Form Part A, Attachment Part A, Attachment Part A, Attachment A_CHP Topical 2 and 3 Questionnaire_v

Census Household Panel

Topical 2 and Topical 3 Questionnaire

Intro2


This survey is a cooperative effort across many government agencies to provide critical, up-to-date information on the U.S. population. Completing this 20-minute survey will help federal, state, and local agencies identify emergent issues in your community.

The authority for the collection of this information for the Household Panel (0607-1025) is provided under Title 13, United States Code, Sections 8(b), 141, 182, and 193. Federal law protects your privacy and keeps your answers confidential (Title 13, United States 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.

The purpose of collecting this information is to recruit a nationally representative survey panel to test the methods to collect data on a variety of topics of interest, and for conducting experimentation on alternative question wording and methodological approaches. The Census Household Panel will enable the availability of frequent data collection for nationwide estimates on a variety of topics and subgroups of the population.

Your privacy is protected by 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). Personally identifiable information collected includes Name, Address, Telephone/cell phone number, DOB or age, Email address, and Race or ethnicity.

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.

Furnishing this information is Voluntary. Failure to do so will produce no consequences.

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 adrm.pra@census.gov. This collection has been approved by the Office of Management and Budget (OMB). This eight-digit OMB approval number, 0607-1025, confirms this approval and expires on 6/30/26. We are required to display this number to conduct this survey.

EMP_Intro First, we are going to ask about your employment.

EMP1 Have you, or has anyone in your household experienced a loss of employment income in the last 4 weeks?  Select only one answer.

• Yes (1)

• No (2)

EMP2
In the last 7 days, did you do ANY work for either pay or profit? Select only one answer.

• Yes (1)

• No (2)

Display This Question:

If EMP2 = Yes

EMP3 Are you employed by the government, by a private company, a nonprofit organization or are you self-employed or working in a family business? Select only one answer.

• Government (1)

• Private company (2)

• Non-profit organization including tax exempt and charitable organizations (3)

• Self-employed (4)

• Working in a family business (5)

Display This Question:

If EMP2 = No

EMP4 What is your main reason for not working for pay or profit? Select only one answer.
I did not work because:

• I did not want to be employed at this time (1)

• I am/was caring for children not in school or daycare (3)

• I am/was caring for an elderly person (4)

• I am/was sick or disabled (5)

• I am retired (6)

• I am/was laid off or furloughed (7)

• My employer closed temporarily or went out of business (8)

• I do/did not have transportation to work (9)

• Other reason, please specify (10) __________________________________________________

SPN5_DAYSTW In the last 7 days, have any of the people in your household teleworked or worked from home?

• Yes, for 1-2 days (1)

• Yes, for 3-4 days (2)

• Yes, for 5 or more days (3)

• No (4)

Display This Question:

If In the last 7 days, have any of the people in your household teleworked or worked from home? = Yes, for 1-2 days

Or In the last 7 days, have any of the people in your household teleworked or worked from home? = Yes, for 3-4 days

Or In the last 7 days, have any of the people in your household teleworked or worked from home? = Yes, for 5 or more days

And If

In the last 7 days, did you do ANY work for either pay or profit? Select only one answer. = Yes

SPN5_DAYSTW_2 In the last 7 days, have you teleworked or worked from home?

• Yes, for 1-2 days (1)

• Yes, for 3-4 days (2)

• Yes, for 5 or more days (3)

• No (4)

D12 In your household, are there… Select all that apply.

• Children under 5 years old? (1)

• Children 5 through 11 years old? (2)

• Children 12 through 17 years old? (3)

Display This Question:

If In your household, are there… Select all that apply. = Children under 5 years old?

INF1 Are there any babies or infants under the age of 12 months (one year) old in your household?

• Yes (1)

• No (2)

Display This Question:

If Are there any babies or infants under the age of 12 months (one year) old in your household? = Yes

INF2 How many months old is the baby or infant in your household? If there is more than one, please report the age of the youngest.

• Under 6 months (1)

• Between 6 months and 9 months (2)

• Between 9 months and 12 months (3)

Display This Question:

If Are there any babies or infants under the age of 12 months (one year) old in your household? = Yes

INF5 How is the baby in your household fed (in addition to any solid foods the baby may be consuming)? If there is more than one baby, please report on the youngest.

• Breastfeeding (or pumped breastmilk) only (1)

• Sometimes breastfeeding (or pumped breastmilk) and sometimes infant formula (2)

• Infant formula only (3)

• Baby isn’t fed breastmilk OR infant formula (4)

Display This Question:

If Are there any babies or infants under the age of 12 months (one year) old in your household? = Yes

And If

How is the baby in your household fed (in addition to any solid foods the baby may be consuming)?... = Sometimes breastfeeding (or pumped breastmilk) and sometimes infant formula

Or How is the baby in your household fed (in addition to any solid foods the baby may be consuming)?... = Infant formula only

INF6 In the last month, did you have difficulty getting infant formula?

