# Appendix A

U.S. PIAAC National Supplement

Screener (Household

- based Sample)A

- 1



### S CQ 0001 OMBIntro

Item Text: According to the Paperwork Reduction Act of 1995, no persons are required

to respond to a collection of information unless it displays a valid O MB control number.

The valid OMB control number for this voluntary survey is 1850

– 0870. The time

required to complete this survey is estimated to average two hours per response,

including the time to review instructions, gather the data needed, and compl ete and

review the PIAAC background questionnaire and exercise. If you have any comments

concerning the accuracy of the time estimate, suggestions for improving this survey, or

any comments or concerns regarding the status of your individual submission of this

survey, please write directly to: PIAAC, National Center for Education Statistics, 1990 K

Street, NW, Washington, DC 20006.A

- 2



### S CQ 10 10 S CQ A

s kNumb e r I nHH

It e m T y p e: Q u e s t io n

It e m Cl a s s : In te g e r

It e m T e x t : Inc lud i n g y o u rs e l f

, ho w m an y p e o p l e li v e i n th is ho u s eh o l d an d h a v e n o u s u al p l a c e o f

r esi de n c e e l s e w he r e ?

Di sp la y :

N ot es: S tart e n u m e r at i on t i m i ng h e r e.

L o w er R a n g e: 1

A n s w e rs All o w e d : 1 U p per R a n g e: 25

Res p o n se V a l u e L abel S k ip T o

1 [ E nt e r co n ti n u o u s a n s w er ] S CQ 1 0 1 5

99 R E F U SE D S CQ 1 0 1 5A

- 3



### S CQ 1015

It e m T y p e: R o ute

It e m Cl a s s : Be g i n Lo op

It e m T e x t : T h e f o ll o w i ng va r i ab l e s

-- na m e

, S c r ee n e r r e s p o n d en t, g e n d e r

, ag e, a g e r a n ge

, work

variables (PaidWork, AwayJob,UnpaidWork, LookWork) a nd t he m is r ep orted f ie ld

( S CQ1 0 2 0

- S CQ1 09 0)

- - s ho u l d ap p e ar a s a g r id

. Al l e n u m e r a t i on i n f or m at i o n i s

e n ter e d i n t hi s gr i d.

Di sp la y :

N ot es:

Res p o n se V a l u e L abel S k ip T o

1 [R ou te e x e c ut e d ] S CQ 1 0 2 0V er si o n Da t e : 1 / 1 3/ 2 0 1 1 P a g e 4 of 45 

### S CQ 10 2 0 S CQN ame H HM

It e m T y p e: Q u e s t io n

It e m Cl a s s : S tri n g

It e m T e x t : [ A ] W h at i s t h e f i r st n a m e o f th e p er s o n, o r o ne of t h e pe r so n s

, w h o i s l i v i ng i n t he

h o u s e h ol d w h o o w n s o r r e nts t h i s h o m e ?

[ B ] N e x t, pl e a s e t el l m e t h e n a m e s of al l o th e r m e m be r s o f th is ho u s eh o l d (s t a r t in g w ith

y ou r s po u s e

, if a p p li c a b le )

.

[C] Ple a s e t e l l m e t h e na m e s of a l l o th er m e m b e r s of t hi s h o use h o ld

.

[HOU SE HOLD (HH) M E M BE RS I NC L UDE PE O PL E W HO T HINK OF T HIS HH A S T H E IR

P RI MA RY PLA CE OF R E S ID E NC E

. IT I NC L UD E S PE R S ONS W HO U S U A L L Y S T A Y IN

T HE HH B UT A RE T E M P OR A RI L Y A W A Y ON B U S IN ESS

, VA C A T ION, IN A HO SP I T AL

, O R L I V ING A T S CHO O L I N A DORM, F R A T E RN I T Y OR S ORORI T Y .]

[ P R ES S T HE DO W N A RROW KE Y T O MO V E T O T HE N E X T B L A NK L IN E

. W H E N A LL

N A M E S A RE E N T E R E D, U S E A RROW UP A ND RIGHT KE Y S T O G E T T O N E X T

QU ES T ION.]

[ P R ES S E N T E R ON A BLA NK L I NE T O E X IT T HE GRID

. ]

[ HOU SE HOLD (HH) M E M BE RS I NC L UDE PE O PL E W HO T HINK OF T HIS HH A S T H E IR

P RI MA RY PLA CE OF R E S ID E NC E

. IT I NC L UD E S PE R S ONS W HO U S U A L L Y S T A Y IN

T HE HH B UT A RE T E M P OR A RI L Y A W A Y ON B U S IN ESS

, VA C A T ION, IN A HO SP I T AL

, OR L I V ING A T S CHO O L I N A DORM, F R A T E RN I T Y OR S OROR I T Y .]

