Attachment A 2022 ACS Content Test Question Wording for Internet

Attachment A

2022 ACS Content Test
Internet Final Field Test Wording
Note: several topics have questions implemented across multiple screens—those screens are denoted by screen name prior to the question text.

TOPIC: Household Roster
Production Wording
roster_a:
The following questions are about
everyone who is living or staying
at [house number and street
name][, apartment number].

Control
Same as Production EXCEPT
for new screens: Undercount
follow-up and Overcount followup.

Test Treatment
Same as Production EXCEPT
for new screens: Undercount
follow-up and Overcount followup.

Roster Treatment
roster_a:
Please list everyone, including people
not related to you, living or staying at
[house number and street name][,
apartment number].

First, create a list of people. Enter
one person on each line. Leave any
extra lines blank. Enter names until
you have listed everyone who lives
or stays there, then click Next.
(Help)
First Name MI Last Name
________ _ ___________
________ _ ____________

Enter one person on each line. Leave any
extra lines blank. When you have
finished listing the names of everyone
who lives or stays there, click Next.
(Help)
First Name MI Last Name
________ _ ___________
________ _ ____________

roster_b:
The following questions are to
make sure this list is as complete
as possible.

roster_b:
We do not want to miss anyone living
or staying at this address.
The names listed so far are:

Other than the [fill
person/people] listed below, does
ANYONE ELSE live or stay
there? (Help)

(name/names)

1

Attachment A
Are there any ADDITIONAL children
living or staying there, for example
babies, grandchildren, or foster
children? These children could be
related or unrelated to you. (Help)

For example, roommates, foster
children, boarders, or live-in
employees.
(name/names)
o
o

o
o

Yes
No

add_1:
Enter the names and then click
Next. Do not include anyone
already on the list above. (Help)
First Name MI Last Name
________ _ ___________
________ _ ____________

Yes
No

add_1:
Enter the names and then click Next.
Do not include anyone already on the list
above (Help)
First Name MI Last Name
________ _ ___________
________ _ ____________

roster_c:
Other than the [fill
person/people] listed below, is
there ANYONE ELSE staying
there even for a short time?
(Help)

roster_c:
The names listed so far are:
(name/names)
Are there any ADDITIONAL people
staying there, for example roommates
and other people or families who have
no other place to stay? (Help)

For example, a friend or relative.
Do not include overnight or
weekend guests who have a
residence somewhere else.

o
o

(name/names)
o Yes
o No

add_2:
add_2:
2

Yes
No

Attachment A
Enter the names and then click
Next. Do not include anyone
already on the list above. (Help)
First Name MI Last Name
________ _ ___________
________ _ ____________

Enter the names and then click Next.
Do not include anyone already on the list
above. (Help)
First Name MI Last Name
________ _ ___________
________ _ ____________

away_now:
[fill Is the person/Are any of these
people] listed below away NOW
for more than two months, like a
college student living away at
school or a member of the armed
forces personnel living away?
(Help)

away_now:
The names listed so far are:
(name/names)
[fill Does this person/Do any of these
people] live somewhere else now, for
example a college student or someone
in the Armed Forces on deployment?
(Help)

(name/names)
o Yes
o No

o
o

Yes
No

remove_one:
Select the name(s) of anyone who
is away NOW for more than two
months. (Help)
 Name 1
 Name 2
 …
 Name x
 No one on this list is away
NOW for more than two
months

remove_one:
Select the people who are living
somewhere else now. (Help)
 Name 1
 Name 2
 …
 Name x
 No one on this list is living
somewhere else now

another_home:

another_home:
The names listed so far are:
3

Attachment A
[fill Does the person/Do any of
these people] listed below have
some other place where [fill he or
she/they] usually [fill
stays?/stay?] (Help)

(name/names)
[fill Is this person/Are any of these
people] staying at [house number and
street name][, apartment number] for
a short visit or for an overnight stay?
(Help)

(name/names)
o Yes
o No

(For children in shared custody, select
NO.)
o
o

Yes
No

another_home_who:
Select the people who are staying there
for a short visit or overnight stay.
(Help)
 Name 1
 Name 2
 …
 Name x

another_home_who:
Select the name(s) of anyone who
has another place where they
usually stay. (Help)
 Name 1
 Name 2
 …
 Name x

 No one on this list is staying
here for a short visit or
overnight stay.

 No one on this list has
another place where they
usually stay

more_than_2:
Is [name] staying at [house number
and street name][, apartment number]
for MORE than two months? (Help)

more_than_2:
Is [name] staying at [house
number and street name][,
apartment number]
for MORE than two months?
(Help)
o Yes
o No

For children in shared custody, select
YES
o
o
4

Yes
No

Attachment A

roster_stay:
Does [name] have another place to
live? (Help)
o
o

Yes
No

roster check:
Thank you for your answers so far.
The rest of the survey will ask about
the following people: (Help)

roster check:
Thank you for your answers so
far. The rest of the survey will
ask about the following people:
(Help)
[show modified roster]

[show modified roster]
Click Next to continue.

Click Next to continue.
No one on Roster:
Since no one is staying here for more
than two months, you will not be
asked any further questions about the
people staying in this unit. However,
you will be asked some basic questions
about the housing unit.

No one on Roster:
Since no one is staying here for
more than two months, you will
not be asked any further
questions about the people
staying in this unit. However, you
will be asked some basic
questions about the housing unit.

Click Next to continue.

Click Next to continue.
Undercount follow-up:
We are conducting research to
understand why people may
not be included on the roster.
Earlier in the survey you
indicated that the [fill:
person/people] listed below
[fill: was/were] not initially

Undercount follow-up:
We are conducting research to
understand why people may
not be included on the roster.
Earlier in the survey you
indicated that the [fill:
person/people] listed below
[fill: was/were] not initially
5

Undercount follow-up:
We are conducting research to
understand why people may not be
included on the roster. Earlier in the
survey you indicated that the [fill:
person/people] listed below [fill:
was/were] not initially listed as living

Attachment A
listed as living or staying at
[house number and street
name][, apartment number].

listed as living or staying at
[house number and street
name][, apartment number].

Could you briefly explain the
living situation of:

Could you briefly explain the
living situation of:

[fill: NAME(s) from add_1 and
add_2 screens]

[fill: NAME(s) from add_1 and
add_2 screens]

Overcount follow-up:
[fill: We are/We are also]
conducting research to
understand why people stay in
more than one place. Earlier in
the survey you indicated that
the [fill: person/people] listed
below sometimes [fill:
live/lives] somewhere else or
[fill: is/are] only staying for a
short time at [house number
and street name][, apartment
number].

Overcount follow-up:
[fill: We are/We are also]
conducting research to
understand why people stay in
more than one place. Earlier in
the survey you indicated that
the [fill: person/people] listed
below sometimes [fill:
live/lives] somewhere else or
[fill: is/are] only staying for a
short time at [house number
and street name][, apartment
number].

Could you briefly explain the
living situation of:

Could you briefly explain the
living situation of:

[fill: NAME(s)]

[fill: NAME(s)]

or staying at [house number and street
name][, apartment number].
Could you briefly explain the living
situation of:
[fill: NAME(s) from add_1 and add_2
screens]

Overcount follow-up:
[fill: We are/We are also] conducting
research to understand why people
stay in more than one place. Earlier in
the survey you indicated that the [fill:
person/people] listed below sometimes
[fill: live/lives] somewhere else or [fill:
is/are] only staying for a short time at
[house number and street name][,
apartment number].
Could you briefly explain the living
situation of:
[fill: NAME(s)]

6

Attachment A
TOPIC: Educational Attainment
Production Wording
What is the highest degree or level of
school (name) has COMPLETED? If
currently enrolled, select the previous
grade or highest degree received. (Help –
with COVID-19 guidance)
NO SCHOOLING COMPLETED
o No schooling completed
NURSERY OR PRESCHOOL
THROUGH GRADE 12
o Nursery school
o Kindergarten
o Grade 1 through 11 - Specify grade 111
o __
o 12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
o Regular high school diploma
o GED or alternative credential
COLLEGE OR SOME COLLEGE
o Some college credit, but less than 1
year of college credit
o 1 or more years of college credit, no
degree
o Associate’s degree (for example: AA,
AS)
o Bachelor’s degree (for example: BA,
BS)
AFTER BACHELOR’S DEGREE
o Master’s degree (for example: MA,
MS, MEng, MEd, MSW, MBA)
o Professional degree beyond a
bachelor’s degree (for example: MD,
DDS, DVM, LLB, JD)
o Doctorate degree (for example: PhD,
EdD)

