Household Pulse Survey Questionnaire, Phase 3, Intent to

Attachment A: Phase 3 COVID-19 Household Pulse Survey, Revised to Reflect Inclusion of Intent to Vaccinate Questions and Other Items Marked for Deletion

Phase 3 COVID-19 Household Pulse Survey

Intro

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.  

Intro2

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 this 20-minute survey will help federal, state, and local agencies identify coronavirus (COVID-19) related issues in your community.

PRA
The U.S. Census Bureau is required by law to protect your information. The Census Bureau is not permitted to publicly release your responses in a way that could identify you. We are conducting this voluntary survey​ under the authority of Title 13, United States Code, Sections 8(b), 182 and 196 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, United States Code, Section 9). Per the Federal Cybersecurity Enhancement Act of 2015, your data are protected from ​cybersecurity risks through screening of the systems that transmit your data.  

We estimate that completing this survey will take 20 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 10/31/2023. 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/householdpulsedata.  

** 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). 

language 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

display_Q42 These questions are for statistical purposes only.

Q1 What year were you born? Please enter a number.

________________________________________________________________

Q2 Are you… Select only one answer.

• Male

• Female

Q3 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 ________________________________________________

Q4 What is your race? Please select all that apply. 

• White

• Black or African American

• American Indian or Alaska Native (specify) ________________________________________________

• Asian Indian

• Chinese

• Filipino

• Japanese

• Korean

• Vietnamese

• Other Asian (specify) ________________________________________________

• Native Hawaiian

• Chamorro

• Samoan

• Other Pacific Islander (specify) ________________________________________________

Q5 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)

Q6 What is your marital status? Select only one answer.

• Now married

• Widowed

• Divorced

• Separated

• Never married

Q7 How many total people – adults and children – currently live in your household, including yourself? Please enter a number.

________________________________________________________________

Q8 How many people under 18 years-old currently live in your household? Please enter a number.

________________________________________________________________

QV1. (RECVDVACC) Have you received a COVID-19 vaccine?

• Yes

• No – skip to GETVACC

QV2. (DOSES) Did you receive (or do you plan to receive) all required doses?

• Yes – skip to HADCOVID

• No – go to WHYNOT

QV3. (GETVACC) Once a vaccine to prevent COVID-19 is available to you, would you… 

1. Definitely get a vaccine – skip to PROBE1

2. Probably get a vaccine  - ask WHYNOT

3. Probably NOT get a vaccine – ask WHYNOT

4. Definitely NOT get a vaccine – ask WHYNOT

QV4. (WHYNOT) Which of the following, if any, are reasons that you [only probably will /probably won’t/definitely won’t] [get a COVID-19 vaccine/won’t receive all required doses of a COVID-19 vaccine]? (Select all that apply)

Scripter: randomize

1. I am concerned about possible side effects of a COVID-19 vaccine

2. I don’t know if a COVID-19 vaccine will work

3. I don’t believe I need a COVID-19 vaccine – go to WHYNOT2

4. I don’t like vaccines

5. My doctor has not recommended it

6. I plan to wait and see if it is safe and may get it later

7. I think other people need it more than I do right now

8. I am concerned about the cost of a COVID-19 vaccine

9. I don’t trust COVID-19 vaccines

10. I don’t trust the government

11. Other (please specify: _____) [ANCHOR]

QV5. (WHYNOT2) (If don’t believe I need a COVID-19 vaccine) Why do you believe that you don’t need a COVID-19 vaccine? (Select all that apply)

Scripter: randomize

1. I already had COVID-19

2. I am not a member of a high-risk group

3. I plan to use masks or other precautions instead

4. I don’t believe COVID-19 is a serious illness

5. I don’t think vaccines are beneficial

6. Other (please specify: _____) [ANCHOR]

QV6. HADCOVID Has a doctor or other health care provider ever told you that you have COVID-19?

• Yes

• No

• Not Sure

Q9 Have you, or has anyone in your household experienced a loss of employment income since March 13, 2020?  Select only one answer.

• Yes

• No

Q10 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

Q11 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

Q12 Are you employed by government, by a private company, a nonprofit organization or were 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

Q13 What is your main reason for not working for pay or profit? Select only one answer.
I did not work because:

• I did not want to be employed at this time

• I am/was sick with coronavirus symptoms

• I am/was caring for someone with coronavirus symptoms

• I am/was caring for children not in school or daycare

• I am/was caring for an elderly person

• I was concerned about getting or spreading the coronavirus

• I am/was sick (not coronavirus related) or disabled

• I am retired

• My employer experienced a reduction in business (including furlough) due to coronavirus pandemic

• I am/was laid off due to coronavirus pandemic

• My employer closed temporarily due to the coronavirus pandemic

• My employer went out of business due to the coronavirus pandemic

• Other reason, please specify ________________________________________________

Q13a 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.

