Screener

2021 AHS Cognitive Testing – Additional Questions for Telephone Screener

We estimate that completing these screening questions will take 15 minutes on average. This information collection has been approved by the Office of Management and Budget (OMB). You can validate that this survey is a legitimate federally-approved information collection using the Office of Management and Budget's approval number 0607-0725, which expires December 31, 2022. We are required to tell you this number to conduct this survey. 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.

1. Is your home (a) owned or being bought by someone in your household, (b) rented, or (c) occupied without payment of rent?

   1. Owned or being bought by someone in your household – Proceed to #2

   2. Rented – Skip to #6

   3. Occupied without payment of rent – Skip to #6

2. Is the home owned in your name?

   1. Yes – Proceed to #3

   2. No – Skip to #6

3. Is there currently any mortgage, home equity lump sum loan, or line of credit on your home?

   1. Yes – Proceed to #4

   2. No – Skip to #6

4. How many mortgages, home equity lump sum loans, and lines of credit are currently on your home? Please give a number for each. Do not include any loans that have been paid off.

Enter a number for each. (If needed and respondent has more than one, ask: How many are mortgages? How many are lump sum loans? How many are lines of credit?)

(If needed, read one or more definitions:

A mortgage may be a fixed rate loan, adjustable rate loan, ARM, or any loan where a fixed amount was borrowed and must be repaid at predetermined intervals.

With a home equity lump sum loan you receive the full amount borrowed up front.

With a home equity line of credit you withdraw funds as needed up to a set limit.)

No. of Mortgages: [ ]

No. of Lump Sum Loans: [ ]

No. of Lines of Credit: [ ]

5. Are you currently refinancing your home?

   1. Yes

   2. No

6. What type of home do you live in? Would you say house or townhouse, apartment or condo, manufactured/mobile home, or something else?

   1. House or townhouse

   2. Apartment or condo

   3. Manufactured/mobile home

   4. Other residence: PLEASE EXPLAIN: [ ]

7. In what county is your home located?

[ ]

8. When did you move to your current home?

Month: [ ]

Year: [ ]

9. Do you live with any pets? Do not include service animals.

   1. Yes

   2. No

Close-out:

If they have an e-mail then say: Thanks for taking some time to answer my questions today. If you qualify, someone will be back in touch with you soon to schedule an interview [email text shown below]

If they do not have an e-mail then read: Thanks for taking some time to answer my questions today. If you qualify, someone will be back in touch with you soon to schedule an interview.

When scheduling: We would like to invite you to participate in an interview session. You will receive $40 as a thank you for completing the interview. The interview is about 60 minutes in length.

The session will be conducted over the telephone. A researcher will send you an email with a link to a form explaining your rights as a participant, and you will need to use your computer or smartphone to sign this. Is this okay?

o Yes	 (CONTINUE) – Great. A researcher will call you at [say interview date and time] and we will conduct the interview at that time. Please be sure to click on the link in the email and sign the form before the interview.
o No	 (END) – Thank you for your time, but at this time we are not conducting in person sessions. We will notify you if that changes.