Form Part A, Attachment Part A, Attachment Part A, Attachment A_Phase 4.0 Questionnaire

Household Pulse Survey 4.0

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 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-XXXX, confirms this approval and expires on XX/XX/XXXX.  

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

Or This survey is available in English and Spanish. Please select the language in which you prefer t... = Español

leadin1 These questions are for statistical purposes only.

Display This Question:

If This survey is available in English and Spanish. Please select the language in which you prefer t... != English

And This survey is available in English and Spanish. Please select the language in which you prefer t... != 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.

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 (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)

• 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 What sex were you assigned at birth, on your original birth certificate? = Male

And Do you currently describe yourself as male, female or transgender? = Female

Or If

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

And Do you currently describe yourself as male, female or transgender? = Transgender

Or If

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

And Do you currently describe yourself as male, female or transgender? = None of these

Or If

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

And Do you currently describe yourself as male, female or transgender? = Male

Or If

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

And Do you currently describe yourself as male, female or transgender? = Transgender

Or If

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

And Do you currently describe yourself as male, female or 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 (1)

• No (2)

Display This Question:

If Just to confirm, you were assigned "${q://QID263/ChoiceGroup/SelectedChoices}" at birth and now y... = No

Carry Forward Displayed Choices from "What sex were you assigned at birth, on your original birth certificate?"

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

• Male (1)

• Female (2)

Display This Question:

If Just to confirm, you were assigned "${q://QID263/ChoiceGroup/SelectedChoices}" at birth and now y... = No

Carry Forward Displayed Choices from "Do you currently describe yourself as male, female or transgender?"

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

• Male (1)

• Female (2)

• Transgender (3)

• None of these (4)

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)

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 In your household, are there… Select all that apply. = Children under 5 years old?

INF1 Are there any babies or infants under the age of 12 months (one year) old in your household?

• Yes (1)

• No (2)

Display This Question:

If Are there any babies or infants under the age of 12 months (one year) old in your household? = 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)

Display This Question:

If Are there any babies or infants under the age of 12 months (one year) old in your household? = Yes

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 (1)

• Sometimes breastfeeding (or pumped breastmilk) and sometimes infant formula (2)

• Infant formula only (3)

• Baby isn’t fed breastmilk OR infant formula (4)

Display This Question:

If Are there any babies or infants under the age of 12 months (one year) old in your household? = Yes

And If

How is the baby in your household fed (in addition to any solid foods the baby may be consuming)?... = Sometimes breastfeeding (or pumped breastmilk) and sometimes infant formula

Or How is the baby in your household fed (in addition to any solid foods the baby may be consuming)?... = Infant formula only

INF6 In the last month, did you have difficulty getting infant formula?

• Yes, in the last 7 days (1)

• Yes, more than 7 days ago but within the last month (2)

• No, did not have trouble getting infant formula in the last month (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 2023, 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)

If no to D14:

D15 Have you or your spouse ever served in the U.S. Armed Forces (Active Duty, Reserve, or National Guard)?  

• No (1)

• Yes, I served on active duty (2)

• Yes, I served in the Reserve or National Guard (3)

• Yes, my spouse served on active duty (4)

• Yes, my spouse served in the Reserve or National Guard (5)

EMP_Intro Next, 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 caring for children not in school or daycare (3)

• I am/was caring for an elderly person (4)

• I am/was sick or disabled (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) __________________________________________________

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 In the last 7 days, have any of the people in your household teleworked or worked from home? = Yes, for 1-2 days

Or In the last 7 days, have any of the people in your household teleworked or worked from home? = Yes, for 3-4 days

Or In the last 7 days, have any of the people in your household teleworked or worked from home? = Yes, for 5 or more days

And If

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

display_HLTH Next, we will ask about health.

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)

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: Children age 5-18 in household, else skip to SOC

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

Universe: Everyone

RANDOMIZE – half see SOC1 and SOC2 first; half see SOCInd1-4 first.

SOC1 How often do you get the social and emotional support you need?

• Always

• Usually

• Sometimes

• Rarely?

• Never

SOC2 How often do you feel lonely?  

• Always

• Usually

• Sometimes

• Rarely

• Never

SOCInd1 In a typical week, how often do you talk on the telephone with family, friends, or neighbors?

• Less than once a week

• 1 or 2 times a week

• 3 or 4 times a week

• 5 or more times a week

SOCInd2 How often do you get together with friends or relatives?

• Less than once a week

• 1 or 2 times a week

• 3 or 4 times a week

• 5 or more times a week

SOCInd3 How often do you attend church or religious services?

• Never or less than once a year

• Once a year

• 2 or 3 times a year

• 4 or more times a year

SOCInd4 Do you belong to any clubs or organizations such as sports teams, parent/teacher organizations, religious, union or other community groups?

• Yes

• No

SOCInd1EXP In a typical week, how often do you text or message with family, friends, or neighbors?

• Less than once a week

• 1 or 2 times a week

• 3 or 4 times a week

• 5 or more times a week

Display This Question:

If there are children age 0-18 in the household

EMP7 Next, we are going to ask about the childcare arrangements for children in the household. 

At any time in the last 4 weeks, were any children in the household unable to attend daycare or another childcare arrangement as a result of child care being closed, unavailable, unaffordable, or because you are concerned about your child’s safety in care?  Please include before school care, after school care, and all other forms of childcare that were unavailable. Select only one answer.

• Yes  (1)

• No  (2)

• Not applicable  (3)

 

 

EMP8 Which if any of the following occurred in the last 4 weeks as a result of childcare being closed, unavailable, unaffordable, or because you are concerned about your child’s safety in care? Select all that apply.

• You (or another adult) took unpaid leave to care for the children   (1)

• You (or another adult) used vacation, or sick days, or other paid leave in order to care for the children  (2)

• You (or another adult) cut your work hours in order to care for the children  (3)

• You (or another adult) left a job in order to care for the children  (4)

• You (or another adult) lost a job because of time away to care for the children  (5)

• You (or another adult) did not look for a job in order to care for the children  (6)

• You (or another adult) supervised one or more children while working  (7)

• Other (specify)   (8) ______________________________________________

• None of the above  (9)

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)

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 activities 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)

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 children ages 0-18 in household

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 children ages 0-18 in houshold

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)

Universe = everyone

FD6_new Do you or does anyone in your household currently 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

Children ages 5-18 in household

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)

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)

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?

• Yes

• No

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)

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)

VAC1 What was the date of your most recent COVID-19 vaccine?

Month (Pick from Month list)

Year (Pick from Year list – 2021-present)

(Disallow dates in the future)

New Question (Universe = people age ≥60 years): There is a vaccine that was recently recommended for some people that helps prevent the respiratory virus called RSV. Have you received the RSV vaccine?

Yes

No

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.

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)

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)

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

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... Apt Unit 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... City 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... State 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... Zip Is Empty

Or = I do not have a street address

rural_route
Do you have a Rural Route address?

• Yes (1)

• No (2)

Display This Question:

If Do you have a Rural Route address? = 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 Do you have a Rural Route address? = 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 Do you have a Rural Route address? , No Is Displayed

And Do you have a Rural Route address? != 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 Do you have a Rural Route address? , No Is Displayed

And Do you have a Rural Route address? != 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."

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

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

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

________________________________________________________________

OPTIN Are you interested in:

Answering optional surveys to help the U.S. Census Bureau? (1)

Yes No

Receiving email updates about news from the U.S. Census Bureau? (2)

Yes No

Feedback_pandemic Is there anything else related to social and 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-XXXX, expiring on XX/XX/XXXX. If you need help during this time, here are some resources that may help: 

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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