Subject ID: ________
Appendix G-1
Farmers’ Market Consumer
Survey Instrument
Form Approved
OMB No.: 0920-xxxx
Exp. Date: xx/xx/xxxx
NYC HEALTH BUCKS EVALUATION
CONSUMER (POINT-OF-PURCHASE) SURVEY
*Interviewer Name: ________________________
*Date of Interview: ____________
*Farmers’ Market Name: ________________________
*Farmers’ Market Location: __ The Bronx
__ Brooklyn
__ Manhattan
__ Queens
__ Staten Island
*Fields to be pre-filled for interviewers.
INSTRUCTIONS TO INTERVIEWER:
[READ TO RECRUIT] “Hello - Did you buy something at the market today?”
[IF YES:] “Do you have 5 minutes to answer some questions about your shopping experience?”
[IF NO:] “Are you planning to buy something at the market today? If you are planning on buying something at the market today, please stop by our table on your way out to take a brief survey.”
[ASK TO DETERMINE ELIGIBILITY] “Before we begin, may I ask if you are over 18? “
[IF NO:] “Thank you for your time, but I cannot administer the survey to anyone under 18. Sorry, and have a great day!”
[IF YES:] “You are eligible to participate in this survey. Before we begin, I’m going to read this form to you to explain a little bit more about the research study and how this survey fits in.
READ CONSENT:
Congratulations! You qualify for our study. I’d like to explain what the study is about before I ask you any other questions. The purpose of this study is to learn about the effects of a farmers’ market coupon program, called NYC Health Bucks, on fruit and vegetable consumption in certain neighborhoods in New York. As part of our study, we are talking to people who shop at New York City farmers’ markets to learn about their fruit and vegetable consumption habits and awareness of the Health Bucks program.
You will be given a (INSERT INCENTIVE- TBD) to compensate you for your time. Information collected in this survey will be maintained in a secure manner. There are no costs for participating in this survey. Participation in this survey is voluntary. Even if you agree to participate, you are not required to answer all the questions. You may stop this survey at any time without penalty.
Do you have any questions about this study, or may I begin now?
[IF YES, REFER TO “FREQUENTLY ASKED QUESTIONS” AND ASK AGAIN]
[IF NO, BEGIN SURVEY]
Q1. During the farmers’ market season (July 1 through November 15), how often do you shop at a farmers’ market? (INTERVIEWER: READ CHOICES.)
____ More than Once a Week
____ About Once a Week
____ Once or Twice a Month
____ About Once a Month
____ Less Than Once a Month
Q2. Which of the following items did you buy at the farmers’ market today?
(INTERVIEWER: READ LIST AND CHECK ALL THAT APPLY.)
____ Fruits
____ Vegetables
____ Jams/Juices
____ Bread
____ Cheese
____ Meats/Fish
____ Baked Goods
____ (VOL) Not Sure/Refused
Q3. How did you pay for your items at the market today? Look at this list*, and as I read each option, tell me if you used it or not. [*Show Card #1.]
(INTERVIEWER: READ LIST AND CHECK ALL THAT APPLY.)
____ Cash
____ Debit or Credit Card (like MasterCard, Visa)
____ Food Stamps (a.k.a. SNAP or EBT Benefits or EBT Tokens)
____ WIC or Senior FMNP Coupons
____ WIC Vouchers (a.k.a. WIC Vegetable and Fruit Checks)
____ Health Bucks
____ Other
____ (VOL) Not Sure/Refused
Q4. Did you notice if any of the following nutrition activities or materials were offered at the market today?
(INTERVIEWER: READ LIST AND CHECK ALL THAT APPLY.)
____ Cooking Demonstrations
____ Educational Handouts
____ Flyers or Brochures
____ Taste Test/Samples
____ Recipes
____ Other
____ (VOL) Not Sure/Refused
Q5. If you were to walk from your home to this particular farmers’ market, how long would it take you to get here?
