PART A, ATTACH A_P PART A, ATTACH A_Phase 3.9 Questionnaire

Household Pulse Survey Phase 3.9

PART A, ATTACH A_Phase 3.9 Questionnaire (1)

OMB: 0607-1013

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0607-1013 can be found here:

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Phase 3.9 Household Pulse Survey

Intro 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 social and economic factors, including ongoing impacts of coronavirus (COVID-19) on topics like:

employment status

food security

housing security

physical and mental wellbeing.

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.

Intro2

This survey is a cooperative effort across many government agencies to provide critical, up-to-date information on the U.S. population. Completing this 20-minute survey will help federal, state, and local agencies identify emergent 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).

language

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 (1)
Español (2)

Display This Question:

If language = English

Or language = Español

leadin1 These questions are for statistical purposes only.

Display This Question:

If language != English

And language != Español

leadin1 These questions are for statistical purposes only.

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

________________________________________________________________

Skip To: End of Survey If Condition: What year were you born? Pl... Is Greater Than 2005. Skip To: End of Survey.

Race_sp What is your race and/or ethnicity? Select all that apply.

White For example, German, Irish, English, Italian, Polish, French, etc. (1)
Hispanic or Latino For example, Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc. (2)
Black or African American For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. (3)
Asian For example, Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc. (4)
American Indian or Alaskan Native For example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Tribal Government, Tlingit, etc. (5)
Middle Eastern or North African For example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, Israeli, etc. (6)
Native Hawaiian or Pacific Islander For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc. (8)

Display This Question:

If If What is NAME's race or ethnicity?Select all that apply. q://QID35/SelectedChoicesCount Is Greater Than 0

Q52
Next, we will collect detailed information for each race and/or ethnicity selected.

Display This Question:

If What is NAME's race or ethnicity?Select all that apply. = WHITE For example, German, Irish, English, Italian, Polish, French, etc.

white_detailsp You said that you are White. Provide details below. Select all that apply.

German (1)
Italian (2)
Irish (3)
Polish (4)
English (5)
French (6)
Enter, for example, Scottish, Norwegian, Dutch, etc. (7) __________________________________________________

Display This Question:

If What is NAME's race or ethnicity?Select all that apply. = HISPANIC OR LATINO For example, Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc.

Hispanic_detailsp You said that you are Hispanic or Latino. Provide details below. Select all that apply.

Mexican or Mexican American (1)
Salvadoran (2)
Puerto Rican (3)
Dominican (4)
Cuban (5)
Colombian (6)
Enter, for example, Guatemalan, Spaniard, Ecuadorian, etc. (7) __________________________________________________

Display This Question:

If What is NAME's race or ethnicity?Select all that apply. = BLACK OR AFRICAN AMERICAN For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.

Black or AA_detailsp You said that you are Black or African American. Provide details below. Select all that apply.

African American (1)
Nigerian (2)
Jamaican (3)
Ethiopian (4)
Haitian (5)
Somali (6)
Enter, for example, Ghanaian, South African, Barbadian, etc. (7) __________________________________________________

Display This Question:

If What is NAME's race or ethnicity?Select all that apply. = ASIAN For example, Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc.

Asian_detailsp You said that you are Asian. Provide details below. Select all that apply.

Chinese (1)
Vietnamese (2)
Filipino (3)
Korean (4)
Asian Indian (5)
Japanese (6)
Enter, for example, Pakistani, Cambodian, Hmong, etc. (7) __________________________________________________

Display This Question:

If What is NAME's race or ethnicity?Select all that apply. = AMERICAN INDIAN OR ALASKA NATIVE For example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Tribal Government, Tlingit, etc.

AIAN_detailsp You said that you are American Indian or Alaska Native. Please enter, for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Tribal Government, Tlingit, etc. Click to write the question text

________________________________________________________________

Display This Question:

If What is NAME's race or ethnicity?Select all that apply. = MIDDLE EASTERN OR NORTH AFRICAN For example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, Israeli, etc.

MENA_detailsp You said that you are Middle Eastern or North African. Provide details below. Select all that apply.

Lebanese (1)
Syrian (2)
Iranian (3)
Moroccan (4)
Egyptian (5)
Israeli (6)
Enter, for example, Algerian, Iraqi, Kurdish, etc. (7) __________________________________________________

Display This Question:

If What is NAME's race or ethnicity?Select all that apply. = NATIVE HAWAIIAN OR PACIFIC ISLANDER For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.

NHPI_detailsp You said that you are Native Hawaiian or Pacific Islander. Provide details below. Select all that apply.

Native Hawaiian (1)
Tongan (2)
Samoan (3)
Fijian (4)
Chamorro (5)
Marshallese (6)
Enter, for example, Palouan, Tahitian, Chuukese, etc. (7) __________________________________________________

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

Less than high school (1)
Some high school (2)
High school graduate or equivalent (for example GED) (3)
Some college, but degree not received or is in progress (4)
Associate’s degree (for example AA, AS) (5)
Bachelor's degree (for example BA, BS, AB) (6)
Graduate degree (for example master's, professional, doctorate) (7)

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

Now married (1)
Widowed (2)
Divorced (3)
Separated (4)
Never married (5)

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

Male (1)
Female (2)

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

Male (1)
Female (2)
Transgender (3)
None of these (4)

Display This Question:

If D6 = Male

And D7 = Female

Or If

D6 = Male

And D7 = Transgender

Or If

D6 = Male

And D7 = None of these

Or If

D6 = Female

And D7 = Male

Or If

D6 = Female

And D7 = Transgender

Or If

D6 = Female

And D7 = 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 (1)
No (2)

Display This Question:

If D8 = No

Carry Forward Displayed Choices from "D6"

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

Male (1)
Female (2)

Display This Question:

If D8 = No

Carry Forward Displayed Choices from "D7"

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

Male (1)
Female (2)
Transgender (3)
None of these (4)

Display This Question:

If SOexperiment = 1

D9_original Which of the following best represents how you think of yourself?

Gay or lesbian (1)
Straight, that is not gay or lesbian (2)
Bisexual (3)
Something else (4)
I don’t know (5)

SOGI_time4_D9orig Timing

First Click (1)

Last Click (2)

Page Submit (3)

Click Count (4)

Display This Question:

If SOexperiment = 2

Or D9_original , Gay or lesbian Is Not Displayed

D9_alternative Which of the following best represents how you think of yourself?

Gay or lesbian (1)
Straight, that is not gay or lesbian (2)
Bisexual (3)
Something else, please specify (4) __________________________________________________
I don’t know (5)

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.

________________________________________________________________

Display This Question:

If If How many people under 18 years-old currently live in your household? Please enter a number. Text Response Is Greater Than 0

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

Children under 5 years old? (1)
Children 5 through 11 years old? (2)
Children 12 through 17 years old? (3)

Display This Question:

If If How many people under 18 years-old currently live in your household? Please enter a number. Text Response Is Greater Than 0

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.

Number enrolled in a public school (1) _________________________________
Number enrolled in a private school (2) _______________________________
Number homeschooled, that is not enrolled in public or private school (3) __________________________________________________
None (4)

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 (1)
Yes, I'm serving on active duty (2)
Yes, I'm serving in the Reserve or National Guard (3)
Yes, my spouse is serving on active duty (4)
Yes, my spouse is serving in the Reserve or National Guard (5)

leadin2 The next set of questions ask about COVID-19 vaccination.

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

Yes (1)
No (2)

Display This Question:

If VAC1 = Yes

VAC2 How long ago was your most recent dose of the COVID-19 vaccine or booster?

On or after September 1, 2022 (1)
Before September 1, 2022 but less than a year ago (2)
More than a year ago (3)

Display This Question:

If If In your household, are there… Select all that apply. q://QID268/SelectedChoicesCount Is Greater Than or Equal to 1

VAC5_rev For the children in this household, how long ago was their most recent dose of the COVID-19 vaccine or booster?

Display This Question:

If D12 = Children under 5 years old?

VAC5_1 Children under 5 years old

On or after December 9, 2022 (1)
Before December 9, 2022 but less than a year ago (2)
More than a year ago (3)
Not vaccinated (4)

Display This Question:

If D12 = Children 5 through 11 years old?

VAC5_2 Children 5-11 years old

On or after October 12, 2022 (1)
Before October 12, 2022 but less than a year ago (2)
More than a year ago (3)
Not vaccinated (4)

Display This Question:

If D12 = Children 12 through 17 years old?

