SEBTC - Households

Reference No.:

OMB No.: xxxx-xxx

Expiration Date: xx/xx/20xx

Summer Electronic Benefit Transfer for Children

Spring Baseline Questionnaire

March 15, 2011

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection will be entered after clearance. The time required to complete this information collection is estimated to average 25 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

SECTION A: INTRODUCTION

[IF INBOUND CALL]

SI1 Just in case we are disconnected, what telephone number can I reach you at to complete the interview?

Provided phone number 1 SKIP TO A2

(VOL) respondent will call back 2 SKIP TO A2

Don’t know 8 SKIP TO A2

Refused 9 SKIP TO A2

[IF SAMPLE FLAGGED AS CELL PHONE]

SC1 Are you in a safe place to talk right now?

IF DRIVING VOLUNTEERED, CODE AS 2 USE LL INTRO FOR LL CALLBACKS

Yes, safe place to talk 1

No, call me later 2 SCHEDULE CALLBACK

No, CB on land-line 3 RECORD NUMBER, SCHEDULE CALLBACK

(VOL) on landline 4 SKIP TO A1

Don’t know 8

Refused 9

[IF SAMPLE FLAGGED AS CELL PHONE]

SC2 Are you driving?

No 1

Yes, call me later 2 SCHEDULE CALLBACK

Don’t know 8

Refused 9

A1. Hello, my name is _________ and I’m calling on behalf of the U.S. Department of Agriculture, Food and Nutrition Service. May I please speak to [NAME OF PARENT]?

[INTERVIEWER NOTE: REFER TO FA Q’S TO ANSWER ANY QUESTIONS, INCLUDING CONTENT OF SURVEY]

SPEAKING TO [NAME OF PARENT] 1 GO TO A3 (in IRB version)

[NAME OF PARENT] COMES TO PHONE 2 GO TO A3 (in IRB version)

NOT A GOOD TIME 4 SCHEDULE CALLBACK

A2. We are conducting a research study about the food choices of children and their families for the U.S.D.A, Food and Nutrition Service. The study will help the government make its child nutrition programs better for school-age children. We are trying to reach the parent or adult in the household who knows most about what [CHILD NAME] ate over the last 30 days?

INTERVIEWER: IF R ANSWERS “PROBABLY” OR “AS MUCH AS ANYONE ELSE,” ENTER “1,” “YES.”

YES 1 GO TO A4.3

YES, BUT NOT AVAILABLE NOW 2 GO TO CALLBACK

NO 3

DON’T KNOW 8

REFUSED 9

A4.1 What is the name of the parent or adult who knows most about what [CHILD NAME] ate over the last 30 days?

ENTER NAME OF PARENT/ADULT:

DON’T KNOW 8

REFUSED 9

A4.2 May I speak with (him/her)?

YES 1

YES, BUT NOT AVAILABLE NOW 2 GO TO CALLBACK

CANNOT COME TO PHONE 3 GO TO CALLBACK

DON’T KNOW 8 GO TO CALLBACK

REFUSED 9 GO TO REFUSAL

[PROGRAMMER: IF A3=1, START WITH SECOND PARAGRAPH]

A4.3 [READ IF A4.2=1] Hello, my name is _________ and I’m calling on behalf of the U.S.D.A., Food and Nutrition Service. We are conducting a research study about the food choices of children and their families.

[READ TO ALL:] The interview will take approximately 25 minutes. It has questions about your child’s food choices as well as general questions about you and your household. Your answers will help the government make its child nutrition programs better for school-age children. As a way of saying thank you, we will give you a $10 gift card when we are finished.

Your participation in this interview is voluntary and you may stop at any time. Your benefits will not be affected if you choose not to participate. If you take part, you may refuse to answer any questions. If you take part, your answers won’t change any benefits you may receive from any agency.

All the information you give us will be kept confidential to the extent allowed by law. Your name will not be attached to any of your answers. Your information will be used only in combination with information from other households for research purposes.

A5. Do you have any questions before I begin?

[INTERVIEWER NOTE: REFER TO FA Q’S TO ANSWER ANY QUESTIONS]

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

A5.1 If now is a good time for you and you are willing to participate, I’d like to begin my questions.

YES, IT’S A GOOD TIME AND I’M WILLING 1 GO TO B1

YES, I’M WILLING BUT NOT AVAILABLE NOW 2 SCHEDULE CALLBACK

DON’T KNOW 8

REFUSED TO PARTICIPATE 9 GO TO REFUSAL

A6. May we call you back at another time?

YES 1 SCHEDULE CALLBACK

NO 2 GO TO REFUSAL

DON’T KNOW 8 SCHEDULE CALLBACK

REFUSED 9 GO TO REFUSAL

SECTION B: HOUSEHOLD CHARACTERISTICS

The first few questions are about the people you live with.

B1. Including yourself, how many people live in your household? Don’t forget to include non‑relatives who live here and, of course, babies and small children. Also include persons who usually live here but are temporarily away for reasons such as: vacation, traveling for work, or in the hospital. Do not include children living away at school.

_________ Number of people [RANGE 1-20]

DON’T KNOW 88

REFUSED 99

B1.1 Do all the people in your household buy and share food together?

YES 1 GO TO B2

NO 2

DON’T KNOW 88

REFUSED 99

B1.2 How many people in your household buy and share food together?

[PROGRAMMER NOTE: IF B1 NE 88/99 B1.2 CANNOT BE GREATER THAN B1]

_________ Number of people

DON’T KNOW 88

REFUSED 99

B2. How many of those (IF B1.1=1, FILL NUMBER FROM B1, OTHERWISE, FILL NUMBER FROM B1.2) people are children age 18 or younger?

[IF B1.1 AND B1.2 = 88 OR 99, READ:] How many people in your household are children age 18 or younger?

[PROGRAMMER NOTE: B2 CANNOT BE GREATER THAN B1/B1.2]

_________ Number of children [RANGE 1-20] GO TO B3

NO CHILDREN IN HOUSEHOLD 00 GO TO C1

DON’T KNOW 88

REFUSED 99

B2.1 Is there at least one child living in your household?

YES 1

NO 2 GO TO F1

DON’T KNOW 8 GO TO REFUSAL

REFUSED 9 GO TO REFUSAL

B4. First, I’d like to make a list of the first names or initials of the children, age 18 or younger. those children. What is the name of the (first/nth) child?