____ Less than 5 Minutes
____ 5 to 10 Minutes
____ More than 10 Minutes
____ (VOL) Not Sure/Refused
Q6. Not including this market, think about the closest location to your home where you can purchase fresh fruits and vegetables. What type of location is this?
(INTERVIEWER: READ LIST, AS NEEDED.)
____ Supermarket or Grocery Store
____ Convenience/Corner Store
____ Bodega
____ Other Farmer’s Market
____ Fresh Fruit & Vegetable Stand or Cart
____ Other
____ (VOL) Not Sure/Refused
Q7. If you were to walk from your home to that location, how long would it take you to get there?
____ Less than 5 Minutes
____ 5 to 10 Minutes
____ More than 10 Minutes
____ (VOL) Not Sure/Refused
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
[INTERVIEWER: ONLY ASK Q7 → 12 IF MARKET ACCEPTS HEALTH BUCKS.]
“Health Bucks are $2 coupons provided for the purchase of fresh fruits and vegetables at certain farmers’ markets in New York City. This is what a Health Buck looks like.”
(INTERVIEWER: REFER BACK TO SHOW CARD #1 HERE.)
Q8. Have you ever seen or heard about Health Bucks before today?
____ Yes
____ No
____ (VOL) Not Sure
____ (VOL) Refused
Q9. IF YES: How did you first hear about Health Bucks?
(INTERVIEWER: READ CHOICES.)
____ Flyer, Brochure, or Other Promotional Handout
____ Poster at the Farmers’ Market
____ Subway/Bus Advertisement
_____ Newspaper
_____ Web
____ Mailing Received at Home
____ From Other People (Family, Friends, etc.)
____ From a Local Community Organization
(i.e. health/community center, church, food pantry, etc.)
____ Saw Them Being Used By Shoppers at the Market
____ Other
____ (VOL) Not Sure/Refused
Q10. Have you ever used Health Bucks?
____ Yes
____ No
____ (VOL) Not Sure
____ (VOL) Refused
Q11. IF YES: About how often, on average, do you use Health Bucks?
____ Every Week During Farmers’ Market Season
____ Every Other Week During Farmers’ Market Season
____ Every Month During Farmers’ Market Season
____ Every Other Month During Farmers’ Market Season
____ Once per Farmers’ Market Season
____ I have only ever used Health Bucks one time.
____ (VOL) Not Sure/Refused
Q12. Did you use Health Bucks today?
____ Yes
____ No
____ (VOL) Not Sure
____ (VOL) Refused
Q13. IF YES: Where did you get the Health Bucks you used today?
(INTERVIEWER: READ LIST AND CHECK ALL THAT APPLY.)
____ At the Farmers’ Market (w/ SNAP or EBT Benefits)
____ At the Farmers’ Market (as part of a promotion)
____ From a Local Community Organization
(i.e. health/community center, church, food pantry, etc.)
____ From a Friend or Relative
____ Other
____ (VOL) Not Sure/Refused
Q14. IF YES: When did you get the Health Bucks you used today?
(INTERVIEWER: READ LIST AND CHECK ALL THAT APPLY.)
____ Today
____ Any Other Day
____ (VOL) Not Sure/Refused
Q15. How much do you agree with these statements about the Health Bucks program?
"I shop at farmers' markets more often because of Health Bucks."
(INTERVIEWER: READ CHOICES.)
____ Strongly Agree
____ Somewhat Agree
____ Neutral
____ Somewhat Disagree
____ Strongly Disagree
____ (VOL) Not Sure/Refused
"I buy more at farmers' markets because of Health Bucks."
(INTERVIEWER: READ CHOICES.)
____ Strongly Agree
____ Somewhat Agree
____ Neutral
____ Somewhat Disagree
____ Strongly Disagree
____ (VOL) Not Sure/Refused
"I spend more in Food Stamps (a.k.a. SNAP or EBT benefits) at farmers' markets because of Health Bucks."
(INTERVIEWER: READ CHOICES.)
