BaH_UX_Screener_OMB

Web-Based Screener (NOTE: Items in grey are FMG standard recruiting items.)
Thank you for your interest in participating in user experience studies with [Insert facility name]. We
are seeking participants to complete tasks and provide feedback on a website. One-on-one
interviews will be held [Insert date] and [Insert date] and will be 60 minutes long. Participation will
take place at [Insert location]. If you qualify for this study, we will contact you to schedule a time that
is convenient for you. Compensation ($[Insert amount approved by OMB]) in the form of a check, will
be provided to those who participate in the study.
Privacy Act Statement [Link to new window].
[Paragraph below in the new window]

Privacy Act Statement
5 U.S.C. 552a(e)(3)

The Fors Marsh Group (FMG), on behalf of the Consumer Financial Protection Bureau
(“Bureau”) is collecting information that will assist the Bureau screen individuals gather data to
complete tasks and provide feedback on a website.
Personally identifiable information such as your name, mailing address, email address, phone
number, race, gender, and ethnicity will be obtained, but not accessible by the Bureau or FMG.
FMG and the Bureau will only have access to the demographic, attitudinal and behavioral
category data that comprise the contents of the screening criteria.
Information collected will be treated in accordance with the System of Records Notice
(“SORN”), CFPB.021 – CFPB Consumer Education and Engagement Records, 83 FR 23435.
Although the Bureau does not anticipate further disclosing the information provided, it may be
disclosed as indicated in the Routine Uses described in the SORN. Direct identifying information
will only be used to facilitate the interview and will be kept private except as required by law.
This collection of information is authorized by Pub. L. No. 111-203, Title X, Sections 1013 and
1022, codified at 12 U.S.C. §§ 5493 and 5512.
Participation is voluntary.
Thank you for your interest.

Paperwork Reduction Act Statement [Link to new window].
[Paragraph below in the new window]
Paperwork Reduction Act
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor,
and a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The OMB control number for this collection is 3170-0024. It expires on
XX/XX/XXXX. The time required to complete this information collection is estimated to
average approximately 5 minutes or less per response. Comments regarding this collection of
information, including the estimated response time, suggestions for improving the usefulness
of the information, or suggestions for reducing the burden to respond to this collection should
be submitted to Bureau at the Consumer Financial Protection Bureau (Attention: PRA Office),
1700 G Street NW, Washington, DC 20552, or by email to CFPB_PRA@cfpb.gov.

[The gray highlighted questions are standard FMG questions]
Q1.

First name: [Text box]

Q2.

Email [Text box]

Q3.

Mobile number: [Text box]

Q4.

Alternate number: [Text box]

Q5.

Which is your age range? [Text box]
1.
2.
3.
4.
5.
6.

Q6.

Last name: [Text box]

18 to 25
26 to 35
36 to 45
46 to 55
56 to 65
Over 65

What is your gender? [Radio buttons, select only one]
1. Male
2. Female

Q7. Do you consider yourself of Hispanic, Latino, or Spanish origin? [Radio buttons, select only one]
1. No, not of Hispanic, Latino, or Spanish origin
2. Yes, Hispanic, Latino, or Spanish origin
Q8.

How do you describe your race? [Check boxes, select all that apply]

1. American Indian or Alaska Native
2. Asian
3. Black or African-American
4. Native Hawaiian or other Pacific Islander
5. White
Q9.

What city and state do you live in? [Text box]

Q10.

Please select the response that best fits you: [Radio buttons, select only one]
1.
2.
3.
4.
5.

I am currently shopping for a home [Continue to Q11]
I recently purchased a home [Skip to Q21]
I am currently shopping for a refinance of my home mortgage [Skip to Q30]
I have recently refinanced my home mortgage [Skip to Q39]
None of these statements apply to me [Terminate]

Q11.

What was the approximate date that you began to shop for your new home?
[Small text box for data entry]

Q12.

What is the approximate date that you plan to close on your home?
[Small text box for data entry]

Q13.

What is the price range of the home you’re intending to buy?
[Multiple choice, select only one]
1.
2.
3.
4.
5.
6.
7.

Q14.

Less than $50,000
$50,000 to $150,000
$150,000 to $300,000
$300,000 to $500,000
$500,000 to $800,000
Greater than $800,000
Don’t know

What type of mortgage are you most interested in?
[Multiple choice, select only one]
1. Fixed rate mortgage
2. Adjustable rate mortgage
3. Other, please specify: [Small text box for data entry]

Q15.

