Formative - Developmental

Provider-Based Sampling Feasibility Study for the Vanguard (Pilot) Study and Data Collection Updates for the National Children's Study (NICHD)

Burden 15 Acculturation Instrument 20110621 - LOI2-QUEX-14

Formative - Developmental

OMB: 0925-0593

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LOI2-QUEX-14 ACCULTURATION QUESTIONNAIRE ATTACHMENT C.4.8

OMB#: 0925-0593

OMB Expiration Date: 07/31/13

Acculturation and Food Programs Instrument

(Pregnant Women)


  1. Were you born in the United States?


Yes (skip to question 2) 1

No 2

Refused 9--97

Don’t know 9--98


    1. In what country were you born?

Specify: _____________________________________________

(Source: http://www.state.gov/s/inr/rls/4250.htm#note2)

Refused 9--97

Don’t know 9—98


    1. About how long have you lived in the United States?

|___|___|

YEARS


Refused 9--97

Don’t know 9—98


  1. Was your mother born in the United States?


Yes (skip to question 3) 1

No 2

Refused 9--97

Don’t know 9--98


    1. In what country was your mother born?


Specify: _____________________________________________

(Source: http://www.state.gov/s/inr/rls/4250.htm#note2)

Refused 9--97

Don’t know 9—98


  1. Was your father born in the United States?


Yes (skip to question 4) 1

No 2

Refused 9--97

Don’t know 9--98


    1. In what country was your father born?

Specify: _____________________________________________

(Source: http://www.state.gov/s/inr/rls/4250.htm#note2)

Refused 9--97

Don’t know 9—98


This question is about your ethnicity, your ethnic group and how you feel about it or react to it. Choose the answer to indicate how much you agree or disagree with the following statement.


  1. I have a strong sense of belonging to my own ethnic group


Strongly agree 1

Disagree 2

Agree 3

Strongly agree 4


These questions are about food programs you may participate in.


  1. Do you currently receive benefits from the WIC program, that is, the Women, Infants and Children program?


Yes 1

No 2

Refused 9--97

Don’t know 9--98


  1. Are you or any members of you household authorized to receive Food Stamps (which include a food stamp card or voucher, or cash grants from the state for food)?


Yes 1

No 2

Refused 9--97

Don’t know 9--98





Thank you for your time and participation!

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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleNutrition LOI Socio-demographics Instrument
File Modified0000-00-00
File Created2021-01-30

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