Part A, Attachment A - Phase 3.1 Household Pulse Survey Questionnaire

Part A, ATTACH A_Phase 3.1 Household Pulse Survey Questionnaire_3.22.2021.docx

Household Pulse Survey

Part A, Attachment A - Phase 3.1 Household Pulse Survey Questionnaire

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⚠️ Notice: This form may be outdated.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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Phase 3.1 COVID-19 Household Pulse Survey

Start of Block: Introduction

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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
.Skin .QuestionText { line-height: 100%;} 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).

End of Block: Introduction

Start of Block: Language

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 (1)
Español (2)

End of Block: Language

Start of Block: Demographics

Display This Question:

If This survey is available in English and Spanish. Please select the language in which you prefer t... = English

Or This survey is available in English and Spanish. Please select the language in which you prefer t... = Español

display_Q42 These questions are for statistical purposes only.

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If This survey is available in English and Spanish. Please select the language in which you prefer t... != English

And This survey is available in English and Spanish. Please select the language in which you prefer t... != Español

display_Q42 These questions are for statistical purposes only.

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

________________________________________________________________

Skip To: End of Survey If Condition: What year were you born? Pl... Is Greater Than 2003. Skip To: End of Survey.

Q2 Are you… Select only one answer.

Male (1)
Female (2)

Q3 Are you of Hispanic, Latino, or Spanish origin?

No, not of Hispanic, Latino, or Spanish origin (1)
Yes, Mexican, Mexican American, Chicano (2)
Yes, Puerto Rican (3)
Yes, Cuban (4)
Yes, another Hispanic, Latino, or Spanish origin (5) ________________________________________________

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

White (1)
Black or African American (2)
American Indian or Alaska Native (specify) (3) ________________________________________________
Asian Indian (4)
Chinese (5)
Filipino (6)
Japanese (7)
Korean (8)
Vietnamese (9)
Other Asian (specify) (10) ________________________________________________
Native Hawaiian (11)
Chamorro (12)
Samoan (13)
Other Pacific Islander (specify) (14) ________________________________________________

Q5 What is the highest degree or level of school you have completed? Select only one answer.

Less than high school (1)
Some high school (2)
High school graduate or equivalent (for example GED) (3)
Some college, but degree not received or is in progress (4)
Associate’s degree (for example AA, AS) (5)
Bachelor's degree (for example BA, BS, AB) (6)
Graduate degree (for example master's, professional, doctorate) (7)

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

Now married (1)
Widowed (2)
Divorced (3)
Separated (4)
Never married (5)

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

________________________________________________________________

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

________________________________________________________________

Q8a Are you or your spouse currently serving in the U.S. Armed Forces (Active Duty, Reserve, or National Guard)?
Reserve and Guard members/spouses who are full-time active duty (AGR/FTS/AR) or currently "activated" should select the "Reserve or National Guard" response(s). Select all that apply.

No (1)
Yes, I'm serving on active duty (2)
Yes, I'm serving in the Reserve or National Guard (3)
Yes, my spouse is serving on active duty (4)
Yes, my spouse is serving in the Reserve or National Guard (5)

End of Block: Demographics

Start of Block: Vaccination Intent

QV1 Have you received a COVID-19 vaccine?

Yes (1)
No (2)

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If Have you received a COVID-19 vaccine? = Yes

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

Yes (1)
No (2)

Display This Question:

If Have you received a COVID-19 vaccine? != Yes

QV3 Once a vaccine to prevent COVID-19 is available to you, would you…

Definitely get a vaccine (1)
Probably get a vaccine (2)
Be unsure about getting a vaccine (3)
Probably NOT get a vaccine (4)
Definitely NOT get a vaccine (5)

End of Block: Vaccination Intent

Start of Block: Vaccination Intent 2

Display This Question:

If Once a vaccine to prevent COVID-19 is available to you, would you… = Probably get a vaccine

Or Once a vaccine to prevent COVID-19 is available to you, would you… = Be unsure about getting a vaccine

Or Once a vaccine to prevent COVID-19 is available to you, would you… = Probably NOT get a vaccine

Or Once a vaccine to prevent COVID-19 is available to you, would you… = Definitely NOT get a vaccine

Or Did you receive (or do you plan to receive) all required doses? = No

QV4 Which of the following, if any, are reasons that you ${e://Field/QV4fill} ${e://Field/QV4fill2}? Select all that apply.

