Supporting Statement Part A, Attachment A: Household Pulse Survey Questionnaire
Household Pulse Survey Questionnaire
April 17, 2020(R)
## THIS QUESTION WILL RANDOMLY ASSIGN PARTICIPANTS TO SEE UNIPOLAR SCALES IN THE ORDER THEY ARE WRITTEN IN THESE REQUIREMENTS (CHOICE 1 TO CHOICE 5), OR TO SEE THEM IN REVERSE ORDER (CHOICE 5 TO CHOICE 1) ##
## WRITTEN ## Show unipolar scales as they are written
## REVERSE ## Show unipolar scales in reverse order
## HEADER TO BE DISPLAYED ON EVERY PAGE AFTER WELCOME PAGE##
## ENGLISH ##
AN OFFICIAL WEBSITE OF THE UNITED STATES GOVERNMENT
Unites States Census Bureau Logo
2020 COVID19 Rapid Response Panel
English | Español | Logout
## SPANISH ##
UN SITIO WEB OFICIAL DEL GOBIERNO DE LOS EE.UU.
Unites States Census Bureau Logo
Encuesta de Planificación del Censo del 2020
English | Español | Salir
## FOOTER TO BE DISPLAYED ON EVERY PAGE ##
## ENGLISH ##
OMB No.: XXXXXXXXX Approval Expires: XXXXXXX
Accessibility – Linked to webpage https://www.census.gov/about/policies/privacy/privacy-policy.html#par_textimage_1 with the following language:
The Census Bureau is committed to making online forms and other public documents on its Internet server accessible to all. Currently, we are reviewing our web sites and making modifications to those pages, which are not in compliance with the Americans with Disabilities Act. We use Hypertext Markup Language (HTML) to create pages that are generally accessible to persons using screen-reading devices, and we are careful in our construction of HTML documents to ensure maximum accessibility. We include alternate text describing graphics.
Many Census Bureau Internet documents are in ASCII or HTML formats. These documents are accessible to persons using screen-reading software. We also have a large number of documents in Adobe Acrobat PDF (Portable Document Format) files. Currently, many people using screen-reading devices cannot read documents in PDF format, specifically those that were created from a scanned hard copy.
Adobe Systems, Inc. is producing various products designed to make Adobe Acrobat documents accessible to persons using screen-reading software. Adobe's accessibility web pages describe their efforts.
To allow us to better serve those with visual disabilities who are having difficulty accessing PDF documents; you may contact us directly for further assistance at 301-763-INFO (4636), 800-923-8282, or by submitting a request at ask.census.gov.
Privacy – Linked to webpage https://www.census.gov/privacy/ with the following language:
We are committed to handling your information responsibly. Your information is kept confidential. This commitment applies to the individuals, households, and businesses that answer our surveys, and to those browsing our website.
Security – Linked to webpage [URL] with the following language:
Data are Encrypted at all Times
Our secure servers use Hypertext Transfer Protocol over Secure Socket Layer (HTTPS) to ensure the encrypted transmission of data between your browser and the U.S. Census Bureau. This means that instead of sending readable text over the Internet, both your browser and our servers encode (scramble) all text using a security key. That way, personal data sent to your browser and data you send back are extremely difficult to decode in the unlikely event of interception by an unauthorized party. As a result of this, your browser must be capable of using the required encryption protocol and strength in order to connect to our servers. If you cannot connect to our secure servers, please upgrade to a newer browser.
Third Party Identity Proofing
Our secure servers use a digital certificate (digital ID) issued by a trusted, third party Certificate Authority (CA) as proof of identity. The only way to be sure of a web site's authenticity is to view their digital ID. In this way, you can be assured that you are not being "spoofed" or tricked by an imposter. The digital ID will contain information such as the name of the organization that owns the web site, the site's registered internet name/address, and the name of the Certification Authority under which the digital ID was issued. The method for viewing a web site's Digital Certificate/ID varies depending on the web browser. Please see your browser's "Help" information for instructions on how to verify a web site's identity.
Burden – Linked to webpage [URL] with the following language:
How long will this survey take?
The Census Bureau estimates that, for the average household, this survey will take about 20
minutes to complete, including the time for reviewing the instructions and answers.