Who are you planning to finance with?
[Multiple choice, select only one]
1. Bank

2.
3.
4.
5.

Credit Union
Broker
Unsure
Other, please specify: [Small text box for data entry]

Q16.

Please take a few sentences to describe what you’ve done so far with your home shopping.
[Large text box for data entry]

Q17.

Please take a few sentences to describe your next steps in your home shopping process.
[Large text box for data entry]

Q18.

Have you purchased any homes before?
[Multiple choice, select only one]
1. Yes [Continue to Q19]
2. No [Skip to Q47]

Q19.

How many homes have you purchased?
[Small text box for data entry]

Q20.

Have you refinanced before? [Multiple choice, select only one]
1. Yes, please specify the number of times you’ve refinanced: [Small text box for data
entry] [Skip to Q47]
2. No [Skip to Q47]

Q21.

What was the date that you closed on your home?
[Small text box for data entry]

Q22.

What is the price range of the home you recently purchased?
[Multiple choice, select only one]
1. Less than $50,000
2. $50,000 to $150,000
3. $150,000 to $300,000
4. $300,000 to $500,000
5. $500,000 to $800,000
6. Greater than $800,000
7. Don’t know

Q23.

What type of mortgage did you choose?
[Multiple choice, select only one]
1. Fixed rate mortgage
2. Adjustable rate mortgage
3. Other, please specify: [Small text box for data entry]

Q24.

Who did you finance with?
[Multiple choice, select only one]
1.
2.
3.
4.

Bank
Credit Union
Broker
Other, please specify: [Small text box for data entry]

Q25.

Please take a few sentences to describe your experience with the home shopping process.
[Large text box for data entry]

Q26.

Please take a few sentences to describe what you would have done differently in your home
shopping process.
[Large text box for data entry]

Q27.

Had you purchased a home before this one?
[Multiple choice, select only one]
1. Yes [Continue to Q28]
2. No [Skip to Q47]

Q28.

How many homes had you purchased before this one?
[Small text box for data entry]

Q29.

Have you refinanced before? [Multiple choice, select only one]
1. Yes, please specify the number of times you’ve refinanced: [Small text box for data
entry] [Skip to Q47]
2. No [Skip to Q47]

Q30.

What was the approximate date that you began to shop for refinancing?
[Small text box for their data entry]

Q31.

What is the approximate date that you’d like to close on your refinance?
[Small textbox for their data entry]

Q32.

What is the price range of the home you’re refinancing?
[Multiple choice, select only one]
1.
2.
3.
4.
5.
6.

Less than $50,000
$50,000 to $150,000
$150,000 to $300,000
$300,000 to $500,000
$500,000 to $800,000
Greater than $800,000

7. Don’t know
Q33.

What type of mortgage are you most interested in?
[Multiple choice, select only one]
1. Fixed rate mortgage
2. Adjustable rate mortgage
3. Other, please specify: [Small text box for data entry]

Q34.

Who are you planning to refinance with?
[Multiple choice, select only one]
1.
2.
3.
4.
5.

Bank
Credit Union
Broker
Unsure
Other, please specify: [Small text box for data entry]

Q35.

Please take a few sentences to describe what you’ve done so far with shopping for
refinancing.
[Large text box for data entry]

Q36.

Please take a few sentences to describe what you’re planning to do next in the refinancing
process.
[Large text box for data entry]

Q37.

How many homes have you purchased?
[Small text box for data entry]

Q38.

Have you refinanced before? [Multiple choice, select only one]
1. Yes, please specify the number of times you’ve refinanced: [Small text box for data]
entry] [Skip to Q47]
2. No [Skip to Q47]

Q39.

What was the approximate date that you refinanced your mortgage?
[Small textbox for their data entry]

Q40.

What is the price range of the home you recently refinanced?
[Multiple choice, select only one]
1.
2.
3.
4.
5.

Less than $50,000
$50,000 to $150,000
$150,000 to $300,000
$300,000 to $500,000
$500,000 to $800,000

6. Greater than $800,000
7. Don’t know
Q41.

What type of mortgage did you choose?
[Multiple choice, select only one]
1. Fixed rate mortgage
2. Adjustable rate mortgage
3. Other, please specify: [Small text box for data entry]

Q42.

Who did you refinance with?
[Multiple choice, select only one]
1.
2.
3.
4.
5.

