CO9 – OMB Race and Ethnicity Cognitive Testing –
Cognitive interviewing screener
Web/Phone Survey Screener Specifications 1
Module 1: Key eligibility screener 3
Q3. Federal employment status 3
Module 2: Demographic characteristics 4
Q5. Hispanic/Latino ethnicity Web 4
Q10.1. Monolingual Spanish speaker ─ English speaking proficiency 5
Q10.2. Monolingual Spanish speaker ─ English reading proficiency 6
Q10.3. Monolingual Spanish speaker ─ English writing proficiency 6
Q10.4. Monolingual Spanish speaker ─ Multilingual family 6
Q10.5. Monolingual Spanish speaker ─ Second language 6
Module 3: Household, home ownership, and employment 7
Q13. Number of children in household 7
Module 4: Device ownership and contact info 8
RTI International, a nonprofit research organization, is conducting research on behalf of the U.S. Census Bureau to improve questions in one of its national surveys.
To determine if you are eligible for the interview, we will ask you a few screening questions about your background and your household. Eligible participants can receive $40 for completing a virtual interview. Interviews will last 60 minutes.
If you are eligible for the study, we will call or email you to schedule a time for the interview.
Your participation in the eligibility screening is completely voluntary. You may stop at any time or skip questions that you do not want to answer.
This voluntary survey is being conducted 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); COMMERCE/CENSUS-5, Decennial Census Programs; and COMMERCE/CENSUS-4, Economic Survey Collections; and COMMERCE/CENSUS-7.
We estimate that completing these screening questions will take 10 minutes on average. By law, the Census Bureau is required to keep your answers confidential. This survey is voluntary, and you may refuse to answer any question. This information collection has been approved by the Office of Management and Budget (OMB). You can validate that this survey is a legitimate using the Office of Management and Budget's approval number 0607-0725, which expires December 31, 2023. We are required to tell you this number to conduct this survey. Send comments regarding this estimate or any other aspect of this survey, including suggestions for reducing the time it takes to complete this survey to [email protected].
If you have questions about the research, you may contact RTI’s project director, Victoria Dounoucos, at 919-485-7738 or [email protected].
Consent to Participate
Do we have your permission to ask you a few questions to find out if you are eligible for this study?
If you agree to participate, please click “Yes, I agree” below and then the “NEXT” button to continue. If you choose not to participate, please click “Exit” and then the “NEXT” button to exit the survey.
1 Yes, I agree [Skip to Q1]
2 Exit [Skip to REFUSAL]
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In what city, state, and ZIP code do you currently live?
City: [______]
State: [______]
ZIP code [______]
[PROGRAMMER: CITY − TEXTBOX with 50 characters Max.; State – TEXTBOX; ZIP code − 5 digits NUMERIC ENTRY ONLY]
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In what country or territory were you born?
This information is being asked to ensure a broad range of experiences are represented in the study. Answers will be strictly kept confidential and will not be shared for any other purpose
1 In United States
2 In some other country or territory ─ please specify
Country: [______]
[PROGRAMMER: Country − TEXTBOX with 50 characters Max]
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How old are you?
[______] [If Q2<18, skip to INELIGIBLE]
[PROGRAMMER: NUMERIC ENTRY ONLY; RANGE = (6-110)]
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Are you employed by the Federal Government? (if federal contractor, mark NO)
1 Yes [skip to INELIGIBLE]
2 No
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Are you male or female?
1 Male
2 Female
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Are you of Hispanic, Latino, or Spanish origin? Please select all that apply.
1 No, not of Hispanic, Latino, or Spanish origin
2 Yes, Mexican, Mexican American., Chicano
3 Yes, Puerto Rican
4 Yes, Cuban
5 Yes, another Hispanic, Latino, or Spanish origin – Enter origin, for example, Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian, and so on:
[PROGRAMMER: WHEN 5 (“Yes, another Hispanic, Latino, or Spanish origin”) IS SELECTED, DISPLAY “please specify” TEXTBOX. Option 1 to be programmed as exclusive]
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What is your race? Please select all that apply.
1 White
2 Black or African American
3 American Indian or Alaska Native
4 Asian
5 Middle Eastern or North African
6 Native Hawaiian or other Pacific Islander
7 Some other race – please specify
[PROGRAMMER: WHEN 6 (“Other”) IS SELECTED, DISPLAY “please specify” TEXTBOX.]
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In your own words, can you tell me more about your ancestry or ethnic origins?
[_________________________________________]
[PROGRAMMER: 100 characters]
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What is the highest grade of school you have completed, or the highest degree you have received?