## SPANISH ##
Núm. de OMB: XXXXXXXX Aprobado hasta: XXXXXXXX
Accesibilidad – Linked to webpage [URL] with the following language:
Privacidad – Linked to webpage [URL] with the following language:
Seguridad – Linked to webpage [URL] with the following language:
Tiempo y esfuerzo – Linked to webpage [URL] with the following language:
¿Cuánto tiempo va a tomar esta encuesta?
La Oficina del Censo calcula que al hogar típico le tomará como promedio aproximadamente 15 minutos completar esta encuesta, incluyendo el tiempo que toma repasar las instrucciones y revisar las respuestas.
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Welcome! Thank you for participating in this survey sponsored by the U.S. Department of Commerce, U.S. Census Bureau. This survey is available in another language. 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.
¡Bienvenido(a)! Gracias por participar en esta encuesta de la Oficina del Censo y el Departamento de Comercio de los Estados Unidos. Esta encuesta está disponible en otro idioma. Por favor seleccione el idioma de su preferencia para contestar la encuesta.
Logic:
Ask this question for all respondents
Only one response permitted here, and respondents will be able to toggle between languages in the remaining of the survey
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Section
Splash Page (display_Information)
Thank you
for participating. This survey helps measure the impact of
coronavirus (COVID-19) on employment status, consumer spending
(including use of stimulus payments), food security, housing
security, education disruptions, and dimensions of physical and
mental wellbeing. Completing this short 20-minute survey will help
the following agencies identify coronavirus (COVID-19) related issues
in your state:
- the U.S. Census Bureau
- the Bureau of Labor Statistics
- the National Center for Health Statistics
- the National Center for Education Statistics
- the United States Department of Agriculture
- the Department of Housing and Urban Development
In this survey:
- we refer to the coronavirus (COVID-19) as coronavirus.
This survey is not the census.
Here is some helpful information:
We will keep your answers confidential.
You can validate that this survey is a legitimate federally-approved information collection using the U.S. Office of Management and Budget approval number 0607-0978, expiring on 08/31/2020. Federal agencies may not sponsor surveys without a valid control number.
To learn more about this survey go to: www.census.gov/plan.
** U.S. Census Bureau Notice and Consent Warning **
You are accessing a United States Government 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 99-474).
Section Splash Page Spanish (display_Information)
Gracias por participar. Completar esta breve encuesta de 15 minutos ayudará a la Oficina del Censo de los Estados Unidos a realizar el próximo censo en el 2020. Esta encuesta debe ser completada por la persona que generalmente abre la correspondencia en su hogar. Esta encuesta no es el censo.
A continuación alguna información útil:
Mantendremos sus respuestas confidenciales.
Puede validar que esta encuesta es una recopilación de información legítima aprobada por el gobierno federal utilizando el número de aprobación 0607-0978 de la Oficina de Administración y Presupuesto de los Estados Unidos, que vence el 08/31/2020. Las agencias federales no pueden patrocinar encuestas sin un número de control válido.
Para obtener más información sobre esta encuesta, visite: www.census.gov/plan.
** Aviso de la Oficina del Censo de los EE. UU. y Advertencia sobre el consentimiento **
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.
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 se trata de una violación de las leyes federales y puede ser penalizado con multas o encarcelamiento (LEY PÚBLICA 99-474).
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These final questions are for statistical purposes only.
Estas últimas preguntas se hacen solo con propósitos estadísticos.
What year were you born? Please enter a number.
____
¿En qué año nació usted? Por favor ingrese un número.
____
Logic:
Open end numeric; Range: 1900 to 2020; If respondent enters a number that falls outside of the above range, display the following message (soft edit): "Please enter a number between 1900 and 2020."
Continue to survey if respondent indicates birth year older than 2002
Need to jump to a ineligible respondent thank you screen.
Are you… Select only one answer.
Male
Female
Usted es… Seleccione solo una respuesta.
Hombre
Mujer
Logic:
Only one response permitted
Do NOT rotate answer choices
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Are you of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin (specify)
¿Es usted de origen hispano, latino, o español?
No, no soy de origen hispano, latino, o español
Sí, mexicano, mexicanoamericano, chicano
Sí, puertorriqueño
Sí, cubano
Sí, de otro origen hispano, latino, o español
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.
What is your race? Please select all that apply.
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Chamorro
Samoan
¿Cuál es su raza? Seleccione todas las que correspondan.
