Form PART A, ATTACH A_P PART A, ATTACH A_P PART A, ATTACH A_Phase 3.6 Questionnaire_v5 (1)

Phase 3.6 Household Pulse Survey

Welcome! Thank you for participating in the Household Pulse Survey sponsored by the U.S. Census Bureau and other federal agencies. 
 
This survey will help measure the impact of coronavirus (COVID-19) on topics like:   employment status

food security

housing security

physical and mental wellbeing.  

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

This survey is also available in Spanish. If you would like to change your language selection, 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.  

This survey is a cooperative effort across many government agencies to provide critical, up-to-date information about the impact of the coronavirus (COVID-19) pandemic on the U.S. population.  Completing this 20-minute survey will help federal, state, and local agencies identify coronavirus (COVID-19) related issues in your community.

PRA
We estimate that completing this voluntary survey will take 20 minutes on average. Send comments regarding this estimate or any other aspect of this survey to adrm.pra@census.gov.  

The U.S. Census Bureau is required by law to protect your information. The Census Bureau is not permitted to publicly release your responses in a way that could identify you. Federal law

protects your privacy and keeps your answers confidential (Title 13, United States Code, Section 9 and Title 5, U.S. Code, Section 552a).  

This collection has been approved by the Office of Management and Budget (OMB). This eight-digit OMB approval number, 0607-1013, confirms this approval and expires on 10/31/2023.  

The uses of your data are limited to those identified in the Privacy Act System of Record Notice titled, “SORN COMMERCE/Census-3, Demographic Survey Collection (Census Bureau Sampling Frame).”  

To learn more about this survey go to: https://www.census.gov/householdpulsedata.  

** 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. 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). 

This survey is available in English and Spanish. Please select the language in which you prefer to complete the survey. 

If you would like to change your language selection later, 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.

• English

• Español

These questions are for statistical purposes only.

D1 What year were you born? Please enter a number. ________________________

D2 Are you of Hispanic, Latino, or Spanish origin? 

• No, not of Hispanic, Latino, or Spanish origin

• Yes, Mexican, Mexican American, Chicano

• Yes, Puerto Rican

• Yes, Cuban

• Yes, another Hispanic, Latino, or Spanish origin _______________________

D3 What is your race? Please select all that apply. 

• White (specify) _____________________________________________

• Black or African American (specify) _____________________________

• American Indian or Alaska Native (specify) _______________________

• Asian Indian

• Chinese

• Filipino

• Japanese

• Korean

• Vietnamese

• Other Asian (specify) _________________________________________

• Native Hawaiian

• Chamorro

• Samoan

• Other Pacific Islander (specify) _________________________________

D4 What is the highest degree or level of school you have completed? Select only one answer.

• Less than high school

• Some high school

• High school graduate or equivalent (for example GED)

• Some college, but degree not received or is in progress

• Associate’s degree (for example AA, AS)

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

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

D5 What is your marital status? Select only one answer.

• Now married

• Widowed

• Divorced

• Separated

• Never married

D6 What sex were you assigned at birth, on your original birth certificate?

• Male

• Female

D7 Do you currently describe yourself as male, female or transgender?

• Male

• Female

• Transgender

• None of these

D8 Just to confirm, you were assigned "${D6/ChoiceGroup/SelectedChoices}" at birth and now you describe yourself as "${D7/ChoiceGroup/SelectedChoices}". Is that correct?

• Yes

• No

D6_correction Please confirm or correct your answer to the following question: ${D6/QuestionText}

• Male

• Female

D7_correction Please confirm or correct your answer to the following question: ${D7/QuestionText}

• Male

• Female

• Transgender

• None of these

D9_second Which of the following best represents how you think of yourself?

• Gay or lesbian

• Straight, that is not gay or lesbian

• Bisexual

• Something else

• I don’t know

D10 How many total people – adults and children – currently live in your household, including yourself? Please enter a number.________________________________________

D11 How many people under 18 years-old currently live in your household? Please enter a number.___________________________________

D12 In your household, are there… Select all that apply.

• Children under 5 years old?

• Children 5 through 11 years old?

• Children 12 through 17 years old?

