Parents-Minor Surveys

Appendix B1

Round 1 Study Participant and Primary

Shopper Survey: English

OMB Control#: 0584-XXXX

Expiration Date: xx/xx/20xx

Healthy Incentives Pilot – Round 1 STUDY PARTICIPANT and Primary Shopper Survey: English

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 Service, Office of Research and Analysis, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-xxxx). Do not return the completed form to this address.

Sampled Respondent Introduction

(R 1,2,3)

NAVIGATION: IF RESPONDENT IS A MINOR (AGES 16-17) GO TO PARENT CONSENT FOR MINORS SCRIPT PC.01

1 Intro.01 (R 1,2,3) [Hello, my name is {INTERVIEWER} from Westat. And I’m calling about the USDA/FNS SNAP study.] May I speak with [NAME OF RESPONDENT]?

R available 11

R lives here – needs appointment 12

R lives at another number or address 13

Never heard of R 14

Phone company recording 15

Answering machine 16

Retry dialing 17

REFUSED 77

DON'T KNOW 99

NAVIGATION: If R available, GO TO 2 [Intro.02].

2 Intro.02 (R 1,2,3) My name is {INTERVIEWER} from Westat. And I’m calling about the USDA/FNS, SNAP, study.] I’d like to make sure that you are the correct person. Your name is {R_FNAME R_LNAME} and your approixmate age is {R’s AGE}?

Yes – exact match 1

Yes – qualified match 2

No – does not match 3

REFUSED 7

DON'T KNOW 9

NAVIGATION: If Yes-exact or qualified match, GO TO Intro.03. If No, ask for respondent and repeat question when respondent is obtained.

GO TO 1 [Intro.01].

3 Intro.03 (R 1) I am calling about the USDA/FNS, SNAP, formerly known as the Food Stamp Program.We’re interested in learning how the program is working in Hampden County, and would like to ask you some questions about food and shopping that will help SNAP improve services and better meet the needs of the people who use this program. The interview takes about 30 minutes you will receive a $20 check as a thank you for participating in the study. Your participation is voluntary. You have the right to stop at any time or skip questions. Taking part in this study will not affect your benefits in any way – either now or in the future. We do not plan to share this information with anyone other than USDA/FNS staff and its contractors, except otherwise required by law. Data that identify you or your family members will not be included in any report. There is a small risk of the loss of privacy of your data, but our data security plans and procedures minimize this risk.

We sent you a letter about the study that provides more information. If you did not receive the letter, I can read it to you.

Do you agree to participate?

YES

IF NO, ADDRESS ISSUES/CONCERNS ABOUT STUDY. CODE AS REFUSAL.

INTERVIEWER: ANSWER QUESTIONS ABOUT ABT, WESTAT, ETC. AND PROVIDE TOLL=FREE # AS NEEDED.

GO TO BEGINNING OF SAMPLED RESPONDENT INTERVIEW

Parent Consent for Minors

(R 1,2,3)

4 PC.01 (R 1,2,3) Are you the parent or legal guardian of {Minor Selected Respondent_FirstName and MSR_LastName}?

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

If No, GO TO PC.03

5 PC.02 (R 1,2,3) I am calling about the USDA/FNS, SNAP, formerly known as the Food Stamp Program.We’re interested in learning how the program is working in Hampden County. {Your daughter/son, Minor Selected Respondent_FirstName and MSR LastName] was selected as a participant in this study._We need your consent to interview FirstName since {she/he} he is a minor. _FirstName} will be asked questions about {her/his} diet, food knowledge, attitudes, and beliefs. After we talk with MINOR we will want to talk to the person who does the grocery shopping for your household.

The interview with MINOR take about 15 minutes and MINOR will receive a $20 check as a thank you for participating in the study. His/her participation is voluntary. He/she has the right to stop at any time or skip questions. Taking part in this study will not affect your benefits in any way – either now or in the future. We do not plan to share this information with anyone other than USDA/FNS staff and its contractors, except as otherwise required by law. Data that identify you or your family members will not be included in any report. To protect confidentiality, we cannot share your youth’s answers with you. There is a small risk of the loss of privacy of your data, but our data security plans and procedures minimize this risk.

May we have your consent to talk to {MR_FirstName}?

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

If Yes, GO TO PC.05. If No, Refuse, or DK, ADDRESS ISSUES/CONCERNS ABOUT STUDY. CODE AS REFUSAL.

INTERVIEWER: ANSWER QUESTIONS ABOUT ABT, WESTAT, ETC. AND PROVIDE TOLL=FREE # AS NEEDED.

6 PC.03 (R 1,2,3) PC3 (R1,2, 3). Who is {Minor Selected Respondent_FirstName and MSR_LastName}’s parent or legal guardian? What is their name ?

________________________

ENTER NAME

REFUSED 7

DON'T KNOW 9

7 PC.04 (R 1,2,3) What is that person’s telephone number? And what type of phone is this?

CATI: ALLOW FOR ENTRY OF MULTIPLE PHONE NUMBERS AND ABILITY TO SELECT PHONE TYPE.

[____] - ______ - ________

ENTER PHONE NUMBER

Home 1

Work 2

Cell 3

Other 4

REFUSED 7

DON'T KNOW 9

PC.05 (R1) SPEAKING WITH MINOR:

8 Intro.06 (R 1,2,3) Hello, my name is {INTERVIEWER} from Westat. And I’m calling about the USDA/FNS, SNAP, study.] I’d like to make sure that you are the correct person. Your name is {R_FNAME R_LNAME} and your approixmate age is {R’s AGE}?

