2 Income Instrument

Generic Clearance for Questionnaire Pretesting Research

Attachment 7 - Income Instrument- all sections - Qs only

Cognitive Interviewing of the Annual Social and Economic Supplement (ASEC) of the Current Population Survey

OMB: 0607-0725

Document [docx]

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Income with Employment and Poverty

Survey Questions

for Cognitive Interviewing Round 1

Necessary Household Questions from CPS, needed for fills

ADDRESS: What is your current physical address?

Number and Street_____________

City___________ State___________

HOME: Are your living quarters…

Owned or being bought by you or someone in your household?
Rented for cash?
Occupied without payment of cash rent?

ROSTER1: Including yourself, what are the first names of each person who lives in your household?

ROSTER2: Enter the age and sex for each household member.

Age Sex

[Name] ____ _____

Main Questionnaire

Employment

There are no select all that apply questions. Even though boxes are used, consider these radio buttons.

Q29a. Did you do any work for pay or profit at any time during 2023, even for one day?

Yes – 1
No – 2

Q29b. Did you/^name do any temporary, part-time, or seasonal work, even for one day during 2023?

Yes – 1
No – 2

Q30. Did you/^name spend any time trying to find a job or on layoff during 2023?

Yes - 1
No - 2

Q31. How many weeks in total were you/they looking for work or on layoff in 2023?

_______ weeks

[] all weeks in 2023

Q32. What was the main reason you/^name did not work in 2023?

Temporary injury, illness, or other health concern - 1
Chronic health condition or disability - 2
Retired - 3
Pregnancy or childbirth - 4
Taking care of children or others - 5
Going to school - 6
Unable to find work - 7
On layoff - 8
Not interested in working - 9
Some other reason - 10

Q33. During 2023, how many weeks did you/^name do any work, even for a few hours? Include paid vacation and sick leave as work.

_______ weeks

[ ] all weeks in 2023

Q35. Did you/^name lose any full weeks of work in 2023 because you/they were on layoff from a job or lost a job?

Q36. Of the remaining [fill 52- minus previous answer] weeks, how many full weeks were you /^name on layoff or looking for a job?

_______ weeks

Q37. Were the [number from Q36] weeks you/they were looking for work or on layoff all in one stretch?

Q38. During the weeks you/they were not working, what was the main reason?

Temporary injury, illness, or other health concern - 1
Chronic health condition or disability - 2
Retired - 3
Pregnancy or childbirth - 4
Taking care of children or other persons - 5
Going to school - 6
Not interested in working - 7
Some other reason - 8

Q39. For how many employers did you/^name work in 2023? If you worked for more than one employer at the same time, only count it as one employer.

One
Two
Three or more

Q41. In the [fill # week/weeks form Q33] that you/^name worked, how many hours did you / they usually work per week?

______ hours

Q43. Were there one or more weeks where you/^name worked less than 35 hours?

Do not count time off with pay like holidays, vacation, or sick leave.

Yes – 1
No – 2

Q44. How many weeks did you/they work less than 35 hours?

_______ weeks

Q45. What was the main reason you / ^name worked less than 35 hours per week?

Job was part-time - 1
Seasonal work - 2
Business was slow - 3
Weather conditions - 4
Physically unable to work full time -5
Caring for family or personal obligation -7
Some other reason - 8

Q45a. Why were you/they physically unable to work full time?

Injury
Short-term illness
Chronic health condition or disability
Some other reason

Q47a. What employer did (name/you) work for the longest in 2023?

Employer name: _________

_____________________________________________________________________________

Randomize: Half of respondents get the Q47 series first (Q47e1 – Q47e1c) and half get Q48a first. Everyone should get all of the questions but we don’t want what they see first to influence their preference.

Q47e1. Which best describes {Employer Name from Q47a}?

Government - 1
Private for-profit company - 2
Non-profit organization including tax exempt and charitable organizations - 3
Self-employed - 4
Family business - 5

Q47e1a. Which one of the following best describes {Employer Name from Q47a}?

Federal - (Federal government civilian employee) - 1
Active Duty (U.S. Armed Forces or Commissioned Corps) - 2
State (including state colleges/universities) - 3
Local (county, city, township) (city or county school district) - 4

Q47e1b. Was {employer name from Q47a } incorporated?

Q47e1c. Were/Was you/ ^name the owner of {employer name from Q47a }?

Yes - 1
No - 2

Q48a. Which one of the following best describes {Employer Name from Q47a}?

Private Sector:

For-profit company or organization
Non-profit organization (including tax-exempt and charitable organizations

Government:

Local government (for example: city or county school district)
State government (including state colleges/universities)
Active Duty U.S. Armed Forces or Commissioned Corps service
Federal government civilian employee

Self-Employed or Other:

Own non-incorporated business, professional practice, or farm
Own incorporated business, professional practice, or farm
Worked without pay in a for-profit family business or farm for 15 hours or more per week

Q4788. Counting all locations where {employer name) operates, what was the total number of employees in 2023?

1- 9
10-49
50-99
100-499
500-999
1,000+ or more

Q47b. What kind of business or industry is {Employer Name from Q47a}?

Include the main activity, product, or service provided at the location where employed. (For example: elementary school, residential construction)

Kind of Business: _________

Q47b1. Is this business or organization mainly manufacturing, retail trade, wholesale trade, or something else?

Manufacturing
Retail trade
Wholesale trade
Something else

Q47c. What kind of work were you/they doing at {employer name from Q47a}?

For example: 4th grade teacher, entry-level plumber

Main Occupation: _________

Q47d1. What were your/their most important activities or duties?

For example: instruct and evaluate students and create lesson plans, assemble and install pipe sections and review building plans for work details.

Job Duties: _________

*** Proceed to Earned Income section as part of the same loop ****

If time permits, loop through a 2^nd person in the household for both Employment and Earned Income.

Income

Earned Income

Continue loop from I&O’s section – everyone who said they worked and told us their main job

Q48a_source

Select all the types of income that (^name/you) received from [fill employer] during 2023.

1 Salary or wages

2 Tips

3 Bonuses

4 Overtime pay

5 Commissions

_____________________________________________________________________________

Q48a_amount

Default screen:

Enter the total amount (^name/you) received, before taxes and other deductions, from this employer in 2023.

amount

(^earnings source

fill from Q48a_source) $____.00

[ ] I want to report monthly or in a different way.

This screen is next if respondent checked to report differently in the default screen.

Q48_per Enter the amount (^name/you) received, before taxes and other deductions, from this employer in 2023.

per Number of

amount payments

(^earnings source

fill from Q48a_source) $____.00 ___(drop down) ____________

Total earnings received in 2023:_______

If the total is not correct, please make corrections above.

_____________________________________________________________________________

Q48b_amount

Universe: respondents indicated being self-employed in I&O section

Default screen:

Enter (^name's/your) gross earnings (earnings before expenses) and expenses for {fill business name} in 2023.

Gross Earnings Expenses

$____.00 $____.00

[ ] I want to report quarterly or in a different way.

(If net earnings is positive, then display this)

(^Name/you) had a net earnings of $[fill total amount from previous questions] in 2023. If not, please verify amounts entered above and make any corrections needed.

(If net earnings is negative, then display this)

(^Name/you) had a loss of $[fill total amount from previous questions] in 2023. If not, please verify amounts entered above and make any corrections needed.

(If net earnings is 0)

(^Name/you) broke even in 2023, meaning earnings and expenses were the same. If the total is not correct, please make corrections above.

This screen is next if respondent checked to report differently in the default screen.

Enter (^name's/your) gross earnings (before expenses) and expenses for {fill business name} in 2023.

Gross Expenses per

Earnings

$____.00 $____.00 ___(drop down)

(If net earnings is positive or if both earnings and expenses entered is 0, then display this)

(^Name/you) had a net earnings of $[fill total amount from previous questions] in 2023. If not, please verify amounts entered above and make any corrections needed.

(If net earnings is negative, then display this)

(^Name/you) had a loss of $[fill total amount from previous questions] in 2023. If not, please verify amounts entered above and make any corrections needed.

(If net earnings and expenses entered are greater than 0 and are the same amount, then display this) (^Name/you) broke even in 2023, meaning earnings and expenses were the same. If not, please verify amounts entered above and make any corrections needed.

END OF I&O + EARNED INCOME LOOP

Income Sources

Unemployment Compensation (Source)

Q51A1:

Which of these unemployment benefits, if any, did (^you/anyone in this household) receive in 2023?

Select all that apply.

State or Federal unemployment compensation
Supplemental Unemployment Benefits (SUB)
Union Unemployment or Strike Benefits
None of the above

_____________________________________________________________________________

Loop through for each thing selected in Q51a1

Q51A1b:

Who received (^FILL FROM Q51A1)?

Select all that apply.

_____________________________________________________________________________

Workers Compensation (Source)

Q52A:

Which of these types of income, if any, did (^you/anyone in this household) receive as a result of a job-related injury or illness in 2023? Exclude sick pay and disability retirement.

Select all that apply.

State Worker's Compensation
Employer or employer's insurance worker’s compensation
Own insurance worker’s compensation
Other payments as a result of a job-related injury or illness
None of the above

_____________________________________________________________________________

Loop through for each thing selected in Q52a

Q52Ab:

Who received (^FILL FROM Q52A)?

Select all that apply.

_____________________________________________________________________________

Social Security (Source)

Q56a:

In 2023, did (^you/anyone in this household) receive any Social Security payments from the U.S. Government?

_____________________________________________________________________________

Q56b:

Who received Social Security payments either for themselves or as combined payments with other family members?

Select all that apply.

_____________________________________________________________________________

SSR:

What were the reasons (^name/you) (^was/were) getting Social Security in 2023?

Select all that apply.

Retired
Disabled
Widowed
Spouse
Surviving child
Dependent child

7 Other

_____________________________________________________________________________

SSCR:

What were the reasons (^Child’s name/the children) (^was/were) getting Social Security in 2023?

Select all that apply.

Disabled
Surviving child
Dependent child

4 Other

_____________________________________________________________________________

Q56g:

Which parent or guardian received these Social Security benefits on behalf of a child?

