Form Part A, Attachment Part A, Attachment Part A, Attachment A_Phase 4.2 Questionnaire_rev4

Phase 4.2 Household Pulse Survey

Welcome! Thank you for participating in the Household Pulse Survey sponsored by the U.S. Census Bureau and other federal agencies. 

This survey will help measure the impact of 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.  

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, 0607-1029, confirms this approval and expires on 01/31/2027.  

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 **  

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Use of this system indicates your consent to collection, monitoring, recording, and use of the information that you provide for any lawful government purpose. So that our website remains safe and available for its intended use, network traffic is monitored to identify unauthorized attempts to access, upload, change information, or otherwise cause damage to the web service. Use of the government computer network for unauthorized purposes is a violation of Federal law and can be punished with fines or imprisonment (PUBLIC LAW 99-474). 

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

If you would like to change your language selection later, please use the drop down menu in the upper right corner of each page to select the language in which you prefer to complete the survey.

• English (1)

• Español (2)

These questions are for statistical purposes only.

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

________________________________________________________________

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

• No, not of Hispanic, Latino, or Spanish origin (1)

• Yes, Mexican, Mexican American, Chicano (2)

• Yes, Puerto Rican (3)

• Yes, Cuban (4)

• Yes, another Hispanic, Latino, or Spanish origin (5) __________________________________________________

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

• White (specify) (1) ______________________________________

• Black or African American (specify) (2) ___________________________

• American Indian or Alaska Native (specify) (3) ________________________

• Asian Indian (4)

• Chinese (5)

• Filipino (6)

• Japanese (7)

• Korean (8)

• Vietnamese (9)

• Other Asian (specify) (10) _______________________________

• Native Hawaiian (11)

• Chamorro (12)

• Samoan (13)

• Other Pacific Islander (specify) (14) _________________________________

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_alt How do you currently describe yourself? Select all that apply.

▢ Male (1)

▢ Female (2)

▢ Transgender (3)

▢ Nonbinary (4)

▢ I use a different term (5) ____________________________________

D8_alt Just to confirm, you were assigned "${D6/ChoiceGroup/SelectedChoices}" at birth and now you describe yourself as "${D7_alt/ChoiceGroup/SelectedChoices}". Is that correct?

• Yes (1)

• No (2)

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

• Male (1)

• Female (2)

D7_altcorrection Please confirm or correct your answer to the following question: ${D7_alt/QuestionText}

▢ Male (1)

▢ Female (2)

▢ Transgender (3)

▢ Nonbinary (4)

▢ I use a different term (5) ____________________________________

D9_writein 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)

• I use a different term: _________________ (4)

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

________________________________________________________________

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

________________________________________________________________

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

• Children under 1 year old?

• Children 1 through 4 years old? (1)

• Children 5 through 11 years old? (2)

• Children 12 through 17 years old? (3)

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)

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)

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)

D13 During the school year that begins in the Summer / Fall of 2024, how many children in this household are or will be 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)

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

• 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)

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)

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)

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 (2)

• I am/was caring for an elderly person (3)

• I am/was sick or disabled (4)

• I am retired (5)

• I am/was laid off or furloughed (6)

• My employer closed temporarily or went out of business (7)

• I do/did not have transportation to work (8)

• Other reason, please specify (9) __________________________________________________

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)

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)

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)

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)

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 (1)

• Yes, some but not all children needed mental health treatment (2)

• No, none of the children needed mental health treatment (3)

MH2 Did the children who needed mental health treatment receive it?

• Yes, all children who needed treatment received it (1)

• Yes, but only some children who needed treatment received it (2)

• No, none of the children who needed treatment received it (3)

MH3 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 (1)

• Satisfied with some but not all of the mental health treatment the children received (2)

• Not satisfied with the mental health treatment the children received (3)

MH4 How difficult was it to get mental health treatment for the children?

• Not difficult (1)

• Somewhat difficult (2)

• Very difficult (3)

• Unable to get treatment due to difficulty (4)

• Did not try to get treatment (5)

SOC1_first How often do you get the social and emotional support you need?

• Always (1)

• Usually (2)

• Sometimes (3)

• Rarely (4)

• Never (5)

SOC2_first How often do you feel lonely?

