3 English Screener Questionnaire

ASK US PANEL Pilot Screener Specifications

MODE = WEB, PHONE (inbound only), or IN-PERSON (nonresponse follow-up in pilot only)

LANGUAGE = ENGLISH, SPANISH

PROGRAMMER NOTE: Recruitment materials will provide link + passcode (and likely QR code) that diverts to either English or Spanish page with a toggle to switch to the other.

Phone or in-person interviewer will choose language.

DEFINE QUEX_LANG = questionnaire language with SP = Spanish or EN = English

Defined per language-specific page chosen via link or by interviewer.

Reclassify QUEX_LANG = EN to QUEX_LANG = SP if interview switched but not otherwise.

[END SCREENER] Do not allow WEB participants back into the roster.

PROGRAMMER NOTE: All questions are classified optional unless otherwise specified as “required”.

For PHONE and IN-PERSON, include volunteered “DK” and “RF” response options on all questions.

PROGRAMMER NOTE: For any questions that ask for any of the following and the respondent enters an invalid response, display the following error message:

Email: “Please enter a valid email address.”

Phone number: “Please enter a valid phone number, including the area code.”

Zip code: “Please enter a valid 5-digit zip code”

STUDY INTRO [IF WEB] Introductory screen in either ENGLISH or SPANISH depending on QUEX_LANG.

You have been invited to join the Ask U.S. Panel pilot, a large, national survey panel pilot that will collect public opinion on a variety of topics and test procedures that may be used to develop and implement future panels. Members of the Ask U.S. Panel will participate in surveys led by the U.S. Census Bureau and other federal agencies focused on producing statistics on topics such as food and nutrition, transportation, employment, and education. You should have received a letter explaining the study.

The pilot is being developed under a cooperative agreement awarded by the Census Bureau pursuant to the Consolidated Appropriations Act of 2021, Public Law 116-260, Section 110. Data collection from the Panel for Census Bureau sponsored surveys is authorized by 13 U.S.C §§ 8(b), 131, 141, 161, 181, 182, and 193; 49 U.S.C. § 329; the Education Sciences Reform Act of 2002, 20 U.S.C. § 9543; Section 1110(a) of the Social Security Act as amended, 42 U.S.C. 1310(a); 7 U.S.C. § 3318; 7 U.S.C. 2204(a); Section 306 of the Public Health Service Act, 42 U.S.C. 242k; and 10 U.S.C. § 1782.

This 5-minute survey will determine if you or someone in your household is eligible for the Ask U.S. Panel pilot. Click ‘Next’ when you are ready to begin.

[IF PHONE] Telephone interviewer (TI) choses LANGUAGE.

You have been invited to join the Ask U.S. Panel pilot, a large, national survey panel pilot that will collect public opinion on a variety of topics and test procedures that will be used to develop and implement future panels . Members of the Ask U.S. Panel will participate in surveys led by the U.S. Census Bureau and other statistical agencies focused on producing statistics on topics such as food and nutrition, transportation, employment, and education. You should have received a letter explaining the study.

The pilot is being developed under a cooperative agreement awarded by the Census Bureau pursuant to the Consolidated Appropriations Act of 2021, Public Law 116-260, Section 110. Data collection from the Panel for Census Bureau sponsored surveys is authorized by 13 U.S.C §§ 8(b), 131, 141, 161, 181, 182, and 193; 49 U.S.C. § 329; the Education Sciences Reform Act of 2002, 20 U.S.C. § 9543; Section 1110(a) of the Social Security Act as amended, 42 U.S.C. 1310(a); 7 U.S.C. § 3318; 7 U.S.C. 2204(a); Section 306 of the Public Health Service Act, 42 U.S.C. 242k; and 10 U.S.C. § 1782.

This 5-minute survey will determine if you or someone in your household is eligible for the Ask U.S. Panel pilot. Also, this call may be monitored or recorded for quality assurance.

[IF IN-PERSON] Field interviewer (FI) choses LANGUAGE.