Yes – exact match 1

Yes – qualified match 2

No – does not match 3

REFUSED 7

DON'T KNOW 9

NAVIGATION: If Yes-exact or qualified match, GO TO [Intro.07]. If No, ASK TO SPEAK WITH CORRECT PERSON.

9 Intro.07 (R1) I am calling about the USDA/FNS, SNAP, formerly known as the Food Stamp Program.We’re interested in learning how the program is working in Hampden County, and would like to ask you some questions about food and shopping that will help SNAP improve services and better meet the needs of the people who use this program. The interview takes about 15 minutes. You will receive a $20 check as a thank you. Your participation is voluntary. You have the right to stop at any time or skip questions. Taking part in this study will not affect your benefits in any way – either now or in the future. We do not plan to share this information with anyone other than USDA/FNS staff and its contractors, except otherwise required by law. Data that identify you or your family members will not be included in any report. The answers you give will not be shared with your parent or guardian. There is a small risk of the loss of privacy of your data, but our data security plans and procedures minimize this risk.

Do you agree to participate?

YES

IF NO, ADDRESS ISSUES/CONCERNS ABOUT STUDY. CODE AS REFUSAL.

INTERVIEWER: ANSWER QUESTIONS ABOUT ABT, WESTAT, ETC. AND PROVIDE TOLL=FREE # AS NEEDED.

Food Preferences and Beliefs

(R 1,2,3)

4 FAB.1-At.01 (R 1,2,3) The following questions are about your food preferences and beliefs. For each statement, tell me how much you agree or disagree. The first statement is: I enjoy trying new foods. Do you . . .

strongly disagree, 1

disagree, 2

neither disagree nor agree, 3

agree, or 4

strongly agree? 5

REFUSED 7

DOES NOT APPLY 8

5 TS.01 (R 1,2,3) I enjoy trying new fruits. Do you . . .

strongly disagree, 1

disagree, 2

neither disagree nor agree, 3

agree, or 4

strongly agree? 5

REFUSED 7

DOES NOT APPLY 8

6 TS.02 (R 1,2,3) I enjoy trying new vegetables.

strongly disagree, 1

disagree, 2

neither disagree nor agree, 3

agree, or 4

strongly agree? 5

REFUSED 7

DOES NOT APPLY 8

7 FAB.1-Bel.04a (R 1,2,3) I eat enough fruits to keep me healthy.

strongly disagree, 1

disagree, 2

neither disagree nor agree, 3

agree, or 4

strongly agree? 5

REFUSED 7

DOES NOT APPLY 8

8 FAB.1-Bel.04b (R 1,2,3) I eat enough vegetables to keep me healthy.

strongly disagree, 1

disagree, 2

neither disagree nor agree, 3

agree, or 4

strongly agree? 5

REFUSED 7

DOES NOT APPLY 8

9 FAB.1-Bel.05 (R 1,2,3) I often encourage my family and friends to eat fruits and vegetables.

strongly disagree, 1

disagree, 2

neither disagree nor agree, 3

agree, or 4

strongly agree? 5

REFUSED 7

DOES NOT APPLY 8

Barriers to Consuming FV

(R 1,2,3)

10 FAB.1-Bel.22 (R 1,2,3) The next items are about barriers to eating fruits and vegetables. For each statement, tell me how much you agree or disagree. The first statement is: It’s hard for me to eat more vegetables because I don’t know how to prepare them. Do you . . .

strongly disagree, 1

disagree, 2

neither disagree nor agree, 3

agree, or 4

strongly agree? 5

REFUSED 7

DOES NOT APPLY 8

11 New.Bar.1v (R 1,2,3) It's hard for me to eat more vegetables because they are hard to find where I shop for food.

strongly disagree, 1

disagree, 2

neither disagree nor agree, 3

agree, or 4

strongly agree? 5

REFUSED 7

DOES NOT APPLY 8

12 New.Bar.1f (R 1,2,3) It's hard for me to eat more fruits because they are hard to find where I shop for food.

strongly disagree, 1

disagree, 2

neither disagree nor agree, 3

agree, or 4

strongly agree? 5

REFUSED 7

DOES NOT APPLY 8

13 FAB-Bar2.01 (R 1,2,3) I don’t eat fruits and vegetables as much as I like to because they cost too much.

strongly disagree, 1

disagree, 2

neither disagree nor agree, 3

agree, or 4

strongly agree? 5

REFUSED 7

DOES NOT APPLY 8

14 FAB-Bar2.02 (R 1,2,3) I don’t eat fruits and vegetables as much as I like to because they often spoil before I get a chance to eat them.

strongly disagree, 1

disagree, 2

neither disagree nor agree, 3

agree, or 4

strongly agree? 5

REFUSED 7

DOES NOT APPLY 8

15 FAB-Bar2.05b (R 1,2,3) I don’t eat fruits and vegetables as much as I like to because my family doesn’t like them.

strongly disagree, 1

disagree, 2

neither disagree nor agree, 3

agree, or 4

strongly agree? 5

REFUSED 7

DOES NOT APPLY 8

16 FAB-Bar2.05a (R 1,2,3) I don’t eat fruits and vegetables because I don't like them.

strongly disagree, 1

disagree, 2

neither disagree nor agree, 3

agree, or 4

strongly agree? 5

REFUSED 7

DOES NOT APPLY 8

Fruit and Vegetable Screener

(R 1,2,3)

17 EATS.1 (R 1,2,3) For this next set of questions, please think about all the fruits, vegetables, and juice that you had last month. Include those that were raw and cooked, eaten as snacks and at meals, eaten at home and away from home in restaurants, with friends, and as take-out, and eaten alone and mixed with other foods. During the past month, how often did you drink 100% pure fruit juice such as orange, mango, apple, grape or pineapple juices? Do not include fruit-flavored drinks with added sugar or fruit juice you made at home and added sugar to.

