Form 1 Study 2 questionnaire

Study 2

Start of Block: Intro

Q1.1
Greetings,
  Thank you for agreeing to participate in this research study. On the next screen, you will be asked to fill out a questionnaire that will take about 10 minutes. The information you provide will contribute to valuable research at the Census Bureau.   The U.S. Census Bureau is required by law to protect your information. The Census Bureau is not permitted to publicly release your responses in a way that could identify you. We are conducting this voluntary survey under the authority of Title 13, United States Code, Sections 8(b), 182, and 196. Federal law protects your privacy and keeps your answers confidential (Title 13, United States Code, Section 9). Per the Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity risks through screening of the systems that transmit your data.   We estimate that completing this survey will take 10 minutes on average. 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]. This collection has been approved by the Office of Management and Budget (OMB). This eight-digit OMB approval number, 0607-0725, confirms this approval and expires on 12/31/2022. We are required to display this number to conduct this survey. By proceeding, you give your consent to participate in this study.   Your privacy is protected by the Privacy Act. The information provided may be shared with other Census Bureau staff for the work-related purposes identified in this statement. For more information on this collection, see SORN “CENSUS-3, Demographic Survey Collection (Census Bureau Sampling Frame)”  by visiting our website at census.gov and click on "Data Protection and Privacy Policy" at the bottom of the home page.

Q2.1
Please select the state where you are currently completing this survey.

▼ AL (1) ... WY (51)

Q6.1 What is your age?

________________________________________________________________

Q7.1 What is your date of birth?

• Month (14) ________________________________________________

• Day (15) ________________________________________________

• Year (16) ________________________________________________

Q10.1 What is your sex?

• Male (1)

• Female (2)

Q11.1 .TextEnteryBox{ padding-left:20px; } What is your race or ethnicity? Select all boxes that apply AND enter origins.

• White (1) ________________________________________________

• Hispanic, Latino or Spanish (2) ________________________________________________

• Black or African American (3) ________________________________________________

• Asian (4) ________________________________________________

• American Indian or Alaska Native (5) ________________________________________________

• Native Hawaiian or Other Pacific Islander (6) ________________________________________________

• Some other race (7) ________________________________________________

Q12.1 What is the highest degree or level of school you have COMPLETED?  If currently enrolled, select the highest degree received.

• No high school diploma (1)

• High school diploma or GED (2)

• Associates degree - Specify: (8) ________________________________________________

• Bachelor's degree (e.g., BS, BA, AB) - Specify: (3) ________________________________________________

• Master's degree (e.g., MS, MA, MBA) - Specify: (4) ________________________________________________

• Doctorate (e.g., PhD, DSc, EdD) - Specify: (5) ________________________________________________

• Other prof degree (e.g., JD, LLB, MD, DDS, DMV) - Specify: (6) ________________________________________________

• Other - Specify: (7) ________________________________________________

Q12.3 Was the last school you attended inside the U.S. or outside the U.S.?

• Inside the U.S (1)

• Outside the U.S. (2)

Q12.5 What was the name of the last school you attended?

________________________________________________________________

Q12.7 About when was your house, apartment or mobile home first built?

• 1970 or later - Specify year: (4) ________________________________________________

• 1960 to 1969 (5)

• 1950 to 1959 (6)

• 1940 to 1949 (7)

• 1939 or earlier - Specify year: (8) ________________________________________________

Q14.1 Does anyone in your household pay for electricity? Select "Yes" if electricity and gas are billed together.

• Yes (1)

• No (2)

Display This Question:

If Does anyone in your household pay for electricity? Select "Yes" if electricity and gas are billed... = Yes

Q14.2 What is the cost of electricity for this unit? If electricity and gas are billed together, enter the combined amount here.

•     (4) ________________________________________________

•     (5) ________________________________________________

Q14.4 Does anyone in your household pay for water and sewer?

• Yes (1)

• No (2)

Display This Question:

If Does anyone in your household pay for water and sewer? = Yes

Q14.5 What was the cost of water and sewer for your household?

•     (8) ________________________________________________

•     (9) ________________________________________________

Q14.7 Do you or any member of this household own or use any of the following types of computers?

	Yes (1)	No (2)
Desktop or Laptop (1)
Smartphone (2)
Tablet or other portable wireless computer (3)
Some other type of computer (4)

Q14.9 When did you last work, even for a few days?

• Within the past 12 months (1)

• 1 to 5 years ago (2)

• Over 5 years ago or never worked (3)

Display This Question:

If When did you last work, even for a few days? = Over 5 years ago or never worked

Q14.20 tr.ChoiceRow:nth-child(odd){ background-color: #f2f2f2 !important; } .Skin .ChoiceRow:hover { background-color: #ffffff; What were your reasons for not working in the past 5 years? Select Yes or No for each item.

