5 ACS English CAI Script Group 2 V1

Generic Clearance for Questionnaire Pretesting Research

Enc 8A - ACS English CAI Script Group 2 V1

2022 ACS Content Test Cognitive Interviews

OMB: 0607-0725

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CAI Script – Group 2 – Version 1 – English – Date 05/13/2020 Participant ID #: |___|___|___|___|___|___|___|___|___|___|

2022 AMERICAN COMMUNITY SURVEY CONTENT TEST


Respondent

Person 2

Person 3

Person 4

Person 5

Person 6

1a. Let’s create a list of everyone, including people not related to you, living or staying at this address.


What is your name?


(What is the name of the next person living or staying here?)


  • Make sure to include the respondent if he/she is staying there.






First name (or initial):

_________________





First name (or initial):

_________________





First name (or initial):

_________________





First name (or initial):

_________________





First name (or initial):

_________________





First name (or initial):

_________________

The following questions are to make sure everyone is included.


The people you have listed so far are…

  • Read all names.


1b. Other than these people, is there anyone else staying here such as…

    • Babies

    • Grandchildren

    • Foster children

    • Any other children, related or unrelated to you

    • Roommates

    • People or families who have no other place to stay?


  • Do not include overnight or weekend guests who have a residence somewhere else.


  • List additional names to the right.


Additional Person 1:



__________________

Additional Person 2:



__________________

Additional Person 3:



__________________

Additional Person 4:



__________________

Additional Person 5:



__________________

Additional Person 6:



__________________



No additional persons

  • Copy names from 1a and 1b.


The following questions are to make sure everyone we have listed should be included in this survey.


I have…

  • Read all names.


1c. Do any of these people live somewhere else now, such as a college student or someone in the Armed Forces on deployment?


  • MARK “No” for:

(1) children in boarding school or summer camp


  • MARK “Yes” for:

(1) children in shared custody who are not currently staying at

the sample address, regardless of the length of stay;

(2) persons who are away NOW for more than two months^


^ - The two-month period is not anchored by a specific

reference date, but can encompass the two months prior to

the interview or the two months following the interview

date.





Respondent:


________________


Yes

No


Person 2:


________________


Yes

No


Person 3:


________________


Yes

No


Person 4:


________________


Yes

No


Person 5:


________________


Yes

No


Person 6:


________________


Yes

No


Additional Person 1:


________________


Yes

No


Additional Person 2:


________________


Yes

No


Additional Person 3:


________________


Yes

No


Additional Person 4:


________________


Yes

No


Additional Person 5:


________________


Yes

No


Additional Person 6:


________________


Yes

No



  • Copy names from 1a and 1b, but OMIT anyone with a “Yes” response to 1c.


I have listed…

  • Read all remaining names.


1d. Are any of these people staying here for a short visit or for an overnight stay?



  • MARK “No” for:

(1) children in shared custody who are currently staying at the

sample address, regardless of where they usually stay;

(2) commuter workers who stay in some other residence closer

to work when their family residence is the sample address.


  • MARK “Yes” for:

(1) Commuter workers who stay at the sample address to be closer to work;

(2) Persons who have some other residence.


Respondent:


________________


Yes

No


Person 2:


________________


Yes

No


Person 3:


________________


Yes

No


Person 4:


________________


Yes

No


Person 5:


________________


Yes

No


Person 6:


________________


Yes

No


Additional Person 1:


________________


Yes

No


Additional Person 2:


________________


Yes

No


Additional Person 3:


________________


Yes

No


Additional Person 4:


________________


Yes

No


Additional Person 5:


________________


Yes

No


Additional Person 6:


________________


Yes

No



  • Copy names with a “Yes” response to 1d.


I have listed…

  • Read names with a “Yes” response to 1d.


1e. Are you/Is <Name> staying here for MORE than two months^?


  • MARK “Yes”:

(1) persons who are staying MORE than two months^;

(2) children in shared custody who are currently staying at the

sample address, regardless of where they usually stay;

(3) commuter workers who stay at the sample address to be

closer to work


^ - The two-month period is not anchored by a specific

reference date, but can encompass the two months prior to

the interview or the two months following the interview

date.


Respondent:


________________


Yes

No


Person 2:


________________


Yes

No


Person 3:


________________


Yes

No


Person 4:


________________


Yes

No


Person 5:


________________


Yes

No


Person 6:


________________


Yes

No


Additional Person 1:


________________


Yes

No


Additional Person 2:


________________


Yes

No


Additional Person 3:


________________


Yes

No


Additional Person 4:


________________


Yes

No


Additional Person 5:


________________


Yes

No


Additional Person 6:


________________


Yes

No


  • Generate the final roster using the first 1-6 names remaining in the order they were mentioned:

- Copy names from 1a and 1b

- OMIT anyone with a “Yes” response to 1c.