I am concerned about possible side effects of a COVID-19 vaccine (1)
I don’t know if a COVID-19 vaccine will work (2)
I don’t believe I need a COVID-19 vaccine (3)
I don’t like vaccines (4)
My doctor has not recommended it (5)
I plan to wait and see if it is safe and may get it later (6)
I think other people need it more than I do right now (7)
I am concerned about the cost of a COVID-19 vaccine (8)
I don’t trust COVID-19 vaccines (9)
I don’t trust the government (10)
Other (please specify) (11) ________________________________________________

Display This Question:

If Which of the following, if any, are reasons that you ${e://Field/QV4fill} ${e://Field/QV4fill2}? ... = I don’t believe I need a COVID-19 vaccine

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

I already had COVID-19 (1)
I am not a member of a high-risk group (2)
I plan to use masks or other precautions instead (3)
I don’t believe COVID-19 is a serious illness (4)
I don’t think vaccines are beneficial (5)
Other (please specify) (6) ________________________________________________

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Display This Question:

If Have you received a COVID-19 vaccine? = Yes

QV5a
Since getting a COVID-19 vaccine, in general have you increased or decreased how often you practice COVID-19 prevention behaviors when in public around people you do not know?

Examples of prevention behaviors include wearing a face mask, maintaining 6 feet of distance from others, and avoiding indoor events and large gatherings.

Please answer even if you have not received all required doses of a vaccine.

I have decreased prevention behaviors since getting a vaccine (1)
I have not changed my behavior since getting a vaccine (2)
I have increased prevention behaviors since getting a vaccine (3)

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

Yes (1)
No (2)
Not Sure (3)

End of Block: Vaccination Intent 2

Start of Block: Employment

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Q9a Have you, or has anyone in your household experienced a loss of employment income in the last 4 weeks? Select only one answer.

Yes (1)
No (2)

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 (1)
No (2)

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 (1)
No (2)

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If Now we are going to ask about your employment. In the last 7 days, did you do ANY work for eithe... = Yes

Q12 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 (1)
Private company (2)
Non-profit organization including tax exempt and charitable organizations (3)
Self-employed (4)
Working in a family business (5)

Display This Question:

If Now we are going to ask about your employment. In the last 7 days, did you do ANY work for eithe... = No

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 (1)
I am/was sick with coronavirus symptoms or caring for someone who was sick with coronavirus symptoms (2)
I am/was caring for children not in school or daycare (3)
I am/was caring for an elderly person (4)
I was concerned about getting or spreading the coronavirus (5)
I am/was sick (not coronavirus related) or disabled (6)
I am retired (7)
I am/was laid off or furloughed due to coronavirus pandemic (8)
My employer closed temporarily due to the coronavirus pandemic (9)
My employer went out of business due to the coronavirus pandemic (10)
I do/did not have transportation to work (11)
Other reason, please specify (12) ________________________________________________

Q13a Working from home is sometimes referred to as telework. In the past 7 days, have any adults in this household teleworked? Select only one answer.

Yes (1)
No (2)

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If Working from home is sometimes referred to as telework. In the past 7 days, have any adults in th... = Yes

Q13b Have any adults teleworked because of the coronavirus pandemic? Select only one answer.

Yes (1)
No (2)

Q13c Since January 1, 2021, have you worked or volunteered outside your home? Select only one answer.

Yes (1)
No (2)

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Display This Question:

If Since January 1, 2021, have you worked or volunteered outside your home? Select only one answer. = Yes

Q13d Since January 1, 2021, which best describes the primary location/setting where you worked or volunteered outside your home? Select only one answer.

Healthcare (e.g., hospital, doctor, dentist or mental health specialist office, outpatient facility, long-term care, home health care, pharmacy, medical laboratory) (1)
Social service (e.g., child, youth, family, elderly, disability services) (2)
Preschool or daycare (3)
K-12 school (4)
Other schools and instructional settings (e.g. college, university, professional, business, technical or trade school, driving school, test preparation, tutoring) (5)
First response (e.g., police or fire protection, emergency relief services) (6)
Death care (e.g., funeral home, crematory, cemetery) (7)
Correctional facility (e.g., jail, prison, detention center, reformatory) (8)
Food and beverage store (e.g., grocery store, warehouse club, supercenters, convenience store, specialty food store, bakery) (9)
Agriculture, forestry, fishing, or hunting (10)
Food manufacturing facility (e.g., meat-processing, produce packing, food or beverage manufacturing) (11)
Non-food manufacturing facility (e.g. metals, equipment and machinery, electronics) (12)
Public transit (e.g., bus, commuter rail, subway, school bus) (13)
United States Postal Service (14)
Other job deemed “essential” during the COVID-19 pandemic (15)
None of the above (16)

Q14a Since January 1, 2021, have you applied for Unemployment Insurance (UI) benefits? Select only one answer.

