NSFG Household Screener Instrument in Capilite Format

N SFG OMB Attachment H OMB No. 0920-0314

NATIONAL SURVEY OF FAMILY GROWTH, YEAR 1 (2022)

HOUSEHOLD SCREENER INSTRUMENT in CAPILITE FORMAT

NOTE: Some question text for the screener may be modified based on changes needed for online administration.

Notice – 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.

{ ASKED IF WEB SCREENER

WSCRLANG

Would you prefer to complete this screening survey in English or Spanish?

1. English

2. Spanish

{ ASKED IF WEB SCREENER

SCIAGE

Are you 18 years of age or older and a member of this household?

1. Yes

2. No

{ ASKED IF WEB SCREENER AND SCIAGE=2

NEWSCIF

A household member age 18 or older is needed to complete this interview. Please ask a household member who is at least 18 years of age to complete this interview.

Exit screener interview

{ ASKED FOR ALL

CONFIRMA

 Screener checkpoint: 

If interviewer-administered screener display: This is sample ID [Sample ID preload].

Display for ALL:

(You are at/Your address is):

[Address number preload], [Street name preload]

[Apartment number preload, if app]
[City name preload], [State where Interview is being conducted preload], [Zip code preload]

 If this address is incorrect, please suspend this screener interview

 Please re-enter the numeric portion of the address to continue

{ ASKED IF INTERVIEWER-ADMINISTERED SCREENER

INFORMANT

 Interviewer checkpoint: 

       Who are you talking to now? 

1.  Household Member
5.  Proxy Reporter

DK Don’t Know

RF Refused

{ ASKED FOR ALL

HHPerson[1].NAME

(I would like/Please enter) the first name (or initials) of the people who usually live here. Please include any unmarried household members away from home living in a dormitory, fraternity or sorority.

Remember that this interview is completely voluntary and confidential.
If there is any question that you do not wish to answer, (please let me know and we/you) can move on to the next question.

Let's start with you, what is your name?

       ENTER Name 

{ ASKED FOR ALL

HHPerson[1].SEX

 If necessary, ask: (Is [Name of household member] male or female?) 

1.  Male
2.  Female

{ ASKED FOR ALL

HHPerson[1].AGE_X

How old (are you/is (she/he))? 

 If necessary, ask: (How old (were you/was (he/she) on (your/his/her) last birthday?) 

      Age probes: Is the household member 

            14 or under? If yes, enter [14]. If no, continue; 
            15-17? If yes, enter [16]. If no, continue; 
            18-19? If yes, enter [18]. If no, continue; 
            20-49? If yes, enter [32]. If no, continue; 
            50 or older? If yes, enter [50]. 

       ENTER [0] if less than 1 year

{ ASKED FOR ALL

HHPerson[1].HISP

      [F1]--Help 

(Do you/Does [Name of household member]) consider (yourself/himself/herself) to be Hispanic or Latino? 

[HELP AVAILABLE]

1.  Yes
5.  No

{ ASKED IF HISP=NO FOR HOUSEHOLD MEMBER

HHPerson[1].RACE

What race (do you/does ([Name of household member]) consider (yourself/himself/herself) to be? 

[HELP AVAILABLE]

       If interviewer-administered screener, READ list: 

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

{ ASKED IF AGE_X=17-22 FOR HOUSEHOLD MEMBER

HHPerson[1].DORMRES

(Do you/does ([Name of household member]) live in a college or university dormitory, fraternity, or sorority during the school year? 

1.  Yes
5.  No

{ ASKED FOR ALL

EndRoster

Are there any other members of this household 
who are currently living in a college or university dormitory, 
fraternity, or sorority? 

       If no others, select [1] to continue 

 Otherwise, if more people to describe, press the [Up-arrow] to return to the roster screen and enter additional household information 

{ ASKED FOR ALL

VERROSTER

To ensure all information is entered correctly, (I would like to/Let’s) review the list of household members. Please indicate if any of this information is incorrect. 

Currently the following members of this household have been listed: 

(You're/There’s) [Name of household member] and (you’re/she’s/he’s) [Age of household member] years old and (consider yourself/considers (himself/herself)) to be [Hispanic or Latino/American Indian or Alaska Native/Asian/Native Hawaiian or Other Pacific Islander/Black or African-American/White] and [female/male].

       If there is incorrect information, go back to the roster screen, by pressing the [Up] arrow, and enter additional household information 

       ASK if necessary: (What should be changed?) 

       SELECT [1] once all information has been verified to be correct 

{ ASKED IF NO HOUSEHOLD MEMBER IS AGE-ELIGIBLE FOR THE SURVEY

EXITAGE

Thank you. In this study, only males and females between the ages of 15 and 49 are being surveyed. These are all the questions for you now. On behalf of RTI and the National Center for Health Statistics, and the U.S. Department of Health and Human Services, thank you for taking the time to help with this screening interview.

We may need to verify later that this screening interview was conducted by a household member for the correct address. For this reason, will you provide a phone number?

 ENTER phone number (XXX-XXX-XXXX)

 Prefer not to provide phone number

{ ASKED IF INTERVIEWER-ADMINSTERED SCREENER AND SELECTED HH MEMBER IS A DORM RESIDENT

EXITSCR1

Thank you for your time. [Name of selected household member] has been selected to provide additional information for this study. Is [Name of selected household member] currently away at school or college?

1.  Yes
5.  No

{ ASKED IF INTERVIEWER-ADMINSTERED SCREENER

EXITSCR2

(You have been selected for the study.  May we begin the interview now? /[Name of selected household member] has been selected to provide
additional information for this study. May I speak to [Name of selected household member] now?)

(My home office may be calling you to verify that I was at the correct address and spoke with a household member. For these reasons, may I have your telephone number?/You may be called later to verify this interview. For this reason, please enter your telephone number) 

1.  Yes
5.  No

{ ASKED IF INTERVIEWER-ADMINISTERED SCREENER

ST_sPhone

May I have a telephone number to contact (you)?

       ENTER Name 

{ ASKED IF INTERVIEWER-ADMINISTERED SCREENER

LANG
Please code the likely interview language.

1.  English
2.  Spanish

3. Unknown

4. Other

{ ASKED IF WEB SCREENER AND INFORMANT SELECTED FOR MAIN INTVW

WEXITSCRC

You have been selected for the study. It would be helpful for us to have at least one additional way to contact you - phone, text, or email. If you prefer not to provide either your phone number or email address, any follow-up information will be sent to you by mail.

 ENTER phone number (XXX-XXX-XXXX)

 ENTER email address (example@mail.com)

 Prefer not to provide either

{ ASKED IN WEB SCREENER IF ANOTHER HOUSEHOLD MEMBER IS SELECTED AND THAT PERSON IS UNDER AGE 18

WEXITSCRPG

[Name of selected household member] has been selected to take part in this study. Since [Name of selected household member] is under 18 years of age we need permission from their parent or legal guardian in order to proceed. Are you the parent or legal guardian of [Name of selected household member]?

 Yes

 No

Note: If screener informant is the parent or legal guardian of the selected household member they will be asked for permission for their participation.

{ ASKED IN WEB SCREENER IF ANOTHER HOUSEHOLD MEMBER IS SELECTED AND THAT PERSON IS UNDER AGE 18 AND THE SCREENER INFORMANT IS NOT THEIR PARENT OR LEGAL GUARDIAN (WEXITSCRPG=NO)

WEXITSCRPG2

Please tell me which household member is a parent or legal guardian of [Name of selected household member] who can be asked for permission for [Name of selected household member] to take part in this survey?

(List of household members is displayed)

 ENTER number/name of a household member

{ ASKED IF ASKED IF WEB SCREENER, ANOTHER HOUSEHOLD MEMBER IS SELECTED AND THAT PERSON IS UNDER AGE 18 AND THE SCREENER INFORMANT IS NOT THEIR PARENT OR LEGAL GUARDIAN

WSCRPGPE

Would you please provide a phone number or email address for [household member named in WEXITSCRPG] so that we may contact them by phone, text, or email to request permission for [Name of selected household member] to participate in this survey? If you prefer not to provide a phone number or email address we will send follow-up information by mail.

 ENTER phone number (XXX-XXX-XXXX)

 ENTER email address (example@mail.com)

 Prefer not to provide email address or phone number

NOTE: Contact information is used to confirm this person is the parent or legal guardian of the selected household member and request permission for their participation.

{ ASKED IF WEB SCREENER ANOTHER HOUSEHOLD MEMBER IS SELECTED AND THAT PERSON IS AGE 18 OR OLDER.

WEXITSCR2

[Name of selected household member] has been selected to take part in this study. May we have [Name of selected household member]’s phone number or email address to contact them by text or email? We will also send follow-up information by mail.

 Enter [selected household member]’s phone number (XXX-XXX-XXXX)

 Enter [selected household member]’s email address (example@mail.com)

 Prefer not to provide phone number or email address

{ ASKED FOR WEB SCREENER

WLANG
Please enter (your/[Name of selected household member]’s) likely preferred language for the main interview. English or Spanish are available.

1.  English
2.  Spanish

{ COMPLETED BY INTERVIEWER IF INTERVIEWER-ADMINISTERED SCREENER

SCOBS_2

 Interviewer checkpoint: 

 Do you think the selected respondent is in an active sexual relationship with an opposite-sex partner? 

[HELP AVAILABLE]

1.  Yes
5.  No

{ COMPLETED BY INTERVIEWER IF INTERVIEWER-ADMINISTERED SCREENER

SCOBS_3

 Interviewer checkpoint: 

       What is the probability of getting the main interview? 

1.  High
2.  Medium
3.  Low

{ COMPLETED BY INTERVIEWER IF INTERVIEWER-ADMINISTERED SCREENER

SCComplete

 Interviewer checkpoint: 

       You have reached the end of the NSFG Screener 

       SELECT [1] to exit interview 

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