2022 ACS content testing – cognitive interviewing screener
Web/Phone Survey Screener Specification 1
Module 1: Key eligibility screener 4
Q3. Federal employment status 4
Module 2: Demographic characteristics 5
Q5. Hispanic/Latino ethnicity 5
Q10.1 Spanish speaking proficiency 6
Q10.2 Spanish reading proficiency 7
Q10.3 Spanish/English preference 7
Module 3: Household roster screening 8
Q15. Number of children in household 9
Q18. Children’s relationship 10
Q20. Children living away at college 10
Q21. Children being homeschooled 10
Q23. Number of young children in household 11
Q24. Parent/guardian of children age 3-5 11
Q25. Active duty military member in household 11
Module 4: Home characteristics 12
Module 5: Car purchase and commute 14
Q31 Vehicle purchase in the last 10 years 14
Q35. Commute – purpose of rideshare 14
Module 6: Health insurance and welfare 16
Q37. Health insurance coverage 16
Q38. Type of health insurance 16
Q39. Health insurance coverage for children 16
Q41. Children with disability 17
Module 7: Employment and Income 18
Q54. Prior research experience 21
RTI International is conducting research on behalf of the U.S. Census Bureau to improve questions in one of its national surveys. The purpose of this research is to get feedback on how easy or difficult the survey questions are to answer. Selected participants will be asked for their thoughts and opinions about some survey questions. If you are eligible, we will invite you to a 60-minute interview which will be conducted at a location convenient to you, such as our RTI office or in a public library near your work or residence. [Placeholder: We can also conduct the interview via a secure video conference app if needed.] You will receive $40 for participating in the interview.
To determine if you are eligible for the interview, we must ask you a few screening questions about your background and your household. Your participation in the eligibility screening is completely voluntary. You may stop at any time or skip questions that you do not want to answer.
The U.S. Census Bureau is required by law to protect your information. RTI International and Research Support Services are conducting this voluntary survey for the U.S. Census Bureau under the authority of Title 13 U.S. Code, Sections 131 and 182. Federal law requires that your answers are kept confidential (Title 13, U.S. Code, Section 9), and protects your privacy under the Privacy Act (Title 5 U.S. Code, Section 552a). Routine uses of these data are limited to those identified in the Privacy Act System of Record Notice titled “COMMERCE/CENSUS-10, American Community Survey.” The Census Bureau can use your responses only to produce statistics, and is not permitted to publicly release your responses in a way that could identify you, your business, organization, or institution.
We estimate that completing these screening questions will take 17 minutes on average. This information collection has been approved by the Office of Management and Budget (OMB). You can validate that this survey is a legitimate federally approved information collection using the Office of Management and Budget's approval number 0607-0725, which expires December 31, 2022. We are required to tell you this number to conduct this survey. Send comments regarding this estimate or any other aspect of this survey, including suggestions for reducing the time it takes to complete this survey to [email protected].
If you have questions about the research, contact [NAME] at RTI International via email at [email] or [phone].
If you are eligible for the study, we will call or email you to schedule a time for the interview.
Consent to Participate
Do we have your permission to ask you a few questions to find out if you are eligible for this study?
If you agree to participate, please click “Yes, I agree” below and then the “NEXT” button to continue. If you choose not to participate, please click “Exit” and then the “NEXT” button to exit the survey.
1 Yes, I agree [Skip to Q1]
2 Exit [Skip to REFUSAL]
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Hello, I’m [______________] from the [RTI International/Research Support Service]. Thank you for contacting us about participating in one of our studies.
We are conducting research on behalf of the U.S. Census Bureau to improve questions in one of its national surveys. The purpose of this research is to get feedback on how easy or difficult the survey questions are to answer. Selected participants will be asked for their thoughts and opinions about some survey questions. If you are eligible, we will invite you to a 60-minute interview which will be conducted at a location convenient to you, such as our RTI office or in a public library near your work or residence. [Placeholder: We can also conduct the interview via video conference if meeting online is most convenient for you.] You will receive $40 for participating in the interview.
To determine if you are eligible for the interview, I will ask you a few screening questions about your background and your household. Your participation in the eligibility screening is completely voluntary. You may stop at any time or skip questions that you do not want to answer.
The U.S. Census Bureau is required by law to protect your information. RTI International and Research Support Services are conducting this voluntary survey for the U.S. Census Bureau under the authority of Title 13 U.S. Code, Sections 131 and 182. Federal law requires that your answers are kept confidential (Title 13, U.S. Code, Section 9), and protects your privacy under the Privacy Act (Title 5 U.S. Code, Section 552a). Routine uses of these data are limited to those identified in the Privacy Act System of Record Notice titled “COMMERCE/CENSUS-10, American Community Survey.” The Census Bureau can use your responses only to produce statistics, and is not permitted to publicly release your responses in a way that could identify you, your business, organization, or institution.
