SNAP CATI Client Survey

APPENDIX A

CLIENT SURVEY (ENGLISH VERSION)

M

OMB Approval No.: 0584-XXXX

Approval Expires: XX/XX/XXXX

PR Reference No.: 06843.060

SNAP Client Questionnaire

August 23, 2011

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 is 0584-XXXX. The time required to complete this information collection is estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

SC. SCREENER/PREVIOUS SNAP EXPERIENCE

FILL: IF STATE FROM SMS IS NM or PA: SNAP; IF WA: BASIC FOOD

INTRO = 1 OR NOLETTER =1 OR MOREINFO = 1 OR READLETTER =1

PROGRAMMER: Set variable for pilot versus comparison site. Set variable for STATE from SMS.

Consent 1. My name is [INTERVIEWER NAME]. I’m calling from Mathematica Policy Research about a study we are doing for the U.S. Department of Agriculture or the USDA. The USDA is sponsoring a study about the [IF NM or PA: SNAP; IF WA: Basic Food] program, formerly known as food stamps. Mathematica has been hired to gather data on these programs for the USDA. Mathematica is a Princeton-based policy research company with a long history of conducting studies like this one on behalf of the government.

The study will help us understand more about people’s experiences with [IF NM or PA: SNAP; IF WA: Basic Food], more specifically, what things work well or don’t work so well in your state. You have been chosen to participate in this study from a group of people potentially eligible to receive Medical Assistance. We would like to hear about your opinions and experiences with [IF NM or PA: SNAP; IF WA: Basic Food].The USDA may use this information to create better or improve current [IF NM or PA: SNAP; IF WA: Basic Food] programs. Your participation is voluntary. Choosing to participate or not has no effect on any benefits you are receiving or will receive. While there are no direct benefits to participating in this study, the USDA may use its findings to create better or improve current [IF NM or PA: SNAP; IF WA: Basic Food] programs.

Nothing in this study is experimental; therefore, the only risk to participating is a potential loss of confidentiality. The chances of this occurring are low, however, due to multiple steps we have taken to protect your privacy. As required by law, your answers will be kept strictly confidential and your privacy protected. Your name will not be used in any reports and your answers will not be shared with anyone outside the research team.

Some people may feel uncomfortable answering questions about income, access to food or participation in [IF NM or PA: SNAP; IF WA: Basic Food]; however, you may choose to not answer any questions that make you uncomfortable, at any time for any reason without consequence to you. You may also end your participation at any time for any reason without penalty.

The survey should take about 20-30 minutes. As a token of appreciation, we will be sending a $25 gift cad to people who complete the survey with us. This gift can be used anywhere and will not affect any government assistance you have been or will be receiving. Along with this gift card, we will send a copy of the information we just described to you, including the contact information for Mathematica and our Institutional Review Board.

This study has been approved by an institutional review board. If you have any questions or concerns regarding participation or your rights as a participant, you may contact Katie Goldberg at New England Institutional Review Board at 617-969-1310. If you have additional questions regarding the survey and/or the study, please feel free to contact Daniel Friend, Deputy Survey Director at Mathematica at 1-888-293-5740.

NO QUESTIONS……………………………………..1 Go to Consent 2a

ASKS WHAT IS SNAP………………………………2 Go to Consent 1a

ASKS WHAT IS BASIC FOOD……………………..3 Go to Consent 1b

DOES NOT PARTICIPATE IN SNAP……………...4 Go to Consent 1c

DOES NOT WANT TO PARTICIPATE…………… 2 Status 240, Go to Thanks

CONSENT = 2

Consent 1a. SNAP stands for the Supplemental Nutrition Assistance Program. Some people know it as food stamps. SNAP participants receive an electronic benefits card (or an EBT card) that they can use to purchase groceries.

NO QUESTIONS……………………………………..1 Go to Consent 2a

DOES NOT WANT TO PARTICIPATE…………… 2 Status 240, Go to Thanks

CONSENT = 3

Consent 1b. What is Basic Food?: Basic Food is the name for the food assistance program in Washington. Some people know it as food stamps. Basic Food participants receive an electronic benefits card (also called a Quest card or an EBT card) that they can use to purchase groceries.

NO QUESTIONS……………………………………..1 Go to Consent 2a

DOES NOT WANT TO PARTICIPATE…………… 2 Status 240, Go to Thanks

CONSENT = 4

Consent 1c. That is ok. We are very interested in people’s opinions about the program, even if they don’t participate.

NO QUESTIONS……………………………………..1 Go to Consent 2a

DOES NOT WANT TO PARTICIPATE…………… 2 Status 240, Go to Thanks

CONSENT 1 = 1 OR CONSENT 1a = 1 OR CONSENT 1b = 1 OR CONSENT 1C = 1

Consent 2. Do you have any questions?

NO QUESTIONS……………………………………..1 Go to Consent 2a

QUESTIONS …………… 2 ANSWER QUESTIONS THEN PROCEED TO Consent 2a

(CONSENT 1 = 1 OR CONSENT 1a = 1 OR CONSENT 1b = 1 OR CONSENT 1C = 1) AND CONSENT 2 = 1 OR 2

Consent 2a. Would you like to participate in this survey?

YES 1 Go to Consent 2b

NO 0 Status 240, Go to Thanks

Consent 2b. Great! Let’s get started This call will be recorded for quality assurance purposes. Can you please state your full name for the record?

STRING (20)

FIRST NAME

STRING (20)

MIDDLE INITIAL/NAME

STRING (20) Go To Consent 2c

LAST NAME

Consent 2c: Do you agree to participate in this survey? By saying yes, this means you wish to participate in the survey regarding your opinions and experiences with SNAP and that you understand that your participation is voluntary. A copy of your consent form documenting your agreement and describing the procedures and yours rights will be sent to you for your records.

YES 1 Go to SC0

YES, BUT NOT A GOOD TIME…………………………..2 Go to Callback

NO 0 Status 240, Go to Thanks

ALL RESPONDENTS

FILL CONDITION : STATE

SC0. [IF PA OR NM: SNAP stands for the Supplemental Nutrition Assistance Program/ IF WA: Basic Food], and is a government assistance program to help low-income households pay for food. [IF PA OR NM: SNAP/ IF WA: Basic Food] used to be called the Food Stamp program. [IF WA: Basic Food is sometimes also called SNAP]. The amount of [IF PA OR NM: SNAP food /IF WA: Basic Food] stamps a household gets depends on the household's size, income, and expenses.

What name are you most familiar with? (Because the food assistance program is known by several names, we would like to use the name you are most familiar with.)

IF NM or PA: SNAP / IF WA: Basic FOOD 0

FOOD STAMPS 1

OTHER [SPECIFY] _______________________ 2

DON’T KNOW d

REFUSED r

FILL PREFERRED PROGRAM NAME THROUGHOUT QUESTIONNAIRE

SC1. Are you currently receiving [WA: Basic Food Program,] SNAP or Food Stamp benefits?