	Yes (1)	No (2)
Retired (1)
On layoff from a job (2)
Student (3)
Family Responsibilities (4)
Chronic illness or permanent disability (5)
Suitable job not available (6)
Did not need or want to work (7)
Other reason (8)

Skip To: End of Block If What were your reasons for not working in the past 5 years? Select Yes or No for each item. , Retired [ Yes ] Is Displayed

Display This Question:

If When did you last work, even for a few days? = Within the past 12 months

Or When did you last work, even for a few days? = 1 to 5 years ago

Q14.11 What were your main job duties for your current or most recent job?

________________________________________________________________

Display This Question:

If When did you last work, even for a few days? = Within the past 12 months

Or When did you last work, even for a few days? = 1 to 5 years ago

Q14.13 tr.ChoiceRow:nth-child(odd){ background-color: #f2f2f2 !important; } .Skin .ChoiceRow:hover { background-color: #ffffff; Thinking about your employment last week or most recent employment in the past 5 years, please rate your satisfaction with that job's......
Select one answer for each item

	Very Satisfied (1)	Somewhat Satisfied (2)	Somewhat Dissatisfied (3)	Very Dissatisfied (4)
Salary (1)
Benefits (2)
Job Security (3)
Job Location (4)
Opportunities for Advancement (5)
Intellectual challenge (6)
Level of responsibility (7)
Degree of independence (8)
Contribution to society (9)

Q14.15 Did you receive any wages, salary, commissions, bonuses, or tips during the PAST 12 MONTHS?

• Yes (1)

• No (2)

Display This Question:

If Did you receive any wages, salary, commissions, bonuses, or tips during the PAST 12 MONTHS? = Yes

Q15.18 What is the easiest way for you to tell us the amount of wages, salary, commissions, bonuses or tips you receive? 
This includes jobs before any deductions for taxes, bonds, dues, or other items.

• Weekly (1)

• Every 2 weeks (2)

• Twice a month (5)

• Monthly (3)

• Annually (4)

Display This Question:

If Did you receive any wages, salary, commissions, bonuses, or tips during the PAST 12 MONTHS? = Yes

Q15.19 What was the amount received every  ? Report amount from all jobs before any deductions for taxes, bonds, dues, or other items.

________________________________________________________________

Page Break

Q19.21 According to our calculations, you received $$e{ q://QID248/ChoiceTextEntryValue * 26 } from wages, salary, commissions, bonuses, or tips last year.  Is this correct?

• Yes (1)

• No - Specify correct amount: $ (2) ________________________________________________

Q20.1 Please select "Neither agree nor disagree" below (to make sure the system is working correctly).

• Strongly agree (4)

• Agree (5)

• Slightly agree (6)

• Neither agree nor disagree (7)

• Slightly disagree (8)

• Disagree (9)

• Strongly disagree (10)

Q20.3 Thank you for your responses.  Please answer these final few questions about your experience.  There are no right or wrong answers - we just want your opinion.

Q20.4 How easy or difficult was it for you to complete this survey?

• Extremely easy (1)

• Somewhat easy (2)

• Neither easy nor difficult (3)

• Somewhat difficult (4)

• Extremely difficult (5)

Display This Question:

If What is the highest degree or level of school you have COMPLETED?  If currently enrolled, select... = Associates degree - Specify:

And And What is the highest degree or level of school you have COMPLETED?  If currently enrolled, select... Associates degree - Specify: Is Empty

Q20.6
On the question about education level, you gave the following answer:
 
 
We noticed that you did not also specify the type of degree you completed in the box appearing on the same line.
  Was it because

• I did not notice the specify box (1)

• I did not have any additional information to add (2)

• I did not prefer to give an answer (4)

• I did not understand what was needed in the box (5)

• Other reason - Specify: (3) ________________________________________________

Q20.17 Here are two ways to present the specify box. Which one do you prefer, if any?

• Image:Specify to right blue 2 (1)

• Image:Hb2 (2)

• No preference (3)

Q20.19 Here are three ways to present this question.  Which one do you prefer, if any?

• Image:Alternate shading dynamic highlighting2 (1)

• Image:No shading dynamic highlighting2 (3)

• Image:Alternate shading no dynamic highlighting2 (2)

• No preference (4)

Q20.21 Here are two ways that ask respondents to report dollar amounts. Which one do you prefer, if any?

• Image:Freq1 (1)

• Image:Freq2 (2)

• No preference (3)

Q20.23 Here are four ways to enter a state. Which one do you prefer, if any?

• Image:State c1 (1)

• Image:State c2 (2)

• Image:State c3 (3)

• Image:State c4 (4)

• No preference (5)

Q20.25 Here are three ways to present the month within a drop-down. Which one do you prefer, if any?

• Image:Dob c1 (1)

• Image:Dob c2 (2)

• Image:Dob c3 (3)

• No preference (4)

Q20.27 In the space below, please share any other comments you have on the design of the questions presented in this survey.

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

End of Block: Post survey

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