SEBTC - Households

Reference No.:

OMB No.: 0584-0559

Expiration Date: 03/31/2014

Summer Electronic Benefits Transfer for Children

Spring Baseline Questionnaire

January 17, 2012 (Proposed)

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 25 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

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

[%UFName % ULName]?

[INTERVIEWER NOTE: REFER TO FA Q’S TO ANSWER ANY QUESTIONS, INCLUDING CONTENT OF SURVEY]

SPEAKING TO [NAME OF PARENT] 1 GO TO A2

[NAME OF PARENT] COMES TO PHONE 2 GO TO A2

NOT A GOOD TIME 4 SCHEDULE CALLBACK

[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 GO TO A2

(VOL) respondent will call back 2 GO TO A2

Don’t know 8 GO TO A2

Refused 9 GO TO A2

QUALIFIED LEVEL 1: SI1=1

[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 GO TO A2

Don’t know 8

Refused 9

[IF SAMPLE FLAGGED AS CELL PHONE]

SC2 Are you driving?

No 1

Yes, call me later 2 SCHEDULE CALLBACK

Don’t know 8

Refused 9

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.

A2a. Is there a child living in your home who attends an elementary,middle or high school in the [NAME OF SCHOOL DISTRICT] public school system?

YES 1

NO 2 TERMINATE

DON’T KNOW 88 GO TO REFUSAL

REFUSED 99 GO TO REFUSAL

A3. Are you the parent or adult in the household who knows the most about what the school-age children in this household ate over the last 30 days?

[IF R ANSWERS “PROBABLY” OR “AS MUCH AS ANYONE ELSE,” ENTER “1,YES.”]

YES 1 GO TO A4.3

YES, BUT NOT AVAILABLE NOW 2 GO TO CALLBACK

NO 3

DON’T KNOW 8

REFUSED 9

A4.1 What is the name of the parent or adult who knows the most about what the school-age children in this household ate over the last 30 days?

ENTER NAME OF PARENT/ADULT:

DON’T KNOW 8

REFUSED 9

QUALIFIED LEVEL 2: (A3=1 OR 2) OR (GAVE NAME IN A4.1)

A4.2 May I speak with (him/her)?

YES 1

YES, BUT NOT AVAILABLE NOW 2 GO TO CALLBACK

CANNOT COME TO PHONE 3 GO TO CALLBACK

(VOL) Not available at this phone number 4 GO TO UPDATE PHONE

DON’T KNOW 8 GO TO CALLBACK

REFUSED 9 GO TO REFUSAL

A4.3 [READ IF A4.2=1] Hello, my name is _________ and I’m calling on behalf of the USDA., Food and Nutrition Service. We are conducting a research study about the food choices of children and their families.

[READ TO ALL:] Are you at least 18 years old?

YES 1

NO 2 SCREEN-OUT RESP UNDER 18

DON’T KNOW/REFUSED 8 SCREEN-OUT RESP UNDER 18 REF

QUALIFIED LEVEL 3: A4.3=1

[READ TO ALL:]

A4.4 For quality assurances purposes, this call may be monitored or recorded.

The study has two parts - an interview that will take about 25 minutes and a second interview during the summer. As a way of saying thank you, you will get a total of $35 for completing both interviews. We will send you a $10 VISA gift card when we finish today’s interview and a $25 VISA gift card after completing the interview in the summer. You will get a total of $35 if you do both interviews.

The interviews have questions about your children’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.

Your participation in this interview is voluntary and you may stop at any time. You may also refuse to answer any question. Your benefits will not be affected by any answers to questions or if you choose not to participate.

All the information you give us will be kept private to the extent allowed by law. There is a small risk of the loss of confidentiality of your data, but procedures are in place to minimize this risk. 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.

Do you have any questions about the interview before I begin?

[REFER TO FA Q’S TO ANSWER ANY QUESTIONS]

A5 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 A7

YES, I’M WILLING BUT NOT AVAILABLE NOW 2 SCHEDULE CALLBACK

DON’T KNOW 8

REFUSED TO PARTICIPATE 9 GO TO REFUSAL

A6. May we call you back at another time?

YES 1 SCHEDULE CALLBACK

NO 2 GO TO REFUSAL

DON’T KNOW 8 SCHEDULE CALLBACK

REFUSED 9 GO TO REFUSAL

SECTION B: HOUSEHOLD CHARACTERISTICS

The first few questions are about the people you live with.

