SNAP Households

AG-3198-D-10-0051 Mathematica Policy Research

APPENDIX A

telephone survey – english

This page has been left blank for double-sided copying.

M PR Reference No.: 6801.400

SNAP Food Security
Telephone Survey

Final Questionnaire

March 8, 2011

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  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: PRA (0584-NEW).  Do not return the completed form to this address.

H ello screen

Hello, may I speak to SAMPLE MEMBER?

SAMPLE MEMBER COMES TO PHONE 1 GO TO INTRO1

SAMPLE MEMBER UNAVAILABLE/BAD TIME 2 SCHEDULE CALL BACK

NO ONE ANSWERS 3 GO TO NO ANSWER

SCREEN

NO SUCH PERSON AT THIS NUMBER 4 GO TO LOCATING

SCREEN

INTRO1 Hello, my name is ______________ and I’m calling from Mathematica Policy Research. As you may recall from the letter we recently mailed you, we are conducting a survey on behalf of the U.S. Department of Agriculture that funds the Supplemental Nutrition and Assistance Program, or [STATE SNAP NAME], which is also known as food stamps, to learn more about families and their food needs. The interview will take about 25-30 minutes, and your cooperation is completely voluntary. Your participation in the survey will not affect any government assistance you are receiving now or in the future. All answers you give will be confidential and no individual results will be presented. As a token of appreciation, we will be sending you a $20 gift card after the interview is complete.

PROCEED WITH INTERVIEW 1

BAD TIME/CALL BACK 2 SCHEDULE CALL BACK

DID NOT RECEIVE LETTER 3 GO TO LETTER SCREEN

SCRN1a. Based on the information we have, you were most recently approved for [STATE SNAP NAME] benefits (NEW: in MONTH, YEAR / CURRENT: around 6 months ago). Is that correct?

PROBE: This program used to be called food stamps. It puts money on an [EBT/STATE NAME] card that you can use to buy food.

YES 1 GO TO A1

NO 0

DON’T KNOW d GO TO Sup Review

REFUSED r GO TO Sup Review

SCRN1b. Are you…

Currently participating in [STATE SNAP NAME]

but have (been for some time/recently started), 1 GO TO END

Not currently participating in

[STATE SNAP NAME] and have not applied, or 2 GO TO END

Have you recently applied? 3

DON’T KNOW d GO TO END

REFUSED r GO TO END

SCRN1c. What was the outcome of that application?

APPLICATION IS STILL PENDING 1

APPLICATION WAS DENIED 2

DON’T KNOW d

REFUSED r

END Those are all the questions I have. This survey is for people who (just recently were approved to participate in [STATE SNAP NAME]/have been participating in [STATE SNAP NAME] for about 6 months). Thank you for your time. Good‑bye. CODE AS INELIGIBLE

A1. Are you the person who does most of the planning or preparing of meals in your family?

INTERVIEWER: IF R ANSWERS “SOMETIMES” OR “50/50,” ENTER YES.

YES 1 GO TO A2

NO 0

DON’T KNOW d GO TO A2

REFUSED r GO TO A2

A1a. Who does most of the planning or preparing of meals?

(STRING (NUM))

FIRST NAME

(STRING (NUM))

LAST NAME

DON’T KNOW d

REFUSED r

A2. Are you the person who does most of the shopping for food in your family?

YES 1 GO TO A3

NO 0

DON’T KNOW d GO TO A3

REFUSED r GO TO A3

A2a. Who does most of the shopping for food?

(STRING (NUM))

FIRST NAME

(STRING (NUM))

LAST NAME

DON’T KNOW d

REFUSED r

A3. CHECK:

IS RESPONDENT THE MEAL PLANNER OR FOOD SHOPPER?

YES 1 GO TO B1

NO 0 GO TO A3a

IF NEITHER FOOD SHOPPER NOR MEAL PLANNER IS AVAILABLE, SCHEDULE CALL BACK.

A3a. Can I please speak to [FILL NAME COLLECTED AT A2a]?

COMES TO PHONE 1 GO TO INTRO2

FOOD SHOPPER UNAVAILABLE 2

BAD TIME/CALL BACK 3 SCHEDULE

CALL BACK

A4a. Can I please speak to [FILL NAME COLLECTED AT A1a]?

COMES TO PHONE 1 GO TO INTRO2

MEAL PLANNER UNAVAILABLE 2 SCHEDULE

CALL BACK

BAD TIME/CALL BACK 3 SCHEDULE

CALL BACK

INTRO2 Hello, my name is __________ and I’m calling from Mathematica Policy Research. We are conducting a survey on behalf of the U.S. Department of Agriculture that funds the Supplemental Nutrition and Assistance Program, or [STATE SNAP NAME], which is also known as food stamps, to learn more about families and their food needs. The interview will take about 25-30 minutes, and your cooperation is completely voluntary. Your participation in the survey will not affect any government assistance you are receiving now or in the future. All answers you give will be confidential and no individual results will be presented. As a token of appreciation, we will be sending you a $20 gift card after the interview is complete.

PROCEED WITH INTERVIEW 1 GO TO B1

BAD TIME/CALL BACK 2 SCHEDULE

CALL BACK

T he first few questions are about the people you live with.

B1. Please tell me the first name of everyone who lives in your household. By household, I mean the people who live with you and share food with you. Please include babies, small children, and people who are not related to you.

