Form QID CAPI Project Respondent Questionnaire

Project Code 380		OMB No. 0535-0213: Approval Expires 12/31/2010
	CAPI Project Respondent Questionnaire			NATIONAL AGRICULTURAL STATISTICS SERVICE

Survey State
CAPI Survey Name or Names
Respondent POID
Enumerator Name/ID
Date	mm/dd/yyyy
Wireless Device
Mode (circle)	1- CAPI face to face 2- CAPI phone 3- CAPI paper

1. Was your experience with this computer assisted interview a positive experience?

¹ Yes ³ No – Go to Question 1a

1a. Explain why not? ___________________________________________________________________________________

2. Are you confident that the data collected during this computer assisted interview is confidential?

¹ Yes ³ No – Go to Question 2a

2a. Explain why not? ____________________________________________________________________________________

3. Are you willing to participate in future computer assisted interviews?

¹ Yes ³ No – Go to Question 3a

3a. Explain why not? ___________________________________________________________________________________

4. Did you think this computer assisted interview was faster than a normal face to face interview?

¹ Yes ³ No – Go to Question 4a

4a. Explain why not? ____________________________________________________________________________________

5. Would you be willing to use your personal computer and the NASS website to complete surveys yourself?

¹ Yes ³ No – Go to Question 3a

5a. Explain why not?

___________________________________________________________________________________

6. Which of the following do you prefer to use when completing NASS surveys?

¹ Mail Surveys

² Web surveys via my personal computer

³ Field Interview via Computer assisted interview

⁴ Telephone interview

⁵ Field Interview via Paper Form

___________________________________________________________________________________

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB number is 0535-0213. The time required to complete this information collection is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.