2 Income Exploratory Interviews Protocol

Generic Clearance for Questionnaire Pretesting Research

Attachment 4 Income Exploratory Interviews Protocol

CPS Annual Social and Economic Supplement (ASEC) Exploratory Interviews

OMB: 0607-0725

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ASEC Income Exploratory Interviews

PARTICIPANT ID #: _________________________ DATE: ____ / ____ / _____

INTERVIEWER’S NAME: _________________________________________________

START TIME: ______: ______ AM / PM END TIME: ____________:___________ AM/PM

R AGE: (YOUNGER THAN 65 / 65+) ____

CHILDREN 5-18 IN HOUSEHOLD? (Y/N) _____

NUMBER OF CHILDREN YOUNGER THAN 13: ____



Introduction

[READ OR PARAPHRASE]

Hello, I’m [NAME] with [CONTRACTOR], a survey research company, and I am talking to you on behalf of the U.S. Census Bureau. Thanks for agreeing to help us today. Let me tell you a little about what we will be doing:


We are conducting a study so we can learn how to best ask questions on topics like income in Census Bureau surveys. Since people receive different amounts of income in different ways, it is important to write questions that make sense to everyone and are easy to answer. It is important that everyone understands the questions in the same way because people’s answers to the questions help us produce statistics about the U.S. This survey asks questions about you and other people who live with you.


If you agree to take part in this study, I will ask you some questions to learn more about you and your household. Sometimes I will ask you a follow up question that may sound a little strange. For example, I might ask you what a certain word or question means to you or how you came up with your answer. The reason for this is to learn about the process you go through in your mind when you answer the questions. There are no right or wrong answers. We are interviewing people from all over the country to help find the words and questions that will work best for everyone.


Your participation in this interview is very important because it will help the Census Bureau improve its surveys. You will receive $40 after completing the interview. [CONTRACTOR WILL DESCRIBE HOW RESPONDENT WILL RECEIVE INCENTIVE]

Informed consent

Before we start, I want to talk about the consent form I shared with you via email. Did you have a chance to review and sign this form? [IF NO, PASTE LINK INTO CHAT: Can you please open the link to this form shared in the chat?]


[CONSENT LINK]


I just want to review some of the important information that was included in that consent document:


  • With your permission, I would like to audio and video record our conversation including a screen recording of your computer screen. This will allow me to concentrate on what you are saying instead of taking a lot of notes while you are talking. It will also help me write a summary of the interview.

  • All your responses and everything you say will be kept strictly confidential, and only researchers working on this project will see your answers or hear the recording. Your name will not be used in any of our reports. Nothing you tell us today will be shared with other federal agencies.

  • Your participation is voluntary, and you may stop at any time. You may choose not to answer any questions you don’t want to answer.

  • The interview should take about 1 hour.

  • The form also has the contact name and telephone number of the project director, should you have any additional questions about the study. It also contains information about how to get in touch with the Institutional Review Board representative if you have any questions about your rights as a research participant in this study.


[IF OBSERVER IS PRESENT: I also wanted to let you know that this interview is being observed by someone from the Census Bureau/someone else who works on this study. They are observing the interview because they are also interested in learning how our surveys work, and whether we need to change something that does not work.]


Do you have any questions about this information? [IF YES: ADDRESS PARTICIPANT QUESTIONS].


Do you agree to participate in this interview? [IF YES: CONTINUE WITH INTERVIEW. IF NO: ADDRESS ANY PARTICIPANT CONCERNS. IF STILL UNWILLING TO PARTICIPATE, TERMINATE INTERVIEW].


Is it okay if I record this interview today? [IF YES: START RECORDING AND COLLECT VERBAL CONSENT ON RECORDING. IF NO: CONTINUE WITH INTERVIEW WITHOUT RECORDING.]


Now that recording has started, can you confirm that you agree to participate in this interview and be recorded?


[IF PARTICIPANT HAS NOT ALREADY SIGNED FORM]: Please go ahead and sign and date both sections of the form and click “Submit.”