RESPONDENT LIVES ALONE 0 GO TO B4

ENTER NAMES 1

(ALLOW UP TO 10 NAMES)

B2. And what is [NAME 1]’s relationship to you?

INTERVIEWER: CODE COHABITEE’S CHILD AND OTHER CHILDREN WHO ARE NOT NATURAL, ADOPTED OR STEP, BUT FOR WHOM THE SAMPLE MEMBER TAKES RESPONSIBILITY, AS “OTHER CUSTODIAL CHILD.”

HUSBAND OR WIFE 1

UNMARRIED PARTNER 2

SON OR DAUGHTER (INCLUDING

BIOLOGICAL, STEP, OR ADOPTED CHILD) 3

OTHER CUSTODIAL OR FOSTER CHILD 4

PARENT (MOTHER, FATHER,

INCLUDING STEPPARENTS AND IN-LAWS) 5

SIBLING (BROTHER OR SISTER

INCLUDING IN-LAWS) 6

GRANDCHILD 7

OTHER RELATIVE 8

NON-RELATIVE (INCLUDING

ROOMER OR BOARDER) 9

OTHER SPECIFY 10

________________________________(STRING (NUM))

DON’T KNOW d

REFUSED r

B3. What is [NAME 1]’s age?

| | |

YEARS 1

MONTHS 2

ASK B2 AND B3 FOR ALL HOUSEHOLD MEMBERS RECORDED IN B1.

B4. (Do you/Does anyone in your household) have a physical, mental, or other health condition that limits the kind or amount of work that (you/anyone in the household) can do?

YES 1

NO 0

DON’T KNOW d

REFUSED r

The next few questions are about changes that may have occurred in your household in the past 6 months.

C1. Has there been a change in the number of people living in your household over the past 6 months?

YES 1

NO 0 GO TO C2

DON’T KNOW d GO TO C2

REFUSED r GO TO C2

C1a. What caused that change?

CODE ALL THAT APPLY

BIRTH OF CHILD 1

NEW STEP, FOSTER OR ADOPTED CHILD 2

MARRIAGE/NEW PARTNER 3

SEPARATION OR DIVORCE 4

DEATH OF HOUSEHOLD MEMBER 5

FAMILY/BOARDER MOVING IN 6

FAMILY/BOARDER MOVING OUT 7

OTHER (SPECIFY) 8

________________________________(STRING (NUM))

DON’T KNOW d

REFUSED r

C2. At any time in the past 6 months (were you/was your household) evicted from your house or apartment?

YES 1

NO 0

DON’T KNOW d

REFUSED r

C3. Have you (or anyone in your household) had a change in employment or a change in pay or hours worked from a job in the past 6 months?

YES 1

NO 0 GO TO D1

DON’T KNOW d GO TO D1

REFUSED r GO TO D1

IF PARTICIPANT LIVES ALONE, GO TO C3b

C3a. Who in your household had a change in employment or a change in pay or hours worked from a job in the past 6 months?

[LIST ALL MEMBERS OF HOUSEHOLD AGE 15 AND OVER FROM B1]

CODE ALL THAT APPLY

RESPONDENT 1

NAME 1 2

NAME 2 3

NAME 3 4

NAME 4 5

C3b. What was that change in employment or a change in pay or hours worked from a job that (you/[NAME]) experienced in the past 6 months?

CODE ALL THAT APPLY

OBTAINED A JOB 1

LOST JOB 2

INCREASE IN PAY OR HOURS 3

DECREASE IN PAY OR HOURS 4

OTHER (SPECIFY) 5

________________________________(STRING (NUM))

DON’T KNOW d

REFUSED r

[REPEAT FOR EACH PERSON RECORDED IN C3a]

D1. Next, we’re going to ask you about your participation in SNAP.

D1a. [IF CURRENT PARTICIPANT, GO TO D1b. IF NEW PARTICIPANT, ASK:] Have you already received your SNAP benefits? That is, has money been put on your [EBT/STATE NAME] card?

YES 1

NO 0 GO TO D6

DON’T KNOW d GO TO D6

REFUSED r GO TO D6

D1b. (And on what / On what) date did (you/your household) receive your most recent SNAP benefits? That is, when was money most recently put on your [EBT/STATE NAME] card?

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

MONTH DAY YEAR

DON’T KNOW d

REFUSED r

D2. How many dollars were put on your (household’s) [EBT/STATE NAME] card this most recent time?

$ | | | | AMOUNT ISSUED ON EBT CARD

DON’T KNOW d GO TO D5

REFUSED r GO TO D5

D3. How much of the [FILL AMOUNT IN D2] that you most recently received have you used so far?

$ | | | | AMOUNT SPENT SO FAR GO TO D5

DON’T KNOW d

REFUSED r

$ | | | | BALANCE REMAINING GO TO D5

D4. Would you say as of now you have used…

CODE ONE ONLY

Less than half, 1

About half, 2

Or more than half of your monthly

SNAP benefits? 3

DON’T KNOW d

REFUSED r

IF NEW PARTICIPANT, GO TO D6. IF CURRENT PARTICIPANT, ASK:

D5. How many weeks do your SNAP benefits usually last? Do they last…

CODE ONE ONLY

1 week or less, 1

2 weeks, 2

3 weeks, 3

4 weeks, or 4

more than 4 weeks? 5

DON’T KNOW d

REFUSED r

D6. Before (you/your household) began receiving SNAP benefits this most recent time, that is in (NEW: MONTH, YEAR / CURRENT: MONTH, YEAR), had you (or anyone in your household) ever participated in SNAP before?