- OMIT anyone with a “No” response to 1e.


Respondent:


_________________

Person 2:


__________________

Person 3:


__________________

Person 4:


__________________

Person 5:


__________________

Person 6:


__________________

  • Ask as topic-based, that is, ask question for each person before moving to next question.


  • Use flash card for relationships.


2a. Of the people you named, who owns or rents this place?


  • Fill in response as Householder. When listing non-householders as Persons 2-6, maintain order established in final roster.


2b. Using this list on my screen, how is <NAME>/are you related to <FILL “YOU” IF RESPONDENT IS HOUSEHOLDER / HOUSEHOLDER NAME>?


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

Roommate or housemate

Foster child

Other nonrelative


Householder:


_________________

Person 2:


_________________


Opposite-sex husband/wife/
spouse

Opposite-sex unmarried partner

Same-sex husband/wife/
spouse

Same-sex unmarried partner

Biological Son/Daughter

Adopted Son/Daughter

 Stepson/
Stepdaughter

Brother/Sister

Father/Mother

Grandchild

Parent-in-law

Son/daughter-law

Other relative

Roommate/ Housemate

Foster child

Other nonrelative

Person 3:


_________________


Opposite-sex husband/wife/
spouse

Opposite-sex unmarried partner

Same-sex husband/wife/
spouse

Same-sex unmarried partner

Biological Son/Daughter

Adopted Son/Daughter

 Stepson/
Stepdaughter

Brother/Sister

Father/Mother

Grandchild

Parent-in-law

Son/daughter-law

Other relative

Roommate/ Housemate

Foster child

Other nonrelative

Person 4:


__________________


Opposite-sex husband/wife/
spouse

Opposite-sex unmarried partner

Same-sex husband/wife/
spouse

Same-sex unmarried partner

Biological Son/Daughter

Adopted Son/Daughter

 Stepson/
Stepdaughter

Brother/Sister

Father/Mother

Grandchild

Parent-in-law

Son/daughter-law

Other relative

Roommate/ Housemate

Foster child

Other nonrelative

Person 5:


__________________


Opposite-sex husband/wife/
spouse

Opposite-sex unmarried partner

Same-sex husband/wife/
spouse

Same-sex unmarried partner

Biological Son/Daughter

Adopted Son/Daughter

 Stepson/
Stepdaughter

Brother/Sister

Father/Mother

Grandchild

Parent-in-law

Son/daughter-law

Other relative

Roommate/ Housemate

Foster child

Other nonrelative

Person 6:


___________________


Opposite-sex husband/wife/
spouse

Opposite-sex unmarried partner

Same-sex husband/wife/
spouse

Same-sex unmarried partner

Biological Son/Daughter

Adopted Son/Daughter

 Stepson/
Stepdaughter

Brother/Sister

Father/Mother

Grandchild

Parent-in-law

Son/daughter-law

Other relative

Roommate/ Housemate

Foster child

Other nonrelative

  • UNRELATED HOUSEHOLD CHECK:


  • IS ENTIRE HOUSEHOLD UNRELATED (relationships for ALL household members are “ Roomer/Boarder”,” Housemate/Roommate”,” Foster child”, or “ Other non-relative“) ?

Yes

No

  • Ask or verify:

3. Are you/Is <FILL HOUSEHOLDER>/Is <FILL OTHER NAME> male or female?

Householder:

__________________


Male

Female


Person 2:

_________________


Male

Female


Person 3:

_________________


Male

Female


Person 4:

_________________


Male

Female


Person 5:

__________________


Male

Female


Person 6:

___________________


Male

Female


4a. What is your/<FILL HOUSEHOLDER’s>/<FILL OTHER NAME’s> date of birth?

  • Enter birth month.

  • Enter birth day.

  • Enter birth year (Enter 4 digits - ex: 1964).

Birth Month: _______

Birth Day: _________

Birth Year: ________

Birth Month: _______

Birth Day: _________

Birth Year: ________

Birth Month: _______

Birth Day: _________

Birth Year: ________

Birth Month: _______

Birth Day: _________

Birth Year: ________

Birth Month: _______

Birth Day: _________

Birth Year: ________

Birth Month: _______

Birth Day: _________

Birth Year: ________

4b. Would you say you are/<Name> is <FILL AGE>?


(If no: What is your best estimate of your/<NAME’s> age?)



  • Make sure the respondent gives the age in completed years as of today. Do not round the age up if the person was close to having a birthday. If the exact age is not known, an estimate will do. Do not enter age in months. For babies less than 1 year old, enter 0 as the age.

Yes

No: ___________


Yes

No: ___________


Yes

No: ___________


Yes

No: ___________


Yes

No: ___________


Yes

No: ___________



  • Complete all parts of question 5 (A-C) for each person before moving on to the next person.


5a. Are you/Is <NAME> of Hispanic, Latino, or Spanish origin?


  • If response is “Yes, of Hispanic, Latino, or Spanish origin,” ask Question 5b. If not, check appropriate box and move to next person.

Householder:





No, not of Hispanic, Latino, or Spanish origin


Yes, of Hispanic, Latino, or Spanish origin

Person 2:





No, not of Hispanic, Latino, or Spanish origin


Yes, of Hispanic, Latino, or Spanish origin

Person 3:





No, not of Hispanic, Latino, or Spanish origin


Yes, of Hispanic, Latino, or Spanish origin

Person 4:





No, not of Hispanic, Latino, or Spanish origin


Yes, of Hispanic, Latino, or Spanish origin

Person 5:





No, not of Hispanic, Latino, or Spanish origin


Yes, of Hispanic, Latino, or Spanish origin

Person 6:





No, not of Hispanic, Latino, or Spanish origin


Yes, of Hispanic, Latino, or Spanish origin

5b. Are you/Is <NAME> Mexican, Mexican American, or Chicano; Puerto Rican; Cuban; or of some other Hispanic, Latino, or Spanish Origin?


  • If response is “Yes, another Hispanic, Latino, or Spanish origin,” ask Question 5c. Otherwise, check appropriate box and move to next person.


5c. What is that origin or origins? For example, Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian, etc.?


  • Enter the group(s) provided by the respondent in the “Yes, another Hispanic, Latino, or Spanish origin” write-in box.


Yes, Mexican, Mexican American, or Chicano


Yes, Puerto Rican


Yes, Cuban


Yes, another Hispanic, Latino, or Spanish origin(s):


__________________

Yes, Mexican, Mexican American, or Chicano


Yes, Puerto Rican


Yes, Cuban


Yes, another Hispanic, Latino, or Spanish origin(s):


__________________

Yes, Mexican, Mexican American, or Chicano


Yes, Puerto Rican


Yes, Cuban


Yes, another Hispanic, Latino, or Spanish origin(s):


__________________

Yes, Mexican, Mexican American, or Chicano


Yes, Puerto Rican


Yes, Cuban


Yes, another Hispanic, Latino, or Spanish origin(s):


__________________

Yes, Mexican, Mexican American, or Chicano


Yes, Puerto Rican


Yes, Cuban


Yes, another Hispanic, Latino, or Spanish origin(s):


__________________

Yes, Mexican, Mexican American, or Chicano


Yes, Puerto Rican


Yes, Cuban


Yes, another Hispanic, Latino, or Spanish origin(s):


__________________


  • Complete all parts of Question 6 (A-G) for each person before moving on to the next person.


  • Flashcard: “RACE”


6a. Using this list, choose one or more races.


Are you/Is <NAME> White, Black or African American, American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, or Some other race?


Householder:




White


Black or African American


American Indian or Alaska Native


Asian


Native Hawaiian or Other Pacific Islander


Some other race

Person 2:




White


Black or African American


American Indian or Alaska Native


Asian


Native Hawaiian or Other Pacific Islander


Some other race

Person 3:




White


Black or African American


American Indian or Alaska Native


Asian


Native Hawaiian or Other Pacific Islander


Some other race

Person 4:




White


Black or African American


American Indian or Alaska Native


Asian


Native Hawaiian or Other Pacific Islander


Some other race

Person 5:




White


Black or African American


American Indian or Alaska Native


Asian


Native Hawaiian or Other Pacific Islander


Some other race

Person 6:




White


Black or African American


American Indian or Alaska Native


Asian


Native Hawaiian or Other Pacific Islander


Some other race

6a_SKIP

  • If person has a response of “White” to Question 6a, ask Question 6b for that person.

  • Otherwise, SKIP to 6b_SKIP.

6b. What is your/<NAME’s> White origin or origins? For example, German, Irish, English, Italian, Lebanese, Egyptian, etc.