Blanca
Negra o afroamericana
Indígena de las Américas o nativa de Alaska (especifique el nombre de la tribu en la cual está inscrito[a] o la tribu principal) /* SPECIFY */ ## OPEN-ENDED RESPONSE UP TO 60 CHARACTERS ##
India asiática
China
Filipina
Japonesa
Coreana
Vietnamita
Otra asiática (especifique la raza, por ejemplo, hmong, laosiana, tailandesa, paquistaní, camboyana, etc.) /* SPECIFY */ ## OPEN-ENDED RESPONSE UP TO 60 CHARACTERS ##
Nativa de Hawái
Chamorra
Samoana
Otra de las islas del Pacífico (especifique raza, por ejemplo, fiyiana, tongana, etc.) /* SPECIFY */ ## OPEN-ENDED RESPONSE UP TO 60 CHARACTERS ##
Alguna otra raza (especifique la raza) /* SPECIFY */ ## OPEN-ENDED RESPONSE UP TO 60 CHARACTERS ##
Logic:
Multiple responses permitted
Do NOT rotate answer choices
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What is the highest degree or level of school you have completed? Select only one answer.
Less than high school
Some high school
High school graduate or equivalent (for example GED)
Some college, but degree not received or is in progress
Associate’s degree (for example AA, AS)
Bachelor's degree (for example BA, BS, AB)
Graduate degree (for example master's, professional, doctorate)
¿Cuál es el grado o nivel de educación más alto que ha completado? Seleccione solo una respuesta.
Logic:
Only one response permitted
Do NOT rotate answer choices
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What is your marital status? Select only one answer.
Now married
Widowed
Divorced
Separated
Never married
¿Cuál es su estado civil? Seleccione solo una respuesta.
Casado(a) actualmente
Viudo(a)
Divorciado(a)
Separado(a)
Nunca me he casado
Logic:
Only one response permitted
Do NOT rotate answer choices
How many total people – adults and children – currently live in your household, including yourself? Please enter a number.
____
¿Cuántas personas en total – adultos y niños – viven actualmente en su hogar, incluyéndose a sí mismo(a)? Por favor ingrese 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):
For English: “Please enter a number between 1 and 40.”
For Spanish: “Por favor ingrese un número entre 1 y 40.”
How many people under 18 years-old currently live in your household? Please enter a number.
____
¿
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):
For English: “Please enter a number between 1 and 40.”
For Spanish: “Por favor ingrese un número entre 1 y 40.”
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This survey is a cooperative effort across many agencies to provide critical, timely information about the experience of the coronavirus (COVID-19) pandemic and its impact on the population of the United States. This survey is not the census. The 2020 Census is also underway.
Have you, or has anyone in your household experienced a loss of employment income since March 13, 2020? Select only one answer.
Yes
No
¿? Seleccione solo una respuesta.
Logic:
Only one response permitted
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.
Yes
No
¿? Seleccione solo una respuesta.
Logic:
Only one response permitted
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.
Yes
No
¿
Logic:
Only one response permitted
Are you employed by government, by a private company, a nonprofit organization or are you self-employed or working in a family business? Select only one answer.
Government
Private company
Non-profit organization including tax exempt and charitable organizations
Self-employed
Working in a family business
¿
Logic:
If Q11 = 1 ask Q12
Only one response permitted
What is your main reason for not working for pay or profit? Select only one answer.
I did not want to be employed at this time;
I did not work because I am/was sick with coronavirus symptoms;
I did not work because I am/was caring for someone with coronavirus symptoms;
I did not work because I am/was caring for children not in school or daycare;
I did not work because I am/was caring for an elderly person;
I am/was sick (not coronavirus related) or disabled;
I am retired;
I did not have work due to coronavirus pandemic related reduction in business (including furlough);
I am/was laid off due to coronavirus pandemic;
My employment closed temporarily due to the coronavirus pandemic;
My employment went out of business due to the coronavirus pandemic;
Other reason, please specifiy)
¿
Logic:
If Q11 = 2 ask Q13
Only one response permitted
Are you receiving pay for the time you are not working? Select only one answer.
Yes, I use paid leave;
Yes, I receive full pay but do not have to take leave;
Yes, I receive partial pay;
No, I receive no pay
¿? Seleccione solo una respuesta.
Logic:
If Q11 = 2 ask Q14
Only one response permitted
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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.
Enough of the kinds of food (I/we) wanted to eat
Enough, but not always the kinds of food (I/we) wanted to eat
Sometimes not enough to eat
Often not enough to eat
¿? Seleccione solo una respuesta.
