Household Pulse Survey Questionnaire, Phase 3

Household Pulse Survey

Part A, ATTACH A_HH Pulse Questionnaire_Standard ICR_Phase 3_English_Spanish

Household Pulse Survey

OMB: 0607-1013

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0607-1013 can be found here:

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Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Household Pulse Survey Questionnaire
August 5, 2020
QUESTIONNAIRE (ENGLISH)
## HEADER TO BE DISPLAYED ON EVERY PAGE AFTER WELCOME PAGE##
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AN OFFICIAL WEBSITE OF THE UNITED STATES GOVERNMENT
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2020 Household Pulse Survey
English | Español | Logout
## SPANISH ##
UN SITIO WEB OFICIAL DEL GOBIERNO DE LOS EE.UU.
Unites States Census Bureau Logo
Encuesta del Pulso de los Hogares
English | Español | Salir
## FOOTER TO BE DISPLAYED ON EVERY PAGE ##
## ENGLISH ##
OMB No.: 0607-1013 Approval Expires:10/31/2020
/* START PAGE */
Page Title: Login
Section Splash Page (display_Information)
Welcome! Thank you for participating in the Household Pulse Survey During COVID-19 sponsored by the
U.S. Census Bureau and other federal agencies. This survey will help measure the impact of coronavirus
(COVID-19) on topics like:
• employment status
• food security
• housing security
• education disruptions
• physical and mental wellbeing.
In this survey we refer to the coronavirus (COVID-19) as coronavirus.
This survey is also available in Spanish. If you would like to change your language selection, please use the
drop down menu in the upper right corner of each page to select the language in which you prefer to
complete the survey.
Start Questionnaire
This survey is not the 2020 Census.
This survey is a cooperative effort across many government agencies to provide critical, up-to-date
information about the impact of the coronavirus (COVID-19) pandemic on the U.S. population. Completing

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

this short 10-minute survey will help federal, state, and local agencies identify coronavirus (COVID-19)
related issues in your community.
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) and 182 to study the economic impacts of
the COVID-19 pandemic in the United States. Federal law protects your privacy and keeps your answers
confidential (Title 13, 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, 0607-1013, confirms this approval and expires on
10/31/2020. We are required to display this number to conduct this survey.
Your privacy is protected by 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, “SORN
COMMERCE/Census-3, Demographic Survey Collection (Census Bureau Sampling Frame).” 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.
To learn more about this survey go to:
https://www.census.gov/programssurveys/surveyhelp.html.

You are accessing a United States Government
** U.S. Census Bureau Notice and Consent Warning **
computer network. Any information you enter into this system is confidential. It may be used by the Census
Bureau for statistical purposes and to improve the website. If you want to know more about the use of this
system, and how your privacy is protected, visit our online privacy webpage at
http://www.census.gov/about/policies/privacy/privacy-policy.html.
Use of this system
indicates your consent to collection, monitoring, recording, and use of the information that you provide for
any lawful government purpose. 1 So that our website remains safe and available for its intended use,
network traffic is monitored to identify unauthorized attempts to access, upload, change information, or
otherwise cause damage to the web service. Use of the government computer network for unauthorized
purposes is a violation of Federal law and can be punished with fines or imprisonment (PUBLIC LAW 99474).
Section Splash Page Spanish (display_Information)

¡Bienvenido(a)! Gracias por participar en la Encuesta del Pulso de los Hogares durante la
pandemia de COVID-19, patrocinada por la Oficina del Censo de los EE. UU. y otras agencias
federales. Esta encuesta ayudará a medir el impacto del coronavirus (COVID-19) en temas
como:
• situación de empleo
• seguridad alimentaria
• seguridad de la vivienda
• interrupciones en la educación
• bienestar físico y mental.

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

En esta encuesta nos referimos al coronavirus (COVID-19) como coronavirus.
Esta encuesta también está disponible en inglés. Si quisiera cambiar el idioma que haya
seleccionado, use el menú desplegable en la esquina superior derecha de cada página para
seleccionar el idioma en el que desee completar la encuesta.
Comenzar la encuesta
Esta encuesta no es el Censo del 2020.
Esta encuesta es un esfuerzo conjunto de muchas agencias del gobierno para ofrecer información
crítica y actualizada sobre el impacto de la pandemia del coronavirus (COVID-19) en la población
de los Estados Unidos. Completar esta breve encuesta de 10 minutos ayudará a las agencias
federales, estatales y locales a identificar los problemas relacionados con el coronavirus
(COVID-19) en su comunidad.
La Oficina del Censo de los EE. UU. está obligada por ley a proteger su información. A la Oficina
del Censo no se le permite divulgar sus respuestas de manera que pudieran identificarlo a usted.
Estamos llevando a cabo esta encuesta voluntaria en conformidad con la autoridad del Título 13
del Código de los Estados Unidos, Secciones 8(b), 182 y 196, con el fin de estudiar los impactos
económicos de la pandemia de COVID-19 en los Estados Unidos. La ley federal protege su
privacidad y mantiene sus respuestas confidenciales (Título 13, Código de los Estados Unidos,
Sección 9). En conformidad con la Ley para el Fortalecimiento de la Seguridad Cibernética Federal
del 2015, sus datos están protegidos contra los riesgos de seguridad cibernética mediante los
controles aplicados a los sistemas que transmiten su información.
Calculamos que completar esta encuesta tomará 10 minutos como promedio. Envíe sus
comentarios relacionados con este cálculo o cualquier otro aspecto de la encuesta, incluidas las
sugerencias para reducir el tiempo que toma completarla, a [email protected]. Esta
recopilación ha sido aprobada por la Oficina de Administración y Presupuesto (OMB). Este
número de ocho cifras de aprobación de la OMB, 0607-1013, confirma dicha aprobación y se
vence el 10/31/2020. Estamos obligados a mostrar este número para llevar a cabo la encuesta.
Su privacidad está protegida por la Ley sobre la Privacidad (Título 5, Código de los EE. UU., Sección
552a). Los usos de rutina de estos datos se limitan a los que se identifican en el Aviso sobre el
Sistema de Registros de la Ley sobre la Privacidad, conocido como “SORN COMMERCE/Census-3,
Recopilación de la Encuesta Demográfica (Marco Muestral de la Oficina del Censo)”. La Oficina del
Censo solo puede usar sus respuestas para generar estadísticas, y no se le permite publicar sus
respuestas de manera que pudieran identificarlo a usted. Para conocer más acerca de esta
encuesta, visite: https://www.census.gov/householdpulsedata.
** Aviso de la Oficina del Censo de los EE. UU. y Advertencia sobre el consentimiento **

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Usted está accediendo a una red de computación del gobierno de los Estados Unidos. Toda la información
que escriba en este sistema es confidencial. La Oficina del Censo puede usar dicha información para
propósitos estadísticos y para mejorar el sitio web. Si desea conocer más acerca del uso de este sistema y
cómo se protege su privacidad, visite nuestra página web (disponible en inglés)
http://www.census.gov/about/policies/privacy/privacy-policy.html.
El uso de este sistema indica su consentimiento a que recopilemos, monitoreemos, registremos y usemos la
información que usted proporcione para cualquier propósito legal del gobierno. Con el fin de que nuestro
sitio web siga siendo seguro y que siga disponible para el uso al que está destinado, monitoreamos el
tráfico en la red para identificar los intentos no autorizados de acceder, subir o cambiar información, o de
dañar de alguna otra manera el servicio del sitio web. El uso de la red de computación del gobierno para
fines no autorizados es una violación de las leyes federales y puede ser penalizado con multas o
encarcelamiento (LEY PÚBLICA 99-474).
/* END PAGE */
/* START PAGE */
Page Title: Welcome_Page
Section Welcome Page (display_Welcome)
This survey is available in English and Spanish. Please select the language in which you prefer to complete
the survey. If you would like to change your language selection later, please use the drop down menu in
the upper right corner of each page to select the language in which you prefer to complete the survey.
English
Español
Section Welcome Page (display_Welcome)
Esta encuesta está disponible en inglés y español. Seleccione el idioma en el que desee completar la
encuesta. Si después quisiera cambiar el idioma que haya seleccionado, use el menú desplegable en la
esquina superior derecha de cada página para seleccionar el idioma en el que desee completar la encuesta.
English
Español
/* END PAGE */
/* START PAGE */
Page Title: Age_Gender
Section Display before Q1 (display_Q1)
These questions are for statistical purposes only.
Section Display before Q1 Spanish (display_Q1)
Estas preguntas se hacen solo con propósitos estadísticos.
Section Q1 (birth_year)
What year were you born? Please enter a number.

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

____
Section Q1 Spanish (birth_year)
¿En qué año nació usted? Por favor, anote un número.
____
Logic:
• Open end numeric
• Range: 1900 to 2020
• If a respondent enters a number that falls outside of the above range, display the following
message (soft edit):
o For English: “Please enter a number between 1900 and 2017.”
o For Spanish: “Por favor, anote un número entre 1900 y 2017.”
•
o
Continue to survey if respondent indicates birth year older than 2002
o
Need to jump to a ineligible respondent thank you screen.
•
• Justification: Year of birth is necessary for weighting,
analysis, and basic demographics.
Section Q2 (gender)
Are you… Select only one answer.
1) Male
2) Female
Section Q2 Spanish (gender)
¿Es usted…? Seleccione solo una respuesta.
1) Hombre
2) Mujer
Logic:
•
•

•
•

Only one response permitted
Do NOT rotate answer choices

Justification: Gender is necessary for weighting, analysis, and
basic demographics.

/* END PAGE */
/* START PAGE */
Page Title: Race_Ethnicity
Section Q3 (hispanic)
Are you of Hispanic, Latino, or Spanish origin?
1) No, not of Hispanic, Latino, or Spanish origin
2) Yes, Mexican, Mexican American, Chicano
3) Yes, Puerto Rican
4) Yes, Cuban
5) Yes, another Hispanic, Latino, or Spanish origin (specify)

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Section Q3 Spanish (hispanic)
¿Es usted de origen hispano, latino o español?
1) No, no soy de origen hispano, latino o español
2) Sí, mexicano, mexicanoamericano, chicano
3) Sí, puertorriqueño
4) Sí, cubano
5) Sí, de otro origen hispano, latino o español (especifique)
Logic:

•
•

•
Only one response permitted
•
Do NOT rotate answer choices
•
If respondents choose any answer choices other than 5 (“Yes, another Hispanic, Latino, or
Spanish origin”/ “Sí, de otro origen hispano, latino, o español”), remove and/or disable text field
for answer choice 5.
Justification: Hispanic origin is necessary for weighting,
analysis, and basic demographics.

•
Section Q4 (race)
What is your race? Please select all that apply.
1) White
2) Black or African American
3) American Indian or Alaska Native (specify)
4) Asian Indian
5) Chinese
6) Filipino
7) Japanese
8) Korean
9) Vietnamese
10) Other Asian (specify)
11) Native Hawaiian
12) Chamorro
13) Samoan
14) Other Pacific Islander (specify)
Section Q4 Spanish (race)
¿Cuál es su raza? Seleccione todas las que correspondan.
1) Blanca
2) Negra o afroamericana
3) Indígena de las Américas o nativa de Alaska (especifique)
4) India asiática
5) China
6) Filipina
7) Japonesa
8) Coreana
9) Vietnamita
10) Otra asiática (especifique)

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

11)
12)
13)
14)

Logic:
•

Nativa de Hawái
Chamorro
Samoana
Otra de las islas del Pacífico (especifique)

•
Multiple responses permitted
•
Do NOT rotate answer choices
Justification: Race is necessary for weighting, analysis, and
basic demographics.

•
/* END PAGE */
/* START PAGE */
Page Title: Education
Section Q5 (education)
What is the highest degree or level of school you have completed? Select only one answer.
1) Less than high school
2) Some high school
3) High school graduate or equivalent (for example GED)
4) Some college, but degree not received or is in progress
5) Associate’s degree (for example AA, AS)
6) Bachelor's degree (for example BA, BS, AB)
7) Graduate degree (for example master's, professional, doctorate)
Section Q5 Spanish (education)
¿Cuál es el grado o nivel de educación más alto que usted ha completado? Seleccione solo una
respuesta.
1) Menos de la escuela secundaria o preparatoria (high school)
2) Algo de escuela secundaria o preparatoria (high school)
3) Graduado(a) de la escuela secundaria o preparatoria (high school) o equivalente (por
ejemplo, GED)
4) Algo de universidad, pero no recibió un título o todavía está estudiando
5) Título asociado universitario (por ejemplo, AA, AS)
6) Título de licenciatura universitaria (por ejemplo, BA, BS, AB)
7) Título de posgrado (por ejemplo, título de maestría, título profesional, doctorado)
Logic:
•
Only one response permitted
•
Do NOT rotate answer choices
•
• Justification: Education is necessary for weighting, analysis,
and basic demographics.
/* END PAGE */
/* START PAGE */
Page Title: Household
Section Q6 (marital_status)

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

What is your marital status? Select only one answer.
1) Now married
2) Widowed
3) Divorced
4) Separated
5) Never married
Section Q6 Spanish (marital_status)
¿Cuál es su estado civil? Seleccione solo una respuesta.
1) Casado(a) actualmente
2) Viudo(a)
3) Divorciado(a)
4) Separado(a)
5) Nunca me he casado
Logic:
•

•
Only one response permitted
•
Do NOT rotate answer choices
Justification: Marital status is necessary for understanding
basic respondent characteristics, analysis, and basic demographics.

Section Q7 (household3)
How many total people – adults and children – currently live in your household, including yourself? Please enter
a number.
____
Section Q7 Spanish (household3)
¿Cuántas personas en total –adultos y niños– viven actualmente en su hogar, incluyéndose a sí mismo(a)? Por
favor, anote un número.
____
Logic:

•
•

•
Open end numeric
•
Range: 1 to 40
•
If a respondent enters a number that falls outside of the above range, display the following
message (soft edit):
o
For English: “Please enter a number greater than or equal to 1.”
o
For Spanish: “El valor debe ser superior o igual a 1.”
Justification: The household number of total people is necessary
for weighting, analysis, and basic demographics.

Section Q8 (household3)
How many people under 18 years-old currently live in your household? Please enter a number.
____
Section Q8 Spanish (household3)
¿Cuántas personas menores de 18 años viven actualmente en su hogar? Por favor, anote un número.

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Logic:

•

•
Open end numeric
•
Range: 1 to 40
•
If a respondent enters a number that falls outside of the above range, display the following
message (soft edit):
o
For English: “Please enter a number between 1 and 40.”
o
For Spanish: “Por favor, anote un número entre 1 y 40.”
Justification: The household number of children under 18 is
necessary for setting universes, calculating the number of adults,
weighting, analysis, and basic demographics.

/* END PAGE */
/* START PAGE */
Page Title: Employment
Section Display Q9(display_Q9)
Section Display Q9 (spanish display_Q9)
Section Q9 (employment)
Have you, or has anyone in your household experienced a loss of employment income since March 13,
2020? Select only one answer.
1) Yes
2) No
Section Q9 Spanish (employment)
¿Ha experimentado usted, o alguien en su hogar, una pérdida de ingresos laborales desde el 13 de marzo
de 2020? Seleccione solo una respuesta.

Logic:
•
•

•

1) Sí
2) No
•

Only one response permitted

Justification: The coronavirus pandemic forced the closing of many
employers and the furlough or lay off of many adults. Additional
employees had restrictions in their amount of hours worked. This
item helps understand the experience of household income loss. This
item is distinct from the concept of employment loss, and captures
a broader experience of income related impacts of the coronavirus.
To understand, objectively and with immediacy, individuals’
employment experience in this pandemic, e.g., the degree to which
they have lost employment income; experienced changes in work
status; and/or are now working without pay.
What strategies households are taking to manage economic impacts
from Covid-19, including use of impending stimulus payments,
unemployment insurance benefits, borrowing from family or friends,

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

taking on additional debt, withdrawing from savings, or using their
own sources of income.
Expectations individuals have with regard to the economic impact
(stimulus) payments; how much they expect to (or have) received;
and how it was (or will be) spent, e.g., essential needs (food,
medical care, home), debt reduction, savings or more discretionary
consumer spending.
For many the economic impact payment will enable them to remain
afloat financially; for others it will not be sufficient to cover
basic needs; and for some it will add income to what they are
currently receiving. Understanding how the stimulus is received
and used and will inform additional efforts by federal, state, and
local governments to make targeted decisions about additional
interventions under consideration.
Time Frame: This item uses March 13, 2020 as the reference time
point for understanding the cumulative experience since the start
of the pandemic.

Section Q10 (employment)
Do you expect that you or anyone in your household will experience a loss of employment income in the
next 4 weeks because of the coronavirus pandemic? Select only one answer.
1) Yes
2) No
Section Q10 Spanish (employment)
¿Anticipa que usted, o alguien en su hogar, experimente una pérdida de ingresos laborales en las próximas
4 semanas debido a la pandemia del coronavirus? Seleccione solo una respuesta.

Logic:
•
•

•

1) Sí
2) No
•

Only one response permitted

Justification: One of the important impacts of the coronavirus
pandemic has been ongoing uncertainty in many domains. This item
complements the reported experience of household loss in employment
income by asking the respondent to look forward for the next four
weeks and give an assessment of whether they expect anyone in the
household to experience the loss of employment income. This item is
distinct from the concept of employment loss, and captures a
broader experience of uncertainty related to income related impacts
of the coronavirus.
To understand, objectively and with immediacy, individuals’
employment experience in this pandemic, e.g., the degree to which
they have lost employment income; experienced changes in work
status; and/or are now working without pay.
What strategies households are taking to manage economic impacts
from Covid-19, including use of impending stimulus payments,
unemployment insurance benefits, borrowing from family or friends,
taking on additional debt, withdrawing from savings, or using their
own sources of income.

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

Expectations individuals have with regard to the economic impact
(stimulus) payments; how much they expect to (or have) received;
and how it was (or will be) spent, e.g., essential needs (food,
medical care, home), debt reduction, savings or more discretionary
consumer spending.
For many the economic impact payment will enable them to remain
afloat financially; for others it will not be sufficient to cover
basic needs; and for some it will add income to what they are
currently receiving. Understanding how the stimulus is received
and used and will inform additional efforts by federal, state, and
local governments to make targeted decisions about additional
interventions under consideration.
Time Frame: This item uses the next four weeks as the reference
time point for understanding the forward looking expectation over a
period of approximately a month. Because of the interview
frequency, four weeks is a more easily and consistent time frame
for recall than using a month which may end up being up to six or
seven weeks if people think of the end of the next month, and as
little as a couple weeks if we are interviewing at the end of a
month.

•
•
Section Q11 (employment)
Now we are going to ask about your employment.
In the last 7 days, did you do ANY work for either pay or profit? Select only one answer.
1) Yes
2) No
Section Q11 Spanish (employment)
Ahora vamos a preguntar sobre su empleo.
En los últimos 7 días, ¿hizo ALGÚN trabajo, ya sea pagado o por beneficios? Seleccione solo una respuesta.
1) Sí
2) No
Logic:
•
•

•

Only one response permitted

Justification: Employment and employment loss are critical concerns
in normal times, but particularly exacerbated by the coronavirus
pandemic. This item is focused on measuring the recent employment
status of the population, and monitoring change from interview
period to interview period.
To understand, objectively and with immediacy, individuals’
employment experience in this pandemic, e.g., the degree to which
they have lost employment income; experienced changes in work
status; and/or are now working without pay.

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

What strategies households are taking to manage economic impacts
from Covid-19, including use of impending stimulus payments,
unemployment insurance benefits, borrowing from family or friends,
taking on additional debt, withdrawing from savings, or using their
own sources of income.
Expectations individuals have with regard to the economic impact
(stimulus) payments; how much they expect to (or have) received;
and how it was (or will be) spent, e.g., essential needs (food,
medical care, home), debt reduction, savings or more discretionary
consumer spending.
For many the economic impact payment will enable them to remain
afloat financially; for others it will not be sufficient to cover
basic needs; and for some it will add income to what they are
currently receiving. Understanding how the stimulus is received
and used and will inform additional efforts by federal, state, and
local governments to make targeted decisions about additional
interventions under consideration.
Time Frame: This item uses the last seven days as the reference
time period to allow for monitoring the level of work for pay over
a short term, and monitor changes over time. The last 7 days gives
a specific period for short-term recall.