[IF NEEDED: Include only 100% pure juices. Do not include fruit-flavored drinks with added sugar, like cranberry cocktail, Hi-C, lemonade, Kool-Aid, Gatorade, Tampico, and Sunny Delight.] [IF "every day", ASK: How many times a day?]

NEVER 1

1 TO 3 TIMES LAST MONTH 2

1 TO 2 TIMES PER WEEK 3

3 TO 4 TIMES PER WEEK 4

5 TO 6 TIMES PER WEEK 5

1 TIME PER DAY 6

2 TIMES PER DAY 7

3 TIMES PER DAY 8

4 TIMES PER DAY 9

5 OR MORE TIMES PER DAY 10

REFUSED 77

DON'T KNOW 99

NAVIGATION: If Never, GO TO 19 [EATS.2].

18 EATS.1a (R 1,2,3) Each time you drank 100% juice, how much did you usually drink? Would you say . . .

less than 3/4 cup (less than 6 ounces), 1

3/4 to 1 1/4 cup (6 to 10 ounces), 2

1 1/4 to 2 cups (10 to 16 ounces), or 3

more than 2 cups (more than 16 ounces)? 4

REFUSED 77

DON'T KNOW 99

19 EATS.2 (R 1,2,3) During the past month, how often did you eat fruit? Include fresh, frozen or canned fruit. Do not include juices or dried fruits.

NEVER 1

1 TO 3 TIMES LAST MONTH 2

1 TO 2 TIMES PER WEEK 3

3 TO 4 TIMES PER WEEK 4

5 TO 6 TIMES PER WEEK 5

1 TIME PER DAY 6

2 TIMES PER DAY 7

3 TIMES PER DAY 8

4 TIMES PER DAY 9

5 OR MORE TIMES PER DAY 10

REFUSED 77

DON'T KNOW 99

NAVIGATION: If Never, GO TO 21 [EATS.3].

20 EATS.2a (R 1,2,3) Each time you ate fruit, how much did you usually eat?

LESS THAN 1 MEDIUM FRUIT 1

1 MEDIUM FRUIT 2

2 MEDIUM FRUITS 3

MORE THAN 2 MEDIUM FRUITS 4

LESS THAN 1/2 CUP 5

ABOUT 1/2 CUP 6

ABOUT 1 CUP 7

MORE THAN 1 CUP 8

REFUSED 77

DON'T KNOW 99

21 EATS.3 (R 1,2,3) (During the past month), how often did you eat a green leafy or lettuce salad, with or without other vegetables?

IF NEEDED: INCLUDE: spinach salads.

NEVER 1

1 TO 3 TIMES LAST MONTH 2

1 TO 2 TIMES PER WEEK 3

3 TO 4 TIMES PER WEEK 4

5 TO 6 TIMES PER WEEK 5

1 TIME PER DAY 6

2 TIMES PER DAY 7

3 TIMES PER DAY 8

4 TIMES PER DAY 9

5 OR MORE TIMES PER DAY 10

REFUSED 77

DON'T KNOW 99

NAVIGATION: If Never, GO TO 23 [EATS.4].

22 EATS.3a (R 1,2,3) Each time you ate green leafy or lettuce salad, how much did you usually eat? Would you say . . .

about 1/2 cup, 1

about 1 cup, 2

about 2 cups, or 3

more than 2 cups? 4

REFUSED 77

DON'T KNOW 99

23 EATS.4 (R 1,2,3) (During the past month), how often did you eat any kind of fried potatoes, including french fries, home fries, or hash brown potatoes?

IF NEEDED: DO NOT INCLUDE potato chips. INCLUDE Tater tots and other fresh or frozen fried potatoes.

NEVER 1

1 TO 3 TIMES LAST MONTH 2

1 TO 2 TIMES PER WEEK 3

3 TO 4 TIMES PER WEEK 4

5 TO 6 TIMES PER WEEK 5

1 TIME PER DAY 6

2 TIMES PER DAY 7

3 TIMES PER DAY 8

4 TIMES PER DAY 9

5 OR MORE TIMES PER DAY 10

REFUSED 77

DON'T KNOW 99

NAVIGATION: If Never, GO TO 25 [EATS.5].

24 EATS.4a (R 1,2,3) Each time you ate fried potatoes, how much did you usually eat? Would you say . . .

small order or less (about 1 cup or less), 1

medium order (about 1 1/2 cups), 2

large order (about 2 cups), or 3

super size order or more (about 3 cups or more)? 4

REFUSED 77

DON'T KNOW 99

25 EATS.5 (R 1,2,3) (During the past month), how often did you eat any other kind of potatoes, such as baked, boiled, mashed potatoes, sweet potatoes, or potato salad?

IF NEEDED: INCLUDE all types of potatoes except fried. INCLUDE potatoes au gratin, scalloped potatoes.

NEVER 1

1 TO 3 TIMES LAST MONTH 2

1 TO 2 TIMES PER WEEK 3

3 TO 4 TIMES PER WEEK 4

5 TO 6 TIMES PER WEEK 5

1 TIME PER DAY 6

2 TIMES PER DAY 7

3 TIMES PER DAY 8

4 TIMES PER DAY 9

5 OR MORE TIMES PER DAY 10

REFUSED 77

DON'T KNOW 99

NAVIGATION: If Never, GO TO 27 [EATS.6].