Bank
Credit Union
Broker
Unsure
Other, please specify: [Small text box for data entry]

Q43.

Please take a few sentences to describe your experience with the refinancing process.
[Large text box for data entry]

Q44.

Please take a few sentences to describe what you would have done differently in the
refinancing process.
[Large text box for data entry]

Q45.

How many homes have you purchased?
[Small text box for data entry]

Q46.

Have you refinanced before this time? [Multiple choice, select only one]
1. Yes, please specify the number of times you’ve refinanced before this time: [Small text
box for data entry] [Continue to Q47]
2. No [Continue to Q47]

Q47.

Have you ever been through foreclosure?
[Yes or No]

Q48.

What is the highest educational degree that you have earned?
[Radio buttons, select only one]
1.
2.
3.
4.
5.
6.

Less than high school degree or equivalent
High school graduate (grade 12, diploma, or GED)
Trade school certificate
Some college courses completed
Graduated with a 2 year degree (Associates)
Graduated with a 4 year degree (Bachelors)

7. Some graduate school courses completed
8. Graduated with a post-graduate degree
Q49.

Which of the following best describes what you are currently doing?
[Check boxes, select all that apply]
1. Going to high school
2. Going to community college, 2-year degree program, or trade school (either full-time or
part-time)
3. Going to a 4-year college/university (either full-time or part-time)
4. Working full-time
5. Working part-time
6. Homemaker
7. Retired
8. Not employed [Terminate]

Q50.

What is your occupation? [Text box]

Q51.

What industry do you work in? [Text box]

Q52.

What is your annual household income? [Radio buttons, select only one]
1. Less than $30K
2. $30K - $50K
3. $50K - $100K
4. $100 - $150K
5. More than $150K

Q53.

How did you hear about research opportunities with us? [Check boxes, select all that apply]
1.
2.
3.
4.
5.
6.
7.
8.
9.

Google
Facebook
Washington Post online
Washington Post paper
Express newspaper
Craigslist.org
Restaurants or Cafes in Ballston (e.g., Starbucks, Panera, Buzz Bakery)
Friend or Family
Other [Text box]

Thank you for completing this survey. We hope to be in contact with you soon about scheduling a
time for you to participate. If you have any questions please contact us at [Insert facility email
address] or call us at [Insert facility phone number]. You can also visit our website at [Insert facility
website address] or our Facebook page: [Insert facility Facebook page].

Phone-Based Screener (for those who qualify based on web-based screener)
Hello ______. Thank you for your interest in participating in user experience studies at [Insert facility
name]. My name is ________ and I wanted to follow up regarding an online questionnaire that you
completed recently for an upcoming interview about buying a home. I wanted to ask a couple more
questions to see if you qualify. Your participation is completely voluntary. Do you have a few
minutes?
Before we begin, I need to tell you about our privacy policy.
The information you provide through your responses to Fors Marsh will assist the study sponsor, the
Consumer Financial Protection Bureau (“Bureau”), in determining your eligibility in participating in
usability testing about a financial education website.
A federal law called the Privacy Act directs how the Bureau collects, keeps and shares your personal,
private information- including the personal information contained in your answers to these
questions. Your participation is completely voluntary, and is subject to the CFPB privacy policy that
can be found on our website, consumerfinance.gov.

Abbreviated Paperwork Reduction Act
This survey has been approved under the Paperwork Reduction act of 1995 by the Federal
Government’s Office of Management and Budget and assigned OMB control number 31700024. Without this OMB control number we could not conduct this survey. The survey will only
take about 3 minutes.

Q1. Can you please verify your age range? [Refer to Q5 in web screener]
Q2. What is your current occupation? [Refer to Q46 in web screener]
Q3. You had mentioned on the online questionnaire that you’ve [Insert response from Q17, Q27,
Q38, or Q47]. Can you tell me a little more about that? [Open ended. Terminate if responses are
inconsistent with web screener.]
Invitation:
We would like to invite you to participate in an interview. We will discuss with you your expectations
about buying a home. The entire interview should last about an hour, and you will be paid $75 when
you are done. Are you willing to participate in this study? Ok, great, let’s find a time that works for
you. I’ll be sending you an email confirmation with your scheduled interview.
Reconfirm participant’s email address.
Terminate message: both for web and phone screener

We are sorry but you do not qualify for this study. Would you like us to contact you for future studies
that you qualify for? [Radio buttons, select only one]
1. Yes
2. No