Final - Screening Form

Screening Questionnaire
Equitable Engagement at HUD

Share your Experience with HUD
Thank you for your interest in sharing your experience with the U.S. Department of
Housing and Urban Development (HUD) and being a part of HUD’s efforts to create fair
pathways to homeownership.
If you identify as Hispanic/Latino/Latina or African American/Black and are interested in
participating in a one-hour phone or video conversation with HUD, please fill out the
below form. You must be 18 years or older to participate. Note: You will not receive
money or an incentive for participating.
By filling this out you are consenting to provide this data. The HUD project team will
store your data in a secure location and will not share your personal data with the rest of
HUD or anyone else.
OMB Control Number: 2511-0001
Expiration Date: 09/30/2024
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless such collection displays a valid OMB control number. The time required to complete this information collection
is estimated to average 5 minutes. All responses to this collection of information are voluntary. If you have comments
or concerns regarding this collection, please contact Helen Nicholas of HUD’s Customer Experience team at
helen.e.nicholas@hud.gov.

* Required
1. What is your age? *
•

I am 17 or younger

•

I am 18 or older

2. Which category best describes your race and ethnicity? (Select all that
apply) *
•

Hispanic or Latino/Latina

•

Black or African American

•

Other _______________________________________

Screening Questionnaire
Equitable Engagement at HUD

3. Which best describes your situation? *
•

I don’t see buying a home as an option for me

•

I am not a homeowner, but I may buy a home in the future

•

I am not a homeowner, but I am actively looking to buy a home

•

I tried to buy a home in the last five years but was not able to

•

I currently own a home that I bought in the last five years

•

I currently own a home that I bought over five years ago

•

Other ______________________________________

4. If you own your home or have owned a home in the past, select all that
apply:
•

I have a federally-insured mortgage (an FHA, VA, or USDA loan)

•

I have a mortgage from a private lender

•

A friend or family member helped me with my down payment

•

A government organization or program helped me with my down
payment

•

N/A – I don’t own a home

•

I don’t know or prefer not to say

•

Other _______________________________________

5. What’s your credit rating?
•

Above 670

•

From 580-669

•

From 300-579

•

Below 300

•

I don’t know

•

I don’t have a credit rating because I have no credit history on file

•

I prefer not to say

Screening Questionnaire
Equitable Engagement at HUD

6. What is your preferred spoken language?
•

English

•

Spanish

•

Other _______________________________________

7. Please provide your first and last name: ______________________________
8. Please provide your phone number: ______________________________
9. Please provide your email address: ______________________________
10. Please let us know how you prefer to be contacted:
•

Text my cell phone

•

Leave a voicemail/call

•

Send an email

[Upon completing/submitting]
Thanks!
Thank you for completing these questions! If you are eligible to participate, you will
receive an email from the HUD customer experience team to schedule a time that works
for you.