PROBE: This program used to be called food stamps.

PROBE: IF RESPONDENT MENTIONS RECEIVING SNAP AS A CHILD, SAY: Since turning 18.

YES 1

NO 0 GO TO E1

DON’T KNOW d GO TO E1

REFUSED r GO TO E1

IF CURRENT PARTICIPANT GO TO D9; IF NEW ENTRANT, ASK D7, D8 AND D9

D7. Were you (or anyone in your household) receiving SNAP benefits 3 months ago, that is, in [FILL MONTH AND YEAR]?

YES 1

NO 0

DON’T KNOW d

REFUSED r

D8. Were you (or anyone in your household) receiving SNAP benefits 6 months ago, that is, in [FILL MONTH AND YEAR]?

YES 1

NO 0

DON’T KNOW d

REFUSED r

D9. Were you (or anyone in your household) receiving SNAP benefits a year ago, that is, in [FILL MONTH AND YEAR]?

YES 1

NO 0

DON’T KNOW d

REFUSED r

E1. Where do you buy most of your groceries?

INTERVIEWER: RECORD NAME OF STORE

____________________________________________________

[ ___ ] R MENTIONED MORE THAN ONE STORE READ PROBE

PROBE: If you had to choose just one of these stores, which one would you say you shop at most often?

E1a. What kind of store is that?

INTERVIEWER: CODE TYPE OF STORE

CODE ONE ONLY

SUPERMARKETS/GROCERY STORES 1

DISCOUNT STORES SUCH AS WAL-MART,

TARGET, OR KMART 2

WAREHOUSE CLUBS, SUCH AS PRICE CLUB, COSTCO, PACE, SAM’S CLUB, BJ’S 3

CONVENIENCE STORES SUCH AS 7-11,

QUICK CHECK, QUICK STOP, WAWA 4

ETHNIC FOOD STORES SUCH AS

BODEGA’S ASIAN FOOD MARKETS, OR

CARIBBEAN MARKETS 5

FARMER’S MARKET 6

DOLLAR STORES 7

OTHER (SPECIFY) 8

________________________________(STRING (NUM))

DON’T KNOW d

REFUSED r

E2. What is the main reason you shop at (FILL NAME FROM E1)?

CODE ONE ONLY

LOW PRICES 01

SALES 02

QUALITY OF FOOD 03

VARIETY OF FOODS (GENERAL) 04

VARIETY OF SPECIAL FOODS

(SUCH AS GLUTEN FREE) 05

CLOSE TO HOME/CONVENIENT 06

EASY TO GET TO 07

PRODUCE SELECTION 08

MEAT DEPARTMENT 09

LOYALTY/FREQUENT SHOPPER PROGRAM 10

OTHER (SPECIFY) 11

________________________________(STRING (NUM))

DON’T KNOW d

REFUSED r

E3. How do you usually get to (FILL NAME FROM E1)?

CODE ALL THAT APPLY

DRIVE OWN CAR 1

DRIVE SOMEONE ELSE’S CAR 2

SOMEONE ELSE DRIVES ME 3

WALK 4

BUS 5

TAXI 6

RIDE BICYCLE 7

OTHER (SPECIFY) 8

________________________________(STRING (NUM))

DON’T KNOW d

REFUSED r

E3a. Do you usually go to (FILL NAME FROM E1) directly from home?

YES 1

NO 0

DON’T KNOW d

REFUSED r

E3b. About how long does it take to go one way from home to (FILL NAME FROM E1)?

| | | NUMBER OF MINUTES ONE WAY

DON’T KNOW d

REFUSED r

E3c. And approximately how many miles away is (FILL NAME FROM E1) from your home – one way?

| | | MILES ONE WAY

LESS THAN ONE MILE n

DON’T KNOW d

REFUSED r

These next questions are about all the places at which you bought food last week. By last week I mean Sunday through Saturday. When answering these questions, please think about all food purchases, meaning those purchased with and without your SNAP EBT card.

F1. First, did (you/anyone in your household) shop for food at a supermarket or grocery store last week?

YES 1

NO 0

DON’T KNOW d

REFUSED r

F2. Think about other places where people buy food, such as meat markets, produce stands, bakeries, warehouse clubs, and convenience stores. Did (you/anyone in your household) buy food from any stores such as these last week?

YES 1

NO 0

DON’T KNOW d

REFUSED r

F3. Last week, did (you/anyone in your household) buy food at a restaurant, fast food place, cafeteria, or vending machine? (Include any children who may have bought food at the school cafeteria.)

YES 1

NO 0

DON’T KNOW d

REFUSED r

F4. Did (you/anyone in your household) buy food from any other kind of place last week?

YES 1

NO 0

DON’T KNOW d

REFUSED r

IF “NO” TO F1, F2, F3, AND F4, GO TO F10.

Now I’m going to ask you about the actual amount you spent on food last week in all the places where you bought food. Then, since last week may have been unusual for you, I will ask about the amount you usually spend.

IF F1=YES, ASK:

F5. How much did (you/anyone in your household) actually spend at supermarkets and grocery stores last week (including any purchases made with [STATE NAME EBT CARD] card or food stamp benefits?