VAC5_3 Children 12-17 years old

On or after September 1, 2022 (1)
Before September 1, 2022 but less than a year ago (2)
More than a year ago (3)
Not vaccinated (4)

Display This Question:

If VAC5_1 = Not vaccinated

Or VAC5_2 = Not vaccinated

Or VAC5_3 = Not vaccinated

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 (1)
No (2)

Display This Question:

If VAC8_B = Yes

VAC8_C When did you test positive or were told you have or had COVID-19? Select all that apply

Within the last four weeks (1)
More than four weeks ago, but within the last year (2)
More than a year ago.

New TREAT1. [Universe: VAC8_C: 1-2] Paxlovid and Lagevrio are oral antiviral medications that can be prescribed by a doctor to treat COVID-19. Did you take Paxlovid or Lagevrio for your most recent COVID-19 infection?

Yes (1)
No (2)
Don’t know (3)

Display This Question:

If VAC8_B = Yes

PASC1 How would you describe your coronavirus symptoms when they were at their worst?

I had no symptoms (1)
I had mild symptoms (2)
I had moderate symptoms (3)
I had severe symptoms (4)

Display This Question:

If VAC8_B = Yes

PASC2 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 or 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, changes to your menstrual cycle, changes to taste/smell, or inability to exercise.

Yes (1)
No (2)

Display This Question:

If PASC1 = I had mild symptoms

Or PASC1 = I had moderate symptoms

Or PASC1 = I had severe symptoms

Or PASC2 = Yes

PASC3 Do you have symptoms now?

Yes (1)
No (2)

Display This Question:

If PASC2 = Yes

And PASC3 = Yes

PASC4 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 (1)
Yes, a little (2)
Not at all (3)

NEW: COVID-Test1: [Universe: all adults] Over the last year, have you obtained COVID-19 at-home tests?

Yes – go to COVID-Test1a
No – go to COVID-Test2

NEW: COVID-Test1a: [Universe: yes to COVID-Test1] Over the last year, how have you obtained COVID-19 at home tests?

Select all that apply.

I obtained free tests through my health insurance (including mail order or at a pharmacy or store)
I ordered free tests from covidtests.gov or the US Postal Service
I received free at-home tests from the local health department, my employer, my school, or another source
I paid for tests at a pharmacy or store, and got reimbursed by my insurance
I paid for tests at a pharmacy or store, and did not get reimbursed by my insurance
Other, please specify

NEW: COVID-Test2: [Universe: all adults] As of May 11, 2023, health insurance companies will no longer be required to cover the cost of COVID-19 tests. You may have to pay a co-pay or deductible for tests done in a doctor's office or pharmacy, and you may not be reimbursed for tests you buy at the store. As a result of this change in policy, will you (Select all that apply):

Purchase at-home tests without reimbursement
Test less frequently
Not test for COVID-19 at all, even if feeling sick or exposed to COVID-19
Go to a doctor or pharmacy to receive a lab test instead of an at-home test
I don’t know

EMP_Intro Now we are going to ask about your employment.

EMP1 Have you, or has anyone in your household experienced a loss of employment income in the last 4 weeks? Select only one answer.

Yes (1)
No (2)

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

Yes (1)
No (2)

Display This Question:

If EMP2 = Yes

EMP3 Are you employed by the government, by a private company, a nonprofit organization or are you self-employed or working in a family business? Select only one answer.

Government (1)
Private company (2)
Non-profit organization including tax exempt and charitable organizations (3)
Self-employed (4)
Working in a family business (5)

Display This Question:

If EMP2 = No

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 (1)
I am/was sick or caring for someone who is/was sick with coronavirus symptoms or concerned about getting or spreading coronavirus (including long-term effects of coronavirus) (2)
I am/was caring for children not in school or daycare (3)
I am/was caring for an elderly person (4)
I am/was sick or disabled (not coronavirus related) (5)
I am retired (6)
I am/was laid off or furloughed (7)
My employer closed temporarily or went out of business (8)
I do/did not have transportation to work (9)
Other reason, please specify (10) __________________________________________________

Display This Question:

If EMP4 = I am/was caring for children not in school or daycare

Or EMP4 = I am/was caring for an elderly person

Or EMP4 = I am/was laid off or furloughed

Or EMP4 = My employer closed temporarily or went out of business

EMP4a Was this because of...? Select only one answer.

The coronavirus pandemic (1)
A natural disaster (Hurricane, Fire, Flood, Tornado, etc.) (2)
Some other reason, please specify (3) __________________________________________________

Display This Question:

If EMP2 = Yes

EMP6 What kind of business, 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 (1)
Mining, Quarrying, and Oil and Gas Extraction (2)
Utilities (3)
Construction (4)
Manufacturing (5)
Wholesale Trade (6)
Retail Trade (7)
Transportation and Warehousing (8)
Information Technology (9)
Finance and Insurance (10)
Real Estate and Rental and Leasing (11)
Professional, Scientific, and Technical Services (12)
Management of Companies and Enterprises (13)
Administrative and Support Services (14)
Waste Management and Remediation Services (15)
Educational Services (16)
Health Care (17)
Social Assistance (18)
Arts, Entertainment, and Recreation (19)
Accommodation and Food Services (20)
Public Administration (21)
Other Services (except Public Administration) (22)

EMPUI1 Since January 1, 2023, have you applied for Unemployment Insurance (UI) benefits? Select only one answer.

Yes (1)
No (2)

EMPUI2 Since January 1, 2023, have you received Unemployment Insurance (UI) benefits? Select only one answer.

Yes (1)
No (2)

Display This Question:

If EMPUI2 = Yes

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

Yes (1)
No (2)

INFLATE1 In the area where you live and shop, do you think prices in general have changed in the last 2 months? Select only one answer.

I think prices have increased (1)
I do not think prices have changed (2)
I think prices have decreased (3)
I do not know (4)

Display This Question:

If INFLATE1 = I think prices have increased

INFLATE2 How stressful, if at all, has the increase in prices in the last 2 months been for you? Select only one answer.

Very stressful (1)
Moderately stressful (2)
A little stressful (3)
Not at all stressful (4)

Display This Question:

If INFLATE1 = I think prices have increased

INFLATE3 What changes, if any, have you made or do you plan to make 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 (1)
Switch from name brand to generic products (2)
Purchase less fresh produce and/or meat (3)
Go out to eat less often or order food for delivery less often (4)
Cancel or reduce subscription services (for example, streaming services, meal delivery services, cell phone plan) (5)
Cancel or decrease plans to attend events (6)
Drive less or change mode of transportation (for example, bike or take public transportation instead of drive) (7)
Delay major purchases (for example, home repair/renovation, vacations, vehicles, home appliances, cell phone or computer) (8)
Delay medical treatment (for example, refill prescription, surgery) (9)
Work additional job(s)/shift(s) to supplement income (10)
Contribute less to savings and/or retirement accounts (11)
Increase use of credit cards, loans, and/or pawnshops (12)
Decrease use of utilities (for example, cooling, heating, water, electricity) (13)
Move to less expensive housing (14)
Ask friends and/or family for help (15)
Change or reduce plans for childcare arrangements to save money (16)
Utilize benefits from charities (17)
Other (18)
I have not made any changes (19)

INFLATE4 In the area you live and shop, how concerned are you, if at all, that prices will increase in the next 6 months? Select only one answer.

Very concerned (1)
Somewhat concerned (2)
A little concerned (3)
Not at all concerned (4)

display_SPN 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 (1)
A little difficult (2)
Somewhat difficult (3)
Very difficult (4)

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 (1)
Yes, for 3-4 days (2)
Yes, for 5 or more days (3)
No (4)

Display This Question:

If SPN5_DAYSTW = Yes, for 1-2 days

Or SPN5_DAYSTW = Yes, for 3-4 days

Or SPN5_DAYSTW = Yes, for 5 or more days

And If

EMP2 = Yes

SPN5_DAYSTW_2 In the last 7 days, have you teleworked or worked from home?

Yes, for 1-2 days (1)
Yes, for 3-4 days (2)
Yes, for 5 or more days (3)
No (4)

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 (1)
Credit cards or loans (2)
Money from savings or selling assets or possessions (including withdrawals from retirement accounts) (3)
Borrowing from friends or family (4)
Unemployment insurance (UI) benefit payments (5)
Money saved from deferred or forgiven payments (to meet your spending needs) (6)
Supplemental Nutrition Assistance Program (SNAP) (7)
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (8)
School meal debit/EBT cards (9)
Government rental assistance (10)
Other, specify: (11) _______________________________________

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 (1)
Enough, but not always the kinds of food (I/we) wanted to eat (2)
Sometimes not enough to eat (3)
Often not enough to eat (4)

Display This Question:

If FD1 = Enough, but not always the kinds of food (I/we) wanted to eat

Or FD1 = Sometimes not enough to eat

Or FD1 = Often not enough to eat

And If

If How many people under 18 years-old currently live in your household? Please enter a number. Text Response Is Greater Than 0

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 (1)
Sometimes true (2)
Never true (3)

Display This Question:

If FD1 = Enough, but not always the kinds of food (I/we) wanted to eat

Or FD1 = Sometimes not enough to eat

Or FD1 = Often not enough to eat

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 (1)
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) (2)
Couldn’t go to store due to safety concerns (3)
None of the above (4)

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 (1)
No (2)

Display This Question:

If If How many people under 18 years-old currently live in your household? Please enter a number. Text Response Is Greater Than 0

FD5 Do any of the children in this household... Select all that apply.

Receive free meals at school (1)
Pay for reduced-price meals at school (2)
Pay for full-price meals at school (3)
Pick up free meals at a school or other location (4)
Receive or use an EBT card to help buy groceries (5)
Eat free meals at a location other than school (6)
Have free meals delivered (7)
None of the above (8)

FD6_new Do you or does anyone in your household receive benefits from… Select all that apply.

Supplemental Nutrition Assistance Program (SNAP) or Food Stamp Program (1)
WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) (2)
None of these (3)

Display This Question:

If FD5 = Pay for reduced-price meals at school

Or FD5 = Pay for full-price meals at school

Or FD5 = None of the above

And If

D12 = Children 5 through 11 years old?

Or D12 = Children 12 through 17 years old?

FD7_new Does having to pay for the food children eat at school make it difficult for your household to pay for other expenses?

Yes (1)
No (2)

display_Q28 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.

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 dollar amount.

________________________________________________________________

Display This Question:

If If 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 pur... Text Response Contains ,

Or Or 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 pur... Text Response Contains %

Q28_warn Please do not include any special characters such as , - % + $ in your response above. Enter only numbers.

Display This Question:

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 (1)
No, I need to correct the amount (2)

Display This Question:

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 dollar amount.

________________________________________________________________

Display This Question:

If If 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 y... Text Response Contains ,

Or Or 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 y... Text Response Contains %

Q28_warn2 Please do not include any special characters such as , - % + $ in your response above. Enter only numbers.

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. Enter dollar amount.

________________________________________________________________

Display This Question:

If If 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 cafeteria... Text Response Contains ,

Or Or 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 cafeteria... Text Response Contains %

Q29_warn Please do not include any special characters such as , - % + $ in your response above. Enter only numbers.

Display This Question:

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 (1)
No, I need to correct the amount (2)

Display This Question:

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 the previous question. Enter dollar amount.

________________________________________________________________

Display This Question:

If If 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 ... Text Response Contains ,

Or Or 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 ... Text Response Contains %

Q29_warn2 Please do not include any special characters such as , - % + $ in your response above. Enter only numbers.

Display This Question:

If D12 = Children under 5 years old?

INF1 Are there any babies or infants under the age of 18 months (one and a half years) old in your household?

Yes (1)
No (2)

Display This Question:

If INF1 = Yes

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 (1)
Between 6 months and 9 months (2)
Between 9 months and 12 months (3)
Between 12 and 18 months (4)

Display This Question:

If INF1 = Yes

INF3 Has your household been affected by a shortage in Infant Formula ?

Yes (1)
No (2)

Display This Question:

If INF3 = Yes

INF4 Please state how you dealt with the Infant Formula shortage. Select all that apply.

Increased breastfeeding or using pumped breastmilk (1)
Changed from powder to liquid (liquid concentrate or ready-to-feed (RTF)) (2)
Got Infant Formula at a different store than where I usually shop (3)
Got Infant Formula online (for example, Instacart, Amazon, Google Market, secondary market, or other) (4)
Received direct shipment of Infant Formula from the Infant Formula company (5)
Changed to a different brand of Infant Formula (any form, powder or liquid, including non-American brands) (6)
Changed from Infant Formula to something else (for example: Cow milk, Goat milk, Soy milk, Almond milk, Oat milk, or Toddler Drink/Formula) (7)
Stopped offering Infant Formula (8)
Watering down formula (9)
Making your own formula (10)
Received formula from family, friends, or others (like community groups or online networks) (11)
Other, specify: (12) __________________________________________________

INF5. How is the baby in your household fed (in addition to any solid foods the baby may be consuming)? If there is more than one baby, please report on the youngest.

Breastfeeding (or pumped breastmilk) only (Go to ND1)
Sometimes breastfeeding (or pumped breastmilk) and sometimes infant formula
Infant formula only

Baby isn’t fed breastmilk OR Infant formula

Display This Question:

If INF1 = Yes and INF5 in (2,3)

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

Yes (1)
No (2)
I did not try to get formula in the last 7 days (3)

Display This Question:

If INF1 = Yes and INF5 in (2,3)

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

Formula for more than one month (1)
Formula for about two or three weeks (2)
Formula for about a week (3)
Formula for less than a week (4)
None (5)

Display This Question:

If INF1 = Yes and INF5 in (2,3)

INF8 What type of Infant Formula does the baby get? Select all that apply.

Regular or Routine Infant Formula (for example, Similac, Enfamil, NAN1, Good Start, Earth’s Best, Happy Baby, Burt’s Bees, Baby’s Only, Kendamil, J&J Sunrise, Store Label, Private Label) (1)
Extensively Hydrolyzed Infant Formula (for example, Alimentum, Gerber Extensive HA, Nutramigen) (2)
Amino Acid Based Infant Formula (for example, Alfamino, EleCare, Neocate, PurAmino) (3)
Specialty/Metabolic Infant Formulas (for example, Calcilo XD, Pregestimil, Enfaport, Cyclinex-1, Glutarex-1, Hominex-1, I-Valex-1, Ketonex-1, Phenex-1, Pro-Phree, Propimex-1, RCF, Tyrex-1) (4)
The baby does not get formula (5)

ND1 The next set of questions asks about natural disasters, such as hurricanes, floods and fires.

In the past year, were you displaced from your home because of a natural disaster?

Yes (1)
No (2)

Display This Question:

If ND1 = Yes

ND2 What type of natural disaster? Select all that apply.

Hurricane (1)
Flood (2)
Fire (3)
Tornado (4)
Other, specify (5) ____________________________________________

Display This Question:

If ND1 = Yes

ND3 How long were you displaced from your home?

Less than a week (1)
More than a week but less than a month (2)
One to six months (3)
More than six months (4)
Never returned to home (5)

Display This Question:

If ND1 = Yes

ND4 Altogether, how much damage to your property or possessions did you experience as a result of natural disasters in the last year? Would you say no damage, some damage, a moderate amount of damage, or a lot of damage?

No damage (1)
Some damage (2)
Moderate amount of damage (3)
A lot of damage (4)

Display This Question:

If ND1 = Yes

ND5 In the first month after the natural disaster, to what extent did you experience any of the following:

Display This Question:

If ND1 = Yes

ND5A A shortage of food?

Not at all (1)
A little (2)
Some (3)
A lot (4)

Display This Question:

If ND1 = Yes

ND5B A shortage of drinkable water?

Not at all (1)
A little (2)
Some (3)
A lot (4)

Display This Question:

If ND1 = Yes

ND5C Loss of electricity?

Not at all (1)
A little (2)
Some (3)
A lot (4)

Display This Question:

If ND1 = Yes

ND5D Unsanitary conditions, such as inadequate toilets?

Not at all (1)
A little (2)
Some (3)
A lot (4)

Display This Question:

If ND1 = Yes

ND5E Feeling isolated?

Not at all (1)
A little (2)
Some (3)
A lot (4)

Display This Question:

If ND1 = Yes

ND5F Fear of crime?

Not at all (1)
A little (2)
Some (3)
A lot (4)

Display This Question:

If ND1 = Yes

ND5G Offers that seemed like a scam?

Not at all (1)
A little (2)
Some (3)
A lot (4)

display_HLTH Next, we will ask about health and medical care.

HLTH_intro Over the last 2 weeks, how often have you been bothered by...

HLTH1 Feeling nervous, anxious, or on edge? Select only one answer.

Not at all (1)
Several days (2)
More than half the days (3)
Nearly every day (4)

HLTH2 Not being able to stop or control worrying? Select only one answer.

Not at all (1)
Several days (2)
More than half the days (3)
Nearly every day (4)

HLTH3 Having little interest or pleasure in doing things? Select only one answer.

Not at all (1)
Several days (2)
More than half the days (3)
Nearly every day (4)

HLTH4 Feeling down, depressed, or hopeless? Select only one answer.

Not at all (1)
Several days (2)
More than half the days (3)
Nearly every day (4)

Universe: If How many people under 18 years-old currently live in your household? Please enter a number. Text Response Is Greater Than 0

MH1 During the last 4 weeks, did any children in your household need mental health treatment? Mental health treatment includes health services like counseling or medication.

Yes, all children needed mental health treatment
Yes, some but not all children needed mental health treatment
No, none of the children needed mental health treatment [skip questions MH2-MH4 ]

MH2 If yes, did the children who need mental health treatment receive it?

Yes, all children who needed treatment received it
Yes, but only some children who needed treatment received it
No, none of the children who needed treatment received it [skip question b]

MH3 If yes, were you satisfied with the type, quality, and quantity of mental health treatment the children received?

Satisfied with all of the mental health treatment the children received
Satisfied with some but not all of the mental health treatment the children received
Not satisfied with the mental health treatment the children received

MH 4 How difficult was it to get mental health treatment for the children?

Not difficult
Somewhat difficult
Very difficult
Unable to get treatment due to difficulty
Did not try to get treatment

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 (1)	No (2)
Insurance through a current or former employer or union (through yourself or another family member) (1)
Insurance purchased directly from an insurance company, including marketplace coverage (through yourself or another family member) (2)
Medicare, for people 65 and older, or people with certain disabilities (3)
Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability (4)
TRICARE or other military health care (5)
VA (including those who have ever used or enrolled for VA health care) (6)
Indian Health Service (7)
Other (8)

Display This Question:

If HLTH8 = Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability [ No ]

MEDICAID_1 Since January 1, 2022, have you ever had Medicaid coverage?

Yes, I had Medicaid coverage, but I no longer have it (1)
No, I have not had Medicaid since January 1, 2022 (3)

Display This Question:

If MEDICAID_1 = Yes, I had Medicaid coverage, but I no longer have it

MEDICAID_2 What was the main reason you no longer have Medicaid?

I gained new coverage and chose to drop Medicaid (1)
I moved to a new state (2)
I no longer qualify for Medicaid (3)
I tried to stay in Medicaid, but I could not complete the renewal process (4)

Display This Question:

If If How many people under 18 years-old currently live in your household? Please enter a number. Text Response Is Greater Than 0

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

No - no difficulty (1)
Yes - some difficulty (2)
Yes - a lot of difficulty (3)
Cannot do at all (4)

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

No - no difficulty (1)
Yes - some difficulty (2)
Yes - a lot of difficulty (3)
Cannot do at all (4)

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

No - no difficulty (1)
Yes - some difficulty (2)
Yes - a lot of difficulty (3)
Cannot do at all (4)

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

No - no difficulty (1)
Yes - some difficulty (2)
Yes - a lot of difficulty (3)
Cannot do at all (4)

DIS5 Do you have difficulty with self-care, such as washing all over or dressing? Select only one answer.

No - no difficulty (1)
Yes - some difficulty (2)
Yes - a lot of difficulty (3)
Cannot do at all (4)

DIS6 Using your usual language, do you have difficulty communicating, for example understanding or being understood? Select only one answer.

No - no difficulty (1)
Yes - some difficulty (2)
Yes - a lot of difficulty (3)
Cannot do at all (4)

HSE1
The next questions ask about housing.

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

Owned by you or someone in this household free and clear? (1)
Owned by you or someone in this household with a mortgage or loan (including home equity loans)? (2)
Rented? (3)
Occupied without payment of rent? (4)

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

A mobile home (1)
A one-family house detached from any other house (2)
A one-family house attached to one or more houses (3)
A building with 2 apartments (4)
A building with 3 or 4 apartments (5)
A building with 5 or more apartments (6)
Boat, RV, van, etc. (7)

Display This Question:

If HSE1 = Rented?

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

My rent did not change (1)
My rent decreased (2)
My rent increased by less than $100 (3)
My rent increased by $100-$249 (4)
My rent increased by $250-$500 (5)
My rent increased by more than $500 (6)

Display This Question:

If HSE1 = Rented?

