SEBTC - Households
Evaluation of the Impact of the Household-Based Summer Demonstrations on Food Insecurity Among Children (SEBTC)
Appendix B English Follow-Up instrument 3 16 11 Final
SEBTC - Households
OMB: 0584-0559
OMB No.: xxxx-xxxx
Expiration Date: xx/xx/20xx
Summer Electronic Benefit Transfer for Children
Summer Follow-Up Questionnaire
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection will be entered after clearance. The time required to complete this information collection is estimated to average XX minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. |
SECTION A: INTRODUCTION |
[IF INBOUND CALL]
SI1 Just in case we are disconnected, what telephone number can I reach you at to complete the interview?
Provided
phone number 1
(VOL) respondent will call back 2
DON’T KNOW d
REFUSED r
[IF SAMPLE FLAGGED AS CELL PHONE]
SC1 Are you in a safe place to talk right now?
IF DRIVING VOLUNTEERED, CODE AS 2
USE LL INTRO FOR LL CALLBACKS
Yes, safe place to talk 1
No,
call me later 2 SCHEDULE
CALLBACK
No,
CB on land-line 3 RECORD
NUMBER,
SCHEDULE CALLBACK
(VOL)
on landline 4 SKIP
TO A1
DON’T KNOW d
REFUSED r
[IF SAMPLE FLAGGED AS CELL PHONE]
SC2 Are you driving?
No 1
Yes,
call me later 2 SCHEDULE
CALLBACK
DON’T KNOW d
REFUSED r
PROGRAMMER: IF BASELINE INTERVIEW COMPLETED, GO TO A7. OTHERWISE, ASK A1.
A1. Hello, my name is _________ and I’m calling on behalf of the U.S. Department of Agriculture, Food and Nutrition Service. May I please speak to [NAME OF PARENT]?
INTERVIEWER NOTE: REFER TO FA Q’S TO ANSWER ANY QUESTIONS, INCLUDING CONTENT OF SURVEY.
SPEAKING TO [NAME OF PARENT] 1
[NAME OF PARENT] COMES TO PHONE 2
NOT
A GOOD TIME, SCHEDULE CALLBACK 4 GO
TO CALLBACK
A2. We are conducting a research study about the food choices of children and their families for the U.S.D.A., Food and Nutrition Service. The study will help the government make its child nutrition programs better for school-age children. We are trying to reach the parent or adult in the household who knows most about what [CHILD NAME] eats.
INTERVIEWER NOTE: REFER TO FAQ’S TO ANSWER ANY QUESTIONS, INCLUDING CONTENT OF SURVEY.
YES 1
NO 0
DON’T KNOW d
REFUSED r
A3. Are you the parent or adult in the household who knows most about what [CHILD NAME] ate over the last 30 days?
INTERVIEWER: IF R ANSWERS “PROBABLY” OR “AS MUCH AS ANYONE ELSE,” ENTER “1,” “YES.”
YES 1 GO
TO A4.3,
2nd PARAGRAPH
YES,
BUT NOT AVAILABLE NOW 2 GO
TO CALLBACK
NO 0
DON’T KNOW d
REFUSED r
A4.1 What is the name of the parent or adult who knows most about what [CHILD NAME] ate over the last 30 days?
ENTER NAME OF PARENT/ADULT.
DON’T KNOW d
REFUSED r
A4.2 May I speak with (him/her)?
YES 1
YES,
BUT NOT AVAILABLE NOW 2
CANNOT COME TO PHONE 3
DOES
NOT LIVE HERE 4 GO
TO A6.1
DON’T KNOW d
REFUSED r
PROGRAMMER: IF A3=1, START WITH SECOND PARAGRAPH
A4.3 Hello, my name is _________ and I’m calling on behalf of the U.S. Department of Agriculture, Food and Nutrition Service. We are conducting a research study about the food choices of children and their families for the U.S. Department of Agriculture, Food and Nutrition Service.
The interview will take approximately 25 minutes. It has questions about your child’s food choices as well as general questions about you and your household. Your answers will help the government make its child nutrition programs better for school-age children. As a way of saying thank you, we will give you a $10 gift card when we are finished.
Your participation in this interview is voluntary and you may stop at any time. Your benefits will not be affected if you choose not to participate. If you take part, you may refuse to answer any questions. If you take part, your answers won’t change any benefits you may receive from any agency.
All the information you give us will be kept confidential to the extent allowed by law. Your name will not be attached to any of your answers. Your information will be used only in combination with information from other households for research purposes
A5. Do you have any questions before I begin?
YES 1
NO 0
DON’T
KNOW d
REFUSED r
INTERVIEWER NOTE: REFER TO FAQ’S TO ANSWER ANY QUESTIONS.
A5.1 If now is a good time for you and you are willing to participate, I’d like to begin my questions.
YES,
IT’S A GOOD TIME AND I’M WILLING 1 GO
TO B1
YES,
I’M WILLING BUT NOT AVAILABLE NOW 2 SCHEDULE
CALLBACK
DON’T KNOW d
REFUSED
TO PARTICIPATE r GO
TO REFUSAL
A6.1 Please tell me that person’s name and telephone number.
INTERVIEWER: BE SURE TO VERIFY SPELLING.
ENTER FIRST NAME:
DON’T KNOW d
REFUSED r
PROBE FOR MIDDLE NAME IF NOT REPORTED
ENTER “NMN” FOR NO MIDDLE NAME
ENTER MIDDLE NAME:
DON’T KNOW d
REFUSED r
ENTER LAST NAME:
DON’T KNOW d
REFUSED r
A6.2 What is this person’s telephone number, beginning with the area code?
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EXTENSION: | | | | |
DON’T KNOW d
REFUSED r
A6.3 Is there an alternate telephone number for [FIRST NAME] [LAST NAME]?
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EXTENSION: | | | | |
DON’T KNOW d
REFUSED r
A7. Hello, my name is _________ and I’m calling on behalf of the U.S. Department of Agriculture, Food and Nutrition Service. May I please speak to [NAME OF PARENT]?
SPEAKING TO [NAME OF PARENT] 1
[NAME OF PARENT] COMES TO PHONE 2
PERSON ASKS WHAT CALL IS ABOUT 3
NOT
A GOOD TIME, SCHEDULE CALLBACK 4 GO
TO CALLBACK
A
GO
TO FAQ. RESPOND TO QUESTIONS, RETURN TO QUESTION A2 AND CHANGE
ANSWER TO “NO” TO CONTINUE
YES 1
NO 0
DON’T KNOW d
REFUSED r
A9. The interview will take approximately 25 minutes. It has questions about your child’s food choices as well as general questions about you and your household. Your answers will help the government make its child nutrition programs better for school-age children. As a way of saying thank you, we will give you a $10 gift card when we are finished.
Your participation in this interview is voluntary and you may stop at any time. Your benefits will not be affected if you choose not to participate. If you take part, you may refuse to answer any questions. If you take part, your answers won’t change any benefits you may receive from any agency.
All the information you give us will be kept confidential to the extent allowed by law. Your name will not be attached to any of your answers. Your information will be used only in combination with information from other households for research purposes
A9.1 Do you have any questions before I begin?
YES 1 GO
TO FAQ
NO 0
DON’T KNOW d
REFUSED r
A9.2 If now is a good time for you and you are willing to participate, I’d like to begin my questions.
