RTI International and Research Support Services are conducting research on behalf of the U.S. Census Bureau to improve questions in one of its national surveys. The purpose of this research is to get feedback on how easy or difficult the survey questions are to answer. Selected participants will be asked for their thoughts and opinions about some survey questions. If you are eligible, we will invite you to a 60-minute interview which will be conducted via Microsoft Teams. You will receive a $40 gift card for participating in the interview.
To determine if you are eligible for the interview, we must ask you a few screening questions about your background and your household. Your participation in the eligibility screening is completely voluntary. You may stop at any time or skip questions that you do not want to answer.
This voluntary survey is being conducted under the authority of Title 13 U.S. Code, Sections 141, 182, and 193. Federal law requires that your answers are kept confidential (Title 13, U.S. Code, Section 9), and protects your privacy under the Privacy Act (Title 5 U.S. Code, Section 552a). Routine uses of these data are limited to those identified in the Privacy Act System of Record Notice titled “COMMERCE/CENSUS-5, Decennial Census Programs.” The Census Bureau can use your responses only to produce statistics and is not permitted to publicly release your responses in a way that could identify you, your business, organization, or institution.
We estimate that completing these screening questions will take 15 minutes on average. This information collection has been approved by the Office of Management and Budget (OMB). You can validate that this survey is a legitimate using the Office of Management and Budget's approval number 0607-0725, which expires 12/31/2025. We are required to tell you this number to conduct this survey. Send comments regarding this estimate or any other aspect of this survey, including suggestions for reducing the time it takes to complete this survey to adrm.pra@census.gov.
If you have questions about the research, you may contact RTI’s project director, Gretchen McHenry, at
919-541-7221 or gmchenry@rti.org.
If you are eligible for the study, we will call or email you to schedule a time for the interview.
Consent to Participate
Do we have your permission to ask you a few questions to find out if you are eligible for this study?
If you agree to participate, please click “Yes, I agree” below and then the “NEXT” button to continue. If you choose not to participate, please click “Exit” and then the “NEXT” button to exit the survey.
1 Yes, I agree [Skip to Q1]
2 Exit [Skip to REFUSAL]
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In what city, state, and ZIP code do you currently live?
City: [______]
State or Territory: [______]
ZIP code [______]
[PROGRAMMER: CITY − TEXTBOX with 50 characters Max.; State – DROPDOWN; ZIP code − 5 digits NUMERIC ENTRY ONLY]
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How old are you?
[______] [If Q2<18, skip to INELIGIBLE]
[PROGRAMMER: NUMERIC ENTRY ONLY; RANGE = (6-110)]
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Are you employed by the Federal Government? (if federal contractor, mark NO)
1 Yes [skip to INELIGIBLE]
2 No
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What is your gender? (open-ended)
Are you transgender?
[ ] 1 Yes
[ ] 2 No
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Are you gay, lesbian, bisexual, pansexual, or asexual?
Yes
No
(If Yes): How would you describe your sexual orientation? (open-ended)
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Are you of Hispanic, Latino, or Spanish origin? Please select all that apply.
1 No, not of Hispanic, Latino, or Spanish origin
2 Yes, Mexican, Mexican Am., Chicano
[ ] 3 Yes, Puerto Rican
[ ] 4 Yes, Cuban
[ ] 5 Yes, another Hispanic, Latino, or Spanish origin – Enter origin, for example, Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian, and so on: [_____________________]
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What is your race? Please select all that apply.
1 White
2 Black or African American
3 American Indian or Alaska Native
4 Asian
5 Native Hawaiian or other Pacific Islander
6 Other – please specify
[PROGRAMMER: WHEN 6 (“Other”) IS SELECTED, DISPLAY “please specify” TEXTBOX.]
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What is the highest grade of school you have completed, or the highest degree you have received?
1 Less than high school diploma or equivalent
2 GED or ABE certificate
3 High school diploma
4 Some college, no degree
5 Associate’s degree (AA, AS, or equivalent)
6 Bachelor’s degree (BA, BS, or equivalent)
7 Post Bachelor’s degree (MA, MS, PhD, JD, MD, etc.)
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How well do you speak English?
1 Very well
2 Well
3 Not well
4 Not at all
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How well do you speak Spanish?
1 Very well
2 Well
3 Not well
4 Not at all
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How well do you read Spanish?
1 Very well
2 Well
3 Not well
4 Not at all
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If you complete a form or a survey, do you prefer to complete it in Spanish or in English?
1 Spanish
2 English
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What is your current marital status?
1 Married
4 Separated
5 Divorced
6 Widowed
[ ] 7 Never married
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Does anyone live or stay with you at your current address?
1 Yes [ask Q18]
2 No [skip to Q22]
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[Ask if Q17 = Yes] Who lives or stays with you? Please select all that apply.
1 Parent(s)
2 Grandparent(s)
3 Husband/wife/spouse
4 Unmarried partner
5 Children
6 Grandchildren
7 Other relatives(s)
8 Roommates or friends
9Other – please specify
[PROGRAMMER: WHEN 9 (“Other”) IS SELECTED, DISPLAY “please specify” TEXTBOX.]
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How many people age 18 or older currently live or stay at your address, INCLUDING yourself?
[______]
[PROGRAMMER: NUMERIC ENTRY ONLY; RANGE = (0-19)]
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How many people younger than 18 currently live or stay at your address?
[______]
[PROGRAMMER: NUMERIC ENTRY ONLY; RANGE = (0-19)]
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[Ask if Q20>0] What is your relationship to the children living or staying with you? Please select all that apply.
1 Your biological children
2 Your adopted children
3 Your foster children
4 Your grandchildren
5 Related to you in some other way
6 Not related to you
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What is your household’s annual income? Your best guess is fine.
1 Less than $15,000
2 $15,000 to $25,000
3 $25,000 to $50,000
4 $50,000 to $100,000
5 More than $100,000
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Finally, we just have a few more questions about your contact information. If you are eligible and selected to participate in the study, we will use the information to contact you to schedule an interview.
What is your name?
Name: [________________________]
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What is your email address?
[_________________________________________]
[PROGRAMMER: email verification]
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What is the best telephone number to reach you?
Phone ([___]) [___] − [_______]
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What is the best time to reach you by phone?
[_________________________________________]
[PROGRAMMER: textbox character limit: 50, place on the same page with Q51]
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Do you have a computer or tablet with a web camera?
1 Yes
2 No
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[Ask if Q27= YES] Would you be willing and able to download a video conferencing app to your computer or tablet to do the interview online?
1 Yes
2 No
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When did you last participate in a research study?
[______]
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Thank you for taking the time to answer our questions today. We will get back to you soon if you are eligible for an interview.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Weimer, Belinda |
| File Modified | 0000-00-00 |
| File Created | 2025-08-12 |