Section Q12 (employment)
Are you employed by government, by a private company, a nonprofit organization or are you selfemployed or working in a family business? Select only one answer.
1) Government
2) Private company
3) Non-profit organization including tax exempt and charitable organizations
4) Self-employed
5) Working in a family business
Section Q12 Spanish (employment)
¿Está empleado(a) por el gobierno, por una empresa privada, por una organización sin fines de lucro, por
cuenta propia o trabaja en una empresa familiar? Seleccione solo una respuesta.
1) Gobierno
2) Empresa privada
3) Organización sin fines de lucro, incluso organizaciones exentas de impuestos y caritativas
4) Por cuenta propia
5) Una empresa familiar
Logic:
•
If Q11 = 1 ask Q12
•
Only one response permitted
• Justification: The kind of work is a characteristic of employment
that will allow for the contextualization of the experience of
employment and the ability to understand which areas retain
employment levels, and the concomitant uncertainty experienced by
different groups.
• To understand, objectively and with immediacy, individuals’
employment experience in this pandemic, e.g., the degree to which

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

they have lost employment income; experienced changes in work
status; and/or are now working without pay.
What strategies households are taking to manage economic impacts
from Covid-19, including use of impending stimulus payments,
unemployment insurance benefits, borrowing from family or friends,
taking on additional debt, withdrawing from savings, or using their
own sources of income.
Expectations individuals have with regard to the economic impact
(stimulus) payments; how much they expect to (or have) received;
and how it was (or will be) spent, e.g., essential needs (food,
medical care, home), debt reduction, savings or more discretionary
consumer spending.
For many the economic impact payment will enable them to remain
afloat financially; for others it will not be sufficient to cover
basic needs; and for some it will add income to what they are
currently receiving. Understanding how the stimulus is received
and used and will inform additional efforts by federal, state, and
local governments to make targeted decisions about additional
interventions under consideration.
Time Frame:
No time frame is necessary in this question text
as it follows up only those employed in the last seven days.

Section Q13 (employment)
What is your main reason for not working for pay or profit? Select only one answer.
I did not work because:
1) I did not want to be employed at this time (1)
2) I am/was sick with coronavirus symptoms (2)
3) I am/was caring for someone with coronavirus symptoms (3)
4) I am/was caring for children not in school or daycare (4)
5) I am/was caring for an elderly person (5)
6) I was concerned about getting or spreading the coronavirus (13)
7) I am/was sick (not coronavirus related) or disabled (6)
8) I am retired (7)
9) My employer experienced a reduction in business (including furlough) due to coronavirus
pandemic (8)
10) I am/was laid off due to coronavirus pandemic (9)
11) My employer closed temporarily due to the coronavirus pandemic (10)
12) My employer went out of business due to the coronavirus pandemic (11)
13) Other reason, please specify (12)
Section Q13 Spanish (employment)
¿Cuál es la principal razón por la cual no trabaja por pago o beneficio? Seleccione solo una respuesta.
No trabajé porque:
1)
2)
3)
4)
5)

No quería estar empleado(a) en este momento
Estoy/estaba enfermo(a) con síntomas del coronavirus
Estoy/estaba cuidando a alguien con síntomas del coronavirus
Estoy/estaba cuidando a niños que no asistieron a la escuela o guardería
Estoy/estaba cuidando a un anciano

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

6)
7)
8)
9)
10)
11)
12)
13)
Logic:

•
•

•

Me preocupaba contagiarme con el coronavirus o contagiar a otras personas
Estoy/estaba enfermo(a) (no relacionado con el coronavirus) o discapacitado(a)
Estoy jubilado(a)
Mi empleador experimentó una reducción en los negocios relacionada con la pandemia del
coronavirus (incluyendo suspensión temporal del empleo)
He sido/fui despedido(a) debido a la pandemia del coronavirus
Mi empleador cerró temporalmente debido a la pandemia del coronavirus
Mi empleador se fue a la quiebra debido a la pandemia del coronavirus
Otra razón, por favor, especifique

•
If Q11 = 2 ask Q13
•
Only one response permitted
•
Note that the values shown here are the order of response options, note the recode values
exported by the program. The program exports 6 (new response option) with a value of 13. The
rest (original response options) are numbered sequentially.
Justification: The Bureau of Labor Statistics and Census follow
up the respondents who respond that they weren’t working for pay
with this item to identify the main reasons they weren’t working
for pay. This item is critical to separating major areas associated
with coronavirus pandemic related job loss.
To understand, objectively and with immediacy, individuals’
employment experience in this pandemic, e.g., the degree to which
they have lost employment income; experienced changes in work
status; and/or are now working without pay.
What strategies households are taking to manage economic impacts
from Covid-19, including use of impending stimulus payments,
unemployment insurance benefits, borrowing from family or friends,
taking on additional debt, withdrawing from savings, or using their
own sources of income.
Expectations individuals have with regard to the economic impact
(stimulus) payments; how much they expect to (or have) received;
and how it was (or will be) spent, e.g., essential needs (food,
medical care, home), debt reduction, savings or more discretionary
consumer spending.
For many the economic impact payment will enable them to remain
afloat financially; for others it will not be sufficient to cover
basic needs; and for some it will add income to what they are
currently receiving. Understanding how the stimulus is received
and used and will inform additional efforts by federal, state, and
local governments to make targeted decisions about additional
interventions under consideration.
Time Frame:
This question asks a follow-up to the question
about work in the last seven days. As a follow-up it has the same
time reference as that item.

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Section Q13a (employment)
Working from home is sometimes referred to as telework. Did any adults in this household substitute
some or all of their typical in-person work for telework because of the coronavirus pandemic, including
yourself? Select only one answer.
1) Yes, at least one adult substituted some or all of their typical in-person work for telework
2) No, no adults substituted their typical in-person work for telework
3) No, there has been no change in telework
Section Q13a Spanish (employment)
Con frecuencia, trabajar desde la casa se llama teletrabajo. ¿Debido a la pandemia, alguno de los
adultos en este hogar, incluido usted, ha sustituido parte o todo su trabajo típico presencial por
teletrabajo? Seleccione solo una respuesta.
1) Sí, al menos un adulto ha sustituido parte o todo su trabajo típico presencial por
teletrabajo/trabajo desde la casa
2) No, ningún adulto ha sustituido su trabajo típico presencial por teletrabajo/trabajo desde la
casa
3) No, no ha habido cambio en la frecuencia de teletrabajo/trabajo desde la casa
Logic:
•
•

•

Only one response permitted

Justification: The Bureau of Transportation Statistics has
requested phase 2 content that focuses on Teleworking, trips to
stores and work, and planned long distance trips that have been
cancelled. The impact of stay-at-home orders and business closures
on transportation patterns. This asks about the change to telework
by any of the adults in the household. The importance of the
transition to telework is many-fold, the focus in this series is on
transportation and transit changes.
Time Frame:
This question asks about changes due to the
coronavirus pandemic. A time frame is not necessary for this item
because it specifically asks about changes in typical in-person
work that occurred due to the coronavirus pandemic.
The question focuses on the cumulative experience. It is necessary
as a component of the bi-weekly interview because it is an
important covariate when household income changes are experienced.
Additionally as the economy both opens and closes, the proportion
who are able to telework are increasing. Changes in the delivery of
education and increasing online learning create changes for both
those involved in teaching and for those in households with
children. This measure captures the most basic measure of telework
which will help provide context for the continuing changes
associated with work and household life during the coronavirus
pandemic.

Section Q14 (employment)
Are you receiving pay for the time you are not working? Select only one answer.
1) Yes, I use paid leave
2) Yes, I receive full pay but do not have to take leave

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

3) Yes, I receive partial pay
4) No, I receive no pay
Section Q14 Spanish (employment)
¿Está usted recibiendo un pago por el tiempo que no está trabajando? Seleccione solo una respuesta.
1)
Sí, uso la licencia pagada
2)
Sí, recibo el sueldo completo, pero no tengo que tomar licencia
3)
Sí, recibo un pago parcial
4)
No, no recibo ningún pago
Logic:
•
•

•

•
•

If Q11 = 2 ask Q14
Only one response permitted

Justification: The Bureau of Labor Statistics and Census follow
up the respondents who respond that they weren’t working for pay
with this item to identify the main reasons they weren’t working
for pay. This item is critical to separating major areas associated
with coronavirus pandemic related job loss.
To understand, objectively and with immediacy, individuals’
employment experience in this pandemic, e.g., the degree to which
they have lost employment income; experienced changes in work
status; and/or are now working without pay.
What strategies households are taking to manage economic impacts
from Covid-19, including use of impending stimulus payments,
unemployment insurance benefits, borrowing from family or friends,
taking on additional debt, withdrawing from savings, or using their
own sources of income.
Expectations individuals have with regard to the economic impact
(stimulus) payments; how much they expect to (or have) received;
and how it was (or will be) spent, e.g., essential needs (food,
medical care, home), debt reduction, savings or more discretionary
consumer spending.
For many the economic impact payment will enable them to remain
afloat financially; for others it will not be sufficient to cover
basic needs; and for some it will add income to what they are
currently receiving. Understanding how the stimulus is received
and used and will inform additional efforts by federal, state, and
local governments to make targeted decisions about additional
interventions under consideration.
Time Frame:
This question asks a follow-up to the question
about work in the last seven days. As a follow-up it has the same
time reference as that item.

Section Q14a (employment)
Since March 13, 2020, have you applied for Unemployment Insurance (UI) benefits? Select only one
answer.
1) Yes
2) No

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Section Q14a Spanish (employment)
Desde el 13 de marzo de 2020, ¿ha solicitado beneficios de Seguro por Desempleo (“UI” por sus siglas en
inglés)? Seleccione solo una respuesta.
1) Sí
2) No
Logic:

•

Only one response permitted

Justification: We currently have no other information on the complete
Unemployment Insurance picture, specifically: on those who did not
apply for Unemployment Insurance Benefits, who applied and did not
receive benefits, and who received benefits. Given this, the HH
Pulse is an important and only avenue to obtain this information. It
is important to obtain this information for reasons provided below.
As can be seen by these reasons, not only is it important to know
this from an individual/household perspective in terms of individuals
labor force dynamics, but knowing about the receipt (or not applying
for UI ) is beneficial to the analysis of other questions that are
currently in the HH Pulse
- Information about application for and receipt of Unemployment
Insurance (UI) benefits is important in studying the labor force
dynamics of those who have lost their jobs.
- Information about application for and receipt of UI benefits is
useful in interpreting measures of unemployment from other surveys
such as the CPS.
- Unemployment Insurance benefits can be an important source of
income for those who have lost jobs, so the receipt of UI benefits
provides important information to be used in combination with other
questions in the survey (for example the mental health questions,
the food insecurity questions and the expenditure questions).
Combining UI benefits receipt information with information from
these other questions can help to provide insights into why
particular answers are being received. In addition the
Unemployment Insurance benefits questions can provide additional
clarity into what particular answers might mean and what
respondents are including in their answers (i.e. the loss of
earnings income questions).
Time Frame:
The reason for asking since March 13th was to obtain a
complete picture of people’s Unemployment Insurance experience since
the pandemic.
- We had thought about asking when people started receiving
Unemployment Insurance (and indeed this was a question we asked
when the questions were being tested), but for space reasons, it
was decided to not ask when people started receiving Unemployment
Insurance
o The addition of a question asking when people who received
UI, started receiving benefits could be a good addition.
Such information would provide even more very useful
information that could shed light on the labor force dynamics
of unemployment insurance, but was not included due to
respondent burden concerns.

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Time
-

Other timeframes could be entertained, BUT the timeframe
would have to be at least 4 weeks. A one week time frame is
too short to capture the application and receipt dynamic
(i.e. people who have applied for UI in many cases are
unlikely to have received UI benefits within a week of
application, so there would be a bias towards people who
applied not receiving benefits, which in turn would bias
measures of the “success” rate of applications).
Accumulative data since the start of the pandemic is useful for
comparison to and explorations of why the number of UI benefit
recipients are remaining persistently high, while unemployment
rates measured over the last 4 weeks are dropping.
Frame:
Justification for asking bi-weekly
The Unemployment Insurance program and receipt of benefits is very
dynamic and is evolving, therefore asking questions about UI
application and receipt at a high frequency is extremely useful,
particularly in terms of studying income assistance during the
pandemic.
Because the receipt of UI benefits can influence how household and
individuals address food purchases and other household needs (such
as medical care), and can influence individuals mental and physical
health, having the receipt of UI measured in conjunction with these
other measures that are being asked in the HH Pulse bi-weekly seems
important.

Section Q14b (employment)
Since March 13, 2020, did you receive Unemployment Insurance (UI) benefits? Select only one answer.
1) Yes
2) No
Section Q14b Spanish (employment)
Desde el 13 de marzo de 2020, ¿ha recibido beneficios de Seguro por Desempleo (UI)? Seleccione solo una
respuesta.
1) Sí
2) No
Logic:

•
•

Display Q14b if Q14a = 1.
Only one response permitted

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

for UI ) is beneficial to the analysis of other questions that are
currently in the HH Pulse
- Information about application for and receipt of Unemployment
Insurance (UI) benefits is important in studying the labor force
dynamics of those who have lost their jobs.
- Information about application for and receipt of UI benefits is
useful in interpreting measures of unemployment from other surveys
such as the CPS.
- Unemployment Insurance benefits can be an important source of
income for those who have lost jobs, so the receipt of UI benefits
provides important information to be used in combination with other
questions in the survey (for example the mental health questions,
the food insecurity questions and the expenditure questions).
Combining UI benefits receipt information with information from
these other questions can help to provide insights into why
particular answers are being received. In addition the
Unemployment Insurance benefits questions can provide additional
clarity into what particular answers might mean and what
respondents are including in their answers (i.e. the loss of
earnings income questions).
Time Frame:
The reason for asking since March 13th was to obtain a
complete picture of people’s Unemployment Insurance experience since
the pandemic.
- We had thought about asking when people started receiving
Unemployment Insurance (and indeed this was a question we asked
when the questions were being tested), but for space reasons, it
was decided to not ask when people started receiving Unemployment
Insurance
o The addition of a question asking when people who received
UI, started receiving benefits could be a good addition.
Such information would provide even more very useful
information that could shed light on the labor force dynamics
of unemployment insurance, but was not included due to
respondent burden concerns.
o Other timeframes could be entertained, BUT the timeframe
would have to be at least 4 weeks. A one week time frame is
too short to capture the application and receipt dynamic
(i.e. people who have applied for UI in many cases are
unlikely to have received UI benefits within a week of
application, so there would be a bias towards people who
applied not receiving benefits, which in turn would bias
measures of the “success” rate of applications).
- Accumulative data since the start of the pandemic is useful for
comparison to and explorations of why the number of UI benefit
recipients are remaining persistently high, while unemployment
rates measured over the last 4 weeks are dropping.
Time Frame:
Justification for asking bi-weekly
- The Unemployment Insurance program and receipt of benefits is very
dynamic and is evolving, therefore asking questions about UI
application and receipt at a high frequency is extremely useful,
particularly in terms of studying income assistance during the
pandemic.

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Because the receipt of UI benefits can influence how household and
individuals address food purchases and other household needs (such
as medical care), and can influence individuals mental and physical
health, having the receipt of UI measured in conjunction with these
other measures that are being asked in the HH Pulse bi-weekly seems
important.
Time Frame:
Justification for asking bi-weekly
- The Unemployment Insurance program and receipt of benefits is very
dynamic and is evolving, therefore asking questions about UI
application and receipt at a high frequency is extremely useful,
particularly in terms of studying income assistance during the
pandemic.
- Because the receipt of UI benefits can influence how household and
individuals address food purchases and other household needs (such
as medical care), and can influence individuals mental and physical
health, having the receipt of UI measured in conjunction with these
other measures that are being asked in the HH Pulse bi-weekly seems
important.
Section Q14c (employment)
Including yourself, how many people in your household received Unemployment Insurance (UI) benefits
since March 13, 2020? Please enter a number.
Section Q14c Spanish (employment)
Incluido usted, ¿cuántas personas en su hogar recibieron beneficios de Seguro por Desempleo (UI) desde el
13 de marzo de 2020? Por favor, anote un número.
Logic:

•
Display Q14c if # adults in household >1. This can be calculated using embedded data= Q7
– Q8
•
Open end numeric
•
Range: 0 to 40
•
If a respondent enters a number that falls outside of the above range, display the following
message (soft edit):
o
For English: “Please enter a number greater than or equal to 1.”
o
For Spanish: “El valor debe ser superior o igual a 1.”

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Information about application for and receipt of UI benefits is
useful in interpreting measures of unemployment from other surveys
such as the CPS.
- Unemployment Insurance benefits can be an important source of
income for those who have lost jobs, so the receipt of UI benefits
provides important information to be used in combination with other
questions in the survey (for example the mental health questions,
the food insecurity questions and the expenditure questions).
Combining UI benefits receipt information with information from
these other questions can help to provide insights into why
particular answers are being received. In addition the
Unemployment Insurance benefits questions can provide additional
clarity into what particular answers might mean and what
respondents are including in their answers (i.e. the loss of
earnings income questions).
Time Frame:
The reason for asking since March 13th was to obtain a
complete picture of people’s Unemployment Insurance experience since
the pandemic.
- We had thought about asking when people started receiving
Unemployment Insurance (and indeed this was a question we asked
when the questions were being tested), but for space reasons, it
was decided to not ask when people started receiving Unemployment
Insurance
o The addition of a question asking when people who received
UI, started receiving benefits could be a good addition.
Such information would provide even more very useful
information that could shed light on the labor force dynamics
of unemployment insurance, but was not included due to
respondent burden concerns.
o Other timeframes could be entertained, BUT the timeframe
would have to be at least 4 weeks. A one week time frame is
too short to capture the application and receipt dynamic
(i.e. people who have applied for UI in many cases are
unlikely to have received UI benefits within a week of
application, so there would be a bias towards people who
applied not receiving benefits, which in turn would bias
measures of the “success” rate of applications).
- Accumulative data since the start of the pandemic is useful for
comparison to and explorations of why the number of UI benefit
recipients are remaining persistently high, while unemployment
rates measured over the last 4 weeks are dropping.
Time Frame:
Justification for asking bi-weekly
- The Unemployment Insurance program and receipt of benefits is very
dynamic and is evolving, therefore asking questions about UI
application and receipt at a high frequency is extremely useful,
particularly in terms of studying income assistance during the
pandemic.
- Because the receipt of UI benefits can influence how household and
individuals address food purchases and other household needs (such
as medical care), and can influence individuals mental and physical
health, having the receipt of UI measured in conjunction with these
other measures that are being asked in the HH Pulse bi-weekly seems
important.

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Section Q14d (employment)
Do you currently receive Social Security benefits (Retirement, Disability, or Survivors), Supplemental
Security Income (SSI) benefits, or Medicare benefits? Select only one answer.
1) Yes
2) No
Section Q14d Spanish (employment)
¿Recibe actualmente beneficios de Seguro Social (ya sea por Jubilación, Discapacidad o Sobreviviente), o
beneficios de Seguridad de Ingreso Suplementario (“SSI” por sus siglas en inglés), o beneficios de
Medicare? Seleccione solo una respuesta.
1) Sí
2) No
Logic:
•
•

•

Only one response permitted

Justification: These data are necessary to assess any impact of
the pandemic on people’s claiming of retirement benefits early
and/or disability applications. This item is critical to identify
respondents already getting SSA benefits, it helps screen the
intent to apply and follow-up items.
Time Frame:
This set of items are necessary on each iteration
of data collection to follow changes in the proportion of nonrecipients applying and getting benefits.

Section Q14e (employment)
Did you apply or attempt to apply for Social Security benefits (Retirement, Disability, or Survivors),
Supplemental Security Income (SSI) benefits, or Medicare benefits after March 13, 2020? Select only
one answer.
1) Yes, applied or attempted to apply
2) No
Section Q14e Spanish (employment)
¿Solicitó o intentó solicitar beneficios de Seguro Social (ya sea por Jubilación, Discapacidad o
Sobreviviente), beneficios de Seguridad de Ingreso Suplementario (SSI), o beneficios de Medicare después
del 13 de marzo de 2020? Seleccione solo una respuesta.
1) Sí, solicité o intenté solicitar
2) No
Logic:
•
•

•
•

Only one response permitted

Justification: These data are necessary to assess any impact of
the pandemic on people’s claiming of retirement benefits early
and/or disability applications. This item is critical to identify

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

respondents already getting SSA benefits, it helps screen the
intent to apply and follow-up items.
Time Frame:
This set of items are necessary on each iteration
of data collection to follow changes in the proportion of nonrecipients applying and getting benefits. This item uses March 13,
2020 as the reference time point for understanding the cumulative
experience since the start of the pandemic.