YES,
IT’S A GOOD TIME AND I’M WILLING 1 GO
TO B1
YES, I’M WILLING BUT NOT AVAILABLE NOW 2
DON’T
KNOW d
REFUSED TO PARTICIPATE r
A10. May we call you back at another time?
YES 1 GO
TO CALLBACK
NO 0
GO
TO SUPERVISOR REVIEW
DON’T
KNOW d GO
TO CALLBACK
REFUSED r GO
TO SUPERVISOR REVIEW
SECTION B: HOUSEHOLD CHARACTERISTICS VERIFICATION
PROGRAMMER: IF BASELINE INTERVIEW NOT COMPLETED, ASK B1. OTHERWISE, GO TO B6.
The first few questions are about the people you live with.
B1. Including yourself, how many people live in your household? Don’t forget to include non‑relatives who live here and, of course, babies and small children. Also include persons who usually live here but are temporarily away for reasons such as: vacation, traveling for work, or in the hospital.
| | | PEOPLE
DON’T KNOW d
REFUSED r
B1.1 Do all the people in your household buy and share food together?
YES 1
GO
TO B2
NO 0
DON’T KNOW d
REFUSED r
B1.2 How many people in your household buy and share food together?
| | | PEOPLE
DON’T KNOW d
REFUSED r
B2. How many of those (IF B1.1=1, FILL NUMBER FROM B1, OTHERWISE, FILL NUMBER FROM B1.2) people are children age18 years or younger or over 18 but still in high school during the most recently completed school year?
|
|
|
ENTER
NUMBER OF CHILDREN
GO TO B3
DON’T KNOW d
REFUSED r
B2.1 Is there at least one child living in your household?
YES 1
NO 0
DON’T KNOW d
REFUSED r
B3. I’d like to make a list of the first names or initials of the children age 18 or younger and those over 18 who were still in high school in the most recently completed school year. What is the name of the (first/nth) child?
PROGRAMMER: CREATE GRID FOR NUMBER OF CHILDREN IN GRADES PRE-K-12.
B4. Please tell me the birth date of each child starting with [CHILD #1].
| | | / | | | / | | | | |
MONTH DAY YEAR
DON’T KNOW d
REFUSED r
B5. How many of those children in your household were in grades pre-K through 12 in the most recently completed school year?
| | | ENTER NUMBER OF CHILDREN IN K-12
DON’T KNOW d
REFUSED r
PROGRAMMER: IF BASELINE INTERVIEW NOT COMPLETED, GO TO C1
B6. According to my records from our last interview, there were (IF BASELINE B.1=1, FILL NUMBER FROM BASELINE B1, OTHERWISE, FILL NUMBER FROM BASELINE INTERVIEW B1.2) people in your household that buy and share their food together. Is that still correct?
YES 1 GO
TO B7
NO 0
DON’T KNOW d
REFUSED r
B6.1 Including yourself, how many people live in your household? Don’t forget to include non-relatives who live here and, of course, babies and small children. Also include persons who usually live here but are temporarily away for reasons such as: vacation, traveling for work, or in the hospital.
| | | PEOPLE
DON’T KNOW d
REFUSED r
B6.1.1 Do all the people in your household buy and share food together?
YES 1
GO
TO B7
NO 0
DON’T KNOW d
REFUSED r
B6.1.2 How many people in your household buy and share food together?
| | | PEOPLE
DON’T KNOW d
REFUSED r
PROGRAMMER: IF BASELINE INTERVIEW NOT COMPLETED, GO TO C1
B7. According to my records from the last interview, there were [FILL NUMBER FROM BASELINE INTERVIEW B2] children age 18 or younger including those over 18 and still in high school in your household and there were [FILL NUMBER FROM BASELINE INTERVIEW B3] children in grades Pre-K-12. Is that still correct?
INTERVIEWER: IF NUMBER ONLY CHANGED BECAUSE OF BIRTHDAYS BETWEEN BASELINE AND FOLLOW-UP INTERVIEW, RECORD YES, CORRECT “1.”
YES 1
GO
TO SECTION D
NO 0
DON’T KNOW d
REFUSED r
B7.1 How many children age 18 or younger or over 18 and still in high school are currently living in your household?
| | | ENTER NUMBER OF CHILDREN
DON’T KNOW d
REFUSED r
B7.2 Of the children currently living in your household, how many were in grades Pre-K through 12 during the most recently completed school year?
| | | ENTER NUMBER OF CHILDREN WHO WERE IN K-12
DON’T KNOW d
REFUSED r
SECTION C: CHILD DEMOGRAPHICS
PROGRAMMER: IF BASELINE INTERVIEW NOT COMPLETED, ASK C1. OTHERWISE, GO TO D1.
For the next set of questions, we are going to focus on [CHILD NAME].
C1. Is [CHILD NAME] a boy or girl?
INTERVIEWER: ASK IF THEY HAVE NOT ALREADY MENTIONED CHILD’S SEX.
BOY 1
GIRL 2
DON’T KNOW d
REFUSED r
C1a. Does [CHILD NAME] currently live in this household?
YES 1
NO 2
DON’T KNOW d
REFUSED r
[PROGRAMMER NOTE:
IF C1a=1, GO TO C2 (FOCAL CHILD CURRENTLY IN HOUSEHOLD; ASK FULL QUESTIONNAIRE)
IF C1a>1, AND B2<88, OR B2.1=1, GO TO F1 (FOCAL CHILD CURRENTLY NOT IN HOUSEHOLD, BUT OTHER CHILDREN ARE IN HOUSEHOLD; ASK QUESTIONS PERTAINING TO HOUSEHOLD, INCLUDING ADULT AND CHILD FOOD SECURITY)
IF C1a>1, AND B2.1=2, GO TO F1 (FOCAL CHILD CURRENTLY NOT IN HOUSEHOLD, AND NO OTHER CHILDREN ARE IN HOUSEHOLD; ASK QUESTIONS PERTAINING TO HOUSEHOLD, EXCLUDING CHILD FOOD SECURITY)]
C2. Please tell me [CHILD NAME]’s birth date.
| | | / | | | / | | | | |
MONTH DAY YEAR
DON’T KNOW d
REFUSED r
C3. Is [CHILD NAME] of Hispanic or Latino origin?
YES 1
NO 0
DON’T KNOW d
REFUSED r
C4. I am going to read a list of five race categories. Please choose one or more races that you consider [CHILD NAME] to be. White; Black or African American; American Indian or Alaska Native; Asian; or Native Hawaiian or other Pacific Islander?
WHITE 1
BLACK OR AFRICAN AMERICAN 2
AMERICAN INDIAN OR ALASKA NATIVE 3
ASIAN 4
NATIVE HAWAIIAN OR
OTHER PACIFIC ISLANDER 5
DON’T KNOW d
REFUSED r
SECTION D: DIETARY BEHAVIORS – CHILD
D1. During the last 30 days, did [CHILD NAME] usually eat breakfast each day?
YES 1
NO 0
DON’T KNOW d
REFUSED r
These questions are about the different kinds of foods [CHILD NAME] ate or drank during the last 30 days. First, I’m going to ask you about the types of items [CHILD NAME] usually drinks at mealtimes and between meals. When answering, please include meals and snacks eaten at home, at school, in restaurants, and anyplace else. During the last 30 days, how often did [CHILD NAME] drink…
D2. 100% pure fruit juice, such as orange, mango, apple, grape, and pineapple juice? Do not include fruit-flavored drinks with added sugar or fruit juice you made at home with added sugar. (You can tell me per day, per week or per month.)