  • Enter the group(s) provided by the respondent in the corresponding write-in box in this row.













6b_SKIP

  • If person has a response of “Black or African American” to Question 6a, ask Question 6c for that person.

  • Otherwise, SKIP to 6c_SKIP.

6c. What is your/<NAME’s> Black or African American origin or origins? For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.


  • Enter the group(s) provided by the respondent in the corresponding write-in box in this row.

Householder:




Origin(s):




Person 2:

_________________


Origin(s):




Person 3:

__________________


Origin(s):




Person 4:

__________________


Origin(s):




Person 5:

__________________


Origin(s):




Person 6:

__________________


Origin(s):




6c_SKIP

  • If person has a response of “American Indian or Alaska Native” to Question 6a, ask Question 6d for that person.

  • Otherwise, SKIP to 6d_SKIP.

6d. What is your/<NAME’s> 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.


  • Enter the group(s) provided by the respondent in the corresponding write-in box in this row.

Householder:




Tribe(s):




Person 2:

__________________


Tribe(s):




Person 3:

__________________

Tribe(s):




Person 4:

_________________

Tribe(s):




Person 5:

_________________

Tribe(s):




Person 6:




Tribe(s):




6d_SKIP

  • If person has a response of “Asian” to Question 6a, ask Question 6e for that person.

  • Otherwise, SKIP to 6e_SKIP.

6e. You may choose one or more Asian groups. Are you/Is <NAME> Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, or of some other Asian origin?


  • If Chinese, Filipino, Asian Indian, Vietnamese, Korean, or Japanese, check the appropriate box.


  • If response is “Other Asian,” ask Question 6f. Otherwise, check appropriate box and move to next person.


6f. What is that origin or origins? For example, Pakistani, Cambodian, Hmong, etc.?


  • Enter the group(s) provided in the corresponding Other Asian write-in space in this row.

Chinese


Filipino


Asian Indian


Vietnamese


Korean


Japanese


Other Asian:


__________________

Chinese


Filipino


Asian Indian


Vietnamese


Korean


Japanese


Other Asian:


__________________

Chinese


Filipino


Asian Indian


Vietnamese


Korean


Japanese


Other Asian:


__________________

Chinese


Filipino


Asian Indian


Vietnamese


Korean


Japanese


Other Asian:


__________________

Chinese


Filipino


Asian Indian


Vietnamese


Korean


Japanese


Other Asian:


__________________

Chinese


Filipino


Asian Indian


Vietnamese


Korean


Japanese


Other Asian:


__________________

6f_SKIP

  • If person has a response of “Native Hawaiian or Other Pacific Islander” to Question 6a, ask Question 6g for that person.

  • Otherwise, SKIP to 6g_SKIP.

6g. You may choose one or more Pacific Islander groups. Are you/Is <NAME> Native Hawaiian, Samoan, Chamorro, or of some other Pacific Islander origin?


  • If Native Hawaiian, Samoan, or Chamorro, check the appropriate box.


  • If response is “Other Pacific Islander,” ask Question 6h. Otherwise, check appropriate box and move to next person.


6h. What is that origin or origins? For example, Tongan, Fijian, Marshallese, etc.?


  • Enter the group(s) provided in the corresponding Other Pacific Islander write-in space in this row.

Householder:





Native Hawaiian


Samoan


Chamorro


Other Pacific Islander:


__________________

Person 2:

_________________



Native Hawaiian


Samoan


Chamorro


Other Pacific Islander:


__________________

Person 3:

_________________



Native Hawaiian


Samoan


Chamorro


Other Pacific Islander:


__________________

Person 4:

_________________



Native Hawaiian


Samoan


Chamorro


Other Pacific Islander:


__________________

Person 5:

__________________



Native Hawaiian


Samoan


Chamorro


Other Pacific Islander:


__________________

Person 6:

_________________



Native Hawaiian


Samoan


Chamorro


Other Pacific Islander:


__________________

6h_SKIP

  • If person has a response of “Some Other Race” to Question 6a, ask Question 6i for that person.

  • Otherwise, SKIP to 6i_SKIP.

6i. What is your/<NAME’s> other race or origin?


  • Enter the group(s) provided by the respondent in the corresponding write-in box in this row.













6i_SKIP

  • After asking race questions for all persons on roster, continue with detailed person questions.


I will now be asking a series of questions about you/<NAME>.

The next few questions deal with your/<NAME’s> place of birth and citizenship.


7. Where were you/was <NAME> born?


In the United States

Outside the United States


  • If person was born in the United States, ask: In what state were you born?