PROGRAMMER: CREATE GRID, USING B2 FOR NUMBER OF CHILDREN IF B2<88. IF B2=88,99 ALLOW UP TO 20.

B5. Please tell me the birth date of each child starting with [CHILD #1].

| | | / | | | / | | | | |

MONTH DAY YEAR

DON’T KNOW 8

REFUSED 9

B3. How many of these children in your household are in grades pre-K through 12 in your public school system?

[PROGRAMMER NOTE: B3 CANNOT BE GREATER THAN B5]

_________ENTER NUMBER OF CHILDREN IN PRE-K-12 (range 0-20)

DON’T KNOW 88 SKIP TO C1

REFUSED 99 SKIP TO C1

For the next set of questions, we are going to focus on the children in the household who are in grades Pre-K through 12 in your public school system.

SECTION C: CHILD DEMOGRAPHICS

For the next set of questions, we are going to focus on [CHILD NAME].

C1. Is [CHILD NAME] a boy or girl?

INTERVIEWER: ASK IF THEY HAVE NOT ALREADY MENTIONED CHILD’S SEX

BOY 1

GIRL 2

DON’T KNOW 8

REFUSED 9

C1a. Does [CHILD NAME] currently live in this household?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

[PROGRAMMER NOTE:

• IF C1a=1, GO TO C2 (FOCAL CHILD CURRENTLY IN HOUSEHOLD; ASK FULL QUESTIONNAIRE)

• IF C1a>1, AND B2<88, OR B2.1=1, GO TO F1 (FOCAL CHILD CURRENTLY NOT IN HOUSEHOLD, BUT OTHER CHILDREN ARE IN HOUSEHOLD; ASK QUESTIONS PERTAINING TO HOUSEHOLD, INCLUDING ADULT AND CHILD FOOD SECURITY)

• IF C1a>1, AND B2.1=2, GO TO F1 (FOCAL CHILD CURRENTLY NOT IN HOUSEHOLD, AND NO OTHER CHILDREN ARE IN HOUSEHOLD; ASK QUESTIONS PERTAINING TO HOUSEHOLD, EXCLUDING CHILD FOOD SECURITY)]

[ASK SECTION C IF C1a=1. OTHERWISE, GO TO F1]

C3. Is [CHILD NAME] of Hispanic or Latino origin?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

C4. I am going to read a list of five race categories. Please choose one or more races that you consider [CHILD NAME] to be. American Indian or Alaska Native; Asian; Black or African America; Native Hawaiian or other Pacific Islander; White?

MARK ALL THAT APPLY

AMERICAN INDIAN OR ALASKA NATIVE 1

ASIAN 2

BLACK OR AFRICAN AMERICAN 3

NATIVE HAWAIIAN OR

OTHER PACIFIC ISLANDER 4

WHITE 5

DON’T KNOW 8

REFUSED 9

SECTION D: DIETARY BEHAVIORS – CHILD

D1. During the last 30 days, did [CHILD NAME] usually eat breakfast each day?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

These questions are about the different kinds of foods [CHILD NAME] ate or drank during the last 30 days. First, I’m going to ask you about the types of items [CHILD NAME] usually drinks at mealtimes and between meals. When answering, please include meals and snacks eaten at home, at school, in restaurants, and anyplace else. During the last 30 days, how often did [CHILD NAME] drink…

D2. 100% pure fruit juice, such as orange, mango, apple, grape, and pineapple juice? Do not include fruit-flavored drinks with added sugar or fruit juice you made at home with added sugar. (You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: ONLY 100% PURE JUICES

DO NOT INCLUDE: FRUIT-FLAVORED DRINKS WITH ADDED SUGAR, LIKE CRANBERRY DRINK, HI-C, LEMONADE, KOOL-AID, GATORADE, TAMPICO (tam-pee-koh), AND SUNNY DELIGHT.

0__NEVER

1__ PER DAY (RANGE 1-300)

2__ PER WEEK (RANGE 1-300)

3__ PER MONTH (RANGE 1-300)

8 DON’T KNOW/NOT SURE

9 REFUSED

[IF DAY>4 OR WEEK>28 OR MONTH>120: You said (display # of times) per (display unit). Is that correct?]

1__ YES, CONTINUE

2__ NO, CORRECT NUMBER PER DAY/WEEK/MONTH

D2.1 During the last 30 days, how often did [CHILD NAME] drink sweetened fruit drinks, sports or energy drinks, such as Kool-Aid, lemonade, Hi-C, cranberry drink, Gatorade, Red Bull, or Vitamin Water? Include fruit juices you made at home with added sugar. Do not include diet drinks or artificially sweetened drinks. (You can tell me per day, per week or per month.)

0__NEVER

1__ PER DAY (RANGE 1-300)

2__ PER WEEK (RANGE 1-300)

3__ PER MONTH (RANGE 1-300)

8 DON’T KNOW/NOT SURE

9 REFUSED

[IF DAY>4 OR WEEK>28 OR MONTH>120: You said (display # of times) per (display unit). Is that correct?]

1__ YES, CONTINUE

2__ NO, CORRECT NUMBER PER DAY/WEEK/MONTH

D2.2 (During the last 30 days, how often did [CHILD NAME] drink):

Regular soda or pop that contains sugar? Do not include diet soda. (You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: MANZANITA (man-zuh-nee-tuh) AND PENAFIEL (pen-yah-fee-EL) SODAS.

DO NOT INCLUDE DIET OR SUGAR-FREE DRINKS. DO NOT INCLUDE JUICES OR TEA IN CANS.

0__NEVER

1__ PER DAY (RANGE 1-300)

2__ PER WEEK (RANGE 1-300)

3__ PER MONTH (RANGE 1-300)

8 DON’T KNOW/NOT SURE

9 REFUSED

[IF DAY>4 OR WEEK>28 OR MONTH>120: You said (display # of times) per (display unit). Is that correct?]