INTERVIEWER INSTRUCTIONS:
INCLUDE: ONLY 100% PURE JUICES
DO NOT INCLUDE: FRUIT-FLAVORED DRINKS WITH ADDED SUGAR, LIKE CRANBERRY DRINK, HI-C, LEMONADE, KOOL-AID, GATORADE, TAMPICO (tam‑pee-koh), AND SUNNY DELIGHT.
| | | | TIMES
NEVER 0
DON’T KNOW d
REFUSED r
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
DON’T KNOW d
REFUSED r
[IF DAY>4 OR WEEK>28 OR MONTH>120: You said (display # of times) per (display unit). Is that correct?]
YES, CONTINUE 1
NO, CORRECT NUMBER PER DAY/WEEK/MONTH 0
D2.1 During the last 30 days, how often did [CHILD NAME] drink sweetened fruit drinks, sports or energy drinks, such as Kool-Aid, lemonade, Hi-C, cranberry drink, Gatorade, Red Bull, or Vitamin Water? Include fruit juices you made at home with added sugar. Do not include diet drinks or artificially sweetened drinks. (You can tell me per day, per week or per month.)
| | | | TIMES
NEVER 0
DON’T KNOW d
REFUSED r
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
DON’T KNOW d
REFUSED r
[IF DAY>4 OR WEEK>28 OR MONTH>120: You said (display # of times) per (display unit). Is that correct?]
YES, CONTINUE 1
NO, CORRECT NUMBER PER DAY/WEEK/MONTH 0
D2.2 During the last 30 days, how often did [CHILD NAME] drink:
Regular soda or pop that contains sugar? Do not include diet soda. (You can tell me per day, per week or per month.)
INTERVIEWER INSTRUCTIONS:
INCLUDE: MANZANITA man-zuh-nee-tuh) AND PENAFIEL (pen-yah-fee-EL) SODAS.
DO NOT INCLUDE DIET OR SUGAR-FREE DRINKS. DO NOT INCLUDE JUICES OR TEA IN CANS.
| | | | TIMES
NEVER 0
DON’T KNOW d
REFUSED r
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
DON’T KNOW d
REFUSED r
[IF DAY>4 OR WEEK>28 OR MONTH>120: You said (display # of times) per (display unit). Is that correct?]
YES, CONTINUE 1
NO, CORRECT NUMBER PER DAY/WEEK/MONTH 0
D2.3 (During the last 30 days, how often did [CHILD NAME] have:)
Milk (either to drink or on cereal)? Do not include soy milk or small amounts of milk in coffee or tea. (You can tell me per day, per week or per month.)
INTERVIEWER INSTRUCTION:
INCLUDE: SKIM, NO-FAT, LOW-FAT, WHOLE MILK, BUTTERMILK, AND LACTOSE-FREE MILK. ALSO INCLUDE CHOCOLATE OR OTHER FLAVORED MILKS.
DO NOT INCLUDE: CREAM
| | | | TIMES
NEVER 0 GO
TO D3
DON’T KNOW d
REFUSED r
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
DON’T KNOW d
REFUSED r
[IF DAY>4 OR WEEK>28 OR MONTH>120: You said (display # of times) per (display unit). Is that correct?]
YES, CONTINUE 1
NO, CORRECT NUMBER PER DAY/WEEK/MONTH 0
D2.3.1 What type of milk did [CHILD NAME] usually have? Was it whole or regular milk, 2% fat or reduced-fat milk, 1% fat or 1/2% fat or low-fat milk, or fat-free, skim, nonfat milk? Do not include soy milk or rice milk.
INTERVIEWER INSTRUCTION:
IF RESPONDENT CANNOT PROVIDE USUAL TYPE, CODE ALL THAT APPLY.
IF RESPONDENT MENTIONS CHOCOLATE OR OTHER FLAVORED MILKS, ASK: Do you know if it is whole, 2%, 1% or nonfat milk?
WHOLE MILK 1
2% FAT MILK 2
1% OR 1/2% FAT MILK 3
FAT-FREE, SKIM, NONFAT MILK 4
DON’T KNOW d
REFUSED r
Now I’m going to ask you about some kinds of food [CHILD NAME] ate during the last 30 days, including mealtimes and snacks.
D3. During the last 30 days, how often did [CHILD NAME] eat hot or cold cereal? (You can tell me per day, per week or per month.)
| | | | TIMES
NEVER 0 GO
TO D4
DON’T KNOW d
REFUSED r
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
DON’T KNOW d
REFUSED r
[IF DAY>3 OR WEEK>22 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]
YES, CONTINUE 1
NO, CORRECT NUMBER PER DAY/WEEK/MONTH 0
D3.1 During the last 30 days, what kind of cereal did [CHILD NAME] usually eat?
INTERVIEWER: ENTER FIRST FEW LETTERS OF CEREAL NAME TO START THE LOOK UP.
SELECT CEREAL FROM LIST. IF CEREAL NOT ON LIST, PRESS BS TO DELETE THE ENTRY AND TYPE ** TO ENTER CEREAL NAME.
DON’T KNOW d
REFUSED r
D3.2 Was there another cereal that [CHILD NAME] ate?
YES 1
NO 0
DON’T KNOW d
REFUSED r
D3.3 During the last 30 days, what second kind of cereal did [CHILD NAME] usually eat?
INTERVIEWER: ENTER FIRST FEW LETTERS OF CEREAL NAME TO START THE LOOK UP.
SELECT CEREAL FROM LIST. IF CEREAL NOT ON LIST, PRESS BS TO DELETE THE ENTRY AND TYPE ** TO ENTER CEREAL NAME.
OTHER, SPECIFY 7
DON’T KNOW d
REFUSED r
D4. (During the last 30 days, how often did [CHILD NAME] have:)
Fruit? Include fresh, frozen or canned fruit. Do not include juices. (You can tell me per day, per week or per month.)
INTERVIEWER INSTRUCTIONS:
DO NOT INCLUDE: DRIED FRUITS
| | | | TIMES
NEVER 0
DON’T KNOW d
REFUSED r
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
DON’T KNOW d
REFUSED r
[IF DAY>3 OR WEEK>22 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]
YES, CONTINUE 1
NO, CORRECT NUMBER PER DAY/WEEK/MONTH 0
D5. During the last 30 days, how often did [CHILD NAME] eat a green leafy or lettuce salad, with or without other vegetables? (You can tell me per day, per week or per month.)
INTERVIEWER INSTRUCTIONS:
INCLUDE: SPINACH SALADS
| | | | TIMES
NEVER 0
DON’T KNOW d
REFUSED r
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
DON’T KNOW d
REFUSED r
[IF DAY>3 OR WEEK>22 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]
YES, CONTINUE 1
NO, CORRECT NUMBER PER DAY/WEEK/MONTH 0
D6. During the last 30 days, how often did [CHILD NAME] eat any kind of fried potatoes, including French fries, home fries, or hash brown potatoes? (You can tell me per day, per week or per month.)
INTERVIEWER INSTRUCTIONS:
DO NOT INCLUDE: POTATO CHIPS
| | | | TIMES
NEVER 0
DON’T KNOW d
REFUSED r
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
DON’T KNOW d
REFUSED r
[IF DAY>3 OR WEEK>22 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]
YES, CONTINUE 1
NO, CORRECT NUMBER PER DAY/WEEK/MONTH 0
D7. During the last 30 days, how often did [CHILD NAME] eat other kind of potatoes such as mashed potatoes, sweet potatoes, or potato salad?
(You can tell me per day, per week or per month.)
INTERVIEWER INSTRUCTIONS:
INCLUDE: ALL TYPES OF POTATOES EXCEPT FRIED. INCLUDE POTATOES AU GRATIN, AND SCALLOPED POTATOES.
| | | | TIMES
NEVER 0
DON’T KNOW d
REFUSED r
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
DON’T KNOW d
REFUSED r
[IF DAY>3 OR WEEK>22 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]
YES, CONTINUE 1
NO, CORRECT NUMBER PER DAY/WEEK/MONTH 0
D8. (During the last 30 days, how often did [CHILD NAME] eat:)
Refried beans, baked beans, beans in soup, pork and beans or any other type of cooked dried beans? Do not include green beans.
(You can tell me per day, per week or per month.)
INTERVIEWER INSTRUCTIONS:
INCLUDE: SOYBEANS, KIDNEY, PINTO, GARBANZO, BLACK BEANS, LENTILS, BLACK‑EYED PEAS, COW PEAS, AND LIMA BEANS. INCLUDE CANNED BEANS.
| | | | TIMES
NEVER 0
DON’T KNOW d
REFUSED r
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
DON’T KNOW d
REFUSED r
[IF DAY>3 OR WEEK>22 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]
YES, CONTINUE 1
NO, CORRECT NUMBER PER DAY/WEEK/MONTH 0
D9. (During the last 30 days, not including what you just told me about (lettuce salads, potatoes, cooked dried beans) how often did [CHILD NAME] eat) other vegetables?
(You can tell me per day, per week or per month.)
INTERVIEWER INSTRUCTIONS:
DO NOT INCLUDE: RICE
EXAMPLES OF OTHER VEGETABLES INCLUDE: TOMATOES, GREEN BEANS, CARROTS, CORN, CABBAGE, BEAN SPROUTS, COLLARD GREENS, AND BROCCOLI. INCLUDE ANY FORM OF THE VEGETABLE (RAW, COOKED, CANNED, OR FROZEN).
| | | | TIMES
NEVER 0
DON’T KNOW d
REFUSED r
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
DON’T KNOW d
REFUSED r
[IF DAY>3 OR WEEK>22 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]
YES, CONTINUE 1
NO, CORRECT NUMBER PER DAY/WEEK/MONTH 0
D10. (During the last 30 days, how often did [CHILD NAME] have:)
Mexican-type salsa made with tomato?
(You can tell me per day, per week or per month.)
INTERVIEWER INSTRUCTIONS:
INCLUDE: ALL TOMATO-BASED SALSAS
| | | | TIMES
NEVER 0
DON’T KNOW d
REFUSED r
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
DON’T KNOW d
REFUSED r
[IF DAY>3 OR WEEK>22 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]
YES, CONTINUE 1
NO, CORRECT NUMBER PER DAY/WEEK/MONTH 0
D11. (During the last 30 days, how often did [CHILD NAME] eat:)
Pizza? Include frozen pizza, fast food pizza, and homemade pizza.
(You can tell me per day, per week or per month.)
| | | | TIMES
NEVER 0
DON’T KNOW d
REFUSED r
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
DON’T KNOW d
REFUSED r
[IF DAY>3 OR WEEK>22 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]
YES, CONTINUE 1
NO, CORRECT NUMBER PER DAY/WEEK/MONTH 0
D12. (During the last 30 days, how often did [CHILD NAME] have:)
Tomato sauce such as with spaghetti or noodles or mixed into foods such as lasagna? (Please do not count tomato sauce on pizza.)
(You can tell me per day, per week or per month.)
| | | | TIMES
NEVER 0
DON’T KNOW d
REFUSED r
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
DON’T KNOW d
REFUSED r
[IF DAY>3 OR WEEK>22 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]
YES, CONTINUE 1
NO, CORRECT NUMBER PER DAY/WEEK/MONTH 0
D13. (During the last 30 days, how often did [CHILD NAME] eat:)
Cheese? Include cheese as a snack, cheese on burgers, sandwiches, and cheese in foods such as lasagna, quesadillas, or casseroles. (Please do not count cheese on pizza.)
(You can tell me per day, per week or per month.)
INTERVIEWER INSTRUCTIONS:
INCLUDE: MACARONI AND CHEESE, ENCHILADAS
DO NOT INCLUDE: CREAM CHEESE OR CHEESES MADE FROM NON-DAIRY FOODS, SUCH AS SOY OR RICE, OR CHEESE ON PIZZA.
| | | | TIMES
NEVER 0
DON’T KNOW d
REFUSED r
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
DON’T KNOW d
REFUSED r
[IF DAY>3 OR WEEK>22 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]
YES, CONTINUE 1
NO, CORRECT NUMBER PER DAY/WEEK/MONTH 0
D14. (During the last 30 days, how often did [CHILD NAME] eat:)
Canned tuna or other canned fish (including in salads, sandwiches or casseroles)?
(You can tell me per day, per week or per month.)
| | | | TIMES
NEVER 0
DON’T KNOW d
REFUSED r
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
DON’T KNOW d
REFUSED r
[IF DAY>3 OR WEEK>22 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]
YES, CONTINUE 1
NO, CORRECT NUMBER PER DAY/WEEK/MONTH 0
D15. (During the last 30 days, how often did [CHILD NAME] eat:)
Eggs? Do not include egg whites only or egg substitutes.
(You can tell me per day, per week or per month.)
INTERVIEWER INSTRUCTIONS:
INCLUDE: EGGS IN SALADS, QUICHE, AND SOUFFLÉS
DO NOT INCLUDE: EGGS IN BAKED GOODS AND DESSERTS.
| | | | TIMES
NEVER 0
DON’T KNOW d
REFUSED r
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
DON’T KNOW d
REFUSED r
[IF DAY>3 OR WEEK>22 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]
YES, CONTINUE 1
NO, CORRECT NUMBER PER DAY/WEEK/MONTH 0
D16. (During the last 30 days, how often did [CHILD NAME] have:)
Peanut butter?
(You can tell me per day, per week or per month.)
INTERVIEWER INSTRUCTIONS:
INCLUDE: PEANUT BUTTER ON BREAD, CRACKERS, FRUIT, OR VEGETABLES
DO NOT INCLUDE: PEANUT BUTTER IN BAKED GOODS.
| | | | TIMES
NEVER 0
DON’T KNOW d
REFUSED r
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
DON’T KNOW d
REFUSED r
[IF DAY>3 OR WEEK>22 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]
YES, CONTINUE 1
NO, CORRECT NUMBER PER DAY/WEEK/MONTH 0
D17. (During the last 30 days, how often did [CHILD NAME] eat:)
Whole grain bread (and tortillas) including toast, rolls and in sandwiches? Whole grain breads include whole wheat, rye, oatmeal and pumpernickel. Do not include white bread.