PROBE: Your best estimate is fine.

$ | | | |.| | | AMOUNT SPENT LAST WEEK

DON’T KNOW d GO TO F6

REFUSED r GO TO F6

F5a. How much of the [FILL AMOUNT FROM F5] was for non-food items, such as pet food, paper products, alcohol, detergents, or cleaning supplies?

PROBE: Your best estimate is fine.

$ | | | |.| | | AMOUNT SPENT ON NON-FOOD ITEMS

DON’T KNOW d

REFUSED r

IF F2=YES, ASK:

F6. How much did (you/your household) spend at stores such as meat markets, produce stands, bakeries, warehouse clubs, and convenience stores last week (including any purchases made with your [STATE NAME EBT CARD] or food stamp benefits)?

PROBE: Your best estimate is fine.

$ | | | |.| | | AMOUNT SPENT LAST WEEK

DON’T KNOW d GO TO F7

REFUSED r GO TO F7

F6a. How much of the [FILL AMOUNT FROM F6] was for nonfood items, such as pet food, paper products, alcohol, detergents, or cleaning supplies?

PROBE: Your best estimate is fine.

$ | | | |.| | | AMOUNT SPENT ON NON-FOOD ITEMS

DON’T KNOW d

REFUSED r

IF F3=YES, ASK:

F7. How much did (you/your household) spend for food at restaurants, fast food places, cafeterias, and vending machines last week, not including alcohol purchases?

PROBE: Your best estimate is fine.

$ | | | |.| | | AMOUNT SPENT LAST WEEK

DON’T KNOW d

REFUSED r

IF F4=YES, ASK:

F8. How much did (you/your household) spend for food at any other kind of place last week?

PROBE: Your best estimate is fine.

$ | | | |.| | | AMOUNT SPENT LAST WEEK

DON’T KNOW d

REFUSED r

IF D1a=0, GO TO F10. ELSE ASK:

F9. Let’s see, (you/your household) spent about [SUM OF F5, F6, F7 AND F8] on food last week. How much of that was bought using your [STATE NAME EBT CARD] card?

$ | | | | AMOUNT SPENT WITH EBT CARD GO TO F10

DON’T KNOW d

REFUSED r

F9a. Would you say you spent…

CODE ONE ONLY

Less than half, 1

About half, 2

Or more than half? 3

DON’T KNOW d

REFUSED r

F10. [Let’s see, it seems that (you/your household) did not buy any food last week./Again,(your/your household) spent about (FILL AMOUNT) on food last week.] Now think about how much (you/your household) usually (spend/spends). How much (do you/does your household) usually spend on food at all the different places we’ve been talking about in a week? (Please include any purchases made with your [STATE NAME EBT CARD] or food stamp benefits). Do not include nonfood items such as pet food, paper products, detergent or cleaning supplies.

$ | | | |.| | | AMOUNT SPENT IN A TYPICAL WEEK

DON’T KNOW d

REFUSED r

That completes our questions about food purchased over the last week. Now we’re going to talk about things people sometimes do each month to save money when buying food.

F11. In the last 30 days, have you (or anyone in your household)…

	YES	NO	DON’T KNOW	REFUSED
a. Used coupons when buying food?	1	0	d	r
b. Bought food in large quantities to receive bulk discounts?	1	0	d	r
c. Bought food items because they were on sale?	1	0	d	r
d. Bought food that was near or past its expiration date at a discount?	1	0	d	r

IF NO FEMALE AGE 15-45 IN HH OR B3 > 18 YEARS (NO SCHOOL-AGE CHILDREN

PRESENT IN HH), GO TO SECTION H

IF FEMALE AGE 15-45 IN HH BUT B3>18 YEARS, GO TO G4

IF B3<= 18 YEARS (SCHOOL-AGE CHILDREN PRESENT IN HH), CONTINUE.

The next questions are about programs you (or someone in your household) may be participating in.

IF B3 = 5-18 YEARS (SCHOOL-AGE CHILDREN PRESENT IN HH), ASK:

G1. During the past 30 days, did any children in the household (between 5 and 18 years old) receive free or reduced-cost lunches at school?

YES 1

NO 0

DON’T KNOW d

REFUSED r

IF B3 = 5-18 YEARS (SCHOOL-AGE CHILDREN PRESENT IN HH), ASK:

G2. During the past 30 days, did any children in the household (between 5 and 18 years old) receive free or reduced-cost breakfasts at school?

YES 1

NO 0

DON’T KNOW d

REFUSED r

IF B3 < 5 YEARS (PRE-SCHOOL AGED CHILDREN IN HH), ASK:

G3. During the past 30 days, did (your child/any children in the household) receive free or reduced-cost food at a day-care or Head Start program?

YES 1

NO 0

DON’T KNOW d

REFUSED r

IF B3 <5, OR FEMALE AGE 15-45 IN HH, ASK:

G4. During the past 30 days, did any (women/women or children/children) in this household get food through the WIC program?

YES 1

NO 0

DON’T KNOW d

REFUSED r

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 (you/your household) in the last 30 days.

H1. The first statement is, “(I/We) worried whether (my/our) food would run out before (I/we) got money to buy more.” Was that often true, sometimes true, or never true for (you/your household) in the last 30 days?