We estimate that completing these screening questions will take 17 minutes on average. This information collection has been approved by the Office of Management and Budget (OMB). You can validate that this survey is a legitimate federally-approved information collection using the Office of Management and Budget's approval number 0607-0725, which expires December 31, 2022. We are required to tell you this number to conduct this survey. Send comments regarding this estimate or any other aspect of this survey, including suggestions for reducing the time it takes to complete this survey to [email protected].
Do you agree to continue?
1 Yes
2 No
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In what city, state, and ZIP code do you currently live?
City: [______]
State: [______]
ZIP code [______]
[PROGRAMMER: CITY − TEXTBOX with 50 characters Max.; State – DROPDOWN; ZIP code − 5 digits NUMERIC ENTRY ONLY]
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How old are you?
[______] [If Q2<18, skip to INELIGIBLE]
[PROGRAMMER: NUMERIC ENTRY ONLY; RANGE = (6-110)]
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Are you employed by the Federal Government? (if federal contractor, mark NO)
1 Yes [skip to INELIGIBLE]
2 No
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Are you male or female?
1 Male
2 Female
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[Wording for Web programming only]
Are you of Hispanic, Latino, or Spanish origin?
1 No, not of Hispanic, Latino, or Spanish origin
2 Yes, Mexican, Mexican Am., Chicano
2 Yes, Puerto Rican
2 Yes, Cuban
2
Yes, another Hispanic, Latino, or Spanish origin – Enter
origin, for example, Salvadoran, Dominican, Colombian, Guatemalan,
Spaniard, Ecuadorian, and so on:
_______________
Are you of Hispanic, Latino, or Spanish origin?
1 No
2 Yes
[IF Q5=2] Are you Mexican, Mexican American, or Chicano; Puerto Rican; Cuban; or of another Hispanic, Latino, or Spanish origin; for example, Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian, and so on?
1 Mexican, Mexican Am., Chicano
2 Puerto Rican
3 Cuban
4 Another Hispanic, Latino, or Spanish origin
[IF Q5A=4] What is that origin? (For example, Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian, and so on?)
______________
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What is your race? [Wording for Web programming only: Please select all that apply.]
[Phone prompt: “You can indicate more than one race.” Record respondent’s response. ]
1 White
2 Black or African American
3 American Indian or Alaska Native
4 Asian
5 Native Hawaiian or other Pacific Islander
6 Other – please specify
[PROGRAMMER: WHEN 6 (“Other”) IS SELECTED, DISPLAY “please specify” TEXTBOX.]
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What is the highest grade of school you have completed, or the highest degree you have received?
[Phone prompt: (do not read options to respondent)]
1 Less than high school diploma or equivalent
2 GED or ABE certificate
3 High school diploma
4 Some college, no degree
5 Associate’s degree (AA, AS, or equivalent)
6 Bachelor’s degree (BA, BS, or equivalent)
7 Post Bachelor’s degree (MA, MS, PhD, JD, MD, etc.)
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How well do you speak English?
[Phone prompt: “is it ‘very well,’ ‘well,’ ‘not very well,’ or you don’t speak English at all?”]
1 Very well
2 Well
3 Not well
4 Not at all
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Do you speak a language other than English at home?
1 Yes [ask Q9.2]
2 No [skip to Q11]
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NOTE TO OMB: Q9.1−Q9.2 will not be included in the Spanish translation of the screener. Q10.1-Q10.3 will be included in the Spanish translation of this screener only. They will not be used in the English screener.
[IF Q9.1=1] What language or languages do you speak at home? [Wording for Web programming only: Please select all that apply.]
[Phone prompt: (do not read options to respondents, prompt only when necessary.)]
1 Spanish
2 Chinese
3 Korean
4 Vietnamese
5 Arabic
6 Russian
7 Other – please specify
[PROGRAMMER: WHEN 7 (“Other”) IS SELECTED, DISPLAY “please specify” TEXTBOX.]
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How well do you speak Spanish?
[Phone prompt: “is it ‘very well,’ ‘well,’ ‘not very well,’ or you don’t speak Spanish at all?”]
1 Very well
2 Well
3 Not well
4 Not at all
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How well do you read Spanish?
[Phone prompt: “is it ‘very well,’ ‘well,’ ‘not very well,’ or you don’t speak Spanish at all?”]
1 Very well
2 Well
3 Not well
4 Not at all
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If you complete a form or a survey, do you prefer to complete it in Spanish or in English?
1 Spanish
2 English
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What is your current marital or relationship status?
[Phone prompt: (do not read options to respondents.) Prompt respondents “Are you currently in a relationship?” only when they answer “single.”]