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

Yes (1)
No (2)

Display This Question:

If HSE1 = Owned by you or someone in this household with a mortgage or loan (including home equity loans)?

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

Yes (1)
No (2)

Display This Question:

If HSE3 = No

Or HSE4 = No

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

________________________________________________________________

HSE7rev. Thinking of all the places you’ve lived during the last six months, did you ever feel pressure to move due to any of the following reasons? Select all that apply.

Because the landlord raised the rent?
Because you missed a rent payment and you thought you would be evicted?
Because the landlord did not make repairs?
Because you were threatened with eviction or told to leave by your landlord?
Because your landlord changed the locks, removed your belongings, or shut off your utilities?
Because the neighborhood was dangerous?
Some other pressure
Did not feel pressure to move. (skip to HSE8)

(Universe HSE7rev 1-7)

HSE7b. During the last six months, did you actually move from any place you were living as a result of this pressure?

Display This Question:

If HSE3 = No

HSE8 How likely is it that your household will have to leave this home or apartment within the next 2 months because of eviction? Select only one answer.

Very likely (1)
Somewhat likely (2)
Not very likely (3)
Not likely at all (4)

Display This Question:

If HSE4 = No

HSE9 How likely is it that your household will have to leave this home within the next 2 months because of foreclosure? Select only one answer.

Very likely (1)
Somewhat likely (2)
Not very likely (3)
Not likely at all (4)

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 (1)
Some months (2)
1 or 2 months (3)
Never (4)

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 (1)
Some months (2)
1 or 2 months (3)
Never (4)

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 (1)
Some months (2)
1 or 2 months (3)
Never (4)

GAS1 Has the cost of gas in the last 7 days caused you to: Select all that apply.

Choose not to take a trip (for example, chose not to visit a friend/restaurant/park etc., change a task from in-person to online to reduce gas use) (1)
Combine trips (2)
Take alternative modes of transportation (for example, public transit, ridesharing, bike, etc.) (3)
None of these - the cost of gas has not affected my driving behavior (4)

Display This Question:

If If During the school year that began in the Summer / Fall of 2022, how many children in this househo... Text Response Is Greater Than 0

Or Or During the school year that began in the Summer / Fall of 2022, how many children in this househo... Text Response Is Greater Than 0

INC1 In 2022 what was your total household income before taxes? Select only one answer.

Less than $25,000 (1)
$25,000 - $34,999 (2)
$35,000 - $49,999 (3)
$50,000 - $74,999 (4)
$75,000 - $99,999 (5)
$100,000 - $149,999 (6)
$150,000 - $199,999 (7)
$200,000 and above (8)

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 (1) __________________________________________________
Street Name (2) __________________________________________________
Apt Unit (3) __________________________________________________
City (4) __________________________________________________
State (5) __________________________________________________
Zip (6) __________________________________________________

no_address

I do not have a street address (1)

Display This Question:

If If 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, pleas... Address Number Is Empty

And And 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, pleas... Street Name Is Empty

Or no_address = I do not have a street address

rural_route
Do you have a Rural Route address?

Yes (1)
No (2)

Display This Question:

If rural_route = Yes

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 (1) __________________________________________________
Rural Route No (2) __________________________________________________
RR Box ID (3) __________________________________________________
City (4) __________________________________________________
State (5) __________________________________________________
Zip Code (6) __________________________________________________

Display This Question:

If rural_route = Yes

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.

________________________________________________________________

Display This Question:

If rural_route , No Is Displayed

And rural_route != Yes

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) __________________________________________________

Display This Question:

If rural_route , No Is Displayed

And rural_route != Yes

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 are 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 the social and economic effects of coronavirus and other emergent issues change over time, we may contact you again in the coming weeks. What is the best way for us to contact you?

Text message (1)
Email (2)

Display This Question:

If bestmethod = Text message

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

________________________________________________________________

Display This Question:

If bestmethod = Email

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

________________________________________________________________

Feedback_pandemic Is there anything else related to the coronavirus pandemic or other social and end economic issues 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

The National Suicide Prevention Lifeline: 988lifeline.org

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File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	Phase 3.8 Household Pulse Survey
Author	Qualtrics
File Modified	0000-00-00
File Created	2023-08-29