Yes (1)
No (2)

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Q14b Since January 1, 2021, have you received Unemployment Insurance (UI) benefits? Select only one answer.

Yes (1)
No (2)

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Display This Question:

If Since January 1, 2021, have you received Unemployment Insurance (UI) benefits? Select only one an... = Yes

Q14c Have you received Unemployment Insurance (UI) benefits in the last 7 days? Select only one answer.

Yes (1)
No (2)

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 (1)
No (2)

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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 January 1, 2021? Select only one answer.

Yes, applied or attempted to apply (1)
No (2)

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Display This Question:

If Did you apply or attempt to apply for Social Security benefits (Retirement, Disability, or Surviv... = Yes, applied or attempted to apply

Q14f What type of benefits did you apply or attempt to apply for after January 1, 2021? Select all that apply.

Social Security Retirement (1)
Social Security Disability (2)
Social Security Survivors (3)
Supplemental Security Income (SSI) (4)
Medicare (5)

Display This Question:

If Did you apply or attempt to apply for Social Security benefits (Retirement, Disability, or Surviv... = No

And Do you currently receive Social Security benefits (Retirement, Disability, or Survivors), Supplem... != Yes

Q14g How likely are you to apply for Social Security benefits (Retirement, Disability, or Survivors), Supplemental Security Income (SSI) benefits, or Medicare benefits during 2021? Select only one answer.

Extremely likely (1)
Very likely (2)
Somewhat likely (3)
Not at all likely (4)

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Display This Question:

If How likely are you to apply for Social Security benefits (Retirement, Disability, or Survivors),... = Extremely likely

Or How likely are you to apply for Social Security benefits (Retirement, Disability, or Survivors),... = Very likely

Or How likely are you to apply for Social Security benefits (Retirement, Disability, or Survivors),... = Somewhat likely

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

Social Security Retirement (1)
Social Security Disability (2)
Social Security Survivors (3)
Supplemental Security Income (SSI) (4)
Medicare (5)

Display This Question:

If How likely are you to apply for Social Security benefits (Retirement, Disability, or Survivors),... , Extremely likely Is Displayed

Or Did you apply or attempt to apply for Social Security benefits (Retirement, Disability, or Surviv... = Yes, applied or attempted to apply

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 (1)
I have decided not to apply (2)
I applied or decided to apply earlier than expected (3)
I applied or decided to apply later than expected (4)

End of Block: Employment

Start of Block: Stimulus and Finances

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display_Q15 The next questions ask about the last 7 days. Please only include experiences that occurred in the last 7 days.

Q15 In the last 7 days, did you or anyone in your household receive a “stimulus payment,” that is a coronavirus related Economic Impact Payment from the Federal Government?

Yes (1)
No (2)

Display This Question:

If In the last 7 days, did you or anyone in your household receive a “stimulus payment,” that is a c... = Yes

Q15a Thinking about your use of the "stimulus payment," did you:

Mostly spend it (1)
Mostly save it (2)
Mostly use it to pay off debt (3)

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If In the last 7 days, did you or anyone in your household receive a “stimulus payment,” that is a c... = Yes

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) (1)
Clothing (clothing, accessories, shoes) (2)
Household supplies and personal care products (3)
Household items (TV, electronics, furniture, appliances) (4)
Recreational goods (sports and fitness equipment, bicycles, toys, games) (5)
Rent (6)
Mortgage (scheduled or monthly) (7)
Utilities and telecommunications (natural gas, electricity, cable, internet, cellphone) (8)
Vehicle payments (scheduled or monthly) (9)
Paying down credit card, student loans, or other debts (10)
Charitable donations or giving to family members (11)
Savings or investments (12)
Other, specify (13) ________________________________________________

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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 (1)
A little difficult (2)
Somewhat difficult (3)
Very difficult (4)

Q19b In the last 7 days, have you or your household changed your spending or shopping in the following categories?

	Yes (1)	No (2)
Online purchases (Q19b_1)
Curbside pick-up (Q19b_2)
In-store shopping (Q19b_3)

Q19b2 In the last 7 days, have you or your household changed your use of the following services?

	Yes (1)	No (2)
Eating at restaurants (1)
In-person medical or dental appointments (2)
Housekeeping or caregiving services (3)

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Display This Question:

If In the last 7 days, have you or your household changed your spending or shopping in the following... [ Yes] (Count) > 0

Or In the last 7 days, have you or your household changed your use of the following services? [ Yes] (Count) > 0

Q19bb Did you or your household spend more or less in each category in the last 7 days?