[ P R ES S T HE DO W N A RROW KE Y T O MO V E T O T HE N E X T B L A NK L IN E

. W H E N A LL

N A M E S A RE E N T E R E D, U S E A RROW UP A ND RIGHT KE Y S T O G E T T O N E X T

QU ES T ION.]

Di sp la y : For the f i rs t lin e o n t he gr id

, di s p la y t ext A

. For t h e s e c o nd l i ne

, di s p la y t ext B

. For al l

s u bse q u en t li n e s

, d i s pl ay t e x t C.

N ot es: All ow 2 5 ch a r a c t e r s f o r n a m e s

.

T hi s va r i ab le s h o ul d a p p e a r as th e f i rs t c o l u m n o n t he gr id

.

L o w er R a n g e:

A n s w e rs All o w e d : U p per R a n g e:

Res p o n se V a l u e L abel S k ip T o

1 [ E nt e r co n ti n u o u s a n s w er ] S CQ 1 025A

- 5



### S CQ 1025 S CQWhoIsRespondent

It e m T y p e: Q u e s t io n

It e m Cl a s s : Enumerated

It e m T e x t : [ E N T E R A ' 1 ' N E X T T O T HE R E SP OND E N T .]

[ I F NOT O BV IOU S

, ASK : T h a n k y ou f o r t el l in g m e a b ou t al l th e p e o p l e w h o l iv e in t h i s

h o u s e h ol d. N o w

, I n e e d t o a s k y o ur n a m e, s o I k n o w w h i c h h o use h o l d m e m be r y ou ar e .]

[ E N T E R A ' 1 ' N E X T T O T HE R E SP OND E N T .]

Di sp la y :

N ot es: All ow on ly o n e r e s p on s e t o t hi s q u est io n. T h is va r ia b l e s h ou ld a p p e a r a s t he s e c o n d

c ol u m n i n t h e g r i d

.

A n s w e rs All o w e d : 1

Res p o n se V a l u e L a bel S k ip T o

1 R ESP ON D E NT R e s p o n d e nt S CQ 1 030A

- 6



### S CQ 1030

It e m T y p e: R o ute

It e m Cl a s s : If T h en

It e m T e x t : All ow op en m ove m e n t t h r o u gh gr id

. Do n o t r e q ui r e u s ers t o a s k a l l i t e m s f o r e ach p er s o n

b e f ore go i n g to t h e ne x t pe r so n

.

Di sp la y :

N ot es:

Re s p o n se V a l u e L abel S k ip T o

1 [R ou te e x e c ut e d ] S CQ 1 040V er si o n Da t e : 12/11/12 P a g e 7 of 45



### S CQ 10 4 0 S CQGender

It e m T y p e: Q u e s t io n

It e m Cl a s s : Enumerated

It e m T e x t : [CODE G E ND E R. IF NOT O BV IOU S

, ASK : Is {N A M E } m al e o r f e m a le ?]

Di sp la y :

N ot es:

A n s w e rs All o w e d : 1

Res p o n se V a l u e L abel S k ip T o

1 MALE Male S CQ 1 0 50

2 FEMALE Female S CQ 1 0 50V er si o n Da t e : 12/11/12 P a g e 8 of 45



### S CQ 105 0 S CQ Age

It e m T y p e: Q u e s t io n

It e m Cl a s s : In te g e r

It e m T e x t : H o w o l d { a r e y o u /is N AME }?

[ I F U N D E R 1 Y EA R, E N T E R A S "0" ]

Di sp la y :

N ot es: T hi s va r i ab le s h o ul d a p p e a r as th e f ou r th c o lu m n on t he gr i d.

L o w er R a n g e: 0

A n s w e rs All o w e d : 1 U p per R a n g e: 130

Res p o n se V a l u e L abel S k ip T o

1 [ E nt e r co n ti n u o u s a n s w er ] S CQ 1 055

98 DON’T KNOW S CQ 1 06 2

99 R E F U SE D S CQ 1 06 2V er si o n Da t e : 12/11/12 P a g e 9 of 45



### S CQ 1055

It e m T y p e: Check

It e m Cl a s s : Soft

It e m T e x t : If o ut s id e t he ra n ge of 0 to 9 9, d isp la y t he f o l lo w in g: " I j u s t ne ed to c h e c k t h a t

{ y o ur/N A M E ' s } a g e i s { S CQ 1 0 5 0}. Is t hi s r ig ht ? "

A ss o c ia t e d v a r ia b le : S CQ 1 0 5 0

Di sp la y :

N ot es:

Res p o n se V a l u e L abel S k ip T o

1 [Check executed ] S CQ107 0V er si o n Da t e : 12/11/12 P a g e 10 of 45



### S CQ 10 6 2 S CQ AgeRange

It e m T y p e: Q u e s t io n

It e m Cl a s s : Enumerated

It e m T e x t : { A r e y

ou /Is N A ME }

. . .

Di sp la y :

N ot es: T hi s va r i ab le s h o ul d a p p e a r as th e f i f th c o l u m n o n t he gr id

.

