Parent Survey

OMB Control No.: 0584-NEW

Expiration Date: xx/xx/20xx

Public reporting burden for this collection of information is estimated to average (insert time) hours [or 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-xxxx*). Do not return the completed form to this address.

BACKPACK PROGRAM PARENT QUESTIONNAIRE SUMMER 2012 (ROUND 1)

INTRODUCTION

NOTE: Interviews will be conducted with primary care giver or other adult who can answer questions about children in the household.

FOR CONTINUING SAMPLE:

INTRO1: Hello, may I speak to [NAME OF ADULT WHO COMPLETED YEAR 1 SURVEYS]?

Yes/speaking or available  START

No  schedule call-back

START: My name is _____________________ and I’m calling on behalf of the [PROGRAM]. We contacted you in 2011 on [R1 COMPLETION DATE] and [R2 COMPLETION DATE] to ask you some questions about [PROGRAM]. Thank you so much for your earlier participation in our study. To understand how people’s experiences with [PROGRAM] change over time, we’d like to complete another interview with you now. 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. All your answers are private and the information you provide will not be identified by your name. 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 confidential. ASK FIRST SURVEY QUESTION.

FOR SUPPLEMENTAL SAMPLE

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: 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 SUMMER FOOD SERVICE PROGRAM AND DEMONSTRATION PROJECTS

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 participated in the (NAME OF PROGRAM).

Name	Age (years)

Now I am going to ask you a few questions about the summer program that (NAME/each of them) attended this summer (IF NEEDED, FROM DATE TO DATE).

For each person listed in #1, Cycle through #2a through #10c.

2. Please tell me if (NAME) is in any summer program now, has attended a program this summer but the program is over, if s/he attended for a while but dropped out?

Name of PERSON	Is currently attending	Attended but program over	Attended for a while but dropped out	DK	Refused
	AUTO FILLED IN #3

3. How many weeks did the (NAME OF PERSON) attend the (NAME OF PROGRAM) in …? Would you say (NAME OF PERSON) attended the program most weekdays, some weekdays, or only on Fridays?

Name of PERSON WHO ATTENDED PROGRAM (AUTO FILL FROM # 2)	Number of weeks and frequency
	June		July		August
	# weeks	How often	# weeks	How often	# weeks	How often

^*Codes for How often:

Most weekdays 1

Some weekdays 2

Only on fridays 3

Other, specify 7

REFUSED 77

DON’T KNOW 99

4. Did (NAME) ever bring home a backpack with food for the weekend?

Name of PERSON WHO ATTENDED PROGRAM (AUTO FILL FROM # 2)	YES	NO	REFUSED	DK
	GO TO #5	GO TO #6	GO TO #7	GO TO #7

5. How many backpacks did (NAME OF PERSON) bring home a backpack in <June, July, August>?

Name of PERSON WHO BROUGHT A BACKPACK HOME (AUTOFILL FROM # 4, IF YES)	June	July	August
	Specify #; 77=Refused, 99=DK

6. Can you tell me why (NAME OF EACH PERSON) did not bring home a backpack with food for the weekend? (CHECK ALL THAT APPLY)

Name of PERSON WHO DID NOT BRING BACKPACK HOME (AUTO FILL FROM # 4, IF NO)	Forgot to bring it/ left it at SFSP site	Doesn’t like food in backpack	Friends tease him/her if s/he brings backpack home	Other, specify	Refused	DK

7. How did you find out that (NAME OF PROGRAM) has a weekend backpack program?

Flyer 1

Brochure 2

Newsletter 3

Word of mouth 4

Other, specify:________________ 5

REFUSED 77

DON’T KNOW 99

8. Why did you decide to send your household members to (NAME OF PROGRAM) this summer?

Backpack with food for the weekend 1

Activities 2

Center timing 3

Near home (or work) 4

Always send them there for the summer 5

Cost of the program 6

Other, specify:_________________________________ 7

REFUSED 77

DON’T KNOW 99

9. What do your children (or others in the summer program) like about the (NAME OF PROGRAM)?

INTERVIEWER: Do not read, check all that apply

Activities offered 1

Foods provided 2

Program staff 3

Location 4

Timing 5

All of their friends attend this program 6

Other, specify:___________________________ 7

REFUSED 77

DON’T KNOW 99

SFSP Backpack Food Description, Consumption, Sharing and Wastage

Now I am going to ask you some questions about the backpack that your children (or others in the backpack demonstration) received through (NAME OF THE PROGRAM)

10. Now please think about the most recent backpack (NAME) received. What foods were provided in that backpack?

INTERVIEWER: DO NOT READ, CHECK ALL THAT APPLY

Name of Person	Milk	Fruit	Juice	Vegetables	Bread/ Grains	Meat	Meat alternate (e.g., beans, tofu)

11. Thinking about all the food that was provided in the backpacks, can you tell me where (NAME OF FOOD) was stored or kept at home?

INTERVIEWER: Do not read, check all that apply

Food	Fridge	Pantry	Counter or Table	Backpack	Child’s room	Other, specify	Refused
Milk
Fruit
Fruit Juice
Vegetable
Bread/Grains
Meat
Meat alternate (e.g., beans, tofu)

12. For this question, please tell me how often your children (or others in the backpack demonstration) drank or ate (NAME OF FOOD)?

Food	Always	Most of the time	Sometimes	Rarely	Never	Refused	DK
Milk
Fruit
Fruit Juice
Vegetable
Bread/Grains
Meat
Meat alternate (e.g., beans, tofu)

13. Did any of the PEOPLE in your household share (NAME OF FOOD) from the backpack with each other, other children in the household who did not attend a summer program, adults in the household, friends, or others?