Section Q14f (employment)
What type of benefits did you apply or attempt to apply for since March 13, 2020? Select all that apply.
1) Social Security Retirement
2) Social Security Disability
3) Social Security Survivors
4) Supplemental Security Income (SSI)
5) Medicare
Section Q14f Spanish (employment)
¿Qué tipo de beneficios solicitó o intentó solicitar desde el 13 de marzo de 2020? Seleccione todas las que
correspondan.
1)
2)
3)
4)
5)
Logic:
•
•

•

•
•

Jubilación de Seguro Social
Discapacidad de Seguro Social
Sobreviviente de Seguro Social
Seguridad de Ingreso Suplementario (SSI)
Medicare
Display Q14f if Q14e = 1
Multiple responses permitted

Justification: These data are necessary to assess any impact of
the pandemic on people’s claiming of retirement benefits early
and/or disability applications. This item identifies which program
or programs the respondents applied for.
Time Frame:
This set of items are necessary on each iteration
of data collection to follow changes in the proportion of nonrecipients applying and getting benefits. This item uses March 13,
2020 as the reference time point for understanding the cumulative
experience since the start of the pandemic.

Section Q14g (employment)
How likely are you to apply for Social Security benefits (Retirement, Disability, or Survivors),
Supplemental Security Income (SSI) benefits, or Medicare benefits in the next 12 months?
Select only one answer.
1) Extremely likely
2) Very likely
3) Somewhat likely

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

4) Not at all likely
Section Q14g Spanish (employment)
¿Qué tan probable es que solicite beneficios de Seguro Social (ya sea de Jubilación, Discapacidad o
Sobreviviente), beneficios de Seguridad de Ingreso Suplementario (SSI), o beneficios de Medicare en los
próximos 12 meses? Seleccione solo una respuesta.
1)
2)
3)
4)
Logic:
•
•

•

•
•

Extremadamente probable
Muy probable
Algo probable
Nada probable
Display Q14g if Q14e = 2
Only one response permitted

Justification: These data are necessary to assess any impact of
the pandemic on people’s claiming of retirement benefits early
and/or disability applications. This item identifies how likely
respondents are to apply for SSA benefits over the next 12 months
given that they had not applied at the time of the survey.
Time Frame:
This set of items are necessary on each iteration
of data collection to follow changes in the proportion of nonrecipients applying and getting benefits. This item uses the next
12-months as the reference time point for prospectively gauging the
likelihood of applying.

•
Section Q14h (employment)
What type of benefits do you think that you will apply for? Select all that apply.
1) Social Security Retirement
2) Social Security Disability
3) Social Security Survivors
4) Supplemental Security Income (SSI)
5) Medicare
Section Q14h Spanish (employment)
¿Qué tipo de beneficios piensa que solicitará? Seleccione todas las que correspondan.
1) Jubilación de Seguro Social
2) Discapacidad de Seguro Social
3) Sobreviviente de Seguro Social
4) Seguridad de Ingreso Suplementario (SSI)
5) Medicare
Logic:

•
•

Display Q14h if Q14g in (1,2,3)
Multiple responses permitted

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•
•

•

Justification: These data are necessary to assess any impact of
the pandemic on people’s claiming of retirement benefits early
and/or disability applications. This item identifies which program
or programs the respondents applied for.
Time Frame:
This set of items are necessary on each iteration
of data collection to follow changes in the proportion of nonrecipients applying and getting benefits. This item uses the next
12-months as the reference time point for prospectively gauging the
likelihood of applying.

Section Q14i (employment)
How has the coronavirus pandemic affected your decision about applying or not applying for

Social Security benefits (Retirement, Disability, or Survivors), Supplemental Security
Income (SSI) benefits, or Medicare benefits? Select only one answer.

1) The coronavirus pandemic has not affected my decision about applying for benefits
2) I have decided not to apply
3) I applied or decided to apply earlier than expected
4) I applied or decided to apply later than expected
Section Q14i Spanish (employment)
¿Cómo ha impactado la pandemia del coronavirus su decisión de solicitar o no a beneficios de
Seguro Social (ya sea de Jubilación, Discapacidad o Sobreviviente), beneficios de Seguridad de
Ingreso Suplementario (SSI), o beneficios de Medicare? Seleccione solo una respuesta.
1)
2)
3)
4)
Logic:

•
•

•

•
•

La pandemia del coronavirus no ha afectado mi decisión de solicitar beneficios
He decidido no solicitar beneficios
He solicitado, o decidí solicitar, antes de lo esperado
He solicitado, o decidí solicitar, después de lo esperado
Display to everyone
Only one response permitted

Justification: These data are necessary to assess any impact of
the pandemic on people’s claiming of retirement benefits early
and/or disability applications. This item identifies how likely
respondents are to apply for SSA benefits over the next 12 months
given that they had not applied at the time of the survey.
Time Frame:
This set of items are necessary on each iteration
of data collection to follow changes in the proportion of nonrecipients applying and getting benefits. This item follows up the
likelihood of application with a ‘how has coronavirus changed your
decision’ question. It therefore uses the same inherent next 12months as the reference time point for prospectively gauging the
likelihood of applying.

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Section Q15 (stimulus questions) - [PROGRAM BUT KEEP ON HOLD UNTIL FURTHER NOTICE]
In the last 7 days, if you or anyone in your household received a “stimulus payment,” that is a coronavirus
related Economic Impact Payment from the Federal Government, did you: Select only one answer.
1)
2)
3)
4)

Mostly spend it
Mostly save it
Mostly use it to pay off debt
Not applicable, I did not receive the stimulus payment

Section Q15 Spanish (stimulus questions) - [PROGRAM BUT KEEP ON HOLD UNTIL FURTHER NOTICE]
En los últimos 7 días, si usted o alguien en su hogar recibió un "pago de estímulo", que es un pago del
gobierno federal por el impacto económico relacionado con el coronavirus, usted: Seleccione solo una
respuesta.
1)
2)
3)
4)
Logic:
•

•

Gastó la mayor parte
Ahorró la mayor parte
Usó la mayor parte para pagar deudas
No aplica, no recibí el pago de estímulo

•
Only one response permitted
Justification: This item was added late in Phase 1, it is a
critical measure to identify households that may have access to the
resource provided by the economic impact/stimulus payments. This
item complements information about losses of employment income, and
use of other benefits programs to offset the impact of the
pandemic. This item can be held off the interview instrument in
Phase 2 until a bill for an additional impact payment is passed.
To understand, objectively and with immediacy, individuals’
employment experience in this pandemic, e.g., the degree to which
they have lost employment income; experienced changes in work
status; and/or are now working without pay.
What strategies households are taking to manage economic impacts
from Covid-19, including use of impending stimulus payments,
unemployment insurance benefits, borrowing from family or friends,
taking on additional debt, withdrawing from savings, or using their
own sources of income.
Expectations individuals have with regard to the economic impact
(stimulus) payments; how much they expect to (or have) received;
and how it was (or will be) spent, e.g., essential needs (food,
medical care, home), debt reduction, savings or more discretionary
consumer spending.
For many the economic impact payment will enable them to remain
afloat financially; for others it will not be sufficient to cover
basic needs; and for some it will add income to what they are
currently receiving. Understanding how the stimulus is received

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

and used and will inform additional efforts by federal, state, and
local governments to make targeted decisions about additional
interventions under consideration.
Time Frame:
This item was established to ask about the
economic impact payment which was assumed to possibly have multiple
disbursements. Also with the delays in the program, targeting a
specific reference date was not expected to be as useful as
understanding the receipt and use of the impact payments overall.

Section Q19 (stimulus questions) - [PROGRAM BUT KEEP ON HOLD UNTIL FURTHER NOTICE]
What did you and your household mostly spend the most recent “stimulus payment” on? Select all that
apply.
1. Food (groceries, eating out, take out)
2. Clothing (clothing, accessories, shoes)
3. Household supplies and personal care products
4. Household items (TV, electronics, furniture, appliances)
5. Recreational goods (sports and fitness equipment, bicycles, toys, games)
6. Rent
7. Mortgage (scheduled or monthly)
8. Utilities and telecommunications (natural gas, electricity, cable, internet, cell phone)
9. Vehicle payments (scheduled or monthly)
10. Paying down credit card, student loans or other debts
11. Charitable donations or giving to family members
12. Saved or invested
13. Other, specify
Section Q19 Spanish (stimulus questions) - [PROGRAM BUT KEEP ON HOLD UNTIL FURTHER NOTICE]
¿En qué gastaron usted y las personas en su hogar la mayor parte del “pago de estímulo” más reciente?
Seleccione todas las que correspondan.
o Comida (compras en supermercados, comer en restaurantes, comida para llevar)
o Ropa (ropa, accesorios, zapatos)
o Suministros para el hogar y productos de aseo personal
o Artículos para el hogar (TV, equipos electrónicos, muebles, electrodomésticos)
o Productos recreativos (equipos deportivos y de entrenamiento, bicicletas, juguetes, juegos)
o Alquiler/renta
o Hipoteca (programada o mensual)
o Servicios públicos y telecomunicaciones (gas natural, electricidad, cable, Internet, teléfono celular)
o Pagos de un vehículo (programados o mensuales)
o Pago de tarjeta de crédito, préstamos estudiantiles o alguna otra deuda
o Donaciones a instituciones caritativas o a parientes
o Lo ahorró o lo invirtió
o Otro, especifique
Logic:
• Universe: If Q15 in (1,2,3)
• Multiple responses permitted
•

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

Justification: This item was added late in Phase 1, it is a
critical measure to identify households that may have access to the
resource provided by the economic impact/stimulus payments. This
item complements information about losses of employment income, and
use of other benefits programs to offset the impact of the
pandemic. This item can be held off the interview instrument in
Phase 2 until a bill for an additional impact payment is passed. In
combination with the receipt of impact/stimulus payments item, this
item helps understand how those funds are used.
To understand, objectively and with immediacy, individuals’
employment experience in this pandemic, e.g., the degree to which
they have lost employment income; experienced changes in work
status; and/or are now working without pay.
What strategies households are taking to manage economic impacts
from Covid-19, including use of impending stimulus payments,
unemployment insurance benefits, borrowing from family or friends,
taking on additional debt, withdrawing from savings, or using their
own sources of income.
Expectations individuals have with regard to the economic impact
(stimulus) payments; how much they expect to (or have) received;
and how it was (or will be) spent, e.g., essential needs (food,
medical care, home), debt reduction, savings or more discretionary
consumer spending.
For many the economic impact payment will enable them to remain
afloat financially; for others it will not be sufficient to cover
basic needs; and for some it will add income to what they are
currently receiving. Understanding how the stimulus is received
and used and will inform additional efforts by federal, state, and
local governments to make targeted decisions about additional
interventions under consideration.
Time Frame:
This item was established to ask about the
economic impact payment which was assumed to possibly have multiple
disbursements. Also with the delays in the program, targeting a
specific reference date was not expected to be as useful as
understanding the receipt and use of the impact payments overall.
It is important to have on each collection to provide information
about EIP in the context of other characteristics or responses.

Section Q19a ()
In the last 7 days, how difficult has it been for your household to pay for usual household expenses,
including but not limited to food, rent or mortgage, car payments, medical expenses, student loans, and so
on? Select only one answer.
1)
2)
3)
4)

Not at all difficult
A little difficult
Somewhat difficult
Very difficult

Section Q19a Spanish ()
En los últimos 7 días, ¿qué tan difícil ha sido para su hogar pagar los gastos habituales del hogar,

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

incluyendo, entre otros, comida, renta o hipoteca, pagos de autos, gastos médicos, préstamos estudiantiles
y otros gastos? Seleccione solo una respuesta.
1)
2)
3)
4)
Logic:

Nada difícil
Un poco difícil
Algo difícil
Muy difícil
Only one response permitted

•

Justification: This item is a critical measure of how difficult it is
for households meet their spending needs. As the pandemic continues
to impact the family economy, this item allows the reporting of the
mix of resource sources used. It is critical to include on each
interview, as the mix can be expected to change as reserves are
expended.
Time Frame:
This item was established to ask about the weekly
difficulty to pay for usual expenses and uses the ‘last seven days’
as the reference period. For many parts of the economy, wages are
weekly or hourly, and this frequency and reference period allows for
rapid collection and understanding of the changing mix and the
interaction with other HPS survey items.
Section Q19b ()
In the last 7 days, which of the following changes have you or your household made to your spending
or shopping? Select all that apply.
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)

More purchases online (as opposed to in store)
More purchases by curbside pick-up (as opposed to in store)
More purchases in-store (as opposed to purchases online or curbside pickup)
Increased use of credit cards or smartphone apps for purchases, instead of using cash
Avoided eating at restaurants
Resumed eating at restaurants
Canceled or postponed in-person medical or dental appointments
Attended in-person medical or dental appointments
Canceled or postponed housekeeping or caregiving services
Resumed or started new housekeeping or caregiving services
Did not make any changes to spending or shopping behavior

Section Q19b Spanish ()
En los últimos 7 días, ¿cuáles de los siguientes cambios en sus hábitos de gasto o compra ha hecho
usted o alguien en su hogar? Seleccione todas las que correspondan.
1) He realizado más compras por internet (en vez de comprar en la tienda)
2) He realizado más compras que me traen a la calle mientras espero en el carro (en vez de
entrar en la tienda)
3) He realizado más compras en las tiendas (en lugar de compras por internet o compras para
recoger frente a la tienda)
4) He usado con más frecuencia las tarjetas de crédito, o aplicaciones en teléfonos

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

inteligentes, para pagar por las compras, en vez de usar dinero en efectivo
He evitado salir a comer en restaurantes
He evitado salir a comer en restaurantes
He cancelado o retrasado citas médicas o dentales en persona
He asistido en persona a las citas médicas o dentales
Ha cancelado o retrasado servicios de limpieza de casa o servicios de cuidado
He vuelto a recibir o he empezado a recibir servicios de limpieza de casa o servicios de
cuidado
11) No he hecho cambios en mis hábitos de gasto o compra
5)
6)
7)
8)
9)
10)

Logic:
•

•

•
Multiple responses permitted
Justification: This item is a critical measure about how spending
or shopping behavior changes. As the pandemic continues to impact
the family economy, this item allows the reporting whether new
changes in behavior around spending have occurred in the last seven
days. As the economy opens or constricts, these responses will
allow monitoring of the types of changes. It is critical to include
on each interview, as the proportion saying the pandemic is now
making it more difficult, and whether there are changes in behavior
from week to week.
Time Frame:
This item was established to ask about the weekly
impact of the pandemic on the ability to pay and uses the ‘last
seven days’ as the reference period. For many parts of the economy,
wages are weekly or hourly, and this frequency and reference period
allows for rapid collection and understanding of the changing mix
and the interaction with other HPS survey items.

Section Q19c ()
In the last 7 days, for which of the following reasons have you or your household changed spending? Select
all that apply.
1) Place where I usually shop or spend was closed or had limited hours (e.g., restaurant,
doctor/dentist office, health club, hair salon, child care center, etc.)
2) Place where I usually shop or spend re-opened or increased hours
3) Concerned about going to public or crowded places or having contact with high-risk people
4) No longer concerned about going to public or crowded places or having contact with high-risk
people
5) Loss of income
6) Increased income
7) Concerns about being laid off or having hours reduced
8) No longer concerned about being laid off or having hours reduced
9) Working from home/teleworking
10) Resumed working at my workplace
11) Concerns about the economy
12) No longer concerned about the economy
13) Other, specify:
Section Q19c Spanish ()
En los últimos 7 días, ¿por cuáles de las siguientes razones usted o alguien en su hogar ha hecho
cambios en sus gastos? Seleccione todas las que correspondan.

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

1) El lugar donde hago compras o gasto dinero habitualmente cerró o tiene un horario limitado (por
ejemplo, restaurante, consulta del médico/dentista, gimnasio, peluquería, guardería, etc.)
2) El lugar donde hago compras o gasto dinero habitualmente volvió a abrir o aumentó el horario de
servicio
3) Me preocupa ir a lugares públicos o donde haya muchas personas, o tener contacto con personas
de alto riesgo
4) Ya no me preocupa ir a lugares públicos o donde haya muchas personas, o tener contacto con
personas de alto riesgo
5) Pérdida de ingresos
6) Aumento en ingresos
7) Me preocupa un posible despido o reducción de horas de trabajo
8) Ya no me preocupa un posible despido o reducción de horas de trabajo
9) Estoy trabajando desde casa/teletrabajo
10) Regresé a trabajar desde el lugar habitual de mi trabajo
11) Me preocupa la economía
12) Ya no me preocupa la economía
13) Otro, especifique:
Logic:
•

•

•
Multiple responses permitted
Justification: This item is a critical measure about why spending
or shopping behavior changes. As the pandemic continues to impact
the family economy, this item allows the reporting whether new
changes in behavior around spending have occurred in the last seven
days and why. As the economy opens or constricts, these responses
will allow monitoring of the types of changes. It is critical to
include on each interview, as the proportion saying the pandemic is
now making it more difficult, and whether there are changes in
behavior from week to week.
Time Frame:
This item was established to ask about the weekly
impact of the pandemic on the ability to pay and uses the ‘last
seven days’ as the reference period. For many parts of the economy,
wages are weekly or hourly, and this frequency and reference period
allows for rapid collection and understanding of the changing mix
and the interaction with other HPS survey items.

Section Q20 (stimulus questions)
Thinking about your experience in the last 7 days, which of the following did you or your household
members use to meet your spending needs? Select all that apply.
1) Regular income sources like those received before the pandemic
2) Credit cards or loans
3) Money from savings or selling assets
4) Borrowing from friends or family
5) Unemployment insurance (UI) benefit payments
6) Stimulus (economic impact) payment
7) Money saved from deferred or forgiven payments (to meet your spending needs)
8) Supplemental Nutrition Assistance Program (SNAP)
Section Q20 Spanish (stimulus questions)

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Pensando en sus experiencias en los en los últimos 7 días, ¿cuál de los siguientes recursos usó usted, o
miembros de su hogar, para poder cubrir sus gastos? Seleccione todas las que correspondan.
1) Fuentes de ingresos regulares, como las recibidas antes de la pandemia
2) Tarjetas de crédito o préstamos
3) Dinero de los ahorros o de la venta de sus bienes
4) Dinero prestado por familiares o amigos
5) Pagos de los beneficios de seguro por desempleo (UI por sus siglas en inglés)
6) Pago de estímulo (impacto económico)
7) Dinero ahorrado de pagos suspendidos o perdonados (para cubrir sus gastos)
8) Programa de Asistencia Nutricional Suplementaria (SNAP por sus siglas en inglés)
Logic:

•

Multiple responses permitted

Justification: This item was added late in Phase 1, it is a critical
measure to how households meet their spending needs. As the pandemic
continues to impact the family economy, this item allows the
reporting of the mix of resource sources used. It is critical to
include on each interview, as the mix can be expected to change as
reserves are expended.
Time Frame:
This item was established to ask about the weekly mix of
resources used and uses the ‘last seven days’ as the reference
period. For many parts of the economy, wages are weekly or hourly,
and this frequency and reference period allows for rapid collection
and understanding of the changing mix and the interaction with other
HPS survey items.
Section Q21a (employment)
In the last 7 days, have you taken fewer trips to stores than you normally would have because of the
coronavirus pandemic? Curbside pick-up should be counted as trips to stores. Select only one answer.
1) Yes
2) No
Section Q21a Spanish (employment)
En los últimos 7 días, ¿ha ido usted menos veces a las tiendas de lo que hubiera hecho normalmente
debido a la pandemia del coronavirus? Las compras que le traen a la calle mientras espera en el carro
cuentan como visita a las tiendas. Seleccione solo una respuesta.
1) Sí
2) No
Logic:
•
•

•

Only one response permitted

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

telework is many-fold, the focus in this series is on
transportation and transit changes.
Time Frame:
This question asks the changes in ‘trip’ behavior
over the last seven-days. The question is looking for suppressed
transportation behavior over the last seven days in comparison to
the normal non-pandemic transportation. An additional non-pandemic
time frame is not necessary for this item because it focuses on
differences from the ‘normal’ transportation trips the respondent
would have taken prior to the coronavirus pandemic.

