EBSA Customer Interviews Recruitment Screener Questions

Department of Labor 

Employment and Benefits Security Administration  

Customer Interviews 

Customer Recruitment Screener Questions

12/9/22

The OMB control number for this collection is 1225-0093 and expires on 02/29/2024. According to the Paperwork Reduction Act of 1995, no person is required to respond to a collection of information unless such collection displays a valid OMB control number. Collection of this information is authorized by OMB. The obligation to respond to this collection is voluntary. We estimate it takes about 10 minutes to complete.

Q1 What is your age group? (Select one)

• Less than 18 years old [Disqualify and end survey]

• 18-24

• 25-44

• 45-67

• 68+ [Disqualify and end survey]

Disqualify/End Survey Message: We’re sorry. Based on your answers, you don’t match the specific profile for the interviews. We greatly appreciate your time and interest. You may close your browser.

Q2 Where do you live? (Select one) [Drop down list of states]

▼ Alabama ... I do not live in the United States [Disqualify and end survey]

Q3 Do you have job-based health insurance or a job-based retirement plan? (Select one)

• Yes

• No

• I don't know

Display This Question:

If Do you have job-based health insurance or a job-based retirement plan? (Select one) = No

Or Do you have job-based health insurance or a job-based retirement plan? (Select one) = I don't know

Q3a Do you receive benefits from a family member who has job-based health insurance or a job-based retirement plan? (Select one)

• Yes

• No [Disqualify and end survey]

Q4 Does the company/organization you work for (or the insured family member works for) have more than 100 employees? (Select one)

• Yes

• No [Disqualify and end survey]

• I don't know [Disqualify and end survey]

Q5 Do you have coverage through any of these programs: Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE? (Select one)

• Yes [Disqualify and end survey]

• No

• I don't know [Disqualify and end survey]

Q6 What racial/ethnic group best describes you? (Select all that apply)

• American Indian or Alaska Native

• Asian/Pacific Islander

• Black/African American

• Hispanic/Latino/Latina

• White/Caucasian

• Other (specify) __________________________________________________

• I prefer not to answer

Q7 What language(s) do you speak? (Select all that apply)

• English

• Spanish

• Chinese

• Vietnamese

• Korean

• Haitian Creole

• Polish

• Tagalog

• Arabic

• Russian

• Portuguese

• French

• Other (specify) __________________________________________________

• I prefer not to answer

Display This Question:

If What language(s) do you speak? (Select all that apply) != English

Q8 Would you say you speak English…? (Select one)

• Very well

• Well

• A little

• Not at all

Q9 Do you identify with any of the following statements? (Select all that apply)

• I wear glasses.

• I have difficulty seeing small words or shapes.

• I have difficulty seeing certain colors. (Please specify.) _______________

• I have a vision impairment. (Please specify.) ______________________

• I prefer not to answer.

• None of the above

Q10 What is the highest level of school you completed? (Select one)

• Some high school or less – no diploma or GED

• High school diploma or GED

• Some college, no degree

• College degree or more

• I prefer not to answer

Q11 How do you describe your gender identity? (Select the best fit)

• Woman, female, or feminine

• Man, male, or masculine

• Transgender woman, female, or feminine

• Transgender man, male, or masculine

• Nonbinary, gender queer, or gender fluid

• Not listed here/I prefer to self-describe: (specify) _____________________________

• I prefer not to answer

Q12 Were you born in the United States? (Select one)

• Yes

• No

• I prefer not to answer

Q13 What is the combined income of all members of your household for the past 12 months (before taxes and from all sources)? (Select one)

• $25,000 or less

• $25,001 to $40,000

• $40,001 to $60,000

• $60,001 or more

• I prefer not to answer

Q14 Which devices do you have access to? (Select all that apply)

• Computer/laptop

• Tablet (iPad, Microsoft Surface, etc.)

• Mobile phone

• Other (specify) __________________________________________________

• None of the above [Disqualify and end survey]

Thank you. You qualify to take part in the interview. Please fill out the information below and list some days and times in the next two weeks that you are available for a 40-minute interview. Your information will be kept private. You will receive a $75 gift card after successful completion of the interview. We will follow up with you shortly to schedule an interview.

• First name __________________________________________________

• Last name __________________________________________________

• Email address __________________________________________________

• Mobile phone (include area code) ___________________________________

• Days/times available for a 30-minute interview (include time zone) _____________

Thank you for submitting your responses.

November 2022 7