Household Screener

OMB Control Number: 0536-0068
Expiration Date: 03/31/2015

MPRID: |____|____|____|____|____|____|____|____|

National Food Study – Household Screener
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not 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 is 0536‐0068. The time required to complete this information collection is 
estimated to average less than 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 
needed, and completing and reviewing the collection of information.

INTRODUCTION
Hello. My name is [FILL NAME]. I work for Mathematica
Policy Research and we’re conducting the National
Food Study for the U.S. Department of Agriculture. We
recently sent a post card to this address.
SHOW ID CARD
The National Food Study will help the USDA improve its
programs by answering questions about where
households get food and how much they pay for food.

If you are eligible and you complete the study you will
receive $100 or more.
All of your responses to this information collection are
voluntary. The information that you provide will be kept
completely confidential. We will use your information
only for statistical purposes and your responses will not
have any effect on services you currently receive or may
apply for in the future.
2. May I begin the five minute questionnaire?

OFFER THE STUDY BROCHURE
1

I am here to conduct a five minute questionnaire to see if
your household is eligible to participate in the study.

0

 YES
 NO

GO TO Q3
GO TO Q2b

REFUSALS
2b. I understand if you don’t want to participate in the study. You can still help us by completing just this 5
minute questionnaire. Your answers will help us know whether households that participate in the study are
representative of all households.
May I begin the five minute questionnaire?
 YES
0  NO
1

GO TO Q3

2c. [PROVIDE $5 INCENTIVE] I can offer you $5 for answering these questions. It should
take less than 5 minutes.
1
0

 YES
 NO

GO TO Q3
GO TO BACK PAGE Q R1

VERIFY ADDRESS
3. I have this address as [READ ADDRESS ON CONTACT SHEET]. Is that your exact address?
 YES. EXACTLY AS LISTED
GO TO Q.4
2  MOSTLY CORRECT, BUT NEEDS MINOR CHANGES
MAKE CHANGES ON CONTACT SHEET
3  INCORRECT ADDRESS
TERMINATE INTERVIEW AND FIND CORRECT ADDRESS
1

Page 1

4. Is your mailing address the same as your street address? PROBE: Do you get your mail sent to this address?


d
r
1
0

YES
GO TO Q.5
NO
DON’T KNOW
REFUSED

GO TO Q.5

4a. Please give me your complete mailing address (including apartment number).
STREET ADDRESS:
P.O. BOX OR RURAL ROUTE:
CITY:
STATE:

ZIP:

5. ASK IF ADDRESS APPEARS TO BE A SINGLE-FAMILY DWELLING OR SINGLE DETACHED HOUSE, ELSE
SKIP TO Q6. Are there any other housing units or living quarters—either occupied or vacant—at this
address? A separate housing unit has either (1) direct access from the outside or from a common hallway, or
(2) a kitchen or cooking equipment for the exclusive use of the occupants.

2
0
d
r
1

YES, ONE OTHER UNIT
YES, MORE THAN ONE OTHER UNIT
NO
DON’T KNOW
GO TO Q.6
REFUSED

5a. What is the exact address of the (first) unit or living quarters?

0
d
r
1

SAME
GO TO Q.5b
NOT SAME
WRITE ADDRESS BELOW
DON’T KNOW
GO TO Q.5b
REFUSED

1ST UNIT:
STREET ADDRESS:
P.O. BOX OR RURAL ROUTE:
CITY:
STATE:

ZIP:

2ND UNIT:
STREET ADDRESS:
P.O. BOX OR RURAL ROUTE:
CITY:
STATE:

ZIP:

Page 2

5b. Do the occupants of the additional units or living quarters live separately from the
people in your household?
1

 YES

0

 NO

THIS IS A SEPARATE UNIT AND WILL BE ELIGIBLE FOR SELECTION IN A
LATER SAMPLE RELEASE. CONTINUE WITH CURRENT RESPONDENT.
THIS UNIT IS PART OF THE HOUSEHOLD. COUNT IN HOUSEHOLD SIZE.
CONTINUE WITH CURRENT RESPONDENT.

6. Do you or a member of your household live or stay at this address year round?

0
d
r
1

YES
GO TO Q.7
NO
DON’T KNOW
REFUSED

GO TO Q.6a

6a. How many months of the year do members of this household stay at this address?
 6 MONTHS OR MORE
0  LESS THAN 6 MONTHS
1

GO TO Q.7
TERMINATE. READ IF NECESSARY: This study only
includes people at their permanent residence. Based on
your responses, you are not eligible for the study at this
time. STATUS ON CONTACT SHEET 024.