QUALIFIED LEVEL 4: REACHES B1

B1. Including yourself, how many people live in your household? Don’t forget to include non‑relatives who live here and, of course, babies, small children and foster children. Also include persons who usually live here but are temporarily away for reasons such as: vacation, traveling for work, or in the hospital. Do not include children living away at school.

INTERVIEWER: BY TEMPORARILY AWAY WE MEAN AWAY WITHIN THE LAST 30 DAYS.

_________ Number of people [RANGE 1-20]

DON’T KNOW 88

REFUSED 99

[If B1=1:]

B1a. Just to confirm, you are the only person living in the household. There are no children, non-relatives, or people who usually live there but are currently away?

YES 1 SCREEN-OUT: 1 PERSON

IN HH

NO, CORRECT NUMBER 2

B1.1 Do all the people who live with you share the food that is bought for the household?

YES 1 GO TO B2

NO 2

DON’T KNOW 88

REFUSED 99

B1.2 Including yourself, how many people in your household share the food that is bought for the household?

[PROGRAMMER NOTE: IF B1 NE 88/99 B1.2 CANNOT BE GREATER THAN B1]

_________ Number of people

DON’T KNOW 88

REFUSED 99

B2. How many of those (IF B1.1=1, FILL NUMBER FROM B1, OTHERWISE, FILL NUMBER FROM B1.2) people are children age 18 or younger or over 18 but still in high school?

[IF B1.1 AND B1.2 = 88 OR 99, READ:] How many people in your household are children age 18 or younger or over 18 but still in high school?

[PROGRAMMER NOTE: B2 CANNOT BE GREATER THAN B1/B1.2]

_________ Number of children [RANGE 1-20] GO TO B3

NO CHILDREN IN HOUSEHOLD 00 SCREEN-OUT: NO

CHILDREN IN HH

DON’T KNOW 88 SCREEN-OUT: DK/REF

NUM OF CHILDREN IN HH

REFUSED 99 SCREEN-OUT DK/REF

NUM OF CHILDREN IN HH

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 but still in high school and their birthdays. What is the name of the (first child?[IF 1 CHILD READ:] What is the name of the child age 18 or younger, or over 18 but still in high school living in your household?

B4a. What is (NAME1)’s birthday?

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

MONTH DAY YEAR

DON’T KNOW 8 SCREEN-OUT: DK/REF

NUM OF CHILDREN IN HH

REFUSED 9 SCREEN-OUT: DK/REF

NUM OF CHILDREN IN HH

B4b. IF CHILD IS 3 YEARS OR OLDER: Is that child in grades pre-K through 12 in your public school system?

YES 1

NO 2

DON’T KNOW 88

REFUSED 99

B4c. IF B4b=YES AND AGE AT B4a=20 OR OVER: Just to confirm, (NAME1) was born in (INSERT YEAR FROM B4a)?

YES 1

NO 2 GO TO B4a & CORRECT

DON’T KNOW 88

REFUSED 99

B5. What is the name of the next child?

B5a. What is (NAME2)’s birthday?

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

MONTH DAY YEAR

DON’T KNOW 8

REFUSED 9

B5b. IF CHILD IS 3 YEARS OR OLDER: Is that child in grades pre-K through 12 in your public school system?

YES 1

NO 2

DON’T KNOW 88

REFUSED 99

B5c. IF B5b=YES AND AGE AT B5a=20 OR OVER: Just to confirm, (NAME 2) was born in (INSERT YEAR FROM B5a)?

YES 1

NO 2 GO TO B5a & CORRECT

DON’T KNOW 88

REFUSED 99

PROGRAMMER: CREATE GRID, USING B2 FOR NUMBER OF CHILDREN IF B2<88. IF B2=88,99 ALLOW UP TO 20.

IF MORE THAN1 CHILD IN HOUSEHOLD, USE RANDOM SELECTION TO CHOOSE FOCAL CHILD.

SECTION C: CHILD DEMOGRAPHICS

QUALIFIED LEVEL 5: REACHES C1

[IF NUMBER OF CHILDREN >1] For the next set of questions, we are going to focus on [CHILD NAME].

READ IF NECESSARY: Throughout the survey there will be questions asked only about [CHILD NAME]. This child has been randomly selected and we cannot change to ask about a different child.

