Recruitment Screener

AHS 2025 Cognitive Testing – RECRUITMENT SCREENER

SECTION I: Introduction

The U.S. Census Bureau is conducting research to improve questions in one of its national surveys. The purpose of this research is to get feedback on how easy or difficult the survey questions are to answer. Selected participants will be asked for their thoughts and opinions about some survey questions. 

 

To determine if you are eligible for the interview, we must ask you a few screening questions about your background and your household. 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.

Privacy Act Statement:

The U.S. Census Bureau is conducting this voluntary study on behalf of the U.S. Department of Housing and Urban Development (HUD) under the authority of 12 U.S.C. Section 1701z-1, 1701z-2(g), and 1701z-10a, and 13 U.S.C. Sections 8(b).

The purpose of collecting this information is to improve the questions that will be used in the American Housing Survey and inform future surveys.

Sharing of the information provided to us may be shared for the work-related purposes in this statement as identified in the Privacy Act System of Records Notice COMMERCE/Census - 3, Demographic Survey Collection (Census Bureau Sampling Frame).

We estimate that completing these screening questions will take 5 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 federally approved information collection using the Office of Management and Budget's approval number 0607-0725, which expires December 31, 2025.  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 are eligible for the study, we will call or email you to schedule a time for the 90-minute interview which will be conducted via a secure video-conferencing app called Microsoft Teams.

 

SECTION II: Screening Survey

1. Are you 18 years or older?

• Yes

• No (Send to End Survey)

2. What is your name?

First name: _____________________

Last name: _____________________

3. What is your email address?

______________________________

4. What is the best number to reach you during the day?

Mobile ([ ]) [ ] – [ ]

Home (if not mobile) ([ ]) [ ] – [ ]

Work (if any) ([ ]) [ ] – [ ] EXT.[ ]

5. In what city, state, and ZIP code do you currently live?

City: _____________________

State: _____________________

Zip code: __________________

6. In what year were you born?

______________________________

7. Do you currently describe yourself as male, female, or transgender?

• Female

• Male

• Transgender, non-binary, or another gender

• Prefer not to answer

8. What is your race and/or ethnicity? Select all that apply.

• American Indian or Alaska Native

• Asian

• Black or African American

• Hispanic or Latino

• Middle Eastern or North African

• Native Hawaiian or Pacific Islander

• White

9. What is the highest grade of school you have completed, or the highest degree you have received?

• Less than high school

• Completed high school

• Some college, no degree

• Associate’s degree (AA/AS)

• Bachelor’s Degree (BA/BS)

• Post-Bachelor's degree (for example, MA, MS, Ph.D., JD, etc.)

• Other degree or studies (specify)________________

10. How many people aged 18 or older currently live in your household, INCLUDING yourself?

• 1

• 2

• 3

• 4

• 5

• Other (specify)________________

11. How many people younger than 18 currently live in your household?

• 0

• 1

• 2

• 3

• 4

• 5

• Other (specify)________________

12. (if Q10 >1 or if Q11 >0) Who lives or stays with you? Please select all that apply.

[ ] Parent(s)

[ ] Grandparent(s)

[ ] Husband/wife/spouse

[ ] Unmarried partner

[ ] Child(ren)

[ ] Grandchild(ren)

[ ] Other relative(s)

[ ] Roommate(s)

[ ] Friend(s)

[ ] Renter

[ ] Landlord or homeowner

[ ] Other – please specify ______________

13. What type of home do you live in? Would you say house or townhouse, apartment, or condo, manufactured/mobile home, or something else?

• House or townhouse

• Apartment or condo

• Manufactured/mobile home

• Some other type of residence (specify)________________

14. Is your home owned, rented, or occupied without payment of rent?

• Owned

• Rented

• Occupied without payment of rent

15. (If Q14. = Rented or Occupied w/o rent) Do you receive government assistance for rent payment?

• Yes

• No

16. (If Q14. = Owned) Do you currently have a mortgage or home loan on your home?

• Yes

• No

17. (If Q14. = Owned) Have you made any energy efficient home improvements in the last two years?

• Yes

• No

18. Are you knowledgeable about the insurance on the home where you currently live?

• Yes

• No

19. Does your home have another residential unit or short-term or long-term rental unit on the property?

• Yes

• No

20. (If Q19.= Yes) Is it a full-time residential unit or is it a short-term rental?

• Full-time residential unit

• Short-term rental

21. Have you moved residences within the past two years?

• Yes

• No

22. Do you live in a home that has experienced damage from a natural disaster within the past year?

• Yes

• No

23. Have you participated in any research studies with the U.S. Census Bureau?

• Yes

• No

24. (if Q23. = Yes) In what year?

____________________

25. Are you employed by the Federal Government? (If a contractor, select No)

• Yes

• No

26. Would you be willing to use a free software called Microsoft Teams to participate in an online research study?

• Yes

• No

SECTION III: End Survey

Thank you for taking time to answer the previous questions. If you qualify, someone will be back in touch within the next month to schedule an interview.

If you do not qualify for this study, we will hold on to your information and may reach out if you qualify for another study.