CODE ONE ONLY

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW d

REFUSED r

H2. “The food that (I/we) bought just didn’t last, and (I/we) didn’t have money to get more.” Was that often, sometimes, or never true for (you/your household) in the last 30 days?

CODE ONE ONLY

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW d

REFUSED r

H3. “(I/We) couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for (you/your household) in the last 30 days?

CODE ONE ONLY

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW d

REFUSED r

INSERT CHECK: IF AFFIRMATIVE RESPONSE (i.e., OFTEN TRUE OR SOMETIMES TRUE) TO ONE OR MORE OF QUESTIONS H1-H3, THEN CONTINUE, ELSE SKIP TO H10.

H4. 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 0 GO TO H5

DON’T KNOW d GO TO H5

REFUSED r GO TO H5

H4a. How many days did this happen in the last 30 days?

| | | NUMBER OF DAYS GO TO H5

DON’T KNOW d

REFUSED r GO TO H5

H4b. Do you think it was more than one or two days?

YES 1

NO 0

DON’T KNOW d

REFUSED r

H5. 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 0

DON’T KNOW d

REFUSED r

H6. In the last 30 days, were you ever hungry but didn’t eat because there wasn’t enough money for food?

YES 1

NO 0

DON’T KNOW d

REFUSED r

H7. In the last 30 days, did you lose weight because there wasn’t enough money for food?

YES 1

NO 0

DON’T KNOW d

REFUSED r

INSERT CHECK: IF AFFIRMATIVE RESPONSE (i.e., OFTEN TRUE OR SOMETIMES TRUE) TO ONE OR MORE OF QUESTIONS H4-H7, THEN CONTINUE, ELSE SKIP TO H10.

H8. 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 0 GO TO H10

DON’T KNOW d GO TO H10

REFUSED r GO TO H10

H9. How many times did this happen in the last 30 days?

| | | NUMBER OF TIMES GO TO H10

DON’T KNOW d

REFUSED r GO TO H10

H9a. Do you think it was more than one or two days?

YES 1

NO 0

DON’T KNOW d

REFUSED r

IF NO CHILDREN IN HOUSEHOLD, GO TO H17. ELSE ASK:

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 any child under 18 years old living in the household.

H10. “(I/We) relied on only a few kinds of low-cost food to feed (the child in (my/our) household/the children) because (I was/we were) running out of money to buy food.” Was that often, sometimes, or never true for (you/your household) in the last 30 days?

CODE ONE ONLY

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW d

REFUSED r

H11. “(I/We) couldn’t feed (the children in (my/our)household/ the children) a balanced meal, because (I/we) couldn’t afford that.” Was that often, sometimes, or never true for (you/your household) in the last 30 days?

CODE ONE ONLY

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW d

REFUSED r

H12. “(The child in (my/our) household was/The children were) not eating enough because (I/we) just couldn’t afford enough food.” Was that often, sometimes, or never true for (you/your household) in the last 30 days?

CODE ONE ONLY

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW d

REFUSED r

INSERT CHECK: IF AFFIRMATIVE RESPONSE (i.e., OFTEN TRUE OR SOMETIMES TRUE) TO ONE OR MORE OF QUESTIONS H10-H12, THEN CONTINUE, ELSE SKIP TO H17.

H13. In the last 30 days, did you ever cut the size of (the child’s/any of the children’s) meals because there wasn’t enough money for food?

YES 1

NO 0

DON’T KNOW d

REFUSED r

H14. In the last 30 days, did (the child/any of the children) ever skip a meal because there wasn’t enough money for food?

YES 1

NO 0 GO TO H15

DON’T KNOW d GO TO H15

REFUSED r GO TO H15

H14a. How many days did this happen in the last 30 days?

| | | NUMBER OF DAYS GO TO H15

DON’T KNOW d

REFUSED r GO TO H15

H14b. Do you think it was more than one or two days?

YES 1

NO 0

DON’T KNOW d

REFUSED r

H15. In the last 30 days, (was the child/were the children) ever hungry but you just couldn’t afford more food?

YES 1

NO 0

DON’T KNOW d

REFUSED r

H16. In the last 30 days, did (the child/any of the children) ever not eat for a whole day because there wasn’t enough money for food?

YES 1

NO 0

DON’T KNOW d

REFUSED r

The next questions are about some community programs you (or someone in your household) may have participated in during the past 30 days.

H17. In the last 30 days, did (you/ you or other adults in your household) ever get emergency food from a church, a food pantry or food bank?

PROBE: This includes all religious and charitable organizations.

YES 1

NO 0

DON’T KNOW d

REFUSED r

H18. During the past 30 days, did (you/anyone in this household) go to a community program or senior center to eat prepared meals?

YES 1

NO 0

DON’T KNOW d

REFUSED r

H19. During the last 30 days, did you (you/you or other adults in your household) ever eat any meals at a soup kitchen or shelter?

YES 1

NO 0

DON’T KNOW d

REFUSED r

H20. During the past 30 days, did (you/anyone in this household) receive any meals from “Meals on Wheels” or any other program delivering meals to your home?

YES 1

NO 0

DON’T KNOW d

REFUSED r

The next questions are about sources of income. The answer to these and all other questions on this survey will be kept strictly confidential and will never be associated with your name.

I1a. During (LAST MONTH), did you (or anyone in your household) receive any (INSERT ITEM)…

I1b. FOR EACH YES RESPONSE AT I1a, ASK: How much did you receive last month from (INSERT ITEM)?