1 Less than high school diploma or equivalent
2 High school diploma (including GED or ABE certificate)
3 Some college, no degree
4 Associate’s degree (AA, AS, or equivalent)
5 Bachelor’s degree (BA, BS, or equivalent)
6 Post Bachelor’s degree (MA, MS, PhD, JD, MD, etc.)
7 I have not completed any formal education
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Do you speak a language other than English at home?
1 Yes [ask Q9.2]
2 No [skip to Q11]
NOTE TO OMB: Q8−Q9 will not be included in the Spanish translation of the screener.
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[IF Q8=1] What language or languages do you speak? Please select all that apply.
1 Spanish [ask Q10.1]
2 Chinese [skip to Q11]
3 Korean [skip to Q11]
4 Vietnamese [skip to Q11]
5 Arabic [skip to Q11]
6 Russian [skip to Q11]
7 Other – please specify [skip to Q11]
[PROGRAMMER: WHEN 7 (“Other”) IS SELECTED, DISPLAY “please specify” TEXTBOX.]
NOTE TO OMB: Q8−Q9 will not be included in the Spanish translation of the screener.
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¿Qué tan bien habla usted inglés?
1 Muy bien
2 Bien
3 No lo habla bien
4 No lo habla
NOTE TO OMB: Q10.1 – Q10.5. will not be included in the English screener.
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¿Qué tan bien lee usted en inglés?
1 Muy bien
2 Bien
3 No lo lee bien
4 No lo lee
NOTE TO OMB: Q10.1 – Q10.5. will not be included in the English screener.
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¿Qué tan bien escribe usted en inglés?
1 Muy bien
2 Bien
3 No lo escribe bien
4 No lo escribe
NOTE TO OMB: Q10.1 – Q10.5. will not be included in the English screener.
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En su hogar, ¿habla usted un idioma que no sea inglés?
1 Sí [ask Q10.5]
2 No [skip to Q11]
NOTE TO OMB: Q10.1 – Q10.5. will not be included in the English screener.
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[IF Q10.4=1] ¿Qué idioma o idiomas habla usted en su hogar? Seleccione uno o más idiomas
1 Español
2 Chino
3 Coreano
4 Vietnamés
5 Árabe
6 Ruso
7 Otro - Especifique
[PROGRAMMER: WHEN 7 (“Other”) IS SELECTED, DISPLAY “please specify” TEXTBOX.]
NOTE TO OMB: Q10.1 – Q10.5. will not be included in the English screener.
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Does anyone live or stay with you at your current address? Also include people who only sometimes live or stay with you.
1 Yes [ask Q12]
2 No [skip to Q13]
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[If Q11=1] How many people age 18 or older currently live or stay at your address, INCLUDING yourself?
[______] adult/adults
[PROGRAMMER: NUMERIC ENTRY ONLY; RANGE = (1-19)]
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[If Q11=1] How many people younger than 18 currently live or stay at your address?
[______] child/children
[PROGRAMMER: NUMERIC ENTRY ONLY; RANGE = (0-19)]
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We will now collect what electronic devices you own. Do you own any of the following device? Please select all that apply.
1 Smartphone
2 Desktop
3 Laptop
4 Tablet
5 None of the above
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Finally, we just have a few more questions about your contact information. If you are eligible and selected to participate in the study, we will use the information to contact you to schedule an interview.
What is your name?
[Phone prompt: read if needed to assure respondents: “The information you provide will only be used to contact you for an interview”]
Name: [________________________]
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What is your email address?
[_________________________________________]
[PROGRAMMER: email verification]
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What is the best telephone number to reach you?
Phone ([___]) [___] − [_______]
What is the best time to reach you by phone?
[_________________________________________]
[PROGRAMMER: textbox character limit: 50, place on the same page with Q22]
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Can you participate in the interview by the following ways? Please select all that apply.
1 By phone (calls only)
2 On a smartphone or tablet via videoconferencing application, such as Microsoft Teams
3 On a computer via videoconferencing application, such as Microsoft Teams
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How did you hear about this study?
1 Community publication (for example, local paper)
2 Flyer
3 Friends or family
4 RTI or Census Bureau employee
5 Craigslist
6 Facebook
7 Reddit
8 Other – specify: _______________
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Census Bureau is also interested in inviting you to participate in additional research activities.
Do we have your permission to allow additional Census Bureau staff to contact you to solicit your participation in other research activities?
1 Yes
2 No
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Thank you for taking the time to answer our questions today. We will get back to you soon if you are eligible for an interview.
Based on your responses, you are not eligible to participate in this study. Thank you for taking the time to answer our questions today.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Weimer, Belinda |
| File Modified | 0000-00-00 |
| File Created | 2025-08-12 |