National Household Food Acquisition and Purchase Survey -- Respondents

APPENDIX M
PRIMARY RESPONDENT BOOK

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2

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Daily List for Household ― Day 0
(√) CHECK DAY

A

Mon

Tue

Wed

Thu

Sat

Sun

Meals, snacks, and drinks you got outside your home
Write name of PLACE where you got meals, snacks, and drinks from outside your home (include places
where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

B

Fri

(√) Check (√) FILL OUT
if free
Red page

Groceries and other foods and drinks you brought home
Write name of PLACE where you got groceries and other food and drinks to be brought home (include
places where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

QUESTIONS? Call 1-866-275-8659

(√) Check (√) FILL OUT
if free
Blue page

Office Use

Daily List for Household ― Day 
(√) CHECK DAY

A

Mon

Tue

Wed

Thu

Sat

Sun

Meals, snacks, and drinks you got outside your home
Write name of PLACE where you got meals, snacks, and drinks from outside your home (include places
where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

B

Fri

(√) Check (√) FILL OUT
if free
Red page

Groceries and other foods and drinks you brought home
Write name of PLACE where you got groceries and other food and drinks to be brought home (include
places where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

QUESTIONS? Call 1-866-275-8659

(√) Check (√) FILL OUT
if free
Blue page

Office Use

Daily List for Household ― Day 
(√) CHECK DAY

A

Mon

Tue

Wed

Thu

Sat

Sun

Meals, snacks, and drinks you got outside your home
Write name of PLACE where you got meals, snacks, and drinks from outside your home (include places
where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

B

Fri

(√) Check (√) FILL OUT
if free
Red page

Groceries and other foods and drinks you brought home
Write name of PLACE where you got groceries and other food and drinks to be brought home (include
places where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

QUESTIONS? Call 1-866-275-8659

(√) Check (√) FILL OUT
if free
Blue page

Office Use

Daily List for Household ― Day 
(√) CHECK DAY

A

Mon

Tue

Wed

Thu

Sat

Sun

Meals, snacks, and drinks you got outside your home
Write name of PLACE where you got meals, snacks, and drinks from outside your home (include places
where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

B

Fri

(√) Check (√) FILL OUT
if free
Red page

Groceries and other foods and drinks you brought home
Write name of PLACE where you got groceries and other food and drinks to be brought home (include
places where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

QUESTIONS? Call 1-866-275-8659

(√) Check (√) FILL OUT
if free
Blue page

Office Use

Daily List for Household ― Day 
(√) CHECK DAY

A

Mon

Tue

Wed

Thu

Sat

Sun

Meals, snacks, and drinks you got outside your home
Write name of PLACE where you got meals, snacks, and drinks from outside your home (include places
where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

B

Fri

(√) Check (√) FILL OUT
if free
Red page

Groceries and other foods and drinks you brought home
Write name of PLACE where you got groceries and other food and drinks to be brought home (include
places where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

QUESTIONS? Call 1-866-275-8659

(√) Check (√) FILL OUT
if free
Blue page

Office Use

Daily List for Household ― Day 
(√) CHECK DAY

A

Mon

Tue

Wed

Thu

Sat

Sun

Meals, snacks, and drinks you got outside your home
Write name of PLACE where you got meals, snacks, and drinks from outside your home (include places
where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

B

Fri

(√) Check (√) FILL OUT
if free
Red page

Groceries and other foods and drinks you brought home
Write name of PLACE where you got groceries and other food and drinks to be brought home (include
places where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

QUESTIONS? Call 1-866-275-8659

(√) Check (√) FILL OUT
if free
Blue page

Office Use

Daily List for Household ― Day 
(√) CHECK DAY

A

Mon

Tue

Wed

Thu

Sat

Sun

Meals, snacks, and drinks you got outside your home
Write name of PLACE where you got meals, snacks, and drinks from outside your home (include places
where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

B

Fri

(√) Check (√) FILL OUT
if free
Red page

Groceries and other foods and drinks you brought home
Write name of PLACE where you got groceries and other food and drinks to be brought home (include
places where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

QUESTIONS? Call 1-866-275-8659

(√) Check (√) FILL OUT
if free
Blue page

Office Use

Daily List for Household ― Day 
(√) CHECK DAY

A

Mon

Tue

Wed

Thu

Sat

Sun

Meals, snacks, and drinks you got outside your home
Write name of PLACE where you got meals, snacks, and drinks from outside your home (include places
where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

B

Fri

(√) Check (√) FILL OUT
if free
Red page

Groceries and other foods and drinks you brought home
Write name of PLACE where you got groceries and other food and drinks to be brought home (include
places where you bought food and places where you got food for free)

WHO got the food

NAME of place

ENTER Total Paid
(include tax and tip)

1.

$ ________.____

2.

$ ________.____

3.

$ ________.____

4.

$ ________.____

5.

$ ________.____

6.

$ ________.____

7.

$ ________.____

8.

$ ________.____

9.

$ ________.____

10.

$ ________.____

QUESTIONS? Call 1-866-275-8659

(√) Check (√) FILL OUT
if free
Blue page

Office Use

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$ ________.______

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$ ________.______

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$ ________.______

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Office Use

$ ________.______

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Office Use

$ ________.______

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Office Use

$ ________.______

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Office Use

PLACES – Scan a place before scanning food from that place
Convenience store, corner store, bodega

Grocery store or supermarket

Big box or discount store

Liquor or package store

Drug store or pharmacy

Wholesale club

Farmers’ market / farm stand

Garden, hunting, fishing

Food bank or pantry

Other place
Bakery, delicatessen
(deli), fish or meat
market, or any other
store not listed.

Questions? Call us toll-free at 1-866-275-8659

BULK FOODS

BULK FOODS: Dried Fruit

1|Page

Questions? Call us toll free at 1-866-275-8659

BULK FOODS: Candy

2|Page

Questions? Call us toll free at 1-866-275-8659

BULK FOODS: Candy

3|Page

Questions? Call us toll free at 1-866-275-8659

BULK FOODS: Grains & Rice

PICTURE NOT
AVAILABLE

PICTURE NOT
AVAILABLE

4|Page

Questions? Call us toll free at 1-866-275-8659

BULK FOODS: Grains & Rice

5|Page

Questions? Call us toll free at 1-866-275-8659

BULK FOODS: Nuts & Seeds

6|Page

Questions? Call us toll free at 1-866-275-8659

BULK FOODS: Nuts & Seeds

7|Page

Questions? Call us toll free at 1-866-275-8659

DELI
FOODS

DELI CHEESE

8|Page

Questions? Call us toll free at 1-866-275-8659

DELI MEAT

9|Page

Questions? Call us toll free at 1-866-275-8659

DELI SALADS

10 | P a g e

Questions? Call us toll free at 1-866-275-8659

DELI SALADS

11 | P a g e

Questions? Call us toll free at 1-866-275-8659

DELI SALADS

12 | P a g e

Questions? Call us toll free at 1-866-275-8659

FRUITS and
VEGETABLES

FRUITS & VEGETABLES:

Alfalfa Sprouts – Bean Sprouts

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

13 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Beans – Bok Choy

BERRIES
SEE NEXT PAGE

Scan quantity code

Scan quantity code

14 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES: Berries
BERRIES

15 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Broccoflower – Carrot Sticks

Scan quantity code

Scan quantity code

Scan quantity code

16 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Carrots – Cherries

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity

17 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Chervil – Corn

Scan quantity code

Scan quantity code

Scan quantity code

18 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Cranberries – Eggplant

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

19 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Eggplant (cont.) – Ginger Root

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

20 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Gooseberries – Guava

Scan quantity code

Scan quantity code

21 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Guineito – Kumquat

PICTURE NOT
AVAILABLE

Scan quantity code

PICTURE NOT
AVAILABLE

Scan quantity code

Scan quantity code

22 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Leek – Lettuce

Scan quantity code

LETTUCE

Scan quantity code

LETTUCE

Scan quantity code
(# heads)

Scan quantity code
(# heads)

Scan quantity code
(# heads)

Scan quantity code
(# heads)

Scan quantity code
(# heads)

23 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Lettuce (cont.) – Mint

LETTUCE

Scan quantity code
(# heads)

Scan quantity code
(# heads)

Scan quantity code

PICTURE NOT
AVAILABLE
Scan quantity code

Scan quantity code

Scan quantity code

24 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Mushrooms

MUSHROOMS

25 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Mushrooms – Okra

MUSHROOMS

PICTURE NOT
AVAILABLE

Scan quantity code

26 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Bulb Onion – Yellow/Brown Onion

ONIONS

Scan quantity code

Scan quantity code of

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

27 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Orange – Peas

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

28 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Peas (cont.) – Peppers

PEPPERS

`

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

29 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Peppers (cont.)

PEPPERS

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

PICTURE NOT
AVAILABLE

Scan quantity code

Scan quantity code

PICTURE NOT
AVAILABLE
Scan quantity code

Scan quantity code

30 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Peppers (cont.) - Persimmon

PEPPERS

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

PICTURE NOT
AVAILABLE

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

31 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Persimmon – Potato

Scan quantity code

Scan quantity code

PICTURE NOT
AVAILABLE

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

32 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Potato (cont.) – Radicchio

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

33 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Radish – Romanesco

PICTURE NOT
AVAILABLE

Scan quantity code
(# heads)

PICTURE NOT
AVAILABLE

34 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Rosemary – Sprouts

35 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Squash

SQUASH

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code
36 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Squash (cont.)

SQUASH

Scan quantity code

Scan quantity code

PICTURE NOT
AVAILABLE

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

PICTURE NOT
AVAILABLE

Scan quantity code

Scan quantity code

37 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Squash (cont.)

SQUASH
PICTURE NOT
AVAILABLE

Scan quantity code

Scan quantity code

PICTURE NOT
AVAILABLE

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

PICTURE NOT
AVAILABLE

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

38 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Squash (cont.) – Tangerines

SQUASH

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

39 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Taro Root – Turnip

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code

Scan quantity code
40 | P a g e

Questions? Call us toll-free at 1-866-275-8659

FRUITS & VEGETABLES:

Turnip Greens – Yuca Root

Scan quantity code

Scan quantity code

41 | P a g e

Questions? Call us toll-free at 1-866-275-8659

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Quantity Codes for Fruits & Vegetables

Scan a barcode to tell us how many fruits or vegetables you got

1

6

2

7

3

8

4

9

5

10
Questions? Call us toll-free at 1-866-275-8659

Quantity Codes for Fruits & Vegetables

Scan a barcode to tell us how many fruits or vegetables you got

11

16

12

17

13

18

14

19

15

20
Questions? Call us toll-free at 1-866-275-8659

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