1 Married
2 Single and in a relationship
3 Single and not in a relationship
4 Separated
5 Divorced
6 Widowed
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Does anyone live or stay with you at your current address?
[Phone prompt: “Also include people who only sometimes live or stay with you.”]
1 Yes [ask Q13]
2 No [skip to Q20]
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[Ask if Q12 = Yes] Who lives or stays with you? [Wording for Web programming only: Please select all that apply.
[Phone prompt: (do not read the response to respondents. Record responses and prompt options if necessary)]
1 Parent(s)
2 Grandparent(s)
3 Husband/wife/spouse
4 Unmarried partner
5 Children
6 Grandchildren
7 Other relatives(s)
8 Roommates
9 Friends
10 Other – please specify
[PROGRAMMER: WHEN 10 (“Other”) IS SELECTED, DISPLAY “please specify” TEXTBOX.]
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How many people age 18 or older currently live or stay at your address, INCLUDING yourself?
[______]
[PROGRAMMER: NUMERIC ENTRY ONLY; RANGE = (0-19)]
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How many people younger than 18 currently live or stay at your address?
[______]
[PROGRAMMER: NUMERIC ENTRY ONLY; RANGE = (0-19)]
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Are all of the people who live with you part of a single family?
1 Yes
2 No
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[Ask if Q13 = 5, 6, 8, 9, 10] Are the [Q13] living or staying with you part of your extended family (such as your uncles, aunts, cousins, nieces, nephews, or in-laws)?
1 Yes
2 No
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[Ask if Q15>0] What is your relationship to the children living or staying with you? [Wording for Web programming only: Please select all that apply.]
[phone prompt: record responses and prompt respondents “Anyone else?” at the end. Prompt options if necessary]
1 your biological children
2 your adopted children
3 your foster children
4 your grandchildren
5 related to you in some other way
6 not related to you
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[Ask if Q18 in (1:5)] Do any of the children living with you sometimes live or stay somewhere else due to a custody arrangement?
1 Yes
2 No
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Do you have any children currently living away at college or children who would be living away at college if the college were not closed due to the coronavirus (COVID-19) pandemic?
1 Yes [skip to Q25 if Q12=2]
2 No [skip to Q25 if Q12=2]
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[Ask if Q15>0] Are any children living or staying with you homeschooled? Do not include children temporarily being schooled at home due to the coronavirus (COVID-19) pandemic.
1 Yes
2 No
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[Ask if Q15>0] Are any of the children living or staying with you attending nursery school, preschool, kindergarten, or grades 1 − 12? Include children temporarily being schooled at home due to the coronavirus (COVID-19) pandemic.
1 Yes
2 No
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[Ask if Q15=1] Is the child living or staying at your address 5 years old or younger?
[Ask if Q15>1] Among the [Q15] children living or staying at your address, how many of them are 5 years old or younger?
[______]
[PROGRAMMER: NUMERIC ENTRY ONLY; RANGE = (0-Q15)]
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[Ask if Q18 in 3:6 & Q23>0] Are you the parent or legal guardian of the young child [if Q23=1]/ children [if Q23>1] living or staying with you?
1 Yes
2 No
[Ask if Q23>0 & (Q18 in 1:2 or Q24=1)] Is the child [if Q23=1] /Are the children [if Q23>1] between 3 and 5 years old?
1 Yes
2 No
[PROGRAMMER: variable name: Q24_1; question hidden on the same page]
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Are you, or is anyone who usually lives or stays with you, currently deployed in the United States Armed Forces?
1 Yes
2 No
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Is your home owned or rented?
1 Owned
2 Rented
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What type of home do you live in?
1 House or townhouse
2 Apartment or condo
3 Mobile home
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[Ask if Q26=1] Do you pay a homeowner’s association fee or condo fee?
1 Yes
2 No
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[Ask if Q26=1] Are you part of a voluntary neighborhood association?
1 Yes
2 No
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Does your home use…
|
Yes |
No |
a. a sump pump? |
1 |
2 |
b. a water softener? |
1 |
2 |
c. a septic system? |
1 |
2 |
d. a wood or pellet stove? |
1 |
2 |
e. solar panels? |
1 |
2 |
f. natural gas to heat your home? |
1 |
2 |
g. butane/propane to heat your home? |
1 |
2 |
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Have you purchased or leased any kind of car in the last 10 years?
1 Yes
2 No
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Do you or any member of your household drive an electric or hybrid car?
1 Yes
2 No
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[Ask if Q32=1] Is it an electric vehicle, or a hybrid vehicle?
1 Electric vehicle
2 Hybrid vehicle
3 Don’t know
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Have you ever used a ride-share or ride-hailing service (such as Lyft or Uber)?
1 Yes [ask Q35]
2 No [skip to Q36]
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[Ask if Q34=1] For what situations have you used ride-sharing services? Please select all that apply.
