Part A, Attachment A - Household Pulse Survey Questionnaire

Supporting Statement Part A, Attachment A: Household Pulse Survey Questionnaire

Household Pulse Survey Questionnaire

April 17, 2020(R)

QUESTIONNAIRE (ENGLISH)

Page Title: Autocode

Section Code Answer Order (QORDER)

## THIS QUESTION WILL RANDOMLY ASSIGN PARTICIPANTS TO SEE UNIPOLAR SCALES IN THE ORDER THEY ARE WRITTEN IN THESE REQUIREMENTS (CHOICE 1 TO CHOICE 5), OR TO SEE THEM IN REVERSE ORDER (CHOICE 5 TO CHOICE 1) ##

1. ## WRITTEN ## Show unipolar scales as they are written

2. ## REVERSE ## Show unipolar scales in reverse order

## HEADER TO BE DISPLAYED ON EVERY PAGE AFTER WELCOME PAGE##

## ENGLISH ##

AN OFFICIAL WEBSITE OF THE UNITED STATES GOVERNMENT

Unites States Census Bureau Logo

2020 COVID19 Rapid Response Panel

English | Español | Logout

## SPANISH ##

UN SITIO WEB OFICIAL DEL GOBIERNO DE LOS EE.UU.

Unites States Census Bureau Logo

Encuesta de Planificación del Censo del 2020

English | Español | Salir

## FOOTER TO BE DISPLAYED ON EVERY PAGE ##

## ENGLISH ##

OMB No.: XXXXXXXXX Approval Expires: XXXXXXX

Accessibility – Linked to webpage https://www.census.gov/about/policies/privacy/privacy-policy.html#par_textimage_1 with the following language:

The Census Bureau is committed to making online forms and other public documents on its Internet server accessible to all. Currently, we are reviewing our web sites and making modifications to those pages, which are not in compliance with the Americans with Disabilities Act. We use Hypertext Markup Language (HTML) to create pages that are generally accessible to persons using screen-reading devices, and we are careful in our construction of HTML documents to ensure maximum accessibility. We include alternate text describing graphics.

Many Census Bureau Internet documents are in ASCII or HTML formats. These documents are accessible to persons using screen-reading software. We also have a large number of documents in Adobe Acrobat PDF (Portable Document Format) files. Currently, many people using screen-reading devices cannot read documents in PDF format, specifically those that were created from a scanned hard copy.

Adobe Systems, Inc. is producing various products designed to make Adobe Acrobat documents accessible to persons using screen-reading software. Adobe's accessibility web pages describe their efforts.

To allow us to better serve those with visual disabilities who are having difficulty accessing PDF documents; you may contact us directly for further assistance at 301-763-INFO (4636), 800-923-8282, or by submitting a request at ask.census.gov.

Privacy – Linked to webpage https://www.census.gov/privacy/ with the following language:

We are committed to handling your information responsibly. Your information is kept confidential. This commitment applies to the individuals, households, and businesses that answer our surveys, and to those browsing our website.

Security – Linked to webpage [URL] with the following language:

Data are Encrypted at all Times

Our secure servers use Hypertext Transfer Protocol over Secure Socket Layer (HTTPS) to ensure the encrypted transmission of data between your browser and the U.S. Census Bureau. This means that instead of sending readable text over the Internet, both your browser and our servers encode (scramble) all text using a security key. That way, personal data sent to your browser and data you send back are extremely difficult to decode in the unlikely event of interception by an unauthorized party. As a result of this, your browser must be capable of using the required encryption protocol and strength in order to connect to our servers. If you cannot connect to our secure servers, please upgrade to a newer browser.

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Our secure servers use a digital certificate (digital ID) issued by a trusted, third party Certificate Authority (CA) as proof of identity. The only way to be sure of a web site's authenticity is to view their digital ID. In this way, you can be assured that you are not being "spoofed" or tricked by an imposter. The digital ID will contain information such as the name of the organization that owns the web site, the site's registered internet name/address, and the name of the Certification Authority under which the digital ID was issued. The method for viewing a web site's Digital Certificate/ID varies depending on the web browser. Please see your browser's "Help" information for instructions on how to verify a web site's identity.

Burden – Linked to webpage [URL] with the following language:

How long will this survey take?

The Census Bureau estimates that, for the average household, this survey will take about 20

minutes to complete, including the time for reviewing the instructions and answers.

## SPANISH ##

Núm. de OMB: XXXXXXXX Aprobado hasta: XXXXXXXX

Accesibilidad – Linked to webpage [URL] with the following language:

Privacidad – Linked to webpage [URL] with the following language:

Seguridad – Linked to webpage [URL] with the following language:

Tiempo y esfuerzo – Linked to webpage [URL] with the following language:

¿Cuánto tiempo va a tomar esta encuesta?