• Always (1)

• Usually (2)

• Sometimes (3)

• Rarely (4)

• Never (5)

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

• Less than once a week (1)

• 1 or 2 times a week (2)

• 3 or 4 times a week (3)

• 5 or more times a week (4)

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

• Less than once a week (1)

• 1 or 2 times a week (2)

• 3 or 4 times a week (3)

• 5 or more times a week (4)

SOCInd3 How often do you attend church or religious services?

• Never or less than once a year (1)

• 1 to 3 times per year (2)

• 4 to 11 times per year (3)

• 12 or more times per year (4)

SOCInd4 Altogether, how often do you attend meetings of clubs or organizations you belong to, such as church groups, unions, fraternal or athletic groups, or school groups?

• I do not belong to a group (0)

• Never or less than once a year (1)

• 1 to 3 times per year (2)

• 4 to 11 times per year (3)

• 12 or more times per year (4)

SHORTAGE1 In the past month, have you or a member of your household been directly affected by a shortage of the following? Select all that apply.

• A medicine or medication that requires a prescription or is given by provider, pharmacist, or hospital (1)

• A medicine or medication that is sold over the counter (without a prescription) (2)

• A medical equipment or supplies used at home such as infusion pumps, glucose monitors, home ventilators, masks, gloves, etc. (3)

• Other critical medical products, please specify ____ (4)

• My household has not been affected by any of these shortages (5)

SHORTAGE2A How did you or a member of your household respond to the shortage? Select all that apply.

• Changed to a substitute or alternative medication, equipment, or medical product (1)

• Spent more money or time to find the medication, equipment, or medical products (2)

• Delayed, stopped, rationed or re-used medication, equipment, or medical products (3)

• Delayed or canceled a medical procedure or treatment because medication, equipment or products needed for care were not available to me or a provider (4)

• Consulted a medical professional or other sources to help me get medication, equipment, or medical products (5)

• Experienced negative physical health impacts (6)

• Experienced negative mental health impacts (7)

• I don’t know (8)

• Other, specify _____ (9)

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)

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)

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.

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)

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)

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)

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 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)

• Summer Electronic Benefits Transfer (Summer EBT) (3)

• None of these (4)

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)

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

• Hurricane (1)

• Flood (2)

• Fire (3)

• Tornado (4)

• Other, specify (5) __________________________________________

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)

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)

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

ND5A A shortage of food?

• Not at all (1)

• A little (2)

• Some (3)

• A lot (4)

ND5B A shortage of drinkable water?

• Not at all (1)

• A little (2)

• Some (3)

• A lot (4)

ND5C Loss of electricity?

• Not at all (1)

• A little (2)

• Some (3)

• A lot (4)

ND5D Unsanitary conditions, such as inadequate toilets?

• Not at all (1)

• A little (2)

• Some (3)

• A lot (4)

ND5E Feeling isolated, down, depressed, anxious, nervous or on edge?

• Not at all (1)

• A little (2)

• Some (3)

• A lot (4)

ND5F Fear of crime?

• Not at all (1)

• A little (2)

• Some (3)

• A lot (4)

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)

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)

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

• Yes (1)

• No (2)

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

• Yes (1)

• No (2)

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 (1)

• Because you missed a rent payment and you thought you would be evicted (2)

• Because the landlord did not make repairs (3)

• Because you were threatened with eviction or told to leave by your landlord (4)

• Because your landlord changed the locks, removed your belongings, or shut off your utilities (5)

• Because the neighborhood was dangerous (6)

• Some other pressure, please specify (7) _____________________________

• Did not feel pressure to move (8)

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

• Yes (1)

• No (2)

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)

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)

TRANS1 Which of the following transportation options do you have access to: (Check all that apply)

• Walk

• Bike or e-scooter

• Motorcycle or moped

• Your own personal vehicle (e.g., car, truck, SUV)

• A personal vehicle borrowed from a friend, family member, neighbor, coworker, or acquaintance (including carpooling)

• Rental car or carsharing service (e.g., Zipcar)

• Taxi service or rideshare (e.g., Uber, Lyft)

• Bus

• Rail transit (subway, light rail, streetcar, commuter rail)

• Ferryboat

• Paratransit (that is, specialized, door-to-door transport service for people with disabilities)