Section Q21b (employment)
In the last 7 days, have you taken fewer trips than you normally would have by bus, rail, or ride-sharing
services, like Uber and Lyft, because of the coronavirus pandemic? Select only one answer.
1) Yes
2) No
3) Did not use before
Section Q21b Spanish (employment)
En los últimos 7 días, ¿ha hecho usted menos viajes de los que haría normalmente ya sea en autobús, tren
o viajes compartidos, como Uber y Lyft, debido a la pandemia del coronavirus? Seleccione solo una
respuesta.
1) Sí
2) No
3) No los usaba antes
Logic:
•
•

•

Only one response permitted

Section Q21c (employment)
Before the coronavirus pandemic, did you plan to take any overnight trips or trips to places more than 100
miles away in 2020? Include trips you had not made travel reservations or arrangements for in your
answer. Select only one answer.
1) Yes
2) No

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Section Q21c Spanish (employment)
Antes de la pandemia del coronavirus, ¿había planeado hacer algún viaje pasando la noche o viajes a
lugares a más de 100 millas de distancia en 2020? Incluya en su respuesta viajes para los cuales todavía no
había hecho reservaciones o arreglos. Seleccione solo una respuesta.
1) Sí
2) No
Logic:
•
•

•

Only one response permitted

•
Section Q21d (employment)
Were any of these trips cancelled because of the coronavirus pandemic? Include trips you had not made
travel reservations or arrangements for in your answer. Select only one answer.
1) Yes
2) No
Section Q21d Spanish (employment)
¿Fue cancelado alguno de estos viajes debido a la pandemia del coronavirus? Incluya en su respuesta viajes
para los cuales todavía no había hecho reservaciones o arreglos. Seleccione solo una respuesta.
1) Sí
2) No
Logic:

•
•

Display Q13e if Q13d = 1
Only one response permitted

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

telework is many-fold, the focus in this series is on
transportation and transit changes.
100 miles indicates a trip of a more substantial nature. While a
smaller distance might have been used, this limit, and the focus on
overnight trips should focus on trips that generally required more
planning and greater consequence for cancellation.
Time Frame:
This question asks about cancelled trips due to
the coronavirus pandemic for the year 2020. The focus of this item
is to follow-up about cancelled plans. The question also focuses on
the cumulative experience.

•

/* END PAGE */
/* START PAGE */
Page Title: Food Security
Section Q23 (food security)
Getting enough food can also be a problem for some people. Which of these statements best describes the
food eaten in your household before March 13, 2020? Select only one answer.
1) Enough of the kinds of food (I/we) wanted to eat
2) Enough, but not always the kinds of food (I/we) wanted to eat
3) Sometimes not enough to eat
4) Often not enough to eat
Section Q23 Spanish (food security)

Conseguir suficiente comida también puede ser un problema para algunas personas. ¿Cuál de estas declaraciones
describe mejor las comidas que comieron en su hogar antes del 13 de marzo de 2020? Seleccione solo una respuesta.

1) Suficiente cantidad de los tipos de comida que (yo/nosotros) quería(mos) comer
2) Suficiente cantidad, pero no siempre los tipos de comida que (yo/nosotros) quería(mos)
comer
3) A veces no había suficiente para comer
4) A menudo no había suficiente para comer

Logic:

•

•
Only one response permitted
•
Note all respondents will then be asked Q24, regardless of response to Q23
•
Justification: This item provides a general baseline for food
sufficiency among the respondents to the HPS. By asking this item,
subsequent items can be put into context around how the food
sufficiency experience changes following the start of the pandemic.
The Economic Research Service (ERS) monitors food security in U.S.
households annually. The Covid-19 Household Pulse Survey provides
real-time surveillance and monitoring of food security status on an
ongoing basis.

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

The COVID pandemic has elevated the households’ needs for
accessing emergency food and other food assistance programs. These
data will be used to understand how households are responding to
food hardships and what resources are available in their
communities.
The balance of food-at-home and food-away-from-home spending
are shifting in response to the Covid-19 pandemic. These data
enable us to understand how spending patterns shift as the
situation unfolds.
Time Frame:
This is a baseline status that is necessary in
each administration to put the recent experience into context. This
item is not included in isolation, and is necessary in combination
with the other HPS survey items.

Section Q24 (food security)
In the last 7 days, which of these statements best describes the food eaten in your household? Select only
one answer.
1) Enough of the kinds of food (I/we) wanted to eat
2) Enough, but not always the kinds of food (I/we) wanted to eat
3) Sometimes not enough to eat
4) Often not enough to eat
Section Q24 Spanish (food security)
En los últimos 7 días, ¿cuál de estas declaraciones describe mejor las comidas que comieron en su hogar?
Seleccione solo una respuesta.
1) Suficiente cantidad de los tipos de comida que (yo/nosotros) quería(mos) comer
2) Suficiente cantidad, pero no siempre los tipos de comida que (yo/nosotros) quería(mos)
comer
3) A veces no había suficiente para comer
4) A menudo no había suficiente para comer
Logic:
•
Only one response permitted
• Justification: This item provides a recent food sufficiency
context to provide an estimate of current household food resources.
This item combined with the general baseline for food sufficiency
among the respondents allows for an approximation of the degree to
which food sufficieny has gotten better or worse and can be put
into context of the other items in the HPS.
• The Economic Research Service (ERS) monitors food security in U.S.
households annually. The Covid-19 Household Pulse Survey provides
real-time surveillance and monitoring of food security status on an
ongoing basis.
•
The COVID pandemic has elevated the households’ needs for
accessing emergency food and other food assistance programs. These
data will be used to understand how households are responding to
food hardships and what resources are available in their
communities.
•
The balance of food-at-home and food-away-from-home spending
are shifting in response to the Covid-19 pandemic. These data

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

enable us to understand how spending patterns shift as the
situation unfolds.
•
•

Time Frame:
This is an item that asks about the ‘last seven
days’ status that is necessary in each administration to put the
recent experience into context, and analyze with other
contemporaneous characteristics and background variables.

Section Q24a (food security)
Please indicate whether the next statement was often true, sometimes true, or never true in the last 7
days for the children living in your household who are under 18 years old.
"The children were not eating enough because we just couldn't afford enough food."
1) Often true
2) Sometimes true
3) Never true
Section Q24a Spanish (food security)
Por favor, indique si la siguiente declaración era cierta con frecuencia, a veces cierta o nunca fue cierta en
los últimos 7 días para los niños que viven en su hogar que tienen menos de 18 años.
"Los niños no comían lo suficiente porque no había dinero para comprar suficiente comida".
1) Cierta con frecuencia
2) A veces cierta
3) Nunca fue cierta
Logic:
• ASK Q24a IF Q24 NE 1 AND Q8 >0. ELSE SKIP TO Q24
• Only one response permitted
• Justification: This item provides a recent child food sufficiency
context to provide an estimate of whether children have enough food
to eat. This item combined with the food sufficiency items help
develop a picture of how children may be impacted differently and
can be put into context of the other items in the HPS.
• The Economic Research Service (ERS) monitors food security in U.S.
households annually. The Covid-19 Household Pulse Survey provides
real-time surveillance and monitoring of food security status on an
ongoing basis.
•
The COVID pandemic has elevated the households’ needs for
accessing emergency food and other food assistance programs. These
data will be used to understand how households are responding to
food hardships and what resources are available in their
communities.
•
The balance of food-at-home and food-away-from-home spending
are shifting in response to the Covid-19 pandemic. These data
enable us to understand how spending patterns shift as the
situation unfolds.
•

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

Section Q25 (food security)
Why did you not have enough to eat (or not what you wanted to eat)? Select all that apply.
1)
Couldn’t afford to buy more food
2)
Couldn’t get out to buy food (for example, didn’t have transportation, or had mobility
or health problems that prevented you from getting out)
3)
Afraid to go or didn’t want to go out to buy food
4)
Couldn’t get groceries or meals delivered to me
5)
The stores didn’t have the food I wanted
Section Q25 Spanish (food security)
¿Por qué no tenía lo suficiente para comer (o no tenía lo que quería comer)? Seleccione todas las que
correspondan
1) No había suficiente dinero para comprar más comida.
2) No podía salir a comprar comida (por ejemplo no tenía transporte, o tenía problemas de
movilidad o de salud que le impedía salir).
3) Tenía miedo a ir o no quería salir a comprar comida.
4) No logró que le llevaran o entregaran comida a su casa.
5) Las tiendas no tenían la comida que quería.
Logic:
•
Multiple responses permitted
•
If Q24 in (2,3,4) then ask Q25
• Justification: This item provides a set of reasons that may be
selected as contributing to the reported food insufficiency. Asking
this item only for those reporting some degree of food
insufficiency, helps identify some of the underlying reasons. This
item is in the context of recent food insufficiency and can be
expected to provide important underlying information to use in
combination with other HPS items.
• The Economic Research Service (ERS) monitors food security in U.S.
households annually. The Covid-19 Household Pulse Survey provides
real-time surveillance and monitoring of food security status on an
ongoing basis.
•
The COVID pandemic has elevated the households’ needs for
accessing emergency food and other food assistance programs. These
data will be used to understand how households are responding to
food hardships and what resources are available in their
communities.
•
The balance of food-at-home and food-away-from-home spending
are shifting in response to the Covid-19 pandemic. These data
enable us to understand how spending patterns shift as the
situation unfolds.
•
• Time Frame:
This is an item follows up the recent experience
that asks about the ‘last seven days’ status. It is necessary to
include in each administration to put the recent experience into

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

context, and analyze with other contemporaneous characteristics and
background variables.
Section Q26 (food security)
During the last 7 days, did you or anyone in your household get free groceries or a free meal? Select only
one answer.
1) Yes
2) No
Section Q26 Spanish (food security)
Durante los últimos 7 días, ¿consiguió usted o alguien en su hogar alimentos gratis o una comida gratis?
Seleccione solo una respuesta.
1) Sí
2) No
Logic:
•
Only one response permitted
• Justification: Household food insufficiency has been a
characteristic associated with job loss and other economic impacts.
The ability to get free food helps households meet their food
needs, and this item provides some information as to the degree
that type of service is utilized. There are no other estimates at
the state or national level that provide this as a population
estimate. This item is in the context of recent food insufficiency
and can be expected to provide important underlying information to
use in combination with other HPS items.
• The Economic Research Service (ERS) monitors food security in U.S.
households annually. The Covid-19 Household Pulse Survey provides
real-time surveillance and monitoring of food security status on an
ongoing basis.
•
The COVID pandemic has elevated the households’ needs for
accessing emergency food and other food assistance programs. These
data will be used to understand how households are responding to
food hardships and what resources are available in their
communities.
•
The balance of food-at-home and food-away-from-home spending
are shifting in response to the Covid-19 pandemic. These data
enable us to understand how spending patterns shift as the
situation unfolds.
•
• Time Frame:
This is an item follows up the recent experience
that asks about the ‘last seven days’ status. It is necessary to
include in each administration to put the recent experience into
context, and analyze with other contemporaneous characteristics and
background variables.
Section Q27 (food security)
Where did you get free groceries or free meals? Select all that apply.
1) Free meals through the school or other programs aimed at children
2) Food pantry or food bank

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

3)
4)
5)
6)
7)

Home-delivered meal service like Meals on Wheels
Church, synagogue, temple, mosque or other religious organization
Shelter or soup kitchen
Other community program
Family, friends, or neighbors

Section Q27 Spanish (food security)
¿Dónde consiguió alimentos gratis o una comida gratis? Seleccione todas las que correspondan.
1) Comidas gratis a través de la escuela u otros programas dirigidos a niños
2) Despensa de alimentos o banco de alimentos
3) Servicio de comidas entregadas a su casa, como Meals on Wheels
4) Iglesia, sinagoga, templo, mezquita u otra organización religiosa
5) Refugio o comedor de beneficencia
6) Otro programa comunitario
7) Familia, amigos o vecinos
Logic:
•

•

•
•

•
If Q26 = 1 then ask Q27
Justification: Household food insufficiency has been a
characteristic associated with job loss and other economic impacts.
The ability to get free food helps households meet their food
needs, and this item provides some information about the source of
the free food. Understanding where the population is getting free
food can help planning and resource allocation to meet food
sufficiency needs. There are no other estimates at the state or
national level that provide this as a population estimate. This
item is in the context of recent food insufficiency and can be
expected to provide important underlying information to use in
combination with other HPS items.
The Economic Research Service (ERS) monitors food security in U.S.
households annually. The Covid-19 Household Pulse Survey provides
real-time surveillance and monitoring of food security status on an
ongoing basis.
The COVID pandemic has elevated the households’ needs for
accessing emergency food and other food assistance programs. These
data will be used to understand how households are responding to
food hardships and what resources are available in their
communities.
The balance of food-at-home and food-away-from-home spending
are shifting in response to the Covid-19 pandemic. These data
enable us to understand how spending patterns shift as the
situation unfolds.
Time Frame:
This is an item follows up the recent experience
that asks about the ‘last seven days’ status. It is necessary to
include in each administration to put the recent experience into
context, and analyze with other contemporaneous characteristics and
background variables.

Section Q27a (food security)

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Do you or does anyone in your household receive benefits from the Supplemental Nutrition
Assistance Program (SNAP) or the Food Stamp Program? Select only one answer.
1) Yes
2) No
Section Q27a Spanish (food security)
¿Usted o alguien en su hogar recibe beneficios del Programa de Asistencia Nutricional Suplementaria
(SNAP) o el Programa de Cupones de Alimentos? Seleccione solo una respuesta.
1) Sí
2) No
Logic:
•
Only one response permitted
•
• Justification: The biweekly collection of current SNAP enrollment
data will allow us to track changes in SNAP participation during
rapidly changing economic circumstances. It complements the HPS
questions about food insufficiency and free food. The question will
be used to understand how SNAP participation relates to food
insufficiency and other outcomes during the pandemic. We know that
reported participation in assistance programs is underreported and
affected by recall bias. Including this item on a rapid response
survey at each administration will help to overcome that recall
bias and provide near real-time estimation of relationship between
SNAP and other outcomes.
• The Economic Research Service (ERS) monitors food security in U.S.
households annually. The Covid-19 Household Pulse Survey provides
real-time surveillance and monitoring of food security status on an
ongoing basis.
•
The COVID pandemic has elevated the households’ needs for
accessing emergency food and other food assistance programs. These
data will be used to understand how households are responding to
food hardships and what resources are available in their
communities.
•
The balance of food-at-home and food-away-from-home spending
are shifting in response to the Covid-19 pandemic. These data
enable us to understand how spending patterns shift as the
situation unfolds.
•
• Time Frame:
This item will capture cross-sectional prevalence
estimates. Current status estimates are desired to support
understanding how the SNAP program supports the HPS food
sufficiency reports. SNAP data from other sources have a
significant lag and/or complexity because of it’s decentralized
administrative records framework.
•
Section Q27b (food security)
In which month(s) were SNAP or food stamp benefits received? Select all that apply.
1) January 2020

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

2)
3)
4)
5)
6)
7)
8)
9)
10)
11)

February 2020
March 2020
April 2020
May 2020
June 2020
July 2020
August 2020
September 2020
October 2020
November 2020

Section Q27b Spanish (food security)
¿En cuál(es) mes(es) recibió beneficios de SNAP o de cupones de alimentos? Seleccione todas las que
correspondan.
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
Logic:

•
•

•

•
•
•

Enero de 2020
Febrero de 2020
Marzo de 2020
Abril de 2020
Mayo de 2020
Junio de 2020
Julio de 2020
Agosto 2020
Septiembre 2020
Octubre 2020
Noviembre 2020
Display Q27b if Q27a = 1.
Multiple responses permitted
Display will add August and subsequent months as Pulse survey continues

Justification: We would like to include the history of SNAP
participation throughout 2020 because the information will be
useful for understanding which current households have enrolled
during the pandemic. This information could also help understand
how changes to SNAP implemented in response to the COVID pandemic
have affected participation and impacted food sufficiency. Being
able to link reported SNAP participation during 2020 from the Pulse
survey with information on the rollout of these SNAP flexibilities
will enable more timely research on the impacts of these program
changes on participation, food insufficiency and other outcomes
than will be possible from other surveys.
The Economic Research Service (ERS) monitors food security in U.S.
households annually. The Covid-19 Household Pulse Survey provides
real-time surveillance and monitoring of food security status on an
ongoing basis.
The COVID pandemic has elevated the households’ needs for
accessing emergency food and other food assistance programs. These

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

•
•

data will be used to understand how households are responding to
food hardships and what resources are available in their
communities.
The balance of food-at-home and food-away-from-home spending
are shifting in response to the Covid-19 pandemic. These data
enable us to understand how spending patterns shift as the
situation unfolds.
Time Frame:
This item will capture month during 2020 in which
benefits were received. This will help but current status estimates
into context to support understanding how the SNAP program supports
the HPS food sufficiency reports. SNAP data from other sources have
a significant lag and/or complexity because of it’s decentralized
administrative records framework.

Section Display Q28 (display_Q28 food security)
The next questions are about how much money you and your household spend on food at supermarkets,
grocery stores, other types of stores, and food service establishments, like restaurants and drive-thrus.
When you answer these questions, please do not include money spent on alcoholic beverages.
Section Display Q28 Spanish (display_Q28 food security)
Las siguientes preguntas se tratan de cuánto dinero usted y las personas en su hogar gastan en alimentos
en supermercados, bodegas, otros tipos de tiendas y establecimientos de servicio de alimentos, tales como
restaurantes y sitios de comida rápida con servicio por ventanilla. Cuando responda a estas preguntas, por
favor no incluya el dinero gastado en bebidas alcohólicas.
Section Q28 (food security)
During the last 7 days , how much money did you and your household spend on food at supermarkets,
grocery stores, online, and other places you buy food to prepare and eat at home? Please include
purchases made with SNAP or food stamps. Enter amount.
1) Enter amount $_________
Section Q28 Spanish (food security)
Durante los últimos 7 días, ¿cuánto dinero gastaron usted y las personas en su hogar en alimentos en
supermercados, bodegas, por internet y otros lugares donde compra alimentos para preparar y comer en
casa? Incluya las compras realizadas con SNAP o cupones de alimentos. Anote la cantidad.
1) Anote la cantidad $_________
Logic:

•
Only one response permitted
•
Validate reasonable range for dollar amount
•
If a respondent enters a number that falls outside of the above range, display the following
message (soft edit):
o For English: “Please enter a valid number. Only enter numbers or leave the box blank.
Delete any spaces or letters.”
o
For Spanish: “Por favor, anote un número válido. Solo anote números o deje el espacio
vacío. Borre cualquier espacio o letras. ”
•

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

•
•

Justification: Household food insufficiency has been a
characteristic associated with job loss and other economic impacts.
This item helps understand the shift in expenses from externally
prepared purchased food to the purchase of food for home
preparation. This item in combination with prepared food spending
help understand this mix and the associated expenses. As the
economy opens and closes this mix is expected to change. This item
is in the context of recent food insufficiency and can be expected
to provide important underlying information to use in combination
with other HPS items.
The Economic Research Service (ERS) monitors food security in U.S.
households annually. The Covid-19 Household Pulse Survey provides
real-time surveillance and monitoring of food security status on an
ongoing basis.
The COVID pandemic has elevated the households’ needs for
accessing emergency food and other food assistance programs. These
data will be used to understand how households are responding to
food hardships and what resources are available in their
communities.
The balance of food-at-home and food-away-from-home spending
are shifting in response to the Covid-19 pandemic. These data
enable us to understand how spending patterns shift as the
situation unfolds.
Time Frame:
This is an item follows up the recent experience
that asks about the ‘last seven days’ status. It is necessary to
include in each administration to put the recent experience into
context, and analyze with other contemporaneous characteristics and
background variables.