• Yes, in the last 7 days (1)

• Yes, more than 7 days ago but within the last month (2)

• No, did not have trouble getting infant formula in the last month (3)

display_HLTH Next, we will ask about health.

DIS1 Do you have difficulty seeing, even when wearing glasses? Select only one answer.

• No - no difficulty (1)

• Yes - some difficulty (2)

• Yes - a lot of difficulty (3)

• Cannot do at all (4)

DIS2 Do you have difficulty hearing, even when using a hearing aid? Select only one answer.

• No - no difficulty (1)

• Yes - some difficulty (2)

• Yes - a lot of difficulty (3)

• Cannot do at all (4)

DIS4 Do you have difficulty walking or climbing stairs? Select only one answer.

• No - no difficulty (1)

• Yes - some difficulty (2)

• Yes - a lot of difficulty (3)

• Cannot do at all (4)

DIS3 Do you have difficulty remembering or concentrating? Select only one answer.

• No - no difficulty (1)

• Yes - some difficulty (2)

• Yes - a lot of difficulty (3)

• Cannot do at all (4)

DIS5 Do you have difficulty with self-care, such as washing all over or dressing? Select only one answer.

• No - no difficulty (1)

• Yes - some difficulty (2)

• Yes - a lot of difficulty (3)

• Cannot do at all (4)

DIS6 Using your usual language, do you have difficulty communicating, for example understanding or being understood? Select only one answer.

• No - no difficulty (1)

• Yes - some difficulty (2)

• Yes - a lot of difficulty (3)

• Cannot do at all (4)

HLTH_intro Over the last 2 weeks, how often have you been bothered by...

HLTH1 Feeling nervous, anxious, or on edge? Select only one answer.

• Not at all (1)

• Several days (2)

• More than half the days (3)

• Nearly every day (4)

HLTH2 Not being able to stop or control worrying? Select only one answer.

• Not at all (1)

• Several days (2)

• More than half the days (3)

• Nearly every day (4)

HLTH3 Having little interest or pleasure in doing things? Select only one answer.

• Not at all (1)

• Several days (2)

• More than half the days (3)

• Nearly every day (4)

HLTH4 Feeling down, depressed, or hopeless? Select only one answer.

• Not at all (1)

• Several days (2)

• More than half the days (3)

• Nearly every day (4)

Universe: Children age 5-18 in household, else skip to SOC

MH1 During the last 4 weeks, did any children in your household need mental health treatment? Mental health treatment includes health services like counseling or medication.

• Yes, all children needed mental health treatment

• Yes, some but not all children needed mental health treatment

• No, none of the children needed mental health treatment [skip questions MH2-MH4 ]
  
  

MH2 If yes, did the children who need mental health treatment receive it?

• Yes, all children who needed treatment received it

• Yes, but only some children who needed treatment received it

• No, none of the children who needed treatment received it [skip question b]

MH3 If yes, were you satisfied with the type, quality, and quantity of mental health treatment the children received?

• Satisfied with all of the mental health treatment the children received

• Satisfied with some but not all of the mental health treatment the children received

• Not satisfied with the mental health treatment the children received
  
  

MH 4 How difficult was it to get mental health treatment for the children?

• Not difficult

• Somewhat difficult

• Very difficult

• Unable to get treatment due to difficulty

• Did not try to get treatment

Universe: Everyone

RANDOMIZE – half see SOC1 and SOC2 first; half see SOCInd1-4 first.

SOC1 How often do you get the social and emotional support you need?

• Always

• Usually

• Sometimes

• Rarely

• Never

SOC2 How often do you feel lonely?  

• Always

• Usually

• Sometimes

• Rarely

• Never

SOCInd1 In a typical week, how often do you talk on the telephone with family, friends, or neighbors?

• Less than once a week

• 1 or 2 times a week

• 3 or 4 times a week

• 5 or more times a week

SOCInd2 How often do you get together with friends or relatives?

• Less than once a week

• 1 or 2 times a week

• 3 or 4 times a week

• 5 or more times a week

SOCInd3 How often do you attend church or religious services?

• Never or less than once a year

• Once a year

• 2 or 3 times a year

• 4 or more times a year

SOCInd4 Do you belong to any clubs or organizations such as sports teams, parent/teacher organizations, religious, union or other community groups?