_____________________________________________________________________________

SSDIa1:

Did (^name/you) receive (^your/their) first Social Security Disability payment in 2023?

2 No

_____________________________________________________________________________

Q56f:

Is there anyone in this household, who we have not already counted, who received Social Security income in 2023 on behalf of any children in this household? Include all children under 19 years of age.

2 No

_____________________________________________________________________________

CSS:

Which children under age 19 were receiving Social Security in 2023?

Select all that apply.

_____________________________________________________________________________

CRSS:

What was the reason (^Child's name) was getting Social Security in 2023?

Select all that apply.

Disabled child
Surviving child
Dependent child

4 Other

_____________________________________________________________________________

Q56g2:

Which parent or guardian received these Social Security benefits on behalf of a child?

Select all that apply.

_____________________________________________________________________________

Supplemental Security Income (SSI) (Source)

Q57a:

In 2023, did (^you/ anyone in this household) receive any SSI payments (Supplemental Security Income)?

SSI payments are assistance payments to low-income aged, blind and disabled persons, and come from state or local welfare offices, the Federal government, or both.

2 No

_____________________________________________________________________________

Q57b:

Who received SSI (Supplemental Security Income)?

Select all that apply.

_____________________________________________________________________________

SSIR:

What were the reasons (^name/you) (^was/were) getting SSI (Supplemental Security Income) in 2023?

Select all that apply.

Disabled
Blind
On behalf of a disabled child
On behalf of a blind child

5 Other

_____________________________________________________________________________

Q57d:

Is there anyone in this household, who we have not already counted, who received Supplemental Security Income in 2023 on behalf of any children in this household?

2 No

_____________________________________________________________________________

Q57e:

Which parent or guardian received these Supplemental Security Income payments on behalf of a child?

Select all that apply.

_____________________________________________________________________________

RSSI:

What were the reasons (^name/you) (^was/were) getting Supplemental Security Income on behalf of a child in 2023?

Select all that apply.

Disabled child/children
Blind child/children

3 Other

Feedback desired from respondents:

No specific feedback desired. Only change is formatting for ISR. Note any problems in general.

_____________________________________________________________________________

CSSI:

Which children under age 19 were receiving Supplemental Security Income in 2023?

Select all that apply.

_____________________________________________________________________________

Disability Income (Source)

Q59AR:

During 2023, did (^you/anyone in the household) have a disability or health problem which prevented (^you/them) from working, even for a short time, or limited the work (^you/they) could do?

2 No

_____________________________________________________________________________

Q59b:

Who had a disability or health problem which prevented or limited their work in 2023?

Select all that apply.

_____________________________________________________________________________

Q60a:

(^Did you/Is there anyone in this household who) ever (^retire or leave/ retired or left) a job for health reasons?

2 No

_____________________________________________________________________________

Q60b:

Who retired or left a job for health reasons in 2023?

Select all that apply.

_____________________________________________________________________________

Q61C:

In 2023, which sources of income, if any, did (^you/name) receive due to a disability or health problem?

Select all that apply.

Worker’s compensation
Company or union disability
Federal government (Civil service) disability
U.S. Military retirement disability
State or local government employee disability
U.S. Railroad retirement disability
Accident or disability insurance
Black Lung miner’s disability
State temporary sickness
Other source

11 None of the above

Veterans Payments (Source)

Q60A88:

Which sources of Veteran’s (VA) payments, if any, did (^you/anyone in this household) receive in 2023? Include assistance received by children of veterans.

Select all that apply.

Service-connected disability compensation
Survivor benefits
Veterans’ pension
Educational assistance (including assistance received by children of veterans)
Other Veterans’ payments

6 None of the above

Q60b_88:

Who received the (^FILL FROM Q60A88) either for themselves or as combined payments with other family members?

Select all that apply.

Q60D88:

(^Are/Is) (^name/you) required to fill out an annual income questionnaire for the Department of Veterans’ Affairs?

2 No

Survivor Benefits (Source)

Q58a:

Which types of survivor benefits, if any, did (^anyone in this household/you) receive in 2023? Exclude Social Security and VA benefits.

Select all that apply.

Company or union survivor pension (include profit sharing)
Federal government survivor (Civil service) pension
U.S. Military retirement survivor pension
State or local government survivor pension
U.S. Railroad retirement survivor pension
Worker’s compensation survivor pension
Black Lung survivor pension
Regular payments from estates or trusts
Regular payments from annuities or paid-up insurance policies
Other type of survivor benefits

11 None of the above

Q58b:

Who received the (^FILL FROM Q58a)?

Select all that apply.

Public Assistance (Source)

Q59A88:

Which types of cash assistance, if any, did (^anyone in this household/you) receive in 2023?

Select all that apply.

(^State Program Name)/Temporary Assistance to Needy Families (TANF)/welfare/Aid to Families
General assistance
Emergency assistance/short-term cash assistance
Diversion payments
Refugee Cash and Medical Assistance program
General Assistance from Bureau of Indian Affairs, or Tribal Administered General Assistance
Some other program

8 None of the above

Q59A89:

Which types of cash assistance, if any, did (^anyone in this household/you) receive on behalf of children in the household in 2023? Do not include Food Stamps (SNAP), SSI, Energy Assistance, WIC, School meals, Childcare, and Education Assistance.

Select all that apply.

(^State Program Name)/Temporary Assistance to Needy Families (TANF)/welfare/Aid to Families
General assistance
Emergency assistance/short-term cash assistance
Diversion payments
Refugee Cash and Medical Assistance program
General Assistance from Bureau of Indian Affairs, or Tribal Administered General Assistance
Some other program
None of the above

Q59b_88:

Who received this cash assistance: {fill type of cash assistance}?

Select all that apply.

Pensions (Source)

Q62Ar:

Which types of pension income, if any, did (^anyone in this household/you) receive in 2023?

Do not include distributions or withdrawals from IRAs, 401(k)s, or similar accounts.

Select all that apply.

1 Company

2 Union

3 Federal government

4 State government

5 Local government

6 U.S. Military

7 U.S. Railroad retirement

8 Other type of pension

9 None of the above

Q62b:

Who received income from a (^FILL FROM Q62Ar) pension?

Select all that apply.

Annuities (Source)

Q96Ar:

In 2023, did (^you/ anyone in this household) receive any income from an annuity?

1 Yes

2 No

Q96Br:

Who received annuity income?

Select all that apply.

Retirement Accounts (Source)

Q97Ar:

In 2023, which types of retirement accounts, if any, did (^you/anyone in this household) have that were designated specifically for retirement savings?

Select all that apply.

1- 401(k)

2- 403(b)

3- Roth IRA

4- Regular IRA

5- KEOGH plan

6- SEP plan (Simplified Employee Pension)

7- Other type of retirement account

8- None of the above

Q97Br:

Who had a (^FILL FROM Q97Ar)?

Select all that apply.

Q98Ar:

Did (^you/NAME) withdraw any money or receive a distribution from (^your/their) (^FILL FROM Q97AR) in 2023, including any distributions (^you/they) may have been required to take?

1 Yes

2 No

Employers Pension Plan

Q74a:

Did (^the/any) employer or union that (^name/you) worked for in 2023 offer a pension plan for any of its employees?

1 Yes

2 No

Q74a2: Were/was you/name eligible to participate in the pension plan?

Yes

Q74b:

Did (^name/you) participate in the pension plan?

1 Yes

Income-Earnings Accounts Outside of Retirement (Source)

Q99Ara:

Besides retirement accounts, in 2023, which types of assets, if any, did (^you/anyone in this household) have that may have paid interest?

Select all that apply.

Interest-earning checking account
Savings account
CD (certificate of deposit)
Savings bond
Other savings or investments that pay interest
None of the above

Q99Ba:

Who had the (^FILL FROM Q99Ara)? For joint accounts, include each person.

Select all that apply.

Q99Arf:

In 2023, which types of assets did (^you/ anyone in this household) have that pay dividends?

Select all that apply.

Shares of stock in corporations
Mutual funds
Other savings or investments that pay dividends
None of the above

Q99Bf:

Who had (^FILL FROM Q99Arf)? For joint accounts, include each person.

Select all that apply.

CAPGDIS:

Did (^you/NAME) receive any capital gains from (^your/their) (^FILL FROM Q99Arf) in 2023?

1 Yes

2 No

Property Income (Source)

Q65A2:

Which types of income, if any, did (^name/you) receive in 2023?

Select all that apply.

Royalties
Rent

3 Income from roomers or boarders (exclude amounts paid by relatives)

4 Income from estates or trusts (exclude estates or trusts already reported)

5 None of the above

Q65b:

Who received the (^FILL FROM Q65A2)? For joint ownership, include each person.

Select all that apply.

Education Assistance (Source)

Q66a:

In 2023, did (^you/anyone in this household) attend school beyond the high school level including a college, university, vocational, business, or trade school?

1 Yes

2 No

NQ66bd:

Which types of educational assistance, if any, did (^anyone in this household/you) receive for tuition, fees, books, or living expenses in 2023?

Do not include VA educational benefits.

Select all that apply.

1 Pell Grant

2 Assistance from a welfare or social service office

3 Other government assistance

4 Scholarships, grants, etc.

5 Other assistance (employers, friends, etc.)

6 None of the above

Q66c:

Who received the (^FILL FROM Q66b)?

Select all that apply.

Child Support (Source)

Q70a:

In 2023, did (^you/anyone in this household) receive any child support payments?

1 Yes

2 No

Q70b:

Who received these child support payments?

Select all that apply.

Regular Financial Assistance (Source)

Q72a:

In 2023, did (^you/anyone in this household) receive (^any other/any) regular financial assistance from friends or relatives not living in this household?

Do not include amounts that must be paid back.

Q72b:

Who received this regular financial assistance?

Select all that apply.

Other Money Income (Source)

Q73A1R:

Which types of other income, if any, did (^anyone in the household/you) receive in 2023?

Select all that apply.

Alaska Permanent Fund
Foster child care
Alimony
Jury duty
Armed forces reserves
Severance pay
Hobbies
Other source
None

Q73A1b:

Who received (^FILL FROM Q73A1R)?