D13 During the school year that began in the Summer / Fall of 2022, how many children in this household were enrolled in Kindergarten through 12th grade or grade equivalent? Enter whole numbers for all that apply. Enter ‘0’ if none

• Number enrolled in a public school ______________________________________

• Number enrolled in a private school _____________________________________

• Number homeschooled, that is not enrolled in public or private school

________________________________________________

• None

D14 Are you or your spouse currently serving in the U.S. Armed Forces (Active Duty, Reserve, or National Guard)?  
Reserve and Guard members/spouses who are full-time active duty (AGR/FTS/AR) or currently "activated" should select the "Reserve or National Guard" response(s).  Select all that apply.

• No

• Yes, I'm serving on active duty

• Yes, I'm serving in the Reserve or National Guard

• Yes, my spouse is serving on active duty

• Yes, my spouse is serving in the Reserve or National Guard

The next set of questions ask about COVID-19 vaccination.

VAC1 Have you received at least one dose of a COVID-19 vaccine?

• Yes

• No - go to VAC5_B

VAC2 (Universe: VAC1 = 1) Which of the following best describes your COVID-19 vaccine status (not including boosters):

• I received 2 doses of a two-shot series like Moderna or Pfizer or a single dose vaccine like Johnson & Johnson (2)

• I received one dose of a two-shot series like Moderna or Pfizer (1)

VAC2_Booster (Universe: VAC1 = 1)

Have you received at least one COVID-19 vaccine booster?

• Yes - go to VAC5_B

• No

VAC4_B. (Universe: VAC2_Booster=2) Which of the following, if any, are reasons that you have not received a COVID-19 booster dose? Select all that apply.

• I am not yet eligible to receive a COVID-19 booster dose

• I plan to get a booster and am eligible, but haven’t made an appointment or haven’t had time to do it

• I don’t believe a COVID-19 booster is necessary

• My doctor has not recommended it

• I already had COVID-19

• I am not required to get a COVID-19 booster (by my work or school)

• I experienced side effects from my previous dose(s) of the COVID-19 vaccine

• It's hard for me to get a COVID-19 booster dose because I do not have transportation or cannot get an appointment

• Other (please specify) ______________________________

(Universe: D11 > 0)

VAC5_A Have any of the children living in your household received at least one dose of a COVID-19 vaccine? Please respond “yes” if any of the children living in your household have received at least one dose, even if some of the children have not.

• Yes

• No

• Don’t know

(Universe: VAC5_A = Yes AND Under 5 years old selected in D12)

VAC5_B1 Are any of the children under 5 years old fully vaccinated against COVID-19?

• Yes

• No

• Don’t know

(Universe: VAC5_B1 = Yes)

VAC5_C1 (If yes) Have any of the children under 5 years old received a booster or additional doses of a COVID-19 vaccine?

• Yes

• No

• Don’t know

(Universe: VAC5_A = Yes AND 5-11 years old selected in D12)

VAC5_B2 Are any of the children 5-11 years old fully vaccinated against COVID-19?

• Yes

• No

• Don’t know

(Universe: VAC5_B2 = Yes)

VAC5_C2 (If yes) Have any of the children 5-11 years old received a booster or additional doses of a COVID-19 vaccine?

• Yes

• No

• Don’t know

(Universe: VAC5_A = Yes AND 12-17 years old selected in D12)

VAC5_B3 Are any of the children 12-17 years old fully vaccinated against COVID-19?

• Yes

• No

• Don’t know

(Universe: VAC5_B3 = Yes)

VAC5_C3 (If yes) Have any of the children 12-17 years old received a booster or additional doses of a COVID-19 vaccine?

• Yes

• No

• Don’t know

(Universe: If any of VAC5_B1, VAC5_B2 OR VAC5_B3 = no)

VAC6 Now that vaccines to prevent COVID-19 are available to most children, will the parents or guardians of children living in your household…

	Definitely get the children a vaccine (1)	Probably get the children a vaccine (2)	Be unsure about getting the children a vaccine (3)	Probably NOT get the children a vaccine (4)	Definitely NOT get the children a vaccine (5)	I do not know the plans for vaccination (6)
Universe: If Under 5 is selected in D12 Children under 5 years old
Universe: If 5-11 selected in D12 Children 5-11 years old
Universe: If 12-17 selected in D12 Children 12-17 years old

(Universe: VAC6 in (2,3,4,5) for any age category)

VAC7 Which of the following, if any, are reasons that the parents or guardians of children living in your household may not or will not get a vaccine for all of the children? Select all that apply.