C1. Is [CHILD NAME] a boy or girl?

[ASK IF THEY HAVE NOT ALREADY MENTIONED CHILD’S SEX]

BOY 1

GIRL 2

DON’T KNOW 8

REFUSED 9

[ASK IF B1 NE 1]

C1a. During the past 30 days, since [DATE (DATE OF INTERVIEW -30 DAYS)], how many days did [CHILD NAME] live in this household?

IF RESPONDENT SAYS EVERYDAY, ENTER 30.

_________ Number of days [RANGE 1-30]

NONE 0

DON’T KNOW 88

REFUSED 99

SECTION D: DIETARY BEHAVIORS – CHILD

THIS SECTION DELETED IN THIS VERSION

SECTION E: PROGRAM PARTICIPATION – CHILD

For the next series of questions we’ll be asking about meals and snacks [CHILDNAME] may have had during the last 30 days since [DATE (DATE OF INTERVIEW -30 DAYS)].

E1. During the last 30 days did [CHILD NAME] usually eat breakfast each day?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

E2.1. On school days during the last 30 days, did [CHILD NAME] get free or reduced price breakfasts at school?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

E2.2 On school days during the last 30 days, did [CHILD NAME] get free or reduced price lunches at school?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

E2.3 During the last 30 days, how many days a week did [CHILD NAME] get free supper meals at an after school program held in (his/her) school building?

ONE DAY 1

TWO DAYS 2

THREE DAYS 3

FOUR DAYS 4

FIVE DAYS/EVERYDAY 5

NO DAYS/EATS SUPPER SOMEPLACE ELSE 6

DON’T KNOW 8

REFUSED 9

IF E2.3=6, 8, OR 9 INSERT “an”; IF E2.3=1-5 INSERT “any other”.

E3. During the last 30 days, did [CHILD NAME] participate in (an/any other) after school program where meals or snacks are served?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

E4. During the last 30 days since [DATE (DATE OF INTERVIEW -30 DAYS)], did [CHILD NAME] get food through a backpack food program for children?

[IF NEEDED: THE BACKPACK FOOD PROGRAM PROVIDES FOOD FOR CHILDREN TO TAKE HOME OVER WEEKENDS AND HOLIDAYS]

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

[ASK F1-F8a FOR ALL RESPONDENTS]

SECTION F: FOOD SECURITY – HOUSEHOLD

[PROGRAMMER NOTE: SELECT APPROPRIATE FILLS DEPENDING ON NUMBER OF ADULTS AND CHILDREN IN THE HOUSEHOLD. DEFAULT TO MULTIPLE ADULTS AND MULTIPLE CHILDREN IN HOUSEHOLD.]

QUALIFIED LEVEL 6: REACHES F1

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 8

REFUSED 9

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 8

REFUSED 9

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 8

REFUSED 9

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 2 GO TO F5

DON’T KNOW 8 GO TO F5

REFUSED 9 GO TO F5

[ASK IF F4=1]

F4a. In the last 30 days, how many days did this happen?

_________ Number of days [RANGE 1-30] GO TO F5

DON’T KNOW 88

REFUSED 99 GO TO F5

F4b. Do you think it was one or two days, or more than two days?

ONE OR TWO DAYS 1

MORE THAN TWO DAYS 2

DON’T KNOW 8

REFUSED 9

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 2

DON’T KNOW 8

REFUSED 9

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 2

DON’T KNOW 8

REFUSED 9

F7. In the last 30 days, did you lose weight because there wasn’t enough money for food?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

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 2 GO TO F9

DON’T KNOW 8 GO TO F9

REFUSED 9 GO TO F9

[ASK IF F8=1]

F8a. In the last 30 days, how many days did this happen?

_________ Number of days [RANGE 1-30] GO TO F9

DON’T KNOW 88

REFUSED 99 GO TO F9

F8b. Do you think it was one or two days, or more than two days?

ONE OR TWO DAYS 1

MORE THAN TWO DAYS 2

DON’T KNOW 8

REFUSED 9

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].