(You can tell me per day, per week or per month.)
| | | | TIMES
NEVER 0
DON’T KNOW d
REFUSED r
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
DON’T KNOW d
REFUSED r
[IF DAY>3 OR WEEK>22 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]
YES, CONTINUE 1
NO, CORRECT NUMBER PER DAY/WEEK/MONTH 0
D18. (During the last 30 days, how often did [CHILD NAME] eat;)
Cookies, cake, pie, doughnuts, or brownies? Do not include sugar-free kinds.
(You can tell me per day, per week or per month.)
INTERVIEWER INSTRUCTIONS:
INCLUDE: LOW-FAT KINDS, TWINKIES AND HOSTESS CUPCAKES
DO NOT INCLUDE: ICE CREAM AND OTHER FROZEN DESSERTS OR CANDY
| | | | TIMES
NEVER 0
DON’T KNOW d
REFUSED r
ENTER UNIT
DAY 1
WEEK 2
MONTH 3
DON’T KNOW d
REFUSED r
[IF DAY>3 OR WEEK>22 OR MONTH>90: You said (display # of times) per (display unit). Is that correct?]
YES, CONTINUE 1
NO, CORRECT NUMBER PER DAY/WEEK/MONTH 0
D19. How confident are you, that the food and drinks you just told me about included all the food and drinks [CHILD NAME] had at school, home, or other places? Would you say very confident, somewhat confident, not too confident, or not at all confident?
VERY CONFIDENT 1
SOMEWHAT CONFIDENT 2
NOT TOO CONFIDENT 3
NOT AT ALL CONFIDENT 4
DON’T KNOW d
REFUSED r
SECTION E: PROGRAM PARTICIPATION – CHILD
E1.1 During the last 30 days did [CHILD NAME] usually eat lunchtime meals at home?
YES 1 GO
TO E5
NO 0
DON’T
KNOW d
REFUSED r
E1.2 During the last 30 days, where did [CHILD NAME] usually get lunch?
IF NEEDED, SAY: “A friend’s home, a relative’s home, etc.”
MARK ALL THAT APPLY
FRIEND’S
HOME 1
RELATIVE’S HOME 2
SCHOOL 3
CAMP
(LOCAL) 4 GO
TO E4
CAMP
(SLEEP AWAY) 5 GO
TO E5
CHURCH,
SYNAGOGUE, OR MOSQUE 6 GO
TO E4
DAYCARE 7 GO
TO E5
PLAYGROUND 8
SOME PLACE ELSE (SPECIFY) 9
DOES
NOT EAT LUNCH 10
DON’T KNOW d
REFUSED r
E1.3 At any time during the last 30 days did [CHILD NAME] attend summer school?
YES 1
NO 0
DON’T KNOW d
REFUSED r
E2. During the last 30 days, did [CHILD NAME] usually get a complete school lunch at this summer school?
YES 1
NO 0
DON’T KNOW d
REFUSED r
E3. During the last 30 days, did [CHILD NAME] usually get a complete breakfast at this summer school?
YES 1
NO 0
DON’T KNOW d
REFUSED r
PROGRAMMER: IF E1.2 = 4, 6, 8, OR 9, ASK E4, ELSE GO TO E5.
E4. What is the name and location of the [FILL WITH PLACES FROM E1.2]?
NAME:
LOCATION:
DON’T KNOW d
REFUSED r
E4.1 PROGRAMMER: PROVIDE DROP DOWN LIST OF SFSP SITES IN AREA
INTERVIEWER: IS NAME/LOCATION AN SFSP SITE?
YES 1 GO
TO E5.2
NO 0
E4.2 Were the meals [CHILD NAME] received at [FILL WITH PLACES FROM E1.2] free (or included in the price of that program)?
YES 1 GO
TO E5.2
NO 0
DON’T
KNOW d
REFUSED r
E5. Is there a program in your neighborhood that provides free, nutritious meals to all children 18 years of age and younger (or children over 18 and still in high school) during the summer months? There are no income or residency requirements for children to participate. All summer meals are free. Meals may be served at schools, camps, or community based organization sites such as Boys and Girls Clubs. Activities are also offered to children who participate in the program.
YES 1
NO 0
DON’T KNOW d
REFUSED r
E5.1 Why doesn’t [CHILD NAME] go to that summer program?
MARK ALL THAT APPLY
PREFERS
TO EAT AT HOME 1
DOESN’T LIKE THE FOOD THEY SERVE 2
FOOD SERVED DOESN’T MEET CHILD’S
DIETARY NEEDS 3
NOT INTERESTED IN ACTIVITIES AT PROGRAM 4
HAS FEW OR NO FRIENDS AT PROGRAM 5
NO TRANSPORTATION TO PROGRAM 6
DON’T LIKE LOCATION OF PROGRAM 7
DON’T LIKE ORGANIZATION THAT
RUNS THE PROGRAM 8
OTHER (SPECIFY) 9
DON’T KNOW d
REFUSED r
E5.2 How many weeks during the last 30 days has [CHILD NAME] participated in the summer program that provided meals?
| | | WEEKS
DON’T KNOW d
REFUSED r
E5.3 How many days a week does [CHILD NAME] participate in this summer program?
PROBE: Your best estimate is fine.
| | DAYS A WEEK
DON’T KNOW d
REFUSED r
E6. During the last 30 days, did [CHILD NAME] receive food through a backpack food program for children?
YES 1
NO 0
DON’T KNOW d
REFUSED r
SECTION F: FOOD SECURITY – HOUSEHOLD
[PROGRAMMER NOTE: SELECT APPROPRIATE FILLS DEPENDING ON NUMBER OF ADULTS AND CHILDREN IN THE HOUSEHOLD. IF DK/REF ON B1.1 AND B1.2, PROGRAM AS IF MULTIPLE ADULTS AND CHILDREN]
MULTIPLE ADULTS: ( B1>B2) OR (B1>2 AND B2.1>1) OR (B2.1=8,9)
SINGLE ADULT: B1=1
MULTIPLE CHILDREN: B2>1, OR B2.1=1,8,9
SINGLE CHILD: B2=1, OR B2.1=2
The next questions are about the food eaten in your household in the last 30 days and whether you were able to afford the food you need.
F1. Now I’m going to read you several statements that people have made about their food situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for your household in the last 30 days.
The first statement is “We worried whether our food would run out before we got money to buy more.” Was that often true, sometimes true, or never true for your household in the last 30 days?
OFTEN TRUE 1
SOMETIMES TRUE 2
NEVER TRUE 3
DON’T KNOW d
REFUSED r
F2. “The food that we bought just didn’t last, and we didn’t have money to get more.” Was that often, sometimes, or never true for your household in the last 30 days?
OFTEN TRUE 1
SOMETIMES TRUE 2
NEVER TRUE 3
DON’T KNOW d
REFUSED r
F3. “We couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for your household in the last 30 days?
OFTEN TRUE 1
SOMETIMES TRUE 2
NEVER TRUE 3
DON’T KNOW d
REFUSED r
PROGRAMMER: IF AFFIRMATIVE RESPONSE (I.E., “OFTEN TRUE” OR “SOMETIMES TRUE”) TO ONE OR MORE OF QUESTIONS F1-F3, THEN CONTINUE TO F4; OTHERWISE, SKIP TO F9.
F4. In the last 30 days, did [you/you or other adults in your household] ever cut the size of your meals or skip meals because there wasn't enough money for food?
YES 1
NO 0
DON’T KNOW d
REFUSED r
F4a. In the last 30 days, how many days did this happen?
(1-30)
| | | DAYS
DON’T KNOW d
REFUSED r
F5. In the last 30 days, did you ever eat less than you felt you should because there wasn't enough money for food?
YES 1
NO 0
DON’T KNOW d
REFUSED r
F6. In the last 30 days, were you ever hungry but didn’t eat because there wasn’t enough money for food?
YES 1
NO 0
DON’T KNOW d
REFUSED r
F7. 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
PROGRAMMER: IF AFFIRMATIVE RESPONSE TO ONE OR MORE OF QUESTIONS F4‑F7, THEN CONTINUE TO F8. OTHERWISE, SKIP TO F9.
F8. In the last 30 days, did [you/you or other adults in your household] ever not eat for a whole day because there wasn't enough money for food?
YES 1
NO 0
DON’T KNOW d
REFUSED r
F8a. In the last 30 days, how many days did this happen?
(1-30)
| | | DAYS
DON’T KNOW d
REFUSED r
SELECT APPROPRIATE FILLS DEPENDING ON NUMBER OF ADULTS AND NUMBER OF CHILDREN IN THE HOUSEHOLD.
F9. Now I’m going to read you several statements that people have made about the food situation of their children. For these statements, please tell me whether the statement was often true, sometimes true, or never true in the last 30 days for [your child/children living in the household who are under 18 years old or 18 or older but still in high school].
“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 your household in the last 30 days?
OFTEN TRUE 1
SOMETIMES TRUE 2
NEVER TRUE 3
DON’T KNOW d
REFUSED r
F10. “[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 your household in the last 30 days?
OFTEN TRUE 1
SOMETIMES TRUE 2
NEVER TRUE 3
DON’T KNOW d
REFUSED r
F11. “[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 your household in the last 30 days?
OFTEN TRUE 1
SOMETIMES TRUE 2
NEVER TRUE 3
DON’T KNOW d
REFUSED r
PROGRAMMER: IF AFFIRMATIVE RESPONSE (I.E., “OFTEN TRUE” OR “SOMETIMES TRUE”) TO ONE OR MORE OF QUESTIONS F9-F11, THEN CONTINUE TO F12. OTHERWISE, SKIP TO G1.
F12. In the last 30 days, did you ever cut the size of [your child’s/any of the children’s] meals because there wasn’t enough money for food?
YES 1
NO 0
DON’T KNOW d
REFUSED r
F13. In the last 30 days, did [CHILD NAME/any of the children] ever skip meals because there wasn’t enough money for food?
YES 1
NO 0
DON’T KNOW d
REFUSED r
F13a. In the last 30 days, how many days did this happen?
(1-30)
| | | DAYS
DON’T KNOW d
REFUSED r
F14. In the last 30 days, [was your child/were the children] ever hungry but you just couldn’t afford more food?
YES 1
NO 0
DON’T KNOW d
REFUSED r
F15. In the last 30 days, did [your child/any of the children] ever not eat for a whole day because there wasn't enough money for food?
YES 1
NO 0
DON’T KNOW d
REFUSED r
SECTION G: SHOPPING AND EATING BEHAVIOR – HOUSEHOLD
Now, I’d like to ask some questions about shopping for food and eating at restaurants.
G1. First I’ll ask you about money spent at supermarkets or grocery stores. Then we will talk about money spent at other types of stores.
During the last 30 days, how much money [did your family/did you] spend at supermarkets or grocery stores? Please include purchases made with SNAP benefits or food stamps. (You can tell me per week or per month.)
INTERVIEWER: RECORD “0” IF NO MONEY WAS SPENT.
$ | |,| | | | SPENT AT SUPERMARKETS OR GROCERY STORES
DON’T
KNOW d
REFUSED r
ENTER UNIT
WEEK 1
MONTH 2
DON’T KNOW d
REFUSED r
G2. Was any of this money spent on nonfood items such as cleaning or paper products, pet food, cigarettes or alcoholic beverages?
YES 1
NO 0
DON’T KNOW d
REFUSED r
G3. About how much money was spent on nonfood items? (You can tell me per week or per month.)
INTERVIEWER: RECORD “0” IF NO MONEY WAS SPENT.
$ | |,| | | |
PROGRAMMER: HARD EDIT: AMOUNT CANNOT BE MORE THAN THE AMOUNT ENTERED ON QUESTION G1.
DON'T KNOW d
REFUSED r
ENTER UNIT
WEEK 1
MONTH 2
DON'T KNOW d
REFUSED r
G4. During the last 30 days, [did your family/did you] spend money on food at stores other than grocery stores? These other stores could include convenience stores like 7-11 or Mini Mart, wholesale stores like Costco or Sam’s Club, stores like Wal-Mart, Kmart, dollar stores, bakeries, meat markets, vegetable stands, or farmer’s markets. Please do not include stores that you have already told me about. Please include purchases made with SNAP benefits or food stamps.
YES 1
NO 0
DON’T KNOW d
REFUSED r
G5. About how much money [did your family/did you] spend on food at these types of stores during the last 30 days? Please include purchases made with SNAP benefits or food stamps. (Please do not include any stores you have already told me about.) (You can tell me per week or per month.)
$ | |,| | | |
DON’T KNOW d
REFUSED r
ENTER UNIT
WEEK 1
MONTH 2
DON’T KNOW d
REFUSED r
G6. During the last 30 days, how many times did your family eat food from a fast food restaurant? Include fast food meals at home, or at fast food restaurants, carryout, or drive thru. (You can tell me per week or per month.)
IF NEEDED, SAY: “Such as food you get at McDonald’s, KFC, Panda Express, or Taco Bell.”
| | | TIMES
DON’T KNOW d
REFUSED r
ENTER UNIT
WEEK 1
MONTH 2
DON’T KNOW d
REFUSED r
G7. During the last 30 days, how many times did your family usually eat food at other kinds of restaurants? (You can tell me per week or per month.)
IF NEEDED, SAY: “Such as food you get at Applebee’s, Chili’s, TGI Fridays, etc.”
| | | TIMES
DON’T KNOW d
REFUSED r
ENTER UNIT
WEEK 1
MONTH 2
DON’T KNOW d
REFUSED r
PROGRAMMER: IF G6 AND G7=0, GO TO H1.
G8. About how much money [did your family/did you] spend on food at all types of restaurants including fast food restaurants during the last 30 days? (You can tell me per week or per month.)
$ | |,| | | |
DON’T KNOW d
REFUSED r
ENTER UNIT
WEEK 1
MONTH 2
DON’T KNOW d
REFUSED r
SECTION H: PROGRAM PARTICIPATION – HOUSEHOLD
H1. Next, I’m going to read the names of some programs that provide food or meals to individuals or households.
H1.1 In the last 30 days did you or anyone in your household receive food or benefits from the Women, Infants and Children program called WIC?
YES 1
NO 0
DON’T KNOW d
REFUSED r
H1.2a How many women or children in the household got WIC food or benefits?
| | | WOMEN AND CHILDREN
DON’T KNOW d
REFUSED r
H1.2b (Is that person who got WIC foods an infant less than 1 year old?/How many of those [NUMBER FROM H1.2a] people who got WIC food or benefits are infants less than 1 year old?)
| | | INFANTS
NONE 0
DON’T KNOW d
REFUSED r
H2. In the last 30 days did you or anyone in your household receive food from food pantries or food banks?
