Part A, Attachment Part A, Attachment A_CHP Topical 4, 5, 6 Questionnaires_

91

Topical 4 Questionnaire

Opinion Benchmarking Survey

Language Thank you for your continued participation in the Census Household Panel! This month’s survey will be short (less than 10 minutes) and will ask you your opinion about various topics relevant to the United States. The information being collected is for research purposes only, and will assist ongoing efforts to understand opinions of the American public.

This survey is available in English and Spanish. Please select the language in which you prefer to complete the survey.

If you would like to change your language selection later, please use the drop-down menu in the upper right corner of each page to select the language in which you prefer to complete the survey.

• English (1)

• Español (2)

<<page break>>

Click the “Continue” button below to begin. 

------

The authority for the collection of this information for the Census Household Panel Topicals 4 (0607-1025) is provided under Title 13, Sections 141, 182, and 193.

The purpose of Topical 4 is to provide important methodological data to compare the CHP responses against a national opinion research survey. These data will be used for methodological assessment of the current panel members representativeness compared to national benchmarks and other similar data collection strategies and will be used to inform future directions for recruitment and replenishment.

Additionally, we ask some questions about improving the Census Household Panel respondent experience and opinion questions on including a time capsule question in a future decennial census.

Disclosure of the information provided to us to other Census Bureau staff for work-related purposes is permitted under the Privacy Act of 1974 (5 U.S.C. § 552a). Disclosure of this information is also subject to all of the published routine uses as identified in the Privacy Act System of Records Notice COMMERCE/Census-3 Demographic Survey Collection (Census Bureau Sampling Frame).

Staff (employees and contractors) received training on privacy and confidentiality policies and practices; access to PII is restricted to authorized personnel only. Personally identifiable information collected includes name, address, telephone/cell phone number, DOB or age, email address, race, or ethnicity.

FedRAMP-approved computer systems that maintain sensitive information are in compliance with the Federal Information Security Management Act. Unsecured telecommunications to transmit individually identifiable information is prohibited. Information will only be shared with staff and contractors that are special sworn status and sponsors of reimbursable surveys.

Furnishing this information is voluntary. Failure to do so will result in no consequences to you. However, without complete survey responses, the Census Bureau will not have access to all of the requested information. Also, only respondents who complete the survey will be eligible for an incentive.

Q1 Our records have your name as ${e://Field/FirstNameFill} ${e://Field/LastNameFill}. Is this correct?

If you need to update the spelling of your name or if your name has legally changed, please email addp.household.panel@census.gov.

Yes (1)

No (3)

End of Block: Eligibility

Start of Block: Not Eligible

Display This Question:

If Q1 = No

R2a You are not eligible to complete this survey. Thank you for your time.

Skip To: End of Survey If R2a Is Displayed

End of Block: Not Eligible

ECON1MOD

How would you rate economic conditions in your community today?

1. Excellent

2. Good

3. Only fair

4. Poor

ECON1BMOD

A year from now, what do you expect economic conditions in your community will be?

1. Better

2. Worse

3. About the same

COMTYPE2

How would you describe the community where you currently live? [REVERSE ORDER OF PUNCHES FOR RANDOM HALF SAMPLE]

1. Urban

2. Suburban

3. Rural

TYPOLOGYb

Which statement comes closer to your own view, even if neither is exactly right?

1. Business corporations make too much profit

2. Most corporations make a fair and reasonable amount of profit

CRIMESAFE

How would you describe the area where you live, in terms of crime?

1. Extremely safe

2. Very safe

3. Somewhat safe

4. Not too safe

5. Not at all safe

POLICE_FUND

Thinking about police departments in your area, do you think that spending on policing should be…

1. Increased a lot

2. Increased a little

3. Stay about the same

4. Decreased a little

5. Decreased a lot

VOL12_CPS

In the past 12 months, did you spend any time volunteering for any organization or association? (This includes activities you may do infrequently or for children’s schools or youth organizations.)

1. Yes

2. No

Base: if AE1B=1	[confirmed 18+]
Show on same screen as EMINUSE

INTMOB

Do you access the internet on a cell phone, tablet or other mobile handheld device, at least occasionally?

1. Yes

2. No

INTFREQ

About how often do you use the internet?

1. Almost constantly

2. Several times a day

3. About once a day

4. Several times a week

5. Less often

HOME4NW2

Do you currently subscribe to internet service installed at your home (other than data plans on mobile devices)?

1. Yes

2. No

BBHOME

Is the home internet service you subscribe to…

1. Dial-up (over a landline phone connection)

2. High-speed broadband like cable, fiber optic, wireless router, satellite, or DSL

3. Other service (please specify): [open-end text box]

4. Not sure

Soft prompt if select 3 and left blank: You did not provide a response in the text box. If you would like to skip, click Next.

SMUSE

Please indicate whether or not you ever use the following websites or apps. [RANDOMIZE AND SPLIT ACROSS TWO SCREENS]

1. Facebook

2. YouTube

3. X (formerly Twitter)

4. Instagram

5. Snapchat

6. WhatsApp

7. LinkedIn

8. Pinterest

9. TikTok

10. BeReal

11. Reddit

RESPONSE OPTIONS:

1. Yes, use this

2. No, don’t use this

RADIO

Do you listen to the radio?

1. Yes

2. No

BOOKS1

In the past 12 months, about how many books did you read either all or part of the way through? (Please include any print, electronic, or audiobooks you may have read or listened to.)

[Enter 0 if none]

[NUMERIC FIELD RANGE 0-100]

Soft prompt if enters less than 0 or more than 100: Please enter a number between 0 and 100. If you read more than 100 books, please enter 100 and click Next.

DEVICE1a

Do you have a cell phone?

1. Yes, have a cell phone

2. No, do not have a cell phone

SMART2

Is your cell phone a smartphone?

1. Yes, smartphone

2. No, not a smartphone

NHISLL

Is there at least one working telephone inside your home that is not a cell phone?

1. Yes

2. No

REGISTRATION

Are you registered to vote at your current address?

1. Yes

2. No

3. Not sure

VOTED2020

Did you happen to vote in the 2020 presidential election?

1. Yes

2. No

_______________________________________________________________________________

Base: Ask to a random half of the sample

ATTN_CHK Data quality is important to us. Please select square to show you are paying attention.

1. Circle

2. Oval

3. Square

4. Triangle

_______________________________________________________________________________

The U.S. decennial census is the count of all the people who live in the United States.  Every 10 years during the census, the Census Bureau collects data like name, date of birth, sex, race, and ethnicity for the people living at each address. These data are kept confidential for 72 years to respect people’s privacy. After 72 years, the National Archives makes these data available to the public. 

TIMECAP1

1. Does knowing that responses become available to the public after 72 years make you more likely to complete the next census, less likely, or does it not make a difference to you?

• More likely

• Less likely

• Does not make a difference to me

  

TIMECAP2

2. During the next census, would you be interested in entering a message on your census questionnaire that future generations could read in 72 years when the data are made available? 

• Yes 

• No 

• Don't know

TIMECAP3

3. Sometimes leaving a message to be read in the future is called a “time capsule.” Before answering this survey, had you heard of a time capsule? 

• Yes 

• No 

• Don't know

TIMECAP4

4. [if yes or don’t know to timecap2] If the next census includes a chance to enter a message to future generations, do you think you would post about your message on your social media account? 

• Yes, I think I'd post about my message on social media

• No, I don't think I would post about it

• I don't have a social media account

• Don't know

CHP1 We would like to understand why you chose to be part of the Census Household Panel and what, if anything, you value about being part of it. What does being part of the Census Household Panel mean to you and what motivates you to participate in the surveys?

[open-end]

CHP2 How can we improve your experience with the Census Household Panel?

[open-end]

CHP3 Which topics for future surveys do you prefer most from the list below. Please rank the following potential future survey topics from most to least preferable. Move your highest preference to the top.

[randomize list]

______ Effects of inflation on your budget (1)

______ Employment (2)

______ Education (3)

______ Other (specify) (4)

Please rate this survey overall from 1 to 7 where 1 is Poor and 7 is Excellent.

Poor						Excellent
1	2	3	4	5	6	7

If you do not have any feedback for us today, please click “Continue” through to the end of the survey so we can make sure your opinions are counted.

Start of Block: Contact Update

POC_display Please review the contact information we have for you and indicate whether the information is correct or needs to be updated.

Q3 Our records have your phone number as ${e://Field/BestPhone}. Is this correct?

• Yes (1)

• No (2)

lay This Question:

If Q3 = Yes

Q4 Is this number a cell phone or land line?

• Cell phone (1)

• Land line (2)

• Neither (3)

his Question:

If Q4 = Cell phone

Q5 We send survey invitations via text message. Are text message invitations acceptable on this number?

• Yes (1)

• No (2)

<<page break>>

ty

Q6 What is a good phone number to reach you?

________________________________________________________________

Q7 Is this number a cell phone or land line?

• Cell phone (1)

• Land line (2)

• Neither (3)

Q8 We send survey invitations via text message. Are text message invitations acceptable on this number?