“[I/We] relied on only a few kinds of low-cost food to feed [my/our] [child/ 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 8

REFUSED 9

F10. “[I/We] couldn’t feed [my/our] child/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 8

REFUSED 9

[SINGLE ADULT/SINGLE CHILD: My child was]

[MULTIPLE ADULTS/SINGLE CHILD: Our child was]

[SINGLE OR MULTIPLE ADULTS/MULTIPLE CHILDREN: The children were]

F11. “[My child was /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 8

REFUSED 9

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 2

DON’T KNOW 8

REFUSED 9

F13. In the last 30 days, did [your child/any of the children] ever skip meals because there wasn’t enough money for food?

YES 1

NO 2 GO TO F14

DON’T KNOW 8 GO TO F14

REFUSED 9 GO TO F14

[ASK IF F13=1]

F13a. In the last 30 days, how many days did this happen?

_________ Number of days [RANGE 1-30] GO TO F14

DON’T KNOW 88

REFUSED 99 GO TO F14

F13b. Do you think it was one or two days, or more than two days?

ONE OR TWO DAYS 1

MORE THAN TWO DAYS 2

DON’T KNOW 8

REFUSED 9

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 2

DON’T KNOW 8

REFUSED 9

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 2

DON’T KNOW 8

REFUSED 9

SECTION G: PROGRAM PARTICIPATION – HOUSEHOLD

G1. Next, I’m going to read the names of some programs that provide food or meals to individuals or households.

G1.1 In the last 30 days that is since [DATE OF INTERVIEW -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 2 GO TO G1.3

DON’T KNOW 8 GO TO G1.3

REFUSED 9 GO TO G1.3

G1.2a How many women or children in the household got WIC foods or benefits?

_________ Number of women or children [RANGE 1-20]

DON’T KNOW 88 GO TO G1.3

REFUSED 99 GO TO G1.3

[ASK IF G1.2A=1]

G1.2ba Is that person who got WIC foods or benefits an infant less than 1 year old?

YES 1 [CODE AS 1 IN G1.2B]

NO 2

DON’T KNOW 88

REFUSED 99

[ASK IF G1.2A>1 AND NOT DK/REF]

G1.2b How many of those [NUMBER FROM G1.2a] people who got WIC foods or benefits are infants less than 1 year old?

_________ Number of infants [RANGE 0-20]

DON’T KNOW 88

REFUSED 99

CREATE PROGRAMMED VARIABLE COMBINING G1.2BA AND G1.2B

G1.3 In the last 30 days did you or anyone in your household receive food or meals from food pantries, food banks, local soup kitchens or emergency kitchens?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

G2. Are you [IF MULTIPLE PEOPLE IN HOUSEHOLD: or others in your household] currently receiving [FILL STATE SNAP PROGRAM NAME] benefits?

YES 1

NO 2 GO TO G6

DON’T KNOW 8 GO TO G6

REFUSED 9 GO TO G6

G3. How long have you (and your household) been receiving [FILL STATE SNAP PROGRAM NAME] benefits?

RANGE 1 -

1__ DAYS [RANGE 1-365]

2__ WEEKS [RANGE 1-52]

3__ MONTHS [RANGE 1-12]

4__YEARS [RANGE 1-50]

888 DON’T KNOW/NOT SURE

999 REFUSED

G4. What is the amount of the [FILL STATE SNAP PROGRAM NAME] benefits (you receive/your household receives) per month?

_________ Enter amount [$1 - $9999]

DON’T KNOW 8

REFUSED 9

G5. How many weeks do your [FILL STATE SNAP PROGRAM NAME] benefits usually last?

[CODE ANY ANSWER GREATER THAN 8 WEEKS AS 8]

_________ Enter number of weeks (range 0-8)

DON’T KNOW 88

REFUSED 99

G6. Do you (or others in your household) currently receive monthly commodity foods as part of the Food Distribution Program on Indian Reservations (FDPIR [fid-purr])?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

G7. Please tell me if you have access to a working refrigerator to store food you get for your household?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

[ASK ALL]

SECTION H: SHOPPING AND EATING BEHAVIOR – HOUSEHOLD

Now, I’d like to ask some questions about shopping for food and eating at restaurants.

H1. First I’ll ask you about money spent at supermarkets and other stores. Then we will talk about money spent at fast food restaurants and other restaurants.

Excluding any purchases made with government benefits like SNAP or WIC, since [DATE (DATE OF INTERVIEW –30 DAYS)] how much money [did your family/did you] spend out of pocket at supermarkets, grocery stores, and other stores? Please do not include fast food restaurants and other types of restaurants. (You can tell me per week or per month.)