Section Q28check (food security)
You said that you spent ${fill response to Q28}.00 on food at supermarkets, grocery stores, online, and
other places during the last 7 days. This amount seems unusually high. Are you sure it is the correct
amount?
1. Yes
2. No, I need to correct the amount
Section Q28check Spanish (food security)
Usted dijo que durante los últimos 7 días, gastó ${fill response to Q28}.00 en alimentos en supermercados,
bodegas, por internet y otros lugares. Esta cantidad parece demasiado grande. ¿Está seguro(a) de que es la
cantidad correcta?
1. Sí
2. No, necesito corregir la cantidad
Logic:
• Display if Q28 > 1000
•
Justification: this is a check item for unusually large amounts
Section Q28correction (food security)

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Please provide the correct amount (or your best estimate).
During the last 7 days, how much money did you and your household spend on food at supermarkets,
grocery stores, online, and other places you buy food to prepare and eat at home? Please include
purchases made with SNAP or food stamps. Enter amount.
1) Enter amount $_________
Section Q28correction Spanish (food security)
Por favor, anote la cantidad correcta (o lo mejor que pueda calcular).
Durante los últimos 7 días, ¿cuánto dinero gastaron usted y las personas en su hogar en alimentos en
supermercados, bodegas, por internet y otros lugares donde compra alimentos para preparar y comer en
casa? Incluya las compras realizadas con SNAP o cupones de alimentos. Anote la cantidad.
1) Anote la cantidad $_________
Logic:
•

•

Display if Q28_check = 2 (No)
Justification: this is an updated amount following the check item
for unusually large amounts

Section Q29 (food security)
During the last 7 days, how much money did you and your household spend on prepared meals, including
eating out, fast food, and carry out or delivered meals? Please include money spent in cafeterias at work or
at school or on vending machines. Please do not include money you have already told us about in the
previous question (above). Enter amount.
1) Enter amount $_________
Section Q29 Spanish (food security)
Durante los últimos 7 días, ¿cuánto dinero gastaron usted y las personas en su hogar en comidas
preparadas, incluyendo comer en restaurantes, comida rápida y comidas para llevar o entregadas a su
casa? Por favor, incluya el dinero gastado en cafeterías en el trabajo o en la escuela o en máquinas
expendedoras. Por favor, no incluya el dinero del que ya nos ha hablado en la pregunta anterior (arriba).
Anote la cantidad.
1)
Anote la cantidad $_________
Logic:

•

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

•
•

Justification: Household food insufficiency has been a
characteristic associated with job loss and other economic impacts.
This item helps understand the shift in expenses from externally
prepared purchased food to the purchase of food for home
preparation. This item in combination with spending on food to
prepare at home helps understand this mix and the associated
expenses. As the economy opens and closes this mix is expected to
change. This item is in the context of recent food insufficiency
and can be expected to provide important underlying information to
use in combination with other HPS items.
The Economic Research Service (ERS) monitors food security in U.S.
households annually. The Covid-19 Household Pulse Survey provides
real-time surveillance and monitoring of food security status on an
ongoing basis.
The COVID pandemic has elevated the households’ needs for
accessing emergency food and other food assistance programs. These
data will be used to understand how households are responding to
food hardships and what resources are available in their
communities.
The balance of food-at-home and food-away-from-home spending
are shifting in response to the Covid-19 pandemic. These data
enable us to understand how spending patterns shift as the
situation unfolds.
Time Frame:
This is an item follows up the recent experience
that asks about the ‘last seven days’ status. It is necessary to
include in each administration to put the recent experience into
context, and analyze with other contemporaneous characteristics and
background variables.

Section Q29check (food security)
You said that you spent ${fill response to Q29}.00 on prepared meals during the last 7 days. This amount
seems unusually high. Are you sure it is the correct amount?
1. Yes
2. No, I need to correct the amount
Section Q29check Spanish (food security)
Usted dijo que durante los últimos 7 días, gastó ${fill response to Q29}.00 en comidas preparadas. Esta
cantidad parece demasiado grande. ¿Está seguro(a) de que es la cantidad correcta?
1. Sí
2. No, necesito corregir la cantidad
Logic:
• Display if Q28 > 1000
•
Justification: this is a check item for unusually large amounts
Section Q29correction (food security)
Please provide the correct amount (or your best estimate).

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

During the last 7 days, how much money did you and your household spend on prepared meals, including
eating out, fast food, and carry out or delivered meals? Please include money spent in cafeterias at work or
at school or on vending machines. Please do not include money you have already told us about in the
previous question (above). Enter amount.
1) Enter amount $_________
Section Q29correction Spanish (food security)
Por favor, anote la cantidad correcta (o lo mejor que pueda calcular).
Durante los últimos 7 días, ¿cuánto dinero gastaron usted y las personas en su hogar en comidas
preparadas, incluyendo comer en restaurantes, comida rápida y comidas para llevar o entregadas a su
casa? Por favor, incluya el dinero gastado en cafeterías en el trabajo o en la escuela o en máquinas
expendedoras. Por favor, no incluya el dinero del que ya nos ha hablado en la pregunta anterior (arriba).
Anote la cantidad.
1)
Anote la cantidad $_________
Logic:
•

•

Display if Q28_check = 2 (No)
Justification: this is an updated amount following the check item
for unusually large amounts

Section Q30 (food security)
How confident are you that your household will be able to afford the kinds of food you need for the next
four weeks? Select only one answer.
1) Not at all confident
2) Somewhat confident
3) Moderately confident
4) Very confident
Section Q30 Spanish (food security)
¿Qué tan seguro(a) está de que su hogar tendrá suficiente dinero para pagar los tipos de alimentos que
necesita para las próximas cuatro semanas? Seleccione solo una respuesta.
1) No está seguro(a) en absoluto
2) Algo seguro(a)
3) Moderadamente seguro(a)
4) Muy seguro(a)
Logic:
•
Only one response permitted
•
Note: From HUD
•
• Justification: Household food insufficiency has been a
characteristic associated with job loss and other economic impacts.
This item helps understand the expectations around being able to
afford food for the following four weeks. The expectations help
measure the uncertainty present in the household economy. As the
economy opens and closes this mix is expected to change. This item
is in the context of recent food insufficiency and can be expected

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

•
•

to provide important underlying information to use in combination
with other HPS items.
The Economic Research Service (ERS) monitors food security in U.S.
households annually. The Covid-19 Household Pulse Survey provides
real-time surveillance and monitoring of food security status on an
ongoing basis.
The COVID pandemic has elevated the households’ needs for
accessing emergency food and other food assistance programs. These
data will be used to understand how households are responding to
food hardships and what resources are available in their
communities.
The balance of food-at-home and food-away-from-home spending
are shifting in response to the Covid-19 pandemic. These data
enable us to understand how spending patterns shift as the
situation unfolds.
Time Frame: This item uses the next four weeks as the reference
time point for understanding the forward looking expectation over a
period of approximately a month. Because of the interview
frequency, four weeks is a more easily and consistent time frame
for recall than using a month which may end up being up to six or
seven weeks if people think of the end of the next month, and as
little as a couple weeks if we are interviewing at the end of a
month.

/* END PAGE */
/* START PAGE */
Page Title: Mental Health and Health Status
Section Q31 (general health status)
Would you say your health in general is excellent, very good, good, fair, or poor? Select only one
answer.
1) Excellent
2) Very good
3) Good
4) Fair
5) Poor
Section Q31 Spanish (general health status)
¿Diría usted que su salud en general es excelente, muy buena, buena, regular o mala? Seleccione solo
una respuesta.
1) Excelente
2) Muy buena
3) Buena
4) Regular
5) Mala
Logic:
•
Only one response permitted
• Justification: The general health status item is a well established
measure and is useful for providing context and comparison with

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

other data sources. This item is associated with well being and
socioeconomic status.
Information on the health impact of COVID-19 on death and
hospitalization is available from several sources, but the impact
on other measures of health is limited. Key issues relate to
access to health care resources (both related and not directly
related to COVID-19) along with overall health indicators and
indicators of mental health. As some of these measures are key
components of core health data collections such as the National
Health Interview Survey, the analysis and interpretation of data
obtained from the proposed survey can be informed by existing
information.
Access to health care is a fundamental determinant of health, and
its equitable distribution across the population is a critical
issue of health services research and policymaking. Unmet needs
are generally the result of cost-related barriers, accessibility
problems (lack of transportation or lack of availability in area),
and acceptability (personal preferences). The coronavirus pandemic
has the potential to greatly exacerbate these causes, especially
accessibility problems (for example, due to doctor’s offices
limiting in-person appointments, urgent care clinics focusing on
COVID-19 symptoms and excluding others, or public transportation
systems cutting back on service). The inclusion of questions on
access to care provides an opportunity to examine the prevalence of
persons with recent unmet needs, whether that prevalence changes
over time, and whether historic demographic inequities in access to
care are widening.
Positive mental health is critical to work productively, make
meaningful contributions, and cope with the stresses of life. In
contrast, mental illness and stress can lead to problems
functioning in social, work, or family activities. Part of DHHS’s
strategic goals are to help identify and address mental health
problems and to invest in programs and interventions focused on
prevention, screening, and early detection of serious problems.
Joblessness, social isolation, disruptions to routines, news
reports about deaths, and concerns about the physical health of
oneself and one’s family have the potential to create grief, panic,
hopelessness and fear. The inclusion of questions on mental health
provides an opportunity to examine the prevalence and
characteristics of persons with varying levels of anxiety and
depression, and whether that prevalence changes over time.
Time Frame: This item asks current status.

Section Q32 (anxiety)
Over the last 7 days, how often have you been bothered by the following problems ... Feeling nervous,
anxious, or on edge? Would you say…not at all, several days, more than half the days, or nearly every day?
Select only one answer.
1) Not at all
2) Several days
3) More than half the days
4) Nearly every day

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Section Q32 Spanish (anxiety)
Durante los últimos 7 días, ¿con qué frecuencia se ha visto afectado(a) por los siguientes problemas ...
Sentirse nervioso(a), ansioso(a), o irritable? ¿Diría queno en absoluto, varios días, más de la mitad de los
días o casi todos los días? Seleccione solo una respuesta.
1) No en absoluto
2) Varios días
3) Más de la mitad de los días
4) Casi todos los días
Logic:
•
Only one response permitted
• Justification: This item asks about feelings of anxiety and
nervousness. It is well tested in the National Health Interview
Survey and provides a good basic measure to help understand the
mental health impact of the coronavirus pandemic.
• Information on the health impact of COVID-19 on death and
hospitalization is available from several sources, but the impact
on other measures of health is limited. Key issues relate to
access to health care resources (both related and not directly
related to COVID-19) along with overall health indicators and
indicators of mental health. As some of these measures are key
components of core health data collections such as the National
Health Interview Survey, the analysis and interpretation of data
obtained from the proposed survey can be informed by existing
information.
• Access to health care is a fundamental determinant of health, and
its equitable distribution across the population is a critical
issue of health services research and policymaking. Unmet needs
are generally the result of cost-related barriers, accessibility
problems (lack of transportation or lack of availability in area),
and acceptability (personal preferences). The coronavirus pandemic
has the potential to greatly exacerbate these causes, especially
accessibility problems (for example, due to doctor’s offices
limiting in-person appointments, urgent care clinics focusing on
COVID-19 symptoms and excluding others, or public transportation
systems cutting back on service). The inclusion of questions on
access to care provides an opportunity to examine the prevalence of
persons with recent unmet needs, whether that prevalence changes
over time, and whether historic demographic inequities in access to
care are widening.
• Positive mental health is critical to work productively, make
meaningful contributions, and cope with the stresses of life. In
contrast, mental illness and stress can lead to problems
functioning in social, work, or family activities. Part of DHHS’s
strategic goals are to help identify and address mental health
problems and to invest in programs and interventions focused on
prevention, screening, and early detection of serious problems.
Joblessness, social isolation, disruptions to routines, news
reports about deaths, and concerns about the physical health of
oneself and one’s family have the potential to create grief, panic,
hopelessness and fear. The inclusion of questions on mental health
provides an opportunity to examine the prevalence and

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

characteristics of persons with varying levels of anxiety and
depression, and whether that prevalence changes over time.
•
•

Time Frame: This item asks status over the last seven days. This
aligns it with other items in the HPS and focus on recent status.
The NHIS uses a two week timeframe, but doesn’t collect data as
frequently as the HPS.

Section Q33 (anxiety)
Over the last 7 days, how often have you been bothered by the following problems ... Not being able to
stop or control worrying? Would you say not at all, several days, more than half the days, or nearly every
day? Select only one answer.
1) Not at all
2) Several days
3) More than half the days
4) Nearly every day
Section Q33 Spanish (anxiety)
Durante los últimos 7 días, ¿con qué frecuencia se ha visto afectado(a) por los siguientes problemas ... No
ser capaz de detener o controlar la preocupación? ¿Diría que no en absoluto, varios días, más de la mitad
de los días o casi todos los días? Seleccione solo una respuesta.
1) No en absoluto
2) Varios días
3) Más de la mitad de los días
4) Casi todos los días
Logic:
•
Only one response permitted
• Justification: This item asks about feelings of worry. It is well
tested in the National Health Interview Survey and provides a good
basic measure to help understand the mental health impact of the
coronavirus pandemic.
• Information on the health impact of COVID-19 on death and
hospitalization is available from several sources, but the impact
on other measures of health is limited. Key issues relate to
access to health care resources (both related and not directly
related to COVID-19) along with overall health indicators and
indicators of mental health. As some of these measures are key
components of core health data collections such as the National
Health Interview Survey, the analysis and interpretation of data
obtained from the proposed survey can be informed by existing
information.
• Access to health care is a fundamental determinant of health, and
its equitable distribution across the population is a critical
issue of health services research and policymaking. Unmet needs
are generally the result of cost-related barriers, accessibility
problems (lack of transportation or lack of availability in area),
and acceptability (personal preferences). The coronavirus pandemic
has the potential to greatly exacerbate these causes, especially
accessibility problems (for example, due to doctor’s offices
limiting in-person appointments, urgent care clinics focusing on
COVID-19 symptoms and excluding others, or public transportation

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

•
•

systems cutting back on service). The inclusion of questions on
access to care provides an opportunity to examine the prevalence of
persons with recent unmet needs, whether that prevalence changes
over time, and whether historic demographic inequities in access to
care are widening.
Positive mental health is critical to work productively, make
meaningful contributions, and cope with the stresses of life. In
contrast, mental illness and stress can lead to problems
functioning in social, work, or family activities. Part of DHHS’s
strategic goals are to help identify and address mental health
problems and to invest in programs and interventions focused on
prevention, screening, and early detection of serious problems.
Joblessness, social isolation, disruptions to routines, news
reports about deaths, and concerns about the physical health of
oneself and one’s family have the potential to create grief, panic,
hopelessness and fear. The inclusion of questions on mental health
provides an opportunity to examine the prevalence and
characteristics of persons with varying levels of anxiety and
depression, and whether that prevalence changes over time.
Time Frame: This item asks status over the last seven days. This
aligns it with other items in the HPS and focus on recent status.
The NHIS uses a two week timeframe, but doesn’t collect data as
frequently as the HPS.

Section Q34 (depression)
Over the last 7 days, how often have you been bothered by ... having little interest or pleasure in doing
things? Would you say not at all, several days, more than half the days, or nearly every day? Select only one
answer.
1) Not at all
2) Several days
3) More than half the days
4) Nearly every day
Section Q34 Spanish (depression)
Durante los últimos 7 días, ¿con qué frecuencia se ha visto afectado(a) por ... tener poco interés o placer
en hacer las cosas? ¿Diría que no en absoluto, varios días, más de la mitad de los días o casi todos los días?
Seleccione solo una respuesta.
1) No en absoluto
2) Varios días
3) Más de la mitad de los días
4) Casi todos los días
Logic:
•
Only one response permitted
• Justification: This item asks about feelings of depression and lack
of interest. It is well tested in the National Health Interview
Survey and provides a good basic measure to help understand the
mental health impact of the coronavirus pandemic.
• Information on the health impact of COVID-19 on death and
hospitalization is available from several sources, but the impact
on other measures of health is limited. Key issues relate to

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

•
•

access to health care resources (both related and not directly
related to COVID-19) along with overall health indicators and
indicators of mental health. As some of these measures are key
components of core health data collections such as the National
Health Interview Survey, the analysis and interpretation of data
obtained from the proposed survey can be informed by existing
information.
Access to health care is a fundamental determinant of health, and
its equitable distribution across the population is a critical
issue of health services research and policymaking. Unmet needs
are generally the result of cost-related barriers, accessibility
problems (lack of transportation or lack of availability in area),
and acceptability (personal preferences). The coronavirus pandemic
has the potential to greatly exacerbate these causes, especially
accessibility problems (for example, due to doctor’s offices
limiting in-person appointments, urgent care clinics focusing on
COVID-19 symptoms and excluding others, or public transportation
systems cutting back on service). The inclusion of questions on
access to care provides an opportunity to examine the prevalence of
persons with recent unmet needs, whether that prevalence changes
over time, and whether historic demographic inequities in access to
care are widening.
Positive mental health is critical to work productively, make
meaningful contributions, and cope with the stresses of life. In
contrast, mental illness and stress can lead to problems
functioning in social, work, or family activities. Part of DHHS’s
strategic goals are to help identify and address mental health
problems and to invest in programs and interventions focused on
prevention, screening, and early detection of serious problems.
Joblessness, social isolation, disruptions to routines, news
reports about deaths, and concerns about the physical health of
oneself and one’s family have the potential to create grief, panic,
hopelessness and fear. The inclusion of questions on mental health
provides an opportunity to examine the prevalence and
characteristics of persons with varying levels of anxiety and
depression, and whether that prevalence changes over time.
Time Frame: This item asks status over the last seven days. This
aligns it with other items in the HPS and focus on recent status.
The NHIS uses a two week timeframe, but doesn’t collect data as
frequently as the HPS.

Section Q35 (depression)
Over the last 7 days, how often have you been bothered by ... feeling down, depressed, or hopeless?
Would you say not at all, several days, more than half the days, or nearly every day? Select only one
answer.
1) Not at all
2) Several days
3) More than half the days
4) Nearly every day

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Section Q35 Spanish (depression)
Durante los últimos 7 días, ¿con qué frecuencia se ha visto afectado(a) por ... sentirse triste, deprimido(a)
o sin esperanza? ¿Diría que no en absoluto, varios días, más de la mitad de los días o casi todos los días?
Seleccione solo una respuesta.
1) No en absoluto
2) Varios días
3) Más de la mitad de los días
4) Casi todos los días
Logic:
•

•

•
Only one response permitted
Justification: This item asks about feelings of depression and
hopelessness. It is well tested in the National Health Interview
Survey and provides a good basic measure to help understand the
mental health impact of the coronavirus pandemic.
Information on the health impact of COVID-19 on death and
hospitalization is available from several sources, but the impact
on other measures of health is limited. Key issues relate to
access to health care resources (both related and not directly
related to COVID-19) along with overall health indicators and
indicators of mental health. As some of these measures are key
components of core health data collections such as the National
Health Interview Survey, the analysis and interpretation of data
obtained from the proposed survey can be informed by existing
information.
Access to health care is a fundamental determinant of health, and
its equitable distribution across the population is a critical
issue of health services research and policymaking. Unmet needs
are generally the result of cost-related barriers, accessibility
problems (lack of transportation or lack of availability in area),
and acceptability (personal preferences). The coronavirus pandemic
has the potential to greatly exacerbate these causes, especially
accessibility problems (for example, due to doctor’s offices
limiting in-person appointments, urgent care clinics focusing on
COVID-19 symptoms and excluding others, or public transportation
systems cutting back on service). The inclusion of questions on
access to care provides an opportunity to examine the prevalence of
persons with recent unmet needs, whether that prevalence changes
over time, and whether historic demographic inequities in access to
care are widening.
Positive mental health is critical to work productively, make
meaningful contributions, and cope with the stresses of life. In
contrast, mental illness and stress can lead to problems
functioning in social, work, or family activities. Part of DHHS’s
strategic goals are to help identify and address mental health
problems and to invest in programs and interventions focused on
prevention, screening, and early detection of serious problems.
Joblessness, social isolation, disruptions to routines, news
reports about deaths, and concerns about the physical health of
oneself and one’s family have the potential to create grief, panic,
hopelessness and fear. The inclusion of questions on mental health

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

provides an opportunity to examine the prevalence and
characteristics of persons with varying levels of anxiety and
depression, and whether that prevalence changes over time.
•
•

Section Q36 (insurance)
Are you currently covered by any of the following types of health insurance or health coverage plans? Mark
Yes or No for each.
1) Insurance through a current or former employer or union (through yourself or another
family member)
2) Insurance purchased directly from an insurance company, including marketplace coverage
(through yourself or another family member)
3) Medicare, for people 65 and older, or people with certain disabilities
4) Medicaid, Medical Assistance, or any kind of government-assistance plan for those with
low incomes or a disability;
5) TRICARE or other military health care
6) VA (including those who have ever used or enrolled for VA health care)
7) Indian Health Service
8) Other
Section Q36 Spanish (insurance)
¿Está usted actualmente cubierto(a) por alguno de los siguientes tipos de seguro de salud o planes de
cobertura de salud? Marque Sí o No para cada caso.
1) Seguro a través de un empleador o sindicato actual o anterior (a través de usted u otro
miembro de la familia)
2) Seguro comprado directamente a una compañía de seguros, incluyendo la cobertura del
mercado (a través de usted u otro miembro de la familia)
3) Medicare, para personas de 65 años y más, o personas con ciertas discapacidades
4) Medicaid, Asistencia Médica o cualquier tipo de plan de asistencia gubernamental para
personas con bajos ingresos o discapacidad
5) TRICARE u otro servicio de atención médica militar
6) Administración de Veteranos (VA por sus siglas en inglés) (incluyendo aquellos que alguna vez
han utilizado o se han inscrito para recibir atención médica de la VA)
7) Servicio de Salud de los Indígenas
8) Otro
Logic:
•
Matrix style question with Yes/No response option for each row
•
Only one response permitted per row
• Justification: This item is based on the American Community Survey,
and helps provide health insurance coverage context for the
responses in the HPS. Asking about delays in care and changes in
employment status require this basic measure to provide the
coverage context.
• Information on the health impact of COVID-19 on death and
hospitalization is available from several sources, but the impact

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

•
•

on other measures of health is limited. Key issues relate to
access to health care resources (both related and not directly
related to COVID-19) along with overall health indicators and
indicators of mental health. As some of these measures are key
components of core health data collections such as the National
Health Interview Survey, the analysis and interpretation of data
obtained from the proposed survey can be informed by existing
information.
Access to health care is a fundamental determinant of health, and
its equitable distribution across the population is a critical
issue of health services research and policymaking. Unmet needs
are generally the result of cost-related barriers, accessibility
problems (lack of transportation or lack of availability in area),
and acceptability (personal preferences). The coronavirus pandemic
has the potential to greatly exacerbate these causes, especially
accessibility problems (for example, due to doctor’s offices
limiting in-person appointments, urgent care clinics focusing on
COVID-19 symptoms and excluding others, or public transportation
systems cutting back on service). The inclusion of questions on
access to care provides an opportunity to examine the prevalence of
persons with recent unmet needs, whether that prevalence changes
over time, and whether historic demographic inequities in access to
care are widening.
Positive mental health is critical to work productively, make
meaningful contributions, and cope with the stresses of life. In
contrast, mental illness and stress can lead to problems
functioning in social, work, or family activities. Part of DHHS’s
strategic goals are to help identify and address mental health
problems and to invest in programs and interventions focused on
prevention, screening, and early detection of serious problems.
Joblessness, social isolation, disruptions to routines, news
reports about deaths, and concerns about the physical health of
oneself and one’s family have the potential to create grief, panic,
hopelessness and fear. The inclusion of questions on mental health
provides an opportunity to examine the prevalence and
characteristics of persons with varying levels of anxiety and
depression, and whether that prevalence changes over time.
Time Frame: This item asks current status.