Logic:
Only one response permitted
Note all respondents will then be asked Q24, regardless of response to Q23
In the last 7 days, which of these statements best describes the food eaten in your household? Select only one answer.
Enough of the kinds of food (I/we) wanted to eat
Enough, but not always the kinds of food (I/we) wanted to eat
Sometimes not enough to eat
Often not enough to eat
¿? Seleccione solo una respuesta.
Logic:
Only one response permitted
Why did you not have enough to eat (or not what you wanted to eat)? Choose all that apply.
Couldn’t afford to buy more food
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)
Afraid to go or didn’t want to go out to buy food
Couldn’t get groceries or meals delivered to me
The stores didn’t have the food I wanted
¿?
Logic:
Only one response permitted
If Q24 in (2,3,4) then ask Q25
During the last 7 days, did you or anyone in your household get free groceries or a free meal? Select only one answer.
Yes
No
¿? Seleccione solo una respuesta.
Logic:
Only one response permitted
Where did you get free groceries or free meals? Choose all that apply.
Free meals through the school or other programs aimed at children
Food pantry or food bank
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
¿?
Logic:
If Q26 = 1 then ask Q27
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.
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.
Enter amount $_________
¿?
Logic:
Only one response permitted
Validate reasonable range for dollar amount
During the last 7 days, how much money did you or 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 item Q28 (above). Enter amount.
Enter amount $_________
¿?
Logic:
Only one response permitted
Validate reasonable range for dollar amount
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.
Not at all confident
Somewhat confident
Moderately confident
Very confident
¿?
Logic:
Only one response permitted
Note: From HUD
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Would you say your health in general is excellent, very good, good, fair, or poor? Select only one answer.
Excellent
Very good
Good
Fair
Poor
¿? Seleccione solo una respuesta.
Logic:
Only one response permitted
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.
Not at all
Several days
More than half the days
Nearly every day
¿? Seleccione solo una respuesta.
Logic:
Only one response permitted
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.
Not at all
Several days
More than half the days
Nearly every day
¿? Seleccione solo una respuesta.
Logic:
Only one response permitted
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.
Not at all
Several days
More than half the days
Nearly every day
¿? Seleccione solo una respuesta.
Logic:
Only one response permitted
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.
Not at all
Several days
More than half the days
Nearly every day
¿? Seleccione solo una respuesta.
Logic:
Only one response permitted
Are you currently covered by any of the following types of health insurance or health coverage plans? Mark Yes or No for each.
Insurance through a current or former employer or union (through yourself or another family member)
Insurance purchased directly from an insurance company, including marketplace coverage (through yourself or another family member)
Medicare, for people 65 and older, or people with certain disabilities
Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability;
TRICARE or other military health care
VA (including those who have ever used or enrolled for VA health care)
Indian Health Service
Other
¿? Seleccione solo una respuesta.
Logic:
Matrix style question with Yes/No response option for each row
Only one response permitted per row
At any time in the last 4 weeks, did you DELAY getting medical care because of the coronavirus pandemic? Select only one answer.
Yes
No
¿? Seleccione solo una respuesta.
Logic:
Only one response permitted
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.
Yes
No
¿? Seleccione solo una respuesta.
Logic:
Only one response permitted
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Is your house or apartment…? Select only one answer.
Owned free and clear?
Owned with a mortgage or loan (including home equitly loans)?
Rented?
Occupied without payment of rent?
¿
Logic:
Only one response permitted
Did you pay your last month’s rent or mortgage on time? Select only one answer.
Yes
No
Payment was deferred
¿? Seleccione solo una respuesta.
Logic:
If Q39 in (2,3) ask Q40
Only one response permitted
How confident are you that your household will be able to pay your next rent or mortgage payment on time? Select only one answer.
No confidence
Slight confidence
Moderate confidence
High confidence
Payment is/will be deferred
¿?
Logic:
If Q39 in (2,3) ask Q41
Only one response permitted
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At any time during February 2020, were any children in this household 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.
Yes, enrolled in a public or private school
Yes, homeschooled
No
¿
Logic:
Multiple responses permitted
Make “No” answer choice exclusive
How has the coronavirus pandemic affected how the children in this household received education? Select all that apply.
Classes normally taught in person at the school were cancelled;
Classes normally taught in person moved to a distance-learning format using online resources, either self-paced or in real time;
Classes normally taught in person moved to a distance-learning format using paper materials sent home to children;
Classes normally taught in person changed in some other way -- Please specify:
There was no change because schools did not close)
¿
Logic:
If Q42 includes 1 ask Q43
Multiple responses permitted
How often is a computer or other digital device available to children for educational purposes? Select only one answer.