1__ YES, CONTINUE

2__ NO, CORRECT NUMBER PER DAY/WEEK/MONTH

D2.3 (During the last 30 days, how often did [CHILD NAME] have):

Milk (either to drink or on cereal)? Do not include soy milk or small amounts of milk in coffee or tea. (You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTION:

INCLUDE: SKIM, NO-FAT, LOW-FAT, WHOLE MILK, BUTTERMILK, AND LACTOSE-FREE MILK. ALSO INCLUDE CHOCOLATE OR OTHER FLAVORED MILKS.

DO NOT INCLUDE: CREAM.

0__NEVER SKIP TO D3

1__ PER DAY (RANGE 1-300)

2__ PER WEEK (RANGE 1-300)

3__ PER MONTH (RANGE 1-300)

8 DON’T KNOW/NOT SURE

9 REFUSED

[IF DAY>4 OR WEEK>28 OR MONTH>120: You said (display # of times) per (display unit). Is that correct?]

1__ YES, CONTINUE

2__ NO, CORRECT NUMBER PER DAY/WEEK/MONTH

D2.3.1 What type of milk did [CHILD NAME] usually have? Was it whole or regular milk, 2% fat or reduced-fat milk, 1% fat or 1/2% fat or low-fat milk, or fat-free, skim, nonfat milk? Do not include soy milk or rice milk.

INTERVIEWER INSTRUCTION:

IF RESPONDENT CANNOT PROVIDE USUAL TYPE, CODE ALL THAT APPLY.

IF RESPONDENT MENTIONS CHOCOLATE OR OTHER FLAVORED MILKS, ASK: Do you know if it is whole, 2%, 1% or nonfat milk?

WHOLE MILK 1

2% FAT MILK 2

1% OR 1/2% FAT MILK 3

FAT-FREE, SKIM, NONFAT MILK 4

DON’T KNOW 8

REFUSED 9

Now I’m going to ask you about some kinds of food [CHILD NAME] ate during the last 30 days, including mealtimes and snacks.

D3. During the last 30 days, how often did [CHILD NAME] eat hot or cold cereal? (You can tell me per day, per week or per month.)

0__NEVER SKIP TO D4

1__ PER DAY (RANGE 1-300)

2__ PER WEEK (RANGE 1-300)

3__ PER MONTH (RANGE 1-300)

8 DON’T KNOW/NOT SURE

9 REFUSED

[IF DAY>3 OR WEEK>21 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]

1__ YES, CONTINUE

2__ NO, CORRECT NUMBER PER DAY/WEEK/MONTH

D3.1 During the last 30 days, what kinds of cereal did [CHILD NAME] usually eat?

INTERVIEWER: ENTER FIRST FEW LETTERS OF CEREAL NAME TO START THE LOOK UP.

SELECT CEREAL FROM LIST. IF CEREAL NOT ON LIST, PRESS BS TO DELETE THE ENTRY AND TYPE ** TO ENTER CEREAL NAME.

OTHER, SPECIFY 777

DON’T KNOW 888

REFUSED 999

D3.2 Was there another cereal that [CHILD NAME] ate?

YES 1

NO 2 GO TO D4

DON’T KNOW 8 GO TO D4

REFUSED 9 GO TO D4

D3.3 During the last 30 days, what second kind of cereal did [CHILD NAME] usually eat?

INTERVIEWER: ENTER FIRST FEW LETTERS OF CEREAL NAME TO START THE LOOK UP.

SELECT CEREAL FROM LIST. IF CEREAL NOT ON LIST, PRESS BS TO DELETE THE ENTRY AND TYPE ** TO ENTER CEREAL NAME.

OTHER, SPECIFY 777

DON’T KNOW 888

REFUSED 999

D4. (During the last 30 days, how often did [CHILD NAME] have:)

Fruit? Include fresh, frozen or canned fruit. Do not include juices.

(You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

DO NOT INCLUDE: DRIED FRUITS.

0__NEVER

1__ PER DAY (RANGE 1-300)

2__ PER WEEK (RANGE 1-300)

3__ PER MONTH (RANGE 1-300)

8 DON’T KNOW/NOT SURE

9 REFUSED

[IF DAY>3 OR WEEK>21 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]

1__ YES, CONTINUE

2__ NO, CORRECT NUMBER PER DAY/WEEK/MONTH

D5. During the last 30 days, how often did [CHILD NAME] eat a green leafy or lettuce salad, with or without other vegetables?

(You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: SPINACH SALADS

0__NEVER

1__ PER DAY (RANGE 1-300)

2__ PER WEEK (RANGE 1-300)

3__ PER MONTH (RANGE 1-300)

8 DON’T KNOW/NOT SURE

9 REFUSED

[IF DAY>3 OR WEEK>21 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]

1__ YES, CONTINUE

2__ NO, CORRECT NUMBER PER DAY/WEEK/MONTH

D6. During the last 30 days, how often did [CHILD NAME] eat any kind of fried potatoes, including French fries, home fries, or hash brown potatoes?

(You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

DO NOT INCLUDE: POTATO CHIPS

0__NEVER

1__ PER DAY (RANGE 1-300)

2__ PER WEEK (RANGE 1-300)

3__ PER MONTH (RANGE 1-300)

8 DON’T KNOW/NOT SURE

9 REFUSED

[IF DAY>3 OR WEEK>21 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]

1__ YES, CONTINUE

2__ NO, CORRECT NUMBER PER DAY/WEEK/MONTH

D7. During the last 30 days, how often did [CHILD NAME] eat other kind of potatoes such as mashed potatoes, sweet potatoes, or potato salad?

(You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: ALL TYPES OF POTATOES EXCEPT FRIED. INCLUDE POTATOES AU GRATIN, AND SCALLOPED POTATOES.

0__NEVER

1__ PER DAY (RANGE 1-300)

2__ PER WEEK (RANGE 1-300)

3__ PER MONTH (RANGE 1-300)

8 DON’T KNOW/NOT SURE

9 REFUSED

[IF DAY>3 OR WEEK>21 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]

1__ YES, CONTINUE

2__ NO, CORRECT NUMBER PER DAY/WEEK/MONTH

D8. (During the last 30 days, how often did [CHILD NAME] eat:)

Refried beans, baked beans, beans in soup, pork and beans or any other type of cooked dried beans? Do not include green beans.

(You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: SOYBEANS, KIDNEY, PINTO, GARBANZO, BLACK BEANS, LENTILS, BLACK‑EYED PEAS, COW PEAS, AND LIMA BEANS. INCLUDE CANNED BEANS.