INTERVIEWER:


1. DID THE PARTICIPANT HAVE ANY QUESTIONS OR CONCERNS?

  • Yes

  • No (SKIP TO QUESTION 3)

2. PLEASE SPECIFY:

_____________________________________________________________________________________

_____________________________________________________________________________________


3. HAS THE PARTICIPANT READ AND SIGNED THE INFORMED CONSENT?

  • Yes

  • No (END INTERVIEW)

Income type and amount

PROBE RESPONDENT ON THEIR SOURCES OF INCOME. IF NONE, OR IF INTERVIEW IS RUNNING SHORT, ASK PROBES ABOUT OTHER HOUSEHOLD MEMBERS.

General income

  1. To start, could you please tell me about the ways you make or receive money? If nothing comes to mind, that is okay too.

    1. Do you make or receive money from anywhere else? [CAN USE WORD “INCOME” AT THIS POINT IF NEEDED]

    2. If not apparent: Do you currently have a job or do other work for pay?

Q1) Sources of income received:

  1. Wages or salary

  2. Income from your own nonfarm business, partnership, or professional practice

  3. Income from your own farm

  4. Social Security or Supplemental Security Income (SSI)

  5. Unemployment compensation

  6. Interest on savings, CDs, bonds, retirement accounts, and so on

  7. Dividends on stocks, mutual funds, and so on

  8. Pensions and company retirement

  9. Withdrawals from retirement accounts (401K, 403B, IRA, KEOGH, SEP, and so on)

  10. Public assistance or welfare

  11. Rental properties, estates or trusts



  1. Now I am going to show you a list of some different ways people make or receive money. Do you receive money from any of these sources, other than the ones you have already mentioned? [SHOW LIST (Q1)]

    1. If yes: Can you tell me more about that?

INTERVIEWER CHECK: Mark off types of income mentioned by respondent.

  1. Wages or salary

  2. Income from your own nonfarm business, partnership, or professional practice

  3. Income from your own farm

  4. Social Security or Supplemental Security Income (SSI)

  5. Unemployment compensation

  6. Interest on savings, CDs, bonds, retirement accounts, and so on

  7. Dividends on stocks, mutual funds, and so on

  8. Pensions and company retirement, survivor, or disability income

  9. Withdrawals from retirement accounts (401K, 403B, IRA, KEOGH, SEP, and so on)

  10. Public assistance or welfare

  11. Rental properties, estates or trusts



  1. Are there any words or phrases on this list that are confusing to you, or that you think other people might not understand?

Self-employment income

  1. Can you tell me more about your job or any other work you do for pay? PROBE TO GET A SENSE OF INDUSTRY AND OCCUPATION

    1. Who pays you for your work? How do you get paid?

  2. Sometimes people forget about or do not report small amounts of money they earn, or work that they do on the side in addition to a primary job. Did you have any of these kinds of sources of money this year?

    1. If yes: Tell me more about that.

    2. Is there anything the Census Bureau could do to remind people of these types of income or encourage them to include them in their answers?

Q2) List:

  1. Babysitting or childcare

  2. Hair, beauty, or other personal care services

  3. Direct sales programs like Avon, Scentsy, Herbalife, or doTERRA

  4. Landscaping

  5. Delivery services like Instacart, DoorDash, or Ubereats

  6. Other app-based jobs like Uber or Lyft

  7. Selling handmade items, in person or online on sites like Etsy

  8. Re-selling items, in person or online on sites like eBay

  9. Responding to surveys online for money

  10. Social media-related income, such as sponsored posts, YouTube video views, or streaming subscriptions

  11. Other services paid for in cash or via an app like Venmo or Cash App



  1. [SHOW LIST (Q2)] Can you take a look at this list and let me know if you had any of these sources of income?

    1. If yes to any: Tell me more about that.


  2. If not apparent: Would you consider yourself to be employed by [ENTITY WHO PAYS THEM FROM PROBE 1a]? Would you consider yourself to be self-employed? What about an independent contractor?

Retirement income (#7, 8)

  1. If R mentioned this type of income in Q1:

    1. Tell me more about that. PROBE TO GET A SENSE OF HOW THEY GET THIS INCOME AND IF IT’S BEING WITHDRAWN/DISTRIBUTED: What kind? How do you receive it? How frequently do you receive it? How much do you receive?

  2. If R is 65+ and did not mention this type of income:

    1. If currently working:

      1. If yes: Does your job offer any kind of benefits or programs to people who retire? Tell me more about that. Do you know the name of the program?