• Yes

• No

SOCInd1EXP In a typical week, how often do you text or message with family, friends, or neighbors?

• Less than once a week

• 1 or 2 times a week

• 3 or 4 times a week

• 5 or more times a week

Display This Question:

If there are children age 0-18 in the household

EMP7 Next, we are going to ask about the childcare arrangements for children in the household. 

At any time in the last 4 weeks, were any children in the household unable to attend daycare or another childcare arrangement as a result of childcare being closed, unavailable, unaffordable, or because you are concerned about your child’s safety in care?  Please include before school care, after school care, and all other forms of childcare that were unavailable. Select only one answer.

• Yes  (1)

• No  (2)

• Not applicable  (3)

 

 

EMP8 Which if any of the following occurred in the last 4 weeks as a result of childcare being closed, unavailable, unaffordable, or because you are concerned about your child’s safety in care? Select all that apply.

• You (or another adult) took unpaid leave to care for the children   (1)

• You (or another adult) used vacation, or sick days, or other paid leave in order to care for the children  (2)

• You (or another adult) cut your work hours in order to care for the children  (3)

• You (or another adult) left a job in order to care for the children  (4)

• You (or another adult) lost a job because of time away to care for the children  (5)

• You (or another adult) did not look for a job in order to care for the children  (6)

• You (or another adult) supervised one or more children while working  (7)

• Other (specify)   (8) ______________________________________________

• None of the above  (9)

Display This Question:

If there are children age 5-18 in the household

D13 During the school year that began in the Summer / Fall of 2023, how many children in this household were enrolled in Kindergarten through 12th grade or grade equivalent? Enter whole numbers for all that apply.

• Number enrolled in a public school (1) _________________________________

• Number enrolled in a private school (2) _______________________________

• Number homeschooled, that is not enrolled in public or private school (3) __________________________________________________

• None (4)

INFLATE1 In the area where you live and shop, do you think prices in general have changed in the last 2 months? Select only one answer.

• I think prices have increased (1)

• I do not think prices have changed (2)

• I think prices have decreased (3)

• I do not know (4)

Display This Question:

If INFLATE1 = I think prices have increased

INFLATE2 How stressful, if at all, has the increase in prices in the last 2 months been for you? Select only one answer.

• Very stressful (1)

• Moderately stressful (2)

• A little stressful (3)

• Not at all stressful (4)

INFLATE4 In the area you live and shop, how concerned are you, if at all, that prices will increase in the next 6 months? Select only one answer.

• Very concerned (1)

• Somewhat concerned (2)

• A little concerned (3)

• Not at all concerned (4)

display_SPN The next questions ask about your household's activities in the last 7 days. Please only include experiences that occurred in the last 7 days.

SPN4
In the last 7 days, how difficult has it been for your household to pay for usual household expenses, including but not limited to food, rent or mortgage, car payments, medical expenses, student loans, and so on? Select only one answer.

• Not at all difficult (1)

• A little difficult (2)

• Somewhat difficult (3)

• Very difficult (4)

FD1 Getting enough food can also be a problem for some people. In the last 7 days, which of these statements best describes the food eaten in your household? Select only one answer.

• Enough of the kinds of food (I/we) wanted to eat (1)

• Enough, but not always the kinds of food (I/we) wanted to eat (2)

• Sometimes not enough to eat (3)

• Often not enough to eat (4)

Display This Question:

If FD1 = Enough, but not always the kinds of food (I/we) wanted to eat

Or FD1 = Sometimes not enough to eat

Or FD1 = Often not enough to eat

And If

If children ages 0-18 in household

FD2
Please indicate whether the next statement was often true, sometimes true, or never true in the last 7 days for the children living in your household who are under 18 years old.  

"The children were not eating enough because we just couldn't afford enough food."

• Often true (1)

• Sometimes true (2)

• Never true (3)

Display This Question:

If FD1 = Enough, but not always the kinds of food (I/we) wanted to eat

Or FD1 = Sometimes not enough to eat

Or FD1 = Often not enough to eat

FD3 Why did you not have enough to eat (or not what you wanted to eat)? Select all that apply.

• Couldn’t afford to buy more food (1)

• Couldn’t get to store to buy food (for example, didn’t have transportation, have mobility or health limitations that prevent you from getting out) (2)

• Couldn’t go to store due to safety concerns (3)

• None of the above (4)

FD4 During the last 7 days, did you or anyone in your household get free groceries from a food pantry, food bank, church, or other place that provides free food? Select only one answer.

• Yes (1)

• No (2)

Display This Question:

If children ages 0-18 in houshold

FD5 Do any of the children in this household... Select all that apply.