  • Enter the abbreviation for the person’s state of birth

  • If U.S. but state unknown, enter US


In the United States

State:
________________

Outside the United States

In the United States

State:
________________

Outside the United States

In the United States

State:
________________

Outside the United States

In the United States

State:
________________

Outside the United States

In the United States

State:
________________

Outside the United States

In the United States

State:
________________

Outside the United States

7_SKIP

  • If person was born in the United States, SKIP to Question 13a.

  • Otherwise, go to Question 8.


8. In what country were you/was <NAME> born?

Country:

________________

Country:

________________

Country:

________________

Country:

________________

Country:

________________

Country:

________________

9. Are you/Is <NAME> a citizen of the United States?


Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

9_SKIP

  • If response is “Yes,” go to Question 10.

  • If response is “No,” SKIP to Question 12.

10. Were you/Was <NAME> born abroad of U.S. citizen parent or parents, or did you/<NAME> become a citizen by naturalization?


Born abroad of U.S. citizen parent or parents

Citizen by naturalization

Born abroad of U.S. citizen parent or parents

Citizen by naturalization

Born abroad of U.S. citizen parent or parents

Citizen by naturalization

Born abroad of U.S. citizen parent or parents

Citizen by naturalization

Born abroad of U.S. citizen parent or parents

Citizen by naturalization

Born abroad of U.S. citizen parent or parents

Citizen by naturalization

Born abroad of U.S. citizen parent or parents

Citizen by naturalization

11. In what year did you/<NAME> become a naturalized citizen of the United States?













12. When did you/<NAME> come to live in the United States? If you/<NAME> came to live in the United States more than once, give the latest year.













The next questions are about schooling and education.


13a. At any time IN THE LAST 3 MONTHS, have you/has <NAME> attended school or college? Include only nursery or preschool, kindergarten, elementary school, home school, and schooling that leads to a high school diploma or a college degree.


Yes

No


Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

13a_SKIP

  • If response is “Yes,” go to Question 13b.

  • If response is “No,” SKIP to Question 14.


13b. Was that a public school or college, a private school or college, or home

school?


Public school or college

Private school or college or home school

Public school or college

Private school or college or home school

Public school or college

Private school or college or home school

Public school or college

Private school or college or home school

Public school or college

Private school or college or home school

Public school or college

Private school or college or home school

Public school or college

Private school or college or home school

13c. What grade or level were you/was <NAME> attending?


Nursery school or preschool

Kindergarten

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12

College undergraduate years, that is a college freshman to senior

Graduate or professional school beyond a bachelor's degree, for example a Master's or PhD program or medical or law school


Nursery school or preschool

Kindergarten

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12

College undergraduate years, that is a college freshman to senior

Graduate or professional school beyond a bachelor's degree, for example a Master's or PhD program or medical or law school


Nursery school or preschool

Kindergarten

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12

College undergraduate years, that is a college freshman to senior

Graduate or professional school beyond a bachelor's degree, for example a Master's or PhD program or medical or law school

Nursery school or preschool

Kindergarten

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12

College undergraduate years, that is a college freshman to senior

Graduate or professional school beyond a bachelor's degree, for example a Master's or PhD program or medical or law school

Nursery school or preschool

Kindergarten

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12

College undergraduate years, that is a college freshman to senior

Graduate or professional school beyond a bachelor's degree, for example a Master's or PhD program or medical or law school

Nursery school or preschool

Kindergarten

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12

College undergraduate years, that is a college freshman to senior

Graduate or professional school beyond a bachelor's degree, for example a Master's or PhD program or medical or law school

Nursery school or preschool

Kindergarten

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12

College undergraduate years, that is a college freshman to senior

Graduate or professional school beyond a bachelor's degree, for example a Master's or PhD program or medical or law school


  • Complete Question 14 for each person before moving on to the next question.

  • Use flashcard for highest grade of school or degree completed.


14. Using this list, what is the highest grade of school or degree you have/<NAME> has COMPLETED? If you are/<NAME> is currently enrolled, select the previous grade or highest degree received.


Less than grade 1

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12, no diploma

Regular high school diploma

GED or alternative credential

Some college, no degree

Associate’s degree (for example: AA, AS)

Bachelor’s degree (for example: BA, BS)

Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)

Professional degree beyond a bachelor’s degree (for example: MD, DDS, DVM, LLB, JD)

Doctorate degree (for example: PhD, EdD)


  • Do not read “Vocational and technical license.”