Select all that apply.

Income Amounts

New unemployment amount question (Q59 series):

Universe: anyone selected in Q51A1b; loop through Q59 for each person selected in Q51A1b

Q59amt -- Default screen:

For {name fill}, enter the amount of unemployment received each month and the number of payments in 2023.

Number of

amount payments

For: {fill name} each month

(^unemployment

source fill from Q51A1 $____.00 _____________

[ ] I want to report yearly or in a different way.

Q59_alt -- Alternative periodicity screen:

Enter the amount of unemployment (^name/you) received in 2023.

Amount per Number of payments

(^unemployment

source fill from Q51A1) $____.00 ___(drop down) _________

Total unemployment in 2023: _______

If the total is not correct, please make corrections above.

New workers compensation (Q52 series):

Universe: loop through this question for anyone selected in Q52Ab

Q52amt

Enter the amount of workers compensation (^name/you) received in 2023.

per Number of

amount payments

Worker’s compensation $____.00 ___(drop down) _________

Total worker’s compensation in 2023: _______

If the total is not correct, please make corrections above.

New Social Security (Q56 series):

Universe: loop for anyone selected in Q56b

Q56amt -- Default screen:

For {name fill}, enter the amount of Social Security received each month and the number of payments in 2023.

Number of

amount payments

For: {fill name} each month

Social Security $____.00 _____________

[ ] I want to report yearly or in a different way.

Q56amt_alt -- Alternative periodicity screen:

Enter the amount of Social Security (^name/you) received in 2023.

per Number of

amount payments

Social Security $____.00 ___(drop down) _________

Total Social Security in 2023: _______

If the total is not correct, please make corrections above.

New Social Security Disability (Q562 series):

Universe: SSR = 2

Q562 -- Default screen:

For {name fill}, enter the amount of Social Security Disability received each month and the number of payments in 2023.

Number of

amount payments

For: {fill name} each month

Social Security Disability $____.00 _____________

[ ] I want to report yearly or in a different way.

Q562_alt -- Alternative periodicity screen:

Enter the amount of Social Security Disability (^name/you) received in 2023.

per Number of

amount payments

Social Security Disability $____.00 ___(drop down) _________

Total Social Security Disability in 2023: _______

If the total is not correct, please make corrections above.

Universe: valid entry for either Q562 or Q562_alt

Q562d3

Is this $(total amount from Q562d) before or after any monthly Medicare deductions?

After deductions
Before deductions

Universe: Q56d3 = 1 or 2

Q562md

How much were (name’s/your) monthly Medicare deductions?

Include Medicare Advantage, Part B, and Part D premiums.

$[text].00 per month

Universe: SSDIA1 = 1

BACKPAY1

In 2023, did (name/you) receive an initial Social Security Disability payment that was larger than the usual payment that we haven’t accounted for yet?

Sometimes the initial payment is larger to make up for the delay in receiving the first payment.

BACKPAY2

How much was that initial disability payment?

$[text].00 per month

Social Security for Children (Q56i series)

Universe: anyone indicated in Q56b AND age is less than 15

Q56i -- Default screen:

For {name fill}, enter the amount of Social Security payments received each month for all children in this household and the number of payments in 2023.

Number of

amount payments

For: {fill name} each month

Social Security

for children $____.00 _____________

[ ] I want to report yearly or in a different way.

Q56i_alt -- Alternative periodicity screen:

Enter the amount of Social Security payments for all children in this household (^name/you) received in 2023.

per Number of

amount payments

Social Security

for children $____.00 ___(drop down) _________

Total Social Security for children in 2023:_______

If the total is not correct, please make corrections above.

Supplemental Security Income (SSI) (Q57c series):

Universe: Anyone indicated in Q57b

Q57c -- Default screen:

For {name fill}, enter the amount of Supplemental Security Income received each month and the number of payments in 2023.

Number of

amount payments

For: {fill name} each month

Supplemental Security Income $____.00 _____________

[ ] I want to report yearly or in a different way.

Q57c_alt -- Alternative periodicity screen:

Enter the amount of Supplemental Security Income (^name/you) received in 2023.

per Number of

amount payments

Supplemental Security Income $____.00 ___(drop down) _________

Total Supplemental Security Income in 2023: _______

If the total is not correct, please make corrections above.

Supplemental Security Income for Children (Q57i series)

Universe: anyone listed in Q57e

Enter the amount of Supplemental Security Income (^name/you) received on behalf of children in 2023.

per Number of

amount payments

Supplemental Security Income $____.00 ___(drop down) _________

Total Supplemental Security Income on behalf of children in 2023: _______

If the total is not correct, please make corrections above.

Disability Income (Q61e series)

Universe: Q61c = 1-10

Q61e –Default screen:

For {name fill}, enter the amount of disability income each month and the number of payments in 2023.

Number of

amount payments

For: {fill name} each month

(^Disability Income

Source fill from Q61c) $____.00 _____________

[ ] I want to report yearly or in a different way.

Q61e_alt -- Alternative periodicity screen:

Enter the amount of disability income (^name/you) received in 2023.

per Number of

amount payments

(^Disability Income

source fill from Q61c) $____.00 ___(drop down) _________

Total Disability Income in 2023: _______

If the total is not correct, please make corrections above.

_____________________________________________________________________________

Veterans Payments (Q60V series)

Universe: anyone selected in Q60b_88

Q60V -- Default screen:

For {name fill}, enter the amount of veterans payments received and the number of payments in 2023.

Number of

amount payments

For: {fill name} each month

(^Veterans Payments

source fill from Q60A88) $____.00 _____________

[ ] I want to report yearly or in a different way.

Q60V_alt -- Alternative periodicity screen:

Enter the amount of Veterans Payments (^name/you) received in 2023.

per Number of

amount payments

(^Veterans Payments

source fill from NQ##) $____.00 ___(drop down) _________

Total Veterans Payments in 2023: _______

If the total is not correct, please make corrections above.

Survivor Benefits (Q58E1 series)

Universe: anyone selected in Q58b

Q58E1

For {name fill}, enter the amount of Survivor Benefits received in 2023.

per Number of

amount payments

(^Survivor Benefits

source fill from Q58A) $____.00 ___(drop down) _________

Total survivor benefits in 2023: _______

If the total is not correct, please make corrections above.

Public Assistance (Q59e series):

Universe: anyone selected in Q59b_88

Q59e -- Default screen:

For {name fill}, enter the amount of cash assistance received each month and the number of payments in 2023.

Number of

amount payments

For: {fill name} each month

(^Public Assistance

source fill from Q59A88) $____.00 _____________

[ ] I want to report yearly or in a different way.

Q59e_alt -- Alternative periodicity screen:

Enter the amount of cash assistance (^name/you) received in 2023.

per Number of

amount payments

(^Public Assistance

source fill from NQ##) $____.00 ___(drop down) _________

Total cash assistance in 2023: _______

If the total is not correct, please make corrections above.

Pensions (Q62E1 series)

Universe: anyone selected in Q62B

Q62E1 -- Default screen:

For {name fill}, enter the amount of pension income received each month and the number of payments in 2023.

Number of

amount payments

For: {fill name} each month

(^Pensions

source fill from NQ##) $____.00 _____________

[ ] I want to report yearly or in a different way.

Q62E1_alt -- Alternative periodicity screen:

Enter the amount of pension income (^name/you) received in 2023.

per Number of

amount payments

(^Pensions

source fill from NQ##) $____.00 ___(drop down) _________

Total from pensions in 2023: _______

If the total is not correct, please make corrections above.

Annuities (ANNNEW1 series)

Universe: anyone indicated in Q96Br

ANNNEW1

Enter the total amount of annuity income (^name/you) received in 2023.

per Number of

amount payments

$____.00 ___(drop down) _________

Total from annuities in 2023: _______

If the total is not correct, please make corrections above.

Withdrawals/Distributions from retirement plan (DISTNEW1 series)

Universe: Anyone indicated in Q97Br

DISTNEW -- Default screen:

Enter the total amount withdrawn or distributed from (^name’s/your) retirement account in 2023.

amount

(^retirement source

fill from Q97Ar) $____.00

[ ] I want to report monthly or in a different way.

DISTNEW_alt -- Alternative periodicity screen:

Enter the total amount withdrawn or distributed from (^name's/your) retirement account(s) in 2023.

per Number of

amount payments

(^retirement

source fill from Q97Ar) $____.00 ___(drop down) _________

Total from retirement plans in 2023: _______

If the total is not correct, please make corrections above.

Universe: Anyone indicated in Q97Br

ROLLA

Did (^you/name) re-invest or "roll over" any of the money into an IRA or some other kind of retirement plan?

1 Yes

2 No

Universe: ROLLA = 1

ROLLAMTA

How much did (^you/name) re-invest or “roll over” into an IRA or some other kind of retirement plan in 2023?

Enter dollar amount $_______________

Universe: ROLLAMTA = 2

ROLLB

(^Do/Does) (^you/name) plan to re-invest or roll over any of the money?

1 Yes

2 No

ROLLAMTB

How much (^do/does) (^you/name) plan to re-invest or “roll over” into an IRA or some other kind of retirement plan?

$________________

Interest/Dividends on retirement accounts (RETIRENEW series)

Universe: Anyone indicated in Q97Br

RETIRENEW1

Default screen:

For {name fill}, enter the total amount of interest or dividends received from retirement account(s) in 2023, including small amounts reinvested or credited to the account.

amount

(^retirement source

fill from Q97Ar) $____.00

Universe: RETIRENEW1 = SKIP

RETIRENEW2:

The Census Bureau can estimate the amount earned in this account based on the size of the account. How much money was in (name’s/your) (1st account type fill-in from Q97CR/Q97DR) account at the end of 2023?

$[text].00

Contributions to Retirement Accounts (CONTRIB series)

Universe: anyone indicated in Q97Br

CONTRIB1:

Earlier you said that (^you/name) (^have/has) a retirement account, such as a 401(k), 403(b), IRA, or other account designed specifically for retirement savings. Did (^you/they) contribute any money to (^your/their) plan(s), for example, through payroll deductions? Do not include amounts reinvested or “rolled over” from other retirement accounts.

