ACASI Household Screener

Household Screener

INTRO01 (IF HOUSEHOLD RETURNED ROSTER)

Hello, I am __________ from Westat. Someone from your household recently returned a brief survey regarding an important health and safety study being conducted by the Bureau of Justice Statistics. We have determined that your household is eligible to participate in the study

I have a few questions that will tell us whether anyone living here can take part in our study. . All information you provide will be treated as confidential and is protected by federal statute (Title 42 USC, Section 3735 and 3789g). Your participation is voluntary. However, your cooperation is very important to the success of this study. If an adult is selected for the study, that person will receive $40 as a thank you for completing a full interview.

INTRO02 (IF HOUSEHOLD DID NOT RETURN ROSTER)

Hello, I am __________ from Westat. We recently sent your household a brief survey regarding an important health and safety study being conducted by the Bureau of Justice Statistics. I have a few questions that will tell us whether anyone living here can take part in our study.

All information you provide will be treated as confidential and is protected by federal statute (Title 42 USC, Section 3735 and 3789g). Your participation is voluntary. However, your cooperation is very important to the success of this study. If an adult is selected for the study, that person will receive $40 as a thank you for completing a full interview.

IF NOT OBVIOUS, ASK IF THE RESPONDENT IS 18 OR OLDER.

First let me verify, do you live at (ADDRESS)?

1 YOU ARE SPEAKING TO AN ADULT RESIDENT GO TO INTRO03

2 YOU ARE NOT SPEAKING TO AN ADULT RESIDENT (ASK TO SPEAK TO ADULT RESIDENT AND RESET TO INTRO01 OR INTRO02)

INTRO03

We would like to record some of the questions and answers for training and data quality. I’d like to continue now, unless you have any questions.

1 CONSENT TO RECORDING GO TO HM0001

7 DOES NOT CONSENT TO RECORDING GO TO INTRO04

INTRO04 (IF INTRO03=7)

That’s fine, the interview will not be recorded.

HM0001

I am going to ask some questions about the adults ages 18 or over who think of this address as their main home.

This includes adults who usually stay at this address but are temporarily away on business, on vacation, or in a hospital.

It does not include college students who live away from home.

(Including yourself,) How many adults live at this address and have no other place they usually live?

|__|__|__| NUMBER OF PEOPLE

HM0002

[A] What is [your first name | the first name of the adult, or one of the adults, who lives at this address and owns or rents this home]? ________________________________________

[B] Next, please tell me the first names of all other adults in this household. ______________________________________________________

HM0005

Just to confirm, {you are / NAME is} …?

1 MALE

2 FEMALE

-8 DON’T KNOW

-7 REFUSED

HM0006

How old {are you / is NAME}?

1. |__|__|__|

-8 DON’T KNOW

-7 REFUSED

HM0008 (IF DK OR REFUSED IN HM0006)

Please look at this list. [Are you/Is NAME] …

1. Under 18 years old,

2. 18 to 24 years old,

3. 25 to 29 years old,

4. 30 to 39 years old,

5. 40 to 49 years old,

6. 50 to 59 years old,

7. 60 to 64 years old,

8. 65 years old or above

-8 DON’T KNOW

-7 REFUSED

HM0010

{Are you/Is NAME} Hispanic, Latina, or of Spanish origin?

1 YES

2 NO

-8 DON’T KNOW

-7 REFUSED

HM0010a

What is {your/NAME’s} origin? Please choose all that apply.

1. Mexican, Mexican American, Chicano or Chicana,

2. Puerto Rican,

3. Cuban, or

4. Another Hispanic, Latina, or Spanish origin?

-8 DON’T KNOW

-7 REFUSED

HM011

What is {your/NAME’s} race? Please choose 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

-8 DON’T KNOW

-7 REFUSED

HM0020

I just asked you questions about {NUMBER} adult household member(s): {LIST ALL HH MEMBERS}.

Before we move on, I just want to confirm, are there any other adults who live at this address?

1 YES GO TO HM0001

2 NO GO TO H2

H2

RUN THE SAMPLING ALGORITHM. ELIGIBILITY IS DETERMINED WHEN THE ENUMERATION IS COMPLETED. SELECTION IS BASED ON RANDOM SELECTION OF ADULT FEMALE AGES 18-49. SP=SAMPLED ADULT. IF AN SP HAS BEEN SELECTED, GO TO HX0014. ELSE IF NO HOUSEHOLD MEMBER IS SELECTED, END SCREENER AND DISPLAY:

“Thank you for your time today. Based on the information you’ve given us, your household has not been selected for participation in the study.”

HX0014

Based on the information you have provided, we have selected {SP FILL 1} to participate in the study. Can I just confirm that {SP FILL 1} is {GENDER} and {AGE} years old?

Contact Information

HL0001

I’d like to take a brief moment and get some of your contact information for my records.

HL0002

What is your telephone number, in case my office wants to check my work?

__________ _________________________ _____

AREA CODE PHONE NUMBER EXT.

HL0003

Is this a home or cell phone number?

1. HOME

2. CELL

3. OTHER

-8 DON’T KNOW

-7 REFUSED

HL0004

Is there a second telephone number where you can be reached?

__________ _________________________ _____

AREA CODE PHONE NUMBER EXT.

HL0005

Is this a home or cell phone number?

1. HOME

2. CELL

3. OTHER

-8 DON’T KNOW

-7 REFUSED

HL006

Thank you for the contact information.

IF {SP FILL 1} IS AVAILABLE, ATTEMPT TO ADMINISTER INTERVIEW.

IF {SP FILL 1} IS NOT AVAILABLE, ATTEMPT TO SCHEDULE APPOINTMENT FOR RETURN VISIT.

5 Attachment E: Field Household Roster