APPENDIX A
RECOMMENDED REVISIONS TO MEAL DELIVERY QUESTIONNAIRE
OMB Control # 0584-0560NEW
Expiration Date: 7/31/2014
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 (0584-0560*). Do not return the completed form to this address.
MEAL DELIVERY PROGRAM
PARENT QUESTIONNAIRE SUMMER 2012 (Round 3)
INTRODUCTION
NOTE: Interviews will be conducted with primary care giver or other adult who can answer questions about children in the household.
INTRO1: Hello, may I speak to [NAMED ADULT FROM SAMPLE FILE]?
Yes/speaking or available Continue
No INTRO4
INTRO2: My name is ______________ and I’m calling on behalf of the [PROGRAM]. Our records show that one or more children from your household is taking part in this program and we’d like to ask you some questions about this. Are you familiar with your child(ren)’s participation in this program?
Yes START
No Continue
INTRO3: May I speak to an adult in this household who is familiar with this program?
Knowledgeable adult available INTRO2 [TO NEW ADULT]
Adult not available Collect first name and schedule call-back
INTRO4: My name is ______________ and I’m calling on behalf of the [PROGRAM]. Our records show that one or more children from your household is taking part in this program and we’d like to ask you some questions about this. May I speak to an adult in this household who is familiar with this program?
Knowledgeable adult speaking or available START
Adult not available schedule call-back
START: The interview takes about 30 minutes to complete. Your participation in this survey is voluntary. You have the right to stop at any time or skip questions with no penalty. All your answers are private and the information you provide will not be identified by your name, except as otherwise required by law. You will receive (INCENTIVE) as a thank you for completing the survey. Your answers to our survey questions will provide important [PROGRAM] with important information to help improve its services. Any information you provide will remain private.
ASK FIRST SURVEY QUESTION.
PARTICIPATION IN MEAL DELIVERY DEMONSTRATION PROJECT
For this survey, when I say household I mean your family and other people who live in your household and with whom you share food and food expenses.
1. Thinking about your household please tell me the first name and age of all people in your household who received a meal delivery from (NAME OF MEAL DELIVERY PROGRAM).
Name |
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2. Was the meal delivery:
At Home 1
Drop-off Site 2
REFUSED 77
DON’T KNOW 99
FOR MEAL DELIVERY AT HOME
3. How many days a week do you receive meal delivery for (NAME OF PERSON)?
No. days per week ____|___|___| days
REFUSED 77
DON’T KNOW 99
4. How many (weeks) did (NAME OF PERSON) receive a meal from the (NAME OF PROGRAM) at your home?
June: |___|___| weeks
July: |___|___| weeks
August: |___|___| weeks
5. Did you or someone else have to be home at the time of meal delivery?
Yes 1
No 2
REFUSED 77
DON’T KNOW 99
6. Did you have to sign a (FORM OR SLIP) each time you received the meal delivery?
Yes 1
No 2
REFUSED 77
DON’T KNOW 99
7. Were you satisfied with the schedule of meal delivery?
Yes 1
No 2
REFUSED 77
DON’T KNOW 99
FOR MEAL DELIVERY AT A DROP-OFF SITE
8. How many days a week do you receive meals at a drop-off site?
No. days per week ____|___|___| days
REFUSED 77
DON’T KNOW 99
9. How many weeks did (NAME OF PERSON) receive meals from (NAME OF PROGRAM)?
June: |___|___| weeks
July: |___|___| weeks
August: |___|___| weeks
10. How far do you have to travel to pick up the meals from (name of program)?
One mile or less 1
More than one mile 2
REFUSED 77
DON’T KNOW 99
11. Who usually picks up the meals? (CHECK ALL THAT APPLY)
Parent 1
Sibling 2
Relative 3
Child himself/herself 4
Other, specify: ________________ 5
REFUSED 77
DON’T KNOW 99
12. Did you have to sign a (FORM OR SLIP) each time you picked up the meal?
Yes 1
No 2
REFUSED 77
DON’T KNOW 99
13. Was there ever an occasion when the meal wasn’t picked up?
Yes 1 GO TO #14
No 2 GO TO #15
REFUSED 77 GO TO #15
DON’T KNOW 99 GO TO #15
14. Please tell me if the meals were not picked up on one or more occasion because …
INTERVIEWER: Check all that apply
It takes too long to get to the drop-off site 1
You did not have transportation to get to the drop-off site 2
The timing of meal pick up is not convenient for you 3
There is a long wait to pick up a meal 4
Other, specify:_________________________________ 5
REFUSED 77
DON’T KNOW 99
MEALS ALWAYS PICKED UP, DOES NOT APPLY 88
FOR MEAL DELIVERY AT HOME AND DROP-OFF SITE
15. How did you find out about the meal delivery program?
Flyer 1
Brochure 2
Newsletter 3
Word of mouth 4
Other, specify:_______________ 5
REFUSED 77
DON’T KNOW 99
16. Where did you find out about the meal delivery program?
At child’s school...................................1
At summer food program.....................2
At another program signup..................3
At church..............................................4
Some other advertising........................5
Other, specify.......................................6
REFUSED..........................................77
DON’T KNOW ....................................99
17. Why did you enroll your children (or others) to receive a meal delivery from (NAME OF PROGRAM)?
Needed the food and no other option...1
Needed the food and more
convenient than other options .........2
Other, specify........................................3
REFUSED...........................................77
DON’T KNOW.....................................99
SFSP Meal Description, Consumption, Sharing and Wastage
Now I am going to ask you some questions about the meals that your children (or others) received through (NAME OF THE PROGRAM)
18. Now please think about the most recent meal delivery you received. What foods were provided?
INTERVIEWER: Do not read. Check all that apply.
Name of Person |
Milk |
Fruit |
Juice |
Vegetable |
Bread/ Grains |
Meat |
Meat Alternate |
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19. For this question, please tell me how often your children (or others who received the meal delivery) drank or ate (NAME OF FOOD)?
How many… |
Always |
Most of the Time |
Sometimes |
Rarely |
Never |
Refused |
DK |
Drank Milk |
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Ate Fruit |
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Drank Fruit Juice |
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Vegetable |
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Bread/Grains |
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Meat |
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Meat Alternate |
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20. Did any of the PEOPLE in your household share (NAME OF FOOD) from the meal delivery with each other, other children in the household who did not receive a meal delivery, adults in the household, friends, or others?
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Share (NAME OF FOOD) |
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Food |
Yes |
No |
Refused |
DK |
Milk |
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Fruit |
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Fruit Juice |
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Vegetable |
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Bread/Grains |
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Meat |
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Meat Alternate |
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21. If yes to #20 (for each food), who did they share (NAME OF FOOD) it with?
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Who was (NAME OF FOOD) shared with? |
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Food |
Children in the HH who also get a meal delivery |
Children in the HH who don’t get a meal delivery |
Adults |
Friend |
Pet |
Other, Specify |
Refused |
DK |
Milk |
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Fruit |
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Fruit Juice |
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Vegetable |
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Bread/Grains |
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Meat |
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Meat Alternate |
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22. Thinking about all the food that was provided in the meal delivery package, can you tell me whether any of the food became spoiled?
Food |
Yes, became spoiled |
Don’t know |
Refused |
Milk |
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Fruit |
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Fruit Juice |
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Vegetable |
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Bread/Grains |
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Meat |
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Meat Alternate |
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23. Were there any foods in the meal delivery package that were not eaten by anyone?
Yes 1 GO TO #24
No 2 GO TO #25
REFUSED 77 GO TO #25
DON’T KNOW 99 GO TO #25
24. I am going to ask you about the foods that were left over. Which foods were left over? What was the reason for not eating these foods? What was done with the food?
Food |
Why was (food not eaten)* |
What was |
Milk |
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Fruit |
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Fruit Juice |
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Vegetable |
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Bread/Grains |
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Meat |
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Meat Alternate |
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*Codes for Why Was (Food Not Eaten)
Child did not like it...................................1
Plan to eat it later....................................2
Didn’t know how to cook it......................3
We went out to eat..................................4
Child hasn’t been home..........................5
Food was spoiled....................................6
Other, specify..........................................7
REFUSED.............................................77
DON’T KNOW.......................................99
**Codes for what was done with food:
Thrown away 1
Returned to Drop-off site 2
Given away to friend/neighbor 3
Saved for later 4
Other, specify 5
REFUSED 77
DON’T KNOW 99
Parent Satisfaction with SFSP Demonstration and Foods
Now I am going to ask you a few questions about your impression of the meals included in the meal delivery.