A n s w e rs All o w e d : 1

Res p o n se V a l u e L abel S k ip T o

1 U n d e r 1 6 y

e a r s o l d ? U n d e r 1 6 Y e ar s O l d S CQ 1 070

2 1 6 to 2 4 y

e a rs old ? F 16 T o 2 4 Y e ar s O l d SCQ1070

3 2 5 t o 3 4 y

e a r s o l d? F 25 T o 3 4 Y e ar s O l d S CQ 1 0 7 0

4 3 5 to 4 5 y

e a rs old? F 35 T o 4 5 Y e ar s O l d SCQ1070

5 4 6 t o 5 5 y

e a r s o l d ? F4 6 T o 5 5 Y e ar s O l d S CQ 1 0 7 0

6 5 6 t o 6 5 y

e a r s o l d ? F5 6 T o 6 5 Y e ar s O l d S CQ 1 0 7 0

7 6 6 t o 74 y

e a r s o l d ? F6 6 T o 74 Y e ar s O l d S CQ 1 0 7 0

8 75 years old or older? F75YearsOldOrOlder SCQ1070

98 DON’T KNOW S CQ 1 063

99 R E F U SE D S CQ 1 063V er si o n Da t e : 12/11/12 P a g e 11 of 45



### S CQ 106 3 S CQBroad AgeRange

It e m T y p e: Q u e s t io n

It e m Cl a s s : Enumerated

It e m T e x t : {Are you/Is NAM E}...

Di sp la y :

N ot es: This variable should appear as the sixth column on the grid.

A n s w e rs All o w e d :

Res p o n se V a l u e L abel S k ip T o

1 Under 16 years old? Under16YearsOld_ S CQ 1 070

2 16 to 34 years old? _16To34YearsOld_ S CQ 1 070

3 35 to 65 years old? _35To65YearsOld_ S CQ 1 070

4 66 to 74 years old? _66To74YearsOld_ S CQ 1 070

5 75 years old or older? _75YearsOldorOlder_ S CQ 1 070A

- 12



### S CQ 107 0 S CQPaidWork

It e m T y p e: Question

It e m Cl a s s : Enumerated

It e m T e x t : Last week {were you/was NAME} doing PAID wor k for at least one hour, either as an

employee or as self

- employed?

Di sp la y :

N ot es: This item should appear as the seventh column on the grid.

If answer “1” Yes, no more screener questions necessary.

Person considered employed

. (67. 73% will stop here based on PIAAC 2011)

A n s w e rs All o w e d : 1

Res p o n se V a l u e L abel S k ip T o

1 Yes Yes S CQ 1 090



### 2 No No S CQ 1 071

98 DON’T KNOW S CQ 1 071

99 R E F U SE D S CQ 1 071V er si o n Da t e : 12/11/12 P a g e 13 of 45



### S CQ 1071 S CQ AwayJob

It e m T y p e: Q u e s t io n

It e m Cl a s s : Enumerated

It e m T e x t : 

### Last week, { were you/was NAME} away from a job or business that {you /NAME} plan (s)

to return to?

Di sp la y :

N ot es: This item should appear as the eighth column on the grid.

If answer “1” Yes, no more screener questions necessary.

Person considered employed

. (3.28 % will stop here based on PIAAC 2011)

A n s w e rs All o w e d : 1

Res p o n se V a l u e L abel S k ip T o

1 Yes Yes S CQ 1 0 90

2 No No S CQ 1 072

98 DON’T KNOW S CQ 1 072

99 REFUSED S CQ 1 072V er si o n Da t e : 12/11/12 P a g e 14 of 45



### S CQ 107 2 S CQUnpaidWork

It e m T y p e: Question

It e m Cl a s s : Enumerated

It e m T e x t : Last week {were you/was NAME} doing UNPAID work for at least one hour for a business

that { you /NAME} own (s) or a relative owns?

Di sp la y :

N ot es: This item should appear as the eigh th column on the grid.

If answer “1” Yes, no more screener questions ne cessary.

Person considered employed

. ( 1.65 % will stop here based on PIAAC 2011)

A n s w e rs All o w e d : 1

Res p o n se V a l u e L abel S k ip T o

1 Yes Yes S CQ 1 090



### 2 No No S CQ 1 073

98 DON’T KNOW S CQ 1 073

99 R E F U SE D S CQ 1 073A

- 15



### S CQ 107 3 S CQLookWork

It e m T y p e: Question

It e m Cl a s s : Enumerated

It e m T e x t : In the 4 weeks ending last Sunday, { were you /was NAME} looking for paid work at any

time?

Di sp la y :

N ot es: This item should appear as the ninth column on the grid.

If answer “1” Yes, person considered unem ployed

.