YES 1 GO TO SC3

NO 0

DON’T KNOW d

REFUSED r

IF NONPARTICIPANT: SC1 = 0 , d, r AND IF STATE = WA, NM

SC1b. Do you currently receive commodities as part of the Food Distribution Program on Indian Reservations (FDPIR)?

YES 1 GO TO END

NO 0

DON’T KNOW d

REFUSED r

IF NONPARTICIPANT: SC1 = 0 , d, r

FILL CONDITION : STATE

SC2. Have you ever applied for [WA: Basic Food,] SNAP or Food Stamps? (IF NECESSARY: [The Washington Basic Food Program/SNAP] is the new name for the Food Stamp Program.)

YES 1

NO 0 GO TO D1

DON’T KNOW d GO TO D1

REFUSED r GO TO D1

IF NONPARTICIPANT, EVER APPLIED: SC2 = 01

SC2b. When you applied for benefits, was it in this state or another state?

this state 1 GO TO SC2d

another state 2

DON’T KNOW d GO TO SC2d

REFUSED r GO TO SC2d

IF NONPARTICIPANT, APPLIED IN ANOTHER STATE: SC2B=1

SC2c. In what state did you apply?

[DROP-DOWN LIST]

DON’T KNOW d

REFUSED r

NONPARTICIPANT, EVER APPLIED,: SC2=1

FILL CONDITION : STATE, DATE

SC2d. In the past three years—that is, since [DATE]—did you apply for, or did you have to complete paperwork to recertify for, [WA: Basic Food,] SNAP or Food Stamps?

YES 1

NO 0 GO TO SC4d

DON’T KNOW d GO TO SC4d

REFUSED r GO TO SC4d

NONPARTICIPANT, EVER APPLIED OR PARTICIPANT:SC1=1 OR SC2=1

FILL CONDITION : STATE

SC3. When was the last time you applied for, or were recertified for [WA: Basic Food, or] SNAP benefits?

| | | / | | | | |

MONTH YEAR

(RANGE) (RANGE)

DON’T KNOW d

REFUSED r

NONPARTICIPANT, EVER APPLIED OR PARTICIPANT:SC1=1 OR SC2=1

FILL CONDITION : SC3

SC4. Had you ever applied before this last time—that is, before [FILL SC3]?

YES 1

NO 0

DON’T KNOW d

REFUSED r

IF EVER APPLIED PREVIOUSLY, OR DK OR REF: SC4 = 1, d, r

SC4d. Would you say that was within the past 10 years?

YES 1

NO 0

DON’T KNOW d

REFUSED r

IF NONPARTICIPANT AND EVER APPLIED: SC1 = 0 AND SC2 = 1

FILL CONDITION : STATE, SC3

SC5. The last time you applied for, or were recertified for [WA: Basic Food,] SNAP or Food Stamps, in [FILL SC3], did you complete the application process?

IF NECESSARY: We want to know about the most recent time you applied for SNAP.

YES 1

NO 0 GO TO SC11

DON’T KNOW d GO TO SC11

REFUSED r GO TO SC11

IF NONPARTICIPANT AND COMPLETED APPLICATION: SC5 = 1

SC6. This last time you applied or were recertified--did you receive benefits?

YES 1

NO 0 GO TO SC9

DON’T KNOW d GO TO SC9

REFUSED r GO TO SC9

IF PREVIOUS PARTICIPANT: SC6 = 1

SC7. Did you use the benefits you received?

YES 1

NO 0

DON’T KNOW d

REFUSED r

IF PREVIOUS PARTICIPANT: SC6 = 1

SC8. How long has it been since you last received benefits?

| | | NUMBER (MONTHS/YEARS)

DON’T KNOW d

REFUSED r

IF NONPARTICIPANT, COMPLETED APPLICATION, BUT DID NOT GET BENEFITS: SC6 = 0, d, r

SC9. Why didn’t you receive benefits after you completed the application or paperwork for recertification?

NOT ELIGIBLE, INCOME WAS TOO HIGH 1

NOT ELIGIBLE, ASSETS (CASH, SAVINGS ACCOUNT, CD, U.S. SAVINGS BONDS) WERE TOO HIGH 2

NOT ELIGIBLE, VALUE OF CAR WAS TOO HIGH 3

NOT ELIGIBLE, VALUE OF BOAT, SNOWMOBILE, CAMPER WAS TOO HIGH 4

NOT ELIGIBLE, IMMIGRATION STATUS 5

OTHER (SPECIFY) 99 GO TO SC11

________________________________(STRING (NUM))

DON’T KNOW d GO TO SC11

REFUSED r GO TO SC11

IF NONPARTICIPANT, COMPLETED APPLICATION, DID NOT GET BENEFITS BECAUSE INELIGIBLE, SC9 = 1, 2, 3, 4

FILL CONDITION: SC9

SC10. Would you apply again if your circumstances changed—for example, if [you lost some income/you had a change in immigration status/the rules changed] and you became eligible?

YES 1 GO TO A1

NO 0 GO TO SC12

DON’T KNOW d GO TO A1

REFUSED r GO TO A1

IF NONPARTICIPANT, COMPLETED APPLICATION, DID NOT GET BENEFITS BECAUSE OTHER, SC9 = 99, D, R

SC11. Would you consider applying again?

YES 1 GO TO A1

NO 0

DON’T KNOW d GO TO A1

REFUSED r GO TO A1

IF NONPARTICIPANT, COMPLETED APPLICATION, DID NOT GET BENEFITS, WOULDN’T APPLY AGAIN, SC10 = 0 or SC11 = 0

FILL CONDITION: STATE

SC12. Why wouldn’t you apply again?

	MARK ONE PER ROW
	YES	NO	DK	REF
a. Would you not apply again because you think it would be hard to get to the [WA: Basic Food/NM or PA: SNAP] office?	1	0	d	r
b. Would you not apply again because you think the application process is too long and complicated?	1	0	d	r
c. (Would you not apply again because) you’d have to answer questions that are too personal when you applied for benefits?	1	0	d	r
d. (Would you not apply again because) you’d feel embarrassed about applying for benefits?.	1	0	d	r
e. (Would you not apply again because) you think you would not be eligible for benefits?	1	0	d	r
f. Would you not apply again because you think you’d be eligible for only a small amount of benefits?	1	0	d	r
g. (Would you not apply again because) you can get by on your own without benefits?	1	0	d	r
h. (Would you not apply again because you think) others need benefits more than you?	1	0	d	r
i. (Would you not apply again because) you’d dislike relying on government assistance?	1	0	d	r
j. Would you not apply again because other family members or friends would discourage you from using benefits?	1	0	d	r
k. (Would you not apply again because) you think staff at the [WA: Basic Food/NM or PA: SNAP] office would treat you disrespectfully?	1	0	d	r
l. (Would you not apply again because you think) You only need benefits temporarily?	1	0	d	r
m. (Would you not apply again because) you could get food from friends and/or relatives?.	1	0	d	r
n. Would you not apply again because you could get food from food pantries, food banks, or some other program?.	1	0	d	r
o. Is there any other important reason you would not apply again that I have not mentioned? (Specify)	1	0	d	r
________________________________(STRING (NUM))

A. REASONS FOR APPLYING FOR SNAP

(SNAP PARTICIPANTS OR RECENT APPLICANTS)

IF SNAP PARTICIPANT OR RECENT APPLICANT: SC1 = 1 or SC2d = 1

FILL CONDITION: STATE, SC3

Thinking about your most recent experience applying for [WA: Basic Food/NM or PA: SNAP]:

A1. Why did you decide to apply for [WA: Basic Food/NM or PA: SNAP] in [fill DATE from SC3]? Anything else?