• Concern about possible side effects of a COVID-19 vaccine for children

• Plan to wait and see if it is safe and may get it later

• Not sure if a COVID-19 vaccine will work for children

• Don't believe children need a COVID-19 vaccine

• The children in this household are not members of a high-risk group

• The children’s doctor has not recommended it

• Other people need it more than the children in this household do right now

• Concern about missing work to have the children vaccinated

• Unable to get a COVID-19 vaccine for children in this household

• Parents or guardians in this household do not vaccinate their children

• Don't trust COVID-19 vaccines

• Don't trust the government

• Concern about the cost of a COVID-19 vaccine

• Other (specify) ________________________________________________

VAC8_B. Have you ever tested positive for COVID-19 (using a rapid point-of-care test, self-test, or laboratory test) or been told by a doctor or other health care provider that you have or had COVID-19?

• Yes

• No

VAC8_C. (Universe: tested or have/had COVID-19, VAC8_B=1) When did you test positive or were told you have or had COVID-19?

• Within the last four weeks

• More than four weeks ago

• Both

NEW: TREAT1_A. (Universe: VAC8_B =1 AND VAC8_C=1 or 3), All adults who had or tested positive for COVID-19 in past four weeks)

The FDA has issued emergency use authorizations (EUAs) for a number of treatments for COVID-19 for people at high risk of severe disease. These include oral antiviral medications or pills that can be taken at home, and monoclonal antibody treatments that can be administered at a doctor’s office or hospital. When you had COVID-19 in the past 4 weeks, did you receive an antiviral or monoclonal antibody treatment, such as a pill or IV infusion?

	Oral antiviral medications (examples: Paxlovid, molnupiravir)	Monoclonal antibody treatments (example: sotrovimab)
Yes
No

NEW: TREAT2_A. (Universe: Those who said “No” to taking antivirals or monoclonal antibodies) Which of the following, if any, are reasons that you did not take antivirals or monoclonal antibodies? Select all the apply.

• I wasn’t very sick/I had no symptoms

• I didn’t think I needed a treatment

• I am not a member of a high-risk group

• My healthcare provider did not offer or recommend them

• I was concerned about possible side effects of these treatments

• I was concerned about cost

• I didn’t think these treatments were effective

• It was hard for me or my healthcare provider to get them

• I hadn’t heard of them

• Other (please specify) ________________________________

PASC1: (Universe: VAC8_B = 1 tested positive for COVID-19 or believed had COVID-19) How would you describe your coronavirus symptoms when they were at their worst?

• I had no symptoms

• I had mild symptoms

• I had moderate symptoms

• I had severe symptoms

PASC2: (Universe: VAC8_B = 1 tested positive for COVID-19 or believed had COVID-19) Did you have any symptoms lasting 3 months or longer that you did not have prior to having coronavirus or COVID-19? Long term symptoms may include: tiredness or fatigue, difficulty thinking, concentrating, forgetfulness, or memory problems (sometimes referred to as "brain fog", difficulty breathing or shortness of breath, joint or muscle pain, fast-beating or pounding heart (also known as heart palpitations), chest pain, dizziness on standing, menstrual changes, changes to taste/smell, or inability to exercise.

• Yes

• No

PASC3: (Universe: VAC8_B = 1 tested positive for COVID-19 or believed had COVID-19)

Do you have symptoms now?

• Yes

• No

PASC4. (Universe PASC2 = 1 yes and PASC3 = yes) Do these long-term symptoms reduce your ability to carry out day-to-day activities compared with the time before you had COVID-19? 

 

• Yes, a lot;

• Yes, a little;

• Not at all   

EMP1 Now we are going to ask about your employment. 
Have you, or has anyone in your household experienced a loss of employment income in the last 4 weeks?  Select only one answer.