• Receive free meals at school (1)

• Pay for reduced-price meals at school (2)

• Pay for full-price meals at school (3)

• Pick up free meals at a school or other location (4)

• Receive or use an EBT card to help buy groceries (5)

• Eat free meals at a location other than school (6)

• Have free meals delivered (7)

• None of the above (8)

Universe = everyone

FD6_new Do you or does anyone in your household currently receive benefits from… Select all that apply.

• Supplemental Nutrition Assistance Program (SNAP) or Food Stamp Program (1)

• WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) (2)

• None of these (3)

Display This Question:

If FD5 = Pay for reduced-price meals at school

Or FD5 = Pay for full-price meals at school

Or FD5 = None of the above

And If

Children ages 5-18 in household

FD7_new Does having to pay for the food children eat at school make it difficult for your household to pay for other expenses?

• Yes (1)

• No (2)

ND1 The next set of questions asks about natural disasters, such as hurricanes, floods and fires.

In the past year, were you displaced from your home because of a natural disaster?

• Yes (1)

• No (2)

Display This Question:

If ND1 = Yes

ND2 What type of natural disaster? Select all that apply.

• Hurricane (1)

• Flood (2)

• Fire (3)

• Tornado (4)

• Other, specify (5) ____________________________________________

Display This Question:

If ND1 = Yes

ND3 How long were you displaced from your home?

• Less than a week (1)

• More than a week but less than a month (2)

• One to six months (3)

• More than six months (4)

• Never returned to home (5)

Display This Question:

If ND1 = Yes

ND4 Altogether, how much damage to your property or possessions did you experience as a result of natural disasters in the last year? Would you say no damage, some damage, a moderate amount of damage, or a lot of damage?

• No damage (1)

• Some damage (2)

• Moderate amount of damage (3)

• A lot of damage (4)

Display This Question:

If ND1 = Yes

ND5 In the first month after the natural disaster, to what extent did you experience any of the following:

Display This Question:

If ND1 = Yes

ND5A A shortage of food?

• Not at all (1)

• A little (2)

• Some (3)

• A lot (4)

Display This Question:

If ND1 = Yes

ND5B A shortage of drinkable water?

• Not at all (1)

• A little (2)

• Some (3)

• A lot (4)

Display This Question:

If ND1 = Yes

ND5C Loss of electricity?

• Not at all (1)

• A little (2)

• Some (3)

• A lot (4)

Display This Question:

If ND1 = Yes

ND5D Unsanitary conditions, such as inadequate toilets?

• Not at all (1)

• A little (2)

• Some (3)

• A lot (4)

Display This Question:

If ND1 = Yes

ND5E Feeling isolated?

• Not at all (1)

• A little (2)

• Some (3)

• A lot (4)

Display This Question:

If ND1 = Yes

ND5F Fear of crime?

• Not at all (1)

• A little (2)

• Some (3)

• A lot (4)

Display This Question:

If ND1 = Yes

ND5G Offers that seemed like a scam?

• Not at all (1)

• A little (2)

• Some (3)

• A lot (4)

HSE1
The next questions ask about housing.


Is your house or apartment…? Select only one answer.

• Owned by you or someone in this household free and clear? (1)

• Owned by you or someone in this household with a mortgage or loan (including home equity loans)? (2)

• Rented? (3)

• Occupied without payment of rent? (4)

HSE2 Which best describes this building? Include all apartments, flats, etc., even if vacant. Select only one answer.

• A mobile home (1)

• A one-family house detached from any other house (2)

• A one-family house attached to one or more houses (3)

• A building with 2 apartments (4)

• A building with 3 or 4 apartments (5)

• A building with 5 or more apartments (6)

• Boat, RV, van, etc. (7)

Display This Question:

If HSE1 = Rented?

HSEnew2 Has your monthly rent changed during the last 12 months? If so, by how much?

• My rent did not change (1)

• My rent decreased (2)

• My rent increased by less than $100 (3)

• My rent increased by $100-$249 (4)

• My rent increased by $250-$500 (5)

• My rent increased by more than $500 (6)

Display This Question:

If HSE1 = Rented?

HSE3 Is this household currently caught up on rent payments? Select only one answer.

• Yes (1)

• No (2)

Display This Question:

If HSE1 = Owned by you or someone in this household with a mortgage or loan (including home equity loans)?

HSE4 Is this household currently caught up on mortgage payments? Select only one answer.

• Yes (1)

• No (2)

Display This Question:

If HSE3 = No

Or HSE4 = No

HSE6 How many months behind is this household in paying your rent or mortgage?

________________________________________________________________

HSE7rev. Thinking of all the places you’ve lived during the last six months, did you ever feel pressure to move due to any of the following reasons? Select all that apply.