A n s w e rs All o w e d : 1

Res p o n se V a l u e L abel S k ip T o

1 Yes Yes S CQ 1 090



### 2 No No S CQ 1 090

98 DON’T KNOW S CQ 1 090

99 R E F U SE D S CQ 1 090A

- 16



### S CQ 10 90 S CQ MisreportedHHM

It e m T y p e: Instruction

It e m Cl a s s : Enumerated

It e m T e x t : [L E AV E EMP T Y U NLES S PE R S ON W A S M IS R EP OR T E D A ND IS NOT A HOU SE HO L D

M EMBE R. IF M I S R EP OR T E D, E N T E R " 1 " .]

Di sp la y : Do no t al l o w " MI S R EP OR T " a s an o p t i on on t h e f i r st li ne of t h e g r i d, (r e f e r e n c e p e rs o n )

. If

a pe r son is m a r k e d a s "M I S R EP OR T E D," a l l o th er f ie l d s o n t he gr i d a ss o c ia t e d w i th t h i s

p er s o n s ho u l d b e " s h ow on l y ."

N ot es: T h e d e f a ul t f or th i s f i el d i s b l an k

- i t w i l l o n l y b e f ill ed i f n e c e ss a r y

.

T hi s va r i ab le s h o ul d a p p e a r as th e tenth c o l u m n o n t he gr id

.

Res p o n se V a l u e L abel S k ip T o

1 MISREPORTE D Misreported S CQ1100A

- 17

SCQ1100 SCQAllInfoEntered

It e m T y p e: Q u e s t io n

It e m Cl a s s : Enumerated

It e m T e x t : C h e c k e n u m e r at i o n g r i d to e n s u r e t h a t a l l n e c e ss a r y i te m s hav e b e en a n s w ere d

. If a n y

n e c e ss a r y f iel ds a r e b l an k

, r et u r n t o g r i d

. El s e

, go to S CQ1 10 5

.

Di sp la y :

N ot es:

Res p o n se V a l u e L abel S k ip T oA

- 18



### S CQ 110 5 SCQAnyoneElse

It e m T y p e: Route

It e m Cl a s s : If Then

It e m T e x t : W e h a v e li s t e d {NUM B E R} h ou s e ho ld m e m b e r{ s } :

{N A M E /G E ND E R/ A G E } H av e w e m i ss e d a ny o th er...

- m e m be r s o f t h is ho u s eh o l d w ho are r el at e d t o { y o u /R E F E R E NCE PE R S ON}?

- p e o pl e l ivin g h ere w h o a r e n o t r el at e d t o { y o u /R E F E R E NCE PE R S ON}, in c l u di ng f r i e nd s

o r b o a r d e rs ?

- h o use h o l d m e m be r s w ho usu a l ly l iv e h ere b u t a r e n ot h ere cur r e n t l y

, s uch a s s o m e o n e

a w a y on va c a ti o n

, b usi ne ss

, in a h osp i ta l

, or a st ud e n t li v i n g i n a d or m it o r y ?

Di sp la y : D i s p l a y th e n u m b e r of ho u s eh o l d m e m b ers c oll e c t e d i n t h e e n u m erat io n g r id i n {NUM BE R}.

D i s pl ay t h e na m e

, ge n d er a nd a g e o f a ll h o u s e h ol d m e m b e r s c o l le c ted i n t he g r i d in

{N A M E /G E ND E R/ A G E }

.

N ot es: T h e n u m b er of h o use h o l d m e m be r s co ll ected i n t h e en u m era t i o n g r i d i s t he val ue t ha t

s h o ul d b e s t o r ed as h o u s e h ol d s i z e

.

En d e n u m e r at i o n ti m in g h ere w h e n all household members information collected in grid and

SCQ1105=2

.

A n s w e rs All o w e d : 1

Res p o n se V a l u e L abel S k ip T o

1 YES Yes SCQ 1106

2 NO No S CQ 1110

99 REFUSED S CQ 11 10A

- 19



### S CQ 1 106

It e m T y p e: Check

It e m Cl a s s : H a r d

It e m T e x t : PLEAS E A DD A DD I T ION A L INFORM A T ION T O T HE T ABLE

.

Di sp la y :

N ot es: If SCQ110 5 < >Yes

Res p o n se V a l u e L abel S k ip T o

1 [Check executed] S CQ 1 020A

- 20



### S CQ 111 0

It e m T y p e: Route

It e m Cl a s s : If Then

It e m T e x t : Insert s a m p l in g m es s a ge s h e r e. B a s e d o n co ll ected ho u s eh o l d ch a r a c t e r ist i c s, d et e r m in e

i f t h e r e i s a t le a s t o ne e l i g ib l e p er s o n i n t h e h o u s e h ol d.

If t h e r e i s a t le a s t o ne e l i g ibl e p er s o n, th e n g o to S CQ1 1 1 5

. El s e

, g o t o S CQ 11 2 4

.