Hello, my name is [FI NAME] with RTI International. You have been invited to join the Ask U.S. Panel pilot, a large, national survey panel pilot that will collect public opinion on a variety of topics and test procedures that will be used to develop and implement future panels. Members of the Ask U.S. Panel will participate in surveys led by the U.S. Census Bureau and other statistical agencies focused on producing statistics on topics such as food and nutrition, transportation, employment, and education. You should have received a letter explaining the study.

The pilot is being developed under a cooperative agreement awarded by the Census Bureau pursuant to the Consolidated Appropriations Act of 2021, Public Law 116-260, Section 110. Data collection from the Panel for Census Bureau sponsored surveys is authorized by 13 U.S.C §§ 8(b), 131, 141, 161, 181, 182, and 193; 49 U.S.C. § 329; the Education Sciences Reform Act of 2002, 20 U.S.C. § 9543; Section 1110(a) of the Social Security Act as amended, 42 U.S.C. 1310(a); 7 U.S.C. § 3318; 7 U.S.C. 2204(a); Section 306 of the Public Health Service Act, 42 U.S.C. 242k; and 10 U.S.C. § 1782.

This 5-minute survey will determine if you or someone in your household is eligible for the Ask U.S. Panel pilot.

R1 [IF PHONE OR IN-PERSON] First, to verify, do you receive mail at [ADDRESS FILL]?

1 YES

2 NO

R2 [IF (PHONE OR IN-PERSON) AND (R1 = NO)] May I speak with someone at least 18 years old who receives mail at this address?

1 YES [GOTO restart with introductory script]

2 NO [GOTO R2a]

3 YES, but not available [GO TO R2b]

R2a [IF (PHONE OR IN-PERSON) AND (R2 = NO)] We need to speak to a resident of this address who is at least 18 years old. Thank you for your time.

[END SCREENER]

R2b [IF (PHONE OR IN-PERSON) AND (R2= YES, but not available)] Thank you for answering these questions. We need to speak to a resident of this address who is at least 18 years old. Please ask an adult member of your household to call 1-866-558-0774 to complete these questions.

[END SCREENER]

R3 [IF ((PHONE OR IN-PERSON) AND (R1 = YES)) OR WEB] How old are you?

_______ Years old (RANGE 1-110)

R3a [IF WEB AND R3 < 18] Please reenter your age.

_______ Years old (RANGE 1-110)

PROGRAMMER NOTE:

IF R3 = (BLANK, DON’T KNOW, REFUSED), SHOW ERROR MESSAGE: This question is required to continue.

POP UP: [IF WEB AND R3a < 18] Thank you for answering these questions. We are unable to complete this portion of the survey online. Please ask an adult member of your household to call 1-866-558-0774 to complete these questions or an interviewer will follow up with your household in person.

[END SCREENER]

[IF (PHONE OR IN-PERSON) AND R3a < 18] These questions must be answered by someone aged 18 or older. [GOTO R2]

R4 REQUIRED [IF R3 ≥ 18] Including yourself, how many adults 18 years of age or older consider [ADDRESS FILL] their primary residence? Please don’t count anyone who lives most of their time somewhere else, even if they are currently staying here.

_______ # of adults 18 years of age or older, including yourself (RANGE 1-25)

PROGRAMMER NOTE:

IF R4 = (BLANK, DON’T KNOW, REFUSED), SHOW ERROR MESSAGE: This question is required to continue.

R5 Is [ADDRESS FILL] …

1 Owned by you or someone else in this household?

2 Rented by you or someone else in this household?

3 Occupied without payment of rent?

PROGRAMMER NOTE:

IF R6 = BLANK, SHOW ERROR MESSAGE: This question is important for classification purposes. Please try to answer if you can.

R6 Including you and the adults regularly living with you, does anyone primarily speak a language other than [(English IF QUEX_LANG=EN) OR (Spanish IF QUEX_LANG=SP)] at home?