NEW CHILD (OR OTHER DEPENDENT LIKE GRANDCHILD) 1 GO TO A3

SEPARATION, DIVORCE, OR WIDOWED 2 GO TO A3

JOB LOSS OR WAGES REDUCED 3 GO TO A3

LOSS OR REDUCTION OF OTHER INCOME 4 GO TO A3

BECAME DISABLED OR OTHERWISE UNABLE TO WORK 5 GO TO A3

JUST DECIDED IT WAS TIME 6 GO TO A3

APPLIED AT THE SAME TIME I WAS APPLYING FOR ANOTHER PROGRAM 7 GO TO A3

RECEIVED ASSISTANCE OR ENCOURAGEMENT FROM SOMEONE ELSE 8 GO TO A3

JUST HEARD ABOUT THE PROGRAM 9 GO TO A3

NEEDED TO RECERTIFY/RENEW BENEFITS 10 GO TO A3

OTHER (SPECIFY) 99 GO TO A3

________________________________(STRING (NUM))

DON’T KNOW d GO TO A4

REFUSED r GO TO A4

IF ENCOURAGED TO APPLY: A1 = 8

A2. Who encouraged you to apply?

(STRING (NUM))

DESCRIPTION

DON’T KNOW d

REFUSED r

IF SC3 NE d, r

FILL CONDITION: A1

A3. You said you decided to apply because: [FILL A1]. Which reason was the most important?

PROBE: (IF NECESSARY: You said [FILL A1 RESPONSES].)

NEW CHILD (OR OTHER DEPENDENT LIKE GRANDCHILD) 1

SEPARATION, DIVORCE, OR WIDOWED 2

JOB LOSS OR WAGES REDUCED 3

LOSS OR REDUCTION OF OTHER INCOME 4

BECAME DISABLED OR OTHERWISE UNABLE TO WORK 5

JUST DECIDED IT WAS TIME 6

APPLIED AT THE SAME TIME I WAS APPLYING FOR ANOTHER PROGRAM 7

RECEIVED ASSISTANCE OR ENCOURAGEMENT FROM SOMEONE ELSE 8

JUST HEARD ABOUT THE PROGRAM 9

NEEDED TO RECERTIFY/RENEW BENEFITS 10

OTHER (SPECIFY) 99

________________________________(STRING (NUM))

DON’T KNOW d

REFUSED r

IF SNAP PARTICIPANT OR RECENT APPLICANT: SC1 = 1 or SC2d = 1

FILL CONDITION: STATE

A4. I’m going to read some factors that affect people’s decisions to apply for [WA: Basic Food/NM or PA: SNAP]. Please tell me if each one was a factor in your decision to apply.

	MARK ONE PER ROW
	yES	NO	DK	REF
a. I am able to use a computer to apply from home or another place—was this factor in your decision to apply?	1	0	d	r
b. I am able to have a telephone interview instead of going to the benefit office (Was this factor in your decision to apply?)	1	0	d	r
c. I am more informed about the program because I learned about it at [WA: a mobile community service office,] my senior center or a medical clinic (Was this factor in your decision to apply?)	1	0	d	r
d. People at the [WA: Basic Food/NM or PA: SNAP] are more helpful than they used to be (Was this factor in your decision to apply?)	1	0	d	r

IF APPLIED MORE THAN ONE TIME IN PAST 3 YEARS: SC4b = 1

FILL CONDITION: STATE

A5a. Earlier, you said you applied for or were recertified for [WA: Basic Food/NM or PA: SNAP] more than once. In your experience, is the [WA: Basic Food/NM or PA: SNAP] application shorter or longer than it used to be?

SHORTER 1

LONGER 2

IF VOLUNTEERED: ABOUT THE SAME 3 GO TO A6a

DON’T KNOW d GO TO A6a

REFUSED r GO TO A6a

IF A5a = 1, 2

FILL CONDITION: A5a

A5b. Would you say it is a lot [FILL A5a] or a little [FILL A5a]?

A LOT 1

A LITTLE 2

DON’T KNOW d

REFUSED r

IF SC2d = 1

FILL CONDITION: STATE

A6a. (Earlier, you told me you applied for, or were recertified for [WA: Basic Food/NM or PA: SNAP] more than once. In your experience . . . )

. . . has it become easier or harder to submit the application than it used to be?

EASIER 1

HARDER 2

IF VOLUNTEERED: ABOUT THE SAME 3 GO TO A7a

DON’T KNOW d GO TO A7a

REFUSED r GO TO A7a

IF A6a = 1, 2

FILL CONDITION: A6a

A6b. Would you say it has become a lot [FILL 6a] or a little [FILL 6a]?

A LOT 1

A LITTLE 2

DON’T KNOW d

REFUSED r

IF SC2d = 1

FILL CONDITION: STATE

A7a. (Earlier, you told me you applied for, or were recertified for [WA: Basic Food/NM or PA: SNAP] more than once. In your experience . . . )

. . . have staff at the benefit office become more respectful or less respectful of you than they used to be?

MORE RESPECTFUL 1

LESS RESPECTFUL 2

IF VOLUNTEERED: ABOUT THE SAME 3 GO TO A8a

DON’T KNOW d GO TO A8a

REFUSED r GO TO A8a

IF A7a = 1, 2

FILL CONDITION: A7a

A7b. Would you say that staff at the benefit office have become a lot [FILL 7a] or a little [FILL 7a]?

A LOT 1

A LITTLE 2

DON’T KNOW d

REFUSED r

IF SC2d = 1

FILL CONDITION: STATE

A8a. (Earlier, you told me you applied for, or were recertified for [WA: Basic Food/NM or PA: SNAP] more than once. In your experience . . .)

. . . has it become easier or harder than before to get in touch with someone at the benefit office to get information?

EASIER 1

HARDER 2

IF VOLUNTEERED: ABOUT THE SAME 3 GO TO A9a

DON’T KNOW d GO TO A9a

REFUSED r GO TO A9a

IF A8a = 1, 2

FILL CONDITION: A8a

A8b. Would you say it has become a lot [FILL 8a] or a little [FILL 8a]?

