Part A, Attachment A - Phase 3.2 Household Pulse Survey Questionnaire

Phase 3.2 COVID-19 Household Pulse Survey

DRAFT

Intro Welcome! Thank you for participating in the Household Pulse Survey 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 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 (1)

• Español (2)

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.

Display This Question:

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.

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 (specify) (1)

________________________________________________

• Black or African American (specify) (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)

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

• Now married (1)

• Widowed (2)

• Divorced (3)

• Separated (4)

• Never married (5)

GI1. What sex were you assigned at birth, on your original birth certificate?

• Male (1)

• Female (2)

GI2. Do you currently describe yourself as male, female or transgender?

• Male (1)

• Female (2)

• Transgender (3)

• None of these (4)

GI3. Just to confirm, you were assigned {FILL} at birth and now you describe yourself as {FILL}. Is that correct?

• Yes (1)

• No (2) <skip back to GI1 and/or GI2 to correct>

SO1. Which of the following best represents how you think of yourself?

1 Gay or lesbian

2 Straight, that is not gay or lesbian

3 Bisexual

4 Something else

5 I don’t know

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.

________________________________________________________________

Universe: If Q8 > 0.

Q8a In your household, are there… Select all that apply.

• Children under 5 years old? (1)

• Children 5 through 11 years old? (2)

• Children 12 through 17 years old? (3)

Q8b 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)

QV1 Have you received at least one dose of a COVID-19 vaccine?

• Yes (1)

• No (2)

Display This Question:

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

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

• Yes, received all required doses (1)

• Yes, plan to receive all required doses (2)

• No, don’t plan to receive all required doses (3)

Display This Question:

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

QV3 Now that vaccines to prevent COVID-19 are available to most adults in the United States, will 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)

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 protect me (2)

• I don’t believe I need a COVID-19 vaccine (3)

• My doctor has not recommended it (4)

• I plan to wait and see if it is safe and may get it later (5)

• I am concerned about the cost of a COVID-19 vaccine (6)

• I don’t trust COVID-19 vaccines (7)

• I don’t trust the government (8)

• I don’t think COVID-19 is that big of a threat (9)

• It’s hard for me to get a COVID-19 vaccine (10)

• [If QV2Q2=3, show] I believe one dose is enough to protect me (11)

• [If QV2Q2=3, show] I experienced side effects from the dose of COVID-19 vaccine I received (12)

• Other (please specify) (13) ________________________________________________

If Q8a includes 3 Display QV_C1

QV_C1 Have any of the children aged 12-17 years living in your household received at least one dose of a COVID-19 vaccine?

o Yes

o No

o Don’t know

If QV_C1 !=yes then display QV_C2

QV_C2 Now that vaccines to prevent COVID-19 are available to most children between ages 12 and 17, will the parents or guardians of children ages 12-17 living in your household…

o Definitely get the children a vaccine

o Probably get the children a vaccine

o Be unsure about getting the children a vaccine

o Probably NOT get the children a vaccine

o Definitely NOT get the children a vaccine

o I do not know the plans for vaccination of children aged 12-17 living in my household

Universe: If QV_C2 is not equal to “Definitely get a vaccine” or I do not know about plans… display QV_C3

QV_C3 Which of the following, if any, are reasons that the parents or guardians of children ages 12-17 living in your household [only probably will / probably won’t/definitely won’t/ are unsure about whether to] get a COVID-19 vaccine for the children? (Select all that apply)

o Concern about possible side effects of a COVID-19 vaccine for children

o Plans to wait and see if it is safe and may get it later

o Not sure if a COVID-19 vaccine will work for children

o The parents or guardians don’t believe their children need a COVID-19 vaccine

o The children in this household are not members of a high-risk group

o The children’s doctor has not recommended it

o Other people need it more than the children in this household do right now

o Concern about missing work to have the children vaccinated

o Unable to get a COVID-19 vaccine for children in this household

o Parents or guardians in this household do not vaccinate their children

o Lack of trust in COVID-19 vaccines

o Lack of trust in the government

o Concern about the cost of a COVID-19 vaccine

o Other/Please specify

Display This Question:

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

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

• Yes (1)

• No (2)

• Not Sure (3)

Q9a Now we are going to ask about your employment. 

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

o Yes (1)

o No (2)

Q11 In the last 7 days, did you do ANY work for either pay or profit? Select only one answer.

• Yes (1)

• No (2)

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... = 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) ________________________________________________

Q13c In the last 7 days, have you worked or volunteered outside your home? Select only one answer.

• Yes (1)

• No (2)

Display This Question:

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

Q13d In the last 7 days, which best describes the primary location/setting where you worked or volunteered outside your home? Select only one answer.

• Hospital

• Nursing and residential healthcare facility

• Pharmacy

• Ambulatory healthcare (e.g. doctor, dentist or mental health specialist office, outpatient facility, medical and diagnostic laboratory, home health care)

• 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)

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 “Child Tax Credit” payment, that is an advance payment from the expansion of the child tax credit as part of the Federal Government‘s American Rescue Plan? Please report "yes" if you received the payment as a paper check or as a direct deposit.

• 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 payments from the “Child Tax Credit" did you:

• Mostly spend it (1)

• Mostly save it (2)

• Mostly use it to pay off debt (3)

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

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

• Food (groceries, eating out, take out) (1)

• Clothing (including accessories or shoes) (2)

• Childcare (formal facility, paying family or caregiver directly) (3)

• School books and supplies (14)

• School tuition (15)

• Tutoring services (16)

• After school programs (other than tutoring and childcare) (17)

• Transportation for school (bus service, metro, etc..) (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) ________________________________________________

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 activities in the following categories? 