Section Q37 (access)
At any time in the last 4 weeks, did you DELAY getting medical care because of the coronavirus pandemic?
Select only one answer.
1) Yes
2) No
Section Q37 Spanish (access)
En cualquier momento de las últimas 4 semanas, ¿decidió POSPONER recibir atención médica debido a la
pandemia del coronavirus? Seleccione solo una respuesta.
3) Sí
4) No

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Logic:
•
•

•

•
•

•
Only one response permitted
Justification: This item asks about delays in getting health care
sercices as a result of the coronavirus pandemic. This helps data
users to understand the health impact of the coronavirus pandemic.
Information on the health impact of COVID-19 on death and
hospitalization is available from several sources, but the impact
on other measures of health is limited. Key issues relate to
access to health care resources (both related and not directly
related to COVID-19) along with overall health indicators and
indicators of mental health. As some of these measures are key
components of core health data collections such as the National
Health Interview Survey, the analysis and interpretation of data
obtained from the proposed survey can be informed by existing
information.
Access to health care is a fundamental determinant of health, and
its equitable distribution across the population is a critical
issue of health services research and policymaking. Unmet needs
are generally the result of cost-related barriers, accessibility
problems (lack of transportation or lack of availability in area),
and acceptability (personal preferences). The coronavirus pandemic
has the potential to greatly exacerbate these causes, especially
accessibility problems (for example, due to doctor’s offices
limiting in-person appointments, urgent care clinics focusing on
COVID-19 symptoms and excluding others, or public transportation
systems cutting back on service). The inclusion of questions on
access to care provides an opportunity to examine the prevalence of
persons with recent unmet needs, whether that prevalence changes
over time, and whether historic demographic inequities in access to
care are widening.
Positive mental health is critical to work productively, make
meaningful contributions, and cope with the stresses of life. In
contrast, mental illness and stress can lead to problems
functioning in social, work, or family activities. Part of DHHS’s
strategic goals are to help identify and address mental health
problems and to invest in programs and interventions focused on
prevention, screening, and early detection of serious problems.
Joblessness, social isolation, disruptions to routines, news
reports about deaths, and concerns about the physical health of
oneself and one’s family have the potential to create grief, panic,
hopelessness and fear. The inclusion of questions on mental health
provides an opportunity to examine the prevalence and
characteristics of persons with varying levels of anxiety and
depression, and whether that prevalence changes over time.
Time Frame: This item asks status over the last four weeks, because
health care appointments and delays are often considered over
periods longer than days. This important situation helps see how
the burden on the health care system impacts other medical care.

Section Q38 (access)

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

At any time in the last 4 weeks, did you need medical care for something other than coronavirus, but DID
NOT GET IT because of the coronavirus pandemic? Select only one answer.
1) Yes
2) No
Section Q38 Spanish (access)
En cualquier momento de las últimas 4 semanas, ¿necesitó atención médica por otras situaciones aparte
del coronavirus, pero NO LA RECIBIÓ debido a la pandemia del coronavirus? Seleccione solo una
respuesta.
3) Sí
4) No
Logic:
•
Only one response permitted
• Justification: This item asks about delays in getting health care
sercices as a result of the coronavirus pandemic. This helps data
users to understand the health impact of the coronavirus pandemic.
• Information on the health impact of COVID-19 on death and
hospitalization is available from several sources, but the impact
on other measures of health is limited. Key issues relate to
access to health care resources (both related and not directly
related to COVID-19) along with overall health indicators and
indicators of mental health. As some of these measures are key
components of core health data collections such as the National
Health Interview Survey, the analysis and interpretation of data
obtained from the proposed survey can be informed by existing
information.
• Access to health care is a fundamental determinant of health, and
its equitable distribution across the population is a critical
issue of health services research and policymaking. Unmet needs
are generally the result of cost-related barriers, accessibility
problems (lack of transportation or lack of availability in area),
and acceptability (personal preferences). The coronavirus pandemic
has the potential to greatly exacerbate these causes, especially
accessibility problems (for example, due to doctor’s offices
limiting in-person appointments, urgent care clinics focusing on
COVID-19 symptoms and excluding others, or public transportation
systems cutting back on service). The inclusion of questions on
access to care provides an opportunity to examine the prevalence of
persons with recent unmet needs, whether that prevalence changes
over time, and whether historic demographic inequities in access to
care are widening.
• Positive mental health is critical to work productively, make
meaningful contributions, and cope with the stresses of life. In
contrast, mental illness and stress can lead to problems
functioning in social, work, or family activities. Part of DHHS’s
strategic goals are to help identify and address mental health
problems and to invest in programs and interventions focused on
prevention, screening, and early detection of serious problems.
Joblessness, social isolation, disruptions to routines, news
reports about deaths, and concerns about the physical health of
oneself and one’s family have the potential to create grief, panic,

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

hopelessness and fear. The inclusion of questions on mental health
provides an opportunity to examine the prevalence and
characteristics of persons with varying levels of anxiety and
depression, and whether that prevalence changes over time.
•
•

Time Frame: This item asks status over the last four weeks, because
health care appointments and delays are often considered over
periods longer than days. This important situation helps see how
the burden on the health care system impacts other medical care.

Section Q38a ()
At any time in the last 4 weeks, did you take prescription medication to help you with any emotions or with
your concentration, behavior or mental health? Select only one answer.
1) Yes
2) No
Section Q38a Spanish ()
En algún momento en las últimas 4 semanas, ¿usó algún medicamento recetado para ayudarle a manejar
sus emociones o su concentración, comportamiento o salud mental? Seleccione solo una respuesta.
1) Sí
2) No
Logic:
•
Only one response permitted
• Justification: These items ask about the receipt of mental health
services and the use of prescription mediction in treating mental
health and impacts to these services as a result of the coronavirus
pandemic. This helps data users to understand the health impact of
the coronavirus pandemic.
• Information on the health impact of COVID-19 on death and
hospitalization is available from several sources, but the impact
on other measures of health is limited. Key issues relate to
access to health care resources (both related and not directly
related to COVID-19) along with overall health indicators and
indicators of mental health. As some of these measures are key
components of core health data collections such as the National
Health Interview Survey, the analysis and interpretation of data
obtained from the proposed survey can be informed by existing
information.
• Access to health care is a fundamental determinant of health, and
its equitable distribution across the population is a critical
issue of health services research and policymaking. Unmet needs
are generally the result of cost-related barriers, accessibility
problems (lack of transportation or lack of availability in area),
and acceptability (personal preferences). The coronavirus pandemic
has the potential to greatly exacerbate these causes, especially
accessibility problems (for example, due to doctor’s offices
limiting in-person appointments, urgent care clinics focusing on
COVID-19 symptoms and excluding others, or public transportation
systems cutting back on service). The inclusion of questions on
access to care provides an opportunity to examine the prevalence of
persons with recent unmet needs, whether that prevalence changes

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

•
•

over time, and whether historic demographic inequities in access to
care are widening.
Positive mental health is critical to work productively, make
meaningful contributions, and cope with the stresses of life. In
contrast, mental illness and stress can lead to problems
functioning in social, work, or family activities. Part of DHHS’s
strategic goals are to help identify and address mental health
problems and to invest in programs and interventions focused on
prevention, screening, and early detection of serious problems.
Joblessness, social isolation, disruptions to routines, news
reports about deaths, and concerns about the physical health of
oneself and one’s family have the potential to create grief, panic,
hopelessness and fear. The inclusion of questions on mental health
provides an opportunity to examine the prevalence and
characteristics of persons with varying levels of anxiety and
depression, and whether that prevalence changes over time.
Time Frame: This item asks status over the last four weeks, because
health care appointments and delays are often considered over
periods longer than days. This important situation helps see how
the burden on the health care system impacts other medical care.

Section Q38b ()
At any time in the last 4 weeks, did you receive counseling or therapy from a mental health professional
such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker? Include counseling or
therapy online or by phone. Select only one answer.
1) Yes
2) No
Section Q38b Spanish ()
En algún momento en las últimas 4 semanas, ¿recibió asesoramiento psicológico o terapia de un
professional de salud mental, como por ejemplo psiquiatra, psicólogo, enfermera psiquiátrica, o trabajador
social clínico? Incluya asesoramiento psicológico o terapia recibida por teléfono o en línea.
Seleccione solo una respuesta.
1) Sí
2) No
Logic:
•

•

•
Only one response permitted
Justification: These items ask about the receipt of mental health
services and the use of prescription mediction in treating mental
health and impacts to these services as a result of the coronavirus
pandemic. This helps data users to understand the health impact of
the coronavirus pandemic.
Information on the health impact of COVID-19 on death and
hospitalization is available from several sources, but the impact
on other measures of health is limited. Key issues relate to
access to health care resources (both related and not directly
related to COVID-19) along with overall health indicators and
indicators of mental health. As some of these measures are key
components of core health data collections such as the National

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

•
•

Health Interview Survey, the analysis and interpretation of data
obtained from the proposed survey can be informed by existing
information.
Access to health care is a fundamental determinant of health, and
its equitable distribution across the population is a critical
issue of health services research and policymaking. Unmet needs
are generally the result of cost-related barriers, accessibility
problems (lack of transportation or lack of availability in area),
and acceptability (personal preferences). The coronavirus pandemic
has the potential to greatly exacerbate these causes, especially
accessibility problems (for example, due to doctor’s offices
limiting in-person appointments, urgent care clinics focusing on
COVID-19 symptoms and excluding others, or public transportation
systems cutting back on service). The inclusion of questions on
access to care provides an opportunity to examine the prevalence of
persons with recent unmet needs, whether that prevalence changes
over time, and whether historic demographic inequities in access to
care are widening.
Positive mental health is critical to work productively, make
meaningful contributions, and cope with the stresses of life. In
contrast, mental illness and stress can lead to problems
functioning in social, work, or family activities. Part of DHHS’s
strategic goals are to help identify and address mental health
problems and to invest in programs and interventions focused on
prevention, screening, and early detection of serious problems.
Joblessness, social isolation, disruptions to routines, news
reports about deaths, and concerns about the physical health of
oneself and one’s family have the potential to create grief, panic,
hopelessness and fear. The inclusion of questions on mental health
provides an opportunity to examine the prevalence and
characteristics of persons with varying levels of anxiety and
depression, and whether that prevalence changes over time.
Time Frame: This item asks status over the last four weeks, because
health care appointments and delays are often considered over
periods longer than days. This important situation helps see how
the burden on the health care system impacts other medical care.

Section Q38c ()
At any time in the last 4 weeks, did you need counseling or therapy from a mental health professional, but
DID NOT GET IT for any reason? Select only one answer.
1) Yes
2) No
Section Q38c Spanish ()
En algún momento en las últimas 4 semanas, ¿necesitó asesoramiento psicológico o terapia de un
professional de salud mental, PERO NO LO RECIBIÓ por alguna razón? Seleccione solo una respuesta.
1) Sí
2) No
Logic:
•
Only one response permitted

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

•
•

Justification: These items ask about the receipt of mental health
services and the use of prescription mediction in treating mental
health and impacts to these services as a result of the coronavirus
pandemic. This helps data users to understand the health impact of
the coronavirus pandemic.
Information on the health impact of COVID-19 on death and
hospitalization is available from several sources, but the impact
on other measures of health is limited. Key issues relate to
access to health care resources (both related and not directly
related to COVID-19) along with overall health indicators and
indicators of mental health. As some of these measures are key
components of core health data collections such as the National
Health Interview Survey, the analysis and interpretation of data
obtained from the proposed survey can be informed by existing
information.
Access to health care is a fundamental determinant of health, and
its equitable distribution across the population is a critical
issue of health services research and policymaking. Unmet needs
are generally the result of cost-related barriers, accessibility
problems (lack of transportation or lack of availability in area),
and acceptability (personal preferences). The coronavirus pandemic
has the potential to greatly exacerbate these causes, especially
accessibility problems (for example, due to doctor’s offices
limiting in-person appointments, urgent care clinics focusing on
COVID-19 symptoms and excluding others, or public transportation
systems cutting back on service). The inclusion of questions on
access to care provides an opportunity to examine the prevalence of
persons with recent unmet needs, whether that prevalence changes
over time, and whether historic demographic inequities in access to
care are widening.
Positive mental health is critical to work productively, make
meaningful contributions, and cope with the stresses of life. In
contrast, mental illness and stress can lead to problems
functioning in social, work, or family activities. Part of DHHS’s
strategic goals are to help identify and address mental health
problems and to invest in programs and interventions focused on
prevention, screening, and early detection of serious problems.
Joblessness, social isolation, disruptions to routines, news
reports about deaths, and concerns about the physical health of
oneself and one’s family have the potential to create grief, panic,
hopelessness and fear. The inclusion of questions on mental health
provides an opportunity to examine the prevalence and
characteristics of persons with varying levels of anxiety and
depression, and whether that prevalence changes over time.
Time Frame: This item asks status over the last four weeks, because
health care appointments and delays are often considered over
periods longer than days. This important situation helps see how
the burden on the health care system impacts other medical care.

/* END PAGE */

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

/* START PAGE */
Page Title: Housing
Section Q39 (housing)
Is your house or apartment…? Select only one answer.
1) Owned by you or someone in your household free and clear?
2) Owned by your or someone in your household with a mortgage or loan (including home
equity loans)?
3) Rented?
4) Occupied without payment of rent?
Section Q39 Spanish (housing)
¿Es su casa o apartamento... ? Seleccione solo una respuesta.
1) ¿Propiedad suya o de alguien en este hogar libre y sin deuda?
2) ¿Propiedad suya o de alguien en este hogar con una hipoteca o crédito hipotecario (incluye
los préstamos con la propiedad como garantía)?
3) ¿Alquilado(a)/rentado(a)?
4) ¿Ocupado(a) sin pago de alquiler o renta?

Logic:
•
Only one response permitted
• Justification: The housing items are necessary to differentiate the
experience of renters from owners, and to understand the impact of
housing uncertainty as it relates to the coronavirus pandemic.
Renters may be at greater risk of eviction and forcosure among
owners in certain situations may increase. These questions allow
for the evaluation of other areas of HPS items can be considered
alongside housing and housing security.
• With of $1.2 trillion of FHA insurance-in-force, HUD has a strong
interest in understanding if households made their previous
mortgage payment on time and believe they will be able to make
their next mortgage payment on time. The COVID-19 Household Pulse
Survey data on recent mortgage payment activity and next mortgage
payment intentions will fill in these existing data gaps.
•
With more than 4 million households receiving HUD rental
assistance, HUD has a strong interest in understanding how COVID-19
will impact renter's ability to make their rent payments. The
COVID-19 Household Pulse Survey data on recent renter's payment
activity and renter's ability to make next rental payment will help
HUD better understand the impact of COVID-19 on our rental
assistance programs.
•
Nearly 700,000 landlords participate in HUD's Housing Choice
Voucher Program. HUD has a strong interest in understanding how
COVID-19 will impact landlord's cash flow. The COVID-19 Household
Pulse Survey data on recent renter's payment activity and renter's
ability to make next rental payment will help HUD better understand
the impact of COVID-19 on landlords.
• Time Frame: This item asks about the status of the current living
arrangements.

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Section Q39a (housing)
Which best describes this building? Include all apartments, flats, etc., even if vacant. Select only one
answer.
1) A mobile home
2) A one-family house detached from any other house
3) A one-family house attached to one or more houses
4) A building with 2 apartments
5) A building with 3 or 4 apartments
6) A building with 5 to 9 apartments
7) A building with 10 to 19 apartments
8) A building with 20 to 49 apartments
9) A building with 50 or more apartments
10) Boat, RV, van, etc.
Section Q39a Spanish (housing)
¿Cuál describe mejor este edificio? Incluya todos los apartmentos o pisos, aunque estén
desocupados. Seleccione solo una respuesta.
1. Una casa móvil
2. Una casa separada de cualquier otra casa
3. Una casa unida a una o más casas
4. Un edificio con 2 apartamentos
5. Un edificio con 3 a 4 apartamentos
6. Un edificio con 5 a 9 apartamentos
7. Un edificio con 10 a 19 apartamentos
8. Un edificio con 20 a 49 apartamentos
9. Un edificio con 50 apartamentos o más
10. Bote o barco, vehículo recreativo, van, etc.
Logic:
•
Only one response permitted
• Justification: Q39a is to help HUD understand what it going on
with small multifamily rentals.
• The rental industry has been publishing statistics on the number of
renters making their rent payments on time
(https://www.nmhc.org/research-insight/nmhc-rent-payment-tracker/).
However, this tracker only covers about 11m of the more than 44m
renters, and those 11m units are highly skewed towards the
professionally managed rental properties. Of the remaining 33m
renters, about 4m renters are HUD-assisted, so HUD has some data on
them. Another 1m are covered by other rental assistance programs.
Unfortunately, we have no good data on the remain 28m renters, most
of whom are in rental units owned by "mom and pop" landlords.
• When we pair Q39 with data from the 2018 Rental Housing Finance
Survey (see attached), we will be able to estimate the probability
the Pulse respondent is NOT in a professionally managed property.
That will help us improve our understanding of this portion of the
rental market. .

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

•
•

With of $1.2 trillion of FHA insurance-in-force, HUD has a strong
interest in understanding if households made their previous
mortgage payment on time and believe they will be able to make
their next mortgage payment on time. The COVID-19 Household Pulse
Survey data on recent mortgage payment activity and next mortgage
payment intentions will fill in these existing data gaps.
With more than 4 million households receiving HUD rental
assistance, HUD has a strong interest in understanding how COVID-19
will impact renter's ability to make their rent payments. The
COVID-19 Household Pulse Survey data on recent renter's payment
activity and renter's ability to make next rental payment will help
HUD better understand the impact of COVID-19 on our rental
assistance programs.
Nearly 700,000 landlords participate in HUD's Housing Choice
Voucher Program. HUD has a strong interest in understanding how
COVID-19 will impact landlord's cash flow. The COVID-19 Household
Pulse Survey data on recent renter's payment activity and renter's
ability to make next rental payment will help HUD better understand
the impact of COVID-19 on landlords.
Time Frame:
As a characteristic of the household living
situation, this item is required for each administration.