• Other methods, please specify _______________

TRANS2 Which one of the following statements best describes your access to transportation in the past 30 days: 

• Enough transportation to meet your needs;

• Enough transportation, but not always the kinds you want to use;

• Sometimes not enough transportation to meet your needs;

• Often not enough transportation to meet your needs, or

• Always not enough transportation to meet your needs 

If TRANS2=3, 4, or 5:

TRANS3 If you do not have enough transportation to meet your needs, which of the following reasons explain why (select all that apply):

• My transportation options are not available when I need them

• My transportation options require more travel time than I have available

• My transportation options are unpredictable (travel time, availability)

• My transportation options cost more than I can afford

• My transportation options feel unsafe

• I have a disability that limits my travel options or makes travel challenging

• None of the above

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)

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)

VAC2_new What was the date of your most recent COVID-19 vaccine?

• Month (1) __________________________________________________

• Year (2) __________________________________________________

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)

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 (3)

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)

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, my symptoms lasted between 3 and 6 months (1)

• Yes, my symptoms lasted 6 months to a year (2)

• Yes, my symptoms lasted more than a year (3)

• No (4)

PASC3 Do you have symptoms now?

• Yes (1)

• No (2)

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)

VAC3_new 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 (1)

• No (2)

Next, we have a few questions about participation with the arts and entertainment.

ART1 During the last month, did you attend any live music, dance, or theater performances in person?

• Yes (1)

• No (2)

ART2 During the last month, did you go in person to an art exhibit, such as paintings, sculpture, textiles, graphic design, or photography?

• Yes (1)

• No (2)

ART3 During the last month, did you go to the movies?

• Yes (1)

• No (2)

ART4 During the last month, did you create, practice, or perform art of your own?
This may have included music, dance, or theater; creative writing; crafts or visual arts; digital art; or film or photography done for artistic purposes.

• Yes (1)

• No (2)

ART5 Please indicate whether you strongly agree, agree, disagree, or strongly disagree with the next statement.

“There are plenty of opportunities for me to take part in arts and cultural activities in my neighborhood or community.”

• Strongly agree (1)

• Agree (2)

• Disagree (3)

• Strongly Disagree (4)

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)

MEDICAID_1 Since January 1, 2023, 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, 2023 (2)

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)

INT1 Do you or anyone in this household access the internet from home?

• Yes

• No

• Don't know

 

INT2 Do you or anyone in this household access the internet using a cell phone or mobile data plan?

• Yes

• No

• Don't know

INT3 During 2024, have you or your household received free or reduced-price internet through any of the following programs? Select all that apply.

• Affordable Connectivity Program

• Lifeline Program

• State or local program

• Program through an Internet Service Provider

• Other program

• None / not applicable

 

[If any program selected in INT3]

INT4 If the program that helped you pay for home internet ended, did you or will you have to cancel your home internet service because you couldn't afford it?

• ​Yes, and this has already happened

• Yes, would need to cancel or cut back internet service

• No

• Don't know

INC1 In 2023 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)

The U.S. Census Bureau is interested in understanding geographic differences in experiences. 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) __________________________________________________

• I do not have a street address (1)

Do you have a Rural Route address?

• Yes (1)

• No (2)

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) __________________________________________________

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.

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

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) __________________________________________________

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."

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Income Range Test

Note to Programmer: Set EXP_GROUP to 1,2,3. EXP_GROUP=1 will be the control group. EXP_GROUP=2 will the instruction group and EXP_GROUP=3 will be the “I’m not sure” button group.

The AHS lead-in questions:

IF HSE1=1,2:

DOWNPAY When you purchased your current home, did you or the owners make a down payment?

 

1. Yes

2. No

 

(If DOWNPAY = No, Dk, Rf then ask NODOWNPAY)

(If DOWNPAY = Yes then ask DWNAMT)

 

NODOWNPAY

 

Did you or the owners borrow the full purchase price, pay the full purchase price upfront, or do something else?

 

1. Borrowed the full purchase price                                                                  

2. Paid the full purchase price upfront

3. Something else; specify [write-in box]

 

DWNAMT

We’d like to learn more about the total amount of the down payment for your home. What is the easiest way for you to report this?

