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pdfAppendix B. NHES-FS Screener Surveys
B.1 Screener version A
B.2 Screener version B
B.1 Screener version A
Version A
25113010
OMB No. 1850-0803: Approval Expires 09/30/2016
UNITED STATES DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. Census Bureau
National Household Education Survey
The National Center for Education Statistics is authorized to conduct this survey under Section 9543, 20 U.S. Code.
Your participation is voluntary. Your answers may be used only for statistical purposes and may not be disclosed,
or used, in identifiable form for any other purpose except as required by law (Section 9573, 20 U.S. Code). The
information you provide will be combined with information from other participants to produce statistical summaries
and reports.
NATES-11AC
(12/21/2012)
§:,?+¤
25113028
Version A
National Household Education Survey
Start Here
▼
Return this form even if there
are only one or two people in
the household.
This survey should be filled out
by an adult household member
living at this address.
▼
▼
The Department of Education is
studying the education and training
experiences of adults and children.
Each household is different, and we
need your response so we can send
you a survey that is right for your
household.
Please use a blue or black pen if
available
You / Person 1
Person 2
▼
▼
2. What is his or
her first name,
initials, or
nickname? . . .
First names will
First name/initials/nickname
be used only to
ask you questions
about the education
of a specific person.
3. How old is
this person in
years? . . . . . . .
First name/initials/nickname
Mark for babies less
than 1 year old
Mark for babies less
than 1 year old
age in years
4. What is this
person’s sex?. .
1. How many people live in this
household?
Include adults and children who
are temporarily away from home
(for example, living in college
housing) if they have no other
permanent home.
Continue answering
questions 2 thru 6 for
each person living in this
household. Include all
adults and children. Start
with yourself.
5. Is this person
currently in . . .
Mark [X] ONE only.
6. What is this
person’s
current grade
or equivalent? .
age in years
Male
Male
Female
Female
Public or private
school, or preschool,
Public or private
school, or preschool,
Homeschool instead
of school for some
or all classes,
Homeschool instead
of school for some
or all classes,
College, university or
vocational school, or
College, university or
vocational school, or
Not in school?
Not in school?
GO TO person 2.
GO TO person 3.
Preschool
Preschool
Kindergarten
Kindergarten
write grade
1 through 12
NATES-11AC
2
write grade
1 through 12
College, university or
vocational school
College, university or
vocational school
None of these
None of these
§:,?=¤
Version A
25113036
Conducted for:
U.S. Department of Education
National Center for Education Statistics
Person 3
Person 4
Person 5
▼
▼
▼
First name/initials/nickname
First name/initials/nickname
First name/initials/nickname
Mark for babies less
than 1 year old
age in years
age in years
Mark for babies less
than 1 year old
age in years
Male
Male
Male
Female
Female
Female
Public or private
school, or preschool,
Public or private
school, or preschool,
Public or private
school, or preschool,
Homeschool instead
of school for some
or all classes,
Homeschool instead
of school for some
or all classes,
Homeschool instead
of school for some
or all classes,
College, university or
vocational school, or
College, university or
vocational school, or
College, university or
vocational school, or
Not in school?
Not in school?
Not in school?
GO TO person 4.
GO TO person 5.
GO TO page 4.
Preschool
Preschool
Preschool
Kindergarten
Kindergarten
Kindergarten
write grade
1 through 12
▼
Mark for babies less
than 1 year old
write grade
1 through 12
write grade
1 through 12
College, university or
vocational school
College, university or
vocational school
College, university or
vocational school
None of these
None of these
None of these
If there are more than 5 people in your household, continue on the next page. Otherwise, stop here and
return this form in the postage-paid envelope provided.
NATES-11AC
3
§:,?E¤
25113044
Version A
National Household Education Survey
Continue
If there are more than 5 people in
your household, please continue
answering for each person living
in this household.
If you have finished answering about
everyone in the household please
return the survey in the postage-paid
envelope provided.
Person 6
Person 7
▼
▼
2. What is his or
her first name,
initials, or
nickname? . . .
First names will
First name/initials/nickname
be used only to
ask you questions
about the education
of a specific person.
3. How old is
this person in
years? . . . . . . .
First name/initials/nickname
Mark for babies less
than 1 year old
Mark for babies less
than 1 year old
age in years
4. What is this
person’s sex?. .
5. Is this person
currently in . . .
Mark [X] ONE only.
6. What is this
person’s
current grade
or equivalent? .
age in years
Male
Male
Female
Female
Public or private
school, or preschool,
Public or private
school, or preschool,
Homeschool instead
of school for some
or all classes,
Homeschool instead
of school for some
or all classes,
College, university or
vocational school, or
College, university or
vocational school, or
Not in school?
Not in school?
GO TO person 7.
GO TO person 8.
Preschool
Preschool
Kindergarten
Kindergarten
write grade
1 through 12
NATES-11AC
4
write grade
1 through 12
College, university or
vocational school
College, university or
vocational school
None of these
None of these
§:,?M¤
25113051
Version A
Conducted for:
U.S. Department of Education
National Center for Education Statistics
Person 8
Person 9
Person 10
▼
▼
▼
First name/initials/nickname
First name/initials/nickname
First name/initials/nickname
Mark for babies less
than 1 year old
Mark for babies less
than 1 year old
age in years
age in years
age in years
Male
Male
Male
Female
Female
Female
Public or private
school, or preschool,
Public or private
school, or preschool,
Public or private
school, or preschool,
Homeschool instead
of school for some
or all classes,
Homeschool instead
of school for some
or all classes,
Homeschool instead
of school for some
or all classes,
College, university or
vocational school, or
College, university or
vocational school, or
College, university or
vocational school, or
Not in school?
Not in school?
Not in school?
GO TO person 9.
GO TO person 10.
Return survey.
Preschool
Preschool
Preschool
Kindergarten
Kindergarten
Kindergarten
write grade
1 through 12
▼ ▼
Mark for babies less
than 1 year old
write grade
1 through 12
write grade
1 through 12
College, university or
vocational school
College, university or
vocational school
College, university or
vocational school
None of these
None of these
None of these
Please verify you have filled out a column for everyone in your household.
Thank you. Please return this form in the postage-paid envelope provided or mail it to:
U.S. Census Bureau
ATTN: DCB 60-A
1201 E. 10th Street
Jeffersonville, IN 47132-0001
Toll-free number for questions: 1-800-845-8243
NATES-11AC
5
§:,?T¤
25113069
Version A
THIS PAGE INTENTIONALLY LEFT BLANK
NATES-11AC
6
§:,?f¤
Version A
25113077
Thank you.
Please return this questionnaire in the postage-paid envelope provided.
If you have lost the envelope, mail the completed questionnaire to:
U.S. Census Bureau
ATTN: DCB 60-A
1201 E. 10th Street
Jeffersonville, IN 47132-0001
NATES-11AC
7
§:,?n¤
Version A
25113085
Commonly Asked Questions
Q:
Q:
How did you get my address?
A: Your address was randomly selected from among all of the home addresses in the nation. It was
selected using scientific sampling methods to represent other households in the U.S.
Why don’t you ask more questions about education in this questionnaire?
A: The purpose of this questionnaire is to find out if anyone in your household is eligible for the next
stage of the survey. If so, we will send a second questionnaire that will ask about educational
experiences of a member of your household.
Q:
Q:
If there are no children or anyone currently in school in my household, should I respond?
A: Yes, you should respond to this survey. Once you return the questionnaire, the study will be able
to see if anyone in your household is eligible for the next and final survey. If no one is eligible,
you will not receive another survey.
Why should I take part in this study? Do I have to do this?
A: This survey is the only way that the Department of Education can learn about children’s afterschool care and adult training and education from your perspective. You represent thousands of other
households like yours, and you cannot be replaced. Your answers and opinions are very
important to the success of this study. You may choose not to answer any or all questions in this
survey. In order for the survey to be representative, it is important that you complete and return
this questionnaire. Those who do not return the survey will not be represented in key statistics
used by policymakers and researchers.
Q:
How will the information I provide be used? Will my privacy be protected?
A: Your responses will be combined with those of others to produce statistical summaries and
reports. Your individual data will not be reported. Your answers may be used only for statistical
purposes and may not be disclosed, or used, in identifiable form for any other purpose except as
required by law (Section 9573, 20 U.S. Code).
Q:
How much time will it take?
A: On average, it should take 3 minutes for you to respond, including the time for reviewing
instructions and completing and reviewing the collection of information.
Q:
Who is sponsoring the study? Is this study conducted by the Federal Government?
A: The National Center for Education Statistics, within the Department of Education, is authorized to
conduct this study (Section 9543, 20 U.S. Code). The U.S. Census Bureau is conducting this study
on behalf of the U.S. Department of Education. This study has been approved by the Office of
Management and Budget, the office that reviews all federally sponsored surveys. The approval
number assigned to this study is 1850-0803. You may send any comments about this survey,
including its length, to the Federal Government. Write to: Andrew Zukerberg, National Center for
Education Statistics, U.S. Department of Education, 1990 K Street NW, Room 9036, Washington,
DC 20006-5650. You may send email to NHES@census.gov. If you have any questions about the
study, contact the Census Bureau toll-free at 1-800-845-8243.
NATES-11AC
8
§:,?v¤
B.2 Screener version B
Version B
25113010
OMB No. 1850-0803: Approval Expires 09/30/2016
UNITED STATES DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. Census Bureau
National Household Education Survey
The National Center for Education Statistics is authorized to conduct this survey under Section 9543, 20 U.S. Code.
Your participation is voluntary. Your answers may be used only for statistical purposes and may not be disclosed,
or used, in identifiable form for any other purpose except as required by law (Section 9573, 20 U.S. Code). The
information you provide will be combined with information from other participants to produce statistical summaries
and reports.
NATES-11AC
(07/30/2013) Draft 2
§:,?+¤
25113028
Version B
National Household Education Survey
Start Here
▼
▼
▼
The Department of Education is
studying the education and training
experiences of adults and children.
Each household is different, and we
need your response so we can send
you a survey that is right for your
household.
Return this form even if there
are only one or two people in
the household.
This survey should be filled out
by an adult household member
living at this address.
Please use a blue or black pen if
available
Continue answering
questions 2 thru 6 for
each person living in this
household. Include all
adults and children. Start
with yourself.
Person 2
▼
▼
2. What is his or
her first name,
initials, or
nickname? . . .
First names will
First name/initials/nickname
be used only to
ask you questions
about the education
of a specific person.
First name/initials/nickname
3. What is this
person’s
month and
year of birth?. .
month/year of birth
4. What is this
person’s sex?. .
1. How many people live in this
household?
Include adults and children who
are temporarily away from home
(for example, living in college
housing) if they have no other
permanent home.
You / Person 1
5. Is this person
currently in . . .
Mark [X] ONE only.
6. What is this
person’s
current grade
or equivalent? .
month/year of birth
Male
Male
Female
Female
Homeschool instead
of school for some
or all classes,
Homeschool instead
of school for some
or all classes,
Public or private
school, or preschool,
Public or private
school, or preschool,
College, university or
vocational school, or
College, university or
vocational school, or
Not in school?
Not in school?
GO TO person 2.
GO TO person 3.
Preschool
Preschool
Kindergarten
Kindergarten
write grade
1 through 12
NATES-11AC
2
write grade
1 through 12
College, university or
vocational school
College, university or
vocational school
None of these
None of these
§:,?=¤
Version B
25113036
Conducted for:
U.S. Department of Education
National Center for Education Statistics
Person 3
Person 4
Person 5
▼
▼
▼
First name/initials/nickname
First name/initials/nickname
First name/initials/nickname
month/year of birth
month/year of birth
Male
Male
Male
Female
Female
Female
Homeschool instead
of school for some
or all classes,
Homeschool instead
of school for some
or all classes,
Homeschool instead
of school for some
or all classes,
Public or private
school, or preschool,
Public or private
school, or preschool,
Public or private
school, or preschool,
College, university or
vocational school, or
College, university or
vocational school, or
College, university or
vocational school, or
Not in school?
Not in school?
Not in school?
GO TO person 4.
GO TO person 5.
GO TO person 6.
Preschool
Preschool
Preschool
Kindergarten
Kindergarten
Kindergarten
write grade
1 through 12
▼
month/year of birth
write grade
1 through 12
write grade
1 through 12
College, university or
vocational school
College, university or
vocational school
College, university or
vocational school
None of these
None of these
None of these
If there are more than 5 people in your household, continue on the next page. Otherwise, stop here and
return this form in the postage-paid envelope provided.
NATES-11AC
3
§:,?E¤
25113044
Version B
National Household Education Survey
Continue
If there are more than 5 people in
your household, please continue
answering for each person living
in this household.
If you have finished answering about
everyone in the household please
return the survey in the postage-paid
envelope provided.
Person 6
Person 7
▼
▼
2. What is his or
her first name,
initials, or
nickname? . . .
First names will
First name/initials/nickname
be used only to
ask you questions
about the education
of a specific person.
First name/initials/nickname
3. What is this
person’s
month and
year of birth?. .
month/year of birth
4. What is this
person’s sex?. .
5. Is this person
currently in . . .
Mark [X] ONE only.
6. What is this
person’s
current grade
or equivalent? .
month/year of birth
Male
Male
Female
Female
Homeschool instead
of school for some
or all classes,
Homeschool instead
of school for some
or all classes,
Public or private
school, or preschool,
Public or private
school, or preschool,
College, university or
vocational school, or
College, university or
vocational school, or
Not in school?
Not in school?
GO TO person 7.
GO TO person 8.
