6 ACS English CAI Script Group 2 V2

CAI Script – Group 2 – Version 2 – 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 living or staying at this address, even if they are not related to you. 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 here.	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. 1b. Other than the people you have already mentioned, are there any children living or staying here, such as babies, grandchildren, or foster children? These children could be related or unrelated to you.	Additional Person 1: __________________	Additional Person 2: __________________	Additional Person 3: __________________	Additional Person 4: __________________	Additional Person 5: __________________	Additional Person 6: __________________
1c. Other than the people you have already mentioned, is there anyone else staying here, such as roommates and other people or families who have no other place to stay? Do not include overnight or weekend guests who have a residence somewhere else.	Additional Person 7: __________________	Additional Person 8: __________________	Additional Person 9: __________________	Additional Person 10: __________________	Additional Person 11: __________________	Additional Person 12: __________________
	No additional persons

Copy names from 1a, 1b, and 1c. I have listed… Read all names. 1d. Do any of these people live somewhere else, 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: children in shared custody who are not currently staying at the sample address, regardless of the length of stay; 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
	Additional Person 7: ________________ Yes No	Additional Person 8: ________________ Yes No	Additional Person 9: ________________ Yes No	Additional Person 10: ________________ Yes No	Additional Person 11: ________________ Yes No	Additional Person 12: ________________ Yes No

Copy names from 1a, 1b and 1c, but OMIT anyone with a “Yes” response to 1d. I have listed… Read all remaining names. 1e. Are any of these people staying here for a short time? MARK “No” for: children in shared custody who are currently staying at the sample address, regardless of where they usually stay; commuter workers who stay in some other residence closer to work when their family residence is the sample address. MARK “Yes” for: commuter workers who stay at the sample address to be closer to work; 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
	Additional Person 7: ________________ Yes No	Additional Person 8: ________________ Yes No	Additional Person 9: ________________ Yes No	Additional Person 10: ________________ Yes No	Additional Person 11: ________________ Yes No	Additional Person 12: ________________ Yes No

Copy names with a “Yes” response to 1e. I have listed… Read names with a “Yes” response to 1e. 1f. 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 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
	Additional Person 7: ________________ Yes No	Additional Person 8: ________________ Yes No	Additional Person 9: ________________ Yes No	Additional Person 10: ________________ Yes No	Additional Person 11: ________________ Yes No	Additional Person 12: ________________ Yes No
Generate the final roster using the first 1-6 names remaining in the order they were mentioned. - Copy names from 1a, 1b, and 1c. - OMIT anyone with a “Yes” response to 1d. - OMIT anyone with a “No” response to 1f.	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 level of school or degree completed. 14. Using this list, what is the highest level 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 1 year of school completed 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, 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 1 year of school completed 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, no diploma Regular high school diploma GED or alternative credential Some college, no degree 1 or more years of college credit, 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 1 year of school completed 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, no diploma Regular high school diploma GED or alternative credential Some college, no degree 1 or more years of college credit, 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 1 year of school completed 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, no diploma Regular high school diploma GED or alternative credential Some college, no degree 1 or more years of college credit, 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 1 year of school completed 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, no diploma Regular high school diploma GED or alternative credential Some college, no degree 1 or more years of college credit, 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 1 year of school completed 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, no diploma Regular high school diploma GED or alternative credential Some college, no degree 1 or more years of college credit, 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 1 year of school completed 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, no diploma Regular high school diploma GED or alternative credential Some college, no degree 1 or more years of college credit, 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 level of school or degree you have/<NAME> has COMPLETED?

Less than 1 year of school completed 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, no diploma Regular high school diploma GED or alternative credential Some college, no degree 1 or more years of college credit, no degree Associate’s degree Bachelor’s degree Master’s degree Professional degree beyond a bachelor’s degree Doctorate degree

Less than 1 year of school completed 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, no diploma Regular high school diploma GED or alternative credential Some college, no degree 1 or more years of college credit, no degree Associate’s degree Bachelor’s degree Master’s degree Professional degree beyond a bachelor’s degree Doctorate degree

Less than 1 year of school completed 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, no diploma Regular high school diploma GED or alternative credential Some college, no degree 1 or more years of college credit, no degree Associate’s degree Bachelor’s degree Master’s degree Professional degree beyond a bachelor’s degree Doctorate degree

Less than 1 year of school completed 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, no diploma Regular high school diploma GED or alternative credential Some college, no degree 1 or more years of college credit, no degree Associate’s degree Bachelor’s degree Master’s degree Professional degree beyond a bachelor’s degree Doctorate degree

Less than 1 year of school completed 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, no diploma Regular high school diploma GED or alternative credential Some college, no degree 1 or more years of college credit, no degree Associate’s degree Bachelor’s degree Master’s degree Professional degree beyond a bachelor’s degree Doctorate degree

Less than 1 year of school completed 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, no diploma Regular high school diploma GED or alternative credential Some college, no degree 1 or more years of 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 steps? 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 with self care, such as washing all over 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 on to next person.
27. Because of a physical, mental, or emotional condition, 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

10