I1c. FOR EACH YES RESPONSE AT I1a AND B1 NOT=0, ASK: How much did other people in your household (besides yourself) receive from (ITEM) last month altogether?

	I1a. During (LAST MONTH), did you (or anyone in your household) receive any (ITEM)?				I1b. How much did you receive last month from (ITEM)?	I1c. How much did other people in your household receive from (ITEM) last month altogether?
	YES	NO	DK	REF
a. TANF, Temporary Assistance to Needy Families (also known as [STATE WELFARE NAME])?	1	0	d	r	$| | | | |	$| | | | |
b. Other welfare such as General Assistance?	1	0	d	r	$| | | | |	$| | | | |
c. Social Security checks from the government for retirement, disability, or survivors’ benefits?	1	0	d	r	$| | | | |	$ | | | | |
d. Other retirement benefits such as a government or private pension or annuity?	1	0	d	r	$| | | | |	$| | | | |
e. SSI or Supplemental Security Income from the federal, state, or local government?	1	0	d	r	$| | | | |	$| | | | |
f. Veteran’s Benefits?	1	0	d	r	$| | | | |	$| | | | |
g. Unemployment Insurance or worker’s compensation benefits?	1	0	d	r	$| | | | |	$| | | | |
h. Child support payments?	1	0	d	r	$| | | | |	$| | | | |
i. Payments from roomers or boarders?	1	0	d	r	$| | | | |	$| | | | |
j. Financial support from friends or family?	1	0	d	r	$| | | | |	$| | | | |
k. Any other income besides earnings? (SPECIFY)	1	0	d	r	$| | | | |	$| | | | |

I2. Are you currently working at a job for pay? Include any self-employment.

YES 1

NO 0 GO TO I6

DON’T KNOW d GO TO I6

REFUSED r GO TO I6

I3. How many hours do you usually work per week on this job?

| | | NUMBER OF HOURS

DON’T KNOW d

REFUSED r

I4. How much do you earn per hour on this job, before taxes and other deductions?

$ | | |.| | | HOURLY WAGE GO TO I6

NOT PAID BY THE HOUR 0

DON’T KNOW d GO TO I6

REFUSED r GO TO I6

I5. ENTER AMOUNT

$ | | |,| | | |.| | |

ENTER PAY PERIOD

CODE ONE ONLY

WEEK 1

DAY 2

EVERY TWO WEEKS 3

TWICE A MONTH 4

MONTHLY 5

YEARLY 6

OTHER (SPECIFY) 7

(STRING (NUM))

DON’T KNOW d

REFUSED r

IF R LIVES ALONE, GO TO I9

I6. Does anyone (else) in your household work at a job for pay?

YES 1

NO 0 GO TO I9

DON’T KNOW d GO TO I9

REFUSED r GO TO I9

I7. How many (other) people in your household work at a job for pay?

PROBE: Not including yourself.

| | | NUMBER OF WORKING HOUSEHOLD MEMBERS

NONE 0 GO TO I9

DON’T KNOW d

REFUSED r

I8_1a. How many hours per week does (PERSON 1) person usually work?

| | | NUMBER OF HOURS

DON’T KNOW d

REFUSED r

IF I8_1a > 0

I8_1b. How much does (PERSON 1) earn per hour on this job, before taxes and other deductions?

PROBE: Your best estimate is fine.

$ | | |.| | | HOURLY WAGE GO TO LOOP

NOT PAID BY THE HOUR 0

DON’T KNOW d GO TO LOOP

REFUSED r GO TO LOOP

I8_1c. ENTER AMOUNT

$ | | |,| | | |.| | |

ENTER PAY PERIOD

CODE ONE ONLY

WEEK 1

DAY 2

EVERY TWO WEEKS 3

TWICE A MONTH 4

MONTHLY 5

YEARLY 6

OTHER (SPECIFY) 7

(STRING (NUM))

DON’T KNOW d

REFUSED r

I8_2a. How many hours per week does (PERSON 2) person usually work?

| | | NUMBER OF HOURS

DON’T KNOW d

REFUSED r

IF I8_2a > 0

I8_2b. How much does (PERSON 2) earn per hour on this job, before taxes and other deductions?

PROBE: Your best estimate is fine.

$ | | |.| | | HOURLY WAGE GO TO LOOP

NOT PAID BY THE HOUR 0

DON’T KNOW d GO TO LOOP

REFUSED r GO TO LOOP

I8_2c. ENTER AMOUNT

$ | | |,| | | |.| | |

ENTER PAY PERIOD

CODE ONE ONLY

WEEK 1

DAY 2

EVERY TWO WEEKS 3

TWICE A MONTH 4

MONTHLY 5

YEARLY 6

OTHER (SPECIFY) 7

(STRING (NUM))

DON’T KNOW d

REFUSED r

CONTINUE LOOP UNTIL ALL ADULT HOUSEHOLD MEMBERS (15 YEARS OF AGE AND OLDER) ARE ACCOUNTED FOR.

I9. Do you (or anyone in your household) currently own a car, truck, or other type of vehicle?

YES 1 GO TO I11

NO 0

DON’T KNOW d

REFUSED r

I10. Do you have access to car, truck, or other type of vehicle when you need one?