Section Q40a (housing)
How many bedrooms are in your home? Please enter a number.
Section Q40a Spanish (housing)
¿Cuántos dormitorios tiene su casa? Por favor, anote un número.
Logic:

•
•

•

•
Open end numeric
•
Range: 0 to XX
•
If a respondent enters a number that falls outside of the above range, display the following
message (soft edit): XX
Justification: Q40a is simply designed to detect overcrowding. As
of now, overcrowding has not been an issue because households have
been able to pay their rent (at least those in professionallymanaged properties). If evictions start to increase, we will see a
lot of recently evicted people moving in with family or friends. We
believe the simplest way to get a sense of that is to measure
changes in number of persons-to-number of bedrooms ratio. It is not
a perfect measure, but it is the most common proxy for
overcrowding. .
With of $1.2 trillion of FHA insurance-in-force, HUD has a strong
interest in understanding if households made their previous
mortgage payment on time and believe they will be able to make
their next mortgage payment on time. The COVID-19 Household Pulse
Survey data on recent mortgage payment activity and next mortgage
payment intentions will fill in these existing data gaps.

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

•
•

With more than 4 million households receiving HUD rental
assistance, HUD has a strong interest in understanding how COVID-19
will impact renter's ability to make their rent payments. The
COVID-19 Household Pulse Survey data on recent renter's payment
activity and renter's ability to make next rental payment will help
HUD better understand the impact of COVID-19 on our rental
assistance programs.
Nearly 700,000 landlords participate in HUD's Housing Choice
Voucher Program. HUD has a strong interest in understanding how
COVID-19 will impact landlord's cash flow. The COVID-19 Household
Pulse Survey data on recent renter's payment activity and renter's
ability to make next rental payment will help HUD better understand
the impact of COVID-19 on landlords.
Time Frame:
As a characteristic of the household living
situation, this item is required for each administration.

Section Q40b (housing)
Is this household currently caught up on rent payments? Select only one answer.
1) Yes
2) No
Section Q40b Spanish (housing)
¿Está su hogar al día con los pagos de renta? Seleccione solo una respuesta.
1) Sí
2) No
Logic:
•

•

•
Ask Q40b if Q39 = 3
•
Only one response permitted
Justification: The housing items are necessary to differentiate the
experience of renters from owners, and to understand the impact of
housing uncertainty as it relates to the coronavirus pandemic.
Renters may be at greater risk of eviction and forcosure among
owners in certain situations may increase. This item asks about
currency status on rent payments among renters. These questions
allow for the evaluation of other areas of HPS items can be
considered alongside housing and housing security. .
With of $1.2 trillion of FHA insurance-in-force, HUD has a strong
interest in understanding if households made their previous
mortgage payment on time and believe they will be able to make
their next mortgage payment on time. The COVID-19 Household Pulse
Survey data on recent mortgage payment activity and next mortgage
payment intentions will fill in these existing data gaps.
With more than 4 million households receiving HUD rental
assistance, HUD has a strong interest in understanding how COVID-19
will impact renter's ability to make their rent payments. The
COVID-19 Household Pulse Survey data on recent renter's payment
activity and renter's ability to make next rental payment will help
HUD better understand the impact of COVID-19 on our rental
assistance programs.

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

•
•

Nearly 700,000 landlords participate in HUD's Housing Choice
Voucher Program. HUD has a strong interest in understanding how
COVID-19 will impact landlord's cash flow. The COVID-19 Household
Pulse Survey data on recent renter's payment activity and renter's
ability to make next rental payment will help HUD better understand
the impact of COVID-19 on landlords.
Time Frame: This item asks about the status of the current living
arrangements.

Section Q40c (housing)
Is this household currently caught up on mortgage payments? Select only one answer.
1) Yes
2) No
Section Q40c Spanish (housing)
¿Está su hogar al día con los pagos de hipoteca? Seleccione solo una respuesta.
1) Sí
2) No
Logic:
•

•

•
Ask Q40c if Q39 = 2
•
Only one response permitted
Justification: The housing items are necessary to differentiate the
experience of renters from owners, and to understand the impact of
housing uncertainty as it relates to the coronavirus pandemic.
Renters may be at greater risk of eviction and forcosure among
owners in certain situations may increase. This item asks about
currency status on mortgage payments among owners. These questions
allow for the evaluation of other areas of HPS items can be
considered alongside housing and housing security. .
With of $1.2 trillion of FHA insurance-in-force, HUD has a strong
interest in understanding if households made their previous
mortgage payment on time and believe they will be able to make
their next mortgage payment on time. The COVID-19 Household Pulse
Survey data on recent mortgage payment activity and next mortgage
payment intentions will fill in these existing data gaps.
With more than 4 million households receiving HUD rental
assistance, HUD has a strong interest in understanding how COVID-19
will impact renter's ability to make their rent payments. The
COVID-19 Household Pulse Survey data on recent renter's payment
activity and renter's ability to make next rental payment will help
HUD better understand the impact of COVID-19 on our rental
assistance programs.
Nearly 700,000 landlords participate in HUD's Housing Choice
Voucher Program. HUD has a strong interest in understanding how
COVID-19 will impact landlord's cash flow. The COVID-19 Household
Pulse Survey data on recent renter's payment activity and renter's
ability to make next rental payment will help HUD better understand
the impact of COVID-19 on landlords.

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•
•

Time Frame: This item asks about the status of the current living
arrangements.

Section Q41 (housing)
How confident are you that your household will be able to pay your next rent or mortgage payment on
time? Select only one answer.
1) Not at all confident
2) Slightly confident
3) Moderately confident
4) Highly confident
5) Payment is/will be deferred
Section Q41 Spanish (housing)
¿Qué tan seguro(a) está usted de que su hogar será capaz de pagar su próximo pago de alquiler o hipoteca
a tiempo? Seleccione solo una respuesta.
1) No está seguro(a) en absoluto
2) Algo seguro(a)
3) Moderadamente seguro(a)
4) Muy seguro(a)
5) El pago es/será suspendido
Logic:
•

•

•
Ask Q41 if Q39 in (2,3)
•
Only one response permitted
Justification: The housing items are necessary to differentiate the
experience of renters from owners, and to understand the impact of
housing uncertainty as it relates to the coronavirus pandemic.
Renters may be at greater risk of eviction and forcosure among
certainty in being able to pay next months rent or mortgage. With
the economic impact of the pandemic, concern over ability to pay
rent and mortgage and security of shelter is a significant priority
for well being. These questions allow for the evaluation of other
areas of HPS items can be considered alongside housing and housing
security. .
With of $1.2 trillion of FHA insurance-in-force, HUD has a strong
interest in understanding if households made their previous
mortgage payment on time and believe they will be able to make
their next mortgage payment on time. The COVID-19 Household Pulse
Survey data on recent mortgage payment activity and next mortgage
payment intentions will fill in these existing data gaps.
With more than 4 million households receiving HUD rental
assistance, HUD has a strong interest in understanding how COVID-19
will impact renter's ability to make their rent payments. The
COVID-19 Household Pulse Survey data on recent renter's payment
activity and renter's ability to make next rental payment will help
HUD better understand the impact of COVID-19 on our rental
assistance programs.

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

Section Q41a (housing)
How likely is it that your household will have to leave this home or apartment within the next two
months because of eviction? Select only one answer.
1) Very likely
2) Somewhat likely
3) Not very likely
4) Not likely at all
Section Q41a Spanish (housing)
¿Qué tan probable es que su hogar tenga que dejar esta casa o apartamento durante los próximos
dos meses debido a un desalojo? Seleccione solo una respuesta.
1) Muy probable
2) Algo probable
3) Poco probable
4) Nada probable
Logic:

•

•
•

Ask Q41a if Q40b = 2
Only one response permitted

Justification: The housing items are necessary to differentiate the
experience of renters from owners, and to understand the impact of
housing uncertainty as it relates to the coronavirus pandemic.
Renters may be at greater risk of eviction and forcosure among
certainty in being able to pay next months rent or mortgage. With
the economic impact of the pandemic, concern over ability to pay
rent and mortgage and security of shelter is a significant priority
for well being. These questions allow for the evaluation of other
areas of HPS items can be considered alongside housing and housing
security.
With of $1.2 trillion of FHA insurance-in-force, HUD has a strong
interest in understanding if households made their previous
mortgage payment on time and believe they will be able to make
their next mortgage payment on time. The COVID-19 Household Pulse
Survey data on recent mortgage payment activity and next mortgage
payment intentions will fill in these existing data gaps.
With more than 4 million households receiving HUD rental
assistance, HUD has a strong interest in understanding how COVID-19
will impact renter's ability to make their rent payments. The
COVID-19 Household Pulse Survey data on recent renter's payment

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

activity and renter's ability to make next rental payment will help
HUD better understand the impact of COVID-19 on our rental
assistance programs.
Nearly 700,000 landlords participate in HUD's Housing Choice
Voucher Program. HUD has a strong interest in understanding how
COVID-19 will impact landlord's cash flow. The COVID-19 Household
Pulse Survey data on recent renter's payment activity and renter's
ability to make next rental payment will help HUD better understand
the impact of COVID-19 on landlords.
Time Frame: This item asks about the expectation of paying next two
months rent or mortgage, and is a future oriented expectation.

Section Q41b (housing)
How likely is it that your household will have to leave this home within the next two months because
of foreclosure? Select only one answer.
1) Very likely
2) Somewhat likely
3) Not very likely
4) Not likely at all
Section Q41b Spanish (housing)
¿Qué tan probable es que su hogar tenga que dejar esta vivienda durante los próximos dos meses
debido a una ejecución hipotecaria (“foreclosure”)? Seleccione solo una respuesta.
1) Muy probable
2) Algo probable
3) Poco probable
4) Nada probable
Logic:

•

•
•

Ask Q41b if Q40c = 2
Only one response permitted

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

will impact renter's ability to make their rent payments. The
COVID-19 Household Pulse Survey data on recent renter's payment
activity and renter's ability to make next rental payment will help
HUD better understand the impact of COVID-19 on our rental
assistance programs.
Nearly 700,000 landlords participate in HUD's Housing Choice
Voucher Program. HUD has a strong interest in understanding how
COVID-19 will impact landlord's cash flow. The COVID-19 Household
Pulse Survey data on recent renter's payment activity and renter's
ability to make next rental payment will help HUD better understand
the impact of COVID-19 on landlords.
Time Frame: This item asks about the expectation of paying next two
months rent or mortgage, and is a future oriented expectation.

/* END PAGE */
Page Title: Education
Section Q42 (education)
At any time during the 2020-2021 school year, will any children in this household be enrolled in a public
school, enrolled in a private school, or educated in a homeschool setting in Kindergarten through 12th
grade or grade equivalent? Select all that apply.
1) Yes, enrolled in a public or private school
2) Yes, homeschooled
3) No
Section Q42 Spanish (education)
En cualquier momento durante el año escolar 2020-2021, ¿serán algunos niños en este hogar inscritos en
una escuela pública, inscritos en una escuela privada, o recibieron educación en el hogar (homeschooling)
para grados entre kindergarten hasta el 12º grado, o nivel equivalente? Seleccione todas las que
correspondan.
1)
Sí, inscritos en una escuela pública o privada
2)
Sí, educados en el hogar (homeschooled)
3)
No
Logic:
•
Multiple responses permitted
•
Make “No” answer choice exclusive
• Justification:
This set of items asks about the delivery of K-12
and Post-Secondary education and the changing environment and
burden in hours, cost and program for children receiving education
at different levels.
• The modes of educational delivery to households with school-age
children when COVID-19 caused suspension of most in-person
educational activities in public and private schools.
•
The burden placed on households for the education of school-age
children as a result of school closures.
•
The degree to which technology is available to households for
education of school-age children to facilitate online and distance
learning.
•
Differences in the ability to provide educational continuity to
students based on geography and socioeconomic characteristics.

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

Time Frame: In phase 2 these questions focus on the 2020-2021
calendar year.

Section Q43 (education)
How has the coronavirus pandemic affected how the children in this household received education for the
2020 – 2021 school year? Select all that apply.
1) Classes normally taught in person at the school were cancelled
2) Classes normally taught in person moved to a distance-learning format using online
resources, either self-paced or in real time
3) Classes normally taught in person moved to a distance-learning format using paper
materials sent home to children
4) Classes normally taught in person changed in some other way -- Please specify:
5) The coronavirus pandemic did not affect how children in this household receive education
Section Q43 Spanish (education)
¿Cómo ha afectado la pandemia del coronavirus la forma en que los niños de este hogar recibieron
educación durante el año escolar 2020 – 2021? Seleccione todas las que correspondan.
1)
Las clases que normalmente se enseñaban en persona en la escuela fueron canceladas
2)
Las clases que normalmente se enseñaban en persona se trasladaron a un formato de
aprendizaje a distancia utilizando recursos por internet, ya sea a ritmo del estudiante o en
tiempo real
3)
Las clases que normalmente se enseñaban en persona se trasladaron a un formato de
aprendizaje a distancia utilizando materiales impresos en papel enviados a casa a los niños
4)
Clases que normalmente se enseñaban en persona cambiaron de alguna otra manera -Por favor especifique:
5)
La pandemia del coronavirus no ha afectado la manera en que los niños de este hogar
reciben educación
Logic:
•
Ask Q43 if Q42 includes 1
•
Multiple responses permitted
• Justification:
This set of items asks about the delivery of K-12
and Post-Secondary education and the changing environment and
burden in hours, cost and program for children receiving education
at different levels.
• The modes of educational delivery to households with school-age
children when COVID-19 caused suspension of most in-person
educational activities in public and private schools.
•
The burden placed on households for the education of school-age
children as a result of school closures.
•
The degree to which technology is available to households for
education of school-age children to facilitate online and distance
learning.
•
Differences in the ability to provide educational continuity to
students based on geography and socioeconomic characteristics.
• Time Frame: In phase 2 these questions focus on the 2020-2021
calendar year.
Section Q44 (education)

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

How often is a computer or other digital device available to children for educational purposes? Select only
one answer.
1) Always available
2) Usually available
3) Sometimes available
4) Rarely available
5) Never available
Section Q44 Spanish (education)
¿Con qué frecuencia tienen los niños acceso a una computadora u otro dispositivo digital para fines
educativos? Seleccione solo una respuesta.
1)
Siempre disponible
2)
Por lo general disponible
3)
A veces disponible
4)
Rara vez disponible
5)
Nunca disponible
Logic:
•
Ask Q44 if Q42 includes 1
•
One response allowed
• Justification:
This set of items asks about the delivery of K-12
and Post-Secondary education and the changing environment and
burden in hours, cost and program for children receiving education
at different levels.
• The modes of educational delivery to households with school-age
children when COVID-19 caused suspension of most in-person
educational activities in public and private schools.
•
The burden placed on households for the education of school-age
children as a result of school closures.
•
The degree to which technology is available to households for
education of school-age children to facilitate online and distance
learning.
•
Differences in the ability to provide educational continuity to
students based on geography and socioeconomic characteristics.
• Time Frame: In phase 2 these questions focus on the 2020-2021
calendar year.
Section Q45 (education)
Is the computer or other digital device …? Select all that apply..
1) Provided by the children’s school or school district to use outside of school
2) Provided by someone in the household or family, or it is the child’s
3) Provided by another source.
Section Q45 Spanish (education)
¿Esta computadora u otro dispositivo digital fue ...? Seleccione todas las que correspondan.
1)
Proporcionado por la escuela o distrito escolar de los niños para usar fuera de la escuela
2)
Proporcionado por alguien en el hogar o familia, o es del niño(a)
3)
Proporcionado por otra fuente.
Logic:
•
Ask Q45 if Q42 includes 1 and Q44 in (1,2,3,4)

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

•
•
•
•
•

•
Multiple responses permitted
Justification:
This set of items asks about the delivery of K-12
and Post-Secondary education and the changing environment and
burden in hours, cost and program for children receiving education
at different levels.
The modes of educational delivery to households with school-age
children when COVID-19 caused suspension of most in-person
educational activities in public and private schools.
The burden placed on households for the education of school-age
children as a result of school closures.
The degree to which technology is available to households for
education of school-age children to facilitate online and distance
learning.
Differences in the ability to provide educational continuity to
students based on geography and socioeconomic characteristics.
Time Frame: In phase 2 these questions focus on the 2020-2021
calendar year.

Section Q46 (education)
How often is the Internet available to children for educational purposes? Select only one answer.
1) Always available
2) Usually available
3) Sometimes available
4) Rarely available
5) Never available
Section Q46 Spanish (education)
¿Con qué frecuencia tienen los niños acceso al internet para fines educativos? Seleccione solo una
respuesta.
1)
Siempre disponible
2)
Por lo general disponible
3)
A veces disponible
4)
Rara vez disponible
1.
Nunca disponible
Logic:
•
Ask Q46 if Q42 includes 1
•
One response allowed
• Justification:
This set of items asks about the delivery of K-12
and Post-Secondary education and the changing environment and
burden in hours, cost and program for children receiving education
at different levels.
• The modes of educational delivery to households with school-age
children when COVID-19 caused suspension of most in-person
educational activities in public and private schools.
•
The burden placed on households for the education of school-age
children as a result of school closures.
•
The degree to which technology is available to households for
education of school-age children to facilitate online and distance
learning.

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•
•

Section Q47 (education)
Are Internet services …? Select all that apply..
1) Paid for by the children’s school or school district
2) Paid for by someone in the household or family
3) Paid for by another source
Section Q47 Spanish (education)
¿Este servicio de internet es ...? Seleccione todas las que correspondan.
1)
Pagado por la escuela o el distrito escolar de los niños
2)
Pagado por alguien en el hogar o la familia
3)
Pagado por otra fuente
Logic:
•
Ask Q47 if Q42 includes 1 and Q46 in (1,2,3,4)
•
Multiple responses permitted
•

•
•
•
•
•

Justification:
This set of items asks about the delivery of K-12
and Post-Secondary education and the changing environment and
burden in hours, cost and program for children receiving education
at different levels.
The modes of educational delivery to households with school-age
children when COVID-19 caused suspension of most in-person
educational activities in public and private schools.
The burden placed on households for the education of school-age
children as a result of school closures.
The degree to which technology is available to households for
education of school-age children to facilitate online and distance
learning.
Differences in the ability to provide educational continuity to
students based on geography and socioeconomic characteristics.
Time Frame: In phase 2 these questions focus on the 2020-2021
calendar year.

Section Q47a (education)
During the last 7 days, on how many days did the student(s) have live contact with their teachers in
person, by phone, or by video? Select only one answer.
1) None
2) 1 day
3) 2-3 days
4) 4 or more days
Section Q47a Spanish (education)
Durante los últimos 7 días, ¿en cuántos días tuvieron los estudiantes contacto en vivo con sus maestros, ya
sea en persona, por teléfono o por video? Seleccione solo una respuesta.
1) Ningún día

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

2) 1 día
3) 2-3 días
4) 4 o más días
Logic:

Ask Q47a if Q42 includes 1
One response allowed

•
•
•

•
•
•
•
•

Justification:
This set of items asks about the delivery of
K-12 and Post-Secondary education and the changing environment
and burden in hours, cost and program for children receiving
education at different levels.
The modes of educational delivery to households with school-age
children when COVID-19 caused suspension of most in-person
educational activities in public and private schools.
The burden placed on households for the education of
school-age children as a result of school closures.
The degree to which technology is available to households
for education of school-age children to facilitate online and
distance learning.
Differences in the ability to provide educational
continuity to students based on geography and socioeconomic
characteristics.
Time Frame: In phase 2 these questions focus on the 2020-2021
calendar year, the hours series ask about the last 7 days. By
the time the Phase 2 fields, school will be starting in many
areas.

Section Q48a (education)
During the last 7 days, about how many hours did the student(s) spend doing learning activities on their
own? Do not include time spent with teachers or other household members. Enter the total number of
hours for all students. If none, enter 0.
___________
Section Q48a Spanish (education)
Durante los últimos 7 días, ¿apróximadamente cuántas horas pasaron los estudiantes por si mismo en
actividades de aprendizaje? No incluya tiempo pasado con maestros u otros miembros del hogar. Anote el
número total de horas para todos los estudiantes. Si no pasaron ningún tiempo, anote 0. ___________
Logic:

Ask Q48a if Q42 includes 1
Ensure numeric response and range reasonableness (valid responses: 0-168)

•
•
•

•

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•
•
•
•

The burden placed on households for the education of
school-age children as a result of school closures.
The degree to which technology is available to households
for education of school-age children to facilitate online and
distance learning.
Differences in the ability to provide educational
continuity to students based on geography and socioeconomic
characteristics.
Time Frame: In phase 2 these questions focus on the 2020-2021
calendar year, the hours series ask about the last 7 days. By
the time the Phase 2 fields, school will be starting in many
areas.