• Because the landlord raised the rent?​

• Because you missed a rent payment and you thought you would be evicted?

• Because the landlord did not make repairs?

• Because you were threatened with eviction or told to leave by your landlord?

• Because your landlord changed the locks, removed your belongings, or shut off your utilities?

• Because the neighborhood was dangerous?

• Some other pressure

• Did not feel pressure to move. (skip to HSE8)

(Universe HSE7rev 1-7)

HSE7b. During the last six months, did you actually move from any place you were living as a result of this pressure?

• Yes

• No

Display This Question:

If HSE3 = No

HSE8 How likely is it that your household will have to leave this home or apartment within the next 2 months because of eviction? Select only one answer.

• Very likely (1)

• Somewhat likely (2)

• Not very likely (3)

• Not likely at all (4)

Display This Question:

If HSE4 = No

HSE9 How likely is it that your household will have to leave this home within the next 2 months because of foreclosure? Select only one answer.

• Very likely (1)

• Somewhat likely (2)

• Not very likely (3)

• Not likely at all (4)

HSE10 In the last 12 months, how many months did your household reduce or forego expenses for basic household necessities, such as medicine or food, in order to pay an energy bill?

• Almost every month (1)

• Some months (2)

• 1 or 2 months (3)

• Never (4)

HSE11 In the last 12 months, how many months did your household keep your home at a temperature that you felt was unsafe or unhealthy?

• Almost every month (1)

• Some months (2)

• 1 or 2 months (3)

• Never (4)

HSE12 In the last 12 months, how many times was your household unable to pay an energy bill or unable to pay the full bill amount?

• Almost every month (1)

• Some months (2)

• 1 or 2 months (3)

• Never (4)

GAS1 Has the cost of gas in the last 7 days caused you to:  Select all that apply.

• Choose not to take a trip (for example, chose not to visit a friend/restaurant/park etc., change a task from in-person to online to reduce gas use) (1)

• Combine trips (2)

• Take alternative modes of transportation (for example, public transit, ridesharing, bike, etc.) (3)

• None of these - the cost of gas has not affected my driving behavior (4)

leadin2 The next set of questions ask about COVID-19 vaccination.

VAC1 Have you received at least one dose of a COVID-19 vaccine?

• Yes (1)

• No (2)

VAC1 What was the date of your most recent COVID-19 vaccine?

Month (Pick from Month list)

Year (Pick from Year list – 2021-present)

(Disallow dates in the future)

New Question (Universe = people age ≥60 years): There is a vaccine that was recently recommended for some people that helps prevent the respiratory virus called RSV. Have you received the RSV vaccine?

Yes

No

VAC8_B Have you ever tested positive for COVID-19 (using a rapid point-of-care test, self-test, or laboratory test) or been told by a doctor or other health care provider that you have or had COVID-19?

• Yes (1)

• No (2)

Display This Question:

If VAC8_B = Yes

VAC8_C When did you test positive or were told you have or had COVID-19? Select all that apply

• Within the last four weeks (1)

• More than four weeks ago, but within the last year (2)

• More than a year ago.

Display This Question:

If VAC8_B = Yes

PASC1 How would you describe your coronavirus symptoms when they were at their worst?

• I had no symptoms (1)

• I had mild symptoms (2)

• I had moderate symptoms (3)

• I had severe symptoms (4)

Display This Question:

If VAC8_B = Yes

PASC2 Did you have any symptoms lasting 3 months or longer that you did not have prior to having coronavirus or COVID-19?

Long term symptoms may include: tiredness or fatigue, difficulty thinking or concentrating, forgetfulness, or memory problems (sometimes referred to as "brain fog"), difficulty breathing or shortness of breath, joint or muscle pain, fast-beating or pounding heart (also known as heart palpitations), chest pain, dizziness on standing, changes to your menstrual cycle, changes to taste/smell, or inability to exercise.

• Yes (1)

• No (2)

Display This Question:

If PASC1 = I had mild symptoms

Or PASC1 = I had moderate symptoms

Or PASC1 = I had severe symptoms

Or PASC2 = Yes

PASC3 Do you have symptoms now?

• Yes (1)

• No (2)

Display This Question:

If PASC2 = Yes

And PASC3 = Yes

PASC4 Do these long-term symptoms reduce your ability to carry out day-to-day activities compared with the time before you had COVID-19?

• Yes, a lot (1)

• Yes, a little (2)

• Not at all (3)

END That concludes the survey. Please click on the “Submit” button when you are finished.   Thank you for participating in the Census Household Panel.

Page 15 of 15