La Oficina del Censo calcula que al hogar típico le tomará como promedio aproximadamente 15 minutos completar esta encuesta, incluyendo el tiempo que toma repasar las instrucciones y revisar las respuestas.

/* START PAGE */

Page Title: Welcome_Page

Section Welcome Page (display_Welcome)

Welcome! Thank you for participating in this survey sponsored by the U.S. Department of Commerce, U.S. Census Bureau. This survey is available in another language. 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.

¡Bienvenido(a)! Gracias por participar en esta encuesta de la Oficina del Censo y el Departamento de Comercio de los Estados Unidos. Esta encuesta está disponible en otro idioma. Por favor seleccione el idioma de su preferencia para contestar la encuesta.

Logic:

• Ask this question for all respondents

• Only one response permitted here, and respondents will be able to toggle between languages in the remaining of the survey

/* END PAGE */

/* START PAGE */

Page Title: Login

Section Splash Page (display_Information)
Thank you for participating. This survey helps measure the impact of coronavirus (COVID-19) on employment status, consumer spending (including use of stimulus payments), food security, housing security, education disruptions, and dimensions of physical and mental wellbeing. Completing this short 20-minute survey will help the following agencies identify coronavirus (COVID-19) related issues in your state:

- the U.S. Census Bureau

- the Bureau of Labor Statistics

- the National Center for Health Statistics

- the National Center for Education Statistics

- the United States Department of Agriculture

- the Department of Housing and Urban Development

In this survey:

- we refer to the coronavirus (COVID-19) as coronavirus.

This survey is not the census.

Here is some helpful information:

• We will keep your answers confidential.

• You can validate that this survey is a legitimate federally-approved information collection using the U.S. Office of Management and Budget approval number 0607-0978, expiring on 08/31/2020. Federal agencies may not sponsor surveys without a valid control number.

• To learn more about this survey go to: www.census.gov/plan.

** U.S. Census Bureau Notice and Consent Warning **

You are accessing a United States Government computer network. Any information you enter into this system is confidential. It may be used by the Census Bureau for statistical purposes and to improve the website. If you want to know more about the use of this system, and how your privacy is protected, visit our online privacy webpage at http://www.census.gov/about/policies/privacy/privacy-policy.html.

Use of this system indicates your consent to collection, monitoring, recording, and use of the information that you provide for any lawful government purpose. 1 So that our website remains safe and available for its intended use, network traffic is monitored to identify unauthorized attempts to access, upload, change information, or otherwise cause damage to the web service. Use of the government computer network for unauthorized purposes is a violation of Federal law and can be punished with fines or imprisonment (PUBLIC LAW 99-474).

Section Splash Page Spanish (display_Information)

Gracias por participar. Completar esta breve encuesta de 15 minutos ayudará a la Oficina del Censo de los Estados Unidos a realizar el próximo censo en el 2020. Esta encuesta debe ser completada por la persona que generalmente abre la correspondencia en su hogar. Esta encuesta no es el censo.

A continuación alguna información útil:

• Mantendremos sus respuestas confidenciales.

• Puede validar que esta encuesta es una recopilación de información legítima aprobada por el gobierno federal utilizando el número de aprobación 0607-0978 de la Oficina de Administración y Presupuesto de los Estados Unidos, que vence el 08/31/2020. Las agencias federales no pueden patrocinar encuestas sin un número de control válido.

• Para obtener más información sobre esta encuesta, visite: www.census.gov/plan.

** Aviso de la Oficina del Censo de los EE. UU. y Advertencia sobre el consentimiento **

Usted está accediendo a una red de computación del gobierno de los Estados Unidos. Toda la información que escriba en este sistema es confidencial. La Oficina del Censo puede usar dicha información para propósitos estadísticos y para mejorar el sitio web. Si desea conocer más acerca del uso de este sistema y cómo se protege su privacidad, visite nuestra página web.

El uso de este sistema indica su consentimiento a que recopilemos, monitoreemos, registremos y usemos la información que usted proporcione para cualquier propósito legal del gobierno. Con el fin de que nuestro sitio web siga siendo seguro y que siga disponible para el uso al que está destinado, monitoreamos el tráfico en la red para identificar los intentos no autorizados de acceder, subir o cambiar información, o de dañar de alguna otra manera el servicio del sitio web. El uso de la red de computación del gobierno para fines no autorizados se trata de una violación de las leyes federales y puede ser penalizado con multas o encarcelamiento (LEY PÚBLICA 99-474).

/* END PAGE */

/* START PAGE */

Page Title: Age_Gender

Section Display before Q1 (display_Q1)

These final questions are for statistical purposes only.

Section Display before Q1 Spanish (display_Q1)

Estas últimas preguntas se hacen solo con propósitos estadísticos.

Section Q1 (birth_year)

What year were you born? Please enter a number.