25. How would you describe the meals that are provided? Would you say the foods are healthy, somewhat healthy, or not at all healthy?
Very healthy 1
Somewhat healthy 2
Not at all healthy 3
REFUSED 77
DON'T KNOW 99
For the next few questions, please tell me if you agree strongly, agree, neither agree nor disagree, disagree, or disagree strongly with these statements.
26. The delivery packages generally include a variety of foods. Would you say you …
Agree strongly 1
Agree 2
Neither agree nor disagree 3
Disagree 4
Disagree strongly 5
REFUSED 77
DON'T KNOW 99
27. The delivery package foods are convenient to eat. Would you say you …
Agree strongly 1
Agree 2
Neither agree nor disagree 3
Disagree 4
Disagree strongly 5
REFUSED 77
DON'T KNOW 99
28. People who get the meal delivery in my household like the foods provided in the package. Would you say you …
Agree strongly 1
Agree 2
Neither agree nor disagree 3
Disagree 4
Disagree strongly 5
REFUSED 77
DON'T KNOW 99
HH Food Security
The next questions are about the food eaten in your household in the last 30 days, which is (REFER TO START AND END DATE).
29. Which of these statements best describes the food eaten in your household in the last 30 days: —enough of the kinds of food (I/we) want to eat; —enough, but not always the kinds of food (I/we) want; —sometimes not enough to eat; or, —often not enough to eat?
Enough of the kinds of food we want to eat 1
Enough but not always the kinds of food we want 2
Sometimes not enough to eat 3
Often not enough to eat 4
REFUSED 77
DON'T KNOW 99
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—that is, since last (name of current month).
30. 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?
Often true 1
Sometimes true 2
Never true 3
REFUSED 77
DON'T KNOW 99
31. “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?
Often true 1
Sometimes true 2
Never true 3
REFUSED 77
DON'T KNOW 99
32. “(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?
Often true 1
Sometimes true 2
Never true 3
REFUSED 77
DON'T KNOW 99
Screener for Stage 2 Adult-Referenced Questions: If affirmative response (i.e., "often true" or "sometimes true") to one or more of Questions 30-32, OR, response [3] or [4] to question 29, then continue to Adult Stage 2; otherwise, skip to Child Stage 1.
Adult Stage 2
33. In the last 30 days, since last (name of current month), 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
REFUSED 77
DON’T KNOW 99
34. [IF YES ABOVE, ASK] In the last 30 days, how many days did this happen?
INTERVIEWER: If needed, did that happen on 3 or more days? Y/N
|___|___| days
Enter Number
REFUSED 77
DON’T KNOW 99
35. 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
REFUSED 77
DON’T KNOW 99
36. In the last 30 days, were you every hungry but didn't eat because there wasn't enough money for food?
Yes 1
No 2
REFUSED 77
DON’T KNOW 99
37. In the last 30 days, did you lose weight because there wasn’t enough money for food?
Yes 1
No 2
REFUSED 77
DON’T KNOW 99
Screener for Stage 3 Adult-Referenced Questions: If affirmative response to one or more of questions 29 through 32, then continue to Adult Stage 3; otherwise skip to Child Stage 1.
Adult Stage 3
38. 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
REFUSED 77
DON’T KNOW 99
39. [IF YES ABOVE, ASK] In the last 30 days, how many days did this happen?
INTERVIEWER: If needed, did that happen on 3 or more days? Y/N
|___|___| days
Enter Number
REFUSED 77
DON’T KNOW 99
Child Stage 1:
ADMINISTER TO ALL HOUSEHOLDS WITH CHILDREN
UNDER 18
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).
40. “(I/we) relied on only a few kinds of low-cost food to feed (my/our) child/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?
Often true 1
Sometimes true 2
Never true 3
REFUSED 77
DON'T KNOW 99
41. “(I/We) couldn’t feed (my/our) child/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?
Often true 1
Sometimes true 2
Never true 3
REFUSED 77
DON’T KNOW 99
42. "(My/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 (you/your household) in the last 30 days?
Often true 1
Sometimes true 2
Never true 3
REFUSED 77
DON’T KNOW 99
Screener for Stage 2 Child Referenced Questions: If affirmative response (i.e., "often true" or "sometimes true") to one or more of questions 40-42, then continue to Child Stage 2; otherwise skip to #48.
Child Stage 2
43. In the last 30 days, since (current day) of last month, 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
REFUSED 77
DON’T KNOW 99
44. In the last 30 days, did (CHILD’S NAME/any of the children) ever skip meals because there wasn’t enough money for food?
Yes 1
No 2
REFUSED 77
DON’T KNOW 99
45. [IF YES ABOVE ASK] In the last 30 days, how many days did this happen?
INTERVIEWER: If needed, did that happen on 3 or more days? Y/N
|___|___| days
Enter Number
REFUSED 77
DON’T KNOW 99
46. 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
REFUSED 77
DON’T KNOW 99
47. 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
REFUSED 77
DON’T KNOW 99
48. Would you say that children in your household eat more balanced meals and healthy foods during the regular school year, during the summer, or about the same in the summer and the school year?
Regular school year 1
Summer 2
Eats about the same 77
REFUSED 77
DON’T KNOW 99
49. Thinking about the food available to (NAME OF CHILD) during summer and comparing it to the school year … (CHECK ONE BOX FOR EACH ROW)
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More in the summer |
About the same in summer and school year |
Less in the summer |
DK |
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Was the quantity of food available … |
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Was the variety of food available… |
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Was the amount of fruits and vegetables available … |
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Was the amount of meat available… |
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Was the amount of milk and milk products available … |
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Children ate regular meals … |
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Children ate fast food … |
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Participation in Other Nutrition Assistance Programs
The next few questions are about your household’s participation in other nutrition assistance programs.
50. Have any children in your household participated this summer in a summer food program where they eat meals on site?
Yes ... 1
No ...... 2
REFUSED 77
DON’T KNOW 99
51. Did any children in your household participate last summer in a summer food program where they ate meals on site?
Yes ... 1
No ...... 2
REFUSED 77
DON’T KNOW 99
52. Did your household receive SNAP or food stamp benefits in the past 30 days?
Yes 1
No 2
REFUSED 77
DON’T KNOW 99
53. Did anyone in your household receive assistance from the Women, Infant, and Children program – also known as the WIC program in the past 30 days?
Yes 1 GO TO #54
No 2 GO TO #55
REFUSED 77 GO TO #55
DON’T KNOW 99 GO TO #55
54. How many women participated in WIC in the past 30 days?
|___|___| women
Enter Number
REFUSED 77
DON’T KNOW 99
55. How many Infants and Children participated in WIC in the past 30 days?
|___|___| infants and children
Enter Number
REFUSED 77
DON’T KNOW 99
56. Did any children in your household attend the Head Start program or a preschool child care program where they get free meals in the past 30 days?
Yes 1 GO TO #57
No 2 GO TO #58
REFUSED 77 GO TO #58
DON’T KNOW 55 GO TO #58
57. How many children participated in Head Start or other preschool child care program in the past 30 days?
|___|___| children
Enter Number
REFUSED 77
DON’T KNOW 99
58. Did any children in your household receive free or reduced price school lunches in the past school year (i.e., in the winter or spring 2012)?
Yes 1 GO TO #59
No 2 GO TO #60
REFUSED 77 GO TO #60
DON’T KNOW 55 GO TO #60
59. How many children received free or reduced price lunch in the winter or spring 2012?
|___|___| children
Enter Number
REFUSED 77
DON’T KNOW 99
60. Did anyone in your household receive assistance from Meals on Wheels or the Senior Nutrition Progam in the past 30 days?
Yes 1
No 2
REFUSED 77
DON’T KNOW 99
Perception of Change in Food Expenditure
Now I am going to ask you a couple of questions about the money you spend on food during the school year and summer.
61. Compared with the amount of money you spend on food each month during the school year, would you say you spend:
The same amount on food in the summer months 1
More on food in the summer months 2
Less on food in the summer months 3
REFUSED 77
DON’T KNOW 99
I’m going to read a statement to you. Please tell me how strongly you agree or disagree with the statement.
