Form PART A, ATTACH A_C PART A, ATTACH A_C PART A, ATTACH A_CHP Screener, Baseline, and Topical Que

Census Household Panel Initial Instrument Specifications

Screener/Baseline Instrument

MODE = WEB, PHONE (inbound/outbound)

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 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”.

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

You have been invited to join the Census Household Panel, a large, national survey panel that will collect information on topics such as food and nutrition, transportation, employment, and education. You should have received a letter or an email explaining the study.

By law, the Census Bureau is required to keep your answers confidential. This survey is voluntary and you may refuse to answer any question. The results of this study may be used to inform future surveys and censuses. This collection has been approved by the Office of Management and Budget (OMB). This eight-digit OMB approval number, 0607-XXXX, confirms this approval. We are required to display this number to conduct this survey.

The U.S. Census Bureau is conducting this study under the authority of 13 U.S.C. Sections 131, 141, 182, 193, and 196. Your privacy is protected by the Privacy Act of 1974 (5 U.S.C. Section 552a). There are a limited number of uses of your data that are permitted under the Privacy Act. You can find a list of these uses in the System of Records Notice (SORN). For this survey, the SORNs are named: COMMERCE/Census -3, Demographic Survey Collection (Census Bureau Sampling Frame) and COMMERCE/CENSUS-5, Decennial Census Programs.

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

You have been invited to join the Census Household Panel, a large, national survey panel that will collect information on topics such as food and nutrition, transportation, employment, and education. You should have received a letter or an email explaining the study.

By law, the Census Bureau is required to keep your answers confidential (Title 13, United States Code, Section 9). This survey is voluntary, and you may refuse to answer any question. The results of this study may be used to inform future surveys and censuses. This collection has been approved by the Office of Management and Budget (OMB). This eight-digit OMB approval number, 0607-XXXX, confirms this approval. We are required to display this number to conduct this survey.

The U.S. Census Bureau is conducting this study under the authority of 13 U.S.C. Sections 131, 141, 182, 193, and 196. Your privacy is protected by the Privacy Act of 1974 (5 U.S.C. Section 552a). There are a limited number of uses of your data that are permitted under the Privacy Act. You can find a list of these uses in the System of Records Notice (SORN). For this survey, the SORNs are named: COMMERCE/Census -3, Demographic Survey Collection (Census Bureau Sampling Frame) and COMMERCE/CENSUS-5, Decennial Census Programs.

R1 What year were you born? Please enter a number.

________________________________________________________________

R2 [IF R1 > 2005] May I speak with someone at least 18 years old who lives at this address?

Display sampled address –

ADDRESS NUMBER: _____________ [MAX 50 CHARACTERS]

STREET NAME: _________________[MAX 50 CHARACTERS]

APT UNIT: ________________ [MAX 30 CHARACTERS]

CITY: __________ [MAX 30 CHARACTERS]

STATE: ___________ [MAX 30 CHARACTERS]

ZIP CODE: __________ [MAX 5 DIGITS]

1 YES [GOTO STUDY INTRO WITH NEW MEMBER]

2 NO [GOTO R2a]

3 YES, but not available [GO TO R2b]

R2a [IF (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 and CLOSEOUT]

R2b [IF (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 [update with TQA line] to complete these questions.

[END SCREENER]

R4 REQUIRED [IF R1= ELIGIBLE (RESPONDENT OVER 18))] How many total people – adults and children – currently live in your household, including yourself? ? Please don’t count anyone who lives most of their time somewhere else, even if they are currently staying here. Please enter a number.

_______ # of people including yourself (RANGE 1-25)

PROGRAMMER NOTE:

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

R4a REQUIRED How many people under 18 years-old currently live in your household? Please don’t count anyone who lives most of their time somewhere else, even if they are currently staying here. Please enter a number.

_______ # of people under 18 years-old (RANGE 1-25)

PROGRAMMER NOTE:

IF R4a = (BLANK, DON’T KNOW, REFUSED), SHOW ERROR MESSAGE: This question is required to continue.

PROGRAMMER NOTE: CALCULATE THE DIFFERENCE BETWEEN R4 AND R4A TO GENERATE NUMBER OF ADULTS. USE NUMBER OF ADULTS IN R14 FOR SCREENER END DECISION.

-- 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 full name?

First _________________________ Last_________________________

[MAX OF 100 CHARACTERS IN EACH FIELD]

PROGRAMMER NOTE:

Generate lines for respondent/iwer to record names for all household members.

ROSTER6 [FOR ALL COMPLETED LINES] What is [fill First_Name Last_Name]’s month and year of birth?

__ Month [RANGE: 1-12] ____ Year [RANGE: 1911-2021]

AGE [if YEAR is blank] What is [fill First_Name Last_Name]’s age in years

____________ years old

PROGRAMMER NOTE:

Ask AGE if ROSTER6 (Month and Year of Birth) is empty . If Month and Year of Birth are reported fill AGE with calculated value based on current date – mm/yy of birth.

SEX [FOR ALL COMPLETED LINES] What sex was [fill First_Name Last_Name] assigned at birth, on [fill your/their] original birth certificate?

1. Male

2. Female

PROGRAMMER NOTE:

Generate lines for respondent/iwer to record sex assigned at birth for themselves and all household members.

GENID [FOR ALL COMPLETED LINES] [fill Do you/Does [fill First_Name Last_Name]] currently describe [fill yourself/themselves] as male, female, transgender, or some other way?

1. Male

2. Female

3. Transgender

4. Other (Please specify:__________)

PROGRAMMER NOTE:

Generate lines for respondent/iwer to record gender identity for themselves and all household members.