26 EATS.5a (R 1,2,3) Each time you ate these potatoes, how much did you usually eat? Would you say . . .

1 small potato or less (1/2 cup or less), 1

1 medium potato (1/2 to 1 cup), 2

1 large potato (1 to 1 1/2 cups), or 3

2 medium potatos or more (1 1/2 cups or more)? 4

REFUSED 77

DON'T KNOW 99

27 EATS.6 (R 1,2,3) (During the past month), how often did you eat refried beans, baked beans, beans in soup, pork and beans or any other type of cooked dried beans? Do not include green beans.

IF NEEDED: INCLUDE: soybeans, kidney, pinto, garbanzo, lentils, black, black-eyed peas, cow peas, and lima beans.

NEVER 1

1 TO 3 TIMES LAST MONTH 2

1 TO 2 TIMES PER WEEK 3

3 TO 4 TIMES PER WEEK 4

5 TO 6 TIMES PER WEEK 5

1 TIME PER DAY 6

2 TIMES PER DAY 7

3 TIMES PER DAY 8

4 TIMES PER DAY 9

5 OR MORE TIMES PER DAY 10

REFUSED 77

DON'T KNOW 99

NAVIGATION: If Never, GO TO 29 [EATS.7].

28 EATS.6a (R 1,2,3) Each time you ate these beans, how much did you usually eat? Would you say . . .

less than 1/2 cup, 1

1/2 to 1 cup, 2

1 to 1 1/2 cups, or 3

more than 1 1/2 cups? 4

REFUSED 77

DON'T KNOW 99

29 EATS.7 (R 1,2,3) (During the past month), not including lettuce salads, potatoes, and cooked dried beans, how often did you eat other vegetables?

IF NEEDED: DO NOT INCLUDE rice. Examples of other vegetables to IF NEEDED: INCLUDE: tomatoes, green beans, carrots, corn, cabbage, bean sprouts, collard greens, plantains, yucca, chayote or other squash, and broccoli. IF NEEDED: INCLUDE any form of the vegetable: raw, cooked, canned, frozen, or dried.

NEVER 1

1 TO 3 TIMES LAST MONTH 2

1 TO 2 TIMES PER WEEK 3

3 TO 4 TIMES PER WEEK 4

5 TO 6 TIMES PER WEEK 5

1 TIME PER DAY 6

2 TIMES PER DAY 7

3 TIMES PER DAY 8

4 TIMES PER DAY 9

5 OR MORE TIMES PER DAY 10

REFUSED 77

DON'T KNOW 99

NAVIGATION: If Never, GO TO 31 [EATS.8].

30 EATS.7a (R 1,2,3) Each of these times that you ate other vegetables, how much did you usually eat? Would you say . . .

less than 1/2 cup, 1

1/2 to 1 cup, 2

1 to 2 cups, or 3

more than 2 cups? 4

REFUSED 77

DON'T KNOW 99

31 EATS.8 (R 1,2,3) (During the past month), how often did you have tomato sauces such as with spaghetti or noodles or mixed into foods such as lasagna? Please do not count tomato sauce on pizza.

NEVER 1

1 TO 3 TIMES LAST MONTH 2

1 TO 2 TIMES PER WEEK 3

3 TO 4 TIMES PER WEEK 4

5 TO 6 TIMES PER WEEK 5

1 TIME PER DAY 6

2 TIMES PER DAY 7

3 TIMES PER DAY 8

4 TIMES PER DAY 9

5 OR MORE TIMES PER DAY 10

REFUSED 77

DON'T KNOW 99

NAVIGATION: If Never, GO TO 33 [EATS.11].

32 EATS.8a (R 1,2,3) Each time you ate tomato sauce, how much did you usually eat? Would you say . . .

about 1/4 cup, 1

about 1/2 cup, 2

about 1 cup, or 3

more than 1 cup? 4

REFUSED 77

DON'T KNOW 99

33 EATS.11 (R 1,2,3) (During the past month), how often did you have Mexican-type salsa made with tomato?

IF NEEDED: INCLUDE: all tomato-based salsas.

NEVER 1

1 TO 3 TIMES LAST MONTH 2

1 TO 2 TIMES PER WEEK 3

3 TO 4 TIMES PER WEEK 4

5 TO 6 TIMES PER WEEK 5

1 TIME PER DAY 6

2 TIMES PER DAY 7

3 TIMES PER DAY 8

4 TIMES PER DAY 9

5 OR MORE TIMES PER DAY 10

REFUSED 77

DON'T KNOW 99

NAVIGATION: If Never, for Round 1 GO TO 35 [NHANES.DMQ.241]; for Rounds 2,3 GO TO 40 [FAB-Shop.01].

34 EATS.11a (R 1,2,3) Each time you ate salsa, how much did you usually eat? Would you say . . .

less than 1 tablespoon, 1

1-2 tablespoons, 2

3-5 tablespoons, or 3

more than 5 tablespoons? 4

REFUSED 77

DON'T KNOW 99

Respondent Characteristics

(R 1)

35 NHANES.DMQ.241 (R 1) Now I'm going to ask you a few questions about yourself. Do you consider yourself to be Hispanic or Latino?

IF NEEDED: READ IF NEEDED: Where do your ancestors come from? Are they Puerto Rican; Cuban/Cuban American; Dominican Republic; Mexican/Mexican American; Central/South American; Other Latin American; Other Hispanic or Latino

Hispanic or Latino 1

Not Hispanic or Latino 2

REFUSED 7

DON'T KNOW 9

36 NHANES.SCQ.270 (R 1) What race do you consider yourself to be? You may give one or more races. Are you American Indian or Alaskan Native, Asian, Black or African American, native Hawaiian or Pacific Islander, or white?

IF NEEDED: Select all that apply.