Di sp la y :

N ot es: Eli g ib i li ty i s d e ter m i n e d a t t h e ti m e e n u m e r at i on i s c o m p l e te d

. S CQ 11 05 is t h e f i na l

e n u m e r at i o n q u e s t i on t ha t m ust b e a ns w e r e d to d e ter m i n e eli g ib i li t y

.

Res p o n se V a l u e L abel S k ip T o

1 [Route executed]A

- 21



### S CQ 1 115 S CQEligiblePersons

It e m T y p e: Inst r u c t i on

It e m Cl a s s : Enumerated

It e m T e x t : Ba s ed on t he i n f o r m a t i on y o u h a v e p r o v i d e d, w e h av e s el e c t e d th e f oll o w i n g pe o pl e t o

p art i c i p a te i n th e s t u d y : { PE R S ON( S ) }

[ P R ES S 1 A ND E N T E R T O CON T IN UE .]

Di sp la y :

N ot es: D i s p l a y n a m e

, a ge a n d ge n d er o f e l ig i bl e S P (s ) i n "PE R S ON( S ) "

.

Res p o n se V a l u e L abel S k ip T o

1 CONTINUE Continue S CQ 116aA

- 22



### S CQ 1 16a S CQDOB

It e m T y p e: Question

It e m Cl a s s : Integer

It e m T e x t : What is ^AuxNameYour birth date?

Di sp la y : Interviewer Instruction

– Enter complete date, including date, month and year. If

respondent does not know complete date enter DK. If respondent refuses to p rovide

complete date, enter RF.

N ot es: ENTER AS DD/MM/YYYY.

CAPI Instr: Soft edit to compare SCQ116a to Screener Age SCQXXXX.If difference is greater than

one year, display the edit: “ I need to verify what I entered. I recorded that ^AuxNameYour

dat e of birth is SCQ 116aDOB. Is this correct?”

Res p o n se V a l u e L abel S k ip T o

1 [Enter Continuous answer] Continue S CQ 1117

9 DON’T KNOW SCQ116bMM

7 REFUSED SCQ116bMM

It e m T y p e: Check

It e m Cl a s s : Hard edit

It e m T e x t : Date cannot be in future

It e m Cl a s s : Soft edit

It e m T ext : Date cannot be before 1/1/1890

Derived age must be +/

- 1 of enumeration ageA

- 23



### S CQ 1 16bMM

It e m T y p e: Question

It e m Cl a s s : Integer

It e m T e x t : Can you please tell me ^AuxNameYour month of birth?”

N ot es: [ ENTER AS MM]

If DON”T KNOW OR REFUSED then current month used

Lower Range : 1

Upper Range : 12

Res p o n se V a l u e L abel S k ip T o

1 [Enter Continuous answer] Continue S CQ 116cYY

9 DON’T KNOW SCQ116cYY

7 REFUSED SCQ116cYYA

- 24



### S CQ 1 16cYY

It e m T y p e: Qu estion

It e m Cl a s s : Integer

It e m T e x t : Can you please tell me ^AuxNameYour year of birth?”

N ot es: [ ENTER AS YYYY]

CAPI Instr: Soft edit to compare SCQ116cYYYY to Screener Age SCQXXXX. If difference is greater

than one year, display the edit: “ I ne ed to verify what I entered. I recorded that

^AuxNameYour year of birth is SCQ 116cYYYY. Is this correct?”

If DON”T KNOW OR REFUSED then backward calculate year from enumeration age.

Day set = 15(mid

- month) for date calculations.

Res p o n se V a l u e L abel S k ip T o

1 [Enter Continuous answer] Continue S CQ 1117

9 DON’T KNOW SCQ1117

7 REFUSED SCQ1117

It e m T y p e: Check

It e m Cl a s s : Hard edit

It e m T e x t : Year cannot be in future

It e m Cl a s s : Soft edit

It e m T ext : Year cannot be before 1890

Derived age must be +/

- 1 of enumeration age

Note: When done, the following variables set or derived

– SCQ1116Age (derived age);

SCQ1116a (day of derived DOB); SCQ1116b (month of derived DOB); SCQ1116c (year

of derived DOB).A

- 25



### S CQ 1117 SC QSPEthnicity

It e m T y p e: Q u e s t io n

It e m Cl a s s : Enumerated

It e m T e x t : [ S HO W C A RD 1 ]

Do an y of t h e f o llo w i ng gr o u p s re p r ese n t { y o u r /N AME ' s} n at i o n a l o r i g i n o r a n c e s t r y ?

M e x i c a n/ M e x i c an

- A m e r i c an

, Pu erto R i c an

, C u b an

, o th e r H i s pa n i c o r L at i n o? Y ou c a n

s el e c t m ore t h an o n e an s w e r

.

[ SE L E CT AL L T H A T APP L Y .]