PROGRAMMER NOTE: Display This Question:

If SEX = Male and GENID = Female

Or If SEX = Male and GENID = Transgender

Or If SEX = Male and GENID = None of these

Or If SEX = Female and GENID = Male

Or If SEX = Female and GENID = Transgender

Or If SEX = Female and GENID = None of these

GENCHK Just to confirm, you were assigned "${SEX/ChoiceGroup/SelectedChoices}" at birth and now you describe yourself as "${GENID/ChoiceGroup/SelectedChoices}". Is that correct?

1. Yes

2. No

SEX_CORRECTION Please confirm or correct your answer to the following question: What sex were you assigned at birth, on your original birth certificate?

1. Male

2. Female

PROGRAMMER NOTE: If the response to GENCHK is ‘No’ then display SEX_CORRECTION

GENID_CORRECTION Please confirm or correct your answer to the following question: Do you currently describe yourself as male, female or transgender?

1. Male

2. Female

3. Transgender

4. Other (Please specify:__________)

PROGRAMMER NOTE: If the response to GENCHK is ‘No’ then display GENID_CORRECTION

DEM2. [FOR ALL COMPLETED LINES] Which of the following best represents how [you/they fill] think of [yourself/themselves fill]?

1. Gay or lesbian

2. Straight, that is not gay or lesbian

3. Bisexual

4. I use a different term: [write-in]

DEM3. [FOR ALL COMPLETED LINES] Are [you/they fill] of Hispanic, Latino, or Spanish origin?

1. No, not of Hispanic, Latino, or Spanish origin

2. Yes, Mexican, Mexican Am., Chicano

3. Yes, Puerto Rican

4. Yes, Cuban

5. Yes, another Hispanic, Latino, or Spanish origin – for example, Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian, etc. [Specify]

DEM4. [FOR ALL COMPLETED LINES] What is [your/their fill] race? Please select all that apply.

1. White

2. Black or African American

3. American Indian or Alaska Native

4. Native Hawaiian or Other Pacific Islander

5. Asian

DEM4a [FOR ALL COMPLETED LINES] What is [your/their fill] ancestry or ethnic origin? For example: Italian, Jamaican, African Am., Cambodian, Cape Verdean, Norwegian, Dominican, French Canadian, Haitian, Korean, Lebanese, Afro-Latino, Polish, Nigerian, Mexican, Taiwanese, Ukrainian, and so on.)

________________________________________________________

DEM13. [FOR ALL COMPLETED LINES] What is [your/their fill] marital status?

1. Now married

2. Not married but in a domestic partnership

3. Widowed

4. Divorced

5. Separated

6. Never married

DEM5. [FOR ALL COMPLETED LINES] What is the highest degree or level of school [you/they fill] have completed? Mark ONE response. If currently enrolled, mark the previous grade or highest degree received.

1. No schooling completed

2. Nursery school

3. Kindergarten

4. Grade 1 through 11 – Specify

5. 12^th grade – NO DIPLOMA

6. Regular high school diploma

7. GED or alternative credential

8. Some college credit, but less than 1 year of college credit

9. 1 or more years of college credit, no degree

10. Associate’s degree (for example: AA, AS)

11. Bachelor’s degree (for example: BA, BS)

12. Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)

13. Professional degree beyond a bachelor’s degree (for example: MD, DDS, DVM, LLB, JD)

14. Doctorate degree (for example: PhD, EdD)

[PROGRAMMER NOTE: SHIFTING TO RESPONDENT FOCUSED QUESTIONS AT THIS POINT]

DEM14. Are you or your spouse currently serving in the U.S. Armed Forces (Active Duty, Reserve, or National Guard)? Reserve and Guard members or spouses who are full-time active duty (AGR/FTS/AR) or currently “activated” should select the “Reserve or National Guard” response(s). Please [IF PHONE OR IN-PERSON: tell me] [IF WEB: select] all that apply.

1. No

2. Yes, I’m serving on active duty

3. Yes, I'm serving in the Reserve or National Guard

4. Yes, my spouse is serving on active duty

5. Yes, my spouse is serving in the Reserve or National Guard

PROGRAMMER NOTE: If “No” is selected with any other option, display error message: “You cannot select “No” with any other option. Please check and correct your answer.”

DEM8. LAST WEEK, did you do ANY work for pay? By last week, we mean the week beginning on Sunday, [STARTDATE] and ending on Saturday [ENDDATE].

1. Yes

2. No

DEM9 [IF DEM8=2] What was your main reason for not working LAST WEEK?

1. Retired

2. On layoff from a job

3. Student

4. Chronic illness or permanent disability

5. Did not need or want to work

6. Other

DEM10. [IF DEM8=1] Please review the list below and select the broad job category that best describes the kind of work you are doing at your current job.

1. Management occupations

2. Business and financial operations occupations

3. Computer and mathematical occupations

4. Architecture and engineering occupations

5. Life, physical, and social science occupations

6. Community and social service occupations

7. Legal occupations

8. Educational instruction, and library occupations

9. Arts, design, entertainment, sports, and media occupations

10. Health diagnosing and treating practitioners and other technical occupations

11. Health technologists and technicians

12. Healthcare support occupations

13. Fire fighting and prevention, and other protective service workers including supervisors

14. Law enforcement workers including supervisors

15. Food preparation and serving related occupations

16. Building and grounds cleaning and maintenance occupations

17. Personal care and service occupations

18. Sales and related occupations

19. Office and administrative support occupations

20. Farming, fishing, and forestry occupations

21. Construction and extraction occupations

22. Installation, maintenance, and repair occupations

23. Production occupations

24. Transportation occupations

25. Material moving occupations

26. Unemployed or Not Working

R12 IN THE PAST 12 MONTHS, did you (anyone in your household) receive assistance from programs such as Food Stamps or Supplemental Nutrition Assistance Program (SNAP), Women Infants and Children (WIC), Medicaid, Temporary Assistance for Needy Families (TANF), or General Assistance from a federal, state, or local agency

1. Yes

2. No

LANGUAGE (ACS)

LANG 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 Yes

2 No

LANG2 [IF LANG=1 AND QUEX_LANG=ENGLISH] What language other than English do you speak at home?