American Indian or Alaskan Native 1

Asian 2

Black 3

Native Hawaiian or other Pacific Islander 4

White 5

REFUSED 77

37 NHANES.ACQ.011 (R 1) What language or languages do you usually speak at home?

IF NEEDED: Select all that apply.

ENGLISH 11

SPANISH 12

OTHER 13

REFUSED 77

DON'T KNOW 99

38 Marr.1 (R 1) Are you . . .

IF RESPONDENT SAYS "Single", RE-READ REPONSE OPTIONS.

married, 1

not married but living with a partner, 2

widowed, 3

divorced, 4

separated, or 5

never married? 6

Other: _________________________ 7

REFUSED 77

39 NHANES.DMQ.141 (R 1) What is the highest grade or level of school you have completed or the highest degree you have received?

[IF R SAYS "high school", PROBE: Did you get a diploma or GED?] Training note: if respondent says "some technical school" or "technical certificate", then probe the two or three most likely lower levels of education. For example: "Of these, which would be the highest level of school you have completed: 12th grade no diploma; high school graduate, or GED or equivalent?

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

NEVER ATTENDED/KINDERGARTEN ONLY 0

REFUSED 77

DON’T KNOW 99

Transition to Shopper

(R 1,2,3)

40 FAB-Shop.01 (R 1,2,3) Now I would now like to ask you about food shopping. Who is the primary food shopper in your household? The primary food shopper is the person who does the grocery shopping most often.

RESPONDENT 1

R TAKES TURNS WITH OTHERS 2

R GOES TOGETHER WITH OTHERS 3

SPOUSE OR PARTNER OF R 4

A PARENT OF R 5

SOMEONE OTHER THAN R 6

REFUSED 77

DON'T KNOW 99

NAVIGATION: If spouse or partner, parent, someone else, Refuse, or D/K, then CONTINUE with 41 [C1a]. Otherwise, GO TO beginning of shopper interview [CSWP.101a].

Respondent Contact Information

(R 1,2,3)

41 C1a (R 1,2,3) I have some questions that I need to ask the primary food shopper. Once {PRIMARY SHOPPER’S_FNAME, PS_LNAME} has completed the primary shopper interview, we will send your household a {$20/$30/$40} check to thank you for participating in the study. Let me make sure I have your name correctly – is it {RESPONDENT FNAME, MNAME, LNAME}?

IF NEEDED: If No, enter corrected respondent name.

FNAME

MNAME

LNAME

NAVIGATION: GO TO contact information section of shopper interview [C1c].

End Respondent Interview

(R 1,2,3)

42 CR6 (R 1,2,3) Thank you for all the time you’ve spent answering questions about food which will help SNAP improve services and better meet the needs of the people who use this program.

43 CR7 (R 1,2) We look forward to talking you again in about three to six months.

44 CR9 (R 1,2,3) May I speak with the primary food shopper now?

Healthy Incentives Pilot – Round 1 Primary Food Shopper Questionnaire

Shopper Introduction

NAVIGATION: IF THE SAMPLED RESPONDENT INTERVIEW IS WITH AN ADULT RESPONDENT AND HAS BEEN COMPLETED, GO TO GO TO INTROSHOP.01

1 IntroShop.01 (R 1,2,3) Hello, my name is [INTERVIEWER NAME], may I speak with [NAME OF PRIMARY SHOPPER]?

2 IntroShop.02 (R 1,2,3) My name is [INTERVIEWER NAME] and I am calling about the USDA /FNS SNAP, formerly known as the Food Stamp Program. We’re interested in learning how the program is working in Hampden County. Are you the primary food shopper in your household? The primary food shopper is the person who does the grocery shopping most often.

Yes 1

No 2

NAVIGATION: If Yes, GO TO 4 [IntroShop.04]. If No, GO TO the Parent Consent for Minors interview, item [PC01].

3 IntroShop.03 (R 1,2,3) May I speak with [NAME OF SHOPPER]?

Yes 1

No 2

HH Composition

(R 1,2,3)

4 IntroShop.04 (R 1,2,3) My name is [INTERVIEWER] and I am calling about the USDA/FNS SNAP, formerly known as the Food Stamp Program. We’re interested in learning how the program is working in Hampden County. We would like to ask you some questions about food and shopping that will help SNAP improve services and better meet the needs of the people who use this program. This part of the interview takes about 10 minutes. We are sending [NAME OF SAMPLED RESPONDENT] a [$20/$30/$40] check to thank your household for for participating in the study. Your participation is voluntary. You have the right to stop at any time or skip questions. Taking part in this study will not affect your benefits in any way – either now or in the future. We do not plan to share this information with anyone other than USDA/FNS and its contractors, except otherwise required by law. Data that identify you or your family members will not be included in any report. There is a small risk of the loss of privacy of your data, but our data security plans and procedures minimize this risk. {R’S_FN, R_LN} mentioned that you did most of the shopping in the household. We’d like to ask you some questions about your household, shopping for your household and about food in the home.

Do you agree to participate?

5 CSWP.101a (R 1,2,3) How many people currently live in your household, including yourself? By household, I mean your family and other people who live with you and with whom you share food and food expenses.

|___|___|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

6 CSWP.101b.a (R 1,2,3) Of these, how many are adults between 18 and 65 years?

|___|___|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

7 CSWP.101b.s (R 1,2,3) Of these, how many are adults over 65 years?

|___|___|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

8 CSWP.101c (R 1,2,3) How many are children between the ages of 5 and 17 years?

|___|___|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

9 CSWP.101d (R 1,2,3) And, how many are children under 5 years of age?

|___|___|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

Participation in Other Nutrition Assistance Programs

(R 1)

10 Household.1 (R 1) The next questions ask about participation in nutrition assistance programs. In the {current/last} school year, have any children in your household received free or reduced price lunch from the National School Lunch Program?