Di sp la y :

N ot es:

A n s w e rs All o w e d :

Res p o n se V a l u e L abel S k ip T o

1 M E X IC A N/ ME X IC A N

- AME RIC A N M e x i c a n

_ M e x i c a n _A m eri c a n S CQ 1118

2 P U E R T O R I C A N Pu ertoR i c a n S CQ 1118

3 C U BA N C u b a n S CQ 1 118

4 O T H E R H I SPA N I C OR L A T I N O Oth e rH i s p a n icO r La t in o S CQ 1 118

5 NOT H ISPA NIC N o tH i s pa n i c S CQ 1 118

98 DON’T KNOW S CQ 1119

99 R E F U SE D S CQ 1119A

- 26



### S CQ 1118

It e m T y p e: Check

It e m Cl a s s : Hard

It e m T e x t : If S CQ 1 1 1 7

= 5 a n d a n o th e r r e s p o n s e

, di s p l a y : " I'm s o rr y

, b u t N O T H I S PA NIC i s n o t a l lo w e d

w ith a n y o t he r r e s p on s e."

Di sp la y :

N ot es:

Res p o n se V a l u e L abel S k ip T o

1 [Check executed] S CQ 1121A

- 27



### S CQ 1119 S CQEthnicityObserve

It e m T y p e: Q u e s t io n

It e m Cl a s s : Enumerated

It e m T e x t : [R E CORD SP ' S E T HN I CI T Y B Y O BSE R V A T ION, IF P O SS I BLE ]

Di sp la y :

N ot es:

A n s w e rs All o w e d :

Res p o n se V a l u e L abel S k ip T o

1 M E X IC A N/ ME X IC A N

- AME RIC A N M e x i c a n

_ M e x i c a n _A m eri c a n S CQ 1121

2 P U E R T O R I C A N Pu ertoR i c a n S CQ 1121

3 C U BA N C u b a n S CQ 11 21

4 O T H E R H I SPA N I C OR L A T I N O Oth e rH i s p a n icO r La t in o S CQ 11 21

5 NOT H ISPA NIC N o tH i s pa n i c S CQ 11 21

98 DON’T KNOW S CQ 1121A

- 28



### S CQ 1121 S CQSPRace

It e m T y p e: Q u e s t io n

It e m Cl a s s : Enumerated

It e m T e x t : [SHOWCARD 2]

W h a t r a c e do y

o u c o nsi de r { y

ou r se l f /N A ME } t o be ? W h i te, Bl ack o r A fr ican A m e r ica n

, A s ia n, Na ti v e Ha w a i ia n o r o th e r P a c i f ic I s la n de r

, o r A m eri c a n In d ia n o r Ala s k a Na t i v e? Y o u

can s e le c t m o r e t h a n on e a n s w er.

[ SE L E CT AL L T H A T APP L Y .]

Di sp la y :

N ot es:

A n s w e rs All o w e d :

Res p o n se V a l u e L abel S k ip T o

1 WHITE White S CQ 11 23

2 BLACK/AFRICAN AMERICAN Black_AfricanA m eri c an S CQ 1123

3 ASIAN Asian S CQ 11 23

4 NATIVE HAWAIIAN/PACIFIC NativeHawaiian_PacificIslander S CQ 11 23

ISLANDER

5 AMERICAN INDIAN/ALASKA AmericanIndian_AlaskaNative S CQ 11 23

NATIVE

98 DON’T KNOW S CQ 1122

99 REFUSED S CQ 1122A

- 29



### S CQ 1122 S CQRaceObserve

It e m T y p e: Q u e s t io n

It e m Cl a s s : Enumerated

It e m T e x t : [RECORD SP’S RACE BY OBSERVATION, IF POSSIBLE]

Di sp la y :

N ot es:

A n s w e rs All o w e d :

Res p o n se V a l u e L abel S k ip T o

1 WHITE White S CQ 1123

2 BLACK/AFRICAN AMERICAN Black_AfricanA m eri c an S CQ 1123

3 ASIAN Asian S CQ 11 23

4 NATIVE HAWAIIAN/PACIFIC NativeHawaiian_PacificIslander S CQ 11 23

ISLANDER

5 AMERICAN INDIAN/ALASKA AmericanIndian_AlaskaNative S CQ 11 23

NATIVE

98 DON’T KNOW S CQ 11 23A

- 30



### S CQ 1123

It e m T y p e: Q u e s t io n

It e m Cl a s s : If then

It e m T e x t : If another SP, go to SCQ1117.

Else, go to SCQ1124.

Di sp la y :

N ot es:

Res p o n se V a l u e L abel S k ip T o

1 [Route executed]A

- 31



### S CQ 1124 SCQHomePhone

It e m T y p e: Q u e s t io n

It e m Cl a s s : Enumerated

It e m T e x t : What is your home telephone number (in case my office wants to check my work)?

