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Nutrition LOI Socio-demographics Instrument
ICR 201211-0925-001 · OMB 0925-0593 · Object 35996201.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Nutrition LOI Socio-demographics Instrument |
| Author | JB |
| Last Modified By | Writer |
| File Modified | 2011-06-17 |
| File Created | 2026-11-13 |
| Conversion State | complete |
Extracted Text
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
a. 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
b. About how long have you lived in the United States?
|___|___|
YEARS
Refused 9--97
Don’t know 9—98
2. Was your mother born in the United States?
Yes (skip to question 3) 1
No 2
Refused 9--97
Don’t know 9--98
a. 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
3. Was your father born in the United States?
Yes (skip to question 4) 1
No 2
Refused 9--97
Don’t know 9--98
a. 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.
4. 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.
5. 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
6. 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!