• Yes

• No

EMP2
In the last 7 days, did you do ANY work for either pay or profit? Select only one answer.

• Yes

• No

EMP3 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.

• Government

• Private company

• Non-profit organization including tax exempt and charitable organizations

• Self-employed

• Working in a family business

EMP4 What is your main reason for not working for pay or profit? Select only one answer.
I did not work because:

• I did not want to be employed at this time

• I am/was sick with coronavirus symptoms or caring for someone who was sick with coronavirus symptoms (including long-term effects of coronavirus)

• I am/was caring for children not in school or daycare

• I am/was caring for an elderly person

• I was concerned about getting or spreading the coronavirus

• I am/was sick or disabled (not coronavirus related)

• I am retired

• I am/was laid off or furloughed due to coronavirus pandemic

• My employer closed temporarily due to the coronavirus pandemic

• My employer went out of business due to the coronavirus pandemic

• I do/did not have transportation to work

• Other reason, please specify _______________________________________

(Universe: EMP2 = 1 {worked for pay in the last 7 days})

EMP6 What kind of business or industry or organization is this? That is, What do they make or do where you work? (Select only one answer).

• Agriculture, Forestry, Fishing and Hunting

• Mining, Quarrying, and Oil and Gas Extraction

• Utilities

• Construction

• Manufacturing

• Wholesale Trade

• Retail Trade

• Transportation and Warehousing

• Information Technology

• Finance and Insurance

• Real Estate and Rental and Leasing

• Professional, Scientific, and Technical Services

• Management of Companies and Enterprises

• Administrative and Support Services

• Waste Management and Remediation Services

• Educational Services

• Health Care

• Social Assistance

• Arts, Entertainment, and Recreation

• Accommodation and Food Services

• Public Administration

• Other Services (except Public Administration)

EMPUI1 Since June 1, 2022, have you applied for Unemployment Insurance (UI) benefits? Select only one answer.

• Yes

• No

EMPUI2 Since June 1, 2022, have you received Unemployment Insurance (UI) benefits? Select only one answer.

• Yes

• No

EMPUI3 Have you received Unemployment Insurance (UI) benefits in the last 7 days? Select only one answer.

• Yes

• No

Next, we are going to ask about the childcare arrangements for children in the household.

(Universe: Children in household)

CCARE1. In the last 7 days, did your household use any of the following individuals or arrangements to look after the children in the household.

Select all that apply.

• Family day care provider caring for 2 or more children outside of your home?

• Child care or day care center?

• Nursery or preschool?

• Before care, aftercare, or summer camp?

• Federally supported Head Start program?

• Non-relative such as a friend, neighbor, sitter, nanny, or au pair?

• Relative other than the parent, such as sibling, or grandparent?

• None of these

(Universe: If anything is marked in CCARE1, ask:)

CCARE2. Did you or anyone in the household PAY for that childcare? Select only one answer.

• Yes

• No

CCARE3. In the last 7 days, how much did your household pay for all the childcare together?

$________________

(Ask everyone)

INFLATE1 In the area where you live and shop, do you think prices in general have changed in the last two months? Select only one answer.

• I think prices have increased

• I do not think prices have changed

• I think prices have decreased

• I do not know

(Universe: INFLATE1=1)

INFLATE2 How stressful, if at all, has the increase in prices in the last two months been for you? Select only one answer.

• Very stressful

• Moderately stressful

• A little stressful

• Not at all stressful

(Universe: INFLATE1=1)

INFLATE3 What changes, if any, have you made to cope with the increase in prices? (Select all that apply).

• Shop at stores that offer lower prices, look for sales, and/or use coupons

• Switch from name brand to generic products

• Purchase less fresh produce and/or meat

• Go out to eat less often or order food for delivery less often

• Cancel or reduce subscription services (e.g., streaming services, meal delivery services, cell phone plan)

• Cancel or decrease plans to attend events

• Drive less or change mode of transportation (e.g., bike or take metro instead of drive)

• Delay major purchases (e.g., home repair/renovation, vacations, vehicles, home appliances, cell phone or computer)

• Delay medical treatment (e.g., refill prescription, surgery)

• Work additional job(s)/shift(s) to supplement income

• Contribute less to savings and/or retirement accounts

• Increase use of credit cards, loans, and/or pawnshops

• Decrease use of utilities (e.g., cooling, heating, water, electricity)

• Move to less expensive housing

• Ask friends and/or family for help

• Change or reduce plans for childcare arrangements to save money

• Utilize benefits from charities

• Other

• I have not made any changes

(Ask everyone)

INFLATE4 In the area you live and shop, how concerned are you, if at all, that prices will increase in the next six months? Select only one answer.

• Very concerned

• Somewhat concerned

• A little concerned

• Not at all concerned.

The next questions ask about your household's spending in the last 7 days. Please only include experiences that occurred in the last 7 days.

SPN4
In the last 7 days, how difficult has it been for your household to pay for usual household expenses, including but not limited to food, rent or mortgage, car payments, medical expenses, student loans, and so on? Select only one answer.

• Not at all difficult

• A little difficult

• Somewhat difficult

• Very difficult

SPN5_DAYSTW

In the last 7 days, have any of the people in your household teleworked or worked from home?

• Yes, for 1-2 days

• Yes, for 3-4 days

• Yes, for 5 or more days

• No, Skip to SPN6

(Universe: If SPN5_DAYSTW = 1, 2, or 3)

SPN5_DAYSTW_2

In the last 7 days, have you teleworked or worked from home?

• Yes, for 1-2 days

• Yes, for 3-4 days

• Yes, for 5 or more days

• No

SPN6 Thinking about your experience in the last 7 days, which of the following did you or your household members use to meet your spending needs? Select all that apply. 

• Regular income sources like those received before the pandemic

• Credit cards or loans

• Money from savings or selling assets or possessions (including withdrawals from retirement accounts)

• Borrowing from friends or family

• Unemployment insurance (UI) benefit payments

• Money saved from deferred or forgiven payments [to meet your spending needs]

• Supplemental Nutrition Assistance Program (SNAP)

• Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

• School meal debit/EBT cards (10)

• Government rental assistance (11)

• Other, specify: (12) ________________________________________________

FD1 Getting enough food can also be a problem for some people. In the last 7 days, which of these statements best describes the food eaten in your household? Select only one answer.

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

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

• Sometimes not enough to eat

• Often not enough to eat

FD2
Please indicate whether the next statement was often true, sometimes true, or never true in the last 7 days for the children living in your household who are under 18 years old.  

"The children were not eating enough because we just couldn't afford enough food."

• Often true

• Sometimes true

• Never true

FD3 Why did you not have enough to eat (or not what you wanted to eat)? Select all that apply.

• Couldn’t afford to buy more food

• Couldn’t get to store to buy food (for example, didn’t have transportation, have mobility or health limitations that prevent you from getting out)

• Couldn’t go to store due to safety concerns

• None of the above

FD4 During the last 7 days, did you or anyone in your household get free groceries from a food pantry, food bank, church, or other place that provides free food? Select only one answer.

• Yes

• No

FD5 In the last 7 days, did the children in this household... Select all that apply.

• Pick up free meals at a school or other location

• Receive or use an EBT card to help buy groceries

• Eat free meals on-site, at school or other location

• Have free meals delivered

• Children did not receive free meals or food assistance

FD6 Do you or does anyone in your household receive benefits from the Supplemental Nutrition Assistance Program (SNAP) or the Food Stamp Program? Select only one answer.

• Yes

• No

(Universe: All)

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. 

(Universe: All)

Q28 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.

________________________________________________________________

(Universe: If Q28 >= 1000)

Q28_check You said that you spent $${Q28/ChoiceTextEntryValue}.00 on food at supermarkets, grocery stores, online, and other places during the last 7 days.  This amount seems unusually high.  Are you sure it is the correct amount?

• Yes

• No, I need to correct the amount

(Universe: If Q28_check = No, I need to correct the amount)

Q28_correction Please provide the correct amount (or your best estimate).
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.

________________________________

Universe: All

Q29 During the last 7 days, how much money did you and 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 the previous question (above).  Enter amount.

________________________________

(Universe: If Q29 >= 1000)

Q29_check You said that you spent $${Q29/ChoiceTextEntryValue}.00 on prepared meals during the last 7 days.  This amount seems unusually high.  Are you sure it is the correct amount?

• Yes

• No, I need to correct the amount

(Universe: If Q29_check = No, I need to correct the amount)

Q29_correction Please provide the correct amount (or your best estimate).
During the last 7 days, how much money did you and 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.

_____________________________________

Universe D12=Under 5

INF1. Are there any babies or infants under the age of 1 year in your household?

• Yes -continue

• No – skip to HLTH1

INF2. How many months old is the baby or infant in your household? If there is more than one, please report the age of the youngest.

• Under 6 months?

• Between 6 months and 9 months?

• Between 9 months and 12 months?

INF3. Was your household affected by the Infant Formula shortage this year?

• Yes

• No – go to INF5

INF4. Please state how you dealt with the infant formula shortage this year: (Select all that apply):

• Increased breastfeeding

• Changed from powder to liquid (i.e., liquid concentrate or ready-to-feed (RTF))

• Got Infant Formula at a different store than where I usually shop

• Got Infant Formula online (e.g., Instacart, Amazon, Google Market, secondary market, or other)

• Received direct shipment of Infant Formula from the Infant Formula company

• Changed to a different brand of Infant Formula (any form, powder or liquid)

• Changed from Infant Formula to something else (for example: Cow milk, Goat milk, Soy milk, Almond milk, Oat milk, or Toddler Drink/Formula)

• Stopped offering Infant Formula

• Watering down formula or “making your own” formula

• Other, specify?

INF5. Does the baby typically use Infant Formula?

• Yes

• No – skip to HLTH1

INF6. In the last 7 days, did you have difficulty obtaining Infant Formula?

• Yes

• No

INF7. Currently, how much Infant Formula do you have on hand:

• None

• Formula for less than a week

• Formula for about a week

• Formula for more than a week but less than two weeks

• Formula for more than two weeks

INF8. What type of Infant Formula does your infant typically use? Mark all that apply.

• Regular or Routine Infant Formula (e.g Similac, Enfamil, Enfagrow, Pregestimil, Enfaport, NAN, Good Start, NIDO, KLIM, Earths Best, Happy Baby, Burts Bees, Kabrita, Babys Only, Else, Lil Mixins, Babys Choice, Kendamil, J&J Sunrise, PediaSmart, Family Wellness, Happy Tot, Store Label, Private Label)

• Extensively Hydrolyzed Infant Formula (e.g., Alimentum, Alimentum Liquid, Gerber Extensive, Nutramigen)

• Amino Acid Based Infant Formula (e.g., Alfamino, EleCare, Neocate, Puramino)

• Metabolic Infant Formulas (e.g., Calcilo, Cyclinex-1, Glutarex-1, Hominex-1, I-Valex-1, Ketonex-1, Phenex-1, Pro-Phree, Propimex-1, RCF, Tyrex-1)

• Other

• Don’t know

Next, we will ask about health and medical care.

HLTH1 Over the last 2 weeks, how often have you been bothered by... Feeling nervous, anxious, or on edge? Select only one answer.

• Not at all

• Several days

• More than half the days

• Nearly every day

HLTH2 Over the last 2 weeks, how often have you been bothered by... Not being able to stop or control worrying? Select only one answer.

• Not at all

• Several days

• More than half the days

• Nearly every day

HLTH3 Over the last 2 weeks, how often have you been bothered by... Having little interest or pleasure in doing things? Select only one answer.

• Not at all

• Several days

• More than half the days

• Nearly every day

HLTH4 Over the last 2 weeks, how often have you been bothered by... Feeling down, depressed, or hopeless? Select only one answer.

• Not at all

• Several days

• More than half the days

• Nearly every day

HLTH8 Are you currently covered by any of the following types of health insurance or health coverage plans? Mark Yes or No for each.

	Yes	No
Insurance through a current or former employer or union (through yourself or another family member)
Insurance purchased directly from an insurance company, including marketplace coverage (through yourself or another family member)
Medicare, for people 65 and older, or people with certain disabilities
Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability
TRICARE or other military health care
VA (including those who have ever used or enrolled for VA health care)
Indian Health Service
Other

HLTH14 (Universe: D11 > 0)
Think about all of the children living in your household. IN THE PAST 4 WEEKS, did any of these children seem to (check all that apply):

• Feel anxious or clingy?

• Feel very sad or depressed?

• Show changes in eating behaviors, such as eating more or less than normal, or became extremely picky?

• Show changes in their ability to stay focused, such as becoming easily distracted?

• Show unusual anger or outbursts?

• Engage in problematic behaviors such as lying, cheating, stealing, or bullying?

• Behave in ways that they’ve previously outgrown, such as thumb sucking or wetting the bed?

• Complain of physical pain with no medical issue such as stomach aches or pains?

• None of the children in my household exhibited any of these behaviors

DIS1 Do you have difficulty seeing, even when wearing glasses? Select only one answer.

• No - no difficulty

• Yes - some difficulty

• Yes - a lot of difficulty

• Cannot do at all

DIS2 Do you have difficulty hearing, even when using a hearing aid? Select only one answer.

• No - no difficulty

• Yes - some difficulty

• Yes - a lot of difficulty

• Cannot do at all

DIS3 Do you have difficulty remembering or concentrating? Select only one answer.

• No - no difficulty

• Yes - some difficulty

• Yes - a lot of difficulty

• Cannot do at all

DIS4 Do you have difficulty walking or climbing stairs? Select only one answer.

• No - no difficulty

• Yes - some difficulty

• Yes - a lot of difficulty

• Cannot do at all

DIS5 Do you have difficulty with self-care, such as washing all over or dressing?

• No - no difficulty

• Yes - some difficulty

• Yes - a lot of difficulty

• Cannot do at all

DIS6 Using your usual language, do you have difficulty communicating, for example understanding or being understood?

• No - no difficulty

• Yes - some difficulty

• Yes - a lot of difficulty

• Cannot do at all

The next questions ask about housing.

HSE1 Is your house or apartment…? Select only one answer.

• Owned by you or someone in this household free and clear?

• Owned by you or someone in this household with a mortgage or loan (including home equity loans)?

• Rented?

• Occupied without payment of rent?

HSE2 Which best describes this building? Include all apartments, flats, etc., even if vacant. Select only one answer.

• A mobile home

• A one-family house detached from any other house

• A one-family house attached to one or more houses

• A building with 2 apartments

• A building with 3 or 4 apartments

• A building with 5 or more apartments

• Boat, RV, van, etc.

(Universe: Ask if HSE1=3)

HSEnew1 What is your current monthly rent? ___________

(Universe: Ask if HSE1=3)

HSEnew2 Has your monthly rent changed during the last 12 months? If so, by how much? 

• My rent did not change.

• My rent decreased.

• My rent increased by less than $100.

• My rent increased by $100-$249. 

• My rent increased by $250-$500.

• My rent increased by more than $500.

. 

HSE3 Is this household currently caught up on rent payments? Select only one answer.

• Yes

• No

HSE4 Is this household currently caught up on mortgage payments? Select only one answer.

• Yes

• No

HSE6 How many months behind is this household in paying your rent or mortgage?

_____________________________

HSE7 Have you or anyone in your household applied for emergency rental assistance through your state or local government to cover your unpaid rent or utility bills?

• My household applied and received assistance

• My household applied and is waiting for a response

• My household applied and the application was denied

• My household did not apply

HSE8 How likely is it that your household will have to leave this home or apartment within the next two months because of eviction? Select only one answer.

• Very likely

• Somewhat likely

• Not very likely

• Not likely at all

HSE9 How likely is it that your household will have to leave this home within the next two months because of foreclosure? Select only one answer.

• Very likely

• Somewhat likely

• Not very likely

• Not likely at all

HSE10 In the last 12 months, how many months did your household reduce or forego expenses for basic household necessities, such as medicine or food, in order to pay an energy bill?