A LOT 1

A LITTLE 2

DON’T KNOW d

REFUSED r

B. SNAP Application Process

SNAP PARTICIPANTS OR RECENT APPLICANTS

IF SNAP PARTICIPANT OR RECENT APPLICANT: SC1 = 1 or SC2d = 1

FILL CONDITION: STATE

The following questions are about your most recent experience applying or recertifying for [WA: Basic Food/NM or PA: SNAP].

B1. How did you learn about [WA: Basic Food/NM or PA: SNAP]? Anything else?

IF NECESSARY: Who called you? What office or agency did they call from?

WHILE APPLYING FOR OTHER BENEFITS/ REFERRED BY ANOTHER AGENCY 1

FROM SENIOR CENTER, COMMUNITY CENTER OR OTHER GATHERING PLACE IN COMMUNITY 2

FROM VA/VETERANS GROUP 3

FROM FOOD BANK OR OTHER EMERGENCY FOOD PROVIDER 4

FROM CHURCH OR OTHER PLACE OF WORSHIP 5

FROM DOCTOR’S OFFICE, CLINIC, OR HOSPITAL 6

FROM EMPLOYER 7

FROM FRIEND/FAMILY 8

OTHER (SPECIFY) 99

________________________________(STRING (NUM))

DON’T KNOW d

REFUSED r

FILL CONDITION: STATE

B2. Think back for a moment to before you applied for {IF PA OR NM: SNAP/IF WA: Basic Food].

Before you applied, did you call the [WA: Basic Food/NM or PA: SNAP] office or a hotline to learn more about [WA: Basic Food/NM or PA: SNAP] and how to apply?

YES 1

NO 0

DON’T KNOW d

REFUSED r

FILL CONDITION: STATE

B3. Before you applied, did you have a telephone call or meeting where someone asked you questions about your income, assets, or expenses to figure out whether you might qualify for [WA: Basic Food/NM or PA: SNAP] benefits and how much you could receive?

YES 1

NO 0

DON’T KNOW d

REFUSED r

FILL CONDITION: STATE

B5. When you applied, did someone submit the application for you?

YES 1

NO 0 GO TO B7

DON’T KNOW d GO TO B7

REFUSED r GO TO B7

IF SOMEONE SUBMITTED APPLICATION: B5 = 1

B6. Who submitted the application for you?

(STRING (NUM))

DESCRIPTION

DON’T KNOW d

REFUSED r

IF SOMEONE SUBMITTED APPLICATION: B5 ne 1

FILL CONDITION: STATE

B7. Thinking only about the application, that is, excluding other documentation you may have had to provide, did you submit your application by mail, [PA: by telephone], [WA or PA: by computer], or in person at the local [WA: Basic Food/NM or PA: SNAP] benefit office?

BY MAIL 1

[IF PA]: BY TELEPHONE 2

[IF PA or WA]: BY COMPUTER 3

IN PERSON 4

DON’T KNOW d

REFUSED r

FILL CONDITION: STATE

B8. The last time you applied, did you have any help with the application?

Help could include translation, filling out the application, getting the necessary documents, getting transportation to the [WA: basic food/PA or NM: SNAP] office, having someone be with you at the office, or having someone else go to the office for you.

YES 1

NO 0 GO TO B10

DON’T KNOW d GO TO B10

REFUSED r GO TO B10

IF HELP ON THE APPLICATION: B8=1

FILL CONDITION: STATE

B9. Who provided the most help?

[WA: BASIC FOOD/NM OR PA: SNAP] OFFICE STAFF OR ANY ORGANIZATION IN THE COMMUNITY (e.g., BENEFITS DATA TRUST, LIBRARY, SENIOR CENTER, OUTREACH WORKER OR LEGAL AID REPRESENTATIVE) 1

RELATIVE, FRIEND, OR NEIGHBOR 2

CLERGY 3

OTHER (SPECIFY) 99

________________________________(STRING (NUM))

DON’T KNOW d

REFUSED r

INSERT ENTRANCE CONDITION

FILL CONDITION: STATE, IF B7=2

B10. After you completed the application form, did you have a follow-up interview either in person or by telephone with someone from the [WA: Basic Food/NM, PA: SNAP] office?

[IF B7=2] IF NECESSARY: The follow-up interview is separate from the application interview.

YES 1

NO 0 GO TO B12

DON’T KNOW d GO TO B12

REFUSED r GO TO B12

IF HAD AN INTERVIEW: B10=1

FILL CONDITION: STATE

B11. Did the follow-up interview take place by telephone, at the local [WA: Basic Food/PA or NM: SNAP] program office, at your home, or at some other place?

TELEPHONE 1

LOCAL [WA: BASIC FOOD/PA OR NM: SNAP] PROGRAM OFFICE 2

YOUR HOME 3

SOME OTHER PLACE 4

DON’T KNOW d

REFUSED r

SKIP B13 if B7=4 (applied in person); GO TO B15

B12. Did you need to go to the SNAP office to complete the application process?

YES 1

NO 0 GO TO B15

DON’T KNOW d GO TO B15

REFUSED r GO TO B15

IF WENT TO SNAP OFFICE: B12 = 1

B13. How many times did you need to go to the SNAP office to complete the application process?

ONE 1

TWO 2

THREE OR MORE TIMES 3

DON’T KNOW d

REFUSED r

FILL CONDITION: STATE

B15. Did you need to use any of your own money to pay for transportation to go to an office or to get something to complete the [WA: Basic Food/NM, PA: SNAP] application? Please include gas, bus fare, parking, tolls, or any money that you may have paid a driver.

YES 1

NO 0 GO TO C1

DON’T KNOW d GO TO C1

REFUSED r GO TO C1

IF B15 = 1

B16. How much did you pay out-of-pocket for transportation?

$ | | | . | | | NUMBER (NUMBER RANGE)

DON’T KNOW d

REFUSED r

SOFT CHECK: IF YES 1 GO TO C1

NO 0 GO TO B16

C. Participation Experience

SNAP PARTICIPANTS

IF SNAP PARTICIPANT (SC1 = 1)

FILL CONDITION: STATE

The following questions are about your current experiences with [WA: Basic Food/NM or PA: SNAP].

C1. Please tell me if you are very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied with . . .

	MARK ONE PER ROW
	VERY SATISFIED	SOMEWHAT SATISFIED	SOMEWHAT DISSATISFIED	VERY DISSATISFIED	DON’T KNOW	REFUSED
a. the [WA: Basic Food/NM or PA: SNAP] Program overall	1	2	3	4	d	r
b. the process of applying for [WA: Basic Food/NM or PA: SNAP] benefits	1	2	3	4	d	r
c. using the [WA: Basic Food/NM or PA: SNAP] benefit card	1	2	3	4	d	r
d. getting information or explanations in my preferred language	1	2	3	4	d	r

FILL CONDITION: STATE

C2. Now, please tell me your opinions of the services you received from the [WA: Basic Food/NM or PA: SNAP] staff. Please tell me if you strongly agree, somewhat agree, somewhat disagree, or strongly disagree with each statement.