Less than grade 1

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

 Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12, no diploma

Regular high school diploma

GED or alternative credential

Some college, no degree

Associate’s degree

Bachelor’s degree

Master’s degree

Professional degree beyond a bachelor’s degree

Doctorate degree

Vocational and technical license

Less than grade 1

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

 Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12, no diploma

Regular high school diploma

GED or alternative credential

Some college, no degree

Associate’s degree

Bachelor’s degree

Master’s degree

Professional degree beyond a bachelor’s degree

Doctorate degree

Vocational and technical license

Less than grade 1

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

 Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12, no diploma

Regular high school diploma

GED or alternative credential

Some college, no degree

Associate’s degree

Bachelor’s degree

Master’s degree

Professional degree beyond a bachelor’s degree

Doctorate degree

Vocational and technical license

Less than grade 1

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

 Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12, no diploma

Regular high school diploma

GED or alternative credential

Some college, no degree

Associate’s degree

Bachelor’s degree

Master’s degree

Professional degree beyond a bachelor’s degree

Doctorate degree

Vocational and technical license

Less than grade 1

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

 Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12, no diploma

Regular high school diploma

GED or alternative credential

Some college, no degree

Associate’s degree

Bachelor’s degree

Master’s degree

Professional degree beyond a bachelor’s degree

Doctorate degree

Vocational and technical license

Less than grade 1

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

 Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12, no diploma

Regular high school diploma

GED or alternative credential

Some college, no degree

Associate’s degree

Bachelor’s degree

Master’s degree

Professional degree beyond a bachelor’s degree

Doctorate degree

Vocational and technical license

14­_SKIP

  • If response to Question 14 ranges from “Less than grade 1” to “Grade 10” or is “Associate’s degree,” SKIP to Question 20.

  • If response to Question 13a is “No” and response to Question 14 is “Grade 11,” SKIP to Question 16.

  • If response to Question 13a is “Yes” and response to Question 14 is “Grade 11,” SKIP to Question 20.

  • If response to Question 14 is “Grade 12, no diploma” or “Regular high school diploma,” SKIP to Question 16.

  • If response to Question 14 is “GED or alternative credential,” SKIP to Question 17.

  • If response to Question 14 is “Some college credit, no degree,” SKIP to Question 18.

  • If response to Question 14 ranges from “Bachelor’s degree” to “Doctorate degree,” SKIP to Question 19.

  • If response to Question 14 is “Vocational or technical license,” go to Question 15.

15. Other than the vocational or technical license, what is the highest grade of school or degree you have/<NAME> has completed?

Less than grade 1

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

 Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12, no diploma

Regular high school diploma

GED or alternative credential

Some college credit, no degree

Associate’s degree

Bachelor’s degree

Master’s degree

Professional degree beyond a bachelor’s degree

Doctorate degree


Less than grade 1

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

 Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12, no diploma

Regular high school diploma

GED or alternative credential

Some college credit, no degree

Associate’s degree

Bachelor’s degree

Master’s degree

Professional degree beyond a bachelor’s degree

Doctorate degree


Less than grade 1

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

 Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12, no diploma

Regular high school diploma

GED or alternative credential

Some college credit, no degree

Associate’s degree

Bachelor’s degree

Master’s degree

Professional degree beyond a bachelor’s degree

Doctorate degree


Less than grade 1

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

 Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12, no diploma

Regular high school diploma

GED or alternative credential

Some college credit, no degree

Associate’s degree

Bachelor’s degree

Master’s degree

Professional degree beyond a bachelor’s degree

Doctorate degree


Less than grade 1

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

 Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12, no diploma

Regular high school diploma

GED or alternative credential

Some college credit, no degree

Associate’s degree

Bachelor’s degree

Master’s degree

Professional degree beyond a bachelor’s degree

Doctorate degree


Less than grade 1

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

 Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12, no diploma

Regular high school diploma

GED or alternative credential

Some college credit, no degree

Associate’s degree

Bachelor’s degree

Master’s degree

Professional degree beyond a bachelor’s degree

Doctorate degree


15_SKIP

  • If response to Question 15 ranges from “Less than grade 1” to “Grade 10” or is “Associate’s degree,” SKIP to Question 20.

  • If response to Question 13a is “No” and response to Question 15 is “Grade 11,” go to Question 16.

  • If response to Question 13a is “Yes” and response to Question 15 is “Grade 11,” SKIP to Question 20.

  • If response to Question 14 is “Grade 12, no diploma” or “Regular high school diploma,” go to Question 16.