INTERVIEWER: If the interview is in summer, ask about "last school" year, if during the school year, ask about "current" school year.

Yes 1

No 2

REFUSED 77

DON'T KNOW 99

NAVIGATION: SKIP this item if no children 5-17 years old in household.

11 Household.2 (R 1) In the last month, did anyone in your household receive assistance from the WIC program?

INTERVIEWER: refer to calendar for past 30 days reference period

Yes 1

No 2

REFUSED 77

DON'T KNOW 99

12 Household.3a (R 1) In the last month, did any children in your household attend the Head Start program or a child care program where they got free meals?

INTERVIEWER: refer to calendar for past 30 days reference period

Yes 1

No 2

REFUSED 77

DON'T KNOW 99

NAVIGATION: SKIP this item if no children 0-5 years old in household.

13 Household.4 (R 1) In the last month, did anyone in your household receive assistance from Meals on Wheels or the Senior Nutrition Progam?

INTERVIEWER: refer to calendar for past 30 days reference period

Yes 1

No 2

REFUSED 77

DON'T KNOW 99

NAVIGATION: SKIP this item if no adults over age 65 in household.

14 Household.5 (R 1) In the last month, did anyone in your household receive food from a food pantry or soup kitchen, such as the Open Pantry, Lorraine’s Food Pantry and Soup Kitchen, or Kate’s Kitchen?

INTERVIEWER: refer to calendar for past 30 days reference period

Yes 1

No 2

REFUSED 77

DON'T KNOW 99

Family Food Environment

(R 1,2,3)

15 NHANES.CBQ.020 (R 1,2,3) The next questions ask how often you have certain types of food available at home. How often do you have fruits available at home? This includes fresh, dried, canned and frozen fruits. Would you say always, most of the time, sometimes, rarely, or never?

INTERVIEWER: READ IF NEEDED: "Do not include juice".

Always 1

Most of the time 2

Sometimes 3

Rarely 4

Never 5

REFUSED 7

DON'T KNOW 9

16 Have.1 (R 1,2,3) How often do you have fruits in the refrigerator or on the kitchen counter? [Would you say always, most of the time, sometimes, rarely, or never?]

Always 1

Most of the time 2

Sometimes 3

Rarely 4

Never 5

Don't have a refrigerator 6

REFUSED 7

DON'T KNOW 9

17 NHANES.CBQ.030 (R 1,2,3) How often do you have vegetables available at home? This includes fresh, dried, canned, and frozen vegetables. [Would you say always, most of the time, sometimes, rarely, or never?]

Always 1

Most of the time 2

Sometimes 3

Rarely 4

Never 5

Don't have a freezer 6

REFUSED 7

DON'T KNOW 9

18 Have.2 (R 1,2,3) How often do you have ready to eat vegetables such as baby carrots, cherry tomatoes, or vegetables that you have sliced to make them ready to eat in the refrigerator or on the kitchen counter? [Would you say always, most of the time, sometimes, rarely, or never?]

INTERVIEWER: IF NEEDED, SAY: Include vegetables you can eat without heating or cooking.

Always 1

Most of the time 2

Sometimes 3

Rarely 4

Never 5

REFUSED 7

DON'T KNOW 9

19 NHANES.CBQ.040 (R 1,2,3) How often {does your family/do you} have salty snacks such as chips and crackers available at home? Do not include nuts. [Would you say always, most of the time, sometimes, rarely, or never?]

Always 1

Most of the time 2

Sometimes 3

Rarely 4

Never 5

REFUSED 7

DON'T KNOW 9

20 NHANES.CBQ.050 (R 1,2,3) How often {does your family/do you} have 1% fat, skim or fat-free milk available at home? Please do not include 2% milk. [Would you say always, most of the time, sometimes, rarely, or never?]

Always 1

Most of the time 2

Sometimes 3

Rarely 4

Never 5

REFUSED 7

DON'T KNOW 9

21 NHANES.CBQ.060 (R 1,2,3) How often {does your family/do you} have soft drinks, fruit-flavored drinks, or fruit punch available at home? Please do not include diet drinks, 100 percent juice or sports drinks. [Would you say always, most of the time, sometimes, rarely, or never?]

Always 1

Most of the time 2

Sometimes 3

Rarely 4

Never 5

REFUSED 7

DON'T KNOW 9

22 NHANES.CBQ.180 (R 1,2,3) The next questions ask about your evening meals at home. During the past month, how often did all or most of your family sit down and eat evening meals together at home?

Always 1

Most of the time 2

Sometimes 3

Rarely 4

Never 5

REFUSED 7

DON'T KNOW 9

NAVIGATION: SKIP THIS ITEM if only 1 person in HH.

23 NHANES.CBQ.190 (R 1,2,3) During the past month, how often were evening meals cooked at home?

INTERVIEWER: IF NEEDED, SAY: Include leftovers from meals cooked at home.

Always 1

Most of the time 2

Sometimes 3

Rarely 4

Never 5

REFUSED 7

DON'T KNOW 9

General Shopping Patterns

(R 1,2,3)

24 FAB.Shop.02 (R 1,2,3) Where do you usually go grocery shopping?

Large chain grocery store or supermarket 1

Natural or organic supermarket (such as Whole Foods Market) 2

Small local store or corner store 3

Convenience store (such as 7-Eleven or mini market) 4

Warehouse club store (such as Sam’s Club or Costco) 5

Discount superstore (such as Wal-Mart) 6

Online delivery (such as Peapod or Fresh Direct) 7

Ethnic market 8

Farmer’s market/co-op 9

OTHER, specify □

REFUSED 77

DON'T KNOW 99

25 Shop.14 (R 1,2,3) You said you usually shop for groceries at a {STORE TYPE IN Q 24 [FAB.Shop.02]}. Why do you usually shop at a {STORE TYPE IN Q 24 [FAB.Shop.02]}?