Preschool
Preschool
Kindergarten
Kindergarten
write grade
1 through 12
NATES-11AC
4
write grade
1 through 12
College, university or
vocational school
College, university or
vocational school
None of these
None of these
§:,?M¤
25113051
Version B
Conducted for:
U.S. Department of Education
National Center for Education Statistics
Person 8
Person 9
Person 10
▼
▼
▼
First name/initials/nickname
First name/initials/nickname
First name/initials/nickname
month/year of birth
month/year of birth
Male
Male
Male
Female
Female
Female
Homeschool instead
of school for some
or all classes,
Homeschool instead
of school for some
or all classes,
Homeschool instead
of school for some
or all classes,
Public or private
school, or preschool,
Public or private
school, or preschool,
Public or private
school, or preschool,
College, university or
vocational school, or
College, university or
vocational school, or
College, university or
vocational school, or
Not in school?
Not in school?
Not in school?
GO TO person 9.
GO TO person 10.
Return survey.
Preschool
Preschool
Preschool
Kindergarten
Kindergarten
Kindergarten
write grade
1 through 12
▼ ▼
month/year of birth
write grade
1 through 12
write grade
1 through 12
College, university or
vocational school
College, university or
vocational school
College, university or
vocational school
None of these
None of these
None of these
Please verify you have filled out a column for everyone in your household.
Thank you. Please return this form in the postage-paid envelope provided or mail it to:
U.S. Census Bureau
ATTN: DCB 60-A
1201 E. 10th Street
Jeffersonville, IN 47132-0001
Toll-free number for questions: 1-800-845-8243
NATES-11AC
5
§:,?T¤
25113069
Version B
THIS PAGE INTENTIONALLY LEFT BLANK
NATES-11AC
6
§:,?f¤
Version B
25113077
Thank you.
Please return this questionnaire in the postage-paid envelope provided.
If you have lost the envelope, mail the completed questionnaire to:
U.S. Census Bureau
ATTN: DCB 60-A
1201 E. 10th Street
Jeffersonville, IN 47132-0001
NATES-11AC
7
§:,?n¤
Version B
25113085
Commonly Asked Questions
Q:
Q:
How did you get my address?
A: Your address was randomly selected from among all of the home addresses in the nation. It was
selected using scientific sampling methods to represent other households in the U.S.
Why don’t you ask more questions about education in this questionnaire?
A: The purpose of this questionnaire is to find out if anyone in your household is eligible for the next
stage of the survey. If so, we will send a second questionnaire that will ask about educational
experiences of a member of your household.
Q:
Q:
If there are no children or anyone currently in school in my household, should I respond?
A: Yes, you should respond to this survey. Once you return the questionnaire, the study will be able
to see if anyone in your household is eligible for the next and final survey. If no one is eligible,
you will not receive another survey.
Why should I take part in this study? Do I have to do this?
A: This survey is the only way that the Department of Education can learn about children’s afterschool care and adult training and education from your perspective. You represent thousands of other
households like yours, and you cannot be replaced. Your answers and opinions are very
important to the success of this study. You may choose not to answer any or all questions in this
survey. In order for the survey to be representative, it is important that you complete and return
this questionnaire. Those who do not return the survey will not be represented in key statistics
used by policymakers and researchers.
Q:
How will the information I provide be used? Will my privacy be protected?
A: Your responses will be combined with those of others to produce statistical summaries and
reports. Your individual data will not be reported. Your answers may be used only for statistical
purposes and may not be disclosed, or used, in identifiable form for any other purpose except as
required by law (Section 9573, 20 U.S. Code).
Q:
How much time will it take?
A: On average, it should take 3 minutes for you to respond, including the time for reviewing
instructions and completing and reviewing the collection of information.
Q:
Who is sponsoring the study? Is this study conducted by the Federal Government?
A: The National Center for Education Statistics, within the Department of Education, is authorized to
conduct this study (Section 9543, 20 U.S. Code). The U.S. Census Bureau is conducting this study
on behalf of the U.S. Department of Education. This study has been approved by the Office of
Management and Budget, the office that reviews all federally sponsored surveys. The approval
number assigned to this study is 1850-0803. You may send any comments about this survey,
including its length, to the Federal Government. Write to: Andrew Zukerberg, National Center for
Education Statistics, U.S. Department of Education, 1990 K Street NW, Room 9036, Washington,
DC 20006-5650. You may send email to NHES@census.gov. If you have any questions about the
study, contact the Census Bureau toll-free at 1-800-845-8243.
NATES-11AC
8
§:,?v¤
| File Type | application/pdf |
| Author | Sarah Hastedt |
| File Modified | 2013-10-17 |
| File Created | 2013-09-26 |