• Yes (1)

• No (2)

<<page break>>

Q9 Our records have your email address as ${m://Email1}. Is this correct?

• Yes (1)

• No (2)

<<page break>>

Q10 We usually send updates, notifications, and survey links via email. What is the best email address for us to reach you?

________________________________________________________________

<<page break>>

Q11_a Our records have the following address as your home address where we will mail incentives for taking surveys. Is this correct?

${e://Field/ADDRESS1} ${e://Field/ADDRESS2}
${e://Field/CITY}, ${e://Field/STATE} ${e://Field/ZIP}

• Yes (1)

• No (2)

splay This Question:

Q_11b Our records have the following address as your home address where we will mail incentives for taking surveys. Is this correct?

${e://Field/ADDRESS1}
${e://Field/CITY}, ${e://Field/STATE} ${e://Field/ZIP}

• Yes (1)

• No (2)

Q12 Please enter your home address.

• Address 1 (2) __________________________________________________

• Address 2 (3) __________________________________________________

• City (4) __________________________________________________

• State (5) __________________________________________________

• ZIP Code (6) __________________________________________________

End of Block: Contact Update

Start of Block: Submit_Page

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

End of Block: Submit_Page

Topical 5 Questionnaire

Health Benchmark Survey

Thank you for your continued participation in the Census Household Panel! We are conducting a study with our federal partner agencies and we need your help.  We are interested in your health and wellness, and will be asking you a series of questions about your health history, behaviors, and opinions.  This should take about 20 minutes or less to complete.  The information being collected is for research purposes only, and will assist ongoing efforts to track the health of the American public.

This survey is available in English and Spanish. Please select the language in which you prefer to complete the survey.

If you would like to change your language selection later, please use the drop-down menu in the upper right corner of each page to select the language in which you prefer to complete the survey.

• English (1)

• Español (2)

<<page break>>

Click the “Continue” button below to begin. 

------

The authority for the collection of this information for the Census Household Panel Topical 5, (0607-1025) is provided under Title 13, Section 8(b)) and [insert partner agency authorities].

The purpose of collecting this information is to provide important methodological data to compare the Census Household Panel responses against a national health benchmark survey. These data will be used for methodological assessment of the current panel members representativeness compared to this benchmark and other similar data collection strategies and will be used to inform future directions for recruitment and replenishment.

Disclosure of the information provided to us to other Census Bureau staff for work-related purposes is permitted under the Privacy Act of 1974 (5 U.S.C. § 552a). Disclosure of this information is also subject to all of the published routine uses as identified in the Privacy Act System of Records Notice COMMERCE/Census-3 Demographic Survey Collection (Census Bureau Sampling Frame).

Staff (employees and contractors) received training on privacy and confidentiality policies and practices; access to PII is restricted to authorized personnel only. Personally identifiable information collected includes name, address, telephone/cell phone number, DOB or age, email address, race, or ethnicity.

FedRAMP-approved computer systems that maintain sensitive information are in compliance with the Federal Information Security Management Act. Unsecured telecommunications to transmit individually identifiable information is prohibited. Information will only be shared with staff and contractors that are special sworn status and sponsors of reimbursable surveys.

Furnishing this information is voluntary. Failure to do so will result in no consequences to you. However, without complete survey responses, the Census Bureau will not have access to all of the requested information. Also, only respondents who complete the survey will be eligible for an incentive.

Start of Block: Eligibility

Q1 Our records have your name as ${e://Field/FirstNameFill} ${e://Field/LastNameFill}. Is this correct?

If you need to update the spelling of your name or if your name has legally changed, please email addp.household.panel@census.gov.

Yes (1)

No (3)

End of Block: Eligibility

Start of Block: Not Eligible

R2a You are not eligible to complete this survey. Thank you for your time.

Skip To: End of Survey If R2a Is Displayed

End of Block: Not Eligible

SECTION: Whole Person Health

PROGRAMMING: CREATE “TM_START_WPH”; CREATE “DATE_START_ WPH”

CAPTURE TIME IN TM_START_ WPH

CAPTURE DATE IN DATE_START_ WPH

#[SP; PROMPT TWICE IF REFUSED]

PHSTAT.

Would you say your <u>health in general</u> is excellent, very good, good, fair, or poor?

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

#[SHOW IF PHSTAT=1,2,3,4,5]

[MP]

PROBE_SRH.

When you said your health in general was [INSERT RESPONSE FROM PHSTAT; MAKE FIRST LETTER LOWERCASE], which of the following, if any, were you thinking about?

[REMOVE BOLD] <i>Please select all that apply.</i>

1. Your diet and nutrition

2. Your exercise habits

3. Your smoking or drinking habits

4. Your health problems or conditions

5. Your lack of health problems or conditions

6. The amount of pain that you have

7. Your ability to do daily activities without assistance

8. The amount of sleep you get

9. Your mental or emotional health

10. The Coronavirus or COVID-19 pandemic

11. Something else, please specify: [TEXTBOX]

12. None of the above [SP]

WPH_QOL.

How would you rate your quality of life, focusing on what matters most to you?

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

WPH_SOC.

How would you rate your social and family connections?

CAWI RESPONSE OPTIONS:

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

WPH_DIET.

In general, how healthy is your overall diet?

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

WPH_PHYS.

How would you rate your physical activity?

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

WPH_STRESS.

How would you rate your ability to manage stress?

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

WPH_SLEEP.

How would you rate your sleep?

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

WPH_SPIRIT.

How would you rate your spirituality or spiritual life?

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

WPH_HEALTH.

How would you rate your ability to manage your most bothersome symptom or health concern?

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

[Ask to a random half of the sample]

ATTN_CHK For data quality purposes, please select fair from the list below.

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

PROGRAMMING: CREATE “TM_END_WPH”; CREATE “DATE_END_ WPH”

CAPTURE TIME IN TM_END_ WPH

CAPTURE DATE IN DATE_END_ WPH

SECTION: Calibration Variables

PROGRAMMING: CREATE “TM_START_CALIBRATE”; CREATE “DATE_START_ CALIBRATE”

CAPTURE TIME IN TM_START_ CALIBRATE

CAPTURE DATE IN DATE_START_ CALIBRATE

GAD2.

Over the <u>last 2 weeks</u>, how often have you been bothered by the following problems?

1. Feeling nervous, anxious, or on edge

1. Not at all

2. Several days

3. More than half the days

4. Nearly every day

2. Not being able to stop or control worrying

1. Not at all

2. Several days

3. More than half the days

4. Nearly every day

[SHOW THIS FOOTER AT THE BOTTOM OF PAGE FOR GAD2]

INSERT FOOTER <center> These questions may be difficult to answer. If you need help, please click here for a list of resources. </center>

LINK BEHIND “HERE”: 8935 RTS3 Resources.pdf

CREATE DOV_GAD:

WHEN COMPUTING DOV_GAD, FOR GAD2A AND GAD2B, “NOT AT ALL”=0, “SEVERAL”=1, “MORE THAN HALF”=2, “NEARLY EVERY”=3. ALSO, 77s, 98s, and 99s=0

IF SUM(GAD2A AND GAD2B)>=3, DOV_GAD=1, ELSE DOV_GAD=0

#[GRID SP]

[RECORD TIME ON SCREEN]

PHQ.

Over the <u>last 2 weeks</u>, how often have you been bothered by the following problems?

1. Little interest or pleasure in doing things

1. Not at all

2. Several days

3. More than half the days

4. Nearly every day

2. Feeling down, depressed, or hopeless

1. Not at all

2. Several days

3. More than half the days

4. Nearly every day

[SHOW THIS FOOTER AT THE BOTTOM OF PAGE FOR PHQ2]

INSERT FOOTER <center> These questions may be difficult to answer. If you need help, please click here for a list of resources. </center>

LINK BEHIND “HERE”: 8935 RTS3 Resources.pdf

CREATE DOV_PHQ:

WHEN COMPUTING DOV_PHQ, FOR PHQA AND PHQB, “NOT AT ALL”=0, “SEVERAL”=1, “MORE THAN HALF”=2, “NEARLY EVERY”=3. ALSO, 77s, 98s, and 99s=0

IF SUM(PHQA AND PHQB)>=3, DOV_PHQ =1, ELSE DOV_ PHQ=0

SOCERRNDS.

Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do this at all

SOCSCLPAR.

Because of a physical, mental, or emotional condition, do you have difficulty participating in social activities such as visiting friends, attending clubs and meetings, or going to parties?

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do this at all

#[DISPLAY]

HOVER_DISPLAY1.

[DESKTOP/LAPTOP] There are terms in the following question that have some additional text available to help explain what they are. If you are interested in that additional information, please hover over the terms in blue text to see it.

[MOBILE] There are terms in the following question that have some additional text available to help explain what they are. If you are interested in that additional information, please tap on the terms in blue text to see it.

SOCWRKLIM.

Are you limited in the kind <u>or</u> amount of work you can do because of a physical, mental, or emotional problem? [INSERT FOLLOWING HOVER TEXT OVER “work”: <i>Work includes paid work, volunteer work, schoolwork, and homework.</i>

1. Yes

2. No

CHRONSERIES.

