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
Q7.1. Internet use frequency 5
(For ASEC) Q8.1. Marital event in the past year 6
Module 3: Household characteristics 6
(For ASEC) Q10. Cohabitation status II 6
Q12. Number of children in household 7
(For ASEC) Q12.2. Young child (age between 5 and 13) in household 7
(For ASEC) Q13. Children event in the past year 7
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 8
(For ASEC) Q17. Lack of access to regular healthcare 8
(For ASEC) Q18. Social Assistance programs 9
Module 5: Employment and Income 9
(For ASEC) Q25. New job in the past year (life event) 10
(For ASEC) Q26 Seasonal/non-standard work (last year) 11
(For ASEC) Q30. Other income 11
Q36.1 Interview participation. 13
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 90 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 13 U.S.C. Sections 141, 182, and 193. Federal law requires that your answers are kept confidential (Title 13, U.S. 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 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-3, Demographic Survey Collection (Census Bureau Sampling Frame).” 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 12/31/2025. 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 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]
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How old are you?
[______] [If Q2<18, skip to INELIGIBLE]
[PROGRAMMER: NUMERIC ENTRY ONLY; RANGE = (6-110)]
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Are you employed by the Federal Government? (if federal contractor, mark NO)
1 Yes [skip to INELIGIBLE]
2 No
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In what state or district do you currently live?
State: [______]
In what city and ZIP code do you currently live?
City: [______]
ZIP code [______]
[PROGRAMMER: CITY − TEXTBOX with 50 characters Max.; State – TEXTBOX; ZIP code − 5 digits NUMERIC ENTRY ONLY]
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Which of the following best describes the place where you now live?
1 A large city
2 A suburb
4 A small city or town
5 A rural area
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What sex were you assigned at birth, on your original birth certificate?
1 Male
2 Female
4 I don’t want to answer
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What is your race and/or ethnicity? Please select all that apply.
1 American Indian or Alaska Native White
2 Asian
3 Black or African American
4 Hispanic or Latino
5 Middle Eastern or North African
6 Native Hawaiian or other Pacific Islander
7 White
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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
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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
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Do you own a smartphone (such as an iPhone or Android)?
1 Yes
2 No
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In 2023, 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.]
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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]
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[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.]
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[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)]
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[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)]
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[Ask if Q12>=1] Is any child living or staying at your address 13 or younger?
1 Yes
2 No
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In 2023, did you or a partner or spouse ─
1 give birth to any children?
2 adopt any children?
3 foster any children?
4 None of the above
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Do you currently have health insurance?
1 Yes
2 No, I don’t have any health insurance
3 Don’t know
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[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
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
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[Ask if Q15=1 or Q15=4 or Q15=5] Is this health insurance in your own name, or do you get it through someone else?
1 It’s in my name
2 I get it through someone else
3 Don’t know
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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.]
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In 2023, 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.]
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Were you working at any time in 2023?
1 Yes
2 No
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[Ask if Q22=1] In 2023, did you work for an employer, were you self-employed, or did you have some other work arrangement?
1 I worked for an employer
2 I was self-employed
3 I had another work arrangement ─ Please specify
[PROGRAMMER: IF 3 (“Other”) IS SELECTED, DISPLAY “Please specify” TEXTBOX.]
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[Ask if Q22=1] In 2023, 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
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[Ask if Q22 = 1] At any point in 2023, did you work two or more jobs at the same time?
Please include any side jobs you did for pay in addition to a primary job.
1 Yes
2 No
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[Ask if Q22=1] Did you start a job in 2023?
1 Yes
2 No
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[Ask if Q22=1] In 2023 did you do any of the following types of work?
|
Yes (1) |
No (2) |
Q26.1 Temporary or seasonal work (for example, holiday sales associate, summer camp counselor, crop harvester, etc.) |
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Q26.2 In-person jobs or tasks through companies that connect you directly with customers using a website or mobile app (for example, delivering food or groceries or driving for a rideshare service) |
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Q26.3 Freelancing or consulting work |
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Q26.4 Other types of side jobs that provide additional income streams. Do not include time spent answering online surveys Please Specify: |
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[PROGRAMMER: IF Q26.4 =1, DISPLAY “Please specify” TEXTBOX.]
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In 2023, did you receive 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]
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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]
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What is the best telephone number to reach you? (Numbers only, please do not include special characters)
Phone ([___]) [___] − [_______]
What is the best time to reach you by phone?
1 Mornings (8-10 AM)
2 Midday (11 AM-1 PM)
3 Afternoons (2-5 PM)
4 Evenings (after 5 PM)
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
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[Ask if Q35=1] What is the name of your family or friend?
Name: [________________________]
[Ask if Q35=1] What is the email address of your family or friend?
[_________________________________________]
[PROGRAMMER: email verification]
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Would you be able to participate in a [90; 60] minute virtual interview at a day/time to be determined in [MONTH]? The interview will use a free software called Microsoft Teams.
1 Yes
2 No
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Would you be willing to share your phone or computer screen during the interview?
1 Yes
2 No
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We would like to audio and video record interviews. Would you be willing to have the interview video and audio recorded?
1 Yes
2 No
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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: _______________
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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 |
| File Title | Attachment 2 - Screener Spec |
| Author | Weimer, Belinda |
| File Modified | 0000-00-00 |
| File Created | 2025-08-12 |