Page 243 - QAP Manual 2020

Other Comments:

4. Explanation for difficulty completing survey ( For example, individual participated in section one
but refused to participate in section two and offered to come another day but individual refused).
Unusual anamalies or contradictions, detailed reasons why sections were not completed, or anything
that may be questioned after the survey was completed.
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Additional Questions for Surveyor(s):

I-1 SURVEYOR, in what language was the survey conducted?
□ 1. English
□ 2. Spanish

□ 3. Mandarin
□ 4. Tagalong
□ 5. Vietnamese
□ 6. Korean
□ 7. Arabic

□ 8. Armenian
□ 9. Farsi
□ 10. Hmong
□ 11. Khmer
□ 12. Laos
□ 13. Russian

□ 14. American Sign Language (ASL)
□ 0. Other ____________________

I-2 Was this survey conducted face to face, or remotely (via video-conference)

□ 1. Face to face, in-person
□ 2. Remotely via video conference software

I-3 If the survey was conducted face-to-face, where was the face-to-face survey held?
Check ALL THAT APPLY.

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