1 [IF PHONE OR IN-PERSON: YES] [IF WEB: Yes]

2 [IF PHONE OR IN-PERSON: NO] [IF WEB: No] [GOTO R8]

R7 [IF R6 = 1] What are the languages?

1. [IF PHONE OR IN-PERSON: (SPANISH IF QUEX_LANG=EN) OR (ENGLISH IF QUEX_LANG=SP)]] [IF WEB: (Spanish IF QUEX_LANG=EN) OR (English if QUEX_LANG=SP)]]

2. [IF PHONE OR IN-PERSON: CHINESE] [IF WEB: Chinese]

3 [IF PHONE OR IN-PERSON: VIETNAMESE] [IF WEB: Vietnamese]

4 [IF PHONE OR IN-PERSON: KOREAN] [IF WEB: Korean]

5 [IF PHONE OR IN-PERSON: RUSSIAN] [IF WEB: Russian]

6 [IF PHONE OR IN-PERSON: ARABIC] [IF WEB: Arabic]

7 [IF PHONE OR IN-PERSON: OTHER, SPECIFY: _________] [IF WEB: Other, specify ___________________] [MAX 20 CHARACTERS]

-- START OF THE HOUSEHOLD ROSTER --

R8 [IF R4 > 1: Next are a few questions about the people who live here with you. Let’s start with you.]

What is your first name?

_________________ [MAX OF 100 CHARACTERS]

R9 [IF R6=1 AND QUEX_LANG=SP] How well do you speak English?

1. Very well

2. Well

3. Not well

4. Not at all

R10 [IF R4 = 2 AND ROSTER LINE = 2] And what is the first name of the other adult in this household? This information will only be used to contact this person if they are selected to participate.

_________________ [MAX OF 100 CHARACTERS]

[IF R4 > 2] Now we need some general information about the other adults in this household. Let's start with the oldest and work down to the youngest, not including yourself.

What is the first name of the [oldest/next oldest] adult in this household? This information will only be used to contact this person if they are selected for a screening survey.

_________________ [MAX OF 100 CHARACTERS]

PROGRAMMER NOTE:

DEFINE NAMEFILL

NAMEFILL = R10

IF R10 = BLANK or DK/REF, RRNAMEFILL = person # [FILL ROSTER NUMBER]

R11 [IF R4 > 1] How old is [NAMEFILL]?

______ Years old (RANGE 18-110)

PROGRAMMER NOTE: REPEAT R10 and R11 [R4 – 2] times.

R12 IN THE PAST 12 MONTHS, did you or any member of this household receive benefits from the Food Stamp Program or SNAP (the Supplemental Nutrition Assistance Program)? Do NOT include WIC, the School Lunch Program, or assistance from food banks.

1 [IF PHONE OR IN-PERSON: YES] [IF WEB: Yes]

2 [IF PHONE OR IN-PERSON: NO] [IF WEB: No]

R13 At this house, apartment, or mobile home, do you or any member of this household have access to the Internet?

1 Yes, by paying a cell phone company or Internet service provider

2 Yes, without paying a cell phone company or Internet service provider

3 No access to the Internet at this house, apartment, or mobile home

PROGRAMMER NOTE: Randomization …..

DEFINE SELECT_1 – SELECT_[FILL ROSTER NUMBER]

SELECT_[ROSTER NUMBER] = SELECTED (1) or NOT SELECTED (0)

DEFINE NUMSELECTED

NUMSELECTED = sum(of SELECT_1 – SELECT_[FILL ROSTER NUMBER])

* Currently, NUMSELECTED = 1 or 2; possibly 0

R14 [IF R4 = 1 and NUMSELECTED = 0] Thank you for providing your information. You were not randomly selected for additional survey questions.

[IF ON OR BEFORE EARLY BIRD GO TO R17a; ELSE END SCREENER]

[IF R4 = 1 and NUMSELECTED = 1] Thank you for providing your information. You are eligible to participate in the Ask U.S. Panel pilot.

