMOUNT for past 12
months________

Version 2
Retirement, survivor, disability payments,
or retirement account withdrawals or
distributions. DO NOT include amounts
rolled over into other retirement accounts.
Yes
No
TOTAL AMOUNT for past 12
months________

RETIREMENT INCOME

CATI/CAPI VERSION
2014 CURRENT WORDING

ROUND 1 ENGLISH

ROUND 2 ENGLISH

FINAL WORDING

Did <(Name)/you> receive any
retirement, survivor, or disability
pensions DURING THE PAST 12 MONTHS?
Yes
No

Did <(Name)/you> receive any survivor or
disability income DURING THE PAST 12
MONTHS?
Yes
No

What was the amount?
(Do not include Social Security.) ________

What was the amount?
(Do not include Social Security)

Did <(Name)/you> receive any retirement
income from a previous employer or union
or income from retirement accounts such
as a 401(k), 403(b), IRA, or other accounts
designed specifically for retirement savings
DURING THE PAST 12 MONTHS?
DO NOT include amounts rolled over into
other retirement accounts.

Did <(Name)/you> receive a pension or any
retirement income from a previous
employer or union, or any regular
withdrawals or distributions from
retirement accounts such as a 401(k),
403(b), IRA, Roth IRA, or other accounts
designed specifically for retirement
DURING THE PAST 12 MONTHS?

Did <(Name)/you> receive a pension or
any retirement income from a previous
employer or union, or any regular
withdrawals or distributions from
retirement accounts such as a 401(k),
403(b), IRA, Roth IRA, or other accounts
designed specifically for retirement
DURING THE PAST 12 MONTHS?

What was the amount?
(Do not include Social Security) ________

RETIREMENT INCOME

INTERNET VERSION
2014 CURRENT WORDING

FINAL WORDING

Did (Name) receive any retirement, survivor, or disability
pensions during the PAST 12 MONTHS? Do NOT include
Social Security.
Yes
No

Did (Name) receive any survivor or disability
income DURING THE PAST 12 MONTHS?
Yes
No

What was the amount?
TOTAL AMOUNT for
past 12 months

What was the amount?
(Do not include Social Security)
Did (Name) receive a pension or any
retirement income from a previous
employer or union, or any regular
withdrawals or distributions from
retirement accounts such as a 401(k), 403(b),
IRA, Roth IRA, or other accounts designed
specifically for retirement DURING THE PAST
12 MONTHS?
What was the amount?
(Do not include Social Security) ________

RETIREMENT INCOME

CONTENT FOLLOW UP VERSION
2014 CURRENT WORDING
Did <(Name)/you> receive any retirement,
survivor,
or disability pensions DURING THE PAST 12
MONTHS?
Yes
No
What was the amount?
(Do not include Social Security.) ________

FINAL WORDING
Did (you/ name) receive any pension income from a previous employer or union, (other than Social Security or VA benefits) DURING THE PAST
12
MONTHS?
PLEASE DO NOT INCLUDE ANNUITIES OR DISTRIBUTIONS OR WITHDRAWALS FROM IRAs, 401(k)s, OR SIMILAR ACCOUNTS!
Yes
No
What type of pension did (you/name) have DURING THE PAST 12 MONTHS? Did (you/name) have a …
READ EACH CATEGORY!
Enter all that apply, separate using the space bar or a comma.
Probe for all sources, anything else?
Company Pension
Union Pension
Federal Government Pension
State Government Pension
Local Government Pension
U.S. Military Pension
U.S. Railroad Retirement
Other
What was the source of (your/name’s) pension income?
Specify other source of pension income
Enter "Other Pension" if the answer is "Don't Know"
_________________________________________________
How much did (name/you) receive in [(ACCOUNT TYPE) FILL FROM PENTYPE or PENOTH)]DURING THE PAST 12 MONTHS?
Enter dollar amount
______________
****repeat for first and second pension type reported****

RETIREMENT INCOME
Did (you/ name) receive any income from an annuity DURING THE PAST 12 MONTHS?
Yes
No
How much did (name/you) receive in annuities DURING THE PAST 12 MONTHS?
Enter dollar amount
_______________
Did (you/ name) have any retirement accounts such as a 401(k), 403(b), IRA, or other account designed specifically for retirement savings
DURING
THE PAST 12 MONTHS?
Yes
No
What type of retirement account (did you/ NAME) have? Did (you/he/she) have a …
READ EACH CATEGORY!
Enter all that apply, separate using the space bar or a comma.
Probe for all sources, anything else?
401(k)
403(b)
Roth IRA
KEOGH plan (“KEE‐OH”)
SEP plan (Simplified Employee Pension)
Another type of retirement account
What was the source of (name's/your) retirement account?
Specify other source of retirement account
Enter "Other Retirement Account" if the answer is "Don't Know"
_____________________________________________
Did (you/NAME) withdraw any money or receive a distribution from (your/his/her) [(ACCOUNT TYPE) FILL IN FROM RETTYPE or RETOTH]
account
DURING THE PAST 12 MONTHS?
(IF AGE 70+ ADD: including distributions you may have been required to take?)
Yes
No

RETIREMENT INCOME

How much was (name's/your) withdrawal or distribution from [(ACCOUNT TYPE) FILL FROM RETTYPE or RETOTH)] DURING THE PAST 12
MONTHS?
Enter dollar amount
_______________
Did [you/name] re‐invest or "roll over" any of the money into an IRA or some other kind of retirement plan DURING THE PAST 12 MONTHS?
Yes
No
How much did (you/name) re‐invest or “roll over” into an IRA or some other kind of retirement plan DURING THE PAST 12 MONTHS? Enter
dollar amount
_______________
Do/Does (you/name) plan to re‐invest or roll over any of the money?
Yes
No
How much do/does (you/name) plan to re‐invest or “roll over” into an IRA or some other kind of retirement plan?
Enter dollar amount
_______________
****repeat for first and second retirement account type reported****

File Type	application/pdf
Author	Andrew W Roberts
File Modified	2015-07-28
File Created	2015-07-27