____

Section Q1 Spanish (birth_year)

¿En qué año nació usted? Por favor ingrese un número.

____

Logic:

• Open end numeric; Range: 1900 to 2020; If respondent enters a number that falls outside of the above range, display the following message (soft edit): "Please enter a number between 1900 and 2020."

• • Continue to survey if respondent indicates birth year older than 2002

  • Need to jump to a ineligible respondent thank you screen.

Section Q2 (gender)

Are you… Select only one answer.

1. Male

2. Female

Section Q2 Spanish (gender)

Usted es… Seleccione solo una respuesta.

1. Hombre

2. Mujer

Logic:

• Only one response permitted

• Do NOT rotate answer choices

/* END PAGE */

/* START PAGE */

Page Title: Race_Ethnicity

Section Q3 (hispanic)

Are you of Hispanic, Latino, or Spanish origin?

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

2. Yes, Mexican, Mexican American, Chicano

3. Yes, Puerto Rican

4. Yes, Cuban

5. Yes, another Hispanic, Latino, or Spanish origin (specify)

Section Q3 Spanish (hispanic)

¿Es usted de origen hispano, latino, o español?

1. No, no soy de origen hispano, latino, o español

2. Sí, mexicano, mexicanoamericano, chicano

3. Sí, puertorriqueño

4. Sí, cubano

5. Sí, de otro origen hispano, latino, o español

Logic:

• Only one response permitted

• Do NOT rotate answer choices

• If respondents choose any answer choices other than 5 (“Yes, another Hispanic, Latino, or Spanish origin”/ “Sí, de otro origen hispano, latino, o español”), remove and/or disable text field for answer choice 5.

Section Q4 (race)

What is your race? Please select all that apply.

1. White

2. Black or African American

3. American Indian or Alaska Native

4. Asian Indian

5. Chinese

6. Filipino

7. Japanese

8. Korean

9. Vietnamese

10. Other Asian

11. Native Hawaiian

12. Chamorro

13. Samoan

14. Other Pacific Islanders

Section Q4 Spanish (race)

¿Cuál es su raza? Seleccione todas las que correspondan.

1. Blanca

2. Negra o afroamericana

3. Indígena de las Américas o nativa de Alaska (especifique el nombre de la tribu en la cual está inscrito[a] o la tribu principal) /* SPECIFY */ ## OPEN-ENDED RESPONSE UP TO 60 CHARACTERS ##

4. India asiática

5. China

6. Filipina

7. Japonesa

8. Coreana

9. Vietnamita

10. Otra asiática (especifique la raza, por ejemplo, hmong, laosiana, tailandesa, paquistaní, camboyana, etc.) /* SPECIFY */ ## OPEN-ENDED RESPONSE UP TO 60 CHARACTERS ##

11. Nativa de Hawái

12. Chamorra

13. Samoana

14. Otra de las islas del Pacífico (especifique raza, por ejemplo, fiyiana, tongana, etc.) /* SPECIFY */ ## OPEN-ENDED RESPONSE UP TO 60 CHARACTERS ##

15. Alguna otra raza (especifique la raza) /* SPECIFY */ ## OPEN-ENDED RESPONSE UP TO 60 CHARACTERS ##

Logic:

• Multiple responses permitted

• Do NOT rotate answer choices

/* END PAGE */

/* START PAGE */

Page Title: Education

Section Q5 (education)

What is the highest degree or level of school you have completed? Select only one answer.

1. Less than high school

2. Some high school

3. High school graduate or equivalent (for example GED)

4. Some college, but degree not received or is in progress

5. Associate’s degree (for example AA, AS)

6. Bachelor's degree (for example BA, BS, AB)

7. Graduate degree (for example master's, professional, doctorate)

Section Q5 Spanish (education)

¿Cuál es el grado o nivel de educación más alto que ha completado? Seleccione solo una respuesta.

Logic:

• Only one response permitted

• Do NOT rotate answer choices

/* END PAGE */

/* START PAGE */

Page Title: Household

Section Q6 (marital_status)

What is your marital status? Select only one answer.

1. Now married

2. Widowed

3. Divorced

4. Separated

5. Never married

Section Q6 Spanish (marital_status)

¿Cuál es su estado civil? Seleccione solo una respuesta.

1. Casado(a) actualmente

2. Viudo(a)

3. Divorciado(a)

4. Separado(a)

5. Nunca me he casado

Logic:

• Only one response permitted

• Do NOT rotate answer choices

Section Q7 (household3)

How many total people – adults and children – currently live in your household, including yourself? Please enter a number.

____

Section Q7 Spanish (household3)

¿Cuántas personas en total – adultos y niños – viven actualmente en su hogar, incluyéndose a sí mismo(a)? Por favor ingrese un número.

