Screener

NSCH-LC Screener

The US Census Bureau is looking for participants to help test survey materials for an upcoming survey on children’s and young adult’s health topics. Thank you for your interest in this research opportunity. We need to ask you a few simple questions to see if you are eligible to participate in our research study.

Eligibility Questions

E1. Are you employed by the federal government? If you are a contractor, select "No".

Yes

No

E1a. [IF YES] Since you are a federal employee, we are unable to pay you the $50. However, you may still be eligible for the study. Are you still interested in participating?

Yes

No ->Ineligible

E2. Have you participated in any other research studies with the U.S. Census Bureau in the past year?

Yes ->Ineligible

No

E3. Eligible participants who complete the research session will receive $50, sent by USPS Priority Mail. Do you have an address where we can mail the money? This could be a home address, a P.O. box, or an address of a friend or family member. 

Yes

No ->Ineligible

E4. This research study will take place remotely via video chat. You and the researcher will each be in your own homes and will use a video chat application to talk and screen share.  Do you have a desktop, laptop, or tablet capable of using video chat applications? We do not recommend using a phone for this study.

Yes

No ->Ineligible

Screening Questions

S1. Do you have any children, stepchildren, or foster children age 4-17 who CURRENTLY live in your household? Mark yes, even if the child only lives in your household part-time.

Yes

No ->S6

S2. How many children, stepchildren, or foster children age 4-17 CURRENTLY live in your household?____

S3. [IF ONLY ONE CHILD]

What is this child’s first name? _____

How old is this child? __

What is this child’s sex? Male/Female

S4. [IF MULTIPLE CHILDREN]

Please provide the first name, age, and sex for each of these children:

Child 1

First name ____

Age __

Sex: Male/Female

Child 2

First name ____

Age __

Sex: Male/Female

Child 3

First name ____

Age __

Sex Male/Female

Child 4

First name ____

Age __

Sex Male/Female

Child 5

First name ____

Age __

Sex Male/Female

S5. Do any of these children have any physical, mental, or cognitive health conditions?

Yes

No

S6. Do you have any children, stepchildren, or foster children age 4-17 who USED TO live in your household?

Yes

No ->S11

S7. How many children, stepchildren, or foster children age 4-17 USED TO live in your household?____

S8. [IF ONLY ONE CHILD]

What is this child’s first name? _____

How old is this child? __

What is this child’s sex? Male/Female

S9. [IF MULTIPLE CHILDREN] Please provide the first name, age, and sex for each of these children:

Child 1

First name ____

Age __

Sex Male/Female

Child 2

First name ____

Age __

Sex Male/Female

Child 3

First name ____

Age __

Sex Male/Female

Child 4

First name ____

Age __

Sex Male/Female

Child 5

First name ____

Age __

Sex Male/Female

Other children age 4-17__________________________________

S10. Do any of these children have any physical, mental, or cognitive health conditions?

Yes

No

S11. Do you have any children, stepchildren, or foster children age 18-22 who CURRENTLY live in your household? Mark yes, even if the person only lives in your household part-time.

Yes

No ->S16

S12. How many children, stepchildren, or foster children age 18-22 CURRENTLY live in your household?___

S13. [IF ONLY ONE PERSON]

What is this person’s first name? _____

How old is this person? __

What is this person’s sex? Male/Female

S14. [IF MULTIPLE PEOPLE] Please provide the first name, age, and sex for each of these people:

Person 1

First name ____

Age __

Sex Male/Female

Person 2

First name ____

Age __

Sex Male/Female

Person 3

First name ____

Age __

Sex Male/Female

Person 4

First name ____

Age __

Sex Male/Female

Person 5

First name ____

Age __

Sex Male/Female

S15. Do any of these people have any physical, mental, or cognitive health conditions?

Yes

No

S16. Do you have any children, stepchildren, or foster children age 18-22 who USED TO live in your household?

Yes

No ->D1

S17. How many children, stepchildren, or foster children age 18-22 USED TO live in your household? ____

S18. [IF ONLY ONE PERSON]

What is this person’s first name? _____

How old is this person? __

What is this person’s sex? Male/Female

S19. [IF MULTIPLE PEOPLE] Please provide the first name, age, and sex for each of these people:

Person 1

First name ____

Age __

Sex Male/Female

Person 2

First name ____

Age __

Sex Male/Female

Person 3

First name ____

Age __

Sex Male/Female

Person 4

First name ____

Age __

Sex Male/Female

Person 5

First name ____

Age __

Sex Male/Female

Other people age 18-22__________________________

S20. Do any of these people have any physical, mental, or cognitive health conditions?

Yes

No

Don’t know

Demographics

Demo 1. What is your name?

First and Last Name ___________________

Demo 2. Are you male or female?

Male

Female

Demo 3. What is the highest degree or level of school you have completed?

Less than high school

Completed high school (including GED)

Some college credit, no degree

Vocational certificate or diploma

Associate degree (AA/AS)

Bachelor’s degree (BA/BS)

Post-Bachelor's degree (For example MA, MS, Ph.D, JD, etc.)

Demo 4. What is your current age?

Age ________

Demo 5. What is your marital status?

Married

Not married, but living with a partner

Never married

Divorced

Separated

Widowed

Demo 6. Are you of Hispanic, Latino, or Spanish origin?

Yes

No

Demo 7. What is your race? Select all that apply.

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

Demo 8. In what city, state, and ZIP code do you currently live?

City ___________________________

State __________________________

Zip Code _______________________

Demo 9. How did you hear about this research opportunity? __________________________________

Demo 10. What is your telephone number? ____________________________________

Demo 11. What is your email address? ______________________________________

Thank you for your time.
You may be selected to participate in our study. If you are selected, our staff will contact you to schedule a time that works best for you.
 

END SCREENER

[IF RESPONDENT IS INELIGIBLE]

Thank you for your time.

Unfortunately, you are not eligible to participate in this research study. Would you like us to keep your contact information on file for future research opportunities?

Yes

No -> END SCREENER

What is your name? _______________________________________

What is your email address? ______________________________________