CO11 – CPS Core & ASEC Exploratory Qualitative Interviews, Cognitive and Usability Testing Recruitment Screener
Web Survey Screener Specifications 1
Module 1: Key eligibility screener 4
Q2. Federal employment status 4
Module 2: Demographic characteristics 5
Q5. Hispanic/Latino ethnicity Web 5
Q7.1. Internet use frequency 6
(For ASEC) Q8. Marital status 6
(For ASEC) Q8.1. Marital event in the past year 6
Module 3: Household characteristics 7
(For ASEC) Q10. Cohabitation status II 7
Q12. Number of children in household 8
(For ASEC) Q12.1. Young child (age 13 or younger) in household 8
(For ASEC) Q12.2. Young child (age between 5 and 13) in household 8
(For ASEC) Q13. Children event in the past year 8
Module 4: Health Insurance and social programs 8
(For ASEC) Q14. Health insurance coverage 8
(For ASEC) Q15. Type of health insurance 8
(For ASEC) Q16. Health insurance policy holder 9
(For ASEC) Q17. Lack of access to regular healthcare 9
(For ASEC) Q18. Social Assistance programs 9
Module 5: Employment and Income 10
Q19. Current employment status 10
Q20. Current unemployment status 10
Q23.2. Unemployment duration 11
Q25. New job in the past year (life event) 11
(FOR CPS CORE) Q28. Work Deviation 12
(FOR CPS CORE) Q29.1 Job seeking 12
(FOR CPS CORE) Q29.2 Job seeking II 12
(FOR CPS CORE) Q29.3 Job seeking III 13
(FOR CPS CORE) Q29.4 Job seeking activities 13
(For ASEC) Q30. Other income 13
Q36. Interview participation. 15
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 to participate in the research, we will ask you a few screening questions about your background and your household. Eligible participants can receive $40 for a virtual interview, which 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 Title 13 U.S. Code, Sections 131 and 182. Federal law requires that your answers are kept confidential (Title 13, U.S. Code, Section 9), and protects your privacy under the Privacy Act (Title 5 U.S. Code, Section 552a). Routine uses of these data are limited to those identified in the Privacy Act System of Record Notice titled “COMMERCE/CENSUS-5, Decennial Census Programs.” The Census Bureau can use your responses only to produce statistics and is not permitted to publicly release your responses in a way that could identify you, your business, organization, or institution.
We estimate that completing these screening questions will take 15 minutes on average. 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 XXXXX. 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, Patty LeBaron, at 312-777-5204 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]
|------------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
How old are you?
[______] [If Q2<18, skip to INELIGIBLE]
[PROGRAMMER: NUMERIC ENTRY ONLY; RANGE = (6-110)]
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
Are you employed by the Federal Government? (if federal contractor, mark NO)
1 Yes [skip to INELIGIBLE]
2 No
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
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]
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
Which of the following best describes the place where you now live?
1 A large city
2 A suburb near a large city
3 A small city
4 A small town
5 A rural area
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
What sex were you assigned at birth, on your original birth certificate?
1 Male
2 Female
4 I don’t want to answer
Do you currently describe yourself as male, female, or transgender? Please select all that apply.
1 Male
2 Female
3 Transgender
4 I use a different term: ________________________
5 I don’t want to answer
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
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]
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
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 Native Hawaiian or other Pacific Islander
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
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
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
How frequently do you use the Internet? 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 Rarely
6 Never [PROGRAMMER: CATI mode only]
Do you own a smartphone (such as an iPhone or Android) or a tablet (such as iPad, Galaxy, etc.)?
1 Yes, smartphone
2 Yes, tablet
3 Yes, smartphone and tablet
4 No, neither
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
What is your current marital status?
1 Married
2 Living with an unmarried partner
3 Widowed
4 Separated
5 Divorced
6 Never married
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
[Ask if Q8 = 1,3,4,5] In the past 12 months, did you become─ Please select all that apply.
1 Married?
2 Widowed?
3 Separated?
4 Divorced?
5 None of the above
[PROGRAMMER: Make 5 (“None of the above”) as an exclusive option.]
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
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 Q10]
2 No [skip to Q14]
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
[Ask if Q9 = Yes] Who lives or stays with you? Please select all that apply.
1 Parent(s)
2 Grandparent(s)
3 Husband/wife/spouse
4 Unmarried partner
5 Children
6 Grandchildren
7 Other relatives(s)
8 Roommates
9 Friends
10 Other – please specify
[PROGRAMMER: WHEN 10 (“Other”) IS SELECTED, DISPLAY “please specify” TEXTBOX.]
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
[If Q9=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)]
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
[If Q9=1] How many people younger than 18 currently live or stay at your address?
[______] child/children
[PROGRAMMER: NUMERIC ENTRY ONLY; RANGE = (0-19)]
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
[Ask if Q12>=1] Is any child living or staying at your address less than 5 years old?
1 Yes
2 No
[Ask if Q12>=1] Is any child living or staying at your address between 5 and 13 years of age?
1 Yes
2 No
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
[Ask if Q10 =5] In the past 12 months, did you or a partner or spouse ─
1 give birth to any children?
2 adopt any children?
3 foster any children?
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
Do you currently have health insurance?
1 Yes
2 No, I don’t have any health insurance
3 Don’t know
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
[Ask if Q14=1] What type of health insurance? Please select all that apply.
1 Insurance coverage through an employer, school, or other group-based program (through you or another family member)
2 Medicare for people 65 and over
3 Medicaid or other type of government-assistance plan for people with low incomes or disabilities
4 Coverage purchased through healthcare.gov or other state-led marketplace associated with the Affordable Care Act (also known as Obamacare)
5 TRICARE, VA healthcare, or other military health care
6 Other type of insurance – please specify
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
[Ask if Q15=1 or Q15=4 or Q15=5] Is this health insurance in your own name?