YES 1

NO 0

DON’T KNOW d

REFUSED r

I11. Do you (or anyone in your household) currently have a credit card that you can use to make purchases?

YES 1

NO 0

DON’T KNOW d

REFUSED r

Now, I’d like to ask you some questions about where you live.

I12. First, please tell me the kind of place where you now live?

CODE ONE ONLY

HOUSE, TOWNHOUSE, CONDO 1

MOBILE HOME/TRAILER 2

APARTMENT 3

ROOM 4

MOTEL/HOTEL 5 GO TO I14

HOMELESS, LIVING IN A SHELTER OR MISSION 6 GO TO I14

HOMELESS, LIVING ON THE STREET 7 GO TO I14

CAR, VAN OR RECREATIONAL VEHICLE 8 GO TO I14

ABANDONED BUILDING 9 GO TO I14

OTHER (SPECIFY) 10

(STRING (NUM))

DON’T KNOW d

REFUSED r

I13. Do you…

CODE ONE ONLY

Own the place you live, 1 GO TO I15

Rent your own place or contribute to rent

at a friend or family’s place, or 2

Live rent free? 3

DON’T KNOW d

REFUSED r

I13a. Does your household receive Section 8 or Public Housing Assistance?

YES 1

NO 0

DON’T KNOW d

REFUSED r

I14. Do you have access to a place where you can prepare a meal?

YES 1

NO 0

DON’T KNOW d

REFUSED r

IF I12 EQUALS 7, 8, 9, OR 10, GO TO J1. ELSE, CONTINUE.

I15. Do you currently have the following items in your home in working condition…

	YES	NO	DON’T KNOW	REFUSED
a. Refrigerator?	1	0	d	r
b. Stand alone food freezer?	1	0	d	r
c. Gas or electric stove?	1	0	d	r
d. Microwave oven?	1	0	d	r

J1a. Now I am going to ask you some questions about feelings you may have experienced over the past 30 days.

During the past 30 days, how often did you feel . . .

PROBE: Would you say: All of the time, most of the time, some of the time, a little of the time, or none of the time?

	ALL OF THE TIME	MOST OF THE TIME	SOME OF THE TIME	A LITTLE OF THE TIME	NONE OF THE TIME	DON’T KNOW	REFUSED
a. So sad that nothing could cheer you up?	1	2	3	4	5	d	r
b. Nervous?	1	2	3	4	5	d	r
c. Restless or fidgety?	1	2	3	4	5	d	r
d. Hopeless?	1	2	3	4	5	d	r
e. That everything was an effort?	1	2	3	4	5	d	r
f. Worthless?	1	2	3	4	5	d	r

J2. If (you/your household) had a problem with which you needed help, for example, sickness or moving, how much help would you expect to get from family living nearby?

CODE ONE ONLY

All of the help needed, 1

Most of the help needed, 2

Very little of the help needed, or 3

No help? 4

DON’T KNOW d

REFUSED r

J3. If (you/your household) had a problem with which you needed help, how much help would you expect to get from friends?

CODE ONE ONLY

All of the help needed, 1

Most of the help needed, 2

Very little of the help needed, or 3

No help? 4

DON’T KNOW d

REFUSED r

J4. If (you/your household) had a problem with which you needed help, how much help would you expect to get from other people in the community besides family and friends, such as a social service agency or a church?

CODE ONE ONLY

All of the help needed, 1

Most of the help needed, 2

Very little of the help needed, or 3

No help? 4

DON’T KNOW d

REFUSED r

The next question is about your neighborhood.

J5. Do you consider your neighborhood very safe from crime, somewhat safe, or very unsafe?

CODE ONE ONLY

VERY SAFE 1

SOMEWHAT SAFE 2

VERY UNSAFE 3

DON’T KNOW d

REFUSED r

The last few questions are for classification purposes only.

K1. What is your date of birth?

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

MONTH DAY YEAR

DON’T KNOW d

REFUSED r

K2. Are you of Hispanic or Latino origin?

YES 1

NO 0

DON’T KNOW d

REFUSED r

K3. 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 or White?

CODE ALL THAT APPLY

AMERICAN INDIAN OR ALASKA NATIVE 3

ASIAN 4

BLACK OR AFRICAN AMERICAN 2

NATIVE HAWAIIAN OR

OTHER PACIFIC ISLANDER 5

WHITE 1

OTHER (SPECIFY) 6

(STRING (NUM))

DON’T KNOW d

REFUSED r

K4. What is the highest level of education you have completed so far?

Would you say…

CODE ONE ONLY

Less than 9th grade, 1

Some high school, but no diploma, 2

High school graduate (diploma or

equivalent diploma [GED]), 3

Technical, trade or vocational degree, 4

Some college, but no degree, 5

Associate’s degree, 6

Bachelor’s degree, 7

Some graduate school but no degree, 8

Master’s degree, or 9

Professional school or doctorate? 10

DON’T KNOW d

REFUSED r

K5. ASK ONLY IF NEEDED: Are you male or female?

MALE 1

FEMALE 2

DON’T KNOW d

REFUSED r

K6. In general, would say your health is excellent, very good, good, fair or poor?

CODE ONE ONLY

EXCELLENT 1

VERY GOOD 2

GOOD 3

FAIR 4

POOR 5

DON’T KNOW d

REFUSED r

K7. How tall are you without shoes?

