Generic Screener

US Census Bureau

Center for Behavioral Science Methodology (CBSM)

Telephone Screener

Fall, 2019

CBSM Universal Screener

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

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

Mobile ([ ]) [ ] – [ ]

Home (if not mobile) ([ ]) [ ] – [ ]

Work (if any) ([ ]) [ ] – [ ] EXT.[ ]

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

City:_____________________

State:_____________________

Zip code:__________________

5. Is your home owned, rented or occupied without payment of rent?

   • Owned

   • Rented

   • Occupied without payment of rent

6. What type of home do you live in?

• House or townhouse

• Apartment or condo

• Something else

• Don’t know/Refused

7. Are you male or female?

• Male

• Female

8. In what year were you born?

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

• Yes

• No

10. 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

• 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. 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)

12a. What is your current job title or job description? [open text]

12b. Are you employed by the Federal Government? (if federal contractor, mark NO)

• Yes

• No

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

13a. If more than 1: Are they all related or not?

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

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

• Yes (ask follow-up question)

• 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

16. We will now collect what electronic devices you own. Do you own a:

1. Smartphone

• Yes - Is it an iPhone, Android, Blackberry or Windows phone, or are you not sure?

• No

1. Desktop

• Yes

• No

1. Laptop

• Yes

• No

1. Tablet

• Yes - Is it an iPad, Samsung Galaxy Tab, Google Nexus, or Kindle Fire or are you not sure?

• No

17. 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]

18. Who typically handles the mail in your household?

• Only you

• You and other members of the household?

• Someone in the household other than you?

19. 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

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

• Yes

• No

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

• Yes

• No

22. Is your household’s annual income … (Read until interrupted.)

• Less than $15,000?

• $15,000 to $25,000?

• $25,000 to$50,000?

• $50,000 to $100,000?

• More than $100,000?

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

• Yes

• No

24. Did the ad you are responding to mention a code? If so, what was the code?_____________

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