Telephone Screener
Hello, I’m _____________ from the Census Bureau. Thank you for contacting us about participating in our focus groups. I just need to get a little bit of background information to start.
ID Number:
Contact Date:
What is your name?
First name:
Last name:
(Ask if not obvious) Are you male or female?
o Male
o Female
In what year were you born?
Are you of Hispanic, Latino, or Spanish origin?
o Yes
o No
What is your race? Please select one or more. White, Black or African American, American Indian or Alaska Native, Asian, or Native Hawaiian or other Pacific Islander?
(Allow up to 3 answers)
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or other Pacific Islander
What is the highest grade of school you have completed, or the highest degree you have received?
(do not read categories to respondent)
Less than high school
Completed high school
Some college, no degree
Associate’s degree (AA/AS)
Bachelor’s Degree (BA/BS)
Post-Bachelor's degree (For example MA, MS, Ph.D, JD, etc.)
Are you working for pay full-time, part-time, or are you not working for pay at this time?
o Full-time (ask both follow-up questions)
o Part-time (ask both follow-up questions)
o Not working for pay at this time (skip to next question)
a. What is your current job title or job description?
Are you employed by the Federal Government? (if federal contractor, mark NO)
o Yes
o No
In what city, state, and ZIP code do you currently live?
City: State: Zip:
How many people age 18 or older currently live in your household, INCLUDING yourself?
How many people younger than 18 currently live in your household?
Is your house, apartment, or mobile home –
Owned by you or someone in this household with a mortgage or loan? Include home equity loans.
Owned by you or someone in this household free and clear (without a mortgage or loan)?
Rented?
Occupied without payment of rent?
Do you own a cell phone?
o Yes (ask follow-up question)
o No (skip to next question)
Some cell phones are called “smartphones” because of certain features they have. Is your cell phone a smartphone, such as an iPhone, Android, Blackberry or Windows phone, or are you not sure?
Yes
No
Not sure
Do you own a desktop or laptop computer, or both?
o Desktop computer
o Laptop computer
o Both desktop and laptop computer
o Neither
Do you own a tablet computer such as an iPad, Samsung Galaxy Tab, Google Nexus, or Kindle Fire?
o Yes
o No
Do you have at least one year of Internet experience?
o Yes (ask follow-up question)
o No (skip to next question)
How often do you use the Internet either on a computer or on a mobile device like a smartphone or tablet?...Several times a day, about once a day, a few times a week, a few times a month, or a few times a year?
Several times a day
About once a day
A few times a week
A few times a month
A few times a year
Not at all [do not read to respondent]
Name two things you do on the Internet besides e-mail.
1.
2.
Internet Activity #1:
Research
Social media/communication (Facebook, Twitter, Craigslist)
Shopping
Banking or paying bills online
Music / movies / videos
Gaming
News
Travel (directions/reservations)
Employment
Other
Internet Activity #2:
Research
Social media/communication (Facebook, Twitter, Craigslist)
Shopping
Banking or paying bills online
Music / movies / videos
Gaming
News
Travel (directions/reservations)
Employment
Other
c. If you were asked to do a survey, would you rather complete it on paper, over the phone, or online?
On paper
Over the phone
Online
How did you hear about this research opportunity?
E-mail link
Census Bureau employee
Friend or family member (but not a Census Bureau employee)
Craigslist
Google advertisement
Flyer
Newspaper advertisement
Other – specify:
Have you participated in any research studies with the U.S. Census Bureau?
o Yes
o No
What is your daytime telephone number?
What is the e-mail address we should use when sending directions to our office, should you qualify?
Is your household’s annual income …
o Less than $15,000?
o $15,000 to $25,000?
o $25,000 to$50,000?
o $50,000 to $75,000?
o $75,000 to $100,000?
o More than $100,000?
Are you a United States citizen? You do not have to be a U.S. citizen to participate in our studies.
o Yes
o No
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Slight changes to participate |
| Author | Dawn V Nelson |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |