QUESTIONNAIRE CLEAN 1.5.21 revision v3

Draft Small Business Pulse Survey Phase 4

Instrument for Cognitive Testing

1.5.21 v.3

First screen (PRA/PA statements):

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 interview under the authority of Title 13, United States Code, Sections 131 and 182. Federal law protects your privacy and keeps your answers confidential (Title 13, United States Code, Section 9). Per the Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity risks through screening of the systems that transmit your data.

We estimate that completing this voluntary interview will take 45 minutes on average. Send comments regarding this estimate or any other aspect of this interview, including suggestions for reducing the time it takes to complete this interview, to [email protected]. This collection has been approved by the Office of Management and Budget (OMB). This eight-digit OMB approval number, 0607-1014, confirms this approval and expires on 10/31/2023. We are required to display this number to conduct this survey. By proceeding, you give your consent to participate in this study.

Your privacy is protected by the Privacy Act. The information provided may be shared with other Census Bureau staff for the work-related purposes identified in this statement. For more information on this collection, see SORN “COMMERCE/CENSUS-4, Economic Survey Collection” by visiting our website at census.gov and clicking on "Data Protection and Privacy Policy" at the bottom of the home page.

Welcome to the Small Business Pulse Survey

The U.S. Census Bureau is requesting your assistance in understanding the effect of changing business conditions due to the Coronavirus pandemic on your business. Your response is especially important right now as it helps policy makers, government officials, and businesses like yours understand these effects. Please complete this short 20 question survey; it will take approximately 5 minutes.

This survey asks about the experience of your business over the last week, but also about the experience of your business since the start of the Coronavirus pandemic. The White House declared a national emergency because of the Coronavirus pandemic on March 13, 2020.

Login ID:

For the completion of this survey, please provide data for: XXXX

Is XX-XXXXXXX the Employer Identification Number (EIN) used on this businesses latest Internal Revenue Service Form 941, Employer's Federal Quarterly Tax Return?

o Yes

o No

If no, please provide EIN:

Q1. Overall, how has this business been affected by the Coronavirus pandemic?

Select only one:
• Large negative effect
• Moderate negative effect
• Little or no effect
• Moderate positive effect
• Large positive effect

Q2. In the last month, what were the total operating revenues/sales/receipts for this business, not including any financial assistance or loans?

Select only one:
• $0 - $500
• $501 - $2,500
• $2,501 - $5,000
• $5,001 - $15,000
• $15,001 - $50,000
• $50,001 - $125,000
• $125,001 - $200,000
• $200,001 - $500,000
• $500,001 or more
• Don’t know

Q3. In the last week, did this business have a change in operating revenues/sales/receipts, not including any financial assistance or loans?

Select only one:
• Yes, increased
• Yes, decreased
• No

Q4. In the last week, did this business do any of the following?

Select only one:
• Open a previously closed location
• Temporarily close a location
• Permanently close a location
• None of the above

Q5. In the last week, did this business have a change in the number of paid employees?

Select only one:
• Yes, increased
• Yes, decreased
• No change

Q6. In the last week, did this business have a change in the total number of hours worked by paid employees?

Select only one:

• Yes, increased

• Yes, decreased

• No change

Q7. In the last week, did this business require employees to test negative for COVID-19 prior to working onsite?

Select only one:

• Yes

• No

• Not applicable, this business did not have employees onsite in the last week.

Q8. In the last week, did this business require employees to have proof of vaccination for COVID-19 prior to working onsite?

Select only one:

• Yes

• No

• Not applicable, this business did not have employees onsite in the last week.

Q9. In the last week, did this business have any of the following?

Select all that apply:
• Domestic supplier delays
• Foreign supplier delays
• Difficulty locating alternate domestic suppliers
• Difficulty locating alternate foreign suppliers
• Production delays at this business
• Delays in delivery/shipping to customers
• None of the above

Q10. In the last week, was this business’s operating capacity affected by any of the following?

Note: Operating capacity is the maximum amount of activity this business could conduct under realistic operating conditions.

Select all that apply:
• Ability to re-hire furloughed or laid off employees and/or hire new employees
• Availability of employees to work
• Ability of employees to work remotely

• Availability of COVID-19 tests for employees

• Availability of COVID-19 vaccine for employees
• Physical distancing of employees
• Physical distancing of customers or clients and/or limits on the number of concurrent customers or clients
• Availability of Personal Protective Equipment (PPE) and/or related equipment or supplies
• Availability of other supplies or inputs used to provide good or services
• None of the above

Q11. How would you describe this business’s current operating capacity relative to one year ago?

Note: Operating capacity is the maximum amount of activity this business could conduct under realistic operating conditions.

Select only one:

• Operating capacity has increased 50% or more
• Operating capacity has increased less than 50%
• No change in operating capacity
• Operating capacity has decreased less than 50%
• Operating capacity has decreased 50% or more

Q12. The White House declared a national emergency because of the Coronavirus pandemic on March 13, 2020.

Since March 13, 2020, did this business decrease the amount of square footage leased/rented for operations?

Select only one:

• Yes

• No

• Not applicable, this business does not lease/rent space.

Q13. Since March 13, 2020, did this business permanently add pickup/carryout/delivery as a means of providing goods/services to its customers?