The next few questions are about medical conditions you may have been told you had.

Have you <u>ever</u> been told by a doctor or other health professional that you had…

GRID ITEMS, RANDOMIZE:

HYPEV. Hypertension, also called high blood pressure?

CHLEV. High cholesterol?

CHDEV. Coronary heart disease?

ASEV. Asthma?

COPDEV. Chronic Obstructive Pulmonary Disease (C.O.P.D.), emphysema, or chronic bronchitis?

CANEV. Cancer or a malignancy of any kind?

ARTHEV. Some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?

1. Yes

2. No

#[SHOW IF CHLEV = 1]

CHL12M.

During the past 12 months, have you had high cholesterol?

1. Yes

2. No

#[SHOW IF ASEV = 1]

ASTILL.

Do you still have asthma?

1. Yes

2. No

#[GRID SP]

PULMSERIES.

The next few questions are about other medical conditions you may have been told you had.

Have you <u>ever</u> been told by a doctor or other health professional that you had…

GRID ITEMS, RANDOMIZE AND RECORD:

ANGEV. Angina, also called angina pectoris?

MIEV. A heart attack, also called myocardial infarction?

STREV. A stroke?

1. Yes

2. No

PREDIB.

Has a doctor or other health professional <u>ever</u> told you that you had prediabetes or borderline diabetes?

1. Yes

2. No

GESDIB.

[SHOW IF (SEX=2)]

Has a doctor or other health professional <u>ever</u> told you that you had gestational diabetes, a type of diabetes that occurs <u>only</u> during pregnancy?

1. Yes

2. No

3. Not applicable

DIBEV.

[SHOW IF (PREDIB= 1) AND (GESDIB= 1)] Not including prediabetes or gestational diabetes, has a doctor or other health professional <u>ever</u> told you that you had diabetes?

[SHOW IF (PREDIB= 1) AND (GESDIB= 2,3,77,98,99)] Not including prediabetes, has a doctor or other health professional <u>ever</u> told you that you had diabetes?

[SHOW IF (PREDIB= 2,77,98,99) AND (GESDIB= 1)] Not including gestational diabetes, has a doctor or other health professional <u>ever</u> told you that you had diabetes?

[SHOW IF (PREDIB= 2,77,98,99) AND (GESDIB= 2,3,77,98,99)] Has a doctor or other health professional <u>ever</u> told you that you had diabetes?

1. Yes

2. No

SMKEV.

Have you smoked at least 100 cigarettes in your entire life?

1. Yes

2. No

#[SHOW IF ACCSSINT=1]

[DISPLAY]

HOVER_DISPLAY2.

[DESKTOP/LAPTOP] There are terms in the following question that have some additional text available to help explain what they are. If you are interested in that additional information, please hover over the terms in blue text to see it.

[MOBILE] There are terms in the following question that have some additional text available to help explain what they are. If you are interested in that additional information, please tap on the terms in blue text to see it.

#[SHOW IF ACCSSINT=1]

[GRID; SP]

HIT_GRID.

During the past 12 months, have you used the Internet for any of the following reasons?

[INSERT FOLLOWING HOVER TEXT OVER “Internet”: <i>Include Internet and data use through a computer, tablet, smartphone, or other electronic device.</i>

GRID ITEMS:

HITLOOK. To look for health or medical information.

HITCOMM. To communicate with a doctor or doctor’s office.

HITTEST. To look up medical test results.

1. Yes

2. No

EMPLASTWK.

Last week, did you work for pay at a job or business?

1. Yes

2. No

CEVOLUN1.

During the past 12 months, did you spend any time volunteering for any organization or association?

1. Yes

2. No

#[SHOW IF CEVOLUN1=2,77,98]

CEVOLUN2.

Some people don’t think of activities they do infrequently or for children’s schools or youth organizations as volunteer activities. During the past 12 months, have you done any of these types of activities?

1. Yes

2. No

CEMMETNG.

During the past 12 months, did you attend a public meeting, such as a zoning or school board meeting, that discussed a local issue?

1. Yes

2. No

CEVOTELC.

Did you vote in the <u>last local</u> elections, such as for mayor, councilmembers, or school board?

1. Yes

2. No

PROGRAMMING: CREATE “TM_END_ CALIBRATE”; CREATE “DATE_END_ CALIBRATE”

CAPTURE TIME IN TM_END_ CALIBRATE

CAPTURE DATE IN DATE_END_ CALIBRATE

SECTION: Quality of Life

PROGRAMMING: CREATE “TM_START_QOL”; CREATE “DATE_START_ QOL”

CAPTURE TIME IN TM_START_ QOL

CAPTURE DATE IN DATE_START_ QOL

LSATIS4.

In general, how satisfied are you with your life?

1. Very satisfied

2. Satisfied

3. Dissatisfied

4. Very dissatisfied

#[NUMBOX]

HEALTHYDAY2.

Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

<u>Number of days:</u>

[NUMBER BOX, RANGE 0-30, 98, 99]

#[NUMBOX]

HEALTHYDAY3.

Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

<u>Number of days:</u>

[NUMBER BOX, RANGE 0-30, 98, 99]

[SHOW THIS FOOTER AT THE BOTTOM OF PAGE FOR HEALTHYDAY3]

INSERT FOOTER <center> These questions may be difficult to answer. If you need help, please click here for a list of resources. </center>

LINK BEHIND “HERE”: 8935 RTS2 Resources.pdf

#[NUMBOX]

HEALTHYDAY4.

During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?

<u>Number of days:</u>

[NUMBER BOX, RANGE 0-30, 98, 99]

[SHOW THIS FOOTER AT THE BOTTOM OF PAGE FOR HEALTHYDAY4]

INSERT FOOTER <center> These questions may be difficult to answer. If you need help, please click here for a list of resources. </center>

LINK BEHIND “HERE”: 8935 RTS2 Resources.pdf

PROGRAMMING: CREATE “TM_END_ QOL”; CREATE “DATE_END_ QOL”

CAPTURE TIME IN TM_END_ QOL

CAPTURE DATE IN DATE_END_ QOL

SECTION: Social and Family Connections

PROGRAMMING: CREATE “TM_START_SOC”; CREATE “DATE_START_ SOC”

CAPTURE TIME IN TM_START_ SOC

CAPTURE DATE IN DATE_START_ SOC

[GRID SP]

LSNS6_FAMILYGRID.

Considering the people to whom you are related by birth, marriage, or adoption, how many relatives do you…

GRID ITEMS:

LSNS6_1. See or hear from at least once a month?

LSNS6_2. Feel at ease with that you can talk about private matters?

LSNS6_3. Feel close to such that you could call them for help?

0. None

1. One

2. Two

3. Three or Four

4. Five through Eight

5. Nine or More

[GRID SP]

LSNS6_FRIENDGRID.

Considering all of your friends, including those who live in your neighborhood…

GRID ITEMS:

LSNS6_4. See or hear from at least once a month?

LSNS6_5. Feel at ease with that you can talk about private matters?

LSNS6_6. Feel close to such that you could call them for help?

0. None

1. One

2. Two

3. Three or Four

4. Five through Eight

5. Nine or More

[GRID SP]

STRAIN_GRID.

How often do members of your family or your friends…

GRID ITEMS:

STRAIN1. Criticize you?

STRAIN2. Make too many demands on you?

STRAIN3. Let you down when you are counting on them?

STRAIN4 Get on your nerves?

0. Never

1. Rarely

2. Some of the time

3. Often

UCLA_GRID.

The next questions are about how you feel about different aspects of your life. For each one, [CAWI: indicate; CATI: tell me] how often you feel that way.

GRID ITEMS:

SUPPORT. How often do you get the social and emotional support that you need?

UCLA1. How often do you feel socially isolated from others?

UCLA2. How often do you feel you lack companionship?

UCLA3. How often do you feel left out?

1. Always

2. Usually

3. Sometimes

4. Rarely

5. Never

SECTION: Diet

PROGRAMMING: CREATE “TM_START_DIET”; CREATE “DATE_START_ DIET”

CAPTURE TIME IN TM_START_ DIET

CAPTURE DATE IN DATE_START_ DIET

DQQ_INTRO.

The next questions are about foods and drinks that you consumed yesterday during the day or night, whether you had it at home or somewhere else.

[GRID SP]

DQQ_GRID1.

Yesterday, did you eat any of the following foods and vegetables?

GRID ITEMS:

DQQ1. Bread, rice, pasta, tortilla, or cereal?

DQQ2. Fresh corn, popcorn, oats, granola, brown rice, or quinoa?

DQQ3. Potato?

DQQ4. Beans, refried beans, peas, lentils, hummus, chickpeas, tofu, or lima beans?

DQQ5. Carrots, orange squash, pumpkin, sweet potato, or red bell pepper?

DQQ6. Broccoli, spinach, arugula, kale, collards, turnip greens, or mustard greens?