  • If response to Question 14 is “GED or alternative credential,” SKIP to Question 17.

  • If response to Question 14 is “Some college credit, no degree,” SKIP to Question 18.

  • If response to Question 14 ranges from “Bachelor’s degree” to “Doctorate degree,” SKIP to Question 19.


16. Did you/<NAME> receive a high school diploma, a GED or alternative credential?


Regular high school diploma

GED or alternative credential

No diploma or GED


Regular high school diploma

GED or alternative credential

No diploma or GED


Regular high school diploma

GED or alternative credential

No diploma or GED


Regular high school diploma

GED or alternative credential

No diploma or GED


Regular high school diploma

GED or alternative credential

No diploma or GED


Regular high school diploma

GED or alternative credential

No diploma or GED


16_SKIP

  • If response is “No diploma or GED,” SKIP to Question 20.

  • Otherwise, go to Question 17.

17. Did you/<NAME> complete any college credit?


Yes

No

Yes

No


Yes

No


Yes

No


Yes

No


Yes

No


Yes

No


17_SKIP

  • If response is “No,” SKIP to Question 20.

  • Otherwise, go to Question 18.

18. Did you/<NAME> complete 1 or more years of college credit?


Yes

No

Yes

No


Yes

No


Yes

No


Yes

No


Yes

No


Yes

No


18_SKIP

  • If Question 18 was asked, SKIP to Question 20.

19. This question focuses on your/<NAME’s> BACHELOR’S DEGREE. What was the specific major or majors of any BACHELOR’S DEGREES you have/<NAME> has received? For example, chemical engineering, elementary teacher education or organizational psychology.


  • If this person has more than one major or Bachelor's degree, ask for all major fields. Separate with commas.




















20. What is your/<NAME’s> ancestry or ethnic origin?


(For example: Italian, Jamaican, African-American, Cambodian, Cape Verdean, Norwegian, Dominican, French Canadian, Haitian, Korean, Lebanese, Polish, Nigerian, Mexican, Taiwanese, Ukrainian and so on.)
































21a. Do you/Does <NAME> speak a language other than English at home?


Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

21a_SKIP

  • If response is “No,” SKIP to Question 22a for that person.

  • Otherwise, go to Question 21b for that person

21b. What is this language?


(For example: Korean, Italian, Spanish, Vietnamese)













21c. How well do you/does <NAME> speak English-


Very well,

Well,

Not well,

or Not at all?

Very well

Well

Not well

Not at all

Very well

Well

Not well

Not at all

Very well

Well

Not well

Not at all

Very well

Well

Not well

Not at all

Very well

Well

Not well

Not at all

Very well

Well

Not well

Not at all

22a. Did you/<NAME> live in this <FILL BUILDING TYPE> 1 year ago?


Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

22a_SKIP

  • If response is “Yes,” SKIP to Question 23a.

  • Otherwise, go to Question 22b.


22b. Did you/<NAME> live in-


the United States,

Puerto Rico,

or another country?


United States

Puerto Rico

Another country

United States

Puerto Rico

Another country

United States

Puerto Rico

Another country

United States

Puerto Rico

Another country

United States

Puerto Rico

Another country

United States

Puerto Rico

Another country

22b_SKIP

  • If response is “United States” or “Puerto Rico,” SKIP to Question 22d.

  • Otherwise, go to Question 22c.

22c. What was the foreign country?

Foreign Country:

_______________

Foreign Country:

_______________

Foreign Country:

_______________

Foreign Country:

_______________

Foreign Country:

_______________

Foreign Country:

_______________

22c_SKIP

  • If response is “Puerto Rico,” go to Question 22d.

  • Otherwise, SKIP to Question 23a.

22d. What was the street address?


Last Street Address:

_____________________________________________

Last Street Address:

_____________________________________________

Last Street Address:

_____________________________________________

Last Street Address:

_____________________________________________

Last Street Address:

_____________________________________________

Last Street Address:

_____________________________________________

22e. What was the city or town?

Last City Address:

______________________________

Last City Address:

______________________________

Last City Address:

______________________________

Last City Address:

______________________________

Last City Address:

______________________________

Last City Address:

______________________________

22f. What was the county/<FILL “municipio” IF PUERTO RICO>?

Last County:

______________________________

Last County:

______________________________

Last County:

______________________________

Last County:

______________________________

Last County:

______________________________

Last County:

______________________________

22f_SKIP

  • If person lived in Puerto Rico, SKIP to Question 22h.

  • Otherwise, go to Question 22g.