Display This Choice:

If In the last 7 days, have you or your household changed your spending or shopping in the following... = Online purchases [ Yes ]

Display This Choice:

If In the last 7 days, have you or your household changed your spending or shopping in the following... = Curbside pick-up [ Yes ]

Display This Choice:

If In the last 7 days, have you or your household changed your spending or shopping in the following... = In-store shopping [ Yes ]

Display This Choice:

If In the last 7 days, have you or your household changed your use of the following services? = Eating at restaurants [ Yes ]

Display This Choice:

If In the last 7 days, have you or your household changed your use of the following services? = In-person medical or dental appointments [ Yes ]

Display This Choice:

If In the last 7 days, have you or your household changed your use of the following services? = Housekeeping or caregiving services [ Yes ]

	More (1)	Less (2)
Display This Choice: If In the last 7 days, have you or your household changed your spending or shopping in the following... = Online purchases [ Yes ] Online purchases (Q19bb_1)
Display This Choice: If In the last 7 days, have you or your household changed your spending or shopping in the following... = Curbside pick-up [ Yes ] Curbside pick-up (Q19bb_2)
Display This Choice: If In the last 7 days, have you or your household changed your spending or shopping in the following... = In-store shopping [ Yes ] In-store shopping (Q19bb_3)
Display This Choice: If In the last 7 days, have you or your household changed your use of the following services? = Eating at restaurants [ Yes ] Eating at restaurants (Q19bb_6)
Display This Choice: If In the last 7 days, have you or your household changed your use of the following services? = In-person medical or dental appointments [ Yes ] In-person medical or dental appointments (Q19bb_7)
Display This Choice: If In the last 7 days, have you or your household changed your use of the following services? = Housekeeping or caregiving services [ Yes ] Housekeeping or caregiving services (Q19bb_8)

Q19b3 In the last 7 days, have you or your household increased or decreased your use of cash for purchases as opposed to cashless payment methods (e.g., credit cards, debit cards, smartphone apps)? Select only one answer.

Increased use of cash (1)
Decreased use of cash (2)
No change in the use of cash (3)

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Display This Question:

If In the last 7 days, have you or your household changed your spending or shopping in the following... [ Yes] (Count) > 0

Or In the last 7 days, have you or your household changed your use of the following services? [ Yes] (Count) > 0

Or In the last 7 days, have you or your household increased or decreased your use of cash for purcha... = Increased use of cash

Or In the last 7 days, have you or your household increased or decreased your use of cash for purcha... = Decreased use of cash

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, etc.) (1)
Usual shopping places re-opened or increased hours (2)
Concerned about going to public or crowded places or having contact with high-risk people (3)
Less concerned about going to public or crowded places or having contact with high-risk people (4)
Loss of income (5)
Increased income (6)
Concerns about being laid off or having hours reduced (7)
Less concerned about being laid off or having hours reduced (8)
Working from home/teleworking (9)
Resumed working onsite at workplace (10)
Concerns about the economy (11)
Less concerned about the economy (12)
Other, specify: (13) ________________________________________________

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 (1)
Credit cards or loans (2)
Money from savings or selling assets or possessions (including withdrawals from retirement accounts) (3)
Borrowing from friends or family (4)
Unemployment insurance (UI) benefit payments (5)
Stimulus (economic impact) payment (6)
Money saved from deferred or forgiven payments [to meet your spending needs] (7)
Supplemental Nutrition Assistance Program (SNAP) (8)
Other, specify: (9) ________________________________________________

Q21aa Considering shopping in the last 7 days, because of the coronavirus pandemic have you or your household members: Select all that apply.

Combined shopping trips so that you’ve taken fewer trips overall (1)
Done more of your usual shopping online resulting in fewer trips to stores (4)
⊗Not made any changes in shopping trips in the last 7 days (5)

Q21b
Prior to the coronavirus pandemic, in a typical week, did you use bus, rail, or ride-sharing services, like Uber and Lyft? Select only one answer.

Yes (1)
No (2)

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Display This Question:

If Prior to the coronavirus pandemic, in a typical week, did you use bus, rail, or ride-sharing serv... = Yes

Q21bb 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 (1)
No (2)

Q21c During the next 4 weeks, are you planning to take any overnight trips or trips to places more than 100 miles away? Select only one answer.

Yes (1)
No (2)

End of Block: Stimulus and Finances

Start of Block: Food Security

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Q24 Getting enough food can also be a problem for some people. 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 (1)
Enough, but not always the kinds of food (I/we) wanted to eat (2)
Sometimes not enough to eat (3)
Often not enough to eat (4)

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Display This Question:

If Getting enough food can also be a problem for some people. In the last 7 days, which of these st... = Enough, but not always the kinds of food (I/we) wanted to eat

Or Getting enough food can also be a problem for some people. In the last 7 days, which of these st... = Sometimes not enough to eat

Or Getting enough food can also be a problem for some people. In the last 7 days, which of these st... = Often not enough to eat

And If

If How many people under 18 years-old currently live in your household? Please enter a number. Text Response Is Greater Than 0

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 (1)
Sometimes true (2)
Never true (3)

Display This Question:

If Getting enough food can also be a problem for some people. In the last 7 days, which of these st... = Enough, but not always the kinds of food (I/we) wanted to eat

Or Getting enough food can also be a problem for some people. In the last 7 days, which of these st... = Sometimes not enough to eat

Or Getting enough food can also be a problem for some people. In the last 7 days, which of these st... = Often not enough to eat

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 (1)
Couldn’t get to store to buy food (for example, didn’t have transportation, have mobility or health limitations that prevent you from getting out) (2)
Couldn’t go to store due to safety concerns (3)
⊗None of the above (4)

Q26 During the last 7 days, did you or anyone in your household get free groceries from a food pantry, food bank, church, or other place that provides free food? Select only one answer.

Yes (1)
No (2)

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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 (1)
No (2)

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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.

________________________________________________________________

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If If During the last 7 days, how much money did you and your household spend on food at supermarkets,... Text Response Contains ,

Or Or During the last 7 days, how much money did you and your household spend on food at supermarkets,... Text Response Contains %

Or Or During the last 7 days, how much money did you and your household spend on food at supermarkets,... Text Response Contains +

Or Or During the last 7 days, how much money did you and your household spend on food at supermarkets,... Text Response Contains -

Or Or During the last 7 days, how much money did you and your household spend on food at supermarkets,... Text Response Contains $

Q28_warn Please do not include any special characters such as , - % + $ in your response above. Enter only numbers.

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If If During the last 7 days, how much money did you and your household spend on food at supermarkets,... Text Response Is Greater Than or Equal to 1000

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 (1)
No, I need to correct the amount (2)

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If You said that you spent $${q://QID85/ChoiceTextEntryValue}.00 on food at supermarkets, grocery st... = 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.

________________________________________________________________

Display This Question:

If If Please provide the correct amount (or your best estimate). During the last 7 days, how much money... Text Response Contains ,

Or Or Please provide the correct amount (or your best estimate). During the last 7 days, how much money... Text Response Contains %

Or Or Please provide the correct amount (or your best estimate). During the last 7 days, how much money... Text Response Contains +

Or Or Please provide the correct amount (or your best estimate). During the last 7 days, how much money... Text Response Contains -

Or Or Please provide the correct amount (or your best estimate). During the last 7 days, how much money... Text Response Contains $

Q28_warn2 Please do not include any special characters such as , - % + $ in your response above. Enter only numbers.

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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.

________________________________________________________________

Display This Question:

If If During the last 7 days, how much money did you and your household spend on prepared meals, includ... Text Response Contains ,

Or Or During the last 7 days, how much money did you and your household spend on prepared meals, includ... Text Response Contains %

Or Or During the last 7 days, how much money did you and your household spend on prepared meals, includ... Text Response Contains +

Or Or During the last 7 days, how much money did you and your household spend on prepared meals, includ... Text Response Contains -

Or Or During the last 7 days, how much money did you and your household spend on prepared meals, includ... Text Response Contains $

Q29_warn Please do not include any special characters such as , - % + $ in your response above. Enter only numbers.

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If If 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 cafeteria... Text Response Is Greater Than or Equal to 1000

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 (1)
No, I need to correct the amount (2)

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If You said that you spent $${q://QID86/ChoiceTextEntryValue}.00 on prepared meals during the last 7... = 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.

________________________________________________________________

Display This Question:

If If Please provide the correct amount (or your best estimate). During the last 7 days, how much money... Text Response Contains ,

Or Or Please provide the correct amount (or your best estimate). During the last 7 days, how much money... Text Response Contains %

Or Or Please provide the correct amount (or your best estimate). During the last 7 days, how much money... Text Response Contains +

Or Or Please provide the correct amount (or your best estimate). During the last 7 days, how much money... Text Response Contains -

Or Or Please provide the correct amount (or your best estimate). During the last 7 days, how much money... Text Response Contains $

Q29_warn2 Please do not include any special characters such as , - % + $ in your response above. Enter only numbers.