Select only one:

• Yes

• No

• This business already used pickup/carryout/delivery as a means of providing goods/services to its customers prior to March 13, 2020.

Q14. Since March 13, 2020, what changes did this business make to its budgeted capital expenditures for 2020?

Select all that apply:
• Canceled budgeted capital expenditure(s)

• Postponed budgeted capital expenditure(s)

• Decreased budgeted capital expenditure(s)

• Increased budgeted capital expenditure(s)

• Introduced new unbudgeted capital expenditure(s)

• This business had no changes to budgeted capital expenditure(s) for 2020.

Q15. The Families First Coronavirus Response Act (FFCRA) went into effect on April 1, 2020.

Since April 1, 2020, did any of this business’s employees use COVID-19 related emergency paid sick leave provided by the Families First Coronavirus Response Act (FFCRA)?

Select only one:

• Yes

• No, no eligible employees requested or had a qualifying reason for FFCRA emergency paid sick leave

• No, all of this business’s employees were exempted as health care providers or emergency responders

• No, this business used the small business exemption (for employers below 50 employees where providing paid leave would have jeopardized the viability of the business as a going concern).

Q16. Since April 1, 2020, did any of this business’s employees use COVID-19 related expanded family and medical leave provided by the Families First Coronavirus Response Act (FFCRA)?

Select only one:

• Yes

• No, no eligible employees requested or had a qualifying reason for FFCRA expanded family and medical leave

• No, all of this business’s employees were exempted as health care providers or emergency responders

• No, this business used the small business exemption (for employers below 50 employees where providing paid leave would have jeopardized the viability of the business as a going concern).

Q17. On December 27, 2020, the Consolidated Appropriations Act 2021 was enacted providing additional Coronavirus pandemic relief.

Since December 27, 2020, has this business requested financial assistance from any of the following sources?

Select all that apply:
• Paycheck Protection Program (PPP)
• Economic Injury Disaster Loans (EIDL)
• Small Business Administration (SBA) Loan Forgiveness
• Main Street Lending Program
• Deferral of Federal Employment Tax Deposits and Payments
• COVID-19 Related Federal Paid Sick and Expanded Family and Medical Leave Tax Credits
• Federal Employee Retention and Rehiring Tax Credit
• Other Federal programs
• State or local government programs
• Banks or other financial institutions
• Owner(s)
• Family or friends
• Other sources
• This business has not requested financial assistance from any source since December 27, 2020.

Q18. Since December 27, 2020, has this business received financial assistance from any of the following sources?

Select all that apply:
• Paycheck Protection Program (PPP)
• Economic Injury Disaster Loans (EIDL)
• SBA Loan Forgiveness
• Main Street Lending Program
• Deferral of Federal Employment Tax Deposits and Payments
• COVID-19 Related Federal Paid Sick and Expanded Family and Medical Leave Tax Credits

• Federal Employee Retention and Rehiring Tax Credit
• Other Federal programs
• State or local government programs
• Banks or other financial institutions
• Owner(s)
• Family or friends
• Other sources
• This business has not received financial assistance from any source since December 27, 2020.

Q19. In the next 6 months, do you think this business will have business travel expenditures for air, rail, car rental, or lodging?

Select only one:

• Yes

• No

• Not applicable, this business does not usually have business travel expenditures.

Q20. In the next 6 months, do you think this business will need to do any of the following?

Select all that apply:

• Obtain financial assistance or additional capital

• Identify new supply chain options

• Develop online sales or websites

• Increase marketing or sales

• Learn how to better provide for the safety of customers and employees

• Identify and hire new employees

• Make a capital expenditure

• Cancel or postpone a budgeted capital expenditure

• Permanently close this business

• None of the above

Q21. In your opinion, how much time do you think will pass before this business returns to its usual level of operations?

Select only one:
• 1 month or less
• 2-3 months
• 4-6 months
• More than 6 months
• I do not believe this business will return to its usual level of operations.
• This business has permanently closed.
• There has been little or no effect on this business's usual level of operations.
• This business has returned to its usual level of operations.

Would you like to provide any information about your responses to these questions or this business's experiences during the Coronavirus pandemic?

Remarks (500 characters)

OMB Number

This collection has been approved by the Office of Management and Budget (OMB). The eight-digit OMB approval number is 0607-1014 and appears in the top right corner of each reporting screen. Without this approval, we could not conduct this survey.

Authority and Confidentiality

Title 13, United States Code, Sections 131 and 182, authorizes the U.S. Census Bureau to conduct this collection and to request your voluntary assistance. The Census Bureau is required by Section 9 of the same law to keep your information confidential and use your responses only to produce statistics. The Census Bureau is not permitted to publicly release your responses in a way that could identify your business, organization, or institution. Per the Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity risks through screening of the systems that transmit your data.

Burden Estimate Statement

We estimate the Small Business Pulse Survey will take an average of 5 minutes to complete. Factors such as company size, complexity and activity will affect your actual time to complete the survey. This estimate includes the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review the survey.

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:

EID Survey Comments 0607-1014

U.S. Census Bureau

4600 Silver Hill Road

Room EID-6K081

Washington, DC 20233

You may email comments to [email protected]. Be sure to use “EID Survey Comments 0607-1014” as the subject.

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