Form 1 Instrument

Generic Clearance for Questionnaire Pretesting Research

Attachment G RE_Two_Page_Question_Testing_Instrument-1_African Descent Edits

Cognitive testing for the 2023 Race and Ethnicity Questions: Census Household - Addendum

OMB: 0607-0725

Document [docx]

Download: docx | pdf

R/E Two Page Question Testing Instrument

Start of Block: Start Block

Intro Thank you for agreeing to participate in this research study. On the next screen, you will be asked to begin filling out a short questionnaire. After you have filled out the questionnaire for yourself and others in your household, we will talk about your answers.

End of Block: Start Block

Start of Block: Default Question Block

Privacy Act Statement: 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, 0607-0725, confirms this approval. We are required to display this number to conduct this survey. We estimate that this survey will take about xx minutes. By proceeding with this study, you give your consent to participate in this study.

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); COMMERCE/CENSUS-5, Decennial Census Programs; and COMMERCE/CENSUS-4.

Page Break

Number in HH This questionnaire is similar to what you might receive as part of a government survey. Please answer the questions as you would if you were answering from the home where you live or stay most of the time.

1. How many people were living or staying in this house, apartment, or mobile home on April 1, 2023?

________________________________________________________________

End of Block: Default Question Block

Start of Block: Two Page R/E

P1b Name Please provide information for each person living here. Please start by listing yourself.

2. What is your name? Type your name below.

First name (1) __________________________________________________
MI (2) __________________________________________________
Last name (3) __________________________________________________

P1b Sex 3. Are you male or female?

Male (1)
Female (2)

P1b Age 4. What is your age and what is your date of birth?

Age on April 1, 2023 (1) __________________________________________________
Date of birth (mm/dd/yyyy) (2) __________________________________________________

Page Break

P1b Race Ethnicity 5. What is your race and/or ethnicity? (Help)
Select all that apply.

White For example, German, Irish, English, Italian, Polish, French, etc. (1)
Hispanic or Latino For example, Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc. (2)
Black or African American For example, People of African Descent, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. (3)
Asian For example, Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc. (4)
American Indian or Alaska Native For example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat, Tribal Government, Tlingit, etc. (5)
Middle Eastern or North African For example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, Israeli, etc. (6)
Native Hawaiian or Pacific Islander For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc. (7)

Page Break

Display This Question:

If 5. What is your race and/or ethnicity? (Help)Select all that apply. = White For example, German, Irish, English, Italian, Polish, French, etc.

P1b RE FU Intro 5a. Next, we will collect detailed information for each race or ethnicity selected.

Display This Question:

If 5. What is your race and/or ethnicity? (Help)Select all that apply. = White For example, German, Irish, English, Italian, Polish, French, etc.

P1b White detail You said that you are White. Provide details below.
Select all that apply.

German (1)
Irish (2)
English (3)
Italian (4)
Polish (5)
French (6)
Enter, for example, Scottish, Norwegian, Dutch, etc. (7) __________________________________________________

Display This Question:

If 5. What is your race and/or ethnicity? (Help)Select all that apply. = Hispanic or Latino For example, Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc.

P1b Hispanic detail You said that you are Hispanic or Latino. Provide details below.
Select all that apply.

Mexican or Mexican American (1)
Puerto Rican (2)
Cuban (3)
Salvadoran (4)
Dominican (5)
Colombian (6)
Enter, for example, Guatemalan, Spaniard, Ecuadorian, etc. (7) __________________________________________________

Display This Question:

If 5. What is your race and/or ethnicity? (Help)Select all that apply. = Black or African American For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.

P1b Black AA detail You said that you are Black or African American. Provide details below.
Select all that apply.

African American (1)
Jamaican (2)
Haitian (3)
Nigerian (4)
Ethiopian (5)
Somali (6)
Enter, for example, Ghanaian, South African, Barbadian, etc. (7) __________________________________________________

Display This Question:

If 5. What is your race and/or ethnicity? (Help)Select all that apply. = Asian For example, Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc.

P1b Asian detail You said that you are Asian. Provide details below.
Select all that apply.

Chinese (1)
Filipino (2)
Asian Indian (3)
Vietnamese (4)
Korean (5)
Japanese (6)
Enter, for example, Pakistani, Cambodian, Hmong, etc. (7) __________________________________________________

Display This Question:

If 5. What is your race and/or ethnicity? (Help)Select all that apply. = American Indian or Alaska Native For example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat, Tribal Government, Tlingit, etc.

P1b AIAN detail You said that you are American Indian or Alaska Native. Please enter, for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Tribal Government, Tlingit, etc.

________________________________________________________________

Display This Question:

If 5. What is your race and/or ethnicity? (Help)Select all that apply. = Middle Eastern or North African For example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, Israeli, etc.

P1b MENA detail You said that you are Middle Eastern or North African. Provide details below.
Select all that apply.

Lebanese (1)
Iranian (2)
Egyptian (3)
Syrian (4)
Moroccan (5)
Israeli (6)
Enter, for example, Algerian, Iraqi, Kurdish, etc. (7) __________________________________________________

Display This Question:

If 5. What is your race and/or ethnicity? (Help)Select all that apply. = Native Hawaiian or Pacific Islander For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.

P1b NHPI detail You said that you are Native Hawaiian or Pacific Islander. Provide details below.
Select all that apply.

Native Hawaiian (1)
Samoan (2)
Chamorro (3)
Tongan (4)
Fijian (5)
Marshallese (6)
Enter, for example, Palauan, Tahitian, Chuukese, etc. (7) __________________________________________________

Page Break

Display This Question:

If If This questionnaire is similar to what you might receive as part of a government survey. Please answer the questions as you would if you were answering from the home where you live or stay most of t... Text Response Is Greater Than or Equal to 2

P2b Name 6. Type name of Person 2.

First name (1) __________________________________________________
MI (2) __________________________________________________
Last name (3) __________________________________________________

Page Break

Display This Question:

P2b Relationship 7. How is ${P2b Name/ChoiceTextEntryValue/1} related to you?

Opposite-sex husband/wife/spouse (1)
Opposite-sex unmarried partner (2)
Same-sex husband/wife/spouse (3)
Same-sex unmarried partner (4)
Biological son or daughter (5)
Adopted son or daughter (6)
Stepson or stepdaughter (7)
Brother or sister (8)
Father or mother (9)
Grandchild (10)
Parent-in-law (11)
Son-in-law or daughter-in-law (12)
Other relative (13)
Roommate or housemate (14)
Foster child (15)
Other non-relative (16)

Display This Question:

P2b Sex 8. What is ${P2b Name/ChoiceTextEntryValue/1}'s sex?

Male (1)
Female (2)

Display This Question:

P2b Age 9. What is ${P2b Name/ChoiceTextEntryValue/1}'s age and date of birth?
For babies less than 1 year old, do not type the age in months. Type 0 as the age.

Age on April 1, 2023 (1) __________________________________________________
Date of birth (mm/dd/yyyy) (2) __________________________________________________

Page Break

Display This Question:

P2b Race Ethnicity 10. What is ${P2b Name/ChoiceTextEntryValue/1}'s race and/or ethnicity? (Help)
Select all that apply.

White For example, German, Irish, English, Italian, Polish, French, etc. (1)
Hispanic or Latino For example, Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc. (2)
Black or African American For example, People of African Descent, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. (3)
Asian For example, Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc. (4)
American Indian or Alaska Native For example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat, Tribal Government, Tlingit, etc. (5)
Middle Eastern or North African For example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, Israeli, etc. (6)
Native Hawaiian or Pacific Islander For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc. (7)

Page Break

Display This Question:

If If 10. What is ${q://QID24/ChoiceTextEntryValue/1}'s race and/or ethnicity? (Help) Select all that apply. q://QID53/SelectedChoicesCount Is Greater Than 0

P2b RE FU Intro 10a. Next, we will collect detailed information for each race or ethnicity selected.

Display This Question:

If 10. What is ${q://QID24/ChoiceTextEntryValue/1}'s race and/or ethnicity? (Help)Select all that ap... = White For example, German, Irish, English, Italian, Polish, French, etc.

P2b White detail You said that ${P2b Name/ChoiceTextEntryValue/1} is White. Provide details below.
Select all that apply.

German (1)
Irish (2)
English (3)
Italian (4)
Polish (5)
French (6)
Enter, for example, Scottish, Norwegian, Dutch, etc. (7) __________________________________________________

Display This Question:

If 10. What is ${q://QID24/ChoiceTextEntryValue/1}'s race and/or ethnicity? (Help)Select all that ap... = Hispanic or Latino For example, Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc.

P2b Hispanic detail You said that ${P2b Name/ChoiceTextEntryValue/1} is Hispanic or Latino. Provide details below.
Select all that apply.

Mexican or Mexican American (1)
Puerto Rican (2)
Cuban (3)
Salvadoran (4)
Dominican (5)
Colombian (6)
Enter, for example, Guatemalan, Spaniard, Ecuadorian, etc. (7) __________________________________________________

Display This Question:

If 10. What is ${q://QID24/ChoiceTextEntryValue/1}'s race and/or ethnicity? (Help)Select all that ap... = Black or African American For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.

P2b Black AA detail You said that ${P2b Name/ChoiceTextEntryValue/1} is Black or African American. Provide details below.
Select all that apply.

African American (1)
Jamaican (2)
Haitian (3)
Nigerian (4)
Ethiopian (5)
Somali (6)
Enter, for example, Ghanaian, South African, Barbadian, etc. (7) __________________________________________________

Display This Question:

If 10. What is ${q://QID24/ChoiceTextEntryValue/1}'s race and/or ethnicity? (Help)Select all that ap... = Asian For example, Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc.

P2b Asian detail You said that ${P2b Name/ChoiceTextEntryValue/1} is Asian. Provide details below.
Select all that apply.

Chinese (1)
Filipino (2)
Asian Indian (3)
Vietnamese (4)
Korean (5)
Japanese (6)
Enter, for example, Pakistani, Cambodian, Hmong, etc. (7) __________________________________________________

Display This Question:

If 10. What is ${q://QID24/ChoiceTextEntryValue/1}'s race and/or ethnicity? (Help)Select all that ap... = American Indian or Alaska Native For example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat, Tribal Government, Tlingit, etc.

P2b AIAN detail You said that ${P2b Name/ChoiceTextEntryValue/1} is American Indian or Alaska Native. Please enter, for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Tribal Government, Tlingit, etc.

________________________________________________________________

Display This Question:

If 10. What is ${q://QID24/ChoiceTextEntryValue/1}'s race and/or ethnicity? (Help)Select all that ap... = Middle Eastern or North African For example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, Israeli, etc.

P2b MENA detail You said that ${P2b Name/ChoiceTextEntryValue/1} is Middle Eastern or North African. Provide details below.
Select all that apply.

Lebanese (1)
Iranian (2)
Egyptian (3)
Syrian (4)
Moroccan (5)
Israeli (6)
Enter, for example, Algerian, Iraqi, Kurdish, etc. (7) __________________________________________________

Display This Question:

If 10. What is ${q://QID24/ChoiceTextEntryValue/1}'s race and/or ethnicity? (Help)Select all that ap... = Native Hawaiian or Pacific Islander For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.

P2b NHPI detail You said that ${P2b Name/ChoiceTextEntryValue/1} is Native Hawaiian or Pacific Islander. Provide details below.
Select all that apply.

Native Hawaiian (1)
Samoan (2)
Chamorro (3)
Tongan (4)
Fijian (5)
Marshallese (6)
Enter, for example, Palauan, Tahitian, Chuukese, etc. (7) __________________________________________________

Page Break

Display This Question:

P3b Name 11. Type name of Person 3.

First name (1) __________________________________________________
MI (2) __________________________________________________
Last name (3) __________________________________________________

Page Break

Display This Question:

P3b Relationship 12. How is ${P3b Name/ChoiceTextEntryValue/1} related to you?

Opposite-sex husband/wife/spouse (1)
Opposite-sex unmarried partner (2)
Same-sex husband/wife/spouse (3)
Same-sex unmarried partner (4)
Biological son or daughter (5)
Adopted son or daughter (6)
Stepson or stepdaughter (7)
Brother or sister (8)
Father or mother (9)
Grandchild (10)
Parent-in-law (11)
Son-in-law or daughter-in-law (12)
Other relative (13)
Roommate or housemate (14)
Foster child (15)
Other non-relative (16)

Display This Question:

P3b Sex 13. What is ${P3b Name/ChoiceTextEntryValue/1}'s sex?

Male (1)
Female (2)

Display This Question:

P3b Age 14. What is ${P3b Name/ChoiceTextEntryValue/1}'s age and date of birth?
For babies less than 1 year old, do not type the age in months. Type 0 as the age.

Age on April 1, 2023 (1) __________________________________________________
Date of birth (mm/dd/yyyy) (2) __________________________________________________

Page Break

Display This Question:

P3b Race Ethnicity 15. What is ${P3b Name/ChoiceTextEntryValue/1}'s race and/or ethnicity? (Help)
Select all that apply.

White For example, German, Irish, English, Italian, Polish, French, etc. (1)
Hispanic or Latino For example, Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc. (2)
Black or African American For example, People of African Descent, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. (3)
Asian For example, Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc. (4)
American Indian or Alaska Native For example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat, Tribal Government, Tlingit, etc. (5)
Middle Eastern or North African For example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, Israeli, etc. (6)
Native Hawaiian or Pacific Islander For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc. (7)

Page Break

Display This Question:

If If 15. What is ${q://QID28/ChoiceTextEntryValue/1}'s race and/or ethnicity? (Help) Select all that apply. q://QID62/SelectedChoicesCount Is Greater Than 0

P3b RE FU Intro 15a. Next, we will collect detailed information for each race or ethnicity selected.

Display This Question:

If 15. What is ${q://QID28/ChoiceTextEntryValue/1}'s race and/or ethnicity? (Help)Select all that ap... = White For example, German, Irish, English, Italian, Polish, French, etc.

P3b White detail You said that ${P3b Name/ChoiceTextEntryValue/1} is White. Provide details below.
Select all that apply.

German (1)
Irish (2)
English (3)
Italian (4)
Polish (5)
French (6)
Enter, for example, Scottish, Norwegian, Dutch, etc. (7) __________________________________________________

Display This Question:

If 15. What is ${q://QID28/ChoiceTextEntryValue/1}'s race and/or ethnicity? (Help)Select all that ap... = Hispanic or Latino For example, Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc.

P3b Hispanic detail You said that ${P3b Name/ChoiceTextEntryValue/1} is Hispanic or Latino. Provide details below.
Select all that apply.

Mexican or Mexican American (1)
Puerto Rican (2)
Cuban (3)
Salvadoran (4)
Dominican (5)
Colombian (6)
Enter, for example, Guatemalan, Spaniard, Ecuadorian, etc. (7) __________________________________________________

Display This Question:

If 15. What is ${q://QID28/ChoiceTextEntryValue/1}'s race and/or ethnicity? (Help)Select all that ap... = Black or African American For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.

P3b Black AA detail You said that ${P3b Name/ChoiceTextEntryValue/1} is Black or African American. Provide details below.
Select all that apply.

African American (1)
Jamaican (2)
Haitian (3)
Nigerian (4)
Ethiopian (5)
Somali (6)
Enter, for example, Ghanaian, South African, Barbadian, etc. (7) __________________________________________________

Display This Question:

If 15. What is ${q://QID28/ChoiceTextEntryValue/1}'s race and/or ethnicity? (Help)Select all that ap... = Asian For example, Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc.

P3b Asian detail You said that ${P3b Name/ChoiceTextEntryValue/1} is Asian. Provide details below.
Select all that apply.

Chinese (1)
Filipino (2)
Asian Indian (3)
Vietnamese (4)
Korean (5)
Japanese (6)
Enter, for example, Pakistani, Cambodian, Hmong, etc. (7) __________________________________________________

Display This Question:

If 15. What is ${q://QID28/ChoiceTextEntryValue/1}'s race and/or ethnicity? (Help)Select all that ap... = American Indian or Alaska Native For example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat, Tribal Government, Tlingit, etc.

P3b AIAN detail You said that ${P3b Name/ChoiceTextEntryValue/1} is American Indian or Alaska Native. Please enter, for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Tribal Government, Tlingit, etc.

________________________________________________________________

Display This Question:

If 15. What is ${q://QID28/ChoiceTextEntryValue/1}'s race and/or ethnicity? (Help)Select all that ap... = Middle Eastern or North African For example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, Israeli, etc.

P3b MENA You said that ${P3b Name/ChoiceTextEntryValue/1} is Middle Eastern or North African. Provide details below.
Select all that apply.

Lebanese (1)
Iranian (2)
Egyptian (3)
Syrian (4)
Moroccan (5)
Israeli (6)
Enter, for example, Algerian, Iraqi, Kurdish, etc. (7) __________________________________________________

Display This Question:

If 15. What is ${q://QID28/ChoiceTextEntryValue/1}'s race and/or ethnicity? (Help)Select all that ap... = Native Hawaiian or Pacific Islander For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.

P3b NHPI detail You said that ${P3b Name/ChoiceTextEntryValue/1} is Native Hawaiian or Pacific Islander. Provide details below.
Select all that apply.

Native Hawaiian (1)
Samoan (2)
Chamorro (3)
Tongan (4)
Fijian (5)
Marshallese (6)
Enter, for example, Palauan, Tahitian, Chuukese, etc. (7) __________________________________________________

Q120
Do not click NEXT until your interviewer asks and moves on to the next page with you together.

End of Block: Two Page R/E

Start of Block: Probing Screens

Q90 Thank you for your participation in our study. Please turn your attention back to your interviewer.

RE Probe
Now I'd like to review and discuss the questions. Please look at your answer to the question below.
5. What is your race and/or ethnicity? (Help)
Select all that apply.

You selected:
${P1b Race Ethnicity/ChoiceGroup/SelectedChoices}

White For example, German, Irish, English, Italian, Polish, French, etc. (1)
Hispanic or Latino For example, Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc. (2)
Black or African American For example, People of African Descent, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. (3)
Asian For example, Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc. (4)
American Indian or Alaska Native For example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat, Tribal Government, Tlingit, etc. (5)
Middle Eastern or North African For example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, Israeli, etc. (6)
Native Hawaiian or Pacific Islander For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc. (7)

Q99
Do not click NEXT until your interviewer asks and moves on to the next page with you together.

Page Break

Q98 Now please look at your answers to the questions below.

Display This Question:

If If 5. What is your race and/or ethnicity? (Help) Select all that apply. q://QID19266345/SelectedChoicesCount Is Greater Than 0

Q103 5a. Next, we will collect detailed information for each race or ethnicity selected.

Display This Question:

If 5. What is your race and/or ethnicity? (Help)Select all that apply. = White For example, German, Irish, English, Italian, Polish, French, etc.

White Probe You said that you are White. Provide details below.
Select all that apply.

You selected or entered:
${P1b White detail/ChoiceGroup/SelectedChoicesTextEntry}

German (1)
Irish (2)
English (3)
Italian (4)
Polish (5)
French (6)
Enter, for example, Scottish, Norwegian, Dutch, etc. (7) __________________________________________________

Display This Question:

Hispanic Probe You said that you are Hispanic or Latino. Provide details below.
Select all that apply.

You selected or entered:
${P1b Hispanic detail/ChoiceGroup/SelectedChoicesTextEntry}

Mexican or Mexican American (1)
Puerto Rican (2)
Cuban (3)
Salvadoran (4)
Dominican (5)
Colombian (6)
Enter, for example, Guatemalan, Spaniard, Ecuadorian, etc. (7) __________________________________________________

Display This Question:

Black AA Probe You said that you are Black or African American. Provide details below.
Select all that apply.

You selected or entered:
${P1b Black AA detail/ChoiceGroup/SelectedChoicesTextEntry}

African American (1)
Jamaican (2)
Haitian (3)
Nigerian (4)
Ethiopian (5)
Somali (6)
Enter, for example, Ghanaian, South African, Barbadian, etc. (7) __________________________________________________

Display This Question:

If 5. What is your race and/or ethnicity? (Help)Select all that apply. = Asian For example, Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc.

Asian Probe You said that you are Asian. Provide details below.
Select all that apply.

You selected or entered:
${P1b Asian detail/ChoiceGroup/SelectedChoicesTextEntry}

Chinese (1)
Filipino (2)
Asian Indian (3)
Vietnamese (4)
Korean (5)
Japanese (6)
Enter, for example, Pakistani, Cambodian, Hmong, etc. (7) __________________________________________________

Display This Question:

AIAN Probe You said that you are American Indian or Alaska Native. Please enter, for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Tribal Government, Tlingit, etc.

You entered:

________________________________________________________________

Display This Question:

MENA Probe You said that you are Middle Eastern or North African. Provide details below.
Select all that apply.

You selected or entered:
${P1b MENA detail/ChoiceGroup/SelectedChoicesTextEntry}

Lebanese (1)
Iranian (2)
Egyptian (3)
Syrian (4)
Moroccan (5)
Israeli (6)
Enter, for example, Algerian, Iraqi, Kurdish, etc. (7) __________________________________________________

Display This Question:

NHPI Probe You said that you are Native Hawaiian or Pacific Islander. Provide details below.
Select all that apply.

You selected or entered:
${P1b NHPI detail/ChoiceGroup/SelectedChoicesTextEntry}

Native Hawaiian (1)
Samoan (2)
Chamorro (3)
Tongan (4)
Fijian (5)
Marshallese (6)
Enter, for example, Palauan, Tahitian, Chuukese, etc. (7) __________________________________________________

Q105
Do not click NEXT until your interviewer asks and moves on to the next page with you together.

Page Break

Stem Probe
5. What is your race and/or ethnicity? (Help)
Select all that apply.

White For example, German, Irish, English, Italian, Polish, French, etc. (1)
Hispanic or Latino For example, Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc. (2)
Black or African American For example, People of African Descent, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. (3)
Asian For example, Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc. (4)
American Indian or Alaska Native For example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat, Tribal Government, Tlingit, etc. (5)
Middle Eastern or North African For example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, Israeli, etc. (6)
Native Hawaiian or Pacific Islander For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc. (7)

Q113
Do not click NEXT until your interviewer asks and moves on to the next page with you together.

Page Break

Display This Question:

If If 5. What is your race and/or ethnicity? (Help) Select all that apply. q://QID19266345/SelectedChoicesCount Is Greater Than 0

Q114 5a. Next, we will collect detailed information for each race or ethnicity selected.

Display This Question:

If 5. What is your race and/or ethnicity? (Help)Select all that apply. = White For example, German, Irish, English, Italian, Polish, French, etc.

Instr Probe White You said that you are White. Provide details below.
Select all that apply.

German (1)
Irish (2)
English (3)
Italian (4)
Polish (5)
French (6)
Enter, for example, Scottish, Norwegian, Dutch, etc. (7) __________________________________________________

Display This Question:

Instr Probe Hisp You said that you are Hispanic or Latino. Provide details below.
Select all that apply.

Mexican or Mexican American (1)
Puerto Rican (2)
Cuban (3)
Salvadoran (4)
Dominican (5)
Colombian (6)
Enter, for example, Guatemalan, Spaniard, Ecuadorian, etc. (7) __________________________________________________

Display This Question:

Instr Probe Black You said that you are Black or African American. Provide details below.
Select all that apply.

African American (1)
Jamaican (2)
Haitian (3)
Nigerian (4)
Ethiopian (5)
Somali (6)
Enter, for example, Ghanaian, South African, Barbadian, etc. (7) __________________________________________________

Display This Question:

If 5. What is your race and/or ethnicity? (Help)Select all that apply. = Asian For example, Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc.

Instr Probe Asian You said that you are Asian. Provide details below.
Select all that apply.

Chinese (1)
Filipino (2)
Asian Indian (3)
Vietnamese (4)
Korean (5)
Japanese (6)
Enter, for example, Pakistani, Cambodian, Hmong, etc. (7) __________________________________________________

Display This Question:

Instr Probe AIAN You said that you are American Indian or Alaska Native. Please enter, for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Tribal Government, Tlingit, etc.

________________________________________________________________

Display This Question:

Instr Probe MENA You said that you are Middle Eastern or North African. Provide details below.
Select all that apply.

Lebanese (1)
Iranian (2)
Egyptian (3)
Syrian (4)
Moroccan (5)
Israeli (6)
Enter, for example, Algerian, Iraqi, Kurdish, etc. (7) __________________________________________________

Display This Question:

Instr Probe NHPI You said that you are Native Hawaiian or Pacific Islander. Provide details below.
Select all that apply.

Native Hawaiian (1)
Samoan (2)
Chamorro (3)
Tongan (4)
Fijian (5)
Marshallese (6)
Enter, for example, Palauan, Tahitian, Chuukese, etc. (7) __________________________________________________

Q111
Do not click NEXT until your interviewer asks and moves on to the next page with you together.

Page Break

Alternate Intro TEXT TO INTRODUCE ALTERNATE OF RACE/ETHNICITY VERSION A HERE

Vertical as Alt 5. What is your race and/or ethnicity? (Help)
Select all that apply.

White For example, German, Irish, English, Italian, Polish, French, etc. (1)
German (2)
Irish (3)
English (4)
Italian (5)
Polish (6)
French (7)
Enter, for example, Scottish, Norwegian, Dutch, etc. (8) __________________________________________________
Hispanic or Latino For example, Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc. (9)
Mexican or Mexican American (10)
Puerto Rican (11)
Cuban (12)
Salvadoran (13)
Dominican (14)
Colombian (15)
Enter, for example, Guatemalan, Spaniard, Ecuadorian, etc. (16) __________________________________________________
Black or African American For example, People of African Descent, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. (17)
African American (18)
Jamaican (19)
Haitian (20)
Nigerian (21)
Ethiopian (22)
Somali (23)
Enter, for example, Ghanaian, South African, Barbadian, etc. (24) __________________________________________________
Asian For example, Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc. (25)
Chinese (26)
Filipino (27)
Asian Indian (28)
Vietnamese (29)
Korean (30)
Japanese (31)
Enter, for example, Pakistani, Cambodian, Hmong, etc. (32) __________________________________________________
American Indian or Alaska Native For example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Tribal Government, Tlingit, etc. (33) __________________________________________________
Middle Eastern or North African For example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, Israeli, etc. (34)
Lebanese (35)
Iranian (36)
Egyptian (37)
Syrian (38)
Moroccan (39)
Israeli (40)
Enter, for example, Algerian, Iraqi, Kurdish, etc. (41) __________________________________________________
Native Hawaiian or Pacific Islander For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc. (42)
Native Hawaiian (43)
Samoan (44)
Chamorro (45)
Tongan (46)
Fijian (47)
Marshallese (48)
Enter, for example, Palauan, Tahitian, Chuukese, etc. (49) __________________________________________________

Q104
Do not click NEXT until your interviewer asks and moves on to the next page with you together.

Page Break

Q102 INTRO TEXT FOR HELP PROBE TASK

Help Probe 5. What is your race and/or ethnicity? (Help)
Select all that apply.

White For example, German, Irish, English, Italian, Polish, French, etc. (1)
Hispanic or Latino For example, Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc. (2)
Black or African American For example, People of African Descent, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. (3)
Asian For example, Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc. (4)
American Indian or Alaska Native For example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat, Tribal Government, Tlingit, etc. (5)
Middle Eastern or North African For example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, Israeli, etc. (6)
Native Hawaiian or Pacific Islander For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc. (7)

Q106
Do not click NEXT until your interviewer asks and moves on to the next page with you together.

End of Block: Probing Screens

Page 24 of 24

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	R/E Two Page Question Testing Instrument
Author	Qualtrics
File Modified	0000-00-00
File Created	2025-08-12