Previously Approved Universal Screener w/ privacy language

US Census Bureau

Center for Behavioral Science Methodology (CBSM)

Telephone Screener

Fall, 2018

PART A: CBSM Universal Screener

Hello, I’m _____________ from the Census Bureau. Thank you for contacting us about participating in one of our studies.

I would like to first provide a statement about how the Census Bureau protects your privacy.

Privacy Act Statement

The U.S. Census Bureau is conducting this voluntary study on behalf of the U.S. Department of Housing and Urban Development (HUD) under the authority of 12 U.S.C. Section 1701z-1, 1701z-2(g), and 1701z-10a, and 13 U.S.C, Sections 8(b).

The purpose of collecting this information is to improve the questions that will be used in the American Housing Survey and inform future surveys.

Sharing of the information provided to us may be shared for the work-related purposes in this statement as identified in the Privacy Act System of Records Notice COMMERCE/Census -3, Demographic Survey Collection (Census Bureau Sampling Frame).

I just need to get a little bit of background information to start.

[Auto filled: ID Number]

[Auto filled: Last Contact Date]

[Auto filled: Eligible Date]

1. What is your name?

First name:_____________________

Last name:_____________________

2. What is your daytime telephone number? [Probe for all 3 phone numbers]

Mobile ([ ]) [ ] – [ ]

Home (if not mobile) ([ ]) [ ] – [ ]

Work (if any) ([ ]) [ ] – [ ] EXT.[ ]

3. In what city, state, and ZIP code do you currently live?

City:_____________________

State:_____________________

Zip code:__________________

4. Are you male or female?

• Male

• Female

5. In what year were you born?

6. Are you of Hispanic, Latino, or Spanish origin?

• Yes ( score 1 point)

• No

7. What is your race? Please select one or more. White, Black or African American, American Indian or Alaska Native, Asian, or Native Hawaiian or other Pacific Islander? (Allow up to 3 answers)

• White (if white NOT selected  score 1 point)

• Black or African American

• American Indian or Alaska Native

• Asian

• Native Hawaiian or other Pacific Islander

8. What is the highest grade of school you have completed, or the highest degree you have received?

(do not read categories to respondent)

• Less than high school

• Completed high school

• Some college, no degree

• Associate’s degree (AA/AS)

• Bachelor’s Degree (BA/BS)

• Post-Bachelor's degree  (For example MA, MS, Ph.D, JD, etc.)

9. Are you working for pay full-time, part-time, or are you not working for pay at this time?

• Full-time (ask follow-up questions a and b)

• Part-time (ask follow-up questions a and b)

• Not working for pay at this time (skip to next question)

a. What is your current job title or job description? [open text]

2. Are you employed by the Federal Government? (if federal contractor, mark NO)

• Yes

• No

10. How many people age 18 or older currently live in your household, INCLUDING yourself?

( score 1 point for each person)

11. How many people younger than 18 currently live in your household?

( score 1 point for each person)

12. Do you speak a language other than English at home?

• Yes (ask follow-up question) ( score 1 point)

• No (skip to next question)

1. What language or languages do you speak at home? Please select one or more.

[ ] Spanish

[ ] Chinese

[ ] Korean

[ ] Vietnamese

[ ] Arabic

[ ] Russian

[ ] Other - Specify

13. Do you own a cell phone?

• Yes (ask follow-up question)

• No (skip to next question)

1. Some cell phones are called “smartphones” because of certain features they have. Is your cell phone a smartphone, such as an iPhone, Android, Blackberry or Windows phone, or are you not sure?

2. What type of smartphone do you have?

14. Do you own a desktop or laptop computer, or both?

• Desktop computer

• Laptop computer

• Both desktop and laptop computer

• Neither

15. Do you own a tablet computer such as an iPad, Samsung Galaxy Tab, Google Nexus, or Kindle Fire?

• Yes

• No

16. Do you have at least one year of Internet experience?

• Yes (ask follow-up question)

• No (skip to next question)

1. How often do you use the Internet either on a computer or on a mobile device like a smartphone or tablet?...Several times a day, about once a day, a few times a week, a few times a month, or a few times a year?

• Several times a day

• About once a day

• A few times a week

• A few times a month

• A few times a year

• Not at all [do not read to respondent]

2. Name two things you do on the Internet besides e-mail.

Internet Activity #1:

• Research

• Social media/communication (Facebook, Twitter, Craigslist)

• Shopping

• Banking or paying bills online

• Music / movies / videos

• Gaming

• News

• Travel (directions/reservations)

• Employment

• Other

Internet Activity #2:

• Research

• Social media/communication (Facebook, Twitter, Craigslist)

• Shopping

• Banking or paying bills online

• Music / movies / videos

• Gaming

• News

• Travel (directions/reservations)

• Employment

• Other

17. How did you hear about this research opportunity?

• E-mail link

• Census Bureau employee

• Friend or family member (but not a Census Bureau employee)

• Facebook

• Craigslist

• Google advertisement

• Flyer

• Newspaper advertisement

• Other – specify

18. Have you participated in any research studies with the U.S. Census Bureau?

• Yes

• No

19. Would you be willing to come to our office in Suitland, Maryland, to participate in a research study?

• Yes

• No

20. What is the e-mail address we should use when sending directions to our office, should you qualify for a study?

21. Is your household’s annual income …

• Less than $15,000? ( score 1 point)

• $15,000 to $25,000? ( score 1 point)

• $25,000 to$50,000?

• $50,000 to $100,000?

• More than $100,000?

22. Are you a United States citizen? You do not have to be a U.S. citizen to participate in our studies.

• Yes

• No

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