[IF R4 > 1 and NUMSELECTED = 0] Thank you for providing your household information. No one in your household was selected for additional survey questions.

[IF ON OR BEFORE MAY 1 GO TO R17a; ELSE END SCREENER]

[IF R4 > 1 and NUMSELECTED = 1] Thank you for your help. The following household member is eligible to participate in the Ask U.S. Panel pilot.

RRNAMEFILL (You) OR NAMEFILL AGE

[IF R4 > 1 and NUMSELECTED = 2] Thank you for your help. The following household members are eligible to participate in the Ask U.S. Panel pilot:

RRNAMEFILL (You) OR NAMEFILL AGE

R15 [IF SELECT_1 = SELECTED] What is your last name?

_________________ [MAX OF 100 CHARACTERS]

[IF (SELECT_1 = NOT SELECTED) and (NUMSELECTED > 1)] What is [NAMEFILL_1]’s last name?

_________________ [MAX OF 100 CHARACTERS]

R15b [IF R4 > 1 and NUMSELECTED = 2] What is [NAMEFILL_2]’s last name?

_________________ [MAX OF 100 CHARACTERS]

IF R15 or R15b = BLANK: This question is important. This information will only be used to contact [you/this person] for future surveys. Please answer if you can.]

R16 [IF SELECT_1 = SELECTED] Please provide your contact information. This information will be used to send updates, notifications, and survey links. We will only use this information if you are selected to participate.

Email address [MAX OF 30 CHARACTERS]

Home phone (including area code) [10 NUMBERS]

Cell phone (including area code) [10 NUMBERS]

R16a [IF (SELECT_1 = NOT SELECTED) and (NUMSELECTED > 1)] Please provide the following contact information for [NAMEFILL_1]. This information will be used to send updates, notifications, and survey links. We will only use this information if [NAMEFILL_1] is selected to participate.

Email address [MAX OF 30 CHARACTERS]

Home phone (including area code) [10 NUMBERS]

Cell phone (including area code) [10 NUMBERS]

R16b [IF (SELECT_1 = NOT SELECTED) and (NUMSELECTED = 2)] Please provide the following contact information for [NAMEFILL_2]. This information will be used to send updates, notifications, and survey links. We will only use this information if [NAMEFILL_2] is selected to participate. Email address [MAX OF 30 CHARACTERS]

Home phone (including area code) [10 NUMBERS]

Cell phone (including area code) [10 NUMBERS]

[IF R16 or R16a or R16b = BLANK: This question is important. This information will only be used to contact [you/this person] for future surveys. Please answer if you can.]

[IF SELECT_1 = SELECTED] Thank you for answering our questions. To complete your enrollment in the panel pilot, we need to collect some additional information. These questions will take approximately 5-10 minutes of your time to answer. If you complete the enrollment survey you will receive an additional $20 as a token of our appreciation. If you choose to join the panel pilot, you will also have the chance to receive an additional payment for participating in a future panel survey.

R17 [IF SELECT_1 = SELECTED] Would you like to begin your enrollment survey now?

1 [IF PHONE OR IN-PERSON: YES] [IF WEB: Yes] [BEGIN BASELINE]

2 [IF PHONE OR IN-PERSON: NO] [IF WEB: No]

R17a [IF (SELECT_1=SELECTED AND R17=NO) | SELECT_1=NOT SELECTED] and PHONE or WEB AND ON OR BEFORE EARLY BIRD DATE OR IN-PERSON: You will receive $5 for having completed this survey today. [IF PHONE OR WEB: Would you prefer to receive this payment in the form of cash, a physical gift card, an electronic gift card, or mailed check?]

