Cognitive Interview Data Collections for DOL Research

OMB No.: 1290-0043

Expiration: 10/31/2025

Appendix E. Respondent Screener

Help Improve a National Survey about Work

Introduction to self-administered screener (on landing page):

We are doing research to improve survey questions about where people work, the jobs they do, and how they are paid. These questions will be used in a large national survey. The purpose of this study is to get feedback or how easy or difficult the survey questions are to answer.

The study is conducted by Westat and funded by the U.S. Department of Labor. If you qualify, we will ask you to complete select survey questions and ask you questions to help us revise them. The interview will be conducted virtually via Zoom and take up to 90 minutes. If you qualify and take part in the interview, you will receive a $50 electronic Amazon gift card.

If you have any questions about this study, please contact April Fales at AprilFales@Westat.com or XXX-XXX-XXXX.

Public reporting burden for this data collection instrument is estimated to average 5 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting the form. This collection of information is voluntary. You are not required to respond to this collection of information unless it displays a valid OMB control number. Please send comments regarding the burden estimate or any other aspect of this collection of information to the Department of Labor, Chief Evaluation Office, 200 Constitution Ave NW., Washington, DC 20210, or email ChiefEvaluationOffice@dol.gov and reference OMB control number 1290-0043. NOTE: Please do not send your completed form to this address.

Now we will ask you a few questions to determine if you are eligible for this study. It should take only about 5 minutes of your time.

Screener Questions

1. Are you at least 18 years old?

• Yes

• No Go to IE statement

Some people work more than one job. If you work more than one job, please answer the next questions about your main job, that is the job where you usually work the most hours.

2. How long have you been working at your job?

• Not currently working Go to IE statement

• Less than one month Go to IE statement

• One month to less than six months

• Six months to less than one year

• More than one year

3. Which of the following are you employed by?

• Government (federal, state, or local)  Go to IE statement

• Private for-profit company

• Non-profit organization

• I own my own store/shop  Go to IE statement

• Independent contractor, independent consultant, or freelance worker

4. How are you paid?

• Hourly

• Salary

• Some other way, please specify:

5. [IF SALARIED] What is your annual salary before taxes and deductions are taken out?

• Less than $35,000

• $35,000 to 49,999

• $50,000 to $99,999

• $100,000 or more  Go to IE statement

6. Do you supervise anyone on this job?

• Yes  Go to IE statement

• No

7. Which of the following best describes the type of business or industry at your job?

• Child day care services

• Cleaning and building maintenance

• Construction

• Food service (including restaurants, bars, fast food places, and cafeterias)

• Grocery store or supermarket

• Home health care

• Hotel or motel

• Landscaping

• Nursing home

• Retail store

• Security services (including security guard)

• Another type of business or industry

IF Q7 = 1 TO 11 GO TO Q8; IF Q7 = Another type of business or industry GO TO Q7A

7a. What type of business or industry to do work in?

7b. What is your occupation?

Demographic Questions

8. How old are you?

• 18 to 24

• 25 to 34

• 35 to 44

• 45 to 54

• 55 to 64

• 65 or older

9. Are you: Select all that apply

• Female

• Male

• Transgender, non-binary, or another gender

10. What is your race and/or ethnicity? Select all that apply.

• American Indian or Alaska Native

For example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

• Asian

For example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.

• Black or African American

For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.

• Hispanic or Latino

For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.

• Middle Eastern or North African

For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.

• Native Hawaiian or Pacific Islander

For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.

• White

For example, English, German, Irish, Italian, Polish, Scottish, etc.

• I do not wish to provide this information

11. What is the highest degree or level of school you have COMPLETED?

• Less than high school

• High school diploma or GED

• Some college credit, no degree

• Associate’s degree

• Bachelor’s degree

• Master’s degree, Doctorate degree, or other professional degree beyond Bachelor’s degree

12. Do you have internet access at home (other than a cell phone)?

• Yes

• No

13. Have you ever used Zoom before?

• Yes

• No

14. Are you willing to use Zoom for this interview?

• Yes

• No

Thank you! We will review your answers. If you are eligible for the study, we will be in touch with you within one week to schedule a virtual interview.

Please enter your contact information below. We will destroy this information after the interview is over.

Name:

Phone number:

Email address:

IE Statement:

We’re sorry but you do not qualify for this study. Thank you for your time.

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	April Fales
File Modified	0000-00-00
File Created	2024-07-20