____________________________________ [Auto-Complete with list of languages]

LANG3 [IF (IF LANG=1 AND QUEX_LANG=ENGLISH) or QUEX_LANG=SPANISH] How well do you speak English?

1. Very well

2. Well

3. Not well

4. Not at all

HOUSING

R5 Is this house, apartment, or mobile home…? Select only one answer.

1. Owned by you or someone in this household with a mortgage or loan (Include home equity loans)?

2. Owned by you or someone in this household free and clear?

3. Rented?

4. Occupied without payment of rent?

TRANSIENCE

TRAN1 In the last 2 years, how many times have you moved, either temporarily or permanently? If you moved seasonally, e.g. into a college dorm each fall, count each move separately.

__________ (number of times) [RANGE: 0 – 24]

TRAN2 How long have you lived at your current address?

___ Years _____ Months [RANGE: 0 – 11]

PROGRAMMER NOTE: If Years=0 AND Months=0, display error message: “Either Years or Months must be greater than 0, they cannot both be 0.”

INTERNET ACCESS

Now, we have some questions about your access to and use of the internet.

INT1: Do you use the Internet at home? This includes accessing the Internet with a cell phone, computer, tablet, or other device.

1 Yes

2 No

INT2: [IF INT1=2] What are the reasons why you do not use the Internet at home? Please [IF PHONE OR IN-PERSON: tell me] [IF WEB: select] all that apply.

1. Don’t need it or not interested

2. Can’t afford it

3. Not worth the cost

4. Can use it elsewhere

5. Not available in area

6. No computing device, or device inadequate or broken

7. Online privacy or cybersecurity concerns

8. Personal safety concerns

9. Household moved or is in the process of moving

10. Other: ____________________________

INT3. [IF INT1=1] How frequently do you use the Internet in your home? This includes accessing the Internet through a cell phone, computer, or tablet.

1. Daily

2. At least once a week

3. At least once a month

4. Less than once a month

5. Never

INT4 [IF INT3=1|2|3|4] Which of the following devices do you usually use to access the internet? Please [IF PHONE OR IN-PERSON: tell me] [IF WEB: select] all that apply.

1. A laptop or desktop computer

2. A tablet

3. Smartphone or cell phone

4. Other device: ________________________

INT5 [IF INT3=1|2|3|4] Do you have access to the Internet using a:

Please [IF PHONE OR IN-PERSON: tell me] [IF WEB: select] all that apply.

1. Cellular data plan for a smartphone or other mobile device?

2. Broadband (high speed) Internet service such as cable, fiber optic, fixed wireless (not satellite), or DSL service installed in this household?

3. Satellite Internet service installed in this household?

4. Dial-up Internet service installed in this household?

5. Some other service? (Specify: _______________)

INT6. Overall, would you say you can access the internet whenever you need to?

1 Yes

2 No

R14 [IF NUMADULTS >= 1 and NUMSELECTED = 0] [NOTSELECTED1.] Thank you for answering our questions. Your household is not eligible to join the Census Household Panel at this time.

[ELSE END SCREENER]

[IF NUMADULTS >= 1 and NUMSELECTED = 1] Thank you for providing your information. You are eligible to participate in the Census Household Panel.

[THIS BEGINS THE BODY OF PRIOR BASELINE CONTENT – WE CAN REVISIT WHAT ITEMS NEED TO BE ABOVE OR BELOW THIS PARTITION]

DIGITAL AFFINITY

DIG1. [IF INT3=4|5] Do you regularly access the internet outside of your home?

1 Yes

2 No

DIG2a. For which of the following communication purposes have you used the internet in the past 6 months? Please [IF PHONE OR IN-PERSON: tell me] [IF WEB: select] all that apply.

1. E-mail

2. Texting or instant messaging

3. Social media (e.g., Facebook, Twitter, Instagram, LinkedIn)

4. Video or voice calls or conferencing

5. None of the above

DIG2b. For which of the following entertainment purposes have you used the internet in the past 6 months? Please select all that apply.

1. Streaming or watching videos

2. Streaming or downloading music, radio programs, or podcasts

3. Posting or uploading blog posts, videos, or other content you created

4. None of the above

DIG2c. For which of the following work purposes have you used the internet in the past 6 months? Please select all that apply.

1. Telecommute or working from home

2. Search or apply for a job

3. Online classes or job training

4. None of the above

DIG2d. For which of the following retail or service purposes have you used the internet in the past 6 months? Please select all that apply.

1. Request services provided by other people (e.g., Lyft, Uber, Airbnb, Angie’s List)

2. Advertise products or services

3. Online shopping, travel reservation, or other consumer services

4. Sell goods (e.g., Etsy, or eBay)

5. Banking, investing, or paying bills online

6. None of the above

DIG2e. For which of the following other purposes have you used the internet in the past 6 months? Please select all that apply.

1. Interact with appliances connected to the Internet, such as a thermostat, light bulb, or security system

2. Communicate with a doctor or other health professional

3. Accessing health records or health insurance records online

4. Accessing news or information

5. None of the above

PROGRAMMER NOTE: Cannot select “None of the above” in combination with other response options for DIG2a-DIG2e. If this happens, display error message: “You cannot select “None of the above” with any other option. Please check and correct your answer.””

HEALTH

Next, we have some questions about your health.

HEALTH1. In general, would you say your health is…

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

HEALTH INSURANCE

INS1. The next questions are about health insurance. Include health insurance obtained through employment or purchased directly as well as government programs like Medicare, and Medicaid that provide medical care or help pay medical bills. Are you CURRENTLY covered by any kind of health insurance or some other kind of health care plan?

