Individuals - SNAP Participants

F OCUS GROUP

PARTICIPANT INFORMATION FORM

Please do not include your name or address on this form. The information will be used only to summarize participant information for this meeting.

LOCATION: DATE/TIME:

1. Please indicate your gender.

MARK ONE

1  Male

2  Female

2. Please indicate your age.

MARK ONE

1  18 - 24 years

2  25 - 34 years

3  35 - 44 years

4  45 - 59 years

6  60 years or older

3. I am:

MARK ONE

1  Hispanic or Latino(a)

2  Not Hispanic or Latino(a)

4. I consider myself:

MARK ALL THAT APPLY

1  American Indian or Alaskan Native

2  Asian

3  Black or African American

4  Hispanic or Latino

5  Native Hawaiian or Other Pacific Islander

6  White

5. My marital status is:

MARK ONE

1  Never married

2  Married

3  Living with Partner

4  Separated

5  Divorced

6  Widowed

6. I am currently:

MARK ONE

1  Working 20 hours or more per week

2  Working less than 20 hours per week

3  Not employed

7. Do you have a health problem or disability

which prevents you from working or which

limits the kind or amount of work you can do?

1  Yes

2  No

8. What is the highest grade or year of school that you have completed?

MARK ONE

1  Less than 9th grade

2  Some high school, but no diploma

3  High school graduate (diploma or GED)

4  Some college, but no degree

5  Associate’s degree

6  Bachelor’s degree or higher

9. Please indicate if you are currently receiving support from any of the following sources:

MARK ALL THAT APPLY

1  TANF (Temporary Assistance for Needy

Families) or welfare

2  Unemployment Insurance

3  WIC (Women, Infants, and Children’s

Program)

3  SSI (Social Security Retirement, Disability,

or Survivor’s benefits)

3  Medicaid

10. Including yourself, how many people live in

your household? Please include all adults and

children.

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Public Burden Statement:  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number.  The OMB control number for this project is 0584-0547.  Public reporting burden for this collection of information is estimated to be 108.25 hours per response including the time for participating in the interviews and providing the extant data collection.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:  U.S. Department of Agriculture, Food and Nutrition Services, Office of Research and Analysis, 3101 Park Center Drive, Room 1014, Alexandria, VA, 22302, ATTN: Rosemarie Downer

hank you for your help!

O.3