      2. If no: Have you had a job or done other work for pay in the past?

          1. If yes: Did that job offer any kind of benefits or programs to people who retire? Tell me more about that. Do you know the name of the program?

    2. If currently/ever worked:

      1. Do you expect to receive any kind of future income or benefit from a former job- for example, a benefit after you retire or stop working? Tell me more about that. Do you know the name of the program?

      2. Have you had a job that provided options for you to save money for retirement? Tell me more about that. If needed: Did you participate? Do you know the name of the program?

    3. Have you ever saved money for retirement on your own, separate from any job you may have had? PROBE TO LEARN MORE ABOUT HOW RESPONDENT SAVED AND TYPE OF ACCOUNT (e.g., savings account, 401K, IRA).

    4. Can you tell me more about how you are planning to cover future expenses when you are retired or no longer working?



Q3) During 2022, did you or anyone in this household receive any pension income from a previous employer or union, other than Social Security or VA benefits? Do not include distributions or withdrawals from IRAs, 401(k)s, or similar accounts.

  • Yes

  • No

Q4) (If yes): What was the source of the pension income? Select all that apply.

  • Company

  • Union

  • Federal government

  • State government

  • Local government

  • U.S. military

  • U.S. Railroad Retirement pension

  • Some other source, specify: ______________

Q5) During 2022, did you or anyone in this household receive any income from an annuity?

  • Yes

  • No


Q6) At any time during 2022, did you or anyone in this household have any retirement accounts such as a 401(k), 403(b), IRA, or another account designed specifically for retirement savings?

  • Yes

  • No



Q7) (If yes): What type of retirement account? Select all that apply.

  • 401(k)

  • 403(b)

  • Roth IRA

  • Regular IRA

  • KEOGH plan

  • Simplified Employee Pension (SEP plan)

  • Another type of retirement account, specify: ___________

Q8) Did you or anyone in your household withdraw any money or receive a distribution from a [LIST ALL SELECTED IN PRIOR QUESTION] in 2022, including any distributions that may have been required to take?

  • Yes

  • No



  1. All: I’m going to ask you to answer a few questions on this topic. [SHARE SCREEN AND HAVE R ANSWER SERIES (Q3-Q8)]

Thank you for answering those. I have a few follow-ups to learn more about how you came up with your answers to these questions.

    1. If yes to any item not already discussed: You selected yes to [QUESTION(S)].Tell me more about that. PROBE AS NEEDED: What kind of income do you receive? How do you receive it? How frequently do you receive it? How much do you receive?

    2. If no: Have you looked into participating in any of these types of programs or having these kinds of accounts? If yes: Tell me more about that. PROBE AS NEEDED: When did you receive it? What kind of assistance?

    3. If U.S. Railroad Retirement pension selected in Q4: You selected “U.S. Railroad Retirement pension” as a source of pension income. Can you tell me more about why you said yes to this option?

    4. Are there any terms in these questions that are confusing to you, or that you think other people might not understand?

    5. Can you think of anything that is missing from these questions that people who are retired might receive?

Public assistance (#9)

  1. If R mentioned this type of income in Q1:

    1. Tell me more about that. PROBE AS NEEDED TO GET A SENSE OF PROGRAMS THEY ARE INCLUDING: What kind of assistance do you receive? How do you receive it? How frequently do you receive it? How much do you receive?

Q9) At any time during 2022, even for one month, did you or anyone in this household receive any CASH assistance from a state or county welfare program?

  • Yes

  • No



  1. All: Now I’m going to show you a question on the screen. [SHOW VERSION 1 (Q9)] How would you answer this question? Tell me more about that.

    1. If yes and not already discussed: Tell me more about that. PROBE AS NEEDED TO GET A SENSE OF PROGRAMS THEY ARE INCLUDING: What kind of assistance do you receive? How do you receive it? How frequently do you receive it? How much do you receive?

    2. If needed: What kinds of assistance do you think this question is asking about?

    3. [SHOW FLASHCARD] Do you receive any of the types of assistance listed on this card?

Q10) At any time during 2022, even for one month, did you or anyone in this household receive any CASH assistance from a state or county welfare program?

INCLUDE:

  • Welfare or welfare to work

  • Temporary Assistance for Needy Families (TANF)/Aid to Families with Dependent Children (AFDC)

  • General assistance

  • Diversion payments

  • Refugee cash

  • General assistance from Indian Affairs.



Do NOT include:

  • Food stamps or Supplemental Nutrition Assistance Program (SNAP) benefits

  • Supplemental Security Income (SSI)

  • Energy assistance

  • Women, Infants and Children (WIC)

  • School meals

  • Childcare

  • Education assistance



  • Yes

  • No



  1. All: Now I’m going to show you another version of this question. [SHOW VERSION 2 (Q10)] How would you answer this question? Tell me more about that.

    1. If yes and not already discussed: Tell me more about that. PROBE AS NEEDED TO GET A SENSE OF PROGRAMS THEY ARE INCLUDING: What kind of assistance do you receive? How do you receive it? How frequently do you receive it? How much do you receive?

    2. If no: Have you applied for or received any of these types of assistance in the past?

      1. If yes: Tell me more about that. PROBE AS NEEDED: What kind of assistance?

    3. All: Could you please take a moment to look at the bullet points in this question, starting with “Include” INDICATE TO SECTION AND PAUSE TO LET RESPONDENT READ

      1. If needed: Did you receive any of the types of assistance mentioned in either of these lists?

      2. Are there any examples on these lists that are confusing to you, or that you think other people might not understand?

      3. Can you think of any types of assistance that are missing from these lists?

    4. All: Are you familiar with any assistance programs in your state that we haven’t already mentioned?

      1. If yes: Have you applied for or received assistance from a state program? PROBE TO DETERMINE WHETHER THEY HAD ALREADY INCLUDED THIS IN THEIR ANSWER.

Interest and dividends (#5, 6)

  1. If R mentioned this type of income in Q1:

    1. Tell me more about that. PROBE AS NEEDED TO GET A SENSE OF WHAT THEY ARE INCLUDING: What did you receive? How do you receive it? How frequently do you receive it? How much do you receive?

Q11) At any time during 2022, did you or anyone in this household have money in any of the following? Select all that apply.

  • Interest-earning checking account

  • Savings account

  • Money market fund

  • Certificates of deposit (CDs)

  • Savings bonds

  • Shares of stock in corporations or mutual funds

  • Any other savings or investments that pay interest or dividends, specify: ______________



  1. All: Now I’m going to show you a question on the screen. [SHOW MODIFIED QUESTION ON ACCOUNT TYPES (Q11)] How would you answer this question? Tell me more about that.

    1. If yes: Tell me more about that. PROBE AS NEEDED TO GET A SENSE OF WHAT THEY ARE INCLUDING: What did you receive? How do you receive it? How frequently do you receive it? How much do you receive?

    2. Are there any categories on this list that are confusing to you, or that you think other people might not understand?

    3. Can you think of anything that is missing from this list?

Q12) (If “Shares of stock in corporations or mutual funds” selected in Q11): Did you or anyone in this household receive any capital gains from shares of stock, mutual funds, or other assets in 2022?

  • Yes

  • No



  1. If “Shares of stock in corporations or mutual funds” selected in Q11: I’m going to show you one additional question. [SHOW MODIFIED QUESTION ON CAPITAL GAINS (Q12)]

    1. How would you answer this question?

    2. In your own words, what is this question asking you?

Unemployment compensation (#4)

    1. If R mentioned this type of income in Q1: Tell me more about that. PROBE TO GET A SENSE OF HOW THEY GET THIS- THROUGH JOB, PROGRAM, ETC.

Q13) At any time during 2022, did you or anyone in the household receive any State or Federal unemployment compensation?

  • Yes

  • No



  1. All: Now I’m going to show you a question on the screen. [SHOW MODIFIED (Q13)] How would you answer this question? Tell me more about that.

    1. If yes: PROBE AS NEEDED TO GET A SENSE OF PROGRAMS THEY ARE INCLUDING: What kind of assistance do you receive? How do you receive it? Who was it from? How frequently do you receive it? How much do you receive?

    2. If no: Have you ever applied for or received any of these types of assistance in the past?

      1. If yes: Tell me more about that. PROBE AS NEEDED: When did you receive it? What kind of assistance? How do you receive it? Who was it from? How frequently do you receive it? How much do you receive?

    3. If no or if needed: What kinds of assistance do you think this question is asking about?

Other ASEC questions

Now I’m going to ask you some questions about a few different types of programs and types of expenses. Could you please answer the following questions? [HAVE R ANSWER SERIES (Q14-Q32)]

Now I have a few follow-up questions to learn more about how you came up with your answers to these questions.