1. [IF PHONE OR IN-PERSON: CASH] [IF WEB: Cash]

2. [IF PHONE: PHYSICAL GIFT CARD] [IF WEB: Physical gift card]

3. [IF PHONE: ELECTRONIC GIFT CARD] [IF WEB: Electronic gift card]

4. [IF PHONE: MAILED CHECK] [IF WEB: Mailed check]

R17b [IF PHONE OR WEB AND R17a = 1 | 2 | 4] The address we have on file is [ADDRESSFILL]. Is this the address you would like us to mail your [IF R17a=1 and PHONE OR WEB: cash] [IF R17a=2: gift card]?

1 [IF PHONE: YES] [IF WEB: Yes]

2 [IF PHONE: NO] [IF WEB: No]

R17c [IF R17b=2] Please provide the mailing address to which we should send your payment.

ADDRESS: _____________

CITY: __________

STATE: ___________

ZIP CODE: __________ [MAX 5 DIGITS]

[IF R17c = BLANK: This question is important. This information will only be used to send your payment. Please answer if you can.]

R17d [IF R17a=3 AND NOT MISSING EMAILFILL] The email we have on file is [EMAILFILL]. Is this the email to which you would like us to send your electronic gift card?

1 [IF PHONE: YES] [IF WEB: Yes]

2 [IF PHONE: NO] [IF WEB: No]

R17e [IF R17d=2 | MISSING EMAILFILL] Please provide the email address to which we should send your electronic gift card.

__________________

[IF R17e = BLANK: This question is important. This information will only be used to send your payment. Please answer if you can.]

R17f. [IF IN-PERSON AND R17a = 1] INTERVIEWER: GIVE REPONDENT $5 IN CASH.

This form states that you have received the money. This copy is for your records.

INTERVIEWER: DID THE RESPONDENT ACCEPT THE INCENTIVE PAYMENT?

1 YES

2 NO

[IF (PHONE OR IN-PERSON) AND (SELECT_1 = NOT SELECTED) OR (SELECT_1 = SELECTED AND R17 = NO AND NUMSELECTED = 2)] We’d like to ask [NAMEFILL_1] some additional questions to complete their enrollment in the panel. We need to collect some additional information from them.

R18 [IF (PHONE OR IN-PERSON) and (SELECT_1 = NOT SELECTED)] Is [NAMEFILL_1] available to speak with me now?

1 YES

2 NO

R18a [IF (PHONE OR IN-PERSON) AND either ((SELECT_1 = NOT SELECTED AND R18 = NO) OR (SELECT_1 = SELECTED and R17 = NO and NUMSELECTED = 2)] Is [NAMEFILL_2] available to speak with me now?

1 YES

2 NO

[IF R18 = 1 OR R18a = 1] The questions [RRNAMEFILL] just completed indicate that you are eligible to participate in the Ask U.S. Panel pilot, a large nationally representative survey panel pilot led by the U.S. Census Bureau. The purpose of the panel pilot is to track public opinion on a variety of topics. The panel consists of individuals and households living across the U.S. that have agreed to be contacted and invited to participate in surveys led by the U.S. Census Bureau and other statistical agencies.

To complete your enrollment in the panel pilot, we need to collect some information from you. These questions will take approximately 20 minutes of your time to answer. If you complete the enrollment survey you will receive $20 as a token of our appreciation. If you choose to join the panel pilot, you will also have the chance to receive an additional payment for participating in a future panel survey.

R18b. Would you like to begin your enrollment survey now?

1 YES [BEGIN BASELINE]

2 NO

R19 [IF R17=NO] We will contact you soon to complete the enrollment survey. Thank you for your time.

R19a [IF R18=NO] We will contact [NAMEFILL_1] soon to complete the enrollment survey. Thank you for your time.

R19c [IF R17=NO AND (R18a=NO | R18b=NO)] We will contact you and [NAMEFILL_2] soon to complete the enrollment survey. Thank you for your time.

R19d [IF NUMSELECTED=2 AND SELECT_1 = NOT SELECTED AND R18=NO AND R18a=NO] We will contact [NAMEFILL_1] and [NAMEFILL_2] soon to complete the enrollment survey. Thank you for your time.

April 24, 2021 Page 13 of 13