1 Yes

2 No

INS2. [IF INS1 =1] Are you CURRENTLY covered by any of the following types of health insurance or health coverage plans? Mark “Yes” or “No” for EACH type of coverage.

1. Insurance through a current or former employer or union (of yours or another family member)

2. Insurance purchased directly from an insurance company (by you or another family member)

3. Medicare, for people 65 and older, or people with certain disabilities

4. Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability

5. TRICARE or other military health care

6. VA (enrolled for VA health care)

7. Indian Health Service

8. Any other type of health insurance or health coverage

[IF INS2 ‘h’ is selcected] (Please specify the other type of health insurance or health coverage: _______)

FOOD INSUFFICIENCY

FOOD1. Are you the person who does most of the shopping for food in your household? If shopping for food is split evenly between you and other household members, select “Yes.”

1 Yes

2 No

FOOD2. In the last 7 days, which of these statements best describes the food eaten in your household?

1. Enough of the kinds of food [IF HHNUMBER=1: I] [IF HHNUMBER>1: we] wanted to eat

2. Enough, but not always the kinds of food [IF HHNUMBER =1: I] [IF HHNUMBER >1: we] wanted to eat

3. Sometimes not enough to eat

4. Often not enough to eat

FOOD3. Do you or anyone in your household receive benefits from the Supplemental Nutrition Assistance Program (SNAP) or the Food Stamp Program?

1 Yes

2 No

FOOD4. The WIC program - the Women, Infants, and Children program-- provides healthy foods and other services to low-income pregnant and breastfeeding women, infants, and children up to age 5. Is anyone in your household now receiving benefits from WIC?

1 Yes

2 No

NEWS SOURCES

The next several questions will ask about your use of various media outlets, your participation in your community, and your opinion of government institutions.

NEWS1. How often do you get your news from the following sources - Never, rarely, sometimes, or often?]

	Never	Rarely	Sometimes	Often
Television	4	3	2	1
Radio
Print publications
A smartphone, computer, or tablet

VOLUNTEERING

The next questions will ask about volunteer activities you have participated in during the past year. For these questions, please include any volunteering you have done for an organization as well as any informal donations of time to help with an event or project.

VOL1 Since [CURRENT MONTH] 1st of last year, have you done any volunteer activities through or for an organization?

1 Yes

2 No

VOL2 [IF VOL1=2] Sometimes people don’t think of activities they do infrequently or activities they do for children’s schools or youth organizations as volunteer activities. Since [CURRENT MONTH] 1st of last year, have you done any of these types of volunteer activities?

1 Yes

2 No

PRIVACY AND CONFIDENTIALITY

PRIV1. In general, how concerned would you say you are about your personal privacy?

1. Extremely concerned

2. Very concerned

3. Somewhat concerned

4. A little concerned

5. Not at all concerned
   
   
   

PRIV2. What about while using the internet? How concerned are you about your privacy while you are using the internet?

1. Extremely concerned

2. Very concerned

3. Somewhat concerned

4. A little concerned

5. Not at all concerned

PRIV4. Do you think federal government agencies share a single central database of the name, address, and date of birth of U.S. residents?

1 Yes

2 No

TRUST IN GOVERNMENT

TRUST1a. Below is a list of institutions in American society. Please indicate how much confidence you, yourself, have in each one – a great deal, quite a lot, some or very little.

	A great deal	Quite a lot	Some	Very little
The military	4	3	2	1
The pólice
The U.S. Supreme Court
The presidency
Public schools
For data quality purposes, please select “Some” [ask to random half]
The criminal justice system
Congress
U.S. Census Bureau
U.S. statistical agencies

TRUST1b. Below is a list of institutions in American society. Please indicate how much confidence you, yourself, have in each one – a great deal, quite a lot, some or very little.

	A great deal	Quite a lot	Some	Very little
Small business	4	3	2	1
The church or organized religion
The medical system
Banks
Newspapers
Organized labor
Big business
News on the internet
News on social media
Television news

TRUST2. The census, the number of deaths in the U.S. by different diseases, the crime rate, and unemployment rate are examples of federal statistics produced by federal statistical agencies (like the Census Bureau and the Bureau of Labor Statistics) that are part of the federal government. Have you ever used federal statistics for study or work?

1 Yes

2 No

TRUST3. Personally, how much trust do you have in the federal statistics in the United States? Would you say that you tend to trust federal statistics or tend not to trust them?

1. Tend to trust

2. Tend not to trust

INCOME. Which category represents the total combined income of all members of your FAMILY during the past 12 months? Include as family any related individuals who currently live in the same household as you.

This includes money from jobs, net income from business, farm or rent, pensions, dividends, interest, social security payments and any other money income received by members of your FAMILY who are 15 years of age or older.

1. Less than $5,000

2. $5,000 to $7,499

3. $7,500 to $9,999

4. $10,000 to $12,499

5. $12,500 to $14,999

6. $15,000 to $19,999

7. $20,000 to $24,999

8. $25,000 to $29,999

9. $30,000 to $34,999

10. $35,000 to $39,999

11. $40,000 to $49,999

12. $50,000 to $59,999

13. $60,000 to $74,999

14. $75,000 to $99,999

15. $100,000 to $149,999

16. $150,000 and over

CONTACT

CON1a. [IF NOT MISSING EMAILFILL (SCREENER)] We usually send updates, notifications, and survey links via email. The email address we have on record for you is [EMAILFILL]. Is this the best email for us to use to reach you?

1 Yes

2 No

CON1b. [IF MISSING EMAILFILL (SCREENER)] We usually send updates, notifications, and survey links via email. Do you have an email address you can use for this purpose?

1 Yes

2 No

CON2. [IF CON1a=2 | CON1b=1] What is the best email address for us to reach you?