End of Block: Food Security

Start of Block: Mental Health and Health Status

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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 (1)
Several days (2)
More than half the days (3)
Nearly every day (4)

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 (1)
Several days (2)
More than half the days (3)
Nearly every day (4)

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 (1)
Several days (2)
More than half the days (3)
Nearly every day (4)

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 (1)
Several days (2)
More than half the days (3)
Nearly every day (4)

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display_Q36 The next set of questions ask about medical care.

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 (1)	No (2)
Insurance through a current or former employer or union (through yourself or another family member) (1)
Insurance purchased directly from an insurance company, including marketplace coverage (through yourself or another family member) (2)
Medicare, for people 65 and older, or people with certain disabilities (3)
Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability (4)
TRICARE or other military health care (5)
VA (including those who have ever used or enrolled for VA health care) (6)
Indian Health Service (7)
Other (8)

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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 (1)
No (2)

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 (1)
No (2)

QTH1 At any time in the last 4 weeks, did you have an appointment with a doctor, nurse, or other health professional by video or by phone? Please only include appointments for yourself and not others in your household.

Yes (1)
No (2)

Display This Question:

If If How many people under 18 years-old currently live in your household? Please enter a number. Text Response Is Greater Than 0

QTH2 At any time in the last 4 weeks, did any children in the household have an appointment with a doctor, nurse, or other health professional by video or by phone? Select only one answer.

Yes (1)
No (2)

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 (1)
No (2)

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 (1)
No (2)

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 (1)
No (2)

Display This Question:

If If How many people under 18 years-old currently live in your household? Please enter a number. Text Response Is Greater Than 0

Q38d
The next question is about preventative health care for the children in your household.

At any time in the last 12 months, did any children in the household miss, delay or skip any PREVENTIVE check-ups because of the coronavirus pandemic? Select only one answer.

Yes (1)
No (2)

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If The next question is about preventative health care for the children in your household. At any ti... = Yes

Q38e Did any of the following reasons contribute to this child missing, delaying or skipping any PREVENTIVE check-ups? Select all that apply.

Health care provider’s location was closed due to the coronavirus pandemic (1)
Health care provider’s location was open but had limited appointments due to the coronavirus pandemic (2)
Parent, adult caregiver, or child was concerned about going to the health care provider’s location due to the coronavirus pandemic (3)
This child no longer had health insurance or had a change in health insurance due to the coronavirus pandemic (4)
Someone in the household was ill with the coronavirus (5)
Someone in the household had been in contact with someone who was ill with the coronavirus (6)
⊗None of the above (7)

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QD1 Do you have difficulty seeing, even when wearing glasses? Select only one answer.

No - no difficulty (1)
Yes - some difficulty (2)
Yes - a lot of difficulty (3)
Cannot do at all (4)

QD2 Do you have difficulty hearing, even when using a hearing aid? Select only one answer.

No - no difficulty (1)
Yes - some difficulty (2)
Yes - a lot of difficulty (3)
Cannot do at all (4)

QD3 Do you have difficulty remembering or concentrating? Select only one answer.

No - no difficulty (1)
Yes - some difficulty (2)
Yes - a lot of difficulty (3)
Cannot do at all (4)

QD4 Do you have difficulty walking or climbing stairs? Select only one answer.

No - no difficulty (1)
Yes - some difficulty (2)
Yes - a lot of difficulty (3)
Cannot do at all (4)

End of Block: Mental Health and Health Status

Start of Block: Housing

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

Owned by you or someone in this household free and clear? (1)
Owned by you or someone in this household with a mortgage or loan (including home equity loans)? (2)
Rented? (3)
Occupied without payment of rent? (4)

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

A mobile home (1)
A one-family house detached from any other house (2)
A one-family house attached to one or more houses (3)
A building with 2 apartments (4)
A building with 3 or 4 apartments (5)
A building with 5 or more apartments (6)
Boat, RV, van, etc. (7)

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Display This Question:

If Is your house or apartment…? Select only one answer. = Rented?

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

Yes (1)
No (2)

Display This Question:

If Is your house or apartment…? Select only one answer. = Owned by you or someone in this household with a mortgage or loan (including home equity loans)?

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

Yes (1)
No (2)

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If Is your house or apartment…? Select only one answer. = Owned by you or someone in this household with a mortgage or loan (including home equity loans)?

Or Is your house or apartment…? Select only one answer. = Rented?