Section Q48b (education)
During the last 7 days, about how much time did the student(s) typically spend on all learning activities
relative to a school day before the coronavirus pandemic? Select only one answer.
1) Much less than a school day before the coronavirus pandemic
2) A little bit less than a school day before the coronavirus pandemic
3) As much as a school day before the coronavirus pandemic
4) A little bit more than a school day before the coronavirus pandemic
5) Much more than a school day before the coronavirus pandemic
Section Q48b Spanish (education)
Durante los últimos 7 días, ¿cuánto tiempo pasaron los estudiantes típicamente en actividades de
aprendizaje en comparación con una día escolar antes de la pandemia del coronavirus?
Seleccione solo una respuesta.
1) Mucho menos que una jornada escolar antes de la pandemia del coronavirus
2) Un poco menos que una jornada escolar antes de la pandemia del coronavirus
3) Igual que una jornada escolar antes de la pandemia del coronavirus
4) Un poco más que una jornada escolar antes de la pandemia del coronavirus
5) Mucho más que una jornada escolar antes de la pandemia del coronavirus
Logic:

Ask Q48b if Q42 includes 1
One response allowed

•
•
•

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•
•

Differences in the ability to provide educational
continuity to students based on geography and socioeconomic
characteristics.
Time Frame: In phase 2 these questions focus on the 2020-2021
calendar year, the hours series ask about the last 7 days. By
the time the Phase 2 fields, school will be starting in many
areas.

Section QPS1 (education)
Before the coronavirus pandemic, how many members of your household, including yourself, were
planning to take classes this fall from a college, university, community college, trade school, or other
occupational school (such as a cosmetology school or a school of culinary arts)? Please enter a number.
Section QPS1 Spanish (education)
Antes de la pandemia del coronavirus, ¿cuántos miembros de su hogar, incluyendo usted, habían planeado
tomar clases este otoño en una universidad, instituto superior comunitario, escuela de oficios u otra
escuela ocupacional (por ejemplo escuela de cosmetología o escuela de artes culinarias)? Por favor, anote
un número.
Logic:

•

•
•
•
•
•

•
Open end numeric
•
Range: 0 to 40
•
If a respondent enters a number that falls outside of the above range, display the following
message (soft edit):
o
For English: “Please enter a number between 1 and 40.”
o
For Spanish: “Por favor anote un número entre 1 y 40.”
Justification:
This set of items asks about the delivery of
Post-Secondary education and the changing environment and burden in
hours, cost and program for children receiving education at
different levels. This item drives the universe for the postsecondary education content.
Post secondary education represents a significant source of revenue
for schools and cost for households. It occupies a considerable
amount of time and effort for young adults. Changing venue and
programs also create changes in living situations and household
burden.
The modes of educational delivery to households with school-age
children when COVID-19 caused suspension of most in-person
educational activities in public and private schools.
The burden placed on households for the education of school-age
children as a result of school closures.
The degree to which technology is available to households for
education of school-age children to facilitate online and distance
learning.
Differences in the ability to provide educational continuity to
students based on geography and socioeconomic characteristics.
Time Frame: In phase 2 these questions focus on the 2020-2021
calendar year.

Section QPS2 (education)

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Thinking of all the members of your household who were planning to take classes from a college,
university, community college, trade school, or other occupational school this fall, what type of
program(s) are the classes a part of? Select all that apply.
1) Certificate or diploma program from a school that provides occupational training
(usually a 2-year program, often leading to a license, such as cosmetology)
2) Associate's degree program (usually a 2-year degree)
3) Bachelor's degree program (usually a 4-year degree)
4) Graduate degree program (for example, Master's, PhD, MD)
5) Another credential program not listed above
6) Classes that are not part of a credential program
Section QPS2 Spanish (education)
Pensando en todos los miembros de su hogar que habían planeado tomar clases este otoño en una
universidad, instituto superior comunitario, escuela de oficios u otra escuela ocupacional, ¿a qué tipo de
programa(s) pertenecen las clases? Seleccione todas las que correspondan.
1) Programa de certificación o diploma de una escuela que ofrece formación
ocupacional (por lo general un programa de 2 años, que a menudo resulta en una
licencia, como la cosmetología)
2) Título asociado universitario (por lo general un programa de dos años)
3) Título de licenciatura universitaria (por lo general un programa de 4 años)
4) Título de posgrado (por ejemplo, título de maestría, título profesional, doctorado)
5) Otro programa acreditado no listado arriba
6) Clases que no son parte de un programa acreditado
Logic:
•

•

•
•

•
Ask QPS2 if QPS1 > 0
•
Multiple responses allowed
Justification:
This set of items asks about the delivery of
Post-Secondary education and the changing environment and burden in
hours, cost and program for children receiving education at
different levels. For households with members who are in postsecondary programs, this item identifies which programs are planned
to be enrolled in by household members. It is a critical
characteristic to understand the change in planning for program
participation.
Post secondary education represents a significant source of revenue
for schools and cost for households. It occupies a considerable
amount of time and effort for young adults. Changing venue and
programs also create changes in living situations and household
burden.
The modes of educational delivery to households with school-age
children when COVID-19 caused suspension of most in-person
educational activities in public and private schools.
The burden placed on households for the education of school-age
children as a result of school closures.

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•
•
•

The degree to which technology is available to households for
education of school-age children to facilitate online and distance
learning.
Differences in the ability to provide educational continuity to
students based on geography and socioeconomic characteristics.
Time Frame: In phase 2 these questions focus on the 2020-2021
calendar year.

Section QPS3 (education)
Thinking of all the members of your household who were planning to take classes from a college,
university, community college, trade school, or other occupational school this fall, has the
coronavirus pandemic resulted in any of the changes listed below? Select all that apply.
1. Plans to take classes this fall have not changed.
2. All plans to take classes this fall have been cancelled.
3. Classes will be in different formats in the fall (for example, change from in-person to
online).
4. Fewer classes will be taken this fall.
5. More classes will be taken this fall.
6. Classes will be taken from a different institution.
7. Classes will be taken for a different kind of certificate or degree.
Section QPS3 Spanish (education)
Pensando en todos los miembros de su hogar que habían planeado tomar clases este otoño en
una universidad, instituto superior comunitario, escuela de oficios u otra escuela ocupacional, ¿ha
causado la pandemia del coronavirus alguno de los cambios listados a continuación? Seleccione
todas las que correspondan.
1. No han cambiado los planes para tomar clases este otoño.
2. Se han cancelado todos los planes para tomar clases este otoño.
3. Se tomarán clases en diferentes formatos este otoño (por ejemplo, cambio de clases
presenciales a clases en línea).
4. Se tomarán menos clases este otoño.
5. Se tomarán más clases este otoño.
6. Se tomarán clases en otra institución este otoño.
7. Se tomarán clases para otro tipo de certificado o diploma.
Logic:
•

•
Ask QPS3 if QPS1 > 0
•
Displayed as a grid in pretesting - Mark all.
Justification:
This set of items asks about the delivery of
Post-Secondary education and the changing environment and burden in
hours, cost and program for children receiving education at
different levels. For households with members who are in postsecondary programs, this item identifies what type of changes are
expected in the delivery of post-secondary education. It is a
critical characteristic to understand the change in planning for
program participation.

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

Post secondary education represents a significant source of revenue
for schools and cost for households. It occupies a considerable
amount of time and effort for young adults. Changing venue and
programs also create changes in living situations and household
burden.
The modes of educational delivery to households with school-age
children when COVID-19 caused suspension of most in-person
educational activities in public and private schools.
The burden placed on households for the education of school-age
children as a result of school closures.
The degree to which technology is available to households for
education of school-age children to facilitate online and distance
learning.
Differences in the ability to provide educational continuity to
students based on geography and socioeconomic characteristics.
Time Frame: In phase 2 these questions focus on the 2020-2021
calendar year.

•
•
•
•
•

Section QPS4 (education)
Why did household members’ plans to take classes this fall change? Select all that apply.
1) Had coronavirus or concerns about getting coronavirus
2) Institution changed content or format of classes (e.g., from in-person to online)
3) Changes to financial aid
4) Changes to campus life
5) Uncertainty about how classes/program might change
6) Not able to pay for classes/educational expenses because of changes to income from the
pandemic
7) Some other reason related to the pandemic, please specify
Section QPS4 Spanish (education)
¿Por qué cambiaron los miembros de su hogar los planes de estudio para este otoño? Seleccione
todas las que correspondan.Algún miembro de su hogar:
1) Tuvieron coronavirus o les preocupaba contagiarse con coronavirus
2) La institución cambió el contenido o formato de las clases (por ejemplo, de presencial a
en línea)
3) Cambios en asistencia financiera
4) Cambios en la vida en el campus
5) Incertidumbre con respecto a cómo pueden cambiar las clases/el programa
6) No podrán pagar las clases/los gastos educativos debido a los cambios en sus ingresos
por la pandemia
7) Alguna otra razón relacionada con la pandemia. Por favor especifique
Logic:
•

Ask QPS4 if QPS1 > 0 and at least one of QPS3_2, QPS3_3, QPS3_4, QPS3_5, or QPS3_6 =
1.
Justification:
This set of items asks about the delivery of
Post-Secondary education and the changing environment and burden in
•

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•

•
•
•
•
•

hours, cost and program for children receiving education at
different levels. For households with members who are in postsecondary programs, this item focuses on why plans for
participation in those programs changed. Multiple responses may be
selected and will illuminate the complexity of the return to school
for those households with members considering post-secondary
education. It is a critical characteristic to understand the change
in planning for program participation.
Post secondary education represents a significant source of revenue
for schools and cost for households. It occupies a considerable
amount of time and effort for young adults. Changing venue and
programs also create changes in living situations and household
burden.
The modes of educational delivery to households with school-age
children when COVID-19 caused suspension of most in-person
educational activities in public and private schools.
The burden placed on households for the education of school-age
children as a result of school closures.
The degree to which technology is available to households for
education of school-age children to facilitate online and distance
learning.
Differences in the ability to provide educational continuity to
students based on geography and socioeconomic characteristics.
Time Frame: In phase 2 these questions focus on the 2020-2021
calendar year.

/* END PAGE */
/* START PAGE */
Page Title: Income
Section Q50 (income)
In 2019 what was your total household income before taxes? Select only one answer.
1) Less than $25,000
2) $25,000 - $34,999
3) $35,000 - $49,999
4) $50,000 - $74,999
5) $75,000 - $99,999
6) $100,000 - $149,999
7) $150,000 - $199,999
8) $200,000 and above
Section Q50 Spanish (income)
En 2019, ¿cuál fue el ingreso total de su hogar antes de los impuestos? Seleccione solo una respuesta.
1) Menos de $25,000
2) $25,000 - $34,999
3) $35,000 - $49,999
4) $50,000 - $74,999
5) $75,000 - $99,999
6) $100,000 - $149,999

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

7) $150,000 - $199,999
8) $200,000 y más
Logic:
•
•

•
Only one response permitted
•
Do NOT rotate answer choices
Justification: This item collects a basic categorical household
income for 2019. This sets an economic foundation for understanding
the rest of the data elements in the HPS.
Time Frame: This item asks status about income for the last full
year (2019) to set a baseline economic status for the respondent
and their household.

/* END PAGE */
/* START PAGE */
Page Title: Address_Page
Section Address
Start of Block: Address
The U.S. Census Bureau is interested in understanding geographic differences in experiences with the
coronavirus pandemic. To help us analyze survey responses across the entire United States, please provide
your complete current street address below. Your address information will only be used for statistical
analyses conducted by the U.S. Census Bureau and will not be used for any other purpose or shared with
any other parties.

o Address Number (Q51) ________________________________________________
o Street Name (Q52) ________________________________________________
o Apt Unit (Q53) ________________________________________________
o City (Q54) ________________________________________________
o State (Q55) ________________________________________________
o Zip (Q56) ________________________________________________
o I do not have a street address (Q57)
Residence - Spanish
Residencia

La Oficina del Censo de los Estados Unidos está interesada en entender las diferencias geográficas en las experiencias
con la pandemia del coronavirus. Para ayudarnos a analizar las respuestas de las encuestas en todo los Estados

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Unidos, por favor, proporcione su dirección de calle completa y actual a continuación. Su dirección solo se utilizará
para análisis estadísticos realizados por la Oficina del Censo de los Estados Unidos y no se utilizará para ningún otro
propósito ni se compartirá con nadie más.

o Número de la dirección________________________________________________
o Nombre de calle ________________________________________________
o Apartamento o Unidad ________________________________________________
o Ciudad ________________________________________________
o Estado ________________________________________________
Código Postal ___

no_address

▢

No tengo una dirección

rural_route Q58
Do you have a Rural Route address?

o Yes (1)
o No (2)
Rural_Route – Spanish
¿Tiene una dirección de Ruta Rural?
☒Sí
☐No
Page Break

Ayuda

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Display This Question:
If Do you have a Rural Route address? = Yes

rural_address Please provide the Rural Route address where you currently reside.
Also, provide a description of the physical location in the space provided.

o RR Descriptor (Q59) ________________________________________________
o Rural Route No (Q60) ________________________________________________
o RR Box ID (Q61) ________________________________________________
o City (Q62) ________________________________________________
o State (Q63) ________________________________________________
o Zip Code (Q64) ________________________________________________
Display This Question:
If Do you have a Rural Route address? = Yes

rural_description Q65 Please provide as much information as possible.
For example, if you also have a street address associated with your residence, such as one used for
emergency services (E - 911) or for you to have a package delivered to your home, then please provide it
here.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Rural_address - Spanish

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

rural_address Por favor indique la dirección de la Ruta Rural donde vive actualmente.
Además, proporcione una descripción de la ubicación física a continuación.

o Descriptor RR (Q57) ________________________________________________
o Núm. Ruta Rural (Q58) ________________________________________________
o ID Buzón RR (Q59) ________________________________________________
o Ciudad (Q60) ________________________________________________
o Estado (Q61) ________________________________________________
o Código Postal (Q62) ________________________________________________
Display This Question:
Muestre esta pregunta:
If Do you have a Rural Route address? = Yes
Si Tiene una dirección de Ruta Rural? = Sí

rural_description Q63 Por favor proporcione tanta información como sea posible.
Por ejemplo, si también tiene una dirección asociada a su residencia, como la que se usa para servicios de
emergencia (E - 911) o para que le entreguen un paquete en su casa, por favor proporciónela a
continuación.

Page Break

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Display This Question:
If Do you have a Rural Route address? , No Is Displayed
And Do you have a Rural Route address? != Yes

other_address Please provide the city and state or ZIP Code where you are currently living. Also, describe
the physical location in the space provided.

o City (Q66) ________________________________________________
o State (Q67) ________________________________________________
o Zip (Q68) ________________________________________________
Display This Question:
If Do you have a Rural Route address? , No Is Displayed
And Do you have a Rural Route address? != Yes

other_description Q69 Please provide as much information as possible.
For example: a location description such as "The apartment over the gas station" or "The brick house
with the screened porch on the northeast corner of Farm Road and HC46" or
a name of a park, street
intersection or shelter, if you are experiencing homelessness, as well as the name of the city and state. For
example, "Friendship Park, Anywhere PA."
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

other_address Por favor, proporcione la ciudad y el estado o el código postal donde vive actualmente.
Además, describa la ubicación física a continuación.

o Ciudad ________________________________________________
o Estado ________________________________________________
o Código Postal ________________________________________________

Display This Question:
Muestre esta pregunta:
If Do you have a Rural Route address? , No Is Displayed
Si Tiene una dirección de Ruta Rural? , se muestra No
And Do you have a Rural Route address? != Yes
Y Tiene una dirección de Ruta Rural? !=Sí

other_description Por favor proporcione tanta información como sea posible.
Por ejemplo:
• Una descripción de la ubicación, como “apartamento encima de la estación de gasolina” o “casa de
ladrillo con porche enmallado en la esquina noreste de Farm Road y HC 46” o
• Nombre de parque, intersección de calle o refugio, en caso de que usted esté sin hogar, así como el
nombre de la ciudad y estado. Por ejemplo, “Friendship Park, Anywhere, PA.”

End of Block: Address

/* END PAGE */
/* START PAGE */
Because we are interested in how coronavirus experiences change over time, we may contact you again in
the coming weeks. What is the best way for us to contact you?
o Text message
o Email

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Como nos interesa la manera en que las experiencias con el coronavirus cambian con el tiempo, puede ser
que nos pongamos en contacto con usted en las próximas semanas. ¿Cuál es la mejor forma para
ponernos en contacto con usted?
o Mensaje de texto
o Correo electrónico
To help us contact you, please provide the best phone number to reach you.
________________________________________________________________
Para ayudarnos a contactarle, por favor, proporcione el mejor número de télefono para comunicarnos con
usted.
To help us contact you, please provide the best email address to reach you.
________________________________________________________________
Para ayudarnos a contactarle, por favor, proporcione la mejor dirección de correo electrónico para
comunicarnos con usted.
/* END PAGE */
/* START PAGE */

Section QXX (Open-ended feedback items)
Thank you.
Is there anything else related to the coronavirus pandemic you would like to tell us?
(open-ended text box)
Section QXX Spanish (Open-ended feedback items)
Gracias.
¿Hay algo más relacionado con la pandemia del coronavirus que le gustaría contarnos?
(open-ended text box)
Page Title: Submit_Page
Section Submit Page (Submit)
That concludes the survey. Please click on the “Submit” button when you are finished.
Section Submit Page Spanish (Submit)
Con esto terminamos la encuesta. Haga clic en el botón “Enviar” cuando haya terminado.
## SUBMIT BUTTON DISPLAYED HERE ##
Logic:

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

•
Users can still use the “Previous” navigator to go back to the survey before clicking the
Submit button.
/* END PAGE */
/* START PAGE */
Page Title: Thank_You_Page
Section Thank You Page (display_ThankYou)
Thank you for participating in the 2020 Household Pulse Survey.
If you have any questions about this survey please visit https://www.census.gov/householdpulsedata. You
can validate that this survey is a legitimate federally-approved information collection using the U.S. Office
of Management and Budget approval number 0607-1013, expiring on 07/31/2020.
Section Thank You Page Spanish (display_ThankYou)
Gracias por participar en la Encuesta del Pulso de los Hogares.
Si tiene alguna pregunta sobre esta encuesta, visite https://www.census.gov/householdpulsedata. Puede
confirmar que esta encuesta es una recopilación de información legítima aprobada por el gobierno federal
usando el número de aprobación 0607-1013 de la Oficina de Administración y Presupuesto de los Estados
Unidos, que vence el 07/31/2020.
/* END PAGE */
Stimulus Questions – Not Programmed in Round 1
Section Q17 (stimulus questions)
Q17. What was the amount of the coronavirus (COVID-19) related economic impact (stimulus) payment
that was received in total for all the covered adults and children? Enter amount.
Enter amount $
Section Q17 Spanish (stimulus questions)
Q17. ¿Cuál fue la cantidad del pago por el impacto económico (estímulo) debido al coronavirus (COVID19) que se recibió en total para todos los adultos y niños cubiertos? Anote la cantidad.
Anote la cantidad $
Section Q15new (stimulus questions)

If you, or anyone in your household, already received, or plan to receive a “stimulus payment,” that
is the coronavirus related Economic Impact Payment from the Federal Government, did or will you
use it: Select only one answer.
o Mostly to pay for expenses (food, clothing, shelter, etc.)
o Mostly to pay off debt (car loans, student loans, credit cards)
o Mostly to add to savings
o Not applicable, I did not and do not expect to receive the stimulus payment

Household Pulse Survey Phase 3 Supporting Statement Part A, Attachment A: Questionnaire

Section Q15new Spanish (stimulus questions)

Si usted, o alguien en su hogar, ha recibido ya, o anticipa recibir, un “pago de estímulo”, que es el
pago del gobierno federal por el impacto económico relacionado con el coronavirus, ¿para qué lo
usó o lo usará? Seleccione solo una respuesta.
o La mayor parte para pagar gastos (comida, ropa, vivienda, etc.)
o La mayor parte para pagar deudas (préstamos de autos, préstamos estudiantiles, tarjetas de
crédito)
o La mayor parte para añadir a los ahorros
o No corresponde, no se recibió ni se anticipa recibir el pago de estímulo
Section Q21 (stimulus questions)
Q21. How many people was the coronavirus stimulus payment for?
Enter count of people (including you) _______
Section Q21 Spanish (stimulus questions)
Q21. ¿Para cuántas personas era el pago de estímulo del coronavirus?
Anote el número de personas (incluyendo usted) _______

File Type	application/pdf
Author	Kyley McGeeney
File Modified	2020-09-10
File Created	2020-08-19