1 Yes
2 No
3 Don’t know
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
If you are sick or need to see a medical professional, where do you go? Please select all that apply.
1 Doctor’s office
2 Hospital
3 Walk-in health clinic (e.g., MinuteClinic, Patient First, Urgent Care)
4 Pharmacy
5 Other places, please specify:
6 None of the above
[PROGRAMMER: Make 6 (“None of the above”) as an exclusive option.]
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
In[FILL PREVIOUS CALENDAR YEAR], did you or someone in your household receive benefits from any of the following programs? Please select all that apply.
1 Supplemental Nutrition Assistance Program (SNAP), sometimes referred to as food stamps
2 Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
3 School Lunch Program
4 Temporary Assistance for Needy Families (TANF)
5 Energy assistance (heating/cooling)
6 Housing or rent assistance
7 Broadband or internet assistance
8 Other public assistance – please specify
9 Did not receive any of the benefits above
[PROGRAMMER: IF 8 (“Other”) IS SELECTED, DISPLAY “Please specify” TEXTBOX.]
[PROGRAMMER: Make 9 (“Did not receive any of the benefits above”) as an exclusive option.]
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
Are you currently working? Do not include time spent answering online surveys.
1 Yes, 35 or more hours per week
2 Yes, less than 35 hours per week
3 No
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
[Ask if Q19=3] Which of the following best describes you?
1 Retired
2 Unemployed or out of work
3 Unable to work due to disability
4 Other (please specify)
[PROGRAMMER: IF 4 (“Other”) IS SELECTED, DISPLAY “Please specify” TEXTBOX.]
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
[Ask if Q19=1 or 2] Do you currently work for an employer, are you self-employed, or do you have some other work arrangement?
1 I work for an employer
2 I am self-employed
3 I have another work arrangement ─ Please specify
[PROGRAMMER: IF 3 (“Other”) IS SELECTED, DISPLAY “Please specify” TEXTBOX.]
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
Were you working at any time in [FILL PREVIOUS CALENDAR YEAR]?
1 Yes
2 No
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
[Ask if Q19=3] In [FILL PREVIOUS CALENDAR YEAR], did you have any periods where you were not working?
1 Yes - I was retired for some time
2 Yes, I was unemployed or out of work for some time
3 Yes, I was unable to work due to disability for some time
4 Yes, I was not working for some other reason (please specify)
5 No
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
[Ask if (Q19= 1 or 2) OR (Q22=2)] How long were you not working in [FILL PREVIOUS CALENDAR YEAR]?
[______] months
[______] weeks
[PROGRAMMER: NUMERIC ENTRY ONLY; RANGE = (0-30)]
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
[Ask if Q19 = 1 or 2] Do you work at one job, or more than one job?
1 I work at one job
2 I work at more than one job
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
[Ask if Q19=1 or 2] Did you start your current job within the past 12 months?
1 Yes
2 No
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
[Ask if Q19=1 or 2] In [FILL PREVIOUS CALENDAR YEAR], did you do any temporary or seasonal work? For example, tour guide, summer camp counselor, crop harvester, etc.
1 Yes
2 No
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
[Ask if Q19=1 or 2] Some workers find in-person jobs or tasks (for example, delivering food or groceries or driving for a rideshare service) through companies that connect them directly with customers using a website or mobile app. Did you do any of this type of work in [FILL PREVIOUS CALENDAR YEAR]?
1 Yes
2 No
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
[Ask if Q19=1 or 2] Did you do any freelancing or consulting work in [FILL PREVIOUS CALENDAR YEAR]?
1 Yes
2 No
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
[Ask if Q19=1] From [Date 1] to [Date 2], were you on vacation, temporarily ill, on maternity/paternity leave, on jury duty, or off of work for family/personal reasons?
1 Yes
2 No
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
[Ask if Q19=2 OR Q22=2] Are you currently looking for work?
1 Yes
2 No
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
[Ask if Q29.1=2] Did you look for work within the past 12 months?
1 Yes
2 No
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
[Ask if Q29.1=2] Did you look for work within the past four weeks?
1 Yes
2 No
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
[Ask if Q29.3=1] During the LAST four weeks, have you been ACTIVELY looking for work? For example, had a job interview or filled out an application for a job.
1 Yes
2 No
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
In [FILL PREVIOUS CALENDAR YEAR], have you received income from any of the following sources? Please select all that apply.]
1 Interest and dividends earned from savings or investments
2 Retirement or pension income, including regular payments from estates, trusts, or annuities
3 Rental income
4 Commission
5 Bonus
6 Tips
7 Unemployment benefits
8 Worker compensation
9 Social Security or supplemental security income
10 TANF or other public assistance benefits
11 None of the above
[PROGRAMMER: Option 11 to be programmed as exclusive]
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
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 the interview.
What is your name?
Name: [________________________]
What is your email address?
[_________________________________________]
[PROGRAMMER: email verification]
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
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]
Could you think of any family or friends who may be interested in participating in our interview? Please provide their name and email address for us to reach out to them in the next screen.
1 Yes
2 No
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
What is the name of your family or friend?
Name: [________________________]
What is the email address of your family or friend?
[_________________________________________]
[PROGRAMMER: email verification]
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
Would you be able to participate in a [90; 60] minute virtual interview at a day/time to be determined in [MONTH]?
1 Yes
2 No
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
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: _______________
|-----------------------------------------------------------------NEXT SCREEN------------------------------------------------------------------------|
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 |