School meals

[ONLY ASK IF CHILDREN 5-18 IN THE HOUSEHOLDINDICATED IN SCREENING. ASK ABOUT ONE CHILD IF MORE THAN ONE]

Q14) During 2022, did any children ages 5 to 18 in this household eat any free or reduced-price school meals?

  • Yes

  • No

Q15) Did they eat a free or reduced-price breakfast, lunch, or both?

  • Breakfast

  • Lunch

  • Both

Q16) During 2022, did any children ages 5 to 18 in this household usually eat a breakfast, lunch, or both provided by the school? Select all that apply for each child.

Breakfast

Lunch

Did not eat meals offered by school

[Child 1 name]




[Child 2 name]






Q17) If necessary: During 2022, did any of these children receive free- or reduced-price school meals? Select all that apply for each child.

Breakfast

Lunch

Did not receive free/reduced-price school meals

[Child 1 name]




[Child 2 name]






  1. How easy or difficult was it to answer these questions?

  2. If child ate any meals: Can you tell me more about the meals that children in this household ate at school?

    1. How were these meals paid for?

    2. If needed: Did anyone in your household pay anything for these meals?

  3. If child did not eat meals: Do you know if any other children at the school eat free or reduced-price meals?

WIC

Q18) At any time during 2022, did you or anyone in this household receive WIC- the Women, Infants, and Children Nutrition Program?

  • Yes

  • No

Q19) (If yes): Who received WIC for themselves or on behalf of a child?

[open-ended]

  1. How easy or difficult was it to answer these questions? If needed: How certain are you about your answers?

  2. If participant or anyone in household received benefits from WIC (Q18): Can you tell me more about the benefits received from WIC in this household?

    1. How were these benefits obtained or received?

    2. What types of benefits did you include in your answers to these questions?

SNAP

Q20) At any time during 2022, did you or anyone in this household receive benefits from SNAP (the Supplemental Nutritional Assistance Program) or the Food Stamp program, or use a SNAP or food stamp benefit card? Do not include WIC benefits.

  • Yes

  • No

Q21) At any time during 2022, even for one month, did you or anyone in this household receive any food assistance from a state program name? Do not include WIC benefits. Include SNAP (Supplemental Nutritional Assistance Program).

  • Yes

  • No

Q22) (If yes): Who was covered by that food assistance during 2022?

[open-ended]



  1. How easy or difficult was it to answer these questions? If needed: How certain are you about your answers?

  2. If participant or anyone in household received benefits from SNAP (Q20): Can you tell me more about the benefits received from SNAP in this household?

    1. How were these benefits obtained or received?

    2. What types of benefits did you include in your answers to these questions?

    3. Do you or anyone in your household have an EBT card as part of these SNAP benefits?

  3. If participant mentions having an EBT card: Did you include P-EBT in your answers to these questions?

  4. Did you include benefits from WIC in any of your answers to these questions?

  5. Are you aware of any nutritional assistance programs in your state that we haven’t already mentioned?



Medical expenses

Premiums

Q23) Last year, how much did you pay out-of-pocket for ALL health insurance premiums covering yourself or others in the household? Include both comprehensive and supplemental plans (such as vision and dental insurance). Do NOT include Medicare deductions from any Social Security or Social Security Disability payments mentioned earlier.

[Dollar field]



  1. How easy or difficult was it to answer this question? If needed: How certain are you about your answer?

  2. What does “premium” mean to you in this question?

  3. Was there anything in this question that was confusing to you, or that you think other people might not understand?

Co-pays and medical care

Q24) Last year, how much was paid out-of-pocket for your OWN medical care, such as copays for doctor and dentist visits, diagnostic tests, prescription medicine, glasses and contacts, and medical supplies? Include any amount paid out-of-pocket on your behalf by anyone else in this household.

[Dollar field]



  1. How easy or difficult was it to answer this question? If needed: How certain are you about your answer?

  2. Was there anything in this question that was confusing to you, or that you think other people might not understand?

  3. Can you think of any types of medical expenses you had last year that are missing from the examples in these questions?