Universe: CONTRIB1 = 1

CONTRIB2:

What is the easiest way for you to tell us (^your/ name's) contribution to (^your/their) retirement account in 2023?

Percent of earnings
Annual dollar amount

Universe: CONTRIB2 = 1

CONTRIB3a:

What percent of (^your/their) earnings did (^you/they) contribute to (^your/their) account(s) in 2023?

______%

Universe: CONTRIB2 = 2

CONTRIB3b:

How much did (you/they) contribute to (your/their) account(s) in 2023?

$_____.00

Interest/Dividends on non-retirement accounts (Q63/NONRETIRENEW series)

Universe: anyone indicated in Q99Ba

Q63cp -- Default screen:

Enter the amount (^name/you) received in interests and dividends in 2023, including small amounts reinvested or credited to the account.

amount

(^fill from Q99AR

or Q99BR) $____.00

[ ] I want to report monthly or in a different way.

Q63cp_alt -- Alternative periodicity screen:

Enter the amount (^name/you) received in interests and dividends in 2023, including small amounts reinvested or credited to the account.

per Number of

amount payments

(^fill from Q99AR or Q99BR) $____.00 ___(drop down) _________

Total interests or dividends from non-retirement accounts in 2023: _______

If the total is not correct, please make corrections above.

NONRETIRENEW12:

Universe: Q99Ara = 1 and Q63cp = SKIP OR Q63cp_alt = SKIP

The Census Bureau can estimate the amount earned in this account based on the size of the account. How much money did (you/name) have in checking accounts at the end of 2023?

$[text].00

Property Income (Q65 series)

Universe: Q65A2 = 1 AND anyone indicated in Q65b

Q65c -- Default screen:

Enter the total amount (^name/you) received for rental income during 2023, after expenses. If there was a loss, enter the amount of that loss and select “Loss.”

amount

Rental income $____.00 □ Loss

Q65d --Default screen:

Enter the total amount (^name/you) received in 2023.

amount

(^fill from

Q65A2) $____.00

[ ] I want to report monthly or in a different way.

Q65d_alt -- Alternative periodicity screen:

Enter) the amount (^name/you) received in 2023.

per Number of

amount payments

(^fill from Q65A2 ) $____.00 ___(drop down) _________

Total from (^fill from Q65A2 ) in 2023: _______

If the total is not correct, please make corrections above.

Educational Assistance

Universe: NQ66BD = 1-5

NQ669D:

Default screen:

Enter the total amount of educational assistance (^name/you) received in 2023.

amount

(^fill from NQ66bd) $____.00

[ ] I want to report monthly or in a different way.

Alternative periodicity screen:

NQ669G:

Enter the amount of educational assistance (^name/you) received in 2023.

per Number of

amount payments

(^Fill from NQ66bd) $____.00 ___(drop down) _________

Total educational assistance in 2023: _______

If the total is not correct, please make corrections above.

Child Support

Universe: anyone selected in Q70b

Q70cp:

Enter the amount of child support payments (^name/you) received in 2023.

per Number of

amount payments

$____.00 ___(drop down) _________

Total in 2023 for child support _______

If the total is not correct, please make corrections above.

Regular Financial Assistance:

Universe: anyone selected in Q72b

Q72cp:

Enter the amount of regular financial assistance (^name/you) received from friends or relatives during 2023.

per Number of

amount payments

$____.00 ___(drop down) _________

Total regular financial assistance in 2023: _______

If the total is not correct, please make corrections above.

Other Money Income

Universe: anyone selected in Q73A1b

Q731P:

Enter the amount of other income (^name/you) received in 2023.

per Number of

amount payments

(^source fill Q731Arc1) $____.00 ___(drop down) _________

Total other income received in 2023: _______

If the total is not correct, please make corrections above.

Poverty

Housing

MORT_YN:

Which of these loans do you have on this property?

Select all that apply.

1- Mortgage or similar

2- Second Mortgage

3- Home Equity Loan

4- None

_____________________________________________________________________________

NUMROOMS:

How many separate bedrooms do your living quarters contain?

Count as bedrooms those rooms you would list if these living quarters were for sale or rent. If this is an efficiency/studio apartment, enter 0.

[Text entry, whole digits]

_____________________________________________________________________________

Food Assistance

SNAP_YN:

At any time during 2023, even for one month, did (you/anyone in this household) receive benefits from SNAP (the Supplemental Nutritional Assistance Program), the Food Stamp program, (state program fill,/blank) or use a SNAP or food stamp benefit card?

Do not include WIC.

1- Yes

2- No

_____________________________________________________________________________

SNAP_ROST:

Who received SNAP[, (state program fill) benefits,] or foods stamps at any time in 2023?

Select all that Apply

[Names from household roster]

_____________________________________________________________________________

SNAP_AMT:

What was the value of SNAP [,(state program fill) benefits,] or food stamps received in 2023 for the entire household?

$[text].00 per [periodicity dropdown—month, year]

SNAP_FREQ:

How many monthly SNAP[, state program fill,] or food stamp payments were received in 2023?