22g. What was the state?


  • Enter the state abbreviation.

Last State:

_______________

Last State:

_______________

Last State:

_______________

Last State:

_______________

Last State:

_______________

Last State:

_______________

22h. What was the ZIP Code?

Last Zip Code:

_______________

Last Zip Code:

_______________

Last Zip Code:

_______________

Last Zip Code:

_______________

Last Zip Code:

_______________

Last Zip Code:

_______________


  • Complete Questions 23a – 24b for each person before moving on to the next person.


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


23a. Are you/Is <NAME> currently covered by health insurance through a current or former employer, union, or professional association of yours or another family member/<[him/her] or another family member>?


Yes

No


Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

23b. Are you/Is <NAME> currently covered by Medicare, for people age 65 or older or people with certain disabilities?


Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

23c. Are you/Is <NAME> currently covered by Medicaid, the Children’s Health Insurance Program (CHIP) or any kind of government-assistance plan for those with low incomes or a disability?


Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

23d. Are you/Is <NAME> currently covered by health insurance purchased directly from an insurance company, through a State or Federal Marketplace, HealthCare.gov, or a similar website by you or another family member/<[him/her] or another family member>?


Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No


23e. Are you/Is <NAME> currently covered by TRICARE or other military health care?


Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

23f. Are you/Is <NAME> currently covered through the VA or enrolled for VA health care?


Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

23g. Are you/Is <NAME> currently covered through the Indian Health Service?


Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

23h. Are you/Is <NAME> currently covered by any other health insurance or health coverage plan?


Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

23h_SKIP

  • If response was not “Yes” to any questions 23a through 23h, SKIP to Question 25a.

  • Otherwise, go to Question 24a.

24a. 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

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

24a_SKIP

  • If response is “No,” SKIP to Question 25a.

  • Otherwise, go to Question 24b.



24b. Do you/does<NAME> or another family member receive a tax credit or subsidy based on family income to help pay the premium?


Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

  • Complete all parts of Questions 25 (A-B), 26 (A-D), and 27 for each person before moving on to the next person.


The next questions ask about difficulties you/<NAME> may have doing certain activities.


25a. Do you/does <NAME> have difficulty seeing, even if wearing glasses?


No difficulty

Some difficulty

A lot of difficulty

Cannot do at all


No difficulty

Some difficulty

A lot of difficulty

Cannot do at all


No difficulty

Some difficulty

A lot of difficulty

Cannot do at all


No difficulty

Some difficulty

A lot of difficulty

Cannot do at all


No difficulty

Some difficulty

A lot of difficulty

Cannot do at all


No difficulty

Some difficulty

A lot of difficulty

Cannot do at all


No difficulty

Some difficulty

A lot of difficulty

Cannot do at all


25b. Do you/does <NAME> have difficulty hearing, even if using a hearing aid?


No difficulty

Some difficulty

A lot of difficulty

Cannot do at all


No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

25b_SKIP

  • If person is at least 5 years old, ask Questions 26a through 26d for that person.

  • Otherwise, the interview is closed.

26a. Do you/does <NAME> have difficulty walking or climbing stairs?


No difficulty

Some difficulty

A lot of difficulty

Cannot do at all


No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

26b. Do you/does <NAME> have difficulty remembering or concentrating?


No difficulty

Some difficulty

A lot of difficulty

Cannot do at all


No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

26c. Do you/does <NAME> have difficulty bathing or dressing?


No difficulty

Some difficulty

A lot of difficulty

Cannot do at all


No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

26d. Using your/<his/her> usual language, do you/does <NAME> have difficulty communicating, for example understanding or being understood?


No difficulty

Some difficulty

A lot of difficulty

Cannot do at all


No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

26d_SKIP

  • If person is at least 15 years old, ask Question 27 for that person.

  • Otherwise, move onto the next person.


27. Do you/does <NAME> have difficulty doing errands alone such as visiting a doctor’s office or shopping?


No difficulty

Some difficulty

A lot of difficulty

Cannot do at all


No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

28. I will now be asking about your/<NAME’s> marital status.


Are you/Is <NAME>-


Married,

Widowed,

Divorced,

Separated,

or Never married?


Married

Widowed

Divorced

Separated

Never married

Married

Widowed

Divorced

Separated

Never married

Married

Widowed

Divorced

Separated

Never married

Married

Widowed

Divorced

Separated

Never married

Married

Widowed

Divorced

Separated

Never married

Married

Widowed

Divorced

Separated

Never married


7


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AuthorCensus
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File Created2021-01-14

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