___________ [MAX OF 50 CHARACTERS]

CON3a. [IF NOT MISING R16_CELL PHONE (SCREENER)] We can also send updates, notifications, and survey links via text message. The cell phone number we have on record for you is [R16_CELL PHONE]. Is this the best cellphone number for us to use to reach you?

1 Yes

2 No

CON3b. [IF MISSING R16_CELL PHONE (SCREENER)] We can also send updates, notifications, and survey links via text message. Do you have a cellphone you can use for this purpose?

1 Yes

2 No

CON4. [IF CON3a=2 | CON3b=1] What is the best cellphone number for us to reach you?

_____________ [MAX 10 NUMBERS]

CON5. How would you prefer we contact you?

1. Email

2. Text message

PROGRAMMER NOTE: PROGRAM CON5 AS MULTI-SELECT.

INCENT2. [IF INCENT1 = 1 and PHONE or WEB | 2 | 4] Thank you for answering our questions and welcome to the Census Household Panel. You will receive $20 in the mail for completing this initial survey and may be eligible for $10 for each additional survey you complete. We anticipate sending panel members one survey every month for up to three years.

The address we have on file is [ADDRESSFILL]. Is this the address to which we should mail your payment?

1 Yes

2 No

INCENT3. [IF INCENT1= 1 and PHONE or WEB | 2 | 4 and INCENT2 <> YES] Please provide the mailing address to which we should send your payment.

ADDRESS NUMBER: _____________ [MAX 50 CHARACTERS]

STREET NAME: _________________[MAX 50 CHARACTERS]

APT UNIT: ________________ [MAX 30 CHARACTERS]

CITY: __________ [MAX 30 CHARACTERS]

STATE: ___________ [MAX 30 CHARACTERS]

ZIP CODE: __________ [MAX 5 DIGITS]

OUTRO. Those are all the questions we have for you today. Thank you for joining the Census Household Panel. You can find more information about the panel at this website. Xxxxxxxxx.gov. Please look out for an email or text message for your next survey invitation.

First Topical Instrument

2030 CENSUS BARRIERS, ATTITUDES AND MOTIVATORS SURVEY

WEB QUESTIONNAIRE

Contents

Intro/Definition 3

Awareness 3

Self-reported intent to participate 3

Retrospective participation 4

Census Importance 6

Motivators 7

Census Benefits/Harms 7

Census knowledge 8

Concerns 11

Undercount of Young Children 12

Ancestry 13

Media 13

Misinformation 14

Recommendations from NAC: Administrative records/Differential privacy [Frames Survey] 15

Generations 16

Disability 16

Submission 16

SURVEY NOTES

1. Within household selection:[TBD]

PROGRAMMING NOTES:

• For random half of respondents, unipolar scales appear as they are written. (C1)

• For other half, unipolar scales are all reverse order (C2)

• Respondents may skip any question. Please assign a value of “999” to any item a respondent skips.

• Do not include back buttons

• No soft prompts

• Header: U.S. Census Bureau Logo

• Footer: OMB number and expiration date

• Split ballots indicated in the programming for specific items

• Over 18 years old

/* START PAGE */

SHOW ALL:

Intro. Welcome! Thank you for participating in this survey as a member of the Census Household Panel. This survey is sponsored by the U.S. Department of Commerce’s U.S. Census Bureau and aims to inform research to improve the next census. You will receive $[TBD] for your participation in this survey.

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

• Español

Logic:

• Ask this question for all respondents

• Only one response permitted here, and respondents will be able to toggle between languages in the remainder of the survey

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Thank you for participating. Completing this 15-minute survey will help the U.S. Census Bureau plan for the 2030 Census. You will receive $XX for your participation in this survey.

We estimate that completing this voluntary survey will take 15 minutes on average. Send comments regarding this time estimate or any other aspect of this survey to [email protected].

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. Federal law protects your privacy and keeps your answers confidential (Title 13, United States Code, Section 9 and Title 5, U.S. Code, Section 552a).

This collection has been approved by the Office of Management and Budget (OMB). This eight-digit OMB approval number, 0607-XXXX, confirms this approval and expires on XX/XX/XXXX.

The uses of your data are limited to those identified in the Privacy Act System of Record Notice titled, “SORN COMMERCE/Census-5, Decennial Census Programs.”

** 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. 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). 

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Intro/Definition

SHOW ALL:

Display_Q1. The census is the count of all the people who live in the United States. It happens every 10 years. It asks how many people live in your household, their age, sex, race, and ethnicity. The last census was in 2020. [Adapted from 2020 CBAMS mindset panel]

Awareness

ASK ALL:

Qhearcensusaid. Before today, do you remember ever hearing about the census, or do you not remember hearing about it? Select only one answer. [2020 Creative testing only in EN]

1. Do remember hearing about it

2. Do not remember hearing about it

Logic:

• Only one response permitted

• If QORDER = C1 then show written order of answers choices.

• If QORDER = C2 then show reversed order of answer choices.

Self-reported intent to participate

ASK ALL:

Intent1. If the census were held today, how likely would you be to fill out the census form? Select only one answer. [2020 CBAMS and 2020 CBAMS mindset panel]

1. Extremely likely

2. Very likely

3. Somewhat likely

4. Not too likely

5. Not at all likely

Logic:

• Only one response permitted

• If QORDER = C1 then show written order of answers choices.

• If QORDER = C2 then show reversed order of answer choices.

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/* START PAGE */

Retrospective participation

Display_Q2. As you may know, the last census started around April 1^st, 2020. Please think about the 2020 Census when answering the following questions. [New]

SRParticipation2020_1. To the best of your knowledge, did you or someone else in your household respond to the 2020 Census? Select only one answer. [New]

1. Yes, I responded

2. Yes, someone else in my household responded [GO TO SRParticipation2020_2A]

3. No [GO TO NOPART1]

Logic:

• Only one response permitted

ASK if SRParticipation2020_1= 2

SRParticipation2020_2A. Do you remember who in your household responded to the 2020 Census form?