DQQ7. Lettuce, tomatoes, green beans, celery, green peppers, cabbage, or cucumber?

DQQ8. Zucchini, mushrooms, eggplant, cauliflower, okra, asparagus, or radish?

1. Yes

2. No

[GRID SP]

DQQ_GRID2.

Yesterday, did you eat any of the following fruits?

GRID ITEMS:

DQQ8. Cantaloupe, mango, papaya, apricots, or dried apricots?

DQQ9. Orange, clementine, mandarin, tangerine, or grapefruit?

DQQ10.1. Banana, apple, watermelon, grapes, avocado, berries, or cherries?

DQQ10.2. Pineapple, pear, kiwi, plums, prunes, peaches, or nectarines?

1. Yes

2. No

[GRID SP]

DQQ_GRID3.

Yesterday, did you eat any of the following sweets?

GRID ITEMS:

DQQ11. Cakes, cookies, brownies, donuts, pastries, or pie?

DQQ12. Candy, candy bars, chocolates, ice cream, popsicles, milkshake, or pudding?

1. Yes

2. No

[GRID SP]

DQQ_GRID4.

Yesterday, did you eat any of the following foods of animal origin?

GRID ITEMS:

DQQ13. Eggs?

DQQ14. Cheese?

DQQ15. Yogurt?

DQQ16. Sausages, hot dogs, pepperoni, luncheon meat, ham, or bacon?

DQQ17. Beef, hamburger, lamb, or venison?

DQQ18. Pork?

DQQ19. Chicken or turkey?

DQQ20. Fish, tunafish, shrimp, or seafood?

1. Yes

2. No

[GRID SP]

DQQ_GRID5.

Yesterday, did you eat any of the following other foods?

GRID ITEMS:

DQQ21. Peanut butter, almond butter, peanuts, almonds, cashews, walnuts, pecans, or pistachios?

DQQ22. Potato chips, Cheetos, Doritos, Fritos, or Pringles?

DQQ23. Yogurt?

DQQ24. French fries, onion rings, fried chicken, chicken nuggets, fish sticks, fish fry, or fried shrimp?

1. Yes

2. No

[GRID SP]

DQQ_GRID6.

Yesterday, did you have any of the following beverages?

GRID ITEMS:

DQQ25. Milk, including dairy milk on cereal or in lattes?

DQQ26. Coffee with sugar, sweet coffee drinks, hot cocoa, or chocolate milk?

DQQ27. Fruit juice, fruit-flavored drinks, lemonade, or sweet tea?

DQQ28. Soft drinks or pop such as Coke, Pepsi, Sprite, or Dr Pepper, sports drinks, or energy drinks?

1. Yes

2. No

[SP]

DQQ29.

Yesterday, did you get food from any place like McDonald's, Burger King, Subway, Dunkin, Wendy's, Taco Bell, or Chick-Fil-A?

1. Yes

2. No

PROGRAMMING: CREATE “TM_END_ DIET”; CREATE “DATE_END_ DIET”

CAPTURE TIME IN TM_END_ DIET

CAPTURE DATE IN DATE_END_ DIET

SECTION: Physical Activity

PROGRAMMING: CREATE “TM_START_PHYS”; CREATE “DATE_START_ PHYS”

CAPTURE TIME IN TM_START_ PHYS

CAPTURE DATE IN DATE_START_ PHYS

[DISPLAY]

ACTV_INTRO.

The next questions are about physical activities (exercise, sports, physically active hobbies…) that you may do in your leisure time. The first questions ask about <u>light or moderate</u> physical activities, then there will be questions about <u>vigorous</u> physical activities.

[NUMBOX, DROPDOWN, FOR DROPDOWN HAVE “Per week” AS DEFAULT DISPLAYED]

[PROMPT IF NUMBERBOX HAS VALUE BUT DROPDOWN LIST IS EMPTY]

MODNO. 

How often do you do <u>light or moderate</u> leisure time physical activities for <u>at least 10 minutes</u> that cause <u>only light</u> sweating or a <u>slight to moderate</u> increase in breathing or heart rate?

<u>per day/week/month</u>

[NUMBER BOX, RANGE 0-995, 998] Number of times [DROPDOWN LIST]

DROPDOWN LIST RESPONSE OPTIONS:

1. Never

2. Per day

3. Per week

4. Per month

5. Per year

6. Unable to do this type of activity

[SHOW IF MODNO_DROPDOWN=2,3,4,5 AND (MODNO_NUMBOX>0 AND MODNO_NUMBOX NE ‘998’)]

[NUMBOX, DROPDOWN, FOR DROPDOWN HAVE “Minutes” AS DEFAULT DISPLAYED]

[PROMPT IF NUMBERBOX HAS VALUE BUT DROPDOWN LIST IS EMPTY]

MODLNGNO. 

About how long do you do these light or moderate leisure-time physical activities each time?

<u>Minutes/Hours</u>

[NUMBER BOX, RANGE 1-90, 998] Number of [DROPDOWN LIST]

DROPDOWN LIST RESPONSE OPTIONS:

1. Minutes

2. Hours

[NUMBOX, DROPDOWN, FOR DROPDOWN HAVE “Per week” AS DEFAULT DISPLAYED]

[PROMPT IF NUMBERBOX HAS VALUE BUT DROPDOWN LIST IS EMPTY]

VIGNO. 

How often do you do <u>vigorous</u> leisure-time physical activities for <u>at least 10 minutes</u> that cause <u>heavy</u> sweating or <u>large</u> increases in breathing or heart rate?

<u>per day/week/month</u>

[NUMBER BOX, RANGE 0-99, 998] Number of times [DROPDOWN LIST]

DROPDOWN LIST RESPONSE OPTIONS:

1. Never

2. Per day

3. Per week

4. Per month

5. Per year

6. Unable to do this type of activity

[SHOW IF VIGNO_DROPDOWN=2,3,4,5 AND (VIGNO_NUMBOX>0 AND VIGNO_NUMBOX NE ‘998’)]

[NUMBOX, DROPDOWN, FOR DROPDOWN HAVE “Minutes” AS DEFAULT DISPLAYED]

[PROMPT IF NUMBERBOX HAS VALUE BUT DROPDOWN LIST IS EMPTY]

VIGLNGNO. 

About how long do you do these vigorous leisure-time physical activities each time?

<u>Minutes/Hours</u>

[NUMBER BOX, RANGE 1-90, 998] Number of [DROPDOWN LIST]

DROPDOWN LIST RESPONSE OPTIONS:

1. Minutes

2. Hours

[NUMBOX, DROPDOWN, FOR DROPDOWN HAVE “Per week” AS DEFAULT DISPLAYED]

[PROMPT IF NUMBERBOX HAS VALUE BUT DROPDOWN LIST IS EMPTY]

STRNGNO. 

How often do you do leisure time physical activities specifically designed to <u>strengthen</u> your muscles such as lifting weights or doing calisthenics?

[SPACE]

<i>Include all such activities even if you have mentioned them before.</i>

<u>per day/week/month</u>

[NUMBER BOX, RANGE 0-995, 998] Number of times [DROPDOWN LIST]

DROPDOWN LIST RESPONSE OPTIONS:

1. Never

2. Per day

3. Per week

4. Per month

5. Per year

6. Unable to do this type of activity

PROBE22_1. 

In the last week, did you do any of the following things for 20 or more minutes at once?

<i>Please select all that apply.</i>

1. Running or jogging

2. Hiking

3. Walking as part of your job

4. Walking outside of work

5. Yardwork or cleaning your home

6. Working out with exercise equipment

7. Lifting weights

8. Cycling, swimming, or other aerobic exercises

9. Yoga or stretching

10. Playing a sport, please specify which sport: [TEXTBOX]

11. Other, please specify: [TEXTBOX]

PROGRAMMING: CREATE “TM_END_ PHYS”; CREATE “DATE_END_ PHYS”

CAPTURE TIME IN TM_END_ PHYS

CAPTURE DATE IN DATE_END_ PHYS

SECTION: Stress

PROGRAMMING: CREATE “TM_START_ STRESS”; CREATE “DATE_START_ STRESS”

CAPTURE TIME IN TM_START_ STRESS

CAPTURE DATE IN DATE_START_ STRESS

#[SP]

STRESS.

Stress means a situation in which a person feels tense, restless, nervous, or anxious, or is unable to sleep at night because their mind is troubled all the time.

Within the last 30 days, how often have you felt this kind of stress?

1. Always

2. Usually

3. Sometimes

4. Rarely

5. Never

[SHOW THIS FOOTER AT THE BOTTOM OF PAGE FOR STRESS]

INSERT FOOTER <center> These questions may be difficult to answer. If you need help, please click here for a list of resources. </center>

LINK BEHIND “HERE”: 8935 RTS2 Resources.pdf

#[SP]

PSS_2.

In the last month, how often have you felt that you were unable to control the important things in your life?

1. Always

2. Usually

3. Sometimes

4. Rarely

5. Never

[SHOW THIS FOOTER AT THE BOTTOM OF PAGE FOR PSS_2]

INSERT FOOTER <center> These questions may be difficult to answer. If you need help, please click here for a list of resources. </center>

LINK BEHIND “HERE”: 8935 RTS2 Resources.pdf

#[SP]

PSS_4.