PROBE: This includes stores such as Wal-mart, Target, and Kmart, convenience stores like 7-11 or Mini Mart, stores like Costco or Sam’s Club, dollar stores, bakeries, meat markets, vegetable stands, or farmer’s markets.

[RECORD “0” IF NO MONEY WAS SPENT]

0__NO MONEY SPENT GO TO H4

1__ PER WEEK [RANGE $1-$9,999]

2__ PER MONTH [RANGE $1-$9,999]

8 DON’T KNOW/NOT SURE GO TO H4

9 REFUSED GO TO H4

H2. Was any of this money spent on nonfood items such as cleaning or paper products, pet food, cigarettes or alcoholic beverages?

YES 1

NO 2 GO TO H4

DON’T KNOW 8 GO TO H4

REFUSED 9 GO TO H4

H3. About how much money was spent on nonfood items? (You can tell me per week or per month.)

PROGRAMMER: AMOUNT CANNOT BE MORE THAN THE AMOUNT ENTERED ON QUESTION H1.

[RECORD “0” IF NO MONEY WAS SPENT]

0__NO MONEY SPENT

1__ PER WEEK [RANGE $1-$9,999]

2__ PER MONTH [RANGE $1-$9,999]

8 DON’T KNOW/NOT SURE

9 REFUSED

H4. [IF G1.1=1:] Did the [AMOUNT REPORTED AT H1] you spent on food include purchases made with your household’s WIC fruit & vegetable voucher?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

H5. [IF G2=1:] Did the [AMOUNT REPORTED AT H1] you spent on food include purchases made with your household’s SNAP Benefits?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

H6. 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.”]

0__NEVER

1__ PER WEEK [RANGE 1-99]

2__ PER MONTH [RANGE 1-99]

8 DON’T KNOW/NOT SURE

9 REFUSED

H7. During the last 30 days, how many times did your family 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.”]

0__NEVER

1__ PER WEEK [RANGE 1-99]

2__ PER MONTH [RANGE 1-99]

8 DON’T KNOW/NOT SURE

9 REFUSED

[PROGRAMMER: IF H6 AND H7=0, GO TO I1]

H8. 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.)

0__NO MONEY SPENT

1__ PER WEEK [RANGE $1-$9,999]

2__ PER MONTH [RANGE $1-$9,999]

8 DON’T KNOW/NOT SURE

9 REFUSED

SECTION I: CAREGIVER DEMOGRAPHICS

I1. Now, I have a few questions about you.

[RECORD GENDER FROM OBSERVATION.]

[ONLY IF NECESSARY – ASK: Because it is sometimes difficult to determine over the phone, I am asked to confirm with everyone…Are you male or female?]

MALE 1

FEMALE 2

DON’T KNOW 8

REFUSED 9

I2. What is your relationship to [CHILD NAME]?

READ ONLY IF NECESSARY: Are you [CHILD NAME’s]…

BIOLOGICAL/ADOPTIVE PARENT 1

STEP-PARENT 2

GRANDPARENT 3

GREAT GRANDPARENT 4

SIBLING/STEPSIBLING 5

OTHER RELATIVE OR IN‑LAW 6

FOSTER PARENT 7

OTHER NON-RELATIVE 8

PARENT’S PARTNER 9

DON’T KNOW 88

REFUSED 99

I3. Are you of Hispanic or Latino origin?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

I4. I am going to read a list of five race categories. Please choose one or more races that you consider yourself to be. American Indian or Alaska Native; Asian; Black or African American; Native Hawaiian or other Pacific Islander; White?

MARK ALL THAT APPLY

AMERICAN INDIAN OR ALASKA NATIVE 1

ASIAN 2

BLACK OR AFRICAN AMERICAN 3

NATIVE HAWAIIAN OR

OTHER PACIFIC ISLANDER 4

WHITE 5

DON’T KNOW 8

REFUSED 9

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 8

REFUSED 9

I6. Please tell me your birth date.

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

MONTH DAY YEAR

DON’T KNOW 8

REFUSED 9

PROGRAMMER: MUST BE OLDER THAN 18. IF NOT ASK:

I6a. You said your date of birth is [INPUT ANSWER FROM I6), is this correct?

YES 1

NO 2 REPEAT I6

I7. 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 88

REFUSED 99

I8. The next questions are about your current job or business. Were you working for pay in the last 30 days that is, since [DATE (DATE OF INTERVIEW -30 DAYS)]?

YES 1 GO TO I10

NO 2

DON’T KNOW 8

REFUSED 9

I9. Was any other adult in the household working for pay in the last 30 days that is, since [DATE (DATE OF INTERVIEW -30 DAYS)]?

YES 1

NO 2

DON’T KNOW 8

REFUSED 9

I10. What was your household’s total income last month, during [MONTH (CURRENT MONTH -1)] 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 (TAH-nif) and SSI. Do not include the value of SNAP benefits or food stamps, WIC, Medicaid, or public housing.

NO INCOME 0 GO TO I12

GAVE ANSWER 1 [RANGE $1 – 99,999] GO TO I12

DON’T KNOW 8

REFUSED 9

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 8

REFUSED 9

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 year, including all earnings, Social Security, pensions, child support, and cash welfare benefits such as TANF (TAH-nif) and SSI. Do not include the value of SNAP benefits or food stamps, WIC, Medicaid, or public housing.

NO INCOME 0 GO TO I14

GAVE ANSWER 1 [RANGE $1 – 999,999] GO TO I14

DON’T KNOW 8

REFUSED 9

I13. 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 88

REFUSED 99

I14. 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 2

DON’T KNOW 8

REFUSED 9

SECTION J: ADDITIONAL CONTACT INFORMATION

QUALIFIED LEVEL 6: REACHES J1

J1. [IF NOT INBOUND CALL FROM IN-PERSON INTERVIEWER:] Thank you very much for your time. You have helped us greatly with this important study. I’d like to confirm your address so we can send you a $10 VISA gift card within the next few weeks.

J1. [IF INBOUND CALL FROM IN-PERSON INTERVIEWER:] Thank you very much for your time. You have helped us greatly with this important study. The field interviewer will give you your $10 VISA gift card. While we have you on the phone, we would like to confirm your mailing address.

[ASK ALL:]

J1a. According to our records we have…

[IF A3=1, FILL NAME FROM FILE. ELSE, FILL FROM A4.1]

[FILL STREET ADDRESS FROM SAMPLE FRAME]

[FILL CITY, STATE, ZIP CODE FROM SAMPLE FRAME]

NAME AND ADDRESS IS CORRECT 1 GO TO J2

NAME AND ADDRESS NEEDS UPDATING 0

UPDATE: NAME

UPDATE: STREET ADDRESS:

CITY:

STATE:

ZIP CODE:

J2. We would also like to conduct a follow up interview in a couple of weeks to see how you are doing during the summer. You will receive a $25 VISA gift card for participating in that interview.

In case we can’t reach you at this number, is there another number we should try?

PHONE NUMBER: | | | | - | | | | - | | | | |

NO ADDITIONAL PHONE AVAILABLE 1

(VOL) GAVE INTERNATIONAL PHONE NUMBER 2

REFUSED TO PARTICIPATE IN FOLLOW-UP

INTERVIEW 9 GO TO END

[ASK J2.A IF RESPONDENT PROVIDES PHONE IN J2, OTHERWISE SKIP TO J2.B]

J2.a. What type of phone number is this?

HOME 1

CELL 2

WORK 3

OTHER, SPECIFY 4

DON’T KNOW 8

REFUSED 9

J2.b. Please give me an email address that we can reach you at?

EMAIL ADDRESS:

NO EMAIL ADDRESS AVAILABLE 2

DON’T KNOW 8

REFUSED 9

J3. In case we have trouble reaching you in a couple of weeks, please give me the name and telephone number of a relative or friend who would know where you could be reached.(Please give me the name of someone not currently living in the household.)

[BE SURE TO VERIFY SPELLING]

ENTER FIRST NAME:

DON’T KNOW 8

REFUSED 9

ENTER LAST NAME:

DON’T KNOW 8

REFUSED 9

J4. What is this person’s telephone number, beginning with the area code?

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

(VOL) GAVE INTERNATIONAL PHONE NUMBER 2

DON’T KNOW 8

REFUSED 9

J5. And what is [NAME FROM ABOVE]’s relationship to you?

RELATIONSHIP:

DON’T KNOW 8

REFUSED 9

Thank you again for your help and have a good day/good evening. We look forward to speaking with you again during the summer when you will be eligible for a $25 VISA gift card.