Control
Same as production

Test Treatment
What is the highest grade of school or
degree (Name) has COMPLETED? If
currently enrolled, select the previous
grade or highest degree received. (Help)

o

o
o

o

LESS THAN GRADE 1
o Less than grade 1
GRADE 1 THROUGH GRADE 12
o Grade 1 through 11 – Specify grade 111
o ___
o 12th grade – NO DIPLOMA
HIGH SCHOOL GRADUATE
o Regular high school diploma
o GED or alternative credential
COLLEGE OR SOME COLLEGE
o Some college credit, but less than 1
year of college credit
o 1 or more years of college credit, no
degree
o Associate’s degree (for example: AA,
AS)
o Bachelor’s degree (for example: BA,
BS)
AFTER BACHELOR’S DEGREE
o Master’s degree (for example: MA, MS,
MEng, MEd, MSW, MBA)
o Professional degree beyond a
bachelor’s degree (for example: MD,
DDS, DVM, LLB, JD)
o Doctorate degree (for example: PhD,
EdD)

7

Roster Treatment
Same as production

Attachment A
TOPIC: Health Insurance
Production Wording
Is (Name) CURRENTLY covered by any
of the following types of health insurance
or health coverage plans? Select "Yes" or
"No" for EACH type of coverage in items a
– h. (Help)
a. Insurance through a current or
former employer or union of
(Name) or another family member
b. Insurance purchased directly from
an insurance company by (Name)
or another family member
c. Medicare, for people 65 and older,
or people with certain disabilities
d. Medicaid, Medical Assistance, or
any kind of government-assistance
plan for those with low incomes or
a disability
e. TRICARE or other military health
care
f. VA (enrolled for VA health care)
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify
Specify
_________________________

Response options are listed to the right in
two columns Yes and No*

Control
Same as Production

Test Treatment
Is (Name) CURRENTLY covered by any
of the following types of health insurance
or health coverage plans?

Roster Treatment
Is (Name) CURRENTLY covered by any
of the following types of health insurance
or health coverage plans?

Do NOT include plans that cover only one
type of service, such as dental, drug, or
vision plans.

Do NOT include plans that cover only one
type of service, such as dental, drug, or
vision plans. (Help)

Select "Yes" or "No" for EACH type of
coverage in items a – h. (Help)

YES, INSURED
Mark (X) for all that apply.

a. Insurance through a current or
former employer, union, or
professional association (of (Name)
or another family member)
b. Medicare, for people 65 and older,
or people with certain disabilities
c. Medicaid, Children’s Health
Insurance Program (CHIP), or any
kind of government-assistance plan
for those with low incomes or a
disability
d. Insurance purchased directly from
an insurance company, a broker, or
a State or Federal Marketplace,
such as Healthcare.gov
e. Veteran’s health care (enrolled for
VA)
f. TRICARE or other military health
care
g. Indian Health Service
h. Any other type of health insurance
or health coverage plan – Specify

8

 Insurance through a current or
former employer, union, or
professional association (of (Name)
or another family member)
 Medicare, for people 65 and older,
or people with certain disabilities
 Medicaid, Children’s Health
Insurance Program (CHIP), or any
kind of government-assistance plan
for those with low incomes or a
disability
 Insurance purchased directly from
an insurance company, a broker, or
a State or Federal Marketplace,
such as Healthcare.gov
 Veteran’s health care (enrolled for
VA)
 TRICARE or other military health
care
 Indian Health Service
 Any other type of health insurance
or health coverage plan – Specify

Attachment A
Specify
_________________________

Response options are listed to the right in
two columns Yes and No*

9

Specify
___________________
NO, UNINSURED
 No health insurance or health
coverage plan

Attachment A

10

Attachment A
TOPIC: Disability
Production Wording

deaf:
a. Is (Name) deaf or (does he/ does
she/ does he or she) have serious
difficulty hearing? (Help)
o
o

Test Treatment
The next questions ask about
difficulties (Name) may have doing
certain activities.
blind:

a. Does (Name) have difficulty
seeing, even if wearing
glasses? (Help)

Yes
No

blind:
b. Is (Name) blind or (does he/does
she/ does he or she) have serious
difficulty seeing even when wearing
glasses? (Help)
o
o