In the last month, how often have you felt confident about your ability to handle your personal problems?

1. Always

2. Usually

3. Sometimes

4. Rarely

5. Never

[SHOW THIS FOOTER AT THE BOTTOM OF PAGE FOR PSS_4]

INSERT FOOTER <center> These questions may be difficult to answer. If you need help, please click here for a list of resources. </center>

LINK BEHIND “HERE”: 8935 RTS2 Resources.pdf

#[SP]

PSS_5.

In the last month, how often have you felt that things were going your way?

1. Always

2. Usually

3. Sometimes

4. Rarely

5. Never

[SHOW THIS FOOTER AT THE BOTTOM OF PAGE FOR PSS_5]

INSERT FOOTER <center> These questions may be difficult to answer. If you need help, please click here for a list of resources. </center>

LINK BEHIND “HERE”: 8935 RTS2 Resources.pdf

#[SP]

PSS_10.

In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

1. Always

2. Usually

3. Sometimes

4. Rarely

5. Never

[SHOW THIS FOOTER AT THE BOTTOM OF PAGE FOR PSS_10]

INSERT FOOTER <center> These questions may be difficult to answer. If you need help, please click here for a list of resources. </center>

LINK BEHIND “HERE”: 8935 RTS2 Resources.pdf

CREATE DOV_PSS:

PROGRAMMING: CREATE “TM_END_ STRESS”; CREATE “DATE_END_ STRESS”

CAPTURE TIME IN TM_END_ STRESS

CAPTURE DATE IN DATE_END_ STRESS

SECTION: Sleep

PROGRAMMING: CREATE “TM_START_ SLEEP”; CREATE “DATE_START_ SLEEP”

CAPTURE TIME IN TM_START_ SLEEP

CAPTURE DATE IN DATE_START_ SLEEP

[NUMBOX]

PSQI_1.

During the past month, what time have you usually gone to bed at night?

Insert hour, minutes and am/pm

[NUMBOX]

PSQI_2

During the past month, how long (in minutes) has it usually taken you to fall asleep each night?

[0-1440] minutes

[NUMBOX]

PSQI_3.

During the past month, what time have you usually gotten up in the morning?

[0-100] Insert hour, minutes and am/pm

[NUMBOX]

PSQI_4.

During the past month, how many hours of actual sleep did you get at night?

This may be different than the number of hours you spent in bed.

[0-24] hours

[GRID, SP]

PSQI_5.

During the past month, how often have you had trouble sleeping because you…

GRID ITEMS:

1. Cannot get to sleep within 30 minutes

2. Wake up in the middle of the night or early morning

3. Have to get up to use the bathroom

4. Cannot breathe comfortably

5. Cough or snore loudly

6. Feel too cold

7. Feel too hot

8. Had bad dreams

9. Have pain

10. Some other reason, please specify [TEXTBOX]

0. Not during the past month

1. Less than once a week

2. Once or twice a week

3. Three or more times a week

[SP]

PSQI_6.

During the past month, how would you rate your sleep quality overall?

0. Very good

1. Fairly good

2. Fairy bad

3. Very bad

[GRID, SP]

PSQI_67GRID.

During the past month, how often have you…

CAWI GRID ITEMS:

PSQI_6. taken medicine to help you sleep?

PSQI_7. had trouble staying awake while driving, eating meals, or engaging in social activity?

0. Not during the past month

1. Less than once a week

2. Once or twice a week

3. Three or more times a week

[SP]

PSQI_9.

During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done?

0. No problem at all

1. Only a slight problem

2. Somewhat of a problem

3. A very big problem

PROGRAMMING: CREATE “TM_END_ SLEEP”; CREATE “DATE_END_ SLEEP”

CAPTURE TIME IN TM_END_ SLEEP

CAPTURE DATE IN DATE_END_ SLEEP

SECTION: Discrimination

PROGRAMMING: CREATE “TM_START_DISCRIM”; CREATE “DATE_START_DISCRIM”

CAPTURE TIME IN TM_START_DISCRIM

CAPTURE DATE IN DATE_START_DISCRIM

#[GRID SP]

EDS.

These next questions are about times and places where you were treated unfairly. In your day-to-day life, how often have any of the following things happened to you?

GRID ITEMS, RANDOMIZE AND RECORD:

EDSA. You are treated with less courtesy or respect than other people

EDSB. Compared to other people, you receive poorer service at restaurants or stores

EDSC. People act as if they think you are not smart

EDSD. People act as if they are afraid of you

EDSE. You are threatened or harassed

1. At least once a week

2. A few times a month

3. A few times a year

4. Less than once a year

5. Never

CREATE DOV_EDS:

IF ANY OF EDSA TO EDSE = 1-4 DOV_EDS=1

ELSE DOV_EDS=0

#[SHOW IF P_DISCR=1 AND DOV_EDS=1]

[SP]

EDS_FU.

What do you think the main reason is for these experiences?

1. Your Ancestry or National Origins

2. Your Gender

3. Your Race

4. Your Age

5. Your Religion

6. Your Height

7. Your Weight

8. Some other Aspect of Your Physical Appearance

9. Your Sexual Orientation

10. Your Education or Income Level

#[GRID SP]

HVS.

In your day-to-day life, how often did you…

GRID ITEMS, RANDOMIZE AND RECORD:

HVSA. Try to prepare for possible insults from other people before leaving home?

HVSB. Feel that you have to be very careful about appearance to get good service or avoid getting harassed?

HVSC. Carefully watch what you say and how you say it?

HVSD. Try to avoid certain social situations and places?

1. Almost every day

2. At least once a week

3. A few times a month

4. A few times a year

5. Less than once a year

6. Never

CREATE DOV_HVS:

IF ANY OF HVSA TO HVSD = 1-5 DOV_HVS=1

ELSE DOV_HVS=0

CREATE PROBE_EDSHVS_FILL:

IF RND_01 = 1 PROBE_EDSHVS_FILL = you are treated with less courtesy or respect than other people

IF RND_01 = 2 PROBE_EDSHVS_FILL = you receive poorer service than other people at restaurants or stores

IF RND_01 = 3 PROBE_EDSHVS_FILL = people act as if they think you are not smart

IF RND_01 = 4 PROBE_EDSHVS_FILL = people act as if they are afraid of you

IF RND_01 = 5 PROBE_EDSHVS_FILL = you are threatened or harassed

IF RND_01 = 6 PROBE_EDSHVS_FILL = you try to prepare for possible insults from other people before leaving home

IF RND_01 = 7 PROBE_EDSHVS_FILL = you feel that you have to be very careful about appearance to get good service or avoid getting harassed

IF RND_01 = 8 PROBE_EDSHVS_FILL = you carefully watch what you say and how you say it

IF RND_01 = 9 PROBE_EDSHVS_FILL = you try to avoid certain social situations and places

#[TEXTBOX]

PROBE_EDSHVS.

When we asked you how often [PROBE_EDSHVS_FILL], what were you thinking about?

[LARGE TEXTBOX]

#[SP]

PROBE_DISCRIM.

[SHOW IF P_PROMPT=1] We want to better understand how you think about some of the questions we are asking you in this survey.

When answering the previous few questions about your experiences and how you have been treated, which of the following, if any, were you mainly thinking about?

1. Racism or discrimination based on your race and ethnicity

2. Negative social interactions, such as receiving poor service at stores or dealing with rude people

3. Social inequalities based on things like age, gender, and education

4. Something else, please specify [TEXTBOX]

PROGRAMMING: CREATE “TM_END_ DISCRIM”; CREATE “DATE_END_ DISCRIM”

CAPTURE TIME IN TM_END_ DISCRIM

CAPTURE DATE IN DATE_END_ DISCRIM

SECTION CLOSE: Burden and Close

[COPY OF ATEST SID 3459]

BURDEN1.

How burdensome was it to complete this survey?

1. Not at all burdensome

2. A little burdensome

3. Moderately burdensome

4. Very burdensome

5. Extremely burdensome

[COPY OF ATEST SID 3459]

BURDEN2.

How difficult was it to answer the questions?

1. Not at all difficult

2. A little difficult

3. Moderately difficult

4. Very difficult

5. Extremely difficult

RE-COMPUTE QUAL=1 “COMPLETE”

SET CO_DATE, CO_TIME, CO_TIMER VALUES HERE

SCRIPTING NOTES: PUT QFINAL1, QFINAL1_TEXT, in the same screen.

[SINGLE CHOICE]

QFINAL1.

Thank you for your time today. To help us improve your experience, please give us feedback on this survey.

Please rate this survey overall from 1 to 7 where 1 is Poor and 7 is Excellent.

Poor						Excellent
1	2	3	4	5	6	7

If you do not have any feedback for us today, please click “Continue” through to the end of the survey so we can make sure your opinions are counted.

QFINAL1_TEXT.

Those are all the questions we have.