  4. What do you see as the difference between these two questions, if any [POINT TO QUESTIONS 23 AND 24]?

Question 3

Q25) Last year, how much was paid out-of-pocket for your non-prescription healthcare products such as vitamins, allergy and cold medicine, pain relievers, quit smoking aids, and anything else not yet reported? Include any amount paid out-of-pocket on your behalf by anyone in this household.

[Dollar field]

Q26) Last year, how much was paid out-of-pocket for your OWN medical care (e.g., copays for doctor and dentist visits, diagnostic tests, prescription medicine, glasses and contacts, and medical supplies) AND non-prescription healthcare products (e.g., vitamins, allergy and cold medicine, pain relievers, quit smoking aids, and other expenses)? Include any amount paid out-of-pocket on your behalf by anyone in this household.

[Dollar field]



  1. How easy or difficult was it to answer these question? If needed: How certain are you about your answers?

  2. Was there anything in these questions that was confusing to you, or that you think other people might not understand?

  3. Can you think of any types of medical expenses you had last year that are missing from the examples in these questions?

  4. What do you see as the difference between these two questions, if any [POINT TO QUESTIONS 25 AND 26]?

  5. Are there any expenses that you counted in your answer to more than one question? Tell me more about that.



Energy assistance

Q27) In 2022, did you receive energy assistance to help pay heating and cooling costs from the federal, state, or local government? This assistance can be received directly by the household or it can be paid directly to the electric company, gas company, or fuel dealer.

  • Yes

  • No



  1. How easy or difficult was it to answer this questions? If needed: How certain are you about your answers?

  2. Was there anything in these questions that was confusing to you, or that you think other people might not understand?

  3. If participant reports receiving any energy assistance (including any additional/unexpected check): Could you tell me more about the energy assistance that your received?

    1. How was this energy assistance obtained or received?

    2. What types of energy assistance did you include in your answers to these questions?

  4. If participant did NOT report any energy assistance: Did you use anything other than your regular income to pay your heating and cooling costs? If nothing comes to mind, that is okay too.

Housing assistance

Q28) Is this public housing, that is, is it owned by a local housing authority or other public agency?

  • Yes

  • No

Q29) Are you paying lower rent because the Federal, State, or local government is paying part of the cost?

  • Yes

  • No



  1. How easy or difficult was it to answer these questions? If needed: How certain are you about your answers?

  2. Was there anything in these questions that was confusing to you, or that you think other people might not understand?

  3. What does “public housing” mean to you in this question? How about “Section 8”?

  4. If participant reports paying lower rent because the Federal, State, or local government is paying part of the cost: Could you tell me more about the program paying part of your rent? For example, what type of program is it and who offers/sponsors it?

Child care

Q30) Now we want to ask about some of your expenses for children. Did you or anyone in this household PAY for the care of any children while you or they worked, searched for work or were in training/education in 2022?

  • Yes

  • No

Q31) Do you or does anyone in this household currently use any of the following types of child care for [CHILD]? Select all that apply.

  • Pre-kindergarten or 3-K

  • Head Start

  • Preschool, nursery school, or daycare center

  • Family daycare or paid care provided in someone else’s home

  • A paid babysitter or nanny in the home

  • Free care with a relative

  • Paid care with a relative

  • Any other type of child care, specify: ____

Q32) Do you or does anyone in this household receive government assistance, for instance a voucher or child care subsidy, to help pay for [CHILD]’s child care?

Yes
No



Loop through previous two questions for each child under 13.



  1. How easy or difficult was it to answer these questions? If needed: How certain are you about your answers?

  2. Was there anything in these questions that was confusing to you, or that you think other people might not understand?

Conclusion

  1. [IF APPLICABLE:] Before we finish, I want to give my colleagues that are observing a chance to let me know if they have any other questions for you. Give me one moment please. [INTERVIEWER: CHECK FOR TEAMS DIRECT MESSAGE FROM CENSUS BUREAU OBSERVERS ABOUT ANY ADDITIONAL QUESTIONS THEY HAVE FOR THE RESPONDENT. ASK THESE QUESTIONS AND RECORD RESPONSES IN THE CASE SUMMARY.]

  2. Was there anything else you wanted to mention about your income and program participation that we haven’t talked about today?

Great, thank you very much. Those are all of the questions that I had for you today. Thank you very much for your participation.