Di sp la y :

N ot es:

A n s w e rs All o w e d : 1

Res p o n se V a l u e L abel S k ip T o

1 E NT E R PHONE NUMBER EnterPhoneNumber S CQ 1125

2 NO HOME PHONE NoHomePhone S CQ 1150

99 R E F U SE D S CQ 1150A

- 32



### S CQ 1125 S CQPhone No

It e m T y p e: Q u e s t io n

It e m Cl a s s : In te g e r

It e m T e x t : W h a t i s y

o u r ho m e t el e ph o n e n u m b er ( in c a s e m y o ff i c e w a nts t o ch e c k m y w or k ) ?]

NUM B E R: ( { A R EA }) { E X CH A NG E }

- {LOC A L}

Di sp la y : 1 0

- digit string

N ot es:

L o w er R a n g e:

A n s w e rs All o w e d : U p per R a n g e:

Res p o n se V a l u e L abel S k ip T o

1 [ E nt e r co n ti n u o u s a n s w er] S CQ 1 140A

- 33



### SCQ1140 SCQPhoneConfirm

It e m T y p e: Q u e s t io n

It e m Cl a s s : Enumerated

It e m T e x t : CONFIRM TELEPHONE NUMB ER: ({AREA}){EXCHANGE}

- {LOCAL}

Di sp la y :

N ot es:

Res p o n se V a l u e L abel S k ip T o

1 YES Yes S CQ 1150

2 NO No SCQ1145A

- 34



### S CQ 1 145

It e m T y p e: Check

It e m Cl a s s : Hard

It e m T e x t : RE

- ENTER TELEPHONE NUMBER

Di sp la y :

N ot es:

Res p o n se V a l u e L abel S k ip T o

1 [Check executed] S CQ 1150A

- 35



### S CQ 1 150 S CQOtherNumb e r

It e m T y p e: Q u e s t io n

It e m Cl a s s : Enumerated

It e m T e x t : Is t h e r e {a/ a n o th e r } ph o n e n u m b er w h ere y o u c o u l d be r ea c h ed ?

Di sp la y : If S CQ 1 1 2 4

= 1

, di s p l a y " a n ot h er "

. El s e

, di s p la y "a"

.

N ot es:

A n s w e rs All o w e d :

Res p o n se V a l u e L abel S k ip T o

1 YES Yes S CQ 115 5

2 NO OTHER PHONE NoOtherPhone S CQ2005

99 R E F U SE D S CQ2005A

- 36



### S CQ 1 155 S CQOthPhNo

It e m T y p e: Q u e s t io n

It e m Cl a s s : In te g e r

It e m T e x t : [What is that phone n umber?}

NUM B E R: ( { A R EA }) { E X CH A NG E }

- {LOC A L}

Di sp la y : 10

- digit string

N ot es:

L o w er R a n g e:

A n s w e rs All o w e d : U p per R a n g e:

Res p o n se V a l u e L abel S k ip T o

1 [ E nt e r co n ti n u o u s a n s w er] S CQ 1170A

- 37



### S CQ 1 170 S CQOtherConfirm

It e m T y p e: Q u e s t io n

It e m Cl a s s : Enumerated

It e m T e x t : I h av e t he p h o n e nu m b er a s : ( { A R EA }) { E X CH A NG E }

- {LOC A L}

Is t h i s c o rr e c t?

Di sp la y :

N ot es:

L o w er R a n g e:

A n s w e rs All o w e d : 1 U p per R a n g e:

Res p o n se V a l u e L abel S k ip T o

1 YES Yes S CQ 1180

2 NO No S CQ 117 5A

- 38



### S CQ 1 175

It e m T y p e: Check

It e m Cl a s s : Hard

It e m T e x t : RE

- ENTER TELEPHONE NUMBER

Di sp la y :

N ot es:

Res p o n se V a l u e L abel S k ip T o

1 [Check executed] S CQ 1180

99 R E F U SE D S CQ 1 0 1 5A

- 39



### S CQ 1 180 S CQOtherPhoneLocated

It e m T y p e: Q u e s t io n

I t e m Cl a s s : Enumerated

It e m T e x t : W h e r e i s t h i s p h on e l ocat e d? Is i t in y o ur h o m e, a t w or k

, so m e pl ace e lse, or i s i t a c e llu l a r

p h o n e ?

Di sp la y :

N ot es:

A n s w e rs All o w e d :

Res p o n se V a l u e L abel S k ip T o

1 OWN HOME OwnHome S CQ2005

2 WORK Work S CQ20 05

3 CELLULAR PHONE CellPhone S CQ2005

91 OTHER, SPECIFY OthSpecify S CQ2005

98 DON’T KNOW S CQ2005

99 REFUSED S CQ2005A

- 40



### S CQ2005 S CQLanguage

It e m T y p e: Q u e s t io n

It e m Cl a s s : Enumerated

It e m T e x t : [ T HIS S CR E E N E R IN T E R V I E W W A S CONDUC T E D IN:]

D i sp la y :

N ot es:

A n s w e rs All o w e d : 1

Res p o n se V a l u e L abel S k ip T o

1 ENGLISH English S CQ3010

2 SPANISH Spanish S CQ3010

91 OTHER, SPECIFY OthSpecify S CQ3010A

- 41



### S CQ3010

It e m T y p e: Route

It e m Cl a s s : If Then

It e m T e x t : If h i dd en DU p r oce d ure is r e q ui r e d

, g o to S CQ3 0 1 2

.