____

Logic:

• Open end numeric

• Range: 1 to 40

• If a respondent enters a number that falls outside of the above range, display the following message (soft edit):

  • For English: “Please enter a number between 1 and 40.”

  • For Spanish: “Por favor ingrese un número entre 1 y 40.”

Section Q8 (household3)

How many people under 18 years-old currently live in your household? Please enter a number.

____

Section Q8 Spanish (household3)

¿

Logic:

• Open end numeric

• Range: 1 to 40

• If a respondent enters a number that falls outside of the above range, display the following message (soft edit):

  • For English: “Please enter a number between 1 and 40.”

  • For Spanish: “Por favor ingrese un número entre 1 y 40.”

/* END PAGE */

/* START PAGE */

Page Title: Employment

Section Display Q9(display_Q9)

This survey is a cooperative effort across many agencies to provide critical, timely information about the experience of the coronavirus (COVID-19) pandemic and its impact on the population of the United States. This survey is not the census. The 2020 Census is also underway.

Section Display Q9 (spanish display_Q9)

Section Q9 (employment)

Have you, or has anyone in your household experienced a loss of employment income since March 13, 2020? Select only one answer.

1. Yes

2. No

Section Q9 Spanish (employment)

¿? Seleccione solo una respuesta.

Logic:

• Only one response permitted

Section Q10 (employment)

Do you expect that you or anyone in your household will experience a loss of employment income in the next 4 weeks because of the coronavirus pandemic? Select only one answer.

1. Yes

2. No

Section Q10 Spanish (employment)

¿? Seleccione solo una respuesta.

Logic:

• Only one response permitted

Section Q11 (employment)

Now we are going to ask about your employment. In the last 7 days, did you do ANY work for either pay or profit? Select only one answer.

1. Yes

2. No

Section Q11 Spanish (employment)

¿

Logic:

• Only one response permitted

Section Q12 (employment)

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

1. Government

2. Private company

3. Non-profit organization including tax exempt and charitable organizations

4. Self-employed

5. Working in a family business

Section Q12 Spanish (employment)

¿

Logic:

• If Q11 = 1 ask Q12

• Only one response permitted

Section Q13 (employment)

What is your main reason for not working for pay or profit? Select only one answer.

1. I did not want to be employed at this time;

2. I did not work because I am/was sick with coronavirus symptoms;

3. I did not work because I am/was caring for someone with coronavirus symptoms;

4. I did not work because I am/was caring for children not in school or daycare;

5. I did not work because I am/was caring for an elderly person;

6. I am/was sick (not coronavirus related) or disabled;

7. I am retired;

8. I did not have work due to coronavirus pandemic related reduction in business (including furlough);

9. I am/was laid off due to coronavirus pandemic;

10. My employment closed temporarily due to the coronavirus pandemic;

11. My employment went out of business due to the coronavirus pandemic;

12. Other reason, please specifiy)

Section Q13 Spanish (employment)

¿

Logic:

• If Q11 = 2 ask Q13

• Only one response permitted

Section Q14 (employment)

Are you receiving pay for the time you are not working? Select only one answer.

1. Yes, I use paid leave;

2. Yes, I receive full pay but do not have to take leave;

3. Yes, I receive partial pay;

4. No, I receive no pay

Section Q14 Spanish (employment)

¿? Seleccione solo una respuesta.

Logic:

• If Q11 = 2 ask Q14

• Only one response permitted

/* END PAGE */

/* START PAGE */

Page Title: Food Security

Section Q23 (food security)

Getting enough food can also be a problem for some people. Which of these statements best describes the food eaten in your household before March 13, 2020? Select only one answer.

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

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

3. Sometimes not enough to eat

4. Often not enough to eat

Section Q23 Spanish (food security)

¿? Seleccione solo una respuesta.

Logic:

• Only one response permitted

• Note all respondents will then be asked Q24, regardless of response to Q23

Section Q24 (food security)

In the last 7 days, which of these statements best describes the food eaten in your household? Select only one answer.

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

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

3. Sometimes not enough to eat

4. Often not enough to eat

Section Q24 Spanish (food security)

¿? Seleccione solo una respuesta.

Logic:

• Only one response permitted

Section Q25 (food security)

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

1. Couldn’t afford to buy more food

2. Couldn’t get out to buy food (for example, didn’t have transportation, or had mobility or health problems that prevented you from getting out)

3. Afraid to go or didn’t want to go out to buy food

4. Couldn’t get groceries or meals delivered to me

5. The stores didn’t have the food I wanted

Section Q25 Spanish (food security)

¿?

Logic:

• Only one response permitted

• If Q24 in (2,3,4) then ask Q25

Section Q26 (food security)

During the last 7 days, did you or anyone in your household get free groceries or a free meal? Select only one answer.

1. Yes

2. No

Section Q26 Spanish (food security)

¿? Seleccione solo una respuesta.