YES 1
NO 0
DON’T KNOW d
REFUSED r
H3. In the last 30 days did you or anyone in your household receive meals at local soup kitchens or emergency kitchens?
YES 1
NO 0
DON’T KNOW d
REFUSED r
H4. Are you (or others in your household) receiving [IF CT, OR, OR TX, FILL WITH “SNAP benefits (formerly known as food stamps”; IF MO, FILL WITH: “Food Stamp Program benefits”; IF MI, FILL WITH: “Food Assistance Program benefits”] now?
YES 1 GO
TO H6
NO 0
DON’T KNOW d
REFUSED r
H4.1. Have you (or others in your household applied for [IF CT, OR, OR TX, FILL WITH “SNAP benefits (formerly known as food stamps”; IF MO, FILL WITH: “Food Stamp Program benefits”; IF MI, FILL WITH: “Food Assistance Program benefits”] in the last 30 days?
YES 1
NO 0
DON’T KNOW d
REFUSED r
H5. Do you (or others in your household) currently receive monthly Native American Food Commodities as part of the Food Distribution Program on Indian Reservations (FDPIR)?
YES 1
NO 2
DON’T KNOW d
REFUSED r
PROGRAMMER: IF SAMPLED HOUSEHOLD IS IN THE TREATMENT GROUP, ASK H6. OTHERWISE, GO TO I1.
H6. According to my records, you’ve received special summertime food benefits for your (child/children). Did you use these summer benefits?
YES 1
NO 0 GO
TO H19
[FOR
OREGON AND MISSOURI ONLY]
NOT AWARE OF RECEIPT OF SPECIAL
SUMMERTIME BENEFITS 3 GO TO H19
DON’T KNOW d
REFUSED r
PROGRAMMER: IF SAMPLED HOUSEHOLD IS IN MISSOURI OR OREGON AND H4=1 (RECEIVES SNAP), GO TO H8; IF SAMPLED HOUSEHOLD IS IN MI OR TX, GO TO H9. FOR ALL OTHERS, ASK H7.
H7. What was the total monthly amount of the special summertime food benefits you received just for your (child/children)?
$ | | | | AMOUNT
DON’T KNOW d
REFUSED r
H7.1 In the past 30 days was there ever a time when there was a zero balance on your EBT card for special summertime benefits?
YES 1
NO 0
DON’T KNOW d
REFUSED r
H7.2 How long did that zero balance last? You can tell me the number of days or weeks.
| | | NUMBER
DON’T
KNOW d
REFUSED r
ENTER UNIT
DAYS 1
WEEKS 2
DON’T KNOW d
REFUSED r
PROGRAMMER: IF H4=0, d, r, GO TO H11 (FOR TREATMENTS IN OREGON OR MISSOURI WITHOUT SNAP BENEFITS.
H8. In the past 30 days was there ever a time when there was a zero balance on your [IF OREGON FILL WITH “SNAP”; IF MO FILL WITH “Food Stamp Program”] EBT card?
YES 1
NO 0
DON’T KNOW d
REFUSED r
H8.1 How long did that zero balance last? You can tell me the number of days or weeks.
| | | NUMBER
DON’T
KNOW d
REFUSED r
ENTER UNIT
DAYS 1
WEEKS 2
DON’T KNOW d
REFUSED r
H9. Now, think about the special summertime food benefits that you received for your (child/children). Using a scale of excellent, very good, good, fair, or poor, how would you rate the food benefits for…
|
EXCELLENT |
VERY GOOD |
GOOD |
FAIR |
POOR |
DON’T KNOW |
REFUSED |
a. Providing the right quantity of food? |
5 |
4 |
3 |
2 |
1 |
d |
r |
b. Offering foods that (your children like/your child likes) to eat? |
5 |
4 |
3 |
2 |
1 |
d |
r |
c. Offering food choices in sizes that you can find on the shelf? For example, if the benefit is for a 64 oz. container of juice, you can find it in the store where you shop |
5 |
4 |
3 |
2 |
1 |
d |
r |
d. Letting you shop at stores that are convenient and easy to shop at |
5 |
4 |
3 |
2 |
1 |
d |
r |
H10. Now, I’d like to ask you about any problems that you may have had with the EBT card that had the special summertime food benefits. In the last 30 days, has your card been lost or stolen?
YES 1
NO 0
DON’T KNOW d
REFUSED r
H11. Now, I’d like to ask you about any problems that you may have had with your the [OREGON FILL WITH “SNAP”; IF MO FILL WITH “Food Stamp Program”] EBT card? In the last 30 days, has your card been lost or stolen?
YES 1
NO 0
DON’T KNOW d
REFUSED r
PROGRAMMER: IF RESPONDENT IS IN OREGON OR MISSOURI AND RECEIVING SNAP, GO TO H14.
H12. Using a scale of excellent, very good, good, fair, or poor, what overall rating would you give to the ease of obtaining the EBT card for the special summertime benefits for children?
EXCELLENT 5
VERY GOOD 4
GOOD 3
FAIR 2
POOR 1
DON’T KNOW d
REFUSED r
H13. Using a scale of excellent, very good, good, fair, or poor, what overall rating would you give to the directions for using the EBT card for the special summertime benefits for children?
EXCELLENT 5
VERY GOOD 4
GOOD 3
FAIR 2
POOR 1
DON’T KNOW d
REFUSED r
H14. (Using a scale of excellent, very good, good, fair, or poor,) what overall rating would you give to the ease of using the EBT card to get food?
EXCELLENT 5
VERY GOOD 4
GOOD 3
FAIR 2
POOR 1
DON’T KNOW d
REFUSED r
H15. Using a scale of excellent, very good, good, fair, or poor, what overall rating would you give to the ease of resolving problems with the EBT card [for the special summertime benefits] for children? [PROGRAMMER: OMIT PHRASE IN BRACKETS WHERE H4=1 AND STATE = MO OR STATE=OR]
EXCELLENT 5
VERY GOOD 4
GOOD 3
FAIR 2
POOR 1
HAD NO PROBLEMS n
DON’T KNOW d
REFUSED r
H16. When you purchased food with your special summertime benefits, did you buy any food with [CHILD NAME] in mind?
YES 1
NO 0
DON’T KNOW d
REFUSED r
H17. How much of your special summertime benefits did you spend on food that you bought with [CHILD NAME] in mind? Would you say…
Less than 10 percent 1
10 to 25 percent 2
25 to 50 percent 3
50 to 75 percent 4
More than 75 percent 5
DON’T KNOW d
REFUSED r
H18. During the last 30 days were you ever embarrassed using the EBT card for the special summertime benefits for children?
YES 1
NO 0
DON’T KNOW d
REFUSED r
H19. Did you decide not to use your special summertime food benefit for children because you felt embarrassed using the EBT card to get food?
YES 1
NO 0
DON’T KNOW d
REFUSED r
SECTION I: CAREGIVER DEMOGRAPHICS |
PROGRAMMER: IF BASELINE INTERVIEW NOT COMPLETED, ASK I1. OTHERWISE, GO TO I14.1.
I1. Now, I have a few questions about you.
I2. What is your relationship to [CHILD NAME]?
READ ONLY IF NECESSARY: Are you [CHILD NAME’s]…
BIOLOGICAL/ADOPTIVE MOTHER 1
BIOLOGICAL/ADOPTIVE FATHER 2
STEPMOTHER 3
STEPFATHER 4
GRANDMOTHER 5
GRANDFATHER 6
GREAT GRANDMOTHER 7
GREAT GRANDFATHER 8
SISTER/STEPSISTER 9
BROTHER/STEPBROTHER 10
OTHER RELATIVE OR IN‑LAW (FEMALE) 11
OTHER RELATIVE OR IN‑LAW (MALE) 12
FOSTER PARENT (FEMALE) 13
FOSTER PARENT (MALE) 14
OTHER NON-RELATIVE (FEMALE) 15
OTHER NON-RELATIVE (MALE) 16
PARENT’S PARTNER (FEMALE) 17
PARENT’S PARTNER (MALE) 18
DON’T KNOW d
REFUSED r
I3. Are you of Hispanic, Latino, or Spanish origin?
YES 1
NO 0
DON’T KNOW d
REFUSED r
I4. I am going to read a list of five race categories. Please choose one or more races that you consider yourself to be. White; Black or African American; American Indian or Alaska Native; Asian; or Native Hawaiian or other Pacific Islander?
MARK ALL THAT APPLY
WHITE 1
BLACK OR AFRICAN AMERICAN 2
AMERICAN INDIAN OR ALASKA NATIVE 3
ASIAN 4
NATIVE HAWAIIAN OR
OTHER PACIFIC ISLANDER 5
DON’T KNOW d
REFUSED r
I5. What is your current marital status? Are you now married, divorced, separated, widowed, never married, or living with a partner?
MARRIED 1
SEPARATED OR DIVORCED 2
WIDOWED 3
NEVER MARRIED 4
LIVING WITH PARTNER 5
DON’T KNOW d
REFUSED r
I6. Please tell me your birth date.
| | | / | | | / | | | | |
MONTH DAY YEAR
DON’T KNOW d
REFUSED r
I6.1 What is the highest grade or level of school you have completed or the highest degree you have received? ENTER HIGHEST LEVEL OF SCHOOL.
NEVER ATTENDED/KINDERGARTEN ONLY 0
1ST GRADE 1
2ND GRADE 2
3RD GRADE 3
4TH GRADE 4
5TH GRADE 5
6TH GRADE 6
7TH GRADE 7
8TH GRADE 8
9TH GRADE 9
10TH GRADE 10
11TH GRADE 11
12TH GRADE, NO DIPLOMA 12
HIGH SCHOOL GRADUATE 13
GED OR EQUIVALENT 14
SOME COLLEGE, NO DEGREE 15
ASSOCIATE DEGREE: OCCUPATIONAL,
TECHNICAL, OR VOCATIONAL PROGRAM 16
ASSOCIATE DEGREE: ACADEMIC PROGRAM 17
BACHELOR’S DEGREE (EXAMPLE: BA, AB,
BS, BBA) 18
MASTER’S DEGREE (EXAMPLE: MA, MS, MEng,
MEd, MBA) 19
PROFESSIONAL SCHOOL DEGREE
(EXAMPLE: MD, DDS, DVM, JD) 20
DOCTORAL DEGREE (EXAMPLE: PhD, EdD) 21
DON’T KNOW d
REFUSED r
I7. The next questions are about your current job or business. Were you working in the last 30 days?
YES 1
GO
TO I9
NO 0
DON’T KNOW d
REFUSED r
I8. Was any other adult in the household working in the last 30 days?
YES 1
NO 0
DON’T KNOW d
REFUSED r
I9. Please tell me if you have access to a working refrigerator?
YES 1
NO 0
DON’T KNOW d
REFUSED r
I10. And now, my final questions. What was your household’s total income last month before taxes? Please include all types of income received by all household members last month, including all earnings, Social Security, pensions, child support, and cash welfare benefits such as TANF and SSI. Do not include the value of SNAP benefits or food stamps, WIC, Medicaid, or public housing.
NONE 0
GO
TO I12
$
|
|
|,|
|
|
|
LAST
MONTH GO TO I12
DON’T KNOW d
REFUSED r
I11. Please stop me when I reach your household’s total income for last month. Was it…
Less than $500, 1
$500 to$999, 2
$1,000 to $1,499, 3
$1,500 to $1,999, 4
$2,000 to $2,499, 5
$2,500 to $2,999, 6
$3,000 or more? 7
DON’T KNOW d
REFUSED r
I12. And, what was your household’s total income last year before taxes? Please include all types of income received by all household members last month, including all earnings, Social Security, pensions, child support, and cash welfare benefits such as TANF and SSI. Do not include the value of SNAP benefits or food stamps, WIC, Medicaid, or public housing.
NONE 0
GO
TO I13
$
|
|
|
|,|
|
|
|
LAST
YEAR GO TO I13
DON’T KNOW d
REFUSED r
I12.1 Please stop me when I reach your household’s total income for last year. Was it…
Less than $10,000, 1
$10,000 to $19,999, 2
$20,000 to $34,999, 3
$35,000 to $49,999, 4
$50,000 to $74,999, 5
$75,000 to $99,999, 6
$100,000 to $149,999 or, 7
$150,000 or more? 8
DON’T KNOW d
REFUSED r
I13. Has a doctor or other health care professional ever told you or anyone in your household that they had a disability? By disability, I mean a physical or mental impairment.
YES 1
NO 0
DON’T KNOW d
REFUSED r
PROGRAMMER: IF BASELINE NOT COMPLETED, SKIP TO J1.
I14.1 And now, my final questions. Thinking about [NAME OF PAST MONTH], what was your household’s total income last month before taxes? Please include all types of income received by all household members last month, including all earnings, Social Security, pensions, child support, and cash welfare benefits such as TANF and SSI. Do not include the value of SNAP benefits or food stamps, WIC, Medicaid, or public housing.
NONE 0
GO
TO J1
$
|
|
|,|
|
|
|
LAST
MONTH GO TO J1
DON’T KNOW d
REFUSED r
I14.2 Please stop me when I reach your household’s total income for last month. Was it…
Less than $500, 1
$500 to $999, 2
$1,000 to $1,499, 3
$1,500 to $1,999, 4
$2,000 to $2,499, 5
$2,500 to $2,999, 6
$3,000 or more? 7
DON’T KNOW d
REFUSED r
SECTION J: CLOSING AND ADDRESS VERIFICATION |
J1. (PHONE VERSION) Thank you very much for your time. You have helped us greatly with this important study. We will send you a $10 gift card within the next few weeks and I’d like to confirm your mailing address. According to our records we have…
[FILL STREET ADDRESS FROM SAMPLE FRAME]
[FILL CITY, STATE, ZIP CODE FROM SAMPLE FRAME]
ADDRESS
IS CORRECT 1 GO
TO J2
ADDRESS NEEDS UPDATING 0
UPDATE: STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
J1. (FIELD VERSION) Thank you very much for your time. You have helped us greatly with this important study. The field interviewer will give you your $10 gift card.
J2. If you have any questions about this study or your rights as a participant, I can give you a telephone number to call. This completes the survey!
| File Type | application/msword |
| File Title | Summer Electronic Benefit Transfer for Children Summer Follow-Up Questionnaire |
| Subject | Questionnaire |
| Author | Rhoda Cohen |
| Last Modified By | hwilson |
| File Modified | 2011-03-16 |
| File Created | 2011-03-16 |
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