El s e

, g o t o S CQ 30 1 5

.

Di sp la y :

N ot es:

Res p o n se V a l u e L abel S k ip T o

1 [Route executed]A

- 42



### S CQ3 0 12 S CQHiddenDU

It e m T y p e: Instruction

It e m Cl a s s : Enumerated

It e m T e x t : W e w a n t to be s ure t ha t eve r y h o u s e h ol d i n th is a r ea h a s b e e n g ive n a c h an c e t o

p art i c i p a te i n th is i m p o r ta n t s t ud y

. A r e t he r e a n y o th e r li v i n g qu arte rs

, li k e a b ase m e n t or

g ara g e a p art m e n t t h at w e m a y h a v e m i ss e d?

IF NO

- ---- > CODE 2

IF Y E S

----- > DO T HE D U s T H A T R M E N T ION E D A PPEA R ON T HE L IS T ING S H EE T S ?

IF Y E S

----- > CODE 2

IF NO

- ---- > DO DUs MEE T D E F IN I T ION OF D U ? [ PE R S ONS L I VE / EA T

SEPA R A T EL Y A ND H AV E E N T R A NCE DIR E C T LY FROM OU T S IDE OR T HROU G H

COM M ON HA L L ]

IF Y E S

----- > CODE 1

IF NO

- ---- > CODE 2

Di sp la y :

N ot es:

Res p o n se V a l u e L abel S k ip T o

1 HIDDEN DU PROCEDURE H i d d e n Du P ro c ed ur e R eq u i r e d S CQ3013

REQUIRED

2 NO, HIDDEN DU PROCEDURE N o _H id d e nD uP r oce d ure N otR S CQ3013

NOT REQUIRED equired

98 DON’T KNOW DK S CQ3013A

- 43



### S CQ3013

It e m T y p e: Route

It e m Cl a s s : If Then

It e m T e x t : If S CQ 3 0 1 2 i s Y E S th en u p d a te t b lC a s e In f o. Hi d de nC a s eP e n d in g Y N to Y ;

If S CQ 3 0 1 2 i s DK t h e n u p da te t b l C a s eI n f o .H idd e n Case P e n di n g Y N t o Y ;

If S CQ 3 0 1 2 i s NO th e n u p da te t b l C a s eI n f o .H idd e n Case P e n di n g Y N t o N.

Di sp la y :

N ot es:

Res p o n se V a l u e L abel S k ip T o

1 [Route executed] S CQ30 1 5A

- 44



### S CQ3015

It e m T y p e: Route

It e m Cl a s s : If Then

It e m T e x t : If h o u s e h ol d c o nt a i ns SP (s)

, go to S CQ4 00 5.

El s e

, g o t o S CQ 4 0 10

.

Di sp la y :

N ot es:

Res p o n se V a l u e L abel S k ip T o

1 [Route executed]A

- 45



### S CQ4005 S CQCompleteEligible

It e m T y p e: Instruct io n

It e m Cl a s s : Enumerated

It e m T e x t : [ E ND OF S CR E E N E R. A T T E M P T T O A D M INI S T E R B Q W I T H S P

. IF N O T AVA I LAB L E

,

SE T APP OIN T M E NT FOR B Q A ND E X E RC ISE ]

[ P R ES S F10 A ND E N T E R T O CON T IN UE ]

[ P R ES S 1 A ND E N T E R T O CON T IN UE ]

Di sp la y :

N ot es: En d i nst r u m en t ti m in g h ere.

COM PLE T E S CR E E N E R, 1

- 2 SAMP LE PE R S ONS SELE C T E D

Res p o n se V a l u e L abel S k ip T o

1 F10 F10 ENDA

- 46



### S CQ4010 S CQCompleteInelig

It e m T y p e: Instruct io n

It e m Cl a s s : Enumerated

It e m T e x t : T h a n k y

o u v ery m uch f o r y

o ur ti m e t o d a y

. B ased on t h e in f o r m a ti o n y ou h av e g i v e n u s

, n o

o ne in y o ur h o u s e h ol d i s e l ig i bl e t o pa r t i c ip ate i n o u r st ud y

. T h a nk y ou

. [ P R ES S F10 A ND E N T E R T O CON T IN UE .]

[ P R ES S 1 A ND E N T E R T O CON T IN UE .]

Di sp la y :

N ot es: En d i n st r u m en t ti m in g h ere.

COM PLE T E S CR E E N E R, NO EL IGI B LE SA M PL E PE R S ON( S )

Res p o n se V a l u e L abel S k ip T o

1 F10 F10 E ND