Universal Screener - English

US Census Bureau

Center for Behavioral Science Methodology (CBSM)

Telephone Screener

Fall, 2022

CBSM Universal Screener

Hello, I’m _____________ from the Census Bureau. Thank you for contacting us about participating in one of our studies. [IF INTERVIEWER ADMINISTERED, READ: Before we begin, I would like to read a statement about how we protect your data.]

Privacy Act Statement

The U.S. Census Bureau is conducting this voluntary study under the authority of 13 U.S.C. Section(s) [choose applicable: [8(b), 131, 141, 161, 182, 193, 196]. The purpose of collecting this information is to improve and inform future surveys.

Your privacy is protected by the Privacy Act of 1974 (5 U.S.C. Section 552a). The Privacy Act permits sharing of the information provided to us for work-related purposes as identified in the Privacy Act System of Records Notices (SORNs) COMMERCE/Census -3, Demographic Survey Collection (Census Bureau Sampling Frame); COMMERCE/CENSUS-5, Decennial Census Programs; COMMERCE/CENSUS-4, Economic Survey Collections; and COMMERCE/CENSUS-7, Demographic Survey Collection (non-Census Bureau Sampling Frame).

[If Title 13 collection: The confidentiality of your data is protected by 13 U.S.C. Section 9. 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, your business, organization, or institution].

[IF INTERVIEWER ADMINISTERED, READ: Thanks for that, I just need to get a little bit of background information to start.]

[Auto filled: ID Number]

[Auto filled: Last Contact Date]

[Auto filled: Eligible Date]

1. What is your name?

First name:_____________________

Last name:_____________________

2. What is your email address?

3. What is the best number to reach you during the day?

Mobile ([ ]) [ ] – [ ]

Home (if not mobile) ([ ]) [ ] – [ ]

Work (if any) ([ ]) [ ] – [ ] EXT.[ ]

3a. IF PROVIDED MOBILE NUMBER: If you qualify to participate in a study, we may send you a text message to remind you of your appointment. Do we have permission to send you text message reminders?

• Yes, you have my permission to send me text message reminders

• No, I prefer not to receive them

4. In what city, state, and ZIP code do you currently live?

City:_____________________

State:_____________________

Zip code:__________________

5. Is your home owned, rented or occupied without payment of rent?

• Owned

• Rented

• Occupied without payment of rent

6. What type of home do you live in?

• House or townhouse

• Apartment or condo

• Something else (Please specify________)

• [ONLY DISPLAY IF INTERVIEWER ADMINISTERED] Don’t know/Refused

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

• Male

• Female

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

• Male

• Female

• Transgender

• None of these

9. In what year were you born?

10. Are you of Hispanic, Latino, or Spanish origin?

• Yes

• No

11. What is your race? Please select one or more. White, Black or African American, American Indian or Alaska Native, Asian, or Native Hawaiian or other Pacific Islander?

• White

• Black or African American

• American Indian or Alaska Native

• Asian

• Native Hawaiian or other Pacific Islander

12. What is the highest grade of school you have completed, or the highest degree you have received? (do not read categories to respondent)

• Less than high school

• Completed high school

• Some college, no degree

• Associate’s degree (AA/AS)

• Bachelor’s Degree (BA/BS)

• Post-Bachelor's degree (for example, MA, MS, Ph.D, JD, etc.)

• Other degree or studies (specify)________________

13. Are you working for pay full-time, part-time, or are you not working for pay at this time?

• Full-time (ask follow-up questions a and b)

• Part-time (ask follow-up questions a and b)

• Not working for pay at this time (skip to next question)

13a. What is your current job title or job description? [open text]

13b. Are you employed by the Federal Government? (if federal contractor, mark NO)

• Yes

• No

14. How many people age 18 or older currently live in your household, INCLUDING yourself?

15. How many people younger than 18 currently live in your household?

16. [ASK IF HOUSEHOLD HAS > 1 PERSON] Who lives or stays with you? Please select all that apply.

[ ] Parent(s)

[ ] Grandparent(s)

[ ] Husband/wife/spouse

[ ] Unmarried partner

[ ] Children

[ ] Grandchildren

[ ] Other relative(s)

[ ] Roommates

[ ] Friends

[ ] SPANISH ONLY: Renter

[ ] SPANISH ONLY: landlord or home owner

[ ] Other – please specify ______________

17. [ENGLISH ONLY] Do you speak a language other than English at home?

• Yes (ask follow-up question)

• No (skip to next question)

17a. What language or languages do you speak at home? Please select one or more.

[ ] Spanish

[ ] Chinese

[ ] Vietnamese

[ ] Korean

[ ] Russian

[ ] Arabic

[ ] Other – Specify

18. SPANISH ONLY: Were you born in the United States or in another country?

• United States  SKIP NEXT QUESTION

• Another country.

19. SPANISH ONLY: What country were you born in? __________________

20. SPANISH ONLY: Can you fill out a survey in:

• Spanish more easily than English

• English more easily than Spanish

• Both about the same?

21. SPANISH ONLY: It’s not necessary for you to speak English to participate in one of our studies [IF INTERVIEWER ADMINISTERED DISPLAY: , but I still need to ask a few questions about your English]. How well do you speak English? [IF INTERVIEWER ADMINISTERED, DISPLAY: Would you say...]

• Very well

• Well

• Not well

• IF SELF ADMINISTERED, SHOW: I don’t speak English. / IF INTERVIEWER ADMINISTERED, SHOW: Does not speak English.

22. Do you own a:

22a. Smartphone

• Yes - Is it an iPhone, Android, Blackberry or Windows phone, or are you not sure?

• No

22b. Desktop

• Yes

• No

22c. Laptop

• Yes

• No

22d. Tablet

• Yes - Is it an iPad, Samsung Galaxy Tab, Google Nexus, or Kindle Fire or are you not sure?

• No

23. Could you complete a survey online?

• Yes

• No

24. SPANISH ONLY: If you had to participate in a survey, would you prefer to answer it on a paper form, by telephone or on the internet?

• On a paper form

• By telephone

• On the internet

25. Who typically handles the mail in your household?

• Only you

• You and other members of the household?

• Someone in the household other than you?

26. Have you participated in any research studies with the U.S. Census Bureau?

• Yes

• No

26a. IF YES: In what year?_____[IF NEEDED: Was it within the last 3 months?]

27. Some of our studies are conducted in person, and some are conducted remotely. One of our in-person locations is in Suitland, MD. Would you be willing to come to our office in Suitland, Maryland, to participate in a research study?

• Yes

• No

28. Would you be willing to use a free software called Microsoft Teams to participate in an online research study?

• Yes

• No

29. [if interviewer administered] Is your household’s annual income … (Read until interrupted.)

• Less than $15,000?

• $15,000 to $25,000?

• $25,000 to $50,000?

• $50,000 to $100,000?

• More than $100,000?

[if self administered] Is your household’s annual income …

• Less than $15,000?

• $15,000 to $24,999?

• $25,000 to $49,999?

• $50,000 to $100,000?

• More than $100,000?

30. Are you responding to an ad that mentions a code? If so, what was the code?_____________

31. If you are not selected, would you like us to contact you for future study opportunities?

• Yes

• No

32. IF YES: What is the best way to reach you?

• Phone:

• Email: