Form 1 Questionnaire

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Intro

Greetings,
Thank you for agreeing to participate in this research study. On the next
screen, you will be asked to fill out a questionnaire that will take about 10
minutes. The information you provide will contribute to valuable research at
the Census Bureau.
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. We are conducting this voluntary survey
under the authority of Title 13, United States Code, Sections 141, 182, and 193. Federal law protects your privacy
and keeps your answers confidential (Title 13, United States Code, Section 9). Per the Federal Cybersecurity
Enhancement Act of 2015, your data are protected from cybersecurity risks through screening of the systems
that transmit your data.
We estimate that completing this survey will take 10 minutes on average. 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]. This collection has been approved by the Office of Management and
Budget (OMB). This eight-digit OMB approval number, 0607-0725, confirms this approval and expires on
12/31/2025. We are required to display this number to conduct this survey. By proceeding, you give your
consent to participate in this study.
Your privacy is protected by the Privacy Act. The information provided may be shared with other Census
Bureau staff for the work-related purposes identified in this statement. For more information on this
collection, see SORN “CENSUS-3, Demographic Survey Collection (Census Bureau Sampling Frame)”  by visiting
our website at census.gov and click on "Data Protection and Privacy Policy" at the bottom of the home page.

Age
What is your age?
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Sex gender order
What sex were you assigned at birth, on your original
birth certificate?
Male
Female

Do you current describe yourself as male, female, or
transgender?
Male
Female
Transgender
None of these

Gender sex order

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Do you current describe yourself as male, female, or
transgender?
Male
Female
Transgender
None of these

What sex were you assigned at birth, on your original
birth certificate?
Male
Female

Employment - CAP and radio
Which of the following BEST describes your
employment status?
Employed for pay or income
Self-employed
Unemployed or out of work
Full-time student
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Stay at home parent
Retired
Disabled or unable to work

Employment nonbold Q CAP and radio
Which of the following BEST describes your employment
status?
Employed for pay or income
Self-employed
Unemployed or out of work
Full-time student
Stay at home parent
Retired
Disabled or unable to work

Employment - no cap and radio
Which of the following best describes your
employment status?
Employed for pay or income
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Self-employed
Unemployed or out of work
Full-time student
Stay at home parent
Retired
Disabled or unable to work

Employment nonbold Q no cap and radio
Which of the following best describes your employment
status?
Employed for pay or income
Self-employed
Unemployed or out of work
Full-time student
Stay at home parent
Retired
Disabled or unable to work

Employment CAP and checkbox

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Which of the following BEST describes your
employment status?
Employed for pay or income
Self-employed
Unemployed or out of work
Full-time student
Stay at home parent
Retired
Disabled or unable to work

Employment nonbold Q - CAP and checkbox
Which of the following BEST describes your employment
status?
Employed for pay or income
Self-employed
Unemployed or out of work
Full-time student
Stay at home parent
Retired
Disabled or unable to work

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Employment no cap and checkbox
Which of the following best describes your
employment status?
Employed for pay or income
Self-employed
Unemployed or out of work
Full-time student
Stay at home parent
Retired
Disabled or unable to work

Employment nonbold Q - no cap and checkbox
Which of the following best describes your employment
status?
Employed for pay or income
Self-employed
Unemployed or out of work
Full-time student
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Stay at home parent
Retired
Disabled or unable to work

CAPs with probes
In the PAST 12 MONTHS, did you do any work for pay?
Yes
No

During the PAST 12 MONTHS (52 weeks), how many
WEEKS did you work?
Count paid vacation, sick leave, and military service
Include weeks when you only worked for a few hours

What was your employer's MAIN BUSINESS OR
INDUSTRY; that is, what did that employer do or
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make?
If you had more than one job, think of the one you
worked for the longest.
If your employer had more than one type of business,
report the type of business primarily performed at the
location where you worked.

During the PAST 12 MONTHS, did you take any workrelated training, such as workshops or seminars?
Include conferences or professional meetings ONLY IF
you attended a training session at the conference or
meeting
Do NOT include college coursework for which you were
enrolled in a degree program
Yes
No

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Have you EVER taken courses at a community
college?
Yes
No

nonbold - CAPs with probes
In the PAST 12 MONTHS, did you do any work for pay?
Yes
No

During the PAST 12 MONTHS (52 weeks), how many
WEEKS did you work?
Count paid vacation, sick leave, and military service
Include weeks when you only worked for a few hours

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What was your employer's MAIN BUSINESS OR INDUSTRY;
that is, what did that employer do or make?
If you had more than one job, think of the one you
worked for the longest.
If your employer had more than one type of business,
report the type of business primarily performed at the
location where you worked.

During the PAST 12 MONTHS, did you take any workrelated training, such as workshops or seminars?
Include conferences or professional meetings ONLY IF
you attended a training session at the conference or
meeting
Do NOT include college coursework for which you were
enrolled in a degree program
Yes
No

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Have you EVER taken courses at a community college?
Yes
No

no caps with probes
In the past 12 months, did you do any work for pay?
Yes
No

During the past 12 months (52 weeks), how many
weeks did you work?
Count paid vacation, sick leave, and military service
Include weeks when you only worked for a few hours

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What was your employer's main business or industry;
that is, what did that employer do or make?
If you had more than one job, think of the one you
worked for the longest.
If your employer had more than one type of business,
report the type of business primarily performed at the
location where you worked.

During the past 12 months, did you take any workrelated training, such as workshops or seminars?
Include conferences or professional meetings only if
you attended a training session at the conference or
meeting
Do not include college coursework for which you were
enrolled in a degree program
Yes
No

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Have you ever taken courses at a community college?
Yes
No

nonbold Q - no caps with probes
In the past 12 months, did you do any work for pay?
Yes
No

During the past 12 months (52 weeks), how many weeks
did you work?
Count paid vacation, sick leave, and military service
Include weeks when you only worked for a few hours

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What was your employer's main business or industry;
that is, what did that employer do or make?
If you had more than one job, think of the one you
worked for the longest.
If your employer had more than one type of business,
report the type of business primarily performed at the
location where you worked.

During the past 12 months, did you take any work-related
training, such as workshops or seminars?
Include conferences or professional meetings only if
you attended a training session at the conference or
meeting
Do not include college coursework for which you were
enrolled in a degree program
Yes
No

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Have you ever taken courses at a community college?
Yes
No

1 Question - race
What is your race and/or ethnicity? (Help)
Select all that apply.
White
For example, German, Irish, English, Italian, Polish, French, etc.
German
Irish
English
Italian
Polish
French
Enter, for example, Scottish, Norwegian, Dutch, etc.
Hispanic or Latino
For example, Mexican or Mexican American, Puerto Rican, Cuban,
Salvadoran, Dominican, Colombian, etc.
Mexican or Mexican American
Puerto Rican
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Cuban
Salvadoran
Dominican
Colombian
Enter, for example, Guatemalan, Spaniard, Ecuadorian, etc.

Black or African American
For example, African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc.
African American
Jamaican
Haitian
Nigerian
Ethiopian
Somali
Enter, for example, Ghanaian, South African, Barbadian, etc.

Asian
For example, Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese,
etc.
Chinese
Filipino
Asian Indian
Vietnamese
Korean
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Japanese
Enter, for example, Pakistani, Cambodian, Hmong, etc.

American Indian or Alaska Native
For example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat Tribal Government, Tlingit, etc.

Middle Eastern or North African
For example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, Israeli, etc.
Lebanese
Iranian
Egyptian
Syrian
Moroccan
Israeli
Enter, for example, Algerian, Iraqi, Kurdish, etc.
Native Hawaiian or Pacific Islander
For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian,
Marshallese, etc.
Native Hawaiian
Samoan
Chamorro
Tongan
Fijian
Marshallese
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Enter, for example, Palauan, Tahitian, Chuukese, etc.