Always available;
Usually available;
Sometimes available;
Rarely available;
Never available
¿
Logic:
If Q42 includes 1 ask Q44
One response allowed
Is the computer or other digital device …? Select all that apply..
Provided by the children’s school or school district to use outside of school;
Provided by someone in the household or family, or it is the child’s;
Provided by another source.
¿
Logic:
If Q42 includes 1 and Q44 in (1,2,3,4) ask Q45
Multiple responses permitted
How often is the Internet available to children for educational purposes? Select only one answer.
Always available;
Usually available;
Sometimes available;
Rarely available;
Never available
¿
Logic:
If Q42 includes 1 ask Q46
One response allowed
Are Internet services …? Select all that apply..
Paid for by the children’s school or school district;
Paid for by someone in the household or family;
Paid for by another source
¿
Logic:
If Q42 includes 1 and Q46 in (1,2,3,4) ask Q47
Multiple responses permitted
During the last 7 days, about how many hours did the student have live contact either by phone or video with their teachers? Enter number of hours.
Enter number of hours _________
(If none, enter zero)
¿
Logic:
If Q42 includes 1 ask Q48
Ensure numeric response and range reasonableness (valid responses: 0-168)
Including hours spent during weekdays and weekends, about how many hours did household members spend on ALL teaching activities with the children in this household during the last 7 days? Enter number of hours.
Enter number of hours _________
(If none, enter zero)
¿
Logic:
If Q42 includes 1 ask Q49
Ensure numeric response and range reasonableness (valid responses: 0-168)
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In 2019 what was your total household income before taxes? Select only one answer.
Less than $25,000
$25,000 - $34,999
$35,000 - $49,999
$50,000 - $74,999
$75,000 - $99,999
$100,000 - $149,999
$150,000 - $199,999
$200,000 and above
En el 2019, ¿cuál fue el ingreso total de su hogar antes de que le descontaran los impuestos? Seleccione solo una respuesta.
Menos de $25,000
$25,000 - $34,999
$35,000 - $49,999
$50,000 - $74,999
$75,000 - $99,999
$100,000 - $149,999
$150,000 - $199,999
$200,000 y más
Logic:
Only one response permitted
Do NOT rotate answer choices
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Start of Block: Address
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residence 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 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.
Address Number (Q51) ________________________________________________
Street Name (Q52) ________________________________________________
Apt Unit (Q53) ________________________________________________
City (Q54) ________________________________________________
State (Q55) ________________________________________________
Zip (Q56) ________________________________________________
Display This Question:
If all address fields above are blank
|
no_address
I do not have a street address (Q57)
Page Break |
|
Display This Question:
If all address fields are blank
Or = I do not have a street address is selected
|
|
rural_route
Q58
Do you have a Rural Route address?
Yes (1)
No (2)
Page Break |
|
Display This Question:
If Do you have a Rural Route address? = Yes
|
rural_address
Please provide the Rural Route address where you reside.
Also,
provide a description of the physical location in the space provided.
RR Descriptor (Q59) ________________________________________________
Rural Route No (Q60) ________________________________________________
RR Box ID (Q61) ________________________________________________
City (Q62) ________________________________________________
State (Q63) ________________________________________________
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.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Page Break |
|
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.
City (Q66) ________________________________________________
State (Q67) ________________________________________________
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."
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
End of Block: Address
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That concludes the survey. Please click on the “Submit” button when you are finished.
Con esto terminamos la encuesta. Haga clic en el botón “Enviar” cuando haya terminado.
## SUBMIT BUTTON DISPLAYED HERE ##
Logic:
Users can still use the “Previous” navigator to go back to the survey before clicking the Submit button.
/* END PAGE */
/* START PAGE */
Thank you for participating in the 2020 COVID Rapid Response Survey.
If you have any questions about this survey please visit www.census.gov/plan. You can validate that this survey is a legitimate federally-approved information collection using the U.S. Office of Management and Budget approval number 0607-0978, expiring on 08/31/2020.
Gracias por participar en la Encuesta de Planificación del Censo del 2020.
