FMCS OMB B3 Telephone Survey Screenshots English

APPENDIX B3: SNAP PARTICIPANT TELEPHONE SURVEY – ENGLISH SCREENSHOTS

NOTE: These screenshots are illustrative. The entire survey will be programmed similarly.

OMB Number: 0584-0564

Expiration Date: 11/30/2014

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 collection is 0584-0564. The time required to complete this information collection is estimated to average 25 minutes per response, including the time to review instructions, searching existing data resources, gather the data needed, and complete and review the information collected.

This section includes questions from the survey.

_{Click Next to continue.}

From the list below, please mark the stores where you bought groceries in the past year. Check all that apply.

• Large chain grocery store like Safeway or {FILL REGIONAL EXAMPLE}

• Warehouse club store like Sam’s Club or Costco

• Discount store like Wal-Mart or Target

• I did not buy groceries at any of these types of stores

Did you use your SNAP/EBT card to buy FRESH fruits and vegetables at these stores?

When you shop at {Fill FARMERS MARKET}, how many times do you buy each of the items in the table below?

When I shop at {Fill FARMERS MARKET} I buy…	Almost every time	Some of the time	Rarely	Never	Not sold at THIS FARMERS MARKET
Fruits
Vegetables
Meat (like beef or chicken) or Fish
Eggs
Dairy products like milk, yogurt, or cheese
Baked goods like bread, pie, or cake
Honey
Fruit juice or fruit drinks
Food in cans or jars like jam, jelly or pickles
Some other kind of food Please tell us what kind ________________________

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How many of these people are more than 60 years old?

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