Display This Question:

If BestPhone Is Not Empty

POC_display Please review the contact information we have for you and indicate whether the information is correct or needs to be updated.

Display This Question:

If BestPhone Is Not Empty

And BestPhone != -99

Q3
Our records have your phone number as ${e://Field/BestPhone}. Is this correct?

• Yes (1)

• No (2)

Display This Question:

If Q3 = Yes

Q4
Is this number a cell phone or land line?

• Cell phone (1)

• Land line (2)

• Neither (3)

Display This Question:

If Q4 = Cell phone

Q5 We send survey invitations via text message. Are text message invitations acceptable on this number?

• Yes (1)

• No (2)

Display This Question:

If Q3 != Yes

And Q3 , Yes Is Displayed

Or If

Q4 = Neither

Or If

BestPhone = -99

Or BestPhone Is Empty

Q6 What is a good phone number to reach you?

________________________________________________________________

Display This Question:

If If What is a good phone number to reach you? Text Response Is Not Empty

Q7
Is this number a cell phone or land line?

• Cell phone (1)

• Land line (2)

• Neither (3)

Display This Question:

If Q7 = Cell phone

Q8 We send survey invitations via text message. Are text message invitations acceptable on this number?

• Yes (1)

• No (2)

Display This Question:

If Contact List Email1 Is Not Empty

And Contact List Email1 != -99

And Contact List Email1 != DELETE@TEMP.COM

And Contact List Email1 != delete@temp.com

Q9
Our records have your email address as ${m://Email1}. Is this correct?

• Yes (1)

• No (2)

Display This Question:

If Contact List Email1 = -99

Or Contact List Email1 Is Empty

Or Contact List Email1 = DELETE@TEMP.COM

Or If

Q9 , Yes Is Displayed

And Q9 != Yes

Q10 We usually send updates, notifications, and survey links via email. What is the best email address for us to reach you?

________________________________________________________________

Display This Question:

If ADDRESS1 Is Not Empty

And ADDRESS2 Is Not Empty

And CITY Is Not Empty

And STATE Is Not Empty

And ZIP Is Not Empty

And ADDRESS1 != -99

And ADDRESS2 != -99

And CITY != -99

And STATE != -99

And ZIP != -99

Q11_a Our records have the following address as your home address where we will mail incentives for taking surveys. Is this correct?

${e://Field/ADDRESS1} ${e://Field/ADDRESS2}
${e://Field/CITY}, ${e://Field/STATE} ${e://Field/ZIP}

• Yes (1)

• No (2)

Display This Question:

If ADDRESS1 Is Not Empty

And ADDRESS2 = -99

And CITY Is Not Empty

And STATE Is Not Empty

And ZIP Is Not Empty

And ADDRESS1 != -99

And CITY != -99

And STATE != -99

And ZIP != -99

Or If

ADDRESS1 Is Not Empty

And ADDRESS2 Is Empty

And CITY Is Not Empty

And STATE Is Not Empty

And ZIP Is Not Empty

And ADDRESS1 != -99

And CITY != -99

And STATE != -99

And ZIP != -99

Q_11b Our records have the following address as your home address where we will mail incentives for taking surveys. Is this correct?

${e://Field/ADDRESS1}
${e://Field/CITY}, ${e://Field/STATE} ${e://Field/ZIP}

• Yes (1)

• No (2)

Display This Question:

If Q11_a = No

Or Q_11b = No

Or If

ADDRESS1 Is Empty

Or CITY Is Empty

Or STATE Is Empty

Or ZIP Is Empty

Or ADDRESS1 = -99

Or CITY = -99

Or STATE = -99

Or ZIP = -99

Q12 Please enter your home address.

• Address 1 (2) __________________________________________________

• Address 2 (3) __________________________________________________

• City (4) __________________________________________________

• State (5) __________________________________________________

• ZIP Code (6) __________________________________________________

End of Block: Contact Update

Start of Block: Submit_Page

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

End of Block: Submit_Page

Topical 6 Questionnaire

Demographic Program Roster Research

Language Thank you for your continued participation in the Census Household Panel! This month’s survey will be short (less than 10 minutes) and will ask you about any updates to the people living with you since you joined the panel a few months ago. The information being collected is for research purposes only, and will assist ongoing efforts to understand living situations of the American public.

This survey is available in English and Spanish. Please select the language in which you prefer to complete the survey.

If you would like to change your language selection later, please use the drop-down menu in the upper right corner of each page to select the language in which you prefer to complete the survey.

• English (1)

• Español (2)

<<page break>>

Click the “Continue” button below to begin. 

------

The authority for the collection of this information for the Census Household Panel Topical 4 6 (0607-1025) is provided under Title 13, Sections 141 and 182.

The purpose of collecting this information is to support the development of content for a Census Bureau survey being redeveloped to move towards a multi-mode design that would allow for Internet Self Response (ISR). To ensure this design is ready for full implementation, we are incorporating the roster and demographic questions into the Census Household Panel to test their usability in the field.

Disclosure of the information provided to us to other Census Bureau staff for work-related purposes is permitted under the Privacy Act of 1974 (5 U.S.C. § 552a). Disclosure of this information is also subject to all of the published routine uses as identified in the Privacy Act System of Records Notice COMMERCE/Census-3 Demographic Survey Collection (Census Bureau Sampling Frame).

Staff (employees and contractors) received training on privacy and confidentiality policies and practices; access to PII is restricted to authorized personnel only. Personally identifiable information collected includes name, address, telephone/cell phone number, DOB or age, email address, race, or ethnicity.

FedRAMP-approved computer systems that maintain sensitive information are in compliance with the Federal Information Security Management Act. Unsecured telecommunications to transmit individually identifiable information is prohibited. Information will only be shared with staff and contractors that are special sworn status and sponsors of reimbursable surveys.

Furnishing this information is voluntary. Failure to do so will result in no consequences to you. However, without complete survey responses, the Census Bureau will not have access to all of the requested information. Also, only respondents who complete the survey will be eligible for an incentive.

Start of Block: Eligibility

Q1 Our records have your name as ${e://Field/FirstNameFill} ${e://Field/LastNameFill}. Is this correct?

If you need to update the spelling of your name or if your name has legally changed, please email addp.household.panel@census.gov.

Yes (1)

No (3)

End of Block: Eligibility

Start of Block: Not Eligible

Display This Question:

R2a You are not eligible to complete this survey. Thank you for your time.

Skip To: End of Survey If R2a Is Displayed

End of Block: Not Eligible

Identify and Loop Through People Who Have Left the Household: 

ROST_RNAME

Last October, the following people were listed as living or staying with you: 

•  List names (but do not list respondent)
  
  

Is there anyone on this list who no longer lives or stays with you?

• Only include people who live and stay with you most of the time. Do not include family members who live on-campus at college or boarding schools, or are living in Military Barracks.

1. Yes, I need to remove one or more people

2. No, all of these people still live or stay with me
   
   

ROST_REMOVE

Who no longer lives or stays here? Select all that apply.

  List names (do not list respondent)

REASON_LEFT

What is the main reason [NAME] no longer lives with you? Select one.

1. Deceased

2. Moved to a separate address in the U.S.

3. On active duty in the Armed Forces

4. Moved outside of the U.S.

5. Moved to a nursing home, hospital, or group living facility

6. Institutionalized (for example, jail or a correctional facility)

7. Any other reason, Specify: _______________

MONTH_LEFT

When did [NAME] [fill]?

If reason_left = 1, then fill = “pass away”

If reason_left = 2, 3, 4, 5 or 6 = “leave”

DROP DOWN [MONTH][YEAR]

[] They never lived at this address (consider an open write-in response for details)

HHSTAT2_REL

When you lived together, how was ^HHSTAT2_ROSTNAMEFIL related to ^TEMPNAME?

1. Spouse

2. Unmarried partner

3. Child

4. Sibling

5. Parent

6. Grandchild

7. Parent-in-law

8. Son-in-law or Daughter-in-law

9. Other relative

10. Roommate or Housemate

11. Foster child

12. Other nonrelative

Identify and Loop Through Demos for People Who Are Added to the Household: 

ROST_FNAME

For one person household (based on previous CHP response): Is there anyone living or staying with you?

• Include babies, small children, non-relatives, or anyone else who recently started living or staying with you.

• Only include people who live and stay with you most of the time. Do not include family members who live on-campus at college or boarding schools, or are living in Military Barracks.

1. Yes

2. No

For multiple person household:

ROST_FNAME: Is there anyone else living or staying with you now that is not on this list?

*List updated Roster (list roster after respondent removes any names) (list all names, but not respondent)

• Include babies, small children, non-relatives, or anyone else who recently started living or staying with you.

• Only include people who live and stay with you most of the time. Do not include family members who live on-campus at college or boarding schools, or are living in Military Barracks.

1. Yes, I need to add one or more people

2. No, the list is correct

NEW_NUM 

How many people are living or staying with you now that are not on this list? 

 

[Write-in] 

ROST_ADD

List the names of each additional person who is now living or staying with you:

The names listed so far are:

List updated roster

[Programming Note: Display the number of lines noted in NEW_NUM.]