Logic:

• Only one response permitted

Section Q27 (food security)

Where did you get free groceries or free meals? Choose all that apply.

1. Free meals through the school or other programs aimed at children

2. Food pantry or food bank

3. Home-delivered meal service like Meals on Wheels

4. Church, synagogue, temple, mosque or other religious organization

5. Shelter or soup kitchen

6. Other community program

7. Family, friends, or neighbors

Section Q27 Spanish (food security)

¿?

Logic:

• If Q26 = 1 then ask Q27

Section Display Q28 (display_Q28 food security)

The next questions are about how much money you and your household spend on food at supermarkets, grocery stores, other types of stores, and food service establishments, like restaurants and drive-thrus. When you answer these questions, please do not include money spent on alcoholic beverages.

Section Q28 (food security)

During the last 7 days , how much money did you and your household spend on food at supermarkets, grocery stores, online, and other places you buy food to prepare and eat at home? Please include purchases made with SNAP or food stamps. Enter amount.

1. Enter amount $_________

Section Q28 Spanish (food security)

¿?

Logic:

• Only one response permitted

• Validate reasonable range for dollar amount

Section Q29 (food security)

During the last 7 days, how much money did you or your household spend on prepared meals, including eating out, fast food, and carry out or delivered meals? Please include money spent in cafeterias at work or at school or on vending machines. Please do not include money you have already told us about in item Q28 (above). Enter amount.

1. Enter amount $_________

Section Q29 Spanish (food security)

¿?

Logic:

• Only one response permitted

• Validate reasonable range for dollar amount

Section Q30 (food security)

How confident are you that your household will be able to afford the kinds of food you need for the next four weeks? Select only one answer.

1. Not at all confident

2. Somewhat confident

3. Moderately confident

4. Very confident

Section Q30 Spanish (food security)

¿?

Logic:

• Only one response permitted

• Note: From HUD

/* END PAGE */

/* START PAGE */

Page Title: Mental Health and Health Status

Section Q31 (general health status)

Would you say your health in general is excellent, very good, good, fair, or poor? Select only one answer.

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

Section Q31 Spanish (general health status)

¿? Seleccione solo una respuesta.

Logic:

• Only one response permitted

Section Q32 (anxiety)

Over the last 7 days, how often have you been bothered by the following problems ... Feeling nervous, anxious, or on edge? Would you say not at all, several days, more than half the days, or nearly every day? Select only one answer.

1. Not at all

2. Several days

3. More than half the days

4. Nearly every day

Section Q32 Spanish (anxiety)

¿? Seleccione solo una respuesta.

Logic:

• Only one response permitted

Section Q33 (anxiety)

Over the last 7 days, how often have you been bothered by the following problems ... Not being able to stop or control worrying? Would you say not at all, several days, more than half the days, or nearly every day? Select only one answer.

1. Not at all

2. Several days

3. More than half the days

4. Nearly every day

Section Q33 Spanish (anxiety)

¿? Seleccione solo una respuesta.

Logic:

• Only one response permitted

Section Q34 (depression)

Over the last 7 days, how often have you been bothered by ... having little interest or pleasure in doing things? Would you say not at all, several days, more than half the days, or nearly every day? Select only one answer.

1. Not at all

2. Several days

3. More than half the days

4. Nearly every day

Section Q34 Spanish (depression)

¿? Seleccione solo una respuesta.

Logic:

• Only one response permitted

Section Q35 (depression)

Over the last 7 days, how often have you been bothered by ... feeling down, depressed, or hopeless? Would you say not at all, several days, more than half the days, or nearly every day? Select only one answer.

1. Not at all

2. Several days

3. More than half the days

4. Nearly every day

Section Q35 Spanish (depression)

¿? Seleccione solo una respuesta.

Logic:

• Only one response permitted

Section Q36 (insurance)

Are you currently covered by any of the following types of health insurance or health coverage plans? Mark Yes or No for each.

1. Insurance through a current or former employer or union (through yourself or another family member)

2. Insurance purchased directly from an insurance company, including marketplace coverage (through yourself or another family member)

3. Medicare, for people 65 and older, or people with certain disabilities

4. Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability;

5. TRICARE or other military health care

6. VA (including those who have ever used or enrolled for VA health care)

7. Indian Health Service

8. Other

Section Q36 Spanish (insurance)

¿? Seleccione solo una respuesta.

Logic:

• Matrix style question with Yes/No response option for each row

• Only one response permitted per row

Section Q37 (access)

At any time in the last 4 weeks, did you DELAY getting medical care because of the coronavirus pandemic? Select only one answer.

1. Yes

2. No

Section Q37 Spanish (access)

¿? Seleccione solo una respuesta.

Logic:

• Only one response permitted

Section Q38 (access)

At any time in the last 4 weeks, did you need medical care for something other than coronavirus, but DID NOT GET IT because of the coronavirus pandemic? Select only one answer.