	MARK ONE PER ROW
	STRONGLY AGREE	SOMEWHAT AGREE	SOMEWHAT DISAGREE	STRONGLY DISAGREE	DON’T KNOW	REFUSED	N/A
a. The kinds of services I received were suitable for my needs	1	2	3	4	d	r
b. Overall, the [WA: Basic Food/NM or PA: SNAP] staff kept me well informed	1	2	3	4	d	r
c. I felt that the [WA: Basic Food/NM or PA: SNAP] staff were doing their part to help me solve my problems	1	2	3	4	d	r
d. [WA: Basic Food/SNAP] staff were knowledgeable about [WA: Basic Food Program/NM or PA: SNAP] benefits and procedures	1	2	3	4	d	r
e. [WA: Basic Food/NM or PA: SNAP] staff treat me respectfully	1	2	3	4	d	r
f. [WA: Basic Food/NM or PA: SNAP] staff are available to help me by telephone	1	2	3	4	d	r
g. [WA: Basic Food/SNAP] staff are available for in-person meetings to help me	1	2	3	4	d	r	NA

Some people have said they feel comfortable about using [WA: Basic Food/NM or PA: SNAP] benefits, while others have said they do not feel comfortable using the benefits. We’d like to know how you feel about this. Please answer “yes” or “no” after I read each item.

FILL CONDITION: STATE

C3. Have you ever done anything to hide that you receive [WA: Basic Food/NM or PA: SNAP] benefits?

YES 1

NO 0

DON’T KNOW d

REFUSED r

FILL CONDITION: STATE

C4. Have you ever avoided telling people you receive [WA: Basic Food/NM or PA: SNAP] benefits?

YES 1

NO 0

DON’T KNOW d

REFUSED r

FILL CONDITION: STATE

C4b. Do you shop at very late or other odd hours to avoid being seen at the store when using your [WA: Basic Food/NM or PA: SNAP] benefits?

YES 1

NO 0

DON’T KNOW d

REFUSED r

FILL CONDITION: STATE

C5. When you use your [WA: Basic Food/NM or PA: SNAP] benefits, do you ever go out of your way to shop at a store where no one knows you?

YES 1

NO 0

DON’T KNOW d

REFUSED r

FILL CONDITION: STATE

C6. Have you ever been treated disrespectfully when using [WA: Basic Food/NM or PA: SNAP] benefits?

YES 1

NO 0

DON’T KNOW d

REFUSED r

FILL CONDITION: STATE

C7. Were you ever treated disrespectfully when you told people that you received [WA: Basic Food/NM or PA: SNAP] benefits?

YES 1

NO 0

IF VOLUNTEERED: NEVER TOLD ANYONE RECEIVED BENEFITS 2

DON’T KNOW d

REFUSED r

D. Knowledge of SNAP

IF NONPARTICIPANT OR NOT RECENT APPLICANT: SC1 ne 1

FILL CONDITION: STATE

D1. Had you heard of [WA: the Basic Food Program,] SNAP or the Food Stamp Program before today's interview?

YES 1

NO 0

DON’T KNOW d

REFUSED r

FILL CONDITION: STATE

D2. Do you think you may be eligible to receive [WA: Basic Food/NM or PA: SNAP] benefits?

YES 1

NO 0

DON’T KNOW d

REFUSED r

HEARD OF SNAP BEFORE INTERVIEW AND THINK MAY BE ELIGIBLE: IF D1 = 1 AND D2 = 1

FILL CONDITION: STATE

D3. Before today’s interview, did you think that that you might be eligible to receive [WA: Basic Food/NM or PA: SNAP] benefits?

YES 1

NO 0

DON’T KNOW d

REFUSED r

D5. How certain are you about where to go or whom to contact to apply for benefits? Would you say very certain, somewhat certain, somewhat uncertain, or very uncertain?

VERY CERTAIN 1

SOMEWHAT CERTAIN 2

SOMEWHAT UNCERTAIN 3

VERY UNCERTAIN 4

DON’T KNOW d

REFUSED r

E. Reasons for Not Applying for SNAP

IF NONPARTICIPANT OR NOT RECENT APPLICANT

IF NONPARTICIPANT OR NOT RECENT APPLICANT: SC1 NE 1

FILL CONDITION: STATE

E1. Now I am going to read several possible reasons why you might not have applied for [WA: Basic Food/NM or PA: SNAP] benefits recently.

	MARK ONE PER ROW
	YES	NO	DK	REF
a. It would be hard to get to the [WA: Basic Food/NM or PA: SNAP] office—is this a reason why you might not have applied for SNAP?	1	0	d	r
b. The application process is too long and complicated? (Is this a reason why you might not have applied for SNAP?)	1	0	d	r
c. You would have to answer questions that are too personal when you applied for benefits? (Is this a reason why you might not have applied for SNAP?)	1	0	d	r
d. You would feel embarrassed applying for benefits? (Is this a reason why you might not have applied for SNAP?)	1	0	d	r
e. You wouldn’t be eligible for benefits? Is this a reason why you might not have applied for SNAP?	1	0	d	r
f. You would be eligible for only a small amount of benefits? (Is this a reason why you might not have applied for SNAP?)	1	0	d	r
g. You can get by on your own without benefits? (Is this a reason why you might not have applied for SNAP?)	1	0	d	r
h. Others need benefits more than you do(Is this a reason why you might not have applied for SNAP?)?	1	0	d	r
i. You would dislike relying on government assistance? Is this a reason why you might not have applied for SNAP?	1	0	d	r
j. Other family members or friends would discourage you from using benefits? (Is this a reason why you might not have applied for SNAP?)	1	0	d	r
k. Staff at the [WA: Basic Food/NM or PA: SNAP] office would treat you disrespectfully? (Is this a reason why you might not have applied for SNAP?)	1	0	d	r
l. You only need benefits for a short time? (Is this a reason why you might not have applied for SNAP?)	1	0	d	r
m. You could get food from friends and relatives? Is this a reason why you might not have applied for SNAP?	1	0	d	r
n. You could get food from food pantries, food banks, or some other program? (Is this a reason why you might not have applied for SNAP?)	1	0	d	r
o. Is there any other important reason you have not applied for [IF PA or NM: SNAP/ IF WA: Basic Food] that I have not mentioned? (Specify)	1	0	d	r
________________________________________(STRING (NUM))

E1p. The benefit card is a debit card that you can use at food store checkouts to pay for your food. Do you think you would find the benefit card difficult to use?

YES 1 GO TO E1q

NO 0 GO TO E1x

DON’T KNOW d GO TO E1q

REFUSED r GO TO E1x

IF E1P= YES OR D THEN ASK E1Q

FILL CONDITION:

E1q. Is this a reason why you might not have applied for [IF PA or NM: SNAP/ IF WA: Basic Food]?

YES 1

NO 0

DON’T KNOW d

REFUSED r

IF MORE THAN ONE “YES” RESPONSE IN E1, THEN ASK E1x

FILL CONDITION: STATE, E1

E1x. You mentioned [FILL E1 = YES] as reasons why you have not applied recently. Which is the most important reason why you have not applied?

	MARK ONE ONLY
a. It would be hard to get to the [WA: Basic Food/NM or PA: SNAP] office	1
b. The application process is too long and complicated	2
c. You would have to answer questions that are too personal when you applied for benefits	3
d. You would feel embarrassed applying for benefits	4
e. You wouldn’t be eligible for benefits	5
f. You would be eligible for only a small amount of benefits	6
g. You can get by on your own without benefits	7
h. Others need benefits more than you do	8
i. You would dislike relying on government assistance	9
j. Other family members or friends would discourage you from using benefits	10
k. Staff at the [WA: Basic Food/NM or PA: SNAP] office would treat you disrespectfully	11
l. You only need benefits for a short time	12
m. You could get food from friends and relatives.	13
n. You could get food from food pantries, food banks, or some other program	14
o. You find the benefit card difficult to use	15
p. [FILL: Some other reason]	16
________________________________(STRING (NUM))

IF APPLICATION IS TOO LONG: E1b = 1

E2. You mentioned that the application process would be too long and complicated. Is this because. . .

	MARK ONE PER ROW
	yES	NO	DK	REF
a. you think you would have to wait a long time before receiving benefits?	1	0	d	r
b. you think you would have to wait a long time at the benefit office? Is this a reason you think that the application process would be too long and complicated?	1	0	d	r
c. you think the application form is too long and complicated? Is this a reason you think that the application process would be too long and complicated?	1	0	d	r
d. you think it would be difficult to gather all the necessary paperwork? Is this a reason you think that the application process would be too long and complicated?	1	0	d	r
e. there is some other reason I haven’t mentioned that you think the application process would be too long and complicated? (Specify)	1	0	d	r
____________________________(STRING (NUM))

E2a. [IF WA or PA]: In some states, applications can be completed and submitted over a computer. Is that true in [STATE]?

YES 1

NO 0

NOT SURE n

REFUSED r

E2b. Can the application be completed and submitted by telephone in [STATE]?

YES 1

NO 0

NOT SURE n

REFUSED r

E2c. Can organizations in your community, such as senior centers or food banks, offer assistance with the application process?

YES 1

NO 0

NOT SURE n

REFUSED r

IF CAN GET BY ON OWN: E1g = 1

E3. You mentioned that you can get by on your own. Does this mean that you…

	MARK ONE PER ROW
	yES	NO	DK	REF
a. have enough food for you and your household?	1	0	d	r
b. have enough assistance from another program?	1	0	d	r
c. have other friends or family to help provide you with what you need?	1	0	d	r
d. are able to draw from your assets, such as bank accounts or retirement plans?	1	0	d	r
e. have some other reason I haven’t mentioned? (Specify)	1	0	d	r
________________________________(STRING (NUM))

IF ONLY NEED BENEFITS A SHORT TIME: E1l = 1

E4. You mentioned that you only need benefits for a short time. What circumstances do you expect to change that make this only a temporary need? Do you…

	MARK ONE PER ROW
	yES	NO	DK	REF
a. expect to have more income by the time your application would be processed?	1	0	d	r
b. expect to receive more help from family or friends soon?	1	0	d	r
c. expect some other change in the near future that I haven’t mentioned? (Specify)	1	0	d	r
________________________________(STRING (NUM))

FILL CONDITION: STATE

E5. Now I would like to ask you what might make you more likely to apply for [WA: Basic Food/NM or PA: SNAP] benefits.

	MARK ONE PER ROW
	yES	NO	DK	REF
a. Do you think a simpler application process would encourage you to apply for [WA: Basic Food/NM or PA: SNAP] benefits?	1	0	d	r
b. Would better treatment from staff at the [WA: Basic Food/NM or PA: SNAP] office encourage you to apply?	1	0	d	r
c. Would more information about your eligibility encourage you to apply?	1	0	d	r
d. Is there any other important change that would encourage you to apply? (Specify)	1	0	d	r
________________________________(STRING (NUM))

Some people have said they feel comfortable about using [WA: Basic Food/NM or PA: SNAP] benefits, while others have said they do not feel comfortable using the benefits. We’d like to know how you feel about this. Please answer “yes” or “no” after I read each item.

FILL CONDITION: STATE

E6. “I would avoid telling people that I got [WA: Basic Food/NM or PA: SNAP] benefits.”

YES 1

NO 0

DON’T KNOW d

REFUSED r

FILL CONDITION: STATE

E7. “I would shop at very late or other odd hours to avoid being seen at the store when using my [WA: Basic Food/NM or PA: SNAP] benefits.”

YES 1

NO 0

DON’T KNOW d

REFUSED r

FILL CONDITION: STATE

E8. “I might not shop in certain stores because I don't want people there to know I use [WA: Basic Food/NM or PA: SNAP] benefits.”

YES 1

NO 0

DON’T KNOW d

REFUSED r

FILL CONDITION: STATE

E9. “People in stores would treat me disrespectfully when I use [WA: Basic Food/NM or PA: SNAP] benefits.”

YES 1

NO 0

DON’T KNOW d

REFUSED r

FILL CONDITION: STATE

E10. “People would treat me disrespectfully if they found out that I got [WA: Basic Food/NM or PA: SNAP] benefits.”

YES 1

NO 0

DON’T KNOW d

REFUSED r

F. Experience with Extra Help Pilot

participants and nonparticipants in pilot sites

IF R IS IN WASHINGTON, then ask F1 through F6, then GO TO F16

F1. The Medicare Savings Plan helps pay for Medicare.

After you applied for the Medicare Savings Plan, . . .

	MARK ONE PER ROW
	yES	NO	DK	REF
a. did you receive information or an application for Basic Food in the mail?	1	0	d	r
b. did you receive a call inviting you to apply for Basic Food?	1	0	d	r
c. did you see any advertisements, like posters or television commercials, about Basic Food?	1	0	d	r
d. did you see places you could apply for Basic Food other than at the benefit office, such as at a senior center, community center, or a mobile community services office?	1	0	d	r
e. have you been contacted in some other way about applying for Basic Food?	1	0	d	r

IF R IS IN WASHINGTON

F2. I’d like to know if you have seen or heard about Basic Food in any of the following places. Have you...

	MARK ONE PER ROW
	yES	NO	DK	REF
a. read any articles or advertisements about Basic Food in the newspaper?	1	0	d	r
b. heard any announcements or advertisements on the radio or TV that [FILL CONTENT]?	1	0	d	r
c. seen any posters, flyers, or brochures that [FILL CONTENT]?	1	0	d	r
d. seen any billboards or advertisements on buses, taxis, or trains that [FILL CONTENT]?	1	0	d	r
e. seen any advertisements on a computer that [FILL CONTENT]?	1	0	d	r
f. heard any presentations by community groups that describe [FILL CONTENT]?	1	0	d	r
g. talked with someone by telephone or in person at a community group about whether you might be eligible?.	1	0	d	r
h. received any mail or telephone calls about Basic Food that mention [FILL CONTENT]?	1	0	d	r
i. anything else? (SPECIFY)	1	0	d	r
________________________________(STRING (NUM))

IF R IS IN WASHINGTON

IF F2 = yes for any items

F3. Did you decide to apply as a result of reading, hearing, seeing, or getting information about Basic Food?