1. Dollars

2. Percent

IF EXP_GROUP=1 AND DWNAMT=Dollars: (CONTROL GROUP)

DWNDLR Considering all sources of money, what was the total amount of the down payment?

Enter amount in dollars.

[Numeric write-in] label=dollars

IF EXP_GROUP=1 AND DWNAMT=Percent: (CONTROL GROUP)

DWNPCT Considering all sources of money, what was the total amount of the down payment?

Enter amount in percent

 

[Numeric write-in] label=Percent

  

IF DWNAMT is skipped OR DWNDLR is skipped or if DWNPCT is skipped:

DWNCAT This information is important for us. Please provide us with an estimate.

As a percentage of the purchase price, what was the down payment amount?

 

1. 0 to 5 percent

2. 6 to 15 percent

3. 16 to 20 percent

4. More than 20 percent

___________________________________________________________________________

IF EXP_GROUP=2 AND DWNAMT=Dollars: (Instructions)

DWNDLR Considering all sources of money, what was the total amount of the down payment?

Enter amount in dollars. If you are not sure, please provide your best estimate.

[Numeric write-in] label=dollars

  

IF EXP_GROUP=2 AND DWNAMT=Percent: (Instructions)

DWNPCT Considering all sources of money, what was the total amount of the down payment?

Enter amount in percent. If you are not sure, please provide your best estimate.

 

[Numeric write-in] label=Percent

  

IF DWNAMT is skipped OR DWNDLR is skipped or if DWNPCT is skipped:

DWNCAT This is important information for us. Please provide us with an estimate.

As a percentage of the purchase price, what was the down payment amount?

 

5. 0 to 5 percent

6. 6 to 15 percent

7. 16 to 20 percent

8. More than 20 percent

____________________________________________________________________________

IF EXP_GROUP=3 AND DWNAMT=Dollars: (“I’m not sure” Button)

DWNDLR Considering all sources of money, what was the total amount of the down payment?

Enter amount in dollars.

[Numeric write-in] label=dollars

 

 [Checkbox] I’m not sure

  

IF EXP_GROUP=3 AND DWNAMT=Percent: (“I’m not sure” Button)

DWNPCT Considering all sources of money, what was the total amount of the down payment?

Enter amount in percent.

 

[Numeric write-in] label=Percent

[Checkbox] I’m not sure

  

IF DWNAMT is skipped OR DWNDLR is skipped/I’m not sure or if DWNPCT is skipped/I’m not sure:

DWNCAT This information is important for us. Please provide us with an estimate.

As a percentage of the purchase price, what was the down payment amount?

 

1. 0 to 5 percent

2. 6 to 15 percent

3. 16 to 20 percent

4. More than 20 percent

Note to Programmer: Continue to use EXP_GROUP. EXP_GROUP=1 will be the control group. EXP_GROUP=2 will the instruction group and EXP_GROUP=3 will be the “I’m not sure” button group.

IF HSE1=2,3 AND EXP_GROUP=1: (CONTROL GROUP)

MORT_RENT1 How much was this household's [HSE1=3: rent/ HSE1=2 mortgage] payment last month] [IF HSE1=3: , including any condominium or association fees? IF HSE1=2: ? Include any condominium or association fees and amounts paid for property taxes, property insurance, mortgage insurance, and any other fees included in a typical monthly payment.]

[Numeric write-in]

If MORT_RENT1 is skipped:
MORT_RENT_R1 This information is important to us. Please provide us with an estimate.

Last month, how much was this household’s [HSE1=3: rent/ HSE1=2 mortgage] payment [IF HSE1=3: , including any condominium or association fees? IF HSE1=2: ? Include any condominium or association fees and amounts paid for property taxes, property insurance, mortgage insurance, and any other fees included in a typical monthly payment.]

1. Less than $400

2. $400 to $749

3. $750 to $1,199

4. $1,200 or more

IF HSE1=2,3 AND EXP_GROUP= 2 (INSTRUCTIONS

MORT_RENT2 How much was this household's [HSE1=3: rent/ HSE1=2 mortgage] payment last month, including any condominium or association fees? [IF HSE1=3: , including any condominium or association fees? IF HSE1=2: ? Include any condominium or association fees and amounts paid for property taxes, property insurance, mortgage insurance, and any other fees included in a typical monthly payment.]

If you are not sure, please provide your best estimate.

