Screener

Remote Cognitive Interview Participant Telephone Screener

2021 NSCH Content Testing

ID Number:

Contact Date:

Hello, I’m _____________ from the U.S. Census Bureau. Thank you for contacting us about participating in our research study for the National Survey of Children’s Health. In order to see whether or not you qualify for this study, I need to ask you a few questions.

1. What is your name?

First name:

Last name:

2. Do you have any children under the age of 18 living in your household?

• Yes

  • What are the first names and ages of these children? [Continue to Question 3]

Child 1:

Child 2:

Child 3:

Child 4:

Child 5:

Other children:

• No  We are looking for participants with children under the age of 18 living in their household.[Skip to Q18]

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

o Yes  Being a federal Employee does not disqualify you from participating, however, we will not be allowed to pay you a stipend for your participation. Are you interested in continuing with this eligibility screening?

o No

4. Have you participated in any other research studies in the past year with the U.S. Census Bureau?

   • Yes  [Skip to question 18]

   • No

5. This research study will take place remotely via video chat. You and the researcher will each be in your own homes and will use the Skype for Business application to talk and screen share. Do you have a laptop, tablet, or phone capable of using video chat applications?

• Yes

• No  [Skip to Question 18]

6. Are you willing and able to download and install Skype for Business prior to participating in this research study?

• Yes  Great, we will email you the instructions for downloading and installing the application. [Continue on to question 7]

• No  At this time we are only able to conduct this research through the Skype for Business application. [Skip to Q18]

Now I just need to get some background information.

7. What is your current age?

8. [Ask if not obvious] Are you male or female?

• Male

• Female

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

   • Yes

   • No

10. What is your race? Please select one or more of the following: White, Black or African American, American Indian or Alaska Native, Asian, or Native Hawaiian or other Pacific Islander?

• White

• Black or African American

• American Indian or Alaska Native

• Asian

• Native Hawaiian or other Pacific Islander

11. 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.)

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

City: State: Zip:

13. Have you or anyone in your household been tested for COVID-19, also known as the coronavirus?

• Yes

• No

14. Have you or anyone in your household had a COVID-19 Antibodies blood test?

• Yes

• No

15. How did you hear about this research opportunity?

• Census Bureau employee

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

• Facebook/Social Media

• Craigslist

• Other – specify:

16. What is your daytime telephone number?

17. What is your e-mail address? We will email you the instructions for downloading and installing the Skype for Business application.

__________________________@_____________.com

18. [IF CALLER DOES NOT QUALIFY FOR STUDY] Thanks for your interest in our study. Unfortunately you’re not eligible to participate this time. May I keep your name and contact information on file? We may contact you for a future study.

• Yes

• No

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