0__NEVER

1__ PER DAY (RANGE 1-300)

2__ PER WEEK (RANGE 1-300)

3__ PER MONTH (RANGE 1-300)

8 DON’T KNOW/NOT SURE

9 REFUSED

[IF DAY>3 OR WEEK>21 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]

1__ YES, CONTINUE

2__ NO, CORRECT NUMBER PER DAY/WEEK/MONTH

D9. (During the last 30 days, not including what you just told me about (lettuce salads, potatoes, cooked dried beans) how often did [CHILD NAME]:)

Eat other vegetables?

(You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

DO NOT INCLUDE: RICE

EXAMPLES OF OTHER VEGETABLES INCLUDE: TOMATOES, GREEN BEANS, CARROTS, CORN, CABBAGE, BEAN SPROUTS, COLLARD GREENS, AND BROCCOLI. INCLUDE ANY FORM OF THE VEGETABLE (RAW, COOKED, CANNED, OR FROZEN).

0__NEVER

1__ PER DAY (RANGE 1-300)

2__ PER WEEK (RANGE 1-300)

3__ PER MONTH (RANGE 1-300)

8 DON’T KNOW/NOT SURE

9 REFUSED

[IF DAY>3 OR WEEK>21 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]

1__ YES, CONTINUE

2__ NO, CORRECT NUMBER PER DAY/WEEK/MONTH

D10. (During the last 30 days, how often did [CHILD NAME] have:)

Mexican-type salsa made with tomato?

(You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: ALL TOMATO-BASED SALSAS.

0__NEVER

1__ PER DAY (RANGE 1-300)

2__ PER WEEK (RANGE 1-300)

3__ PER MONTH (RANGE 1-300)

8 DON’T KNOW/NOT SURE

9 REFUSED

[IF DAY>3 OR WEEK>21 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]

1__ YES, CONTINUE

2__ NO, CORRECT NUMBER PER DAY/WEEK/MONTH

D11. (During the last 30 days, how often did [CHILD NAME] eat:)

Pizza? Include frozen pizza, fast food pizza, and homemade pizza.

(You can tell me per day, per week or per month.)

0__NEVER

1__ PER DAY (RANGE 1-300)

2__ PER WEEK (RANGE 1-300)

3__ PER MONTH (RANGE 1-300)

8 DON’T KNOW/NOT SURE

9 REFUSED

[IF DAY>3 OR WEEK>21 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]

1__ YES, CONTINUE

2__ NO, CORRECT NUMBER PER DAY/WEEK/MONTH

D12. (During the last 30 days, how often did [CHILD NAME] have:)

Tomato sauce such as with spaghetti or noodles or mixed into foods such as lasagna? (Please do not count tomato sauce on pizza.)

(You can tell me per day, per week or per month.)

0__NEVER

1__ PER DAY (RANGE 1-300)

2__ PER WEEK (RANGE 1-300)

3__ PER MONTH (RANGE 1-300)

8 DON’T KNOW/NOT SURE

9 REFUSED

[IF DAY>3 OR WEEK>21 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]

1__ YES, CONTINUE

2__ NO, CORRECT NUMBER PER DAY/WEEK/MONTH

D13. (During the last 30 days, how often did [CHILD NAME] eat:)

Cheese? Include cheese as a snack, cheese on burgers, sandwiches, and cheese in foods such as lasagna, quesadillas, or casseroles.

(Please do not count cheese on pizza.)

(You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: MACARONI AND CHEESE, ENCHILADAS

DO NOT INCLUDE: CREAM CHEESE OR CHEESES MADE FROM NON-DAIRY FOODS, SUCH AS SOY OR RICE, OR CHEESE ON PIZZA.

0__NEVER

1__ PER DAY (RANGE 1-300)

2__ PER WEEK (RANGE 1-300)

3__ PER MONTH (RANGE 1-300)

8 DON’T KNOW/NOT SURE

9 REFUSED

[IF DAY>3 OR WEEK>21 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]

1__ YES, CONTINUE

2__ NO, CORRECT NUMBER PER DAY/WEEK/MONTH

D14. (During the last 30 days, how often did [CHILD NAME] eat:)

Canned tuna or other canned fish (including in salads, sandwiches or casseroles)?

(You can tell me per day, per week or per month.)

0__NEVER

1__ PER DAY (RANGE 1-300)

2__ PER WEEK (RANGE 1-300)

3__ PER MONTH (RANGE 1-300)

8 DON’T KNOW/NOT SURE

9 REFUSED

[IF DAY>3 OR WEEK>21 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]

1__ YES, CONTINUE

2__ NO, CORRECT NUMBER PER DAY/WEEK/MONTH

D15. (During the last 30 days, how often did [CHILD NAME] eat:)

Eggs? Do not include egg whites only or egg substitutes.

(You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: EGGS IN SALADS, QUICHE, AND SOUFFLÉS

DO NOT INCLUDE: EGGS IN BAKED GOODS AND DESSERTS.

0__NEVER

1__ PER DAY (RANGE 1-300)

2__ PER WEEK (RANGE 1-300)

3__ PER MONTH (RANGE 1-300)

8 DON’T KNOW/NOT SURE

9 REFUSED

[IF DAY>3 OR WEEK>21 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]

1__ YES, CONTINUE

2__ NO, CORRECT NUMBER PER DAY/WEEK/MONTH

D16. (During the last 30 days, how often did [CHILD NAME] have:)

Peanut butter?

(You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: PEANUT BUTTER ON BREAD, CRACKERS, FRUIT, OR VEGETABLES.

DO NOT INCLUDE: PEANUT BUTTER IN BAKED GOODS

0__NEVER

1__ PER DAY (RANGE 1-300)

2__ PER WEEK (RANGE 1-300)

3__ PER MONTH (RANGE 1-300)

8 DON’T KNOW/NOT SURE

9 REFUSED

[IF DAY>3 OR WEEK>21 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]

1__ YES, CONTINUE

2__ NO, CORRECT NUMBER PER DAY/WEEK/MONTH

D17. (During the last 30 days, how often did [CHILD NAME] eat:)

Whole grain bread (and tortillas) including toast, rolls and in sandwiches? Whole grain breads include whole wheat, rye, oatmeal and pumpernickel. Do not include white bread.