YES 1

NO 0 GO TO F5

DON’T KNOW d GO TO F5

REFUSED r GO TO F5

IF R IS IN WASHINGTON

IF APPLIED AS A RESULT OF OUTREACH: F3 = 1

F4. Did you complete that application?

YES 1

NO 0

DON’T KNOW d

REFUSED r

IF R IS IN WASHINGTON

IF APPLIED AS A RESULT OF OUTREACH: F3 = 1

FILL CONDITION: F2 RESPONSES

F5. Which of the following was important in helping you decide to apply? Anything else?

(IF NECESSARY: You mentioned [fill items where F2 = yes])

	MARK ONE PER ROW
	yES	NO	DK	REF
a. Reading articles or advertisements about Basic Food in the newspaper-- was this important in helping you decide to apply?	1	0	d	r
b. Hearing announcements or advertisements on the radio or TV that [FILL CONTENT]-- was this important in helping you decide to apply?	1	0	d	r
c. Seeing posters, flyers, or brochures that [FILL CONTENT] (was this important in helping you decide to apply?)	1	0	d	r
d. Seeing billboards or advertisements on buses, taxis, or trains that [FILL CONTENT] (was this important in helping you decide to apply?)	1	0	d	r
e. Seeing advertisements on a computer that [FILL CONTENT] (was this important in helping you decide to apply?)	1	0	d	r
f. Hearing presentations by community groups that describe [FILL CONTENT]. Was this important in helping you decide to apply?	1	0	d	r
g. Talking with someone by telephone or in person at a community group about whether you might be eligible.( was this important in helping you decide to apply?)	1	0	d	r
h. Receiving any mail or telephone calls about Basic Food that mention [FILL CONTENT] (was this important in helping you decide to apply?)	1	0	d	r
i. Anything else that helped you decide to apply? (SPECIFY)	1	0	d	r
________________________________(STRING (NUM))

IF R IS IN PENNSYLVANIA, ASK F7 THROUGH F9, then GO TO F16

F7. The Medicare Extra Help program helps pay for Medicare prescription drugs payments.

After applying for Medicare Extra Help,. . .

	MARK ONE PER ROW
	yES	NO	DK	REF
a. did you receive information or an application for SNAP in the mail?	1	0	d	r
b. did you receive a call inviting you to apply for SNAP?	1	0	d	r
c. were you contacted in some other way about applying for SNAP?	1	0	d	r

IF R IS IN PENNSYLVANIA
IF CONTACTED ABOUT APPLYING FOR SNAP: F7c = 1

F8. How were you contacted?

(STRING (NUM))

DESCRIPTION

DON’T KNOW d

REFUSED r

IF R IS IN PENNSYLVANIA

IF F7a = 1 OR F7b = 1 OR F7c = 1

F9. Was the reason you applied for SNAP because you received information or someone contacted you?

YES 1

NO 0

DON’T KNOW d

REFUSED r

IF R IS IN NEW MEXICO, ASK F10 THROUGH F16

F10. The Medicare Savings Plan helps pay for Medicare.

Did you receive information or an application for the Medicare Savings Plan in the mail?

YES 1

NO 0 GO TO F12

DON’T KNOW d GO TO F12

REFUSED r GO TO F12

IF R IS IN NEW MEXICO
IF RECEIVED APPLICATION FOR MSP BY MAIL: F10 = 1

F11. Did this Medicare Savings Plan application also include questions to apply for SNAP at the same time?

YES 1

NO 0

DON’T KNOW d

REFUSED r

IF R IS IN NEW MEXICO

F12. Did you submit an application for the Medicare Savings Plan and SNAP together?

YES 1

NO 0 GO TO F14

DON’T KNOW d GO TO F14

REFUSED r GO TO F14

IF R IS IN NEW MEXICO
IF SUBMITTED APPLICATION FOR MSP AND SNAP TOGETHER: F12 = 1

F13. Did you complete that application, which includes submitting the required documents and participating in an interview?

YES 1

NO 0

DON’T KNOW d

REFUSED r

IF R IS IN NEW MEXICO
IF R COMPLETED APPLICATION FOR MSP AND SNAP TOGETHER: F13 = 1

F14. Did you receive an Electronic Benefits, or EBT, card?

YES 1

NO 0 GO TO F16

DON’T KNOW d GO TO F16

REFUSED r GO TO F16

IF R IS IN NEW MEXICO
IF F14 = YES

F15. Was that card for $44, $95, $180, or $300?

$44 1

$95 2

$180 1

$300 2

DON’T KNOW d

REFUSED r

ALL STATES
IF RECEIVED SNAP INFORMATION:

IF WA: IF ANY OF F1a through F1e = YES

IF PA: IF ANY OF F7a through F1c = YES

IF NM: IF F10 = YES

F16a. Our next questions are about the information you received. Were you satisfied or dissatisfied with your ability to get information in your own language?

SATISFIED 1

DISSATISFIED 2

DON’T KNOW d GO TO F17a

REFUSED r GO TO F17a

ALL STATES, IF F16a=1 or 2

FILL CONDITION: F16a RESPONSE

F16b. Would you say you were somewhat [FILL F16a] or very [FILL F16b] (with your ability to get information in your own language)?

SOMEWHAT 1

VERY 2

DON’T KNOW d

REFUSED r

ALL STATES

FILL CONDITION: STATE

F17a. Were you satisfied or dissatisfied with the information you received about why you should apply for [PA or NM: SNAP / WA: Basic Food]?

SATISFIED 1

DISSATISFIED 2

DON’T KNOW d GO TO F18a

REFUSED r GO TO F18a

ALL STATES

FILL CONDITION: F17a RESPONSE

F17b. Would you say you were somewhat [FILL F17a] or very [FILL F17b] (with the information you received about why you should apply for [PA or NM: SNAP / WA: Basic Food])?

SOMEWHAT 1

VERY 2

DON’T KNOW d

REFUSED r

ALL STATES

FILL CONDITION: STATE

F18a. Were you satisfied or dissatisfied with the information you received about how to apply for [PA or NM: SNAP / WA: Basic Food]?

SATISFIED 1

DISSATISFIED 2

DON’T KNOW d GO TO F19a

REFUSED r GO TO F19a

ALL STATES

FILL CONDITION: F18a RESPONSE

F18b. Would you say you were somewhat [FILL F18a] or very [FILL F18b] (with the information you received about how to apply for [PA or NM: SNAP / WA: Basic Food])?

SOMEWHAT 1

VERY 2

DON’T KNOW d

REFUSED r

ALL STATES

FILL CONDITION: STATE

F19a. Were you satisfied or dissatisfied with how easy it is to get answers to your questions about [PA or NM: SNAP / WA: Basic Food]?

