Paper Screener Form

OMB No. 0920-0314: Approval Expires 12/31/2024

National Survey of Family Growth

Household Screening Survey

Congratulations! Your address has been selected for the National Survey of Family Growth. An adult age 18 or older can fill out this survey.

Below are a few questions about the people who usually live here, to determine eligibility for the survey and to let us select one person. Please include any unmarried children away from home living in a college or university dormitory, fraternity or sorority. Answers to each question are voluntary.

If someone is selected for the National Survey of Family Growth (NSFG), they will be offered $40 as a token of appreciation for completing the NSFG survey.

Please write clearly and mark the box or circle next to your answer.

1. How many children ages 0 to 14 live here?

Children ages 0-14

2. How many children ages 15 to 17 live here?

Children ages 15-17

3. How many adults ages 18 to 59 live here?

Adults ages 18-59

4. How many adults age 60 or older live here?

Adults age 60 or older

5. Please provide the following information for each person who lives here and is 18 to 59 years old.
This information will only be used to contact this person if selected for the NSFG survey and provide their $40 token of appreciation for completing the survey. If more than 5 adults (ages 18 to 59), list the 5 youngest.

First Name (or initials)

Sex

Age

Hispanic origin

Race

Current residence

1

Male

Hispanic or Latino

American Indian or Alaska Native

At this address

Female

Asian

Dormitory, fraternity, or sorority

Not Hispanic or Latino

Native Hawaiian or other Pacific Islander

Black of African American

Other

White

Phone number:





Email address:

2

Male

Hispanic or Latino

American Indian or Alaska Native

At this address

Female

Asian

Dormitory, fraternity, or sorority

Not Hispanic or Latino

Native Hawaiian or other Pacific Islander

Black of African American

Other

White

Phone number:





Email address:

First Name (or initials)

Sex

Age

Hispanic origin

Race

Current residence

3

Male

Hispanic or Latino

American Indian or Alaska Native

At this address

Female

Asian

Dormitory, fraternity, or sorority

Not Hispanic or Latino

Native Hawaiian or other Pacific Islander

Black of African American

Other

White

Phone number:





Email address:

4

Male

Hispanic or Latino

American Indian or Alaska Native

At this address

Female

Asian

Dormitory, fraternity, or sorority

Not Hispanic or Latino

Native Hawaiian or other Pacific Islander

Black of African American

Other

White

Phone number:





Email address:

5

Male

Hispanic or Latino

American Indian or Alaska Native

At this address

Female

Asian

Dormitory, fraternity, or sorority

Not Hispanic or Latino

Native Hawaiian or other Pacific Islander

Black of African American

Other

White

Phone number:





Email address:

Thank you very much for your help. Please return this screening survey in the provided postage-paid envelope.

If you have questions, you may call RTI toll-free at 800–262–4494.
This number is answered Monday – Friday, 9am - 5pm (ET).

CDC estimates the average public reporting burden for this collection of information as 3 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333; ATTN: PRA (0920-0314).

Assurance of Confidentiality – We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m) and the Confidential Information Protection and Statistical Efficiency Act (Title III of the Foundations for Evidence-Based Policymaking Act of 2018 (Pub. L. No. 115-435, 132 Stat. 5529 § 302)). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.

3