1. Yes

2. No

Section Q38 Spanish (access)

¿? Seleccione solo una respuesta.

Logic:

• Only one response permitted

/* END PAGE */

/* START PAGE */

Page Title: Housing

Section Q39 (housing)

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

1. Owned free and clear?

2. Owned with a mortgage or loan (including home equitly loans)?

3. Rented?

4. Occupied without payment of rent?

Section Q39 Spanish (housing)

¿

Logic:

• Only one response permitted

Section Q40 (housing)

Did you pay your last month’s rent or mortgage on time? Select only one answer.

1. Yes

2. No

3. Payment was deferred

Section Q40 Spanish (housing)

¿? Seleccione solo una respuesta.

Logic:

• If Q39 in (2,3) ask Q40

• Only one response permitted

Section Q41 (housing)

How confident are you that your household will be able to pay your next rent or mortgage payment on time? Select only one answer.

1. No confidence

2. Slight confidence

3. Moderate confidence

4. High confidence

5. Payment is/will be deferred

Section Q41 Spanish (housing)

¿?

Logic:

• If Q39 in (2,3) ask Q41

• Only one response permitted

/* END PAGE */

Page Title: Education

Section Q42 (education)

At any time during February 2020, were any children in this household enrolled in a public school, enrolled in a private school, or educated in a homeschool setting in Kindergarten through 12th grade or grade equivalent? Select all that apply.

1. Yes, enrolled in a public or private school

2. Yes, homeschooled

3. No

Section Q42 Spanish (education)

¿

Logic:

• Multiple responses permitted

• Make “No” answer choice exclusive

Section Q43 (education)

How has the coronavirus pandemic affected how the children in this household received education? Select all that apply.

1. Classes normally taught in person at the school were cancelled;

2. Classes normally taught in person moved to a distance-learning format using online resources, either self-paced or in real time;

3. Classes normally taught in person moved to a distance-learning format using paper materials sent home to children;

4. Classes normally taught in person changed in some other way -- Please specify:

5. There was no change because schools did not close)

Section Q43 Spanish (education)

¿

Logic:

• If Q42 includes 1 ask Q43

• Multiple responses permitted

Section Q44 (education)

How often is a computer or other digital device available to children for educational purposes? Select only one answer.

1. Always available;

2. Usually available;

3. Sometimes available;

4. Rarely available;

5. Never available

Section Q44 Spanish (education)

¿

Logic:

• If Q42 includes 1 ask Q44

• One response allowed

Section Q45 (education)

Is the computer or other digital device …? Select all that apply..

1. Provided by the children’s school or school district to use outside of school;

2. Provided by someone in the household or family, or it is the child’s;

3. Provided by another source.

Section Q45 Spanish (education)

¿

Logic:

• If Q42 includes 1 and Q44 in (1,2,3,4) ask Q45

• Multiple responses permitted

Section Q46 (education)

How often is the Internet available to children for educational purposes? Select only one answer.

1. Always available;

2. Usually available;

3. Sometimes available;

4. Rarely available;

5. Never available

Section Q46 Spanish (education)

¿

Logic:

• If Q42 includes 1 ask Q46

• One response allowed

Section Q47 (education)

Are Internet services …? Select all that apply..

1. Paid for by the children’s school or school district;

2. Paid for by someone in the household or family;

3. Paid for by another source

Section Q47 Spanish (education)

¿

Logic:

• If Q42 includes 1 and Q46 in (1,2,3,4) ask Q47

• Multiple responses permitted

Section Q48 (education)

During the last 7 days, about how many hours did the student have live contact either by phone or video with their teachers? Enter number of hours.

1. Enter number of hours _________

(If none, enter zero)

Section Q48 Spanish (education)

¿

Logic:

• If Q42 includes 1 ask Q48

• Ensure numeric response and range reasonableness (valid responses: 0-168)

Section Q49 (education)

Including hours spent during weekdays and weekends, about how many hours did household members spend on ALL teaching activities with the children in this household during the last 7 days? Enter number of hours.

1. Enter number of hours _________

(If none, enter zero)

Section Q49 Spanish (education)

¿

Logic:

• If Q42 includes 1 ask Q49

• Ensure numeric response and range reasonableness (valid responses: 0-168)

/* END PAGE */

/* START PAGE */

Page Title: Income

Section Q50 (income)

In 2019 what was your total household income before taxes? Select only one answer.

1. Less than $25,000

2. $25,000 - $34,999

3. $35,000 - $49,999

4. $50,000 - $74,999

5. $75,000 - $99,999

6. $100,000 - $149,999

7. $150,000 - $199,999

8. $200,000 and above

Section Q50 Spanish (income)

En el 2019, ¿cuál fue el ingreso total de su hogar antes de que le descontaran los impuestos? Seleccione solo una respuesta.