HOUSEHOLD INFORMATION
7. Including yourself, how many people live in your household? Don’t forget to include babies, small children,
and non-relatives who live here. 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 people living away at school.
|

|

| NUMBER

 DON’T KNOW
r  REFUSED
d

8. Do all the people in your household live together and share food?
1
0

 YES
 NO

FILL HH SIZE BOX ON NEXT PAGE WITH Q.7 RESPONSE. SKIP TO Q.9

8a. How many people live together and share food?
|

|

| NUMBER

ENTER IN HH SIZE BOX ON NEXT PAGE

 DON’T KNOW
r  REFUSED
d

Page 3

INTERVIEWER: ENTER HH SIZE AND CHECK OPEN QUOTA GROUPS LISTED ON CONTACT SHEET
HH
SIZE

INCOME
CATEGORY

OPEN QUOTA GROUPS
Group-A

Group-B

Group-C

Group-D

9. From now on when we refer to your household we mean the [FILL HH SIZE] people that live together and
share food. The next question is about your household’s income. This card [SHOW INCOME SOURCES HAND
CARD] lists types of income people receive. Please tell me which types of income are received by people in
your household. SNAP BENEFITS ARE NOT COUNTED AS INCOME.
1

 EARNINGS FROM WORK

2

 UNEMPLOYMENT COMPENSATION

3

 WORKERS COMPENSATION

4

 DISABILITY OR SSI

5

 SOCIAL SECURITY

6

 PENSIONS AND RETIREMENT INCOME

 CHILD SUPPORT
8  ALIMONY
9  CASH WELFARE (LIKE TANF OR GENERAL ASSISTANCE)
10  INVESTMENT INCOME
11  OTHER
d  DON’T KNOW
r  REFUSED
7

10. Including your household’s income from [LIST INCOME SOURCES IN Q9], which group (A, B or C)
corresponds to your household total income before taxes? SHOW HAND CARD FOR THE HOUSEHOLD SIZE.

2
3
d
r
1

GROUP A
GROUP B
GROUP C
DON’T KNOW
REFUSED

FILL INCOME CATEGORY BOX ABOVE AND GO TO Q.11

GO TO Q.10a

CATEGORIES FOR
Q10a and Q10b

10a. Was it [FILL-Q10a] or more last year?
 YES
GO TO Q.10b
 NO
ENTER “A” IN INCOME CATEGORY BOX ABOVE
d  DON’T KNOW
GO TO Q.10b
r  REFUSED
GO TO Q.10b
1

0

10b. Was it [FILL-Q10b] or more last year?
 YES
ENTER “C” IN INCOME CATEGORY BOX ABOVE
0  NO
ENTER “B” IN INCOME CATEGORY BOX ABOVE
ENTER “DK” IN INCOME CATEGORY
d  DON’T KNOW
BOX ABOVE
r  REFUSED
ENTER “REF” IN INCOME CATEGORY
BOX ABOVE
1

HH
FILL-Q10a FILL-Q10b
Size
1

$11,000

$21,000

2

$15,000

$28,000

3

$19,000

$35,000

4

$23,000

$43,000

5

$27,000

$50,000

6

$31,000

$57,000

7

$35,000

$65,000

8+

$39,000

$72,000

Page 4

11. Do you or any member of your household currently receive [FILL STATE SNAP NAME]? This program puts
money on an EBT card that you can use to buy food.


d
r
1
0

YES
GO TO INT CHECK #1
NO
DON’T KNOW
GO TO INT CHECK #2
REFUSED

FILL FOR QUESTION 11
ROW STATE

INTERVIEWER CHECK #1
IS QUOTA GROUP D OPEN?
1

YES

0

NO

GO TO “ELIGIBLE” SECTION
GO TO “NOT ELIGIBLE” SECTION

FILL STATE SNAP NAME

1

AL, AR, CT, IL,KY, LA, MS

SNAP

2

ND, NE, NM, PA, SC, SD, TX

SNAP

INTERVIEWER CHECK #2:

3

FL, KS, MI, OH

Benefits from the Food
Assistance Program

IS THE HOUSEHOLD’S INCOME CATEGORY AN
OPEN QUOTA GROUP?