1. Spouse or partner

2. A child

3. A housemate/roommate

4. A relative [Please specify]

5. Other non-relative

6. Do not remember

Logic:

• Only one response permitted

• Age_2A sould have a drop-down menu to select the year

IntroAge_2A. Can you tell us a bit more about the person who responded?

Age_2A. What year was this person born? (if you don't know the exact year this person was born, your best guess is fine)

Gender_2A. Is this person

1. Male

2. Female

ASK if SRParticipation2020_1 =3

NOPART1. Which of the following are the TOP THREE reasons why your household did not complete the 2020 Census? Select up to three answers. [New]

/* RANDOM ROTATE OPTIONS */

1. Did not want to speak with a U.S Census Bureau enumerator

2. Did not have time or forgot to respond

3. Did not want to give out personal information

4. Do not trust the government

5. I was worried my responses could cause trouble with my living situation (e.g., increasing rent, evictions, inspections, limiting the number of people living in my place, etc.)

6. Did not get a census form

7. I rented the place where I lived and did not think I had to respond to the 2020 Census

8. Concerned about citizenship status

9. I am not a citizen and did not think I had to respond to the 2020 Census

10. Did not think my response would matter

11. Was concerned about COVID-19 (e.g., wanted to avoid interacting with people outside my household)

12. Did not know the 2020 Census was happening

13. I thought someone else at my household was going to respond

14. A census interviewer did not visit my household to encourage me to respond

15. Other [specify]

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/* START PAGE */

TrustAcc. How much trust do you have in the accuracy of the 2020 Census results? Select only one answer. [New]

1. A great deal

2. Quite a lot

3. Some

4. Very little

5. None at all

ASK if TrustAcc =1 OR 2

SPLIT SAMPLE:

TrustAcc2. Can you tell us a bit about how you came up with your answer? [New]

TrustFs. How much trust do you have in federal statistics in the United States? Select only one answer. [modified version from RoPOAR survey]

1. A great deal

2. Quite a lot

3. Some

4. Very little

5. None at all

SPLIT SAMPLE:

TrustFS2. Can you tell us a bit about how you came up with your answer? [New]

Logic:

• Only one response permitted

• If QORDER = C1 then show written order of answer choices.

• If QORDER = C2 then show reversed order of answer choices.

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Census Importance

/* START PAGE */

/* RANDOM ROTATE SERIES */

CensImp. Thinking about the census overall, how important do you feel it is for you to fill out the census form? Select only one answer. {2pac Survey]

1. Extremely important 

2. Very important 

3. Somewhat important 

4. Not too important 

5. Not at all important 

Logic:

• Only one response permitted

• If QORDER = C1 then show written order of answer choices.

• If QORDER = C2 then show reversed order of answer choices.

ASK ALL:

Personally_counted. How much, if at all, do you think it matters if you personally are counted in the census? Select only one answer. [2020 CBAMS]

1. A great deal

2. A lot

3. A moderate amount

4. A little

5. Not at all

Personally_counted2. Can you tell us a bit about how you came up with your answer?[New]

ChildM. How much, if at all, do you think it matters if CHILDREN (in your community) are counted in the census? Select only one answer.  

1. A great deal 

2. A lot 

3. A moderate amount 

4. A little 

5. Not at all 

Logic:

• Only one response permitted

• If QORDER = C1 then show written order of answer choices.

• If QORDER = C2 then show reversed order of answer choices.

/* RANDOM ROTATE SERIES */

Motivators

all_motivators_B. Which of the following are the most important reasons, to you personally, /for filling out the census form every ten years? Select all that apply. [2020 CBAMS]

1. It helps determine funding for public services in my community, like schools and fire departments

2. It determines how many elected representatives my state has in Congress

3. It is used to enforce civil rights laws

4. It provides information for my local government to plan for changes in my community

5. It shows that I am proud of my cultural heritage

6. It is my civic duty (along with voting, jury duty, paying taxes)

7. It contributes to a better future for my community

8. Other [specify]

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Census Benefits/Harms

/*Random Rotate series where 50% get harm first and 50% get benefit first. Please consider asking benefits and harms in each own page to randomize the blocks in Qualtrics/

Benefits_harms2. Do you believe that answering and submitting your census form could benefit your community? Select only one answer [Frames 2pac survey]

1. Yes [if Yes ask Benefits_harms2A]

2. No

ASK if Benefits_harms2 = 1

Benefits_harms2A. Please provide an example of a way the census could benefit your community [New].

Benefits_harms4. Do you believe that answering and submitting your census form could harm your community? Select only one answer [Frames 2pac survey]

1. Yes [if Yes ask Benefits_harms4A]

2. No

ASK if Benefits_harms4 = 1

Benefits_harms4A. Please provide an example of a way the census could harm your community [New].

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/* RANDOM ROTATE SERIES (census knowledge) */

Census knowledge

ASK ALL: The following questions are about the census in general. There is no need to look up this information. Please answer to the best of your knowledge.