1. Menos de $25,000

2. $25,000 - $34,999

3. $35,000 - $49,999

4. $50,000 - $74,999

5. $75,000 - $99,999

6. $100,000 - $149,999

7. $150,000 - $199,999

8. $200,000 y más

Logic:

• Only one response permitted

• Do NOT rotate answer choices

/* END PAGE */

/* START PAGE */

Page Title: Address_Page

Section Address

Start of Block: Address

residence The U.S. Census Bureau is interested in understanding geographic differences in experiences with the coronavirus pandemic. To help us analyze survey responses across the entire United States, please provide your complete street address below. Your address information will only be used for statistical analyses conducted by the U.S. Census Bureau and will not be used for any other purpose or shared with any other parties. 

• Address Number (Q51) ________________________________________________

• Street Name (Q52) ________________________________________________

• Apt Unit (Q53) ________________________________________________

• City (Q54) ________________________________________________

• State (Q55) ________________________________________________

• Zip (Q56) ________________________________________________

Display This Question:

If all address fields above are blank

no_address  

• I do not have a street address (Q57)

Page Break

Display This Question:

If all address fields are blank

Or = I do not have a street address is selected

rural_route Q58
Do you have a Rural Route address?

• Yes (1)

• No (2)

Page Break

Display This Question:

If Do you have a Rural Route address? = Yes

rural_address Please provide the Rural Route address where you reside.  

Also, provide a description of the physical location in the space provided.

• RR Descriptor (Q59) ________________________________________________

• Rural Route No (Q60) ________________________________________________

• RR Box ID (Q61) ________________________________________________

• City (Q62) ________________________________________________

• State (Q63) ________________________________________________

• Zip Code (Q64) ________________________________________________

Display This Question:

If Do you have a Rural Route address? = Yes

rural_description Q65 Please provide as much information as possible.
For example, if you also have a street address associated with your residence, such as one used for emergency services (E - 911) or for you to have a package delivered to your home, then please provide it here.

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Page Break

Display This Question:

If Do you have a Rural Route address? , No Is Displayed

And Do you have a Rural Route address? != Yes

other_address Please provide the city and state or ZIP Code where you are currently living.Also, describe the physical location in the space provided.

• City (Q66) ________________________________________________

• State (Q67) ________________________________________________

• Zip (Q68) ________________________________________________

Display This Question:

If Do you have a Rural Route address? , No Is Displayed

And Do you have a Rural Route address? != Yes

other_description Q69 Please provide as much information as possible.
 
For example: a location description such as "The apartment over the gas station" or "The brick house with the screened porch on the northeast corner of Farm Road and HC46" or a name of a park, street intersection or shelter, if you are experiencing homelessness, as well as the name of the city and state. For example, "Friendship Park, Anywhere PA."

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

End of Block: Address

/* END PAGE */

/* START PAGE */

Page Title: Submit_Page

Section Submit Page (Submit)

That concludes the survey. Please click on the “Submit” button when you are finished.

Section Submit Page Spanish (Submit)

Con esto terminamos la encuesta. Haga clic en el botón “Enviar” cuando haya terminado.

## SUBMIT BUTTON DISPLAYED HERE ##

Logic:

• Users can still use the “Previous” navigator to go back to the survey before clicking the Submit button.

/* END PAGE */

/* START PAGE */

Page Title: Thank_You_Page

Section Thank You Page (display_ThankYou)

Thank you for participating in the 2020 COVID Rapid Response Survey.

If you have any questions about this survey please visit www.census.gov/plan. You can validate that this survey is a legitimate federally-approved information collection using the U.S. Office of Management and Budget approval number 0607-0978, expiring on 08/31/2020.

Section Thank You Page Spanish (display_ThankYou)

Gracias por participar en la Encuesta de Planificación del Censo del 2020.

Si tiene alguna pregunta sobre esta encuesta, visite www.census.gov/plan. Puede confirmar que esta encuesta es una recopilación de información legítima aprobada por el gobierno federal usando el número de aprobación 0607-0978 de la Oficina de Administración y Presupuesto de los Estados Unidos, que vence el 08/31/2020.