[Numeric write-in]

If MORT_RENT2 is skipped:
MORT_RENT_R2 This information is important to us. Please provide us with an estimate.

Last month, how much was this household’s [HSE1=3: rent/ HSE1=2 mortgage] payment [IF HSE1=3: , including any condominium or association fees? IF HSE1=2: ? Include any condominium or association fees and amounts paid for property taxes, property insurance, mortgage insurance, and any other fees included in a typical monthly payment.]

1. Less than $400

2. $400 to $749

3. $750 to $1,199

4. $1,200 or more

IF HSE1=2,3 AND EXP_GROUP= 3 (“I’m not sure” Button)

MORT_RENT3 How much was this household's [HSE1=3: rent/ HSE1=2 mortgage] payment last month [IF HSE1=3: , including any condominium or association fees? IF HSE1=2: ? Include any condominium or association fees and amounts paid for property taxes, property insurance, mortgage insurance, and any other fees included in a typical monthly payment.]

[Numeric write-in]

[checkbox] I’m not sure

If MORT_RENT3 is skipped OR “I’m not sure” is selected:
MORT_RENT_R3 This information is important to us. Please provide us with an estimate.

Last month, how much was this household’s [HSE1=3: rent/ HSE1=2 mortgage] payment [IF HSE1=3: , including any condominium or association fees? IF HSE1=2: ? Include any condominium or association fees and amounts paid for property taxes, property insurance, mortgage insurance, and any other fees included in a typical monthly payment.]

1. Less than $400

2. $400 to $749

3. $750 to $1,199

4. $1,200 or more

___________________________________________________________________________

SIPP Utilities

EXP_GROUP=1: (CONTROL)

UTILITIES_1 How much did this household pay for electricity, gas, basic telephone service, and other utilities last month? Other common examples of utilities include water, heating oil and wood, trash or recycling, and mobile telephone service (excluding data plans, applications, games, and ringtones.) Do not include cable TV or internet.

[Write-in amount]

IF UTILITIES_1 is skipped:

UTILITIES_R1 This information is important to us. Please provide us with an estimate.

Last month, how much did this household pay for electricity, gas, basic telephone services, and other utilities? Other common examples of utilities include water, heating oil and wood, trash or recycling, and mobile telephone service (excluding data plans, applications, games, and ringtones.) Do not include cable TV or internet.

1. Less than $100

2. $100 to $199

3. $200 to $299

4. $300 or more

EXP_GROUP=2: (Instructions)

UTILITIES_2 How much did this household pay for electricity, gas, basic telephone service, and other utilities last month? Other common examples of utilities include water, heating oil and wood, trash or recycling, and mobile telephone service (excluding data plans, applications, games, and ringtones.) Do not include cable TV or internet.

If you are not sure, please provide your best estimate.

[Write-in amount]

IF UTILITIES_2 is skipped:

UTILITIES_R2 This information is important to us. Please provide us with an estimate.

Last month, how much did this household pay for electricity, gas, basic telephone services, and other utilities? Other common examples of utilities include water, heating oil and wood, trash or recycling, and mobile telephone service (excluding data plans, applications, games, and ringtones.) Do not include cable TV or internet.

1. Less than $100

2. $100 to $199

3. $200 to $299

4. $300 or more

EXP_GROUP=3 (I’m not sure button)

UTILITIES_3 How much did this household pay for electricity, gas, basic telephone service, and other utilities last month? Other common examples of utilities include water, heating oil and wood, trash or recycling, and mobile telephone service (excluding data plans, applications, games, and ringtones.) Do not include cable TV or internet.

[Numeric write-in]

[checkbox] I’m not sure

IF UTILITIES_3 is skipped OR “I’m not sure” is selected:

UTILITIES_R3 This information is important to us. Please provide us with an estimate.

Last month, how much did this household pay for electricity, gas, basic telephone services, and other utilities? Other common examples of utilities include water, heating oil and wood, trash or recycling, and mobile telephone service (excluding data plans, applications, games, and ringtones.) Do not include cable TV or internet.

1. Less than $100

2. $100 to $199

3. $200 to $299

4. $300 or more

Job Series

The questions you answered earlier were about your job and economic status last week. The next set of questions ask about your job and economic status last year.

WORK1 Did you work at a job or business at any time during 2023?

1. Yes [continue to JOB1]

2. No [skip to END, no JOB# questions are relevant]

[If WORK1=1]

JOB1 What is the easiest way for you to tell us how much you earned from your main job in 2023, before taxes and other deductions?

1. Weekly

2. Every other week (biweekly)

3. Monthly

4. Yearly

[If answered JOB1]

JOB2 Earlier we asked you about your household income. The next question asks about income from your main job.

How much did you earn from your main job, before taxes and other deductions, in 2023?

$[Numeric write-in] per [label filled with answer to JOB1]

[ask if JOB1 <4 and answered JOB2; new flag/variable for control/experimental here – ideally 40% of people don’t get the check box, 60% get the check box, but could do 33% control and 66% experiment]

[Would like the R to be able to choose/use both options]

JOB2B For how many [fill JOB1 response (weeks, 2-week periods, months)] did you earn [fill JOB2] from your main job in 2023?

_____ [fill from JOB1 (weeks, 2-week periods, months)]

[ ] all [fill from JOB1]

[If JOB1 or JOB2 or JOB2B is skipped (first unfold)]

JOB3 For the entire year of 2023, how much did you earn from your main job, before taxes and other deductions?

[ ] $1 - $44,999 [skip to JOB4-01]

[ ] $45,000 and $59,999 [skip to JOB4-45]

[ ] $60,000 or more [skip to JOB4-60]

[ ] I remember the exact amount: $_______ [skip to FUREM]

[If no answer, skip to FURAN1]

---------------------------------------------

[If range answer selected for JOB3, ask appropriate JOB4-## (second unfold)]

JOB4-01 [For Less than $45K, in JOB3]

Please choose the range that more closely matches what you earned from your main job, before taxes and other deductions, in 2023.

[ ] $1- $14,999 [skip to JOB5-01]

[ ] $15,000 - $29,999 [skip to JOB5-15]

[ ] $30,000 - $44,999 [skip to JOB5-30]

[ ] I remember the exact amount: $_______ [skip to FUREM]

[If no answer, skip to FURAN2]

JOB4-45 [For $45K - $60K, in JOB3]

Please choose the range that more closely matches what you earned from your main job, before taxes and other deductions, in 2023.

[ ] $45,000- $49,999 [skip to JOB5-45, the RU series]

[ ] $50,000 - $54,999 [skip to JOB5-50, the RU series]

[ ] $55,000 - $59,999 [skip to JOB5-55, the RU series]

[ ] I remember the exact amount: $_______ [skip to FUREM]

[If no answer, skip to FURAN2]

JOB4-60 [For $60K+, in JOB3]

Please choose the range that more closely matches what you earned from your main job, before taxes and other deductions, in 2023.

[ ] $60,000- $74,999 [skip to JOB5-60]

[ ] $75,000 - $99,999 [skip to JOB5-75]

[ ] $100,000 or more [skip to JOB5-100]

[ ] I remember the exact amount: $_______ [skip to FUREM]

[If no answer, skip to FURAN2]

---------------------------------------------

[New Screen, not DICE way]

If JOB4-01, JOB-45, or JOB4-60 is answered, ask the appropriate JOB5-## (third unfold):

JOB5-01 [For Less than $15K to JOB4-01]

Please choose the range that more closely matches what you earned from your main job, before taxes and other deductions, in 2023.

[ ] $1- $4,999

[ ] $5,000 - $9,999

[ ] $10,000 - $14,999

[ ] I remember the exact amount: $_______ [skip to FUREM]

[If no answer, skip to FURAN2; If answered, skip to END]

JOB5-15 [For $15K - $30K to JOB4-01]

Please choose the range that more closely matches what you earned from your main job, before taxes and other deductions, in 2023.

[ ] $15,00- $19,999

[ ] $20,000 - $24,999

[ ] $25,000 - $29,999

[ ] I remember the exact amount: $_______ [skip to FUREM]

[If no answer, skip to FURAN2; If answered, skip to END]

JOB5-30 [For $30K - $45K to JOB4-01]

Please choose the range that more closely matches what you earned from your main job, before taxes and other deductions, in 2023.