(You can tell me per day, per week or per month.)

0__NEVER

1__ PER DAY (RANGE 1-300)

2__ PER WEEK (RANGE 1-300)

3__ PER MONTH (RANGE 1-300)

8 DON’T KNOW/NOT SURE

9 REFUSED

[IF DAY>3 OR WEEK>21 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]

1__ YES, CONTINUE

2__ NO, CORRECT NUMBER PER DAY/WEEK/MONTH

D18. (During the last 30 days, how often did [CHILD NAME] eat:)

Cookies, cake, pie, doughnuts, or brownies? Do not include sugar-free kinds.

(You can tell me per day, per week or per month.)

INTERVIEWER INSTRUCTIONS:

INCLUDE: LOW-FAT KINDS, TWINKIES AND HOSTESS CUPCAKES

DO NOT INCLUDE: ICE CREAM AND OTHER FROZEN DESSERTS OR CANDY

0__NEVER

1__ PER DAY (RANGE 1-300)

2__ PER WEEK (RANGE 1-300)

3__ PER MONTH (RANGE 1-300)

8 DON’T KNOW/NOT SURE

9 REFUSED

[IF DAY>3 OR WEEK>21 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]

1__ YES, CONTINUE

2__ NO, CORRECT NUMBER PER DAY/WEEK/MONTH

D19. How confident are you, that the food and drinks you just told me about included all the food and drinks [CHILD NAME] had at school, home, or other places? Would you say very confident, somewhat confident, not too confident, or not at all confident?

VERY CONFIDENT 1

SOMEWHAT CONFIDENT 2

NOT TOO CONFIDENT 3

NOT AT ALL CONFIDENT 4

DON’T KNOW 8

REFUSED 9

SECTION E: PROGRAM PARTICIPATION – CHILD

E1. During the last 30 days, did [CHILD NAME] get free or reduced price breakfasts at school?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

E2. During the last 30 days, did [CHILD NAME] get free or reduced price lunches at school?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

E3. During the last 30 days, did [CHILD NAME] get food through a backpack food program for children?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

E4. During the last 30 days, did [CHILD NAME] participate in an after school meal or snack program for children?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

[ASK F1-F8a FOR ALL RESPONDENTS]

SECTION F: FOOD SECURITY – HOUSEHOLD

[PROGRAMMER NOTE: SELECT APPROPRIATE FILLS DEPENDING ON NUMBER OF ADULTS AND CHILDREN IN THE HOUSEHOLD. IF DK/REF ON B1.1 AND B1.2, PROGRAM AS IF MULTIPLE ADULTS AND CHILDREN]

MULTIPLE ADULTS: ( B1>B2) OR (B1>2 AND B2.1>1) OR (B2.1=8,9)

SINGLE ADULT: B1=1

MULTIPLE CHILDREN: B2>1, OR B2.1=1,8,9

SINGLE CHILD: B2=1, OR B2.1=2

The next questions are about the food eaten in your household in the last 30 days and whether you were able to afford the food you need.

F1. Now I’m going to read you several statements that people have made about their food situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for your household in the last 30 days.

The first statement is “We worried whether our food would run out before we got money to buy more.” Was that often true, sometimes true, or never true for your household in the last 30 days?

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW 8

REFUSED 9

F2. “The food that we bought just didn’t last, and we didn’t have money to get more.” Was that often, sometimes, or never true for your household in the last 30 days?

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW 8

REFUSED 9

F3. “We couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for your household in the last 30 days?

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW 8

REFUSED 9

PROGRAMMER: IF AFFIRMATIVE RESPONSE (I.E., “OFTEN TRUE” OR “SOMETIMES TRUE”) TO ONE OR MORE OF QUESTIONS F1-F3, THEN CONTINUE TO F4; OTHERWISE, SKIP TO F9.

F4. In the last 30 days, did [you/you or other adults in your household] ever cut the size of your meals or skip meals because there wasn't enough money for food?

YES 1

NO 2 SKIP TO F5

DON’T KNOW 8 SKIP TO F5

REFUSED 9 SKIP TO F5

[ASK IF F4=1]

F4a. In the last 30 days, how many days did this happen?

_________ Number of days [RANGE 1-30]

DON’T KNOW 88

REFUSED 99

F5. In the last 30 days, did you ever eat less than you felt you should because there wasn't enough money for food?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

F6. In the last 30 days, were you ever hungry but didn’t eat because there wasn’t enough money for food?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

F7. In the last 30 days, did you lose weight because there wasn’t enough money for food?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

PROGRAMMER: IF AFFIRMATIVE RESPONSE TO ONE OR MORE OF QUESTIONS F4‑F7, THEN CONTINUE TO F8. OTHERWISE, SKIP TO F9.

F8. In the last 30 days, did [you/you or other adults in your household] ever not eat for a whole day because there wasn't enough money for food?

YES 1

NO 2 SKIP TO F9

DON’T KNOW 8 SKIP TO F9

REFUSED 9 SKIP TO F9

[ASK IF F8=1]

F8a. In the last 30 days, how many days did this happen?

_________ Number of days [RANGE 1-30]

DON’T KNOW 88

REFUSED 99

SELECT APPROPRIATE FILLS DEPENDING ON NUMBER OF ADULTS AND NUMBER OF CHILDREN IN THE HOUSEHOLD.

[ASK F9-F15 IF C1a=1 OR (C1a >1 AND (B2<88 OR B2.1=1)). ELSE SKIP TO G1 ]

F9. Now I’m going to read you several statements that people have made about the food situation of their children. For these statements, please tell me whether the statement was often true, sometimes true, or never true in the last 30 days for [your child/children living in the household who are under 18 years old or 18 or older but still in high school].

“[I/We] relied on only a few kinds of low-cost food to feed [my/our] [child/ children] because [I was/we were] running out of money to buy food.” Was that often, sometimes, or never true for your household in the last 30 days?

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW 8

REFUSED 9

F10. “[I/We] couldn’t feed [my/our] child/children] a balanced meal, because [I/we] couldn’t afford that.” Was that often, sometimes, or never true for your household in the last 30 days?

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW 8

REFUSED 9

F11. “[My child was /Our child was/The children were] not eating enough because [I/we] just couldn’t afford enough food.” Was that often, sometimes, or never true for your household in the last 30 days?