Control
Same as Production

o
o
o
o
deaf:

b. Does (Name) have difficulty
hearing, even if using a
hearing aid? (Help)
o
o
o
o

Yes
No

difficulty concentrating:
a. Because of a physical, mental, or
emotional condition, does
(Name) have serious difficulty
concentrating, remembering, or
making decisions? (Help)

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all

difficulty walking:

a. Does (Name) have difficulty
walking or climbing steps?
(Help)
o
o
o
o
11

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all

Roster Treatment
Same as Production

Attachment A
o Yes
o No

difficulty concentrating:

b. Does (Name) have difficulty
remembering or
concentrating? (Help)

difficulty walking:
b. Does (Name) have serious
difficulty walking or climbing
stairs? (Help)
o
o

o
o
o
o

Yes
No

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all

difficulty dressing:

c. Does (Name) have difficulty
with self-care, such as
washing all over or dressing?
(Help)

difficulty dressing:
c. Does (Name) have difficulty
dressing or bathing? (Help)
o
o

o
o
o
o

Yes
No

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all

difficulty language:

d. Using (his/her) usual
language, does (Name) have
difficulty communicating, for
example understanding or
being understood? (Help)
o
o
o
o

12

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all

Attachment A
difficulty doing errands:
Because of a physical, mental, or
emotional condition, does (Name)
have difficulty doing errands alone
such as visiting a doctor’s office or
shopping? (Help)
o
o

difficulty doing errands:
Because of a physical, mental, or
emotional condition, does (Name) have
difficulty doing errands alone such as
visiting a doctor's office or shopping?
(Help)
o
o
o
o

Yes
No

13

No difficulty
Some difficulty
A lot of difficulty

Cannot do at all

Attachment A
TOPIC: Income
Production Wording
wages:
The next few questions are about (Name)’s
income during the PAST 12 MONTHS.
For each type of income (Name) received, give
your best estimate of the TOTAL AMOUNT
during the PAST 12 MONTHS. (NOTE: The
“past 12 months” is the period from today’s
date one year ago up through today.)

Control
Test Treatment
Same as
wages:
Production The next few questions are about (Name)’s
taxable and non-taxable income in 2021.

Roster Treatment
wages:
The next few questions are about (Name)’s
income in 2021.

For each type of income (Name) received, give
your best estimate of the TOTAL AMOUNT
received in 2021. (NOTE: This is from
January 1,2021 to December 31, 2021.)

For each type of income (Name) received, give
your best estimate of the TOTAL AMOUNT
received in 2021. (NOTE: This is from
January 1,2021 to December 31, 2021.)

For income received jointly, report the
appropriate share for each person – or, if
that’s not possible, report the whole amount
for only one person and select "No" for the
other person.

For income received jointly, report the
appropriate share for each person – or, if
that’s not possible, report the whole amount
for only one person and select "No" for the
other person.

a. Did (Name) receive any wages, salary,
commissions, bonuses, or tips during the
PAST 12 MONTHS? (Help – with COVID19 guidance)
o Yes
o No

a. Did (Name) receive any wages, salary,
commissions, bonuses, or tips in
2021? (Help – with COVID-19 guidance)

a. Did (Name) receive any wages, salary,
commissions, bonuses, or tips in
2021? (Help – with COVID-19 guidance)

wages amount:
What was the amount? Report amount from
all jobs before any deductions for taxes, bonds,
dues, or other items. (Help – with COVID-19
guidance)

wages amount:
What was the amount? Report amount from
all jobs before any deductions for taxes, bonds,
dues, or other items. (Help – with COVID-19
guidance)

wages amount:
What was the amount? Report amount from
all jobs before any deductions for taxes, bonds,
dues, or other items. (Help – with COVID-19
guidance)

TOTAL AMOUNT for
past 12 months
$ ______ .00

TOTAL AMOUNT for 2021
$ ______ .00

TOTAL AMOUNT for 2021
$ ______ .00

For income received jointly, report the
appropriate share for each person – or, if
that’s not possible, report the whole amount
for only one person and select "No" for the
other person.

o
o

o
o

Yes
No

14

Yes
No

Attachment A

self-employment:
b. Did (Name) receive any self-employment
income from (his/her/his or her) own
nonfarm businesses or farm businesses,
including proprietorships and partnerships,
during the PAST 12 MONTHS? (Help)
o
o

Yes
No

self-employment:
b. Did (Name) receive any self-employment
income, including work paid for in cash, in
2021? Include income from (his/her/his or her)
own businesses (farm or non-farm) including
proprietorships and partnerships. (Help)
o
o

self-employment:
b. Did (Name) receive any self-employment
income from (his/her/his or her) own
nonfarm businesses or farm businesses,
including proprietorships and partnerships
in 2021? (Help)
o
o

Yes
No

Yes
No

self-employment amount:
What was the amount? Report NET income
after business expenses.

self-employment amount:
What was the amount? Report NET income
after business expenses.

self-employment amount:
What was the amount? Report NET income
after business expenses.