ENTER HEIGHT IN FEET AND INCHES OR METERS AND CENTIMETERS

| | NUMBER

FEET 1

METERS 2

DON’T KNOW d

REFUSED r

| | | NUMBER

INCHES 1

CENTIMETERS 2

DON’T KNOW d

REFUSED r

K8. How much do you weigh without shoes?

IF RESPONDENT SAYS SHE IS PREGNANT, SAY: How much did you weigh before your pregnancy?

| | | | NUMBER

POUNDS 1

KILOGRAMS 2

DON’T KNOW d

REFUSED r

IF CURRENT PARTICIPANT, GO TO END. IF NEW PARTICIPANT, ASK L1.

L1. I would like to thank you for participating in the survey. We would like to interview you again in 6 months and I would like to know how to get in touch with you. There will be a $20.00 gift card for completing that survey as well.

COLLECT/CONFIRM CURRENT CONTACT INFO FOR RESPONDENT

(STRING (NUM))

FIRST NAME

(STRING (NUM))

MIDDLE INITIAL/NAME

(STRING (NUM))

LAST NAME

(STRING (NUM))

ADDRESS 1

(STRING (NUM))

ADDRESS 2

(STRING (NUM))

CITY

(STRING (NUM))

STATE/TERRITORY

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

ZIP CODE (+ 4 IF NEEDED)

| | | | - | | | | - | | | | | PHONE NUMBER - HOME

| | | | - | | | | - | | | | | PHONE NUMBER – CELLULAR

| | | | - | | | | - | | | | | PHONE NUMBER - OTHER

(RANGE) (RANGE) (RANGE)

(STRING (NUM))

EMAIL

DON’T KNOW d

REFUSED r

L2. Next, I would like to ask you for the name, address, and telephone number of 3 close friends or relatives we can contact in case you move and we cannot easily locate you for your next interview. All information collected will be held in strictest confidence and will only be used to locate you if we cannot reach you at your current address.

CONTACT 1:

(STRING (NUM))

FIRST NAME

(STRING (NUM))

MIDDLE INITIAL/NAME

(STRING (NUM))

LAST NAME

_________________________________(STRING (NUM))

RELATIONSHIP TO RESPONDENT

(STRING (NUM))

ADDRESS 1

(STRING (NUM))

ADDRESS 2

(STRING (NUM))

CITY

(STRING (NUM))

STATE/TERRITORY

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

ZIP CODE (+ 4 IF NEEDED)

| | | | - | | | | - | | | | | PHONE NUMBER - HOME

| | | | - | | | | - | | | | | PHONE NUMBER – CELLULAR

| | | | - | | | | - | | | | | PHONE NUMBER - OTHER

(RANGE) (RANGE) (RANGE)

(STRING (NUM))

EMAIL

DON’T KNOW d GO TO L3

REFUSED r GO TO L3

CONTACT 2:

(STRING (NUM))

FIRST NAME

(STRING (NUM))

MIDDLE INITIAL/NAME

(STRING (NUM))

LAST NAME

_________________________________(STRING (NUM))

RELATIONSHIP TO RESPONDENT

(STRING (NUM))

ADDRESS 1

(STRING (NUM))

ADDRESS 2

(STRING (NUM))

CITY

(STRING (NUM))

STATE/TERRITORY

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

ZIP CODE (+ 4 IF NEEDED)

| | | | - | | | | - | | | | | PHONE NUMBER - HOME

| | | | - | | | | - | | | | | PHONE NUMBER – CELLULAR

| | | | - | | | | - | | | | | PHONE NUMBER - OTHER

(RANGE) (RANGE) (RANGE)

(STRING (NUM))

EMAIL

DON’T KNOW d GO TO L3

REFUSED r GO TO L3

CONTACT 3:

(STRING (NUM))

FIRST NAME

(STRING (NUM))

MIDDLE INITIAL/NAME

(STRING (NUM))

LAST NAME

_________________________________(STRING (NUM))

RELATIONSHIP TO RESPONDENT

(STRING (NUM))

ADDRESS 1

(STRING (NUM))

ADDRESS 2

(STRING (NUM))

CITY

(STRING (NUM))

STATE/TERRITORY

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

ZIP CODE (+ 4 IF NEEDED)

| | | | - | | | | - | | | | | PHONE NUMBER - HOME

| | | | - | | | | - | | | | | PHONE NUMBER – CELLULAR

| | | | - | | | | - | | | | | PHONE NUMBER - OTHER

(RANGE) (RANGE) (RANGE)

(STRING (NUM))

EMAIL

DON’T KNOW d

REFUSED r

L3. Those are all of our questions. Once again, thank you very much for your participation in the survey.

END. Those are all our questions. Thank you very much for your participation in the survey. Please (provide/confirm) the name and address where we should send the gift card.

RECORD NAME AND ADDRESS FOR CHECK

[IF ADDRESS COLLECTED AT L1, PRE-FILL HERE]

(STRING (NUM))

FIRST NAME

(STRING (NUM))

MIDDLE INITIAL/NAME

(STRING (NUM))

LAST NAME

(STRING (NUM))

ADDRESS 1

(STRING (NUM))

ADDRESS 2

(STRING (NUM))

CITY

(STRING (NUM))

STATE/TERRITORY

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

ZIP CODE (+ 4 IF NEEDED)

DON’T KNOW d

REFUSED r