• Yes, at least one adult substituted some or all of their typical in-person work for telework

• No, no adults substituted their typical in-person work for telework

• No, there has been no change in telework

Q14a Since March 13, 2020, have you applied for Unemployment Insurance (UI) benefits? Select only one answer.

• Yes

• No

Q14b Since March 13, 2020, did you receive Unemployment Insurance (UI) benefits? Select only one answer. 

• Yes

• No

Q14d Do you currently receive Social Security benefits (Retirement, Disability, or Survivors), Supplemental Security Income (SSI) benefits, or Medicare benefits? Select only one answer.

• Yes

• No

Q14e 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. 

• Yes, applied or attempted to apply

• No

Q14f What type of benefits did you apply or attempt to apply for after March 13, 2020? Select all that apply.

• Social Security Retirement

• Social Security Disability

• Social Security Survivors

• Supplemental Security Income (SSI)

• Medicare

Q14g 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. 

• Extremely likely

• Very likely

• Somewhat likely

• Not at all likely

Q14h What type of benefits do you think that you will apply for? Select all that apply.

• Social Security Retirement

• Social Security Disability

• Social Security Survivors

• Supplemental Security Income (SSI)

• Medicare

Q14i 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. 

• The coronavirus pandemic has not affected my decision about applying for benefits

• I have decided not to apply

• I applied or decided to apply earlier than expected

• I applied or decided to apply later than expected

Q15 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.   

• Mostly spend it

• Mostly save it

• Mostly use it to pay off debt

• Not applicable, I did not receive the stimulus payment

Q19 What did you and your household mostly spend the most recent “stimulus payment” on? Select all that apply.

• Food (groceries, eating out, take out)

• Clothing (clothing, accessories, shoes)

• Household supplies and personal care products

• Household items (TV, electronics, furniture, appliances)

• Recreational goods (sports and fitness equipment, bicycles, toys, games)

• Rent

• Mortgage (scheduled or monthly)

• Utilities and telecommunications (natural gas, electricity, cable, internet, cellphone)

• Vehicle payments (scheduled or monthly)

• Paying down credit card, student loans, or other debts

• Charitable donations or giving to family members

• Savings or investments

• Other, specify ________________________________________________

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.

• Not at all difficult

• A little difficult

• Somewhat difficult

• Very difficult

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.

• 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

• Increased use of cash instead of using credit cards or smartphone apps for purchases

• 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

Q19c In the last 7 days, for which of the following reasons have you or your household changed spending? Select all that apply. 

• Usual shopping places were closed or had limited hours (e.g., restaurant, doctor/dentist office, health club, hair salon, child care center, etc.)

• Usual shopping places re-opened or increased hours

• Concerned about going to public or crowded places or having contact with high-risk people

• No longer concerned about going to public or crowded places or having contact with high-risk people

• Loss of income

• Increased income

• Concerns about being laid off or having hours reduced

• No longer concerned about being laid off or having hours reduced

• Working from home/teleworking

• Resumed working onsite at workplace

• Concerns about the economy

• No longer concerned about the economy

• Other, specify: ________________________________________________

Q20 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. 

• Regular income sources like those received before the pandemic

• Credit cards or loans

• Money from savings or selling assets

• Borrowing from friends or family

• Unemployment insurance (UI) benefit payments

• Stimulus (economic impact) payment

• Money saved from deferred or forgiven payments [to meet your spending needs]

• Supplemental Nutrition Assistance Program (SNAP)

Q21a
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.

• Yes

• No

Q21b 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.

• Yes

• No

• Did not use before

Q21c 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.

• Yes

• No

Q24 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

Q24a
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."

• Often true

• Sometimes true

• Never true

Q25 Why did you not have enough to eat (or not what you wanted to eat)? Select 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

Q26 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

Q27 Where did you get free groceries or free meals? Select 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

Q27a 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.

• Yes

• No

display_Q28 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. 

Q28 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.

________________________________________________________________

Q28_check You said that you spent $${Q28/ChoiceTextEntryValue}.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?

• Yes

• No, I need to correct the amount

Q28_correction 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.

________________________________________________________________

Q29 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.

________________________________________________________________

Q29_check You said that you spent $${Q29/ChoiceTextEntryValue}.00 on prepared meals during the last 7 days.  This amount seems unusually high.  Are you sure it is the correct amount?

• Yes

• No, I need to correct the amount

Q29_correction Please provide the correct amount (or your best estimate).
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 item Q28(above). Enter amount.