If net income was a loss, enter the amount and
select “Loss.” (Help)

If net income was a loss, enter the amount and
select “Loss.” (Help)

If net income was a loss, enter the amount
and select “Loss.” (Help)

TOTAL AMOUNT for
past 12 months
$ ______ .00

TOTAL AMOUNT for 2021
$ ______ .00

TOTAL AMOUNT for 2021
$ ______ .00

__ Loss

__ Loss

interest:
Option 1
The next few questions are about (Name)’s
income during the PAST 12 MONTHS.

interest:
Option 1
The next few questions are about (Name)’s
taxable and non-taxable income in 2021.

interest:
Option 1
The next few questions are about (Name)’s
income in 2021.

For each type of income (Name) received, give
your best estimate of the TOTAL AMOUNT
during the PAST 12 MONTHS. (NOTE: The
“past 12 months” is the period from today’s
date one year ago up through today.)

For each type of income (Name) received, give
your best estimate of the TOTAL AMOUNT
received in 2021. (NOTE: This is from
January 1, 2021 to December 31, 2021.)

For each type of income (Name) received, give
your best estimate of the TOTAL AMOUNT
received in 2021. (NOTE: This is from
January 1, 2021 to December 31, 2021.)

__ Loss

15

Attachment A
For income received jointly, report the
appropriate share for each person – or, if
that’s not possible, report the whole amount
for only one person and select "No" for the
other person.
c. Did (Name) receive any interest,
dividends, net rental income, royalty
income, or income from estates and trusts
during the PAST 12 MONTHS? Report even
small amounts credited to an account. (Help)
Option 2
c. Did (Name) receive any interest,
dividends, net rental income, royalty
income, or income from estates and trusts
during the PAST 12 MONTHS? Report even
small amounts credited to an account. (Help)
For income received jointly, report the
appropriate share for each person – or, if
that’s not possible, report the whole amount
for only one person and select "No" for the
other person.
o
o

Yes
No

For income received jointly, report the
appropriate share for each person – or, if
that’s not possible, report the whole amount
for only one person and select "No" for the
other person.

For income received jointly, report the
appropriate share for each person – or, if
that’s not possible, report the whole amount
for only one person and select "No" for the
other person.

c. Did (Name) receive any interest,
dividends, royalty income, or income from
estates and trusts in 2021? Report even small
amounts credited to an account. (Help)

c. Did (Name) receive any interest,
dividends, net rental income, royalty
income, or income from estates and trusts in
2021? Report even small amounts credited to
an account. (Help)

Option 2
c. Did (Name) receive any interest,
dividends, royalty income, or income from
estates and trusts in 2021? Report even small
amounts credited to an account. (Help)

Option 2
c. Did (Name) receive any interest,
dividends, net rental income, royalty
income, or income from estates and trusts in
2021? Report even small amounts credited to
an account. (Help)

For income received jointly, report the
appropriate share for each person – or, if
that’s not possible, report the whole amount
for only one person and select "No" for the
other person.
o
o

Yes
No

For income received jointly, report the
appropriate share for each person – or, if
that’s not possible, report the whole amount
for only one person and select "No" for the
other person.
o
o

Yes
No

interest amount:
What was the amount?
If net income was a loss, enter the amount and
select “Loss.” (Help)
TOTAL AMOUNT for
past 12 months
$ ______ .00
__ Loss

interest amount:
What was the amount? (Help)

interest amount:
What was the amount?