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW 8

REFUSED 9

PROGRAMMER: IF AFFIRMATIVE RESPONSE (I.E., “OFTEN TRUE” OR “SOMETIMES TRUE”) TO ONE OR MORE OF QUESTIONS F9-F11, THEN CONTINUE TO F12. OTHERWISE, SKIP TO G1.

F12. In the last 30 days, did you ever cut the size of [your child’s/any of the children’s] meals because there wasn’t enough money for food?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

F13. In the last 30 days, did [your child/any of the children] ever skip meals because there wasn’t enough money for food?

YES 1

NO 2 SKIP TO F14

DON’T KNOW 8 SKIP TO F14

REFUSED 9 SKIP TO F14

[ASK IF F13=1]

F13a. In the last 30 days, how many days did this happen?

_________ Number of days [RANGE 1-30]

DON’T KNOW 88

REFUSED 99

F14. In the last 30 days, [was your child/were the children] ever hungry but you just couldn’t afford more food?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

F15. In the last 30 days, did [your child/any of the children] ever not eat for a whole day because there wasn't enough money for food?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

[ASK ALL]

SECTION G: SHOPPING AND EATING BEHAVIOR – HOUSEHOLD

Now, I’d like to ask some questions about shopping for food and eating at restaurants.

G1. First I’ll ask you about money spent at supermarkets or grocery stores. Then we will talk about money spent at other types of stores.

During the last 30 days, how much money [did your family/did you] spend at supermarkets or grocery stores? Please include purchases made with SNAP benefits or food stamps. (You can tell me per week or per month.)

INTERVIEWER: RECORD “0” IF NO MONEY WAS SPENT

0__NO MONEY SPENT GO TO G4

1__ PER WEEK [RANGE $1-$9,999]

2__ PER MONTH [RANGE $1-$9,999]

8 DON’T KNOW/NOT SURE GO TO G4

9 REFUSED GO TO G4

G2. Was any of this money spent on nonfood items such as cleaning or paper products, pet food, cigarettes or alcoholic beverages?

YES 1

NO 2 GO TO G4

DON’T KNOW 8 GO TO G4

REFUSED 9 GO TO G4

G3. About how much money was spent on nonfood items? (You can tell me per week or per month.)

PROGRAMMER: AMOUNT CANNOT BE MORE THAN THE AMOUNT ENTERED ON QUESTION G1.

INTERVIEWER: RECORD “0” IF NO MONEY WAS SPENT

0__NO MONEY SPENT

1__ PER WEEK [RANGE $1-$9,999]

2__ PER MONTH [RANGE $1-$9,999]

8 DON’T KNOW/NOT SURE GO TO G4

9 REFUSED GO TO G4

G4. During the last 30 days, [did your family/did you] spend money on food at stores other than grocery stores? These other stores could include convenience stores like 7-11 or Mini Mart, wholesale stores like Costco or Sam’s Club, stores like Wal-Mart, Kmart, dollar stores, bakeries, meat markets, vegetable stands, or farmer’s markets. Please do not include stores that you have already told me about. Please include purchases made with SNAP benefits or food stamps.

YES 1

NO 2 GO TO G6

DON’T KNOW 8 GO TO G6

REFUSED 9 GO TO G6

G5. About how much money [did your family/did you] spend on food at these types of stores during the last 30 days? Please include purchases made with SNAP benefits or food stamps. (Please do not include any stores you have already told me about.) (You can tell me per week or per month.)

INTERVIEWER: RECORD “0” IF NO MONEY WAS SPENT

0__NO MONEY SPENT

1__ PER WEEK [RANGE $1-$9,999]

2__ PER MONTH [RANGE $1-$9,999]

8 DON’T KNOW/NOT SURE

9 REFUSED

G6. During the last 30 days, how many times did your family eat food from a fast food restaurant? Include fast food meals at home, or at fast food restaurants, carryout, or drive thru. (You can tell me per week or per month.)

IF NEEDED, SAY: “Such as food you get at McDonald’s, KFC, Panda Express, or Taco Bell.”

0__NEVER

1__ PER WEEK [RANGE 1-99]

2__ PER MONTH [RANGE 1-99]

8 DON’T KNOW/NOT SURE

9 REFUSED

G7. During the last 30 days, how many times did your family usually eat food at other kinds of restaurants? (You can tell me per week or per month.)

IF NEEDED, SAY: “Such as food you get at Applebee’s, Chili’s, TGI Fridays, etc.”

0__NEVER

1__ PER WEEK [RANGE 1-99]

2__ PER MONTH [RANGE 1-99]

8 DON’T KNOW/NOT SURE

9 REFUSED

[PROGRAMMER: IF G6 AND G7=0, GO TO H1]

G8. About how much money [did your family/did you] spend on food at all types of restaurants including fast food restaurants during the last 30 days? (You can tell me per week or per month.)

0__NO MONEY SPENT

1__ PER WEEK [RANGE $1-$9,999]

2__ PER MONTH [RANGE $1-$9,999]

8 DON’T KNOW/NOT SURE

9 REFUSED

SECTION H: PROGRAM PARTICIPATION – HOUSEHOLD

H1. Next, I’m going to read the names of some programs that provide food or meals to individuals or households.

H1.1 In the last 30 days did you or anyone in your household receive food or benefits from the Women, Infants and Children program called WIC?

YES 1

NO 2 GO TO H1.3

DON’T KNOW 8 GO TO H1.3

REFUSED 9 GO TO H1.3

H1.2a How many women or children in the household got WIC foods?

_________ Number of women or children [RANGE 1-20]

DON’T KNOW 88 GO TO H1.3

REFUSED 99 GO TO H1.3

H1.2b (Is that person who got WIC foods an infant less than 1 year old?/How many of those [NUMBER FROM H1.2a] people who got WIC foods are infants less than 1 year old?)

_________ Number of infants [RANGE 0-20]

DON’T KNOW 88

REFUSED 99

H1.3 In the last 30 days did you or anyone in your household receive food from food pantries or food banks?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

H1.4 In the last 30 days did you or anyone in your household receive meals at local soup kitchens or emergency kitchens?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

H2. Are you [IF MULTIPLE PEOPLE IN HOUSEHOLD: or others in your household] receiving [IF CT, OR, OR TX, FILL WITH “SNAP benefits (formerly known as food stamps”; IF MO, FILL WITH: “Food Stamp Program benefits”; IF MI, FILL WITH: “Food Assistance Program benefits”] (formerly known as food stamps) now?

YES 1

NO 2 GO TO H6

DON’T KNOW 8 GO TO H6

REFUSED 9 GO TO H6

H3. How long have you (and your household) been receiving [IF CT, OR, OR TX, FILL WITH “SNAP benefits (formerly known as food stamps”; IF MO, FILL WITH: “Food Stamp Program benefits”; IF MI, FILL WITH: “Food Assistance Program benefits”] (food stamps)?

RANGE 1 -

1__ DAYS [RANGE 1-365]

2__ WEEKS [RANGE 1-52]

3__ MONTHS [RANGE 1-12]

4__YEARS [RANGE 1-50]

888 DON’T KNOW/NOT SURE

999 REFUSED

H4. What is the amount of the [IF CT, OR, OR TX, FILL WITH “SNAP benefits (formerly known as food stamps”; IF MO, FILL WITH: “Food Stamp Program benefits”; IF MI, FILL WITH: “Food Assistance Program benefits”] you receive per month?

_________ Enter amount [$1 - $9999]

DON’T KNOW 8

REFUSED 9

H5. How many weeks do your [IF CT, OR, OR TX, FILL WITH “SNAP benefits (formerly known as food stamps”; IF MO, FILL WITH: “Food Stamp Program benefits”; IF MI, FILL WITH: “Food Assistance Program benefits”] usually last?

[INTERVIEWER NOTE: Code any answer greater than 8 weeks as 8]

_________ Enter number of weeks (range 0-8) GO TO I1

DON’T KNOW 88 GO TO I1

REFUSED 99 GO TO I1

H6. Do you (or others in your household) currently receive monthly Native American Food Commodities as part of the Food Distribution Program on Indian Reservations (FDPIR)?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

SECTION I: CAREGIVER DEMOGRAPHICS

I1. Now, I have a few questions about you.

I2. What is your relationship to [CHILD NAME]?

READ ONLY IF NECESSARY: Are you [CHILD NAME’s]…

BIOLOGICAL/ADOPTIVE MOTHER 1

BIOLOGICAL/ADOPTIVE FATHER 2

STEPMOTHER 3

STEPFATHER 4

GRANDMOTHER 5

GRANDFATHER 6

GREAT GRANDMOTHER 7

GREAT GRANDFATHER 8

SISTER/STEPSISTER 9

BROTHER/STEPBROTHER 10

OTHER RELATIVE OR IN‑LAW (FEMALE) 11

OTHER RELATIVE OR IN‑LAW (MALE) 12

FOSTER PARENT (FEMALE) 13

FOSTER PARENT (MALE) 14

OTHER NON-RELATIVE (FEMALE) 15

OTHER NON-RELATIVE (MALE) 16

PARENT’S PARTNER (FEMALE) 17

PARENT’S PARTNER (MALE) 18

DON’T KNOW 88

REFUSED 99

I3. Are you of Hispanic or Latino origin?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

I4. I am going to read a list of five race categories. Please choose one or more races that you consider yourself to be. American Indian or Alaska Native; Asian; Black or African American; Native Hawaiian or other Pacific Islander; White?

MARK ALL THAT APPLY

AMERICAN INDIAN OR ALASKA NATIVE 1

ASIAN 2

BLACK OR AFRICAN AMERICAN 3

NATIVE HAWAIIAN OR

OTHER PACIFIC ISLANDER 4

WHITE 5

DON’T KNOW 8

REFUSED 9

I5 . What is your current marital status? Are you now married, divorced, separated, widowed,

never married, or living with a partner?

MARRIED 1

SEPARATED OR DIVORCED 2

WIDOWED 3

NEVER MARRIED 4

LIVING WITH PARTNER 5

DON’T KNOW 8

REFUSED 9

I6. Please tell me your birth date.

| | | / | | | / | | | | |

MONTH DAY YEAR

DON’T KNOW 8

REFUSED 9

I6.1 What is the highest grade or level of school you have completed or the highest degree you have received? ENTER HIGHEST LEVEL OF SCHOOL.

NEVER ATTENDED/KINDERGARTEN ONLY 0

1ST GRADE 1

2ND GRADE 2

3RD GRADE 3

4TH GRADE 4

5TH GRADE 5

6TH GRADE 6

7TH GRADE 7

8TH GRADE 8

9TH GRADE 9

10TH GRADE 10

11TH GRADE 11

12TH GRADE, NO DIPLOMA 12

HIGH SCHOOL GRADUATE 13

GED OR EQUIVALENT 14

SOME COLLEGE, NO DEGREE 15

ASSOCIATE DEGREE: OCCUPATIONAL,

TECHNICAL, OR VOCATIONAL PROGRAM 16

ASSOCIATE DEGREE: ACADEMIC PROGRAM 17

BACHELOR’S DEGREE (EXAMPLE: BA, AB,

BS, BBA) 18

MASTER’S DEGREE (EXAMPLE: MA, MS, MEng,

MEd, MBA) 19

PROFESSIONAL SCHOOL DEGREE

(EXAMPLE: MD, DDS, DVM, JD) 20

DOCTORAL DEGREE (EXAMPLE: PhD, EdD) 21

DON’T KNOW 88

REFUSED 99

I7. The next questions are about your current job or business. Were you working in the last 30 days?

YES 1 GO TO I9

NO 2

DON’T KNOW 8

REFUSED 9

I8. Was any other adult in the household working in the last 30 days?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

I9. Please tell me if you have access to a working refrigerator?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

I10. And now, my final questions. What was your household’s total income last month before taxes? Please include all types of income received by all household members last month, including all earnings, Social Security, pensions, child support, and cash welfare benefits such as TANF and SSI. Do not include the value of SNAP benefits or food stamps, WIC, Medicaid, or public housing.

NO INCOME 0 GO TO I12

GAVE ANSWER 1 [RANGE $1 – 99,999] GO TO I12

DON’T KNOW 8

REFUSED 9

I11. Please stop me when I reach your household’s total income for last month. Was it…

Less than $500, 1

$500 to $999, 2

$1,000 to $1,499, 3

$1,500 to $1,999, 4

$2,000 to $2,499, 5

$2,500 to $2,999, 6

$3,000 or more? 7

DON’T KNOW 8

REFUSED 9

I12. And, what was your household’s total income last year before taxes? Please include all types of income received by all household members last year, including all earnings, Social Security, pensions, child support, and cash welfare benefits such as TANF and SSI. Do not include the value of SNAP benefits or food stamps, WIC, Medicaid, or public housing.

NO INCOME 0 GO TO I14

GAVE ANSWER 1 [RANGE $1 – 999,999] GO TO I14

DON’T KNOW 8

REFUSED 9

I13. Please stop me when I reach your household’s total income for last year. Was it…

Less than $10,000, 1

$10,000 to $19,999, 2

$20,000 to $34,999, 3

$35,000 to $49,999, 4

$50,000 to $74,999, 5

$75,000 to $99,999, 6

$100,000 to $149,999 or, 7

$150,000 or more? 8

DON’T KNOW 88

REFUSED 99

I14. Has a doctor or other health care professional ever told you or anyone in your household that they had a disability? By disability, I mean a physical or mental impairment.

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

SECTION J: ADDITIONAL CONTACT INFORMATION

J1. (PHONE VERSION) Thank you very much for your time. You have helped us greatly with this important study. We will send you a $10 gift card within the next few weeks and I’d like to confirm your mailing address. According to our records we have…

[IF A3=1, FILL NAME FROM FILE. ELSE, FILL FROM A4.1]

[FILL STREET ADDRESS FROM SAMPLE FRAME]

[FILL CITY, STATE, ZIP CODE FROM SAMPLE FRAME]

NAME AND ADDRESS IS CORRECT 1 GO TO J2

NAME AND ADDRESS NEEDS UPDATING 0

UPDATE: NAME

UPDATE: STREET ADDRESS:

CITY:

STATE:

ZIP CODE:

J1. (FIELD VERSION) Thank you very much for your time. You have helped us greatly with this important study. The field interviewer will give you your $10 gift card.

J2. We would also like to conduct a follow up interview in a couple of months to see how you[ are doing during the summer. If you participate in this follow up survey, you will receive another $10 gift card for participating in that interview.

In case we can’t reach you at this number, would you please tell me another phone number and email address?

PHONE NUMBER: | | | | - | | | | - | | | | |

NO ADDITIONAL PHONE AVAILABLE 1

EMAIL ADDRESS:

NO EMAIL ADDRESS AVAILABLE 2

REFUSED TO PARTICIPATE IN FOLLOW-UP

INTERVIEW 9 GO TO J6

[ASK J2.A IF RESPONDENT PROVIDES PHONE IN J2, OTHERWISE SKIP TO J2.1]

J2.a. What type of phone number is this?

HOME 1

CELL 2

WORK 3

OTHER, SPECIFY 4

DON’T KNOW 8

REFUSED 9

J2.1. Will [CHILD NAME] be staying with you for most of the summer?

YES 1 GO TO J3

NO 2

DON’T KNOW 8 GO TO J3

REFUSED 9 GO TO J3

J2.2 . Will [CHILD NAME] be staying at someone else’s home, staying in different homes, or staying some place else for most of the summer?

SOMEONE ELSE’S HOME 1

DIFFERENT HOMES 2 GO TO J3

SOME PLACE ELSE (SPECIFY:) 3 GO TO J3

DON’T KNOW 8 GO TO J3

REFUSED 9 GO TO J3

J2.3. Please give me the name and telephone number of the person [CHILD NAME] will be staying with for most of the summer.

INTERVIEWER: BE SURE TO VERIFY SPELLING.

ENTER FIRST NAME:

DON’T KNOW 8

REFUSED 9

J2.4. What is [J2.3 FIRST NAME] [J2.3 LAST NAME]’s telephone number, beginning with the area code?

| | | | - | | | | - | | | | |

EXTENSION: | | | | |

DON’T KNOW 8

REFUSED 9

J2.5. And what is [J2.3 FIRST NAME] [J2.3 LAST NAME]’s relationship to you?

RELATIONSHIP:

DON’T KNOW 8

REFUSED 9

J3. In case we have trouble reaching you (or [J2.3 FIRST NAME] [J2.3 LAST NAME]) in a couple of months, please give me the names and telephone numbers of three relatives or friends who would know where you could be reached.(Please give me the names of persons not currently living in the household.

INTERVIEWER: BE SURE TO VERIFY SPELLING.

REFERRING TO PERSON (1, 2 OR 3)

ENTER FIRST NAME:

DON’T KNOW 8

REFUSED 9

ENTER LAST NAME:

DON’T KNOW 8

REFUSED 9

REFERRING TO PERSON (1, 2 OR 3)

J4. What is this person’s telephone number, beginning with the area code?

| | | | - | | | | - | | | | |

EXTENSION: | | | | |

DON’T KNOW 8

REFUSED 9

REFERRING TO PERSON (1, 2 OR 3)

J5. And what is [NAME FROM ABOVE]’s relationship to you?

RELATIONSHIP:

DON’T KNOW 8

REFUSED 9

SECTION K: RELEASE OF RECORDS

K1. We would like your permission to let [Name Department] give us your records on how you used your Summer EBT card.  We are asking them for the period June through September of this year. We also would like to have the [Name Department] tell us whether you have participated in the SNAP or WIC program in the past year.

 

[For sites with passive consent] Finally, we would also like your permission to have the [name of school district] provide us with information from your child/children's National School Lunch application as well as some administrative information from your child's school records. This data will include items such as age, grade level and other administrative information. It will not include academic or disciplinary information.

 

Your records will only be used for this study.  They will be kept confidential to the extent provided by law. Any datasets resulting from this study will not identify you or your child. Releasing your records is completely voluntary, and you may refuse. Your decision won’t change any benefits you may get from any agency.  Would you be willing to release these records?

 

YES 1 GO TO K2

NO 2 GO TO END

 

K2 There is minimal risk to participating in this study. The main risk is a breach of confidentiality, but procedures are in place to protect your information. Finally, if you have any questions about this study or your rights as a participant, I can give you a telephone number to call. This completes the survey!