INTERVIEWER: Do not read response options. SELECT ALL THAT APPLY.

Close to home 1

Close to work or school 2

Location convenient (other) 3

Affordable price 4

Lots of in-store promotions 5

Variety of products 6

Ethnic foods are available 7

Preferred products are always available 8

Better or fresher produce 9

Good service 10

Clean 11

Familiarity with store 12

Convenient hours of operation 13

Accepts EBT card 14

Other 15

REFUSED 16

DON'T KNOW 17

26 Shop.15 (R 1,2,3) How often do you usually shop for groceries?

More than once a week 1

Once a week 2

Every other week 3

Once a month 4

Every other month 5

2-3 times a year 6

Yearly or not at all 7

REFUSED 77

DON'T KNOW 99

27 Shop.16 (R 1,2,3) Do you go out of your way or make special efforts to go to a particular store to shop for fruits and vegetables?

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

28 Shop.17 (R 1,2,3) How often does limited transportation keep you from shopping for groceries?

Always 1

Most of the time 2

Sometimes 3

Rarely 4

Never 5

REFUSED 7

DON'T KNOW 9

29 Shop.18 (R 1,2,3) How often does distance to grocery store keep you from shopping for groceries?

Always 1

Most of the time 2

Sometimes 3

Rarely 4

Never 5

REFUSED 7

DON'T KNOW 9

Food Expenditures

(R 1,2,3)

30 CES.x1a (R 1,2,3) The next questions ask about money spent for food, beverages, and other items you and/or your household usually purchase. What has been your household usual MONTHLY expense for grocery shopping purchases made only with SNAP? Include grocery stores, convenience stores, specialty stores, and farmers markets.

$ |___|___|___|___|___|___|___|___|___|

NO MONEY SPENT 0

REFUSED 7

DON'T KNOW 9

ENTER UNIT

Week 1

Month 2

REFUSED 7

DON'T KNOW 9

31 CES.x1b (R 1,2,3) What has been your household usual MONTHLY expense for grocery shopping purchases not using SNAP? Include grocery stores, convenience stores, specialty stores, and farmers markets.

$ |___|___|___|___|___|___|___|___|___|

NO MONEY SPENT 0

REFUSED 7

DON'T KNOW 9

ENTER UNIT

Week 1

Month 2

REFUSED 7

DON'T KNOW 9

32 CES.x2 (R 1,2,3) About how much of this amount was for nonfood items, such as paper products, detergents, home cleaning supplies, pet foods, and alcoholic beverages?

$ |___|___|___|___|___|___|___|___|___|

NO MONEY SPENT 0

REFUSED 7

DON'T KNOW 9

ENTER UNIT

Week 1

Month 2

REFUSED 7

DON'T KNOW 9

33 CES.x3 (R 1,2,3) What has been your household’s usual MONTHLY expense for meals or snacks from restaurants, fast food places, cafeterias, carryouts, or other such places?

$ |___|___|___|___|___|___|___|___|___|

NO MONEY SPENT 0

REFUSED 7

DON'T KNOW 9

ENTER UNIT

Week 1

Month 2

REFUSED 7

DON'T KNOW 9

34 Expend.01 (R 1,2,3) What has been your household’s usual MONTHLY expense for fruits and vegetables?

$ |___|___|___|___|___|___|___|___|___|

NO MONEY SPENT 0

REFUSED 7

DON'T KNOW 9

ENTER UNIT

Week 1

Month 2

REFUSED 7

DON'T KNOW 9

Shopper Employment Status

(R 1,2,3)

35 Employ.01s (R 1,2,3) Now I would like to ask you about employment. We would like to know what you do – are you working now, looking for work, retired, keeping house, a student, or what?

Working at a job or businessfull time now 11

Working part time now 12

Only temporarily laid off 13

Sick leave or maternity leave 14

Looking for work 15

Unemployed 16

Retired 17

Disabled, permanently or temporarily 18

Keeping house 19

Student 20

Other 21

REFUSED 77

DON'T KNOW 99

HH Employment Status

(R 1,2,3)

36 Employ.02 (R 1,2,3) Regarding employment, not including yourself, how many adults age 18 and older in the household were employed full-time last week?

|___|___|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

NAVIGATION: SKIP this item if HH has 1 adult, or if Shopper is minor and HH has 0 adults and GO TO 39 [Employ.05].

37 Employ.03 (R 1,2,3) Not including yourself, how many adults in the household were employed part-time last week?

|___|___|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

38 Employ.04 (R 1,2,3) Not including yourself, how many adults in the household were not employed last week?

|___|___|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

39 Employ.05 (R 1,2,3) Were any youth (16 or 17 year old) in your household employed last week?

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

NAVIGATION: SKIP this item if no children aged 5-17 in HH and GO TO NAVIGATION instructions following 42 [Employ.08]. If No, Refused or D/K, follow navigation rule for 42 [Employ.08].