  • [ENSURE RESPONDENT HAS COMPLETED VOUCHER FORM AND PROVIDE INFORMATION ON RECEIVING $40 INCENTIVE]

  • [TURN OFF THE RECORDER]


Appendix: Respondent materials

List of income types

  1. Sources of income received:

  1. Wages or salary

  2. Income from your own nonfarm business, partnership, or professional practice

  3. Income from your own farm

  4. Social Security or Supplemental Security Income (SSI)

  5. Unemployment compensation

  6. Interest on savings, CDs, bonds, retirement accounts, and so on

  7. Dividends on stocks, mutual funds, and so on

  8. Pensions and company retirement

  9. Withdrawals from retirement accounts (401K, 403B, IRA, KEOGH, SEP, and so on)

  10. Public assistance or welfare

  11. Rental properties, estates or trusts

Income type questions for respondent feedback

Self-employment income

  1. List:

  1. Babysitting or childcare

  2. Hair, beauty, or other personal care services

  3. Direct sales programs like Avon, Scentsy, Herbalife, or doTERRA

  4. Landscaping

  5. Delivery services like Instacart, DoorDash, or Ubereats

  6. Other app-based jobs like Uber or Lyft

  7. Selling handmade items, in person or online on sites like Etsy

  8. Re-selling items, in person or online on sites like eBay

  9. Responding to surveys online for money

  10. Social media-related income, such as sponsored posts, YouTube video views, or streaming subscriptions

  11. Other services paid for in cash or via an app like Venmo or Cash App

Retirement

  1. During 2022, did you or anyone in this household receive any pension income from a previous employer or union, other than Social Security or VA benefits? Do not include distributions or withdrawals from IRAs, 401(k)s, or similar accounts.

  • Yes

  • No


  1. (If yes): What was the source of the pension income? Select all that apply.

  • Company

  • Union

  • Federal government

  • State government

  • Local government

  • U.S. military

  • U.S. Railroad Retirement pension

  • Some other source, specify: ______________



  1. During 2022, did you or anyone in this household receive any income from an annuity?

  • Yes

  • No


  1. At any time during 2022, did you or anyone in this household have any retirement accounts such as a 401(k), 403(b), IRA, or another account designed specifically for retirement savings?

  • Yes

  • No



  1. (If yes): What type of retirement account? Select all that apply.

  • 401(k)

  • 403(b)

  • Roth IRA

  • Regular IRA

  • KEOGH plan

  • Simplified Employee Pension (SEP plan)

  • Another type of retirement account, specify: ___________



  1. Did you or anyone in your household withdraw any money or receive a distribution from a [LIST ALL SELECTED IN PRIOR QUESTION] in 2022, including any distributions that may have been required to take?

  • Yes

  • No

Public assistance

Version 1

  1. At any time during 2022, even for one month, did you or anyone in this household receive any CASH assistance from a state or county welfare program?

  • Yes

  • No

Version 2

  1. At any time during 2022, even for one month, did you or anyone in this household receive any CASH assistance from a state or county welfare program?

INCLUDE:

  • Welfare or welfare to work

  • Temporary Assistance for Needy Families (TANF)/Aid to Families with Dependent Children (AFDC)

  • General assistance

  • Diversion payments

  • Refugee cash

  • General assistance from Indian Affairs.



Do NOT include:

  • Food stamps or Supplemental Nutrition Assistance Program (SNAP) benefits

  • Supplemental Security Income (SSI)

  • Energy assistance

  • Women, Infants and Children (WIC)

  • School meals

  • Childcare

  • Education assistance



  • Yes

  • No

Flashcard

[FLASHCARD WILL DISPLAY LIST OF PROGRAM NAMES SPECIFIC TO THE RESPONDENT’S STATE. SEE ATTACHED EXCEL]

Interest and dividends

  1. At any time during 2022, did you or anyone in this household have money in any of the following? Select all that apply.

  • Interest-earning checking account

  • Savings account

  • Money market fund

  • Certificates of deposit (CDs)

  • Savings bonds

  • Shares of stock in corporations or mutual funds

  • Any other savings or investments that pay interest or dividends, specify: ______________



  1. (If “Shares of stock in corporations or mutual funds” selected): Did you or anyone in this household receive any capital gains from shares of stock, mutual funds, or other assets in 2022?

