Constituent Engagement Related to Use of AI

Instrument 5. Screener for participants

OMB No.: ####-####

Expiration Date: MM/DD/YYYY

Instrument 5. Screener for participants

Summer 2024

THE PAPERWORK REDUCTION ACT OF 1995

This collection of information is voluntary and will be used to provide the Administration for Children and Families with information about the use of artificial intelligence in public benefits programs. Public reporting burden for this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB number and expiration date for this collection are OMB #: ####-####, Exp: MM/DD/YYYY. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Tiffany Waits at [email protected].

This survey will take about 2 minutes and will ask you some questions about yourself. Participation is voluntary and you do not have to answer any question you are not comfortable with. You can also stop at any time. The information from these questions will help us determine your eligibility to participate in a short survey or focus group about your opinions on the use of artificial intelligence (AI).

Your name and any other identifiable information will not be reported on an individual level. Your answers to these questions will not be shared with anyone outside of the team conducting the surveys and focus groups. If you are eligible and selected to participate in the survey or focus group we will follow up with additional information about how to participate.

All

1. Which of the following best describes how you currently think of yourself?

SELECT ONE

□ Female/Woman 1

□ Male/Man 2

□ Nonbinary 3

□ I use a different term (please describe) 4

m I prefer not to answer n

all

2. What is your race and/or ethnicity?

Select all that apply

□ American Indian or Alaska Native

For example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

□ Asian

For example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.

□ Black or African American

For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.

□ Hispanic or Latino

For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.

□ Middle Eastern or North African

For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.

□ Native Hawaiian or other Pacific Islander

For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijan, Marshallese, etc.

□ White

For example, English, German, Irish, Italian, Polish, Scottish, etc.

all

3. Are you currently participating in any of the following public benefits? Public benefits are programs provided by the government to support individuals and families in need or programs aimed at improving people’s lives.

Select all that apply

□ Temporary Assistance for Needy Families (TANF)

Provides cash assistance to families with dependent children.

□ Head Start or Early Head Start

Provides childcare and preschool.

□ Low Income Home Energy Assistance Program (LIHEAP)

Helps households to reduce costs associated with home energy bills, such as heating and air conditioning, energy crises, weatherization, and minor energy-related home repairs.

□ Child Support Services

Helps ensure that children receive child support payments.

□ Supplemental Nutrition Assistance Program (SNAP)

Provides food benefits to low-income families to supplement their grocery budget to afford nutritious food for health and well-being.

□ Special Supplemental Food Program for Women, Infants, and Children (WIC)

Provides food or vouchers, education, and referred to help feed pregnant women and children up to age six.

□ Medicaid

Offers free or low-cost health benefits to adults, kids, pregnant women, seniors, and people with disabilities.

□ Supplemental Security Income Program (SSI)

Provides cash to low-income seniors, adults, and children with disabilities.

□ I participate in a public benefit not mentioned above (please describe it, providing the full name of the program and a brief description of the services provided)

________________________________________________________

□ I do not participate in any of these public benefits

ALL

4. What state do you currently live in?

5. Which of the following best describes the area where you live?

SELECT ONE

□ Large city 1

□ Small or mid-sized city 2

□ Suburbs 3

□ Semi-rural area 4

□ Rural area 5

m I prefer not to answer……………………………………………………………...n

6. What is your age group?

□ Under 18 1

□ 18 to 29 2

□ 30 to 39 3

□ 40 to 49 4

□ 50 to 59 5

□ 60 or over 6

m I prefer not to answer……………………………………………………………...n

END. Thank you. Please click SUBMIT to complete this form. We will contact you if you are eligible to participate in the survey or focus group.

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Mathematica
File Modified	0000-00-00
File Created	2025-02-17