1 Run errands
2 Get to/from work
3 Go out with friends
4 Go to/from airport or train station for travel
5 Other – please specify
[PROGRAMMER: WHEN 5 (“Other”) IS SELECTED, DISPLAY “please specify” TEXTBOX.]
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Your response to this next question may be affected by the coronavirus (COVID-19) pandemic. Please answer about your typical situation, before the coronavirus pandemic. Do you carpool to work at least some days?
1 Yes
2 No
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Do you currently have health insurance?
1 Yes
2 No, I don’t have any health insurance
3 Don’t know
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[Ask if Q37=1] What type of health insurance? [Wording for Web programming only: Please select all that apply.]
[Phone prompt: record responses and prompt options if necessary]
1 Insurance coverage through an employer, school, or other group-based program (through you or another family member)
2 Medicare for people 65 and over
3 Medicaid, or any other type of government-assistance plan for people with low income or disability.
4 Coverage purchased through healthcare.gov or another marketplace associated with the Affordable Care Act (also known as Obamacare)
5 Other type of insurance – please specify
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[Ask if Q15>0] Do any children in your household have health insurance coverage different from your own?
1 Yes – please specify the type(s) of coverage these children have
2 No.
[PROGRAMMER: IF 1 (“Yes”) IS SELECTED, DISPLAY “Please specify” TEXTBOX.]
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Do you have any difficulty seeing, hearing, walking, remembering, or communicating with others?
1 Yes
2 No
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[Ask if Q15 >0] Are there any children living or staying with you who have a physical, mental, or emotional condition that limits their ordinary activities?
[Phone prompt, if needed: Ordinary activities include seeing, hearing, walking, remembering, or communicating with others.]
1 Yes
2 No
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In the past year, which of the following did you or someone in your household receive benefits from? [Wording for Web programming only: Please select all that apply.]
[Phone prompt: read the options to respondents and record responses]
1 Food Stamp Program
2 Supplement Nutrition Assistance Program (SNAP)
3 WIC
4 School Lunch Program
5 Other public assistance – please specify
6 Did not receive any of the benefits above
[PROGRAMMER: IF 5 (“Other”) IS SELECTED, DISPLAY “Please specify” TEXTBOX.]
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Did you work for pay at any time last year, that is since [MONTH CALENDAR YEAR-1]?
1 Yes
2 No
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[Ask if Q43=YES] Did you have any periods of unemployment during the year or did you work for pay the whole year?
1 I worked for pay the whole year
2 I was unemployed for some time during the year
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[Ask if Q43=YES] Did you work at one job, or more than one job?
1 I worked at one job
2 I worked at more than one job
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[Ask if Q43=YES] Your response to this next question may be affected by the coronavirus (COVID-19) pandemic. Please answer about your typical situation, before the coronavirus pandemic. How many hours do you typically work each week?
1 20 hours or less
2 21 to 40 hours
3 41 to 60 hours
4 More than 60 hours
5 Varies week to week
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In the past year, have you received income from the following sources? [Wording for Web programming only: Please select all that apply.]
[Phone prompt: record responses and prompt options if necessary]
1 Retirement income
2 Rental income
3 Commission
4 Bonus
5 Tips
6 Unemployment benefits
7 TANF or other public assistance benefits
8 None of the above
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What is your household’s annual income? Your best guess is fine.
[Phone prompt: Is it…read options until interrupted]
1 Less than $15,000
2 $15,000 to $25,000
3 $25,000 to $50,000
4 $50,000 to $100,000
5 More than $100,000
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Finally, we just have a few more questions about your contact information. If you are eligible and selected to participate in the study, we will use the information to contact you to schedule an interview.
What is your name?
[Phone prompt: read if needed to assure respondents: “The information you provide will only be used to contact you for an interview”]
Name: [________________________]
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What is your email address?
[_________________________________________]
[PROGRAMMER: email verification]
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
What is the best telephone number to reach you?
Phone ([___]) [___] − [_______]
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What is the best time to reach you by phone?
[_________________________________________]
[PROGRAMMER: textbox character limit: 50, place on the same page with Q51]
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
Do you have a computer or tablet with a web camera?
1 Yes
2 No
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[Ask if Q53= YES] Would you be willing and able to download a video conferencing app to your computer or tablet to do the interview online?
1 Yes
2 No
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How did you hear about this study?
1 Community publication (for example, local paper)
2 Flyer
3 Friends or family
4 RTI or Census Bureau employee
5 Craigslist
6 Facebook
7 Reddit
8 Other – specify: _______________
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When did you last participate in a research study?
[______]
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Thank you for taking the time to answer our questions today. We will get back to you soon if you are eligible for an interview.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Weimer, Belinda |
| File Modified | 0000-00-00 |
| File Created | 2021-01-14 |