Si tiene alguna pregunta sobre esta encuesta, visite www.census.gov/plan. Puede confirmar que esta encuesta es una recopilación de información legítima aprobada por el gobierno federal usando el número de aprobación 0607-0978 de la Oficina de Administración y Presupuesto de los Estados Unidos, que vence el 08/31/2020.
Screen Name |
RESIDENCE |
Help Text link |
RESIDENCE |
Help Text Before REFDATE |
Please type in the street address of the place where you will be living on <REFDATE>.
If you have more than one address associated with your residence, please provide the street address if available.
For example, if you normally use a P.O. Box or Rural Route address for mailing purposes, please enter a physical street address, such as what you would give to a shipping company to have a package delivered to your home. In addition, some P.O. Box addresses look like street addresses, but are actually the addresses for private mailboxes at a business or the Post Office.
We only want the street address of where you will be living or staying on <REFDATE>.
For Street Addresses, such as 5007 N Maple Ave, you can enter your address into the address fields.
this in the Apt/Unit. |
Help Text On or After REFDATE |
Please type in the street address of the place where you were living on <REFDATE>.
If you have more than one address associated with your residence, please provide the street address if available.
For example, if you normally use a P.O. Box or Rural Route address for mailing purposes, please enter a physical street address, such as what you would give to a shipping company to have a package delivered to your home. In addition, some P.O. Box addresses look like street addresses, |
|
but are actually the addresses for private mailboxes at a business or the Post Office.
We only want the street address of where you were living or staying on <REFDATE>.
For Street Addresses, such as 5007 N Maple Ave, you can enter your address into the address fields.
will need to enter both the unit type and number. For example, enter “Apt A” or “Lot 3” or “Unit 2-H” or “Room 12”.
this in the Apt/Unit. |
RURAL ROUTE
Screen Name |
RURAL_ROUTE |
Help Text link |
RURAL_ROUTE |
Help Text |
You have previously indicated that you do not have a street address. Please let us know if you have a Rural Route address, such as RR 101 Box 2 Suitland, MD 20746. |
|
|
RR_ADDRESS
Screen Name |
RR_ADDRESS |
Help Text link |
RR_ADDRESS |
Help Text Before REFDATE |
If you normally use a Rural Route address for mailing purposes, you will need to enter your Rural Route address.
If you have a Street Address, such as what you would give to a shipping company to have a package delivered to your home, please use the “Previous” buttons to take you to that address collection screen.
Otherwise, enter your Rural Route address into the address fields.
o RR – Rural Route |
|
You may also describe the physical location of where you will be living on <REFDATE> in the “Physical Location Description” box. Please provide as much information as possible. |
Help Text On or After REFDATE |
If you normally use a Rural Route address for mailing purposes, you will need to enter your Rural Route address.
If you have a Street Address, such as what you would give to a shipping company to have a package delivered to your home, please use the “Previous” buttons to take you to that address collection screen.
Otherwise, enter your Rural Route address into the address fields.
You may also describe the physical location of where you were living on <REFDATE> in the “Physical Location Description” box. Please provide as much information as possible. |
HOMELESS
Screen Name |
HOMELESS |
Help Text link |
HOMELESS |
Help Text Before REFDATE |
You have previously indicated that you do not have a street address or a Rural Route address. Answer "Yes" if you will be experiencing homelessness or will not have a permanent place to live on <REFDATE>. |
|
|
Help Text On or After REFDATE |
You have previously indicated that you do not have a street address or a Rural Route address. Answer "Yes" if you were experiencing homelessness or did not have a permanent place to live on <REFDATE>. |
OTHER_ADDRESS
Screen Name |
OTHER_ADDRESS |
Help Text link |
OTHER_ADDRESS |
Help Text Before REFDATE |
If you have a Street Address, such as what you would give to a shipping company to have a package delivered to your home, please use the “Previous” buttons to take you to that address collection screen.
Otherwise, please provide a city and state, OR ZIP Code into the address fields.
You may also describe the physical location of where you will be living on <REFDATE> in the “Physical Location Description” box. Please provide as much information as possible. |
Help Text On or After REFDATE |
If you have a Street Address, such as what you would give to a shipping company to have a package delivered to your home, please use the “Previous” buttons to take you to that address collection screen.
Otherwise, please provide a city and state, OR ZIP Code into the address fields.
You may also describe the physical location of where you were living on <REFDATE> in the “Physical Location Description” box. Please provide as much information as possible. |
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Kyley McGeeney |
File Modified | 0000-00-00 |
File Created | 2021-05-08 |