First Name: [Text box displayed] Last Name: [Text box displayed]

REASON_ADDED

What is the main reason [NAME] started living with you? Select one.

1. Birth

2. Moved here after living inside of the U.S.

3. Returned from active duty in the Armed Forces

4. Moved here after living outside of the U.S.

5. Moved here after living in a nursing home, hospital, or group living facility

6. Moved here after being institutionalized (for example, jail or a correctional facility

7. Any other reason, Specify:________________

MONTH_ENTERED

When [fill] [NAME] [fill]?

If reason_added = 1, then fill = “was [NAME] born”

If reason_left = 2, 3, 4, 5 or 6 = “did [NAME] move in”

DROP DOWN [MONTH] [YEAR]

NAME_VERIFY

For one-person household:

Have you legally changed your name since September?

[Show the September roster]

1. Yes

2. No

For multi-person household:

Is there anyone on this list who legally changed their name since September?

[Show the September roster without the people who left]

1. Yes, one or more people have legally changed their name

2. No, everyone is listed correctly

If No: move to next question

If Yes: move to NAME_CHANGE

NAME_CHANGE

For one-person household:

[Show the September roster]

Please make any name corrections below.

For multi-person household:

Who has legally changed their name since September?

[Show the September roster without the respondent or people who left]

Please make any name corrections below.

DOB_BMONTH, DOB_BDAY, DOB_BYEAR

What ^ISWAS ^TEMPNAME’s date of birth?

DROP DOWN [Month] [Day] [Year]

WHICH_AGE

How old is TEMPNAME now?

1. ^AGEX

2. ^AGEX+1 years old

AGEGES

Approximately how old do you think TEMPNAME is? Your best guess is fine.

SEX

What sex was ^TEMPNAME assigned at birth, on their original birth certificate?

1. Male

2. Female

GENID

Does ^TEMPNAME currently describe themselves as male, female, transgender, or some other way?

1. Male

2. Female

3. Transgender

4. Nonbinary

5. ^THEY_I_FILL use a different term: __________________________________

DEM2

Which of the following best represents how ^TEMPNAME thinks of themselves?

1. Gay or lesbian

2. Straight, that is not gay or lesbian

3. Bisexual

4. They use a different term: __________________

RELRPEXP

'What ^AREISWASWERE ^TEMPNAME’s relationship to ^PYOUFIL?'

1. Spouse

2. Unmarried partner

3. Child

4. Sibling

5. Parent

6. Grandchild

7. Parent-in-law

8. Son-in-law or Daughter-in-law

9. Other relative

10. Roommate or Housemate

11. Foster child

12. Other nonrelative

ORIGIN

^C_AREISWAS ^TEMPNAME of Hispanic, Latino, or Spanish origin?

1. No, not of Hispanic, Latino, or Spanish origin

2. Yes, Mexican, Mexican American, or Chicano

3. Yes, Puerto Rican

4. Yes, Cuban

5. Yes, another Hispanic, Latino, or Spanish origin, Specify: ________________

RACE

What is [name]’s race?

Mark all that apply.

1. White

2. Black or African American

3. American Indian or Alaska Native

4. Asian

5. Native Hawaiian or Other Pacific Islander

6. Some other race, Specify: ________________________

I_BORNUS

^C_WASWERE ^TEMPNAME born in the United States or in a U.S. territory?

1. Yes

2. No

HHSPEAK2

Does ^TEMPNAME regularly speak a language other than ^LANGUAGE at home?

If Language = 1 then display: Include American Sign Language as an English Language.

If Language = 2 then display: Include Mexican Sign Language and Spanish Sign Language as a Spanish Language.

1. Yes

2. No, only ^LANGUAGE

WHOSPEAK

Who regularly speaks a language other than ^LANGUAGE at home?

Select all that apply.

1. Display the ^LNO ^ROST_FNAME ^ROST_LNAME where AGE >= 2

…

20.Display the ^LNO ^ROST_FNAME ^ROST_LNAME where AGE >= 2

LANG1

What language is regularly spoken at home?

If more than one, select the language spoken most often.

1. Spanish or Spanish Creole (only if Language = 1)

2. English (only if Language = 2)

3. Chinese

4. French (including Patois, Cajun)

5. French Creole

6. Tagalog or Filipino

7. Vietnamese

8. German

9. Korean

10. Russian

11. Italian

12. Hindi or Urdu

13. Arabic

14. Portuguese or Portuguese Creole

15. Polish

16. Persian

17. Gujarati

18. Other, please specify: _________________

HOWWELL

How well ^DODOES ^TEMPNAME speak English?

1. Very well

2. Well

3. Not well

4. Not at all

MARITAL_STATUS

What [AREISWAS] ^TEMPNAME’s marital status?

1. Married

2. Widowed

3. Divorced

4. Separated

5. Never Married

WHO_SPOUSE

Who is ^PTEMPNAME spouse?

1. ^PTEMPNAME's spouse does not live in this household

2. Display the ^LNO ^ROST_FNAME ^ROST_LNAME where AGE >= 15

…

20.Display the ^LNO ^ROST_FNAME ^ROST_LNAME where AGE >= 15

PAR1HHLD

^DODOES ^NAMEFIL2 have a parent who lives in this household?

Include biological, step and adoptive parents.

1. Yes

2. No

PAR1_WHO

Who is ^PNAMEFIL2 parent?

1. Display the ^LNO ^ROST_FNAME ^ROST_MNAME ^ROST_LNAME where AGE >= 15 and not equal WHO_SP

…

20.Display the ^LNO ^ROST_FNAME ^ROST_MNAME ^ROST_LNAME where AGE >= 15 and not equal WHO_SP

PAR1TYPE

Is ^NAMEFIL2 ^PPAR1NAME biological, step, or adopted child?

1. Biological child

2. Stepchild

3. Adopted child

4. Foster child

PAR2HHLD

^DODOES ^NAMEFIL2 have another parent who lives in this household?

Include biological, step and adoptive parents.

1. Yes

2. No

PAR2_WHO

Who is ^PNAMEFIL2 other parent?

1. Display the ^LNO ^ROST_FNAME ^ROST_MNAME ^ROST_LNAME where AGE >= 15 and not equal WHO_SP

…

20.Display the ^LNO ^ROST_FNAME ^ROST_MNAME ^ROST_LNAME where AGE >= 15 and not equal WHO_SP

PAR2TYPE

^C_AREISWAS ^NAMEFIL2 ^PPAR2NAME biological, step, or adopted child?

1. Biological child

2. Stepchild

3. Adopted child

4. Foster child

EDUC

“What ^ISWAS_EDUC the highest degree or level of school ^TEMPNAME has completed?

31. Less than 1^st grade

32. 1^st, 2^nd, 3^rd or 4^th grade

33. 5^th or 6^th grade

34. 7^th or 8^th grade

35. 9^th grade

36. 10^th grade

37. 11^th grade

38. 12^th grade, no diploma

39. High School Graduate (regular high school diploma)

40. GED or equivalent

41. Some college credit, but less than 1 year of college credit

42. 1 or more years of college, no degree

43. Associate degree (for example: AA, AS))

44. Bachelor’s degree (for example: BA, BS)

45. Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA )

46. Professional degree beyond a bachelor’s degree (for example: MD, DDS, DVM, LLB, JD)

47. Doctorate degree (for example: PhD, EdD)

HSGRAD_GED 

 

Did ^TEMPNAME get ^HISHER high school diploma by graduating from high school, or by passing a GED exam or other equivalent? 

 

1. Graduating from high school 

2. GED or other equivalent 

3. No diploma or GED 

Begin a Loop to Re-ask/Confirm or Ask New Questions about Original Household Members Who Still Live in the Household: 

 

Intro: Now we’d like to ask and update some information about you and the people who have been staying or living with you since October.  

 

[Programming Note: Develop this loop using the Unselected Choices in ROSTER_REMOVE] 

 

RELRPEXP 

 
'What ^AREISWASWERE ^TEMPNAME’s relationship to ^PYOUFIL?' 

 

1. Spouse

2. Unmarried partner

3. Child

4. Sibling

5. Parent

6. Grandchild

7. Parent-in-law

8. Son-in-law or Daughter-in-law

9. Other relative

10. Roommate or Housemate

11. Foster child

12. Other nonrelative

 

I_BORNUS 

^C_WASWERE ^TEMPNAME born in the United States or in a U.S. territory?  

 

1. Yes 

2. No 

 

HHSPEAK2 

 

Does ^TEMPNAME regularly speak a language other than ^LANGUAGE at home? 

 

If Language = 1 then display: Include American Sign Language as an English Language. 

If Language = 2 then display: Include Mexican Sign Language and Spanish Sign Language as a Spanish Language. 

 

1. Yes 

2. No, only ^LANGUAGE 

 

WHOSPEAK 

  Who regularly speaks a language other than ^LANGUAGE at home?   

Select all that apply. 