____ Strongly Agree
____ Somewhat Agree
____ Neutral
____ Somewhat Disagree
____ Strongly Disagree
____ (VOL) Not Sure/Refused
"Health Bucks help me to eat more fresh fruits & vegetables."
(INTERVIEWER: READ CHOICES.)
____ Strongly Agree
____ Somewhat Agree
____ Neutral
____ Somewhat Disagree
____ Strongly Disagree
____ (VOL) Not Sure/Refused
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Q16. Thinking about nutrition . . . How many total servings of fruit and/or vegetables did you eat yesterday? A serving would equal one medium apple, a handful of broccoli, or a cup of carrots.
(INTERVIEWER: DO NOT READ CHOICES ALOUD.)
____ None ____ 6
____ 1 ____ 7
____ 2 ____ 8
____ 3 ____ 9
____ 4 ____ 10+
____ 5 ____ (VOL) Not Sure/Refused
Q17. Was the amount of fruit and vegetables that you ate yesterday much more than usual, about the same as usual, or much less than usual?
____ Much more than usual
____ About the same as usual
____ Much less than Usual
____ (VOL) Not Sure/Refused
Q18. Compared to one year ago, would you say you are now eating more, less, or the same amount of fruits and vegetables?
____ More ____ Less ____ Same
____ (VOL) Not Sure/Refused
*Upon completion of the survey, please ask the respondent the following questions:
Q19. What is your age? ____ years
____ (VOL) Don’t Know/Not Sure
____ (VOL) Refused
Q20. Are you male or female? ____ Male
____ Female
____ (VOL) Don’t Know/Not Sure
____ (VOL) Refused
Q21. Are you Hispanic or Latino?
____ Yes
____ No
____ (VOL) Don’t Know/Not Sure
____ (VOL) Refused
[IF HISPANIC: Some people, aside from being Hispanic, also consider themselves to be a member of a racial group.] Which one of these groups would you say best represents your race?
(INTERVIEWER: READ CHOICES; MULTIPLE RESPONSE.)
____ White
____ Black or African American
____ Asian
____ Native Hawaiian or Other Pacific Islander
____ American Indian or Alaska Native
____ (VOL) Don’t Know/Not Sure
____ (VOL) Refused
Q22. Including yourself, how many people live in your household?
____ total # of people
____ (VOL) Don’t Know/Not Sure
____ (VOL) Refused
Q23. How many children under the age of 18 live in your household?
____ # of children
____ (VOL) Don’t Know/Not Sure
____ (VOL) Refused
Q24. The next question is about your combined household income. By household income we mean the combined income from everyone living in the household including even roommates or those on disability income. Can you tell me the annual combined income for your household?
$________/year income
____ (VOL) Don’t Know/Not Sure
____ (VOL) Refused
If Not Sure/Refused:
Q Can you just tell me if your annual household income is less than $PVTYLVL?
1 YES
2 NO
7 DON’T KNOW/NOT SURE
9 REFUSED
Q25. Please indicate which of the following programs you or someone in your household currently participates in.
(INTERVIEWER: READ LIST AND CHECK ALL THAT APPLY.)
____ Food Stamps (a.k.a. SNAP or EBT Benefits)
____ WIC
____ WIC Farmers’ Market Nutrition Program (FMNP)
____ Senior Farmers’ Market Nutrition Program (SFMNP)
____ None of the Above
____ (VOL) Don’t Know/Not Sure
____ (VOL) Refused
Q26. Please specify your zip code of residence: ____________
____ (VOL) Don’t Know/Not Sure
____ (VOL) Refused
[THANK PARTICIPANT FOR TAKING THE SURVEY, AND HAND OUT FREE METRO CARD.]
| File Type | application/msword |
| File Title | Point-of-Purchase (Consumer) Survey Domains |
| Author | HewittC |
| Last Modified By | HewittC |
| File Modified | 2010-01-21 |
| File Created | 2009-11-09 |