/* END PAGE */

RESIDENCE

Screen Name	RESIDENCE
Help Text link	RESIDENCE
Help Text Before REFDATE	Please type in the street address of the place where you will be living on <REFDATE>. If you have more than one address associated with your residence, please provide the street address if available. For example, if you normally use a P.O. Box or Rural Route address for mailing purposes, please enter a physical street address, such as what you would give to a shipping company to have a package delivered to your home. In addition, some P.O. Box addresses look like street addresses, but are actually the addresses for private mailboxes at a business or the Post Office. We only want the street address of where you will be living or staying on <REFDATE>. For Street Addresses, such as 5007 N Maple Ave, you can enter your address into the address fields. Address Number is the numeric or alphanumeric identifier from your street address, for example 5007 or 5007-A. Street Name is the name of your street, for example N Maple Ave. Apt/Unit refers to any unit information that is part of your address, such as an apartment number, unit number, or lot. You will need to enter both the unit type and number. For example, enter “Apt A” or “Lot 3” or “Unit 2-H” or “Room 12”. If you share the same address with other living quarters, such as a basement or garage apartment, or even a separate structure on the same lot (e.g., a trailer behind the main house), please provide this in the Apt/Unit.
Help Text On or After REFDATE	Please type in the street address of the place where you were living on <REFDATE>. If you have more than one address associated with your residence, please provide the street address if available. For example, if you normally use a P.O. Box or Rural Route address for mailing purposes, please enter a physical street address, such as what you would give to a shipping company to have a package delivered to your home. In addition, some P.O. Box addresses look like street addresses,

but are actually the addresses for private mailboxes at a business or the Post Office. We only want the street address of where you were living or staying on <REFDATE>. For Street Addresses, such as 5007 N Maple Ave, you can enter your address into the address fields. Address Number is the numeric or alphanumeric identifier from your street address, for example 5007 or 5007-A. Street Name is the name of your street, for example N Maple Ave. Apt/Unit refers to any unit information that is part of your address, such as an apartment number, unit number, or lot. You will need to enter both the unit type and number. For example, enter “Apt A” or “Lot 3” or “Unit 2-H” or “Room 12”. If you share the same address with other living quarters, such as a basement or garage apartment, or even a separate structure on the same lot (e.g., a trailer behind the main house), please provide this in the Apt/Unit.

RURAL ROUTE

Screen Name	RURAL_ROUTE
Help Text link	RURAL_ROUTE
Help Text	You have previously indicated that you do not have a street address. Please let us know if you have a Rural Route address, such as RR 101 Box 2 Suitland, MD 20746.

RR_ADDRESS

Screen Name	RR_ADDRESS
Help Text link	RR_ADDRESS
Help Text Before REFDATE	If you normally use a Rural Route address for mailing purposes, you will need to enter your Rural Route address. If you have a Street Address, such as what you would give to a shipping company to have a package delivered to your home, please use the “Previous” buttons to take you to that address collection screen. Otherwise, enter your Rural Route address into the address fields. Use the drop-down menu to select the Rural Route Descriptor, such as: o RR – Rural Route

HC – Contract Delivery Service Route (formerly Highway Contract Route) SR – Star Route PS – Postal Service RTE – Route Provide the number of the Rural Route Provide the number of the Box Provide a city, state, and ZIP Code You may also describe the physical location of where you will be living on <REFDATE> in the “Physical Location Description” box. Please provide as much information as possible.

Help Text On or After REFDATE

If you normally use a Rural Route address for mailing purposes, you will need to enter your Rural Route address. If you have a Street Address, such as what you would give to a shipping company to have a package delivered to your home, please use the “Previous” buttons to take you to that address collection screen. Otherwise, enter your Rural Route address into the address fields. Use the drop-down menu to select the Rural Route Descriptor, such as: RR – Rural Route HC – Contract Delivery Service Route (formerly Highway Contract Route) SR – Star Route PS – Postal Service RTE – Route Provide the number of the Rural Route Provide the number of the Box Provide a city, state, and ZIP Code You may also describe the physical location of where you were living on <REFDATE> in the “Physical Location Description” box. Please provide as much information as possible.

HOMELESS

Screen Name	HOMELESS
Help Text link	HOMELESS
Help Text Before REFDATE	You have previously indicated that you do not have a street address or a Rural Route address. Answer "Yes" if you will be experiencing homelessness or will not have a permanent place to live on <REFDATE>.

Help Text On or After REFDATE	You have previously indicated that you do not have a street address or a Rural Route address. Answer "Yes" if you were experiencing homelessness or did not have a permanent place to live on <REFDATE>.

OTHER_ADDRESS

Screen Name	OTHER_ADDRESS
Help Text link	OTHER_ADDRESS
Help Text Before REFDATE	If you have a Street Address, such as what you would give to a shipping company to have a package delivered to your home, please use the “Previous” buttons to take you to that address collection screen. Otherwise, please provide a city and state, OR ZIP Code into the address fields. You may also describe the physical location of where you will be living on <REFDATE> in the “Physical Location Description” box. Please provide as much information as possible.
Help Text On or After REFDATE	If you have a Street Address, such as what you would give to a shipping company to have a package delivered to your home, please use the “Previous” buttons to take you to that address collection screen. Otherwise, please provide a city and state, OR ZIP Code into the address fields. You may also describe the physical location of where you were living on <REFDATE> in the “Physical Location Description” box. Please provide as much information as possible.