/*ROTATE LIST*/[CBAMS 2020]

use1. Is the census used to decide how much money communities will get from the government, or is it not used for this? Select only one answer. [CBAMS 2020 and CBAMS mindset panel]

1. Yes, used for this

2. No, not used for this

3. Don't know

Logic:

• Only one response permitted

• Do NOT rotate answer choices

use2. Is the census used to decide how many representatives each state will have in Congress, or is it not used for this? Select only one answer. [CBAMS 2020 and CBAMS mindset panel]

1. Yes, used for this

2. No, not used for this

3. Don't know

Logic:

• Only one response permitted

• Do NOT rotate answer choices

use3. Is the census used to see what changes have taken place in the size, location, and characteristics of the people in the United States, or is it not used for this? Select only one answer. [CBAMS 2020 and CBAMS mindset panel]

1. Yes, used for this

2. No, not used

3. Don't know

Logic:

• Only one response permitted

• Do NOT rotate answer choices

use4. Is the census used to determine property taxes, or is it not used for this? Select only one answer. [CBAMS 2020 and CBAMS mindset panel]

1. Yes, used for this

2. No, not used

3. Don't know

Logic:

• Only one response permitted

• Do NOT rotate answer choices

use5. Is the census used to help the police and FBI keep track of people who break the law, or is it not used for this? Select only one answer. [CBAMS 2020 and CBAMS mindset panel]

1. Yes, used for this

2. No, not used

3. Don't know

Logic:

• Only one response permitted

• Do NOT rotate answer choices

use6. Is the census used to locate people living in the country without documentation, or is it not used for this? Select only one answer. [CBAMS 2020 and CBAMS mindset panel]

1. Yes, used for this

2. No, not used

3. Don't know

Logic:

• Only one response permitted

• Do NOT rotate answer choices

use7. Is the census used to count both citizens and non-citizens, or only citizens? Select only one answer. [CBAMS 2020 and CBAMS mindset panel]

1. Yes, used for counting both citizens and non-citizens

2. No, used only for counting citizens

3. Don't know

Logic:

• Only one response permitted

• Do NOT rotate answer choices

Use8. Is the census used to determine the rate of unemployment, or is it not used for this? Select only one answer. [CBAMS 2020 and CBAMS mindset panel]

1. Yes, used for counting both citizens and non-citizens

2. No, used only for counting citizens

3. Don't know

Logic:

• Only one response permitted

• Do NOT rotate answer choices

ChildE. Does the census count children of ALL ages, including babies and toddlers, or only     children of school age?    

1. Yes, used for counting children of ALL ages, including babies and toddlers  

2. No, used only for counting children of school age 

3. Don't know  

Logic:

• Only one response permitted

• Do NOT rotate answer choices

ChildF.  Can you tell us a bit about how you came up with your answer? [New]

legal1. Does the law require you to answer the census, or is this not required by law? Select only one answer. [CBAMS 2020 and CBAMS mindset panel]

1. Yes, required by law

2. No, not required by law

3. Don't know

Logic:

• Only one response permitted

• Do NOT rotate answer choices

legal2. Is the Census Bureau required by law to keep information confidential, or is this not required by law? Select only one answer. [CBAMS 2020 and CBAMS mindset panel]

1. Yes, required by law

2. No, not required by law

3. Don't know

Logic:

• Only one response permitted

• Do NOT rotate answer choices

Legal3. Does the U.S. Constitution require that the census be conducted, or is this not something the Constitution requires? Select only one answer. [CBAMS 2020 and CBAMS mindset panel]

1. Yes, the U.S. Constitution requires it

2. No, the U.S. Constitution does not require it

3. Don't know

Logic:

• Only one response permitted

• Do NOT rotate answer choices

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/* CONCERN BATTERY SERIES */

/* RANDOM ROTATE CONCERN1, CONCERN2, CONCERN3 CONCERN4*/

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Concerns

ASK ALL: The following questions are about the 2020 Census:

ASK ALL:

Concern4.How concerned are you, if at all, about the accuracy of 2020 Census results? Select only one answer. [New]

• Extremely concerned

• Very concerned

• Somewhat concerned

• Not too concerned

• Not at all concerned

Logic:

• Only one response permitted

• If QORDER = C1 then show written order of answer choices.

• If QORDER = C2 then show reversed order of answer choices.

Concern1. How concerned are you, if at all, that the U.S. Census Bureau will not keep answers to the 2020 Census confidential? Select only one answer. [CBAMS 2020 and CBAMS mindset panel]

• Extremely concerned

• Very concerned

• Somewhat concerned

• Not too concerned

• Not at all concerned

Logic:

• Only one response permitted

• If QORDER = C1 then show written order of answer choices.

• If QORDER = C2 then show reversed order of answer choices.

ASK ALL:

Concern3. How concerned are you, if at all, that an unauthorized person or hacker might gain access to 2020 Census responses? Select only one answer. [2PAC Survey/Adapted from 2020 CBAMS]

• Extremely concerned

• Very concerned

• Somewhat concerned

• Not too concerned

• Not at all concerned

ASK ALL:

Concern5. How concerned are you, if at all, that 2020 Census responses might be used to monitor the data of the community where you live? Select only one answer. [new]

• Extremely concerned

• Very concerned

• Somewhat concerned

• Not too concerned

• Not at all concerned

Logic:

• Only one response permitted

• If QORDER = C1 then show written order of answer choices.

• If QORDER = C2 then show reversed order of answer choices.

ASK ALL:

/* CONCERN BATTERY SERIES */

/* RANDOM ROTATE CONCERN1, CONCERN2, CONCERN3 CONCERN4*/

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Undercount of Young Children

Eleg. When does a CHILD become eligible to be included in the census? MARK ALL THAT APPLY 

1. When they are born 

2. When they start school 

3. When they get a job 

4. When they can vote 

5. When they become a citizen

6. It is up to the parents/guardians to decide 

7. Other, please specify 

•  Only one response permitted

• Do NOT rotate answer choices

 

Ancestry

Ancestry1. How important is it to you to know your family history or ancestry? [Ipsos 6/17/2021-6/20/2021]

1. Extremely important 

2. Very important 

3. Somewhat important 

4. Not too important 

5. Not at all important 

Ancestry2. Have you used census data to research your family history or ancestry? [New]

1. Yes, I have used census data

2. Yes, I have used census data from an ancestry website

3. No, I haven’t used census datafor this purpose

4. Other [Specify]

Contact preference

Media

ASK ALL:

Media1. How often do you get news from… [New]

1. Television via cable, streaming (e.g., Netflix, Hulu), satellite, or antenna

2. Radio

3. Print Publications

4. Social media sites such as Facebook, Twitter, or Instagram, NextDoor

5. Online websites, publications, articles

6. Podcasts

7. Family and friends

8. Members from my community/neighborhood

9. Chat groups in applications such as WhatsApp, Telegram and Signal

1. Never

2. Rarely

3. Sometimes

4. Often

Media2. Below is a list of different sources people get information from. Do you remember hearing about the 2020 Census from any of these sources? Select all that apply [New]

1. Television via cable, streaming (e.g., Netflix, Hulu), satellite, or antenna

2. Radio

3. Print Publications

4. Social media sites such as Facebook, Twitter, or Instagram, NextDoor

5. Online websites, publications, articles

6. Family and friends

7. Leaders from community organizations, such as churches and schools

8. State or local representatives

9. Mail from government

10. Other [specify]

IF MEDIA2 SELECTIONS > 1

Media3. Below are the information sources you selected. Please rank these sources in order of how much you trust each one of them. For example, a score of 1 means you believe it is the most trustworthy source on the list. [Repeat selections from Media2 If they selected one or more only] [New]

Misinformation

Mis4. When it comes to getting information about current events and important issues in the United States and around the world, do you think the spread of misinformation is a major problem, a minor problem or not a problem at all? Select only one answer. [I-poll. Survey by Pearson Institute. Conducted by AP-NORC Center for Public Affairs Research 09/09/2021-09/13/2021]

1. Major problem

2. Minor problem

3. Not a problem at all

Logic:

• Only one response permitted

• If QORDER = C1 then show written order of answer choices.

• If QORDER = C2 then show reversed order of answer choices.

Mis5. How often do you personally encounter misinformation? [New]

1. Often

2. Sometimes

3. Rarely

4. Never

Mis6. Where do you most often encounter misinformation? [New]

1. Friends or family

2. Newspapers

3. Television

4. Radio

5. Social Media sites such as Facebook, Twitter, or Instagram, NextDoor

6. Online websites

7. Other [Please specify]

Mis7. How often, if at all, do you verify the accuracy of information that you think might be false? [New]

1. Often

2. Sometimes

3. Rarely

4. Never

Mis8. Suppose you wanted to find out if some information that you encountered is true. Would you look to any of the following sources for information, or not? [Adapted from the 2019 World Risk Poll https://wrp.lrfoundation.org.uk/LRF_WorldRiskReport_Book.pdf]

1. Friends or family

2. Medical professionals, such as your local doctor or nurse

3. Newspapers, television or radio

4. The internet/social media

5. Information provided by a federal agency, such as a website

6. A famous person you like

7. Local religious leaders

8. Other [Please specify]

Recommendations from NAC: Administrative records/Differential privacy [Frames Survey]

Q17. Government agencies already collect data separately about people's jobs, earnings, and participation in government programs but do not always share the data across agencies.

To what extent are you in favor of or against combining these data sources? [Frames Survey]

1. Strongly in favor of it

2. Somewhat in favor of it

3. Neither in favor nor against it

4. Somewhat against it

5. Strongly against it

Q18. The Census Bureau is a government agency that is responsible for producing data about the American people and economy. The next few questions ask about the Census Bureau.

Individuals provide information to federal, state, and local agencies when applying for government programs, filing taxes, or completing surveys. The Census Bureau is planning to link this information together to produce statistics.

To what extent are you in favor of or against linking information about individuals? [Frames Survey]

1. Strongly in favor of it

2. Somewhat in favor of it

3. Neither in favor nor against it

4. Somewhat against it

5. Strongly against it

Q19. The Census Bureau is planning to use information about individuals, available from private companies, such as your contact information or age. This information would only be used to produce statistics.

To what extent are you in favor of or against the Census Bureau obtaining your information from private companies? [Frames Survey]

1. Strongly in favor of it

2. Somewhat in favor of it

3. Neither in favor nor against it

4. Somewhat against it

5. Strongly against it

Generations

SELFNAT. Were you born in the United States, on the island of Puerto Rico, another U.S. territory, or in another country? [ Adapted from 2020 Tracking Survey]

1. United States

2. Puerto Rico

3. Other U.S. territory

4. In another country

ParentG. Where were your parents or guardian born? [https://www.pewresearch.org/race-ethnicity/wp-content/uploads/sites/18/2021/07/RE_2021.07.15_State-of-Latinos_TOPLINE.pdf]

Parent1/Parent 2/Guardian 2 [Programmer will tes Qualtrics implementation options]

1. United States

2. Puerto Rico

3. Other U.S. territory

4. In another country

5. I do not know

Disability

Disability. Does anyone living in your household have any disability that keep them from participating fully in work, school, housework, or other activities? [Robert Wood Johnson Foundation/Harvard School of Public Health/NPR/SSR 2022]

1. Yes, myself

2. Yes, myself and someone in my household

3. Yes, someone in my household

4. No

5. Do not know

Submission

Page Title: Submit_Page

Section Submit Page (Submit)

Your completion of this survey marks the end of the ASK US Panel. Thank you for your participation in the pilot program.

Please click on the “Submit” button when you are finished.

Completar esta encuesta marca el final del Panel "Preguntamos a Estados Unidos". Gracias por su participación en el programa piloto.

Haga clic en el botón “Enviar” cuando termine.

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/* START PAGE */

Page Title: Thank_You_Page

Section Thank You Page (display_ThankYou)

Thank you for participating in the 2030 Census Planning Survey.

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-XXXX, expiring on XX/XX/XXXX.