  • Yes

  • No

Unemployment compensation

  1. At any time during 2022, did you or anyone in the household receive any State or Federal unemployment compensation?

  • Yes

  • No

Other ASEC questions

School meals

  1. During 2022, did any children ages 5 to 18 in this household eat any free or reduced-price school meals?

  • Yes

  • No



  1. Did they eat a free or reduced-price breakfast, lunch, or both?

  • Breakfast

  • Lunch

  • Both



  1. During 2022, did any children ages 5 to 18 in this household usually eat a breakfast, lunch, or both provided by the school? Select all that apply for each child.

Breakfast

Lunch

Did not eat meals offered by school

[Child 1 name]




[Child 2 name]






  1. If necessary: During 2022, did any of these children receive free- or reduced-price school meals? Select all that apply for each child.

Breakfast

Lunch

Did not receive free/reduced-price school meals

[Child 1 name]




[Child 2 name]






WIC

  1. At any time during 2022, did you or anyone in this household receive WIC- the Women, Infants, and Children Nutrition Program?

  • Yes

  • No



  1. (If yes): Who received WIC for themselves or on behalf of a child?

[open-ended]



SNAP

  1. At any time during 2022, did you or anyone in this household receive benefits from SNAP (the Supplemental Nutritional Assistance Program) or the Food Stamp program, or use a SNAP or food stamp benefit card? Do not include WIC benefits.

  • Yes

  • No



  1. At any time during 2022, even for one month, did you or anyone in this household receive any food assistance from a state program name? Do not include WIC benefits. Include SNAP (Supplemental Nutritional Assistance Program).

  • Yes

  • No



  1. (If yes): Who was covered by that food assistance during 2022?

[open-ended]



Medical expenses


  1. Last year, how much did you pay out-of-pocket for ALL health insurance premiums covering yourself or others in the household? Include both comprehensive and supplemental plans (such as vision and dental insurance). Do NOT include Medicare deductions from any Social Security or Social Security Disability payments mentioned earlier.

[Dollar field]


  1. Last year, how much was paid out-of-pocket for your OWN medical care, such as copays for doctor and dentist visits, diagnostic tests, prescription medicine, glasses and contacts, and medical supplies? Include any amount paid out-of-pocket on your behalf by anyone else in this household.

[Dollar field]



  1. Last year, how much was paid out-of-pocket for your non-prescription healthcare products such as vitamins, allergy and cold medicine, pain relievers, quit smoking aids, and anything else not yet reported? Include any amount paid out-of-pocket on your behalf by anyone in this household.

[Dollar field]



Combined Question Draft:

  1. Last year, how much was paid out-of-pocket for your OWN medical care (e.g., copays for doctor and dentist visits, diagnostic tests, prescription medicine, glasses and contacts, and medical supplies) AND non-prescription healthcare products (e.g., vitamins, allergy and cold medicine, pain relievers, quit smoking aids, and other expenses)? Include any amount paid out-of-pocket on your behalf by anyone in this household.

[Dollar field]

Energy assistance

  1. In 2022, did you receive energy assistance to help pay heating and cooling costs from the federal, state, or local government? This assistance can be received directly by the household or it can be paid directly to the electric company, gas company, or fuel dealer.

  • Yes

  • No

Housing assistance

  1. Is this public housing, that is, is it owned by a local housing authority or other public agency?

  • Yes

  • No

  1. Are you paying lower rent because the Federal, State, or local government is paying part of the cost?

  • Yes

  • No


Child care

  1. Now we want to ask about some of your expenses for children. Did you or anyone in this household PAY for the care of any children while you or they worked, searched for work or were in training/education in 2022?

  • Yes

  • No

  1. Do you or does anyone in this household currently use any of the following types of child care for [CHILD]? Select all that apply.

  • Pre-kindergarten or 3-K

  • Head Start

  • Preschool, nursery school, or daycare center

  • Family daycare or paid care provided in someone else’s home

  • A paid babysitter or nanny in the home

  • Free care with a relative

  • Paid care with a relative

  • Any other type of child care, specify: ____

  1. Do you or does anyone in this household receive government assistance, for instance a voucher or child care subsidy, to help pay for [CHILD]’s child care?

Yes
No



Loop through previous two questions for each child under 13.

28


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AuthorJessica Holzberg (CENSUS/CBSM FED)
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File Created2025-08-12
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