Form 1 Screener

2024 SIPP Redesign Content Cognitive Interviewing Screener

The US Census Bureau is looking for participants to help test questions for a survey on employment, health insurance, and program participation. Thank you for your interest in this research opportunity. Eligible participants who complete a 60-minute research session will receive a $50 stipend. In order to establish your eligibility to participate, we need to ask you a few simple questions.

Eligibility Questions

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

Yes

No

E1a. (If yes) Since you are a federal employee, we are not able to pay you the $50 stipend. 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 to screen share.

Yes

No ->Ineligible

Section A - Residency

A1. During the past 6 months, how many times have you moved to a new address?

________ times

Section B - Employment

B1. Are you currently employed?

Yes

No

B1a (IF Yes to B1) How many jobs do you currently have?

________ jobs

B1b (IF YES to B1) Have you changed any jobs within the past 6 months?

Yes

No

B1c (IF Yes to B1) Please briefly describe your job(s). For example: Teacher, Engineer, Uber Eats driver, tutor, etc.

_____________________________ (open-ended response)

B1d (IF NO to B1) Have you been employed within the past 6 months?

Yes

No

Section C - SNAP

C1. Have you received Food Stamps or SNAP benefits within the past 6 months?

Yes

No

C1a (IF Yes to C1) Did you live with anyone during the past 6 months who received those same Food Stamps or SNAP benefits?

Yes

No

C1b (IF Yes to C1) Are you currently living with anyone who received their own Food Stamps or SNAP benefits, separate from yours, within the past 6 months?

Yes

No

C1c (IF NO to C1) Are you currently living with anyone who received Food Stamps or SNAP benefits within the past 6 months?

Yes

No

Section D – Health Insurance

D1 (IF Yes to D1) Were you covered by health insurance or a health coverage plan AT ANY TIME during the past 6 months?

Yes

No

D1a. (IF YES to D1) Was there any time during the past 6 months when you were not covered by health insurance or a health coverage plan?

Yes

No

D1b. (IF YES to D1) Did you have any changes to your health insurance or health coverage plan during the past 6 months?

Yes

No

Demographics

[IF RESPONDENT IS ELIGIBLE]

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 grade of school you have completed, or the highest degree you have received?

Less than high school

Completed high school

Some college, no degree

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

Yes

No

Demo 6. 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

Other (Specify)

Demo 7. How many people live in your household?

Age ______________

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

City ___________________________

State __________________________

Zip Code _______________________

Demo 9. What is your time zone?

Eastern Standard Time

Central Standard Time

Mountain Standard Time

Pacific Standard Time

Alaska Standard Time

Hawaii-Aleutian Standard Time

Demo 10. How did you hear about this research opportunity? __________________________________

Demo 11. What is your telephone number? We may use it to contact you if you are selected to participate in a research session.

____________________________________

Demo 12. 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]

Unfortunately, you are not eligible to participate in this research project. 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? ______________________________________

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