Where were you born?
In the United States- Select name of state.
Outside the United States- Enter name of foreign country, or Puerto Rico,
Guam, etc.

What is the highest degree or level of school you have
COMPLETED? 
If currently enrolled, select the highest degree received.
No high school diploma
High school diploma or GED
Associates degree (e.g., AA, AS) - Specify
Bachelor's degree (e.g., BS, BA, AB) - Specify
Master's degree (e.g., MS, MA, MBA) - Specify

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Doctorate (e.g., PhD, DSc, EdD) - Specify
Other professional degree (e.g., JD, LLB, MD, DDS, DVM) - Specify

Other - Specify

Did you study a language other than English in high
school? 
Yes - Enter, for example, Spanish, French
No

2 Question
What is your race and/or ethnicity? (Help)
Select all that apply.
White
For example, German, Irish, English, Italian, Polish, French, etc.
Hispanic or Latino
For example, Mexican or Mexican American, Puerto Rican, Cuban,
Salvadoran, Dominican, Colombian, etc.

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Black or African American
For example, African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc.
Asian
For example, Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese,
etc.
American Indian or Alaska Native
For example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat, Tribal Government, Tlingit, etc.
Middle Eastern or North African
For example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, Israeli, etc.
Native Hawaiian or Pacific Islander
For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian,
Marshallese, etc.

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

You said that you are White. Provide details below.
Select all that apply.
German
Irish
English
Italian
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Polish
French
Enter, for example, Scottish, Norwegian, Dutch, etc.

You said that you are Hispanic or Latino. Provide
details below.
Select all that apply.
Mexican or Mexican American
Puerto Rican
Cuban
Salvadoran
Dominican
Colombian
Enter, for example, Guatemalan, Spaniard, Ecuadorian, etc.

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

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African American
Jamaican
Haitian
Nigerian
Ethiopian
Somali
Enter, for example, Ghanaian, South African, Barbadian, etc.

You said that you are Asian. Provide details below.
Select all that apply.
Chinese
Filipino
Asian Indian
Vietnamese
Korean
Japanese
Enter, for example, Pakistani, Cambodian, Hmong, etc.

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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 said that you are Middle Eastern or North African.
Provide details below.
Select all that apply.
Lebanese
Iranian
Egyptian
Syrian
Moroccan
Israeli
Enter, for example, Algerian, Iraqi, Kurdish, etc.

You said that you are Native Hawaiian or Pacific
Islander. Provide details below.
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Select all that apply.
Native Hawaiian
Samoan
Chamorro
Tongan
Fijian
Marshallese
Enter, for example, Palauan, Tahitian, Chuukese, etc.

Where were you born?
In the United States
Outside the United States (e.g., including Puerto Rico, Guam, etc.)

In what state were you born? 

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In which country were you born?

What is the highest degree or level of school you have
COMPLETED? 
If currently enrolled, select the highest degree received.
No high school diploma
High school diploma or GED
Associates degree (e.g., AA, AS)
Bachelor's degree (e.g., BS, BA, AB)
Master's degree (e.g., MS, MA, MBA)
Doctorate (e.g., PhD, DSc, EdD)
Other professional degree (e.g., JD, LLB, MD, DDS, DVM)
Other

What type of Associate's degree do you have? 
Specify, for example, AA, AS

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What type of Bachelor's degree do you have? 
Specify, for example, BS, BA, AB

What type of Master's degree do you have? 
Specify, for example, MS, MA, MBA

What type of Doctorate do you have? 
Specify, for example, PhD, DSc, EdD

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What type of Professional degree do you have?
Specify, for example, JD, LLB, MD, DDS, DVM

Specify the degree or highest level of school you have
completed. 

Did you study a language other than English in high
school?
Yes
No

What was this language? 