 

1. Display the ^LNO ^ROST_FNAME ^ROST_LNAME where AGE >= 2 

… 

20.Display the ^LNO ^ROST_FNAME ^ROST_LNAME where AGE >= 2 

 

LANG1 

 

What language is regularly spoken at home? 

 

If more than one, select the language spoken most often.  

 

1. Spanish or Spanish Creole (only if Language = 1) 

2. English (only if Language = 2) 

3. Chinese 

4. French (including Patois, Cajun) 

5. French Creole 

6. Tagalog or Filipino 

7. Vietnamese 

8. German 

9. Korean 

10. Russian 

11. Italian 

12. Hindi or Urdu 

13. Arabic 

14. Portuguese or Portuguese Creole 

15. Polish 

16. Persian 

17. Gujarati 

18. Other, please specify: _________________ 

 

 HOWWELL  

How well ^DODOES ^TEMPNAME speak English? 

 

1. Very well 

2. Well 

3. Not well 

4. Not at all 

 

MARITAL_STATUS 

What [AREISWAS] ^TEMPNAME’s marital status? 

 

1. Married 

2. Widowed 

3. Divorced 

4. Separated 

5. Never Married 

 

WHO_SPOUSE  

Who is ^PTEMPNAME spouse? 

1. ^PTEMPNAME's spouse does not live in this household  

2. Display the ^LNO ^ROST_FNAME ^ROST_LNAME where AGE >= 15 

… 

20.Display the ^LNO ^ROST_FNAME ^ROST_LNAME where AGE >= 15 

 

PAR1HHLD

^DODOES ^NAMEFIL2 have a parent who lives in this household?

Include biological, step and adoptive parents.

1. Yes

2. No

PAR1_WHO

Who is ^PNAMEFIL2 parent?

1. Display the ^LNO ^ROST_FNAME ^ROST_MNAME ^ROST_LNAME where AGE >= 15 and not equal WHO_SP

…

20.Display the ^LNO ^ROST_FNAME ^ROST_MNAME ^ROST_LNAME where AGE >= 15 and not equal WHO_SP

PAR1TYPE

Is ^NAMEFIL2 ^PPAR1NAME biological, step, or adopted child?

1. Biological child

2. Stepchild

3. Adopted child

4. Foster child

PAR2HHLD

^DODOES ^NAMEFIL2 have another parent who lives in this household?

Include biological, step and adoptive parents.

1. Yes

2. No

PAR2_WHO

Who is ^PNAMEFIL2 other parent?

1. Display the ^LNO ^ROST_FNAME ^ROST_MNAME ^ROST_LNAME where AGE >= 15 and not equal WHO_SP

…

20.Display the ^LNO ^ROST_FNAME ^ROST_MNAME ^ROST_LNAME where AGE >= 15 and not equal WHO_SP

PAR2TYPE

^C_AREISWAS ^NAMEFIL2 ^PPAR2NAME biological, step, or adopted child?

1. Biological child

2. Stepchild

3. Adopted child

4. Foster child

 

EDUC

We’d like to make sure our records are correct.  Last time we recorded that [First Name Last_Name] highest degree or level of school completed is ^EDUC_FILL2.  Is this still correct?   

1. Yes 

2. No 

 

 
 If the answer is no 
 
 
“What ^ISWAS_EDUC the highest degree or level of school ^TEMPNAME has completed?  

31. Less than 1^st grade 

32. 1^st, 2^nd, 3^rd or 4^th grade 

33. 5^th or 6^th grade 

34. 7^th or 8^th grade 

35. 9^th grade 

36. 10^th grade 

37. 11^th grade 

38. 12^th grade, no diploma 

39. High School Graduate (regular high school diploma)   

40. GED or equivalent 

41. Some college credit, but less than 1 year of college credit  

42. 1 or more years of college, no degree  

43. Associate degree (for example: AA, AS)) 

44. Bachelor’s degree (for example: BA, BS) 

45. Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA ) 

46. Professional degree beyond a bachelor’s degree (for example: MD, DDS, DVM, LLB, JD) 

47. Doctorate degree (for example: PhD, EdD) 

 

HSGRAD_GED 

 

Did ^TEMPNAME get ^HISHER high school diploma by graduating from high school, or by passing a GED exam or other equivalent? 

 

1. Graduating from high school 

2. GED or other equivalent 

3. No diploma or GED 

 

Asked to the CHP Respondent – Not part of a loop 

AF_HHLD

Did you or anyone in your household ever serve on active duty in the U.S. Armed Forces?

1. Yes

2. No

AF_WHO

Which household members have served on active duty in the U.S. Armed Forces?

Select all that apply.

1. Display the ^LNO ^ROST_FNAME ^ROST_LNAME where AGE >= 17 and PEOPLE_TO_ROSTER = 1

…

20.Display the ^LNO ^ROST_FNAME ^ROST_LNAME where AGE >= 17 and PEOPLE_TO_ROSTER = 1

AFWHEN

During which time period(s) did ^TEMPNAME serve on Active duty?

Select all that apply.

1. September 2001 to present

2. August 1990 to August 2001 (including Persian Gulf War)

3. May 1975 to July 1990

4. Vietnam Era (August 1964 to April 1975)

5. February 1955 to July 1964

6. Korean War (July 1950 to January 1955)

7. January 1947 to June 1950

8. World War II or earlier (December 1946 or earlier)

AFNOW

^C_AREIS ^TEMPNAME now on active duty?

1. Yes

2. No

Trust1a_check Below is a list of institutions in American society. Please indicate how much confidence you, yourself, have in each one.

	A great deal (1)	Quite a lot (2)	Some (3)	Very little (4)
The military (1)
The police (2)
The U.S. Supreme Court (3)
The presidency (4)
Public schools (5)
For data quality purposes, please select “Some” (6)
The criminal justice system (8)
Congress (9)
U.S. Census Bureau (10)
U.S. statistical agencies (11)

End of Block: Trust1a_with check

Start of Block: Trust1a_no check

Trust1a_no check Below is a list of institutions in American society. Please indicate how much confidence you, yourself, have in each one.

	A great deal (1)	Quite a lot (2)	Some (3)	Very little (4)
The military (1)
The police (2)
The U.S. Supreme Court (3)
The presidency (4)
Public schools (5)
The criminal justice system (8)
Congress (9)
U.S. Census Bureau (10)
U.S. statistical agencies (11)

End of Block: Trust1a_no check

TRUST1b Below is a list of institutions in American society. Please indicate how much confidence you, yourself, have in each one.

	A great deal (1)	Quite a lot (2)	Some (3)	Very little (4)
Small business (1)
The church or organized religion (2)
The medical system (3)
Banks (4)
Newspapers (5)
Organized labor (12)
Big business (13)
News on the internet (14)
News on social media (15)
Television news (16)

TRUST2 The census, the number of deaths in the U.S. by different diseases, the crime rate, and unemployment rate are examples of federal statistics produced by federal statistical agencies (like the Census Bureau and the Bureau of Labor Statistics) that are part of the federal government. Have you ever used federal statistics for study or work?

• Yes (1)

• No (2)

TRUST3 Personally, how much trust do you have in the federal statistics in the United States? Would you say that you tend to trust federal statistics or tend not to trust them?

• Tend to trust (1)

• Tend not to trust (2)

POC_display Please review the contact information we have for you and indicate whether the information is correct or needs to be updated.

Q3
Our records have your phone number as ${e://Field/BestPhone}. Is this correct?

• Yes (1)

• No (2)

Q4
Is this number a cell phone or land line?

• Cell phone (1)

• Land line (2)

• Neither (3)

Q5 We send survey invitations via text message. Are text message invitations acceptable on this number?

• Yes (1)

• No (2)

<<page break>>

Q6 What is a good phone number to reach you?

________________________________________________________________

Q7 Is this number a cell phone or land line?

• Cell phone (1)

• Land line (2)

• Neither (3)

Q8 We send survey invitations via text message. Are text message invitations acceptable on this number?

• Yes (1)

• No (2)

Q9
Our records have your email address as ${m://Email1}. Is this correct?

• Yes (1)

• No (2)

<<page break>>

Q10 We usually send updates, notifications, and survey links via email. What is the best email address for us to reach you?

________________________________________________________________

<<page break>>

Q11_a Our records have the following address as your home address where we will mail incentives for taking surveys. Is this correct?

${e://Field/ADDRESS1} ${e://Field/ADDRESS2}
${e://Field/CITY}, ${e://Field/STATE} ${e://Field/ZIP}

• Yes (1)

• No (2)

Q_11b Our records have the following address as your home address where we will mail incentives for taking surveys. Is this correct?

${e://Field/ADDRESS1}
${e://Field/CITY}, ${e://Field/STATE} ${e://Field/ZIP}

• Yes (1)

• No (2)

<<page break>>

Q12 Please enter your home address.

• Address 1 (2) __________________________________________________

• Address 2 (3) __________________________________________________

• City (4) __________________________________________________

• State (5) __________________________________________________

• ZIP Code (6) __________________________________________________

End of Block: Contact Update

Start of Block: Submit_Page

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

End of Block: Submit_Page