40 Employ.06 (R 1,2,3) How many youth were employed full time last week?

|___|___|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

41 Employ.07 (R 1,2,3) How many youth were employed part time last week?

|___|___|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

42 Employ.08 (R 1,2,3) How many youth were not employed last week?

|___|___|

ENTER NUMBER

REFUSED 77

DON'T KNOW 99

If Sampled Respondent is a minor and sampled respondent interview has not been completed, GO TO parent consent for minors interview. If Sampled Respondent is a minor and sampled respondent interview is complete, GO TO 66 [C6]. If Sampled Respondent is not Primary Shopper, GO TO 66 [C6]. If Sampled Respondent is Primary Shopper, GO TO 43 [C1b].

Contact Information

(R 1,2,3)

43 C1b (R 1,2,3) To thank you for participating in the study, we want to send your household a {$20/$30/$40} check. Let me make sure I have your name correctly – is it {RESPONDENT NAME}?

INTERVIEWER: If No, enter corrected respondent name.

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

44 C1c (R 1,2,3) Please give the best place to mail your incentive check to. What is your mailing address?

45 C1d (R 1,2,3) Is this also the address where you live?

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

46 C1e (R 1,2,3) What is the address where you live?

47 C2a (R 1,2) We’re eager to talk to you again between {February and May 2012, in about 3 to 5 months/August and November 2012, in about 9 to 11 months}. We want to make sure we don’t lose track of you. We will not share your contact information with DTA or USDA/FNS, except otherwise required by law. What is your home phone number, starting with the area code:

[____] - ______ - ________

ENTER PHONE NUMBER

REFUSED 7

DON'T KNOW 9

48 C2b (R 1,2) May I have your cell phone number, starting with the area code:

[____] - ______ - ________

ENTER PHONE NUMBER

REFUSED 7

DON'T KNOW 9

49 C2c (R 1,2) Do you have an email address?

Yes 1

No 2

REFUSED 7

DON'T KNOW 9

50 C2d (R 1,2) What is your email address. [ENTER EMAIL ADDRESS. READ THE E-MAIL ADDRESS BACK TO THE RESPONDENT FOR THEM TO VERIFY.]

________________ @ ________________

51 C3a (R 1,2) Could you please tell me the name and address of someone who is likely to know where you are if you move or we can’t reach you? [RECORD NAME OR INDICATE REFUSAL OR DON’T KNOW]

________________________

ENTER NAME

REFUSED 7

DON'T KNOW 9

52 C3b (R 1,2) What is their address?

53 C3c (R 1,2) What is their phone number? And what type of phone is this? [ALLOW FOR ENTRY OF MULTIPLE PHONE NUMBERS AND ABILITY TO SELECT PHONE TYPE HOME, WORK, CELL PHONE.]

[____] - ______ - ________

ENTER PHONE NUMBER

Home 1

Work 2

Cell 3

Other 4

REFUSED 7

DON'T KNOW 9

54 C3d (R 1,2) Do you know if they have an email address it is and what it is?

________________ @ ________________

55 C3e (R 1,2) What is this person’s relationship to you?

Husband/partner 1

Wife/Partner 2

Boyfriend 3

Girlfriend 4

Mother 5

Father 6

Sibling 7

Friend 8

Other relative 9

56 C4a (R 1,2) Is there someone else who would know where you are if you move or we can’t reach you [RECORD NAME]?

________________________

ENTER NAME

REFUSED 7

DON'T KNOW 9

57 C4b (R 1,2) What is their address?

58 C4c (R 1,2) What is their phone number? And what type of phone is this? [ALLOW FOR ENTRY OF MULTIPLE PHONE NUMBERS AND ABILITY TO SELECT PHONE TYPE HOME, WORK, CELL PHONE.]

[____] - ______ - ________

ENTER PHONE NUMBER

Home 1

Work 2

Cell 3

Other 4

REFUSED 7

DON'T KNOW 9

59 C4d (R 1,2) Do you know if they have an email address it is and what it is?

________________ @ ________________

60 C4e (R 1,2) What is this person’s relationship to you?

Husband/partner 1

Wife/Partner 2

Boyfriend 3

Girlfriend 4

Mother 5

Father 6

Sibling 7

Friend 8

Other relative 9

61 C5a (R 1,2) Is there someone else who would know where you are if you move or we can’t reach you [RECORD NAME]?

________________________

ENTER NAME

REFUSED 7

DON'T KNOW 9

62 C5b (R 1,2) What is their address?

63 C5c (R 1,2) What is their phone number? And what type of phone is this? [ALLOW FOR ENTRY OF MULTIPLE PHONE NUMBERS AND ABILITY TO SELECT PHONE TYPE HOME, WORK, CELL PHONE.]

[____] - ______ - ________

ENTER PHONE NUMBER

Home 1

Work 2

Cell 3

Other 4

REFUSED 7

DON'T KNOW 9

64 C5d (R 1,2) Do you know if they have an email address it is and what it is?

________________ @ ________________

65 C5e (R 1,2) What is this person’s relationship to you?

Husband/partner 1

Wife/Partner 2

Boyfriend 3

Girlfriend 4

Mother 5

Father 6

Sibling 7

Friend 8

Other relative 9

NAVIGATION: If Sampled Respondent is a minor and primary shopper interview has NOT been completed, GO TO 3 [IntroShop.03]. If Sampled Respondent is a minor and primary shopper interview has been completed, GO TO 66 [C6]. If Sampled Respondent is Primary Shopper, GO TO 66 [C6]. If Sampled Respondent is not a minor and if Sampled Respondent is NOT Primary Shopper, then return to “End Respondent Interview” section of respondent interview.

End Shopper Interview

(R 1,2,3)

66 C6 (R 1,2,3) Thank you for all the time you’ve spent answering questions about food and shopping which will help SNAP improve services and better meet the needs of the people who use this program.

67 C7 (R 1,2) We look forward to talking you again in about three to six months.

68 C8 (R 1,2,3) Good bye.