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Enter, for example, Spanish, French

2 question_racenextpage
What is your race and/or ethnicity? (Help)
Select all that apply.
White
For example, German, Irish, English, Italian, Polish, French, etc.
Hispanic or Latino
For example, Mexican or Mexican American, Puerto Rican, Cuban,
Salvadoran, Dominican, Colombian, etc.
Black or African American
For example, African American, Jamaican, Haitian, Nigerian, Ethiopian,
Somali, etc.
Asian
For example, Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese,
etc.
American Indian or Alaska Native
For example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of
Barrow Inupiat, Tribal Government, Tlingit, etc.
Middle Eastern or North African
For example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, Israeli, etc.

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Native Hawaiian or Pacific Islander
For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian,
Marshallese, etc.

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

You said that you are White. Provide details below.
Select all that apply.
German
Irish
English
Italian
Polish
French
Enter, for example, Scottish, Norwegian, Dutch, etc.

You said that you are Hispanic or Latino. Provide
details below.
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Select all that apply.
Mexican or Mexican American
Puerto Rican
Cuban
Salvadoran
Dominican
Colombian
Enter, for example, Guatemalan, Spaniard, Ecuadorian, etc.

You said that you are Black or African American.
Provide details below.
Select all that apply.
African American
Jamaican
Haitian
Nigerian
Ethiopian
Somali

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Enter, for example, Ghanaian, South African, Barbadian, etc.

You said that you are Asian. Provide details below.
Select all that apply.
Chinese
Filipino
Asian Indian
Vietnamese
Korean
Japanese
Enter, for example, Pakistani, Cambodian, Hmong, etc.

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.

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You said that you are Middle Eastern or North African.
Provide details below.
Select all that apply.
Lebanese
Iranian
Egyptian
Syrian
Moroccan
Israeli
Enter, for example, Algerian, Iraqi, Kurdish, etc.

You said that you are Native Hawaiian or Pacific
Islander. Provide details below.
Select all that apply.
Native Hawaiian
Samoan
Chamorro
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Tongan
Fijian
Marshallese
Enter, for example, Palauan, Tahitian, Chuukese, etc.

Where were you born?
In the United States
Outside the United States (e.g., including Puerto Rico, Guam, etc.)

In what state were you born? 

In which country were you born?

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What is the highest degree or level of school you have
COMPLETED? 
If currently enrolled, select the highest degree received.
No high school diploma
High school diploma or GED
Associates degree (e.g., AA, AS)
Bachelor's degree (e.g., BS, BA, AB)
Master's degree (e.g., MS, MA, MBA)
Doctorate (e.g., PhD, DSc, EdD)
Other professional degree (e.g., JD, LLB, MD, DDS, DVM)
Other

What type of Associate's degree do you have? 
Specify, for example, AA, AS

What type of Bachelor's degree do you have? 
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Specify, for example, BS, BA, AB

What type of Master's degree do you have? 
Specify, for example, MS, MA, MBA

What type of Doctorate do you have? 
Specify, for example, PhD, DSc, EdD

What type of Professional degree do you have?
Specify, for example, JD, LLB, MD, DDS, DVM

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Specify the degree or highest level of school you have
completed. 

Did you study a language other than English in high
school?
Yes
No

What was this language? 
Enter, for example, Spanish, French

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White - placeholder
Please enter the following name: Jane Doe
First Name

Last Name

White blank
Please enter the following name: Jane Doe
First Name

Last Name

Grey placeholder
Please enter the following name: Jane Doe
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First Name

Last Name

Grey blank
Please enter the following name: Jane Doe
First Name

Last Name

Introduction to images
On the following pages, you will see screen images. 
Look at each image until you have figured out what you
would do next.  

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Let me know when you are finished.

Help modal - people icon

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Help circle people

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FAQ

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Login User ID with instruction

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Login User ID

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Download and Upload

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Econ dashboard

Grid with summation
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Review screen

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Review - icon children running

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Grid with lines for eye tracking
Answer the question on the next screen.  You are able to
click on the image to answer the question.

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Grid with swim lanes for eye tracking
Answer the question on the next screen.  You are able to
click on the image to answer the question.
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Powered by Qualtrics

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