4

AZ

Nutrition Assistance

5

CA

CalFresh

6

IN

Food Stamps or SNAP

7

NC

Benefits from the Food and
Nutrition Services

8

NJ

NJ SNAP

9

NY

Food Stamps

10

WA

Benefits from the Basic
Food Program

11

WI

FoodShare

1

YES

GO TO “ELIGIBLE” SECTION

0

NO

d

DON’T KNOW
TERMINATE. STATUS
ON CONTACT SHEET 220.

r

REFUSED
TERMINATE. STATUS
ON CONTACT SHEET 220.

GO TO “NOT ELIGIBLE” SECTION

NOT ELIGIBLE CONTINUE HERE
Thank you for your time. I’m sorry your household is not eligible for the study.
READ IF NECESSARY: In order to produce a representative sample we only take households with certain characteristics.
Based on your responses you are not eligible at this time.
22. May I have your name and telephone number in case my supervisor wants to confirm that I spoke with you?
FIRST NAME:
LAST NAME:
TELEPHONE: (______) -______ - ________
Area Code

 NO TELEPHONE
 DON’T KNOW
r  REFUSED
0
d

23. WHAT LANGUAGE WAS USED FOR THIS INTERVIEW?


3
4
5
6
1
2

ENGLISH
SPANISH
KOREAN
VIETNAMESE
CHINESE
TRANSLATED BY OTHER HH MEMBER

THANK AGAIN AND TERMINATE. COMPLETE INTERVIEWER OBSERVATIONS ON BACK PAGE. STATUS ON
CONTACT SHEET 023.
Page 5

ELIGIBLE CONTINUE HERE
12. Are you the person who does most of the shopping for food in your household?
 YES
0  NO
d  DON’T KNOW
r  REFUSED
1

13. Are you the person who does most of the planning or preparing of meals in your household?
IF RESPONDENT ANSWERS “SOMETIMES” OR “50/50,” ENTER YES.
 YES
 NO
d  DON’T KNOW
r  REFUSED
1

0

GO TO INTERVIEWER CHECK #3

INTERVIEWER CHECK #3:
IS RESPONDENT THE FOOD SHOPPER (Q12=YES) OR MEAL PLANNER (Q13=YES)?
YES
NO

1
0

GO TO CONTACT INFORMATION
GO TO Q.14

14. Your household is eligible to take part in the study, but I need to speak with the person who does most of
the shopping for food in your household. What is the name of the person who does most of the shopping for
food?
FIRST NAME

15. Can I speak with [FILL Q.14 NAME]?
 YES
GO TO NEW RESPONDENT INTRO
0  NO
d  DON’T KNOW
GO TO Q.16
r  REFUSED
1

16. What is the best telephone number to reach [FILL Q.14 NAME] at?
(______) - ______ - _______________
Area Code

 NO TELEPHONE
 DON’T KNOW
r  REFUSED
0
d

As I mentioned, your household is eligible for the study, but I need to speak with the Food Shopper or Meal
Planner. I’d like to schedule a time to come back.
IF PHONE NUMBER PROVIDED:

I will call [FILL Q.14 NAME] at the phone number you provided to
schedule a time to come back. When is a good time to call?

IF PHONE NUMBER NOT PROVIDED:

When is a good time to come back?

WHEN YOU RETURN TO TALK TO THE RESPONDENT START AT THE NEW RESPONDENT INTRO ON PAGE 7.

Page 6

NEW RESPONDENT INTRO:
Hello. My name is [FILL NAME]. I work for Mathematica Policy Research and we’re conducting the National Food Study for the
U.S. Department of Agriculture. We recently sent a post card to this address. SHOW ID CARD
The National Food Study will help the USDA improve its programs by answering questions about where households get food
and how much they pay for food.
The addresses we visit are scientifically selected to represent all households in the country. Taking part is completely voluntary
and any information that you provide will be kept completely confidential. We will use your information only for statistical
purposes and your responses will not have any effect on services you currently receive or may apply for in the future.
GO TO CONTACT INFORMATION

CONTACT INFORMATION:
Your household is eligible for this study! In this study, you will be asked to complete one 30-minute interview and one 35-minute
interview, and keep track of foods you get during the week. You will receive a $100 check at the end of the week. You will also
receive up to three (3) $10 gift cards, one for each time you call us to report the foods you get during the week. Other members
of your household can receive gift cards if they report the foods they get during the week.
I’d like to get your contact information before we continue.

17. What is your name?
FIRST NAME

18. What is the best telephone number to reach you at?
(______) - ______ - _______________
Area Code

NO TELEPHONE
DON’T KNOW
REFUSED

0
d
r

SKIP TO Q.20

19. Is there another number where you can be reached?
(______) - ______ - _______________
Area Code

NO TELEPHONE
DON’T KNOW
REFUSED

0
d
r

20. What language would you be most comfortable using for our interviews?
1

ENGLISH
2  SPANISH
3  KOREAN
4

VIETNAMESE

5

OTHER (SPECIFY)

21. Do you have time now to discuss the study and learn about what you’ll be doing for the week? This will take a
little over an hour.
1

YES

2

NO

3

NO

COMPLETE INTERVIEWER OBSERVATIONS ON BACK PAGE. CONTINUE TO INITIAL INTERVIEW AND
TRAINING. STATUS ON CONTACT SHEET 021.
NO. SCHEDULE ALTERNATIVE TIME FOR INTITIAL INTERVIEW AND TRAINING. COMPLETE
INTERVIEWER OBSERVATIONS ON BACK PAGE. STATUS ON CONTACT SHEET 021.
REFUSED TO PARTICIPATE. GO TO LAST PAGE (Q.25). STATUS ON CONTACT SHEET 022.

Page 7

REFUSALS
IF RESPONDENT REFUSED THE SCREENER
(STATUS=220)

IF RESPONDENT IS ELIGIBLE AND REFUSES TO
PARTICIPATE IN THE STUDY (STATUS=022)

Can you help us by answering just 4 quick questions?
We want to know if people who participate in our study
are a good representation of all households in the United
States.

I would like to ask a few questions so that we know if
people who participate in our study are a good
representation of all households in the United States.
25. How many people in your household are…

R1. How many people are in your household?

DON’T
KNOW

NUM
d

|___|___| NUMBER OF PEOPLE

 DON’T KNOW

r  REFUSED

R2. Is your total household income greater than
$30,000 a year?
1
0

 YES
 NO

d

 DON’T KNOW
REFUSED

r

$ ___|,___|___|___|.00

 DON’T KNOW

r

$ ___|,___|___|___|.00

# _____

d



r



Age 5-9…………

# _____

d



r



Age 10-13………

# _____

d



r



Age 14-18…….

# _____

d



r



Over 18 years old

# _____

d



r



d

$ ___|,___|___|___|.00

REFUSED

 DON’T KNOW

r

 DON’T KNOW

r

REFUSED

27. Last week, how much did your household
spend while eating out?

R4. Last week, how much did your household
spend while eating out?
d

Under age 5……

26. Last week, how much did your household
spend on groceries?

R3. Last week, how much did your household
spend on groceries?
d

REF

d

$ ___|,___|___|___|.00

REFUSED

 DON’T KNOW

r

REFUSED

Those are all the questions I have. Thank you for
your time. If you change your mind about taking part
in the study, please call us at the toll-free number on
the brochure. Have a nice day!

Those are all the questions I have. Thank you for
your time. If you change your mind about taking part
in the study, please call us at the toll-free number on
the brochure. Have a nice day!

STATUS ON CONTACT SHEET 220.

STATUS ON CONTACT SHEET 022.

INTERVIEWER: ENTER OBSERVATIONS OF THE PERSON WHO COMPLETED OR REFUSED THE SCREENER
I1. RESPONDENT GENDER

1

 MALE

2

 FEMALE

I2. RESPONDENT AGE (APPROXIMATE)

1

 18-29

2

 30-49

I3. RESPONDENT RACE/ETHNICITY

1

4

2

5

I4. RESPONDENT LANGUAGE

 50-69

 WHITE
 BLACK OR AFRICAN AMERICAN
3  HISPANIC
1
2

I5. DID YOU TALK TO ANYONE ELSE WHO
LIVES AT THIS ADDRESS BEFORE YOU
TALKED TO THE RESPONDENT?

3

1

ENGLISH
SPANISH

 YES

2

4

 Over 70

 AMERICAN INDIAN
 ASIAN
6  OTHER

3

KOREAN

5

CHINESE

4

VIETNAMESE

6

OTHER / UNKNOWN

 NO

Page 8