(Amount fill from SNAP_AMT) for ____(text box 2 digits <13) months

_____________________________________________________________________________

SNAP_CHK:

Your total SNAP[, state program fill,] or food stamp payments was $[fill from SNAP_AMT * SNAP_FREQ]. Does that look right to you?

1 Yes

2 No, I need to correct something.

_____________________________________________________________________________

SNAP_RNG:

If you don't know the exact value, please estimate.

What was the value of SNAP[,(state program fill) benefits.,] or food stamps received in 2023 for the entire household?

1 $0 to $999

2 $1,000 to $2,999

3 $3,000 or more

_____________________________________________________________________________

SNAP_RNG2:

Was it…?

1 $0 to $99

2 $100 to $499

3 $500 or more

School Meals

SMEAL_YN:

During 2023, did any of the children in this household usually eat a complete breakfast and/or lunch provided by the school?

_____________________________________________________________________________

SMEAL_ROST:

For each child, please indicate which school-provided meals they usually ate in 2023.

Select all that apply.

_____________________________________________________________________________

SUBMEAL_YN:

During 2023, did [any of these children/this child] receive free or reduced price school meals?

_____________________________________________________________________________

SUBMEAL_ROST:

For each child, please indicate which school-provided meals were free or reduced price in 2023.

Select all that apply.

_____________________________________________________________________________

Non-Cash Benefits

NCREC:

At any time during 2023, even for one month, did (you/anyone in this household) receive any of the following?

_____________________________________________________________________________

WIC_ROST:

Who were the WIC benefits for?

Select all that apply.

Roster names (children under 6, women between 15 and 45)

_____________________________________________________________________________

WIC_MNTH:

For how many months was WIC received in 2023?

_____________________________________________________________________________

ENG_ASST:

During 2023, how much [fill from NCREC--energy assistance/heating or cooling assistance/energy, heating, and cooling assistance] was received for the entire year?

$[text].00

_____________________________________________________________________________

ENG_RNG:

If you don’t know the exact value, please estimate.

During 2023, how much energy assistance was received for the entire year?

1 $0 to $999

2 $1,000 to $2,999

3 $3,000 or more

_____________________________________________________________________________

ENG_RNG2:

Was it…?

1 $0 to $99

2 $100 to $499

3 $500 or more

_____________________________________________________________________________

Child Care

CHCARE_PAID:

Which type(s) of paid care were used for [CHILD] in 2023?

Select all that apply.

Child care center/preschool/nursery school
Home-based child care provider/paid care in provider’s home
Paid care inside of your home (e.g., nanny/babysitter)
Paid care with family, friends, or neighbors
Before and/or after-school care
Summer camps
Other
None, did not pay for child care

_____________________________________________________________________________

CHCARE_UNPAID:

Which types of free child care were used for [CHILD] in 2023?

Select all that apply

Care by a parent/guardian at home
Head Start
Pre-Kindergarten
Free care with family, friends, or neighbors
Fully-subsidized child care through subsidy or voucher
Other
None

_____________________________________________________________________________

CHCARE_MAIN:

What was the main type of child care received by [CHILD] in 2023?

List of options (aside from 8 on CHCARE_PAID) selected on CHCARE_PAID and CHCARE_UNPAID

_____________________________________________________________________________

CHCARE_AMT:

Across all types of child care, how much was paid for each child in 2023?

_____________________________________________________________________________

CHCARE_FREQ:

How many payments for child care were made in 2023?

_____________________________________________________________________________

CHCARE_CHK:

Does the total cost of child care for 2023 look correct to you?

_____________________________________________________________________________

CHCARE_SUB:

Was/were the child's/children's care fully or partially covered by a voucher or child care subsidy?

__________________________________________________________________________

CHCARE_PROB:

Did [you / anyone in this household] have to work fewer hours in 2023 because of problems obtaining child care?

__________________________________________________________________________

CHCARE_PROBTIME:

Considering all of your/the children, how much time did you/others in the household lose from work in 2023 because of trouble finding child care?

[text] [Periodicity dropdown—hours, days, weeks]

__________________________________________________________________________

CHCARE_ADAPT:

During 2023, did you [or anyone in the household] take any of the actions below in order to care for your [child/children] because child care was closed, unavailable, or unaffordable, or you were concerned for your [child’s/children’s] safety in care?

Select all that apply.

Took unpaid leave
Used vacation, sick days, or other paid leave
Cut your work hours
Quit a job
Were fired from a job
Did not look for a job
Supervised one or more children while working
Other (specify)
None of the above

__________________________________________________________________________

Child Support

AWAY_KIDS:

Did (you/anyone in this household) have any children living elsewhere with their other parent or guardian during 2023?

Yes No

[Adult 1]

[Adult 2]

[Adult N]

_____________________________________________________________________________

CHSUP_ROST:

In 2023, did (you/anyone in this household) pay any child support for children living elsewhere?

_____________________________________________________________________________

CHSUP_AMT:

How much child support was paid in 2023?

_____________________________________________________________________________

[End of questionnaire]

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Jennifer Sinibaldi (CENSUS/CBSM FED)
File Modified	0000-00-00
File Created	2025-08-12