SATISFIED 1

DISSATISFIED 2

DON’T KNOW d GO TO G1

REFUSED r GO TO G1

ALL STATES

FILL CONDITION: F19a RESPONSE

F19b. Would you say you were somewhat [FILL F19a] or very [FILL F19b] (with how easy it is to get answers to your questions about [PA or NM: SNAP / WA: Basic Food])?

SOMEWHAT 1

VERY 2

DON’T KNOW d

REFUSED r

G. Demographics

all RESPONDENTS

all

G1. (INTERVIEWER: ASK IF NOT OBVIOUS): What is your gender?

MALE 1

FEMALE 2

G2. What is the highest grade or level of school you have completed or the highest degree you have received?

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’S DEGREE; OCCUPATIONAL, TECHNICAL, OR VOCATIONAL PROGRAM 16

ASSOCIATE’S 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 d

REFUSED r

G3. Are you of Hispanic or Latino origin?

hispanic or latino 1

Not hispanic or latino 0

DON’T KNOW d

REFUSED r

G4. 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 or some other race.

American Indian or Alaska Native 1

asian 2

Black or African American 3

Native Hawaiian or other Pacific Islander 4

WHITE 5

SOME OTHER RACE (SPECIFY) 99

________________________________(STRING (30))

DON’T KNOW d

REFUSED r

G5. Are you married, widowed, divorced, separated, never married, or living with a partner?

MARRIED 1

WIDOWED 2

DIVORCED 3

SEPARATED 4

NEVER MARRIED 5

LIVING WITH A PARTNER 6

DON’T KNOW d

REFUSED r

G6. Including yourself, how many people live in your household?

| | | NUMBER OF PEOPLE IN HOUSEHOLD

DON’T KNOW d

REFUSED r

SOFT CHECK: IF NUMBER OF PEOPLE GT 8 Soft check statement/question

IF G6 = 1 GO TO G8.

G7. Who lives in your household?

MARK ALL THAT APPLY

HUSBAND/WIFE/PARTNER 1

CHILD OR CHILDREN 2

BROTHER(S) OR SISTER(S) 3

GRANDCHILD OR GRANDCHILDREN 4

SON-IN-LAW OR DAUGHTER-IN-LAW 5

OTHER RELATIVE 6

(STRING (NUM))

NON-RELATIVE OR FRIEND 7

DON’T KNOW d

REFUSED r

G8. What language do you primarily speak at home?

ENGLISH 1

SPANISH 2

AMERICAN INDIAN, ALASKA NATIVE LANGUAGE (E.G., CHEROKEE, NAVAJO, YUPIK, YAKAMA) 3

OTHER EUROPEAN LANGUAGES

FRENCH (INCLUDES CREOLE) 4

GERMAN 5

GREEK 6

ITALIAN 7

POLISH 8

PORTUGUESE 9

RUSSIAN 10

SERBO-CROATIAN (INCLUDES BOSNIAN, YUGOSLAVIAN) 11

ASIAN AND PACIFIC ISLAND LANGUAGES:

CHINESE (E.G., CANTONESE, MANDARIN) 12

JAPANESE 13

KOREAN 14

TAGALOG, FILIPINO 15

VIETNAMESE 16

OTHER LANGUAGES:

ARABIC 17

HINDU, URDU 18

AFRICAN LANGUAGE (E.G., SWAHILI, YORUBA) 19

ALL OTHER NON-ENGLISH LANGUAGES (SPECIFY) 20

OTHER (SPECIFY) 99

________________________________(STRING (NUM))

DON’T KNOW d

REFUSED r

G11. Is there a computer that you can use, either in your home, at the library, or at some other place?

YES 1

NO 0 GO TO H1

DON’T KNOW d GO TO H1

REFUSED r GO TO H1

IF USE A COMPUTER: G11 = 1

G12. Where do you use a computer most often?

MY HOME 1

FRIEND OR RELATIVE’S HOME 2

LIBRARY 3

SENIOR OR COMMUNITY CENTER 4

OTHER (SPECIFY) 99

________________________________(STRING (NUM))

DON’T KNOW d

REFUSED r

IF USE A COMPUTER: G11 = 1

G12a. How often do you use the computer?

DAILY 1

A FEW TIMES A WEEK 2

ONCE A WEEK 3

LESS OFTEN THAN ONCE A WEEK 4

DON’T KNOW d

REFUSED r

H. Household Food Security

(all RESPONDENTS)

ALL

FILL CONDITION: NUMBER OF PEOPLE IN HH (G6)

The next questions are about the food eaten in your household in the past 30 days and whether you were able to afford the food you needed.

H1. I'm going to read you two statements that people have made about their food situation. Please tell me whether the statement was OFTEN, SOMETIMES, or NEVER true for (you/you and the other members of your household) in the past 30 days.

The first statement is, "The food that (I/we) bought didn't last, and (I/we) didn't have money to get more." Was that often, sometimes, or never true for (you/your household) in the past 30 days?

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW d

REFUSED r

FILL CONDITION: G6

H2. “(I/we) couldn't afford to eat balanced meals." Was that often, sometimes, or never true for (you/your household) in the past 30 days?

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW d

REFUSED r

FILL CONDITION: DATE, G6

H3. In the past 30 days, since [date 30 days ago] did you [if G6>1: 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 0 GO TO H5

DON’T KNOW d GO TO H5

REFUSED r GO TO H5

IF H3 = YES

H4. In the past 30 days, how many days did this happen?

| | | DAYS (NUMBER RANGE)

DON’T KNOW d

REFUSED r

H5. In the past 30 days, did you ever eat less than you felt you should because there wasn't enough money to buy food?

YES 1

NO 0

DON’T KNOW d

REFUSED r

H6. In the past 30 days, were you ever hungry but didn't eat because you couldn't afford enough food?

YES 1

NO 0

DON’T KNOW d

REFUSED r

I. Respondent Contact Information

ALL RESPONDENTS

INSERT ENTRANCE CONDITION

INSERT FILL CONDITION OR DELETE ROW

Confirm address for post-pay incentive

COLLECT/CONFIRM CURRENT CONTACT INFORMATION FOR RESPONDENT

(STRING (NUM))

FIRST NAME

(STRING (NUM))

MIDDLE INITIAL/NAME

(STRING (NUM))

LAST NAME

(STRING (NUM))

ADDRESS 1

(STRING (NUM))

ADDRESS 2

(STRING (NUM))

CITY

(STRING (NUM))

STATE/TERRITORY

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

ZIP CODE (+ 4 IF NEEDED)

| | | | - | | | | - | | | | | TELEPHONE NUMBER: HOME

| | | | - | | | | - | | | | | TELEPHONE NUMBER: CELLULAR

| | | | - | | | | - | | | | | TELEPHONE NUMBER: OTHER

(RANGE) (RANGE) (RANGE)

(STRING (NUM))

EMAIL

HARD CHECK: IF ZIP CODE = Hard check statement/question