________________________________________________________________

Q32 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

Q33 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

Q34 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

Q35 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

Q36 Are you currently covered by any of the following types of health insurance or health coverage plans? Mark Yes or No for each.

	Yes	No
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

Q37 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

Q38 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

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.

• Yes

• No

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.

• Yes

• No

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.

• Yes

• No

Q39 Is your house or apartment…? Select only one answer.

• Owned by you or someone in this household free and clear?

• Owned by you or someone in this household with a mortgage or loan (including home equity loans)?

• Rented?

• Occupied without payment of rent?

Q39a Which best describes this building? Include all apartments, flats, etc., even if vacant. Select only one answer.

• A mobile home

• A one-family house detached from any other house

• A one-family house attached to one or more houses

• A building with 2 apartments

• A building with 3 or 4 apartments

• A building with 5 to 9 apartments

• A building with 10 to 19 apartments

• A building with 20 to 49 apartments

• A building with 50 or more apartments

• Boat, RV, van, etc.

Q40b Is this household currently caught up on rent payments? Select only one answer.

• Yes

• No

Q40c Is this household currently caught up on mortgage payments? Select only one answer.

• Yes

• No

Q41 How confident are you that your household will be able to pay your next rent or mortgage payment on time? Select only one answer.

• Not at all confident

• Slightly confident

• Moderately confident

• Highly confident

• Payment is/will be deferred

Q41a 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.

• Very likely

• Somewhat likely

• Not very likely

• Not likely at all

Q41b 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.

• Very likely

• Somewhat likely

• Not very likely

• Not likely at all

Q42 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. 

• Yes, enrolled in a public or private school

• Yes, homeschooled

• Yes, homeschooled (not enrolled in a public or private school)

• No

Q43 How has the coronavirus pandemic affected how the children in this household receive education for the 2020-2021 school year? Select all that apply.

• Classes normally taught in person at the school were canceled

• 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: ________________________________________________

• The coronavirus pandemic did not affect how children in this household receive education

Q44 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

Q45 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

Q46 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

Q47 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

Q47a 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. 

• None

• 1 day

• 2-3 days

• 4 or more days

Q48a 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.

________________________________________________________________

Q48b 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.

• Much less than a school day before the coronavirus pandemic

• A little bit less than a school day before the coronavirus pandemic

• As much as a school day before the coronavirus pandemic

• A little bit more than a school day before the coronavirus pandemic

• Much more than a school day before the coronavirus pandemic

QPS1 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.

________________________________________________________________

QPS2
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.

• Certificate or diploma program from a school that provides occupational training (usually a 2-year program, often leading to a license, such as cosmetology)

• Associate's degree program (usually a 2-year degree)

• Bachelor's degree program (usually a 4-year degree)

• Graduate degree program (for example, Master's, PhD, MD)

• Another credential program not listed above

• Classes that are not part of a credential program

QPS3 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.

• Plans to take classes this fall have not changed.

• All plans to take classes this fall have been canceled.

• Classes will be in different formats in the fall (for example, change from in-person to online).

• Fewer classes will be taken this fall.

• More classes will be taken this fall.

• Classes will be taken from a different institution.

• Classes will be taken for a different kind of certificate or degree.

QPS4 Why did household members’ plans to take classes this fall change? Select all that apply.

• Had coronavirus or concerns about getting coronavirus

• Caring for someone with coronavirus

• Caring for others whose care arrangements are disrupted (e.g., loss of day care or adult care programs)

• Institution changed content or format of classes (e.g., from in-person to online)

• Changes to financial aid

• Changes to campus life

• Uncertainty about how classes/program might change

• Not able to pay for classes/educational expenses because of changes to income from the pandemic

• Some other reason related to the pandemic, please specify ________________________________________________

Q50 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

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 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. 

• Address Number ________________________________________________

• Street Name ________________________________________________

• Apt Unit ________________________________________________

• City ________________________________________________

• State ________________________________________________

• Zip ________________________________________________

bestmethod 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?

• Text message

• Email

bestnumber To help us contact you, please provide the best phone number to reach you.

________________________________________________________________

bestemail To help us contact you, please provide the best email address to reach you.

________________________________________________________________

Feedback_pandemic Thank  you.


Is there anything else related to the coronavirus pandemic you would like to tell us?

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Q69 That concludes the survey. Please click on the “Submit” button when you are finished.  

Thank you for participating in the 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 10/31/2020.  

If you need help during this time, here are some resources that may help: 

General: https://www.coronavirus.gov/

Meal finder for kids:  https://www.fns.usda.gov/meals4kids

Unemployment services: https://www.usa.gov/unemployment 

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