	Share (NAME OF FOOD)
Food	Yes	No	Refused	DK
Milk
Fruit
Fruit Juice
Vegetable
Bread/Grains
Meat
Meat alternate (e.g., beans, tofu)

14. If yes to #13 (for each food), who did they share (NAME OF FOOD) it with?

	Who was (NAME OF FOOD) shared with?
Food	Children in the HH who also get backpack	Children in the HH who don’t get backpack	Adults in the household	Friends	Pet	Other, Specify	Refused	DK
Milk
Fruit
Fruit Juice
Vegetable
Bread/Grains
Meat
Meat alternate (e.g., beans, tofu)

15. Were there any foods in the backpack that were not eaten by anyone?

Yes 1 GO TO #16

No 2 GO TO #17

REFUSED 77 GO TO #17

DON’T KNOW 99 GO TO #17

16. 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 over the weekend? What was done with the food?

Food	Why Was (Food Not Eaten)	What was done with food?*
Milk
Fruit
Fruit Juice
Vegetable
Bread/Grains
Meat
Meat alternate (e.g., beans, tofu)

^*Codes for What was done with food:

Thrown away 1

Returned to center 2

Given away to friend/neighbor 3

Saved for later 4

Food was spoiled 5

Other, specify 7

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 foods included in the backpacks.

17. How would you describe the food that is provided in the (NAME OF PROGRAM) backpack? Would you say the food is 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.

18. The backpacks 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

19. The backpack 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

20. People who get the backpack in my household like the foods provided in the backpack. 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).

21. 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).

22. 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

23. “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

24. “(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 22-24, OR, response [3] or [4] to question 21, then continue to Adult Stage 2; otherwise, skip to Child Stage 1.

Adult Stage 2

25. 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

26. [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

27. 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

28. 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

29. 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 25 through 29, then continue to Adult Stage 3; otherwise skip to Child Stage 1.

Adult Stage 3

30. 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

31. [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).

32. “(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

33. “(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

34. “(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

INTERVIEWER for Stage 2 Child Referenced Questions: If affirmative response (i.e., “often true” or “sometimes true”) to one or more of questions 32-34, then continue to Child Stage 2; otherwise skip to #40.

Child Stage 2

35. 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

36. 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

37. [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

38. 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

39. 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

40. 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

41. Thinking about the food available to the children in your household during summer and comparing it to the school year … (CHECK ONE BOX FOR EACH ROW)

	More in the summer	About the same in summer and school year	Less in the summer	DK	Refused
Was the quantity of food available …
Was the variety of food available…
Was the amount of fruits and vegetables available …
Was the amount of meat available…
Was the amount of milk and milk products available …
Children ate regular meals …
Children ate fast food …

Participation in Other Nutrition Assistance Programs

The next few questions are about your household’s participation in other nutrition assistance programs.

42. Did your household receive SNAP or food stamp benefits in the past 30 days?

Yes 1

No 2

REFUSED 77

DON’T KNOW 99

43. 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 #44

No 2 GO TO #46

REFUSED 77 GO TO #46

DON’T KNOW 99 GO TO #46

44. How many women participated in WIC in the past 30 days?

|___|___| women

Enter Number

REFUSED 77

DON’T KNOW 99

45. How many Infants and Children participated in WIC in the past 30 days?

|___|___| infants and children

Enter Number

REFUSED 77

DON’T KNOW 99

46. Did any children in your household attend the Head Start program or a preschool child care program where they got free meals in the past 30 days?

Yes 1

No 2

REFUSED 77

DON’T KNOW 99

47. 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

48. 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 #49

No 2 GO TO #50

REFUSED 77 GO TO #50

DON’T KNOW 99 GO TO #50

49. How many children received free or reduced price lunch in the winter or spring, 2012?

|___|___| children

Enter Number

REFUSED 77

DON’T KNOW 99

50. 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.

51. 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.

52. Because the people in my household participated in the summer food 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.

53. 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

54. Of these, how many are adults age 65 or older?

|___|___|

Enter Number

REFUSED 77

DON’T KNOW 99

55. How many are adults age 18 to 64?

|___|___|

Enter Number

REFUSED 77

DON’T KNOW 99

56. How many are children age of 5 to 17?

|___|___|

Enter Number

REFUSED 77

DON’T KNOW 99

57. And, how many are children under five years of age?

|___|___|

Enter Number

REFUSED 77

DON’T KNOW 99

58. 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.

59. 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

60. Are you Hispanic or Latino?

Yes 1

No 2

Not Hispanic or Latino........................ 3

REFUSED 77

DON’T KNOW 99

61. 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

62. 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

63. Are you …?

Married 1

Divorced 3

Widowed 2

Separated 4

Never Married 5

Living With Partner 6

REFUSED 77

DON’T KNOW 99

64. 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

65. What is your date of birth?

|___|___| / |___|___| / |___|___|___|___|

mm dd yyyy

REFUSED 77

DON’T KNOW 99

66. 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

67. Not including yourself, how many adults in the household were employed full-time last week?

|___|___|

Enter Number

REFUSED 77

DON’T KNOW 99

68. Not including yourself, how many adults in the household were employed part-time last week?

|___|___|

Enter Number

REFUSED 77

DON’T KNOW 99

69. Not including yourself, how many adults in the household were not employed last week?

|___|___|

Enter Number

REFUSED 77

DON’T KNOW 99

70. 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.

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