TOTAL AMOUNT for 2021
$ ______ .00

If net income was a loss, enter the amount and
select “Loss.” (Help)
TOTAL AMOUNT for 2021
$ ______ .00

16

Attachment A
__ Loss

rental:
d. Did (Name) receive any rental income in
2021? (Help)
For income received jointly, report the
appropriate share for each person – or, if
that’s not possible, report the whole amount
for only one person and select "No" for the
other person.
o
o

Yes
No

rental amount:
What was the amount? (Help)
Report NET income after expenses. If net
rental income was a loss, enter the amount and
select “Loss.”
TOTAL AMOUNT for 2021
$ ______ .00
__ Loss
social security:
d. Did (Name) receive any Social Security or
Railroad Retirement benefits during the
PAST 12 MONTHS? (Help)
For income received jointly, report the
appropriate share for each person – or, if
that’s not possible, report the whole amount

social security:
e. Did (Name) receive any Social Security or
Railroad Retirement benefits in 2021?
(Help)

social security:
d. Did (Name) receive any Social Security or
Railroad Retirement benefits in 2021?
(Help)

For income received jointly, report the
appropriate share for each person – or, if

For income received jointly, report the
appropriate share for each person – or, if

17

Attachment A
for only one person and select "No" for the
other person.
o
o

Yes
No

social security amount:
What was the amount? (Help)
TOTAL AMOUNT for
past 12 months
$ ______ .00

ssi:
e. Did (Name) receive any Supplemental
Security Income (SSI) payments during the
PAST 12 MONTHS? (Help)
o
o

Yes
No

ssi amount:
What was the amount? (Help)
TOTAL AMOUNT for
past 12 months
$ ______ .00

public assistance:
f. Did (Name) receive any public assistance
or welfare payments from the state or local
welfare office during the PAST 12
MONTHS? (Help – with COVID-19
guidance)
o

Yes

that’s not possible, report the whole amount
for only one person and select "No" for the
other person.
o
o

that’s not possible, report the whole amount
for only one person and select "No" for the
other person.
o
o

Yes
No

Yes
No

social security amount:
What was the amount? (Help)

social security amount:
What was the amount? (Help)

TOTAL AMOUNT for 2021
$ ______ .00

TOTAL AMOUNT for 2021
$ ______

ssi:
f. Did (Name) receive any Supplemental
Security Income (SSI) payments in 2021?
(Help)

ssi:
e. Did (Name) receive any Supplemental
Security Income (SSI) payments in 2021?
(Help)

o
o

o
o

Yes
No

Yes
No

ssi amount:
What was the amount? (Help)

ssi amount:
What was the amount? (Help)

TOTAL AMOUNT for 2021
$ ______ .00

TOTAL AMOUNT for 2021
$ ______ .00

public assistance:
g. Did (Name) receive any financial
assistance from the state or local welfare
office in 2021?

public assistance:
f. Did (Name) receive any public assistance
or welfare payments from the state or local
welfare office in 2021? (Help – with COVID19 guidance)

Do NOT include SNAP (Food Stamps),
unemployment compensation, or non-cash
18

o

Yes

Attachment A
o No

benefits like energy or housing assistance.
(Help – with COVID-19 guidance)
o
o

public assistance amount:
What was the amount? (Help – with
COVID-19 guidance)

o

No

Yes
No

public assistance amount:
What was the amount? (Help – with
COVID-19 guidance)

public assistance amount:
What was the amount? (Help – with
COVID-19 guidance)

TOTAL AMOUNT for
past 12 months
$ ______ .00

TOTAL AMOUNT for 2021
$ ______ .00

TOTAL AMOUNT for 2021
$ ______ .00

survivor or disability:
g. Did (Name) receive any survivor or
disability income DURING THE PAST 12
MONTHS? (Help)

survivor or disability:
h. Did (Name) receive any survivor or
disability income in 2021? (Help)

survivor or disability:
g. Did (Name) receive any survivor or
disability income in 2021? (Help)

o
o

Yes
No

survivor or disability amount:
What was the amount? Do not include Social
Security. (Help)

o
o

o
o

Yes
No

Yes
No

survivor or disability amount:
What was the amount? Do NOT include
Social Security. (Help)

survivor or disability amount:
What was the amount? Do not include Social
Security. (Help)

TOTAL AMOUNT for
past 12 months
$ ______ .00

TOTAL AMOUNT for 2021
$ ______ .00

TOTAL AMOUNT for 2021
$ ______ .00

pension or retirement:
h. Did (Name) receive a pension or any
retirement income from a previous
employer or union, or any regular
withdrawals or distributions from

pension or retirement:
i. Did (Name) receive a pension or any
retirement income in 2021? INCLUDE
income from a previous employer or union and

pension or retirement:
h. Did (Name) receive a pension or any
retirement income from a previous
employer or union, or any regular