	Yes (1)	No (2)
Working onsite at a workplace (Q19b_1)
Teleworking or work from home (Q19b_2)
In-store shopping (Q19b_3)
Eating indoors at restaurants (Q19b2_1)
In-person medical or dental appointments (Q19b2_2)
Having in-home housekeeping or caregiving services (Q19b2_3)

Display This Question:

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

Q19bb Did you or your household do 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 activities in the following... = Working on-site at a workplace [ Yes ]

Display This Choice:

If In the last 7 days, have you or your household changed your activities in the following... = Teleworking or work from home [ Yes ]

Display This Choice:

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

Display This Choice:

If In the last 7 days, have you or your household changed your activities in the following...= Eating indoors at restaurants [ Yes ]

Display This Choice:

If In the last 7 days, have you or your household changed your activities in the following...= In-person medical or dental appointments [ Yes ]

Display This Choice:

If In the last 7 days, have you or your household changed your activities in the following...= 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 activities in the following... = Working onsite at a workplace [ Yes ] Working onsite at a workplace (Q19bb_1)
Display This Choice: If In the last 7 days, have you or your household changed your activities in the following... = Telework or work from home [ Yes ] Teleworking or work from home (Q19bb_2)
Display This Choice: If In the last 7 days, have you or your household changed your activities 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 changed your activities in the following...= Eating indoors at restaurants [ Yes ] Eating indoors at restaurants (Q19bb_4)
Display This Choice: If In the last 7 days, have you or your changed your activities in the following...  = In-person medical or dental appointments [ Yes ] In-person medical or dental appointments (Q19bb_5)
Display This Choice: If In the last 7 days, have you or your changed your activities in the following...  = Housekeeping or caregiving services [ Yes ] Housekeeping or caregiving services (Q19bb_6)

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)

• Child Tax Credit payment (10)

• Money saved from deferred or forgiven payments [to meet your spending needs] (7)

• Supplemental Nutrition Assistance Program (SNAP) (8)

• School meal debit/EBT cards (11)

• Government rental assistance (12)

• Other, specify: (9) ________________________________________________

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)

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)

Display This Question: If check boxes for either children 5-11 or 12-17 are checked.

Q48aa 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 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)

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)

Q32 Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious, or on edge? 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 2 weeks, how often have you been bothered by the not being able to stop or control worrying? 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 2 weeks, how often have you been bothered by having little interest or pleasure in doing things? 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 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless? Select only one answer.

• Not at all (1)

• Several days (2)

• More than half the days (3)

• Nearly every day (4)

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)

Display if all insurance categories are marked as ‘no’

NEW Q1 How likely are you to apply for Medicaid or insurance coverage from a Health Insurance Marketplace during 2021? Select only one answer.

o Extremely likely

o Very likely

o Somewhat likely

o Not at all likely

If Q1 = Not at all likely,

NEW Q2 What is the main reason you are not likely to apply? Select only one answer.

o You don’t think you would be eligible for health insurance

o You think insurance would cost too much

o You don’t think you need health insurance

o It is too hard to sign up or you don’t know how to apply

o You don’t think Medicaid or Marketplace health insurance is good insurance

o You don’t want government help to get health insurance

o You don’t know enough about these options

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)

Universe: If yes to QTH1

QTH1b Did the appointment(s) take place over the phone without video or did the appointment(s) use video? Select all that apply.

• Phone appointments without video (1)

• Video appointments (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)

Universe: If Yes to QTH2

QTH2b Did the children’s appointment(s) take place over the phone without video or did the appointment(s) use video? Select all that apply.

• Phone appointments without video (1)

• Video appointments (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

If there are children under age 18 in the household then display…

Q38d

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

During the last 12 months did any of the children in the household have a PREVENTIVE check-up?

• Yes, all children had a preventive check-up (1)

• Some, but not all, children had a preventive check-up (2)

• None of the children had a preventive check-up (3)

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)

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)

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)

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)?

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

Q41 How confident are you that the household will be able to pay the 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)

Ask only if Q40b = 2 or Q40c = 2.

Q41a How many months behind is this household in paying your rent or mortgage?

______ Enter number of months

Q41b. [ONLY AMONG RENTERS BEHIND ON RENT] Have you or anyone in your household applied for emergency rental assistance through your state or local government to cover your unpaid rent or utility bills?

• My household applied and received assistance

• My household applied and is waiting for a response

• My household applied and the application was denied

• My household did not apply

Display This Question:

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)

In the last 12 months, how many months did your household reduce or forego expenses for basic household necessities, such as medicine or food, in order to pay an energy bill?

• Almost every month (1)

• Some months (2)

• 1 or 2 months (3)

• Never (4)

In the last 12 months, how many months did your household keep your home at a temperature that you felt was unsafe or unhealthy?

• Almost every month (1)

• Some months (2)

• 1 or 2 months (3)

• Never (4)

In the last 12 months, how many times was your household unable to pay an energy bill or unable to pay the full bill amount?

• Almost every month (1)

• Some months (2)

• 1 or 2 months (3)

• Never (4)

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 ended in the Spring of 2021, 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)

If Q42a gt 0 ask

[NEW] 42b. After the end of the normal school year in the Spring of 2021, did any of the Kindergarten through 12th grade students in your household: Please select all that apply.

 Attend a traditional summer school program because of poor grades?

 Attend a summer school program to help students catch up with lost learning time during the pandemic?

 Attend school-led summer camps for subjects like math, science or reading?

 Work with private tutors to help students catch up with lost learning time during the pandemic?

Q50 In 2020 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)

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) ________________________________________________

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.

________________________________________________________________

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 10/31/2023.  

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 

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