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 (1)
Slightly confident (2)
Moderately confident (3)
Highly confident (4)
Payment is/will be deferred (5)

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If Is this household currently caught up on rent payments? Select only one answer. = No

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 (1)
Somewhat likely (2)
Not very likely (3)
Not likely at all (4)

Display This Question:

If Is this household currently caught up on mortgage payments? Select only one answer. = No

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 (1)
Somewhat likely (2)
Not very likely (3)
Not likely at all (4)

End of Block: Housing

Start of Block: Education

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display_Q42a The next set of questions ask about education.

Display This Question:

If If How many people under 18 years-old currently live in your household? Please enter a number. Text Response Is Not Equal to 0

Q42a
During the school year that started in the Fall of 2020, how many children in this household were enrolled in Kindergarten through 12th grade or grade equivalent? Enter numbers for all that apply. Enter ‘0’ if none.

Number enrolled in a public school (1) ________________________________________________
Number enrolled in a private school (2) ________________________________________________
Number homeschooled, that is not enrolled in public or private school (3) ________________________________________________
⊗None (4)

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If If During the school year that started in the Fall of 2020, how many children in this household were enrolled in Kindergarten through 12th grade or grade equivalent? Enter numbers for all that ap... Number enrolled in a public school Is Greater Than 0

Or Or During the school year that started in the Fall of 2020, how many children in this household were enrolled in Kindergarten through 12th grade or grade equivalent? Enter numbers for all that ap... Number enrolled in a private school Is Greater Than 0

Q43a During the last 7 days, how did the children in this household receive their education? Select all that apply.

Children received in-person instruction from a teacher at their school (1)
Children received virtual/online instruction from a teacher in real time (2)
Children learned on their own using on-line materials provided by their school (3)
Children learned on their own using paper materials provided by their school (4)
Children learned on their own using materials that were NOT provided by their school (5)
Children did not participate in any learning activities because their school was closed (6)
Children were sick and could not participate in education (7)
Other, specify (8) ________________________________________________

Display This Question:

Q43aa
Because of the pandemic, are any of the children in your household currently receiving their education with a combination of in-person learning at school and another form of learning (e.g., virtual instruction, online or paper material provided by the school)? Select only one answer.

Yes (1)
No (2)

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Q44 How often are computers or other digital devices available to children for educational purposes? Select only one answer.

Always available (i.e., each child has their own device) (1)
Usually available (2)
Sometimes available (3)
Rarely available (4)
Never available (5)

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Q46 How often is the Internet available to children for educational purposes? Select only one answer.

Always available (1)
Usually available (2)
Sometimes available (3)
Rarely available (4)
Never available (5)

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If How often is the Internet available to children for educational purposes? Select only one answer. = Always available

Or How often is the Internet available to children for educational purposes? Select only one answer. = Usually available

Or How often is the Internet available to children for educational purposes? Select only one answer. = Sometimes available

Or How often is the Internet available to children for educational purposes? Select only one answer. = Rarely available

Q47 Are Internet services in your home …? Select all that apply.

Paid for by the children’s school or school district (1)
Paid for by someone in the household or family (2)
Paid for by another source (3)
⊗Not available in my home (4)

Display This Question:

Q47a During the last 7 days, on how many days did the student(s) have real time contact, that is not pre-recorded contact, with their teachers by video, in person, or by phone? Select only one answer.

None (1)
1 day (2)
2-3 days (3)
4 or more days (4)

Display This Question:

Q48aa In the In the last 7 days, did the students in this household receive any food assistance from school? Select only one answer.

Yes (1)
No (2)

Display This Question:

If In the In the last 7 days, did the students in this household receive any food assistance from sc... = Yes

Q48bb Did the student(s)... Select all that apply.

Pick up meals at a school or other location (1)
Receive an EBT card to help buy groceries (2)
Eat meals on-site, at school or other location (3)
Have meals delivered (4)

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Display This Question:

If If How many people under 18 years-old currently live in your household? Please enter a number. Text Response Is Not Equal to 0

Q49 Next we are going to ask about the childcare arrangements for children in the household.

At any time in the last 4 weeks, were any children in the household unable to attend daycare or another childcare arrangement because of the coronavirus pandemic? Please include before school care, after school care, and all other forms of childcare that were unavailable. Select only one answer.

Yes (1)
No (2)
Not applicable (3)

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If Next we are going to ask about the childcare arrangements for children in the household. At any... = Yes

Q49b Which if any of the following occurred as a result of childcare being closed or unavailable? Select all that apply.