19

Attachment A
retirement accounts such as 401(k), 403(b),
IRA, Roth IRA, or other accounts designed
specifically for retirement DURING THE
PAST 12 MONTHS? (Help)
o
o

Yes
No

pension or retirement amount:
What was the amount? Do not include Social
Security. (Help)
TOTAL AMOUNT for
past 12 months
$ ______ .00

other income:
i. Did (Name) receive income on a
REGULAR basis from any other sources
such as Department of Veterans
Affairs (VA) payments, unemployment
compensation, child support or alimony
during the PAST 12 MONTHS? Do NOT
include lump sum payments such as money
from an inheritance or the sale of a home.
(Help – with COVID-19 guidance)
o Yes
o No

other income amount:
What was the amount? (Help – with
COVID-19 guidance)
TOTAL AMOUNT for
past 12 months
$ ______ .00

any regular withdrawals or distributions from
IRA, Roth IRA, 401(k), 403(b), or other
accounts designed specifically for retirement.
(Help)
o
o

withdrawals or distributions from
retirement accounts such as 401(k), 403(b),
IRA, Roth IRA, or other accounts designed
specifically for retirement in 2021? (Help)
o
o

Yes
No

Yes
No

pension or retirement amount:
What was the amount? Do NOT include
Social Security. (Help)

pension or retirement amount:
What was the amount? Do not include Social
Security. (Help)

TOTAL AMOUNT for 2021
$ ______ .00

TOTAL AMOUNT for 2021
$ ______ .00

other income:
j. Did (Name) receive income on a
REGULAR basis from any other sources
such as Department of Veterans
Affairs (VA) payments, unemployment
compensation, child support or alimony in
2021? Do NOT include lump sum payments
such as money from an inheritance or the sale
of a home. (Help – with COVID-19
guidance)

other income:
i. Did (Name) receive income on a
REGULAR basis from any other sources
such as Department of Veterans
Affairs (VA) payments, unemployment
compensation, child support or alimony in
2021? Do NOT include lump sum payments
such as money from an inheritance or the sale
of a home. (Help – with COVID-19
guidance)

o
o

o
o

Yes
No

Yes
No

other income amount:
What was the amount? (Help – with
COVID-19 guidance)

other income amount:
What was the amount? (Help – with
COVID-19 guidance)

TOTAL AMOUNT for 2021
$ ______ .00

TOTAL AMOUNT for 2021
$ ______ .00

20

Attachment A

total income:
What was (Name)’s total income during the
PAST 12 MONTHS? (Help – with COVID19 guidance)
If net income was a loss, enter the amount and
select “Loss”.

total income:
Including all types of income, what was
(Name)’s total income in 2021? (Help – with
COVID-19 guidance)
If net income was a loss, enter the amount and
select “Loss”.

total income:
What was (Name)’s total income in 2021?
(Help – with COVID-19 guidance)
If net income was a loss, enter the amount and
select “Loss”.

__ None
__ None

__ None

OR

OR

TOTAL AMOUNT for 2021
$ _______ .00

TOTAL AMOUNT for 2021
$ _______ .00

OR
TOTAL AMOUNT for
past 12 months
$ _______ .00
__ Loss

verify total income:
Option 1
According to our calculations, (Name)
received $(calculated income) from all
income sources during the PAST 12
MONTHS. Is this correct? (Help)

__ Loss

__ Loss

verify total income:
Option 1
According to our calculations, (Name)
received $(calculated income) from all
income sources in 2021. Is this correct?
(Help)

verify total income:
Option 1
According to our calculations, (Name)
received $(calculated income) from all
income sources in 2021. Is this correct?
(Help)

Option 2
We have recorded that (Name) received no
income during the PAST 12 MONTHS. Is
this correct? (Help)

Option 2
We have recorded that (Name) received no
income in 2021. Is this correct? (Help)

Option 2
We have recorded that (Name) received no
income in 2021. Is this correct? (Help)

o Yes
o No

o Yes
o No

o Yes
o No

estimate total income:

estimate total income:

estimate total income:
21

Attachment A
What is your best estimate of the total
income (Name) received from all sources
during the PAST 12 MONTHS? (Help)

What is your best estimate of the total
income (Name) received from all sources in
2021? (Help)

What is your best estimate of the total
income (Name) received from all sources in
2021? (Help)

If net income was a loss, enter the amount and
select “Loss”.

If net income was a loss, enter the amount and
select “Loss”.

If net income was a loss, enter the amount and
select “Loss”.

TOTAL AMOUNT for
past 12 months
$ _______ .00

TOTAL AMOUNT for 2021
$ _______ .00

TOTAL AMOUNT for 2021
$ _______ .00

__ Loss

__ Loss

__ Loss

22

Attachment A

TOPIC: SNAP
Production Wording
IN THE PAST 12 MONTHS, did you or
any member of this household receive
benefits from the Food Stamp Program
or SNAP (the Supplemental Nutrition
Assistance Program)? Do NOT include
WIC, the School Lunch Program, or
assistance from food banks. (Help)
o Yes
o No

Control
Same as
Production

Test Treatment
IN 2021, did you or any member of this
household receive benefits from the Food
Stamp Program or SNAP (the Supplemental
Nutrition Assistance Program)? Do NOT
include WIC, the School Lunch Program, or
assistance from food banks. (Help)

o Yes
o No

23

Roster Treatment
Same as Test Treatment

Attachment A
TOPIC: Weeks Worked
Production Wording
last worked:
When did (Name) last work, even for a
few days? (Help)
o Within the past 12 months
o 1 to 5 years ago
o Over 5 years ago or never
worked

Control
Same as Production

Test Treatment
last worked:
39. When did (Name) last work for pay,
even for a few days? (Help)
o Within the past 12 months
o 1 to 5 years ago
o Over 5 years ago or never worked

worked few days:
40. In 2021, did (Name) work for pay,
even for a few days? (Help)
o
Yes
o
No

worked every week:
a. During the PAST 12 MONTHS (52
weeks), did (Name) work EVERY
week? Count paid vacation, paid sick
leave, and military service as work.
(Help)
o Yes
o No

worked every week:
41. a. In 2021 (52 weeks), did (Name)
work EVERY week? Count paid
vacation, paid sick leave, and military
service as work. Include all jobs for pay.
(Help)
o
Yes
o
No

weeks worked:
b. During the PAST 12 MONTHS (52
weeks), how many WEEKS did (Name)
work? Include paid time off and
include weeks when (Name) only
worked for a few hours. (Help)

weeks worked:
41b. In 2021 (52 weeks), how many
WEEKS did (Name) work for at least
one day? Include weeks when (Name) only
worked for a few hours. Include all jobs for
pay. Count paid vacation, paid sick leave,
and military service as work. (Help)

Weeks
__

Weeks
__
24

Roster Treatment
Same as Test Treatment

Attachment A
hours worked:
During the PAST 12 MONTHS, in the
WEEKS WORKED, how many hours
did (Name) usually work each WEEK?
(Help)

hours worked:
42. In 2021, for the weeks worked, how
many HOURS did (Name) usually work
each WEEK? Include all jobs for pay and
military service. (Help)

Usual hours worked each
WEEK ____________

Usual hours worked each
WEEK ____________

25

Attachment A

TOPIC: Sewer
Production
Wording
N/A

Control

Test Treatment

Roster Treatment

Is this (mobile home/house/apartment/unit)
connected to a public sewer? (Help)

Same as Control

Same as Control

o
o
o

Yes, connected to public sewer
No, connected to septic tank
No, use other type of system

26

Attachment A
TOPIC: Electric Vehicles
Production
Wording
N/A

Control

Test Treatment

Roster Treatment

Are any of the following types of electric
vehicles kept at home for use by
members of this household? (Help)

Do you or any member of this household
own or lease an electric vehicle? Include
both all-electric and plug-in hybrid electric
vehicles. (Help)

Same as Control

a. A plug-in electric vehicle?
o Yes
o No
b. A hybrid electric vehicle?
o Yes
o No

o

Yes

o No

27

Attachment A
TOPIC: Solar Panels
Production Control
Wording
N/A
Does this (mobile
home/house/apartment/unit) use solar
panels that generate electricity? (Help)
o

Test Treatment

Roster Treatment

Same as Control

Same as Control

Yes

o No

28