[ ] $30,00- $34,999

[ ] $35,000 - $39,999

[ ] $40,000 - $44,999

[ ] I remember the exact amount: $_______ [skip to FUREM]

[If no answer, skip to FURAN2; If answered, skip to END]

Begin Real Unfold (RU) series-----

JOB5-45 [For $45K- $49,999 to JOB4-45]

Please choose the range that more closely matches what you earned from your main job, before taxes and other deductions, in 2023.

[ ] $45,00- $46,999

[ ] $47,000 - $48,999

[ ] $49,000 - $49,999

[ ] I remember the exact amount: $_______ [skip to FUREM]

[If no answer, skip to FURAN2 ; If answered, skip to END]

JOB5-50 [For $50K- $54,999 to JOB4-45]

Please choose the range that more closely matches what you earned from your main job, before taxes and other deductions, in 2023.

[ ] $50,00- $51,999

[ ] $52,000 - $53,999

[ ] $54,000 - $54,999

[ ] I remember the exact amount: $_______ [skip to FUREM]

[If no answer, skip to FURAN2; If answered, skip to END]

JOB5-55 [For $55K- $59,999 to JOB4-45]

Please choose the range that more closely matches what you earned from your main job, before taxes and other deductions, in 2023.

[ ] $55,00- $56,999

[ ] $57,000 - $58,999

[ ] $59,000 - $59,999

[ ] I remember the exact amount: $_______ [skip to FUREM]

[If no answer, skip to FURAN2; If answered, skip to END]

End RU series------

JOB5-60 [For $60K - $75K to JOB4-60]

Please choose the range that more closely matches what you earned from your main job, before taxes and other deductions, in 2023.

[ ] $60,000- $64,999

[ ] $65,000 - $69,999

[ ] $70,000 - $74,999

[ ] I remember the exact amount: $_______ [skip to FUREM]

[If no answer, skip to FURAN2; If answered, skip to END]

JOB5-75 [For $75K-$100K to JOB4-60]

Please choose the range that more closely matches what you earned from your main job, before taxes and other deductions, in 2023.

[ ] $75,000- $79,999

[ ] $80,000 - $84,999

[ ] $85,000 - $99,999

[ ] I remember the exact amount: $_______ [skip to FUREM]

[If no answer, skip to FURAN2; If answered, skip to END]

JOB5-100 [For $100K or more to JOB4-60]

Please choose the range that more closely matches what you earned from your main job, before taxes and other deductions, in 2023.

[ ] $100,000 - $124,999

[ ] $125,000 - $149,999

[ ] $150,000 or more

[ ] I remember the exact amount: $_______ [skip to FUREM]

[If no answer, skip to FURAN2; If answered, skip to END]

---- End of series;

Begin Follow-up questions, if applicable ------

[If someone skips JOB3, ask this follow-up, then skip to END]

FURAN1 These questions are part of an important experiment. Please help us improve them.

Why did you skip the previous question, with the different choices for the amount of pay?

(select one response)

[randomize options, except for Other]

1. Don’t remember how much I earned in 2023

2. Don’t want to report this information

3. Question was confusing

4. Other __________

[If someone skips any of the JOB4 or JOB5 questions, ask this follow-up, then skip to END.]

FURAN2 These questions are part of an important experiment. Please help us improve them.

Why did you skip the previous question, with the different choices for the amount of pay?

(select one response)

[randomize options, except for Other]

1. Wasn’t sure which option to choose

2. Don’t want to report this information

3. Felt like I was answering the same questions

4. Other __________

[If someone chooses “I remember” to JOB3 or any of the JOB4 or JOB5 questions, ask this follow-up (regardless of whether they provide a value or not).]

FUREM These questions are part of an important experiment. Please help us improve them.

Why did you choose to enter an exact amount?

(select one response)

1. The categories helped me remember

2. My estimated income was close enough

2. Options were confusing

3. Felt like I was answering the same questions

4. Other __________

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

________________________________________________________________

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

________________________________________________________________

Are you interested in:

	Yes (1)	No (2)
Answering optional surveys to help the U.S. Census Bureau? (1)
Receiving email updates about news from the U.S. Census Bureau? (2)

Is there anything else related to the coronavirus pandemic or other social and economic issues you would like to tell us?

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

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 0607-1029, expiring on 01/31/2027.  

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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