You (or another adult) took unpaid leave to care for the children (1)
You (or another adult) used vacation, or sick days, or other paid leave in order to care for the children (2)
You (or another adult) cut your work hours in order to care for the children (3)
You (or another adult) left a job in order to care for the children (4)
You (or another adult) lost a job because of time away to care for the children (5)
You (or another adult) did not look for a job in order to care for the children (6)
You (or another adult) supervised one or more children while working (7)
Other, specify: (8) ________________________________________________
⊗None of the above (9)

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QPS1 How many members of your household, including yourself, are currently taking, or were planning to take classes this term 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.

________________________________________________________________

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Display This Question:

If If How many members of your household, including yourself, are currently taking, or were planning to... Text Response Is Greater Than 0

QPS3 For all those people counted in the previous question, has the coronavirus pandemic resulted in any of the changes listed below? Select all that apply.

⊗Plans to take classes this term have not changed (1)
All plans to take classes this term have been canceled (2)
Classes are in different formats this term (for example, change from in-person to online) (3)
Fewer classes are being taken this term (4)
More classes are being taken this term (5)
Classes are being taken from a different institution (6)
Classes are being taken for a different kind of certificate or degree (7)

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Display This Question:

If For all those people counted in the previous question, has the coronavirus pandemic resulted in a... = All plans to take classes this term have been canceled

Or For all those people counted in the previous question, has the coronavirus pandemic resulted in a... = Classes are in different formats this term (for example, change from in-person to online)

Or For all those people counted in the previous question, has the coronavirus pandemic resulted in a... = Fewer classes are being taken this term

Or For all those people counted in the previous question, has the coronavirus pandemic resulted in a... = More classes are being taken this term

Or For all those people counted in the previous question, has the coronavirus pandemic resulted in a... = Classes are being taken from a different institution

Or For all those people counted in the previous question, has the coronavirus pandemic resulted in a... = Classes are being taken for a different kind of certificate or degree

QPS4 Why did household members’ classes this term change? Select all that apply.

Had coronavirus or concerns about getting coronavirus (1)
Caring for someone with coronavirus (2)
Caring for others whose care arrangements are disrupted (e.g., loss of day care or adult care programs) (3)
Institution changed content or format of classes (e.g., from in-person to online) (4)
Changes to financial aid (5)
Changes to campus life (6)
Uncertainty about how classes/program might change (7)
Not able to pay for classes/educational expenses because of changes to income from the pandemic (8)
Some other reason related to the pandemic, please specify (9) ________________________________________________

End of Block: Education

Start of Block: Income

Q50 In 2019 what was your total household income before taxes? Select only one answer.

Less than $25,000 (1)
$25,000 - $34,999 (2)
$35,000 - $49,999 (3)
$50,000 - $74,999 (4)
$75,000 - $99,999 (5)
$100,000 - $149,999 (6)
$150,000 - $199,999 (7)
$200,000 and above (8)

End of Block: Income

Start of Block: Address

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 (1) ________________________________________________
Street Name (2) ________________________________________________
Apt Unit (3) ________________________________________________
City (4) ________________________________________________
State (5) ________________________________________________
Zip (6) ________________________________________________

no_address

I do not have a street address (1)

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Display This Question:

If If 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, pleas... Address Number Is Empty

And And 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, pleas... Street Name Is Empty

Or = I do not have a street address

rural_route
Do you have a Rural Route address?

Yes (1)
No (2)

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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.

RR Descriptor (1) ________________________________________________
Rural Route No (2) ________________________________________________
RR Box ID (3) ________________________________________________
City (4) ________________________________________________
State (5) ________________________________________________
Zip Code (6) ________________________________________________

Display This Question:

If Do you have a Rural Route address? = Yes

rural_description 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.

________________________________________________________________

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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 (1) ________________________________________________
State (2) ________________________________________________
Zip (3) ________________________________________________

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 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 experiencing homelessness, as well as the name of the city and state. For example, "Friendship Park, Anywhere PA."

________________________________________________________________

End of Block: Address

Start of Block: Contact Information

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 (1)
Email (2)

Display This Question:

If Because we are interested in how coronavirus experiences change over time, we may contact you aga... = Text message

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

________________________________________________________________

Display This Question:

If Because we are interested in how coronavirus experiences change over time, we may contact you aga... = Email

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

________________________________________________________________

End of Block: Contact Information

Start of Block: Feedback

Feedback_pandemic Thank you.

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

________________________________________________________________

End of Block: Feedback

Start of Block: Conclusion

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 10/31/2023. 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

End of Block: Conclusion

Page 55 of 55

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	Phase 3.1 COVID-19 Household Pulse Survey
Author	Qualtrics
File Modified	0000-00-00
File Created	2021-03-26