• Almost every month

• Some months

• 1 or 2 months

• Never

HSE11 In the last 12 months, how many months did your household keep your home at a temperature that you felt was unsafe or unhealthy?

• Almost every month

• Some months

• 1 or 2 months

• Never

HSE12 In the last 12 months, how many times was your household unable to pay an energy bill or unable to pay the full bill amount?

• Almost every month

• Some months

• 1 or 2 months

• Never

Has the cost of gas in the last 7 days caused you to: Select all that apply.

• Choose not to take a trip (e.g., chose not to visit a friend/restaurant/park etc., change a task from in-person to online to reduce gas use)

• Combine trips

• Take alternative modes of transportation (e.g., public transit, ridesharing, bike, etc.)

• None of these – the cost of gas has not affected my driving behavior

The next questions ask about education.

K12ED1 During the last 7 days, how did the children in this household receive their education? Select all that apply.

• Children received in-person instruction from a teacher at their school

• Children received virtual/online instruction from a teacher in real time

• Children learned on their own using on-line materials provided by their school

• Children learned on their own using paper materials provided by their school

• Children learned on their own using materials that were NOT provided by their school

• Children did not participate in any learning activities because their school was closed

• Children were sick and could not participate in education

• Children were on summer break

• Other, specify ________________________________________________

(Universe: <If D13_1 > 0, D13_2 > 0 or D13_3 > 0 then display ED1>)

ED1 After the end of the normal school year in the Spring of 2022, did any of the Kindergarten through 12th grade students in your household: Please select all that apply.

• Attend a traditional summer school program because of poor grades?

• Attend a summer school program to help students catch up with lost learning time during the pandemic?

• Attend school-led summer camps for subjects like math, science or reading?

• Work with private tutors to help students catch up with lost learning time during the pandemic?

• None of these

INC1 In 2021 what was your total household income before taxes? Select only one answer.

• Less than $25,000

• $25,000 - $34,999

• $35,000 - $49,999

• $50,000 - $74,999

• $75,000 - $99,999

• $100,000 - $149,999

• $150,000 - $199,999

• $200,000 and above

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 current 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 _______________________________________________

• Street Name ________________________________________________

• Apt Unit ________________________________________________

• City ________________________________________________

• State ________________________________________________

• Zip ________________________________________________

If an address is given, skip to Best Contact.

Universe: If there is no address.

rural_route

Do you have a Rural Route address?

• Yes

• No

rural_address Please provide the Rural Route address where you currently reside.  

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

• RR Descriptor ________________________________________________

• Rural Route No ________________________________________________

• RR Box ID ________________________________________________

• City ________________________________________________

• State ________________________________________________

• Zip Code ________________________________________________

rural_description 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.

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

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 (1) ________________________________________________

• State (2) ________________________________________________

• Zip (3) ________________________________________________

other_description 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 experiencing homelessness, as well as the name of the city and state. For example, "Friendship Park, Anywhere PA."

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

bestmethod Because we are interested in how coronavirus experiences change over time, we may contact you again in the coming weeks. What is the best way for us to contact you?

• Text message

• Email

bestnumber To help us contact you, please provide the best phone number to reach you.

________________________________________________________________

bestemail To help us contact you, please provide the best email address to reach you.

________________________________________________________________

feedback_pandemic Thank you.

Is there anything else related to the coronavirus pandemic you would like to tell us?

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Q69 That concludes the survey. Please click on the “Submit” button when you are finished.  

Thank you for participating in the Household Pulse Survey. If you have any questions about this survey please visit https://www.census.gov/householdpulsedata. You can validate that this survey is a legitimate federally-approved information collection using the U.S. Office of Management and Budget approval number 0607-1013, expiring on 10/31/2023.  

If you need help during this time, here are some resources that may help: 

Infant formula:

Information for Families During the Infant Formula Shortage | Nutrition | CDC

Questions & Answers for Consumers Concerning Infant Formula | FDA

General: https://www.coronavirus.gov/

Meal finder for kids:  https://www.fns.usda.gov/meals4kids

Unemployment services: https://www.usa.gov/unemployment 

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