62. Because the people in my household received meals from (NAME OF MEAL DELIVERY PROGRAM), I spent less money on food during the summer months than if s/he/they had not particpated in the program. Do you …
Agree strongly 1
Agree 2
Neither agree nor disagree 3
Disagree 4
Disagree strongly 5
REFUSED 77
DON’T KNOW 99
Household and Respondent Characteristics
We are almost done. The last few questions are about you and the people who live in your household.
63. Thinking about your entire household, meaning family or other people living in your home, including family and other people who share food and food expenses, how many people currently live in your household, including yourself?
|___|___|
Enter Number
REFUSED 77
DON’T KNOW 99
64. Of these, how many are adults age 65 or older?
|___|___|
Enter Number
REFUSED 77
DON’T KNOW 99
65. How many are adults age 18 to 64?
|___|___|
Enter Number
REFUSED 77
DON’T KNOW 99
66. How many are children age 5 to 17?
|___|___|
Enter Number
REFUSED 77
DON’T KNOW 99
67. And, how many are children under five years of age?
|___|___|
Enter Number
REFUSED 77
DON’T KNOW 99
68. Does anyone in your family have any difficulty in doing day to day activities because of a physical, mental or emotional (or other health) condition?
Yes 1
No 2
REFUSED 77
DON’T KNOW 99
The next set of questions ask about some basic information about you.
69. Are you male or female?
INTERVIEWER: If gender is obvious, enter item without asking; otherwise ask this question.
Male 1
Female 2
REFUSED 77
DON’T KNOW 99
70. Are you Hispanic or Latino?
Yes 1
No 2
Not Hispanic or Latino........................ 3
REFUSED 77
DON’T KNOW 99
71. Which one or more of the following would you say is your race?
INTERVIEWER: Please read. 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
72. What language or languages do you usually speak at home? (DO NOT READ)
INTERVIEWER: Select all that apply.
English 1
Spanish 2
Other, specify:________________ 3
REFUSED 77
DON’T KNOW 99
73. Are you …?
Married 1
Divorced 3
Widowed 2
Separated 4
Never Married 5
Living With Partner 6
REFUSED 77
DON’T KNOW 99
74. What is the highest grade or year of school you completed?
INTERVIEWER: Do not read
Never Attended/Kindergarten Only 0
Grades 1 through 8 (elementary/middle school) 1
Grades 8 through 11 (some high school) 2
Grade 12 or GED (high school graduate) 3
College 1 to 3 years (some college or technical school) 4
College 4 years or more (college graduate) 5
REFUSED 77
DON’T KNOW 99
75. What is your date of birth?
|___|___| / |___|___| / |___|___|___|___|
mm dd yyyy
REFUSED 77
DON’T KNOW 99
76. Are you currently …?
Employed for wages 1
Self-employed 2
Out of work for more than 1 year 3
Out of work for less than 1 year 4
A homemaker 5
A student 6
Retired 7
Unable to work 8
REFUSED 77
DON’T KNOW 99
77. Not including yourself, how many adults in the household were employed full-time last week?
|___|___|
Enter Number
REFUSED 77
DON’T KNOW 99
78. Not including yourself, how many adults in the household were employed part-time last week?
|___|___|
Enter Number
REFUSED 77
DON’T KNOW 99
79. .Not including yourself, how many adults in the household were not employed last week?
|___|___|
Enter Number
REFUSED 77
DON’T KNOW 99
80. Is your annual household income from all sources …?
Less than $25,000 1
If yes, ask…
Less than $20,000 2
If yes, ask…
Less than $15,000 3
If yes, ask…
Less than $10,000 4
If NO to LESS THAN $25,000, ask…
Less than 35,000 5
Less than 50,000 6
Less than 75,000 7
75,000 or more 8
REFUSED 77
DON’T KNOW 99
END1: Thank you so much for completing this interview. The information you provided will help administrators better understand and improve the [PROGRAM]. Because it is important to learn about people’s experiences after they have been in this program for a longer period of time, we’d like to call you again in about 4 to 6 weeks to conduct a follow-up interview. Will this number [READ CURRENT PHONE NUMBER] be the best number to call?
Yes END3
No Continue to END2
END2: What is the best number to call next time?
(_____)_____-________
END3: In case we can’t reach you at this number, please tell me one or two other numbers where we might be able to contact you:
(_____)_____-________
(_____)_____-________
END4: Thank you again for your time. Goodbye.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Beth Riley |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |